{ "cells": [ { "cell_type": "code", "execution_count": 1, "id": "d36b940b", "metadata": {}, "outputs": [], "source": [ "from dotenv import load_dotenv" ] }, { "cell_type": "code", "execution_count": 2, "id": "65bf2562", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "True" ] }, "execution_count": 2, "metadata": {}, "output_type": "execute_result" } ], "source": [ "load_dotenv()" ] }, { "cell_type": "code", "execution_count": 3, "id": "007f9450", "metadata": {}, "outputs": [ { "name": "stderr", "output_type": "stream", "text": [ "c:\\Users\\emon1\\AppData\\Local\\Programs\\Python\\Python311\\Lib\\site-packages\\tqdm\\auto.py:21: TqdmWarning: IProgress not found. Please update jupyter and ipywidgets. See https://ipywidgets.readthedocs.io/en/stable/user_install.html\n", " from .autonotebook import tqdm as notebook_tqdm\n" ] } ], "source": [ "import torch\n", "from transformers import AutoTokenizer, AutoModelForCausalLM" ] }, { "cell_type": "code", "execution_count": 4, "id": "dc787681", "metadata": {}, "outputs": [], "source": [ "MODEL_PATH = \"../biogpt-merged/\"" ] }, { "cell_type": "code", "execution_count": 5, "id": "74657bf5", "metadata": {}, "outputs": [], "source": [ "tokenizer = AutoTokenizer.from_pretrained(MODEL_PATH)\n", "if tokenizer.pad_token is None:\n", " tokenizer.pad_token = tokenizer.eos_token" ] }, { "cell_type": "code", "execution_count": 6, "id": "be7ffddf", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "BioGptForCausalLM(\n", " (biogpt): BioGptModel(\n", " (embed_tokens): BioGptScaledWordEmbedding(42384, 1024, padding_idx=1)\n", " (embed_positions): BioGptLearnedPositionalEmbedding(1026, 1024)\n", " (layers): ModuleList(\n", " (0-23): 24 x BioGptDecoderLayer(\n", " (self_attn): BioGptAttention(\n", " (k_proj): Linear(in_features=1024, out_features=1024, bias=True)\n", " (v_proj): Linear(in_features=1024, out_features=1024, bias=True)\n", " (q_proj): Linear(in_features=1024, out_features=1024, bias=True)\n", " (out_proj): Linear(in_features=1024, out_features=1024, bias=True)\n", " )\n", " (activation_fn): GELUActivation()\n", " (self_attn_layer_norm): LayerNorm((1024,), eps=1e-05, elementwise_affine=True)\n", " (fc1): Linear(in_features=1024, out_features=4096, bias=True)\n", " (fc2): Linear(in_features=4096, out_features=1024, bias=True)\n", " (final_layer_norm): LayerNorm((1024,), eps=1e-05, elementwise_affine=True)\n", " )\n", " )\n", " (layer_norm): LayerNorm((1024,), eps=1e-05, elementwise_affine=True)\n", " )\n", " (output_projection): Linear(in_features=1024, out_features=42384, bias=False)\n", ")" ] }, "execution_count": 6, "metadata": {}, "output_type": "execute_result" } ], "source": [ "model = AutoModelForCausalLM.from_pretrained(\n", " MODEL_PATH,\n", " torch_dtype=torch.float32,\n", " low_cpu_mem_usage=True,\n", ")\n", "model.eval()" ] }, { "cell_type": "code", "execution_count": 7, "id": "8ee0f530", "metadata": {}, "outputs": [], "source": [ "# Custom LLM with output cleanup\n", "class FineTunedBioGPT:\n", " def invoke(self, prompt):\n", " inputs = tokenizer(prompt, return_tensors=\"pt\", truncation=True, max_length=256)\n", " \n", " with torch.no_grad():\n", " outputs = model.generate(\n", " **inputs,\n", " max_new_tokens=150,\n", " temperature=0.7,\n", " top_p=0.9,\n", " do_sample=True,\n", " repetition_penalty=1.8,\n", " pad_token_id=tokenizer.pad_token_id,\n", " eos_token_id=tokenizer.eos_token_id,\n", " no_repeat_ngram_size=3,\n", " )\n", " \n", " generated = tokenizer.decode(outputs[0], skip_special_tokens=True)\n", " \n", " # Remove prompt\n", " if generated.startswith(prompt):\n", " response = generated[len(prompt):].strip()\n", " else:\n", " response = generated.strip()\n", " \n", " # Cleanup artifacts\n", " response = self.clean_response(response)\n", " \n", " class Response:\n", " def __init__(self, content):\n", " self.content = content\n", " \n", " return Response(response)\n", " \n", " def clean_response(self, text):\n", " # Remove common artifacts\n", " artifacts = [\n", " \"Chat Doctor\", \"ChatDoctor\", \"Chat Doctors\",\n", " \"Hope I have answered your question\",\n", " \"Let me know if I can assist you further\",\n", " \"Thanks for posting on\",\n", " \"Wishing you good health\",\n", " \"Feel free to ask any more questions\",\n", " \"Good luck\", \"Take care\",\n", " \"Viz-chat\", \"Superord\", \"Immuno-therapy\",\n", " \"IDSA website\", \"Infectious Disease Society\"\n", " ]\n", " \n", " for artifact in artifacts:\n", " text = text.replace(artifact, \"\")\n", " \n", " # Split into sentences\n", " sentences = [s.strip() for s in text.split('.') if s.strip()]\n", " \n", " # Keep only coherent sentences (length > 20 chars)\n", " good_sentences = []\n", " for sent in sentences[:3]:\n", " if len(sent) > 20 and not any(bad in sent.lower() for bad in ['chat', 'doctor.', 'regards']):\n", " good_sentences.append(sent)\n", " \n", " # Return first 2-3 good sentences\n", " if good_sentences:\n", " return '. '.join(good_sentences[:2]) + '.'\n", " \n", " return \"\"\n", "\n", "llm = FineTunedBioGPT()" ] }, { "cell_type": "markdown", "id": "d0aa6889", "metadata": {}, "source": [ "### RAG components" ] }, { "cell_type": "code", "execution_count": 8, "id": "4670ecc5", "metadata": {}, "outputs": [], "source": [ "from langchain_community.document_loaders import PyPDFLoader" ] }, { "cell_type": "code", "execution_count": 9, "id": "3163bd38", "metadata": {}, "outputs": [], "source": [ "loader = PyPDFLoader('../data/medical_book.pdf')" ] }, { "cell_type": "code", "execution_count": 10, "id": "483f5b6c", "metadata": {}, "outputs": [], "source": [ "docs = loader.load()" ] }, { "cell_type": "code", "execution_count": 11, "id": "9af2a7de", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 0, 'page_label': '1'}, page_content='The GALE\\nENCYCLOPEDIA\\nof MEDICINE\\nSECOND EDITION'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 1, 'page_label': '2'}, page_content='The GALE\\nENCYCLOPEDIA\\nof MEDICINE\\nSECOND EDITION\\nJACQUELINE L. LONGE, EDITOR\\nDEIRDRE S. BLANCHFIELD, ASSOCIATE EDITOR\\nVOLUME\\nC-F\\n2'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 2, 'page_label': '3'}, page_content='STAFF\\nJacqueline L. Longe, Project Editor\\nDeirdre S. Blanchfield, Associate Editor\\nChristine B. Jeryan, Managing Editor\\nDonna Olendorf, Senior Editor\\nStacey Blachford, Associate Editor\\nKate Kretschmann, Melissa C. McDade, Ryan\\nThomason, Assistant Editors\\nMark Springer, Technical Specialist\\nAndrea Lopeman, Programmer/Analyst\\nBarbara J. Yarrow,Manager, Imaging and Multimedia\\nContent\\nRobyn V . Young,Project Manager, Imaging and\\nMultimedia Content\\nDean Dauphinais, Senior Editor, Imaging and\\nMultimedia Content\\nKelly A. Quin, Editor, Imaging and Multimedia Content\\nLeitha Etheridge-Sims, Mary K. Grimes, Dave Oblender,\\nImage Catalogers\\nPamela A. Reed, Imaging Coordinator\\nRandy Bassett, Imaging Supervisor\\nRobert Duncan, Senior Imaging Specialist\\nDan Newell, Imaging Specialist\\nChristine O’Bryan,Graphic Specialist\\nMaria Franklin, Permissions Manager\\nMargaret A. Chamberlain, Permissions Specialist\\nMichelle DiMercurio, Senior Art Director\\nMike Logusz, Graphic Artist\\nMary Beth Trimper,Manager, Composition and\\nElectronic Prepress\\nEvi Seoud, Assistant Manager, Composition Purchasing\\nand Electronic Prepress\\nDorothy Maki, Manufacturing Manager\\nWendy Blurton, Senior Manufacturing Specialist\\nThe GALE\\nENCYCLOPEDIA\\nof MEDICINE\\nSECOND EDITION\\nSince this page cannot legibly accommodate all copyright notices, the\\nacknowledgments constitute an extension of the copyright notice.\\nWhile every effort has been made to ensure the reliability of the infor-\\nmation presented in this publication, the Gale Group neither guarantees\\nthe accuracy of the data contained herein nor assumes any responsibili-\\nty for errors, omissions or discrepancies. The Gale Group accepts no\\npayment for listing, and inclusion in the publication of any organiza-\\ntion, agency, institution, publication, service, or individual does not\\nimply endorsement of the editor or publisher. Errors brought to the\\nattention of the publisher and verified to the satisfaction of the publish-\\ner will be corrected in future editions.\\nThis book is printed on recycled paper that meets Environmental Pro-\\ntection Agency standards.\\nThe paper used in this publication meets the minimum requirements of\\nAmerican National Standard for Information Sciences-Permanence\\nPaper for Printed Library Materials, ANSI Z39.48-1984.\\nThis publication is a creative work fully protected by all applicable\\ncopyright laws, as well as by misappropriation, trade secret, unfair com-\\npetition, and other applicable laws. The authors and editor of this work\\nhave added value to the underlying factual material herein through one\\nor more of the following: unique and original selection, coordination,\\nexpression, arrangement, and classification of the information.\\nGale Group and design is a trademark used herein under license.\\nAll rights to this publication will be vigorously defended.\\nCopyright © 2002\\nGale Group\\n27500 Drake Road\\nFarmington Hills, MI 48331-3535\\nAll rights reserved including the right of reproduction in whole or in\\npart in any form.\\nISBN 0-7876-5489-2 (set)\\n0-7876-5490-6 (V ol. 1)\\n0-7876-5491-4 (V ol. 2)\\n0-7876-5492-2 (V ol. 3)\\n0-7876-5493-0 (V ol. 4)\\n0-7876-5494-9 (V ol. 5)\\nPrinted in the United States of America\\n10 9 8 7 6 5 4 3 2 1\\nLibrary of Congress Cataloging-in-Publication Data\\nGale encyclopedia of medicine / Jacqueline L. Longe, editor;\\nDeirdre S. Blanchfield, associate editor — 2nd ed.\\np. cm.\\nIncludes bibliographical references and index.\\nContents: V ol. 1. A-B — v. 2. C-F — v. 3.\\nG-M — v. 4. N-S — v. 5. T-Z.\\nISBN 0-7876-5489-2 (set: hardcover) — ISBN 0-7876-5490-6\\n(vol. 1) — ISBN 0-7876-5491-4 (vol. 2) — ISBN 0-7876-5492-2\\n(vol. 3) — ISBN 0-7876-5493-0 (vol. 4) — ISBN 0-7876-5494-9\\n(vol. 5)\\n1. Internal medicine—Encyclopedias. I. Longe, Jacqueline L. \\nII. Blanchfield, Deirdre S. III. Gale Research Company.\\nRC41.G35 2001\\n616’.003—dc21\\n2001051245'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 3, 'page_label': '4'}, page_content='Introduction.................................................... ix\\nAdvisory Board.............................................. xi\\nContributors ................................................. xiii\\nEntries\\nVolume 1: A-B.............................................. 1\\nVolume 2: C-F.......................................... 625\\nVolume 3: G-M....................................... 1375\\nVolume 4: N-S........................................ 2307\\nVolume 5: T-Z........................................ 3237\\nOrganizations ............................................ 3603\\nGeneral Index............................................ 3625\\nGALE ENCYCLOPEDIA OF MEDICINE 2 V\\nCONTENTS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 4, 'page_label': '5'}, page_content='The Gale Encyclopedia of Medicine 2is a medical ref-\\nerence product designed to inform and educate readers\\nabout a wide variety of disorders, conditions, treatments,\\nand diagnostic tests. The Gale Group believes the product\\nto be comprehensive, but not necessarily definitive. It is\\nintended to supplement, not replace, consultation with a\\nphysician or other healthcare practitioner. While the Gale\\nGroup has made substantial efforts to provide information\\nthat is accurate, comprehensive, and up-to-date, the Gale\\nGroup makes no representations or warranties of any\\nkind, including without limitation, warranties of mer-\\nchantability or fitness for a particular purpose, nor does it\\nguarantee the accuracy, comprehensiveness, or timeliness\\nof the information contained in this product. Readers\\nshould be aware that the universe of medical knowledge\\nis constantly growing and changing, and that differences\\nof medical opinion exist among authorities. Readers are\\nalso advised to seek professional diagnosis and treatment\\nfor any medical condition, and to discuss information\\nobtained from this book with their health care provider.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 VII\\nPLEASE READ—IMPORTANT INFORMATION'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 5, 'page_label': '6'}, page_content='The Gale Encyclopedia of Medicine 2 (GEM2) is a\\none-stop source for medical information on nearly 1,700\\ncommon medical disorders, conditions, tests, and treat-\\nments, including high-profile diseases such as AIDS,\\nAlzheimer’s disease, cancer, and heart attack. This ency-\\nclopedia avoids medical jargon and uses language that\\nlaypersons can understand, while still providing thor-\\nough coverage of each topic. The Gale Encyclopedia of\\nMedicine 2 fills a gap between basic consumer health\\nresources, such as single-volume family medical guides,\\nand highly technical professional materials.\\nSCOPE\\nAlmost 1,700 full-length articles are included in the\\nGale Encyclopedia of Medicine 2 , including disorders/\\nconditions, tests/procedures, and treatments/therapies.\\nMany common drugs are also covered, with generic drug\\nnames appearing first and brand names following in\\nparentheses, eg. acetaminophen (Tylenol). Throughout\\nthe Gale Encyclopedia of Medicine 2 , many prominent\\nindividuals are highlighted as sidebar biographies that\\naccompany the main topical essays. Articles follow a\\nstandardized format that provides information at a\\nglance. Rubrics include:\\nDisorders/Conditions Tests/Treatments\\nDefinition Definition\\nDescription Purpose\\nCauses and symptoms Precautions\\nDiagnosis Description\\nTreatment Preparation\\nAlternative treatment Aftercare\\nPrognosis Risks\\nPrevention Normal/Abnormal results\\nResources Resources\\nKey terms Key terms\\nIn recent years there has been a resurgence of interest\\nin holistic medicine that emphasizes the connection\\nbetween mind and body. Aimed at achieving and main-\\ntaining good health rather than just eliminating disease,\\nthis approach has come to be known as alternative medi-\\ncine. The Gale Encyclopedia of Medicine 2 includes a\\nnumber of essays on alternative therapies, ranging from\\ntraditional Chinese medicine to homeopathy and from\\nmeditation to aromatherapy. In addition to full essays on\\nalternative therapies, the encyclopedia features specific\\nAlternative treatment sections for diseases and condi-\\ntions that may be helped by complementary therapies.\\nINCLUSION CRITERIA\\nA preliminary list of diseases, disorders, tests and treat-\\nments was compiled from a wide variety of sources,\\nincluding professional medical guides and textbooks as\\nwell as consumer guides and encyclopedias. The general\\nadvisory board, made up of public librarians, medical\\nlibrarians and consumer health experts, evaluated the top-\\nics and made suggestions for inclusion. The list was sorted\\nby category and sent to GEM2 medical advisors, certified\\nphysicians with various medical specialities, for review.\\nFinal selection of topics to include was made by the med-\\nical advisors in conjunction with the Gale Group editor.\\nABOUT THE CONTRIBUTORS\\nThe essays were compiled by experienced medical\\nwriters, including physicians, pharmacists, nurses, and\\nother health care professionals. GEM2 medical advisors\\nreviewed the completed essays to insure that they are\\nappropriate, up-to-date, and medically accurate.\\nHOW TO USE THIS BOOK\\nThe Gale Encyclopedia of Medicine 2 has been\\ndesigned with ready reference in mind.\\n• Straight alphabetical arrangement allows users to\\nlocate information quickly.\\n• Bold-faced terms function as print hyperlinks that\\npoint the reader to related entries in the encyclopedia.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 IX\\nINTRODUCTION'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 6, 'page_label': '7'}, page_content='• Cross-references placed throughout the encyclopedia\\ndirect readers to where information on subjects with-\\nout entries can be found. Synonyms are also cross-ref-\\nerenced.\\n• A list of key terms are provided where appropriate to\\ndefine unfamiliar terms or concepts.\\n• Valuable contact information for organizations and\\nsupport groups is included with each entry. The\\nappendix contains an extensive list of organizations\\narranged in alphabetical order.\\n• Resources section directs users to additional sources\\nof medical information on a topic.\\n• A comprehensive general index allows users to easily\\ntarget detailed aspects of any topic, including Latin\\nnames.\\nGRAPHICS\\nThe Gale Encyclopedia of Medicine 2 is enhanced\\nwith over 675 color images, including photos, charts,\\ntables, and customized line drawings.\\nGALE ENCYCLOPEDIA OF MEDICINE 2X\\nIntroduction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 7, 'page_label': '8'}, page_content='MEDICAL ADVISORS\\nA. Richard Adrouny, M.D.,\\nF.A.C.P.\\nClinical Assistant Professor of\\nMedicine\\nDivision of Oncology\\nStanford University\\nDirector of Medical Oncology\\nCommunity Hospital of Los Gatos-\\nSaratoga\\nLos Gatos, CA\\nLaurie Barclay, M.D.\\nNeurological Consulting Services\\nTampa, FL\\nKenneth J. Berniker, M.D.\\nAttending Physician\\nEmergency Department\\nKaiser Permanente Medical Center\\nVallejo, CA\\nRosalyn Carson-DeWitt, M.D.\\nDurham, NC\\nRobin Dipasquale, N.D.\\nClinical Faculty\\nBastyr University\\nSeattle, W A\\nFaye Fishman, D.O.\\nRandolph, NJ\\nJ. Gary Grant, M.D.\\nPacific Grove, CA\\nLaith F. Gulli, M.D.\\nM.Sc., M.Sc.(MedSci), MSA,\\nMsc.Psych., MRSNZ\\nFRSH, FRIPHH, FAIC, FZS\\nDAPA, DABFC, DABCI\\nConsultant Psychotherapist in\\nPrivate Practice\\nLathrup Village, MI\\nL. Anne Hirschel, D.D.S.\\nSouthfield, MI\\nLarry I. Lutwick M.D., F.A.C.P.\\nDirector, Infectious Diseases\\nV A Medical Center\\nBrooklyn, NY\\nIra Michelson, M.D., M.B.A.,\\nF.A.C.O.G.\\nPhysician and Clinical Instructor\\nUniversity of Michigan\\nAnn Arbor, MI\\nSusan Mockus, M.D.\\nScientific Consultant\\nSeattle, W A\\nRalph M. Myerson, M.D.,\\nF.A.C.P.\\nClinical Professor of Medicine\\nMedical College of Pennsylvania–\\nHahnemann University\\nPhiladelphia, PA\\nRonald Pies, M.D.\\nClinical Professor of Psychiatry\\nTufts University\\nSchool of Medicine\\nBoston, MA\\nLecturer on Psychiatry\\nHarvard Medical School\\nCambridge, MA\\nLee A. Shratter, M.D.\\nStaff Radiologist\\nThe Permanente Medical Group\\nRichmond, CA\\nAmy B. Tuteur, M.D.\\nSharon, MA\\nLIBRARIAN ADVISORS\\nMaureen O. Carleton, MLIS\\nMedical Reference Specialist\\nKing County Library System\\nBellevue, W A\\nElizabeth Clewis Crim, MLS\\nCollection Specialist\\nPrince William Public Library, V A\\nValerie J. Lawrence, MLS\\nAssistant Librarian\\nWestern States Chiropractic\\nCollege\\nPortland, OR\\nBarbara J. O’Hara, MLS\\nAdult Services Librarian\\nFree Library of Philadelphia, PA\\nAlan M. Rees, MLS\\nProfessor Emeritus\\nCase Western Reserve University\\nCleveland, OH\\nGALE ENCYCLOPEDIA OF MEDICINE 2 XI\\nADVISORY BOARD\\nA number of experts in the library and medical communities provided invaluable assistance in the formulation of this ency-\\nclopedia. Our advisory board performed a myriad of duties, from defining the scope of coverage to reviewing individual\\nentries for accuracy and accessibility. The editor would like to express her appreciation to them.'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 8, 'page_label': '9'}, page_content='Margaret Alic, Ph.D.\\nScience Writer\\nEastsound, W A\\nJanet Byron Anderson\\nLinguist/Language Consultant\\nRocky River, OH\\nLisa Andres, M.S., C.G.C.\\nCertified Genetic Counselor and\\nMedical Writer\\nSan Jose, CA\\nGreg Annussek\\nMedical Writer/Editor\\nNew York, NY\\nBill Asenjo, M.S., C.R.C.\\nScience Writer\\nIowa City, IA\\nSharon A. Aufox, M.S., C.G.C.\\nGenetic Counselor\\nRockford Memorial Hospital\\nRockford, IL\\nSandra Bain Cushman\\nMassage Therapist, Alexander\\nTechnique Practitioner\\nCharlottesville, V A\\nHoward Baker\\nMedical Writer\\nNorth York, Ontario\\nLaurie Barclay, M.D.\\nNeurological Consulting Services\\nTampa, FL\\nJeanine Barone\\nNutritionist, Exercise Physiologist\\nNew York, NY\\nJulia R. Barrett\\nScience Writer\\nMadison, WI\\nDonald G. Barstow, R.N.\\nClincal Nurse Specialist\\nOklahoma City, OK\\nCarin Lea Beltz, M.S.\\nGenetic Counselor and Program\\nDirector\\nThe Center for Genetic Counseling\\nIndianapolis, IN\\nLinda K. Bennington, C.N.S.\\nScience Writer\\nVirginia Beach, V A\\nIssac R. Berniker\\nMedical Writer\\nVallejo, CA\\nKathleen Berrisford, M.S.V .\\nScience Writer\\nBethanne Black\\nMedical Writer\\nAtlanta, GA\\nJennifer Bowjanowski, M.S.,\\nC.G.C.\\nGenetic Counselor\\nChildren’s Hospital Oakland\\nOakland, CA\\nMichelle Q. Bosworth, M.S., C.G.C.\\nGenetic Counselor\\nEugene, OR\\nBarbara Boughton\\nHealth and Medical Writer\\nEl Cerrito, CA\\nCheryl Branche, M.D.\\nRetired General Practitioner\\nJackson, MS\\nMichelle Lee Brandt\\nMedical Writer\\nSan Francisco, CA\\nMaury M. Breecher, Ph.D.\\nHealth Communicator/Journalist\\nNorthport, AL\\nRuthan Brodsky\\nMedical Writer\\nBloomfield Hills, MI\\nTom Brody, Ph.D.\\nScience Writer\\nBerkeley, CA\\nLeonard C. Bruno, Ph.D.\\nMedical Writer\\nChevy Chase, MD\\nDiane Calbrese\\nMedical Sciences and Technology\\nWriter\\nSilver Spring, Maryland\\nRichard H. Camer\\nEditor\\nInternational Medical News Group\\nSilver Spring, MD\\nRosalyn Carson-DeWitt, M.D.\\nMedical Writer\\nDurham, NC\\nLata Cherath, Ph.D.\\nScience Writing Intern\\nCancer Research Institute\\nNew York, NY\\nLinda Chrisman\\nMassage Therapist and Educator\\nOakland, CA\\nLisa Christenson, Ph.D.\\nScience Writer\\nHamden, CT\\nGeoffrey N. Clark, D.V .M.\\nEditor\\nCanine Sports Medicine Update\\nNewmarket, NH\\nGALE ENCYCLOPEDIA OF MEDICINE 2 XIII\\nCONTRIBUTORS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 9, 'page_label': '10'}, page_content='Rhonda Cloos, R.N.\\nMedical Writer\\nAustin, TX\\nGloria Cooksey, C.N.E\\nMedical Writer\\nSacramento, CA\\nAmy Cooper, M.A., M.S.I.\\nMedical Writer\\nVermillion, SD\\nDavid A. Cramer, M.D.\\nMedical Writer\\nChicago, IL\\nEsther Csapo Rastega, R.N., B.S.N.\\nMedical Writer\\nHolbrook, MA\\nArnold Cua, M.D.\\nPhysician\\nBrooklyn, NY\\nTish Davidson, A.M.\\nMedical Writer\\nFremont, California\\nDominic De Bellis, Ph.D.\\nMedical Writer/Editor\\nMahopac, NY\\nLori De Milto\\nMedical Writer\\nSicklerville, NJ\\nRobert S. Dinsmoor\\nMedical Writer\\nSouth Hamilton, MA\\nStephanie Dionne, B.S.\\nMedical Writer\\nAnn Arbor, MI\\nMartin W. Dodge, Ph.D.\\nTechnical Writer/Editor\\nCentinela Hospital and Medical\\nCenter\\nInglewood, CA\\nDavid Doermann\\nMedical Writer\\nSalt Lake City, UT\\nStefanie B. N. Dugan, M.S.\\nGenetic Counselor\\nMilwaukee, WI\\nDoug Dupler, M.A.\\nScience Writer\\nBoulder, CO\\nJulie A. Gelderloos\\nBiomedical Writer\\nPlaya del Rey, CA\\nGary Gilles, M.A.\\nMedical Writer\\nWauconda, IL\\nHarry W. Golden\\nMedical Writer\\nShoreline Medical Writers\\nOld Lyme, CT\\nDebra Gordon\\nMedical Writer\\nNazareth, PA\\nMegan Gourley\\nWriter\\nGermantown, MD\\nJill Granger, M.S.\\nSenior Research Associate\\nUniversity of Michigan\\nAnn Arbor, MI\\nAlison Grant\\nMedical Writer\\nAverill Park, NY\\nElliot Greene, M.A.\\nformer president, American\\nMassage Therapy Association\\nMassage Therapist\\nSilver Spring, MD\\nPeter Gregutt\\nWriter\\nAsheville, NC\\nLaith F. Gulli, M.D.\\nM.Sc., M.Sc.(MedSci), M.S.A.,\\nMsc.Psych, MRSNZ\\nFRSH, FRIPHH, FAIC, FZS\\nDAPA, DABFC, DABCI\\nConsultant Psychotherapist in\\nPrivate Practice\\nLathrup Village, MI\\nKapil Gupta, M.D.\\nMedical Writer\\nWinston-Salem, NC\\nMaureen Haggerty\\nMedical Writer\\nAmbler, PA\\nClare Hanrahan\\nMedical Writer\\nAsheville, NC\\nThomas Scott Eagan\\nStudent Researcher\\nUniversity of Arizona\\nTucson, AZ\\nAltha Roberts Edgren\\nMedical Writer\\nMedical Ink\\nSt. Paul, MN\\nKaren Ericson, R.N.\\nMedical Writer\\nEstes Park, CO\\nL. Fleming Fallon Jr., M.D.,\\nDr.PH\\nAssociate Professor of Public\\nHealth\\nBowling Green State University\\nBowling Green, OH\\nFaye Fishman, D.O.\\nPhysician\\nRandolph, NJ\\nJanis Flores\\nMedical Writer\\nLexikon Communications\\nSebastopol, CA\\nRisa Flynn\\nMedical Writer\\nCulver City, CA\\nPaula Ford-Martin\\nMedical Writer\\nChaplin, MN\\nJanie F. Franz\\nWriter\\nGrand Forks, ND\\nSallie Freeman, Ph.D., B.S.N.\\nMedical Writer\\nAtlanta, GA\\nRebecca J. Frey, Ph.D.\\nResearch and Administrative\\nAssociate\\nEast Rock Institute\\nNew Haven, CT\\nCynthia L. Frozena, R.N.\\nNurse, Medical Writer\\nManitowoc, WI\\nRon Gasbarro, Pharm.D.\\nMedical Writer\\nNew Milford, PA\\nGALE ENCYCLOPEDIA OF MEDICINE 2XIV\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 10, 'page_label': '11'}, page_content='Ann M. Haren\\nScience Writer\\nMadison, CT\\nJudy C. Hawkins, M.S.\\nGenetic Counselor\\nThe University of Texas Medical\\nBranch\\nGalveston, TX\\nCaroline Helwick\\nMedical Writer\\nNew Orleans, LA\\nDavid Helwig\\nMedical Writer\\nLondon, Ontario\\nLisette Hilton\\nMedical Writer\\nBoca Raton, FL\\nKatherine S. Hunt, M.S.\\nGenetic Counselor\\nUniversity of New Mexico Health\\nSciences Center\\nAlbuquerque, NM\\nKevin Hwang, M.D.\\nMedical Writer\\nMorristown, NJ\\nHolly Ann Ishmael, M.S., C.G.C.\\nGenetic Counselor\\nThe Children’s Mercy Hospital\\nKansas City, MO\\nDawn A. Jacob, M.S.\\nGenetic Counselor\\nObstetrix Medical Group of Texas\\nFort Worth, TX\\nSally J. Jacobs, Ed.D.\\nMedical Writer\\nLos Angeles, CA\\nMichelle L. Johnson, M.S., J.D.\\nPatent Attorney and Medical Writer\\nPortland, OR\\nPaul A. Johnson, Ed.M.\\nMedical Writer\\nSan Diego, CA\\nCindy L. A. Jones, Ph.D.\\nBiomedical Writer\\nSagescript Communications\\nLakewood, CO\\nDavid Kaminstein, M.D.\\nMedical Writer\\nJohn T. Lohr, Ph.D.\\nAssistant Director, Biotechnology\\nCenter\\nUtah State University\\nLogan, UT\\nLarry Lutwick, M.D., F.A.C.P.\\nDirector, Infectious Diseases\\nV A Medical Center\\nBrooklyn, NY\\nSuzanne M. Lutwick\\nMedical Writer\\nBrooklyn, NY\\nNicole Mallory, M.S.\\nMedical Student\\nWayne State University\\nDetroit, MI\\nWarren Maltzman, Ph.D.\\nConsultant, Molecular Pathology\\nDemarest, NJ\\nAdrienne Massel, R.N.\\nMedical Writer\\nBeloit, WI\\nRuth E. Mawyer, R.N.\\nMedical Writer\\nCharlottesville, V A\\nRichard A. McCartney M.D.\\nFellow, American College of\\nSurgeons\\nDiplomat American Board of\\nSurgery\\nRichland, W A\\nBonny McClain, Ph.D.\\nMedical Writer\\nGreensboro, NC\\nSally C. McFarlane-Parrott\\nMedical Writer\\nAnn Arbor, MI\\nMercedes McLaughlin\\nMedical Writer\\nPhoenixville, CA\\nAlison McTavish, M.Sc.\\nMedical Writer and Editor\\nMontreal, Quebec\\nLiz Meszaros\\nMedical Writer\\nLakewood, OH\\nWest Chester, PA\\nBeth A. Kapes\\nMedical Writer\\nBay Village, OH\\nChristine Kuehn Kelly\\nMedical Writer\\nHavertown, PA\\nBob Kirsch\\nMedical Writer\\nOssining, NY\\nJoseph Knight, P.A.\\nMedical Writer\\nWinton, CA\\nMelissa Knopper\\nMedical Writer\\nChicago, IL\\nKaren Krajewski, M.S., C.G.C.\\nGenetic Counselor\\nAssistant Professor of Neurology\\nWayne State University\\nDetroit, MI\\nJeanne Krob, M.D., F.A.C.S.\\nPhysician, writer\\nPittsburgh, PA\\nJennifer Lamb\\nMedical Writer\\nSpokane, W A\\nRichard H. Lampert\\nSenior Medical Editor\\nW.B. Saunders Co.\\nPhiladelphia, PA\\nJeffrey P. Larson, R.P.T.\\nPhysical Therapist\\nSabin, MN\\nJill Lasker\\nMedical Writer\\nMidlothian, V A\\nKristy Layman\\nMusic Therapist\\nEast Lansing, MI\\nVictor Leipzig, Ph.D.\\nBiological Consultant\\nHuntington Beach, CA\\nLorraine Lica, Ph.D.\\nMedical Writer\\nSan Diego, CA\\nGALE ENCYCLOPEDIA OF MEDICINE 2 XV\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 11, 'page_label': '12'}, page_content='Betty Mishkin\\nMedical Writer\\nSkokie, IL\\nBarbara J. Mitchell\\nMedical Writer\\nHallstead, PA\\nMark A. Mitchell, M.D.\\nMedical Writer\\nSeattle, W A\\nSusan J. Montgomery\\nMedical Writer\\nMilwaukee, WI\\nLouann W. Murray, PhD\\nMedical Writer\\nHuntington Beach, CA\\nBilal Nasser, M.Sc.\\nSenior Medical Student\\nUniversidad Iberoamericana\\nSanto Domingo, Domincan \\nRepublic\\nLaura Ninger\\nMedical Writer\\nWeehawken, NJ\\nNancy J. Nordenson\\nMedical Writer\\nMinneapolis, MN\\nTeresa Norris, R.N.\\nMedical Writer\\nUte Park, NM\\nLisa Papp, R.N.\\nMedical Writer\\nCherry Hill, NJ\\nPatience Paradox\\nMedical Writer\\nBainbridge Island, W A\\nBarbara J. Pettersen\\nGenetic Counselor\\nGenetic Counseling of Central\\nOregon\\nBend, OR\\nGenevieve Pham-Kanter, M.S.\\nMedical Writer\\nChicago, IL\\nCollette Placek\\nMedical Writer\\nWheaton, IL\\nBelinda Rowland, Ph.D.\\nMedical Writer\\nV oorheesville, NY\\nAndrea Ruskin, M.D.\\nWhittingham Cancer Center\\nNorwalk, CT\\nLaura Ruth, Ph.D.\\nMedical, Science, & Technology\\nWriter\\nLos Angeles, CA\\nKaren Sandrick\\nMedical Writer\\nChicago, IL\\nKausalya Santhanam, Ph.D.\\nTechnical Writer\\nBranford, CT\\nJason S. Schliesser, D.C.\\nChiropractor\\nHolland Chiropractic, Inc.\\nHolland, OH\\nJoan Schonbeck\\nMedical Writer\\nNursing\\nMassachusetts Department of\\nMental Health\\nMarlborough, MA\\nLaurie Heron Seaver, M.D.\\nClinical Geneticist\\nGreenwood Genetic Center\\nGreenwood, SC\\nCatherine Seeley\\nMedical Writer\\nKristen Mahoney Shannon, M.S.,\\nC.G.C.\\nGenetic Counselor\\nCenter for Cancer Risk Analysis\\nMassachusetts General Hospital\\nBoston, MA\\nKim A. Sharp, M.Ln.\\nWriter\\nRichmond, TX\\nJudith Sims, M.S.\\nMedical Writer\\nLogan, UT\\nJoyce S. Siok, R.N.\\nMedical Writer\\nSouth Windsor, CT\\nJ. Ricker Polsdorfer, M.D.\\nMedical Writer\\nPhoenix, AZ\\nScott Polzin, M.S., C.G.C.\\nMedical Writer\\nBuffalo Grove, IL\\nElizabeth J. Pulcini, M.S.\\nMedical Writer\\nPhoenix, Arizona\\nNada Quercia, M.S., C.C.G.C.\\nGenetic Counselor\\nDivision of Clinical and Metabolic\\nGenetics\\nThe Hospital for Sick Children\\nToronto, ON, Canada\\nAnn Quigley\\nMedical Writer\\nNew York, NY\\nRobert Ramirez, B.S.\\nMedical Student\\nUniversity of Medicine & Dentistry\\nof New Jersey\\nStratford, NJ\\nKulbir Rangi, D.O.\\nMedical Doctor and Writer\\nNew York, NY\\nEsther Csapo Rastegari, Ed.M.,\\nR.N./B.S.N.\\nRegistered Nurse, Medical Writer\\nHolbrook, MA\\nToni Rizzo\\nMedical Writer\\nSalt Lake City, UT\\nMartha Robbins\\nMedical Writer\\nEvanston, IL\\nRichard Robinson\\nMedical Writer\\nTucson, AZ\\nNancy Ross-Flanigan\\nScience Writer\\nBelleville, MI\\nAnna Rovid Spickler, D.V .M.,\\nPh.D.\\nMedical Writer\\nMoorehead, KY\\nGALE ENCYCLOPEDIA OF MEDICINE 2XVI\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 12, 'page_label': '13'}, page_content='Jennifer Sisk\\nMedical Writer\\nHavertown, PA\\nPatricia Skinner\\nMedical Writer\\nAmman, Jordan\\nGenevieve Slomski, Ph.D.\\nMedical Writer\\nNew Britain, CT\\nStephanie Slon\\nMedical Writer\\nPortland, OR\\nLinda Wasmer Smith\\nMedical Writer\\nAlbuquerque, NM\\nJava O. Solis, M.S.\\nMedical Writer\\nDecatur, GA\\nElaine Souder, PhD\\nMedical Writer\\nLittle Rock, AR\\nJane E. Spehar\\nMedical Writer\\nCanton, OH\\nLorraine Steefel, R.N.\\nMedical Writer\\nMorganville, NJ\\nKurt Sternlof\\nScience Writer\\nNew Rochelle, NY\\nRoger E. Stevenson, M.D.\\nDirector\\nGreenwood Genetic Center\\nGreenwood, SC\\nDorothy Stonely\\nMedical Writer\\nLos Gatos, CA\\nAmy Vance, M.S., C.G.C.\\nGenetic Counselor\\nGeneSage, Inc.\\nSan Francisco, CA\\nMichael Sherwin Walston\\nStudent Researcher\\nUniversity of Arizona\\nTucson, AZ\\nRonald Watson, Ph.D.\\nScience Writer\\nTucson, AZ\\nEllen S. Weber, M.S.N.\\nMedical Writer\\nFort Wayne, IN\\nKen R. Wells\\nFreelance Writer\\nLaguna Hills, CA\\nJennifer F. Wilson, M.S.\\nScience Writer\\nHaddonfield, NJ\\nKathleen D. Wright, R.N.\\nMedical Writer\\nDelmar, DE\\nJennifer Wurges\\nMedical Writer\\nRochester Hills, MI\\nMary Zoll, Ph.D.\\nScience Writer\\nNewton Center, MA\\nJon Zonderman\\nMedical Writer\\nOrange, CA\\nMichael V . Zuck, Ph.D.\\nMedical Writer\\nBoulder, CO\\nLiz Swain\\nMedical Writer\\nSan Diego, CA\\nDeanna M. Swartout-Corbeil,\\nR.N.\\nMedical Writer\\nThompsons Station, TN\\nKeith Tatarelli, J.D.\\nMedical Writer\\nMary Jane Tenerelli, M.S.\\nMedical Writer\\nEast Northport, NY\\nCatherine L. Tesla, M.S., C.G.C.\\nSenior Associate, Faculty\\nDept. of Pediatrics, Division of\\nMedical Genetics\\nEmory University School of\\nMedicine\\nAtlanta, GA\\nBethany Thivierge\\nBiotechnical Writer/Editor\\nTechnicality Resources\\nRockland, ME\\nMai Tran, Pharm.D.\\nMedical Writer\\nTroy, MI\\nCarol Turkington\\nMedical Writer\\nLancaster, PA\\nJudith Turner, B.S.\\nMedical Writer\\nSandy, UT\\nAmy B. Tuteur, M.D.\\nMedical Advisor\\nSharon, MA\\nSamuel Uretsky, Pharm.D.\\nMedical Writer\\nWantagh, NY\\nGALE ENCYCLOPEDIA OF MEDICINE 2 XVII\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 13, 'page_label': '14'}, page_content='CABG surgery see Coronary artery bypass\\ngraft surgery\\nCAD see Coronary artery disease\\nCaffeine\\nDefinition\\nCaffeine is a drug that stimulates the central nervous\\nsystem.\\nPurpose\\nCaffeine makes people more alert, less drowsy, and\\nimproves coordination. Combined with certain pain\\nrelievers or medicines for treating migraine headache ,\\ncaffeine makes those drugs work more quickly and effec-\\ntively. Caffeine alone can also help relieve headaches.\\nAntihistamines are sometimes combined with caffeine\\nto counteract the drowsiness that those drugs cause. Caf-\\nfeine is also sometimes used to treat other conditions,\\nincluding breathing problems in newborns and in young\\nbabies after surgery.\\nDescription\\nCaffeine is found naturally in coffee, tea, and chocolate.\\nColas and some other soft drinks contain it. Caffeine also\\ncomes in tablet and capsule forms and can be bought without\\na prescription. Over-the-counter caffeine brands include No\\nDoz, Overtime, Pep-Back, Quick-Pep, Caffedrine, and\\nVivarin. Some pain relievers, medicines for migraine\\nheadaches, and antihistamines also contain caffeine.\\nRecommended dosage\\nAdults and children age 12 years and over\\n100–200 mg no more than every 3–4 hours. In\\ntimed-release form, the dose is 200–250 mg once a day.\\nTimed-release forms should not be taken less than six\\nhours before bedtime.\\nChildren under 12 years\\nNot recommended.\\nOther considerations\\nAvoid taking too much caffeine when it is being\\ntaken as an over-the-counter drug. Consider how much\\ncaffeine is being taken in from coffee, tea, chocolate, soft\\ndrinks, and other foods that contain caffeine. Check with\\na pharmacist or physician to find out how much caffeine\\nis safe to use.\\nPrecautions\\nCaffeine cannot replace sleep and should not be used\\nregularly to stay awake as the drug can lead to more seri-\\nous sleep disorders, like insomnia.\\nPeople who use large amounts of caffeine over long\\nperiods build up a tolerance to it. When that happens,\\nthey have to use more and more caffeine to get the same\\neffects. Heavy caffeine use can also lead to dependence.\\nIf the person then stops using caffeine abruptly, with-\\ndrawal symptoms may occur. These can include throb-\\nbing headaches, fatigue, drowsiness, yawning, irritabili-\\nty, restlessness, vomiting, or runny nose. These symp-\\ntoms can go on for as long as a week if caffeine is avoid-\\ned. Then the symptoms usually disappear.\\nIf taken too close to bedtime, caffeine can interfere\\nwith sleep. Even if it does not prevent a person from\\nfalling asleep, it may disturb sleep during the night.\\nThe notion that caffeine helps people sober up after\\ndrinking too much alcohol is a myth. In fact, using caf-\\nfeine and alcohol together is not a good idea. The combi-\\nnation can lead to an upset stomach, nausea, and vomiting.\\nOlder people may be more sensitive to caffeine and\\nthus more likely to have certain side effects, such as irri-\\ntability, nervousness, anxiety, and sleep problems.\\nC\\nGALE ENCYCLOPEDIA OF MEDICINE 2 625\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 625'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 14, 'page_label': '15'}, page_content='Special conditions\\nCaffeine may cause problems for people with certain\\nmedical conditions or who are taking certain medicines.\\nALLERGIES. Anyone with allergies to foods, dyes,\\npreservatives, or to the compounds aminophylline,\\ndyphylline, oxtriphylline, theobromine, or theophylline\\nshould check with a physician before using caffeine.\\nAnyone who has ever had an unusual reaction to caffeine\\nshould also check with a physician before using it again.\\nPREGNANCY. Caffeine can pass from a pregnant\\nwoman’s body into the developing fetus. Although there\\nis no evidence that caffeine causes birth defects in peo-\\nple, it does cause such effects in laboratory animals given\\nvery large doses (equal to human doses of 12–24 cups of\\ncoffee a day). In humans, evidence exists that doses of\\nmore than 300 mg of caffeine a day (about the amount of\\ncaffeine in 2–3 cups of coffee) may cause miscarriage or\\nproblems with the baby’s heart rhythm. Women who take\\nmore than 300 mg of caffeine a day during pregnancy\\nare also more likely to have babies with low birth\\nweights. Any woman who is pregnant or planning to\\nbecome pregnant should check with her physician before\\nusing caffeine.\\nBREASTFEEDING. Caffeine passes into breast milk\\nand can affect the nursing baby. Nursing babies whose\\nmothers use 600 mg or more of caffeine a day may be\\nirritable and have trouble sleeping. Women who are\\nbreastfeeding should check with their physicians before\\nusing caffeine.\\nOTHER MEDICAL CONDITIONS. Caffeine may cause\\nproblems for people with these medical conditions:\\n• peptic ulcer\\n• heart arrhythmias or palpitations\\nKEY TERMS\\nArrhythmia—Abnormal heart rhythm.\\nCentral nervous system —The brain, spinal cord\\nand nerves throughout the body.\\nFetus—A developing baby inside the womb.\\nPalpitation—Rapid, forceful, throbbing, or flutter-\\ning heartbeat.\\nWithdrawal symptoms —A group of physical or\\nmental symptoms that may occur when a person\\nsuddenly stops using a drug to which he or she has\\nbecome dependent.\\n• heart disease or recent heart attack (within a few\\nweeks)\\n• high blood pressure\\n• liver disease\\n• insomnia (trouble sleeping)\\n• anxiety or panic attacks\\n• agoraphobia (fear of being in open places)\\n• premenstrual syndrome (PMS)\\nUSE OF CERTAIN MEDICINES. Using caffeine with\\ncertain other drugs may interfere with the effects of the\\ndrugs or cause unwanted—and possibly serious—side\\neffects.\\nSide effects\\nAt recommended doses, caffeine can cause restless-\\nness, irritability, nervousness, shakiness,headache, light-\\nheadedness, sleeplessness, nausea, vomiting, and upset\\nstomach. At higher than recommended doses, caffeine can\\ncause excitement, agitation, anxiety, confusion, a sensa-\\ntion of light flashing before the eyes, unusual sensitivity to\\ntouch, unusual sensitivity of other senses, ringing in the\\nears, frequent urination, muscle twitches or tremors, heart\\narrhythmias, rapid heartbeat, flushing, and convulsions.\\nInteractions\\nCertain drugs interfere with the breakdown of caf-\\nfeine in the body. These include oral contraceptives that\\ncontain estrogen, the antiarrhythmia drug mexiletine\\n(Mexitil), the ulcer drug cimetidine (Tagamet), and the\\ndrug disulfiram (Antabuse), used to treat alcoholism.\\nCaffeine interferes with drugs that regulate heart\\nrhythm, such as quinidine and propranolol (Inderal). Caf-\\nfeine may also interfere with the body’s absorption of iron.\\nAnyone who takes iron supplements should take them at\\nleast an hour before or two hours after using caffeine.\\nSerious side effects are possible when caffeine is\\ncombined with certain drugs. For example, taking caf-\\nfeine with the decongestant phenylpropanolamine can\\nraise blood pressure. And very serious heart problems\\nmay occur if caffeine and monoamine oxidase\\ninhibitors (MAO) are taken together. These drugs are\\nused to treat Parkinson’s disease, depression, and other\\npsychiatric conditions. Consult with a pharmacist or\\nphysician about which drugs can interact with caffeine.\\nBecause caffeine stimulates the nervous system,\\nanyone taking other central nervous system (CNS) stim-\\nulants should be careful about using caffeine.\\nNancy Ross-Flanigan\\nGALE ENCYCLOPEDIA OF MEDICINE 2626\\nCaffeine\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 626'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 15, 'page_label': '16'}, page_content='CAH see Congenital adrenal hyperplasia\\nCaisson disease see Decompression\\nsickness\\nCalcaneal spurs see Heel spurs\\nCalcitonin see Bone disorder drugs\\nCalcium carbonate see Antacids\\nCalcium channel blockers\\nDefinition\\nCalcium channel blockers are medicines that slow\\nthe movement of calcium into the cells of the heart and\\nblood vessels. This, in turn, relaxes blood vessels,\\nincreases the supply of oxygen-rich blood to the heart,\\nand reduces the heart’s workload.\\nPurpose\\nCalcium channel blockers are used to treat high\\nblood pressure, to correct abnormal heart rhythms, and to\\nrelieve the type of chest pain called angina pectoris.\\nPhysicians also prescribe calcium channel blockers to\\ntreat panic attacks and bipolar disorder (manic depres-\\nsive illness) and to prevent migraine headache.\\nPrecautions\\nSeeing a physician regularly while taking calcium\\nchannel blockers is important. The physician will check\\nto make certain the medicine is working as it should and\\nwill watch for unwanted side effects. People who have\\nhigh blood pressure often feel perfectly fine. However,\\nthey should continue to see their prescribing physician\\neven when they feel well so that he can keep a close\\nwatch on their condition. They should also continue to\\ntake their medicine even when they feel fine.\\nCalcium channel blockers will not cure high blood\\npressure, but will help to control the condition. To avoid\\nthe serious health problems associated with high blood\\npressure, patients may have to take this type of medica-\\ntion for the rest of their lives. Furthermore, the blockers\\nalone may not be enough. People with high blood pres-\\nsure may also need to avoid certain foods and keep their\\nweight under control. The health care professional who\\nis treating the condition can offer advice as to what mea-\\nsures may be necessary. Patients being treated for high\\nblood pressure should not change their diets without\\nconsulting their physicians.\\nAnyone taking calcium channel blockers for high\\nblood pressure should not take any other prescription or\\nover-the-counter medication without first checking with\\nthe prescribing physician, as some of these drugs may\\nincrease blood pressure.\\nSome people feel drowsy or less alert than usual\\nwhen taking calcium channel blockers. Anyone who\\ntakes these drugs should not drive, use machines, or do\\nanything else that might be dangerous until they have\\nfound out how the drugs affect them.\\nPeople who normally have chest pain when they\\nexercise or exert themselves may not have the pain when\\nthey are taking calcium channel blockers. This could lead\\nthem to be more active than they should be. Anyone tak-\\ning calcium channel blockers should therefore consult\\nwith the prescribing physician concerning how much\\nexercise and activity may be considered safe.\\nSome people get headaches that last for a short time\\nafter taking a dose of this medication. This problem usu-\\nally goes away during the course of treatment. If it does\\nnot, or if the headaches are severe, the prescribing physi-\\ncian should be informed.\\nPatients taking certain calcium channel blockers\\nmay need to check their pulse regularly, as the drugs may\\nslow the pulse too much. If the pulse is too slow, circula-\\ntion problems may result. The prescribing physician can\\nshow patients the correct way to check their pulse.\\nThis type of medication may cause the gums to\\nswell, bleed, or become tender. If this problem occurs, a\\nmedical physician or dentist should be consulted. To help\\nprevent the problem, care should be taken when brushing\\nand flossing the teeth. Regular dental check-ups and\\ncleanings are also recommended.\\nOlder people may be unusually sensitive to the\\neffects of calcium channel blockers. This may increase\\nthe chance of side effects.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines may develop problems if\\nthey also take calcium channel blockers. Before taking\\nthese drugs, the prescribing physician should be\\ninformed about any of these conditions:\\nALLERGIES. Anyone who has had a previous unusual\\nreaction to any calcium channel blocker should let his or\\nher physician know before taking the drugs again. The\\nphysician should also be notified about any allergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. The effects of taking calcium channel\\nblockers during pregnancy have not been studied in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 627\\nCalcium channel blockers\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 627'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 16, 'page_label': '17'}, page_content='humans. However, in studies of laboratory animals, large\\ndoses of these drugs have been reported to cause birth\\ndefects, stillbirth, poor bone growth, and other problems\\nwhen taken during pregnancy. Women who are pregnant\\nor who may become pregnant should check with their\\nphysicians before using these drugs.\\nBREASTFEEDING. Some calcium channel blockers\\npass into breast milk, but there have been no reports of\\nproblems in nursing babies whose mothers were taking\\nthis type of medication. However, women who need to\\ntake this medicine and want to breastfeed their babies\\nshould check with their physicians.\\nOTHER MEDICAL CONDITIONS. Calcium channel\\nblockers may worsen heart or blood vessel disorders.\\nThe effects of calcium channel blockers may be\\ngreater in people with kidney or liver disease, as their\\nbodies are slower to clear the drug from their systems.\\nCertain calcium channel blockers may also cause\\nproblems in people with a history of heart rhythm prob-\\nlems or with depression, Parkinson’s disease , or other\\ntypes of parkinsonism.\\nUSE OF CERTAIN MEDICINES. Taking calcium chan-\\nnel blockers with certain other drugs may affect the way\\nthe drugs work or may increase the chance of side effects.\\nAs with most medications, certain side effects are\\npossible and some interactions with other substances\\nmay occur.\\nSide effects\\nSide effects are not common with this medicine, but\\nsome may occur. Minor discomforts, such as dizziness ,\\nlightheadedness, flushing, headache, and nausea, usual-\\nKEY TERMS\\nAngina pectoris —A feeling of tightness, heavi-\\nness, or pain in the chest, caused by a lack of oxy-\\ngen in the muscular wall of the heart.\\nBipolar disorder —A severe mental illness, also\\nknown as manic depression, in which a person\\nhas extreme mood swings, ranging from a highly\\nexcited state—sometimes with a false sense of\\nwell-being—to depression.\\nMigraine —A throbbing headache that usually\\naffects only one side of the head. Nausea, vomit-\\ning, increased sensitivity to light, and other symp-\\ntoms often accompany migraine.\\nly go away as the body adjusts to the drug and do not\\nrequire medical treatment unless they persist or they are\\nbothersome.\\nIf any of the following side effects occur, the pre-\\nscribing physician should be notified as soon as possible:\\n• breathing problems, coughing or wheezing\\n• irregular, fast, or pounding heartbeat\\n• slow heartbeat (less than 50 beats per minute)\\n• skin rash\\n• swollen ankles, feet, or lower legs\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking calcium blockers should\\ncontact the prescribing physician.\\nInteractions\\nCalcium channel blockers may interact with a num-\\nber of other medications. When this happens, the effects\\nof one or both of the drugs may change or the risk of side\\neffects may increase. Anyone who takes calcium channel\\nblockers should not take any other prescription or non-\\nprescription (over-the-counter) medicines without first\\nchecking with the prescribing physician. Substances that\\nmay interact with calcium channel blockers include:\\n• Diuretics (water pills). This type of medicine may\\ncause low levels of potassium in the body, which may\\nincrease the chance of unwanted effects from some cal-\\ncium channel blockers.\\n• Beta-blockers, such as atenolol (Tenormin), propra-\\nnolol (Inderal), and metoprolol (Lopressor), used to\\ntreat high blood pressure, angina, and other conditions.\\nAlso, eye drop forms of beta blockers, such as timolol\\n(Timoptic), used to treat glaucoma. Taking any of these\\ndrugs with calcium channel blockers may increase the\\neffects of both types of medicine and may cause prob-\\nlems if either drug is stopped suddenly.\\n• Digitalis heart medicines. Taking these medicines with\\ncalcium channel blockers may increase the action of the\\nheart medication.\\n• Medicines used to correct irregular heart rhythms, such as\\nquinidine (Quinidex), disopyramide (Norpace), and pro-\\ncainamide (Procan, Pronestyl). The effects of these drugs\\nmay increase if used with calcium channel blockers.\\n• Anti-seizure medications such as carbamazepine (Tegre-\\ntol). Calcium channel drugs may increase the effects of\\nthese medicines.\\n• Cyclosporine (Sandimmune), a medicine that suppress-\\nes the immune system. Effects may increase if this drug\\nis taken with calcium channel blockers.\\n• Grapefruit juice may increase the effects of some calci-\\num channel blockers.\\nGALE ENCYCLOPEDIA OF MEDICINE 2628\\nCalcium channel blockers\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 628'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 17, 'page_label': '18'}, page_content='The above list does not include every drug that may\\ninteract with calcium channel blockers. The prescribing\\nphysician or pharmacist will advise as to whether com-\\nbining calcium channel blockers with any other prescrip-\\ntion or nonprescription (over-the-counter) medication is\\nappropriate or not.\\nDescription\\nCalcium channel blockers are available only with a\\nphysician’s prescription and are sold in tablet, capsule,\\nand injectable forms. Some commonly used calcium\\nchannel blockers include amlopidine (Norvasc), dilti-\\nazem (Cardizem), isradipine (DynaCirc), nifedipine\\n(Adalat, Procardia), nicardipine (Cardene), and vera-\\npamil (Calan, Isoptin, Verelan).\\nThe recommended dosage depends on the type,\\nstrength, and form of calcium channel blocker and the\\ncondition for which it is prescribed. Correct dosage is\\ndetermined by the prescribing physician and further\\ninformation can be obtained from the pharmacist.\\nCalcium channel blockers should be taken as direct-\\ned. Larger or more frequent doses should not be taken,\\nnor should doses be missed. This medicine may take sev-\\neral weeks to noticeably lower blood pressure. The\\npatient taking calcium channel blockers should keep tak-\\ning the medicine, to give it time to work. Once it begins\\nto work and symptoms improve, it should continue to be\\ntaken as prescribed.\\nThis medicine should not be discontinued without\\nchecking with the prescribing physician. Some condi-\\ntions may worsen when patients stop taking calcium\\nchannel blockers abruptly. The prescribing physician will\\nadvise as to how to gradually taper down before stopping\\nthe medication completely.\\nRisks\\nA report from the European Cardiology Society in\\n2000 found that patients taking certain calcium chan-\\nnel blockers had a 27% greater risk of heart attack ,\\nand a 26% greater risk of heart failure than patients\\ntaking other high blood pressure medicines. However,\\nthere are many patients affected by conditions that still\\nmake calcium channel blockers the best choice for\\nthem. The patient should discuss this issue with the\\nprescribing physician.\\nNormal results\\nThe expected result of taking a calcium channel\\nblocker is to either correct abnormal heart rhythms,\\nreturn blood pressure to normal, or relieve chest pain.\\nResources\\nBOOKS\\nBeers, Mark H. and Robert Berkow, eds. The Merck Manual of\\nDiagnosis and Therapy. 17th ed. Whitehouse Station, NJ:\\nMerck and Company, Inc., 1999.\\nPERIODICALS\\nZoler, Mitchel L.“Drug Update: Calcium Channel Blockers For\\nHypertension.” Family Practice News(April 1, 2000): 53.\\n“The Pressure’s On: A Hypertension Drug Taken by 28 Million\\nPeople is Under Scrutiny. What Are the Other Options?\\n(Calcium Channel Blockers).”Time (September 11,\\n2000): 126.\\nORGANIZATION\\nNational Heart, Lung and Blood Institute. .\\nDeanna M. Swartout-Corbeil, R.N.\\nCalcium imbalance see Hypercalcemia;\\nHypocalcemia\\nCalcium polycarbophil see Laxatives\\nCalifornia flower essences see Flower\\nremedies\\nCalluses see Corns and calluses\\nCalorie-modified diet see Diets\\nCalymmatobacteriosis see Granuloma\\ninguinale\\nCampylobacter jejuni infection see\\nCampylobacteriosis\\nCampylobacteriosis\\nDefinition\\nCampylobacteriosis refers to infection by the group\\nof bacteria known as Campylobacter . The term comes\\nfrom the Greek word meaning “curved rod” referring to\\nthe bacteria’s curved shape. The most common disease\\ncaused by these organisms is diarrhea, which most often\\naffects children and younger adults. Campylobacter\\ninfections account for a substantial percent of food-borne\\nillness encountered each year.\\nDescription\\nThere are over 15 different subtypes, all of which are\\ncurved Gram-negative rods. C. jeuni is the subtype that\\nGALE ENCYCLOPEDIA OF MEDICINE 2 629\\nCampylobacteriosis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 629'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 18, 'page_label': '19'}, page_content='most often causes gastrointestinal disease. However, some\\nspecies such as C. fetus produce disease outside the intes-\\ntine, particularly in those with altered immune systems,\\nsuch as people with AIDS, cancer, and liver disease.\\nCampylobacter are often found in the intestine of\\nanimals raised for food produce and pets. Infected ani-\\nmals often have no symptoms. Chickens are the most\\ncommon source of human infection. It is estimated that\\n1% of the general population is infected each year.\\nCauses and symptoms\\nImproper or incomplete food preparation is the most\\ncommon way the disease is spread, with poultry account-\\ning for over half the cases. Untreated water and raw milk\\nare also potential sources.\\nThe incubation period after exposure is from one to\\n10 days. A day or two of mild fever, muscle aches, and\\nheadache occur before intestinal symptoms begin. Diar-\\nrhea with or without blood and severe abdominal cramps\\nare the major intestinal symptoms. The severity of symp-\\ntoms is variable, ranging from only mild fever to dehy-\\ndration and rarely death (mainly in the very young or\\nold). The disease usually lasts about one week, but per-\\nKEY TERMS\\nAntibiotic—A medication that is designed to kill or\\nweaken bacteria.\\nAnti-motility medications —Medications such as\\nloperamide (Imodium), dephenoxylate (Lomotil), or\\nmedications containing codeine or narcotics which\\ndecrease the ability of the intestine to contract. This\\ncan worsen the condition of a patient with dysen-\\ntery or colitis.\\nFluoroquinolones —A relatively new group of anti-\\nbiotics that have had good success in treating infec-\\ntions with many Gram-negative bacteria. One\\ndrawback is that they should not be used in child-\\nren under 17 years of age, because of possible\\neffect on bone growth.\\nFood-borne illness—A disease that is transmitted by\\neating or handling contaminated food.\\nGram-negative —Refers to the property of many\\nbacteria that causes them to not take up color with\\nGram’s stain, a method which is used to identify\\nbacteria. Gram-positive bacteria which take up the\\nstain turn purple, while Gram-negative bacteria\\nwhich do not take up the stain turn red.\\nGuillain-Barré syndrome —Progressive and usually\\nreversible paralysis or weakness of multiple muscles\\nusually starting in the lower extremities and often\\nascending to the muscles involved in respiration.\\nThe syndrome is due to inflammation and loss of\\nthe myelin covering of the nerve fibers, often asso-\\nciated with an acute infection.\\nMeninges —Outer covering of the spinal cord and\\nbrain. Infection is called meningitis, which can lead\\nto damage to the brain or spinal cord and even\\ndeath.\\nOral Rehydration Solution (ORS) —A liquid prepa-\\nration developed by the World Health Organization\\nthat can decrease fluid loss in persons with diar-\\nrhea. Originally developed to be prepared with\\nmaterials available in the home, commercial prepa-\\nrations have recently come into use.\\nStool—Passage of fecal material; a bowel move-\\nment.\\nsists longer in about 20% of cases. At least 10% will have\\na relapse, and some patients will continue to pass the\\nbacteria for several weeks.\\nComplications\\nDehydration is the most common complication.\\nEspecially at the extremes of age, this should be watched\\nfor and treated with either Oral Rehydration Solution or\\nintravenous fluid replacement.\\nInfection may also involve areas outside the intes-\\ntine. This is unusual, except for infections with C. fetus.\\nC. fetus infections tend to occur in those who have dis-\\neases of decreased immunity such as AIDS, cancer, etc.\\nThis subtype is particularly adapted to protect itself from\\nthe body’s defenses.\\nAreas outside the intestine that may be involved are:\\n• Nervous system involvement either by direct infection\\nof the meninges (outer covering of the spinal and brain)\\nor more commonly by producing the Guillain-Barré\\nsyndrome (progressive and reversible paralysis or\\nweakness of many muscles). In fact, Campylobacter\\nmay be responsible for 40% of the reported cases of\\nthis syndrome.\\nGALE ENCYCLOPEDIA OF MEDICINE 2630\\nCampylobacteriosis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 630'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 19, 'page_label': '20'}, page_content='• Joint inflammation can occur weeks later (leading to an\\nunusual form of arthritis).\\n• Infection of vessels and heart valves is a special charac-\\nteristic of C. fetus. Immunocompromised patients may\\ndevelop repeated episodes of passage of bacteria into\\nthe bloodstream from these sites of infection.\\n• The gallbladder, pancreas, and bone may be affected.\\nDiagnosis\\nCampylobacter is only one of many causes of acute\\ndiarrhea. Culture (growing the bacteria in the laboratory)\\nof freshly obtained diarrhea fluid is the only way to be\\ncertain of the diagnosis.\\nTreatment\\nThe first aim of treatment is to keep up nutrition\\nand avoid dehydration. Medications used to treat diar-\\nrhea by decreasing intestinal motility, such as Lop-\\neramide or Diphenoxylate are also useful, but should\\nonly be used with the advice of a physician. Antibiotics\\nare of value, if started within three days of onset of\\nsymptoms. They are indicated for those with severe or\\npersistent symptoms. Either an erythromycin type drug\\nor one of the fluoroquinolones (such as ciprofloxacin)\\nfor five to seven days are the accepted therapies.\\nPrognosis\\nMost patients with Campylobacter infection rapidly\\nrecover without treatment. For certain groups of patients,\\ninfection becomes chronic and requires repeated courses\\nof antibiotics.\\nPrevention\\nGood hand washing technique as well as proper\\npreparation and cooking of food is the best way to pre-\\nvent infection.\\nResources\\nBOOKS\\nBlaser, Martin J. “Infections due to Campylobacter and Related\\nSpecies.” In Harrison’s Principles of Internal Medicine,\\ned. Anthony S. Fauci, et al. New York: McGraw-Hill,\\n1997.\\nHamer, Davidson H., and Sherwood L. Gorbach. “Campy-\\nlobacter.” In Sleisenger & Fordtran’s Gastrointestinal and\\nLiver Disease, ed. Mark Feldman, et al. Philadelphia: W.\\nB. Saunders Co., 1997.\\nThielman, Nathan M., and Richard L. Guerrant. “Food-Borne\\nIllness.” In Conn’s Current Therapy, 1996, ed. Robert E.\\nRakel. Philadelphia: W. B. Saunders Co., 1996.\\nWolfe, Martin S. “Acute Infectious Diarrhea.” In Conn’s Cur-\\nrent Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W.\\nB. Saunders Co., 1996.\\nPERIODICALS\\nLew, Edward A., Michael A. Poles, and Douglas T. Dieterich.\\n“Diarrheal Disease Associated with HIV Infection.”Gas-\\ntroenterology Clinics of North America(June 1997): 259-\\n290.\\n“Traveler’s Diarrhea: Don’t Let It Ruin Your Trip.”Mayo Clin-\\nic Health Letter (Jan. 1997).\\n“When Microbes are on the Menu.”Harvard Health Letter\\n(Dec. 1994) : 4-5.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nOTHER\\nCenters for Disease Control. .\\nDavid Kaminstein, MD\\nCancer\\nDefinition\\nCancer is not just one disease, but a large group of\\nalmost one hundred diseases. Its two main characteristics\\nare uncontrolled growth of the cells in the human body\\nand the ability of these cells to migrate from the original\\nsite and spread to distant sites. If the spread is not con-\\ntrolled, cancer can result in death.\\nDescription\\nOne out of every four deaths in the United States is\\nfrom cancer. It is second only to heart disease as a cause\\nof death in the states. About 1.2 million Americans are\\ndiagnosed with cancer annually; more than 500,000 die\\nof cancer annually.\\nCancer can attack anyone. Since the occurrence of\\ncancer increases as individuals age, most of the cases are\\nseen in adults, middle-aged or older. Sixty percent of all\\ncancers are diagnosed in people who are older than 65\\nyears of age. The most common cancers are skin cancer,\\nlung cancer, colon cancer , breast cancer (in women),\\nand prostate cancer (in men). In addition, cancer of the\\nkidneys, ovaries, uterus, pancreas, bladder, rectum, and\\nblood and lymph node cancer (leukemias and lym-\\nphomas) are also included among the 12 major cancers\\nthat affect most Americans.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 631\\nCancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 631'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 20, 'page_label': '21'}, page_content='Cancer, by definition, is a disease of the genes. A\\ngene is a small part of DNA, which is the master mole-\\ncule of the cell. Genes make “proteins,” which are the\\nultimate workhorses of the cells. It is these proteins that\\nallow our bodies to carry out all the many processes that\\npermit us to breathe, think, move, etc.\\nThroughout people’s lives, the cells in their bodies\\nare growing, dividing, and replacing themselves. Many\\ngenes produce proteins that are involved in controlling\\nthe processes of cell growth and division. An alteration\\n(mutation) to the DNA molecule can disrupt the genes\\nand produce faulty proteins. This causes the cell to\\nbecome abnormal and lose its restraints on growth. The\\nabnormal cell begins to divide uncontrollably and even-\\ntually forms a new growth known as a “tumor” or neo-\\nplasm (medical term for cancer meaning “new growth”).\\nIn a healthy individual, the immune system can rec-\\nognize the neoplastic cells and destroy them before they\\nget a chance to divide. However, some mutant cells may\\nescape immune detection and survive to become tumors\\nor cancers.\\nTumors are of two types, benign or malignant. A\\nbenign tumor is not considered cancer. It is slow growing,\\ndoes not spread or invade surrounding tissue, and once it\\nis removed, it doesn’t usually recur. A malignant tumor,\\non the other hand, is cancer. It invades surrounding tissue\\nand spreads to other parts of the body. If the cancer cells\\nhave spread to the surrounding tissues, then, even after\\nthe malignant tumor is removed, it generally recurs.\\nA majority of cancers are caused by changes in the\\ncell’s DNA because of damage due to the environment.\\nEnvironmental factors that are responsible for causing\\nthe initial mutation in the DNA are called carcinogens,\\nand there are many types.\\nThere are some cancers that have a genetic basis. In\\nother words, an individual could inherit faulty DNA from\\nhis parents, which could predispose him to getting cancer.\\nWhile there is scientific evidence that both factors (envi-\\nronmental and genetic) play a role, less than 10% of all\\ncancers are purely hereditary. Cancers that are known to\\nhave a hereditary link are breast cancer, colon cancer,\\novarian cancer, and uterine cancer. Besides genes, cer-\\ntain physiological traits could be inherited and could con-\\ntribute to cancers. For example, inheriting fair skin makes\\na person more likely to develop skin cancer, but only if\\nthey also have prolonged exposure to intensive sunlight.\\nThere are several different types of cancers:\\n• Carcinomas are cancers that arise in the epithelium (the\\nlayers of cells covering the body’s surface and lining the\\ninternal organs and various glands). Ninety percent of\\nhuman cancers fall into this category. Carcinomas can be\\nsubdivided into two types: adenocarcinomas and squa-\\nmous cell carcinomas. Adenocarcinomas are cancers that\\ndevelop in an organ or a gland, while squamous cell car-\\ncinomas refer to cancers that originate in the skin.\\n• Melanomas also originate in the skin, usually in the\\npigment cells (melanocytes).\\n• Sarcomas are cancers of the supporting tissues of the\\nbody, such as bone, muscle and blood vessels.\\n• Cancers of the blood and lymph glands are called\\nleukemias and lymphomas respectively.\\n• Gliomas are cancers of the nerve tissue.\\nCauses and symptoms\\nThe major risk factors for cancer are: tobacco, alco-\\nhol, diet, sexual and reproductive behavior, infectious\\nagents, family history, occupation, environment and pol-\\nlution.\\nAccording to the estimates of the American Cancer\\nSociety (ACS), approximately 40% of the cancer deaths\\nin 1998 will be due to tobacco and excessive alcohol use.\\nAn additional one-third of the deaths will be related to\\ndiet and nutrition. Many of the one million skin cancers\\nthat are expected to be diagnosed in 1998 will be due to\\nover-exposure to ultraviolet light from the sun’s rays.\\nTobacco\\nEighty to ninety percent of the lung cancer cases\\noccur in smokers. Smoking has also been shown to be a\\ncontributory factor in cancers of upper respiratory tract,\\nesophagus, larynx, bladder, pancreas, and probably liver,\\nstomach, and kidney as well. Recently, scientists have\\nalso shown that second-hand smoke (or passive smoking)\\ncan increase one’s risk of developing cancer.\\nAlcohol\\nExcessive consumption of alcohol is a risk factor in\\ncertain cancers, such as liver cancer. Alcohol, in combi-\\nnation with tobacco, significantly increases the chances\\nthat an individual will develop mouth, pharynx, larynx\\nand esophageal cancers.\\nDiet\\nThirty-five percent of all cancers are due to dietary\\ncauses. Excessive intake of fat leading to obesity has\\nbeen associated with cancers of the breast, colon, rectum,\\npancreas, prostate, gall bladder, ovaries and uterus.\\nSexual and reproductive behavior\\nThe human papilloma virus, which is sexually trans-\\nmitted, has been shown to cause cancer of the cervix.\\nGALE ENCYCLOPEDIA OF MEDICINE 2632\\nCancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 632'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 21, 'page_label': '22'}, page_content='Having too many sex partners and becoming sexually\\nactive early has been shown to increase one’s chances of\\ncontracting this disease. In addition, it has also been\\nshown that women who don’t have children or have chil-\\ndren late in life have an increased risk for both ovarian\\nand breast cancer.\\nInfectious agents\\nIn the last 20 years, scientists have obtained evidence\\nto show that approximately 15% of the world’s cancer\\ndeaths can be traced to viruses, bacteria, or parasites. The\\nmost common cancer-causing pathogens and the cancers\\nassociated with them are shown in table form.\\nFamily history\\nCertain cancers like breast, colon, ovarian and uter-\\nine cancer recur generation after generation in some fami-\\nlies. A few cancers, such as the eye cancer “retinoblas-\\ntoma,” a type of colon cancer, and a type of breast cancer\\nknown as “early-onset breast cancer,” have been shown to\\nbe linked to certain genes that can be tracked within a\\nfamily. It is therefore possible that inheriting particular\\ngenes makes a person susceptible to certain cancers.\\nOccupational hazards\\nThere is evidence to prove that certain occupational\\nhazards account for 4% of all cancer deaths. For exam-\\nple, asbestos workers have an increased incidence of\\nlung cancer. Similarly, a higher likelihood of getting\\nbladder cancer is associated with dye, rubber and gas\\nworkers; skin and lung cancer with smelters, gold miners\\nand arsenic workers; leukemia with glue and varnish\\nworkers; liver cancer with PVC manufacturers; and lung,\\nbone and bone marrow cancer with radiologists and ura-\\nnium miners.\\nEnvironment\\nRadiation is believed to cause 1–2% of all cancer\\ndeaths. Ultra-violet radiation from the sun accounts for a\\nmajority of melanoma deaths. Other sources of radiation\\nare x rays, radon gas, and ionizing radiation from nuclear\\nmaterial.\\nPollution\\nSeveral studies have shown that there is a well-\\nestablished link between asbestos and cancer. Chlorina-\\ntion of water may account for a small rise in cancer risk.\\nHowever, the main danger from pollution occurs when\\ndangerous chemicals from the industries escape into the\\nsurrounding environment. It has been estimated that 1%\\nof cancer deaths are due to air, land and water pollution.\\nCancer is a progressive disease, and goes through sev-\\neral stages. Each stage may produce a number of symp-\\ntoms. Some symptoms are produced early and may occur\\ndue to a tumor that is growing within an organ or a gland.\\nAs the tumor grows, it may press on the nearby nerves,\\norgans and blood vessels. This causes pain and some pres-\\nsure which may be the earliest warning signs of cancer.\\nDespite the fact that there are several hundred differ-\\nent types of cancers, producing very different symptoms,\\nthe ACS has established the following seven symptoms\\nas possible warning signals of cancer:\\n• changes in the size, color, or shape of a wart or a mole\\n• a sore that does not heal\\n• persistent cough, hoarseness, or sore throat\\n• a lump or thickening in the breast or elsewhere\\n• unusual bleeding or discharge\\n• chronic indigestion or difficulty in swallowing\\n• any change in bowel or bladder habits\\nMany other diseases, besides cancer, could produce\\nthe same symptoms. However, it is important to have\\nthese symptoms checked, as soon as possible, especially\\nif they linger. The earlier a cancer is diagnosed and treat-\\ned, the better the chance of it being cured. Many cancers\\nsuch as breast cancer may not have any early symptoms.\\nTherefore, it is important to undergo routine screening\\ntests such as breast self-exams and mammograms.\\nDiagnosis\\nDiagnosis begins with a thorough physical examina-\\ntion and a complete medical history. The doctor will\\nobserve, feel and palpate (apply pressure by touch) differ-\\nent parts of the body in order to identify any variations\\nfrom the normal size, feel and texture of the organ or tissue.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 633\\nCancer\\nFrequency Of Cancer-Related Death\\nCancer Site Number of Deaths Per Year\\nLung 160,100\\nColon and rectum 56,500\\nBreast 43,900\\nProstate 39,200\\nPancreas 28,900\\nLymphoma 26,300\\nLeukemia 21,600\\nBrain 17,400\\nStomach 13,700\\nLiver 13,000\\nEsophagus 11,900\\nBladder 12,500\\nKidney 11,600\\nMultiple myeloma 11,300\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 633'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 22, 'page_label': '23'}, page_content='As part of the physical exam, the doctor will inspect\\nthe oral cavity or the mouth. By focusing a light into the\\nmouth, he will look for abnormalities in color, moisture,\\nsurface texture, or presence of any thickening or sore in the\\nlips, tongue, gums, the hard palate on the roof of the mouth,\\nand the throat. To detect thyroid cancer, the doctor will\\nobserve the front of the neck for swelling. He may gently\\nmanipulate the neck and palpate the front and side surfaces\\nof the thyroid gland (located at the base of the neck) to\\ndetect any nodules or tenderness. As part of the physical\\nexamination, the doctor will also palpate the lymph nodes\\nin the neck, under the arms and in the groin. Many illnesses\\nand cancers cause a swelling of the lymph nodes.\\nThe doctor may conduct a thorough examination of\\nthe skin to look for sores that have been present for more\\nthan three weeks and that bleed, ooze, or crust; irritated\\npatches that may itch or hurt, and any change in the size\\nof a wart or a mole.\\nExamination of the female pelvis is used to detect\\ncancers of the ovaries, uterus, cervix, and vagina. In the\\nvisual examination, the doctor looks for abnormal dis-\\ncharges or the presence of sores. Then, using gloved\\nhands the physician palpates the internal pelvic organs\\nsuch as the uterus and ovaries to detect any abnormal\\nmasses. Breast examination includes visual observation\\nwhere the doctor looks for any discharge, unevenness,\\ndiscoloration, or scaling. The doctor palpates both\\nbreasts to feel for masses or lumps.\\nFor males, inspection of the rectum and the prostate\\nis also included in the physical examination. The doctor\\ninserts a gloved finger into the rectum and rotates it slow-\\nly to feel for any growths, tumors, or other abnormalities.\\nThe doctor also conducts an examination of the testes,\\nwhere the doctor observes the genital area and looks for\\nswelling or other abnormalities. The testicles are palpat-\\ned to identify any lumps, thickening or differences in the\\nsize, weight and firmness.\\nIf the doctor detects an abnormality on physical exam-\\nination, or the patient has some symptom that could be\\nindicative of cancer, the doctor may order diagnostic tests.\\nLaboratory studies of sputum (sputum cytology),\\nblood, urine, and stool can detect abnormalities that may\\nindicate cancer. Sputum cytology is a test where the\\nphlegm that is coughed up from the lungs is microscopi-\\ncally examined. It is often used to detect lung cancer. A\\nblood test for cancer is easy to perform, usually inexpen-\\nsive and risk-free. The blood sample is obtained by a lab\\ntechnician or a doctor by inserting a needle into a vein\\nand is relatively painless. Blood tests can be either spe-\\ncific or non-specific. Often times, in certain cancers, the\\ncancer cells release particular proteins (called tumor\\nmarkers) and blood tests can be used to detect the pres-\\nence of these tumor markers. However, with a few excep-\\ntions, tumor markers are not used for routine screening\\nof cancers, because several non-cancerous conditions\\nalso produce positive results. Blood tests are generally\\nmore useful in monitoring the effectiveness of the treat-\\nment, or in following the course of the disease and\\ndetecting recurrent disease.\\nImaging tests such as computed tomography scans\\n(CT scans), magnetic resonance imaging (MRI), ultra-\\nsound and fiberoptic scope examinations help the doctors\\ndetermine the location of the tumor even if it is deep\\nwithin the body. Conventional x rays are often used for\\ninitial evaluation, because they are relatively cheap, pain-\\nless and easily accessible. In order to increase the infor-\\nmation obtained from a conventional x ray, air or a dye\\n(such as barium or iodine) may be used as a contrast\\nmedium to outline or highlight parts of the body.\\nThe most definitive diagnostic test is the biopsy,\\nwherein a piece of tissue is surgically removed for micro-\\nscope examination. Besides confirming a cancer, the\\nbiopsy also provides information about the type of can-\\ncer, the stage it has reached, the aggressiveness of the\\ncancer and the extent of its spread. Since a biopsy pro-\\nvides the most accurate analysis, it is considered the gold\\nstandard of diagnostic tests.\\nScreening examinations conducted regularly by\\nhealthcare professionals can result in the detection of can-\\ncers of the breast, colon, rectum, cervix, prostate, testis,\\ntongue, mouth, and skin at early stages, when treatment is\\nmore likely to be successful. Some of the routine screen-\\ning tests recommended by the ACS are sigmoidoscopy\\n(for colorectal cancer), mammography (for breast can-\\ncer), pap smear (for cervical cancer ), and the PSA test\\n(for prostate cancer). Self-examinations for cancers of the\\nbreast, testes, mouth, and skin can also help in detecting\\nthe tumors before the symptoms become serious.\\nA recent revolution in molecular biology and cancer\\ngenetics has contributed a great deal to the development\\nof several tests designed to assess one’s risk of getting\\ncancers. These new techniques include genetic testing ,\\nwhere molecular probes are used to identify mutations in\\ncertain genes that have been linked to particular cancers.\\nAt present, however, there are a lot of limitations to genet-\\nic testing and its utility appears ambiguous, emphasizing\\nthe need to develop better strategies for early detection.\\nTreatment\\nThe aim of cancer treatment is to remove all or as\\nmuch of the tumor as possible and to prevent the recur-\\nrence or spread of the primary tumor. While devising a\\ntreatment plan for cancer, the likelihood of curing the\\nGALE ENCYCLOPEDIA OF MEDICINE 2634\\nCancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 634'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 23, 'page_label': '24'}, page_content='cancer has to be weighed against the side effects of the\\ntreatment. If the cancer is very aggressive and a cure is\\nnot possible, then the treatment should be aimed at\\nrelieving the symptoms and controlling the cancer for as\\nlong as possible.\\nCancer treatment can take many different forms, and\\nit is always tailored to the individual patient. The deci-\\nsion on which type of treatment is the most appropriate\\ndepends on the type and location of cancer, the extent to\\nwhich it has already spread, the patient’s age, sex, gener-\\nal health status and personal treatment preferences. The\\nmajor types of treatment are: surgery, radiation, chemo-\\ntherapy , immunotherapy, hormone therapy, and bone-\\nmarrow transplantation.\\nSurgery\\nSurgery is the removal of a visible tumor and is the\\nmost frequently used cancer treatment. It is most effec-\\ntive when a cancer is small and confined to one area of\\nthe body.\\nSurgery can be used for many purposes.\\n• Treatment. Treatment of cancer by surgery involves\\nremoval of the tumor to cure the disease. This is typical-\\nly done when the cancer is localized to a discrete area.\\nAlong with the cancer, some part of the normal sur-\\nrounding tissue is also removed to ensure that no cancer\\ncells remain in the area. Since cancer usually spreads\\nvia the lymphatic system, adjoining lymph nodes may\\nbe examined and sometimes they are removed as well.\\n• Preventive surgery. Preventive or prophylactic surgery\\ninvolves removal of an abnormal looking area that is\\nlikely to become malignant over time. For example,\\n40% of the people with a colon disease known as ulcer-\\native colitis, ultimately die of colon cancer. Rather than\\nlive with the fear of developing colon cancer, these peo-\\nple may choose to have their colons removed and\\nreduce the risk significantly.\\n• Diagnostic purposes. The most definitive tool for diag-\\nnosing cancer is a biopsy. Sometimes, a biopsy can be\\nperformed by inserting a needle through the skin. How-\\never, at other times, the only way to obtain some tissue\\nsample for biopsy is by performing a surgical operation.\\n• Cytoreductive surgery is a procedure where the doctor\\nremoves as much of the cancer as possible, and then\\ntreats the remaining with radiation therapy or chemo-\\ntherapy or both.\\n• Palliative surgery is aimed at curing the symptoms, not\\nthe cancer. Usually, in such cases, the tumor is so large or\\nhas spread so much that removing the entire tumor is not\\nan option. For example, a tumor in the abdomen may be\\nso large that it may press on and block a portion of the\\nintestine, interfering with digestion and causing pain and\\nvomiting. “Debulking surgery” may remove a part of the\\nblockage and relieve the symptoms. In tumors that are\\ndependent on hormones, removal of the organs that\\nsecrete the hormones is an option. For example, in\\nprostate cancer, the release of testosterone by the testi-\\ncles stimulates the growth of cancerous cells. Hence, a\\nman may undergo an “orchiectomy” (removal of testi-\\ncles) to slow the progress of the disease. Similarly, in a\\ntype of aggressive breast cancer, removal of the ovaries\\n(oophorectomy) will stop the synthesis of hormones\\nfrom the ovaries and slow the progression of the cancer.\\nRadiation\\nRadiation kills tumor cells. Radiation is used alone\\nin cases where a tumor is unsuitable for surgery. More\\noften, it is used in conjunction with surgery and\\nchemotherapy. Radiation can be either external or inter-\\nnal. In the external form, the radiation is aimed at the\\ntumor from outside the body. In internal radiation (also\\nknown as brachytherapy), a radioactive substance in the\\nform of pellets or liquid is placed at the cancerous site\\nby means of a pill, injection or insertion in a sealed con-\\ntainer.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 635\\nCancer\\nCommon Pathogens And The Cancers Associated With Them\\nCausative Angent Type of Cancer\\nViruses\\nPapillomaviruses Cancer of the cervix\\nHepatitis B virus Liver cancer\\nHepatitis C virus Liver cancer\\nEpstein-Barr virus Burkitt’s lymphoma\\nCancers of the upper pharynx Hodgkin’s lymphoma, Non-Hodgkin’s lymphoma, Gastric cancers\\nHuman immunodeficiency virus (HIV) Kaposi’s sarcoma lymphoma\\nBacteria\\nHelicobacter pylori Stomach cancer lymphomas\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 635'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 24, 'page_label': '25'}, page_content='Chemotherapy\\nChemotherapy is the use of drugs to kill cancer cells.\\nIt destroys the hard-to-detect cancer cells that have\\nspread and are circulating in the body. Chemotherapeutic\\ndrugs can be taken either orally (by mouth) or intra-\\nvenously, and may be given alone or in conjunction with\\nsurgery, radiation or both.\\nWhen chemotherapy is used before surgery or radia-\\ntion, it is known as primary chemotherapy or “neoadju-\\nvant chemotherapy.” An advantage of neoadjuvant\\nchemotherapy is that since the cancer cells have not been\\nexposed to anti-cancer drugs, they are especially vulnera-\\nble. It can therefore be used effectively to reduce the size\\nof the tumor for surgery or target it for radiation. Howev-\\ner, the toxic effects of neoadjuvant chemotherapy are\\nsevere. In addition, it may make the body less tolerant to\\nthe side effects of other treatments that follow such as\\nradiation therapy. The more common use of chemothera-\\npy is adjuvant therapy, which is given to enhance the\\neffectiveness of other treatments For example, after\\nsurgery, adjuvant chemotherapy is given to destroy any\\ncancerous cells that still remain in the body.\\nImmunotherapy\\nImmunotherapy uses the body’s own immune sys-\\ntem to destroy cancer cells. This form of treatment is\\nbeing intensively studied in clinical trials and is not yet\\nwidely available to most cancer patients. The various\\nimmunological agents being tested include substances\\nproduced by the body (such as the interferons, inter-\\nleukins, and growth factors), monoclonal antibodies and\\nvaccines. Unlike traditional vaccines, cancer vaccines do\\nnot prevent cancer. Instead, they are designed to treat\\npeople who already have the disease. Cancer vaccines\\nwork by boosting the body’s immune system and training\\nthe immune cells to specifically destroy cancer cells.\\nHormone therapy\\nHormone therapy is standard treatment for some\\ntypes of cancers that are hormone-dependent and grow\\nfaster in the presence of particular hormones. These\\ninclude cancer of the prostate, breast, and uterus. Hor-\\nmone therapy involves blocking the production or action\\nof these hormones. As a result the growth of the tumor\\nslows down and survival may be extended for several\\nmonths or years.\\nBone marrow transplantation\\nThe bone marrow is the tissue within the bone cavi-\\nties that contains blood-forming cells. Healthy bone\\nmarrow tissue constantly replenishes the blood supply\\nand is essential to life. Sometimes, the amount of drugs\\nor radiation needed to destroy cancer cells also destroys\\nbone marrow. Replacing the bone marrow with healthy\\ncells counteracts this adverse effect. A bone marrow\\ntransplant is the removal of marrow from one person and\\nthe transplant of the blood-forming cells either to the\\nsame person or to someone else. Bone-marrow trans-\\nplantation, while not a therapy in itself, is often used to\\n“rescue” a patient, by allowing those with cancer to\\nundergo very aggressive therapy.\\nMany different specialists generally work together\\nas a team to treat cancer patients. An oncologist is a\\nphysician who specializes in cancer care. The oncologist\\nprovides chemotherapy, hormone therapy, and any other\\nnon-surgical treatment that does not involve radiation.\\nThe oncologist often serves as the primary physician and\\ncoordinates the patient’s treatment plan.\\nThe radiation oncologist specializes in using radia-\\ntion to treat cancer, while the surgical oncologist performs\\nthe operations needed to diagnose or treat cancer. Gyne-\\ncologist-oncologists and pediatric-oncologists, as their\\ntitles suggest, are physicians involved with treating\\nwomen’s and children’s cancers respectively. Many other\\nspecialists may also be involved in the care of a cancer\\npatient. For example, radiologists specialize in the use of\\nx rays, ultrasounds, computed tomography scans (CT\\nscans), MRI imaging and other techniques that are used to\\ndiagnose cancer. Hematologists specialize in disorders of\\nthe blood and are consulted in case of blood cancers and\\nbone marrow cancers. The samples that are removed for\\nbiopsy are sent to a laboratory, where a pathologist exam-\\nines them to determine the type of cancer and extent of\\nthe disease. Only some of the specialists who are involved\\nwith cancer care have been mentioned above. There are\\nmany other specialties, and virtually any type of medical\\nor surgical specialist may become involved with care of\\nthe cancer patient should it become necessary.\\nAlternative treatment\\nThere are a multitude of alternative treatments avail-\\nable to help the person with cancer. They can be used in\\nconjunction with, or separate from, surgery, chemothera-\\npy, and radiation therapy. Alternative treatment of cancer\\nis a complicated arena and a trained health practitioner\\nshould be consulted.\\nAlthough the effectiveness of complementary thera-\\npies such as acupuncture in alleviating cancer pain has\\nnot been clinically proven, many cancer patients find it\\nsafe and beneficial. Bodywork therapies such as massage\\nand reflexology ease muscle tension and may alleviate\\nthe side effects such as nausea and vomiting . Home-\\nopathy and herbal remedies used in Chinese traditional\\nGALE ENCYCLOPEDIA OF MEDICINE 2636\\nCancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 636'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 25, 'page_label': '26'}, page_content='herbal medicine have also been shown to alleviate some\\nof the side effects of radiation and chemotherapy and are\\nbeing recommended by many doctors.\\nCertain foods including many vegetables, fruits and\\ngrains are believed to offer protection against various\\ncancers. However, isolation of the individual constituent\\nof vegetables and fruits that are anti-cancer agents has\\nproven difficult. In laboratory studies, vitamins such as\\nA, C and E, as well as compounds such as isothio-\\ncyanates and dithiolthiones found in broccoli, cauli-\\nflower, and cabbage, and beta-carotene found in carrots\\nhave been shown to protect against cancer. Studies have\\nshown that eating a diet rich in fiber as found in fruits\\nand vegetables reduces the risk of colon cancer. Exercise\\nand a low fat diet help control weight and reduce the risk\\nof endometrial, breast, and colon cancer.\\nCertain drugs, which are currently being used for\\ntreatment, could also be suitable for prevention. For\\nexample, the drug tamoxifen (Nolvadex), which has been\\nvery effective against breast cancer, is currently being\\ntested by the National Cancer Institute for its ability to\\nprevent cancer. Similarly, retinoids derived from vitamin\\nA are being tested for their ability to slow the progression\\nor prevent head and neck cancers. Certain studies have\\nsuggested that cancer incidence is lower in areas where\\nsoil and foods are rich in the mineral selenium. More tri-\\nals are needed to explain these intriguing connections.\\nPrognosis\\n“Lifetime risk” is the term that cancer researchers\\nuse to refer to the probability that an individual over the\\ncourse of a lifetime will develop cancer or die from it. In\\nthe United States, men have a one in two lifetime risk of\\ndeveloping cancer, and for women the risk is one in\\nthree. Overall, African-Americans are more likely to\\ndevelop cancer than whites. African-Americans are also\\n30% more likely to die of cancer than whites.\\nMost cancers are curable if detected and treated at\\ntheir early stages. A cancer patient’s prognosis is affected\\nby many factors, particularly the type of cancer the\\npatient has, the stage of the cancer, the extent to which it\\nhas metastasized and the aggressiveness of the cancer. In\\naddition, the patient’s age, general health status and the\\neffectiveness of the treatment being pursued are also\\nimportant factors.\\nTo help predict the future course and outcome of the\\ndisease and the likelihood of recovery from the disease,\\ndoctors often use statistics. The five-year survival rates\\nare the most common measures used. The number refers\\nto the proportion of people with cancer who are expected\\nto be alive, five years after initial diagnosis, compared\\nwith a similar population that is free of cancer. It is\\nimportant to note that while statistics can give some\\ninformation about the average survival experience of\\ncancer patients in a given population, it cannot be used to\\nindicate individual prognosis, because no two patients\\nare exactly alike.\\nPrevention\\nAccording to nutritionists and epidemiologists from\\nleading universities in the United States, a person can\\nreduce the chances of getting cancer by following some\\nsimple guidelines:\\n• eating plenty of vegetables and fruits\\n• exercising vigorously for at least 20 minutes every day\\n• avoiding excessive weight gain\\n• avoiding tobacco (even second hand smoke)\\n• decreasing or avoiding consumption of animal fats and\\nred meats\\n• avoiding excessive amounts of alcohol\\n• avoiding the midday sun (between 11 \\nA.M. and 3 P.M.)\\nwhen the suns rays are the strongest\\n• avoiding risky sexual practices\\n• avoiding known carcinogens in the environment or\\nwork place\\nGALE ENCYCLOPEDIA OF MEDICINE 2 637\\nCancer\\nA transmission electron micrograph (TEM) of two spindle\\ncell nuclei from a human sarcoma. Sarcomas are cancers of\\nthe connective tissue (bone, nerves, smooth muscle).(Pho-\\ntograph by Dr. Brian Eyden, Photo Researchers, Inc. Repro-\\nduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 637'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 26, 'page_label': '27'}, page_content='Resources\\nBOOKS\\nBuckman, Robert. What You Really Need to Know about Can-\\ncer: A Comprehensive Guide for Patients and Their Fami-\\nlies. Johns Hopkins University Press, 1997.\\nMorra, Marion E. Choices. Avon Books, October 1994.\\nMurphy, Gerald P. American Cancer Textbook of Clinical\\nOncology. American Cancer Society, 1995.\\nMurphy, Gerald P. Informed Decisions: The Complete Book of\\nCancer Diagnosis, Treatment and Recovery.American\\nCancer Society, 1997.\\nSimone, Joseph V . “Oncology: Introduction.” In Cecil Textbook\\nof Medicine, edited by Russel L. Cecil et al. Philadelphia:\\nW.B. Saunders Company, 2000.\\nPERIODICALS\\n“What You Need to Know about Cancer.”Scientific American\\n(September 1996).\\nORGANIZATIONS\\nAmerican Cancer Society (National Headquarters). 1599\\nClifton Road, N.E. Atlanta, GA 30329. (800) 227-2345.\\n.\\nCancer Research Institute (National Headquarters). 681 Fifth\\nAvenue, New York, NY 10022. (800) 992-2623. .\\nNational Cancer Institute. 9000 Rockville Pike, Building 31,\\nroom 10A16, Bethesda, Maryland, 20892. (800) 422-\\n6237. .\\nRosalyn Carson-DeWitt\\nKEY TERMS\\nBenign—A growth that does not spread to other\\nparts of the body. Recovery is favorable with treat-\\nment.\\nBiopsy—The surgical removal and microscopic\\nexamination of living tissue for diagnostic purposes.\\nBone marrow—Spongy material that fills the inner\\ncavities of the bones. The progenitors of all the\\nblood cells are produced in this bone marrow.\\nCarcinogen —Any substance capable of causing\\ncancer by mutating the cell’s DNA.\\nChemotherapy—Treatment with drugs that are anti\\ncancer.\\nEpithelium —The layer of cells covering the body’s\\nsurface and lining the internal organs and various\\nglands.\\nHormone therapy—Treatment of cancer by inhibit-\\ning the production of hormones such as testos-\\nterone and estrogen.\\nImmunotherapy—Treatment of cancer by stimulat-\\ning the body’s immune defense system.\\nMalignant —A general term for cells that can dis-\\nlodge from the original tumor, invade and destroy\\nother tissues and organs.\\nMetastasis—The spread of cancer from one part of\\nthe body to another.\\nRadiation therapy —Treatment using high-energy\\nradiation from x-ray machines, cobalt, radium, or\\nother sources.\\nSore—An open wound or a bruise or lesion on the\\nskin.\\nTumor—An abnormal growth resulting from a cell\\nthat lost its normal growth control restraints and\\nstarted multiplying uncontrollably.\\nX rays—High-energy radiation used in high doses,\\neither to diagnose or treat disease.\\nCancer chemotherapy drugs see Anticancer\\ndrugs\\nCancer therapy, definitive\\nDefinition\\nDefinitive cancer therapy is a treatment plan\\ndesigned to potentially cure cancer using one or a combi-\\nnation of interventions including surgery, radiation,\\nchemical agents, or biological therapies.\\nPurpose\\nThe primary purpose of definitive care is to establish\\na cure and to destruct and remove all cancer cells from\\nthe infected person.\\nSurgery is not only a diagnostic tool, but also used\\nfor tumor removal. The surgeon usually identifies poten-\\ntial candidates for tumor removal and repairs intraopera-\\ntively (during the operation procedure). Surgery can be\\ncurative for some stomach, genital/urinary, thyroid,\\nbreast, skin, and central nervous system cancers. The best\\nchance for a surgical cure is usually with the first opera-\\nGALE ENCYCLOPEDIA OF MEDICINE 2638\\nCancer therapy, definitive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 638'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 27, 'page_label': '28'}, page_content='tion. It is essential that the cancer surgeon (oncologic sur-\\ngeon) be experienced in the specific procedure.\\nRadiation therapy is commonly administered to\\napproximately 50% of cancer patients during the course of\\nillness. It can be used as the sole method of cure for tumors\\nin the mouth and neighboring structures in the oral cavity,\\nvagina, prostate, cervix, esophagus, Hodgkin’s disease,\\nand certain types of cancer in the spinal cord and brain.\\nResearch and clinical trials have demonstrated that combi-\\nnation treatment is more effective than radiotherapy alone.\\nChemotherapy is curative for only a small percent-\\nage of cancers. It is most effective for choriocarcinoma,\\ncancer of the testis, some types of lymphomas, and can-\\ncer of skeletal muscles.\\nBiological therapies are a new and promising direc-\\ntion for cancer cures. Usually when cancer cells grow\\nthey manage to derive a blood supply that allows passage\\nof nutrients promoting continuation of abnormal cancer\\ngrowth. Research that focuses on destroying these blood\\nvessels is called angiogenesis. Cutting off the blood sup-\\nply has been shown to destroy tumors, since this stops\\nthe flow of essential nutrients required for cancer growth.\\nUse of certain growth factors can also stimulate self-\\ndestructive pathways in cancer cells (apoptosis). Gene\\ntherapy is directed towards inhibiting specific cellular\\nsignals that promote cancer cell multiplication.\\nPrecautions\\nSurgical resection requires an experienced surgeon,\\npreoperative assessment, imaging studies, and delicate\\noperative technique. Care should be taken during the pro-\\ncedure to avoid unnecessary tumor manipulation, which\\ncan cause cancer cells to infiltrate adjacent structures. If\\nmanipulation is excessive, cells can enter nearby areas\\nfor future re-growth. Accurate isolation of the tumor can\\nalso help to avoid contamination of the surgical area.\\nEarly ligation of the blood supply to the tumor is an\\nessential component of a surgical cure.\\nRadiotherapy requires extensive treatment planning\\nand imaging. Care must be taken to localize the cancer\\nfield while attempting to spare destruction of normal tis-\\nsue. This requires image monitoring and exact position-\\ning during radiation treatment sessions.\\nChemotherapy usually causes destruction of normal\\ncells, and cancer cells can become immune to chemical\\ndestruction. Side effects and patient tolerance issues are\\ntypically anticipated and dosages may have to be specifi-\\ncally altered. Very few chemotherapeutic agents offer\\ncurative responses.\\nBiological therapies may cause patient toxicity\\nresulting in extensive side effects. This can occur since\\nthe optimal dose may be exceedingly elevated above\\npatient tolerance.\\nDescription\\nSurgery\\nSurgical removal of the tumor must be performed with\\ncare and accuracy. The surgeon must avoid over manipula-\\ntion of the surgical field. Too much movement within the\\narea can cause cancer cell displacement into surrounding\\ntissue. If this occurs and no further treatment is indicated,\\nthe tumor may grow again. The surgeon should also per-\\nform an assessment concerning tissue removal around the\\ncancer site. Tissue around the site may not by inspection\\nseem cancerous, but adjacent structures may have cancer\\ncells and surrounding tissue removal is usually part of the\\noperative procedure. Pieces of tumor and the surrounding\\narea are analyzed microscopically during the operation for\\ncell type. An adequate resection (removal of tissue) will\\nreveal normal cells in the specimens analyzed from areas\\nbordering the cancerous growth. Surgery can also help to\\ndecrease the tumor bulk and, along with other treatment\\nmeasures, may provide a cure for certain cancers.\\nNot only can surgery be curative for some cancers,\\nbut it is an essential diagnostic tool that must be assessed\\nintraoperatively since microscopic analysis will guide\\nthe surgeon concerning tumor and surrounding tissue\\nremoval. These diagnostic procedures include an aspira-\\ntion biopsy, which inserts a needle to extract (aspirate)\\nfluid contained inside a cancerous growth; a needle biop-\\nsy uses a specialized needle to obtain a core tissue speci-\\nmen; an incision biopsy removes a section from a large\\ntumor; and an excision biopsy removes the entire tumor.\\nThe surgeon can also take samples of neighboring lymph\\nnodes. Cancer in surrounding lymph nodes is an impor-\\ntant avenue for distant spread of cancer to other areas. If\\nmicroscopic analysis determines the presence of cancer\\ncells in lymph nodes then the surgeon may decide to per-\\nform a more aggressive surgical approach.\\nRadiation therapy\\nSimilar to surgical intervention, radiotherapy is a\\nlocalized treatment. It involves the administration of ion-\\nizing radiation to a solid tumor location. This generates\\nreactive oxygen molecules, causing the destruction of\\nDNA in local cells. There are three commonly used\\nradiotherapy beams: gamma rays from a linear accelera-\\ntor machine produce a focused beam; orthovoltage rays\\nare of less energy, thus penetrate less and typically deliv-\\ner higher doses to superficial tissues (efficient for treat-\\ning skin cancers); and megavoltage rays are high energy\\nproducing beams and can penetrate deeply situated inter-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 639\\nCancer therapy, definitive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 639'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 28, 'page_label': '29'}, page_content='nal organs, while sparing extensive skin damage. Two\\ncommon routes can deliver radiation. Brachytherapy\\ndelivers radiation to a local area by placing radioactive\\nmaterials within close proximity to the cancerous site.\\nTeletherapy delivers radiation to a specific area using an\\nexternal beam machine.\\nChemotherapy\\nCurative chemotherapy usually requires multiple\\nadministrations of the chemical agent. Chemotherapy or\\nsystemic therapy is administered in the blood and circu-\\nlates through the entire body. The choice of chemothera-\\npeutic agents depends on the specific type of cancer.\\nChemotherapy is more commonly used for metastatic\\n(malignant cancer which has spread to other areas\\nbeyond the primary site of cancer growth) disease, since\\nvery few cancers are cured by systemic therapy.\\nBiologic therapy\\nBiologic therapies primarily function to alter the\\npatient’s response to cancer. These treatments are mostly\\ninvestigations and there are numerous research protocols\\nstudying the effects of biologic treatments. These proto-\\ncols usually have strict admission criteria that may\\nexclude potential candidates who can benefit from treat-\\nment. These treatments tend to stimulate specific immune\\ncells or immune chemicals to destroy cancer cells.\\nPreparation\\nFor all treatment modalities imaging studies, biopsy,\\nand constant blood analysis is essential before, during,\\nand after treatments. Surgical candidates should undergo\\nextensive pre-operative evaluation with imaging studies,\\nblood chemistry analysis, stabilized health status, and\\nreadiness of staff for any potential complications and cell\\nbiopsy analysis. Patients with other pre-existing chronic\\ndisease may require intensive post-operative monitoring.\\nFor radiotherapy, the patient undergoes extensive imag-\\ning studies. Additional planning strategies include beam\\nKEY TERMS\\nBone marrow suppression —A decrease in cells\\nresponsible for providing immunity, carrying oxygen\\nand those responsible for normal blood clotting.\\nDNA—The molecule responsible for cell multipli-\\ncation.\\nTitrate—To analyze the best end point (for dose)\\nfor a medication.\\nlocalization to spare normal tissues, calibration of fractionat-\\ned doses, and specific positioning during treatment sessions.\\nPatients who receive curative chemotherapy should\\nbe informed of possible side effects associated with the\\nchemotherapeutic agent. Patients should also be informed\\nof temporary lifestyle changes and medications that may\\noffer some symptomatic relief.\\nPatients undergoing biologic therapies are usually\\nadvised of potential side effects, treatment cycles and\\nspecific tests for monitoring progress according to the\\nspecific research protocol.\\nAftercare\\nPatients will typically be evaluated by imaging stud-\\nies, blood analysis, physical examination , and health\\nimprovement. These follow-up visits usually occur at spe-\\ncific time intervals during the course of treatment. Surgi-\\ncal patients may require closer observation during the ini-\\ntial post-operative period to avoid potential complica-\\ntions. Reconstructive surgery can be considered to\\nimprove appearance and restore function. Certain surgical\\nprocedures (such as flaps and microsurgery of blood ves-\\nsels) can restore new tissues to a previous surgery site.\\nRisks\\nSurgical risks\\nSurgical therapy can be both disfiguring and dis-\\nabling. Many normal tissues can be adversely affected\\nby radiotherapy. Side effects that commonly occur\\nshortly after a treatment cycle include nausea, vomiting,\\nfatigue , loss of appetite, and bone marrow suppression\\n(a decrease in the cells that provide defense against\\ninfections and those which carry oxygen to cells). \\nRadiation risks\\nRadiotherapy can also cause difficulty swallowing,\\noral gum disease, and dry mouth . Additionally, radia-\\ntion therapy can cause damage to local structures within\\nthe irradiated field.\\nChemotherapy risks\\nChemotherapy commonly causes bone marrow\\nsuppression. Additionally, a cell called platelets—\\nimportant for normal blood clotting—may be signifi-\\ncantly lowered, causing patients to bleed. This may be\\nproblematic enough to limit the treatment course. Bone\\nmarrow suppression can increase susceptibility to\\ninfection and also cause infertility . Patients commonly\\nhave bouts of nausea and vomiting shortly after a\\ntreatment session. Rapidly multiplying normal cells are\\nalso affected such as skin cells (causing blistering and\\nulceration) and hair cells (causing loss of hair, a condi-\\ntion called alopecia).\\nGALE ENCYCLOPEDIA OF MEDICINE 2640\\nCancer therapy, definitive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 640'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 29, 'page_label': '30'}, page_content='Biologic therapies risks\\nBiologic therapies can cause patients to develop sup-\\npression of cells that help the body fight against infec-\\ntion. Administration of certain chemicals that have anti-\\ncancer effects can cause heart damage. Injection of killer\\nimmune cells (lymphokine-activated killer cells) may\\ncause bone marrow suppression, and the host may reject\\nthe newly introduced cells.\\nResources\\nBOOKS\\nAbeloff, Martin D., et al. Clinical Oncology. 2nd ed. Churchill\\nLivingstone, Inc, 2000.\\nFauci, Anthony S., et al, eds. Harrison’s Principles of Internal\\nMedicine. 14th ed. McGraw Hill, 1998.\\nGoroll, Allan H., et al, eds. Primary Care Medicine. 4th ed.\\nLippincott, Williams & Wilkins, 2000.\\nOTHER\\nAmerican Cancer Society. .\\nNational Cancer Institute. .\\nLaith Farid Gulli, M.D.\\nNicole Mallory, M.S.\\nCancer therapy, palliative\\nDefinition\\nPalliative cancer therapy is treatment specifically\\ndirected to help improve the symptoms associated with\\nterminal cancer.\\nPurpose\\nPalliative care is directed to improving symptoms\\nassociated with incurable cancer. Care can include\\nsurgery, radiation therapy , chemotherapy , sympto-\\nmatic treatments resulting from cancer, and side effects\\nof treatment. The primary objective of palliative care is\\nto improve the quality of remaining duration of life.\\nTreatment usually involves a combination of modalities\\n(multimodality approach) and numerous specialists are\\ntypically involved in the treatment planning process.\\nTherapeutic planning usually involves meticulous coor-\\ndination with the treatment team.\\nSurgery can be utilized for palliation after careful\\nevaluation and planning. The use of surgery in these cases\\nmay reduce the tumor bulk and help improve the quality of\\nlife by relieving pain, alleviating obstruction, or control-\\nling bleeding. Radiotherapy for terminal cancer patients\\ncan also alleviate pain, bleeding, and obstruction of neigh-\\nboring areas. Chemotherapy may be helpful to reduce\\ntumor size and provide some reduction to metastatic dis-\\nease. Long-term chemotherapy patients develop drug\\nresistance, a situation that renders chemotherapeutic treat-\\nments ineffective. If this occurs patients are usually given\\na second line medication or, if admission criteria are met,\\nthey may participate in an experimental research protocol.\\nPalliative treatments and terminal cancer in combination\\ncan cause many symptoms that can become problematic.\\nThese symptoms commonly include pain, nausea, vomit-\\ning, difficulty in breathing, constipation, dehydration,\\nagitation, and delirium. The palliative treatment-planning\\ngoal focuses to reduce these symptoms.\\nPrecautions\\nSurgery for the purpose of tumor removal, biopsy, or\\nsize reduction is associated with postoperative pain and\\nlocal nerve damage, which may be both severe and difficult\\nto alleviate. Chemotherapy and radiation therapy can also\\nproduce nerve damage and severe pain. Additionally,\\npatients with malignant cancer are susceptible to infections\\nlike herpes, pneumonia, urinary tract infections, and\\nwound abscess, all of which can cause severe pain. Pain\\nassociated with cancer and/or treatments can significantly\\nimpair the patient’s capabilities for performing daily tasks\\nand hence impair quality of life. These complications may\\nnegatively impact the patient’s psychological well being.\\nDescription\\nPain is one of the common symptoms associated with\\ncancer. Approximately 75% of terminal cancer patients\\nhave pain. Pain is a subjective symptom and thus it cannot\\nbe measured using technological approaches. Pain can be\\nassessed using numeric scales (from one to 10, one is rated\\nas no pain while 10 is severe) or rating specific facial\\nexpressions associated with various levels of pain. The\\nmajority of cancer patients experience pain as a result of\\ntumor mass that compresses neighboring nerves, bone, or\\nsoft tissues, or from direct nerve injury (neuropathic pain).\\nPain can occur from affected nerves in the ribs, muscles,\\nand internal structures such as the abdomen (cramping\\ntype pain associated with obstruction). Many patients also\\nexperience various types of pain as a direct result of fol-\\nlow-up tests, treatments (surgery, radiation, and chemo-\\ntherapy) and diagnostic procedures (i.e., biopsy).\\nPreparation\\nPatients are typically informed that their diagnosis is\\nterminal and treatments are directed to improve quality\\nof life for the remaining time and to minimize emotional\\nsuffering associated with pain.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 641\\nCancer therapy, palliative\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 641'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 30, 'page_label': '31'}, page_content='A careful history is necessary to assess duration, sever-\\nity, and location of pain. A physical examinationmay ver-\\nify the presence of pain. Imaging analysis may further con-\\nfirm the presence of potential causes of pain. The World\\nHealth Organization (WHO) recommends an analgesic lad-\\nder. This treatment approach provides medication selec-\\ntions based on previous analgesic use and severity of pain.\\nThe ladder starts with the use of non-opioid (non-mor-\\nphine) drugs such as aspirin, acetaminophin, or non-\\nsteroidal anti-inflammatory medications for control of mild\\npain. Chronic pain must be treated with constant and con-\\nsistently administered medication(s). The “take as needed”\\napproach is not advised. Supplemental doses may be rec-\\nommended in addition to the standard dose for circum-\\nstances that may worsen pain. Opioids (i.e., morphine and\\ncodeine) are the medications of choice for moderate to\\nsevere pain. Doses are adjusted to produce maximum pain\\nrelief while minimizing side effects. These medications are\\nconveniently administered orally. Administering steroids\\ncan help reduce nausea and vomiting. Delirium and anxi-\\nety may be improved by psychoactive medications.\\nAftercare\\nCare for palliation is continuous and consistent for\\nthe remainder of life. Patients who have less than six\\nmonths of life remaining may choose a hospice to stop\\ntreatment and control pain.\\nRisks\\nPatients taking opioids for pain relief can develop tol-\\nerance and dependence. Tolerance develops when a patient\\nrequires increasing amounts of medication to produce pain\\nreduction. Dependence shows characteristic withdrawal\\nsymptoms if medications are abruptly stopped. These\\nsymptoms can be avoided by tapering down doses in the\\nevent that these medications should be stopped.\\nResources\\nBOOKS\\nAbeloff, Martin D., et al. Clinical Oncology. 2nd ed. Churchill\\nLivingstone, Inc, 2000.\\nKEY TERMS\\nOpioids—Narcotic pain killing medication.\\nWorld Health Organization (WHO)—An interna-\\ntional organization concerned with world health\\nand welfare.\\nFauci, Anthony S., et al., eds. Harrison’s Principles of Internal\\nMedicine. 14th ed. McGraw Hill, 1998.\\nGoroll, Allan H., et al., eds. Primary Care Medicine. 4th ed.\\nLippincott, Williams & Wilkins, 2000.\\nWashington Manual of Medical Therapeutics.30th ed. Wash-\\nington University School of Medicine, Department of\\nMedicine, 2001.\\nPERIODICALS\\nMercadante, S., F. Fulfaro, and A. Casuccio. “The Impact of\\nHome Palliative Care on Symptoms in Advanced Cancer\\nPatients.” Support Care Cancer (July 2000).\\nORGANIZATIONS\\nNational Cancer Institute. .\\nAmerican Cancer Society. .\\nAmerican Pain Society. .\\nLaith Farid Gulli, M.D.\\nNicole Mallory, M.S.\\nCancer therapy, supportive\\nDefinition\\nSupportive cancer therapy is the use of medicines to\\ncounteract unwanted effects of cancer treatment.\\nPurpose\\nAlong with their beneficial effects, many cancer\\ntreatments produce uncomfortable and sometimes harm-\\nful side effects. For example, cancer drugs may cause\\nnausea or vomiting. They may also destroy red or white\\nblood cells, resulting in a low blood count. Fortunately,\\nmany of these side effects can be relieved with other\\nmedicines.\\nDescription\\nDifferent kinds of drugs are used for different pur-\\nposes in supportive cancer therapy. To relieve nausea\\nand vomiting , a physician may prescribe dolasetron\\n(Anzemet), granisetron (Kytril) or ondansetron (Zofran).\\nDrugs called colony stimulating factors are used to help\\nthe bone marrow make new white blood cells to replace\\nthose destroyed by cancer treatment. Examples of colony\\nstimulating factors are filgrastim (Neupogen) and sar-\\ngramostim (Leukine). Another type of drug, epoetin\\n(Epogen, Procrit), stimulates the bone marrow to make\\nnew red blood cells. It is a synthetically made version of\\nhuman erythropoietin that is made naturally in the body\\nand has the same effect on bone marrow.\\nGALE ENCYCLOPEDIA OF MEDICINE 2642\\nCancer therapy, supportive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 642'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 31, 'page_label': '32'}, page_content='Some physicians who treat cancer recommend that\\ntheir patients use marijuana to relieve nausea and vom-\\niting. This practice is controversial for several reasons.\\nUsing marijuana, even for medicinal purposes, is illegal\\nin most states. Also, most of the evidence that marijuana\\neffectively relieves nausea and vomiting comes from\\nreports of people who have used it, not from carefully\\ndesigned scientific studies. An oral medication that con-\\ntains one of the active ingredients of marijuana is avail-\\nable with a physician’s prescription and sometimes is\\nused to treat nausea and vomiting in patients undergoing\\ncancer treatment. However, the drug, dronabinol (Mari-\\nnol), takes longer to work than smoked marijuana and\\nmay be difficult for patients with nausea and vomiting to\\nswallow and keep down.\\nIn 1997, the National Institutes of Health issued a\\nreport calling for more research into medical uses of\\nmarijuana. The panel of experts who wrote the report\\nalso recommended that researchers investigate other\\nways of getting the active ingredients of marijuana into\\nthe body, such as nasal sprays, skin patches and inhalers.\\nPatients who want to use marijuana to relieve side\\neffects of cancer treatment should talk to their physicians\\nand should carefully consider the benefits and risks, both\\nmedical and legal.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nsupportive cancer therapy. Check with the physician who\\nprescribed the drug or the pharmacist who filled the pre-\\nscription for the correct dosage.\\nPrecautions\\nDolasetron, granisetron and ondansetron\\nIf severe nausea and vomiting occur after taking this\\nmedicine, check with a physician.\\nThe use of ondansetron after abdominal surgery may\\ncover up symptoms of stomach problems.\\nPeople with liver disease may be more likely to have\\nside effects from ondansetron.\\nColony stimulating factors\\nCertain cancer drugs reduce the body’s ability to\\nfight infections. Although colony stimulating factors help\\nrestore the body’s natural defenses, the process takes\\ntime. Getting prompt treatment for infections is impor-\\ntant, even while taking this medicine. Call the physician\\nat the first sign of illness or infection, such as a sore\\nthroat, fever or chills.\\nSeeing a physician regularly while taking this medi-\\ncine is important. This will give the physician a chance to\\nmake sure the medicine is working and to check for\\nunwanted side effects.\\nPeople with certain medical conditions may have\\nproblems if they take colony stimulating factors. In peo-\\nple who have kidney disease, liver disease, or conditions\\ncaused by inflammation or immune system problems,\\ncolony stimulating factors may make these problems\\nworse. People with heart disease may be more likely to\\nhave side effects such as water retention and heart\\nrhythm problems when they take these drugs. And people\\nwith lung disease may be more likely to have shortness\\nof breath. Anyone who has any of these medical condi-\\ntions should check with his or her physician before using\\ncolony stimulating factors.\\nEpoetin\\nThis medicine may cause seizures (convulsions),\\nespecially in people with a history of seizures. Anyone\\nwho takes these drugs should not drive, use machines or\\ndo anything else that might be dangerous if they have had\\na seizure.\\nEpoetin helps the body make new red blood cells, but\\nit cannot do its job unless there is plenty of iron in the\\nbody. The physician may recommend taking iron supple-\\nments or certain vitamins that help get iron into the body.\\nFollow the physician’s orders to make sure the body has\\nenough iron for this medicine to work. Do not take iron\\nsupplements unless they are prescribed by a physician.\\nIn studies of laboratory animals, epoetin taken dur-\\ning pregnancy caused birth defects , including damage\\nto the bones and spine. However, the drug has not been\\nreported to cause problems in human babies whose\\nmothers take it. Women who are pregnant or who may\\nbecome pregnant should check with their physicians for\\nthe most up-to-date information on the safety of taking\\nthis medicine during pregnancy.\\nPeople with certain medical conditions may have\\nproblems if they take this medicine. For example, the\\nchance of side effects may be greater in people with high\\nblood pressure, heart or blood vessel disease or a history\\nof blood clots. Epoetin may not work properly in people\\nwho have bone problems or sickle cell anemia.\\nDronabinol\\nThis medicine contains sesame oil and one of the\\nactive ingredients of marijuana. Anyone who has had\\nallergic or unusual reactions to sesame oil or marijuana\\nproducts should let his or her physician know before tak-\\ning dronabinol.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 643\\nCancer therapy, supportive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 643'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 32, 'page_label': '33'}, page_content='Because dronabinol works on the central nervous sys-\\ntem, it may add to the effects of alcohol and other drugs\\nthat slow down the central nervous system. Examples of\\nthese drugs are antihistamines , cold medicine, allergy\\nmedicine, sleep aids, medicine for seizures, tranquilizers,\\nsome pain relievers, and muscle relaxants . Dronabinol\\nmay also add to the effects of anesthetics, including those\\nused for dental procedures. Anyone taking dronabinol\\nshould not drink alcohol and should check with his or her\\nphysician before taking any of the drugs listed above.\\nThis drug makes some people feel drowsy, dizzy,\\nlightheaded or “high,” with a sense of well-being.\\nBecause of these possible reactions, anyone who takes\\ndronabinol should not drive, use machines or do anything\\nelse that might be dangerous until they have found out\\nhow the drug affects them. The dizziness and lighthead-\\nedness are especially likely when getting up after sitting\\nKEY TERMS\\nBipolar disorder —A severe mental illness in\\nwhich a person has extreme mood swings, ranging\\nfrom a highly excited state—sometimes with a\\nfalse sense of well-being—to depression\\nBone marrow —Soft tissue that fills the hollow\\ncenters of bones. Blood cells and platelets (disk-\\nshaped bodies in the blood that are important in\\nclotting) are produced in the bone marrow.\\nHallucination—A false or distorted perception of\\nobjects, sounds, or events that seems real. Hallucina-\\ntions usually result from drugs or mental disorders.\\nImmune system —The body’s natural defenses\\nagainst disease and infection.\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nSchizophrenia —A severe mental disorder in\\nwhich people lose touch with reality and may\\nhave illogical thoughts, delusions, hallucinations,\\nbehavioral problems and other disturbances.\\nSickle cell anemia—An inherited disorder in which\\nred blood cells contain an abnormal form of hemo-\\nglobin, a protein that carries oxygen. The abnormal\\nform of hemoglobin causes the red cells to become\\nsickle- or crescent-shaped. The misshapen cells\\nmay clog blood vessels, preventing oxygen from\\nreaching tissues and leading to pain, blood clots\\nand other problems. Sickle cell anemia is most\\ncommon in people of African descent and in peo-\\nple from Italy, Greece, India, and the Middle East.\\nor lying down. Getting up gradually and holding onto\\nsomething for support should lessen the problem.\\nIn laboratory studies, giving high doses of dronabi-\\nnol to pregnant animals increased the risk of the unborn\\nbaby’s death. The medicine’s effects on pregnant women\\nhave not been studied. Women who are pregnant or who\\nmay become pregnant should check with their physicians\\nbefore taking this medicine.\\nDronabinol passes into breast milk and may affect\\nnursing babies whose mothers take the medicine. Women\\nwho are breastfeeding their babies should check with\\ntheir physicians before using dronabinol.\\nBecause of its possible mind-altering effects, dron-\\nabinol should be used with care in children and older\\npeople. Both children and older people should be\\nwatched carefully when they are taking this medicine.\\nUsing dronabinol may worsen some medical condi-\\ntions, including high blood pressure, heart disease, bipo-\\nlar disorder and schizophrenia.\\nGeneral precautions for all types of supportive\\ncancer therapy\\nAnyone who previously has had unusual reactions to\\ndrugs used in supportive cancer therapy should let his or\\nher physician know before taking the drugs again. The\\nphysician should also be told about any allergies to\\nfoods, dyes, preservatives, or other substances.\\nSide effects\\nDolasetron, granisetron and ondansetron\\nThe most common minor side effects are headache,\\ndizziness or lightheadedness, drowsiness, dry mouth ,\\ndiarrhea , constipation , abdominal pain or stomach\\ncramps and unusual tiredness or weakness. These prob-\\nlems usually do not require medical treatment.\\nCheck with a physician as soon as possible if fever\\noccurs after taking granisetron.\\nIf any of these symptoms occur after taking ondan-\\nsetron, check with a physician immediately:\\n• breathing problems or wheezing\\n• chest pain or tightness in chest\\n• skin rash,hives or itching\\nColony stimulating factors\\nAs this medicine starts to work, it may cause mild\\npain in the lower back or hips. This is nothing to worry\\nabout, and it will usually go away within a few days. If\\nthe pain is too uncomfortable, the physician may pre-\\nGALE ENCYCLOPEDIA OF MEDICINE 2644\\nCancer therapy, supportive\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 644'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 33, 'page_label': '34'}, page_content='scribe a painkiller. Be sure to let the physician know if\\nthe painkiller does not help.\\nOther possible side effects include headache, joint or\\nmuscle pain, and skin rash or itching. These side effects\\nusually go away as the body adjusts to the medicine and\\ndo not need medical treatment. If they continue or they\\ninterfere with normal activities, check with a physician.\\nEpoetin\\nThis medicine may cause flu-like symptoms, such as\\nmuscle aches, bone pain, fever, chills, shivering, and\\nsweating, within a few hours after it is taken. These symp-\\ntoms usually go away within 12 hours. If they do not, or if\\nthey are troubling, check with a physician. Other possible\\nside effects that do not need medical attention are diar-\\nrhea, nausea or vomiting, and tiredness or weakness.\\nCertain side effects should be brought to a physi-\\ncian’s attention as soon as possible. These include\\nheadache, vision problems, increased blood pressure,\\nfast heartbeat, weight gain, and swelling of the face, fin-\\ngers, lower legs, ankles or feet.\\nAnyone who has chest pain or seizures after taking\\nepoetin should check with a physician immediately.\\nDronabinol\\nSide effects such as dizziness, drowsiness, confusion\\nand clumsiness or unsteadiness usually do not need med-\\nical attention unless they are long-lasting or they inter-\\nfere with normal activities.\\nOther side effects or signs of overdose should have\\nimmediate medical attention. These include:\\n• fast or pounding heartbeat\\n• constipation\\n• trouble urinating\\n• red eyes\\n• slurred speech\\n• mood changes, including depression, nervousness or\\nanxiety\\n• confusion\\n• forgetfulness\\n• changes in sight, smell, taste, touch or hearing\\n• a sense that time is speeding up or slowing down\\n• hallucinations\\nGeneral advice on side effects for all types of\\nsupportive cancer therapy\\nOther side effects are possible with any type of sup-\\nportive cancer therapy. Anyone who has unusual symp-\\ntoms during or after treatment with these drugs should\\nget in touch with his or her physician.\\nInteractions\\nAnyone who has supportive cancer therapy should\\nlet the physician know all other medicines he or she is\\ntaking. Some combinations of drugs may interact, which\\nmay increase or decrease the effects of one or both drugs\\nor may increase the risk of side effects. Ask the physician\\nwhether the possible interactions can interfere with drug\\ntherapy or cause harmful effects.\\nResources\\nPERIODICALS\\n“Marijuana as Medicine: How Strong is the Science?”Con-\\nsumer Reports 62 (May 1997): 62.\\nMorris, Kelly. “The Cannabis Remedy—Wonder Worker or\\nEvil Weed?”The Lancet 350 (20 Dec.1997): 1828.\\nNancy Ross-Flanigan\\nCandida albicans infection see Candidiasis\\nCandidiasis\\nDefinition\\nCandidiasis is an infection caused by a species of the\\nyeast Candida, usually Candida albicans. This is a com-\\nmon cause of vaginal infections in women. Also,Candida\\nmay cause mouth infections in people with reduced\\nimmune function, or in patients taking certain antibiotics.\\nCandida can be found in virtually all normal people but\\ncauses problems in only a fraction. In recent years, howev-\\ner, several serious categories of candidiasis have become\\nmore common, due to overuse of antibiotics, the rise of\\nAIDS, the increase in organ transplantations, and the use of\\ninvasive devices (catheters, artificial joints and valves)—all\\nof which increase a patient’s susceptibility to infection.\\nDescription\\nV aginal candidiasis\\nOver one million women in the United States devel-\\nop vaginal yeast infections each year. It is not life-threat-\\nening, but it can be uncomfortable and frustrating.\\nOral candidiasis\\nThis disorder, also known as thrush, causes white,\\ncurd-like patches in the mouth or throat.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 645\\nCandidiasis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 645'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 34, 'page_label': '35'}, page_content='Deep organ candidiasis\\nAlso known as invasive candidiasis, deep organ candidi-\\nasis is a serious systemic infection that can affect the esopha-\\ngus, heart, blood, liver, spleen, kidneys, eyes, and skin. Like\\nvaginal and oral candidiasis, it is an opportunistic disease\\nthat strikes when a person’s resistance is lowered, often due\\nto another illness. There are many diagnostic categories of\\ndeep organ candidiasis, depending on the tissues involved.\\nCauses and symptoms\\nV aginal candidiasis\\nMost women with vaginal candidiasis experience\\nsevere vaginal itching . They also have a discharge that\\noften looks like cottage cheese and has a sweet or bread-\\nlike odor. The vulva and vagina can be red, swollen, and\\npainful. Sexual intercourse can also be painful.\\nOral candidiasis\\nWhitish patches can appear on the tongue, inside of\\nthe cheeks, or the palate. Oral candidiasis typically\\noccurs in people with abnormal immune systems. These\\ncan include people undergoing chemotherapy for can-\\ncer, people taking immunosuppressive drugs to protect\\ntransplanted organs, or people with HIV infection.\\nDeep organ candidiasis\\nAnything that weakens the body’s natural barrier\\nagainst colonizing organisms—including stomach\\nsurgery, burns, nasogastric tubes, and catheters—can\\npredispose a person for deep organ candidiasis. Rising\\nnumbers of AIDS patients, organ transplant recipients,\\nand other individuals whose immune systems are com-\\npromised help account for the dramatic increase in deep\\norgan candidiasis in recent years. Patients with granulo-\\ncytopenia (deficiency of white blood cells) are particular-\\nly at risk for deep organ candidiasis.\\nDiagnosis\\nOften clinical appearance gives a strong suggestion\\nabout the diagnosis. Generally, a clinician will take a\\nsample of the vaginal discharge or swab an area of oral\\nplaque, and then inspect this material under a micro-\\nscope. Under the microscope, it is possible to see charac-\\nteristic forms of yeasts at various stages in the lifecycle.\\nFungal blood cultures should be taken for patients\\nsuspected of having deep organ candidiasis. Tissue biop-\\nsy may be needed for a definitive diagnosis.\\nTreatment\\nV aginal candidiasis\\nIn most cases, vaginal candidiasis can be treated\\nsuccessfully with a variety of over-the-counter antifungal\\ncreams or suppositories. These include Monistat, Gyne-\\nLotrimin, and Mycelex. However, infections often recur.\\nIf a women has frequent recurrences, she should consult\\nher doctor about prescription drugs such as Vagistat-1,\\nDiflucan, and others.\\nOral candidiasis\\nThis is usually treated with prescription lozenges or\\nmouthwashes. Some of the most-used prescriptions are\\nnystatin mouthwashes (Nilstat or Nitrostat) and clotrima-\\nzole lozenges.\\nDeep organ candidiasis\\nThe recent increase in deep organ candidiasis has led\\nto the creation of treatment guidelines, including, but not\\nlimited to, the following: Catheters should be removed\\nfrom patients in whom these devices are still present.\\nAntifungal chemotherapy should be started to prevent the\\nspread of the disease. Drugs should be prescribed based\\non a patient’s specific history and defense status.\\nAlternative treatment\\nHome remedies for vaginal candidiasis include vine-\\ngar douches or insertion of a paste made from Lacto-\\nbacillus acidophilus powder into the vagina. In theory,\\nGALE ENCYCLOPEDIA OF MEDICINE 2646\\nCandidiasis\\nThis patient’s tongue is infected with candidiasis.(Photo-\\ngraph by Edward H. Gill, Custom Medical Stock Photo. Repro-\\nduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 646'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 35, 'page_label': '36'}, page_content='these remedies will make the vagina more acidic and\\ntherefore less hospitable to the growth of Candida. Fresh\\ngarlic ( Allium sativum ) is believed to have antifungal\\naction, so incorporating it into the diet or inserting a\\ngauze-wrapped, peeled garlic clove into the vagina may\\nbe helpful. The insert should be changed twice daily.\\nSome women report success with these remedies; they\\nshould try a conventional treatment if an alternative rem-\\nedy isn’t effective.\\nPrognosis\\nV aginal candidiasis\\nAlthough most cases of vaginal candidiasis are\\ncured reliably, these infections can recur. To limit recur-\\nrences, women may need to take a prescription anti-fun-\\ngal drug such as terconazole (sold as Terazol) or take\\nother anti-fungal drugs on a preventive basis.\\nOral candidiasis\\nThese infections can also recur, sometimes because the\\ninfecting Candida develops resistance to one drug. There-\\nfore, a physician may need to prescribe a different drug.\\nDeep organ candidiasis\\nThe prognosis depends on the category of disease as\\nwell as on the condition of the patient when the infection\\nstrikes. Patients who are already suffering from a serious\\nunderlying disease are more susceptible to deep organ\\ncandidiasis that speads throughout the body.\\nPrevention\\nBecause Candida is part of the normal group of\\nmicroorganisms that co-exist with all people, it is impos-\\nsible to avoid contact with it. Good vaginal hygiene and\\ngood oral hygiene might reduce problems, but they are\\nnot guarantees against candidiasis.\\nBecause hospital-acquired (nosocomial) deep organ\\ncandidiasis is on the rise, people need to be made aware\\nof it. Patients should be sure that catheters are properly\\nmaintained and used for the shortest possible time\\nlength. The frequency, length, and scope of courses of\\nantibiotic treatment should also be cut back.\\nResources\\nBOOKS\\nCarlson, K. J., S. A. Eisenstat, and T. Ziporyn. The Harvard\\nGuide to Women’s Health.Harvard University Press, 1996.\\nPERIODICALS\\nGreenspan, Deborah, and John S. Greenspan. “HIV-Related\\nOral Disease.“ The Lancet 348 (14 Sept. 1996): 729-734.\\nTobin, Marla J. “Vulvovaginal candidiasis: Topical vs. Oral\\nTherapy.”American Family Physician 51 (15 May 1995):\\n1715-1723.\\nRichard H. Lampert\\nCandidosis see Candidiasis\\nCanker sores\\nDefinition\\nCanker sores are small sores or ulcers that appear inside\\nthe mouth. They are painful, self-healing, and can recur.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 647\\nCanker sores\\nA transmission electron microscopy (TEM) of Candida albi-\\ncans. (Custom Medical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nBiopsy—The removal and examination of tissue\\nfrom a live body.\\nColonize—To become established in a host.\\nGranulocytopenia—A condition characterized by\\na deficiency of white blood cells.\\nNasogastric—Tube inserted through the nasal pas-\\nsages into the stomach.\\nOpportunistic —Infection caused by microorgan-\\nisms that are usually harmless, but which can\\ncause disease when a host’s resistance is lowered.\\nSystemic—Afflicting an entire body system or the\\nbody in general.\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 647'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 36, 'page_label': '37'}, page_content='Description\\nCanker sores occur on the inside of the mouth, usu-\\nally on the inside of the lips, cheeks, and/or soft palate.\\nThey can also occur on the tongue and in the throat.\\nOften, several canker sores will appear at the same time\\nand may be grouped in clusters. Canker sores appear as a\\nwhitish, round area with a red border. The sores are\\npainful and sensitive to touch. The average canker sore is\\nabout one-quarter inch in size, although they can occa-\\nsionally be larger. Canker sores are not infectious.\\nApproximately 20% of the U.S. population is affect-\\ned with recurring canker sores, and more women than\\nmen get them. Women are more likely to have canker\\nsores during their premenstrual period.\\nCanker sores are sometimes confused with cold\\nsores. Cold sores are caused by herpes simplex virus.\\nThis disease, also known as oral herpes or fever blisters,\\ncan occur anywhere on the body. Most commonly, her-\\npes infection occurs on the outside of the lips and the\\ngums, and much less frequently on the inside the mouth.\\nCold sores are infectious.\\nCauses and symptoms\\nThe exact cause of canker sores is uncertain, howev-\\ner, they seem to be related to a localized immune reac-\\ntion. Other proposed causes for this disease are trauma to\\nthe affected areas from toothbrush scrapes, stress, hor-\\nmones, and food allergies . Canker sores tend to appear\\nin response to stress. The initial symptom is a tingling or\\nmildly painful itching sensation in the area where the\\nsore will appear. After one to several days, a small red\\nswelling appears. The sore is round, and is a whitish\\ncolor with a grayish colored center. Usually, there is a red\\nring of inflammation surrounding the sore. The main\\nsymptom is pain. Canker sores can be very painful, espe-\\ncially if they are touched repeatedly, e.g., by the tongue.\\nThey last for one to two weeks.\\nKEY TERMS\\nInflammation—A local reaction to tissue injury or\\ndamage, usually characterized by pain, swelling,\\nand redness.\\nSore—A wound, lesion, or ulcer on the skin.\\nUlcer—A site of damage to the skin or mucous\\nmembrane that is characterized by the formation\\nof pus, death of tissue, and is frequently accompa-\\nnied by an inflammatory reaction.\\nDiagnosis\\nCanker sores are diagnosed by observation of the\\nblister. A distinction between canker sores and cold sores\\nmust be made because cold sores are infectious and the\\nherpes infection can be transmitted to other people. The\\ntwo sores can usually be distinguished visually and there\\nare specific diagnostic tests for herpes infection.\\nTreatment\\nSince canker sores heal by themselves, treatment is\\nnot usually necessary. Pain relief remedies, such as topi-\\ncal anesthetics, may be used to reduce the pain of the\\nsores. The use of corticosteroid ointments sometimes\\nspeeds healing. Avoidance of spicy or acidic foods can\\nhelp reduce the pain associated with canker sores.\\nAlternative treatment\\nAlternative therapies for canker sores are aimed at\\nhealing existing sores and preventing their recurrence.\\nSeveral herbal remedies, including calendula (Calendula\\nofficinalis ), myrrh ( Commiphora molmol ), and gold-\\nenseal ( Hydrastis canadensis ), may be helpful in the\\ntreatment of existing sores. Compresses soaked in teas\\nmade from these herbs are applied directly to the sores.\\nThe tannic acid in a tea bag can also help dry up the sores\\nwhen the wet tea bag is used as a compress. Taking dan-\\ndelion ( Taraxacum officinale ) tea or capsules may help\\nheal sores and also prevent future outbreaks. Since\\ncanker sores are often brought on by stress, such stress-\\nrelieving techniques as meditation , guided imagery ,\\nand certain acupressure exercises may help prevent\\ncanker sores or lessen their severity.\\nPrognosis\\nThere is no cure for canker sores. They do not get\\nlarger or occur more frequently with age.\\nResources\\nBOOKS\\nLarsen, D. E., ed. Mayo Clinic Family Health Book.New York:\\nWilliam Morrow, 1996.\\nSchlossberg, D. Current Therapy of Infectious Disease.St.\\nLouis: Mosby, 1996.\\nJohn T. Lohr, PhD\\nCaptopril see Angiotensin-converting\\nenzyme inhibitors\\nCarbamazepine see Anticonvulsant drugs\\nCarbidopa see Antiparkinson drugs\\nGALE ENCYCLOPEDIA OF MEDICINE 2648\\nCanker sores\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 648'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 37, 'page_label': '38'}, page_content='Carbohydrate intolerance\\nDefinition\\nCarbohydrate intolerance is the inability of the body\\nto completely process the nutrient carbohydrate (a classi-\\nfication that includes sugars and starches) into a source of\\nenergy for the body, usually because of the deficiency of\\nan enzyme needed for digestion. Lactose intolerance, the\\ninability to digest the sugar found in milk, is widespread\\nand affects up to 70% of the world’s adult population.\\nDescription\\nCarbohydrates are the primary source of energy and,\\nalong with fats and proteins, one of the three major nutri-\\nents in the human diet. Carbohydrates are classified\\naccording to their structure based on the number of basic\\nsugar, or saccharide units they contain.\\nA monosaccharide is the simplest carbohydrate and\\ncalled a simple sugar. Simple sugars include glucose (the\\nform in which sugar circulates in the blood), fructose\\n(found in fruit and honey), and galactose (produced by\\nthe digestion of milk). These simple sugars are important\\nbecause they can be absorbed by the small intestine. Two\\nsimple sugars linked together make a disaccharide. The\\ndisaccharide sugars present in the diet are maltose (a\\nproduct of the digestion of starch), sucrose (table sugar),\\nand lactose (the sugar in milk). These disaccharides must\\nbe broken down by enzymes into two simple sugars so\\nthat they can be absorbed by the intestine. Polysaccha-\\nrides are much more complex carbohydrates made up of\\nmany simple sugars, the most important of which are\\nglycogen, which is stored in the liver, and starch.\\nDigestion of sugars\\nDigestion of food begins in the mouth, moves on to\\nthe stomach, and then into the small intestine. Along the\\nway, specific enzymes are needed to process different\\ntypes of sugars. An enzyme is a substance that acts as a\\ncatalyst to produce chemical changes without being\\nchanged itself. The enzymes lactase, maltase, and isoma-\\nltase (or sucrase) are needed to break down the disaccha-\\nrides; when one or more is inadequate, the result is car-\\nbohydrate intolerance.\\nTypes of intolerance\\nCarbohydrate intolerance can be primary or sec-\\nondary. Primary deficiency is caused by an enzyme defect\\npresent at birth or developed over time. The most common\\nis lactose intolerance. Secondary deficiencies are caused\\nby a disease or disorder of the intestinal tract, and disap-\\npear when the disease is treated. These include protein\\ndeficiency,celiac disease, and some intestinal infections.\\nAdult lactose intolerance is the most common of all\\nenzyme deficiencies, and it is estimated that 30–50 mil-\\nlion Americans have this condition. Some racial and eth-\\nnic populations are affected more than others. Lactose\\nintolerance is found in as many as 75% of African Ameri-\\ncans, Jewish Americans, Mexican Americans, and Native\\nAmericans, and in 90% of Asian Americans. Descendants\\nof Northern Europeans and some Mediterranean peoples\\nusually do not develop the condition. Deficiencies in\\nenzymes other than lactase are extremely rare.\\nCauses and symptoms\\nEnzymes play an important role in breaking down\\ncarbohydrates into forms that can pass through the intes-\\ntine and be used by the body. Usually they are named by\\nadding ase to the name of the substance they act on, so\\nlactase is the enzyme needed to process lactose. Cooked\\nstarch is broken down in the mouth to a disaccharide by\\namylase, an enzyme in the saliva. The disaccharides mal-\\ntose, sucrose, and lactose cannot be absorbed until they\\nhave been separated into simple sugar molecules by their\\ncorresponding enzymes present in the cells lining the\\nintestinal tract. If this process is not completed, digestion\\nis interrupted.\\nAlthough not common, a deficiency in the enzymes\\nneeded to digest lactose, maltose, and sucrose is some-\\ntimes present at birth. Intestinal lactase enzymes usually\\ndecrease naturally with age, but this happens to varying\\ndegrees. Because of the uneven distribution of enzyme\\ndeficiency based on race and ethnic heritage, especially\\nin lactose intolerance, genetics are believed to play a role\\nin the cause of primary carbohydrate intolerance.\\nDigestive diseases such as celiac disease and tropi-\\ncal sprue (which affect absorption in the intestine), as\\nwell as intestinal infections and injuries, can reduce the\\namount of enzymes produced. In cancer patients, treat-\\nment with radiation therapy or chemotherapy may\\naffect the cells in the intestine that normally secrete lac-\\ntase, leading to intolerance.\\nThe severity of the symptoms depends on the extent\\nof the enzyme deficiency, and range from a feeling of\\nmild bloating to severe diarrhea. In the case of a lactase\\ndeficiency, undigested milk sugar remains in the intes-\\ntine, which is then fermented by the bacteria normally\\npresent in the intestine. These bacteria produce gas,\\ncramping, bloating, a “gurgly” feeling in the abdomen,\\nand flatulence. In a growing child, the main symptoms\\nare diarrhea and a failure to gain weight. In an individual\\nwith lactase deficiency, gastrointestinal distress begins\\nGALE ENCYCLOPEDIA OF MEDICINE 2 649\\nCarbohydrate intolerance\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 649'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 38, 'page_label': '39'}, page_content='about 30 minutes to two hours after eating or drinking\\nfoods containing lactose. Food intolerances can be con-\\nfused with food allergies, since the symptoms of nausea,\\ncramps, bloating, and diarrhea are similar.\\nSugars that aren’t broken down into one of the sim-\\nplest forms cause the body to push fluid into the intestines,\\nwhich results in watery diarrhea (osmotic diarrhea). Diar-\\nrhea may sweep other nutrients out of the intestine before\\nthey can be absorbed, causing malnutrition.\\nDiagnosis\\nCarbohydrate intolerance can be diagnosed using\\noral tolerance tests. The carbohydrate being investigated\\nis given by mouth in liquid form and several blood levels\\nare measured and compared to normal values. This helps\\nevaluate the individual’s ability to digest the sugar.\\nTo identify lactose intolerance in children and\\nadults, the hydrogen breath test is used to measure the\\namount of hydrogen in the breath. The patient drinks a\\nbeverage containing lactose and the breath is analyzed\\nat regular intervals. If undigested lactose in the large\\nintestine (colon) is fermented by bacteria, various gases\\nare produced. Hydrogen is absorbed from the intestines\\nKEY TERMS\\nCeliac disease—A disease, occurring in both chil-\\ndren and adults, which is caused by a sensitivity to\\ngluten, a protein found in grains. It results in\\nchronic inflammation and shrinkage of the lining\\nof the small intestine.\\nDigestion—The mechanical, chemical, and enzy-\\nmatic process in which food is converted into the\\nmaterials suitable for use by the body.\\nEnzyme—A substance produced by the body to\\nassist in a chemical reaction. In carbohydrate\\nintolerance, lack of an enzyme makes it impossi-\\nble for one type of sugar to be broken down into a\\nsimpler form so that it can be absorbed by the\\nintestines and used by the body.\\nMetabolism —All the physical and chemical\\nchanges that take place within an organism.\\nNutrient—Food or another substance that supplies\\nthe body with the elements needed for metabolism.\\nSugars—Those carbohydrates having the general\\ncomposition of one part carbon, two parts hydro-\\ngen, and one part oxygen.\\nand carried by the bloodstream into the lungs where it\\nis exhaled. Normally there is very little hydrogen\\ndetectable in the breath, so its presence indicates faulty\\ndigestion of lactose.\\nWhen lactose intolerance is suspected in infants and\\nyoung children, many pediatricians recommend simply\\nchanging from cow’s milk to soy formula and watching\\nfor improvement. If needed, a stool sample can be tested\\nfor acidity. The inadequate digestion of lactose will result\\nin an increase of acid in the waste matter excreted by the\\nbowels and the presence of glucose.\\nTreatment\\nCarbohydrate intolerance caused by temporary\\nintestinal diseases disappears when the condition is suc-\\ncessfully treated. In primary conditions, no treatment\\nexists to improve the body’s ability to produce the\\nenzymes, but symptoms can be controlled by diet.\\nBecause the degree of lactose intolerance varies so\\nmuch, treatment should be tailored for the individual.\\nYoung children showing signs of intolerance should\\navoid milk products; infants should switch to soy-based\\nformula. Older children and adults can adjust their intake\\nof lactose depending on how much and what they can\\ntolerate. For some, a small glass of milk will not cause\\nproblems, while others may be able to handle ice cream\\nor aged cheeses such as cheddar or Swiss, but not other\\ndairy products. Generally, small amounts of lactose-con-\\ntaining foods taken throughout the day are better tolerat-\\ned than a large amount consumed all at once.\\nFor those individuals who are sensitive to even very\\nsmall amounts of lactose, the lactase enzyme is available\\nwithout a prescription. It comes in liquid form for use\\nwith milk. The addition of a few drops to a quart of milk\\nwill reduce the lactose content by 70% after 24 hours in\\nthe refrigerator. Heating the milk speeds up the process,\\nand doubling the amount of lactase liquid will result in\\nmilk that is 90% lactose free. Chewable lactase enzyme\\ntablets are also available. Three to six tablets taken\\nbefore a meal or snack will aid in the digestion of solid\\nfoods. Lactose-reduced milk and other products are also\\navailable in stores. The milk contains the same nutrients\\nas regular milk.\\nBecause dairy products are an important source of\\ncalcium, people who reduce or severely limit their intake\\nof dairy products may need to consider other ways to\\nconsume an adequate amount of calcium in their diets.\\nPrognosis\\nWith good dietary management, individuals with\\ncarbohydrate intolerance can lead normal lives.\\nGALE ENCYCLOPEDIA OF MEDICINE 2650\\nCarbohydrate intolerance\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 650'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 39, 'page_label': '40'}, page_content='Prevention\\nSince the cause of the enzyme deficiency leading to\\ncarbohydrate intolerance is unknown, there is no way to\\nprevent this condition.\\nResources\\nBOOKS\\nMacdonald, Ian. “Carbohydrates.” In Modern Nutrition in\\nHealth and Disease, ed. Maurice E. Shils, et al. Philadel-\\nphia: Lea & Febiger, 1994.\\nWilliams, Sue Rodwell. Essentials of Nutrition and Diet Thera-\\npy. Philadelphia: Mosby, 1997.\\nPERIODICALS\\n“If You Think You Can’t Stomach Milk.”Tufts University Diet\\n& Nutrition Letter, 13 (Sept. 1995): 7.\\n“Lactose Intolerance.”Mayo Clinic Health Newsletter, 15 (Feb.\\n1997): 7.\\n“Most Frequently Asked Questions About Lactose Intoler-\\nance.” Nutrition Today(Mar./Apr. 1996): 78-79.\\nOTHER\\nNational Institute of Diabetes and Digestive and Kidney Dis-\\nease. .\\nKaren Ericson, RN\\nCarbon monoxide poisoning\\nDefinition\\nCarbon monoxide (CO) poisoning occurs when car-\\nbon monoxide gas is inhaled. CO is a colorless, odorless,\\nhighly poisonous gas that is produced by incomplete\\ncombustion. It is found in automobile exhaust fumes,\\nfaulty stoves and heating systems, fires, and cigarette\\nsmoke. Other sources include woodburning stoves,\\nkerosene heaters, improperly ventilated water heaters\\nand gas stoves, and blocked or poorly maintained chim-\\nney flues. CO interferes with the ability of the blood to\\ncarry oxygen. The result is headache , nausea, convul-\\nsions, and finally death by asphyxiation.\\nDescription\\nCarbon monoxide, sometimes called coal gas, has\\nbeen known as a toxic substance since the third century\\nB.C. It was used for executions and suicides in early Rome.\\nToday it is the leading cause of accidental poisoning in the\\nUnited States. According to the Journal of the American\\nMedical Association, 1,500 Americans die each year from\\naccidental exposure to CO, and another 2,300 from inten-\\ntional exposure (suicide). An additional 10,000 people\\nseek medical attention after exposure to CO and recover.\\nAnyone who is exposed to CO will become sick, and\\nthe entire body is involved in CO poisoning. A develop-\\ning fetus can also be poisoned if a pregnant woman\\nbreathes CO gas. Infants, people with heart or lung dis-\\nease, or those with anemia may be more seriously affect-\\ned. People such as underground parking garage atten-\\ndants who are exposed to car exhausts in a confined area\\nare more likely to be poisoned by CO. Firemen also run a\\nhigher risk of inhaling CO.\\nCauses and symptoms\\nNormally when a person breathes fresh air into the\\nlungs, the oxygen in the air binds with a molecule called\\nhemoglobin (Hb) that is found in red blood cells. This\\nallows oxygen to be moved from the lungs to every part\\nof the body. When the oxygen/hemoglobin complex\\nreaches a muscle where it is needed, the oxygen is\\nreleased. Because the oxygen binding process is\\nreversible, hemoglobin can be used over and over again\\nto pick up oxygen and move it throughout the body.\\nInhaling carbon monoxide gas interferes with this\\noxygen transport system. In the lungs, CO competes with\\noxygen to bind with the hemoglobin molecule. Hemo-\\nglobin prefers CO to oxygen and accepts it more than\\n200 times more readily than it accepts oxygen. Not only\\ndoes the hemoglobin prefer CO, it holds on to the CO\\nmuch more tightly, forming a complex called carboxyhe-\\nmoglobin (COHb). As a person breathes CO contaminat-\\ned air, more and more oxygen transportation sites on the\\nhemoglobin molecules become blocked by CO. Gradual-\\nly, there are fewer and fewer sites available for oxygen.\\nAll cells need oxygen to live. When they don’t get\\nenough oxygen, cellular metabolism is disrupted and\\neventually cells begin to die.\\nThe symptoms of CO poisoning and the speed with\\nwhich they appear depend on the concentration of CO in\\nthe air and the rate and efficiency with which a person\\nbreathes. Heavy smokers can start off with up to 9% of\\ntheir hemoglobin already bound to CO, which they regu-\\nlarly inhale in cigarette smoke. This makes them much\\nmore susceptible to environmental CO. The Occupation-\\nal Safety and Health Administration (OSHA) has estab-\\nlished a maximum permissible exposure level of 50 parts\\nper million (ppm) over eight hours.\\nWith exposure to 200 ppm for two to three hours, a\\nperson begins to experience headache, fatigue, nausea,\\nand dizziness . These symptoms correspond to 15–25%\\nCOHb in the blood. When the concentration of COHb\\nreaches 50% or more, death results in a very short time.\\nEmergency room physicians have the most experience\\ndiagnosing and treating CO poisoning.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 651\\nCarbon monoxide poisoning\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 651'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 40, 'page_label': '41'}, page_content='The symptoms of CO poisoning in order of increas-\\ning severity include:\\n• headache\\n• shortness of breath\\n• dizziness\\n• fatigue\\n• mental confusion and difficulty thinking\\n• loss of fine hand-eye coordination\\n• nausea and vomiting\\n• rapid heart rate\\n• hallucinations\\n• inability to execute voluntary movements accurately\\n• collapse\\n• lowered body temperature (hypothermia)\\n• coma\\n• convulsions\\n• seriously low blood pressure\\n• cardiac and respiratory failure\\n• death\\nIn some cases, the skin, mucous membranes, and\\nnails of a person with CO poisoning are cherry red or\\nbright pink. Because the color change doesn’t always\\noccur, it is an unreliable symptom to rely on for diagnosis.\\nAlthough most CO poisoning is acute, or sudden, it is\\npossible to suffer from chronic CO poisoning. This condi-\\ntion exists when a person is exposed to low levels of the gas\\nover a period of days to months. Symptoms are often vague\\nand include (in order of frequency) fatigue, headache,\\ndizziness, sleep disturbances, cardiac symptoms, apathy,\\nnausea, and memory disturbances. Little is known about\\nchronic CO poisoning, and it is often misdiagnosed.\\nKEY TERMS\\nCarboxyhemoglobin (COHb) —Hemoglobin that\\nis bound to carbon monoxide instead of oxygen.\\nHemoglobin (Hb) —A molecule that normally\\nbinds to oxygen in order to carry it to our cells,\\nwhere it is required for life.\\nHypothermia—Development of a subnormal body\\ntemperature.\\npH—A measurement of the acidity or alkalinity of\\na fluid. A neutral fluid, neither acid nor alkali, has\\na pH of 7.\\nDiagnosis\\nThe main reason to suspect CO poisoning is evidence\\nthat fuel is being burned in a confined area, for example a\\ncar running inside a closed garage, a charcoal grill burn-\\ning indoors, or an unvented kerosene heater in a work-\\nshop. Under these circumstances, one or more persons\\nsuffering from the symptoms listed above strongly sug-\\ngests CO poisoning. In the absence of some concrete rea-\\nson to suspect CO poisoning, the disorder is often misdi-\\nagnosed as migraine headache , stroke, psychiatric ill-\\nness, food poisoning, alcohol poisoning, or heart disease.\\nConcrete confirmation of CO poisoning comes from\\na carboxyhemoglobin test. This blood test measures the\\namount of CO that is bound to hemoglobin in the body.\\nBlood is drawn as soon after suspected exposure to CO\\nas possible.\\nOther tests that are useful in determining the extent\\nof CO poisoning include measurement of other arterial\\nblood gases and pH; a complete blood count ; measure-\\nment of other blood components such as sodium, potassi-\\num, bicarbonate, urea nitrogen, and lactic acid; an elec-\\ntrocardiogram (ECG); and a chest x ray.\\nTreatment\\nImmediate treatment for CO poisoning is to remove\\nthe victim from the source of carbon monoxide gas and\\nget him or her into fresh air. If the victim is not breathing\\nand has no pulse, cardiopulmonary resuscitation\\n(CPR) should be started. Depending on the severity of\\nthe poisoning, 100% oxygen may be given with a tight\\nfitting mask as soon as it is available.\\nTaken with other symptoms of CO poisoning, COHb\\nlevels of over 25% in healthy individuals, over 15% in\\npatients with a history of heart or lung disease, and over\\n10% in pregnant women usually indicate the need for\\nhospitalization. In the hospital, fluids and electrolytes are\\ngiven to correct any imbalances that have arisen from the\\nbreakdown of cellular metabolism.\\nIn severe cases of CO poisoning, patients are given\\nhyperbaric oxygen therapy. This treatment involves plac-\\ning the patient in a chamber breathing 100% oxygen at a\\npressure of more than one atmosphere (the normal pres-\\nsure the atmosphere exerts at sea level). The increased\\npressure forces more oxygen into the blood. Hyperbaric\\nfacilities are specialized, and are usually available only at\\nlarger hospitals.\\nPrognosis\\nThe speed and degree of recovery from CO poison-\\ning depends on the length and duration of exposure to\\nGALE ENCYCLOPEDIA OF MEDICINE 2652\\nCarbon monoxide poisoning\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 652'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 41, 'page_label': '42'}, page_content='the gas. The half-life of CO in normal room air is four to\\nfive hours. This means that, in four to five hours, half of\\nthe CO bound to hemoglobin will be replaced with oxy-\\ngen. At normal atmospheric pressures, but breathing\\n100% oxygen, the half-life for the elimination of CO\\nfrom the body is 50-70 minutes. In hyperbaric therapy at\\nthree atmospheres of pressure, the half-life is reduced to\\n20-25 minutes.\\nAlthough the symptoms of CO poisoning may sub-\\nside in a few hours, some patients show memory prob-\\nlems, fatigue, confusion, and mood changes for two to\\nfour weeks after their exposure to the gas.\\nPrevention\\nCarbon monoxide poisoning is preventable. Particu-\\nlar care should be paid to situations where fuel is burned\\nin a confined area. Portable and permanently installed\\ncarbon monoxide detectors that sound a warning similar\\nto smoke detectors are available for under $50. Specific\\nactions that will prevent CO poisoning include:\\n• stop smoking. Smokers have less tolerance to environ-\\nmental CO\\n• have heating systems and appliances installed by a\\nqualified contractor to assure that they are properly\\nvented and meet local building codes\\n• inspect and properly maintain heating systems, chim-\\nneys, and appliances\\n• do not use a gas oven or stove to heat the home\\n• do not burn charcoal indoors\\n• make sure there is good ventilation if using a kerosene\\nheater indoors\\n• do not leave cars or trucks running inside the garage\\n• keep car windows rolled up when stuck in heavy traffic,\\nespecially if inside a tunnel\\nResources\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nOTHER\\n“Carbon Monoxide Headquarters.”Wayne State University\\nSchool of Medicine..\\nTish Davidson\\nCarbunculosis see Boils\\nCarcinoembryonic antigen test\\nDefinition\\nThe carcinoembryonic antigen (CEA) test is a labo-\\nratory blood study. CEA is a substance which is normally\\nfound only during fetal development, but may reappear\\nin adults who develop certain types of cancer.\\nPurpose\\nThe CEA test is ordered for patients with known\\ncancers. The CEA test is most commonly ordered when a\\npatient has a cancer of the gastrointestinal system. These\\ninclude cancer of the colon, rectum, stomach (gastric\\ncancer), esophagus, liver, or pancreas. It is also used with\\ncancers of the breast, lung, or prostate.\\nThe CEA level in the blood is one of the factors that\\ndoctors consider when determining the prognosis, or\\nmost likely outcome of a cancer. In general, a higher\\nCEA level predicts a more severe disease, one that is less\\nlikely to be curable. But it does not give clear-cut infor-\\nmation. The results of a CEA test are usually considered\\nalong with other laboratory and/or imaging studies to fol-\\nlow the course of the disease.\\nOnce treatment for the cancer has begun, CEA tests\\nhave a valuable role in monitoring the patient’s progress.\\nA decreasing CEA level means therapy is effective in\\nfighting the cancer. A stable or increasing CEA level may\\nmean the treatment is not working, and/or that the tumor\\nis growing. It is important to understand that serial CEA\\nmeasurements, which means several done over a period\\nof time, are the most useful. A single test result is diffi-\\ncult to evaluate, but a number of tests, done weeks apart,\\nshows trends in disease progression or regression.\\nCertain types of cancer treatments, such as hormone\\ntherapy for breast cancer , may actually cause the CEA\\nlevel to go up. This elevation does not accurately reflect\\nthe state of the disease. It is sometimes referred to as a\\n“flare response.” Recognition that a rise in CEA may be\\ntemporary and due to therapy is significant. If this possi-\\nbility is not taken into account, the patient may be unnec-\\nessarily discouraged. Further, treatment that is actually\\neffective may be stopped or changed prematurely.\\nCEA tests are also used to help detect recurrence of a\\ncancer after surgery and/or other treatment has been com-\\npleted. A rising CEA level may be the first sign of cancer\\nreturn, and may show up months before other studies or\\npatient symptoms would raise concern. Unfortunately, this\\ndoes not always mean the recurrent cancer can be cured.\\nFor example, only a small percentage of patients with col-\\norectal cancers and rising CEA levels will benefit from\\nGALE ENCYCLOPEDIA OF MEDICINE 2 653\\nCarcinoembryonic antigen test\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 653'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 42, 'page_label': '43'}, page_content='another surgical exploration. Those with recurrence in the\\nsame area as the original cancer, or with a single metastat-\\nic tumor in the liver or lung, have a chance that surgery\\nwill eliminate the disease. Patients with more widespread\\nreturn of the cancer are generally not treatable with\\nsurgery. The CEA test will not separate the two groups.\\nPatients who are most likely to benefit from non-\\nstandard treatments, such as bone marrow transplants,\\nmay be determined on the basis of CEA values, com-\\nbined with other test results. CEA levels may be one of\\nthe criteria for determining whether the patient will bene-\\nfit from more expensive studies, such as CT scan or MRI.\\nPrecautions\\nThe CEA test is not a screening test for cancer. It is\\nnot useful for detecting the presence of cancer. Many\\ncancers do not produce an increased CEA level. Some\\nnoncancerous diseases, such as hepatitis, inflammatory\\nbowel disease, pancreatitis, and obstructive pulmonary\\ndisease, may cause an elevated CEA level.\\nDescription\\nDetermination of the CEA level is a laboratory\\nblood test. Obtaining a specimen of blood for the study\\ntakes only a few minutes. CEA testing should be covered\\nby most insurance plans.\\nPreparation\\nNo preparation is required.\\nAftercare\\nNone.\\nRisks\\nThere are no complications or side effects of this\\ntest. However, the results of a CEA study should be inter-\\npreted with caution. A single test result may not yield\\nclinically useful information. Several studies over a peri-\\nod of months may be needed.\\nAnother concern is the potential for false positive as\\nwell as false negative results. A false positive result\\nmeans the test shows an abnormal value when cancer is\\nnot present. A false negative means the test reveals a nor-\\nmal value when cancer actually is present.\\nNormal results\\nThe absolute numbers which are considered normal\\nvary from one laboratory to another. Any results reported\\nshould come with information regarding the testing facil-\\nity’s normal range.\\nAbnormal results\\nA single abnormal CEA value may be significant,\\nbut must be regarded cautiously. In general, very high\\nCEA levels indicate more serious cancer, with a poorer\\nchance for cure. But some benign diseases and certain\\ncancer treatments may produce an elevated CEA test.\\nCigarette smoking will also cause the CEA level to be\\nabnormally high.\\nResources\\nBOOKS\\nCooper, Dennis L. “Tumor Markers.” In Cecil Textbook of\\nMedicine, ed. J. Claude Bennet and Fred Plum. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nEllen S. Weber, MSN\\nCarcinoid tumors see Neuroendocrine\\ntumors\\nCardiac arrest see Sudden cardiac death\\nCardiac arrhythmias see Arrhythmias\\nCardiac blood pool scan\\nDefinition\\nA cardiac blood pool scan is a non-invasive test that\\nuses a mildly radioactive marker to observe the function-\\ning of the left ventricle of the heart.\\nPurpose\\nThe left ventricle is the main pump for distributing\\nblood through the body. A cardiac blood pool scan is\\nused to determine how efficiently the left ventricle is\\nworking. The scan can detect aneurysms of the left ven-\\ntricle, motion abnormalities caused by damage to the\\nheart wall, cardiac shunts between the left and right ven-\\ntricle, and coronary occlusive artery disease.\\nPrecautions\\nPregnant women are the only patients who should\\nnot participate in a cardiac blood pool scan. However, the\\naccuracy of the results may be affected if the patient\\nmoves during imaging, has had other recent nuclear\\nscans, or has an irregular heartbeat.\\nGALE ENCYCLOPEDIA OF MEDICINE 2654\\nCardiac blood pool scan\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 654'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 43, 'page_label': '44'}, page_content='Description\\nA cardiac blood pool scan is sometimes called\\nequilibrium radionuclide angiocardiography or gated\\n(synchronized) cardiac blood pool imaging. A multi-\\nple-gated acquisition (MUGA) scan is a variation of\\nthis test.\\nTo perform a cardiac blood pool scan, the patient\\nlies under a special gamma scintillation camera that\\ndetects radiation. A protein tagged with a radioactive\\nmarker (usually technetium-99m) is injected into the\\npatient’s forearm.\\nThe camera is synchronized with an electrocardio-\\ngram (ECG) to take a picture at specific times in the\\ncycle of heart contraction and relaxation. When data\\nfrom many sequential pictures is processed by a comput-\\ner, a doctor can analyze whether the left ventricle is func-\\ntioning normally.\\nThe patient needs to remain silent and motionless\\nduring the test. Sometimes the patient is asked to exer-\\ncise, then another set of pictures is taken for comparison.\\nThis test normally takes about 30 minutes.\\nPreparation\\nNo changes in diet or medication are necessary. An\\nECG will probably be done before the test.\\nAftercare\\nThe patient may resume normal activities immedi-\\nately.\\nRisks\\nCardiac blood pool scans are a safe and effective\\nway of measuring left ventricle function. The only risk is\\nto the fetus of a pregnant woman.\\nNormal results\\nA computer is used to process the information from\\nthe test, then the results are analyzed by a doctor. A nor-\\nmally functioning left ventricle will contract symmetri-\\ncally, show even distribution of the radioactively tagged\\nprotein, and eject about 55–65% of volume of blood it\\nholds on each contraction.\\nAbnormal results\\nPatients with damage to the ventricle or heart wall\\nwill show an uneven distribution of the radiopharmaceu-\\ntical. The volume of blood ejected in each contraction\\nwill be less than 55%.\\nKEY TERMS\\nAneurysm—A sac or bulge that forms because of a\\nweak spot in the wall of an artery or heart chamber.\\nCardiac shunt —A defect in the wall of the heart\\nthat allows blood from different chambers to mix.\\nCoronary occlusive artery disease —Blockage of\\nthe arteries that supply blood to the heart; fre-\\nquently a precursor to a heart attack.\\nElectrocardiogram (ECG)—A graph that shows the\\nelectrical charges that trigger the heart to contract.\\nHeart abnormalities alter the graph, giving clues to\\nthe source of the abnormality.\\nVentricle—One of the two bottom chambers of\\nthe heart (the heart has four chambers). The left\\nventricle acts as the body’s main pump for blood.\\nResources\\nBOOKS\\n“Cardiac Blood Pool Imaging.” In Illustrated Guide to Diag-\\nnostic Tests, ed. J. A. Lewis. Springhouse, PA: Spring-\\nhouse Corp., 1994.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nTish Davidson\\nCardiac catheterization\\nDefinition\\nCardiac catheterization (also called heart catheteri-\\nzation) is a diagnostic procedure which does a compre-\\nhensive examination of how the heart and its blood ves-\\nsels function. One or more catheters is inserted through a\\nperipheral blood vessel in the arm (antecubital artery or\\nvein) or leg (femoral artery or vein) with x-ray guidance.\\nThis procedure gathers information such as adequacy of\\nblood supply through the coronary arteries, blood pres-\\nsures, blood flow throughout chambers of the heart, col-\\nlection of blood samples, and x rays of the heart’s ventri-\\ncles or arteries.\\nA test that can be performed on either side of the\\nheart, cardiac catheterization checks for different func-\\ntions in both the left and right sides. When testing the\\nheart’s right side, tricuspid and pulmonary valve function\\nGALE ENCYCLOPEDIA OF MEDICINE 2 655\\nCardiac catheterization\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 655'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 44, 'page_label': '45'}, page_content='are evaluated, in addition to measuring pressures of and\\ncollecting blood samples from the right atrium, ventricle,\\nand pulmonary artery. Left-sided heart catheterization is\\nperformed by way of a catheter through an artery which\\ntests the blood flow of the coronary arteries, function of\\nthe mitral and aortic valves, and left ventricle.\\nPurpose\\nThe primary reason for conducting a cardiac\\ncatheterization is to diagnose and manage persons known\\nor suspected to have heart disease, a frequently fatal con-\\ndition that leads to 1.5 million heart attacks annually in\\nthe United States.\\nSymptoms and diagnoses that may lead to perform-\\ning this procedure include:\\n• chest pain, characterized by prolonged heavy pressure\\nor a squeezing pain\\n• abnormal treadmill stress test\\n• myocardial infarction, also known as a heart attack\\n• congenital heart defects, or heart problems that origi-\\nnated from birth\\n• a diagnosis of valvular-heart disease\\n• a need to measure the heart muscle’s ability to pump\\nblood\\nTypically performed along with angiography, a tech-\\nnique of injecting a dye into the vascular system to outline\\nthe heart and blood vessels, a catheterization can aid in the\\nvisualization of any blockages, narrowing, or abnormalities\\nin the coronary arteries. If these signs are visible, the cardi-\\nologist may assess the patient’s need and readiness for\\ncoronary bypass surgery, or perhaps a less invasive\\napproach, such as dilation of a narrowed blood vessel either\\nsurgically or with the use of a balloon (angioplasty).\\nWhen looking at the left side of the heart, fluoro-\\nscopic guidance also allows the following diagnoses to\\nbe assessed:\\n• enlargement of the left ventricle\\n• ventricular aneurysms (abnormal dilation of a blood\\nvessel)\\n• narrowing of the aortic valve\\n• insufficiency of the aortic or mitral valve\\n• the detour of blood from one side of the heart to the\\nother due to septal defects (also known as shunting)\\nPrecautions\\nCardiac catheterization is categorized as an “inva-\\nsive” procedure which involves the heart, its valves, and\\ncoronary arteries, in addition to a large artery in the arm\\nor leg. Due to the nature of the test, it is important to\\nevaluate for the following conditions before considering\\nthis procedure:\\n• A diagnosis of a bleeding disorder, poor kidney func-\\ntion, or debilitation. Any of these pre-existing condi-\\ntions typically raises the risk of the catheterization pro-\\ncedure and may be reason to cancel the procedure.\\n• A diagnosis of heart valve disease. If this is detected,\\nantibiotics may be given before the test to prevent\\ninflammation of the membrane which lines the heart\\n(endocarditis).\\nDescription\\nTo understand how a cardiac catheterization is able\\nto diagnose and manage heart disease, the basic work-\\nings of the heart muscle must also be understood. Just as\\nthe body relies on a constant supply of blood to aid in its\\neveryday functions, so does the heart. The heart is made\\nup of an intricate web of blood vessels (coronary arter-\\nies) that ensure an adequate supply of blood rich in oxy-\\ngen and nutrients. It is easy to see how an abnormality in\\nany of these arteries can be detrimental to the heart’s\\nfunction. These abnormalities cause the heart’s blood\\nflow to decrease and result in the condition known as\\ncoronary artery disease or coronary insufficiency.\\nCatheterization is a valuable tool in detecting and\\ntreating abnormalities of the heart. Through the use of\\nfluoroscopic (x ray) guidance, a catheter, which may\\nresemble a balloon-tipped tube, is strung through the\\nveins or arteries into the heart, so the cardiologist can\\nmonitor a body’s various functions at each moment.\\nGenerally a test that lasts two to three hours, a\\npatient should expect the following prior to and during\\nthe catheterization procedure:\\n• A mild sedative may be given that will allow the patient\\nto relax but remain conscious during the test.\\n• An intravenous needle will be inserted in the arm to\\nadminister medication. Electrodes will be attached to\\nthe chest to enable the painless procedure known as an\\nelectrocardiograph.\\n• Prior to inserting a catheter into an artery or vein in the\\narm or leg, the incision site will be made numb by\\ninjecting a local anesthetic. When the anesthetic is\\ninjected it may feel like a pin-prick followed by a quick\\nstinging sensation. Pressure may also be experienced as\\nthe catheter travels through the blood vessel.\\n• After the catheter is guided into the coronary-artery\\nsystem, a dye (also called a radiocontrast material) is\\ninjected to aid in the identification of any abnormalities\\nGALE ENCYCLOPEDIA OF MEDICINE 2656\\nCardiac catheterization\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 656'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 45, 'page_label': '46'}, page_content='of the heart. During this time, the patient may experi-\\nence a hot, flushed feeling or a quickly passing nausea.\\nCoughing or breathing deeply aids in any discomfort.\\n• Medication may be given during the procedure if chest\\npain is experienced, and nitroglycerin may also be admin-\\nistered to allow expansion of the heart’s blood vessels.\\n• When the test is complete, the physician will remove the\\ncatheter and close the skin with several sutures or tape.\\nPreparation\\nPrior to the cardiac catheterization procedure, it is\\nimportant to relay information to the physician or nurse\\nregarding allergies to shellfish (such as shrimp or scal-\\nlops) which contain iodine, iodine itself, or the dyes that\\nare commonly used in other diagnostic tests.\\nBecause this procedure is categorized as a surgery, the\\npatient will be instructed not to eat or drink anything for at\\nleast six hours prior to the test. Just before the test begins,\\nthe patient will urinate and change into a hospital gown,\\nthen lie flat on a padded table that may also be tilted in\\norder for the heart to be examined from a variety of angles.\\nAftercare\\nWhile cardiac catheterization may be performed on\\nan outpatient basis, a patient may require close monitor-\\ning following the procedure while remaining in the hos-\\npital for at least 24 hours. The patient will be instructed\\nto rest in bed for at least eight hours immediately after\\nthe test. If the catheter was inserted into a vein or artery\\nin the leg or groin area, the leg will be kept extended for\\nfour to six hours. If a vein or artery in the arm was used\\nto insert the catheter, the arm will need to remain extend-\\ned for a minimum of three hours.\\nThe patient should expect a hard ridge to form over\\nthe incision site that diminishes as the site heals. Bluish\\ndiscoloration under the skin at the point of insertion\\nshould also be expected but fades in two weeks. It is also\\nnot uncommon for the incision site to bleed during the\\nfirst 24 hours following surgery. If this should happen,\\nthe patient should apply pressure to the site with a clean\\ntissue or cloth for 10–15 minutes.\\nRisks\\nSimilar to all surgical procedures, the cardiac\\ncatheterization test does involve some risks. Complica-\\ntions that may occur during the procedure include\\n• cardiac arrhythmias (an irregular heart beat)\\n• pericardial tamponade (a condition that causes excess\\npressure in the pericardium which affects the heart due\\nto accumulation of excess fluid)\\n• the rare occurrence of myocardial infarction (heart\\nattack) or stroke may also develop due to clotting or\\nplaque rupture of one or more of the coronary or brain\\narteries.\\nBefore left-side catheterization is performed, the\\nanticoagulant medication heparin may be administered.\\nThis drug helps decrease the risk of the development of a\\nblood clot in an artery (thrombosis) and blood clots trav-\\neling throughout the body (embolization).\\nThe risks of the catheterization procedure increase\\nin patients over the age of 60, those who have severe\\nheart failure , or persons with serious valvular heart\\ndisease.\\nNormal results\\nNormal findings from a cardiac catheterization will\\nindicate no abnormalities of heart chamber size or con-\\nfiguration, wall motion or thickness, the direction of\\nblood flow, or motion of the valves. Smooth and regular\\noutlines on the x ray indicate normal coronary arteries.\\nAn essential part of the catheterization is measuring\\nintracardiac pressures, or the pressure in the heart’s\\nchambers and vessels. Pressure readings that are higher\\nGALE ENCYCLOPEDIA OF MEDICINE 2 657\\nCardiac catheterization\\nThe catheter\\nextends from the \\ngroin area to \\nthe heart.\\nThe cardiac catheter runs from the groin to the heart.(Illus-\\ntration by Argosy Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 657'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 46, 'page_label': '47'}, page_content='than normal are significant for a patient’s overall diagno-\\nsis. The pressure readings that are lower, other than those\\nwhich are produced as a result of shock, typically are not\\nsignificant.\\nAn ejection fraction, or a comparison of how much\\nblood is ejected from the heart’s left ventricle during its\\ncontraction phase with a measurement of blood remain-\\ning at the end of the left ventricle’s relaxation phase, is\\nalso determined by performing a catheterization. The\\ncardiologist will look for a normal ejection fraction read-\\ning of 60–70%.\\nAbnormal results\\nCardiac catheterization provides valuable still and\\nmotion x-ray pictures of the coronary arteries that help in\\ndiagnosing coronary artery disease, poor heart function,\\ndisease of the heart valves, and septal defects (a defect in\\nthe septum, the wall that separates two heart chambers).\\nThe most prominent sign of coronary artery disease\\nis the narrowing or blockage in the coronary arteries,\\nwith narrowing that is greater than 70% considered sig-\\nnificant. A clear indication for intervention (by angio-\\nplasty or surgery) is a finding of significant narrowing\\nof the left main coronary artery and/or blockage or\\nsevere narrowing in the high, left anterior descending\\ncoronary artery.\\nKEY TERMS\\nAneurysm—An abnormal dilatation of a blood ves-\\nsel, usually an artery. It can be caused by a congeni-\\ntal defect or weakness in the vessel’s wall.\\nAngiography—In cardiac catheterization, a picture\\nof the heart and coronary arteries is seen after\\ninjecting a radiopaque substance (often referred to\\nas a dye) throughout the veins and arteries.\\nAngioplasty —An alternative to vascular surgery, a\\nballoon catheter is used to mechanically dilate the\\naffected area of the artery and enlarge the constrict-\\ned or narrowed segment.\\nAortic valve —The valve between the heart’s left\\nventricle and ascending aorta that prevents regurgi-\\ntation of blood back into the left ventricle.\\nCatheter—A tube made of elastic, elastic web, rub-\\nber, glass, metal, or plastic used to evacuate or inject\\nfluids into the body. In cardiac catheterization, a\\nlong, fine catheter is used for passage through a\\nblood vessel into the chambers of the heart.\\nCoronary bypass surgery —A surgical procedure\\nwhich places a shunt to allow blood to travel from\\nthe aorta to a branch of the coronary artery at a\\npoint past an obstruction.\\nLeft anterior descending coronary artery (LAD) —\\nOne of the heart’s coronary artery branches from\\nthe left main coronary artery which supplies blood\\nto the left ventricle.\\nMitral valve—The bicuspid valve which is between\\nthe left atrium and left ventricle of the heart.\\nPulmonary valve —The heart valve which is posi-\\ntioned between the right ventricle and the opening\\ninto the pulmonary artery.\\nShunt— A passageway (or an artificially created pas-\\nsageway) that diverts blood flow from one main\\nroute to another.\\nTricuspid valve—The right atrioventricular valve of\\nthe heart.\\nA finding of impaired wall motion is an additional\\nindicator of coronary artery disease, aneurysm, an\\nenlarged heart, or a congenital heart problem. Using the\\nfindings from an ejection fraction test which measures\\nwall motion, cardiologists look at an ejection fraction\\nreading under 35% as increasing the risk of complica-\\ntions while also decreasing a successful long term or\\nshort term outcome with surgery.\\nDetecting the difference in pressure above and\\nbelow the heart valve can verify heart valve disease. The\\ngreater narrowing correlates with the higher pressure dif-\\nference.\\nTo confirm septal defects, a catheterization measures\\noxygen content on both the left and right sides of the\\nheart. The right heart pumps unoxygenated blood to the\\nlungs, and the left heart pumps blood that contains oxy-\\ngen from the lungs to the rest of the body. Right side ele-\\nvated oxygen levels indicate left-to-right atrial or ven-\\ntricular shunt . A left side that experiences decreased\\noxygen indicates a right-to-left shunt.\\nResources\\nBOOKS\\nBennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-\\nicine. Philadelphia: W. B. Saunders Co., 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 2658\\nCardiac catheterization\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 658'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 47, 'page_label': '48'}, page_content='Everything You Need to Know About Medical Tests.Ed.\\nMichael Shaw, et al. Springhouse, PA: Springhouse Cor-\\nporation, 1996.\\nGriffith, H. Winter. “Cardiac Catheterization & Angiocardiog-\\nraphy.” In Complete Guide To Symptoms, Illness and\\nSurgery. New York: The Berkley Publishing Group, 1995.\\n“Heart.” In Current Medical Diagnosis and Treatment, 1996.\\n35th ed. Ed. Stephen McPhee, et al. Stamford: Appleton\\n& Lange, 1995.\\nThe Patient’s Guide to Medical Tests.Ed. Barry L. Zaret, et al.\\nBoston: Houghton Mifflin, 1997.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nBeth A. Kapes\\nCardiac compression see Cardiac\\ntamponade\\nCardiac conduction disorder see Heart\\nblock\\nCardiac mapping see Electrophysiology\\nstudy of the heart\\nCardiac rehabilitation\\nDefinition\\nCardiac rehabilitation is a comprehensive exercise,\\neducation, and behavioral modification program designed\\nto improve the physical and emotional condition of\\npatients with heart disease.\\nPurpose\\nHeart attack survivors, bypass and angioplasty\\npatients, and individuals with angina, congestive heart\\nfailure, and heart transplants are all candidates for a car-\\ndiac rehabilitation program. Cardiac rehabilitation is pre-\\nscribed to control symptoms, improve exercise tolerance,\\nand improve the overall quality of life in these patients.\\nPrecautions\\nA cardiac rehabilitation program should be imple-\\nmented and closely monitored by a trained team of\\nhealthcare professionals.\\nDescription\\nCardiac rehabilitation is overseen by a specialized\\nteam of doctors, nurses, and other healthcare profession-\\nals. Members of the cardiac rehabilitation team may\\ninclude a dietician or nutritionist, physical therapist,\\nexercise physiologist, psychologist, vocational coun-\\nselor, occupational therapist, and social worker. The pro-\\ngram frequently begins in a hospital setting and contin-\\nues on an outpatient basis after the patient is discharged\\nover a period of six to 12 months.\\nComponents of a cardiac rehabilitation program\\nvary by individual clinical need, and each program will\\nbe carefully constructed for the patient by his or her reha-\\nbilitation team.\\n• Exercise. Exercise programs typically start out slowly,\\nwith simple range-of-motion arm and leg exercises.\\nWalking and stair climbing soon follow. Blood pressure\\nis carefully monitored before and after exercise ses-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 659\\nCardiac rehabilitation\\nThis 40-year-old male is working out on a treadmill, moni-\\ntored by his physician, following heart surgery.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 659'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 48, 'page_label': '49'}, page_content='sions, and patients are taught how to measure their\\nheart rate and evaluate any possible cardiac symptoms\\nduring each session. Patients with advanced coronary\\ndisease may require continuous ECG monitoring\\nthroughout their exercise sessions. Once discharged\\nfrom the hospital, the patient works with his cardiac\\nteam to create an individual exercise plan.\\n• Diet. Cardiac patients will work with a nutritionist or\\ndietician to develop a low-fat, low-cholesterol diet\\nplan. Patients with high blood pressure may be put on a\\nsalt-restricted diet and instructed to limit alcohol\\nintake. Weight loss may also be a goal with obese car-\\ndiac patients.\\n• Counseling. A psychologist or social worker can help\\ncardiac patients with issues that may be contributing to\\ntheir heart condition, such as stress and anxiety. Relax-\\nation techniques may be taught to patients to help them\\ndeal with these feelings. Cardiac patients frequently\\nexperience a period of depression, and group or indi-\\nvidual counseling can be beneficial in overcoming\\nthese feelings. V ocational counselors can assist cardiac\\npatients in returning to the workforce.\\n• Education. The patient and family should be fully edu-\\ncated on the physical limitations of the patient, his rec-\\nommended diet and exercise plan, his emotional status,\\nand the lifestyle changes required to improve the\\npatient’s overall health.\\n• Smoking cessation. Cardiac patients who smoke are\\ntwice as likely to have a heart attack in the following\\nfive years than non-smoking patients. These patients\\nare strongly encouraged to enroll in a smoking cessa-\\ntion program, which typically includes patient educa-\\ntion and behavioral counseling. Nicotine replacement\\ntherapy, which uses nicotine patches, nose spray, or\\ngum to wean patients off of cigarettes, may also be part\\nof the program. Antidepressants and anti-anxiety med-\\nication may be helpful in some cases.\\nAftercare\\nLong-term maintenance is a critical feature of car-\\ndiac rehabilitation. Patients require support from their\\nKEY TERMS\\nAngina—Chest pain.\\nBypass surgery —A surgical procedure that grafts\\nblood vessels onto arteries to reroute the blood flow\\naround blockages in the arteries (arteriosclerosis).\\nhealthcare team, family, and friends to continue the\\nlifestyle changes they implemented during the rehabilita-\\ntion period.\\nRisks\\nThe risks of another heart attack during cardiac reha-\\nbilitation are slight, and greatly reduced by careful, con-\\ntinuous monitoring of the physical status of the patient.\\nNormal results\\nThe outcome of the cardiac rehabilitation program\\ndepends on a number of variables, including patient fol-\\nlow-through, type and degree of heart disease, and the\\navailability of an adequate support network for the\\npatient. Patients who successfully complete the program\\nwill ideally reach an age-appropriate level of physical\\nactivity and be able to return to the workforce and/or\\nother daily activities.\\nResources\\nBOOKS\\nThe American Heart Association. American Heart Association\\nGuide to Heart Attack Treatment, Recovery, and Preven-\\ntion. New York: Times Books, 1996.\\nDeBakey, Michael E., and Antonio Gotto Jr. The New Living\\nHeart. Holbrook, MA: Adams Media Corporation, 1997.\\nPERIODICALS\\nHarvard Medical School. “Cardiac Rehabilitation.”Harvard\\nHealth Letter, 7 no. 5 (Jan. 1997): 3-7.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nPaula Anne Ford-Martin\\nCardiac tamponade\\nDefinition\\nCardiac tamponade occurs when the heart is\\nsqueezed by fluid that collects inside the sac that sur-\\nrounds it.\\nDescription\\nThe heart is surrounded by a sac called the pericardi-\\num. When this sac becomes filled with fluid, the liquid\\npresses on the heart, preventing the lower chambers of\\nthe heart from properly filling with blood.\\nGALE ENCYCLOPEDIA OF MEDICINE 2660\\nCardiac tamponade\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 660'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 49, 'page_label': '50'}, page_content='Because the lower chambers (the ventricles) cannot fill\\nwith the correct amount of blood, less than normal amounts\\nof blood reach the lungs and the rest of the body. This con-\\ndition is very serious and can be fatal if not treated.\\nCauses and symptoms\\nFluid can collect inside the pericardium and com-\\npress the heart when the kidneys do not properly remove\\nwaste from the blood, when the pericardium swells from\\nunknown causes, from infection, or when the pericardium\\nis damaged by cancer. Blunt or penetrating injury from\\ntrauma to the chest or heart can also result in cardiac tam-\\nponade when large amounts of blood fill the pericardium.\\nTamponade can also occur during heart surgery.\\nWhen the heart is compressed by the surrounding\\nfluid, three conditions occur: a reduced amount of blood\\nis pumped to the body by the heart, the lower chambers\\nof the ventricles are filled with a less than normal amount\\nof blood, and higher than normal blood pressures occur\\ninside the heart, caused by the pressure of the fluid push-\\ning in on the heart from the outside.\\nWhen tamponade occurs because of trauma, the\\nsound of the heart beats can become faint, and the blood\\npressure in the arteries decreases, while the blood pres-\\nsure in the veins increases.\\nIn cases of tamponade caused by more slowly devel-\\noping diseases, shortness of breath , a feeling of tight-\\nness in the chest, increased blood pressure in the large\\nveins in the neck (the jugular veins), weight gain, and\\nfluid retention by the body can occur.\\nDiagnosis\\nWhen cardiac tamponade is suspected, accurate diag-\\nnosis can be life-saving. The most accurate way to identi-\\nfy this condition is by using a test called an echocardio-\\ngram. This test uses sound waves to create an image of\\nthe heart and its surrounding sac, making it easy to visual-\\nize any fluid that has collected inside the sac.\\nTreatment\\nIf the abnormal fluid buildup in the pericardial sac is\\ncaused by cancer or kidney disease, drugs used to treat\\nthese conditions can help lessen the amount of fluid col-\\nlecting inside the sac. Drugs that help maintain normal\\nblood pressure throughout the body can also help this\\ncondition; however, these drugs are only a temporary\\ntreatment. The fluid within the pericardium must be\\ndrained out to reduce the pressure on the heart and\\nrestore proper heart pumping.\\nThe fluid inside the pericardium is drained by insert-\\ning a needle through the chest and into the sac itself. This\\nKEY TERMS\\nPericardiocentesis —A procedure used to drain\\nfluid out of the sac surrounding the heart. This is\\ndone by inserting a needle through the chest and\\ninto the sac.\\nallows the fluid to flow out of the sac, relieving the\\nabnormal pressure on the heart. This procedure is called\\npericardiocentesis. In severe cases, a tube (catheter) can\\nbe inserted into the sac or a section of the sac can be sur-\\ngically cut away to allow for more drainage.\\nPrognosis\\nThis condition is life-threatening. However, drug\\ntreatments can be helpful, and surgical treatments can\\nsuccessfully drain the trapped fluid, though it may reac-\\ncumulate. Some risk of death exists with surgical\\ndrainage of the accumulated fluid.\\nResources\\nBOOKS\\nBraunwald, Eugene. “Pericardial Disease.” In Harrison’s Prin-\\nciples of Internal Medicine, ed. Anthony S. Fauci, et al.\\nNew York: McGraw-Hill, 1997.\\nShabetai, Ralph. “Diseases of the Pericardium.” In Hurst’s The\\nHeart, ed. Robert C. Schlant, et. al. New York: McGraw\\nHill, 1994.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nDominic De Bellis, PhD\\nCardiac tumors see Myxoma\\nCardiogenic shock see Shock\\nCardiomyopathy see Congestive cardio-\\nmyopathy; Restrictive cardiomyopathy\\nCardiopulmonary\\nresuscitation (CPR)\\nDefinition\\nCardiopulmonary resuscitation (CPR) is a procedure\\nto support and maintain breathing and circulation for a\\nGALE ENCYCLOPEDIA OF MEDICINE 2 661\\nCardiopulmonary resuscitation (CPR)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 661'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 50, 'page_label': '51'}, page_content='person who has stopped breathing (respiratory arrest)\\nand/or whose heart has stopped (cardiac arrest).\\nPurpose\\nCPR is performed to restore and maintain breathing\\nand circulation and to provide oxygen and blood flow to\\nthe heart, brain, and other vital organs. CPR should be\\nperformed if a person is unconscious and not breathing.\\nRespiratory and cardiac arrest can be caused by allergic\\nreactions, an ineffective heartbeat, asphyxiation, breath-\\ning passages that are blocked, choking, drowning, drug\\nreactions or overdoses, electric shock, exposure to cold,\\nsevere shock, or trauma. CPR can be performed by\\ntrained bystanders or healthcare professionals on infants,\\nchildren, and adults. It should always be performed by\\nthe person on the scene who is most experienced in CPR.\\nPrecautions\\nCPR should never be performed on a healthy person\\nbecause it can cause serious injury to a beating heart by\\ninterfering with normal heartbeats.\\nDescription\\nCPR is part of the emergency cardiac care system\\ndesigned to save lives. Many deaths can be prevented by\\nprompt recognition of the problem and notification of the\\nemergency medical system (EMS), followed by early\\nCPR, defibrillation (which delivers a brief electric\\nshock to the heart in attempt to get the heart to beat nor-\\nmally), and advanced cardiac life support measures.\\nCPR must be performed within four to six minutes\\nafter cessation of breathing so as to prevent brain damage\\nor death. It is a two-part procedure that involves rescue\\nbreathing and external chest compressions. To provide\\noxygen to a person’s lungs, the rescuer administers mouth-\\nto-mouth breaths, then helps circulate blood through the\\nheart to vital organs by external chest compressions.\\nMouth-to-mouth breathing and external chest compression\\nshould be performed together, but if the rescuer is not\\nstrong enough to do both, the external chest compressions\\nshould be done. This is more effective than no resuscita-\\ntion attempt, as is CPR that is performed “poorly.”\\nWhen performed by a bystander, CPR is designed to\\nsupport and maintain breathing and circulation until\\nemergency medical personnel arrive and take over. When\\nperformed by healthcare personnel, it is used in conjunc-\\ntion with other basic and advanced life support measures.\\nAccording to the American Heart Association, early\\nCPR and defibrillation combined with early advanced\\nemergency care can increase survival rates for people\\nwith a type of abnormal heart beat called ventricular\\nfibrillation by as much as 40%. CPR by bystanders may\\nprolong life during deadly ventricular fibrillation, giving\\nemergency medical service personnel time to arrive.\\nHowever, many CPR attempts are not ultimately\\nsuccessful in restoring a person to a good quality of life.\\nOften, there is brain damage even if the heart starts beat-\\ning again. CPR is therefore not generally recommended\\nfor the chronically or terminally ill or frail elderly. For\\nthese people, it represents a traumatic and not a peaceful\\nend of life.\\nEach year, CPR helps save thousands of lives in the\\nUnited States. More than five million Americans annual-\\nly receive training in CPR through American Heart Asso-\\nciation and American Red Cross courses. In addition to\\ncourses taught by instructors, the American Heart Asso-\\nciation also has an interactive video called Learning Sys-\\ntem, which is available at more than 500 healthcare insti-\\ntutions. Both organizations teach CPR the same way, but\\nuse different terms. These organizations recommend that\\nfamily members or other people who live with people\\nwho are at risk for respiratory or cardiac arrest be trained\\nin CPR. A hand-held device called a CPR Prompt is\\navailable to walk people trained in CPR through the pro-\\ncedure, using American Heart Association guidelines.\\nCPR has been practiced for more than 40 years.\\nPerforming CPR\\nThe basic procedure for CPR is the same for all peo-\\nple, with a few modifications for infants and children to\\naccount for their smaller size.\\nPERFORMING CPR ON AN ADULT. The first step is to\\ncall the emergency medical system for help by telephon-\\ning 911; then to begin CPR, following these steps:\\n• The rescuer opens a person’s airway by placing the\\nhead face up, with the forehead tilted back and the chin\\nlifted. The rescuer checks again for breathing (three to\\nfive seconds), then begins rescue breathing (mouth-to-\\nmouth artificial respiration), pinching the nostrils shut\\nwhile holding the chin in the other hand. The rescuer’s\\nmouth is placed against the unconscious person’s\\nmouth with the lips making a tight seal, then gently\\nexhales for about one to one and a half seconds. The\\nrescuer breaks away for a moment and then repeats.\\nThe person’s head is repositioned after each mouth-to-\\nmouth breath.\\n• After two breaths, the rescuer checks the unconscious\\nperson’s pulse by moving the hand that was under the\\nperson’s chin to the artery in the neck (carotid artery).\\nIf the unconscious person has a heartbeat, the rescuer\\ncontinues rescue breathing until help arrives or the per-\\nGALE ENCYCLOPEDIA OF MEDICINE 2662\\nCardiopulmonary resuscitation (CPR)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 662'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 51, 'page_label': '52'}, page_content='GALE ENCYCLOPEDIA OF MEDICINE 2 663\\nCardiopulmonary resuscitation (CPR)\\nFigure B\\nFigure C\\nFigure D\\nFigure E\\nFigure A\\nFigure F\\nCPR in basic life support. Figure A:The victim should be flat on his back and his mouth should be checked for debris. Figure\\nB: If the victim is unconscious, open airway, lift neck, and tilt head back. Figure C: If victim is not breathing, begin artificial\\nbreathing with four quick full breaths. Figure D: Check for carotid pulse. Figure E: If pulse is absent, begin artificial circula-\\ntion by depressing sternum. Figure F: Mouth-to-mouth resuscitation of an infant.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 663'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 52, 'page_label': '53'}, page_content='son begins breathing without assistance. If the uncon-\\nscious person is breathing, the rescuer turns the person\\nonto his or her side.\\n• If there is no heartbeat, the rescuer performs chest com-\\npressions. The rescuer kneels next to the unconscious\\nperson, placing the heel of one hand in the spot on the\\nlower chest where the two halves of the rib cage come\\ntogether. The rescuer puts one hand on top of the other\\non the person’s chest and interlocks the fingers. The\\narms are straightened, the rescuer’s shoulders are posi-\\ntioned directly above the hands on the unconscious per-\\nson’s chest. The hands are pressed down, using only the\\npalms, so that the person’s breastbone sinks in about\\n1.5–2 inches. The rescuer releases pressure without\\nremoving the hands, then repeats about 15 times per\\n10–15 second intervals.\\n• The rescuer tilts the unconscious person’s head and\\nreturns to rescue breathing for one or two quick breaths.\\nThen breathing and chest compressions are alternated\\nfor one minute before checking for a pulse. If the res-\\ncuer finds signs of a heartbeat and breathing, CPR is\\nstopped. If the unconscious person is breathing but has\\nno pulse, the chest compressions are continued. If the\\nunconscious person has a pulse but is not breathing,\\nrescue breathing is continued.\\n• For children over the age of eight, the rescuer performs\\nCPR exactly as for an adult.\\nPERFORMING CPR ON AN INFANT OR CHILD UNDER\\nTHE AGE OF EIGHT. The procedures outlined above are\\nfollowed with these differences:\\n• The rescuer administers CPR for one minute, then calls\\nfor help.\\n• The rescuer makes a seal around the child’s mouth or\\ninfant’s nose and mouth to give gentle breaths. The res-\\ncuer delivers 20 rescue breaths per minute, taking 1.5–2\\nseconds for each breath.\\n• Chest compressions are given with only one hand for a\\nchild and with two or three fingers for an infant. The\\nbreastbone is depressed only 1–1.5 in (2.5–3.8 cm) for\\na child and 0.5–1 in (1.3–2.5 cm) for an infant, and the\\nrescuer gives at least 100 chest compressions per\\nminute.\\nNew developments in CPR\\nSome new ways of performing CPR have been tried.\\nActive compression-decompression resuscitation, ab-\\ndominal compression done in between chest compres-\\nsions, and chest compression using a pneumatic vest\\nhave all been tested but none are currently recommended\\nfor routine use.\\nThe active compression-decompression device was\\ndeveloped to improve blood flow from the heart, but clini-\\ncal studies have found no significant difference in survival\\nbetween standard and active compression-decompression\\nCPR. Interposed abdominal counterpulsation, which\\nrequires two or more rescuers, one compressing the chest\\nand the other compressing the abdomen, was developed to\\nimprove pressure and therefore blood flow. It has been\\nshown in a small study to improve survival but more data\\nis needed. A pneumatic vest, which circles the chest of an\\nunconscious person and compresses it, increases pressure\\nwithin the chest during external chest compression. The\\nvest has been shown to improve survival in a preliminary\\nstudy but more data is necessary for a full assessment.\\nPreparation\\nIf a person suddenly becomes unconscious, a rescuer\\nshould call out for help from other bystanders, and then\\ndetermine if the unconscious person is responsive by\\ngently shaking the shoulder and shouting a question.\\nUpon receiving no answer, the rescuer should call the\\nemergency medical system. The rescuer should check to\\nsee whether the unconscious person is breathing by\\nkneeling near the person’s shoulders, looking at the per-\\nson’s chest, and placing a cheek next to the unconscious\\nperson’s mouth. The rescuer should look for signs of\\nbreathing in the chest and abdomen, and listen and feel\\nfor signs of breathing through the person’s lips. If no\\nsigns of breathing are present after three to five seconds,\\nCPR should be started.\\nAftercare\\nEmergency medical care is always necessary after\\nsuccessful CPR. Once a person’s breathing and heartbeat\\nhave been restored, the rescuer should make the person\\ncomfortable and stay there until emergency medical per-\\nsonnel arrive. The rescuer can continue to reassure the\\nperson that help is coming and talk positively until pro-\\nfessionals arrive and take over.\\nRisks\\nCPR can cause injury to a person’s ribs, liver, lungs,\\nand heart. However, these risks must be accepted if CPR\\nis necessary to save the person’s life.\\nNormal results\\nIn many cases, successful CPR results in restoration\\nof consciousness and life. Barring other injuries, a\\nrevived person usually returns to normal functions within\\na few hours of being revived.\\nGALE ENCYCLOPEDIA OF MEDICINE 2664\\nCardiopulmonary resuscitation (CPR)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 664'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 53, 'page_label': '54'}, page_content='Abnormal results\\nThese include injuries incurred during CPR and lack\\nof success with CPR. Possible sites for injuries include a\\nperson’s ribs, liver, lungs, and heart. Partially successful\\nCPR may result in brain damage. Unsuccessful CPR\\nresults in death.\\nResources\\nBOOKS\\nAlton, Thygerson. First Aid and CPR. 4th ed. Sudbury, Massa-\\nchusetts: Jones & Bartlett Pub, 2001.\\nKnoop, Kevin J. and Lawrence B. Stack. Atlas of Emergency\\nMedicine. 2nd ed. New York: McGraw Hill, 2001.\\nNational Safety Council. First Aid and CPR for Infants and\\nChildren. 4th ed. Sudbury, Massachusetts: Jones &\\nBartlett Pub, 2001.\\nSkinner, David B. and Richard Vincent. Cardiopulmonary\\nResuscitation. 2nd ed. New York: Oxford University\\nPress, 1996.\\nPERIODICALS\\nDavies, N. and D. Gould. “Updating cardiopulmonary resusci-\\ntation skills: a study to examine the efficacy of self-\\ninstruction on nurses’ competence.”Journal of Clinical\\nNursing 9 (2000): 400-410.\\nEftestol T., K. Sunde, S. O. Aase, J. H. Husoy, and P. A. Steen.\\n“‘Probability of successful defibrillation’ as a monitor\\nduring CPR in out-of-hospital cardiac arrested patients.”\\nResuscitation 48 (2001): 245-254.\\nKern, K. B., H. R. Halperin, and J. Field. “New guidelines for\\ncardiopulmonary resuscitation and emergency cardiac\\ncare: changes in the management of cardiac arrest.”Jour-\\nnal of the American Medical Association 285 (2001):\\n1267-1269.\\nMeyer W. and F. Balck. “Resuscitation decision index: a new\\napproach to decision-making in prehospital CPR.”Resus-\\ncitation 48 (2001): 255-263.\\nORGANIZATIONS\\nAmerican College of Emergency Physicians. P.O. Box 619911,\\nDallas, TX 75261-9911. (800) 798-1822 or (972) 550-\\n0911. Fax: (972) 580-2816. . .\\nAmerican College of Osteopathic Emergency Physicians. 142\\nE. Ontario Street, Suite 550, Chicago, IL 60611. (312)\\n587-3709 or (800) 521-3709. Fax: (312) 587-9951.\\n.\\nAmerican Heart Association, National Center. 7272 Greenville\\nAvenue, Dallas, TX 75231. (877) 242-4277. .\\nHeimlich Institute. PO Box 8858, Cincinnati, OH 45208.\\n. .\\nNational Safe Kids Campaign. 1301 Pennsylvania Avenue, Suite\\n1000, Washington, DC 20004-1707. .\\nKEY TERMS\\nCardiac arrest —Temporary or permanent cessa-\\ntion of the heartbeat.\\nCardiopulmonary —Relating to the heart and the\\nlungs.\\nDefibrillation —A procedure to stop the type of\\nirregular heart beat called ventricular fibrillation,\\nusually by using electric shock.\\nResuscitation—Bringing a person back to life after\\nan apparent death or in cases of impending death.\\nVentricular fibrillation —An irregular heartbeat\\nwhere the heart beats very fast but ineffectively. Ven-\\ntricular fibrillation is fatal if not quickly corrected.\\nOTHER\\nAmerican Heart Association. and\\n.\\nColumbia Presbyterian Medical Center. .\\nLearn CPR. .\\nNational Registry of Cardiopulmonary Resuscitation. .\\nUniversity of Washington School of Medicine. .\\nL. Fleming Fallon, Jr., MD, DrPH\\nCardioversion\\nDefinition\\nCardioversion refers to the process of restoring the\\nheart’s normal rhythm by applying a controlled electric\\nshock to the exterior of the chest.\\nPurpose\\nWhen the heart beats too fast, blood no longer circu-\\nlates effectively in the body. Cardioversion is used to\\nstop this abnormal beating so that the heart can begin\\nnormal rhythm and pump more efficiently.\\nPrecautions\\nNot all unusual heart rhythms (called arrhythmias)\\nare dangerous or fatal. Atrial fibrillation and atrial flutter\\noften revert to normal rhythms without the need for car-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 665\\nCardioversion\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 665'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 54, 'page_label': '55'}, page_content='dioversion. Healthcare providers may also try to correct\\nthe heart rhythm with medication or recommend a lifestyle\\nchange before trying cardioversion. However,ventricular\\ntachycardia lasting more than 30 seconds and ventricu-\\nlar fibrillationrequire immediate cardioversion.\\nDescription\\nElective cardioversion is usually scheduled ahead of\\ntime. After arriving at the hospital, an intravenous (IV)\\ncatheter will be placed in the arm and oxygen will be\\ngiven through a face mask. A short-acting general anes-\\nthetic will be administered through the vein. During the\\ntwo or three minutes of anesthesia, the doctor will apply\\ntwo paddles to the exterior of the chest and administer\\nthe electric shock. It may be necessary to give the shock\\ntwo or three times to obtain normal rhythm.\\nPreparation\\nMedication to thin the blood is usually given for at\\nleast three weeks before elective cardioversion. Food\\nintake should be stopped eight hours before the procedure.\\nAftercare\\nMedical personnel will monitor the heart rhythm for\\na few hours, after which the patient is usually sent home.\\nIt is advisable to arrange for transportation home,\\nbecause drowsiness may last several hours. The doctor\\nmay prescribe anti-arrhythmic medication to prevent the\\nabnormal rhythm from returning.\\nRisks\\nCardioverters have been in use for many years and\\nthe risks are few. Those unlikely risks that remain\\nKEY TERMS\\nAtrial fibrillation —A condition in which the\\nupper chamber of the heart quivers instead of\\npumping in an organized way.\\nAtrial flutter —A rapid pulsation of the upper\\nchamber of the heart that interferes with normal\\nfunction.\\nVentricular fibrillation—A condition in which the\\nlower chamber of the heart quivers instead of\\npumping in an organized way.\\nVentricular tachycardia—A rapid heart beat, usu-\\nally over 100 beats per minute.\\ninclude those instances when the device delivers greater\\nor lesser power than expected or when power setting and\\ncontrol knobs are not set correctly. Unfortunately, in a\\nnumber of cases, the heart prefers its abnormal rhythm\\nand reverts to it despite cardioversion.\\nNormal results\\nMost cardioversions are successful and, at least for a\\ntime, restore the normal heart rhythm.\\nResources\\nBOOKS\\nMcGoon, Michael D., ed. Mayo Clinic Heart Book: The Ulti-\\nmate Guide to Heart Health. New York: William Morrow\\nand Co., Inc., 1993.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nDorothy Elinor Stonely\\nCarisoprodol see Muscle relaxants\\nCarotid artery surgery see Endarterectomy\\nCarotid Doppler ultrasound see Doppler\\nultrasonography\\nCarotid endarterectomy see Endarterectomy\\nCarotid sinus massage\\nDefinition\\nCarotid sinus massage involves rubbing the large\\npart of the arterial wall at the point where the common\\ncarotid artery, located in the neck, divides into its two\\nmain branches.\\nPurpose\\nSinus, in this case, means an area in a blood vessel\\nthat is bigger than the rest of the vessel. This is a normal\\ndilation of the vessel. Located in the neck just below the\\nangle of the jaw, the carotid sinus sits above the point\\nwhere the carotid artery divides into its two main branch-\\nes. Rubbing the carotid sinus stimulates an area in the\\nartery wall that contains nerve endings. These nerves\\nrespond to changes in blood pressure and are capable of\\nslowing the heart rate. The response to this simple proce-\\ndure often slows a rapid heart rate (for example, atrial\\nGALE ENCYCLOPEDIA OF MEDICINE 2666\\nCarotid sinus massage\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 666'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 55, 'page_label': '56'}, page_content='flutter or atrial tachycardia) and can provide important\\ndiagnostic information to the physician.\\nDescription\\nThe patient will be asked to lie down, with the neck\\nfully extended and the head turned away from the side\\nbeing massaged. While watching an electrocardiogram\\nmonitor, the doctor will gently touch the carotid sinus. If\\nthere is no change in the heart rate on the monitor, the\\npressure is applied more firmly with a gentle rotating\\nmotion. After massaging one side of the neck, the mas-\\nsage will be repeated on the other side. Both sides of the\\nneck are never massaged at the same time.\\nPreparation\\nNo special preparation is needed for carotid sinus\\nmassage.\\nAftercare\\nNo aftercare is required.\\nRisks\\nThe physician must be sure there is no evidence of\\nblockage in the carotid artery before performing the pro-\\ncedure. Massage in a blocked area might cause a clot to\\nbreak loose and cause a stroke.\\nNormal results\\nCarotid sinus massage will slow the heart rate during\\nepisodes of atrial flutter, fibrillation, and some tachycar-\\nKEY TERMS\\nAngina pectoris —Chest pain usually caused by a\\nlack of oxygen in the heart muscle.\\nArrhythmia —Any deviation from a normal heart\\nbeat.\\nAtrial fibrillation —A condition in which the\\nupper chamber of the heart quivers instead of\\npumping in an organized way.\\nAtrial flutter—Rapid, inefficient contraction of the\\nupper chamber of the heart.\\nCarotid artery—One of the major arteries supply-\\ning blood to the head and neck.\\nTachycardia—A rapid heart beat, usually over 100\\nbeats per minute.\\ndias. It has been known to stop the arrhythmia complete-\\nly. If the procedure is being done to help diagnose angi-\\nna pectoris, massaging the carotid sinus may make the\\ndiscomfort go away.\\nResources\\nBOOKS\\nMcGood, Michael D., ed. Mayo Clinic Heart Book: The Ulti-\\nmate Guide to Heart Health. New York: William Morrow\\nand Co., Inc., 1993.\\nDorothy Elinor Stonely\\nCarpal tunnel syndrome\\nDefinition\\nCarpal tunnel syndrome is a disorder caused by\\ncompression at the wrist of the median nerve supplying\\nthe hand, causing numbness and tingling.\\nDescription\\nThe carpal tunnel is an area in the wrist where the\\nbones and ligaments create a small passageway for the\\nmedian nerve. The median nerve is responsible for both\\nsensation and movement in the hand, in particular the\\nthumb and first three fingers. When the median nerve is\\ncompressed, an individual’s hand will feel as if it has\\n“gone to sleep.”\\nWomen between the ages of 30 and 60 have the\\nhighest rates of carpal tunnel syndrome. Research has\\ndemonstrated that carpal tunnel syndrome is a very sig-\\nnificant cause of missed work days due to pain. In 1995,\\nabout $270 million was spent on sick days taken for pain\\nfrom repetitive motion injuries.\\nCauses and symptoms\\nCompression of the median nerve in the wrist can\\noccur during a number of different conditions, particular-\\nly those conditions which lead to changes in fluid accu-\\nmulation throughout the body. Because the area of the\\nwrist through which the median nerve passes is very nar-\\nrow, any swelling in the area will lead to pressure on the\\nmedian nerve. This pressure will ultimately interfere\\nwith the nerve’s ability to function normally. Pregnancy,\\nobesity , arthritis, certain thyroid conditions, diabetes,\\nand certain pituitary abnormalities all predispose to\\ncarpal tunnel syndrome. Other conditions which increase\\nthe risk for carpal tunnel syndrome include some forms\\nGALE ENCYCLOPEDIA OF MEDICINE 2 667\\nCarpal tunnel syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 667'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 56, 'page_label': '57'}, page_content='of arthritis and various injuries to the arm and wrist\\n(including fractures, sprains, and dislocations). Further-\\nmore, activities which cause an individual to repeatedly\\nbend the wrist inward toward the forearm can predispose\\nto carpal tunnel syndrome. Certain jobs which require\\nrepeated strong wrist motions carry a relatively high risk\\nof carpal tunnel syndrome. Injuries of this type are\\nreferred to as “repetitive motion” injuries, and are more\\nfrequent among secretaries doing a lot of typing, people\\nworking at computer keyboards or cash registers, factory\\nworkers, and some musicians.\\nSymptoms of carpal tunnel syndrome include numb-\\nness, burning, tingling, and a prickly pin-like sensation\\nover the palm surface of the hand, and into the thumb,\\nforefinger, middle finger, and half of the ring finger.\\nSome individuals notice a shooting pain which goes from\\nthe wrist up the arm, or down into the hand and fingers.\\nWith continued median nerve compression, an individual\\nmay begin to experience muscle weakness, making it dif-\\nficult to open jars and hold objects with the affected\\nhand. Eventually, the muscles of the hand served by the\\nmedian nerve may begin to grow noticeably smaller\\n(atrophy), especially the fleshy part of the thumb.\\nUntreated, carpal tunnel syndrome may eventually result\\nin permanent weakness, loss of sensation, or even paral-\\nysis of the thumb and fingers of the affected hand.\\nDiagnosis\\nThe diagnosis of carpal tunnel syndrome is made in\\npart by checking to see whether the patient’s symptoms\\ncan be brought on by holding his or her hand in position\\nwith wrist bent for about a minute. Wrist x rays are often\\ntaken to rule out the possibility of a tumor causing pres-\\nsure on the median nerve. A physician examining a patient\\nsuspected of having carpal tunnel syndrome will perform a\\nvariety of simple tests to measure muscle strength and sen-\\nsation in the affected hand and arm. Further testing might\\ninclude electromyographic or nerve conduction velocity\\ntesting to determine the exact severity of nerve damage.\\nThese tests involve stimulating the median nerve with\\nelectricity and measuring the resulting speed and strength\\nof the muscle response, as well as recording speed of\\nnerve transmission across the carpel tunnel.\\nTreatment\\nCarpal tunnel syndrome is initially treated with\\nsplints, which support the wrist and prevent it from flex-\\ning inward into the position which exacerbates median\\nnerve compression. Some people get significant relief by\\nwearing such splints to sleep at night, while others will\\nneed to wear the splints all day, especially if they are per-\\nforming jobs which stress the wrist. Ibuprofen or other\\nnonsteroidal anti-inflammatory drugs may be pre-\\nscribed to decrease pain and swelling. When carpal tun-\\nnel syndrome is more advanced, injection of steroids into\\nthe wrist to decrease inflammation may be necessary.\\nThe most severe cases of carpal tunnel syndrome\\nmay require surgery to decrease the compression of the\\nmedian nerve and restore its normal function. Such a\\nrepair involves cutting that ligament which crosses the\\nwrist, thus allowing the median nerve more room and\\ndecreasing compression. This surgery is done almost\\nexclusively on an outpatient basis and is often performed\\nwithout the patient having to be made unconscious. Care-\\nful injection of numbing medicines (local anesthesia) or\\nnerve blocks (the injection of anesthetics directly into the\\nnerve) create sufficient numbness to allow the surgery to\\nbe performed painlessly, without the risks associated with\\ngeneral anesthesia. Recovery from this type of surgery is\\nusually quick and without complications.\\nGALE ENCYCLOPEDIA OF MEDICINE 2668\\nCarpal tunnel syndrome\\nCarpal tunnel ligament\\nMedian nerve\\nCarpal tunnel ligament (severed)\\nMedian nerve\\nThe most severe cases of carpal tunnel syndrome may\\nrequire surgery to decrease the compression of the median\\nnerve and restore its normal function.This procedure\\ninvolves severing the ligament that crosses the wrist, thus\\nallowing the median nerve more room and decreasing com-\\npression. (Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 668'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 57, 'page_label': '58'}, page_content='Prognosis\\nWithout treatment, continued pressure on the medi-\\nan nerve puts an individual at risk for permanent disabili-\\nty in the affected hand. Most people are able to control\\nthe symptoms of carpal tunnel syndrome with splinting\\nand anti-inflammatory agents. For those who go on to\\nrequire surgery, about 95% will have complete cessation\\nof symptoms.\\nPrevention\\nPrevention is generally aimed at becoming aware of\\nthe repetitive motions which one must make which could\\nput the wrist into a bent position. People who must work\\nlong hours at a computer keyboard, for example, may need\\nto take advantage of recent advances in “ergonomics,”\\nwhich try to position the keyboard and computer compo-\\nnents in a way that increases efficiency and decreases\\nstress. Early use of a splint may also be helpful for people\\nwhose jobs increase the risk of carpal tunnel syndrome.\\nResources\\nBOOKS\\nAsbury, Arthur K. “Carpal Tunnel Syndrome.” In Harrison’s\\nPrinciples of Internal Medicine, ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1997.\\nCrouch, Tammy. Carpal Tunnel Syndrome and Repetitive\\nStress Injuries. Berkeley: Frog, 1995.\\nPERIODICALS\\nBrody, Jane E. “Experts on Carpal Tunnel Syndrome Say that\\nConservative Treatment is the Best First Approach.”The\\nNew York Times119 (28 Feb.1996): B9+.\\n“Carpal Tunnel Syndrome.”Postgraduate Medicine 98 no. 3\\n(Sept. 1995): 216.\\nGlazer, Sarah. “Repetitive Stress Injury: A Modern Malady.”\\nThe Washington Post110 (12 Mar. 1996): WH12.\\nKEY TERMS\\nCarpal tunnel—A passageway in the wrist, created\\nby the bones and ligaments of the wrist, through\\nwhich the median nerve passes.\\nElectromyography —A type of test in which a\\nnerve’s function is tested by stimulating a nerve\\nwith electricity, and then measuring the speed and\\nstrength of the corresponding muscle’s response.\\nMedian nerve —A nerve which runs through the\\nwrist and into the hand. It provides sensation and\\nsome movement to the hand, the thumb, the index\\nfinger, the middle finger, and half of the ring finger.\\nSeiler, John Gray. “Carpal Tunnel Syndrome: Update on Diag-\\nnostic Testing and Treatment Options.”Consultant 37 no.\\n5 (May 1997): 1233+.\\nRosalyn Carson-DeWitt, MD\\nCasts see Immobilization\\nCAT scan see Computed tomography scans\\nCat-bite infection see Animal bite infections\\nCat-scratch disease\\nDefinition\\nCat-scratch disease is an uncommon infection that\\ntypically results from a cat’s scratch or bite. Most suffer-\\ners experience only moderate discomfort and find that\\ntheir symptoms clear up without any lasting harm after a\\nfew weeks or months. Professional medical treatment is\\nrarely needed.\\nDescription\\nCat-scratch disease (also called cat-scratch fever) is\\ncaused by the Bartonella henselae bacterium, which is\\nfound in cats around the world and is transmitted from\\ncat to cat by fleas. Researchers have discovered that large\\nnumbers of North American cats carry antibodies for the\\ndisease (meaning that the cats have been infected at some\\npoint in their lives). Some parts of North America have\\nmuch higher rates of cat infection than others, however.\\nBartonella henselae is uncommon or absent in cold cli-\\nmates, which fleas have difficulty tolerating, but preva-\\nlent in warm, humid places such as Memphis, Tennessee,\\nwhere antibodies were found in 71% of the cats tested.\\nThe bacterium, which remains in a cat’s bloodstream for\\nseveral months after infection, seems to be harmless to\\nmost cats, and normally an infected cat will not display\\nany symptoms. Kittens (cats less than one year old) are\\nmore likely than adult cats to be carrying the infection.\\nBartonella henselae can infect people who are\\nscratched or (more rarely) bitten or licked by a cat. It\\ncannot be passed from person to person. Although cats\\nare popular pets found in about 30% of American house-\\nholds, human infection appears to be rare. One study\\nestimated that for every 100,000 Americans there are\\nonly 2.5 cases of cat-scratch disease each year (2.5/\\n100,000). It is also unusual for more than one family\\nmember to become ill; a Florida investigation discovered\\nmultiple cases in only 3.5% of the families studied. Chil-\\ndren and teenagers appear to be the most likely victims\\nof cat-scratch disease, although the possibility exists that\\nGALE ENCYCLOPEDIA OF MEDICINE 2 669\\nCat-scratch disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 669'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 58, 'page_label': '59'}, page_content='the disease may be more common among adults than pre-\\nviously thought.\\nCauses and symptoms\\nThe first sign of cat-scratch disease may be a small\\nblister at the site of a scratch or bite three to 10 days after\\ninjury. The blister (which sometimes contains pus) often\\nlooks like an insect bite and is usually found on the hands,\\narms, or head. Within two weeks of the blister’s appear-\\nance, lymph nodes near the site of injury become swollen.\\nOften the infected person develops a fever or experiences\\nfatigue or headaches. The symptoms usually disappear\\nwithin a month, although the lymph nodes may remain\\nswollen for several months. Hepatitis, pneumonia, and\\nother dangerous complications can arise, but the likelihood\\nof cat-scratch disease posing a serious threat to health is\\nvery small. AIDS patients and other immunocompromised\\npeople face the greatest risk of dangerous complications.\\nOccasionally, the symptoms of cat-scratch disease take\\nthe form of what is called Parinaud’s oculoglandular syn-\\ndrome. In such cases, a small sore develops on the palpe-\\nbral conjunctiva (the membrane lining the inner eyelid),\\nand is often accompanied by conjunctivitis(inflammation\\nof the membrane) and swollen lymph nodes in front of the\\near. Researchers suspect that the first step in the develop-\\nKEY TERMS\\nAcetaminophen —A drug for relieving pain and\\nfever.\\nAIDS—Acquired immunodeficiency syndrome. A\\ndisease that attacks the immune system.\\nAntibiotics —A category of manufactured sub-\\nstances used to combat infection.\\nAntibodies —Special substances created by the\\nbody to combat infection.\\nBacterium—A tiny organism. Some bacteria cause\\ndisease.\\nHepatitis—A disease that inflames the liver.\\nImmune system—A body system that combats dis-\\nease.\\nImmunocompromised—Having a damaged immune\\nsystem.\\nLymph nodes—Small, kidney-shaped organs that\\nfilter a fluid called lymph.\\nPneumonia—A disease that inflames the lungs.\\nPus—A thick yellowish or greenish fluid.\\nment of Parinaud’s oculoglandular syndrome occurs when\\nBartonella henselae bacteria pass from a cat’s saliva to its\\nfur during grooming. Rubbing one’s eyes after handling the\\ncat then transmits the bacteria to the conjunctiva.\\nDiagnosis\\nA family doctor should be called whenever a cat\\nscratch or bite fails to heal normally or is followed by a\\npersistent fever or other unusual symptoms such as long-\\nlasting bone or joint pain. The appearance of painful and\\nswollen lymph nodes is another reason for consulting a\\ndoctor. When cat-scratch disease is suspected, the doctor\\nwill ask about a history of exposure to cats and look for\\nevidence of a cat scratch or bite and swollen lymph\\nnodes. A blood test for Bartonella henselae may be\\nordered to confirm the doctor’s diagnosis.\\nTreatment\\nFor otherwise healthy people, rest and over-the-\\ncounter medications for reducing fever and discomfort\\n(such as acetaminophen ) while waiting for the disease\\nto run its course are usually all that is necessary. Antibi-\\notics are prescribed in some cases, particularly when\\ncomplications occur or the lymph nodes remain swollen\\nand painful for more than two or three months, but there\\nis no agreement among doctors about when and how they\\nshould be used. If a lymph node becomes very swollen\\nand painful, the family doctor may decide to drain it.\\nPrognosis\\nMost people recover completely from a bout of cat-\\nscratch disease. Further attacks are rare.\\nPrevention\\nCertain common-sense precautions can be taken to\\nguard against the disease. Scratches and bites should be\\nwashed immediately with soap and water, and it is never\\na good idea to rub one’s eyes after handling a cat without\\nfirst washing one’s hands. Children should be told not to\\nplay with stray cats or make cats angry. Immunocompro-\\nmised people should avoid owning kittens, which are\\nmore likely than adult cats to be infectious. Because cat-\\nscratch disease is usually not a life-threatening illness\\nand people tend to form strong emotional bonds with\\ntheir cats, doctors do not recommend getting rid of a cat\\nsuspected of carrying the disease.\\nResources\\nBOOKS\\nTompkins, Lucy Stuart. “Bartonella Infections, Including Cat-\\nScratch Disease.” In Harrison’s Principles of Internal\\nGALE ENCYCLOPEDIA OF MEDICINE 2670\\nCat-scratch disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 670'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 59, 'page_label': '60'}, page_content='Medicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nPERIODICALS\\nSmith, David L. “Cat-Scratch Disease and Related Clinical Syn-\\ndromes.”American Family Physician(Apr. 1997): 1783+.\\nHoward Baker\\nCat-scratch fever see Cat-scratch disease\\nCataract surgery\\nDefinition\\nCataract surgery is a procedure performed to remove\\na cloudy lens from the eye; usually an intraocular lens is\\nimplanted at the same time.\\nPurpose\\nThe purpose of cataract surgery is to restore clear\\nvision. It is indicated when cloudy vision due to\\ncataracts has progressed to such an extent that it inter-\\nferes with normal daily activities.\\nPrecautions\\nCataract surgery is not performed on both eyes at\\nonce. To avoid risking blindness in both eyes in the\\nevent of infection or other catastrophe, the first eye is\\nallowed to heal before the cataract is removed from the\\nsecond eye.\\nThe presence of cataracts can mask additional eye\\nproblems, such as retinal damage, that neither doctors\\nnor patients are aware of prior to surgery. Since such\\nconditions will continue to impair sight after cataract\\nremoval if they are not identified and treated, the eventu-\\nal outcome of cataract surgery will depend on the out-\\ncome of other problems.\\nIn 1997 and 1998, evidence that cataract surgery can\\ncontribute to the progression of age-related macular\\ndegeneration (ARMD) was published. ARMD is the\\ndegeneration of the central part of the retina. According-\\nly, ARMD patients with cataracts must weigh the risks of\\nthe loss of central vision, within four or five years,\\nagainst short-term improvement. When an ARMD\\npatient chooses cataract surgery, the surgeon should\\nshield the retina against bright light to protect it from\\npossible light-induced damage during surgery and install\\nan intraocular lens capable of absorbing ultraviolet and\\nblue light, which seem to do the most damage.\\nKEY TERMS\\nAge-related macular degeneration (ARMD) —\\nDegeneration of the macula (the central part of the\\nretina where the rods and cones are most dense)\\nthat leads to loss of central vision in people over 60.\\nCataract —Progressive opacity or clouding of an\\neye lens, which obstructs the passage of light to\\nthe retina.\\nCornea—Clear outer covering of the front of the eye.\\nIntraocular lens—Lens made of silicone or plastic\\nplaced within the eye; can be corrective.\\nRetina—Innermost layer at the back of the eye,\\nwhich contains light receptors, the rods and cones.\\nDescription\\nThere are two types of cataract surgery: intracapsular\\nand extracapsular. Intracapsular surgery is the removal of\\nboth the lens and the thin capsule that surround them.\\nThis type of surgery was common before 1980, but has\\nsince been displaced by extracapsular surgery. Removal\\nof the capsule requires a large incision and doesn’t allow\\ncomfortable intraocular lens implantation. Thus, people\\nwho undergo intracapsular cataract surgery have long\\nrecovery periods and have to wear very thick glasses.\\nExtracapsular cataract surgery is the removal of\\nthe lens where the capsule is left in place. Each year in\\nthe United States, over a million cataracts are removed\\nthis way.\\nThere are two methods for extracapsular cataract\\nsurgery. The usual technique is phacoemulsification. A\\ntiny incision (about 0.12 in or 3 mm long) is made next\\nto the cornea (the eye’s outer covering), and an ultrasonic\\nprobe is used to break the cataract into minute pieces,\\nwhich are then removed by suction. When the lens is too\\nhard to be emulsified ultrasonically, the surgeon will use\\na different extracapsular technique requiring a larger\\nincision. An incision about 0.37 in (9 mm) long is made,\\nand the whole lens (without its capsule) is removed\\nthrough the incision. Both kinds of extracapsular extrac-\\ntion leave the back of the capsule intact, so a silicone or\\nplastic intraocular lens can be stably implanted in about\\nthe same location as the original lens.\\nThe surgery takes about 30–60 minutes per eye.\\nPreparation\\nPatients must have a pre-operation eye examination,\\nwhich will include ultrasound analysis to make sure the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 671\\nCataract surgery\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 671'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 60, 'page_label': '61'}, page_content='retina (the innermost layer of the eye, containing the light\\nreceptors) is intact and also to measure eye curvature so\\nthat a lens with the proper correction can be implanted.\\nThe patient will also have a pre-operative physical exam-\\nination. In addition, patients start a course of antibiotic\\neye drops or ointment the day before surgery.\\nAftercare\\nProper post-operative care is especially important after\\ncataract surgery. Patients will need someone to drive them\\nhome after the surgery and should not bend over or do any-\\nthing strenuous for about two weeks. They should refrain\\nfrom rubbing the eye, should wear glasses to protect their\\neye, and should wear a shield while sleeping so the eye\\nwon’t be rubbed or bumped accidentally. The patient will\\nusually continue their antibiotic for two to three weeks and\\nwill also take anti-inflammatory medication for about the\\nsame length of time. If the patient experiences inflamma-\\ntion, redness, or pain, they should seek immediate medical\\ntreatment to avoid serious complications.\\nRisks\\nCataract surgery itself is quite safe; over 90% of the\\ntime, there are no complications. Possible complications\\ninclude intraocular infection (endophthalmitis), central\\nretinal inflammation (macular edema), post-operative\\nglaucoma, retinal detachment, bleeding under the reti-\\nna (choroidal hemorrhage), and tiny lens fragments in\\nthe back (vitreous) cavity of the eye, all of which can\\nlead to loss of sight.\\nNormal results\\nOrdinarily, patients experience improved visual acu-\\nity and improved perception of the vividness of colors,\\nleading to increased abilities in many activities, including\\nreading, needlework, driving, golf, and tennis, for exam-\\nple. In addition, sometimes implanted corrective lenses\\neliminate the need for eyeglasses or contact lenses.\\nResources\\nBOOKS\\nSalmans, Sandra. Your Eyes: Questions You Have. Answers You\\nNeed. Allentown, PA: People’s Medical Society, 1996.\\nShulman, Julius. Cataracts. New York: St. Martin’s Press, 1995.\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street, P.O.\\nBox 7424, San Francisco, CA 94120-7424. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2672\\nCataract surgery\\nCataract surgery in progress. (Photograph by David Sutton/Zuma Images, The Stock Market. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 672'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 61, 'page_label': '62'}, page_content='American Society of Cataract and Refractive Surgery. 4000\\nLegato Road, Suite 850, Fairfax, V A 22033-4055. (703)\\n591-2220. .\\nOTHER\\n“Cataract in Adults: A Patient’s Guide.”National Library of\\nMedicine Page..\\n“Patient Information.”Digital Journal of Ophthalmology.\\n.\\nLorraine Lica, PhD\\nCataracts\\nDefinition\\nA cataract is a cloudiness or opacity in the normally\\ntransparent crystalline lens of the eye. This cloudiness\\ncan cause a decrease in vision and may lead to eventual\\nblindness.\\nDescription\\nThe human eye has several parts. The outer layer of\\nthe eyeball consists of a transparent dome-shaped cornea\\nand an opaque, white sclera. The cornea and sclera help\\nprotect the eye. The next layer includes the iris, pupil, and\\nciliary body. The iris is the colored part of the eye and the\\npupil is the small dark round hole in the middle of the iris.\\nThe pupil and iris allow light into the eye. The ciliary body\\ncontains muscles that help in the eye’s focusing ability.\\nThe lens lies behind the pupil and iris. It is covered by a\\ncellophane-like capsule. The lens is normally transparent,\\nelliptical in shape, and somewhat elastic. This elasticity\\nallows the lens to focus on both near and far objects. The\\nlens is attached to the ciliary body by fibers (zonules of\\nZinn). Muscles in the ciliary body act on the zonules,\\nwhich then change the shape of the lens. This process is\\ncalled accommodation—the lens focuses images to help\\nmake vision clear. As people age, the lens hardens and\\nchanges shape less easily. As a result, the accommodation\\nprocess becomes more difficult, making it harder to see\\nthings up close. This generally occurs around the age of 40\\nand continues until about age 65. The condition is called\\npresbyopia. It is a normal condition of aging, generally\\nresulting in the need for reading glasses.\\nThe lens is made up of approximately 35% protein\\nand 65% water. As people age, degenerative changes in\\nthe lens’ proteins occur. Changes in the proteins, water\\ncontent, enzymes, and other chemicals are some of the\\nreasons for the formation of a cataract.\\nThe major areas of the lens are the nucleus, the cor-\\ntex, and the capsule. The nucleus is in the center of the\\nlens, the cortex surrounds the nucleus, and the capsule is\\nthe outer layer. Opacities can occur in any area of the\\nlens. Cataracts, then, can be classified according to loca-\\ntion (nuclear, cortical, or posterior subcapular cataracts).\\nThe density and location of the cataract determines the\\namount of vision affected. If the cataract forms in the area\\nof the lens directly behind the pupil, vision may be signif-\\nicantly impaired. A cataract that occurs on the outer edges\\nor side of the lens will create less of a visual problem.\\nCataracts in the elderly are so common that they are\\nthought to be a normal part of the aging process.\\nBetween the ages of 52 and 64, there is a 50% chance of\\nhaving a cataract, while at least 70% of those 70 and\\nolder are affected. Cataracts associated with aging (senile\\nor age-related cataracts) most often occur in both eyes,\\nwith each cataract progressing at a different rate. Initial-\\nly, cataracts may not affect vision. If the cataract remains\\nsmall or at the periphery of the lens, the visual changes\\nmay be minor.\\nCataracts that occur in people other than the elderly\\nare much less common. Congenital cataracts occur very\\nrarely in newborns. Genetic defects or an infection or\\ndisease in the mother during pregnancy are among the\\ncauses of congenital cataracts. Traumatic cataracts may\\ndevelop after a foreign body or trauma injures the lens or\\neye. Systemic illnesses, such as diabetes, may result in\\ncataracts. Cataracts can also occur secondary to other eye\\ndiseases—for example, an inflammation of the inner\\nlayer of the eye (uveitis) or glaucoma. Such cataracts are\\ncalled complicated cataracts. Toxic cataracts result from\\nchemical toxicity, such as steroid use. Cataracts can also\\nresult from exposure to the sun’s ultraviolet (UV) rays.\\nCauses and symptoms\\nRecent studies have been conducted to try to deter-\\nmine whether diet or the use of vitamins might have an\\neffect on the formation of cataracts in older people. The\\nresults have been mixed, with some studies finding that\\nthere is a connection and other studies finding none.\\nMuch interest has been focused on the use of antioxidant\\nsupplements as a protection against cataracts. Antioxidant\\nvitamins such as vitamins A, C, E and beta-carotene help\\nthe body clean-up oxygen-free radicals. Some vitamins\\nare marketed specifically for the eyes. Patients should\\nspeak to their doctors about the use of such vitamins.\\nSmoking and alcohol intake have been implicated in\\ncataract formation. Some studies have determined that a\\ndiet high in fat will increase the likelihood of cataract\\nformation, while an increase in foods rich in antioxidants\\nwill reduce the incidence. More research is needed to\\ndetermine if diet, smoking, alcohol consumption, or vita-\\nmins have any connection to the formation of cataracts.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 673\\nCataracts\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 673'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 62, 'page_label': '63'}, page_content='There are several common symptoms of cataracts:\\n• gradual, painless onset of blurry, filmy, or fuzzy vision\\n• poor central vision\\n• frequent changes in eyeglass prescription\\n• changes in color vision\\n• increased glare from lights, especially oncoming head-\\nlights when driving at night\\n• “second sight” improvement in near vision (no longer\\nneeding reading glasses), but a decrease in distance\\nvision\\n• poor vision in sunlight\\n• presence of a milky whiteness in the pupil as the\\ncataract progresses.\\nDiagnosis\\nBoth ophthalmologists and optometrists may detect\\nand monitor cataract growth and prescribe prescription\\nlenses for visual deficits. However, only an ophthalmolo-\\ngist can perform cataract extraction.\\nCataracts are easily diagnosed from the reporting of\\nsymptoms, a visual acuity exam using an eye chart, and\\nby examination of the eye itself. Shining a penlight into\\nthe pupil may reveal opacities or a color change of the\\nlens even before visual symptoms have developed. An\\ninstrument called a slit lamp is basically a large micro-\\nscope. This lets the doctor examine the front of the eye\\nand the lens. The slit lamp helps the doctor determine the\\nlocation of the cataract.\\nSome other diagnostic tests may be used to deter-\\nmine if cataracts are present or how well the patient may\\npotentially see after surgery. These include a glare test,\\npotential vision test, and contrast sensitivity test.\\nTreatment\\nFor cataracts that cause no symptoms or only minor\\nvisual changes, no treatment may be necessary. Continued\\nmonitoring and assessment of the cataract is needed by an\\nophthalmologist or optometrist at scheduled office visits.\\nIncreased strength in prescription eyeglasses or contact\\nlenses may be helpful. This may be all that is required if\\nthe cataract does not reduce the patient’s quality of life.\\nCataract surgery—the only option for patients whose\\ncataracts interfere with vision to the extent of affecting\\ntheir daily lives—is the most frequently performed surgery\\nin the United States. It generally improves vision in over\\n90% of patients. Some people have heard that a cataract\\nshould be “ripe” before being removed. A “ripe” or mature\\ncataract is when the lens is completely opaque. Most\\ncataracts are removed before they reach that stage. Some-\\ntimes cataracts need to be removed so that the doctor can\\nexamine the back of the eye more carefully. This is impor-\\ntant in patients with diseases that may affect the eye. If\\ncataracts are present in both eyes, only one eye at a time\\nshould be operated on. Healing occurs in the first eye\\nbefore the second cataract is removed, sometimes as early\\nas the following week. A final eyeglass prescription is usu-\\nally given about four to six weeks after surgery. Patients\\nwill still need reading glasses. The overall health of the\\npatient needs to be considered in making the decision to\\noperate. However, age alone need not preclude effective\\nsurgical treatment of cataracts. People in their 90s can\\nhave successful return of vision after cataract surgery.\\nSurgery to remove cataracts is generally an outpa-\\ntient procedure. A local anesthetic is used and the proce-\\ndure lasts about an hour. Removal of the cloudy lens can\\nbe done by several different procedures. The three types\\nof cataract surgery available are:\\n• Extracapsular cataract extraction. This type of cataract\\nextraction is the most common. The lens and the front\\nportion of the capsule are removed. The back part of the\\ncapsule remains, providing strength to the eye.\\n• Intracapsular cataract extraction. The lens and the\\nentire capsule are removed. This method carries an\\nincreased risk for detachment of the retina and swelling\\nafter surgery. It is rarely used.\\n• Phacoemulsification. This type of extracapsular extrac-\\ntion needs a very small incision, resulting in faster heal-\\ning. Ultrasonic vibration is applied to the lens to break\\nit up into very small pieces which are then aspirated out\\nof the eye with suction by the ophthalmologist.\\nA replacement lens is usually inserted at the time of\\nthe surgery. A plastic artificial lens called an intraocular\\nlens (IOL) is placed in the remaining posterior lens cap-\\nsule of the eye. When the intracapsular extraction\\nGALE ENCYCLOPEDIA OF MEDICINE 2674\\nCataracts\\nA dense cataract on lens of eye.(Photograph by Margaret\\nCubberly, Phototake NYC. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 674'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 63, 'page_label': '64'}, page_content='method is used, an IOL may be clipped onto the iris.\\nContact lenses and cataract glasses (aphakic lenses) are\\nprescribed if an IOL was not inserted. A folding IOL is\\nused when phacoemulsification is performed to accom-\\nmodate the small incision.\\nAntibiotic drops to prevent infection and steroids to\\nreduce inflammation are prescribed after surgery. An eye\\nshield or glasses during the day will protect the eye from\\ninjury while it heals. During the night, an eye shield is\\nworn. The patient returns to the doctor the day after\\nsurgery for assessment, with several follow-up visits over\\nthe next two months to monitor the healing process.\\nPrognosis\\nThe success rate of cataract extraction is very high,\\nwith a good prognosis. A visual acuity of 20/40 or better\\nmay be achieved. If an extracapsular cataract extraction\\nwas performed, a secondary cataract may develop in the\\nremaining back portion of the capsule. This can occur one\\nto two years after surgery. Y AG capsulotomy is most often\\nused for this type of cataract. Y AG stands for yttrium alu-\\nminum garnet, the name of the laser used for this proce-\\ndure. This is a painless outpatient procedure and requires\\nno incision. The laser beam makes a small opening in the\\nremaining back part of the capsule, allowing light through.\\nIn a very small percentage (3–5%) of surgical cataract\\nextractions, complications occur. Infections, swelling of\\nthe cornea (edema), bleeding, retinal detachment , and\\nthe onset of glaucoma have been reported. Some problems\\nmay occur one to two days, or even several weeks, after\\nsurgery. Any haziness, redness, decrease in vision, nausea,\\nor pain should be reported to the surgeon immediately.\\nPrevention\\nPreventive measures emphasize protecting the eyes\\nfrom UV radiation by wearing glasses with a special coating\\nto protect against UV rays. Dark lenses alone are not suffi-\\ncient. The lenses must protect against UV light (specifically,\\nUV-A and UV-B). Antioxidants may also provide some pro-\\ntection by reducing free radicals that can damage lens pro-\\nteins. A healthy diet rich in sources of antioxidants, includ-\\ning citrus fruits, sweet potatoes, carrots, green leafy vegeta-\\nbles, and/or vitamin supplements may be helpful. When tak-\\ning certain medications, such as steroids, more frequent eye\\nexams may be necessary. Patients should speak to their doc-\\ntors to see if medications may affect their eyes.\\nResources\\nBOOKS\\n“Cataract.” In Medical-Surgical Nursing: Concepts and Clini-\\ncal Practice. 5th ed. Ed. Wilma J. Phipps, et al. St. Louis:\\nMosby-Year Book, Inc., 1995.\\nKEY TERMS\\nAphakia—Absence of the lens of the eye.\\nCiliary body—A structure in the eye that contains\\nmuscles which will affect the focusing of the lens.\\nGlaucoma —Disease of the eye characterized by\\nincreased pressure of the fluid inside the eye.\\nUntreated, glaucoma can lead to blindness.\\nPhacoemulsification —Surgical procedure to\\nremove a cataract using sound waves to disinte-\\ngrate the lens which is then removed by suction.\\nRetina—The innermost layer of the eyeball. Images\\nfocused onto the retina are then sent to the brain.\\nUltraviolet radiation (UV) —Invisible light rays\\nwhich may be responsible for sunburns, skin can-\\ncers, and cataract formation.\\nUveitis—Inflammation of the uvea. The uvea is a\\ncontinuous layer of tissue which consists of the\\niris, the ciliary body, and the choroid. The uvea\\nlies between the retina and sclera.\\nPERIODICALS\\n“Cataracts.” Well-Connected Health Report 26(31 May 1997).\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street, P.O.\\nBox 7424, San Francisco, CA 94120-7424. .\\nAmerican Optometric Association. 243 North Lindbergh Blvd.,\\nSt. Louis, MO 63141. (314) 991-4100. .\\nThe Lighthouse. 111 East 59th St., New York, NY 10022.\\n(800) 334-5497. .\\nPrevent Blindness America. 500 East Remington Road,\\nSchaumburg, IL 60173. (800) 331-2020. .\\nCynthia L. Frozena, RN\\nCatatonia\\nDefinition\\nCatatonia is a condition marked by changes in mus-\\ncle tone or activity associated with a large number of\\nserious mental and physical illnesses. There are two dis-\\ntinct sets of symptoms that are characteristic of this con-\\ndition. In catatonic stupor the individual experiences a\\nGALE ENCYCLOPEDIA OF MEDICINE 2 675\\nCatatonia\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 675'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 64, 'page_label': '65'}, page_content='deficit of motor (movement) activity that can render\\nhim/her motionless. Catatonic excitement, or excessive\\nmovement, is associated with violent behavior directed\\ntoward oneself or others.\\nFeatures of catatonia may also be seen in Neuroleptic\\nMalignant Syndrome (NMS) which is an uncommon (but\\npotentially lethal) reaction to some medications used to\\ntreat major mental illnesses. NMS is considered a medical\\nemergency since 25% of untreated cases result in death.\\nCatatonia can also be present in individuals suffering\\nfrom a number of other physical and emotional conditions\\nsuch as drug intoxication, depression, and schizophrenia.\\nIt is most commonly associated with mood disorders.\\nDescription\\nIn catatonic stupor, motor activity may be reduced to\\nzero. Individuals avoid bathing and grooming, make little\\nor no eye contact with others, may be mute and rigid, and\\ninitiate no social behaviors. In catatonic excitement the\\nindividual is extremely hyperactive although the activity\\nseems to have no purpose. Violence toward him/herself\\nor others may also be seen.\\nNMS is observed as a dangerous side effect associat-\\ned with certain neuroleptic (antipsychotic) drugs such as\\nhaloperidol (Haldol). It comes on suddenly and is char-\\nacterized by stiffening of the muscles, fever, confusion\\nand heavy sweating.\\nCatatonia can also be categorized as intrinsic or\\nextrinsic. If the condition has an identifiable cause, it is\\ndesignated as extrinsic. If no cause can be determined\\nfollowing physical examination, laboratory testing, and\\nhistory taking, the illness is considered to be intrinsic.\\nCauses and symptoms\\nThe causes of catatonia are largely unknown\\nalthough research indicates that brain structure and func-\\ntion are altered in this condition. While this and other\\ninformation point to a physical cause, none has yet been\\nproven. A variety of medical conditions also may lead to\\ncatatonia including head trauma, cerebrovascular disease,\\nencephalitis, and certain metabolic disorders. NMS is an\\nadverse side effect of certain antipsychotic drugs.\\nA variety of symptoms are associated with catatonia.\\nAmong the more common are echopraxia (imitation of\\nthe gestures of others) and echolalia (parrot-like repeti-\\ntion of words spoken by others). Other signs and symp-\\ntoms include violence directed toward him/herself, the\\nassumption of inappropriate posture, selective mutism,\\nnegativism, facial grimaces, and animal-like noises.\\nCatatonic stupor is marked by immobility and a behav-\\nior known as cerea flexibilitas (waxy flexibility) in which\\nKEY TERMS\\nBarbiturates —A group of medicines that slow\\nbreathing and lower the body temperature and\\nblood pressure. They can be habit forming and are\\nnow used chiefly for anesthesia.\\nBenzodiazipines—This group of medicines is used\\nto help reduce anxiety (especially before surgery)\\nand to help people sleep.\\nElectroconvulsive therapy—This type of therapy is\\nused to treat major depression and severe mental\\nillness that does not respond to medications. A\\nmeasured dose of electricity is introduced into the\\nbrain in order to produce a convulsion. Electro-\\nconvulsive therapy is safe and effective.\\nMutism—The inability or refusal to speak.\\nNegativism —Behavior characterized by resis-\\ntance, opposition, and refusal to cooperate with\\nrequests, even the most reasonable ones.\\nNeuroleptic drugs —Antipsychotic drugs, includ-\\ning major tranquilizers, used in the treatment of\\npsychoses like schizophrenia.\\nthe individual can be made to assume bizarre (and some-\\ntimes painful) postures that they will maintain for extended\\nperiods of time. The individual may become dehydrated and\\nmalnourished because food and liquids are refused. In\\nextreme situations such individuals must be fed through a\\ntube. Catatonic excitement is characterized by hyperactivity\\nand violence; the individual may harm him/herself or oth-\\ners. On rare occasions,isolationor restraint may be needed\\nto ensure the individual’s safety and the safety of others.\\nDiagnosis\\nRecognition of catatonia is made on the basis of specif-\\nic movement symptoms. These include odd ways of walk-\\ning such as walking on tiptoes or ritualistic pacing, and\\nrarely, hopping and skipping. Repetitive odd movements of\\nthe fingers or hands, as well as imitating the speech or\\nmovements of others also may indicate that catatonia is pre-\\nsent. There are no laboratory or other tests that can be used\\nto positively diagnose this condition, but medical and neuro-\\nlogical tests are necessary to rule out underlying lesions or\\ndisorders that may be causing the symptoms observed.\\nTreatment\\nTreatment of catatonia includes medications such as\\nbenzodiazipines (which are the preferred treatment) and\\nrarely barbiturates. Antipsychotic drugs may be appropri-\\nGALE ENCYCLOPEDIA OF MEDICINE 2676\\nCatatonia\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 676'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 65, 'page_label': '66'}, page_content='ate in some cases, but often cause catatonia to worsen. Elec-\\ntroconvulsive therapymay prove beneficial for clients who\\ndo not respond to medication. If these approaches are\\nunsuccessful, treatment will be redirected to attempts to\\ncontrol the signs and symptoms of the illness.\\nPrognosis\\nCatatonia usually responds quickly to medication\\ninterventions.\\nPrevention\\nThere is currently no known way to prevent catatonia\\nbecause the cause has not yet been identified. Research\\nefforts continue to explore possible origins. Avoiding\\nexcessive use of neuroleptic drugs can help minimize the\\nrisk of developing catatonic-like symptoms.\\nResources\\nBOOKS\\nDiagnostic and Statistical Manual for Mental Disorders.4th\\nedition. Washington, DC: American Psychiatric Associa-\\ntion, 1994.\\nFrisch, Noreen Cavan, and Lawrence E. Frisch. Psychiatric Men-\\ntal Health Nursing.Albany, NY: Delmar Publishers, 1998.\\nDonald G. Barstow, RN\\nCatecholamines tests\\nDefinition\\nCatecholamines is a collective term for the hormones\\nepinephrine, norepinephrine, and dopamine. Manufac-\\ntured chiefly by the chromaffin cells of the adrenal\\nglands, these hormones are involved in readying the body\\nfor the “fight-or-flight” response (also known as the alarm\\nreaction). When these hormones are released, the heart\\nbeats stronger and faster, blood pressure rises, more blood\\nflows to the brain and muscles, the liver releases stores of\\nenergy as a sugar the body can readily use (glucose), the\\nrate of breathing increases and airways widen, and diges-\\ntive activity slows. These reactions direct more oxygen\\nand fuel to the organs most active in responding to\\nstress—mainly the brain, heart, and skeletal muscles.\\nPurpose\\nPheochromocytoma (a tumor of the chromaffin\\ncells of the adrenal gland) and tumors of the nervous sys-\\ntem (neuroblastomas, ganglioneuroblastomas, and gan-\\nglioneuromas) that affect hormone production can cause\\nexcessive levels of different catecholamines to be secret-\\ned. This results in constant or intermittent high blood\\npressure ( hypertension ). Episodes of high blood pres-\\nsure may be accompanied by symptoms such as\\nheadache, sweating, palpitations, and anxiety. The cat-\\necholamines test can be ordered, then, to determine if\\nhigh blood pressure and other symptoms are related to\\nimproper hormone secretion and to identify the type of\\ntumor causing elevated catecholamine levels.\\nDescription\\nThe catecholamines test can be performed on either\\nblood or urine. If performed on blood, the test may\\nrequire one or two samples, depending on the physician’s\\nrequest. The first blood sample will be drawn after the\\npatient has been lying down in a warm, comfortable\\nenvironment for at least 30 minutes. If a second sample is\\nneeded, the patient will be asked to stand for 10 minutes\\nbefore the blood is drawn. Instead of a venipuncture,\\nwhich can be stressful for the patient, possibly increasing\\ncatecholamine levels in the blood, a plastic or rubber\\ntube-like device called a catheter may be used to collect\\nthe blood samples. The catheter would be inserted in a\\nvein 24 hours in advance, eliminating the need for needle\\npunctures at the time of the test.\\nIt may take up to a week for a lab to complete testing\\nof the samples. Because blood levels of catecholamines\\ncommonly go up and down in response to such factors as\\ntemperature, stress, postural change, diet, smoking, obe-\\nsity, and many drugs, abnormally high blood test results\\nshould be confirmed with a 24-hour urine test. In addition,\\ncatecholamine secretion from a tumor may not be steady,\\nbut may occur periodically during the day, and potentially\\ncould be missed when blood testing is used. The urine test\\nprovides the laboratory with a specimen that reflects cate-\\ncholamine production over an entire 24-hour period. If\\nurine is tested, the patient or a healthcare worker must col-\\nlect all the urine passed over the 24-hour period.\\nPreparation\\nIt is important that the patient refrain from using cer-\\ntain medications, especially cold or allergy remedies, for\\ntwo weeks before the test. Certain foods—including\\nbananas, avocados, cheese, coffee, tea, cocoa, beer,\\nlicorice, citrus fruit, vanilla, and Chianti—must be avoid-\\ned for 48 hours prior to testing. However, people should\\nbe sure to get adequate amounts of vitamin C before the\\ntest, because this vitamin is necessary for catecholamine\\nformation. The patient should be fasting (nothing to eat\\nor drink) for 10 to 24 hours before the blood test and\\nshould not smoke for 24 hours beforehand. Some labora-\\ntories may call for additional restrictions. As much as\\npossible, the patient should try to avoid excessive physi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 677\\nCatecholamines tests\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 677'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 66, 'page_label': '67'}, page_content='cal exercise and emotional stress before the test, because\\neither may alter test results by causing increased secre-\\ntion of epinephrine and norepinephrine.\\nPatients collecting their own 24-hour urine samples\\nwill be given a container with special instructions. The\\nurine samples must be refrigerated.\\nRisks\\nRisks for the blood test are minimal, but may\\ninclude slight bleeding from the venipuncture site, faint-\\ning or feeling lightheaded after blood is drawn, or blood\\naccumulating under the puncture site (hematoma). There\\nare no risks for the urine test.\\nNormal results\\nReference ranges are laboratory-specific, vary accord-\\ning to methodology of testing, and differ between blood\\nand urine samples. If testing is done by the method called\\nHigh Performance Liquid Chromatography (HPLC), typi-\\ncal values for blood and urine follow.\\nKEY TERMS\\nDopamine—Dopamine is a precursor of epineph-\\nrine and norepinephrine.\\nEpinephrine—Epinephrine, also called adrenaline,\\nis a naturally occurring hormone released by the\\nadrenal glands in response to signals from the sym-\\npathetic nervous system. These signals are triggered\\nby stress, exercise, or by emotions such as fear.\\nGanglioneuroma —A ganglioneuroma is a tumor\\ncomposed of mature nerve cells.\\nNeuroblastoma—Neuroblastoma is a tumor of the\\nadrenal glands or sympathetic nervous system.\\nNeuroblastomas can range from being relatively\\nharmless to highly malignant.\\nNorepinephrine —Norepinephrine is a hormone\\nsecreted by certain nerve endings of the sympa-\\nthetic nervous system, and by the medulla (center)\\nof the adrenal glands. Its primary function is to\\nhelp maintain a constant blood pressure by stimu-\\nlating certain blood vessels to constrict when the\\nblood pressure falls below normal.\\nPheochromocytoma —A pheochromocytoma is a\\ntumor that originates from the adrenal gland’s\\nchromaffin cells, causing overproduction of cate-\\ncholamines, powerful hormones that induce high\\nblood pressure and other symptoms.\\nReference ranges for blood catecholamines\\nSupine (lying down): Epinephrine less than 50\\npg/mL, norepinephrine less than 410 pg/mL, and\\ndopamine less than 90 pg/mL. Standing: Values for blood\\nspecimens taken when the subject is standing are higher\\nthan the ranges for supine posture for norepinephrine and\\nepinephrine, but not for dopamine.\\nReference ranges for urine catecholamines\\nEpinephrine 0–20 microgram per 24 hours; norepi-\\nnephrine 15–80 microgram per 24 hours; dopamine\\n65–400 microgram per 24 hours.\\nAbnormal results\\nDepending on the results, high catecholamine levels\\ncan indicate different conditions and/or causes:\\n• High catecholamine levels can help to verify pheochro-\\nmocytoma, neuroblastoma, or ganglioneuroma. An aid\\nto diagnosis is the fact that an adrenal medullary tumor\\n(pheochromocytoma) secretes epinephrine, whereas gan-\\nglioneuroma and neuroblastoma secrete norepinephrine.\\n• Elevations are possible with, but do not directly confirm,\\nthyroid disorders, low blood sugar ( hypoglycemia), or\\nheart disease.\\n• Electroshock therapy, or shock resulting from hemor-\\nrhage or exposure to toxins, can raise catecholamine\\nlevels.\\n• In the patient with normal or low baseline cate-\\ncholamine levels, failure to show an increase in the\\nsample taken after standing suggests an autonomic ner-\\nvous system dysfunction (the division of the nervous\\nsystem responsible for the automatic or unconscious\\nregulation of internal body functioning).\\nResources\\nBOOKS\\nCahill, Mathew. Handbook of Diagnostic Tests.Springhouse,\\nPA: Springhouse Corporation, 1995.\\nJacobs, David S., et al. Laboratory Test Handbook.4th ed. New\\nYork: Lexi-Comp Inc., 1996.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nCatheter ablation\\nDefinition\\nCatheter ablation of an irregular heartbeat involves\\nhaving a tube (a catheter) inserted into the heart through\\nGALE ENCYCLOPEDIA OF MEDICINE 2678\\nCatheter ablation\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 678'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 67, 'page_label': '68'}, page_content='which electrical energy is sent to either reset the heart-\\nbeat or stop the heart from beating so a mechanical pace-\\nmaker can be put in place.\\nPurpose\\nIrregular heartbeats can occur in healthy people\\nwithout causing any dangerous symptoms or requiring\\nmedical attention. Slight changes in the normal patterns\\nof heartbeats often reset themselves without notice.\\nBut when the heartbeat is greatly disrupted—either\\nbecause of traumatic injury, disease, hypertension ,\\nsurgery, or reduced blood flow to the heart caused by\\nblockages in the blood vessels that nourish the heart—\\nthe condition must be recognized and treated immediate-\\nly. Otherwise, it can be fatal.\\nVarious drugs can be used to control and help reset\\nthese abnormal heart rhythms ( arrhythmias). The tech-\\nnique of catheter ablation (meaning tube-guided removal)\\nis used to interrupt the abnormal contractions in the heart,\\nallowing normal heart beating to resume. Atrial fibrilla-\\ntion and flutter and Wolff-Parkinson-White syndrome\\nare two of the most common disorders treated with\\ncatheter ablation.\\nPrecautions\\nThe improper correction of abnormal heartbeats can\\ncause additional arrhythmias and can be fatal. Abnormali-\\nties in different areas of the heart cause different types of\\nirregular heartbeats; the type of arrhythmia must be clear-\\nly defined before this procedure can be properly done.\\nDescription\\nCatheter ablation involves delivering highly focused\\nheat (or radio frequency energy) to specific areas of the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 679\\nCatheter ablation\\nDuring catheter ablation, a long flexible tube called a catheter is inserted into a vein in the patient’s groin and guided toward\\nthe heart. A special x-ray machine called a fluoroscope helps the electrophysiologist visualize correct placement.(Photo-\\ngraph by Collette Placek. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 679'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 68, 'page_label': '69'}, page_content='heart. Radio frequency energy is very rapidly alternating\\nelectrical current that is produced at the tip of the\\ncatheter that is placed inside the heart. At the same time\\nas the catheter is inserted, a second electrode is placed on\\nthe patient’s skin. When the catheter is energized, the\\nbody conducts the energy from the catheter’s tip, through\\nthe heart and to the electrode on the skin’s surface, com-\\npleting the circuit.\\nAlthough very little electricity is given off by the\\ncatheter, the instrument does generate a large amount of\\nheat. This heat is absorbed by the heart tissue, causing a\\nsmall localized burn and destroying the tissue in contact\\nwith the catheter tip; in this way, small regions of heart\\ntissue are burned in a controlled manner. This controlled\\ndestruction of small sections of heart muscle actually\\nkills the nerve cells causing the irregular heartbeat, stop-\\nping the nerve signals that are passing through this sec-\\ntion of the heart. This usually causes the irregular heart-\\nbeat to be reset into a normal heartbeat.\\nPreparation\\nPeople can undergo this procedure by having gener-\\nal anesthesia or by taking medicines to make them\\nrelaxed and sleepy (sedatives) along with painkillers.\\nOnce the type of irregular heartbeat is identified and\\nthese medicines are given, the catheter is inserted\\nthrough a blood vessel and into the heart. Importantly,\\ncorrect placement of the catheter is visualized by using a\\nspecialized type of x-ray machine called a fluoroscope.\\nAftercare\\nBeing sure the patient is comfortable during and\\nafter this procedure is very important. However, because\\neach person may have a different arrhythmia and possi-\\nbly other medical problems as well, each patient’s needs\\nmust be evaluated individually.\\nKEY TERMS\\nFluoroscope —A specialized x-ray machine used\\nto visualize the placement of the catheter when\\nattempting to correct irregular heartbeats.\\nPacemaker —An electrical device that has elec-\\ntrodes attached to the heart to electrically stimu-\\nlate the heart to beat normally. Pacemakers can be\\ninternal (placed under the skin) or external, with\\nthe electrodes placed on the skin or threaded\\nthrough a tube placed into the heart.\\nRisks\\nOverall, fewer than 5% of people having this proce-\\ndure experience complications. The most common com-\\nplications are usually related to blood vessel injury when\\nthe catheter is inserted and to different heart-related\\nproblems due to the moving of the catheter within the\\nheart. However, in general, this technique is safe and can\\ncontrol many different heart arrhythmias.\\nNormal results\\nDepending upon the type of irregular heartbeat\\nbeing treated, either the normal heartbeat resumes after\\ntreatment or the ability of the heart to beat on its own is\\nlost, requiring the insertion of a pacemaker to stimulate\\nthe heart to beat regularly.\\nAbnormal results\\nAdditional irregular heartbeats can occur as a result\\nof this procedure, as can damage to the blood vessels that\\nfeed the heart. Because this procedure requires the use of\\nthe x-ray machine called a fluoroscope, there is exposure\\nto x-ray radiation, but it’s doubtful that this is harmful in\\nadult patients. The risk versus benefit is considered with\\npediatric patients.\\nResources\\nBOOKS\\nScheinman, Melvin M. “Treatment of Cardiac Arrhythmias\\nwith Catheter Ablative Techniques.” In Hurst’s The Heart,\\ned. Robert C. Schlant, et al. New York: McGraw Hill,\\n1994.\\nPERIODICALS\\nLashus, Andrew G., Christopher L. Case, and Paul C. Gillette.\\n“Catheter Ablation Treatment of Supraventricular Tachy-\\ncardia-Induced Cardiomyopathy.”Archives of Pediatrics\\nand Adolescent Medicine 151 (Mar. 1997): 264.\\nPatlak, Margie. “When Heartbeats Go Haywire.”FDA Con-\\nsumer 31 (Apr. 1997): 12.\\n“Radiofrequency Catheter Ablation for Treatment of Cardiac\\nArrhythmias.” Medical Letter on Drugs and Therapeutics\\n38 (26 Mar. 1996): 409.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nDominic De Bellis, PhD\\nCat’s cry syndrome see Cri du chat\\nsyndrome\\nCBC see Blood count\\nGALE ENCYCLOPEDIA OF MEDICINE 2680\\nCatheter ablation\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 680'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 69, 'page_label': '70'}, page_content='CEA test see Carcinoembryonic antigen test\\nCEB see Chronic fatigue syndrome\\nCefaclor see Cephalosporins\\nCefadroxil see Cephalosporins\\nCefixime see Cephalosporins\\nCefprozil see Cephalosporins\\nCefurox see Cephalosporins\\nCeliac disease\\nDefinition\\nCeliac disease is a disease of the digestive system\\nthat damages the small intestine and interferes with the\\nabsorption of nutrients from food.\\nDescription\\nCeliac disease occurs when the body reacts abnor-\\nmally to gluten, a protein found in wheat, rye, barley, and\\npossibly oats. When someone with celiac disease eats\\nfoods containing gluten, that person’s immune system\\ncauses an inflammatory response in the small intestine,\\nwhich damages the tissues and results in impaired ability\\nto absorb nutrients from foods. The inflammation and\\nmalabsorption create wide-ranging problems in many\\nsystems of the body. Since the body’s own immune sys-\\ntem causes the damage, celiac disease is classified as an\\n“autoimmune” disorder. Celiac disease may also be called\\nsprue, nontropical sprue, gluten sensitive enteropathy,\\nceliac sprue, and adult celiac disease.\\nCeliac disease may be discovered at any age, from\\ninfancy through adulthood. The disorder is more com-\\nmonly found among white Europeans or in people of\\nEuropean descent. It is very unusual to find celiac dis-\\nease in African or Asian people. The exact incidence of\\nthe disease is uncertain. Estimates vary from one in\\n5000, to as many as one in every 300 individuals with\\nthis background. The prevalence of celiac disease seems\\nto be different from one European country to another,\\nand between Europe and the United States. This may be\\ndue to differences in diet and/or unrecognized disease. A\\nrecent study of random blood samples tested for celiac\\ndisease in the US showed one in 250 testing positive. It is\\nclearly underdiagnosed, probably due to the symptoms\\nbeing attributed to another problem, or lack of knowl-\\nedge about celiac disease by physicians and laboratories.\\nBecause of the known genetic component, relatives of\\npatients with celiac disease are considered at higher risk\\nfor the disorder.\\nBecause celiac disease has a hereditary influence,\\nclose relatives (especially first degree relatives, such as\\nchildren, siblings, and parents) have a higher risk of\\nbeing affected with the condition. The chance that a first\\ndegree relative of someone with celiac disease will have\\nthe disease is about 10%.\\nAs more is learned about celiac disease, it becomes\\nevident that it has many variations which may not pro-\\nduce typical symptoms. It may even be clinically “silent,”\\nwhere no obvious problems related to the disease are\\napparent.\\nCauses and symptoms\\nCeliac disease can run in families and has a genetic\\nbasis, although the pattern of inheritance is complicated.\\nThe type of inheritance pattern that celiac disease fol-\\nlows is called multifactorial (caused by many factors,\\nboth genetic and environmental). Researchers think that\\nseveral factors must exist in order for the disease to\\noccur. The patient must have a genetic predisposition to\\ndevelop the disorder. Then, something in their environ-\\nment acts as a stimulus, or “trigger,” to their immune sys-\\ntem, causing the disease to become active for the first\\ntime. For conditions with multifactorial inheritance, peo-\\nple without the genetic predisposition are less likely to\\ndevelop the condition with exposure to the same triggers.\\nOr, they may require more exposure to the stimulus\\nbefore developing the disease than someone with a\\ngenetic predisposition. Some of the things which may\\nprovoke a reaction include surgery, especially gastroin-\\ntestinal surgery; a change to a low fat diet, which has an\\nincreased number of wheat-based foods; pregnancy ;\\nchildbirth; severe emotional stress; or a viral infection.\\nThis combination of genetic susceptibility and an outside\\nagent leads to celiac disease.\\nEach person with celiac disease is affected different-\\nly. When food containing gluten reaches the small intes-\\ntine, the immune system begins to attack a substance\\ncalled gliadin, which is found in the gluten. The resulting\\ninflammation causes damage to the delicate finger-like\\nstructures in the intestine, called villi, where food absorp-\\ntion actually takes place. The patient may experience a\\nnumber of symptoms related to the inflammation and the\\nchemicals it releases, and/or the lack of ability to absorb\\nnutrients from food, which can cause malnutrition.\\nThe most commonly recognized symptoms of celiac\\ndisease relate to the improper absorption of food in the\\ngastrointestinal system. Many patients with gastrointesti-\\nnal symptoms will have diarrhea and fatty, greasy,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 681\\nCeliac disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 681'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 70, 'page_label': '71'}, page_content='unusually foul-smelling stools. The patient may com-\\nplain of excessive gas (flatulence), distended abdomen,\\nweight loss, and generalized weakness. Not all people\\nhave digestive system complications; some people only\\nhave irritability or depression. Irritability is one of the\\nmost common symptoms in children with celiac disease.\\nNot all patients have these problems. Unrecognized\\nand therefore untreated celiac disease may cause or con-\\ntribute to a variety of other conditions. The decreased\\nability to digest, absorb, and utilize food properly (mal-\\nabsorption) may cause anemia (low red blood count )\\nfrom iron deficiency or easy bruising from a lack of vita-\\nmin K. Poor mineral absorption may result in osteoporo-\\nsis, or “brittle bones,” which may lead to bone fractures.\\nVitamin D levels may be insufficient and bring about a\\n“softening” of bones (osteomalacia), which produces\\npain and bony deformities, such as flattening or bending.\\nDefects in the tooth enamel, characteristic of celiac dis-\\nease, may be recognized by dentists. Celiac disease may\\nbe discovered during medical tests performed to investi-\\ngate failure to thrive in infants, or lack of proper growth\\nin children and adolescents. People with celiac disease\\nmay also experience lactose intolerance because they\\ndon’t produce enough of the enzyme lactase, which\\nbreaks down the sugar in milk into a form the body can\\nabsorb. Other symptoms can include muscle cramps,\\nfatigue, delayed growth, tingling or numbness in the legs\\n(from nerve damage), pale sores in the mouth (called\\naphthus ulcers), tooth discoloration, or missed menstrual\\nperiods (due to severe weight loss).\\nA distinctive, painful skin rash, called dermatitis\\nherpetiformis, may be the first sign of celiac disease.\\nApproximately 10% of patients with celiac disease have\\nthis rash, but it is estimated that 85% or more of patients\\nwith the rash have the disease.\\nMany disorders are associated with celiac disease,\\nthough the nature of the connection is unclear. One type\\nof epilepsy is linked to celiac disease. Once their celiac\\ndisease is successfully treated, a significant number of\\nthese patients have fewer or no seizures. Patients with\\nalopecia areata, a condition where hair loss occurs in\\nsharply defined areas, have been shown to have a higher\\nrisk of celiac disease than the general population. There\\nappears to be a higher percentage of celiac disease\\namong people with Down syndrome , but the link\\nbetween the conditions is unknown.\\nSeveral conditions attributed to a disorder of the\\nimmune system have been associated with celiac disease.\\nPeople with insulin dependent diabetes (type I) have a\\nmuch higher incidence of celiac disease. One source esti-\\nmates that as many as one in 20 insulin-dependent dia-\\nbetics may have celiac disease. Patients with other condi-\\ntions where celiac disease may be more commonly found\\ninclude those with juvenile chronic arthritis, some thy-\\nroid diseases, and IgA deficiency.\\nThere is an increased risk of intestinal lymphoma, a\\ntype of cancer, in individuals with celiac disease. Suc-\\ncessful treatment of the celiac disease seems to decrease\\nthe chance of developing lymphoma.\\nDiagnosis\\nBecause of the variety of ways celiac disease can\\nmanifest itself, it is often not discovered promptly. Its\\nsymptoms are similar to many other conditions including\\nirritible bowel syndrome, Crohn’s disease, ulcerative\\ncolitis , diverticulosis, intestinal infections, chronic\\nfatigue syndrome , and depression. The condition may\\npersist without diagnosis for so long that the patient\\naccepts a general feeling of illness as normal. This leads\\nto further delay in identifying and treating the disorder. It\\nis not unusual for the disease to be identified in the\\ncourse of medical investigations for seemingly unrelated\\nproblems. For example, celiac disease has been discov-\\nered during testing to find the cause of infertility.\\nIf celiac disease is suspected, a blood test can be\\nordered. This test looks for the antibodies to gluten (called\\nantigliadin, anti-endomysium, and antireticulin) that the\\nimmune system produces in celiac disease. Antibodies are\\nchemicals produced by the immune system in response to\\nsubstances that the body perceives to be threatening. Some\\nexperts advocate not just evaluating patients with symp-\\ntoms, but using these blood studies as a screening test for\\nhigh-risk individuals, such as those with relatives (espe-\\ncially first degree relatives) known to have the disorder. An\\nabnormal result points towards celiac disease, but further\\ntests are needed to confirm the diagnosis. Because celiac\\ndisease affects the ability of the body to absorb nutrients\\nfrom food, several tests may be ordered to look for nutri-\\ntional deficiencies. For example, doctors may order a test\\nof iron levels in the blood because low levels of iron (ane-\\nmia) may accompany celiac disease. Doctors may also\\norder a test for fat in the stool, since celiac disease pre-\\nvents the body from absorbing fat from food.\\nIf these tests above are suspicious for celiac disease,\\nthe next step is a biopsy (removal of a tiny piece of tissue\\nsurgically) of the small intestine. This is usually done by a\\ngastroenterologist, a physician who specializes in diagnos-\\ning and treating bowel disorders. It is generally performed\\nin the office, or in a hospital’s outpatient department. The\\npatient remains awake, but is sedated. A narrow tube,\\ncalled an endoscope, is passed through the mouth, down\\nthrough the stomach, and into the small intestine. A small\\nsample of tissue is taken and sent to the laboratory for\\nanalysis. If it shows a pattern of tissue damage characteris-\\ntic of celiac disease, the diagnosis is established.\\nGALE ENCYCLOPEDIA OF MEDICINE 2682\\nCeliac disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 682'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 71, 'page_label': '72'}, page_content='The patient is then placed on a gluten-free diet\\n(GFD). The physician will periodically recheck the level\\nof antibody in the patient’s blood. After several months,\\nthe small intestine is biopsied again. If the diagnosis of\\nceliac disease was correct (and the patient followed the\\nrigorous diet), healing of the intestine will be apparent.\\nMost experts agree that it is necessary to follow these\\nsteps in order to be sure of an accurate diagnosis.\\nTreatment\\nThe only treatment for celiac disease is a gluten-free\\ndiet. This may be easy for the doctor to prescribe, but dif-\\nficult for the patient to follow. For most people, adhering\\nto this diet will stop symptoms and prevent damage to the\\nintestines. Damaged villi can be functional again in three\\nto six months. This diet must be followed for life. For\\npeople whose symptoms are cured by the gluten-free diet,\\nthis is further evidence that their diagnosis is correct.\\nGluten is present in any product that contains wheat,\\nrye, barley, or oats. It helps make bread rise, and gives\\nmany foods a smooth, pleasing texture. In addition to the\\nmany obvious places gluten can be found in a normal\\ndiet, such as breads, cereals, and pasta, there are many\\nhidden sources of gluten. These include ingredients\\nadded to foods to improve texture or enhance flavor and\\nproducts used in food packaging. Gluten may even be\\npresent on surfaces used for food preparation or cooking.\\nFresh foods that have not been artificially processed,\\nsuch as fruits, vegetables, and meats, are permitted as\\npart of a GFD. Gluten-free foods can be found in health\\nfood stores and in some supermarkets. Mail-order food\\ncompanies often have a selection of gluten-free products.\\nHelp in dietary planning is available from dieticians\\n(healthcare professionals specializing in food and nutri-\\ntion) or from support groups for individuals with celiac\\ndisease. There are many cookbooks on the market specif-\\nically for those on a GFD.\\nTreating celiac disease with a GFD is almost always\\ncompletely effective. Gastrointestinal complaints and\\nother symptoms are alleviated. Secondary complications,\\nsuch as anemia and osteoporosis, resolve in almost all\\npatients. People who have experienced lactose intoler-\\nance related to their celiac disease usually see those\\nsymptoms subside, as well. Although there is no risk and\\nmuch potential benefit to this treatment, it is clear that\\navoiding all foods containing gluten can be difficult.\\nExperts emphasize the need for lifelong adherence to\\nthe GFD to avoid the long-term complications of this dis-\\norder. They point out that although the disease may have\\nsymptom-free periods if the diet is not followed, silent\\ndamage continues to occur. Celiac disease cannot be “out-\\ngrown” or cured, according to medical authorities.\\nKEY TERMS\\nAntibodies —Proteins that provoke the immune\\nsystem to attack particular substances. In celiac\\ndisease, the immune system makes antibodies to a\\ncomponent of gluten.\\nGluten—A protein found in wheat, rye, barley,\\nand oats.\\nVilli—Tiny, finger-like projections that enable the\\nsmall intestine to absorb nutrients from food.\\nPrognosis\\nPatients with celiac disease must adhere to a strict\\nGFD throughout their lifetime. Once the diet has been\\nfollowed for several years, individuals with celiac dis-\\nease have similar mortality rates as the general popula-\\ntion. However, about 10% of people with celiac disease\\ndevelop a cancer involving the gastrointestinal tract (both\\ncarcinoma and lymphoma).\\nThere are a small number of patients who develop a\\nrefractory type of celiac disease, where the GFD no\\nlonger seems effective. Once the diet has been thorough-\\nly assessed to ensure no hidden sources of gluten are\\ncausing the problem, medications may be prescribed.\\nSteroids or immunosuppressant drugs are often used to\\ntry to control the disease. It is unclear whether these\\nefforts meet with much success.\\nPrevention\\nThere is no way to prevent celiac disease. However,\\nthe key to decreasing its impact on overall health is early\\ndiagnosis and strict adherence to the prescribed gluten-\\nfree diet.\\nResources\\nBOOKS\\nLowell, Jax Peters. Against the Grain: The Slightly Eccentric\\nGuide to Living Well without Wheat or Gluten.New York:\\nHenry Holt, 1996.\\nPERIODICALS\\nGluten-Free Living (bimonthly newsletter) PO Box 105, Hast-\\nings-on-Hudson, NY 10706.\\nGuest, Jean. “Wheat’s Your Problem?”Diabetes Forecast49\\n(August 1996): 44–51.\\nPruessner, H. “Detecting Celiac Disease in Your Patients.”\\nAmerican Family Physician 57 (March 1998): 1023–34.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 683\\nCeliac disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 683'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 72, 'page_label': '73'}, page_content='ORGANIZATIONS\\nAmerican Celiac Society. 58 Musano Court, West Orange, NJ,\\n7052. (201) 325-8837.\\nCeliac Disease Foundation. 13251 Ventura Blvd., Suite 1, Stu-\\ndio City, CA 91604-1838. (818) 990-2354.\\nCeliac Sprue Association/United States of America (CSA/\\nUSA). PO Box 31700, Omaha, NE 68131-0700. (402)\\n558-0600.\\nGluten Intolerance Group. PO Box 23053, Seattle, W A, 98102-\\n0353. (206) 325-6980.\\nNational Center for Nutrition and Dietetics. American Dietetic\\nAssociation, 216 West Jackson Boulevard, Suite 800,\\nChicago, IL, 60606-6995. (800) 366-1655.\\nOTHER\\nNational Institute of Diabetes & Digestive & Kidney Diseases.\\n.\\nAmy Vance, MS, CGC\\nCellulitis\\nDefinition\\nCellulitis is a spreading bacterial infection just\\nbelow the skin surface. It is most commonly caused by\\nStreptococcus pyogenes or Staphylococcus aureus.\\nDescription\\nThe word “cellulitis” actually means “inflammation\\nof the cells.” Specifically, cellulitis refers to an infection\\nof the tissue just below the skin surface. In humans, the\\nskin and the tissues under the skin are the most common\\nlocations for microbial infection. Skin is the first defense\\nagainst invading bacteria and other microbes. An infec-\\ntion can occur when this normally strong barrier is dam-\\naged due to surgery, injury, or a burn. Even something as\\nsmall as a scratch or an insect bite allows bacteria to enter\\nthe skin, which may lead to an infection. Usually, the\\nimmune system kills any invading bacteria, but some-\\ntimes the bacteria are able to grow and cause an infection.\\nOnce past the skin surface, the warmth, moisture, and\\nnutrients allow bacteria to grow rapidly. Disease-causing\\nbacteria release proteins called enzymes which cause tis-\\nsue damage. The body’s reaction to damage is inflamma-\\ntion which is characterized by pain, redness, heat, and\\nswelling. This red, painful region grows bigger as the\\ninfection and resulting tissue damage spread. An untreat-\\ned infection may spread to the lymphatic system ( acute\\nlymphangitis ), the lymph nodes ( lymphadenitis ), the\\nbloodstream (bacteremia), or into deeper tissues. Celluli-\\ntis most often occurs on the face, neck, and legs.\\nOrbital cellulitis\\nA very serious infection, called orbital cellulitis,\\noccurs when bacteria enter and infect the tissues sur-\\nrounding the eye. In 50–70% of all cases of orbital cel-\\nlulitis, the infection spreads to the eye(s) from the sinus-\\nes or the upper respiratory tract (nose and throat). Twen-\\nty-five percent of orbital infections occur after surgery on\\nthe face. Other sources of orbital infection include a\\ndirect infection from an eye injury, from a dental or\\nthroat infection, and through the bloodstream.\\nInfection of the tissues surrounding the eye causes\\nredness, swollen eyelids, severe pain, and causes the eye\\nto bulge out. This serious infection can lead to a tempo-\\nrary loss of vision, blindness, brain abscesses, inflamma-\\ntion of the brain and spinal tissues ( meningitis ), and\\nother complications. Before the discovery of antibiotics,\\norbital cellulitis caused blindness in 20% of patients and\\ndeath in 17% of patients. Antibiotic treatment has signif-\\nicantly reduced the incidence of blindness and death.\\nCauses and symptoms\\nAlthough other kinds of bacteria can cause cellulitis,\\nit is most often caused by Streptococcus pyogenes (the\\nbacteria which causes strep throat) and Staphylococcus\\naureus. Streptococcus pyogenes is the so-called “flesh-\\neating bacteria” and, in rare cases, can cause a danger-\\nous, deep skin infection called necrotizing fasciitis.\\nOrbital cellulitis may be caused by bacteria which cannot\\ngrow in the presence of oxygen (anaerobic bacteria). In\\nchildren, Haemophilus influenzae type B frequently\\ncauses orbital cellulitis following a sinus infection.\\nStreptococcus pyogenes can be picked up from a\\nperson who has strep throat or an infected sore. Other\\ncellulitis-causing bacteria can be acquired from direct\\ncontact with infected sores. Persons who are at a higher\\nrisk for cellulitis are those who have a severe underlying\\ndisease (such as cancer, diabetes, and kidney disease),\\nare taking steroid medications, have a reduced immune\\nsystem (because of AIDS, organ transplant, etc.), have\\nbeen burned, have insect bites, have reduced blood circu-\\nlation to limbs, or have had a leg vein removed for coro-\\nnary bypass surgery. In addition, chicken pox, human or\\nanimal bite wounds, skin wounds, and recent surgery\\ncan put a person at a higher risk for cellulitis.\\nThe characteristic symptoms of cellulitis are red-\\nness, warmth, pain, and swelling. The infected area\\nappears as a red patch that gets larger rapidly within the\\nfirst 24 hours. A thick red line which progresses towards\\nthe heart may appear indicating an infection of the lymph\\nvessels (lymphangitis). Other symptoms which may\\noccur include fever, chills, tiredness, muscle aches, and a\\nGALE ENCYCLOPEDIA OF MEDICINE 2684\\nCellulitis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 684'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 73, 'page_label': '74'}, page_content='general ill feeling. Some people also experience nausea,\\nvomiting, stiff joints, and hair loss at the infection site.\\nThe characteristic symptoms of orbital cellulitis are\\neye pain, redness, swelling, warmth, and tenderness. The\\neye may bulge out and it may be difficult or impossible\\nto move. Temporary loss of vision, pus drainage from the\\neye, chills, fever, headaches, vomiting, and a general ill\\nfeeling may occur.\\nDiagnosis\\nCellulitis may be diagnosed and treated by a family\\ndoctor, an infectious disease specialist, a doctor who spe-\\ncializes in skin diseases (dermatologist), or in the case of\\norbital cellulitis, an eye doctor (ophthalmologist). The\\ndiagnosis of cellulitis is based mainly on the patient’s\\nsymptoms. The patient’s recent medical history is also\\nused in the diagnosis.\\nLaboratory tests may be done to determine which\\nkind of bacteria is causing the infection but these tests\\nare not always successful. If the skin injury is visible, a\\nsterile cotton swab is used to pick up a sample from the\\nwound. If there is no obvious skin injury, a needle may\\nbe used to inject a small amount of sterile salt solution\\ninto the infected skin, and then the solution is withdrawn.\\nThe salt solution should pick up some of the bacteria\\ncausing the infection. A blood sample may be taken from\\nthe patient’s arm to see if bacteria have entered the\\nbloodstream. Also, a blood test may be done to count the\\nnumber of white blood cells in the blood. High numbers\\nof white blood cells suggest that the body is trying to\\nfight a bacterial infection.\\nFor orbital cellulitis, the doctor may often perform a\\nspecial x-ray scan called computed tomography scan\\n(CT). This scan enables the doctor to see the patient’s\\nhead in cross-section to determine exactly where the\\ninfection is and see if any damage has occurred. A CT\\nscan takes about 20 minutes.\\nTreatment\\nAntibiotic treatment is the only way to battle this\\npotentially life-threatening infection. Mild to moderate\\ncellulitis can be treated with the following antibiotics\\ntaken every four to eight hours by mouth:\\n• penicillins (Bicillin, Wycillin, Pen Vee, V-Cillin)\\n• erythromycin (E-Mycin, Ery-Tab)\\n• cephalexin (Biocef, Keflex)\\n• cloxacillin (Tegopen)\\nOther medications may be recommended, such as\\nacetaminophen (Tylenol) or ibuprofen (Motrin, Advil)\\nto relieve pain, and aspirin to decrease fever.\\nA normally healthy person is usually not hospital-\\nized for mild or moderate cellulitis. General treatment\\nmeasures include elevation of the infected area, rest, and\\napplication of warm, moist compresses to the infected\\narea. The doctor will want to see the patient again to\\nmake sure that the antibiotic treatment is effective in\\nstopping the infection.\\nPersons at high risk for severe cellulitis will proba-\\nbly be hospitalized for treatment and monitoring. Antibi-\\notics may be given intravenously to patients with severe\\ncellulitis. Complications such as deep infection, or bone\\nor joint infections, might require surgical drainage and a\\nlonger course of antibiotic treatment. Extensive tissue\\ndestruction may require plastic surgery to repair. In cases\\nof orbital cellulitis caused by a sinus infection, surgery\\nmay be required to drain the sinuses.\\nPrognosis\\nOver 90% of all cellulitis cases are cured after seven to\\n10 days of antibiotic treatment. Persons with serious dis-\\nease and/or those who are taking immunosuppressive drugs\\nmay experience a more severe form of cellulitis which can\\nbe life threatening. Serious complications include blood\\npoisoning(bacteria growing in the blood stream), meningi-\\ntis (brain and spinal cord infection), tissue death (necrosis),\\nand/or lymphangitis (infection of the lymph vessels).\\nSevere cellulitis caused by Streptococcus pyogenes can\\nlead to destructive and life-threatening necrotizing fasciitis.\\nPrevention\\nCellulitis may be prevented by wearing appropriate\\nprotective equipment during work and sports to avoid\\nGALE ENCYCLOPEDIA OF MEDICINE 2 685\\nCellulitis\\nThis person’s lower leg is swollen and inflamed due to cel-\\nlulitis. Cellulitis is a Streptococcus bacterial infection of the\\nskin and the tissues beneath it.The face, neck, or legs are\\ncommon sites of cellulitis. (Custom Medical Stock Photo.\\nReproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 685'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 74, 'page_label': '75'}, page_content='skin injury, cleaning cuts and skin injuries with antiseptic\\nsoap, keeping wounds clean and protected, watching\\nwounds for signs of infection, taking the entire pre-\\nscribed dose of antibiotic, and maintaining good general\\nhealth. Persons with diabetes should try to maintain good\\nblood sugar control.\\nResources\\nBOOKS\\nDermatology. 3rd ed. Ed. Peter J. Lynch. Baltimore: Williams\\nand Wilkins, 1994.\\nWestfall, Christopher T., John W. Shore, and Ann Sullivan\\nBaker. “Orbital Infections.” In Infectious Diseases. 2nd\\ned. Philadelphia: W. B. Saunders Co., 1998.\\nPERIODICALS\\nLewis, Ronald T. “Soft Tissue Infections.”World Journal of\\nSurgery 22, no. 2 (Feb. 1998): 146-51.\\nOTHER\\nMayo Clinic Online.5 Mar. 1998 .\\nBelinda Rowland, PhD\\nCell therapy\\nDefinition\\nCell therapy is the transplantation of human or ani-\\nmal cells to replace or repair damaged tissue and/or cells.\\nPurpose\\nCell therapy has been used successfully to rebuild\\ndamaged cartilage in joints, repair spinal cord injuries,\\nstrengthen a weakened immune system, treat autoim-\\nmune diseases such as AIDS, and help patients with neu-\\nKEY TERMS\\nInflammation—A local, protective response to tis-\\nsue injury. It is characterized by redness, warmth,\\nswelling, and pain.\\nNecrotizing fasciitis —A destructive infection\\nwhich follows severe cellulitis and involves the\\ndeep skin and underlying tissues.\\nSinuses —Air cavities found in the bones of the\\nhead. The sinuses which are connected to the nose\\nare prone to infection.\\nrological disorders such as Alzheimer’s disease ,\\nParkinson’s disease , and epilepsy. Further uses have\\nshown positive results in the treatment of a wide range of\\nchronic conditions such as arteriosclerosis, congenital\\ndefects, and sexual dysfunction . The therapy has also\\nbeen used to treat cancer patients at a number of clinics\\nin Tijuana, Mexico, although this application has not\\nbeen well supported with controlled clinical studies.\\nDescription\\nOrigins\\nThe theory behind cell therapy has been in existence\\nfor several hundred years. The first recorded discussion of\\nthe concept of cell therapy can be traced to Phillippus\\nAureolus Paracelsus (1493–1541), a German-Swiss physi-\\ncian and alchemist who wrote in his Der grossen Wun-\\ndartzney (“Great Surgery Book”) in 1536 that “the heart\\nheals the heart, lung heals the lung, spleen heals the spleen;\\nlike cures like.” Paracelsus and many of his contemporaries\\nagreed that the best way to treat an illness was to use living\\ntissue to restore the ailing. In 1667, at a laboratory in the\\npalace of Louis XIV , Jean-Baptiste Denis (1640–1704)\\nattempted to transfuse blood from a calf into a mentally ill\\npatient—and since blood transfusion is, in effect, a form\\nof cell therapy, this could be the first documented case of\\nthis procedure. However, the first recorded attempt at non-\\nblood cellular therapy occurred in 1912 when German\\nphysicians attempted to treat children with hypothy-\\nroidism, or an underactive thyroid, with thyroid cells.\\nIn 1931, Dr. Paul Niehans (1882–1971), a Swiss\\nphysician, became known as “the father of cell therapy”\\nquite by chance. After a surgical accident by a colleague,\\nNiehans attempted to transplant a patient’s severely dam-\\naged parathyroid glands with those of a steer. When the\\npatient began to rapidly deteriorate before the transplant\\ncould take place, Niehans decided to dice the steer’s\\nparathyroid gland into fine pieces, mix the pieces in a\\nsaline solution, and inject them into the dying patient.\\nImmediately, the patient began to improve and, in fact,\\nlived for another 30 years.\\nCell therapy is, in effect, a type of organ transplant\\nwhich has also been referred to as “live cell therapy,”\\n“xenotransplant therapy,” “cellular suspensions,” “glan-\\ndular therapy,” or “fresh cell therapy.” The procedure\\ninvolves the injection of either whole fetal xenogenic\\n(animal) cells (e.g., from sheep, cows, pigs, and sharks)\\nor cell extracts from human tissue. The latter is known as\\nautologous cell therapy if the cells are extracted from and\\ntransplanted back into the same patient. Several different\\ntypes of cells can be administered simultaneously.\\nJust as Paracelsus’ theory of “like cures like,” the\\ntypes of cells that are administered correspond in some\\nGALE ENCYCLOPEDIA OF MEDICINE 2686\\nCell therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 686'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 75, 'page_label': '76'}, page_content='way with the organ or tissue in the patient that is failing.\\nNo one knows exactly how cell therapy works, but pro-\\nponents claim that the injected cells travel to the similar\\norgan from which they were taken to revitalize and stim-\\nulate that organ’s function and regenerate its cellular\\nstructure. In other words, the cells are not species specif-\\nic, but only organ specific. Supporters of cellular treat-\\nment believe that embryonic and fetal animal tissue con-\\ntain active therapeutic agents distinct from vitamins ,\\nminerals, hormones, or enzymes.\\nSwedish researchers have successfully transplanted\\nhuman fetal stem cells into human recipients, and the\\nprocedure is being investigated further as a possible\\ntreatment for repairing brain cells in Parkinson’s\\npatients. However, because the cells used in these appli-\\ncations must be harvested from aborted human fetuses,\\nthere is an ethical debate over their use.\\nCurrently, applications of cell therapy in the United\\nStates is still in the research, experimental, and clinical\\ntrial stages. The U.S. Food and Drug Administration\\nhas approved the use of one cellular therapy technique\\nfor repairing damaged knee joints. The procedure\\ninvolves removing healthy chondrocyte cells, the type\\nof cell that forms cartilage, from the patient, culturing\\nthem in a laboratory for three to four weeks, and then\\ntransplanting them back into the damaged knee joint of\\nthe patient.\\nPreparations\\nThere are several processes to prepare cells for use.\\nOne form involves extracting cells from the patient they\\nare to be used on and then culturing them in a laboratory\\nsetting until they multiply to the level needed for trans-\\nplant back into the patient. Another procedure uses fresh-\\nly removed fetal animal tissue, which has been processed\\nand suspended in a saline solution. The preparation of\\nfresh cells then may be either injected immediately into\\nthe patient, or preserved by being freeze-dried or deep-\\nfrozen in liquid nitrogen before being injected. Cells may\\nbe tested for pathogens, such as bacteria, viruses, or par-\\nasites, before use.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 687\\nCell therapy\\nPAUL NIEHANS (1882–1971)\\nPaul Niehans was born and raised in Switzerland.\\nHis father, a doctor, was dismayed when he entered the\\nseminary, but Niehans quickly grew dissatisfied with reli-\\ngious life and took up medicine after all. He first studied\\nat Bern, then completed an internship in Zurich.\\nNiehans enlisted in the Swiss Army in 1912. When\\nwar erupted in the Balkans, Niehans set up a hospital in\\nBelgrade, Yugoslavia. The war provided him the opportu-\\nnity to treat numerous patients, gaining a firsthand knowl-\\nedge of the body and its workings.\\nSince 1913, Niehans had been intrigued with Alexis\\nCarrel’s experiments concerning the adaptive abilities of\\ncells, though Niehans himself specialized in glandular\\ntransplants and by 1925 was one of the leading glandular\\nsurgeons in Europe.\\nNiehans referred to 1931 as the birth year of cellular\\ntherapy. That year, he treated a patient suffering from\\ntetany whose parathyroid had been erroneously removed\\nby another physician. Too weak for a glandular transplant,\\nthe patient was given injections of the parathyroid glands\\nof an ox, and she soon recovered. Niehans made more\\ninjections, even experimenting on himself, and reported\\nhe could cure illnesses through injections of live cells\\nextracted from healthy animal organs. He believed\\nadding new tissue stimulated rejuvenation and recovery.\\nNiehans treated Pope Pious XII with his injections\\nand was nominated to the Vatican Academy of Science\\nfollowing the pope’s recovery.\\nNiehans remained a controversial figure throughout\\nhis life. As of 2000, the Clinique Paul Niehans in Switzer-\\nland, founded by his daughter, continues his work.\\n(AP/Wide World Photos. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 687'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 76, 'page_label': '77'}, page_content='Precautions\\nPatients undergoing cell therapy treatments which\\nuse cells transplanted from animals or other humans run\\nthe risk of cell rejection, in which the body recognizes\\nthe cells as a foreign substance and uses the immune sys-\\ntem’s T-cells to attack and destroy them. Some forms of\\ncell therapy use special coatings on the cells designed to\\ntrick the immune system into recognizing the new cells\\nas native to the body.\\nThere is also the chance of the cell solution transmit-\\nting bacterial or viral infection or other disease and para-\\nsites to the patient. Careful screening and testing of cells\\nfor pathogens can reduce this risk.\\nMany forms of cell therapy in the United States are\\nstill largely experimental procedures. Patients should\\napproach these treatments with extreme caution, should\\ninquire about their proven efficacy and legal use in the\\nUnited States, and should only accept treatment from a\\nlicensed physician who should educate the patient com-\\npletely on the risks and possible side effects involved\\nwith cell therapy. These same cautions apply for patients\\ninterested in participating in clinical trials of cell therapy\\ntreatments.\\nSide effects\\nBecause cell therapy encompasses such a wide range\\nof treatments and applications, and many of these treat-\\nments are still experimental, the full range of possible\\nside effects of the treatments are not yet known. Anaphy-\\nlactic shock (severe allergic reaction), immune system\\nreactions, and encephalitis (inflammation of the brain)\\nare just a few of the known reported side effects in some\\npatients to date.\\nSide effects of the FDA-approved chondrocyte cell\\ntherapy used in knee joint repair may include tissue\\nhypertrophy, a condition where too much cartilage grows\\nin the joint where the cells were transplanted to and the\\nknee joint begins to stiffen.\\nKEY TERMS\\nAnaphylactic shock—A severe allergic reaction that\\ncauses blood pressure drop, racing heart, swelling\\nof the airway, rash, and possibly convulsions.\\nCulturing —To grow cells in a special substance,\\nor media, in the laboratory.\\nEncephalitis—Inflammation of the brain.\\nResearch and general acceptance\\nThere is a growing debate in the medical community\\nover the efficacy and ethical implications of cell therapy.\\nMuch of the ethical debate revolves around the use of\\nhuman fetal stem cells in treatment, and the fact that\\nthese cells must be harvested from aborted fetuses.\\nWhile some cell therapy procedures have had proven\\nsuccess in clinical studies, others are still largely\\nunproven, including cell therapy for cancer treatment.\\nUntil more large, controlled clinical studies are per-\\nformed on these procedures to either prove or disprove\\ntheir efficacy, they will remain fringe treatments.\\nResources\\nBOOKS\\nSheridan, William, and George Morstyn. Cell Therapy: Stem\\nCell Transplantation, Gene Therapy, and Cellular\\nImmunotherapy. Cambridge, UK: Cambridge University\\nPress, 1996.\\nPERIODICALS\\nSinha, Gunjan. “On the Road to Recovery: Fetal pig cell thera-\\npy has put Parkinson’s patient Jim Finn back in the driver’s\\nseat.”Popular Science255, no. 4 (Oct 1999): 77.\\nORGANIZATIONS\\nCenter for Cell and Gene Therapy. Baylor College of Medicine.\\n1102 Bates St, Suite 1100, Houston, Texas 77030-2399.\\n(713) 770-4663. .\\nPaula Ford-Martin\\nCentral Mississippi Valley disease see\\nHistoplasmosis\\nCentral nervous system\\ndepressants\\nDefinition\\nCentral nervous system (CNS) depressants are drugs\\nthat can be used to slow down brain activity.\\nPurpose\\nCNS depressants may be prescribed by a physician\\nto treat anxiety, muscle tension, pain, insomnia, acute\\nstress reactions, panic attacks, and seizure disorders. In\\nhigher doses, some CNS depressants may be used as\\ngeneral anesthetics.\\nGALE ENCYCLOPEDIA OF MEDICINE 2688\\nCentral nervous system depressants\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 688'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 77, 'page_label': '78'}, page_content='Description\\nThroughout history, humans have sought relief from\\nanxiety and insomnia by using substances that depress\\nbrain activity and induce a drowsy or calming effect. CNS\\ndepressants include a wide range of drugs such as alcohol,\\nnarcotics, barbiturates (Amytal, Nembutal, Seconal), ben-\\nzodiazepines (Ativan, Halcion, Librium, Valium, Xanax),\\nchloral hydrate, and methaqualone (Quaaludes), as well as\\nnewer CNS depressants developed in the 1990s, such as\\nBuspirone (Buspar) and Zolpidem (Ambien), which are\\nthought to have the fewest sideeffects. Most CNS depres-\\nsants activate a neurotransmitter called gamma-aminobu-\\ntyric acid (GABA), which helps decrease brain activity.\\nStreet names for CNS depressants include Reds, Yellows,\\nBlues, Ludes, Barbs, and Downers.\\nPrecautions\\nMost CNS depressants have the potential to be physi-\\ncally and psychologically addictive. Alcohol is the most\\nwidely abused depressant. The body tends to develop tol-\\nerance for CNS depressants, and larger doses are needed\\nto achieve the same effects. Withdrawal from some CNS\\ndepressants can be uncomfortable; for example, with-\\ndrawal from a depressant treating insomnia or anxiety can\\ncause rebound insomnia or anxiety as the brain’s activity\\nbounces back after being suppressed. In some cases with-\\ndrawal can result in life-threatening seizures. Generally,\\ndepressant withdrawal should be undertaken under a\\nphysician’s supervision. Many physicians will reduce the\\ndepressant dosage gradually, to give the body time to\\nadjust. Certain CNS depressants such as barbiturates are\\neasy to overdose on, since there is a relatively small dif-\\nference between the optimal dose and an overdose. A\\nsmall miscalculation can lead to coma, slowed breathing,\\nand death. CNS depressants should be administered to\\nelderly individuals with care, as these individuals have a\\nreduced ability to metabolize CNS depressants.\\nSide Effects\\nEspecially when taken in excess, CNS depressants can\\ncause confusion and dizziness, and impair judgment, mem-\\nory, intellectual performance, and motor coordination.\\nInteractions\\nCNS depressants should be used with other medica-\\ntions, such as antidepressant medications, only under a\\nphysician’s supervision. Certain herbal remedies, such as\\nValerian and Kava, may dangerously exacerbate the\\neffects of certain CNS depressants. Also, ingesting a com-\\nbination of CNS depressants, such Valium and alcohol,\\nfor example, is not advised. When mixed together, CNS\\nKEY TERMS\\nGABA (gamma-aminobutyric acid)— A neuro-\\ntransmitter that slows down the activity of nerve\\ncells in the brain.\\nNeurotransmitter— A chemical compound in the\\nbrain that carries signals from one nerve cell to\\nanother.\\ndepressants tend to amplify each other’s effects, which\\ncan cause severely reduced heart rate and even death.\\nResources\\nBOOKS\\nFontanarosa, P. Alternative Medicine: An Objective Assess-\\nment. American Medical Association, 2000.\\nORGANIZATIONS\\nAmerican Society of Addiction Medicine. 4601 North Park\\nAvenue, Arcade Suite 101, Chevy Chase, MD 20815.\\n(301) 656-3920. .\\nNational Clearinghouse for Alcohol and Drug Abuse Informa-\\ntion (NCADI) Center for Substance Abuse Prevention.\\n5600 Fishers Lane, Rockville, MD 20857. (301) 443-\\n0365. .\\nNational Institute on Drug Abuse. 6001 Executive Blvd, Bethes-\\nda, MD 20892. (301) 443-1124 .\\nAnn Quigley\\nCentral nervous system\\ninfections\\nDefinition\\nThe central nervous system, or CNS, comprises the\\nbrain, the spinal cord, and associated membranes. Under\\nsome circumstances, bacteria may enter areas of the CNS.\\nIf this occurs, abscesses or empyemas may be established.\\nDescription\\nIn general, the CNS is well defended against infec-\\ntion. The spine and brain are sheathed in tough, protec-\\ntive membranes. The outermost membrane, the dura\\nmater, and the next layer, the arachnoid, entirely encase\\nthe brain and spinal cord. However, these defenses are\\nnot absolute. In rare cases, bacteria gain access to areas\\nwithin the CNS.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 689\\nCentral nervous system infections\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 689'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 78, 'page_label': '79'}, page_content='Bacterial infection of the CNS can result in abscess-\\nes and empyemas (accumulations of pus). Abscesses\\nhave fixed boundaries, but empyemas lack definable\\nshape and size. CNS infections are classified according\\nto the location where they occur. For example, a spinal\\nepidural abscess is located above the dura mater, and a\\ncranial subdural empyema occurs between the dura\\nmater and the arachnoid.\\nAs pus and other material from an infection accumu-\\nlate, pressure is exerted on the brain or spinal cord. This\\npressure can damage the nervous system tissue, possibly\\npermanently. Without treatment, a CNS infection is fatal.\\nCauses and symptoms\\nTypically, bacterial invasion results from the spread\\nof a nearby infection; for example, a chronic sinus or\\nmiddle ear infection can extend beyond its initial site.\\nBacteria may also be conveyed to the CNS from distant\\nsites of infection by the bloodstream. In rare cases, head\\ntrauma or surgical procedures may introduce bacteria\\nKEY TERMS\\nAbscess—A pus-filled area with definite borders.\\nArachnoid—One of the membranes that sheathes\\nthe spinal cord and brain; the arachnoid is the sec-\\nond-layer membrane.\\nCerebrospinal fluid—Fluid that is normally found\\nin the spinal cord and brain. Abnormal levels of\\ncertain molecules in this fluid can indicate the\\npresence of infection or damage to the central ner-\\nvous system.\\nCT scan (computed tomography)—Cross-sectional\\nx rays of the body are compiled to create a three-\\ndimensional image of the body’s internal structures.\\nDura mater—One of the membranes that sheathes\\nthe spinal cord and brain; the dura mater is the\\noutermost layer.\\nEmpyema—A pus-filled area with indefinite borders.\\nLumbar puncture —A procedure in which a nee-\\ndle is inserted into the lower spine to collect a\\nsample of cerebrospinal fluid.\\nMRI (magnetic resonance imaging) —An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\ndirectly into the CNS. However, the source of infection\\ncannot always be identified.\\nSpecific symptoms of a CNS infection hinge on its\\nexact location, but may include severe headache or back\\npain, weakness, sensory loss, and a fever. An individual\\nmay report a stiff neck, nausea or vomiting, and tiredness\\nor disorientation. There is a potential for seizures, paral-\\nysis, or coma.\\nDiagnosis\\nPhysical symptoms, such as a fever and intense\\nbackache or a fever, severe headache, and stiff neck, raise\\nthe suspicion of a CNS infection. Blood tests may indi-\\ncate the presence of an infection but do not pinpoint its\\nlocation. CT scans or MRI scans of the brain and spine\\ncan provide definitive diagnosis, with an MRI scan being\\nthe most sensitive. A lumbar puncture and analysis of the\\ncerebrospinal fluid can help diagnose an epidural\\nabscess; however, the procedure can be dangerous in\\ncases of subdural empyema.\\nTreatment\\nA two-pronged approach is taken to treat CNS infec-\\ntions. First, antibiotic therapy against an array of potential\\ninfectious bacteria is begun. The second stage involves\\nsurgery to drain the infected site. Although some CNS\\ninfections have been resolved with antibiotics alone, the\\nmore aggressive approach is often preferred. Surgery allows\\nimmediate relief of pressure on the brain or spinal cord, as\\nwell as an opportunity to collect infectious material for bac-\\nterial identification. Once the bacterial species is identified,\\ndrug therapy can be altered to a more specific antibiotic.\\nHowever, surgery may not be an option in some cases, such\\nas when there are numerous sites of infection or when infec-\\ntion is located in an inaccessible area of the brain.\\nPrognosis\\nThe fatality rate associated with CNS infections\\nranges from 10% to as high as 40%. Some survivors\\nexperience permanent CNS damage, resulting in partial\\nparalysis, speech problems, or seizures. Rapid diagnosis\\nand treatment are essential for a good prognosis. With\\nprompt medical attention, an individual may recover\\ncompletely.\\nPrevention\\nTreatment for pre-existing infections, such as sinus\\nor middle ear infections, may prevent some cases of CNS\\ninfection. However, since some CNS infections are of\\nunknown origin, not all are preventable.\\nGALE ENCYCLOPEDIA OF MEDICINE 2690\\nCentral nervous system infections\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 690'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 79, 'page_label': '80'}, page_content='Resources\\nBOOKS\\nInfections of the Central Nervous System. 2nd ed. Ed. W. M.\\nScheld, R. J. Whitley, and D. T. Durack. Philadelphia:\\nLippincott-Raven Publishers, 1997.\\nInfectious Diseases of the Central Nervous System. Ed. Ken-\\nneth L. Tyler and Joseph B. Martin. Philadelphia: F. A.\\nDavis Co., 1993.\\nPERIODICALS\\nBrennan, Michael. “Subdural Empyema.”American Family\\nPhysician 51, no. 1 (1995): 157.\\nDarouiche, Rabih O., et al. “Bacterial Spinal Epidural Abscess:\\nReview of 43 Cases and Literature Survey.”Medicine 71\\nno. 6 (1992): 369.\\nJulia Barrett\\nCentral nervous system\\nstimulants\\nDefinition\\nCentral nervous system (CNS) stimulants are medi-\\ncines that speed up physical and mental processes.\\nPurpose\\nCentral nervous system stimulants are used to treat\\nconditions characterized by lack of adrenergic stimula-\\ntion, including narcolepsy and neonatal apnea. Addition-\\nally, methylphenidate (Ritalin) and dextroamphetamine\\nsulfate (Dexedrine) are used for their paradoxical effect\\nin attention-deficit hyperactivity disorder (ADHD).\\nThe anerexiants, benzphetamine (Didrex), diethyl-\\npropion (Tenuate), phendimetrazine (Bontril, Plegine),\\nphentermine (Fastin, Ionamine), and sibutramine\\n(Meridia) are CNS stimulants used for appetite reduction\\nin severe obesity. Although these drugs are structurally\\nsimilar to amphetamine, they cause less sensation of\\nstimulation, and are less suited for use in conditions\\ncharacterized by lack of adrenergic stimulation.\\nPhenylpropanolamine and ephedrine have been used\\nboth as diet aids and as vasoconstrictors.\\nDescription\\nThe majority of CNS stimulants are chemically sim-\\nilar to the neurohormone norepinephrine, and simulate\\nthe traditional “fight or flight” syndrome associated with\\nsympathetic nervous system arousal. Caffeine is more\\nclosely related to the xanthines, such as theophylline. A\\nsmall number of additional members of the CNS stimu-\\nlant class do not fall into specific chemical groups.\\nPrecautions\\nAmphetamines have a high potential for abuse. They\\nshould be used in weight reduction programs only when\\nalternative therapies have been ineffective. Administra-\\ntion for prolonged periods may lead to drug dependence.\\nThese drugs are classified as schedule II under federal\\ndrug control regulations.\\nThe amphetamines and their cogeners are con-\\ntraindicated in advanced arteriosclerosis, symptomatic\\ncardiovascular disease, and moderate to severe hyper-\\ntension and hyperthyroidism. They should not be used\\nto treat patients with hypersensitivity or idiosyncrasy to\\nthe sympathomimetic amines, or with glaucoma, a histo-\\nry of agitated states, a history of drug abuse, or during\\nthe 14 days following administration of monoamine oxi-\\ndase (MAO) inhibitors.\\nMethylphenidate may lower the seizure threshold.\\nBenzphetamine is category X during pregnancy .\\nDiethylpropion is category B. Other anorexiants have not\\nbeen rated; however their use during pregnancy does not\\nappear to be advisable. Safety for use of anorexiants has\\nnot been evaluated.\\nAmphetamines are all category C during pregnancy.\\nBreastfeeding while receiving amphetamines is not rec-\\nommended because the infant may experience withdraw-\\nal symptoms.\\nThere have been reports that when used in children,\\nmethylphenidate and amphetamines may retard growth.\\nAlthough these reports have been questioned, it may be\\nsuggested that the drugs not be administered outside of\\nschool hours (because most children have behavior prob-\\nlems in school), in order to permit full stature to be\\nattained.\\nThe most common adverse effects of CNS stimulants\\nare associated with their primary action. Typical respons-\\nes include overstimulation, dizziness , restlessness, and\\nsimilar reactions. Rarely, hematologic reactions, includ-\\ning leukopenia, agranulocytosis, and bone marrow\\ndepression have been reported. Lowering of the seizure\\nthreshold has been noted with most drugs in this class.\\nWithdrawal syndrome\\nAbrupt discontinuation following prolonged high\\ndosage results in extreme fatigue, mental depression and\\nchanges on the sleep EEG. This response is most evident\\nwith amphetamines, but may be observed with all CNS\\nstimulants taken over a prolonged period of time.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 691\\nCentral nervous system stimulants\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 691'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 80, 'page_label': '81'}, page_content='Resources\\nPERIODICALS\\n“Are our children overmedicated?”Parade,(October 12, 1997): 4.\\n“Attention deficit hyperactivity disorder: not just for kids.”\\nMayo Clinic Health Letter,13 (September 1995): 6.\\n“Attention deficit hyperactivity disorder: there is no easy\\nanswer on whether to medicate or not.”British Medical\\nJournal, 315 (October 11, 1997): 894.\\n“The run on Ritalin: attention deficit disorder and stimulant\\ntreatment in the 1990s.”The Hastings Center Report, 26\\n(March-April 1996): 12.\\nORGANIZATION\\nChildren and Adults with Attention Deficit Disorders\\n(CH.A.D.D.). 499 N.W. 70th Avenue, Suite 109, Planta-\\ntion, FL 33317. (305) 587-3700.\\nOTHER\\nAttention deficit hyperactivity disorderPamphlet. National\\nInstitute of Mental Health, 1994.\\nFacts about childhood hyperactivityPamphlet. National Insti-\\ntute of Child Health and Human Development, 1990.\\nNancy Ross-Flanigan\\nCentral retinal artery occlusion see\\nRetinopathies\\nKEY TERMS\\nAgranulocytosis —An acute febrile condition\\nmarked by severe depression of the granulocyte-\\nproducing bone marrow, and by prostration, chills,\\nswollen neck, and sore throat sometimes with local\\nulceration.\\nAnorexiant—A drug that suppresses appetite.\\nAnxiety—Worry or tension in response to real or\\nimagined stress, danger, or dreaded situations. Physi-\\ncal reactions, such as fast pulse, sweating, trembling,\\nfatigue, and weakness, may accompany anxiety.\\nAttention-deficit hyperactivity disorder (ADHD) —\\nA condition in which a person (usually a child) has\\nan unusually high activity level and a short attention\\nspan. People with the disorder may act impulsively\\nand may have learning and behavioral problems.\\nCentral nervous system—The brain and spinal cord.\\nDepression —A mental condition in which people\\nfeel extremely sad and lose interest in life. People\\nwith depression may also have sleep problems and\\nloss of appetite, and may have trouble concentrat-\\ning and carrying out everyday activities.\\nLeucopenia —A condition in which the number of\\nleukocytes circulating in the blood is abnormally\\nlow and which is most commonly due to a\\ndecreased production of new cells in conjunction\\nwith various infectious diseases or as a reaction to\\nvarious drugs or other chemicals.\\nPregnancy category—A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies,\\nor adverse effects in animals, but not in well-con-\\ntrolled human studies. Category C: No adequate\\nhuman or animal studies, or adverse fetal effects in\\nanimal studies, but no available human data. Cate-\\ngory D: Evidence of fetal risk, but benefits outweigh\\nrisks. Category X: Evidence of fetal risk. Risks out-\\nweigh any benefits.\\nWithdrawal symptoms —A group of physical or\\nmental symptoms that may occur when a person\\nsuddenly stops using a drug on which he or she has\\nbecome dependent.\\nCentral retinal vein occlusion see\\nRetinopathies\\nCephalosporins\\nDefinition\\nCephalosporins are medicines that kill bacteria or\\nprevent their growth.\\nPurpose\\nCephalosporins are used to treat infections in different\\nparts of the body—the ears, nose, throat, lungs, sinuses, and\\nskin, for example. Physicians may prescribe these drugs to\\ntreat pneumonia, strep throat, staph infections,tonsillitis,\\nbronchitis, and gonorrhea. These drugs will not work for\\ncolds, flu, and other infections caused by viruses.\\nDescription\\nExamples of cephalosporins are cefaclor (Ceclor),\\ncefadroxil (Duricef), cefazolin (Ancef, Kefzol, Zolicef),\\nGALE ENCYCLOPEDIA OF MEDICINE 2692\\nCephalosporins\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 692'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 81, 'page_label': '82'}, page_content='cefixime (Suprax), cefoxitin (Mefoxin), cefprozil (Cefzil),\\nceftazidime (Ceptaz, Fortaz, Tazicef, Tazideme), cefurox-\\nime (Ceftin) and cephalexin (Keflex). These medicines are\\navailable only with a physician’s prescription. They are\\nsold in tablet, capsule, liquid, and injectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\ncephalosporin. Check with the physician who prescribed\\nthe drug or the pharmacist who filled the prescription for\\nthe correct dosage.\\nAlways take cephalosporins exactly as directed by\\nyour physician. Never take larger, smaller, more fre-\\nquent, or less frequent doses. Take the drug for exactly as\\nlong as directed—no more and no less. Do not save some\\ndoses of the drug to take for future infections. The medi-\\ncine may not be right for other kinds of infections, even\\nif the symptoms are the same. In addition, take all of the\\nmedicine to treat the infection for which it was pre-\\nscribed. The infection may not clear up completely if too\\nlittle medicine is taken. Taking this medicine for too\\nlong, on the other hand, may open the door to new infec-\\ntions that do not respond to the drug.\\nSome cephalosporins work best when taken on an\\nempty stomach. Others should be taken after meals.\\nCheck with the physician who prescribed the medicine or\\nthe pharmacist who filled the prescription for instruc-\\ntions on how to take the medicine.\\nPrecautions\\nCertain cephalosporins should not be combined with\\nalcohol or with medicines that contain alcohol. Abdomi-\\nnal or stomach cramps, nausea, vomiting, facial flushing,\\nand other symptoms may result within 15–30 minutes\\nand may last for several hours. Do not drink alcoholic\\nbeverages or use other medicines that contain alcohol\\nwhile being treated with cephalosporins and for several\\ndays after treatment ends.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if they\\ntake cephalosporins. Before taking these drugs, be sure\\nto let the physician know about any of these conditions:\\nALLERGIES. Severe allergic reactions to this medicine\\nmay occur. Anyone who is allergic to cephalosporins of\\nany kind should not take other cephalosporins. Anyone\\nwho is allergic to penicillin should check with a physician\\nbefore taking any cephalosporin. The physician should\\nalso be told about any allergies to foods, dyes, preserva-\\ntives, or other substances.\\nKEY TERMS\\nBronchitis —Inflammation of the air passages of\\nthe lungs.\\nColitis—Inflammation of the colon (large bowel).\\nGonorrhea—A sexually transmitted disease (STD)\\nthat causes infection in the genital organs and may\\ncause disease in other parts of the body.\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nPhenylketonuria —(PKU) A genetic disorder in\\nwhich the body lacks an important enzyme. If\\nuntreated, the disorder can lead to brain damage\\nand mental retardation.\\nPneumonia—A disease in which the lungs become\\ninflamed. Pneumonia may be caused by bacteria,\\nviruses, or other organisms, or by physical or\\nchemical irritants.\\nSexually transmitted disease —A disease that is\\npassed from one person to another through sexual\\nintercourse or other intimate sexual contact. Also\\ncalled STD.\\nStaph infection —Infection with Staphylococcus\\nbacteria. These bacteria can infect any part of the\\nbody.\\nStrep throat —A sore throat caused by infection\\nwith Streptococcus bacteria. Symptoms include\\nsore throat, chills, fever, and swollen lymph nodes\\nin the neck.\\nTonsillitis—Inflammation of a tonsil, a small mass\\nof tissue in the throat.\\nDIABETES. Some cephalosporins may cause false\\npositive results on urine sugar tests for diabetes. People\\nwith diabetes should check with their physicians to see if\\nthey need to adjust their medication or their diets.\\nPHENYLKETONURIA. Oral suspensions of cefprozil\\ncontain phenylalanine. People with phenylketonuria\\n(PKU) should consult a physician before taking this\\nmedicine.\\nPREGNANCY. Women who are pregnant or who may\\nbecome pregnant should check with their physicians\\nbefore using cephalosporins.\\nBREASTFEEDING. Cephalosporins may pass into\\nbreast milk and may affect nursing babies. Women who\\nare breastfeeding and who need to take this medicine\\nGALE ENCYCLOPEDIA OF MEDICINE 2 693\\nCephalosporins\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 693'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 82, 'page_label': '83'}, page_content='should check with their physicians. They may need to\\nstop breastfeeding until treatment is finished.\\nOTHER MEDICAL CONDITIONS. Before using\\ncephalosporins, people with any of these medical prob-\\nlems should make sure their physicians are aware of their\\nconditions:\\n• History of stomach or intestinal problems, especially col-\\nitis. Cephalosporins may cause colitis in some people.\\n• Kidney problems. The dose of cephalosporin may need\\nto be lower.\\n• Bleeding problems. Cephalosporins may increase the\\nchance of bleeding in people with a history of bleeding\\nproblems.\\n• Liver disease. The dose of cephalosporin may need to\\nbe lower.\\nUSE OF CERTAIN MEDICINES. Taking cephalosporins\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nGet medical attention immediately if any of these\\nsymptoms develop while taking cephalosporins:\\n• shortness of breath\\n• Pounding heartbeat\\n• Skin rash or hives\\n• Severe cramps or pain in the stomach or abdomen\\n• Fever\\n• Severe watery or bloody diarrhea (may occur up to\\nseveral weeks after stopping the drug)\\n• Unusual bleeding or bruising\\nOther rare side effects may occur. Anyone who has\\nunusual symptoms during or after treatment with\\ncephalosporins should get in touch with his or her physi-\\ncian.\\nInteractions\\nSome cephalosporins cause diarrhea. Certain diar-\\nrhea medicines, such as diphenoxylate-atropine\\n(Lomotil), may make the problem worse. Check with a\\nphysician before taking any medicine for diarrhea caused\\nby taking cephalosporins.\\nBirth control pills may not work properly when\\ntaken at the same time as cephalosporins. To prevent\\npregnancy , use other methods of birth control in addi-\\ntion to the pills while taking cephalosporins.\\nTaking cephalosporins with certain other drugs may\\nincrease the risk of excess bleeding. Among the drugs that\\nmay have this effect when taken with cephalosporins are:\\n• blood thinning drugs (anticoagulants) such as warfarin\\n(Coumadin)\\n• blood viscosity reducing medicines such as pentoxi-\\nfylline (Trental)\\n• the antiseizure medicines divalproex (Depakote) and\\nvalproic acid (Depakene)\\nCephalosporins may also interact with other medi-\\ncines. When this happens, the effects of one or both of\\nthe drugs may change or the risk of side effects may be\\ngreater. Anyone who takes cephalosporins should let the\\nphysician know all other medicines he or she is taking.\\nNancy Ross-Flanigan\\nCerebral abscess see Brain abscess\\nCerebral amyloid angiopathy\\nDefinition\\nCerebral amyloid angiopathy (CAA) is also known\\nas congophilic angiopathy or cerebrovascular amyloido-\\nsis. It is a disease of small blood vessels in the brain in\\nwhich deposits of amyloid protein in the vessel walls\\nmay lead to stroke, brain hemorrhage, or dementia .\\nAmyloid protein resembles a starch and is deposited in\\ntissues during the course of certain chronic diseases.\\nDescription\\nCAA may affect patients over age 45, but is most com-\\nmon in patients over age 65, and becomes more common\\nwith increasing age. Men and women are equally affected.\\nIn some cases, CAA is sporadic but it may also be inherited\\nas an autosomal dominant condition (a form of inheritance\\nin which only one copy of a gene coding for a disease need\\nbe present for that disease to be expressed; if either parent\\nhas the disease, a child has a 50% chance of inheriting the\\ndisease). CAA is responsible for 5–20% of brain hemor-\\nrhages and up to 30% of lobar hemorrhages localized to one\\nlobe of the brain. CAA may be found during an autopsy in\\nover one-third of persons over age 60, even though they\\nmay not have had brain hemorrhage, stroke, or other mani-\\nfestations of the disease during life. In Alzheimer’s disease,\\nCAA is more common than in the general population, and\\nmay occur in more than 80% of patients over age 60.\\nCauses and symptoms\\nThe cause of amyloid deposits in blood vessels in the\\nbrain in sporadic CAA is not known. In hereditary CAA,\\nGALE ENCYCLOPEDIA OF MEDICINE 2694\\nCerebral amyloid angiopathy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 694'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 83, 'page_label': '84'}, page_content='genetic defects, typically on chromosome 21, allow accu-\\nmulation of amyloid, a protein made up of units called\\nbeta-pleated sheet fibrils. The fibrils tend to clump togeth-\\ner, so that the amyloid cannot be dissolved and builds up\\nin the brain blood vessel walls. One form of amyloid fibril\\nsubunit proteins is the amyloid beta protein.\\nDifferent theories have been suggested for the\\nsource of amyloid beta protein in the brain. The systemic\\ntheory suggests that amyloid beta protein in the blood\\nstream is deposited in blood vessels in the brain, causing\\nweakness in the blood vessel wall and breakdown in the\\nblood-brain barrier. Normally, the blood-brain barrier\\nkeeps proteins and other large molecules from escaping\\nfrom the blood vessel to the brain tissue. When there is\\nbreakdown of the blood-brain barrier, amyloid beta pro-\\ntein leaks through the blood vessel wall, and is deposited\\nin the brain substance, where it forms an abnormal struc-\\nture called a neuritic plaque.\\nA second, more likely theory is that amyloid fibrils\\nthat form amyloid beta protein are produced by perivas-\\ncular microglia, or support cells in contact with the brain\\nblood vessel wall. The third theory is that the brain tissue\\ngives rise to amyloid beta protein. Both the nerve cells\\nand the glia are known to produce amyloid precursor\\nprotein, which increases with aging and with cell stress.\\nBleeding into the brain may occur as tiny blood ves-\\nsels carrying amyloid deposits become heavier and more\\nbrittle, and are therefore more likely to burst with minor\\ntrauma or with fluctuating blood pressure. Aneurysms, or\\nballooning of the blood vessel wall, may develop, and\\nmay also rupture as the stretched wall becomes thinner\\nand is under more pressure. Amyloid deposits may\\ndestroy smooth muscle cells or cause inflammation in the\\nblood vessel wall. This may also cause the blood vessel\\nto break more easily.\\nThe most common form of CAA is the sporadic\\nform associated with aging. This type of CAA usually\\ncauses lobar hemorrhage, which may recur in different\\nlobes of the brain. The frontal lobe (behind the forehead)\\nand parietal lobe (behind the frontal lobe) are most often\\naffected; the temporal lobe (near the temple) and occipi-\\ntal lobe (at the back of the brain) are affected less often;\\nand the cerebellum (under the occipital lobe) is rarely\\naffected. Approximately 10–50% of hemorrhages in spo-\\nradic CAA involve more than one lobe.\\nSymptoms of lobar hemorrhage in CAA include\\nsudden onset of headache, neurologic symptoms such as\\nweakness, sensory loss, visual changes, or speech prob-\\nlems, depending on which lobe is involved; and\\ndecreased level of consciousness (a patient who is diffi-\\ncult to arouse), nausea, and vomiting. Sporadic CAA\\nmay be associated with symptoms unrelated to lobar\\nKEY TERMS\\nAmyloid—Amyloid protein resembles a starch and\\nis deposited in tissues during the course of certain\\nchronic diseases.\\nAtaxia—Problems with coordination and walking.\\nAutosomal dominant —A form of inheritance in\\nwhich only one copy of a gene coding for a dis-\\nease need be present for that disease to be\\nexpressed. If either parent has the disease, a child\\nhas a 50% chance of inheriting the disease.\\nChromosome —A cellular structure containing\\ngenetic information in the form of DNA.\\nDementia —Loss of memory and other higher\\nfunctions, such as thinking or speech, lasting six\\nmonths or more.\\nHemorrhage—Bleeding, or escape of blood\\nthrough ruptured or unruptured blood vessel walls.\\nLobar hemorrhage —Bleeding into one of the\\nlobes of the brain.\\nSeizure—Epileptic convulsion, fit, or attack.\\nSporadic —A form of disease found in persons\\nwithout a family history of the disease.\\nSpasticity—Limb stiffness related to disease of the\\nbrain or spinal cord.\\nStroke—Sudden neurological deficit related to\\nimpaired blood supply to the brain.\\nhemorrhage. Petechial hemorrhages (tiny hemorrhages\\ninvolving many small vessels) may produce recurrent,\\nbrief neurologic symptoms secondary to seizures or\\ndecreased blood flow, or may produce rapidly progres-\\nsive dementia (loss of memory and other brain functions)\\nthat worsens in distinct steps rather than gradually. Over\\n40% of patients with hemorrhage secondary to CAA also\\nhave dementia.\\nGenetic factors play a role in certain types of CAA\\nand in diseases associated with CAA:\\n• Dutch type of hereditary cerebral hemorrhage with\\namyloidosis (build up of amyloid protein in blood ves-\\nsels): autosomal dominant, with a genetic mutation\\ninvolving the amyloid precursor protein. Onset is at age\\n40–60 with headaches, brain hemorrhage often in the\\nparietal lobe, strokes, and dementia. More than half of\\npatients die from their first hemorrhage. Patients with\\nthe Dutch type of CAA may produce an abnormal anti-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 695\\nCerebral amyloid angiopathy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 695'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 84, 'page_label': '85'}, page_content='coagulant, or blood thinner, which makes hemorrhage\\nmore likely.\\n• Flemish type of hereditary cerebral hemorrhage with\\namyloidosis: autosomal dominant, with a mutation\\ninvolving the amyloid precursor protein. Symptoms\\ninclude brain hemorrhage or dementia.\\n• Familial Alzheimer’s disease: autosomal dominant,\\ncomprising 5–10% of all Alzheimer’s disease cases (a\\nbrain disease in which death of nerve cells leads to pro-\\ngressive dementia).\\n• Down Syndrome : caused by trisomy 21 (three rather\\nthan two copies of chromosome 21), causing excess\\namyloid precursor protein gene. Children with Down\\nsyndrome are mentally handicapped and may have\\nheart problems.\\n• Icelandic type of hereditary cerebral hemorrhage with\\namyloidosis: autosomal dominant, with mutation in the\\ngene coding for cystatin C. Symptoms often begin at\\nage 30–40 with multiple brain hemorrhages, dementia,\\nparalysis (weakness), and death in 10–20 years.\\nHeadache occurs in more than half of patients, and\\nseizures occur in one-quarter. Unlike most other forms\\nof CAA, most hemorrhages involve the basal ganglia\\ndeep within the brain (Basal ganglia are islands of tis-\\nsues in the cerebellum part of the brain.).\\n• Familial oculo-leptomeningeal amyloidosis: autosomal\\ndominant with unknown gene defect(s), described in\\nJapanese, Italian, and North American families. Symp-\\ntoms can include dementia, ataxia (problems with coor-\\ndination), spasticity (limb stiffness), strokes, seizures,\\nperipheral neuropathy (disease affecting the nerves\\nsupplying the limbs), migraine, spinal cord problems,\\nblindness, and deafness. Brain hemorrhage is rare as\\nthe amyloid protein is deposited in blood vessels in the\\neye and meninges (brain coverings), but not in the brain\\nitself. In Italian families with the disease, patients may\\nbe affected as early as 20–30 years of age.\\n• British type of familial amyloidosis: autosomal domi-\\nnant with unknown gene defect(s), associated with pro-\\ngressive dementia, spasticity, and ataxia. Brain stem,\\nspinal cord, and cerebellum all exhibit amyloid deposits,\\nbut hemorrhage typically does not occur.\\nDiagnosis\\nAs in most neurologic diseases, diagnosis is made\\nmost often from the patient’s history, with careful inquiry\\ninto family history and the patient’s onset and pattern of\\nsymptoms, as well as neurologic examination. Brain\\ncomputed tomography scan (CT) or magnetic reso-\\nnance imaging (MRI) may identify lobar hemorrhage,\\nstroke, or petechial hemorrhages, and are important in\\nexcluding arteriovenous malformation, brain tumor,o r\\nother causes of hemorrhage. Angiography (x-ray study\\nof the interior of blood vessels and the heart) is not help-\\nful in diagnosis of CAA, but may be needed to exclude\\naneurysm. Brain biopsy (surgical removal of a small\\npiece of brain tissue) may show characteristic amyloid\\ndeposits, but is rarely performed, as the risk may not be\\njustifiable in the absence of effective treatment for CAA.\\nIf diagnosis is uncertain, biopsy may be needed to rule\\nout conditions which are potentially treatable. Definite\\ndiagnosis requires microscopic examination of brain tis-\\nsue, either at biopsy, at autopsy, or at surgery when brain\\nhemorrhage is drained. Lumbar puncture to examine\\ncerebrospinal fluid proteins may show characteristic\\nabnormalities, but is not part of the routine exam. In\\nfamilial forms, genetic analysis may be helpful.\\nCAA with hemorrhage must be distinguished from\\nother types of brain hemorrhage. In CAA, hemorrhage\\ntypically occurs in the lobar region, often ruptures into the\\nsubarachnoid space between the brain and its coverings,\\nand occurs at night. In hemorrhage related to high blood\\npressure, hemorrhage is usually deeper within the brain,\\nruptures into the ventricles or cavities deep inside the\\nbrain, and occurs during daytime activities. Other causes\\nof brain hemorrhage are arteriovenous malformations ,\\ntrauma, aneurysms, bleeding into a brain tumor, vasculi-\\ntis (inflammation of blood vessels), or bleeding disorders.\\nTreatment\\nAlthough there is no effective treatment for the under-\\nlying disease process of CAA, measures can be taken to\\nprevent brain hemorrhage in patients diagnosed with CAA.\\nHigh blood pressure should be treated aggressively, and\\neven normal blood pressure can be lowered as much as tol-\\nerated without side effects from medications. Blood thin-\\nners such as Coumadin, antiplatelet agents such as aspirin,\\nor medications designed to dissolve blood clots may cause\\nhemorrhage in patients with CAA, and should be avoided if\\npossible. If these medications are required for other condi-\\ntions, such as heart disease, the potential benefits must be\\ncarefully weighed against the increased risks.\\nSeizures, or recurrent neurologic symptoms thought\\nto be seizures, should be treated with anti-epileptic\\ndrugs, although Depakote (sodium valproate) should be\\navoided because of its antiplatelet effect. Anti-epileptic\\ndrugs are sometimes given to patients with large lobar\\nhemorrhage in an attempt to prevent seizures, although\\nthe benefit of this is unclear.\\nOnce brain hemorrhage has occurred, the patient\\nshould be admitted to a hospital (ICU) for neurologic\\nmonitoring and control of increased pressure within the\\nbrain, blood pressure control, and supportive medical\\nGALE ENCYCLOPEDIA OF MEDICINE 2696\\nCerebral amyloid angiopathy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 696'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 85, 'page_label': '86'}, page_content='care. Antiplatelet agents and blood thinners should be dis-\\ncontinued and their effects reversed, if possible. Surgery\\nmay be needed to remove brain hemorrhage, although\\nbleeding during surgery may be difficult to control.\\nCAA may be rarely associated with cerebral vasculitis,\\nor inflammation of the blood vessel walls. In these cases\\ntreatment with steroids or immune system suppressants\\nmay be helpful. Without tissue examination, vasculitis can-\\nnot be diagnosed reliably, and probably coexists with CAA\\ntoo rarely to justify steroid treatment in most cases.\\nPrognosis\\nSince CAA is associated with progressive blood ves-\\nsel degeneration, and since there is no effective treat-\\nment, most patients have a poor prognosis. Aggressive\\nneurosurgical management allows increased survival fol-\\nlowing lobar hemorrhage, but as of 1998, 20–90% of\\npatients die from the first hemorrhage or its complica-\\ntions, which include progression of hemorrhage, brain\\nedema (swelling) with herniation (downward pressure\\non vital brain structures), seizures, and infections such as\\npneumonia. Many survivors have persistent neurologic\\ndeficits related to the brain lobe affected by hemorrhage,\\nand are at risk for additional hemorrhages, seizures, and\\ndementia. Prognosis is worse in patients who are older,\\nor who have larger hemorrhages or recurrent hemor-\\nrhages within a short time.\\nResources\\nPERIODICALS\\nBornebroek, M., et.al. “White Matter Lesions and Cognitive\\nDeterioration in Presymptomatic Carriers of the Amyloid\\nPrecursor Protein Gene Codon 693 Mutation.”Archives of\\nNeurology 53, no. 1 (1996): 43-48.\\nItoh, Y ., et.al. “Cerebral Amyloid Angiopathy: a Significant\\nCause of Cerebellar as well as Lobar Cerebral Hemor-\\nrhage in the Elderly.”Journal of Neurological Sciences\\n116, no. 2 (1993):135-41.\\nNeau, J. P., et.al. “Recurrent Intracerebral Hemorrhage.”Neu-\\nrology 49, no. 1 (1997): 106-113.\\nOlichney, J. M., et.al. “Cerebral Infarction in Alzheimer’s Dis-\\nease Is Associated with Severe Amyloid Angiopathy and\\nHypertension.” In Archives of Neurology52, no. 7 (1995):\\n702-8.\\nLaurie Barclay, MD\\nCerebral aneurysm\\nDefinition\\nA cerebral aneurysm occurs at a weak point in the\\nwall of a blood vessel (artery) that supplies blood to the\\nbrain. Because of the flaw, the artery wall bulges outward\\nand fills with blood. This bulge is called an aneurysm. An\\naneurysm can rupture, spilling blood into the surround-\\ning body tissue. A ruptured cerebral aneurysm can cause\\npermanent brain damage, disability, or death.\\nDescription\\nA cerebral aneurysm can occur anywhere in the brain.\\nAneurysms can have several shapes. The saccular\\naneurysm, once called a berry aneurysm, resembles a piece\\nof fruit dangling from a branch. Saccular aneurysms are\\nusually found at a branch in the blood vessel where they\\nballoon out by a thin neck. Saccular cerebral aneurysms\\nmost often occur at the branch points of large arteries at the\\nbase of the brain. Aneurysms may also take the form of a\\nbulge in one wall of the artery—a lateral aneurysm—or a\\nwidening of the entire artery—a fusiform aneurysm.\\nThe greatest danger of aneurysms is rupture.\\nApproximately 50–75% of stricken people survive an\\naneurysmal rupture. A ruptured aneurysm spills blood\\ninto the brain or into the fluid-filled area that surrounds\\nthe brain tissue. Bleeding into this area, called the sub-\\narachnoid space, is referred to as subarachnoid hemor-\\nrhage (SAH). About 25,000 people suffer a SAH each\\nyear. It is estimated that people with unruptured\\naneurysm have an annual 1–2% risk of hemorrhage.\\nUnder age 40, more men experience SAH. After age 40,\\nmore women than men are affected.\\nMost people who have suffered a SAH from a rup-\\ntured aneurysm did not know that the aneurysm even\\nexisted. Based on autopsy studies, medical researchers\\nestimate that 1–5% of the population has some type of\\ncerebral aneurysm. Aneurysms rarely occur in the very\\nyoung or the very old; about 60% of aneurysms are diag-\\nnosed in people between ages 40 and 65.\\nSome aneurysms may have a genetic link and run in\\nfamilies. The genetic link has not been completely\\nproven and a pattern of inheritance has not been deter-\\nmined. Some studies seem to show that first-degree rela-\\ntives of people who suffered aneurysmal SAH are more\\nlikely to have aneurysms themselves. These studies\\nreported that such immediate family members were four\\ntimes more likely to have aneurysms than the general\\npopulation. Other studies do not confirm these findings.\\nBetter evidence links aneurysms to certain rare diseases\\nof the connective tissue. These diseases include Marfan\\nsyndrome, pseudoxanthoma elasticum, Ehlers-Danlos\\nsyndrome, and fibromuscular dysplasia. Polycystic kid-\\nney disease is also associated with cerebral aneurysms.\\nThese diseases are also associated with an increased\\nrisk of aneurysmal rupture. Certain other conditions raise\\nGALE ENCYCLOPEDIA OF MEDICINE 2 697\\nCerebral aneurysm\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 697'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 86, 'page_label': '87'}, page_content='the risk of rupture, too. Most aneurysms that rupture are\\na half-inch or larger in diameter. Size is not the only fac-\\ntor, however, because smaller aneurysms also rupture.\\nCigarette smoking, excessive alcohol consumption, and\\nrecreational drug use (for example, use of cocaine) have\\nbeen linked with an increased risk. The role, if any, of\\nhigh blood pressure has not been determined. Some stud-\\nies have implicated high blood pressure in aneurysm for-\\nmation and rupture, but people with normal blood pres-\\nsure also experience aneurysms and SAHs. High blood\\npressure may be a risk factor but not the most important\\none. Pregnancy , labor, and delivery also seem to\\nincrease the possibility that an aneurysm might rupture,\\nbut not all doctors agree. Physical exertion and use of\\noral contraceptives are not suspected causes for aneurys-\\nmal rupture.\\nCauses and symptoms\\nCerebral aneurysms can be caused by brain trauma,\\ninfection, hardening of the arteries ( atherosclerosis), or\\nabnormal rapid cell growth (neoplastic disease), but most\\nseem to arise from a congenital, or developmental,\\ndefect. These congenital aneurysms occur more frequent-\\nly in women. Whatever the cause may be, the inner wall\\nof the blood vessel is abnormally thin and the pressure of\\nthe blood flow causes an aneurysm to form.\\nMost aneurysms go unnoticed until they rupture.\\nHowever, 10–15% of unruptured cerebral aneurysms are\\nfound because of their size or their location. Common\\nwarning signs include symptoms that affect only one eye,\\nsuch as an enlarged pupil, a drooping eyelid, or pain\\nabove or behind the eye. Other symptoms are a localized\\nheadache , unsteady gait, a temporary problem with\\nsight, double vision, or numbness in the face.\\nSome aneurysms bleed occasionally without rupturing.\\nSymptoms of such an aneurysm develop gradually. The\\nsymptoms include headache, nausea, vomiting, neck pain,\\nblack-outs, ringing in the ears,dizziness, or seeing spots.\\nEighty to ninety percent of aneurysms are not diag-\\nnosed until after they have ruptured. Rupture is not\\nalways a sudden event. Nearly 50% of patients who have\\naneurysmal SAHs also experience “the warning leak\\nphenomenon.” Persons with warning leak symptoms\\nhave sudden, atypical headaches that occur days or\\nweeks before the actual rupture. These headaches are\\nGALE ENCYCLOPEDIA OF MEDICINE 2698\\nCerebral aneurysm\\nThree aneurysms can be seen in this section of a cerebral artery removed from a human brain.(Photograph by Martin Rotker,\\nPhototake NYC. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 698'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 87, 'page_label': '88'}, page_content='referred to as sentinel headaches. Nausea, vomiting, and\\ndizziness may accompany sentinel headaches. Unfortu-\\nnately, these symptoms can be confused with tension\\nheadaches or migraines, and treatment can be delayed\\nuntil rupture occurs.\\nWhen an aneurysm ruptures, most victims experi-\\nence a sudden, extremely severe headache. This\\nheadache is typically described as the worst headache of\\nthe victim’s life. Nausea and vomiting commonly\\naccompany the headache. The person may experience a\\nshort loss of consciousness or prolonged coma. Other\\ncommon signs of a SAH include a stiff neck,fever, and a\\nsensitivity to light. About 25% of victims experience\\nneurological problems linked to specific areas of the\\nbrain, swelling of the brain due to fluid accumulation\\n(hydrocephalus), or seizure.\\nDiagnosis\\nBased on the clinical symptoms, a doctor will run\\nseveral tests to confirm an aneurysm or an SAH. A com-\\nputed tomography (CT) scan of the head is the initial\\nprocedure. A magnetic resonance imaging test (MRI)\\nmay be done instead of a CT scan. MRI, however, is not\\nas sensitive as CT for detecting subarachnoid blood. A\\nCT scan can determine whether there has been a hemor-\\nrhage and can assist in pinpointing the location of the\\naneurysm. The scan is most useful when it is done within\\nKEY TERMS\\nCongenital—Existing at birth.\\nEhlers-Danlos syndrome —A rare inheritable dis-\\nease of the connective tissue marked by very elastic\\nskin, very loose joints, and very fragile body tissue.\\nEmbolization—A technique to stop or prevent hem-\\norrhage by introducing a foreign mass, such as an\\nair-filled membrane (balloon), into a blood vessel to\\nblock the flow of blood.\\nFibromuscular dysplasia —A disorder that causes\\nunexplained narrowing of arteries and high blood\\npressure.\\nMagnetic resonance angiography —A noninvasive\\ndiagnostic technique that uses radio waves to map\\nthe internal anatomy of the blood vessels.\\nMarfan syndrome —An inheritable disorder that\\naffects the skeleton, joints, and blood vessels. Major\\nindicators are excessively long arms and legs, lax\\njoints, and vascular defects.\\nNimodipine (Nimotop)—A calcium-channel block-\\ner, that is, a drug that relaxes arterial smooth muscle\\nby slowing the movement of calcium across cell\\nwalls.\\nPolycystic kidney disease—An abnormal condition\\nin which the kidneys are enlarged and contain\\nmany cysts.\\nPseudoxanthoma elasticum—A hereditary disorder\\nof the connective, or elastic, tissue marked by pre-\\nmature aging and breakdown of the skin and\\ndegeneration of the arteries that leads to hemor-\\nrhages.\\nSubarachnoid hemorrhage (SAH) —Loss of blood\\ninto the subarachnoid space, the fluid-filled area\\nthat surrounds the brain tissue.\\nVasospasm—Narrowing of a blood vessel caused\\nby a spasm of the smooth muscle of the vessel wall.\\n72 hours of the rupture. Later scans may miss the signs\\nof hemorrhage.\\nIf the CT scan is negative for a hemorrhage or pro-\\nvides an unclear diagnosis, the doctor will order a cere-\\nbrospinal fluid (CSF) analysis , also called a lumbar\\npuncture. In this procedure, a small amount of cere-\\nbrospinal fluid is removed from the lower back and\\nexamined for traces of blood and blood-breakdown prod-\\nucts. If this test is positive, cerebral angiography is used\\nto map the brain’s blood vessels and the damaged area.\\nThe angiography is done to pinpoint the aneurysm’s\\nlocation. About 15% of people who experience SAH\\nhave more than one aneurysm. For this reason, angiogra-\\nphy should include both the common carotid artery that\\nfeeds the front of the brain and the vertebral artery that\\nfeeds the base of the brain. Occasionally, the angiogra-\\nphy fails to find the aneurysm and must be repeated. If\\nseizures occur, electroencephalography (EEG) may be\\nused to measure the electrical activity of the brain.\\nTreatment\\nUnruptured aneurysm\\nIf an aneurysm has not ruptured and is not causing\\nany symptoms, it may be left untreated. Because there is\\na 1–2% chance of rupture per year, the cumulative risk\\nover a number of years may justify surgical treatment.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 699\\nCerebral aneurysm\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 699'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 88, 'page_label': '89'}, page_content='However, if the aneurysm is small or in a place that\\nwould be difficult to reach, or if the person who has the\\naneurysm is in poor health, the surgical treatment may be\\na greater risk than the aneurysm. Risk of rupture is high-\\ner for people who have more than one aneurysm. Unrup-\\ntured aneurysm would probably be treated with a surgi-\\ncal procedure called the clip ligation, as described below.\\nRuptured aneurysm\\nThe primary treatment for a ruptured aneurysm\\ninvolves stabilizing the victim’s condition, treating the\\nimmediate symptoms, and promptly assessing further\\ntreatment options, especially surgical procedures. The\\npatient may require mechanical ventilation, oxygen, and\\nfluids. Medications may be given to prevent major sec-\\nondary complications such as seizures, rebleeding, and\\nvasospasm (narrowing of the affected blood vessel).\\nVasospasm decreases blood flow to the brain and causes\\nthe death of nerve cells. A drug such as nimodipine\\n(Nimotop) may help prevent vasospasm by relaxing the\\nsmooth muscle tissue of the arteries. Even with treat-\\nment, however, vasospasm may cause stroke or death.\\nTo prevent further hemorrhage from the aneurysm, it\\nmust be removed from circulation. In general, surgical\\nprocedures should be performed as soon as possible to\\nprevent rebleeding. The chances that aneurysm will\\nrebleed are greatest in the first 24 hours, and vasospasm\\nusually does not occur until 72 hours or more after rup-\\nture. If the patient is in poor condition or if there is\\nvasospasm or other complication, surgical procedures\\nmay be delayed. The preferred surgical method is a clip\\nligation in which a clip is placed around the base of the\\naneurysm to block it off from circulation. Surgical coat-\\ning, wrapping, or trapping of the aneurysm may also be\\nperformed. These procedures do not completely remove\\nthe aneurysm from circulation, however, and there is\\nsome risk that it may rebleed in the future. Newer tech-\\nniques that look promising include balloon embolization,\\na procedure that blocks the aneurysm with an inflatable\\nmembrane introduced by means of a catheter inserted\\nthrough the artery.\\nPrognosis\\nAn unruptured aneurysm may not cause any symp-\\ntoms over an entire lifetime. Surgical clip ligation will\\nensure that it won’t rupture, but it may be better to leave\\nthe aneurysm alone in some cases. Familial cerebral\\naneurysms may rupture earlier than those without a\\ngenetic link.\\nThe outlook is not as good for a person who suffers a\\nruptured aneurysm. Fifteen to twenty-five percent of\\npeople who experience a ruptured aneurysm do not sur-\\nvive. An additional 25–50% die as a result of complica-\\ntions associated with the hemorrhage. Of the survivors,\\n15–50% suffer permanent brain damage and disability.\\nThese conditions are caused by the death of nerve cells.\\nNerve cells can be destroyed by the hemorrhage itself or\\nby complications from the hemorrhage, such as\\nvasospasm or hydrocephalus. Hydrocephalus, a dilata-\\ntion (expansion) of the fluid-filled cavity surrounding the\\nbrain, occurs in about 15% of cases. Immediate medical\\ntreatment is vital to prevent further complications and\\nbrain damage in those who survive the initial rupture.\\nPatients who survive SAH and aneurysm clipping are\\nunlikely to die from events related to SAH.\\nPrevention\\nThere are no known methods to prevent an aneurysm\\nfrom forming. If an aneurysm is discovered before it rup-\\ntures, it may be surgically removed. CT or MRI angiogra-\\nphy may be recommended for relatives of patients with\\nfamilial cerebral aneurysms.\\nResources\\nBOOKS\\nSmith, Robert R., Yahgoub Tarassoli, and Yuri Zubkov. Cere-\\nbral Aneurysms: Microvascular and Endovascular Man-\\nagement. New York: Springer-Verlag, 1994.\\nPERIODICALS\\nLeblanc, Richard. “Familial Cerebral Aneurysms.”Canadian\\nJournal of Neurological Sciences24, no. 3 (Aug. 1997):\\n191-199.\\nOlafsson, Elias, Allen Hauser, and Gunnar Gudmundsson. “A\\nPopulation-Based Study of the Prognosis of Ruptured Cere-\\nbral Aneurysms: Mortality and Recurrence of Subarachnoid\\nHemorrhage.”Neurology48 (May 1997): 1191-1195.\\nSawin, Paul D., and Christopher M. Loftus. “Diagnosis of\\nSpontaneous Subarachnoid Hemorrhage.”American Fam-\\nily Physician 55, no. 1 (Jan. 1997): 145.\\nYasui, Nobuyuki, et al. “Long-term Follow-up Study of Unrup-\\ntured Intracranial Aneurysms.”Neurosurgery 40, no. 6\\n(June 1997): 1155-1160.\\nORGANIZATIONS\\nThe Brain Aneurysm Foundation, Inc. 66 Canal St., Boston,\\nMA 02114. (617) 723-3870. .\\nOTHER\\nBernadini, Gary L. “Intracerebral Aneurysms.”Columbia Univer-\\nsity Health Sciences Page..\\n“The Brain Aneurysm Report.”Neurosurgical Sevice Page.\\nHarvard Medical School .\\nJulia Barrett\\nCerebral angiography see Angiography\\nGALE ENCYCLOPEDIA OF MEDICINE 2700\\nCerebral aneurysm\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 700'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 89, 'page_label': '90'}, page_content='Cerebral palsy\\nDefinition\\nCerebral palsy (CP) is the term used for a group of\\nnonprogressive disorders of movement and posture\\ncaused by abnormal development of, or damage to,\\nmotor control centers of the brain. CP is caused by events\\nbefore, during, or after birth. The abnormalities of mus-\\ncle control that define CP are often accompanied by\\nother neurological and physical abnormalities.\\nDescription\\nV oluntary movement (walking, grasping, chewing,\\netc.) is primarily accomplished using muscles that are\\nattached to bones, known as the skeletal muscles. Control\\nof the skeletal muscles originates in the cerebral cortex,\\nthe largest portion of the brain. Palsy means paralysis ,\\nbut may also be used to describe uncontrolled muscle\\nmovement. Therefore, cerebral palsy encompasses any\\ndisorder of abnormal movement and paralysis caused by\\nabnormal function of the cerebral cortex. In truth, howev-\\ner, CP does not include conditions due to progressive dis-\\nease or degeneration of the brain. For this reason, CP is\\nalso referred to as static (nonprogressive) encephalopathy\\n(disease of the brain). Also excluded from CP are any dis-\\norders of muscle control that arise in the muscles them-\\nselves and/or in the peripheral nervous system (nerves\\noutside the brain and spinal cord).\\nCP is not a specific diagnosis, but is more accurately\\nconsidered a description—a description of a broad but\\ndefined group of neurological and physical problems.\\nThe symptoms of CP and their severity are quite\\nvariable. Those with CP may have only minor difficulty\\nwith fine motor skills, such as grasping and manipulating\\nitems with their hands. A severe form of CP could\\ninvolve significant muscle problems in all four limbs,\\nmental retardation , seizures, and difficulties with\\nvision, speech, and hearing.\\nMuscles that receive defective messages from the\\nbrain may be constantly contracted and tight (spastic),\\nexhibit involuntary writhing movements (athetosis), or\\nhave difficulty with voluntary movement (dyskinesia).\\nThere can also be a lack of balance and coordination with\\nunsteady movements (ataxia). A combination of any of\\nthese problems may also occur. Spastic CP and mixed\\nCP constitute the majority of cases. Effects on the mus-\\ncles can range from mild weakness or partial paralysis\\n(paresis), to complete loss of voluntary control of a mus-\\ncle or group of muscles (plegia). CP is also designated by\\nthe number of limbs affected. For instance, affected mus-\\ncles in one limb is monoplegia, both arms or both legs is\\ndiplegia, both limbs on one side of the body is hemiple-\\ngia, and in all four limbs is quadriplegia. Muscles of the\\ntrunk, neck, and head may be affected as well.\\nCP can be caused by a number of different mecha-\\nnisms at various times—from several weeks after concep-\\ntion, through birth, to early childhood. For many years, it\\nwas accepted that most cases of CP were due to brain\\ninjuries received during a traumatic birth, known as birth\\nasphyxia. However, extensive research in the 1980s\\nshowed that only 5–10% of CP can be attributed to birth\\ntrauma. Other possible causes include abnormal develop-\\nment of the brain, prenatal factors that directly or indirectly\\ndamage neurons in the developing brain, premature birth,\\nand brain injuries that occur in the first few years of life.\\nAdvances in the medical care of premature infants in\\nthe last 20 years have dramatically increased the rate of\\nsurvival of these fragile newborns. However, as gesta-\\ntional age at delivery and birth weight of a baby\\ndecrease, the risk for CP dramatically increases. A term\\npregnancy is delivered at 37–41 weeks gestation. The\\nrisk for CP in a preterm infant (32–37 weeks) is\\nincreased about five-fold over the risk for an infant born\\nat term. Survivors of extremely preterm births (less than\\n28 weeks) face as much as a 50-fold increase in risk.\\nAbout 50% of all cases of CP now being diagnosed are in\\nchildren who were born prematurely.\\nTwo factors are involved in the risk for CP associat-\\ned with prematurity. First, premature babies are at high-\\ner risk for various CP-associated medical complications,\\nsuch as intracerebral hemorrhage, infection, and difficul-\\nty in breathing, to name a few. Second, the onset of pre-\\nmature labor may be induced, in part, by complications\\nthat have already caused neurologic damage in the fetus.\\nA combination of both factors almost certainly plays a\\nrole in some cases of CP. The tendency toward premature\\ndelivery runs in families, but the genetic mechanisms are\\nfar from clear.\\nAn increase in multiple pregnancies in recent years,\\nespecially in the United States, is blamed on the\\nincreased use of fertility drugs. As the number of fetuses\\nin a pregnancy increases, the risks for abnormal develop-\\nment and premature delivery also increase. Children\\nfrom twin pregnancies have four times the risk of devel-\\noping CP as children from singleton pregnancies, owing\\nto the fact that more twin pregnancies are delivered pre-\\nmaturely. The risk for CP in a child of triplets is up to 18\\ntimes greater. Furthermore, recent evidence suggests that\\na baby from a pregnancy in which its twin died before\\nbirth is at increased risk for CP.\\nApproximately 500,000 children and adults in the\\nUnited States have CP, and it is newly diagnosed in about\\n6,000 infants and young children each year. The inci-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 701\\nCerebral palsy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 701'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 90, 'page_label': '91'}, page_content='dence of CP has not changed much in the last 20–30\\nyears. Ironically, advances in medicine have decreased\\nthe incidence from some causes, Rh disease for example,\\nbut increased it from others, notably, prematurity and\\nmultiple pregnancies. No particular ethnic groups seem\\nto be at higher risk for CP. However, people of disadvan-\\ntaged background are at higher risk due to poorer access\\nto proper prenatal care and advanced medical services.\\nCauses and symptoms\\nAs noted, CP has many causes, making a discussion\\nof the genetics of CP complicated. A number of heredi-\\ntary/genetic syndromes have signs and symptoms similar\\nto CP, but usually also have problems not typical of CP.\\nPut another way, some hereditary conditions “mimic”\\nCP. Isolated CP, meaning CP that is not a part of some\\nother syndrome or disorder, is usually not inherited.\\nIt might be possible to group the causes of CP into\\nthose that are genetic and those that are non-genetic, but\\nmost would fall somewhere in between. Grouping causes\\ninto those that occur during pregnancy (prenatal), those\\nthat happen around the time of birth (perinatal), and those\\nthat occur after birth (postnatal), is preferable. CP related\\nto premature birth and multiple pregnancies (twins,\\ntriplets, etc., not “many pregnancies”) is somewhat differ-\\nent and considered separately.\\nPrenatal causes\\nAlthough much has been learned about human\\nembryology in the last couple of decades, a great deal\\nremains unknown. Studying prenatal human develop-\\nment is difficult because the embryo and fetus develop in\\na closed environment—the mother’s womb. However,\\nthe relatively recent development of a number of prenatal\\ntests has opened a window on the process. Add to that\\nmore accurate and complete evaluations of newborns,\\nespecially those with problems, and a clearer picture of\\nwhat can go wrong before birth is possible.\\nThe complicated process of brain development before\\nbirth is susceptible to many chance errors that can result in\\nabnormalities of varying degrees. Some of these errors\\nwill result in structural anomalies of the brain, while oth-\\ners may cause undetectable, but significant, abnormalities\\nin how the cerebral cortex is “wired.” An abnormality in\\nstructure or wiring is sometimes hereditary, but is most\\noften due to chance, or a cause unknown at this time.\\nWhether and how much genetics played a role in a particu-\\nlar brain abnormality depends to some degree on the type\\nof anomaly and the form of CP it causes.\\nSeveral maternal-fetal infections are known to\\nincrease the risk for CP, including rubella (German\\nmeasles, now rare in the United States), cytomegalovirus\\n(CMV), and toxoplasmosis . Each of these infections is\\nconsidered a risk to the fetus only if the mother contracts\\nit for the first time during that pregnancy. Even in those\\ncases, though, most babies will be born normal. Most\\nwomen are immune to all three infections by the time\\nthey reach childbearing age, but a woman’s immune sta-\\ntus can be determined using the so-called TORCH (for\\nToxoplasmosis, Rubella, Cytomegalovirus, and Herpes)\\ntest before or during pregnancy.\\nJust as a stroke can cause neurologic damage in an\\nadult, so too can this type of event occur in the fetus. A\\nburst blood vessel in the brain followed by uncontrolled\\nbleeding (coagulopathy), known as intracerebral hemor-\\nrhage, could cause a fetal stroke, or a cerebral blood ves-\\nsel could be obstructed by a clot (embolism). Infants who\\nlater develop CP, along with their mothers, are more like-\\nly than other mother-infant pairs to test positive for fac-\\ntors that put them at increased risk for bleeding episodes\\nor blood clots. Some coagulation disorders are strictly\\nhereditary, but most have a more complicated basis.\\nA teratogen is any substance to which a woman is\\nexposed that has the potential to harm the embryo or\\nfetus. Links between a drug or other chemical exposure\\nduring pregnancy and a risk for CP are difficult to prove.\\nHowever, any substance that might affect fetal brain\\ndevelopment, directly or indirectly, could increase the\\nrisk for CP. Furthermore, any substance that increases the\\nrisk for premature delivery and low birth weight, such as\\nalcohol, tobacco, or cocaine, among others, might indi-\\nrectly increase the risk for CP.\\nThe fetus receives all nutrients and oxygen from\\nblood that circulates through the placenta. Therefore,\\nanything that interferes with normal placental function\\nmight adversely affect development of the fetus, includ-\\ning the brain, or might increase the risk for premature\\ndelivery. Structural abnormalities of the placenta, prema-\\nture detachment of the placenta from the uterine wall\\n(abruption), and placental infections (chorioamnionitis)\\nare thought to pose some risk for CP.\\nCertain conditions in the mother during pregnancy\\nmight pose a risk to fetal development leading to CP.\\nWomen with autoimmune anti-thyroid or anti-phospho-\\nlipid (APA) antibodies are at slightly increased risk for\\nCP in their children. A potentially important clue uncov-\\nered recently points toward high levels of cytokines in\\nthe maternal and fetal circulation as a possible risk for\\nCP. Cytokines are proteins associated with inflammation,\\nsuch as from infection or autoimmune disorders , and\\nthey may be toxic to neurons in the fetal brain. More\\nresearch is needed to determine the exact relationship, if\\nany, between high levels of cytokines in pregnancy and\\nGALE ENCYCLOPEDIA OF MEDICINE 2702\\nCerebral palsy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 702'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 91, 'page_label': '92'}, page_content='CP. A woman has some risk of developing the same com-\\nplications in more than one pregnancy, slightly increas-\\ning the risk for more than one child with CP.\\nSerious physical trauma to the mother during preg-\\nnancy could result in direct trauma to the fetus as well, or\\ninjuries to the mother could compromise the availability\\nof nutrients and oxygen to the developing fetal brain.\\nPerinatal causes\\nBirth asphyxia significant enough to result in CP is\\nnow uncommon in developed countries. Tight nuchal\\ncord (umbilical cord around the baby’s neck) and pro-\\nlapsed cord (cord delivered before the baby) are possible\\ncauses of birth asphyxia, as are bleeding and other com-\\nplications associated with placental abruption and pla-\\ncenta previa (placenta lying over the cervix).\\nInfection in the mother is sometimes not passed to\\nthe fetus through the placenta, but is transmitted to the\\nbaby during delivery. Any such infection that results in\\nserious illness in the newborn has the potential to pro-\\nduce some neurological damage.\\nPostnatal causes\\nThe remaining 15% of CP is due to neurologic\\ninjury sustained after birth. CP that has a postnatal cause\\nKEY TERMS\\nAsphyxia—Lack of oxygen. In the case of cerebral\\npalsy, lack of oxygen to the brain.\\nAtaxia—A deficiency of muscular coordination,\\nespecially when voluntary movements are attempt-\\ned, such as grasping or walking.\\nAthetosis —A condition marked by slow, writhing,\\ninvoluntary muscle movements.\\nCerebral palsy—Movement disability resulting from\\nnonprogressive brain damage.\\nCoagulopathy—A disorder in which blood is either\\ntoo slow or too quick to coagulate (clot).\\nContracture—A tightening of muscles that prevents\\nnormal movement of the associated limb or other\\nbody part.\\nCytokine—A protein associated with inflammation\\nthat, at high levels, may be toxic to nerve cells in\\nthe developing brain.\\nDiplegia —Paralysis affecting like parts on both\\nsides the body, such as both arms or both legs.\\nDorsal rhizotomy —A surgical procedure that cuts\\nnerve roots to reduce spasticity in affected muscles.\\nDyskinesia —Impaired ability to make voluntary\\nmovements.\\nHemiplegia—Paralysis of one side of the body.\\nHypotonia—Reduced or diminished muscle tone.\\nQuadriplegia—Paralysis of all four limbs.\\nSerial casting—A series of casts designed to gradu-\\nally move a limb into a more functional position.\\nSpastic —A condition in which the muscles are\\nrigid, posture may be abnormal, and fine motor\\ncontrol is impaired.\\nSpasticity —Increased mucle tone, or stiffness,\\nwhich leads to uncontrolled, awkward movements.\\nStatic encephalopathy —A disease of the brain that\\ndoes not get better or worse.\\nTenotomy—A surgical procedure that cuts the ten-\\ndon of a contracted muscle to allow lengthening.\\nis sometimes referred to as acquired CP, but this is only\\naccurate for those cases caused by infection or trauma.\\nIncompatibility between the Rh blood types of\\nmother and child (mother Rh negative, baby Rh positive)\\ncan result in severe anemia in the baby (erythroblastosis\\nfetalis). This may lead to other complications, including\\nsevere jaundice, which can cause CP. Rh disease in the\\nnewborn is now rare in developed countries due to rou-\\ntine screening of maternal blood type and treatment of\\npregnancies at risk. The routine, effective treatment of\\njaundice due to other causes has also made it an infre-\\nquent cause of CP in developed countries. Rh blood type\\nposes a risk for recurrence of Rh disease if treatment is\\nnot provided.\\nSerious infections that affect the brain directly, such\\nas meningitis and encephalitis , may cause irreversible\\ndamage to the brain, leading to CP. A seizure disorder\\nearly in life may cause CP, or may be the product of a\\nhidden problem that causes CP in addition to seizures.\\nUnexplained (idiopathic) seizures are hereditary in only\\na small percentage of cases. Although rare in infants born\\nhealthy at or near term, intracerebral hemorrhage and\\nbrain embolism, like fetal stroke, are sometimes genetic.\\nPhysical trauma to an infant or child resulting in\\nbrain injury, such as from abuse, accidents, or near\\nGALE ENCYCLOPEDIA OF MEDICINE 2 703\\nCerebral palsy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 703'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 92, 'page_label': '93'}, page_content='drowning/suffocation, might cause CP. Likewise, inges-\\ntion of a toxic substance such as lead, mercury, poisons,\\nor certain chemicals could cause neurological damage.\\nAccidental overdose of certain medications might also\\ncause similar damage to the central nervous system.\\nBy definition, the defect in cerebral function causing\\nCP is nonprogressive. However, the symptoms of CP\\noften change over time. Most of the symptoms of CP\\nrelate in some way to the aberrant control of muscles. To\\nreview, CP is categorized first by the type of move-\\nment/postural disturbance(s) present, then by a descrip-\\ntion of which limbs are affected, and finally by the sever-\\nity of motor impairment. For example, spastic diplegia\\nrefers to continuously tight muscles that have no volun-\\ntary control in both legs, while athetoid quadraparesis\\ndescribes uncontrolled writhing movements and muscle\\nweakness in all four limbs. These three-part descriptions\\nare helpful in providing a general picture, but cannot give\\na complete description of any one person with CP. In\\naddition, the various “forms” of CP do not occur with\\nequal frequency—spastic diplegia is seen in more indi-\\nviduals than is athetoid quadraparesis. CP can also be\\nloosely categorized as mild, moderate, or severe, but\\nthese are very subjective terms with no firm boundaries\\nbetween them.\\nA muscle that is tensed and contracted is hypertonic,\\nwhile excessively loose muscles are hypotonic. Spastic,\\nhypertonic muscles can cause serious orthopedic prob-\\nlems, including scoliosis (spine curvature), hip disloca-\\ntion, or contractures . A contracture is shortening of a\\nmuscle, aided sometimes by a weak-opposing force from\\na neighboring muscle. Contractures may become perma-\\nnent, or “fixed,” without some sort of intervention. Fixed\\ncontractures may cause postural abnormalities in the\\naffected limbs. Clenched fists and contracted feet (equi-\\nnus or equinovarus) are common in people with CP.\\nSpasticity in the thighs causes them to turn in and cross\\nat the knees, resulting in an unusual method of walking\\nknown as a “scissors gait.” Any of the joints in the limbs\\nmay be stiff (immobilized) due to spasticity of the\\nattached muscles.\\nAthetosis and dyskinesia often occur with spasticity,\\nbut do not often occur alone. The same is true of ataxia.\\nIt is important to remember that “mild CP” or “severe\\nCP” refers not only to the number of symptoms present,\\nbut also to the level of involvement of any particular\\nclass of symptoms.\\nMechanisms that can cause CP are not always\\nrestricted to motor-control areas of the brain. Other neu-\\nrologically based symptoms may include:\\n• mental retardation/learning disabilities\\n• behavioral disorders\\n• seizure disorders\\n• visual impairment\\n• hearing loss\\n• speech impairment (dysarthria)\\n• abnormal sensation and perception\\nThese problems may have a greater impact on a\\nchild’s life than the physical impairments of CP, although\\nnot all children with CP are affected by other problems.\\nMany infants and children with CP have growth impair-\\nment. About one-third of individuals with CP have moder-\\nate-to-severe mental retardation, one-third have mild men-\\ntal retardation, and one-third have normal intelligence.\\nDiagnosis\\nThe signs of CP are not usually noticeable at birth.\\nChildren normally progress through a predictable set of\\ndevelopmental milestones through the first 18 months of\\nlife. Children with CP, however, tend to develop these\\nskills more slowly because of their motor impairments,\\nand delays in reaching milestones are usually the first\\nsymptoms of CP. Babies with more severe cases of CP\\nare usually diagnosed earlier than others.\\nSelected developmental milestones, and the ages for\\nnormally acquiring them, are given below. If a child does\\nnot acquire the skill by the age shown in parentheses,\\nthere is some cause for concern.\\n• sits well unsupported—six months (eight–10 months)\\n• babbles—six months (eight months)\\n• crawls—nine months (12 months)\\n• finger feeds, holds bottle—nine months (12 months)\\n• walks alone—12 months (15–18 months)\\n• uses one or two words other than dada/mama—12\\nmonths (15 months)\\n• walks up and down steps—24 months (24–36 months)\\n• turns pages in books; removes shoes and socks—24\\nmonths (30 months)\\nChildren do not consistently favor one hand over the\\nother before 12–18 months, and doing so may be a sign\\nthat the child has difficulty using the other hand. This\\nsame preference for one side of the body may show up as\\nasymmetric crawling or, later on, favoring one leg while\\nclimbing stairs.\\nIt must be remembered that children normally\\nprogress at somewhat different rates, and slow beginning\\naccomplishment is often followed by normal develop-\\nment. Other causes for developmental delay—some\\nbenign, some serious—should be excluded before con-\\nGALE ENCYCLOPEDIA OF MEDICINE 2704\\nCerebral palsy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 704'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 93, 'page_label': '94'}, page_content='sidering CP as the answer. CP is nonprogressive, so con-\\ntinued loss of previously acquired milestones indicates\\nthat CP is not the cause of the problem.\\nNo one test is diagnostic for CP, but certain factors\\nincrease suspicion. The Apgar score measures a baby’s\\ncondition immediately after birth. Babies that have low\\nApgar scores are at increased risk for CP. Presence of\\nabnormal muscle tone or movements may indicate CP, as\\nmay the persistence of infantile reflexes. Imaging of the\\nbrain using ultrasound, x rays, MRI, and/or CT scans may\\nreveal a structural anomaly. Some brain lesions associated\\nwith CP include scarring, cysts, expansion of the cerebral\\nventricles (hydrocephalus), periventricular leukomalacia\\n(an abnormality of the area surrounding the ventricles),\\nareas of dead tissue (necrosis), and evidence of an intra-\\ncerebral hemorrhage or blood clot. Blood and urine bio-\\nchemical tests, as well as genetic tests, may be used to rule\\nout other possible causes, including muscle and peripheral\\nnerve diseases, mitochondrial and metabolic diseases, and\\nother inherited disorders. Evaluations by a pediatric devel-\\nopmental specialist and a geneticist may be of benefit.\\nTreatment\\nCerebral palsy cannot be cured, but many of the dis-\\nabilities it causes can be managed through planning and\\ntimely care. Treatment for a child with CP depends on the\\nseverity, nature, and location of the primary muscular symp-\\ntoms, as well as any associated problems that might be pre-\\nsent. Optimal care of a child with mild CP may involve reg-\\nular interaction with only a physical therapist and occupa-\\ntional therapist, whereas care for a more severely affected\\nchild may include visits to multiple medical specialists\\nthroughout life. With proper treatment and an effective plan,\\nmost people with CP can lead productive, happy lives.\\nTherapy\\nSpasticity, muscle weakness, coordination, ataxia,\\nand scoliosis are all significant impairments that affect the\\nposture and mobility of a person with CP. Physical and\\noccupational therapists work with the patient, and the fam-\\nily, to maximize the ability to move affected limbs, devel-\\nop normal motor patterns, and maintain posture. “Assistive\\ntechnology,” things such as wheelchairs, walkers, shoe\\ninserts, crutches, and braces, are often required. A speech\\ntherapist, and high-tech aids such as computer-controlled\\ncommunication devices, can make a tremendous differ-\\nence in the life of those who have speech impairments.\\nMedications\\nBefore fixed contractures develop, muscle-relaxant\\ndrugs such as diazepam (Valium), dantrolene (Dantri-\\num), and baclofen (Lioresal) may be prescribed. Botu-\\nlinum toxin (Botox), a newer and highly effective treat-\\nment, is injected directly into the affected muscles. Alco-\\nhol or phenol injections into the nerve controlling the\\nmuscle are another option. Multiple medications are\\navailable to control seizures, and athetosis can be treated\\nusing medications such as trihexyphenidyl HCl (Artane)\\nand benztropine (Cogentin).\\nSurgery\\nFixed contractures are usually treated with either\\nserial casting or surgery. The most commonly used surgi-\\ncal procedures are tenotomy, tendon transfer, and dorsal\\nrhizotomy. In tenotomy, tendons of the affected muscle\\nare cut and the limb is cast in a more normal position\\nwhile the tendon regrows. Alternatively, tendon transfer\\ninvolves cutting and reattaching a tendon at a different\\npoint on the bone to enhance the length and function of\\nthe muscle. A neurosurgeon performing dorsal rhizotomy\\ncarefully cuts selected nerve roots in the spinal cord to\\nprevent them from stimulating the spastic muscles. Neu-\\nrosurgical techniques in the brain such as implanting tiny\\nelectrodes directly into the cerebellum, or cutting a por-\\ntion of the hypothalamus, have very specific uses and\\nhave had mixed results.\\nEducation\\nParents of a child newly diagnosed with CP are not\\nlikely to have the necessary expertise to coordinate the\\nfull range of care their child will need. Although\\nknowledgeable and caring medical professionals are\\nindispensable for developing a care plan, a potentially\\nmore important source of information and advice is\\nother parents who have dealt with the same set of diffi-\\nculties. Support groups for parents of children with CP\\ncan be significant sources of both practical advice and\\nemotional support. Many cities have support groups\\nthat can be located through the United Cerebral Palsy\\nAssociation, and most large medical centers have spe-\\ncial multidisciplinary clinics for children with develop-\\nmental disorders.\\nPrognosis\\nCerebral palsy can affect every stage of maturation,\\nfrom childhood through adolescence to adulthood. At\\neach stage, those with CP, along with their caregivers,\\nmust strive to achieve and maintain the fullest range of\\nexperiences and education consistent with their abilities.\\nThe advice and intervention of various professionals\\nremains crucial for many people with CP. Although CP\\nitself is not considered a terminal disorder, it can affect a\\nperson’s lifespan by increasing the risk for certain med-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 705\\nCerebral palsy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 705'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 94, 'page_label': '95'}, page_content='ical problems. People with mild cerebral palsy may have\\nnear-normal lifespans, but the lifespan of those with\\nmore severe forms may be shortened. However, over\\n90% of infants with CP survive into adulthood.\\nThe cause of most cases of CP remains unknown,\\nbut it has become clear in recent years that birth difficul-\\nties are not to blame in most cases. Rather, developmen-\\ntal problems before birth, usually unknown and generally\\nundiagnosable, are responsible for most cases. The rate\\nof survival for preterm infants has leveled off in recent\\nyears, and methods to improve the long-term health of\\nthese at-risk babies are now being sought. Current\\nresearch is also focusing on the possible benefits of rec-\\nognizing and treating coagulopathies and inflammatory\\ndisorders in the prenatal and perinatal periods. The use of\\nmagnesium sulfate in pregnant women with preeclamp-\\nsia or threatened preterm delivery may reduce the risk of\\nCP in very preterm infants. Finally, the risk of CP can be\\ndecreased through good maternal nutrition , avoidance\\nof drugs and alcohol during pregnancy, and prevention or\\nprompt treatment of infections.\\nResources\\nBOOKS\\nMiller, Freema, and Steven J. Bachrach. Cerebral Palsy: A\\nComplete Guide for Caregiving.Baltimore: Johns Hop-\\nkins University Press, 1995.\\nPeacock, Judith. Cerebral Palsy.Mankato, MN: Capstone\\nPress, 2000.\\nPimm, Paul. Living With Cerebral Palsy.Austin, TX: Raintree\\nSteck-Vaughn Publishers, 2000.\\nPincus, Dion. Everything You Need to Know About Cerebral\\nPalsy.New York: Rosen Publishing Group, Inc., 2000.\\nPERIODICALS\\nChambers, Henry G. “Research in Cerebral Palsy.”The Excep-\\ntional Parent29 (July 1999): 50.\\nMyers, Scott M. and Bruce K. Shapiro. “Origins and Causes of\\nCerebral Palsy: Symptoms and Diagnosis.”The Excep-\\ntional Parent29 (April 1999): 28.\\nSeppa, Nathan. “Infections may underlie cerebral palsy.”Sci-\\nence News 154 (October 17, 1998): 244.\\nStephenson, Joan. “Cerebral Palsy Clues.”The Journal of the\\nAmerican Medical Association 280 (21 October 1998):\\n1298.\\nORGANIZATIONS\\nEpilepsy Foundation of America. 4351 Garden City Dr., Suite\\n406, Landover, MD 20785-2267. (301) 459-3700 or (800)\\n332-1000. .\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (888) 663-4637. resource-\\ncenter@modimes.org. .\\nNational Easter Seal Society. 230 W. Monroe St., Suite 1800,\\nChicago, IL 60606-4802. (312) 726-6200 or (800) 221-\\n6827. .\\nNational Institute of Neurological Disorders and Stroke. 31\\nCenter Drive, MSC 2540, Bldg. 31, Room 8806, Bethes-\\nda, MD 20814. (301) 496-5751 or (800) 352-9424.\\n.\\nNational Society of Genetic Counselors. 233 Canterbury Dr.,\\nWallingford, PA 19086-6617. (610) 872-1192. .\\nUnited Cerebral Palsy Association, Inc. (UCP). 1660 L St. NW,\\nSuite 700, Washington, DC 20036-5602. (202)776-0406\\nor (800)872-5827. .\\nOTHER\\n“Cerebral Palsy Information Page.”National Institute of Neu-\\nrological Disorders and Stroke..\\n“Cerebral Palsy: Hope Through Research.”National Institute\\nof Neurological Disorders and Stroke..\\nScott J. Polzin, MS\\nCerebrospinal fluid (CSF)\\nanalysis\\nDefinition\\nCerebrospinal fluid (CSF) analysis is a laboratory\\ntest to examine a sample of the fluid surrounding the\\nbrain and spinal cord. This fluid is a clear, watery liquid\\nthat protects the central nervous system from injury and\\ncushions it from the surrounding bone structure. It con-\\ntains a variety of substances, particularly glucose (sugar),\\nprotein, and white blood cells from the immune system.\\nThe fluid is withdrawn through a needle in a procedure\\ncalled a lumbar puncture.\\nPurpose\\nThe purpose of a CSF analysis is to diagnose med-\\nical disorders that affect the central nervous system.\\nSome of these conditions include:\\n• viral and bacterial infections, such as meningitis and\\nencephalitis\\n• tumors or cancers of the nervous system\\n• syphilis, a sexually transmitted disease\\n• bleeding (hemorrhaging) around the brain and spinal\\ncord\\n• multiple sclerosis, a disease that affects the myelin\\ncoating of the nerve fibers of the brain and spinal cord\\n• Guillain-Barré syndrome, an inflammation of the nerves.\\nGALE ENCYCLOPEDIA OF MEDICINE 2706\\nCerebrospinal fluid (CSF) analysis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 706'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 95, 'page_label': '96'}, page_content='Precautions\\nIn some circumstances, a lumbar puncture to with-\\ndraw a small amount of CSF for analysis may lead to\\nserious complications. Lumbar puncture should be per-\\nformed only with extreme caution, and only if the bene-\\nfits are thought to outweigh the risks, in certain condi-\\ntions. For example, in people who have blood clotting\\n(coagulation) or bleeding disorders, lumbar puncture\\ncan cause bleeding that can compress the spinal cord. If\\nthere is a large brain tumor or other mass, removal of\\nCSF can cause the brain to droop down within the skull\\ncavity (herniate), compressing the brain stem and other\\nvital structures, and leading to irreversible brain damage\\nor death. These problems are easily avoided by check-\\ning blood coagulation through a blood test and by doing\\na computed tomography scan (CT) or magnetic reso-\\nnance imaging (MRI) scan before attempting the lum-\\nbar puncture. In addition, a lumbar puncture procedure\\nshould never be performed at the site of a localized skin\\ninfection on the lower back because the infection may\\nbe introduced into the CSF and may spread to the brain\\nor spinal cord.\\nDescription\\nThe procedure to remove cerebrospinal fluid is\\ncalled a lumbar puncture, or spinal tap, because the area\\nof the spinal column used to obtain the sample is in the\\nlumbar spine, or lower section of the back. In rare\\ninstances, such as a spinal fluid blockage in the middle of\\nthe back, a doctor may perform a spinal tap in the neck.\\nThe lower lumbar spine (usually between the vertebrae\\nknown as L4–5) is preferable because the spinal cord\\nstops near L2, and a needle introduced below this level\\nwill miss the spinal cord and encounter only nerve roots,\\nwhich are easily pushed aside.\\nA lumbar puncture takes about 30 minutes. Patients\\ncan undergo the test in a doctor’s office, laboratory, or\\noutpatient hospital setting. Sometimes it requires an\\ninpatient hospital stay. If the patient has spinal arthritis,\\nis extremely uncooperative, or obese, it may be necessary\\nto introduce the spinal needle using x-ray guidance.\\nIn order to get an accurate sample of cerebrospinal\\nfluid, it is critical that a patient is in the proper position.\\nThe spine must be curved to allow as much space as possi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 707\\nCerebrospinal fluid (CSF) analysis\\nSpinal cord\\nCerebrospinal fluid\\nVertebrae\\nDuring a lumbar puncture, or spinal tap, a procedure in which cerebrospinal fluid is aspirated, the physician inserts a hollow,\\nthin needle in the space between two vertebrae of the lower back and slowly advances it toward the spine.The cerebrospinal\\nfluid pressure is then measured and the fluid is withdrawn for laboratory analysis.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 707'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 96, 'page_label': '97'}, page_content='ble between the lower vertebrae, or bones of the back, for\\nthe doctor to insert a lumbar puncture needle between the\\nvertebrae and withdraw a small amount of fluid. The most\\ncommon position is for the patient to lie on his or her side\\nwith the back at the edge of the exam table, head and chin\\nbent down, knees drawn up to the chest, and arms clasped\\naround the knees. (Small infants and people who are obese\\nmay need to curve their spines in a sitting position.) Peo-\\nple should talk to their doctor if they have any questions\\nabout their position because it is important to be comfort-\\nable and to remain still during the entire procedure. In fact,\\nthe doctor will explain the procedure to the patient (or\\nguardian) so that the patient can agree in writing to have it\\ndone (informed consent). If the patient is anxious or unco-\\noperative, a short-acting sedative may be given.\\nDuring a lumbar puncture, the doctor drapes the\\nback with a sterile covering that has an opening over the\\npuncture site and cleans the skin surface with an antisep-\\ntic solution. Patients receive a local anesthetic to mini-\\nmize any pain in the lower back.\\nThe doctor inserts a hollow, thin needle in the space\\nbetween two vertebrae of the lower back and slowly\\nadvances it toward the spine. A steady flow of clear cere-\\nbrospinal fluid, normally the color of water, will begin to\\nKEY TERMS\\nEncephalitis—An inflammation or infection of the\\nbrain and spinal cord caused by a virus or as a\\ncomplication of another infection.\\nGuillain-Barré syndrome—An inflammation involv-\\ning nerves that affect the extremities. The inflamma-\\ntion may spread to the face, arms, and chest.\\nImmune system—Protects the body against infec-\\ntion.\\nManometer—A device used to measure fluid pres-\\nsure.\\nMeningitis —An infection or inflammation of the\\nmembranes or tissues that cover the brain and\\nspinal cord, and caused by bacteria or a virus.\\nMultiple sclerosis —A disease that destroys the\\ncovering (myelin sheath) of nerve fibers of the\\nbrain and spinal cord.\\nSpinal canal —The cavity or hollow space within\\nthe spine that contains cerebrospinal fluid.\\nVertebrae—The bones of the spinal column. There\\nare 33 along the spine, with five (called L1-L5)\\nmaking up the lower lumbar region.\\nfill the needle as soon as it enters the spinal canal. The\\ndoctor measures the cerebrospinal fluid pressure with a\\nspecial instrument called a manometer and withdraws\\nseveral vials of fluid for laboratory analysis. The amount\\nof fluid collected depends on the type and number of\\ntests needed to diagnose a particular medical disorder.\\nIn some cases, the doctor must remove and reposi-\\ntion the needle. This occurs when there is not an even\\nflow of fluid, the needle hits bone or a blood vessel, or\\nthe patient reports sharp, unusual pain.\\nPreparation\\nPatients can go about their normal activities before a\\nlumbar puncture. Experts recommend that patients relax\\nbefore the procedure to release any muscle tension, since\\nthe lumbar puncture needle must pass through muscle\\ntissue before it reaches the spinal canal. A patient’s level\\nof relaxation before and during the procedure plays a\\ncritical role in the test’s success.\\nAftercare\\nAfter the procedure, the doctor covers the site of the\\npuncture with a sterile bandage. Patients must avoid sit-\\nting or standing and remain lying down for as long as six\\nhours after the lumbar puncture. They should also drink\\nplenty of fluid to help prevent lumbar puncture\\nheadache, which is discussed in the next section.\\nRisks\\nFor most people, the most common side effect after\\nthe removal of CSF is a headache. This occurs in\\n10–30% of adult patients and in up to 40% of children. It\\nis caused by a decreased CSF pressure related to a small\\nleak of CSF through the puncture site. These headaches\\nusually are a dull pain, although some people report a\\nthrobbing sensation. A stiff neck and nausea may accom-\\npany the headache. Lumbar puncture headaches typically\\nbegin within two days after the procedure and persist\\nfrom a few days to several weeks or months.\\nSince an upright position worsens the pain, patients\\nwith a lumbar puncture headache can control the pain by\\nlying in a flat position and taking a prescription or non-\\nprescription pain relief medication, preferably one con-\\ntaining caffeine . In rare cases, the puncture site leak is\\n“patched” using the patient’s own blood.\\nPeople should talk to their doctor about complica-\\ntions from a lumbar puncture. In most cases, this test to\\nanalyze CSF is a safe and effective procedure. Some\\npatients experience pain, difficulty urinating, infection,\\nor leakage of cerebrospinal fluid from the puncture site\\nafter the procedure.\\nGALE ENCYCLOPEDIA OF MEDICINE 2708\\nCerebrospinal fluid (CSF) analysis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 708'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 97, 'page_label': '98'}, page_content='Normal results\\nNormal CSF is clear and colorless. It may be cloudy\\nin infections; straw- or yellow-colored if there is excess\\nprotein, as may occur with cancer or inflammation;\\nblood-tinged if there was recent bleeding; or yellow to\\nbrown (xanthochromic) if caused by an older instance of\\nbleeding.\\nA series of laboratory tests analyze the CSF for a\\nvariety of substances to rule out possible medical disor-\\nders of the central nervous system. The following are\\nnormal values for commonly tested substances:\\n• CSF pressure: 50–180 mmH\\n2O\\n• glucose: 40–85 mg/dL\\n• protein: 15–50 mg/dL\\n• leukocytes (white blood cells) total less than 5 per mL\\n• lymphocytes: 60–70%\\n• monocytes: 30–50%\\n• neutrophils: none\\nNormally, there are no red blood cells in the CSF\\nunless the needle passes though a blood vessel on route\\nto the CSF. If this is the case, there should be more red\\nblood cells in the first tube collected than in the last.\\nAbnormal results\\nAbnormal test result values in the pressure or any of\\nthe substances found in the cerebrospinal fluid may sug-\\ngest a number of medical problems including a tumor or\\nspinal cord obstruction; hemorrhaging or bleeding in the\\ncentral nervous system; infection from bacterial, viral, or\\nfungal microorganisms; or an inflammation of the\\nnerves. It is important for patients to review the results of\\na cerebrospinal fluid analysis with their doctor and to\\ndiscuss any treatment plans.\\nResources\\nBOOKS\\nAnderson, Kenneth, ed. Mosby’s Medical, Nursing and Allied\\nHealth Dictionary. 4th ed. Chicago: Mosby Year-Book,\\nInc., 1994.\\nConn’s Current Therapy, 1996.Ed. Robert E. Rakel. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\n“General Problems in Infectious Diseases.” In Current Medical\\nDiagnosis and Treatment, 1996.35th ed. Ed. Stephen\\nMcPhee, et al. Stamford: Appleton & Lange, 1995.\\nPERIODICALS\\nLederman, Richard J. “Lumbar Puncture: Essential Steps to a\\nSafe and Valid Procedure.”Geriatrics (June 1996): 51-55.\\nORGANIZATIONS\\nAmerican Academy of Neurology. 1080 Montreal Ave., St.\\nPaul, MN 55116. (612) 695-1940. .\\nMartha Floberg Robbins\\nCerebrovascular accident see Stroke\\nCerebrovascular amyloidosis see Cerebral\\namyloid angiopathy\\nCerumen impaction\\nDefinition\\nCerumen impaction is a condition in which earwax\\nhas become tightly packed in the external ear canal to the\\npoint that the canal is blocked.\\nDescription\\nCerumen impaction develops when earwax accumu-\\nlates in the inner part of the ear canal and blocks the\\neardrum. It affects between 2–6% of the general popula-\\ntion in the United States. Impaction does not happen\\nunder normal circumstances because cerumen is pro-\\nduced by glands in the outer part of the ear canal; it is not\\nproduced in the inner part. The cerumen traps sand or\\ndust particles before they reach the ear drum. It also pro-\\ntects the outer part of the ear canal because it repels\\nwater. The slow movement of the outer layer of skin of\\nthe ear canal carries cerumen toward the outer opening of\\nthe ear. As the older cerumen reaches the opening of the\\near, it dries out and falls away.\\nCauses and symptoms\\nCauses\\nCerumen is most likely to become impacted when it\\nis pushed against the eardrum by cotton-tipped applica-\\ntors, hair pins, or other objects that people put in their\\nears; and when it is trapped against the eardrum by a\\nhearing aid. Less common causes of cerumen impaction\\ninclude overproduction of earwax by the glands in the\\near canal, or an abnormally shaped ear canal.\\nSymptoms\\nThe most important symptom of cerumen impaction\\nis partial loss of hearing. Other symptoms are itching ,\\ntinnitus (noise or ringing in the ears), a sensation of full-\\nness in the ear, and pain.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 709\\nCerumen impaction\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 709'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 98, 'page_label': '99'}, page_content='Diagnosis\\nThe diagnosis of impacted cerumen is usually made\\nby examining the ear canal and eardrum with an oto-\\nscope, an instrument with a light attached that allows the\\ndoctor to look into the canal.\\nTreatment\\nIrrigation is the most common method of removing\\nimpacted cerumen. It involves washing out the ear canal\\nwith water from a commercial irrigator or a syringe with\\na catheter attached. Although some doctors use Water\\nPiks to remove cerumen, most do not recommend them\\nbecause the stream of water is too forceful and may dam-\\nage the eardrum. The doctor may add a small amount of\\nalcohol, hydrogen peroxide, or other antiseptic. The\\nwater must be close to body temperature; if it is too cold\\nor too warm, the patient may feel dizzy or nauseated.\\nAfter the ear has been irrigated, the doctor will apply\\nantibiotic ear drops to protect the ear from infection.\\nIrrigation should not be used to remove cerumen if\\nthe patient’s eardrum is ruptured or missing; if the patient\\nhas a history of chronic otitis media (inflammation of\\nthe middle ear) or a myringotomy (cutting the eardrum to\\nallow fluid to escape from the middle ear); or if the\\npatient has hearing in only one ear.\\nIf irrigation cannot be used or fails to remove the\\ncerumen, the patient is referred to an ear, nose, and throat\\n(ENT) specialist. The specialist can remove the wax with\\na vacuum device or a curette, which is a small scoop-\\nshaped surgical instrument.\\nSome doctors prescribe special ear drops, such as\\nCerumenex, to soften the wax. The most common side\\neffect of Cerumenex is an allergic skin reaction. Over-\\nthe-counter wax removal products include Debrox or\\nMurine Ear Drops. A 3% solution of hydrogen peroxide\\nmay also be used. These products are less likely to irri-\\ntate the skin of the ear.\\nPrognosis\\nIn most cases, impacted cerumen is successfully\\nremoved by irrigation with no lasting side effects. Irriga-\\ntion can, however, lead to infection of the outer or the\\nmiddle ear if the patient has a damaged or absent ear\\ndrum. Patients who try to remove earwax themselves\\nwith hair pins or similar objects run the risk of perforat-\\ning the ear drum or damaging the fragile skin covering\\nthe ear canal, causing bleeding and the risk of infection.\\nPrevention\\nThe best method of cleaning the external ear is to\\nwipe the outer opening with a damp washcloth folded over\\nthe index finger, without going into the ear canal itself.\\nTwo techniques have been recommended to prevent ceru-\\nmen from reaccumulating in the ear. The patient may place\\ntwo or three drops of mineral oil into each ear once a\\nweek, allow it to remain for two or three minutes, and\\nrinse it out with warm water; or place two drops of Dome-\\nboro otic solution in each ear once a week after showering.\\nPatients who wear hearing aidsshould have their ears\\nexamined periodically for signs of cerumen accumulation.\\nResources\\nBOOKS\\nJackler, Robert K., MD, and Michael J. Kaplan, MD. “Ceru-\\nmen Impaction.” In “Ear, Nose, & Throat,”Current Med-\\nGALE ENCYCLOPEDIA OF MEDICINE 2710\\nCerumen impaction\\nStream of fluid\\nWax\\nEardrumSyringe\\nEar wax is removed by flushing the ear canal with warm fluid.(Illustration by Argosy, Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 710'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 99, 'page_label': '100'}, page_content='ical Diagnosis & Treatment 2001. 40th ed. Ed. L. M. Tier-\\nney, Jr., MD, et al. New York: Lange Medical\\nBooks/McGraw-Hill, 2001.\\n“External Ear: Obstructions.” In The Merck Manual of Diagno-\\nsis and Therapy, ed. Mark H. Beers, MD, and Robert\\nBerkow, MD. Whitehouse Station, NJ: Merck Research\\nLaboratories, 1999.\\nPERIODICALS\\nBrownson, Paul J., MD. “Cerumen Management.”Update: The\\nNewsletter of the Council for Accreditation in Occupa-\\ntional Hearing Conservation 11, (no. 4), (Winter 2000-\\n2001).\\nORGANIZATIONS\\nAmerican Academy of Otolaryngology, Head and Neck Surgery.\\n1 Prince Street, Alexandria, V A 22314. (703) 836-4444.\\nRebecca J. Frey, PhD\\nCervical biopsy see Cervical conization\\nCervical cancer\\nDefinition\\nCervical cancer is a disease in which the cells of the\\ncervix become abnormal and start to grow uncontrol-\\nlably, forming tumors.\\nDescription\\nIn the United States, cervical cancer is the fifth most\\ncommon cancer among women aged 35–54, and the third\\nmost common cancer of the female reproductive tract. In\\nsome developing countries, it is the most common type\\nof cancer. It generally begins as an abnormality in the\\ncells on the outside of the cervix. The cervix is the lower\\npart or neck of the uterus (womb). It connects the body\\nof the uterus to the vagina (birth canal).\\nApproximately 90% of cervical cancers are squamous\\ncell carcinomas. This type of cancer originates in the thin,\\nflat, squamous cells on the surface of the ectocervix, the\\npart of the cervix that is next to the vagina. (Squamous\\ncells are the thin, flat cells of the surfaces of the skin and\\ncervix and linings of various organs.) Another 10% of cer-\\nvical cancers are of the adenocarcinoma type. This cancer\\noriginates in the mucus-producing cells of the inner or\\nendocervix, near the body of the uterus. Occasionally, the\\ncancer may have characteristics of both types and is called\\nadenosquamous carcinoma or mixed carcinoma.\\nThe initial changes that may occur in some cervical\\ncells are not cancerous. However, these precancerous\\ncells form a lesion called dysplasia or a squamous\\nintraepithelial lesion (SIL), since it occurs within the\\nepithelial or outer layer of cells. These abnormal cells\\ncan also be described as cervical intraepithelial neoplasia\\n(CIN). Moderate to severe dysplasia may be called carci-\\nnoma in situ or non-invasive cervical cancer.\\nDysplasia is a common condition and the abnormal\\ncells often disappear without treatment. However, these\\nprecancerous cells can become cancerous. This may take\\nyears, although it can happen in less than a year. Eventu-\\nally, the abnormal cells start to grow uncontrollably into\\nthe deeper layers of the cervix, becoming an invasive cer-\\nvical cancer.\\nAlthough cervical cancer used to be one of the most\\ncommon causes of cancer death among American\\nwomen, in the past 40 years there has been a 75% decrease\\nin mortality. This is primarily due to routine screening\\nwith Pap tests (Pap smear), to identify precancerous and\\nearly-invasive stages of cervical cancer. With treatment,\\nthese conditions have a cure rate of nearly 100%.\\nWorldwide, there are more than 400,000 new cases\\nof cervical cancer diagnosed each year. The American\\nCancer Society (ACS) estimates that there will be 12,900\\nnew cases of invasive cervical cancer diagnosed in the\\nUnited States in 2001. More than one million women\\nwill be diagnosed with a precancerous lesion or non-\\ninvasive cancer of the cervix.\\nOlder women are at the highest risk for cervical can-\\ncer. Although girls under the age of 15 rarely develop this\\nGALE ENCYCLOPEDIA OF MEDICINE 2 711\\nCervical cancer\\nKEY TERMS\\nCerumen—The medical term for earwax.\\nCurette —A small scoop-shaped surgical instru-\\nment that can be used to remove cerumen if irriga-\\ntion does not work or cannot be used.\\nImpaction —A condition in which earwax has\\nbecome tightly packed in the outer ear to the point\\nthat the external ear canal is blocked.\\nIrrigation —The technique of removing cerumen\\nfrom the ear canal by flushing it with water.\\nMyringotomy—Surgical cutting of the ear drum to\\nallow fluid to escape from the middle ear.\\nOtitis media —Inflammation of the middle ear.\\nPatients who have had recurrent otitis media\\nshould not have cerumen removed by irrigation.\\nTinnitus—A sensation of noise or ringing in the ears.\\nTinnitus may be a symptom of cerumen impaction.\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 711'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 100, 'page_label': '101'}, page_content='cancer, the risk factor begins to increase in the late teens.\\nRates for carcinoma in situ peak between the ages of 20\\nand 30. In the United States, the incidence of invasive\\ncervical cancer increases rapidly with age for African\\nAmerican women over the age of 25. The incidence rises\\nmore slowly for Caucasian women. However, women\\nover age 65 account for more than 25% of all cases of\\ninvasive cervical cancer.\\nThe incidence of cervical cancer is highest among\\npoor women and among women in developing countries.\\nIn the United States, the death rates from cervical cancer\\nare higher among Hispanic, Native American, and\\nAfrican American women than among Caucasian\\nwomen. These groups of women are much less likely to\\nreceive regular Pap tests. Therefore, their cervical can-\\ncers usually are diagnosed at a much later stage, after the\\ncancer has spread to other parts of the body.\\nCauses and symptoms\\nHuman papilloma virus\\nInfection with the common human papilloma virus\\n(HPV) is a cause of approximately 90% of all cervical\\ncancers. There are more than 80 types of HPV . About 30\\nof these types can be transmitted sexually, including\\nthose that cause genital warts (papillomas). About half\\nof the sexually transmitted HPVs are associated with cer-\\nvical cancer. These “high-risk” HPVs produce a protein\\nthat can cause cervical epithelial cells to grow uncontrol-\\nlably. The virus makes a second protein that interferes\\nwith tumor suppressors that are produced by the human\\nimmune system. The HPV-16 strain is thought to be a\\ncause of about 50% of cervical cancers.\\nMore than six million women in the United States\\nhave persistent HPV infections, for which there is no\\ncure. Nevertheless, most women with HPV do not devel-\\nop cervical cancer.\\nSymptoms of invasive cervical cancer\\nMost women do not have symptoms of cervical can-\\ncer until it has become invasive. At that point, the symp-\\ntoms may include:\\n• unusual vaginal discharge\\n• light vaginal bleeding or spots of blood outside of nor-\\nmal menstruation\\n• pain or vaginal bleeding with sexual intercourse\\n• post-menopausal vaginal bleeding\\nOnce the cancer has invaded the tissue surrounding\\nthe cervix, a woman may experience pain in the pelvic\\nregion and heavy bleeding from the vagina.\\nDiagnosis\\nThe Pap test\\nMost often, cervical cancer is first detected with a\\nPap test that is performed as part of a regular pelvic\\nexamination. The vagina is spread with a metal or plastic\\ninstrument called a speculum. A swab is used to remove\\nmucus and cells from the cervix. This sample is sent to a\\nlaboratory for microscopic examination.\\nThe Pap test is a screening tool rather than a diag-\\nnostic tool. It is very efficient at detecting cervical\\nabnormalities. The Bethesda System commonly is used\\nto report Pap test results. A negative test means that no\\nabnormalities are present in the cervical tissue. A posi-\\ntive Pap test describes abnormal cervical cells as low-\\ngrade or high-grade SIL, depending on the extent of\\ndysplasia. About 5–10% of Pap tests show at least mild\\nabnormalities. However, a number of factors other than\\ncervical cancer can cause abnormalities, including\\ninflammation from bacteria or yeast infections. A few\\nmonths after the infection is treated, the Pap test is\\nrepeated.\\nBiopsy\\nFollowing an abnormal Pap test, a colposcopy is\\nusually performed. The physician uses a magnifying\\nscope to view the surface of the cervix. The cervix may\\nbe coated with an iodine solution that causes normal cells\\nto turn brown and abnormal cells to turn white or yellow.\\nThis is called a Schiller test. If any abnormal areas are\\nobserved, a colposcopic biopsy may be performed. A\\nbiopsy is the removal of a small piece of tissue for micro-\\nscopic examination by a pathologist.\\nOther types of cervical biopsies may be performed.\\nAn endocervical curettage is a biopsy in which a narrow\\ninstrument called a curette is used to scrape tissue from\\ninside the opening of the cervix. A cone biopsy, or\\nconization, is used to remove a cone-shaped piece of tis-\\nsue from the cervix. In a cold knife cone biopsy, a surgi-\\ncal scalpel or laser is used to remove the tissue. A loop\\nelectrosurgical excision procedure (LEEP) is a cone\\nbiopsy using a wire that is heated by an electrical cur-\\nrent. Cone biopsies can be used to determine whether\\nabnormal cells have invaded below the surface of the\\ncervix. They also can be used to treat many precancers\\nand very early cancers. Biopsies may be performed with\\na local or general anesthetic. They may cause cramping\\nand bleeding.\\nDiagnosing the stage\\nFollowing a diagnosis of cervical cancer, various\\nprocedures may be used to stage the disease (determine\\nGALE ENCYCLOPEDIA OF MEDICINE 2712\\nCervical cancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 712'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 101, 'page_label': '102'}, page_content='how far the cancer has spread). For example, additional\\npelvic exams may be performed under anesthesia.\\nThere are several procedures for determining if cer-\\nvical cancer has invaded the urinary tract. With cys-\\ntoscopy, a lighted tube with a lens is inserted through the\\nurethra (the urine tube from the bladder to the exterior)\\nand into the bladder to examine these organs for cancer-\\nous cells. Tissue samples may be removed for micro-\\nscopic examination by a pathologist. Intravenous urog-\\nraphy (intravenous pyelogram or IVP) is an x ray of the\\nurinary system, following the injection of special dye.\\nThe kidneys remove the dye from the bloodstream and\\nthe dye passes into the ureters (the tubes from the kid-\\nneys to the bladder) and bladder. IVP can detect a\\nblocked ureter, caused by the spread of cancer to the\\npelvic lymph nodes (small glands that are part of the\\nimmune system).\\nA procedure called proctoscopy or sigmoidoscopy is\\nsimilar to cystoscopy. It is used to determine whether the\\ncancer has spread to the rectum or lower large intestine.\\nComputed tomography (CT or CAT) scans, ultra-\\nsound, or other imaging techniques may be used to deter-\\nmine the spread of cancer to various parts of the body.\\nWith a CT scan, an x-ray beam rotates around the body,\\ntaking images from various angles. It is used to deter-\\nmine if the cancer has spread to the lymph nodes. Mag-\\nnetic resonance imaging (MRI), which uses a magnetic\\nfield to image the body, sometimes is used for evaluating\\nthe spread of cervical cancer. Chest x rays may be used\\nto detect cervical cancer that has spread to the lungs.\\nTreatment\\nFollowing a diagnosis of cervical cancer, the physi-\\ncian takes a medical history and performs a complete\\nphysical examination . This includes an evaluation of\\nsymptoms and risk factors for cervical cancer. The lymph\\nnodes are examined for evidence that the cancer has\\nspread from the cervix. The choice of treatment depends\\non the clinical stage of the disease.\\nThe FIGO system of staging\\nThe International Federation of Gynecologists and\\nObstetricians (FIGO) system usually is used to stage cer-\\nvical cancer:\\n• Stage 0: Carcinoma in situ; non-invasive cancer that is\\nconfined to the layer of cells lining the cervix\\n• Stage I: Cancer that has spread into the connective tis-\\nsue of the cervix but is confined to the uterus\\n• Stage IA: Very small cancerous area that is visible only\\nwith a microscope\\n• Stage IA1: Invasion area is less than 3 mm (0.13 in)\\ndeep and 7 mm (0.33 in) wide\\n• Stage IA2: Invasion area is 3–5 mm (0.13–0.2 in) deep\\nand less than 7 mm (0.33 in) wide\\n• Stage IB: Cancer can be seen without a microscope or is\\ndeeper than 5 mm (0.2 in) or wider than 7 mm (0.33 in)\\n• Stage IB1: Cancer is no larger than 4 cm (1.6 in)\\n• Stage IB2: Stage IB cancer is larger than 4 cm (1.6 in)\\n• Stage II: Cancer has spread from the cervix but is con-\\nfined to the pelvic region\\n• Stage IIA: Cancer has spread to the upper region of the\\nvagina, but not to the lower one-third of the vagina\\n• Stage IIB: Cancer has spread to the parametrial tissue\\nadjacent to the cervix\\n• Stage III: Cancer has spread to the lower one-third of\\nthe vagina or to the wall of the pelvis and may be\\nblocking the ureters\\n• Stage IIIA: Cancer has spread to the lower vagina but\\nnot to the pelvic wall\\n• Stage IIIB: Cancer has spread to the pelvic wall and/or\\nis blocking the flow of urine through the ureters to the\\nbladder\\n• Stage IV: Cancer has spread to other parts of the body\\n• Stage IV A: Cancer has spread to the bladder or rectum\\n• Stage IVB: Cancer has spread to distant organs such as\\nthe lungs\\n• Recurrent: Following treatment, cancer has returned to\\nthe cervix or some other part of the body\\nIn addition to the stage of the cancer, factors such as\\na woman’s age, general health, and preferences may\\ninfluence the choice of treatment. The exact location of\\nthe cancer within the cervix and the type of cervical can-\\ncer also are important considerations.\\nTreatment of precancer and carcinoma in situ\\nMost low-grade SILs that are detected with Pap tests\\nrevert to normal without treatment. Most high-grade\\nSILs require treatment. Treatments to remove precancer-\\nous cells include:\\n• cold knife cone biopsy\\n• LEEP\\n• cryosurgery (freezing the cells with a metal probe)\\n• cauterization or diathermy (burning off the cells)\\n• laser surgery (burning off the cells with a laser beam)\\nThese methods also may be used to treat cancer that\\nis confined to the surface of the cervix (stage 0) and other\\nGALE ENCYCLOPEDIA OF MEDICINE 2 713\\nCervical cancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 713'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 102, 'page_label': '103'}, page_content='early-stage cervical cancers in women who may want to\\nbecome pregnant. They may be used in conjunction with\\nother treatments. These procedures may cause bleeding\\nor cramping. All of these treatments require close follow-\\nup to detect any recurrence of the cancer.\\nSurgery\\nA simple hysterectomy is used to treat some stages\\n0 and IA cervical cancers. Usually only the uterus is\\nremoved, although occasionally the fallopian tubes and\\novaries are removed as well. The tissues adjoining the\\nuterus, including the vagina, remain intact. The uterus\\nmay be removed either through the abdomen or the\\nvagina.\\nIn a radical hysterectomy, the uterus and adjoining\\ntissues, including the ovaries, the upper region (1 in) of\\nthe vagina near the cervix, and the pelvic lymph nodes,\\nare all removed. A radical hysterectomy usually involves\\nabdominal surgery. However, it can be performed vagi-\\nnally, in combination with a laparoscopic pelvic lymph\\nnode dissection. With laparoscopy , a tube is inserted\\nthrough a very small surgical incision for the removal of\\nthe lymph nodes. These operations are used to treat\\nstages IA2, IB, and IIA cervical cancers, particularly in\\nyoung women. Following a hysterectomy, the tissue is\\nexamined to see if the cancer has spread and requires\\nadditional radiation treatment. Women who have had\\nhysterectomies cannot become pregnant, but complica-\\ntions from a hysterectomy are rare.\\nIf cervical cancer recurs following treatment, a\\npelvic exenteration (extensive surgery) may be per-\\nformed. This includes a radical hysterectomy, with the\\nadditional removal of the bladder, rectum, part of the\\ncolon, and/or all of the vagina. Such operations require\\nthe creation of new openings for the urine and feces. A\\nnew vagina may be created surgically. Often the clitoris\\nand other outer genitals are left intact.\\nRecovery from a pelvic exenteration may take six\\nmonths to two years. This treatment is successful with\\n40–50% of recurrent cervical cancers that are confined to\\nthe pelvis. If the recurrent cancer has spread to other\\norgans, radiation or chemotherapy may be used to alle-\\nviate some of the symptoms.\\nRadiation\\nRadiation therapy, which involves the use of high-\\ndosage x rays or other high-energy waves to kill cancer\\ncells, often is used for treating stages IB, IIA, and IIB\\ncervical cancers, or in combination with surgery. With\\nexternal-beam radiation therapy, the rays are focused on\\nthe pelvic area from a source outside the body. With\\nimplant or internal radiation therapy, a pellet of radioac-\\ntive material is placed internally, near the tumor. Alterna-\\ntively, thin needles may be used to insert the radioactive\\nmaterial directly into the tumor.\\nRadiation therapy to the pelvic region can have\\nmany side effects:\\n• skin reaction in the area of treatment\\n• fatigue\\n• upset stomach and loose bowels\\n• vaginal stenosis (narrowing of the vagina due to build-\\nup of scar tissue) leading to painful sexual intercourse\\n• premature menopause in young women\\n• problems with urination\\nChemotherapy\\nChemotherapy, the use of one or more drugs to kill\\ncancer cells, is used to treat disease that has spread\\nbeyond the cervix. Most often it is used following\\nsurgery or radiation treatment. Stages IIB, III, IV , and\\nrecurrent cervical cancers usually are treated with a\\ncombination of external and internal radiation and\\nchemotherapy. The common drugs used for cervical\\ncancer are cisplatin, ifosfamide, and fluorouracil. These\\nmay be injected or taken by mouth. The National Cancer\\nInstitute recommends that chemotherapy with cisplatin\\nbe considered for all women receiving radiation therapy\\nfor cervical cancer.\\nThe side effects of chemotherapy depend on a num-\\nber of factors, including the type of drug, the dosage, and\\nthe length of the treatment. Side effects may include:\\n• nausea and vomiting\\n• fatigue\\n• changes in appetite\\n• hair loss\\n• mouth or vaginal sores\\n• infections\\n• menstrual cycle changes\\n• premature menopause\\n• infertility\\n• bleeding or anemia (low red blood cell count)\\nWith the exception of menopause and infertility,\\nmost of the side effects are temporary.\\nAlternative treatment\\nBiological therapy sometimes is used to treat cervi-\\ncal cancer, either alone or in combination with\\nchemotherapy. Treatment with the immune-system pro-\\nGALE ENCYCLOPEDIA OF MEDICINE 2714\\nCervical cancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 714'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 103, 'page_label': '104'}, page_content='tein interferon is used to boost the immune response.\\nBiological therapy can cause temporary flu-like symp-\\ntoms and other side effects.\\nSome research suggests that vitamin A (carotene)\\nmay help to prevent or stop cancerous changes in cells\\nsuch as those on the surface of the cervix. Other studies\\nsuggest that vitamins C and E may reduce the risk of\\ncervical cancer.\\nPrognosis\\nFor cervical cancers that are diagnosed in the pre-\\ninvasive stage, the five-year-survival rate is almost 100%.\\nWhen cervical cancer is detected in the early invasive\\nstages, approximately 91% of women survive five years\\nor more. Stage IVB cervical cancer is not considered to\\nKEY TERMS\\nAdenocarcinoma —Cervical cancer that originates\\nin the mucus-producing cells of the inner or endo-\\ncervix.\\nBiopsy—Removal of a small sample of tissue for\\nexamination under a microscope; used for the diag-\\nnosis and treatment of cervical cancer and precan-\\ncerous conditions.\\nCarcinoma in situ —Cancer that is confined to the\\ncells in which it originated and has not spread to\\nother tissues.\\nCervical intraepithelial neoplasia (CIN) —Abnor-\\nmal cell growth on the surface of the cervix.\\nCervix—Narrow, lower end of the uterus forming\\nthe opening to the vagina.\\nColposcopy—Diagnostic procedure using a hollow,\\nlighted tube (colposcope) to look inside the cervix\\nand uterus.\\nConization —Cone biopsy; removal of a cone-\\nshaped section of tissue from the cervix for diagno-\\nsis or treatment.\\nDysplasia —Abnormal cellular changes that may\\nbecome cancerous.\\nEndocervical curettage —Biopsy performed with a\\ncurette to scrape the mucous membrane of the cer-\\nvical canal.\\nHuman papilloma virus (HPV) —Virus that causes\\nabnormal cell growth (warts or papillomas); some\\ntypes can cause cervical cancer.\\nHysterectomy—Removal of the uterus.\\nInterferon —Potent immune-defense protein pro-\\nduced by viral-infected cells; used as an anti-cancer\\nand anti-viral drug.\\nLaparoscopy —Laparoscopic pelvic lymph node\\ndissection; insertion of a tube through a very small\\nsurgical incision to remove lymph nodes.\\nLoop electrosurgical excision procedure (LEEP) —\\nCone biopsy performed with a wire that is heated\\nby electrical current.\\nLymph nodes —Small round glands, located\\nthroughout the body, that filter the lymphatic fluid;\\npart of the body’s immune defense.\\nPap test —Pap smear; removal of cervical cells to\\nscreen for cancer.\\nPelvic exenteration —Extensive surgery to remove\\nthe uterus, ovaries, pelvic lymph nodes, part or all\\nof the vagina, and the bladder, rectum, and/or part\\nof the colon.\\nSquamous cells —Thin, flat cells on the surfaces of\\nthe skin and cervix and linings of various organs.\\nSquamous intraepithelial lesion (SIL) —Abnormal\\ngrowth of squamous cells on the surface of the\\ncervix.\\nVaginal stenosis—Narrowing of the vagina due to a\\nbuild-up of scar tissue.\\nbe curable. The five-year-survival rate for all cervical can-\\ncers combined is about 70%. The death rate from cervical\\ncancer continues to decline by about 2% each year.\\nWomen over age 65 account for 40–50% of all deaths\\nfrom cervical cancer.\\nPrevention\\nViral infections\\nMost cervical cancers are preventable. More than\\n90% of women with cervical cancer are infected with\\nHPV . HPV infection is the single most important risk\\nfactor. This is particularly true for young women because\\nthe cells lining the cervix do not fully mature until age\\n18. These immature cells are more susceptible to cancer-\\ncausing agents and viruses.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 715\\nCervical cancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 715'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 104, 'page_label': '105'}, page_content='Since HPV is a sexually-transmitted infection, sexu-\\nal behaviors can put women at risk for HPV infection\\nand cervical cancer. These behaviors include:\\n• sexual intercourse at age 16 or younger\\n• partners who began having intercourse at a young age\\n• multiple sexual partners\\n• sexual partners who have had multiple partners (“high-\\nrisk males”)\\n• a partner who has had a previous sexual partner with\\ncervical cancer\\nHPV infection may not produce any symptoms, so\\nsexual partners may not know that they are infected.\\nHowever, Pap tests can detect the infection. Condoms do\\nnot necessarily prevent HPV infection.\\nInfection with the human immunodeficiency virus\\n(HIV) that causes acquired immunodeficiency syndrome\\n(AIDS) is a risk factor for cervical cancer. Women who\\ntest positive for HIV may have impaired immune sys-\\ntems that cannot correct precancerous conditions. Fur-\\nthermore, sexual behavior that puts women at risk for\\nHIV infection, also puts them at risk for HPV infection.\\nThere is some evidence suggesting that another sexually\\ntransmitted virus, the genital herpes virus, also may be\\ninvolved in cervical cancer.\\nSmoking\\nSmoking may double the risk of cervical cancer.\\nChemicals produced by tobacco smoke can damage the\\nDNA of cervical cells. The risk increases with the number\\nof years a woman smokes and the amount she smokes.\\nDiet and drugs\\nDiets that are low in fruits and vegetables increase\\nthe risk of cervical cancer. Women also have an increased\\nrisk of cervical cancer if their mothers took the drug\\ndiethylstilbestrol (DES) while they were pregnant. This\\ndrug was given to women between 1940 and 1971 to pre-\\nvent miscarriages. Some statistical studies have suggest-\\ned that the long-term use of oral contraceptives may\\nslightly increase the risk of cervical cancer.\\nPap tests\\nMost cases of cervical cancers are preventable,\\nsince they start with easily detectable precancerous\\nchanges. Therefore, the best prevention for cervical can-\\ncer is a regular Pap test. When precancerous changes are\\ndetected, appropriate treatment can prevent the develop-\\nment of invasive cancer. The ACS recommends that\\nwomen have annual Pap tests beginning when they first\\nstart having sex or at age 18. Women who are past\\nmenopause or some women with hysterectomies contin-\\nue to require Pap tests.\\nThe National Breast and Cervical Cancer Early\\nDetection Program provides free or low-cost Pap tests\\nand treatment for women without health insurance, for\\nolder women, and for members of racial and ethnic\\nminorities. The program is administered through individ-\\nual states, under the direction of the Centers for Disease\\nControl and Prevention.\\nSpecial concerns\\nIf a woman is diagnosed with very early-stage (IA)\\ncervical cancer while pregnant, the physician usually will\\nrecommend a hysterectomy after the baby is born. For\\nlater-stage cancers, the pregnancy is terminated or the\\nbaby is removed by cesarean section as soon as it can\\nsurvive outside the womb. This is followed by a hysterec-\\ntomy and/or radiation treatment. For the most advanced\\nstages of cervical cancer, treatment is initiated despite\\nthe pregnancy.\\nMany women with cervical cancer have hysterec-\\ntomies, which are major surgeries. Although normal\\nactivities, including sexual intercourse, can be resumed\\nin four-eight weeks, a woman may have emotional prob-\\nlems following a hysterectomy. A strong support system\\ncan help with these difficulties.\\nResources\\nBOOKS\\nFalco, Kristine. Reclaiming Our Lives After Breast and Gyne-\\ncologic Cancer.Northvale, NJ: Jason Aronson, Inc., 1998.\\nHolland, Jimmie C. and Sheldon Lewis. The Human Side of\\nCancer: Living with Hope, Coping with Uncertainty.New\\nYork: HarperCollins, 2000.\\nRunowicz, Carolyn D., Jeanne A. Petrek, and Ted S. Gansler.\\nWomen and Cancer: A Thorough and Compassionate\\nResource for Patients and their Families.New York: Vil-\\nlard Books, 1999.\\nSweeney, Julia. God Said “Ha!”New York: Bantam Books, 1997.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Road, N.E., Atlanta,\\nGA 30329. (800) ACS-2345. .\\nCenters for Disease Control and Prevention. National Center\\nfor Chronic Disease Prevention and Health Promotion.\\nMail Stop K-64. 4770 Buford Highway NE, Atlanta, GA\\n30341-3717. (770) 488-4751. (888) 842-6355.\\n.\\nEyesOnThePrize.Org. 446 S. Anaheim Hills Road, #108, Ana-\\nheim Hills, CA 92807. .\\nGynecologic Cancer Foundation. 401 North Michigan Avenue,\\nChicago, IL 60611. (800) 444-4441. (312) 644-6610.\\n.\\nNational Cancer Institute. Public Inquiries Office, Building 31,\\nRoom 10A31, 31 Center Drive, MSC 2580, Bethesda, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 2716\\nCervical cancer\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 716'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 105, 'page_label': '106'}, page_content='20892-2580. (800) 4-CANCER. .\\n.\\nNational Cervical Cancer Coalition. 16501 Sherman Way,\\nSuite #110, Van Nuys, CA 91406. (800) 685-5531. (818)\\n909-3849. .\\nOTHER\\n“Cancer of the Cervix.”CancerNet. 12 Dec. 2000. National Can-\\ncer Institute. NIH Publication No. 95-2047. 3 Apr. 2001.\\n.\\n“Cervical Cancer.”Cancer Resource Center.American Cancer\\nSociety. 16 Mar. 2000. 3 Apr. 2001. .\\n“Cervical Cancer.”National Institutes of Health Consensus\\nDevelopment Conference Statement.1-3 Apr. 1996. 3 Apr.\\n2001. .\\n“Cervical Cytology: Evaluation and Management of Abnormali-\\nties.”American College of Obstetricians and Gynecologists\\n(ACOG) Techincal Bulletin.Number 183 (August 1993).\\nLata Cherath\\nMargaret Alic, Ph.D.\\nCervical conization\\nDefinition\\nCervical conization is both a diagnostic and treat-\\nment tool used to detect and treat abnormalities of the\\ncervix. It is also known as a cone biopsy or cold knife\\ncone biopsy.\\nPurpose\\nCervical conization is performed if the results of a\\ncervical biopsy have found a precancerous condition in the\\ncervix. The cervix is the small cylindrical organ at the\\nlower part of the uterus, which separates the uterus from\\nthe vagina. Cervical conization also may be performed if\\nthere is an abnormal cervical smear test ( PAP test). A\\nbiopsy is a diagnostic test in which tissue or cells are\\nremoved from the body and examined under a microscope,\\nprimarily to look for cancer or other abnormalities.\\nPrecautions\\nAs with any operation that is performed under gen-\\neral anesthesia, the patient must not eat or drink anything\\nfor six to eight hours before surgery.\\nDescription\\nThe patient lies on the table with her legs raised in\\nstirrups, similar to the position when having a PAP test.\\nKEY TERMS\\nBiopsy—The removal of a small piece of living tis-\\nsue for examination under a microscope.\\nPAP test —The short term for Papanicolaou test,\\nthis procedure tests a smear of cellular material\\nscraped from the cervix and examined under a\\nmicroscope to detect abnormal cells.\\nThe patient is given general anesthesia, and the vagina is\\nheld open with an instrument called a speculum. Using a\\nscalpel or laser the doctor removes a cone-shaped piece\\nof the cervix containing the area with abnormal cells.\\nThe resulting crater is repaired by stitching flaps of tissue\\nover the wound. Alternatively, the wound may be left\\nopen, and heat or freezing is used to stop bleeding.\\nOnce the tissue has been removed, it is examined\\nunder a microscope for signs of cancer. If cancer is pre-\\nsent, other tests will be needed. Surgery will be per-\\nformed to remove the cervix and uterus ( hysterectomy)\\nand other treatments may be used as well. If the abnor-\\nmal cells are precancerous, a laser can be used to\\ndestroy them.\\nCold knife cone biopsy used to be the preferred\\ntreatment for removing abnormal cells in the cervix.\\nNow, most cone biopsies are performed using laser\\nsurgery. Cold knife cone biopsy is generally used only\\nfor special situations. For example, if a biopsy did not\\nremove all the abnormal cells, the cold knife cone proce-\\ndure allows the physician to remove what’s left.\\nAftercare\\nAn overnight stay in the hospital may be required.\\nAfter the test, the patient may feel some cramps or dis-\\ncomfort for about a week. Women should not have sex,\\nuse tampons, or douche until after seeing their physician\\nfor a follow up appointment (a week or more after the\\nprocedure).\\nRisks\\nBecause cone biopsies carry risks such as bleeding\\nand problems with subsequent pregnancies, they have\\nbeen replaced with newer technologies except in a few\\ncircumstances.\\nAbout one in 10 women experience bleeding from\\nthe vagina about two weeks after the biopsy. There is\\nalso a slight risk of infection or perforation of the uterus.\\nIn a few women, the cervical canal becomes narrowed or\\nGALE ENCYCLOPEDIA OF MEDICINE 2 717\\nCervical conization\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 717'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 106, 'page_label': '107'}, page_content='completely blocked, which can later interfere with the\\nmovement of sperm. This can impair a woman’s fertility.\\nIf too much muscle tissue has been removed, the\\nprocedure can lead to an incompetent cervix, which can\\nbe a problem with subsequent pregnancies. An incompe-\\ntent cervix cannot seal properly to maintain a\\npregnancy. If untreated, the condition increases the odds\\nof miscarriage or premature labor.\\nCervical conization also may temporarily alter cer-\\nvical cells, which can make a Pap smear test hard to\\ninterpret accurately for three or four months.\\nNormal results\\nThis procedure is only performed if an abnormality\\nis known or suspected.\\nAbnormal results\\nThe presence of precancerous or cancerous cells in\\nthe cervix.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nPERIODICALS\\nClifford, Catherine. “Cervical Cancer: Smart Way to Protect\\nYourself.”Redbook 189 (Oct. 1997): 124-28.\\nIsraeloff, Roberta. “Your Pap Test is Abnormal: What Does it\\nMean?” Cosmopolitan, Apr. 1995, 120-22.\\nORGANIZATIONS\\nCancer Information Service. (800) 4-CANCER. .\\nCarol A. Turkington\\nCervical disk disease\\nDefinition\\nCervical disk disease refers to a gradual deteriora-\\ntion of the spongy disks in the top part of the spine.\\nDescription\\nThe spine is made up of 33 bones called vertebrae\\nseparated by spongy rings of elastic material. These\\nrings, known as disks, are often compared to shock\\nabsorbers because they help to cushion the vertebrae.\\nJust as importantly, they also make it possible to turn the\\nhead and neck. Over time, these disks slowly become\\nflattened and less elastic due to everyday wear and tear.\\nWhen this process occurs in the disks of the neck, it is\\nreferred to as cervical disk disease. Other general terms\\nfor this process include degenerative disk disease and\\nintervertebral disk disease.\\nCervical disk disease affects everyone to some\\ndegree, often without causing any bothersome symp-\\ntoms. However, this condition can also lead to specific\\nproblems related to nerve functioning. For example, the\\nouter edge of a disk may tear, allowing the gelatinous\\nmaterial inside to bulge outward ( herniated disk ). This\\ncan put pressure on nerves that exit the spine. Two adja-\\ncent vertebrae may rub together (sometimes resulting in\\nbone spurs) that can also pinch these nerves. In other\\ncases, the inner part of the ring may push on the spinal\\ncord itself, which passes through the disk. Any of these\\nsituations can cause pain and limit movement. While\\nsymptoms primarily affect the neck, they can also occur\\nin other parts of the body.\\nCauses and symptoms\\nCervical disk disease is a gradual process that occurs\\nwith aging, though poor posture, repeated lifting, and\\ntobacco use can hasten its course. Symptoms include\\npain when moving the neck and limited neck movement.\\nThe condition can also affect the hand, shoulder, and arm\\nresulting in pain, numbness/tingling, and weakness. If\\nthe spinal cord itself is affected, these symptoms may\\noccur in the legs. Loss of bowel or bladder control may\\nalso occur.\\nDiagnosis\\nCervical disk disease is typically diagnosed by an\\northopedist or a neurologist. After taking a medical his-\\ntory and conducting a physical examination, the doctor\\nwill recommend an imaging procedure to gather more\\ninformation about the nature of the problem. This may\\ninclude a CT scan, an MRI, or myelography . In addi-\\ntion, an electromyogram (EMG) may be used to evalu-\\nate the functioning of nerves in the arms, hands, or legs.\\nCervical disk disease is typically covered by medical\\ninsurance.\\nTreatment\\nTreatment usually involves physical therapy, several\\nweeks of drug therapy with nonsteroidal anti-inflam-\\nmatory drugs (NSAIDs), and limited use of a cervical\\ncollar (to reduce neck movement). Neck traction and\\nheat treatments may also be recommended. In some\\nGALE ENCYCLOPEDIA OF MEDICINE 2718\\nCervical disk disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 718'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 107, 'page_label': '108'}, page_content='cases, steroids or anesthetic drugs may be injected into\\nthe spinal canal to help alleviate symptoms. Aside from\\nthese measures, maintaining good posture and placing a\\npillow under the neck and head during sleep can be help-\\nful. Treatment may last anywhere from several weeks to\\nthree months or more. Neck surgery is not usually\\nadvised unless other therapies have failed.\\nAlternative treatment\\nAcupuncture , therapeutic massage, and yoga are\\nbelieved by some practitioners of alternative medicine to\\nhave generalized pain-relieving effects. However, any\\ntherapy that involves manipulating the neck is not recom-\\nmended and should be approved by the primary doctor\\nbeforehand.\\nPrognosis\\nIn most people symptoms go away within three\\nmonths if not sooner. A smaller number may require\\nsurgery to correct the problem.\\nPrevention\\nWhile some degree of disk degeneration is inevitable,\\npeople can reduce their risk by practicing good posture\\n(during sitting, standing, and lifting), performing neck-\\nKEY TERMS\\nBone spur—An overgrowth of bone.\\nCervical—Relating to the top part of the spine that\\nis composed of the seven vertebrae of the neck\\nand the disks that separate them.\\nComputed tomography (CT) scan —An imaging\\nprocedure that produces a three-dimensional pic-\\nture of organs or structures inside the body.\\nMyelography —An imaging procedure involving\\nthe injection of a radioactive dye into the fluid sur-\\nrounding the spine. A myelography can be used to\\ndetect herniated disks, nerve root damage, and\\nother problems affecting the cervical spine.\\nNeurologist —A doctor who specializes in disor-\\nders of the brain and central nervous system.\\nOrthopedist —A doctor who specializes in disor-\\nders of the musculoskeletal system.\\nMagnetic resonance imaging —A type of imaging\\nthat uses magnetic fields to generate a picture of\\ninternal structures.\\nstretching exercises, maintaining an ideal weight, and quit-\\nting smoking.\\nResources\\nBOOKS\\nDee, Roger, et al. Principles of Orthopaedic Practice. New\\nYork: McGraw-Hill, 1997.\\nPERIODICALS\\nHeckmann, J. G., et al. “Herniated Cervical Intervertebral\\nDiscs with Radiculopathy: An Outcome Study of Conser-\\nvatively or Surgically Treated Patients.”Journal of Spinal\\nDisorders 12 (Oct. 1999): 396-401.\\nORGANIZATIONS\\nAmerican Academy of Orthopaedic Surgeons. 6300 North\\nRiver Road, Rosemont, IL 60018-4262. (800) 346-2267.\\n.\\nGreg Annussek\\nCervical osteoarthritis see Cervical\\nspondylosis\\nCervical spondylosis\\nDefinition\\nCervical spondylosis refers to common age-related\\nchanges in the area of the spine at the back of the neck.\\nWith age, the vertebrae (the component bones of the\\nspine) gradually form bone spurs, and their shock-\\nabsorbing disks slowly shrink. These changes can alter\\nthe alignment and stability of the spine. They may go\\nunnoticed, or they may produce problems related to pres-\\nsure on the spine and associated nerves and blood ves-\\nsels. This pressure can cause weakness, numbness, and\\npain in various areas of the body. In severe cases, walk-\\ning and other activities may be compromised.\\nDescription\\nAs it runs from the brain down the back, the spinal\\ncord is protected by ringlike bones, called vertebrae,\\nstacked one upon the other. The vertebrae are not in\\ndirect contact with one another, however. The interven-\\ning spaces are filled with structures called disks. The\\ndisks are made up of a tough, fibrous outer tissue with an\\ninner core of elastic or gel-like tissue.\\nOne of the most important functions of disks is pro-\\ntecting the vertebrae and the nerves and blood vessels\\nbetween the vertebrae. The disks also lend flexibility to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 719\\nCervical spondylosis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 719'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 108, 'page_label': '109'}, page_content='the spinal cord, facilitating movements such as turning\\nthe head or bending the neck. As people age, disks gradu-\\nally become tougher and more unyielding. Disks also\\nshrink with age, which reduces the amount of padding\\nbetween the vertebrae.\\nAs the amount of padding shrinks, the spine loses\\nstability. The vertebrae react by constructing osteo-\\nphytes, commonly known as bone spurs. There are seven\\nvertebrae in the neck; development of osteophytes on\\nthese bones is sometimes called cervical osteoarthritis .\\nOsteophytes may help to stabilize the degenerating back-\\nbone and help protect the spinal cord.\\nBy age 50, 25–50% of people develop cervical spondy-\\nlosis; by 75 years of age, it is seen in at least 70% of people.\\nAlthough shrunken vertebral disks, osteophyte growth, and\\nother changes in their cervical spine may exist, many of\\nthese people never develop significant problems.\\nHowever, about 50% of people over age 50 experience\\nneck pain and stiffness due to cervical spondylosis. Of\\nthese people, 25–40% have at least one episode of cervical\\nradiculopathy, a condition that arises when osteophytes\\ncompress nerves between the vertebrae. Another potential\\nproblem occurs if osteophytes, degenerating disks, or shift-\\ning vertebrae narrow the spinal canal. This pressure com-\\npresses the spinal cord and its blood vessels, causing cervi-\\ncal spondylitic myelopathy, a disorder in which large seg-\\nments of the spinal cord are damaged. This disorder affects\\nfewer than 5% of people with cervical spondylosis. Symp-\\ntoms of both cervical spondylitic myelopathy and cervical\\nradiculopathy may be present in some people.\\nCauses and symptoms\\nAs people age, shrinkage of the vertebral disks\\nprompts the vertebrae to form osteophytes to stabilize the\\nback bone. However, the position and alignment of the\\ndisks and vertebrae may shift despite the osteophytes.\\nSymptoms may arise from problems with one or more\\ndisks or vertebrae.\\nOsteophyte formation and other changes do not nec-\\nessarily lead to symptoms, but after age 50, half of the\\npopulation experiences occasional neck pain and stiff-\\nness. As disks degenerate, the cervical spine becomes\\nless stable, and the neck is more vulnerable to injuries,\\nincluding muscle and ligament strains. Contact between\\nthe edges of the vertebrae can also cause pain. In some\\npeople, this pain may be referred—that is, perceived as\\noccurring in the head, shoulders, or chest, rather than the\\nneck. Other symptoms may include vertigo (a type of\\ndizziness) or ringing in the ears.\\nThe neck pain and stiffness can be intermittent, as\\ncan symptoms of radiculopathy. Radiculopathy refers to\\ncompression on the base, or root, of nerves that lead\\naway from the spinal cord. Normally, these nerves fit\\ncomfortably through spaces between the vertebrae.\\nThese spaces are called intervertebral foramina. As the\\nosteophytes form, they can impinge on this area and\\ngradually make the fit between the vertebrae too snug.\\nThe poor fit increases the chances that a minor inci-\\ndent, such as overdoing normal activities, may place\\nexcess pressure on the nerve root, sometimes referred to\\nas a pinched nerve. Pressure may also accumulate as a\\ndirect consequence of osteophyte formation. The pres-\\nsure on the nerve root causes severe shooting pain in the\\nneck, arms, shoulder, and/or upper back, depending on\\nwhich nerve roots of the cervical spine are affected. The\\npain is often aggravated by movement, but in most cases,\\nsymptoms resolve within four-six weeks.\\nCervical spondylosis can cause cervical spondylitic\\nmyelopathy through stenosis- or osteophyte-related pres-\\nsure on the spinal cord. Spinal stenosis is a narrowing of\\nthe spinal canal—the area through the center of the verte-\\nbral column occupied by the spinal cord. Stenosis occurs\\nbecause of misaligned vertebrae and out-of-place or\\ndegenerating disks. The problems created by spondylosis\\ncan be exacerbated if a person has a naturally narrow\\nspinal canal. Pressure against the spinal cord can also be\\ncreated by osteophytes forming on the inner surface of\\nvertebrae and pushing against the spinal cord. Stenosis or\\nosteophytes can compress the spinal cord and its blood\\nvessels, impeding or choking off needed nutrients to the\\nspinal cord cells; in effect, the cells starve to death.\\nWith the death of these cells, the functions that they\\nonce performed are impaired. These functions may\\ninclude conveying sensory information to the brain or\\ntransmitting the brain’s commands to voluntary muscles.\\nPain is usually absent, but a person may experience leg\\nnumbness and an inability to make the legs move proper-\\nly. Other symptoms can include clumsiness and weakness\\nin the hands, stiffness and weakness in the legs, and spon-\\ntaneous twitches in the legs. A person’s ability to walk is\\naffected, and a wide-legged, shuffling gait is sometimes\\nadopted to compensate for the lack of sensation in the\\nlegs and the accompanying, realistic fear of falling. In\\nvery few cases, bladder control becomes a problem.\\nDiagnosis\\nCervical spondylosis is often suspected based on the\\nsymptoms and their history. Careful neurological exami-\\nnation can help determine which nerve roots are involved,\\nbased on the location of the pain and numbness, and the\\npattern of weakness and changes in reflex responses. To\\nconfirm the suspected diagnosis, and to rule out other\\npossibilities, imaging tests are ordered. The first test is an\\nx ray. X rays reveal the presence of osteophytes, stenosis,\\nGALE ENCYCLOPEDIA OF MEDICINE 2720\\nCervical spondylosis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 720'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 109, 'page_label': '110'}, page_content='constricted space between the vertebrae, and misalign-\\nment in the cervical spine—in short, an x ray confirms\\nthat a person has cervical spondylosis. To demonstrate\\nthat the condition is causing the symptoms, more details\\nare needed. Other imaging tests, such as magnetic reso-\\nnance imaging (MRI) and computed tomography myel-\\nography, help assess effects of cervical spondylosis on\\nassociated nerve tissue and blood vessels.\\nAn MRI may be preferred, because it is a noninva-\\nsive procedure and does not require injecting a contrast\\nmedium as does computed tomography myelography.\\nMRIs also have greater sensitivity for detecting disk\\nproblems and spinal cord involvement, and the test\\nallows the physician to create images of a larger area\\nfrom various angles. However, these images may not\\nshow enough detail about the vertebrae themselves. Com-\\nputed tomography myelography yields a superior image\\nof the bones involved in cervical spondylosis. Added ben-\\nKEY TERMS\\nAlexander technique —A technique developed by\\nFrederick Alexander that focuses on the variations\\nin body posture, muscles, and breathing. Defects in\\nthese functions can lead to stress, nervous tension\\nor possible loss of function.\\nBone spur—Also called an osteophyte, it is an out-\\ngrowth or ridge that forms on a bone.\\nCervical—Referring to structures within the neck.\\nComputed tomography myelography —This med-\\nical procedure combines aspects of computed\\ntomography scanning and plain-film myelography.\\nA CT scan is an imaging technique in which cross-\\nsectional x rays of the body are compiled to create a\\nthree-dimensional image of the body’s internal\\nstructures. Myelography involves injecting a water-\\nsoluble substance into the area around the spine to\\nmake it visible on x rays. In computed tomography\\nmyelography or CT myelography, the water-soluble\\nsubstance is injected, but the imaging is done with\\na CT scan.\\nDisk—A ringlike structure that fits between the ver-\\ntebrae in the spine to protect the bones, nerves, and\\nblood vessels. The outer layer is a tough, fibrous tis-\\nsue, and the inner core is composed of more elastic\\ntissue.\\nFeldenkrais method—A therapy based on creating a\\ngood self image by correction and improvements of\\nbody movements.\\nMagnetic resonance imaging (MRI) —An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\nMyelopathy—A disorder in which the tissue of the\\nspinal cord is diseased or damaged.\\nOrthosis—An external device, such as a splint or a\\nbrace, that prevents or assists movement.\\nOsteophyte—Also referred to as bone spur, it is an\\noutgrowth or ridge that forms on a bone.\\nRadiculopathy —Sometimes referred to as a\\npinched nerve, it refers to compression of the nerve\\nroot—the part of a nerve between vertebrae. This\\ncompression causes pain to be perceived in areas to\\nwhich the nerve leads.\\nSpine—A term for the backbone that includes the\\nvertebrae, disks, and spinal cord as a whole.\\nStenosis —A condition in which a canal or other\\npassageway in the body is constricted.\\nTraction—A medical treatment that exerts a pulling\\nor extending force. Used for cervical problems, it\\nrelieves pressure on structures between the verte-\\nbrae and muscular tension.\\nVertebrae—The ringlike component bones of the\\nspine.\\nefits include that it takes less time to perform and tends to\\nbe less expensive than an MRI. A good diagnosis may be\\nreached with either a computed tomography myelography\\nor an MRI, but sometimes complementary information\\nfrom both tests is necessary. Nerve conduction velocity,\\nelectromyogram (EMG), and/or somatosensory evoked\\npotential testing may help to confirm which nerve roots\\nare involved.\\nTreatment\\nWhen possible, conservative treatment of symptoms\\nis preferred. Conservative treatment begins with rest—\\neither restricting normal activities to a less strenuous\\nlevel or bed rest for three to five days. If rest is not ade-\\nquate to relieve symptoms, a cervical orthosis may be\\nprescribed., such as a soft cervical collar or stiffer neck\\nbrace to restrict neck movement and shift some of the\\nhead’s weight from the neck to the shoulders. Cervical\\nGALE ENCYCLOPEDIA OF MEDICINE 2 721\\nCervical spondylosis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 721'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 110, 'page_label': '111'}, page_content='traction may also be suggested, either at home with the\\nadvice of a physical therapist or in a health-care setting.\\nPain is treated with nonsteroidal anti-inflammato-\\nry drugs, such as aspirin or ibuprofen. If these drugs are\\nineffective, a short-term prescription for corticosteroids\\nor muscle relaxants may be given. For chronic pain, tri-\\ncyclic antidepressants can be prescribed. Although these\\ndrugs were developed to treat depression, they are also\\neffective in treating pain. Once any pain is resolved,\\nexercises to strengthen neck muscle and preserve flexi-\\nbility are prescribed.\\nIf the pain is severe, a short treatment of epidural\\ncorticosteroids may be prescribed with discretion. A cor-\\nticosteroid such as prednisone can be combined with an\\nanaesthetic and injected with a long needle into the space\\nbetween the damaged disk and the covering of the nerve\\nand spinal cord. Injection into the cervical epidural space\\nrelieves severe pain that is not managed with convention-\\nal treatment. Frequent use of this treatment is not med-\\nically recommended and is used only if the more conser-\\nvative therapy is not effective.\\nIf pain is continuous and does not respond to conser-\\nvative treatment, surgery may be suggested. Surgery is\\nusually not recommended for neck pain, but it may be\\nnecessary to address radiculopathy and myelopathy.\\nSurgery is particularly recommended for people who\\nhave already developed moderate to severe symptoms of\\nmyelopathy, although age or poor health may prohibit\\nthat recommendation. The specific details of the surgery\\ndepend on the structures involved, but the overall goal is\\nto relieve pressure on the nerve root, spinal cord, or\\nblood vessels and to stabilize the spine.\\nAlternative treatment\\nAlternative therapy is not meant to replace conven-\\ntional medical treatment, but it can be a useful adjunct. Its\\nmain roles are to relieve tension, manage pain, and\\nstrengthen neck and back muscles. Massage is one way to\\nrelieve tension, and yoga provides the additional benefit\\nof strengthening muscles. Chiropractic and acupunc-\\nture have been reported to relieve the pain associated\\nwith disk problems, although great care needs to be taken\\nto avoid exacerbating them. Practitioners of the Alexan-\\nder technique or the Feldenkrais method can provide\\ninstruction on correct posture and exercise that may help\\nprevent further symptoms. Vitamin and mineral supple-\\nmentation along with herbal therapies and homeopathy\\ncan help build and rebalance the weakened structure.\\nPrognosis\\nThe gradual progression of cervical spondylosis\\ncannot be stopped; however, it doesn’t always cause\\nsymptoms. For the individuals who do experience prob-\\nlems, conservative treatment is very effective in manag-\\ning the symptoms. Nearly all people with neck pain,\\napproximately 75% of persons with radiculopathy, and\\nup to 50% of people with myelopathy find relief through\\ntherapy alone. For the remaining people with radiculopa-\\nthy or myelopathy, surgery may be recommended.\\nSurgery is deemed successful in 70–80% of cases.\\nPrevention\\nSince cervical spondylosis is part of the normal\\naging process, not much can be done to prevent it. It may\\nbe possible to ward off some or all of the symptoms by\\nengaging in regular physical exercise and limiting occu-\\npational or recreational activities that place pressure on\\nthe head, neck, and shoulders. The best exercises for the\\nhealth of the cervical spine are noncontact activities,\\nsuch as swimming, walking, or yoga. Once symptoms\\nhave already developed, the emphasis is on symptom\\nmanagement rather than prevention.\\nResources\\nBOOKS\\nBorenstein, David G., Sam W. Wiesel, and Scott D. Boden.\\n“Mechanical Disorders of the Cervical Spine.” In Neck\\nPain: Medical Diagnosis and Comprehensive Manage-\\nment. Philadelphia: W. B. Saunders Co., 1996.\\nMacnab, Ian, and John McCulloch. Neck Ache and Shoulder\\nPain. Baltimore: Williams & Wilkins, 1994.\\nPERIODICALS\\nBohlman, Henry H. “Cervical Spondylosis and Myelopathy.”\\nInstructional Course Lectures 44 (1995): 81.\\nMcCormack, Bruce M., and Phillip R. Weinstein. “Cervical\\nSpondylosis: An Update.”Western Journal of Medicine\\n165 (July/Aug. 1996): 43.\\nNeuwirth, Michael, and Joseph Marsicano. “Cervical Spondy-\\nlosis: Diagnosis, Symptomatology, and Treatment.”\\nOrthopaedic Nursing 15, no. 1 (1996): 31.\\nJulia Barrett\\nCervicitis\\nDefinition\\nCervicitis is an inflammation of the cervix.\\nDescription\\nCervicitis is a inflammation of the cervix (the open-\\ning into the uterus). This inflammation can be chronic\\nand may or may not have an identified cause.\\nGALE ENCYCLOPEDIA OF MEDICINE 2722\\nCervicitis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 722'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 111, 'page_label': '112'}, page_content='Causes and symptoms\\nThe most common cause of cervicitis is infection,\\neither local or as a result of various sexually transmitted\\ndiseases , such as chlamydia or gonorrhea . Cervicitis\\ncan also be caused by birth control devices such as a cer-\\nvical cap or diaphragm, or chemical exposure. Other risk\\nfactors include multiple sexual partners or cervical trau-\\nma following birth. In postmenopausal women, cervicitis\\nis sometimes related to a lack of estrogen.\\nAlthough a woman may not notice any signs of\\ninfection, symptoms of cervicitis include the following:\\n• persistent unusual vaginal discharge\\n• abnormal bleeding, either between periods or following\\nsexual intercourse\\n• painful sexual intercourse\\n• vaginal pain\\n• frequent need to urinate\\n• burning or itching in the vaginal area\\nDiagnosis\\nThe standard method of diagnosing cervicitis is\\nthrough a pelvic examination or a Pap smear. During the\\npelvic exam , the physician usually swabs the affected\\narea, and then sends the tissue sample to a laboratory.\\nThe laboratory tries to identify the specific organism\\nresponsible for causing the cervicitis. A biopsy to take a\\nsample of tissue from the affected area is sometimes\\nrequired in order to rule out cancer. Colposcopy, a pro-\\ncedure used to look at the cervix under a microscope,\\nmay also be used to rule out cancer.\\nTreatment\\nThe first course of treatment for cervicitis is usually\\nantibiotics. If these medicines do not cure the cervicitis,\\nother treatment options include:\\n• Loop Electrosurgical Excision Procedure (LEEP)\\n• cryotherapy\\nKEY TERMS\\nCryotherapy—Freezing the affected tissue.\\nElectrocoagulation —Using electrical current to\\ncauterize the affected tissue.\\nLEEP—Loop Electrosurgical Excision Procedure.\\n• electrocoagulation\\n• laser treatment\\nPrognosis\\nCervicitis will usually be cured when the course of\\ntherapy is complete. Severe cases, however, may last for\\na few months, even after the therapy is complete. If the\\ncervicitis was caused by a sexually transmitted disease,\\nboth partners should be treated with medication.\\nPrevention\\nPracticing safe sexual behavior, such as monogamy,\\nis one way of lowering the prevalence of cervicitis. In\\naddition, women who began sexual activity at a later age\\nhave been shown to have a lower incidence of cervicitis.\\nAnother recommendation is to use a latex condom con-\\nsistently during intercourse. If the cervicitis is caused by\\nany sexually transmitted disease, the patient is advised to\\nnotify all sexual partners.\\nResources\\nBOOKS\\nBerkow, Robert. The Merck Manual of Medical Information.\\nWhitehouse Station: Merck Research Laboratories, 1997.\\nDambro, Mark R. The 5-Minute Clinical Consult. Baltimore:\\nWilliams and Wilkins, 2001.\\nLarson, David E. Mayo Clinic Family Health Book.New York:\\nWilliam Morrow and Company, 1996.\\nMandell, Gerald L. Mandell, Douglas, and Bennet’s Principles\\nand Practice of Infectious Diseases. Philadelphia:\\nChurchill Livingstone, 2000.\\nTierney, Lawrence, et. al. Current Medical Diagnosis and\\nTreatment. Los Altos: Lange Medical Publications, 2001.\\nPERIODICALS\\nMalik, S. N., et. al. “Benign Cellular Changes in Pap Smears.\\nCauses and Significance.”Acta Cytologica (Jan-Feb\\n2001): 5-8.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th Street, SW P.O. Box 96920, Washington, DC 20090-\\n6920. (202) 863-2518. .\\nKim Sharp, M.Ln.\\nCesarean section\\nDefinition\\nA cesarean section is a surgical procedure in which\\nincisions are made through a woman’s abdomen and\\nuterus to deliver her baby.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 723\\nCesarean section\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 723'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 112, 'page_label': '113'}, page_content='Purpose\\nCesarean sections, also called c-sections, are per-\\nformed whenever abnormal conditions complicate labor\\nand vaginal delivery, threatening the life or health of the\\nmother or the baby. The procedure is performed in the\\nUnited States on nearly one of every four babies deliv-\\nered—more than 900,000 babies each year. The proce-\\ndure is often used in cases where the mother has had a\\nprevious c-section. Dystocia, or difficult labor, is the\\nother common cause of c-sections.\\nDifficult labor is commonly caused by one of the\\nthree following conditions: abnormalities in the mother’s\\nbirth canal; abnormalities in the position of the fetus; or\\nabnormalities in the labor, including weak or infrequent\\ncontractions.\\nAnother major factor is fetal distress, a condition\\nwhere the fetus is not getting enough oxygen. Fetal brain\\ndamage can result from oxygen deprivation. Fetal dis-\\ntress is often related to abnormalities in the position of\\nthe fetus or abnormalities in the birth canal, causing\\nreduced blood flow through the placenta. Other condi-\\ntions also can make c-section advisable, such as vaginal\\nherpes, hypertension, and diabetes in the mother.\\nPrecautions\\nThere are several ways that obstetricians and other\\ndoctors diagnose conditions that may make a c-section\\nnecessary. Ultrasound testing reveals the positions of the\\nbaby and the placenta and may be used to estimate the\\nbaby’s size and gestational age. Fetal heart monitors, in\\nuse since the 1970s, transmit any signals of fetal distress.\\nOxygen deprivation may be determined by checking the\\namniotic fluid for meconium (feces)—a lack of oxygen\\ncauses an unborn baby to defecate. Oxygen deprivation\\nmay also be determined by testing the pH of a blood\\nsample taken from the baby’s scalp; a pH of 7.25 or high-\\ner is normal, between 7.2 and 7.25 is suspicious, and\\nbelow 7.2 is a sign of trouble.\\nWhen a c-section is being considered because labor\\nis not progressing, the mother should first be encouraged\\nto walk around to stimulate labor. Labor may also be\\nstimulated with the drug oxytocin.\\nWhen a c-section is being considered because the\\nbaby is in a breech position, the doctor may first attempt\\nto reposition the baby; this is called external cephalic\\nversion. The doctor may also try a vaginal breech deliv-\\nery, depending on the size of the mother’s pelvis, the size\\nGALE ENCYCLOPEDIA OF MEDICINE 2724\\nCesarean section\\nThis baby is being delivered by cesarean section.(Photograph by John Smith, Custom Medical Stock Photo.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 724'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 113, 'page_label': '114'}, page_content='of the baby, and the type of breech position the baby is\\nin. However, a c-section is safer than a vaginal delivery\\nwhen the baby is 8 lb (3.6 kg) or larger, in a breech posi-\\ntion with the feet crossed, or in a breech position with the\\nhead hyperextended.\\nA woman should receive regular prenatal care and\\nbe able to alert her doctor to the first signs of trouble.\\nOnce labor begins, she should be encouraged to move\\naround and to urinate. The doctor should be conservative\\nin diagnosing dystocia (nonprogressive labor) and fetal\\ndistress, taking a position of “watchful waiting” before\\ndeciding to operate.\\nDescription\\nThe most common reason that a cesarean section is\\nperformed (in 35% of all cases, according to the United\\nStates Public Health Service) is that the woman has had a\\nprevious c-section. The “once a cesarean, always a cesare-\\nan” rule originated when the classical uterine incision was\\nmade vertically; the resulting scar was weak and had a risk\\nof rupturing in subsequent deliveries. Today, the incision is\\nalmost always made horizontally across the lower end of\\nthe uterus (this is called a “low transverse incision”),\\nresulting in reduced blood loss and a decreased chance of\\nrupture. This kind of incision allows many women to have\\na vaginal birth after a cesarean (VBAC).\\nThe second most common reason that a c-section is\\nperformed (in 30% of all cases) is difficult childbirth\\ndue to nonprogressive labor (dystocia). Uterine contrac-\\nKEY TERMS\\nBreech presentation —The condition in which the\\nbaby enters the birth canal with its buttocks or feet\\nfirst.\\nCephalopelvic disproportion (CPD) —The condi-\\ntion in which the baby’s head is too large to fit\\nthrough the mother’s pelvis.\\nClassical incision—In a cesarean section, an incision\\nmade vertically along the uterus; this kind of incision\\nmakes a larger opening but also creates more bleed-\\ning, a greater chance of infection, and a weaker scar.\\nDystocia —Failure to progress in labor, either\\nbecause the cervix will not dilate (expand) further\\nor (after full dilation) the head does not descend\\nthrough the mother’s pelvis.\\nLow transverse incision—Incision made horizontal-\\nly across the lower end of the uterus; this kind of\\nincision is preferred for less bleeding and stronger\\nhealing.\\nPlacenta previa —The placenta totally or partially\\ncovers the cervix, preventing vaginal delivery.\\nPlacental abruption —Separation of the placenta\\nfrom the uterine wall before the baby is born, cut-\\nting off blood flow to the baby.\\nProlapsed cord—The umbilical cord is pushed into\\nthe vagina ahead of the baby and becomes com-\\npressed, cutting off blood flow to the baby.\\nRespiratory distress syndrome (RDS) —Difficulty\\nbreathing, found in infants with immature lungs.\\nTransverse presentation —The baby is laying side-\\nways across the cervix instead of head first.\\nVBAC—Vaginal birth after cesarean.\\ntions may be weak or irregular, the cervix may not be\\ndilating, or the mother’s pelvic structure may not allow\\nadequate passage for birth. When the baby’s head is too\\nlarge to fit through the pelvis, the condition is called\\ncephalopelvic disproportion (CPD).\\nAnother 12% of c-sections are performed to deliver\\na baby in a breech presentation: buttocks or feet first.\\nBreech presentation is found in about 3% of all births.\\nIn 9% of all cases, c-sections are performed in\\nresponse to fetal distress. Fetal distress refers to any situ-\\nation that threatens the baby, such as the umbilical cord\\ngetting wrapped around the baby’s neck. This may\\nappear on the fetal heart monitor as an abnormal heart\\nrate or rhythm.\\nThe remaining 14% of c-sections are indicated by\\nother serious factors. One is prolapse of the umbilical\\ncord: the cord is pushed into the vagina ahead of the baby\\nand becomes compressed, cutting off blood flow to the\\nbaby. Another is placental abruption: the placenta sepa-\\nrates from the uterine wall before the baby is born, cut-\\nting off blood flow to the baby. The risk of this is espe-\\ncially high in multiple births (twins, triplets, or more). A\\nthird factor is placenta previa : the placenta covers the\\ncervix partially or completely, making vaginal delivery\\nimpossible. In some cases requiring c-section, the baby is\\nin a transverse position, lying horizontally across the\\npelvis, perhaps with a shoulder in the birth canal.\\nThe mother’s health may make delivery by c-section\\nthe safer choice, especially in cases of maternal diabetes,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 725\\nCesarean section\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 725'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 114, 'page_label': '115'}, page_content='hypertension, genital herpes, Rh blood incompatibility,\\nand preeclampsia (high blood pressure related to preg-\\nnancy).\\nPreparation\\nWhen a c-section becomes necessary, the mother is\\nprepped for surgery. A catheter is inserted into her blad-\\nder and an intravenous (IV) line is inserted into her arm.\\nLeads for monitoring the mother’s heart rate, rhythm,\\nand blood pressure are attached. In the operating room,\\nthe mother is given anesthesia—usually a regional anes-\\nthetic (epidural or spinal), making her numb from below\\nher breasts to her toes. In some cases, a general anesthet-\\nic will be administered. Surgical drapes are placed over\\nthe body, except the head; these drapes block the direct\\nview of the procedure.\\nThe abdomen is washed with an anti-bacterial solu-\\ntion and a portion of the pubic hair may be shaved. The\\nfirst incision opens the abdomen. Infrequently, it will be\\nvertical from just below the navel to the top of the pubic\\nbone, or more commonly, it will be a horizontal incision\\nacross and above the pubic bone (informally called a\\n“bikini cut”).\\nThe second incision opens the uterus. In most cases\\na transverse incision is made. This is the favored type\\nbecause it heals well and makes it possible for a woman\\nto attempt a vaginal delivery in the future. The classical\\nincision is vertical. Because it provides a larger opening\\nthan a low transverse incision, it is used in the most criti-\\ncal situations, such as placenta previa. However, the clas-\\nsical incision causes more bleeding, a greater risk of\\nabdominal infection, and a weaker scar, so the low trans-\\nverse incision is preferred.\\nOnce the uterus is opened, the amniotic sac is rup-\\ntured and the baby is delivered. The time from the initial\\nincision to birth is typically five minutes.\\nOnce the umbilical cord is clamped and cut, the new-\\nborn is evaluated. The placenta is removed from the\\nmother, and her uterus and abdomen are stitched closed\\n(surgical staples may be used instead in closing the outer-\\nmost layer of the abdominal incision). From birth through\\nsuturing may take 30–40 minutes. Thus the entire surgical\\nprocedure may be performed in less than one hour.\\nAftercare\\nA woman who undergoes a c-section requires both\\nthe care given to any new mother and the care given to\\nany patient recovering from major surgery. She should be\\noffered pain medication that does not interfere with\\nbreastfeeding. She should be encouraged to get out of bed\\nand walk around eight to 24 hours after surgery to stimu-\\nlate circulation (thus avoiding the formation of blood\\nclots) and bowel movement. She should limit climbing\\nstairs to once a day, and avoid lifting anything heavier\\nthan the baby. She should nap as often as the baby sleeps,\\nand arrange for help with the housework, meals, and care\\nof other children. She may resume driving after two\\nweeks, although some doctors recommend waiting for six\\nweeks, the typical recovery period from major surgery.\\nRisks\\nBecause a c-section is a surgical procedure, it carries\\nmore risk to both the mother and the baby. The maternal\\ndeath rate is less than 0.02%, but that is four times the\\nmaternal death rate associated with vaginal delivery.\\nHowever, many women have a c-section for serious med-\\nical problems. The mother is at risk for increased bleeding\\n(because a c-section may result in twice the blood loss of\\na vaginal delivery) from the two incisions, the placental\\nattachment site, and possible damage to a uterine artery.\\nComplications occur in less than 10% of cases. The moth-\\ner may develop infection of either incision, the urinary\\ntract, or the tissue lining the uterus (endometritis). Less\\ncommonly, she may receive injury to the surrounding\\norgans, like the bladder and bowel. When a general anes-\\nthesia is used, she may experience complications from the\\nanesthesia. Very rarely, she may develop a wound\\nhematoma at the site of either incision or other blood clots\\nleading to pelvic thrombophlebitis (inflammation of the\\nmajor vein running from the pelvis into the leg) or a pul-\\nmonary embolus (a blood clot lodging in the lung).\\nNormal results\\nThe after-effects of a c-section vary, depending on\\nthe woman’s age, physical fitness, and overall health.\\nFollowing this procedure, a woman commonly experi-\\nences gas pains, incision pain, and uterine contractions—\\nwhich are also common in vaginal delivery. Her hospital\\nstay may be two to four days. Breastfeeding the baby is\\nencouraged, taking care that it is in a position that keeps\\nthe baby from resting on the mother’s incision. As the\\nwoman heals, she may gradually increase appropriate\\nexercises to regain abdominal tone. Full recovery may be\\nseen in four to six weeks.\\nThe prognosis for a successful vaginal birth after a\\ncesarean (VBAC) may be at least 75%, especially when the\\nc-section involved a low transverse incision in the uterus\\nand there were no complications during or after delivery.\\nAbnormal results\\nOf the hundreds of thousands of women in the Unit-\\ned States who undergo a c-section each year, about 500\\nGALE ENCYCLOPEDIA OF MEDICINE 2726\\nCesarean section\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 726'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 115, 'page_label': '116'}, page_content='die from serious infections, hemorrhaging, or other com-\\nplications. These deaths may be related to the health con-\\nditions that made the operation necessary, and not simply\\nto the operation itself.\\nUndergoing a c-section may also inflict psychologi-\\ncal distress on the mother, beyond hormonal mood\\nswings and postpartum depression (“baby blues”). The\\nwoman may feel disappointment and a sense of failure\\nfor not experiencing a vaginal delivery. She may feel iso-\\nlated if the father or birthing coach is not with her in the\\noperating room, or if she is treated by an unfamiliar doc-\\ntor rather than by her own doctor or midwife. She may\\nfeel helpless from a loss of control over labor and deliv-\\nery with no opportunity to actively participate. To over-\\ncome these feelings, the woman must understand why\\nthe c-section was necessary. She must accept that she\\ncouldn’t control the unforeseen events that made the c-\\nsection the optimum means of delivery, and recognize\\nthat preserving the health and safety of both her and her\\nchild was more important than her delivering vaginally.\\nWomen who undergo a c-section should be encouraged\\nto share their feelings with others. Hospitals can often\\nrecommend support groups for such mothers. Women\\nshould also be encouraged to seek professional help if\\nnegative emotions persist.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Family Physicians. 8880 Ward Parkway,\\nKansas City, MO 64114. (816) 333-9700. .\\nChildbirth.Org. .\\nInternational Cesarean Awareness Network. 1304 Kingsdale\\nAve., Redondo Beach, CA 90278. (310) 542-6400.\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nNational Institute of Child Health and Human Development.\\nBldg 31, Room 2A32, MSC 2425, 31 Center Drive,\\nBethesda, MD 20892-2425. (800) 505-2742. .\\nUnited States Department of Health and Human Services. 200\\nIndependence Avenue SW, Washington DC 20201. (202)\\n619-0257. .\\nOTHER\\n“Cesarean Childbirth.”Perspectives: A Mental Health Maga-\\nzine. .\\n“The Cesarean Section FAQ.”Childbirth.org. 18 July 1998\\n.\\nBethany Thivierge\\nCestodiasis see Tapeworm diseases\\nCFS see Chronic fatigue syndrome\\nCGD see Chronic granulomatous disease\\nChagas’ disease\\nDefinition\\nChagas’ disease is named after Dr. Carlos Chagas\\nwho first found the organism in the early 1900s. It\\ninvolves damage to the nerves that control the heart,\\ndigestive and other organs, and eventually leads to dam-\\nage to these organs. Worldwide, Chagas’ disease affects\\nover 15 million persons, and kills 50,000 each year.\\nResearchers believe that the parasite that causes the dis-\\nease is only found in the Americas.\\nDescription\\nWhen a person is infected with Chagas’ disease, the\\nparasite known as Trypanosoma cruzi first causes a mild,\\nshort-lived period of “acute” illness; then after a long\\nperiod without symptoms, the effects of the infection\\nbegin to appear. The heart, esophagus, and colon are\\nmost frequently involved. These organs become unable\\nto contract properly, and begin to stretch or dilate.\\nCauses and symptoms\\nT. cruzi is carried by insects or bugs known as redu-\\nviid or “kissing bugs.” These insects are very common in\\nCentral and South America where they inhabit poorly\\nconstructed houses and huts. The insects deposit their\\nwaste material, exposing inhabitants to the parasites. The\\nparasites then enter the body by way of a cut or via the\\neyes or mouth. T. cruzi can also be transmitted by blood\\ntransfusion . Eating uncooked, contaminated food or\\nbreastfeeding can also transmit the disease. The reduvi-\\nids, in turn, become infected with the parasite by biting\\ninfected animals and humans.\\nThere are three phases related to infection:\\n• Acute phase lasts about two months, with non-specific\\nsymptoms of low grade fever, headache, fatigue, and\\nenlarged liver or spleen.\\n• Indeterminate phase lasts 10–20 years, during which\\ntime no symptoms occur, but the parasites are repro-\\nducing in various organs.\\n• Chronic phase is the stage when symptoms related to\\ndamage of major organs (heart, esophagus, colon) begin.\\nIn the chronic phase, irregularities of heart rhythm,\\nheart failure, and blood clots cause weakness, fainting,\\nand even sudden death.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 727\\nChagas’ disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 727'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 116, 'page_label': '117'}, page_content='Esophageal symptoms are related to difficulty with\\nswallowing and chest pain. Because the esophagus does\\nnot empty properly, food regurgitates into the lungs caus-\\ning cough, bronchitis , and repeated bouts of pneumo-\\nnia. Inability to eat, weight loss, and malnutrition\\nbecome a significant factor in affecting survival.\\nInvolvement of the large intestine (colon) causes\\nconstipation, distention, and abdominal pain.\\nDiagnosis\\nThe best way to diagnose acute infection is to identi-\\nfy the parasites in tissue or blood. Occasionally it is pos-\\nsible to culture the organism from infected tissue, but this\\nprocess usually requires too much time to be of value. In\\nthe chronic phase, antibody levels can be measured.\\nEfforts to develop new, more accurate tests are ongoing.\\nTreatment\\nIn most cases treatment of symptoms is all that is\\npossible. Present medications can reduce the duration\\nand severity of an acute infection, but are only 50%\\neffective, at best, in eliminating the organisms.\\nCardiac effects are managed with pacemakers and\\nmedications. Esophageal complications require either\\nendoscopic or surgical methods to improve esophageal\\nemptying, similar to those used to treat the disorder\\nknown as achalasia . Constipation is treated by increas-\\ning fiber and bulk laxatives, or removal of diseased por-\\ntions of the colon.\\nKEY TERMS\\nAchalasia —An esophageal disease of unknown\\ncause, in which the lower sphincter or muscle is\\nunable to relax normally, and leads to the accu-\\nmulation of material within the esophagus.\\nEndoscopy —Exam using an endoscope (a thin\\nflexible tube which uses a lens or miniature cam-\\nera to view various areas of the gastrointestinal\\ntract). When the procedure is performed to exam-\\nine certain organs such as the bile ducts or pan-\\ncreas, the organs are not viewed directly, but\\nrather indirectly through the injection of x ray.\\nParasite—An organism that lives on or in another\\nand takes nourishment (food and fluids) from that\\norganism.\\nRegurgitation —Flow of material back up the\\nesophagus and into the throat or lungs.\\nPrognosis\\nThose patients with gastrointestinal complications\\noften respond to some form of treatment. Cardiac prob-\\nlems are more difficult to treat, particularly since trans-\\nplant would rekindle infection.\\nPrevention\\nVisitors traveling to areas of known infection should\\navoid staying in mud, adobe, or similar huts. Mosquito\\nnets and insect repellents are useful in helping to avoid\\ncontact with the bugs. Blood screening is not always\\neffective in many regions where infection is common. It\\nis necessary to carefully screen people who have emi-\\ngrated from Central and South America before they make\\nblood donations.\\nResources\\nBOOKS\\nKirchoff, Louis V . “Trypanosomiasis.” In Harrison’s Principles\\nof Internal Medicine, ed. Anthony S. Fauci, et al. New\\nYork: McGraw-Hill, 1997.\\nOwen, Robert L. “American Trypanosomiasis (Chagas’ Dis-\\nease).” In Sleisenger & Fordtran’s Gastrointestinal and\\nLiver Disease, ed. Mark Feldman, et al. Philadelphia: W.\\nB. Saunders Co., 1997.\\nPERIODICALS\\nKirchoff, Louis V . “American Trypanosomiasis (Chagas’ Dis-\\nease).” Gastroenterology Clinics of North America(Sept.\\n1996): 517-533.\\nKirchoff, Louis V . “Current Concepts: American Trypanosomi-\\nasis (Chagas’ Disease)-A Tropical Disease Now in the\\nUnited States.” New England Journal of Medicine 329,\\nno. 9 (1993): 639.\\nOTHER\\nCenters for Disease Control. .\\nDavid Kaminstein, MD\\nChalazion see Eyelid disorders\\nChancroid\\nDefinition\\nChancroid is a sexually transmitted disease caused\\nby a bacterial infection that is characterized by painful\\nsores on the genitals.\\nGALE ENCYCLOPEDIA OF MEDICINE 2728\\nChancroid\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 728'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 117, 'page_label': '118'}, page_content='Description\\nChancroid is an infection of the genitals that is\\ncaused by the bacterium Haemophilus ducreyi . Chan-\\ncroid is a sexually transmitted disease, which means that\\nit is spread from person to person almost always by sexu-\\nal contact. However, there have been a few cases in\\nwhich healthcare providers have become infected\\nthrough contact with infected patients.\\nCommon locations for chancroid sores (ulcers) in\\nmen are the shaft or head of the penis, foreskin, the\\ngroove behind the head of the penis, the opening of the\\npenis, and the scrotum. In women, common locations are\\nthe labia majora (outer lips), labia minora (inner lips),\\nperianal area (area around the anal opening), and inner\\nthighs. It is rare for the ulcer(s) to be on the vaginal walls\\nor cervix. In about 50% of the patients with chancroid,\\nthe infection spreads to either or both of the lymph nodes\\nin the groin.\\nChancroid is most commonly found in developing\\nand third world countries. In the United States, the most\\ncommon cause of genital ulcers is genital herpes , fol-\\nlowed by syphilis, and then chancroid. As of 1997, there\\nwere fewer than 1,500 cases of chancroid in the United\\nStates per year and it occurred primarily in African\\nAmericans, Hispanic Americans, and Native Americans.\\nThere are occasional localized outbreaks of chancroid in\\nthe United States. In addition, the practice of exchanging\\nsex for drugs has lead to a link between crack cocaine\\nuse and chancroid.\\nEven though the incidence of chancroid in the United\\nStates decreased in the 1990s, there is an alarming con-\\nnection between chancroid and human immunodeficien-\\ncy virus (HIV) infection. HIV causes AIDS (acquired\\nimmunodeficiency syndrome) and is easily spread from\\nperson to person through chancroid ulcers. Uncircum-\\ncised men with chancroid ulcers have a 48% risk of\\nacquiring HIV from sexual contact. Women with chan-\\ncroid ulcers are also at a greater risk of being infected\\nwith HIV during sexual contact. Genital ulcers seem to\\nact as doorways for HIV to enter and exit.\\nCauses and symptoms\\nHaemophilus ducreyi is spread from person to per-\\nson by vaginal, anal, and oral sexual contact. Uncircum-\\ncised men are about three times more likely than circum-\\ncised men to become infected following exposure to\\nHaemophilus ducreyi. Having unprotected sex, exchang-\\ning sex for drugs, and having unprotected sex with a\\nprostitute are other risk factors. Many cases of chancroid\\nin the United States occur in persons who had traveled to\\ncountries where the disease is more common.\\nChancroid occurs when Haemophilus ducreyi pene-\\ntrates the skin through an injury, like a scratch or cut.\\nOnce past the skin surface, the warmth, moisture, and\\nnutrients allow bacteria to grow rapidly. The first sign of\\nchancroid is a small, red papule that occurs within three\\nto seven days following exposure to the bacteria, but may\\ntake up to one month. Usually within one day, the papule\\nbecomes an ulcer. The chancroid ulcer is painful, bleeds\\neasily, drains a grey or yellowish pus, and has sharply\\ndefined, ragged edges. They can vary in size from an\\neighth of an inch to two inches in diameter. Men usually\\nhave only one ulcer, but women often have four or more.\\nSometimes “kissing” ulcers occur when one ulcer\\nspreads the bacterial infection to an opposite skin sur-\\nface. For example, kissing ulcers can form on the lips of\\nthe labia majora. Alternatively, women may not have any\\nexternal sores but may experience painful urination,\\nintercourse, and/or bowel movements and may have a\\nvaginal discharge or rectal bleeding.\\nSigns that the infection has spread to the lymph node\\nappear about one week after the formation of the genital\\nulcer. Lymph nodes are small organs in the lymphatic\\nsystem that filter waste materials from nearly every\\norgan in the body. This lymph node infection is called\\n“lymphadenitis” and the swollen, painful lymph node is\\ncalled a “bubo.” The bubo, which appears as a red, spher-\\nical lump, may burst through the skin, releasing a thick\\npus and forming another ulcer.\\nDiagnosis\\nChancroid may be diagnosed and treated by urolo-\\ngists (urinary tract doctors for men), gynecologists (for\\nwomen), and infectious disease specialists. Part of the\\ndiagnosis of chancroid involves ruling out genital herpes\\nand syphilis because genital ulcers are also symptoms of\\nthese diseases. The appearance of these three diseases\\nGALE ENCYCLOPEDIA OF MEDICINE 2 729\\nChancroid\\nA close-up view of a chancroid specimen.(Custom Medical\\nStock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 729'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 118, 'page_label': '119'}, page_content='can be close enough to be confusing. However, the pres-\\nence of a pus-filled lump in the groin of a patient with a\\ngenital ulcer is highly specific for chancroid.\\nFor a clear-cut diagnosis of chancroid, Haemophilus\\nducreyi must be isolated from the ulcer. To do this, a ster-\\nile cotton swab is wiped over the ulcer to obtain a pus\\nsample. In the laboratory, the sample is put into special\\nmedia and placed in an incubator. Haemophilus ducreyi\\ntakes from two to five days to grow in the laboratory. In\\naddition, the pus may be examined under the microscope\\nto see which bacteria are in the ulcer. A sample of the pus\\nmay also be tested to see if the herpes virus is present. A\\nblood sample will probably be taken from the patient’s\\narm to test for the presence of antibodies to the bacteria\\nthat causes syphilis.\\nTreatment\\nThe only treatment for chancroid is antibiotics given\\neither once or for several days. Antibiotics taken by mouth\\nfor one to two weeks include erythromycin (E-Mycin,\\nEry-Tab), amoxicillin plus clavulanic acid (Augmentin),\\nco-trimoxazole (Bactrim, Septra), or ciprofloxacin\\n(Cipro). Antibiotics given in one dose include ceftriaxone\\n(Rocephin), spectinomycin (Trobicin), co-trimoxazole, or\\nofloxacin (Floxin).\\nThe ulcer(s) may be cleaned and soaked to reduce\\nthe swelling. Salt solution dressings may be applied to\\nthe ulcer(s) to reduce the spread of the bacteria and pre-\\nvent additional ulcers. A serious infection of the foreskin\\nmay require circumcision . Pus would be removed from\\ninfected lymph nodes by using a needle and syringe.\\nVery large buboes may require surgical drainage.\\nPrognosis\\nWithout treatment, chancroid may either go away\\nquickly or patients may experience the painful ulcers for\\nmany months. A complete cure is obtained with antibiotic\\ntreatment. Severe ulcers may cause permanent scars.\\nSevere scarring of the foreskin may require circumcision.\\nUrethral fistulas (abnormal passageways from the urine\\ntube to the skin) may occur and requires corrective surgery.\\nKEY TERMS\\nBubo—A tender, swollen lymph node in the groin\\nthat may follow a chancroid ulcer.\\nGroin—The region of the body that lies between\\nthe abdomen and the thighs.\\nPrevention\\nThe best prevention for chancroid is to use a con-\\ndom during sexual intercourse. Chancroid can also be\\nprevented by abstinence (avoidance of any sexual con-\\ntact) and by being in a monogamous relationship with a\\ndisease-free partner. To prevent the spread of chancroid,\\nit is important that all sexual contacts of the patient are\\nidentified and treated.\\nResources\\nBOOKS\\n“Chancroid.” In The Skin and Infection: A Color Atlas and\\nText, ed. Charles V . Sanders and Lee T. Nesbitt Jr. Balti-\\nmore: Williams and Wilkins, 1995.\\nRonald, Allan Ross, and Michelle J. Alfa. “Chancroid, Lym-\\nphogranuloma Venerum, and Granuloma Inguinale.” In\\nInfectious Diseases. 2nd ed. Ed. Sherwood L. Gorbach, et\\nal. Philadelphia: W. B. Saunders Co., 1998.\\nPERIODICALS\\nDiCarlo, Richard P., and David H. Martin. “The Clinical Diag-\\nnosis of Genital Ulcer Disease in Men.”Clinical Infec-\\ntious Diseases 25 (Aug. 1997): 292-8.\\nORGANIZATIONS\\nPlanned Parenthood Federation of America, Inc. 810 Seventh\\nAve., New York, NY , 10019. (800) 669-0156. .\\nOTHER\\nMayo Clinic Online.5 Mar. 1998 .\\nBelinda Rowland, PhD\\nChange of life see Menopause\\nCharacter disorders see Personality\\ndisorders\\nCharcoal, activated\\nDefinition\\nActivated charcoal is a fine, black, odorless, and\\ntasteless powder. It is made from wood or other materials\\nthat have been exposed to very high temperatures in an\\nairless environment. It is then treated, or activated, to\\nincrease its ability to adsorb by reheating with oxidizing\\ngas or other chemicals to break it into a very fine powder.\\nActivated charcoal is pure carbon specially processed to\\nmake it highly adsorbent of particles and gases in the\\nbody’s digestive system.\\nActivated charcoal has often been used since ancient\\ntimes to cure a variety of ailments including poisoning.\\nGALE ENCYCLOPEDIA OF MEDICINE 2730\\nCharcoal, activated\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 730'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 119, 'page_label': '120'}, page_content='Its healing effects have been well documented since as\\nearly as 1550 B.C. by the Egyptians. However, charcoal\\nwas almost forgotten until 15 years ago when it was\\nrediscovered as a wonderful oral agent to treat most over-\\ndoses and toxins.\\nDescription\\nActivated charcoal’s most important use is for treat-\\nment of poisoning. It helps prevent the absorption of\\nmost poisons or drugs by the stomach and intestines. In\\naddition to being used for most swallowed poisons in\\nhumans, charcoal has been effectively used in dogs, rab-\\nbits, rats, and other animals, as well. It can also adsorb\\ngas in the bowels and has been used for the treatment of\\ngas or diarrhea. Charcoal’s other uses such as treatment\\nof viruses, bacteria, bacterial toxic byproducts, snake\\nvenoms and other substances by adsorption have not\\nbeen supported by clinical studies. By adding water to\\nthe powder to make a paste, activated charcoal can be\\nused as an external application to alleviate pain and itch-\\ning from bites and stings.\\nPoisons and drug overdoses\\nIt is estimated that one million children accidentally\\noverdose on drugs mistaken as candies or eat, drink, or\\ninhale poisonous household products each year. Infants\\nand toddlers are at the greatest risk for accidental poison-\\ning. Activated charcoal is one of the agents most com-\\nmonly used for these cases. It can absorb large amounts of\\npoisons quickly. In addition, it is non-toxic, may be stored\\nfor a long time, and can be conveniently administered at\\nhome. Charcoal works by binding to irritating or toxic\\nsubstances in the stomach and intestines. This prevents\\nthe toxic drug or chemical from spreading throughout the\\nbody. The activated charcoal with the toxic substance\\nbound to it is then excreted in the stool without harm to\\nthe body. When poisoning is suspected the local poison\\ncontrol center should be contacted for instructions. They\\nmay recommend using activated charcoal, which should\\nbe available at home so that it can be given to the poi-\\nsoned child or pet immediately. For severe poisoning,\\nseveral doses of activated charcoal may be needed.\\nIntestinal disorders\\nIn the past, activated charcoal was a popular remedy\\nfor gas. Even before the discovery of America by Euro-\\npeans, Native Americans used powdered charcoal mixed\\nwith water to treat an upset stomach. Now charcoal is\\nbeing rediscovered as an alternative treatment for this con-\\ndition. Activated charcoal works like a sponge. Its huge\\nsurface area is ideal for soaking up different substances,\\nincluding gas. In one study, people taking activated char-\\nKEY TERMS\\nAntidote —A remedy to counteract a poison or\\ninjury.\\nAdsorption—The binding of a chemical (e.g., drug\\nor poison) to a solid material such as activated\\ncharcoal or clay.\\ncoal after eating a meal with high gas-producing foods did\\nnot produce more gas than those who did not have these\\nfoods. Charcoal has also been used to treat other intestinal\\ndisorders such as diarrhea, constipation, and cramps.\\nThere are few studies to support these uses and there are\\nalso concerns that frequent use of charcoal may decrease\\nabsorption of essential nutrients, especially in children.\\nOther uses\\nBesides being a general antidote for poisons or reme-\\ndy for gas, activated charcoal has been used to treat other\\nconditions as well. Based on its ability to adsorb or bind\\nto other substances, charcoal has been effectively used to\\nclean skin wounds and to adsorb waste materials from the\\ngastrointestinal tract. In addition, it has been used to\\nadsorb snake venoms, viruses, bacteria, and harmful\\nmaterials excreted by bacteria or fungi. However, because\\nof lack of scientific studies, these uses are not recom-\\nmended. Activated charcoal, when used together with\\nother remedies such as aloe vera, acidophilus, and psylli-\\num, helps to keep symptoms of ulcerative colitis under\\ncontrol. While charcoal shows some anti-aging activity in\\nrats, it is doubtful if it can do the same for humans.\\nRecommended dosage\\nFor poisoning\\nActivated charcoal is available without prescription.\\nHowever, in case of accidental poisoning or drug overdose\\nan emergency poison control center, hospital emergency\\nroom, or doctor’s office should be called for advice. In case\\nthat both syrup of ipecac and charcoal are recommended\\nfor treatment of the poison, ipecac should be given first.\\nCharcoal should not be given for at least 30 minutes after\\nipecac or until vomiting from ipecac stops. Activated char-\\ncoal is often mixed with a liquid before being swallowed or\\nput into the tube leading to the stomach. Activated charcoal\\nis available as 1.1 oz (33 ml) liquid bottles. It is also avail-\\nable in 0.5 oz (15 ml) container sizes and as slurry of char-\\ncoal pre-mixed in water or as a container in which water or\\nsoda pop is added. Keeping activated charcoal at home is a\\nGALE ENCYCLOPEDIA OF MEDICINE 2 731\\nCharcoal, activated\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 731'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 120, 'page_label': '121'}, page_content='good idea so that it can be taken immediately when needed\\nfor treatment of poisoning.\\nFor acute poisoning, the dosage is as follows:\\n• Infants (under 1 year of age): 1 g/kg.\\n• Children (1–12 years of age): 15–30 g or 1–2 g/kg with\\nat least 8 oz of water.\\n• Adults: 30–100 g or 1–2 g/kg with at least 8 oz of water.\\nFor diarrhea or gas\\nA person can take charcoal tablets or capsules with\\nwater or sprinkle the content onto foods. The dosage for\\ntreatment of gas or diarrhea in adults is 520–975 mg after\\neach meal and up to 5 g per day.\\nPrecautions\\nParents should keep activated charcoal on hand in\\ncase of emergencies.\\nDo not give charcoal together with syrup of ipecac.\\nThe charcoal will adsorb the ipecac. Charcoal should be\\ntaken 30 minutes after ipecac or after the vomiting from\\nipecac stops.\\nSome activated charcoal products contain sorbitol.\\nSorbitol is a sweetener as well as a laxative, therefore, it\\nmay cause severe diarrhea and vomiting. These products\\nshould not be used in infants.\\nCharcoal may interfere with the absorption of med-\\nications and nutrients such as vitamins or minerals. For\\nuses other than for treatment of poisoning, charcoal\\nshould be taken two hours after other medications.\\nCharcoal should not be used to treat poisoning\\ncaused by corrosive products such as lye or other strong\\nacids or petroleum products such as gasoline, kerosene,\\nor cleaning fluids. Charcoal may make the condition\\nworse and delay diagnosis and treatment. In addition,\\ncharcoal is also not effective if the poison is lithium,\\ncyanide, iron, ethanol, or methanol.\\nParents should not mix charcoal with chocolate\\nsyrup, sherbet, or ice cream, even though it may make\\ncharcoal taste better. These foods may prevent charcoal\\nfrom working properly.\\nActivated charcoal may cause swelling or pain in the\\nstomach. A doctor should be notified immediately. It has\\nbeen known to cause problems in people with intestinal\\nbleeding, blockage or those people who have had recent\\nsurgery. These patients should talk to their doctor before\\nusing this product.\\nCharcoal may be less effective in people with slow\\ndigestion.\\nCharcoal should not be given for more than three or\\nfour days for treatment of diarrhea. Continuing for\\nlonger periods may interfere with normal nutrition.\\nCharcoal should not be used in children under three\\nyears of age to treat diarrhea or gas.\\nActivated charcoal should be kept out of reach of\\nchildren.\\nSide effects\\nCharcoal may cause constipation when taken for\\noverdose or accidental poisoning. A laxative should be\\ntaken after the crisis is over.\\nActivated charcoal may cause the stool to turn black.\\nThis is to be expected.\\nPain or swelling of the stomach may occur. A doctor\\nshould be consulted.\\nInteractions\\nActivated charcoal should not be mixed together\\nwith chocolate syrup, ice cream or sherbet. These foods\\nprevent charcoal from working properly.\\nResources\\nBOOKS\\nBlumenthal, Mark. “Linden Charcoal.”The Complete German\\nCommission E Monographs, Therapeutic Guide to Herbal\\nMedicines. American Botanical Council, Boston: Integra-\\ntive Medicine Communications, 1998. .\\nCooney, David. Activated Charcoal: Antidote, Remedy, and\\nHealth Aid. Brushton, NY: TEACH Services, Inc., 1999.\\nLacy Charles F., Lora L. Amstrong, Naomi B. Ingrim, and\\nLeonard L. Lance. “Charcoal.”The Drug Information\\nHandbook Pocket Version: 1998-1999. Hudson, OH: Lexi-\\nComp Inc., 1998.\\nRoberts. “Activated Charcoal.”Clinical Procedures in Emer-\\ngency Medicine. Philadelphia, PA: W. B. Saunders Com-\\npany, 1998: 726-8. .\\nWilson, Billie A., Margaret T. Shannon, and Carolyn L. Stang.\\n“Charcoal, Activated (Liquid Antidote).”Nurses Drug\\nGuide 2000. Stamford, CT: Appleton & Lange, 2000.\\nMai Tran\\nCharcot Marie Tooth disease\\nDefinition\\nCharcot Marie Tooth disease (CMT) is the name\\nof a group of inherited disorders of the nerves in the\\nperipheral nervous system (nerves throughout the body\\nGALE ENCYCLOPEDIA OF MEDICINE 2732\\nCharcot Marie Tooth disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 732'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 121, 'page_label': '122'}, page_content='that communicate motor and sensory information to and\\nfrom the spinal cord) causing weakness and loss of sen-\\nsation in the limbs.\\nDescription\\nCMT is named for the three neurologists who first\\ndescribed the condition in the late 1800s. It is also known\\nas hereditary motor and sensory neuropathy, and is some-\\ntimes called peroneal muscular atrophy, referring to the\\nmuscles in the leg that are often affected. The age of onset\\nof CMT can vary anywhere from young childhood to the\\n50s or 60s. Symptoms typically begin by the age of 20. For\\nreasons yet unknown, the severity in symptoms can also\\nvary greatly, even among members of the same family.\\nAlthough CMT has been described for many years,\\nit is only since the early 1990s that the genetic cause of\\nmany of the types of CMT have become known. There-\\nfore, knowledge about CMT has increased dramatically\\nwithin a short time.\\nThe peripheral nerves\\nCMT affects the peripheral nerves, those groups of\\nnerve cells carrying information to and from the spinal\\ncord. CMT decreases the ability of these nerves to carry\\nmotor commands to muscles, especially those furthest\\nfrom the spinal cord located in the feet and hands. As a\\nresult, the muscles connected to these nerves eventually\\nweaken. CMT also affects the sensory nerves that carry\\ninformation from the limbs to the brain. Therefore peo-\\nple with CMT also have sensory loss. This causes symp-\\ntoms such as not being able to tell if something is hot or\\ncold or difficulties with balance.\\nThere are two parts of the nerve that can be affected\\nin CMT. A nerve can be likened to an electrical wire, in\\nwhich the wire part is the axon of the nerve and the insu-\\nlation surrounding it is the myelin sheath. The job of the\\nmyelin is to help messages travel very fast through the\\nnerves. CMT is usually classified depending on which\\npart of the nerve is affected. People who have problems\\nwith the myelin have CMT type 1 and people who have\\nabnormalities of the axon have CMT type 2.\\nSpecialized testing of the nerves, called nerve con-\\nduction testing (NCV), can be performed to determine if\\na person has CMT1 or CMT2. These tests measure the\\nspeed at which messages travel through the nerves. In\\nCMT1, the messages move too slowly, but in CMT2 the\\nmessages travel at the normal speed.\\nDemographics\\nCMT has been diagnosed in people from all over the\\nworld. It occurs in approximately one in 2,500 people,\\nwhich is about the same incidence as multiple sclerosis. It\\nis the most common type of inherited neurologic condition.\\nSigns and symptoms\\nCMT is caused by changes (mutations) in any one of\\na number of genes that carry the instructions to make the\\nperipheral nerves. Genes contain the instructions for how\\nthe body grows and develops before and after a person is\\nborn. There are probably at least 15 different genes that\\ncan cause CMT. However, as of early 2001, many have\\nnot yet been identified.\\nCMT types 1 and 2 can be broken down into sub-\\ntypes based upon the gene that is causing CMT. The sub-\\ntypes are labeled by letters, so there is CMT1A, CMT1B,\\netc. Therefore, the gene with a mutation that causes\\nCMT1A is different from that that causes CMT1B.\\nTypes of CMT\\nCMT1A. The most common type of CMT is called\\nCMT1A. It is caused by a mutation in a gene called\\nperipheral myelin protein 22 (PMP22) located on chro-\\nmosome 17. The job of this gene is to make a protein\\n(PMP22) that makes up part of the myelin. In most people\\nwho have CMT, the mutation that causes the condition is\\na duplication (doubling) of the PMP22 gene. Instead of\\nhaving two copies of the PMP22 gene (one on each chro-\\nmosome) there are three copies. It is not known how this\\nextra copy of the PMP22 gene causes the observed symp-\\ntoms. A small percentage of people with CMT1A do not\\nhave a duplication of the PMP22 gene, but rather have a\\npoint mutation in the gene. A point mutation is like a typo\\nin the gene that causes it to work incorrectly.\\nHEREDITARY NEUROPATHY WITH LIABILITY TO PRES-\\nSURE PALSIES (HNPP). HNPP is a condition that is also\\ncaused by a mutation in the PMP22 gene. The mutation\\nis a deletion. Therefore, there is only one copy of the\\nPMP22 gene instead of two. People who have HNPP\\nmay have some of the signs of CMT. However, they also\\nhave episodes where they develop weakness and prob-\\nlems with sensation after compression of certain pressure\\npoints such as the elbows or knee. Often these symptoms\\nwill resolve after a few days or weeks, but sometimes\\nthey are permanent.\\nCMT1B. Another type of CMT, called CMT1B, is\\ncaused by a mutation in a gene called myelin protein zero\\n(MPZ) located on chromosome 1. The job of this gene is\\nto make the layers of myelin stick together as they are\\nwrapped around the axon. The mutations in this gene are\\npoint mutations because they involve a change (either\\ndeletion, substitution, or insertion) at one specific com-\\nponent of a gene.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 733\\nCharcot Marie Tooth disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 733'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 122, 'page_label': '123'}, page_content='CMTX. Another type of CMT, called CMTX, is usu-\\nally considered a subtype of CMT1 because it affects the\\nmyelin, but it has a different type of inheritance than type\\n1 or type 2. In CMTX, the CMT-causing gene is located\\non the X chromosome and is called connexin 32 (Cx32).\\nThe job of this gene is to code for a class of protein called\\nconnexins that form tunnels between the layers of myelin.\\nCMT2. There are at least five different genes that can\\ncause CMT type 2. Therefore, CMT2 has subtypes A, B,\\nC, D and E. As of early 2001, scientists have narrowed in\\non the location of most of the CMT2 causing genes.\\nHowever, the specific genes and the mutations have not\\nyet been found for most types. Very recently, the gene for\\nCMT2E has been found. The gene is called neurofila-\\nment-light (NF-L). Because it has just been discovered,\\nnot much is known about how mutations in this gene\\ncause CMT.\\nCMT3. In the past a condition called Dejerine-Sottas\\ndisease was referred to as CMT3. This is a severe type of\\nCMT in which symptoms begin in infancy or early child-\\nhood. It is now known that this is not a separate type of\\nCMT and in fact people who have onset in infancy or\\nearly childhood often have mutations in the PMP22 or\\nMPZ genes.\\nCMT4. CMT4 is a rare type of CMT in which the\\nnerve conduction tests have slow response results. Howev-\\ner, it is classified differently from CMT1 because it is\\npassed through families by a different pattern of inheri-\\ntance. There are five different subtypes and each has only\\nbeen described in a few families. The symptoms in CMT4\\nare often severe and other symptoms such as deafness may\\nbe present. There are three different genes that have been\\nassociated with CMT4 as of early 2001. They are called\\nMTMR2, EGR2, and NDRG1. More research is required\\nto understand how mutations in these genes cause CMT.\\nInheritance\\nCMT1A and 1B, HNPP, and all of the subtypes of\\nCMT2 have autosomal dominant inheritance. Autosomal\\nrefers to the first 22 pairs of chromosomes that are the\\nsame in males and females. Therefore, males and\\nfemales are affected equally in these types. In a dominant\\ncondition, only one gene of a pair needs to have a muta-\\ntion in order for a person to have symptoms of the condi-\\ntion. Therefore, anyone who has these types has a 50%,\\nor one in two, chance of passing CMT on to each of their\\nchildren. This chance is the same for each pregnancy\\nand does not change based on previous children.\\nCMTX has X-linked inheritance. Since males only\\nhave one X chromosome, they only have one copy of the\\nCx32 gene. Thus, when a male has a mutation in his Cx32\\ngene, he will have CMT. However, females have two X\\nchromosomes and therefore have two copies of the Cx32\\ngene. If they have a mutation in one copy of their Cx32\\ngenes, they will only have mild to moderate symptoms of\\nCMT that may go unnoticed. This is because their normal\\ncopy of the Cx32 gene does make normal myelin.\\nFemales pass on one or the other of their X chromo-\\nsomes to their children—sons or daughters. If a woman\\nwith a Cx32 mutation passes her normal X chromosome,\\nshe will have an unaffected son or daughter who will not\\npass CMT on to his or her children. If the woman passes\\nthe chromosome with Cx32 mutation on she will have an\\naffected son or daughter, although the daughter will be\\nmildly affected or have no symptoms. Therefore, a woman\\nwith a Cx32 mutation has a 50%, or a one in two, chance\\nof passing the mutation to her children: a son will be\\naffected, and a daughter may only have mild symptoms.\\nWhen males pass on an X chromosome, they have a\\ndaughter. When they pass on a Y chromosome, they have\\na son. Since the Cx32 mutation is on the X chromosome,\\na man with CMTX will always pass the Cx32 mutation\\non to his daughters. However, when he has a son, he\\npasses on the Y chromosome, and therefore the son will\\nnot be affected. Therefore, an affected male passes the\\nCx32 gene mutation on to all of his daughters, but to\\nnone of his sons.\\nCMT4 has autosomal recessive inheritance. Males\\nand females are equally affected. In order for a person to\\nhave CMT4, they must have a mutation in both of their\\nCMT-causing genes—one inherited from each parent.\\nThe parents of an affected person are called carriers.\\nThey have one normal copy of the gene and one copy\\nwith a mutation. Carriers do not have symptoms of CMT.\\nTwo carrier parents have a 25%, or one in four, chance of\\npassing CMT on to each of their children.\\nThe onset of symptoms is highly variable, even\\namong members of the same family. Symptoms usually\\nprogress very slowly over a person’s lifetime. The main\\nproblems caused by CMT are weakness and loss of sen-\\nsation mainly in the feet and hands. The first symptoms\\nare usually problems with the feet such as high arches\\nand problems with walking and running. Tripping while\\nwalking and sprained ankles are common. Muscle loss in\\nthe feet and calves leads to “foot drop” where the foot\\ndoes not lift high enough off the ground when walking.\\nComplaints of cold legs are common, as are cramps in\\nthe legs, especially after exercise.\\nIn many people, the fingers and hands eventually\\nbecome affected. Muscle loss in the hands can make fine\\nmovements such as working buttons and zippers difficult.\\nSome patients develop tremor in the upper limbs. Loss of\\nsensation can cause problems such as numbness and the\\nGALE ENCYCLOPEDIA OF MEDICINE 2734\\nCharcot Marie Tooth disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 734'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 123, 'page_label': '124'}, page_content='inability to feel if something is hot or cold. Most people\\nwith CMT remain able to walk throughout their lives.\\nDiagnosis\\nDiagnosis of CMT begins with a careful neurological\\nexam to determine the extent and distribution of weakness. A\\nthorough family history should be taken at this time to deter-\\nmine if other people in the family are affected. Testing may\\nalso be performed to rule out other causes of neuropathy.\\nA nerve conduction velocity test should be per-\\nformed to measure how fast impulses travel through the\\nnerves. This test may show characteristic features of\\nCMT, but it is not diagnostic of CMT. Nerve conduction\\ntesting may be combined with electromyography\\n(EMG), an electrical test of the muscles.\\nA nerve biopsy (removal of a small piece of the\\nnerve) may be performed to look for changes characteris-\\ntic of CMT. However, this testing is not diagnostic of\\nCMT and is usually not necessary for making a diagnosis.\\nDefinitive diagnosis of CMT is made only by genet-\\nic testing, usually performed by drawing a small amount\\nof blood. As of early 2001, testing is available to detect\\nmutations in PMP22, MPZ, Cx32 and EGR2. However,\\nresearch is progressing rapidly and new testing is often\\nmade available every few months. All affected members\\nof a family have the same type of CMT. Therefore once a\\nmutation is found in one affected member, it is possible\\nto test other members who may have symptoms or are at\\nrisk of developing CMT.\\nPrenatal diagnosis\\nTesting during pregnancy to determine whether an\\nunborn child is affected is possible if genetic testing in a\\nfamily has identified a specific CMT-causing mutation.\\nThis can be done after 10–12 weeks of pregnancy using a\\nprocedure called chorionic villus sampling (CVS). CVS\\ninvolves removing a tiny piece of the placenta and exam-\\nining the cells. Testing can also be done by amniocente-\\nsis after 16 weeks gestation by removing a small amount\\nof the amniotic fluid surrounding the baby and analyzing\\nthe cells in the fluid. Each of these procedures has a small\\nrisk of miscarriage associated with it, and those who are\\ninterested in learning more should check with their doctor\\nor genetic counselor. Couples interested in these options\\nshould obtain genetic counseling to carefully explore all\\nof the benefits and limitations of these procedures.\\nTreatment\\nThere is no cure for CMT. However, physical and\\noccupational therapy are an important part of CMT treat-\\nment. Physical therapy is used to preserve range of motion\\nand minimize deformity caused by muscle shortening, or\\ncontracture. Braces are sometimes used to improve control\\nof the lower extremities that can help tremendously with\\nbalance. After wearing braces, people often find that they\\nhave more energy because they are using less energy to\\nfocus on their walking. Occupational therapy is used to\\nprovide devices and techniques that can assist tasks such\\nas dressing, feeding, writing, and other routine activities of\\ndaily life. V oice-activated software can also help people\\nwho have problems with fine motor control.\\nIt is very important that people with CMT avoid\\ninjury that causes them to be immobile for long periods\\nof time. It is often difficult for people with CMT to return\\nto their original strength after injury.\\nThere is a long list of medications that should be\\navoided if possible by people diagnosed with CMT such as\\nhydralazine (Apresoline), megadoses of vitamin A, B\\n6, and\\nD, Taxol, and large intravenous doses of penicillin. Com-\\nplete lists are available from the CMT support groups. Peo-\\nple considering taking any of these medications should\\nweigh the risks and benefits with their physician.\\nPrognosis\\nThe symptoms of CMT usually progress slowly over\\nmany years, but do not usually shorten life expectancy.\\nThe majority of people with CMT do not need to use a\\nwheelchair during their lifetime. Most people with CMT\\nare able to lead full and productive lives despite their\\nphysical challenges.\\nResources\\nBOOKS\\nParry, G. J., ed. Charcot-Marie-Tooth Disorders: A Handbook\\nfor Primary Care Physicians. Available from the CMT\\nAssociation, 1995.\\nShy, M. E., J. Kamholz, and R. E. Lovelace, eds. “Charcot-\\nMarie-Tooth Disorders.”Annals of the New York Academy\\nof Sciences. 1999.\\nPERIODICALS\\nKeller. M. P., and P. F. Chance. “Inherited peripheral neu-\\nropathies.”Seminars in Neurology19, no. 4 (1999): 353–62.\\nQuest. A magazine for patients available from the Muscular\\nDystrophy Association.\\nORGANIZATIONS\\nCharcot Marie Tooth Association (CMTA). 2700 Chestnut\\nParkway, Chester, PA 19013. (610) 499-9264 or (800)\\n606-CMTA. Fax: (610) 499-9267. .\\n.\\nCMT International. Attn: Linda Crabtree, 1 Springbank Dr. St.\\nCatherine’s, ONT L2S2K1. Canada (905) 687-3630.\\n.\\nMuscular Dystrophy Association. 3300 East Sunrise Dr., Tuc-\\nson, AZ 85718. (520) 529-2000 or (800) 572-1717.\\n.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 735\\nCharcot Marie Tooth disease\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 735'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 124, 'page_label': '125'}, page_content='Neuropathy Association. 60 E. 42nd St. Suite 942, New York,\\nNY 10165. (212) 692-0662. .\\nOTHER\\nHNPP—Hereditary Neuropathy with liability to Pressure\\nPalsies. University of Washington, Seattle. .\\n“GeneClinics.” .\\nOMIM—Online Mendelian Inheritance in Man . .\\nKaren M. Krajewski, MS, CGC\\nCharcot’s joints\\nDefinition\\nCharcot’s joints is a progressive degenerative disease\\nof the joints caused by nerve damage resulting in the loss of\\nability to feel pain in the joint and instability of the joint.\\nDescription\\nCharcot’s joints, also called neuropathic joint dis-\\nease, is the result of two conditions present in the joint.\\nThe first factor is the inability to feel pain in the joint due\\nto nerve damage. The second factor is that injuries to the\\njoint go unnoticed leading to instability and making the\\njoint more susceptible to further injury. Repeated small\\ninjuries, strains and even fractures can go unnoticed until\\nfinally the joint is permanently destroyed. Loss of the pro-\\ntective sensation of pain is what leads to the disintegration\\nof the joint and often leads to deformity in the joint.\\nAlthough this condition can affect any joint, the\\nknee is the joint most commonly involved. In individuals\\nwith diabetes mellitus , the foot is most commonly\\naffected. The disease can involve only one joint or it may\\naffect two or three joints. More than three affected joints\\nis very rare. In all cases, the specific joint(s) affected\\ndepends on the location of the nerve damage.\\nCauses and symptoms\\nMany diseases and injuries can interfere with the abil-\\nity to feel pain. Conditions such as diabetes mellitus,\\nspinal injuries and diseases,alcoholism, and even syphilis\\ncan all lead to a loss of the ability to feel pain in some\\nareas. Lack of pain sensation may also be congenital.\\nThe symptoms of Charcot’s joints can go unnoticed\\nfor some time and may be confused with osteoarthritis\\nin the beginning. Swelling and stiffness in a joint without\\nthe expected pain, or with less pain than would be\\nexpected, are the primary symptoms of this condition. As\\nthe condition progresses, however, the joint can become\\nvery painful due to fluid build-up and bony growths.\\nDiagnosis\\nCharcot’s joints is suspected when a person with a\\ndisease that impairs pain sensation exhibits painless\\nswelling and/or stiffness in a joint. Standard x rays will\\nshow damage to the joint, and may also show abnormal\\nbone growth and calcium deposits. Floating bone frag-\\nments from previous injuries may also be visible.\\nTreatment\\nIn the early stages of Charcot’s joints, braces to sta-\\nbilize the joints can help stop or minimize the damage.\\nWhen the disease has progressed beyond braces, surgery\\ncan sometimes repair the joint. If the damage is exten-\\nsive, an artificial joint may be necessary.\\nPrognosis\\nTreatment of the disease causing loss of pain percep-\\ntion may help to slow the damage to the joints.\\nPrevention\\nPreventing or effectively managing the underlying\\ndisease can slow or in some cases reverse joint damage,\\nbut the condition cannot be prevented.\\nResources\\nBOOKS\\nResnick, Donald. Diagnosis of Bone and Joint Disorders.\\nPhiladelphia: W. B. Saunders Co., 1994.\\nDorothy Elinor Stonely\\nGALE ENCYCLOPEDIA OF MEDICINE 2736\\nCharcot’s joints\\nKEY TERMS\\nAxon—Skinny, wire-like extension of nerve cells.\\nMyelin—A fatty sheath surrounding nerves in the\\nperipheral nervous system, which help them con-\\nduct impulses more quickly.\\nNerve conduction testing —Procedure that mea-\\nsures the speed at which impulses move through\\nthe nerves.\\nNeuropathy—A condition caused by nerve dam-\\nage. Major symptoms include weakness, numb-\\nness, paralysis, or pain in the affected area.\\nPeripheral nerves —Nerves throughout the body\\nthat carry information to and from the spinal cord.\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 736'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 125, 'page_label': '126'}, page_content='Charley horse see Muscle spasms and cramps\\nChelation therapy\\nDefinition\\nChelation therapy is an intravenous treatment\\ndesigned to bind heavy metals in the body in order to\\ntreat heavy metal toxicity. Proponents claim it also treats\\ncoronary artery disease and other illnesses that may be\\nlinked to damage from free radicals (reactive molecules).\\nPurpose\\nThe benefits of EDTA chelation for the treatment of\\nlead poisoning and excessively high calcium levels are\\nundisputed. The claims of benefits for those suffering\\nfrom atherosclerosis, coronary artery disease, and other\\ndegenerative diseases are more difficult to prove. Report-\\ned uses for chelation therapy include treatment of angi-\\nna, gangrene, arthritis, multiple sclerosis, Parkinson’s\\ndisease, psoriasis , and Alzheimer’s disease . Improve-\\nment is also claimed for people experiencing diminished\\nsight, hearing, smell, coordination, and sexual potency.\\nDescription\\nOrigins\\nThe term chelation is from the Greek root word\\n“chele,” meaning “claw.” Chelating agents, most com-\\nmonly diamine tetraacetic acid (EDTA), were originally\\ndesigned for industrial applications in the early 1900s. It\\nwas not until the World War II era that the potential for\\nmedical therapy was realized. The initial intent was to\\ndevelop antidotes to poison gas and radioactive contami-\\nnants. The need for widespread therapy of this nature did\\nnot materialize, but more practical uses were found for\\nchelation. During the following decade, EDTA chelation\\ntherapy became standard treatment for people suffering\\nfrom lead poisoning . Patients who had received this\\ntreatment claimed to have other health improvements\\nthat could not be attributed to the lead removal only.\\nEspecially notable were comments from those who had\\npreviously suffered from intermittent claudication and\\nangina. They reported suffering less pain and fatigue ,\\nwith improved endurance, after chelation therapy. These\\nreports stimulated further interest in the potential bene-\\nfits of chelation therapy for people suffering from athero-\\nsclerosis and coronary artery disease.\\nIf the preparatory examination suggests that there is a\\ncondition that could be improved by chelation therapy, and\\nthere is no health reason why it shouldn’t be used, then the\\ntreatment can begin. The patient is generally taken to a\\ncomfortable treatment area, sometimes in a group loca-\\ntion, and an intravenous line is started. A solution of\\nEDTA together with vitamins and minerals tailored for\\nthe individual patient is given. Most treatments take three\\nto four hours, as the infusion must be given slowly in order\\nto be safe. The number of recommended treatments is usu-\\nally between 20 and 40. They are given one to three times\\na week. Maintenance treatments can then be given at the\\nrate of once or twice a month. Maximum benefits are\\nreportedly attained after approximately three months after\\na treatment series. The cost of therapy is considerable, but\\nit is a fraction of the cost of an expensive medical proce-\\ndure like cardiac bypass surgery. Intravenous vitamin C\\nand mercury chelation therapies are also offered.\\nPreparations\\nA candidate for chelation therapy should initially\\nhave a thorough history and physical to define the type and\\nextent of clinical problems. Laboratory tests will be done\\nto determine whether there are any conditions present that\\nwould prevent the use of chelation. Patients who have pre-\\nexisting hypocalcemia, poor liver or kidney function, con-\\ngestive heart failure, hypoglycemia, tuberculosis, clot-\\nting problems, or potentially allergic conditions are at\\nhigher risk for complications from chelation therapy. A\\nDoppler ultrasound may be performed to determine the\\nadequacy of blood flow in different regions of the body.\\nPrecautions\\nIt is important for people who receive chelation ther-\\napy to work with medical personnel who are experienced\\nin the use of this treatment. Treatment should not be\\nundertaken before a good physical, lifestyle evaluation,\\nhistory, and any laboratory tests necessary are per-\\nformed. The staff must be forthcoming about test results\\nand should answer any questions the patient may have.\\nEvaluation and treatment should be individualized and\\ninvolve assessment of kidney function before each treat-\\nment with chelation, since the metals bound by the\\nEDTA are excreted through the kidneys.\\nAlthough EDTA binds harmful, toxic metals like\\nmercury, lead, and cadmium, it also binds some essential\\nnutrients of the body, such as copper, iron, calcium, zinc,\\nand magnesium. Large amounts of zinc are lost during\\nchelation. Zinc deficiency can cause impaired immune\\nfunction and other harmful effects. Supplements of zinc\\nare generally given to patients undergoing chelation, but\\nit is not known whether this is adequate to prevent defi-\\nciency. Also, chelation therapy does not replace proper\\nnutrition , exercise , and appropriate medications or\\nsurgery for specific diseases or conditions.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 737\\nChelation therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 737'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 126, 'page_label': '127'}, page_content='Side effects\\nSide effects of chelation therapy are reportedly\\nunusual, but are occasionally serious. Mild reactions may\\ninclude, but are not limited to, local irritation at the infu-\\nsion site, skin reactions, nausea, headache , dizziness ,\\nhypoglycemia, fever, leg cramps, or loose bowel move-\\nments. Some of the more serious complications reported\\nhave included hypocalcemia, kidney damage, decreased\\nclotting ability, anemia, bone marrow damage, insulin\\nshock, thrombophlebitis with embolism, and even rare\\ndeaths. However, some doctors feel that the latter groups\\nof complications occurred before the safer method cur-\\nrently used for chelation therapy was developed.\\nResearch and general acceptance\\nEDTA chelation is a highly controversial therapy.\\nThe treatment is approved by the United States Food and\\nDrug Administration (FDA) for lead poisoning and seri-\\nously high calcium levels. However, for the treatment of\\natherosclerotic heart disease, EDTA chelation therapy is\\nnot endorsed by the American Heart Association (AHA),\\nthe FDA, the National Institutes of Health (NIH), or the\\nAmerican College of Cardiology. The AHA reports that\\nthere are no adequate, controlled, published scientific\\nstudies using currently approved scientific methods to\\nsupport this therapy for the treatment of coronary artery\\ndisease. However, a pooled analysis from the results of\\nover 70 studies showed positive results in all but one.\\nResources\\nBOOKS\\nCassileth, Barrie. The Alternative Medicine Handbook. New\\nYork: W. W. Norton & Company, Inc., 1998.\\nCranton, Elmer. Bypassing Bypass. Virginia: Medex Publish-\\ners, Inc., 1997.\\nKEY TERMS\\nAngina—Chest pain caused by reduced oxygen to\\nthe heart.\\nAtherosclerosis—Arterial disease characterized by\\nfatty deposits on inner arterial walls.\\nHypocalcemia—Low blood calcium.\\nHypoglycemia—Low blood sugar.\\nIntermittent claudication —Leg pain and weak-\\nness caused by walking.\\nThrombophlebitis—Inflammation of a vein togeth-\\ner with clot formation.\\nPERIODICALS\\nChappel, Stall. Journal of the Advancement of Medicine 6\\n(1993): 139-160.\\nORGANIZATIONS\\nThe American College for Advancement in Medicine (ACAM).\\n23121 Verdugo Dr., Suite 204, Laguna Hills, CA 92653.\\n(714) 583-7666.\\nAmerican Heart Association. (2000).\\nOTHER\\nCranton, Elmer. Chelation therapy. (1999).\\nGreen, Saul. Quackwatch: Chelation therapy. (2000).\\nJudith Turner\\nChemica see Skin resurfacing\\nChemical debridement see Debridement\\nChemobrasion see Skin resurfacing\\nChemonucleolysis\\nDefinition\\nChemonucleolysis is a medical procedure that\\ninvolves the dissolving of the gelatinous cushioning\\nmaterial in an intervertebral disk by the injection of an\\nenzyme such as chymopapain.\\nPurpose\\nBetween each vertebra lies a disk of cushioning\\nmaterial that keeps the spinal bones from rubbing togeth-\\ner and absorbs some of the shock to the spine from body\\nmovements. In the center of the disk is soft, gelatinous\\nmaterial called the nucleus pulposus (NP). The NP is sur-\\nrounded by a tough fibrous coating. Sometimes when the\\nback is injured, this coating can weaken and bulge or tear\\nto allow the NP to ooze out. When this happens, it is\\ncalled a herniated nucleus pulposus (HNP), or—in com-\\nmon language—a herniated disk.\\nWhen the disk bulges or herniates, it can put pres-\\nsure on nerves which originate in the spinal column, and\\ngo to other parts of the body. This causes lower back\\npain, and/or pain to the hips, legs, arms, shoulders, and\\nneck, depending on the location of the herniated disk.\\nChemonucleolysis uses chymopapain, an enzyme de-\\nrived from papyrus, to dissolve the disk material that has\\nGALE ENCYCLOPEDIA OF MEDICINE 2738\\nChemonucleolysis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 738'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 127, 'page_label': '128'}, page_content='been displaced because of injury. Herniated disks are the\\ncause of only a small proportion of cases of lower back\\npain, and chemonucleolysis is appropriate for only some\\ncases of HNP.\\nChemonucleolysis is a conservative alternative to\\ndisk surgery. There are three types of disk injuries. A\\nprotruded disk is one that is intact but bulging. In an\\nextruded disk, the fibrous wrapper has torn and the NP\\nhas oozed out, but is still connected to the disk. In a\\nsequestered disk, a fragment of the NP has broken loose\\nfrom the disk and is free in the spinal canal. Chemonu-\\ncleolysis is effective on protruded and extruded disks,\\nbut not on sequestered disk injuries. In the United\\nStates, chymopapain chemonucleolysis is approved\\nonly for use in the lumbar (lower) spine. In other coun-\\ntries, it has also been used successfully to treat cervical\\n(upper spine) hernias.\\nOther indications that a patient is a good candidate\\nfor chemonucleolysis instead of surgery include:\\n• the patient is 18–50 years of age\\n• leg pain is worse than lower back pain\\n• other conservative treatments have failed\\n• the spot where the herniated disk presses on the nerve\\nhas been pinpointed by myelography , computed\\ntomography scan (CT scan), or magnetic resonance\\nimaging (MRI)\\n• the patient wishes to avoid surgery\\nPrecautions\\nThere are some situations in which chemonucleoly-\\nsis should not be performed. Chymopapain is derived\\nfrom the papaya. About 0.3% of patients are allergic to\\nchymopapain and go into life-threatening shock when\\nexposed to the enzyme. Chemonucleolysis should not be\\nperformed on patients allergic to chymopapain or\\npapaya. It also should not be done:\\n• when the patient is pregnant\\nKEY TERMS\\nChymopapain—An enzyme from the milky white\\nfluid of the papaya, used for medical purposes in\\nchemonucleolysis.\\nMyelography —An x-ray test that evaluates the\\nsubarachnoid space of the spine.\\nNucleus pulposus (NP)—an elastic, pulpy mass in\\nthe center of each vertebral disk.\\n• if the disk is sequestered\\n• if the patient has had several failed back operations\\n• if a spinal cord tumor is present\\n• if the patient has a neurological disease such as multi-\\nple sclerosis\\nOther conditions may affect the appropriateness of\\nchemonucleolysis, including hypertension, obesity, dia-\\nbetes, and a family history of stroke.\\nDescription\\nA small gauge needle is placed in the center of the\\naffected disk. Chymopapain is introduced into the disk.\\nThe patient needs to remain still.\\nPreparation\\nPatients will need tests such as a myelogram or CT\\nscan to pinpoint the herniated disk. Some doctors medicate\\nthe patient 24 hours prior to the operation in order to\\ndecrease the chances of post-operative lower back stiffness.\\nAftercare\\nPatients may feel lower back stiffness, which goes\\naway in few weeks. Heavy lifting and sports activities\\nshould be avoided for at least three months.\\nRisks\\nThe greatest risk is that the patient may be allergic to\\nchymopapain. The death rate for chemonucleolysis is\\nonly 0.02%. Complications overall are five to 10 times\\nless than with conventional surgery, and the failure rate is\\nroughly comparable to the failure rate in conventional\\ndisk surgery.\\nNormal results\\nMany patients feel immediate relief from pain, but,\\nin about 30% of patients, maximal relief takes six weeks.\\nThe long term (seven to 20 years) success rate averages\\nabout 75%, which is comparable to the success rate for\\nconventional surgery.\\nResources\\nPERIODICALS\\nAlexander, Herbert. “Chemonucleolysis for Lumbar Disc Her-\\nniation: How Does it Stack up to Other Minimally Inva-\\nsive Approaches?”Journal of Musculoskelatal Medicine\\n12, no. 2 (1995): 13-24.\\nTish Davidson\\nGALE ENCYCLOPEDIA OF MEDICINE 2 739\\nChemonucleolysis\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 739'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 128, 'page_label': '129'}, page_content='Chemotherapy\\nDefinition\\nChemotherapy is treatment of cancer with anti-\\ncancer drugs.\\nPurpose\\nThe main purpose of chemotherapy is to kill cancer\\ncells. It is usually used to treat patients with cancer that\\nhas spread from the place in the body where it started\\n(metastasized). Chemotherapy destroys cancer cells any-\\nwhere in the body. It even kills cells that have broken off\\nfrom the main tumor and traveled through the blood or\\nlymph systems to other parts of the body.\\nChemotherapy can cure some types of cancer. In\\nsome cases, it is used to slow the growth of cancer cells\\nor to keep the cancer from spreading to other parts of the\\nbody. When a cancer has been removed by surgery,\\nchemotherapy may be used to keep the cancer from com-\\ning back (adjuvant therapy). Chemotherapy also can ease\\nthe symptoms of cancer, helping some patients to have a\\nbetter quality of life.\\nPrecautions\\nThere are many different types of chemotherapy\\ndrugs. Oncologists, doctors who specialize in treating\\ncancer, determine which drugs are best suited for\\neach patient. This decision is based on the type of\\ncancer, the patient’s age and health, and other drugs\\nthe patient is taking. Some patients should not be\\ntreated with certain chemotherapy drugs. Age and\\nother conditions may affect the drugs with which a\\nperson may be treated. Heart disease, kidney disease,\\nand diabetes are conditions that may limit the choice\\nof treatment drugs.\\nDescription\\nMore than 50 chemotherapy drugs are currently\\navailable to treat cancer and many more are being tested\\nfor their ability to destroy cancer cells. Most chemothera-\\npy drugs interfere with the ability of cells to grow or mul-\\ntiply. Although these drugs affect all cells in the body,\\nmany useful treatments are most effective against rapidly\\ngrowing cells. Cancer cells grow more quickly than most\\nother body cells. Other cells that grow fast are cells of the\\nbone marrow that produce blood cells, cells in the stom-\\nach and intestines, and cells of the hair follicles. There-\\nfore, the most common side effects of chemotherapy are\\nlinked to their effects on other fast growing cells.\\nTypes of chemotherapy drugs\\nChemotherapy drugs are classified based on how\\nthey work. The main types of chemotherapy drugs are\\ndescribed below:\\n• Alkylating drugs kill cancer cells by directly attacking\\nDNA, the genetic material of the genes. Cyclophos-\\nphamide is an alkylating drug.\\n• Antimetabolites interfere with the production of DNA\\nand keep cells from growing and multiplying. An\\nexample of an antimetabolite is 5-fluorouracil (5-FU).\\n• Antitumor antibiotics are made from natural sub-\\nstances such as fungi in the soil. They interfere with\\nimportant cell functions, including production of DNA\\nand cell proteins. Doxorubicin and bleomycin belong to\\nthis group of chemotherapy drugs.\\n• Plant alkaloids prevent cells from dividing normally.\\nVinblastine and vincristine are plant alkaloids obtained\\nfrom the periwinkle plant.\\n• Steroid hormones slow the growth of some cancers that\\ndepend on hormones. For example, tamoxifen is used\\nto treat breast cancers that depend on the hormone\\nestrogen for growth.\\nCombination chemotherapy\\nChemotherapy is usually given in addition to other\\ncancer treatments, such as surgery and radiation therapy.\\nWhen given with other treatments, it is called adjuvant\\nchemotherapy. An oncologist decides which chemothera-\\npy drug or combination of drugs will work best for each\\npatient. The use of two or more drugs together often works\\nbetter than a single drug for treating cancer. This is called\\ncombination chemotherapy. Scientific studies of different\\ndrug combinations help doctors learn which combinations\\nwork best for each type of cancer.\\nHow chemotherapy is given\\nChemotherapy is administered in different ways,\\ndepending on the drugs to be given and the type of can-\\ncer. Doctors decide the dose of chemotherapy drugs con-\\nsidering many factors, among them being the patient’s\\nheight and weight.\\nChemotherapy may be given by one or more of the\\nfollowing methods:\\n• orally\\n• by injection\\n• through a catheter or port\\n• topically\\nGALE ENCYCLOPEDIA OF MEDICINE 2740\\nChemotherapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 740'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 129, 'page_label': '130'}, page_content='Oral chemotherapy is given by mouth in the form a\\npill, capsule, or liquid. This is the easiest method and can\\nusually be done at home.\\nIntravenous (IV) chemotherapy is injected into a\\nvein. A small needle is inserted into a vein on the hand or\\nlower arm. The needle is usually attached to a small tube\\ncalled a catheter, which delivers the drug to the needle\\nfrom an IV bag or bottle.\\nIntramuscular (IM) chemotherapy is injected into a\\nmuscle. Chemotherapy given by intramuscular injection\\nis absorbed into the blood more slowly than IV\\nchemotherapy. Because of this, the effects of IM\\nchemotherapy may last longer than chemotherapy given\\nintravenously. Chemotherapy may also be injected sub-\\ncutaneously (SQ or SC), which means under the skin.\\nInjection of chemotherapy directly into the cancer is\\ncalled intralesional (IL) injection.\\nChemotherapy may also be given by a catheter or\\nport permanently inserted into a central vein or body cav-\\nity. A port is a small reservoir or container that is placed\\nin a vein or under the skin in the area where the drug will\\nbe given. These methods eliminate the need for repeated\\ninjections and may allow patients to spend less time in\\nthe hospital while receiving chemotherapy. A common\\nlocation for a permanent catheter is the external jugular\\nvein in the neck. Intraperitoneal (IP) chemotherapy is\\nadministered into the abdominal cavity through a\\ncatheter or port. Chemotherapy given by catheter or port\\ninto the spinal fluid is called intrathecal (IT) administra-\\ntion. Catheters and ports may also be placed in the chest\\ncavity, bladder, or pelvis, depending on the location of\\nthe cancer to be treated.\\nTopical chemotherapy is given as a cream or oint-\\nment applied directly to the cancer. This method is more\\ncommon in treatment of certain types of skin cancer.\\nTreatment location and schedule\\nPatients may take chemotherapy at home, in the doc-\\ntor’s office, or as an inpatient or outpatient at the hospi-\\ntal. Most patients stay in the hospital when first begin-\\nning chemotherapy, so their doctor can check for any\\nside effects and change the dose if needed.\\nHow often and how long chemotherapy is given\\ndepends on the type of cancer, how patients respond to\\nthe drugs, patients’ health and ability to tolerate the\\ndrugs, and the types of drugs given. Chemotherapy\\nadministration may take only a few minutes or may last\\nas long as several hours. Chemotherapy may be given\\ndaily, weekly, or monthly. A rest period may follow a\\ncourse of treatment before the next course begins. In\\ncombination chemotherapy, more than one drug may be\\ngiven at a time, or they may be given alternately, one fol-\\nlowing the other.\\nPreparation\\nA number of medical tests are done before\\nchemotherapy is started. The oncologist will determine\\nhow much the cancer has spread from the results of x\\nrays and other imaging tests and from samples of the\\ntumor taken during surgery.\\nBlood tests give the doctor important information\\nabout the function of the blood cells and levels of chemi-\\ncals in the blood. A complete blood count (CBC) is\\ncommonly done before and regularly during treatment.\\nThe CBC shows the numbers of white blood cells, red\\nblood cells, and platelets in the blood. Because\\nchemotherapy affects the bone marrow, where blood\\ncells are made, levels of these cells often drop during\\nchemotherapy. The white blood cells and platelets are\\nmost likely to be affected by chemotherapy. A drop in the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 741\\nChemotherapy\\nPatient undergoing high dose stem cell chemotherapy.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 741'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 130, 'page_label': '131'}, page_content='white blood cell count means that the immune system\\ncannot function properly. Low levels of platelets can\\ncause a patient to bleed easily from a cut or other wound.\\nA low red blood cell count can lead to anemia (deficien-\\ncy of red blood cells) and fatigue.\\nWhen a chemotherapy treatment takes a long time, the\\npatient may prepare for it by wearing comfortable clothes.\\nBringing a book to read or a tape to listen to may help pass\\nthe time and ease the stress of receiving chemotherapy.\\nSome patients bring a friend or family member to provide\\ncompany and support during treatment.\\nSometimes, patients taking chemotherapy drugs\\nknown to cause nausea are given medications called anti-\\nemetics before chemotherapy is administered. Anti-emet-\\nic drugs help to lessen feelings of nausea. Two anti-nau-\\nsea medications that may be used are Kytril and Zofran.\\nOther ways to prepare for chemotherapy and help\\nlessen nausea are:\\n• regularly eat nutritious foods and drink lots of fluids\\n• eat and drink normally until about two hours before\\nchemotherapy\\n• eat high carbohydrate, low-fat foods and avoid spicy\\nfoods\\nAftercare\\nTips for helping to control side effects after chemo-\\ntherapy include:\\n• follow any instructions given by the doctor or nurse\\n• take all prescribed medications\\n• eat small amounts of bland foods\\n• drink lots of fluids\\n• get plenty of rest\\nSome patients find it helps to breathe fresh air or get\\nmild exercise, such as taking a walk.\\nRisks\\nChemotherapy drugs are toxic to normal cells as\\nwell as cancer cells. A dose that will destroy cancer cells\\nwill probably cause damage to some normal cells. Doc-\\ntors adjust doses to do the least amount of harm possible\\nto normal cells. Some patients feel few or no side effects,\\nand others may have more serious side effects. In some\\ncases, a dose adjustment is all that is needed to reduce or\\nstop a side effect.\\nSome chemotherapy drugs have more side effects\\nthan others. Some of the most common side effects are:\\n• nausea and vomiting\\n• loss of appetite\\n• hair loss\\n• anemia and fatigue\\n• infection\\n• easy bleeding or bruising\\n• sores in the mouth and throat\\n• neuropathy and other damage to the nervous system\\n• kidney damage\\nNausea and vomiting are common, but can usually\\nbe controlled by taking antinausea drugs , drinking\\nenough fluids, and avoiding spicy foods. Loss of appetite\\nmay be due to nausea or the stress of undergoing cancer\\ntreatment.\\nSome chemotherapy drugs cause hair loss, but it is\\nalmost always temporary.\\nLow blood cell counts caused by the effect of\\nchemotherapy on the bone marrow can lead to anemia,\\ninfections, and easy bleeding and bruising. Patients with\\nanemia have too few red blood cells to deliver oxygen\\nand nutrients to the body’s tissues. Anemic patients feel\\ntired and weak. If red blood cell levels fall too low, a\\nblood transfusion may be given.\\nPatients receiving chemotherapy are more likely to\\nget infections. This happens because their infection-\\nfighting white blood cells are reduced. It is important to\\ntake measures to avoid getting infections. When the\\nwhite blood cell count drops too low, the doctor may pre-\\nscribe medications called colony stimulating factors that\\nhelp white blood cells grow. Neupogen and Leukine are\\ntwo colony stimulants used as treatments to help fight\\ninfection.\\nPlatelets are blood cells that make the blood clot.\\nWhen patients do not have enough platelets, they may\\nbleed or bruise easily, even from small injuries. Patients\\nwith low blood platelets should take precautions to avoid\\ninjuries. Medicines such as aspirin and other pain reliev-\\ners can affect platelets and slow down the clotting process.\\nChemotherapy can cause irritation and dryness in the\\nmouth and throat. Painful sores may form that can bleed\\nand become infected. Precautions to avoid this side effect\\ninclude getting dental care before chemotherapy begins,\\nbrushing the teeth and gums regularly with a soft brush,\\nand avoiding mouth washes that contain salt or alcohol.\\nNormal results\\nThe main goal of chemotherapy is to cure cancer.\\nMany cancers are cured by chemotherapy. It may be used\\nin combination with surgery to keep a cancer from spread-\\nGALE ENCYCLOPEDIA OF MEDICINE 2742\\nChemotherapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 742'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 131, 'page_label': '132'}, page_content='ing to other parts of the body. Some widespread, fast-\\ngrowing cancers are more difficult to treat. In these cases,\\nchemotherapy may slow the growth of the cancer cells.\\nDoctors can tell if the chemotherapy is working by\\nthe results of medical tests. Physical examination, blood\\ntests, and x rays are all used to check the effects of treat-\\nment on the cancer.\\nThe possible outcomes of chemotherapy are:\\n• Complete remission or response. The cancer complete-\\nly disappears. The course of chemotherapy is complet-\\ned and the patient is tested regularly for a recurrence.\\n• Partial remission or response. The cancer shrinks in\\nsize but does not disappear. The same chemotherapy\\nmay be continued or a different combination of drugs\\nmay be tried.\\n• Stabilization. The cancer does not grow or shrink.\\nOther therapy options may be explored. A tumor may\\nstay stabilized for many years.\\n• Progression. The cancer continues to grow. Other thera-\\npy options may be explored.\\n• A secondary malignancy may develop from the one\\nbeing treated, and that second cancer may need addi-\\ntional chemotherapy or other treatment.\\nResources\\nBOOKS\\nDollinger, Malin, et al. Everyone’s Guide to Cancer Therapy:\\nHow Cancer is Diagnosed, Treated, and Managed Day to\\nDay. 3rd ed. Kansas City: Andres & McMeel, 1998.\\nDrum, David. Making the Chemotherapy Decision. Los Ange-\\nles: Lowell House, 1996.\\nKEY TERMS\\nAdjuvant therapy —Treatment given after surgery\\nor radiation therapy to prevent the cancer from\\ncoming back.\\nAlkaloid—A type of chemical commonly found in\\nplants and often having medicinal properties.\\nAlykylating drug—A drug that kills cells by direct-\\nly damaging DNA.\\nAntiemetic —A medicine that helps control nau-\\nsea; also called an anti-nausea drug.\\nAntimetabolite —A drug that interferes with a\\ncell’s growth or ability to multiply.\\nPlatelets—Blood cells that function in blood clot-\\nting.\\nMcKay, Judith, and Nancee Hirano. The Chemotherapy Sur-\\nvival Guide. Oakland, CA: New Harbinger Publications,\\n1993.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nNational Cancer Institute. Building 31, Room 10A31, 31 Cen-\\nter Drive, MSC 2580, Bethesda, MD 20892-2580. (800)\\n422-6237. .\\nOTHER\\n“Introduction to Chemotherapy.”OncoLink. University of\\nPennsylvania Cancer Center. 1998 .\\n“What is Chemotherapy?”OncoLink. University of Pennsylva-\\nnia Cancer Center. 1998 .\\nToni Rizzo\\nChest drainage therapy\\nDefinition\\nChest drainage therapy involves the removal of air,\\nblood, pus, or other secretions from the chest cavity.\\nPurpose\\nChest drainage therapy is done to relieve pressure on\\nthe lungs, and remove fluid that could promote infection.\\nInstalling a chest drainage tube can be either an emer-\\ngency or a planned procedure.\\nRemoving air or fluids from the chest involves the\\ninsertion of a tube through the skin and the muscles\\nbetween the ribs, and into the chest cavity. This cavity is\\nalso called the pleural space. Insertion of this tube is\\ncalled thoracostomy, and chest drainage therapy is some-\\ntimes called thoracostomy tube drainage.\\nConditions that may need to be treated by chest\\ndrainage therapy include emphysema (air in the tissues\\nof the lungs), tuberculosis , and spontaneous pneu-\\nmothorax (air in the chest cavity) that causes more\\nthan a 25% collapse of the lung. Other conditions\\ninclude cancer that causes excessive secretions,\\nempyema (pus in the thoracic cavity), or hemothorax\\n(blood in the thoracic cavity). Almost all chest drainage\\ntherapy is done to drain blood from the chest cavity\\nafter lung or heart surgery. In cases where the lung is\\ncollapsed, removing fluids by chest drainage therapy\\nallows the lung to reinflate.\\nOftentimes an x ray is performed prior to treatment\\nto determine whether the problem is either fluid or air in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 743\\nChest drainage therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 743'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 132, 'page_label': '133'}, page_content='the pleural space. Sometimes a procedure called thora-\\ncentesis is performed in an effort to avoid inserting a\\nchest drainage tube. In this procedure a needle with a\\ncatheter is inserted into the pleural space and fluid is\\nremoved. When fluid continues to accumulate, chest\\ndrainage therapy is usually the next step. This is especial-\\nly true when there is a lung infection underlying the fluid\\nbuild-up.\\nPrecautions\\nChest drainage therapy is not done if a collapsed\\nlung is not life-threatening. It also should be avoided for\\npatients who have blood clotting problems.\\nDescription\\nMost patients are awake when the chest drainage\\ntube is inserted. They are given a sedative and a local\\nanesthetic. Chest drainage tubes are usually inserted\\nbetween the ribs. The exact location depends on the type\\nof material to be drained and its location in the lungs.\\nAn incision is made in the skin and through the mus-\\ncles between the ribs. A chest tube is inserted and\\nsecured in place. The doctor connects one end of the tube\\nto the chest drainage system.\\nThe chest drainage system must remain sealed to\\nprevent air from entering the chest cavity through the\\ntube. One commonly used system is a water-seal\\ndrainage system, comprised of three compartments that\\ncollect and drain the fluid or air without allowing air to\\nbackflow into the tube. An alternative to this system is to\\nconnect the tube to a negative suction pump.\\nOnce the tube and drainage system are in place, a\\nchest x ray is done to confirm that the tube is in the right\\nlocation, and that it is working. In some cases it may be\\nKEY TERMS\\nEmpyema—Pus in the pleural cavity.\\nHemothorax—Blood in the pleural cavity.\\nPleural cavity—The area of the chest that includes\\nthe lining of the chest cavity, the space the lungs\\nare located in, and the membrane covering of the\\nlungs.\\nSpontaneous pneumothorax —Air in the chest\\ncavity that occurs because of disease or other nat-\\nurally occurring cause. Air and blood together in\\nthis space is called a pneumohemothorax.\\nnecessary to insert more than one tube to drain localized\\npockets of fluid that have accumulated.\\nPreparation\\nA chest x ray is usually done before the chest\\ndrainage tube is inserted. Sometimes fluid becomes\\ntrapped in isolated spaces in the lung, and it is necessary\\nto do an ultrasound to determine where to locate the\\ndrainage tube. Computed tomography scans (CT) are\\nuseful in locating small pockets of fluids caused by can-\\ncer or tuberculosis.\\nAftercare\\nNormally after the material has been removed\\nfrom the chest cavity and the situation is resolved, the\\nchest drainage tube is removed. In cases where the rea-\\nson for the tube was air in the pleural cavity, the tube is\\nclamped and left in place several hours before it is\\nremoved to make sure no more air is leaking into the\\nspace. If the patient is on mechanical ventilation, the\\ntube is often left in place until a respirator is no longer\\nnecessary. Chest drainage therapy is usually done in\\nconjunction with treating the underlying cause of the\\nfluid build-up.\\nThe fluid that has been drained is examined for bac-\\nterial growth, cancer cells, pus, and blood—to determine\\nthe underlying cause of the condition and appropriate\\ntreatment.\\nRisks\\nProblems can arise in the insertion of the tube if the\\nmembrane lining the chest cavity is thick or if it has\\nmany adhesions. The tube will not drain correctly if the\\nchest cavity contains blood clots or thick secretions that\\nare often associated with infections. Excessive bleeding\\nmay occur during the insertion and positioning of the\\ntube. Infection may result from the procedure. Pain is\\nalso a common complication.\\nNormal results\\nThe gas, pus, or blood is drained from the chest cavity,\\nand the lungs reinflate or begin to function more efficiently.\\nThe site at which the tube was inserted heals normally.\\nResources\\nBOOKS\\n“Chest Drainage Therapy.” In Everything You Need to Know\\nAbout Medical Treatments.Springhouse, PA: Springhouse\\nCorp., 1996.\\nCurrent Medical Diagnosis and Treatment, 1998.37th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2744\\nChest drainage therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 744'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 133, 'page_label': '134'}, page_content='“Thoracostomy Tube Drainage.” In The Merck Manual of\\nDiagnosis and Therapy.16th ed. Ed. Robert Berkow. Rah-\\nway, NJ: Merck Research Laboratories, 1992.\\nTish Davidson\\nChest pain see Angina\\nChest physical therapy\\nDefinition\\nChest physical therapy is the term for a group of treat-\\nments designed to improve respiratory efficiency, promote\\nexpansion of the lungs, strengthen respiratory muscles,\\nand eliminate secretions from the respiratory system.\\nPurpose\\nThe purpose of chest physical therapy, also called\\nchest physiotherapy, is to help patients breathe more\\nfreely and to get more oxygen into the body. Chest physi-\\ncal therapy includes postural drainage, chest percussion,\\nchest vibration, turning, deep breathing exercises, and\\ncoughing. It is usually done in conjunction with other\\ntreatments to rid the airways of secretions. These other\\ntreatments include suctioning, nebulizer treatments, and\\nthe administration of expectorant drugs.\\nChest physical therapy can be used with newborns,\\ninfants, children, and adults. People who benefit from\\nchest physical therapy exhibit a wide range of problems\\nthat make it difficult to clear secretions from their lungs.\\nSome people who may receive chest physical therapy\\ninclude people with cystic fibrosis or neuromuscular dis-\\neases like Guillain-Barré syndrome, progressive mus-\\ncle weakness ( myasthenia gravis ), or tetanus . People\\nwith lung diseases such as bronchitis , pneumonia ,o r\\nchronic obstructive pulmonary disease (COPD) also ben-\\nefit from chest physical therapy. People who are likely to\\naspirate their mucous secretions because of diseases such\\nas cerebral palsy or muscular dystrophy also receive\\nchest physical therapy, as do some people who are\\nbedridden, confined to a wheelchair, or who cannot\\nbreathe deeply because of postoperative pain.\\nPrecautions\\nChest physical therapy should not be performed on\\npeople with\\n• bleeding from the lungs\\n• neck or head injuries\\n• fractured ribs\\n• collapsed lungs\\n• damaged chest walls\\n• tuberculosis\\n• acute asthma\\n• recent heart attack\\n• pulmonary embolism\\n• lung abscess\\n• active hemorrhage\\n• some spine injuries\\n• recent surgery, open wounds, or burns\\nDescription\\nChest physical therapy can be performed in a variety\\nof settings including critical care units, hospitals, nursing\\nhomes, outpatient clinics, and at the patient’s home.\\nDepending on the circumstances, chest physical therapy\\nmay be performed by anyone from a respiratory care ther-\\napist to a trained member of the patient’s family. Different\\npatient conditions warrant different levels of training.\\nChest physical therapy consists of a variety of proce-\\ndures that are applied depending on the patient’s health\\nand condition. Hospitalized patients are reevaluated fre-\\nquently to establish which procedures are most effective\\nand best tolerated. Patients receiving long term chest phys-\\nical therapy are reevaluated about every three months.\\nTurning\\nTurning from side to side permits lung expansion.\\nPatients may turn themselves or be turned by a caregiver.\\nThe head of the bed is also elevated to promote drainage\\nif the patient can tolerate this position. Critically ill\\npatients and those dependent on mechanical respiration\\nare turned once every one to two hours around the clock.\\nCoughing\\nCoughing helps break up secretions in the lungs so\\nthat the mucus can be suctioned out or expectorated.\\nPatients sit upright and inhale deeply through the nose.\\nThey then exhale in short puffs or coughs. Coughing is\\nrepeated several times a day.\\nDeep breathing\\nDeep breathing helps expand the lungs and forces\\nbetter distribution of the air into all sections of the lung.\\nThe patient either sits in a chair or sits upright in bed and\\ninhales, pushing the abdomen out to force maximum\\namounts of air into the lung. The abdomen is then con-\\ntracted, and the patient exhales. Deep breathing exercises\\nare done several times each day for short periods.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 745\\nChest physical therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 745'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 134, 'page_label': '135'}, page_content='Postural drainage\\nPostural drainage uses the force of gravity to assist\\nin effectively draining secretions from the lungs and into\\nthe central airway where they can either be coughed up\\nor suctioned out. The patient is placed in a head or chest\\ndown position and is kept in this position for up to 15\\nminutes. Critical care patients and those depending on\\nmechanical ventilation receive postural drainage therapy\\nfour to six times daily. Percussion and vibration may be\\nperformed in conjunction with postural drainage.\\nPercussion\\nPercussion is rhythmically striking the chest wall\\nwith cupped hands. It is also called cupping, clapping, or\\ntapotement. The purpose of percussion is to break up\\nthick secretions in the lungs so that they can be more eas-\\nily removed. Percussion is performed on each lung seg-\\nment for one to two minutes at a time.\\nVibration\\nAs with percussion, the purpose of vibration is to\\nhelp break up lung secretions. Vibration can be either\\nKEY TERMS\\nCoughing—Coughing helps break up secretions in\\nthe lungs so that the mucus can be suctioned out or\\nexpectorated. Patients sit upright and inhale deeply\\nthrough the nose. They then exhale in short puffs or\\ncoughs. Coughing is repeated several times per day.\\nDeep breathing—Deep breathing helps expand the\\nlungs and forces better distribution of the air into all\\nsections of the lung. The patient either sits in a chair\\nor sits upright in bed and inhales, pushing the\\nabdomen out to force maximum amounts of air into\\nthe lung. The abdomen is then contracted, and the\\npatient exhales. Deep breathing exercises are done\\nseveral times each day for short periods.\\nPercussion —This consists of rhythmically striking\\nthe chest wall with cupped hands. It is also called\\ncupping, clapping, or tapotement. The purpose of\\npercussion is to break up thick secretions in the\\nlungs so that they can be more easily removed. Per-\\ncussion is performed on each lung segment for one\\nto two minutes at a time.\\nPostural drainage—This technique uses the force of\\ngravity to assist in effectively draining secretions\\nfrom the lungs and into the central airway where\\nthey can either be coughed up or suctioned out. The\\npatient is placed in a head or chest down position\\nand is kept in this position for up to 15 minutes. Crit-\\nical care patients and those depending on mechani-\\ncal ventilation receive postural draingage therapy\\nfour to six times daily. Percussion and vibration may\\nbe performed in conjunction with postural drainage.\\nTurning—Turning from side to side permits lung\\nexpansion. Patients may turn themselves or be\\nturned by a caregiver. The head of the bed is also\\nelevated to promote drainage if the patient can tol-\\nerate this position. Critically ill patients and those\\ndependent on mechanical respiration are turned\\nonce every one to two hours around the clock.\\nVibration—The purpose of vibration is to help\\nbreak up lung secretions. Vibration can be either\\nmechanical or manual. It is performed as the\\npatient breathes deeply. When done manually, the\\nperson performing the vibration places his or her\\nhands against the patient’s chest and creates vibra-\\ntions by quickly contracting and relaxing arm and\\nshoulder muscles while the patient exhales. The\\nprocedure is repeated several times each day for\\nabout five exhalations.\\nmechanical or manual. It is performed as the patient\\nbreathes deeply. When done manually, the person per-\\nforming the vibration places his or her hands against the\\npatient’s chest and creates vibrations by quickly contract-\\ning and relaxing arm and shoulder muscles while the\\npatient exhales. The procedure is repeated several times\\neach day for about five exhalations.\\nPreparation\\nThe only preparation needed for chest physical ther-\\napy is an evaluation of the patient’s condition and deter-\\nmination of which chest physical therapy techniques\\nwould be most beneficial.\\nAftercare\\nPatients practice oral hygiene procedures to lessen\\nthe bad taste or odor of the secretions they spit out.\\nRisks\\nRisks and complications associated with chest phys-\\nical therapy depend on the health of the patient. Although\\nGALE ENCYCLOPEDIA OF MEDICINE 2746\\nChest physical therapy\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 746'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 135, 'page_label': '136'}, page_content='chest physical therapy usually poses few problems, in\\nsome patients it may cause\\n• oxygen deficiency if the head is kept lowered for\\ndrainage\\n• increased intracranial pressure\\n• temporary low blood pressure\\n• bleeding in the lungs\\n• pain or injury to the ribs, muscles, or spine\\n• vomiting\\n• inhaling secretions into the lungs\\n• heart irregularities\\nNormal results\\nThe patient is considered to be responding positively\\nto chest physical therapy if some, but not necessarily all,\\nof these changes occur:\\n• increased volume of sputum secretions\\n• changes in breath sounds\\n• improved vital signs\\n• improved chest x ray\\n• increased oxygen in the blood as measured by arterial\\nblood gas values\\n• patient reports of eased breathing\\nResources\\nPERIODICALS\\n“AARC Clinical Practical Guideline: Postural Drainage.”Res-\\npiratory Care 36 (1991): 1418-1426.\\nORGANIZATIONS\\nCystic Fibrosis Foundation. 6931 Arlington Road, Bethesda,\\nMD 20814. (800) 344-4823. .\\nTish Davidson\\nChest radiography see Chest x ray\\nChest x ray\\nDefinition\\nA chest x ray is a procedure used to evaluate organs\\nand structures within the chest for symptoms of disease.\\nChest x rays include views of the lungs, heart, small por-\\ntions of the gastrointestinal tract, thyroid gland and the\\nbones of the chest area. X rays are a form of radiation\\nthat can penetrate the body and produce an image on an\\nx-ray film. Another name for x ray is radiograph.\\nPurpose\\nChest x rays are ordered for a wide variety of diag-\\nnostic purposes. In fact, this is probably the most frequent-\\nly performed x ray. In some cases, chest x rays are ordered\\nfor a single check of an organ’s condition, and at other\\ntimes, serial x rays are ordered to compare to previous\\nstudies. Some common reasons for chest x rays include:\\nPulmonary disorders\\nChest films are frequently ordered to diagnose or\\nrule out pneumonia. Other pulmonary disorders such as\\nemphysema or pneumothorax (presence of air or gas in\\nthe chest cavity outside the lungs) may be detected or\\nevaluated through the use of chest x ray.\\nCancer\\nA chest x ray may be ordered by a physician to\\ncheck for possible tumors of the lungs, thyroid, lymphoid\\ntissue, or bones of the thorax. These may be primary\\ntumors. X rays also check for secondary spread of can-\\ncer from one organ to another.\\nCardiac disorders\\nWhile less sensitive than echocardiography, chest x\\nray can be used to check for disorders such as congestive\\nheart failure or pulmonary edema.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 747\\nChest x ray\\nA normal chest x ray of a child. (Photograph by Peter Berndt,\\nM.D., P .A, Custom Medical Stock Photo. Reproduced by per-\\nmission.)\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 747'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 136, 'page_label': '137'}, page_content='Other\\nTuberculosis can be observed on chest x rays, as\\ncan cardiac disease and damage to the ribs or lungs.\\nChest x rays are used to see foreign bodies that may\\nhave been swallowed or inhaled, and to evaluate\\nresponse to treatment for various diseases. Often the\\nchest x ray is also used to verify correct placement of\\nchest tubes or catheters.\\nKEY TERMS\\nBronchi—Plural of bronchus. The air passages in\\nthe lungs through which inhaled air passes on its\\nway to the lungs.\\nDiaphragm —The large muscle that is located\\nbetween the abdomen and the chest area. The\\ndiaphragm aids in breathing.\\nGastrointestinal—The digestive organs and struc-\\ntures, including the stomach and intestines.\\nInterstitial lung disease —About 180 diseases fall\\ninto this category of breathing disorders. Injury or\\nforeign substances in the lungs, (such as asbestos\\nfibers) as well as infections, cancers, or inherited\\ndisorders may cause the diseases. They can lead to\\nbreathing or heart failure.\\nLymphoid—Tissues relating to the lymphatic sys-\\ntem. A thin, yellowish fluid, called lymph fluid,\\ntravels throughout the body. The lymphatic system\\nhelps control fluids in the body.\\nPortable chest x ray—An x ray procedure taken by\\nequipment that can be brought to the patient. The\\nresulting radiographs may not be as high in quality\\nas stationary x ray radiographs, but allow a tech-\\nnologist to come to the bedridden patient.\\nPulmonary—Refers to the lungs and the breathing\\nsystem and function.\\nSerial x rays—A number of x rays performed at set\\ntimes in the disease progression or treatment inter-\\nvals. The radiographs will be compared to one\\nanother to track changes.\\nSternum—Also referred to as the breast bone, this\\nis the long flat bone in the middle of the chest.\\nThorax—The chest area, which runs between the\\nabdomen and neck and is encased in the ribs.\\nX ray—A form of electromagnetic radiation with\\nshorter wavelengths than normal light. X rays can\\npenetrate most structures.\\nPrecautions\\nPregnant women, particularly those in the first or\\nsecond trimester, should not have chest x rays unless\\nabsolutely necessary. If the exam is ordered, women who\\nare, or could possibly be, pregnant must wear a protec-\\ntive lead apron. Because the procedure involves radia-\\ntion, care should always be taken to avoid overexposure,\\nparticularly for children. However, the amount of radia-\\ntion from one chest x ray procedure is minimal.\\nDescription\\nRoutine chest x rays consist of two views, the frontal\\nview (referred to as posterioranterior or PA), and the lat-\\neral (side) view. It is preferred that the patient stand for\\nthis exam, particularly when studying collection of fluid\\nin the lungs.\\nDuring the actual time of exposure, the technologist\\nwill ask the patient to hold his or her breath. It is very\\nimportant in taking a chest x ray to ensure there is no\\nmotion that could detract from the quality and sharpness\\nof the film image. The procedure will only take a few\\nminutes and the time patients must hold their breaths is a\\nmatter of a few seconds.\\nThe chest x ray may be performed in a physician’s\\noffice or referred to an outpatient radiology facility or\\nhospital radiology department. In some cases, particular-\\nly for bedridden patients, a portable chest x ray may be\\ntaken. Portable films are sometimes of poorer quality\\nthan those taken with permanent equipment, but are the\\nbest choice for some patients or situations. Bedridden\\npatients may be placed in as upright a position as possi-\\nble to get a clear picture, particularly of chest fluid.\\nPreparation\\nThere is no advance preparation necessary for chest\\nx rays. Once the patient arrives at the exam area, a hospi-\\ntal gown will replace all clothing on the upper body and\\nall jewelry must be removed.\\nAftercare\\nNo aftercare is required by patients who have chest x\\nrays.\\nRisks\\nThe only risk associated with chest x ray is minimal\\nexposure to radiation, particularly for pregnant women\\nand children. Those patients should use protective lead\\naprons during the procedure. Technologists are cautioned\\nto carefully check possible dislodging of any tubes or\\nGALE ENCYCLOPEDIA OF MEDICINE 2748\\nChest x ray\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 748'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 137, 'page_label': '138'}, page_content='monitors in the chest area from the patient’s placement\\nduring the exam.\\nNormal results\\nA radiologist, or physician specially trained in the\\ntechnique and interpretation of x rays, will evaluate the\\nresults. A normal chest x ray will show normal structures\\nfor the age and medical history or the patient. Findings,\\nwhether normal or abnormal, will be provided to the\\nreferring physician in the form of a written report.\\nAbnormal results\\nAbnormal findings on chest x rays are used in con-\\njunction with a physician’s physical exam findings,\\npatient medical history and other diagnostic tests to reach\\na final diagnosis. For many diseases, chest x rays are\\nmore effective when compared to previous chest studies.\\nThe patient is asked to help the radiology facility in\\nlocating previous chest radiographs from other facilities.\\nPulmonary disorders\\nPneumonia shows up on radiographs as patches and\\nirregular areas of density (from fluid in the lungs). If the\\nbronchi, which are usually not visible, can be seen, a\\ndiagnosis of bronchial pneumonia may be made. Shifts or\\nshadows in the hila (lung roots) may indicate emphysema\\nor a pulmonary abscess. Widening of the spaces between\\nribs suggests emphysema. Other pulmonary diseases may\\nalso be detected or suspected through chest x ray.\\nCancer\\nIn nearly all patients with lung cancer, some sort of\\nabnormality can be seen on a chest radiograph. Hilar\\nmasses (enlargements at that part of the lungs where ves-\\nsels and nerves enter) are one of the more common\\nsymptoms as are abnormal masses and fluid buildup on\\nthe outside surface of the lungs or surrounding areas.\\nInterstitial lung disease, which is a large category of dis-\\norders, many of which are related to exposure of sub-\\nstances (such as asbestos fibers), may be detected on a\\nchest x ray as fiberlike deposits, often in the lower por-\\ntions of the lungs.\\nOther\\nCongestive heart failure and other cardiac diseases\\nmay be indicated on the view of a heart and lung in a\\nchest radiograph. Fractures of the sternum and ribs are\\nusually easily detected as breaks on the chest x ray. In\\nsome instances, the radiologist’s view of the diaphragm\\nmay indicate an abdominal problem. Tuberculosis can\\nalso be indicated by elevation of the diaphragm. Foreign\\nbodies which may have been swallowed or inhaled can\\nusually be located by the radiologist as they will look dif-\\nferent from any other tissue or structure in the chest. Ser-\\nial chest x rays may be ordered to track changes over a\\nperiod of time.\\nResources\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nEmphysema Anonymous, Inc. P.O. Box 3224, Seminole, FL\\n34642. (813)391-9977.\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTeresa Norris, RN\\nChickenpox\\nDefinition\\nChickenpox (also called varicella) is a common and\\nextremely infectious childhood disease that also affects\\nadults on occasion. It produces an itchy, blistery rash that\\ntypically lasts about a week and is sometimes accompa-\\nnied by a fever or other symptoms. A single attack of\\nchickenpox almost always confers lifelong immunity\\nagainst the disease. Because the symptoms of chicken-\\npox are easily recognized and in most cases merely\\nunpleasant rather than dangerous, treatment can almost\\nalways be carried out at home. Severe complications can\\ndevelop, however, and professional medical attention is\\nessential in some circumstances.\\nDescription\\nBefore the varicella vaccine (Varivax) was released\\nfor use in 1995, virtually all of the four million children\\nborn each year in the United States contracted chicken-\\npox, resulting in hospitalization in five of every 1,000\\ncases and 100 deaths. Chickenpox is caused by the vari-\\ncella-zoster virus (a member of the herpes virus family),\\nwhich is spread through the air or by direct contact with\\nan infected person. Once someone has been infected with\\nthe virus, an incubation period of about 10–21 days pass-\\nes before symptoms begin. The period during which\\ninfected people are able to spread the disease is believed\\nto start one or two days before the rash breaks out and to\\ncontinue until all the blisters have formed scabs, which\\nusually happens fout to seven days after the rash breaks\\nGALE ENCYCLOPEDIA OF MEDICINE 2 749\\nChickenpox\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 749'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 138, 'page_label': '139'}, page_content='out but may be longer in adolescents and adults. For this\\nreason, doctors recommend keeping children with chick-\\nenpox away from school for about a week. It is not nec-\\nessary, however, to wait until all the scabs have fallen off.\\nChickenpox has been a typical part of growing up for\\nmost children in the industrialized world (although this\\nmay change if the new varicella vaccine becomes more\\nwidely accepted). The disease can strike at any age, but\\nby ages nine or 10 about 80–90% of American children\\nhave already been infected. U.S. children living in rural\\nareas and many foreign-born children are less likely to be\\nimmune. Because almost every case of chickenpox, no\\nmatter how mild, leads to lifelong protection against fur-\\nther attacks, adults account for less than 5% of all cases in\\nthe United States. Study results reported by the Centers\\nfor Disease Control and Prevention (CDC) indicate that\\nmore than 90% of American adults are immune to the\\nchickenpox virus. Adults, however, are much more likely\\nthan children to suffer dangerous complications. More\\nthan half of all chickenpox deaths occur among adults.\\nCauses and symptoms\\nA case of chickenpox usually starts without warning\\nor with only a mild fever and a slight feeling of unwellness.\\nWithin a few hours or days small red spots begin to appear\\non the scalp, neck, or upper half of the trunk. After a further\\n12–24 hours the spots typically become itchy, fluid-filled\\nbumps called vesicles, which continue to appear in crops\\nfor the next two to five days. In any area of skin, lesions of\\na variety of stages can be seen. These blisters can spread to\\ncover much of the skin, and in some cases may also be\\nfound inside the mouth, nose, ears, vagina, or rectum.\\nSome people develop only a few blisters, but in most cases\\nthe number reaches 250–500. The blisters soon begin to\\nform scabs and fall off. Scarring usually does not occur\\nunless the blisters have been scratched and become infect-\\ned. Occasionally a minor and temporary darkening of the\\nskin (called hyperpigmentation) is noticed around some\\nof the blisters. The degree of itchiness can range from bare-\\nly noticeable to extreme. Some chickenpox sufferers also\\nhave headaches, abdominal pain, or a fever. Full recovery\\nusually takes five to 10 days after the first symptoms\\nappear. Again, the most severe cases of the disease tend to\\nbe found among older children and adults.\\nAlthough for most people chickenpox is no more\\nthan a matter of a few days’ discomfort, some groups are\\nat risk for developing complications, the most common\\nof which are bacterial infections of the blisters, pneumo-\\nnia, dehydration, encephalitis, and hepatitis:\\n• Infants. Complications occur much more often among\\nchildren less than one year old than among older chil-\\ndren. The threat is greatest to newborns, who are more\\nat risk of death from chickenpox than any other group.\\nUnder certain circumstances, children born to mothers\\nwho contract chickenpox just prior to delivery face an\\nincreased possibility of dangerous consequences,\\nincluding brain damage and death. If the infection\\noccurs during early pregnancy , there is a small (less\\nthan 5%) risk of congenital abnormalities.\\n• Immunocompromised children. Children whose\\nimmune systems have been weakened by a genetic dis-\\norder, disease, or medical treatment usually experience\\nthe most severe symptoms of any group. They have the\\nsecond-highest rate of death from chickenpox.\\n• Adults and children 15 and older. Among this group,\\nthe typical symptoms of chickenpox tend to strike with\\ngreater force, and the risk of complications is much\\nhigher than among young children.\\nImmediate medical help should always be sought\\nwhen anyone in these high-risk groups contracts the dis-\\nease.\\nDiagnosis\\nWhere children are concerned, especially those with\\nrecent exposure to the disease, diagnosis can usually be\\nmade at home, by a school nurse, or by a doctor over the\\ntelephone if the child’s parent or caregiver is unsure that\\nthe disease is chickenpox.\\nA doctor should be called immediately if:\\n• The child’s fever goes above 102°F (38.9°C) or takes\\nmore than four days to disappear.\\n• The child’s blisters appear infected. Signs of infection\\ninclude leakage of pus from the blisters or excessive\\nredness, warmth, tenderness, or swelling around the\\nblisters.\\n• The child seems nervous, confused, unresponsive, or\\nunusually sleepy; complains of a stiff neck or severe\\nheadache ; shows signs of poor balance or has trouble\\nwalking; finds bright lights hard to look at; is having\\nbreathing problems or is coughing a lot; is complaining\\nof chest pain; is vomiting repeatedly; or is having con-\\nvulsions. These may be signs of Reye’s syndrome or\\nencephalitis, two rare but potentially very dangerous\\nconditions.\\nTreatment\\nWith children, treatment usually takes place in the\\nhome and focuses on reducing discomfort and fever.\\nBecause chickenpox is a viral disease, antibiotics are\\nineffective against it.\\nApplying wet compresses or bathing the child in cool\\nor lukewarm water once a day can help the itch. Adding\\nGALE ENCYCLOPEDIA OF MEDICINE 2750\\nChickenpox\\nGEM -0625 to 1002 - C 10/22/03 6:10 PM Page 750'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 139, 'page_label': '140'}, page_content='four to eight ounces of baking soda or one or two cups of\\noatmeal to the bath is a good idea (oatmeal bath packets\\nare sold by pharmacies). Only mild soap should be used\\nin the bath. Patting, not rubbing, is recommended for dry-\\ning the child off, to prevent irritating the blisters.\\nCalamine lotion (and some other kinds of lotions) also\\nhelp to reduce itchiness. Because scratching can cause\\nblisters to become infected and lead to scarring, the\\nchild’s nails should be cut short. Of course, older children\\nneed to be warned not to scratch. For babies, light mittens\\nor socks on the hands can help guard against scratching.\\nIf mouth blisters make eating or drinking an\\nunpleasant experience, cold drinks and soft, bland foods\\ncan ease the child’s discomfort. Painful genital blisters\\ncan be treated with an anesthetic cream recommended by\\na doctor or pharmacist. Antibiotics are often prescribed if\\nblisters become infected.\\nFever and discomfort can be reduced by aceta-\\nminophen or another medication that does not contain\\naspirin . Aspirin and any medications that contain\\naspirin or other salicylates must not be used with chick-\\nenpox, for they appear to increase the chances of devel-\\noping Reye’s syndrome.The best idea is to consult a doc-\\ntor or pharmacist if one is unsure about which medica-\\ntions are safe.\\nImmunocompromised chickenpox sufferers are\\nsometimes given an antiviral drug called acyclovir (Zovi-\\nrax). Studies have shown that Zovirax also lessens the\\nsymptoms of otherwise healthy children and adults who\\ncontract chickenpox, but the suggestion that it should be\\nused to treat the disease among the general population,\\nespecially in children, is controversial.\\nAlternative treatment\\nAlternative practitioners seek to lessen the discom-\\nfort and fever caused by chickenpox. Like other practi-\\ntioners, they suggest cool or lukewarm baths. Rolled oats\\n(Avena sativa ) in the bath water help relieve itching .\\n(Place oats in a sock, run the bath, turn the sock to\\nrelease the milky anti-itch properties.) Other recom-\\nmended remedies for itching include applying aloe vera,\\nwitch hazel, or herbal preparations of rosemary (Rosmar-\\ninus officinalis) and calendula ( Calendual officinalis ) to\\nthe blisters. Homeopathic remedies are selected on a case\\nby case basis. Some common remedy choices are tartar\\nemetic (antimonium tartaricum), windflower (pulsatilla),\\npoison ivy (Rhus toxicodendron), and sulphur.\\nPrognosis\\nMost cases of chickenpox run their course within a\\nweek without causing lasting harm. However, there is\\none long-term consequence of chickenpox that strikes\\nabout 20% of the population, particularly people 50 and\\nolder. Like all herpes viruses, the varicella-zoster virus\\nnever leaves the body after an episode of chickenpox, but\\nlies dormant in the nerve cells, where it may be reactivat-\\ned years later by disease or age-related weakening of the\\nimmune system. The result is shingles (also called her-\\npes zoster), a very painful nerve inflammation, accompa-\\nnied by a rash, that usually affects the trunk or the face\\nfor 10 days or more. Especially in the elderly, pain,\\ncalled postherpetic neuralgia , may persist at the site of\\nthe shingles for months or years. As of 1998, two newer\\ndrugs for treatment of shingles are available. Both vala-\\ncyclovir (Valtrex) and famciclovir (Famvir) stop the\\nreplication of herpes zoster when administered within 72\\nhours of appearance of the rash. The effectiveness of\\nthese two drugs in immunocompromised patients has not\\nGALE ENCYCLOPEDIA OF MEDICINE 2 751\\nChickenpox\\nA five-year-old girl with chickenpox.The first symptom of\\nthe disease is the rash that is evident on the girl’s back and\\nneck.The rash and the mild fever that accompanies it\\nshould disappear in a week or two.(Photograph by Jim Selby,\\nPhoto Researchers, Inc. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 751'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 140, 'page_label': '141'}, page_content='been established, and Famvir is not recommended for\\npatients under 18 years, as of 1998.\\nPrevention\\nA substance known as varicella-zoster immune\\nglobulin (VZIG), which reduces the severity of chick-\\nenpox symptoms, is available to treat immunocompro-\\nmised children and others at high risk of developing\\ncomplications. It is administered by injection within\\n96 hours of known or suspected exposure to the dis-\\nease and is not useful after that. VZIG is produced as a\\ngamma globulin from blood of recently infected indi-\\nviduals.\\nA vaccine for chickenpox became available in the\\nUnited States in 1995 under the name Varivax. Varivax\\nis a live, attenuated (weakened) virus vaccine. It has\\nbeen proven to be 85% effective for preventing all cases\\nof chickenpox and close to 100% effective in prevent-\\ning severe cases. Side effects are normally limited to\\noccasional soreness or redness at the injection site.\\nCDC guidelines state that the vaccine should be given\\nto all children (with the exception of certain high-risk\\ngroups) at 12–18 months of age, preferably when they\\nKEY TERMS\\nAcetaminophen —A drug for relieving pain and\\nfever. Tylenol is the most common example.\\nAcyclovir —An antiviral drug used for combating\\nchickenpox and other herpes viruses. Sold under\\nthe name Zovirax.\\nDehydration—Excessive water loss by the body.\\nEncephalitis—A disease that inflames the brain.\\nHepatitis—A disease that inflames the liver.\\nImmune system—A biochemical complex that pro-\\ntects the body against pathogenic organisms and\\nother foreign bodies.\\nImmunocompromised—Having a damaged immune\\nsystem.\\nPneumonia—A disease that inflames the lungs.\\nPus—A thick yellowish or greenish fluid containing\\ninflammatory cells. Usually caused by bacterial\\ninfection.\\nReye’s syndrome—A rare but often fatal disease that\\ninvolves the brain, liver, and kidneys.\\nSalicylates —Substances containing salicylic acid,\\nwhich are used for relieving pain and fever. Aspirin\\nis the most common example.\\nShingles—A disease (also called herpes zoster) that\\ncauses a rash and a very painful nerve inflamma-\\ntion. An attack of chickenpox will eventually give\\nrise to shingles in about 20% of the population.\\nTrunk—That part of the body that does not include\\nthe head, arms, and legs.\\nVaricella-zoster immune globulin (VZIG) —A sub-\\nstance that can reduce the severity of chickenpox\\nsymptoms.\\nVaricella-zoster virus—The virus that causes chick-\\nenpox and shingles.\\nVarivax—A vaccine for the prevention of chicken-\\npox.\\nVirus—A tiny particle that can cause infections by\\nduplicating itself inside a cell using the cell’s own\\nsoftware. Antibiotics are ineffective against viruses,\\nthough antiviral drugs exist for some viruses,\\nincluding chickenpox.\\nreceive their measles-mumps-rubella vaccine. For older\\nchildren, up to age 12, the CDC recommends vaccina-\\ntion when a reliable determination that the child in\\nquestion has already had chickenpox cannot be made.\\nVaccination is also recommended for any older child or\\nadult considered susceptible to the disease, particularly\\nthose, such as health care workers and women of child-\\nbearing age, who face a greater likelihood of severe ill-\\nness or transmitting infection. A single dose of the vac-\\ncine is sufficient for children up to age 12; older chil-\\ndren and adults receive a second dose four to eight\\nweeks later. In 1997 the cost of two adult doses of the\\nvaccine in the United States was about $80. Although\\nthis cost was not always covered by health insurance\\nplans, children up to age 18 without access to the\\nappropriate coverage could be vaccinated free of charge\\nthrough the federal Vaccines for Children program.\\nVarivax is not given to patients who already have overt\\nsigns of the disease. The vaccine is also not recom-\\nmended for those women who are pregnant, or they\\nshould delay pregnancy for three months following a\\ncomplete vaccination. The vaccine is useful when given\\nearly after exposure to chickenpox and, if given in the\\nmidst of the incubation period, it can be preventative.\\nThe Infectious Diseases Society of America stated in\\nGALE ENCYCLOPEDIA OF MEDICINE 2752\\nChickenpox\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 752'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 141, 'page_label': '142'}, page_content='2000 that immunization is recommended for all adults\\nwho have never had chickenpox.\\nWhile there was initial concern regarding the vac-\\ncine’s safety and effectiveness when first released, the\\nvaccination is gaining acceptance as numerous states\\nrequire it for admittance into day care or public school.\\nIn 2000, 59% of toddlers in the United States were\\nimmunized; up from 43.2% in 1998. A study published\\nin 2001 indicates that the varicella vaccine is highly\\neffective when used in clinical practice. Although evi-\\ndence has not ruled out a booster shot later in life, all\\nresearch addressing the vaccine’s effectiveness through-\\nout its six-year use indicates that chickenpox may be\\nthe first human herpesvirus to be wiped out. Although\\ninitial concerns questioned if the vaccination might\\nmake shingles more likely, studies are beginning to\\nshow the effectiveness of the vaccine in reducing cases\\nof that disease.\\nResources\\nBOOKS\\nThe Burton Goldberg Group. Alternative Medicine: The Defin-\\nitive Guide. Puyallup, W A: Future Medicine Publishing,\\n1993.\\nPattishall, Evan G., III. “Chickenpox.” In Primary Pediatric\\nCare, edited by Robert A. Hoekelman, et al. St. Louis:\\nMosby, 1997.\\nPERIODICALS\\nArvin, Ann M. “Varicella Vaccine—The First Six Years.”New\\nEngland Journal of Medicine 344, no. 13 (March 2001).\\nHenderson, C. W. “Chickenpox Immunization Confirmed Effec-\\ntive in Adults.”Vaccine Weekly(September 2000): 22.\\nShapiro, Eugene D., and Phillip S. LaRussa. “Vaccination for\\nVaricella—Just Do It!” Journal of the American Medical\\nAssociation 278 (1997): 1529-1530.\\nORGANIZATION\\nCenters for Disease Control and Prevention. National Immu-\\nnization Hotline. 1600 Clifton Rd. NE, Atlanta, GA\\n30333. (800) 232-2522 (English). (800) 232-0233 (Span-\\nish). .\\nOTHER\\nABCNEWS.com. “Varicella Vaccine: States Mandate Chicken-\\npox Immunization.” 1 August 2000. . (3 May 2001).\\nCenters for Disease Control and Prevention. “Prevention of\\nVaricella: Recommendations of the Advisory Committee\\non Immunization Practices (ACIP).” 12 July 1996. . (12 December 1997).\\nBeth Kapes\\nChild abuse\\nDefinition\\nChild abuse is the blanket term for four types of\\nchild mistreatment: physical abuse, sexual abuse, emo-\\ntional abuse, and neglect. In many cases children are the\\nvictims of more than one type of abuse. The abusers can\\nbe parents or other family members, caretakers such as\\nteachers and babysitters, acquaintances (including other\\nchildren), and (in rare instances) strangers.\\nDescription\\nPrevalence of abuse\\nChild abuse was once viewed as a minor social prob-\\nlem affecting only a handful of United States children.\\nHowever, in recent years it has received close attention from\\nthe media, law enforcement, and the helping professions,\\nand with increased public and professional awareness has\\ncome a sharp rise in the number of reported cases. But\\nbecause abuse is often hidden from view and its victims too\\nyoung or fearful to speak out, experts suggest that its true\\nprevalence is possibly much greater than the official data\\nindicate. In 1996, more than three million victims of alleged\\nabuse were reported to child protective services (CPS) agen-\\ncies in the United States, and the reports were substantiated\\nin more than one million cases. Put another way, 1.5% of\\nthe country’s children were confirmed victims of abuse in\\n1996. Parents were the abusers in 77% of the confirmed\\ncases, other relatives in 11%. Sexual abuse was more likely\\nto be committed by males, whereas females were responsi-\\nble for the majority of neglect cases. More than 1,000 Unit-\\ned States children died from abuse in 1996.\\nAlthough experts are quick to point out that abuse\\noccurs among all social, ethnic, and income groups,\\nreported cases usually involve poor families with little\\neducation. Young mothers, single-parent families, and\\nparental alcohol or drug abuse are also common in report-\\ned cases. Charles F. Johnson remarks, “More than 90% of\\nabusing parents have neither psychotic nor criminal per-\\nsonalities. Rather they tend to be lonely, unhappy, angry,\\nyoung, and single parents who do not plan their pregnan-\\ncies, have little or no knowledge of child development, and\\nhave unrealistic expectations for child behavior.” About\\n10%, or perhaps as many as 40%, of abusive parents were\\nthemselves physically abused as children, but most abused\\nchildren do not grow up to be abusive parents.\\nTypes of abuse\\nPHYSICAL ABUSE. Physical abuse is the nonacciden-\\ntal infliction of physical injury to a child. The abuser is\\nGALE ENCYCLOPEDIA OF MEDICINE 2 753\\nChild abuse\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 753'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 142, 'page_label': '143'}, page_content='usually a family member or other caretaker, and is more\\nlikely to be male. In 1996, 24% of the confirmed cases of\\nUnited Stateschild abuse involved physical abuse.\\nA rare form of physical abuse is Munchausen syn-\\ndrome by proxy, in which a caretaker (most often the\\nmother) seeks attention by making the child sick or\\nappear to be sick.\\nSEXUAL ABUSE. Charles F. Johnson defines child\\nsexual abuse as “any activity with a child, before the age\\nof legal consent, that is for the sexual gratification of an\\nadult or a significantly older child.” It includes, among\\nother things, sexual touching and penetration, persuading\\na child to expose his or her sexual organs, and allowing a\\nchild to view pornography. In most cases the child is\\nrelated to or knows the abuser, and about one in five\\nabusers are themselves underage. Sexual abuse was pre-\\nsent in 12% of the confirmed 1996 abuse cases. An esti-\\nmated 20–25% of females and 10–15% of males report\\nthat they were sexually abused by age 18.\\nEMOTIONAL ABUSE. Emotional abuse, according to\\nRichard D. Krugman, “has been defined as the rejection,\\nignoring, criticizing, isolation, or terrorizing of children,\\nall of which have the effect of eroding their self-esteem.”\\nEmotional abuse usually expresses itself in verbal attacks\\ninvolving rejection, scapegoating, belittlement, and so\\nforth. Because it often accompanies other types of abuse\\nand is difficult to prove, it is rarely reported, and\\naccounted for only 6% of the confirmed 1996 cases.\\nNEGLECT. Neglect—failure to satisfy a child’s basic\\nneeds—can assume many forms. Physical neglect is the\\nfailure (beyond the constraints imposed by poverty) to\\nprovide adequate food, clothing, shelter, or supervision.\\nEmotional neglect is the failure to satisfy a child’s nor-\\nmal emotional needs, or behavior that damages a child’s\\nnormal emotional and psychological development (such\\nas permitting drug abuse in the home). Failing to see that\\na child receives proper schooling or medical care is also\\nconsidered neglect. In 1996 neglect was the finding in\\n52% of the confirmed abuse cases.\\nCauses and symptoms\\nPhysical abuse\\nThe usual physical abuse scenario involves a parent\\nwho loses control and lashes out at a child. The trigger\\nmay be normal child behavior such as crying or dirtying\\na diaper. Unlike nonabusive parents, who may become\\nangry at or upset with their children from time to time\\nbut are genuinely loving, abusive parents tend to harbor\\ndeep-rooted negative feelings toward their children.\\nUnexplained or suspicious bruises or other marks\\non the skin are typical signs of physical abuse, as are\\nburns . Skull and other bone fractures are often seen\\nin young abused children, and in fact, head injuries are\\nthe leading cause of death from abuse. Children less\\nthan one year old are particularly vulnerable to injury\\nfrom shaking. This is called shaken baby syndrome\\nor shaken impact syndrome. Not surprisingly, physical\\nabuse also causes a wide variety of behavioral changes\\nin children.\\nSexual abuse\\nJohn M. Leventhal observes, “The two prerequisites\\nfor this form of maltreatment include sexual arousal to\\nchildren and the willingness to act on this arousal. Fac-\\ntors that may contribute to this willingness include alco-\\nhol or drug abuse, poor impulse control, and a belief that\\nthe sexual behaviors are acceptable and not harmful to\\nthe child.” The chances of abuse are higher if the child is\\ndevelopmentally handicapped or vulnerable in some\\nother way.\\nGenital or anal injuries or abnormalities (including\\nthe presence of sexually transmitted diseases ) can be\\nsigns of sexual abuse, but often there is no physical evi-\\ndence for a doctor to find. In fact, physical examinations\\nof children in cases of suspected sexual abuse supply\\ngrounds for further suspicion only 15–20% of the time.\\nAnxiety, poor academic performance, and suicidal con-\\nduct are some of the behavioral signs of sexual abuse, but\\nare also found in children suffering other kinds of stress.\\nExcessive masturbation and other unusually sexualized\\nkinds of behavior are more closely associated with sexu-\\nal abuse itself.\\nEmotional abuse\\nEmotional abuse can happen in many settings: at\\nhome, at school, on sports teams, and so on. Some of the\\npossible symptoms include loss of self-esteem, sleep dis-\\nturbances, headaches or stomachaches, school avoid-\\nance, and running away from home.\\nNeglect\\nMany cases of neglect occur because the parent\\nexperiences strong negative feelings toward the child.\\nAt other times, the parent may truly care about the\\nchild, but lack the ability or strength to adequately pro-\\nvide for the child’s needs because he or she is handi-\\ncapped by depression, drug abuse, mental retardation ,\\nor some other problem.\\nNeglected children often do not receive adequate\\nnourishment or emotional and mental stimulation. As a\\nresult, their physical, social, emotional, and mental\\ndevelopment is hindered. They may, for instance, be\\nGALE ENCYCLOPEDIA OF MEDICINE 2754\\nChild abuse\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 754'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 143, 'page_label': '144'}, page_content='underweight, develop language skills less quickly than\\nother children, and seem emotionally needy.\\nDiagnosis\\nDoctors and many other professionals who work\\nwith children are required by law to report suspected\\nabuse to their state’s Child Protective Services (CPS)\\nagency. Abuse investigations are often a group effort\\ninvolving medical personnel, social workers, police\\nofficers, and others. Some hospitals and communities\\nmaintain child protection teams that respond to cases\\nof possible abuse. Careful questioning of the parents\\nis crucial, as is interviewing the child (if he or she is\\ncapable of being interviewed). The investigators\\nmust ensure, however, that their questioning does not\\nfurther traumatize the child. A physical examination\\nfor signs of abuse or neglect is, of course, always\\nGALE ENCYCLOPEDIA OF MEDICINE 2 755\\nChild abuse\\nChild Abuse: Signs And Symptoms\\nAlthough these signs do not necessarily indicate that a child has been abused, they may help adults recognize that something is wrong. The possibility of abuse\\nshould be investigated if a child shows a number of these symptoms, or any of them to a marked degree:\\nSexual Abuse\\nBeing overly affectionate or knowledgeable in a sexual way inappropriate to the child’s age\\nMedical problems such as chronic itching, pain in the genitals, venereal diseases\\nOther extreme reactions, such as depression, self-mutilation, suicide attempts, running away, overdoses, anorexia\\nPersonality changes such as becoming insecure or clinging\\nRegressing to younger behavior patterns such as thumb sucking or bringing out discarded cuddly toys\\nSudden loss of appetite or compulsive eating\\nBeing isolated or withdrawn\\nInability to concentrate\\nLack of trust or fear someone they know well, such as not wanting to be alone with a babysitter\\nStarting to wet again, day or night/nightmares\\nBecome worried about clothing being removed\\nSuddenly drawing sexually explicit pictures\\nTrying to be “ultra-good” or perfect; overreacting to criticism\\nPhysical Abuse\\nUnexplained recurrent injuries or burns\\nImprobable excuses or refusal to explain injuries\\nWearing clothes to cover injuries, even in hot weather\\nRefusal to undress for gym\\nBald patches\\nChronic running away\\nFear of medical help or examination\\nSelf-destructive tendencies\\nAggression towards others\\nFear of physical contact—shrinking back if touched\\nAdmitting that they are punished, but the punishment is excessive (such as a child being beaten every night to “make him/her study”)\\nFear of suspected abuser being contacted\\nEmotional Abuse\\nPhysical, mental, and emotional development lags\\nSudden speech disorders\\nContinual self-depreciation (“I’m stupid, ugly, worthless, etc.”)\\nOverreaction to mistakes\\nExtreme fear of any new situation\\nInappropriate response to pain (“I deserve this”)\\nNeurotic behavior (rocking, hair twisting, self-mutilation)\\nExtremes of passivity or aggression\\nNeglect\\nConstant hunger\\nPoor personal hygiene\\nNo social relationships\\nConstant tiredness\\nPoor state of clothing\\nCompulsive scavenging\\nEmaciation\\nUntreated medical problems\\nDestructive tendencies\\nA child may be subjected to a combination of different kinds of abuse. It is also possible that a child may show no outward signs and hide what is happening from\\neveryone.\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 755'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 144, 'page_label': '145'}, page_content='necessary, and may include x rays, blood tests, and\\nother procedures.\\nTreatment\\nNotification of the appropriate authorities, treatment\\nof the child’s injuries, and protecting the child from fur-\\nther harm are the immediate priorities in abuse cases. If\\nthe child does not require hospital treatment, protection\\noften involves placing him or her with relatives or in fos-\\nter care. Once the immediate concerns are dealt with, it\\nbecomes essential to determine how the child’s long-\\nterm medical, psychological, educational, and other\\nneeds can best be met, a process that involves evaluating\\nnot only the child’s needs but also the family’s (such as\\nfor drug abuse counseling or parental skills training). If\\nthe child has brothers or sisters, the authorities must\\ndetermine whether they have been abused as well. On\\ninvestigation, signs of physical abuse are discovered in\\nabout 20% of the brothers and sisters of abused children.\\nPrognosis\\nChild abuse can have lifelong consequences.\\nResearch shows that abused children and adolescents are\\nmore likely, for instance, to do poorly in school, suffer\\nemotional problems, develop an antisocial personality,\\nbecome promiscuous, abuse drugs and alcohol, and\\nattempt suicide. As adults they often have trouble estab-\\nlishing intimate relationships. Whether professional treat-\\nment is able to moderate the long-term psychological\\neffects of abuse is a question that remains unanswered.\\nPrevention\\nGovernment efforts to prevent abuse include home-\\nvisitor programs aimed at high-risk families and school-\\nbased efforts to teach children how to respond to attempt-\\ned sexual abuse. Emotional abuse prevention has been\\npromoted through the media.\\nWhen children reach age three, parents should begin\\nteaching them about “bad touches” and about confiding\\nin a suitable adult if they are touched or treated in a way\\nthat makes them uneasy. Parents also need to exercise\\ncaution in hiring babysitters and other caretakers. Any-\\none who suspects abuse should immediately report those\\nsuspicions to the police or his or her local CPS agency,\\nwhich will usually be listed in the blue pages of the tele-\\nphone book under Rehabilitative Services or Child and\\nFamily Services, or in the yellow pages. Round-the-\\nclock crisis counseling for children and adults is offered\\nby the Childhelp USA/IOF Foresters National Child\\nAbuse Hotline. The National Committee to Prevent Child\\nAbuse is an excellent source of information on the many\\nsupport groups and other organizations that help abused\\nand at-risk children and their families. One of these orga-\\nnizations, National Parents Anonymous, sponsors 2,100\\nlocal self-help groups throughout the United States,\\nCanada, and Europe. Telephone numbers for its local\\ngroups are listed in the white pages of the telephone book\\nunder Parents Anonymous or can be obtained by calling\\nthe national headquarters.\\nResources\\nBOOKS\\nJohnson, Charles F. “Abuse and Neglect of Children.” In Nel-\\nson Textbook of Pediatrics, ed. Richard E. Behrman.\\nPhiladelphia: W. B. Saunders Co., 1996.\\nKrugman, Richard D. “Child Abuse & Neglect.” In Pediatric\\nDiagnosis & Treatment, ed. William W. Hay Jr., et al.\\nStamford: Appleton & Lange, 1997.\\nLeventhal, John M. “Child Maltreatment: Neglect to Abuse.” In\\nRudolph’s Pediatric, ed. Abraham M. Rudolph, et al.\\nStamford: Appleton & Lange, 1996.\\nORGANIZATIONS\\nChildhelp USA/IOF Foresters National Child Abuse Hotline.\\n(800) 422-4453.\\nNational Clearinghouse on Child Abuse and Neglect Informa-\\ntion. P.O. Box 1182, Washington, DC 20013-1182. (800)\\n394-3366. .\\nNational Committee to Prevent Child Abuse. 200 S. Michigan\\nAve., 17th Floor, Chicago, IL 60604. (312) 663-3520.\\n.\\nNational Parents Anonymous. 675 W. Foothill Blvd., Suite 220,\\nClaremont, CA 91711. (909) 621-6184.\\nHoward Baker\\nChild development see Children’s health\\nChild safety see Children’s health\\nChildbirth\\nDefinition\\nChildbirth includes both labor (the process of birth)\\nand delivery (the birth itself); it refers to the entire\\nprocess as an infant makes its way from the womb down\\nthe birth canal to the outside world.\\nDescription\\nChildbirth usually begins spontaneously, following\\nabout 280 days after conception, but it may be started by\\nartificial means if the pregnancy continues past 42\\nGALE ENCYCLOPEDIA OF MEDICINE 2756\\nChildbirth\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 756'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 145, 'page_label': '146'}, page_content='weeks gestation. The average length of labor is about 14\\nhours for a first pregnancy and about eight hours in sub-\\nsequent pregnancies. However, many women experience\\na much longer or shorter labor.\\nLabor can be described in terms of a series of phases.\\nFirst stage of labor\\nDuring the first phase of labor, the cervix dilates\\n(opens) from 0–10 cm. This phase has an early, or latent,\\nphase and an active phase. During the latent phase,\\nprogress is usually very slow. It may take quite a while\\nand many contractions before the cervix dilates the first\\nfew centimeters. Contractions increase in strength as\\nlabor progresses. Most women are relatively comfortable\\nduring the latent phase and walking around is encour-\\naged, since it naturally stimulates the process.\\nAs labor begins, the muscular wall of the uterus\\nbegins to contract as the cervix relaxes and expands. As a\\nportion of the amniotic sac surrounding the baby is pushed\\ninto the opening, it bursts under the pressure, releasing\\namniotic fluid. This is called “breaking the bag of waters.”\\nDuring a contraction, the infant experiences intense\\npressure that pushes it against the cervix, eventually forc-\\ning the cervix to stretch open. At the same time, the con-\\ntractions cause the cervix to thin. During this first stage, a\\nwoman’s contractions occur more and more often and last\\nlonger and longer. The doctor or nurse will do a periodic\\npelvic exam to determine how the mother is progressing.\\nIf the contractions aren’t forceful enough to open the\\ncervix, a drug may be given to make the uterus contract.\\nAs pain and discomfort increase, women may be\\ntempted to request pain medication. If possible, though,\\nadministration of pain medication or anesthetics should\\nbe delayed until the active phase of labor begins—at\\nwhich point the medication will not act to slow down or\\nstop the labor.\\nThe active stage of labor is faster and more efficient\\nthan the latent phase. In this phase, contractions are\\nlonger and more regular, usually occurring about every\\ntwo minutes. These stronger contractions are also more\\npainful. Women who use the breathing exercises learned\\nin childbirth classes find that these can help cope with\\nthe pain experienced during this phase. Many women\\nalso receive some pain medication at this point—either a\\nshort-term medication, such as Nubain or Numorphan, or\\nan epidural anesthesia.\\nAs the cervix dilates to 8–9 cm, the phase called the\\ntransition begins. This refers to the transition from the\\nfirst phase (during which the cervix dilates from 0–10\\ncm) and the second phase (during which the baby is\\npushed out through the birth canal). As the baby’s head\\nbegins to descend, women begin to feel the urge to\\n“push” or bear down. Active pushing by the mother\\nshould not begin until the second phase, since pushing\\ntoo early can cause the cervix to swell or to tear and\\nbleed. The attending healthcare practitioner should coun-\\nsel the mother on when to begin to push.\\nSecond stage of labor\\nAs the mother enters the second stage of labor, her\\nbaby’s head appears at the top of the cervix. Uterine con-\\ntractions get stronger. The infant passes down the vagina,\\nhelped along by contractions of the abdominal muscles\\nand the mother’s pushing. Active pushing by the mother\\nis very important during this phase of labor. If an epidur-\\nal anesthetic is being used, many practitioners recom-\\nmend decreasing the amount administered during this\\nphase of labor so that the mother has better control over\\nher abdominal muscles.\\nWhen the top of the baby’s head appears at the open-\\ning of the vagina, the birth is nearing completion. First\\nthe head passes under the pubic bone. It fills the lower\\nvagina and stretches the perineum (the tissues between\\nthe vagina and the rectum). This position is called\\n“crowning,” since only the crown of the head is visible.\\nWhen the entire head is out, the shoulders follow. The\\nattending practitioner suctions the baby’s mouth and\\nnose to ease the baby’s first breath. The rest of the baby\\nusually slips out easily, and the umbilical cord is cut.\\nEpisiotomy\\nAs the baby’s head appears, the perineum may\\nstretch so tight that the baby’s progress is slowed down. If\\nthere is risk of tearing the mother’s skin, the doctor may\\nchoose to make a small incision into the perineum to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 757\\nChildbirth\\nPlacenta\\nUterus\\nUmbilical cord\\nVagina\\nCervix\\nStage 1: Dilation of the cervix\\nStage 1: Dilation of the cervix.(Illustration by Hans & Cassady.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 757'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 146, 'page_label': '147'}, page_content='enlarge the vaginal opening. This is called an episiotomy.\\nIf the woman has not had an epidural or pudendal block,\\nshe will get a local anesthetic to numb the area. Once the\\nepisiotomy is made, the baby is born with a few pushes.\\nThird stage\\nIn the final stage of labor, the placenta is pushed out\\nof the vagina by the continuing uterine contractions. The\\nplacenta is pancake shaped and about 10 inches in diam-\\neter. It has been attached to the wall of the uterus and has\\nserved to convey nourishment from the mother to the\\nfetus throughout the pregnancy. Continuing uterine con-\\ntractions cause it to separate from the uterus at this point.\\nIt is important that all of the placenta be removed from\\nthe uterus. If it is not, the uterine bleeding that is normal\\nafter delivery may be much heavier.\\nBreech presentation\\nApproximately 4% of babies are in what is called\\nthe “breech” position when labor begins. In breech pre-\\nsentation, the baby’s head is not the part pressing against\\nthe cervix. Instead the baby’s bottom or legs are posi-\\ntioned to enter the birth canal instead of the head. An\\nobstetrician may attempt to turn the baby to a head down\\nposition using a technique called version. This is only\\nsuccessful approximately half the time.\\nThe risks of vaginal delivery with breech presentation\\nare much higher than with a head-first presentation and the\\nmother and attending practitioner will need to weigh the\\nrisks and make a decision on whether to deliver via a\\ncesarean section or attempt a vaginal birth. The extent of\\nthe risk depends to a great extent on the type of breech pre-\\nsentation—of which there are three. Frank breech (the\\nbaby’s legs are folded up against its body) is the most com-\\nmon and the safest for vaginal delivery. The other types are\\ncomplete breech (in which the baby’s legs are crossed\\nunder and in front of the body) and footling breech (in\\nwhich one leg or both legs are positioned to enter the birth\\ncanal) are not considered safe to attempt vaginal delivery.\\nEven in complete breech, other factors should be\\nmet before considering a vaginal birth. An ultrasound\\nexamination should be done to be sure the baby does not\\nhave an unusually large head and that the head is tilted\\nforward (flexed) rather than back (hyperextended). Fetal\\nmonitoring and close observation of the progress of labor\\nare also important. A slowing of labor or any indication\\nof difficulty in the body passing through the pelvis\\nshould be an indication that it is safer to consider a\\ncesarean section.\\nForceps delivery\\nIf the labor is not progressing as it should or if the\\nbaby appears to be in distress, the doctor may opt for a\\nforceps delivery. A forceps is a spoon-shaped device that\\nresembles a set of salad tongs. It is placed around the\\nbaby’s head so the doctor can pull the baby gently out of\\nthe vagina.\\nForceps can be used after the cervix is fully dilated,\\nand they might be required if:\\n• the umbilical cord has dropped down in front of the\\nbaby into the birth canal\\n• the baby is too large to pass through the birth canal\\nunaided\\n• the baby shows signs of stress\\n• the mother is too exhausted to push\\nBefore placing the forceps around the baby’s head,\\npain medication or anesthesia may be given to the moth-\\ner. The doctor may use a catheter to empty the mother’s\\nbladder, and may clean the perineal area with soapy\\nwater. Often an episiotomy is done before a forceps birth,\\nalthough tears can still occur.\\nThe obstetrician slides half of the forceps at a time\\ninto the vagina and around the side of the baby’s head to\\ngently grasp the head. When both “tongs” are in place, the\\ndoctor pulls on the forceps to help the baby through the\\nbirth canal as the uterus contracts. Sometimes the baby\\ncan be delivered this way after the very next contraction.\\nThe frequency of forceps delivery varies from one\\nhospital to the next, depending on the experience of staff\\nand the types of anesthesia offered at the hospital. Some\\nobstetricians accept the need for a forceps delivery as a\\nway to avoid cesarean birth. However, other obstetrical\\nservices don’t use forceps at all.\\nComplications from forceps deliveries can occur.\\nSometimes they may cause nerve damage or temporary\\nGALE ENCYCLOPEDIA OF MEDICINE 2758\\nChildbirth\\nStage 2: Expulsion of the fetus\\nStage 2: Expulsion of the fetus.(Illustration by Hans & Cassady.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 758'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 147, 'page_label': '148'}, page_content='bruises to the baby’s face. When used by an experienced\\nphysician, forceps can save the life of a baby in distress.\\nV acuum-assisted birth\\nThis method of helping a baby out of the birth canal\\nwas developed as a gentler alternative to forceps. Vacu-\\num-assisted birth can only be used after the cervix is\\nfully dilated (expanded), and the head of the fetus has\\nbegun to descend through the pelvis. In this procedure,\\nthe doctor uses a device called a vacuum extractor, plac-\\ning a large rubber or plastic cup against the baby’s head.\\nA pump creates suction that gently pulls on the cup to\\nease the baby down the birth canal. The force of the suc-\\ntion may cause a bruise on the baby’s head, but it fades\\naway in a day or so.\\nThe vacuum extractor is not as likely as forceps to\\ninjure the mother, and it leaves more room for the baby\\nto pass through the pelvis. However, there may be prob-\\nlems in maintaining the suction during the vacuum-\\nassisted birth, so forceps may be a better choice if it is\\nimportant to remove the baby quickly.\\nCesarean sections\\nA cesarean section, also called a c-section, is a surgi-\\ncal procedure in which incisions are made through a\\nwoman’s abdomen and uterus to deliver her baby.\\nCesarean sections are performed whenever abnor-\\nmal conditions complicate labor and vaginal delivery,\\nthreatening the life or health of the mother or the baby.\\nThe procedure is performed in the United States on near-\\nly one of every four babies delivered—more than\\n900,000 babies each year. The procedure is used in cases\\nwhere the mother has had a previous c-section and the\\narea of the incision has been weakened. Dystocia, or dif-\\nficult labor, is the another common reason for perform-\\ning a c-section.\\nDifficult labor is commonly caused by one of the\\nthree following conditions: abnormalities in the mother’s\\nbirth canal; abnormalities in the position of the fetus;\\nabnormalities in the labor, including weak or infrequent\\ncontractions.\\nAnother major factor is fetal distress, a condition\\nwhere the fetus is not getting enough oxygen. Fetal brain\\ndamage can result from oxygen deprivation. Fetal dis-\\ntress is often related to abnormalities in the position of\\nthe fetus, or abnormalities in the birth canal, causing\\nreduced blood flow through the placenta.\\nOther conditions also can make c-section advisable,\\nsuch as vaginal herpes, hypertension (high blood pres-\\nsure) and diabetes in the mother.\\nCauses and symptoms\\nOne of the first signs of approaching childbirth may\\nbe a “bloody show,” the appearance of a small amount of\\nblood-tinged mucus released from the cervix as it begins\\nto dilate. This is called the “mucus plug.”\\nThe most common sign of the onset of labor is con-\\ntractions. Sometimes women have trouble telling the dif-\\nference between true and false labor pains.\\nTrue labor pains:\\n• develop a regular pattern, with contractions coming\\ncloser together\\n• last from 15–30 seconds at the onset and get progres-\\nsively stronger and longer (up to 60 seconds)\\n• may get stronger with physical activity\\n• occur high up on the abdomen, radiating throughout the\\nabdomen and lower back\\nAnother sign that labor is beginning is the breaking\\nof the “bag of waters,” the amniotic sac which had cush-\\nioned the baby during the pregnancy. When it breaks, it\\nreleases water in a trickle or a gush. Only about 10% of\\nwomen actually experience this water flow in the begin-\\nning of labor, however. Most of the time, the rupture\\noccurs sometime later in labor. If the amniotic sac doesn’t\\nrupture on its own, the doctor will break it during labor.\\nSome women have diarrhea or nausea as labor\\nbegins. Others notice a sudden surge of energy and the\\nurge to clean or arrange things right before labor begins;\\nthis is known as “nesting.”\\nDiagnosis\\nThe onset of labor can be determined by measuring\\nhow much the cervix has dilated. The degree of dilation\\nis estimated by feeling the opening cervix during a pelvic\\nexam. Dilation is measured in centimeters, from zero to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 759\\nChildbirth\\nPlacenta\\nbeing\\ndetached\\nUmbilical\\ncord\\nStage 3: Expulsion of the placenta\\nStage 3: Expulsion of the placenta.(Illustration by Hans &\\nCassady.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 759'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 148, 'page_label': '149'}, page_content='10. Contractions that cause the cervix to dilate are the\\nsign of true labor.\\nFetal monitoring\\nFetal monitoring is a process in which the baby’s\\nheart rate is monitored for indicators of stress during labor\\nand birth. There are several types of fetal monitoring.\\nA special stethoscope called a fetoscope may be\\nused. This is a simple and non-invasive method.\\nThe Doppler method uses ultrasound; it involves a\\nhandheld listening device that transmits the sounds of the\\nheart rate through a speaker or into an attached ear piece.\\nIt can usually pick up the heart sounds 12 weeks after\\nconception. This method offers intermittent monitoring.\\nIt allows the mother freedom to move about and is also\\nuseful during contractions.\\nElectronic fetal monitoring uses ultrasound and\\nprovides a view of the heartbeat in relationship to the\\nmother’s contractions. It can be used either continuously\\nor intermittently. It is often used in high risk pregnan-\\ncies, and is not often recommended for low risk ones\\nKEY TERMS\\nAmniotic sac —The membranous sac that sur-\\nrounds the embryo and fills with watery fluid as\\npregnancy advances.\\nBreech birth—Birth of a baby bottom-first, instead\\nof the usual head first delivery. This can add to\\nlabor and delivery problems because the baby’s\\nbottom doesn’t mold a passage through the birth\\ncanal as well as does the head.\\nCervix—A small cylindrical organ about an inch\\nor so long and less than an inch around that makes\\nup the lower part and neck of the uterus. The\\ncervix separates the body and cavity of the uterus\\nfrom the vagina.\\nEmbryo—The unborn child during the first eight\\nweeks of its development following conception.\\nGestation —The period from conception to birth,\\nduring which the developing fetus is carried in the\\nuterus.\\nPerineum—The area between the thighs that lies\\nbehind the genital organs and in front of the anus.\\nPlacenta —The organ that develops in the uterus\\nduring pregnancy and that links the blood supplies\\nof mother and baby.\\nbecause it renders the mother immobile and requires\\ninterpretation.\\nInternal monitoring does not use ultrasound, is more\\naccurate than electronic monitoring and provides continu-\\nous monitoring for the high risk mother. This requires the\\nmother’s water to be broken and that she be two to three\\ncentimeters dilated. It is used in high-risk situations only.\\nTelemetry monitoring is the newest type of monitor-\\ning. It uses radio waves transmitted from an instrument\\non the mother’s thigh. The mother is able to remain\\nmobile. It provides continuous monitoring and is used in\\nhigh-risk situations.\\nTreatment\\nMost women choose some type of pain relief during\\nchildbirth, ranging from relaxation and imagery to drugs.\\nThe specific choice may depend on what’s available, the\\nwoman’s preferences, her doctor’s recommendations,\\nand how the labor is proceeding. All drugs have some\\nrisks and some advantages.\\nRegional anesthetics\\nRegional anesthetics include epidurals and spinals.\\nIn this technique, medication is injected into the space\\naround the spinal nerves. Depending on the type of med-\\nications used, this type of anesthesia can block nerve sig-\\nnals, causing temporary pain relief, or a loss of sensation\\nfrom the waist down. An epidural or spinal block can\\nprovide complete pain relief during cesarean birth.\\nAn epidural is placed with the woman lying on her\\nside or sitting up in bed with the back rounded to allow\\nmore space between the vertebrae. Her back is scrubbed\\nwith antiseptic, and a local anesthetic is injected in the\\nskin to numb the site. The needle is inserted between two\\nvertebrae and through the tough tissue in front of the\\nspinal column. A catheter is put in place that allows con-\\ntinuous doses of anesthetic to be given.\\nThis type of anesthesia provides complete pain\\nrelief, and can help conserve a woman’s energy, since she\\ncan relax or even sleep during labor. This type of anes-\\nthesia does require an IV and fetal monitor. It may be\\nharder for a woman to bear down when it comes time to\\npush, although the amount of anesthesia can be adjusted\\nas this stage nears.\\nSpinal anesthesia operates on the same principle as\\nepidural anesthesia, and is used primarily in cases of c-\\nsection delivery. It is administered in the same way as an\\nepidural, but the catheter is not left in place. The amount\\nof anesthetic injected is large, since it must be injected at\\none time. Because of the anesthetic’s effect on motor\\nnerves, most women using it cannot push during delivery.\\nGALE ENCYCLOPEDIA OF MEDICINE 2760\\nChildbirth\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 760'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 149, 'page_label': '150'}, page_content='This is a disadvantage in labor, but not an issue during a c-\\nsection. Spinals provide quick and strong anesthesia and\\nallow for major abdominal surgery with almost no pain.\\nNarcotics\\nShort-acting narcotics can ease pain and don’t inter-\\nfere with a woman’s ability to push. However, they can\\ncause sedation, dizziness, nausea, and vomiting. Narcotics\\ncross the placenta and may slow down a baby’s breathing;\\nthey can’t be given too close to the time of delivery.\\nNatural childbirth and preparation for childbirth\\nThere are several methods to prepare for childbirth.\\nThe one selected often depends on what is available\\nthrough the healthcare provider. Overall, family involve-\\nment is receiving increased attention by the healthcare\\nsystems, and many hospitals now offer birthing rooms\\nand maternity centers to help the entire family. There are\\nseveral choices available for childbirth preparation.\\nLamaze, or Lamaze-Pavlov, is the most common in\\nthe United States today. It was the first popular natural\\nchildbirth method, becoming popular in the 1960s.\\nBreathing exercises and concentration on a focal point\\nare practiced to allow mothers to control pain while\\nmaintaining consciousness. This allows the flow of oxy-\\ngen to the baby and to the muscles in the uterus to be\\nmaintained. A partner coaches the mother throughout the\\nbirthing process.\\nThe Read method, named for Dick Read, is a tech-\\nnique of breathing that was originated in the 1930s to\\nhelp mothers deal with apprehension and tension associ-\\nated with childbirth. This natural childbirth method uses\\ndifferent breathing for the different stages of childbirth.\\nThe LeBoyer method stresses a relaxed delivery in a\\nquiet, dim room. It attempts to avoid overstimulation of\\nthe baby and to foster mother-child bonding by placing\\nthe baby on the mother’s abdomen and having the mother\\nmassage him or her immediately after the birth. Then the\\nfather washes the baby in a warm bath.\\nThe Bradley method is called father-coached child-\\nbirth, because it focuses on the father serving as coach\\nthroughout the process. It encourages normal activities\\nduring the first stages of labor.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nCunningham, F. Gary, et.al. Williams Obstetrics. 20th ed.\\nStamford: Appleton & Lange, 1997.\\nJohnson, Robert V . Mayo Clinic Complete Book of Pregnancy\\n& Baby’s First Year.New York: William Morrow and Co.,\\nInc., 1994.\\nRyan, Kenneth J., Ross S. Berkowitz, and Robert L. Barbieri.\\nKistner’s Gynecology.6th ed. St. Louis: Mosby, 1995.\\nTuteur, Amy B. How Your Baby is Born.Emeryville, CA: Ziff-\\nDavis Press, 1994.\\nORGANIZATIONS\\nAmerican Academy of Husband-Coached Childbirth. P.O. Box\\n5224, Sherman Oaks, CA 91413. (800) 423-2397; in Cali-\\nfornia (800) 422-4784.\\nAmerican Society for Prophylaxis in Obstetrics/LAMAZE\\n(ASP.O. /LAMAZE). 1840 Wilson Blvd., Ste. 204,\\nArlington, V A 22201. (800) 368-4404.\\nChildbirth Education Foundation. P.O. Box 5, Richboro, PA\\n18954. (215) 357-2792.\\nInternational Association of Parents and Professionals for Safe\\nAlternatives in Childbirth. Rte. 1, Box 646, Marble Hill,\\nMO 63764. (314) 238-2010.\\nInternational Childbirth Education Association. P.O. Box\\n20048, Minneapolis, MN 55420. (612) 854-8660.\\nPostpartum Support International. 927 North Kellogg Ave.,\\nSanta Barbara, CA 93111. (805) 967-7636.\\nCarol A. Turkington\\nChildhood disintegrative disorder see\\nPervasive developmental disorders\\nChildren’s health\\nDefinition\\nChildren’s health encompasses the physical, mental,\\nemotional, and social well-being of children from infan-\\ncy through adolescence.\\nDescription\\nAll children should have regular well-child check\\nups according to the schedule recommended by their\\nphysician or pediatrician. The American Academy of\\nPediatrics (AAP) advises that children be seen for well-\\nbaby check ups at two weeks, two months, four months,\\nsix months, nine months, twelve months, fifteen months,\\nand eighteen months. Well-child visits are recommended\\nat ages two, three, four, five, six, eight, ten, and annually\\nthereafter through age 21.\\nIn addition, an immunization schedule should be fol-\\nlowed to protect against disease and infection. As of\\n2001, the AAP and the U.S. Centers for Disease Control\\n(CDC) recommended that the following childhood\\nimmunizations be administered by age two:\\nGALE ENCYCLOPEDIA OF MEDICINE 2 761\\nChildren’s health\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 761'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 150, 'page_label': '151'}, page_content='• Hepatitis B. Three doses.\\n• Diphtheria,Tetanus, and Pertussis (DTaP). Four doses.\\n• H. influenzae type b (Hib). Four doses.\\n• Inactivated Polio. Three doses.\\n• Pneumococcal Conjugate. Three doses.\\n• Measles,Mumps, Rubella (MMR). One dose.\\n• Varicella (chickenpox). One dose.\\n• Hepatitis A. (In certain geographical areas and with\\ncertain high risk groups.)\\nSome immunizations may cause mild side effects, or\\nmore rarely, serious adverse reactions. However, the ben-\\nefits of immunization greatly outweigh the incidence of\\nhealth problems arising from them.\\nThere are serious chronic diseases and health prob-\\nlems that are frequently diagnosed in childhood and can-\\nnot be vaccinated against. These include, but are not lim-\\nited to, asthma, type I diabetes (juvenile diabetes),\\nleukemia, hemophilia, and cystic fibrosis.\\nMental health\\nChildren who have difficulty in areas of language\\nacquisition, cognitive development, and behavior control\\nKEY TERMS\\nBipolar disorder —Manic depressive disorder. A\\nmood disorder characterized by manic highs and\\ndepressive lows.\\nChild development—The process of physical, intel-\\nlectual, emotional, and social growth that occurs\\nfrom infancy through adolescence. Erik Erikson,\\nMargaret Mahler, Sigmund Freud, and Jean Piaget\\nare among the most well-known child development\\ntheorists.\\nCPR—Cardiopulmonary resuscitation. A first aid\\ntechnique designed to stimulate breathing and\\nblood flow through a combination of chest com-\\npressions and rescue breathing.\\nImmunization —Creating immunity to a disease\\nthrough a vaccine injection that stimulates the pro-\\nduction of antibodies.\\nLearning disabilities —An impairment of the cogni-\\ntive processes of understanding and using spoken\\nand written language that results in difficulties with\\none or more academic skill sets (e.g., reading, writ-\\ning, mathematics).\\nMotor skills —Controlled movement of muscle\\ngroups. Fine motor skills involve tasks that require\\ndexterity of small muscles, such as buttoning a shirt.\\nTasks such as walking or throwing a ball involve the\\nuse of gross motor skills.\\nObsessive-compulsive disorder —Also known as\\nOCD; a disorder characterized by obsessive\\nthoughts (e.g., fear of contamination) and compul-\\nsive behaviors (e.g., repetitive hand washing) that\\ncause distress and/or functional impairment.\\nPsychological tests—Written, verbal, or visual tasks\\nthat assess psychological functioning, intelligence,\\nand/or personality traits.\\nType 1 diabetes—A chronic immune system disor-\\nder in which the pancreas does not produce suffi-\\ncient amounts of insulin, a hormone that enables\\ncells to use glucose for energy. Also called juvenile\\ndiabetes, it must be treated with insulin injections.\\nmay be suffering from mental illness. Mental health\\nproblems that may afflict children include:\\n• Attention Deficit Hyperactivity Disorder ( ADHD).\\nAccording to the AAP, 4–12% of school-aged children\\nhave ADHD, a condition characterized by poor impulse\\ncontrol and excessive motor activity.\\n• Learning disorders. Learning disabilities affect one in\\n10 school children.\\n• Depression, anxiety, and bipolar disorder . Affective,\\nor mood, disorders can affect kids as well as adults.\\n• Eating disorders. Anorexia nervosa, bulimia nervosa,\\nand binge eating disorder (BED) frequently occur in\\nadolescent girls.\\n• Schizophrenia . A disorder characterized by bizarre\\nthoughts and behaviors, paranoia , impaired sense of\\nreality, and psychosis may be diagnosed in childhood.\\n• Obsessive-compulsive disorder. Also called OCD, this\\nanxiety disorder afflicts one in 200 children.\\n• Autism and pervasive developmental disorder. Severe\\ndevelopmental disabilities that cause a child to become\\nwithdrawn and unresponsive.\\n• Mental retardation. Children under age 18 with an IQ\\nof 70 or below and impairments in adaptive functioning\\nare considered mentally retarded.\\nGALE ENCYCLOPEDIA OF MEDICINE 2762\\nChildren’s health\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 762'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 151, 'page_label': '152'}, page_content='Emotional and social health\\nChildren take their first significant steps toward\\nsocialization and peer interaction when they begin to\\nengage in cooperative play at around age four. Their\\nsocial development will progress throughout childhood\\nand adolescence as they develop friendships, start to be\\ninfluenced by their peers, and begin to show interest in\\nthe opposite sex.\\nFactors which can have a negative impact on the\\nemotional and social well-being of children include:\\n• Violence. Bullying can cause serious damage to a\\nchild’s sense of self-esteem and personal safety, as can\\nexperiences with school violence.\\n• Family turmoil. Divorce, death, and other life-chang-\\ning events that alter the family dynamic can have a seri-\\nous impact on a child. Even a positive event such as the\\nbirth of a sibling or a move to a new city and school can\\nput emotional strain on a child.\\n• Stress. The pressure to perform well academically and\\nin extracurricular activities such as sports can be over-\\nwhelming to some children.\\n• Peer pressure. Although it can have a positive impact,\\npeer pressure is often a source of significant stress for\\nchildren. This is particularly true in adolescence when\\n“fitting in” seems all-important.\\n• Drugs and alcohol. Curiosity is intrinsic to childhood,\\nand over 30% of children have experimented with alco-\\nhol by age 13. Open communication with children that\\nsets forth parental expectations about drug and alcohol\\nuse is essential.\\n• Negative sexual experiences. Sexual abuse and assault\\ncan emotionally scar a child and instill negative feel-\\nings about sexuality and relationships.\\nCauses and symptoms\\nChildhood health problems may be congenital (i.e.,\\npresent at birth) or acquired through infection, immune\\nsystem deficiency, or another disease process. They may\\nalso be caused by physical trauma (e.g., a car accident or\\na playground fall) or a toxic substance (e.g., an allergen,\\ndrug, or poisonous chemical), or triggered by genetic or\\nenvironmental factors.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 763\\nChildren’s health\\nDR. BENJAMIN SPOCK (1903–1998)\\nBenjamin Spock, pediatrician and political activist,\\nwas most noted for his authorship of Baby and Child\\nCare, which significantly changed predominant attitudes\\ntoward the raising of infants and children. He began med-\\nical school at Yale University in 1925, and transferred to\\nColumbia University’s College of Physicians and Sur-\\ngeons in 1927. Spock had decided well before starting his\\nmedical studies that he would “work with children, who\\nhave their whole lives ahead of them” and so, upon tak-\\ning his M.D. degree in 1929 and serving his general\\ninternship at the prestigious Presbyterian Hospital, he\\nspecialized in pediatrics at a small hospital crowded with\\nchildren in New York’s Hell’s Kitchen area.\\nOn a summer vacation in 1943 he began to write his\\nmost famous book and he continued to work on it from\\n1944 to 1946 while serving as a medical officer in the\\nNavy. The book sharply broke with the authoritarian tone\\nand rigorous instructions found in earlier generations of\\nbaby-care books, most of which said to feed infants on a\\nstrict schedule and not to pick them up when they cried.\\nSpock, who spent ten years trying to reconcile his psycho-\\nanalytic training with what mothers were telling him about\\ntheir children, told his readers “Y ou know more than you\\nthink you do. Don’t be afraid to trust your own common\\nsense. Take it easy, trust your own instincts, and follow the\\ndirections that your doctor gives you.” The response was\\noverwhelming. Baby and Child Care rapidly became\\nAmerica’s all-time best-seller except for Shakespeare and\\nthe Bible; by 1976 it had also eclipsed Shakespeare.\\n(Library of Congress.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 763'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 152, 'page_label': '153'}, page_content='Physical and mental health problems in childhood\\ncan cause a wide spectrum of symptoms. However, the\\nfollowing behaviors frequently signify a larger emotion-\\nal, social, or mental disturbance:\\n• signs of alcohol and drug use\\n• falling grades\\n• lack of interest in activities that were previously enjoy-\\nable to the child\\n• excessive anxiety\\n• persistent, prolonged depression\\n• withdrawal from friends and family\\n• violence\\n• temper tantrums or inappropriate displays of anger\\n• self-inflicted injury\\n• bizarre behavior and/or speech\\n• trouble with the police\\n• sexual promiscuity\\n• suicide attempts\\nThe causes of developmental disorders and delays\\nand learning disabilities are not always fully understood.\\nPervasive developmental disorder (PDD) and autistic\\nspectrum disorder (more commonly known as autism)\\nare characterized by unresponsiveness and severe impair-\\nments in one or more of the following areas:\\n• Social interaction. Autistic children are often unaware\\nof acceptable social behavior and are withdrawn and\\nsocially isolated. They frequently do not like physical\\ncontact.\\n• Communication and language. A child with autism or\\nPDD may not speak or may display limited or imma-\\nture language skills.\\n• Behavior. Autistic or PDD children may have difficulty\\ndealing with anger, can be self-injurious, and may dis-\\nplay obsessive behavior.\\nAutism is associated with brain abnormalities, but\\nthe exact mechanisms that trigger the disorder are yet to\\nbe determined. It has been linked to certain congenital\\nconditions such as neurofibromatosis , fragile X syn-\\ndrome, and phenylketonuria (PKU).\\nDiagnosis\\nPhysical, intellectual, emotional, and social matura-\\ntion are all important markers of a child’s overall health\\nand well-being. When evaluating children, pediatricians\\nand child-care specialists assess related skill sets, such as\\na child’s acquisition and use of language, fine and gross\\nmotor skills, cognitive growth, and socialization, and\\nachievement of certain milestones in these areas. A\\ndevelopmental milestone is a task or skill set that a child\\nis expected to reach at a certain age or stage of life. For\\nexample, by age one, most children have achieved the\\nphysical milestone of walking with the assistance of an\\nadult. Developmental disorders may be identified and/or\\ndiagnosed by physicians, teachers, child psychologists,\\ntherapists, counselors, and other professionals who inter-\\nact with children on a regular basis.\\nIt is important to remember that all children are\\nunique, and develop at different paces within this broad\\nframework. Reaching a milestone early or late does not\\nnecessarily indicate a developmental problem. However,\\nif a child is consistently lagging on achieving milestones,\\nor has a significant deficit in one developmental area, he\\nor she may be experiencing developmental delays.\\nPediatricians and other medical professionals typi-\\ncally diagnose physical illness and disease in children. In\\ncases of illness and injury, children will undergo a thor-\\nough physical examination and patient history. Diag-\\nnostic tests may be performed as appropriate. In cases of\\nmental or emotional disorders, a psychologist or other\\nmental healthcare professional will meet with the patient\\nto conduct an interview and take a detailed social and\\nmedical history. Interviews with a parent or guardian\\nmay also be part of the diagnostic process. The physician\\nmay also administer one or more psychological tests\\n(also called clinical inventories, scales, or assessments).\\nTreatment\\nMedications may be prescribed to treat certain child-\\nhood illnesses. Proper dosage is particularly important\\nwith infants and children, as medications such as aceta-\\nminophen can be toxic in excessive amounts. Parents\\nand caregivers should always follow the instructions for\\nuse that accompany medications, and inform the child’s\\npediatrician if the child is taking any other drugs or vita-\\nmins to prevent potentially negative drug interactions.\\nAny side effects or adverse reactions to medication\\nshould be reported to the child’s physician. If antibiotics\\nare prescribed, the full course should always be taken.\\nOther treatments for childhood illness and/or injuries\\ninclude, but are not limited to, nutritional therapy, physical\\ntherapy, respiratory therapy, medical devices (e.g., hear-\\ning aids, glasses, braces), and in some cases, surgery.\\nCounseling is typically a front-line treatment for\\npsychological disorders. Therapy approaches include\\npsychotherapy, cognitive therapy, behavioral therapy,\\nfamily counseling, and group therapy. Therapy or coun-\\nseling may be administered by social workers, nurses,\\nlicensed counselors and therapists, psychologists, or psy-\\nGALE ENCYCLOPEDIA OF MEDICINE 2764\\nChildren’s health\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 764'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 153, 'page_label': '154'}, page_content='chiatrists. Psychoactive medication may also be pre-\\nscribed for symptom relief in children and adolescents\\nwith mental disorders.\\nSupport groups may also provide emotional support\\nfor children with chronic illnesses or mental disorders.\\nThis approach, which allows individuals to seek advice\\nand counsel from others in similar circumstances, can be\\nextremely effective, especially in older children who\\nlook towards their peers for guidance and support.\\nSpeech therapy may be helpful to children with\\ndevelopmental delays in language acquisition. Children\\nwith learning disorders can benefit from special educa-\\ntion therapy.\\nAlternative treatment\\nTherapeutic approaches that encourage self-discov-\\nery and empowerment may be useful in treating some\\nchildhood emotional traumas and mental disorders. Art\\ntherapy , the use of the creative process to express and\\nunderstand emotion, encompasses a broad range of\\nhumanistic disciplines, including visual arts, dance,\\ndrama, music, film, writing, literature, and other artistic\\ngenres. It can be particularly effective in children who\\nmay have difficulty gaining insight to emotions and\\nthoughts they are otherwise incapable of expressing.\\nCertain mild herbal remedies may also be safely\\nused with children, such as ginger ( Zingiber officinale )\\ntea for nausea and aloe vera salve for burns. Parents and\\ncaregivers should always consult their healthcare\\nprovider before administering herbs to children.\\nPrognosis\\nThe prognosis for childhood health problems varies\\nwidely. In general, early detection and proper treatment\\ncan greatly improve the odds of recovery from many\\nchildhood ailments.\\nSome learning disabilities and mild developmental\\ndisorders can be overcome or greatly improved through\\nthe therapies discussed above. However, as of early 2001,\\nthere was no known medical treatment or pharmacologi-\\ncal therapy that is capable of completely eliminating all\\nof the symptoms associated with pervasive developmen-\\ntal disorder (PDD), autism spectrum disorder, and mental\\nretardation. Mental illnesses such as schizophrenia and\\nbipolar disorder are also chronic, lifelong disorders,\\nalthough their symptoms can often be well-controlled\\nwith medication.\\nPrevention\\nParents can take some precautions to ensure the\\nsafety of their children. Childproofing the home, follow-\\ning a recommended immunization schedule, educating\\nkids on safety, learning CPR, and taking kids for regular\\nwell-child check-ups can help to protect against physical\\nharm. In addition, encouraging open communication\\nwith children can help them grow both emotionally and\\nsocially. Providing a loving and supportive home envi-\\nronment can help to nurture an emotionally healthy child\\nwho is independent, self-confident, socially skilled,\\ninsightful, and empathetic towards others.\\nBecause they are still developing motor skills, kids\\ncan be particularly accident prone. Observe the following\\nsafety rules to protect children from injury:\\n• Helmets and padding. Children should always wear a\\nproperly fitted helmet and appropriate protective gear\\nwhen riding a bike, scooter, or similar equipment or\\nparticipating in sports. They should also ride on desig-\\nnated bike paths whenever possible, and learn bicycle\\nsafety rules (i.e., ride with traffic, use hand signals).\\n• Playground safety. Swing sets and other outdoor play\\nequipment should be well-maintained have at least 12\\nin (30 cm) of loose fill materials (e.g., sand, wood\\nchips) underneath to cushion falls, and children should\\nalways be properly supervised at play.\\n• Stay apprised of recalls. Children’s toys, play equip-\\nment, and care products are frequently involved in\\nproduct recalls. The U.S. Consumer Safety Products\\nCommission (CSPC) is the agency responsible for\\ntracking these recalls (see Resources below).\\n• Stay safe in the car. Up to 85% of children’s car seats\\nare improperly installed and/or used. Infants should\\nalways be in a rear-facing car seat until they are over 12\\nmonths of age and weigh more than 20 lb (9 kg). Never\\nGALE ENCYCLOPEDIA OF MEDICINE 2 765\\nChildren’s health\\nLeading Causes Of Illness/Injury In Adolescents\\nTrauma (this could be anything from sports-related injuries to gunshot wounds; alcohol or other drug abuse is frequently a factor)\\nMental health issues (substance abuse, depression, etc.)\\nSexually transmitted infections\\nAcquired immunodeficiency syndrome (AIDS)\\nEating disorders\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 765'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 154, 'page_label': '155'}, page_content='put an infant or car seat in a front passenger seat that\\nhas an air bag. Once they outgrow their forward facing\\ncar seats, children between the ages of four and eight\\nwho weigh between 40–80 lb (18–36 kg) should ride in\\na booster seat. Every child who rides in a car over this\\nage and weight should buckle up with a properly fitted\\nlap and shoulder belt.\\n• Teach children pedestrian safety. Younger children\\nshould never be allowed to cross the street by them-\\nselves, and older kids should know to follow traffic\\nsigns and signals, cross the street at the corner, and look\\nboth ways before stepping off the curb.\\n• Teach children about personal safety. Kids should know\\nwhat to do in case they get lost or are approached by a\\nstranger. It is also imperative that parents talk openly\\nwith their children about their body and sexuality, and\\nwhat behavior is inappropriate, to protect them against\\nsexual predators.\\nChild-proofing the household is also an important\\nstep towards keeping kids healthy. To make a house a\\nsafe home:\\n• Ban guns. Accidental shootings in the home injure an\\nestimated 1,500 children under age 14 each year. If a\\ngun must be in the home, it should be securely locked\\nin a tamper proof box or safe.\\n• Keep all matches, lighters, and flammable materials\\nproperly stored and out of the reach of children.\\n• Make sure hot water heaters are set to 120 degrees or\\nbelow to prevent scalding injuries.\\n• Equip the home with working fire extinguishers and\\nsmoke alarms, and teach children what to do in case of\\nfire.\\n• Secure all medications (including vitamins, herbs, and\\nsupplements), hazardous chemicals, and poisonous\\nsubstances (including alcohol and tobacco).\\n• Don’t smoke. Aside from causing cancer and other\\nhealth problems in smokers, second-hand smoke is haz-\\nardous to a child’s health.\\n• Keep small children away from poisonous plants out-\\ndoors, and remove any indoor plants that are toxic.\\n• Post the phone numbers of poison control and the pedi-\\natrician near the phone, and teach children about dial-\\ning 9-1-1 for emergencies.\\n• Children under age five should never be left alone in the\\nbathtub, wading pool, or near any standing water\\nsource (including an open toilet). Drowning is the lead-\\ning cause of death by injury for children between the\\nages of one and four.\\n• Remove lead paint. Lead is a serious health hazard for\\nchildren, and houses built before 1978 should be tested\\nfor lead paint. If lead is found, the paint should be\\nremoved using the appropriate safety precautions.\\nThese safety guidelines are not all-inclusive, and\\nthere are many age-specific safety precautions that par-\\nents and guardians of children should observe. For exam-\\nple, infants should never be left with a propped-up bottle\\nin their mouths or given small play items because of the\\nchoking hazards involved.\\nResources\\nBOOKS\\nHoltzman, Debra Smiley. The Panic Proof Parent.Chicago:\\nNTC/Contemporary, 2000.\\nPasquariello Jr., Patrick S. ed. The Children’s Hospital of\\nPhiladelphia: Book of Pregnancy and Child Care.New\\nYork: John Wiley & Sons, Inc., 1999.\\nWhite, Linda, and Sunny Mavor. Kids, Herbs, and Health.\\nLoveland, CO: Interweave Press, 1998.\\nORGANIZATIONS\\nNational Institute of Mental Health. 6001 Executive Boulevard,\\nRm. 8184, MSC 9663, Bethesda, MD 20892-9663. (301)\\n443-4513.\\nNational SAFE KIDS Campaign. Children’s National Medical\\nCenter. (202) 662-0600. .\\nU.S. Consumer Products Safety Commission (CPSC). 4330\\nEast-West Highway, Bethesda, MD 20814-4408. (800)\\n638-2772. .\\nPaula Ford-Martin\\nChinese traditional herbal medicine see\\nTraditional Chinese herbalism\\nGALE ENCYCLOPEDIA OF MEDICINE 2766\\nChildren’s health\\nLeading Causes Of Death In Adolescents\\nMotor vehicle crashes\\nSuicide (numbers 2 and 3 are approximately equal)\\nHomicide\\nPoisoning (which includes accidental poisonings due to alcohol or other drug overdose)\\nDrowning\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 766'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 155, 'page_label': '156'}, page_content='Chinese traditional medicine see Traditional\\nChinese medicine\\nChiropractic\\nDefinition\\nChiropractic is from Greek words meaning done by\\nhand. It is grounded in the principle that the body can\\nheal itself when the skeletal system is correctly aligned\\nand the nervous system is functioning properly. To\\nachieve this, the practitioner uses his or her hands or an\\nadjusting tool to perform specific manipulations of the\\nvertebrae. When these bones of the spine are not correct-\\nly articulated, resulting in a condition known as subluxa-\\ntion, the theory is that nerve transmission is disrupted\\nand causes pain and illness manifested in the back as\\nwell as other areas of the body.\\nChiropractic is one of the most popular alternative\\ntherapies currently available. Some would say it now\\nqualifies as mainstream treatment as opposed to comple-\\nmentary medicine. Chiropractic treatment is covered by\\nmany insurance plans. It has become well-accepted treat-\\nment for acute pain and problems of the spine, including\\nlower back pain and whiplash. Applications beyond that\\nscope are not supported by current evidence, although\\nthere are ongoing studies into the usefulness of chiroprac-\\ntic for such problems as ear infections, dysmenorrhea ,\\ninfant colic, migraine headaches, and other conditions.\\nPurpose\\nMost people will experience back pain at some time\\nin their lives. Injuries due to overexertion and poor pos-\\nture are among the most common. Depending on the\\ncause and severity of the condition, options for treatment\\nmay include physical therapy, rest, medications, surgery,\\nor chiropractic care. Chiropractic treatment carries none\\nof the risks of surgical or pharmacologic treatment. Prac-\\ntitioners use a holistic approach to health, which is\\nappreciated by most patients. The goal is not merely to\\nrelieve the present ailment, but to analyze the cause and\\nrecommend appropriate changes of lifestyle to prevent\\nthe problem from recurring again. They believe in a\\nrisk/benefit analysis before use of any intervention. The\\nodds of an adverse outcome are extremely low. Chiro-\\npractic has proven in several studies to be less expensive\\nthan many more traditional routes such as outpatient\\nphysical therapy. Relief from some neuromuscular prob-\\nlems is immediate, although a series of treatments is like-\\nly to be required to maintain the improvement. Spinal\\nmanipulation is an excellent option for acute lower back\\npain, and may also relieve neck pain as well as other\\nmusculoskeletal pain. Although most back pain will sub-\\nside eventually with no treatment at all, chiropractic\\ntreatment can significantly shorten the time it takes to get\\nrelief. Some types of headache can also be successfully\\ntreated by chiropractic.\\nDescription\\nOrigins\\nSpinal manipulation has a long history in many cul-\\ntures but Daniel D. Palmer is the founder of modern chi-\\nropractic theory, dating back to the 1890s. A grocer and\\nmagnetic healer, he applied his knowledge of the nervous\\nsystem and manual therapies in an unusual situation. One\\nrenowned story concerns Harvey Lillard, a janitor in the\\noffice where Palmer worked. The man had been deaf for\\n17 years, ever since he had sustained an injury to his\\nupper spine. Palmer performed an adjustment on a painful\\nvertebra in the region of the injury and Lillard’s hearing\\nwas reputedly restored. Palmer theorized that all commu-\\nnication from the brain to the rest of the body passes\\nthrough the spinal canal, and areas that are poorly aligned\\nor under stress can cause physical symptoms both in the\\nspine and in other areas of the body. Thus the body has\\nthe innate intelligence to heal itself when unencumbered\\nby spinal irregularities causing nerve interference. After\\nhis success with Lillard, other patients began coming to\\nhim for care, and responded well to adjustments. This\\nresulted in Palmer’s further study of the relationship\\nbetween an optimally functional spine and normal health.\\nPalmer founded the first chiropractic college in\\n1897. His son, B. J. Palmer, continued to develop chiro-\\npractic philosophy and practice after his father’s death.\\nB. J. and other faculty members were divided over the\\nrole of subluxation in disease. B. J. saw it as the cause of\\nall disease. The others disagreed and sought a more ratio-\\nnal way of thinking, thus broadening the base of chiro-\\npractic education. From 1910–1920, many other chiro-\\npractic colleges were established. Other innovators,\\nincluding John Howard, Carl Cleveland, Earl Home-\\nwood, Joseph Janse, Herbert Lee, and Claude Watkins,\\nalso helped to advance the profession.\\nThe theories of the Palmers receive somewhat\\nbroader interpretation today. Many chiropractors believe\\nthat back pain can be relieved and health restored\\nthrough chiropractic treatment even in patients who do\\nnot have demonstrable subluxations. Scientific develop-\\nment and research of chiropractic is gaining momentum.\\nThe twenty-first century will likely see the metaphysical\\nconcepts such as innate intelligence give way to more\\nscientific proofs and reform.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 767\\nChiropractic\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 767'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 156, 'page_label': '157'}, page_content='Many people besides the Palmers have contributed\\nto the development of chiropractic theory and technique.\\nSome have gone on to create a variety of procedures and\\nrelated types of therapy that have their roots in chiroprac-\\ntic, including McTimoney-Corley chiropractic, cran-\\niosacral manipulation, naprapathy, and applied kinesiol-\\nogy. Osteopathy is another related holistic discipline\\nthat utilizes spinal and musculoskeletal manipulation as a\\npart of treatment, but osteopathic training is more similar\\nin scope to that of an M.D.\\nInitial visit\\nAn initial chiropractic exam will most often include a\\nhistory and a physical. The patient should be asked about\\nwhat the current complaint is, whether there are chronic\\nhealth problems, family history of disease, dietary habits,\\nmedical care received, and any medications currently\\nbeing taken. Further, the current complaint should be\\ndescribed in terms of how long it has been a problem,\\nhow it has progressed, and whether it is the result of an\\ninjury or occurred spontaneously. Details of how an\\ninjury occurred should be given. The physical exam\\nshould evaluate by observation and palpation whether the\\npainful area has evidence of inflammation or poor align-\\nment. Range of motion may also be assessed. In the spine,\\neither hypomobility (fixation) or hypermobility may be a\\nproblem. Laboratory analysis is helpful in some cases to\\nrule out serious infection or other health issues that may\\nrequire referral for another type of treatment. Many prac-\\ntitioners also insist on x rays during the initial evaluation\\nManipulation\\nWhen spinal manipulation is employed, it is generally\\ndone with the hands, although some practitioners may use\\nan adjusting tool. A classic adjustment involves a high\\nvelocity, low amplitude thrust that produces a usually\\npainless popping noise, and improves the range of motion\\nof the joint that was treated. The patient may lie on a spe-\\ncially designed, padded table that helps the practitioner to\\nachieve the proper positions for treatment. Some adjust-\\nments involve manipulating the entire spine, or large por-\\ntions of it, as a unit; others are small movements designed\\nto affect a single joint. Stretching, traction, and slow\\nmanipulation are other techniques that can be employed to\\nrestore structural integrity and relieve nerve interference.\\nLength of treatment\\nThe number of chiropractic treatments required will\\nvary depending on several factors. Generally longer-term\\ntreatment is needed for conditions that are chronic,\\nsevere, or occur in conjunction with another health prob-\\nlem. Patients who are not in overall good health may also\\nhave longer healing times. Some injuries will inherently\\nrequire more treatments than others in order to get relief.\\nCare is given in three stages. Initially appointments are\\nmore frequent with the goal of relieving immediate pain.\\nNext, the patient moves into a rehabilitative stage to con-\\ntinue the healing process and help to prevent a relapse.\\nFinally, the patient may elect periodic maintenance, or\\nwellness treatments, along with lifestyle changes if need-\\ned in order to stay in good health.\\nFollow-up care\\nDischarge and follow-up therapy are important. If an\\ninjury occurred as a result of poor fitness or health, a pro-\\ngram of exercise or nutrition should be prescribed.\\nHome therapy may also be recommended, involving\\nsuch things as anti-inflammatory medication and appli-\\nGALE ENCYCLOPEDIA OF MEDICINE 2768\\nChiropractic\\nAn example of a McTimoney chiropractic technique on\\npatient’s lumbar vertebra.The McTimoney chiropractic is a\\nsystem of adjustment by hand of displacements of the\\nspinal column and bones. It can also be applied to animals.\\n(Photograph by Francoise Sauze, Custom Medical Stock Photo.\\nReproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 768'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 157, 'page_label': '158'}, page_content='cations of heat or ice packs. Conscious attention to pos-\\nture may help some patients avoid sustaining a similar\\ninjury in the future, and the chiropractor should be able\\nto discern what poor postural habits require correction. A\\nsedentary lifestyle, particularly with a lot of time spent\\nsitting, is likely to contribute to poor posture and may\\npredispose a person to back pain and injury.\\nTypes of practitioners\\nSome practitioners use spinal manipulation to the\\nexclusion of all other modalities, and are known as\\nstraight chiropractors. Others integrate various types of\\ntherapy such as massage, nutritional intervention, or\\ntreatment with vitamins , herbs, or homeopathic reme-\\ndies. They also embrace ideas from other health care tra-\\nditions. This group is known as mixers. The vast majority\\nof chiropractors, perhaps 85%, fall in this latter category.\\nPreparations\\nPatients should enter the chiropractic clinic with an\\nopen mind. This will help to achieve maximum results.\\nPrecautions\\nChiropractic is not an appropriate therapy for dis-\\neases that are severely degenerative and may require\\nmedication or surgery. Many conditions of the spine are\\namenable to manipulative treatment, but that does not\\ninclude fractures . The practitioner should be informed\\nin advance if the patient is on anticoagulants, or has\\nosteoporosis or any other condition that may weaken the\\nbones. There are other circumstances that would con-\\ntraindicate chiropractic care, and these should be detect-\\ned in the history or physical exam. In addition to frac-\\ntures, Down syndrome , some congenital defects, and\\nsome types of cancer are a few of the things that may\\npreclude spinal manipulation. On rare occasions, a frac-\\nture or dislocation may occur. There is also a very slim\\npossibility of experiencing a stroke as a result of spinal\\nmanipulation, but estimates are that it is no more fre-\\nquent than 2.5 occurrences per one million treatments.\\nBe wary of chiropractors who insist on costly x rays\\nand repeated visits with no end in sight. Extensive use is\\nnot scientifically justifiable, especially in most cases of\\nlower back pain. There are some circumstances when x\\nrays are indicated, including acute or possibly severe\\ninjuries such as those that might result from a car accident.\\nSide effects\\nIt is not uncommon to have local discomfort in the\\nform of aches, pains, or spasms for a few days following\\nDANIEL PALMER (1845–1913)\\nChiropractic inventor, Daniel David Palmer, was\\nborn on March 7, 1845, in Toronto, Ontario. He was\\none of five siblings, the children of a shoemaker and his\\nwife, Thomas and Katherine Palmer. Daniel Palmer and\\nhis older brother fell victim to wanderlust and left Cana-\\nda with a tiny cash reserve in April 1865. They immi-\\ngrated to the United States on foot, walking for 30 days\\nbefore arriving in Buffalo, New York. They traveled by\\nboat through the St. Lawrence Seaway to Detroit, Michi-\\ngan. There they survived by working odd jobs and sleep-\\ning on the dock. Daniel Palmer settled in What Cheer,\\nIowa, where he supported himself and his first wife as a\\ngrocer and fish peddler in the early 1880s. He later\\nmoved to Davenport, Iowa, where he raised three\\ndaughters and one son.\\nPalmer was a man of high curiosity. He investigated\\na variety of disciplines of medical science during his\\nlifetime, many of which were in their infancy. He was\\nintrigued by phrenology and assorted spiritual cults, and\\nfor nine years he investigated the relationship between\\nmagnetism and disease. Palmer felt that there was one\\nthing that caused disease. He was intent upon discover-\\ning this one thing, or as he called it: the great secret.\\nIn September 1895, Palmer purported to have cured\\na deaf man by placing pressure on the man’s displaced\\nvertebra. Shortly afterward Palmer claimed to cure\\nanother patient of heart trouble, again by adjusting a dis-\\nplaced vertebra. The double coincidence led Palmer to\\ntheorize that human disease might be the result of dislo-\\ncated or luxated bones, as Palmer called them. That\\nsame year he established the Palmer School of Chiro-\\npractic where he taught a three-month course in the sim-\\nple fundamentals of medicine and spinal adjustment.\\nPalmer, who was married six times during his life,\\ndied in California in 1913; he was destitute. His son,\\nBartlett Joshua Palmer, successfully commercialized the\\npractice of chiropractic.\\na chiropractic treatment. Some patients may also experi-\\nence mild headache or fatigue that resolves quickly.\\nResearch and general acceptance\\nAs recently as the 1970s, the American Medical\\nAssociation (a national group of medical doctors) was\\nquite hostile to chiropractic, which it deemed a cult.\\nAMA members were advised that it was unethical to be\\nassociated with chiropractors. Fortunately that has\\nchanged, and as of 2000, many allopathic or traditionally\\ntrained physicians enjoy cordial referral relationships\\nwith chiropractors. The public is certainly strongly in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 769\\nChiropractic\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 769'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 158, 'page_label': '159'}, page_content='favor of chiropractic treatment. An estimated 15% of\\npeople in the United States used chiropractic care in\\n1997. Chiropractors see the lion’s share of all patients\\nwho seek medical help for back problems.\\nResearch has also supported the use of spinal manip-\\nulation for acute low back pain. There is some anecdotal\\nevidence recommending chiropractic treatment for ail-\\nments unrelated to musculoskeletal problems, but there is\\nnot enough research-based data to support this. On the\\nother hand, a chiropractor may be able to treat problems\\nand diseases unrelated to the skeletal structure by\\nemploying therapies other than spinal manipulation.\\nAlthough many chiropractors limit their practice to\\nspine and joint problems, others claim to treat disorders\\nthat are not closely related to the back or musculoskeletal\\nsystem. These include asthma, bed-wetting, bronchitis,\\ncoughs, dizziness , dysmenorrhea, earache, fainting ,\\nheadache, hyperactivity, indigestion , infertility ,\\nmigraine, pneumonia, and issues related to pregnancy.\\nThere are at least three explanations for possible efficacy\\nfor these conditions. One is that the problem could be\\nlinked to a nerve impingement, as may be possible with\\nbed-wetting, dizziness, fainting, and headache. In a sec-\\nond group, chiropractic treatment may offer some relief\\nfrom complicating pain and spasms caused by the dis-\\nease process, as with asthma, bronchitis, coughs, and\\npneumonia. The discomforts of pregnancy may also be\\nrelieved with gentle chiropractic therapy. A third possi-\\nbility is that manipulation or use of soft-tissue techniques\\nmay directly promote improvement of some conditions.\\nOne particular procedure, known as the endonasal tech-\\nnique, is thought to help the eustachian tube to open and\\nthus improve drainage of the middle ear. The tube is\\nsometimes blocked off due to exudates or inflammatory\\nKEY TERMS\\nAdjustment—A very specific type of manipulation\\nof the spine designed to return it to proper struc-\\ntural and functional form.\\nAllopathic —Conventional practice of medicine\\ngenerally associated with M.D. physicians.\\nDysmenorrhea—Painful menstruation.\\nOsteoporosis —A condition of decreased bone\\ndensity, causing increased bone fragility, that is\\nmost common in elderly women.\\nSubluxation —Misalignment between vertebrae\\nthat structurally and functionally impairs nerve\\nfunction.\\nprocesses. This can offer significant relief from earaches.\\nSome headaches also fall in this category, as skilled use\\nof soft tissue techniques and adjustment may relieve the\\nmuscle tension that may initiate some headaches.\\nDysmenorrhea, hyperactivity, indigestion, and infer-\\ntility are said to be relieved as a result of improved flow\\nof blood and nerve energy following treatment. Evidence\\nfor this is anecdotal at best, but manipulation is unlikely\\nto be harmful if causes treatable by other modalities have\\nbeen ruled out.\\nFor conditions such as cancer, fractures, infectious\\ndiseases, neurologic disease processes, and anything that\\nmay cause increased orthopedic fragility, chiropractic\\ntreatment alone is not an effective therapy, and may even\\nbe harmful in some cases. Those who have known circu-\\nlatory problems, especially with a history of thrombosis,\\nshould not have spinal manipulation.\\nResources\\nBOOKS\\nCassileth, Barrie. The Alternative Medicine Handbook. New\\nYork: W. W. Norton & Co., Inc., 1998.\\nDillard, James, and Terra Ziporyn. Alternative Medicine for\\nDummies. Indianapolis: IDG Bks. Worldwide, 1998.\\nLeach, Robert. The Chiropractic Theories: Principles and\\nClinical Applications. 3rd ed. Philadelphia: Lippincott\\nWilliams & Wilkins, 1994.\\nRondberg, Terry. Chiropractic First.Chandler, AZ: The Chiro-\\npractic Journal, 1996.\\nWoodham, Anne, and David Peters. Encyclopedia of Healing\\nTherapies. New York: DK Publishing, Inc., 1997.\\nORGANIZATIONS\\nAmerican Chiropractic Association. 1701 Clarendon Blvd.,\\nArlington, V A 22209. (800)986-4636. .\\nJudith Turner\\nChlamydial infections see Chlamydial\\npneumonia; Epididymitis;\\nNongonococcal urethritis; Sexually\\ntransmitted diseases\\nChlamydial pneumonia\\nDefinition\\nChlamydial pneumonia refers to one of several\\ntypes of pneumonia that can be caused by various types\\nof the bacteria known as Chlamydia.\\nGALE ENCYCLOPEDIA OF MEDICINE 2770\\nChlamydial pneumonia\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 770'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 159, 'page_label': '160'}, page_content='Description\\nPneumonia is an infection of the lungs. The air sacs\\n(alveoli) and/or the tissues of the lungs become swollen,\\nand the alveoli may fill with pus or fluid. This prevents the\\nlungs from taking in sufficient oxygen, which deprives the\\nblood and the rest of the body’s tissues of oxygen.\\nThere are three major types of Chlamydia: Chlamy-\\ndia psittaci, Chlamydia pneumoniae, and Chlamydia tra-\\nchomatis. Each of these has the potential to cause a type\\nof pneumonia.\\nCauses and symptoms\\nChlamydia trachomatis is a major cause of sexually\\ntransmitted diseases (called nongonococcal urethritis\\nand pelvic inflammatory disease). When a woman with\\nan active chlamydial infection gives birth to a baby, the\\nbaby may aspirate (suck into his or her lungs) some of\\nthe mother’s bacteria-laden secretions while passing\\nthrough the birth canal. This can cause a form of relative-\\nly mild pneumonia in the newborn, occurring about two\\nto six weeks after delivery.\\nChlamydia psittaci is a bacteria carried by many\\ntypes of birds, including pigeons, canaries, parakeets, par-\\nrots, and some gulls. Humans acquire the bacteria through\\ncontact with dust from bird feathers, bird droppings, or\\nfrom the bite of a bird carrying the bacteria. People who\\nkeep birds as pets or who work where birds are kept have\\nthe highest risk for this type of pneumonia. This pneumo-\\nnia, called psittacosis, causes fever, cough, and the pro-\\nduction of sputum containing pus. This type of pneumo-\\nnia may be quite severe, and is usually more serious in\\nolder patients. The illness can last several weeks.\\nChlamydia pneumoniae usually causes a type of rel-\\natively mild “walking pneumonia.” Patients experience\\nfever and cough. This type of pneumonia is called a\\n“community-acquired pneumonia” because it is easily\\npassed from one member of the community to another.\\nDiagnosis\\nLaboratory tests indicating the presence of one of\\nthe strains of Chlamydia are sophisticated, expensive,\\nand performed in only a few laboratories across the\\ncountry. For this reason, doctors diagnose most cases of\\nchlamydial pneumonia by performing a physical exami-\\nnation of the patient, and noting the presence of certain\\nfactors. For instance, if the mother of a baby sick with\\npneumonia is positive for a sexually transmitted disease\\ncaused by Chlamydia trachomatis, the diagnosis is obvi-\\nous. History of exposure to birds in a patient sick with\\npneumonia suggests that Chlamydia psittaci may be the\\nculprit. A mild pneumonia in an otherwise healthy per-\\nson is likely to be a community-acquired walking pneu-\\nmonia, such as that caused by Chlamydia pneumoniae.\\nTreatment\\nTreatment varies depending on the specific type of\\nChlamydia causing the infection. A newborn with\\nChlamydia trachomatis improves rapidly with ery-\\nthromycin. Chlamydia psittaci infection is treated with\\ntetracycline, bed rest, oxygen supplementation, and\\ncodeine-containing cough preparations. Chlamydia\\npneumoniae infection is treated with erythromycin.\\nPrognosis\\nThe prognosis is generally excellent for the newborn\\nwith Chlamydia trachomatis pneumonia. Chlamydia\\npsittaci may linger, and severe cases have a death rate of\\nas high as 30%. The elderly are hardest hit by this type of\\npneumonia. A young, healthy person with Chlamydia\\npneumoniae has an excellent prognosis. In the elderly,\\nhowever, there is a 5–10% death rate from this infection.\\nPrevention\\nPrevention of Chlamydia trachomatis pneumonia\\ninvolves recognizing the symptoms of genital infection in\\nthe mother and treating her prior to delivery of her baby.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 771\\nChlamydial pneumonia\\nA transmission electron microscopy (TEM) of a sectioned\\nChlamydia pneumoniae bacterium. (Photograph by Dr. Kari\\nLounatmaa, Custom Medical Stock Photo. Reproduced by per-\\nmission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 771'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 160, 'page_label': '161'}, page_content='Chlamydia psittacican be prevented by warning peo-\\nple who have birds as pets, or who work around birds, to\\nbe careful to avoid contact with the dust and droppings of\\nthese birds. Sick birds can be treated with an antibiotic in\\ntheir feed. Because people can contract psittacosis from\\neach other, a person sick with this infection should be\\nkept in isolation, so as not to infect other people.\\nChlamydia pneumoniae is difficult to prevent\\nbecause it is spread by respiratory droplets from other\\nsick people. Because people with this type of pneumonia\\ndo not always feel very sick, they often continue to\\nattend school, go to work, and go to other public places.\\nThey then spread the bacteria in the tiny droplets that are\\nreleased into the air during coughing. Therefore, this\\npneumonia is very difficult to prevent and often occurs in\\noutbreaks within communities.\\nResources\\nBOOKS\\nDrew, W. Lawrence. “Chlamydia.”Sherris Medical Microbiol-\\nogy: An Introduction to Infectious Diseases.3rd ed. Ed.\\nKenneth J. Ryan. Norwalk, CT: Appleton & Lange, 1994.\\nStoffman, Phyllis. The Family Guide to Preventing and Treat-\\ning 100 Infectious Diseases. New York: John Wiley &\\nSons, 1995.\\nPERIODICALS\\nDalhoff, Klaus, and Matthias Maass. “Chlamydia Pneumoniae\\nPneumonia in Hospitalized Patients: Clinical Characteris-\\ntics and Diagnosis.”Chest 110, no. 2 (Aug. 1996): 351+.\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nRosalyn Carson-DeWitt, MD\\nChlorhexidine see Antibiotics, topical\\nKEY TERMS\\nAlveoli—The small air sacs clustered at the ends\\nof the bronchioles in the lungs, in which oxygen-\\ncarbon dioxide exchange takes place.\\nAspiration—When solids or liquids that should be\\nswallowed into the stomach are instead breathed\\ninto the respiratory system, or when substances\\nfrom the outside environment are accidentally\\nbreathed into the lungs.\\nSputum—Material produced within the alveoli in\\nresponse to an infectious or inflammatory process.\\nChloroquine see Antimalarial drugs\\nChlorzoxazone see Muscle relaxants\\nChoking\\nDefinition\\nChoking is the inability to breathe because the tra-\\nchea is blocked, constricted, or swollen shut.\\nDescription\\nChoking is a medical emergency. When a person is\\nchoking, air cannot reach the lungs. If the airways cannot\\nbe cleared, death follows rapidly.\\nAnyone can choke, but choking is more common in\\nchildren than in adults. Choking is a common cause of\\naccidental death in young children who are apt to put toys\\nor coins in their mouths, then unintentionally inhale them.\\nAbout 3,000 adults die each year from choking on food.\\nPeople also choke because infection causes the\\nthroat tissue to swell shut. It is believed that this is what\\ncaused George Washington’s death. Allergic reactions\\ncan also cause the throat to swell shut. Acute allergic\\nreactions are called anaphylactic reactions and may be\\nfatal. Strangulation puts external pressure on the trachea\\ncausing another form of choking.\\nFinally, people can choke from obstructive sleep\\napnea. This is a condition where tissues of the body\\nobstruct the airways during sleep. Sleep apnea is most\\ncommon in obese men who sleep on their backs. Smok-\\ning, heavy alcohol use, lung diseases such as emphyse-\\nma, and an inherited tendency toward a narrowed airway\\nand throat all increase the risk of choking during sleep.\\nCauses and symptoms\\nThere are three reasons why people choke. These are:\\n• mechanical obstruction\\n• tissue swelling\\n• crushing of the trachea\\nRegardless of the cause, choking cuts off the air sup-\\nply to the lungs. Indications that a person’s airway is\\nblocked include:\\n• the person cannot speak or cry out\\n• the person’s face turns blue from lack of oxygen\\n• the person desperately grabs at his or her throat\\nGALE ENCYCLOPEDIA OF MEDICINE 2772\\nChoking\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 772'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 161, 'page_label': '162'}, page_content='• the person has a weak cough and labored breathing that\\nproduces a high-pitched noise\\n• the person has all of the above symptoms, then becomes\\nunconscious\\n• during sleep, the person has episodes of gasping, paus-\\nes in breathing, and sudden awakenings.\\nDiagnosis\\nDiagnosing choking due to mechanical obstruction\\nis straightforward, since the symptoms are obvious even\\nto an untrained person. In choking due to infection, the\\nperson, usually a child, will have a fever and signs of ill-\\nness before labored breathing begins. If choking is due to\\nan allergic reaction to medication or insect bites, the per-\\nson’s earlobes and face will swell, giving an external sign\\nthat internal swelling is also occurring.\\nChoking due to sleep apnea is usually diagnosed on\\nreports of symptoms by the person’s sleep partner. There\\nare also alarm devices to detect the occurrence of sleep\\napnea. Eventually sleep may be interrupted so frequently\\nthat daytime drowsiness becomes a problem.\\nTreatment\\nChoking, except during sleep apnea, is a medical\\nemergency. If choking is due to allergic reaction or infec-\\ntion, people should summon emergency help or go\\nimmediately to an emergency room. If choking is due to\\nobstructed airways, the Heimlich maneuver (an emer-\\ngency procedure in which a person is grasped from\\nbehind in order to forcefully expel the obstruction)\\nshould be performed immediately. In severe cases a tra-\\ncheotomy (an incision into the trachea through the neck\\nbelow the larynx) must be performed.\\nPatients who suffer airway obstruction during sleep\\ncan be treated with a device similar to an oxygen mask\\nthat creates positive airway pressure and delivers a mix-\\nture of oxygen and air.\\nPrognosis\\nMany people are treated successfully for choking\\nwith no permanent effects. However, if treatment is\\nunsuccessful, the person dies from lack of oxygen. In\\ncases where the ariway is restored after the critical period\\npasses, there may be permanent brain damage.\\nPrevention\\nWatching children carefully to keep them from\\nputting foreign objects in their mouth and avoiding giv-\\ning young children food like raisins, round slices of hot\\nKEY TERMS\\nTrachea—The windpipe. A tube extending from\\nbelow the voice box into the chest where it splits\\ninto two branches, the bronchi, that go to each\\nlung.\\nTracheotomy—The surgical creation of an open-\\ning in the trachea that functions as an alternative\\nairway so that the patient may breathe.\\ndogs, and grapes can reduce the chance of choking in\\nchildren. Adults should avoid heavy alcohol consump-\\ntion when eating and avoid talking and laughing with\\nfood in their mouths. The risk of obstructive sleep apnea\\nchoking can be reduced by avoiding alcohol, tobacco\\nsmoking, tranquilizers, and sedatives before bed.\\nResources\\nBOOKS\\nBerkow, Robert, Mark Beers, and Andrew Fletcher, eds. “Sleep\\nApnea Syndromes.” In The Merck Manual of Medical\\nInformation. Home Edition. Whitehouse Station, NJ:\\nMerck Research Laboratories, 1997.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nTish Davidson\\nCholangitis\\nDefinition\\nThe term cholangitis means inflammation of the bile\\nducts. The term applies to inflammation of any portion of\\nthe bile ducts, which carry bile from the liver to the gall-\\nbladder and intestine. The inflammation is produced by\\nbacterial infection or sometimes other causes.\\nDescription\\nBile, which is needed for digestion, is produced in\\nthe liver and then enters the common bile duct (CBD)\\nthrough the hepatic ducts. Bile enters the gallbladder\\nbetween meals, when the muscle or sphincter that con-\\ntrols flow of bile between the CBD and intestine is\\nclosed. During this period, bile accumulates in the CBD;\\nGALE ENCYCLOPEDIA OF MEDICINE 2 773\\nCholangitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 773'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 162, 'page_label': '163'}, page_content='the pressure in the CBD rises, as would a pipe closed off\\nat one end. The increase in pressure eventually causes the\\nbile to flow into the gallbladder. During meals, the gall-\\nbladder contracts and the sphincter between the gallblad-\\nder and intestine relaxes, permitting bile to flow into the\\nintestine and take part in digestion.\\nBile that has just been produced by the liver is sterile\\n(free of bacteria). This is partly due to its antibacterial\\nproperties; these are produced by the immunoglobulins\\n(antibodies) secreted in bile, the bile acids which inhibit\\nbacterial growth themselves, and mucus.\\nA small number of bacteria may be present in the bile\\nducts and gallbladder, getting there by moving backward\\nfrom the intestine, which unlike the bile ducts, contains\\nlarge numbers of bacteria. The normal flow of bile out of\\nthe ducts and into the intestine also helps keep too many\\norganisms from multiplying. Bacteria also reach the bile\\nducts from the lymph tissue or from the blood stream.\\nWhen the passage of bile out of the ducts is blocked,\\nthe few bacteria that are there rapidly reproduce. A par-\\ntial blockage to the flow of bile can occur when a stone\\nfrom the gallbladder blocks the duct, and also allows\\nbacteria to flow back into the CBD, and creates ideal\\nconditions for their growth. Tumors, on the other hand,\\ncause a more complete blockage of bile flow, both in and\\nout, so fewer infections occur. The reproducing organ-\\nisms are often able to enter the bloodstream and infect\\nmultiple organs such as the liver and heart valves.\\nAnother source of inflammation of the bile ducts\\noccurs in diseases of altered immunity, known as “autoim-\\nmune diseases.” In these diseases, the body fails to recog-\\nnize certain cells as part of its normal composition. The\\nbody thinks these cells are foreign and produces antibod-\\nies to fight them off, just as it fights against bacteria and\\nviruses. Primary sclerosing cholangitis is a typical exam-\\nple of an autoimmune disease involving the bile ducts.\\nCauses and symptoms\\nAs noted above, the two things that are needed for\\ncholangitis to occur are: 1) obstruction to bile flow, and\\n2) presence of bacteria within the bile ducts. The most\\ncommon cause of cholangitis is infection of the bile\\nducts due to blockage by a gallstone. Strictures (portions\\nof ducts that have become narrow) also function in the\\nsame way. Strictures may be due to congenital (birth)\\nabnormalities of the bile ducts, form as a result of injury\\nto the bile duct (such as surgery, trauma), or result from\\ninflammation that leads to scar tissue and narrowing.\\nThe bacterium most commonly associated with infec-\\ntion of the bile ducts is Escherichia coli (E. coli)which is a\\nnormal inhabitant of the intestine. In some cases, more\\nthan one type of bacteria is involved. Patients with AIDS\\ncan develop infection of narrowed bile ducts with unusual\\norganisms such as Cryptosporidiumand others.\\nThe three symptoms present in about 70% of patients\\nwith cholangitis are abdominal pain, fever, and jaundice.\\nSome patients only have chills and fever with minimal\\nabdominal symptoms. Jaundice or yellow discoloration of\\nthe skin and eyes occurs in about 80% of patients. The\\ncolor change is due to bile pigments that accumulate in the\\nblood and eventually in the skin and eyes.\\nInflammation due to the autoimmune disease prima-\\nry sclerosing cholangitis leads to multiple areas of nar-\\nrowing and eventual infection. Tumors can block the bile\\nduct and also cause cholangitis, but as noted, infection is\\nrelatively infrequent; in fact cholangitis occurs in only\\nabout one in six patients with tumors.\\nAnother type of bile duct infection occurs mainly in\\nSoutheast Asia and is known as recurrent pyogenic\\ncholangitis or Oriental cholangitis. It has also been iden-\\ntified in Asians immigrating to North America. Most\\npatients have stones in the bile ducts and/or gallbladder,\\nand many cases are associated with the presence of para-\\nsites within the ducts. The role of parasites in causing\\ninfection is not clear. Many researchers believe that they\\nare just coincidental, and have nothing to do with the\\nstones or infection.\\nDiagnosis\\nThe above symptoms alone are very suggestive of\\ncholangitis; however, it is important to determine the exact\\ncause and site of possible obstruction. This is because\\nattacks are likely to recur, and different causes require dif-\\nferent treatments. For example, the treatment of cholangi-\\ntis due to a stone in the CBD is different from that due to\\nbile duct strictures. An elevated white blood count sug-\\ngests infection, but may be normal in 20% of patients.\\nAbnormal or elevated tests of liver function, such as biliru-\\nbin and others are also frequently present. The specific\\nbacteria is sometimes identified from blood cultures.\\nX-ray techniques\\nA number of x-ray techniques can make the diagno-\\nsis of bile duct obstruction; these include ultrasound and\\ncomputed tomography scans (CT scans). However,\\nultrasound often cannot tell if an obstruction is due to a\\nstricture or stone, missing a stone in about half the cases.\\nCT scans have an even poorer record of stone detection.\\nAnother method of diagnosing and sometimes treat-\\ning the cause of bile duct obstruction or narrowing is\\ncalled percutaneous transhepatic cholangiography. In\\nthis procedure, dye is injected into the ducts by means of\\nGALE ENCYCLOPEDIA OF MEDICINE 2774\\nCholangitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 774'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 163, 'page_label': '164'}, page_content='a needle placed into the liver. It is also used to drain bile\\nand relieve an obstruction.\\nENDOSCOPIC TECHNIQUES. An endoscope is a thin\\nflexible tube that uses a lens or mirror to look at various\\nparts of the gastrointestinal tract. Endoscopic retro-\\ngrade cholangiopancreatography (ERCP) can accu-\\nrately determine the cause and site of blockage. It also\\nhas the advantage of being able to treat the cause of\\nobstruction, by removing stones and dilating (stretching)\\nstrictures. ERCP involves the injection of x-ray dye into\\nthe bile ducts through an endoscope. Endoscopic ultra-\\nsound is another endoscopic alternative, but is not as\\navailable as ERCP and is not therapeutic.\\nTreatment\\nThe first aim is to control the bacterial infection.\\nBroad-spectrum antibiotics are usually used. If the\\nKEY TERMS\\nAntibiotic—A medication that is designed to kill or\\nweaken bacteria.\\nBilirubin —A pigment produced by the liver that is\\nexcreted in bile which causes a yellow discol-\\noration of the skin and eyes when it accumulates in\\nthose organs. Bilirubin levels can be measured by\\nblood tests, and are most often elevated in patients\\nwith liver disease or a blockage to bile flow.\\nComputed tomography scan (CT scan)—A special-\\nized x-ray procedure in which cross-sections of the\\narea in question can be examined in detail. In eval-\\nuating the bile ducts, iodine-based dye is often\\ninjected intravenously. The procedure is of greatest\\nvalue in diagnosing the complications of gallstones\\n(such as abscesses, pancreatitis) rather than docu-\\nmenting the presence of a stone.\\nEndoscope —An endoscope as used in the field of\\ngastroenterology is a thin flexible tube which uses a\\nlens or miniature camera to view various areas of\\nthe gastrointestinal tract. When the procedure is\\nperformed to examine certain organs such as the\\nbile ducts or pancreas, the organs are not viewed\\ndirectly, but rather indirectly through the injection\\nof x-ray dye into the bile duct.\\nEndoscopy—The performance of an exam using an\\nendoscope is referred by the general term\\nendoscopy. Diagnosis through biopsies or other\\nmeans and therapeutic procedures can be done\\nwith these instruments.\\nExtracorporeal shock-wave lithotripsy (ESWL)—This\\nis a technique that uses high-pressure waves similar\\nto sound waves that can be “focused” on a very small\\narea, thereby fracturing small solid objects such as\\ngallstones, kidney stones, etc. The small fragments\\ncan pass more easily and harmlessly into the intes-\\ntine or can be dissolved with medications.\\nPrimary sclerosing cholangitis —A chronic disease\\nin which it is believed that the immune system fails\\nto recognize the cells that compose the bile ducts as\\npart of the same body, and attempts to destroy\\nthem. It is not clear what exactly causes the disease,\\nbut it is frequently associated with another inflam-\\nmatory disease of the digestive tract, ulcerative coli-\\ntis. The inflammation of the ducts eventually pro-\\nduces formation of scar tissue, causing multiple\\nareas of narrowing (strictures) that block bile flow\\nand lead to bacterial infection. Liver transplant\\ngives the best chance for long-term survival.\\nUltrasound—A non-invasive procedure based on\\nchanges in sound waves of a frequency that cannot\\nbe heard, but respond to changes in tissue composi-\\ntion. It requires no preparation and no radiation\\noccurs. It has become the “gold standard” for diag-\\nnosis of stones in the gallbladder, but is less accurate\\nin diagnosing stones in the bile ducts. Gallstones as\\nsmall as 2 mm can be identified. The procedure can\\nnow also be done through an endoscope, greatly\\nimproving investigation of the bile ducts.\\ninfection does not come under control promptly, as noted\\nby decrease in fever and pain, then other methods to\\nrelieve the obstruction and infection will be needed.\\nEither way, definitive treatment of the cause of bile duct\\ninfection is the next step, and this has undergone revolu-\\ntionary changes in the past decade. Endoscopic, radi-\\nographic and other techniques have made it possible to\\nsuccessfully remove stones and dilate strictures that pre-\\nviously required surgical intervention, often with high\\nmorbidity and mortality.\\nRadiologic and endoscopic techniques\\nJust as with diagnosis, treatment of cholangitis\\ninvolves a number of similar procedures that differ main-\\nly in the way the bile ducts are entered. The aims of these\\ntechniques are immediate relief of obstruction and infec-\\ntion as well as correction of any abnormalities that have\\nGALE ENCYCLOPEDIA OF MEDICINE 2 775\\nCholangitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 775'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 164, 'page_label': '165'}, page_content='caused them. It is important to realize that even with\\nendoscopy, x-ray dye is injected into the ducts and there-\\nfore the radiologist plays a role in both types of proce-\\ndures. When endoscopy is used, the muscle between the\\nintestine and bile duct is widened, to allow stones to\\npass. This is called a sphincterotomy and is often enough\\nto relieve any obstruction and help clear infection. The\\nwidening of the muscle is needed if other procedures\\ninvolving the bile duct are going to be performed.\\nThe above techniques can be summarized as follows:\\n• Insertion of a catheter or thin flexible tube to drain bile\\nand relieve obstruction. When performed by insertion\\nof a needle into the liver the technique is called percuta-\\nneous transhepatic biliary drainage (PTBD); when per-\\nformed endoscopically the catheter exits through the\\nnose and is called a nasobiliary drain.\\n• Balloons can be inserted into the ducts with either\\nmethod to dilate strictures.\\n• Insertion of a prosthesis which is a rigid or flexible tube\\ndesigned to keep a narrowed area open; it is usually\\nplaced after a stricture is dilated with a balloon.\\n• Removal of stones can be accomplished most often by\\nendoscopic techniques. A number of methods have\\nbeen developed to perform this including laser and con-\\ntact lithotripsy in which stones are fragmented by\\nhigh-energy waves.\\nSurgical treatment\\nFortunately, with recent advances in the above meth-\\nods, this is a last option. Nonetheless, about 5–10% of\\npatients will need to undergo surgical exploration of the\\nbile ducts.\\nIn some instances, the bile duct is so narrowed due to\\nprior inflammation or tumor, that it needs connection to a\\ndifferent area of the intestinal tract to drain. This is rather\\ncomplicated surgery and carries a mortality rate of 2%.\\nOther treatment\\nExtracorporeal shock-wave lithotripsy (ESWL) was\\nfirst used to break up kidney stones . The technique has\\nbeen extended to the treatment of gallstones, in both the\\ngallbladder and bile ducts. It is often combined with\\nendoscopic procedures to ease the passage of fragmented\\nstones, or oral medications that can dissolve the frag-\\nments. Rarely, stones are also dissolved by instilling vari-\\nous chemicals such as ether directly into the bile ducts.\\nPrognosis\\nThe outlook for those with cholangitis has markedly\\nimproved in the last several years due in large part to the\\ndevelopment of the techniques described above. For those\\npatients whose episode of infection is caused by some-\\nthing other than a simple stone, the future is not as bright,\\nbut still often responsive to treatment. Some patients with\\nautoimmune disease will need liver transplantation.\\nPrevention\\nThis involves eliminating those factors that increase\\nthe risk of infection of the bile ducts, mainly stones and\\nstrictures. If it is medically possible, patients who have\\ntheir gallbladder and suffer a bout of cholangitis should\\nundergo surgical removal of the gallbladder and removal\\nof any stones.\\nFor other patients, a variety of therapies as outlined\\nabove, including dissolving small stones with bile acids,\\nare also available. A combination of several of these\\nmethods is needed in some patients. Patients should dis-\\ncuss the risks and alternatives of these treatments with\\ntheir physicians.\\nResources\\nBOOKS\\nBilhartz, Lyman E., and Jay D. Horton. “Gallstone Disease and\\nIts Complications.” In Sleisenger & Fordtran’s Gastroin-\\ntestinal and Liver Disease, ed. Mark Feldman, et al.\\nPhiladelphia: W. B. Saunders Co., 1997.\\nGreenberger, Norton J., and Kurt J. Isselbacher. “Diseases of\\nthe Bile Ducts.” In Harrison’s Principles of Internal Med-\\nicine, ed. Anthony S. Fauci, et al. New York: McGraw-\\nHill, 1997.\\nMulvihill, Sean J. “Surgery for Choledocholithiasis.” In\\nSleisenger & Fordtran’s Gastrointestinal and Liver Dis-\\nease, ed. Mark Feldman, et al. Philadelphia: W. B. Saun-\\nders Company. 1997.\\nOstroff, James W., and Jeanne M. LaBerge. “Endoscopic and\\nRadiologic Treatment of Biliary Disease.” In Sleisenger &\\nFordtran’s Gastrointestinal and Liver Disease, ed. Mark\\nFeldman, et al. Philadelphia: W. B. Saunders Company.\\n1997.\\nPaumgartner, Gustav. “Nonsurgical Management of Gallstone\\nDisease.” In Sleisenger & Fordtran’s Gastrointestinal and\\nLiver Disease, ed. Mark Feldman, et al. Philadelphia: W.\\nB. Saunders Company. 1997.\\nPERIODICALS\\nCotton, Peter B., and Robert H. Hawes. “Therapeutic Biliary\\nEndoscopy.”Gastrointestinal Endoscopy Clinics of North\\nAmerica (Jan. 1996): 1-263.\\nLee, Young-Mee, and Marshall M. Kaplan. “Primary Scleros-\\ning Cholangitis.” New England Journal of Medicine 332,\\nno. 14 (1995): 924.\\nOTHER\\n“Endoscopic Retrograde Cholangiopancreatography (ERCP).”\\nAmerican Society for Gastrointestinal Endoscopy..\\nGALE ENCYCLOPEDIA OF MEDICINE 2776\\nCholangitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 776'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 165, 'page_label': '166'}, page_content='“Gallstones.” National Institute of Diabetes and Digestive and\\nKidney Disease. .\\nKaminstein, David S. “Gallstones.”A Healthy Me Page.\\n.\\n“Primary Sclerosing Cholangitis.”National Institute of Dia-\\nbetes and Digestive and Kidney Disease..\\nWorman, Howard J. “Sclerosing Cholangitis.”Columbia Uni-\\nversity Health Sciences Page..\\n“Your Digestive System and How It Works.”National Institute\\nof Diabetes and Digestive and Kidney Disease..\\nDavid Kaminstein, MD\\nCholecystectomy\\nDefinition\\nA cholecystectomy is the surgical removal of the\\ngallbladder. The two basic types of this procedure are\\nopen cholecystectomy and the laparoscopic approach. It\\nis estimated that the laparoscopic procedure is currently\\nused for approximately 80% of cases.\\nPurpose\\nA cholecystectomy is performed to treat cholelithia-\\nsis and cholecystitis . In cholelithiasis, gallstones of\\nvarying shapes and sizes form from the solid components\\nof bile. The presence of stones, often referred to as gall-\\nbladder disease, may produce symptoms of excruciating\\nright upper abdominal pain radiating to the right shoul-\\nder. The gallbladder may become the site of acute infec-\\ntion and inflammation, resulting in symptoms of upper\\nright abdominal pain, nausea and vomiting. This condi-\\ntion is referred to as cholecystitis. The surgical removal\\nof the gallbladder can provide relief of these symptoms.\\nPrecautions\\nAlthough the laparoscopic procedure requires general\\nanesthesia for about the same length of time as the open\\nprocedure, laparoscopy generally produces less postoper-\\native pain, and a shorter recovery period. The laparoscopic\\nprocedure would not be preferred in cases where the gall-\\nbladder is so inflamed that it could rupture, or when adhe-\\nsions (additional fibrous bands of tissue) are present.\\nDescription\\nThe laparoscopic cholecystectomy involves the inser-\\ntion of a long narrow cylindrical tube with a camera on\\nthe end, through an approximately 1 cm incision in the\\nabdomen, which allows visualization of the internal\\norgans and projection of this image onto a video monitor.\\nThree smaller incisions allow for insertion of other instru-\\nments to perform the surgical procedure. A laser may be\\nused for the incision and cautery (burning unwanted tis-\\nsue to stop bleeding), in which case the procedure may be\\ncalled laser laparoscopic cholecystectomy.\\nIn a conventional or open cholecystectomy, the gall-\\nbladder is removed through a surgical incision high in the\\nright abdomen, just beneath the ribs. A drain may be insert-\\ned to prevent accumulation of fluid at the surgical site.\\nPreparation\\nAs with any surgical procedure, the patient will be\\nrequired to sign a consent form after the procedure is\\nexplained thoroughly. Food and fluids will be prohibited\\nafter midnight before the procedure. Enemas may be\\nordered to clean out the bowel. If nausea or vomiting are\\npresent, a suction tube to empty the stomach may be\\nused, and for laparoscopic procedures, a urinary drainage\\ncatheter will also be used to decrease the risk of acciden-\\ntal puncture of the stomach or bladder with insertion of\\nthe trocar (a sharp-pointed instrument).\\nAftercare\\nPost-operative care for the patient who has had an open\\ncholecystectomy, as with those who have had any major\\nsurgery, involves monitoring of blood pressure, pulse, respi-\\nration and temperature. Breathing tends to be shallow\\nbecause of the effect of anesthesia, and the patient’s reluc-\\ntance to breathe deeply due to the pain caused by the prox-\\nimity of the incision to the muscles used for respiration. The\\npatient is shown how to support the operative site when\\nbreathing deeply and coughing, and given pain medication\\nas necessary. Fluid intake and output is measured, and the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 777\\nCholecystectomy\\nA surgeon performs a laparoscopic cholecystectomy on a\\npatient. (Custom Medical Stock Photo. Reproduced by permis-\\nsion.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 777'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 166, 'page_label': '167'}, page_content='operative site is observed for color and amount of wound\\ndrainage. Fluids are given intravenously for 24–48 hours,\\nuntil the patient’s diet is gradually advanced as bowel activi-\\nty resumes. The patient is generally encouraged to walk 8\\nhours after surgery and is discharged from the hospital with-\\nin three to five days, with return to work approximately four\\nto six weeks after the procedure.\\nCare received immediately after laparoscopic cholecys-\\ntectomy is similar to that of any patient undergoing surgery\\nwith general anesthesia. A unique post-operative pain may\\nbe experienced in the right shoulder related to pressure from\\ncarbon dioxide used through the laparoscopic tubes. This\\npain may be relieved by laying on the left side with right\\nknee and thigh drawn up to the chest. Walking will also help\\nincrease the body’s reabsorption of the gas. The patient is\\nusually discharged the day after surgery, and allowed to\\nshower on the second postoperative day. The patient is\\nadvised to gradually resume normal activities over a three\\nday period, while avoiding heavy lifting for about 10 days.\\nRisks\\nPotential problems associated with open cholecys-\\ntectomy include respiratory problems related to location\\nof the incision, wound infection, or abscess formation.\\nPossible complications of laparoscopic cholecystectomy\\ninclude accidental puncture of the bowel or bladder and\\nuncontrolled bleeding. Incomplete reabsorption of the\\ncarbon dioxide gas could irritate the muscles used in res-\\npiration and cause respiratory distress.\\nResources\\nBOOKS\\nMonahan, Frances, and Marianne Neighbors. Medical Surgical\\nNursing:Foundations in Clinical Practice.Philadelphia:\\nW. B. Saunders Co., 1998.\\nKEY TERMS\\nCholecystitis —Infection and inflammation of the\\ngallbladder, causing severe pain and rigidity in the\\nupper right abdomen.\\nCholelithiasis —Also known as gallstones, these\\nhard masses are formed in the gallbladder or pas-\\nsages, and can cause severe upper right abdomi-\\nnal pain radiating to the right shoulder, as a result\\nof blocked bile flow.\\nGallbladder —A hollow pear-shaped sac on the\\nunder surface of the right lobe of the liver. Bile\\ncomes to it from the liver, and passes from it to the\\nintestine to aid in digestion.\\nPERIODICALS\\nWilson, R. G., et al. “Laparoscopic Cholecystectomy as a Safe\\nand Effective Treatment for Severe Acute Cholecystitis.”\\nBritish Medical Journal (15 Aug. 1992): 394-6.\\nOTHER\\n“Gallstones and Laparoscopic Cholecystectomy.”Centers for\\nDisease Control and Prevention..\\nMayo Clinic Online.5 Mar. 1998 .\\n“Patient Information Documents on Digestive Diseases.”\\nNational Institute of Diabetes and Digestive and Kidney\\nDisease. .\\nKathleen D. Wright, RN\\nCholecystitis\\nDefinition\\nCholecystitis refers to a painful inflammation of the\\ngallbladder’s wall. The disorder can occur a single time\\n(acute), or can recur multiple times (chronic).\\nDescription\\nThe gallbladder is a small, pear-shaped organ in the\\nupper right hand corner of the abdomen. It is connected\\nby a series of ducts (tube-like channels) to the liver, pan-\\ncreas, and duodenum (first part of the small intestine). To\\naid in digestion, the liver produces a substance called\\nbile, which is passed into the gallbladder. The gallblad-\\nder concentrates this bile, meaning that it reabsorbs some\\nof the fluid from the bile to make it more potent. After a\\nmeal, bile is squeezed out of the gallbladder by strong\\nmuscular contractions, and passes through a duct into the\\nduodenum. Due to the chemical makeup of bile, the con-\\ntents of the duodenum are kept at an optimal pH level for\\ndigestion. The bile also plays an important part in allow-\\ning fats within the small intestine to be absorbed.\\nCauses and symptoms\\nIn about 95% of all cases of cholecystitis, the gall-\\nbladder contains gallstones . Gallstones are solid accu-\\nmulations of the components of bile, particularly choles-\\nterol, bile pigments, and calcium. These solids may\\noccur when the components of bile are not in the correct\\nproportion to each other. If the bile becomes overly con-\\ncentrated, or if too much of one component is present,\\nstones may form. When these stones block the duct leav-\\ning the gallbladder, bile accumulates within the gallblad-\\nder. The gallbladder continues to contract, but the bile\\nGALE ENCYCLOPEDIA OF MEDICINE 2778\\nCholecystitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 778'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 167, 'page_label': '168'}, page_content='cannot pass out of the gallbladder in the normal way.\\nBack pressure on the gallbladder, chemical changes from\\nthe stagnating bile trapped within the gallbladder, and\\noccasionally bacterial infection, result in damage to the\\ngallbladder wall. As the gallbladder becomes swollen,\\nsome areas of the wall do not receive adequate blood\\nflow, and lack of oxygen causes cells to die.\\nWhen the stone blocks the flow of bile from the liver,\\ncertain normal byproducts of the liver’s processing of red\\nblood cells (called bilirubin) build up. The bilirubin is\\nreabsorbed into the bloodstream, and over time this biliru-\\nbin is deposited in the skin and in the whites of the eyes.\\nBecause bilirubin contains a yellowish color, it causes a\\nyellowish cast to the skin and eyes that is called jaundice.\\nGallstone formation is seen in twice as many women\\nas men, particularly those between the ages of 20 and 60.\\nPregnant women, or those on birth control pills or estro-\\ngen replacement therapy have a greater risk of gallstones,\\nas do Native Americans and Mexican Americans. People\\nwho are overweight, or who lose a large amount of\\nweight quickly are also at greater risk for developing\\ngallstones. Not all individuals with gallstones will go on\\nto have cholecystitis, since many people never have any\\nsymptoms from their gallstones and never know they\\nexist. However, the vast majority of people with chole-\\ncystitis will be found to have gallstones. Rare causes of\\ncholecystitis include severe burns or injury, massive sys-\\ntemic infection, severe illness, diabetes, obstruction by a\\ntumor of the duct leaving the gallbladder, and certain\\nuncommon infections of the gallbladder (including bac-\\nteria and worms).\\nAlthough there are rare reports of patients with\\nchronic cholecystitis who never experience any pain,\\nnearly 100% of the time cholecystitis will be diagnosed\\nafter a patient has experienced a bout of severe pain in\\nthe region of the gallbladder and liver. The pain may be\\ncrampy and episodic, or it may be constant. The pain is\\noften described as pushing through to the right upper\\nback and shoulder. Because deep breathing increases the\\npain, breathing becomes shallow. Fever is often present,\\nand nausea and vomiting are nearly universal. Jaundice\\noccurs when the duct leaving the liver is also obstructed,\\nalthough it may take a number of days for it to become\\napparent. When bacterial infection sets in, the patient\\nmay begin to experience higher fever and shaking chills.\\nDiagnosis\\nDiagnosis of cholecystitis involves a careful abdomi-\\nnal examination. The enlarged, tender gallbladder may be\\nfelt through the abdominal wall. Pressure in the upper\\nright corner of the abdomen may cause the patient to stop\\nbreathing in, due to an increase in pain. This is called\\nMurphy’s sign. Physical examination may also reveal an\\nincreased heart rate and an increased rate of breathing.\\nBlood tests will show an increase in the white blood\\ncount, as well as an increase in bilirubin. Ultrasound is\\nused to look for gallstones and to measure the thickness\\nof the gallbladder wall (a marker of inflammation and\\nscarring). A scan of the liver and gallbladder, with careful\\nattention to the system of ducts throughout (called the bil-\\niary tree) is also used to demonstrate obstruction of ducts.\\nRare complications of cholecystitis include:\\n• massive infection of the gallbladder, in which the gall-\\nbladder becomes filled with pus (called empyema)\\n• perforation of the gallbladder, in which the build-up of\\nmaterial within the gallbladder becomes so great that\\nthe wall of the organ bursts, with a resulting abdominal\\ninfection called peritonitis\\n• formation of abnormal connections between the gall-\\nbladder and other organs (the duodenum, large intes-\\ntine, stomach), called fistulas\\n• obstruction of the intestine by a very large gallstone\\n(called gallstone ileus)\\n• emphysema of the gallbladder, in which certain bacte-\\nria that produce gas infect the gallbladder, resulting in\\nstretching of the gallbladder and disruption of its wall\\nby gas\\nTreatment\\nInitial treatment of cholecystitis usually requires\\nhospitalization. The patient is given fluids, salts, and sug-\\nars through a needle placed in a vein (intravenous or IV).\\nNo food or drink is given by mouth, and often a tube,\\ncalled a nasogastric or NG tube, will need to be passed\\nthrough the nose and down into the stomach to drain out\\nGALE ENCYCLOPEDIA OF MEDICINE 2 779\\nCholecystitis\\nA close-up view of an inflamed gallbladder.(Custom Medical\\nStock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 779'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 168, 'page_label': '169'}, page_content='the excess fluids. If infection is suspected, antibiotics\\nare given.\\nUltimately, treatment almost always involves removal\\nof the gallbladder, a surgery called cholecystectomy .\\nWhile this is not usually recommended while the patient is\\nacutely ill, patients with complications usually do require\\nemergency surgery (immediately following diagnosis)\\nbecause the death rate increases in these cases. Similarly,\\nthose patients who have cholecystitis with no gallstones\\nhave about a 50% chance of death if the gallbladder is not\\nquickly removed. Most patients, however, do best if\\nsurgery is performed after they have been stabilized with\\nfluids, an NG tube, and antibiotics as necessary. When\\nthis is possible, gallbladder removal is done within five to\\nsix days of diagnosis. In patients who have other serious\\nmedical problems that may increase the risks of gallblad-\\nder removal surgery, the surgeon may decide to leave the\\ngallbladder in place. In this case, the operation may\\ninvolve removing obstructing gallstones and draining\\ninfected bile (called cholecystotomy).\\nBoth cholecystectomy and cholecystotomy may be\\nperformed via the classical open abdominal operation\\n(laparotomy). Tiny, “keyhole” incisions, a flexible scope,\\nand a laser device that shatters the stones (a laparoscopic\\nKEY TERMS\\nBile—A substance produced by the liver, and con-\\ncentrated and stored in the gallbladder. Bile con-\\ntains many different substances, including bile\\nsalts, cholesterol, and bilirubin. After a meal, the\\ngallbladder pumps bile into the duodenum (the\\nfirst part of the small intestine) to keep the intes-\\ntine’s contents at the appropriate pH for digestion,\\nand to help break down fats.\\nBilirubin —Produced when red blood cells break\\ndown. It is a yellowish color and when levels are\\nabnormally high, it causes the yellowish tint to\\neyes and skin known as jaundice.\\nCholecystectomy —An operation to remove the\\ngallbladder.\\nCholecystotomy—An operation during which the\\ngallbladder is opened, gallstones are removed,\\nand excess bile is drained. The gallbladder is not\\nremoved.\\nDuct—A tube through which various substances\\ncan pass. These substances can travel through\\nducts to another organ or into the bloodstream.\\nlaser) can be used to destroy the gallstones. The laparo-\\nscopic procedure can also be used to remove the gallblad-\\nder through one of the small incisions. Because of the\\nsmaller incisions, laparoscopic cholecystectomy is a pro-\\ncedure that is less painful and promotes faster healing.\\nPrognosis\\nHospital management of cholecystitis ends the symp-\\ntoms for about 75% of all patients. Of these patients,\\nhowever, 25% will go on to have another attack of chole-\\ncystitis within a year, and 60% will have another attack\\nwithin six years. Each attack of cholecystitis increases a\\npatient’s risk of developing life-threatening complica-\\ntions, requiring risky emergency surgery. Therefore, early\\nremoval of the gallbladder, rather than a “wait-and-see”\\napproach, is usually recommended. Cure is complete in\\nthose patients who undergo cholecystectomy.\\nPrevention\\nPrevention of cholecystitis is probably best attempt-\\ned by maintaining a reasonably ideal weight. Some stud-\\nies have suggested that eating a diet high in fiber, vegeta-\\nbles, and fruit is also protective.\\nResources\\nBOOKS\\nGreenberger, Norton J., and Kirk J. Isselbacher. “Acute and\\nChronic Cholecystitis.” In Harrison’s Principles of Inter-\\nnal Medicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nPERIODICALS\\nChung, Shing C. “Acute Acalculous Cholecystitis.”Postgradu-\\nate Medicine 98, no. 3 (Sept. 1995): 199+.\\nLewis, R. “Gallbladder: An Organ You Can Live Without.”\\nFDA Consumer 25, no. 4 (1991): 13+.\\nLo, Chung-Mau, et al. “Early Decision for Conversion of\\nLaparoscopic Cholecystectomy for Treatment of Acute\\nCholecystitis.” American Journal of Surgery 173, no. 6\\n(June 1997): 513+.\\nORGANIZATIONS\\nDigestive Disease National Coalition. 507 Capitol Court NE,\\nSuite 200, Washington, DC 20003. (202) 544-7497.\\n.\\nNational Digestive Diseases Information Clearinghouse. 2 Infor-\\nmation Way, Bethesda, MD 20892-3570. (800) 891-5389.\\n.\\nRosalyn Carson-DeWitt, MD\\nCholecystography see Gallbladder x rays\\nCholedocholithiasis see Gallstones\\nGALE ENCYCLOPEDIA OF MEDICINE 2780\\nCholecystitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 780'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 169, 'page_label': '170'}, page_content='Cholelithiasis see Gallstones\\nCholelithotomy see Gallstone removal\\nCholera\\nDefinition\\nCholera is an acute illness characterized by watery\\ndiarrhea that is caused by the bacterium Vibrio\\ncholerae . Cholera is spread by eating food or drinking\\nwater contaminated with the bacteria. Although cholera\\nwas a public health problem in the United States and\\nEurope a hundred years ago, modern sanitation and the\\ntreatment of drinking water have virtually eliminated the\\ndisease in developed countries. In third world countries,\\nhowever, cholera is still common.\\nDescription\\nCholera is spread by eating food or drinking water\\nthat has been contaminated with cholera bacteria. Conta-\\nmination usually occurs when human feces from a per-\\nson who has the disease seeps into a community water\\nsupply. Fruits and vegetables can also be contaminated in\\nareas where crops are fertilized with human feces.\\nCholera bacteria also live in warm, brackish water and\\ncan infect persons who eat raw or undercooked seafood\\nobtained from such waters. Cholera is rarely transmitted\\ndirectly from one person to another.\\nCholera often occurs in outbreaks or epidemics. The\\nWorld Health Organization (WHO) estimates that during\\nany cholera epidemic, approximately 0.2–1% of the local\\npopulation will contract the disease. Anyone can get\\ncholera, but infants, children, and the elderly are more\\nlikely to die from the disease because they become dehy-\\ndrated faster than adults. There is no particular season in\\nwhich cholera is more likely to occur.\\nBecause of an extensive system of sewage and water\\ntreatment in the United States, Canada, Europe, Japan,\\nand Australia, cholera is generally not a concern for visi-\\ntors and residents of these countries. People visiting or\\nliving in other parts of the world, particularly on the Indi-\\nan subcontinent and in parts of Africa and South Ameri-\\nca, should be aware of the potential for contracting\\ncholera and practice prevention. Fortunately, the disease\\nis both preventable and treatable.\\nCauses and symptoms\\nBecause V . cholerae bacteria are sensitive to acid,\\nmost cholera-causing bacteria die in the acidic environ-\\nment of the stomach. However, when a person has ingest-\\ned food or water containing large amounts of cholera bac-\\nteria, some will survive to infect the intestines. As would\\nbe expected, antacid usage or the use of any medication\\nthat blocks acid production in the stomach would allow\\nmore bacteria to survive and cause infection.\\nIn the small intestine, the rapidly multiplying bacte-\\nria produce a toxin that causes a large volume of water\\nand electrolytes to be secreted into the bowels and then\\nto be abruptly eliminated as watery diarrhea. V omiting\\nmay also occur. Symptoms begin to appear between one\\nand three days after the contaminated food or water has\\nbeen ingested.\\nMost cases of cholera are mild, but about one in 20\\npatients experience severe, potentially life-threatening\\nsymptoms. In severe cases, fluids can be lost through\\ndiarrhea and vomiting at the rate of one quart per hour.\\nThis can produce a dangerous state of dehydration\\nunless the lost fluids and electrolytes are rapidly replaced.\\nSigns of dehydration include intense thirst, little or no\\nurine output, dry skin and mouth, an absence of tears,\\nglassy or sunken eyes, muscle cramps, weakness, and\\nrapid heart rate. The soft spot on an infant’s head will\\nappear to be sunken or drawn in. Dehydration occurs most\\nrapidly in the very young and the very old because they\\nhave fewer fluid reserves. A doctor should be consulted\\nimmediately any time signs of severe dehydration occur.\\nImmediate replacement of the lost fluids and electrolytes\\nis necessary to prevent kidney failure,coma, and death.\\nDiagnosis\\nRapid diagnosis of cholera can be made by examin-\\ning a fresh stool sample under the microscope for the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 781\\nCholera\\nA false color transmission electron micrograph (TEM) of\\nVibrio cholerae bacterium magnified 6,000 times its original\\nsize. (Photography by T. McCarthy, Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 781'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 170, 'page_label': '171'}, page_content='presence of V . cholerae bacteria. Cholera can also be\\ndiagnosed by culturing a stool sample in the laboratory to\\nisolate the cholera-causing bacteria. In addition, a blood\\ntest may reveal the presence of antibodies against the\\ncholera bacteria. In areas where cholera occurs often,\\nhowever, patients are usually treated for diarrhea and\\nvomiting symptoms as if they had cholera without labo-\\nratory confirmation.\\nTreatment\\nThe key to treating cholera lies in preventing dehy-\\ndration by replacing the fluids and electrolytes lost\\nthrough diarrhea and vomiting. The discovery that rehy-\\ndration can be accomplished orally revolutionized the\\ntreatment of cholera and other, similar diseases by mak-\\ning this simple, cost-effective treatment widely available\\nthroughout the world. The World Health Organization\\nhas developed an inexpensive oral replacement fluid con-\\ntaining appropriate amounts of water, sugar, and salts\\nthat is used worldwide. In cases of severe dehydration,\\nreplacement fluids must be given intravenously. Patients\\nshould be encouraged to drink when they can keep liq-\\nuids down and eat when their appetite returns. Recovery\\ngenerally takes three to six days.\\nAdults may be given the antibiotic tetracycline to\\nshorten the duration of the illness and reduce fluid loss.\\nThe World Health Organization recommends this antibi-\\notic treatment only in cases of severe dehydration. If\\nantibiotics are overused, the cholera bacteria organism\\nmay become resistant to the drug, making the antibiotic\\nineffective in treating even severe cases of cholera. Tetra-\\ncycline is not given to children whose permanent teeth\\nKEY TERMS\\nAntibody —A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nElectrolytes —Salts and minerals that ionize in\\nbody fluids. Common human electrolytes are sodi-\\num, chloride, potassium, and calcium. Electrolytes\\ncontrol the fluid balance of the body and are\\nimportant in muscle contraction, energy genera-\\ntion, and almost all major biochemical reactions\\nin the body.\\nToxin—A poison. In the case of cholera, a poison\\nsecreted as a byproduct of the growth of the\\ncholera bacteria in the small intestine.\\nhave not come in because it can cause the teeth to\\nbecome permanently discolored.\\nPrognosis\\nToday, cholera is a very treatable disease. Patients\\nwith milder cases of cholera usually recover on their own\\nin three to six days without additional complications.\\nThey may eliminate the bacteria in their feces for up to\\ntwo weeks. Chronic carriers of the disease are rare. With\\nprompt fluid and electrolyte replacement, the death rate in\\npatients with severe cholera is less than 1%. Untreated,\\nthe death rate can be greater than 50%. The difficulty in\\ntreating severe cholera is not in knowing how to treat it,\\nbut in getting medical care to ill people in underdeveloped\\nareas of the world where medical resources are limited.\\nPrevention\\nThe best form of cholera prevention is to establish\\ngood sanitation and waste treatment systems. In the\\nabsence of adequate sewage treatment, the following\\nguidelines should be followed to reduce the possibility of\\ninfection:\\n• Boil it. Drink and brush teeth only with water that has\\nbeen boiled or treated with chlorine or iodine tablets. Safe\\ndrinks include coffee and tea made with boiling water or\\ncarbonated bottled water and carbonated soft drinks.\\n• Cook it. Eat only thoroughly cooked foods, and eat\\nthem while they are still hot. Avoid eating food from\\nstreet vendors.\\n• Peel it. Eat only fruit or nuts with a thick, intact skin or\\nshell that is removed immediately before eating.\\n• Forget it. Do not eat raw foods such as oysters or\\nceviche. Avoid salads and raw vegetables. Do not use\\nuntreated ice cubes in otherwise safe drinks.\\n• Stay out of it. Do not swim or fish in polluted water.\\nA cholera vaccine exists that can be given to travel-\\ners and residents of areas where cholera is known to be\\nactive, but the vaccine is not highly effective. It provides\\nonly 25–50% immunity, and then only for a period of\\nabout six months. The vaccine is never given to infants\\nunder six months of age. The United States Centers for\\nDisease Control and Prevention do not currently recom-\\nmend cholera vaccination for travelers. Residents of\\ncholera-plagued areas should discuss the value of the\\nvaccine with their doctor.\\nResources\\nBOOKS\\nUSP DI-Volume II, Advice for the Patient: Drug Information in\\nLay Language. 17th ed. 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2782\\nCholera\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 782'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 171, 'page_label': '172'}, page_content='ORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435. (404) 639-3311.\\n.\\nOTHER\\n“Cholera Prevention.”Centers for Disease Control and Preven-\\ntion. 9 Aug. 1996 .\\nTravel Health Information Page.5 Mar. 1997 .\\nTish Davidson\\nCholestasis\\nDefinition\\nCholestasis is a condition caused by rapidly devel-\\noping (acute) or long-term (chronic) interruption in the\\nexcretion of bile (a digestive fluid that helps the body\\nprocess fat). The term is taken from the Greek chole,\\nbile, and stasis, standing still.\\nDescription\\nCholestasis is caused by obstruction within the liver\\n(intrahepatic) or outside the liver (extrahepatic). The\\nobstruction causes bile salts, the bile pigment bilirubin,\\nand fats (lipids) to accumulate in the blood stream\\ninstead of being eliminated normally.\\nIntrahepatic cholestasis is characterized by wide-\\nspread blockage of small ducts or by disorders, such as\\nhepatitis, that impair the body’s ability to eliminate bile.\\nExtrahepatic cholestasis can occur as a side effect of\\nmany medications. It can also occur as a complication of\\nsurgery, serious injury, tissue-destroying infection, or\\nintravenous feeding. Extrahepatic cholestasis can be\\ncaused by conditions such as tumors and gallstones that\\nblock the flow of bile from the gallbladder to the first\\npart of the small intestine (duodenum).\\nPregnancy increases the sensitivity of the bile ducts\\nto estrogen, and cholestasis often develops during the sec-\\nond and third trimesters of pregnancy. This condition is\\nthe second most common cause of jaundice during preg-\\nnancy, but generalized itching (pruritus gravidarum) is\\nthe only symptom most women experience. Cholestasis\\nof pregnancy tends to run in families. Symptoms usually\\ndisappear within two to four weeks after the baby’s birth\\nbut may reappear if the woman becomes pregnant again.\\nA similar condition affects some women who take\\nbirth-control pills. Symptoms disappear after the woman\\nstops using oral contraceptives. This condition does not\\nlead to chronic liver disease. A woman who develops\\ncholestasis from either of these causes (pregnancy or\\nbirth control hormones) has an increased risk of develop-\\ning cholestasis from the other.\\nBenign familial recurrent cholestasis is a rare condi-\\ntion characterized by brief, repeated episodes of itching\\nand jaundice. Symptoms often disappear. This condition\\ndoes not cause cirrhosis.\\nDrug-induced cholestasis may be a complication of\\nchemotherapy or other medications. The two major types\\nof drug-induced cholestasis are direct toxic injury and\\nreactions unique to an individual (idiosyncratic reactions).\\nIn direct toxic injury, the severity of symptoms parallels\\nthe amount of medication involved. This condition:\\n• develops a short time after treatment begins\\n• follows a predictable pattern\\n• usually causes liver damage\\nDirect toxic reactions develop in 1% of all patients\\nwho take chlorpromazine (Thorazine), a tranquilizer and\\nantinausea drug. Idiosyncratic reactions may occur at the\\nonset of treatment or at a later time. Allergic responses\\nare varied and are not related to the amount of medica-\\ntion being taken.\\nCauses and symptoms\\nIntrahepatic cholestasis is usually caused by hepati-\\ntis or by medications that can produce symptoms resem-\\nbling hepatitis. Phenothiazine-derivative drugs, including\\nchlorpromazine, can cause sudden fever and inflamma-\\ntion. Symptoms usually disappear after use of the drug(s)\\nis stopped. In rare cases, a condition resembling chronic\\nbiliary cirrhosis (a progressive disease characterized by\\ndestruction of small bile ducts) persists even after the\\nmedication is stopped. Some patients experience a simi-\\nlar reaction in response to tricyclic antidepressants\\n(amitriptyline, imipramine), phenylbutazone (Butazo-\\nlidin), erythromycin estolate (Estomycin, Purmycin), and\\nother drugs. Intrahepatic cholestasis may also be caused\\nby alcoholic liver disease, primary biliary cirrhosis ,\\ncancer that has spread (metastasized) from another part\\nof the body, and a number of rare disorders.\\nExtrahepatic cholestasis is most often caused by a stone\\nobstructing the passage through which bile travels from the\\ngallbladder to the small intestine (common bile duct) or by\\npancreatic cancer. Less often, the condition occurs as a result\\nof non-cancerous narrowing of the common duct (strictures),\\nductal carcinoma, or disorders of the pancreas.\\nCholestasis caused by the use of steroids causes lit-\\ntle, if any, inflammation. Symptoms develop gradually\\nGALE ENCYCLOPEDIA OF MEDICINE 2 783\\nCholestasis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 783'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 172, 'page_label': '173'}, page_content='and usually disappear after the drug is discontinued.\\nOther drugs that can cause cholestasis include:\\n• allopurinol (Zyloprim)\\n• amitriptyline (Elavil)\\n• azathioprine (Imuran)\\n• benoxaprofen (Oraflex)\\n• capotril (Capoten)\\n• carbamazepine (Tegretol)\\n• cimetidine (Tagamet)\\n• hydralazine hydrochloride (Apresoline Hydrochloride)\\n• imipramine (Tofranil)\\n• penicillin\\n• quinidine sulfate (Quinidex)\\n• ranitidine (Zantac)\\n• sulfonamides (Apo-Sulfatrim, sulfamethoxazole)\\n• sulindac (Clinoril, Saldac)\\nKEY TERMS\\nBile—A bitter yellow-green substance produced by\\nthe liver. Bile breaks down fats in the small intestine\\nso that they can be used by the body. It is stored in\\nthe gallbladder and passes from the gallbladder\\nthrough the common bile duct to the top of the\\nsmall intestine (duodenum) as needed to digest fat.\\nBiliary—Of bile or of the gallbladder and bile ducts\\nthat transport bile and make up the biliary system or\\ntract.\\nEndoscopic retrograde cholangiopancreatography—\\nA diagnostic procedure for mapping the pancreatic\\nand common bile ducts. A flexible tube with a light\\ntransmitter (fiberoptics) is placed in the duct. A con-\\ntrast dye is instilled directly into the duct and a series\\nof x-ray images are taken.\\nComputed tomography scans (CT) —An imaging\\ntechnique in which cross-sectional x rays of the\\nbody are compiled to create a three-dimensional\\nimage of the body’s internal structures.\\nHepatic— Of the liver, from the Greek hepar.\\nLiver function tests —Tests used to evaluate liver\\nmetabolism, storage, filtration, and excretion. The\\ntests include alkaline phosphatase and serum alanine\\naminotransferase and aspartate aminotransferase.\\nMagnetic resonance imaging (MRI) —An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\nPercutaneous transhepatic cholangiography—An x-\\nray examination of the bile ducts. A needle is\\npassed through the skin (percutaneous) across or\\nover the liver (transhepatic) and directly into a bile\\nduct to inject a contrast dye. The dye enhances the\\nx-ray image mapping the system of bile ducts\\n(cholangiography).\\nPhenothiazine-derivative drugs —A large family of\\ndrugs derived from phenothiazine, a compound\\nthat in itself is too poisonous for human consump-\\ntion. Phenothiazine derivatives include tranquiliz-\\ners, medications that prevent vomiting, antihista-\\nmines, and drugs used to enhance the effectiveness\\nof anesthesia.\\nUltrasonography —A test using sound waves to\\nmeasure blood flow. Gel is applied to a hand-held\\ntransducer that is pressed against the patient’s body.\\nImages are displayed on a monitor.\\nSymptoms of both intrahepatic and extrahepatic\\ncholestasis include a yellow discoloration of the skin\\n(jaundice), dark urine, and pale stools. Itching over the\\nskin may be severe if the condition is advanced.\\nSymptoms of chronic cholestasis include:\\n• skin discoloration\\n• scars or skin injuries caused by scratching\\n• bone pain\\n• yellowish fat deposits beneath the surface of the skin\\n(xanthoma) or around the eyes (xanthelasma)\\nPatients with advanced cholestasis feel ill, tire easi-\\nly, and are often nauseated. Abdominal pain and such\\nsystemic symptoms as anorexia, vomiting, and fever are\\nusually due to the underlying condition that causes\\ncholestasis.\\nDiagnosis\\nDetermining whether obstruction exists inside or\\noutside the liver is the essential part of diagnosis. A his-\\nGALE ENCYCLOPEDIA OF MEDICINE 2784\\nCholestasis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 784'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 173, 'page_label': '174'}, page_content='tory of hepatitis or heavy drinking, recent use of certain\\ndrugs, and symptoms like ascites (abnormal abdominal\\nswelling) and splenomegaly (enlarged spleen) suggest\\nintrahepatic cholestasis. Pain or rigidity in the gallblad-\\nder or pancreas suggest an extrahepatic form.\\nBlood tests and liver function tests can reveal the\\npattern and extent of liver injury, indicate functional\\nabnormalities, and establish the cause of the condition.\\nHowever, most misdiagnoses occur when physicians rely\\nmore on laboratory analysis than on detailed medical his-\\ntory and the results of a thorough physical examination.\\nSpecial attention should be paid to three liver function\\ntests. Levels of alkaline phosphatase (ALP), alanine\\naminotransferase (ALT), and aspartate aminotransferase\\n(AST) can indicate whether the patient’s condition is\\ncaused by an obstructive condition like cholestasis or a\\ndisease of the liver cells (hepatocellular disease) like\\nviral hepatitis or cancer. ALP levels more than three\\ntimes greater than normal indicate cholestasis. High lev-\\nels of AST and particularly of ALT, which is found pre-\\ndominantly in liver cells, indicate hepatocellular disease.\\nOnce the disease pattern has been established, ultra-\\nsound may be performed to determine whether obstruc-\\ntion of the large duct has caused widening of small ducts\\nlocated close to it. Computed tomography scans (CT)\\nand magnetic resonance imaging (MRI) can provide\\nmore detailed information about the source of the\\nobstruction. If these procedures that do not enter the\\npatient’s body (non-invasive procedures) do not provide\\nthe information a family physician, internist, or gastroen-\\nterologist needs to make a diagnosis of cholestasis, one\\nof these procedures may be performed:\\n• direct cholangiography, an x-ray map of the bile ducts,\\nenhanced by the use of contrast dye\\n• percutaneous transhepatic cholangiography, used to\\nidentify obstructions that impede the flow of bile from\\nthe liver to the digestive system, takes x-ray images of\\nthe bile ducts after a contrast dye has been injected by a\\nneedle passed directly into a hepatic duct\\n• endoscopic retrograde cholangiopancreatography\\n(ERCP), which uses a special dye to outline the pancre-\\natic and common bile ducts and highlight the position\\nof any obstruction; a special tube with a light transmit-\\nter is inserted into the duct and a series of x-ray images\\nis taken\\nA doctor who thinks a physical obstruction is\\nresponsible for progressive deterioration of a patient’s\\ncondition may consider an exploratory surgical proce-\\ndure (diagnostic laparotomy). Liver biopsy is sometimes\\nperformed if imaging tests do not indicate why a duct is\\nenlarged, but results of a single biopsy may not represent\\nthe status of the entire organ.\\nTreatment\\nThe goal of treatment is to eliminate or control the\\npatient’s symptoms. Discontinuing the use of certain\\ndrugs can restore normal liver function, but surgery may\\nbe needed to drain or remove obstructions or to widen\\naffected ducts.\\nRifampin (Rifadin, Rimactane), an antibacterial\\ndrug; phenobarbital, a barbiturate anticonvulsant; and\\nother drugs are sometimes prescribed to cleanse the sys-\\ntem and eliminate bile salts and other toxic compounds.\\nPatients who have chronic cholestasis and have trou-\\nble digesting fat may have to restrict the amount of fat in\\ntheir diet and take calcium and water-soluble vitamin\\nsupplements. A liver transplant may become necessary if\\ncomplications occur.\\nPrognosis\\nSymptoms almost always disappear after the under-\\nlying condition is controlled.\\nSome patients who have cholestasis experience symp-\\ntoms only after infection develops, but chronic bile-duct\\nobstruction always leads to cirrhosis. It may also cause\\nosteoporosis(fragile bones) or osteomalacia (soft bones).\\nEmergency care is not required unless inflammation\\nof the bile ducts ( cholangitis ) develops. Cancer should\\nbe considered when an adult suddenly develops cholesta-\\nsis after the age of 50.\\nResources\\nBOOKS\\nBennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-\\nicine. Philadelphia: W. B. Saunders Co., 1996.\\nPERIODICALS\\nPasha T. M., and K. D. Lindor. “Diagnosis and Therapy of\\nCholestatic Liver Disease.”Medical Clinics of North\\nAmerica 80 (Sept. 1996): 995-1019.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar Grove,\\nNJ 07009. (800) 223-0179. .\\nNational Institute of Diabetes, Digestive, and Kidney Diseases\\nof the National Institutes of Health. 31 Center Drive,\\nBethesda, MD 20892-2560. (301) 496-3583. .\\nNational Organization for Rare Disorders. P.O. Box 8923, New\\nFairfield, CT 06812-8923. (800) 999-6673. .\\nOTHER\\n“Hepatic and Biliary Disorders.”The Meck Page.13 Apr. 1998\\n.\\nMaureen Haggerty\\nGALE ENCYCLOPEDIA OF MEDICINE 2 785\\nCholestasis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 785'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 174, 'page_label': '175'}, page_content='Cholesterol, high\\nDefinition\\nCholesterol is a fatty substance found in animal tis-\\nsue and is an important component to the human body. It\\nis manufactured in the liver and carried throughout the\\nbody in the bloodstream. Problems can occur when too\\nmuch cholesterol forms an accumulation of plaque on\\nblood vessel walls, which impedes blood flow to the\\nheart and other organs. The highest cholesterol content is\\nfound in meat, poultry, shellfish, and dairy products.\\nDescription\\nCholesterol is the Dr. Jekyll and Mr. Hyde of medi-\\ncine, since it has both a good side and bad side. It is nec-\\nessary to digest fats from food, make hormones, build cell\\nwalls, and participate in other processes for maintaining a\\nhealthy body. When people talk about cholesterol as a\\nmedical problem, they are usually referring to high cho-\\nlesterol. This can be somewhat misleading, since there are\\nfour components to cholesterol. These are:\\n• LDL, the so-called bad cholesterol\\n• HDL, the so-called good cholesterol\\n• triglycerides, a blood fat lipid that increases the risk for\\nheart disease\\n• total cholesterol\\nHigh LDL (low-density lipoprotein) is a major con-\\ntributing factor of heart disease. The cholesterol forms\\nplaque in the heart’s blood vessels, which restricts or\\nblocks the supply of blood to the heart, and causes a\\ncondition called atherosclerosis . This can lead to a\\n“heart attack,” resulting in damage to the heart and pos-\\nsibly death . The U.S. Food and Drug Administration\\n(FDA) estimates that 90 million American adults,\\nroughly half the adult population, have elevated choles-\\nterol levels.\\nThe population as a whole is at some risk of devel-\\noping high LDL cholesterol in their lifetimes. Specific\\nrisk factors include a family history of high choles-\\nterol, obesity, heart attack or stroke, alcoholism , and\\nlack of regular exercise . The chances of developing\\nhigh cholesterol increase after the age of 45. One of the\\nprimary causes of high LDL cholesterol is too much fat\\nor sugar in the diet, a problem especially true in the\\nUnited States. Cholesterol is also produced naturally in\\nthe liver and overproduction may occur even in people\\nwho limit their intake of high cholesterol food. Low\\nHDL and high triglyceride levels are also risk factors\\nfor atherosclerosis.\\nCauses and symptoms\\nThere are no readily apparent symptoms that indi-\\ncate high LDL or triglycerides, or low HDL. The only\\nway to diagnose the problems is through a simple blood\\ntest. However, one general indication of high cholesterol\\nis obesity. Another is a high-fat diet.\\nDiagnosis\\nHigh cholesterol is often diagnosed and treated by\\ngeneral practitioners or family practice physicians. In\\nsome cases, the condition is treated by an endocrinolo-\\ngist or cardiologist. Total cholesterol, LDL, HDL, and\\ntriglyceride levels as well as the cholesterol to HDL ratio\\nare measured by a blood test called a lipid panel. The\\ncost of a lipid panel is generally $40–100 and is covered\\nby most health insurance and HMO plans, including\\nMedicare, providing there is an appropriate reason for\\nthe test. Home cholesterol testing kits are available over\\nthe counter but test only for total cholesterol. The results\\nshould only be used as a guide and if the total cholesterol\\nlevel is high or low, a lipid panel should be performed by\\na physician. In most adults the recommended levels,\\nmeasured by milligrams per deciliter (mg/dL) of blood,\\nare: total cholesterol, less than 200; LDL, less than 130;\\nHDL, more than 35; triglycerides, 30–200; and choles-\\nterol to HDL ratio, four to one. However, the recom-\\nmended cholesterol levels may vary, depending on other\\nrisk factors such as hypertension , a family history of\\nheart disease, diabetes, age, alcoholism, and smoking.\\nDoctors have always been puzzled by why some\\npeople develop heart disease while others with identical\\nGALE ENCYCLOPEDIA OF MEDICINE 2786\\nCholesterol, high\\nTypes Of Cholesterol\\nTypes Levels\\nTotal cholesterol:\\nDesirable <200\\nBorderline 200 to 240\\nUndesirable >240\\nHDL cholesterol:\\nDesirable >45\\nBorderline 35 to 45\\nUndesirable <35\\nLDL cholesterol:\\nDesirable <130\\nBorderline 130 to 160\\nUndesirable >160\\nRatio of total cholesterol to HDL cholesterol:\\nDesirable <3\\nBorderline 3 to 4\\nUndesirable >4\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 786'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 175, 'page_label': '176'}, page_content='HDL and LDL levels do not. New studies indicate it may\\nbe due to the size of the cholesterol particles in the\\nbloodstream. A test called a nuclear magnetic resonance\\n(NMR) LipoProfile exposes a blood sample to a magnet-\\nic field to determine the size of the cholesterol particles.\\nParticle size can also be determined by a centrifugation\\ntest, where blood samples are spun very quickly to allow\\nparticles to separate and move at different distances. The\\nsmaller the particles, the greater the chance of develop-\\ning heart disease. It allows physicians to treat patients\\nwho have normal or close to normal results from a lipid\\npanel but abnormal particle size.\\nTreatment\\nA wide variety of prescription medicines are avail-\\nable to treat cholesterol problems. These include statins\\nsuch as Mevacor (lovastatin), Lescol (fluvastatin), Prava-\\nchol (pravastatin), Zocor (simvastatin), Baycol (cervas-\\ntatin), and Lipitor (atorvastatin) to lower LDL. A group\\nof drugs called fibric acid derivatives are used to lower\\ntriglycerides and raise HDL. These include Lopid (gem-\\nfibrozil), Atromid-S (clofibrate), and Tricor (fenofibrate).\\nDoctors decide which drug to use based on the severity\\nof the cholesterol problem, side effects, and cost.\\nAlternative treatment\\nThe primary goal of cholesterol treatment is to lower\\nLDL to under 160 mg/dL in people without heart disease\\nand who are at lower risk of developing it. The goal in\\npeople with higher risk factors for heart disease is less than\\n130 mg/dL. In patients who already have heart disease, the\\ngoal is under 100 mg/dL, according to FDA guidelines.\\nAlso, since low HDL levels increase the risks of heart dis-\\nease, the goal of all patients is more than 35 mg/dL.\\nIn both alternative and conventional treatment of\\nhigh cholesterol, the first-line treatment options are exer-\\ncise, diet, weight loss, and stopping smoking. Other\\nalternative treatments include high doses of niacin, soy\\nprotein, garlic, algae, and the Chinese medicine supple-\\nment Cholestin (a red yeast fermented with rice).\\nDiet and exercise\\nSince a large number of people with high cholesterol\\nare overweight, a healthy diet and regular exercise are\\nprobably the most beneficial natural ways to control cho-\\nlesterol levels. In general, the goal is to substantially\\nreduce or eliminate foods high in animal fat. These\\ninclude meat, shellfish, eggs, and dairy products. Several\\nspecific diet options are beneficial. One is the vegetarian\\ndiet. Vegetarians typically get up to 100% more fiber and\\nup to 50% less cholesterol from food than non-vegetari-\\nKEY TERMS\\nAtherosclerosis—A build-up of fatty substances in\\nthe inner layers of the arteries.\\nEstrogen —A hormone that stimulates develop-\\nment of female secondary sex characteristics.\\nGlycemic—The presence of glucose in the blood.\\nHypertension —Abnormally high blood pressure\\nin the arteries.\\nLegumes —A family of plants that bear edible\\nseeds in pods, including beans and peas.\\nLipid—Any of a variety of substances that, along\\nwith proteins and carbohydrates, make up the\\nmain structural components of living cells.\\nPolyunsaturated fats —A non-animal oil or fatty\\nacid rich in unsaturated chemical bonds not associ-\\nated with the formation of cholesterol in the blood.\\nans. The vegetarian low-cholesterol diet consists of at\\nleast six servings of whole grain foods, three or more\\nservings of green leafy vegetables, two to four servings\\nof fruit, two to four servings of legumes, and one or two\\nservings of non-fat dairy products daily.\\nA second diet is the Asian diet, with brown rice\\nbeing the staple. Other allowable foods include fish, veg-\\netables such as bok choy, bean sprouts, and black beans.\\nIt allows for one weekly serving of meat and very few\\ndairy products. The food is flavored with traditional\\nAsian spices and condiments, such as ginger, chilies,\\nturmeric, and soy sauce.\\nAnother regimen is the low glycemic or diabetic\\ndiet, which can raise the HDL (good cholesterol) level by\\nas much as 20% in three weeks. Low glycemic foods\\npromote a slow but steady rise in blood sugar levels fol-\\nlowing a meal, which increases the level of HDL. They\\nalso lower total cholesterol and triglycerides. Low\\nglycemic foods include certain fruits, vegetables, beans,\\nand whole grains. Processed and refined foods and sug-\\nars should be avoided.\\nExercise is an extremely important part of lowering\\nbad cholesterol and raising good cholesterol. It should\\nconsist of 20–30 minutes of vigorous aerobic exercise at\\nleast three times a week. Exercises that cause the heart to\\nbeat faster include fast walking, bicycling, jogging, roller\\nskating, swimming, and walking up stairs. There are also\\na wide selection of aerobic programs available at gyms\\nor on videocassette.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 787\\nCholesterol, high\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 787'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 176, 'page_label': '177'}, page_content='Garlic\\nA number of clinical studies have indicated that garlic\\ncan offer modest reductions in cholesterol. A 1997 study by\\nnutrition researchers at Pennsylvania State University\\nfound men who took garlic capsules for five months\\nreduced their total cholesterol by 7% and LDL by 12%.\\nAnother study showed that seven cloves of fresh garlic a day\\nsignificantly reduced LDL, as did a daily dose of four garlic\\nextract pills. Other studies in 1997 and 1998 back up these\\nresults. However, two more recent studies have questioned\\nthe effectiveness of garlic in lowering “bad cholesterol.”\\nCholestin\\nCholestin hit the over-the-counter market in 1997 as\\na cholesterol-lowering dietary supplement. It is a\\nprocessed form of red yeast fermented with rice, a tradi-\\ntional herbal remedy used for centuries by the Chinese.\\nTwo studies released in 1998 showed Cholestin lowered\\nLDL cholesterol by 20–30%. It also appeared to raise\\nHDL and lower triglyceride levels. Although the supple-\\nment contains hundreds of compounds, the major active\\nLDL-lowering ingredient is lovastatin, a chemical also\\nfound in the prescription drug Mevacor. The FDA banned\\nCholestin in early 1998 but a federal district court judge\\nlifted the ban a year later, ruling the product was a dietary\\nsupplement, not a drug. It is not fully understood how the\\nsubstance works and patients may want to consult with\\ntheir physician before taking Cholestin. No serious side\\neffects have been reported, but minor side effects, includ-\\ning bloating and heartburn, have been reported.\\nOther treatments\\nA study released in 1999 indicated that blue-green\\nalgae contains polyunsaturated fatty acids that lower\\ncholesterol. The algae, known as alga Aphanizomenon\\nflos-aquae (AFA) is available as an over-the-counter\\ndietary supplement. Niacin, also known as nicotinic acid\\nor vitamin B\\n3, has been shown to reduce LDL levels by\\n10–20%, and raise HDL levels by 15–35%. It also can\\nreduce triglycerides. But because an extremely high dose\\nof niacin (2–3 g) is needed to treat cholesterol problems,\\nit should only be taken under a doctor’s supervision to\\nmonitor possible toxic side effects. Niacin can also cause\\nflushing when taken in high doses. Soy protein with high\\nlevels of isoflavones also have been shown to reduce bad\\ncholesterol by up to 10%. A daily diet that contains 62\\nmg of isoflavones in soy protein is recommended, and\\ncan be incorporated into other diet regimens, including\\nvegetarian, Asian, and low glycemic.\\nPrognosis\\nHigh cholesterol is one of the key risk factors for\\nheart disease. Left untreated, too much bad cholesterol\\ncan clog the blood vessels, leading to chest pain\\n(angina), blood clots, and heart attacks. Heart disease is\\nthe number one killer of men and women in the United\\nStates. By reducing LDL, people with heart disease may\\nprevent further heart attacks and strokes, prolong and\\nimprove the quality of their lives, and slow or reverse\\ncholesterol build-up in the arteries. In people without\\nheart disease, lowering LDL can decrease the risk of a\\nfirst heart attack or stroke.\\nPrevention\\nThe best way to prevent cholesterol problems is\\nthrough a combination of healthy lifestyle activities, a\\nprimarily low-fat and high-fiber diet, regular aerobic\\nexercise, not smoking, and maintaining an optimal\\nweight. But for people with high risk factors for heart\\ndisease, such as a family history of heart disease, dia-\\nbetes, and being over the age of 45, these measures\\nmay not be enough to prevent the onset of high choles-\\nterol. There are studies being done on the effective-\\nness of some existing anti-cholesterol drugs for con-\\ntrolling cholesterol levels in patients who do not meet\\nthe criteria for high cholesterol but no definitive\\nresults are available.\\nResources\\nBOOKS\\nBratman, Steven, and David Kroll. Natural Pharmacist: Natur-\\nal Treatments for High Cholesterol.Roseville, CA: Prima\\nPublishing, 2000.\\nIngels, Darin. The Natural Pharmacist: Your Complete Guide\\nto Garlic and Cholesterol. Roseville, CA: Prima Publish-\\ning, 1999.\\nMurray, Michael T. Natural Alternatives to Over-the-Counter\\nand Prescription Drugs. New York: William Morrow &\\nCo., 1999.\\nTrubo, Richard. Cholesterol Cures: From Almonds and Antiox-\\nidants to Garlic, Golf, Wine and Yogurt.Emmaus, PA:\\nRodale Press, 1996.\\nPERIODICALS\\nCarter, Ann. “Cholesterol in Your Diet.”Clinical Reference\\nSystems (July 1, 1999): 282.\\nMarandino, Cristin. “The Case for Cholesterol.”Vegetarian\\nTimes (August 1999): 10.\\nSchmitt, B.D. “Treating High Cholesterol Levels.”Clinical\\nReference Systems (July 1, 1999): 1551.\\nVanTyne, Julia, and Davis, Lori. “Drop Your Cholesterol 25 to\\n100 Points.” Prevention (November 1999): 110.\\nORGANIZATIONS\\nNational Cholesterol Education Program. NHLBI Information\\nCenter, P.O. Box 30105, Bethesda, MD 20824-0105.\\n.\\nKen R. Wells\\nGALE ENCYCLOPEDIA OF MEDICINE 2788\\nCholesterol, high\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 788'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 177, 'page_label': '178'}, page_content='Cholesterol-reducing drugs\\nDefinition\\nCholesterol-reducing drugs are medicines that lower\\nthe amount of cholesterol (a fat-like substance) in the\\nblood.\\nPurpose\\nCholesterol is a chemical that can both benefit and\\nharm the body. On the good side, cholesterol plays impor-\\ntant roles in the structure of cells and in the production of\\nhormones. But too much cholesterol in the blood can lead\\nto heart and blood vessel disease. To complicate matters,\\nnot all cholesterol contributes to heart and blood vessel\\nproblems. One type, called high-density lipoprotein\\n(HDL) cholesterol, or “good cholesterol,” actually lowers\\nthe risk of these problems. The other type, low-density\\nlipoprotein (LDL) cholesterol, or “bad cholesterol,” is the\\ntype that threatens people’s health. The names reflect the\\nway cholesterol moves through the body. To travel\\nthrough the bloodstream, cholesterol must attach itself to\\na protein. The combination of a protein and a fatty sub-\\nstance like cholesterol is called a lipoprotein.\\nMany factors may contribute to the fact that some\\npeople have higher cholesterol levels than others. A diet\\nhigh in certain types of fats is one factor. Medical prob-\\nlems such as poorly controlled diabetes, an underactive\\nthyroid gland, an overactive pituitary gland, liver disease\\nor kidney failure also may cause high cholesterol levels.\\nAnd some people have inherited disorders that prevent\\ntheir bodies from properly using and eliminating fats.\\nThis allows cholesterol to build up in the blood.\\nTreatment for high cholesterol levels usually begins\\nwith changes in daily habits. By losing weight, stopping\\nsmoking , exercising more and reducing the amount of\\nfat and cholesterol in the diet, many people can bring\\ntheir cholesterol levels down to acceptable levels. How-\\never, some may need to use cholesterol-reducing drugs to\\nreduce their risk of health problems.\\nDescription\\nThere are four different classes of cholesterol lower-\\ning drugs:\\nBile acid sequesterants are drugs that act by binding\\nwith the bile produced by the liver. Bile helps the diges-\\ntion and absorption of fats in the intestine. By blocking\\nthe digestion of fats, bile acid sequesterants prevent the\\nformation of cholesterol. Drugs in this class include:\\ncholestyramine (Questran); colestipol (Colestid); and\\ncolesevalam (Welchol).\\nHMG-CoA inhibitors, often called “statins,” are\\ndrugs that block an enzyme called “3-hydroxy-3-methyl-\\nglutaryl-coenzyme A reductase.” This blocks one of the\\nsteps in converting fat to cholesterol. These are the most\\neffective cholesterol lowering agents available. Drugs in\\nthis group include: atorvastatin (Lipitor); cerivastatin\\n(Baycol); fluvastatin (Lescol); lovastatin (Mevacor);\\npravastatin (Pravachol); and simvastatin (Zocor).\\nFibric acid derivatives include clofibrate (Atromid-\\nS); gemfibrozil (Lopid); and fenofibrate (Tricor).\\nAlthough these drugs are less effective than the statins at\\nlowering total cholesterol, they may be able to lower the\\nlow-density lipoprotein (LDL) cholesterol while raising\\nthe high-density lipoprotein (HDL) cholesterol. Their\\nexact mechanism of action is believed to be associated\\nwith inhibition of lipoprotein lipase activity.\\nNiacin, vitamin B-3, is also effective in lowering\\ncholesterol levels. Although the normal vitamin dose of\\nniacin is only 20 mg, the dose required to reduce choles-\\nterol levels is at least 500 mg each day. The mechanism\\nof action of niacin in cholesterol reduction is associated\\nwith the inhibition of VLDL secretion in the blood-\\nstream.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\ncholesterol-reducing drug used. The prescribing physi-\\ncian or the pharmacist who filled the prescription can\\nadvise about the correct dosage.\\nCholesterol-reducing drugs should be taken exactly\\nas directed and doses should not be missed. Double\\ndoses should not be taken to make up for a missed dose.\\nPhysicians may prescribe a combination of choles-\\nterol-reducing drugs, such as pravastatin and colestipol.\\nFollowing the directions for how and when to take the\\ndrugs is very important. The medicine may not work\\nproperly if both drugs are taken at the same time of day.\\nNiacin should not be taken at the same time as an\\nHMG-CoA inhibitor, as this combination may cause\\nsevere muscle problems. If niacin is taken in an over-the-\\ncounter form, both the prescribing physician and phar-\\nmacist should be informed. There are no problems when\\nthe niacin is taken in normal doses as a vitamin.\\nThe prescription should not be stopped without first\\nchecking with the physician who prescribed it. Choles-\\nterol levels may increase when the medicine is stopped,\\nand the physician may prescribe a special diet to make\\nthis less likely.\\nPrecautions\\nSeeing a physician regularly while taking cholesterol-\\nreducing drugs is important. The physician will check to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 789\\nCholesterol-reducing drugs\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 789'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 178, 'page_label': '179'}, page_content='make sure the medicine is working as it should and will\\ndecide whether it is still needed. Blood tests and other\\nmedical tests may be ordered to help the physician moni-\\ntor the drug’s effectiveness and check for side effects.\\nFor most people, cholesterol-reducing drugs are just\\none part of a whole program for lowering cholesterol lev-\\nels. Other important elements of the program may\\ninclude weight loss, exercise, special diets and changes\\nin other habits. The medication should never be viewed\\nas a substitute for other measures ordered by the physi-\\ncian. Cholesterol-reducing drugs will not cure problems\\nthat cause high cholesterol; they will only help control\\ncholesterol levels.\\nPeople over 60 years of age may be unusually sensi-\\ntive to the effects of some cholesterol-reducing drugs.\\nThis may increase the chance of side effects.\\nAnyone who is taking an HMG-CoA reductase\\ninhibitor should notify the health care professional in\\ncharge before having any surgical or dental procedures or\\nreceiving emergency treatment.\\nSpecial conditions\\nPeople who have certain medical conditions or who\\nare taking certain other medications may have problems\\nif they take cholesterol-reducing drugs. Before taking\\nthese drugs, the prescribing physician should be\\ninformed of any of the following conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto cholesterol-reducing drugs in the past should inform\\nthe prescribing physician before taking the drugs again.\\nThe physician should also be told about any allergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Studies of laboratory animals have\\nshown that giving high doses of gemfibrozil during\\npregnancy increases the risk of birth defects and other\\nproblems, including death of the unborn baby. The\\neffects of this drug have not been studied in pregnant\\nwomen. Women who are pregnant or who may become\\npregnant should check with their physicians before\\nusing gemfibrozil.\\nCholesterol-reducing drugs in the group known as\\nHMG-CoA reductase inhibitors (such as lovastatin, flu-\\nvastatin, pravastatin and simvastatin) should not be taken\\nby women who are pregnant or who plan to become\\npregnant soon. By blocking the production of choles-\\nterol, these drugs prevent a fetus from developing proper-\\nly. Women who are able to bear children should use an\\neffective birth control method while taking these drugs.\\nAny woman who becomes pregnant while taking these\\ndrugs should check with her physician immediately.\\nCholestyramine and colestipol will not directly harm\\nan unborn baby, because these drugs are not taken into\\nthe body. However, the drugs may keep the mother’s\\nbody from absorbing vitamins that she and the baby\\nneed. Pregnant women who take these drugs should ask\\ntheir physicians whether they need to take extra vitamins.\\nBREASTFEEDING. Because cholestyramine and cole-\\nstipol interfere with the absorption of vitamins, women\\nwho use these drugs while breastfeeding should ask their\\nphysicians if they need to take extra vitamins.\\nWomen who are breastfeeding should talk to their\\nphysicians before using gemfibrozil. Whether this drug\\npasses into breast milk is not known. But because animal\\nstudies suggest that it may increase the risk of some\\ntypes of cancer, women should carefully consider the\\nsafety of using it while breastfeeding.\\nHMG-CoA reductase inhibitors (such as lovastatin,\\npravastatin, fluvastatin and simvastatin) should not be\\nused by women who are breastfeeding their babies.\\nOTHER MEDICAL CONDITIONS. Cholesterol-reduc-\\ning drugs may make some medical problems worse.\\nBefore using these drugs, people with any of these med-\\nical conditions should make sure their physicians are\\naware of their conditions:\\n• stomach problems, including stomach ulcer\\n• constipation\\n• hemorrhoids\\n• gallstones or gallbladder disease\\n• bleeding problems\\n• underactive thyroid\\n• heart or blood vessel disease\\nIn addition, people with kidney or liver disease may\\nbe more likely to have blood problems or other side\\neffects when they take certain cholesterol-reducing\\ndrugs. And some drugs of this type may actually raise\\ncholesterol levels in people with liver disease.\\nPatients with any of the following medical condi-\\ntions may develop problems that could lead to kidney\\nfailure if they take HMG-CoA reductase inhibitors:\\n• treatments to prevent rejection after an organ transplant\\n• recent major surgery\\n• seizures (convulsions) that are not well controlled\\nPeople with phenylketonuria (PKU) should be\\naware that sugar-free formulations of some cholesterol-\\nreducing drugs contain phenylalanine in aspartame. This\\ningredient can cause problems in people who have\\nphenylketonuria.\\nGALE ENCYCLOPEDIA OF MEDICINE 2790\\nCholesterol-reducing drugs\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 790'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 179, 'page_label': '180'}, page_content='USE OF CERTAIN MEDICINES. Cholesterol-reducing\\ndrugs may change the effects of other medicines. Patients\\nshould not take any other medicine that has not been pre-\\nscribed or approved by a physician who knows they are\\ntaking cholesterol-reducing drugs.\\nSide effects\\nGemfibrozil\\nStudies in animals and humans suggest that gemfi-\\nbrozil increases the risk of some types of cancer. The drug\\nmay also cause gallstones or muscle problems. Patients\\nwho need to take this medicine should ask their physi-\\ncians for the latest information on its benefits and risks.\\nPatients taking gemfibrozil should check with a\\nphysician immediately if any of these side effects occur:\\n• fever or chills\\n• severe stomach pain with nausea and vomiting\\n• pain in the lower back or side\\n• pain or difficulty when urinating\\n• cough or hoarseness\\nHMG-CoA reductase inhibitors\\nThese drugs may damage the liver or muscles.\\nPatients who take the drugs should have blood tests to\\ncheck for liver damage as often as their physician recom-\\nmends. Any unexplained pain, tenderness or weakness in\\nthe muscles should be reported to the physician at once.\\nAll cholesterol-reducing drugs\\nMinor side effects such as heartburn, indigestion ,\\nbelching, bloating, gas, nausea or vomiting, stomach\\npain, dizziness and headache usually go away as the\\nbody adjusts to the drug and do not require medical treat-\\nment unless they continue or they interfere with normal\\nactivities.\\nPatients who have constipation while taking choles-\\nterol-reducing drugs should bring the problem to a physi-\\ncian’s attention as soon as possible.\\nAdditional side effects are possible. Anyone who has\\nunusual symptoms while taking cholesterol-reducing\\ndrugs should get in touch with his or her physician.\\nInteractions\\nCholesterol-reducing drugs may interact with other\\nmedicines. When this happens, the effects of one or both\\nof the drugs may change or the risk of side effects may\\nbe greater. Anyone who takes cholesterol-reducing drugs\\nshould let the physician know all other medicines he or\\nKEY TERMS\\nCell—The basic unit that makes up all living tissue.\\nCholesterol—Fatty substance found in tissue. Nec-\\nessary to maintain a healthy body.\\nEnzyme—A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nHormone —A substance that is produced in one\\npart of the body, then travels through the blood-\\nstream to another part of the body where it has its\\neffect.\\nPhenylketonuria —(PKU) A genetic disorder in\\nwhich the body lacks an important enzyme. If\\nuntreated, the disorder can lead to brain damage\\nand mental retardation.\\nPituitary gland —A pea-sized gland at the base of\\nthe brain that produces many hormones that affect\\ngrowth and body functions.\\nshe is taking and should ask whether the possible interac-\\ntions can interfere with drug therapy. Examples of possi-\\nble interactions are listed below.\\nSome cholesterol-reducing drugs may prevent the\\nfollowing medicines from working properly:\\n• thyroid hormones\\n• water pills (diuretics)\\n• certain antibiotics taken by mouth, such as tetracy-\\nclines, penicillin G and vancomycin\\n• the beta-blocker Inderal, used to treat high blood pressure\\n• digitalis heart medicines\\n• phenylbutazone, a nonsteroidal anti-inflammatory drug\\nTaking some cholesterol-reducing drugs with blood\\nthinners (anticoagulants) may increase the chance of\\nbleeding.\\nCombining HMG-CoA reductase inhibitors with\\ngemfibrozil, cyclosporine (Sandimmune) or niacin may\\ncause or worsen problems with the kidneys or muscles.\\nResources\\nBOOKS\\nNesto, R. W., and L. Christensen. Cholesterol-Lowering\\nDrugs: Everything You and Your Family Need to Know.\\nNew York: Morrow, William & Co, 2000.\\nParsons, W. B. Cholesterol Control Without Diet! The Niacin\\nSolution. Scottsdale, AZ: Lilac Press, 1998.\\nNancy Ross-Flanigan\\nGALE ENCYCLOPEDIA OF MEDICINE 2 791\\nCholesterol-reducing drugs\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 791'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 180, 'page_label': '181'}, page_content='Cholesterol test\\nDefinition\\nThe cholesterol test is a quantitative analysis of the\\ncholesterol levels in a sample of the patient’s blood. Total\\nserum cholesterol (TC) is the measurement routinely taken.\\nDoctors sometimes order a complete lipoprotein profile to\\nbetter evaluate the risk for atherosclerosis (coronary\\nartery disease, or CAD). The full lipoprotein profile also\\nincludes measurements of triglyceride levels (a chemical\\ncompound that forms 95% of the fats and oils stored in ani-\\nmal or vegetable cells) and lipoproteins (high density and\\nlow density). Blood fats are also called “lipids.”\\nThe type of cholesterol in the blood is as important as\\nthe total quantity. Cholesterol is a fatty substance and can-\\nnot be dissolved in water. It must combine with a protein\\nmolecule called a lipoprotein in order to be transported in\\nthe blood. There are five major types of lipoproteins in the\\nhuman body; they differ in the amount of cholesterol that\\nthey carry in comparison to other fats and fatty acids, and\\nin their functions in the body. Lipoproteins are classified,\\nas follows, according to their density:\\n• Chylomicrons. These are normally found in the blood\\nonly after a person has eaten foods containing fats.\\nThey contain about 7% cholesterol. Chylomicrons\\ntransport fats and cholesterol from the intestine into the\\nliver and then into the bloodstream. They are metabo-\\nlized in the process of carrying food energy to muscle\\nand fat cells.\\n• Very low-density lipoproteins (VLDL). These lipopro-\\nteins carry mostly triglycerides, but they also contain\\n16–22% cholesterol. VLDLs are made in the liver and\\neventually become IDL particles after they have lost\\ntheir triglyceride content.\\n• Intermediate-density lipoproteins (IDL). IDLs are\\nshort-lived lipoproteins containing about 30% choles-\\nterol that are converted in the liver to low-density\\nlipoproteins (LDLs).\\n• Low-density lipoproteins (LDL). LDL molecules carry\\ncholesterol from the liver to other body tissues. They\\ncontain about 50% cholesterol. Extra LDLs are absorbed\\nby the liver and their cholesterol is excreted into the bile.\\nLDL particles are involved in the formation of plaques\\n(abnormal deposits of cholesterol) in the walls of the\\ncoronary arteries. LDL is known as “bad cholesterol.”\\n• High-density lipoproteins (HDL). HDL molecules are\\nmade in the intestines and the liver. HDLs are about\\n50% protein and 19% cholesterol. They help to remove\\ncholesterol from artery walls. Lifestyle changes,\\nincluding exercising, keeping weight within recom-\\nmended limits, and giving up smoking can increase the\\nbody’s levels of HDL cholesterol. HDL is known as\\n“good cholesterol.”\\nBecause of the difference in density and cholesterol\\ncontent of lipoproteins, two patients with the same total\\ncholesterol level can have very different lipid profiles\\nand different risk for CAD. The critical factor is the level\\nof HDL cholesterol in the blood serum. Some doctors\\nuse the ratio of the total cholesterol level to HDL choles-\\nterol when assessing the patient’s degree of risk. A low\\nTC/HDL ratio is associated with a lower degree of risk.\\nPurpose\\nThe purpose of the TC test is to measure the levels\\nof cholesterol in the patient’s blood. The patient’s choles-\\nterol can also be fractionated (separated into different\\nportions) in order to determine the TC/HDL ratio. The\\nresults help the doctor to assess the patient’s risk for\\ncoronary artery disease (CAD). High LDL levels are\\nassociated with increased risk of CAD whereas high\\nHDL levels are associated with relatively lower risk.\\nIn addition, the results of the cholesterol test can\\nassist the doctor in evaluating the patient’s metabolism of\\nfat, or in diagnosing inflammation of the pancreas, liver\\ndisease, or disorders of the thyroid gland.\\nThe frequency of cholesterol testing depends on the\\npatient’s degree of risk for CAD. People with low choles-\\nterol levels may need to be tested once every five years.\\nPeople with high levels of blood cholesterol should be\\ntested more frequently, according to their doctor’s advice.\\nThe doctor may recommend a detailed evaluation of the\\ndifferent types of lipids in the patient’s blood. It is ideal to\\ncheck the HDL and triglycerides as well as the cholesterol\\nand LDL. In addition, the National Cholesterol Education\\nProgram (NCEP) suggests further evaluation if the patient\\nhas any of the symptoms of CAD or if she or he has two\\nor more of the following risk factors for CAD:\\n• male sex\\n• high blood pressure\\n• smoking\\n• diabetes\\n• low HDL levels\\n• family history of CAD before age 55\\nPrecautions\\nPatients who are seriously ill or hospitalized for\\nsurgery should not be given cholesterol tests because the\\nresults will not indicate the patient’s normal cholesterol\\nlevel. Acute illness, high fever, starvation , or recent\\nsurgery lowers blood cholesterol levels.\\nGALE ENCYCLOPEDIA OF MEDICINE 2792\\nCholesterol test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 792'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 181, 'page_label': '182'}, page_content='Description\\nThe cholesterol test requires a sample of the\\npatient’s blood. Fasting before the test is required to get\\nan accurate triglyceride and LDL level. The blood is\\nwithdrawn by the usual vacuum tube technique from one\\nof the patient’s veins. The blood test takes between three\\nand five minutes.\\nPreparation\\nPatients who are scheduled for a lipid profile test\\nshould fast (except for water) for 12–14 hours before the\\nblood sample is drawn. If the patient’s cholesterol is to\\nbe fractionated, he or she should also avoid alcohol for\\n24 hours before the test.\\nPatients should also stop taking any medications that\\nmay affect the accuracy of the test results. These include\\ncorticosteroids, estrogen or androgens, oral contracep-\\ntives, some diuretics, haloperidol, some antibiotics, and\\nniacin. Antilipemics are drugs that lower the concentra-\\ntion of fatty substances in the blood. When these are\\ntaken by the patient, blood testing may be done frequent-\\nly to evaluate the liver function as well as lipids. The\\npatient’s doctor will give the patient a list of specific\\nmedications to be discontinued before the test.\\nAftercare\\nAftercare includes routine care of the skin around the\\nneedle puncture. Most patients have no aftereffects, but\\nKEY TERMS\\nAtherosclerosis—A disease of the coronary arteries\\nin which cholesterol is deposited in plaques on the\\narterial walls. The plaque narrows or blocks blood\\nflow to the heart. Atherosclerosis is sometimes\\ncalled coronary artery disease, or CAD.\\nFractionation —A laboratory test or process in\\nwhich blood or another fluid is broken down into\\nits components. Fractionation can be used to assess\\nthe proportions of the different types of cholesterol\\nin a blood sample.\\nHigh-density lipoprotein (HDL)—A type of lipopro-\\ntein that protects against CAD by removing choles-\\nterol deposits from arteries or preventing their for-\\nmation.\\nHypercholesterolemia—The presence of excessive-\\nly high levels of cholesterol in the blood.\\nLipid—Any organic compound that is greasy, insol-\\nuble in water, but soluble in alcohol. Fats, waxes,\\nand oils are examples of lipids.\\nLipoprotein —A complex molecule that consists of\\na protein membrane surrounding a core of lipids.\\nLipoproteins carry cholesterol and other lipids from\\nthe digestive tract to the liver and other body tis-\\nsues. There are five major types of lipoproteins.\\nLow-density lipoprotein (LDL) —A type of lipopro-\\ntein that consists of about 50% cholesterol and is\\nassociated with an increased risk of CAD.\\nPlaque—An abnormal deposit of hardened choles-\\nterol on the wall of an artery.\\nTriglyceride —A chemical compound that forms\\nabout 95% of the fats and oils stored in animal and\\nvegetable cells. Triglyceride levels are sometimes\\nmeasured as well as cholesterol when a patient is\\nscreened for heart disease.\\nsome may have a small bruise or swelling. A washcloth\\nsoaked in warm water usually relieves any discomfort. In\\naddition, the patient should resume taking any prescrip-\\ntion medications that were discontinued before the test.\\nRisks\\nThe primary risk to the patient is a mild stinging or\\nburning sensation during the venipuncture, with minor\\nswelling or bruising afterward.\\nNormal results\\nThe “normal” values for serum lipids depend on the\\npatient’s age, sex, and race. Normal values for people in\\nWestern countries are usually given as 140–220 mg/dL in\\nadults, although as many as 5% of the population has TC\\nhigher than 300 mg/dL. Among Asians, the figures are\\nabout 20% lower. As a rule, both TC and LDL levels rise\\nas people get older.\\nSome doctors prefer to speak of “desired” rather\\nthan “normal” cholesterol values, on the grounds that\\n“normal” refers to statistically average levels that may\\nstill be too high for good health. Desirable values are as\\nfollows:\\n• Total cholesterol (TC): less than 200 mg/dL\\n• HDL cholesterol: 40–70 mg/dL in males, 40–80 mg/dL\\nin females\\n• LDL cholesterol: less than 130 mg/dL\\n• TC/HDL ratio: under 4.0 in males, 3.8 in females.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 793\\nCholesterol test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 793'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 182, 'page_label': '183'}, page_content='Abnormal results\\nIt is possible for blood cholesterol levels to be too\\nlow as well as too high.\\nAbnormally low levels\\nTC levels less than 160 mg/dL are associated with\\nhigher mortality rates from cancer, liver disease, respira-\\ntory disorders, and injuries. The connection between\\nunusually low cholesterol and increased mortality is not\\nclear, although some researchers think that the low level\\nis a secondary sign of the underlying disease and not the\\ncause of disease or death.\\nLow levels of serum cholesterol are also associated\\nwith malnutrition or hyperthyroidism. Further diagnos-\\ntic testing may be necessary in order to locate the cause.\\nAbnormally high levels\\nPrior to 1980, hypercholesterolemia (an abnormal-\\nly high TC level) was defined as any value above the\\n95th percentile for the population. These figures ranged\\nfrom 210 mg/dL in persons younger than 20 to more than\\n280 mg/dL in persons older than 60. It is now known,\\nhowever, that TC levels over 200 mg/dL are associated\\nwith significantly higher risk of CAD. Levels of 280\\nmg/dL or more are considered elevated. Treatment with\\ndiet and medication has proven to successfully lower risk\\nof heart attack and stroke.\\nElevated cholesterol levels may also result from\\nhepatitis, blockage of the bile ducts, disorders of lipid\\nmetabolism, nephrotic syndrome , inflammation of the\\npancreas, or hypothyroidism.\\nResources\\nBOOKS\\nBaron, Robert B., and Warren S. Browner. “Lipid Abnormali-\\nties.” In Current Medical Diagnosis and Treatment, 1998.\\n37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton\\n& Lange, 1997.\\n“Laboratory and Reference Guides.” In The Merck Manual of\\nDiagnosis and Therapy.16th ed. Ed. Robert Berkow. Rah-\\nway, NJ: Merck Research Laboratories, 1992.\\nSobel, David S., and Tom Ferguson. The People’s Book of\\nMedical Tests.New York: Summit Books, 1985.\\nRebecca J. Frey\\nCholinergic drugs\\nDefinition\\nCholinergic drugs are medications that produce the\\nsame effects as the parasympathetic nervous system.\\nPurpose\\nCholinergic drugs produce the same effects as acetyl-\\ncholine. Acetylcholine is the most common neurohor-\\nmone of the parasympathetic nervous system, the part of\\nthe peripheral nervous system responsible for the every\\nday work of the body. While the sympathetic nervous sys-\\ntem acts during times of excitation, the parasympathetic\\nsystem deals with everyday activities such as salivation,\\ndigestion, and muscle relaxation.\\nThe cholinergic drugs may be used in several ways.\\nThe cholinergic muscle stimulants are used to diagnose and\\ntreat myathenia gravis, a disease that causes severe muscle\\nweakness. This class of drugs includes ambenonium chlo-\\nride (Mytelase), edrophonium chloride (Tensilon), neostig-\\nmine (Prostigmine), and piridogstimina (Mestinón). These\\ndrugs are also widely used in surgery, both to reduce the\\nrisk of urinary retention, and to reverse the effects of the\\nmuscle relaxant drugs that are used in surgery.\\nCholinergic drugs are also used in control of glauco-\\nma, a disease that is caused by increased pressure inside\\nthe eye. The most common drugs used for this purpose\\nare demecarium (Humorsol) and echthiophate (Phospho-\\nline iodide).\\nDescription\\nCholinergic drugs usually act in one of two ways.\\nSome directly mimic the effect of acetylcholine, while\\nothers block the effects of acetylcholinesterase. Acetyl-\\ncholinesterase is an enzyme that destroys naturally\\noccurring acetylcholine. By blocking the enzyme, the\\nnaturally occurring acetylcholine has a longer action.\\nRecommended dosage\\nCholinergic drugs are available only by prescription.\\nThey may be available as eye drops, capsules, tablets, or\\ninjections.\\nPrecautions\\nCholinergic drugs should be avoided when the\\npatient has any sort of obstruction in the urinary or diges-\\ntive tracts, such a a tumor, or severe inflammation which\\nis causing blockage.\\nThey should be used with caution in patients with\\nasthma, epilepsy, slow heart beat, hyperthyroidism,o r\\ngastric ulcers.\\nThe effects of the cholinergic drugs are to produce\\nthe same effects as stimulation of the parasympathetic\\nnervous system. These effects include slowing of the\\nheartbeat, increases in normal secretions including the\\nGALE ENCYCLOPEDIA OF MEDICINE 2794\\nCholinergic drugs\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 794'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 183, 'page_label': '184'}, page_content='digestive acids of the stomach, saliva and tears. For this\\nreason, patients who already have a problem in one of\\nthese areas, such as a slow heartbeat or stomach ulcers\\nshould use these drugs with great caution, since the med-\\nication will make their conditions worse.\\nSide effects\\nWhen used properly, cholinergic drugs will increase\\nmuscle strength in patients with myasthenia gravis . In\\neye drop form, they can reduce the intraoccular pressure\\nin glaucoma.\\nThe possible adverse effects of cholinergic drugs are:\\n• slow heart beat, possibly leading to cardiac arrest\\n• muscle weakness, muscle cramps, and muscle pain\\n• convulsions\\n• weak breathing, inability to breath\\n• increased stomach acid and saliva\\n• nausea and vomiting\\n• dizziness, drowsiness, and headache\\nResources\\nBOOKS\\nBeyond the Limits: A Self Portrait of Myasthenia Gravis.\\nSusanville, CA: Palette-Publishing, March 1994.\\nPERIODICALS\\n“Classic Papers in Glaucoma.”Archives of Ophthalmology\\n(March 2001).\\nKEY TERMS\\nCholinergic—Nerves that are stimulated by acetyl-\\ncholine.\\nGlaucoma —a disease of the eye marked by\\nincreased pressure within the eyeball that can\\nresult in damage to the optic disk and gradual loss\\nof vision.\\nMyasthenia gravis—a disease characterized by pro-\\ngressive weakness and exhaustibility of voluntary\\nmuscles without atrophy or sensory disturbance\\nand caused by an autoimmune attack on acetyl-\\ncholine receptors at neuromuscular junctions.\\nParasympathetic nervous system —the part of the\\nnervous system that contains chiefly cholinergic\\nfibers, that tends to induce secretion, to increase\\nthe tone and contractility of smooth muscle, and\\nto slow the heart rate.\\n“Congenital myasthenic syndromes: recent advances.”\\nArchives of Neurology(February 1999).\\nSamuel Uretsky, PharmD\\nChondromalacia patellae\\nDefinition\\nChondromalacia patellae refers to the progressive\\nerosion of the articular cartilage of the knee joint, that is\\nthe cartilage underlying the kneecap (patella) that articu-\\nlates with the knee joint.\\nDescription\\nChondromalacia patellae (CMP), also known as\\npatello-femoral pain syndrome or patello-femoral stress\\nsyndrome, is a syndrome that causes pain/discomfort at\\nthe front of the knee. It is associated with irritation or\\nwear on the underside of the kneecap, or patella. In a nor-\\nmal knee, the articular cartilage is smooth and elastic and\\nglides smoothly over the surface of the thighbone, or\\nfemur when the knee is bent. Erosion of the cartilage\\nroughens the surface and prevents this smooth action.\\nCMP is most common in adolescent females,\\nalthough older people may also develop it. An average of\\ntwo out of 10,000 people develop this condition, many of\\nthem runners or other athletes.\\nCauses and symptoms\\nCMP is the result of the normal aging process,\\noveruse, injury, or uneven pressures exerted on the knee\\njoint. In teens, CMP may be caused by uneven growth or\\nuneven strength in the thigh muscles. Growth spurts,\\ncommon in teens, may result in a mildly abnormal align-\\nment of the patella, which increases the angle formed by\\nthe thigh and the patellar tendon (Q-angle). This condi-\\ntion adds to the damage. Symptoms include pain, nor-\\nmally around the kneecap, and a grinding sensation felt\\nwhen extending the leg. The pain may radiate to the back\\nof the knee, or it may be intermittent and brought on by\\nsquatting, kneeling, going up or down stairs, especially\\ndown, or by repeated bending of the joint.\\nDiagnosis\\nDiagnosis is established during a physical examina-\\ntion performed by a general practitioner or an orthope-\\ndist, and is based on frequency of symptoms and con-\\nfirmed by x rays of the knee. The CMP erosion can also\\nGALE ENCYCLOPEDIA OF MEDICINE 2 795\\nChondromalacia patellae\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 795'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 184, 'page_label': '185'}, page_content='be seen on an MRI, although this type of scan is not rou-\\ntinely performed for this purpose. The patient should\\ninform the doctor about any previous injuries to the joint.\\nTreatment\\nInitial treatment may consist of resting the knee\\nusing crutches, along with aspirin , Tylenol, or a non-\\nsteroidal anti-inflammatory drug (NSAID) such as\\nMotrin for seven to 10 days. The person should limit\\nsports activity until the joint is healed and may use ice\\nfollowed by heat to decrease inflammation. When the\\ndoctor allows the patient to resume sports, a knee brace\\nmay be prescribed in the form of a stabilizer with a hole\\nat the kneecap.\\nTreatment also includes low impact exercises to\\nstrengthen the quadriceps muscles which help stabilize\\nthe knee joint. Physical therapy may be suggested at the\\nstart of this program so as to help the patient learn the\\ncorrect method of performing the exercises.\\nApproximately 85% of people do well with conserv-\\native CMP treatment. The remainder still have severe\\npain and may require arthroscopic surgery to repair the\\ntissues inside the knee joint. In more severe cases, open\\nsurgery may be required to realign the kneecap and per-\\nhaps other corrections.\\nAlternative treatments\\nPhysical therapy offers treatments that may help\\nCMP patients. Aqua therapy has the benefit of exercising\\nthe knee without putting stress on it and it also strength-\\nens the thigh muscles. Biofeedback can be used to learn\\ntensing and relaxing specific muscles to relieve pain.\\nThese techniques have the benefit of no side effects.\\nMassage therapy might be beneficial as well. Calcium,\\nminerals , and vitamins as part of a balanced diet will\\naid healing and help prevent further problems.\\nKEY TERMS\\nArthroscopic knee surgery—Surgery performed to\\nexamine or repair tissues inside the knee joint\\nthrough a special scope (arthroscope).\\nFemur—The thigh bone.\\nIsometric exercises —Exercises which strengthen\\nthrough muscle resistance.\\nOsteoarthritis—Degenerative joint disease.\\nQuadriceps, hip flexors, hamstrings—Major mus-\\ncles in the thigh area which affect knee mechanics.\\nPrognosis\\nIn most teens with CMP, the prognosis is excellent\\nsince the damage is reversible when treatment starts\\nbefore the cartilage begins to break down. With proper\\ntreatment and preventive techniques, teenagers will com-\\nplete their growth without permanent damage to the\\njoint. Only about 15% of patients require surgical inter-\\nvention. Older people may go on to develop osteoarthri-\\ntis in the knee.\\nPrevention\\nProper exercises are the best preventive measure.\\nSince tightness of thigh muscles is a risk factor, warming\\nup before athletic activities is recommended, as well as\\nparticipating in a variety of sports rather than just one.\\nStretching exercises increase flexibility of the quadri-\\nceps, hip flexors, and hamstrings. Strengthening exercis-\\nes such as short arc leg extensions, straight leg raises,\\nquadriceps isometric exercises, and stationary bicycling\\nare also recommended.\\nResources\\nOTHER\\nChondromalacia patellae. .\\nChondromalacia Patellae..\\n“Major Domains of Complementary & Alternative Medicine.”\\n.\\nQuestions and Answers About Knee Problems..\\nQuestions and Answers About Knee Problems..\\nBarbara J. Mitchell\\nChorea see Movement disorders\\nChoriocarcinoma\\nDefinition\\nA choriocarcinoma is type of cancer germ cell con-\\ntaining trophoblast cells.\\nDescription\\nChoriocarcinomas are cancers that develop from\\ngerm cells, cells that ordinarily turn into sperm or eggs.\\nChoriocarcinomas resemble the cells that surround an\\nGALE ENCYCLOPEDIA OF MEDICINE 2796\\nChoriocarcinoma\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 796'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 185, 'page_label': '186'}, page_content='embryo in the uterus. Most of these cancers form inside\\nthe reproductive organs. Some originate in the testes or\\novaries, especially in young adults. Others develop in the\\nuterus after a pregnancy or miscarriage—particularly\\noften after a mole. A few choriocarcinomas arise in sites\\noutside the reproductive organs. Such “extragonadal”\\ntumors are usually found in young adults and are more\\ncommon in males.\\nChoriocarcinomas are one of the most dangerous\\ngerm cell cancers. Choriocarcinomas usually grow\\nquickly and spread widely. Occasionally, this cancer\\ngrows so fast that the original tumor outgrows its blood\\nsupply and dies, leaving behind only a small scar.\\nCauses and symptoms\\nChoriocarcinomas result from genetic damage to a\\ngerm cell. Males with Klinefelter syndrome are espe-\\ncially likely to develop extragonadal germ cell tumors.\\nThe symptoms of a choriocarcinoma vary, depend-\\ning on where the tumor originates and where it spreads.\\nIn the uterus, the most common symptom is bleeding.\\nCancers in the ovary often have only subtle signs such as\\nKEY TERMS\\nBiopsy—A sample of an organ taken to look for\\nabnormalities. Also, the technique used to take such\\nsamples.\\nChemotherapy —The treatment of cancer with\\ndrugs.\\nComputed tomography (CT)—A special x ray tech-\\nnique that produces a cross sectional image of the\\norgans inside the body.\\nExtragonadal —In a location other than the repro-\\nductive organs.\\nGerm cell—One of the cells that ordinarily develop\\ninto eggs or sperm (also sperm and eggs).\\nGonads—The ovaries or testes.\\nKlinefelter syndrome—A condition caused by extra\\nX chromosome(s) in a male, that results in small\\ntestes and infertility together with increased height,\\ndecreased facial hair, and sometimes breast\\nenlargement.\\nMagnetic resonance imaging —A type of study that\\nuses changes induced by magnets to see cells and\\ntissues inside the body.\\nMole—A mass of abnormal, partially developed tis-\\nsues inside the uterus (womb). Moles develop dur-\\ning a pregnancy that begins with an abnormal fertil-\\nization.\\nOvaries—The female sex organs that make eggs\\nand female hormones.\\nRemission—The disappearance of the symptoms of\\ncancer, although all of the cancer cells may not be\\ngone.\\nReproductive organs—The group of organs (includ-\\ning the testes, ovaries, and uterus) whose purpose is\\nto produce a new individual and continue the\\nspecies.\\nTestes—The male sex organs that make sperm and\\nmale hormones.\\nTesticular cancer —A cancer that originates in the\\ntestes.\\nTrophoblast—The tissues that surround an embryo\\nand attach it to the uterus.\\nTumor—A lump made up of abnormal cells.\\nUterus—The organ where a child develops (womb).\\nwidening of the waistline or pain. In the testes, chorio-\\ncarcinomas can often be felt as small painless lumps.\\nChoriocarcinomas that spread to other organs may reveal\\ntheir presence by bleeding. In the brain, this bleeding can\\ncause a stroke.\\nDiagnosis\\nChoriocarcinomas are usually referred to an\\noncologist, a doctor who specializes in cancer treat-\\nment. To diagnose this tumor, the doctor will do a\\nphysical examination and examine the internal\\norgans with x rays or ultrasound studies. Choriocarci-\\nnomas are not always biopsied before being treated,\\nbecause they tend to bleed heavily. Spreading of the\\ncancer is detected with x rays, ultrasound studies,\\ncomputed tomography (CT), or magnetic resonance\\nimaging (MRI) scans.\\nMost choriocarcinomas make human chorionic\\ngonadotropin (hCG), a hormone normally found only\\nduring pregnancy. The presence of hCG in the blood can\\nhelp diagnose this cancer and monitor the success of\\ntreatment.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 797\\nChoriocarcinoma\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 797'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 186, 'page_label': '187'}, page_content='Treatment\\nChoriocarcinomas are usually treated by surgical\\nremoval of the tumor and chemotherapy . Radiation is\\noccasionally used, particularly for tumors in the brain.\\nAlternative treatment\\nComplementary treatments can decrease stress,\\nreduce the side effects of cancer treatment, and help\\npatients feel more in control. For instance, some people\\nfind activities such as yoga, massage, music therapy ,\\nmeditation, prayer, or mild physical exercise helpful.\\nPrognosis\\nThe prognosis for choriocarcinomas in the uterus is\\nvery good. Although these tumors have often spread\\nthroughout the body, chemotherapy results in a cure or\\nremission in at least 80–90% of cases. Women who have\\nhad choriocarcinomas often go on to have normal preg-\\nnancies and deliveries.\\nChoriocarcinomas in other sites have a poorer prog-\\nnosis. These tumors tend to spread quickly and don’t\\nalways respond well to chemotherapy. Although treat-\\nment can be effective, the outcome usually depends on\\nhow widely the cancer is dispersed. Generally, the prog-\\nnosis is worse if the cancer can be found in the liver or\\nbrain, if hCG levels are high, or if the original tumor\\ndeveloped outside the gonads. Five-year survival with\\ntesticular cancers can range from 92% for tumors that\\nhave spread only to the lungs to 48% to tumors that have\\nspread to other internal organs.\\nPrevention\\nThere is no known means of prevention. However,\\nearly detection of the symptoms and prompt medical\\ntreatment can improve the odds of survival.\\nResources\\nBOOKS\\nBaker, Vicki V . “Gestational Trophoblastic Disease.” In Clini-\\ncal Oncology, 2nd ed. Ed. Martin D. Abeloff, et al.\\nPhiladelphia: Churchhill Livingstone, 2000.\\nCrum, Christopher P. “The Female Genital Tract.” In Robbins\\nPathologic Basis of Disease, 6th ed. Ed. Ramzi S. Cotran,\\nVinay Kumar, and Tucker Collins. Philadelphia: W.B.\\nSaunders, 1999.\\nSmall, Eric J., and Frank M. Torti. “The Testes.” In Clinical\\nOncology, 2nd ed. Ed. Martin D. Abeloff, et al. Philadel-\\nphia: Churchhill Livingstone, 2000.\\nSmithson, William A. “Gonadal and Germ Cell Neoplasms.” In\\nNelson Textbook of Pediatrics, 16th ed. Ed. Richard E.\\nBehrman, et al. Philadelphia: W.B. Saunders, 2000.\\n“The Male Genital Tract.” In Robbins Pathologic Basis of Dis-\\nease, 6th ed. Ed. Ramzi S. Cotran, Vinay Kumar, and\\nTucker Collins. Philadelphia: W.B. Saunders, 1999.\\nThigpen, James Tate. “Ovaries and Fallopian Tubes.” In Clini-\\ncal Oncology, 2nd ed. Ed. Martin D. Abeloff, et al.\\nPhiladelphia: Churchill Livingstone, 2000.\\nPERIODICALS\\nNewlands, Edward S., Fernando J. Paradinas, and Rosemary A.\\nFisher. “Current Therapeutic Issues in Gynecologic Can-\\ncer. Recent Advances in Gestational Trophoblastic Dis-\\nease.” Hematology/Oncology Clinics of North America\\n13, no. 1 (Feb. 1999): 225-44.\\nOTHER\\n“Chemotherapy and You: A Guide to Self-help During Cancer\\nTreatment.”CancerNet. June 1999. 5 Apr. 2001 .\\n“Extragonadal Germ Cell Tumors.”CancerNet. Aug. 2000. 27\\nApr. 2001 .\\n“Ovarian Germ Cell Tumor.”CancerNet. Feb. 2001. 27 Apr.\\n2001 .\\nAnna Rovid Spickler, D.V .M., Ph.D.\\nChorionic gonadotropin test see Human\\nchorionic gonadotropin pregnancy test\\nChorionic villus sampling\\nDefinition\\nChorionic villus sampling (CVS), also known as\\nchorionic villus biopsy, is a prenatal test that can detect\\ngenetic and chromosomal abnormalities of an unborn baby.\\nPurpose\\nChorionic villus sampling is performed on pregnant\\nwomen who are at risk for carrying a fetus with a genet-\\nic or chromosomal defect. Although it carries a slightly\\nhigher risk, CVS may be used in place of amniocentesis\\nfor women who have one or more of the following risk\\nfactors:\\n• Women age 35 and older. The chance of having a child\\nwith Down syndrome increases with maternal age. For\\ninstance, the chance of having a baby with Down syn-\\ndrome is one in 378 for a 35-year-old woman and\\nincreases to one in 30 for a 45-year-old woman.\\n• A history of miscarriages or children born with birth\\ndefects.\\n• A family history of genetic disease. Prenatal genetic\\ntesting is recommended if either the mother or father of\\nGALE ENCYCLOPEDIA OF MEDICINE 2798\\nChorionic villus sampling\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 798'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 187, 'page_label': '188'}, page_content='the unborn baby has a family history of genetic disease\\nor is known to be a carrier of a genetic disease.\\nPrecautions\\nChorionic villus sampling is not recommended for\\nwomen who have vaginal bleeding or spotting during the\\npregnancy. It is not typically recommended for women\\nwho have Rh sensitization from a previous pregnancy.\\nDescription\\nChorionic villus sampling has been in use since the\\n1980s. This prenatal testing procedure involves taking a\\nsample of the chorion frondosum—that part of the chori-\\nonic membrane containing the villi—for laboratory\\nanalysis. The chorionic membrane is the outer sac which\\nsurrounds the developing fetus. Chorionic villi are\\nmicroscopic, finger-like projections that emerge from the\\nchorionic membrane and eventually form the placenta.\\nThe cells that make up the chorionic villi are of fetal ori-\\ngin so laboratory analysis can identify any genetic, chro-\\nmosomal, or biochemical diseases of the fetus.\\nChorionic villus sampling is best performed\\nbetween 10 and 12 weeks of pregnancy. The procedure is\\nperformed either through the vagina and the cervix\\n(transcervically) or through the abdomen (transabdomi-\\nnally) depending upon the preferences of the patient or\\nthe doctor. In some cases, the location of the placenta\\ndictates which method the doctor uses. Both methods are\\nequally safe and effective. Following the preparation\\ntime, both procedures take only about five minutes.\\nWomen undergoing chorionic villus sampling may expe-\\nrience no pain at all or feel cramping or pinching. Occa-\\nsionally, a second sampling procedure must be per-\\nformed if insufficient villus material was obtained.\\nFor the transcervical procedure, the woman lies on\\nan examining table on her back with her feet in stirrups.\\nThe woman’s vaginal area is thoroughly cleansed with an\\nantiseptic, a sterile speculum is inserted into her vagina\\nand opened, and the cervix is cleansed with an antiseptic.\\nUsing ultrasound (a device which uses sound waves to\\nvisualize internal organs) as a guide, the doctor inserts a\\nthin, plastic tube called a catheter through the cervix and\\ninto the uterus. The passage of the catheter through the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 799\\nChorionic villus sampling\\nUltrasound transducer\\nChorionic villi\\nAmniotic fluid\\nFetus (8-10 weeks)\\nUterine cavity\\nCatheter\\nVagina\\n Bladder\\nChorionic villus sampling is performed on pregnant women who are at risk for carrying a fetus with a genetic or chromoso-\\nmal defect.This procedure can be performed through the vagina and the cervix (transcervically) or through the abdomen\\n(transabdominally). In the transcervical procedure, as depicted above, the physician uses ultrasound to help guide a catheter\\nthrough the cervix into the uterus. By applying suction from the syringe attached to the other end of the catheter, a small\\nsample of the chorionic villi are obtained.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 799'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 188, 'page_label': '189'}, page_content='cervix may cause cramping. The doctor carefully watch-\\nes the image produced by the ultrasound and advances\\nthe catheter to the chorionic villi. By applying suction\\nfrom the syringe attached to the other end of the catheter,\\na small sample of the chorionic villi are obtained. A\\ncramping or pinching feeling may be felt as the sample is\\nbeing taken. The catheter is then easily withdrawn.\\nFor the transabdominal method, the woman lies on\\nher back on an examining table. Ultrasound enables the\\ndoctor to locate the placenta. The specific area on the\\nwoman’s abdomen is cleansed thoroughly with an anti-\\nseptic and a local anesthetic may be injected to numb the\\narea. With ultrasound guidance, a long needle is inserted\\nthrough the woman’s abdominal wall, through the uterine\\nwall and to the chorionic villi. The sample is obtained by\\napplying suction from the syringe.\\nThe chorionic villus sample is immediately placed\\ninto nutrient medium and sent to the laboratory. At the lab-\\nKEY TERMS\\nChorionic villi —Microscopic, finger-like projec-\\ntions that emerge from the outer sac which sur-\\nrounds the developing baby. Chorionic villi are of\\nfetal origin and eventually form the placenta.\\nChromosomes—Human cells carry DNA in tightly\\ncompressed rod-like structures called chromo-\\nsomes. Humans have 23 pairs of chromosomes\\nincluding the sex chromosomes.\\nDown syndrome —A chromosomal disorder\\ncaused by an extra copy or a rearrangement of\\nchromosome 21. Children with Down syndrome\\nhave varying degrees of mental retardation and\\nmay have heart defects.\\nFetus—Term for an unborn baby after the eighth\\nweek of pregnancy. Prior to seven weeks, it is\\ncalled an embryo.\\nRh sensitization—A woman with a negative blood\\ntype (Rh negative) who has produced antibodies\\nagainst her fetus with a positive blood type (Rh\\npositive). The mother’s body considered the fetal\\nblood cells a foreign object and mounted an\\nimmune attack on it.\\nUltrasound —A safe, painless procedure which\\nuses sound waves to visualize internal organs. A\\nwand that transmits and receives the sound waves\\nis moved over the woman’s abdomen and internal\\norgans can be seen on a video screen.\\noratory, the sample is examined under the microscope and\\nany contaminating cells or material is carefully removed.\\nThe villi can be analyzed immediately, or incubated for a\\nday or more to allow for cell division. The cells are\\nstopped in the midst of cell division and spread onto a\\nmicroscope slide. Cells with clearly separated chromo-\\nsomes are photographed so that the type and number of\\nchromosomes can be analyzed. Chromosomes are strings\\nof DNA which have been tightly compressed. Humans\\nhave 23 pairs of chromosomes including the sex chromo-\\nsomes. Rearrangements of the chromosomes or the pres-\\nence of additional or fewer chromosomes can be identified\\nby examination of the photograph. Down syndrome, for\\ninstance, is caused by an extra copy of chromosome 21. In\\naddition to the chromosomal analysis, specialized tests can\\nbe performed as needed to look for specific diseases such\\nas Tay-Sachs disease. Depending upon which tests are\\nperformed, results may be available as early as two days or\\nup to eight days after the procedure.\\nChorionic villus sampling costs between $1,200 and\\n$1,800. Insurance coverage for this test may vary.\\nAlternate procedures\\nThere are alternate procedures for diagnosing genet-\\nic and chromosomal disorders of the fetus. Amniocente-\\nsis is commonly used and involves inserting a needle\\nthrough the pregnant woman’s abdomen to obtain a sam-\\nple of amniotic fluid. Amniocentesis is usually per-\\nformed in the second trimester at approximately 16\\nweeks gestation and the laboratory analysis may take two\\nto three weeks. The two advantages of chorionic villus\\nsampling are that it is performed during the first trimester\\nand the results are available in about one week. However,\\nas of 1997, amniocentesis is being performed in the first\\ntrimester, but this is still very rare. The risk of miscar-\\nriage after amniocentesis is 0.5–1% (one to two women\\nout of 200) which is lower than that for chorionic villus\\nsampling (1–3%).\\nA noninvasive alternative is the maternal blood test\\ncalled triple marker screening or multiple marker screen-\\ning. A sample of the pregnant woman’s blood is analyzed\\nfor three different markers: alphafetoprotein (AFP),\\nhuman chorionic gonadotropin, and unconjugated estriol.\\nThe levels of these three markers in the mother’s blood\\ncan identify unborn babies who are at risk for certain\\ngenetic or chromosomal defects. This is a screening test\\nwhich determines the chance that the fetus has the defect,\\nbut it can not diagnose defects. A negative test result\\ndoes not necessarily mean the unborn baby does not have\\na birth defect. For instance, this screening test can only\\npredict 60–70% of the fetuses with Down syndrome.\\nPregnant women who have a positive triple marker\\nGALE ENCYCLOPEDIA OF MEDICINE 2800\\nChorionic villus sampling\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 800'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 189, 'page_label': '190'}, page_content='screen are encouraged to undergo a diagnostic test, such\\nas amniocentesis (by the time an AFP is done, it is too\\nlate to perform a CVS).\\nPreparation\\nPrior to the chorionic villus sampling procedure the\\nwoman needs to drink fluids and refrain from urinating\\nto ensure her bladder is full. These preparations create a\\nbetter ultrasound picture.\\nAftercare\\nIt is generally recommended that women undergoing\\nchorionic villus sampling have someone drive them\\nhome and have no plans for the rest of the day. Women\\nwith Rh negative blood must receive a Rho (D) immune\\nglobulin injection following the procedure. Women\\nshould call their doctor if they experience excessive\\nbleeding, vaginal discharge, fever, or abdominal pain\\nafter the procedure.\\nRisks\\nOf women who undergo transcervical chorionic vil-\\nlus sampling, one third experience minimal vaginal spot-\\nting and 7–10% experience vaginal bleeding. One out of\\nfive women experience cramping following the proce-\\ndure. Two to three women out of 100 (or 2–3%) will mis-\\ncarry following chorionic villus sampling. The risk of\\ninfection is very low. Rupture of the amniotic mem-\\nbranes is a rare complication. Women with Rh negative\\nblood may be at an increased risk for developing Rh\\nincompatibility following chorionic villus sampling.\\nThere have been reports of limb defects in babies\\nfollowing chorionic villus sampling. However, in 1996\\nthe World Health Organization reported that the inci-\\ndence of babies born with limb defects from 138,966\\nwomen who had undergone chorionic villus sampling\\nwas the same as for women who had not. Therefore, this\\nstudy found no connection between chorionic villus sam-\\npling and limb defects.\\nNormal results\\nNo genetic, chromosomal, or biochemical abnor-\\nmalities were found in the fetal cells. The gender of the\\nfetus will be identified but will be made known to the\\nparents only with their approval.\\nAbnormal results\\nAnalysis of the cells from the chorionic villus\\nenables the detection of over 200 diseases and disorders\\nsuch as Down Syndrome, Tay-Sachs disease, and cystic\\nfibrosis. Gross rearrangements of the chromosomes and\\nchromosome additions or losses are detected.\\nResources\\nBOOKS\\nEisenberg, E., et. al. What to Expect When You’re Expecting.\\nNew York: Workman Publishing, 1996.\\nPERIODICALS\\nFroster, U. G., et. al. “Limb Defects and Chorionic Villus Sam-\\npling: Results from an International Registry, 1992–94.”\\nLancet 347 (1996): 489-94.\\nSundberg, K., et. al. “Randomised Study of Risk of Fetal Loss\\nRelated to Early Amniocentesis Versus Chorionic Villus\\nSampling.” Lancet 350 (1997): 697-703.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nOTHER\\nFamily Internet Page..\\nBelinda Rowland, PhD\\nChoroiditis see Uveitis\\nChoroiretinitis see Uveitis\\nChromosome studies see Genetic testing\\nChronic arthritis of childhood see Juvenile\\narthritis\\nChronic constrictive pericarditis see\\nPericarditis\\nChronic Epstein-Barr virus see Chronic\\nfatigue syndrome\\nChronic fatigue syndrome\\nDefinition\\nChronic fatigue syndrome (CFS) is a condition that\\ncauses extreme tiredness. People with CFS have debili-\\ntating fatigue that lasts for six months or longer. They\\nalso have many other symptoms. Some of these are pain\\nin the joints and muscles, headache , and sore throat .\\nCFS does not have a known cause, but appears to result\\nfrom a combination of factors.\\nDescription\\nCFS is the most common name for this disorder, but\\nit also has been called chronic fatigue and immune disor-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 801\\nChronic fatigue syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 801'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 190, 'page_label': '191'}, page_content='der (CFIDS), myalgic encephalomyelitis, low natural\\nkiller cell disease, post-viral syndrome, Epstein-Barr dis-\\nease, and Yuppie flu. CFS has so many names because\\nresearchers have been unable to find out exactly what\\ncauses it and because there are many similar, overlapping\\nconditions. Reports of a CFS-like syndrome called\\nneurasthenia date back to 1869. Later, people with simi-\\nlar symptoms were said to have fibromyalgia because\\none of the main symptoms is myalgia, or muscle pain.\\nBecause of the similarity of symptoms, fibromyalgia and\\nCFS are considered to be overlapping syndromes.\\nIn the early to mid-1980s, there were outbreaks of\\nCFS in some areas of the United States. Doctors found that\\nmany people with CFS had high levels of antibodies to the\\nEpstein-Barr virus (EBV), which causes mononucleosis, in\\ntheir blood. For a while they thought they had found the\\nculprit, but it turned out that many healthy people also had\\nhigh EBV antibodies. Scientists have also found high levels\\nof other viral antibodies in the blood of people with CFS.\\nThese findings have led many scientists to believe that a\\nvirus or combination of viruses may trigger CFS.\\nCFS was sometimes referred to as Yuppie flu because\\nit seemed to often affect young, middle-class profession-\\nals. In fact, CFS can affect people of any gender, age,\\nrace, or socioeconomic group. Although anyone can get\\nCFS, most patients diagnosed with CFS are 25–45 years\\nold, and about 80% of cases are in women. Estimates of\\nhow many people are afflicted with CFS vary due to the\\nsimilarity of CFS symptoms to other diseases and the dif-\\nficulty in identifying it. The Centers for Disease Control\\nand Prevention (CDC) has estimated that four to 10 peo-\\nple per 100,000 in the United States have CFS. According\\nto the CFIDS Foundation, about 500,000 adults in the\\nUnited States (0.3% of the population) have CFS. This\\nprobably is a low estimate since these figures do not\\ninclude children and are based on the CDC definition of\\nCFS, which is very strict for research purposes.\\nCauses and symptoms\\nThere is no single known cause for CFS. Studies\\nhave pointed to several different conditions that might be\\nresponsible. These include:\\n• viral infections\\n• chemical toxins\\n• allergies\\n• immune abnormalities\\n• psychological disorders\\nAlthough the cause is still controversial, many doc-\\ntors and researchers now think that CFS may not be a\\nsingle illness. Instead, they think CFS may be a group of\\nsymptoms caused by several conditions. One theory is\\nthat a microorganism, such as a virus, or a chemical\\ninjures the body and damages the immune system, allow-\\ning dormant viruses to become active. About 90% of all\\npeople have a virus in the herpes family dormant (not\\nactively growing or reproducing) in their bodies since\\nchildhood. When these viruses start growing again, the\\nimmune system may overreact and produce chemicals\\ncalled cytokines that can cause flu-like symptoms.\\nImmune abnormalities have been found in studies of\\npeople with CFS, although the same abnormalities are\\nalso found in people with allergies, autoimmune dis-\\neases, cancer, and other disorders.\\nThe role of psychological problems in CFS is very\\ncontroversial. Because many people with CFS are diag-\\nnosed with depression and other psychiatric disorders,\\nsome experts conclude that the symptoms of CFS are\\npsychological. However, many people with CFS did not\\nhave psychological disorders before getting the illness.\\nMany doctors think that patients become depressed or\\nanxious because of the effects of the symptoms of their\\nCFS. One recent study concluded that depression was the\\nresult of CFS and was not its cause.\\nHaving CFS is not just a matter of being tired. Peo-\\nple with CFS have severe fatigue that keeps them from\\nperforming their normal daily activities. They find it dif-\\nficult or impossible to work, attend school, or even to\\ntake part in social activities. They may have sleep distur-\\nbances that keep them from getting enough rest or they\\nmay sleep too much. Many people with CFS feel just as\\ntired after a full night’s sleep as before they went to bed.\\nWhen they exercise or try to be active in spite of their\\nfatigue, people with CFS experience what some patients\\ncall “payback”—debilitating exhaustion that can confine\\nthem to bed for days.\\nOther symptoms of CFS include:\\n• muscle pain (myalgia)\\n• joint pain (arthralgia)\\n• sore throat\\n• headache\\n• fever and chills\\n• tender lymph nodes\\n• trouble concentrating\\n• memory loss\\nA recent study at Johns Hopkins University found an\\nabnormality in blood pressure regulation in 22 of 23\\npatients with CFS. This abnormality, called neurally\\nmediated hypotension , causes a sudden drop in blood\\npressure when a person has been standing, exercising or\\nexposed to heat for a while. When this occurs, patients\\nGALE ENCYCLOPEDIA OF MEDICINE 2802\\nChronic fatigue syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 802'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 191, 'page_label': '192'}, page_content='feel lightheaded and may faint. They often are exhausted\\nfor hours to days after one of these episodes. When treat-\\ned with salt and medications to stabilize blood pressure,\\nmany patients in the study had marked improvements in\\ntheir CFS symptoms.\\nDiagnosis\\nCFS is diagnosed by evaluating symptoms and elim-\\ninating other causes of fatigue. Doctors carefully ques-\\ntion patients about their symptoms, any other illnesses\\nthey have had, and medications they are taking. They\\nalso conduct a physical examination , neurological\\nexamination, and laboratory tests to identify any underly-\\ning disorders or other diseases that cause fatigue. In the\\nUnited States, many doctors use the CDC case definition\\nto determine if a patient has CFS.\\nTo be diagnosed with CFS, patients must meet both\\nof the following criteria:\\n• Unexplained continuing or recurring chronic fatigue for\\nat least six months that is of new or definite onset, is not\\nthe result of ongoing exertion, and is not mainly\\nrelieved by rest, and causes occupational, educational,\\nsocial, or personal activities to be greatly reduced.\\n• Four or more of the following symptoms: loss of short-\\nterm memory or ability to concentrate; sore throat; tender\\nlymph nodes; muscle pain; multi-joint pain without\\nswelling or redness; headaches of a new type, pattern, or\\nseverity; unrefreshing sleep; and post-exertional malaise\\n(a vague feeling of discomfort or tiredness following\\nexercise or other physical or mental activity) lasting more\\nthan 24 hours. These symptoms must have continued or\\nrecurred during six or more consecutive months of illness\\nand must not have started before the fatigue began.\\nTreatment\\nThere is no cure for CFS, but many treatments are\\navailable to help relieve the symptoms. Treatments usual-\\nly are individualized to each person’s particular symp-\\ntoms and needs. The first treatment most doctors recom-\\nmend is a combination of rest, exercise, and a balanced\\ndiet. Prioritizing activities, avoiding overexertion, and\\nresting when needed are key to maintaining existing\\nenergy reserves. A program of moderate exercise helps to\\nkeep patients from losing physical conditioning, but too\\nmuch exercise can worsen fatigue and other CFS symp-\\ntoms. Counseling and stress reduction techniques also\\nmay help some people with CFS.\\nMany medications, nutritional supplements, and herbal\\npreparations have been used to treat CFS. While many of\\nthese are unproven, others seem to provide some people\\nwith relief. People with CFS should discuss their treatment\\nKEY TERMS\\nArthralgia—Joint pain.\\nCytokines—Proteins produced by certain types of\\nlymphocytes. They are important controllers of\\nimmune functions.\\nDepression —A psychological condition, with\\nfeelings of sadness, sleep disturbance, fatigue, and\\ninability to concentrate.\\nEpstein-Barr virus (EBV) —A virus in the herpes\\nfamily that causes mononucleosis.\\nFibromyalgia —A disorder closely related to CFS.\\nSymptoms include pain, tenderness, and muscle\\nstiffness.\\nLymph node —Small immune organs containing\\nlymphocytes. They are found in the neck, armpits,\\ngroin, and other locations in the body.\\nLymphocytes—White blood cells that are respon-\\nsible for the actions of the immune system.\\nMononucleosis —A flu-like illness caused by the\\nEpstein-Barr virus.\\nMyalgia—Muscle pain.\\nMyalgic encephalomyelitis —An older name for\\nchronic fatigue syndrome; encephalomyelitis refers\\nto inflammation of the brain and spinal cord.\\nNatural killer (NK) cell —A lymphocyte that acts\\nas a primary immune defense against infection.\\nNeurally mediated hypotension —A rapid fall in\\nblood pressure that causes dizziness, blurred\\nvision, and fainting, and is often followed by pro-\\nlonged fatigue.\\nNeurasthenia —Nervous exhaustion—a disorder\\nwith symptoms of irritability and weakness, com-\\nmonly diagnosed in the late 1800s.\\nplan with their doctors, and carefully weigh the benefits and\\nrisks of each therapy before making a decision.\\nDrugs\\nNonsteroidal anti-inflammatory drugs (NSAIDs),\\nsuch as ibuprofen and naproxen, may be used to relieve\\npain and reduce fever. Another medication that is pre-\\nscribed to relieve pain and muscle spasms is cyclobenza-\\nprine (sold as Flexeril).\\nMany doctors prescribe low dosages of antidepres-\\nsants for their sedative effects and to relieve symptoms of\\nGALE ENCYCLOPEDIA OF MEDICINE 2 803\\nChronic fatigue syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 803'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 192, 'page_label': '193'}, page_content='depression. Antianxiety drugs , such as benzodi-\\nazepines or buspirone may be prescribed for excessive\\nanxiety that has lasted for at least six months.\\nOther medications that have been tested or are being\\ntested for treatment of CFS are:\\n• Fludrocortisone (Florinef), a synthetic steroid, which is\\ncurrently being tested for treatment of people with\\nCFS. It causes the body to retain salt, thereby increas-\\ning blood pressure. It has helped some people with CFS\\nwho have neurally mediated hypotension.\\n• Beta-adrenergic blocking drugs, often prescribed for high\\nblood pressure. Such drugs, including atenolol (Tenoretic,\\nTenormin) and propranolol (Inderal), are sometimes pre-\\nscribed for neurally mediated hypotension.\\n• Gamma globulin, which contains human antibodies to a\\nvariety of organisms that cause infection. It has been\\nused experimentally to boost immune function in peo-\\nple with CFS.\\n• Ampligen, a drug which stimulates the immune system\\nand has antiviral activity. In one small study, ampligen\\nimproved mental function in people with CFS.\\nAlternative treatment\\nA variety of nutritional supplements are used for\\ntreatment of CFS. Among these are vitamin C, vitamin\\nB\\n12, vitamin A, vitamin E, and various dietary minerals.\\nThese supplements may help improve immune and men-\\ntal functions. Several herbs have been shown to improve\\nimmune function and have other beneficial effects. Some\\nthat are used for CFS are astragalus ( Astragalus mem-\\nbranaceus), echinacea (Echinacea spp.), garlic ( Allium\\nsativum), ginseng (Panax ginseng), gingko (Gingko bilo-\\nba), evening primrose oil ( Oenothera biennis ), shiitake\\nmushroom extract ( Lentinus edodes ), borage seed oil,\\nand quercetin.\\nMany people have enhanced their healing process\\nfor CFS with the use of a treatment program inclusive of\\none or more alternative therapies. Stress reduction tech-\\nniques such as biofeedback, meditation, acupuncture,\\nand yoga may help people with sleep disturbances relax\\nand get more rest. They also help some people reduce\\ndepression and anxiety caused by CFS.\\nPrognosis\\nThe course of CFS varies widely for different peo-\\nple. Some people get progressively worse over time,\\nwhile others gradually improve. Some individuals have\\nperiods of illness that alternate with periods of good\\nhealth. While many people with CFS never fully regain\\ntheir health, they find relief from symptoms and adapt to\\nthe demands of the disorder by carefully following a\\ntreatment plan combining adequate rest, nutrition,e x e r -\\ncise, and other therapies.\\nPrevention\\nBecause the cause of CFS is not known, there current-\\nly are no recommendations for preventing the disorder.\\nResources\\nBOOKS\\nDemitrack, Mark A., and Susan E. Abbey. Chronic Fatigue\\nSyndrome: An Integrative Approach to Evaluation and\\nTreatment. New York: The Guilford Press, 1996.\\nFisher, Gregg Charles. Chronic Fatigue Syndrome: A Compre-\\nhensive Guide to Symptoms, Treatments, and Solving the\\nPractical Problems of CFS. New York: Warner Books,\\n1997.\\nHoffman, Ronald L. Tired All the Time: How to Regain Your\\nLost Energy. New York: Poseidon Press, 1993.\\nJohnson, Hillary. Osler’s Web: Inside the Labyrinth of the\\nChronic Fatigue Syndrome Epidemic. New York: Crown\\nPublishers, 1996.\\nPERIODICALS\\nCannon, J. G., et al. “Interleukin-1 beta, Interleukin-1 Receptor\\nAntagonist, and Soluble Interleukin-1 Receptor Type II\\nSecretion in Chronic Fatigue Syndrome.”Journal of Clin-\\nical Immunology 17 (May 1997): 253-61.\\nHoude, Susan Crocker, and Renee Kampfe-Leacher. “Chronic\\nFatigue Syndrome: An Update for Clinicians in Primary\\nCare.” The Nurse Practitioner 22 (July 1997): 30-40.\\nLerner, A. Martin, et al. “Hypothesis: A Unified Theory of the\\nCause of Chronic Fatigue Syndrome.”Infectious Diseases\\nin Clinical Practice 6 (1997): 239-243.\\n“New Treatment for Chronic Fatigue Syndrome.”Tufts Univer-\\nsity Diet & Nutrition Letter 13 (Feb. 1996): 1-2.\\nWeiss, Rick. “A Cure for Chronic Fatigue? If New Research\\nProves Right, Some Sufferers Have Nothing More than an\\nEasy-to-Fix Blood Pressure Problem.”The Nurse Practi-\\ntioner 22 (July 1997): 30-40.\\nORGANIZATIONS\\nAmerican Association for Chronic Fatigue Syndrome. 7 Van\\nBuren St., Albany, NY 12206. (518) 435-1765. .\\nThe CFIDS Association. Community Health Services, P.O.\\nBox 220398, Charlotte, NC 28222-0398. (704) 362-2343.\\nThe National CFS Association. 919 Scott Ave., Kansas City,\\nKS 66105. (913) 321-2278.\\nThe National CFIDS Foundation. 103 Aletha Road, Needham,\\nMA 02192. (781) 449-3535. .\\nOTHER\\n“The Facts about Chronic Fatigue Syndrome.”Centers for Dis-\\nease Control. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2804\\nChronic fatigue syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 804'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 193, 'page_label': '194'}, page_content='“Chronic Fatigue Syndrome.”National Institutes of Health.\\n.\\nToni Rizzo\\nChronic granulomatous\\ndisease\\nDefinition\\nChronic granulomatous disease (CGD) is an inherit-\\ned disorder in which white blood cells lose their ability to\\ndestroy certain bacteria and fungi.\\nDescription\\nCGD is an X-linked genetic disease, meaning the\\ndefective gene is carried on the X chromosome (one\\nof the sex chromosomes). Females have two copies of\\nthe X chromosome, whereas males have one X and\\none Y . CGD also is a recessive defect meaning that\\nboth copies of the chromosome must have the defect\\nbefore it can be expressed. Females who have one X\\nchromosome without the defect do not get this dis-\\nease. Males, since they only have one X chromosome,\\nget the disease if the defect is present. Thus, CGD\\naffects mostly males.\\nCGD is an immunodeficiency disorder. Patients\\nwith immunodeficiency disorders suffer frequent infec-\\ntions. This happens because part of their immune system\\nisn’t working properly and the infectious microorgan-\\nisms are not killed as rapidly as is normal. In CGD there\\nis a defect in the ability of the white blood cells to kill\\nbacteria and fungi. The white blood cells affected are\\nphagocytic cells. They are part of the non-specific\\nimmune system and move via the blood to all parts of the\\nbody where they ingest and destroy microbes. Phagocyt-\\nic cells are the first line of defense against microorgan-\\nisms. In this disease, the decreased ability to kill\\nmicrobes that they have ingested leads to a failure to\\neffectively combat infectious diseases. Patients with\\nCGD are subject to certain types of recurring infection,\\nespecially those of the skin, lungs, mouth, nose,\\nintestines, and lymph nodes. With the exception of the\\nlymph nodes, all of these areas are considered external\\ntissues that come into contact with microorganisms from\\nthe environment. The lymph system drains all areas of\\nthe body to eliminate destroyed microorganisms and to\\nassist the immune system in attacking microorganisms.\\nInfections occur in the lymph nodes as a consequence of\\nthe normal draining function.\\nKEY TERMS\\nImmunodeficiency —A weakening of the body’s\\nimmune system.\\nPhagocytic cells —A cell that ingests microorgan-\\nisms and foreign particles.\\nCauses and symptoms\\nThe genetic defect that causes CGD reduces the\\namount of hydrogen peroxide and superoxide that white\\nblood cells can make. These chemicals are important for\\nkilling bacteria and fungi. Without them the white blood\\ncells ingest the microorganisms, but can’t kill them. In\\nsome cases, the microbes then replicate inside the white\\nblood cell eventually causing its death.\\nSymptoms of the disease usually appear by age two.\\nFrequent, recurrent infections of the skin, lungs (e.g.\\npneumonia), mouth (e.g. gingivitis), nose, intestines and\\nlymph nodes are a hallmark of this disease. Patients may\\nalso develop multiple, recurrent liver abscesses and bone\\ninfections (osteomyelitis).\\nDiagnosis\\nDiagnosis is made based on the observation of a pat-\\ntern of recurrent infections. Blood tests of lymphocyte\\nand antibody functions will be normal. Tests of phago-\\ncytic cells will show normal ingestion, but a greatly\\ndecreased ability to kill bacteria.\\nTreatment\\nEarly, aggressive treatment of all infections is criti-\\ncal to the successful management of CGD. Patients are\\ntreated with antibiotics and immune serum. Antibiotics\\nare used at the first sign of infection. Immune serum is a\\nsource of antibodies that help fight infections. Interferon\\ngamma is an experimental treatment for CGD that has\\nshown promising results. There is no cure for the under-\\nlying cause of chronic granulomatous disease\\nPrognosis\\nAlthough antibiotics can treat most infections and\\nmay help prevent others, premature death may result,\\ntypically due to repeated lung infections.\\nPrevention\\nSince CGD is a hereditary disorder, it cannot cur-\\nrently be prevented. Patients and their families may ben-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 805\\nChronic granulomatous disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 805'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 194, 'page_label': '195'}, page_content='efit from genetic counseling . Preventive (prophylactic)\\nantibiotics may help keep some infections from occur-\\nring, and good hygiene, especially rigorous skin and\\nmouth care, can help prevent infections in these areas.\\nAvoiding crowds or other people who have infections are\\nalso effective preventive measures.\\nResources\\nBOOKS\\nAbbas, Abul K., Andrew H. Lichtman, and Jordan S. Pober.\\nCellular and Molecular Immunology. 3rd ed. Philadel-\\nphia. W. B. Saunders Co., 1997.\\nProfessional Guide to Diseases. 5th ed. Springhouse, PA:\\nSpringhouse Corporation, 1995.\\nORGANIZATIONS\\nChronic Granulomatous Disease Association. 2616 Monterey\\nRoad, San Marino, CA 91108-1646. (818) 441-4118.\\nNational Organization for Rare Disorders. P.O. Box 8923, New\\nFairfield, CT 06812-8923. (800) 999-6673. .\\nJohn T. Lohr, PhD\\nChronic kidney failure\\nDefinition\\nChronic kidney failure occurs when disease or disor-\\nder damages the kidneys so that they are no longer capa-\\nble of adequately removing fluids and wastes from the\\nbody or of maintaining the proper level of certain kidney-\\nregulated chemicals in the bloodstream.\\nDescription\\nChronic kidney failure, also known as chronic renal\\nfailure, affects over 250,000 Americans annually. It is\\ncaused by a number of diseases and inherited disorders,\\nbut the progression of chronic kidney failure is always the\\nsame. The kidneys, which serve as the body’s natural fil-\\ntration system, gradually lose their ability to remove flu-\\nids and waste products (urea) from the bloodstream. They\\nalso fail to regulate certain chemicals in the bloodstream,\\nand deposit protein into the urine. Chronic kidney failure\\nis irreversible, and will eventually lead to total kidney\\nfailure, also known as end-stage renal disease (ESRD).\\nWithout proper treatment intervention to remove wastes\\nand fluids from the bloodstream, ESRD is fatal.\\nCauses and symptoms\\nKidney failure is triggered by disease or a hereditary\\ndisorder in the kidneys. Both kidneys are typically affect-\\ned. The four most common causes of chronic kidney fail-\\nure include:\\n• Diabetes. Diabetes mellitus (DM), both insulin depen-\\ndant (IDDM) and non-insulin dependant (NIDDM),\\noccurs when the body cannot produce and/or use\\ninsulin, the hormone necessary for the body to process\\nglucose. Long-term diabetes may cause the glomeruli,\\nthe filtering units located in the nephrons of the kid-\\nneys, to gradually lose functioning.\\n• Glomerulonephritis . Glomerulonephritis is a chronic\\ninflammation of the glomeruli, or filtering units of the\\nkidney. Certain types of glomerulonephritis are treat-\\nable, and may only cause a temporary disruption of kid-\\nney functioning.\\n• Hypertension. High blood pressure is unique in that it\\nis both a cause and a major symptom of kidney failure.\\nThe kidneys can become stressed and ultimately sustain\\npermanent damage from blood pushing through them at\\nan excessive level of pressure over a long period of time.\\n• Polycystic kidney disease. Polycystic kidney disease is\\nan inherited disorder that causes cysts to be formed on\\nthe nephrons, or functioning units, of the kidneys. The\\ncysts hamper the regular functioning of the kidney.\\nOther possible causes of chronic kidney failure\\ninclude kidney cancer , obstructions such as kidney\\nstones, pyelonephritis , reflux nephropathy, systemic\\nlupus erythematosus , amyloidosis , sickle cell anemia,\\nAlport syndrome, and oxalosis.\\nInitially, symptoms of chronic kidney failure devel-\\nop slowly. Even individuals with mild to moderate kid-\\nney failure may show few symptoms in spite of increased\\nurea in their blood. Among the symptoms that may be\\npresent at this point are frequent urination during the\\nnight and high blood pressure.\\nMost symptoms of chronic kidney failure are not\\napparent until kidney disease has progressed significant-\\nly. Common symptoms include:\\n• Anemia. The kidneys are responsible for the production\\nof erythropoietin (EPO), a hormone which stimulates red\\nblood cell production. If kidney disease causes shrinking\\nof the kidney, this red cell production is hampered.\\n• Bad breath or a bad taste in mouth. Urea, or waste prod-\\nucts, in the saliva may cause an ammonia-like taste in\\nthe mouth.\\n• Bone and joint problems. The kidneys produce vitamin\\nD, which aids in the absorption of calcium and keeps\\nbones strong. For patients with kidney failure, bones\\nmay become brittle, and in the case of children, normal\\ngrowth may be stunted. Joint pain may also occur as a\\nresult of unchecked phosphate levels in the blood.\\nGALE ENCYCLOPEDIA OF MEDICINE 2806\\nChronic kidney failure\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 806'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 195, 'page_label': '196'}, page_content='• Edema. Puffiness or swelling around the eyes, arms,\\nhands, and feet.\\n• Frequent urination.\\n• Foamy or bloody urine. Protein in the urine may cause\\nit to foam significantly. Blood in the urine may indicate\\nbleeding from diseased or obstructed kidneys, bladder,\\nor ureters.\\n• Headaches. High blood pressure may trigger headaches.\\n• Hypertension, or high blood pressure. The retention of\\nfluids and wastes causes blood volume to increase,\\nwhich in turn, causes blood pressure to rise.\\n• Increased fatigue. Toxic substances in the blood and the\\npresence of anemia may cause feelings of exhaustion.\\n• Itching . Phosphorus, which is typically eliminated in\\nthe urine, accumulates in the blood of patients with kid-\\nney failure. This heightened phosphorus level may\\ncause itching of the skin.\\n• Lower back pain. Pain where the kidneys are located, in\\nthe small of the back below the ribs.\\n• Nausea, loss of appetite, and vomiting. Urea in the gas-\\ntric juices may cause upset stomach. This can lead to\\nmalnutrition and weight loss.\\nDiagnosis\\nKidney failure is typically diagnosed and treated by a\\nnephrologist, a doctor that specializes in treating the kid-\\nneys. The patient that is suspected of having chronic kid-\\nney failure will undergo an extensive blood work-up. A\\nblood test will assess the levels of creatinine, blood urea\\nnitrogen (BUN), uric acid, phosphate, sodium, and potas-\\nsium in the blood. Urine samples will also be collected,\\nusually over a 24-hour period, to assess protein loss.\\nUncovering the cause of kidney failure is critical to\\nproper treatment. A full assessment of the kidneys is nec-\\nessary to determine if the underlying disease is treatable\\nand if the kidney failure is chronic or acute. An x ray,\\nMRI, computed tomography scan, ultrasound, renal\\nbiopsy, and/or arteriogram of the kidneys may be\\nemployed to determine the cause of kidney failure and\\nlevel of remaining kidney function. X rays and ultra-\\nsound of the bladder and/or ureters may also be taken.\\nTreatment\\nChronic kidney failure is an irreversible condition.\\nHemodialysis, peritoneal dialysis, or kidney transplan-\\ntation must be employed to replace the lost function of\\nthe kidneys. In addition, dietary changes and treatment to\\nrelieve specific symptoms such as anemia and high blood\\npressure are critical to the treatment process.\\nKEY TERMS\\nEnd-stage renal disease (ESRD)—Total kidney fail-\\nure; chronic kidney failure is diagnosed as ESRD\\nwhen kidney function falls to 5–10% of capacity.\\nNephrotic syndrome —Characterized by protein\\nloss in the urine, low protein levels in the blood,\\nand fluid retention.\\nUreters—The two ducts that pass urine from each\\nkidney to the bladder.\\nHemodialysis\\nHemodialysis is the most frequently prescribed type\\nof dialysis treatment in the United States. Most\\nhemodialysis patients require treatment three times a\\nweek, for an average of three to four hours per dialysis\\n“run” depending on the type of dialyzer used and their\\ncurrent physical condition. The treatment involves circu-\\nlating the patient’s blood outside of the body through an\\nextracorporeal circuit (ECC), or dialysis circuit. The\\ndialysis circuit consists of plastic blood tubing, a two-\\ncompartment filter known as a dialyzer, or artificial kid-\\nney, and a dialysis machine that monitors and maintains\\nblood flow and administers dialysate, a chemical bath\\nused to draw waste products out of the blood. The\\npatient’s blood leaves and enters the body through two\\nneedles inserted into the patient’s vein, called an access\\nsite, and is pushed through the blood compartment of the\\ndialyzer. Once inside of the dialyzer, excess fluids and\\ntoxins are pulled out of the bloodstream and into the\\ndialysate compartment, where they are carried out of the\\nbody. At the same time, electrolytes and other chemicals\\nin the dialysate solution move from the dialysate into the\\nbloodstream. The purified, chemically-balanced blood is\\nthen returned to the body.\\nPeritoneal dialysis\\nIn peritoneal dialysis (PD), the patient’s peritoneum,\\nor lining of the abdomen, acts as a blood filter. A catheter\\nis surgically inserted into the patient’s abdomen. During\\ntreatment, the catheter is used to fill the abdominal cavity\\nwith dialysate. Waste products and excess fluids move\\nfrom the patient’s bloodstream into the dialysate solu-\\ntion. After a waiting period of six to 24 hours, depending\\non the treatment method used, the waste-filled dialysate\\nis drained from the abdomen, and replaced with clean\\ndialysate. There are three types of peritoneal dialysis,\\nwhich vary by treatment time and administration\\nmethod: Continuous Ambulatory Peritoneal Dialysis\\nGALE ENCYCLOPEDIA OF MEDICINE 2 807\\nChronic kidney failure\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 807'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 196, 'page_label': '197'}, page_content='(CAPD), Continuous Cyclic Peritoneal Dialysis (CCPD),\\nand Intermittent Peritoneal Dialysis (IPD).\\nKidney transplantation\\nKidney transplantation involves surgically attaching\\na functioning kidney, or graft, from a brain dead organ\\ndonor (a cadaver transplant), or from a living donor, to a\\npatient with ESRD. Patients with chronic renal disease\\nwho need a transplant and don’t have a living donor reg-\\nister with UNOS (United Network for Organ Sharing),\\nthe federal organ procurement agency, to be placed on a\\nwaiting list for a cadaver kidney transplant. Kidney avail-\\nability is based on the patient’s health status. When the\\nnew kidney is transplanted, the patient’s existing, dis-\\neased kidneys may or may not be removed, depending on\\nthe circumstances surrounding the kidney failure. A regi-\\nmen of immunosuppressive, or anti-rejection medication,\\nis required after transplantation surgery.\\nDietary management\\nA diet low in sodium, potassium, and phosphorous,\\nthree substances that the kidneys regulate, is critical in\\nmanaging kidney disease. Other dietary restrictions, such\\nas a reduction in protein, may be prescribed depending\\non the cause of kidney failure and the type of dialysis\\ntreatment employed. Patients with chronic kidney failure\\nalso need to limit their fluid intake.\\nMedications and dietary supplements\\nKidney failure patients with hypertension typically\\ntake medication to control their high blood pressure.\\nEpoetin alfa, or EPO (Epogen), a hormone therapy, and\\nintravenous or oral iron supplements are used to manage\\nanemia. A multivitamin may be prescribed to replace vit-\\namins lost during dialysis treatments. Vitamin D, which\\npromotes the absorption of calcium, along with calcium\\nsupplements, may also be prescribed.\\nSince 1973, Medicare has picked up 80% of ESRD\\ntreatment costs, including the costs of dialysis and trans-\\nplantation and of some medications. To qualify for bene-\\nfits, a patient must be insured or eligible for benefits\\nunder Social Security, or be a spouse or child of an eligi-\\nble American. Private insurance and state Medicaid pro-\\ngrams often cover the remaining 20% of treatment costs.\\nPrognosis\\nEarly diagnosis and treatment of kidney failure is criti-\\ncal to improving length and quality of life in chronic kidney\\nfailure patients. Patient outcome varies by the cause of\\nchronic kidney failure and the method chosen to treat it.\\nOverall, patients with chronic kidney disease leading to\\nESRD have a shortened lifespan. According to the United\\nStates Renal Data System (USRDS), the lifespan of an\\nESRD patient is 18–47% of the lifespan of the age-sex-race\\nmatched general population. ESRD patients on dialysis\\nhave a lifespan that is 16–37% of the general population.\\nThe demand for kidneys to transplant continues to\\nexceed supply. In 1996, over 34,000 Americans were on\\nthe UNOS waiting list for a kidney transplant, but only\\n11,330 living donor and cadaver transplants were actual-\\nly performed. Cadaver kidney transplants have a 50%\\nchance of functioning nine years, and living donor kid-\\nneys that have two matching antigen pairs have a 50%\\nchance of functioning for 24 years. However, some trans-\\nplant grafts have functioned for over 30 years.\\nResources\\nBOOKS\\nBock, G. H., E. J. Ruley, and M. P. Moore. A Parent’s Guide to\\nKidney Disorders. Minneapolis: University of Minnesota\\nPress, 1993.\\nBrenner, Barry M., and Floyd C. Rector Jr., eds. The Kidney.\\nPhiladelphia: W. B. Saunders Co., 1991.\\nCameron, J. S. Kidney Failure: The Facts.New York: Oxford\\nUniv. Press, 1996.\\nRoss, Linda M., ed. Kidney and Urinary Tract Diseases and\\nDisorders Sourcebook.V ol. 21. Health Reference Series.\\nDetroit: Omnigraphics, 1997.\\nU.S. Renal Data System. USRDS 1997 Annual Data Report.\\nBethesda, MD: The National Institutes of Health, National\\nInstitute of Diabetes and Digestive and Kidney Diseases,\\n1996.\\nPERIODICALS\\nFriedman, Elia A. “End-stage Renal Disease Therapy: An\\nAmerican Success Story.”Journal of the American Med-\\nical Association 275 (Apr. 1996): 1118-22.\\nTaylor, Judy H. “End-stage Renal Disease in Children: Diagno-\\nsis, Management, and Interventions.”Pediatric Nursing\\n22 (Nov./Dec. 1996): 481-92.\\nORGANIZATIONS\\nAmerican Association of Kidney Patients (AAKP). 100 S. Ash-\\nley Drive, Suite 280, Tampa, FL 33602. (800) 749-2257.\\n.\\nAmerican Kidney Fund (AKF). Suite 1010, 6110 Executive\\nBoulevard, Rockville, MD 20852. (800) 638-8299.\\n.\\nNational Institute of Diabetes and Digestive and Kidney Dis-\\neases (NIDDK). Building 31, Room 9A04, 31 Center\\nDrive, MSC 2560, Bethesda, MD 208792-2560. (301)\\n496-3583. .\\nNational Kidney Foundation. 30 East 33rd St., New York, NY\\n10016. (800) 622-9010. .\\nUnited States Renal Data System (USRDS). The University of\\nMichigan, 315 W. Huron, Suite 240, Ann Arbor, MI 48103.\\n(734) 998-6611. .\\nPaula Anne Ford-Martin\\nGALE ENCYCLOPEDIA OF MEDICINE 2808\\nChronic kidney failure\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 808'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 197, 'page_label': '198'}, page_content='Chronic leukemias see Leukemias, chronic\\nChronic obstructive lung\\ndisease\\nDefinition\\nChronic obstructive lung disease, also known as\\nchronic obstructive pulmonary disease (COPD), is a gen-\\neral term for a group of conditions in which there is per-\\nsistent difficulty in expelling (or exhaling) air from the\\nlungs. COPD commonly refers to two related, progres-\\nsive diseases of the respiratory system, chronic bronchi-\\ntis and emphysema . Because smoking is the major\\ncause of both diseases, chronic bronchitis and emphyse-\\nma often occur together in the same patient.\\nDescription\\nCOPD is one of the fastest-growing health prob-\\nlems. Nearly 16 million people in the United States, 14\\nmillion with chronic bronchitis and two million with\\nemphysema, suffer from COPD. COPD is responsible\\nfor more than 96,000 deaths annually, making it the\\nfourth leading cause of death. Although COPD is more\\ncommon in men than women, the increase in incidence\\nof smoking among women since World War II has pro-\\nduced an increase in deaths from COPD in women.\\nCOPD has a large economic impact on the healthcare\\nsystem and a destructive impact on the lives of patients\\nand their families. Quality of life for a person with\\nCOPD decreases as the disease progresses.\\nChronic bronchitis\\nIn chronic bronchitis, chronic inflammation caused\\nby cigarette smoking results in a narrowing of the open-\\nings in the bronchi, the large air tubes of the respiratory\\nsystem, and interferes with the flow of air. Inflammation\\nalso causes the glands that line the bronchi to produce\\nexcessive amounts of mucus, further narrowing the air-\\nways and blocking airflow. The result is often a chronic\\ncough that produces sputum (mainly mucus) and short-\\nness of breath . Cigarette smoke also damages the cilia,\\nsmall hair-like projections that move bacteria and foreign\\nparticles out of the lungs, increasing the risk of infections.\\nEmphysema\\nEmphysema is a disease in which cigarette smoke\\ncauses an overproduction of the enzyme elastase, one of\\nthe immune system’s infection-fighting biochemicals.\\nThis results in irreversible destruction of a protein in the\\nlung called elastin which is important for maintaining the\\nstructure of the walls of the alveoli, the terminal small air\\nsacs of the respiratory system. As the walls of the alveoli\\nrupture, the number of alveoli is reduced and many of\\nthose remaining are enlarged, making the lungs of the\\npatient with emphysema less elastic and overinflated.\\nDue to the higher pressure inside the chest that must be\\ndeveloped to force air out of the less-elastic lungs, the\\nbronchioles, small air tubes of the respiratory system,\\ntend to collapse during exhalation. Stale air gets trapped\\nin the air sacs and fresh air cannot be brought in.\\nCauses and symptoms\\nThere are several important risk factors for COPD:\\n• Lifestyle. Cigarette smoking is by far the most important\\nrisk factor for COPD (80% of all cases). Cigar and pipe\\nsmoking can also cause COPD. Air pollution and indus-\\ntrial dusts and fumes are other important risk factors.\\n• Age. Chronic bronchitis is more common in people\\nover 40 years old; emphysema occurs more often in\\npeople 65 years of age and older.\\n• Socioeconomic class. COPD-related deaths are about\\ntwice as high among unskilled and semi-skilled labor-\\ners as among professionals.\\n• Family clustering. It is thought that heredity predispos-\\nes people in certain families to the development of\\nCOPD when other causes, such as smoking and air pol-\\nlution, are present.\\n• Lung infections. Lung infections make all forms of\\nCOPD worse.\\nIn the general population, emphysema usually devel-\\nops in older individuals with a long smoking history. How-\\never, there is also a form of emphysema that runs in fami-\\nlies. People with this type of emphysema have a hereditary\\ndeficiency of a blood component, an enzyme inhibitor\\ncalled alpha-1-antitrypsin (AAT). This type of emphysema\\nis sometimes called “early onset emphysema” because it\\ncan appear when a person is as young as 30 or 40 years\\nold. It is estimated that there are between 75,000 and\\n150,000 Americans who were born with AAT-deficiency.\\nOf this group, emphysema afflicts an estimated 20,000-\\n40,000 people (1–3% of all cases of emphysema). The risk\\nof developing emphysema for an AAT-deficient individual\\nwho also smokes is much greater than for others.\\nThe first symptoms of chronic bronchitis are cough\\nand mucus production. These symptoms resemble a chest\\ncold that lingers on for weeks. Later, shortness of breath\\ndevelops. Cough, sputum production, and shortness of\\nbreath may become worse if a person develops a lung\\ninfection. A person with chronic bronchitis may later\\nGALE ENCYCLOPEDIA OF MEDICINE 2 809\\nChronic obstructive lung disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 809'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 198, 'page_label': '199'}, page_content='develop emphysema as well. In emphysema, shortness of\\nbreath on exertion is the predominant early symptom.\\nCoughing is usually minor and there is little sputum. As\\nthe disease progresses, the shortness of breath occurs\\nwith less exertion, and eventually may be present even\\nwhen at rest. At this point, a sputum-producing cough\\nmay also occur. Either chronic bronchitis or emphysema\\nmay lead to respiratory failure—a condition in which\\nthere occurs a dangerously low level of oxygen or a seri-\\nous excess of carbon dioxide in the blood.\\nDiagnosis\\nThe first step in diagnosing COPD is a good medical\\nevaluation, including a medical history and a physical\\nexamination of the chest using a stethoscope. In addition,\\nthe doctor may request one or more of the following tests:\\nPulmonary function test\\nUsing a spirometer, an instrument that measures the air\\ntaken into and exhaled from the lungs, the doctor will deter-\\nmine two important values: (1) vital capacity (VC), the largest\\namount of air expelled after the deepest inhalation, and (2)\\nforced expiratory volume (FEV1), the maximum amount of\\nair expired in one second. The pulmonary function testcan\\nbe performed in the doctor’s office, but is expensive.\\nChest x ray\\nChest x rays can detect only about half of the cases of\\nemphysema. Chest x rays are rarely useful for diagnosing\\nchronic bronchitis.\\nBlood gas levels\\nBlood may be drawn from an artery (more painful\\nthan drawing blood from a vein) to determine the amount\\nof oxygen and carbon dioxide present. Low oxygen and\\nhigh carbon dioxide levels are often indicative of chronic\\nbronchitis, but not always of emphysema.\\nTests for cause of infection\\nIf infection is present, blood and sputum tests may\\nbe done to determine the cause of infection.\\nElectrocardiogram (ECG)\\nMany patients with lung disease also develop heart\\nproblems. The ECG identifies signs of heart disease.\\nTreatment\\nThe precise nature of the patient’s condition will\\ndetermine the type of treatment prescribed for COPD.\\nWith a program of complete respiratory care, disability\\ncan be minimized, acute episodes prevented, hospitaliza-\\ntions reduced, and some early deaths avoided. On the\\nother hand, no treatment has been shown to slow the\\nprogress of the disease, and only oxygen therapy increas-\\nes survival rate.\\nDrugs\\nMedications frequently prescribed for COPD\\npatients include:\\nGALE ENCYCLOPEDIA OF MEDICINE 2810\\nChronic obstructive lung disease\\nA\\nB\\nC\\nD\\nA. lung cancer. B. pneumonia. C. emphysema. D. phlegm from chronic bronchitis.(Illustration by Argosy, Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 810'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 199, 'page_label': '200'}, page_content='• Bronchodilators. These agents open narrowed airways\\nand offer significant symptomatic relief for many, but\\nnot all, people with COPD. There are three types of\\nbronchodilators: Beta2 agonists, anticholinergic agents,\\nand theophylline and its derivatives. Depending on the\\nspecific drug, a bronchodilator may be inhaled, inject-\\ned, or taken orally.\\n• Corticosteroids . Corticosteroids, usually inhaled,\\nblock inflammation and are most useful for patients\\nwith chronic bronchitis with or without emphysema.\\nSteroids are generally not useful in patients who have\\nemphysema.\\n• Oxygen replacement. Eventually, patients with low\\nblood oxygen levels may need to rely on supplemental\\noxygen from portable or stationary tanks.\\n• Antibiotics. Antibiotics are frequently given at the first\\nsign of a respiratory infection, such as increased spu-\\ntum production or a change in color of sputum from\\nclear to yellow or green.\\n• Vaccines. To prevent pulmonary infection from viruses\\nand bacteria, people with COPD should be vaccinated\\nagainst influenza each year at least six weeks before\\nflu season and have a one-time pneumococcal ( pneu-\\nmonia) vaccine.\\n• Expectorants. These agents help loosen and expel\\nmucus secretions from the airways.\\n• Diuretics. These drugs are given to prevent excess\\nwater retention in patients with associated right heart\\nfailure.\\n• Augmentation therapy (for emphysema due to AAT-\\ndeficiency only). Replacement AAT (Prolastin), derived\\nfrom human blood which has been screened for viruses,\\nis injected weekly or bimonthly for life.\\nSurgery\\nSurgical procedures for emphysema are very rare.\\nThey are expensive and often not covered by insurance.\\nThe great majority of patients cannot be helped by\\nsurgery, and no single procedure is ideal for those who\\ncan be helped. In January of 1996, the government tem-\\nporarily suspended Medicare payments for lung reduc-\\ntion surgery.\\n• Lung transplantation . Lung transplantation has been\\nsuccessfully employed in some patients with end-stage\\nCOPD. In the hands of an experienced team, the one-\\nyear survival rate is over 70%.\\n• Lung volume reduction. These procedures remove\\n20–30% of severely diseased lung tissue; the remaining\\nparts of the lung are joined together. Mortality rates can\\nbe as high as 15% and complication rates are even\\nKEY TERMS\\nAlpha-1-antitrypsin (AAT) —A blood component\\nthat breaks down infection-fighting enzymes such\\nas elastase.\\nAlveoli—Terminal air sacs of the respiratory sys-\\ntem, where gas (oxygen and carbon dioxide)\\nexchange occurs.\\nBronchi—Large air tubes of the respiratory system.\\nBronchioles —Small air tubes of the respiratory\\nsystem.\\nBronchodilators —Drugs that open wider the\\nbronchial tubes of the respiratory system.\\nCorticosteroids —A group of hormones that are\\nused as drugs to block inflammation.\\nForced expiratory volume (FEV1)—The maximum\\namount of air expired in one second.\\nSpirometer —An instrument used by a doctor to\\nperform a breathing test.\\nVital capacity (VC) —The largest amount of air\\nexpelled after one’s deepest inhalation.\\nhigher. When the operation is successful, patients\\nreport significant improvement in symptoms.\\nPulmonary rehabilitation\\nA structured, outpatient pulmonary rehabilitation\\nprogram improves functional capacity in certain patients\\nwith COPD. Services may include general exercise train-\\ning, administration of oxygen and nutritional supplements,\\nintermittent mechanical ventilatory support, continuous\\npositive airway pressure, relaxation techniques, breathing\\nexercises and techniques (such as pursed lip breathing),\\nand methods for mobilizing and removing secretions.\\nAlternative treatment\\nFor both chronic bronchitis and emphysema, alter-\\nnative practitioners recommend diet and nutritional sup-\\nplements, a variety of herbal medicines, hydrotherapy,\\nacupressure and acupuncture , aromatherapy , home-\\nopathy, and yoga.\\nPrognosis\\nCOPD is a disease that can be treated and controlled,\\nbut not cured. Survival of patients with COPD is clearly\\nrelated to the degree of their lung function when they are\\nGALE ENCYCLOPEDIA OF MEDICINE 2 811\\nChronic obstructive lung disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 811'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 200, 'page_label': '201'}, page_content='diagnosed and the rate at which they lose this function.\\nOverall, the median survival is about 10 years for\\npatients with COPD who have lost approximately two-\\nthirds of their lung function at diagnosis.\\nPrevention\\nLifestyle modifications that can help prevent COPD,\\nor improve function in COPD patients, include: quitting\\nsmoking, avoiding respiratory irritants and infections,\\navoiding allergens, maintaining good nutrition, drinking\\nlots of fluids, avoiding excessively low or high tempera-\\ntures and very high altitudes, maintaining proper weight,\\nand exercising to increase muscle tone.\\nResources\\nBOOKS\\nThe Burton Goldberg Group. Alternative Medicine: The Defin-\\nitive Guide. Fife, W A: Future Medicine Publishing, 1995.\\nHonig, Eric G., and Ronald H. Ingram Jr. “Chronic Bronchitis,\\nEmphysema, and Airways Obstruction.” In Harrison’s\\nPrinciples of Internal Medicine, ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1997.\\nRies, Andrew L., et al. Shortness of Breath. St. Louis: Mosby,\\n1996.\\nPERIODICALS\\nCelli, Bartolome, et al. “The Challenge of COPD: Therapeutic\\nStrategies That Work.”Patient Care31 (15 Mar. 1997):\\n101-118.\\nCordova, Francis C., and Gerard J. Griner. “Management of\\nAdvanced Chronic Obstructive Pulmonary Disease.”\\nComprehensive Therapy 23, no. 6: 413-424.\\nLefrak, Stephen S., et al. “Recent Advances in Surgery for\\nEmphysema.” Annual Review of Medicine 48: 387-398.\\nPetty, Thomas L., and Gail G. Weinmann. “Building a National\\nStrategy for the Prevention and Management of and\\nResearch in Chronic Obstructive Pulmonary Disease.”\\nJournal of the American Medical Association277 (15 Jan.\\n1997): 246-253.\\nORGANIZATIONS\\nAmerican Association for Respiratory Care. 11030 Ables Lane,\\nDallas, TX 75229. (214) 243-2272. .\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Jewish Medical and Research Center. 1400 Jackson\\nSt., Denver, CO 80206. (800) 222-LUNG (Lung Line).\\n.\\nHarry W. Golden\\nChronic obstructive pulmonary disease see\\nEmphysema; Chronic obstructive lung\\ndisease\\nChurg-Strauss syndrome see Vasculitis\\nCingulotomy see Psychosurgery\\nCiprofloxacin see Fluoroquinolones\\nCircadian rhythm sleep disorders see Jet lag\\nCircumcision\\nDefinition\\nThe surgical removal of the foreskin of the penis or\\nprepuce.\\nPurpose\\nIn the United States, circumcision in infant boys is\\nperformed for social, medical, or cultural/religious rea-\\nsons. Once a routine operation urged by pediatricians\\nand obstetricians for newborns in the middle of the twen-\\ntieth century, circumcision has become an elective option\\nthat parents make for their sons on an individual basis.\\nFamilies who practice Judaism or Islam may select to\\nhave their sons circumcised as a religious practice. Oth-\\ners choose circumcision for medical benefits.\\nFemale circumcision (also known as female genital\\nmutilation) is usually performed for cultural and social\\nreasons by family members and others who are not mem-\\nbers of the medical profession, with no anesthesia. Not\\nonly is the prepuce removed but often the vaginal open-\\ning is sewn to make it smaller. This practice is supposed\\nto ensure the virginity of a bride on her wedding day. It\\nalso prevents the woman from achieving sexual pleasure\\nduring coitus. This practice is not universally approved\\nby the medical profession and is considered by some as a\\nhuman rights violation.\\nThough the incidence of male circumcision has\\ndecreased from 90% in 1979 to 60% in 1996, it is still the\\nmost common surgical operation in the United States.\\nCircumcision rates are much lower for the rest of the\\nindustrialized world. In Britain, it is only done for reli-\\ngious practices or to correct a specific medical condition\\nof the penis.\\nSome of the medical reasons parents choose cir-\\ncumcision are to protect against infections of the uri-\\nnary tract and the foreskin, prevent cancer , lower the\\nrisk of getting sexually transmitted diseases , and pre-\\nvent phimosis (a tightening of the foreskin that may\\nclose the opening of the penis). Though studies indi-\\ncate that uncircumcised boys under the age of five are\\n20 times more likely than circumcised boys to have\\nGALE ENCYCLOPEDIA OF MEDICINE 2812\\nCircumcision\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 812'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 201, 'page_label': '202'}, page_content='urinary tract infections (UTIs), the rate of incidence of\\nUTIs is quite low. There are also indications that cir-\\ncumcised men are less likely to suffer from penile can-\\ncer, inflammation of the penis, or have many sexually\\ntransmitted diseases. Here again, the rate of incidence\\nis low. Good hygiene usually prevents most infections\\nof the penis. Phimosis and penile cancer are very rare,\\neven in men who have not been circumcised. Education\\nand good safe sex practices can prevent sexually trans-\\nmitted diseases in ways that a surgical procedure can-\\nnot because these are diseases acquired through risky\\nbehaviors.\\nWith these factors in mind, the American Academy\\nof Pediatrics has issued a policy statement that states\\nthough there is existing scientific evidence that indicates\\nthe medical benefits of circumcision, the benefits aren’t\\nKEY TERMS\\nForeskin—A covering fold of skin over the tip of\\nthe penis.\\nGlans—The cone-shaped tip of the penis.\\nHernia—Bulging of abdominal structures through\\nan abnormal opening in the muscular wall.\\nHydrocele—Collection of fluid in the scrotum.\\nHypospadias—A congenital deformity of the penis\\nwhere the urinary tract opening is not at the tip of\\nthe glans.\\nPhimosis —A tightening of the foreskin that may\\nclose the opening of the penis.\\nPrepuce—A fold like the foreskin that covers the\\nclitoris; another name for foreskin.\\nstrong enough to recommended circumcision as a routine\\npractice.\\nPrecautions\\nCircumcision should not be performed on infants\\nwith certain deformities of the penis that may require a\\nportion of the foreskin for repair. The most common con-\\ndition for surgery using the foreskin is hypospadias, a\\ncongenital deformity of the penis where the urinary tract\\nopening is not at the tip of the glans. Also, infants with a\\nlarge hydrocoele or hernia may suffer important compli-\\ncations through circumcision. Premature infants and\\ninfants with serious infections are also poor candidates to\\nbe circumcised, as are infants with hemophilia , other\\nbleeding disorders, or whose mothers had taken anticoag-\\nulant drugs. In older boys or men, circumcision is a minor\\nprocedure. Therefore, it can be performed in virtually\\nanyone without a serious illness or unusual deformity.\\nDescription\\nThe foreskin of the penis protects the sensitivity of\\nthe glans and shields it from irritation by urine, feces,\\nand foreign materials. It also protects the urinary opening\\nagainst infection and incidental injury.\\nIn circumcision of infants, the foreskin is pulled\\ntightly into a specially designed clamp, and the foreskin\\npulls away from the broadened tip of the penis. Pressure\\nfrom the clamp stops bleeding from blood vessels that\\nsupplied the foreskin. In older boys or adults, an incision\\nis made around the base of the foreskin, the foreskin is\\nGALE ENCYCLOPEDIA OF MEDICINE 2 813\\nCircumcision\\nFigure A Figure B\\nFigure C Figure D\\nA typical circumcision procedure involves the following\\nsteps: Figure A:The surgeon makes an incision around the\\nforeskin. Figure B:The foreskin is then freed from the skin\\ncovering the penile shaft. Figure C:The surgeon cuts the\\nforeskin to the initial incision, lifting the foreskin from the\\nmucous membrane. Figure D:The surgeon sutures the top\\nedge of the skin that covers the penile shaft and the mucous\\nmembrane. (Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 813'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 202, 'page_label': '203'}, page_content='pulled back, and then it is cut away from the tip of the\\npenis. Stitches are usually used to close the skin edges.\\nPreparation\\nDespite a long-standing belief that infants do not\\nexperience serious pain from circumcision, most author-\\nities now believe that some form of local anesthesia is\\nnecessary. The physician injects local anesthesia at the\\nbase of the penis or under the skin around the penis (sub-\\ncutaneous ring block). Both anesthetics block key\\nnerves. EMLA cream, a topical formula of several anes-\\nthetics can also be used.\\nAftercare\\nAfter circumcision, the wound should be washed\\ndaily. An antibiotic ointment or petroleum jelly may be\\napplied to the site. If there is an incision, a wound dress-\\ning will be present and should be changed each time the\\ndiaper is changed. Sometimes a plastic ring is used\\ninstead of a bandage. The ring will usually fall off in five\\nto eight days. The penis will heal in seven to 10 days.\\nInfants who undergo circumcision may be fussy for\\nsome hours afterward, so parents should be prepared for\\ncrying, feeding problems, and sleep problems. Generally\\nthese go away within a day. In older boys, the penis may be\\npainful, but this will go away gradually. A topical anesthet-\\nic ointment or spray may be used to relieve this temporary\\ndiscomfort. There may also be a “bruise” on the penis,\\nwhich typically goes away with no particular attention.\\nRisks\\nComplications following newborn circumcision\\nappear in one out of every 500 procedures. Most compli-\\ncations are minor. Bleeding occurs in half of the compli-\\ncations and is usually easy to control. Infections are rare\\nand present with fever and signs of inflammation.\\nThere may be injuries to the penis itself, and these\\nmay be difficult to repair. In 2000, there were reports that\\nthe surgical clamps used in circumcision were at fault in\\nover 100 injuries reported between July 1996 and January\\n2000. In nearly all cases, the clamps were assumed to be\\nin working order but had been repaired with replacement\\nparts that were not of the manufacturer’s specifications.\\nPhysicians were urged to inspect the clamps before use\\nand ensure that their dimensions fit their infant patients.\\nResources\\nBOOKS\\nGollaher, David L. Circumcision: A History of the World’s\\nMost Controversial Surgery.Basic Books, 2000.\\nPERIODICALS\\nImperio, Winnie Anne. “Circumcision Appears Safe, But Not\\nHugely Beneficial.”OB GYN News 35, no. 7 (1 Apr.\\n2000): 9.\\nSchmitt, B. D. “The Circumcision Descision: Pros and Cons.”\\nClinical Reference Systems (2000): 1579.\\nOTHER\\nAmerican Academy of Pediatrics. New AAP Circumcision Poli-\\ncy Released (Press Release). 1 Mar. 1999. .\\nJanie F. Franz\\nCirrhosis\\nDefinition\\nCirrhosis is a chronic, degenerative disease in which\\nnormal liver cells are damaged and are then replaced by\\nscar tissue.\\nDescription\\nCirrhosis changes the structure of the liver and the\\nblood vessels that nourish it. The disease reduces the\\nliver’s ability to manufacture proteins and process hor-\\nmones, nutrients, medications, and poisons.\\nCirrhosis gets worse over time and can become\\npotentially life threatening. This disease can cause:\\n• excessive bleeding (hemorrhage)\\n• impotence\\n• liver cancer\\n• coma due to accumulated ammonia and body wastes\\n(liver failure)\\nGALE ENCYCLOPEDIA OF MEDICINE 2814\\nCirrhosis\\nAB\\nA. uncircumcised penis. B. circumcised penis.(Illustration by\\nArgosy Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 814'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 203, 'page_label': '204'}, page_content='• death\\nCirrhosis is the seventh leading cause of disease-\\nrelated death in the United States. It is twice as common\\nin men as in women. The disease occurs in more than\\nhalf of all malnourished chronic alcoholics and kills\\nabout 25,000 people a year. It is the third most common\\ncause of death in adults between the ages of 45 and 65.\\nTypes of cirrhosis\\nPortal or nutritional cirrhosis is the form of the dis-\\nease most common in the United States. About 30–50%\\nof all cases of cirrhosis are this type. Nine out of every 10\\npeople who have nutritional cirrhosis have a history of\\nalcoholism . Portal or nutritional cirrhosis is also called\\nLaënnec’s cirrhosis.\\nBiliary cirrhosis is caused by intrahepatic bile-duct\\ndiseases that impede bile flow. Bile is formed in the liver\\nand is carried by ducts to the intestines. Bile then helps\\ndigest fats in the intestines. Biliary cirrhosis can scar or\\nblock these ducts. It represents 15–20% of all cirrhosis.\\nVarious types of chronic hepatitis, especially hepati-\\ntis B and hepatitis C , can cause postnecrotic cirrhosis.\\nThis form of the disease affects up to 40% of all patients\\nwho have cirrhosis.\\nDisorders like the inability to metabolize iron and\\nsimilar disorders may cause pigment cirrhosis ( hemo-\\nchromatosis), which accounts for 5–10% of all instances\\nof the disease.\\nCauses and symptoms\\nLong-term alcoholism is the primary cause of cir-\\nrhosis in the United States. Men and women respond dif-\\nferently to alcohol. Although most men can safely con-\\nsume two to five drinks a day, one or two drinks a day\\ncan cause liver damage in women. Individual tolerance to\\nalcohol varies, but people who drink more and drink\\nmore often have a higher risk of developing cirrhosis. In\\nsome people, one drink a day can cause liver scarring.\\nChronic liver infections like hepatitis B and particu-\\nlarly hepatitis C are commonly linked to cirrhosis. Peo-\\nple at high risk of contracting hepatitis B include those\\nexposed to the virus through contact with blood and body\\nfluids. This includes healthcare workers and intraveneous\\nGALE ENCYCLOPEDIA OF MEDICINE 2 815\\nCirrhosis\\nA micrograph of a human liver showing tissue damaged by cirrhosis.(Photograph by Professor P . Motta, Photo Researchers, Inc.\\nReproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 815'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 204, 'page_label': '205'}, page_content='(IV) drug users. People in the past have contracted\\nhepatitis C through blood transfusions.\\nLiver injury, reactions to prescription medications,\\nexposure to toxic substances, and repeated episodes of\\nheart failure with liver congestion can cause cirrhosis.\\nThe disorder can also be a result of diseases that run in\\nfamilies (inherited diseases) like:\\n• a lack of a specific liver enzyme (alpha\\n1-antitrypsin\\ndeficiency)\\n• the absence of a milk-digesting enzyme (galactosemia)\\n• an inability to convert sugars to energy (glycogen stor-\\nage disease)\\n• an absorption deficit in which excess iron is deposited in\\nthe liver, pancreas, heart, and other organs (hemochro-\\nmatosis)\\n• a disorder characterized by accumulations of copper in\\nthe liver, brain, kidneys, and corneas (Wilson’s disease)\\nPoor nutrition increases a person’s risk of develop-\\ning cirrhosis. In about 10 out of every 100 patients, the\\ncause of cirrhosis cannot be determined. Many people\\nwho have cirrhosis do not have any symptoms (often\\ncalled compensated cirrhosis). Their disease is detected\\nduring a routine physical or when tests for an unrelated\\nmedical problem are performed. This type of cirrhosis\\ncan also be detected when complications occur (decom-\\npensated cirrhosis).\\nSymptoms of cirrhosis are usually caused by the loss\\nof functioning liver cells or organ swelling due to scarring.\\nThe liver enlarges during the early stages of illness. The\\npalms of the hands turn red and patients may experience:\\n• constipation\\n• diarrhea\\n• dull abdominal pain\\n• fatigue\\n• indigestion\\n• loss of appetite\\n• nausea\\n• vomiting\\n• weakness\\n• weight loss\\nAs the disease progresses, the spleen enlarges and\\nfluid collects in the abdomen (ascites) and legs (edema).\\nSpider-like blood vessels appear on the chest and shoul-\\nders, and bruising becomes common. Men sometimes\\nlose chest hair. Their breasts may grow and their testicles\\nmay shrink. Women may have menstrual irregularities.\\nCirrhosis can cause extremely dry skin and intense\\nitching . The whites of the eyes and the skin may turn\\nyellow ( jaundice ), and urine may be dark yellow or\\nbrown. Stools may be black or bloody. Sometimes the\\npatient develops persistent high blood pressure due to the\\nscarring (portal hypertension ). This type of hyperten-\\nsion can be life threatening. It can cause veins to enlarge\\nin the stomach and in the tube leading from the mouth to\\nthe stomach (esophagus). These enlarged veins are called\\nvarices, and they can rupture and bleed massively.\\nOther symptoms of cirrhosis include:\\n• anemia\\n• bleeding gums\\n• decreased interest in sex\\n•f e v e r\\n• fluid in the lungs\\n• hallucinations\\n• lethargy\\n• lightheadedness\\n• muscle weakness\\n• musty breath\\n• painful nerve inflammation (neuritis)\\n• slurred speech\\n• tremors\\nIf the liver loses its ability to remove toxins from the\\nbrain, the patient may have additional symptoms. The\\npatient may become forgetful and unresponsive, neglect\\npersonal care, have trouble concentrating, and acquire\\nnew sleeping habits. These symptoms are related to\\nammonia intoxication and the failure of the liver to con-\\nvert ammonia to urea. High protein intake in these\\npatients can also lead to these symptoms.\\nDiagnosis\\nA patient’s medical history can reveal illnesses or\\nlifestyles likely to lead to cirrhosis. Liver changes can be\\nseen during a physical examination . A doctor who sus-\\npects cirrhosis may order blood and urine tests to measure\\nliver function. Because only a small number of healthy\\ncells are needed to carry out essential liver functions, test\\nresults may be normal even when cirrhosis is present.\\nComputed tomography scans (CT), ultrasound,\\nand other imaging techniques can be used during diagno-\\nsis. They can help determine the size of the liver, indicate\\nhealthy and scarred areas of the organ, and detect gall-\\nstones. Cirrhosis is sometimes diagnosed during surgery\\nor by examining the liver with a laparoscope. This view-\\nGALE ENCYCLOPEDIA OF MEDICINE 2816\\nCirrhosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 816'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 205, 'page_label': '206'}, page_content='ing device is inserted into the patient’s body through a\\ntiny incision in the abdomen.\\nLiver biopsy is usually needed to confirm a diagno-\\nsis of cirrhosis. In this procedure, a tissue sample is\\nremoved from the liver and is examined under a micro-\\nscope in order to learn more about the organ.\\nTreatment\\nThe goal of treatment is to cure or reduce the condi-\\ntion causing cirrhosis, prevent or delay disease progres-\\nsion, and prevent or treat complications.\\nSalt and fluid intake are often limited, and activity is\\nencouraged. A diet high in calories and moderately high in\\nprotein can benefit some patients. Tube feedings or vita-\\nmin supplements may be prescribed if the liver continues\\nto deteriorate. Patients are asked not to consume alcohol.\\nMedication\\nIron supplements, diuretics, and antibiotics may be\\nused for anemia, fluid retention, and ammonia accumula-\\ntion associated with cirrhosis. Vasoconstrictors are some-\\ntimes needed to stop internal bleeding and antiemetics\\nmay be prescribed to control nausea.\\nLaxatives help the body absorb toxins and acceler-\\nate their removal from the digestive tract. Beta blockers\\nmay be prescribed to control cirrhosis-induced portal\\nhypertension. Because the diseased liver can no longer\\nefficiently neutralize harmful substances, medications\\nmust be given with caution. Interferon medicines may be\\nused by patients with chronic hepatitis B and hepatitis C\\nto prevent post-hepatic cirrhosis.\\nSurgery\\nMedication that causes scarring can be injected\\ndirectly into veins to control bleeding from varices in the\\nstomach or esophagus. Varices may require a special sur-\\ngical procedure called balloon tamponade ligation to stop\\nthe bleeding. Surgery may be required to repair disease-\\nrelated throat damage. It is sometimes necessary to\\nremove diseased portions of the spleen and other organs.\\nLiver transplants can benefit patients with advanced\\ncirrhosis. However, the new liver will eventually become\\ndiseased unless the underlying cause of cirrhosis is\\nremoved. Patients with alcoholic cirrhosis must demon-\\nstrate a willingness to stop drinking before being consid-\\nered suitable transplant candidates.\\nSupportive measures\\nA balanced diet promotes regeneration of healthy\\nliver cells. Eating five or six small meals throughout the\\nday should prevent the sick or bloated feeling patients\\nwith cirrhosis often have after eating. Alcohol and caf-\\nfeine, which destroy liver cells, should be avoided. So\\nshould any foods that upset the stomach. Patients with\\nbrain disease associated with cirrhosis should avoid\\nexcessive amounts of protein in the diet.\\nA patient can keep a food diary that describes what\\nwas eaten, when it was eaten, and how the patient felt\\nafterwards. This diary can be useful in identifying foods\\nthat are hard to digest and in scheduling meals to coin-\\ncide with the times the patient is most hungry.\\nPatients who have cirrhosis should weigh them-\\nselves every day and notify their doctor of a sudden gain\\nof five pounds or more. A doctor should also be notified\\nif symptoms of cirrhosis appear in anyone who has not\\nbeen diagnosed with the disease. A doctor should also be\\nnotified if a patient diagnosed with cirrhosis:\\n• vomits blood\\n• passes black stools\\n• seems confused or unresponsive\\n• shows signs of infection (redness, swelling, tenderness,\\npain)\\nAlternative treatment\\nAlternative treatments for cirrhosis are aimed at pro-\\nmoting the function of healthy liver cells and relieving the\\nsymptoms associated with the disease. Several herbal\\nremedies may be helpful to cirrhosis patients. Dandelion\\n(Taraxacum officinale ) and rock-poppy ( Chelidonium\\nmajus) may help improve the efficiency of liver cells.\\nMilk thistle extract ( Silybum marianum ) may slow dis-\\nease progression and significantly improve survival rates\\nin alcoholics and other cirrhosis patients. Practitioners of\\nhomeopathy and traditional Chinese medicine can also\\nprescribe treatments that support healthy liver function.\\nPrognosis\\nCirrhosis-related liver damage cannot be reversed,\\nbut further damage can be prevented by patients who:\\n• eat properly\\n• get enough rest\\n• do not consume alcohol\\n• remain free of infection\\nIf the underlying cause of cirrhosis cannot be cor-\\nrected or removed, scarring will continue. The liver will\\nfail, and the patient will probably die within five years.\\nPatients who stop drinking after being diagnosed with\\ncirrhosis can increase their likelihood of living more than\\na few years from 40% to 60–70%.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 817\\nCirrhosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 817'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 206, 'page_label': '207'}, page_content='Prevention\\nEliminating alcohol abuse could prevent 75–80% of\\nall cases of cirrhosis.\\nOther preventive measures include:\\n• obtaining counseling or other treatment for alcoholism\\n• taking precautions (practicing safe sex, avoiding dirty\\nneedles) to prevent hepatitis\\n• getting immunizations against hepatitis if a person is in\\na high-risk group\\n• receiving appropriate medical treatment quickly when\\ndiagnosed with hepatitis B or hepatitis C\\n• having blood drawn at regular intervals to rid the body\\nof excess iron from hemochromatosis\\n• using medicines (chelating agents) to rid the body of\\nexcess copper from Wilson’s disease\\n• wearing protective clothing and following product\\ndirections when using toxic chemicals at work, at\\nhome, or in the garden\\nResources\\nBOOKS\\nBerkow, Robert, ed. The Merck Manual of Medical Informa-\\ntion: Home Edition. Whitehouse Station, NJ: Merck\\nResearch Laboratories, 1997.\\nThe Editors of Time-Life Books. The Medical Advisor: The\\nComplete Guide to Alternative and Conventional Treat-\\nments. Alexandria, V A: Time Life, Inc., 1996.\\nSpringhouse Corporation. Everything You Need to Know About\\nDiseases. Springhouse, PA: Springhouse Corporation,\\n1996.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar Grove,\\nNJ 07009. (800) 223-0179. .\\nUnited Network for Organ Sharing. 1100 Boulders Parkway,\\nSuite 500, P.O. Box 13770, Richmond, V A 23225-8770.\\n(804) 330-8500.\\nOTHER\\n“Cirrhosis of the Liver.”ThriveOnline. 8 May 1998 .\\n“Cirrhosis of the Liver.”National Institute of Diabetes and Diges-\\ntive and Kidney Disease..\\nMaureen Haggerty\\nCisapride see Antigastroesophageal reflux\\ndrugs\\nCK test see Creatine kinase test\\nClap see Gonorrhea\\nClarithromycin see Erythromycins\\nCleft lip and palate\\nDefinition\\nA cleft is a birth defect that occurs when the tissues\\nof the lip and/or palate of the fetus do not fuse very early\\nin pregnancy . A cleft lip, sometimes referred to as a\\nharelip, is an opening in the upper lip that can extend into\\nthe base of the nostril. A cleft palate is an opening in the\\nroof of the mouth.\\nDescription\\nBabies born with cleft lips will have an opening involv-\\ning the upper lip. The length of the opening ranges from a\\nsmall notch, to a cleft that extends into the base of the nos-\\ntril. Cleft lips may involve one or both sides of the lip.\\nBabies born with cleft palates have openings in the\\npalate, which is the roof of the mouth. The size and posi-\\ntion of the opening varies. The cleft may be only in the\\nhard palate, the bony portion of the roof of the mouth,\\nopening into the floor of the nose. It may be only in the\\nsoft palate, the soft portion of the roof of the mouth. The\\ncleft palate may involve both the hard and soft palate and\\nmay occur on both sides of the center of the palate.\\nBabies may have cleft lips with or without cleft\\npalates. Cleft palates may also occur without cleft lips.\\nThe incidence of cleft lip and palate not associated\\nwith a syndrome is one in 700 newborns. Native Ameri-\\ncans have an incidence of 3.6 in 1,000 newborns. The inci-\\ndence among Japanese newborns is 2.1 in 1,000. The inci-\\ndence among whites is one in 1,000 newborns. African\\nAmericans have an incidence of 0.3 in 1,000 newborns.\\nCauses and symptoms\\nCleft lips and palates not associated with a syn-\\ndrome are caused by a combination of genetic and envi-\\nronmental factors. Inheritance caused by such a combi-\\nnation is called multifactorial. The embryo inherits genes\\nthat increase the risk for cleft lip and/or palate. When an\\nembryo with such genes is exposed to certain environ-\\nmental factors the embryo develops a cleft.\\nThe risk of a baby being born with a cleft lip or\\npalate increases with the number of affected relatives and\\nincreases with relatives that have more severe clefts.\\nEnvironmental factors that increase the risk of cleft\\nlip and palate include cigarette and alcohol use during\\nGALE ENCYCLOPEDIA OF MEDICINE 2818\\nCleft lip and palate\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 818'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 207, 'page_label': '208'}, page_content='pregnancy. Some drugs also increase the incidence of\\nclefting, such as phenytoin, sodium valproate, and\\nmethotrexate. The pregnant mother’s nutrition may\\naffect the incidence of clefting as well.\\nBabies born with a cleft lip will be seen to have an\\nelongated opening in the upper lip. The size of this opening\\nmay range from a small notch in the upper lip to an open-\\ning that extends into the base of the nostril. The cleft lip\\nmay be below the right or left nostril or below both nostrils.\\nBabies born with a cleft palate will be seen to have\\nan opening into the roof of the mouth. The size and posi-\\ntion of the cleft varies and it may involve only the hard\\npalate, or only the soft palate and may occur on both\\nsides of the center of the palate.\\nIn some cases the cleft palate will be covered with\\nthe normal lining of the mouth and can only be felt by\\nthe examiner.\\nBabies with cleft lips and palates have feeding diffi-\\nculties, which are more severe in babies with cleft\\npalates. The difficulty in feeding is due to the baby being\\nunable to achieve complete suction. In the case of clefts\\nof the hard palate, liquids enter the nose from the mouth\\nthrough the opening in the hard palate.\\nA cleft palate also affects a child’s speech, since the\\npalate is necessary for speech formation. The child’s\\nspeech pattern may still be affected despite surgical repair.\\nEar infections are more common in babies born with\\ncleft palates. The infections occur because the muscles of\\nthe palate do not open the Eustachian tubes which drain\\nthe middle ear. This allows fluid to collect and increases\\nthe risk of infection and hearing loss.\\nTeeth may also erupt misaligned.\\nDiagnosis\\nCleft lip and palate can be diagnosed before birth by\\nultrasound. After birth, cleft lip and palate are diagnosed\\nby physical exam.\\nTreatment\\nIf cleft lip and/or palate are diagnosed by ultrasound\\nbefore birth, further testing may be required to diagnose\\nassociated abnormalities if present. Referral to a cleft\\nteam is essential. A cleft team consists of specialists in\\nthe management of babies with clefts and includes sur-\\ngeons as well as nurses and speech therapists. Members\\nof the team inform the parents of all aspects of manage-\\nment. Feeding methods are also discussed, since feeding\\nis the first problem that must be dealt with. It may be\\npossible to breastfeed a baby born with only a cleft lip,\\nbut babies born with cleft palates usually have more\\nproblems with feeding and frequently require special\\nbottles and teats. A palatal obturator is a device that fits\\ninto the roof of the mouth, thus blocking the cleft open-\\ning and allowing easier suckling.\\nSurgery to repair cleft lips is sometimes performed\\nafter orthodontic treatment to narrow the gap in the upper\\nlip. The orthodontic treatment can involve acrylic splints\\nwith or without screws or may involve the use of adhesive\\ntape placed across the gap in the lip. The orthodontic treat-\\nment for cleft lip should be started within the first three\\nweeks of life and continue until the cleft lip is repaired.\\nThe timing of surgical cleft lip repair depends on the\\njudgment of the surgeon who will perform the operation.\\nThe procedure is usually performed between one and\\nthree months of age. The goals of the operation are to\\nclose the gap in the upper lip, place scars in the natural\\nskin curves and to repair muscle so that the lip appears\\nnormal during movement. The closure is done in the\\nthree layers (skin, muscle, and mucosa) that line the\\ninside of the lip. At the time of the procedure, if the nose\\nis shaped abnormally due to the cleft lip, it is also cor-\\nrected. Sometimes further surgery may be needed on the\\nlip and/or nose to refine the result.\\nThe goals of the surgeon repairing a cleft palate are\\nnormal speech, normal facial growth, and hearing for the\\naffected infant. The repair of the cleft palate is usually per-\\nformed between three and 18 months of age. The timing\\nmay extend beyond this and varies with the type of cleft\\npalate and center where the procedure is being performed.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 819\\nCleft lip and palate\\nThis infant has an unilateral cleft lip and palate.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 819'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 208, 'page_label': '209'}, page_content='Depending of the type of cleft palate, more than one oper-\\nation may be needed to close the cleft and improve speech.\\nNonsurgical treatment of a cleft palate is available for\\npatients who are at high risk for surgery and consists of a\\nprosthetic appliance worn to block the opening in the palate.\\nBabies born with cleft palates are vulnerable to ear\\ninfections. Their Eustachian tubes do not effectively\\ndrain fluid from the middle ear so fluid accumulates and\\ninfection sets in. This may lead to hearing loss. These\\nchildren require drainage tubes to be inserted to prevent\\nfluid accumulation.\\nBabies born with clefts usually require orthodontic\\ntreatment between 13 and 18 years of age. They also\\nrequire speech therapy.\\nPrognosis\\nBabies born with cleft lip and palate have a good\\nprognosis, and approximately 80% will develop normal\\nspeech. There is no known means of preventing clefting.\\nGood prenatal care is essential and avoiding harmful\\nsubstances appear to reduce the risk.\\nResources\\nPERIODICALS\\nLitwak-Saleh, Kim. “Practical Points in the case of the Patient\\nwith post-Cleft lip repair.”Journal of Post Anesthesia\\nNursing 8 (February 1993): 35–37.\\nChung, Kevin C. “Maternal Cigarette Smoking during Preg-\\nnancy and the risk of having a child with Cleft\\nLip/Palate.” Plastic and Reconstructive Surgery 105 (Feb-\\nruary 2000): 458–491.\\nChristensen, Karr. “The 20th Century Danish Facial Cleft Pop-\\nulation—Epidemiological and Genetic-Epidemiolical\\nStudies.” Cleft Palate—Craniofacial Journal 36 (March\\n1999): 96–104.\\nBender, Patricia L. “Genetics of Cleft Lip and Palate.”Journal\\nof Pediatric Nursing15 (August 2000): 242–249.\\nRohrich, Rod J. “Optimal Timing of Cleft Palate Closure.”\\nPlastic and Reconstructive Surgery 106 (August):\\n413–421.\\nCockell, Anna. “Prenatal Diagnosis and Management of orofacial\\nClefts.”Prenatal Diagnosis20 (February 2000): 149–151.\\nDenk, Michael J. “Topics in Pediatric Plastic Surgery.”Pedi-\\natric Clinics of North America 45 (December 1998).\\nORGANIZATIONS\\nCleft Palate Foundation. (800) 24-CLEFT. .\\nFarris F. Gulli, MD\\nCleft palate see Cleft lip and palate\\nClimacteric see Menopause\\nClenched fist injury\\nDefinition\\nA clenched fist injury (CFI) is a bite wound on the\\nhand, caused when a person’s closed fist strikes the teeth\\nof another person, usually in the course of a fight. CFIs are\\nsometimes referred to as closed fist injuries or fight bites.\\nDescription\\nClenched fist injuries are most common over the\\nmetacarpo phalangeal joint. Their appearance is deceptive\\nbecause they do not bleed heavily and the underlying injury\\nis hidden by soft tissue when the patient opens his hand and\\nstraightens the injured finger. CFIs can, however, have seri-\\nous consequences, including infection, cellulitis, inflam-\\nmation of the bone or bone marrow (osteomyelitis), septic\\narthritis, and inflammation of the sheaths covering the ten-\\ndons of the hand (tenosynovitis). These may lead to perma-\\nnent loss of function or amputation.\\nMost CFIs result in tissue injury due to the force of\\nimpact, ragged-edged tears in the skin resulting from\\ncontact with the teeth, and contamination of the wound\\nby the bacteria in human saliva. As the patient opens his\\nhand, the skin of the finger is pulled backward over the\\ndeeper part of the wound, thus sealing bacteria within the\\ninjured tissue. This sealing of the wound by normal\\nmotions of the finger is the reason why clenched fist\\ninjuries have the highest rate of infection of any human\\nbite. The rate of infection of clenched-fist injuries varies\\nfrom 15–50%.\\nCauses and symptoms\\nThe causes of CFIs include fighting and other forms\\nof aggressive behavior, often combined with drug or\\nalcohol consumption.\\nThe symptoms of clenched fist injury include pain\\nin the affected part of the hand and some stiffness of the\\ninjured finger with limitation of movement. If the patient\\nhas delayed getting medical treatment, there may be evi-\\ndence of infection, including swelling, redness, and sup-\\npuration (a discharge of pus). The skin around the wound\\nwill be warm to the touch and fever may be present.\\nDiagnosis\\nDiagnosis of clenched fist injuries is usually made\\non the basis of the location of the injury and x-ray find-\\nings. The most common finding in CFI x rays is soft tis-\\nsue swelling, but the x rays may also reveal air pockets in\\ndeep tissues or the joint spaces, fragments of teeth, frac-\\nGALE ENCYCLOPEDIA OF MEDICINE 2820\\nClenched fist injury\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 820'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 209, 'page_label': '210'}, page_content='ture lines in the bones, or small loose bone chips. Diag-\\nnosis is often complicated by the fact that the patient will\\nbe reluctant to admit how the injury happened. The treat-\\ning physician must maintain a high level of suspicion and\\noften ask directly.\\nTreatment\\nTreatment of clenched fist injuries is complicated by\\nseveral factors. One factor is the anatomical structure of\\nthe human hand, which contains many small closed\\nspaces that make it easy for infection to spread and per-\\nsist. Another is the number of disease-causing bacteria\\ntransmitted by human bites; at least 42 different species\\nhave been identified. In addition, CFIs typically do not\\nreceive immediate treatment because the patient is con-\\ncerned about legal consequences. The longer the delay,\\nthe higher the chances of infection and permanent dam-\\nage to the hand. Patients who wait longer than 24 hours\\nto seek treatment or have signs of infection or damage to\\nthe tendon, joint capsule, or bones are usually referred\\nimmediately to a doctor who specializes in hand surgery.\\nThe first step in treatment of clenched fist injury is irri-\\ngation, a procedure by which the wound is flushed with a\\nstream of water under high pressure or with an antiseptic\\nsolution. Incision and drainage of the wound (I&D) may be\\nrequired as well as debridement, the surgical removal of\\ndead tissue and foreign objects from a wound. Careful\\nexamination of the depth of the wound is essential to prop-\\ner treatment. The surgeon may need to enlarge the sides of\\nthe wound in order to make an accurate evaluation. The\\npatient will be asked to move the affected joint through its\\nfull range of motion so that the surgeon can determine\\nwhether the tendon or joint capsule has been damaged. Fol-\\nlowing these procedures, the surgeon will pack the wound\\nand put the hand in a splint. Bite wounds are never sutured\\n(sewn shut) because of the possibility of enclosing bacteria\\ninside the injury. After 24 hours, the packing will be\\nremoved and the hand reexamined for signs of infection.\\nIf the wound has become infected, the patient is usu-\\nally hospitalized and given parenteral (injectable) antibi-\\notics. The wound is irrigated and examined to determine\\nthe extent of the injury. Cultures are taken for both aerobic\\n(requiring air or oxygen to live) and anaerobic (not requir-\\ning air or oxygen) species of bacteria. The cultures should\\nbe taken from areas deep in the wound rather than from\\nthe surface for greater accuracy. Tetanustoxoid should be\\ngiven if the patient has not been immunized within the last\\n10 years. The patient should also receive treatment and\\nfollow-up for the rare possibility of HIV and hepatitis\\ntransmission. Although no well-documented cases of HIV\\ntransmission by human bites exist as of 2001, the potential\\nfor transmission by this route is still present.\\nKEY TERMS\\nAntibiotic—A chemical substance produced by a\\nmicroorganism which can inhibit the growth of or\\nkill other microorganisms.\\nDebridement— Surgical removal of damaged tis-\\nsue and foreign objects from a wound.\\nI&D—Incision and drainage of a wound.\\nIrrigation—Cleansing a wound with large amounts\\nof water and/or an antiseptic solution.\\nParenteral—Administered inside the body but out-\\nside the digestive tract.\\nTetanus toxoid—Tetanus toxoid is a vaccine used\\nto prevent tetanus (also known as lockjaw).\\nInfected clenched fist injuries usually contain sever-\\nal disease-causing bacteria, the most common being\\nStreptococcus pyogenes , Staphylococcus aureus , Bac-\\nteroides sp., Peptostreptococcus sp., and Eikenella corro-\\ndens. Broad-spectrum antibiotics are usually given.\\nUninfected and relatively superficial CFIs may be treated\\nwith oral penicillin plus dicloxacillin or Augmentin. For\\ninfected CFIs, parenteral penicillin G is usually given\\ntogether with nafcillin or cefuroxime. CFIs infected by\\ndrug-resistant strains of S. aureus may require treatment\\nwith vancomycin.\\nPrognosis\\nThe prognosis depends on the patient’s underlying\\nstate of health and compliance with treatment; depth of\\nthe wound; the involvement of the joint capsule or ten-\\ndon; and the length of time before the wound is treated.\\nThe more superficial the wound and the faster the treat-\\nment, the better the prognosis.\\nPrevention\\nThe best way to prevent clenched fist injuries is to\\navoid fist fights, intoxication, and association with peo-\\nple who practice these forms of behavior. If involved in a\\nfistfight, people should avoid directing punches at their\\nopponent’s mouth. The next best preventive measure is to\\nget medical treatment at once for a clenched-fist injury.\\nResources\\nBOOKS\\nJacobs, Richard A., MD. “Animal & Human Bite Wounds.” In\\n“General Problems in Infectious Diseases.”Current Med-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 821\\nClenched fist injury\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 821'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 210, 'page_label': '211'}, page_content='ical Diagnosis & Treatment 2001. 40th edition. Ed. L. M.\\nTierney, Jr., MD, et al. New York: Lange Medical\\nBooks/McGraw-Hill, 2001.\\nTaylor, Mark D., MD, and Samuel E. Wilson, MD. “Bacterial\\nDiseases of the Skin.” In Conn’s Current Therapy 2001,\\ned. Robert E. Rakel, MD, and Edward T. Bope, MD.\\nPhiladelphia: W. B. Saunders Company, 2001.\\nPERIODICALS\\nBerlet, Greg, et al. “Clenched-fist injury complicated by methi-\\ncillin-resistant Staphylococcus aureus.” Canadian Journal\\nof Surgery/Journal canadien de chirurgie40 (4) (August\\n1997): 313-314.\\nORGANIZATIONS\\nMassachusetts College of Emergency Physicians (MACEP). \\nP. O. Box 296, Swansea, MA 02777. (508) 643-0117. Fax:\\n(508) 643-0141.\\nRebecca J. Frey, PhD\\nClomiphene see Infertility drugs\\nClonazepam see Benzodiazepines\\nClosed fracture reduction see Fracture\\nrepair\\nClostridium difficile colitis see Antibiotic-\\nassociated colitis\\nClotrimazole see Antifungal drugs, topical\\nClotting disorders see Coagulation disorders\\nClubfoot\\nDefinition\\nClubfoot is a condition in which one or both feet are\\ntwisted into an abnormal position at birth. The condition\\nis also known as talipes.\\nDescription\\nTrue clubfoot is characterized by abnormal bone for-\\nmation in the foot. There are four variations of clubfoot,\\nincluding talipes varus, talipes valgus, talipes equines,\\nand talipes calcaneus. In talipes varus, the most common\\nform of clubfoot, the foot generally turns inward so that\\nthe leg and foot look somewhat like the letter J. In talipes\\nvalgus, the foot rotates outward like the letter L. In tal-\\nipes equinus, the foot points downward, similar to that of\\na toe dancer. In talipes calcaneus, the foot points upward,\\nwith the heel pointing down.\\nClubfoot can affect one foot or both. Sometimes an\\ninfant’s feet appear abnormal at birth because of the\\nintrauterine position of the fetus birth. If there is no\\nanatomic abnormality of the bone, this is not true club-\\nfoot, and the problem can usually be corrected by apply-\\ning special braces or casts to straighten the foot.\\nThe ratio of males to females with clubfoot is 2.5 to\\n1. The incidence of clubfoot varies only slightly. In the\\nUnited States, the incidence is approximately 1 in every\\n1,000 live births. A 1980 Danish study reported an over-\\nall incidence of 1.20 in every 1,000 children; by 1994,\\nthat number had doubled to 2.41 in every 1,000 live\\nbirths. No reason was offered for the increase.\\nCauses and symptoms\\nExperts do not agree on the precise cause of club-\\nfoot. The exact genetic mechanism of inheritance has\\nbeen extensively investigated using family studies and\\nother epidemiological methods. As of 1999, no definitive\\nconclusions had been reached, although a Mendelian pat-\\ntern of inheritance is suspected. This may be due to the\\ninteraction of several different inheritance patterns, dif-\\nferent patterns of development appearing as the same\\ncondition, or a complex interaction between genetic and\\nenvironmental factors. The MSX1 gene has been associ-\\nated with clubfoot in animal studies. But, as of 2001,\\nthese findings have not been replicated in humans.\\nA family history of clubfoot has been reported in\\n24.4% of families in a single study. These findings sug-\\ngest the potential role of one or more genes being respon-\\nsible for clubfoot.\\nSeveral environmental causes have been proposed\\nfor clubfoot. Obstetricians feel that intrauterine crowd-\\ning causes clubfoot. This theory is supported by a sig-\\nnificantly higher incidence of clubfoot among twins\\ncompared to singleton births. Intrauterine exposure to\\nthe drug misoprostol has been linked with clubfoot.\\nMisoprostol is commonly used when trying, usually\\nunsuccessfully, to induce abortion in Brazil and in\\nother countries in South and Central America.\\nResearchers in Norway have reported that males who\\nare in the printing trades have significantly more off-\\nspring with clubfoot than men in other occupations.\\nFor unknown reasons, amniocentesis , a prenatal test,\\nhas also been associated with clubfoot. The infants of\\nmothers who smoke during pregnancy have a greater\\nchance of being born with clubfoot than are offspring\\nof women who do not smoke.\\nTrue clubfoot is usually obvious at birth. The four\\nmost common varieties have been described. A clubfoot\\nhas a typical appearance of pointing downward and\\nGALE ENCYCLOPEDIA OF MEDICINE 2822\\nClubfoot\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 822'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 211, 'page_label': '212'}, page_content='being twisted inwards. Since the condition starts in the\\nfirst trimester of pregnancy, the abnormality is quite well\\nestablished at birth, and the foot is often very rigid.\\nUncorrected clubfoot in an adult causes only part of the\\nfoot, usually the outer edge, or the heel or the toes, to\\ntouch the ground. For a person with clubfoot, walking\\nbecomes difficult or impossible.\\nDiagnosis\\nTrue clubfoot is usually recognizable and obvious\\non physical examination. A routine x ray of the foot that\\nshows the bones to be malformed or misaligned supplies\\na confirmed diagnosis of clubfoot. Ultrasonography is\\nnot always useful in diagnosing the presence of clubfoot\\nprior to the birth of a child.\\nTreatment\\nMost orthopedic surgeons agree that the initial treat-\\nment of congenital (present at birth) clubfoot should be\\nnon-operative. Non-surgical treatment should begin in\\nthe first days of life to take advantage of the favorable\\nfibro-elastic properties of the foot’s connective tissues,\\nthose forming the ligaments, joint capsules, and tendons.\\nIn a common treatment, a series of casts is applied over a\\nperiod of months to reposition the foot into a normal\\nalignment. In mild cases, splinting and wearing braces at\\nnight may correct the abnormality.\\nWhen clubfoot is severe enough to require surgery,\\nthe condition is usually not completely correctable,\\nalthough significant improvement is possible. In the most\\nsevere cases, surgery may be required, especially when\\nthe Achilles tendon, which joins the muscles in the calf\\nto the bone of the heel, needs to be lengthened. Because\\nan early operation induces fibrosis, a scarring and stiff-\\nness of the tissue, surgery should be delayed until an\\naffected child is at least three months old.\\nMuch of a clubfoot abnormality can be corrected by\\nthe use of manipulation and casting during the first three\\nmonths of life. Proper manipulative techniques must be\\nfollowed by applications of appropriately molded plaster\\ncasts to provide effective and safe correction of most\\nvarieties of clubfoot. Long-term care by an orthopedist is\\nrequired after initial treatment to ensure that the correc-\\ntion of the abnormality is maintained. Exercises, correc-\\ntive shoes, or nighttime splints may be needed until the\\nchild stops growing.\\nPrognosis\\nWith prompt, expert treatment, clubfoot is usually\\ncorrectable. Most individuals are able to wear regular\\nshoes and lead active lives. If clubfoot is not appropriate-\\nly treated, the abnormality becomes fixed. This has an\\neffect on the growth of the leg and foot, and some degree\\nof permanent disability usually results.\\nResources\\nBOOKS\\nHall, Judith G. “Chromosomal Clinical Abnormalilties.” In\\nNelson Textbook of Pediatrics.16th ed. Ed. Richard E.\\nBehrman et al. Philadelphia: Saunders, 2000, 325–34.\\nJones, KL. “XO Syndrome.” In Smith’s Recognizable Pat-\\nterns of Human Malformation. 5th ed. Ed. Kenneth L.\\nJones and Judy Fletcher Philadelphia: Saunders, 1997,\\npp. 81–7.\\nThoene, Jess G., ed. Physicians’ Guide to Rare Diseases.2nd\\ned. Montvale, NJ: Dowden Publishing Co., 1995.\\nVan Allen, Margot I., and Judith G. Hall. “Congenital Anom-\\nalies.” In Cecil Textbook of Medicine.21st ed. Ed. Lee\\nGoldman, et al. Philadelphia: Saunders, 2000, 150–52.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 823\\nClubfoot\\nPerson suffering from clubfoot. About one of every 400 new-\\nborns has some form of this birth defect.(Photo\\nResearchers, Inc. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 823'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 212, 'page_label': '213'}, page_content='PERIODICALS\\nChesney, D., et al. “Epidemiology and Genetic Theories in the\\nEtiology of Congenital Talipes Equinovarus.”Bulletin of\\nthe Hospital for Joint Diseases 58, no. 1 (1999): 59–64.\\nGonzalez, C. H., et al. “Congenital Abnormalities in Brazilian\\nChildren Associated with Misoprostol Misuse in First\\nTrimester of Pregnancy.”Lancet 351, no. 9116 (May 30,\\n1998): 1624–27.\\nHonein, M. A., L. J. Paulozzi, and C. A. Moore. “Family Histo-\\nry, Maternal Smoking, and Clubfoot: An Indication of a\\nGene-Environment Interaction.”American Journal of Epi-\\ndemiology 157, no. 7 (October 1, 2000): 658–65.\\nLochmiller, C., et al. “Genetic Epidemiology Study of Idio-\\npathic Talipes Equinovarus.”American Journal of Med-\\nical Genetics 79, no. 2 (September 1, 1998): 90–6.\\nRebbeck, T. R., et al. “A Single-Gene Explanation for the Prob-\\nability of Having Idiopathic Talipes Equinovarus.”Ameri-\\ncan Journal of Human Genetics 53, no.5 (November\\n1993): 1051–63.\\nRobertson, W. W., and D. Corbett. “Congenital Clubfoot.\\nMonth of Conception.”Clinics in Orthopedics 340, no.\\n338 (May 1997): 14–18.\\nORGANIZATIONS\\nMarch of Dimes/Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (888) 663-4637. resource-\\ncenter@modimes.org. .\\nNational Easter Seal Society. 230 W. Monroe St., Suite 1800,\\nChicago, IL 60606-4802. (312) 726-6200 or (800) 221-\\n6827. .\\nNational Organization for Rare Disorders (NORD). PO Box\\n8923, New Fairfield, CT 06812-8923. (203) 746-6518 or\\n(800) 999-6673. Fax: (203) 746-6481. .\\nOTHER\\n“Clubfoot.” National Library of Medicine. .\\nClubfoot.net. .\\nPonseti, Ignacio, MD. “Treatment of Congenital Clubfoot.”\\nRevised January 1998. University of Iowa Health Care.\\n.\\nSchopler, Steven A., MD. “Clubfoot.”Southern California\\nOrthopedic Institute..\\nL. Fleming Fallon, Jr., MD, DrPH\\nKEY TERMS\\nEnterovirus —Any of a group of viruses that pri-\\nmarily affect the gastrointestinal tract.\\nIntrauterine—Situated or occuring in the uterus.\\nOrthopedist —A doctor specializing in treatment\\nof the skeletal system and its associated muscles\\nand joints.\\nCluster headache\\nDefinition\\nCluster headaches are characterized by an intense\\none-sided pain centered by the eye or temple. The pain\\nlasts for one to two hours on average and may recur sev-\\neral times in a day.\\nDescription\\nCluster headaches have been known as histamine\\nheadaches, red migraines, and Horton’s disease, among\\nothers. The constant factor is the pain, which transcends\\nby far the distress of the more common tension-type\\nheadache or even that of a migraine headache.\\nCluster headaches afflict less than 0.5% of the popu-\\nlation and predominantly affect men; approximately 80%\\nof sufferers are male. Onset typically occurs in the late\\n20s, but there is no absolute age restriction. Approximate-\\nly 80% of cluster headaches are classified as episodic; the\\nremaining 20% are considered chronic. Both display the\\nsame symptoms. However, episodic cluster headaches\\noccur during one- to five-month periods followed by six-\\nto 24-month attack-free, or remission, periods. There is\\nno such reprieve for chronic cluster headache sufferers.\\nCauses and symptoms\\nBiochemical, hormonal, and vascular changes\\ninduce cluster headaches, but why these changes occur\\nremains unclear. Episodic cluster headaches seem to be\\nlinked to changes in day length, possibly signaling a con-\\nnection to the so-called biological clock. Alcohol, tobac-\\nco, histamine, or stress can trigger cluster headaches.\\nDecreased blood oxygen levels (hypoxemia) can also act\\nas a trigger, particularly during the night when an indi-\\nvidual is sleeping. Interestingly, the triggers do not cause\\ncluster headaches during remission periods.\\nThe primary cluster headache symptom is excruciat-\\ning one-sided head pain centered behind an eye or near\\nthe temple. This pain may radiate outward from the ini-\\ntial focus and encompass the mouth and teeth. For this\\nreason, some cluster headache sufferers may mistakenly\\nattribute their pain to a dental problem. Secondary symp-\\ntoms, occurring on the same side as the pain, include eye\\ntearing, nasal congestion followed by a runny nose, pupil\\ncontraction, and facial drooping or flushing.\\nDiagnosis\\nCluster headache symptoms guide the diagnosis. A\\nmedical examination includes recording headache\\nGALE ENCYCLOPEDIA OF MEDICINE 2824\\nCluster headache\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 824'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 213, 'page_label': '214'}, page_content='details, such as frequency and duration, when it occurs,\\npain intensity and location, possible triggers, and any\\nprior symptoms. This history allows other potential prob-\\nlems to be discounted.\\nTreatment\\nTreatment for cluster headaches is composed of\\ninduction, maintenance, and symptomatic therapies. The\\nfirst two therapies are prophylactic treatments, geared\\ntoward preventing headaches. Symptomatic therapy is\\nmeant to stop or shorten a headache.\\nInduction and maintenance therapies begin together.\\nInduction therapy is intended to break the headache cycle\\nwith drugs such as corticosteroids (for example, pred-\\nnisone) or dihydroergotamine. These drugs are not meant\\nfor long-term therapy, but rather as a jump-start for main-\\ntenance therapy. Maintenance therapy drugs include ver-\\napamil, lithium carbonate, ergotamine, and methy-\\nsergide. These drugs have long-term effectiveness, but\\nmust be taken for at least a week before a response is\\nobserved. With long-term treatment, methysergide must\\nbe stopped for one month each year to avoid dangerous\\nside effects (formation of fibrous tissue inside the\\nabdominal artery, lungs, and heart valves).\\nDespite prophylactic treatment, headaches may still\\noccur. Symptomatic therapy includes oxygen inhalation,\\nKEY TERMS\\nBiological clock—A synonym for the body’s circa-\\ndian rhythm, the natural biological variations that\\noccur over the course of a day.\\nMigraine headache —An intense throbbing pain\\nthat occurs on one or both sides of the head. The\\nheadache is usually accompanied by other symp-\\ntoms, such as nausea, vomiting, and aversion to\\nlight.\\nProphylactic—Referring to treatment that prevents\\nsymptoms from occurring.\\nTension-type headache—A dull pain that seems to\\nexert pressure on the head; the most common\\nform of headache.\\nsumatriptan injection, and application of local anesthet-\\nics inside the nose. Surgery is a last resort for chronic\\ncluster headaches that fail to respond to therapy.\\nAlternative treatment\\nSince some cluster headaches are triggered by stress,\\nstress reduction techniques, such as yoga, meditation,\\nand regular exercise, may be effective. Some cluster\\nheadaches may be an allergic response triggered by food or\\nenvironmental substances, therefore identifying and\\nremoving the allergen(s) may be key to resolution of the\\nproblem. Histamine is another suspected trigger of cluster\\nheadaches, and this response may be controlled with vita-\\nmin C and the bioflavonoids quercetin and bromelain\\n(pineapple enzyme). Supplementation with essential fatty\\nacids (EFA) will help decrease any inflammatory response.\\nPhysical medicine therapies such as adjustments of\\nthe spine, craniosacral treatment, and massage at the\\ntemporomandibular joint (TMJ) can clear blockages, as\\ncan traditional Chinese medical therapies including\\nacupuncture. Homeopathic treatment can also be bene-\\nficial. Nervous system relaxant herbs, used singly or in\\ncombination, can allow the central nervous system to\\nrelax as well as assist in peripheral nerve response. A few\\nherbs to consider for relaxation are valerian ( Valeriana\\nofficinalis), chamomile ( Matricaria recutita ), rosemary\\n(Rosemarinus officinalis ), and skullcap ( Scutellaria\\nbaicalensis).\\nPrognosis\\nIn general, drug therapy offers effective treatment.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 825\\nCluster headache\\nCluster Headache\\nAreas of pain\\nNerves\\nThe primary cluster headache symptom is excruciating one-\\nsided head pain located behind an eye or near the temple.\\nSecondary symptoms include eye tearing, nasal congestion,\\nand a runny nose.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 825'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 214, 'page_label': '215'}, page_content='Prevention\\nAvoiding triggers, adhering to medical treatment,\\nand controlling stress can help ward off some cluster\\nheadaches.\\nResources\\nPERIODICALS\\nDiamond, Seymour. “Cluster Headache: How to Distinguish\\nfrom Migraine.” Consultant, 36, no. 7 (1996): 1449.\\nLewis, Todd A., and Glen D. Solomon. “Advances in Cluster\\nHeadache Management.” Cleveland Clinic Journal of\\nMedicine 63, no. 4 (1996): 237.\\nORGANIZATIONS\\nAmerican Council for Headache Education (ACHE). 19 Man-\\ntua Road, Mt. Royal, NJ 08061. (800) 255-2243. .\\nNational Headache Foundation. 428 W. St. James Place, Chicago,\\nIL 60614. (800) 843-2256. .\\nJulia Barrett\\nCMV see Cytomegalovirus infection\\nCNS depressants see Central nervous\\nsystem depressants\\nCNS stimulants see Central nervous system\\nstimulants\\nCoagulation disorders\\nDefinition\\nCoagulation disorders deal with disruption of the\\nbody’s ability to control blood clotting. The most com-\\nmonly known coagulation disorder is hemophilia, a con-\\ndition in which patients bleed for long periods of time\\nbefore clotting. There are other coagulation disorders\\nwith a variety of causes.\\nDescription\\nCoagulation, or clotting, occurs as a complex\\nprocess involving several components of the blood. Plas-\\nma, the fluid component of the blood, carries a number\\nof proteins and coagulation factors that regulate bleed-\\ning. Platelets, small colorless fragments in the blood, ini-\\ntiate contraction of damaged blood vessels so that less\\nblood is lost. They also help plug damaged blood vessels\\nand work with plasma to accelerate blood clotting. A dis-\\norder affecting platelet production or one of the many\\nsteps in the entire process can disrupt clotting.\\nCoagulation disorders arise from different causes\\nand produce different complications. Some common\\ncoagulation disorders are:\\n• Hemophilia, or hemophilia A (Factor VIII deficiency),\\nan inherited coagulation disorder, affects about 20,000\\nAmericans. This genetic disorder is carried by females\\nbut most often affects males.\\n• Christmas disease, also known as hemophilia B or Fac-\\ntor IX deficiency, is less common than hemophilia A\\nwith similar in symptoms.\\n• Disseminated intravascular coagulation disorder, also\\nknown as consumption coagulopathy, occurs as a result\\nof other diseases and conditions. This disease acceler-\\nates clotting, which can actually cause hemorrhage.\\n• Thrombocytopenia is the most common cause of\\ncoagulation disorder. It is characterized by a lack of cir-\\nculating platelets in the blood. This disease also\\nincludes idiopathic thrombocytopenia.\\n• V on Willebrand’s disease is a hereditary disorder with\\nprolonged bleeding time due to a clotting factor defi-\\nciency and impaired platelet function. It is the most\\ncommon hereditary coagulation disorder.\\n• Hypoprothrombinemia is a congenital deficiency of\\nclotting factors that can lead to hemorrhage.\\n• Other coagulation disorders include Factor XI deficien-\\ncy, also known as hemophilia C, and Factor VII defi-\\nciency. Hemophilia C afflicts one in 100,000 people\\nand is the second most common bleeding disorder\\namong women. Factor VII is also called serum pro-\\nthrombin conversion accelerator (SPCA) deficiency.\\nOne in 500,000 people may be afflicted with this disor-\\nder that is often diagnosed in newborns because of\\nbleeding into the brain as a result of traumatic delivery.\\nCauses and symptoms\\nSome coagulation disorders present symptoms such\\nas severe bruising. Others will show no apparent symp-\\ntoms, but carry the threat of severe internal bleeding.\\nHemophilia\\nBecause of its hereditary nature, hemophilia A may\\nbe suspected before symptoms occur. Some signs of\\nhemophilia A are numerous large, deep bruises and pain\\nand swelling of joints caused by internal bleeding.\\nPatients with hemophilia do not bleed faster, just longer.\\nA person with mild hemophilia may first discover the\\ndisorder with prolonged bleeding following a surgical\\nprocedure. If there is bleeding into the neck, head, or\\nGALE ENCYCLOPEDIA OF MEDICINE 2826\\nCoagulation disorders\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 826'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 215, 'page_label': '216'}, page_content='digestive tract, or bleeding from an injury, emergency\\nmeasures may be required.\\nMild and severe hemophilia A are inherited through\\na complex genetic system that passes a recessive gene on\\nthe female chromosome. Women usually do not show\\nsigns of hemophilia but are carriers of the disease. Each\\nmale child of the carrier has a 50% chance of having\\nhemophilia, and each female child has a 50% chance of\\npassing the gene on.\\nChristmas disease\\nChristmas disease, or hemophilia B, is also heredi-\\ntary but less common than hemophilia A. The severity of\\nChristmas disease varies from mild to severe, although\\nmild cases are more common. The severity depends on\\nthe degree of deficiency of the Factor IX (clotting factor).\\nHemophilia B symptoms are similar to those of hemo-\\nphilia A, including numerous, large, and deep bruises\\nand prolonged bleeding. The more dangerous symptoms\\nare those that represent possible internal bleeding, such\\nas swelling of joints, or bleeding into internal organs\\nupon trauma. Hemophilia most often occurs in families\\nwith a known history of the disease, but occasionally,\\nnew cases will occur in families with no apparent history.\\nDisseminated intravascular coagulation\\nThe name of this disorder arises from the fact that\\nmalfunction of clotting factors cause platelets to clot in\\nsmall blood vessels throughout the body. This action leads\\nto a lack of clotting factors and platelets at a site of injury\\nthat requires clotting. Patients with disseminated intravas-\\ncular coagulation (DIC) will bleed abnormally even\\nthough there is no history of coagulation abnormality.\\nSymptoms may include minute spots of hemorrhage on\\nthe skin, and purple patches or hematomas caused by\\nbleeding in the skin. A patient may bleed from surgery or\\nintravenous injection (IV) sites. Related symptoms include\\nvomiting, seizures, coma, shortness of breath , shock,\\nsevere pain in the back, muscles, abdomen, or chest.\\nDIC is not a hereditary disorder or a common one. It\\nis most commonly caused by complications during preg-\\nnancy or delivery, overwhelming infections, acute\\nleukemia, metastatic cancer, extensive burns and trauma,\\nand even snakebites. There are a number of other causes\\nof DIC, and it is not commonly understood why or how\\nthese various disorders can lead to the coagulation prob-\\nlem. What the underlying causes of DIC have in common\\nis some factor that affects proteins, platelets, or other clot-\\nting factors and processes. For example, uterine tissue can\\nenter the mother’s circulation during prolonged labor,\\nintroducing foreign proteins into the blood, or the venom\\nof some exotic snakes can activate one of the clotting fac-\\nKEY TERMS\\nClotting factor —Also known as coagulation fac-\\ntors. Proteins in the plasma which serve to activate\\nvarious parts of the blood clotting process by\\nbeing transformed from inactive to active form.\\nEnzyme—A substance that causes a chemical\\nreaction, usually a protein. Enzymes are secreted\\nby cells.\\nHemorrhage—Abnormal bleeding from the blood\\nvessels.\\nHeparin —An anticoagulant, or blood clot “dis-\\nsolver.”\\nIdiopathic—Refers to a disease of unknown cause,\\nand sometime to a primary disease.\\nMetastatic —The term used to describe a sec-\\nondary cancer, or one that has spread from one\\narea of the body to another.\\nSerum reagents—Serum is fluid, or the fluid portion\\nof the blood retained after removal of the blood\\ncells and fibrin clot. Reagents are substances added\\nto the serum to produce a chemical reaction.\\nThrombosis—Formation of a clot in the blood that\\neither blocks, or partially blocks a blood vessel.\\nThe thrombus may lead to infarction, or death of\\ntissue, due to a blocked blood supply.\\ntors. Severe head trauma can expose blood to brain tissue.\\nNo matter the cause of DIC, the results are a malfunction\\nof thrombin (an enzyme) and prothrombin (a glycopro-\\ntein), which activate the fibrinolytic system, releasing\\nclotting factors in the blood. DIC can alternate from hem-\\norrhage to thrombosis, and both can exist, which further\\ncomplicates diagnosis and treatment.\\nThrombocytopenia\\nThrombocytopenia may be acquired or congenital. It\\nrepresents a defective or decreased production of\\nplatelets. Symptoms include sudden onset of small spots\\nof hemorrhage on the skin, or bleeding into mucous\\nmembranes (such as nosebleeds). The disorder may also\\nbe evident as blood in vomit or stools, bleeding during\\nsurgery, or heavy menstrual flow in women. Some\\npatients show none of these symptoms, but complain of\\nfatigue and general weakness. There are several causes\\nof thrombocytopenia, which is more commonly acquired\\nas a result of another disorder. Common underlying dis-\\norders include leukemia, drug toxicity, or aplastic ane-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 827\\nCoagulation disorders\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 827'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 216, 'page_label': '217'}, page_content='mia, all of which lead to decreased or defective produc-\\ntion of platelets in the bone marrow. Other diseases may\\ndestroy platelets outside the marrow. These include\\nsevere infection, disseminated intravascular coagulation,\\nand cirrhosis of the liver. The idiopathic form most com-\\nmonly occurs in children, and is most likely the result of\\nproduction of antibodies that cause destruction of\\nplatelets in the spleen and to a lesser extent the liver.\\nV on Willebrand’s disease is caused by a defect in the\\nV on Willebrand clotting factor, often accompanied by a\\ndeficiency of Factor VIII as well. It is a hereditary disor-\\nder that affects both males and females. In rare cases, it\\nmay be acquired. Symptoms include easy bruising, bleed-\\ning in small cuts that stops and starts, abnormal bleeding\\nafter surgery, and abnormally heavy menstrual bleeding.\\nNosebleeds and blood in the stool with a black, tarlike\\nappearance are also signs of V on Willebrand’s disease.\\nHypoprothrombinemia\\nThis disorder is a deficiency in prothrombin, or Factor\\nII, a glycoprotein formed and stored in the liver. Prothrom-\\nbin, under the right conditions, is converted to thrombin,\\nwhich activates fibrin and begins the process of coagula-\\ntion. Some patients may show no symptoms, and others\\nwill suffer severe hemorrhaging. Patients may experience\\neasy bruising, profuse nosebleeds, postpartum hemorrhage,\\nexcessively prolonged or heavy menstrual bleeding, and\\npostsurgical hemorrhage. Hypoprothrombinemia may also\\nbe acquired rather than inherited, and usually results from a\\nVitamin K deficiency caused by liver diseases, newborn\\nhemorrhagic disease, or a number of other factors.\\nOther coagulation disorders\\nFactor XI deficiency, or hemophilia C, occurs more\\nfrequently among certain ethnic groups, with an incidence\\nof about one in 10,000 among Ashkenazi Jews. Nearly\\n50% of patients with this disorder experience no symp-\\ntoms, but others may notice blood in their urine, nose-\\nbleeds, or bruising. Although joint bleeding seldom occurs,\\nsome factor XI patients will experience bleeding long after\\nan injury occurs. Some women will experience prolonged\\nbleeding after childbirth. Patients with factor VII deficien-\\ncy vary greatly in their bleeding severity. Women may\\nexperience heavy menstrual bleeding, bleeding from the\\ngums or nose, bleeding deep within the skin, and episodes\\nof bleeding into the stomach, intestine, and urinary tract.\\nFactor VII patients may also suffer bleeding into joints.\\nDiagnosis\\nSeveral blood tests can be used to detect various\\ncoagulation disorders. There are hundreds of different\\ntests a doctor can order to look for indications of specific\\ndiseases. In addition to blood tests, physicians will com-\\nplete a medical history and physical examination. In the\\ncase of acquired coagulation disorders, information such\\nas prior or current diseases and medications will be\\nimportant in determining the cause of the blood disorder.\\n• Hemohilia A will be diagnosed with laboratory tests\\ndetecting presence of clotting factor VIII, factor IX, and\\nothers, as well as the presence or absence of clotting\\nfactor inhibitors.\\n• Christmas disease will be checked against normal\\nbleeding and clotting time, as well as for abnormal\\nserum reagents in factor IX deficiency. Other tests of\\nprothrombin time and thromboplastic generation may\\nalso be ordered.\\n• There is no one test or group of tests that can always\\nmake (or exclude) a diagnosis of DIC. DIC can be diag-\\nnosed through a number of laboratory tests which mea-\\nsure concentration of platelets and fibrinogen in the\\nblood with normal counts and prolonged prothrombin\\ntime. Other supportive data include diminished levels\\nof factors V , fibrinogen, and VIII, decreased hemoglo-\\nbin, and others. Since many of the test results also indi-\\ncate other disorders, the physician may have to put\\ntogether several results to reach a diagnosis of DIC.\\nSerial tests may also be recommended, because a single\\nexamine at one moment in time may not reveal the\\nprocess that is occurring.\\n• Tests for thrombocytopenia include coagulation tests\\nrevealing a decreased platelet count, prolonged bleed-\\ning time, and other measurements. If these tests indi-\\ncate that platelet destruction is causing the disorder, the\\nphysician may order bone marrow examination.\\n• V on Willebrand’s disease will be diagnosed with the\\nassistance of laboratory tests which show prolonged\\nbleeding time, absent or reduced levels of factor VIII,\\nnormal platelet count, and others.\\n• Hypothrombinemia is diagnosed with history informa-\\ntion and the use of tests that measure vitamin K defi-\\nciency, deficiency of prothrombin, and clotting factors\\nV , VII, IX, and X.\\n• Factor XI deficiency is diagnosed most often after\\ninjury-related bleeding. Blood tests can help pinpoint\\nfactor VII deficiency.\\nTreatment\\nIn mild cases, treatment may involve the use of\\ndrugs that stimulate the release of deficient clotting fac-\\ntors. In severe cases, bleeding may only stop if the clot-\\nting factor that is missing is replaced through infusion of\\ndonated human blood in the form of fresh frozen plasma\\nor cryoprecipitate.\\nGALE ENCYCLOPEDIA OF MEDICINE 2828\\nCoagulation disorders\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 828'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 217, 'page_label': '218'}, page_content='• Hemophilia A in mild episodes may require infusion of\\na drug called desmopressin or DDA VP. Severe bleeding\\nepisodes will require transfusions of human blood clot-\\nting factors. Hemophiliacs are encouraged to receive\\nphysical therapy to help damaged joints and to exercise\\nin non-contact sports such as swimming, bicycle riding,\\nor walking.\\n• Christmas disease patients are treated similarly to\\nhemophilia A patients. There are commercial products\\nand human blood products available to provide coagu-\\nlation. Cryoprecipitate was invented in 1965 to replace\\nthe need for whole plasma transfusions, which intro-\\nduced more volume than needed. By the 1970s, people\\nwere able to infuse themselves with freeze-dried clot-\\nting factor. Superficial wounds can be cleaned and ban-\\ndaged. Parents of hemophiliac children receiving\\nimmunizations should inform the vaccination provider\\nin advance to decrease the possibility of bleeding prob-\\nlems. These children should probably not receive injec-\\ntions which go into the muscle.\\n• Treatment for disseminated intravascular coagulation\\npatients is complicated by the large variety of underly-\\ning causes of the disorder. If at all possible, the physi-\\ncian will first treat this underlying disorder. If the\\npatient is not already bleeding, this supportive treat-\\nment may eliminate the DIC. However, if bleeding is\\noccurring, the patient may need blood, platelets, fresh\\nfrozen plasma, or other blood products. Heparin has\\nbeen controversial in treating DIC, but it is often used\\nas a last resort to stop hemorrhage. Heparin has not\\nproven useful in treating patients with DIC resulting\\nfrom heat stroke, exotic snakebites, trauma, mis-\\nmatched transfusions, and acute problems resulting\\nfrom obstetrical complications.\\n• Secondary acquired thrombocytopenia is best alleviated\\nby treating the underlying cause or disorder. The specif-\\nic treatment may depend on the underlying cause.\\nSometimes, cortocoosterids or immune globulin may\\nbe given to improve platelet production.\\n• V on Willebrand’s disease is treated by several methods\\nto reduce bleeding time and to replace factor VIII,\\nwhich consequently will replace the V on Willebrand\\nfactor. This may include infusion of cryoprecipitate or\\nfresh frozen plasma. Desmopressin may also help raise\\nlevels of the V on Willebrand factor.\\n• Hypoprothrombinemia may be treated with concen-\\ntrates of prothrombin. Vitamin K may also be produced,\\nand in bleeding episodes, the patient may receive fresh\\nplasma products.\\n• Factor XI (hemophilia C) is most often treated with\\nplasma, since there are no commercially available con-\\ncentrates of factor XI in the United States. Factor VII\\npatients may be treated with prothrombin complex con-\\ncentrates. As of early 1998, factor VII concentrate was\\nnot licensed in the United States and could only be used\\nwith special permission.\\nAlternative treatment\\nThis can be a very severe condition and should be\\nmanaged by a practitioner of alternative medicine in con-\\njunction with a medical doctor; this condition should not\\nbe self managed. For patients known to suffer from hemo-\\nphilia A or B and other bleeding disorders, avoidance of\\nactivities that can cause severe injury should be practiced.\\nComprehensive care addresses the whole person by help-\\ning to deal with the psychosocial aspects of the disease.\\nPrognosis\\nThe prognosis for patients with mild forms of coag-\\nulation disorders is normally good. Many people can\\nlead a normal life and maintain a normal life expectancy.\\nWithout treatment of bleeding episodes, severe muscle\\nand joint pain, and eventually, damage, can occur. Any\\nincident that causes blood to collect in the head, neck, or\\ndigestive system can be very serious and requires imme-\\ndiate attention. DIC can be severe enough to cause clots\\nto form and a stroke could occur. DIC is also serious\\nenough to cause gangrene in the fingers, nose, or geni-\\ntals. The prognosis depends on early intervention and\\ntreatment of the underlying condition. Hemorrhage from\\na coagulation disorder, particularly into the brain or\\ndigestive track, can prove fatal. In the past, patients who\\nreceived regular transfusions of human blood products\\nwere subject to increased risk of AIDS and other dis-\\neases. However, efforts have been made since the early\\n1990s to ensure the safety of the blood supply.\\nPrevention\\nPrevention of coagulation disorders varies. Acquired\\ndisorders may only be prevented by preventing onset of the\\nunderlying disorder (such as cirrhosis). Hereditary disor-\\nders can be predicted with prenatal testing and genetic\\ncounseling. Prevention of severe bleeding episodes may be\\naccomplished by refraining from activities that could cause\\ninjury, such as contact sports. Open communication with\\nhealthcare providers prior to procedures or tests that could\\ncause bleeding may prevent a severe bleeding incident.\\nResources\\nBOOKS\\nBellenir, Karen. Genetic Disorders Sourcebook. Omnigraphics,\\nInc., 1995.\\nPERIODICALS\\nCommunity Alert. New York: National Hemophilia Foundation.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 829\\nCoagulation disorders\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 829'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 218, 'page_label': '219'}, page_content='ORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Hemophilia Foundation. 116 West 32nd St., 11th\\nFloor, New York, NY 10001. 800-424-2634. .\\nTeresa Norris, RN\\nCoagulopathies see Coagulation disorders\\nCoal miner’s disease see Black lung disease\\nCoal worker’s pneumoconiosis see Black\\nlung disease\\nCoarctation of the aorta\\nDefinition\\nA defect that develops in the fetus in which there is a\\nnarrowing of the aortic arch, the main blood artery that\\ndelivers blood from the left ventricle of the heart to the rest\\nof the body. Coarctation of the aorta is diagnosed in both\\nnewborns and adults. Approximately 10% of newborns with\\ncongenital heart diseasehave coarctation of the aorta.\\nDescription\\nBlood leaves the heart by way of the left ventricle\\nand is distributed to the body by arteries. The aortic arch\\nis the first artery to carry blood as it leaves the heart.\\nOther arteries to the head and arms branch off the aortic\\narch. A narrowing of the aorta at any spot produces resis-\\ntance to the flow of blood. This causes high blood pres-\\nsure before the narrowing and low pressure below the nar-\\nrowing (downstream). Parts of the body supplied by arter-\\nies that branch off the aortic arch before the narrowing\\nhave high blood pressure, while most of the lower body\\ndoesn’t receive enough blood supply. To compensate for\\nthis, the heart works harder, and the blood pressure rises.\\nApproximately half of all infants with coarctation of\\nthe aorta are diagnosed within the first two months of\\nlife. Frequently, there are other congenital cardiac com-\\nplications present. Infants with Turner syndromehave a\\n45% rate of also having coarctation. There is evidence\\nthat some cases of coarctation may be inherited.\\nCauses and symptoms\\nIn newborns with congenital heart disease, coarcta-\\ntion of the aorta develops while the baby is in the womb.\\nAmong the consequences of coarctation of the aorta is\\nventricular hypertrophy, an enlarging of the left ventricle\\nin response to the increased back pressure of the blood\\nand the demand for more blood by the body. Symptoms\\nin infants include shortness of breath (dyspnea), diffi-\\nculty in feeding, and poor weight gain. Older children\\nusually don’t have symptoms, but may display fatigue,\\nshortness of breath, or a feeling of lameness in their legs.\\nDiagnosis\\nInfants usually have an abnormal “gallop” heart\\nrhythm and may also have heart murmurs . Sometimes\\nexcessive arterial pulses can be seen in the carotid and\\nsuprasternal notch arteries, indicating increased pressure\\nin these arteries, while the femoral pulse is weak or can’t\\nbe detected. The systolic pressure is higher in the arms\\nthan in the legs. Enlargement of the heart can be seen in x\\nrays. Similar symptoms are seen in older children and\\nadults. A 10 mm Hg (mercury) pressure difference\\nbetween the upper and lower extremities is diagnostic for\\ncoarctation of the aorta. For some patients, the systolic\\npressure difference is observed only during exercise .\\nInfants frequently have an abnormal electrocardiogram\\n(ECG) that indicates that the right or both ventricles are\\nenlarged, while in older children the ECG may be normal\\nor show that the left ventricle is enlarged. The coarctation\\nmay be detected in echocardiographic examination.\\nTreatment\\nDrugs can be used to treat the hypertension and\\nheart failure . Surgery is recommended for infants with\\nother, associated cardiac defects and for those infants not\\nresponding to drug therapy. Surgery is indicated for\\ninfants that don’t require immediate surgery, but who\\ndevelop severe hypertension during the first several\\nmonths of life. Patients are advised to avoid vigorous\\nexercise prior to surgical correction of the coarctation.\\nRecoarctation can occur in some patients, even if they\\nhave had surgery.\\nPrognosis\\nApproximately half of all infants diagnosed with\\ncoarctation of the aorta have no other cardiac defects and\\nwill respond well to medical management. Most of these\\nchildren will eventually outgrow the condition after sev-\\neral years of life. Although their hypertension may\\nincrease for several months early in life, it will eventually\\ndecrease as the circulatory system develops. Surgery is\\nrequired for infants that have severe coarctation of the\\naorta or have associated cardiac defects. The average life\\nspan of children who have coarctation of the aorta is 34\\nGALE ENCYCLOPEDIA OF MEDICINE 2830\\nCoarctation of the aorta\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 830'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 219, 'page_label': '220'}, page_content='years of age. The most common complications for chil-\\ndren who have not had surgery are hypertension, aortic\\nrupture, intracranial bleeding, and congestive heart fail-\\nure. Women who have an uncorrected coarctation of the\\naorta have a mortality rate of 10% during pregnancy and\\na 90% rate of complications.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V . Fuster, eds. The Heart.\\n9th ed. New York: McGraw-Hill, 1998.\\nBerkow, Robert, ed. Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research Laboratories,\\n1997.\\nJohn T. Lohr, PhD\\nCocaine\\nDefinition\\nCocaine is a highly addictive central nervous system\\nstimulant extracted from the leaves of the coca plant,\\nErythroxylon coca.\\nDescription\\nIn its most common form, cocaine is a whitish crys-\\ntalline powder that produces feelings of euphoria when\\ningested.\\nNow classified as a Schedule II drug, cocaine has\\nlegitimate medical uses as well as a long history of recre-\\national abuse. Administered by a licensed physician, the\\ndrug can be used as a local anesthetic for certain eye and\\near problems and in some kinds of surgery.\\nForms of the drug\\nIn powder form, cocaine is known by such street\\nnames as “coke,” “blow,” “C,” “flake,” “snow” and\\nKEY TERMS\\nDyspnea—Difficulty in breathing. Usually associ-\\nated with heart or lung diseases.\\nElectrocardiogram—A graph of the heart’s beating\\nproduced by an instrument that detects the electri-\\ncal signals made by the heart.\\n“toot.” It is most commonly inhaled or “snorted.” It may\\nalso be dissolved in water and injected.\\nCrack is a smokable form of cocaine that produces\\nan immediate and more intense high. It comes in off-\\nwhite chunks or chips called “rocks.” Little crumbs of\\ncrack are sometimes called “kibbles & bits.”\\nIn addition to their stand-alone use, both cocaine and\\ncrack are often mixed with other substances. Cocaine\\nmay be mixed with methcathinone (a more recent drug of\\nabuse, known as “cat,” that is similar to methampheta-\\nmine) to create a “wildcat.” A hollowed-out cigar filled\\nwith a mixture of crack and marijuana is known as a\\n“woolah.” And either cocaine or crack used in conjunc-\\ntion with heroin is called a “speedball.” Cocaine used\\ntogether with alcohol represents the most common fatal\\ntwo-drug combination.\\nHistory\\nCocaine is one of the oldest known psychoactive\\ndrugs. Coca leaves, the source of cocaine, were used by\\nthe Incas and other inhabitants of the Andean region of\\nSouth America for thousands of years, both as a stimu-\\nlant and to depress appetite and combat apoxia ( altitude\\nsickness).\\nDespite the long history of coca leaf use, it was not\\nuntil the latter part of the nineteenth century that the\\nactive ingredient of the plant, cocaine hydrochloride, was\\nfirst extracted from those leaves. The new drug soon\\nbecame a common ingredient in patent medicines and\\nother popular products (including the original formula\\nfor Coca-Cola). This widespread use quickly raised con-\\ncerns about the drug’s negative effects. In the early\\n1900s, several legislative steps were taken to address\\nthose concerns; the Harrison Act of 1914 banned the use\\nof cocaine and other substances in non-prescription prod-\\nucts. In the wake of those actions, cocaine use declined\\nsubstantially.\\nThe drug culture of the 1960s sparked renewed\\ninterest in cocaine. With the advent of crack in the 1980s,\\nuse of the drug had once again become a national prob-\\nlem. Cocaine use declined significantly during the early\\n1990s, but it remains a significant problem and is on the\\nincrease in certain geographic areas and among certain\\nage groups.\\nCauses and symptoms\\nAs with other forms of addiction , cocaine abuse is\\nthe result of a complex combination of internal and\\nexternal factors. Genetic predisposition, family history,\\nand immediate environment can all affect a person’s\\nprobability of becoming addicted.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 831\\nCocaine\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 831'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 220, 'page_label': '221'}, page_content='As many as three to four million people are estimat-\\ned to be chronic cocaine users. The 1997 National\\nHousehold Survey on Drug Abuse reported an estimated\\n600,000 current crack users, showing no significant\\nchange since the late 1980s.\\nHow cocaine affects the brain\\nExtensive research has been conducted to determine\\nhow cocaine works on the brain and why it is so addictive.\\nCocaine has been found to affect an area of the brain\\nknown as the ventral tegmental area (VTA), which con-\\nnects with the nucleus accumbens, a major pleasure cen-\\nter. Like other commonly abused addictive drugs,\\ncocaine’s effects are related to the action of the neuro-\\ntransmitter dopamine, which carries information between\\nneurons. Cocaine interferes with the normal functioning\\nof neurons by blocking the re-uptake of dopamine, which\\nbuilds up in the synapses and is believed to cause the\\npleasurable feelings reported by cocaine users.\\nShort-term effects of use\\nThe short-term effects of cocaine can include:\\n• rapid heartbeat\\n• constricted blood vessels\\n• dilated pupils\\n• increased temperature\\n• increased energy\\n• reduced appetite\\n• increased sense of alertness\\n• euphoria\\n• death due to overdose\\nLong-term effects of use\\nThe long-term effects of cocaine and crack use\\ninclude:\\n• dependence, addiction\\n• irritability\\n• mood swings\\n• restlessness\\n• weight loss\\n• auditory hallucinations\\n• paranoia\\nCocaine use and pregnancy\\nThe rise in cocaine use as well as the appearance of\\ncrack cocaine in the late 1980s spurred fears about its\\neffects on the developing fetus and, since then, several\\nresearch reports have suggested that prenatal cocaine use\\ncould be associated to a wide range of fetal, newborn,\\nand child development problems. According to the The\\nLindesmith Center-Drug Policy Foundation, many of\\nthese early reports had methodological flaws, and most\\nresearchers nowadays propose more cautious conclu-\\nsions concerning prenatal cocaine effects. Much evi-\\ndence would seem to point to the lack of quality prenatal\\ncare and the use of alcohol and tobacco as primary fac-\\ntors in poor fetal development among pregnant cocaine\\nusers. Research sponsored by the National Institute on\\nDrug Abuse (NIDA) and the Albert Einstein Medical\\nCenter in Philadelphia corroborate the Lindensmith Cen-\\nter findings in reporting that the lack of quality prenatal\\ncare is associated with undesirable effects often attrib-\\nuted to cocaine exposure such as prematurity, low birth\\nweight, and fetal or infant death. The Center for Disease\\nControl and Prevention (CDC) however, reports that\\nmothers who use cocaine early in pregnancy are five\\ntimes as likely to have a baby with a malformation of the\\nurinary tract as mothers who do not use the drug. Thus,\\ncocaine use during pregnancy is assuredly most inadvis-\\nable, especially since it is also often associated with the\\nuse of alcohol known to cause long-term developmental\\nproblems. Supporting the cocaine-exposed expecting\\nmother so as to discourage cocaine use remains an\\nimportant task for all health caregivers.\\nDiagnosis\\nDiagnosing cocaine addiction can be difficult.\\nMany of the signs of short-term cocaine use are not\\nobvious. Since cocaine users often also use other drugs,\\nit may not be easy to distinguish the effects of one drug\\nfrom another.\\nCocaine use has been documented in significant\\nnumbers of eighth graders as well as older teens. Over all\\nage groups, more men than women use the drug. The\\nhighest rate of cocaine use is found among adults 18 to\\n25 years old.\\nMedical complications\\nCocaine has been linked to several serious health\\nproblems, including:\\n• arrhythmia\\n• heart attacks\\n• chest pain\\n• respiratory failure\\n• strokes\\n• seizures\\nGALE ENCYCLOPEDIA OF MEDICINE 2832\\nCocaine\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 832'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 221, 'page_label': '222'}, page_content='Other complications may vary depending on how\\nthe drug is administered. Prolonged snorting, for exam-\\nple, can irritate the nasal septum, producing nosebleeds,\\nchronic runny nose, and other problems. Intravenous\\nusers face an increased risk of infectious diseases such as\\nHIV/AIDS and hepatitis.\\nTesting\\nDrug testing can be useful in diagnosing and treating\\ncocaine abuse. Urine testing can detect cocaine; besides\\nproviding an objective alternative to reliance on what a\\npatient says, such tests can also be used as a follow-up to\\ntreatment to confirm that the patient has remained drug-free.\\nTreatment\\nThe last two decades have seen a dramatic rise in the\\nnumber of cocaine addicts seeking treatment. But like all\\nforms of drug abuse, cocaine abuse/addiction is a multi-\\nfaceted phenomenon involving environmental, social,\\nand familial as well as physiological factors. This greatly\\ncomplicates the challenge of effectively treating cocaine\\naddiction.\\nPharmacological treatments\\nTo date, no medications have been approved specifi-\\ncally for treating cocaine addiction. But several were\\nunder development at this writing. Selegeline, delivered\\neither via a time-release pill or a transdermal patch,\\nshows promise as a possible anti-cocaine medication.\\nClinical studies have shown the drug disulfiram (also\\nused to treat alcoholics) to be effective in treating\\ncocaine abusers. In addition, antidepressant medications\\nare sometimes used to control the mood swings associat-\\ned with the early stages of cocaine withdrawal.\\nBehavioral approaches\\nA wide range of behavioral interventions have been\\nsuccessfully used to treat cocaine addiction. The\\napproach used must be tailored to the specific needs of\\neach individual patient, however.\\nContingency management rewards drug abstinence\\n(confirmed by urine testing) with points or vouchers\\nwhich patients can exchange for such things as an\\nevening out or membership in a gym. Cognitive-behav-\\nioral therapy helps users learn to recognize and avoid\\nsituations most likely to lead to cocaine use and to devel-\\nop healthier ways to cope with stressful situations. Resi-\\ndential programs/therapeutic communities may also be\\nhelpful, particularly in more severe cases. Patients typi-\\ncally spend six to 12 months in such programs, which\\nmay also include vocational training and other features.\\nKEY TERMS\\nApoxia—Apoxia refers to altitude sickness.\\nArrhythmia—Irregular heartbeat.\\nCentral nervous system —Part of the nervous sys-\\ntem consisting of the brain, cranial nerves and\\nspinal cord. The brain is the center of higher\\nprocesses, such as thought and emotion and is\\nresponsible for the coordination and control of\\nbodily activities and the interpretation of informa-\\ntion from the senses. The cranial nerves and spinal\\ncord link the brain to the peripheral nervous sys-\\ntem, that is the nerves present in the rest of body.\\nNasal septum —The membrane that separates the\\nnostrils.\\nNeurotransmitter —A chemical that carries nerve\\nimpulses across a synapse.\\nSynapse—The gap between two nerve cells.\\nAlternative treatment\\nVarious alternative or complementary approaches\\nhave been used in treating cocaine addiction, often in\\ncombination with more conventional therapies. In Japan,\\nthe herb acorus has been traditionally used both to assist\\nearly-stage cocaine withdrawal and in later recovery\\nstages. Other herbs sometimes used to treat drug addic-\\ntions of various kinds include kola nut, guarana seed and\\nyohimbe (to boost short-term energy), and valerian root,\\nhops leaf, scullcap leaf, and chamomile (to calm the\\npatient). The amino acids phenylalanine and tyrosine\\nhave been used to reduce cocaine addicts’ craving for the\\ndrug, and vitamin therapy may be used to help strengthen\\nthe patient. Gentle massage has been used to help infants\\nborn with congenital cocaine addiction. Other tech-\\nniques, such as acupuncture , EEG biofeedback , and\\nvisualization, may also be useful in treating addiction.\\nPrognosis\\nBecause addiction involves so many different factors,\\nprospects for individual addicts vary widely. However,\\nresearch has consistently shown that treatment can signifi-\\ncantly reduce both drug abuse and subsequent criminal\\nactivity. The comprehensive Services Research Outcomes\\nStudy (1998) found a 45% drop in cocaine use five years\\nafter treatment, compared to use during the five years before\\ntreatment. The study also found that females generally\\nrespond better to treatment than males, and older patients\\ntend to reduce their drug use more than younger patients.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 833\\nCocaine\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 833'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 222, 'page_label': '223'}, page_content='Some research also supports the idea that 12-step\\nprograms used in conjunction with other approaches can\\nsignificantly enhance the prospects for a positive out-\\ncome. One study of people in outpatient drug-treatment\\nprograms found that participation in a 12-step program\\nnearly doubled their chances of remaining drug-free.\\nPrevention\\nDespite significant variation over time, cocaine\\naddiction has proven to be a persistent public health prob-\\nlem. Interdiction and source control are expensive and\\nhave failed to eliminate the problem, and some law\\nenforcement officials are now recommending more\\nemphasis on demand reduction through education and\\nother measures to address the causes of cocaine addiction.\\nResources\\nBOOKS\\nGold, Mark S. Cocaine (and Crack): Clinical Aspects (181-\\n198), Substance Abuse: A Comprehensive Textbook.Balti-\\nmore: Williams & Wilkins, 1997.\\nPERIODICALS\\nAvants, S. Kelly. “A Randomized Controlled Trial of Auricular\\nAcupuncture for Cocaine Dependence.”JAMA (22\\nNovember 2000).\\nHarvey, John A., and Barry Kosofsky, eds. “Cocaine: Effects\\non the Developing Brain.”Annals of the New York Acade-\\nmy of Sciences 846 (1998).\\nLeDuff, Charlie. “Cocaine Quietly Reclaims Its Hold as Good\\nTimes Return.”New York Times(21 August 2000): 2.\\nGoode, Erica. “Acupuncture Helps Some Quell Need for\\nCocaine.” New York Times(15 August 2000): D7.\\nORGANIZATIONS\\nCocaine Anonymous. 6125 Washington Blvd. Suite 202, Cul-\\nver City, CA 90232. (800) 347-8998.\\nNar-Anon Family Group Headquarters, Inc. P.O. Box 2562,\\nPalos Verdes Peninsula, CA 90274. (310) 547-5800.\\nPeter Gregutt\\nCoccidioidomycosis\\nDefinition\\nCoccidioidomycosis is an infection caused by inhal-\\ning the microscopic spores of the fungus Coccidioides\\nimmitis. Spores are the tiny, thick-walled structures that\\nfungi use to reproduce. Coccidioidomycosis exists in\\nthree forms. The acute form produces flu-like symptoms.\\nThe chronic form can develop as many as 20 years after\\ninitial infection and, in the lungs, can produce inflamed,\\ninjured areas that can fill with pus (abscesses). Dissemi-\\nnated coccidioidomycosis describes the type of coccid-\\nioidomycosis that spreads throughout the body affecting\\nmany organ systems and is often fatal.\\nDescription\\nCoccidioidomycosis is an airborne infection. The\\nfungus that causes the disease is found in the dry desert\\nsoil of the southwestern United States, Mexico, and Cen-\\ntral and South America. Coccidioidomycosis is some-\\ntimes called San Joaquin fever, valley fever, or desert\\nfever because of its prevalence in the farming valleys of\\nCalifornia. Although commonly acquired, overt coccid-\\nioidomycosis is a rare disease. Chronic infections occur\\nin only one out of every 100,000 people.\\nAlthough anyone can get coccidioidomycosis, farm\\nlaborers, construction workers, and archaeologists who\\nwork where it is dusty are at greater risk to become\\ninfected. People of any age can get coccidioidomycosis,\\nbut the disease most commonly occurs in the 25–55 age\\ngroup. In its acute form, coccidioidomycosis infects men\\nand women equally.\\nChronic and disseminated forms of coccidioidomy-\\ncosis occur more frequently in men and pregnant women.\\nAlthough it is not clear why, people of color are 10-20\\ntimes more likely to develop the disseminated form of\\nthe disease than caucasians. People who have a weak-\\nened immune system (immunocompromised), either\\nfrom diseases such as AIDS or leukemia, or as the result\\nof medications that suppressed the immune system ( cor-\\nticosteroids, chemotherapy), are more likely to develop\\ndisseminated coccidioidomycosis.\\nCauses and symptoms\\nWhen the spores of C. immitis are inhaled, they can\\nbecome lodged in the lungs, divide, and cause localized\\ninflammation. This is known as acute or primary coccid-\\nioidomycosis. The disease is not spread from one person\\nto another. Approximately 60% of people who are infect-\\ned exhibit no symptoms (asymptomatic). In the other\\n40%, symptoms appear 10–30 days after exposure.\\nThese symptoms include a fever which can reach 104°F\\n(39.5°C), dry cough, chest pains, joint and muscle aches,\\nheadache , and weight loss. About two weeks after the\\nstart of the fever, some people develop a painful red rash\\nor lumps on the lower legs. Symptoms usually disappear\\nwithout treatment in about one month. People who have\\nbeen infected gain partial immunity to reinfection.\\nThe chronic form of coccidioidomycosis normally\\noccurs after a long latent period of 20 or more years dur-\\ning which the patient experiences no symptoms of the\\ndisease. In the chronic phase, coccidioidomycosis causes\\nGALE ENCYCLOPEDIA OF MEDICINE 2834\\nCoccidioidomycosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 834'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 223, 'page_label': '224'}, page_content='lung abscesses that rupture, spilling pus and fluid into the\\nlungs, and causing serious damage to the lungs. The\\npatient experiences difficulty breathing and has a fever,\\nchest pain, and other signs of pneumonia. Medical treat-\\nment is essential for recovery.\\nIn its disseminated form, coccidioidomycosis\\nspreads to other parts of the body including the liver,\\nbones, skin, brain, heart, and lining around the heart\\n(pericardium). Symptoms include fever, joint pain, loss\\nof appetite, weight loss, night sweats, skin lesions , and\\ndifficulty breathing. Also, in 30–50% of patients with\\ndisseminated coccidioidomycosis, the tissue coverings of\\nthe brain and spinal cord become inflamed (meningitis).\\nDiagnosis\\nMany cases of coccidioidomycosis go undiagnosed\\nbecause the symptoms resemble those of common viral\\ndiseases. However, a skin test similar to that for tubercu-\\nlosis will determine whether a person has been infected.\\nThe test is simple and accurate, but it does not indicate\\nwhether the disease was limited to its acute form or if it\\nhas progressed to its chronic form.\\nDiagnosis of chronic or disseminated coccidioidomy-\\ncosis is made by culturing a sample of sputum or other\\nbody fluids in the laboratory to isolate the fungus. A blood\\nserum test is used to detect the presence of an antibody pro-\\nduced in response to C. immitis infection. Chest x rays are\\noften used to assess lung damage, but alone cannot lead to\\na definitive diagnosis of coccidioidomycosis because other\\ndiseases can produce similar results on the x ray.\\nTreatment\\nIn most cases of acute coccidioidomycosis, the\\nbody’s own immune system is adequate to bring about\\nrecovery without medical intervention. Fever and pain\\ncan be treated with non-prescription drugs.\\nChronic and disseminated coccidioidomycosis, how-\\never, are serious diseases that require treatment with pre-\\nscription drugs. Patients with intact immune systems who\\ndevelop chronic coccidiodomycosis are treated with the\\ndrug ketoconazole (Nizoral) or amphotericin B (Fungi-\\nzone). Patients with suppressed immune systems are treat-\\ned with amphotericin B (Fungizone). Amphotericin B is a\\npowerful fungistatic drug with potentially toxic side\\neffects. As a result, hospitalization is required in order to\\nmonitor patients. The patient may also receive other drugs\\nto minimize the side effects of the amphotericin B.\\nPatients with AIDS must continue to take itracona-\\nzole (Sporonox) or fluconazole (Diflucan) orally or\\nreceive weekly intravenous doses of amphotericin B for\\nthe rest of their lives in order to prevent a relapse.\\nBecause of the high cost of fluconazole, Pfizer, the man-\\nKEY TERMS\\nAbscess —An area of inflamed and injured body\\ntissue that fills with pus.\\nAcidophilus —The bacteria Lactobacillus aci-\\ndophilus that usually found in yogurt.\\nAntibody —A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAntigen —A foreign protein to which the body\\nreacts by making antibodies.\\nAsymptomatic —Persons who carry a disease but\\nwho do not exhibit symptoms of the disease are\\nsaid to be asymptomatic.\\nBifidobacteria—A group of bacteria normally pre-\\nsent in the intestine. Commercial supplements\\ncontaining these bacteria are available.\\nCorticosteroids —A group of hormones produced\\nnaturally by the adrenal gland or manufactured syn-\\nthetically. They are often used to treat inflammation.\\nExamples include cortisone and prednisone.\\nImmunocompromised —A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nMeningitis —An inflammation of the membranes\\nsurrounding the brain or spinal cord.\\nPericardium—The tissue sac around the heart.\\nufacturer of the drug, has established a financial assis-\\ntance plan to make the drug available at lower cost to\\nthose who meet certain criteria. Patients needing this\\ndrug should ask their doctors about this program.\\nAlternative treatment\\nAlternative treatment for fungal infections focuses\\non creating an internal environment where the fungus\\ncannot survive. This is accomplished by eating a diet low\\nin dairy products, sugars, including honey and fruit juice,\\nand foods like beer that contain yeast. This is comple-\\nmented by a diet consisting, in large part, of uncooked\\nand unprocessed foods. Supplements of vitamins C, E,\\nA-plus, and B complex may also be useful. Lactobacillus\\nacidophilus and Bifidobacterium will replenish the good\\nbacteria in the intestines. Antifungal herbs, like garlic\\n(Allium sativum ), can be consumed in relatively large\\ndoes and for an extended period of time in order to\\nincrease effectiveness.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 835\\nCoccidioidomycosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 835'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 224, 'page_label': '225'}, page_content='Prognosis\\nMost people who are infected with coccidiodomycosis\\nonly suffer from the mild, acute form of the disease and\\nrecover without further complications. Patients who suffer\\nfrom chronic coccidiodomycosis and who have no underly-\\ning lung or immune system diseases also stand a good\\nchange of recovery, although they must be alert to a relapse.\\nThe picture for patients with the disseminated form of\\nthe disease, many of whom have AIDS, is less positive.\\nUntreated disseminated coccidiodomycosis is almost\\nalways fatal within a short time. With treatment, chance of\\nsurvival increases, but the death rate remains high when\\nmeningitis or diffuse lung (pulmonary) disease is present.\\nAIDS patients must constantly guard against relapse.\\nPrevention\\nBecause the fungus that causes coccidioidomycosis\\nis airborne and microscopic, the only method of preven-\\ntion is to avoid visiting areas where it is found in the soil.\\nUnfortunately, for many people this is impractical. Main-\\ntaining general good health and avoiding HIV infection\\nwill limit coccidioidomycosis to the acute and relatively\\nmild form in most people.\\nResources\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nCanadian HIV/AIDS Clearinghouse. 1565 Carling Avenue,\\nSuite 400, Ottawa, ON K1Z 8R1. (877) 999-7740. .\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nNational Aids Hotline. (800) 342-2437.\\nProject Inform. 205 13th Street, #2001, San Francisco, CA\\n94103. (800) 822-7422. .\\nOTHER\\nPowderly, William G. “Coccidioidomycosis.”Journal of the\\nInternational Association of Physicians in AIDS Care.\\nDec. 1996 .\\nTish Davidson\\nCoccyx injuries\\nDefinition\\nThe coccyx—or tailbone—is the last bone of the\\nvertebral column, and usually consists of three to five\\nfused vertebrae that connect with the sacrum, a part of\\nthe pelvis.\\nDescription\\nThe coccyx consists of fused vertebrae, which are\\nnot flexible like the other vertebrae of the vertebral col-\\numn which are all interspaced by intervertebral disks and\\njoined together by elastic ligaments. Since the spinal\\ncord ends just before the coccyx begins, coccygeal verte-\\nbrae also lack a central foramen (hole). In the coccyx, the\\nvertebrae generally fuse together in early adulthood and\\nmay also fuse with the sacrum, the bone located between\\nthe 5th lumbar vertebra and the coccyx, as a person ages.\\nIn males, the coccyx curves downward, and in females, it\\nis straighter to allow a baby to pass through the birth\\ncanal without impediment.\\nPain in or around the coccyx is called coccydynia or\\ncoccygodynia. Coccydynia presents a range of symptoms\\nassociated to a variety of underlying causes and conditions.\\nCauses and symptoms\\nCauses\\nCoccydynia can be caused by a number of factors.\\nUsually, patients report pain after a fall onto their but-\\ntocks, as occurs when going down stairs or while skating.\\nOthers have pain during pregnancy or after childbirth.\\nSome experience repetitive strain from rowing or cycling,\\nand some cite anal intercourse as the cause of pain. In\\nmany cases, pain derives from a malformation of the coc-\\ncyx itself. Sometimes bony spurs appear on the coccyx,\\nbut only seem to be painful in thin patients who do not\\nhave the padding to protect the region from the spur.\\nOther causes of coccydynia include cancer or dam-\\nage to the sacrum that generates referred pain, meaning\\npain that appears in one region but originates from anoth-\\ner. Muscle strain or tension, pinched nerves or damaged\\nnerves, or dislocation of the coccyx due to gross obesity\\nare other causes.\\nSymptoms\\nThe most common symptom of coccydynia, irre-\\nspective of the cause of the condition, is pain when sit-\\nting, or when rising from a sitting position. If the condi-\\ntion lasts long enough, the patient may even experience\\npain when standing or lying down. Sometimes, numb-\\nness occurs in the lower part of the spine. Some patients\\nwill experience pain during bowel movements, sexual\\nintercourse, or menstruation.\\nSecondary symptoms include back pain from sitting\\nin odd positions in order to relieve pain, and painful feet\\nfrom standing too much, because patients avoid sitting.\\nGALE ENCYCLOPEDIA OF MEDICINE 2836\\nCoccyx injuries\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 836'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 225, 'page_label': '226'}, page_content='Sometimes the entire buttocks experience pain. Rarely,\\nexhaustion, depression, and lack of sleep may occur.\\nDiagnosis\\nDiagnosis of fracture is usually made by inserting a\\ngloved finger in the rectum and pressing on the coccyx.\\nX rays and magnetic resonance imaging (MRI) are also\\noften used. Since coccyx pain may be the result of other\\nfactors like cancer, these must be ruled out through a\\nvariety of tests before treatment can begin.\\nTreatment\\nTreatment exists to either control the pain or elimi-\\nnate the cause. Pain control may be dangerous if an\\nKEY TERMS\\nCoccyx—The last bone of the spinal column, con-\\nsisting of three to five fused vertebrae that connect\\nwith the sacrum, a part of the pelvis.\\nCoccydynia—Also called coccygodynia. Pain in or\\naround the coccyx.\\nForamen—A small opening, perforation, or orifice.\\nMagnetic resonance imaging (MRI) —An imaging\\ntechnique that produces pictures of the inside of\\nthe body.\\nSacrum—The triangle-shaped bone located\\nbetween the fifth lumbar vertebra and the coccyx\\nthat consists of five vertebrae fused together. The\\nsacrum joins on each side with the bones of the\\npelvis.\\nSpinal cord —Elongated nerve bundles that lie in\\nthe vertebral canal and from which the spinal\\nnerves emerge.\\nVertebrae—Bones in the cervical, thoracic, and\\nlumbar regions of the body that make up the verte-\\nbral column. Vertebrae have a central foramen\\n(hole), and their superposition makes up the verte-\\nbral canal that encloses the spinal cord.\\nVertebral column —The vertebral column, also\\ncalled the spinal column or spine, consists of a\\nseries of vertebrae connected by ligaments. It pro-\\nvides a supporting axis for the body and protects\\nthe spinal cord. The vertebral column consists of\\nseven cervical vertebrae in the neck, followed by\\n12 thoracic vertebrae that connect to the ribs, five\\nlumbar vertebrae in the lower back, the sacrum,\\nand the coccyx.\\nunderlying condition exists of which the pain is a warn-\\ning sign. Nerve blocks and a variety of drugs are other\\noptions to control pain.\\nElimination of the root cause of the pain is ideal.\\nThis is done through careful diagnosis and the applica-\\ntion of manual treatments, corticosteroid injections into\\nthe coccyx vertebrae, or surgery. Injections into the\\nfourth and fifth sacral nerves and coccygeal nerves often\\nbring relief, but are considered more as a pain control\\nmeasure than as curative treatment. Manual treatments\\nhave not been found to be effective. Surgery is a radical\\nprocedure whose indications are inconsistent and depen-\\ndent on the subjectivity of the physician.\\nPrognosis\\nWith current treatment, prognosis is good and\\npatients usually are able to live pain free.\\nPrevention\\nThere probably is no real prevention, expect weight\\ncontrol. Some women may choose to give birth through\\nceasarian section instead of vaginally after an episode of\\ncoccyx pain from a previous delivery.\\nResources\\nOTHER\\nMaigne, Jean-Yves. “Treatment Strategies for Coccydynia.”\\nMay 7, 2001 .\\n“Treatments for Coccydynia.” May 7, 2001 .\\n“What is Coccydynia?” May 7, 2001 .\\nJanie Franz\\nCochlear implants\\nDefinition\\nA cochlear implant is a surgical treatment for hear-\\ning loss that works like an artificial human cochlea in the\\ninner ear, helping to send sound from the ear to the brain.\\nIt is different from a hearing aid, which simply amplifies\\nsound.\\nPurpose\\nA cochlear implant bypasses damaged hair cells and\\nhelps establish some degree of hearing by stimulating the\\nhearing (auditory) nerve directly.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 837\\nCochlear implants\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 837'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 226, 'page_label': '227'}, page_content='Precautions\\nBecause the implants are controversial, very expen-\\nsive, and have uncertain results, the U.S. Food and Drug\\nAdministration (FDA) has limited the implants to people:\\n• who get no significant benefit from hearing aids\\n• who are at least 2 years old (the age at which specialists\\ncan verify severity of deafness)\\n• with severe to profound hearing loss.\\nDescription\\nHearing loss is caused by a number of different\\nproblems that occur either in the hearing nerve or parts of\\nthe middle or inner ear. The most common type of deaf-\\nness is caused by damaged hair cells in the cochlea, the\\nhearing part of the inner ear. Normally, hair cells stimu-\\nlate the hearing nerve, which transmits sound signals to\\nthe brain. When hair cells stop functioning, the hearing\\nnerve remains unstimulated, and the person can’t hear.\\nHair cells can be destroyed by many things, including\\ninfection, trauma, loud noise, aging, or birth defects.\\nAll cochlear implants consist of a microphone\\nworn behind the ear that picks up sound and sends it\\nalong a wire to a speech processor, which is worn in a\\nsmall shoulder pouch, pocket, or belt. The processor\\nboosts the sound, filters out background noise, and\\nturns sound into digital signals before sending it to a\\ntransmitter worn behind the ear. A magnet holds the\\ntransmitter in place through its attraction to the\\nreceiver-stimulator, a part of the device that is surgical-\\nly attached beneath the skin in the skull. The receiver\\npicks up digital signs forwarded by the transmitter, and\\nconverts them into electrical impulses. These electrical\\nimpulses flow through electrodes contained in a narrow,\\nflexible tube that has been threaded into the cochlea.\\nAs many as 24 electrodes (depending on the type of\\nimplant) carry the impulses that stimulate the hearing\\nnerve. The brain then interprets the signals as specific\\nsounds.\\nDespite the benefits that the implant appears to offer,\\nsome hearing specialists and members of the deaf com-\\nmunity still believe that the benefits may not outweigh\\nthe risks and limitations of the device. Because the\\ndevice must be surgically implanted, it carries some sur-\\ngical risk. Also, manufacturers can’t promise how well a\\nperson will hear with an implant. Moreover, after getting\\nan implant, some people say they feel alienated from the\\nDeaf community, while at the same time not feeling fully\\na part of the hearing world.\\nThe sounds heard through an implant are different\\nfrom the normal hearing sounds, and have been\\ndescribed as artificial or “robotlike.” This is because the\\nimplant’s handful of electrodes cannot hope to match the\\ncomplexity of a person’s 15,000 hair cells.\\nSurgical procedure\\nDuring the procedure, the surgeon makes an incision\\nbehind the ear and opens the mastoid bone (the ridge on\\nthe skull behind the ear) leading into the middle ear. The\\nsurgeon then places the receiver-stimulator in the bone,\\nand gently threads the electrodes into the cochlea. This\\noperation takes between one and one-half to five hours.\\nPreparation\\nBefore a person gets an implant, specialists at an\\nimplant clinic conduct a careful evaluation, including\\nextensive hearing tests to determine how well the candi-\\ndate can hear.\\nUnfortunately, it is not possible to predict who will\\nbenefit from an implant. In general, the later in life a per-\\nson becomes deaf, and the shorter the duration of deaf-\\nness, the better the person is likely to understand speech\\nwith an implant. Likewise,someone with a healthy hearing\\nnerve will do better than someone with a damaged nerve.\\nFirst, candidates undergo a trial with a powerful hear-\\ning aid. If the aid can’t improve hearing enough, a physi-\\ncian then performs a physical exam and orders a scan of\\nthe inner ear (some patients with a scarred cochlea aren’t\\ngood candidates). A doctor may also order a psychological\\nexam to better understand the person’s expectations.\\nPatients need to be highly motivated, and have a realistic\\nunderstanding of what an implant can and cannot do.\\nAftercare\\nThe patient remains in the hospital for a day or two\\nafter the surgery. After a month, the surgical wounds will\\nGALE ENCYCLOPEDIA OF MEDICINE 2838\\nCochlear implants\\nA close-up view of a cochlear implant.(Photograph by L.\\nSteinmark, Custom Medical Stock Photo. Reproduced by per-\\nmission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 838'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 227, 'page_label': '228'}, page_content='have healed and the patient returns to the implant clinic\\nto be fitted with the external parts of the device (the\\nspeech processor, microphone, and transmitter). A clini-\\ncican tunes the speech processor and sets levels of stimu-\\nlation for each electrode, from soft to loud.\\nThe patient is then trained in how to interpret the\\nsounds heard through the device. The length of the train-\\ning varies from days to years, depending on how well the\\nperson can interpret the sounds heard through the device.\\nRisks\\nAs with all operations, there are a few risks of\\nsurgery. These include:\\n• dizziness\\n• facial paralysis (rarely)\\n• infection at the incision site\\nScientists aren’t sure about the long-term effects of\\nelectrical stimulation on the nervous system. It is also\\npossible to damage the implant’s internal components\\nby a blow to the head, which will render the device\\nunworkable.\\nNormal results\\nMost profoundly, deaf patients who receive an\\nimplant are able to discern medium and loud sounds,\\nincluding speech, at comfortable listening levels. Many\\nuse sound clues from the implant, together with speech\\nreading and other facial cues. Almost all adults improve\\ntheir communication skills when combining the implant\\nwith speech reading (lip reading), and some can under-\\nstand spoken words without speech reading. More than\\nhalf of adults who lost hearing after they learned to speak\\ncan understand some speech without speech reading.\\nAbout 30% can understand spoken sounds well enough\\nto use the phone.\\nChildren who were born deaf or who lost their hear-\\ning before they could speak have the most difficulty in\\nlearning to use the implant. Research suggests, however,\\nthat most of these children are able to learn spoken lan-\\nguage and understand speech using the implant.\\nResources\\nBOOKS\\nClark, Graeme M., Robert S. C. Cowan, and Richard Dowell.\\nCochlear Implantation for Infants and Children.New\\nYork: Singular Publishing Group, 1997.\\nTye-Murray, Nancy. Cochlear Implants and Children: A Hand-\\nbook for Parents.New York: Alexander Graham Bell\\nAssociation for the Deaf, 1992.\\nKEY TERMS\\nCochlea —The hearing part of the inner ear. This\\nsnail-shaped structure contains fluid and thou-\\nsands of microscopic hair cells tuned to various\\nfrequencies.\\nHair cells—Sensory receptors in the inner ear that\\ntransform sound vibrations into messages that trav-\\nel to the brain.\\nInner ear —The interior section of the ear, where\\nsound vibrations and information about balance\\nare translated into nerve impulses.\\nMiddle ear —The small cavity between the\\neardrum and the oval window that houses the\\nthree tiny bones of hearing.\\nPERIODICALS\\nArana-Ward, Marie. “The Pros and Cons of Cochlear\\nImplants.” Newsday, 3 June 1997, B29.\\nPlatman, Cheryl. “Hearing aids: A Link to the World.”FDA\\nConsumer 24 (1 Feb. 1990): 18-23.\\nSignor, Roger. “Sound Advice: Cochlear Implants Improve\\nLearning for Deaf Children.”St. Louis Post-Dispatch,9\\nJune 1995: 01C.\\nORGANIZATIONS\\nAlexander Graham Bell Association for the Deaf. 3417 V olta\\nPlace NW, Washington, DC 20007. (202) 337-5220.\\n.\\nAmerican Speech-Language-Hearing Association. 10801\\nRockville Pike, Rockville, MD 20852. (800) 638-8255.\\n.\\nCochlear Implant Club International. 5335 Wisconsin Ave.\\nNW, Suite 440, Washington, D.C. 20015-2052. (202) 895-\\n2781. .\\nHearing Loss Link. 2600 W. Peterson Ave., Ste. 202, Chicago,\\nIL 60659. (312) 743-1032, (312) 743-1007 (TDD).\\nNational Association for the Deaf. 814 Thayer Ave., Silver\\nSpring, MD 20910. (301) 587-1788, (301) 587-1789\\n(TDD). .\\nCarol A. Turkington\\nCognitive-behavioral therapy\\nDefinition\\nCognitive-behavioral therapy is an action-oriented\\nform of psychosocial therapy that assumes that maladap-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 839\\nCognitive-behavioral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 839'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 228, 'page_label': '229'}, page_content='tive, or faulty, thinking patterns cause maladaptive\\nbehavior and “negative” emotions. (Maladaptive behav-\\nior is behavior that is counter-productive or interferes\\nwith everyday living.) The treatment focuses on chang-\\ning an individual’s thoughts (cognitive patterns) in order\\nto change his or her behavior and emotional state.\\nPurpose\\nTheoretically, cognitive-behavioral therapy can be\\nemployed in any situation in which there is a pattern of\\nunwanted behavior accompanied by distress and impair-\\nment. It is a recommended treatment option for a number\\nof mental disorders, including affective (mood) disor-\\nders, personality disorders , social phobia, obsessive-\\ncompulsive disorder (OCD), eating disorders, substance\\nabuse, anxiety or panic disorder , agoraphobia , post-\\ntraumatic stress disorder (PTSD), and attention-\\ndeficit/hyperactivity disorder (ADHD). It is also fre-\\nquently used as a tool to deal with chronic pain for\\npatients with illnesses such as rheumatoid arthritis ,\\nback problems, and cancer. Patients with sleep disor-\\nders may also find cognitive-behavioral therapy a useful\\ntreatment for insomnia.\\nPrecautions\\nCognitive-behavioral therapy may not be suitable for\\nsome patients. Those who don’t have a specific behav-\\nioral issue they wish to address and whose goals for ther-\\napy are to gain insight into the past may be better served\\nby psychodynamic therapy. Patients must also be willing\\nto take a very active role in the treatment process.\\nCognitive-behavioral intervention may be inappro-\\npriate for some severely psychotic patients and for cogni-\\ntively impaired patients (for example, patients with\\norganic brain disease or a traumatic brain injury),\\ndepending on their level of functioning.\\nDescription\\nCognitive-behavioral therapy combines the individ-\\nual goals of cognitive therapy and behavioral therapy.\\nPioneered by psychologists Aaron Beck and Albert\\nEllis in the 1960s, cognitive therapy assumes that mal-\\nadaptive behaviors and disturbed mood or emotions are\\nthe result of inappropriate or irrational thinking patterns,\\ncalled automatic thoughts. Instead of reacting to the real-\\nity of a situation, an individual reacts to his or her own\\ndistorted viewpoint of the situation. For example, a per-\\nson may conclude that he is “worthless” simply because\\nhe failed an exam or didn’t get a date. Cognitive thera-\\npists attempt to make their patients aware of these dis-\\ntorted thinking patterns, or cognitive distortions, and\\nchange them (a process termed cognitive restructuring).\\nBehavioral therapy, or behavior modification, trains\\nindividuals to replace undesirable behaviors with healthi-\\ner behavioral patterns. Unlike psychodynamic therapies,\\nit does not focus on uncovering or understanding the\\nunconscious motivations that may be behind the maladap-\\ntive behavior. In other words, strictly behavioral therapists\\ndon’t try to find out why their patients behave the way\\nthey do, they just teach them to change the behavior.\\nCognitive-behavioral therapy integrates the cogni-\\ntive restructuring approach of cognitive therapy with the\\nbehavioral modification techniques of behavioral thera-\\npy. The therapist works with the patient to identify both\\nthe thoughts and the behaviors that are causing distress,\\nand to change those thoughts in order to readjust the\\nbehavior. In some cases, the patient may have certain\\nfundamental core beliefs, called schemas, which are\\nflawed and require modification. For example, a patient\\nsuffering from depression may be avoiding social contact\\nwith others, and suffering considerable emotional dis-\\ntress because of his isolation. When questioned why, the\\npatient reveals to his therapist that he is afraid of rejec-\\ntion, of what others may do or say to him. Upon further\\nexploration with his therapist, they discover that his real\\nfear is not rejection, but the belief that he is hopelessly\\nuninteresting and unlovable. His therapist then tests the\\nreality of that assertion by having the patient name\\nfriends and family who love him and enjoy his company.\\nBy showing the patient that others value him, the thera-\\npist both exposes the irrationality of the patient’s belief\\nand provides him with a new model of thought to change\\nhis old behavior pattern. In this case, the person learns to\\nthink, “I am an interesting and lovable person; therefore I\\nshould not have difficulty making new friends in social\\nsituations.” If enough “irrational cognitions” are\\nchanged, this patient may experience considerable relief\\nfrom his depression.\\nA number of different techniques may be employed\\nin cognitive-behavioral therapy to help patients uncover\\nand examine their thoughts and change their behaviors.\\nThey include:\\n• Behavioral homework assignments. Cognitive-behav-\\nioral therapists frequently request that their patients\\ncomplete homework assignments between therapy ses-\\nsions. These may consist of real-life “behavioral exper-\\niments” where patients are encouraged to try out new\\nresponses to situations discussed in therapy sessions.\\n• Cognitive rehearsal. The patient imagines a difficult sit-\\nuation and the therapist guides him through the step-by-\\nstep process of facing and successfully dealing with it.\\nThe patient then works on practicing, or rehearsing,\\nGALE ENCYCLOPEDIA OF MEDICINE 2840\\nCognitive-behavioral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 840'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 229, 'page_label': '230'}, page_content='these steps mentally. Ideally, when the situation arises\\nin real life, the patient will draw on the rehearsed\\nbehavior to address it.\\n• Journal. Patients are asked to keep a detailed diary\\nrecounting their thoughts, feelings, and actions when\\nspecific situations arise. The journal helps to make the\\npatient aware of his or her maladaptive thoughts and to\\nshow their consequences on behavior. In later stages of\\ntherapy, it may serve to demonstrate and reinforce posi-\\ntive behaviors.\\n• Modeling. The therapist and patient engage in role-\\nplaying exercises in which the therapist acts out appro-\\npriate behaviors or responses to situations.\\n• Conditioning. The therapist uses reinforcement to\\nencourage a particular behavior. For example, a child\\nwith ADHD gets a gold star every time he stays focused\\non tasks and accomplishes certain daily chores. The\\ngold star reinforces and increases the desired behavior\\nby identifying it with something positive. Reinforce-\\nment can also be used to extinguish unwanted behav-\\niors by imposing negative consequences.\\n• Systematic desensitization. Patients imagine a situation\\nthey fear, while the therapist employs techniques to help\\nthe patient relax, helping the person cope with their fear\\nreaction and eventually eliminate the anxiety altogether.\\nFor example, a patient in treatment for agoraphobia, or\\nfear of open or public places, will relax and then picture\\nherself on the sidewalk outside of her house. In her next\\nsession, she may relax herself and then imagine a visit to\\na crowded shopping mall. The imagery of the anxiety-\\nproducing situations gets progressively more intense\\nuntil, eventually, the therapist and patient approach the\\nanxiety-causing situation in real-life (a “graded expo-\\nsure”), perhaps by visiting a mall. Exposure may be\\nincreased to the point of “flooding,” providing maximum\\nexposure to the real situation. By repeatedly pairing a\\ndesired response (relaxation) with a fear-producing situa-\\ntion (open, public spaces), the patient gradually becomes\\ndesensitized to the old response of fear and learns to\\nreact with feelings of relaxation.\\n• Validity testing. Patients are asked to test the validity of\\nthe automatic thoughts and schemas they encounter.\\nThe therapist may ask the patient to defend or produce\\nevidence that a schema is true. If the patient is unable to\\nmeet the challenge, the faulty nature of the schema is\\nexposed.\\nInitial treatment sessions are typically spent explain-\\ning the basic tenets of cognitive-behavioral therapy to the\\npatient and establishing a positive working relationship\\nbetween therapist and patient. Cognitive-behavioral thera-\\npy is a collaborative, action-oriented therapy effort. As\\nsuch, it empowers the patient by giving him an active role\\nKEY TERMS\\nAutomatic thoughts—Thoughts that automatically\\ncome to mind when a particular situation occurs.\\nCognitive-behavioral therapy seeks to challenge\\nautomatic thoughts.\\nCognitive restructuring—The process of replacing\\nmaladaptive thought patterns with constructive\\nthoughts and beliefs.\\nMaladaptive —Unsuitable or counterproductive;\\nfor example, maladaptive behavior is behavior\\nthat is inappropriate to a given situation.\\nPsychodynamic therapy—A therapeutic approach\\nthat assumes dysfunctional or unwanted behavior\\nis caused by unconscious, internal conflicts and\\nfocuses on gaining insight into these motivations.\\nRelaxation technique —A technique used to\\nrelieve stress. Exercise, biofeedback, hypnosis,\\nand meditation are all effective relaxation tools.\\nRelaxation techniques are used in cognitive-\\nbehavioral therapy to teach patients new ways of\\ncoping with stressful situations.\\nSchemas —Fundamental core beliefs or assump-\\ntions that are part of the perceptual filter people\\nuse to view the world. Cognitive-behavioral thera-\\npy seeks to change maladaptive schemas.\\nin the therapy process and discourages any overdepen-\\ndence on the therapist that may occur in other therapeutic\\nrelationships. Therapy is typically administered in an out-\\npatient setting in either an individual or group session.\\nTherapists include psychologists (Ph.D., Psy.D., Ed.D. or\\nM.A. degree), clinical social workers (M.S.W., D.S.W., or\\nL.S.W. degree), counselors (M.A. or M.S. degree), or\\npsychiatrists (M.D. with specialization in psychiatry) and\\nshould be trained in cognitive-behavioral techniques,\\nalthough some brief cognitive-behavioral interventions\\nmay be suggested by a primary physician/caregiver.\\nTreatment is relatively short in comparison to some other\\nforms of psychotherapy, usually lasting no longer than 16\\nweeks. Many insurance plans provide reimbursement for\\ncognitive-behavioral therapy services. Because coverage\\nis dependent on the disorder or illness the therapy is treat-\\ning, patients should check with their individual plans.\\nRational-emotive behavior therapy\\nRational-emotive behavior therapy (REBT) is a pop-\\nular variation of cognitive-behavioral therapy developed\\nGALE ENCYCLOPEDIA OF MEDICINE 2 841\\nCognitive-behavioral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 841'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 230, 'page_label': '231'}, page_content='in 1955 by psychologist Albert Ellis. REBT is based on\\nthe belief that a person’s past experiences shape their\\nbelief system and thinking patterns. People form illogi-\\ncal, irrational thinking patterns that become the cause of\\nboth their negative emotions and of further irrational\\nideas. REBT focuses on helping patients discover these\\nirrational beliefs that guide their behavior and replace\\nthem with rational beliefs and thoughts in order to relieve\\ntheir emotional distress.\\nThere are 10 basic irrational assumptions that trigger\\nmaladaptive emotions and behaviors:\\n• It is a necessity for an adult to be loved and approved of\\nby almost everyone for virtually everything.\\n• A person must be thoroughly competent, adequate, and\\nsuccessful in all respects.\\n• Certain people are bad, wicked, or villainous and\\nshould be punished for their sins.\\n• It is catastrophic when things are not going the way one\\nwould like.\\n• Human unhappiness is externally caused. People have\\nlittle or no ability to control their sorrows or to rid\\nthemselves of negative feelings.\\n• It is right to be terribly preoccupied with and upset\\nabout something that may be dangerous or fearsome.\\n• It is easier to avoid facing many of life’s difficulties and\\nresponsibilities than it is to undertake more rewarding\\nforms of self-discipline.\\n• The past is all-important. Because something once\\nstrongly affected someone’s life, it should continue to\\ndo so indefinitely.\\n• People and things should be different from the way they\\nare. It is catastrophic if perfect solutions to the grim\\nrealities of life are not immediately found.\\n• Maximal human happiness can be achieved by inertia\\nand inaction or by passively and without commitment.\\nMeichenbaum’s self-instructional approach\\nPsychologist Donald Meichenbaum pioneered the\\nself-instructional, or “self-talk,” approach to cognitive-\\nbehavioral therapy in the 1970s. This approach focuses\\non changing what people say to themselves, both inter-\\nnally and out loud. It is based on the belief that an indi-\\nvidual’s actions follow directly from this self-talk. This\\ntype of therapy emphasizes teaching patients coping\\nskills that they can use in a variety of situations to help\\nthemselves. The technique used to accomplish this is\\nself-instructional inner dialogue, a method of talking\\nthrough a problem or situation as it occurs.\\nPreparation\\nPatients may seek therapy independently, or be\\nreferred for treatment by a primary physician, psycholo-\\ngist, or psychiatrist. Because the patient and therapist\\nwork closely together to achieve specific therapeutic\\nobjectives, it is important that their working relationship\\nis comfortable and their goals are compatible. Prior to\\nbeginning treatment, the patient and therapist should\\nmeet for a consultation session, or mutual interview. The\\nconsultation gives the therapist the opportunity to make\\nan initial assessment of the patient and recommend a\\ncourse of treatment and goals for therapy. It also gives\\nthe patient an opportunity to find out important details\\nabout the therapist’s approach to treatment, professional\\ncredentials, and any other issues of interest.\\nIn some managed-care clinical settings, an intake\\ninterview or evaluation is required before a patient\\nbegins therapy. The intake interview is used to evaluate\\nthe patient and assign him or her to a therapist. It may be\\nconducted by a psychiatric nurse, counselor, or social\\nworker.\\nNormal results\\nMany patients who undergo cognitive-behavioral\\ntherapy successfully learn how to replace their mal-\\nadaptive thoughts and behaviors with positive ones that\\nfacilitate individual growth and happiness. Cognitive-\\nbehavioral therapy may be used in conjunction with\\npharmaceutical and other treatment interventions, so\\noverall success rates are difficult to gauge. However,\\nsuccess rates of 65% or more have been reported with\\ncognitive-behavioral therapy alone as a treatment for\\npanic attacks and agoraphobia. Relapse has been report-\\ned in some patient populations, perhaps due to the brief\\nnature of the therapy, but follow-up sessions can put\\npatients back on track.\\nResources\\nBOOKS\\nGreenberger, Dennis, and Christine Padesky. Mind over Mood:\\nA Cognitive Therapy Treatment Manual for Clients.New\\nYork: Guilford Press, 1995.\\nPERIODICALS\\nEnright, Simon. “Cognitive Behaviour Therapy.”British Med-\\nical Journal 314, no. 7097 (June 1997): 1811-16.\\nGoisman, R. M. “Cognitive-Behavioral Therapy Today.”Har-\\nvard Mental Health Letter 13, no. 11 (May 1997): 4-7.\\nORGANIZATIONS\\nAlbert Ellis Institute. 45 East 65th St., New York, NY 10021.\\n(800) 323-4738. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2842\\nCognitive-behavioral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 842'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 231, 'page_label': '232'}, page_content='Beck Institute. GSB Building, City Line and Belmont Avenues,\\nSuite 700, Bala Cynwyd, PA 19004-1610. (610) 664-\\n3020. .\\nThe National Association of Cognitive-Behavioral Therapists.\\nP.O. Box 2195, Weirton, WV 26062. (800) 853-1135.\\n.\\nPaula Anne Ford-Martin\\nColchicine see Gout drugs\\nCOLD see Chronic obstructive lung disease\\nCold agglutinins test\\nDefinition\\nThe cold agglutinins test is performed to detect the\\npresence of antibodies in blood that are sensitive to tem-\\nperature changes. Antibodies are proteins produced by\\nthe immune system in response to specific disease\\nagents; autoantibodies are antibodies that the body pro-\\nduces against one of its own substances. Cold agglutinins\\nare autoantibodies that cause red blood cells to clump,\\nbut only when the blood is cooled below the normal body\\ntemperature of 98.6°F (37°C). The clumping is most pro-\\nnounced at temperatures below 78°F (25.6°C).\\nPurpose\\nThe cold agglutinins test is used to confirm the diag-\\nnosis of certain diseases that stimulate the body to pro-\\nduce cold agglutinins. The disease most commonly diag-\\nnosed by this test is mycoplasmal pneumonia ,b u t\\nmononucleosis, mumps, measles , scarlet fever , some\\nparasitic infections, cirrhosis of the liver, and some\\ntypes of hemolytic anemia can also cause the formation\\nof cold agglutinins. Hemolytic anemias are conditions in\\nwhich the blood is low in oxygen because the red blood\\ncells are breaking down at a faster rate than their normal\\nlife expectancy of 120 days. In addition to these illness-\\nes, some people have a benign condition called chronic\\ncold agglutinin disease, in which exposure to cold causes\\ntemporary clumping of red blood cells and consequent\\nnumbness in ears, fingers, and toes.\\nDescription\\nSince cold agglutinins cause red blood cells to\\nclump only at temperatures lower than 98.6°F (37°C),\\nthe test consists of chilling a sample of the patient’s\\nblood. There is a bedside version of the test in which the\\ndoctor collects four or five drops of blood in a small tube,\\nKEY TERMS\\nAgglutinin —An antibody that causes red blood\\ncells to stick or clump together.\\nAntibody —A protein molecule produced by the\\nimmune system that is specific to a disease agent,\\nsuch as Mycoplasma pneumoniae . The antibody\\ncombines with the organism and disables it.\\nAutoantibody —An antibody produced by the\\nbody in reaction to any of its own cells or cell\\nproducts.\\nCold agglutinins—Antibodies that cause clumping\\nof red blood cells when the blood temperature falls\\nbelow normal body temperature (98.6°F/37°C).\\nHemolytic anemia —Oxygen deficiency in the\\nblood, caused by shortened survival of red blood\\ncells.\\nMycoplasma—A type of free-living microorganism\\nthat has no cell wall. Mycoplasmas cause some\\nvarieties of pneumonia and urinary tract infections\\nthat stimulate the body to produce cold agglutinins.\\nTiter—The concentration of a substance in a given\\nsample of blood or other tissue fluid.\\ncools the tube in ice water for 30–60 seconds, and looks\\nfor clumping of red blood cells. If the cells clump after\\nchilling and unclump as they rewarm, a cold agglutinin\\ntiter (concentration) greater than 1:64 is present. Bedside\\ntest results, however, should be confirmed by a laborato-\\nry. The laboratory test measures the clumping of red\\nblood cells in different dilutions of the patient’s blood\\nserum at 39.2°F (4°C).\\nNormal results\\nThe results of the cold agglutinins test require a doc-\\ntor’s interpretation. In general, however, a normal value\\nis lower than 1:32.\\nAbnormal results\\nAny value higher than 1:32 suggests a diagnosis of\\nmycoplasmal pneumonia or one of the other viral infec-\\ntions or disease conditions indicated by this test.\\nResources\\nBOOKS\\nDabrow, Michael B., and Thomas G. Gabuzda. “Acquired\\nHemolytic Anemia.” In Current Diagnosis.V ol. 9. Ed. Rex\\nB. Conn, et al. Philadelphia: W. B. Saunders Co., 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 843\\nCold agglutinins test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 843'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 232, 'page_label': '233'}, page_content='Feizi, Ten. “Cold Agglutinins.” In Encyclopedia of Immunolo-\\ngy. V ol. 3. Ed. Ivan M. Roitt and Peter J. Delves. London:\\nAcademic Press, 1992.\\nRebecca J. Frey\\nCold sensitivity antibodies test see\\nCryoglobulin test\\nCold sore\\nDefinition\\nA cold sore is a fluid-filled blister which usually\\nappears at the edge of the lips. Cold sores are caused by a\\nherpes simplex virus infection.\\nDescription\\nA cold sore is a fluid-filled, painful blister that is\\nusually on or around the lips. Other names for a cold sore\\nare fever blister, oral herpes, labial herpes, herpes labi-\\nalis, and herpes febrilis. Cold sores most often occur on\\nthe lips which distinguishes them from the common\\ncanker sore, which is usually inside the mouth. Cold\\nsores do not usually occur inside the mouth except dur-\\ning the initial episode. Canker sores usually form either\\non the tongue or inside the cheeks.\\nCold sores are caused by a herpes virus. There are\\neight different kinds of human herpes viruses. Only two\\nof these, herpes simplex types 1 and 2, can cause cold\\nsores. It is commonly believed that herpes simplex virus\\ntype 1 infects above the waist and herpes simplex virus\\ntype 2 infects below the waist. This is not completely\\ntrue. Both herpes virus type 1 and type 2 can cause her-\\npes lesions on the lips or genitals, but recurrent cold\\nsores are almost always type 1.\\nOral herpes is very common. More than 60% of\\nAmericans have had a cold sore, and almost 25% of\\nthose infected experience recurrent outbreaks. Most of\\nthese persons became infected before age 10. Anyone\\ncan become infected by herpes virus and, once infected,\\nthe virus remains latent for life. Herpes viruses are\\nspread from person to person by direct skin-to-skin con-\\ntact. The highest risk for spreading the virus is the time\\nperiod beginning with the appearance of blisters and end-\\ning with scab formation. However, infected persons need\\nnot have visible blisters to spread the infection to others\\nsince the virus may be present in the saliva without obvi-\\nous oral lesions.\\nViruses are different from bacteria. While bacteria\\nare independent and can reproduce on their own, viruses\\nenter human cells and force them to make more virus. The\\ninfected human cell is usually killed and releases thou-\\nsands of new viruses. The cell death and resulting tissue\\ndamage causes the actual cold sores. In addition, the her-\\npes virus can infect a cell and instead of making the cell\\nproduce new viruses, it hides inside the cell and waits.\\nThe herpes virus hides in the nervous system. This is\\ncalled “latency.” A latent virus can wait inside the nervous\\nsystem for days, months, or even years. At some future\\ntime, the virus “awakens” and causes the cell to produce\\nthousands of new viruses that cause an active infection.\\nThis process of latency and active infection is best\\nunderstood by considering the cold sore cycle. An active\\ninfection is obvious because cold sores are present. The\\nfirst infection is called the “primary” infection. This active\\ninfection is then controlled by the body’s immune system\\nand the sores heal. In between active infections, the virus\\nis latent. At some point in the future, latent viruses become\\nactivated and once again cause sores. These are called\\n“recurrent” infections. Although it is unknown what trig-\\ngers latent virus to activate, several conditions seem to\\nbring on infections. These include stress, illness, tired-\\nness, exposure to sunlight, menstruation, fever, and diet.\\nCauses and symptoms\\nWhile anyone can be infected by herpes virus, not\\neveryone will show symptoms. The first symptoms of\\nherpes occur within two-20 days after contact with an\\ninfected person. Symptoms of the primary infection are\\nusually more severe than those of recurrent infections.\\nThe primary infection can cause symptoms like other\\nviral infections including tiredness, headache, fever, and\\nswollen lymph nodes in the neck.\\nTypically, 50-80% of persons with oral herpes expe-\\nrience a prodrome (symptoms of oncoming disease) of\\npain, burning, itching, or tingling at the site where blis-\\nters will form. This prodrome stage may last anywhere\\nfrom a few hours to one to two days. The herpes infec-\\ntion prodrome occurs in both the primary infection and\\nrecurrent infections.\\nIn 95% of the patients with cold sores, the blisters\\noccur at the outer edge of the lips which is called the\\n“vermilion border.” Less often, blisters form on the nose,\\nchin, or cheek. Following the prodrome, the disease\\nprocess is rapid. First, small red bumps appear that\\nquickly form fluid-filled blisters. The painful blisters\\nmay either burst and form a scab or dry up and form a\\nscab. Within two days of the first red bumps, all the blis-\\nters have formed scabs. The skin heals completely and\\nwithout scarring within six to ten days.\\nGALE ENCYCLOPEDIA OF MEDICINE 2844\\nCold sore\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 844'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 233, 'page_label': '234'}, page_content='Some children have a very serious primary (first\\nepisode) herpes infection called “gingivostomatitis.” This\\ncauses fever, swollen lymph glands, and numerous blis-\\nters inside the mouth and on the lips and tongue that may\\nform large, open sores. These painful sores may last up\\nto three weeks and can make eating and drinking diffi-\\ncult. Because of this, young children with gingivostom-\\natitis are at risk for dehydration (excessive loss of water\\nfrom the body).\\nMost people experience fewer than two recurrent\\noutbreaks of cold sores each year. Some people never\\nexperience outbreaks, while some have very frequent\\noutbreaks. In most people, the blisters form in the same\\narea each time and are triggered by the same factors\\n(such as stress, sun exposure, etc).\\nDiagnosis\\nBecause oral herpes is so common, it is diagnosed\\nprimarily by symptoms. It can be diagnosed and treated\\nby the family doctor, dermatologists (doctors who spe-\\ncialize in skin diseases) and infectious disease special-\\nists. Laboratory tests may be performed to look for the\\nvirus. Because healing sores do not shed much virus, a\\nsample from an open sore would be taken for viral cul-\\nture. A sterile cotton swab would be wiped over open\\nsores and the sample used to infect human cells in cul-\\nture. Cells that are killed by the herpes virus have a cer-\\ntain appearance under microscopic examination. The\\nresults of this test are available within two to 10 days.\\nOral herpes may resemble a bacterial infection called\\nimpetigo. This skin infection is most commonly seen in\\nchildren and causes herpes-like blisters around the mouth\\nand nose. Also, because oral herpes can occur inside the\\nmouth, the blisters could be mistaken for common canker\\nsores. Therefore, the doctor would need to determine\\nwhether the blisters are oral herpes, canker sores, or\\nimpetigo. The diagnosis and treatment of herpes infec-\\ntions should be covered by most insurance providers.\\nTreatment\\nThere is no cure for herpes virus infections. There\\nare antiviral drugs available that have some effect on\\nlessening the symptoms and decreasing the length of her-\\npes outbreaks. There is evidence that some may also pre-\\nvent future outbreaks. These antiviral drugs work by\\ninterfering with the replication of the viruses, and are\\nmost effective when taken as early in the infection\\nprocess as possible. For the best results, drug treatment\\nshould begin during the prodrome stage before blisters\\nare visible. Depending on the length of the outbreak,\\ndrug treatment could continue for up to 10 days.\\nAcyclovir (Zovirax) is the drug of choice for herpes\\ninfection and can be given intravenously or taken by\\nmouth. It can be applied directly to sores as an ointment\\nbut is not very useful in this form. A liquid form for chil-\\ndren is also available. Acyclovir is effective in treating\\nboth the primary infection and recurrent outbreaks.\\nWhen taken by mouth to prevent an outbreak, acyclovir\\nreduces the frequency of herpes outbreaks.\\nDuring an outbreak of cold sores, salty foods, citrus\\nfoods (oranges etc.), and other foods that irritate the sores\\nshould be avoided. Wash the sores once or twice a day\\nwith warm, soapy water and pat gently to dry. Over-the-\\ncounter lip products that contain the chemical phenol\\n(such as Blistex Medicated Lip Ointment) and numbing\\nointments (Anbesol) help to relieve cold sores. A bandage\\nmay be placed over the sores to protect them and prevent\\nspreading the virus to other sites on the lips or face.\\nAcetaminophen (Tylenol) or ibuprofen (Motrin, Advil)\\nmay be taken if necessary to reduce pain and fever.\\nAlternative treatment\\nVitamin and mineral supplements and diet may have\\nan effect on the recurrence and duration of cold sores. In\\ngeneral, cold sore sufferers should eat a healthy diet of\\nunprocessed foods such as vegetables, fruits, and whole\\ngrains. Alcohol, caffeine, and sugar should be avoided.\\nAn imbalance in the amino acids lysine and arginine\\nis thought to be one contributing factor in herpes virus out-\\nbreaks. A diet that is rich in the amino acid lysine may\\nhelp prevent recurrences of cold sores. Foods which con-\\ntain high levels of lysine include most vegetables,\\nlegumes, fish, turkey, and chicken. In one study, patients\\ntaking lysine supplements had milder symptoms during an\\noutbreak, a shorter healing time, and had fewer outbreaks\\nGALE ENCYCLOPEDIA OF MEDICINE 2 845\\nCold sore\\nA close-up view of a patient’s mouth with gingivostomatitis\\ncold sores. (Custom Medical Stock Photo. Reproduced by per-\\nmission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 845'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 234, 'page_label': '235'}, page_content='than patients who did not take lysine. Patients should take\\n1,000 mg of lysine three times a day during a cold sore\\noutbreak and 500 mg daily on an ongoing basis to prevent\\nrecurrences. Intake of the amino acid arginine should be\\nreduced. Foods rich in arginine that should be avoided are\\nchocolate, peanuts, almonds, and other nuts and seeds.\\nVitamin C and bioflavonoids (a substance in fruits\\nthat helps the body to absorb and use vitamin C) have\\nbeen shown to reduce the duration of a cold sore outbreak\\nand reduce the number of sores. The vitamin B complex\\nincludes important vitamins that support the nervous sys-\\ntem where viruses can hide out. B complex vitamins can\\nalso help manage stress, an important contributing factor\\nto the outbreak of herpes viruses. Applying the oil in vita-\\nmin E capsules directly to cold sores may provide relief.\\nZinc lozenges appear to affect the reproduction of viruses\\nand also enhance the immune system. Ointments contain-\\ning lemon balm ( Melissa officinalis ) or licorice ( Gly-\\ncyrrhiza glabra) and peppermint (Mentha piperita) have\\nbeen shown to help cold sores heal.\\nPrognosis\\nOral herpes can be painful and embarrassing, but it\\nis not a serious infection. There is no cure for oral herpes,\\nbut outbreaks usually occur less frequently after age 35.\\nThe spread of the herpes virus to the eyes is very serious.\\nThe herpes virus can infect the cells in the cornea and\\ncause scarring that may impair vision.\\nPrevention\\nThe only way to prevent oral herpes is to avoid con-\\ntact with infected persons. This is not an easy solution\\nbecause many people aren’t aware that they are infected\\nand can easily infect others. Currently there are no her-\\npes vaccines available, although herpes vaccines are\\nbeing tested.\\nKEY TERMS\\nLatent—A nonactive virus which is in a dormant\\nstate within a cell. The herpes virus is latent in the\\nnervous system.\\nProdrome—The Symptoms that warn of the begin-\\nning of disease. The herpes prodrome consists of\\npain, burning, tingling, or itching at a site before\\nblisters are visible.\\nRecurrence—The return of an active infection fol-\\nlowing a period of latency.\\nSeveral practices can reduce the occurrence of cold\\nsores and the spread of virus to other body locations or\\npeople. These practices are:\\n• Avoidance of sun exposure to the face. Before getting\\nprolonged exposure to the sun, apply sunscreen to the\\nface and especially to the lips. Wearing a hat with a\\nlarge brim is also helpful.\\n• Avoid touching cold sores. Squeezing, picking, or\\npinching blisters can allow the virus to spread to other\\nparts of the lips or face and infect those sites.\\n• Wash hands frequently. Persons with oral herpes should\\nwash their hands carefully before touching others. An\\ninfected person can spread the virus to others even\\nwhen he or she has no obvious blisters.\\n• Avoid contact with others during active infection.\\nInfected persons should avoid kissing or sexual contact\\nwith others until after the cold sores have healed.\\n• Wear gloves when applying ointment to a child’s sore.\\n• Be especially careful with infants. Never kiss the eyes\\nor lips of a baby who is under six months old.\\n• Be watchful of infected children. Do not allow infected\\nchildren to share toys that may be put into the mouth.\\nToys that have been mouthed should be disinfected\\nbefore other children play with them.\\n• Maintain good general health. A healthy diet, plenty of\\nsleep, and exercise help to minimize the chance of get-\\nting a cold or the flu, which are known to bring on cold\\nsores. Also, good general health keeps the immune sys-\\ntem strong; this helps to keep the virus in check and\\nprevents outbreaks.\\nResources\\nBOOKS\\nGorbach, Sherman, John Bartlett, and Neil Blacklow, eds.\\nInfectious Diseases. Philadelphia: W. B.Saunders Co.,\\n1998.\\nPERIODICALS\\nKott, Andrea. “The Common Cold Sore.”Parents, Nov. 1997,\\n101-105.\\nMurray, Michael T. “Natural Help for Herpes and Cold Sores.”\\nLet’s Live, Apr. 1997, 68+.\\nOTHER\\nMayo Clinic Online.5 Mar. 1998 .\\nBelinda Rowland, PhD\\nCold spot myocardial imaging see Thallium\\nheart scan\\nColds see Common cold\\nGALE ENCYCLOPEDIA OF MEDICINE 2846\\nCold sore\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 846'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 235, 'page_label': '236'}, page_content='Colic\\nDefinition\\nColic is persistent, unexplained crying in a healthy\\nbaby between two weeks and five months of age.\\nDescription\\nColic, which is not a disease, affects 10–20% of all\\ninfants. It is more common in boys than in girls and most\\ncommon in a family’s first child. Symptoms of colic usu-\\nally appear when a baby is 14–21 days old, reach a\\ncrescendo at the age of three months, and disappear with-\\nin the next eight weeks. Episodes occur frequently but\\nintermittently and usually begin with prolonged periods\\nof crying in the late afternoon or evening. They can last\\nfor just a few minutes or continue for several hours.\\nSome babies who have colic are simply fussy. Others cry\\nso hard that their faces turn red, then pale.\\nCauses and symptoms\\nNo one knows what causes colic. The condition may\\nbe the result of swallowing large amounts of air, which\\nbecomes trapped in the digestive tract and causes bloat-\\ning and severe abdominal pain.\\nOther possible causes of colic include:\\n• digestive tract immaturity\\n• food intolerances\\n• hunger or overfeeding\\n• lack of sleep\\n• loneliness\\n• overheated milk or formula\\n• overstimulation resulting from noise, light, or activity\\n• tension\\nDuring a colicky episode, babies’ bellies often look\\nswollen, feel hard, and make a rumbling sound. Crying\\nintensifies, tapers off, then gets louder. Many babies\\ngrow rigid, clench their fists, curl their toes, and draw\\ntheir legs toward their body. A burp or a bowel move-\\nment can end an attack. Most babies who have colic\\ndon’t seem to be in pain between attacks.\\nDiagnosis\\nPediatricians and family physicians suspect colic in\\nan infant who:\\n• has cried loudly for at least three hours a day at least\\nthree times a week for three weeks or longer\\n• is not hungry but cries for several hours between din-\\nnertime and midnight\\n• demonstrates the clenched fists, rigidity, and other\\nphysical traits associated with colic\\nThe baby’s medical history and a parent’s descrip-\\ntion of eating, sleeping, and crying patterns are used to\\nconfirm a diagnosis of colic. Physical examination and\\nlaboratory tests are used to rule out infection, intestinal\\nblockage, and other conditions that can cause abdominal\\npain and other colic-like symptoms.\\nTreatment\\nMedications do not cure colic. Doctors sometimes\\nrecommend simethicone (Mylicon Drops) to relieve gas\\npain, but generally advise parents to take a practical\\napproach to the problem.\\nGently massaging the baby’s back can release a\\ntrapped gas bubble, and holding the baby in a sitting\\nposition can help prevent air from being swallowed dur-\\ning feedings. Bottle-fed babies can swallow air if nipple\\nholes are either too large or too small.\\nNipple-hole size can be checked by filling a bottle\\nwith cold formula, turning it upside down, and counting\\nthe number of drops released when it is shaken or\\nsqueezed. A nipple hole that is the right size will release\\nabout one drop of formula every second.\\nBabies should not be fed every time they cry, but\\nfeeding and burping a baby more often may alleviate\\nsymptoms of colic. A bottle-fed baby should be burped\\nafter every ounce, and a baby who is breastfeeding\\nshould be burped every five minutes.\\nWhen cow’s milk is the source of the symptoms,\\nbottle-fed babies should be switched to a soy milk\\nhydrolyzed protein formula. A woman whose baby is\\nbreastfeeding should eliminate dairy products from her\\ndiet for seven days, then gradually reintroduce them\\nunless the baby’s symptoms reappear.\\nSince intolerance to foods other than cow’s milk may\\nalso lead to symptoms of colic, breastfeeding women may\\nalso relieve their babies’ colic by eliminating from their diet:\\n• coffee\\n• tea\\n• cocoa\\n• citrus\\n• peanuts\\n• wheat\\n• broccoli and other vegetables belonging to the cabbage\\nfamily\\nGALE ENCYCLOPEDIA OF MEDICINE 2 847\\nColic\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 847'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 236, 'page_label': '237'}, page_content='Rocking a baby in a quiet, darkened room can pre-\\nvent overstimulation, and a baby usually calms down\\nwhen cuddled in a warm, soft blanket.\\nColicky babies cry less when they are soothed by the\\nmotion of a wind-up swing, a car ride, or being carried in\\na parent’s arms. Pacifiers can soothe babies who are\\nupset, but a pacifier should never be attached to a string.\\nA doctor should be notified if a baby who has been\\ndiagnosed with colic:\\n• develops a rectal fever higher than 101°F (38.3°C)\\n• cries for more than four hours\\n• vomits\\n• has diarrhea or stools that are black or bloody\\n• loses weight\\n• eats less than normal\\nAlternative treatment\\nApplying gentle pressure to the webbed area\\nbetween the thumb and index finger of either hand can\\ncalm a crying child. So can gently massaging the area\\ndirectly above the child’s navel and the corresponding\\nspot on the spine. Applying warm compresses or holding\\nyour hand firmly over the child’s abdomen can relieve\\ncramping.\\nTeas made with chamomile ( Matricaria recutita ),\\nlemon balm ( Melissa officinalis ), peppermint ( Mentha\\npiperita), or dill (Anethum graveolens) can lessen bowel\\ninflammation and reduce gas. A homeopathic combina-\\ntion called “colic” may be effective, and constitutional\\nhomeopathic treatment can help strenthen the child’s\\nentire constitution.\\nPrognosis\\nColic is distressing, but it is not dangerous. Symp-\\ntoms almost always disappear before a child is six\\nmonths old.\\nPrevention\\nMany doctors believe that colic cannot be prevented.\\nSome alternative practitioners, however, feel that colic\\ncan be prevented by an awareness of food intolerances\\nand their impact.\\nResources\\nBOOKS\\nTaylor, Robert, ed. Family Medicine Principles and Practice.\\nNew York: Springer-Verlag, 1994.\\nORGANIZATIONS\\nAmerican Academy of Family Physicians. 8880 Ward Parkway,\\nKansas City, MO 64114. (816) 333-9700. .\\nAmerican Academy of Pediatrics. 141 Northwest Point Boule-\\nvard, Elk Grove Village, IL 60007-1098. (847) 434-4000.\\n.\\nOTHER\\n“Colic.” University of Michigan Health System Page.7 May\\n1998 .\\n“Colic.”WebMD Health.7 May 1998 .\\n“Colic.” YourHealth.com Page.8 May 1998 .\\nMaureen Haggerty\\nCollapsed lung see Pneumothorax\\nColloidal bath see Therapeutic baths\\nColon cancer\\nDefinition\\nCancer of the colon is the disease characterized by\\nthe development of malignant cells in the lining or\\nepithelium of the first and longest portion of the large\\nintestine. Malignant cells have lost normal control mech-\\nanisms governing growth. These cells may invade sur-\\nrounding local tissue, or they may spread throughout the\\nbody and invade other organ systems.\\nSynonyms for the colon include the large bowel or\\nthe large intestine. The rectum is the continuation of the\\nlarge intestine into the pelvis that terminates in the anus.\\nDescription\\nThe colon is a tubular organ beginning in the right\\nlower aspect of the abdomen. Anatomically, it ascends on\\nthe right side of the abdomen, traverses from right to left\\nin the upper abdomen, descends vertically down the left\\nside, takes an S-shaped curve in the lower left abdomen,\\nand then flows into the rectum as it leaves the abdomen\\nfor the pelvis. These portions of the colon are named sep-\\narately though they are part of the same organ:\\n• cecum, the beginning of the colon\\n• ascending colon, the right vertical ascent of the colon\\n• transverse colon, the portion traversing from right to left\\n• descending colon, the left vertical descent of the colon\\n• sigmoid colon, the s-shaped segment of colon above the\\npelvis\\nGALE ENCYCLOPEDIA OF MEDICINE 2848\\nColon cancer\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 848'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 237, 'page_label': '238'}, page_content='These portions of the colon are recognized anatomi-\\ncally based on the arterial blood supply and venous and\\nlymphatic drainage of these segments of the colon.\\nLymph, a protein-rich fluid that bathes the cells of the\\nbody, is transported in small channels known as lymphat-\\nics that run along side the veins of the colon. Lymph\\nnodes are small filters through which the lymph travels\\non its way back to the blood stream. Cancer can spread\\nelsewhere in the body by invading the lymph and vascu-\\nlar systems. Therefore, these anatomic considerations\\nbecome very important in the treatment of colon cancer.\\nThe small intestine is the continuation of the upper\\ngastrointestinal tract that is responsible for the transport\\nof ingested nutrients into the body. The waste left after\\nthe small intestine has completed absorption of nutrients\\namounts to a few liters (about the same as quart) of mate-\\nrial per day and is directly delivered to the colon (at the\\ncecum) for processing. Physiologically, the colon is\\nresponsible for the preservation of fluid and electrolytes\\nas it propels the increasingly solid waste towards the rec-\\ntum and anus for excretion.\\nWhen cells lining the colon become malignant, they\\nfirst grow locally and may invade partially or totally\\nthrough the wall of the bowel and even into adjacent\\nstructures and organs. In the process, the tumor can pene-\\ntrate and invade the lymphatics or the capillaries locally\\nand it gains access to the circulation. As the malignant\\ncells work their way to other areas of the body, they\\nagain become locally invasive in the new area to which\\nthey have spread. These tumor deposits, originating in\\nthe colon primary tumor, are then known as metastases.\\nIf metastases are found in the regional lymph nodes from\\nthe primary, they are known as regional metastases or\\nregional nodal metastases. If they are distant from the\\nprimary tumor, they are known as distant metastases. The\\npatient with distant metastases has systemic disease.\\nThus the cancer originating in the colon begins locally\\nand, given time, can become systemic in its extent.\\nBy the time the primary is originally detected, it is\\nusually larger than 0.4 in (1 cm) in size and has over a\\nmillion cells. This amount of growth itself is estimated to\\ntake about three to seven years. Each time the cells dou-\\nble in number, the size of the tumor quadruples. Thus,\\nlike most cancers, the part that is identified clinically is\\nlater in the progression than would be desired and\\nscreening becomes a very important endeavor to aid in\\nearlier detection of this disease.\\nThere are about 94,000 cases of colon cancer diag-\\nnosed per year in the United States. Together, colon and\\nrectal cancers account for 10% of cancers in men and\\n11% of cancers in women. It is the second most com-\\nmon site-specific cancer affecting both men and\\nwomen. (Lung cancer is the first affecting both men and\\nwomen, breast is the leader in women and prostate the\\nleader in men.) Nearly 48,000 people died from colon\\ncancer in the United States in 2000. In recent years the\\nincidence of this disease is decreasing very slightly, as\\nhas the mortality rate. It is difficult to tell if the\\ndecrease in mortality reflects earlier diagnosis, less\\ndeath related to the actual treatment of the disease, or a\\ncombination of both factors.\\nCancer of the colon is thought to arise sporadically\\nin about 80% of those who develop the disease. Twenty\\npercent of cases are thought to have genetic predisposi-\\ntion that ranges from familial syndromes affecting 50%\\nof the offspring of a mutation carrier, to a risk of 6%\\nwhen there is just a family history of colon cancer occur-\\nring in a first degree relative. Development of colon can-\\ncer at an early age, or at multiple sites, or recurrent colon\\ncancer suggests a genetically transmitted form of the dis-\\nease as opposed to the sporadic form.\\nCauses and symptoms\\nCauses of colon cancer are probably environmental\\nin the sporadic cases (80%) and genetic in the heredity\\npredisposed cases (20%). Since malignant cells have a\\nchanged genetic makeup, this means that in 80% of\\ncases, the environment spontaneously induces change,\\nwhereas in those born with a genetic predisposition, they\\nare either destined to get the cancer or it will take less\\nenvironmental exposure to induce the cancer. Exposure\\nto agents in the environment that may induce mutation is\\nthe process of carcinogenesis and is caused by agents\\nknown as carcinogens (cancer-causing agents). Specific\\ncarcinogens have been difficult to identify; however,\\ndietary factors seem to be involved.\\nColon cancer is more common in industrialized\\nnations and diets high in fat, red meat, total calories, and\\nalcohol seem to predispose. Diets high in fiber are asso-\\nciated with a decreased risk. The mechanism for protec-\\ntion by high-fiber diets may be related to less exposure of\\nthe colon lining to carcinogens from the environment, as\\nthe transit time through the bowel is faster with a high-\\nfiber diet than it is with a low-fiber diet.\\nAge plays a definite role in the predisposition to\\ncolon cancer. Colon cancer is uncommon before age 40.\\nThis incidence increases substantially after age 50 and\\ndoubles with each succeeding decade.\\nThere is also a slight increase risk for colon cancer\\nin the individual who smokes.\\nPatients who suffer from inflammatory diseases of\\nthe colon known as ulcerative colitis and Crohn’s colitis\\nare also at increased risk.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 849\\nColon cancer\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 849'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 238, 'page_label': '239'}, page_content='As for genetic predisposition, on chromosome 5,\\nthere is a gene called the APC gene associated with the\\nfamilial adenomatous polyposis syndrome. There are\\nmultiple different mutations that occur at this site, yet\\nthey all cause a defect in tumor suppression that results\\nin early and frequent development of colon cancer. This\\ngenetic aberration is transmitted to 50% of offspring and\\neach of those affected will develop colon cancer, usually\\nat an early age. There is another syndrome, hereditary\\nnon-polyposis colon cancer (also known as Lynch syn-\\ndrome), related to mutations in any of four genes respon-\\nsible for DNA mismatch repair. In patients with colon\\ncancer, the p53 gene is mutated 70% of the time. When\\nthe p53 gene is mutated and ineffective, cells with dam-\\naged DNA escape repair or destruction. This allows for\\nthe damaged cell to perpetuate itself, and continued\\nreplication of the damaged DNA may lead to tumor\\ndevelopment. Though these syndromes have a very high\\nincidence of colon cancer, family history without the\\nsyndrome is also a substantial risk factor. When consid-\\nering first-degree relatives, history of one with colon can-\\ncer raises the baseline risk of 2% to 6%. (Most physi-\\ncians think that this baseline is about 4%.) The presence\\nof a second raises the risk to 17%.\\nThe development of polyps of the colon almost\\nalways precedes the development of colon cancer by five\\nor more years. Polyps are benign growths of the colon\\nlining. They can be unrelated to cancer, precancerous, or\\nmalignant. Polyps, when identified, are removed for\\ndiagnosis. If the polyps are benign, the patient should\\nundergo careful surveillance for the development of\\nmore polyps or the development of colon cancer.\\nColon cancer causes symptoms related to its local\\npresence in the large bowel or by its effect on other\\norgans if it has spread. These symptoms may occur alone\\nor in combination:\\n• a change in bowel habit\\n• blood in the stool\\n• bloating, persistent abdominal distention\\n• constipation\\n• a feeling of fullness even after having a bowel move-\\nment\\n• narrowing of the stool—so-called ribbon stools\\n• persistent, chronic fatigue\\n• abdominal discomfort\\n• unexplained weight loss\\n• very rarely, nausea and vomiting\\nMost of these symptoms are caused by the physical\\npresence of the tumor mass in the colon. Similar symp-\\ntoms can be caused by other processes; these are not\\nabsolutely specific to colon cancer. The key is recogniz-\\ning that the persistence of these types of symptoms with-\\nout ready explanation should prompt the individual to\\nseek medical evaluation.\\nMany of the symptoms are understood by remem-\\nbering that the colon is a tubular conduit. If a tumor\\ndevelops, as it reaches a certain size it will begin to cause\\nsymptoms related to the obstruction of that conduit. In\\naddition, the tumor commonly oozes blood that is lost in\\nthe stool. (Often, this blood is not visible.) This phenom-\\nenon results in anemia and chronic fatigue. Weight loss is\\na late symptom, often implying substantial obstruction or\\nthe presence of systemic disease.\\nDiagnosis\\nScreening\\nOf all of the major cancers, only colorectal cancer\\ncan be prevented by screening. In all other cancers (breast\\nand prostate, for example), screening tests look for small,\\nmalignant lesions. Screening for colorectal cancers, how-\\never, is the search for pre-malignant, benign polyps. This\\nscreening can be close to 100% effective in preventing\\ncancer development, not just in detecting small cancers.\\nScreening involves physical exam, simple laboratory\\ntests, and the visualization of the lining of the colon. The\\nways to visualize the colon epithelium are with x rays (indi-\\nrect visualization), and endoscopy (direct visualization).\\nThe physical examination involves the perfor-\\nmance of a digital rectal exam (DRE). The DRE includes\\nmanual examination of the rectum, anus, and the\\nprostate. During this examination, the physician exam-\\nines the anus and the surrounding skin for hemorrhoids,\\nabscesses, and other irregularities. After lubricating the\\ngloved finger and anus, the examiner gently slides the\\nfinger into the anus and follows the contours of the rec-\\ntum. The examiner notes the tone of the anus and feels\\nthe walls and the edges for texture, tenderness and mass-\\nes as far as the examining finger can reach. At the time of\\nthis exam, the physician checks the stool on the examin-\\ning glove with a chemical to see if any occult (invisible),\\nblood is present. At home, after having a bowel move-\\nment, the patient is asked to swipe a sample of stool\\nobtained with a small stick on a card. After 3 such speci-\\nmens are on the card, the card is then easily chemically\\ntested for occult blood also. (The stool analysis men-\\ntioned here is known as a fecal occult blood test ,o r\\nFOBT, and, while it can be helpful, it is not 100% accu-\\nrate—only about 50% of cancers are FOBT-positive.)\\nThese exams are accomplished as an easy part of a rou-\\ntine yearly physical exam.\\nGALE ENCYCLOPEDIA OF MEDICINE 2850\\nColon cancer\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 850'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 239, 'page_label': '240'}, page_content='Proteins are sometimes produced by cancers, and\\nthese may be elevated in the patient’s blood. When this\\noccurs, the protein produced is known as a tumor marker.\\nThere is a tumor marker for some cancers of the colon; it\\nis known as carcinoembryonic antigen, or CEA. Unfortu-\\nnately, this protein may be made by other adenocarcino-\\nmas as well, or it may not be produced by a particular\\ncolon cancer. Therefore, screening by chemical analysis\\nfor CEA has not been helpful. CEA has been helpful\\nwhen used in a follow-up role for patients treated for\\ncolon cancer if their tumor makes the protein.\\nIndirect visualization of the colon may be accom-\\nplished by placing barium through the rectum and filling the\\ncolon with this compound. Barium produces a white con-\\ntrast image of the lining of the colon on x ray and thus, the\\ncontour of the lining of the colon may be seen. Detail can be\\nincreased if the barium utilized is thinned and air also intro-\\nduced. These studies are known as the barium enema(BE)\\nand the double contrast barium enema (DCBE).\\nDirect visualization of the lining of the colon is\\naccomplished using a scope or endoscope. The physician\\nintroduces the instrument through the rectum and passes\\nit proximally, visualizing the colon epithelium in the\\nprocess. Older, shorter scopes were rigid. Today, utiliz-\\ning fiberoptic technology, the scopes are flexible and can\\nreach much farther. If the left colon only is visualized, it\\nis called flexible sigmoidoscopy. When the entire colon\\nis visualized, the procedure is known as colonoscopy.\\nUnlike the indirect visualizations of the colon (the\\nBE and the DCBE), the endoscopic screeenings allow the\\nphysician to remove polyps and biopsy suspicious tissue.\\n(A biopsy is a removal of tissue for examination by a\\npthologist.) For this reason, many physicians prefer endo-\\nscopic screening. All of the visualizations, the BE,\\nDCBE, and each type of endoscopy require pre-procedure\\npreparation (evacuation) of the colon.\\nThe American Cancer Society has recommended the\\nfollowing screening protocol for those of normal risk\\nover 50 years of age:\\n• yearly DRE with occult blood in stool testing\\n• flexible sigmoidoscopy at age 50\\n• flexible sigmoidoscopy repeated every five years\\nMany physicians, however, recommend full colono-\\nscopy every five to seven years. Screening evaluations\\nshould start sooner for patients who have predisposing\\nfactors, such as family history, history of polyps, or a\\nfamilial syndrome.\\nEvaluation of patients with symptoms\\nFor those whose symptoms prompt them to visit\\ntheir physician, and if their symptoms could possibly be\\nrelated to colon cancer, the entire colon will be inspect-\\ned. The combination of a flexible sigmoidoscopy and\\nDCBE may be performed but the preferred evaluation of\\nthe entire colon and rectum is that of complete\\ncolonoscopy. Colonoscopy allows direct visualization,\\nphotography, and the opportunity to obtain a biopsy of\\nany abnormality visualized. If, for technical reasons, the\\nentire colon is not visualized endoscopically, a DCBE\\nshould complement the colonoscopy.\\nThe diagnosis of colon cancer is actually made by\\nthe performance of a biopsy of any abnormal lesion in\\nthe colon. When a tumor growth is identified, it could be\\neither a benign polyp (or lesion) or a cancer; the biopsy\\nresolves the issue. The endoscopist may take many sam-\\nples so as to exclude any sampling errors.\\nIf the patient presents with advanced disease, or has\\nadvanced disease at the time of diagnosis, areas where\\nthe tumor has spread (such as the liver) may be amenable\\nto biopsy. Such biopsies are usually obtained using a spe-\\ncial needle under local anesthesia.\\nOnce a diagnosis of colon cancer has been estab-\\nlished by biopsy, in addition to the physical exam,\\nstudies will be performed to assess the extent of the\\ndisease. Blood studies include a complete blood\\ncount, liver function tests , and a CEA. Imaging stud-\\nies will include a chest x ray and a CAT scan (comput-\\ned tomography scan) of the abdomen. The chest x ray\\nwill determine if there is spread to the lung, and the\\nCAT scan will evaluate potential spread to the liver as\\nwell as any local invasive characteristics of the primary\\ntumor. If the patient has any neurologic symptoms, a\\nCAT scan of the brain will be performed, and if the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 851\\nColon cancer\\nA colon with a cancerous growth.(Illustration by Argosy Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 851'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 240, 'page_label': '241'}, page_content='patient is experiencing bone pain , a bone scan will\\nalso be performed.\\nTreatment\\nOnce the diagnosis has been confirmed by biopsy,\\nthe clinical stage of the cancer is assigned. Using the\\ncharacteristics of the primary tumor, its depth of penetra-\\ntion through the bowel, and the presence or absence of\\nregional or distant metastases, the stage of the cancer is\\nderived. Often, the depth of penetration through the\\nbowel or the presence of regional lymph nodes can’t be\\nassigned before surgery.\\nColon cancer is assigned stages I through IV based\\non the following general criteria:\\n• Stage I: the tumor is confined to the epithelium or has\\nnot penetrated through the first layer of muscle in the\\nbowel wall.\\n• Stage II: the tumor has penetrated through to the outer\\nwall of the colon or has gone through it, possibly invad-\\ning other local tissue.\\n• Stage III: any depth or size of tumor associated with\\nregional lymph node involvement.\\nKEY TERMS\\nAdenocarcinoma —Type of cancer beginning in\\nglandular epithelium.\\nAdjuvant therapy —Treatment involving radiation,\\nchemotherapy (drug treatment), or hormone thera-\\npy, or a combination of all three given after the pri-\\nmary treatment for the possibility of residual micro-\\nscopic disease.\\nAnastomosis—Surgical reconnection of the ends of\\nthe bowel after removal of a portion of the bowel.\\nAnemia—The condition caused by too few circulat-\\ning red blood cells, often manifested in part by\\nfatigue.\\nCarcinogens —Substances in the environment that\\ncause cancer, presumably by inducing mutations,\\nwith prolonged exposure.\\nElectrolytes—Salts, such as sodium and chloride.\\nEpithelium —Cells composing the lining of an\\norgan.\\nLymphatics—Channels that are conduits for lymph.\\nLymph nodes—Cellular filters through which lym-\\nphatics flow.\\nMalignant —Cells that have been altered such that\\nthey have lost normal control mechanisms and are\\ncapable of local invasion and spread to other areas\\nof the body.\\nMetastasis—Site of invasive tumor growth that orig-\\ninated from a malignancy elsewhere in the body.\\nMutation —A change in the genetic makeup of a\\ncell that may occur spontaneously or be environ-\\nmentally induced.\\nOccult blood —Presence of blood that cannot be\\nseen with the naked eye.\\nPolyps—Localized growths of the epithelium that\\ncan be benign, precancerous, or harbor malig-\\nnancy.\\nRadical resection—Surgical resection that takes the\\nblood supply and lymph system supplying the\\norgan along with the organ.\\nResect—To remove surgically.\\nSacrum—Posterior bony wall of the pelvis.\\nSystemic—Referring to throughout the body.\\n• Stage IV: any of previous criteria associated with dis-\\ntant metastasis.\\nWith many cancers other than colon cancer, staging\\nplays an important pre-treatment role to best determine\\ntreatment options. In colon cancer, almost all colon can-\\ncers are treated with surgery first, regardless of stage.\\nColon cancers through stage III, and even some stage IV\\ncolon cancers, are treated with surgery first before any\\nother treatments are considered.\\nSurgery\\nSurgical removal of the involved anatomic segment\\nof colon (colectomy) along with its blood supply and\\nregional lymph nodes is the primary therapy for colon\\ncancer. Usually, on the basis of the blood supply, the par-\\ntial colectomies are separated into right, left, transverse,\\nor sigmoid. The removal of the blood supply at its origin\\nalong with the regional lymph nodes that accompany it\\nassures an adequate margin of normal colon on either\\nside of the primary tumor. When the cancer lies in a posi-\\ntion such that the blood supply and lymph drainage lies\\nbetween two of the major vessels, both vessels are taken\\nto assure complete radical resection or removal (extend-\\nGALE ENCYCLOPEDIA OF MEDICINE 2852\\nColon cancer\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 852'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 241, 'page_label': '242'}, page_content='ed radical right or left colectomy). If the primary tumor\\npenetrates through the bowel wall, any tissue adjacent to\\nthe tumor extension is also taken if feasible.\\nSurgery is used as primary therapy for stages I\\nthrough III colon cancer unless there are signs that local\\ninvasion will not permit complete removal of the tumor,\\nas may occur in advanced stage III tumors. However, this\\ncircumstance is very rare, and occurs in less than 2% of\\nall colon cancer cases.\\nAfter the resection is completed, the ends of the\\nremaining colon are reconstructed; the hook-up is called\\nan anastomosis. Once healing has occurred, there may be a\\nslight increase in the frequency of bowel movements. This\\neffect usually lasts only for several weeks. Most patients\\ngo on to develop completely normal bowel function.\\nOccasionally, the anastomosis would be risky and\\ncannot be performed. (Most commonly, this occurs when\\nthe bowel could not be adequately evacuated in an emer-\\ngency circumstance due to bowel obstruction.) When the\\nanastomosis cannot be performed, a colostomy is per-\\nformed instead. A colostomy is performed by bringing the\\nend of the colon through the abdominal wall and sewing it\\nto the skin. The patient will have to wear an appliance (a\\nbag) to manage the stool. The colostomy may be tempo-\\nrary and the patient may undergo a hook-up at a later, safer\\ndate, or the colostomy may be permanent. In most cases,\\nemergent colostomies are not reversed and are permanent.\\nRadiation\\nRadiation therapy is used as an adjunct to surgery\\nif there is concern about potential for local recurrence\\npost-operatively and the area of concern will tolerate the\\nradiation. For instance, if the tumor invaded muscle of\\nthe abdominal wall but was not completely removed, this\\narea would be considered for radiation. Radiation has\\nsignificant dose limits when residual bowel is exposed to\\nit because the small and large intestine do not tolerate\\nradiation well.\\nRadiation is also used in the treatment of patients\\nwho present with or progress to having metastatic dis-\\nease. It is particularly useful in shrinking metastatic\\ncolon cancer to the brain.\\nChemotherapy\\nChemotherapy is useful for patients who have had\\nall identifiable tumor removed and are at risk for recur-\\nrence (adjuvant chemotherapy). Chemotherapy may also\\nbe used when the cancer is stage IV and is beyond the\\nscope of regional therapy, but this use is rare.\\nAdjuvant therapy is considered in stage II disease\\nwith deep penetration or in stage III patients. Standard\\ntherapy is treatment with 5-fluorouracil, (5FU) combined\\nwith leucovorin for a period of six to 12 months. 5FU is\\nan antimetabolite and leukovorin improves the response\\nrate. (A response is a temporary regression of the cancer\\nin response to the chemotherapy.) Another agent, lev-\\namisole, (which seems to stimulate the immune system),\\nmay be substituted for leucovorin. These protocols\\nreduce rate of recurrence by about 15% and reduce mor-\\ntality by about 10%. The regimens do have some toxicity,\\nbut usually are tolerated fairly well.\\nSimilar chemotherapy may be administered for stage\\nIV disease or if a patient progresses and develops metas-\\ntases. Results show response rates of about 20%. Unfortu-\\nnately, these patients eventually succumb to the disease,\\nand this chemotherapy may not prolong survival or\\nimprove quality of life in Stage IV patients. Clinical trials\\nhave now shown that the results can be improved with the\\naddition of another agent to this regimen. Irinotecan does\\nnot seem to increase toxicity but it improved response rates\\nto 39%, added two to three months to disease-free survival,\\nand prolonged overall survival by a little over two months.\\nAlternative treatment\\nAlternative therapies have not been studied in a\\nlarge-scale, scientific way. Large doses of vitamins ,\\nfiber, and green tea are among therapies tried. Avoiding\\ncigarettes and alcohol may be helpful. Before initiating\\nany alternative therapies, the patient is wise to consult\\nhis/her physician to be sure that these therapies do not\\ncomplicate or interfere with the established therapy.\\nPrognosis\\nPrognosis is the long-term outlook or survival after\\ntherapy. Overall, about 50% of patients treated for colon\\ncancer survive the disease. As expected, the survival rates\\nare dependent upon the stage of the cancer at the time of\\ndiagnosis, making early detection a very worthwhile\\nendeavor.\\nAbout 15% of patients present with stage I disease\\nand 85–90% survive. Stage II represents 20–30% of\\ncases and 65–75% survive. Thirt to forty percent com-\\nprise the stage III presentation of which 55% survive.\\nThe remaining 20–25% present with stage IV disease\\nand are very rarely cured.\\nPrevention\\nThere is not an absolute way of preventing colon\\ncancer. Still, there are steps an individual can take to dra-\\nmatically lessen the risk or to identify the precursors of\\ncolon cancer so that it does not manifest itself. The\\npatient with a familial history can enter screening and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 853\\nColon cancer\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 853'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 242, 'page_label': '243'}, page_content='surveillance programs earlier than the general popula-\\ntion. High-fiber diets and vitamins, avoiding obesity, and\\nstaying active lessen the risk. Avoiding cigarettes and\\nalcohol may be helpful. By controlling these environ-\\nmental factors, an individual can lessen risk and to this\\ndegree prevent the disease.\\nBy undergoing appropriate screening when uncon-\\ntrollable genetic risk factors have been identified, an\\nindividual may be rewarded by the identification of\\nbenign polyps that can be treated as opposed to having\\nthese growths degenerate into a malignancy.\\nResources\\nBOOKS\\nAbelhoff, Martin, James O. Armitage, Allen S. Lichter, and John\\nE. Niederhuber. Clinical Oncology Library. Philadelphia:\\nChurchill Livingstone, 1999.\\nJorde, Lynn B., John C. Carey, Michael J. Bamshad, and Ray-\\nmond L. White. Medical Genetics, Second Edition. St.\\nLouis: Mosby, 1999.\\nKirkwood, John M., Michael T. Lotze, and Joyce M. Yasko.\\nCurrent Cancer Therapeutics,Third Edition. Philadel-\\nphia: Churchill Livingstone, 1998\\nPERIODICALS\\nGreenlee, Robert T., Mary Beth Hill-Harmon, Taylor Murray,\\nand Michael Thun. “Cancer Statistics 2001.”CA: A Can-\\ncer Journal for Clinicians, 51, no. 1 (Jan/Feb 2001).\\nSaltz, Leonard, et al. “Irinotecan plus Fluorouracil and Leucov-\\norin for Metastatic Colorectal Cancer.”The New England\\nJournal of Medicine V olune 343, No. 13 (September 28,\\n2000).\\nORGANIZATIONS\\nAmerican Cancer Society. (800) ACS-2345. .\\nCancer Information Service of the NCI. (1-800-4-CANCER).\\n.\\nColon Cancer Alliance. .\\nNational Cancer Institute Cancer Trials. . .\\nRichard A. McCartney, MD\\nColon therapy see Colonic irrigation\\nColonic irrigation\\nDefinition\\nColonic irrigation is also known as hydrotherapy of\\nthe colon, high colonic, entero-lavage, or simply colonic. It\\nis the process of cleansing the colon by passing several gal-\\nlons of water through it with the use of special equipment.\\nIt is similar to an enema but treats the whole colon, not just\\nthe lower bowel. This has the effect of flushing out impact-\\ned fecal matter, toxins, mucous, and even parasites that\\noften build up over the passage of time. It is a procedure\\nthat should only be undertaken by a qualified practitioner.\\nPurpose\\nAnyone suffering from gas, bloating, cramping\\npains, acne and other skin complaints, arthritis, and a list\\nof bowel complaints such as diverticulitis and irritable\\nbowel etc., may benefit from colonic irrigation. In partic-\\nular, cancer patients are often advised to undertake a\\ncourse of colonic irrigation sessions as an essential part\\nof their treatment. When a biological cancer therapy\\nbegins to enable the body to breakdown a cancerous\\nmass, it is essential that speedy and effective elimination\\nof the resulting toxins is achieved.\\nColon and bowel cancer is one of the leading causes\\nof death in the United States, and alternative practitioners\\ninsist that it can be prevented by efficient hygiene proce-\\ndures. Providing that care is taken to replace the natural\\norganisms that flourish in the bowel, many health benefits\\ncan be expected from colonic irrigation. In general, alter-\\nnative practitioners maintain that an ill-functioning bowel\\nis the source of all disease, and therefore keeping it clean\\nwill be an effective protection against this.\\nRemoving large amounts of toxic matter relieves the\\npatient and can lead to the alleviation of symptoms such\\nas arthritis, chronic fatigue syndrome, candidiasis, and\\na host of other illnesses. Properly executed, colonic irriga-\\ntion can help restore normal peristaltic action to a slug-\\ngish bowel, thus reducing the need for more hydrotherapy\\ntreatments over time. In addition, removing the layer of\\nfecal matter which coats the intestines in many individu-\\nals allows improved assimilation of the nutrients from\\nfoods and can alleviate symptoms of vitamin and other\\nnutrient deficiencies. Many alternative health practition-\\ners consider some form of hydrotherapy for the bowel to\\nbe essential in the treatment of degenerative diseases.\\nDescription\\nOrigins\\nCleansing the colon with the use of hydrotherapy is\\nnot a new concept. Forms of colonic irrigation have been\\nused successfully for decades to relieve chronic toxicity\\nand even acute cases of toxemia.\\nOver time, many people develop a thick layer of\\nfecal matter that coats their colon. It hardens and\\nbecomes impacted, reducing the efficiency of the bowel,\\nGALE ENCYCLOPEDIA OF MEDICINE 2854\\nColonic irrigation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 854'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 243, 'page_label': '244'}, page_content='and in some cases, completely obstructing normal elimi-\\nnation of waste matter from the body. It is quite common\\nfor people to only have one bowel movement per day,\\nand some as few as one or two per week.\\nAlternative practitioners advise that we probably\\nshould have one bowel movement for every meal that we\\neat. If not, then we are not eliminating wastes complete-\\nly, and if input exceeds output, then we will surely suffer\\nthe consequences at some point.\\nIncomplete elimination of body wastes may result in\\nthe following, depending on where the deposits end up:\\n• sluggish system\\n• joint pain and arthritis\\n• irritable bowel syndrome\\n• diverticulitis\\n• Crohn’s disease\\n• leaky gut syndrome\\n• heart problem\\n• migraine\\n• allergies\\n• bad breath\\n• acne and other skin problems such as psoriasis\\n• asthma\\n• early senility and Alzheimer’s disease\\n• chronic fatigue syndrome\\n• cancer, particularly of the bowel\\n• multiple sclerosis\\nDuring colonic irrigation, a small speculum is\\npassed into the patient’s bowel through the rectum. This\\nis attached to a tube, which leads to a machine that\\npumps temperature-controlled water into the colon at a\\ncontrolled rate (to be controlled by either the practitioner\\nor the patient). The temperature of the water should ide-\\nally be kept as close to body temperature as possible.\\nThe patient will temporarily be filled with water up\\nto the level of the entire colon. Patients say they can feel\\nthe water up under their ribs but that the process,\\nalthough sometimes uncomfortable, is not painful. The\\namount of water will vary but will generally be in the\\nregion of between two and six liters (or quarts) at any\\none time. This triggers peristaltic action and the patient\\nwill begin to expel the water along with fecal matter back\\nthrough the tube and into the machine.\\nThe fecal matter is flushed out through a viewing\\ntube, so that what is eliminated may be monitored. Quite\\noften, unsuspected parasites are expelled, along with\\nvery old fecal material, very dark in color, which may\\nKEY TERMS\\nDysbiosis —The condition that results when the\\nnatural flora of the gut are thrown out of balance,\\nsuch as when antibiotics are taken.\\nPeristalsis —The natural wave-like action of a\\nhealthy bowel that transports matter from one end\\nof the bowel to the other.\\nProbiotics —Supplements of beneficial microor-\\nganisms that normally colonize the gut.\\nToxemia—Poisoning of the blood.\\nhave been in the colon for years. Some therapists com-\\nment that it looks like aging rubber.\\nDuring the treatment, the therapist will gently massage\\nthe patient’s abdomen to help dislodge impacted fecal mat-\\nter. In addition to massage, sometimes acupressure,\\nreflexology, or lymphatic drainage techniques may be used\\nto loosen deposits and stimulate the bowel. It is important\\nthat the right amount of water is used, as too much will\\ncause discomfort and too little will be ineffective. If cor-\\nrectly done, colonic irrigation is not painful at all and some\\npatients claim to sleep through their treatment.\\nSanitation is vital to this process. The tubes and\\nspeculums used are generally disposable, but other parts\\nof the machine, such as the viewing tube, must be steril-\\nized after each patient.\\nNormally, a series of treatments will be required to\\nachieve desired results regarding the elimination of\\nimpacted, decaying matter, and restoration of bowel reg-\\nularity. Initially, only gas and recent fecal matter may be\\nexpelled. The residue attached to the colon wall is usual-\\nly the result of years of neglect, and therapists say that\\none cannot expect complete relief in only one session.\\nImpacted fecal matter can cause an imbalance of the\\nnatural organisms that normally populate the bowel, caus-\\ning what is known as dysbiosis. Under ideal conditions,\\nthe bowel is populated by a variety of naturally occurring\\norganisms. It seems that the enzymes occurring in fresh\\nfruit and vegetables encourage these beneficial organ-\\nisms. One of the results of eating processed denatured\\nfoods is that this natural balance is upset, and food may\\nbegin to rot in the bowel instead of being processed.\\nDecomposing matter can cause a toxic condition and\\nmay lead to many health problems, as constipation caus-\\nes backed up pollution of the body cells. The process of\\nrepair and elimination of wastes enters a downward spi-\\nral which at best will cause fatigue, lack of energy and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 855\\nColonic irrigation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 855'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 244, 'page_label': '245'}, page_content='premature aging, and, at worst, can cause degenerative\\ndiseases, among them allergies, and even cancer and\\nAlzheimer’s disease.\\nThe cost of colonic irrigation treatments varies, but\\nis generally between $35–70 per session, which may\\nlast from 45 minutes to one hour. The cost of the\\nmachine itself ranges from $4,000–12,000, but again, it\\nshould be noted that only qualified therapists should\\nconduct sessions.\\nPreparations\\nMost practitioners prefer that distilled or purified\\nwater is used for colonic irrigation, but others use steril-\\nized tap water.\\nPrecautions\\nIt may be advisable to use a probiotic pessary after\\ncolonic irrigation, to ensure replacement of desirable nat-\\nural flora. There are certain conditions that either partly\\nor completely preclude the use of colonic irrigation, such\\nas an active attack of Crohn’s disease, bleeding ulcers,\\nand hyperacidosis. If in doubt, a qualified practitioner\\nshould be consulted. Anyone suffering from these condi-\\ntions should always notify the practitioner when receiv-\\ning colonic irrigation treatments.\\nSide effects\\nSome allopathic practitioners claim that colonic irri-\\ngation flushes out essential electrolytes and friendly bac-\\nteria from the bowel and that it can be dangerous. Practi-\\ntioners counter that this can easily be remedied with the\\nuse of probiotics, and that in any case, these possible dis-\\nadvantages are easily offset by the benefits of having\\nlarge amounts of putrefying matter, harmful organisms,\\nand parasites removed from the system.\\nResearch and general acceptance\\nAlthough many alternative health care practitioners\\nswear by colonic irrigation, there is a large allopathic\\nlobby that claims that there are no benefits to be had, and\\nthat there are dangers involved. However, there are many\\ndecades of records and research from the alternative\\nhealth care community that indicate that this therapy may\\nhave a valuable place in the treatment of degenerative\\ndiseases and toxic conditions.\\nResources\\nBOOKS\\nBonk, Melinda, ed. Alternative Medicine Yellow Pages.\\nTiburon, CA: Future Medicine Publishing, Inc., 1994.\\nORGANIZATIONS\\nCalifornia Colon Hygienist Society. 333 Miller Ave., Suite 1,\\nMill Valley, CA 94941. (415) 383-7224.\\nIntestinal Health Institute. 4427 East Fifth St., Tucson, AZ\\n85711. (520) 325-9686. info@sheilas.com. .\\nPatricia Skinner\\nColonoscopy\\nDefinition\\nColonoscopy is a medical procedure where a long,\\nflexible, tubular instrument called the colonoscope is\\nused to view the entire inner lining of the colon (large\\nintestine) and the rectum.\\nPurpose\\nA colonoscopy is generally recommended when the\\npatient complains of rectal bleeding or has a change in\\nbowel habits and other unexplained abdominal symp-\\ntoms. The test is frequently used to test for colorectal\\ncancer, especially when polyps or tumor-like growths\\nhave been detected using the barium enema and other\\ndiagnostic tests. Polyps can be removed through the\\ncolonoscope and samples of tissue (biopsies) can be\\ntaken to test for the presence of cancerous cells.\\nThe test also enables the physician to check for\\nbowel diseases such as ulcerative colitis and Crohn’s\\ndisease. It is a necessary tool in monitoring patients who\\nhave a past history of polyps or colon cancer.\\nDescription\\nThe procedure can be done either in the doctor’s\\noffice or in a special procedure room of a local hospital.\\nAn intravenous (IV) line will be started in a vein in the\\narm. The patient is generally given a sedative and a pain-\\nkiller through the IV line.\\nDuring the colonoscopy, the patient will be asked to\\nlie on his/her left side with his/her knees drawn up\\ntowards the abdomen. The doctor begins the procedure\\nby inserting a lubricated, gloved finger into the anus to\\ncheck for any abnormal masses or blockage. A thin, well-\\nlubricated colonoscope will then be inserted into the anus\\nand it will be gently advanced through the colon. The lin-\\ning of the intestine will be examined through the scope.\\nOccasionally air may be pumped through the colono-\\nscope to help clear the path or open the colon. If there are\\nGALE ENCYCLOPEDIA OF MEDICINE 2856\\nColonoscopy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 856'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 245, 'page_label': '246'}, page_content='excessive secretions, stool, or blood that obstruct the\\nviewing, they will be suctioned out through the scope.\\nThe doctor may press on the abdomen or ask the patient\\nto change his/her position in order to advance the scope\\nthrough the colon.\\nThe entire length of the large intestine can be exam-\\nined in this manner. If suspicious growths are observed,\\ntiny biopsy forceps or brushes can be inserted through\\nthe colon and tissue samples can be obtained. Small\\npolyps can also be removed through the colonoscope.\\nAfter the procedure, the colonoscope is slowly with-\\ndrawn and the instilled air is allowed to escape. The anal\\narea is then cleansed with tissues.\\nThe procedure may take anywhere from 30 minutes\\nto two hours depending on how easy it is to advance the\\nscope through the colon. Colonoscopy can be a long and\\nuncomfortable procedure, and the bowel cleaning prepa-\\nration may be tiring and can produce diarrhea and\\ncramping. During the colonoscopy, the sedative and the\\npain medications will keep the patient very drowsy and\\nrelaxed. Most patients complain of minor discomfort and\\npressure from the colonoscope moving inside. However,\\nthe procedure is not painful.\\nPreparation\\nThe doctor should be notified if the patient has aller-\\ngies to any medications or anesthetics; any bleeding\\nproblems; or if the woman is pregnant. The doctor should\\nalso be informed of all the medications that the person is\\ncurrently on and if he or she has had a barium x-ray\\nexamination recently. If the patient has had heart valves\\nreplaced, the doctor should be informed so that appropri-\\nate antibiotics can be administered to prevent any\\nchance of infection. The risks of the procedure will be\\nGALE ENCYCLOPEDIA OF MEDICINE 2 857\\nColonoscopy\\nViewing monitor\\nLight\\nPolyp\\nRectum\\nColon\\nColonoscope\\nPolyp\\nLight\\nColonoscopy is a procedure where a long and flexible tubular instrument called a colonoscope is inserted into the patient’s\\nanus in order to view the lining of the colon and rectum. It is performed to test for colorectal cancer and other bowel dis-\\neases, and enables the physician to collect tissue samples for laboratory analysis.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 857'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 246, 'page_label': '247'}, page_content='explained to the patient before performing the procedure\\nand the patient will be asked to sign a consent form.\\nIt is important that the colon be thoroughly cleaned\\nbefore performing the examination. Hence, before the\\nexamination, considerable preparation is necessary to\\nclear the colon of all stool. The patient will be asked to\\nrefrain from eating any solid food for 24–48 hours before\\nthe test. Only clear liquids such as juices, broth, and Jello\\nare recommended. The patient is advised to drink plenty\\nof water to avoid dehydration . The evening before the\\ntest, the patient will have to take a strong laxative that the\\ndoctor has prescribed. Several 1 qt enemas of warm tap\\nwater may have to be taken on the morning of the exam.\\nCommercial enemas (e.g., Fleet) may be used.\\nThe patient will be given specific instructions on\\nhow to use the enema and how many such enemas are\\nnecessary. Generally, the procedure has to be repeated\\nKEY TERMS\\nBarium enema —An x-ray test of the bowel after\\ngiving the patient an enema of a white chalky sub-\\nstance that outlines the colon and the rectum.\\nBiopsy—Removal of a tissue sample for examina-\\ntion under the microscope to check for cancer\\ncells.\\nColonoscope —A thin, flexible, hollow, lighted\\ntube that in inserted through the rectum into the\\ncolon to enable the doctor to view the entire lin-\\ning of the colon.\\nCrohn’s disease—A chronic inflammatory disease\\nwhere the immune system starts attacking one’s\\nown body. The disease generally starts in the gas-\\ntrointestinal tract.\\nDiverticulosis —A pouchlike section that bulges\\nthrough the large intestine’s muscular walls but is\\nnot inflamed. It may cause bleeding, stomach dis-\\ntress and excess gas.\\nPathologist —A doctor who specializes in the\\ndiagnosis of disease by studying cells and tissues\\nunder a microscope.\\nPolyps—An abnormal growth that develops on the\\ninside of a hollow organ such as the colon.\\nUlcerative colitis —A chronic condition where\\nrecurrent ulcers are found in the colon. It is mani-\\nfested clinically by abdominal cramping, and rec-\\ntal bleeding.\\nuntil the return from the enema is clear of stool particles.\\nOn the morning of the examination, the patient is\\ninstructed not to eat or drink anything. The preparatory\\nprocedures are extremely important since, if the colon is\\nnot thoroughly clean, the exam cannot be done.\\nAftercare\\nAfter the procedure, the patient is kept under obser-\\nvation until the effects of the medications wear off. The\\npatient will have to be driven home by somebody and can\\ngenerally resume a normal diet and usual activities\\nunless otherwise instructed. The patient will be advised\\nto drink lots of fluids to replace those lost by laxatives\\nand fasting.\\nFor a few hours after the procedure, the patient may\\nfeel groggy. There may be some abdominal cramping\\nand considerable amount of gas may be passed. If a biop-\\nsy was performed or a polyp was removed, there may be\\nsmall amounts of blood in the stool for a few days. If the\\npatient experiences severe abdominal pain or has persis-\\ntent and heavy bleeding, it should be brought to the doc-\\ntor’s attention immediately.\\nRisks\\nThe procedure is virtually free of any complications\\nand risks. Very rarely (two in 1000 cases) there may be a\\nperforation (a hole) in the intestinal wall. Heavy bleeding\\ndue to the removal of the polyp or from the biopsy site\\noccurs very infrequently (one in 1000 cases). Infections\\ndue to a colonoscopy are also extremely rare. Patients\\nwith artificial or abnormal heart valves are usually given\\nantibiotics before and after the procedure to prevent an\\ninfection.\\nNormal results\\nThe results are said to be normal if the lining of the\\ncolon is a pale reddish pink and there are no abnormal\\nlooking masses that are found in the lining of the colon.\\nAbnormal results\\nAbnormal results would imply that polyps or other\\nsuspicious-looking masses were detected in the lining of\\nthe intestine. Polyps can be removed during the proce-\\ndure and tissue samples can be biopsied. If cancerous\\ncells are detected in the tissue samples, then a diagnosis\\nof colon cancer is made. The pathologist analyzes the\\ntumor cells further to estimate the aggressiveness of the\\ntumor and the extent of spread of the disease. This is\\ncrucial before deciding on the mode of treatment for the\\ndisease. Abnormal findings could also be due to inflam-\\nGALE ENCYCLOPEDIA OF MEDICINE 2858\\nColonoscopy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 858'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 247, 'page_label': '248'}, page_content='matory bowel diseases such as ulcerative colitis or\\nCrohn’s disease. A condition called diverticulosis,\\nwhere many small fingerlike pouches protrude from the\\ncolon wall, may also contribute to an abnormal result in\\nthe colonoscopy.\\nResources\\nBOOKS\\nBerkow, Robert, et al., eds. Merck Manual of Diagnosis and\\nTherapy. 16th ed. Merck Research Laboratories, 1992.\\nThe Patient’s Guide to Medical Tests.Ed. Barry L. Zaret, et al.\\nBoston: Houghton Mifflin, 1997.\\nSobel, David S., and T. Ferguson. The People’s Book of Med-\\nical Tests.Summit Books, 1985.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nCancer Research Institute. 681 Fifth Ave., New York, N.Y .\\n10022. (800) 992-2623. .\\nNational Cancer Institute. Building 31, Room 10A31, 31 Cen-\\nter Drive, MSC 2580, Bethesda, MD 20892-2580. (800)\\n422-6237. .\\nUnited Ostomy Association, Inc. (UOA). 19772 MacArthur\\nBlvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826.\\n.\\nLata Cherath, PhD\\nColor blindness\\nDefinition\\nColor blindness is an abnormal condition character-\\nized by the inability to clearly distinguish different colors\\nof the spectrum. The difficulties can be mild to severe. It\\nis a misleading term because people with color blindness\\nare not blind. Rather, they tend to see colors in a limited\\nrange of hues; a rare few may not see colors at all.\\nDescription\\nNormal color vision requires the use of specialized\\nreceptor cells called cones, which are located in the reti-\\nna of the eye. There are three types of cones, termed red,\\nblue, and green, which enable people to see a wide spec-\\ntrum of colors. An abnormality, or deficiency, of any of\\nthe types of cones will result in abnormal color vision.\\nThere are three basic variants of color blindness.\\nRed/green color blindness (deuteranopia) is the most\\ncommon deficiency, affecting 8% of Caucasian males\\nand 0.5% of Caucasian females. The prevalence varies\\nwith culture.\\nBlue color blindness (protanopia) is an inability to\\ndistinguish both blue and yellow, which are seen as white\\nor gray. Protanopia is quite rare and has equal prevalence\\nin males and females. It is common for young children to\\nhave blue/green confusion that becomes less pronounced\\nin adulthood. Blue color deficiency often appears in peo-\\nple who have physical disorders such as liver disease or\\ndiabetes mellitus.\\nA total inability to distinguish colors (achromatop-\\nsia) is exceedingly rare. These affected individuals view\\nthe world in shades of gray. They frequently have poor\\nvisual acuity and are extremely sensitive to light (photo-\\nphobia), which causes them to squint in ordinary light.\\nResearchers studying red/green color blindness in\\nthe United Kingdom reported an average prevalence of\\nonly 4.7% in one group. Only 1% of Eskimo males are\\ncolor blind. Approximately 2.9% of boys from Saudi\\nArabia and 3.7% from India were found to have deficient\\ncolor vision. Red/green color blindness may slightly\\nincrease an affected person’s chances of contracting lep-\\nrosy. Pre-term infants exhibit an increased prevalence of\\nblue color blindness. Achromatopsia has a prevalence of\\nabout 1 in 33,000 in the United States and affects males\\nand females equally.\\nCauses and symptoms\\nRed/green and blue color blindness appear to be\\nlocated on at least two different gene locations. The\\nmajority of affected individuals are males. Females are\\ncarriers, but are not normally affected. This indicates that\\nthe X chromosome is one of the locations for color blind-\\nness. Male offspring of females who carry the altered\\ngene have a 50-50 chance of being color-blind. The rare\\nfemale that has red/green color blindness, or rarer still,\\nblue color blindness, indicates there is an involvement of\\nanother gene. As of 2001, the location of this gene has\\nnot been identified.\\nAchromatopsia, the complete inability to distinguish\\ncolor, is an autosomal recessive disease of the retina.\\nThis means that both parents have one copy of the altered\\ngene but do not have the disease. Each of their children\\nhas a 25% chance of not having the gene, a 50% chance\\nof having one altered gene (and, like the parents, being\\nunaffected), and a 25% risk of having both the altered\\ngene and the condition. In 1997, the achromatopsia gene\\nwas located on chromosome 2.\\nThe inability to correctly identify colors is the only\\nsign of color blindness. It is important to note that people\\nwith red/green or blue varieties of color blindness use\\nother cues such as color saturation and object shape or\\nlocation to distinguish colors. They can often distinguish\\nGALE ENCYCLOPEDIA OF MEDICINE 2 859\\nColor blindness\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 859'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 248, 'page_label': '249'}, page_content='red or green if they can visually compare the colors.\\nHowever, most have difficulty accurately identifying col-\\nors without any other references. Most people with any\\nimpairment in color vision learn colors, as do other\\nyoung children. These individuals often reach adoles-\\ncence before their visual deficiency is identified.\\nColor blindness is sometimes acquired. Chronic ill-\\nnesses that can lead to color blindness include Alzheimer’s\\ndisease, diabetes mellitus, glaucoma, leukemia, liver dis-\\nease, chronic alcoholism, macular degeneration, multi-\\nple sclerosis, Parkinson’s disease, sickle cell anemia, and\\nretinitis pigmentosa. Accidents or strokes that damage the\\nretina or affect particular areas of the brain eye can lead to\\ncolor blindness. Some medications such as antibiotics,\\nbarbiturates, anti-tuberculosis drugs, high blood pressure\\nmedications, and several medications used to treat nervous\\ndisorders and psychological problems may cause color\\nblindness. Industrial or environmental chemicals such as\\ncarbon monoxide, carbon disulfide, fertilizers, styrene, and\\nsome containing lead can cause loss of color vision. Occa-\\nsionally, changes can occur in the affected person’s capaci-\\nty to see colors after age 60.\\nDiagnosis\\nThere are several tests available to identify problems\\nassociated with color vision. The most commonly used is\\nthe American Optical/Hardy, Rand, and Ritter Pseudo-\\nisochromatic test. It is composed of several discs filled\\nwith colored dots of different sizes and colors. A person\\nwith normal color vision looking at a test item sees a\\nKEY TERMS\\nAchromatopsia —The inability to distinguish any\\ncolors.\\nCones—Receptor cells that allow the perception\\nof colors.\\nDeuteranopia—The inability or difficulty in distin-\\nguishing red/green colors.\\nPhotophobia—An extreme sensitivity to light.\\nProtanopia —The inability of difficulty in distin-\\nguishing blue and yellow colors.\\nRetina—The light-sensitive layer of tissue in the\\nback of the eye that receives and transmits visual\\nsignals to the brain through the optic nerve.\\nRod—Photoreceptor that is highly sensitive to low\\nlevels of light and transmits images in shades of gray.\\nnumber that is clearly located somewhere in the center of\\na circle of variously colored dots. A color-blind person is\\nnot able to distinguish the number.\\nThe Ishihara test is comprised of eight plates that are\\nsimilar to the American Optical Pseudoisochromatic test\\nplates. The individual being tested looks for numbers\\namong the various colored dots on each test plate. Some\\nplates distinguish between red/green and blue color\\nblindness. Individuals with normal color vision perceive\\none number. Those with red/green color deficiency see a\\ndifferent number. Those with blue color vision see yet a\\ndifferent number.\\nA third analytical tool is the Titmus II Vision Tester\\nColor Perception test. The subject looks into a stereo-\\nscopic machine. The test stimulus most often used in\\nprofessional offices contains six different designs or\\nnumbers on a black background, framed in a yellow bor-\\nder. Titmus II can test one eye at a time. However, its\\nvalue is limited because it can only identify red/green\\ndeficiencies and is not highly accurate.\\nTreatment\\nThere is no treatment or cure for color blindness.\\nMost color vision deficient persons compensate well for\\ntheir abnormality and usually rely on color cues and\\ndetails that are not consciously evident to persons with\\ntypical color vision.\\nInherited color blindness cannot be prevented. In the\\ncase of some types of acquired color deficiency, if the\\ncause of the problem is removed, the condition may\\nimprove with time. But for most people with acquired\\ncolor blindness, the damage is usually permanent.\\nPrognosis\\nColor blindness that is inherited is present in both\\neyes and remains constant over an individual’s entire life.\\nSome cases of acquired color vision loss are not severe,\\nmay appear in only one eye, and last for only a short\\ntime. Other cases tend to be progressive, becoming worse\\nwith time.\\nResources\\nBOOKS\\nRosenthal, Odeda, and Robert H. Phillips. Coping with Color\\nBlindness. Garden City Park, NY: Avery Publishing\\nGroup, 1997.\\nSacks, Oliver. The Island of the Colorblind. New York, Knopf,\\n1997.\\nWiggs, Janey L. “Color Vision.” In:Ophthalmology, ed. Myron\\nYanoff and Jay S. Duker. St. Louis, Mosby, 2000.\\nGALE ENCYCLOPEDIA OF MEDICINE 2860\\nColor blindness\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 860'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 249, 'page_label': '250'}, page_content='PERIODICALS\\nArbour NC; Zlotogora J; Knowlton RG; Merin S; Rosenmann\\nA; Kanis AB; Rokhlina T; Stone EM; Sheffield VC.\\n“Homozygosity Mapping of Achromatopsia to Chromo-\\nsome 2 Using DNA Pooling.”Human Molecular Genetics\\n1997 May; 6(5): 689-694.\\nDobson V; Quinn GE; Abramov I; Hardy RJ; Tung B;\\nSiatkowski RM; Phelps DL. “Color Vision Measured with\\nPseudoisochromatic Plates at Five-and-a-Half Years in\\nEyes of Children from the CRYO-ROP Study.”Investiga-\\ntions in Ophthalmology and Visual Science (Nov 1996);\\n37(12): 2467-2474.\\nHolroyd E; Hall DM. “A Re-Appraisal of Screening for Colour\\nVision Impairments.”Child Care Health Developments\\n(Sep 1997); 23(5): 391-398.\\nOsuobeni EP. “Prevalence of Congenital Red-Green Color\\nVision Defects in Arab Boys from Riyadh, Saudi Arabia.”\\nOphthalmic Epidemiology (Dec 1996); 3(3): 167-170.\\nORGANIZATIONS\\nAchromatopsia Network. C/O Frances Futterman, PO Box\\n214, Berkeley, CA 94701-0214. .\\nAmerican Academy of Ophthalmology. PO Box 7424, San\\nFrancisco, CA 94120-7424. (415) 561-8500. .\\nInternational Colour Vision Society: Forschungsstelle fuer\\nExperimentelle Ophthalmologie. Roentgenweg 11, Tue-\\nbingen, D-72076. Germany .\\nNational Society to Prevent Blindness. 500 East Remington\\nRd., Schaumburg, IL 60173. (708) 843-2020 or (800)\\n331-2020. .\\nOTHER\\n“Breaking the Code of Color.”Seeing, Hearing and Smelling\\nthe World. .\\n“Color Blindness.”Geocities. .\\n“Medical Encyclopedia: Colorblind.”MEDLINEplus. .\\nUniversity of Manchester. .\\nUniversity of Nevada–Reno. .\\nL. Fleming Fallon, Jr., MD, MPH\\nColorectal cancer see Colon cancer; Rectal\\ncancer\\nColostomy\\nDefinition\\nOstomy is a surgical procedure used to create an\\nopening for urine and feces to be released from the body.\\nColostomy refers to a surgical procedure where a portion\\nof the large intestine is brought through the abdominal\\nwall to carry stool out of the body.\\nPurpose\\nA colostomy is created as a means to treat various\\ndisorders of the large intestine, including cancer, obstruc-\\ntion, inflammatory bowel disease, ruptured diverticulum,\\nischemia (compromised blood supply), or traumatic\\ninjury. Temporary colostomies are created to divert stool\\nfrom injured or diseased portions of the large intestine,\\nallowing rest and healing. Permanent colostomies are per-\\nformed when the distal bowel (bowel at the farthest dis-\\ntance) must be removed or is blocked and inoperable.\\nAlthough colorectal cancer is the most common indica-\\ntion for a permanent colostomy, only about 10–15% of\\npatients with this diagnosis require a colostomy.\\nDescription\\nSurgery will result in one of three types of colos-\\ntomies:\\n• End colostomy. The functioning end of the intestine\\n(the section of bowel that remains connected to the\\nupper gastrointestinal tract) is brought out onto the sur-\\nface of the abdomen, forming the stoma by cuffing the\\nintestine back on itself and suturing the end to the skin.\\nA stoma is an artificial opening created to the surface of\\nthe body. The surface of the stoma is actually the lining\\nof the intestine, usually appearing moist and pink. The\\ndistal portion of bowel (now connected only to the rec-\\ntum) may be removed, or sutured closed and left in the\\nabdomen. An end colostomy is usually a permanent\\nostomy, resulting from trauma, cancer or another patho-\\nlogical condition.\\n• Double–barrel colostomy. This colsotomy involves the\\ncreation of two separate stomas on the abdominal wall.\\nThe proximal (nearest) stoma is the functional end that\\nis connected to the upper gastrointestinal tract and will\\ndrain stool. The distal stoma, connected to the rectum\\nand also called a mucous fistula, drains small amounts\\nof mucus material. This is most often a temporary\\ncolostomy performed to rest an area of bowel, and to be\\nlater closed.\\n• Loop colostomy. This colostomy is created by bringing\\na loop of bowel through an incision in the abdominal\\nwall. The loop is held in place outside the abdomen by\\na plastic rod slipped beneath it. An incision is made in\\nthe bowel to allow the passage of stool through the loop\\ncolostomy. The supporting rod is removed approxi-\\nmately 7-10 days after surgery, when healing has\\noccurred that will prevent the loop of bowel from\\nGALE ENCYCLOPEDIA OF MEDICINE 2 861\\nColostomy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 861'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 250, 'page_label': '251'}, page_content='retracting into the abdomen. A loop colostomy is most\\noften performed for creation of a temporary stoma to\\ndivert stool away from an area of intestine that has been\\nblocked or ruptured.\\nPreparation\\nAs with any surgical procedure, the patient will be\\nrequired to sign a consent form after the procedure is\\nexplained thoroughly. Blood and urine studies, along\\nwith various x rays and an electrocardiograph (EKG),\\nmay be ordered as the doctor deems necessary. If possi-\\nble, the patient should visit an enterostomal therapist,\\nwho will mark an appropriate place on the abdomen for\\nthe stoma, and offer pre-operative education on ostomy\\nmanagement.\\nIn order to empty and cleanse the bowel, the patient\\nmay be placed on a low residue diet for several days prior\\nto surgery. A liquid diet may be ordered for at least the\\nday before surgery, with nothing by mouth after mid-\\nnight. A series of enemas and/or oral preparations\\n(GoLytely or Colyte) may be ordered to empty the bowel\\nof stool. Oral anti-infectives (neomycin, erythromycin,\\nor kanamycin sulfate) may be ordered to decrease bacte-\\nria in the intestine and help prevent post-operative infec-\\ntion. A nasogastric tube is inserted from the nose to the\\nstomach on the day of surgery or during surgery to\\nremove gastric secretions and prevent nausea and vom-\\niting. A urinary catheter (a thin plastic tube) may also be\\ninserted to keep the bladder empty during surgery, giving\\nmore space in the surgical field and decreasing chances\\nof accidental injury.\\nAftercare\\nPost-operative care for the patient with a new colos-\\ntomy, as with those who have had any major surgery,\\ninvolves monitoring of blood pressure, pulse, respirations,\\nand temperature. Breathing tends to be shallow because\\nof the effect of anesthesia and the patient’s reluctance to\\nbreathe deeply and experience pain that is caused by the\\nabdominal incision. The patient is instructed how to sup-\\nport the operative site during deep breathing and cough-\\ning, and given pain medication as necessary. Fluid intake\\nand output is measured, and the operative site is observed\\nGALE ENCYCLOPEDIA OF MEDICINE 2862\\nColostomy\\nClosed incision\\nCatheter\\nColostomy bag\\nColon\\nGlass rod\\nA colostomy is a surgical procedure in which a portion of the large intestine, or colon, is brought through the abdominal wall\\nto carry feces out of the body.There are three types of colostomies: end colostomy, double-barrel colostomy, and loop\\ncolostomy.The loop colostomy is featured in the illustration above.(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 862'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 251, 'page_label': '252'}, page_content='for color and amount of wound drainage. The nasogastric\\ntube will remain in place, attached to low intermittent\\nsuction until bowel activity resumes. For the first 24–48\\nhours after surgery, the colostomy will drain bloody\\nmucus. Fluids and electrolytes are infused intravenously\\nuntil the patient’s diet is can gradually be resumed, begin-\\nning with liquids. Usually within 72 hours, passage of gas\\nand stool through the stoma begins. Initially the stool is\\nliquid, gradually thickening as the patient begins to take\\nsolid foods. The patient is usually out of bed in 8–24\\nhours after surgery and discharged in 2–4 days.\\nA colostomy pouch will generally have been placed\\non the patient’s abdomen, around the stoma, during\\nsurgery. During the hospital stay, the patient and his or\\nher caregivers will be educated on how to care for the\\ncolostomy. Determination of appropriate pouching sup-\\nplies and a schedule of how often to change the pouch\\nshould be established. Regular assessment and meticu-\\nlous care of the skin surrounding the stoma is important\\nto maintain an adequate surface on which to apply the\\npouch. Some patients with colostomies are able to rou-\\ntinely irrigate the stoma, resulting in regulation of bowel\\nfunction; rather than needing to wear a pouch, these\\npatients may need only a dressing or cap over their\\nstoma. Often, an enterostomal therapist will visit the\\npatient at home after discharge to help with the patient’s\\nresumption of normal daily activities.\\nRisks\\nPotential complications of colostomy surgery include:\\n• excessive bleeding\\n• surgical wound infection\\n• thrombophlebitis (inflammation and blood clot to veins\\nin the legs)\\n• pneumonia\\n• pulmonary embolism (blood clot or air bubble in the\\nlungs’ blood supply)\\nNormal results\\nComplete healing is expected without complica-\\ntions. The period of time required for recovery from the\\nsurgery may vary depending of the patient’s overall\\nhealth prior to surgery. The colostomy patient without\\nother medical complications should be able to resume all\\ndaily activities once recovered from the surgery.\\nAbnormal results\\nThe doctor should be made aware of any of the fol-\\nlowing problems after surgery:\\n• increased pain, swelling, redness, drainage, or bleeding\\nin the surgical area\\nKEY TERMS\\nDiverticulum—Pouches that project off the wall of\\nthe intestine, visible as opaque on an x ray after the\\npatient has swallowed a contrast (dye) substance.\\nEmbolism —Blockage of a blood vessel by any\\nsmall piece of material traveling in the blood. The\\nemboli may be caused by germs, air, blood clots,\\nor fat.\\nEnema—Insertion of a tube into the rectum to\\ninfuse fluid into the bowel and encourage a bowel\\nmovement. Ordinary enemas contain tap water,\\nmixtures of soap and water, glycerine and water,\\nor other materials.\\nIntestine—Commonly called the bowels, divided\\ninto the small and large intestine. They extend\\nfrom the stomach to the anus. The small intestine\\nis about 20 ft (6 m) long. The large intestine is\\nabout 5 ft (1.5 m) long.\\nIschemia —A compromise in blood supply deliv-\\nered to body tissues that causes tissue damage or\\ndeath.\\nOstomy—A surgically created opening in the\\nabdomen for elimination of waste products (urine\\nor stool).\\n• headache, muscle aches,dizziness, or fever\\n• increased abdominal pain or swelling, constipation ,\\nnausea or vomiting or black, tarry stools\\nStomal complications to be monitored include:\\n• Death (necrosis) of stomal tissue. Caused by inade-\\nquate blood supply, this complication is usually visible\\n12–24 hours after the operation and may require addi-\\ntional surgery.\\n• Retraction (stoma is flush with the abdomen surface or\\nhas moved below it). Caused by insufficient stomal\\nlength, this complication may be managed by use of\\nspecial pouching supplies. Elective revision of the\\nstoma is also an option.\\n• Prolapse (stoma increases length above the surface of\\nthe abdomen). Most often results from an overly large\\nopening in the abdominal wall or inadequate fixation of\\nthe bowel to the abdominal wall. Surgical correction is\\nrequired when blood supply is compromised.\\n• Stenosis (narrowing at the opening of the stoma). Often\\nassociated with infection around the stoma or scarring.\\nMild stenosis can be removed under local anesthesia.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 863\\nColostomy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 863'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 252, 'page_label': '253'}, page_content='A colposcopy makes it possible for a physician to view this\\nhealthy cervix without surgery.(Photograph by Dr. P . Marazzi,\\nCustom Medical Stock Photo. Reproduced by permission.)\\nSevere stenosis may require surgery for reshaping the\\nstoma.\\n• Parastomal hernia (bowel causing bulge in the abdomi-\\nnal wall next to the stoma). This is due to placement of\\nthe stoma where the abdominal wall is weak or creation\\nof an overly large opening in the abdominal wall. The\\nuse of an ostomy support belt and special pouching\\nsupplies may be adequate. If severe, the defect in the\\nabdominal wall should be repaired and the stoma\\nmoved to another location.\\nResources\\nBOOKS\\nDoughty, Dorothy. Urinary and Fecal Incontinence.St. Louis:\\nMosby-Year Book, Inc., 1991.\\nHampton, Beverly, and Ruth Bryant. Ostomies and Continent\\nDiversions. St. Louis: Mosby-Year Book, Inc., 1992.\\nMonahan, Frances. Medical-Surgical Nursing. Philadelphia: W.\\nB. Saunders Co., 1998.\\nSuddarth, Doris. The Lippincott Manual of Nursing. Philadel-\\nphia: J. B. Lippincott, 1991.\\nORGANIZATIONS\\nUnited Ostomy Association, Inc. (UOA). 19772 MacArthur\\nBlvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826.\\n.\\nWound Ostomy and Continence Nurses Society. 1550 South\\nCoast Highway, Suite #201 Laguna Beach, CA 92651.\\nOTHER\\n“Colostomy.”ThriveOnline. 20 Apr. 1998 .\\nKathleen D. Wright, RN\\nColposcopy\\nDefinition\\nColposcopy is a procedure that allows a physician to\\ntake a closer look at a woman’s cervix and vagina using a\\nspecial instrument called a colposcope. It is used to\\ncheck for precancerous or abnormal areas. The colpo-\\nscope can magnify the area between 10 and 40 times;\\nsome devices also can take photographs.\\nPurpose\\nThe colposcope helps to identify abnormal areas of\\nthe cervix or vagina so that small pieces of tissue (biop-\\nsies) can be taken for further analysis.\\nColposcopy is used to identify or rule out the exis-\\ntence of any precancerous conditions in the cervical tis-\\nsue. If a PAP test shows abnormal cell growth, further\\ntesting, such as colposcopy, often is required. A PAP test\\nis a screening test that involves scraping cells from the\\noutside of the cervix. If abnormal cells are found, the\\nphysician will attempt to find the area that produced the\\nabnormal cells and remove it for further study (biopsy).\\nOnly then can a diagnosis be made.\\nColposcopy may also be performed if the cervix\\nlooks abnormal during a routine examination. It may also\\nbe suggested for women with genital warts and for\\ndiethylstilbestrol (DES) daughters (women whose moth-\\ners took DES when pregnant with them).\\nPrecautions\\nWomen who are pregnant, or who suspect that they\\nare pregnant, must tell their doctor before the procedure\\nbegins. Pregnant women can, and should, have a col-\\nposcopy if they have an abnormal PAP test. However, spe-\\ncial precautions must be taken during biopsy of the cervix.\\nDescription\\nA colposcopy is performed in a physician’s office\\nand is similar to a regular gynecologic exam. An instru-\\nment called a speculum is used to hold the vagina open,\\nand the gynecologist looks at the cervix and vagina\\nthrough the colposcope instead simply by eye, as in a\\nroutine examination.\\nThe colposcope is placed outside the patient’s body\\nand never touches the skin. The cervix and vagina are\\nswabbed with dilute acetic acid (vinegar). The solution\\nhighlights abnormal areas by turning them white (instead\\nof a normal pink color). Abnormal areas can also be\\nidentified by looking for a characteristic pattern made by\\nabnormal blood vessels.\\nGALE ENCYCLOPEDIA OF MEDICINE 2864\\nColposcopy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 864'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 253, 'page_label': '254'}, page_content='If any abnormal areas are seen, the doctor will take a\\nbiopsy of the tissue, a common procedure that takes\\nabout 15 minutes. Several samples might be taken,\\ndepending on the size of the abnormal area. A biopsy\\nmay cause temporary discomfort and cramping, which\\nusually go away within a few minutes. If the abnormal\\narea appears to extend inside the cervical canal, a scrap-\\ning of the canal may be done. The biopsy results are usu-\\nally available within a week.\\nIf the tissue sample indicates abnormal growth (dys-\\nplasia) or precancer, and if the entire abnormal area can\\nbe seen, the doctor can destroy the tissue using one of\\nseveral procedures, including ones that use high heat\\n(diathermy), extreme cold (cryosurgery), or lasers.\\nAnother procedure, called a loop electrosurgical excision\\n(LEEP), uses low-voltage high-frequency radio waves to\\nexcise tissue. If any of the abnormal tissue is within the\\ncervical canal, a cone biopsy (removal of a conical sec-\\ntion of the cervix for inspection) will be needed.\\nPreparation\\nColposcopy is a painless procedure that does not\\nrequire any anesthetic medication. If a biopsy is done,\\nthere may be mild cramps or a sharp pinching when the\\ntissue is removed. To lessen this pain, your doctor may\\nrecommend 800 mg of ibuprofen (Motrin) taken the\\nnight before and the morning of the procedure (no later\\nthan 30 minutes before the appointment). Patients who\\nare pregnant or allergic to aspirin or ibuprofen can take\\ntwo tablets of acetaminophen (Tylenol) instead.\\nAftercare\\nIf a biopsy was done, there may be a dark vaginal\\ndischarge afterwards. After the sample is removed, the\\nKEY TERMS\\nBiopsy—Removal of sample of abnormal tissue for\\nmore extensive examination under a microscope.\\nCervix—The neck of the uterus.\\nCryosurgery—Freezing and destroying abnormal\\ncells.\\nDES—The abbreviation for diethylstilbestrol, a\\nsynthetic form of estrogen that was widely pre-\\nscribed to women from 1940 to 1970 to prevent\\ncomplications. It was linked to several serious\\nbirth defects and disorders of the reproductive sys-\\ntem in daughters of women who took DES. In\\n1971, the FDA suggested it not be used during\\npregnancy and banned its use in 1979 as a growth\\npromoter in livestock.\\nDiathermy —Also called electrocautery, this is a\\nprocedure that heats and destroys abnormal cells.\\nIt is gradually being replaced by cryosurgery,\\nlasers, or LEEP.\\nHuman papilloma virus—A virus that causes com-\\nmon warts of the hands and feet, as well as lesions\\nin the genital and vaginal area. More than 50\\ntypes of HPV have been identified, some of which\\nare linked to cancerous and precancerous condi-\\ntions, including cancer of the cervix.\\nLoop electrosurgical excision (LEEP) —A proce-\\ndure that can help diagnose and treat cervical\\nabnormalities, using a thin wire loop that emits a\\nlow-voltage high-frequency radio wave that can\\nexcise tissue. It is considered better than either\\nlasers or electrocautery because it can both diag-\\nnose and treat precancerous cells or early stage\\ncancer at the same time.\\nPAP test—The common term for the Papanicolaou\\ntest, a simple smear method of examining stained\\ncells to detect cancer of the cervix.\\nSpeculum—A retractor used to separate the walls\\nof the vagina to make visual examination easier.\\ndoctor applies Monsel’s solution to the area to stop the\\nbleeding. When this mixes with blood it creates a black\\nfluid that looks like coffee grounds for a couple of days\\nafter the procedure. It is also normal to have some spot-\\nting after a colposcopy.\\nPatients should not use tampons or put anything else\\nin the vagina for at least a week after the procedure, or\\nuntil the doctor says it’s safe. In addition, women should\\nGALE ENCYCLOPEDIA OF MEDICINE 2 865\\nColposcopy\\nThis colposcopic view of the cervix reveals CIN 2 dysplasia,\\nor abnormal growth of cells.This is the second stage in the\\ndevelopment of cervical cancer.(Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 865'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 254, 'page_label': '255'}, page_content='not have sex or douche for at least a week after the proce-\\ndure because of the risk of infection.\\nRisks\\nOccasionally, patients may have bleeding or infec-\\ntion after biopsy. Bleeding is usually controlled with a\\ntopical medication.\\nA patient should call her doctor right away if she\\nnotices any of the following symptoms:\\n• heavy vaginal bleeding (more than one sanitary pad an\\nhour)\\n• fever, chills, or an unpleasant vaginal odor\\n• lower abdominal pain.\\nNormal results\\nIf visual inspection shows that the surface of the\\ncervix is smooth and pink, this is considered normal. If\\nabnormal areas are found and biopsied and the results\\nshow no indication of cancer, a precancerous condition,\\nor other disease, this also is considered normal.\\nAbnormal results\\nAbnormal conditions that can be detected using col-\\nposcopy and biopsy include precancerous tissue changes\\n(cervical dysplasia), cancer, and cervical warts (human\\npapilloma virus).\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nRyan, Kenneth J., Ross S. Berkowitz, and Robert L. Barbieri.\\nKistner’s Gynecology.6th ed. St. Louis: Mosby, 1995.\\nORGANIZATIONS\\nAmerican Society for Colposcopy and Cervical Pathology. 20\\nW. Washington St., Ste. #1, Hagerstown, MD 21740.\\n(800) 787-7227. .\\nCarol A. Turkington\\nComa\\nDefinition\\nComa, from the Greek word “koma,” meaning deep\\nsleep, is a state of extreme unresponsiveness, in which an\\nindividual exhibits no voluntary movement or behavior.\\nFurthermore, in a deep coma, even painful stimuli\\n(actions which, when performed on a healthy individual,\\nresult in reactions) are unable to affect any response, and\\nnormal reflexes may be lost.\\nDescription\\nComa lies on a spectrum with other alterations in con-\\nsciousness. The level of consciousness required by, for\\nexample, someone reading this passage lies at one extreme\\nend of the spectrum, while complete brain death lies at the\\nother end of the spectrum. In between are such states as\\nobtundation, drowsiness, and stupor. All of these are con-\\nditions which, unlike coma, still allow the individual to\\nrespond to stimuli, although such a response may be brief\\nand require stimulus of greater than normal intensity.\\nIn order to understand the loss of function suffered\\nby a comatose individual, it is necessary to first under-\\nstand the important characteristics of the conscious state.\\nConsciousness is defined by two fundamental elements:\\nawareness and arousal.\\nAwareness allows one to receive and process all the\\ninformation communicated by the five senses, and thus\\nrelate to oneself and to the outside world. Awareness has\\nboth psychological and physiological components. The\\npsychological component is governed by an individual’s\\nmind and mental processes. The physiological compo-\\nnent refers to the functioning of an individual’s brain,\\nand therefore that brain’s physical and chemical condi-\\ntion. Awareness is regulated by cortical areas within the\\ncerebral hemispheres, the outermost layer of the brain\\nthat separates humans from other animals by allowing\\nfor greater intellectual functioning.\\nArousal is regulated solely by physiological func-\\ntioning and consists of more primitive responsiveness to\\nthe world, as demonstrated by predictable reflex (invol-\\nuntary) responses to stimuli. Arousal is maintained by\\nthe reticular activating system (RAS). This is not an\\nanatomical area of the brain, but rather a network of\\nstructures (including the brainstem, the medulla, and the\\nthalamus) and nerve pathways, which function together\\nto produce and maintain arousal.\\nCauses and symptoms\\nComa, then, is the result of something that interferes\\nwith the functioning of the cerebral cortex and/or the\\nfunctioning of the structures which make up the RAS. In\\nfact, a huge and varied number of conditions can result in\\ncoma. A good way of categorizing these conditions is to\\nconsider the anatomic and the metabolic causes of coma.\\nAnatomic causes of coma are those conditions that dis-\\nrupt the normal physical architecture of the brain struc-\\ntures responsible for consciousness, either at the level of\\nGALE ENCYCLOPEDIA OF MEDICINE 2866\\nComa\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 866'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 255, 'page_label': '256'}, page_content='GALE ENCYCLOPEDIA OF MEDICINE 2 867\\nComa\\nStructural lesions within this region also resulting\\nin compression of the brain-stem and damage to\\nthe reticular activating substance (RAS)\\nLesions within the brain-stem directly suppressing\\nthe reticular activating substance (RAS)\\nDiffuse and bilateral damage to the cerebral cortex\\n(relative preservation of brain-stem reflexes)\\nMass lesions in this region resulting in\\ncompression of the brain-stem and damage\\nto the reticular activating substance (RAS)\\nBrain-stem\\ncompression\\nAsymmetrical brain-\\nstem signs\\nLocal brain-stem\\npressure\\nSymmetrical\\ndepression of\\nbrain-stem reflexes\\nPossible causes\\n• Damage due to lack of oxygen or restricted blood flow, perhaps\\n resulting from cardiac arrest, an anaesthetic accident, or shock\\n• Damage incurred from metabolic processes associated with\\n kidney or liver failure, or with hypoglycemia\\n• Trauma damage\\n• Damage due to a bout with meningitis, encephalomyelitis, or a\\n severe systemic infection\\nPossible causes • Cerebellar tumors, abscesses, or hemorrhages Possible causes • Drug overdosage\\nCortex\\nMid-brain reticular\\nformation\\nA side-view of the brain, showing movement\\nof the reticular activating substance (RAS)\\nessential to consciousness\\nThalamus\\nThe four brain conditions that result in coma.(Illustration by Hans & Cassady.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 867'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 256, 'page_label': '257'}, page_content='the cerebal cortex or the brainstem, while metabolic\\ncauses of coma consist of those conditions that change\\nthe chemical environment of the brain, thereby adversely\\naffecting function.\\nThere are many metabolic causes of coma, including:\\n• A decrease in the delivery to the brain of substances\\nnecessary for appropriate brain functioning, such as\\noxygen, glucose (sugar), and sodium.\\n• The presence of certain substances that disrupt the\\nfunctioning of neurons. Drugs or alcohol in toxic quan-\\ntities can result in neuronal dysfunction, as can sub-\\nstances normally found in the body, but that, due to\\nsome diseased state, accumulate at toxic levels. Accu-\\nmulated substances that might cause coma include\\nammonia due to liver disease, ketones due to uncon-\\ntrolled diabetes, or carbon dioxide due to a severe asth-\\nma attack.\\n• The changes in chemical levels in the brain due to the\\nelectrical derangements caused by seizures.\\nDiagnosis\\nAs in any neurologic condition, history and exami-\\nnation form the cornerstone of diagnosis when the\\npatient is in a coma; however, history must be obtained\\nfrom family, friends, or EMS. The Glasgow Coma Scale\\nis a system of examining a comatose patient. It is helpful\\nfor evaluating the depth of the coma, tracking the\\npatient’s progress, and predicting (somewhat) the ulti-\\nKEY TERMS\\nAnatomic—Related to the physical structure of an\\norgan or organism.\\nMetabolic—Refers to the chemical processes of an\\norgan or organism.\\nNeuron—The cells within the body which make\\nup the nervous system, specifically those along\\nwhich information travels.\\nPhysiological—Pertaining to the functioning of an\\norgan, as governed by the interactions between its\\nphysical and chemical conditions.\\nPsychological—Pertaining to the mind, its mental\\nprocesses, and its emotional makeup.\\nStimulus/stimuli —Action or actions performed\\non an individual which predictably provoke(s) a\\nreaction.\\nmate outcome of the coma. The Glasgow Coma Scale\\nassigns a different number of points for exam results in\\nthree different categories: opening the eyes, verbal\\nresponse (using words or voice to respond), and motor\\nresponse (moving a part of the body). Fifteen is the\\nlargest possible number of total points, indicating the\\nhighest level of functioning. The highest level of func-\\ntioning would be demonstrated by an individual who\\nspontaneously opens his/her eyes, gives appropriate\\nanswers to questions about his/her situation, and can\\ncarry out a command (such as “move your leg” or “nod\\nyour head”). Three is the least possible number of total\\npoints and would be given to a patient for whom not even\\na painful stimulus is sufficient to provoke a response. In\\nthe middle are those patients who may be able to\\nrespond, but who require an intense or painful stimulus,\\nand whose response may demonstrate some degree of\\nbrain malfunctioning (such as a person whose only\\nresponse to pain in a limb is to bend that limb in toward\\nthe body). When performed as part of the admission\\nexamination, a Glasgow score of three to five points\\noften suggests that the patient has likely suffered fatal\\nbrain damage, while eight or more points indicates that\\nthe patient’s chances for recovery are good. Expansion of\\nthe pupils and respiratory pattern are also important.\\nMetabolic causes of coma are diagnosed from blood\\nwork and urinalysis to evaluate blood chemistry, drug\\nscreen, and blood cell abnormalities that may indicate\\ninfection. Anatomic causes of coma are diagnosed from\\ncomputed tomography scans (CT) or magnetic reso-\\nnance imaging (MRI) scans.\\nTreatment\\nComa is a medical emergency, and attention must\\nfirst be directed to maintaining the patient’s respiration\\nand circulation, using intubation aand ventilation, admin-\\nistration of intravenous fluids or blood as needed, and\\nother supportive care. If head trama has not been exclud-\\ned, the neck should be stablized in the event of fracture. It\\nis obviously extremely important for a physician to deter-\\nmine quickly the cause of a coma, so that potentially\\nreversible conditions are treated immediately. For exam-\\nple, an infection may be treated with antibiotics; a brain\\ntumor may be removed; and brain swelling from an\\ninjury can be reduced with certain medications. Various\\nmetabolic disorders can be addressed by supplying the\\nindividual with the correct amount of oxygen, glucose, or\\nsodium; by treating the underlying disease in liver dis-\\nease, asthma, or diabetes; and by halting seizures with\\nmedication. Because of their low incidence of side effects\\nand potential for prompt reversal of coma in certain con-\\nditions, glucose, the B-vitamin thiamine, and Narcan (to\\ncounteract any narcotic-type drugs) are routinely given.\\nGALE ENCYCLOPEDIA OF MEDICINE 2868\\nComa\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 868'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 257, 'page_label': '258'}, page_content='Prognosis\\nSome conditions that cause coma can be completely\\nreversed, restoring the individual to his or her original\\nlevel of functioning. However, if areas of the brain have\\nbeen sufficiently damaged due to the severity or duration\\nof the condition which led to the coma, the individual\\nmay recover from the coma with permanent disabilities,\\nor may even never regain consciousness. Take, for exam-\\nple, the situation of someone whose coma was caused by\\nbrain injury in a car accident. Such an injury can result in\\none of three outcomes. In the event of a less severe brain\\ninjury, with minimal swelling, an individual may indeed\\nrecover consciousness and regain all of his or her original\\nabilities. In the event of a more severe brain injury, with\\nswelling that resulted in further pressure on areas of the\\nbrain, an individual may regain consciousness, but may\\nhave some degree of impairment. The impairment may\\nbe physical (such as paralysis of a leg) or may even\\nresult in a change in the individual’s intellectual func-\\ntioning and/or personality. The most severe types of\\nbrain injury, short of death, result in states in which the\\nindividual loses all ability to function and remains deeply\\nunresponsive. An individual who has suffered such a\\nsevere brain injury may remain in a coma indefinitely.\\nThis condition is termed persistent vegetative state.\\nOutcome from a coma is therefore quite variable and\\ndepends a great deal on the cause and duration of the coma.\\nIn the case of drug poisonings, extremely high rates of\\nrecovery can be expected following prompt medical atten-\\ntion. Patients who have suffered head injuries tend to do\\nbetter than do patients whose coma was caused by other\\ntypes of medical illnesses. Leaving out those people whose\\ncoma followed drug poisoning, only about 15% of patients\\nwho remain in a coma for more than just a few hours make\\na good recovery. Those adult patients who remain in a\\ncoma for greater than four weeks have almost no chance of\\neventually regaining their previous level of functioning. On\\nthe other hand, children and young adults have regained\\nfunctioning even after two months in a coma.\\nResources\\nBOOKS\\nGuberman, Alan. An Introduction to Clinical Neurology.\\nBoston: Little, Brown and Co., 1994.\\nLiebman, Michael. Neuroanatomy Made Easy and Under-\\nstandable. Baltimore: University Park Press, 1991.\\nRopper, Allan H., and Joseph B. Martin. “Acute Confusional\\nStates and Coma.” In Harrison’s Principles of Internal\\nMedicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nPERIODICALS\\nEngeler, Amy. “A Life on Hold: What a Coma Really Looks\\nLike.” Redbook, July 1996, 72+.\\nORGANIZATIONS\\nAmerican Academy of Neurology. 1080 Montreal Ave., St.\\nPaul, MN 55116. (612) 695-1940. .\\nComa Recovery Association, Inc. 570 Elmont Rd., Suite 104,\\nElmont, NY 11003. (516) 355-0951.\\nRosalyn Carson-DeWitt, MD\\nCombat neurosis see Post-traumatic stress\\ndisorder\\nCommon cold\\nDefinition\\nThe common cold is a viral infection of the upper\\nrespiratory system, including the nose, throat, sinuses,\\neustachian tubes, trachea, larynx, and bronchial tubes.\\nAlthough over 200 different viruses can cause a cold,\\n30–50% are caused by a group known as rhinoviruses.\\nAlmost all colds clear up in less than two weeks without\\ncomplications.\\nDescription\\nColds, sometimes called rhinovirus or coronavirus\\ninfections, are the most common illness to strike any part\\nof the body. It is estimated that the average person has\\nmore than 50 colds during a lifetime. Anyone can get a\\ncold, although pre-school and grade school children\\ncatch them more frequently than adolescents and adults.\\nRepeated exposure to viruses causing colds creates par-\\ntial immunity.\\nAlthough most colds resolve on their own without\\ncomplications, they are a leading cause of visits to the\\ndoctor and of time lost from work and school. Treating\\nsymptoms of the common cold has given rise to a multi-\\nmillion dollar industry in over-the-counter medications.\\nCold season in the United States begins in early\\nautumn and extends through early spring. Although it is\\nnot true that getting wet or being in a draft causes a cold\\n(a person has to come in contact with the virus to catch a\\ncold), certain conditions may lead to increased suscepti-\\nbility. These include:\\n• fatigue and overwork\\n• emotional stress\\n• poor nutrition\\n• smoking\\n• living or working in crowded conditions\\nGALE ENCYCLOPEDIA OF MEDICINE 2 869\\nCommon cold\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 869'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 258, 'page_label': '259'}, page_content='Colds make the upper respiratory system less resis-\\ntant to bacterial infection. Secondary bacterial infection\\nmay lead to middle ear infection, bronchitis , pneumo-\\nnia, sinus infection, or strep throat. People with chronic\\nlung disease, asthma, diabetes, or a weakened immune\\nsystem are more likely to develop these complications.\\nCauses and symptoms\\nColds are caused by more than 200 different viruses.\\nThe most common groups are rhinoviruses and coron-\\naviruses. Different groups of viruses are more infectious\\nat different seasons of the year, but knowing the exact\\nvirus causing the cold is not important in treatment.\\nPeople with colds are contagious during the first two\\nto four days of the infection. Colds pass from person to\\nperson in several ways. When an infected person coughs,\\nsneezes, or speaks, tiny fluid droplets containing the virus\\nare expelled. If these are breathed in by other people, the\\nvirus may establish itself in their noses and airways.\\nColds may also be passed through direct contact. If a\\nperson with a cold touches his runny nose or watery eyes,\\nthen shakes hands with another person some of the virus is\\ntransferred to the uninfected person. If that person then\\ntouches his mouth, nose, or eyes, the virus is transferred to\\nan environment where it can reproduce and cause a cold.\\nFinally, cold viruses can be spread through inani-\\nmate objects (door knobs, telephones, toys) that become\\ncontaminated with the virus. This is a common method\\nof transmission in child care centers. If a child with a\\ncold touches his runny nose, then plays with a toy, some\\nof the virus may be transferred to the toy. When another\\nchild plays with the toy a short time later, he may pick up\\nsome of the virus on his hands. The second child then\\ntouches his contaminated hands to his eyes, nose, or\\nmouth and transfers some of the cold virus to himself.\\nOnce acquired, the cold virus attaches itself to the\\nlining of the nasal passages and sinuses. This causes the\\ninfected cells to release a chemical called histamine. His-\\ntamine increases the blood flow to the infected cells,\\ncausing swelling, congestion, and increased mucus pro-\\nduction. Within one to three days the infected person\\nbegins to show cold symptoms.\\nThe first cold symptoms are a tickle in the throat,\\nrunny nose, and sneezing. The initial discharge from the\\nnose is clear and thin. Later it changes to a thick yellow\\nor greenish discharge. Most adults do not develop a fever\\nwhen they catch a cold. Young children may develop a\\nlow fever of up to 102°F (38.9°C).\\nIn addition to a runny nose and fever, signs of a cold\\ninclude coughing, sneezing, nasal congestion, headache,\\nmuscle ache, chills, sore throat , hoarseness, watery\\neyes, tiredness, and lack of appetite. The cough that\\naccompanies a cold is usually intermittent and dry.\\nMost people begin to feel better four to five days\\nafter their cold symptoms become noticeable. All symp-\\ntoms are generally gone within ten days, except for a dry\\ncough that may linger for up to three weeks.\\nColds make people more susceptible to bacterial\\ninfections such as strep throat, middle ear infections, and\\nsinus infections. A person whose cold does not begin to\\nimprove within a week; or who experiences chest pain,\\nfever for more than a few days, difficulty breathing,\\nbluish lips or fingernails, a cough that brings up green-\\nish-yellow or grayish sputum, skin rash, swollen glands,\\nor whitish spots on the tonsils or throat should consult a\\ndoctor to see if they have acquired a secondary bacterial\\ninfection that needs to be treated with an antibiotic.\\nPeople who have emphysema, chronic lung disease,\\ndiabetes, or a weakened immune system—either from\\ndiseases such as AIDS or leukemia, or as the result of\\nmedications, ( corticosteroids , chemotherapy drugs)—\\nshould consult their doctor if they get a cold. People with\\nthese health problems are more likely to get a secondary\\ninfection.\\nDiagnosis\\nColds are diagnosed by observing a person’s symp-\\ntoms. There are no laboratory tests readily available to\\ndetect the cold virus. However, a doctor may do a throat\\nculture or blood test to rule out a secondary infection.\\nInfluenza is sometimes confused with a cold, but flu\\ncauses much more severe symptoms and generally a\\nfever. Allergies to molds or pollens also can make the\\nnose run. Allergies are usually more persistent than the\\ncommon cold. An allergist can do tests to determine if\\nthe cold-like symptoms are being caused by an allergic\\nreaction. Also, some people get a runny nose when they\\ngo outside in winter and breathe cold air. This type of\\nrunny nose is not a symptom of a cold.\\nTreatment\\nThere are no medicines that will cure the common\\ncold. Given time, the body’s immune system will make\\nantibodies to fight the infection, and the cold will be\\nresolved without any intervention. Antibiotics are use-\\nless against a cold. However, a great deal of money is\\nspent by pharmaceutical companies in the United States\\npromoting products designed to relieve cold symptoms.\\nThese products usually contain antihistamines , decon-\\ngestants, and/or pain relievers.\\nAntihistamines block the action of the chemical hist-\\namine that is produced when the cold virus invades the\\nGALE ENCYCLOPEDIA OF MEDICINE 2870\\nCommon cold\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 870'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 259, 'page_label': '260'}, page_content='cells lining the nasal passages. Histamine increases\\nblood flow and causes the cells to swell. Antihistamines\\nare taken to relieve the symptoms of sneezing, runny\\nnose, itchy eyes, and congestion. Side effects are dry\\nmouth and drowsiness, especially with the first few\\ndoses. Antihistamines should not be taken by people who\\nare driving or operating dangerous equipment. Some\\npeople have allergic reactions to antihistamines. Com-\\nmon over-the-counter antihistamines include Chlor-\\nTrimeton, Dimetapp, Tavist, and Actifed. The generic\\nname for two common antihistamines are chlorpheni-\\nramine and diphenhydramine.\\nDecongestants work to constrict the blood flow to\\nthe vessels in the nose. This can shrink the tissue, reduce\\ncongestion, and open inflamed nasal passages, making\\nbreathing easier. Decongestants can make people feel jit-\\ntery or keep them from sleeping. They should not be used\\nby people with heart disease, high blood pressure, or\\nglaucoma . Some common decongestants are Neo-\\nSynepherine, Novafed, and Sudafed. The generic names\\nof common decongestants include phenylephrine,\\nphenylpropanolamine, pseudoephedrine, and in nasal\\nsprays naphazoline, oxymetazoline and xylometazoline.\\nMany over the counter medications are combina-\\ntions of both antihistamines and decongestants; an ache\\nand pain reliever, such as acetaminophen (Datril,\\nTylenol, Panadol) or ibuprofen (Advil, Nuprin, Motrin,\\nMedipren); and a cough suppressant (dextromethor-\\nphan). Common combination medications include\\nTylenol Cold and Flu, Triaminic, Sudafed Plus, and\\nTavist D. Aspirin should not be given to children with a\\ncold because of its association with a risk of Reye’s syn-\\ndrome, a serious disease.\\nNasal sprays and nose drops are other products pro-\\nmoted for reducing nasal congestion. These usually con-\\ntain a decongestant, but the decongestant can act more\\nquickly and strongly than ones found in pills or liquids\\nbecause it is applied directly in the nose. Congestion\\nreturns after a few hours.\\nPeople can become dependent on nasal sprays and\\nnose drops. If used for a long time, users may suffer\\nwithdrawal symptoms when these products are discon-\\ntinued. Nasal sprays and nose drops should not be used\\nfor more than a few days. Check the label for recommen-\\ndations on length and frequency of use.\\nPeople react differently to different cold medications\\nand may find some more helpful than others. A medica-\\ntion may be effective initially, then lose some of its effec-\\ntiveness. Children sometimes react differently than\\nadults. Over-the-counter cold remedies should not be\\ngiven to infants without consulting a doctor first.\\nCare should be taken not to exceed the recommend-\\ned dosages, especially when combination medications or\\nnasal sprays are taken. Individuals should determine\\nwhether they wish to use any of these drugs. None of\\nthem shorten or cure a cold. At best they help a person\\nfeel more comfortable. People who are confused about\\nthe drugs in any over-the-counter cold remedies should\\nask their pharmacist for an explanation.\\nIn addition to the optional use of over the counter\\ncold remedies, there are some self-care steps that people\\ncan take to ease their discomfort. These include:\\n• drinking plenty of fluids, but avoiding acidic juices,\\nwhich may irritate the throat\\n• gargling with warm salt water—made by adding one\\nteaspoon of salt to 8 oz of water—for a sore throat\\n• not smoking\\n• getting plenty of rest\\n• using a cool-mist room humidifier to ease congestion\\nand sore throat\\n• rubbing Vaseline or other lubricant under the nose to\\nprevent irritation from frequent nose blowing\\n• for babies too young to blow their noses, the mucus\\nshould be suctioned gently with an infant nasal aspira-\\ntor, it may be necessary to soften the mucus first with a\\nfew drops of salt water\\nAlternative treatment\\nAlternative practitioners emphasize that people get\\ncolds because their immune systems are weak. They\\npoint out that everyone is exposed to cold viruses, but not\\neveryone gets every cold. The difference seems to be in\\nthe ability of the immune system to fight infection. Pre-\\nvention focuses on strengthening the immune system by\\neating a healthy diet low in sugars and high in fresh fruits\\nand vegetables, practicing meditation to reduce stress,\\nand getting regular moderate exercise.\\nOnce cold symptoms appear, some naturopathic\\npractitioners believe the symptoms should be allowed to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 871\\nCommon cold\\nCold Remedies\\nSymptoms Side effects\\nAntihistamines Congestion Drowsiness\\nItchy eyes Dry mouth and eyes\\nRunny nose\\nSneezing\\nStuffy nose\\nDecongestants Congestion Insomnia\\nStuffy nose Rapid heart beat Stimulation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 871'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 260, 'page_label': '261'}, page_content='run their course without interference. Others suggest the\\nfollowing:\\n• Inhaling a steaming mixture of lemon oil, thyme oil,\\neucalyptus, and tea tree oil ( Melaleuca spp.). ( Aro-\\nmatherapy)\\n• Gargling with a mixture of water, salt, and turmeric\\npowder or astringents such as alum, sumac, sage, and\\nbayberry to ease a sore throat. (Ayurvedic medicine)\\n• Taking coneflower ( Echinacea spp.) or goldenseal\\n(Hydrastis canadensis ). Other useful herbs to reduce\\nsymptoms include yarrow ( Achillea millefolium ), eye-\\nbright (Euphrasia officinalis ), garlic (Allium sativum ),\\nand onions (Allium cepa). (Herbal)\\n• Microdoses of Viscue album, Natrum muriaticum, Alli-\\num cepa, or Nux vomica. (Homeopathy)\\n• Taking yin chiao (sometimes transliterated as yinquiao)\\ntablets that contain honeysuckle and forsythia when\\nsymptoms appear. Natural herb loquat syrup for cough\\nand sinus congestion and Chinese ephedra ( ma-huang)\\nfor runny nose. (Chinese traditional medicine)\\n• The use of zinc lozenges every two hours along with\\nhigh doses of vitamin C is suggested. Some practition-\\ners also suggest eliminating dairy products for the dura-\\ntion of the cold. (Nutritional therapy).\\nThe use of zinc lozenges may be moving toward\\nacceptance by practitioners of traditional medicine. In\\n1996 the Cleveland Clinic tested zinc gluconate lozenges\\nand found using zinc in the first 24 hours after cold\\nsymptoms occurred shortened the duration of symptoms.\\nKEY TERMS\\nBronchial tubes —The major airways to the lungs\\nand their main branches.\\nCoronavirus—a genus of viruses that cause respi-\\nratory disease and gastroenteritis.\\nCorticosteroids —A group of hormones produced\\nnaturally by the adrenal gland or manufactured\\nsynthetically. They are often used to treat inflam-\\nmation. Examples include cortisone and pred-\\nnisone.\\nEustachian tube—A thin tube between the middle\\near and the pharnyx. Its purpose is to equalize\\npressure on either side of the ear drum.\\nRhinovirus—A virus that infects the upper respira-\\ntory system and causes the common cold.\\nThe mechanism by which zinc worked was not clear, but\\nadditional studies are underway.\\nPrognosis\\nGiven time, the body will make antibodies to cure\\nitself of a cold. Most colds last a week to 10 days. Most\\npeople start feeling better within four or five days. Occa-\\nsionally a cold will lead to a secondary bacterial infection\\nthat causes strep throat, bronchitis, pneumonia, sinus\\ninfection, or a middle ear infection. These conditions usu-\\nally clear up rapidly when treated with an antibiotic.\\nPrevention\\nIt is not possible to prevent colds because the viruses\\nthat cause colds are common and highly infectious. How-\\never, there are some steps individuals can take to reduce\\ntheir spread. These include:\\n• washing hands well and frequently, especially after\\ntouching the nose or before handling food\\n• covering the mouth and nose when sneezing\\n• disposing of used tissues properly\\n• avoiding close contact with someone who has a cold\\nduring the first two to four days of their infection\\n• not sharing food, eating utensils, or cups with anyone\\n• avoiding crowded places where cold germs can spread\\n• eating a healthy diet and getting adequate sleep\\nResources\\nBOOKS\\nBurton Goldberg Group. “Colds and Flu.” In Alternative Medi-\\ncine: The Definitive Guide, ed. James Strohecker.\\nPuyallup, W A: Future Medicine Publishing, 1994.\\nCastleman, Michael. “Cold and Flu Therapy.” In Nature’s\\nCures. Emmaus, PA: Rodale Press, 1996.\\nSilverstein Alvin, et al. Common Cold and Flu (Diseases and\\nPeople). Springfield, MA: Enslow Publishers, 1996.\\nTish Davidson\\nCommon variable\\nimmunodeficiency\\nDefinition\\nCommon variable immunodeficiency is an immun-\\nodeficiency disorder characterized by a low level of anti-\\nbodies. Patients with this disease are subject to recurring\\ninfections.\\nGALE ENCYCLOPEDIA OF MEDICINE 2872\\nCommon variable immunodeficiency\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 872'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 261, 'page_label': '262'}, page_content='Description\\nImmunodeficiency means that the immune system is\\ndeficient in one or more of its components and is unable\\nto respond effectively. Common variable immunodefi-\\nciency is the most common of the immunodeficiency dis-\\norders. Patients with this disease have frequent infec-\\ntions, especially those caused by the same microorgan-\\nism. Recurring infections are an indication that the\\nimmune system is not responding normally and develop-\\ning immunity to reinfection. Patients with common vari-\\nable immunodeficiency have a normal number of B cells,\\nthe lymphocytes that make antibodies. In approximately\\none-third of these patients, the number of B cells in the\\nblood that have IgG antibodies on their surface is lower\\nthan normal, but there are normal numbers of B cells in\\ntheir bone marrow. B cells with IgG antibodies on their\\nsurface are capable of responding to microorganisms.\\nThe lack of IgG on the surface of the B cells means that\\nthey are not prepared to fight infection. The T-cell lym-\\nphocytes, those cells responsible for cellular immunity,\\nare usually normal, although some cell signal compo-\\nnents may be lacking.\\nCauses and symptoms\\nThe cause of common variable immunodeficiency is\\nnot known, although some forms seem to be hereditary.\\nThe main symptom is recurring infections that tend to be\\nchronic rather than acute. Patients may also develop diar-\\nrhea and, as a consequence of the diarrhea, do not absorb\\nfood efficiently. This can lead to malnourishment that can\\naggravate the disorder. Common variable immunodefi-\\nciency normally appears in children after the age of 10.\\nAutoimmune disorders such as rheumatoid arthritis ,\\nthyroiditis, and systemic lupus erythematosus and cer-\\ntain cancers such as lymphomas and leukemias may be\\nassociated with common variable immunodeficiency.\\nDiagnosis\\nAs is true of most immunodeficiency disorders, one\\nof the first signs that the patient has the condition is\\nrecurrent infections. Patients with common variable\\nimmunodeficiency are subject to recurrent infections,\\nespecially those caused by microbes that don’t normally\\ncause disease in normal persons. The main diagnostic\\ntest that distinguishes common variable immunodeficien-\\ncy from other immunodeficiency diseases is the low anti-\\nbody level despite the normal number of B cells. Anti-\\nbody levels are tested in the serum by a procedure called\\nelectrophoresis. This procedure both quantifies the\\namount of antibody present and identifies the various\\nclasses of antibodies. The main class of antibody for\\nfighting infectious diseases is IgG.\\nTreatment\\nThere is no treatment that will cure the disorder.\\nTreatment for common variable immunodeficiency aims\\nat boosting the body’s immune response and preventing\\nor controlling infections. Immune serum, obtained from\\ndonated blood, is given as a source of antibodies to boost\\nthe immune response. Immune serum is obtained from\\ndonated blood. It contains whatever antibodies the\\ndonors had in their blood. Consequently, it may not con-\\ntain all the antibodies that the patient needs and may lack\\nantibodies specific for some of the recurring infections\\nthat these patients suffer. Antibiotics are used routinely\\nat the first sign of an infection to help the patient elimi-\\nnate infectious microorganisms.\\nPrognosis\\nWith good medical care, people with common vari-\\nable immunodeficiency usually have a normal life span.\\nPrevention\\nThe disease itself cannot be prevented, but patients and\\ntheir families can take precautions to prevent the recurrent\\ninfections commonly associated with it. For example, good\\nhygiene and nutritionare important, as is avoiding crowds\\nor other people who have active infections.\\nResources\\nBOOKS\\nAbbas, Abul K., Andrew H. Lichtman, and Jordan S. Pober.\\nCellular and Molecular Immunology. 3rd ed. Philadel-\\nphia: W. B. Saunders Co., 1997.\\nProfessional Guide to Diseases. 5th ed. Springhouse, PA:\\nSpringhouse Corporation, 1995.\\nJohn T. Lohr, PhD\\nComplement deficiencies\\nDefinition\\nComplement deficiencies are a group of disorders in\\nwhich there is a reduced level of specific proteins, com-\\nplement, involved in proper immune functioning.\\nDescription\\nComplement plays several functions in immunity. It\\ncan poke holes in bacteria, kill bacteria that are first tar-\\ngeted by antibodies, or, working with antibodies, point\\nGALE ENCYCLOPEDIA OF MEDICINE 2 873\\nComplement deficiencies\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 873'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 262, 'page_label': '263'}, page_content='out which bacteria need to be engulfed by white blood\\ncells. Without sufficient complement, the body is prone\\nto frequent infections, like pneumonia or meningitis,o r\\nother illnesses, including autoimmune diseases, like sys-\\ntemic lupus erythematosus . Since there are more than\\n20 different types of complement, the disease that results\\ndepends on the specific complement that is lacking.\\nCause and symptoms\\nA defect in the complement system can be genetic, but\\na secondary complement deficiency can also result from\\nailments that involve a lot of protein loss, including serious\\nburns, liver or kidney disease, and autoimmune diseases,\\nlike lupus. Symptoms vary depending on the specific com-\\nplement deficiency and the disease that results. Some peo-\\nKEY TERMS\\nAutoimmune diseases —A group of diseases, like\\nrheumatoid arthritis and systemic lupus erythe-\\nmatosus, in which immune cells turn on the body,\\nattacking various tissues and organs.\\nHereditary angioedema—A complement deficien-\\ncy characterized by lymphatic vessel blockages\\nthat cause temporary swelling (edema) of areas of\\nthe skin, mucous membranes, and, sometimes,\\ninternal organs.\\nLeucocyte adhesion deficiency syndrome —A\\ncomplement deficiency syndrome characterized\\nby recurrent infections of the skin, mucous mem-\\nbranes, and gastrointestinal tract and the absence\\nof pus formation. This disorder is sometimes\\napparent at birth when separation of the umbilical\\ncord takes longer than normal.\\nMeningitis —An inflammation of the lining sur-\\nrounding the brain and spinal cord.\\nParoxysmal nocturnal hemoglobinuria (PNH) —A\\nrare complement disorder characterized by\\nepisodes of red blood cell destruction (hemolysis)\\nand blood in the urine (hemoglobinuria) that is\\nworse at night.\\nSystemic lupus erythematosus —An autoimmune\\ndisease in which the immune system attacks the\\nbody’s connective tissue. A butterfly-shaped facial\\nrash is characteristic.\\nWhite blood cells —Cells that are key in immune\\ndefense. There are various types, including those\\nthat engulf and kill invading bacteria.\\nple remain healthy with no symptoms at all. Others, who\\nsuffer from frequent infections, may develop a high fever,\\ndiarrhea, headaches with a stiff neck, or a cough with\\nchest pain. If an autoimmune disease develops, like lupus,\\nthe person may lose weight, suffer from a rash, and have\\njoint pain. Other symptoms of complement deficiency dis-\\neases (like hereditary angioedema, paroxysmal nocturnal\\nhemoglobinuria, or leukocyte adhesion deficiency syn-\\ndrome) include abdominal and back pain, skin infections,\\nedema or swelling of the face and red bumps on the skin.\\nDiagnosis\\nThere are blood tests that determine the activity of the\\ncomplement system. The two most common screening\\ntests, CH50 and APH50, tell the physician which group of\\ncomplement components have a defect. More specific\\nblood tests for the individual complement components\\n(e.g., C3 or C4 complement) are then performed. Other\\nspecialized blood tests, including C1 esterase level, Ham\\ntest, and a white blood count, may also be performed.\\nTreatment\\nThere is no way to treat the actual complement defi-\\nciency. However, antibiotics are used to treat infections\\nand vaccinations are given to reduce the risk of disease.\\nOften, the person is vaccinated against infections that\\ninclude influenza, pneumonia, and meningitis. In some\\ncases, (e.g., a specific disease called paroxysmal noctur-\\nnal hemoglobinuria [PNH]), a bone marrow transplant\\nmay be recommended.\\nAlternative treatment\\nThere is no alternative treatment for complement\\nproblems.\\nPrognosis\\nSince complement deficiencies include a wide range\\nof disorders, the prognoses can also vary widely. Some\\npatients remain healthy their entire life. Others are hospi-\\ntalized frequently because of infections which, if not\\nproperly treated, can be fatal. Those with autoimmune\\ndiseases could have a normal life expectancy. There are\\nsome complement deficiencies, that have a high mortali-\\nty rate. In those cases, death may occur within 10 years\\nafter diagnosis.\\nPrevention\\nThere is currently no way to prevent complement\\ndeficiencies.\\nGALE ENCYCLOPEDIA OF MEDICINE 2874\\nComplement deficiencies\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 874'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 263, 'page_label': '264'}, page_content='Resources\\nBOOKS\\nMcLean, Robert H., and Thomas R. Welch. “Complement.” In\\nHandbook of Human Immunology, ed. Mary S. Leffell, et\\nal. Boca Raton: CRC Press, 1997.\\nPERIODICALS\\n“Complement Deficiency States.”Immune Deficiency and\\nAllied Disorders Newsletter 2 (June 1996): 1-6.\\nORGANIZATIONS\\nImmune Deficiency Foundation. 25 W. Chesapeake Ave., Suite\\n206, Towson, MD 21204. (800) 296-4433. .\\nOTHER\\n“The Clinical Presentation of the Primary Immunodeficiency\\nDiseases.”International Patient Organization for Patient’s\\nwith Primary Immunodeficiences..\\nJeanine Barone, Physiologist\\nComplete blood count see Blood count\\nComputed tomography scans\\nDefinition\\nComputed tomography (CT) scans are completed\\nwith the use of a 360-degree x-ray beam and computer\\nproduction of images. These scans allow for cross-\\nsectional views of body organs and tissues.\\nPurpose\\nCT scans are used to image a wide variety of body\\nstructures and internal organs. Since the 1990s, CT\\nequipment has become more affordable and available. In\\nsome diagnoses, CT scans have become the first imaging\\nexam of choice. Because the computerized image is so\\nsharp, focused, and three-dimensional, many tissues can\\nbe better differentiated than on standard x rays. Common\\nCT indications include:\\n• Sinus studies. The CT scan can show details of sinusi-\\ntis and bone fractures . Physicians may order a CT of\\nthe sinuses to provide an accurate map for surgery.\\n• Brain studies. Brain scans can detect hematomas,\\ntumors, and strokes. The introduction of CT scanning,\\nespecially spiral CT, has helped reduce the need for more\\ninvasive procedures such as cerebral angiography.\\n• Body scans. CT scans of the body will often be used\\nto observe abdominal organs, such as the liver, kid-\\nneys, adrenal glands, spleen, and lymph nodes, and\\nextremities.\\n• Aorta scans. CT scans can focus on the thoracic or\\nabdominal aorta to locate aneurysms and other possible\\naortic diseases.\\n• Chest scans. CT scans of the chest are useful in distin-\\nguishing tumors and in detailing accumulation of fluid\\nin chest infections.\\nPrecautions\\nPregnant women or those who could possibly be\\npregnant should not have a CT scan unless the diagnostic\\nbenefits outweigh the risks. Pregnant patients should par-\\nticularly avoid full body or abdominal scans. If the exam\\nis necessary for obstetrics purposes, technologists are\\ninstructed not to repeat films if there are errors. Pregnant\\npatients receiving CT or any x-ray exam away from the\\nabdominal area may be protected by a lead apron; most\\nradiation, known as scatter, travels through the body and\\nis not blocked by the apron.\\nContrast agents are often used in CT exams and the\\nuse of these agents should be discussed with the medical\\nprofessional prior to the procedure. Patients should be\\nasked to sign a consent form concerning the administra-\\ntion of contrast. One of the common contrast agents,\\niodine, can cause allergic reactions. Patients who are\\nknown to be allergic to iodine (or shellfish) should\\ninform the physician prior to the CT scan.\\nDescription\\nComputed tomography, also called CT scan, CAT\\nscan, or computerized axial tomography, is a combina-\\ntion of focused x-ray beams and computerized produc-\\ntion of an image. Introduced in the early 1970s, this radi-\\nologic procedure has advanced rapidly and is now widely\\nused, sometimes in the place of standard x rays.\\nCT equipment\\nA CT scan may be performed in a hospital or outpa-\\ntient imaging center. Although the equipment looks large\\nand intimidating, it is very sophisticated and fairly com-\\nfortable. The patient is asked to lie on a gantry, or narrow\\ntable, that slides into the center of the scanner. The scan-\\nner looks like a doughnut and is round in the middle,\\nwhich allows the x-ray beam to rotate around the patient.\\nThe scanner section may also be tilted slightly to allow\\nfor certain cross-sectional angles.\\nCT procedure\\nThe patient will feel the gantry move very slightly as\\nthe precise adjustments for each sectional image are\\nGALE ENCYCLOPEDIA OF MEDICINE 2 875\\nComputed tomography scans\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 875'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 264, 'page_label': '265'}, page_content='made. A technologist watches the procedure from a win-\\ndow and views the images on a computer screen.\\nIt is essential that the patient lie very still during the\\nprocedure to prevent motion blurring. In some studies,\\nsuch as chest CTs, the patient will be asked to hold his or\\nher breath during image capture.\\nFollowing the procedure, films of the images are\\nusually printed for the radiologist and referring physician\\nto review. A radiologist can also interpret CT exams on a\\nspecial computer screen. The procedure time will vary in\\nlength depending on the area being imaged. Average\\nstudy times are from 30 to 60 minutes. Some patients\\nmay be concerned about claustrophobia, but the width of\\nthe “doughnut” portion of the scanner is such that many\\npatients can be reassured of openness.\\nThe CT image\\nWhile traditional x rays image organs in two dimen-\\nsions, with the possibility that organs in the front of the\\nbody are superimposed over those in the back, CT scans\\nallow for a more three-dimensional effect. Some have\\ncompared CT images to slices in a loaf of bread. Precise\\nsections of the body can be located and imaged as cross-\\nsectional views. The screen before the technologist\\nshows a computer’s analysis of each section detected by\\nthe x-ray beam. Thus, various densities of tissue can be\\neasily distinguished.\\nContrast agents\\nContrast agents are often used in CT exams and in\\nother radiology procedures to illuminate certain details\\nof anatomy which may not be easily seen. Some con-\\ntrasts are natural, such as air or water. Other times, a\\nwater-based contrast agent is administered for specific\\ndiagnostic purposes. Barium sulfate is commonly used in\\ngastroenterology procedures. The patient may drink this\\ncontrast, or receive it in an enema. Oral and rectal con-\\ntrast are usually given when examining the abdomen or\\ncells, and not given when scanning the brain or chest.\\nIodine is the most widely used intravenous contrast agent\\nand is given through an intravenous needle.\\nIf contrast agents are used in the CT exam, these will\\nbe administered several minutes before the study begins.\\nAbdominal CT patients may be asked to drink a contrast\\nmedium. Some patients may experience a salty taste, flush-\\ning of the face, warmth or slight nausea, or hives from an\\nintravenous contrast injection. Technologists and radiolo-\\ngists have equipment and training to help patients through\\nthese minor reactions and to handle more severe reactions.\\nSevere reactions to contrast are rare, but do occur.\\nSpiral CT\\nSpiral CT, also called helical CT, is a newer version\\nof CT scanning which is continuous in motion and\\nallows for three-dimensional recreation of images. For\\nexample, traditional CT allows the technologist to take\\nslices at very small and precise intervals one after the\\nother. Spiral CT allows for a continuous flow of images,\\nwithout stopping the scanner to move to the next image\\nslice. A major advantage of spiral CT is the ability to\\nreconstruct images anywhere along the length of the\\nstudy area. The procedure also speeds up the imaging\\nprocess, meaning less time for the patient to lie still. The\\nability to image contrast more rapidly after it is injected,\\nwhen it is at its highest level, is another advantage of spi-\\nral CT’s high speed.\\nSome facilities will have both spiral and convention-\\nal CT available. Although spiral is more advantageous\\nfor many applications, conventional CT is still a superior\\nand precise method for imaging many tissues and struc-\\ntures. The physician will evaluate which type of CT\\nworks best for the specific exam purpose.\\nPreparation\\nIf a contrast medium is administered, the patient\\nmay be asked to fast from about four to six hours prior to\\nthe procedure. Patients will usually be given a gown (like\\na typical hospital gown) to be worn during the procedure.\\nAll metal and jewelry should be removed to avoid arti-\\nfacts on the film.\\nAftercare\\nNo aftercare is generally required following a CT\\nscan. Immediately following the exam, the technologist\\nwill continue to watch the patient for possible adverse\\ncontrast reactions. Patients are instructed to advise the\\nGALE ENCYCLOPEDIA OF MEDICINE 2876\\nComputed tomography scans\\nColorized CT scan of human abdomen—aorta is dead cen-\\nter/red (Photo Researchers. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 876'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 265, 'page_label': '266'}, page_content='technologist of any symptoms, particularly respiratory\\ndifficulty. The site of contrast injection will be bandaged\\nand may feel tender following the exam. Hives may\\ndevelop later and usually do not require treatment.\\nRisks\\nRadiation exposure from a CT scan is similar to,\\nthough higher than, that of a conventional x ray.\\nAlthough this is a risk to pregnant women, the exposure\\nto other adults is minimal and should produce no effects.\\nAlthough severe contrast reactions are rare, they are a\\nrisk of many CT procedures.\\nNormal results\\nNormal findings on a CT exam show bone, the most\\ndense tissue, as white areas. Tissues and fat will show as\\nvarious shades of gray, and fluids will be gray or black.\\nAir will also look black. Intravenous, oral, and rectal con-\\ntrast appear as white areas. The radiologist can determine\\nif tissues and organs appear normal by the sensitivity of\\nthe gray shadows. In CT, the images that can cut through\\na section of tissue or organ provide three-dimensional\\nviewing for the radiologist and referring physician.\\nAbnormal results\\nAbnormal results may show different characteristics\\nof tissues within organs. Accumulations of blood or other\\nfluids where they do not belong may be detected. Radiol-\\nogists can differentiate among types of tumors through-\\nout the body by viewing details of their makeup.\\nSinus studies\\nThe increasing availability and lowered cost of CT\\nscanning has led to its increased use in sinus studies,\\neither as a replacement for a sinus x ray or as a follow-up\\nto an abnormal sinus radiograph. The sensitivity of CT\\nallows for location of areas of sinus infection, particularly\\nchronic infection. CT scans can show the extent and loca-\\ntion of tiny fractures to the sinus and nasal bones. Foreign\\nbodies in the sinus and nasal area are also easily detected\\nby CT. CT imaging of the sinuses is important in evaluat-\\ning trauma or disease of the sphenoid bone (the wedge\\nshaped bone at the base of the skull). Sinus tumors will\\nshow as shades of gray indicating the difference in their\\ndensity from that of normal tissues in the area.\\nBrain studies\\nThe precise differences in density allowed by CT scan\\ncan clearly show tumors, strokes, or lesions in the brain area\\nas altered densities. These lighter or darker areas on the\\nimage may indicate a tumor or hematoma within the brain\\nand skull area. Different types of tumors can be identified\\nby the presence of edema, by the tissue’s density, or by\\nstudying blood vessel location and activity. The speed and\\nconvenience of CT often allows for detection of hemorrhage\\nbefore symptoms even occur. Congenital abnormalities in\\nchildren, such as hydrocephalus, may also be confirmed\\nwith CT. Hydrocephalus is suggested by enlargement of the\\nfluid structures called ventricles of the brain.\\nBody scans\\nThe body scan can identify abnormal body structures\\nand organs. Throughout the body, a CT may indicate\\ntumors or cysts, enlarged lymph nodes, abnormal collec-\\ntions of fluids, blood or fat, and metastasis of cancer.\\nTumors resulting from metastasis are different in makeup\\nthan primary tumors, or those that originate in the loca-\\ntion of study. Fractures or damage to soft tissues and liga-\\nments will be more easily seen on the sensitive images\\nproduced by CT scanning, though CT is not usually done\\nfor these. Liver conditions, such as cirrhosis or abscessed\\nor fatty liver, may be observed on the body scan.\\nCT of the aorta\\nCT provides the ability to see and measure the thick-\\nness of the aortal wall, which is very helpful in diagnos-\\ning aortic aneurysms. The use of contrast will help see\\ndetails within the aorta. In addition, density can identify\\ncalcification, and this helps differentiate between acute\\nand chronic problems. An abnormal CT scan may indi-\\ncate signs of aortic clots. Aortic rupture is suggested by\\nsigns such as a hematoma around the aorta or the escape\\nof blood from its cavity.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 877\\nComputed tomography scans\\nComputerized CT scan of facial sinuses. (Pascal Goet-\\ngheluck. Photo Researchers. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 877'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 266, 'page_label': '267'}, page_content='Chest scans\\nIn addition to those findings that may indicate aortic\\naneurysms, chest CT studies can show other problems in\\nthe heart and lungs, and distinguish between an aortic\\naneurysm and a tumor adjacent to the aorta. The com-\\nputer will not only show differences between air, water,\\ntissues, and bone, but will also assign numerical values\\nto the various densities. Coin-sized lesions in the lungs\\nmay be indicative of tuberculosis or tumors. CT will\\nhelp distinguish among the two. Enlarged lymph nodes\\nin the chest area may indicate Hodgkin’s disease. Spiral\\nCT is particularly effective at identifying pulmonary\\nemboli (clots in the lung’s blood vessels).\\nResources\\nBOOKS\\nIllustrated Guide to Diagnostic Tests.Ed. J. A. Lewis. Spring-\\nhouse, PA: Springhouse Corp. 1994.\\nKEY TERMS\\nAneurysm—The bulging of the blood vessel wall.\\nAortic aneurysms are the most dangerous.\\nAneurysms can break and cause bleeding.\\nContrast (agent, medium) —A substance injected\\ninto the body that illuminates certain structures\\nthat would otherwise be hard to see on the radi-\\nograph (film).\\nGantry—A name for the couch or table used in a\\nCT scan. The patient lies on the gantry while it\\nslides into the x-ray scanner portion.\\nHematoma —A collection of blood that has\\nescaped from the vessels. It may clot and harden,\\ncausing pain to the patient.\\nHydrocephalus —A collection of fluid on or\\naround the brain. The pressure from the spinal\\nfluid causes the ventricles to widen.\\nMetastasis—Secondary cancer, or cancer that has\\nspread from one body organ or tissue to another.\\nRadiologist—A medical doctor specially trained in\\nradiology (x ray) interpretation and its use in the\\ndiagnosis of disease and injury.\\nSpiral CT —Also referred to as helical CT, this\\nmethod allows for continuous 360-degree x-ray\\nimage capture.\\nThoracic—Refers to the chest area. The thorax\\nruns between the abdomen and neck and is\\nencased in the ribs.\\nPERIODICALS\\nPapatheofanis, Frank J. “Helical CT and Pulmonary Disease.”\\nDecisions in Imaging Economics (Jan./Feb. 1997): 61-63.\\nORGANIZATIONS\\nAmerican College of Radiology. 1891 Preston White Drive,\\nReston, V A 22091. (800) 227-5463. .\\nTeresa Norris, RN\\nComputerized axial tomography see\\nComputed tomography scans\\nConcussion\\nDefinition\\nConcussion is a trauma-induced change in mental\\nstatus, with confusion and amnesia, and with or without\\na brief loss of consciousness.\\nDescription\\nA concussion occurs when the head hits or is hit by\\nan object, or when the brain is jarred against the skull,\\nwith sufficient force to cause temporary loss of function\\nin the higher centers of the brain. The injured person may\\nremain conscious or lose consciousness briefly, and is\\ndisoriented for some minutes after the blow. According\\nto the Centers for Disease Control and Prevention,\\napproximately 300,000 people sustain mild to moderate\\nsports-related brain injuries each year, most of them\\nyoung men between 16 and 25.\\nWhile concussion usually resolves on its own with-\\nout lasting effect, it can set the stage for a much more\\nserious condition. “Second impact syndrome” occurs\\nwhen a person with a concussion, even a very mild one,\\nsuffers a second blow before fully recovering from the\\nfirst. The brain swelling and increased intracranial pres-\\nsure that can result is potentially fatal. More than 20 such\\ncases have been reported since the syndrome was first\\ndescribed in 1984.\\nCauses and symptoms\\nCauses\\nMost concussions are caused by motor vehicle acci-\\ndents and sports injuries . In motor vehicle accidents,\\nconcussion can occur without an actual blow to the head.\\nInstead, concussion occurs because the skull suddenly\\ndecelerates or stops, which causes the brain to be jarred\\nagainst the skull. Contact sports, especially football,\\nGALE ENCYCLOPEDIA OF MEDICINE 2878\\nConcussion\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 878'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 267, 'page_label': '268'}, page_content='hockey, and boxing, are among those most likely to lead\\nto concussion. Other significant causes include falls, col-\\nlisions, or blows due to bicycling, horseback riding, ski-\\ning, and soccer.\\nThe risk of concussion from football is extremely\\nhigh, especially at the high school level. Studies show\\nthat approximately one in five players suffer concussion\\nor more serious brain injury during their brief high-\\nschool careers. The rate at the collegiate level is approxi-\\nmately 1 in 20. Rates for hockey players are not known\\nas certainly, but are believed to be similar.\\nConcussion and lasting brain damage is an especial-\\nly significant risk for boxers, since the goal of the sport\\nis, in fact, to deliver a concussion to the opponent. For\\nthis reason, the American Academy of Neurology has\\ncalled for a ban on boxing. Repeated concussions over\\nmonths or years can cause cumulative head injury. The\\ncumulative brain injuries suffered by most boxers can\\nlead to permanent brain damage. Multiple blows to the\\nhead can cause “punch-drunk” syndrome or dementia\\npugilistica, as evidenced by Muhammed Ali, whose\\nparkinsonism is a result of his career in the ring.\\nYoung children are likely to suffer concussions from\\nfalls or collisions on the playground or around the home.\\nChild abuse is, unfortunately, another common cause of\\nconcussion.\\nSymptoms\\nSymptoms of concussion include:\\n• headache\\n• disorientation as to time, date, or place\\n• confusion\\n• dizziness\\n• vacant stare or confused expression\\n• incoherent or incomprehensible speech\\n• incoordination or weakness\\n• amnesia for the events immediately preceding the blow\\n• nausea or vomiting\\n• double vision\\n• ringing in the ears\\nThese symptoms may last from several minutes to\\nseveral hours. More severe or longer-lasting symptoms\\nmay indicate more severe brain injury. The person with a\\nconcussion may or may not lose consciousness from the\\nblow; if so, it will be for several minutes at the most.\\nMore prolonged unconsciousness indicates more severe\\nbrain injury.\\nThe severity of concussion is graded on a three-point\\nscale, used as a basis for treatment decisions.\\nKEY TERMS\\nAmnesia —A loss of memory that may be caused\\nby brain injury, such as concussion.\\nParkinsonism —A neurological disorder that\\nincludes a fine tremor, muscular weakness and\\nrigidity, and an altered way of walking.\\n• Grade 1: no loss of consciousness, transient confusion,\\nand other symptoms that resolve within 15 minutes.\\n• Grade 2: no loss of consciousness, transient confusion,\\nand other symptoms that require more than 15 minutes\\nto resolve.\\n• Grade 3: loss of consciousness for any period.\\nDays or weeks after the accident, the person may\\nshow signs of:\\n• headache\\n• poor attention and concentration\\n• memory difficulties\\n• anxiety\\n• depression\\n• sleep disturbances\\n• light and noise intolerance\\nThe occurrence of such symptoms is called “post-\\nconcussion syndrome.”\\nDiagnosis\\nIt is very important for those attending a person with\\nconcussion to pay close attention to the person’s symp-\\ntoms and progression immediately after the accident. The\\nduration of unconsciousness and degree of confusion are\\nvery important indicators of the severity of the injury and\\nhelp guide the diagnostic process and treatment decisions.\\nA doctor, nurse, or emergency medical technician\\nmay make an immediate assessment based on the severi-\\nty of the symptoms; a neurologic exam of the pupils,\\ncoordination, and sensation; and brief tests of orienta-\\ntion, memory, and concentration. Those with very mild\\nconcussions may not need to be hospitalized or have\\nexpensive diagnostic tests. Questionable or more severe\\ncases may require computed tomography scan (CT) or\\nmagnetic resonance imaging (MRI) scans to look for\\nbrain injury.\\nTreatment\\nThe symptoms of concussion usually clear quickly\\nand without lasting effect, if no further injury is sus-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 879\\nConcussion\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 879'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 268, 'page_label': '269'}, page_content='tained during the healing process. Guidelines for return-\\ning to sports activities are based on the severity of the\\nconcussion.\\nA grade 1 concussion can usually be treated with\\nrest and continued observation alone. The person may\\nreturn to sports activities that same day, but only after\\nexamination by a trained professional, and after all\\nsymptoms have completely resolved. If the person sus-\\ntains a second concussion of any severity that same day,\\nhe or she should not be allowed to continue contact\\nsports until he or she has been symptom-free, during\\nboth rest and activity, for one week.\\nA person with a grade 2 concussion must discontin-\\nue sports activity for the day, should be evaluated by a\\ntrained professional, and should be observed closely\\nthroughout the day to make sure that all symptoms have\\ncompletely cleared. Worsening of symptoms, or continu-\\nation of any symptoms beyond one week, indicates the\\nneed for a CT or MRI scan. Return to contact sports\\nshould only occur after one week with no symptoms,\\nboth at rest and during activity, and following examina-\\ntion by a physician. Following a second grade 2 concus-\\nsion, the person should remain symptom-free for two\\nweeks before resuming contact sports.\\nA person with a grade 3 concussion (involving any\\nloss of consciousness, no matter how brief) should be\\nexamined by a medical professional either on the scene or\\nin an emergency room. More severe symptoms may war-\\nrant a CT or MRI scan, along with a thorough neurological\\nand physical exam. The person should be hospitalized if\\nany abnormalities are found or if confusion persists. Pro-\\nlonged unconsciousness and worsening symptoms require\\nurgent neurosurgical evaluation or transfer to a trauma cen-\\nter. Following discharge from professional care, the patient\\nis closely monitored for neurological symptoms which may\\narise or worsen. If headaches or other symptoms worsen or\\nlast longer than one week, a CT or MRI scan should be per-\\nformed. Contact sports are avoided for one week following\\nunconsciousness of only seconds, and for two weeks for\\nunconsciousness of a minute or more. A person receiving a\\nsecond grade 3 concussion should avoid contact sports for\\nat least a month after all symptoms have cleared, and then\\nonly with the approval of a physician. If signs of brain\\nswelling or bleeding are seen on a CT or MRI scan, the ath-\\nlete should not return to the sport for the rest of the season,\\nor even indefinitely.\\nFor someone who has sustained a concussion of any\\nseverity, it is critically important that he or she avoid the\\npossibility of another blow to the head until well after all\\nsymptoms have cleared to prevent second-impact syn-\\ndrome. The guidelines above are designed to minimize\\nthe risk of this syndrome.\\nPrognosis\\nConcussion usually leaves no lasting neurological\\nproblems. Nonetheless, symptoms of post-concussion\\nsyndrome may last for weeks or even months.\\nStudies of concussion in contact sports have shown\\nthat the risk of sustaining a second concussion is even\\ngreater than it was for the first if the person continues to\\nengage in the sport.\\nPrevention\\nMany cases of concussion can be prevented by using\\nappropriate protective equipment. This includes seat\\nbelts and air bags in automobiles, and helmets in all con-\\ntact sports. Helmets should also be worn when bicycling,\\nskiing, or horseback riding. Soccer players should avoid\\nheading the ball when it is kicked at high velocity from\\nclose range. Playground equipment should be underlaid\\nwith soft material, either sand or special matting.\\nThe value of high-contact sports such as boxing,\\nfootball, or hockey should be weighed against the high\\nrisk of brain injury during a young person’s participation\\nin the sport. Steering a child’s general enthusiasm for\\nsports into activities less apt to produce head impacts\\nmay reduce the likelihood of brain injury.\\nResources\\nBOOKS\\nEvans, R. Neurology and Trauma.W. B. Saunders Co., 1996.\\nPERIODICALS\\nQuality Standards Subcommittee, American Academy of Neu-\\nrology. “Practice Parameter: The Management of Concus-\\nsion in Sports.”Neurology 48 (Mar. 1997): 581-585.\\n“Sports-Related Recurrent Brain Injuries—United States.”\\nMorbidity and Mortality Weekly Report, 14 Mar. 1997,\\n224-227.\\nORGANIZATIONS\\nAmerican Academy of Neurology. 1080 Montreal Ave., St.\\nPaul, MN 55116. (612) 695-1940. .\\nRichard Robinson\\nCondom\\nDefinition\\nMale condoms are thin sheaths of latex (rubber),\\npolyurethane (plastic), or animal tissue that are rolled onto\\nan erect penis immediately prior to intercourse. They are\\ncommonly called “safes” or “rubbers.” Female condoms\\nare made of polyurethane and are inserted into the vaginal\\nGALE ENCYCLOPEDIA OF MEDICINE 2880\\nCondom\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 880'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 269, 'page_label': '270'}, page_content='canal before sexual relations. The open end covers the out-\\nside of the vagina, and the closed ring fits over the cervix\\n(opening into the uterus). Both types of condoms collect\\nthe male semen at ejaculation, acting as a barrier to fertil-\\nization. Condoms also perform as barriers to the exchange\\nof bodily fluids and are subsequently an important tool in\\nthe prevention of sexually transmitted diseases(STDs).\\nPurpose\\nBoth male and female condoms are used to prevent\\npregnancy and to protect against STDs such as human\\nimmunodeficiency virus (HIV), gonorrhea, chlamydia,\\nand syphilis . To accomplish these goals, the condom\\nmust be applied and removed correctly.\\nPrecautions\\nMale and female condoms should not be used togeth-\\ner as there is a risk that one of them may come off. The\\nmale condom should not be snug on the tip of the penis. A\\nspace of about 0.5 in should be left at the end to avoid the\\npossibility of it breaking during sexual intercourse. The\\npenis must be withdrawn quickly after ejaculation to pre-\\nvent the condom from falling off as the penis softens. The\\ncondom should therefore always be removed while the\\npenis is still erect to prevent the sperm from spilling into\\nthe vagina.\\nDescription\\nMale condoms made from animal tissue and linen\\nhave been in use for centuries. Latex condoms were\\nintroduced in the late 1800s and gained immediate pop-\\nularity because they were inexpensive and effective. At\\nthat time, they were primarily used to protect against\\nSTDs. A common complaint made by many consumers\\nis that condoms reduce penis sensitivity and impair\\norgasm. Both men and women may develop allergies to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 881\\nCondom\\nPenis\\nCondom\\nA condom is most effective when it is placed on the penis correctly without trapping air between the penis and the condom.\\n(Illustration by Argosy, Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 881'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 270, 'page_label': '271'}, page_content='the latex. Consumer interest in female condoms has\\nbeen slight.\\nMale condoms may be purchased lubricated, ribbed,\\nor treated with spermicide (a chemical that kills sperm).\\nTo be effective, condoms must be removed carefully so\\nas not to “spill” the contents into the vaginal canal. Con-\\ndoms that leak or break do not provide protection against\\npregnancy or disease.\\nIf used correctly, male condoms have an effective-\\nness rate of about 90% for preventing pregnancy, but\\nthis rate can be increased to about 99% if used with a\\nspermicide. (Several types of spermicides are available;\\nthey can be purchased in the form of contraceptive\\ncreams and jellies, foams, or films.) Benefits associated\\nwith this type of contraceptive device include easy avail-\\nability (no prescription is required), convenience of use,\\nand lack of serious side effects. The primary disadvan-\\ntage is that sexual activity must be interrupted in order\\nto put the condom on.\\nFemale condoms, when used correctly and at every\\ninstance of intercourse, were shown to prevent pregnancy\\nin over 95% of women surveyed over the course of six\\nmonths. When used inconsistently, the female condom\\nwas shown to have a failure rate of 21% in the same\\nstudy. One benefit of the female condom is that it may be\\ninserted immediately before sexual intercourse or up to\\neight hours prior, so that sexual activity does not need to\\nbe interrupted for its insertion. One study performed by a\\nmanufacturer of the female condom indicated that\\n50–75% of couples in numerous countries found the bar-\\nrier acceptable for use.\\nCondoms provide better protection against STDs\\nthan any other contraceptive method. One study conduct-\\ned in the 1990s indicated that out of 123 couples with\\none HIV-positive partner, not one healthy individual con-\\nKEY TERMS\\nEjaculate—To expel semen.\\nSemen—The thick whitish liquid released from the\\npenis during sexual intercourse. It contains sperm\\nand other secretions.\\nSperm or spermatozoa —The part of the semen\\nthat is generative—can cause fertilization of the\\nfemale ovum.\\nSpermicide—An agent that is destructive to sperm.\\nVagina—The genital canal in the female, leading\\nfrom the vulva to the uterus.\\ntracted the disease when condoms were used with every\\ninstance of sexual intercourse. A similar 1993 study\\nshowed that out of 171 couples with one HIV-positive\\npartner, all but two individuals were protected against\\nHIV transmission with condom use. In addition to HIV ,\\ncondoms provide effective transmission against gonor-\\nrhea, chlamydia, syphilis, chancroid, and trichomonia-\\nsis. A measure of protection is also provided against\\nhepatitis B virus (HBV), human papillomavirus (HPV),\\nand herpes simplex virus (HSV).\\nBefore purchasing a condom, check the expiration\\ndate. Prior to use, examine the condom for holes. If a\\nlubricant is going to be used, it should be water solu-\\nble because petroleum jellies, such as Vaseline, and\\nother oil based lubricants can weaken latex. It is also\\nimportant to note that condoms made from animal tis-\\nsue or plastic are not recommended as a protection\\nagainst STDs.\\nResources\\nOTHER\\n“The Condom.”Sexual Health InfoCenter..\\n“Condoms.” Planned Parenthood Page..\\n“The Female Condom.”Frontsake Health Center.2001.\\n.\\n“Spermicides, Condoms and Other Barrier Methods.”Epigee\\nBirth Control Guide. .\\nStephanie Dionne\\nConduct disorder\\nDefinition\\nConduct disorder (CD) is a behavioral and emotion-\\nal disorder of childhood and adolescence. Children with\\nconduct disorder act inappropriately, infringe on the\\nrights of others, and violate the behavioral expectations\\nof others.\\nDescription\\nCD is present in approximately 9% of boys and\\n2–9% of girls under the age of 18. Children with con-\\nduct disorder act out aggressively and express anger\\ninappropriately. They engage in a variety of antisocial\\nand destructive acts, including violence towards people\\nand animals, destruction of property, lying, stealing,\\nGALE ENCYCLOPEDIA OF MEDICINE 2882\\nConduct disorder\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 882'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 271, 'page_label': '272'}, page_content='truancy, and running away from home. They often\\nbegin using and abusing drugs and alcohol, and having\\nsex at an early age. Irritability, temper tantrums, and\\nlow self-esteem are common personality traits of chil-\\ndren with CD.\\nCauses and symptoms\\nThere are two sub-types of CD, one beginning in\\nchildhood and the other in adolescence. There is no\\nknown cause. Researchers and physicians suggest that\\nthis disease may be caused by the following:\\n• poor parent-child relationships\\n• dysfunctional families\\n• drug abuse\\n• physical abuse\\n• poor relationships with other children\\n• cognitive problems leading to school failures\\n• brain damage\\n• biological defects\\nDifficulty in school is an early sign of potential con-\\nduct disorder problems. While the patient’s IQ tends to\\nbe in the normal range, they can have trouble with verbal\\nand abstract reasoning skills and may lag behind their\\nclassmates, and consequently, feel as if they don’t “fit\\nin.” The frustration and loss of self-esteem resulting from\\nthis academic and social inadequacy can trigger the\\ndevelopment of CD.\\nA dysfunctional home environment can be another\\nmajor contributor to CD. An emotionally, physically, or\\nsexually abusive home environment, a family history of\\nantisocial personality disorder, or parental substance\\nabuse can damage a child’s perceptions of himself and\\nput him on a path toward negative behavior. Other less\\nobvious environmental factors can also play a part in the\\ndevelopment of conduct disorder. Long-term studies\\nhave shown that maternal smoking during pregnancy\\nmay be linked to the development of CD in boys. Ani-\\nmal and human studies point out that nicotine can have\\nundesirable effects on babies. These include altered\\nstructure and function of their nervous systems, learning\\ndeficits, and behavioral problems. In a study of 177 boys\\nages seven-12 years, those with mothers who smoked\\nover one half a package of cigarettes daily while preg-\\nnant were more apt to have a CD than those with moth-\\ners who did not smoke.\\nOther conditions that may cause or co-exist with CD\\ninclude head injury , substance abuse disorder, major\\ndepressive disorder, and attention deficit hyperactivity\\ndisorder ( ADHD). Thirty to fifty percent of children\\ndiagnosed with ADHD, a disorder characterized by a\\npersistent pattern of inattention and/or hyperactivity, also\\nhave CD.\\nCD is defined as a repetitive behavioral pattern of\\nviolating the rights of others or societal norms. Three of\\nthe following criteria, or symptoms, are required over the\\nprevious 12 months for a diagnosis of CD (one of the\\nthree must have occurred in the past six months):\\n• bullies, threatens, or intimidates others\\n• picks fights\\n• has used a dangerous weapon\\n• has been physically cruel to people\\n• has been physically cruel to animals\\n• has stolen while confronting a victim (for example,\\nmugging or extortion)\\n• has forced someone into sexual activity\\n• has deliberately set a fire with the intention of causing\\ndamage\\n• has deliberately destroyed property of others\\n• has broken into someone else’s house or car\\n• frequently lies to get something or to avoid obligations\\n• has stolen without confronting a victim or breaking and\\nentering (e.g., shoplifting or forgery)\\n• stays out at night; breaks curfew (beginning before 13\\nyears of age)\\n• has run away from home overnight at least twice (or\\nonce for a lengthy period)\\n• is often truant from school (beginning before 13 years\\nof age).\\nDiagnosis\\nCD is diagnosed and treated by a number of social\\nworkers, school counselors, psychiatrists, and psycholo-\\ngists. Genuine diagnosis may require psychiatric exper-\\ntise to rule out such conditions as bipolar disorder or\\nADHD. A comprehensive evaluation of the child should\\nideally include interviews with the child and parents, a\\nfull social and medical history, a cognitive evaluation,\\nand a psychiatric exam. One or more clinical inventories\\nor scales may be used to assess the child for conduct dis-\\norder—including the Youth Self-Report, the Overt\\nAggression Scale (OAS), Behavioral Assessment Sys-\\ntem for Children (BASC), Child Behavior Checklist\\n(CBCL), and Diagnostic Interview Schedule for Chil-\\ndren (DISC). The tests are verbal and/or written and are\\nadministered in both hospital and outpatient settings.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 883\\nConduct disorder\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 883'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 272, 'page_label': '273'}, page_content='Treatment\\nTreating conduct disorder requires an approach that\\naddresses both the child and his environment. Behavioral\\ntherapy and psychotherapy can help a child with CD to\\ncontrol his anger and develop new coping skills. Family\\ngroup therapy may also be effective in some cases. Par-\\nents should be counseled on how to set appropriate limits\\nwith their child and be consistent and realistic when dis-\\nciplining. If an abusive home life is at the root of the con-\\nduct problem, every effort should be made to move the\\nchild into a more supportive environment. Parent training\\nprograms are increasing in number.\\nFor children with coexisting ADHD, substance\\nabuse, depression, or learning disorders , treating these\\nconditions first is preferred, and may result in a signifi-\\ncant improvement to the CD condition. In all cases of\\nCD, treatment should begin when symptoms first appear.\\nRecent studies have shown Ritalin to be a useful drug for\\nboth ADHD and CD.\\nWhen aggressive behavior is severe, mood stabi-\\nlizing medication, including lithium (Cibalith-S,\\nEskalith, Lithane, Lithobid, Lithonate, Lithotabs), car-\\nbamazepine (Tegretol, Atretol), and propranolol\\n(Inderal), may be an appropriate option for treating the\\naggressive symptoms. However, placing the child into\\na structured setting or treatment program such as a psy-\\nchiatric hospital may be just as beneficial for easing\\naggression as medication.\\nPrognosis\\nThe prognosis for children with CD is not bright.\\nFollow-up studies of conduct disordered children have\\nshown a high incidence of antisocial personality disor-\\nder, affective illnesses, and chronic criminal behavior\\nlater in life. However, proper treatment of co-existing\\ndisorders, early identification and intervention, and\\nlong-term support may improve the outlook signifi-\\ncantly.\\nKEY TERMS\\nADHD—Attention deficit hyperactivity disorder; a\\ndisorder characterized by a persistent pattern of\\ninattention and/or hyperactivity.\\nMajor depressive disorder —A mood disorder\\ncharacterized by profound feelings of sadness or\\ndespair.\\nPrevention\\nA supportive, nurturing, and structured home envi-\\nronment is believed to be the best defense against CD.\\nChildren with learning disabilities and/or difficulties in\\nschool should get immediate and appropriate academic\\nassistance. Addressing these problems when they first\\nappear helps to prevent the frustration and low self-\\nesteem that may lead to CD later on.\\nResources\\nBOOKS\\nDiagnostic and Statistical Manual of Mental Disorders.4th ed.\\nWashington, DC: American Psychiatric Association,\\n2000.\\nMaxmen, Jerrold S., and Nicholas G. Ward. “Disorders Usually\\nFirst Diagnosed in Infancy, Childhood, or Adolescence.”\\nIn Essential Psychopathology and Its Treatment.2nd ed.\\nNew York: W. W. Norton, 1995.\\nSholevar, Pirooz. Conduct Disorders in Childhood and Adoles-\\ncence. Washington, DC: American Psychiatric Press, Inc.,\\n1995.\\nPERIODICALS\\nBrodkin, Adele M., and Melba Coleman. “He’s Trouble with a\\nCapital T: What Can You Do for a Child with Conduct\\nDisorder?” Instructor, Apr. 1996: 18-9.\\nThompson, L. L., et al. “Contribution of ADHD Symptoms to\\nSubstance Problems and Delinquency in Conduct-Disor-\\ndered Adolescents.”Journal of Abnormal Child Psycholo-\\ngy 24, no. 3 (June 1996): 325-47.\\nORGANIZATIONS\\nAmerican Academy of Child and Adolescent Psychiatry\\n(AACAP). 3615 Wisconsin Ave. NW, Washington, DC\\n20016. (202) 966-7300. .\\nChildren and Adults with Attention Deficit Disorder\\n(CH.A.D.D.). 8181 Professional Place, Suite 201\\nPaula Anne Ford-Martin\\nConductive hearing loss see Hearing loss\\nCondylomata acuminata see Genital warts\\nCone biopsy see Cervical conization\\nCongenital adrenal hyperplasia\\nDefinition\\nCongenital adrenal hyperplasia is (CAH) a genetic\\ndisorder characterized by a deficiency in the hormones\\ncortisol and aldosterone and an over-production of the\\nGALE ENCYCLOPEDIA OF MEDICINE 2884\\nCongenital adrenal hyperplasia\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 884'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 273, 'page_label': '274'}, page_content='hormone androgen, which is present at birth and affects\\nsexual development.\\nDescription\\nCAH is a form of adrenal insufficiency in which the\\nenzyme that produces two important adrenal steroid hor-\\nmones, cortisol and aldosterone, is deficient. Because\\ncortisol production is impeded, the adrenal gland instead\\noverproduces androgens (male steroid hormones).\\nFemales with CAH are born with an enlarged clitoris and\\nnormal internal reproductive tract structures. Males have\\nnormal genitals at birth. CAH causes abnormal growth\\nfor both sexes; patients will be tall as children and short\\nas adults. Females develop male characteristics, and\\nmales experience premature sexual development.\\nIn its most severe form, called salt-wasting CAH, a\\nlife-threatening adrenal crisis can occur if the disorder\\nis untreated. Adrenal crisis can cause dehydration ,\\nshock, and death within 14 days of birth. There is also\\na mild form of CAH that occurs later in childhood or\\nyoung adult life in which patients have partial enzyme\\ndeficiency.\\nCAH, a genetic disorder, is the most common adren-\\nal gland disorder in infants and children, occurring in one\\nin 10,000 total births worldwide. It affects both females\\nand males. It is also called adrenogenital syndrome.\\nCauses and symptoms\\nCAH is an inherited disorder. It is a recessive dis-\\nease, which means that a child must inherit one copy of\\nthe defective gene from each parent who is a carrier;\\nwhen two carriers have children, each pregnancy carries\\na 25% risk of producing an affected child.\\nIn females, CAH produces an enlarged clitoris at\\nbirth and masculinization of features as the child grows,\\nsuch as deepening of the voice, facial hair, and failure to\\nmenstruate or abnormal periods at puberty . Females\\nwith severe CAH may be mistaken for males at birth. In\\nmales, the genitals are normal at birth, but the child\\nbecomes muscular, the penis enlarges, pubic hair\\nappears, and the voice deepens long before normal\\npuberty, sometimes as early as two to three years of age.\\nIn the severe salt-wasting form of CAH, newborns\\nmay develop symptoms shortly after birth, including\\nvomiting, dehydration, electrolyte (a compound such as\\nsodium or calcium that separates to form ions when dis-\\nsolved in water) changes, and cardiac arrhythmia.\\nIn the mild form of CAH, which occurs in late child-\\nhood or early adulthood, symptoms include premature\\ndevelopment of pubic hair, irregular menstrual periods,\\nunwanted body hair, or severe acne. However, some-\\ntimes there are no symptoms.\\nDiagnosis\\nCAH is diagnosed by a careful examination of the\\ngenitals and blood and urine tests that measure the hor-\\nmones produced by the adrenal gland. A number of\\nstates in the United States perform a hormonal test (a\\nheel prick blood test) for CAH and other inherited dis-\\neases within a few days of birth. In questionable cases,\\ngenetic testing can provide a definitive diagnosis. For\\nsome forms of CAH, prenatal diagnosis is possible\\nthrough chronic villus sampling in the first trimester and\\nby measuring certain hormones in the amniotic fluid\\nduring the second trimester.\\nTreatment\\nThe goal of treatment for CAH is to return the\\nandrogen levels to normal. This is usually accomplished\\nthrough drug therapy, although surgery is an alternative.\\nLifelong treatment is required.\\nDrug therapy consists of a cortisol-like steroid med-\\nication called a glucocorticoid. Oral hydrocortisone is\\nprescribed for children, and prednisone or dexametha-\\nsone is prescribed for older patients. For patients with\\nsalt-wasting CAH, fludrocortisone, which acts like\\naldosterone (the missing hormone), is also prescribed.\\nInfants and small children may also receive salt tablets,\\nwhile older patients are told to eat salty foods. Medical\\ntherapy achieves hormonal balance most of the time, but\\nCAH patients can have periods of fluctuating hormonal\\ncontrol that lead to increases in the dose of steroids pre-\\nscribed. Side effects of steroids include stunted growth.\\nSteroid therapy should not be suddenly stopped, since\\nadrenal insufficiency results.\\nPatients with CAH should see a pediatric endocrinol-\\nogist frequently. The endocrinologist will assess height,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 885\\nCongenital adrenal hyperplasia\\nAdrenal cortical hyperplasia.The adrenal on the right is nor-\\nmal, that on the left shows hyperplasia.(Photo Researchers,\\nInc. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 885'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 274, 'page_label': '275'}, page_content='weight, and blood pressure, and order an annual x ray of\\nthe wrist (to assess bone age), as well as assess blood hor-\\nmone levels. CAH patients with the milder form of the\\ndisorder are usually effectively treated with hydrocorti-\\nsone or prednisone, if they need medical treatment at all.\\nFemales with CAH who have masculine external\\ngenitalia require surgery to reconstruct the clitoris and/or\\nvagina. This is usually performed between the ages of\\none and three.\\nAn experimental type of drug therapy—a three-drug\\ncombination, with an androgen blocking agent (flu-\\ntamide), an aromatase inhibitor (testolactone), and low\\ndose hydrocortisone—is currently being studied by\\nphysicians at the National Institutes of Health. Prelimi-\\nnary results are encouraging, but it will be many years\\nbefore the safety and effectiveness of this therapy is\\nfully known.\\nAdrenalectomy, a surgical procedure to remove the\\nadrenal glands, is a more radical treatment for CAH. It\\nwas widely used before the advent of steroids. Today, it is\\nrecommended for CAH patients with little or no enzyme\\nactivity and can be accomplished by laparoscopy. This is\\na minimally invasive type of surgery done through one or\\nmore small 1 in (2.5 cm) incisions and a laparoscope, an\\ninstrument with a fiber-optic light containing a tube with\\nKEY TERMS\\nAdrenal glands—The two endocrine glands locat-\\ned above the kidney that secrete hormones and\\nepinephrine.\\nAldosterone—A hormone secreted by the adrenal\\nglands that is important for maintaining salt and\\nwater balance in the body.\\nAndrogens —Steroid hormones that cause mas-\\nculinization.\\nCongenital—Present at birth.\\nCortisol—A steroid hormone secreted by the\\nadrenal cortex that is important for maintenance of\\nbody fluids, electrolytes, and blood sugar levels.\\nHormone —A chemical messenger produced by\\nthe endocrine glands or certain other cells. Hor-\\nmones are usually carried in the blood stream and\\nregulate some metabolic activities.\\nSteroids—Hormones, including aldosterone, cor-\\ntisol, and androgens, derived from cholesterol that\\nshare a four-ring structure.\\nopenings for surgical instruments. Adrenalectomy is fol-\\nlowed by hormone therapy, but in lower doses than CAH\\npatients not treated surgically receive.\\nPrognosis\\nCAH can be controlled and successfully treated in\\nmost patients as long as they remain on drug therapy.\\nPrevention\\nPrenatal therapy, in which a pregnant woman at risk\\nfor a second CAH child is given dexamethasone to\\ndecrease secretion of androgens by the adrenal glands of\\nthe female fetus, has been in use for about 10 years. This\\ntherapy is started in the first trimester when fetal adrenal\\nproduction of androgens begins, but before prenatal diag-\\nnosis is done that would provide definitive information\\nabout the sex of the fetus and its disease status. This\\nmeans that a number of fetuses are exposed to unneces-\\nsary steroid treatment in order to prevent the develop-\\nment of male-like genitals in female fetuses with CAH.\\nSeveral hundred children have undergone this treatment\\nwith no major adverse effects, but its long-term risks are\\nunknown. Since there is very little data on the effective-\\nness and safety of prenatal therapy, it should only be\\noffered to patients who clearly understand the risks and\\nbenefits and who are capable of complying with strict\\nmonitoring and follow-up throughout pregnancy and\\nafter the child is born.\\nParents with a family history of CAH, including a\\nchild who has CAH, should seek genetic counseling .\\nGenetic testing during pregnancy can provide informa-\\ntion on the risk of having a child with CAH.\\nResources\\nBOOKS\\n“Fetal Adrenal Development.” In Williams Obstetrics, 20th ed.\\nStamford, CT: Appleton & Lange, 1997.\\n“Fetal Treatment.” In Medical Genetics, ed. Lynn B. Jorde, et\\nal. St. Louis: Mosby, 1995.\\nHay Jr., William W., et al., eds. Current Pediatric Diagnosis\\nand Treatment.Stamford, CT: Appleton & Lange, 1997.\\nPERIODICALS\\nGussinye, Miquel, et al. “Bone Mineral Density in Prepubertal\\nand in Adolescent and Young Adult Patients with the Salt-\\nWasting Form of Congenital Adrenal Hyperplasia.”Pedi-\\natrics 100 (Oct. 1997): 671.\\nORGANIZATIONS\\nAmerican Academy of Pediatrics. 141 Northwest Point Boule-\\nvard, Elk Grove Village, IL 60007-1098. (847) 434-4000.\\nNational Adrenal Diseases Foundation. 510 Northern Boule-\\nvard, Great Neck, NY 11021. (516) 487-4992. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2886\\nCongenital adrenal hyperplasia\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 886'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 275, 'page_label': '276'}, page_content='OTHER\\nThe Johns Hopkins Children’s Center. “Congenital Adrenal\\nHyperplasia Due to 21-Hydroxylase Deficiency.” .\\nJennifer Sisk\\nCongenital amputation\\nDefinition\\nCongenital amputation is the absence of a fetal\\nlimb or fetal part at birth. This condition may be the\\nresult of the constriction of fibrous bands within the\\nmembrane that surrounds the developing fetus (amniotic\\nband syndrome) or the exposure to substances known to\\ncause birth defects (teratogenic agents). Other factors,\\nincluding genetics, may also play a role.\\nDescription\\nAn estimated one in 2,000 babies are born with all\\nor part of a limb missing, ranging from a missing part of\\na finger to the absence of both arms and both legs. Con-\\ngenital amputation is the least common reason for\\namputation. However, there are occasional periods in\\nhistory where the number of congenital amputations\\nincreased. For example, the thalidomide tragedy of the\\nearly 1960s occurred after pregnant mothers in western\\nEurope were given a tranquilizer containing the drug.\\nThe result was a drastic increase in the number of babies\\nborn with deformed limbs. In this example, the birth\\ndefect usually presented itself as very small, deformed\\nversions of normal limbs. More recently, birth defects as\\na result of radiation exposure near the site of the Cher-\\nnobyl disaster in Russia have left numerous children\\nwith malformed or absent limbs.\\nCauses and symptoms\\nThe exact cause of congenital amputations is\\nunknown. However, according to the March of Dimes,\\nmost birth defects have one or more genetic factors and\\none or more environmental factors. It is also known that\\nmost birth defects occur in the first three months of preg-\\nnancy, when the organs of the fetus are forming. Within\\nthese crucial first weeks, frequently prior to when a\\nwoman is aware of the pregnancy, the developing fetus is\\nmost susceptible to substances that can cause birth\\ndefects (teratogens). Exposure to teratogens can cause\\ncongenital amputation. In other cases, tight amniotic\\nbands may constrict the developing fetus, preventing a\\nlimb from forming properly, if at all. It is estimated that\\nthis amniotic band syndrome occurs in between one in\\n12,000 and one in 15,000 live births.\\nAn infant with congenital amputation may be miss-\\ning an entire limb or just a portion of a limb. Congenital\\namputation resulting in the complete absence of a limb\\nbeyond a certain point (and leaving a stump) is called\\ntransverse deficiency or amelia. Longitudinal deficien-\\ncies occur when a specific part of a limb is missing; for\\nexample, when the fibula bone in the lower leg is miss-\\ning, but the rest of the leg is intact. Phocomelia is the\\ncondition in which only a mid-portion of a limb is miss-\\ning, as when the hands or feet are attached directly to\\nthe trunk.\\nDiagnosis\\nMany cases of congenital amputation are not diag-\\nnosed until the baby is born. Ultrasound examinations\\nmay reveal the absence of a limb in some developing\\nfetuses, but routine ultrasounds may not pick up signs of\\nmore subtle defects. However, if a doctor suspects that\\nthe fetus is at risk for developing a limb deficiency (for\\nexample, if the mother has been exposed to radiation), a\\nmore detailed ultrasound examination may be performed.\\nTreatment\\nSuccessful treatment of a child with congenital\\namputation involves an entire medical team, including a\\npediatrician, an orthopedist, a psychiatrist or psycholo-\\ngist, a prosthetist (an expert in making prosthetics, or\\nartificial limbs), a social worker, and occupational and\\nphysical therapists. The accepted method of treatment is\\nto fit the child early with a functional prosthesis because\\nthis leads to normal development and less wasting away\\n(atrophy) of the muscles of the limbs present. However,\\nsome parents and physicians believe that the child should\\nbe allowed to learn to play and perform tasks without a\\nprosthesis, if possible. When the child is older, he or she\\ncan be involved in the decision of whether or not to be\\nfitted for a prosthesis.\\nRecently, there have been cases in which physicians\\nhave detected amniotic band constriction interfering with\\nlimb development fairly early in its course. In 1997, doc-\\ntors at the Florida Institute for Fetal Diagnosis and Ther-\\napy reported two cases in which minimally invasive\\nsurgery freed constricting amniotic bands and preserved\\nthe affected limbs.\\nAlternative treatment\\nPrevention of birth defects begins with building the\\nwell-being of the mother before pregnancy. Prenatal care\\nGALE ENCYCLOPEDIA OF MEDICINE 2 887\\nCongenital amputation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 887'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 276, 'page_label': '277'}, page_content='should be strong and educational so that the mother\\nunderstands both her genetic risks and her environmental\\nrisks. Several disciplines in alternative therapy also rec-\\nommend various supplements and vitamins that may\\nreduce the chances of birth defects. If a surgical proce-\\ndure is planned, naturopathic and homeopathic pre- and\\npost-surgical therapies can speed recovery.\\nPrognosis\\nA congenital limb deficiency has a profound effect\\non the life of the child and parents. However, occupation-\\nal therapy can help the child learn to accomplish many\\ntasks. In addition, some experts believe that early fitting\\nof a prosthesis will enhance acceptance of the prosthesis\\nby the child and parents.\\nPrevention\\nStudies have suggested that a multivitamin including\\nfolic acid may reduce birth defects, including congenital\\nabnormalities. Smoking, drinking alcohol, and eating a\\npoor diet while pregnant may increase the risk of con-\\ngenital abnormalities. Daily, heavy exposure to chemi-\\ncals may be dangerous while pregnant.\\nResources\\nBOOKS\\nBanasik, Jacquelyn L. “Genetic and Developmental Disor-\\nders.” In Perspectives on Pathophysiology, ed. Lee-Ellen\\nC. Copstead. Philadelphia: W. B. Saunders Co., 1994.\\nORGANIZATIONS\\nInternational Child Amputee Network. .\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nJeffrey P. Larson, RPT\\nCongenital bladder diverticulum see\\nCongenital bladder anomalies\\nKEY TERMS\\nProsthesis— An artificial replacement for a missing\\npart of the body.\\nTeratogen— Any substance, agent, or process that\\ninterferes with normal prenatal development,\\ncausing the formation of one or more develop-\\nmental abnormalities of the fetus.\\nCongenital bladder anomalies\\nDefinition\\nThe two most common congenital bladder abnor-\\nmalities are exstrophy and congenital diverticula. An\\nexstrophic bladder is one that is open to the outside and\\nturned inside-out, so that its inside is visible at birth, pro-\\ntruding from the lower abdomen. A diverticulum is an\\nextension of a hollow organ, usually shaped like a pouch\\nwith a narrow opening.\\nDescription\\nDuring fetal development, folds enclose tissues and\\norgans and eventually fuse at the edges to form sealed\\ncompartments. Both in the front and the back, folds\\neventually become major body structures. In the back,\\nthe entire spinal column folds in like a pipe wrapped in a\\npillow. In the front, the entire lower urinary system is\\nfolded in.\\n• Exstrophy of the bladder represents a failure of this\\nfolding process to complete itself, so the organs form\\nwith more or less of their front side missing and open to\\nthe outside. At the same time, the front of the pelvic\\nbone is widely separated. The abdominal wall is open,\\ntoo. In fact, the defect often extends all the way to the\\npenis in the male or splits the clitoris in the female.\\n• A congenital bladder diverticulum represent an area of\\nweakness in the bladder wall through which extrudes\\nsome of the lining of the bladder. (A small balloon\\nsqueezed in a fist will create diverticula-like effect\\nbetween the fingers.) Bladder diverticula may be multi-\\nple, and they often occur at the ureterovesical junc-\\ntion—the entrance of the upper urinary system into the\\nbladder. In this location, they may cause urine to reflux\\ninto the ureter and kidney, leading to infection and pos-\\nsible kidney damage.\\nCauses and symptoms\\nAs with many birth defects, the causes are not well\\nknown. Lack of prenatal care and nutrition has been\\nlinked to many birth defects; however, beyond the avoid-\\nance of known teratogens (anything that can cause a birth\\ndefect), there is little prevention possible. Exstrophy is\\nrare, occurring in about one in 40,000 births. Diverticula\\nare more common, but less serious.\\nIf left untreated, the patient with bladder exstrophy\\nwill have no control over urination and is more likely to\\ndevelop bladder cancer . Diverticula, particularly if it\\ncauses urine reflux, may lead to chronic infection and its\\nsubsequent consequences.\\nGALE ENCYCLOPEDIA OF MEDICINE 2888\\nCongenital bladder anomalies\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 888'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 277, 'page_label': '278'}, page_content='Diagnosis\\nA major consideration with congenital abnormali-\\nties is that they tend to be multiple. Further, each one\\nis unique in its extent and severity. Exstrophy can\\ninvolve the rectum and large bowel and coexist with\\nhernias. The obvious bladder exstrophy seen at birth\\nwill prompt immediate action and a search for other\\nanomalies.\\nDiverticula are not visible and will be detected only\\nif they cause trouble. They are usually found in an\\nexamination for the cause of recurring urinary infec-\\ntions. X rays of the urinary system or a cystoscopy\\n(examination with a telescope-like instrument) will\\nidentify them. Often, the two procedures are done\\ntogether: a urologist will perform the cystoscopy, then a\\nradiologist will instill a contrast agent into the bladder\\nand take x rays.\\nTreatment\\nSurgery is necessary and can usually produce suc-\\ncessful results. If possible, the surgery must be done\\nwithin 48 hours of birth. Prior to surgery, the exposed\\norgans must be protected and all related defects identi-\\nfied and managed. Delay in the surgery leads to the\\nfrequent need to divert the urine into the bowel\\nbecause the partially repaired bladder cannot control\\nthe flow. After surgery, the likelihood of infection\\nrequires monitoring.\\nAlternative treatment\\nAfter surgery ongoing precautions to reduce fre-\\nquency of infection may need to be used. Cranberry\\njuice has the ability to keep bacteria from adhering to\\nthe membranes and can help prevent infection when-\\never there is increased risk. There are botanical and\\nhomeopathic treatments available, however consulta-\\ntion by a trained practitioner is recommended before\\ntreatment.\\nPrognosis\\nWith immediate surgery, three-quarters of patients\\ncan be successfully repaired. They will have control of\\ntheir urine and no long-term consequences. The rate of\\ninfection is greater for those with congenital bladder\\nanomalies, since any abnormality in the urinary system\\npredisposes it to invasion by bacteria.\\nPrevention\\nBirth defects often have no precisely identified\\ncause, therefore prevention is limited to general mea-\\nsures such as early and continuous prenatal care, appro-\\npriate nutrition, and a healthy lifestyle.\\nKEY TERMS\\nCongenital—Present at birth.\\nCystoscopy —Examination of the urinary bladder\\nwith a thin telescope-like instrument.\\nExstrophy —Being turned inside out combined\\nwith being outside the body.\\nDiverticulum—A pouch extending from a hollow\\norgan.\\nRadiologist —A physician who specializes in cre-\\nating images of the internal organs of the body.\\nTeratogen—Any agent that can cause birth defects.\\nUreter—The tube that transports urine from the\\nkidney to the bladder.\\nUreterovesical junction—The joining of the ureter\\nto the bladder.\\nUrologist—A surgeon who specializes in diseases\\nof the urinary system.\\nResources\\nBOOKS\\n“Anomalies of the Bladder.” In Nelson Textbook of Pediatrics,\\ned. Richard E. Behrman. Philadelphia: W. B. Saunders\\nCo., 1996.\\nAtala, Anthony, and Michael Keating. “Vesicoureteral Reflux\\nand Megaureter.” In Campbell’s Urology, ed. Patrick C.\\nWalsh, et al. Philadelphia: W. B. Saunders Co., 1998.\\nGearhart, John P., and Robert D. Jeffs. “Exstrophy-epispadias\\nComplex and Bladder Anomalies.” In Campbell’s\\nUrology, ed. Patrick C. Walsh, et al. Philadelphia: W. B.\\nSaunders Co., 1998.\\n“Vesicoureteral Reflux.” In Nelson Textbook of Pediatrics,e d .\\nRichard E. Behrman. Philadelphia: W. B. Saunders Co., 1996.\\nJ. Ricker Polsdorfer, MD\\nCongenital brain defects\\nDefinition\\nCongenital brain defects are a group of disorders of\\nbrain development.\\nDescription\\nBrain development begins shortly after conception\\nand continues throughout the growth of a fetus. A com-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 889\\nCongenital brain defects\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 889'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 278, 'page_label': '279'}, page_content='plex genetic program coordinates the formation, growth,\\nand migration of billions of neurons, or nerve cells, and\\ntheir development into discrete, interacting brain\\nregions. Interruption of this program, especially early in\\ndevelopment, can cause structural defects in the brain.\\nIn addition, normal brain formation requires proper\\ndevelopment of the surrounding skull, and skull defects\\nmay lead to brain malformation. Congenital brain\\ndefects may be caused by inherited genetic defects,\\nspontaneous mutations within the genes of the embryo,\\nor effects on the embryo due to the mother’s infection,\\ntrauma, or drug use.\\nEarly on in development, a flat strip of tissue\\nalong the back of the fetus rolls up to form a tube. This\\nso-called “neural tube” develops into the spinal cord,\\nand at one end, the brain. Closure of the tube is\\nrequired for subsequent development of the tissue\\nwithin. Anencephaly (literally “without brain”), results\\nwhen the topmost portion of the tube fails to close.\\nAnencephaly is the most common severe malformation\\nseen in stillborn births. It is about four times more\\ncommon in females than males. Anencephaly is some-\\ntimes seen to run in families, and for parents who have\\nconceived one anencephalic fetus, the risk of a second\\nis as high as 5%. Fewer than half of babies with anen-\\ncephaly are born alive, and survival beyond the first\\nmonth is rare.\\nEncephalocele is a protrusion of part of the brain\\nthrough a defect in the skull. The most common site for\\nencephalocele is along the front-to-back midline of the\\nskull, usually at the rear, although frontal encephaloceles\\nare more common among Asians. Pressure within the\\nskull pushes out cranial tissue. The protective layer over\\nthe brain, the meninges, grows to cover the protrusion, as\\ndoes skin in some cases. Defects in skull closure are\\nthought to cause some cases of encephalocele, while\\ndefects in neural tube closure may cause others.\\nEncephaloceles may be small and contain little or no\\nbrain tissue, or may be quite large and contain a signifi-\\ncant fraction of the brain.\\nFailure of neural-tube closure below the level of\\nthe brain prevents full development of the surrounding\\nvertebral bones and leads to spina bifida , or a divided\\nspinal column. Incomplete closure causes protrusion\\nof the spinal cord and meninges, called meningomye-\\nlocele. Some cases of spina bifida are accompanied by\\nanother defect at the base of the brain, known as the\\nArnold-Chiari malformation or Chiari II malforma-\\ntion. For reasons that are unclear, part of the cerebel-\\nlum is displaced downward into the spinal column.\\nSymptoms may be present at birth or delayed until\\nearly childhood.\\nThe Dandy-Walker malformation is marked by\\nincomplete formation, or absence of, the central section\\nof the cerebellum, and the growth of cysts within the\\nlowest of the brain’s ventricles. The ventricles are fluid-\\nfilled cavities within the brain, through which cere-\\nbrospinal fluid (CSF) normally circulates. The cysts\\nmay block the exit of the fluid, causing hydrocephalus.\\nSymptoms may be present at birth or delayed until early\\nchildhood.\\nSoon after closure of the neural tube, the brain\\ndivides into two halves, or hemispheres. Failure of divi-\\nsion is termed holoprosencephaly (literally “whole\\nforebrain”). Holoprosencephaly is almost always\\naccompanied by facial and cranial deformities along the\\nmidline, including cleft lip, cleft palate, fused eye sock-\\nets and a single eye (cyclopia), and deformities of the\\nlimbs, heart, gastrointestinal tract, and other internal\\norgans. Most infants are either stillborn or die soon\\nafter birth. Survivors suffer from severe neurological\\nimpairments.\\nThe normal ridges and valleys of the mature brain\\nare formed after cells from the inside of the developing\\nbrain migrate to the outside and multiply. When these\\ncells fail to migrate, the surface remains smooth, a con-\\ndition called lissencephaly (“smooth brain”). Lissen-\\ncephaly is often associated with facial abnormalities\\nincluding a small jaw, a high forehead, a short nose, and\\nlow-set ears.\\nIf damaged during growth, especially within the\\nfirst 20 weeks, brain tissue may stop growing, while\\ntissue around it continues to form. This causes an\\nabnormal cleft or groove to appear on the surface of\\nthe brain, called schizencephaly (literally “split\\nbrain”). This cleft should not be confused with the nor-\\nmal wrinkled brain surface, nor should the name be\\nmistaken for schizophrenia , a mental disorder. Gener-\\nalized destruction of tissue or lack of brain develop-\\nment may lead to hydranencephaly, in which cere-\\nbrospinal fluid fills much of the space normally occu-\\npied by the brain. Hydranencephaly is distinct from\\nhydrocephalus, in which CSF accumulates within a\\nnormally-formed brain, putting pressure on it and pos-\\nsibly causing skull expansion.\\nExcessive brain size is termed megalencephaly (lit-\\nerally “big brain”). Megalencephaly is defined as any\\nbrain size above the 98th percentile within the popula-\\ntion. Some cases are familial, and may be entirely\\nbenign. Others are due to metabolic or neurologic dis-\\nease. The opposite condition, microcephaly, may be\\ncaused by failure of the brain to develop, or by intrauter-\\nine infection, drug toxicity, or brain trauma.\\nGALE ENCYCLOPEDIA OF MEDICINE 2890\\nCongenital brain defects\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 890'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 279, 'page_label': '280'}, page_content='Causes and symptoms\\nCauses\\nCongenital brain defects may have genetic, infec-\\ntious, toxic, or traumatic causes. In most cases, no certain\\ncause can be identified.\\nGENETIC CAUSES. Some brain defects are caused by\\ntrisomy, the inclusion of a third copy of a chromosome\\nnormally occurring in pairs. Most trisomies occur\\nbecause of improper division of the chromosomes during\\nformation of eggs or sperm. Trisomy of chromosome 9\\ncan cause some cases of Dandy-Walker and Chiari II\\nmalformation. Some cases of holoprosencephaly are\\ncaused by trisomy of chromosome 13, while others are\\ndue to abnormalities in chromosomes 7 or 18. Individual\\ngene defects, either inherited or spontaneous, are respon-\\nsible for other cases of congenital brain malformations.\\nDRUGS. Drugs known to cause congenital brain\\ndefects when used by the mother during critical develop-\\nmental periods include:\\n• anticonvulsant drugs\\n• retinoic acid and tretinoin\\n• warfarin\\n• alcohol\\n• cocaine\\nOTHER. Other causes of congenital brain defects\\ninclude:\\n• intrauterine infections, including cytomegalovirus,\\nrubella, herpes simplex, and varicella zoster\\n• maternal diabetes mellitus\\n• maternal phenylketonuria\\n• fetal trauma\\nSymptoms\\nBesides the features listed above, symptoms of con-\\ngenital brain defects may include:\\n• Chiari II malformation: impaired swallowing and gag\\nreflex, loss of the breathing reflex, facial paralysis ,\\nuncontrolled eye movements ( nystagmus ), impaired\\nbalance and gait.\\n• Dandy-Walker malformation: symptoms of hydro-\\ncephalus, lack of muscle tone or “floppiness,” seizures,\\nspasticity, deafness, irritability, visual impairment ,\\ndeterioration of consciousness, paralysis.\\n• Lissencephaly: lack of muscle tone, seizures, develop-\\nmental delay, spasticity,cerebral palsy.\\n• Hydranencephaly: irritability, spasticity, seizures, tem-\\nperature oscillations.\\nKEY TERMS\\nAmniocentesis —Removal of fluid from the sac\\nsurrounding a fetus for purposes of diagnosis.\\nCerebrospinal fluid —Fluid produced within the\\nbrain for nutrient transport and structural purposes.\\nCSF circulates through the ventricles, open spaces\\nwithin the brain, and drains through the mem-\\nbranes surrounding the brain.\\nCongenital—Defect present at birth.\\nFetus—The unborn human, developing in a\\nwoman’s uterus, from the eighth week after fertil-\\nization to birth.\\n• megalencephaly due to neurological or metabolic dis-\\nease: mental retardation, seizures.\\nDiagnosis\\nCongenital brain defects are diagnosed either from\\ndirect physical examinationor imaging studies including\\ncomputed tomography scans (CT) and magnetic reso-\\nnance imaging (MRI) scans. Electroencephalography\\n(EEG) may be used to reveal characteristic abnormalities.\\nPrenatal diagnosis of neural tube defects causing\\nanencephaly or meningomyelocele is possible through\\nultrasound examination and maternal blood testing for\\nalpha-fetoprotein, which is almost always elevated.\\nUltrasound can also be used to diagnose Dandy-Walker\\nand Chiari II malformations. Amniocentesis may reveal\\ntrisomies or other chromosomal abnormalities.\\nTreatment\\nMeningomyelocele may be treated with surgery to\\nclose the open portion of the spinal cord. Surgery for\\nencephalocele is possible only if there is a minimal\\namount of brain tissue protruding. Malformations associ-\\nated with hydrocephalus (Dandy-Walker, Chiari II, and\\nsome cases of hydranencephaly) may be treated by\\ninstallation of a drainage shunt for cerebrospinal fluid.\\nDrugs may be used to treat some symptoms of brain\\ndefects, including seizures and spasticity.\\nPrognosis\\nMost congenital brain defects carry a very poor prog-\\nnosis. Surgical treatment of meningomyelocele and\\nencephalocele may be successful, with lasting neurologi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 891\\nCongenital brain defects\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 891'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 280, 'page_label': '281'}, page_content='cal deficiencies that vary in severity. Early treatment of\\nhydrocephalus may prevent more severe brain damage.\\nPrevention\\nSome cases of congenital brain defects can be pre-\\nvented with good maternal nutrition , including folic\\nacid supplements. Folic acid is a vitamin that has been\\nshown to reduce the incidence of neural tube defects.\\nPregnant women should avoid exposure to infection,\\nespecially during the first trimester. Abstention from\\ndrugs and alcohol during pregnancy may reduce risk.\\nGenetic counseling is advisable for parents who have\\nhad one child with anencephaly, since the likelihood of\\nhaving another is increased.\\nResources\\nBOOKS\\nBradley, W. G., et al. Neurology in Clinical Practice.2nd ed.\\nButterworth-Heinemann, 1996.\\nFenichel, G. M. Clinical Pediatric Neurology.3rd ed. W. B.\\nSaunders Co., 1997.\\nNorman, M. G., et al. Congenital Malformations of the Brain.\\nOxford University Press, 1995.\\nRichard Robinson\\nCongenital defects see Birth defects\\nCongenital hip dysplasia\\nDefinition\\nA condition of abnormal development of the hip,\\nresulting in hip joint instability and potential dislocation\\nof the thigh bone from the socket in the pelvis. This con-\\ndition has been more recently termed developmental hip\\ndysplasia, as it often develops over the first few weeks,\\nmonths, or years of life.\\nDescription\\nCongenital hip dysplasia is a disorder in children\\nthat is either present at birth or shortly thereafter. During\\ngestation, the infant’s hip should be developing with the\\nhead of the thigh bone (femur) sitting perfectly centered\\nin its shallow socket (acetabulum). The acetabulum\\nshould cover the head of the femur as if it were a ball sit-\\nting inside of a cup. In the event of congenital hip dyspla-\\nsia, the development of the acetabulum in an infant\\nallows the femoral head to ride upward out of the joint\\nsocket, especially when weight bearing begins.\\nCauses and symptoms\\nClinical studies show a familial tendency toward hip\\ndysplasia, with more females affected than males. This\\ndisorder is found in many cultures around the world.\\nHowever, statistics show that the Native American popu-\\nlation has a high incidence of hip dislocation. This has\\nbeen documented to be due to the common practice of\\nswaddling and using cradleboards for restraining the\\ninfants. This places the infant’s hips into extreme adduc-\\ntion (brought together). The incidence of congenital hip\\ndysplasia is also higher in infants born by caesarian and\\nbreech position births. Evidence also shows a greater\\nchance of this hip abnormality in the first born compared\\nto the second or third child. Hormonal changes within the\\nmother during pregnancy, resulting in increased ligament\\nlaxity, is thought to possibly cross over to the placenta\\nand cause the baby to have lax ligaments while still in the\\nwomb. Other symptoms of complete dislocation include a\\nshortening of the leg and limited ability to abduct the leg.\\nDiagnosis\\nBecause the abnormalities of this hip problem often\\nvary, a thorough physical examination is necessary for\\nan accurate diagnosis of congenital hip dysplasia. The\\nhip disorder can be diagnosed by moving the hip to\\ndetermine if the head of the femur is moving in and out\\nof the hip joint. One specific method, called the Ortolani\\ntest, begins with each of the examiners’ hands around the\\ninfant’s knees, with the second and third fingers pointing\\ndown the child’s thigh. With the legs abducted (moved\\napart), the examiner may be able to discern a distinct\\nclicking sound with motion. If symptoms are present\\nwith a noted increase in abduction, the test is considered\\npositive for hip joint instability. It is important to note\\nthis test is only valid a few weeks after birth.\\nThe Barlow method is another test performed with the\\ninfant’s hip brought together with knees in full bent posi-\\ntion. The examiner’s middle finger is placed over the out-\\nside of the hipbone while the thumb is placed on the inner\\nside of the knee. The hip is abducted to where it can be felt\\nif the hip is sliding out and then back in the joint. In older\\nbabies, if there is a lack of range of motion in one hip or\\neven both hips, it is possible that the movement is blocked\\nbecause the hip has dislocated and the muscles have con-\\ntracted in that position. Also in older infants, hip disloca-\\ntion is evident if one leg looks shorter than the other.\\nX-ray films can be helpful in detecting abnormal find-\\nings of the hip joint. X rays may also be helpful in finding\\nthe proper positioning of the hip joint for treatments of\\nGALE ENCYCLOPEDIA OF MEDICINE 2892\\nCongenital hip dysplasia\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 892'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 281, 'page_label': '282'}, page_content='casting. Ultrasound has been noted as a safe and effective\\ntool for the diagnosis of congenital hip dysplasia. Ultra-\\nsound has advantages over x rays, as several positions are\\nnoted during the ultrasound procedure. This is in contrast\\nto only one position observed during the x ray.\\nTreatment\\nThe objective of treatment is to replace the head of the\\nfemur into the acetabulum and, by applying constant pres-\\nsure, to enlarge and deepen the socket. In the past, stabi-\\nlization was achieved by placing rolled cotton diapers or a\\npillow between the thighs, thereby keeping the knees in a\\nfrog like position. More recently, the Pavlik harness and\\nvon Rosen splint are commonly used in infants up to the\\nage of six months. A stiff shell cast may be used, which\\nachieves the same purpose, spreading the legs apart and\\nforcing the head of the femur into the acetabulum. In some\\ncases, in older children between six to 18 months, surgery\\nmay be necessary to reposition the joint. Also at this age,\\nthe use of closed manipulation may be applied successful-\\nly, by moving the leg around manually to replace joint.\\nOperations are not only performed to reduce the disloca-\\ntion of the hip, but also to repair a defect in the acetabu-\\nlum. A cast is applied after the operation to hold the head\\nof the femur in the correct position. The use of a home\\ntraction program is now more common. However, after\\nthe age of eight years, surgical procedures are primarily\\ndone for pain reduction measures only. Total hip surgeries\\nmay be inevitable later in adulthood.\\nAlternative treatment\\nNonsurgical treatments include exercise programs,\\northosis (a force system, often involving braces), and\\nmedications. A physical therapist may develop a program\\nthat includes strengthening, range-of-motion exercises,\\npain control, and functional activities. Chiropractic\\nmedicine may be helpful, especially the procedures of\\nclosed manipulations, to reduce the dislocated hip joint.\\nPrognosis\\nUnless corrected soon after birth, abnormal stresses\\ncause malformation of the developing femur, with a char-\\nacteristic limp or waddling gait. If cases of congenital\\nhip dysplasia go untreated, the child will have difficulty\\nwalking, which could result in life-long pain. In addition,\\nif this condition goes untreated, the abnormal hip posi-\\ntioning will force the acetabulum to locate to another\\nposition to accommodate the displaced femur.\\nPrevention\\nPrevention includes proper prenatal care to deter-\\nmine the position of the baby in the womb. This may be\\nKEY TERMS\\nAcetabulum —The large cup-shaped cavity at the\\njunction of pelvis and femur or thigh bone.\\nOrthosis —A force system designed to control or\\ncorrect or compensate for a bone deformity,\\ndeforming forces, or forces absent from the body.\\nhelpful in preparing for possible breech births associated\\nwith hip problems. Avoiding excessive and prolonged\\ninfant hip adduction may help prevent strain on the hip\\njoints. Early diagnosis remains an important part of pre-\\nvention of congenital hip dysplasia.\\nResources\\nBOOKS\\nChandrasoma, Parakrama, and Clive R. Taylor. Concise Pathol-\\nogy. East Norwalk, CT: Appleton & Lange, 1991.\\nPERIODICALS\\nFeeney, Tracy. “Early Intervention: Key to Success in Treat-\\nment of Infants with Hip Dysplasia.”Advance For Physi-\\ncal Therapy (Nov. 1995).\\nJamali, Mohammed and Kymberly McCoy. “Developmental\\nDysplasia of the Hip.”Advance For Physical Therapy8,\\nno. 18 (May 1998).\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nJeffrey P. Larson, RPT\\nCongenital lobar emphysema\\nDefinition\\nCongenital lobar emphysema is a chronic disease\\nthat causes respiratory distress in infants.\\nDescription\\nCongenital lobar emphysema, also called infantile\\nlobar emphysema, is a respiratory disease that occurs in\\ninfants when air enters the lungs but cannot leave easily.\\nThe lungs become over-inflated, causing respiratory\\nfunction to decrease and air to leak out into the space\\naround the lungs.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 893\\nCongenital lobar emphysema\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 893'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 282, 'page_label': '283'}, page_content='Half of the cases of congenital lobar emphysema\\noccur in the first four weeks of life, and three-quarters\\noccur in infants less than six months old. Congenital\\nlobar emphysema is more common in boys than in girls.\\nEach person has two lungs, right and left. The right\\nlung is divided into three sections, called lobes, and the\\nleft lung into two lobes. Congenital lobar emphysema\\nusually affects only one lobe, and this is usually an upper\\nlobe. It occurs most frequently in the left upper lobe, fol-\\nlowed by the right middle lobe.\\nCauses and symptoms\\nThe cause of congenital lobar emphysema often can-\\nnot be identified. The airway may be obstructed or the\\ninfant’s lungs may not have developed properly. Congen-\\nital lobar emphysema is almost never of genetic origin.\\nSymptoms of congenital lobar emphysema include:\\n• shortness of breath\\n• wheezing\\n• lips and fingernail beds that have a bluish tinge\\nDiagnosis\\nCongenital lobar emphysema is usually identified\\nwithin the first two weeks of the infant’s life. It is diag-\\nnosed by respiratory symptoms and a chest x ray, which\\nshows the over-inflation of the affected lobe and may\\nshow a blocked air passage.\\nTreatment\\nFor infants with no, mild, or intermittent symptoms,\\nno treatment is necessary. For more serious cases of con-\\ngenital lobar emphysema, surgery is necessary, usually a\\nlobectomy to remove the affected lung lobe.\\nAlternative treatment\\nAlternative treatments that may be helpful for con-\\ngenital lobar emphysema are aimed at supporting and\\nKEY TERMS\\nCongenital—A disease or condition that is present\\nat birth.\\nEmphysema—A condition in which the air sacs in\\nthe lungs become overinflated, causing a decrease\\nin respiratory function.\\nLobar—Relating to a lobe, a rounded projecting\\npart of the lungs.\\nstrengthening the patient’s respiratory function. Vitamin\\nand mineral supplementation may be recommended as\\nmay herbal remedies such as lobelia ( Lobelia inflata )\\nthat strengthen the lungs and enhance their elasticity.\\nHomeopathic constitutional care may also be beneficial\\nfor this condition.\\nPrognosis\\nSurgery for congenital lobar emphysema has excel-\\nlent results.\\nPrevention\\nCongenital lobar emphysema cannot be prevented.\\nResources\\nBOOKS\\nBaum, Gerald L., et al., eds. Textbook of Pulmonary Diseases.\\nPhiladelphia: Lippincott-Raven, 1998.\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York, NY\\n10019. (800) 586-4872. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Jewish Center for Immunology and Respiratory Med-\\nicine. 1400 Jackson St., Denver, CO 80206. (800) 222-\\n5864. .\\nLori De Milto\\nCongenital megacolon see Hirschsprung’s\\ndisease\\nCongenital thymic hypoplasia see DiGeorge\\nsyndrome\\nCongenital ureter anomalies\\nDefinition\\nThe ureter drains urine from the kidney into the\\nbladder. It is not simply a tube but an active organ that\\npropels urine forward by muscular action. It has a valve\\nat its bottom end that prevents urine from flowing back-\\nward into the kidney. Normally, there is one ureter on\\neach side of the body for each kidney. However, among\\nthe many abnormalities of ureteral development, duplica-\\ntion is quite common. Ureters may also be malformed in\\na variety of ways—some harmful, others not.\\nGALE ENCYCLOPEDIA OF MEDICINE 2894\\nCongenital ureter anomalies\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 894'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 283, 'page_label': '284'}, page_content='Description\\nThe urogenital system, for some reason, is more\\nlikely than any other to have birth defects, and they can\\noccur in endless variety. Ureters can be duplicated com-\\npletely or partially, they can be in the wrong place, they\\ncan be deformed, and they can end in the wrong place.\\nThe trouble these abnormalities bring is directly related\\nto their effect on the flow of urine. As long as urine flows\\nnormally through them, and only in one direction, no\\nharm is done.\\n• Duplication of ureters is quite common, either in part or\\ncompletely. Kidneys are sometimes duplicated as well.\\nSomeone may have four kidneys and four ureters or two\\nkidneys, half of each drained by a separate ureter, or a sin-\\ngle kidney with two, three, or four ureters attached. As\\nlong as urine can flow easily in the correct direction, such\\nmalformations may never be detected. If, however, one of\\nthe ureters has a dead end, a stricture or stenosis (narrow-\\ning), or a leaky ureterovesical valve (valve between the\\nureter and bladder), infection is the likely result.\\n• Stricture or stenosis of a ureter prevents urine from\\nflowing freely. Whenever flow is obstructed in the\\nbody—urine, bile, mucus, or any other liquid—infec-\\ntion follows. Ureters can be obstructed anywhere along\\ntheir course, though the ureterovesical valve is the most\\ncommon place.\\n• A ureter may have an ectopic (out of place) orifice\\n(opening)—it may enter the bladder, or even another\\nstructure, where it does not belong and therefore with-\\nout an adequate valve to control reflux.\\n• The primary ureter, or a duplicate, may not even reach\\nthe bladder, but rather terminate in a dead end. Urine\\nwill stagnate there and eventually cause infection.\\n• A ureter can be perfectly normal but in the wrong place,\\nsuch as behind the vena cava (the large vein in the mid-\\ndle of the abdomen). A so-called retrocaval ureter may\\nbe pinched by the vena cava so that flow is hindered.\\nOther aberrant locations may also lead to compression\\nand impaired flow.\\nBesides infection, urine that backs up will cause the\\nureter and the kidney to dilate. Eventually, the kidney\\nwill stop functioning because of the back pressure. This\\ncondition is called hydronephrosis—a kidney swollen\\nwith urine.\\nCauses and symptoms\\nThe causes of birth defects are multiple and often\\nunknown. Furthermore, the precise cause of specific\\nbirth defects has only rarely been identified. Such is the\\ncase with congenital ureteral anomalies.\\nKEY TERMS\\nCongenital—Present at birth.\\nContrast agent —A chemical or other substance\\nplaced in the body to show structures that would\\nnot otherwise be visible on x ray or other imaging\\nstudies.\\nCystoscopy —Looking into the urinary bladder\\nwith a thin telescope-like instrument.\\nEctopic—Out of place.\\nSepticemia —A serious whole body infection\\nspreading through the blood stream.\\nUretreovesical valve —A sphincter (an opening\\ncontrolled by a circular muscle), located where\\nthe ureter enters the bladder, that keeps urine from\\nflowing backward toward the kidney.\\nUrogenital—Both the urinary system and the sex-\\nual organs, which form together in the developing\\nembryo.\\nPractically the only symptom generated by ureteral\\nabnormalities is urinary tract infection. A lower tract\\ninfection—in the bladder—is called cystitis. In children,\\nit may cause fever and systemic symptoms, but in adults\\nit causes only cloudy, burning, and frequent urine. Upper\\ntract infections, on the other hand, can be serious for both\\nadults and children, causing high fevers, back pain,\\nsevere generalized discomfort, and even leading to kid-\\nney failure or septicemia (infection spreading throughout\\nthe body by way of the blood stream).\\nIn rare cases, urine from an ectopic ureter will bypass\\nthe bladder and dribble out of the bottom somewhere,\\nthrough a natural orifice like the vagina or a completely\\nseparate unnatural opening.\\nDiagnosis\\nSerious or recurrent urinary infections will prompt a\\nsearch for underlying abnormalities. Cystoscopy (look-\\ning into the bladder with a thin telescope-like instrument)\\nand x rays with a contrast agent to illuminate the urinary\\nsystem will usually identify the defect. Computed\\ntomography scans (CT) and magnetic resonance\\nimaging (MRI) scans may provide additional informa-\\ntion. Urine cultures to identify the infecting germs will\\nbe repeated frequently until the problem is corrected.\\nTreatment\\nSometimes the recurring infections caused by flow\\nabnormalities can be treated with repeated and changing\\nGALE ENCYCLOPEDIA OF MEDICINE 2 895\\nCongenital ureter anomalies\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 895'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 284, 'page_label': '285'}, page_content='courses of antibiotics . Over time, the infecting germs\\ndevelop resistance to most treatments, especially the\\nsafer ones. If it can be done with acceptable risk, it is bet-\\nter to repair the defect surgically. Urologists have an\\narsenal of approaches to urine drainage that range from\\nsimply reimplanting a ureter into the bladder, in such a\\nway that an effective valve is created, to building a new\\nbladder out of a piece of bowel.\\nAlternative treatment\\nThere are botanical and homeopathic treatments\\navailable for urinary tract infection. None can take the\\nplace of correcting a problem that is occurring because of\\na malformed or dysfunctional organ system. Once cor-\\nrection of the cause is addressed and there is unimpeded\\nflow of urine, adequate fluid intake can contribute to pre-\\nvention of future infections.\\nPrognosis\\nAs long as damage to the kidneys from infection or\\nback pressure has not become significant, the surgical\\nrepair of troublesome ureteral defects produces excellent\\nlong-term results in the great majority of cases. Monitor-\\ning for recurrent infections is always a good idea, and\\noccasional checking of kidney function will detect hid-\\nden ongoing damage.\\nResources\\nBOOKS\\nBauer, Stuart B. “Anomalies of the Kidney and Ureteropelvic\\nJunction.” In Campbell’s Urology, ed. Patrick C. Walsh, et\\nal. Philadelphia: W. B. Saunders Co., 1998.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\n“Vesicoureteral Reflux.” In Nelson Textbook of Pediatrics,e d .\\nRichard E. Behrman. Philadelphia: W. B. Saunders Co.,\\n1996.\\nSchlussel, Richard N., and Alan B. Retik. “Anomalies of the\\nUreter.” In Campbell’s Urology, ed. Patrick C. Walsh, et\\nal. Philadelphia: W. B. Saunders Co., 1998.\\nJ. Ricker Polsdorfer, MD\\nCongestive cardiomyopathy\\nDefinition\\nCardiomyopathy is an ongoing disease process that\\ndamages the muscle wall of the lower chambers of the\\nheart. Congestive cardiomyopathy is the most common\\nform of cardiomyopathy. In congestive cardiomyopathy,\\nalso called dilated cardiomyopathy, the walls of the heart\\nchambers stretch (dilate) to hold a greater volume of\\nblood than normal. Congestive cardiomyopathy is the\\nfinal stage of many heart diseases and the most common\\ncondition resulting in congestive heart failure.\\nDescription\\nAbout 50,000 Americans develop cardiomyopathy\\neach year. Of those, 87% have congestive cardiomyopa-\\nthy. Primary cardiomyopathy accounts for only 1% of all\\ndeaths from heart disease.\\nWhen the heart muscle is damaged by a disease\\nprocess, it cannot pump enough blood to meet the body’s\\nneeds. Uninjured areas of the walls of the two lower heart\\nchambers (called ventricles) stretch to make up for the\\nlost pumping action. At first, the enlarged chambers allow\\nmore blood to be pumped with less force. The stretched\\nmuscle can also contract more forcefully. Over time, the\\nheart muscle continues to stretch, ultimately becoming\\nweaker. The heart is forced to work harder to pump blood\\nby beating faster. Eventually it cannot keep up, and blood\\nbacks up into the veins, legs, and lungs. When this hap-\\npens, the condition is called congestive heart failure.\\nCongestive cardiomyopathy usually affects both\\nventricles. Blood backed up into the lungs from the left\\nventricle causes fluid to congest the lung tissue. This is\\ncalled pulmonary edema. When the right ventricle fails\\nto pump enough blood, blood backs up into the veins\\ncausing edema in the legs, feet, ankles, and abdomen.\\nCauses and symptoms\\nCongestive cardiomyopathy may be caused by a\\nnumber of conditions. Cardiomyopathy with a known\\ncause is called secondary cardiomyopathy. When no\\ncause can be identified, it is called primary cardiomyopa-\\nthy or idiopathic cardiomyopathy. About 80% of all cases\\nof cardiomyopathy do not have a known cause. Many\\nheart specialists think that many cases of idiopathic con-\\ngestive cardiomyopathy may be caused by a viral infec-\\ntion. Because cardiomyopathy may occur many years\\nafter a viral infection and viruses sometimes go undetect-\\ned in laboratory tests, it is difficult to know if a virus is the\\ncause. Some people have a weak heart from advanced\\ncoronary artery disease that causes heart muscle dam-\\nage. This is sometimes called ischemic cardiomyopathy.\\nConditions that can cause congestive cardiomyopa-\\nthy are:\\n• Coronary artery disease\\n• Infections\\nGALE ENCYCLOPEDIA OF MEDICINE 2896\\nCongestive cardiomyopathy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 896'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 285, 'page_label': '286'}, page_content='• noninfectious inflammatory conditions\\n• alcohol and other drugs or toxins\\n• hypertension\\n• nutritional and metabolic disorders\\n• pregnancy.\\nCoronary artery disease is one of the most common\\ncauses of congestive cardiomyopathy. In coronary artery\\ndisease, the arteries supplying blood to the heart become\\nnarrowed or blocked. When blood flow to an area of the\\nheart is completely blocked, the person has a heart\\nattack. The heart muscle suffers damage when its blood\\nsupply is reduced or blocked. Significant recurrent mus-\\ncle damage can occur silently. This damage can lead to\\ncongestive cardiomyopathy.\\nInfections caused by bacteria, viruses, and other\\nmicroorganisms can involve the heart, causing inflamma-\\ntion of the heart muscle ( myocarditis ). The inflamma-\\ntion may damage the heart muscle and cause congestive\\ncardiomyopathy. In the United States, the coxsackievirus\\nKEY TERMS\\nAngiotensin-converting enzyme (ACE) inhibitor—A\\ndrug that relaxes blood vessel walls and lowers\\nblood pressure.\\nAtherosclerosis —Buildup of a fatty substance\\ncalled a plaque inside blood vessels.\\nCardiac catheterization—A diagnostic test for eval-\\nuating heart disease; a catheter is inserted into an\\nartery and passed into the heart.\\nCardiomyopathy—Disease of the heart muscle.\\nCongestive cardiomyopathy —Also called dilated\\ncardiomyopathy; cardiomyopathy in which the\\nwalls of the heart chambers stretch, enlarging the\\nheart ventricles so they can hold a greater volume\\nof blood than normal.\\nCoxsackievirus B —A type of virus in the group\\nEnterovirus that causes an infection similar to polio,\\nbut without paralysis.\\nDigitalis —A drug that helps the heart muscle to\\nhave stronger pumping action.\\nDilated cardiomyopathy —Also called congestive\\ncardiomyopathy; cardiomyopathy in which the\\nwalls of the heart chambers stretch, enlarging the\\nheart ventricles so they can hold a greater volume\\nof blood than normal.\\nDiuretic —A type of drug that helps the kidneys\\neliminate excess salt and water.\\nEdema—Swelling caused by fluid buildup in tis-\\nsues.\\nGranulomatous myocarditis— Also called giant cell\\nmyocarditis, this noninfectious inflammation of the\\nheart causes large areas of tissue death in the heart\\nmuscle, ventricular enlargement, and clots inside\\nthe heart chambers.\\nIdiopathic cardiomyopathy —Cardiomyopathy\\nwithout a known cause.\\nSarcoidosis—A chronic disease that causes forma-\\ntion of abnormal areas containing inflammatory\\ncells, called granulomas, in any organ or tissue; in\\nthe heart, large areas of the heart muscle can be\\ninvolved, causing cardiomyopathy.\\nVasodilator —Any drug that relaxes blood vessel\\nwalls.\\nVentricle—One of the two lower chambers of the\\nheart.\\nWegener’s granulomatosis —A disease usually\\naffecting males that causes the infiltration of inflam-\\nmatory cells and tissue death in the lungs, kidneys,\\nblood vessels, heart, and other tissues.\\nB is the most common cause of viral congestive car-\\ndiomyopathy.\\nMyocarditis can also be caused by noninfectious\\ndisorders. For example, the conditions sarcoidosis, gran-\\nulomatous myocarditis, and Wegener’s granulomatosis\\ncause inflammation and tissue death in the heart muscle.\\nYears of drinking excessive amounts of alcohol can\\nweaken the heart muscle, leading to congestive cardiomy-\\nopathy. Other drugs and toxins, such as cocaine, pesti-\\ncides, and other chemicals, may have the same effect.\\nHigh blood pressure (hypertension) puts extra pres-\\nsure on blood vessels and the heart. This increased pres-\\nsure makes the heart work harder to pump blood, which\\nmay thicken and damage the chamber walls.\\nSevere nutritional deficiencies can weaken the heart\\nmuscle and affect its pumping ability. Certain disorders\\nof metabolism, including diabetes mellitus and thyroid\\ndisorders, can also lead to congestive cardiomyopathy.\\nOccasionally, inflammation of the heart muscle and\\ncongestive cardiomyopathy may develop late in pregnan-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 897\\nCongestive cardiomyopathy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 897'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 286, 'page_label': '287'}, page_content='cy or shortly after a woman gives birth. This type of con-\\ngestive cardiomyopathy is called peripartum cardiomy-\\nopathy. The cause of congestive cardiomyopathy in preg-\\nnancy is not known.\\nCongestive cardiomyopathy usually is a chronic\\ncondition, developing gradually over time. Patients with\\nearly congestive cardiomyopathy may not have symp-\\ntoms. The most common symptoms are fatigue and\\nshortness of breath on exertion. Unfortunately, sudden\\ncardiac death is not uncommon with this condition. It\\nstems from irregular heart rhythms in the ventricles (ven-\\ntricular arrhythmias).\\nPatients with more advanced congestive cardiomy-\\nopathy may also have chest or abdominal pains, extreme\\ntiredness, dizziness, and swelling of the legs and ankles.\\nDiagnosis\\nDiagnosis of congestive cardiomyopathy is based on:\\n• symptoms\\n• medical history\\n• physical examination\\n• chest x ray\\n• electrocardiogram (ECG; also called EKG)\\n• echocardiogram\\n• cardiac catheterization\\nThe diagnosis is based on the patient’s symptoms, a\\ncomplete physical examination, and tests that detect\\nabnormalities of the heart chambers. The physician lis-\\ntens to the heart with a stethoscope to detect abnormal\\nheart rhythms and heart sounds. A heart murmur might\\nmean that the heart valves are not closing properly due to\\nthe ventricles being enlarged.\\nA chest x ray can show if the heart is enlarged and if\\nthere is fluid in the lungs. Abnormalities of heart valves\\nand other structures may also be seen on a chest x ray.\\nAn electrocardiogram provides a record of electrical\\nchanges in the heart muscle during the heartbeat. It gives\\ninformation on the heart rhythm and can show if the\\nheart chamber is enlarged. An ECG can detect damage to\\nthe heart muscle and the amount of damage.\\nEchocardiography uses sound waves to make\\nimages of the heart. These images can show if the heart\\nwall or chambers are enlarged and if there are any abnor-\\nmalities of the heart valves. Echocardiography can also\\nevaluate the pumping efficiency of the ventricles.\\nCardiac catheterization usually is only used if a\\ndiagnosis cannot be made with other methods. In cardiac\\ncatheterization, a small tube (called a catheter) is inserted\\ninto an artery and passed into the heart. It is used to mea-\\nsure pressure in the heart and the amount of blood\\npumped by the heart. A small tissue sample of the heart\\nmuscle can be removed through the catheter for examina-\\ntion under a microscope (biopsy). This biopsy can show\\nthe type and amount of damage to the heart muscle.\\nTreatment\\nWhen a patient is diagnosed with congestive car-\\ndiomyopathy, physicians try to find out the cause. If\\ncoronary artery disease is not the culprit, in most other\\ncases a cause is not identified. When a condition respon-\\nsible for the congestive cardiomyopathy is diagnosed,\\ntreatment is aimed at correcting the underlying condi-\\ntion. Congestive cardiomyopathy caused by drinking\\nexcess alcohol or by drugs or toxins can be treated by\\neliminating the alcohol or toxin completely. In some\\ncases, the heart may recover after the toxic substance is\\nremoved from the body. Bacterial myocarditis is treated\\nwith an antibiotic to eliminate the bacteria.\\nThere is no cure for idiopathic congestive cardiomy-\\nopathy. Medicines are given to reduce the workload of\\nthe heart and to relieve the symptoms.\\nOne or more of the following types of medicines\\nmay be prescribed for congestive cardiomyopathy:\\n• digitalis\\n• diuretics\\n• vasodilators\\n• beta blockers\\n• angiotensin converting enzyme inhibitors (ACE inhib-\\nitors)\\n• angiotensin receptor blockers\\nDigitalis helps the heart muscle to have stronger\\npumping action. Diuretics help eliminate excess salt and\\nwater from the kidneys by making patients urinate more\\noften. This helps reduce the swelling caused by fluid\\nbuildup in the tissues. Vasodilators, beta blockers, and\\nACE inhibitors lower blood pressure and expand the\\nblood vessels so blood can move more easily through\\nthem. This action makes it easier for the heart to pump\\nblood through the vessels.\\nPatients may also be given anticoagulant medica-\\ntions to prevent clots from forming due to pooling of\\nblood in the heart chambers. Medicines to prevent abnor-\\nmal heart rhythms (arrhythmias) may be given, but some\\nof these drugs can also reduce the force of heart contrac-\\ntions. Automatic implantable cardioverter defibrillators\\n(AICDs) can treat life-threatening arrhythmias, which\\nare relatively common in severe cardiomyopathy.\\nGALE ENCYCLOPEDIA OF MEDICINE 2898\\nCongestive cardiomyopathy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 898'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 287, 'page_label': '288'}, page_content='Certain lifestyle changes may help reduce the work-\\nload on the heart and relieve symptoms. Some patients\\nmay need to change their diet, stop drinking alcohol,\\nbegin a physician-supervised exercise program, and/or\\nstop smoking.\\nSevere congestive cardiomyopathy usually causes\\nheart failure. When the heart muscle is damaged so\\nseverely that medicines cannot help, a heart transplant\\nmay be the only remaining treatment to be considered.\\nPrognosis\\nThe outlook for a patient with congestive cardiomy-\\nopathy depends on the severity of the disease and the\\nperson’s health. Generally, congestive cardiomyopathy\\nworsens over time and the prognosis is not good. About\\n50% of patients with congestive cardiomyopathy live for\\nfive years after the diagnosis. Twenty five percent of\\npatients are alive 10 years after diagnosis. Women with\\ncongestive cardiomyopathy live twice as long as men\\nwith the disease. Many of the deaths are caused by sud-\\nden abnormal heart rhythms.\\nPrevention\\nBecause idiopathic congestive cardiomyopathy does\\nnot have a known cause, there is no sure way to prevent\\nit. The best way to prevent congestive cardiomyopathy is\\nto avoid known causes such as drinking excess alcohol or\\ntaking toxic drugs. Eating a nutritious diet and getting\\nregular exercise to improve overall fitness also can help\\nthe heart to stay healthy.\\nCongestive cardiomyopathy may also be prevented by\\nidentifying and treating any conditions that might damage\\nthe heart muscle. These include high blood pressure and\\ncoronary artery disease. Regular blood pressure checks\\nand obtaining immediate medical care for hypertension\\nand symptoms of coronary artery disease, such as chest\\npain, are important to keep the heart functioning properly.\\nFinally, diagnosing and treating congestive car-\\ndiomyopathy before the heart becomes severely damaged\\nmay improve the outlook.\\nResources\\nBOOKS\\nBellenir, Karen, and Peter D. Dresser, eds. Cardiovascular Dis-\\neases and Disorders Sourcebook.Detroit: Omnigraphics,\\n1995.\\nTexas Heart Institute. Heart Owner’s Handbook.New York:\\nJohn Wiley and Sons, 1996.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. P.O. Box 20345,\\nHouston, TX 77225-0345. .\\nToni Rizzo\\nCongestive heart failure see Heart failure\\nCongenital heart disease\\nDefinition\\nCongenital heart disease, also called congenital\\nheart defect, includes a variety of malformations of the\\nheart or its major blood vessels that are present at birth.\\nDescription\\nCongenital heart disease occurs when the heart or\\nblood vessels near the heart do not develop properly\\nbefore birth. Some infants are born with mild types of\\ncongenital heart disease, but most need surgery in order\\nto survive. Patients who have had surgery are likely to\\nexperience other cardiac problems later in life.\\nMost types of congenital heart disease obstruct the\\nflow of blood in the heart or the nearby vessels, or cause\\nan abnormal flow of blood through the heart. Rarer types\\nof congenital heart disease occur when the newborn has\\nonly one ventricle, or when the pulmonary artery and the\\naorta come out of the same ventricle, or when one side of\\nthe heart is not completely formed.\\nPatent ductus arteriosus\\nPatent ductus arteriosus refers to the opening of a\\npassageway—or temporary blood vessel (ductus)—to\\ncarry the blood from the heart to the aorta before birth,\\nallowing blood to bypass the lungs, which are not yet\\nfunctional. The ductus should close spontaneously in the\\nfirst few hours or days after birth. When it does not close\\nin the newborn, some of the blood that should flow\\nthrough the aorta then returns to the lungs. Patent ductus\\narteriosus is common in premature babies, but rare in\\nfull-term babies. It has also been associated with mothers\\nwho had German measles (rubella) while pregnant.\\nHypoplastic left heart syndrome\\nHypoplastic left heart syndrome, a condition in\\nwhich the left side of the heart is underdeveloped, is rare,\\nbut it is the most serious type of congenital heart disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 899\\nCongenital heart disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 899'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 288, 'page_label': '289'}, page_content='With this syndrome, blood reaches the aorta, which\\npumps blood to the entire body, only from the ductus,\\nwhich then normally closes within a few days of birth. In\\nhypoplastic left heart syndrome, the baby seems normal\\nat birth, but as the ductus closes, blood cannot reach the\\naorta and circulation fails.\\nObstruction defects\\nWhen heart valves, arteries, or veins are narrowed,\\nthey partly or completely block the flow of blood. The\\nmost common obstruction defects are pulmonary valve\\nstenosis , aortic valve stenosis , and coarctation of the\\naorta. Bicuspid aortic valve and subaortic stenosis are\\nless common.\\nStenosis is a narrowing of the valves or arteries. In\\npulmonary stenosis, the pulmonary valve does not open\\nproperly, forcing the right ventricle to work harder. In\\naortic stenosis, the improperly formed aortic valve is nar-\\nrowed. As the left ventricle works harder to pump blood\\nthrough the body, it becomes enlarged. In coarctation of\\nthe aorta, the aorta is constricted, reducing the flow of\\nblood to the lower part of the body and increasing blood\\npressure in the upper body.\\nA bicuspid aortic valve has only two flaps instead\\nof three, which can lead to stenosis in adulthood.\\nSubaortic stenosis is a narrowing of the left ventricle\\nbelow the aortic valve, that limits the flow of blood from\\nthe left ventricle.\\nSeptal defects\\nWhen a baby is born with a hole in the septum (the\\nwall separating the right and left sides of the heart),\\nblood leaks from the left side of the heart to the right,\\nor from a higher pressure zone to a lower pressure\\nzone. A major leakage can lead to enlargement of the\\nheart and failing circulation. The most common types\\nof septal defects are atrial septal defect , an opening\\nbetween the two upper heart chambers, and ventricu-\\nlar septal defect , an opening between the two lower\\nheart chambers. Ventricular septal defect accounts for\\nabout 15% of all cases of congenital heart disease in\\nthe United States.\\nCyanotic defects\\nHeart disorders that cause a decreased, inadequate\\namount of oxygen in blood pumped to the body are\\ncalled cyanotic defects. Cyanotic defects, including trun-\\ncus arteriosus, total anomalous pulmonary venous return,\\ntetralogy of Fallot, transposition of the great arteries,\\nand tricuspid atresia, result in a blue discoloration of the\\nskin due to low oxygen levels. About 10% of cases of\\ncongenital heart disease in the United States are tetralogy\\nof Fallot, which includes four defects. The major defects\\nare a large hole between the ventricles, which allows\\noxygen-poor blood to mix with oxygen-rich blood, and\\nnarrowing at or beneath the pulmonary valve. The other\\ndefects are an overly muscular right ventricle and an\\naorta that lies over the ventricular hole.\\nIn transposition (reversal of position) of the great\\narteries, the pulmonary artery and the aorta are reversed,\\ncausing oxygen-rich blood to re-circulate to the lungs\\nwhile oxygen-poor blood goes to the rest of the body. In\\ntricuspid atresia, the baby lacks a triscupid valve and\\nblood cannot flow properly from the right atrium to the\\nright ventricle.\\nOther defects\\nEbstein’s anomaly is a rare congenital syndrome that\\ncauses malformed tricuspid valve leaflets, which allow\\nblood to leak between the right ventricle and the right\\natrium. It also may cause a hole in the wall between the\\nleft and right atrium. Treatment often involves repairing\\nthe tricuspid valve. Ebstein’s anomaly may be associated\\nwith maternal use of the psychiatric drug lithium during\\npregnancy.\\nBrugada syndrome is another rare congenital heart\\ndefect that appears in adulthood and may cause sudden\\ndeath if untreated. Symptoms, which include rapid,\\nuneven heart beat, often appear at night. Scientists believe\\nthat Brugada syndrome is caused by mutations in the gene\\nSCN5A, which involves cardiac sodium channels.\\nInfants born with DiGeorge sequence can have heart\\ndefects such as a malformed aortic arch and tetralogy of\\nFallot. Researchers believe DiGeorge sequence is most\\noften caused by mutations in genes in the region 22q11.\\nMarfan syndrome is a connective tissue disorder\\nthat causes tears in the aorta. Since the disease also causes\\nexcessive bone growth, most Marfan syndrome patients\\nare over six feet tall. In athletes, and others, it can lead to\\nsudden death. Researchers believe the defect responsible\\nfor Marfan’s syndrome is found in gene FBN1, on chro-\\nmosome 15.\\nAbout 32,000 infants are born every year with con-\\ngenital heart disease, which is the most common birth\\ndefect. About half of these cases require medical treat-\\nment. More than one million people with heart defects\\nare currently living in the United States.\\nCauses and symptoms\\nIn most cases, the causes of congenital heart disease\\nare unknown. Genetic and environmental factors and\\nlifestyle habits can all be involved. The likelihood of hav-\\nGALE ENCYCLOPEDIA OF MEDICINE 2900\\nCongenital heart disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 900'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 289, 'page_label': '290'}, page_content='ing a child with a congenital heart disease increases if the\\nmother or father, another child, or another relative had\\ncongenital heart disease or a family history of sudden\\ndeath. Viral infections, such as German measles, can pro-\\nduce congenital heart disease. Women with diabetes and\\nphenylketonuria also are at higher risk of having chil-\\ndren with congenital heart defects. Many cases of congen-\\nital heart disease result from the mother’s excessive use of\\nalcohol or taking illegal drugs, such as cocaine, while\\npregnant. The mother’s exposure to certain anticonvulsant\\nand dermatologic drugs during pregnancy can also cause\\ncongenital heart disease. There are many genetic condi-\\ntions, such as Down syndrome , which affect multiple\\norgans and can cause congenital heart disease.\\nSymptoms of congenital heart disease in general\\ninclude: shortness of breath, difficulty feeding in infan-\\ncy, sweating, cyanosis (bluish discoloration of the skin),\\nheart murmur, respiratory infections that recur excessive-\\nly, stunted growth, and limbs and muscles that are under-\\ndeveloped.\\nSymptoms of specific types of congenital heart dis-\\nease are as follows:\\n• Patent ductus arteriosus: quick tiring, slow growth, sus-\\nceptibility to pneumonia, rapid breathing. If the ductus\\nis small, there are no symptoms.\\n• Hypoplastic left heart syndrome: ashen color, rapid and\\ndifficult breathing, inability to eat.\\n• Obstruction defects: cyanosis (skin that is discolored\\nblue), chest pain, tiring easily, dizziness or fainting ,\\ncongestive heart failure, and high blood pressure.\\n• Septal defects: difficulty breathing, stunted growth.\\nSometimes there are no symptoms.\\n• Cyanotic defects: cyanosis, sudden rapid breathing or\\nunconsciousness, and shortness of breath and fainting\\nduring exercise.\\nDiagnosis\\nEchocardiography and cardiac magnetic reso-\\nnance imaging (MRI) are used to confirm congenital\\nheart disease when it is suggested by the symptoms and\\nphysical examination. An echocardiograph will display\\nan image of the heart that is formed by sound waves. It\\ndetects valve and other heart problems. Fetal echocardio-\\ngraphy is used to diagnose congenital heart disease in\\nutero, usually after 20 weeks of pregnancy. Between 10\\nand 14 weeks of pregnancy, physicians also may use an\\nultrasound to look for a thickness at the nuchal translu-\\ncency, a pocket of fluid in back of the embryo’s neck,\\nwhich may indicate a cardiac defect in 55% of cases.\\nCardiac MRI, a scanning method that uses magnetic\\nKEY TERMS\\nAorta—The main artery located above the heart\\nthat pumps oxygenated blood out into the body.\\nMany congenital heart defects affect the aorta.\\nCongenital—Refers to a disorder that is present at\\nbirth.\\nCyanotic—Marked by bluish discoloration of the\\nskin due to a lack of oxygen in the blood. It is one\\nof the types of congenital heart disease.\\nDuctus—The blood vessel that joins the pul-\\nmonary artery and the aorta. When the ductus\\ndoes not close at birth, it causes a type of congeni-\\ntal heart disease called patent ductus arteriosus.\\nElectrocardiograph (ECG, EKG) —A test used to\\nmeasure electrical impulses coming from the heart\\nin order to gain information about its structure or\\nfunction.\\nHypoplastic —Incomplete or underdevelopment\\nof a tissue or organ. Hypoplastic left heart syn-\\ndrome is the most serious type of congenital heart\\ndisease.\\nNeuchal translucency— A pocket of fluid at the\\nback of an embryo’s neck visible via ultrasound\\nthat, when thickened, may indicate the infant will\\nbe born with a congenital heart defect.\\nSeptal—Relating to the septum, the thin muscle\\nwall dividing the right and left sides of the heart.\\nHoles in the septum are called septal defects.\\nStenosis —The constricting or narrowing of an\\nopening or passageway.\\nfields and radio waves, can help physicians evaluate con-\\ngenital heart disease, but is not always necessary. Physi-\\ncians also may use a chest x ray to look at the size and\\nlocation of the heart and lungs, or an electrocardiograph\\n(ECG), which measures electrical impulses to create a\\ngraph of the heart beat.\\nTreatment\\nCongenital heart disease is treated with drugs and/or\\nsurgery. Drugs used include diuretics , which aid the\\nbaby in excreting water and salts, and digoxin, which\\nstrengthens the contraction of the heart, slows the heart-\\nbeat, and removes fluid from tissues.\\nSurgical procedures seek to repair the defect as\\nmuch as possible and restore circulation to as close to\\nGALE ENCYCLOPEDIA OF MEDICINE 2 901\\nCongenital heart disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 901'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 290, 'page_label': '291'}, page_content='normal as possible. Sometimes, multiple surgical proce-\\ndures are necessary. Surgical procedures include: arterial\\nswitch, balloon atrial septostomy, balloon valvulo-\\nplasty, Damus-Kaye-Stansel procedure, Fontan proce-\\ndure, pulmonary artery banding, Ross procedure, shunt\\nprocedure, and venous switch or intra-atrial baffle.\\nArterial switch, to correct transposition of the great\\narteries, involves connecting the aorta to the left ventricle\\nand connecting the pulmonary artery to the right ventri-\\ncle. Balloon atrial septostomy, also done to correct trans-\\nposition of the great arteries, enlarges the atrial opening\\nduring heart catheterization. Balloon valvuloplasty uses a\\nballoon-tipped catheter to open a narrowed heart valve,\\nimproving the flow of blood in pulmonary stenosis. It is\\nsometimes used in aortic stenosis. Transposition of the\\ngreat arteries can also be corrected by the Damus-Kaye-\\nStansel procedure, in which the pulmonary artery is cut\\nin two and connected to the ascending aorta and the far-\\nthest section of the right ventricle.\\nFor tricuspid atresia and pulmonary atresia, the\\nFontan procedure connects the right atrium to the pul-\\nmonary artery directly or with a conduit, and the atrial\\ndefect is closed. Pulmonary artery banding, narrowing\\nthe pulmonary artery with a band to reduce blood flow\\nand pressure in the lungs, is used for ventricular septal\\ndefect, atrioventricular canal defect, and tricuspid atresia.\\nLater, the band can be removed and the defect corrected\\nwith open-heart surgery.\\nTo correct aortic stenosis, the Ross procedure grafts\\nthe pulmonary artery to the aorta. For tetralogy of Fallot,\\ntricuspid atresia, or pulmonary atresia, the shunt proce-\\ndure creates a passage between blood vessels, sending\\nblood into parts of the body that need it. For transposi-\\ntion of the great arteries, venous switch creates a tunnel\\ninside the atria to re-direct oxygen-rich blood to the right\\nventricle and aorta and venous blood to the left ventricle\\nand pulmonary artery.\\nWhen all other options fail, some patients may need\\na heart transplant. Children with congenital heart disease\\nrequire lifelong monitoring, even after successful\\nsurgery. The American Heart Association recommends\\nregular dental check-ups and the preventive use of\\nantibiotics to protect patients from heart infections, or\\nendocarditis . Since children with congenital heart dis-\\nease have slower growth, nutrition is important. Physi-\\ncians may also limit their athletic activity.\\nPrognosis\\nThe outlook for children with congenital heart dis-\\nease has improved markedly in the past two decades.\\nMany types of congenital heart disease that would have\\nbeen fatal can now be treated successfully. Research on\\ndiagnosing heart defects when the fetus is in the womb\\nmay lead to future treatment to correct defects before\\nbirth. Promising new prevention methods and treatments\\ninclude genetic screening and the cultivation of cardiac\\ntissue in the laboratory that could be used to repair con-\\ngenital heart defects.\\nResources\\nBOOKS\\nMayo Clinic Heart Book. New York: William Morrow and\\nCompany, 2000.\\nWild, C. L., and M. J. Neary. Heart Defects in Children: What\\nEvery Parent Should Know.Minneapolis: Chronimed Pub-\\nlishing, 2000.\\nWilliams, R. A. The Athlete and Heart Disease. Philadelphia:\\nLippincott Williams & Wilkins, 1999.\\nPERIODICALS\\n“Coping with Congenital Heart Disease in Your Baby.”Ameri-\\ncan Family Physician 59 (April 1, 1999): 1867.\\nHyett, Jon, et. al. “Using Fetal Nuchal Translucency to Secreen\\nfor Major Congenital Cardiac Defects at 10–14 Weeks:\\nPopulation Based Cohort Study.”Lancet 318 (January\\n1999): 81-85.\\nORGANIZATIONS\\nAmerican Heart Association. 7272 Greenville Ave., Dallas, TX\\n75231-4596. (214) 373-6300 or (800) 242-8721.\\n. .\\nCongenital Heart Disease Information and Resources. 1561\\nClark Dr., Yardley, PA 19067. .\\nTexas Heart Institute Heart Information Service. P.O. Box\\n20345, Houston, TX 77225-0345. (800) 292-2221.\\n.\\nMelissa Knopper\\nConjunctivitis\\nDefinition\\nConjuctivitis is an inflammation or redness of the\\nlining of the white part of the eye and the underside of\\nthe eyelid (conjunctiva) that can be caused by infection,\\nallergic reaction, or physical agents like infrared or ultra-\\nviolet light.\\nDescription\\nConjunctivitis is the inflammation of the conjuncti-\\nva, a thin, delicate membrane that covers the eyeball and\\nlines the eyelid. Conjunctivitis is an extremely common\\neye problem because the conjunctiva is continually\\nGALE ENCYCLOPEDIA OF MEDICINE 2902\\nConjunctivitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 902'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 291, 'page_label': '292'}, page_content='exposed to microorganisms and environmental agents\\nthat can cause infections or allergic reactions. Conjunc-\\ntivitis can be acute or chronic depending upon how long\\nthe condition lasts, the severity of symptoms, and the\\ntype of organism or agent involved. It can also affect one\\nor both eyes and, if caused by infection, can be very easi-\\nly transmitted to others during close physical contact,\\nparticularly among children in a daycare center. Other\\nnames for conjunctivitis include pink eye and red eye.\\nCauses and symptoms\\nConjunctivitis may be caused by a viral infection,\\nsuch as a cold, acute respiratory infection, or disease\\nsuch as measles, herpes simplex, or herpes zoster. Symp-\\ntoms include mild to severe discomfort in one or both\\neyes, redness, swelling of the eyelids, and watery, yellow,\\nor green discharge. Symptoms may last anywhere from\\nseveral days to two weeks. Infection with an adenovirus,\\nhowever, may also cause a significant amount of pus-like\\ndischarge and a scratchy, foreign body-type of sensation\\nin the eye. This may also be accompanied by swelling\\nand tenderness of the lymph nodes near the ear.\\nBacterial conjunctivitis can occur in adults and chil-\\ndren and is caused by organisms such as Staphylococcus,\\nStreptococcus , and Hemophilus . Symptoms of bacterial\\nconjunctivitis include a pus-like discharge and crusty\\neyelids after awakening. Redness of the conjunctiva can\\nbe mild to severe and may be accompanied by swelling.\\nPersons with symptoms of conjunctivitis who are sexual-\\nly active may possibly be infected with the bacteria that\\ncause either gonorrhea or chlamydia. There may be\\nlarge amounts of pus-like discharge, and symptoms may\\ninclude intolerance to light (photophobia), watery\\nmucous discharge, and tenderness in the lymph nodes\\nnear the ear that may persist for up to three months.\\nConjunctivitis may also be caused by environmental\\nhazards, such as wind, smoke, dust, and allergic reac-\\ntions caused by pollen, dust, or grass. Symptoms range\\nfrom itching and redness to a mucous discharge. Persons\\nwho wear contact lenses may develop allergic conjunc-\\ntivitis caused by the various eye solutions and foreign\\nproteins contained in them.\\nOther less common causes of conjunctivitis include\\nexposure to sun lamps or the electrical arcs used during\\nwelding, and problems with inadequate drainage of the\\ntear ducts.\\nDiagnosis\\nAn accurate diagnosis of conjunctivitis centers on\\ntaking a patient history to learn when symptoms began,\\nhow long the condition has been going on, the symptoms\\nexperienced, and other predisposing factors, such as\\nupper respiratory complaints, allergies, sexually trans-\\nmitted diseases, herpes simplex infections, and exposure\\nto persons with pink eye. It may be helpful to learn\\nwhether an aspect of an individual’s occupation may be\\nthe cause, for example, welding. Diagnostic tests are usu-\\nally not indicated unless initial treatment fails or an infec-\\ntion with gonorrhea or chlamydia is suspected. In such\\ncases, the discharge may be cultured and Gram stained to\\ndetermine the organism responsible for causing the condi-\\ntion. Cultures and smears are relatively painless.\\nTreatment\\nThe treatment of conjunctivitis depends on what\\ncaused the condition. In all cases, warm compresses\\napplied to the affected eye several times a day may help\\nto reduce discomfort.\\nConjunctivitis due to a viral infection, particularly\\nthose due to adenoviruses, are usually treated by applying\\nwarm compresses to the eye(s) and applying topical antibi-\\notic ointments to prevent secondary bacterial infections.\\nViral conjunctivitis caused by herpes simplex should\\nbe referred to an ophthalmologist. Topical steroids are com-\\nmonly prescribed in combination with antiviral therapy.\\nIn cases of bacterial conjunctivitis, a physician may\\nprescribe an antibiotic eye ointment or eye drops contain-\\ning sodium sulfacetamide (Sulamyd) to be applied daily\\nfor seven to 14 days. If, after 72 hours, the condition does\\nnot improve, a physician or primary care provider should\\nbe notified because the bacteria involved may be resistant\\nto the antibiotic used or the cause may not be bacterial.\\nFor cases of conjunctivitis caused by a gonococcal\\norganism, a physician may prescribe an intramuscular\\ninjection of ceftriaxone (Rocephin) and a topical antibi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 903\\nConjunctivitis\\nThis person has severe conjunctivitis, most likely caused\\nby an allergic reaction. (Custom Medical Stock Photo. Repro-\\nduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 903'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 292, 'page_label': '293'}, page_content='otic ointment containing erythromycin or bactracin to be\\napplied four times daily for two to three weeks. Sexual\\npartners should also be treated.\\nWith accompanying chlamydia infection, a topical\\nantibiotic ointment containing erythromycin (Ilotycin)\\nmay be prescribed to be applied 1-2 times daily. In addi-\\ntion, oral erythromycin or tetracycline therapy may be\\nindicated for three to four weeks. Here again, sexual\\npartners should also be treated.\\nAllergic conjunctivitis can be treated by removing\\nthe allergic substance from a person’s environment, if\\npossible; by applying cool compresses to the eye; and by\\nadministering eye drops four to six times daily for four\\ndays. Also, the antihistamine diphenhydramine\\nhydrochloride (Benadryl) may help to relieve itchy eyes.\\nAlternative treatment\\nConjunctivitis caused by gonococcal and chlamydial\\ninfection usually requires conventional medical treat-\\nment. With bacterial, viral, and allergic conjunctivitis,\\nhowever, alternative options can be helpful. Internal\\nimmune enhancement with supplementation can aid in\\nthe resolution of bacterial and viral conjunctivitis.\\nRemoval of the allergic agent is an essential step in treat-\\ning allergic conjunctivitis. As with any of the recom-\\nmended treatments, however, if no improvement is seen\\nwithin 48–72 hours, a physician should be consulted.\\nHomeopathically, there are a number of acute reme-\\ndies designed to treat conjunctivitis. These include Pul-\\nsatilla (windflower, Pulsatilla nigricans ), Belladonna ,\\nand eyebright ( Euphrasia officinalis ). Eye drops, pre-\\npared with homeopathic remedies and/or herbs, can be a\\ngood substitute for pharmaceutical eye drops. Eye washes\\ncan also be made. Herbal eyewashes made with eyebright\\n(1 tsp. dried herb steeped in 1 pint of boiling water) or\\nchamomile (Matricaria recutita; 2–3 tsp in 1 pt of boiling\\nwater) may be helpful. Eyewashes should be strained and\\ncooled before use, and close attention should be paid to\\nmake sure that any solution put into the eye is sterile.\\nOther simple home remedies may help relieve the\\ndiscomfort associated with conjunctivitis. A boric acid\\neyewash can be used to clean and soothe the eyes. A\\nwarm compress applied to the eyes for five to 10 minutes\\nthree times a day can help relieve the discomfort of bac-\\nterial and viral conjunctivitis. A cool compress or cool,\\ndamp tea bags placed on the eyes can ease the discomfort\\nof allergic conjunctivitis.\\nPrognosis\\nIf treated properly, the prognosis for conjunctivitis is\\ngood. Conjunctivitis caused by an allergic reaction\\nshould clear up once the allergen is removed. However,\\nallergic conjunctivitis will likely recur if the individual\\nagain comes into contact with the particular allergen.\\nConjunctivitis caused by bacteria or a virus, if treated\\nproperly, is usually resolved in 10–14 days. If there is no\\nrelief of symptoms in 48–72 hours, or there is moderate\\nto severe eye pain, changes in vision, or the conjunctivi-\\ntis is suspected to be caused by herpes simplex, a physi-\\ncian should be notified immediately. If untreated or if\\ntreatment fails and is not corrected, conjunctivitis may\\ncause visual impairment by spreading to other parts of\\nthe eye, such as the cornea.\\nPrevention\\nConjunctivitis can, in many cases, be prevented, or\\nat least the course of the disease can be shortened by fol-\\nlowing some simple practices.\\n• Frequently wash hands using antiseptic soap, and use\\nsingle-use towels during the disease to prevent spread-\\ning the infection.\\n• Avoid chemical irritants and known allergens.\\n• If in an area where welding occurs, use the proper pro-\\ntective eye wear and screens to prevent damaging the\\neyes.\\n• Use a clean tissue to remove discharge from eyes, and\\nwash hands to prevent the spread of infection.\\nGALE ENCYCLOPEDIA OF MEDICINE 2904\\nConjunctivitis\\nEyelid\\nConjunctiva\\nCornea\\nLens\\nConjunctivitis is the inflammation of the conjunctiva, a thin,\\ndelicate membrane that covers the eyeball and lines the\\neyelid. It may be caused by a viral infection, such as a cold\\nor acute respiratory infection, or by such diseases as\\nmeasles, herpes simplex, or herpes zoster.(Illustration by\\nElectronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 904'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 293, 'page_label': '294'}, page_content='• If medication is prescribed, finish the course of antibi-\\notics, as directed, to make sure that the infection is\\ncleared up and does not recur.\\n• Avoid contact, such as vigorous physical activities,\\nwith other persons until symptoms resolve.\\nResources\\nBOOKS\\n“The Conjunctiva.” In Ophthamology Principles and Concepts.\\n8th ed. Ed. Frank Newell. St. Louis: Mosby-Year Books\\nInc., 1996.\\nSchwab, Ivan R., and Chandler R. Dawson. “Conjunctiva.” In\\nGeneral Ophthamology. 14th ed. Ed. Daniel G. Vaughan,\\nTaylor Asbury, and Paul Riordan-Eva. Norwalk, CT:\\nAppleton & Lange, 1995.\\nUphold, Constance R., and Mary Virginia Graham. “Problems\\nof the Eyes.” In Clinical Guidelines in Adult Health.\\nGainesville, FL: Barmarrae Books, 1994.\\nPERIODICALS\\nBrown, Melissa. “The Red Eye.”Current Concepts in Ophthal-\\nmology (Jan. 1995): 9-15.\\nKEY TERMS\\nAdenovirus—A virus that affects the upper respira-\\ntory tract.\\nChlamydia—The most common bacterial sexually\\ntransmitted disease in the United States that often\\naccompanies gonorrhea and is known for its lack\\nof evident symptoms in the majority of women.\\nGonococcal —The bacteria Neisseria gonorrheae\\nthat causes gonorrhea, a sexually transmitted\\ninfection of the genitals and urinary tract. The\\ngonococcal organism may occasionally affect the\\neye, causing blindness if not treated.\\nHerpes simplex virus —A virus that can cause\\nfever and blistering on the skin, mucous mem-\\nbranes, or genitalia.\\nHerpes zoster virus —Acute inflammatory virus\\nthat attacks the nerve cells on the root of each\\nspinal nerve with skin eruptions along a sensory\\nnerve ending.\\nStaphylococcus —A bacterial organism, looking\\nmuch like a cluster of grapes, that can infect vari-\\nous body systems.\\nStreptococcus—An organism that causes infections of\\neither the upper respiratory or gastrointestinal tract.\\nWeber, Carol Martinez and Joseph Eichenbaum. “Acute Red\\nEye: Differentiating Viral Conjunctivitis From Other Less\\nCommon Causes.” Postgraduate Medicine (May 1997):\\n185-195.\\nOTHER\\nGriffith, H. Winter. “Conjunctivitis (Pink Eye).”ThriveOnline.\\n.\\nLisa Papp, RN\\nConsciousness disorders see Coma\\nConstipation\\nDefinition\\nConstipation is an acute or chronic condition in\\nwhich bowel movements occur less often than usual or\\nconsist of hard, dry stools that are painful or difficult to\\npass. Bowel habits vary, but an adult who has not had a\\nbowel movement in three days or a child who has not had\\na bowel movement in four days is considered constipated.\\nDescription\\nConstipation is one of the most common medical\\ncomplaints in the United States. Constipation can occur\\nat any age, and is more common among individuals who\\nresist the urge to move their bowels at their body’s sig-\\nnal. This often happens when children start school or\\nenter daycare and feel shy about asking permission to use\\nthe bathroom.\\nConstipation is more common in women than in\\nmen and is especially apt to occur during pregnancy .\\nAge alone does not increase the frequency of constipa-\\ntion, but elderly people (especially women) are more\\nlikely to suffer from constipation.\\nAlthough this condition is rarely serious, it can lead to:\\n• bowel obstruction\\n• chronic constipation\\n• hemorrhoids (a mass of dilated veins in swollen tissue\\naround the anus)\\n• hernia (a protrusion of an organ through a tear in the\\nmuscle wall)\\n• spastic colitis (irritable bowel syndrome , a condition\\ncharacterized by alternating periods of diarrhea and\\nconstipation)\\n• laxative dependency\\nGALE ENCYCLOPEDIA OF MEDICINE 2 905\\nConstipation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 905'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 294, 'page_label': '295'}, page_content='Chronic constipation may be a symptom of colorec-\\ntal cancer, depression, diabetes, diverticulosis (small\\npouches in the muscles of the large intestine), lead poi-\\nsoning, or Parkinson’s disease.\\nIn someone who is elderly or disabled, constipation\\nmay be a symptom of bowel impaction, a more serious\\ncondition in which feces are trapped in the lower part of\\nthe large intestine. A doctor should be called if an elderly\\nor disabled person is constipated for a week or more or if\\na child seems to be constipated.\\nA doctor should be notified whenever constipation\\noccurs after starting a new prescription, vitamin, or min-\\neral supplement or is accompanied by blood in the stools,\\nchanges in bowel patterns, or fever and abdominal pain.\\nCauses and symptoms\\nConstipation usually results from not getting enough\\nexercise, not drinking enough water, or from a diet that\\ndoes not include an adequate amount of fiber-rich foods\\nlike beans, bran cereals, fruits, raw vegetables, rice, and\\nwhole-grain breads.\\nOther causes of constipation include anal fissure (a\\ntear or crack in the lining of the anus); chronic kidney\\nfailure; colon or rectal cancer ; depression; hypercal-\\ncemia (abnormally high levels of calcium in the blood);\\nhypothyroidism (underactive thyroid gland); illness\\nrequiring complete bed rest; irritable bowel syndrome;\\nand stress.\\nConstipation can also be a side effect of:\\n• aluminum salts in antacids\\n• antihistamines\\n• antipsychotic drugs\\n• aspirin\\n• belladonna ( Atopa belladonna, source of atropine, a\\nmedication used to relieve spasms and dilate the pupils\\nof the eye)\\n• beta blockers (medications used to stabilize irregular\\nheartbeat, lower high blood pressure, reduce chest pain)\\n• blood pressure medications\\n• calcium channel blockers (medication prescribed to\\ntreat high blood pressure, chest pain, some types of\\nirregular heartbeat and stroke, and some non-cardiac\\ndiseases)\\n• diuretics (drugs that promote the formation and secre-\\ntion of urine)\\n• iron or calcium supplements\\n• narcotics (potentially addictive drugs that relieve pain\\nand cause mood changes)\\n• tricyclic antidepressants (medications prescribed to\\ntreat chronic pain, depression, headaches, and other ill-\\nnesses)\\nAn adult who is constipated may feel bloated, have a\\nheadache, swollen abdomen, or pass rock-like feces; or\\nstrain, bleed, or feel pain during bowel movements. A\\nconstipated baby may strain, cry, draw the legs toward\\nthe abdomen, or arch the back when having a bowel\\nmovement.\\nDiagnosis\\nEveryone becomes constipated once in a while, but a\\ndoctor should be notified if significant changes in bowel\\npatterns last for more than a week or if symptoms contin-\\nue more than three weeks after increasing activity and\\nfiber and fluid intake.\\nThe patient’s observations and medical history help\\na primary care physician diagnose constipation. The doc-\\ntor uses his fingers to see if there is a hardened mass in\\nthe abdomen, and may perform a rectal examination .\\nOther diagnostic procedures include a barium enema ,\\nwhich reveals blockage inside the intestine; laboratory\\nanalysis of blood and stool samples for internal bleeding\\nor other symptoms of systemic disease; and a sigmoi-\\ndoscopy (examination of the sigmoid area of the colon\\nwith a flexible tube equipped with a magnifying lens).\\nPhysical and psychological assessments and a\\ndetailed history of bowel habits are especially important\\nwhen an elderly person complains of constipation.\\nTreatment\\nIf changes in diet and activity fail to relieve occa-\\nsional constipation, an over-the-counter laxative may be\\nused for a few days. Preparations that soften stools or add\\nbulk (bran, psyllium) work more slowly but are safer\\nthan Epsom salts and other harsh laxatives or herbal lax-\\natives containing senna ( Cassia senna ) or buckthorn\\n(Rhamnus purshianna ), which can harm the nerves and\\nlining of the colon.\\nA woman who is pregnant should never use a laxa-\\ntive. Neither should anyone who is experiencing abdomi-\\nnal pain, nausea, or vomiting.\\nA warm-water or mineral oil enema can relieve con-\\nstipation, and a non-digestible sugar (lactulose) or spe-\\ncial electrolyte solution is recommended for adults and\\nolder children with stubborn symptoms.\\nIf a patient has an impacted bowel, the doctor inserts\\na gloved finger into the rectum and gently dislodges the\\nhardened feces.\\nGALE ENCYCLOPEDIA OF MEDICINE 2906\\nConstipation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 906'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 295, 'page_label': '296'}, page_content='Alternative treatment\\nInitially, alternative practitioners will suggest that\\nthe patient drink an adequate amount of water each day\\n(six to eight glasses), exercise on a regular basis, and eat\\na diet high in soluble and insoluble fibers. Soluble fibers\\ninclude pectin, flax, and gums; insoluble fibers include\\npsyllium and brans from grains like wheat and oats.\\nFresh fruits and vegetables contain both soluble and\\ninsoluble fibers. Castor oil, applied topically to the\\nabdomen and covered by a heat source (a heating pad or\\nhot water bottle), can help relieve constipation when\\nused nightly for 20–30 minutes.\\nAcupressure\\nThis needleless form of acupuncture is said to relax\\nthe abdomen, ease discomfort, and stimulate regular bowel\\nmovements when diet and exercise fail to do so. After lying\\ndown, the patient closes his eyes and takes a deep breath.\\nFor two minutes, he applies gentle fingertip pressure to a\\npoint about two and one-half inches below the navel.\\nAccupressure can also be applied to the outer edges\\nof one elbow crease and maintained for 30 seconds\\nbefore pressing the crease of the other elbow. This should\\nbe done three times a day to relieve constipation.\\nAromatherapy\\nSix drops of rosemary ( Rosmarinus officinalis ) and\\nsix drops of thyme ( Thymus spp.) diluted by 1 oz of\\nalmond oil, olive oil, or another carrier oil can relieve\\nconstipation when used to massage the abdomen.\\nHerbal therapy\\nA variety of herbal therapies can be useful in the\\ntreatment of constipation. Several herbs, including\\nchamomile (Matricaria recutita), dandelion (Taraxacum\\nmongolicum ), and burdock ( Arctium lappa ), act as bit-\\nters, stimulating the movement of the digestive and\\nexcretory systems. There are also “laxative” herbs that\\nassist with bowel movement. Two of these are senna\\n(Cassia senna ) and buckthorn ( Rhamnus purshiana ).\\nThese “laxative” herbs are stronger acting on elimination\\nthan bitters and can sometimes cause cramping (mixing\\nthem with a calming herb like fennel or caraway can help\\nreduce cramping). Both senna and buckthorn are power-\\nful herbs that are best used with direction from an experi-\\nenced practitioner, since they can have adverse side\\neffects and the patient may become dependent on them.\\nHomeopathy\\nHomeopathy also can offer assistance with consti-\\npation. There are acute remedies for constipation that can\\nbe found in one of the many home remedy books on\\nhomeopathic medicine. A constitutional prescription also\\ncan help rebalance someone who is struggling with con-\\nstipation.\\nMassage\\nMassaging the leg from knee to hip in the morning,\\nat night, and before trying to move the bowels is said to\\nrelieve constipation. There is also a specific Swedish\\nmassage technique that can help relieve constipation.\\nYoga\\nThe knee-chest position, said to relieve gas and stim-\\nulate abdominal organs, involves:\\n• standing straight with arms at the sides\\n• lifting the right knee toward the chest\\n• grasping the right ankle with the left hand\\n• pulling the leg as close to the chest as possible\\n• holding the position for about eight seconds\\n• repeating these steps with the left leg\\nThe cobra position, which can be repeated as many\\nas four time a day, involves:\\n• lying on the stomach with legs together\\n• placing the palms just below the shoulders, holding\\nelbows close to the body\\n• inhaling, then lifting the head (face forward) and chest\\noff the floor\\nGALE ENCYCLOPEDIA OF MEDICINE 2 907\\nConstipation\\nTransverse colon\\nDescending colon\\nStool\\nSigmoid colon\\nRectum\\nConstipation is an acute or chronic condition in which\\nbowel movements occur less often than usual or consist of\\nhard, dry stools that are painful or difficult to pass.(Illustra-\\ntion by Electronic Illustrators Group).\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 907'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 296, 'page_label': '297'}, page_content='• keeping the navel in contact with the floor\\n• looking as far upward as possible\\n• holding this position for three to six seconds\\n• exhaling and lowering the chest\\nPrognosis\\nChanges in diet and exercise usually eliminate the\\nproblem.\\nPrevention\\nMost Americans consume between 11–18 g of fiber\\na day. Consumption of 30 grams of fiber and between six\\nand eight glasses of water each day can generally prevent\\nconstipation.\\nThirty-five grams of fiber a day (an amount equal to\\nfive servings of fruits and vegetables, and a large bowl of\\nhigh-fiber cereal) can relieve constipation.\\nDaily use of 500 mg vitamin C and 400 mg magne-\\nsium can prevent constipation. If symptoms do occur,\\neach dosage can be increased by 100 mg a day, up to a\\nmaximum of 5,000 mg vitamin C and 1,000 mg magne-\\nsium. Use of preventive doses should be resumed after\\nrelief occurs, and vitamin C should be decreased to the\\npre-diarrhea dosage if the patient develops diarrhea.\\nSitting on the toilet for 10 minutes at the same time\\nevery day, preferably after a meal, can induce regular\\nbowel movements. This may not become effective for a\\nfew months, and it is important to defecate whenever\\nnecessary.\\nFiber supplements containing psyllium ( Plantago\\npsyllium) usually become effective within about 48 hours\\nand can be used every day without causing dependency.\\nPowdered flaxseed ( Linium usitatissimum ) works the\\nsame way. Insoluble fiber, like wheat or oat bran, is as\\neffective as psyllium but may give the patient gas at first.\\nResources\\nBOOKS\\nThe Consumer’s Medical Desk Reference.Ed. Charles B.\\nInlander. New York: Hyperion, 1995.\\nThe Editors of Time-Life Books. The Medical Advisor: The\\nComplete Guide to Alternative and Conventional Treat-\\nments. Alexandria, V A: Time Life, Inc., 1996.\\nNew Choices in Natural Healing. Ed. Bill Gottlieb, et al.\\nEmmaus, PA: Rodale Press, 1995.\\nPERIODICALS\\nHarari D., et al. “Bowel Habit in Relation to Age and Gender:\\nFindings from the National Health Interview Survey and\\nClinical Implications.” Archives of Internal Medicine\\n(Feb. 1996): 315-320.\\nKarlsrud, K., and P. Schneider. “Tummy Troubles.”Parents,\\nApr. 1997, 83-84.\\nOTHER\\n“Constipation.” ThriveOnline. 15 Mar. 1998 .\\nMaureen Haggerty\\nConstitutional homeopathic remedies see\\nHomeopathic remedies, constitutional\\nprescribing\\nConsumption see Tuberculosis\\nContact dermatitis\\nDefinition\\nContact dermatitis is the name for any skin inflam-\\nmation that occurs when the skin’s surface comes in con-\\ntact with a substance originating outside the body. There\\nare two kinds of contact dermatitis, irritant and allergic.\\nDescription\\nThousands of natural and man-made substances can\\ncause contact dermatitis, which is the most common skin\\ncondition requiring medical attention and the foremost\\nsource of work-related disease. Florists, domestic work-\\ners, hairdressers, food preparers, and employees in\\nindustry, construction, and health care are the people\\nmost at risk of contracting work-related contact dermati-\\ntis. Americans spend roughly $300 million a year in their\\nquest for relief from contact dermatitis, not counting the\\nconsiderable sums devoted by governments and business-\\nes to regulating and policing the use of skin-threatening\\nchemicals in the workplace. But exactly how many peo-\\nple suffer from contact dermatitis remains unclear; a 1997\\narticle in the Journal of the American Medical Associa-\\ntion notes that figures ranging from 1% to 15% have been\\nput forward for Western industrial nations.\\nCauses and symptoms\\nIrritant contact dermatitis (ICD) is the more com-\\nmonly reported of the two kinds of contact dermatitis,\\nand is seen in about 80% of cases. It can be caused by\\nsoaps, detergents, solvents, adhesives, fiberglass, and\\nother substances that are able to directly injure the skin.\\nMost attacks are slight and confined to the hands and\\nforearms, but can affect any part of the body that comes\\nGALE ENCYCLOPEDIA OF MEDICINE 2908\\nContact dermatitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 908'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 297, 'page_label': '298'}, page_content='in contact with an irritating substance. The symptoms\\ncan take many forms: redness, itching , crusting,\\nswelling, blistering, oozing, dryness, scaliness, thicken-\\ning of the skin, and a feeling of warmth at the site of con-\\ntact. In extreme cases, severe blistering can occur and\\nopen sores can form. Jobs that require frequent skin\\nexposure to water, such as hairdressing and food prepara-\\ntion, can make the skin more susceptible to ICD.\\nAllergic contact dermatitis (ACD) results when\\nrepeated exposure to an allergen (an allergy-causing sub-\\nstance) triggers an immune response that inflames the\\nskin. Tens of thousands of drugs, pesticides, cosmetics,\\nfood additives, commercial chemicals, and other sub-\\nstances have been identified as potential allergens. Fewer\\nthan 30, however, are responsible the majority of ACD\\ncases. Common culprits include poison ivy, poison oak,\\nand poison sumac; fragrances and preservatives in cosmet-\\nics and personal care products; latex items such as gloves\\nand condoms; and formaldehyde. Many people find that\\nthey are allergic to the nickel in inexpensive jewelry. ACD\\nis usually confined to the area of skin that comes in contact\\nwith the allergen, typically the hands or face. Symptoms\\nrange from mild to severe and resemble those of ICD; a\\npatch test may be needed to determine which kind of con-\\ntact dermatitis a person is suffering from.\\nDiagnosis\\nDiagnosis begins with a physical examination and\\nasking the patient questions about his or her health and\\ndaily activities. When contact dermatitis is suspected, the\\ndoctor attempts to learn as much as possible about the\\npatient’s hobbies, workplace duties, use of medications\\nand cosmetics, etc.—anything that might shed light on\\nthe source of the disease. In some cases, an examination\\nof the home or workplace is undertaken. If the dermatitis\\nis mild, responds well to treatment, and does not recur,\\nordinarily the investigation is at an end. More difficult\\ncases require patch testing to identify the allergen.\\nTwo methods of patch testing are currently used. The\\nmost widely used method, the Finn chamber method,\\nemploys a multiwell, aluminum patch. Each well is filled\\nwith a small amount of the allergen being tested and the\\npatch is taped to normal skin on the patient’s upper back.\\nAfter 48 hours, the patch is removed and an initial reading\\nis taken. A second reading is made a few days later. The\\nsecond method of patch testing involves applying a small\\namount of the test substance to directly to normal skin\\nand covering it with a dressing that keeps air out and\\nkeeps the test substance in (occlusive dressing). After 48\\nhours, the dressing is taken off to see if a reaction has\\noccurred. Identifying the allergen may require repeated\\ntesting, can take weeks or months, and is not always suc-\\ncessful. Moreover, patch testing works only with ACD,\\nthough it is considered an essential step in ruling out ICD.\\nTreatment\\nThe best treatment for contact dermatitis is to identify\\nthe allergen or irritating substance and avoid further con-\\ntact with it. If the culprit is, for instance, a cosmetic, avoid-\\nance is a simple matter, but in some situations, such as an\\nallergy to an essential workplace chemical for which no\\nsubstitute can be found, avoidance may be impossible or\\nforce the sufferer to find new work or make other drastic\\nchanges in his or her life. Barrier creams and protective\\nclothing such as gloves, masks, and long-sleeved shirts are\\nways of coping with contact dermatitis when avoidance is\\nimpossible, though they are not always effective.\\nFor the symptoms themselves, treatments in mild\\ncases include cool compresses and nonprescription\\nlotions and ointments. When the symptoms are severe,\\ncorticosteroids applied to the skin or taken orally are\\nused. Contact dermatitis that leads to a bacterial skin\\ninfection is treated with antibiotics.\\nAlternative treatment\\nHerbal remedies have been used for centuries to\\ntreat skin disorders including contact dermatitis. An\\nexperienced herbalist can recommend the remedies that\\nGALE ENCYCLOPEDIA OF MEDICINE 2 909\\nContact dermatitis\\nThe abdomen of a male patient afflicted with contact der-\\nmatitis, triggered by an allergic reaction to a nickel belt\\nbuckle. (Photograph by Dr. P . Marazzi, Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 909'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 298, 'page_label': '299'}, page_content='will be most effective for an individual’s condition.\\nAmong the herbs often recommended are:\\n• Burdock (Arctium lappa) minimizes inflammation and\\nboosts the immune system. It is taken internally as a tea\\nor tincture (a concentrated herbal extract prepared with\\nalcohol).\\n• Calendula (Calendula officinalis) is a natural antiseptic\\nand anti-inflammatory agent. It is applied topically in a\\nlotion, ointment, or oil to the affected area.\\n• Aloe (Aloe barbadensis ) soothes skin irritations. The\\ngel is applied topically to the affected area.\\nA homeopath treating a patient with contact dermati-\\ntis will do a thorough investigation of the individual’s his-\\ntory and exposures before prescribing a remedy. One\\nhomeopathic remedy commonly prescribed to relieve the\\nitching associated with contact dermatitis is Rhus toxico-\\ndendron taken internally three to four times daily.\\nPoison ivy, poison oak, and poison sumac are common\\nculprits in cases of allergic contact dermatitis. Following\\nexposure to these plants, rash development may be prevent-\\ned by washing the area with soap and water within 15 min-\\nutes of exposure. The leaves of jewelweed (Impatiensspp.),\\nwhich often grows near poison ivy, may neutralize the poi-\\nson-ivy allergen if rubbed on the skin right after contact.\\nSeveral topical remedies may help relieve the itching asso-\\nciated with allergic contact dermatitis, including the juice\\nof plantain leaves (Plantago major); a paste made of equal\\nparts of green clay and goldenseal root ( Hydrastis\\ncanadensis); a paste made of salt, water, clay, and pepper-\\nmint (Mentha piperita) oil; and calamine lotion.\\nPrognosis\\nIf the offending substance is promptly identified and\\navoided, the chances of a quick and complete recovery\\nare excellent. Otherwise, symptom management—not\\ncure—is the best doctors can offer. For some people,\\nKEY TERMS\\nAntibiotics—Substances used against microorgan-\\nisms that cause infection.\\nCorticosteroids —A group of anti-inflammatory\\nsubstances often used to treat skin conditions.\\nImmune response—The protective reaction by the\\nimmune system against foreign antigens (sub-\\nstances that the body perceives as potentially dan-\\ngerous). The immune system combats disease by\\nneutralizing or destroying antigens.\\ncontact dermatitis becomes a chronic and disabling con-\\ndition that can have a profound effect on employability\\nand quality of life.\\nPrevention\\nAvoidance of known or suspected allergens or irritat-\\ning substances is the best prevention. If avoidance is diffi-\\ncult, barrier creams and protective clothing can be tried.\\nSkin that comes in contact with an offending substance\\nshould be thoroughly washed as soon as possible.\\nResources\\nBOOKS\\nSwerlick, Robert A., and Thomas J. Lawley. “Eczema, Psoriasis,\\nCutaneous Infections, Acne, and Other Common Skin Dis-\\norders.” In Harrison’s Principles of Internal Medicine,e d .\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1997.\\nWolf Jr., John E. “Contact Dermatitis.” In Conn’s Current\\nTherapy, 1996, ed. Robert E. Rakel. Philadelphia: W. B.\\nSaunders Co., 1996.\\nPERIODICALS\\nBeltrani, Vincent S., and Vincent P. Beltrani. “Contact Dermati-\\ntis.” Annals of Allergy, Asthma, and Immunology78 (Feb.\\n1997): 160-75.\\nLeung, Donald Y . M., et al. “Allergic and Immunologic Skin\\nDisorders.” Journal of the American Medical Association\\n278 (1997): 1914+.\\nRietschel, Robert L. “Occupational Contact Dermatitis.”The\\nLancet 349 (1997): 1093+.\\nOTHER\\nStewart, Leslie. “Contact Dermatitis.”National Jewish Medical\\nResearch Center Page.25 Aug. 1995. 17 June 1998\\n.\\nHoward Baker\\nContact lenses see Eye glasses and contact\\nlenses\\nContinent urinary diversion see Urinary\\ndiversion surgery\\nContinuous ambulatory electrocardiography\\nsee Holter monitoring\\nContinuous positive airway see Inhalation\\ntherapies\\nContraception\\nDefinition\\nContraception (birth control) prevents pregnancy\\nby interfering with the normal process of ovulation, fer-\\nGALE ENCYCLOPEDIA OF MEDICINE 2910\\nContraception\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 910'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 299, 'page_label': '300'}, page_content='tilization, and implantation. There are different kinds of\\nbirth control that act at different points in the process.\\nPurpose\\nEvery month, a woman’s body begins the process\\nthat can potentially lead to pregnancy. An egg (ovum)\\nmatures, the mucus that is secreted by the cervix (a cylin-\\ndrical-shaped organ at the lower end of the uterus)\\nchanges to be more inviting to sperm, and the lining of\\nthe uterus grows in preparation for receiving a fertilized\\negg. Any woman who wants to prevent pregnancy must\\nuse a reliable form of birth control.\\nBirth control (contraception) is designed to interfere\\nwith the normal process and prevent the pregnancy that\\ncould result. There are different kinds of birth control\\nthat act at different points in the process, from ovulation,\\nthrough fertilization, to implantation. Each method has\\nits own side effects and risks. Some methods are more\\nreliable than others.\\nAlthough there are many different types of birth\\ncontrol, they can be divided into a few groups based on\\nhow they work. These groups include:\\n• Hormonal methods—These use medications (hor-\\nmones) to prevent ovulation. Hormonal methods\\ninclude birth control pills ( oral contraceptives), Depo\\nProvera injections and Norplant.\\n• Barrier methods—These methods work by preventing\\nthe sperm from getting to and fertilizing the egg. Barri-\\ner methods include the condom, diaphragm, and cervi-\\ncal cap. The condom is the only form of birth control\\nthat also protects against sexually transmitted dis-\\neases, including HIV (the virus that causes AIDS).\\n• Spermicides—These medications kill sperm on con-\\ntact. Most spermicides contain nonoxynyl-9. Spermi-\\ncides come in many different forms such as jelly, foam,\\ntablets, and even a transparent film. All are placed in\\nthe vagina. Spermicides work best when they are used\\nat the same time as a barrier method.\\n• Intrauterine devices—Intrauterine contraceptive\\ndevices (IUDs) are inserted into the uterus, where they\\nstay from one to 10 years. An IUD prevents the fertil-\\nized egg from implanting in the lining of the uterus, and\\nmay have other effects as well.\\n• Tubal sterilization—Tubal sterilization is a permanent\\nform of contraception for women. Each fallopian tube\\nis either tied or burned closed. The sperm cannot reach\\nthe egg, and the egg cannot travel to the uterus.\\n• Vasectomy—is the male form of sterilization, and\\nshould also be considered permanent. In vasectomy ,\\nthe vas defrens, the tiny tubes that carry the sperm into\\nthe semen, are cut and tied off. Thus, no sperm can get\\ninto the semen.\\nUnfortunately, there is no perfect form of birth con-\\ntrol. Only abstinence (not having sexual intercourse) can\\nprotect against unwanted pregnancy with 100% reliability.\\nThe failure rates, which means the rates of pregnancy, for\\nmost forms of birth control are quite low. However, some\\nforms of birth control are more difficult or inconvenient to\\nuse than others. In actual practice, the birth control meth-\\nods that are more difficult or inconvenient have much\\nhigher failure rates because they are not used faithfully.\\nDescription\\nAll the different forms of birth control have one thing\\nin common. They are only effective if used faithfully.\\nBirth control pills will work only if taken every day; the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 911\\nContraception\\nVarious types of contraception.(Photo Researchers, Inc.\\nReproduced by permission.)\\nTypes Of Contraceptives\\nEffectiveness Predicted (%) Actual (%)\\nBirth control pills 99.9 97\\nCondoms 98 88\\nDepo Provera 99.7 99.7\\nDiaphragm 94 82\\nIUDs 99.2 97\\nNorplant 99.7 99.7\\nTubal sterilization 99.8 99.6\\nSpermicides 97 79\\nVasectomy 99.9 99.9\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 911'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 300, 'page_label': '301'}, page_content='diaphragm is effective only if used during every episode\\nof sexual intercourse. The same is true for condoms and\\nthe cervical cap. Some methods are automatically work-\\ning every day, no matter what. These methods include\\nDepo Provera, Norplant, the IUD, and tubal sterilization.\\nThere are many different ways to use birth control.\\nThey can be divided into several groups:\\n• By mouth (oral)—Birth control pills must be taken by\\nmouth every day.\\n• Injected—Depo Provera is a hormonal medication that\\nis given by injection every three months.\\n• Implanted—Norplant is a long-acting hormonal form\\nof birth control that is implanted under the skin of the\\nupper arm.\\n• Vaginal—Spermicides and barrier methods work in the\\nvagina.\\n• Intra-uterine—The IUD is inserted into the uterus.\\n• Surgical—Tubal sterilization is a form of surgery. A\\ndoctor must perform the procedure in a hospital or sur-\\ngical clinic. Many women need general anesthesia.\\nThe methods of birth control differ from each other\\nin the timing of when they are used. Some methods of\\nbirth control must be used specifically at the time of sex-\\nual intercourse (condoms, diaphragm, cervical cap, sper-\\nmicides). All other methods of birth control must be\\nworking all the time to provide protection (hormonal\\nmethods, IUDs, tubal sterilization).\\nPrecautions\\nThere are risks associated with some forms of birth\\ncontrol. Some of the risks of each method are listed\\nbelow:\\n• Birth control pills—The hormone (estrogen) in birth\\ncontrol pills can increase the risk of heart attack in\\nwomen over 40 who smoke.\\n• IUD—The IUD can increase the risk of serious pelvic\\ninfection. The IUD can also injure the uterus by poking\\ninto or through the uterine wall. Surgery might be need-\\ned to fix this.\\n• Tubal sterilization—“Tying the tubes” is a surgical pro-\\ncedure and has all the risks of any other surgery, includ-\\ning the risks of anesthesia, infection, and bleeding.\\nPreparation\\nNo specific preparation is needed before using con-\\ntraception. However, a woman must be sure that she is\\nnot already pregnant before using a hormonal method or\\nhaving an IUD placed.\\nAftercare\\nNo aftercare is needed.\\nRisks\\nMany methods of birth control have side effects.\\nKnowing the side effects can help a woman to determine\\nwhich method of birth control is right for her.\\n• Hormonal methods—The hormones in birth control\\npills, Depo Provera, and Norplant can cause changes in\\nmenstrual periods, changes in mood, weight gain, acne,\\nand headaches. In addition, it may take many months to\\nbegin ovulating again once a woman stops using Depo\\nProvera or Norplant.\\n• Barrier methods—A woman must insert the diaphragm\\nin just the right way to be sure that it works properly.\\nSome women get more urinary tract infections if they\\nuse a diaphragm. This is because the diaphragm can\\npress against the urethra, the tube that connects the\\nbladder to the outside.\\n• Spermicides—Some women and men are allergic to\\nspermicides or find them irritating to the skin.\\n• IUD—The IUD is a foreign body that stays inside the\\nuterus, and the uterus tries to get it out. A woman may\\nhave heavier menstrual periods and more menstrual\\ncramping with an IUD in place.\\nGALE ENCYCLOPEDIA OF MEDICINE 2912\\nContraception\\nA variety of intrauterine contraceptive devices.The proba-\\nbility of a pregnancy for year of use is about 2 to 3%. IUDs\\nmade with copper coils should be replaced every 3 to 5\\nyears. (Photo Researchers, Inc. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 912'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 301, 'page_label': '302'}, page_content='• Tubal sterilization—Some women report increased\\nmenstrual discomfort after tubal ligation . It is not\\nknown if this is related to the tubal ligation itself.\\nThere is no perfect form of birth control. Every\\nmethod has a small failure rate and side effects. Some\\nmethods carry additional risks. However, every method\\nof birth control can be effective if used properly.\\nResources\\nBOOKS\\nOsathanondh, Rapin, Michael R. Stelluto, and Karen J. Carl-\\nson. “Contraception.” In Primary Care of Women,e d .\\nKaren J. Carlson and Stephanie A. Eisenstat. St. Louis:\\nMosby-Year Book, Inc., 1995.\\nOsathanondh, Rapin. “Conception Control.” In Kistner’s Gyne-\\ncology, ed. Kenneth J. Ryan, Ross S. Berkowitz, and\\nRobert L. Barbieri. St. Louis: Mosby, 1995.\\nAmy B. Tuteur, MD\\nContractures\\nDefinition\\nContractures are the chronic loss of joint motion due\\nto structural changes in non-bony tissue. These non-bony\\ntissues include muscles, ligaments, and tendons.\\nDescription\\nContractures can occur at any joint of the body. This\\njoint dysfunction may be a result of immobilization from\\ninjury or disease; nerve injury, such as spinal cord dam-\\nage and stroke; or muscle, tendon, or ligament disease.\\nKEY TERMS\\nFallopian tubes —The thin tubes that connect the\\novary to the uterus. Ova (eggs) travel from the\\novary to the uterus. If the egg has been fertilized, it\\ncan implant in the uterus.\\nFertilization —The joining of the sperm and the\\negg; conception.\\nImplantation—The process in which the fertilized\\negg embeds itself in the wall of the uterus.\\nOvulation—The release of an egg (ovum) from the\\novary.\\nCauses and symptoms\\nThere are a number of pathologies and diseases that\\ncan lead to joint contractures. The primary causes result-\\ning in a joint contraction are muscle imbalance, pain,\\nprolonged bed rest, and immobilization. Because of the\\nfrequency of fractures and surgery, immobilization is\\nthe most frequent cause of joint contractures. Symptoms\\ninclude a significant loss of motion to any specific joint\\nthat results in immobility. If the contracture is of a signif-\\nicant degree, pain can result even without any voluntary\\njoint movement.\\nDiagnosis\\nManual testing of joint mobility by a healthcare pro-\\nfessional skilled in joint mobilization techniques (e.g. a\\nphysical therapist) will identify indications of restricted\\nstructures within the joint. Measuring the motion of the\\njoint with a device termed a “goniometer” can be useful\\nif the decrease of motion can be shown to be a proven\\nresult of a joint contracture. X rays can be of some bene-\\nfit in the diagnosis of contractures, because a visible\\ndecrease in joint space may indicate a tight, contracted\\njoint. Most physicians will make the diagnosis after a\\nthorough physical examination involving physical and\\nmanual testing of the joint motion.\\nTreatment\\nManual techniques\\nJoint mobilization and stretching of soft tissues is a\\ncommon technique used to increase joint elasticity.\\nStructures are stretched in similar directions to those\\nwhich take place upon normal joint motion. Some\\nhealthcare professionals may use some form of heat prior\\nto the stretching and mobilization. If appropriate, exer-\\ncise may follow manual techniques to help maintain the\\nadditional motion achieved.\\nMechanical techniques\\nDevices known as continuous passive motion\\nmachines are very popular, especially following surgery\\nof joints. Continuous passive motion machines (CPM)\\nare specifically adjusted to each individual’s need. This\\nmethod is administered within the first 24–72 hours after\\nthe injury or surgery. The joint is mechanically moved\\nthrough the patient’s tolerable motion. CPM machines\\nhave been proved to accelerate the return motion process,\\nallowing patients more function in less time.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 913\\nContractures\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 913'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 302, 'page_label': '303'}, page_content='Casting or splinting\\nCasting or splinting techniques are used to provide a\\nconstant stretch to the soft tissues surrounding a joint. It\\nis most effective when used to increase motion of a joint\\nfrom prolonged immobilization. It is also popular for\\ntreating contractures resulting from an increase in muscle\\ntone from nerve injury. After an initial holding cast is\\napplied for seven to 10 days, a series of positional casts\\nare applied at weekly intervals. Before the application of\\neach new cast, the joint is moved as much as can be toler-\\nated by the patient, and measured by a goniometer. When\\nas much motion as possible is obtained after stretching,\\nanother final cast is applied to maintain the newly\\nacquired motion.\\nSurgery\\nIn some cases the contracture may be severe and not\\nrespond to conservative treatment. In this event, manipu-\\nlation of the joint under a general anesthesia may be nec-\\nessary.\\nAlternative treatment\\nIn some areas of the body, chiropractic techniques\\nhave been found to be useful to improve motion. Mas-\\nsage therapy can be beneficial by promoting additional\\ncirculation to joint structures, causing better elasticity.\\nYoga can help prevent as well as rehabilitate a contrac-\\nture and can facilitate the return of joint mobility.\\nPrognosis\\nPrognosis of contractures will depend upon the\\ncause of the contracture. In general, the earlier the treat-\\nment for the contracture begins, the better the prognosis.\\nPrevention\\nPrevention of contractures and deformities from\\nspinal cord injury , fracture, and immobilization is\\nachieved through a program of positioning, splinting if\\nKEY TERMS\\nMobilization —Making movable, restoring the\\npower of motion in a joint. Movement which\\nincreases joint mobility.\\nMuscle tone— Also termed tonus; the normal\\nstate of balanced tension in the tissues of the body,\\nespecially the muscles.\\nappropriate, and range-of-motion exercises either manu-\\nally or mechanically aided. These activities should be\\nstarted as early as possible for optimal results.\\nResources\\nBOOKS\\nUmphred, Darcy A. “Traumatic Spinal Cord Injury.” In Neuro-\\nlogical Rehabilitation. St. Louis: C. V . Mosby Co., 1990.\\nPERIODICALS\\nIto, Caryn S. “Conservative Management of Joint Deformities\\nand Dynamic Posturing.”Orthopaedic Physical Therapy\\nClinics of North America 2, no. 1 (Mar. 1993): 25-38.\\nMurphy, John. “Continuous Passive Motion.”Advance Maga-\\nzine for Physical Therapists (Jan. 1996): 8.\\nORGANIZATIONS\\nThe American College of Rheumatology. 1800 Century Place,\\nSuite 250, Atlanta, GA 30345. (404) 633-3777. .\\nAmerican Physical Therapy Association. 1111 North Fairfax\\nSt., Alexandria, Virginia 22314. (800) 999-2782. .\\nJeffrey P. Larson, RPT\\nConversion disorder see Somatoform\\ndisorders\\nCooley’s anemia see Thalassemia\\nCooling treatments\\nDefinition\\nCooling treatments lower body temperature in order\\nto relieve pain, swelling, constriction of blood vessels,\\nand to decrease the liklihood of cellular damage by slow-\\ning the metabolism. Sponge baths, cold compresses, and\\ncold packs are all wet cooling treatments. Dry treat-\\nments, such as ice bags and chemical cold packs, are also\\nused to lower body temperature.\\nPurpose\\nThe most common reason for cooling a body is\\nfever or hyperthermia (extremely high fever). The body\\ncan sustain temperatures up to 104°F (40°C) with rela-\\ntive safety; however, when temperatures rise above\\n104°F (40°C), damage to the brain, muscles, blood, and\\nkidneys is increasingly likely. Cooling treatments are\\nalso applied immediately following sprains, bruises ,\\nburns, eye injuries, and muscle spasms to help alleviate\\nthe resulting swelling, pain, and discoloration of the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 2914\\nCooling treatments\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 914'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 303, 'page_label': '304'}, page_content='Cooling treatments slow chemical reactions within\\nthe body. For this reason, cooling tissues below normal\\ntemperature (98.6°F/37°C) can prevent injury from inad-\\nequate oxygen or nutrition . Cold water drowning vic-\\ntims suffering from hypothermia (cooling of the body\\nbelow its normal temperature) have been successfully\\nresuscitated after long periods underwater without med-\\nical complications because of this effect. For the past 40\\nyears, heart surgeons have been experimenting with\\nhypothermia to protect tissues from lack of blood circu-\\nlation during an operation. Neurosurgeons are also work-\\ning with hypothermia to protect the very sensitive brain\\ntissues during periods of absent or reduced blood flow.\\nDescription\\nDepending on the medical need, various cooling\\nmethods are used.\\n• Cold packs and ice bags are placed on a localized site\\nand provide topical relief. These compresses should be\\ncovered with a waterproof material to protect the skin.\\nRepeated treatments produce the desired pain and\\nswelling relief.\\n• Cold treatments are placed on the groin and under the\\narms to treat hyperthermia. Treatments are refreshed\\nperiodically until the appropriate temperature is attained.\\n• A tepid sponge bath relieves fever without cooling the\\nbody too fast. Eighty degrees Farenheit is still 20°F\\nbelow body temperature and yet warm enough not to\\ndrive blood from the skin, thereby preventing the cool-\\ning from getting to the body’s core. Limbs are bathed\\nfirst and then the chest, abdomen, back, and buttocks.\\n• Perfusion of isolated regions like the brain by using\\ncooled blood is an experimental treatment, offering\\npromising results for the treatment of stroke.\\nPreparation\\nTopical treatments are prepared with ice, cold water\\n(59°F/15°C), and chemical cold packs. Tepid baths\\nshould be 80–93°F (26.7–34°C).\\nRisks\\nSmall children, adults with circulation problems, and\\nthe elderly are all at risk of tissue damage. Rapid cooling\\ncauses chills, which in effect raise the body’s temperature\\nby raising its metabolism. Blood clots may form from\\nthickened blood caused by the temperature change.\\nResources\\nPERIODICALS\\nBarone, F. C., G. Z. Feuerstein, and R. F. White. “Brain Cool-\\ning During Transient Focal Ischemia Provides Complete\\nNeuroprotection.” Neuroscience & Biobehavioral Reviews\\n21 (Jan. 1997): 31-44.\\nImamaki M., T. Hirayama, and M. Nakajima. “Separate-\\nHypothermia Retrograde Cerebral Perfusion.”Annals of\\nThoracic Surgery 63 (Feb. 1997): 54754-54758.\\nPlattner, O., et al. “Efficacy of Intraoperative Cooling Meth-\\nods.” Anesthesiology 87 (Nov. 1997): 1089-1095.\\nJ. Ricker Polsdorfer, MD\\nCoombs’ tests\\nDefinition\\nCoombs’ tests are blood tests that identify the causes\\nof anemia.\\nPurpose\\nAnemia, which literally means no blood, refers to\\nblood with abnormally low oxygen-carrying capacity.\\nThe hemoglobin in red blood cells carries oxygen. One\\nof the many causes of anemia is destruction of red blood\\ncells, a process called hemolysis (hemo means blood and\\nlysis means disintegration). A simple blood count\\ndetects anemia. Even the test done before a blood dona-\\ntion can identify anemia. To detect hemolysis requires\\nother tests. The Coombs’ tests are conducted in order to\\ndetermine the cause of anemia.\\nOne characteristic of hemolysis is the autoimmune\\nresponse against the body’s red blood cells. Instead of\\nprotecting the body from outside agents, the immune\\nsystem attacks parts of its own body with a deluge of\\nantibodies. Autoimmunity is thought to be the cause of\\nmany collagen-vascular diseases, including rheumatoid\\narthritis and systemic lupus erythematosus . It is also\\nthe cause of the autoimmune hemolytic anemias . The\\nCoombs’ tests detect the antibodies responsible for the\\ndestruction of the red blood cells.\\nCauses of autoimmune hemolytic anemia include:\\n• drugs such as penicillin, methyldopa (lowers blood\\npressure), and quinidine (treats heart rhythm distur-\\nbances)\\n• cancers of the lymph system—Hodgkin’s disease and\\nlymphomas\\n• virus infections\\n• collagen-vascular diseases\\n• mismatched blood transfusions\\n• Rh incompatibility between a mother and fetus. This\\ndisease is called erythroblastosis fetalis\\nGALE ENCYCLOPEDIA OF MEDICINE 2 915\\nCoombs’ tests\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 915'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 304, 'page_label': '305'}, page_content='Many times the cause cannot be identified.\\nDescription\\nThere are two Coombs’ tests. A direct Coombs’ test\\ndetects the two different antigens that might induce\\nhemolysis in the patient’s red blood cells. An indirect\\nCoombs’ test looks for antibodies to someone else’s red\\nblood cells in the patient’s serum (the blood without the\\ncells). Combining the two tests gives clues to the origin\\nof the hemolysis.\\nPreparation\\nNo preparation is needed for this test. It will proba-\\nbly be among the second or third set of blood tests done\\nafter anemia is diagnosed and there is a suspicion that its\\ncause is hemolysis.\\nAftercare\\nCoombs’ tests are done on blood that is drawn from\\nthe arm.\\nRisks\\nTaking blood for testing is the most common med-\\nical procedure performed. The worst complication is a\\nKEY TERMS\\nAntibody—A protein made by the immune system\\nand used as a weapon against foreign invaders in\\nthe body.\\nAntigen—The chemical that stimulates an immune\\nresponse.\\nAnemia—Reduced oxygen-carrying capacity of\\nthe blood, due to too little hemoglobin or too few\\nred blood cells.\\nCollagen-vascular disease —Various diseases\\ninflaming and destroying connective tissue.\\nHematologist —Physician who specializes in dis-\\neases of the blood.\\nHemoglobin—The red pigment in blood that car-\\nries oxygen.\\nHemolysis—Breaking apart red blood cells.\\nRh—A blood typing group, like the ABO system.\\nWhen a mother is Rh negative and her baby is Rh\\npositive, she may develop antibodies to the baby’s\\nblood that will cause it to hemolyze.\\nbruise at the site of the puncture or punctures. It is\\nextremely rare for the needle to injure an important struc-\\nture such as an artery or a nerve.\\nNormal results\\nIf the Coombs’ tests are negative, the anemia is\\nunlikely to be autoimmune, and the hematologist will\\nhave to search elsewhere for a cause.\\nAbnormal results\\nIf the test is positive, the antigens that react will nar-\\nrow the search for a cause. Coombs’ tests are also done\\nfor blood transfusion reactions to determine why the\\ntransfused blood did not match, and when there is a\\nchance a newborn may have an Rh problem.\\nResources\\nBOOKS\\nRosse, Wendell, and H. Franklin Bunn. “Hemolytic Anemias\\nand Acute Blood Loss.” In Harrison’s Principles of Inter-\\nnal Medicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nSchreiber, Alan D. “Autoimmune Hemolytic Anemia.” In Cecil\\nTextbook of Medicine, ed. J. Claude Bennett and Fred\\nPlum. Philadelphia: W. B. Saunders Co., 1996.\\nTeresa Norris, RN\\nCoordination tests see Balance and\\ncoordination tests\\nCOPD see Emphysema; Chronic\\nobstructive lung disease\\nCopper deficiency see Mineral deficiency\\nCopper excess see Wilson’s disease\\nCor pulmonale\\nDefinition\\nCor pulmonale is an increase in bulk of the right\\nventricle of the heart, generally caused by chronic dis-\\neases or malfunction of the lungs. This condition can\\nlead to heart failure.\\nDescription\\nCor pulmonale, or pulmonary heart disease, occurs in\\n25% of patients with chronic obstructive pulmonary dis-\\nGALE ENCYCLOPEDIA OF MEDICINE 2916\\nCor pulmonale\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 916'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 305, 'page_label': '306'}, page_content='ease (COPD). In fact, about 85% of patients diagnosed\\nwith cor pulmonale have COPD. Chronic bronchitis and\\nemphysema are types of COPD. High blood pressure in\\nthe blood vessels of the lungs (pulmonary hypertension)\\ncauses the enlargement of the right ventricle. In addition\\nto COPD, cor pulmonale may also be caused by lung dis-\\neases, such as cystic fibrosis, pulmonary embolism, and\\npneumoconiosis. Loss of lung tissue after lung surgery\\nor certain chest-wall disturbances can produce cor pul-\\nmonale, as can neuromuscular diseases, such as muscu-\\nlar dystrophy . A large pulmonary thromboembolism\\n(blood clot) may lead to acute cor pulmonale.\\nCauses and symptoms\\nAny respiratory disease or malfunction that affects\\nthe circulatory system of the lungs may lead to cor pul-\\nmonale. These circulatory changes cause the right ventri-\\ncle to compensate for the extra work required to pump\\nblood through the lungs. The right ventricle has thin\\nwalls and is crescent-shaped. The resulting pressure\\ncauses the right ventricle to dilate and bulge, eventually\\nleading to its failure.\\nCor pulmonale should be expected in any patient\\nwith COPD and other respiratory or neuromuscular dis-\\neases. Initial symptoms of cor pulmonale may actually\\nreflect those of the underlying disease. These may\\ninclude chronic coughing, wheezing, weakness, fatigue,\\nand shortness of breath . Edema (abnormal buildup of\\nfluid), weakness, and discomfort in the upper chest may\\nbe evident in cor pulmonale.\\nDiagnosis\\nAn electrocardiograph (EKG) will show signs such\\nas frequent premature contractions in the atria or ventri-\\ncles. Chest x rays may show enlargement of the right\\ndescending pulmonary artery. This sign, along with an\\nenlarged main pulmonary artery, indicates pulmonary\\nartery hypertension in patients with COPD. Magnetic\\nresonance imaging (MRI) is often the preferred method\\nof diagnosis for cor pulmonale because it can clearly\\nshow and measure volume of the pulmonary arteries.\\nOther tests used to support a diagnosis of cor pulmonale\\nmay include arterial blood gas analysis , pulmonary\\nfunction tests, and hematocrit.\\nTreatment\\nTreatment of cor pulmonale is aimed at increasing a\\npatient’s exercise tolerance and improving oxygen levels\\nof the arterial blood. Treatment is also aimed at the\\nunderlying condition that is producing cor pulmonale.\\nCommon treatments include antibiotics for respiratory\\nKEY TERMS\\nVentricle—A cavity, as in the brain or heart. The\\nright ventricle of the heart drives blood from the\\nheart into the pulmonary artery, which supplies\\nblood to the lungs.\\ninfection; anticoagulants to reduce the risk of throm-\\nboembolism; and digitalis, oxygen, and phlebotomy to\\nreduce red blood cell count. A low-salt diet and restricted\\nfluids are often prescribed.\\nAlternative treatment\\nCo-management of the patient with cor pulmonale\\nshould be coordinated between the medical doctor and\\nthe alternative practitioner. The first step in treatment is\\nto determine the cause of the condition and to evaluate\\nall organ systems of the body. Dietary considerations, for\\nexample, a low-salt diet and reduced fluid intake aimed\\nat reducing the edema associated with cor pulmonale,\\ncan be supportive aspects of treatment.\\nPrognosis\\nThe prognosis for cor pulmonale is poor, particularly\\nbecause it occurs late in the process of serious disease.\\nPrevention\\nCor pulmonale is best prevented by prevention of\\nCOPD and other irreversible diseases that lead to heart\\nfailure. Smoking cessation is critically important. Care-\\nfully following the recommended course of treatment for\\nthe underlying disease may help prevent cor pulmonale.\\nResources\\nBOOKS\\nProfessional Guide to Diseases. 5th ed. Springhouse, PA:\\nSpringhouse Corporation, 1995.\\nRothfield, Glenn S., Suzanne Levert, and Greg Rothfield. Nat-\\nural Medicine for Heart Disease: The Best Alternative\\nMethods for Prevention and Treatment: High Cholesterol,\\nHigh Blood Pressure, Stroke, Chest.New York: Rodale\\nPress, 1996.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nJ. Ricker Polsdorfer, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 2 917\\nCor pulmonale\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 917'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 306, 'page_label': '307'}, page_content='A close-up view of an abrasion on patient’s cornea.(Photo-\\ngraph by Dennis R. Cain, CRA, Custom Medical Stock Photo.\\nReproduced by permission.)\\nCori’s disease see Glycogen storage\\ndiseases\\nCorkscrew esophagus see Diffuse\\nesophageal spasm\\nCorneal abrasion\\nDefinition\\nA corneal abrasion is a worn or scraped-off area of\\nthe outer, clear layer of the eye (cornea).\\nDescription\\nThe cornea is the clear, dome-shaped outer area of\\nthe eye. It lies in front of the colored part of the eye (iris)\\nand the black hole in the iris (pupil). The outermost layer\\nof the eyeball consists of the cornea and the white part of\\nthe eye (sclera). A corneal abrasion is basically a superfi-\\ncial cut or scrape on the cornea. A corneal abrasion is not\\nas serious as a corneal ulcer, which is generally deeper\\nand more severe than an abrasion.\\nCauses and symptoms\\nA corneal abrasion is usually the result of direct injury\\nto the eye, often from a fingernail scratch, makeup brushes,\\ncontact lenses, foreign body, or even twigs. Patients often\\ncomplain of feeling a foreign body in their eye, and they\\nmay have pain, sensitivity to light, or tearing.\\nDiagnosis\\nOphthalmologists and optometrists, who treat eye\\ndisorders, are well qualified to diagnose corneal abra-\\nsions. The doctor will check the patient’s vision (visual\\nacuity) in both eyes with an eye chart. A patient history\\nwill also be taken, which may help to determine the\\ncause of the abrasion. A slit lamp, which is basically a\\nmicroscope and light source, will allow the doctor to see\\nthe abrasion. Fluorescein, a yellow dye, may be placed\\ninto the eye to determine the extent of the abrasion. The\\nfluorescein will temporarily stain the affected area.\\nTreatment\\nThe cornea has a remarkable ability to heal itself, so\\ntreatment is designed to minimize complications. If the\\nabrasion is very small, the doctor might just suggest an\\neye lubricant and a follow-up visit the next day. A very\\nsmall abrasion should heal in one to two days; others\\nusually in one week. However, to avoid a possible infec-\\ntion, an antibiotic eye drop may be prescribed. Some-\\ntimes additional eye drops may make the eye feel more\\ncomfortable. Depending upon the extent of the abrasion,\\nsome doctors may patch the affected eye. It is very\\nimportant to go for the follow-up checkup to make sure\\nan infection does not occur. Use of contact lenses should\\nnot be resumed without the doctor’s approval.\\nPrognosis\\nIn typical cases, the prognosis is good. The cornea\\nwill heal itself, usually within several days. A very deep\\nabrasion may lead to scarring. If the abrasion does not\\nheal properly, a recurrent corneal erosion (RCE) may\\nresult months or even years later. The symptoms are the\\nsame as for an abrasion (e.g., tearing, foreign body sensa-\\ntion, and blurred vision), but it will keep occurring. Simi-\\nlar or additional treatment for the RCE may be necessary.\\nPrevention\\nEveryone should wear eye protection whenever this\\nis recommended. This should be standard practice when\\nusing power tools and playing certain sports. Goggles\\nshould even be worn when mowing the lawn, because a\\ntwig can be thrown upward toward the face. Contact lens\\nwearers should be careful to follow their doctors’ instruc-\\ntions on caring for and wearing their lenses. Ill-fitting or\\ndirty lenses could lead to an abrasion, so patients should\\ngo for their prescribed checkups.\\nGALE ENCYCLOPEDIA OF MEDICINE 2918\\nCorneal abrasion\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 918'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 307, 'page_label': '308'}, page_content='Resources\\nBOOKS\\nElkington, A. R., and P. T. Khaw. The ABC of Eyes. 2nd ed.\\nAmerican College of Physicians Press, 1994.\\nFriedlaender, Mitchell H. 20/20: A Total Guide to Improving Your\\nVision and Preventing Eye Disease.Rodale Press, 1991.\\nORGANIZATIONS\\nAmerican Academy of Family Physicians. 8880 Ward Parkway,\\nKansas City, MO 64114. (816) 333-9700. .\\nRichard H. Lampert\\nCorneal infection see Keratitis\\nCorneal keratoplasty see Corneal\\ntransplantation\\nCorneal transplantation\\nDefinition\\nIn corneal transplant, also known as keratoplasty, a\\npatient’s damaged cornea is replaced by the cornea from\\nthe eye of a human cadaver. This is the single most com-\\nmon type of human transplant surgery and has the high-\\nest success rate. Eye banks acquire and store eyes from\\ndonor individuals largely to supply the need for trans-\\nplant corneas.\\nPurpose\\nCorneal transplant is used when vision is lost in an\\neye because the cornea has been damaged by disease or\\ntraumatic injury. Some of the disease conditions that\\nmight require corneal transplant include the bulging out-\\nward of the cornea (keratoconus), a malfunction of the\\ninner layer of the cornea (Fuchs’ dystrophy), and painful\\nswelling of the cornea (pseudophakic bullous keratopa-\\nthy). Some of these conditions cause cloudiness of the\\ncornea; others alter its natural curvature, which can also\\nreduce the quality of vision.\\nInjury to the cornea can occur because of chemical\\nburns, mechanical trauma, or infection by viruses, bacte-\\nria, fungi, or protozoa. The herpes virus produces one of\\nthe more common infections leading to corneal transplant.\\nSurgery would only be used when damage to the\\ncornea is too severe to be treated with corrective lenses.\\nOccasionally, corneal transplant is combined with other\\ntypes of eye surgery (such as cataract surgery) to solve\\nmultiple eye problems in one procedure.\\nPrecautions\\nCorneal transplant is a very safe procedure that can\\nbe performed on almost any patient who would benefit\\nfrom it. Any active infection or inflammation of the eye\\nusually needs to be brought under control before surgery\\ncan be performed.\\nDescription\\nThe cornea is the transparent layer of tissue at the\\nvery front of the eye. It is composed almost entirely of a\\nspecial type of collagen. It normally contains no blood\\nvessels, but because it contains nerve endings, damage to\\nthe cornea can be very painful.\\nIn a corneal transplant, a disc of tissue is removed\\nfrom the center of the eye and replaced by a correspond-\\ning disc from a donor eye. The circular incision is made\\nusing an instrument called a trephine. In one form of\\ncorneal transplant (penetrating keratoplasty), the disc\\nremoved is the entire thickness of the cornea and so is the\\nreplacement disc. Over 90% of all corneal transplants in\\nthe United States are of this type. In lamellar keratoplas-\\nty, on the other hand, only the outer layer of the cornea is\\nremoved and replaced.\\nThe donor cornea is attached with extremely fine\\nsutures. Surgery can be performed under anesthesia that is\\nconfined to one area of the body while the patient is\\nawake (local anesthesia) or under anesthesia that places\\nthe entire body of the patient in a state of unconsciousness\\n(general anesthesia.) Surgery requires 30–90 minutes.\\nOver 40,000 corneal transplants are performed in the\\nUnited States each year. Medicare reimbursement for a\\ncorneal transplant in one eye was about $1,200 in 1997.\\nA less common but related procedure called epiker-\\natophakia involves suturing the donor cornea directly\\nGALE ENCYCLOPEDIA OF MEDICINE 2 919\\nCorneal transplantation\\nA corneal transplant in progress. (Photograph by Chet\\nSzymecki, Phototake NYC. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 919'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 308, 'page_label': '309'}, page_content='onto the surface of the existing host cornea. The only tis-\\nsue removed from the host is the extremely thin epithe-\\nlial cell layer on the outside of the host cornea. There is\\nno permanent damage to the host cornea, and this proce-\\ndure can be reversed. It is usually employed in children.\\nIn adults, the use of contact lenses can usually achieve\\nthe same goals.\\nPreparation\\nNo special preparation for corneal transplant is need-\\ned. Some eye surgeons may request the patient have a com-\\nplete physical examination before surgery. The patient\\nmay also be asked to skip breakfast on the day of surgery.\\nAftercare\\nCorneal transplant is often performed on an outpa-\\ntient basis, although some patients need brief hospitaliza-\\ntion after surgery. The patient will wear an eye patch at\\nleast overnight. An eye shield or glasses must be worn to\\nprotect the eye until the surgical wound has healed. Eye\\ndrops will be prescribed for the patient to use for several\\nweeks after surgery. These drops include antibiotics to\\nprevent infection as well as corticosteroids to reduce\\ninflammation and prevent graft rejection.\\nKEY TERMS\\nCadaver—The human body after death.\\nCataract—A condition of cloudiness of the lens of\\nthe eye.\\nCornea—The transparent layer of tissue at the very\\nfront of the eye.\\nCorticosteroids —Synthetic hormones widely used\\nto fight inflammation.\\nEpikeratophakia—A procedure in which the donor\\ncornea is attached directly onto the host cornea.\\nEpithelial cells—Cells that form a thin surface coat-\\ning on the outside of a body structure.\\nFibrous connective tissue —Dense tissue found in\\nvarious parts of the body containing very few living\\ncells.\\nFuchs’ dystrophy—A hereditary disease of the inner\\nlayer of the cornea. Treatment requires penetrating\\nkeratoplasty. The lens of the eye may also be affect-\\ned and require surgical replacement at the same\\ntime as the cornea.\\nGlaucoma—A vision defect caused when excessive\\nfluid pressure within the eye damages the optic\\nnerve.\\nHistocompatibility antigens —Proteins scattered\\nthroughout body tissues that are unique for almost\\nevery individual.\\nKeratoconus —An eye condition in which the\\ncornea bulges outward, interfering with normal\\nvision. Usually both eyes are affected.\\nPseudophakic bullous keratopathy —Painful\\nswelling of the cornea occasionally occurring after\\nsurgery to implant an artificial lens in place of a\\nlens affected by cataract.\\nRetinal detachment —A serious vision disorder in\\nwhich the light-detecting layer of cells inside the\\neye (retina) is separated from its normal support tis-\\nsue and no longer functions properly.\\nTrephine—A small surgical instrument that is rotat-\\ned to cut a circular incision.\\nFor the first few days after surgery, the eye may feel\\nscratchy and irritated. Vision will be somewhat blurry for\\nas long as several months.\\nSutures are often left in place for six months, and\\noccasionally for as long as two years.\\nRisks\\nCorneal transplants are highly successful, with over\\n90% of operations in United States achieving restoration\\nof sight. However, there is always some risk associated\\nwith any surgery. Complications that can occur include\\ninfection, glaucoma, retinal detachment , cataract for-\\nmation, and rejection of the donor cornea.\\nGraft rejection occurs in 5–30% of patients, a com-\\nplication possible with any procedure involving tissue\\ntransplantation from another person (allograft). Allograft\\nrejection results from a reaction of the patient’s immune\\nsystem to the donor tissue. Cell surface proteins called\\nhistocompatibility antigens trigger this reaction. These\\nantigens are often associated with vascular tissue (blood\\nvessels) within the graft tissue. Since the cornea normal-\\nly contains no blood vessels, it experiences a very low\\nrate of rejection. Generally, blood typing and tissue typ-\\ning are not needed in corneal transplants, and no close\\nmatch between donor and recipient is required. Symp-\\nGALE ENCYCLOPEDIA OF MEDICINE 2920\\nCorneal transplantation\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 920'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 309, 'page_label': '310'}, page_content='toms of rejection include persistent discomfort, sensitivi-\\nty to light, redness, or a change in vision.\\nIf a rejection reaction does occur, it can usually be\\nblocked by steroid treatment. Rejection reactions may\\nbecome noticeable within weeks after surgery, but may\\nnot occur until 10 or even 20 years after the transplant.\\nWhen full rejection does occur, the surgery will usually\\nneed to be repeated.\\nAlthough the cornea is not normally vascular, some\\ncorneal diseases cause vascularization (the growth of\\nblood vessels) into the cornea. In patients with these con-\\nditions, careful testing of both donor and recipient is per-\\nformed just as in transplantation of other organs and tis-\\nsues such as hearts, kidneys, and bone marrow. In such\\npatients, repeated surgery is sometimes necessary in\\norder to achieve a successful transplant.\\nCornea donors are carefully screened. Individuals\\nwith infectious diseases are not accepted as donors.\\nResources\\nBOOKS\\nBoruchoff, S. Arthur, and Richard A. Thoft. “Keratoplasty:\\nLamellar and Penetrating.” In The Cornea, ed. Gilbert\\nSmolin and Richard A. Thoft. Boston: Little, Brown and\\nCo., 1994.\\nBrightbill, Frederick S., ed. Corneal Surgery.St. Louis: Mosby,\\n1993.\\nBruner, William E., Walter J. Stark, and A. Edward Maumenee.\\nManual of Corneal Surgery.New York: Churchill Living-\\nstone, 1987.\\nGeneral Ophthalmology. 14th ed. Ed. Daniel Vaughan. Stam-\\nford: Appleton & Lange, 1995.\\nMiller, Stephen J. H. Parsons’ Diseases of the Eye.18th ed.\\nNew York: Churchill Livingstone, 1990.\\nPERIODICALS\\nWatson, B. C., and G. L. White Jr. “Corneal Transplantation.”\\nAmerican Family Physician 54 (Nov. 1996): 1945-1948.\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street, P.O.\\nBox 7424, San Francisco, CA 94120-7424. .\\nVictor Leipzig, PhD\\nCorneal ulcers\\nDefinition\\nThe cornea, the clear front part of the eye through\\nwhich light passes, is subject to many infections and to\\ninjury from exposure and from foreign objects. Infection\\nand injury cause inflammation of the cornea—a condi-\\ntion called keratitis . Tissue loss because of inflamma-\\ntion produces an ulcer. The ulcer can either be centrally\\nlocated, thus greatly affecting vision, or peripherally\\nlocated. There are about 30,000 cases of bacterial corneal\\nulcers in the United States each year.\\nDescription\\nThe most common cause of corneal ulcers is germs,\\nbut most of them cannot invade a healthy cornea with\\nadequate tears and a functioning eyelid. They gain access\\nbecause injury has impaired these defense mechanisms.\\nA direct injury from a foreign object inoculates germs\\ndirectly through the outer layer of the cornea, just as it\\ndoes to the skin. A caustic chemical can inflame the\\ncornea by itself or so damage it that germs can invade.\\nImproper use of contact lenses has become a common\\ncause of corneal injury. Eyelid or tear function failure is\\nthe other way to make the eye vulnerable to infection.\\nTears and the eyelid together wash the eye and prevent\\nforeign material from settling in. Tears contain enzymes\\nand other substances to help protect against infection.\\nCertain diseases dry up tear production, leaving the\\ncornea dry and defenseless. Other diseases paralyze or\\nweaken the eyelids so that they cannot effectively protect\\nand cleanse the eyes.\\nCauses and symptoms\\nViruses, bacteria, fungi, and a protozoan called\\nAcanthamoeba can all invade the cornea and damage it\\nunder suitable conditions.\\n• Bacteria from a common conjunctivitis (pink eye)\\nrarely spread to the cornea, but can if untreated.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 921\\nCorneal ulcers\\nA close-up view of an ulcer on cornea.(Custom Medical\\nStock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 921'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 310, 'page_label': '311'}, page_content='• Fecal bacteria are more likely to be able to infect the\\ncornea.\\n• A bacterium called Pseudomonas aeruginosa , which\\ncan contaminate eyedrops, is particularly able to cause\\ncorneal infection.\\n• A group of incomplete bacteria known as Chlamydia\\ncan be transmitted to the eye directly by flies or dirty\\nhands. One form of chlamydial infection is the leading\\ncause of blindness in developing countries and is known\\nas Egyptian ophthalmia or trachoma. Another type of\\nChlamydia causes a sexually transmitted disease.\\n• Other sexually transmitted diseases—for example,\\nsyphilis—can affect the cornea.\\nThe most common viruses to damage the cornea are\\nadenoviruses and herpes viruses. Viral and fungal infec-\\ntions are often caused by improper use of topical corti-\\ncosteroids. If topical corticosteroids are used in a patient\\nwith herpes simplex keratitis, the ulcer can get much\\nworse and blindness could result.\\nSymptoms are obvious. The cornea is intensely sen-\\nsitive, so corneal ulcers normally produce severe pain. If\\nthe corneal ulcer is centrally located, vision is impaired\\nor completely absent. Tearing is present and the eye is\\nred. It hurts to look at bright lights.\\nDiagnosis\\nThe doctor will take a case history to try to deter-\\nmine the cause of the ulcer. This can include improper\\nuse of contact lenses; injury, such as a scratch from a\\ntwig; or severe dry eye. An instrument called a slit lamp\\nwill be used to examine the cornea. The slit lamp is a\\nmicroscope with a light source that magnifies the cornea,\\nallowing the extent of the ulcer to be seen. Fluorescein, a\\nyellow dye, may be used to illuminate further detail. If a\\ngerm is responsible for the ulcer, identification may\\nrequire scraping samples directly from the cornea, con-\\njunctiva, and lids, and sending them to the laboratory.\\nKEY TERMS\\nFluorescein —A fluorescent chemical used to\\nexamine the cornea.\\nGerm—A disease-causing microorganism.\\nInflammation—The body’s reaction to irritation.\\nTopical corticosteroids —Cortisone and related\\ndrugs used on the skin and in the eye, usually for\\nallergic conditions.\\nTreatment\\nA corneal ulcer needs to be treated aggressively, as it\\ncan result in loss of vision. The first step is to eliminate\\ninfection. Broad spectrum antibiotics will be used\\nbefore the lab results come back. Medications may then\\nbe changed to more specifically target the cause of the\\ninfection. A combination of medications may be neces-\\nsary. Patients should return for their follow-up visits so\\nthat the doctor can monitor the healing process. The\\ncornea can heal from many insults, but if it remains\\nscarred, corneal transplantation may be necessary to\\nrestore vision. If the corneal ulcer is large, hospitaliza-\\ntion may be necessary.\\nPrognosis\\nTreated early enough, corneal infections will usually\\nresolve, perhaps even without the formation of an ulcer.\\nHowever, left untreated, infections can lead to ulcers and\\nthe corneal ulcer can result in scarring or perforation of\\nthe cornea. Other problems may occur as well, including\\nglaucoma . Patients with certain systemic diseases that\\nimpede healing (such as diabetes mellitus or rheuma-\\ntoid arthritis) may need more aggressive treatment. The\\nlater the treatment, the more damage will be done and the\\nmore scarring will result. Corneal transplant is standard\\ntreatment with a high probability of success.\\nPrevention\\nAttentive care of contact lenses will greatly reduce\\nthe incidence of corneal damage and ulceration. Germs\\nthat cause no problems in the mouth or on the hands can\\ndamage the eye, so contact lens wearers must wash their\\nhands before touching their lenses and must not use sali-\\nva to moisten them. Tap water should not be used to rinse\\nthe lenses. Contacts should be removed whenever there\\nis irritation and left out until the eyes are back to normal.\\nIt is not advisable to wear contact lenses while swim-\\nming or in hot tubs. Daily wear contact lenses have been\\nfound to be less of a risk than contacts for overnight wear\\n(extended wear). Organisms have been cultured from\\ncontact lens cases, so the cases should be rinsed in hot\\nwater and allowed to air dry. Cases should be replaced\\nevery three months. Patients should follow their doctors’\\nschedules for replacement of the contacts.\\nEye protection in the workplace, or wherever tiny\\nparticles are flying around, is essential. Ultraviolet (UV)\\ncoatings on glasses or sunglasses can help protect the\\neyes from the sun’s rays. Goggles with UV protection\\nshould be worn when skiing or in suntanning salons to\\nprotect against UV rays. Prompt attention to any red eye\\nshould prevent progressive damage.\\nGALE ENCYCLOPEDIA OF MEDICINE 2922\\nCorneal ulcers\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 922'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 311, 'page_label': '312'}, page_content='For people with inadequate tears, use of artificial\\ntears eyedrops will prevent damage from drying. Eyelids\\nthat do not close adequately may temporarily have to be\\nsewn shut to protect the eye until more lasting treatment\\ncan be instituted.\\nResources\\nBOOKS\\nNewell, Frank W. “Ulcerative Keratitis.” In Ophthalmology:\\nPrinciples and Concepts. 8th ed. St. Louis: Mosby, 1996.\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street, P.O.\\nBox 7424, San Francisco, CA 94120-7424. .\\nAmerican Optometric Association. 243 North Lindbergh Blvd.,\\nSt. Louis, MO 63141. (314) 991-4100. .\\nPrevent Blindness America. 500 East Remington Road,\\nSchaumburg, IL 60173. (800) 331-2020. .\\nJ. Ricker Polsdorfer, MD\\nCorns and calluses\\nDefinition\\nA corn is a small, painful, raised bump on the outer\\nskin layer. A callus is a rough, thickened patch of skin.\\nDescription\\nCorns and calluses are one of the three major foot\\nproblems in the United States. The other two are foot\\ninfections and toenail problems. Corns and calluses\\naffect about 5% of the population.\\nCorns usually appear on non-weight-bearing areas\\nlike the outside of the little toe or the tops of other toes.\\nWomen have corns more often than men, probably\\nbecause women wear high-heeled shoes and other shoes\\nthat do not fit properly. Corns have hard cores shaped\\nlike inverted pyramids. Sharp pain occurs whenever\\ndownward pressure is applied, and a dull ache may be\\nfelt at other times.\\nCalluses occur most often on the heels and balls of\\nthe feet, the knees, and the palms of the hands. However,\\nthey can develop on any part of the body that is subject to\\nrepeated pressure or irritation. Calluses are usually more\\nthan an inch wide—larger than corns. They generally\\ndon’t hurt unless pressure is applied.\\nTypes of corns\\nA hard corn is a compact lump with a thick core.\\nHard corns usually form on the tops of the toes, on the\\noutside of the little toe, or on the sole of the foot.\\nA soft corn is a small, inflamed patch of skin with a\\nsmooth center. Soft corns usually appear between the toes.\\nA seed corn is the least common type of corn.\\nOccurring only on the heel or ball of the foot, a seed corn\\nconsists of a circle of stiff skin surrounding a plug of\\ncholesterol.\\nTypes of calluses\\nA plantar callus, a callus that occurs on the sole of\\nthe foot, has a white center. Hereditary calluses develop\\nwhere there is no apparent friction, run in families, and\\noccur most often in children.\\nCauses and symptoms\\nCorns and calluses form to prevent injury to skin\\nthat is repeatedly pinched, rubbed, or irritated. The most\\ncommon causes are:\\n• shoes that are too tight or too loose, or have very high\\nheels\\n• tight socks or stockings\\n• deformed toes\\nGALE ENCYCLOPEDIA OF MEDICINE 2 923\\nCorns and calluses\\nCorns on toes. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 923'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 312, 'page_label': '313'}, page_content='• walking down a long hill, or standing or walking on a\\nhard surface for a long time\\nJobs or hobbies that cause steady or recurring pres-\\nsure on the same spot can also cause calluses.\\nSymptoms include hard growths on the skin in\\nresponse to direct pressure. Corns may be extremely sore\\nand surrounded by inflamed, swollen skin.\\nDiagnosis\\nCorns can be recognized on sight. A family physi-\\ncian or podiatrist may scrape skin off what seems to be a\\ncallus, but may actually be a wart. If the lesion is a wart,\\nit will bleed. A callus will not bleed, but will reveal\\nanother layer of dead skin.\\nTreatment\\nCorns and calluses do not usually require medical\\nattention unless the person who has them has diabetes\\nmellitus , poor circulation, or other problems that make\\nself-care difficult.\\nTreatment should begin as soon as an abnormality\\nappears. The first step is to identify and eliminate the\\nsource of pressure. Placing moleskin pads over corns can\\nrelieve pressure, and large wads of cotton, lamb’s wool,\\nor moleskin can cushion calluses.\\nUsing hydrocortisone creams or soaking feet in a\\nsolution of Epsom salts and very warm water for at least\\nfive minutes a day before rubbing the area with a pumice\\nstone will remove part or all of some calluses. Rubbing\\ncorns just makes them hurt more.\\nApplying petroleum jelly or lanolin-enriched hand\\nlotion helps keep skin soft, but corn-removing ointments\\nthat contain acid can damage healthy skin. They should\\nnever be used by pregnant women or by people who are\\ndiabetic or who have poor circulation.\\nKEY TERMS\\nAyurveda—Ayurveda is a system of wholistic\\nmedicine from India that aims to bring the individ-\\nual into harmony with nature. It provides guid-\\nance regarding food and lifestyle, so that healthy\\npeople can stay healthy and people with health\\nchallenges can improve their health.\\nBursitis —Inflammation of a bursa, a fluid-filled\\ncavity or sac. In the body, bursae are located at\\nplaces where friction might otherwise develop.\\nIt is important to see a doctor if the skin of a corn or\\ncallus is cut, because it may become infected. If a corn\\ndischarges pus or clear fluid, it is infected. A family\\nphysician, podiatrist, or orthopedist may:\\n• remove (debride) affected layers of skin\\n• prescribe oral antibiotics to eliminate infection\\n• drain pus from infected corns\\n• inject cortisone into the affected area to decrease pain\\nor inflammation\\n• perform surgery to correct toe deformities or remove\\nbits of bone\\nAlternative treatment\\nStanding and walking correctly can sometimes elim-\\ninate excess foot pressure. Several types of bodywork\\ncan help correct body imbalances. Bodywork is a term\\nused for any of a number of systems, including Aston-\\nPatterning , the Feldenkrais method , and rolfing, that\\nmanipulate the body through massage, movement educa-\\ntion, or meditational techniques.\\nAloe (Aloe barbadensis ) cream is an effective skin\\nsoftener, and two or three daily applications of calendu-\\nla (Calendula officinalis ) salve can soften skin and pre-\\nvent inflammation. One teaspoon of lemon juice mixed\\nwith one teaspoon of dried chamomile ( Martricaria\\nrecutita ) tea and one crushed garlic clove dissolves\\nthickened skin.\\nAn ayurvedic practitioner may recommend the fol-\\nlowing treatment:\\n• apply each day a paste made by combining one tea-\\nspoon of aloe vera gel with half that amount of turmeric\\n(Circuma longa)\\n• bandage overnight\\n• soak in warm water for 10 minutes every morning\\n• massage gently with mustard (Brassica cruciferae) oil\\nPrognosis\\nMost corns and calluses disappear about three weeks\\nafter the pressure that caused them is eliminated. They\\nare apt to recur if the pressure returns.\\nExtreme pain can change the way a person stands or\\nwalks. Such changes can, in turn, cause pain in the ankle,\\nback, hip, or knee.\\nBursitis , a painful, inflamed fluid-filled sac, can\\ndevelop beneath a corn. An ulcer or broken area within a\\ncorn can reach to the bone. Infection can have serious\\nconsequences for people who have diabetes or poor cir-\\nculation.\\nGALE ENCYCLOPEDIA OF MEDICINE 2924\\nCorns and calluses\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 924'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 313, 'page_label': '314'}, page_content='Prevention\\nCorns and calluses can usually be prevented by avoid-\\ning friction-causing activities and wearing shoes that fit\\nproperly, are activity-appropriate, and are kept in good\\nrepair. Soles and heels that wear unevenly may indicate a\\nneed for corrective footwear or special insoles. Socks and\\nstockings should not cramp the toes. Gloves, kneepads,\\nand other protective gear should also be worn as needed.\\nFeet should be measured, while standing, whenever\\nbuying new shoes. It is best to shop for shoes late in the\\nday, when feet are likely to be swollen. It is also impor-\\ntant to buy shoes with toe-wiggling room and to try new\\nshoes on both feet.\\nResources\\nBOOKS\\nThe Editors of Time-Life Books. The Medical Advisor: The\\nComplete Guide to Alternative and Conventional Treat-\\nments. Alexandria, V A: Time Life, Inc., 1996.\\nNew Choices in Natural Healing. Ed. Bill Gottlieb, et al.\\nEmmaus, PA: Rodale Press, 1995.\\nORGANIZATIONS\\nAmerican Podiatric Medical Association. 9312 Old George-\\ntown Road, Bethesda, MD 20814-1698. (301) 571-9200.\\n.\\nOTHER\\n“Corn or Callus.”ThriveOnline. 20 Apr. 1998 .\\n“Corns/Calluses.” YourHealth.com. 20 Apr. 1998 .\\n“Foot Disorders.”Foot Talk Home Page..\\n“Foot Facts.”American Podiatric Medical Association.20 Apr.\\n1998 .\\nMaureen Haggerty\\nCoronary artery bypass graft\\nsurgery\\nDefinition\\nCoronary artery bypass graft surgery is a surgical\\nprocedure in which one or more blocked coronary arter-\\nies are bypassed by a blood vessel graft to restore normal\\nblood flow to the heart. These grafts usually come from\\nthe patient’s own arteries and veins located in the leg,\\narm, or chest.\\nPurpose\\nCoronary artery bypass graft surgery (also called\\ncoronary artery bypass surgery, CABG, and bypass oper-\\nation) is performed to restore blood flow to the heart.\\nThis relieves chest pain and ischemia , improves the\\npatient’s quality of life, and in some cases, prolongs the\\npatient’s life. The goals of the procedure are to enable the\\npatient to resume a normal lifestyle and to lower the risk\\nof a heart attack.\\nThe decision to perform coronary artery bypass graft\\nsurgery is a complex one, and there is some disagreement\\namong experts as to when it is indicated. Many experts\\nfeel that it has been performed too frequently in the Unit-\\ned States. According to the American Heart Association,\\nappropriate candidates for coronary artery bypass graft\\nsurgery include patients with blockages in at least three\\nmajor coronary arteries, especially if the blockages are in\\narteries that feed the heart’s left ventricle; patients with\\nangina so severe that even mild exertion causes chest\\npain; and patients who cannot tolerate percutaneous trans-\\nluminal coronary angioplasty and do not respond well to\\ndrug therapy. It is well accepted that coronary artery\\nbypass graft surgery is the treatment of choice for patients\\nwith severe coronary artery disease (three or more dis-\\neased arteries with impaired function in the left ventricle).\\nPrecautions\\nCoronary artery bypass graft surgery should ideally\\nbe postponed for three months after a heart attack. Patients\\nshould be medically stable before the surgery, if possible.\\nDescription\\nCoronary artery bypass graft surgery builds a detour\\naround one or more blocked coronary arteries with a\\ngraft from a healthy vein or artery. The graft goes around\\nthe clogged artery (or arteries) to create new pathways\\nfor oxygen-rich blood to flow to the heart.\\nCoronary artery bypass graft surgery is major surgery\\nperformed in a hospital. The length of the procedure\\ndepends upon the number of arteries being bypassed, but it\\ngenerally takes from four to six hours—sometimes longer.\\nThe average hospital stay is four to seven days. Full recov-\\nery from coronary artery bypass graft surgery takes three to\\nfour months. Within four to six weeks, people with seden-\\ntary office jobs can return to work; people with physical\\njobs must wait longer and sometimes change careers.\\nCoronary artery bypass graft surgery is widely per-\\nformed in the United States. The American Heart Associ-\\nation estimates that 573,000 coronary artery bypass graft\\nsurgeries were performed on 363,000 patients in 1995.\\nSeventy-four percent of these procedures were per-\\nformed on men and 44% on men and women under the\\nage of 65 (1995 data). The estimated average cost of this\\nprocedure in 1995 was $44,820.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 925\\nCoronary artery bypass graft surgery\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 925'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 314, 'page_label': '315'}, page_content='Procedure\\nThe surgery team for coronary artery bypass graft\\nsurgery includes the cardiovascular surgeon, assisting sur-\\ngeons, a cardiovascular anesthesiologist, a perfusion tech-\\nnologist (who operates the heart-lung machine), and spe-\\ncially trained nurses. After general anesthesia is adminis-\\ntered, the surgeon removes the veins or prepares the arter-\\nies for grafting. If the saphenous vein is to be used, a series\\nof incisions are made in the patient’s thigh or calf. More\\ncommonly, a segment of the internal mammary artery will\\nbe used and the incisions are made in the chest wall. The\\nsurgeon then makes an incision from the patient’s neck to\\nnavel, saws through the breastbone, and retracts the rib\\ncage open to expose the heart. The patient is connected to\\na heart-lung machine, also called a cardiopulmonary\\nbypass pump, that cools the body to reduce the need for\\noxygen and takes over for the heart and lungs during the\\nprocedure. The heart is then stopped and a cold solution of\\npotassium-enriched normal saline is injected into the aor-\\ntic root and the coronary arteries to lower the temperature\\nof the heart, which prevents damage to the tissue.\\nNext, a small opening is made just below the block-\\nage in the diseased coronary artery. Blood will be redirect-\\ned through this opening once the graft is sewn in place. If a\\nleg vein is used, one end is connected to the coronary\\nartery and the other to the aorta. If a mammary artery is\\nused, one end is connected to the coronary artery while the\\nother remains attached to the aorta. The procedure is\\nrepeated on as many coronary arteries as necessary. Most\\npatients who have coronary artery bypass graft surgery\\nhave at least three grafts done during the procedure.\\nElectric shocks start the heart pumping again after\\nthe grafts have been completed. The heart-lung machine\\nis turned off and the blood slowly returns to normal body\\ntemperature. After implanting pacing electrodes (if need-\\ned) and inserting a chest tube, the surgeon closes the\\nchest cavity.\\nSuccess rate of coronary artery bypass graft surgery\\nAbout 90% of patients experience significant improve-\\nments after coronary artery bypass graft surgery. Patients\\nexperience full relief from chest pain and resume their nor-\\nmal activities in about 70% of the cases; the remaining\\n20% experience partial relief. In 5–10% of coronary artery\\nbypass graft surgeries, the bypass graft stops supplying\\nblood to the bypassed artery within one year. Younger peo-\\nGALE ENCYCLOPEDIA OF MEDICINE 2926\\nCoronary artery bypass graft surgery\\nMammary artery\\n(from chest)\\nSaphenous vein\\nBlocked\\ncoronary\\nBlocked\\ncoronary\\nAorta\\nCoronary bypass using\\nthe saphenous vein\\nCoronary bypass using\\nthe mammary artery\\nAorta\\nCoronary artery bypass graft surgery builds a detour around one or more blocked coronary arteries with a graft from a\\nhealthy vein or artery.The graft goes around the clogged artery (or arteries) to create new pathways for oxygen-rich blood to\\nflow to the heart. (Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 926'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 315, 'page_label': '316'}, page_content='ple who are healthy except for the heart disease do well\\nwith bypass surgery. Patients who have poorer results from\\ncoronary artery bypass graft surgery include those over the\\nage of 70, those who have poor left ventricular function, or\\nare undergoing a repeat surgery or other procedures con-\\ncurrently, and those who continue smoking, do not treat\\nhigh cholesterol or other coronary risk factors, or have\\nanother debilitating disease.\\nLong term, symptoms recur in only about 3–4% of\\npatients per year. Five years after coronary artery bypass\\ngraft surgery, survival expectancy is 90%, at 10 years it is\\nabout 80%, at 15 years it is about 55%, and at 20 years it\\nis about 40%.\\nAngina recurs in about 40% of patients after about\\n10 years. In most cases, it is less severe than before the\\nsurgery and can be controlled by drug therapy. In patients\\nwho have had vein grafts, 40% of the grafts are severely\\nobstructed 10 years after the procedure. Repeat coronary\\nartery bypass graft surgery may be necessary, and is usu-\\nally less successful than the first surgery.\\nMinimally invasive coronary artery bypass graft\\nsurgery\\nThere are two new types of minimally invasive coro-\\nnary artery bypass graft surgery: port-access coronary\\nartery bypass (also called PACAB or PortCAB) and min-\\nimally invasive coronary artery bypass (also called MID-\\nCAB). These procedures are minimally invasive because\\nthey do not require the neck-to-navel incision, sawing\\nthrough the breastbone, or opening the rib cage to expose\\nthe heart. Both procedures enable surgeons to work on\\nthe coronary arteries through small chest holes called\\nports and other small incisions. Port-access coronary\\nartery bypass requires the use of a heart-lung machine\\nbut minimally invasive coronary artery bypass does not.\\nAdvantages of these procedures over standard coronary\\nartery bypass graft surgery include a shorter hospital\\nstay, a shorter recovery period, and lower costs.\\nPort-access coronary artery bypass enables surgeons\\nto perform bypasses through smaller incisions. Using a\\nvideo monitor to view the procedure, the surgeon passes\\ninstruments through ports in the patient’s chest to per-\\nform the bypass. Mammary arteries or leg veins are used\\nfor the grafts. Minimally invasive coronary artery bypass\\nis performed on a beating heart and is appropriate only\\nfor bypasses of one or two arteries. Small ports are made\\nin the patient’s chest, along with a small incision directly\\nover the coronary artery to be bypassed. Generally, the\\nsurgeon uses a mammary artery for the bypass.\\nEarly data on outcomes for port-access coronary artery\\nbypass and minimally invasive coronary artery bypass are\\nfavorable. Mortality rates with port-access coronary artery\\nbypass and minimally invasive coronary artery bypass are\\nboth less than 3%—about the same as in standard coronary\\nartery bypass graft surgery. One clinical trial indicated that\\nsurvival at seven years was the same in minimally invasive\\ncoronary artery bypass and standard coronary artery bypass\\ngraft surgery, but that another intervention was necessary\\nfive times more often with minimally invasive coronary\\nartery bypass than with standard coronary artery bypass\\ngraft surgery. The American Heart Association Council on\\nCardio-Thoracic and Vascular Surgery feels that both pro-\\ncedures appear promising but that further study is needed.\\nMore data covering longer term outcomes are necessary in\\norder to fully assess these procedures.\\nPreparation\\nThe patient is usually admitted to the hospital the\\nday before the coronary artery bypass graft surgery is\\nscheduled. Coronary angiography has been previously\\nperformed to show the surgeon where the arteries are\\nblocked and where the grafts might best be positioned.\\nThe patient is given a blood-thinning drug—usually\\nheparin—that helps to prevent blood clots. The evening\\nbefore the surgery, the patient showers with antiseptic\\nsoap and is shaved from chin to toes. After midnight,\\nfood and fluids are restricted. A sedative is prescribed on\\nthe morning of surgery and sometimes the night before.\\nHeart monitoring begins.\\nAftercare\\nThe patient recovers in a surgical intensive care unit\\nfor at least the first two days after the surgery. He or she is\\nconnected to chest and breathing tubes, a mechanical venti-\\nlator, a heart monitor and other monitoring equipment, and\\na urinary catheter. The breathing tube and ventilator are\\nusually removed within six hours of surgery, but the other\\ntubes remain in place as long as the patient is in the inten-\\nsive care unit. Drugs are prescribed to control pain and to\\nprevent unwanted blood clotting. The patient is closely\\nmonitored. Vital signs and other parameters, such as heart\\nsounds and oxygen and carbon dioxide levels in arterial\\nblood, are checked frequently. The chest tube is checked to\\nensure that it is draining properly. The patient is fed intra-\\nvenously for the first day or two. Daily doses of aspirinare\\nstarted within six to 24 hours after the procedure. Chest\\nphysiotherapy is started after the ventilator and breathing\\ntube are removed. The therapy includes coughing, turning\\nfrequently, and taking deep breaths. Other exercises will be\\nencouraged to improve the patient’s circulation and prevent\\ncomplications due to prolonged bed rest.\\nIf there are no complications, the patient begins to\\nresume a normal routine around the second day. This\\nincludes eating regular food, sitting up, and walking\\nGALE ENCYCLOPEDIA OF MEDICINE 2 927\\nCoronary artery bypass graft surgery\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 927'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 316, 'page_label': '317'}, page_content='around a little bit. Before being released from the hospi-\\ntal, the patient usually spends a few days under observa-\\ntion in a non-surgical unit. During this time, counseling is\\nusually provided on eating right and starting a light exer-\\ncise program to keep the heart healthy. Patients should eat\\na lot of fruits, vegetables, grains, and non-fat or low-fat\\ndairy products, and reduce fats to less than 30% of all\\ncalories. An exercise program will usually be tailored for\\nthe patient, who will be encouraged to participate in a\\ncardiac rehabilitation program where exercise will be\\nsupervised by professionals. Cardiac rehabilitation pro-\\ngrams, offered by hospitals and other organizations, may\\nalso include classes on heart-healthy living.\\nFull recovery from coronary artery bypass graft\\nsurgery takes three to four months and is a gradual\\nprocess. Upon release from the hospital, the patient will\\nfeel weak because of the extended bed rest in the hospi-\\ntal. Within a few weeks, the patient should begin to feel\\nstronger.\\nWhile the incision scar from coronary artery bypass\\ngraft surgery heals, which takes one to two months, it\\nmay be sore. The scar should not be bumped, scratched,\\nor otherwise disturbed. An exercise test is often conduct-\\ned after the patient leaves the hospital to determine how\\neffective the surgery was and to confirm that progressive\\nexercise is safe.\\nRisks\\nCoronary artery bypass graft surgery is major surgery\\nand patients may experience any of the complications\\nassociated with major surgery. The risk of death during\\nKEY TERMS\\nAorta—The main artery which carries blood from\\nthe heart to the rest of the body The aorta is the\\nlargest artery in the body.\\nGraft—To implant living tissue surgically. In coro-\\nnary artery bypass graft surgery, healthy veins or\\narteries are grafted to coronary arteries.\\nMammary artery —A chest wall artery that\\ndescends from the aorta and is commonly used for\\nbypass grafts.\\nSaphenous vein —A long vein in the thigh or calf\\ncommonly used for bypass grafts.\\nVentricles —The left and right ventricles are the\\nlarge chambers of the heart. The ventricles propel\\nblood to the lungs and the rest of the body.\\ncoronary artery bypass graft surgery is two to three per-\\ncent. Possible complications include graft closure and\\ndevelopment of blockages in other arteries, long-term\\ndevelopment of atherosclerotic disease of saphenous vein\\ngrafts, abnormal heart rhythms, high or low blood pres-\\nsure, blood clots that can lead to a stroke or heart attack,\\ninfections, and depression. There is a higher risk for com-\\nplications in patients who are heavy smokers, patients\\nwho have serious lung, kidney, or metabolic problems, or\\npatients who have a reduced supply of blood to the brain.\\nResources\\nBOOKS\\nAmerican Heart Association. “Considering Surgery or Other\\nInterventions.” In Guide to Heart Attack Treatment,\\nRecovery, Prevention.New York: Time Books, 1996.\\nDeBakey, Michael E., and Antonio M. Gotto Jr. “Surgical Treat-\\nment of Coronary Artery Disease.” In The New Living\\nHeart. Holbrook, MA: Adams Media Corporation, 1997.\\nTexas Heart Institute. “Heart Surgery.” In Texas Heart Institute\\nHeart Owners Handbook. New York: John Wiley & Sons,\\n1996.\\nPERIODICALS\\nBauman, Alisa. “Too Many Bypasses?”Men’s Health78 (Mar.\\n1998): 80-81.\\nFaxon, David P. “Myocardial Revascularization in 1997:\\nAngioplasty Versus Bypass Surgery.”American Family\\nPhysician (1 Oct. 1997): 1409-1417.\\nHicks Jr., George L. “Cardiac Surgery.”Journal of the Ameri-\\ncan College of Surgeons186, no. 2 (Feb. 1998): 129-132.\\nSmith, Laquita Bowen. “Not-So-Open Heart Surgery: New\\nEquipment Allows for a Three-Inch Incision.”Memphis\\nBusiness Journal 18, no. 53 (12 May 1997): 49.\\nSolomon, Allen J., and Bernard J. Gersh. “Management of\\nChronic Stable Angina: Medical Therapy, Percutaneous\\nTransluminal Coronary Angioplasty, and Coronary Artery\\nBypass Graft Surgery.”Annals of Internal Medicine 128\\n(1 Feb. 1998): 216-223.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nTexas Heart Institute. Heart Information Service. P.O. Box 20345,\\nHouston, TX 77225-0345. .\\nLori De Milto\\nCoronary artery disease\\nDefinition\\nCoronary artery disease is a narrowing or blockage\\nof the arteries and vessels that provide oxygen and nutri-\\nGALE ENCYCLOPEDIA OF MEDICINE 2928\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 928'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 317, 'page_label': '318'}, page_content='ents to the heart. It is caused by atherosclerosis, an accu-\\nmulation of fatty materials on the inner linings of arter-\\nies. The resulting blockage restricts blood flow to the\\nheart. When the blood flow is completely cut off, the\\nresult is a heart attack.\\nDescription\\nCoronary artery disease, also called coronary heart\\ndisease or heart disease, is the leading cause of death for\\nboth men and women in the United States. According to\\nthe American Heart Association, in 1995 one in every 4.8\\ndeaths in the United States was caused by coronary artery\\ndisease. About every 29 seconds, one American will have\\na heart attack; about every minute, one American will die\\nfrom a heart attack. Fourteen million Americans have\\nactive symptoms of coronary artery disease (heart attack\\nor chest pains). Many millions more have silent coronary\\ndisease, the first indication of which can be sudden death.\\nCoronary artery disease occurs when the coronary\\narteries become partially blocked or clogged. This block-\\nage limits the flow of blood from the coronary arteries,\\nwhich are the major arteries supplying oxygen-rich blood\\nto the heart. The coronary arteries expand when the heart\\nis working harder and needs more oxygen. Arteries\\nwould expand, for example, when a person is climbing\\nstairs, exercising, or having sex. If the arteries are unable\\nto expand, the heart is deprived of oxygen (myocardial\\nischemia ). When the blockage is limited, chest pain or\\npressure, called angina, may occur. When the blockage\\ncuts off the flow of blood, the result is heart attack\\n(myocardial infarction or heart muscle death).\\nHealthy coronary arteries are clean, smooth, and\\nslick. The artery walls are flexible and can expand to let\\nmore blood through when the heart needs to work harder.\\nThe disease process in arteries is thought to begin with\\nan injury to the linings and walls of the arteries. This\\ninjury makes them susceptible to atherosclerosis and\\nblood clots (thrombosis).\\nCauses and symptoms\\nCoronary artery disease is usually caused by athero-\\nsclerosis. Cholesterol and other fatty substances accumu-\\nlate on the inner wall of the arteries. They attract fibrous\\ntissue, blood components, and calcium and harden into\\nartery-clogging plaques. Atherosclerotic plaques often\\nform blood clots that can also block the coronary arteries\\n(coronary thrombosis). Congenital defects and muscle\\nspasms can also block blood flow. Recent research indi-\\ncates that infection from organisms such as chlamydia\\nbacteria may be responsible for some cases of coronary\\nartery disease.\\nA number of major contributing factors increase the\\nrisk of developing coronary artery disease. Some of these\\ncan be changed and some cannot. People with more risk\\nfactors are more likely to develop coronary artery disease.\\nMajor risk factors\\nMajor risk factors significantly increase the chance\\nof developing coronary artery disease. Those that cannot\\nbe changed are:\\n• Heredity—People whose parents have coronary artery\\ndisease are more likely to develop it. African-Ameri-\\ncans are also at increased risk because they experience\\na higher rate of severe hypertension than whites do.\\n• Sex—Men are more likely to have heart attacks than\\nwomen are and to have them at a younger age. Over age\\n60, however, women have coronary artery disease at a\\nrate equal to that of men.\\n• Age—Men who are 45 years of age and older and\\nwomen who are 55 years of age and older are more\\nlikely to have coronary artery disease. Occasionally,\\ncoronary disease may strike a person in the 30s. Older\\npeople (those over 65) are more likely to die of a heart\\nattack. Older women are twice as likely as older men to\\ndie within a few weeks of a heart attack.\\nMajor risk factors that can be changed are:\\n• Smoking—Smoking increases both the chance of\\ndeveloping coronary artery disease and the chance of\\ndying from it. Smokers are two to four times more like-\\nly than are non-smokers to die of sudden heart attack.\\nThey are more than twice as likely as non-smokers to\\nhave a heart attack. They are also more likely to die\\nwithin an hour of a heart attack. Second hand smoke\\nmay also increase risk.\\n• High cholesterol—Dietary sources of cholesterol are\\nmeat, eggs, and other animal products. The body also\\nproduces it. Age, sex, heredity, and diet affect one’s\\nblood cholesterol. Total blood cholesterol is considered\\nhigh at levels above 240 mg/dL and borderline at 200-\\n239 mg/dL. High-risk levels of low-density lipoprotein\\n(LDL cholesterol) begin at 130–159 mg/dL, depending\\non other risk factors. Risk of developing coronary\\nartery disease increases steadily as blood cholesterol\\nlevels increase above 160 mg/dL. When a person has\\nother risk factors, the risk multiplies.\\n• High blood pressure—High blood pressure makes the\\nheart work harder and weakens it over time. It increases\\nthe risk of heart attack, stroke, kidney failure, and con-\\ngestive heart failure. A blood pressure of 140 over 90\\nor above is considered high. As the numbers rise, high\\nblood pressure goes from Stage 1 (mild) to Stage 4\\n(very severe). In combination with obesity, smoking,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 929\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 929'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 318, 'page_label': '319'}, page_content='high cholesterol, or diabetes, high blood pressure rais-\\nes the risk of heart attack or stroke several times.\\n• Lack of physical activity—Lack of exercise increases\\nthe risk of coronary artery disease. Even modest physi-\\ncal activity, like walking, is beneficial if done regularly.\\n• Diabetes mellitus—The risk of developing coronary\\nartery disease is seriously increased for diabetics. More\\nthan 80% of diabetics die of some type of heart or\\nblood vessel disease.\\nContributing risk factors\\nContributing risk factors have been linked to coro-\\nnary artery disease, but their significance is not known\\nyet. Contributing risk factors are:\\n• Obesity—Excess weight increases the strain on the\\nheart and increases the risk of developing coronary\\nartery disease even if no other risk factors are present.\\nObesity increases blood pressure and blood cholesterol\\nand can lead to diabetes.\\n• Stress and anger—Some scientists believe that stress\\nand anger can contribute to the development of coro-\\nnary artery disease and increase the blood’s tendency to\\nform clots (thrombosis). Stress, the mental and physical\\nreaction to life’s irritations and challenges, increases\\nthe heart rate and blood pressure and can injure the lin-\\ning of the arteries. Evidence shows that anger increases\\nthe risk of dying from heart disease. The risk of heart\\nattack is more than double after an episode of anger.\\nChest pain (angina) is the main symptom of coro-\\nnary heart disease but it is not always present. Other\\nsymptoms include shortness of breath, chest heaviness,\\ntightness, pain, a burning sensation, squeezing, or pres-\\nsure either behind the breastbone or in the arms, neck, or\\njaws. Many people have no symptoms of coronary artery\\ndisease before having a heart attack; 63% of women and\\n48% of men who died suddenly of coronary artery dis-\\nease had no previous symptoms of the disease, according\\nto the American Heart Association.\\nDiagnosis\\nDiagnosis begins with a visit to the physician, who\\nwill take a medical history, discuss symptoms, listen to\\nthe heart, and perform basic screening tests. These tests\\nwill measure weight, blood pressure, blood lipid levels,\\nand fasting blood glucose levels. Other diagnostic tests\\ninclude resting and exercise electrocardiogram, echocar-\\ndiography, radionuclide scans, and coronary angiogra-\\nphy. The treadmill exercise (stress) test is an appropriate\\nscreening test for those with high risk factors even when\\nthey feel well.\\nAn electrocardiogram (ECG) shows the heart’s\\nactivity and may reveal a lack of oxygen (ischemia).\\nElectrodes covered with conducting jelly are placed on\\nthe patient’s chest, arms, and legs. They send impulses of\\nthe heart’s activity through an oscilloscope (a monitor) to\\na recorder that traces them on paper. The test takes about\\n10 minutes and is performed in a physician’s office. A\\ndefinite diagnosis cannot be made from electrocardiog-\\nraphy. About 50% of patients with significant coronary\\nartery disease have normal resting electrocardiograms.\\nAnother type of electrocardiogram, known as the exer-\\ncise stress test , measures how the heart and blood ves-\\nsels respond to exertion when the patient is exercising on\\na treadmill or a stationary bike. This test is performed in\\na physician’s office or an exercise laboratory. It takes\\n15–30 minutes. It is not perfectly accurate. It sometimes\\ngives a normal reading when the patient has a heart prob-\\nlem or an abnormal reading when the patient does not.\\nIf the electrocardiogram reveals a problem or is\\ninconclusive, the next step is exercise echocardiography\\nor nuclear scanning (angiography). Echocardiography,\\ncardiac ultrasound, uses sound waves to create an image\\nof the heart’s chambers and valves. A technician applies\\ngel to a hand-held transducer, then presses it against the\\npatient’s chest. The heart’s sound waves are converted\\ninto an image that can be displayed on a monitor. It does\\nnot reveal the coronary arteries themselves, but can\\ndetect abnormalities in heart wall motion caused by coro-\\nnary disease. Performed in a cardiology outpatient diag-\\nnostic laboratory, the test takes 30–60 minutes.\\nRadionuclide angiography enables physicians to see\\nthe blood flow of the coronary arteries. Nuclear scans are\\nperformed by injecting a small amount of radiopharma-\\nceutical such as thallium into the bloodstream. A device\\nthat uses gamma rays to produce an image of the radioac-\\ntive material (gamma camera) records pictures of the\\nheart. Radionuclide scans are not dangerous. The radia-\\ntion exposure is about the same as that in a chest x ray.\\nThe tiny amount of radioactive material used disappears\\nfrom the body in a few days. Radionuclide scans cost\\nabout four times as much as exercise stress tests but pro-\\nvide more information.\\nIn radionuclide angiography, a scanning camera\\npasses back and forth over the patient who lies on a table.\\nRadionuclide angiography is usually performed in a hos-\\npital’s nuclear medicine department and takes 30–60\\nminutes. Thallium scanning is usually done in conjunc-\\ntion with an exercise stress test. When the stress test is\\nfinished, thallium or sestamibi is injected. The patient\\nresumes exercise for one minute to absorb the thallium.\\nFor patients who cannot exercise, cardiac blood flow and\\nheart rate may be increased by intravenous dipyridamole\\n(Persantine) or adenosine. Thallium scanning is done\\nGALE ENCYCLOPEDIA OF MEDICINE 2930\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 930'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 319, 'page_label': '320'}, page_content='twice, immediately after injecting the radiopharmaceuti-\\ncal and again four hours (and maybe 24 hours) later. It is\\nusually performed in a hospital’s nuclear medicine\\ndepartment. Each scan takes 30–60 minutes.\\nCoronary angiography is the most accurate method\\nfor making a diagnosis of coronary artery disease, but it\\nis also the most invasive. It is a form of cardiac\\ncatheterization that shows the heart’s chambers, great\\nvessels, and coronary arteries using x-ray technology.\\nDuring coronary angiography the patient is awake but\\nsedated. ECG electrodes are placed on the patient’s chest\\nand an intravenous line is inserted. A local anesthetic is\\ninjected into the site where the catheter will be inserted.\\nThe cardiologist inserts a catheter into a blood vessel and\\nguides it into the heart. A contrast dye is injected to make\\nthe heart visible on x-ray cinematography. Coronary\\nangiography is performed in a cardiac catheterization\\nlaboratory either in an outpatient or inpatient surgery\\nunit. It takes from 30 minutes to two hours.\\nTreatment\\nCoronary artery disease can be treated many ways.\\nThe choice of treatment depends on the severity of the\\ndisease. Treatments include lifestyle changes and drug\\ntherapy, percutaneous transluminal coronary angioplas-\\nty, and coronary artery bypass surgery. Coronary artery\\ndisease is a chronic disease requiring lifelong care.\\nAngioplasty or bypass surgery is not a “cure.”\\nPeople with less severe coronary artery disease may\\ngain adequate control through lifestyle changes and drug\\ntherapy. Many of the lifestyle changes that prevent dis-\\nease progression—a low-fat, low-cholesterol diet, weight\\nloss if needed, exercise, and not smoking—also help pre-\\nvent the disease from developing. These lifestyle changes\\nare discussed in more detail under prevention.\\nDrugs such as nitrates, beta-blockers, and calcium-\\nchannel blockers relieve chest pain and complications of\\ncoronary artery disease, but they cannot clear blocked\\narteries. Nitrates (nitroglycerin) improve blood flow to\\nthe heart. Beta-blockers (acebutelol, propranolol) reduce\\nthe amount of oxygen required by the heart during stress.\\nOne type of calcium-channel blocker (verapamil, dilti-\\nazem hydrochloride) helps keep the arteries open and\\nreduces blood pressure. Aspirin helps prevent blood\\nclots from forming on plaques, reducing the likelihood of\\na heart attack. Cholesterol-lowering medications are also\\nindicated in most cases.\\nPercutaneous transluminal coronary angioplasty and\\nbypass surgery are procedures that enter the body (inva-\\nsive procedures) to improve blood flow in the coronary\\narteries. Percutaneous transluminal coronary angioplasty,\\nKEY TERMS\\nAtherosclerosis —A process in which the walls of\\nthe coronary arteries thicken due to the accumula-\\ntion of plaque in the blood vessels. Atherosclerosis\\nis the cause of coronary artery disease.\\nAngina—Chest pain that happens when diseased\\nblood vessels restrict the flow of blood to the\\nheart. Angina is often the first symptom of coro-\\nnary artery disease.\\nBeta-blocker —A drug that blocks some of the\\neffects of fight-or-flight hormone adrenaline (epi-\\nnephrine and norepinephrine), slowing the heart\\nrate and lowering the blood pressure.\\nCalcium-channel blocker—A drug that blocks the\\nentry of calcium into the muscle cells of small\\nblood vessels (arterioles) and keeps them from\\nnarrowing.\\nCoronary arteries—The main arteries that provide\\nblood to the heart. The coronary arteries surround\\nthe heart like a crown, coming out of the aorta,\\narching down over the top of the heart, and divid-\\ning into two branches. These are the arteries in\\nwhich coronary artery disease occurs.\\nHDL cholesterol —High-density lipoprotein cho-\\nlesterol is a component of cholesterol that helps\\nprotect against heart disease. HDL is nicknamed\\n“good” cholesterol\\nLDL Cholesterol—Low-density lipoprotein choles-\\nterol is the primary cholesterol molecule. High\\nlevels of LDL increase the risk of coronary heart\\ndisease. LDL is nicknamed “bad” cholesterol.\\nPlaque—A deposit of fatty and other substances\\nthat accumulate in the lining of the artery wall.\\nTriglyceride —A fat that comes from food or is\\nmade from other energy sources in the body. Ele-\\nvated triglyceride levels contribute to the develop-\\nment of atherosclerosis.\\nusually called coronary angioplasty, is a non-surgical\\nprocedure. A catheter tipped with a balloon is threaded\\nfrom a blood vessel in the thigh into the blocked artery.\\nThe balloon is inflated, compressing the plaque to\\nenlarge the blood vessel and open the blocked artery. The\\nballoon is deflated, and the catheter is removed. Coro-\\nnary angioplasty is performed by a cardiologist in a hos-\\npital and generally requires a stay of one or two days.\\nCoronary angioplasty is successful about 90% of the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 931\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 931'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 320, 'page_label': '321'}, page_content='time, but for one-third of patients the artery narrows\\nagain within six months. The procedure can be repeated.\\nIt is less invasive and less expensive than coronary artery\\nbypass surgery.\\nIn coronary artery bypass surgery, a healthy artery or\\nvein from an arm, leg, or chest wall is used to build a\\ndetour around the coronary artery blockage. The healthy\\nvessel then supplies oxygen-rich blood to the heart.\\nBypass surgery is major surgery. It is appropriate for\\nthose patients with blockages in two or three major coro-\\nnary arteries, those with severely narrowed left main\\ncoronary arteries, and those who have not responded to\\nother treatments. It is performed in a hospital under gen-\\neral anesthesia. A heart-lung machine is used to support\\nthe patient while the healthy vein or artery is attached\\npast the blockage to the coronary artery. About 70% of\\npatients who have bypass surgery experience full relief\\nfrom angina; about 20% experience partial relief. Only\\nabout 3–4% of patients per year experience a return of\\nsymptoms. Survival rates after bypass surgery decrease\\nover time. At five years after surgery, survival expectancy\\nis 90%; at 10 years about 80%, at 15 years about 55%,\\nand at 20 years about 40%.\\nThree semi-experimental surgical procedures for\\nunblocking coronary arteries are currently being studied.\\nAtherectomy is a procedure in which the cardiologist\\nshaves off and removes strips of plaque from the blocked\\nartery. In laser angioplasty, a catheter with a laser tip is\\ninserted into the affected artery to burn or break down the\\nplaque. A metal coil called a stent can be implanted per-\\nmanently to keep a blocked artery open. Stenting is\\nbecoming more common.\\nAlternative treatment\\nNatural therapies may reduce the risk of certain\\ntypes of heart disease, but once symptoms appear, con-\\nventional medical attention is necessary. A healthy diet\\n(including cold-water fish as a source of essential fatty\\nacids) and exercise, important components of conven-\\ntional prevention and treatment strategies, also are\\nemphasized in alternative approaches to coronary artery\\ndisease. Herbal medicine has a variety of remedies that\\nmay have a beneficial effect on coronary artery disease.\\nFor example, ginger ( Zingiber officinale ) may help\\nreduce cholesterol. Garlic ( Allium sativum ), ginger, and\\nhot red or chili peppers are all circulatory enhancers that\\ncan help prevent blood clots. Yoga and other bodywork,\\nmassage, relaxation therapies, and talking therapies may\\nalso help prevent coronary artery disease and stop, or\\neven reverse, the progression of atherosclerosis. Vitamin\\nand mineral therapy to reduce, reverse, or protect against\\ncoronary artery disease includes chromium; calcium and\\nmagnesium; B-complex vitamins; the anti-oxidant vita-\\nmins C and E; selenium; and zinc. Traditional Chinese\\nmedicine may recommend herbal remedies, massage,\\nacupuncture, and dietary modification.\\nPrognosis\\nIn many cases, coronary artery disease can be suc-\\ncessfully treated. Advances in medicine and healthier\\nlifestyles have caused a substantial decline in death rates\\nfrom coronary artery disease since the mid-1980s. New\\ndiagnostic techniques enable doctors to identify and treat\\ncoronary artery disease in its earliest stages. New tech-\\nnologies and surgical procedures have extended the lives\\nof many patients who would otherwise have died.\\nResearch on coronary artery disease continues.\\nPrevention\\nA healthy lifestyle can help prevent coronary artery\\ndisease and help keep it from progressing. A heart-\\nhealthy lifestyle includes eating right, regular exercise,\\nmaintaining a healthy weight, no smoking, moderate\\ndrinking, no recreational drugs, controlling hypertension,\\nand managing stress. Cardiac rehabilitation programs\\nare excellent to help prevent recurring coronary problems\\nfor people who are at risk and who have had coronary\\nevents and procedures.\\nEat right\\nA healthy diet includes a variety of foods that are\\nlow in fat, especially saturated fat, low in cholesterol,\\nand high in fiber. It includes plenty of fruits and vegeta-\\nbles and limited sodium. Some foods are low in fat but\\nhigh in cholesterol and some are low in cholesterol but\\nhigh in fat. Saturated fat raises cholesterol and, in exces-\\nsive amounts, increases the amount of the clot-forming\\nproteins in blood. Polyunsaturated and monounsaturated\\nfats are good for the heart. Fat should comprise no more\\nthan 30% of total daily calories.\\nCholesterol, a waxy substance containing fats, is\\nfound in foods such as meat, eggs, and other animal\\nproducts. It is also produced in the liver. Soluble fiber\\ncan help lower cholesterol. Dietary cholesterol should be\\nlimited to about 300 milligrams per day. Many popular\\nlipid-lowering drugs can reduce LDL cholesterol by an\\naverage of 25–30% when used with a low-fat, low-cho-\\nlesterol diet.\\nFruits and vegetables are rich in fiber, vitamins, and\\nminerals. They are low-calorie and nearly fat free. Vita-\\nmin C and beta-carotene, found in many fruits and veg-\\netables, keep LDL-cholesterol from turning into a form\\nthat damages coronary arteries.\\nGALE ENCYCLOPEDIA OF MEDICINE 2932\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 932'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 321, 'page_label': '322'}, page_content='Excess sodium can increase the risk of high blood\\npressure. Many processed foods contain large amounts of\\nsodium. Limit daily intake to about 2,400 milligrams,\\nabout the amount in a teaspoon of salt.\\nThe “Food Guide” Pyramid developed by the U.S.\\nDepartments of Agriculture and Health and Human Ser-\\nvices provides easy-to-follow guidelines for daily heart-\\nhealthy eating. It recommends six to 11 servings of bread,\\ncereal, rice, and pasta; three to five servings of vegetables;\\ntwo to four servings of fruit; two to three servings of milk,\\nyogurt, and cheese; and two to three servings of meat,\\npoultry, fish, dry beans, eggs, and nuts. Fats, oils, and\\nsweets should be used sparingly. Canola and olive oil are\\nbetter for the heart than other cooking oils. Coronary\\npatients should be on a strict diet.\\nExercise regularly\\nAerobic exercise can lower blood pressure, help con-\\ntrol weight, and increase HDL (“good”) cholesterol. It may\\nkeep the blood vessels more flexible. The Centers for Dis-\\nease Control and Prevention and the American College of\\nSports Medicine recommend moderate to intense aerobic\\nexercise lasting about 30 minutes four or more times per\\nweek for maximum heart health. Three 10-minute exercise\\nperiods are also beneficial. Aerobic exercise—activities\\nsuch as walking, jogging, and cycling—uses the large mus-\\ncle groups and forces the body to use oxygen more effi-\\nciently. It can also include everyday activities such as active\\ngardening, climbing stairs, or brisk housework. People with\\ncoronary artery disease or risk factors should consult a doc-\\ntor before beginning an exercise program.\\nMaintain a desirable body weight\\nAbout one quarter of all Americans are overweight\\nand nearly one-tenth are obese, according to the Surgeon\\nGeneral’s Report on Nutrition and Health. People who\\nare 20% or more over their ideal body weight have an\\nincreased risk of developing coronary artery disease.\\nLosing weight can help reduce total and LDL choles-\\nterol, reduce triglycerides, and boost HDL cholesterol. It\\nmay also reduce blood pressure. Eating right and exercis-\\ning are two key components of losing weight.\\nAvoid recreational drugs\\nDo not smoke or use tobacco. Smoking has many\\nadverse effects on the heart. It increases the heart rate,\\nconstricts major arteries, and can create irregular heart-\\nbeats. It raises blood pressure, contributes to the develop-\\nment of plaque, increases the formation of blood clots,\\nand causes blood platelets to cluster and impede blood\\nflow. Heart damage caused by smoking can be repaired\\nby quitting. Even heavy smokers can return to heart\\nhealth. Several studies have shown that ex-smokers face\\nthe same risk of heart disease as non-smokers within five\\nto 10 years after they quit.\\nDrink in moderation. Modest consumption of alco-\\nhol may actually protect against coronary artery disease\\nbecause alcohol appears to raise levels of HDL (“good”)\\ncholesterol. The American Heart Association defines\\nmoderate consumption as one ounce of alcohol per day,\\nroughly one cocktail, one 8-ounce glass of wine, or two\\n12-ounce glasses of beer. However, even moderate drink-\\ning can increase risk factors for heart disease for some\\npeople (by raising blood pressure, for example). Exces-\\nsive drinking is always bad for the heart. It usually raises\\nblood pressure and can poison the heart and cause abnor-\\nmal heart rhythms or even heart failure.\\nDo not use other recreational drugs. Commonly used\\nrecreational drugs, particularly cocaine and “crack,” can\\nseriously harm the heart and should never be used.\\nSeek treatment for hypertension\\nHigh blood pressure, one of the most common and\\nserious risk factors for coronary artery disease, can be\\ncompletely controlled through lifestyle changes and\\nmedication. Moderate hypertension can be controlled by\\nreducing dietary intake of sodium and fat, exercising reg-\\nularly, managing stress, abstaining from smoking, and\\ndrinking alcohol in moderation. People for whom these\\nchanges do not work or people with severe hypertension\\nmay be helped by many categories of medication.\\nManage stress\\nEveryone experiences stress, the mental and physi-\\ncal reaction to life’s irritations and challenges. Stress can\\nsometimes be avoided and when it is inevitable, it can be\\ncontrolled. Techniques for controlling stress include: tak-\\ning life more slowly, spending more time with family and\\nfriends, thinking positively, getting enough sleep, exer-\\ncising, and practicing relaxation techniques.\\nResources\\nBOOKS\\nAmerican Heart Association and American Cancer Society.\\nLiving Well, Staying Well.New York: Time Books, 1996.\\nDeBakey Michael E., and Antonio M. Gotto Jr. “Coronary\\nArtery Disease,” and “Surgical Treatment of Coronary\\nArtery Disease.” In The New Living Heart. Holbrook,\\nMA: Adams Media Corporation, 1997.\\n“Heart Disease.” In New Choices in Natural Healing, ed. Bill\\nGottlieb, et al. Emmaus, PA: Rodale Press, 1995.\\n“Heart Disease.” In The Complete Family Guide to Alternative\\nMedicine, ed. C. Norman Shealy. New York: Barnes &\\nNoble Books, 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 933\\nCoronary artery disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 933'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 322, 'page_label': '323'}, page_content='“Heart Problems.” In The Alternative Advisor: The Complete\\nGuide to Natural Therapies & Alternative Treatments.\\nAlexandria, V A: Time-Life Books, 1997.\\nNotelovitz, Morris, and Diana Tonnessen. The Essential Heart\\nBook for Women.New York: St. Martin’s Press, 1996.\\nTexas Heart Institute. “Coronary Artery Disease, Angina, and\\nHeart Attacks.” In Texas Heart Institute Heart Owner’s\\nHandbook. New York: John Wiley & Sons, 1996.\\nPERIODICALS\\n“Exercise Stress Test: A Simple Way to Spot Heart Disease.”\\nMayo Clinic Health Letter (Sept. 1996).\\n“More Evidence for Infection as a Cause of Heart Disease.”\\nHarvard Heart Letter 7 (Feb. 1997): 6-7.\\n“Women and Heart Disease”Harvard Women’s Health Watch4\\n(July 1997): 4-5.\\nZamula, Evelyn. “Balloons to Bypass Bypass Surgery.”FDA\\nConsumer 22 (1 May 1988): 24-27.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. P.O. Box 20345,\\nHouston, TX 77225-0345. .\\nOTHER\\n“Facts About Coronary Heart Disease.”National Heart, Lung,\\nand Blood Institute. 27 Nov. 1998. 3 Mar. 1998 .\\n“Heart and Stroke 1998 Update.”American Heart Association.\\n3 Mar. 1998 .\\nLori De Milto\\nCoronary disease see Coronary artery\\ndisease\\nCoronary heart disease see Coronary artery\\ndisease\\nCoronary stenting\\nDefinition\\nA coronary stent is an artificial support device used\\nin the coronary artery to keep the vessel open.\\nPurpose\\nThe coronary stent is a relatively new tool used to\\nkeep coronary arteries expanded, usually following a bal-\\nloon angioplasty. Balloon angioplasty is used in patients\\nwith coronary artery disease . In this disease, the blood\\nvessels on the heart become narrow. When this happens,\\nthe oxygen supply is reduced to the heart muscle. The\\nprimary cause of coronary artery disease is fat deposits\\nblocking the arteries ( atherosclerosis ). In many cases,\\nballoon angioplasty is unsuccessful and the vessel closes\\nafter the procedure (restenosis). By forming a rigid sup-\\nport, the stent can prevent restenosis and reduce the need\\nfor coronary bypass surgery. The stent is usually a stain-\\nless steel mesh tube. Since the stent will be placed inside\\nan artery, the device comes in various sizes to match the\\nsize of the artery.\\nPrecautions\\nAny foreign object in the body, like a stent, will\\nincrease the risk of thrombosis. Anticlotting medication\\nis given to prevent this complication.\\nDescription\\nCoronary stenting usually follows balloon angio-\\nplasty, which requires inserting a balloon catheter into\\nthe femoral artery in the upper thigh. When this catheter\\nis positioned at the location of the blockage in the coro-\\nnary artery, it is slowly inflated to widen that artery, and\\nis then removed. The stent catheter is then threaded into\\nthe artery and the stent is placed around a deflated bal-\\nloon. When this is correctly positioned in the coronary\\nartery, the balloon is inflated, expanding the stent against\\nthe walls of the coronary artery. The balloon catheter is\\nremoved, leaving the stent in place to hold the coronary\\nartery open. A cardiac angiography will follow to insure\\nthat the stent is keeping the artery open.\\nAlternative procedures\\nBalloon angioplasty and coronary stenting are per-\\nformed to relieve the symptoms of coronary artery disease.\\nBy the time coronary artery disease progresses and\\nrequires balloon angioplasty, there is no alternative to bal-\\nloon angioplasty other than coronary bypass surgery.\\nCoronary bypass surgery carries greater risks. However,\\nsince coronary artery disease can be related to high fat\\ndiets, smoking, and lack of exercise, changes in lifestyle\\nmay reduce the risk of developing the disease. Various\\nmedications for cholesterol, high blood pressure, and dia-\\nbetes also can help treat or prevent coronary artery disease.\\nPreparation\\nBefore the stent is inserted, the patient will probably\\nbe instructed to take aspirin for several days. Aspirin can\\nhelp decrease the possibility of blood clots forming at the\\nGALE ENCYCLOPEDIA OF MEDICINE 2934\\nCoronary stenting\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 934'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 323, 'page_label': '324'}, page_content='stent. Because anesthesia will be used during the proce-\\ndure, the patient should not eat or drink after midnight of\\nthe previous day.\\nAftercare\\nFollowing the procedure, blood thinners (anticoagu-\\nlants) will be given through a needle in a vein for about\\n24 hours. The patient should remain flat and still for\\nawhile to allow the femoral artery to heal from the inser-\\ntion of the catheter. Medication to control blood clotting\\nshould be taken after the patient is discharged from the\\nhospital. A special diet may also be recommended that is\\nlow in vitamin K and cholesterol. With time, the patient\\nshould begin light exercise, like walking. It is important\\nthat no magnetic resonance imaging (MRI) tests are\\ngiven for six months because the magnetic field may\\nmove the stent.\\nRisks\\nAlthough coronary stents greatly reduce the risk of\\nrestenosis following balloon angioplasty, there is still\\nsome risk that the stented artery may close. Thrombosis,\\nbleeding, and artery damage are also risks.\\nResources\\nBOOKS\\nGarratt, Kirk N., Guy S. Reeder, and David R. Holmes Jr.\\n“Cardiac Catheterization and Angiography.” In Mayo\\nKEY TERMS\\nBalloon angioplasty —The use of a balloon\\nattached to a catheter to widen an artery that has\\nbecome narrowed. As the balloon is inflated, it\\nopens the artery.\\nCardiac angiography —A procedure used to visu-\\nalize blood vessels of the heart. A catheter is used\\nto inject a dye into the vessels; the vessels can\\nthen be seen by x ray.\\nCatheter —A long thin flexible tube that can be\\ninserted into the body; in this case, it is threaded\\nto the heart.\\nRestenosis—The narrowing of a blood vessel after\\nit has been opened, usually by balloon angioplasty.\\nThrombosis—The development of a blood clot in\\nthe vessels. This thrombosis may clog a blood ves-\\nsel and stop the flow of blood.\\nClinic Practice of Cardiology, ed. Emilio R. Giuliani, et\\nal. St. Louis: Mosby Publishing, 1996.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nOTHER\\nAdvocateHealthCare. .\\nCindy L. A. Jones, PhD\\nCoronary thrombosis see Heart attack\\nCoronavirus infection see Common cold\\nCorticosteroids\\nDefinition\\nCorticosteriods are a group of natural and synthetic\\nanalogues of the hormones secreted by the hypothalamic-\\nanterior pituitary-adrenocortical (HPA) axis, more com-\\nmonly referred to as the pituitary gland. These include\\nglucocorticoids, which are anti-inflammatory agents with\\na large number of other functions; mineralocorticoids,\\nwhich control salt and water balance primarily through\\naction on the kidneys; and corticotropins, which control\\nsecretion of hormones by the pituitary gland.\\nPurpose\\nGlucocorticoids have multiple effects, and are used\\nfor a large number of conditions. They affect glucose uti-\\nlization, fat metabolism, and bone development, and are\\npotent anti-inflammatory agents. They may be used for\\nreplacement of natural hormones in patients with pitu-\\nitary deficiency ( Addison’s disease ), as well as for a\\nwide number of other conditions including, but not limit-\\ned to, arthritis, asthma, anemia, various cancers, and\\nskin inflammations. Additional uses include inhibition of\\nnausea and vomiting after chemotherapy, treatment of\\nseptic shock, treatment of spinal cord injuries, and treat-\\nment of hirisutism (excessive hair growth). The choice of\\ndrug will vary with the condition. Cortisone and hydro-\\ncortisone, which have both glucocorticoid and mineralo-\\ncorticoid effects, are the drugs of choice for replacement\\ntherapy of natural hormone deficiency. Synthetic com-\\npounds, which have greater anti-inflammatory effects\\nand less effect on salt and water balance, are usually pre-\\nferred for other purposes. These compounds include dex-\\namethasone, which is almost exclusively glucocorticoid\\nin its actions, as well as prednisone, prednisolone,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 935\\nCorticosteroids\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 935'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 324, 'page_label': '325'}, page_content='betamethasone, trimacinolone, and others. Glucocorti-\\ncoids are formulated in oral dosage forms, topical creams\\nand ointments, oral and nasal inhalations, rectal foams,\\nand ear and eye drops.\\nMineralocorticoids control the retention of sodium\\nin the kidneys. In mineralocorticoid deficiency, there is\\nexcessive loss of sodium through the kidneys, with\\nresulting water loss. Fludrocortisone (Florinef) is the\\nonly drug available for treatment of mineralocorticoid\\ndeficiency, and is available only in an oral dosage form.\\nCorticotropin (ACTH, adrenocorticotropic hormone)\\nstimulates the pituitary gland to release cortisone. A defi-\\nciency of corticotropic hormone will have the same effects\\nas a deficiency of cortisone. The hormone, which is avail-\\nable under the brand names Acthar and Actrel, is used for\\ndiagnostic testing, to determine the cause of a glucocorti-\\ncoid deficiency, but is rarely used for replacement therapy\\nsince direct administration of glucocorticoids may be easi-\\ner and offers better control over dosages.\\nKEY TERMS\\nHallucination —A false or distorted perception of\\nobjects, sounds, or events that seems real. Halluci-\\nnations usually result from drugs or mental disor-\\nders.\\nHormone —A substance that is produced in one\\npart of the body, then travels through the blood-\\nstream to another part of the body where it has its\\neffect.\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or ill-\\nness.\\nOintment —A thick, spreadable substance that\\ncontains medicine and is meant to be used on the\\noutside of the body.\\nPregnancy category —A system of classifying\\ndrugs according to their established risks for use\\nduring pregnancy. Category A: controlled human\\nstudies have demonstrated no fetal risk. Category\\nB: animal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nno adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: evidence of fetal risk,\\nbut benefits outweigh risks. Category X: evidence\\nof fetal risk. Risks outweigh any benefits.\\nRecommended dosage\\nThe dosage of glucocorticoids varies with the drug,\\nroute of administration, condition being treated, and\\npatient. Consult specific references.\\nFludrocortisone, for use in replacement therapy, is\\nnormally dosed at 0.1 mg/day. Some patients require\\nhigher doses. It should normally be administered in con-\\njunction with cortisone or hydrocortisone.\\nACTH, when used for diagnostic purposes, is given\\nas 10–25 units dissolved in 500 ml of 5% dextrose injec-\\ntion-infused IV over eight hours. A long-acting form,\\nwhich may be used for replacement therapy, is given by\\nsubcutaneous (SC) or intramuscular (IM) injection at a\\ndose of 40 to 80 units every 24–72 hours.\\nPrecautions\\nGlucocorticoids\\nThe most significant risk associated with administra-\\ntion of glucocorticoids is suppression of natural corticos-\\nteroid secretion. When the hormones are administered,\\nthey suppress the secretion of ACTH, which in turn\\nreduces the secretion of the natural hormones. The extent\\nof suppression varies with dose, drug potency, duration of\\ntreatment, and individual patient response. While suppres-\\nsion is seen primarily with drugs administered systemical-\\nly, it can also occur with topical drugs such as creams and\\nointments, or drugs administered by inhalation. Abrupt\\ncessation of corticosteroids may result in acute adrenal cri-\\nsis (Addisonian crisis) that is marked by dehydration\\nwith severe vomiting and diarrhea, hypotension, and loss\\nof consciousness. Acute adrenal crisis is potentially fatal.\\nChronic overdose of glucocorticoids leads to Cushin-\\ngoid syndrome, which is clinically identical to Cushing’s\\nsyndrome and differs only in that in Cushingoid, the\\nexcessive steroids are from drug therapy rather than\\nexcessive glandular secretion. Symptoms vary, but most\\npeople have upper body obesity, rounded face, increased\\nfat around the neck, and thinning arms and legs. In its\\nlater stages, this condition leads to weakening of bones\\nand muscles with rib and spinal column fractures.\\nThe short term adverse effects of corticosteroids are\\ngenerally mild, and include indigestion , increased\\nappetite, insomnia , and nervousness. There are also a\\nvery large number of infrequent adverse reactions, the\\nmost significant of which is drug induced-paranoia.\\nDelerium, depression, menstrual irregularity, and\\nincreased hair growth are also possible. Consult detailed\\nreviews for further information.\\nLong-term use of topical glucocorticoids can result\\nin thinning of the skin. Oral steroid inhalations may cause\\nGALE ENCYCLOPEDIA OF MEDICINE 2936\\nCorticosteroids\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 936'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 325, 'page_label': '326'}, page_content='fungal overgrowth in the oral cavity. Patients must be\\ninstructed to rinse their mouths carefully after each dose.\\nCorticosteroids are pregnancy category C. The drugs\\nhave caused congenital malformations in animal studies,\\nincluding cleft palate. Breastfeeding should be avoided.\\nMineralocorticoids\\nBecause fludrocortisone has glucocorticoid activity\\nas well as mineralocorticoid action, the same hazards and\\nprecautions apply to fludrocortisone as to the glucocorti-\\ncoids. Overdose of fludrocortisone may also cause\\nedema, hypertension, and congestive heart failure.\\nCorticotropins\\nCorticotropin has all the same risks as the glucocor-\\nticoids. Prolonged use may cause reduced response to the\\nstimulatory effects of corticotropin.\\nWarnings and contraindications\\nUse corticosteroids with caution in patients with the\\nfollowing conditions:\\n• osteoporosis or any other bone disease\\n• current or past tuberculosis\\n• glaucoma or cataracts\\n• infections of any type (virus, bacteria, fungus, amoeba)\\n• sores in the nose or recent nose surgery (if using nasal\\nspray forms of corticosteroids)\\n• underactive or overactive thyroid\\n• liver disease\\n• stomach or intestine problems\\n• diabetes\\n• heart disease\\n• high blood pressure\\n• high cholesterol\\n• kidney disease or kidney stones\\n• myasthenia gravis\\n• systemic lupus erythematosus (SLE)\\n• emotional problems\\n• skin conditions that cause the skin to be thinner to\\nbruise more easily\\nInteractions\\nCorticosteroids have many drug interactions. Con-\\nsult specific references.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Allergy, Asthma and Immunology. 611\\nEast Wells Street, Milwaukee, WI 53202. (414) 272-6071.\\n.\\nAsthma and Allergy Foundation of America. 1125 15th Street\\nNW, Suite 502, Washington, DC 20005. (800) 727-8462.\\n.\\nNational Heart, Lung and Blood Institute. National Institutes of\\nHealth. P.O. Box 30105, Bethesda, MD 20824-0105. (301)\\n251-1222. .\\nSamuel Uretsky, PharmD\\nCorticotropin test see Adrenocorticotropic\\nhormone test\\nCortisol tests\\nDefinition\\nThis test is a measure of serum cortisol (also known\\nas hydrocortisone), or urine cortisol (also known as uri-\\nnary free cortisol), an important hormone produced by a\\npair of endocrine glands called the adrenal glands.\\nPurpose\\nThis test is performed on patients who may have\\nmalfunctioning adrenal glands. Blood and urine cortisol,\\ntogether with the determination of adrenocorticotropic\\nhormone (ACTH), are the three most important tests in\\nthe investigation of Cushing’s syndrome (caused by an\\noverproduction of cortisol) and Addison’s disease\\n(caused by the underproduction of cortisol).\\nPrecautions\\nIncreased levels of cortisol are associated with preg-\\nnancy. Physical and emotional stress can also elevate\\ncortisol levels. Drugs that may cause increased levels of\\ncortisol include estrogen, oral contraceptives, ampheta-\\nmines, cortisone, and spironolactone (Aldactone). Drugs\\nthat may cause decreased levels include androgens,\\naminoglutethimide, betamethasone, and other steroid\\nmedications, danazol, lithium, levodopa, metyrapone and\\nphenytoin (Dilantin).\\nDescription\\nCortisol is a potent hormone known as a glucocorti-\\ncoid that affects the metabolism of carbohydrates, pro-\\nteins, and fats, but especially glucose. Cortisol increases\\nblood sugar levels by stimulating the release of glucose\\nfrom glucose stores in cells. It also acts to inhibit insulin,\\nthus affecting glucose transport into cells.\\nThe hypothalamus (an area of the brain), the pitu-\\nitary gland (sometimes called the “master gland”), and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 937\\nCortisol tests\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 937'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 326, 'page_label': '327'}, page_content='the adrenal glands coordinate the production of cortisol.\\nAfter corticotropin-releasing hormone (CRH) is made in\\nthe hypothalamus, CRH stimulates the pituitary to pro-\\nduce adrenocorticotropic hormone (ACTH). The produc-\\ntion of ACTH in turn stimulates a part of the adrenal\\nglands known as the adrenal cortex to produce cortisol.\\nRising levels of cortisol act as a negative feedback to cur-\\ntail further production of CRH and ACTH, thus complet-\\ning an elaborate feedback mechanism.\\nThere are two methods for evaluating cortisol: blood\\nand urine. The most reliable index of cortisol secretion is\\nthe 24-hour urine sample collection, but when blood lev-\\nels are required or requested by the physician, plasma\\ncortisol should be measured in the morning and again in\\nthe afternoon. Cortisol levels normally rise and fall dur-\\ning the day in what is called a diurnal variation, so that\\ncortisol is at its highest level between 6–8 \\nA.M. and grad-\\nually falls, reaching its lowest point around midnight.\\nOne reason for ordering blood cortisol levels versus a 24-\\nhour urine collection is that sometimes the earliest sign\\nof adrenal malfunction is the loss of this diurnal varia-\\ntion, even though the cortisol levels are not yet elevated.\\nFor example, individuals with Cushing’s syndrome often\\nhave upper normal plasma cortisol levels in the morning\\nand exhibit no decline as the day progresses.\\nKEY TERMS\\nAddison’s disease—A rare disorder in which symp-\\ntoms are caused by a deficiency of hydrocortisone\\n(cortisol) and aldosterone, two corticosteroid hor-\\nmones normally produced by a part of the adrenal\\nglands called the adrenal cortex. Symptoms include\\nweakness, tiredness, vague abdominal pain, weight\\nloss, skin pigmentation and low blood pressure.\\nAdrenal glands—A pair of endocrine glands (glands\\nthat secrete hormones directly into the blood-\\nstream) that are located on top of the kidneys.\\nAdrenocorticotropic hormone (ACTH) —Also\\ncalled corticotropin, this hormone is produced by\\nthe pituitary gland to stimulate the adrenal cortex\\nto release various corticosteroid hormones.\\nCushing’s syndrome—A hormonal disorder caused\\nby an abnormally high level of corticosteroid hor-\\nmones that are produced by the adrenal glands. Cor-\\nticosteroid hormones control the body’s use of nutri-\\nents and the excretion of salts and water in the urine.\\nSymptoms include high blood sugar levels, a moon\\nface, weight gain, and increased blood pressure\\nPreparation\\nWhen testing for cortisol levels through the blood, a\\nblood specimen is usually collected at 8 A.M. and again at\\n4 P.M. It should be noted that normal values may be trans-\\nposed in individuals who have worked during the night\\nand slept during the day for long periods of time.\\nWhen testing for cortisol level through the urine, a\\n24-hour urine sample is collected, refrigerated, and sent\\nto the reference laboratory for examination.\\nRisks\\nRisks for the blood test are minimal, but may\\ninclude slight bleeding from the blood-drawing site,\\nfainting or feeling lightheaded after venipuncture, or\\nhematoma (blood accumulating under the puncture site).\\nNormal results\\nReference ranges for cortisol vary from laboratory to\\nlaboratory but are usually within the following ranges for\\nblood:\\n• adults (8 \\nA.M.): 6–28 mg/dL; adults (4 P.M.): 2–12 mg/dL\\n• child one to six years (8 A.M.): 3–21 mg/dL; child one\\nto six years (4 P.M.): 3–10 mg/dL\\n• newborn: 1/24 mg/dL\\nReference ranges for cortisol vary from laboratory to\\nlaboratory, but are usually within the following ranges\\nfor 24-hour urine collection:\\n• adult: 10–100 mg/24 hours\\n• adolescent: 5–55 mg/24 hours\\n• child: 2–27 mg/24 hours\\nAbnormal results\\nIncreased levels of cortisol are found in Cushing’s\\nsyndrome, excess thyroid ( hyperthyroidism ), obesity ,\\nACTH-producing tumors, and high levels of stress.\\nDecreased levels of cortisol are found in Addison’s\\ndisease, conditions of low thyroid, and hypopituitarism,\\nin which pituitary activity is diminished.\\nResources\\nBOOKS\\nCahill, Mathew. Handbook of Diagnostic Tests.Springhouse,\\nPA: Springhouse Corporation, 1995.\\nJacobs, David S., et al. Laboratory Test Handbook.4th ed. New\\nYork: Lexi-Comp, Inc., 1996.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nGALE ENCYCLOPEDIA OF MEDICINE 2938\\nCortisol tests\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 938'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 327, 'page_label': '328'}, page_content='Cosmetic dentistry\\nDefinition\\nCosmetic dentistry includes a variety of dental treat-\\nments aimed at improving the appearance of the teeth.\\nPurpose\\nThe purpose of cosmetic dentistry is to improve the\\nappearance of the teeth using bleaching, bonding,\\nveneers, reshaping, orthodontics, or implants.\\nDescription\\nBleaching is done to lighten teeth that are stained\\nor discolored. It entails the use of a bleaching solution\\napplied by a dentist or a gel in a tray that fits over the\\nteeth used at home under a dentist’s supervision. Bond-\\ning involves applying tooth-colored plastic putty, called\\ncomposite resin, to the surface of chipped or broken\\nteeth. This resin is also used to fill cavities in front teeth\\n(giving a more natural-looking result) and to fill gaps\\nbetween teeth. Veneers are thin, porcelain shells that\\ncover the front of the teeth. They can improve the\\nappearance of damaged, discolored, misshapen, or mis-\\naligned teeth. Reshaping involves the removal of enam-\\nel from a misshapen tooth so that it matches other teeth.\\nOrthodontics uses braces to correct the position of\\ncrowded or misaligned teeth. Implants are artificial\\nteeth which are attached directly to the jaw to replace\\nmissing teeth.\\nPreparation\\nBleaching involves having a custom-made bleaching\\ntray made by the dentist. This tray is worn at home for\\nseveral hours each day or night. Teeth slowly become\\nwhite over a period of one to six weeks. Bleaching can\\nalso be done in a dentist’s office. A heat- or light-activated\\nbleaching solution is applied to six to eight teeth per visit.\\nBonding involves etching the surface of the tooth so\\ncomposite resin can adhere. The dentist then contours the\\nresin to the right shape, and smooths and polishes the\\nresin after it is hard and dry.\\nTo prepare for the application of a veneer, a thin layer\\nof enamel is removed from the tooth (so that the finished\\ntooth will be flush with surrounding teeth) and an impres-\\nsion of the tooth is taken from which the veneer will be\\ncreated. Before a veneer is applied, the tooth is etched\\nwith an acid solution and an adhesive resin is painted on\\nthe tooth. The veneer is then applied, the resin is hardened\\nwith a bonding light, and the dentist polishes the veneer.\\nKEY TERMS\\nBleaching —Technique used to brighten stained\\nteeth.\\nBonding —Rebuilding, reshaping, and covering\\ntooth defects using tooth-colored materials.\\nComposite resin—Plastic material matching natur-\\nal tooth color used to replace missing parts of a\\ntooth.\\nDuring cosmetic reshaping, some enamel is\\nremoved from the uneven tooth so it more closely match-\\nes other teeth.\\nOrthodontics involves applying braces to the teeth,\\nand wires are threaded through the braces. These wires\\nare adjusted to gradually move the teeth to the desired\\nnew positions. Over time, crowded or misaligned teeth\\nare straightened.\\nImplants are more secure and natural looking than\\ndentures or bridgework, but are much more expensive.\\nFirst an anchor for the implant is attached to the jaw\\nbone. This surgery can take several hours. About six\\nmonths later, after the bone around the anchor has\\nhealed, a post is attached to the anchor, and an artificial\\ntooth is attached to the post. The whole process may take\\nabout nine months to complete.\\nAftercare\\nPeriodic touch-up may be needed to keep the teeth\\nwhite if the teeth have been bleached or bonded. Also, the\\nresin used in bonded teeth can be chipped by ice, popcorn\\nkernels, or hard candy, requiring repair. Veneered teeth\\nmay need to be reveneered after five to 12 years. Once\\northodontic braces are removed, regular visits to the\\northodontist are advised because teeth can shift position.\\nImplanted teeth require regular dental checkups to ensure\\nthat the anchor and post are stable.\\nRisks\\nAfter teeth are bleached, they may darken faster if\\nexposed to staining products such as coffee or tobacco.\\nSome patients experience increased sensitivity to cold\\nwhile teeth are being bleached, but the sensitivity usually\\ndisappears shortly after completion of the treatment.\\nBonded teeth, like bleached teeth, may also stain\\nmore easily than natural teeth. Bonding materials also\\nchip easily.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 939\\nCosmetic dentistry\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 939'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 328, 'page_label': '329'}, page_content='KEY TERMS\\nInflammation—Process whereby the immune sys-\\ntem reacts to infection or other stimulus, charac-\\nterized by pain, swelling, redness, and warmth of\\nthe affected part\\nBecause cosmetic reshaping involves the removal of\\nenamel, the process is irreversible because enamel can-\\nnot be replaced once it is removed.\\nThe anchors of implanted teeth can loosen and cause\\npain; regular dental checkups are recommended.\\nNormal results\\nCosmetic dentistry can improve the appearance of\\nstained, chipped, misshapen, or crowded teeth.\\nResources\\nORGANIZATIONS\\nAmerican Dental Association. 211 E. Chicago Ave., Chicago,\\nIL 60611. (312) 440-2500. .\\nJoseph Knight, PA\\nCosmetic surgery see Plastic, cosmetic, and\\nreconstructive surgery\\nCostochondritis\\nDefinition\\nCostochondritis is an inflammation and associated\\ntenderness of the cartilage (i.e., the costochondral joints)\\nthat attaches the front of the ribs to the breastbone.\\nDescription\\nCostochondritis causes pain in the lower rib area or\\nupper breastbone. Some patients fear they are having a\\nheart attack. The most severe pain is usually between the\\nbreast and the upper abdomen. The pain may be greater\\nwhen in sitting or reclining positions. Stress may aggra-\\nvate this condition. Generally the third or fourth ribs are\\naffected. However, any of the seven costochondral junc-\\ntions may be affected, and more often than not more than\\none site is involved. The inflammation can involve carti-\\nlage areas on both sides of the sternum, but usually is on\\none side only. Costochondritis should be distinguished\\nfrom Tietze Syndrome, which is an inflammation involv-\\ning the same area of the chest, but also includes swelling.\\nCauses and symptoms\\nThe causes of costochondritis are not well-under-\\nstood and may be difficult to establish. The most likely\\ncauses include injury, repetitive minor trauma, and\\nunusual excessive physical activity.\\nThe primary symptom of costochondritis is severe\\nchest wall pain, which may vary in intensity. The pain\\nbecomes worse with trunk movement, deep breathing,\\nand/or exertion, and better with decreased movement, quiet\\nbreathing, or changing of position. It is usually localized but\\nmay radiate extensively from the chest area. The pain has\\nbeen described as sharp, nagging, aching, or pressure-like.\\nDiagnosis\\nDiagnosis is based on pain upon palpation (gentle\\npressing) of the affected joints. Swelling is not associated\\nwith costochondritis. Diagnosis is also dependent on the\\nexclusion of other causes, including heart attack or bac-\\nterial or fungal infections found in IV drug users or post-\\noperative thoracic surgery patients.\\nTreatment\\nThe goals of treatment are to reduce inflammation and\\nto control pain. To accomplish these goals, nonsteroidal\\nanti-inflammatory agents (NSAIDs) are used, with ibupro-\\nfen usually selected as the drug of choice. Other NSAIDS\\noptions are flurbiprofen, mefenamic acid, ketoprofen, and\\nnaproxen. Additional treatment recommendations include\\nthe use of local heat,biofeedback, and gentle stretching of\\nthe pectoralis muscles two to three times a day.\\nFor more difficult cases, where the patient continues\\nto exhibit pain and discomfort, cortisone injections are\\nused as therapy.\\nAlternative treatment\\nSupplements that are used to reduce inflammation\\nhave been used to treat costochondritis. Examples of\\nsuch supplements include ginger root, evening primrose\\noil, bromelain, vitamin E, omega-3 oils, and white wil-\\nlow bark. Glucosamine/chondroitin sulfate, which may\\naid in the healing of cartilage, has also been used. Other\\nalternative therapies include acupuncture and massages.\\nPrognosis\\nThe prognosis for recovery from costochondritis is\\ngood. For most patients, the condition lessens in six\\nGALE ENCYCLOPEDIA OF MEDICINE 2940\\nCostochondritis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 940'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 329, 'page_label': '330'}, page_content='months to a year. However, after one year, about one-half\\nof patients continue with some discomfort, while about\\none-third still report tenderness with palpation.\\nPrevention\\nThough the causes of costochondritis are not well\\nknown, avoidance of activities that may strain (e.g., the\\nrepetitive misuse of muscles) or cause trauma to the rib\\ncage is recommended to prevent the occurrence of costo-\\nchondritis. Modification of improper posture or\\nergonomics of the home or work place may also deter the\\ndevelopment of this condition.\\nResources\\nOTHER\\nDay, C. Costochondritis Web Site.2001. .\\nFlowers, L. K., and B. D. Wippermann. “Costochondritis.”\\neMedicine Journal: Emergency Medicine/Rheumatology.\\n23 Feb. 2001. .\\nJudith Sims\\nCotrel-Dubousset spinal instrumentation see\\nSpinal instrumentation\\nCough\\nDefinition\\nA cough is a forceful release of air from the lungs\\nthat can be heard. Coughing protects the respiratory sys-\\ntem by clearing it of irritants and secretions.\\nDescription\\nWhile people can generally cough voluntarily, a\\ncough is usually a reflex triggered when an irritant stim-\\nulates one or more of the cough receptors found at dif-\\nferent points in the respiratory system. These receptors\\nthen send a message to the cough center in the brain,\\nwhich in turn tells the body to cough. A cough begins\\nwith a deep breath in, at which point the opening\\nbetween the vocal cords at the upper part of the larynx\\n(glottis) shuts, trapping the air in the lungs. As the\\ndiaphragm and other muscles involved in breathing\\npress against the lungs, the glottis suddenly opens, pro-\\nducing an explosive outflow of air at speeds greater than\\n100 mi (160 km) per hour.\\nIn normal situations, most people cough once or\\ntwice an hour during the day to clear the airway of irri-\\ntants. However, when the level of irritants in the air is\\nhigh or when the respiratory system becomes infected,\\ncoughing may become frequent and prolonged. It may\\ninterfere with exercise or sleep, and it may also cause dis-\\ntress if accompanied by dizziness, chest pain, or breath-\\nlessness. In the majority cases, frequent coughing lasts\\none to two weeks and tapers off as the irritant or infection\\nsubsides. If a cough lasts more than three weeks it is con-\\nsidered a chronic cough, and physicians will try to deter-\\nmine a cause beyond an acute infection or irritant.\\nCoughs are generally described as either dry or pro-\\nductive. A dry cough does not bring up a mixture of\\nmucus, irritants, and other substances from the lungs\\n(sputum), while a productive cough does. In the case of a\\nbacterial infection, the sputum brought up in a productive\\ncough may be greenish, gray, or brown. In the case of an\\nallergy or viral infection it may be clear or white. In the\\nmost serious conditions, the sputum may contain blood.\\nCauses and symptoms\\nIn the majority of cases, coughs are caused by respi-\\nratory infections, including:\\n• colds or influenza, the most common causes of coughs\\n• bronchitis, an inflammation of the mucous membranes\\nof the bronchial tubes\\n• croup, a viral inflammation of the larynx, windpipe,\\nand bronchial passages that produces a bark-like cough\\nin children\\n• whooping cough, a bacterial infection accompanied by\\nthe high-pitched cough for which it is named\\n• pneumonia , a potentially serious bacterial infection\\nthat produces discolored or bloody mucus\\n• tuberculosis , another serious bacterial infection that\\nproduces bloody sputum\\n• fungal infections, such as aspergillosis , histoplasmo-\\nsis, and cryptococcoses\\nEnvironmental pollutants, such as cigarette smoke,\\ndust, or smog, can also cause a cough. In the case of cig-\\narette smokers, the nicotine present in the smoke para-\\nlyzes the hairs (cilia) that regularly flush mucus from the\\nrespiratory system. The mucus then builds up, forcing\\nthe body to removed it by coughing. Post-nasal drip, the\\nirritating trickle of mucus from the nasal passages into\\nthe throat caused by allergies or sinusitis, can also result\\nin a cough. Some chronic conditions, such as asthma,\\nchronic bronchitis, emphysema, and cystic fibrosis, are\\ncharacterized in part by a cough. A condition in which\\nstomach acid backs up into the esophagus (gastroe-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 941\\nCough\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 941'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 330, 'page_label': '331'}, page_content='sophageal reflux) can cause coughing, especially when a\\nperson is lying down. A cough can also be a side-effect\\nof medications that are administered via an inhaler. It can\\nalso be a side-effect of beta-blockers and ACE inhibitors,\\nwhich are drugs used for treating high blood pressure.\\nDiagnosis\\nTo determine the cause of a cough, a physician\\nshould take an exact medical history and perform an\\nexam. Information regarding the duration of the cough,\\nwhat other symptoms may accompany it, and what envi-\\nronmental factors may influence it aid the doctor in his or\\nher diagnosis. The appearance of the sputum will also\\nhelp determine what type of infection, if any, may be\\ninvolved. The doctor may even observe the sputum\\nmicroscopically for the presence of bacteria and white\\nblood cells. Chest x rays may help indicate the presence\\nand extent of such infections as pneumonia or tuberculo-\\nsis. If these actions are not enough to determine the cause\\nof the cough, a bronchoscopy or laryngoscopy may be\\nordered. These tests use slender tubular instruments to\\ninspect the interior of the bronchi and larynx.\\nTreatment\\nTreatment of a cough generally involves addressing\\nthe condition causing it. An acute infection such as pneu-\\nmonia may require antibiotics , an asthma-induced\\ncough may be treated with the use of bronchodialators,\\nor an antihistamine may be administered in the case of an\\nallergy. Physicians prefer not to suppress a productive\\ncough, since it aids the body in clearing respiratory sys-\\ntem of infective agents and irritants. However, cough\\nKEY TERMS\\nAntitussives—Drugs used to suppress coughing.\\nExpectorant—Drug used to thin mucus.\\nGastroesophageal reflux —Condition in which\\nstomach acid backs up into the esophagus.\\nGlottis—The opening between the vocal cords at\\nthe upper part of the larynx.\\nLarynx— A part of the respiratory tract between the\\npharynx and the trachea, having walls of cartilage\\nand muscle and containing the vocal cords.\\nSputum—The mixture of mucus, irritants, and\\nother substances expelled from the lungs by\\ncoughing.\\nmedicines may be given if the patient cannot rest because\\nof the cough or if the cough is not productive, as is the\\ncase with most coughs associated with colds or flu. The\\ntwo types of drugs used to treat coughs are antitussives\\nand expectorants.\\nAntitussives\\nAntitussives are drugs that suppress a cough. Nar-\\ncotics—primarily codeine—are used as antitussives and\\nwork by depressing the cough center in the brain. How-\\never, they can cause such side effects as drowsiness, nau-\\nsea, and constipation . Dextromethorphan, the primary\\ningredient in many over-the-counter cough remedies,\\nalso depresses the brain’s cough center, but without the\\nside effects associated with narcotics. Demulcents\\nrelieve coughing by coating irritated passageways.\\nExpectorants\\nExpectorants are drugs that make mucus easier to\\ncough up by thinning it. Guaifenesin and terpin hydrate\\nare the primary ingredients in most over-the-counter\\nexpectorants. However, some studies have shown that in\\nacute infections, simply increasing fluid intake has the\\nsame thinning effect as taking expectorants.\\nAlternative treatment\\nCoughs due to bacterial or viral upper respiratory\\ninfections may be effectively treated with botanical and\\nhomeopathic therapies. The choice of remedy will vary\\nand be specific to the type of cough the patient has. Some\\ncombination over-the-counter herbal and homeopathic\\ncough formulas can be very effective for cough relief.\\nLingering coughs or coughing up blood should be treated\\nby a trained practitioner.\\nMany health practitioners advise increasing fluids\\nand breathing in warm, humidified air as ways of loosen-\\ning chest congestion. Others recommend hot tea flavored\\nwith honey as a temporary home remedy for coughs\\ncaused by colds or flu. Various vitamins, such as vitamin\\nC, may be helpful in preventing or treating conditions\\n(including colds and flu) that lead to coughs. Avoiding of\\nmucous-producing foods can be effective in healing a\\ncough condition. These mucous-producing foods can\\nvary, based on individual intolerance, but dairy products\\nare a major mucous-producing food for most people.\\nPrognosis\\nBecause the majority of coughs are related to the\\ncommon cold or influenza, most will end in seven to 21\\ndays. The outcome of coughs due to a more serious under-\\nlying disease depends on the pathology of that disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 2942\\nCough\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 942'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 331, 'page_label': '332'}, page_content='Prevention\\nIt is important to identify and treat the underlying\\ndisease and origin of the cough. Avoid smoking and\\ncoming in direct contact with people experiencing cold\\nor flu symptoms. Wash hands frequently during episodes\\nof upper-respiratory illnesses.\\nResources\\nBOOKS\\nChandrasoma, Parakrama, and Clive R. Taylor. Concise Pathol-\\nogy. East Norwalk, CT: Appleton & Lange, 1991.\\nSchumann, Lorna. “Alterations in Respiratory Function.” In\\nPerspectives on Pathophysiology, ed. Lee-Ellen Copstead.\\nPhiladelphia: W. B. Saunders Co., 1994.\\nPERIODICALS\\nPhilp, Elizabeth B. “Chronic Cough.”American Family Physi-\\ncian 56 (1 Oct. 1997).\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nJeffrey P. Larson, RPT\\nCough suppressants\\nDefinition\\nCough suppressants are medicines that prevent or\\nstop coughing.\\nPurpose\\nCough suppressants act on the center in the brain\\nthat controls the cough reflex. They are meant to be used\\nonly to relieve dry, hacking coughs associated with colds\\nand flu. They should not be used to treat coughs that\\nbring up mucus or the chronic coughs associated with\\nsmoking, asthma, emphysema or other lung problems.\\nMany cough medicines contain cough suppressants\\nalong with other ingredients. Some combinations of\\ningredients may cancel each other’s effects. One example\\nis the combination of cough suppressant with an expecto-\\nrant—a medicine that loosens and clears mucus from the\\nairways. The cough suppressant interferes with the ability\\nto cough up the mucus that the expectorant loosens.\\nDescription\\nThe cough suppressant described here, dextrom-\\nethorphan, is an ingredient in many cough medicines,\\nKEY TERMS\\nAsthma—A disease in which the air passages of\\nthe lungs become inflamed and narrowed.\\nBronchitis —Inflammation of the air passages of\\nthe lungs.\\nChronic—A word used to describe a long-lasting\\ncondition. Chronic conditions often develop grad-\\nually and involve slow changes.\\nEmphysema —An irreversible lung disease in\\nwhich breathing becomes increasingly difficult.\\nMucus—Thick fluid produced by the moist mem-\\nbranes that line many body cavities and structures.\\nPhenylketonuria (PKU) —A genetic disorder in\\nwhich the body lacks an important enzyme. If\\nuntreated, the disorder can lead to brain damage\\nand mental retardation.\\nsuch as Vicks Formula 44, Drixoral Cough Liquid Caps,\\nSucrets Cough Control, Benylin DM and some Robi-\\ntussin products. These medicines come in capsule, tablet,\\nlozenge, and liquid forms and are available without a\\nphysician’s prescription.\\nRecommended dosage\\nRegular (short-acting) capsules, lozenges, syrups,\\nor tablets:\\nADULTS AND CHILDREN OVER 12. 10-30 mg every\\n4-8 hours, as needed.\\nCHILDREN 6-12. 5-15 mg every 4-8 hours, as needed.\\nCHILDREN 2-6. 2.5-7.5 mg every 4-8 hours, as need-\\ned.\\nChildren under 6 should not be given lozenges con-\\ntaining dextromethorphan because of the high dose of\\ndextromethorphan in each lozenge.\\nCHILDREN UNDER 2. Check with child’s physician.\\nChildren under 6 should not be given lozenges con-\\ntaining dextromethorphan.\\nFor extended-release oral suspension\\nADULTS AND CHILDREN OVER 12. 60 mg every 12\\nhours, as needed.\\nCHILDREN 6-12. 30 mg every 12 hours, as needed.\\nCHILDREN 2-6. 15 mg every 12 hours, as needed.\\nCHILDREN UNDER 2. Check with child’s physician.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 943\\nCough suppressants\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 943'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 332, 'page_label': '333'}, page_content='Precautions\\nDo not take more than the recommended daily\\ndosage of dextromethorphan.\\nDextromethorphan is not meant to be used for\\ncoughs associated with smoking, asthma, emphysema,\\nchronic bronchitis , or other lung conditions. It also\\nshould not be used for coughs that produce mucus.\\nA lingering cough could be a sign of a serious med-\\nical condition. Coughs that last more than seven days or\\nare associated with fever, rash, sore throat , or lasting\\nheadache should have medical attention. Call a physi-\\ncian as soon as possible.\\nPeople with phenylketonuria should be aware that\\nsome products with dextromethorphan also contain the\\nartificial sweetener aspartame, which breaks down in the\\nbody to phenylalanine.\\nAnyone who has asthma or liver disease should\\ncheck with a physician before taking dextromethorphan.\\nWomen who are pregnant or breastfeeding or who\\nplan to become pregnant should check with their physi-\\ncians before taking dextromethorphan.\\nThe dye tartrazine is an ingredient in some cough\\nsuppressant products. This dye causes allergic reactions\\nin some people, especially those who are allergic to\\naspirin.\\nSide effects\\nSide effects are rare, but may include nausea, vomit-\\ning, stomach upset, slight drowsiness, and dizziness.\\nInteractions\\nPatients who take monoamine oxidase inhibitors\\n(MAO inhibitors) should be aware that the co-adminis-\\ntration of products containing dextromethorphan can\\ncause dizziness, fainting , fever, nausea, and possibly\\ncoma. Do not take dextromethorphan unless a physician\\npermits the use of the two drugs together.\\nWhen dextromethorphan is taken with medicines\\nthat cause drowsiness, this effect may be enhanced.\\nNancy Ross-Flanigan\\nCoughing and deep-breathing exercises see\\nChest physical therapy\\nCoxsackievirus infections see Enterovirus\\ninfections\\nCPK test see Creatine kinase test\\nCPR see Cardiopulmonary resuscitation\\nCrab lice see Lice infestation\\nCradle cap see Seborrheic dermatitis\\nCramps see Dysmenorrhea\\nCranial arteritis see Temporal arteritis\\nCranial manipulation see Craniosacral\\ntherapy\\nCraniopharyngioma see Pituitary tumors\\nCraniosacral therapy\\nDefinition\\nCraniosacral therapy is a holistic healing practice\\nthat uses very light touching to balance the craniosacral\\nsystem in the body, which includes the bones, nerves, flu-\\nids, and connective tissues of the cranium and spinal area.\\nPurpose\\nAccording to Upledger, craniosacral therapy is ide-\\nally suited for attention-deficit hyperactivity disorder\\n(ADHD), headaches, chronic middle ear infection, pain,\\nand general health maintenance. It is recommended for\\nautism, fibromyalgia , heart disease, osteoarthritis ,\\npneumonia, rheumatoid arthritis , chronic sinus infec-\\ntions, and gastroenteritis (inflammation of the lining of\\nthe stomach or small intestine). It is also used with other\\ntherapies to treat chronic fatigue syndrome , back pain,\\nand menstrual irregularity. In addition, other craniosacral\\npractitioners have reported benefits for eye dysfunction,\\ndyslexia , depression, motor coordination difficulties,\\ntemporomandibular joint dysfunction (TMD), hyperac-\\ntivity, colic, asthma in babies, floppy baby syndrome,\\nwhiplash , cerebral palsy , certain birth defects , and\\nother central nervous system disorders.\\nDescription\\nOrigins\\nThe first written reference to the movement of the\\nspinal nerves and its importance in life, clarity, and\\n“bringing quiet to the heart” is found in a 4,000-year-old\\ntext from China. Craniosacral work was referred to as\\n“the art of listening.” Bone setters in the Middle Ages\\nalso sensed the subtle movements of the body. They used\\nthese movements to help reset fractures and dislocations\\nand to treat headaches.\\nGALE ENCYCLOPEDIA OF MEDICINE 2944\\nCraniosacral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 944'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 333, 'page_label': '334'}, page_content='In the early 1900s, the research of Dr. William\\nSutherland, an American osteopathic physician, detailed\\nthe movement of the cranium and pelvis. Before his\\nresearch it was believed that the cranium was a solid\\nimmovable mass. Sutherland reported that the skull is\\nactually made up of 22 separate and movable bones that\\nare connected by layers of tissue. He called his work cra-\\nnial osteopathy. Nephi Cotton, an American chiroprac-\\ntor and contemporary of Sutherland, called this approach\\ncraniology. The graduates of these two disciplines have\\nrefined and enhanced these original approaches and\\nrenamed their work as sacro-occipital technique, cranial\\nmovement therapy, or craniosacral therapy.\\nDr. John Upledger, an osteopathic physician, and\\nothers at the Department of Biomechanics at Michigan\\nState University, College of Osteopathic Medicine\\nlearned of Sutherland’s research and developed it further.\\nHe researched the clinical observations of various osteo-\\npathic physicians. This research provided the basis for\\nUpledger’s work that he named craniosacral therapy.\\nCraniosacral therapy addresses the craniosacral sys-\\ntem. This system includes the cranium, spine, and\\nsacrum that are connected by a continuous membrane of\\nconnective tissue deep inside the body, called the dura\\nmater. The dura mater also encloses the brain and the\\ncentral nervous system. Sutherland noticed that cerebral\\nspinal fluid rises and falls within the compartment of the\\ndura mata. He called this movement the primary respira-\\ntory impulse; today it is known as the craniosacral\\nrhythm (CSR) or the cranial wave.\\nCraniosacral therapists can most easily feel the CSR\\nin the body by lightly touching the base of the skull or\\nthe sacrum. During a session, they feel for disturbances\\nin the rate, amplitude, symmetry, and quality of flow of\\nthe CSR. A therapist uses very gentle touch to balance\\nthe flow of the CSR. Once the cerebrospinal fluid moves\\nfreely, the body’s natural healing responses can function.\\nA craniosacral session generally lasts 30–90 min-\\nutes. The client remains fully clothed and lays down on a\\nmassage table while the therapist gently assesses the\\nflow of the CSR. Upledger describes several techniques\\nwhich may be used in a craniosacral therapy session. The\\nfirst is energy cyst release. “This technique is a hands-on\\nmethod of releasing foreign or disruptive energies from\\nthe patient’s body. Energy cysts may cause the disruption\\nof the tissues and organs were they are located.” The\\ntherapist feels these cysts in the client’s body and gently\\nreleases the blockage of energy.\\nSutherland first wrote about a second practice called\\ndirection of energy. In this technique the therapist intends\\nenergy to pass from one of his hands, through the patient,\\ninto the other hand.\\nWILLIAM SUTHERLAND\\n(1873–1954)\\nWilliam Garner Sutherland studied osteopathy\\nunder its founder, Andrew Taylor Still. Dr. Sutherland\\nmade his own important discovery while examining the\\nsutures of cranial bones the skull bones that protect the\\nbrain. What he noticed is that the sutures were designed\\nfor motion. Sutherland termed this motion the Breath of\\nLife. Through his experiments and research he deter-\\nmined that primary respiration was essential to all other\\nphysiological functions.\\nWhen Sutherland developed his techniques for\\ncraniosacral therapy, he wanted it to serve as a vehicle\\nfor listening to the body’s rhythmic motions and treat the\\npatterns of inertia when those motions become congest-\\ned. He believed that the stresses—any physical or emo-\\ntional trauma—created an imbalance in the body that\\nneeded correction to restore it to full health. The therapy\\nis a hands-on method so that the therapist can feel the\\nsubtleties of the patterns of movement and inertia.\\nSutherland felt that this was the way to encourage self-\\nhealing and restoration of the body’s own mechanisms,\\ntaking a holistic approach to creating optimal health.\\nThe Craniosacral Therapy Educational Trust, based\\non Sutherland’s pioneering work, is located at 10 Norm-\\nington Close, Leigham Court Road, London SW16 2QS,\\nUnited Kingdom. The phone number is 07000 785778.\\nThe third technique is called myofascial release.\\nThis is a manipulative form of bodywork that releases\\ntension in the fascia or connective tissue of the body.\\nThis form of bodywork uses stronger touch.\\nUpledger’s fourth technique is position of release.\\nThis involves following the client’s body into the posi-\\ntions in which an injury occurred and holding it there.\\nWhen the rhythm of the CSR suddenly stops the therapist\\nknows that the trauma has been released.\\nThe last technique is somatoemotional release. This\\ntechnique was developed by Upledger and is an offshoot\\nof craniosacral therapy. It is used to release the mind and\\nbody of the residual effects of trauma and injury that are\\n“locked in the tissues.”\\nThe cost of a session varies due to the length of time\\nneeded and the qualifications of the therapist. The cost\\nmay be covered by insurance when the therapy is per-\\nformed or prescribed by a licensed health care provider.\\nPrecautions\\nThis gentle approach is extremely safe in most cases.\\nHowever, craniosacral therapy is not recommended in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 945\\nCraniosacral therapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 945'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 334, 'page_label': '335'}, page_content='cases of acute systemic infections, recent skull fracture,\\nintracranial hemorrhage or aneurysm, or herniation of the\\nmedulla oblongata (brain stem). Craniosacral therapy\\ndoes not preclude the use of other medical approaches.\\nSide effects\\nSome people may experience mild discomfort after a\\ntreatment. This may be due to re-experiencing a trauma or\\ninjury or a previously numb area may come back to life\\nand be more sensitive. These side effects are temporary.\\nResearch and general acceptance\\nMore than 40 scientific papers have been published\\nthat document the various effects of craniosacral therapy.\\nThere are also 10 authoritative textbooks on this therapy.\\nThe most notable scientific papers include Viola M. Fry-\\nman’s work documenting the successful treatment of\\n1,250 newborn children with birth defects. Edna Lay and\\nStephen Blood showed the effects on TMD, and John\\nWood documented results with psychiatric disorders.\\nThe American Dental Association has found craniosacral\\ntherapy to be an effective adjunct to orthodontic work.\\nHowever, the conventional medical community has not\\nendorsed these techniques.\\nResources\\nBOOKS\\nKnaster, Mirka. Discovering the Body’s Wisdom.New York:\\nBantam Books, 1996.\\nMilne, Hugh. Heart of Listening: A Visionary Approach to\\nCraniosacral Work: Anatomy. Technique, Transcendence.\\n2nd ed. Berkeley, CA: North Atlantic Books, 1998.\\nUpledger, John E. “CranioSacral Therapy.” In Clinician’s Com-\\nplete Reference to Complementary and Alternative Medi-\\ncine, ed. Donald Novey. St. Louis, MO: 2000.\\nUpledger, John E. Your Inner Physician and You: CranioSacral\\nTherapy Somatoemotional Release. Berkeley, CA: North\\nAtlantic Books, 1991.\\nUpledger, John E. and John Vredevoogd. Craniosacral Thera-\\npy. Seattle: Eastland Press, 1983.\\nORGANIZATIONS\\nMilne Institute Inc. P.O. Box 2716, Monterey, CA 93942-2716.\\n(831) 649-1825. Fax: (831) 649-1826. . .\\nUpledger Institute. 11211 Prosperity Farms Road, Palm Beach\\nGardens, FL 33410. (800) 233-5880. Fax: (561) 622-\\n4771. .\\nOTHER\\nMilne, Hugh. A Client’s Introduction to Craniosacral Work.\\nPamphlet. Milne Institute.\\nLinda Chrisman\\nCraniotomy\\nDefinition\\nSurgical removal of part of the skull to expose the\\nbrain.\\nPurpose\\nA craniotomy is the most commonly performed\\nsurgery for brain tumor removal. It may also be done to\\nremove a blood clot and control hemorrhage, inspect the\\nbrain, perform a biopsy, or relieve pressure inside the skull.\\nPrecautions\\nBefore the operation, the patient will have undergone\\ndiagnostic procedures such as computed tomography\\nscans (CT) or magnetic resonance imaging(MRI) scans\\nto determine the underlying problem that required the\\ncraniotomy and to get a better look at the brain’s structure.\\nCerebral angiography may be used to study the blood\\nsupply to the tumor, aneurysm, or other brain lesion.\\nDescription\\nThere are two basic ways to open the skull:\\n• a curving incision from behind the hairline, in front of\\nthe ear, arching above the eye\\n• at the nape of the neck around the occipital lobe\\nThe surgeon marks with a felt tip pen a large square\\nflap on the scalp that covers the surgical area. Following\\nthis mark, the surgeon makes an incision into the skin as\\nfar as the thin membrane covering the skull bone.\\nBecause the scalp is well supplied with blood, the sur-\\ngeon will have to seal many small arteries. The surgeon\\nthen folds back a skin flap to expose the bone.\\nUsing a high speed hand drill or an automatic cran-\\niotome, the surgeon makes a circle of holes in the skull,\\nand pushes a soft metal guide under the bone from one\\nhole to the next. A fine wire saw is then moved along the\\nguide channel under the bone between adjacent holes.\\nThe surgeon saws through the bone until the bone flap\\ncan be removed to expose the brain.\\nAfter the surgery for the underlying cause is com-\\npleted, the piece of skull is replaced and secured with\\npieces of fine, soft wire. Finally, the surgeon sutures the\\nmembrane, muscle, and skin of the scalp.\\nPreparation\\nBefore the surgery, patients are usually given drugs\\nto ease anxiety, and other medications to reduce the risk\\nGALE ENCYCLOPEDIA OF MEDICINE 2946\\nCraniotomy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 946'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 335, 'page_label': '336'}, page_content='of swelling, seizures, and infection after the operation.\\nFluids may be restricted, and a diuretic may be given\\nbefore and during surgery if the patient has a tendency to\\nretain water. A catheter is inserted before the patient goes\\nto the operating room.\\nThe scalp is shaved in the operating room right\\nbefore surgery; this is done so that any small nicks in the\\nskin won’t have a chance to become infected before the\\noperation.\\nAftercare\\nOxygen, painkillers, and drugs to control swelling\\nand seizures are given after the operation. Codeine may\\nbe given to relieve the headache that may occur as a\\nresult of stretching or irritation of the nerves of the scalp\\nthat happens during the craniotomy. Some type of\\ndrainage from the head may be in place, depending on\\nthe reason for the surgery.\\nPatients are usually out of bed within a day and out\\nof the hospital within a week. Headache and pain from\\nthe scalp wound can be controlled with medications.\\nThe bandage on the skull should be changed regular-\\nly. Sutures closing the scalp will be removed, but soft\\nwires used to reattach the skull are permanent and\\nrequire no further attention. The patient should avoid get-\\nting the scalp wet until all the sutures have been\\nremoved. A clean cap or scarf can be worn until the hair\\ngrows back.\\nRisks\\nAccessing the area of the brain that needs repair may\\ndamage other brain tissue. Therefore, the procedure car-\\nries with it some risk of brain damage that could leave\\nthe patient with some loss of brain function. The surgeon\\nperforming the operation can give the patient an assess-\\nment of the risk of his or her particular procedure.\\nNormal results\\nWhile every patient’s experience is different depend-\\ning on the reason for the surgery, age, and overall health,\\nif the surgery has been successful, recovery is usually\\nrapid because of the good supply of blood to the area.\\nAbnormal results\\nPossible complications after craniotomy include:\\nGALE ENCYCLOPEDIA OF MEDICINE 2 947\\nCraniotomy\\nFigure A Figure B\\nScalp incisions Bone is sawed\\nat base of flap\\nCut joining\\nburr holes\\nA craniotomy is the most commonly performed surgery for brain tumor removal.There are two basic ways to open the skull:\\na curving incision from behind the hairline in front of the ear and at the nape of the neck (figure A).To reach the brain, the\\nsurgeon uses a hand drill to make holes in the skull, pushing a soft metal guide under the bone.The bone is sawed through\\nuntil the bone flap can be removed to expose the brain (figure B).(Illustration by Electronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 947'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 336, 'page_label': '337'}, page_content='• swelling of the brain\\n• excessive intracranial pressure\\n• infection\\n• seizures\\nResources\\nBOOKS\\nSmeltzer, Suzanne, and Brenda Bare. “Management of Patients\\nwith Neurological Dysfunction.” In Brunner and Sud-\\ndarth’s Textbook of Medical/Surgical Nursing.7th ed.\\nPhiladelphia: J. B. Lippincott Co., 1992.\\nThe Surgery Book: An Illustrated Guide to 73 of the Most Com-\\nmon Operations. Ed. Robert M. Younson, et al. New York:\\nSt. Martin’s Press, 1993.\\nCarol A. Turkington\\nCreatine kinase test\\nDefinition\\nThe creatine kinase test measures the blood levels of\\ncertain muscle and brain enzyme proteins.\\nPurpose\\nCreatine kinase (CK or CPK) is an enzyme (a type\\nof protein) found in muscle and brain. Normally, very lit-\\ntle CK is found circulating in the blood. Elevated levels\\nindicate damage to either muscle or brain; possibly from\\na myocardial infarction ( heart attack ), muscle disease,\\nor stroke.\\nThere are three types, or isoforms, of CK:\\n• CK-I, or BB, is produced primarily by brain and\\nsmooth muscle.\\n• CK-II, or MB, is produced primarily by heart muscle.\\n• CK-III, or MM, is produced primarily by skeletal muscle.\\nPrecautions\\nNo special precautions are necessary, except in\\npatients with a bleeding disorder.\\nKEY TERMS\\nCraniotome—A type of surgical drill used to oper-\\nate on the skull. It has a self-controlled system that\\nstops the drill when the bone is penetrated.\\nDescription\\nA small amount of blood is drawn and used for labo-\\nratory analysis.\\nPreparation\\nPhysical activity may cause a rise in CK levels,\\nespecially the CK-III fraction. Therefore, patients should\\nnot engage in strenuous physical activity the day of the\\ntest. The patient should report any recent injections, falls,\\nor bruises that have occurred, as these may elevate CK\\nlevels as well.\\nAftercare\\nNo aftercare is required, except to keep the puncture\\nsite clean while it heals.\\nRisks\\nThere are no risks to this test beyond the very slight\\nrisk of infection at the puncture site.\\nNormal results\\nIn females, total CK should be 10–79 units per liter\\n(U/L). In males, total CK should be 17–148 U/L. CK lev-\\nels are reduced in the first half of pregnancy , and\\nincreased in the second half. CK levels are elevated in\\nnewborns.\\nThe distribution of isoenzymes should be:\\n• CK-I: 0%\\n• CK-II: 0–5%\\n• CK-III: 95–100%\\nAbnormal results\\nElevation of CK-I may be seen in stroke, extreme\\nshock, or brain tumor.\\nElevation of CK-II is seen after a myocardial infarc-\\ntion. It begins to rise three to six hours after the heart\\nattack, and may peak within 24 hours. It should then\\nreturn to normal. For this reason, it is a useful marker for\\nrecent myocardial infarction, but not for one which\\noccurred more than a day before the test.\\nElevation of CK-III indicates skeletal muscle dam-\\nage. This may occur from normal exercise , trauma, or\\nmuscle disease. CK levels may be very high early on in\\nmuscular dystrophy , but may fall to normal later as\\nmuscle tissue is lost. Elevated CK is also seen in myosi-\\ntis, myoglobinuria, toxoplasmosis , and trichinosis .\\nHypothyroidism may also cause elevated CK.\\nGALE ENCYCLOPEDIA OF MEDICINE 2948\\nCreatine kinase test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 948'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 337, 'page_label': '338'}, page_content='Resources\\nBOOKS\\nCorbett, Jane Vincent. Laboratory Tests and Diagnostic Proce-\\ndures with Nursing Diagnoses. 2nd ed. Los Altos, CA:\\nAppleton & Lange, 1987.\\nRichard Robinson\\nCreatine phosphkinase test see Creatine\\nkinase test\\nCreatinine test\\nDefinition\\nCreatine is an important compound produced by the\\nbody. It combines with phosphorus to make a high-\\nenergy phosphate compound in the body. Creatine phos-\\nphate is used in skeletal muscle contraction.\\nPurpose\\nThe creatinine test is used to diagnose impaired kid-\\nney function and to determine renal (kidney) damage.\\nPrecautions\\nA diet high in meat content can cause transient ele-\\nvations of serum creatinine. Some drugs that may\\nincrease creatinine values include gentamicin, cimeti-\\ndine, heavy-metal chemotherapeutic agents (e.g., cis-\\nplatin), and other drugs toxic to the kidneys, such as the\\ncephalosporins.\\nDescription\\nThe creatinine test is used to measure the amount of\\ncreatinine in the blood. Because creatinine is a nonpro-\\ntein end-product of creatine phosphate, which is used in\\nKEY TERMS\\nSkeletal muscles—Muscles which move the skele-\\nton. All of the muscles under voluntary control are\\nskeletal muscles.\\nSmooth muscles —Muscles that surround the lin-\\nings of the digestive system, airways, and circula-\\ntory system.\\nskeletal muscle contraction, the daily production of crea-\\ntine, and the following product, creatinine, depends on\\nmuscle mass, which fluctuates very little.\\nCreatinine is excreted entirely by the kidneys, and\\ntherefore is directly related to renal function. When the\\nkidneys are functioning normally, the serum creatinine\\nlevel should remain constant and normal. Slight increas-\\nes in creatine levels can appear after meals, especially\\nafter ingestion of large quantities of meat, and some diur-\\nnal variation may occur, with a low point at 7 \\nA.M. and a\\npeak at 7 P.M. Serious renal disorders, such as glomeru-\\nlonephritis , pyelonephritis , and urinary obstruction,\\nwill cause abnormal elevations.\\nThe creatinine level is interpreted in conjunction\\nwith another kidney function test called the Blood Urea\\nNitrogen (BUN). The serum creatinine level has much\\nthe same significance as the BUN but tends to rise later.\\nBecause of this, determinations of creatinine help to\\nchronicle a disease process. Generally, a doubling of cre-\\natinine suggests a 50% reduction in kidney filtration rate.\\nPreparation\\nThe creatinine test requires a blood sample. It is rec-\\nommended that the patient be fasting (nothing to eat or\\ndrink) for at least eight hours before the test. The physi-\\ncian may also require that ascorbic acid (vitamin C),\\nbarbiturates, and diuretics be withheld for 24 hours.\\nRisks\\nRisks for this test are minimal, but may include\\nslight bleeding from the blood-drawing site, fainting or\\nfeeling lightheaded after venipuncture, or hematoma\\n(blood accumulating under the puncture site).\\nNormal results\\nNormal values can vary from laboratory to laborato-\\nry, but are generally in the following ranges:\\n• Adult female: 0.5–1.1 mg/dL\\n• Adult male: 0.6–1.2 mg/dL\\n• Adolescent: 0.5–1.0 mg/dL\\n• Child: 0.3–0.7 mg/dL\\n• Infant: 0.2–0.4 mg/dL\\n• Newborn: 0.3–1.2 mg/dL\\nNote that variations between sources for serum crea-\\ntinine normal ranges are greater than for other important\\ntests. For example, due to the greater amount of muscle\\nmass generally present, males normally demonstrate\\nhigher creatinine levels than females. Also, because the\\nkidney filtration rate normally increases in pregnancy ,\\nserum creatinine should be slightly less during such peri-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 949\\nCreatinine test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 949'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 338, 'page_label': '339'}, page_content='ods. In older patients, creatinine is reduced because of\\ndecreased muscle mass. Similarly, other patients may\\nhave creatinine levels in which muscle abnormalities\\nmust be taken into consideration, such as long-term cor-\\nticosteroid therapy, high thyroid ( hyperthyroidism ),\\nmuscular dystrophy, or paralysis.\\nAbnormal results\\nTwo to 4 mg/dL indicate the presence of impairment\\nof renal function. Greater than 4 mg/dL indicates serious\\nimpairment in renal function.\\nResources\\nBOOKS\\nCahill, Mathew. Handbook of Diagnostic Tests.Springhouse,\\nPA: Springhouse Corporation, 1995.\\nJacobs, David S., et al. Laboratory Test Handbook.4th ed. New\\nYork: Lexi-Comp Inc., 1996.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nCreeping eruption see Cutaneous larva\\nmigrans\\nCREST syndrome see Scleroderma\\nCretinism see Hypothyroidism\\nCreutzfeldt-Jakob disease\\nDefinition\\nCreutzfeldt-Jakob disease (CJD) is a transmissible,\\nrapidly progressing, fatal neurodegenerative disorder\\nKEY TERMS\\nGlomerulonephritis —Glomerulonephritis is an\\ninflammation of the filtering units of the kidney\\n(glomeruli). The condition hinders removal of\\nwaste products, salt, and water from the blood-\\nstream, leading to serious complications. It is the\\nmost common cause of renal failure.\\nPyelonephritis—Pyelonephritis is an inflammation\\nof the kidney itself, usually caused by a bacterial\\ninfection. In its most serious form, complications\\ncan include high blood pressure (hypertension)\\nand renal failure.\\ncalled a spongioform degeneration that seems to be relat-\\ned to “mad cow disease.”\\nDescription\\nBefore 1995, Creutzfeldt-Jakob disease was little-\\nknown outside of the medical profession; even within it,\\nmany practitioners did not know much about it. Most\\ndoctors had never seen a case. With the recognition of a\\nso-called “new variant” or simply variant form of CJD\\nwith the strong possibility that those with it became\\ninfected simply by eating contaminated beef, CJD has\\nbecome one of the most talked-about diseases in the\\nworld. Additionally, the radical theory that the infectious\\nagent is a normal protein that has been changed in its\\nform has also sparked much interest.\\nFirst described in the first part of the twentieth cen-\\ntury independently by Cretzfeldt and Jakob, CJD is a\\nneurodegenerative disease causing a rapidly progressing\\ndementia ending in death, usually within eight months\\nof the onset of symptoms. It is also a very rare disease,\\naffecting only about one in every million in the popula-\\ntion through out the world. In the United States, CJD is\\nthought to affect about 250 people each year. CJD affects\\nadults primarily between ages 50 and 75.\\nSpongiform encephalopathies\\nThe most obvious pathologic feature of CJD is the\\nformation of numerous fluid-filled spaces in the brain\\n(vacuoles) resulting in a sponge-like appearance. CJD is\\none of several human “spongiform encephalopathies,”\\ndiseases that produce this characteristic change in brain\\ntissue. Others are kuru; Gerstmann-Straussler-Scheinker\\ndisease, a genetic predominantly characterized by cere-\\nbellar ataxia (a kind of movement disorder); and fatal\\nfamilial insomnia, associated with progressive insomnia,\\nautonomic system disfunction, and weakness caused by\\nmotor system dysfunction.\\nKuru was prevalent among the Fore people in Papua,\\nNew Guinea, and spread from infected individuals after\\ntheir deaths through the practice of ritual cannibalism, in\\nwhich the relatives of the dead person honored him by\\nconsuming his organs, including the brain. Discovery of\\nthe infectious nature of kuru won the Nobel Prize for\\nCarleton Gadjusek in 1976. The incubation period for\\nkuru was between four to 30 years or more. While kuru\\nhas virtually disappeared following the cessation of these\\ncannibalistic practices, several new cases continue to\\narise each year.\\nCases of CJD have been grouped into three types:\\nfamilial, iatrogenic, and sporadic.\\nGALE ENCYCLOPEDIA OF MEDICINE 2950\\nCreutzfeldt-Jakob disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 950'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 339, 'page_label': '340'}, page_content='• Familial CJD, representing 5–15% of cases, is inherited\\nin an autosomal dominant manner, meaning that either\\nparent may pass along the disease to a child, who may\\nthen develop CJD later in life.\\n• Iatrogenic CJD occurs when a person is infected during\\na medical procedure, such as organ donation, blood\\ntransfusion , or brain surgery. The rise in organ dona-\\ntion has increased this route of transmission; grafts of\\ninfected corneas and dura mater (the tissue covering the\\nbrain) have been shown to transmit CJD. Another\\nsource is hormones concentrated from the pituitary\\nglands of cadavers, some of whom carried CJD, for use\\nin people with growth hormone deficiencies. Iatrogenic\\ninfection from exposure to nerve-containing tissue rep-\\nresents a small fraction of all cases. The incubation\\nperiod between exposure to the infectious agent is very\\nlong and is estimated to be from less than 10 to more\\nthan 30 years. It remains unlikely, but not impossible,\\nthat blood from patients with CJD is infectious to oth-\\ners by transfusion.\\n• Sporadic CJD represents at least 85% of all cases. Spo-\\nradic cases have no identifiable source of infection. Death\\nusually follows first symptoms within eight months.\\nAnimal forms and “mad cow disease”\\nSix forms of spongiform encephalopathies are\\nknown to occur in other mammals: scrapie in sheep, rec-\\nognized for more than 200 years; chronic wasting disease\\nin elk and mule deer in Wyoming and Colorado; trans-\\nmissible mink encephalopathy; exotic ungulate\\nencephalopathy in some types of zoo animals; feline\\nspongiform encephalopathy in domestic cats; and bovine\\nspongiform encephalopathy (BSE) in cows.\\nBSE was first recognized in Britain in 1986. Besides\\nthe spongiform changes in the brain, BSE causes demen-\\ntia-like behavioral changes—hence the name “mad cow\\ndisease.” BSE was thought to be an altered form of\\nscrapie, transmitted to cows when they were fed sheep\\noffal (slaughterhouse waste) as part of their feed, but it is\\nnow thought to be more likely to be a primary cattle dis-\\nease spread by contaminated feed.\\nThe use of slaughterhouse offal in animal feed has\\nbeen common in many countries and has been practiced\\nfor at least 50 years. The trigger for the BSE epidemic in\\nGreat Britain seems to have come in the early 1980s,\\nwhen the use of organic solvents for preparation of offal\\nwas altered there. It is possible that these solvents had\\nbeen destroying the agent called a prion, thereby prevent-\\ning infection, and that the change in preparation proce-\\ndure opened the way for the agent to “jump species” and\\ncause BSE in cows that consumed scrapie-infected meal.\\nThe slaughter of infected (but not yet visibly sick) cows\\nat the end of their useful farm lives, and the use of their\\ncarcasses for feed, spread the infection rapidly and wide-\\nly. For at least a year after BSE was first recognized in\\nBritish herds, infected bovine remains continued to be\\nincorporated into feed, spreading the disease still further.\\nAlthough milk from infected cows has never been shown\\nto pass the infectious agent, passage from infected moth-\\ner to calf may have occurred through unknown means.\\nBeginning in 1988, the British government took\\nsteps to stop the spread of BSE, banning the use of\\nbovine offal in feed and other products and ordering the\\nslaughter of infected cows. By then, the slow-acting\\nagent had become epidemic in British herds. In 1992, it\\nwas diagnosed in over 25,000 animals (1% of the\\nBritish herd). By mid-1997, the cumulative number of\\nBSE cases in the United Kingdom had risen to more\\nthan 170,000. The feeding ban did stem the tide of the\\nepidemic; however, the number of new cases each week\\nfell from a peak of 1,000 in 1993 to less than 300 two\\nyears later.\\nThe export of British feed and beef to member coun-\\ntries was banned by the European Union, but cases of\\nBSE had developed in Europe by then as well; however,\\nby mid-1997, only about 1,000 cases had been identified.\\nIn 1989, the United States banned import of British beef\\nand began monitoring United States herds in 1990. To\\ndate, no BSE has been detected in the United States, and\\nonly one case has been reported in North America in a\\ncow imported to Canada from Great Britain.\\nV ariant CJD: The human equivalent of mad cow\\ndisease?\\nFrom the beginning of the BSE epidemic, scientists\\nand others in Britain feared that BSE might jump species\\nagain to infect humans who had consumed infected beef.\\nThis, however, had never occurred in scrapie from sheep,\\na disease known from hundreds of years. In 1996, the\\nfirst report of this possibility occurred and this fear\\nseemed to be realized with the first cases of a new variant\\nof Creutzfeldt-Jacob disease, termed nvCJD, now just\\nvCJD. Its victims are much younger than the 60–65 year\\nold average for CJD, and the time from symptom onset to\\ndeath has averaged 12 months or more instead of eight.\\nThe disease appears to cause more psychiatric symptoms\\nearly on. EEG abnormalities characteristic of CJD are\\nnot typically seen in vCJD.\\nAs of July 2001, the total number of human cases of\\nvCJD is 102. It is of major concern that the number of\\ncases per year seems to be increasing by a factor of 1.35\\neach year. Almost all the cases have been found in Great\\nBritain with three in France, one in Ireland, and one sus-\\npected in Hong Kong (who spent time in Great Britain).\\nGALE ENCYCLOPEDIA OF MEDICINE 2 951\\nCreutzfeldt-Jakob disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 951'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 340, 'page_label': '341'}, page_content='Evidence is growing stronger that vCJD is in fact\\ncaused by BSE:\\n• almost all of the cases so far have occurred in Great\\nBritain, the location of the BSE epidemic.\\n• BSE injected into monkeys produces a disease very\\nsimilar to vCJD\\n• BSE and vCJD produce the same brain lesions after the\\nsame incubation period when injected into laboratory\\nmice\\n• brain proteins isolated from vCJD victims, but not from\\nthe other forms of CJD, share similar molecular charac-\\nteristics with brain proteins of animals that died from\\nBSE\\nMany researchers now treat the BSE-vCJD connec-\\ntion as solidly established.\\nAssuming that BSE is the source, the question that\\nhas loomed from the beginning has been is how many\\npeople will eventually be affected. Epidemiological\\nmodels of infectious disease produce estimates ranging\\nfrom less than one hundred (a level already broken) to\\ntens of thousands or more, depending on the assumptions\\nused by the modelers. The incubation period of vCJD in\\nhumans is not known, nor are the genetic and environ-\\nmental risk factors that influence susceptibility, nor the\\nquantity of infectious agent needed to cause the disease.\\nIt is estimated that between one and two million infected\\ncattle have been eaten by humans, most in the earliest\\nstages of the epidemic. Estimates cannot be based on the\\nvery few cases that have developed so far. These cases\\ncould represent the very few people with the right combi-\\nnation of exposure and susceptibility to a relatively fast-\\ndeveloping infection, or they could be the first few vic-\\ntims of a slower-acting, more highly infectious agent.\\nCauses and symptoms\\nCauses\\nIt is clear that Creutzfeldt-Jakob disease is caused by\\nan infectious agent, but it is not yet clear what type of\\nagent that is. Originally assumed to be a virus, evidence\\nis accumulating that, instead, CJD is caused by a protein\\ncalled a prion (PREE-on, for “proteinaceous infectious\\nparticle”) transmitted from victim to victim. The other\\nspongiform encephalopathies are also hypothesized to be\\ndue to prion infection.\\nIf this hypothesis is proved true, it would represent\\none of the most radical new ideas in biology since the\\ndiscovery of deoxyribonucleic acid (DNA). All infec-\\ntious diseases, in fact all life, uses nucleic acids—DNA\\nor ribonucleic acid (RNA)—to code the instructions\\nneeded for reproduction. Inactivation of the nucleic acids\\ndestroys the capacity to reproduce. However, when these\\nsame measures are applied to infected tissue from\\nspongiform encephalopathy victims, infectivity is not\\ndestroyed. Furthermore, purification of infected tissue to\\nconcentrate the infectious fraction yields protein, not\\nnucleic acid. While it remains possible that some highly\\nstable nucleic acid remains hidden within the purified\\nprotein, this is seemingly less and less likely as further\\nexperiments are done. The “prion hypothesis,” as it is\\ncalled, is now widely accepted, at least provisionally, by\\nmost researchers in the field. The most vocal proponent\\nof the hypothesis, Stanley Prusiner, was awarded the\\nNobel Prize in 1997 for his work in the prion diseases.\\nA prion is an altered form of a normal brain protein.\\nThe normal protein has a helical shape along part of its\\nlength. In the prion form, a sheet structure replaces the\\nhelix. According to the hypothesis, when the normal\\nform interacts with the prion form, some of its helical\\npart is converted to a sheet, thus creating a new prion\\ncapable of transforming other normal forms. In this way,\\nthe disease process resembles crystallization more than\\ntypical viral infection, in which the virus commands the\\nhost’s cellular machinery to reproduce more of the virus.\\nBuild-up of the sheet form causes accumulation of\\nabnormal protein clumps and degeneration of brain cells,\\nwhich is thought to cause the disease.\\nThe brain protein affected by the prion, called PrP, is\\npart of the membrane of brain cells, but its exact function\\nis unknown. It is composed of about 250 subunits, called\\namino acids, coded for by a gene on chromosome 20.\\nSlight genetic differences, called polymorphisms, give\\nrise to two slightly different normal protein forms: sub-\\nunit 129 is a “methionine” in one form, but is “valine” in\\nthe other. A person may have all of one, all of the other,\\nor a mixture of the two, depending on their genetic inher-\\nitance. Both forms have the normal helical structure, and\\nfunction normally. However, susceptibility to prion con-\\nversion is influenced by subunit 129: a person with a\\nmixture of forms is more resistant to conversion. All the\\ncases of vCJD tested have had just methionine at 129.\\nExposure to the infectious agent is, of course, still\\nrequired for disease development. Prion diseases are not\\ncontagious in the usual sense, and transmission from an\\ninfected person to another person requires direct inocula-\\ntion of infectious material.\\nFamilial CJD, on the other hand, does not require\\nexposure, but develops through the inheritance of other,\\nmore disruptive mutations in the gene for the normal PrP\\nprotein. Researchers believe these mutations increase the\\nlikelihood that the protein may more spontaneously\\n“flip” to the sheet form; once created, these can then con-\\nvert other normal-form molecules. The other two inherit-\\ned human prion diseases, Gerstmann-Straussler-\\nGALE ENCYCLOPEDIA OF MEDICINE 2952\\nCreutzfeldt-Jakob disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 952'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 341, 'page_label': '342'}, page_content='Scheinker disease and fatal familial insomnia, involve\\ndifferent mutations in the same gene.\\nThe large majority of CJD cases are sporadic, mean-\\ning they have no known route of infection or genetic link.\\nCauses of sporadic CJD are likely to be diverse and may\\ninclude spontaneous genetic mutation, spontaneous pro-\\ntein changes, or unrecognized exposure to infectious\\nagents. It is highly likely that future research will identi-\\nfy more risk factors associated with sporadic CJD.\\nSymptoms\\nAbout one in four people with CJD begin their ill-\\nness with weakness, changes in sleep patterns, weight\\nloss, or loss of appetite or sexual drive. A person with\\nCJD may first complain of visual disturbances, including\\ndouble vision, blurry vision, or partial loss of vision.\\nSome visual symptoms are secondary to cortical blind-\\nness related to death of nerve cells in the occipital lobe of\\nthe brain responsible for vision. This form of visual loss\\nis unusual in that patients may be unaware that they are\\nunable to see. These symptoms may appear weeks to\\nmonths before the onset of dementia.\\nThe most characteristic symptom of CJD is rapidly\\nprogressing dementia, or loss of mental function.\\nDementia is marked by:\\n• memory losses\\n• impaired abstraction and planning\\n• language and comprehension disturbances\\n• poor judgment\\n• disorientation\\n• decreased attention and increased restlessness\\n• personality changes and psychosis\\n• hallucinations\\nMuscle spasms and jerking movements, called\\nmyoclonus, are also a prominent symptom of CJD. Bal-\\nance and coordination disturbance (ataxia), is common in\\nCJD, and is more pronounced in nvCJD. Stiffness, diffi-\\nculty moving, and other features representing Parkinson’s\\ndisease are seen and can progress to akinetic mutism,\\nwhich is a state of being unable to speak or move.\\nDiagnosis\\nCJD is diagnosed by a clinical neurological exam\\nand electroencephalography (EEG), which shows char-\\nacteristic spikes called triphasic sharp waves. Magnetic\\nresonance imaging (MRI) or computed tomography\\nscans (CT) should be done to exclude other forms of\\ndementia, and in CJD typically shows atrophy or loss of\\nbrain tissue. Lumbar puncture, or spinal tap, may be\\ndone to rule out other causes of dementia (as cell count,\\nchemical analysis, and other routine tests are normal in\\nCJD) and to identify elevated levels of marker proteins\\nknown as 14-3-3. Another marker, neuron-specific eno-\\nlase, may also be increased in CJD. CJD is conclusively\\ndiagnosed after death by brain autopsy . Scientists are\\ninvestigating whether testing lymphatic tissue such as the\\ntonsil may be an early tool in vCJD diagnosis. Addition-\\nally, recent studies have suggested that other blood tests\\nmay be useful as well.\\nTreatment\\nThere is no cure for CJD, and no treatment that\\nslows the progression of the disease. Drug therapy and\\nnursing care are aimed at minimizing psychiatric symp-\\ntoms and increasing patient comfort. However, the rapid\\nprogression of CJD frustrates most attempts at treatment,\\nsince decreasing cognitive function and more prominent\\nbehavioral symptoms develop so quickly. Despite the\\ngenerally grim prognosis, a few CJD patients progress\\nmore slowly and live longer than the average; for these\\npatients, treatment will be more satisfactory. Scientists\\nare investigating whether some medicines that can\\n“break” the abnormal protein form may be useful and\\nwhether a vaccine could help.\\nPrognosis\\nCreutzfeldt-Jakob disease is invariably fatal, with\\ndeath following symptom onset by an average of eight\\nmonths. About 5% of patients live longer than two years.\\nDeath from vCJD has averaged approximately 12\\nmonths after onset.\\nPrevention\\nThere is no known way to prevent sporadic CJD, by\\nfar the most common type. Not everyone who inherits\\nthe gene mutation for familial CJD will develop the dis-\\nease, but at present, there is no known way to predict\\nwho will and who won’t succumb. The incidence of\\niatrogenic CJD has fallen with recognition of its sources,\\nthe development of better screening techniques for\\ninfected tissue, and the use of sterilization techniques for\\nsurgical instruments that inactivate prion proteins.\\nStrategies for prevention of vCJD are a controversial\\nmatter, as they involve a significant sector of the agricul-\\ntural industry and a central feature of the diet in many\\ncountries. The infectious potential of contaminated meat\\nis unknown, because the ability to detect prions within\\nmeat is limited. Surveillance of North American herds\\nstrongly suggests there is no BSE here, and strict regula-\\ntions on imports of European livestock make future out-\\nbreaks highly unlikely. Therefore, avoidance of all meat\\nGALE ENCYCLOPEDIA OF MEDICINE 2 953\\nCreutzfeldt-Jakob disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 953'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 342, 'page_label': '343'}, page_content='originating in North America, simply on grounds of BSE\\nrisk, is a personal choice unsupported by current data.\\nThe ban on the export of British beef continues in coun-\\ntries of the European Union, although some herds in these\\ncountries have developed low levels of infection as well.\\nResources\\nBOOKS\\nRampton, S. and J. C. Stauber. Mad Cow U.S.A.: Could the\\nNightmare Happen Here? Common Courage Press, 1997.\\nRatzan, S. C., ed. Mad Cow Crisis : Health and the Public\\nGood. New York: University Press, 1998.\\nPERIODICALS\\nHaywood, A. M. “Transmissible Spongiform Encephalopathies.”\\nNew England Journal of Medicine337 (December 18,\\n1997): 1821-1828.\\nPrusiner, S. B. “Prion Disease and the BSE Crisis.”Science\\n278 (October 10, 1997): 245-251.\\nPrusiner, S. B.”The Prion Diseases.”Scientific American 272\\n(January 1995): 48-57.\\nORGANIZATION\\nCreutzfeldt-Jakob Disease Foundation. P.O. Box 611625,\\nNorth Miami, FL 33261-1625. .\\nThe UK Creutzfeldt-Jakob Disease Surveillance Unit. .\\nLarry I. Lutwick, MD\\nCri du chat syndrome\\nDefinition\\nCri du chat syndrome occurs when a piece of chro-\\nmosomal material is missing from a particular region on\\nKEY TERMS\\nAutosomal dominant inheritance —A pattern of\\ninheritance in which a trait will be expressed if the\\ngene is inherited from either parent.\\nEncephalopathy—Brain disorder characterized by\\nmemory impairment and other symptoms.\\nIatrogenic—Caused by a medical procedure.\\nNucleic acids —The cellular molecules DNA and\\nRNA that act as coded instructions for the produc-\\ntion of proteins and are copied for transmission of\\ninherited traits.\\nchromosome 5. Individuals with this syndrome have\\nunusual facial features, poor muscle tone(hypotonia),\\nsmall head size (microcephaly), and mental\\nretardation. A classic feature of the syndrome is the cat-\\nlike cry made by infants with this disorder.\\nDescription\\nDr. Jerome Lejeune first described cri du chat syn-\\ndrome in 1963. The syndrome is named for the cat-like\\ncry made by infants with this genetic disorder. Cri du\\nchat means “cry of the cat” in French. This unusual cry is\\ncaused by abnormal development of the larynx (organ in\\nthe throat responsible for voice production). Cri du chat\\nsyndrome is also called “5p minus syndrome” because it\\nis caused by a deletion, or removal, of genetic material\\nfrom chromosome 5. The deletion that causes cri du chat\\nsyndrome occurs on the short or “p” arm of chromosome\\n5. This deleted genetic material is vital for normal devel-\\nopment. Absence of this material results in the features\\nassociated with cri du chat syndrome.\\nA high-pitched mewing cry during infancy is a classic\\nfeature of cri du chat. Infants with cri du chat also typically\\nhave low birth weight, slow growth, a small head (micro-\\ncephaly) and poor muscle tone (hypotonia). Infants with cri\\ndu chat may have congenital heart defects. Individuals with\\ncri du chat syndrome have language difficulties, delayed\\nmotor skill development, and mental retardation. Behav-\\nioral problems may also develop as the child matures.\\nIt has been estimated that cri du chat syndrome\\noccurs in one of every 50,000 live births. According to\\nthe 5p minus Society, approximately 50–60 children are\\nborn with cri du chat syndrome in the United States each\\nyear. It can occur in all races and in both sexes.\\nCauses and symptoms\\nCri du chat is the result of a chromosome abnormali-\\nty—a deleted piece of chromosomal material on chromo-\\nsome 5. In 90% of patients with cri du chat syndrome,\\nthe deletion is sporadic. This means that it happens ran-\\ndomly and is not hereditary. If a child has cri du chat due\\nto a sporadic deletion, the chance the parents could have\\nanother child with cri du chat is 1%. In approximately\\n10% of patients with cri du chat, there is a hereditary\\nchromosomal rearrangement that causes the deletion. If a\\nparent has this rearrangement, the risk for them to have a\\nchild with cri du chat is greater than 1%.\\nAn abnormal larynx causes the unusual cat-like cry\\nmade by infants that is a hallmark feature of the syndrome.\\nAs children with cri du chat get older, the cat-like cry\\nbecomes less noticeable. This can make the diagnosis\\nmore difficult in older patients. In addition to the cat-like\\nGALE ENCYCLOPEDIA OF MEDICINE 2954\\nCri du chat syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 954'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 343, 'page_label': '344'}, page_content='cry, individuals with cri du chat also have unusual facial\\nfeatures. These facial differences can be very subtle or\\nmore obvious. Microcephaly (small head size) is common.\\nDuring infancy many patients with cri du chat do not gain\\nweight or grow normally. Approximately 30% of infants\\nwith cri du chat have a congenital heart defect. Hypotonia\\n(poor muscle tone) is also common, leading to problems\\nwith eating and slow, but normal, development. Mental\\nretardation is present in all patients with cri du chat, but\\nthe degree of mental retardation varies between patients.\\nDiagnosis\\nDuring infancy, the diagnosis of cri du chat syn-\\ndrome is strongly suspected if the characteristic cat-like\\ncry is heard. If a child has this unusual cry or other fea-\\ntures seen in cri du chat syndrome, chromosome testing\\nshould be performed. Chromosome analysis provides the\\ndefinitive diagnosis of cri du chat syndrome and can be\\nperformed from a blood test. Chromosome analysis, also\\ncalled “karyotyping,” involves staining the chromosomes\\nand examining them under a microscope. In some cases\\nthe deletion of material from chromosome 5 can be easi-\\nly seen. In other cases, further testing must be performed.\\nFISH (fluorescence in-situ hybridization) is a special\\ntechnique that detects very small deletions. The majority\\nof the deletions that cause cri du chat syndrome can be\\nidentified using the FISH technique.\\nKEY TERMS\\nAminocentesis —A procedure performed at 16–18\\nweeks of pregnancy in which a needle is inserted\\nthrough a woman’s abdomen into her uterus to\\ndraw out a small sample of the amniotic fluid from\\naround the baby. Either the fluid itself or cells from\\nthe fluid can be used for a variety of tests to obtain\\ninformation about genetic disorders and other med-\\nical conditions in the fetus.\\nCentromere —The centromere is the constricted\\nregion of a chromosome. It performs certain func-\\ntions during cell division.\\nChorionic villus sampling (CVS) —A procedure\\nused for prenatal diagnosis at 10–12 weeks gesta-\\ntion. Under ultrasound guidance a needle is insert-\\ned either through the mother’s vagina or abdomi-\\nnal wall and a sample of cells is collected from\\naround the early embryo. These cells are then test-\\ned for chromosome abnormalities or other genetic\\ndiseases.\\nChromosome—A microscopic thread-like structure\\nfound within each cell of the body and consists of a\\ncomplex of proteins and DNA. Humans have 46\\nchromosomes arranged into 23 pairs. Changes in\\neither the total number of chromosomes or their\\nshape and size (structure) may lead to physical or\\nmental abnormalities.\\nCongenital —Refers to a disorder that is present at\\nbirth.\\nDeletion —The absence of genetic material that is\\nnormally found in a chromosome. Often, the genet-\\nic material is missing due to an error in replication\\nof an egg or sperm cell.\\nHypotonia—Reduced or diminished muscle tone.\\nKaryotyping —A laboratory procedure in which\\nchromosomes are separated from cells, stained and\\narranged so that their structure can be studied\\nunder the microscope.\\nMicrocephaly—An abnormally small head.\\nCri du chat syndrome can be detected before birth if\\nthe mother undergoes amniocentesis testing or chorionic\\nvillus sampling(CVS). This testing would only be recom-\\nmended if the mother or father is known to have a chro-\\nmosome rearrangement, or if they already have a child\\nwith cri du chat syndrome.\\nTreatment\\nCurrently, there is no cure for cri du chat syndrome.\\nTreatment consists of supportive care and developmental\\ntherapy.\\nPrognosis\\nIndividuals with cri du chat have a 10% mortality\\nduring infancy due to complications associated with con-\\ngenital heart defects, hypotonia, and feeding difficulties.\\nOnce these problems are controlled, most individuals\\nwith cri du chat syndrome have a normal lifespan. The\\ndegree of mental retardation can be severe. However, a\\nrecent study suggested that the severity is somewhat\\naffected by the amount of therapy received.\\nResources\\nBOOKS\\nGardner, R. J. McKinlay, and Grant R. Sutherland. Chromo-\\nsome Abnormalities and Genetic Counseling. New York:\\nOxford University Press, 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 955\\nCri du chat syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 955'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 344, 'page_label': '345'}, page_content='Jones, Kenneth. Smith’s Recognizable Patterns of Human Mal-\\nformation. 5th ed. Philadelphia: W.B. Saunders Company,\\n1997.\\nRimoin, David, Michael Connor, and Reed Pyeritz. Emery and\\nRimoin’s Principles and Practice of Medical Genetics,\\n3rd ed. New York: Churchill Livingstone, 1996.\\nPERIODICALS\\nVan Buggenhout, G. J. C. M., et al. “Cri du Chat Syndrome:\\nChanging Phenotype in Older Patients.”American Jour-\\nnal of Medical Genetics 90 (2000): 203-215.\\nORGANIZATIONS\\n5p- Society. 7108 Katella Ave. #502, Stanton, CA 90680. (888)\\n970-0777. .\\nAlliance of Genetic Support Groups. 4301 Connecticut Ave.\\nNW, Suite 404, Washington, DC 20008. (202) 966-5557.\\nFax: (202) 966-8553. .\\nCri du Chat Society. Dept. of Human Genetics, Box 33, MCV\\nStation, Richmond V A 23298. (804) 786-9632.\\nCri du Chat Syndrome Support Group. .\\nNational Organization for Rare Disorders (NORD). P.O. Box\\n8923, New Fairfield, CT 06812-8923. (203) 746-6518 or\\n(800) 999-6673. Fax: (203) 746-6481. .\\nOTHER\\nOMIM—Online Mendelian Inheritance in Man. .\\nHolly Ann Ishmael, MS\\nCrib death see Sudden infant death\\nsyndrome\\nCrohn’s disease\\nDefinition\\nCrohn’s disease is a type of inflammatory bowel dis-\\nease (IBD), resulting in swelling and dysfunction of the\\nintestinal tract.\\nDescription\\nCrohn’s disease involves inflammation of the intes-\\ntine, especially the small intestine. Inflammation refers\\nto swelling, redness, and loss of normal function. There\\nis evidence that the inflammation is caused by various\\nproducts of the immune system that attack the body itself\\ninstead of helpfully attacking a foreign invader (a virus\\nor bacteria, for example). The inflammation of Crohn’s\\ndisease most commonly affects the last part of the ileum\\n(a section of the small intestine), and often includes the\\nlarge intestine (the colon). However, inflammation may\\nalso occur in other areas of the gastrointestinal tract,\\naffecting the mouth, esophagus, or stomach. Crohn’s dis-\\nease differs from ulcerative colitis, the other major type\\nof IBD, in two important ways:\\n• The inflammation of Crohn’s disease may be discontin-\\nuous, meaning that areas of involvement in the intestine\\nmay be separated by normal, unaffected segments of\\nintestine. The affected areas are called “regional enteri-\\ntis,” while the normal areas are called “skip areas.”\\n• The inflammation of Crohn’s disease affects all the lay-\\ners of the intestinal wall, while ulcerative colitis affects\\nonly the lining of the intestine.\\nAlso, ulcerative colitis does not usually involve the\\nsmall intestine; in rare cases it involves the terminal\\nileum (so-called “backwash” ileitis).\\nIn addition to inflammation, Crohn’s disease causes\\nulcerations, or irritated pits in the intestinal wall. These\\npits occur because the inflammation has made areas of\\ntissue shed.\\nCrohn’s disease may be diagnosed at any age,\\nalthough most diagnoses are made between the ages of\\n15–35. About 0.02–0.04% of the population suffers from\\nthis disorder, with men and women having an equal\\nchance of being stricken. Whites are more frequently\\naffected than other racial groups, and people of Jewish ori-\\ngin are between three and six times more likely to suffer\\nfrom IBD. IBD runs in families; an IBD patient has a 20%\\nchance of having other relatives who are fellow sufferers.\\nCrohn’s disease is a chronic disorder. While the\\nsymptoms can be improved, a patient will not be com-\\npletely cured of the underlying disease.\\nCauses and symptoms\\nThe cause of Crohn’s disease is unknown. No infec-\\ntious agent (virus, bacteria, or fungi) has been identified\\nas the cause of Crohn’s disease. Still, some researchers\\nhave theorized that some type of infection may have\\noriginally been responsible for triggering the immune\\nsystem, resulting in the continuing and out-of-control\\ncycle of inflammation that occurs in Crohn’s disease.\\nOther evidence for a disorder of the immune system\\nincludes the high incidence of other immune disorders\\nthat may occur along with Crohn’s disease.\\nThe first symptoms of Crohn’s disease include diar-\\nrhea, fever, abdominal pain, inability to eat, weight loss,\\nand fatigue. Some patients have severe pain that mimics\\nappendicitis. It is rare, however, for patients to notice\\nblood in their bowel movements. Because Crohn’s disease\\nseverely limits the ability of the affected intestine to absorb\\nGALE ENCYCLOPEDIA OF MEDICINE 2956\\nCrohn’s disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 956'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 345, 'page_label': '346'}, page_content='the nutrients from food, a patient with Crohn’s disease can\\nhave signs of malnutrition, depending on the amount of\\nintestine affected and the duration of the disease.\\nThe combination of severe inflammation, ulceration,\\nand scarring that occurs in Crohn’s disease can result in\\nserious complications, including obstruction, abscess\\nformation, and fistula formation.\\nAn obstruction is a blockage in the intestine. This\\nobstruction prevents the intestinal contents from passing\\nbeyond the point of the blockage. The intestinal contents\\n“back up,” resulting in constipation , vomiting, and\\nintense pain. Although rare in Crohn’s disease (because\\nof the increased thickness of the intestinal wall due to\\nswelling and scarring), a severe bowel obstruction can\\nresult in an intestinal wall perforation (a hole in the intes-\\ntine). Such a hole in the intestinal wall would allow the\\nintestinal contents, usually containing bacteria, to enter\\nthe abdomen. This complication could result in a severe,\\nlife-threatening infection.\\nAbcess formation is the development of a walled-off\\npocket of infection. A patient with an abscess will have\\nbouts of fever, increased abdominal pain, and may have a\\nlump or mass that can be felt through the wall of the\\nabdomen.\\nFistula formation is the formation of abnormal chan-\\nnels. These channels may connect one area of the intes-\\ntine to another neighboring section of intestine. Fistuals\\nmay join an area of the intestine to the vagina or bladder,\\nor they may drain an area of the intestine through the\\nskin. Abscesses and fistulas commonly affect the area\\naround the anus and rectum (the very last portions of the\\ncolon allowing waste to leave the body). These abnormal\\nconnections allow the bacteria that normally live in the\\nintestine to enter other areas of the body, causing poten-\\ntially serious infections.\\nPatients suffering from Crohn’s disease also have a\\nsignificant chance of experiencing other disorders. Some\\nof these may relate specifically to the intestinal disease,\\nand others appear to have some relationship to the imbal-\\nanced immune system. The faulty absorption state of the\\nbowel can result in gallstones and kidney stones .\\nInflamed areas in the abdomen may press on the tube that\\ndrains urine from the kidney to the bladder (the ureter).\\nUreter compression can make urine back up into the kid-\\nney, enlarge the ureter and kidney, and can potentially\\nlead to kidney damage. Patients with Crohn’s disease\\nalso frequently suffer from:\\n• arthritis (inflammation of the joints)\\n• spondylitis (inflammation of the vertebrae, the bones of\\nthe spine)\\n• ulcers of the mouth and skin\\n• painful, red bumps on the skin\\n• inflammation of several eye areas\\n• inflammation of the liver, gallbladder, and/or the chan-\\nnels (ducts) that carry bile between and within the liver,\\ngallbladder, and intestine\\nThe chance of developing cancer of the intestine is\\ngreater than normal among patients with Crohn’s dis-\\nease, although this chance is not as high as among those\\npatients with ulcerative colitis\\nDiagnosis\\nDiagnosis is first suspected based on a patient’s\\nsymptoms. Blood tests may reveal an increase in certain\\ntypes of white blood cells, an indication that some type\\nof inflammation is occurring in the body. The blood tests\\nmay also reveal anemia and other signs of malnutrition\\ndue to malabsorption (low blood protein; variations in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 957\\nCrohn’s disease\\nA barium x-ray showing the colon of a patient with Crohn’s\\ndisease where the large and small intestines join (bottom\\nleft). (Custom Medical Stock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 957'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 346, 'page_label': '347'}, page_content='the amount of calcium, potassium, and magnesium pre-\\nsent in the blood; changes in certain markers of liver\\nfunction). Stool samples may be examined to make sure\\nthat no infectious agent is causing the diarrhea, and to\\nsee if the waste contains blood.\\nDuring an endoscopic exam, a doctor passes a flexi-\\nble tube with a tiny, fiber-optic camera device through\\nthe rectum and into the colon. The doctor can then care-\\nfully examine the lining of the intestine for signs of\\ninflammation and ulceration that might suggest Crohn’s\\ndisease. A tiny sample (a biopsy) of the intestine can\\nalso be taken through the endoscope, and the tissue will\\nbe examined under a microscope for evidence of\\nCrohn’s disease.\\nKEY TERMS\\nAbscess —A walled-off pocket of pus caused by\\ninfection.\\nEndoscope —A medical instrument that can be\\npassed into an area of the body (the bladder or\\nintestine, for example) to allow examination of\\nthat area. The endoscope usually has a fiber-optic\\ncamera that allows a greatly magnified image to\\nbe shown on a television screen viewed by the\\noperator. Many endoscopes also allow the opera-\\ntor to retrieve a small sample (biopsy) of the area\\nbeing examined to more closely view the tissue\\nunder a microscope.\\nFistule —An abnormal channel that creates an\\nopen passageway between two structures that do\\nnot normally connect.\\nGastrointestinal tract —The entire length of the\\ndigestive system, running from the stomach,\\nthrough the small intestine, large intestine, and out\\nthe rectum and anus.\\nImmune system—The body system responsible for\\nproducing various cells and chemicals that fight\\ninfection by viruses, bacteria, fungi, and other for-\\neign invaders. In autoimmune disease, these cells\\nand chemicals turn against the body itself.\\nInflammation —The result of the body’s attempts\\nto fight off and wall off an area that is infected.\\nInflammation results in the classic signs of red-\\nness, heat, swelling, and loss of function.\\nObstruction—A blockage.\\nUlceration—A pitted area or break in the continu-\\nity of a surface such as skin or mucous membrane.\\nX rays can be helpful for diagnosis, and also for\\ndetermining how much of the intestine is involved in the\\ndisease. For these x rays, the patient must either drink a\\nchalky solution containing barium, or receive a barium\\nenema (a solution that is administered through the rec-\\ntum). Barium helps to “light up” the intestine, allowing\\nmore detail to be seen on the resulting x rays.\\nWhile Crohn’s disease and ulcerative colitis are sim-\\nilar, they are also very different. Although it can be diffi-\\ncult to determine whether a patient has Crohn’s disease\\nor ulcerative colitis, it is important to make every effort\\nto distinguish between these two diseases. Because the\\nlong-term complications of the diseases are different,\\ntreatment will depend on careful diagnosis of the specific\\nIBD present.\\nTreatment\\nTreatments for Crohn’s disease try to reduce the\\nunderlying inflammation, the resulting malabsorption/\\nmalnutrition, the uncomfortable symptoms of crampy\\nabdominal pain and diarrhea, and the possible complica-\\ntions (obstructions, abscesses, and fistulas).\\nInflammation can be treated with a drug called sul-\\nfasalazine. Sulfasalazine is made up of two parts. One part\\nis related to the sulfa antibiotics; the other part is a form\\nof the anti-inflammatory chemical, salicylic acid (related\\nto aspirin). Sulfasalazine is not well absorbed from the\\nintestine, so it stays mostly within the intestine, where it is\\nbroken down into its components. It is believed that the\\nsalicylic acid component actively treats Crohn’s disease by\\nfighting inflammation. Some patients do not respond to\\nsulfasalazine, and require steroid medications (such as\\nprednisone). Steroids, however, must be used carefully to\\navoid the complications of these drugs, including\\nincreased risk of infection and weakening of bones (osteo-\\nporosis). Some very potent immunosuppressive drugs,\\nwhich interfere with the products of the immune system\\nand can hopefully decrease inflammation, may be used for\\nthose patients who do not improve on steroids.\\nA new drug called infliximab (Remicade) appears to\\nbe a powerful treatment for Crohn’s disease, particularly\\nfor patients who have not responded well to other forms\\nof treatment. Infliximab is administered through infusion,\\nand consists of a monoclonal antibody that interferes with\\nthe inflammatory process mediated by tumor necrosis\\nfactor-alpha (TNF-a). Patients taking infliximab seem to\\nbe able to decrease their use of steroid medications, and\\nrequire fewer surgical interventions. Furthermore, inflix-\\nimab is the first medication approved for treating fistulas.\\nUnfortunately, infliximab can only be used on a short-\\nterm basis, because its interference with TNF-a activity\\ncan also predispose patients to serious infection. More\\nGALE ENCYCLOPEDIA OF MEDICINE 2958\\nCrohn’s disease\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 958'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 347, 'page_label': '348'}, page_content='research is needed to try to harness the benefits of inflix-\\nimab, while avoiding the potential complications.\\nSerious cases of malabsorption/malnutrition may\\nneed to be treated by providing nutritional supplements.\\nThese supplements must be in a form that can be\\nabsorbed from the damaged, inflamed intestine. Some\\npatients find that certain foods are hard to digest, includ-\\ning milk, large quantities of fiber, and spicy foods. When\\npatients are suffering from an obstruction, or during peri-\\nods of time when symptoms of the disease are at their\\nworst, they may need to drink specially formulated, high-\\ncalorie liquid supplements. Those patients who are\\nseverely ill may need to receive their nutrition through a\\nneedle inserted in a vein (intravenously), or even by a\\ntiny tube (a catheter) inserted directly into a major vein\\nin the chest.\\nA number of medications are available to help\\ndecrease the cramping and pain associated with Crohn’s\\ndisease. These include loperamide, tincture of opium,\\nand codeine. Some fiber preparations (methylcellulose or\\npsyllium) may be helpful, although some patients do not\\ntolerate them well.\\nThe first step in treating an obstruction involves gen-\\neral attempts to decrease inflammation with sul-\\nfasalazine, steroids, or immunosuppressive drugs. A\\npatient with a severe obstruction will have to stop taking\\nall food and drink by mouth, allowing the bowel to\\n“rest.” Abscesses and other infections will require antibi-\\notics. Surgery may be required to repair an obstruction\\nthat does not resolve on its own, to remove an abscess, or\\nto repair a fistula. Such surgery may involve the removal\\nof a section of the intestine. In extremely severe cases of\\nCrohn’s disease that do not respond to treatment, a\\npatient may need to have the entire large intestine\\nremoved (an operation called a colectomy). In this case,\\na piece of the remaining small intestine is pulled through\\nan opening in the abdomen. This bit of intestine is fash-\\nioned surgically to allow a special bag to be placed over\\nit. This bag catches the body’s waste, which no longer\\ncan be passed through the large intestine and out of the\\nanus. This opening, which will remain in place for life, is\\ncalled an ileostomy.\\nPrognosis\\nCrohn’s disease is a life-long illness. The severity of\\nthe disease can vary, and a patient can experience periods\\nof time when the disease is not active and he or she is\\nsymptom-free. However, the complications and risks of\\nCrohn’s disease tend to increase over time. Well over\\n60% of all patients with Crohn’s disease will require\\nsurgery, and about half of these patients will require\\nmore than one operation over time. About 5–10% of all\\nCrohn’s patients will die of their disease, primarily due\\nto massive infection.\\nResources\\nBOOKS\\nGlickman, Robert. “Inflammatory Bowel Disease: Ulcerative\\nColitis and Crohn’s Disease.” In Harrison’s Principles of\\nInternal Medicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1998.\\nLong, James W. The Essential Guide to Chronic Illness. New\\nYork: Harper Perennial, 1997.\\nSaibil, Fred. Crohn’s Disease and Ulcerative Colitis.Buffalo,\\nNY: Firefly Books, 1997.\\nPERIODICALS\\nPeppercorn, Mark A., and Susannah K. Gordon. “Making Sense\\nof a Mystery Ailment: Inflammatory Bowel Disease.”Har-\\nvard Health Letter22, no. 2 (December 1996): 4+.\\nSachar, David. “Maintenance Strategies in Crohn’s Disease.”\\nHospital Practice 31, no. 1 (January 15, 1996): 99+.\\nORGANIZATION\\nCrohn’s & Colitis Foundation of America, Inc. 386 Park\\nAvenue South, 17th Floor, New York, NY 10016-8804.\\n(800) 932-2423.\\nRosalyn S. Carson-DeWitt\\nCromolyn see Antiasthmatic drugs\\nCross-eye see Strabismus\\nCross-gender identification see Gender\\nidentity disorder\\nCroup\\nDefinition\\nCroup is a common childhood ailment. Typically, it\\narises from a viral infection of the larynx (voice box) and\\nis associated with mild upper respiratory symptoms such\\nas a runny nose and cough. The key symptom is a harsh\\nbarking cough. Croup is usually not serious, and most\\nchildren recover within a few days. In a small percentage\\nof cases, a child develops breathing difficulties and may\\nneed medical attention.\\nDescription\\nAt one time, the term croup was primarily associated\\nwith diphtheria, a life-threatening respiratory infection.\\nOwing to widespread vaccinations, diphtheria has\\nbecome rare in the United States, and croup currently\\nGALE ENCYCLOPEDIA OF MEDICINE 2 959\\nCroup\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 959'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 348, 'page_label': '349'}, page_content='refers to a mild viral infection of the larynx. Croup is also\\nknown as laryngotracheitis, a medical term that describes\\nthe inflammation of the trachea (windpipe) and larynx.\\nParainfluenza viruses are the typical root cause of\\nthe infection, but influenza (flu) and cold viruses may\\nsometimes be responsible. All of these viruses are highly\\ncontagious and easily transmitted between individuals\\nvia sneezing and coughing. Children between the ages of\\nthree months and six years are usually affected, with the\\ngreatest incidence at one to two years of age. Croup can\\noccur at any time of the year, but it is most typical during\\nearly autumn and winter. The characteristic harsh bark-\\ning of a croupy cough can be very distressing, but it\\nrarely indicates a serious problem. Most children with\\ncroup can be treated very effectively at home; however,\\n1–5% may require medical treatment.\\nCroup may sometimes be confused with more seri-\\nous conditions, such as epiglottitis or bacterial tracheitis.\\nThese ailments arise from bacterial infection and must\\nreceive medical treatment.\\nCauses and symptoms\\nOwing to an upper respiratory viral infection, the\\nlarynx and trachea may become inflamed or swollen. The\\nhallmark sign of croup is a harsh, barking cough. This\\ncough may be preceded by one to three days of symp-\\ntoms that resemble a slight cold. A croupy cough is often\\naccompanied by a runny nose, hoarseness, and a low\\nfever. When the child inhales, there may be a raspy or\\nhigh-pitched noise, called stridor, owing to the narrowed\\nairway and accumulated mucus. In the presence of stri-\\ndor, medical attention is required.\\nHowever, the airway rarely narrows so much that\\nbreathing is impeded. Symptoms usually abate complete-\\nly within a few days. Medical treatment may be sought if\\nthe child’s symptoms do not respond to home treatment.\\nEmergency medical treatment is required immediate-\\nly if the child has difficulty breathing, swallowing, or talk-\\ning; develops a high fever (103°F/39.4°C or more); seems\\nunalert or confused; or has pale or blue-tinged skin.\\nDiagnosis\\nCroup is diagnosed based on the symptoms. If\\nsymptoms are particularly severe, or do not respond to\\ntreatment, an x ray of the throat area is done to assess the\\npossibility of epiglottitis or other blockage of the airway.\\nTreatment\\nHome treatment is the usual method of managing\\ncroup symptoms. It is important that the child is kept\\ncomfortable and calm to the best degree possible, because\\ncrying can make symptoms seem worse. Humid air can\\nhelp a child with croup feel more comfortable. Recom-\\nmended methods include sitting in a steamy bathroom\\nwith the hot water running or using a cool-water vaporizer\\nor humidifier. Breathing may also be eased by going out-\\nside into cooler air. The child should drink frequently in\\norder to stay well hydrated. To treat any fever, the child\\nmay be given an appropriate dose of acetaminophen\\n(like Tylenol). Antihistamines and decongestants are\\nineffective in treating croup. Children under the age of 18\\nshould not be given aspirin, as it may cause Reye’s syn-\\ndrome, a life-threatening disease of the brain.\\nIf the child does not respond to home treatment,\\nmedical treatment at a doctor’s office or an emergency\\nroom could be necessary. Based on the severity of symp-\\ntoms and the response to treatment, the child may need to\\nbe admitted to a hospital.\\nFor immediate symptom relief, epinephrine may be\\nadministered as an inhaled aerosol. Effects last for up to\\ntwo hours, but there is a possibility that symptoms may\\nreturn. For that reason, the child is kept under supervi-\\nsion for three or more hours. Another effective drug is a\\nglucocorticoid, dexamethasone. This drug requires more\\ntime to take effect, but is longer lasting. It can be admin-\\nistered orally or as an injection. Another glucocorticoid,\\nbudesonide, has been used outside the United States for\\ntreating croup. It is administered as an inhaled aerosol\\nand has been shown to be effective; however, it is not\\navailable as a treatment option in the United States.\\nOf the 1–5% of children requiring medical treat-\\nment, approximately 1% need respiratory support. Such\\nsupport involves intubation (inserting a tube into the tra-\\nchea) and oxygen administration.\\nAlternative treatment\\nBotanical/herbal medicines can be helpful in healing\\nthe cough that is commonly associated with croup. Sev-\\neral herbs to consider for cough treatment include\\naniseed (Pimpinella anisum ), sundew (Drosera rotundi-\\nfolia), thyme ( Thymus vulgaris ), and wild cherry bark\\n(Prunus serotina ). Homeopathic medicine can be very\\neffective in treating cases of croup. Choosing the correct\\nremedy (a common choice is aconite or monkshood,\\nAconitum napellus ) is always the key to the success of\\nthis type of treatment.\\nPrognosis\\nCroup is a temporary condition and children typically\\nrecover completely within three to six days. Children can\\nexperience one or more episodes of croup during early\\nchildhood; however, croup is rarely a dangerous condition.\\nGALE ENCYCLOPEDIA OF MEDICINE 2960\\nCroup\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 960'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 349, 'page_label': '350'}, page_content='Prevention\\nCroup is caused by highly transmissible viruses.\\nSimilar to other common childhood ailments, prevention\\nis not applicable.\\nResources\\nPERIODICALS\\nFolland, David S. “Treatment of Croup: Sending Home an\\nImproved Child and Relieved Parents.”Postgraduate\\nMedicine 101, no. 3 (Mar. 1997): 271.\\nPappas, Diane E., Gregory F. Hayden, and J. Owen Hendley.\\n“Epiglottitis and Croup: Keys to Therapy at Home and in\\nthe Hospital.” Consultant 37, no. 4 (Apr. 1997): 857.\\nJulia Barrett\\nCryoglobulin test\\nDefinition\\nCryoglobulin is an abnormal blood protein associat-\\ned with several diseases. Testing for cryoglobulin is done\\nKEY TERMS\\nDiphtheria —A serious, frequently fatal, bacterial\\ninfection that affects the respiratory tract. Vaccina-\\ntions given in childhood have made diphtheria\\nvery rare in the United States.\\nEpiglottitis —A bacterial infection that affects the\\nepiglottis. The epiglottis is a flap of tissue that pre-\\nvents food and fluid from entering the trachea. The\\ninfection causes it to become swollen, potentially\\nblocking the airway. Other symptoms include a\\nhigh fever, nonbarking cough, muffled voice, and\\nan inability to swallow properly (possibly indicat-\\ned by drooling).\\nGlucocorticoid —A hormone that helps in diges-\\ntion of carbohydrates and reduces inflammation.\\nLarynx—Commonly called the voice box, it is the\\narea of the trachea that contains the vocal cords.\\nStridor —The medical term used to describe the\\nhigh-pitched or rasping noise made when air is\\ninhaled.\\nTrachea—Commonly called the windpipe, it is the\\nair pathway that connects the nose and mouth to\\nthe lungs.\\nwhen a person has symptoms of this protein or is being\\nevaluated for one of the associated diseases.\\nPurpose\\nCryoglobulin clumps in cold temperatures. This\\nphysical characteristic causes people with cryoglobulin\\nto have symptoms during cold weather: blanching,\\nnumbness, and pain in their fingers or toes (Raynaud’s\\nphenomenon); bleeding into the skin (purpura); and pain\\nin joints (arthralgia). People with these symptoms or any\\nother symptoms that appear in cold weather should be\\ntested for cryoglobulin.\\nDiseases that cause the body to make extra or abnor-\\nmal proteins are often associated with cryoglobulin.\\nThese diseases include cancers involving white blood\\ncells, infections, autoimmune disorders , and rheuma-\\ntoid diseases.\\nThis test provides information about the cause of\\nsymptoms in a person who already has a disease process.\\nIt doesn’t diagnose a specific disease or monitor the\\ncourse of a disease.\\nPrecautions\\nThis test is not a screening test for disease in a per-\\nson without symptoms.\\nDescription\\nLaboratory testing for cryoglobulin is based on the\\nfact that cryoglobulin clumps when cooled and dissolves\\nwhen warmed. The test is done on a person’s serum (the\\nyellow liquid part of blood that separates from the cells\\nafter the blood clots). The serum is kept warm from the\\ntime drawn until the cells and the serum are separated in\\nthe laboratory. The serum is placed at 33.8°F (1°C) for\\none to seven days. If there is clumping, cryoglobulins are\\npresent. The amount of cryoglobulins is determined by\\nmeasuring the amount of clumping. Negative tests are\\nchecked through seven days.\\nAdditional testing is done to find out what kind of\\ncryoglobulin protein is present. There are three kinds of\\ncryoglobulin, each associated with different diseases.\\nThe test, also called the cold sensitivity antibodies\\ntest, is covered by insurance when medically necessary.\\nResults are usually available the following day.\\nPreparation\\nThis test requires 15–20 mL of blood. A healthcare\\nworker ties a tourniquet on the person’s upper arm,\\nlocates a vein in the inner elbow region, and inserts a\\nGALE ENCYCLOPEDIA OF MEDICINE 2 961\\nCryoglobulin test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 961'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 350, 'page_label': '351'}, page_content='needle into that vein. Vacuum action draws the blood\\nthrough the needle into an attached tube. Collection of\\nthe sample takes only a few minutes. The blood must be\\nkept warm, at body temperature, until the laboratory can\\nseparate the cells from the serum.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to the\\npuncture site until the bleeding stops reduces bruising.\\nWarm packs to the puncture site relieve discomfort.\\nNormal results\\nNegative or absent.\\nAbnormal results\\nIf the person has cryoglobulin, the amount is report-\\ned. Larger amounts of cryoglobulin are associated with\\ncancers or abnormalities involving white blood cells,\\nmoderate amounts are associated with autoimmune dis-\\norders and rheumatoid diseases, and smaller amounts are\\nassociated with infections.\\nThe type of cryoglobulin is also reported. Type I\\ncryoglobulin, also called monoclonal cryoglobulinemia,\\nis found in cancers or abnormalities of white blood cells.\\nType II, also called mixed cryoglobulinemia, is associat-\\ned with autoimmune disorders, rheumatoid diseases, and\\ninfections, particularly chronic hepatitis B.\\nThe physician must interpret the cryoglobulin result\\nalong with other test results and the patient’s clinical\\ncondition and medical history.\\nResources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nMayo Medical Laboratories. Interpretive Handbook.\\nRochester, MN: Mayo Medical Laboratories, 1997.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nNancy J. Nordenson\\nKEY TERMS\\nCryoglobulin—An abnormal blood protein associ-\\nated with several diseases. It is characterized by its\\ntendency to clump in cold temperatures.\\nCryosurgery see Cryotherapy\\nCryotherapy\\nDefinition\\nCryotherapy is a technique that uses an extremely\\ncold liquid or instrument to freeze and destroy abnormal\\nskin cells that require removal. The technique has been in\\nuse since the turn of the century, but modern techniques\\nhave made it widely available to dermatologists and pri-\\nmary care doctors. The technique is also called\\ncryosurgery.\\nPurpose\\nCryotherapy can be employed to destroy a variety of\\nbenign skin growths, such as warts, pre-cancerous lesions\\n(such as actinic keratoses), and malignant lesions (such as\\nbasal cell and squamous cell cancers). The goal of\\ncryotherapy is to freeze and destroy targeted skin growths\\nwhile preserving the surrounding skin from injury.\\nPrecautions\\nCryotherapy is not recommended for certain areas of\\nthe body because of the danger of destruction of tissue or\\nunacceptable scarring. These areas include: skin that\\noverlies nerves, the corners of the eyes, the fold of skin\\nbetween the nose and lip, the skin surrounding the nos-\\ntrils, and the border between the lips and the rest of the\\nface. Lesions that are suspected or known to be malig-\\nnant melanoma should not be treated with cryotherapy,\\nbut should instead be removed surgically. Similarly, basal\\ncell or squamous cell carcinomas that have reappeared at\\nthe site of a previously treated tumor should also be\\nremoved surgically. If it remains unclear whether a\\ngrowth is benign or malignant, a sample of tissue should\\nbe removed for analysis (biopsy) by a pathologist before\\nany attempts to destroy the lesion with cryotherapy. Care\\nshould be taken in people with diabetes or certain circula-\\ntion problems when cryotherapy is considered for\\ngrowths located on their lower legs, ankles, and feet. In\\nthese patients, healing can be poor and the risk of infec-\\ntion can be higher than for other patients.\\nDescription\\nThere are three main techniques to performing\\ncryotherapy. In the simplest technique, usually reserved\\nfor warts and other benign skin growths, the physician\\nGALE ENCYCLOPEDIA OF MEDICINE 2962\\nCryotherapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 962'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 351, 'page_label': '352'}, page_content='will dip a cotton swab or other applicator into a cup con-\\ntaining a “cryogen,” such as liquid nitrogen, and apply it\\ndirectly to the skin growth to freeze it. At a temperature of\\n-320°F (-196°C), liquid nitrogen is the coldest cryogen\\navailable. The goal is to freeze the skin growth as quickly\\nas possible, and then let it thaw slowly to cause maximum\\ndestruction of the skin cells. A second application may be\\nnecessary depending on the size of the growth. In another\\ncryotherapy technique, a device is used to direct a small\\nspray of liquid nitrogen or other cryogen directly onto the\\nskin growth. Freezing may last from five to 20 seconds,\\ndepending on the size of the lesion. A second freeze-thaw\\ncycle may be required. Sometimes, the physician will\\ninsert a small needle connected to a thermometer into the\\nlesion to make certain the lesion is cooled to a low\\nenough temperature to guarantee maximum destruction.\\nIn a third option, liquid nitrogen or another cryogen is cir-\\nculated through a probe to cool it to low temperatures.\\nThe probe is then brought into direct contact with the skin\\nlesion to freeze it. The freeze time can take two to three\\ntimes longer than with the spray technique.\\nPreparation\\nExtensive preparation prior to cryotherapy is not\\nrequired. The area to be treated should be clean and dry,\\nbut sterile preparation is not necessary. Patients should\\nknow that they will experience some pain at the time of\\nthe freezing, but local anesthesia is usually not required.\\nThe physician may want to reduce the size of certain\\ngrowths, such as warts, prior to the cryotherapy proce-\\ndure, and may have patients apply salicylic acid prepara-\\ntions to the growth over several weeks. Sometimes, the\\nphysician will pare away some of the tissue using a\\ndevice called a curette or a scalpel.\\nAftercare\\nRedness, swelling, and the formation of a blister at the\\nsite of cryotherapy are all expected results of the treatment.\\nA gauze dressing is applied and patients should wash the\\nsite three or four times daily while fluid continues to ooze\\nfrom the wound, usually for five to 14 days. A dry crust\\nthen forms that falls off by itself. Woundson the head and\\nneck may take four to six weeks to heal, but those on the\\nbody, arms, and legs can take longer. Some patients experi-\\nence pain at the site following the treatment. This can usu-\\nally be eased with acetaminophen (Tylenol), though in\\nsome cases a stronger pain reliever may be required.\\nRisks\\nCryotherapy poses little risk and can be well-tolerat-\\ned by elderly and other patients who are not good candi-\\nKEY TERMS\\nActinic keratosis —A crusty, scaly pre-cancerous\\nskin lesion caused by damage from the sun. Fre-\\nquently treated with cryotherapy.\\nBasal cell cancer—The most common form of skin\\ncancer; it usually appears as one or several nod-\\nules having a central depression. It rarely spreads\\n(metasticizes), but is locally invasive.\\nCryogen—A substance with a very low boiling\\npoint, such as liquid nitrogen, used in cryotherapy\\ntreatment.\\nMelanoma —The most dangerous form of skin\\ncancer. It should not be treated with cryotherapy,\\nbut should be removed surgically instead.\\nSquamous cell cancer—A form of skin cancer that\\nusually originates in sun-damaged areas or pre-\\nexisting lesions; at first local and superficial, it\\nmay later spread to other areas of the body.\\ndates for other surgical procedures. As with other surgi-\\ncal procedures, there is some risk of scarring, infection,\\nand damage to underlying skin and tissue. These risks\\nare generally minimal in the hands of experienced users\\nof cryotherapy.\\nNormal results\\nSome redness, swelling, blistering and oozing of\\nfluid are all common results of cryotherapy. Healing time\\ncan vary by the site treated and the cryotherapy technique\\nused. When cryogen is applied directly to the growth,\\nhealing may occur in three weeks. Growths treated on the\\nhead and neck with the spray technique may take four to\\nsix weeks to heal; growths treated on other areas of the\\nbody may take considerably longer. Cryotherapy boasts\\nhigh success rates in permanently removing skin growths;\\neven for malignant lesions such as squamous cell and\\nbasal cell cancers, studies have shown a cure rate of up to\\n98%. For certain types of growths, such as some forms of\\nwarts, repeat treatments over several weeks are necessary\\nto prevent the growth’s return.\\nAbnormal results\\nAlthough cryotherapy is a relatively low risk proce-\\ndure, some side effects may occur as a result of the treat-\\nment. They include:\\n• Infection. Though uncommon, infection is more likely\\non the lower legs where healing can take several months.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 963\\nCryotherapy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 963'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 352, 'page_label': '353'}, page_content='• Pigmentary changes. Both hypopigmentation (lighten-\\ning of the skin) and hyperpigmentation (darkening of\\nthe skin) are possible after cryotherapy. Both generally\\nlast a few months, but can be longer lasting.\\n• Nerve damage. Though rare, damage to nerves is possi-\\nble, particularly in areas where they lie closer to the\\nsurface of the skin, such as the fingers, the wrist, and\\nthe area behind the ear. Reports suggest this will disap-\\npear within several months.\\nResources\\nBOOKS\\nLynch, Peter J., and W. Mitchell Sams Jr. Principles and Prac-\\ntice of Dermatology. 2nd ed. New York: Churchill Living-\\nstone, 1996.\\nRoenigk, Randall K., and Henry H. Roenigk Jr. Roenigk and\\nRoenigk’s Dermatologic Surgery: Principles and Prac-\\ntice. New York: Marcel Dekker, 1996.\\nPERIODICALS\\nJester, David M. “Cryotherapy of Dermal Abnormalities.”Pri-\\nmary Care 24 (June 1997): 269-280.\\nYoung, R., and R. Sinclair. “Practical Cryosurgery.”Australian\\nFamily Physician 26 (Sept. 1997): 1045-1047.\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham Road,\\nP.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-\\n0230. .\\nAmerican Society for Dermatologic Surgery. 930 N. Meacham\\nRoad, P.O. Box 4014, Schaumburg, IL 60168-4014. (847)\\n330-9830. .\\nRichard H. Camer\\nCryptococcosis\\nDefinition\\nCryptococcosis is an infection caused by inhaling\\nthe fungus Cryptococcus neoformans. It is one of the dis-\\neases most often affecting AIDS patients. Cryptococco-\\nsis may be limited to the lungs, but frequently spreads\\nthroughout the body. Although almost any organ can be\\ninfected, the fungus is often fatal if it infects the nervous\\nsystem where it causes an inflammation of the mem-\\nbranes covering the brain and spinal cord (meningitis).\\nDescription\\nThe fungus causing cryptococcus, C. neoformans,i s\\nfound worldwide in soil contaminated with pigeon or\\nother bird droppings. It has also been found on unwashed\\nraw fruit. Cryptococcosis is a rare disease in healthy\\nindividuals, but is the most common fungal infection\\naffecting people with AIDS.\\nPeople with Hodgkin’s disease or who are taking\\nlarge doses of drugs that suppress the functioning of the\\nimmune system (corticosteroids, chemotherapy drugs)\\nare also more susceptible to cryptococcal infection.\\nCryptococcosis is also called cryptococcal meningitis\\n(when the brain is infected), Busse-Buschke disease,\\nEuropean blastomycosis, torular meningitis, or torulosis.\\nCauses and symptoms\\nOnce the cryptococcal fungus reaches the lungs,\\nthree things can happen. The immune system can heal\\nthe body without medical intervention, the disease can\\nstay localized in the lungs, or it can spread throughout\\nthe body. In healthy people with normally functioning\\nimmune systems, the body usually heals itself, and the\\ninfected person notices no symptoms and has no compli-\\ncations (asymptomatic). The disease does not spread\\nfrom one person to another.\\nCryptococcosis is an opportunistic infection that\\nputs people with immune system diseases at higher risk\\nof developing more serious forms of the disease. In the\\nUnited States, 6–10% of all patients with AIDS get cryp-\\ntococcosis.\\nIf the body does not heal itself, the fungus begins to\\ngrow in the lungs and form nodules that can be seen on\\nchest x rays. In the early stages of infection, an individ-\\nual usually only exhibits symptoms of a respiratory\\ninfection, such as a dry cough, so the disease is rarely\\ndiagnosed.\\nThe fungus can remain dormant in the lungs and\\nproduce an active infection later if the immune system is\\nweakened. If the disease becomes active, it can cause\\ncryptococcal pneumonia in the lungs. Unfortunately,\\nhowever, cryptococcal pneumonia has symptoms similar\\nto other pneumonias (cough, chest pain, difficulty\\nbreathing), making it difficult to accurately diagnose.\\nThe infection can spread to other parts of the body, par-\\nticularly the brain and central nervous system.\\nMost patients are not diagnosed as having crypto-\\ncoccosis until they show signs of cryptococcal meningi-\\ntis, or infection of the membranes surrounding the brain\\nand spinal cord. Symptoms appear gradually over a peri-\\nod of two to four weeks. Fever and headache are the\\nmost common symptoms, occurring in about 85% of\\npatients. Nausea, vomiting, unwanted weight loss, and\\nfatigue are also common. Other symptoms seen in\\n25–30% of patients are blurred vision, stiff neck, aver-\\nsion to light, and seizures. Since the symptoms of classic\\nGALE ENCYCLOPEDIA OF MEDICINE 2964\\nCryptococcosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 964'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 353, 'page_label': '354'}, page_content='meningitis, such as stiff neck and aversion to light, do not\\noccur in many patients, diagnosis is often delayed. In\\naddition to meningitis, inflammation of the brain\\n(encephalitis ) and brain lesions called cryptococcomas\\nor tortulomas can also develop.\\nIn addition to the brain, the cryptococcal infection\\ncan spread to the kidneys, bone marrow, heart, adrenal\\nglands, lymph nodes, urinary tract, blood, and skin.\\nOften times preceding the development of cryptococcal\\nmeningitis, painless rashes and lesions that mimic other\\nskin diseases, such as molluscum contagiosum , may\\ndevelop. A small percentage of patients with brain infec-\\ntions show infections in other organs as well.\\nDiagnosis\\nPhysicians who regularly work with AIDS patients\\nhave the most experience in diagnosing cryptococcosis.\\nThe preferred methods of diagnosis use simple and very\\naccurate blood and cerebrospinal fluid (CSF) tests that\\ndetect the presence of an antigen produced by the fungus.\\nThe cerebrospinal fluid test is generally more sensitive to\\ndetecting the meningitis form of the infection. CSF is\\ncollected during a procedure called a lumbar puncture,\\nduring which an anesthetic is applied to a small area of\\nthe back near the spine and a needle is used to withdraw\\na sample of cerebrospinal fluid from the space between\\nthe vertebrae and the spinal cord. Once obtained, a small\\namount of ink (called India ink) is added to a sample of\\nCSF or a sample prepared from skin lesions . If the fun-\\ngus is present, it will become visible when the ink binds\\nto the capsule or covering that surrounds the fungus.\\nFaster results are obtained with the India ink test, but it is\\nless accurate than the blood test (75–85% accuracy com-\\npared to 99% accuracy with the blood test) because some\\nstrains are not visible using this method. Antigen tests\\nare routinely recommended for non-symptomatic\\npatients with advanced AIDS.\\nAnother way to diagnose cryptococcosis is to cul-\\nture a sample of sputum, tissue from a lung biopsy ,o r\\nCSF in the laboratory to isolate the fungus. Cultures are\\nalso done to assess the effectiveness of treatment.\\nChest x rays are useful in assessing lung damage and\\nmay reveal a single mass or multiple distinct nodules, but\\nthe x ray alone does not lead to a definitive diagnosis of\\ncryptococcosis.\\nTreatment\\nOnce cryptococcosis is diagnosed, treatment begins\\nwith amphotericin B (Fungizone), sometimes in combi-\\nnation with 5-flucytosine (Ancobon). Amphotericin B is\\na powerful fungistatic drug with potentially toxic side\\neffects, such as kidney toxicity and lower concentrations\\nof an important blood component called hemoglobin.\\nThis medication can also cause fever, chills, nausea and\\nvomiting, diarrhea, headache, and muscle aches. Treat-\\nment is generally given intravenously during a hospital\\nstay and continues until the patient is stable or improving\\n(no more than two to three weeks). 5-flucytosine is given\\norally. Patients may also receive other medication to\\nminimize the side effects from these drugs.\\nAmphotericin B, with or without 5-flucytosine, is\\ngiven for several weeks until the patient is stable, after\\nwhich the patient receives oral fluconazole (Diflucan).\\nFluconazole is a broad-spectrum antifungal drug with few\\nserious side effects. Patient with AIDS must continue tak-\\ning fluconazole for the rest of their lives to prevent a\\nrelapse of cryptococcosis. Sometimes fluconazole is\\ngiven to patients with advanced AIDS as a preventative\\n(prophylactic) measure.\\nBecause of the high cost of fluconazole, the manu-\\nfacturer of the drug, Pfizer, has established a financial\\nassistance plan to make the drug available at lower cost\\nto those who meet certain criteria. Patients needing this\\ndrug should ask their doctors about this program.\\nPrognosis\\nUntreated cryptococcosis is always fatal. The acute\\nmortality rate for patients with AIDS is 10–25%. Most\\ndeaths are attributable to cryptococcal meningitis and\\noccur within two weeks after diagnosis. For AIDS\\npatients who do not receive continued suppressive thera-\\npy (fluconazole), the relapse rate is 50–60% within six\\nmonths and a shortened life expectancy. Once the crypto-\\ncoccosis infection has been successfully treated, individ-\\nuals may be left with a variety of neurologic symptoms,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 965\\nCryptococcosis\\nThis lesion appearing on this person’s body is due to expo-\\nsure of the C. neoformans fungus. (Photo Researchers, Inc.\\nReproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 965'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 354, 'page_label': '355'}, page_content='such as weakness, headache, and hearing or visual loss.\\nIn addition, fluid may accumulate around the brain\\n(hydrocephalus).\\nPrevention\\nThe best way to prevent cryptococcosis is to stay free of\\nHIV infection. People with suppressed immune systems\\nshould try to stay away from areas contaminated with pigeon\\nor other bird droppings, such as the attics of old buildings,\\nbarns, and areas under bridges where pigeons roost.\\nResources\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nKEY TERMS\\nAdrenal gland—A pair of organs located above the\\nkidneys. The outer tissue of the gland produces the\\nhormones epinephrine (adrenaline) and norepi-\\nnephrine, while the inner tissue produces several\\nsteroid hormones.\\nAmphotericin B (Fengizone) —An antifungal med-\\nication, prescribed for topical or systemic use in\\ntreating fungal infections.\\nAntibody —A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAntigen —A foreign protein or particle capable of\\neliciting an immune response.\\nAsymptomatic —Persons who carry a disease but\\nwho do not exhibit symptoms of the disease are\\nsaid to be asymptomatic.\\nBiopsy—The removal of a tissue sample for diag-\\nnostic purposes.\\nCerebrospinal fluid (CSF)—The clear fluid that sur-\\nrounds the spinal cord and brain and acts as a\\nshock absorber.\\nCorticosteroids —A group of hormones produced\\nnaturally by the adrenal gland or manufactured syn-\\nthetically. They are often used to treat inflammation.\\nExamples include cortisone and prednisone.\\nEncephalitis—Inflammation of the brain.\\nHodgkin’s disease—A disease that causes chronic\\ninflammation of the lymph nodes, spleen, liver and\\nkidneys. It is also called malignant lymphoma.\\nHydrocephalus—Build-up of fluid around the brain.\\nImmunocompromised —A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nIndia ink test —A diagnostic test used to detect the\\ncyptococcal organism C. neoformans. A dye, called\\nIndia ink, is added to a sample of CSF fluid, and if\\nthe fungi is present, they will become visible as the\\ndye binds to the capsule surrounding the fungus.\\nLumbar puncture —Also called a spinal tap, a pro-\\ncedure in which a thin needle is used to withdraw a\\nsample of cerebrospinal fluid for diagnostic purpos-\\nes from the area surrounding the spine.\\nMeningitis—Inflammation of the membranes cover-\\ning the brain and spinal cord called the meninges.\\nMolluscum contagiosum—A disease of the skin and\\nmucuous membranes, caused by a poxvirus and\\nfound all over the world.\\nOpportunistic infection —An infection that is nor-\\nmally mild in a healthy individual, but which takes\\nadvantage of an ill person’s weakened immune sys-\\ntem to move into the body, grow, spread, and cause\\nserious illness.\\nPneumonia —Inflammation of the lungs, typically\\ncaused by a virus, bacteria, or other organism.\\nNational Aids Clearinghouse. 800-458-5231.\\nNational Aids Hotline. 800-342-AIDS.\\nProject Inform. 205 13th Street, #2001, San Francisco, CA\\n94103. (800) 822-7422. .\\nOTHER\\nPowderly, William G. “Cryptococcosis.”Journal of the Inter-\\nnational Association of Physicians in AIDS Care.July\\n1996 .\\n“Project Inform Cryptococcal Infections Fact Sheet.”Project\\nInform. 21 May 1996 .\\nTish Davidson\\nCryptococcus neoformans infection see\\nCryptococcosis\\nCryptorchidism see Undescended testes\\nGALE ENCYCLOPEDIA OF MEDICINE 2966\\nCryptococcosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 966'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 355, 'page_label': '356'}, page_content='Cryptosporidiosis\\nDefinition\\nCryptosporidiosis refers to infection by the spore-\\nforming protozoan known as Cryptosporidia. Protozoa are\\na group of parasites that infect the human intestine, and\\ninclude the better known Giardia. Cryptosporidiawas first\\nidentified in 1976 as a cause of disease in humans.\\nDescription\\nCryptosporidia are normally passed in the feces of\\ninfected persons and animals in the form of cysts. The\\ncysts can remain in the ground and water for months, and\\nwhen ingested produce symptoms after maturing in the\\nintestine and the bile ducts. When viewed under the\\nmicroscope, they appear as small bluish-staining round\\nbodies. Most common sources of infection are other\\nhumans, water supplies, or reservoirs. These are contam-\\ninated by animals that defecate in these areas. An out-\\nbreak in Milwaukee in 1993 in which over 400,000 per-\\nsons were affected was traced to the city’s water supply.\\nCysts of Cryptosporidia are extremely resistant to the\\ndisinfectants that are commonly used in most water treat-\\nment plants and are incompletely removed by filtration.\\nMost persons who experience significant symptoms\\nhave an altered immune system, and suffer from diseases\\nsuch as AIDS and cancer. However, as shown in the\\nMilwaukee outbreak, even those with normal immunity\\ncan experience symptoms.\\nCauses and symptoms\\nCysts of Cryptosporidia mature in the intestine and\\nbile ducts within three to five days of ingestion. As noted,\\nlarge-scale infections from contaminated water supplies\\nhas been documented. However, human to human trans-\\nmission (such as occurs in day care centers or through\\nsexual behavior) is also an important cause.\\nMany individuals can be infected without any ill-\\nness, but the major symptom is diarrhea, which is often\\nwatery and incapacitating. Dehydration , low-grade\\nfever, nausea, and abdominal cramps are frequent.\\nIn those with a normal immune system, the disease\\nusually lasts about 10 days. For patients with altered immu-\\nnity (immunocompromised), the story is quite different,\\nwith diarrhea becoming chronic, debilitating, and even fatal.\\nComplications\\nDehydration and malnutrition are the most com-\\nmon effects of infection. In about 20% of AIDS patients,\\nbile duct infection also occurs and causes symptoms sim-\\nilar to gallbladder attacks. Eighty percent or more of\\nthose with infection of the bile ducts die from the dis-\\nease. The lungs and pancreas are also sometimes\\ninvolved. Cryptosporidia are just one cause of the diar-\\nrhea wasting syndrome in AIDS, which results in severe\\nweight loss and malnutrition.\\nDiagnosis\\nThis is based on either finding the characteristic\\ncysts in stool specimens, or on biopsy of an infected\\norgan, such as the intestine.\\nTreatment\\nThe first aim of treatment is to avoid dehydration.\\nOral Rehydration Solution (ORS) or intravenous fluids\\nmay be needed. Medications used to treat diarrhea by\\ndecreasing intestinal motility (Anti-Motility Agents),\\nsuch as loperamide or diphenoxylate, are also useful, but\\nshould only be used with the advice of a physician.\\nTreatment aimed directly at Cryptosporidia is only\\npartially effective, and rarely eliminates the organism.\\nThe medication most commonly used is paromomycin\\n(Humatin), but others are presently under evaluation.\\nPrognosis\\nCryptosporidia rarely cause a serious disease in per-\\nsons with normal immune systems. Replacement of fluids\\nis all that is usually needed. On the other hand, those with\\naltered immune systems often suffer for months to years.\\nParamomycin and other drugs have been able to improve\\nsymptoms in over half of those treated. Unfortunately,\\nmany organisms are resistant, and recurrence is frequent.\\nPrevention\\nThe best way to prevent cryptosporidiosis is to mini-\\nmize exposure to cysts from infected humans and ani-\\nmals. Proper hand washing technique, especially in day\\ncare centers, is recommended.\\nResources\\nBOOKS\\nDavis, Charles E. “Laboratory Diagnosis of Parasitic Infec-\\ntion.” In Harrison’s Principles of Internal Medicine,e d .\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1997.\\nLiu, Leo X., and Peter F. Weller. “Therapy for Parasitic Infec-\\ntions.” In Harrison’s Principles of Internal Medicine,e d .\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1997.\\nNash, Theodore E., and Peter F. Weller. “Cryptosporidiosis.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 967\\nCryptosporidiosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 967'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 356, 'page_label': '357'}, page_content='Owen, Robert L. “Cryptosporidia.” In Sleisenger & Fordtran’s\\nGastrointestinal and Liver Disease, ed. Mark Feldman, et\\nal. Philadelphia: W. B. Saunders Co., 1997.\\nWeller, Peter F. “Protozoal and Helminthic Infection: General\\nConsideration.” In Harrison’s Principles of Internal Med-\\nicine, ed. Anthony S. Fauci, et al. New York: McGraw-\\nHill, 1997.\\nPERIODICALS\\nHeyworth, Martin F. “Parasitic Diseases in Immunocompro-\\nmised Hosts.” Gastrointestinal Clinics of North America:\\nParasitic Diseases of the Liver and Intestines(Sept.\\n1996): 691-707.\\nLew, Edward A., Machael A. Poles, and Douglas T. Dieterich.\\n“Diarrheal Disease Associated with HIV Infection.”Gas-\\nKEY TERMS\\nAnti-motility medications —Medications such as\\nloperamide (sold as Imodium), dephenoxylate\\n(sold as Lomotil), or medications containing\\ncodeine or narcotics that decrease the ability of\\nthe intestine to contract. This can worsen the con-\\ndition of a patient with dysentery or colitis.\\nCyst—A protective sac that includes either fluid or\\nthe cell of an organism. The cyst enables many\\norganisms to survive in the environment for long\\nperiods of time without need for food or water.\\nImmunocompromised —A change or alteration of\\nthe immune system that normally serves to fight\\noff infections and other illnesses. This can involve\\nchanges in antibodies that the body produces\\n(hygogammaglobulinemia), or defect in the cells\\nthat partake in the immune response. Diseases\\nsuch as AIDS and cancer exhibit changes in the\\nbody’s natural immunity.\\nOral Rehydration Solution (ORS) —A liquid\\npreparation developed by the World Health Orga-\\nnization that can decrease fluid loss in persons\\nwith diarrhea. Originally developed to be pre-\\npared with materials available in the home, com-\\nmercial preparations have recently come into use.\\nParasite—An organism that lives on or in another\\nand takes nourishment (food and fluids) from that\\norganism.\\nProtozoa —Group of extremely small single cell\\n(unicellular) or acellular organisms that are found\\nin moist soil or water. They tend to exist as para-\\nsites, living off other life forms.\\nSpore—A resistant form of certain species of bac-\\nteria, protozoa, and other organisms.\\ntroenterology Clinics of North America(June 1997): 259-\\n290.\\nVakil, Nimish B., et al. “Biliary Cryptosporidiosis in HIV-\\nInfected People after the Waterborne Outbreak of Cryp-\\ntosporidiosis in Milwaukee.”New England Journal of\\nMedicine 334, no. 1 (1996): 19.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nOTHER\\n“Cryptosporidiosis.” Centers for Disease Control. .\\nVakil, Nimish B., et al. “Biliary Cryptosporidiosis in HIV-\\nInfected People after the Waterborne Outbreak of Cryp-\\ntosporidiosis in Milwaukee.”New England Journal of\\nMedicine Online. .\\nDavid Kaminstein, MD\\nC-section see Cesarean section\\nCSF analysis see Cerebrospinal fluid (CSF)\\nanalysis\\nCT-guided biopsy\\nDefinition\\nComputed tomography (CT) is a process that images\\nanatomic information from a cross-sectional plane of the\\nbody. Biopsy is the process of taking a sample of tissue\\nfrom the body for analysis. CT is commonly used in\\nbiopsies to provide images that help guide the tools or\\nequipment necessary to perform the biopsy to the appro-\\npriate area of the body.\\nPurpose\\nCT is used in the process of performing a biopsy,\\nsuch as a needle biopsy, in order to guide the needle to\\nthe site of the biopsy and to provide rapid and precise\\nlocalization of the needle. CT enables imaging of areas\\nthat are normally beyond visible boundaries. This\\nenables the physician to see the target area clearly and\\nhelp to ensure that the tissue being removed is from the\\ntarget lesion.\\nPrecautions\\nThe patient that suffers from claustrophobia will\\nwant to discuss this with their physician. This procedure\\nGALE ENCYCLOPEDIA OF MEDICINE 2968\\nCT-guided biopsy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 968'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 357, 'page_label': '358'}, page_content='involves the patient being placed into the CT scanner, typ-\\nically a small, enclosed area. Depending on the specific\\ntype of biopsies being performed, certain anesthetics will\\nbe used, so discuss drug allergies with your physician.\\nDescription\\nCT can assist in providing more enhanced images of\\na suspicious lesion. It helps to determine whether a\\ntumor is truly solitary or not. CT can characterize the\\ntumor and aid in the estimation of malignancy.\\nPreparation\\nSince there are many different types of biopsies, you\\nshould follow the instructions from your physician to\\nprepare for your CT-guided biopsy. Patients who suffer\\nfrom claustrophobia should discuss their concerns with\\nthe physician. In some cases, medicine can be given that\\nwill relax the patient during the procedure.\\nRisks\\nCT-guided biopsy does not increase the risk of the\\nbiopsy any more than any other radiologic imaging such\\nas x ray.\\nNormal results\\nBecause the area being biopsied, as well as the spe-\\ncific type of biopsy procedure can vary, results will vary.\\nBefore undergoing the procedure, notification procedure\\nshould be clearly defined.\\nResources\\nBOOKS\\nStedman’s Medical Dictionary.27th ed. Philadelphia: Lippin-\\ncot Williams & Wilkins, 2000.\\nTierney, Lawrence, et. al. Current Medical Diagnosis and\\nTreatment. Los Altos: Lange Medical Publications, 2001.\\nPERIODICALS\\nGarpestad, E., et. al. “CT Fluoroscopy Guidance for Trans-\\nbronchial Needle Aspiration.”Chest 119 (February 2001).\\nShaffer, K. “Role of Radiology for Imaging and Biopsy of Soli-\\ntary Pulmonary Nodules.”Chest 116 (December 1999).\\nKEY TERMS\\nLesion—A pathologic change in tissues.\\nMalignancy —A locally invasive and destructive\\ngrowth.\\nWhite, C.S., C.A. Meyer, and P. A. Templeton. “CT Fluo-\\nroscopy for Throacic Interventional Procedures.”Radio-\\nlogic Clinics of North America 38 (March 2000).\\nWhite, C.S., et. al. “Transbronchial Needle Aspiration: Guid-\\nance with CT Fluoroscopy.”Chest 118 (December 2000).\\nKim A. Sharp\\nCT-myelogram see Myelography\\nCT scan see Computed tomography scans\\nCulture-fair test\\nDefinition\\nA culture-fair test is a test designed to be free of cul-\\ntural bias, as far as possible, so that no one culture has an\\nadvantage over another. The test is designed to not be\\ninfluenced by verbal ability, cultural climate, or educa-\\ntional level.\\nPurpose\\nThe purpose of a culture-fair test is to eliminate any\\nsocial or cultural advantages, or disadvantages, that a\\nperson may have due to their upbringing. The test can be\\nadministered to anyone, from any nation, speaking any\\nlanguage. A culture-fair test may help identify learning\\nor emotional problems. The duration of the test varies for\\nthe individual types of tests available, but the time is\\napproximately between 12–18 minutes per section (a test\\nusually has two to four sections).\\nA culture-fair test is often administered by employ-\\ners in order to determine the best location for new\\nemployees in a large company. The wide variety of cul-\\nture-fair tests availiable allows the administrator to\\nselect which area is most vital, whether it be general\\nintelligence, knowledge of a specific area, or emotional\\nstability.\\nPrecautions\\nThere is doubt as to whether any test can truly be\\nculturally unbiased or can ever be made completely fair\\nto all persons independent of culture. There are no other\\nprecautions.\\nDescription\\nA culture-fair test is a non-verbal paper-pencil test\\nthat can be administered to patients as young as four\\nGALE ENCYCLOPEDIA OF MEDICINE 2 969\\nCulture-fair test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 969'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 358, 'page_label': '359'}, page_content='years old. The patient only needs the ability to recognize\\nshapes and figures and perceive their respective relation-\\nships. Some examples of tasks in the test may include:\\n• completing series\\n• classifying\\n• solving matrices\\n• evaluating conditions\\nThe culture-fair test is also often referred to as a cul-\\nture-free test or unbiased test. There are many variations\\nof the test including class, economic, and intelligence\\ntests. The threading theme among the various tests is\\ntheir design to be culturally unbiased.\\nPreparation\\nThe only preparation necessary to administer the test\\nis pre-ordered materials and a quiet and secluded loca-\\ntion for the duration of the test.\\nAftercare\\nPost-test treatment depends on the results of the test\\nand the specifics of the individual patient. Any further\\ntreatment is best prescribed by the doctor.\\nRisks\\nThere are no risks associated with the culture-fair\\ntest.\\nNormal results\\nThe results can be compared to the key that comes\\nwith the purchase of a culture-fair test. All results should\\nbe compared to the included key.\\nAbnormal results\\nThe results can be compared to the key that comes\\nwith the purchase of a culture-fair test. All results should\\nbe compared to the included key.\\nResources\\nBOOKS\\nMaddox, Taddy. Test, 4th ed.Austin, Texas: Pro-Ed Inc., 1997.\\nReber, Arthur S. The Penguin Dictionary of Psychology,1995.\\nMichael Sherwin Walston\\nRonald Watson, PhD\\nCultures for sexually transmitted diseases\\nsee Sexually transmitted diseases cultures\\nCushing’s syndrome\\nDefinition\\nCushing’s syndrome is a relatively rare endocrine\\n(hormonal) disorder resulting from excessive exposure to\\nthe hormone cortisol. The disorder, which leads to a vari-\\nety of symptoms and physical abnormalities, is most\\ncommonly caused by taking medications containing the\\nhormone over a long period of time. A more rare form of\\nthe disorder occurs when the body itself produces an\\nexcessive amount of cortisol.\\nDescription\\nThe adrenals are two glands, each of which is perched\\non the upper part of the two kidneys. The outer part of the\\ngland is known as the cortex; the inner part is known as the\\nmedulla. Each of these parts of the adrenal gland is respon-\\nsible for producing different types of hormones. Regulation\\nof hormone production and release from the adrenal cortex\\ninvolves the pituitary gland, a small gland located at the\\nbase of the brain. After the hypothalamus (the part of the\\nbrain containing secretions important to metabolic activi-\\nties) sends “releasing hormones” to the pituitary gland, the\\npituitary secretes a hormone called adrenocorticotropic\\nhormone (ACTH). The ACTH then travels through the\\nbloodstream to the adrenal cortex, where it encourages the\\nproduction and release of cortisol (sometimes called the\\n“stress” hormone) and other adrenocortical hormones.\\nCortisol, a very potent glucocorticoid—a group of\\nadrenocortical hormones that protects the body from\\nstress and affect protein and carbohydrate metabolism—\\nis involved in regulating the functioning of nearly every\\ntype of organ and tissue in the body, and is considered to\\nbe one of the few hormones absolutely necessary for life.\\nCortisol is involved in:\\n• complex processing and utilization of many nutrients,\\nincluding sugars (carbohydrates), fats, and proteins\\n• normal functioning of the circulatory system and the\\nheart\\n• functioning of muscles\\n• normal kidney function\\n• production of blood cells\\n• normal processes involved in maintaining the skeletal\\nsystem\\n• proper functioning of the brain and nerves\\n• normal responses of the immune system\\nCushing’s syndrome, also called hypercortisolism,\\nhas an adverse effect on all of the processes described\\nGALE ENCYCLOPEDIA OF MEDICINE 2970\\nCushing’s syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 970'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 359, 'page_label': '360'}, page_content='above. The syndrome occurs in approximately 10 to 15\\nout of every one million people per year, usually striking\\nadults between the ages of 20 and 50.\\nCauses and symptoms\\nThe most common cause of Cushing’s syndrome is\\nthe long-term use of glucocorticoid hormones in medica-\\ntions. Medications such as prednisone are used in a num-\\nber of inflammatory conditions. Such conditions include\\nrheumatoid arthritis , asthma, vasculitis , lupus, and a\\nvariety of other autoimmune disorders in which the\\nbody’s immune cells accidentally attack some part of the\\nbody itself. In these disorders, the glucocorticoids are\\nused to dampen the immune response, thereby decreas-\\ning damage to the body.\\nCushing’s syndrome can also be caused by three dif-\\nferent categories of disease:\\n• a pituitary tumor producing abnormally large quantities\\nof ACTH\\n• the abnormal production of ACTH by some source\\nother than the pituitary\\n• a tumor within the adrenal gland overproducing cortisol\\nAlthough it is rare, about two-thirds of endoge-\\nnous (occurring within the body rather than from a\\nsource outside the body, like a medication) Cushing’s\\nsyndrome is a result of Cushing’s disease. The term\\n“Cushing’s disease” refers to Cushing’s syndrome,\\nwhich is caused by excessive secretion of ACTH by a\\npituitary tumor, usually an adenoma (noncancerous\\ntumor). The pituitary tumor causes increased growth of\\nthe adrenal cortex (hyperplasia) and increased cortisol\\nproduction. Cushing’s disease affects women more\\noften than men.\\nTumors in locations other than the pituitary can also\\nproduce ACTH. This is called ectopic ACTH syndrome\\n(“ectopic” refers to something existing out of its normal\\nplace). Tumors in the lung account for more than half of\\nall cases of ectopic ACTH syndrome. Other types of\\ntumors that may produce ACTH include tumors of the\\nthymus, the pancreas, the thyroid, and the adrenal gland.\\nNearly all adrenal gland tumors are benign (noncancer-\\nous), although in rare instances a tumor may actually be\\ncancerous.\\nSymptoms of cortisol excess (resulting from med-\\nication or from the body’s excess production of the hor-\\nmone) include:\\n• weight gain\\n• an abnormal accumulation of fatty pads in the face (cre-\\nating the distinctive “moon face” of Cushing’s syn-\\ndrome); in the trunk (termed “truncal obesity”); and\\nover the upper back and the back of the neck (giving the\\nindividual what has been called a “buffalo hump”)\\n• purple and pink stretch marks across the abdomen and\\nflanks\\n• high blood pressure\\n• weak, thinning bones (osteoporosis)\\n• weak muscles\\n• low energy\\n• thin, fragile skin, with a tendency toward both bruising\\nand slow healing\\n• abnormalities in the processing of sugars (glucose),\\nwith occasional development of actual diabetes\\n• kidney stones\\n• increased risk of infections\\n• emotional disturbances, including mood swings, depres-\\nsion, irritability, confusion, or even a complete break\\nwith reality (psychosis)\\nGALE ENCYCLOPEDIA OF MEDICINE 2 971\\nCushing’s syndrome\\nWoman with Cushing’s syndrome.(Photo Researchers, Inc.\\nReproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 971'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 360, 'page_label': '361'}, page_content='• irregular menstrual periods in women\\n• decreased sex drive in men and difficulty maintaining\\nan erection\\n• abormal hair growth in women (in a male pattern, such\\nas in the beard and mustache area), as well as loss of\\nhair from the head (receding hair line)\\nDiagnosis\\nDiagnosing Cushing’s syndrome can be complex.\\nDiagnosis must not only identify the cortisol excess, but\\nalso locate its source. Many of the symptoms listed\\nabove can be attributed to numerous other diseases.\\nAlthough a number of these symptoms seen together\\nwould certainly suggest Cushing’s syndrome, the symp-\\nKEY TERMS\\nAdenoma —A type of noncancerous (benign)\\ntumor that often involves the overgrowth of certain\\ncells of the type normally found within glands.\\nAdrenocorticotropic hormone (ACTH)—A pituitary\\nhormone that stimulates the cortex of the adrenal\\nglands to produce adrenal cortical hormones.\\nCortisol—A hormone secreted by the cortex of the\\nadrenal gland. Cortisol regulates the function of\\nnearly every organ and tissue in the body.\\nEctopic—In an abnormal position.\\nEndocrine —Pertaining to a gland that secretes\\ndirectly into the bloodstream.\\nGland—A collection of cells whose function is to\\nrelease certain chemicals (hormones) that are\\nimportant to the functioning of other, sometimes\\ndistantly located, organs or body systems.\\nGlucocorticoids —General class of adrenal corti-\\ncal hormones that are mainly active in protecting\\nagainst stress and in protein and carbohydrate\\nmetabolism.\\nHormone —A chemical produced in one part of\\nthe body that travels to another part of the body in\\norder to exert its effect.\\nHypothalamus —the part of the brain containing\\nsecretions important to metabolic activities.\\nPituitary —A gland located at the base of the\\nbrain, the pituitary produces a number of hor-\\nmones, including hormones that regulate growth\\nand reproductive function.\\ntoms are still not specific to Cushing’s syndrome. Fol-\\nlowing a review of the patient’s medical history,physical\\nexamination , and routine blood tests, a series of more\\nsophisticated tests is available to achieve a diagnosis.\\n24-hour free cortisol test\\nThis is the most specific diagnostic test for identify-\\ning Cushing’s syndrome. It involves measuring the\\namount of cortisol present in the urine over a 24-hour\\nperiod. When excess cortisol is present in the blood-\\nstream, it is processed by the kidneys and removed as\\nwaste in the urine. This 24-hour free cortisol test requires\\nthat an individual collect exactly 24-hours’ worth of\\nurine in a single container. The urine is then analyzed in\\na laboratory to determine the quantity of cortisol present.\\nThis technique can also be paired with the administration\\nof dexamethasone, which in a normal individual would\\ncause urine cortisol to be very low. Once a diagnosis has\\nbeen made using the 24-hour free cortisol test, other tests\\nare used to find the exact location of the abnormality\\ncausing excess cortisol production.\\nDexamethasone suppression test\\nThis test is useful in distinguishing individuals with\\nexcess ACTH production due to a pituitary adenoma\\nfrom those with ectopic ACTH-producing tumors.\\nPatients are given dexamethasone (a synthetic glucocor-\\nticoid) orally every six hours for four days. Low doses of\\ndexamethasone are given during the first two days; for\\nthe last two days, higher doses are administered. Before\\ndexamethasone is administered, as well as on each day of\\nthe test, 24-hour urine collections are obtained.\\nBecause cortisol and other glucocorticoids signal the\\npituitary to decrease ACTH, the normal response after\\ntaking dexamethasone is a drop in blood and urine corti-\\nsol levels. Thus, the cortisol response to dexamethasone\\ndiffers depending on whether the cause of Cushing’s syn-\\ndrome is a pituitary adenoma or an ectopic ACTH-pro-\\nducing tumor.\\nHowever, the dexamethasone suppression test may\\nproduce false-positive results in patients with conditions\\nsuch as depression, alcohol abuse, high estrogen levels,\\nacute illness, and stress. On the other hand, drugs such as\\nphenytoin and phenobarbital may produce false-negative\\nresults. Thus, patients are usually advised to stop taking\\nthese drugs at least one week prior to the test.\\nCorticotropin-releasing hormone (CRH)\\nstimulation test\\nThe CRH stimulation test is given to help distin-\\nguish between patients with pituitary adenomas and\\nGALE ENCYCLOPEDIA OF MEDICINE 2972\\nCushing’s syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 972'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 361, 'page_label': '362'}, page_content='those with either ectopic ACTH syndrome or cortisol-\\nsecreting adrenal tumors. In this test, patients are given\\nan injection of CRH, the corticotropin-releasing hor-\\nmone that causes the pituitary to secrete ACTH. In\\npatients with pituitary adenomas, blood levels of ACTH\\nand cortisol usually rise. However, in patients with\\nectopic ACTH syndrome, this rise is rarely seen. In\\npatients with cortisol-secreting adrenal tumors, this rise\\nalmost never occurs.\\nPetrosal sinus sampling\\nAlthough this test is not always necessary, it may be\\nused to distinguish between a pituitary adenoma and an\\nectopic source of ACTH. Petrosal sinus sampling involves\\ndrawing blood directly from veins that drain the pituitary.\\nThis test, which is usually performed with local anesthe-\\nsia and mild sedation, requires inserting tiny, flexible\\ntubes (catheters) through a vein in the upper thigh or\\ngroin area. The catheters are then threaded up slowly until\\nthey reach veins in an area of the skull known as the pet-\\nrosal sinuses. X rays are typically used to confirm the cor-\\nrect position of the catheters. Often CRH is also given\\nduring the test to increase the accuracy of results.\\nWhen blood tested from the petrosal sinuses reveals\\na higher ACTH level than blood drawn from a vein in the\\nforearm, the likely diagnosis is a pituitary adenoma.\\nWhen the two samples show similar levels of ACTH, the\\ndiagnosis indicates ectopic ACTH syndrome.\\nRadiologic imaging tests\\nImaging tests such as computed tomography scans\\n(CT) and magnetic resonance imaging (MRI) are only\\nused to look at the pituitary and adrenal glands after a\\nfirm diagnosis has already been made. The presence of a\\npituitary or adrenal tumor does not necessarily guarantee\\nthat it is the source of increased ACTH production. Many\\nhealthy people with no symptoms or disease whatsoever\\nhave noncancerous tumors in the pituitary and adrenal\\nglands. Thus, CT and MRI is often used to image the\\npituitary and adrenal glands in preparation for surgery.\\nTreatment\\nThe choice of a specific treatment depends on the\\ntype of problem causing the cortisol excess. Pituitary and\\nadrenal adenomas are usually removed surgically. Malig-\\nnant adrenal tumors always require surgical removal.\\nTreatment of ectopic ACTH syndrome also involves\\nremoving all of the cancerous cells that are producing\\nACTH. This may be done through surgery, chemothera-\\npy (using combinations of cancer-killing drugs), or radi-\\nation therapy (using x rays to kill cancer cells), depend-\\ning on the type of cancer and how far it has spread. Radi-\\nation therapy may also be used on the pituitary (with or\\nwithout surgery) for patients who cannot undergo\\nsurgery, or for patients whose surgery did not successful-\\nly decrease pituitary release of ACTH.\\nThere are a number of drugs that are effective in\\ndecreasing adrenal production of cortisol. These medica-\\ntions include mitotane, ketoconazole, metyrapone,\\ntrilostane, aminoglutethimide, and mifepristone . These\\ndrugs are sometimes given prior to surgery in an effort to\\nreverse the problems brought on by cortisol excess. How-\\never, the drugs may also need to be administered after\\nsurgery (sometimes along with radiation treatments) in\\npatients who continue to have excess pituitary production\\nof ACTH.\\nBecause pituitary surgery can cause ACTH levels to\\ndrop too low, some patients require short-term treatment\\nwith a cortisol-like medication after surgery. Patients\\nwho need adrenal surgery may also require glucocorti-\\ncoid replacement. If the entire adrenal gland has been\\nremoved, the patient must take oral glucocorticoids for\\nthe rest of his or her life.\\nPrognosis\\nPrognosis depends on the source of the problem.\\nWhen pituitary adenomas are identified as the source of\\nincreased ACTH leading to cortisol excess, about 80% of\\npatients are cured by surgery. When cortisol excess is\\ndue to some other form of cancer, the prognosis depends\\non the type of cancer and the extent of its spread.\\nResources\\nBOOKS\\nBrickner, Colleen. Inside Out: An Autobiography.Spokane,\\nW A: A.H. Clark Co., 1992.\\nDeGroot, Leslie J., ed., et al. “Cushing’s syndrome.” In\\nEndocrinology, Vol. 2.Philadelphia: W.B. Saunders Co.,\\n1995, 1741-69.\\nWilliams, Gordon H., and Robert G. Dluhy. “Hyperfunction of\\nthe Adrenal Cortex.” In Harrison’s Principles of Internal\\nMedicine, edited by Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1998.\\nPERIODICALS\\nBoscaro, Marco, Luisa Barzon, Francesco Fallo, and Nicoletta\\nSonino. “Cushing’s Syndrome.”Lancet 357 (2001): 783-\\n91.\\nBoscaro, Marco, Luisa Barzon, and Nicoletta Sonino. “The\\nDiagnosis of Cushing’s Syndrome: Atypical Presentations\\nand Laboratory Shortcomings.”Archives of Internal Medi-\\ncine 160 (2000): 3045-53.\\nFindlay, C. A., J. F. Macdonald, A. M. Wallace, N. Geddes, and\\nM. D. C. Donaldson. “Childhood Cushing’s Syndrome\\nInduced by Betamethasone Nose Drops, and Repeat Pre-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 973\\nCushing’s syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 973'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 362, 'page_label': '363'}, page_content='Linear red rashes around a patient’s knee caused by bur-\\nrowing larvae of the dog hookworm Ancylostoma brazilien-\\nsis. (Photograph by Dr. P . Marazzi, Custom Medical Stock Photo.\\nReproduced by permission.)\\nscriptions.” British Medical Journal 3, no.17 (12 Sept.,\\n1998): 739-40.\\nKirk, Lawrence F., Robert B. Hash, Harold P. Katner, and Tom\\nJones. “Cushing’s Disease: Clinical Manifestations and\\nDiagnostic Evaluation.”American Family Physician 62,\\nno. 5 (1 Sept., 2001): 1119-27.\\nNewell-Price J., and A. Grossman. “Diagnosis and Management\\nof Cushing’s Syndrome.”Lancet 353 (1999): 2087-88.\\nOrth, David N. “Cushing’s Syndrome.”The New England Jour-\\nnal of Medicine 332, no. 12 (23 Mar., 1995): 791-803.\\nUtiger, Robert D. “Treatment, and Retreatment, of Cushing’s\\nDisease.” The New England Journal of Medicine 336,\\nno.3 (16 Jan., 1997): 215-17.\\nORGANIZATION\\nCushing’s Support and Research Foundation, Inc. 65 East India\\nRow, Suite 22B, Boston, MA 02110. (617) 723-3674.\\n.\\nNational Adrenal Disease Foundation. 505 Northern Boule-\\nvard, Suite 200, Great Neck, NY 11021. (516) 487-4992.\\n.\\nNational Institute of Neurological Disorders and Stroke\\n(NINDS). National Institutes of Health, Bethesda, MD\\n20892-2560. .\\nPituitary Network Association. 16350 Ventura Boulevard, #231,\\nEncino, CA 91436. (805)499-9973. .\\nRosalyn Carson-DeWitt\\nCutaneous larva migrans\\nDefinition\\nCutaneous larvae migrans is a parasitic skin disease\\ncaused by a hookworm larvae that usually infests dogs,\\ncats, and other animals. Humans can pick up the infec-\\ntion by walking barefoot on soil or beaches contaminated\\nwith animal feces.\\nDescription\\nCutaneous larvae migrans (also called “creeping\\neruption” or “ground itch”) is found in southeastern and\\nGulf states, and in tropical developing countries.\\nThe hookworms that cause the condition are small,\\nround blood-sucking worms that infest about 700 million\\npeople around the world. Cutaneous larvae migrans\\noccurs most often among children, those who crawl\\nbeneath raised buildings, and sunbathers who lie down\\non wet sand contaminated with hookworm larvae.\\nCauses and symptoms\\nAfter an animal passes feces that are infested with\\nhookworm eggs, the eggs hatch into infective larvae that\\nare able to penetrate human skin (even through solid\\nmaterial, such as a beach towel). The larvae are common-\\nly found in shaded, moist, or sandy areas (such as beach-\\nes, a child’s sandbox, or areas underneath a house),\\nwhere they are easily picked up by bare feet or buttocks.\\nIn minor infestations, there may be no symptoms at\\nall. In more severe cases, a red elevation of the skin\\n(papule) appears within a few hours after the larvae have\\npenetrated the skin. This usually arises first in areas that\\nare in contact with the soil, such as the feet, hands, and\\nbuttocks.\\nBetween a few days and a few months after infec-\\ntion, the larvae begin to migrate beneath the skin, leaving\\nextremely itchy red lines that may be accompanied by\\nblisters. These red lines usually appear at the top of the\\nsole of the foot or on the buttocks.\\nTyically, the larvae travel through the bloodstream, to\\nthe lungs, and then migrate into the mouth where they are\\nswallowed and attach to the small intestine lining. There\\nthey mature into adult worms. In cases where the larvae\\nmigrate through the lungs, they can produce anemia,\\ncough, and pneumonia, in addition to the itchy rash.\\nDiagnosis\\nThe condition can be diagnosed by microscopic\\ninspection of feces which can reveal hookworm eggs. In\\naddition visual inspection of the skin would reveal tell-\\ntale itchy red lines and blisters.\\nTreatment\\nPeople without intestinal symptoms do not need\\ntreatment, since the worms will eventually die or be\\nGALE ENCYCLOPEDIA OF MEDICINE 2974\\nCutaneous larva migrans\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 974'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 363, 'page_label': '364'}, page_content='excreted. Thiabendazole or albendazole are used to treat\\nthe infestation. Mild infections can be treated by apply-\\ning one of the drugs to the skin along the tracks and the\\nnormal skin surrounding the area. Thiabendazole also\\ncan be given internally, but taken this way it can cause\\nside effects including dizziness, nausea, and vomiting\\nPrognosis\\nNo matter how severe an infestation, with adequate\\ntreatment patients recover completely. However, if the\\npatient scratches the lesions open, the areas can become\\nvulnerable to bacterial infection.\\nPrevention\\nIn the United States, the prevalence of dogs and cats\\nwith hookworms is the reason why the infective larvae\\nare found so commonly in soil and sand. The play habits\\nof children, together with their attraction to pets, puts\\nthem at high risk for hookworm infection and cutaneous\\nlarvae migrans.\\nHuman hookworm infestation can be prevented by\\npracticing good personal hygiene, deworming pets, and\\nnot allowing children to play in potentially contaminated\\nenvironments.\\nResources\\nBOOKS\\nTurkington, Carol A., and Jeffrey S. Dover. Skin Deep: An A-Z\\nof Skin Disorders, Treatments and Health.2nd ed. New\\nYork: Facts on File, 1998.\\nPERIODICALS\\nRizzitelli, G., G. Scarabelli, and S. Veraldi. “Albendazole: A\\nNew Therapeutic Regimen in Cutaneous Larva Migrans.”\\nInternational Journal of Dermatology 36, no. 9 (Sept.\\n1997): 700-703.\\nCarol A. Turkington\\nCutaneous T-cell lymphoma\\nDefinition\\nCutaneous T-cell lymphoma (CTCL) is a malignan-\\ncy of the T-helper (CD4+) cells of the immune system.\\nKEY TERMS\\nLarvae—Immature forms of certain worms.\\nDescription\\nCTCL, also known as mycosis fungoides, is a cancer\\nof the white blood cells that primarily affects the skin and\\nonly secondarily affects other sites. This disease involves\\nthe uncontrollable proliferation of T-lymphocytes known\\nas T-helper cells, so named because of their role in the\\nimmune response. T-helper cells are characterized by the\\npresence of a protein receptor on its surface called CD4.\\nAccordingly, T-helper cells are said to be CD4+.\\nThe proliferation of T-helper cells results in the pen-\\netration, or infiltration, of these abnormal cells into the\\nepidermal layer of the skin. The skin reacts with slightly\\nscaling lesions that itch, although the sites of greatest\\ninfiltration do not necessarily correspond to the sites of\\nthe lesions. The lesions are most often located on the\\ntrunk, but can be present on any part of the body. In the\\nmost common course of the disease, the patchy lesions\\nprogress to palpable plaques that are deeper red and have\\nmore defined edges. As the disease worsens, skin tumors\\ndevelop that are often mushroom-shaped, hence the\\nname mycosis fungoides. Finally, the cancer progresses\\nto extracutanous involvement, often in the lymph nodes\\nor the viscera.\\nCTCL is a rare disease, with an annual incidence of\\nabout 0.29 cases per 100,000 persons in the United\\nStates. It is about half as common in Eastern Europe.\\nHowever, this discrepancy may be attributed to a differ-\\ning physician awareness of the disease rather than a true\\ndifference in occurrence. In the Unites States, there are\\nabout 500 to 600 new cases a year and about 100 to 200\\ndeaths. Usually seen in older adults, the median age at\\ndiagnosis is 55 to 60 years, and it strikes twice as many\\nmen as women.\\nCauses and symptoms\\nThe cause of CTCL is unknown. Exposure to chemi-\\ncals or pesticides has been suggested but the most recent\\nstudy on the subject failed to show a connection between\\nexposure and development of the disease. The ability to\\nisolate various viruses from cell lines grown from cells of\\nCTCL patients raises the question of a viral cause, but\\nstudies have been unable to confirm these suspicions.\\nThe symptoms of CTCL are seen primarily in the\\nskin, with itchy red patches or plaques and, usually over\\ntime, mushroom-shaped skin tumors. Any part of the\\nskin can be involved and the extent and distribution of\\nthe rash or tumors vary greatly from patient to patient.\\nThe only really universal symptom of the disease is the\\nitch and this symptom is usually what brings the patient\\nto the doctor for treatment. If the disease spreads outside\\nof the skin, the symptoms include swelling of the lymph\\nGALE ENCYCLOPEDIA OF MEDICINE 2 975\\nCutaneous T-cell lymphoma\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 975'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 364, 'page_label': '365'}, page_content='nodes, usually most severe in those draining the areas\\nwith skin involvement. Spread to the viscera is most\\noften manifested as disorders of the lungs, upper diges-\\ntive tract, central nervous system, or liver but virtually\\nany organ can be shown to be involved at autopsy.\\nDiagnosis\\nDiagnosis of CTCL is often difficult in the early\\nstages because of its slow progression and ability to\\nmimic many other benign skin conditions. The early\\npatches of CTCL resemble eczema, psoriasis, and con-\\ntact dermatitis. In a further complication, the early man-\\nifestations of the disease can respond favorably to the\\ntopical corticosteroid treatments prescribed for these skin\\ndisorders. This has the unfortunate result of the disease\\nbeing missed and the patient remaining untreated for\\nyears. CTCL is most likely discovered when a physician\\nmaintains a suspicion about the disease, performs multi-\\nple skin biopsies, and provides close follow-up after the\\ninitial presentation.\\nSkin biopsies showing penetration of abnormal cells\\ninto the epidermal tissue are necessary to make a firm\\ndiagnosis of CTCL. Several molecular studies can also\\nhelp support the diagnosis. The first looks at the cellular\\nproteins seen on the surface of the abnormal cells. Many\\ncases of CTCL show the retention of the CD4+ protein,\\nbut the loss of other proteins usually seen on the surface\\nof mature CD4+ cells, such as Leu-8 or Leu-9. The\\nabnormal cells also show unusual rearrangements at the\\ngenetic level for the gene that encodes the T-cell recep-\\ntors. These rearrangements can be identified using\\nSouthern blot analysis. The information from the molec-\\nular tests, combined with the presence of abnormal cells\\nin the epidermis, strongly supports the CTCL diagnosis.\\nTreatment\\nTreatment of CTCL depends on the stage of the dis-\\nease. The current staging of this disease was first presented\\nat the International Consensus Conference on CTCL in\\n1997. The staging attempts to show the complex interac-\\ntion between the various outward symptoms of the disease\\nand prognosis. The system has seven clinical stages based\\non skin involvement (tumor = T), lymph node involvement\\n(LN), and presence of visceral metastases (M).\\nThe first stage, IA, is characterized by plaques cov-\\nering less than 10% of the body (T1) and no visceral\\ninvolvement (M0). Lymph node condition at this stage\\ncan be uninvolved, reactive to the skin disease, or der-\\nmatopathic (biopsies showing CTCL involvement) but\\nnot enlarged (LN0-2). The shorthand expression of this\\nstage is therefore T1, LN0-2, M0. The next stage, IB, dif-\\nfers from IA in that greater than 10% of the body is cov-\\nered by plaques (T2, LN0-2, M0). Stage IIA occurs with\\nany amount of plaques in addition to the ability to pal-\\npate the lymph node and the lymph uninvolved, reactive,\\nor dermatopathic (T1-2, LN0-2, M0).\\nTreatments applied to the skin are preferred for\\npatients having these preliminary stages of the disease,\\ncommonly topical chemotherapy with mechlorethamine\\nhydrochloride (nitrogen mustard) or phototherapy of\\npsoralen plus ultraviolet A (PUV A). Topical chemothera-\\npy involves application to the skin of nitrogen mustard,\\nan alkylating agent, in a concentration of 10–20 mg/dL\\nin an aqueous or ointment base. Treatment of affected\\nskin is suggested at a minimum and application over the\\nentire skin surface is often recommended. Care needs to\\nbe taken that coverage of involved skin is adequate, as\\npatients who self-apply the drug often cannot reach all\\naffected areas. The most common side effect is skin\\nhypersensitivity to the drug. Nearly all patients respond\\nfavorably to this treatment, with a 32–61% complete\\nresponse rate, based on amount of skin involvement.\\nUnfortunately, only 10–15% of patients maintain a com-\\nplete response rate after discontinuing the treatment.\\nPhototherapy involves treatment with an orally\\nadministered drug, 8-methyloxypsoralen, that renders the\\nskin sensitive to long-wave ultraviolet light (UV A), fol-\\nlowed by controlled exposure to the radiation. During the\\ninitial treatment period, which may last as long as six\\nmonths, patients are treated two to three times weekly.\\nThis is reduced to about once monthly after initial clear-\\ning of the lesions. Redness of the skin and blistering are\\nthe most common side effects of the treatment and are\\nmuch more common in patients presenting with overall\\nskin redness, or erythroderma, so lower intensities of\\nlight are usually used in this case. About 50% of all\\npatients experience complete clearance with this treat-\\nment. Some patients with very fair skin and limited skin\\ninvolvement can successfully treat themselves at home\\nwith special lamps and no psoralen.\\nThe next stage, IIB, involves one or more cutaneous\\ntumors, in combination with absent or present palpable\\nlymph nodes, lymph uninvolved, reactive, or dermatopath-\\nic, and no visceral involvement (T3, LN0-2, M0). Stage III\\nis characterized by erythroderma, an abnormal redness\\nover widespread areas of the skin (T4, LN0-2, M0).\\nFor more extensive disease, radiation therapy is an\\neffective treatment option. It is generally used after the\\ntopical treatments have proven ineffective. Individual\\nplaques or tumors can be treated using electrons, ortho-\\nvoltage x rays, or megavoltage photons with exposure in\\nthe range of 15 to 25 Gy. Photon therapy has proven par-\\nticularly useful once the lymph nodes are involved. Anoth-\\nGALE ENCYCLOPEDIA OF MEDICINE 2976\\nCutaneous T-cell lymphoma\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 976'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 365, 'page_label': '366'}, page_content='er possibility is total-skin electron beam therapy (TSEB),\\nalthough the availability of this treatment method is limit-\\ned. It involves irradiation of the entire body with energized\\nelectrons. Side effects of this treatment include loss of fin-\\nger and toe nails, acute redness of the skin, and inability to\\nsweat for about six to 12 months after therapy. Almost all\\npatients respond favorably to radiation treatment and any\\nreoccurrence is usually much less severe.\\nCombinations of different types of treatments is a very\\ncommon approach to the management of CTCL. Topical\\nnitrogen mustard or PUV A is often used after completion\\nof radiation treatment to prolong the effects. The addition\\nof genetically engineered interferon to PUV A therapy sig-\\nnificantly increases the percentage of patients showing a\\ncomplete response. Furthermore, although treatments using\\nchemotherapy drugs alone, such as deoxycofomycin or\\netretinate, have been disappointing for CTCL, combining\\nthese drugs with interferon has shown promising results.\\nInterferon has also been combined with retinoid treatments,\\nalthough the mechanism of action of retinoids (Vitamin A\\nanalogues) against CTCL is unknown.\\nThe final two stages of the disease are IV A and IVB.\\nIV A presents as any amount of skin involvement, absent\\nor present palpable lymph nodes, no visceral involve-\\nment, and lymph that contains large clusters of convolut-\\ned cells or obliterated nodes (T1-4, LN3-4). IVB differs\\nin the addition of palpable lymph nodes and visceral\\ninvolvement (T1-4, LN3-4, M1). All of the treatment\\nmethods described above are appropriate for the final\\ntwo stages of the disease.\\nAlternative treatment\\nItching of the skin is one of the most troublesome\\nsymptoms of CTCL. One alternative treatment for itchi-\\nness is the application of a brewed solution of chickweed\\nthat is applied to the skin using cloth compresses. Anoth-\\ner suggested topical application is a mixture of vitamin\\nE, vitamin A, unflavored yogurt, honey, and zinc oxide.\\nEvening primrose oil applied topically is also claimed to\\nreduce itch and promote healing.\\nPrognosis\\nThe prognosis for CTCL is dependent on the stage of\\nthe disease. Prognosis is very good if the disease has only\\nprogressed to Stage IA, with a mean survival of 20 or\\nmore years. At this point, the disease is a very low mortali-\\nty risk to the patient, with most deaths occurring to per-\\nsons in this group unrelated to CTCL. For patients diag-\\nnosed at stages IB and IIA, the median survival is about 12\\nyears. The disease in both of these stages involves inter-\\nmediate risk to the patient. Patients in stage III and IV A\\nKEY TERMS\\nAlkylating agent—A chemical that alters the com-\\nposition of the genetic material of rapidly dividing\\ncells, such as cancer cells, causing selective cell\\ndeath; used as a topical chemotherapeutic agent\\nto treat CTCL.\\nErythroderma— An abnormal reddening of the\\nentire skin surface.\\nT-helper cells —A cellular component of the\\nimmune system that plays a major role in ridding\\nthe body of bacteria and viruses, characterized by\\nthe presence of the CD4 protein on its surface; the\\ntype of cell that divides uncontrollable with CTCL.\\nTotal-skin electron beam therapy —A method of\\nradiation therapy used to treat CTCL that involves\\nbombarding the entire body surface with high-\\nenergy electrons.\\nhave a mean life expectancy of about five years. At these\\nlater stages, the disease is high risk, with most deaths\\noccurring by infection due to the depleted immune system\\nof the later-stage patient. Once a patient has reached stage\\nIVB, the mean life expectancy is one year.\\nPrevention\\nStudies have been unable to link CTCL to any envi-\\nronmental or genetic factors, so prevention at this time is\\nnot possible.\\nResources\\nBOOKS\\nHoppe, Richard T. “Mycosis Fungoides and Other Cutanous\\nLymphomas.” In The Lymphomas, ed. George P. Canellos,\\net al. Philadelphia: W.B. Saunders Co., 1999.\\nWilson, Lynn D., et al. “Cutaneous T-Cell Lymphomas.” In\\nCancer Principles & Practice of Oncology, ed. Vincent T.\\nDeVita, et al. Philadelphia: Lippincott Williams &\\nWilkins, 2001.\\nPERIODICALS\\nElmer, Kathleen B., and Rita M. George, “Cutaneous T-Cell\\nLymphoma Presenting as Benign Dermatoses.”American\\nFamily Physician 59 (May 1999): 2809–2815.\\nORGANIZATIONS\\nNational Cancer Institute. Building 31 Room 10A31 31 Center\\nDrive MSC 2580 Bethesda, MD 20892-2580. (800)422-\\n6237. .\\nMichelle Johnson, M.S., J.D.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 977\\nCutaneous T-cell lymphoma\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 977'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 366, 'page_label': '367'}, page_content='Cutis laxa\\nDefinition\\nCutis laxa (Latin for loose or lax skin) is a connec-\\ntive tissue disorder in which the skin lacks elasticity and\\nhangs in loose folds.\\nDescription\\nCutis laxa is extremely rare; less than a few hundred\\ncases worldwide have been described.\\nThe several forms of cutis laxa are divided into pri-\\nmary cutis laxa, which is present from birth and is hered-\\nitary, secondary cutis laxa, which arises later in life and\\nmay be either hereditary, and acquired cutis laxa, which\\narises later in life and is not hereditary. Loose skin, the\\nprimary and most obvious symptom of these diseases, is\\ncaused by underlying defects in connective tissue struc-\\nture, which also cause more serious internal problems in\\nvocal cords, bones, cartilage, blood vessels, bladder, kid-\\nney, digestive system, and lungs. The loose skin is partic-\\nularly obvious on the face, and children with the disorder\\nlook sad or mournful.\\nThere are four genetic forms of the disease: sex-\\nlinked, autosomal dominant, and two types of autosomal\\nrecessive inheritance. The recessive forms are the most\\ncommon and are usually more severe than the other forms.\\nCauses and Symptoms\\nSex-linked cutis laxa is caused by a defective gene on\\nthe X chromosome. In addition to loose skin, its symp-\\ntoms are mild mental retardation , loose joints, bone\\nabnormalities (like hooked nose, pigeon breast, and fun-\\nnel breast), frequent loose stools, urinary tract blockages,\\nand deficiencies in lysyl oxidase, an enzyme required for\\nthe formation of properly functioning connective tissue.\\n(But the defective gene does not code for lysyl oxidase.)\\nAutosomal dominant cutis laxa is caused by a defec-\\ntive gene carried on an autosomal (not sex-linked) chro-\\nmosome. Its symptoms are loose, hanging skin, missing\\nelastic fibers, premature aging, and pulmonary emphy-\\nsema. Only a few families are known with cutis laxa\\ninherited as a dominant trait.\\nAutosomal recessive cutis laxa type 1 is caused by a\\ndefective gene on chromosome 5. Symptoms include\\nemphysema; diverticula in the esophagus, duodenum,\\nand bladder; lax and dislocated joints; tortuous arteries;\\nhernias; lysyl oxidase deficiencies; and retarded growth.\\nAutosomal recessive cutis laxa type 2 is also inherit-\\ned as a recessive trait. In addition to the loose skin, this\\nform of the disease is characterized by bone abnormali-\\nties, the delayed joining of the cranial (skull) bones, hip\\ndislocation, curvature of the spine, flat feet, and exces-\\nsive tooth decay.\\nAcquired cutis laxa tends to follow (and may be\\ncaused by) severe illness characterized by fever, inflam-\\nmation, and a severe skin rash ( erythema multiforme );\\nan injury to the nerves that control blood vessel dilation\\nand contraction; or an autoimmune condition.\\nDiagnosis\\nThe signs of cutis laxa are very obvious, and it is\\nusually easy to diagnose by examining the skin. The\\ndetermination of which form of cutis laxa is present is\\naided by information about the associated symptoms and\\nby family histories.\\nTreatment\\nThere is no effective cure for any of these disorders.\\nComplications are treated by appropriate specialists, for\\nexample, cardiologists, gastroenterologists, rheumatolo-\\ngists, and dermatologists. Plastic surgery can be helpful for\\ncosmetic purposes, but the skin may become loose again.\\nPrognosis\\nThe prognosis for cutis laxa varies with the form of\\nthe disorder. The effects may be relatively mild with indi-\\nviduals living a fairly normal, full life, or the disease may\\nbe fatal.\\nPrevention\\nThe inherited forms of cutis laxa are genetically\\ndetermined and are not currently preventable. Genetic\\ncounseling can be helpful for anyone with a family his-\\ntory of cutis laxa. The cause of acquired cutis laxa is not\\nknown, so no preventive measures can be taken.\\nResources\\nBOOKS\\nPope, F. Michael. “Pseudoxanthoma Elasticum, Cutis Laxa,\\nand Other Disorders of Elastic Tissue.” In Emery and\\nRimoin’s Principles and Practice of Medical Genetics.\\n3rd ed. Ed. David L. Rimoin, et al. New York: Churchill\\nLivingstone, 1998.\\nORGANIZATIONS\\nBritish Coalition of Heritable Disorders of Connective Tissue.\\nRochester House, 5 Aldershot Road, Fleet, Hampshire\\nGU13 9NG, United Kingdom. (012) 52-810472.\\nNational Arthritis and Musculoskeletal and Skin Diseases Infor-\\nmation Clearinghouse, National Institutes of Health. 1\\nAMS Circle, Bethesda, Maryland 20892-3675. (877) 226-\\n4267. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2978\\nCutis laxa\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 978'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 367, 'page_label': '368'}, page_content='OTHER\\nOMIM Homepage, Online Mendelian Inheritance in Man.\\n.\\nLorraine Lica, PhD\\nCuts see Wounds\\nCVA see Stroke\\nCVS see Chorionic villus sampling\\nCyanosis\\nDefinition\\nCyanosis is a physical sign causing bluish discol-\\noration of the skin and mucous membranes. Cyanosis is\\ncaused by a lack of oxygen in the blood. Cyanosis is\\nassociated with cold temperatures, heart failure , lung\\ndiseases, and smothering. It is seen in infants at birth as a\\nresult of heart defects, respiratory distress syndrome ,\\nor lung and breathing problems.\\nKEY TERMS\\nAutosomal—Refers to the 22 pairs (in humans) of\\nchromosomes not involved with sex determination.\\nConnective tissue —Tissue that supports and binds\\nother tissue; much of it occurs outside of cells\\n(extra-cellular) and consists of fibrous webs of the\\npolymers, elastin and collagen. Cutis laxa is associ-\\nated with defects in these fibers.\\nDiverticula—Pouches in the walls of organs.\\nDominant trait—A genetic trait where one copy of\\nthe gene is sufficient to yield an outward display of\\nthe trait; dominant genes mask the presence of\\nrecessive genes; dominant traits can be inherited\\nfrom only one parent.\\nDuodenum—The uppermost part of the small intes-\\ntine, about 10 in (25 cm) long.\\nEsophagus— The tube connecting the throat to the\\nstomach, about 10 in (25 cm) long.\\nFunnel breast (also known as pectus excavatum) —\\nA condition where there is a hollow depression in\\nthe lower part of the chest.\\nGene—A portion of a DNA molecule that either\\ncodes for a protein or RNA molecule or has a regu-\\nlatory function.\\nLysyl oxidase—An enzyme required for the crosslink-\\ning of elastin and collagen molecules to form proper-\\nly functioning connective tissue; present in relatively\\nlow levels in at least some forms of cutis laxa.\\nPigeon breast (also known as pectus carinatum) —\\nA chest shape with a central projection resembling\\nthe keel of a boat.\\nRecessive trait—An inherited trait that is outwardly\\nobvious only when two copies of the gene for that\\ntrait are present; an individual displaying a reces-\\nsive trait must have inherited one copy of the defec-\\ntive gene from each parent.\\nSex-linked—Refers to genes or traits carried on one\\nof the sex chromosomes, usually the X.\\nTortuous arteries —Arteries with many bends and\\ntwists.\\nX chromosome—One of the two types of sex chro-\\nmosomes; females have two X chromosomes, while\\nmales have one X chromosome and one Y chromo-\\nsome.\\nDescription\\nBlood contains a red pigment (hemoglobin) in its red\\nblood cells. Hemoglobin picks up oxygen from the lungs,\\nthen circulates it through arteries and releases it to cells\\nthrough tiny capillaries. After giving up its oxygen, blood cir-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 979\\nCyanosis\\nThis elderly woman’s lips turned purple due to central\\ncyanosis, a condition most commonly due to slow blood cir-\\nculation, leading to a bluish skin coloration.(Photo\\nResearchers, Inc. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 979'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 368, 'page_label': '369'}, page_content='culates back to the lungs through capillaries and veins.\\nHemoglobin, as well as blood, is bright red when it contains\\noxygen, but appears dark or “bluish” after it gives up oxygen.\\nThe blue discoloration of cyanosis is seen most\\nreadily in the beds of the fingernails and toenails, and\\non the lips and tongue. It often appears transiently as a\\nresult of slowed blood flow through the skin due to the\\ncold. As such, it is not a serious symptom. However, in\\nother cases, cyanosis is a serious symptom of underly-\\ning disease.\\nCauses and symptoms\\nThe blue color of the skin and mucous membranes\\nis caused by a lack of oxygen in the blood. Low blood\\noxygen may be caused by poor blood circulation, or\\nheart or breathing problems. It can also be caused by\\nbeing in a low-oxygen environment or by carbon\\nmonoxide poisoning . More rarely, cyanosis can be pre-\\nsent at birth as a sign of congenital heart disease ,i n\\nwhich some of the blood is not pumped to the lungs\\nwhere oxygen would make the blood a bright red color.\\nInstead, the blood goes to the rest of the body and\\nremains unoxygenated. Cyanosis also may be caused by\\npoisoning from chemicals, drugs, or contaminated food\\nand water.\\nOther signs of low blood oxygen may accompany\\ncyanosis, including feeling lightheaded or fainting.\\nTreatment\\nTreatment of the underlying disease can restore\\nproper color to the skin.\\nPrognosis\\nIf the underlying condition (such as heart or lung\\ndisease) can be properly treated, the skin will return to its\\nnormal shade.\\nKEY TERMS\\nHemoglobin —A colored substance (pigment) in\\nthe blood that carries oxygen to tissues and gives\\nblood its red color.\\nRespiratory distress syndrome —Also known as\\nhyaline membrane disease, this is a condition of\\npremature infants in which the lungs are imper-\\nfectly expanded due to a lack of a substance on\\nthe lungs that reduces tension.\\nResources\\nBOOKS\\nCarolson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nFranck, Irene, and David Brownstone. The Parent’s Desk Ref-\\nerence. New York: Prentice Hall, 1991.\\nCarol A. Turkington\\nCyclic vomiting syndrome\\nDefinition\\nCyclic vomiting syndrome (CVS) is a rare disorder\\ncharacterized by recurring periods of vomiting in an oth-\\nerwise normal child.\\nDescription\\nChildren in the pre-school or early school years are\\nmost susceptible to CVS, although it can appear any-\\nwhere from infancy to adulthood. This disorder was\\nidentified a century ago, but its cause is still unknown.\\nEpisodes can be triggered by emotional stress or infec-\\ntions, can last hours or days, and can return at any time.\\nAbdominal pain is a frequent feature.\\nCauses and symptoms\\nThe cause of CVS is still a mystery. Similarities to\\nmigraine suggest a common cause, but as yet no firm evi-\\ndence has surfaced. Patients can usually identify some\\nfactor that precedes an attack. V omiting can be protracted\\nand lead to complications such as dehydration , chemi-\\ncal imbalances, tearing and burning, and bleeding of the\\nesophagus (swallowing tube). Between attacks, there is\\nno sign of any illness.\\nDiagnosis\\nThe most important and difficult aspect of CVS is to\\nbe sure there is not an acute and life-threatening event in\\nprogress. So many diseases can cause vomiting—from\\nbowel obstruction to epilepsy—that an accurate and time-\\nly diagnosis is critical. Because there is no way to prove\\nthe diagnosis of CVS, the physician must instead disprove\\nevery other diagnosis. This can be tedious, expensive,\\nexhausting, and involve almost every system in the body.\\nThe first episode may be diagnosed as a stomach flu when\\nnothing more serious turns up. Only after several episodes\\nand several fruitless searches for a cause will a physician\\nnormally consider the diagnosis of CVS.\\nGALE ENCYCLOPEDIA OF MEDICINE 2980\\nCyclic vomiting syndrome\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 980'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 369, 'page_label': '370'}, page_content='Treatment\\nSeveral different medications have given good\\nresults in small trials. The antimigraine drugs\\namitriptyline and cyproheptadine performed well for one\\nstudy group. Propanolol is sometimes effective, and ery-\\nthromycin helped several patients in one study, not\\nbecause it is an antibiotic but because it irritates the\\nstomach and encourages it to move its contents forward\\ninstead of in reverse.\\nAlternative treatment\\nConstitutional homeopathic medicine can work well\\nin treating CVS because it addresses rebalancing the\\nwhole person, not just the symptoms.\\nPrognosis\\nThe disease may go on for many years without a\\nchange in pattern. If the acute complications of prolonged\\nvomiting can be successfully prevented or managed, most\\npatients can lead normal lives between episodes. Medica-\\ntions may ease the symptoms during attacks.\\nResources\\nPERIODICALS\\nAndersen, J. M., et al. “Effective Prophylactic Therapy for\\nCyclic V omiting Syndrome in Children Using Amitripty-\\nline or Cyproheptadine.”Pediatrics 100 (Dec. 1997): 977-\\n981.\\nFleisher, D. R. “Cyclic V omiting Syndrome: A Paroxismal Dis-\\norder of Brain-Gut Interaction.”Journal of Pediatric Gas-\\ntroenterology & Nutrition25 (1997): S13.\\nFleisher, D. R. “Management of Cyclic V omiting Syndrome.”\\nJournal of Pediatric Gastroenterology & Nutrition21\\n(1995): S52-56.\\nFleisher, D. R. “The Cyclic V omiting Syndrome Described.”\\nJournal of Pediatric Gastroenterology & Nutrition21\\n(1995): S1-5.\\nForbes, D., and G. Withers. “Prophylactic Therapy in Cyclic\\nV omiting Syndrome.”Journal of Pediatric Gastroenterol-\\nogy & Nutrition 21 (1995): S57-59.\\nForbes, D. “Differential Diagnosis of Cyclic V omiting Syn-\\ndrome.” Journal of Pediatric Gastroenterology & Nutri-\\ntion 21 (1995): S11-14.\\nLi, B.U. “Cyclic V omiting Syndrome. Introduction.”Journal of\\nPediatric Gastroenterology & Nutrition21 (1995): 7-8.\\nLi, B. U. “Cyclic V omiting: The Pattern and Syndrome Para-\\ndigm.” Journal of Pediatric Gastroenterology & Nutrition\\n21 (1995): S6-10.\\nVanderhoof, J. A., et al. “Treatment of Cyclic V omiting in\\nChildhood with Erythromycin.”Journal of Pediatric Gas-\\ntroenterology & Nutrition21 (1995): S60-62.\\nJ. Ricker Polsdorfer, MD\\nCyclobenzaprine see Muscle relaxants\\nCyclophospha see Anticancer drugs\\nCyclospora infection see Cyclosporiasis\\nCyclosporiasis\\nDefinition\\nCyclosporiasis refers to infection by the spore-form-\\ning protozoan known as Cyclospora . Protozoa are a\\ngroup of parasites that infect the human intestine. Para-\\nsites are organisms that live in another body, called the\\nhost, and get food and liquids from that host. This para-\\nsite is a member of the group of protozoa known as coc-\\ncidia, to which Cryptosporidia also belongs. This group\\nof parasites infects the human intestine, and causes\\nchronic recurrent infections in those with altered immu-\\nnity or AIDS. Even in people with normal immune func-\\ntion, Cyclopsora can cause prolonged bouts of diarrhea\\nand other gastrointestinal symptoms.\\nDescription\\nUntil recently, Cyclospora was considered to be a\\nform of algae. The parasite causes a common form of\\nwaterborne infectious diarrhea throughout the world. Just\\nhow the parasite gets into water sources is not yet clear. It\\nis known that ingestion of small cysts in contaminated\\nwater leads to disease.\\nCauses and symptoms\\nSymptoms begin after an incubation period of about a\\nday or so following ingestion of cysts. A brief period of flu-\\nlike illness characterized by weakness and low-grade fever\\nis followed by watery diarrhea, nausea, loss of appetite, and\\nmuscle aches. In some patients, symptoms may wax and\\nwane for weeks, and there are those in whom nausea and\\nburping may predominate. It is also believed that infection\\ncan occur without any symptoms at all.\\nIn patients with abnormal immunity (immunocom-\\npromised patients), such as those with AIDS and cancer,\\nprolonged diarrhea and severe weight loss often become\\na major problem. The bile ducts are also susceptible to\\ninfection in AIDS patients.\\nDiagnosis\\nThe disease should be suspected in anyone with a\\nhistory of prolonged or recurrent diarrhea. The parasite is\\nidentified either by staining stool specimens or by apply-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 981\\nCyclosporiasis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 981'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 370, 'page_label': '371'}, page_content='ing certain fluorescent ultraviolet techniques to find the\\ncharacteristic cysts. Biopsy of an infected organ such as\\nthe intestine through an endoscope is another way to\\nmake the diagnosis.\\nTreatment\\nThe first aim of treatment as with any severe diar-\\nrheal illness is to avoid dehydration and malnutrition .\\nOral Rehydration Solution (ORS) or intravenous fluids\\nare sometimes needed. Medications used to treat diarrhea\\nby decreasing intestinal motility, such as loperamide or\\ndiphenoxylate are also useful, but should only be used\\nwith the advice of a physician.\\nKEY TERMS\\nAnti-motility medications —Medications such as\\nloperamide (sold as Imodium), dephenoxylate\\n(sold as Lomotil), or medications containing\\ncodeine or narcotics that decrease the ability of\\nthe intestine to contract. This can worsen the con-\\ndition of a patient with dysentery or colitis.\\nCyst—A protective sac that includes either fluid or\\nthe cell of an organism. The cyst enables many\\norganisms to survive in the environment for long\\nperiods of time without need for food or water.\\nImmunocompromised —A change or alteration of\\nthe immune system that normally serves to fight\\noff infections other illnesses. This can involve\\nchanges in antibodies that the body produces\\n(hygogammaglobulinemia), or a defect in the cells\\nthat partake in the immune response. Diseases\\nsuch as AIDS and cancer exhibit changes in the\\nbody’s natural immunity.\\nOral Rehydration Solution (ORS) —A liquid\\npreparation developed by the World Health Orga-\\nnization that can decrease fluid loss in persons\\nwith diarrhea. Originally developed to be pre-\\npared with materials available in the home, com-\\nmercial preparations have recently come into use.\\nParasite—An organism that lives on or in another\\nand takes nourishment (food and fluids) from that\\norganism.\\nProtozoa —Group of extremely small single cell\\n(unicellular) or acellular organisms that are found\\nin moist soil or water. They tend to exist as para-\\nsites, living off other life forms.\\nSpore—A resistant form of certain species of bac-\\nteria, protozoa, and other organisms.\\nThe use of the medication, trimethoprim-sulfameth-\\noxazole (Bactrim) for one week can be successful in\\ntreating intestinal infections and prevents relapse in those\\nwith a normal immune system. The same medicine can\\nbe prescribed to treat infections of both the intestine or\\nbile ducts in immunocompromised individuals, but main-\\ntenance or continuous treatment is often needed.\\nPrognosis\\nThe outlook is quite good for individuals in whom a\\ndiagnosis is made. Even without treatment, symptoms\\nusually do not last much more than a month or so except\\nin cases with altered immunity. Fortunately, treatment is\\nusually successful even in those patients.\\nPrevention\\nAside from a waterborne source as the origin of\\ninfection, little else is known about how the parasite is\\ntransmitted. Therefore, little can be done regarding pre-\\nvention, except to maintain proper hand washing tech-\\nniques and hygiene.\\nResources\\nBOOKS\\nDavis, Charles E. “Laboratory Diagnosis of Parasitic Infec-\\ntion.” In Harrison’s Principles of Internal Medicine,e d .\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1997.\\nLiu, Leo X., and Peter F. Weller. “Therapy for Parasitic Infec-\\ntions.” In Harrison’s Principles of Internal Medicine,e d .\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1997.\\nNash, Theodore E., and Peter F. Weller. “Cyclosporiasis.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nOwen, Robert L. “Cyclospora Cayetanensis.” In Sleisenger &\\nFordtran’s Gastrointestinal and Liver Disease, ed. Mark\\nFeldman, et al. Philadelphia: W. B. Saunders Co., 1997.\\nWeller, Peter F. “Protozoal and Helminthic Infection: General\\nConsideration.” In Harrison’s Principles of Internal Med-\\nicine, ed. Anthony S. Fauci, et al. New York: McGraw-\\nHill, 1997.\\nPERIODICALS\\nLew, Edward A., Michael A. Poles, and Douglas T. Dieterich.\\n“Diarrheal Disease Associated with HIV Infection.”Gas-\\ntroenterology Clinics of North America(June 1997): 259-\\n290.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nOTHER\\n“Cyclopsora.” Centers for Disease Control. .\\nDavid Kaminstein, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 2982\\nCyclosporiasis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 982'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 371, 'page_label': '372'}, page_content='Cyclosporine see Immunosuppressant\\ndrugs\\nCystectomy\\nDefinition\\nCystectomy is a surgical procedure to remove the\\nbladder.\\nPurpose\\nCystectomy is performed to treat cancer of the blad-\\nder. Radiation and chemotherapy are also used to treat\\nbladder cancer. Surgery is used to remove cancer when\\nit is in the muscle of the bladder.\\nPrecautions\\nCystectomy is an aggressive treatment that may not\\nbe appropriate for patients with superficial tumors that\\nrespond to more conservative treatment.\\nDescription\\nCystectomy is a major surgical operation. The\\npatient is placed under general anesthesia. An incision is\\nmade across the lower abdomen. The ureters are located,\\ntied and cut. The ureters connect the kidneys to the blad-\\nder. Cutting them frees the bladder for removal. The\\nbladder and associated organs are removed. In men, the\\nprostate is removed with the bladder. In women, the\\nuterus, fallopian tubes, ovaries, and part of the vagina are\\nremoved with the bladder. The bladder collects urine\\nfrom the kidneys for excretion at a later time. Since the\\nbladder is removed, a new method must be created to\\nremove the urine. A small piece of the small intestine is\\nremoved, cleaned, and tied at one end to form a tube. The\\nother end is used to form a stoma, an opening through the\\nabdominal wall to the outside. The ureters are then con-\\nnected to the tube. Urine produced by the kidneys now\\nflows down the ureters, into the tube, and through the\\nstoma. The patient wears a bag to collect the urine.\\nPreparation\\nThe medical team will discuss the procedure and tell\\nthe patient where the stoma will appear and what it will\\nlook like. The patient receives instruction on caring for a\\nstoma and bag. Counseling may be initiated. A period of\\nfasting and an enema may be required.\\nKEY TERMS\\nUreters —Tubes that connect the kidneys to the\\nbladder. Urine produced by the kidneys passes\\nthrough the ureters to the bladder.\\nAftercare\\nAfter the operation, the patient is given fluid-based\\nnutrition until the intestines being to function normally\\nagain. Antibiotics are given to prevent infection of the\\nincision sites. The nature of the organs removed mean\\nthat there will be major lifestyle changes for the person\\nundergoing the operation. Men will become impotent\\nbecause nerves controlling penile erection are cut during\\nremoval of the bladder. In women, infertility is a conse-\\nquence because the ovaries and uterus are removed.\\nHowever, most women who undergo cystectomy are\\npostmenopausal and past their childbearing years.\\nBoth men and women are fitted with an external bag\\nthat connects to the stoma and collects the urine. The bag\\nis generally worn around the waist under the clothing. It\\ntakes a period of adjustment to get used to wearing the\\nbag. Because there is no bladder, urine is excreted as it is\\nproduced, essentially continuously. The stoma must be\\ntreated properly to ensure that it does not become infect-\\ned or blocked. Patients must be trained to care for their\\nstoma. Often there is a period of psychological adjust-\\nment to the major change in life style created by the\\nstoma and bag. Patients should be prepared for this by\\ndiscussion with their physician.\\nRisks\\nAs with any major surgery, there is a risk of infec-\\ntion; in this case, infection of the intestine is especially\\ndangerous as it can lead to peritonitis (inflammation of\\nthe membrane lining the abdomen).\\nNormal results\\nThe bladder is successfully removed and a stoma\\ncreated. Intestinal function returns to normal and the\\npatient learns proper care of the stoma and bag. He or she\\nadjusts to lifestyle changes and returns to a normal rou-\\ntine of work and recreation, some sports excluded.\\nAbnormal results\\nThe patient develops an infection at the incision site.\\nThe patient does not make a successful psychological\\nadjustment to the long term consequences of impotence\\nGALE ENCYCLOPEDIA OF MEDICINE 2 983\\nCystectomy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 983'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 372, 'page_label': '373'}, page_content='and urinary diversion. In some women, the vagina is con-\\nstricted, which may require a secondary procedure.\\nResources\\nBOOKS\\nBerkow, Robert, ed. Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research Laboratories,\\n1997.\\nCurrent Surgical Diagnosis and Treatment.10th ed. Ed.\\nLawrence W. Way. Stamford: Appleton & Lange, 1994.\\nSabiston, D. C., and H. K. Lyrly. Essentials of Surgery.\\nPhiladelphia: W. B. Saunders Co., 1994.\\nJohn T. Lohr, PhD\\nCystic fibrosis\\nDefinition\\nCystic fibrosis (CF) is an inherited disease that\\naffects the lungs, digestive system, sweat glands, and\\nmale fertility. Its name derives from the fibrous scar tis-\\nsue that develops in the pancreas, one of the principal\\norgans affected by the disease.\\nDescription\\nCystic fibrosis affects the body’s ability to move salt\\nand water in and out of cells. This defect causes the lungs\\nand pancreas to secrete thick mucus, blocking passage-\\nways and preventing proper function.\\nCF affects approximately 30,000 children and young\\nadults in the United States, and about 3,000 babies are\\nborn with CF every year. CF primarily affects people of\\nwhite northern-European descent; rates are much lower\\nin non-white populations.\\nMany of the symptoms of CF can be treated with\\ndrugs or nutritional supplements. Close attention to and\\nprompt treatment of respiratory and digestive complica-\\ntions have dramatically increased the expected life span\\nof a person with CF. While several decades ago most\\nchildren with CF died by age two, today about half of all\\npeople with CF live past age 31. That median age is\\nexpected to grow as new treatments are developed, and it\\nis estimated that a person born in 1998 with CF has a\\nmedian expected life span of 40 years.\\nCauses and symptoms\\nCauses\\nCystic fibrosis is a genetic disease, meaning it is\\ncaused by a defect in the person’s genes. Genes, found in\\nthe nucleus of all the body’s cells, control cell function\\nby serving as the blueprint for the production of proteins.\\nProteins carry out a wide variety of functions within\\ncells. The gene that, when defective, causes CF, is called\\nthe CFTR gene, which stands for cystic fibrosis trans-\\nmembrane conductance regulator. A simple defect in this\\ngene leads to all the consequences of CF. There are over\\n500 known defects in the CFTR gene that can cause CF.\\nHowever, 70% of all people with a defective CFTR gene\\nhave the same defect, known as delta-F508.\\nMuch as sentences are composed of long strings of\\nwords, each made of letters; genes can be thought of as\\nlong strings of chemical words, each made of chemical\\nletters, called nucleotides. Just as a sentence can be\\nchanged by rearranging its letters, genes can be mutated,\\nor changed, by changes in the sequence of their\\nnucleotide letters. The gene defects in CF are called\\npoint mutations, meaning that the gene is mutated only at\\none small spot along its length. In other words, the delta-\\nF508 mutation is a loss of one “letter” out of thousands\\nwithin the CFTR gene. As a result, the CFTR protein\\nmade from its blueprint is made incorrectly, and cannot\\nperform its function properly.\\nThe CFTR protein helps to produce mucus. Mucus is\\na complex mixture of salts, water, sugars, and proteins that\\ncleanses, lubricates, and protects many passageways in the\\nbody, including those in the lungs and pancreas. The role\\nof the CFTR protein is to allow chloride ions to exit the\\nmucus-producing cells. When the chloride ions leave these\\ncells, water follows, thinning the mucus. In this way, the\\nCFTR protein helps to keep mucus from becoming thick\\nand sluggish, thus allowing the mucus to be moved steadi-\\nly along the passageways to aid in cleansing.\\nIn CF, the CFTR protein cannot allow chloride ions\\nout of the mucus-producing cells. With less chloride\\nleaving, less water leaves, and the mucus becomes thick\\nand sticky. It can no longer move freely through the pas-\\nsageways, so they become clogged. In the pancreas,\\nclogged passageways prevent secretion of digestive\\nenzymes into the intestine, causing serious impairment\\nof digestion—especially of fat—which may lead to mal-\\nnutrition. Mucus in the lungs may plug the airways, pre-\\nventing good air exchange and, ultimately, leading to\\nemphysema. The mucus is also a rich source of nutrients\\nfor bacteria, leading to frequent infections.\\nINHERITANCE OF CYSTIC FIBROSIS. To understand\\nthe inheritance pattern of CF, it is important to realize that\\ngenes actually have two functions. First, as noted above,\\nthey serve as the blueprint for the production of proteins.\\nSecond, they are the material of inheritance: parents pass\\non characteristics to their children by combining the\\ngenes in egg and sperm to make a new individual.\\nGALE ENCYCLOPEDIA OF MEDICINE 2984\\nCystic fibrosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 984'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 373, 'page_label': '374'}, page_content='Each person actually has two copies of each gene,\\nincluding the CFTR gene, in each of their body cells. Dur-\\ning sperm and egg production, however, these two copies\\nseparate, so that each sperm or egg contains only one copy\\nof each gene. When sperm and egg unite, the newly creat-\\ned cell once again has two copies of each gene.\\nThe two gene copies may be the same or they may\\nbe slightly different. For the CFTR gene, for instance, a\\nperson may have two normal copies, or one normal and\\none mutated copy, or two mutated copies. A person with\\ntwo mutated copies will develop cystic fibrosis. A person\\nwith one mutated copy is said to be a carrier. A carrier\\nwill not have symptoms of CF, but can pass on the mutat-\\ned CFTR gene to his/her children.\\nWhen two carriers have children, they have a one in\\nfour chance of having a child with CF each time they\\nconceive. They have a two in four chance of having a\\nchild who is a carrier, and a one in four chance of having\\na child with two normal CFTR genes.\\nApproximately one in every 25 Americans of north-\\nern-European descent is a carrier of the mutated CF\\ngene, while only one in 17,000 African Americans and\\none in 30,000 Asian Americans are carriers. Since carri-\\ners are symptom-free, very few people will know\\nwhether or not they are carriers unless there is a family\\nhistory of the disease. Two white Americans with no\\nfamily history of CF have a one in 2,500 chance of hav-\\ning a child with CF.\\nIt may seem puzzling that a mutated gene with such\\nharmful consequences would remain so common; one\\nmight guess that the high mortality of CF would quickly\\nlead to loss of the mutated gene from the population.\\nSome researchers now believe the reason for the persis-\\ntence of the CF gene is that carriers, those with only one\\ncopy of the gene, are protected from the full effects of\\ncholera, a microorganism that infects the intestine, caus-\\ning intense diarrhea and eventual death by dehydra-\\ntion. It is believed that having one copy of the CF gene is\\nenough to prevent the full effects of cholera infection,\\nwhile not enough to cause the symptoms of CF. This so-\\ncalled “heterozygote advantage” is seen in some other\\ngenetic disorders, including sickle-cell anemia.\\nSymptoms\\nThe most severe effects of cystic fibrosis are seen in\\ntwo body systems: the gastrointestinal (digestive) sys-\\ntem, and the respiratory tract, from the nose to the lungs.\\nCF also affects the sweat glands and male fertility.\\nSymptoms develop gradually, with gastrointestinal\\nsymptoms often the first to appear.\\nGASTROINTESTINAL SYSTEM. Ten to fifteen percent\\nof babies who inherit CF have meconium ileus at birth.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 985\\nCystic fibrosis\\nDOROTHY ANDERSEN, MD (1901–1963)\\nDorothy Andersen was born on May 15, 1901, in\\nAsheville, North Carolina. She was the only child of Hans\\nPeter Andersen and the former Mary Louise Mason.\\nOrphaned as a young adult, Andersen put herself through\\nSaint Johnsbury Academy and Mount Holyoke College\\nbefore enrolling in the Johns Hopkins School of Medicine,\\nfrom which she received her M.D. in 1926.\\nAndersen turned instead to medical research as a\\npathologist at Babies Hospital of the Columbia-Presbyter-\\nian Medical Center in New York City, where she stayed for\\nmore than 20 years, eventually becoming chief of patholo-\\ngy in 1952. Andersen is probably best known for discovery\\nof cystic fibrosis in 1935. That discovery came about during\\nthe postmortem examination of a child who had supposed-\\nly died of celiac disease, a nutritional disorder. She\\nsearched for similar cases in the autopsy files and in med-\\nical literature, eventually realizing that she had found a dis-\\nease that had never been described and to which she gave\\nthe name cystic fibrosis.\\n(Library of Congress)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 985'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 374, 'page_label': '375'}, page_content='Meconium is the first dark stool that a baby passes after\\nbirth; ileus is an obstruction of the digestive tract. The\\nmeconium of a newborn with meconium ileus is thick-\\nened and sticky, due to the presence of thickened mucus\\nfrom the intestinal glands. Meconium ileus causes\\nabdominal swelling and vomiting, and often requires\\nsurgery immediately after birth. Presence of meconium\\nileus is considered highly indicative of CF. Borderline\\ncases may be misdiagnosed, however, and attributed\\ninstead to “milk allergy.”\\nOther abdominal symptoms are caused by the inabil-\\nity of the pancreas to supply digestive enzymes to the\\nintestine. During normal digestion, as food passes from\\nthe stomach into the small intestine, it is mixed with pan-\\ncreatic secretions which help to break down the nutrients\\nfor absorption. While the intestines themselves also pro-\\nvide some digestive enzymes, the pancreas is the major\\nsource of enzymes for the digestion of all types of foods,\\nespecially fats and proteins.\\nIn CF, thick mucus blocks the pancreatic duct,\\nwhich is eventually closed off completely by scar tissue\\nformation, leading to a condition known as pancreatic\\ninsufficiency. Without pancreatic enzymes, large\\namounts of undigested food pass into the large intes-\\ntine. Bacterial action on this rich food source can cause\\ngas and abdominal swelling. The large amount of fat\\nremaining in the feces makes it bulky, oily, and foul-\\nsmelling.\\nBecause nutrients are only poorly digested and\\nabsorbed, the person with CF is often ravenously hungry,\\nunderweight, and shorter than expected for his age.\\nWhen CF is not treated for a longer period, a child may\\ndevelop symptoms of malnutrition, including anemia,\\nbloating, and, paradoxically, appetite loss.\\nDiabetes becomes increasingly likely as a person\\nwith CF ages. Scarring of the pancreas slowly destroys\\nthose pancreatic cells which produce insulin, producing\\ntype I, or insulin-dependent diabetes.\\nGall stones affect approximately 10% of adults with\\nCF. Liver problems are less common, but can be caused by\\nthe buildup of fat within the liver. Complications of liver\\nenlargement may include internal hemorrhaging, abdomi-\\nnal fluid (ascites), spleen enlargement, and liver failure.\\nOther gastrointestinal symptoms can include a pro-\\nlapsed rectum, in which part of the rectal lining protrudes\\nthrough the anus; intestinal obstruction; and rarely,\\nintussusception, in which part of the intestinal tube slips\\nover an adjoining part, cutting off blood supply.\\nSomewhat less than 10% of people with CF do not\\nhave gastrointestinal symptoms. Most of these people do\\nnot have the delta-F508 mutation, but rather a different\\none, which presumably allows at least some of their\\nCFTR proteins to function normally in the pancreas.\\nRESPIRATORY TRACT. The respiratory tract includes\\nthe nose, the throat, the trachea (or windpipe), the\\nbronchi (which branch off from the trachea within each\\nlung), the smaller bronchioles, and the blind sacs called\\nalveoli, in which gas exchange takes place between air\\nand blood.\\nSwelling of the sinuses within the nose is common\\nin people with CF. This usually shows up on x-ray, and\\nmay aid the diagnosis of CF. However, this swelling,\\ncalled pansinusitis, rarely causes problems, and does not\\nusually require treatment.\\nNasal polyps , or growths, affect about one in five\\npeople with CF. These growths are not cancerous, and do\\nnot require removal unless they become annoying. While\\nnasal polyps appear in older people without CF, especially\\nthose with allergies, they are rare in children without CF.\\nThe lungs are the site of the most life-threatening\\neffects of CF. The production of a thick, sticky mucus\\nincreases the likelihood of infection, decreases the abil-\\nity to protect against infection, causes inflammation\\nand swelling, decreases the functional capacity of the\\nlungs, and may lead to emphysema. People with CF\\nwill live with chronic populations of bacteria in their\\nlungs, and lung infection is the major cause of death for\\nthose with CF.\\nThe bronchioles and bronchi normally produce a\\nthin, clear mucus that traps foreign particles including\\nbacteria and viruses. Tiny hair-like projections on the\\nsurface of these passageways slowly sweep the mucus\\nalong, out of the lungs and up the trachea to the back of\\nthe throat, where it may be swallowed or coughed up.\\nThis “mucociliary escalator” is one of the principal\\ndefenses against lung infection.\\nThe thickened mucus of CF prevents easy movement\\nout of the lungs, and increases the irritation and inflam-\\nmation of lung tissue. This inflammation swells the pas-\\nsageways, partially closing them down, further hamper-\\ning the movement of mucus. A person with CF is likely\\nto cough more frequently and more vigorously as the\\nlungs attempt to clean themselves out.\\nAt the same time, infection becomes more likely\\nsince the mucus is a rich source of nutrients. Bronchitis,\\nbronchiolitis, and pneumonia are frequent in CF. The\\nmost common infecting organisms are the bacteria\\nStaphylococcus aureus , Haemophilus influenzae , and\\nPseudomonas aeruginosa . A small percentage of people\\nwith CF have infections caused by Burkholderia cepacia,\\na bacterium which is resistant to most current antibiotics\\n(Burkholderia cepacia was formerly known as\\nGALE ENCYCLOPEDIA OF MEDICINE 2986\\nCystic fibrosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 986'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 375, 'page_label': '376'}, page_content='Pseudomonas cepacia .) The fungus Aspergillus fumiga-\\ntus may infect older children and adults.\\nThe body’s response to infection is to increase\\nmucus production; white blood cells fighting the infec-\\ntion thicken the mucus even further as they break down\\nand release their cell contents. These white blood cells\\nalso provoke more inflammation, continuing the down-\\nward spiral that marks untreated CF.\\nAs mucus accumulates, it can plug up the smaller\\npassageways in the lungs, decreasing functional lung\\nvolume. Getting enough air can become difficult; tired-\\nness, shortness of breath , and intolerance of exercise\\nbecome more common. Because air passes obstructions\\nmore easily during inhalation than during exhalation,\\nover time, air becomes trapped in the smallest chambers\\nof the lungs, the alveoli. As millions of alveoli gradually\\nexpand, the chest takes on the enlarged, barrel-shaped\\nappearance typical of emphysema.\\nFor unknown reasons, recurrent respiratory infec-\\ntions lead to “digital clubbing,” in which the last joint of\\nthe fingers and toes becomes slightly enlarged.\\nSWEAT GLANDS. The CFTR protein helps to regulate\\nthe amount of salt in sweat. People with CF have sweat\\nthat is much saltier than normal, and measuring the salti-\\nness of a person’s sweat is the most important diagnostic\\ntest for CF. Parents may notice that their infants taste salty\\nwhen they kiss them. Excess salt loss is not usually a prob-\\nlem except during prolonged exercise or heat. While most\\nolder children and adults with CF compensate for this\\nextra salt loss by eating more salty foods, infants and\\nyoung children are in danger of suffering its effects (such\\nas heat prostration), especially during summer. Heat pros-\\ntration is marked by lethargy, weakness, and loss of\\nappetite, and should be treated as an emergency condition.\\nFERTILITY. Ninety-eight percent of men with CF are\\nsterile, due to complete obstruction or absence of the vas\\ndeferens, the tube carrying sperm out of the testes. While\\nboys and men with CF form normal sperm and have nor-\\nmal levels of sex hormones, sperm are unable to leave the\\ntestes, and fertilization is not possible. Most women with\\nCF are fertile, though they often have more trouble get-\\nting pregnant than women without CF. In both boys and\\ngirls, puberty is often delayed, most likely due to the\\neffects of poor nutrition or chronic lung infection.\\nWomen with good lung health usually have no problems\\nwith pregnancy , while those with ongoing lung infec-\\ntion often do poorly.\\nDiagnosis\\nThe decision to test a child for cystic fibrosis may be\\ntriggered by concerns about recurring gastrointestinal or\\nKEY TERMS\\nCarrier —A person with one copy of a defective\\ngene, who does not have the disease it causes, but\\ncan pass along the defective gene to offspring.\\nCFTR—Cystic fibrosis transmembrane conduc-\\ntance regulator, the protein responsible for regulat-\\ning chloride movement across cells in some tis-\\nsues. When a person has two defective copies of\\nthe CFTR gene, cystic fibrosis is the result.\\nEmphysema—A pathological accumulation of air\\nin organs or tissues; term especially applied to the\\ncondition when in the lungs.\\nMucociliary escalator—The coordinated action of\\ntiny projections on the surfaces of cells lining the\\nrespiratory tract, which moves mucus up and out\\nof the lungs.\\nMucolytic —An agent that dissolves or destroys\\nmucin, the chief component of mucus.\\nPancreatic insufficiency—Reduction or absence of\\npancreatic secretions into the digestive system due\\nto scarring and blockage of the pancreatic duct.\\nrespiratory symptoms, or salty sweat. A child born with\\nmeconium ileus will be tested before leaving the hospi-\\ntal. Families with a history of CF may wish to have all\\nchildren tested, especially if there is a child who already\\nhas the disease. Some hospitals now require routine\\nscreening of newborns for CF.\\nSweat test\\nThe sweat test is both the easiest and most accurate\\ntest for CF. In this test, a small amount of the drug pilo-\\ncarpine is placed on the skin. A very small electrical cur-\\nrent is then applied to the area, which drives the pilo-\\ncarpine into the skin. The drug stimulates sweating in the\\ntreated area. The sweat is absorbed onto a piece of filter\\npaper, and is then analyzed for its salt content. A person\\nwith CF will have salt concentrations that are one-and-\\none-half to two times greater than normal. The test can\\nbe done on persons of any age, including newborns, and\\nits results can be determined within an hour. Virtually\\nevery person who has CF will test positively on it, and\\nvirtually everyone who does not will test negatively.\\nGenetic testing\\nThe discovery of the CFTR gene in 1989 allowed\\nthe development of an accurate genetic test for CF.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 987\\nCystic fibrosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 987'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 376, 'page_label': '377'}, page_content='Genes from a small blood or tissue sample are analyzed\\nfor specific mutations; presence of two copies of the\\nmutated gene confirms the diagnosis of CF in all but a\\nvery few cases. However, since there are so many differ-\\nent possible mutations, and since testing for all of them\\nwould be too expensive and time-consuming, a negative\\ngene test cannot rule out the possibility of CF.\\nCouples planning a family may decide to have them-\\nselves tested if one or both have a family history of CF.\\nPrenatal genetic testing is possible through amniocente-\\nsis. Many couples who already have one child with CF\\ndecide to undergo prenatal screening in subsequent preg-\\nnancies, and use the results to determine whether to ter-\\nminate the pregnancy. Siblings in these families are also\\nusually tested, both to determine if they will develop CF,\\nand to determine if they are carriers, to aid in their own\\nfamily planning. If the sibling has no symptoms, deter-\\nmining his carrier status is often delayed until his teen\\nyears or later, when he is closer to needing the informa-\\ntion to make decisions.\\nNewborn screening\\nSome states now require screening of newborns for\\nCF, using a test known as the IRT test. This is a blood test\\nwhich measures the level of immunoreactive trypsino-\\ngen, which is generally higher in babies with CF than\\nthose without it. This test gives many false positive\\nresults immediately after birth, and so requires a second\\ntest several weeks later. A second positive result is usual-\\nly followed by a sweat test.\\nTreatment\\nThere is no cure for CF. Treatment has advanced con-\\nsiderably in the past several decades, increasing both the\\nlife span and the quality of life for most people affected\\nby CF. Early diagnosis is important to prevent malnutri-\\ntion and infection from weakening the young child. With\\nproper management, many people with CF engage in the\\nfull range of school and sports activities.\\nNutrition\\nPeople with CF usually require high-calorie diets\\nand vitamin supplements. Height, weight, and growth of\\na person with CF are monitored regularly. Most people\\nwith CF need to take pancreatic enzymes to supplement\\nor replace the inadequate secretions of the pancreas.\\nTablets containing pancreatic enzymes are taken with\\nevery meal; depending on the size of the tablet and the\\nmeal, as many as 20 tablets may be needed. Because of\\nincomplete absorption even with pancreatic enzymes, a\\nperson with CF needs to take in about 30% more food\\nthan a person without CF. Low-fat diets are not recom-\\nmended except in special circumstances, since fat is a\\nsource of both essential fatty acids and abundant calories.\\nSome people with CF cannot absorb enough nutri-\\nents from the foods they eat, even with specialized diets\\nand enzymes. For these people, tube feeding is an option.\\nNutrients can be introduced directly into the stomach\\nthrough a tube inserted either through the nose (a naso-\\ngastric tube) or through the abdominal wall (a gastrosto-\\nmy tube). A jejunostomy tube, inserted into the small\\nintestine, is also an option. Tube feeding can provide\\nnutrition at any time, including at night while the person\\nis sleeping, allowing constant intake of high-quality\\nnutrients. The feeding tube may be removed during the\\nday, allowing normal meals to be taken.\\nRespiratory health\\nThe key to maintaining respiratory health in a person\\nwith CF is regular monitoring and early treatment. Lung\\nfunction tests are done frequently to track changes in\\nfunctional lung volume and respiratory effort. Sputum\\nsamples are analyzed to determine the types of bacteria\\npresent in the lungs. Chest x rays are usually taken at\\nleast once a year. Lung scans, using a radioactive gas,\\ncan show closed off areas not seen on the x ray. Circula-\\ntion in the lungs may be monitored by injection of a\\nradioactive substance into the bloodstream.\\nPeople with CF live with chronic bacterial coloniza-\\ntion; that is, their lungs are constantly host to several\\nspecies of bacteria. Good general health, especially good\\nnutrition, can keep the immune system healthy, which\\ndecreases the frequency with which these colonies begin\\nan infection, or attack on the lung tissue. Exercise is anoth-\\ner important way to maintain health, and people with CF\\nare encouraged to maintain a program of regular exercise.\\nIn addition, clearing mucus from the lungs helps to\\nprevent infection; and mucus control is an important\\naspect of CF management. Postural drainage is used to\\nallow gravity to aid the mucociliary escalator. For this\\ntechnique, the person with CF lies on a tilted surface with\\nhead downward, alternately on the stomach, back, or side,\\ndepending on the section of lung to be drained. An assis-\\ntant thumps the rib cage to help loosen the secretions. A\\ndevice called a “flutter” offers another way to loosen\\nsecretions: it consists of a stainless steel ball in a tube.\\nWhen a person exhales through it, the ball vibrates, send-\\ning vibrations back through the air in the lungs. Some spe-\\ncial breathing techniques may also help clear the lungs.\\nSeveral drugs are available to prevent the airways\\nfrom becoming clogged with mucus. Bronchodilators\\nand theophyllines open up the airways; steroids reduce\\ninflammation; and mucolytics loosen secretions. Acetyl-\\nGALE ENCYCLOPEDIA OF MEDICINE 2988\\nCystic fibrosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 988'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 377, 'page_label': '378'}, page_content='cysteine (Mucomyst) has been used as a mucolytic for\\nmany years but is not prescribe frequently now, while\\nDNase (Pulmozyme) is a newer product gaining in popu-\\nlarity. DNase breaks down the DNA from dead white\\nblood cells and bacteria found in thick mucus.\\nPeople with CF may pick up bacteria from other CF\\npatients. This is especially true of Burkholderia cepacia,\\nwhich is not usually found in people without CF. While\\nthe ideal recommendation from a health standpoint might\\nbe to avoid contact with others who have CF, this is not\\nusually practical (since CF clinics are a major site of care),\\nnor does it meet the psychological and social needs of\\nmany people with CF. At a minimum, CF centers recom-\\nmend avoiding prolonged close contact between people\\nwith CF, and scrupulous hygiene, including frequent hand\\nwashing. Some CF clinics schedule appointments on dif-\\nferent days for those with and without B. cepaciacolonies.\\nSome doctors choose to prescribe antibiotics only dur-\\ning infection, while others prefer long-term antibiotic treat-\\nment against S. aureus. The choice of antibiotic depends on\\nthe particular organism or organisms found. Some antibi-\\notics are given as aerosols directly into the lungs. Antibiotic\\ntreatment may be prolonged and aggressive.\\nSupplemental oxygen may be needed as lung dis-\\nease progresses. Respiratory failure may develop,\\nrequiring temporary use of a ventilator to perform the\\nwork of breathing.\\nLung transplantation has become increasingly\\ncommon for people with CF, although the number of\\npeople who receive them is still much lower than those\\nwho want them. Transplantation is not a cure, however,\\nand has been likened to trading one disease for another.\\nLong-term immunosuppression is required, increasing\\nthe likelihood of other types of infection. About 50% of\\nadults and more than 80% of children who receive lung\\ntransplants live longer than two years. Liver transplants\\nare also done for CF patients whose livers have been\\ndamaged by fibrosis.\\nLong-term use of ibuprofen has been shown to help\\nsome people with CF, presumably by reducing inflam-\\nmation in the lungs. Close medical supervision is neces-\\nsary, however, since the effective dose is high and not\\neveryone benefits. Ibuprofen at the required doses inter-\\nferes with kidney function, and together with aminogly-\\ncoside antibiotics, may cause kidney failure.\\nA number of experimental treatments are currently\\nthe subject of much research. Some evidence indicates\\nthat aminoglycoside antibiotics may help overcome the\\ngenetic defect in some CF mutations, allowing the pro-\\ntein to be made normally. While promising, these results\\nwould apply to only about 5% of those with CF.\\nGene therapy is currently the most ambitious\\napproach to curing CF. In this set of techniques, non-\\ndefective copies of the CFTR gene are delivered to\\naffected cells, where they are taken up and used to create\\nthe CFTR protein. While elegant and simple in theory,\\ngene therapy has met with a large number of difficulties\\nin trials so far, including immune resistance, very short\\nduration of the introduced gene, and inadequately wide-\\nspread delivery.\\nAlternative treatment\\nIn homeopathic medicine, the symptoms of the disease\\nwould be addressed to enhance the quality of life for the\\nperson with cystic fibrosis. Treating the cause of CF,\\nbecause of the genetic basis for the disease, is not possible.\\nHomeopathic medicine seeks to treat the whole person,\\nhowever, and in CF, this approach might include:\\n• mucolytics to help thin mucous\\n• supplementation of pancreatic enzymes to assist in\\ndigestion\\n• respiratory symptoms can be addressed to open lung\\npassages\\n• hydrotherapy techniques to help ease the respiratory\\nsymptoms and help the body eliminate\\n• immune enhancements can help revent the develop-\\nment of secondary infections\\n• dietary enhancements and adjustments are used to treat\\ndigestive and nutritional problems\\nPrognosis\\nPeople with CF may lead relatively normal lives with\\nthe control of symptoms. The possible effect of pregnancy\\non the health of a woman with CF requires careful consid-\\neration before beginning a family as do issues of longevi-\\nty and their children’s status as carriers. Although most\\nmen with CF are functionally sterile, new procedures for\\nremoving sperm from the testes are being tried, and may\\noffer more men the chance to become fathers.\\nApproximately half of people with CF live past the\\nage of 30. Because of better and earlier treatment, a per-\\nson born today with CF is expected, on average, to live to\\nage 40.\\nPrevention\\nAdults with a family history of cystic fibrosis may\\nobtain a genetic test of their carrier status for purposes of\\nfamily planning. Prenatal testing is also available. There\\nis currently no known way to prevent development of CF\\nin a person with two defective gene copies.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 989\\nCystic fibrosis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 989'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 378, 'page_label': '379'}, page_content='Resources\\nBOOKS\\nHarris, Ann, and Maurice Super. Cystic Fibrosis: The Facts.\\nNew York: Oxford University Press, 1995.\\nOrenstein, David. Cystic Fibrosis: A Guide for Patient and\\nFamily.Philadelphia: Lippincott-Raven, 1997.\\nORGANIZATIONS\\nCystic Fibrosis Foundation. 6931 Arlington Road, Bethesda,\\nMD 20814. (800) 344-4823. .\\nOTHER\\nCysticFibrosis.com. .\\nRichard Robinson\\nCystinuria\\nDefinition\\nCystinuria is an inborn error of amino acid transport\\nthat results in the defective absorption by the kidneys of\\nthe amino acid called cystine. The name means “cystine\\nin the urine.”\\nDescription\\nCystine is an amino acid. Amino acids are organic\\ncompounds needed by the body to make proteins and for\\nmany normal functions. When the kidneys don’t absorb\\ncystine, this compound builds up in the urine. When the\\namount of cystine in the urine exceeds its solubility (the\\ngreatest amount that can be dissolved), crystals form. As\\nthe amount of cystine continues to increase in the urine,\\nthe number of crystals also increases. When very large\\nnumbers of cystine crystals form, they clump together\\ninto what is called a stone.\\nCauses and symptoms\\nCystinuria is a rare disease that occurs when people\\ninherit an abnormal gene from their parents. This disease\\noccurs in differing degrees of severity in people who\\nhave inherited either one or two abnormal genes.\\nHumans have two copies of each gene. When both are\\nabnormal, the condition is called homozygous for the\\ndisease. When one copy is normal and the other is abnor-\\nmal, the condition is called heterozygous for the disease.\\nPersons with one abnormal gene can have a milder form\\nof cystinuria that rarely results in the formation of stones.\\nSevere cystinuria occurs when people are homozy-\\ngous for the disease. For these individuals, the kidneys\\nmay excrete as much as 30 times the normal amount of\\ncystine. Research has shown that this condition is caused\\nby mutations on chromosome number two (humans have\\n23 pairs of chromosomes).\\nA person who has inherited cystinuria may have\\nother abnormal bodily functions. In addition to excess\\nlevels of the amino acid cystine, high amounts of the\\namino acids lysine, arginine, and ornithine are found in\\nthe urine. This condition indicates that these amino acids\\nare not being reabsorbed by the body.\\nWhen excess cystine crystals clump together to form\\na stone, the stone can block portions of the interior of the\\nkidney or the tube (the ureter) that connects the kidney to\\nthe urinary bladder. These cystine stones can be painful,\\nand depending upon where the stone becomes trapped,\\nthe pain can be felt in the lower back or the abdomen.\\nNausea and vomiting can also occur, and patients may\\nsometimes feel the need to urinate often. Cystine stones\\ncan also cause blood in the urine. When the urinary tract\\nis blocked by a stone, urinary tract infections or kidney\\nfailure may result.\\nDiagnosis\\nSmall stones (called “silent”) often do not cause any\\nsymptoms, although they can be detected by an x ray.\\nLarge stones are often painful and easily noticed by the\\npatient. Blood in the urine can also mean that a stone has\\nformed.\\nWhen the urine contains extremely high amounts of\\ncystine, yellow-brown hexagonal crystals are visible\\nwhen a sample is examined under the microscope. Urine\\nsamples can also be mixed with chemicals that change\\ncolor when high levels of cystine are present. When the\\ncompound nitroprusside is added to urine that has been\\nmade alkaline by the addition of ammonia, the urine\\nspecimen turns red if it contains excess cystine.\\nTreatment\\nNo treatment can decrease cystine excretion. The\\nbest treatment for cystinuria is to prevent stones from\\nforming. Stones can be prevented by drinking enough\\nliquid each day (about 5–7 qts) to produce at least 8 pts\\nof urine, thus keeping the concentration of cystine in the\\nurine low. Because a person doesn’t drink throughout the\\nnight, less urine is produced, and the likelihood of stone\\nformation increases. This risk can be minimized by\\ndrinking water or other liquids just before going to bed.\\nDrug treatments\\nIn addition to drinking large amounts of fluids, it is\\nhelpful to make the urine more alkaline. Cystine dis-\\nGALE ENCYCLOPEDIA OF MEDICINE 2990\\nCystinuria\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 990'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 379, 'page_label': '380'}, page_content='solves more easily in alkaline urine. To increase urine\\nalkalinity, a person may take sodium bicarbonate and\\nacetazolamide. Penicillamine, a drug that increases the\\nsolubility of cystine, may be prescribed for patients who\\ndo not respond well to other therapies. This drug must be\\nused with caution, however, because it can cause serious\\nside effects or allergic reactions. For those unable to take\\npenicillamine, another drug, alpha-mercaptopropionyl-\\nglycine (Thiola), may be prescribed.\\nSurgical treatments\\nMost stones can be removed from the body by nor-\\nmal urination, helped by drinking large amounts of\\nwater. Large stones that cannot be passed this way must\\nbe removed by surgical procedures.\\nLarge stones can be surgically removed by having a\\ndevice called a uretoscope placed into the urethra, up\\nthrough the bladder and into the ureter, where the trapped\\nstone can be seen and removed. Another method involves\\nusing sound-wave energy aimed from outside the body to\\nbreak the large stone into small pieces that can be passed\\nby urination. This external technique is called extracor-\\nporeal shock-wave lithotripsy (ESWL).\\nFor large stones in the kidney, a procedure called per-\\ncutaneous nephrolithomy may be used. In this procedure,\\nthe surgeon makes a small incision in the back over the\\nkidney. An instrument called a nephroscope is inserted\\nthrough the incision into the kidney. The surgeon uses the\\nnephroscope to locate and remove the stone. If the stone\\nis very large, it may be broken up into smaller pieces by\\nan ultrasonic or other kind of probe before removal.\\nPrognosis\\nAs many as 50% of patients who have had surgical\\ntreatment for a kidney stone will have another stone\\nwithin five years if no medicines are used to treat this\\ncondition.\\nPrevention\\nCystinuria is a genetic disorder that currently cannot\\nbe prevented.\\nResources\\nBOOKS\\nElsas, Louis S., Nicola Longo, and Leon E. Rosenberg. “Inher-\\nited Defects of Membrane Transport.” In Harrison’s Prin-\\nciples of Internal Medicine, ed. Anthony S. Fauci, et al.\\nNew York: McGraw-Hill, 1997.\\n“Kidney Stones in Adults.” In Kidney and Urinary Tract Dis-\\neases and Disorders Sourcebook, ed. Linda M. Ross.\\nDetroit: Omnigraphics, 1997.\\nKEY TERMS\\nAlkaline —A solution is considered alkaline if it\\ncontains fewer hydrogen atoms than pure water.\\nAmino acid —An organic compound made of an\\namino group (containing nitrogen and hydrogen)\\nand a carbolic acid group. Amino acids are an\\nessential part of protein molecules.\\nNephroscope —An instrument made of a light\\nsource in a tube. The tube is inserted into the kid-\\nney through an incision in the back and used to\\nlocate kidney stones. The stones are broken up\\nwith high frequency sound waves and removed by\\nsuction through the scope.\\nNitroprusside—A compound that is used in labo-\\nratory tests to identify large amounts of cystine in\\nurine samples.\\nUretoscope—A tube-shaped device inserted into\\nthe body through the urinary system that allows\\nobjects to be both seen and grasped for removal.\\nPresti Jr., Joseph C., Marshall L. Stoller, and Peter R. Carroll.\\n“Urology.” In Current Medical Diagnosis and Treatment,\\n1998. 37th ed. Ed. Stephen McPhee, et al. Stamford:\\nAppleton & Lange, 1997.\\nORGANIZATIONS\\nCystinuria Support Network. 21001 NE 36th St., Redmond, W A\\n98053. (425) 868-2996. .\\nNational Kidney Foundation. 30 East 33rd St., New York, NY\\n10016. (800) 622-9010. .\\nDominic De Bellis, PhD\\nCystitis\\nDefinition\\nCystitis is defined as inflammation of the urinary blad-\\nder. Urethritis is an inflammation of the urethra, which is\\nthe passageway that connects the bladder with the exterior\\nof the body. Sometimes cystitis and urethritis are referred\\nto collectively as a lower urinary tract infection, or UTI.\\nInfection of the upper urinary tract involves the spread of\\nbacteria to the kidney and is called pyelonephritis.\\nDescription\\nThe frequency of bladder infections in humans varies\\nsignificantly according to age and sex. The male/female\\nGALE ENCYCLOPEDIA OF MEDICINE 2 991\\nCystitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 991'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 380, 'page_label': '381'}, page_content='ratio of UTIs in children younger than 12 months is 4:1\\nbecause of the high rate of birth defects in the urinary\\ntract of male infants. In adult life, the male/female ratio of\\nUTIs is 1:50. After age 50, however, the incidence among\\nmales increases due to prostate disorders.\\nCystitis in women\\nCystitis is a common female problem. It is estimated\\nthat 50% of adult women experience at least one episode\\nof dysuria (painful urination); half of these patients have\\na bacterial UTI. Between 2–5% of women’s visits to pri-\\nmary care doctors are for UTI symptoms. About 90% of\\nUTIs in women are uncomplicated but recurrent.\\nCystitis in men\\nUTIs are uncommon in younger and middle-aged\\nmen, but may occur as complications of bacterial infec-\\ntions of the kidney or prostate gland.\\nCystitis in children\\nIn children, cystitis is often caused by congenital\\nabnormalities (present at birth) of the urinary tract. Vesi-\\ncoureteral reflux is a condition in which the child can-\\nnot completely empty the bladder. It allows urine to\\nremain in or flow backward (reflux) into the partially\\nempty bladder.\\nCauses and symptoms\\nThe causes of cystitis vary according to sex because of\\nthe differences in anatomical structure of the urinary tract.\\nFemales\\nMost bladder infections in women are so-called\\nascending infections, which means that they are caused\\nby disease agents traveling upward through the urethra to\\nthe bladder. The relative shortness of the female urethra\\n(1.2–2 in in length) makes it easy for bacteria to gain\\nentry to the bladder and multiply. The most common bac-\\nteria associated with UTIs in women include Escherichia\\ncoli (about 80% of cases), Staphylococcus saprophyticus,\\nKlebsiella, Enterobacter, and Proteus species. Risk fac-\\ntors for UTIs in women include:\\n• Sexual intercourse. The risk of infection increases if the\\nwoman has multiple partners.\\n• Use of a diaphragm for contraception\\n• An abnormally short urethra\\n• Diabetes or chronic dehydration\\n• The absence of a specific enzyme (fucosyltransferase)\\nin vaginal secretions. The lack of this enzyme makes it\\neasier for the vagina to harbor bacteria that cause UTIs.\\n• Inadequate personal hygiene. Bacteria from fecal matter\\nor vaginal discharges can enter the female urethra\\nbecause its opening is very close to the vagina and anus.\\n• History of previous UTIs. About 80% of women with\\ncystitis develop recurrences within two years.\\nThe early symptoms of cystitis in women are\\ndysuria, or pain on urination; urgency, or a sudden\\nstrong desire to urinate; and increased frequency of uri-\\nnation. About 50% of female patients experience fever,\\npain in the lower back or flanks, nausea and vomiting ,\\nor shaking chills. These symptoms indicate pyelonephri-\\ntis, or spread of the infection to the upper urinary tract.\\nMales\\nMost UTIs in adult males are complications of kid-\\nney or prostate infections. They are usually associated\\nwith a tumor or kidney stones that block the flow of\\nurine and are often persistent infections caused by drug-\\nresistant organisms. UTIs in men are most likely to be\\ncaused by E. coli or another gram-negative bacterium. S.\\nsaprophyticus, which is the second most common cause\\nof UTIs in women, rarely causes infections in men. Risk\\nfactors for UTIs in men include:\\n• Lack of circumcision. The foreskin can harbor bacteria\\nthat cause UTIs.\\n• Urinary catheterization. The longer the period of\\ncatheterization, the higher the risk of UTIs.\\nThe symptoms of cystitis and pyelonephritis in men\\nare the same as in women.\\nHemorrhagic cystitis\\nHemorrhagic cystitis, which is marked by large\\nquantities of blood in the urine, is caused by an acute\\nbacterial infection of the bladder. In some cases, hemor-\\nrhagic cystitis is a side effect of radiation therapy or\\ntreatment with cyclophosphamide. Hemorrhagic cystitis\\nin children is associated with adenovirus type 11.\\nDiagnosis\\nWhen cystitis is suspected, the doctor will first\\nexamine the patient’s abdomen and lower back, to evalu-\\nate unusual enlargements of the kidneys or swelling of\\nthe bladder. In small children, the doctor will check for\\nfever, abdominal masses, and a swollen bladder.\\nThe next step in diagnosis is collection of a urine\\nsample. The procedure differs somewhat for women and\\nmen. Laboratory testing of urine samples can now be\\nperformed with dipsticks that indicate immune system\\nresponses to infection, as well as with microscopic\\nanalysis of samples. Normal human urine is sterile. The\\nGALE ENCYCLOPEDIA OF MEDICINE 2992\\nCystitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 992'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 381, 'page_label': '382'}, page_content='presence of bacteria or pus in the urine usually indicates\\ninfection. The presence of hematuria, or blood in the\\nurine, may indicate acute UTIs, kidney disease, kidney\\nstones, inflammation of the prostate (in men),\\nendometriosis (in women), or cancer of the urinary\\ntract. In some cases, blood in the urine results from ath-\\nletic training, particularly in runners.\\nFemales\\nFemale patients require a pelvic examination as part\\nof the procedure to obtain urine specimens. The patient\\nlies on an obstetrical table with legs in the stirrups. The\\ndoctor first takes a vaginal culture smear. The patient is\\nthen asked to void while lying on the table. The first\\n5–10 ml are collected to test for urethral infection. A\\nmidstream urine sample of 200 ml is then collected to\\ntest for bladder infection.\\nIn women, a vaginal bacterial count that is higher\\nthan those of the two urine samples indicates vaginitis. A\\nhigh bacterial count in the first urine sample indicates\\nurethritis. A count of more than 104 bacteria CFU/ml\\n(colony forming units per milliliter) in the midstream\\nsample indicates a bladder or kidney infection. A colony\\nis a large number of microorganisms that grow from a\\nsingle cell within a substance called a culture. A bacterial\\ncount can be given in CFU (colony forming units).\\nMales\\nIn male patients, the doctor will cleanse the opening\\nto the urethra with an antiseptic before collecting the\\nurine sample. The first 10 ml of specimen are collected\\nseparately. The patient then voids a midstream sample of\\n200 ml. Following the second sample, the doctor will\\nmassage the patient’s prostate and collect several drops\\nof prostatic fluid. The patient then voids a third urine\\nspecimen for prostatic culture.\\nA high bacterial count in the first urine specimen or\\nthe prostatic specimens indicates urethritis or prostate\\ninfections respectively. A bacterial count greater than\\n100,000 bacteria CFU/ml in the midstream sample sug-\\ngests a bladder or kidney infection.\\nOther tests\\nWomen with recurrent UTIs can be given ultrasound\\ntests of the kidneys and bladder together with a voiding\\ncystourethrogram to test for structural abnormalities. (A\\ncystourethrogram is an x-ray test in which an iodine dye\\nis used to better view the urinary bladder and urethra.)\\nV oiding cystourethrograms are also used to evaluate chil-\\ndren with UTIs. In some cases, computed tomography\\nscans (CT scans) can be used to evaluate patients for\\npossible cancers in the urinary tract.\\nKEY TERMS\\nBacteriuria—The presence of bacteria in the urine.\\nDysuria—Painful or difficult urination.\\nHematuria—The presence of blood in the urine.\\nPyelonephritis —Bacterial inflammation of the\\nupper urinary tract.\\nUrethritis—Inflammation of the urethra, which is\\nthe passage through which the urine moves from\\nthe bladder to the outside of the body.\\nTreatment\\nMedications\\nUncomplicated cystitis is treated with antibiotics .\\nThese include penicillin, ampicillin, and amoxicillin;\\nsulfisoxazole or sulfamethoxazole; trimethoprim;\\nnitrofurantoin; cephalosporins ; or fluoroquinolones .\\n(Flouroquinolones are generally not used in children\\nunder 18 years of age.) Treatment for women is short-\\nterm; most patients respond within three days. Men do\\nnot respond as well to short-term treatment and\\nrequire seven to 10 days of oral antibiotics for uncom-\\nplicated UTIs.\\nPatients of either sex may be given phenazopyridine\\nor flavoxate to relieve painful urination.\\nTrimethoprim and nitrofurantoin are preferred for\\ntreating recurrent UTIs in women.\\nOver 50% of older men with UTIs also suffer\\nfrom infection of the prostate gland. Some antibiotics,\\nincluding amoxicillin and the cephalosporins, do not\\naffect the prostate gland. Fluoroquinolone antibiotics\\nor trimethoprim are the drugs of choice for these\\npatients.\\nPatients with pyelonephritis can be treated with oral\\nantibiotics or intramuscular doses of cephalosporins.\\nMedications are given for 10–14 days, and sometimes\\nlonger. If the patient requires hospitalization because of\\nhigh fever and dehydration caused by vomiting, antibi-\\notics can be given intravenously.\\nSurgery\\nA minority of women with complicated UTIs may\\nrequire surgical treatment to prevent recurrent infections.\\nSurgery is also used to treat reflux problems (movement\\nof the urine backwards) or other structural abnormalities\\nin children and anatomical abnormalities in adult males.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 993\\nCystitis\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 993'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 382, 'page_label': '383'}, page_content='Alternative treatment\\nAlternative treatment for cystitis may emphasize elim-\\ninating all sugar from the diet and drinking lots of water.\\nDrinking unsweetened cranberry juice not only adds fluid,\\nbut is also thought to help prevent cystitis by making it\\nmore difficult for bacteria to cling to the bladder wall. A\\nvariety of herbal therapies are also recommended. General-\\nly, the recommended herbs are antimicrobials, such as gar-\\nlic (Allium sativum), goldenseal (Hydrastis canadensis),\\nand bearberry ( Arctostaphylos uva-ursi ), and/or demul-\\ncents that soothe and coat the urinary tract, including corn\\nsilk and marsh mallow (Althaea officinalis).\\nHomeopathic medicine can also be effective in treat-\\ning cystitis. Choosing the correct remedy based on the\\nindividual’s symptoms is always key to the success of\\nthis type of treatment. Acupuncture and Chinese tradi-\\ntional herbal medicine can also be helpful in treating\\nacute and chronic cases of cystitis.\\nPrognosis\\nFemales\\nThe prognosis for recovery from uncomplicated cys-\\ntitis is excellent.\\nMales\\nThe prognosis for recovery from uncomplicated\\nUTIs is excellent; however, complicated UTIs in males\\nare difficult to treat because they often involve bacteria\\nthat are resistant to commonly used antibiotics.\\nPrevention\\nFemales\\nWomen with two or more UTIs within a six-month\\nperiod are sometimes given prophylactic treatment, usu-\\nally nitrofurantoin or trimethoprim for three to six\\nmonths. In some cases the patient is advised to take an\\nantibiotic tablet following sexual intercourse.\\nOther preventive measures for women include:\\n• drinking large amounts of fluid\\n• voiding frequently, particularly after intercourse\\n• proper cleansing of the area around the urethra\\nMales\\nThe primary preventive measure for males is prompt\\ntreatment of prostate infections. Chronic prostatitis may\\ngo unnoticed, but can trigger recurrent UTIs. In addition,\\nmales who require temporary catheterization following\\nsurgery can be given antibiotics to lower the risk of UTIs.\\nResources\\nBOOKS\\nAnderson, E. Everett. “Dysuria, Pyuria, and Hematuria.” In\\nCurrent Diagnosis. V ol. 9. Ed. Rex B. Conn, et al.\\nPhiladelphia: W. B. Saunders Co., 1997.\\nDonovan, James F., and Richard D. Williams. “Urology.” In\\nCurrent Surgical Diagnosis and Treatment. 10th ed. Ed.\\nLawrence W. Way. Stamford: Appleton & Lange, 1994.\\n“Genitourinary Disorders: Lower Urinary Tract and Male Gen-\\nital Tract Infections.” In The Merck Manual of Diagnosis\\nand Therapy. 16th ed. Ed. Robert Berkow. Rahway, NJ:\\nMerck Research Laboratories, 1992.\\nKing, Lowell R. “Bacterial Infections of the Urinary Tract in\\nGirls.” In Conn’s Current Therapy, 1996, ed. Robert E.\\nRakel. Philadelphia: W. B. Saunders Co., 1996.\\n“Lower Urinary Tract Infection.” In Professional Guide to Dis-\\neases, ed. Stanley Loeb et al. Springhouse, PA: Spring-\\nhouse Corporation, 1991.\\nMata, John A. “Bacterial Infections of the Urinary Tract in\\nFemales.” In Conn’s Current Therapy, 1996, ed. Robert E.\\nRakel. Philadelphia: W. B. Saunders Co., 1996.\\nRobertson, Jack R., and David B. Hebert. “Gynecologic Urolo-\\ngy.” In Current Obstetric & Gynecologic Diagnosis &\\nTreatment, ed. Alan H. DeCherney and Martin L. Pernoll.\\nStamford: Appleton & Lange, 1994.\\nRebecca J. Frey\\nCystometry\\nDefinition\\nCystometry is a test of bladder function in which\\npressure and volume of fluid in the bladder is measured\\nduring filling, storage, and voiding.\\nPurpose\\nThe urinary bladder stores urine produced by the kid-\\nneys. The main muscle of the bladder wall, the detrusor,\\nrelaxes to allow expansion of the bladder during filling.\\nThe urethra, the tube through which urine exits, is held\\nclosed by a ring of muscle, known as the urethral sphinc-\\nter. As volume increases, stretching of the detrusor and\\npressure on the sphincter sends signals to the brain, indi-\\ncating the need for urination, or voiding. V oluntary relax-\\nation of the sphincter and automatic contractions of the\\ndetrusor allow successful and virtually complete voiding.\\nA cystometry study is performed to diagnose prob-\\nlems with urination, including incontinence, urinary\\nretention, and recurrent urinary tract infections. Urinary\\ndifficulties may occur because of weak or hyperactive\\nsphincter or detrusor, or incoordination of their two\\nGALE ENCYCLOPEDIA OF MEDICINE 2994\\nCystometry\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 994'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 383, 'page_label': '384'}, page_content='activities. Infection of the bladder or urethra may cause\\nincontinence, as can obstruction of the urethra from scar\\ntissue, prostate enlargement, or other benign or cancer-\\nous growths. Loss of sensation due to nerve damage can\\nlead to chronic overfilling.\\nPrecautions\\nThe mild irritation of the urinary tract necessary for\\ninsertion of the catheter may occasionally cause flushing,\\nsweating, and nausea.\\nDescription\\nThe patient begins by emptying the bladder as much\\nas possible. A thin plastic catheter is then slowly inserted\\ninto the urethra until it reaches the bladder. Measure-\\nments are taken of the residual urine volume and bladder\\npressure. Pressure measurements may require a rectal\\nprobe to account for the contribution of the abdominal\\nmuscles to the pressure recording.\\nThe bladder is then gradually filled with either warm\\nwater, room temperature water, saline solution, carbon diox-\\nide gas, or a contrast solution for x-ray analysis, depending\\non the type of study being done. The patient is asked to\\ndescribe sensations during filling, including temperature\\nsensations and when the first feeling of bladder fullness\\noccurs. Once the bladder is completely full, the patient is\\nasked to begin voiding, and measurements are again made\\nof pressure and volume, as well as flow rate and pressure.\\nPreparation\\nThere is no special preparation needed for this test.\\nThe patient may be asked to stop taking certain medica-\\ntions in advance of the test, including sedatives, choliner-\\ngics, and anticholinergics.\\nAftercare\\nCystometry can be somewhat uncomfortable. The\\npatient may wish to reserve an hour or so afterward to\\nrecover. Urinary frequency or urgency, and some redden-\\ning of the urine, may last for a day. Increasing fluid intake\\nhelps to flush out the bladder, but caffeinated, carbonated,\\nor alcoholic beverages are discouraged, because they may\\nirritate the bladder lining. Signs of infection, such as\\nfever, chills, low back pain , or persistent blood in the\\nurine, should be reported to the examining physician.\\nRisks\\nThere is a slight risk of infection due to tearing of\\nthe urethral lining.\\nKEY TERMS\\nDetrusor—Muscle of the bladder wall.\\nSphincter —Ring of muscle between the bladder\\nand the urethra that functions to close off the ure-\\nthra.\\nUrethra—Tube that empties urine from the blad-\\nder to the exterior of the body.\\nNormal results\\nThe normal bladder should not begin contractions\\nduring filling and should initially expand without resis-\\ntance. A feeling of fullness occurs with a volume of\\n100–200 ml. The adult bladder capacity is 300–500 ml.\\nThe sphincter should relax and open when the patient\\nwills it, accompanied by detrusor contractions. During\\nvoiding, detrusor contraction should be smooth and lead\\nto a steady urine stream.\\nAbnormal results\\nInability of the bladder to relax during filling, or low\\nbladder volume, may indicate interstitial cystitis, prostate\\nenlargement, or bladder cancer. Contraction of the blad-\\nder during filling may be due to irritation from infection\\nor cysts, obstruction of the bladder outlet, or neurological\\ndisease such as stroke, multiple sclerosis, or spinal cord\\ninjury. Diminished sensation may occur with nerve\\nlesions, peripheral neuropathy, or chronic overfilling.\\nResources\\nBOOKS\\nLamm D. L., A. S. Paola, and F. A. Paola. Campbell’s Urology:\\nReview and Assessment. W. B. Saunders Co., 1995.\\nOTHER\\n“Cystometrogram, Simple and Complex.”HealthGate Page.\\n.\\nRichard Robinson\\nCystoscopy\\nDefinition\\nCystoscopy (cystourethroscopy) is a diagnostic pro-\\ncedure that is used to look at the bladder (lower urinary\\nGALE ENCYCLOPEDIA OF MEDICINE 2 995\\nCystoscopy\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 995'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 384, 'page_label': '385'}, page_content='tract), collect urine samples, and examine the prostate\\ngland. Performed with an optic instrument known as a\\ncystoscope (urethroscope), this instrument uses a lighted\\ntip for guidance to aid in diagnosing urinary tract disease\\nand prostate disease. Performed by a urologist, this surgi-\\ncal test also enables biopsies to be taken or small stones\\nto be removed by way of a hollow channel in the cysto-\\nscope.\\nPurpose\\nCategorized as an endoscopic procedure, cystoscopy\\nis used by urologists to examine the entire bladder lining\\nand take biopsies of any areas that look questionable. This\\ntest is not used on a routine basis, but may benefit the urol-\\nogist who is needing further information about a patient\\nwho displays the following symptoms or diagnosis:\\n• blood in the urine (also known as hematuria)\\n• incontinence or the inabililty to control urination\\n• a urinary tract infection\\n• a urinary tract which display signs of congenital abnor-\\nmalities\\n• tumors located in the bladder\\n• the presence of bladder or kidney stones\\n• a stiffness or strained feeling of the urethra or ureters\\n• symptoms of an enlarged prostate\\nBlood and urine studies, in addition to x rays of the\\nkidneys, ureters, and bladder, may all occur before a cys-\\ntoscopy. At the time of surgery, a retrograde pyelogram\\nmay also be performed. Additional blood studies may be\\nneeded immediately following surgery.\\nPrecautions\\nWhile the cystoscopy procedure is commonly relied\\nupon to gather additional diagnostic information, it is an\\ninvasive surgical technique that may involve risks for certain\\npatients. Those who are extremely overweight (obese),\\nsmoke, are recovering from a recent illness, or are treating a\\nchronic condition may face additional risks from surgery.\\nSurgical risk also increases in patients who are cur-\\nrently using certain drugs including antihypertensives;\\nmuscle relaxants; tranquilizers; sleep inducers; insulin;\\nsedatives; beta blockers ; or cortisone. Those who use\\nmind-altering drugs also put themselves at increased risk of\\ncomplications during surgery. The following mind-altering\\ndrugs should be avoided: narcotics; psychedelics; hallu-\\ncinogens; marijuana; sedatives; hypnotics; or cocaine.\\nDescription\\nDepending on the type of information needed from a\\ncystoscopy, the procedure typically takes 10–40 minutes\\nto complete. The patient will be asked to urinate before\\nsurgery which allows an accurate measurement of the\\nremaining urine in the bladder. A well lubricated cysto-\\nscope is inserted through the urethra into the bladder\\nwhere a urine sample is taken. Fluid is then pushed in to\\ninflate the bladder and allow the urologist to examine the\\nentire bladder wall.\\nDuring an examination, the urologist may take the fol-\\nlowing steps: remove either bladder or kidney stones; gather\\ntissue samples; and treat any suspicious lesions. In order to\\nperform x-ray studies (retrograde pyelogram), a harmless\\ndye is injected into the ureters by way of a catheter that is\\npassed through the previously placed cystoscope. After\\ncompletion of all needed tests, the cystoscope is removed.\\nPreparation\\nAs a procedure that can be completed in a hospital,\\ndoctor’s office, or outpatient surgical facility, an injection\\nGALE ENCYCLOPEDIA OF MEDICINE 2996\\nCystoscopy\\nCystoscope\\nUrethra\\nProstate gland\\nBladder\\nCystoscopy is a diagnostic procedure which is used to view\\nthe bladder, collect urine samples, and examine the prostate\\ngland.This procedure also enables biopsies to be taken.\\nThe primary instrument used in cystoscopy is the cysto-\\nscope, a tube which is inserted through the penis into the\\nurethra, and ultimately into the bladder.(Illustration by Elec-\\ntronic Illustrators Group.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 996'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 385, 'page_label': '386'}, page_content='of spinal or general anesthesia may be used prior to a\\ncystoscopy. While this test is typically performed on an\\noutpatient basis, a patient may require up to three days of\\nrecovery in the hospital.\\nAftercare\\nPatients who have undergone a cystoscopy will be\\ninstructed to follow these steps to ensure a quick recovery:\\n• due to soreness or discomfort that may occur in the ure-\\nthra, especially while urinating, several warm baths a\\nday are recommended to relieve any pain\\n• allow four days for recovery\\n• blood may appear in the urine—this is common, and soon\\nclears up in one to two days following the procedure\\n• avoid strenuous exercise for a minimum of two weeks\\nfollowing surgery\\n• sexual relations may continue when the urologist deter-\\nmines that healing is complete\\n• wait at least two days after surgery before driving\\nPatients may also be prescribed pain relievers and\\nantibiotics following surgery. Minor pain may also be\\ntreated with over-the-counter, non-prescription drugs\\nsuch as acetaminophen.\\nRisks\\nAs with any surgical procedure, there are some risks\\ninvolved with a cystoscopy. Complications may include:\\nprofuse bleeding; a damaged urethra; a perforated blad-\\nder; a urinary tract infection; or an injured penis.\\nPatients should also contact their physician if they\\nexperience any of the following symptoms following\\nsurgery: pain, redness, swelling, drainage, or bleeding\\nfrom the surgical site; signs of infection that may include\\nheadache, muscle aches, dizziness or an overall ill feel-\\ning and fever; nausea or vomiting; strenuous or painful\\nurination; or symptoms that may result as side-effects\\nfrom the medication.\\nNormal results\\nA successful cystoscopy includes a thorough exami-\\nnation of the bladder and collection of urine samples for\\ncultures. If no abnormalities are seen, the results are indi-\\ncated as normal.\\nAbnormal results\\nCystoscopy allows the urologist to detect inflamma-\\ntion of the bladder lining, prostatic enlargement, or\\ntumors. If these are seen, further evaluation or biopsies\\nmay be needed in addition to the removal of some tumors.\\nResources\\nBOOKS\\nBuckman, Robert. “Bladder.” In What You Really Need To\\nKnow About Cancer: A Comprehensive Guide for Patients\\nand Their Families.Baltimore: The Johns Hopkins Uni-\\nversity Press, 1997.\\nGriffith, H. Winter. “Cystoscopy.” In Complete Guide To Symp-\\ntoms, Illness & Surgery. New York: Berkley Publishing\\nGroup, 1995.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 997\\nCystoscopy\\nCystoscope\\nUrethra\\nBladder\\nProstate\\nA cystoscope helps the doctor examine the urethra, bladder, and prostate.(Illustration by Argosy Inc.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 997'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 386, 'page_label': '387'}, page_content='The Patient’s Guide to Medical Tests.Ed. Barry L. Zaret, et al.\\nBoston: Houghton Mifflin, 1997.\\n“Urology.” In Current Medical Diagnosis and Treatment, 1996.\\n35th ed. Ed. Stephen McPhee, et al. Stamford: Appleton\\n& Lange, 1995.\\nPERIODICALS\\n“RX For Enlarged Prostate: Patient Involvement.”Executive\\nHealth’s Good Health Report(Apr. 1994): 1+.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nBeth A. Kapes\\nCystourethroscopy see Cystoscopy\\nCytomegalic inclusion disease see\\nCytomegalovirus infection\\nCytomegalovirus antibody\\nscreening test\\nDefinition\\nCytomegalovirus (CMV) is a common human virus.\\nAntibodies to CMV are evidence of a current or past\\ninfection.\\nKEY TERMS\\nEndoscopy—Examination of body organs or cavities\\nthrough the use of an endoscope (a lighted optical\\ninstrument used to see inside body cavities), such as\\na cystoscope used to complete a cystoscopy.\\nRetrograde pyelogram —A pyelography or x-ray\\ntechnique where radiopaque dye is injected into\\nthe kidneys from below, by way of the ureters,\\nallowing further examination of the kidneys.\\nUreter—The tube that carries urine from the kidney\\nto the bladder, with each kidney having one ureter.\\nUrethra—A passageway from the bladder to the\\noutside for the discharge of urine. In the female,\\nthis canal lies between the vagina and clitoris; in\\nthe male, the urethra travels through the penis,\\nopening at the tip.\\nPurpose\\nConsequences of a CMV infection can be devastating\\nin a pregnant woman, a transplant patient, or a person\\nwith human immunodeficiency virus (HIV). Antibody\\nscreening helps control the infection risk for these groups.\\nIn a healthy, nonpregnant person, CMV infection is\\nalmost never serious. Symptoms, if present, are mild,\\noften resembling infectious mononucleosis due to\\nEpstein-Barr virus. Antibody screening distinguishes\\nbetween these two infections.\\nDescription\\nWhen first exposed to CMV , a person’s immune sys-\\ntem is triggered and quickly makes antibodies to fight the\\nvirus. Antibodies are special proteins designed to attack\\nand destroy foreign material, in this case, the cytomega-\\nlovirus.\\nThe test combines a person’s serum with a substance\\nto which CMV antibodies attach. This antibody-antigen\\ncomplex is measured and the amount of original anti-\\nbody determined. If positive for antibodies, the serum is\\ndiluted, or titered, and the test repeated until the serum is\\nso dilute it no longer gives a positive result. The last dilu-\\ntion that gives a positive result is the titer reported.\\nA test positive for CMV antibodies means the per-\\nson has been infected with the virus, either currently or\\nin the past; it doesn’t mean the person has lifetime immu-\\nnity. After an infection, this virus, like all members of the\\nherpes virus group, can stay hidden inside a person and\\ncause infection if the person’s immune system later\\nweakens and antibody protection decreases. In fact, reac-\\ntivation of such hidden (or latent) infection is not at all\\nuncommon and usually occurs without symptoms.\\nTransplant patients and people with weakened\\nimmune systems, including those with HIV , are vulnera-\\nble to infection from several routes, including from\\nanother person, from a donated organ or transfused\\nblood, or from reactivation of a past infection. Before\\ntransplant, both the recipient and donor are usually tested\\nfor antibodies. A recipient who has never had CMV (neg-\\native for antibodies), should not receive an organ from a\\ndonor who has had CMV (positive for antibodies). CVM\\ninfection can be associated with organ rejection, or can\\ncause illness such as pneumonia , hepatitis, or death.\\nSimilarly, blood is usually screened for CMV antibodies\\nbefore being transfused into a person with a weakened\\nimmune system.\\nCMV infection is the most common congenital\\ninfection (existing at birth). The infection, passed from\\nmother to baby, can cause permanent mental or physical\\ndamage, or death. The antibody screening test tells a\\nGALE ENCYCLOPEDIA OF MEDICINE 2998\\nCytomegalovirus antibody screening test\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 998'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 387, 'page_label': '388'}, page_content='woman whether or not she has antibody protection\\nagainst the virus in case she is exposed during preg-\\nnancy.\\nTests that measure a specific type of antibody help\\ntell the difference between a current and a past infection.\\nImmunoglobulin M (IgM) antibodies appear at the\\nbeginning of an infection and last only weeks.\\nImmunoglobulin G (IgG) antibodies appear 10–14 days\\nlater and can last a lifetime. A person suspected of hav-\\ning a current infection should be tested at the beginning\\nof the infection and again 10–14 days later.\\nThe CMV antibody screening test is also called the\\ntransplant reaction screening test. Results are usually\\navailable the following day.\\nPreparation\\nThis test requires 5 mL of blood. Collection of the\\nsample takes only a few minutes.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to the\\npuncture site until the bleeding stops reduces bruising.\\nWarm packs to the puncture site relieve discomfort.\\nNormal results\\nA person without previous exposure to CMV will\\ntest negative.\\nAbnormal results\\nThe presence of antibodies means the person has\\nbeen infected with CMV , either now or in the past. An\\nantibody titer at least four times higher at the end of the\\nillness than at the beginning, or the presence of IgM anti-\\nbodies, indicates a recent or current first time infection.\\nPeople with weak immune systems may not gener-\\nate antibodies against CMV . A current infection in a\\ntransplant patient or a person with HIV is confirmed with\\nother tests, such as viral culture.\\nResources\\nBOOKS\\nAmerican Association of Blood Banks. Technical Manual.12th\\ned. Bethesda: American Association of Blood Banks,\\n1996.\\nIsada, Carlos M., et al. Infectious Diseases Handbook. Hudson:\\nLexi-Comp Inc., 1995.\\nMayo Medical Laboratories. Interpretive Handbook.\\nRochester, MN: Mayo Medical Laboratories, 1997.\\nKEY TERMS\\nAntibody—A special protein built by the body as a\\ndefense against foreign material entering the body.\\nCytomegalovirus (CMV) —A common human\\nvirus causing mild or no symptoms in healthy peo-\\nple, but permanent damage or death to an infect-\\ned fetus, a transplant patient, or a person with HIV.\\nTiter—A dilution of a substance with an exact\\nknown amount of fluid. For example, one part of\\nserum diluted with four parts of saline is a titer\\nof 1:4.\\nPERIODICALS\\nLaliberte, Kimberly A. “CMV Screening: Interpreting the Test\\nResult.” Advance for Medical Laboratory Professionals\\n(14 July 1997): 12-13, 17.\\nNancy J. Nordenson\\nCytomegalovirus infection\\nDefinition\\nCytomegalovirus (CMV) is a virus related to the\\ngroup of herpes viruses. Infection with CMV can cause\\nno symptoms, or can be the source of serious illness in\\npeople with weak immune systems. CMV infection is\\nalso an important cause of birth defects.\\nDescription\\nCMV is an extremely common organism worldwide.\\nIt is believed that about 85% of the adult population in the\\nUnited States have been infected by CMV at some point\\nin their lives. CMV is found in almost all of the body’s\\norgans. It is also found in body fluids, including semen,\\nsaliva, urine, feces, breast milk, blood, and secretions of\\nthe cervix (the narrow, lower section of the uterus).\\nCMV is also able to cross the placenta (the organ\\nthat provides oxygen and nutrients to the unborn baby in\\nthe uterus). Because CMV can cross the placental barri-\\ner, initial infection in a pregnant woman can lead to\\ninfection of the developing baby.\\nCauses and symptoms\\nCMV is passed between people through contact with\\nbody fluids. CMV can also be passed on through sexual\\nGALE ENCYCLOPEDIA OF MEDICINE 2 999\\nCytomegalovirus infection\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 999'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 388, 'page_label': '389'}, page_content='contact. Babies can be born infected with CMV , either\\nbecoming infected in the uterus (congenital infection) or\\nduring birth (from infected cervical secretions).\\nLike other herpes viruses, CMV remains inactive\\n(dormant) within the body for life after the initial infec-\\ntion. Some of the more serious types of CMV infections\\noccur in people who have been harboring the dormant\\nvirus, only to have it reactivate when their immune sys-\\ntem is stressed. Immune systems may be weakened\\nbecause of cancer chemotherapy , medications given\\nafter organ transplantation, or diseases that significantly\\nlower immune resistance like acquired immunodeficien-\\ncy syndrome (AIDS).\\nIn a healthy person, initial CMV infection often\\noccurs without symptoms and is rarely noticed. Occa-\\nsionally, a first-time infection with CMV may cause a\\nmild illness called mononucleosis. Symptoms include\\nswollen glands, liver, and spleen; fever; increased white\\nblood cells; headache; fatigue; and sore throat. About\\n8% of all mononucleosis cases are due to CMV infec-\\ntion. A similar infection, though slightly more serious,\\nmay occur two to four weeks after receiving a blood\\ntransfusion containing CMV .\\nIn people with weakened immune systems, CMV\\ninfection can cause more serious and potentially life-\\nthreatening illnesses. These illnesses include pneumo-\\nnia, and inflammations of the liver (hepatitis), brain\\n(encephalitis ), esophagus (esophagitis), large intestine\\n(colitis), and retina of the eye (retinitis).\\nBabies who contract CMV from their mothers dur-\\ning birth rarely develop any illness from these infections.\\nInfants born prematurely who become CMV infected\\nduring birth have a greater chance of complications,\\nincluding pneumonia, hepatitis, and decreased blood\\nplatelets.\\nHowever, an unborn baby is at great risk for seri-\\nous problems when the mother becomes infected with\\nCMV for the first time while pregnant. About 10% of\\nthese babies will be born with obvious problems,\\nincluding prematurity , lung problems, an enlarged\\nliver and spleen, jaundice , anemia, low birth weight,\\nsmall head size, and inflammation of the retina. About\\n90% of these babies may appear perfectly normal at\\nbirth. Unfortunately, about 20% of these babies will\\nlater develop severe hearing impairments and mental\\nretardation .\\nDiagnosis\\nBody fluids or tissues can be tested to reveal CMV\\ninfection. However, this information is not always partic-\\nularly helpful because CMV stays dormant in the cells\\nfor life. Tests to look for special immune cells (antibod-\\nies) directed specifically against CMV are useful in prov-\\ning that a person has been infected with CMV . However,\\nthese tests do not give any information regarding when\\nthe CMV infection first occurred.\\nTreatment\\nGanciclovir and foscarnet are both antiviral med-\\nications that have been used to treat patients with\\nweak immune systems who develop a serious illness\\nfrom CMV (including retinitis). As of 1998, research\\nis still being done to try to find useful drugs to treat\\nnewborn babies suffering from congenital infection\\nwith CMV . Antiviral drugs are not used to treat\\nCMV infection in otherwise healthy patients because\\nthe drugs have significant side effects that outweigh\\ntheir benefits.\\nPrognosis\\nPrognosis in healthy people with CMV infection\\nis excellent. About 0.1% of all newborn babies will\\nhave serious damage from CMV infection occurring\\nwhile they were developing in the uterus. About 50%\\nof all transplant patients will develop severe illnesses\\ndue to reactivation of dormant CMV infection. These\\nillnesses have a high rate of serious complications\\nand death.\\nPrevention\\nPrevention of CMV infection in the normal,\\nhealthy person involves good handwashing. Blood\\nproducts can be screened or treated to insure that they\\ndo not contain CMV .\\nGALE ENCYCLOPEDIA OF MEDICINE 21000\\nCytomegalovirus infection\\nAn infected retina of an AIDS patient. Cytomegaloviruses\\nare herpes viruses that can, among other problems, act as\\nopportunistic infectious agents in suppressed immune sys-\\ntems, a common problem with AIDS sufferers.(Custom Med-\\nical Stock Photo. Reproduced by permission.)\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 1000'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 389, 'page_label': '390'}, page_content='Resources\\nBOOKS\\nCorey, Lawrence. “Herpesviruses.” In Sherris Medical Micro-\\nbiology: An Introduction to Infectious Diseases.3rd ed.\\nEd. Kenneth J. Ryan. Norwalk, CT: Appleton & Lange,\\n1994.\\nHirsch, Martin S. “Cytomegalovirus and Human Herpesvirus\\nTypes 6, 7, and 8.” In Harrison’s Principles of Internal\\nMedicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nPERIODICALS\\nArribas, J. R., et al. “Cytomegalovirus Encephalitis.”AIDS\\nWeekly Plus (4 Nov. 1996): 30.\\nPlis, Michael A., and Henry Masur. “Promising New Treat-\\nments for Cytomegalovirus Retinitis.”Journal of the\\nAmerican Medical Association 273, no. 18 (10 May\\n1995): 1457+.\\nShelton, Brenda K. “Understanding Cytomegalovirus Infec-\\ntion.” Nursing 25, no. 1 (Jan. 1995): 32.\\nORGANIZATIONS\\nBaylor College of Medicine. 1 Baylor Plaza, Houston, TX\\n77030. (713) 798-4951. .\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nRosalyn Carson-DeWitt, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1001\\nCytomegalovirus infection\\nGEM -0625 to 1002 - C 10/22/03 6:11 PM Page 1001'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 390, 'page_label': '391'}, page_content='D & C see Dilatation and curettage\\nDacryocystitis\\nDefinition\\nDacryocystitis is an inflammation of the tear sac\\n(lacrimal sac) at the inner corner of the eye.\\nDescription\\nTears drain into little openings (puncta) in the inner\\ncorners of the eyelids. From there, the tears travel\\nthrough little tube-like structures (canaliculi) to the\\nlacrimal sac. The nasolacrimal ducts then take the tears\\nfrom the lacrimal sac to the nose. That’s why people\\nneed to blow their nose when they cry a lot.\\nDacryocystitis is usually caused by a blockage of\\nthe nasolacrimal duct, which allows fluid to drain into\\nthe nasal passages. When the lacrimal sac does not\\ndrain, bacteria can grow in the trapped fluid. This con-\\ndition is most common in infants and people over 40\\nyears old.\\nCauses and symptoms\\nIn newborn infants, the nasolacrimal duct may fail to\\nform an opening—a condition called dacryostenosis. The\\ncause of dacryocystitis in adults is usually associated\\nwith inflammation and infection in the nasal region.\\nDacryocystitis can be acute, having a sudden onset, or it\\ncan be chronic, with symptoms occurring over the course\\nof weeks or months. Symptoms of acute dacryocystitis\\ncan include pain, redness, tearing, and swelling at the\\ninner corner of the eye by the nose. In chronic dacryocys-\\ntitis, the eye area may be swollen, watery or teary, and,\\nwhen pressure is applied to the area, there may be a dis-\\ncharge of pus or mucus through the punctum.\\nDiagnosis\\nDacryocystitis usually occurs in only one eye. As\\nmentioned, the symptoms can range from watery eyes,\\npain, swelling, and redness to a discharge of pus when\\npressure is applied to the area between the bridge of the\\nnose and the inner eyelids. A sample of the pus may be\\ncollected on a swab or in a tube for laboratory analysis.\\nThe type of antibiotic and treatment may depend on\\nwhich bacteria is present. In the acute form, a blood test\\nmay reveal an elevated white blood cell (WBC) count;\\nwith a chronic infection, the WBC count is usually nor-\\nmal. To identify the exact location of the blockage, an x\\nray can be taken after a dye is injected into the duct in a\\nprocedure called dacryocystography.\\nD\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1003\\nDacryocystitis of the right eye.The inner corner of the lower\\nlid is bulging from an inflamed tear sac. Blockage of the tear\\nduct causes fluid to be trapped in the tear sac, which\\nbecomes infected. (Custom Medical Stock Photo. Reproduced\\nby permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 391, 'page_label': '392'}, page_content='Treatment\\nA warm compress applied to the area can help\\nrelieve pain and promote drainage. Topical and oral\\nantibiotics may be prescribed if an infection is present.\\nIntravenous antibiotics may be needed if the infection is\\nsevere. In some cases, a tiny tube (cannula) is inserted\\ninto the tear duct which is then flushed with a sterile salt\\nwater solution (sterile saline). If other treatments fail to\\nclear up the symptoms, surgery (dacryocystorhinostomy)\\nto drain the lacrimal sac into the nasal cavity can be per-\\nformed. In extreme cases, the lacrimal sac will be\\nremoved completely.\\nIn infants, gentle massage of the lacrimal sac four\\ntimes daily for up to nine months can drain the sac and\\nsometimes clear a blockage. As the infant grows, the duct\\nmay open by itself. If the duct does not open, it may need\\nto be dilated with a minor surgical procedure.\\nPrognosis\\nTreatment of dacryocystitis with antibiotics is usual-\\nly successful in clearing the infection that is present. If\\nthere is a permanent blockage that prevents drainage,\\ninfection may recur and surgery may be required to open\\nthe duct. If left untreated, the infected sac can rupture,\\nforming an open, draining sore.\\nKEY TERMS\\nCanaliculi —Also known as lacrimal ducts, these\\ntube-like structures carry the tears from the eyes to\\nthe lacrimal sac.\\nCannula— A narrow tube that can be inserted into\\na duct.\\nDacryocystography —An x ray of the tear duct\\nafter injection of a dye that is used to help locate a\\nblockage in the duct.\\nDacryocystorhinostomy—A surgical procedure to\\ndrain the tear sac into the nasal passage.\\nDacryostenosis—Obstruction or narrowing of the\\nnasolacrimal duct. May be present at birth.\\nNasoacrimal duct—The tube that carries the tears\\nfrom the lacrimal sac to the nose.\\nPunctum —Tiny opening at the inner corners of\\nthe upper and lower lids. The area for the begin-\\nning of tear drainage.\\nPrevention\\nThere are no specific recommendations for the pre-\\nvention of dacryocystitis; however, good hygiene may\\ndecrease the chances of infection.\\nResources\\nBOOKS\\n“Lacrimal Apparatus.” In The Merck Manual of Diagnosis and\\nTherapy. 16th ed. Ed. Robert Berkow. Rahway, NJ: Merck\\nResearch Laboratories, 1992.\\nEckman, Margaret, and Nancy Priff, eds. “Disorders of the\\nEyelids and Lacrimal Ducts.” In Diseases. 2nd ed. Spring-\\nhouse, PA: Springhouse Corporation, 1997.\\nGorbach, Sherwood L., John G. Bartlett, and Neil R. Blacklow,\\neds. “Dacryocystitis.” In Infectious Diseases. 2nd ed.\\nPhiladelphia: W. B. Saunders Co., 1998.\\n“Dacryocystitis.” In Current Medical Diagnosis and Treatment,\\n1998. 37th ed. Ed. Stephen McPhee, et al. Stamford:\\nAppleton & Lange, 1997.\\nAltha Roberts Edgren\\nDandruff see Seborrheic dermatitis\\nDeath\\nDefinition\\nDeath is defined as the cessation of all vital func-\\ntions of the body including the heartbeat, brain activity\\n(including the brain stem), and breathing.\\nDescription\\nDeath comes in many forms, whether it be expected\\nafter a diagnosis of terminal illness or an unexpected\\naccident or medical condition.\\nTerminal illness\\nWhen a terminal illness is diagnosed, a person, fam-\\nily, friends, and physicians are all able to prepare for the\\nimpending death. A terminally ill individual goes\\nthrough several levels of emotional acceptance while in\\nthe process of dying. First, there is denial and isolation.\\nThis is followed by anger and resentment. Thirdly, a per-\\nson tries to escape the inevitable. With the realization\\nthat death is eminent, most people suffer from depres-\\nsion. Lastly, the reality of death is realized and accepted.\\nGALE ENCYCLOPEDIA OF MEDICINE 21004\\nDeath'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 392, 'page_label': '393'}, page_content='Causes and symptoms\\nAs of 2001, the two leading causes of death for both\\nmen and women in the United States were heart disease\\nand cancer. Accidental death was a distant third fol-\\nlowed by such problems as stroke, chronic lung disor-\\nders, pneumonia, suicide, cirrhosis, diabetes mellitus ,\\nand murder. The order of these causes of death varies\\namong persons of different age, ethnicity, and gender.\\nDiagnosis\\nIn an age of organ transplantation, identifying the\\nmoment of death may now involve another life. It there-\\nby takes on supreme legal importance. It is largely due to\\nthe need for transplant organs that death has been so pre-\\ncisely defined.\\nThe official signs of death include the following:\\n• no pupil reaction to light\\n• no response of the eyes to caloric (warm or cold) stimu-\\nlation\\n• no jaw reflex (the jaw will react like the knee if hit with\\na reflex hammer)\\n• no gag reflex (touching the back of the throat induces\\nvomiting)\\n• no response to pain\\n• no breathing\\n• a body temperature above 86°F (30°C), which elimi-\\nnates the possibility of resuscitation following cold-\\nwater drowning\\n• no other cause for the above, such as a head injury\\n• no drugs present in the body that could cause apparent\\ndeath\\n• all of the above for 12 hours\\n• all of the above for six hours and a flat-line electroen-\\ncephalogram (brain wave study)\\n• no blood circulating to the brain, as demonstrated by\\nangiography\\nCurrent ability to resuscitate people who have\\n“died” has produced some remarkable stories. Drowning\\nin cold water (under 50°F/10°C) so effectively slows\\nmetabolism that some persons have been revived after a\\nhalf hour under water.\\nTreatment\\nOnly recently has there been concerted public effort\\nto address the care of the dying in an effort to improve\\ntheir comfort and lessen their alienation from those still\\nliving. Hospice care represents one of the greatest\\nELISABETH KÜBLER-ROSS (1926– )\\nContemporary physician who has become a world\\nauthority on the subject of death and after-death states.\\nBorn in Switzerland on July 8, 1926, she worked as a\\ncountry doctor before moving to the United States. Dur-\\ning World War II she spent weekends at the Kantonspital\\n(Cantonai Hospital) in Zürich, where she volunteered to\\nassist escaped refugees. After the war she visited Maj-\\ndanek concentration camp, where the horrors of the\\ndeath chambers stimulated in her a desire to help peo-\\nple facing death and to understand the human impulses\\nof love and destruction. She extended her medical\\nbackground by becoming a practicing psychiatrist. Her\\nformal work with dying patients began in 1965 when\\nshe was a faculty member at the University of Chicago.\\nShe also conducted research on basic questions con-\\ncerning life after death at the Manhattan State Hospital,\\nNew York. Her studies of death and dying have involved\\naccounts by patients who reported out-of-the-body trav-\\nel. Her research tends to show that while dying can be\\npainful, death itself is a peaceful condition. Her 1969\\ntext, On Death and Dying, was hailed by her colleagues\\nand also became a popular best-seller.\\nIn 1978 Kübler-Ross helped to found Shanti Nilaya\\n(Final Home of Peace), a healing and growth center in\\nEscondido, California. This was an extension of her\\nwell-known “Life-Death and Transition” workshops\\nconducted in various parts of the United States and\\nCanada, involving physicians, nurses, social workers,\\nlaypeople, and terminally ill patients. Much of Kübler-\\nRoss’s later research was directed toward proving the\\nexistence of life after death. Her publication To Live\\nUntil We Say Good-bye (1979) was both praised as a\\n“celebration of life” and criticized as “prettifying” the\\nreal situation. She has also dealt with issues such as\\nAIDS and “near death” experiences. In the mid-1980s\\nShanti Nilaya moved from San Diego County, Califor-\\nnia, to Head Waters, Virginia, where it continues to offer\\ncourses and short- and long-term therapeutic sessions.\\nadvances made in this direction. There has also been a\\nliberalization of the use of narcotics and other drugs for\\nsymptomatic relief and improvement in the quality of life\\nfor the dying.\\nLiving will\\nOne of the most difficult issues surrounding death\\nin the era of technology is that there is now a choice, not\\nof the event itself, but of its timing. When to die, and\\nmore often, when to let a loved one die, is coming with-\\nin people’s power to determine. This is both a blessing\\nand a dilemma. Insofar as the decision can be made\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1005\\nDeath'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 393, 'page_label': '394'}, page_content='ahead of time, a living will is an attempt to address this\\ndilemma. By outlining the conditions under which one\\nwould rather be allowed to die, a person can contribute\\nsignificantly to that final decision, even if not competent\\nto do so at the time of actual death. The problem is that\\nthere are uncertainties surrounding every severely ill\\nperson. Each instance presents a greater or lesser chance\\nof survival. The chance is often greater than zero. The\\nbest living will follows an intimate discussion with deci-\\nsion makers covering the many possible scenarios sur-\\nrounding the end of life. This discussion is difficult, for\\nfew people like to contemplate their own demise. How-\\never, the benefits of a living will are substantial, both to\\nphysicians and to loved ones who are faced with making\\nfinal decisions. Most states have passed living will laws,\\nhonoring instructions on artificial life support that were\\nmade while a person was still mentally competent.\\nEuthanasia\\nAnother issue that has received much attention is\\nassisted suicide (euthanasia). In 1997, the State of Ore-\\ngon placed the issue on the ballot, amid much consterna-\\ntion and dispute. Perhaps the main reason euthanasia has\\nbecome front page news is because Dr. Jack Kevorkian, a\\npathologist from Michigan, is one of its most vocal advo-\\ncates. The issue highlights the many new problems gen-\\nerated by increasing ability to intervene effectively in the\\nfinal moments of life and unnaturally prolong the process\\nof dying. The public appearance of euthanasia has also\\nstimulated discussion about more compassionate care of\\nthe dying.\\nKEY TERMS\\nAngiography—X rays of blood vessels filled with a\\ncontrast agent.\\nCaloric testing —Flushing warm and cold water\\ninto the ear stimulates the labyrinth and causes\\nvertigo and nystagmus if all the nerve pathways\\nare intact.\\nElectroencephalogram —Recording of electrical\\nactivity in the brain.\\nHospice—Systematized care of dying persons.\\nLiving will—A legal document detailing a person’s\\nwishes during the end of life, to be carried out by\\ndesignated decision makers.\\nStroke—Interruption of blood flow to a part of the\\nbrain with consequent brain damage, also known\\nas a cerebrovascular accident (CVA).\\nPrevention\\nAutopsy after death is a way to precisely determine\\na cause of death. The word autopsy is derived from\\nGreek meaning to see with one’s own eyes. A pathologist\\nextensively examines a body and submits a detailed\\nreport to an attending physician. Although an autopsy\\ncan do nothing for an individual after death, it can benefit\\nthe family and, in some cases, medical science. Heredi-\\ntary disorders and disease may be found. This knowledge\\ncould be used to prevent illness in other family members.\\nInformation culled from an autopsy can be used to fur-\\nther medical research. The link between smoking and\\nlung cancer was confirmed from data gathered through\\nautopsy. Early information about AIDS was also com-\\npiled through autopsy reports.\\nResources\\nBOOKS\\nFinkbeiner, J. Autopsy: A Manual & Atlas. Philadelphia: Saun-\\nders, 2001.\\nIserson, Kenneth B. Death to Dust: What Happens to Dead\\nBodies? Tucson: Galen Press Ltd, 2001.\\nKubler-Ross, Elisabeth. Death Is of Vital Importance.Tarry-\\ntown, NY: Station Hill Press, 1995.\\nKubler-Ross, Elisabeth. On Death and Dying. New York: Col-\\nlier Books, 1993.\\nLo, Bernard. “Ethical Issues in Clinical Medicine.”Harrison’s\\nPrinciples of Internal Medicine. 14th ed. Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1998.\\nMount, Balfour M. “Care of Dying Patients and Their Fami-\\nlies.” In Cecil Textbook of Medicine.21st ed. Ed. Lee\\nGoldman, et al. Philadelphia: W. B. Saunders, 2000.\\nSheaff, Michael T., and Deborah J. Hopster. Post Mortem Tech-\\nnique Handbook. New York: Springer Verlag, 2001.\\nPERIODICALS\\nBarone, F. C., et al. “Brain Cooling During Transient Focal\\nIschemia Provides Complete Neuroprotection.”Neuro-\\nscience and Biobehavioral Reviews 21 (1997): 31-44.\\nDobell, A. R., and J. S. Bailey. “Charles Drew and the Origins\\nof Deep Hypothermic Circulatory Arrest.”Annals of Tho-\\nracic Surgery 63 (1997): 1193-1199.\\nRoger, V . L., et al. “Time Trends in the Prevalence of Athero-\\nsclerosis: A Population-based Autopsy Study.”American\\nJournal of Medicine 110, no. 4 (2001): 267-273.\\nTargonski, P., et al. “Referral to Autopsy: Effect of Atemortem\\nCardiovascular Disease. A Population-based Study in\\nOlmsted County, Minnesota.”Annals of Epidemiology 11,\\nno. 4 (2001): 264-270.\\nORGANIZATIONS\\nAmerican Academy of Family Physicians. 11400 Tomahawk\\nCreek Parkway, Leawood, KS 66211-2672. (913) 906-\\n6000. .\\nAmerican Medical Association. 515 N. State Street, Chicago,\\nIL 60610. (312) 464-5000. .\\nGALE ENCYCLOPEDIA OF MEDICINE 21006\\nDeath'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 394, 'page_label': '395'}, page_content='American Society of Clinical Pathologists. 2100 West Harrison\\nStreet, Chicago, IL 60612. (312) 738-1336. .\\nCollege of American Pathologists. 325 Waukegan Road, North-\\nfield, IL 60093. (800) 323-4040. .\\nHospice Foundation of America. 2001 S St. NW Suite 300,\\nWashington, DC 20009. (800) 854-3402. .\\nOTHER\\nAmerican Association of Retired Persons..\\nAssociation for Death Education and Counseling.\\n.\\nDeath and Dying Grief Support..\\nNational Center for Health Statistics. .\\nL. Fleming Fallon, Jr., MD, DrPH\\nDebridement\\nDefinition\\nDebridement is the process of removing non-living\\ntissue from pressure ulcers, burns, and other wounds.\\nPurpose\\nDebridement speeds the healing of pressure ulcers,\\nburns, and other wounds. Wounds that contain non-living\\n(necrotic) tissue take longer to heal. The necrotic tissue\\nmay become colonized with bacteria, producing an\\nunpleasant odor. Though the wound is not necessarily\\ninfected, the bacteria can cause inflammation and strain\\nthe body’s ability to fight infection. Necrotic tissue may\\nalso hide pockets of pus called abscesses. Abscesses can\\ndevelop into a general infection that may lead to ampu-\\ntation or death.\\nPrecautions\\nNot all wounds need debridement. Sometimes it is\\nbetter to leave a hardened crust of dead tissue, called an\\neschar, than to remove it and create an open wound, partic-\\nularly if the crust is stable and the wound is not inflamed.\\nBefore performing debridement, the physician will take a\\nmedical history with attention to factors that might com-\\nplicate healing, such as medications being taken and\\nsmoking. The physician will also note the cause of the\\nwound and the ways it has been treated. Some ulcers and\\nother wounds occur in places where blood flow is\\nimpaired, for example, the foot ulcers that can accompany\\ndiabetes mellitus . In such cases, the physician or nurse\\nmay decide not to debride the wound because blood flow\\nmay be insufficient for proper healing.\\nDescription\\nIn debridement, dead tissue is removed so that the\\nremaining living tissue can adequately heal. Dead tissue\\nexposed to the air will form a hard black crust, called an\\neschar. Deeper tissue will remain moist and may appear\\nwhite, or yellow and soft, or flimsy. The four major\\ndebridement techniques are surgical, mechanical, chemi-\\ncal, and autolytic.\\nSurgical debridement\\nSurgical debridement (also known as sharp debride-\\nment) uses a scalpel, scissors, or other instrument to cut\\ndead tissue from a wound. It is the quickest and most\\nefficient method of debridement. It is the preferred\\nmethod if there is rapidly developing inflammation of the\\nbody’s connective tissues (cellulitis) or a more general-\\nized infection ( sepsis) that has entered the bloodstream.\\nThe procedure can be performed at a patient’s bedside. If\\nthe target tissue is deep or close to another organ, howev-\\ner, or if the patient is experiencing extreme pain, the pro-\\ncedure may be done in an operating room. Surgical\\ndebridement is generally performed by a physician, but\\nin some areas of the country an advance practice nurse or\\nphysician assistant may perform the procedure.\\nThe physician will begin by flushing the area with a\\nsaline (salt water) solution, and then will apply a topical\\nanesthetic gel to the edges of the wound to minimize\\npain. Using a forceps to grip the dead tissue, the physi-\\ncian will cut it away bit by bit with a scalpel or scissors.\\nSometimes it is necessary to leave some dead tissue\\nbehind rather than disturb living tissue. The physician\\nmay repeat the process again at another session.\\nMechanical debridement\\nIn mechanical debridement, a saline-moistened\\ndressing is allowed to dry overnight and adhere to the\\ndead tissue. When the dressing is removed, the dead tis-\\nsue is pulled away too. This process is one of the oldest\\nmethods of debridement. It can be very painful because\\nthe dressing can adhere to living as well as nonliving tis-\\nsue. Because mechanical debridement cannot select\\nbetween good and bad tissue, it is an unacceptable\\ndebridement method for clean wounds where a new layer\\nof healing cells is already developing.\\nChemical debridement\\nChemical debridement makes use of certain enzymes\\nand other compounds to dissolve necrotic tissue. It is more\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1007\\nDebridement'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 395, 'page_label': '396'}, page_content='selective than mechanical debridement. In fact, the body\\nmakes its own enzyme, collagenase, to break down colla-\\ngen, one of the major building blocks of skin. A pharma-\\nceutical version of collagenase is available and is highly\\neffective as a debridement agent. As with other debride-\\nment techniques, the area first is flushed with saline. Any\\ncrust of dead tissue is etched in a cross-hatched pattern to\\nallow the enzyme to penetrate. A topical antibiotic is also\\napplied to prevent introducing infection into the blood-\\nstream. A moist dressing is then placed over the wound.\\nAutolytic debridement\\nAutolytic debridement takes advantage of the body’s\\nown ability to dissolve dead tissue. The key to the tech-\\nnique is keeping the wound moist, which can be accom-\\nplished with a variety of dressings. These dressings help\\nto trap wound fluid that contains growth factors, enzymes,\\nand immune cells that promote wound healing. Autolytic\\ndebridement is more selective than any other debridement\\nmethod, but it also takes the longest to work. It is inappro-\\npriate for wounds that have become infected.\\nPreparation\\nThe physician or nurse will begin by assessing the\\nneed for debridement. The wound will be examined, fre-\\nquently by inserting a gloved finger into the wound to\\nestimate the depth of dead tissue and evaluate whether it\\nlies close to other organs, bone, or important body fea-\\ntures. The area may be flushed with a saline solution\\nbefore debridement begins, and a topical anesthetic gel\\nor injection may be applied if surgical or mechanical\\ndebridement is being performed.\\nAftercare\\nAfter surgical debridement, the wound will be\\npacked with a dry dressing for a day to control bleeding.\\nKEY TERMS\\nEschar—A hardened black crust of dead tissue\\nthat may form over a wound.\\nPressure ulcer—Also known as a decubitus ulcer,\\npressure ulcers are open wounds that form when-\\never prolonged pressure is applied to skin covering\\nbony outcrops of the body. Patients who are\\nbedridden are at risk of developing pressure ulcers.\\nPressure ulcers are commonly known as bedsores.\\nSepsis—A severe systemic infection in which bac-\\nteria have entered the blood stream.\\nAfterward, moist dressings are applied to promote wound\\nhealing. Moist dressings are also used after mechanical,\\nchemical, and autolytic debridement. Many factors con-\\ntribute to wound healing, which frequently can take con-\\nsiderable time. Debridement may need to be repeated.\\nRisks\\nIt is possible that underlying tendons, blood vessels\\nor other structures will be damaged during the examina-\\ntion of the wound and during surgical debridement. Sur-\\nface bacteria may also be introduced deeper into the\\nbody, causing infection.\\nNormal results\\nRemoval of dead tissue from pressure ulcers and other\\nwounds speeds healing. Although these procedures cause\\nsome pain, they are generally well tolerated by patients and\\ncan be managed more aggressively. It is not uncommon to\\ndebride a wound again in a subsequent session.\\nResources\\nBOOKS\\nMaklebust, JoAnn, and Mary Y . Sieggreen. Pressure Ulcers:\\nGuidelines for Prevention and Nursing Management,2nd\\ned. Springhouse, PA: Springhouse Corporation, 1996.\\nPERIODICALS\\nBale, S. “A Guide to Wound Debridement.”Journal of Wound\\nCare 6 (Apr. 1997): 179-182.\\nSieggreen, Mary Y ., and JoAnn Maklebust. “Debridement:\\nChoices and Challenges.”Advances in Wound Care,1 0\\n(Mar./Apr. 1997): 32-37.\\nORGANIZATIONS\\nAmerican Academy of Wound Management. 1255 23rd St.,\\nNW, Washington, DC 20037. (202) 521-0368. .\\nWound Care Institute. 1100 N.E. 163rd Street, Suite #101,\\nNorth Miami Beach, FL 33162. (305) 919-9192. .\\nRichard H. Camer\\nDecompression sickness\\nDefinition\\nDecompression sickness (DCS) is a dangerous and\\noccasionally lethal condition caused by nitrogen bubbles\\nthat form in the blood and other tissues of scuba divers\\nwho surface too quickly.\\nGALE ENCYCLOPEDIA OF MEDICINE 21008\\nDecompression sickness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 396, 'page_label': '397'}, page_content='Description\\nAccording to the Divers Alert Network (DAN), a\\nworldwide organization devoted to safe-diving research\\nand promotion, less than 1% of divers fall victim to DCS\\nor the rarer bubble problem called gas embolism , air\\nembolism, or arterial gas embolism (AGE). A study of the\\nUnited States military community in Okinawa, where tens\\nof thousands of sport and military dives are made each\\nyear, identified 84 DCS and 10 AGE cases in 1989–95,\\nincluding nine deaths. This translated into estimates of one\\ncase in every 7,400 dives and one death in every 76,900\\ndives. DCS symptoms can be quite mild, however, and\\nmany cases certainly go unnoticed by divers.\\nAt times the terminology adopted by writers on\\nDCS can be confusing. Some substitute the term\\ndecompression illness (DCI) for DCS. Others treat DCI\\nas a label encompassing both DCS and AGE. An older\\nterm for DCS is caisson disease, coined in the nine-\\nteenth century when it was discovered that bridge con-\\nstruction crews working at the bottom of lakes and\\nrivers in large pressurized enclosures (caissons) were\\nexperiencing joint pain (a typical DCS symptom) on\\nreturning to the surface.\\nCauses and symptoms\\nThe air we breathe is mostly a mixture of two gases,\\nnitrogen (78%) and oxygen (21%). Unlike oxygen, nitro-\\ngen is a biologically inert gas, meaning that it is not\\nmetabolized (converted into other substances) by the\\nbody. For this reason, most of the nitrogen we inhale is\\nexpelled when we exhale, but some is dissolved into the\\nblood and other tissues. During a dive, however, the\\nlungs take in more nitrogen than usual. This happens\\nbecause the surrounding water pressure is greater than\\nthe air pressure at sea level (twice as great at 33 ft [10 m],\\nfor instance). As the water pressure increases, so does the\\npressure of the nitrogen in the compressed air inhaled by\\nthe diver. Because increased pressure causes an increase\\nin gas density, the diver takes in more nitrogen with each\\nbreath than he or she would at sea level. Instead of being\\nexhaled, however, the extra nitrogen safely dissolves into\\nthe tissues, where it remains until the diver begins his or\\nher return to the surface (under some circumstances the\\nextra nitrogen can cause nitrogen narcosis, but that con-\\ndition is distinct from DCS). On the way up, decompres-\\nsion occurs (in other words, the water pressure drops),\\nand with the change in pressure, the extra nitrogen grad-\\nually diffuses out of the tissues and is delivered by the\\nbloodstream to the lungs, which expel it from the body. If\\nthe diver surfaces too quickly, however, potentially dan-\\ngerous nitrogen bubbles can form in the tissues and cause\\nDCS. These bubbles can compress nerves, obstruct arter-\\nies, veins, and lymphatic vessels, and trigger harmful\\nchemical reactions in the blood. The precise reasons for\\nbubble formation remain unclear.\\nHow much extra nitrogen enters the tissues varies\\nwith the dive’s depth and duration. Dive tables prepared\\nby the U.S. Navy and other organizations specify how\\nlong most divers can safely remain at a particular depth.\\nIf the dive table limits are exceeded, the diver must pause\\non the way up to allow the nitrogen to diffuse into the\\nbloodstream without forming bubbles; these pauses are\\ncalled decompression stops, and are carefully calibrated.\\nDCS can occur, however, even when a diver obeys safe\\ndiving rules. In such cases, the predisposing factors\\ninclude fatigue , obesity , dehydration , hypothermia ,\\nand recent alcohol use. As well, people who fly or travel\\nto high-altitude locations without letting 12–24 hours\\npass after their last dive are at risk for DCS as well\\nbecause their bodies undergo further decompression.\\nThis is true even when flying in commercial aircraft.\\nMany travelers are unaware that to save money on fuel\\nthe cabin pressure in commercial aircraft is set much\\nlower than the pressure at sea level. At 30,000 ft (9,144\\nm), for instance, cabin pressure is usually equivalent to\\nthe pressure at 7,000–8,000 ft (2,133–2,438 m) above sea\\nlevel, a safe setting for everyone but recent divers. Exact-\\nly how long a diver should wait before flying or traveling\\nto a high-altitude location depends on how much diving\\nhe or she has done and other considerations. If there is\\nuncertainty about the appropriate waiting period, the sen-\\nsible course of action is to let the full 24 hours pass.\\nBecause the nitrogen bubbles that cause DCS can\\naffect any of the body’s tissues, including the blood,\\nbones, nerves, and muscles, many kinds of symptoms are\\npossible. Symptoms can appear minutes after a diver sur-\\nfaces, and in about 80% of cases do so within eight\\nhours. Pain is often the only symptom; this is sometimes\\ncalled the bends, although many people incorrectly use\\nthat term as a synonym for DCS itself. The pain, which\\nranges from mild to severe, is usually limited to the\\njoints, but can be felt anywhere. Severe itching (pruritis),\\nskin rashes, and skin mottling (cutis marmorata) are\\nother possible symptoms. All of these are sometimes\\nclassified as manifestations of type 1 or “mild” DCS.\\ntype 2 or “serious” DCS can lead, among other things, to\\nparalysis, brain damage, heart attacks, and death. Many\\nDCS victims, however, experience both type 1 and type 2\\nsymptoms.\\nDiagnosis\\nDiagnosis requires taking a medical history (ques-\\ntioning the patient about his or her health and recent\\nactivities) and conducting a physical examination.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1009\\nDecompression sickness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 397, 'page_label': '398'}, page_content='Treatment\\nDCS is treated by giving the patient oxygen and\\nplacing him or her in a hyperbaric chamber, an enclosure\\nin which the air pressure is first gradually increased and\\nthen gradually decreased. This shrinks the bubbles and\\nallows the nitrogen to safely diffuse out of the tissues.\\nHyperbaric chamber facilities exist throughout the Unit-\\ned States. No matter how mild one’s symptoms may\\nappear, immediate transportation to a facility is essential.\\nTreatment is necessary even if the symptoms clear up\\nbefore the facility is reached, because bubbles may still\\nbe in the bloodstream and pose a threat. DAN maintains\\na list of facilities and a 24-hour hotline that can provide\\nadvice on handling DCS and other diving emergencies.\\nPrognosis\\nDCS sufferers who undergo chamber treatment within\\na few hours of symptom onset usually enjoy a full recovery.\\nIf treatment is delayed the consequences are less pre-\\ndictable, although many people have been helped even after\\nseveral days have passed. A 1992 DAN report on diving\\naccidents indicated that full recovery following chamber\\ntreatment was immediate for about 50% of divers. Some\\npeople, however, suffer numbness, tingling, or other symp-\\ntoms that last weeks, months, or even a lifetime. In the Oki-\\nnawa study, six of the 94 patients experienced “long-last-\\ning” symptoms even after repeated chamber treatments.\\nPrevention\\nThe obvious way to minimize the risk of falling vic-\\ntim to DCS is to follow the rules on safe diving and air\\nKEY TERMS\\nGas embolism —The presence of a gas bubble in\\nthe bloodstream that obstructs circulation.\\nHyperbaric chamber —A sealed compartment in\\nwhich air pressure is gradually increased and then\\ngradually decreased, allowing nitrogen bubbles to\\nshrink and the nitrogen to safely diffuse out of\\nbody tissue.\\nLymphatic vessels —Vessels that carry a fluid\\ncalled lymph from the tissues to the bloodstream.\\nNitrogen narcosis —Also called “rapture of the\\ndeep,” the condition is caused by increased nitro-\\ngen pressure at depth and is characterized by\\nsymptoms similar to alcohol intoxication.\\ntravel after a dive. People who are obese, suffer from\\nlung or heart problems, or are otherwise in poor health\\nshould not dive. And because the effect of nitrogen diffu-\\nsion on the fetus remains unknown, diving while preg-\\nnant is not recommended.\\nResources\\nBOOKS\\nMartin, Lawrence. Scuba Diving Explained: Questions and\\nAnswers on Physiology and Medical Aspects of Scuba\\nDiving. Flagstaff, AZ: Best Publishing, 1997.\\nPiantadosi, Claude A. “Physical, Chemical, and Aspiration\\nInjuries of the Lung.” In Cecil Textbook of Medicine, ed. J.\\nClaude Bennett and Fred Plum. Philadelphia: W. B. Saun-\\nders Co., 1996.\\nPERIODICALS\\nArness, Mark K. “Scuba Decompression Illness and Diving\\nFatalities in an Overseas Military Community.”Aviation,\\nSpace, and Environmental Medicine(Apr. 1997): 325-333.\\nClenney, Timothy L., and Lorenz F. Lassen. “Recreational\\nScuba Diving Injuries.”American Family Physician (Apr.\\n1996): 1761+.\\nORGANIZATIONS\\nAmerican College of Hyperbaric Medicine. P.O. Box 25914-\\n130, Houston, Texas 77265. (713) 528-0657. .\\nDivers Alert Network. The Peter B. Bennett Center, 6 West\\nColony Place, Durham, NC 27705. (800) 446-2671.\\n.\\nUndersea and Hyperbaric Medical Society. 10531 Metropolitan\\nAve., Kensington, MD 20895. (301) 942-2980. .\\nHoward Baker\\nDecongestants\\nDefinition\\nDecongestants are medicines used to relieve nasal\\ncongestion (stuffy nose).\\nPurpose\\nA congested or stuffy nose is a common symptom of\\ncolds and allergies. This congestion results when mem-\\nbranes lining the nose become swollen. Decongestants\\nrelieve the swelling by narrowing the blood vessels that\\nsupply the nose. This reduces the blood supply to the\\nswollen membranes, causing the membranes to shrink.\\nThese medicines do not cure colds or reverse the\\neffects of histamines—chemicals released as part of the\\nGALE ENCYCLOPEDIA OF MEDICINE 21010\\nDecongestants'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 398, 'page_label': '399'}, page_content='allergic reaction. They will not relieve all of the symptoms\\nassociated with colds and allergies, only the stuffiness.\\nWhen considering whether to use a decongestant for\\ncold symptoms, keep in mind that most colds go away\\nwith or without treatment and that taking medicine is not\\nthe only way to relieve a stuffy nose. Drinking hot tea or\\nbroth or eating chicken soup may help. There are also\\nadhesive strips can be placed on the nose to help widen\\nthe nasal passages, making breathing through the nasal\\npassages a bit easier when congestion is present.\\nPrecautions\\nDecongestant nasal sprays and nose drops may\\ncause a problem called rebound congestion if used\\nrepeatedly over several days. When this happens, the\\nnose remains stuffy or gets worse with every dose. The\\nonly way to stop the cycle is to stop using the drug. The\\nstuffiness should then go away within about a week.\\nAnyone who shows signs of severe rebound congestion\\nshould also contact his or her physician.\\nDo not use decongestant nasal sprays for more than\\nthree days. Decongestants taken by mouth should not be\\nused for more than seven days. If the congestion has not\\ngone away in this time, or if the symptoms are accompa-\\nnied by fever, call a physician.\\nDo not use a decongestant nasal spray after the prod-\\nuct’s expiration date. If the product has become cloudy\\nor discolored, throw it away and do not use it. Do not\\nshare droppers or spray bottles with anyone else, as this\\ncould spread infection. Do not let droppers and bottle\\ntips touch countertops or other surfaces.\\nSome decongestants cause drowsiness. People who\\ntakes these drugs should not drive, use machines or do\\nanything else that might be dangerous until they have\\nfound out how the drugs affect them.\\nIn general, older people may be more sensitive to the\\neffects of decongestants and may need to take lower\\ndoses to avoid side effects. People in this age group\\nshould not take long-acting (extended release) forms of\\ndecongestants unless they have previously taken a short-\\nacting form with no ill effects.\\nChildren may also be more sensitive to the effects of\\ndecongestants. Before giving any decongestant to a\\nchild, check the package label carefully. Some of these\\nmedicines are too strong for use in children. Serious side\\neffects are possible if they are given large amounts of\\nthese drugs or if they swallow nose drops, nasal spray or\\neye drops. If this happens, call a physician or poison cen-\\nter immediately.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if they\\ntake decongestants. Before taking these drugs, be sure to\\nlet the physician know about any of these conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto decongestants in the past should let his or her physi-\\ncian know before these drugs or any similar drugs are\\nprescribed. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other sub-\\nstances.\\nPREGNANCY. In studies of laboratory animals, some\\ndecongestants have had unwanted effects on fetuses.\\nHowever, it is not known whether such effects also occur\\nin people. Women who are pregnant or who plan to\\nbecome pregnant should check with their physicians\\nbefore taking decongestants.\\nBREASTFEEDING. Some decongestants pass into\\nbreast milk and may have unwanted effects on nursing\\nbabies whose mothers take the drugs. Women who are\\nbreastfeeding should check with their physicians before\\nusing decongestants. If they need to take the medicine, it\\nmay be necessary to bottle feed the baby with formula\\nwhile taking it.\\nOTHER MEDICAL CONDITIONS. Anyone with heart\\nor blood vessel disease, high blood pressure, diabetes,\\nenlarged prostate, or overactive thyroid should not take\\ndecongestants unless under a physician’s supervision.\\nThe medicine can increase blood sugar in people with\\ndiabetes. It can be especially dangerous in people with\\nhigh blood pressure, as it may increase blood pressure.\\nBefore using decongestants, people with any of\\nthese medical problems should make sure their physi-\\ncians are aware of their conditions:\\n• glaucoma\\n• history of mental illness\\nDecongestants may have a variety of side effects,\\nand may also interact with other medications the patient\\nis taking.\\nSide effects\\nDECONGESTANT NASAL SPRAYS AND NOSE DROPS.\\nThe most common side effects from decongestant nasal\\nsprays and nose drops are sneezing and temporary burn-\\ning, stinging, or dryness. These effects are usually tem-\\nporary and do not need medical attention. If any of the\\nfollowing side effects occur after using a decongestant\\nnasal spray or nose drops, stop using the medicine imme-\\ndiately and call the physician:\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1011\\nDecongestants'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 399, 'page_label': '400'}, page_content='• increased blood pressure\\n•headache\\n• fast, slow, or fluttery heartbeat\\n• nervousness\\n•dizziness\\n• nausea\\n• sleep problems\\nDECONGESTANTS TAKEN BY MOUTH. The most\\ncommon side effects of decongestants taken by mouth\\nare nervousness, restlessness, excitability, dizziness,\\ndrowsiness, headache, nausea, weakness, and sleep prob-\\nlems. Anyone who has these symptoms while taking\\ndecongestants should stop taking them immediately.\\nPatients who have these symptoms while taking\\ndecongestants should call the physician immediately:\\n• increased blood pressure\\n• fast, irregular, or fluttery heartbeat\\n• severe headache\\n• tightness or discomfort in the chest\\n• breathing problems\\n• fear or anxiety\\n•hallucinations\\n• trembling or shaking\\n• convulsions (seizures)\\n• pale skin\\n• painful or difficult urination\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking a decongestant should get\\nin touch with his or her physician.\\nInteractions with other medicines\\nDecongestants may interact with a variety of other\\nmedicines. When this happens, the effects of one or both\\nof the drugs may change or the risk of side effects may\\nbe greater. Do not take decongestants at the same time as\\nthese drugs:\\n• Monoamine oxidase inhibitors (MAO inhibitors) such\\nas phenzeline (Nardil) or tranylcypromine (Parnate),\\nused to treat conditions including depression and\\nParkinson’s disease. Do not take decongestants at the\\nsame time as a MAO inhibitor or within two weeks of\\nstopping treatment with an MAO inhibitor unless a\\nphysician approves.\\n• Other products containing the same or other deconges-\\ntants.\\n• Caffeine.\\nIn addition, anyone who takes decongestants should\\nlet the physician know all other medicines he or she is\\ntaking. Among the drugs that may interact with decon-\\ngestants are:\\n• tricyclic antidepressants such as imipramine (Tofranil)\\nor desipramine (Norpramin)\\n• the antidepressant maprotiline (Ludiomil)\\n• amantadine (Symmetrel)\\n• amphetamines\\n• medicine to relieve asthma or other breathing problems\\n• methylphenidate (Ritalin)\\n• appetite suppressants\\n• other medicine for colds, sinus problems, hay fever or\\nother allergies\\n• beta-blockers such as atenolol (Tenormin) and propra-\\nnolol (Inderal)\\n• digitalis glycosides, used to treat heart conditions\\nThe list above does not include every drug that may\\ninteract with decongestants. Be sure to check with a\\nphysician or pharmacist before combining decongestants\\nwith any other prescription or nonprescription (over-the-\\ncounter) medicine.\\nDescription\\nDecongestants are sold in many forms, including\\ntablets, capsules, caplets, gelcaps, liqui-caps, liquids,\\nnasal sprays, and nose drops. These drugs are sometimes\\ncombined with other medicines in cold and allergy prod-\\nucts designed to relieve several symptoms. Some decon-\\ngestant products require a physician’s prescription, but\\nthere are also many nonprescription (over-the-counter)\\nproducts. Ask a physician or pharmacist about choosing\\nan appropriate decongestant.\\nCommonly used decongestants include oxymetazo-\\nline (Afrin and other brands) and pseudoephedrine\\n(Sudafed, Actifed, and other brands). The decongestant\\noxymetazoline is also used in some eye drops to relieve\\nredness and itching.\\nThe recommended dosage depends on the drug.\\nCheck with the physician who prescribed the drug or the\\npharmacist who filled the prescription for the correct\\ndosage, and always take the medicine exactly as directed.\\nIf using nonprescription (over-the-counter) types, follow\\nthe directions on the package label or ask a pharmacist\\nfor assistance. Never take larger or more frequent doses,\\nand do not take the drug for longer than directed.\\nGALE ENCYCLOPEDIA OF MEDICINE 21012\\nDecongestants'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 400, 'page_label': '401'}, page_content='Risks\\nAnyone considering taking a decongestant should\\ntake a close look at the labels of any already in their med-\\nicine cabinet. In 2000, the Food and Drug Administration\\nprohibited over-the-counter sales of medicines contain-\\ning the decongestant phenylpropanolamine. The medi-\\ncine is associated with an increased risk of stroke in peo-\\nple ages 18 to 49, especially women. Many cold reme-\\ndies contained this medicine. Contact a pharmacist if\\nthere is any question about the ingredients in a medica-\\ntion. Over-the-counter remedies containing phenyl-\\npropanolamine should be discarded.\\nNormal results\\nThe desired result when taking decongestants is the\\nshort-term relief of nasal congestion.\\nResources\\nPERIODICALS\\n“An Ingredient Under Fire: Drugmakers are Jittery After an\\nFDA Panel Ruling.”Newsweek (October 30, 2000): 59.\\nHenderson, Charles W. “V oluntary Withdrawal of Cold and\\nAllergy Products Announced.”Medical Letter on the CDC\\nand FDA (November 26, 2000).\\nOTHER\\n“Medline Plus Health Information”. U.S. National Library of\\nMedicine. .\\nDeanna M. Swartout-Corbeil, RN\\nDecubitus ulcers see Bedsores\\nDeep vein thrombosis\\nDefinition\\nDeep vein thrombosis (DVT) is a blood clot in a\\nmajor vein, usually in the legs and/or pelvis.\\nKEY TERMS\\nFetus—A developing baby inside the womb.\\nHallucination —A false or distorted perception of\\nobjects, sounds, or events that seems real. Hallu-\\ncinations usually result from drugs or mental dis-\\norders.\\nDescription\\nDeep vein thrombosis is a common but difficult to\\ndetect illness that can be fatal if not treated effectively.\\nAccording to the American Heart Association, more than\\ntwo million Americans develop deep vein thrombosis\\nannually. An estimated 600,000 of these develop pul-\\nmonary embolism , a potentially fatal complication\\nwhere the blood clots break off and form pulmonary\\nemboli, plugs that block the lung arteries. Sixty thousand\\npeople die of pulmonary embolism each year. Deep vein\\nthrombosis is also called venous thromboembolism,\\nthrombophlebitis or phlebothrombosis.\\nDeep vein thrombosis is a major complication in\\npatients who have had orthopedic surgery or pelvic,\\nabdominal, or thoracic surgery . Patients with cancer\\nand other chronic illnesses (including congestive heart\\nfailure), as well as those who have suffered a recent\\nmyocardial infarction, are also at high risk for develop-\\ning DVT. Deep vein thrombosis can be chronic, with\\nrecurrent episodes.\\nCauses and symptoms\\nDeep vein thrombosis is caused by blood clots in\\nblood vessels that form in veins where blood flow is\\nsluggish or has been disturbed, in pockets in the calf’s\\ndeep veins, or in veins that have been traumatized.\\nSymptoms include swelling and tenderness of the calf or\\nthigh, and possibly warmth. Only 23–50% of patients\\nexperience symptoms, so it’s often “silent.” Some indi-\\nviduals and families have underlying clotting tendencies\\nthat can be tested for.\\nDiagnosis\\nDeep vein thrombosis can be detected through\\nvenography and radionuclide venography, Doppler\\nultrasonography , and impedance plethysmography.\\nVenography is the most accurate test, but it is not used\\nmuch, because it is often painful, expensive, exposes\\nthe patient to radiation, and can cause reactions and\\ncomplications. Venography identifies the location,\\nextent, and degree of attachment of the blood clots, and\\nenables the condition of the deep leg veins to be\\nassessed. A contrast solution is injected into a foot vein\\nthrough a catheter. The physician observes the move-\\nment of the solution through the vein with a fluoro-\\nscope while a series of x rays are taken. Venography\\ntakes 30–45 minutes and can be done in a physician’s\\noffice, a laboratory, or a hospital. Radionuclide venog-\\nraphy, in which a radioactive isotope is injected, is\\noccasionally used, especially if a patient has had reac-\\ntions to contrast solutions.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1013\\nDeep vein thrombosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 401, 'page_label': '402'}, page_content='KEY TERMS\\nPulmonary embolism —An obstruction of a blood\\nvessel in the lungs, usually caused by a blood clot\\nthat blocks a coronary artery. Pulmonary embolism\\ncan be very serious and, in some cases, fatal.\\nThrombosis —The development of a blood clot\\ninside a blood vessel.\\nDoppler ultrasonography is usually the preferred\\nprocedure for detecting deep vein thrombosis. This tech-\\nnique uses sound waves to measure blood flow through\\nleg veins and arteries. A blood pressure cuff is wrapped\\naround the patient’s ankle and a transducer with gel on it\\nis placed over pulse points of the foot and lower leg.\\nHigh-frequency sounds bounce off the soft tissue, and\\nthe echoes are converted into images on a monitor. It is\\nvery accurate in detecting clots above the knee that can\\nbecome pulmonary embolisms. Usually performed in a\\nphysician’s office or hospital outpatient diagnostic cen-\\nter, Doppler ultrasound usually takes 30–45 minutes.\\nImpedance plethysmography records changes in\\nblood volume and vessel resistance. A blood pressure\\ncuff is wrapped around the leg above the knee, four elec-\\ntrodes are placed near the knee and the ankle, and the\\ncuff is inflated. How efficiently the veins return to nor-\\nmal is measured. Performed in a physician’s office, it\\ntakes about 15 minutes.\\nTreatment\\nDeep vein thrombosis can be treated with drug ther-\\napy, bed rest, and gradient elastic stockings. Medications\\ninclude anticoagulants that “thin” blood to prevent fur-\\nther growth of blood clots, as well as clot-dissolving\\ndrugs. Heparin is a common injectable anticoagulant,\\nand is usually followed by coumadin tablets for at least\\nthree months. Bed rest with the patient’s legs elevated is\\nnecessary until the condition improves. Gradient elastic\\nstockings should then be worn, and standing for long\\nperiods of time avoided. In some cases, a filter is placed\\nin the major vein (the inferior vena cava) to trap emboli\\nor clots before they get to the heart and lungs.\\nAlternative treatment\\nDeep vein thrombosis can be life-threatening and\\nmust be treated with conventional medical therapies.\\nHowever, there are alternative therapies that can be used\\nin conjunction with emergency treatments to dissolve the\\nclot that help support the body and prevent recurrence. A\\ntrained alternative health care practitioner should be con-\\nsulted due to the severity of this condition.\\nPrognosis\\nIn many cases, deep vein thrombosis can be success-\\nfully treated if diagnosed early.\\nPrevention\\nDeep vein thrombosis can be prevented through pro-\\nphylactic anticoagulant drugs and venous stasis prevention\\nwith gradient elastic stockings and intermittent pneumatic\\ncompression of the legs. High-risk patients often need to\\nremain on anticoagulants like Coumadin indefinitely.\\nResources\\nBOOKS\\nDeBakey, Michael E., and Antonio M. Gotto Jr. “Invasive\\nDiagnostic Procedures” and “Diseases of the Vein.” In The\\nGALE ENCYCLOPEDIA OF MEDICINE 21014\\nDeep vein thrombosis\\nThis illustration features a dissected human lower leg show-\\ning clot formation (thrombosis) along the length of a vein.\\n(Custom Medical Stock Photo. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 402, 'page_label': '403'}, page_content='New Living Heart. Holbrook, MA: Adams Media Corpo-\\nration, 1997.\\nTexas Heart Institute. “Diseases of the Peripheral Arteries and\\nVeins.” In Texas Heart Institute Heart Owner’s Handbook.\\nNew York: John Wiley & Sons, 1996.\\n“Venous Imaging.” In Diagnostic Nuclear Medicine. 3rd ed.\\nBaltimore: Williams & Wilkins, 1996.\\n“Venous Thromboembolism.” In Mayo Clinic Practice of Car-\\ndiology. 3rd ed. St. Louis: Mosby, 1996.\\nPERIODICALS\\nBarloon, T. J., G. R. Bergus, and J. Seabold. “Diagnostic Imag-\\ning of Lower Limb, Deep Venous Thrombosis.”American\\nFamily Physician 56 (1 September 1997): 791-801.\\nDavidson, Bruce L., and Eric J. Deppert. “Ultrasound for the\\nDiagnosis of Deep Vein Thrombosis: Where to Now?”\\nBritish Medical Journal 316 (3 January 1998): 2.\\nLori De Milto\\nDeer-fly fever see Tularemia\\nDefibrillation\\nDefinition\\nDefibrillation is a process in which an electronic\\ndevice sends an electric shock to the heart to stop an\\nextremely rapid, irregular heartbeat, and restore the nor-\\nmal heart rhythm.\\nPurpose\\nDefibrillation is performed to correct life-threaten-\\ning fibrillations of the heart, which could result in car-\\ndiac arrest. It should be performed immediately after\\nidentifying that the patient is experiencing a cardiac\\nemergency, has no pulse, and is unresponsive.\\nPrecautions\\nDefibrillation should not be performed on a patient\\nwho has a pulse or is alert, as this could cause a lethal\\nheart rhythm disturbance or cardiac arrest. The paddles\\nused in the procedure should not be placed on a woman’s\\nbreasts or over a pacemaker.\\nDescription\\nFibrillations cause the heart to stop pumping blood,\\nleading to brain damage and/or cardiac arrest. About\\n10% of the ability to restart the heart is lost with every\\nminute that the heart stays in fibrillation. Death can\\noccur in minutes unless the normal heart rhythm is\\nrestored through defibrillation. Because immediate\\ndefibrillation is crucial to the patient’s survival, the\\nAmerican Heart Association has called for the integra-\\ntion of defibrillation into an effective emergency cardiac\\ncare system. The system should include early access,\\nearly cardiopulmonary resuscitation , early defibrilla-\\ntion, and early advanced cardiac care.\\nDefibrillators deliver a brief electric shock to the\\nheart, which enables the heart’s natural pacemaker to\\nregain control and establish a normal heart rhythm. The\\ndefibrillator is an electronic device with electrocardio-\\ngram leads and paddles. During defibrillation, the pad-\\ndles are placed on the patient’s chest, caregivers stand\\nback, and the electric shock is delivered. The patient’s\\npulse and heart rhythm are continually monitored. Med-\\nications to treat possible causes of the abnormal heart\\nrhythm may be administered. Defibrillation continues\\nuntil the patient’s condition stabilizes or the procedure is\\nordered to be discontinued.\\nEarly defibrillators, about the size and weight of a\\ncar battery, were used primarily in ambulances and hos-\\npitals. The American Heart Association now advocates\\npublic access defibrillation; this calls for placing auto-\\nmated external defibrillators (AEDS) in police vehicles,\\nairplanes, and at public events, etc. The AEDS are small-\\ner, lighter, less expensive, and easier to use than the early\\ndefibrillators. They are computerized to provide simple,\\nverbal instructions to the operator and to make it impos-\\nsible to deliver a shock to a patient whose heart is not fib-\\nrillating. The placement of AEDs is likely to expand to\\nmany public locations.\\nPreparation\\nAfter help is called for, cardiopulmonary resuscita-\\ntion (CPR) is begun and continued until the caregivers\\narrive and set up the defibrillator. Electrocardiogram\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1015\\nDefibrillation\\nDefibrillation by paddles. (Photograph by Patricia Barber, RBP ,\\nCustom Medical Stock Photo. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 403, 'page_label': '404'}, page_content='leads are attached to the patient’s chest. Gel or paste is\\napplied to the defibrillator paddles, or two gel pads are\\nplaced on the patient’s chest. The caregivers verify lack\\nof a pulse, and select a charge.\\nAftercare\\nAfter defibrillation, the patient’s cardiac status, breath-\\ning, and vital signs are monitored until he or she is stable.\\nTypically, this monitoring takes place after the patient has\\nbeen removed to an intensive care or cardiac care unit in a\\nhospital. An electrocardiogram and chest x ray are taken.\\nThe patient’s skin is cleansed to remove gel or paste, and, if\\nnecessary, ointment is applied to burns. An intravenous\\nline provides additional medication, as needed.\\nRisks\\nSkin burns from the defibrillator paddles are the\\nmost common complication of defibrillation. Other risks\\ninclude injury to the heart muscle, abnormal heart\\nrhythms, and blood clots.\\nResources\\nBOOKS\\nGiuliani, E. R., et. al., eds. “Arrhythmias.” In Mayo Clinic\\nPractice of Cardiology.3rd ed. Ed. E.R. Giuliani. St.\\nLouis: Mosby, 1996.\\nPERIODICALS\\nMatarese, Leonard. “Police and AEDS: A Chance to Save\\nThousands of Lives Each Year.”Public Management 79\\n(June 1997): 4.\\n“Medical Breakthroughs That Could Save Your Life.”Body\\nBulletin (Feb. 1998): 1.\\n“Upping the Odds of Survival.”Hospitals and Health Networks\\n71 (5 June 1997): 13.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nKEY TERMS\\nCardiac arrest —A condition in which the heart\\nstops functioning. Fibrillation can lead to cardiac\\narrest if not corrected quickly.\\nFibrillation—Very rapid contractions or twitching\\nof small muscle fibers in the heart.\\nPacemaker —A surgically implanted electronic\\ndevice that sends out electrical impulses to regu-\\nlate a slow or erratic heartbeat.\\nOTHER\\n“AARC Clinical Practice Guideline: Defibrillation During\\nResuscitation.” American Association of Respiratory\\nCare. 29 Apr. 1998 .\\n“Defibrillation.”American Heart Association. 1997. 9 Apr.\\n1998 .\\nLori De Milto\\nDefinitive cancer therapy see Cancer\\ntherapy, definitive\\nDegenerative arthritis see Osteoarthritis\\nDehydration\\nDefinition\\nDehydration is the loss of water and salts essential\\nfor normal body function.\\nDescription\\nDehydration occurs when the body loses more fluid\\nthan it takes in. This condition can result from illness; a\\nhot, dry climate; prolonged exposure to sun or high tem-\\nperatures; not drinking enough water; and overuse of\\ndiuretics or other medications that increase urination.\\nDehydration can upset the delicate fluid-salt balance\\nneeded to maintain healthy cells and tissues.\\nWater accounts for about 60% of a man’s body\\nweight. It represents about 50% of a woman’s weight.\\nYoung and middle-aged adults who drink when they’re\\nthirsty do not generally have to do anything more to\\nmaintain their body’s fluid balance. Children need more\\nwater because they expend more energy, but most chil-\\ndren who drink when they are thirsty get as much water\\nas their systems require.\\nAge and dehydration\\nAdults over the age of 60 who drink only when they\\nare thirsty probably get only about 90% of the fluid they\\nneed. Developing a habit of drinking only in response to\\nthe body’s thirst signals raises an older person’s risk of\\nbecoming dehydrated. Seniors who have relocated to\\nareas where the weather is warmer or dryer than the cli-\\nmate they are accustomed to are even likelier to become\\ndehydrated unless they make it a practice to drink even\\nwhen they are not thirsty.\\nGALE ENCYCLOPEDIA OF MEDICINE 21016\\nDehydration'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 404, 'page_label': '405'}, page_content='Dehydration in children usually results from losing\\nlarge amounts of fluid and not drinking enough water to\\nreplace the loss. This condition generally occurs in chil-\\ndren who have stomach flu characterized by vomiting\\nand diarrhea , or who can not or will not take enough\\nfluids to compensate for excessive losses associated with\\nfever and sweating of acute illness. An infant can\\nbecome dehydrated only hours after becoming ill. Dehy-\\ndration is a major cause of infant illness and death\\nthroughout the world.\\nTypes of dehydration\\nMild dehydration is the loss of no more than 5% of\\nthe body’s fluid. Loss of 5–10% is considered moderate\\ndehydration. Severe dehydration (loss of 10–15% of\\nbody fluids) is a life-threatening condition that requires\\nimmediate medical care.\\nComplications of dehydration\\nWhen the body’s fluid supply is severely depleted,\\nhypovolemic shock is likely to occur. This condition,\\nwhich is also called physical collapse, is characterized by\\npale, cool, clammy skin; rapid heartbeat; and shallow\\nbreathing.\\nBlood pressure sometimes drops so low it can not be\\nmeasured, and skin at the knees and elbows may become\\nblotchy. Anxiety, restlessness, and thirst increase. After\\nthe patient’s temperature reaches 107°F (41.7°C) damage\\nto the brain and other vital organs occurs quickly.\\nCauses and symptoms\\nStrenuous activity, excessive sweating, high fever,\\nand prolonged vomiting or diarrhea are common causes\\nof dehydration. So are staying in the sun too long, not\\ndrinking enough fluids, and visiting or moving to a warm\\nregion where it doesn’t often rain. Alcohol,caffeine, and\\ndiuretics or other medications that increase the amount of\\nfluid excreted can cause dehydration.\\nReduced fluid intake can be a result of:\\n• appetite loss associated with acute illness\\n• excessive urination (polyuria)\\n• nausea\\n• bacterial or viral infection or inflammation of the phar-\\nynx (pharyngitis)\\n• inflammation of the mouth caused by illness, infection,\\nirritation, or vitamin deficiency (stomatitis)\\nOther conditions that can lead to dehydration include:\\n• disease of the adrenal glands, which regulate the body’s\\nwater and salt balance and the function of many organ\\nsystems\\n• diabetes mellitus\\n• eating disorders\\n• kidney disease\\n• chronic lung disease\\nAn infant who does not wet a diaper in an eight-\\nhour period is dehydrated. The soft spot on the baby’s\\nhead (fontanel) may be depressed. Symptoms of dehy-\\ndration at any age include cracked lips, dry or sticky\\nmouth, lethargy, and sunken eyes. A person who is\\ndehydrated cries without shedding tears and does not\\nurinate very often. The skin is less elastic than it should\\nbe and is slow to return to its normal position after\\nbeing pinched.\\nDehydration can cause confusion, constipation, dis-\\ncomfort, drowsiness, fever, and thirst. The skin turns pale\\nand cold, the mucous membranes lining the mouth and\\nnose lose their natural moisture. The pulse sometimes\\nraces and breathing becomes rapid. Significant fluid loss\\ncan cause serious neurological problems.\\nDiagnosis\\nThe patient’s symptoms and medical history usual-\\nly suggest dehydration. Physical examination may\\nreveal shock, rapid heart rate, and/or low blood pres-\\nsure. Laboratory tests, including blood tests (to check\\nelectrolyte levels) and urine tests (e.g., urine specific\\ngravity and creatinine), are used to evaluate the severi-\\nty of the problem. Other laboratory tests may be\\nordered to determine the underlying condition (such as\\ndiabetes or an adrenal gland disorder) causing the\\ndehydration.\\nTreatment\\nIncreased fluid intake and replacement of lost elec-\\ntrolytes are usually sufficient to restore fluid balances in\\npatients who are mildly or moderately dehydrated. For\\nindividuals who are mildly dehydrated, just drinking\\nplain water may be all the treatment that is needed.\\nAdults who need to replace lost electrolytes may drink\\nsports beverages (e.g., Gatorade or Recharge) or con-\\nsume a little additional salt. Parents should follow label\\ninstructions when giving children Pedialyte or other\\ncommercial products recommended to relieve dehydra-\\ntion. Children who are dehydrated should receive only\\nclear fluids for the first 24 hours.\\nA child who is vomiting should sip one or two tea-\\nspoons of liquid every 10 minutes. A child who is less\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1017\\nDehydration'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 405, 'page_label': '406'}, page_content='KEY TERMS\\nElectrolytes —Mineral salts, such as sodium and\\npotassium, dissolved in body fluid.\\nthan a year old and who is not vomiting should be given\\none tablespoon of liquid every 20 minutes. A child who\\nis more than one year old and who is not vomiting should\\ntake two tablespoons of liquid every 30 minutes. A baby\\nwho is being breast-fed should be given clear liquids for\\ntwo consecutive feedings before breastfeeding is\\nresumed. A bottle-fed baby should be given formula\\ndiluted to half its strength for the first 24 hours after\\ndeveloping symptoms of dehydration.\\nIn order to accurately calculate fluid loss, it’s\\nimportant to chart weight changes every day and keep a\\nrecord of how many times a patient vomits or has diar-\\nrhea. Parents should note how many times a baby’s dia-\\nper must be changed.\\nChildren and adults can gradually return to their\\nnormal diet after they have stopped vomiting and no\\nlonger have diarrhea. Bland foods should be reintro-\\nduced first, with other foods added as the digestive sys-\\ntem is able to tolerate them. Milk, ice cream, cheese,\\nand butter should not be eaten until 72 hours after symp-\\ntoms have disappeared.\\nMedical care\\nSevere dehydration can require hospitalization and\\nintravenous fluid replacement. If an individual’s blood\\npressure drops enough to cause or threaten the develop-\\nment of shock, medical treatment is usually required. A\\ndoctor should be notified whenever an infant or child\\nexhibits signs of dehydration or a parent is concerned\\nthat a stomach virus or other acute illness may lead to\\ndehydration.\\nA doctor should also be notified if:\\n• a child less than three months old develops a fever\\nhigher than 100°F (37.8°C)\\n• a child more than three months old develops a fever\\nhigher than 102°F (38.9°C)\\n• symptoms of dehydration worsen\\n• an individual urinates very sparingly or does not urinate\\nat all during a six-hour period\\n• dizziness, listlessness, or excessive thirst occur\\n• a person who is dieting and using diuretics loses more\\nthan 3 lb (1.3 kg) in a day or more than 5 lb (2.3 kg) a\\nweek\\nWhen treating dehydration, the underlying cause\\nmust also be addressed. For example, if dehydration is\\ncaused by vomiting or diarrhea, medications may be pre-\\nscribed to resolve these symptoms. Patients who are\\ndehydrated due to diabetes, kidney disease, or adrenal\\ngland disorders must receive treatment for these condi-\\ntions as well as for the resulting dehydration.\\nAlternative treatment\\nGelatin water can be substituted for electrolyte-\\nreplacement solutions. It is made by diluting a 3-oz\\npackage in a quart of water or by adding one-quarter\\nteaspoon of salt and a tablespoon of sugar to a pint of\\nwater.\\nPrognosis\\nMild dehydration rarely results in complications. If\\nthe cause is eliminated and lost fluid is replaced, mild\\ndehydration can usually be cured in 24–48 hours.\\nV omiting and diarrhea that continue for several days\\nwithout adequate fluid replacement can be fatal. The risk\\nof life-threatening complications is greater for young\\nchildren and the elderly. However, dehydration that is\\nrapidly recognized and treated has a good outcome.\\nPrevention\\nPatients who are vomiting or who have diarrhea\\ncan prevent dehydration by drinking enough fluid for\\ntheir urine to remain the color of pale straw. Ensuring\\nthat patients always drink adequate fluids during an ill-\\nness will help prevent dehydration. Infants and young\\nchildren with diarrhea and vomiting can be given elec-\\ntrolyte solutions such as Pedialyte to help prevent dehy-\\ndration. People who are not ill can maintain proper\\nfluid balance by drinking several glasses of water\\nbefore going outside on a hot day. It is also a good idea\\nto avoid coffee and tea, which increase body tempera-\\nture and water loss.\\nPatients should know whether any medication they\\nare taking can cause dehydration and should get prompt\\nmedical care to correct any underlying condition that\\nincreases the risk of dehydration.\\nOther methods of preventing dehydration and ensur-\\ning adequate fluid intake include:\\n• eating more soup at mealtime\\n• drinking plenty of water and juice at mealtime and\\nbetween meals\\n• keeping a glass of water nearby when working or relax-\\ning\\nGALE ENCYCLOPEDIA OF MEDICINE 21018\\nDehydration'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 406, 'page_label': '407'}, page_content='Resources\\nBOOKS\\nLarson, David, E., ed. Mayo Clinic Family Health Book.New\\nYork: William Morrow, 1990.\\nOTHER\\n“Dehydration.”HealthAnswers.com. 8 May 1998 .\\n“Dehydration.”Loyola University Health System. 13 May 1998\\n.\\n“Dehydration.”ThriveOnline. 8 May 1998 .\\n“Hydration—Getting Enough Water.” Loyola University\\nHealth System. 13 May 1998 .\\nMaureen Haggerty\\nDelavirdine see Non-nucleoside reverse\\ntranscriptase inhibitors\\nDelayed hypersensitivity \\nskin test\\nDefinition\\nA delayed hypersensitivity test (DHT) is an immune\\nfunction test measuring the presence of activated T cells\\nthat recognize a certain substance.\\nPurpose\\nThe immune system protects against infection by\\nviruses, bacteria, fungi, and parasites. After initial expo-\\nsure to a foreign substance, or antigen, the immune sys-\\ntem creates both antibodies and sensitized T cells. Both\\nthese immune agents respond when the body is reex-\\nposed to the antigen. Antibodies, which are circulating\\nproteins, respond within minutes, to give what is termed\\nan immediate hypersensitivity reaction. T cells’ respons-\\nes occur over several days, and are thus called delayed\\nhypersensitivity reactions. The cascade of events initiat-\\ned by the T cells leads to hardening (induration) and red-\\nness (erythema) at the injection site.\\nA DHT is performed for one of three reasons:\\n• To test for exposure to specific diseases, such as tuber-\\nculosis (TB). Tuberculosis testing is done by injecting\\ninto the skin a small volume of TB antigen, which con-\\ntains no organisms (live or dead) but can still provoke\\nan immune response.\\n• To test for allergic sensitivity to potential skin irritants,\\nsuch as poison ivy. Skin allergy testing is usually done\\nby placing a series of adhesive patches on the skin con-\\ntaining potential allergens, or allergy-causing sub-\\nstances.\\n• To assess the vitality of the T cell response as part of\\nthe evaluation of immune system health in infection,\\ncancer, immune disorders, pre-transplantation screen-\\ning, aging , and malnutrition . DHT can help predict\\nsurvival in immunocompromised patients, and evalu-\\nate the success of restorative therapy. Antigens used\\nfor these tests must be ones the patient has been\\nexposed to before, and, therefore, include inactivated\\nantigens from common infectious agents to which the\\npatient might have been exposed, such as mumps ,\\nCandida albicans , tetanus toxoid, and trichophyton (a\\nskin fungus).\\nPrecautions\\nNo special precautions are necessary for most\\npatients. Those with known hypersensitivity to certain\\nskin irritants should alert the clinician performing the\\ntest. Some commercial preparations of fungal antigens\\ncontain mercury, a source of irritation to some\\npatients.\\nDescription\\nThe most accurate TB test is the Mantoux test, in\\nwhich a small amount of TB antigen is injected into\\nthe skin. The area is examined 48–72 hours after the\\ninjection.\\nIn the patch test, 20–30 adhesive patches are usually\\nplaced on the upper back. The patches are kept in place\\nand the area is kept dry for 48 hours. The patches are\\nthen removed, and the skin is examined 24 hours after-\\nward, and possibly again a day or more following that.\\nPatch testing is usually performed following a patient\\ncomplaint of skin irritation from an unknown substance.\\nTesting may suggest several candidates; identifying the\\nright one requires careful review of the patient’s possi-\\nble exposure.\\nThe test of overall T cell responsiveness is per-\\nformed with several injections. Each area injected is cir-\\ncled and marked. Results are read 48 hours after the\\ninjection.\\nPreparation\\nNo special preparation is necessary.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1019\\nDelayed hypersensitivity skin test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 407, 'page_label': '408'}, page_content='Aftercare\\nPatches should be kept dry. Injection sites may be\\nwashed, but excessive rubbing should be avoided. Patch-\\nes and injection sites may become reddened or irritated.\\nIf a patch causes severe itching or discomfort, the patient\\nshould remove it immediately.\\nRisks\\nDHT is quite safe for virtually all people. There is\\nno risk of infection from the agents injected, since they\\nare purified antigens, not whole organisms. Life threaten-\\ning, hypersensitive reactions ( anaphylaxis ) are a very\\nsmall risk; patients should notify the administering\\nphysician immediately if signs of wheezing, swelling, or\\ndiffuse redness of the skin develops.\\nNormal results\\nAbsence of exposure to TB is indicated by absent or\\nvery little skin reaction; redness or hardness smaller than\\n5 mm (about 0.25 in) is considered normal for a person\\nnot exposed or infected with TB.\\nPatch test sites should be normal or only slightly red.\\nT cell responsiveness tests should be positive; that is,\\nthe injected areas should be reddened and hard. Two affect-\\ned areas of 2 mm or more is considered a positive result.\\nAbnormal results\\nTB exposure is indicated by a reaction of 10 mm or\\nmore. The degree of redness is not important. A 5–10\\nmm area could indicate exposure if there is an underlying\\nrisk to TB.\\nPatch test areas that become reddened and irritated\\nindicate reaction to the substance in the patch.\\nKEY TERMS\\nAllergen —A foreign substance that provokes an\\nimmune reaction in some sensitive people but not\\nin most others.\\nAnaphylaxis —An exaggerated, life-threatening\\nhypersensitivity reaction to a previously encoun-\\ntered antigen.\\nAntibody —An immune system protein made to\\nfight infection.\\nAntigen —A foreign substance detected that pro-\\nvokes an immune reaction.\\nAbsence of any reaction to injected areas indi-\\ncates lack of T cell responsiveness, a condition called\\nanergy. T cell anergy is seen in immune deficiency\\ndiseases including AIDS , some cases of infectious\\ndiseases, malignancies, immunosuppressive therapy\\n(including corticosteroid treatment), some autoim-\\nmune diseases, malnutrition, major surgery, and some\\nviral immunizations.\\nResources\\nBOOKS\\nDavies, R., and S. Ollier. Allergy: The Facts.Oxford University\\nPress, 1989.\\nLawlor Jr., G. J., et. al. Manual of Allergy and Immunology.\\nLittle, Brown and Co., 1995.\\nRichard Robinson\\nDelirium\\nDefinition\\nDelirium is a state of mental confusion that develops\\nquickly and usually fluctuates in intensity.\\nDescription\\nDelirium is a syndrome, or group of symptoms,\\ncaused by a disturbance in the normal functioning of the\\nbrain. The delirious patient has a reduced awareness of\\nand responsiveness to the environment, which may be\\nmanifested as disorientation, incoherence, and memory\\ndisturbance. Delirium is often marked by hallucinations,\\ndelusions, and a dream-like state.\\nDelirium affects at least one in 10 hospitalized\\npatients, and is a common part of many terminal illness-\\nes. Delirium is more common in the elderly than in the\\ngeneral population. While it is not a specific disease\\nitself, patients with delirium usually fare worse than\\nthose with the same illness who do not have delirium.\\nCauses and symptoms\\nCauses\\nThere are a large number of possible causes of delir-\\nium. Metabolic disorders are the single most common\\ncause, accounting for 20–40% of all cases. This type of\\ndelirium, termed “metabolic encephalopathy,” may result\\nfrom organ failure, including liver or kidney failure.\\nOther metabolic causes include diabetes mellitus ,\\nhyperthyroidism and hypothyroidism , vitamin defi-\\nGALE ENCYCLOPEDIA OF MEDICINE 21020\\nDelirium'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 408, 'page_label': '409'}, page_content='ciencies, and imbalances of fluids and electrolytes in the\\nblood. Severe dehydration can also cause delirium.\\nDrug intoxication (“intoxication confusional state”)\\nis responsible for up to 20% of delirium cases, either\\nfrom side effects, overdose, or deliberate ingestion of a\\nmind-altering substance. Medicinal drugs with delirium\\nas a possible side effect or result of overdose include:\\n• anticholinergics, including atropine, scopolamine,\\nchlorpromazine (an antipsychotic), and diphenhy-\\ndramine (an antihistamine)\\n• sedatives, including barbiturates , benzodiazepines ,\\nand ethanol (drinking alcohol)\\n• antidepressant drugs\\n• anticonvulsant drugs\\n• nonsteroidal anti-inflammatory drugs (NSAIDs),\\nincluding ibuprofen and acetaminophen\\n• corticosteroids, including prednisone\\n• anticancer drugs, including methotrexate and procar-\\nbazine\\n• lithium\\n• cimetidine\\n• antibiotics\\n• L-dopa\\nDelirium may result from ingestion of legal or ille-\\ngal psychoactive drugs, including:\\n• ethanol (drinking alcohol)\\n• marijuana\\n•L S D (lysergic acid diethylamide) and other hallucino-\\ngens\\n• amphetamines\\n• cocaine\\n• opiates, including heroin and morphine\\n• PCP (phencyclidine)\\n• inhalants\\nDrug withdrawal may also cause delirium. Delirium\\ntremens, or “DTs,” may occur during alcohol withdrawal\\nafter prolonged or intense consumption. Withdrawal\\nsymptoms are also possible from many of the psychoac-\\ntive prescription drugs.\\nPoisons may cause delirium (“toxic encephalopa-\\nthy”), including:\\n• solvents, such as gasoline, kerosene, turpentine, ben-\\nzene, and alcohols\\n• carbon monoxide\\n• refrigerants (Freon)\\nKEY TERMS\\nDementia—A loss of mental ability severe enough\\nto interfere with functioning. While dementia and\\ndelirium have some of the same symptoms,\\ndementia has a much slower onset.\\nElectroencephalogram (EEG) — A chart of the\\nbrain wave patterns picked up by electrodes\\nplaced on the scalp. This is useful for diagnosing\\ncentral nervous system disorders.\\nEncephalopathy—A brain dysfunction or disorder.\\n• heavy metals, such as lead, mercury, and arsenic\\n• insecticides, such as Parathion and Sevin\\n• mushrooms, such as Amanita species\\n• plants such as jimsonweed ( Datura stramonium ) and\\nmorning glory (Ipomoea spp.)\\n• animal venoms\\nOther causes of delirium include:\\n• infection\\n•fever\\n• head trauma\\n• epilepsy\\n• brain hemorrhage or infarction\\n• brain tumor\\n• low blood oxygen (hypoxemia)\\n•high blood carbon dioxide (hypercapnia)\\n• post-surgical complication.\\nSymptoms\\nThe symptoms of delirium come on quickly, in\\nhours or days, in contrast to those of dementia , which\\ndevelop much more slowly. Delirium symptoms typically\\nfluctuate through the day, with periods of relative calm\\nand lucidity alternating with periods of florid delirium.\\nThe hallmark of delirium is a fluctuating level of con-\\nsciousness. Symptoms may include:\\n• decreased awareness of the environment\\n• confusion or disorientation, especially of time\\n• memory impairment, especially of recent events\\n• hallucinations\\n• illusions and misinterpreted stimuli\\n• increased or decreased activity level\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1021\\nDelirium'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 409, 'page_label': '410'}, page_content='• mood disturbance, possibly including anxiety, eupho-\\nria or depression\\n• language or speech impairment\\nDiagnosis\\nDelirium is diagnosed through the medical history\\nand recognition of symptoms during mental status\\nexamination . The most important part of diagnosis is\\ndetermining the cause of the delirium. Tests may include\\nblood and urine analysis for levels of drugs, fluids, elec-\\ntrolytes, and blood gases, and to test for infection; lum-\\nbar puncture (“spinal tap”) to test for central nervous\\nsystem infection; x ray, computed tomography scans\\n(CT), or magnetic resonance imaging (MRI) scans to\\nlook for tumors, hemorrhage, or other brain abnormali-\\nty; thyroid tests; electroencephalography (EEG); elec-\\ntrocardiography (ECG); and possibly others as dictated\\nby the likely cause.\\nTreatment\\nTreatment of delirium begins with recognizing and\\ntreating the underlying cause. Delirium itself is managed\\nby reducing disturbing stimuli, or providing soothing\\nones; use of simple, clear language in communication;\\nand reassurance, especially from family members. Physi-\\ncal restraints may be needed if the patient is a danger to\\nhimself or others, or if he insists on removing necessary\\nmedical equipment such as intravenous lines or monitors.\\nSedatives or antipsychotic drugs may be used to reduce\\nanxiety, hallucinations, and delusions.\\nPrognosis\\nPersons with delirium usually have a worse prog-\\nnosis for the underlying disease than the person with-\\nout delirium. Nonetheless, those without terminal ill-\\nness usually recover from delirium. They may not,\\nhowever, regain all their original cognitive abilities,\\nand may be left with some permanent impairments,\\nincluding fatigue , irritability, difficulty concentrating,\\nor mood changes.\\nPrevention\\nPrevention of delirium is focused on treating or\\navoiding its underlying causes. The most preventable\\nforms are those induced by drugs. Strategies for reducing\\ndelirium include following prescriptions, consulting the\\nprescribing physician immediately if symptoms occur,\\nand consulting the physician before discontinuing the\\ndrug, even if it has been ineffective; avoiding intoxica-\\ntion with legal or illegal drugs, and seeking professional\\nassistance before suddenly discontinuing an addictive\\ndrug such as alcohol or heroin; maintaining good nutri-\\ntion, which promotes general health and can minimize\\nthe likelihood of delirium from alcohol intoxication and\\nwithdrawal; and avoiding exposure to solvents, insecti-\\ncides, heavy metals, or biological poisons in the home or\\nworkplace.\\nResources\\nBOOKS\\nGuze, Samuel, ed. Adult Psychiatry. Mosby Year Book, 1997.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nRichard Robinson\\nDelta virus hepatitis see Hepatitis D\\nDelusions\\nDefinition\\nA delusion is an unshakable belief in something\\nuntrue. These irrational beliefs defy normal reasoning,\\nand remain firm even when overwhelming proof is pre-\\nsented to dispute them. Delusions are often accompanied\\nby hallucinations and/or feelings of paranoia , which\\nact to strengthen confidence in the delusion. Delusions\\nare distinct from culturally or religiously based beliefs\\nthat may be seen as untrue by outsiders.\\nDescription\\nDelusions are a common symptom of several mood\\nand personality-related mental illnesses, including\\nschizoaffective disorder , schizophrenia , shared psy-\\nchotic disorder, major depressive disorder, and bipolar\\ndisorder . They are also the major feature of delusional\\ndisorder. Individuals with delusional disorder suffer\\nfrom long-term, complex delusions that fall into one of\\nsix categories: persecutory, grandiose, jealousy, ero-\\ntomanic, somatic, or mixed. There are also delusional\\ndisorders such as dementia that clearly have organic or\\nphysical causes.\\nPersecutory\\nIndividuals with persecutory delusional disorder are\\nplagued by feelings of paranoia and an irrational yet\\nunshakable belief that someone is plotting against them,\\nor out to harm them.\\nGALE ENCYCLOPEDIA OF MEDICINE 21022\\nDelusions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 410, 'page_label': '411'}, page_content='Grandiose\\nIndividuals with grandiose delusional disorder have\\nan over-inflated sense of self-worth. Their delusions cen-\\nter on their own importance, such as believing that they\\nhave done or created something of extreme value or have\\na “special mission.”\\nJealousy\\nJealous delusions are unjustified and irrational\\nbeliefs that an individual’s spouse or significant other has\\nbeen unfaithful.\\nErotomanic\\nIndividuals with erotomanic delusional disorder\\nbelieve that another person, often a stranger, is in love\\nwith them. The object of their affection is typically of a\\nhigher social status, sometimes a celebrity. This type of\\ndelusional disorder may lead to stalking or other poten-\\ntially dangerous behavior.\\nSomatic\\nSomatic delusions involve the belief that something\\nis physically wrong with the individual. The delusion\\nmay involve a medical condition or illness or a perceived\\ndeformity. This condition differs from hypochondriasis\\nin that the deformity is perceived as a fixed condition not\\na temporary illness.\\nMixed\\nMixed delusions are those characterized by two or\\nmore of persecutory, grandiose, jealousy, erotomanic, or\\nsomatic themes.\\nCauses and symptoms\\nSome studies have indicated that delusions may be\\ngenerated by abnormalities in the limbic system, the por-\\ntion of the brain on the inner edge of the cerebral cortex\\nthat is believed to regulate emotions. The exact source of\\ndelusions has not been conclusively found, but potential\\ncauses include genetics, neurological abnormalities, and\\nchanges in brain chemistry. Delusions are also a known\\npossible side effect of drug use and abuse (e.g., ampheta-\\nmines, cocaine, PCP).\\nDiagnosis\\nPatients with delusional symptoms should undergo a\\nthorough physical examination and patient history to\\nrule out possible organic causes (such as dementia). If a\\npsychological cause is suspected, a mental health profes-\\nsional will typically conduct an interview with the\\nKEY TERMS\\nHallucinations—False or distorted sensory experi-\\nences that appear to be real perceptions.\\nParanoia—An unfounded or exaggerated distrust\\nof others.\\nShared psychotic disorder—Also known as folie à\\ndeux; shared psychotic disorder is an uncommon\\ndisorder in which the same delusion is shared by\\ntwo or more individuals.\\npatient and administer one of several clinical inventories,\\nor tests, to evaluate mental status.\\nTreatment\\nDelusions that are symptomatic of delusional disor-\\nder should be treated by a psychologist and/or psychia-\\ntrist. Though antipsychotic drugs are often not effec-\\ntive, antipsychotic medication such as thioridazine (Mel-\\nlaril), haloperidol (Haldol), chlorpromazine (Thorazine),\\nclozapine (Clozaril), or risperidone (Risperdal) may be\\nprescribed, and cognitive therapy or psychotherapy may\\nbe attempted.\\nIf an underlying condition such as schizophrenia,\\ndepression, or drug abuse is found to be triggering the\\ndelusions, an appropriate course of medication and/or\\npsychosocial therapy is employed to treat the primary\\ndisorder. The medication, typically, will include an\\nantipsychotic agent.\\nPrognosis\\nDelusional disorder is typically a chronic condition,\\nbut with appropriate treatment, a remission of delusional\\nsymptoms occurs in up to 50% of patients. However,\\nbecause of their strong belief in the reality of their delu-\\nsions and a lack of insight into their condition, individuals\\nwith this disorder may never seek treatment, or may be\\nresistant to exploring their condition in psychotherapy.\\nResources\\nBOOKS\\nAmerican Psychiatric Association. Diagnostic and Statistical\\nManual of Mental Disorders. 4th ed. Washington, DC:\\nAmerican Psychiatric Press, Inc., 1994.\\nMaxmen, Jerrold S., and Nicholas G. Ward. “Schizophrenia\\nand Related Disorders.” In Essential Psychopathology and\\nIts Treatment.2nd ed. New York: W. W. Norton, 1995.\\nSiegel, Ronald K. Whispers: The Voices of Paranoia.New\\nYork: Crown, 1994.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1023\\nDelusions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 411, 'page_label': '412'}, page_content='PERIODICALS\\nManschreck, Theo C. “Delusional Disorder: The Recognition\\nand Management of Paranoia.”Journal of Clinical Psy-\\nchiatry 57, supplement 3 (1996): 32-38.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW, Washing-\\nton DC 20005. (888) 357-7924. .\\nAmerican Psychological Association (APA). 750 First St. NE,\\nWashington, DC 20002-4242. (202) 336-5700. .\\nNational Alliance for the Mentally Ill (NAMI). Colonial Place\\nThree, 2107 Wilson Blvd., Ste. 300, Arlington, V A 22201-\\n3042. (800) 950-6264. .\\nNational Institutes of Mental Health (NIMH). 6001 Executive\\nBoulevard, Rm. 8184, MSC 9663\\nPaula Anne Ford-Martin\\nDementia\\nDefinition\\nDementia is a loss of mental ability severe enough to\\ninterfere with normal activities of daily living, lasting\\nmore than six months, not present since birth, and not\\nassociated with a loss or alteration of consciousness.\\nDescription\\nDementia is a group of symptoms caused by gradual\\ndeath of brain cells. The loss of cognitive abilities that\\noccurs with dementia leads to impairments in memory,\\nreasoning, planning, and personality. While the over-\\nwhelming number of people with dementia are elderly, it\\nis not an inevitable part of aging. Instead, dementia is\\ncaused by specific brain diseases. Alzheimer’s disease\\n(AD) is the most common cause, followed by vascular or\\nmulti-infarct dementia.\\nThe prevalence of dementia has been difficult to\\ndetermine, partly because of differences in definition\\namong different studies, and partly because there is some\\nnormal decline in functional ability with age. Dementia\\naffects 5–8% of all people between ages 65 and 74, and\\nup to 20% of those between 75 and 84. Estimates for\\ndementia in those 85 and over range from 30–47%.\\nBetween two and four million Americans have AD; that\\nnumber is expected to grow to as many as 14 million by\\nthe middle of the twenty-first century as the population\\nas a whole ages.\\nThe cost of dementia can be considerable. While\\nmost people with dementia are retired and do not suffer\\nincome losses from their disease, the cost of care is often\\nenormous. Financial burdens include lost wages for fam-\\nily caregivers, medical supplies and drugs, and home\\nmodifications to ensure safety. Nursing home care may\\ncost several thousand dollars a month or more. The psy-\\nchological cost is not as easily quantifiable but can be\\neven more profound. The person with dementia loses\\ncontrol of many of the essential features of his life and\\npersonality, and loved ones lose a family member even as\\nthey continue to cope with the burdens of increasing\\ndependence and unpredictability.\\nCauses and symptoms\\nCauses\\nDementia is usually caused by degeneration in the\\ncerebral cortex, the part of the brain responsible for\\nthoughts, memories, actions and personality. Death of\\nbrain cells in this region leads to the cognitive impair-\\nment which characterizes dementia.\\nThe most common cause of dementia is AD,\\naccounting for half to three quarters of all cases. The\\nbrain of a person with AD becomes clogged with two\\nabnormal structures, called neurofibrillary tangles and\\nsenile plaques. Neurofibrillary tangles are twisted masses\\nof protein fibers inside nerve cells, or neurons. Senile\\nplaques are composed of parts of neurons surrounding a\\ngroup of proteins called beta-amyloid deposits. Why\\nthese structures develop is unknown. Current research\\nindicates possible roles for inflammation, blood flow\\nrestriction, and toxic molecular fragments known as free\\nradicals. Several genes have been associated with higher\\nincidences of AD, although the exact role of these genes\\nis still unknown.\\nVascular dementia is estimated to cause from 5–30%\\nof all dementias. It occurs from decrease in blood flow to\\nthe brain, most commonly due to a series of small strokes\\n(multi-infarct dementia). Other cerebrovascular causes\\ninclude: vasculitis from syphilis, Lyme disease, or sys-\\ntemic lupus erythematosus ; subdural hematoma; and\\nsubarachnoid hemorrhage. Because of the usually sud-\\nden nature of its cause, the symptoms of vascular demen-\\ntia tend to begin more abruptly than those of Alzheimer’s\\ndementia. Symptoms may progress stepwise with the\\noccurrence of new strokes. Unlike AD, the incidence of\\nvascular dementia is lower after age 75.\\nOther conditions which may cause dementia\\ninclude:\\n• AIDS\\n• Parkinson’s disease\\n• Lewy body disease\\n• Pick’s disease\\nGALE ENCYCLOPEDIA OF MEDICINE 21024\\nDementia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 412, 'page_label': '413'}, page_content='• Huntington’s disease\\n• Creutzfeldt-Jakob disease\\n• brain tumor\\n•hydrocephalus\\n• head trauma\\n• multiple sclerosis\\n• prolonged abuse of alcohol or other drugs\\n• vitamin deficiency: thiamin, niacin, or B\\n12\\n• hypothyroidism\\n• hypercalcemia\\nSymptoms\\nDementia is marked by a gradual impoverishment of\\nthought and other mental activities. Losses eventually\\naffect virtually every aspect of mental life. The slow pro-\\ngression of dementia is in contrast with delirium, which\\ninvolves some of the same symptoms, but has a very\\nrapid onset and fluctuating course with alteration in the\\nlevel of consciousness. However, delirium may occur\\nwith dementia, especially since the person with dementia\\nis more susceptible to the delirium-inducing effects of\\nmay types of drugs.\\nSymptoms include:\\n• Memory losses. Memory loss is usually the first symp-\\ntom noticed. It may begin with misplacing valuables\\nsuch as a wallet or car keys, then progress to forgetting\\nappointments, where the car was left, and the route\\nhome, for instance. More profound losses follow, such\\nas forgetting the names and faces of family members.\\n• Impaired abstraction and planning. The person with\\ndementia may lose the ability to perform familiar tasks, to\\nplan activities, and to draw simple conclusions from facts.\\n• Language and comprehension disturbances. The person\\nmay be unable to understand instructions, or follow the\\nlogic of moderately complex sentences. Later, he or she\\nmay not understand his or her own sentences, and have\\ndifficulty forming thoughts into words.\\n• Poor judgment. The person may not recognize the con-\\nsequences of his or her actions or be able to evaluate the\\nappropriateness of behavior. Behavior may become rib-\\nald, overly-friendly, or aggressive. Personal hygiene\\nmay be ignored.\\n• Impaired orientation ability. The person may not be\\nable to identify the time of day, even from obvious\\nvisual clues; or may not recognize his or her location,\\neven if familiar. This disability may stem partly from\\nlosses of memory and partly from impaired abstraction.\\n• Decreased attention and increased restlessness. This\\nmay cause the person with dementia to begin an activity\\nand quickly lose interest, and to wander frequently.\\nWandering may cause significant safety problems, when\\ncombined with disorientation and memory losses. The\\nperson may begin to cook something on the stove, then\\nbecome distracted and wander away while it is cooking.\\n• Personality changes and psychosis . The person may\\nlose interest in once-pleasurable activities, and become\\nmore passive, depressed, or anxious. Delusions, suspi-\\ncion, paranoia, and hallucinations may occur later in\\nthe disease. Sleep disturbances may occur, including\\ninsomnia and sleep interruptions.\\nDiagnosis\\nSince dementia usually progresses slowly, diagnos-\\ning it in its early stages can be difficult. Several office\\nvisits over several months or more may be needed. Diag-\\nnosis begins with a thorough physical exam and com-\\nplete medical history, usually including comments from\\nfamily members or caregivers. A family history of either\\nAD or cerebrovascular disease may provide clues to the\\ncause of symptoms. Simple tests of mental function,\\nincluding word recall, object naming, and number-sym-\\nbol matching, are used to track changes in the person’s\\ncognitive ability.\\nDepression is common in the elderly and can be\\nmistaken for dementia; therefore, ruling out depression is\\nan important part of the diagnosis. Distinguishing\\ndementia from the mild normal cognitive decline of\\nadvanced age is also critical. The medical history\\nincludes a complete listing of drugs being taken, since a\\nnumber of drugs can cause dementia-like symptoms.\\nDetermining the cause of dementia may require a\\nvariety of medical tests, chosen to match the most likely\\netiology. Cerebrovascular disease, hydrocephalus, and\\ntumors may be diagnosed with x-rays, CT or MRI scans,\\nand vascular imaging studies. Blood tests may reveal\\nnutritional deficiencies or hormone imbalances.\\nTreatment\\nTreatment of dementia begins with treatment of\\nthe underlying disease, where possible. The underlying\\ncauses of nutritional, hormonal, tumor-caused and\\ndrug-related dementias may be reversible to some\\nextent. Treatment for stroke-related dementia begins\\nby minimizing the risk of further strokes, through\\nsmoking cessation, aspirin therapy, and treatment of\\nhypertension , for instance. There are no therapies that\\ncan reverse the progression of AD. Aspirin, estrogen,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1025\\nDementia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 413, 'page_label': '414'}, page_content='vitamin E, and selegiline are currently being evaluated\\nfor their ability to slow the rate of progression.\\nCare for a person with dementia can be difficult and\\ncomplex. The patient must learn to cope with functional\\nand cognitive limitations, while family members or other\\ncaregivers assume increasing responsibility for the per-\\nson’s physical needs. In progressive dementias such as\\nAD, the person may ultimately become completely\\ndependent. Education of the patient and family early on\\nin the disease progression can help them anticipate and\\nplan for inevitable changes.\\nSymptoms of dementia may be treated with a com-\\nbination of psychotherapy, environmental modifications,\\nand medication. Drug therapy can be complicated by for-\\ngetfulness, especially if the prescribed drug must be\\ntaken several times daily.\\nBehavioral approaches may be used to reduce the\\nfrequency or severity of problem behaviors, such as\\naggression or socially inappropriate conduct. Problem\\nbehavior may be a reaction to frustration or overstimula-\\ntion; understanding and modifying the situations that\\ntrigger it can be effective. Strategies may include break-\\ning down complex tasks, such as dressing or feeding,\\ninto simpler steps, or reducing the amount of activity in\\nthe environment to avoid confusion and agitation. Plea-\\nsurable activities, such as crafts, games, and music, can\\nprovide therapeutic stimulation and improve mood.\\nModifying the environment can increase safety and\\ncomfort while decreasing agitation. Home modifications\\nfor safety include removal or lock-up of hazards such as\\nsharp knives, dangerous chemicals, and tools. Child-\\nproof latches or Dutch doors may be used to limit access\\nas well. Lowering the hot water temperature to 120°F\\n(48.9°C) or less reduces the risk of scalding. Bed rails\\nand bathroom safety rails can be important safety mea-\\nsures, as well. Confusion may be reduced with simpler\\ndecorative schemes and presence of familiar objects.\\nCovering or disguising doors (with a mural, for example)\\nmay reduce the tendency to wander. Positioning the bed\\nin view of the bathroom can decrease incontinence.\\nTwo drugs, tacrine (Cognex) and donepezil (Ari-\\ncept), are commonly prescribed for AD. These drugs\\ninhibit the breakdown of acetylcholine in the brain, pro-\\nlonging its ability to conduct chemical messages between\\nbrain cells. They provide temporary improvement in cog-\\nnitive functions for about 40% of patients with mild to\\nmoderate AD. Hydergine is sometimes prescribed as\\nwell, though it is of questionable benefit for most\\npatients.\\nPsychotic symptoms, including paranoia, delusions,\\nand hallucinations, may be treated with antipsychotic\\ndrugs, such as haloperidol, chlorpromazine, risperidone,\\nand clozapine. Side effects of these drugs can be signifi-\\ncant. Antianxiety drugs such as Valium may improve\\nbehavioral symptoms, especially agitation and anxiety,\\nalthough BuSpar has fewer side effects. The anticonvul-\\nsant carbamazepine is also sometimes prescribed for agi-\\ntation. Depression is treated with antidepressants, usually\\nbeginning with selective serotonin reuptake inhibitors\\n(SSRIs) such as Prozac or Paxil, followed by\\nmonoamine oxidase inhibitors or tricyclic antidepres-\\nsants. Electroconvulsive therapymay be appropriate for\\nsome patients with severe depression who are unrespon-\\nsive to drug therapy. In general, medications should be\\nadministered very cautiously to demented patients, in the\\nlowest possible effective doses, to minimize side effects.\\nSupervision of taking medications is generally required.\\nLong-term institutional care may be needed for the\\nperson with dementia, as profound cognitive losses often\\nprecede death by a number of years. Early planning for\\nthe financial burden of nursing home care is critical. Use-\\nful information about financial planning for long-term\\ncare is available through the Alzheimer’s Association.\\nFamily members or others caring for a person with\\ndementia are often subject to extreme stress, and may\\ndevelop feelings of anger, resentment, guilt, and hopeless-\\nness, in addition to the sorrow they feel for their loved one\\nand for themselves. Depression is an extremely common\\nconsequence of being a full-time caregiver for a person\\nwith dementia. Support groups can be an important way\\nto deal with the stress of caregiving. The location and\\ncontact numbers for caregiver support groups are avail-\\nable from the Alzheimer’s Association; they may also be\\navailable through a local social service agency or the\\npatient’s physician. Medical treatment for depression may\\nbe an important adjunct to group support.\\nAlternative treatment\\nSeveral drugs are currently being tested for their\\nability to slow the progress of AD. These include\\nacetyl-l-carnitine, which acts on the cellular energy\\nstructures known as mitochondria; propentofylline,\\nwhich may aid circulation; milameline, which acts sim-\\nilarly to tacrine and donezepil; and ginkgo extract.\\nGinkgo extract, derived from the leaves of the Gink-\\ngo biloba tree, interferes with a circulatory protein called\\nplatelet activating factor. It also increases circulation and\\noxygenation to the brain. Ginkgo extract has been used\\nfor many years in China and is widely prescribed in\\nEurope for treatment of circulatory problems. A 1997\\nstudy of patients with dementia seemed to show that\\ngingko extract could improve their symptoms, though the\\nstudy was criticized for certain flaws in its method.\\nGALE ENCYCLOPEDIA OF MEDICINE 21026\\nDementia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 414, 'page_label': '415'}, page_content='Prognosis\\nThe prognosis for dementia depends on the underly-\\ning disease. On average, people with Alzheimer’s disease\\nlive eight years past their diagnosis, with a range from\\none to 20 years. Vascular dementia is usually progressive,\\nwith death from stroke, infection, or heart disease.\\nPrevention\\nThere is no known way to prevent Alzheimer’s dis-\\nease, although several of the drugs under investigation\\nmay reduce its risk or slow its progression. The risk of\\ndeveloping multi-infarct dementia may be reduced by\\nreducing the risk of stroke.\\nResources\\nBOOKS\\nJacques, Alan. Understanding Dementia. New York: Churchill\\nLivingstone, 1992.\\nMace, Nancy L., and Peter V . Rabins. The 36-Hour Day. Balti-\\nmore: John Hopkins University Press, 1995.\\nORGANIZATIONS\\nAlzheimer’s Association. 919 North Michigan Ave., Suite 1000,\\nChicago, IL 60611. (800) 272-3900. .\\nRichard Robinson\\nKEY TERMS\\nDonepezil—A drug commonly prescribed for\\nAlzheimer’s disease that provides temporary\\nimprovement in cognitive functions for some\\npatients with mild-to-moderate forms of the disease.\\nGinkgo extract —Made from the leaves of the\\nGinkgo biloba tree, this extract, used in other\\ncountries to treat circulatory problems, may\\nimprove the symptoms of patients with dementia.\\nNeurofibrillary tangles —Abnormal structures,\\ncomposed of twisted masses of protein fibers with-\\nin nerve cells, found in the brains of persons with\\nAlzheimer’s disease.\\nSenile plaques —Abnormal structures, composed\\nof parts of nerve cells surrounding protein\\ndeposits, found in the brains of persons with\\nAlzheimer’s disease.\\nTacrine—A drug commonly prescribed for Alz-\\nheimer’s disease that provides temporary improve-\\nment in cognitive functions for some patients with\\nmild-to-moderate forms of the disease.\\nDemyelinating disease see Multiple sclerosis\\nDengue fever\\nDefinition\\nDengue fever is a disease caused by one of a number\\nof viruses that are carried by mosquitoes. These mosqui-\\ntoes then transmit the virus to humans.\\nDescription\\nThe virus that causes dengue fever is called an\\narbovirus, which stands for arthropod-borne virus. Mos-\\nquitoes are a type of arthropod. In a number of regions,\\nmosquitoes carry this virus and are responsible for pass-\\ning it along to humans. These regions include the Middle\\nEast, the far East, Africa, and the Caribbean Islands. In\\nthese locations, the dengue fever arbovirus is endemic,\\nmeaning that the virus naturally and consistently lives in\\nthat location. The disease only shows up in the United\\nStates sporadically.\\nIn order to understand how dengue fever is transmit-\\nted, several terms need to be defined. The word “host”\\nmeans an animal (including a human) that can be infect-\\ned with a particular disease. The word “vector” means an\\norganism that can carry a particular disease-causing\\nagent (like a virus or bacteria) without actually develop-\\ning the disease. The vector can then pass the virus or bac-\\nteria on to a new host.\\nMany of the common illnesses in the United States\\n(including the common cold, many viral causes of diar-\\nrhea, and influenza or “flu”) are spread because the\\nviruses that cause these illness can be passed directly\\nfrom person to person. However, dengue fever cannot be\\npassed directly from one infected person to another.\\nInstead, the virus responsible for dengue fever requires\\nan intermediate vector, a mosquito, that carries the virus\\nfrom one host to another. The mosquito that carries the\\narbovirus responsible for dengue fever is the same type\\nof mosquito that can transmit other diseases, including\\nyellow fever. This mosquito is called Aedes egypti. The\\nmost common victims are children younger than 10 years\\nof age.\\nCauses and symptoms\\nDengue fever can occur when a mosquito carrying\\nthe arbovirus bites a human, passing the virus on to the\\nnew host. Once in the body, the virus travels to various\\nglands where it multiplies. The virus can then enter the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1027\\nDengue fever'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 415, 'page_label': '416'}, page_content='bloodstream. The presence of the virus within the blood\\nvessels, especially those feeding the skin, causes changes\\nto these blood vessels. The vessels swell and leak. The\\nspleen and lymph nodes become enlarged, and patches of\\nliver tissue die. A process called disseminated intravascu-\\nlar coagulation (DIC) occurs, where chemicals responsi-\\nble for clotting are used up and lead to a risk of severe\\nbleeding (hemorrhage).\\nAfter the virus has been transmitted to the human\\nhost, a period of incubation occurs. During this time (last-\\ning about five to eight days) the virus multiplies. Symp-\\ntoms of the disease appear suddenly and include high\\nfever, chills, headache, eye pain, red eyes, enlarged\\nlymph nodes, a red flush to the face, lower back pain,\\nextreme weakness, and severe aches in the legs and joints.\\nThis initial period of illness lasts about two–three\\ndays. After this time, the fever drops rapidly and the\\npatient sweats heavily. After about a day of feeling rela-\\ntively well, the patient’s temperature increases again,\\nalthough not as much as the first time. A rash of small\\nred bumps begins on the arms and legs, spreading to the\\nchest, abdomen, and back. It rarely affects the face. The\\npalms of the hands and the soles of the feet become\\nswollen and turn bright red. The characteristic combina-\\ntion of fever, rash, and headache are called the “dengue\\ntriad.” Most people recover fully from dengue fever,\\nalthough weakness and fatigue may last for several\\nweeks. Once a person has been infected with dengue\\nfever, his or her immune system keeps producing cells\\nthat prevent reinfection for about a year.\\nMore severe illness may occur in some people.\\nThese people may be experiencing dengue fever for the\\nfirst time. However, in some cases a person may have\\nalready had dengue fever at one time, recovered, and\\nthen is reinfected with the virus. In these cases, the first\\ninfection teaches the immune system to recognize the\\npresence of the arbovirus. When the immune cells\\nencounter the virus during later infections, the immune\\nsystem over-reacts. These types of illnesses, called\\ndengue hemorrhagic fever (DHF) or dengue shock syn-\\ndrome (DSS), involve more severe symptoms. Fever and\\nheadache are the first symptoms, but the other initial\\nsymptoms of dengue fever are absent. The patient devel-\\nops a cough, followed by the appearance of small pur-\\nplish spots (petechiae) on the skin. These petechiae are\\nareas where blood is leaking out of the vessels. Large\\nbruised areas appear as the bleeding worsens and abdom-\\ninal pain may be severe. The patient may begin to vomit\\na substance that looks like coffee grounds. This is actual-\\nly a sign of bleeding into the stomach. As the blood ves-\\nsels become more damaged, they leak more and continue\\nto increase in diameter (dilate), causing a decrease in\\nblood flow to all tissues of the body. This state of low\\nblood flow is called shock. Shock can result in damage to\\nthe body’s organs (especially the heart and kidneys)\\nbecause low blood flow deprives them of oxygen.\\nDiagnosis\\nDiagnosis should be suspected in endemic areas when-\\never a high fever goes on for two to seven days, especially if\\naccompanied by a bleeding tendency. Symptoms of shock\\nshould suggest the progression of the disease to DSS.\\nThe arbovirus causing dengue fever is one of the few\\ntypes of arbovirus that can be isolated from the serum of\\nthe blood. The serum is the fluid in which blood cells are\\nsuspended. Serum can be tested because the phase in\\nwhich the virus travels throughout the bloodstream is\\nlonger in dengue fever than in other arboviral infections.\\nA number of tests are used to look for reactions between\\nthe patient’s serum and laboratory-produced antibodies.\\nAntibodies are special cells that recognize the markers\\n(or antigens) present on invading organisms. During\\nthese tests, antibodies are added to a sample of the\\npatient’s serum. Healthcare workers then look for reac-\\ntions that would only occur if viral antigens were present\\nin that serum.\\nTreatment\\nThere is no treatment available to shorten the course\\nof dengue fever, DHF, or DSS. Medications can be given\\nto lower the fever and to decrease the pain of muscle\\naches and headaches. Fluids are given through a needle\\nin a vein to prevent dehydration . Blood transfusions\\nmay be necessary if severe hemorrhaging occurs. Oxy-\\ngen should be administered to patients in shock.\\nPrognosis\\nThe prognosis for uncomplicated dengue fever is\\nvery good, and almost 100% of patients fully recover.\\nHowever, as many as 6–30% of all patients die when\\nDHF occurs. The death rate is especially high among the\\nyoungest patients (under one year old). In places where\\nexcellent medical care is available, very close monitoring\\nand immediate treatment of complications lowers the\\ndeath rate among DHF and DSS patients to about 1%.\\nPrevention\\nPrevention of dengue fever means decreasing the\\nmosquito population. Any sources of standing water\\n(buckets, vases, etc.) where the mosquitoes can breed\\nmust be eliminated. Mosquito repellant is recommended\\nfor those areas where dengue fever is endemic. To help\\nbreak the cycle of transmission, sick patients should be\\nGALE ENCYCLOPEDIA OF MEDICINE 21028\\nDengue fever'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 416, 'page_label': '417'}, page_content='placed in bed nets so that mosquitoes cannot bite them\\nand become arboviral vectors.\\nResources\\nBOOKS\\nDouglas, R. Gordon. “Other Arthropod-Borne Viruses.” In\\nCecil Textbook of Medicine, ed. J. Claude Bennett and\\nFred Plum. Philadelphia: W. B. Saunders Co., 1996.\\nRay, C. George. “Arthropod-Borne and Other Zoonotic Virus-\\nes.” In Sherris Medical Microbiology: An Introduction to\\nInfectious Diseases. 3rd ed. Ed. Kenneth J. Ryan. Nor-\\nwalk, CT: Appleton & Lange, 1994.\\nPERIODICALS\\nFarley, Dixie. “Treating Tropical Diseases.”FDA Consumer\\n(Jan./Feb. 1997): 26+.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nRosalyn Carson-DeWitt, MD\\nDental caries see Tooth decay\\nDental cavity see Tooth decay\\nDental hygiene see Oral hygiene\\nDental injuries see Dental trauma\\nDental trauma\\nDefinition\\nDental trauma is injury to the mouth, including\\nteeth, lips, gums, tongue, and jawbones. The most com-\\nmon dental trauma is a broken or lost tooth.\\nKEY TERMS\\nEndemic—Naturally and consistently present in a\\ncertain geographical region.\\nHost—The organism (such as a monkey or human)\\nin which another organism (such as a virus or bac-\\nteria) is living.\\nVector—A carrier organism (such as a fly or mos-\\nquito) that delivers a virus (or other agent of infec-\\ntion) to a host.\\nDescription\\nDental trauma may be inflicted in a number of ways:\\ncontact sports, motor vehicle accidents, fights, falls, eat-\\ning hard foods, drinking hot liquids, and other such\\nmishaps. As oral tissues are highly sensitive, injuries to\\nthe mouth are typically very painful. Dental trauma\\nshould receive prompt treatment from a dentist.\\nCauses and symptoms\\nSoft tissue injuries, such as a “fat lip,” a burned\\ntongue, or a cut inside the cheek, are characterized by\\npain, redness, and swelling with or without bleeding. A\\nbroken tooth often has a sharp edge that may cut the\\ntongue and cheek. Depending on the position of the frac-\\nture, the tooth may or may not cause toothache pain.\\nWhen a tooth is knocked out (evulsed), the socket is\\nswollen, painful, and bloody. A jawbone may be broken\\nif the upper and lower teeth no longer fit together proper-\\nly (malocclusion ), or if the jaws have pain with limited\\nability to open and close (mobility), especially around\\nthe temporomandibular joint (TMJ).\\nDiagnosis\\nDental trauma is readily apparent upon examination.\\nDental x rays may be taken to determine the extent of the\\ndamage to broken teeth. More comprehensive x rays are\\nneeded to diagnose a broken jaw.\\nTreatment\\nSoft tissue injuries may require only cold compress-\\nes to reduce swelling. Bleeding may be controlled with\\ndirect pressure applied with clean gauze. Deep lacera-\\ntions and punctures may require stitches. Pain may be\\nmanaged with aspirin or acetaminophen (Tylenol,\\nAspirin Free Excedrin) or ibuprofen (Motrin, Advil).\\nTreatment of a broken tooth will vary depending on\\nthe severity of the fracture. For immediate first aid, the\\ninjured tooth and surrounding area should be rinsed gen-\\ntly with warm water to remove dirt, then covered with a\\ncold compress to reduce swelling and ease pain. A dentist\\nshould examine the injury as soon as possible. Any pieces\\nfrom the broken tooth should be saved and brought along.\\nIf a piece of the outer tooth has chipped off, but the\\ninner core (pulp) is undisturbed, the dentist may simply\\nsmooth the rough edges or replace the missing section\\nwith a small composite filling. In some cases, a fragment\\nof broken tooth may be bonded back into place. If\\nenough tooth is missing to compromise the entire tooth\\nstructure, but the pulp is not permanently damaged, the\\ntooth will require a protective coverage with a gold or\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1029\\nDental trauma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 417, 'page_label': '418'}, page_content='KEY TERMS\\nCrown—1 The natural part of the tooth covered by\\nenamel. 2 A restorative crown is a protective shell\\nthat fits over a tooth.\\nEruption—The process of a tooth breaking through\\nthe gum tissue to grow into place in the mouth.\\nEvulsion —The forceful, and usually accidental,\\nremoval of a tooth from its socket in the bone.\\nExtraction—The surgical removal of a tooth from\\nits socket in the bone.\\nMalocclusion —A problem in the way the upper\\nand lower teeth fit together in biting or chewing.\\nPulp—The soft innermost layer of a tooth contain-\\ning blood vessels and nerves.\\nRoot canal treatment —The process of removing\\ndiseased or damaged pulp from a tooth, then fill-\\ning and sealing the pulp chamber and root canals.\\nTemporomandibular joint (TMJ) —The jaw joint\\nformed by the mandible (lower jaw bone) moving\\nagainst the temporal (temple and side) bone of the\\nskull.\\nporcelain crown. If the pulp has been seriously damaged,\\nthe tooth will require root canal treatment before it\\nreceives a crown. A tooth that is vertically fractured or\\nfractured below the gumline will require root canal treat-\\nment and protective restoration. A tooth which no longer\\nhas enough remaining structure to retain a crown may\\nhave to be extracted (surgically removed).\\nWhen a permanent tooth has been knocked out, it\\nmay be saved with prompt action. The tooth must be\\nfound immediately after it has been lost. It should be\\npicked up by the natural crown (the top part covered by\\nhard enamel). It must not be handled by the root. If the\\ntooth is dirty, it may be gently rinsed under running\\nwater. It should never be scrubbed, and it should never be\\nwashed with soap, toothpaste, mouthwash, or other\\nchemicals. The tooth should not be dried or wrapped in a\\ntissue or cloth. It must be kept moist at all times.\\nThe tooth may be placed in a clean container of\\nmilk, cool water with or without a pinch of salt, or in\\nsaliva. If possible, the patient and the tooth should be\\nbrought to the dentist within 30 minutes of the tooth\\nloss. Rapid action improves the chances of successful\\nre-implantation; however, it is possible to save a tooth\\nafter 30 minutes, if the tooth has been kept moist and\\nhandled properly.\\nThe body usually rejects re-implantation of a prima-\\nry (baby) tooth. In this case, the empty socket is treated\\nas a soft tissue injury and monitored until the permanent\\ntooth erupts.\\nA broken jaw must be set back into its proper posi-\\ntion and stabilized with wires while it heals. Healing may\\ntake six weeks or longer, depending on the patient’s age\\nand the severity of the fracture.\\nAlternative treatment\\nThere is no substitute for treatment by a dentist or\\nother medical professional. There are, however, homeo-\\npathic remedies and herbs that can be used simultaneous-\\nly with dental care and throughout the healing process.\\nHomeopathic arnica (Arnica montana) should be taken as\\nsoon as possible after the injury to help the body deal with\\nthe trauma. Repeating a dose several times daily for the\\nduration of healing is also useful. Homeopathic hyper-\\nicum (Hypericum perforatum) can be taken if nerve pain\\nis involved, especially with a tooth extraction or root\\ncanal. Homeopathic comfrey (Symphytum officinale)may\\nbe helpful in treating pain due to broken jaw bones, but\\nshould only be used after the bones have been reset. Cal-\\nendula ( Calendula officinalis ) and plantain ( Plantago\\nmajor) can be used as a mouth rinse to enhance tissue\\nhealing. These herbs should not be used with deep lacera-\\ntions that need to heal from the inside first.\\nPrognosis\\nWhen dental trauma receives timely attention and\\nproper treatment, the prognosis for healing is good. As\\nwith other types of trauma, infection may be a complica-\\ntion, but a course of antibiotics is generally effective.\\nPrevention\\nMost dental trauma is preventable. Car seat belts\\nshould always be worn, and young children should be\\nsecured in appropriate car seats. Homes should be moni-\\ntored for potential tripping and slipping hazards. Child-\\nproofing measures should be taken, especially for tod-\\ndlers. In addition to placing gates across stairs and\\npadding sharp table edges, electrical cords should be\\ntucked away. Young children may receive severe oral\\nburns from gnawing on live power cords.\\nEveryone who participates in contact sports should\\nwear a mouthguard to avoid dental trauma. Athletes in\\nfootball, ice hockey, wrestling, and boxing commonly\\nwear mouthguards. The mandatory use of mouthguards\\nin football prevents about 200,000 oral injuries annually.\\nMouthguards should also be worn along with helmets in\\nnoncontact sports such as skateboarding, in-line skating,\\nGALE ENCYCLOPEDIA OF MEDICINE 21030\\nDental trauma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 418, 'page_label': '419'}, page_content='and bicycling. An athlete who does not wear a mouth-\\nguard is 60 times more likely to sustain dental trauma\\nthan one who does. Any activity involving speed, an\\nincreased chance of falling, and potential contact with a\\nhard piece of equipment has the likelihood of dental trau-\\nma that may be prevented or substantially reduced in\\nseverity with the use of mouthguards.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Pediatric Dentistry. 211 East Chicago\\nAve., Ste. 700, Chicago, IL 60611-2616. (312) 337-2169.\\n.\\nAmerican Association of Endodontists. 211 East Chicago Ave.,\\nSte. 1100, Chicago, IL 60611-2691. (800) 872-3636.\\n.\\nAmerican Association of Oral and Maxillofacial Surgeons.\\n9700 West Bryn Mawr Ave., Rosemont, IL 60018-5701.\\n(847) 678-6200. .\\nAmerican Dental Association. 211 E. Chicago Ave., Chicago,\\nIL 60611. (312) 440-2500. .\\nDonald Gardner Barstow\\nDepersonalization disorder see Dissociative\\ndisorders\\nDepo-Provera/Norplant\\nDefinition\\nNorplant is a long-acting hormone that is inserted\\nunder the skin and prevents conception for up to five\\nyears. Depo-Provera is also a hormone, but is administered\\nby intramuscular injection and provides protection against\\npregnancy for three months. Lunelle is another injectable\\ncontraceptive that is administered monthly (every 28 to 30\\ndays); it was approved by the Food and Drug Administra-\\ntion (FDA) in October 2000. The hormone in Norplant and\\nDepo-Provera is progestin, a synthetic hormone similar to\\none found naturally in a woman’s body; Lunelle contains\\nthe hormones progestin and estrogen.\\nPurpose\\nThe purpose of these hormones is to prevent preg-\\nnancy; they are about 99% effective in achieving this\\ngoal. No hormonal contraceptive methods provide protec-\\ntion from AIDS or other sexually transmitted diseases.\\nDepo-Provera and Lunelle are given as an injection\\nand work in several ways to prevent conception. First,\\nthe egg (ovum) is prevented from maturing and being\\nreleased. The mucus in the cervix (opening into the\\nuterus or womb) becomes thicker, making it difficult for\\nthe sperm to enter. Depo-Provera and Lunelle also cause\\nthe lining of the uterus to become thinner, making\\nimplantation of a fertilized egg unlikely.\\nAn injection of Depo-Provera or Lunelle must be\\ngiven within the first five days of a normal period. Depo-\\nProvera provides protection against pregnancy for three\\nmonths, while Lunelle provides similar protection for\\none month. Ovulation (release of a mature egg) typically\\noccurs within 60 days of the last injection of Lunelle,\\nabout twice as fast after use of Depo-Provera. Also,\\nbecause Lunelle is a combined hormone contraceptive as\\nopposed to progestin-only Depo-Provera and Norplant, it\\nis less likely to cause irregular or absent menstruation.\\nNorplant capsules contain a synthetic hormone that\\nis slowly released over a period of up to five years. It\\nfunctions like Depo-Provera in that it prevents the\\novaries from producing ova (eggs) and also results in\\nthicker mucus in the cervix, which prevents the sperm\\nfrom passing through the cervix. Norplant can be insert-\\ned at any time.\\nPreparation\\nThe woman being considered for Depo-Provera or\\nLunelle will have a pelvic and breast examination, a Pap\\ntest (a microscopic examination of cell samples taken\\nfrom the cervix), blood pressure check, weight check,\\nand a review of her medical history. Women who have\\ndiabetes mellitus , major depression, blood clotting\\nproblems, liver disease, or weight problems should use\\nthese methods only under strict medical supervision.\\nDepo-Provera or Lunelle should not be used if the\\nwoman is pregnant, has unexplained vaginal bleeding,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1031\\nDepo-Provera/Norplant\\nA physician inserts a contraceptive implant under the skin\\nof a woman’s arm.(Photo Researchers, Inc. Reproduced by\\npermission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 419, 'page_label': '420'}, page_content='suffers from severe liver disease, has breast cancer ,o r\\nhas a history of blood clots or stroke.\\nIndividuals who select Norplant will receive the\\nsame basic physical examination . If approved for this\\nmethod, a site of implantation will be selected (usually\\nthe inside of the upper arm), and the area prepared for\\nminor surgery. The skin will be washed with soap and\\nwater, and an antiseptic, such as iodine solution, will be\\napplied. The physician will use a local anesthetic to\\nnumb the area, a small incision will be made, the six\\nNorplant capsules will be inserted, and the incision sewn\\nup (sutured). Protection against pregnancy normally\\nbegins within 24 hours. If necessary, the implants can be\\nremoved in 15–20 minutes. Norplant should not be used\\nby women who are pregnant, have blood clotting prob-\\nlems, or have unexplained vaginal bleeding. Advantages\\ninclude light periods with less cramping and decreased\\nanemia. This form of birth control may also be protective\\nagainst endometrial cancer.\\nBecause Depo-Provera and Norplant use only the\\nhormone progestin, they may provide an alternative for\\nwomen who can not use estrogen-containing birth con-\\ntrol pills. One benefit of Lunelle, however, is that its\\neffects wear off more quickly than Depo-Provera, an\\nimportant factor in the event that a woman has serious\\nside effects or wants to become pregnant.\\nRisks\\nThe most common side effects associated with\\nDepo-Provera and Lunelle are yellowing of the skin,\\nheadache, nervousness, dizziness, abdominal pain, hair\\nloss, rash, increase in the number of migraine headaches,\\nincreased or decreased interest in sexual intercourse, the\\ndevelopment of dark spots on the skin, depression, and\\nweakness. Danger signs that need to reported immediate-\\nly include weight gain, heavy vaginal bleeding, frequent\\nurination, blurred vision, fainting , severe abdominal\\npain, and coughing up blood. Because the effects of\\nDepo-Provera may last up to 12 weeks, it may take a\\nlonger time for women trying to conceive to become\\npregnant after discontinuing the injections.\\nKEY TERMS\\nHormone—A chemical produced in a gland or\\norgan and transported by the blood to another area\\nof the body where it produces a specific effect.\\nPap test—A microscopic examination of cell sam-\\nples taken from the cervix.\\nThe main reactions to Norplant include headache,\\nweight gain, irregular periods or no period at all, breast\\ntenderness, acne, gain or loss of facial hair, color\\nchanges of the skin over the area of insertion, and ovari-\\nan cysts . The doctor should be notified immediately of\\nlumps in the breast, heavy vaginal bleeding, yellowing of\\nthe skin or eyes, or infection of the incision. Women who\\nuse Norplant are discouraged from smoking.\\nNormal results\\nThese hormone contraceptive methods normally\\nresult in a success rate of 99%.\\nResources\\nBOOKS\\nDickason, Elizabeth Jean, Bonnie Lang Silverman, and Judith\\nA. Kaplan. Maternal-Infant Nursing Care. 3rd ed. St.\\nLouis: Mosby-Year Book, Inc., 1998.\\nGorrie, Trula Meyers, Emily Slone McKinney, and Sharon\\nSmith Murray. Foundations of Maternal-Newborn Nurs-\\ning. 2nd ed. Philadelphia: W. B. Saunders Company, 1998.\\nNichols, Francine H., and Elaine Zwelling. Maternal-Newborn\\nNursing: Theory and Practice. Philadelphia: W. B. Saun-\\nders Company, 1997.\\nOlds, Sally B., Marcia L. London, and Patricia Wieland\\nLadewig. Maternal-Newborn Nursing: A Family Centered\\nApproach. Menlo Park: Addison-Wesley, 1996.\\nOTHER\\n“Depo Provera.”Planned Parenthood of Western Washington.\\n.\\n“Lunelle.”Food and Drug Administration (FDA) Page..\\n“Is Depo-Provera For You?”Planned Parenthood Federation of\\nAmerica, Inc. .\\nDonald Gardner Barstow\\nDepression see Bipolar disorder;\\nPostpartum depression\\nDepressive disorders\\nDefinition\\nDepression or depressive disorders (unipolar depres-\\nsion) are mental illnesses characterized by a profound\\nand persistent feeling of sadness or despair and/or a loss\\nof interest in things that were once pleasurable. Distur-\\nbance in sleep, appetite, and mental processes are a com-\\nmon accompaniment.\\nGALE ENCYCLOPEDIA OF MEDICINE 21032\\nDepressive disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 420, 'page_label': '421'}, page_content='Description\\nEveryone experiences feelings of unhappiness and\\nsadness occasionally. But when these depressed feel-\\nings start to dominate everyday life and cause physical\\nand mental deterioration, they become what are known\\nas depressive disorders. Each year in the United\\nStates, depressive disorders affect an estimated 17\\nmillion people at an approximate annual direct and\\nindirect cost of $53 billion. One in four women is like-\\nly to experience an episode of severe depression in her\\nlifetime, with a 10–20% lifetime prevalence, com-\\npared to 5–10% for men. The average age a first\\ndepressive episode occurs is in the mid-20s, although\\nthe disorder strikes all age groups indiscriminately,\\nfrom children to the elderly.\\nThere are two main categories of depressive disor-\\nders: major depressive disorder and dysthymic disorder.\\nMajor depressive disorder is a moderate to severe\\nepisode of depression lasting two or more weeks. Indi-\\nviduals experiencing this major depressive episode may\\nhave trouble sleeping, lose interest in activities they once\\ntook pleasure in, experience a change in weight, have dif-\\nficulty concentrating, feel worthless and hopeless, or\\nhave a preoccupation with death or suicide. In children,\\nthe major depression may appear as irritability.\\nWhile major depressive episodes may be acute\\n(intense but short-lived), dysthymic disorder is an ongo-\\ning, chronic depression that lasts two or more years (one\\nor more years in children) and has an average duration of\\n16 years. The mild to moderate depression of dysthymic\\ndisorder may rise and fall in intensity, and those afflicted\\nwith the disorder may experience some periods of nor-\\nmal, non-depressed mood of up to two months in length.\\nIts onset is gradual, and dysthymic patients may not be\\nable to pinpoint exactly when they started feeling\\ndepressed. Individuals with dysthymic disorder may\\nexperience a change in sleeping and eating patterns, low\\nself-esteem, fatigue, trouble concentrating, and feelings\\nof hopelessness.\\nDepression can also occur in bipolar disorder ,a n\\naffective mental illness that causes radical emotional\\nchanges and mood swings, from manic highs to depres-\\nsive lows. The majority of bipolar individuals experience\\nalternating episodes of mania and depression.\\nCauses and symptoms\\nThe causes behind depression are complex and not\\nyet fully understood. While an imbalance of certain neu-\\nrotransmitters—the chemicals in the brain that transmit\\nmessages between nerve cell— is believed to be key to\\ndepression, external factors such as upbringing (more so\\nin dysthymia than major depression) may be as impor-\\ntant. For example, it is speculated that, if an individual is\\nabused and neglected throughout childhood and adoles-\\ncence, a pattern of low self-esteem and negative thinking\\nmay emerge. From that, a lifelong pattern of depression\\nmay follow.\\nHeredity does seem to play a role in who develops\\ndepressive disorders. Individuals with major depression\\nin their immediate family are up to three times more\\nlikely to have the disorder themselves. It would seem\\nthat biological and genetic factors may make certain\\nindividuals pre-disposed or prone to depressive disor-\\nders, but environmental circumstances may often trig-\\nger the disorder.\\nExternal stressors and significant life changes, such\\nas chronic medical problems, death of a loved one,\\ndivorce or estrangement, miscarriage , or loss of a job,\\ncan also result in a form of depression known as adjust-\\nment disorder. Although periods of adjustment disorder\\nusually resolve themselves, occasionally they may\\nevolve into a major depressive disorder.\\nMajor depressive episode\\nIndividuals experiencing a major depressive episode\\nhave a depressed mood and/or a diminished interest or\\npleasure in activities. Children experiencing a major\\ndepressive episode may appear or feel irritable rather\\nthan depressed. In addition, five or more of the following\\nsymptoms will occur on an almost daily basis for a peri-\\nod of at least two weeks:\\n• Significant change in weight.\\n•Insomnia or hypersomnia (excessive sleep).\\n• Psychomotor agitation or retardation.\\n• Fatigue or loss of energy.\\n• Feelings of worthlessness or inappropriate guilt.\\n• Diminished ability to think or to concentrate, or indeci-\\nsiveness.\\n• Recurrent thoughts of death or suicidal and/or suicide\\nattempts.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1033\\nDepressive disorders\\nSigns Of Mental Depression\\nDepressed mood\\nLack of interest or pleasure in daily activities\\nSignificant weight loss (without dieting) or weight gain\\nDifficulty sleeping or excessive sleeping\\nLoss of energy\\nFeelings of worthlessness or guilt\\nDifficulty in making decisions\\nRestlessness\\nRecurrent thoughts of death'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 421, 'page_label': '422'}, page_content='Dysthymic disorder\\nDysthymia commonly occurs in tandem with other\\npsychiatric and physical conditions. Up to 70% of dys-\\nthymic patients have both dysthymic disorder and major\\ndepressive disorder, known as double depression. Sub-\\nstance abuse, panic disorders, personality disorders ,\\nsocial phobias, and other psychiatric conditions are also\\nfound in many dysthymic patients. Dysthymia is prevalent\\nin patients with certain medical conditions, including mul-\\ntiple sclerosis, AIDS, hypothyroidism, chronic fatigue\\nsyndrome, Parkinson’s disease, diabetes, and post-car-\\ndiac transplantation. The connection between dysthymic\\ndisorder and these medical conditions is unclear, but it\\nmay be related to the way the medical condition and/or its\\npharmacological treatment affects neurotransmitters. Dys-\\nthymic disorder can lengthen or complicate the recovery\\nof patients also suffering from medical conditions.\\nAlong with an underlying feeling of depression,\\npeople with dysthymic disorder experience two or more\\nof the following symptoms on an almost daily basis for a\\nperiod for two or more years (most suffer for five years),\\nor one year or more for children:\\n• under or overeating\\n• insomnia or hypersomnia\\n• low energy or fatigue\\n• low self-esteem\\n• poor concentration or trouble making decisions\\n• feelings of hopelessness\\nDiagnosis\\nIn addition to an interview, several clinical invento-\\nries or scales may be used to assess a patient’s mental\\nstatus and determine the presence of depressive symp-\\ntoms. Among these tests are: the Hamilton Depression\\nScale (HAM-D), Child Depression Inventory (CDI),\\nGeriatric Depression Scale (GDS), Beck Depression\\nInventory (BDI), and the Zung Self-Rating Scale for\\nDepression. These tests may be administered in an out-\\npatient or hospital setting by a general practitioner, social\\nworker, psychiatrist, or psychologist.\\nTreatment\\nMajor depressive and dysthymic disorders are typi-\\ncally treated with antidepressants or psychosocial thera-\\npy. Psychosocial therapy focuses on the personal and\\ninterpersonal issues behind depression, while antidepres-\\nsant medication is prescribed to provide more immediate\\nrelief for the symptoms of the disorder. When used\\ntogether correctly, therapy and antidepressants are a\\npowerful treatment plan for the depressed patient.\\nAntidepressants\\nSelective serotonin reuptake inhibitors (SSRIs)\\nsuch as fluoxetine (Prozac) and sertraline (Zoloft) reduce\\ndepression by increasing levels of serotonin, a neuro-\\ntransmitter. Some clinicians prefer SSRIs for treatment\\nof dysthymic disorder. Anxiety , diarrhea , drowsiness,\\nheadache , sweating, nausea, poor sexual functioning,\\nand insomnia are all possible side effects of SSRIs.\\nTricyclic antidepressants (TCAs) are less expensive\\nthan SSRIs, but have more severe side-effects, which may\\ninclude persistent dry mouth, sedation, dizziness , and\\ncardiac arrhythmias. Because of these side effects, cau-\\ntion is taken when prescribing TCAs to elderly patients.\\nTCAs include amitriptyline (Elavil), imipramine (Tofra-\\nnil), and nortriptyline (Aventyl, Pamelor). A 10-day sup-\\nply of TCAs can be lethal if ingested all at once, so these\\nGALE ENCYCLOPEDIA OF MEDICINE 21034\\nDepressive disorders\\nSubgenual \\nprefrontal \\ncortex\\nNormal\\nAbnormal\\nSubgenual \\nprefrontal \\ncortex\\nRecent scientific research has indicated that the size of the\\nsubgenual prefrontal cortex of the brain (located behind the\\nbridge of the nose) may be a determining factor in heredi-\\ntary depressive disorders. (Illustration by Electronic Illustrators\\nGroup.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 422, 'page_label': '423'}, page_content='drugs may not be a preferred treatment option for patients\\nat risk for suicide.\\nMonoamine oxidase inhibitors (MAOIS) such as\\ntranylcypromine (Parnate) and phenelzine (Nardil) block\\nthe action of monoamine oxidase (MAO), an enzyme in\\nthe central nervous system. Patients taking MAOIs must\\ncut foods high in tyramine (found in aged cheeses and\\nmeats) out of their diet to avoid potentially serious\\nhypertensive side effects.\\nHeterocyclics include bupropion (Wellbutrin) and tra-\\nzodone (Desyrel). Bupropion should not be prescribed to\\npatients with a seizure disorder. Side effects of the drug\\nmay include agitation, anxiety, confusion, tremor, dry\\nmouth, fast or irregular heartbeat, headache, low blood\\npressure, and insomnia. Because trazodone has a sedative\\neffect, it is useful in treating depressed patients with insom-\\nnia. Other possible side effects of trazodone include dry\\nmouth, gastrointestinal distress, dizziness, and headache.\\nPsychosocial therapy\\nPsychotherapy explores an individual’s life to bring\\nto light possible contributing causes of the present\\ndepression. During treatment, the therapist helps the\\npatient to become self-aware of his or her thinking pat-\\nterns and how they came to be. There are several differ-\\nent subtypes of psychotherapy, but all have the common\\ngoal of helping the patient develop healthy problem solv-\\ning and coping skills.\\nCognitive-behavioral therapy assumes that the\\npatient’s faulty thinking is causing the current depression\\nand focuses on changing the depressed patient’s thought\\npatterns and perceptions. The therapist helps the patient\\nidentify negative or distorted thought patterns and the\\nemotions and behavior that accompany them, and then\\nretrains the depressed individual to recognize the think-\\ning and react differently to it.\\nElectroconvulsant therapy\\nECT, or electroconvulsive therapy , is usually\\nemployed after all therapy and pharmaceutical treatment\\noptions have been explored. However, it is sometimes used\\nearly in treatment when severe depression is present and\\nthe patient refuses oral medication, or when the patient is\\nbecoming dehydrated, extremely suicidal, or psychotic.\\nThe treatment consists of a series of electrical pulses\\nthat move into the brain through electrodes on the\\npatient’s head. ECT is given under general anesthesia\\nand patients are administered a muscle relaxant to pre-\\nvent convulsions. Although the exact mechanisms behind\\nthe success of ECT therapy are not known, it is believed\\nthat the electrical current modifies the electrochemical\\nprocesses of the brain, consequently relieving depres-\\nsion. Headaches, muscle soreness, nausea, and confusion\\nare possible side effects immediately following an ECT\\nprocedure. Memory loss, typically transient, has also\\nbeen reported in ECT patients.\\nAlternative treatment\\nSt. John’s wort (Hypericum perforatum ) is used\\nthroughout Europe to treat depressive symptoms. Unlike\\ntraditional prescription antidepressants, this herbal anti-\\ndepressant has few reported side effects. Some users may\\nexperience high blood pressure, headaches, stiff neck,\\nnausea, and vomiting. As of early 1998, United States.\\nclinical trials organized by the National Institute of Men-\\ntal Health were still in the planning phase. Its efficacy in\\nsevere depression is very uncertain.\\nHomeopathic treatment can also be very therapuetic\\nin treating depression. Good nutrition , proper sleep,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1035\\nDepressive disorders\\nPositron emission tomography (PET) scans comparing a\\nnormal brain with that of someone with a depressed mental\\ndisorder. (Photo Researchers, Inc. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 423, 'page_label': '424'}, page_content='exercise, and full engagement in life are very important\\nto a healthy mental state.\\nPrognosis\\nUntreated or improperly treated depression is the\\nnumber one cause of suicide in the United States. Proper\\ntreatment relieves symptoms in 80–90% of depressed\\npatients. After each major depressive episode, the risk of\\nrecurrence climbs significantly—50% after one episode,\\n70% after two episodes, and 90% after three episodes.\\nFor this reason, patients need to be aware of the symp-\\ntoms of recurring depression and may require long-term\\nmaintenance treatment of antidepressants and/or therapy.\\nPrevention\\nPatient education in the form of therapy or self-help\\ngroups is crucial for training patients with depressive dis-\\norders to recognize symptoms of depression and to take\\nan active part in their treatment program. Extended main-\\ntenance treatment with antidepressants may be required\\nin some patients to prevent relapse. Early intervention\\nwith children with depression is effective in arresting\\ndevelopment of more severe problems.\\nResources\\nBOOKS\\nAmerican Psychiatric Association. Diagnostic and Statistical\\nManual of Mental Disorders. 4th ed. Washington, DC:\\nAmerican Psychiatric Press, Inc., 1994.\\nKEY TERMS\\nHypersomnia — The need to sleep excessively; a\\nsymptom of dysthymic and major depressive dis-\\norder.\\nNeurotransmitter—A chemical in the brain that\\ntransmits messages between neurons, or nerve cells.\\nChanges in the levels of certain neurotransmitters,\\nsuch as serotonin, norepinephrine, and dopamine,\\nare thought to be related to depressive disorders.\\nPsychomotor agitation —Disturbed physical and\\nmental processes (e.g., fidgeting, wringing of hands,\\nracing thoughts); a symptom of major depressive\\ndisorder.\\nPsychomotor retardation —Slowed physical and\\nmental processes (e.g., slowed thinking, walking,\\nand talking); a symptom of major depressive dis-\\norder.\\nMaxmen, Jerrold S., and Nicholas G. Ward. “Mood Disorders.”\\nEssential Psychopathology and Its Treatment.2nd ed.\\nNew York: W. W. Norton, 1995.\\nThompson, Tracy. The Beast: A Reckoning with Depression.\\nNew York: GP Putnam, 1995.\\nWhybrow, Peter C. A Mood Apart. New York: HarperCollins,\\n1997.\\nPERIODICALS\\nHirschfeld, R. M., et al. “The National Depressive and Manic-\\nDepressive Association Consensus Statement on the\\nUndertreatment of Depression.”The Journal of the Ameri-\\ncan Medical Association 277, no. 4 (1997): 333-40.\\nMiller, Mark D. “Recognizing and Treating Depression in the\\nElderly.”Medscape Mental Health 2, no. 3 (1997).\\nMiller, Sue. “A Natural Mood Booster.”Newsweek,5 M a y\\n1997: 74-5.\\nSansone, Randy A. and Lori A. Sansone. “Dysthymic Disorder:\\nThe Chronic Depression.”American Family Physician,\\n53, no. 8 (June 1996): 2588-96.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW, Washing-\\nton, DC 20005. (888) 357-7924. .\\nAmerican Psychological Association (APA). 750 First St. NE,\\nWashington, DC 20002-4242. (202) 336-5700. .\\nNational Alliance for the Mentally Ill (NAMI). Colonial Place\\nThree, 2107 Wilson Blvd., Ste. 300, Arlington, V A 22201-\\n3042. (800) 950-6264. .\\nNational Depressive and Manic-Depressive Association\\n(NDMDA). 730 N. Franklin St., Suite 501, Chicago, IL\\n60610. (800) 826-3632. .\\nNational Institute of Mental Health. Mental Health Public\\nInquiries, 5600 Fishers Lane, Room 15C-05, Rockville,\\nMD 20857. (888) 826-9438. .\\nPaula Anne Ford-Martin\\nDermabrasion see Skin resurfacing\\nDermatitis\\nDefinition\\nDermatitis is a general term used to describe inflam-\\nmation of the skin.\\nDescription\\nMost types of dermatitis are characterized by an\\nitchy pink or red rash.\\nContact dermatitis is an allergic reaction to some-\\nthing that irritates the skin and is manifested by one or\\nmore lines of red, swollen, blistered skin that may itch or\\nGALE ENCYCLOPEDIA OF MEDICINE 21036\\nDermatitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 424, 'page_label': '425'}, page_content='seep. It usually appears within 48 hours after touching or\\nbrushing against a substance to which the skin is sensitive.\\nThe condition is more common in adults than in children.\\nContact dermatitis can occur on any part of the body,\\nbut it usually affects the hands, feet, and groin. Contact\\ndermatitis usually does not spread from one person to\\nanother, nor does it spread beyond the area exposed to\\nthe irritant unless affected skin comes into contact with\\nanother part of the body. However, in the case of some\\nirritants, such as poison ivy, contact dermatitis can be\\npassed to another person or to another part of the body.\\nStasis dermatitis is characterized by scaly, greasy\\nlooking skin on the lower legs and around the ankles. Sta-\\nsis dermatitis is most apt to affect the inner side of the calf.\\nNummular dermatitis, which is also called nummular\\neczematous dermatitis or nummular eczema, generally\\naffects the hands, arms, legs, and buttocks of men and\\nwomen older than 55 years of age. This stubborn\\ninflamed rash forms circular, sometimes itchy, patches\\nand is characterized by flares and periods of inactivity.\\nAtopic dermatitis is characterized by itching, scal-\\ning, swelling, and sometimes blistering. In early child-\\nhood it is called infantile eczema and is characterized by\\nredness, oozing, and crusting. It is usually found on the\\nface, inside the elbows, and behind the knees.\\nSeborrheic dermatitis may be dry or moist and is\\ncharacterized by greasy scales and yellowish crusts on the\\nscalp, eyelids, face, external surfaces of the ears, under-\\narms, breasts, and groin. In infants it is called “cradle cap.”\\nCauses and symptoms\\nAllergic reactions are genetically determined, and\\ndifferent substances cause contact dermatitis to develop\\nin different people. A reaction to resin produced by poi-\\nson ivy, poison oak, or poison sumac is the most com-\\nmon source of symptoms. It is, in fact, the most common\\nallergy in this country, affecting one of every two people\\nin the United States.\\nFlowers, herbs, and vegetables can also affect the\\nskin of some people. Burns and sunburn increase the\\nrisk of dermatitis developing, and chemical irritants that\\ncan cause the condition include:\\n• chlorine\\n• cleansers\\n• detergents and soaps\\n• fabric softeners\\n• glues used on artificial nails\\n• perfumes\\n• topical medications\\nContact dermatitis can develop when the first con-\\ntact occurs or after years of use or exposure.\\nStasis dermatitis, a consequence of poor circulation,\\noccurs when leg veins can no longer return blood to the\\nheart as efficiently as they once did. When that happens,\\nfluid collects in the lower legs and causes them to swell.\\nStasis dermatitis can also result in a rash that can break\\ndown into sores known as stasis ulcers.\\nThe cause of nummular dermatitis is not known, but\\nit usually occurs in cold weather and is most common in\\npeople who have dry skin. Hot weather and stress can\\naggravate this condition, as can the following:\\n•allergies\\n• fabric softeners\\n• soaps and detergents\\n• wool clothing\\n• bathing more than once a day\\nAtopic dermatitis can be caused by allergies, asth-\\nma, or stress, and there seems to be a genetic predisposi-\\ntion for atopic conditions. It is sometimes caused by an\\nallergy to nickel in jewelry.\\nSeborrheic dermatitis (for which there may also be a\\ngenetic predisposition) is usually caused by overproduc-\\ntion of the oil glands. In adults it can be associated with\\ndiabetes mellitus or gold allergy. In infants and adults it\\nmay be caused by a biotin deficiency.\\nDiagnosis\\nThe diagnosis of dermatitis is made on the basis of\\nhow the rash looks and its location. The doctor may\\nscrape off a small piece of affected skin for microscopic\\nexamination or direct the patient to discontinue use of any\\npotential irritant that has recently come into contact with\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1037\\nDermatitis\\nDermatitis on hands and fingers. (Custom Medical Stock\\nPhoto. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 425, 'page_label': '426'}, page_content='the affected area. Two weeks after the rash disappears, the\\npatient may resume use of the substances, one at a time,\\nuntil the condition recurs. Eliminating the substance most\\nrecently added should eliminate the irritation.\\nIf the origin of the irritation has still not been identi-\\nfied, a dermatologist may perform one or more patch tests.\\nThis involves dabbing a small amount of a suspected irri-\\ntant onto skin on the patient’s back. If no irritation devel-\\nops within a few days, another patch test is performed. The\\nprocess continues until the patient experiences an allergic\\nreaction at the spot where the irritant was applied.\\nTreatment\\nTreating contact dermatitis begins with eliminating\\nor avoiding the source of irritation. Prescription or over-\\nthe-counter corticosteroid creams can lessen inflamma-\\ntion and relieve irritation. Creams, lotions, or ointments\\nnot specifically formulated for dermatitis can intensify\\nthe irritation. Oral antihistamines are sometimes recom-\\nmended to alleviate itching, and antibiotics are pre-\\nscribed if the rash becomes infected. Medications taken\\nby mouth to relieve symptoms of dermatitis can make\\nskin red and scaly and cause hair loss.\\nKEY TERMS\\nAllergic reaction—An inappropriate or exaggerat-\\ned genetically determined reaction to a chemical\\nthat occurs only on the second or subsequent\\nexposures to the offending agent, after the first\\ncontact has sensitized the body.\\nCorticosteriod —A group of synthetic hormones\\nthat are used to prevent or reduce inflammation.\\nToxic effects may result from rapid withdrawal after\\nprolonged use or from continued use of large doses.\\nPatch test—A skin test that is done to identify aller-\\ngens. A suspected substance is applied to the skin.\\nAfter 24–48 hours, if the area is red and swollen,\\nthe test is positive for that substance. If no reaction\\noccurs, another substance is applied. This is con-\\ntinued until the patient experiences an allergic\\nreaction where the irritant was applied to the skin.\\nRash—A spotted, pink or red skin eruption that\\nmay be accompanied by itching and is caused by\\ndisease, contact with an allergen, food ingestion,\\nor drug reaction.\\nUlcer—An open sore on the skin, resulting from\\ntissue destruction, that is usually accompanied by\\nredness, pain, or infection.\\nPatients who have a history of dermatitis should\\nremove their rings before washing their hands. They\\nshould use bath oils or glycerine-based soaps and bathe\\nin lukewarm saltwater.\\nPatting rather than rubbing the skin after bathing and\\nthoroughly massaging lubricating lotion or nonprescrip-\\ntion cortisone creams into still-damp skin can soothe red,\\nirritated nummular dermatitis. Highly concentrated corti-\\nsone preparations should not be applied to the face,\\narmpits, groin, or rectal area. Periodic medical monitoring\\nis necessary to detect side effects in patients who use such\\npreparations on rashes covering large areas of the body.\\nCoal-tar salves can help relieve symptoms of num-\\nmular dermatitis that have not responded to other treat-\\nments, but these ointments have an unpleasant odor and\\nstain clothing.\\nPatients who have stasis dermatitis should elevate\\ntheir legs as often as possible and sleep with a pillow\\nbetween the lower legs.\\nTar or zinc paste may also be used to treat stasis der-\\nmatitis. Because these compounds must remain in con-\\ntact with the rash for as long as two weeks, the paste and\\nbandages must be applied by a nurse or a doctor.\\nCoal-tar shampoos may be used for seborrheic der-\\nmatitis that occurs on the scalp. Sun exposure after the\\nuse of these shampoos should be avoided because the\\nrisk of sunburn of the scalp is increased.\\nAlternative treatment\\nSome herbal therapies can be useful for skin condi-\\ntions. Among the herbs most often recommended are:\\n• Burdock root (Arctium lappa)\\n• Calendula (Calendula officinalis) ointment\\n• Chamomile (Matricaria recutita) ointment\\n• Cleavers (Galium ssp.)\\n• Evening primrose oil (Oenothera biennis)\\n• Nettles (Urtica dioica)\\nContact dermatitis can be treated botanically and\\nhomeopathically. Grindelia ( Grindelia spp.) and sas-\\nsafras ( Sassafras albidum ) can help when applied topi-\\ncally. Determining the source of the problem and elimi-\\nnating it is essential. Oatmeal baths are very helpful in\\nrelieving the itch. Bentonite clay packs or any mud pack\\ndraws the fluid out, and helps dry up the lesions. Corti-\\nsone creams are not recommended.\\nStasis dermatitis should be treated by a trained prac-\\ntitioner. This condition responds well to topical herbal\\ntherapies, however, the cause must also be addressed.\\nGALE ENCYCLOPEDIA OF MEDICINE 21038\\nDermatitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 426, 'page_label': '427'}, page_content='Selenium-based shampoos, topical applications of flax oil\\nand/or olive oil, and biotin supplementation are among\\nthe therapies recommended for seborrheic dermatitis.\\nPrognosis\\nDermatitis is often chronic, but symptoms can gen-\\nerally be controlled.\\nPrevention\\nContact dermatitis can be prevented by avoiding the\\nsource of irritation. If the irritant cannot be avoided com-\\npletely, the patient should wear gloves and other protec-\\ntive clothing whenever exposure is likely to occur.\\nImmediately washing the exposed area with soap\\nand water can stem allergic reactions to poison ivy, poi-\\nson oak, or poison sumac, but because soaps can dry the\\nskin, patients susceptible to dermatitis should use them\\nonly on the face, feet, genitals, and underarms.\\nClothing should be loose fitting and 100% cotton.\\nNew clothing should be washed in dye-free, unscented\\ndetergent before being worn.\\nInjury to the lower leg can cause stasis dermatitis to\\nulcerate (form open sores). If stasis ulcers develop, a\\ndoctor should be notified immediately.\\nYoga and other relaxation techniques may help pre-\\nvent atopic dermatitis caused by stress.\\nAvoidance of sweating may aid in preventing sebor-\\nrheic dermatitis.\\nA patient who has dermatitis should also notify a\\ndoctor if any of the following occurs:\\n• fever develops\\n• skin oozes or other signs of infection appear\\n• symptoms do not begin to subside after seven days’\\ntreatment\\n• he/she comes into contact with someone who has a\\nwart, cold sore, or other viral skin infection\\nResources\\nBOOKS\\nThe Editors of Time-Life Books. The Medical Advisor: The\\nComplete Guide to Alternative and Conventional Treat-\\nments. Alexandria, V A: Time Life, Inc., 1996.\\nNew Choices in Natural Healing. Ed. Bill Gottlieb, et al.\\nEmmaus, PA: Rodale Press, 1995.\\nOTHER\\n“Allergic Contact Dermatitis.”The Skin Site. 10 Apr. 1998\\n.\\n“Dermatitis, Contact.”ThriveOnline. 10 Apr. 1998 .\\n“Nummular Dermatitis.”The Skin Site. 7 Apr. 1998 .\\n“Poison Ivy, Oak, Sumac.”ThriveOnline. 10 Apr. 1998 .\\n“Stasis Dermatitis.”The Skin Site. 7 Apr. 1998 .\\nMaureen Haggerty\\nDermatophyte infections see Ringworm\\nDES exposure\\nDefinition\\nDES (diethylstilbestrol) is a hormone that was pre-\\nscribed for pregnant women in the 1950s and early\\n1960s. Many years later, doctors discovered that the\\ndaughters of the women who received DES were at high\\nrisk for a variety of problems, including infertility, pre-\\nmature labor, and cancer of the vagina and cervix.\\nDescription\\nIn the 1950s and early 1960s, several drug compa-\\nnies claimed that DES (diethylstilbestrol) could prevent\\nmiscarriages. DES is a synthetic hormone, related to\\nestrogen. Since up to 20% of all pregnancies end in mis-\\ncarriage , this seemed like an important breakthrough\\nand DES was prescribed for many women who had\\nbleeding in early pregnancy. Ultimately, it was found to\\nhave no effect on miscarriages and the practice of pre-\\nscribing DES was stopped in the 1960s. Almost 10 years\\nlater, the daughters of women who had taken DES during\\npregnancy began to develop unusual symptoms.\\nDoctors discovered that when these young women\\nreached their teens, they were at higher risk for a variety\\nof problems, including:\\n• clear cell adenocarcinoma of the vagina and cervix\\n• infertility\\n•premature labor and other problems in pregnancy\\nCauses and symptoms\\nDES has affected a very specific group of women.\\nThese are women who were exposed to DES in utero\\nbefore 18 weeks of pregnancy. In other words, their\\nmothers must have taken DES within the first four to five\\nmonths of pregnancy. It is now known that the female\\nreproductive organs are formed during that time. DES\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1039\\nDES exposure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 427, 'page_label': '428'}, page_content='appears to interfere with proper growth and development\\nof the uterus, cervix, vagina, and fallopian tubes.\\nIn the early 1970s, there was an increase in a rare\\nform of cancer, clear cell adenocarcinoma of the vagina\\nand cervix. Up until that time, doctors had seen these\\ncancers only in elderly women. Suddenly, young women\\nwho had the disease appeared.\\nThis was so unusual that researchers studied these\\nwomen to see if they had anything in common. After a\\ngreat deal of questioning and examination, it was found\\nthat they all had one factor in common. All of the young\\nwomen had been exposed to DES in utero in the early\\nweeks of pregnancy.\\nToday, it is difficult to imagine how shocking this\\ndiscovery was. Doctors had only recently recognized that\\nmedications and exposure to chemicals during pregnancy\\ncould cause birth defects . This was a birth defect that\\nhad gone undetected for almost two decades.\\nSince then, doctors have studied DES daughters very\\ncarefully. Fortunately, the risk of clear cell adenocarcino-\\nma is actually quite low. In fact, it appears that if a DES\\ndaughter has not developed this cancer by age 30, she\\nwill not develop it. Since all DES daughters are now over\\nage 30, there should be no further cases related to DES\\nexposure. However, there are a number of other symp-\\ntoms and problems associated with DES exposure.\\n• Cervix and vagina. DES daughters often have distinc-\\ntive changes of the cervix and vagina that can be seen\\nduring a pelvic exam. These changes include a cervical\\nhood (a vaginal fold draped over the cervix),\\ncockscomb cervix (an abnormally shaped cervix), and\\nadenosis (glandular cells normally located within the\\ncervix that appear on the outside of the cervix and in\\nthe vagina).\\nKEY TERMS\\nCervix—The opening at the bottom of the uterus.\\nColposcopy—A special examination of the cervix\\nusing a magnifying scope. This is a procedure that\\ncan be done in the doctor’s office.\\nFallopian tubes —The tubes that carry the ovum\\n(egg) from the ovary to the uterus.\\nPap smear—A screening test for precancerous and\\ncancerous cells on the cervix. This simple test is\\ndone during a routine pelvic exam and involves\\nscraping cells from the cervix.\\n• Fallopian tubes. Some DES daughters have fallopian\\ntube abnormalities that lead to infertility.\\n• Uterus. Many DES daughters have a uterus that is\\nabnormal in size and shape. The classic sign is the T-\\nshaped uterus. In the normal uterus, the cavity (hollow\\nspace inside) is rounded. In a T-shaped uterus, the cavi-\\nty is reduced to a thin T. The abnormal shape of the\\ninside of the uterus makes it harder for a woman to get\\npregnant and leads to a higher risk of premature labor\\nand birth.\\nDiagnosis\\nWomen who have been exposed to DES should have\\na pelvic exam at least once a year. In addition to the usual\\npelvic exam and Pap smear, DES daughters should also\\nhave Pap smears of the vagina and, if possible, col-\\nposcopy . During colposcopy, the doctor looks at the\\ncervix and vagina through a special magnifying scope. In\\nthis way, tiny areas of abnormal cells can be seen. This\\nprocedure is easily performed in the doctor’s office.\\nWhen DES daughters get pregnant, they may be at\\nhigh risk for premature labor and birth and should be\\nmonitored very carefully.\\nNot all women who were exposed to DES develop\\nproblems in pregnancy. However, if problems like infer-\\ntility or miscarriage do occur, the doctor may recom-\\nmend a special x-ray test to check the woman’s fallopian\\ntubes and uterus. This special test is called a hysterosalp-\\ningogram.\\nTreatment\\nThere is no treatment for the abnormalities of the\\nfallopian tubes and uterus caused by DES exposure. For-\\ntunately, there are treatments that can help with infertility\\nand premature labor. Clear cell adenocarcinoma of the\\nvagina or cervix must be treated with surgery and, possi-\\nbly, chemotherapy.\\nResources\\nBOOKS\\nLaufer, Mark R., and Donald P. Goldstein. “Pediatric and Ado-\\nlescent Gynecology.” In Kistner’s Gynecology,e d . K e n -\\nneth J. Ryan, Ross S. Berkowitz, and Robert L. Barbieri.\\nSt. Louis: Mosby, 1995.\\nSheets, Ellen. “Clear Cell Adenocarcinoma of the Cervix.” In\\nKistner’s Gynecology, ed. Kenneth J. Ryan, Ross S.\\nBerkowitz, and Robert L. Barbieri. St. Louis: Mosby, 1995.\\nAmy B. Tuteur, MD\\nDetached retina see Retinal detachment\\nGALE ENCYCLOPEDIA OF MEDICINE 21040\\nDES exposure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 428, 'page_label': '429'}, page_content='Detoxification\\nDefinition\\nDetoxification is one of the more widely used treat-\\nments and concepts in alternative medicine. It is based on\\nthe principle that illnesses can be caused by the accumu-\\nlation of toxic substances (toxins) in the body. Eliminat-\\ning existing toxins and avoiding new toxins are essential\\nparts of the healing process. Detoxification utilizes a\\nvariety of tests and techniques.\\nPurpose\\nDetoxification is helpful for those patients suffering\\nfrom many chronic diseases and conditions, including\\nallergies, anxiety, arthritis, asthma, chronic infections,\\ndepression, diabetes, headaches, heart disease, high\\ncholesterol, low blood sugar levels, digestive disorders,\\nmental illness, and obesity . It is helpful for those with\\nconditions that are influenced by environmental factors,\\nsuch as cancer , as well as for those who have been\\nexposed to high levels of toxic materials due to accident\\nor occupation. Detoxification therapy is useful for those\\nsuffering from allergies or immune system problems\\nthat conventional medicine is unable to diagnose or\\ntreat, including chronic fatigue syndrome , environ-\\nmental illness/multiple chemical sensitivity, and\\nfibromyalgia. Symptoms for those suffering these con-\\nditions may include unexplained fatigue , increased\\nallergies, hypersensitivity to common materials, intoler-\\nance to certain foods and indigestion , aches and pains,\\nlow grade fever, headaches, insomnia, depression, sore\\nthroats, sudden weight loss or gain, lowered resistance\\nto infection, general malaise, and disability. Detoxifica-\\ntion can be used as a beneficial preventative measure\\nand as a tool to increase overall health, vitality, and\\nresistance to disease.\\nDescription\\nOrigins\\nDetoxification methods of healing have been used for\\nthousands of years. Fasting, is one of the oldest therapeu-\\ntic practices in medicine. Hippocrates, the ancient Greek\\nknown as the “Father of Western medicine,” recommend-\\ned fasting as a means for improving health. Ayurvedic\\nmedicine, a traditional healing system that has developed\\nover thousands of years, utilizes detoxification methods\\nto treat many chronic conditions and to prevent illness.\\nDetoxification treatment has become one of the cor-\\nnerstones of alternative medicine. Conventional medicine\\nnotes that environmental factors can play a significant role\\nin many illnesses. Environmental medicine is a field that\\nstudies exactly how those environmental factors influence\\ndisease. Conditions such as asthma, cancer, chronic\\nfatigue syndrome, multiple chemical sensitivity , and\\nmany others are strongly influenced by exposure to toxic\\nor allergenic substances in the environment. The United\\nStates Centers for Disease Control estimate that over 80%\\nof all illnesses have environmental and lifestyle causes.\\nDetoxification has also become a prominent treat-\\nment as people have become more aware of environmen-\\ntal pollution. It is estimated that one in every four Ameri-\\ncans suffers from some level of heavy metal poisoning.\\nHeavy metals, such as lead, mercury, cadmium, and\\narsenic, are by-products of industry. Synthetic agricul-\\nture chemicals, many of which are known to cause health\\nproblems, are also found in food, air, and water. Ameri-\\ncan agriculture uses nearly 10 lb (4.5 kg) of pesticides\\nper person on the food supply each year. These toxins\\nhave become almost unavoidable. Pesticides that are\\nused only on crops in the southern United States have\\nbeen found in the tissue of animals in the far north of\\nCanada. DDT, a cancer-causing insecticide that has been\\nbanned for decades, is still regularly found in the fatty\\ntissue of animals, birds, and fish, even in extremely\\nremote regions such as the North Pole.\\nThe problem of toxins in the environment is com-\\npounded because humans are at the top of the food chain\\nand are more likely to be exposed to an accumulation of\\ntoxic substances in the food supply. For instance, pesti-\\ncides and herbicides are sprayed on grains that are then\\nfed to farm animals. Toxic substances are stored in the\\nfatty tissue of those animals. In addition, those animals\\nare often injected with synthetic hormones, antibiotics ,\\nand other chemicals. When people eat meat products,\\nthey are exposed to the full range of chemicals and addi-\\ntives used along the entire agricultural chain. Detoxifica-\\ntion specialists call this build up of toxins bioaccumula-\\ntion. They assert that the bioaccumulation of toxic sub-\\nstances over time is responsible for many physical and\\nmental disorders, especially ones that are increasing\\nrapidly (like asthma, cancer, and mental illness). As a\\nresult, detoxification therapies are increasing in impor-\\ntance and popularity.\\nToxins in the body include heavy metals and various\\nchemicals such as pesticides, pollutants, and food addi-\\ntives. Drugs and alcohol have toxic effects in the body.\\nToxins are produced as normal by-products in the\\nintestines by the bacteria that break down food. The diges-\\ntion of protein also creates toxic by-products in the body.\\nThe body has natural methods of detoxification.\\nIndividual cells get detoxified in the lymph and circula-\\ntory system. The liver is the principle organ of detoxifi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1041\\nDetoxification'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 429, 'page_label': '430'}, page_content='cation, assisted by the kidneys and intestines. Toxins can\\nbe excreted from the body by the kidneys, bowels, skin,\\nand lungs. Detoxification treatments become necessary\\nwhen the body’s natural detoxification systems become\\noverwhelmed. This can be caused by long-term effects of\\nimproper diet, stress, overeating, sedentary lifestyles, ill-\\nness, and poor health habits in general. When a build up\\nof toxic substances in the body creates illness, it’s called\\ntoxemia. Some people’s digestive tracts become unable\\nto digest food properly, due to years of overeating and\\ndiets that are high in fat and processed foods and low in\\nfiber (the average American diet). When this happens,\\nfood cannot pass through the digestive tract efficiently.\\nInstead of being digested properly or eliminated from the\\nbowel, food can literally rot inside the digestive tract and\\nproduce toxic by-products. This state is known as toxic\\ncolon syndrome or intestinal toxemia.\\nDetoxification therapies try to activate and assist the\\nbody’s own detoxification processes. They also try to\\neliminate additional exposure to toxins and strengthen\\nthe body and immune system so that toxic imbalances\\nwon’t occur in the future.\\nTesting for toxic substances\\nDetoxification specialists use a variety of tests to\\ndetermine the causes contributing to toxic conditions.\\nThese causes include infections, allergies, addictions,\\ntoxic chemicals, and digestive and organ dysfunction.\\nBlood, urine, stool, and hair analyses, as well as allergy\\ntests, are used to measure a variety of bodily functions\\nthat may indicate problems. Detoxification therapists\\nusually have access to laboratories that specialize in\\nsophisticated diagnostic tests for toxic conditions.\\nPeople who have toxemia are often susceptible to\\ninfection because their immune systems are weakened.\\nInfections can be caused by parasites, bacteria, viruses,\\nand a common yeast. Therapists will screen patients for\\nunderlying infections that may be contributing to illness.\\nLiver function is studied closely with blood and\\nurine tests because the liver is the principle organ in the\\nbody responsible for removing toxic compounds. When\\nthe liver detoxifies a substance from the body, it does so\\nin two phases. Tests are performed that indicate where\\nproblems may be occurring in these phases, which may\\npoint to specific types of toxins. Blood and urine tests\\ncan also be completed that screen for toxic chemicals\\nsuch as PCBs (environmental poisons), formaldehyde (a\\ncommon preservative), pesticides, and heavy metals.\\nAnother useful blood test is a test for zinc deficiency,\\nwhich may reveal heavy metal poisoning. Hair analysis\\nis used to test for heavy metal levels in the body. Blood\\nand urine tests check immune system activity, and hor-\\nmone levels can also indicate specific toxic compounds.\\nA 24-hour urine analysis, where samples are taken\\naround the clock, allows therapists to determine the effi-\\nciency of the digestive tract and kidneys. Together with\\nstool analysis, these tests may indicate toxic bowel syn-\\ndrome and digestive system disorders. Certain blood and\\nurine tests may point to nutritional deficiencies and prop-\\ner recovery diets can be designed for patients as well.\\nDetoxification therapists may also perform extensive\\nallergy and hypersensitivity tests. Intradermal (between\\nlayers of the skin) and sublingual (under the tongue)\\nallergy tests are used to determine a patient’s sensitivity\\nto a variety of common substances, including formalde-\\nhyde, auto exhaust, perfume, tobacco, chlorine, jet fuel,\\nand other chemicals.\\nFood allergies require additional tests because these\\nallergies often cause reactions that are delayed for several\\ndays after the food is eaten. The RAST (radioallergosor-\\nbent test) is a blood test that determines the level of anti-\\nbodies (immunoglobulins) in the blood after specific\\nfoods are eaten. The cytotoxic test is a blood test that\\ndetermines if certain substances affect blood cells, includ-\\ning foods and chemicals. The ELISA-ACT (enzyme-\\nlinked immunoserological assay activated cell test) is\\nconsidered to be one of the most accurate tests for aller-\\ngies and hypersensitivity to foods, chemicals, and other\\nagents. Other tests for food allergies are the elimination\\nand rotation diets, in which foods are systematically eval-\\nuated to determine the ones that are causing problems.\\nDetoxification therapists usually interview and\\ncounsel patients closely to determine and correct\\nlifestyle, occupational, psychological, and emotional fac-\\ntors that may also be contributing to illness.\\nDetoxification therapies\\nDetoxification therapists use a variety of healing\\ntechniques after a diagnosis is made. The first step is to\\neliminate a patient’s exposure to all toxic or allergenic\\nsubstances. These include heavy metals, chemicals, radi-\\nation (from x rays, power lines, cell phones, computer\\nscreens, and microwaves), smog, polluted water, foods,\\ndrugs, caffeine , alcohol, perfume, excess noise, and\\nstress. If mercury poisoning has been determined, the\\npatient will be advised to have mercury fillings from the\\nteeth removed, preferably by a holistic dentist.\\nSpecific treatments are used to stimulate and assist\\nthe body’s detoxification process. Dietary change is\\nimmediately enacted, eliminating allergic and unhealthy\\nfoods, and emphasizing foods that assist detoxification\\nand support healing. Detoxification diets are generally\\nlow in fat, high in fiber, and vegetarian with a raw food\\nemphasis. Processed foods, alcohol, and caffeine are\\nGALE ENCYCLOPEDIA OF MEDICINE 21042\\nDetoxification'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 430, 'page_label': '431'}, page_content='avoided. Nutritional supplements such as vitamins, min-\\nerals, antioxidants, amino acids, and essential fatty acids\\nare often prescribed. Spirulina is a sea algae that is fre-\\nquently given to assist in eliminating heavy metals.\\nLipotropic agents are certain vitamins and nutrients that\\npromote the flow of bile and fat from the liver.\\nMany herbal supplements are used in detoxification\\ntherapies as well. Milk thistle extract, called silymarin, is\\none of the more potent herbs for detoxifying the liver.\\nNaturopathy, Ayurvedic medicine, and traditional Chi-\\nnese medicine (TCM) recommend numerous herbal for-\\nmulas for detoxification and immune strengthening. If\\ninfections or parasites have been found, these are treated\\nwith herbal formulas and, in difficult cases, antibiotics. \\nFor toxic bowel syndrome and digestive tract disor-\\nders, herbal laxatives and high fiber foods such as psylli-\\num seeds may be given to cleanse the digestive tract and\\npromote elimination. Colonics are used to cleanse the\\nlower intestines. Digestive enzymes are prescribed to\\nimprove digestion, and acidophilus and other friendly\\nbacteria are reintroduced into the system with nutritional\\nsupplements.\\nFasting is another major therapy in detoxification.\\nFasting is one of the quickest ways to promote the elimina-\\ntion of stored toxins in the body and to prompt the healing\\nprocess. People with severe toxic conditions are supervised\\nclosely during fasting because the number of toxins in the\\nbody temporarily increases as they are being released.\\nChelation therapy is used by detoxification special-\\nists to rid the body of heavy metals. Chelates are particu-\\nlar substances that bind to heavy metals and speed their\\nelimination. Homeopathic remedies have also been\\nshown to be effective for removing heavy metals.\\nSweating therapies can also detoxify the body\\nbecause the skin is a major organ of elimination. Sweating\\nhelps release those toxins that are stored in the subcuta-\\nneous (under the skin) fat cells. Saunas, therapeutic baths,\\nand exercise are some of these treatments. Body therapies\\nmay also be prescribed, including massage therapy, acu-\\npressure, shiatsu, manual lymph drainage, and polarity\\ntherapy. These body therapies seek to improve circulatory\\nand structural problems, reduce stress, and promote heal-\\ning responses in the body. Mind/body therapies such as\\npsychotherapy, counseling, and stress management tech-\\nniques may be used to heal the psychological components\\nof illness and to help patients overcome their negative pat-\\nterns contributing to illness.\\nPractitioners and treatment costs\\nThe costs of detoxification therapies can vary wide-\\nly, depending on the number of tests and treatments\\nrequired. Detoxification treatments can be lengthy and\\ninvolved since illnesses associated with toxic conditions\\nusually develop over many years and may not clear up\\nquickly. Detoxification treatments may be lengthy\\nbecause they often strive for the holistic healing of the\\nbody, mind, and emotions.\\nPractitioners may be conventionally trained medical\\ndoctors with specialties in environmental medicine or\\ninterests in alternative treatment. The majority of detoxi-\\nfication therapists are alternative practitioners, such as\\nnaturopaths, homeopaths, ayurvedic doctors, or tradition-\\nal Chinese doctors. Insurance coverage varies, depending\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1043\\nDetoxification\\nCommon Herbs Used For Detoxification\\nAntibiotics Anticatarrhals (Help Eliminate Mucus) Blood Cleaners\\nClove Boneset Burdock root\\nEchinacea Echinacea Dandelion root\\nEucalyptus Garlic Echinacea\\nGarlic Goldenseal root Oregon grape root\\nMyrrh Hyssop Red clover blossoms\\nPrickly ash bark Sage Yellow dock root\\nPropolis Yarrow\\nWormwood\\nDiaphoretics/Skin Cleaners Diuretics Laxatives\\nBoneset Cleavers Buckthorn\\nBurdock root Corn silk Cascara sagrada\\nCayenne pepper Horsetail Dandelion root\\nElder flowers Juniper berries Licorice root\\nGinger root Parsley leaf Rhubarb root\\nGoldenseal root Uva ursi Senna leaf\\nPeppermint Yarrow dock Yellow dock\\nOregon grape root\\nYellow dock'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 431, 'page_label': '432'}, page_content='on the practitioner and the treatment involved. Con-\\nsumers should review their individual insurance policies\\nregarding treatment coverage.\\nPreparations\\nPatients can assist diagnosis and treatment by keep-\\ning detailed diaries of their activities, symptoms, and\\ncontact with environmental factors that may be affecting\\ntheir health. Reducing exposure to environmental toxins\\nand making immediate dietary and lifestyle changes may\\nspeed the detoxification process.\\nSide effects\\nDuring the detoxification process, patients may expe-\\nrience side effects of fatigue, malaise, aches and pains,\\nemotional duress, acne, headaches, allergies, and symp-\\ntoms of colds and flu. Detoxification specialists claim that\\nthese negative side effects are part of the healing process.\\nThese reactions are sometimes called healing crises ,\\nwhich are caused by temporarily increased levels of tox-\\nins in the body due to elimination and cleansing.\\nResearch and general acceptance\\nAlthough environmental medicine is gaining more\\nrespect within conventional medicine, detoxification\\nKEY TERMS\\nAllergen —A foreign substance, such as mites in\\nhouse dust or animal dander, that when\\ninhaled,causes the airways to narrow and pro-\\nduces symptoms of asthma.\\nAntibody —A protein, also called immunoglobu-\\nlin, produced by immune system cells to remove\\nantigens (the foreign substances that trigger the\\nimmune response).\\nFibromyalgia —A condition of debilitating pain,\\namong other symptoms, in the muscles and the\\nmyofascia (the thin connective tissue that sur-\\nrounds muscles, bones, and organs).\\nHypersensitivity —The state where even a tiny\\namount of allergen can cause severe allergic reac-\\ntions.\\nMultiple chemical sensitivity —A condition char-\\nacterized by severe and crippling allergic reac-\\ntions to commonly used substances, particularly\\nchemicals. Also called environmental illness.\\ntreatment is scarcely mentioned by the medical establish-\\nment. The research that exists on detoxification is largely\\ntestimonial, consisting of individual personal accounts of\\nhealing without statistics or controlled scientific experi-\\nments. In the alternative medical community, detoxifica-\\ntion is an essential and widely accepted treatment for\\nmany illnesses and chronic conditions.\\nResources\\nBOOKS\\nGoldberg, Burton. Chronic Fatigue, Fibromyalgia and Envi-\\nronmental Illness. Tiburon, CA: Future Medicine, 1998.\\nLappe, Marc. Chemical Deception: The Toxic Threat to Health\\nand the Environment. San Francisco: Sierra Club, 1991.\\nLawson, Lynn. Staying Well in a Toxic World.Chicago: Noble,\\n1993.\\nRandolph, Theron G., M.D. Environmental Medicine: Begin-\\nnings and Bibliographies of Clinical Ecology.Fort\\nCollins, CO: Clinical Ecology Publications, 1987.\\nPERIODICALS\\nAlternative Therapies Magazine. P.O. Box 17969, Durham, NC\\n27715. (919) 668-8825. .\\nJournal of Occupational and Environmental Medicine.1114 N.\\nArlington Heights Rd., Arlington Heights, IL 60004.\\n(847) 818-1800.\\nORGANIZATIONS\\nAmerican Holistic Medical Association. 4101 Lake Boone\\nTrail, Suite 201, Raleigh, NC 27607.\\nCancer Prevention Coalition. 2121 West Taylor St., Chicago,\\nIL 60612. (312) 996-2297. .\\nCenter for Occupational and Environmental Medicine.7510\\nNorthforest Dr., North Charleston, SC 29420. (843) 572-\\n1600. .\\nNortheast Center for Environmental Medicine. P.O. Box 2716,\\nSyracuse, NY 13220. (800) 846-ONUS.\\nNorthwest Center for Environmental Medicine. 177 NE 102nd\\nSt., Portland, OR 97220. (503) 561-0966.\\nOTHER\\nA Citizens Toxic Waste Manual.Greenpeace USA, 1436 U St.\\nNW, Washington, DC 20009. (202) 462-1177.\\nDouglas Dupler\\nDeviated septum\\nDefinition\\nThe nasal septum is a thin structure, separating the\\ntwo sides of the nose. If it is not in the middle of the\\nnose, then it is deviated.\\nGALE ENCYCLOPEDIA OF MEDICINE 21044\\nDeviated septum'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 432, 'page_label': '433'}, page_content='Description\\nThe nasal septum is composed of two parts. Toward\\nthe back of the head the nasal septum is rigid bone, but\\nfurther forward the bone becomes cartilage. With one\\nfinger in each nostril this cartilage can easily be bent\\nback and forth. If the nasal septum is sufficiently dis-\\nplaced to one side, it will impede the flow of air and\\nmucus through the nose. This condition, called a deviat-\\ned septum, can cause symptoms and disease.\\nCauses and symptoms\\nA deviated septum can be a simple variation in nor-\\nmal structure or the result of a broken nose. Any narrow-\\ning of the nasal passageway that it causes will threaten\\nthe drainage of secretions from the sinuses, which must\\npass through the nose. It is a general rule of medicine\\nthat when flow is obstructed, whether it is mucus from\\nthe sinuses or bile from the gall bladder, infection results.\\nPeople with allergic rhinitis (hay fever) are at greater\\nrisk of obstruction because their nasal passageways are\\nalready narrowed by the swollen membranes lining them.\\nThe result is sinusitis, which can be acute and severe or\\nchronic and lingering.\\nDiagnosis\\nIt is easy to see that a septum is deviated. It is more\\ndifficult to determine if that deviation needs correction. It\\nis common for a patient to complain that he/she can\\nbreathe through only one nostril. Then the diagnosis is\\neasy. A deviated septum may also contribute to snoring,\\nsleep apnea, and other breathing disorders.\\nTreatment\\nThe definitive treatment is surgical repositioning of\\nthe septum, accomplished by breaking it loose and fixing\\nit in a proper place while it heals. Decongestants like\\npseudoephedrine or phenylpropanolamine will shrink the\\nmembranes and thereby enlarge the passages. Antihista-\\nmines, nasal cortisone spray, and other allergy treat-\\nments may also be temporarily beneficial.\\nAlternative treatment\\nAs a palliative, saline drops and sprays are very help-\\nful in loosening mucus in the obstructed side and prevent-\\ning drying in the other side, where all the air blows. Hot\\npeppers, such as jalapenos, can produce enough tears and\\ndischarge to flush out a stopped-up nose. An even more\\neffective treatment is called a nasal lavage, often done\\nusing a small pot with a spout. Saline solution is poured\\ninto one nostril and allowed to flow out the other nostril.\\nThen, the process is repeated in reverse. These therapies\\nare all useful to take care of symptoms, but do not correct\\nthe problem. Nasospecific, a procedure where a deflated\\nballoon is inserted in the nostril and inflated to a large\\nenough degree to adjust the septal deviation, can be an\\nalternative to surgery. A trained practitioner in the\\nnasospecific procedure is necessary.\\nPrognosis\\nSurgical repair is curative and carries little risk.\\nChronic infection can be painful and lead to complica-\\ntions until it is resolved. If there is continued obstruction,\\nthe infection will very likely return.\\nPrevention\\nAvoidance of virus colds, airborne dusts, air pollu-\\ntion, and known allergens will minimize the irritation\\nand swelling of the membranes lining the nasal passages.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1045\\nDeviated septum\\nA close-up of person with a deviated septum.(Custom Med-\\nical Stock Photo. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 433, 'page_label': '434'}, page_content='Resources\\nBOOKS\\nBallenger, John Jacob. Disorders of the Nose, Throat, Ear,\\nHead, and Neck. Philadelphia: Lea & Febiger, 1991.\\nJ. Ricker Polsdorfer, MD\\nDextromethorphan see Cough suppressants\\nDiabetes insipidus\\nDefinition\\nDiabetes insipidus (DI) is a disorder that causes the\\npatient to produce tremendous quantities of urine. The\\nmassively increased urine output is usually accompanied\\nby intense thirst.\\nDescription\\nThe balance of fluid within the body is maintained\\nthrough a number of mechanisms. One important chemi-\\ncal involved in fluid balance is called antidiuretic hor-\\nmone (ADH). ADH is produced by the pituitary, a small\\ngland located at the base of the brain. In a healthy person\\nand under normal conditions, ADH is continuously\\nKEY TERMS\\nAllergen—Any substance that irritates people sen-\\nsitive (allergic) to it.\\nAllergic rhinitis —Swelling and inflammation of\\nthe nasal membranes caused by sensitivity to air-\\nborne matter like pollen or cat hair.\\nSaline—A salt solution in water. Normal saline has\\nthe same salt concentration as the body, 0.9%.\\nSinuses—The nasal sinuses, air-filled cavities sur-\\nrounding the eyes and nose, like the nose itself are\\nlined with mucus-producing membranes. They\\nprovide cleansing to the nose, resonance to the\\nvoice, and structure to the face.\\nSinusitis—Infection of the sinuses.\\nSleep apnea —A condition in which breathing is\\ntemporarily interrupted during sleep. It leads to\\nhigh blood pressure, sleepiness, and a variety of\\nother problems.\\nreleased. ADH influences the amount of fluid that the\\nkidneys reabsorb into the circulatory system and the\\namount of fluid that the kidneys pass out of the body in\\nthe form of urine.\\nProduction of ADH is regulated by the osmolality of\\nthe circulating blood. Osmolality refers to the concentra-\\ntion of dissolved chemicals (such as sodium, potassium,\\nand chloride; together called solute) circulating in the\\nfluid base of the blood (plasma). When there is very little\\nfluid compared to the concentration of solute, the pitu-\\nitary will increase ADH production. This tells the kid-\\nneys to retain more water and to decrease the amount of\\nurine produced. As fluid is retained, the concentration of\\nsolute will normalize. At other times, when the fluid con-\\ntent of the blood is high in comparison to the concentra-\\ntion of solute, ADH production will decrease. The kid-\\nneys are then free to pass an increased amount of fluid\\nout of the body in the urine. Again, this will allow the\\nplasma osmolality to return to normal.\\nDiabetes insipidus occurs when either the amount of\\nADH produced by the pituitary is below normal (central\\nDI), or the kidneys’ ability to respond to ADH is defective\\n(nephrogenic DI). In either case, a person with DI will\\npass extraordinarily large quantities of urine, sometimes\\nreaching 10 or more liters each day. At the same time, the\\npatient’s blood will be very highly concentrated, with low\\nfluid volume and high concentrations of solute.\\nDI occurs on average when a person is about 24\\nyears old, and occurs more frequently in males than in\\nfemales.\\nCauses and symptoms\\nDI may run in families. The cause of this type of DI\\nis unknown. Other times, central DI can be caused by:\\n• an injury to the head\\n• brain surgery\\n• cancers that have spread to the pituitary gland (most\\ncommonly occurring with breast cancer)\\n• sarcoidosis (or other related disorders), causing\\ndestruction of the pituitary gland\\n• any condition or illness that causes decreased oxygen\\ndelivery to the brain\\n• the use of certain medications that decrease ADH produc-\\ntion (like the antiseizure drug phenytoin)\\n• the excessive use of alcohol\\nCentral DI may also occur in women who are preg-\\nnant or have just given birth, and in patients with AIDS\\nwho have suffered certain types of brain infections.\\nNephrogenic DI sometimes occurs in patients who are\\nGALE ENCYCLOPEDIA OF MEDICINE 21046\\nDiabetes insipidus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 434, 'page_label': '435'}, page_content='taking the medication lithium, patients who have high\\nlevels of blood calcium, and patients who are pregnant.\\nDI is easily confused with an entirely unrelated dis-\\norder, psychogenic polydipsia. Polydipsia refers to\\ndrinking large amounts of water. Psychogenic polydipsia\\nis a psychiatric problem that makes a person drink huge\\nquantities of water uncontrollably.\\nSymptoms of DI include extreme thirst and the pro-\\nduction of tremendous quantities of urine. Patients with\\nDI typically drink huge amounts of water, and usually\\nreport a specific craving for cold water. When the amount\\nof water passed in the urine exceeds the patient’s ability\\nto drink ample replacement water, the patient may begin\\nto suffer from symptoms of dehydration . These symp-\\ntoms include weakness, fatigue, fever, low blood pres-\\nsure, increased heart rate, dizziness , and confusion. If\\nleft untreated, the patient could lapse into unconscious-\\nness and die.\\nDiagnosis\\nDiagnosis should be suspected in any patient with\\nsudden increased thirst and urination. Laboratory exami-\\nnation of urine will reveal very dilute urine, made up\\nmostly of water with no solute. Examination of the blood\\nwill reveal very concentrated blood, high in solute and\\nlow in fluid volume.\\nA water deprivation test may be performed. This test\\nrequires a patient to stop all fluid intake. The patient is\\nweighed just before the test begins, and urine is collected\\nand examined hourly. The test is stopped when:\\n• the patient has lost more than 5% of his or her original\\nbody weight\\n• the patient has reached certain limits of low blood pres-\\nsure and increased heart rate\\n• the urine is no longer changing significantly from one\\nsample to the next in terms of solute concentration\\nThe next step of the test involves injecting a synthet-\\nic form of ADH, with one last urine sample examined 60\\nminutes later. Comparing plasma and urine osmolality\\nallows the doctor to diagnose either central DI, nephro-\\ngenic DI, partial DI, or psychogenic polydipsia.\\nTreatment\\nA number of medications can be given to decrease\\nthe quantity of fluid passed out into the urine. These\\ninclude vasopressin (Pitressin) injected and desmo-\\npressin acetate (DDA VP) inhaled through the nose. Other\\nmedications that may be given include some antidiuretic\\ndrugs (chlorpropamide, clofibrate, carbamazepine).\\nPatients with nephrogenic DI, however, will also require\\nKEY TERMS\\nConcentration—Refers to the amount of solute pre-\\nsent in a solution, compared to the total amount of\\nsolvent.\\nDilute—A solution that has comparatively more\\nfluid in it, relative to the quantity of solute.\\nOsmolality —A measure of the solute-to-solvent\\nconcentration of a solution.\\nSolute—Solid substances that are dissolved in liq-\\nuid in order to make a solution.\\nspecial diets that restrict the amount of solute taken in.\\nThese patients are also treated with a type of medication\\ncalled a thiazide diuretic.\\nPrognosis\\nUncomplicated diabetes insipidus is controllable\\nwith adequate intake of water and most patients can lead\\nnormal lives.\\nResources\\nBOOKS\\nFishman, Mark C., et al. Medicine. Philadelphia: J. B. Lippin-\\ncott Co., 1996.\\nMoses, Arnold M., and David H. P. Streeten. “Deficiency of\\nVasopressin: Diabetes Insipidus.” In Harrison’s Principles\\nof Internal Medicine, ed. Anthony S. Fauci, et al. New\\nYork: McGraw-Hill, 1997.\\nPERIODICALS\\nAdam, Patricia. “Evaluation and Management of Diabetes\\nInsipidus.” American Family Physician 55, no. 6 (1 May\\n1997): 2146+.\\nSinger, Irwin, et al. “The Management of Diabetes Insipidus in\\nAdults.” Archives of Internal Medicine 157, no. 12 (23\\nJune 1997): 1293+.\\nRosalyn Carson-DeWitt, MD\\nDiabetes mellitus\\nDefinition\\nDiabetes mellitus is a condition in which the pan-\\ncreas no longer produces enough insulin or when cells\\nstop responding to the insulin that is produced, so that\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1047\\nDiabetes mellitus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 435, 'page_label': '436'}, page_content='glucose in the blood cannot be absorbed into the cells of\\nthe body. Symptoms include frequent urination, lethargy,\\nexcessive thirst, and hunger. The treatment includes\\nchanges in diet, oral medications, and in some cases,\\ndaily injections of insulin.\\nDescription\\nDiabetes mellitus is a chronic disease that causes\\nserious health complications including renal (kidney)\\nfailure, heart disease, stroke, and blindness. Approxi-\\nmately 14 million Americans (about 5% of the popula-\\ntion) have diabetes. Unfortunately, as many as one-half\\nare unaware that they have it.\\nBackground\\nEvery cell in the human body needs energy in order\\nto function. The body’s primary energy source is glu-\\ncose, a simple sugar resulting from the digestion of\\nfoods containing carbohydrates (sugars and starches).\\nGlucose from the digested food circulates in the blood\\nas a ready energy source for any cells that need it.\\nInsulin is a hormone or chemical produced by cells in\\nthe pancreas, an organ located behind the stomach.\\nInsulin bonds to a receptor site on the outside of cell and\\nacts like a key to open a doorway into the cell through\\nwhich glucose can enter. Some of the glucose can be\\nconverted to concentrated energy sources like glycogen\\nor fatty acids and saved for later use. When there is not\\nenough insulin produced or when the doorway no longer\\nrecognizes the insulin key, glucose stays in the blood\\nrather entering the cells.\\nThe body will attempt to dilute the high level of\\nglucose in the blood, a condition called hyperglycemia,\\nby drawing water out of the cells and into the blood-\\nstream in an effort to dilute the sugar and excrete it in\\nthe urine. It is not unusual for people with undiagnosed\\ndiabetes to be constantly thirsty, drink large quantities of\\nwater, and urinate frequently as their bodies try to get rid\\nof the extra glucose. This creates high levels of glucose\\nin the urine.\\nAt the same time that the body is trying to get rid\\nof glucose from the blood, the cells are starving for glu-\\ncose and sending signals to the body to eat more food,\\nthus making patients extremely hungry. To provide\\nenergy for the starving cells, the body also tries to con-\\nvert fats and proteins to glucose. The breakdown of fats\\nand proteins for energy causes acid compounds called\\nketones to form in the blood. Ketones will also be\\nexcreted in the urine. As ketones build up in the blood,\\na condition called ketoacidosis can occur. This condi-\\ntion can be life threatening if left untreated, leading to\\ncoma and death.\\nTypes of diabetes mellitus\\nType I diabetes, sometimes called juvenile diabetes,\\nbegins most commonly in childhood or adolescence. In\\nthis form of diabetes, the body produces little or no\\ninsulin. It is characterized by a sudden onset and occurs\\nmore frequently in populations descended from Northern\\nEuropean countries (Finland, Scotland, Scandinavia) than\\nin those from Southern European countries, the Middle\\nEast, or Asia. In the United States, approximately three\\npeople in 1,000 develop Type I diabetes. This form is also\\ncalled insulin-dependent diabetes because people who\\ndevelop this type need to have daily injections of insulin.\\nBrittle diabetics are a subgroup of Type I where\\npatients have frequent and rapid swings of blood sugar\\nlevels between hyperglycemia (a condition where there is\\ntoo much glucose or sugar in the blood) and hypo-\\nglycemia (a condition where there is abnormally low lev-\\nels of glucose or sugar in the blood). These patients may\\nrequire several injections of different types of insulin\\nduring the day to keep the blood sugar level within a fair-\\nly normal range.\\nThe more common form of diabetes, Type II, occurs\\nin approximately 3–5% of Americans under 50 years of\\nage, and increases to 10–15% in those over 50. More\\nthan 90% of the diabetics in the United States are Type II\\ndiabetics. Sometimes called age-onset or adult-onset dia-\\nbetes, this form of diabetes occurs most often in people\\nwho are overweight and who do not exercise . It is also\\nmore common in people of Native American, Hispanic,\\nand African-American descent. People who have migrat-\\ned to Western cultures from East India, Japan, and Aus-\\ntralian Aboriginal cultures are also more likely to devel-\\nop Type II diabetes than those who remain in their origi-\\nnal countries.\\nType II is considered a milder form of diabetes\\nbecause of its slow onset (sometimes developing over the\\ncourse of several years) and because it can usually be\\ncontrolled with diet and oral medication. The conse-\\nquences of uncontrolled and untreated Type II diabetes,\\nhowever, are the just as serious as those for Type I. This\\nform is also called noninsulin-dependent diabetes, a term\\nthat is somewhat misleading. Many people with Type II\\ndiabetes can control the condition with diet and oral\\nmedications, however, insulin injections are sometimes\\nnecessary if treatment with diet and oral medication is\\nnot working.\\nAnother form of diabetes called gestational dia-\\nbetes can develop during pregnancy and generally\\nresolves after the baby is delivered. This diabetic condi-\\ntion develops during the second or third trimester of\\npregnancy in about 2% of pregnancies. The condition is\\nusually treated by diet, however, insulin injections may\\nGALE ENCYCLOPEDIA OF MEDICINE 21048\\nDiabetes mellitus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 436, 'page_label': '437'}, page_content='be required. These women who have diabetes during\\npregnancy are at higher risk for developing Type II dia-\\nbetes within 5–10 years.\\nDiabetes can also develop as a result of pancreatic\\ndisease, alcoholism , malnutrition , or other severe ill-\\nnesses that stress the body.\\nCauses and symptoms\\nCauses\\nThe causes of diabetes mellitus are unclear, howev-\\ner, there seem to be both hereditary (genetic factors\\npassed on in families) and environmental factors\\ninvolved. Research has shown that some people who\\ndevelop diabetes have common genetic markers. In Type\\nI diabetes, the immune system, the body’s defense sys-\\ntem against infection, is believed to be triggered by a\\nvirus or another microorganism to destroy the cells in the\\npancreas that produce insulin. In Type II diabetes, age,\\nobesity, and family history of diabetes play a roll.\\nIn Type II diabetes, the pancreas may produce\\nenough insulin, however, cells have become resistant to\\nthe insulin produced and it may not work as effectively.\\nSymptoms of Type II diabetes can begin so gradually that\\na person may not know that they have it. Early signs are\\nlethargy extreme thirst, and frequent urination. Other\\nsymptoms may include sudden weight loss, slow wound\\nhealing, urinary tract infections, gum disease, or blurred\\nvision. It is not unusual for Type II diabetes to be detect-\\ned while a patient is seeing a doctor about another health\\nconcern that is actually being caused by the yet undiag-\\nnosed diabetes.\\nIndividuals who are at high risk of developing Type\\nII diabetes mellitus include people who:\\n• are obese (more than 20% above their ideal body\\nweight)\\n• have a relative with diabetes mellitus\\n• belong to a high-risk ethnic population (African-Amer-\\nican, Native American, Hispanic, or Native Hawaiian)\\n• have been diagnosed with gestational diabetes or have\\ndelivered a baby weighing more than 9 lbs (4 kg)\\n• have high blood pressure (140/90 mmHg or above)\\n• have a high density lipoprotein cholesterol level less\\nthan or equal to 35 mg/dL and/or a triglyceride level\\ngreater than or equal to 250 mg/dL\\n• have had impaired glucose tolerance or impaired fast-\\ning glucose on previous testing\\nSeveral common medications can impair the body’s\\nuse of insulin, causing a condition known as secondary\\ndiabetes. These medications include treatments for high\\nblood pressure (furosemide, clonidine, and thiazide\\ndiuretics ), drugs with hormonal activity ( oral contra-\\nceptives , thyroid hormone, progestins, and glucocorti-\\ncorids), and the anti-inflammation drug indomethacin.\\nSeveral drugs that are used to treat mood disorders\\n(such as anxiety and depression) can also impair glucose\\nabsorption. These drugs include haloperidol, lithium car-\\nbonate, phenothiazines, tricyclic antidepressants, and\\nadrenergic agonists. Other medications that can cause\\ndiabetes symptoms include isoniazid, nicotinic acid,\\ncimetidine, and heparin.\\nSymptoms\\nSymptoms of diabetes can develop suddenly (over\\ndays or weeks) in previously healthy children or adoles-\\ncents, or can develop gradually (over several years) in\\noverweight adults over the age of 40. The classic symp-\\ntoms include feeling tired and sick, frequent urination,\\nexcessive thirst, excessive hunger, and weight loss.\\nKetoacidosis, a condition due to starvation or\\nuncontrolled diabetes, is common in Type I diabetes.\\nKetones are acid compounds that form in the blood when\\nthe body breaks down fats and proteins. Symptoms\\ninclude abdominal pain, vomiting, rapid breathing,\\nextreme lethargy and drowsiness. Patients with ketoaci-\\ndosis will also have a sweet breath odor. Left untreated,\\nthis condition can lead to coma and death.\\nWith Type II diabetes, the condition may not become\\nevident until the patient presents for medical treatment for\\nsome other condition. A patient may have heart disease,\\nchronic infections of the gums and urinary tract, blurred\\nvision, numbness in the feet and legs, or slow-healing\\nwounds. Women may experience genital itching.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1049\\nDiabetes mellitus\\nWrinkled, dehydrated skin of a person in a diabetic coma.\\nUntreated diabetes mellitus results in elevated blood glu-\\ncose levels, causing a variety of symptoms that can culmi-\\nnate in a diabetic coma. (Photo Researchers, Inc. Reproduced\\nby permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 437, 'page_label': '438'}, page_content='Diagnosis\\nDiabetes is suspected based on symptoms. Urine and\\nblood tests can be used to confirm a diagnose of diabetes\\nbased on the amount of glucose. Urine tests can also\\ndetect ketones and protein in the urine that may help\\ndiagnose diabetes and assess how well the kidneys are\\nfunctioning. These tests can also be used to monitor the\\ndisease once the patient is on a standardized diet, oral\\nmedications, or insulin.\\nUrine tests\\nClinistix and Diastix are paper strips or dipsticks\\nthat change color when dipped in urine. The test strip is\\ncompared to a chart which shows the amount of glucose\\nin the urine based on the change in color. The level of\\nglucose in the urine lags behind the level of glucose in\\nthe blood. Testing the urine with a test stick, paper strip,\\nor tablet that changes color when sugar is present is not\\nas accurate as blood testing, however it can give a fast\\nand simple reading.\\nKetones in the urine can be detected using similar\\ntypes of dipstick tests (Acetest or Ketostix). Ketoacidosis\\ncan be a life-threatening situation in Type I diabetics, so\\nhaving a quick and simple test to detect ketones can\\nassist in establishing a diagnosis sooner.\\nAnother dipstick test can determine the presence of\\nprotein or albumin in the urine. Protein in the urine can\\nKEY TERMS\\nCataracts —A condition where the lens of the eye\\nbecomes cloudy.\\nDiabetic peripheral neuropathy—A condition where\\nthe sensitivity of nerves to pain, temperature, and\\npressure is dulled particularly in the legs and feet.\\nDiabetic retinopathy —A condition where the tiny\\nblood vessels to the retina, the tissues that sense\\nlight at the back of the eye, are damaged, leading to\\nblurred vision, sudden blindness, or black spots,\\nlines, or flashing light in the field of vision.\\nGlaucoma—A condition where pressure within the\\neye causes damage to the optic nerve, which sends\\nvisual images to the brain.\\nHyperglycemia —A condition where there is too\\nmuch glucose or sugar in the blood.\\nHypoglycemia—A condition where there is too lit-\\ntle glucose or sugar in the blood.\\nInsulin—A hormone or chemical produced by the\\npancreas, insulin is needed by cells of the body in\\norder to use glucose (sugar), the body’s main source\\nof energy.\\nKetoacidosis —A condition due to starvation or\\nuncontrolled Type I diabetes. Ketones are acid com-\\npounds that form in the blood when the body\\nbreaks down fats and proteins. Symptoms include\\nabdominal pain, vomiting, rapid breathing, extreme\\ntiredness, and drowsiness.\\nKidney dialysis —A process where blood is filtered\\nthrough a dialysis machine to remove waste prod-\\nucts that would normally be removed by the kid-\\nneys. The filtered blood is then circulated back into\\nthe patient. This process is also called renal dialysis.\\nPancreas—A gland located behind the stomach that\\nproduces insulin.\\nindicate problems with kidney function and can be used\\nto track the development of renal failure. A more sensitive\\ntest for urine protein uses radioactively tagged chemicals\\nto detect microalbuminuria, small amounts of protein in\\nthe urine, that may not show up on dipstick tests.\\nBlood tests\\nFASTING GLUCOSE TEST. Blood is drawn from a vein\\nin the patient’s arm after a period at least eight hours when\\nthe patient has not eaten, usually in the morning before\\nbreakfast. The red blood cells are separated from the sam-\\nple and the amount of glucose is measured in the remain-\\ning plasma. A plasma level of 7.8 mmol/L (200 mg/L) or\\ngreater can indicate diabetes. The fasting glucose test is\\nusually repeated on another day to confirm the results.\\nPOSTPRANDIAL GLUCOSE TEST. Blood is taken right\\nafter the patient has eaten a meal.\\nORAL GLUCOSE TOLERANCE TEST. Blood samples are\\ntaken from a vein before and after a patient drinks a thick,\\nsweet syrup of glucose and other sugars. In a non-diabet-\\nic, the level of glucose in the blood goes up immediately\\nafter the drink and then decreases gradually as insulin is\\nused by the body to metabolize, or absorb, the sugar. In a\\ndiabetic, the glucose in the blood goes up and stays high\\nafter drinking the sweetened liquid. A plasma glucose\\nlevel of 11.1 mmol/L (200 mg/dL) or higher at two hours\\nafter drinking the syrup and at one other point during the\\ntwo-hour test period confirms the diagnosis of diabetes.\\nGALE ENCYCLOPEDIA OF MEDICINE 21050\\nDiabetes mellitus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 438, 'page_label': '439'}, page_content='A diagnosis of diabetes is confirmed if there are\\nsymptoms of diabetes and a plasma glucose level of at\\nleast 11.1 mmol/L, a fasting plasma glucose level of at\\nleast 7 mmol/L; or a two-hour plasma glucose level of at\\nleast 11.1 mmol/L during an oral glucose tolerance test.\\nHome blood glucose monitoring kits are available so\\npatients with diabetes can monitor their own levels. A\\nsmall needle or lancet is used to prick the finger and a\\ndrop of blood is collected and analyzed by a monitoring\\ndevice. Some patients may test their blood glucose levels\\nseveral times during a day and use this information to\\nadjust their doses of insulin.\\nTreatment\\nThere is currently no cure for diabetes; the condi-\\ntion, however, can be managed so that patients can live a\\nrelatively normal life. Treatment of diabetes focuses on\\ntwo goals: keeping blood glucose within normal range\\nand preventing the development of long-term complica-\\ntions. Careful monitoring of diet, exercise, and blood\\nglucose levels are as important as the use of insulin or\\noral medications in preventing complications of diabetes.\\nDietary changes\\nDiet and moderate exercise are the first treatments\\nimplemented in diabetes. For many Type II diabetics,\\nweight loss may be an important goal in helping them to\\ncontrol their diabetes. A well-balanced, nutritious diet pro-\\nvides approximately 50–60% of calories from carbohy-\\ndrates, approximately 10–20% of calories from protein,\\nand less than 30% of calories from fat. The number of\\ncalories required by an individual depends on their age,\\nweight, and activity level. The calorie intake also needs to\\nbe distributed over the course of the entire day so surges of\\nglucose entering the blood system are kept to a minimum.\\nKeeping track of the number of calories provided by\\ndifferent foods can become complicated, so patients are\\nusually advised to consult a nutritionist or dietitian. An\\nindividualized, easy to manage diet plan can be set up for\\neach patient. Both the American Diabetes Association and\\nthe American Dietetic Association recommend diets based\\non the use of food exchange lists. Each food exchange\\ncontains a known amount of calories in the form of pro-\\ntein, fat, or carbohydrate. A patient’s diet plan will consist\\nof a certain number of exchanges from each food category\\n(meat or protein, fruits, breads and starches, vegetables,\\nand fats) to be eaten at meal times and as snacks. Patients\\nhave flexibility in choosing which foods they eat as long\\nas they stick with the number of exchanges prescribed.\\nFor many Type II diabetics, weight loss is an impor-\\ntant factor in controlling their condition. The food\\nexchange system, along with a plan of moderate exer-\\ncise, can help them lose excess weight and improve their\\noverall health.\\nOral medications\\nOral medications are available to lower blood glucose\\nin Type II diabetics. The drugs first prescribed for Type II\\ndiabetes are in a class of compounds called sulfonylureas\\nand include tolbutamide, tolazamide, acetohexamide, and\\nchlorpropamide. Newer drugs in the same class are now\\navailable and include glyburide, glimeperide, and glip-\\nizide. The way that these drugs work is not well under-\\nstood, however, they seem to stimulate cells of the pan-\\ncreas to produce more insulin. New medications that are\\navailable to treat diabetes include metformin, acarbose,\\nand troglitizone. The choice of the right medication\\ndepends in part on the individual patient profile. All drugs\\nhave side effects that may make them inappropriate for\\nparticular patients. Some for example, may stimulate\\nweight gain or cause stomach irritation, so they may not be\\nthe best treatment for someone who is already overweight\\nor who also has stomach ulcers. While these medications\\nare an important aspect of treatment for Type II diabetes,\\nthey are not a substitute for a well planned diet and moder-\\nate exercise. Oral medications are not effective for Type I\\ndiabetes, in which the patient produces little or no insulin.\\nInsulin\\nPatients with Type I diabetes need daily injections of\\ninsulin to help their bodies use glucose. The amount and\\ntype of insulin required depends on the height, weight,\\nage, food intake, and activity level of the individual dia-\\nbetic patient. Some patients with Type II diabetes may\\nneed to use insulin injections if their diabetes cannot be\\ncontrolled with diet, exercise, and oral medication. Injec-\\ntions are given subcutaneously, that is, just under the\\nskin, using a small needle and syringe. Injection sites can\\nbe anywhere on the body where there is looser skin,\\nincluding the upper arm, abdomen, or upper thigh.\\nPurified human insulin is most commonly used,\\nhowever, insulin from beef and pork sources are also\\navailable. Insulin may be given as an injection of a single\\ndose of one type of insulin once a day. Different types of\\ninsulin can be mixed and given in one dose or split into\\ntwo or more doses during a day. Patients who require\\nmultiple injections over the course of a day may be able\\nto use an insulin pump that administers small doses of\\ninsulin on demand. The small battery-operated pump is\\nworn outside the body and is connected to a needle that is\\ninserted into the abdomen. Pumps can be programmed to\\ninject small doses of insulin at various times during the\\nday, or the patient may be able to adjust the insulin doses\\nto coincide with meals and exercise.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1051\\nDiabetes mellitus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 439, 'page_label': '440'}, page_content='Regular insulin is fast-acting and starts to work within\\n15–30 minutes, with its peak glucose-lowering effect\\nabout two hours after it is injected. Its effects last for about\\nfour to six hours. NPH (neutral protamine Hagedorn) and\\nLente insulin are intermediate-acting, starting to work\\nwithin one to three hours and lasting up to 18–26 hours.\\nUltra-lente is a long-acting form of insulin that starts to\\nwork within four to eight hours and lasts 28–36 hours.\\nHypoglycemia, or low blood sugar, can be caused by\\ntoo much insulin, too little food (or eating too late to\\ncoincide with the action of the insulin), alcohol con-\\nsumption, or increased exercise. A patient with symp-\\ntoms of hypoglycemia may be hungry, cranky, confused,\\nand tired. The patient may become sweaty and shaky.\\nLeft untreated, the patient can lose consciousness or have\\na seizure. This condition is sometimes called an insulin\\nreaction and should be treated by giving the patient\\nsomething sweet to eat or drink like a candy, sugar cubes,\\njuice, or another high sugar snack.\\nSurgery\\nTransplantation of a healthy pancreas into a diabetic\\npatient is a successful treatment, however, this transplant\\nis usually done only if a kidney transplant is performed at\\nthe same time. Although a pancreas transplant is possi-\\nble, it is not clear if the potential benefits outweigh the\\nrisks of the surgery and drug therapy needed.\\nAlternative treatment\\nSince diabetes can be life-threatening if not properly\\nmanaged, patients should not attempt to treat this condi-\\ntion without medicial supervision. A variety of alterna-\\ntive therapies can be helpful in managing the symptoms\\nof diabetes and supporting patients with the disease.\\nAcupuncture can help relieve the pain associated with\\ndiabetic neuropathy by stimulation of cetain points. A\\nqualified practitioner should be consulted. Herbal reme-\\ndies may also be helpful in managing diabetes. Although\\nthere is no herbal substitute for insulin, some herbs may\\nhelp adjust blood sugar levels or manage other diabetic\\nsymptoms. Some options include:\\n• fenugreek ( Trigonella foenum-graecum ) has been\\nshown in some studies to reduce blood insulin and glu-\\ncose levels while also lowering cholesterol\\n• bilberry (Vaccinium myrtillus ) may lower blood glu-\\ncose levels, as well as helping to maintain healthy\\nblood vessels\\n• garlic (Allium sativum) may lower blood sugar and cho-\\nlesterol levels\\n• onions (Allium cepa ) may help lower blood glucose\\nlevels by freeing insulin to metabolize it\\n• cayenne pepper (Capsicum frutescens) can help relieve\\npain in the peripheral nerves (a type of diabetic neu-\\nropathy)\\n• ginkgo (Gingko biloba) may maintain blood flow to the\\nretina, helping to prevent diabetic retinopathy\\nAny therapy that lowers stress levels can also be use-\\nful in treating diabetes by helping to reduce insulin\\nrequirements. Among the alternative treatments that aim\\nto lower stress are hypnotherapy , biofeedback , and\\nmeditation.\\nPrognosis\\nUncontrolled diabetes is a leading cause of blind-\\nness, end-stage renal disease, and limb amputations. It\\nalso doubles the risks of heart disease and increases the\\nrisk of stroke. Eye problems including cataracts , glau-\\ncoma, and diabetic retinopathy are also more common in\\ndiabetics.\\nDiabetic peripheral neuropathy is a condition\\nwhere nerve endings, particularly in the legs and feet\\nbecome less sensitive. Diabetic foot ulcers are a partic-\\nular problem since the patient does not feel the pain of\\na blister, callous, or other minor injury. Poor blood cir-\\nculation in the legs and feet contribute to delayed\\nwound healing. The inability to sense pain along with\\nthe complications of delayed wound healing can result\\nin minor injuries, blisters, or callouses becoming\\ninfected and difficult to treat. In cases of severe infec-\\ntion, the infected tissue begins to break down and rot\\naway. The most serious consequence of this condition\\nis the need for amputation of toes, feet, or legs due to\\nsevere infection.\\nHeart disease and kidney disease are common com-\\nplications of diabetes. Long-term complications may\\ninclude the need for kidney dialysis or a kidney trans-\\nplant due to kidney failure.\\nBabies born to diabetic mothers have an increased\\nrisk of birth defects and distress at birth.\\nPrevention\\nResearch continues on ways to prevent diabetes and\\nto detect those at risk for developing diabetes. While the\\nonset of Type I diabetes is unpredictable, the risk of\\ndeveloping Type II diabetes can be reduced by maintain-\\ning ideal weight and exercising regularly. The physical\\nand emotional stress of surgery, illness, pregnancy, and\\nalcoholism can increase the risks of diabetes, so main-\\ntaining a healthy lifestyle is critical to preventing the\\nonset of Type II diabetes and preventing further compli-\\ncations of the disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 21052\\nDiabetes mellitus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 440, 'page_label': '441'}, page_content='Resources\\nBOOKS\\n“Diabetes Mellitus.” In Professional Guide to Diseases. 5th ed.\\nSpringhouse, PA: Springhouse Corporation, 1995.\\nFoster, Daniel W. “Diabetes Mellitus.” In Harrison’s Principles\\nof Internal Medicine, ed. Anthony S. Fauci, et al. New\\nYork: McGraw-Hill, 1997.\\nGarber, Alan J. “Diabetes Mellitus.” In Internal Medicine,e d .\\nJay H. Stein, et al. St. Louis: Mosby, 1998.\\nKaram, John H. “Diabetes Mellitus & Hypoglycemia.” In Cur-\\nrent Medical Diagnosis and Treatment, 1998.37th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange,\\n1997.\\nSherwin, Robert S. “Diabetes Mellitus.” In Cecil Textbook of\\nMedicine, ed. J. Claude Bennett and Fred Plum. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nSmit, Charles Kent, John P. Sheehan, and Margaret M. Ulchak-\\ner. “Diabetes Mellitus.” In Family Medicine, Principles\\nand Practice. 5th ed. Ed. Robert B. Taylor. New York:\\nSpringer-Verlag, 1998.\\nPERIODICALS\\n“Trends in the Prevalence and Incidence of Self-Reported Dia-\\nbetes Mellitus-United States, 1980-1994.”Morbidity &\\nMortality Weekly Report46 (1997): 1014-1018.\\n“Updated Guidelines for the Diagnosis of Diabetes in the US.”\\nDrugs & Therapy Perspectives10 (1997): 12-13.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard Street,\\nAlexandria, V A 22311. (800) 342-2383. .\\nAmerican Dietetic Association. 216 W. Jackson Blvd., Chicago,\\nIL 60606-6995. (312) 899-0040. .\\nJuvenile Diabetes Foundation. 120 Wall St., 19th Floor, New\\nYork, NY 10005. (800) 533-2873. .\\nNational Diabetes Information Clearinghouse. 1 Information\\nWay, Bethesda, MD 20892-3560. (800) 860-8747. .\\nNational Institute of Diabetes and Digestive and Kidney Dis-\\neases (NIDDK). Building 31, Room 9A04, 31 Center\\nDrive, MSC 2560, Bethesda, MD 208792-2560. (301)\\n496-3583. .\\nOTHER\\nCenters for Disease Control. .\\n“Insulin-Dependent Diabetes.” National Institute of Diabetes\\nand Digestive and Kidney Diseases. National Institutes of\\nHealth, NIH Publication No. 94-2098.\\n“Noninsulin-Dependent Diabetes.” National Institute of Dia-\\nbetes and Digestive and Kidney Diseases. National Insti-\\ntutes of Health, NIH Publication No. 92-241.\\nAltha Roberts Edgren\\nDiabetic control index see Glycosylated\\nhemoglobin test\\nDiabetic foot infections\\nDefinition\\nDiabetic foot infections are infections that can\\ndevelop in the skin, muscles, or bones of the foot as a\\nresult of the nerve damage and poor circulation that is\\nassociated with diabetes.\\nDescription\\nPeople who have diabetes have a greater-than-average\\nchance of developing foot infections. Because a person\\nwho has diabetes may not feel foot pain or discomfort,\\nproblems can remain undetected until fever, weakness, or\\nother signs of systemic infection appear. As a result, even\\nminor irritations occur more often, heal more slowly, and\\nare more likely to result in serious health problems.\\nWith diabetes, foot infections occur more frequently\\nbecause the disease causes nervous system changes and\\npoor circulation. Because the nerves that control sweat-\\ning no longer work, the skin of the feet can become very\\ndry and cracked, and calluses tend to occur more fre-\\nquently and build up faster. If not trimmed regularly,\\nthese calluses can turn into open sores or ulcers. Because\\ndiabetic nerve damage can cause a loss of sensation (neu-\\nropathy), if the feet are not regularly inspected, an ulcer\\ncan quickly become infected and, if not treated, may\\nresult in the death of tissue (gangrene) or amputation.\\nThe risk of infection is greatest for people who are\\nover the age of 60 and for those who have one or more of\\nthe following:\\n• poorly controlled diabetes\\n• foot ulcers\\n• laser treatment for changes in the retina\\n• kidney or vascular disease\\n• loss of sensation (neuropathy)\\nCauses and symptoms\\nBacteria can cause an infection through small cracks\\n(fissures) that can develop in the dry skin around the heel\\nand on other parts of the foot or through corns, calluses,\\nblisters, hangnails, or ulcers. If not treated, the bacterial\\ninfection can destroy skin, tissue, and bone or spread\\nthroughout the body.\\nCommon sites of diabetic foot infections include the\\nfollowing:\\n• blisters, corns, or callouses that bleed beneath the skin\\n• bunions, hammertoes, or other abnormalities in the\\nbones of the foot\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1053\\nDiabetic foot infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 441, 'page_label': '442'}, page_content='KEY TERMS\\nFissure—A deep crack.\\nNeuropathy —An abnormality of the nerves out-\\nside the brain and spinal cord.\\nUlcer—A sore or lesion.\\n• scar tissue that has grown over the site of an earlier\\ninfection\\n• foot ulcers caused by pressure, nerve damage, or poor\\ncirculation (Ulcers occur most often over the ball of the\\nfoot, on the bottom of the big toe, or on the sides of the\\nfoot due to poorly fitting shoes.)\\n• injuries that tear or puncture the skin.\\nDiagnosis\\nA physician who specializes in the treatment of the\\nfoot (podiatrist) or the doctor who normally treats the\\npatient’s diabetes will treat the infection. An x ray of the\\nfoot will be taken to determine whether the bone has\\nbecome infected. A sample from the wound will be cul-\\ntured to identify the organism that is causing the infec-\\ntion so that the appropriate antibiotic can be selected.\\nTreatment\\nFrom the results of the culture, the appropriate\\nantibiotic will be prescribed. Any dead or infected tissue\\nwill be surgically removed and, if necessary, a cast\\nand/or special shoes may be used to protect the area. In\\naddition, the patient will be instructed to keep off their\\nfeet. If the ulcer does not heal, the physician may per-\\nform surgery to increase blood flow to the foot. It is also\\nimportant for the patient to practice good diabetes con-\\ntrol and keep blood glucose levels from getting too high.\\nAlternative treatment\\nAcupuncture and vitamin C can boost the body’s\\ninfection-fighting ability. A variety of other vitamins and\\nherbs may improve general health and diabetes control.\\nBecause diabetes is a potentially deadly disease, it can be\\ndangerous to try alternative approaches without a doc-\\ntor’s approval or without consulting a trained practitioner\\nof alternative medicine.\\nPrognosis\\nWithout proper treatment, diabetic foot infections\\ncan lead to serious illness, gangrene, amputation, and\\neven death if the infection spreads throughout the body.\\nIf treated properly and the patient practices good foot\\ncare, the prognosis is generally optimistic\\nPrevention\\nThere are many things that a diabetic individual can\\ndo to prevent the occurrence of foot infections, including\\nthe following:\\n• control blood glucose and do not allow it to get too high\\n• avoid smoking\\n• keep blood pressure and cholesterol under control\\n• exercise to stimulate blood flow\\n• keep feet clean, dry, and warm\\n• check your feet every day for blisters, scratches, and\\nskin that is hard, broken, inflamed or that feels hot or\\ncold when touched\\n• after bathing, carefully dry feet and apply thin coat of\\npetroleum jelly or hand cream to prevent dry skin from\\ncracking\\n• use a pumice stone and emery board to trim calluses\\n• do not neglect an ulcer, should one develop\\nResources\\nBOOKS\\nBennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-\\nicine. Philadelphia: W. B. Saunders Co., 1996.\\nThe Editors of Time-Life Books. The Medical Advisor: The\\nComplete Guide to Alternative and Conventional Treat-\\nments. Alexandria, V A: Time Life, Inc., 1996.\\nMarble, Alexander, et al., eds. Joslin’s Diabetes Mellitus.12th\\ned. Philadelphia: Lea & Jebiger, 1985.\\nGALE ENCYCLOPEDIA OF MEDICINE 21054\\nDiabetic foot infections\\nPersons with diabetes often suffer from foot ulcers, as\\nshown above. (Custom Medical Stock Photo. Reproduced by\\npermission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 442, 'page_label': '443'}, page_content='ORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard Street,\\nAlexandria, V A 22311. (800) 342-2383. .\\nJuvenile Diabetes Foundation. 120 Wall St., 19th Floor, New\\nYork, NY 10005. (800) 533-2873. .\\nNational Diabetes Information Clearinghouse. 1 Information\\nWay, Bethesda, MD 20892-3560. (800) 860-8747.\\n.\\nOTHER\\n“Foot Care.”American Diabetes Association. 17 Feb. 1998\\n.\\nMaureen Haggerty\\nDiabetic ketoacidosis\\nDefinition\\nDiabetic ketoacidosis is a dangerous complication of\\ndiabetes mellitus in which the chemical balance of the\\nbody becomes far too acidic.\\nDescription\\nDiabetic ketoacidosis (DKA) always results from a\\nsevere insulin deficiency. Insulin is the hormone secret-\\ned by the body to lower the blood sugar levels when\\nthey become too high. Diabetes mellitus is the disease\\nresulting from the inability of the body to produce or\\nrespond properly to insulin, required by the body to\\nconvert glucose to energy. In childhood diabetes, DKA\\ncomplications represent the leading cause of death ,\\nmostly due to the accumulation of abnormally large\\namounts of fluid in the brain (cerebral edema ). DKA\\ncombines three major features: hyperglycemia, mean-\\ning excessively high blood sugar kevels hyperketone-\\nmia, meaning an overproduction of ketones by the\\nbody; and acidosis, meaning that the blood has become\\ntoo acidic.\\nInsulin deficiency is responsible for all three condi-\\ntions: the body glucose goes largely unused since most\\ncells are unable to transport glucose into the cell without\\nthe presence of insulin; this condition makes the body\\nuse stored fat as an alternative source instead of the\\nunavailable glucose for energy, a process that produces\\nacidic ketones, which build up because they require\\ninsulin to be broken down. The presence of excess\\nketones in the bloodstream in turn causes the blood to\\nbecome more acidic than the body tissues, which creates\\na toxic condition.\\nCauses and symptoms\\nDKA is most commonly seen in individuals with\\ntype I diabetes, under 19 years of age and is usually\\ncaused by the interruption of their insulin treatment or\\nby acute infection or trauma. A small number of people\\nwith type II diabetes also experience ketoacidosis, but\\nthis is rare given the fact that type II diabetics still pro-\\nduce some insulin naturally. When DKA occurs in type\\nII patients, it is usually caused by a decrease in food\\nintake and an increased insulin deficiency due to hyper-\\nglycemia.\\nSome common DKA symptoms include:\\n• high blood sugar levels\\n• frequent urination (polyuria) and thirst\\n• fatigue and lethargy\\n• nausea\\n• vomiting\\n• abdominal pain\\n• fruity odor to breath\\n• rapid, deep breathing\\n• muscle stiffness or aching\\n•coma\\nDiagnosis\\nDiagnosis requires the demonstration of hyper-\\nglycemia, hyperketonemia, and acidosis. DKA is estab-\\nlished if the patient’s urine or blood is strongly positive\\nfor glucose and ketones. Normal glucose levels in a non-\\ndiabetic person on average range from 80–110 mg/dl. A\\nperson with diabetes will typically fluctuate outside\\nthose parameters. DKA glucose levels exceed 250 mg/dl\\nand can reach 400 to 800 mg/dL. A low serum bicarbon-\\nate level (usually below 15 mEq/L) is also present,\\nindicative of acidosis.\\nA blood test or urinalysis can quickly determine\\nthe concentration of glucose in the bloodstream. Test\\nstrips are available to patients commercially can sub-\\nmerge in urine to detect the presence or concentration\\nof ketones.\\nTreatment\\nKetoacidosis is treated under medical supervision\\nand usually in a hospital setting.\\nBasic treatment includes:\\n• administering insulin to correct the hyperglycemia and\\nhyperketonemia\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1055\\nDiabetic ketoacidosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 443, 'page_label': '444'}, page_content='• Replacing fluids intravenously lost through excessive\\nurination and vomiting\\n• Balancing electrolytes to re-establish the chemical\\nequilibrium of the blood and prevent potassium defi-\\nciency (hypokalemia) during treatment\\n• Treatment for any associated bacterial infection\\nPrognosis\\nWith proper medical attention, DKA is almost\\nalways successfully treated. The DKA mortality rate is\\nabout 10%. Coma on admission adversely affects the\\nprognosis. The major causes of death are circulatory col-\\nlapse, hypokalemia, infection, and cerebral edema.\\nPrevention\\nOnce diabetes has been diagnosed, prevention mea-\\nsures to avoid DKA include regular monitoring of blood\\nglucose, administration of insulin, and lifestyle mainte-\\nnance. Glucose monitoring is especially important dur-\\nKEY TERMS\\nAcidosis —A condition that causes the pH of the\\nblood to drop and become more acidic.\\nDiabetes mellitus —Disease characterized by the\\ninability of the body to produce or respond properly\\nto insulin, which is required by the body to convert\\nglucose to energy.\\nEdema—The presence of abnormally large amounts\\nof fluid in the intercellular tissue spaces of the body.\\nGlucose—The type of sugar found in the blood.\\nHyperglycemia—Condition characterized by exces-\\nsively high levels of glucose in the blood, and\\noccurs when the body does not have enough\\ninsulin or cannot use the insulin it does have to turn\\nglucose into energy. Hyperglycemia is often indica-\\ntive of diabetes that is out of control.\\nHyperketonemia —Condition characterized by an\\noverproduction of ketones by the body.\\nHypoglycemia —Lower than normal levels of glu-\\ncose in the blood.\\nHypokalemia —A deficiency of potassium in the\\nblood.\\nInsulin —A hormone secreted by the pancreas in\\nresponse to high blood sugar levels that induces\\nhypoglycemia. Insulin regulates the body’s use of\\nglucose and the levels of glucose in the blood by\\nacting to open the cells so that they can intake glu-\\ncose.\\nKetones—Poisonous acidic chemicals produced by\\nthe body when fat instead of glucose is burned for\\nenergy. Breakdown of fat occurs when not enough\\ninsulin is present to channel glucose into body cells.\\nLactic acidosis—A serious condition caused by the\\nbuild up of lactic acid in the blood, causing it to\\nbecome excessively acidic. Lactic acid is a by-prod-\\nuct of glucose metabolism.\\nMetabolism —The sum of all chemical reactions\\nthat occur in the body resulting in growth, transfor-\\nmation of foodstuffs into energy, waste elimination\\nand other bodily functions.\\nPolyuria—Excessive secretion of urine.\\nType I diabetes—Also called juvenile diabetes. Type\\nI diabetes typically begins early in life. Affected\\nindividuals have a primary insulin deficiency and\\nmust take insulin to stay alive.\\nType II diabetes—Type II diabetes is the most com-\\nmon form of diabetes and usually appears in middle\\naged adults. It is often associated with obesity and\\nmay be delayed or controlled with diet and exercise.\\ning periods of stress, infection, and trauma when glucose\\nconcentrations typically increase as a response to these\\nsituations. Ketone tests should also be performed during\\nthese periods or when glucose is elevated.\\nResources\\nBOOKS\\nSaudek, Christopher D., Richard R. Rubin, and Cynthia S.\\nShump. The Johns Hopkins Guide to Diabetes. Baltimore:\\nThe Johns Hopkins University Press, 1997.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard Street,\\nAlexandria, V A 22311.(800)-342-2383. .\\nJuvenile Diabetes Foundation. 120 Wall St., New York, NY\\n10005. (800) 533-CURE. .\\nNational Institute of Diabetes and Digestive and Kidney Disor-\\nders (NIDDK). 31 Center Drive, MSC 2560, Bethesda,\\nMD 20892-2560. .\\nGary Gilles\\nGALE ENCYCLOPEDIA OF MEDICINE 21056\\nDiabetic ketoacidosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 444, 'page_label': '445'}, page_content='Diabetic neuropathy\\nDefinition\\nDiabetic neuropathy is a nerve disorder caused by\\ndiabetes mellitus . Diabetic neuropathy may be diffuse,\\naffecting several parts of the body, or focal, affecting a\\nspecific nerve and part of the body.\\nDescription\\nThe nervous system consists of two major divisions:\\nthe central nervous systems (CNS) which includes the\\nbrain, the cranial nerves, and the spinal cord, and the\\nperipheral nervous system (PNS) which includes the\\nnerves that link the CNS with the sensory organs, mus-\\ncles, blood vessels, and glands of the body. These periph-\\neral nerves are either motor, meaning that they are\\ninvolved in motor activity such as walking, or sensory,\\nmeaning that they carry sensory information back to the\\nCNS. The PNS also works with the CNS to regulate\\ninvoluntary (autonomic) processes such as breathing,\\nheartbeat, blood pressure, etc.\\nThere are two types of diffuse diabetic neuropathy\\nthat affect different nervous system functions. Diffuse\\nperipheral neuropathy primarily affects the limbs, dam-\\naging the nerves of the feet and hands. Autonomic neu-\\nropathy is the other form of diffuse neuropathy and it\\naffects the heart and other internal organs.\\nFocal—or localized—diabetic neuropathy affects\\nspecific nerves, most commonly in the torso, leg, or head.\\nDiabetic neuropathy can lead to muscular weakness,\\nloss of feeling or sensation, and loss of autonomic func-\\ntions such as digestion, erection, bladder control and\\nsweating among others.\\nThe longer a person has diabetes, the more likely the\\ndevelopment of one or more forms of neuropathy.\\nApproximately 60–70% of patients with diabetes have\\nneuropathy, but only about 5% will experience painful\\nsymptoms.\\nCauses and symptoms\\nThe exact cause of diabetic neuropathy is not\\nknown. Researchers believe that the process of nerve\\ndamage is related to high glucose concentrations in the\\nblood that could cause chemical changes in nerves, dis-\\nrupting their ability to effectively send messages. High\\nblood glucose is also known to damage the blood vessels\\nthat carry oxygen and other nutrients to the nerves. In\\naddition, some people may have a genetic predisposition\\nto develop neuropathy.\\nThere is a wide range of symptoms associated with\\ndiabetic neuropathy, and they depend on which nerves\\nand parts of the body affected and also on the type of\\nneuropathy present. Some patients have very mild symp-\\ntoms, while others are severely disabled.\\nCommon symptoms of diffuse peripheral neuropa-\\nthy include:\\n• numbness and feelings of tingling or burning\\n• insensitivity to pain\\n• needle-like jabs of pain\\n• extreme sensitivity to touch\\n• loss of balance and coordination\\nCommon symptoms of diffuse autonomic neuropa-\\nthy include:\\n• impaired urination and sexual function\\n• bladder infections\\n• stomach disorders, due to the impaired ability of the\\nstomach to empty (gastric stasis)\\n• nausea, vomiting, bloating\\n• dizziness, lightheadedness,fainting spells\\n• loss of appetite\\nCommon symptoms of focal neuropathy include:\\n• pain in the front of a thigh\\n• severe pain in the lower back\\n• pain in the chest or stomach\\n• ache behind an eye\\n• double vision\\n• paralysis on one side of the face\\nIn severe diabetic neuropathy loss of sensation can\\nlead to injuries that are unnoticed, progressing to infec-\\ntions, ulceration, and possibly amputation.\\nDiagnosis\\nThe diagnosis of neuropathy is based on the symp-\\ntoms that present during a physical exam. Pain assess-\\nment is usually the first step. Patients may have more\\nthan one type of pain, and the history helps the doctor\\ndetermine whether a the pain has a neuropathic cause.\\nThe exam may include:\\n• a screening test for lost sensation\\n• nerve conduction studies to check the flow of electric\\ncurrent through a nerve\\n• electromyography (EMG) to see how well muscles\\nrespond to electrical impulses transmitted by nearby\\nnerves.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1057\\nDiabetic neuropathy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 445, 'page_label': '446'}, page_content='• ultrasound to show how the bladder and other parts of\\nthe urinary tract are functioning\\n• sometimes a nerve biopsy may be performed.\\nSpecialists who treat diabetic neuropathy include:\\n• neurologists: specialists in nervous system disorders\\n• urologists: specialists in urinary tract disorder\\n• gastroenterologists: specialists in digestive disorders\\n• podiatrists: specialists in caring for the feet\\nTreatment\\nTreatment of diabetic neuropathy is usually focused\\non treating the symptoms associated with the neuropathy\\nand addressing the underlying cause by improving the\\ncontrol of blood sugar levels, which may heal the early\\nstages of neuropathy.\\nThere is no cure for the permanent nerve damage\\ncaused by neuropathy. To help control pain, the choice of\\nproven drug therapies has broadened during the past\\ndecade. Pain medication, such as the topical skin cream\\ncapsaicin, is usually no stronger than codeine because of\\nthe potential for addiction with long-term use of such\\ndrugs. Four main classes of drugs are available for pain\\nmanagement, alone or in combination: tricyclic antide-\\npressants (Imipramine, Nortriptyline), narcotic anal-\\ngesics (Morphine), anticonvulsants (Carbamazepine,\\nGabapentin), and antiarrhythmics.\\nKEY TERMS\\nCentral nervous system (CNS) —Part of the ner-\\nvous system consisting of the brain, cranial nerves,\\nand spinal cord. The brain is the center of higher\\nprocesses, such as thought and emotion, and is\\nresponsible for the coordination and control of\\nbodily activities and the interpretation of informa-\\ntion from the senses. The cranial nerves and spinal\\ncord link the brain to the peripheral nervous sys-\\ntem.\\nDiabetes mellitus —Disease characterized by the\\ninability of the body to produce or respond prop-\\nerly to insulin, required by the body to convert\\nglucose to energy.\\nGlucose—The type of sugar found in the blood.\\nPeripheral nervous system (PNS)—One of the two\\nmajor divisions of the nervous system. PNS nerves\\nlink the central nervous system with sensory\\norgans, muscles, blood vessels, and glands.\\nPrognosis\\nEarly stage diabetic neuropathy can usually be\\nreversed with good glucose control. Once nerve damage\\nhas occurred it cannot be reversed. The prognosis is largely\\ndependent on the management of the underlying condition,\\ndiabetes, which may halt the progression of the neuropathy\\nand improve symptoms. Recovery, if it occurs, is slow.\\nPrevention\\nTight glucose control and the avoidance of alcohol\\nand cigarettes help protect nerves from damage.\\nResources\\nBOOKS\\nSaudek, Christopher D., Richard R. Rubin, and Cynthia S.\\nShump. The Johns Hopkins Guide to Diabetes. Baltimore:\\nThe Johns Hopkins University Press, 1997.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard Street,\\nAlexandria, V A 22311. (800) 342-2383). .\\nJuvenile Diabetes Foundation. 120 Wall St., New York, NY\\n10005. (800) 533-CURE. .\\nNational Institute of Diabetes and Digestive and Kidney Disor-\\nders (NIDDK). 31 Center Drive, MSC 2560, Bethesda,\\nMD 20892-2560. .\\nGary Gilles\\nDialysis, kidney\\nDefinition\\nDialysis treatment replaces the function of the kid-\\nneys, which normally serve as the body’s natural filtra-\\ntion system. Through the use of a blood filter and a\\nchemical solution known as dialysate, the treatment\\nremoves waste products and excess fluids from the\\nbloodstream, while maintaining the proper chemical bal-\\nance of the blood. There are two types of dialysis treat-\\nment : hemodialysis and peritoneal dialysis.\\nPurpose\\nDialysis can be used in the treatment of patients suf-\\nfering from poisoning or overdose, in order to quickly\\nremove drugs from the bloodstream. Its most prevalent\\napplication, however, is for patients with temporary or per-\\nmanent kidney failure. For patients with end-stage renal\\ndisease (ESRD), whose kidneys are no longer capable of\\nadequately removing fluids and wastes from their body or\\nGALE ENCYCLOPEDIA OF MEDICINE 21058\\nDialysis, kidney'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 446, 'page_label': '447'}, page_content='of maintaining the proper level of certain kidney-regulated\\nchemicals in the bloodstream, dialysis is the only treat-\\nment option available outside of kidney transplantation.\\nIn 1996 in the United States, over 200,000 people under-\\nwent regular dialysis treatments to manage their ESRD.\\nPrecautions\\nBlood pressure changes associated with hemodialy-\\nsis may pose a risk for patients with heart problems. Peri-\\ntoneal dialysis may be the preferred treatment option in\\nthese cases.\\nPeritoneal dialysis is not recommended for patients\\nwith abdominal adhesions or other abdominal defects,\\nsuch as a hernia, that might compromise the efficiency\\nof the treatment. It is also not recommended for patients\\nwho suffer frequent bouts of diverticulitis, an inflamma-\\ntion of small pouches in the intestinal tract.\\nDescription\\nThere are two types of dialysis treatment: hemodial-\\nysis and peritoneal dialysis:\\nHemodialysis\\nHemodialysis is the most frequently prescribed type\\nof dialysis treatment in the United States. The treatment\\ninvolves circulating the patient’s blood outside of the\\nbody through an extracorporeal circuit (ECC), or dialysis\\ncircuit. Two needles are inserted into the patient’s vein,\\nor access site, and are attached to the ECC, which con-\\nsists of plastic blood tubing, a filter known as a dialyzer\\n(artificial kidney), and a dialysis machine that monitors\\nand maintains blood flow and administers dialysate.\\nDialysate is a chemical bath that is used to draw waste\\nproducts out of the blood.\\nSince the 1980s, the majority of hemodialysis treat-\\nments in the United States have been performed with\\nhollow fiber dialyzers. A hollow fiber dialyzer is com-\\nposed of thousands of tube-like hollow fiber strands\\nencased in a clear plastic cylinder several inches in diam-\\neter. There are two compartments within the dialyzer (the\\nblood compartment and the dialysate compartment). The\\nmembrane that separates these two compartments is\\nsemipermeable. This means that it allows the passage of\\ncertain sized molecules across it, but prevents the pas-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1059\\nDialysis, kidney\\nHemodialyzer (where \\nfiltering takes place)\\nHemodialysis machine\\nBlood flows \\nto dialyzer\\nCleansed blood \\nflows back to body\\nHemodialysis is the most frequently prescribed type of dialysis treatment in the United States.This treatment involves circu-\\nlating the patient’s blood outside of the body through a dialysis circuit.The blood is filtered and cleansed inside the hemodia-\\nlyzer and returned to the body.(Illustration by Electronic Illustrators Group.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 447, 'page_label': '448'}, page_content='sage of other, larger molecules. As blood is pushed\\nthrough the blood compartment in one direction, suction\\nor vacuum pressure pulls the dialysate through the\\ndialysate compartment in a countercurrent, or opposite\\ndirection. These opposing pressures work to drain excess\\nfluids out of the bloodstream and into the dialysate, a\\nprocess called ultrafiltration.\\nA second process called diffusion moves waste\\nproducts in the blood across the membrane into the\\ndialysate compartment, where they are carried out of the\\nbody. At the same time, electrolytes and other chemicals\\nKEY TERMS\\nAccess site —The vein tapped for vascular access\\nin hemodialysis treatments. For patients with tem-\\nporary treatment needs, access to the bloodstream\\nis gained by inserting a catheter into the subcla-\\nvian vein near the patient’s collarbone. Patients in\\nlong-term dialysis require stronger, more durable\\naccess sites, called fistulas or grafts, that are surgi-\\ncally-created.\\nDialysate —A chemical bath used in dialysis to\\ndraw fluids and toxins out of the bloodstream and\\nsupply electrolytes and other chemicals to the\\nbloodstream.\\nDialysis prescription —The general parameters of\\ndialysis treatment that vary according to each\\npatient’s individual needs. Treatment length, type\\nof dialyzer and dialysate used, and rate of ultrafil-\\ntration are all part of the dialysis prescription.\\nDialyzer—An artificial kidney usually composed\\nof hollow fiber that is used in hemodialysis to\\neliminate waste products from the blood and\\nremove excess fluids from the bloodstream.\\nErythropoietin—A hormone produced by the kid-\\nneys that stimulates the production of red blood\\ncells by bone marrow.\\nESRD—End-stage renal disease; chronic or perma-\\nnent kidney failure.\\nExtracorporeal circuit (ECC) —The path the\\nhemodialysis patient’s blood takes outside of the\\nbody. It typically consists of plastic tubing, a\\nhemodialysis machine, and a dialyzer.\\nHematocrit (Hct) level —A measure of red blood\\ncells.\\nPeritoneum —The abdominal cavity; the peri-\\ntoneum acts as a blood filter in peritoneal dialysis.\\nin the dialysate solution cross the membrane into the\\nblood compartment. The purified, chemically-balanced\\nblood is then returned to the body.\\nMost hemodialysis patients require treatment three\\ntimes a week, for an average of three to four hours per\\ndialysis “run.” Specific treatment schedules depend on\\nthe type of dialyzer used and the patient’s current physi-\\ncal condition. While the treatment prescription and regi-\\nmen is usually overseen by a nephrologist (a doctor that\\nspecializes in the kidney), dialysis treatments are typical-\\nly administered by a nurse or patient care technician in\\noutpatient clinics known as dialysis centers, or in hospi-\\ntal-based dialysis units. In-home hemodialysis treatment\\nis also an option for some patients, although access to\\nthis type of treatment may be limited by financial and\\nlifestyle factors. An investment in equipment is required\\nand another person in the household should be available\\nfor support and assistance with treatments.\\nPeritoneal dialysis\\nIn peritoneal dialysis, the patient’s peritoneum, or lin-\\ning of the abdomen, acts as a blood filter. A catheter is sur-\\ngically inserted into the patient’s abdomen. During treat-\\nment, the catheter is used to fill the abdominal cavity with\\ndialysate. Waste products and excess fluids move from the\\npatient’s bloodstream into the dialysate solution. After a\\nwaiting period of six to 24 hours, depending on the treat-\\nment method used, the waste-filled dialysate is drained\\nfrom the abdomen, and replaced with clean dialysate.\\nThere are three types of peritoneal dialysis:\\n• Continuous ambulatory peritoneal dialysis (CAPD). A\\ncontinuous treatment that is self-administered and\\nrequires no machine. The patient inserts fresh dialysate\\nsolution into the abdominal cavity, waits four to six\\nhours, and removes the used solution. The solution is\\nimmediately replaced with fresh dialysate. A bag\\nattached to the catheter is worn under clothing.\\n• Continuous cyclic peritoneal dialysis (CCPD). An\\novernight treatment that uses a machine to drain and\\nrefill the abdominal cavity, CCPD takes 10–12 hours\\nper session.\\n• Intermittent peritoneal dialysis (IPD). This hospital-\\nbased treatment is performed several times a week. A\\nmachine administers and drains the dialysate solution,\\nand sessions can take up to 24 hours.\\nPeritoneal dialysis is often the treatment option of\\nchoice in infants and children, whose small size can\\nmake vascular (through a vein) access difficult to main-\\ntain. Peritoneal dialysis can also be done outside of a\\nclinical setting, which is more conducive to regular\\nschool attendance.\\nGALE ENCYCLOPEDIA OF MEDICINE 21060\\nDialysis, kidney'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 448, 'page_label': '449'}, page_content='Preparation\\nPatients are weighed immediately before and after\\neach hemodialysis treatment to assess their fluid reten-\\ntion. Blood pressure and temperature are taken and the\\npatient is assessed for physical changes since their last\\ndialysis run. Regular blood tests monitor chemical and\\nwaste levels in the blood. Prior to treatment, patients are\\ntypically administered a dose of heparin, an anticoagu-\\nlant that prevents blood clotting, to ensure the free flow\\nof blood through the dialyzer and an uninterrupted dialy-\\nsis run for the patient.\\nAftercare\\nBoth hemodialysis and peritoneal dialysis patients\\nneed to be vigilant about keeping their access sites and\\ncatheters clean and infection-free during and between\\ndialysis runs.\\nDialysis is just one facet of a comprehensive treat-\\nment approach for ESRD. Although dialysis treatment is\\nvery effective in removing toxins and fluids from the\\nbody, there are several functions of the kidney it cannot\\nmimic, such as regulating high blood pressure and red\\nblood cell production. Patients with ESRD need to watch\\ntheir diet and fluid intake carefully and take medications\\nas prescribed to manage their disease.\\nRisks\\nMany of the risks and side effects associated with\\ndialysis are a combined result of both the treatment and\\nthe poor physical condition of the ESRD patient. Dialy-\\nsis patients should always report side effects to their\\nhealthcare provider.\\nAnemia\\nHematocrit (Hct) levels, a measure of red blood\\ncells, are typically low in ESRD patients. This deficiency\\nis caused by a lack of the hormone erythropoietin, which\\nis normally produced by the kidneys. The problem is ele-\\nvated in hemodialysis patients, who may incur blood loss\\nduring hemodialysis treatments. Epoetin alfa, or EPO\\n(sold under the trade name Epogen), a hormone therapy,\\nand intravenous or oral iron supplements are used to\\nmanage anemia in dialysis patients.\\nCramps, nausea, vomiting, and headaches\\nSome hemodialysis patients experience cramps and\\nflu-like symptoms during treatment. These can be caused\\nby a number of factors, including the type of dialysate\\nused, composition of the dialyzer membrane, water qual-\\nity in the dialysis unit, and the ultrafiltration rate of the\\ntreatment. Adjustment of the dialysis prescription often\\nhelps alleviate many symptoms.\\nHypotension\\nBecause of the stress placed on the cardiovascular\\nsystem with regular hemodialysis treatments, patients are\\nat risk for hypotension, a sudden drop in blood pressure.\\nThis can often be controlled by medication and adjust-\\nment of the patient’s dialysis prescription.\\nInfection\\nBoth hemodialysis and peritoneal dialysis patients\\nare at risk for infection. Hemodialysis patients should\\nkeep their access sites clean and watch for signs of red-\\nness and warmth that could indicate infection. Peritoneal\\ndialysis patients must follow the same precautions with\\ntheir catheter. Peritonitis, an infection of the peritoneum,\\ncauses flu-like symptoms and can disrupt dialysis treat-\\nments if not caught early.\\nInfectious diseases\\nBecause there is a great deal of blood exposure\\ninvolved in dialysis treatment, a slight risk of contracting\\nhepatitis B and hepatitis C exists. The hepatitis B vacci-\\nnation is recommended for most hemodialysis patients.\\nAs of 1997, there has only been one documented case of\\nHIV being transmitted in a United States dialysis unit to\\na staff member, and no documented cases of HIV ever\\nbeing transmitted between dialysis patients in the United\\nStates. The strict standards of infection control practiced\\nin modern hemodialysis units makes the chance of con-\\ntracting one of these diseases very small.\\nNormal results\\nPuffiness in the patient related to edema, or fluid\\nretention, may be relieved after dialysis treatment. The\\npatient’s overall sense of physical well-being may also\\nbe improved. Because dialysis is an ongoing treatment\\nprocess for many patients, a baseline for normalcy can be\\ndifficult to gauge.\\nResources\\nBOOKS\\nBock, G. H., E. J. Ruley, and M. P. Moore. A Parent’s Guide to\\nKidney Disorders. Minneapolis: University of Minnesota\\nPress, 1993.\\nCameron, J. S. Kidney Failure: The Facts.New York: Oxford\\nUniversity Press, 1996.\\nLazarus, J. Michael, and Raymond M. Hakim. “Medical\\nAspects of Hemodialysis.” In The Kidney, ed. Barry M.\\nBrenner and Floyd C. Rector Jr. Philadelphia: W. B. Saun-\\nders Co., 1991.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1061\\nDialysis, kidney'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 449, 'page_label': '450'}, page_content='National Kidney Foundation. Dialysis Outcomes Quality Ini-\\ntiatives (NOQI). V ol. 1-5. New York: National Kidney\\nFoundation, 1997.\\nNissenson, Allen R., and Richard N. Fine, eds. Dialysis Thera-\\npy. 2nd ed. Philadelphia: Hanley & Belfus, Inc., 1993.\\nNolph, Karl D. “Peritoneal Dialysis.” In The Kidney, ed. Barry\\nM. Brenner and Floyd C. Rector Jr. Philadelphia: W. B.\\nSaunders Co., 1991.\\nU.S. Renal Data System. USRDS 1997 Annual Data Report.\\nBethesda, MD: The National Institutes of Health, National\\nInstitute of Diabetes and Digestive and Kidney Diseases,\\n1996.\\nPERIODICALS\\nDegroot, Patricia J., Sally Rubens Kenler, and Johanna T.\\nDwyer. “Optimizing Dialysis: Past, Present, and Future.”\\nNutrition Today32 (Jan/Feb. 1997): 30-6.\\n“Dialysis: Need for Artificial Kidney Treatment Is Increasing.”\\nMayo Clinic Health Letter, 15 (Feb. 1997): 1-4.\\nFavero, Martin S. “Infection Control.”Dialysis and Transplan-\\ntation 25 (Oct. 1996): 699-702.\\nFriedman, Elia A. “End-Stage Renal Disease Therapy: An\\nAmerican Success Story.”The Journal of the American\\nMedical Association 275 (Apr. 1996): 1118-22.\\nORGANIZATIONS\\nAmerican Association of Kidney Patients. 100 S. Ashley Dr.,\\n#280, Tampa, FL 33602. (800) 749-2257. .\\nAmerican Kidney Fund. 6110 Executive Boulevard, Rockville,\\nMD 20852. (800) 638-8299. .\\nNational Institute of Diabetes and Digestive and Kidney Dis-\\neases (NIDDK). Building 31, Room 9A04, 31 Center\\nDrive, MSC 2560, Bethesda, MD 208792-2560. (301)\\n496-3583. .\\nNational Kidney Foundation. 30 East 33rd St., New York, NY\\n10016. (800) 622-9010. .\\nUnited States Renal Data System (USRDS). The University of\\nMichigan, 315 W. Huron, Suite 240, Ann Arbor, MI 48103.\\n(734) 998-6611. .\\nPaula Anne Ford-Martin\\nDiaper rash\\nDefinition\\nDermatitis of the buttocks, genitals, lower abdomen,\\nor thigh folds of an infant or toddler is commonly referred\\nto as diaper rash.\\nDescription\\nThe outside layer of skin normally forms a protec-\\ntive barrier that prevents infection. One of the primary\\ncauses of dermatitis in the diaper area is prolonged skin\\ncontact with wetness. Under these circumstances, natural\\noils are stripped away, the outer layer of skin is damaged,\\nand there is increased susceptibility to infection by bacte-\\nria or yeast.\\nDiaper rash is a term that covers a broad variety of\\nskin conditions that occur on the same area of the body.\\nSome babies are more prone to diaper rash than others.\\nCauses and symptoms\\nFrequently a flat, red rash is caused by simple chaf-\\ning of the diaper against tender skin, initiating a friction\\nrash. This type of rash is not seen in the skin folds. It may\\nbe more pronounced around the edges of the diaper, at\\nthe waist and leg bands. The baby generally doesn’t\\nappear to experience much discomfort. Sometimes the\\nchemicals or detergents in the diaper are contributing\\nfactors and may result in contact dermatitis . These\\nrashes should clear up easily with proper attention.\\nIgnoring the condition may lead to a secondary infection\\nthat is more difficult to resolve.\\nFriction of skin against itself can cause a rash in the\\nbaby’s skin folds, called intertrigo. This rash appears as\\nreddened areas that may ooze and is often uncomfortable\\nwhen the diaper is wet. Intertrigo can also be found on\\nother areas of the body where there are deep skin folds\\nthat tend to trap moisture.\\nSeborrheic dermatitis is the diaper area equivalent\\nof cradle cap. It is scaly and greasy in appearance and\\nmay be worse in the folds of the skin.\\nYeast, or candidal dermatitis, is the most common\\ninfectious cause of diaper rash. The affected areas are\\nraised and quite red with distinct borders, and satellite\\nlesions may occur around the edges. Yeast is part of the\\nnormal skin flora, and is often an opportunistic invader\\nwhen simple diaper rash is untreated. It is particularly\\ncommon after treatment with antibiotics, which kill the\\ngood bacteria that normally keep the yeast population in\\ncheck. Usual treatments for diaper rash will not clear it up.\\nRepeated or difficult to resolve episodes of yeast infection\\nmay warrant further medical attention, since this is some-\\ntimes associated with diabetes or immune problems.\\nAnother infectious cause of diaper rash is impetigo.\\nThis bacterial infection is characterized by blisters that\\nooze and crust.\\nDiagnosis\\nThe presence of skin lesions in the diaper area\\nmeans that the baby has diaper rash. However, there are\\nseveral types of rash that may require specific treatment\\nGALE ENCYCLOPEDIA OF MEDICINE 21062\\nDiaper rash'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 450, 'page_label': '451'}, page_content='in order to heal. It is useful to be able to distinguish them\\nby appearance as described above.\\nA baby with a rash that does not clear up within two\\nto three days or a rash with blisters or bleeding should be\\nseen by a healthcare professional for further evaluation.\\nTreatment\\nAntibiotics are generally prescribed for rashes\\ncaused by bacteria, particularly impetigo. This may be a\\ntopical or oral formulation, depending on the size of the\\narea involved and the severity of the infection.\\nOver-the-counter antifungal creams, such as Lotrim-\\nin, are often recommended to treat a rash resulting from\\nyeast. If topical treatment is not effective, an oral antifun-\\ngal may be prescribed.\\nMild steroid creams, such as 0.5–1% hydrocorti-\\nsone, can be used for seborrheic dermatitis and some-\\ntimes intertrigo. Prescription strength creams may be\\nneeded for short-term treatment of more stubborn cases.\\nAlternative treatment\\nGood diaper hygiene will prevent or clear up many\\nsimple cases of diaper rash. Diapers should be checked\\nvery frequently and changed as soon as they are wet or\\nsoiled. Good air circulation is also important for healthy\\nskin. Babies should have some time without wearing a\\ndiaper, and a waterproof pad can be used to protect the\\nbed or other surface. Rubber pants, or other occlusive fab-\\nrics, should not be used over the diaper area. Some cloth-\\nlike disposable diapers promote better air circulation than\\nplastic-type diapers. It may be necessary for mothers to\\nexperiment with diaper types to see if the baby’s skin\\nreacts better to cloth or disposable ones. If disposable dia-\\npers are used, the baby’s skin may react differently to var-\\nious brands. If the baby is wearing cloth diapers, they\\nshould be washed in a mild detergent and double rinsed.\\nThe diaper area should be cleaned with something\\nmild, even plain water. Some wipes contain alcohol or\\nchemicals that can be irritating for some babies. Plain\\nwater may be the best cleansing substance when there is\\na rash. Using warm water in a spray bottle (or giving a\\nquick bath) and then lightly patting the skin dry can pro-\\nduce less skin trauma than using wipes. In the event of\\nsuspected yeast, a tablespoon of cider vinegar can be\\nadded to a cup of warm water and used as a cleansing\\nsolution. This is dilute enough that it should not burn, but\\nacidifies the skin pH enough to hamper the yeast growth.\\nBarrier ointments can be valuable to treat rashes.\\nThose that contain zinc oxide are especially effective.\\nThese creams and ointments protect already irritated skin\\nfrom the additional insult of urine and stool, particularly\\nif the baby has diarrhea . Cornstarch powder may be\\nused on rashes that are moist, such as impetigo.\\nNutrition\\nWhat the baby eats can make a difference in stool fre-\\nquency and acidity. Typically, breast-fed babies will have\\nfewer problems with rashes. When adding a new food to\\nthe diet, the baby should be observed closely to see\\nwhether rashes are produced around the baby’s mouth or\\nanus. If this occurs, the new food should be discontinued.\\nBabies who are taking antibiotics are more likely to\\nget rashes due to yeast. To help bring the good bacterial\\ncounts back to normal, Lactobacillus bifidus can be\\nadded to the diet. It is available in powder form from\\nmost health food stores.\\nHerbal treatment\\nSome herbal preparations can be useful for diaper\\nrash. Calendula reduces inflammation, tightens tissues,\\nand disinfects. It has been recommended for seborrheic\\ndermatitis as well as for general inflammation of the\\nskin. The ointment should be applied at each diaper\\nchange. Chickweed ointment can also be soothing for\\nirritated skin and may be applied once or twice daily.\\nPrognosis\\nTreated appropriately, diaper rash will resolve fairly\\nquickly if there is no underlying health problem or skin\\ndisease.\\nPrevention\\nFrequent diaper changes are important to keep the\\nskin dry and healthy. Application of powders and oint-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1063\\nDiaper rash\\nBaby with severe diaper rash.(Custom Medical Stock Photo.\\nReproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 451, 'page_label': '452'}, page_content='ments is not necessary when there is no rash. Finding the\\nbest combination of cleansing and diapering products for\\nthe individual baby will also help to prevent diaper rash.\\nResources\\nBOOKS\\nEisenberg, Arlene, Heidi Murkoff, and Sandee Hathaway. What\\nto Expect the First Year.New York: Workman Publishing,\\n1989.\\nSears, William, and Martha Sears. The Baby Book. Boston: Lit-\\ntle, Brown and Company, 1993.\\nOTHER\\nGreene, Alan. “Diaper Rash.”Dr. Greene’s HouseCalls.\\n (1996).\\nJudith Turner\\nDiaphragm (birth control)\\nDefinition\\nDiaphragms are dome-shaped barrier methods of\\ncontraception that block sperm from entering the uterus.\\nThey are made of latex (rubber) and formed like a shal-\\nlow cup. Since vaginas vary in size, each patient will\\nneed to be fitted by a doctor or nurse with a diaphragm\\nthat conforms to the shape and contour of the vagina as\\nwell as the strength of the muscles in the vaginal walls.\\nDiaphragms must be used with spermicidal cream or\\njelly. The device should cause no discomfort, and neither\\nthe woman nor her partner should feel that it is there.\\nPurpose\\nThe purpose of a diaphragm is to prevent access to\\nthe womb (uterus) by the sperm and thus prevent concep-\\ntion. The level of effectiveness is about 95%.\\nPrecautions\\nEach client will undergo a physical examinationand\\na Pap smear. If these are normal, the physician will fit the\\npatient for the device and give instructions on how to\\ninsert, remove, and clean the object. She will also be\\ntaught the signs and symptoms of potential complications.\\nKEY TERMS\\nDermatitis—Inflammation of the skin.\\nDescription\\nPrior to insertion, the inside of the dome and the rim\\nare covered with a thick layer (perhaps a tablespoon) of a\\nspermicide that is compatible with the diaphragm being\\nused. The domed area covers the opening into the uterus\\n(cervix) and keeps the spermicide in place. As a result,\\nany sperm that might get under the diaphragm will be\\ndestroyed.\\nDiaphragms may be inserted two to three hours prior\\nto intercourse, and must be left in place for six to eight\\nhours following sexual relations. During this time the\\nwoman may not swim, bathe, or douche, but she may\\nshower. If she desires to have intercourse again before\\nthe six to eight hours have passed, the diaphragm should\\nnot be removed. Instead, an applicator full of spermicide\\nshould be deposited into the vagina.\\nA diaphragm will last for a year or more. It should\\nbe examined weekly for holes. This can be done by hold-\\ning it up to the light or filling it with water.\\nPreparation\\nBefore inserting the diaphragm, the woman should\\nempty her bladder and wash her hands with soap and\\nwater. The device should be checked for leaks by filling\\nit with water or holding it up to the light. A spermicidal\\njelly is then applied to the inside and outside, and espe-\\ncially around the rim. While standing with one foot ele-\\nvated on a chair or step, lying down, or squatting, the\\nwoman folds the diaphragm inward toward the middle\\nand inserts it into the vagina as far as it will go.\\nAftercare\\nWhen removed, the diaphragm should be washed\\nwith a mild soap and water. After being dried, it can be\\ndusted with corn starch before being returned to its con-\\ntainer. The diaphragm should always be stored away\\nfrom sunlight and heat in a cool, dry place. It should not\\nbe washed with harsh or perfumed soaps or used with\\nperfumed powders because either of these substances can\\ndamage the diaphragm.\\nRisks\\nAlthough rare, wearing the diaphragm longer than\\nthe recommended time can result in toxic shock syn-\\ndrome. The signs and symptoms of this serious illness\\ninclude sudden onset of high fever, vomiting, diarrhea,\\ndizziness , faintness, weakness, aching muscles and\\njoints, and rash. The doctor must be notified immediately\\nif any of these conditions appear. An allergic reaction to\\nthe spermicide or the material from which the device is\\nGALE ENCYCLOPEDIA OF MEDICINE 21064\\nDiaphragm (birth control)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 452, 'page_label': '453'}, page_content='made is also possible. Diaphragm use is also associated\\nwith an increased risk of bladder infections.\\nIt should be noted that the diaphragm can become\\ndislodged during intercourse, which could result in an\\nunwanted pregnancy . To ensure a secure fit, a woman\\nshould be examined for a refitting if she gains or loses\\nmore than 10 lbs (4.5 kg), or after she gives birth.\\nNormal results\\nConsumers can expect an efficiency rate of about\\n95% in preventing pregnancy. Using a male condom in\\nconjunction with the diaphragm decreases the potential\\nfor pregnancy. Diaphragms provide no protection against\\nAIDS or other sexually transmitted diseases.\\nResources\\nBOOKS\\nDickason, Elizabeth Jean, Bonnie Lang Silverman, and Judith\\nA. Kaplan. Maternal-Infant Nursing Care. 3rd ed. St.\\nLouis: Mosby-Year Book, Inc., 1998.\\nGorrie, Trula Meyers, Emily Slone McKinney, and Sharon\\nSmith Murray. Foundations of Maternal-Newborn Nurs-\\ning. 2nd ed. Philadelphia: W. B. Saunders Co., 1998.\\nNichols, Francine H., and Elaine Zwelling. Maternal-Newborn\\nNursing: Theory and Practice. Philadelphia.: W. B. Saun-\\nders Co., 1997.\\nOlds, Sally B., Marcia L. London, and Patricia Wieland\\nLadewig. Maternal-Newborn Nursing: A Family Centered\\nApproach. Menlo Park: Addison-Wesley, 1996.\\nORGANIZATIONS\\nPlanned Parenthood Federation of America, Inc. 810 Seventh\\nAve., New York, NY ,10019. (800) 669-0156. .\\nOTHER\\n“The Diaphragm.”Cincinnati Women’s Services..\\n“Guide to Safer Sex.”Sexual Health InfoCenter..\\nDonald G. Barstow, RN\\nDiaphragmatic hernia see Hernia\\nKEY TERMS\\nSpermicide—A substance that kills sperm.\\nToxic shock syndrome—An uncommon, but poten-\\ntially fatal, disease that has been associated with the\\nuse of diaphragms and vaginal tampons. The symp-\\ntoms include high fever, vomiting, and diarrhea.\\nDiarrhea\\nDefinition\\nTo most individuals, diarrhea means an increased\\nfrequency or decreased consistency of bowel move-\\nments; however, the medical definition is more exact\\nthan this. In many developed countries, the average num-\\nber of bowel movements is three per day. However,\\nresearchers have found that diarrhea best correlates with\\nan increase in stool weight; stool weights above 10 oz\\n(300 g) per day generally indicates diarrhea. This is\\nmainly due to excess water, which normally makes up\\n60–85% of fecal matter. In this way, true diarrhea is dis-\\ntinguished from diseases that cause only an increase in\\nthe number of bowel movements (hyperdefecation), or\\nincontinence (involuntary loss of bowel contents).\\nDiarrhea is also classified by physicians into acute,\\nwhich lasts one to two weeks, and chronic, which contin-\\nues for longer than 23 weeks. Viral and bacterial infec-\\ntions are the most common causes of acute diarrhea.\\nDescription\\nIn many cases, acute infectious diarrhea is a mild,\\nlimited annoyance. However, worldwide acute infectious\\ndiarrhea has a huge impact, causing over five million\\ndeaths per year. While most deaths are among children\\nunder five years of age in developing nations, the impact,\\neven in developed countries, is considerable. For exam-\\nple, over 250,000 individuals are admitted to hospitals in\\nthe United States each year because of one of these\\nepisodes. Rapid diagnosis and proper treatment can pre-\\nvent much of the suffering associated with these devas-\\ntating illnesses.\\nChronic diarrhea also has a considerable effect on\\nhealth, as well as on social and economic well being.\\nPatients with celiac disease , inflammatory bowel dis-\\nease, and other prolonged diarrheal illnesses develop\\nnutritional deficiencies that diminish growth and immu-\\nnity. They affect social interaction and result in the loss\\nof many working hours.\\nCauses and symptoms\\nDiarrhea occurs because more fluid passes through\\nthe large intestine (colon) than that organ can absorb. As\\na rule, the colon can absorb several times more fluid than\\nis required on a daily basis. However, when this reserve\\ncapacity is overwhelmed, diarrhea occurs.\\nDiarrhea is caused by infections or illnesses that\\neither lead to excess production of fluids or prevent\\nabsorption of fluids. Also, certain substances in the colon,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1065\\nDiarrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 453, 'page_label': '454'}, page_content='such as fats and bile acids, can interfere with water\\nabsorption and cause diarrhea. In addition, rapid passage\\nof material through the colon can also do the same.\\nSymptoms related to any diarrheal illness are often\\nthose associated with any injury to the gastrointestinal\\ntract, such as fever, nausea, vomiting, and abdominal\\npain. All or none of these may be present depending on\\nthe disease causing the diarrhea. The number of bowel\\nmovements can vary—up to 20 or more per day. In some\\npatients, blood or pus is present in the stool. Bowel\\nmovements may be difficult to flush (float) or contain\\nundigested food material.\\nThe most common causes of acute diarrhea are\\ninfections (the cause of traveler’s diarrhea ), food\\npoisoning , and medications. Medications are a fre-\\nquent and often over-looked cause, especially antibi-\\notics and antacids . Less often, various sugar free\\nfoods, which sometimes contain poorly absorbable\\nmaterials, cause diarrhea.\\nChronic diarrhea is frequently due to many of the\\nsame things that cause the shorter episodes (infections,\\nmedications, etc.); symptoms just last longer. Some\\ninfections can become chronic. This occurs mainly with\\nparasitic infections (such as Giardia) or when patients\\nhave altered immunity (AIDS).\\nThe following are the more usual causes of chronic\\ndiarrhea:\\n• AIDS\\n• colon cancer and other bowel tumors\\n• endocrine or hormonal abnormalities (thyroid,diabetes\\nmellitus, etc.)\\n• food allergy\\n• inflammatory bowel disease ( Crohn’s disease and\\nulcerative colitis)\\n• lactose intolerance\\n• malabsorption syndromes (celiac and Whipple’s dis-\\nease)\\n• other (alcohol, microscopic colitis, radiation, surgery)\\nComplications\\nThe major effects of diarrhea are dehydration, mal-\\nnutrition, and weight loss. Signs of dehydration can be\\nhard to notice, but increasing thirst, dry mouth , weak-\\nness or lightheadedness (particularly if worsening on\\nstanding), or a darkening/decrease in urination are sug-\\ngestive. Severe dehydration leads to changes in the\\nbody’s chemistry and could become life-threatening.\\nDehydration from diarrhea can result in kidney failure,\\nneurological symptoms, arthritis, and skin problems.\\nDiagnosis\\nMost cases of acute diarrhea never need diagnosis or\\ntreatment, as many are mild and produce few problems.\\nBut patients with fever over 102°F (38.9°C), signs of\\ndehydration, bloody bowel movements, severe abdomi-\\nnal pain, known immune disease, or prior use of antibi-\\notics need prompt medical evaluation.\\nWhen diagnostic studies are needed, the most use-\\nful are stool culture and examination for parasites;\\nhowever these are often negative and a cause cannot be\\nfound in a large number of patients. The earlier cul-\\ntures are performed, the greater the chance of obtain-\\ning a positive result. For those with a history of antibi-\\notic use in the preceding two months, stool samples\\nneed to be examined for the toxins that cause antibiot-\\nic-associated colitis . Tests are also available to check\\nstool samples for microscopic amounts of blood and\\nfor cells that indicate severe inflammation of the colon.\\nExamination with an endoscope is sometimes helpful\\nin determining severity and extent of inflammation.\\nTests to check changes in blood chemistry (potassium,\\nmagnesium, etc.) and a complete blood count (CBC)\\nare also often performed.\\nChronic diarrhea is quite different, and most patients\\nwith this condition will receive some degree of testing.\\nMany exams are the same as for an acute episode, as\\nsome infections and parasites cause both types of diar-\\nrhea. A careful history to evaluate medication use,\\ndietary changes, family history of illnesses, and other\\nsymptoms is necessary. Key points in determining the\\nseriousness of symptoms are weight loss of over 10 lb\\n(4.5 kg), blood in the stool, and nocturnal diarrhea\\n(symptoms that awaken the patient from sleep).\\nBoth prescription and over-the-counter medications\\ncan contain additives, such as lactose and sorbitol, that\\nwill produce diarrhea in sensitive individuals. Review of\\nallergies or skin changes may also point to a cause.\\nSocial history may indicate if stress is playing a role or\\nidentify activities which can be associated with diarrhea\\n(for example, diarrhea that occurs in runners).\\nA combination of stool, blood, and urine tests may\\nbe needed in the evaluation of chronic diarrhea; in addi-\\ntion a number of endoscopic and x-ray studies are fre-\\nquently required.\\nTreatment\\nTreatment is ideally directed toward correcting the\\ncause; however, the first aim should be to prevent or treat\\ndehydration and nutritional deficiencies. The type of\\nfluid and nutrient replacement will depend on whether\\noral feedings can be taken and the severity of fluid loss-\\nGALE ENCYCLOPEDIA OF MEDICINE 21066\\nDiarrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 454, 'page_label': '455'}, page_content='es. Oral rehydration solution (ORS) or intravenous fluids\\nare the choices; ORS is preferred if possible.\\nA physician should be notified if the patient is dehy-\\ndrated, and if oral replacement is suggested then com-\\nmercial (Pedialyte and others) or homemade preparations\\ncan be used. The World Health Organization (WHO) has\\nprovided this easy recipe for home preparation, which\\ncan be taken in small frequent sips:\\n• Table salt—3/4 tsp\\n• Baking powder—1 tsp\\n• Orange juice—1 c\\n• Water—1 qt (1 L)\\nWhen feasible, food intake should be continued even\\nin those with acute diarrhea. A physician should be con-\\nsulted as to what type and how much food is permitted.\\nAnti-motility agents (loperamide, diphenoxylate)\\nare useful for those with chronic symptoms; their use is\\nlimited or even contraindicated in most individuals with\\nacute diarrhea, especially in those with high fever or\\nbloody bowel movements. They should not be taken\\nwithout the advice of a physician.\\nOther treatments are available, depending on the\\ncause of symptoms. For example, the bulk agent psylli-\\num helps some patients by absorbing excess fluid and\\nsolidifying stools; cholestyramine, which binds bile\\nacids, is effective in treating bile salt induced diarrhea.\\nLow fat diets or more easily digestible fat is useful in\\nsome patients. New antidiarrheal drugs that decrease\\nexcessive secretion of fluid by the intestinal tract is\\nanother approach for some diseases. Avoidance of med-\\nications or other products that are known to cause diar-\\nrhea (such as lactose) is curative in some, but should be\\ndiscussed with a physician.\\nAlternative treatment\\nIt is especially important to find the cause of diar-\\nrhea, since stopping diarrhea when it is the body’s way of\\neliminating something foreign is not helpful and can be\\nharmful in the long run.\\nOne effective alternative approach to preventing and\\ntreating diarrhea involves oral supplementation of\\naspects of the normal flora in the colon with the yeasts\\nLactobacillus acidophilus , L. bifidus, or Saccharomyces\\nboulardii . In clinical settings, these “biotherapeutic”\\nagents have repeatedly been helpful in the resolution of\\ndiarrhea, especially antibiotic-associated diarrhea. Their\\neffectiveness is also supported by the results of a\\nresearch study published in the Journal of the American\\nMedical Association in 1996.\\nKEY TERMS\\nAnti-motiltiy medications —Medications such as\\nloperamide (Imodium), diphenoxylate (Lomotil),\\nor medications containing codeine or narcotics\\nthat decrease the ability of the intestine to con-\\ntract. These can worsen the condition of a patient\\nwith dysentery or colitis.\\nColitis—Inflammation of the colon.\\nEndoscope—An endoscope, as used in the field of\\ngastroenterology, is a thin flexible tube that uses a\\nlens or miniature camera to view various areas of\\nthe gastrointestinal tract. Both diagnosis, through\\nbiopsies or other means, and therapeutic proce-\\ndures can be done with this instrument.\\nEndoscopy —The performance of an exam using\\nan endoscope is known generally as endoscopy.\\nLactose intolerance —An inability to properly\\ndigest milk and dairy products.\\nOral rehydration solution (ORS)—A liquid prepa-\\nration developed by the World Health Organiza-\\ntion that can decrease fluid loss in persons with\\ndiarrhea. Originally developed to be prepared\\nwith materials available in the home, commercial\\npreparations have recently come into use.\\nSteatorrhea—Excessive amounts of fat in the feces.\\nNutrient replacement also plays a role in preventing\\nand treating episodes of diarrhea. Zinc especially appears\\nto have an effect on the immune system, and deficiency\\nof this mineral can lead to chronic diarrhea. Also, zinc\\nreplacement improves growth in young patients. Plenty\\nof fluids, especially water, should be taken by individuals\\nsuffering from diarrhea to prevent dehydration. The\\nBRAT diet also can be useful in helping to resolve diar-\\nrhea. This diet limits food intake to bananas, rice, apple-\\nsauce, and toast. These foods provide soluble and insolu-\\nble fiber without irritation. If the toast is slightly burnt,\\nthe charcoal can help sequester toxins and pull them\\nfrom the body.\\nAcute homeopathic remedies can be very effective for\\ntreating diarrhea especially in infants and young children.\\nPrognosis\\nPrognosis is related to the cause of the diarrhea; for\\nmost individuals in developed countries, a bout of acute,\\ninfectious diarrhea is at best uncomfortable. However, in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1067\\nDiarrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 455, 'page_label': '456'}, page_content='both industrialized and developing areas, serious compli-\\ncations and death can occur.\\nFor those with chronic symptoms, an extensive num-\\nber of tests are usually necessary to make a proper diag-\\nnosis and begin treatment; a specific diagnosis is found\\nin 90% of patients. In some, however, no specific cause\\nis found and only treatment with bulk agents or anti-\\nmotility agents is indicated.\\nPrevention\\nProper hygiene and food handling techniques will\\nprevent many cases. Traveler’s diarrhea can be avoided\\nby use of Pepto-Bismol and/or antibiotics, if necessary.\\nThe most important action is to prevent the complica-\\ntions of dehydration.\\nResources\\nBOOKS\\nFine, Kenneth D. “Diarrhea.” In Sleisenger & Fordtran’s Gas-\\ntrointestinal and Liver Disease, ed. Mark Feldman, et al.\\nPhiladelphia: W. B. Saunders Co., 1997.\\nFriedman, Lawrence S., and Kurt J. Isselbacher. “Diarrhea.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nHamer, Davidson H., and Sherwood L. Gorbach. “Treatment of\\nInfectious Diarrhea.” In Sleisenger & Fordtran’s Gas-\\ntrointestinal and Liver Disease, ed. Mark Feldman, et al.\\nPhiladelphia: W. B. Saunders Company. 1997.\\nThielman, Nathan M., and Richard L. Guerrant. “Food-Borne\\nIllness.” In Conn’s Current Therapy, 1996, ed. Robert E.\\nRakel. Philadelphia: W. B. Saunders Co., 1996.\\nWolfe, Martin S. “Acute Infectious Diarrhea.” In Conn’s Cur-\\nrent Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W.\\nB. Saunders Co., 1996.\\nPERIODICALS\\nDonowitz, Mark, Freddy T. Kokke, and Roxan Saidi. “Evalua-\\ntion of Patients with Chronic Diarrhea.”New England\\nJournal of Medicine 332 (16 Mar. 1995): 725-729.\\nDupont, Herbert L., and The Practice Parameters Committee of\\nthe American College of Gastroenterology. “Guidelines\\non Acute Infectious Diarrhea in Adults.”American Jour-\\nnal of Gastroenterology92 (1997): 1962-1975.\\nFekety, Robert. “Guidelines for the Diagnosis and Manage-\\nment of Clostridium Difficile-Associated Diarrhea and\\nColitis.” American Journal of Gastroenterology92\\n(1997): 739-750.\\nGianella, Ralph A. “Acute Infectious Diarrhea.”Gastroenterol-\\nogy Clinics of North America (Sept. 1993): 483-707.\\nPenny, Mary E., and Claudio F. Lanata. “Zinc in the Manage-\\nment of Diarrhea in Young Children.”New England Jour-\\nnal of Medicine 333 (28 Sept. 1995): 873-874.\\n“Traveler’s Diarrhea: Don’t Let It Ruin Your Trip.”Mayo Clin-\\nic Health Letter (Jan. 1997).\\n“When Microbes Are on the Menu.”Harvard Health Letter\\n(Dec. 1994): 4-5.\\nORGANIZATIONS\\nWorld Health Organization, Division of Emerging and Other\\nCommunicable Diseases Surveillance and Control.\\nAvenue Appia 20, 1211 Geneva 27, Switzerland. (+00 41\\n22) 791 21 11. .\\nOTHER\\n“Directory of Digestive Diseases Organizations for Patients.”\\nNational Institute of Diabetes and Digestive and Kidney\\nDisease. .\\n“A Neglected Modality for the Treatment and Prevention of\\nSelected Intestinal and Vaginal Infections.”JAMA. .\\nSelected publications and documents on diarrhoeal diseases\\n(including cholera). World Health Organization (WHO).\\n.\\nDavid Kaminstein, MD\\nDiazep see Benzodiazepines\\nDiclofenac see Nonsteroidal anti-\\ninflammatory drugs\\nDicyclomine see Antispasmodic drugs\\nDidanosine see Antiretroviral drugs\\nDiets\\nDefinition\\nHumans may alter their usual eating habits for many\\nreasons, including weight loss, disease prevention or\\ntreatment, removing toxins from the body, or to achieve a\\ngeneral improvement in physical and mental health. Oth-\\ners adopt special diets for religious reasons. In the case\\nof some vegetarians and vegans, dietary changes are\\nmade out of ethical concerns for the rights of animals.\\nPurpose\\nPeople who are moderately to severely overweight\\ncan derive substantial health benefits from a weight-loss\\ndiet. A weight reduction of just 10–20 (4.5–9.1 kg) can\\nresult in reduced cholesterol levels and lower blood pres-\\nsure. Weight-related health problems include heart dis-\\nease, diabetes, high blood pressure, and high levels of\\nblood sugar and cholesterol.\\nIn individuals who are not overweight, dietary\\nchanges may also be useful in the prevention or treat-\\nment of a range of ailments including acquired immun-\\nodeficiency syndrome ( AIDS), cancer, osteoporosis ,\\ninflammatory bowel disease, chronic pulmonary disease,\\nGALE ENCYCLOPEDIA OF MEDICINE 21068\\nDiets'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 456, 'page_label': '457'}, page_content='renal disease, Parkinson’s disease , seizure disorders,\\nand food allergies and intolerances.\\nDescription\\nOrigins\\nThe practice of altering diet for special reasons\\nhas existed since antiquity. For example, Judaism has\\nincluded numerous dietary restrictions for thousands\\nof years. One ancient Jewish sect, the Essenes, is said\\nto have developed a primitive detoxification diet\\naimed at preparing the bodies, minds, and spirits of its\\nmembers for the coming of a “messiah” who would\\ndeliver them from their Roman captors. Preventative\\nand therapeutic diets became quite popular during the\\nlate twentieth century. Books promoting the latest\\ndietary plan continue to make the bestseller lists,\\nalthough not all of the information given is considered\\nauthoritative.\\nThe idea of a healthful diet is to provide all of the\\ncalories and nutrients needed by the body for optimal\\nperformance, at the same time ensuring that neither\\nnutritional deficiencies nor excesses occur. Diet plans\\nthat claim to accomplish those objectives are so numer-\\nous they are virtually uncountable. These diets employ a\\nvariety of approaches, including the following:\\n• Fixed-menu: Offers little choice to the dieter. Specifies\\nexactly which foods will be consumed. Easy to follow,\\nbut may be considered “boring” to some dieters.\\n• Formula: Replaces some or all meals with a nutritional-\\nly balanced liquid formula or powder.\\n• Exchange-type: Allows the dieter to choose between\\nselected foods from each food group.\\n• Flexible: Doesn’t concern itself with the overall diet,\\nsimply with one aspect such as fat or energy.\\nDiets may also be classified according to the types\\nof foods they allow. For example, an omnivorous diet\\nconsists of both animal and plant foods, whereas a lacto-\\novo-vegetarian diet permits no animal flesh, but does\\ninclude eggs, milk, and dairy products. A vegan diet is a\\nstricter form of vegetarianism in which eggs, cheese,\\nand other milk products are prohibited.\\nA third way of classifying diets is according to their\\npurpose: religious, weight-loss, detoxification, lifestyle-\\nrelated, or aimed at prevention or treatment of a specific\\ndisease.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1069\\nDiets\\nFats, oils, sweets\\n(use sparingly)\\nMilk, yogurt, cheese\\n(2–3 servings\\nper day)\\nVegetables\\n(3–5 servings \\nper day)\\nBread, rice, cereal, pasta\\n(6–11 servings per day)\\nMeat, poultry, fish,\\neggs, beans, nuts\\n(2–3) servings per day)\\nFruits\\n(2–4 servings \\nper day)\\nCereal\\nBread\\nMILK\\nSuggested daily food servings. (Illustration by Electronic Illustrators Group.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 457, 'page_label': '458'}, page_content='Precautions\\nDieters should be cautious about plans that severely\\nrestrict the size of food portions, or that eliminate entire\\nfood groups from the diet. It is highly probable that they\\nwill become discouraged and drop out of such programs.\\nThe best diet is one that can be maintained indefinitely\\nwithout ill effects, that offers sufficient variety and bal-\\nance to provide everything needed for good health, and\\nthat is considerate of personal food preferences.\\nLow-fat diets are not recommended for children\\nunder the age of two. Young children need extra fat to\\nmaintain their active, growing bodies. Fat intake may be\\ngradually reduced between the ages of two and five, after\\nwhich it should be limited to a maximum of 30% of total\\ncalories through adulthood. Saturated fat should be\\nrestricted to no more than 10% of total calories.\\nWeight-loss dieters should be wary of the “yo-yo”\\neffect that occurs when numerous attempts are made to\\nreduce weight using high-risk, quick-fix diets. This con-\\ntinued “cycling” between weight loss and weight gain\\ncan slow the basal metabolic rate and can sometimes lead\\nto eating disorders. The dieter may become discouraged\\nand frustrated by this success/failure cycle. The end\\nresult of “yo-yo” dieting is that it becomes more difficult\\nto maintain a healthy weight.\\nCaution should also be exercised about weight-loss\\ndiets that require continued purchases of special prepack-\\naged foods. Not only do these tend to be costly and over-\\nprocessed, they may also prevent dieters from learning\\nthe food-selection and preparation skills essential to\\nmaintenance of weight loss. Further, dieters should con-\\nsider whether they want to carry these special foods to\\nwork, restaurants, or homes of friends.\\nConcern has been expressed about weight-loss diet\\nplans that do not include exercise, considered essential\\nto long-term weight management. Some diets and sup-\\nplements may be inadvisable for patients with special\\nconditions or situations.\\nCertain fad diets purporting to be official diets of\\ngroups such as the American Heart Association and the\\nMayo Clinic are in no way endorsed by those institu-\\ntions. Patients thinking of starting such a diet should\\ncheck with the institution to ensure its name has not been\\nmisappropriated by an unscrupulous practitioner.\\nSide effects\\nA wide range of side effects (some quite serious) can\\nresult from special diets, especially those that are nutri-\\ntionally unbalanced. Further problems can arise if the\\ndieter is taking high doses of dietary supplements. Food\\nis essential to life, and improper nutrition can result in\\nserious illness or death.\\nResearch and general acceptance\\nIt is agreed among traditional and complementary\\npractitioners that many patients could substantially bene-\\nfit from improved eating habits. Specialized diets have\\nproved effective against a wide variety of conditions and\\ndiseases. However, dozens of unproved but widely publi-\\ncized “fad diets” emerge each year, prompting wide-\\nspread concerns about their usefulness, cost to the con-\\nsumer, and their safety.\\nResources\\nORGANIZATIONS\\nAmerican Dietetic Association. 216 West Jackson Blvd.,\\nChicago, IL 60606-6995. (312) 899-0040. .\\nDavid Helwig\\nDiffuse esophageal spasm\\nDefinition\\nDiffuse esophageal spasm is a term used to define an\\nuncoordinated or spastic esophagus.\\nDescription\\nThe esophagus is a muscular tube that actively trans-\\nports food from the throat to the stomach by rhythmic\\ncontractions known as peristalsis. The actual mechanism\\nand anatomy are quite complex, involving three distinct\\nsegments and allowing a person to swallow even when\\nupside-down. Diffuse esophageal spasm describes a con-\\ndition where the entire esophagus is spastic—along its\\nentire length, the muscular activity is increased and\\nuncoordinated. The name corkscrew esophagus describes\\nperfectly the appearance of this disorder on x rays.\\nX rays may reveal a slightly different appearance\\nand result in the designation rosary bead esophagus, but\\nthe cause is still diffuse spasm, and the two entities\\nbehave in the same way.\\nCauses and symptoms\\nThe cause appears to be disruption of the complex\\nsystem of nerves that coordinates the muscular activity.\\nThe result is difficulty swallowing (dysphagia) and pain\\nthat feels like a heart attack and can involve the entire\\nchest, jaw, and arms.\\nGALE ENCYCLOPEDIA OF MEDICINE 21070\\nDiffuse esophageal spasm'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 458, 'page_label': '459'}, page_content='Diagnosis\\nSwallowing problems usually call for esopha-\\ngograms. In the x ray department, the patient is given a\\ncontrast agent to drink. During swallowing, x rays record\\nthe passage of the agent down the esophagus and into the\\nstomach. Instead of a straight tube with well-coordinated\\nwaves of contraction, the resulting x rays show a\\nwrithing organ resembling a giant corkscrew.\\nAnother test that is used in many disorders of\\nesophageal motility is manometry. Pressures inside the\\nesophagus are measured every inch or so using a balloon\\ndevice that is passed all the way down to the stomach.\\nThe result is a precise record of its activity that yields a\\nspecific diagnosis.\\nTreatment\\nSoft and liquid foods pass more easily than solid\\npieces. Medications of several types are helpful—\\nnifedipine, hydralazine, isoproterenol, and nitrates being\\nthe most successful. Several other treatments have uncer-\\ntain results. For severe cases, relief is obtained two-thirds\\nof the time by cutting the muscles along the entire length\\nof the esophagus. This is a major surgical procedure.\\nPrognosis\\nThis condition does not go away, nor is treatment\\nentirely satisfactory. Patients need to be careful of what\\nthey eat and continue on medication if a beneficial one is\\nfound. Fortunately, the condition does not get progres-\\nsively worse as time passes.\\nResources\\nBOOKS\\nBennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-\\nicine. Philadelphia: W. B. Saunders Co., 1996.\\nCurrent Medical Diagnosis and Treatment, 1996.35th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange, 1995.\\nKEY TERMS\\nContrast agent—A substance that produces shad-\\nows on x rays.\\nManometry—Measurement of pressure.\\nPeristalsis —Slow, rhythmic contractions of the\\nmuscles in a tubular organ, such as the intestines,\\nthat propel the contents along.\\nClouse, Ray E. “Motor disorders of the esophagus.” In Sleisenger\\n& Fordtran’s Gastrointestinal and Liver Disease, ed. Mark\\nFeldman, et al. Philadelphia: W. B. Saunders Co., 1997.\\nGoyal, Raj K. “Diseases of the Esophagus.” In Harrison’s\\nPrinciples of Internal Medicine, ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1997.\\nJ. Ricker Polsdorfer, MD\\nDiGeorge syndrome\\nDefinition\\nDiGeorge syndrome (also called congenital thymic\\nhypoplasia, or third and fourth pharyngeal pouch syn-\\ndrome) is a birth defect that is caused by an abnormal\\nchromosome and affects the baby’s immune system. The\\nsyndrome is marked by absence or underdevelopment of\\nthe thymus and parathyroid glands. It is named for the\\npediatrician who first described it in 1965.\\nDescription\\nThe prevalence of DiGeorge syndrome is debated;\\nthe estimates range from 1:4000 to 1:6395. Because\\nthe symptoms caused by the chromosomal abnormality\\nvary somewhat from patient to patient, the syndrome\\nprobably occurs much more often than was previously\\nthought. DiGeorge syndrome is sometimes described\\nas one of the “CATCH 22” disorders, so named\\nbecause of their characteristics—cardiac defects,\\nabnormal facial features, thymus underdevelopment,\\ncleft palate, and hypocalcemia—caused by a deletion\\nof several genes in chromosome 22. The specific facial\\nfeatures associated with DiGeorge syndrome include\\nlow-set ears, wide-set eyes, a small jaw, and a short\\ngroove in the upper lip. The male/female ratio is 1:1.\\nThe syndrome appears to be equally common in all\\nracial and ethnic groups.\\nCauses and symptoms\\nDiGeorge syndrome is caused either by inheritance\\nof a defective chromosome 22 or by a new defect in chro-\\nmosome 22 in the fetus. The type of defect that is\\ninvolved is called deletion. A deletion occurs when the\\ngenetic material in the chromosomes does not recombine\\nproperly during the formation of sperm or egg cells. The\\ndeletion means that several genes from chromosome 22\\nare missing in DiGeorge syndrome patients. According\\nto a 1999 study, 6% of children with DiGeorge syndrome\\ninherited the deletion from a parent, while 94% had a\\nnew deletion. Other conditions that are associated with\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1071\\nDiGeorge syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 459, 'page_label': '460'}, page_content='DiGeorge syndrome are diabetes (a condition where the\\npancreas no longer produces enough insulin) in the\\nmother and fetal alcohol syndrome (a pattern of birth\\ndefects and learning and behavioral problems affecting\\nindividuals whose mothers consumed alcohol during\\npregnancy).\\nThe loss of the genes in the deleted material means\\nthat the baby’s third and fourth pharyngeal pouches fail\\nto develop normally during the twelfth week of pregnan-\\ncy. This developmental failure results in a completely or\\npartially absent thymus gland and parathyroid glands. In\\naddition, 74% of fetuses with DiGeorge syndrome have\\nsevere heart defects. The child is born with a defective\\nimmune system and an abnormally low level of calcium\\nin the blood.\\nThese defects usually become apparent within 48\\nhours of birth. The infant’s heart defects may lead to heart\\nfailure, or there may be seizures and other evidence of a\\nlow level of calcium in the blood (hypocalcemia).\\nDiagnosis\\nDiagnosis of DiGeorge syndrome can be made by\\nultrasound examination around the eighteenth week of\\npregnancy, when abnormalities in the development of the\\nheart or the palate can be detected. Another technique\\nthat is used to diagnose the syndrome before birth is\\ncalled fluorescence in situ hybridization, or FISH. This\\ntechnique uses DNA probes from the DiGeorge region\\non chromosome 22. FISH can be performed on cell sam-\\nples obtained by amniocentesis as early as the fourteenth\\nweek of pregnancy. It confirms about 95% of cases of\\nDiGeorge syndrome.\\nIf the mother has not had prenatal testing, the diag-\\nnosis of DiGeorge syndrome is sometimes suggested by\\nthe child’s facial features at birth. In other cases, the doc-\\ntor makes the diagnosis during heart surgery when he or\\nshe notices the absence or abnormal location of the thy-\\nmus gland. The diagnosis can be confirmed by blood\\ntests for calcium, phosphorus, and parathyroid hormone\\nlevels, and by the sheep cell test for immune function.\\nTreatment\\nHypocalcemia\\nHypocalcemia in DiGeorge patients is unusually dif-\\nficult to treat. Infants are usually given calcium and vita-\\nmin D by mouth. Severe cases have been treated by\\ntransplantation of fetal thymus tissue or bone marrow.\\nHeart defects\\nInfants with life-threatening heart defects are treated\\nsurgically.\\nDefective immune function\\nChildren with DiGeorge syndrome should be kept\\non low-phosphorus diets and kept away from crowds or\\nother sources of infection. They should not be immu-\\nnized with vaccines made from live viruses or given cor-\\nticosteroids.\\nPrognosis\\nThe prognosis is variable; many infants with DiGe-\\norge syndrome die from overwhelming infection,\\nseizures, or heart failure within the first year. Advances\\nin heart surgery indicate that the prognosis is most close-\\nly linked to the severity of the heart defects and the par-\\ntial presence of the thymus gland. In most children who\\nsurvive, the number of T cells, a type of white blood cell,\\nin the blood rises spontaneously as they mature. Sur-\\nvivors are likely to be mentally retarded, however, and to\\nhave other developmental difficulties, including psychi-\\natric problems in later life.\\nPrevention\\nGenetic counseling is recommended for parents of\\nchildren with DiGeorge syndrome because the disorder\\ncan be detected prior to birth. Although most children\\nwith DiGeorge syndrome did not inherit the chromosome\\ndeletion from their parents, they have a 50% chance of\\npassing the deletion on to their own children.\\nBecause of the association between DiGeorge syn-\\ndrome and fetal alcohol syndrome, pregnant women\\nshould avoid drinking alcoholic beverages.\\nResources\\nBOOKS\\n“Common Multiple Congenital Anomaly Syndromes.” In\\nNeonatology: Management, Procedures, On-Call Prob-\\nlems, Diseases and Drugs, ed. Tricia Lacy Gomella, et al.\\nNorwalk, CT: Appleton & Lange, 1994.\\n“DiGeorge Syndrome.” In Physicians’ Guide to Rare Diseases,\\ned. Jess G. Thoene. Montvale, NJ: Dowden Publishing\\nCompany, Inc., 1995.\\n“Immunology; Allergic Disorders: Immunodeficiency Dis-\\neases.” In The Merck Manual of Diagnosis and Therapy,\\ned. Robert Berkow, et al. Rahway, NJ: Merck Research\\nLaboratories, 1999.\\nMcDonald-McGinn, Donna M., et al. 22q11 Deletion Syn-\\ndrome. Philadelphia: The Children’s Hospital of Philadel-\\nphia, 1999.\\nSujansky, Eva, et al. “Genetics & Dysmorphology.” In Current\\nPediatric Diagnosis & Treatment, ed. William W. Hay Jr.,\\net al. Stamford, CT: Appleton & Lange, 1997.\\nORGANIZATIONS\\nCanadian 22q Group. 320 Cote Street Antoine, West Montreal,\\nQuebec H3Y 2J4.\\nGALE ENCYCLOPEDIA OF MEDICINE 21072\\nDiGeorge syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 460, 'page_label': '461'}, page_content='Chromosome Deletion Outreach, Inc. P.O. Box 724, Boca\\nRaton, FL 33429-0724. (888) 236-6680.\\nInternational DiGeorge/VCF Support Network, c/o Family\\nV oices of New York. 46 1/2 Clinton Avenue, Cortland, NY\\n13045. (607) 753-1250.\\nRebecca J. Frey, PhD\\nDigital rectal examination see Rectal\\nexamination\\nDigitalis drugs\\nDefinition\\nDigitalis drugs are medicines made from a type of\\nfoxglove plant (Digitalis purpurea) that have a stimulat-\\ning effect on the heart.\\nPurpose\\nDigitalis drugs are used to treat heart problems such\\nas congestive heart failure and irregular heartbeat.\\nKEY TERMS\\nDeletion—A genetic abnormality in which a seg-\\nment of a chromosome is lost. DiGeorge syn-\\ndrome is caused by a deletion on human chromo-\\nsome 22.\\nFetal alcohol syndrome—A cluster of birth defects\\nthat includes abnormal facial features and mental\\nretardation, caused by the mother’s consumption\\nof alcoholic beverages during pregnancy.\\nFluorescence in situ hybridization (FISH)—A tech-\\nnique for diagnosing DiGeorge syndrome before\\nbirth by analyzing cells obtained by amniocentesis\\nwith DNA probes. FISH is about 95% accurate.\\nHypocalcemia—An abnormally low level of calci-\\num in the blood.\\nHypoplasia —A deficiency or underdevelopment\\nof a tissue or body structure.\\nT cells —A type of white blood cell produced in\\nthe thymus gland. T cells are an important part of\\nthe immune system. Infants born with an underde-\\nveloped or absent thymus do not have a normal\\nlevel of T cells in their blood.\\nThese medicines help make the heart stronger and more\\nefficient. This, in turn, improves blood circulation and\\nhelps relieve the swelling of the hands and ankles that is\\ncommon in people with heart problems.\\nDescription\\nDigitalis drugs, also known as digitalis glycosides,\\nare available only with a physician’s prescription. They\\nare sold in tablet, capsule, liquid, and injectable forms.\\nCommonly used digitalis drugs are digitoxin (Crystodi-\\ngin) and digoxin (Lanoxin).\\nRecommended dosage\\nThe recommended dosage is different for each\\npatient. The physician who prescribes the medicine will\\ndetermine the correct dose. Taking exactly the right\\namount of medicine and taking it exactly as directed are\\nvery important. Never take larger or more frequent doses.\\nDuring treatment with a digitalis heart medicine, the\\nphysician will monitor blood levels of the drug and will\\ndecide whether the dose needs to be changed. Patients\\nshould never change the dose of this medicine unless told\\nto do so by their physicians.\\nPrecautions\\nSeeing a physician regularly while taking digitalis\\ndrugs is very important. The physician will check to\\nmake sure the medicine is working as it should and will\\nmake any necessary changes in dosage or in instructions\\nfor taking the medicine.\\nPatients taking digitalis drugs should learn to take\\ntheir pulse and should check it regularly while under\\ntreatment with this medicine. Changes in pulse rate,\\nrhythm, or force could be signs of side effects.\\nDo not stop taking this medicine suddenly without\\nchecking with the physician who prescribed it. This\\ncould cause a serious change in heart function.\\nDigitalis drugs are responsible for many accidental\\npoisonings in children. Keep this medicine out of the\\nreach of children.\\nBe alert to the signs of overdose. Overdosing is a\\nserious concern with digitalis drugs, because the amount\\nof medicine that most people need to help their heart\\nproblems is very close to the amount that can cause prob-\\nlems from overdose. If any of these signs of overdose\\noccur, check with a physician as soon as possible:\\n• loss of appetite\\n• nausea\\n• vomiting\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1073\\nDigitalis drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 461, 'page_label': '462'}, page_content='• pain in the lower stomach\\n• diarrhea\\n• extreme tiredness or weakness\\n• extremely slow or irregular heartbeat (or fast heartbeat\\nin children)\\n• blurred vision or other vision changes\\n• drowsiness\\n• confusion or depression\\n• headache\\n• fainting\\nAnyone who is taking digitalis drugs should be sure\\nto tell the health care professional in charge before hav-\\ning any surgical or dental procedures or receiving emer-\\ngency treatment. Physicians may advise people taking\\ndigitalis drugs to wear or carry medical identification\\nindicating that they are taking this medicine.\\nPatients need to be very careful not to accidentally\\ntake this medicine in place of another medicine that\\nlooks similar. Patients who are taking other medicines\\nthat look like their digitalis medicine should ask their\\npharmacists for suggestions on how to avoid mix-ups.\\nAnyone who has had unusual reactions to digitalis\\ndrugs in the past should let his or her physician know\\nbefore taking the drugs again. The physician should also\\nbe told about any allergies to foods, dyes, preservatives,\\nor other substances.\\nWomen who are pregnant or breastfeeding or who\\nmay become pregnant should check with their physicians\\nbefore using digitalis drugs.\\nOlder people may be especially sensitive to the\\neffects of digitalis drugs, which may increase the chance\\nof overdose.\\nBefore using digitalis drugs, people with any of the\\nfollowing medical problems should make sure their\\nphysicians are aware of their conditions:\\n• heart disease\\n• heart rhythm problems\\n• severe lung disease\\n• kidney disease\\n• liver disease\\n• thyroid disease\\nSide effects\\nSide effects are rare with this medicine. Check with\\na physician as soon as possible if a skin rash, hives, or\\nany other unusual or troublesome symptoms occur.\\nWatch for signs of overdose.\\nInteractions\\nDigitalis drugs may interact with a number of other\\nmedicines. When this happens, the effects of one or both\\nof the drugs may change or the risk of side effects may\\nbe greater. For example:\\n• Taking digitalis drugs with other heart medicines,\\namphetamines, or diet pills could increase the risk of\\nheart rhythm problems.\\n• Calcium channel blockers, used to treat high blood\\npressure, may cause higher than usual levels of digitalis\\ndrugs in the body that could lead to symptoms of over-\\ndose as covered in the above section.\\n• Diuretics (water pills) or other medicines that lower the\\namount of potassium in the body may increase the side\\neffects of digitalis drugs.\\n• Medicines that increase the amount of potassium in the\\nbody may raise the risk of serious heart rhythm prob-\\nlems when taken with digitalis drugs.\\nGALE ENCYCLOPEDIA OF MEDICINE 21074\\nDigitalis drugs\\nDigitalis purpurea. (Photo Researcher, Inc. Reproduced by\\npermission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 462, 'page_label': '463'}, page_content='• Diarrhea medicine or cholesterol-lowering drugs such as\\ncholestyramine (Questran) and colestipol (Colestid) may\\nkeep digitalis medicines from being absorbed into the\\nbody. To prevent this problem, digitalis drugs should be\\ntaken several hours before or after taking these medicines.\\nThe list above does not include every drug that may\\ninteract with digitalis drugs. Be sure to check with a\\nphysician or pharmacist before taking any other prescrip-\\ntion or nonprescription (over-the-counter) medicine.\\nIn addition, a diet high in fiber may interfere with\\nthe effects of digitalis drugs by preventing the medicine\\nfrom being absorbed into the body. To avoid this prob-\\nlem, eat high fiber foods (such as bran products, whole\\nwheat bread, and fresh fruits and vegetables) several\\nhours before or after taking digitalis medicine.\\nNancy Ross-Flanigan\\nDigoxin see Digitalis drugs; Antiarrhythmic\\ndrugs\\nDilatation and curettage\\nDefinition\\nDilatation and curettage (D & C) is a gynecological\\nprocedure in which the lining of the uterus (endometri-\\num) is scraped away.\\nPurpose\\nD & C is commonly used to obtain tissue for micro-\\nscopic evaluation to rule out cancer. D & C may also be\\nused to diagnose and treat heavy menstrual bleeding, and\\nto diagnose endometrial polyps and uterine fibroids . A\\nD & C can be used as a treatment as well, to remove\\npregnancy tissue after a miscarriage, incomplete abor-\\ntion, or childbirth. Endometrial polyps may be removed,\\nand sometimes benign uterine tumors (fibroids) may be\\nscraped away. D & C can also be used as an early abor-\\ntion technique up to 16 weeks.\\nDescription\\nD & C is usually performed under general anesthe-\\nsia, although local or epidural anesthesia can also be\\nused. A local lessens risk and costs, but the woman will\\nfeel cramping during the procedure. The type of anesthe-\\nsia used often depends upon the reason for the D & C.\\nIn the procedure (which takes only minutes to per-\\nform), the doctor inserts an instrument to hold open the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1075\\nDilatation and curettage\\nCurette\\nUterus\\nFigure A\\nFigure B\\nCervix\\nVagina\\nDilator\\nWhen performing a D & C, the physician inserts a speculum\\nto separate and hold the vaginal walls, then stretches open\\nthe cervix with a dilator. Once the cervix is dilated, the\\nphysician will insert a curette into the uterus and scrapes\\naway small portions of the uterine lining for laboratory\\nanalysis. (Illustration by Electronic Illustrators Group.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 463, 'page_label': '464'}, page_content='vaginal walls, and then stretches the opening of the\\nuterus to the vagina (the cervix) by inserting a series of\\ntapering rods, each thicker than the previous one, or by\\nusing other specialized instruments. This process of\\nopening the cervix is called dilation.\\nOnce the cervix is dilated, the physician inserts a\\nspoon-shaped surgical device called a curette into the\\nuterus. The curette is used to scrape away the uterine lin-\\ning. One or more small tissue samples from the lining of\\nthe uterus or the cervical canal are sent for analysis by\\nmicroscope to check for abnormal cells.\\nAlthough simpler, less expensive techniques such as\\na vacuum aspiration are quickly replacing the D & C as a\\ndiagnostic method, it is still often used to diagnose and\\ntreat a number of conditions.\\nPreparation\\nBecause opening the cervix can be painful, sedatives\\nmay be given before the procedure begins. Deep breath-\\ning and other relaxation techniques may help ease\\ncramping during cervical dilation.\\nAftercare\\nA woman who has had a D & C performed in a hos-\\npital can usually go home the same day or the next day.\\nMany women experience backache and mild cramps\\nafter the procedure, and may pass small blood clots for a\\nday or so. Vaginal staining or bleeding may continue for\\nseveral weeks.\\nMost women can resume normal activities almost\\nimmediately. Patients should avoid sexual intercourse,\\ndouching, and tampon use for at least two weeks to pre-\\nKEY TERMS\\nEndometrial polyps—A growth in the lining of the\\nuterus (endometrium) that may cause bleeding\\nand can develop into cancer.\\nEpidural anesthesia —A type of anesthesia that is\\ninjected into the epidural space of the spinal cord\\nto numb the nerves leading to the lower half of the\\nbody.\\nUterine fibroid —A noncancerous tumor of the\\nuterus that can range from the size of a pea to the\\nsize of a grapefruit. Small fibroids require no treat-\\nment, but those causing serious symptoms may\\nneed to be removed.\\nvent infection while the cervix is closing and to allow the\\nendometrium to heal completely.\\nRisks\\nThe primary risk after the procedure is infection.\\nSigns of infection include:\\n•f e v e r\\n• heavy bleeding\\n• severe cramps\\n• foul-smelling vaginal discharge\\nA woman should report any of these symptoms to\\nher doctor, who can treat the infection with antibiotics\\nbefore it becomes serious.\\nD & C is a surgical operation, which carries certain\\nrisks associated with general anesthesia. Rare complica-\\ntions include puncture of the uterus (which usually heals\\non its own) or puncture of the bowel or bladder (which\\nrequire further surgery to repair).\\nNormal results\\nRemoval of the uterine lining causes no side effects,\\nand may be beneficial if the lining has thickened so much\\nthat it causes heavy periods. The uterine lining soon\\ngrows again normally, as part of the menstrual cycle.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nCarol A. Turkington\\nDilated cardiomyopathy see Congestive\\ncardiomyopathy\\nDiltiazem see Calcium channel blockers\\nDilution test see Kidney function tests\\nDiphenhydramine see Antihistamines\\nDiphtheria\\nDefinition\\nDiphtheria is a potentially fatal, contagious disease\\nthat usually involves the nose, throat, and air passages,\\nGALE ENCYCLOPEDIA OF MEDICINE 21076\\nDiphtheria'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 464, 'page_label': '465'}, page_content='but may also infect the skin. Its most striking feature is\\nthe formation of a grayish membrane covering the tonsils\\nand upper part of the throat.\\nDescription\\nLike many other upper respiratory diseases, diphthe-\\nria is most likely to break out during the winter months.\\nAt one time it was a major childhood killer, but it is now\\nrare in developed countries because of widespread\\nimmunization. Since 1988, all confirmed cases in the\\nUnited States have involved visitors or immigrants. In\\ncountries that do not have routine immunization against\\nthis infection, the mortality rate varies from 1.5–25%.\\nPersons who have not been immunized may get\\ndiphtheria at any age. The disease is spread most often by\\ndroplets from the coughing or sneezing of an infected\\nperson or carrier. The incubation period is two to seven\\ndays, with an average of three days. It is vital to seek\\nmedical help at once when diphtheria is suspected,\\nbecause treatment requires emergency measures for\\nadults as well as children.\\nCauses and symptoms\\nThe symptoms of diphtheria are caused by toxins\\nproduced by the diphtheria bacillus, Corynebacterium\\ndiphtheriae (from the Greek for “rubber membrane”). In\\nfact, toxin production is related to infections of the bacil-\\nlus itself with a particular bacteria virus called a phage\\n(from bacteriophage; a virus that infects bacteria). The\\nintoxication destroys healthy tissue in the upper area of\\nthe throat around the tonsils, or in open wounds in the\\nskin. Fluid from the dying cells then coagulates to form\\nthe telltale gray or grayish green membrane. Inside the\\nmembrane, the bacteria produce an exotoxin, which is a\\npoisonous secretion that causes the life-threatening\\nsymptoms of diphtheria. The exotoxin is carried through-\\nout the body in the bloodstream, destroying healthy tis-\\nsue in other parts of the body.\\nThe most serious complications caused by the exo-\\ntoxin are inflammations of the heart muscle ( myocardi-\\ntis) and damage to the nervous system. The risk of seri-\\nous complications is increased as the time between onset\\nof symptoms and the administration of antitoxin increas-\\nes, and as the size of the membrane formed increases.\\nThe myocarditis may cause disturbances in the heart\\nrhythm and may culminate in heart failure . The symp-\\ntoms of nervous system involvement can include seeing\\ndouble (diplopia), painful or difficult swallowing, and\\nslurred speech or loss of voice, which are all indications\\nof the exotoxin’s effect on nerve functions. The exotoxin\\nmay also cause severe swelling in the neck (“bull neck”).\\nThe signs and symptoms of diphtheria vary accord-\\ning to the location of the infection:\\nNasal\\nNasal diphtheria produces few symptoms other than\\na watery or bloody discharge. On examination, there may\\nbe a small visible membrane in the nasal passages. Nasal\\ninfection rarely causes complications by itself, but it is a\\npublic health problem because it spreads the disease\\nmore rapidly than other forms of diphtheria.\\nPharyngeal\\nPharyngeal diphtheria gets its name from the phar-\\nynx, which is the part of the upper throat that connects\\nthe mouth and nasal passages with the voice box. This is\\nthe most common form of diphtheria, causing the charac-\\nteristic throat membrane. The membrane often bleeds if\\nit is scraped or cut. It is important not to try to remove\\nthe membrane because the trauma may increase the\\nbody’s absorption of the exotoxin. Other signs and symp-\\ntoms of pharyngeal diphtheria include mild sore throat,\\nfever of 101–102°F (38.3–38.9°C), a rapid pulse, and\\ngeneral body weakness.\\nLaryngeal\\nLaryngeal diphtheria, which involves the voice box\\nor larynx, is the form most likely to produce serious\\ncomplications. The fever is usually higher in this form of\\ndiphtheria (103–104°F or 39.4–40°C) and the patient is\\nvery weak. Patients may have a severe cough, have diffi-\\nculty breathing, or lose their voice completely. The\\ndevelopment of a “bull neck” indicates a high level of\\nexotoxin in the bloodstream. Obstruction of the airway\\nmay result in respiratory compromise and death.\\nSkin\\nThis form of diphtheria, which is sometimes called\\ncutaneous diphtheria, accounts for about 33% of diphthe-\\nria cases. It is found chiefly among people with poor\\nhygiene. Any break in the skin can become infected with\\ndiphtheria. The infected tissue develops an ulcerated area\\nand a diphtheria membrane may form over the wound but\\nis not always present. The wound or ulcer is slow to heal\\nand may be numb or insensitive when touched.\\nDiagnosis\\nBecause diphtheria must be treated as quickly as\\npossible, doctors usually make the diagnosis on the basis\\nof the visible symptoms without waiting for test results.\\nIn making the diagnosis, the doctor examines the\\npatient’s eyes, ears, nose, and throat in order to rule out\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1077\\nDiphtheria'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 465, 'page_label': '466'}, page_content='other diseases that may cause fever and sore throat, such\\nas infectious mononucleosis , a sinus infection, or strep\\nthroat. The most important single symptom that sug-\\ngests diphtheria is the membrane. When a patient devel-\\nops skin infections during an outbreak of diphtheria, the\\ndoctor will consider the possibility of cutaneous diphthe-\\nria and take a smear to confirm the diagnosis.\\nLaboratory tests\\nThe diagnosis of diphtheria can be confirmed by the\\nresults of a culture obtained from the infected area. Mater-\\nial from the swab is put on a microscope slide and stained\\nusing a procedure called Gram’s stain. The diphtheria\\nbacillus is called Gram-positive because it holds the dye\\nafter the slide is rinsed with alcohol. Under the micro-\\nscope, diphtheria bacilli look like beaded rod-shaped cells,\\ngrouped in patterns that resemble Chinese characters.\\nAnother laboratory test involves growing the diphtheria\\nbacillus on a special material called Loeffler’s medium.\\nTreatment\\nDiphtheria is a serious disease requiring hospital\\ntreatment in an intensive care unit if the patient has\\ndeveloped respiratory symptoms. Treatment includes a\\ncombination of medications and supportive care:\\nAntitoxin\\nThe most important step is prompt administration of\\ndiphtheria antitoxin, without waiting for laboratory\\nresults. The antitoxin is made from horse serum and\\nworks by neutralizing any circulating exotoxin. The doc-\\ntor must first test the patient for sensitivity to animal\\nserum. Patients who are sensitive (about 10%) must be\\ndesensitized with diluted antitoxin, since the antitoxin is\\nthe only specific substance that will counteract diphthe-\\nria exotoxin. No human antitoxin is available for the\\ntreatment of diphtheria.\\nThe dose ranges from 20,000–100,000 units,\\ndepending on the severity and length of time of symp-\\ntoms occurring before treatment. Diphtheria antitoxin is\\nusually given intravenously.\\nAntibiotics\\nAntibiotics are given to wipe out the bacteria, to\\nprevent the spread of the disease, and to protect the\\npatient from developing pneumonia. They are not a sub-\\nstitute for treatment with antitoxin. Both adults and chil-\\ndren may be given penicillin, ampicillin, or ery-\\nthromycin. Erythromycin appears to be more effective\\nthan penicillin in treating people who are carriers\\nbecause of better penetration into the infected area.\\nCutaneous diphtheria is usually treated by cleansing\\nthe wound thoroughly with soap and water, and giving\\nthe patient antibiotics for 10 days.\\nSupportive care\\nDiphtheria patients need bed rest with intensive\\nnursing care, including extra fluids, oxygenation, and\\nmonitoring for possible heart problems, airway blockage,\\nor involvement of the nervous system. Patients with\\nlaryngeal diphtheria are kept in a croup tent or high-\\nhumidity environment; they may also need throat suc-\\ntioning or emergency surgery if their airway is blocked.\\nPatients recovering from diphtheria should rest at\\nhome for a minimum of two to three weeks, especially if\\nthey have heart complications. In addition, patients\\nshould be immunized against diphtheria after recovery,\\nbecause having the disease does not always induce anti-\\ntoxin formation and protect them from reinfection.\\nPrevention of complications\\nDiphtheria patients who develop myocarditis may be\\ntreated with oxygen and with medications to prevent\\nirregular heart rhythms. An artificial pacemaker may be\\nneeded. Patients with difficulty swallowing can be fed\\nthrough a tube inserted into the stomach through the\\nnose. Patients who cannot breathe are usually put on\\nmechanical respirators.\\nPrognosis\\nThe prognosis depends on the size and location of\\nthe membrane and on early treatment with antitoxin; the\\nlonger the delay, the higher the death rate. The most vul-\\nnerable patients are children under age 15 and those who\\ndevelop pneumonia or myocarditis. Nasal and cutaneous\\ndiphtheria are rarely fatal.\\nPrevention\\nPrevention of diphtheria has four aspects:\\nImmunization\\nUniversal immunization is the most effective means\\nof preventing diphtheria. The standard course of immu-\\nnization for healthy children is three doses of DPT\\n(diphtheria-tetanus-pertussis) preparation given between\\ntwo months and six months of age, with booster doses\\ngiven at 18 months and at entry into school. Adults\\nshould be immunized at 10 year intervals with Td\\n(tetanus-diphtheria) toxoid. A toxoid is a bacterial toxin\\nthat is treated to make it harmless but still can induce\\nimmunity to the disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 21078\\nDiphtheria'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 466, 'page_label': '467'}, page_content='Isolation of patients\\nDiphtheria patients must be isolated for one to\\nseven days or until two successive cultures show that\\nthey are no longer contagious. Children placed in isola-\\ntion are usually assigned a primary nurse for emotional\\nsupport.\\nIdentification and treatment of contacts\\nBecause diphtheria is highly contagious and has a\\nshort incubation period, family members and other con-\\ntacts of diphtheria patients must be watched for symp-\\ntoms and tested to see if they are carriers. They are usual-\\nly given antibiotics for seven days and a booster shot of\\ndiphtheria/tetanus toxoid.\\nReporting cases to public health authorities\\nReporting is necessary to track potential epidemics,\\nto help doctors identify the specific strain of diphtheria,\\nand to see if resistance to penicillin or erythromycin has\\ndeveloped.\\nKEY TERMS\\nAntitoxin—An antibody against an exotoxin, usu-\\nally derived from horse serum.\\nBacillus —A rod-shaped bacterium, such as the\\ndiphtheria bacterium.\\nCarrier —A person who may harbor an organism\\nwithout symptoms and may transmit it to others.\\nCutaneous—Located in the skin.\\nDiphtheria-tetanus-pertussis (DTP)—The standard\\npreparation used to immunize children against\\ndiphtheria, tetanus, and whooping cough. A so-\\ncalled “acellular pertussis” vaccine (aP) is usually\\nused since its release in the mid-1990s.\\nExotoxin —A poisonous secretion produced by\\nbacilli which is carried in the bloodstream to other\\nparts of the body.\\nGram’s stain—A dye staining technique used in\\nlaboratory tests to determine the presence and\\ntype of bacteria.\\nLoeffler’s medium—A special substance used to\\ngrow diphtheria bacilli to confirm the diagnosis.\\nMyocarditis—Inflammation of the heart tissue.\\nToxoid—A preparation made from inactivated\\nexotoxin, used in immunization.\\nResources\\nBOOKS\\nAbzug, Mark J. “Infectious Diseases: Bacterial, Spirochetal,\\nProtozoal, Metazoal, & Mycotic.” In Handbook of Pedi-\\natrics, ed. Gerald B. Merenstein, et al. Norwalk, CT:\\nAppleton & Lange, 1994.\\nChambers, Henry F. “Infectious Diseases: Bacterial & Chlamy-\\ndial.” In Current Medical Diagnosis and Treatment, 1998.\\n37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton\\n& Lange, 1997.\\n“Childhood Infections: Bacterial Infections.” In The Merck\\nManual of Diagnosis and Therapy.16th ed. Ed. Robert\\nBerkow. Rahway, NJ: Merck Research Laboratories, 1992.\\nMirza, Ayesha, and Russell W. Steele. “Diphtheria.” In Conn’s\\nCurrent Therapy, 1996, ed. Robert E. Rakel. Philadelphia:\\nW. B. Saunders Co., 1996.\\nOgle, John W. “Infections: Bacterial & Spirochetal.” In Current\\nPediatric Diagnosis & Treatment, ed. William W. Hay Jr.,\\net al. Stamford: Appleton & Lange, 1997.\\nSimoes, Eric A. F., and Jessie R. Groothuis. “Immunization.”\\nIn Current Pediatric Diagnosis & Treatment, ed. William\\nW. Hay Jr., et al. Stamford: Appleton & Lange, 1997.\\nRebecca J. Frey\\nDiplegia see Paralysis\\nDirect Coombs’ test see Coombs’ tests\\nDirect laryngoscopy see Laryngoscopy\\nDiscoid lupus erythematosus\\nDefinition\\nDiscoid lupus erythematosus (DLE) is a disease in\\nwhich coin-shaped (discoid) red bumps appear on the skin.\\nDescription\\nThe disease called discoid lupus erythematosus only\\naffects the skin, although similar discoid skin lesions can\\noccur in the serious disease called systemic lupus ery-\\nthematosus (SLE). Only about 10% of all patients with\\nDLE will go on to develop the multi-organ disease SLE.\\nThe tendency to develop DLE seems to run in fami-\\nlies. Although men or women of any age can develop\\nDLE, it occurs in women three times more frequently than\\nin men. The typical DLE patient is a woman in her 30s.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1079\\nDiscoid lupus erythematosus'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 467, 'page_label': '468'}, page_content='Causes and symptoms\\nThe cause of DLE is unknown. It is thought that\\nDLE (like SLE) may be an autoimmune disorder.\\nAutoimmune disorders are those that occur when cells\\nof the immune system are misdirected against the body.\\nNormally, immune cells work to recognize and help\\ndestroy foreign invaders like bacteria, viruses, and fungi.\\nIn autoimmune disorders, these cells mistakenly recog-\\nnize various tissues of the body as foreign invaders, and\\nattack and destroy these tissues. In SLE, the misdirected\\nimmune cells are antibodies. In DLE, the damaging cells\\nare believed to be a type of white blood cell called a T\\nlymphocyte. The injury to the skin results in inflamma-\\ntion and the characteristic discoid lesions.\\nIn DLE, the characteristic skin lesion is circular and\\nraised. The reddish rash is about 5–10 mm in diameter,\\nwith the center often somewhat scaly and lighter in color\\nthan the darker outer ring. The surface of these lesions is\\nsometimes described as “warty.” There is rarely any itch-\\ning or pain associated with discoid lesions. They tend to\\nappear on the face, ears, neck, scalp, chest, back, and\\narms. As DLE lesions heal, they leave thickened, scarred\\nareas of skin. When the scalp is severely affected, there\\nmay be associated hair loss (alopecia).\\nPeople with DLE tend to be quite sensitive to the\\nsun. They are more likely to get a sunburn, and the sun\\nis likely to worsen their discoid lesions.\\nDiagnosis\\nDiagnosis of DLE usually requires a skin biopsy. A\\nsmall sample of a discoid lesion is removed, specially\\nprepared, and examined under a microscope. Usually, the\\nlesion has certain microscopic characteristics that allow it\\nto be identified as a DLE lesion. Blood tests will not\\nreveal the type of antibodies present in SLE, and physical\\nexamination usually does not reveal anything other than\\nthe skin lesions. If antibodies exist in the blood, or if other\\nsymptoms or physical signs are found, it is possible that\\nthe discoid lesions are a sign of SLE rather than DLE.\\nTreatment\\nTreatment of DLE primarily involves the use of a\\nvariety of skin creams. Sunscreens are used for protec-\\ntion. Steroid creams can be applied to decrease inflamma-\\ntion. Occasionally, small amounts of a steroid preparation\\nwill be injected with a needle into a specific lesion.\\nBecause of their long list of side effects, steroid prepara-\\ntions taken by mouth are avoided. Sometimes, short-term\\ntreatment with oral steroids will be used for particularly\\nsevere DLE outbreaks. Medications used to treat the\\ninfectious disease malaria are often used to treat DLE.\\nAlternative treatment\\nAlternative treatments for DLE include eating a\\nhealthy diet, low in red meat and dairy products and high\\nin fish containing omega-3 fatty acids. These types of\\nfish include mackerel, sardines, and salmon. Following a\\nhealthy diet is thought to decrease inflammation. Dietary\\nsupplements believed to be helpful include vitamins B,\\nC, E, and selenium. Vitamin A is also recommended to\\nimprove DLE lesions. Constitutional homeopathic treat-\\nment can help heal DLE as well as help prevent it devel-\\noping into SLE.\\nPrognosis\\nFor the most part, the prognosis for people with\\nDLE is excellent. While the lesions may be cosmetically\\nunsightly, they are not life threatening and usually do not\\ncause a patient to change his or her lifestyle. Only about\\n10% of patients with DLE will go on to develop SLE.\\nPrevention\\nDLE cannot be prevented. Recommendations to pre-\\nvent flares of DLE in patients with the disease include\\navoiding exposure to sun and consistently using sun-\\nscreen.\\nResources\\nBOOKS\\nAaseng, Nathan. Autoimmune Diseases. New York: F. Watts,\\n1995.\\nHahn, Bevra Hannahs. “Systemic Lupus Erythematosus.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 21080\\nDiscoid lupus erythematosus\\nDiscoloration of the hands is one characteristic of discoid\\nlupus erythematosus. (Custom Medical Stock Photo. Repro-\\nduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 468, 'page_label': '469'}, page_content='Long, James W. The Essential Guide to Chronic Illness. New\\nYork: HarperPerennial, 1997.\\nWallace, Daniel J. The Lupus Book. New York: Oxford Univer-\\nsity Press, 1995.\\nPERIODICALS\\nMann, Judy. “The Harsh Realities of Lupus.”The Washington\\nPost, 120, no. 281 (8 Oct. 1997): C12.\\nUmansky, Diane. “Living with Lupus.”American Health for\\nWomen 16, no. 5 (June 1997): 92+.\\nORGANIZATIONS\\nThe American College of Rheumatology. 1800 Century Place,\\nSuite 250, Atlanta, GA 30345. (404) 633-3777. .\\nLupus Foundation of America. 1300 Piccard Dr., Suite 200,\\nRockville, MD 20850. (800) 558-0121. .\\nRosalyn Carson-DeWitt, MD\\nDisk removal\\nDefinition\\nOne of the most common types of back surgery is\\ndisk removal (diskectomy), the removal of an interverte-\\nbral disk, the flexible plate that connects any two adja-\\ncent vertebrae in the spine. Intervertebral disks act as\\nshock absorbers, protecting the brain and spinal cord\\nfrom the impact produced by the body’s movements.\\nPurpose\\nAbout 150,000 Americans undergo disk removal\\neach year in the United States. Removing the invertebral\\nKEY TERMS\\nAntibody —Specialized cells of the immune sys-\\ntem that can recognize organisms invading the\\nbody (like bacteria, viruses, and fungi). The anti-\\nbodies are then able to start a complex chain of\\nevents designed to kill these foreign invaders.\\nAutoimmune disorder —A disorder in which the\\nbody’s antibodies mistake the body’s own tissues\\nfor foreign invaders. The immune system then\\nattacks and causes damage to these tissues.\\nImmune system—The system of specialized organs,\\nlymph nodes, and blood cells throughout the body\\nthat work together to defend the body against for-\\neign invaders (bacteria, viruses, fungi, etc.).\\ndisk is performed to treat back pain that has lasted at least\\nsix weeks as a result of an abnormal disk and that has not\\nresponded to conservative treatment. Surgery is also per-\\nformed if there is pressure on the lumbosacral nerve roots\\nthat causes weakness or bowel or bladder disfunction.\\nAs a person ages, the disks between the vertebrae\\ndegenerate and dry out, and the fibers holding them in\\nplace tear. Eventually, the disk can form a blister-like\\nbulge, compressing nerves in the spine and causing pain.\\nThis is called a “prolapsed” (or herniated) disk. If such a\\ndisk causes muscle weakness or interferes with bladder\\nor bowel function because it is pressing on a nerve root,\\nimmediate surgery to remove the disk may be needed.\\nThe aim of the surgery is to try to relieve all pressure\\non nerve roots by removing the pulpy material from the\\ndisk, or the disk itself. If it is necessary to remove materi-\\nal from several nearby vertebrae, the spine may become\\nunsteady. In this case, the surgeon will perform a spinal\\nfusion, removing all the disks between two or more verte-\\nbrae and roughening the bones so that the vertebrae heal\\ntogether. Bone strips taken from the patient’s leg or hip\\nmay be used to help hold the vertebrae together. Spinal\\nfusion decreases pain but it also decreases spinal mobility.\\nPrecautions\\nThe doctor will obtain x rays, neuroimaging stud-\\nies, including computed tomography scan (CT scan)\\nmyelogram and magnetic resonance imaging (MRI),\\nand clinical exams to determine the precise location of\\nthe affected disk.\\nDescription\\nThe surgery is done under general anaesthesia,\\nwhich puts the patient to sleep and affects the whole\\nbody. Operating on the patient’s back, the neurosurgeon\\nor orthopedic surgeon makes an opening into the verte-\\nbral canal, and then moves the dura and the bundle of\\nnerves called the “cauda equina” (horse’s tail) aside,\\nwhich exposes the disk. If a portion of the disk has\\nmoved from between the vertebrae out into the nerve\\ncanal, it is simply removed. If the disk itself has become\\nfragmented and partially displaced, or not fragmented\\nbut bulging extensively, the surgeon will remove the\\nbulging or displaced part of the disk and the part that lies\\nin the space between the vertebrae.\\nPreparation\\nThe patient is given an injection an hour before the\\nsurgery to dry up internal fluids and encourage drowsi-\\nness.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1081\\nDisk removal'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 469, 'page_label': '470'}, page_content='Aftercare\\nAfter the operation, the patient will awaken lying\\nflat and face down, and must remain this way for several\\ndays, changing position only to avoid bedsores . There\\nmaybe slight pain or stiffness in the back area.\\nPatients should sleep on a firm mattress and avoid\\nbending at the waist, lifting heavy weights, or sitting in\\none spot for a long time (such as riding in a car).\\nAfter surgery, patients can usually leave the hospital\\non the fourth or fifth day. They must:\\n• avoid sitting for more than 15–20 minutes\\n• use a reclined chair\\n• avoid bending, twisting, or lifting\\n• begin gentle walking (indoors or outdoors), gradually\\nincreasing\\n• begin stationary biking or gentle swimming after two\\nweeks\\n• continue exercise for the next four weeks\\n• slow down if they experience more than minor pain in\\nthe back or leg\\nRisks\\nAll surgery carries some risk due to heart and lung\\nproblems or the anesthesia itself, but this risk is generally\\nKEY TERMS\\nDiskectomy—The surgical removal of a portion of\\nan invertebral disk.\\nDura—The strongest and outermost of three mem-\\nbranes that protect the brain, spinal cord, and\\nnerves of the cauda equina.\\nHerniated disk—A blisterlike bulging or protrusion\\nof the contents of the disk out through the fibers\\nthat normally hold them in place. It is also called a\\nruptured disk, slipped disk, or displaced disk.\\nIntervertebral disk —Cylindrical elastic-like gel\\npads that separate and join each pair of vertebrae\\nin the spine.\\nLaminectomy —An operation in which the sur-\\ngeon cuts through the covering of a vertebra to\\nreach a herniated disk in order to remove it.\\nVertebra—The bones that make up the back bone\\n(spine).\\nextremely small. (The risk of death from general anes-\\nthesia for all types of surgery, for example, is only about\\n1 in 1,600.)\\nThe most common risk of the surgery is infection,\\nwhich occurs in 1–2% of cases. Rarely, the surgery can\\ndamage nerves in the lower back or major blood vessels\\nin front of the disk. Occasionally, there may be some\\nresidual paralysis of a particular leg or bladder muscle\\nafter surgery, but this is the result of the disk problem\\nthat necessitated the surgery, not the operation itself.\\nWhile disk removals can relieve pain in 90% of\\ncases, there are some people who do not get pain relief,\\ndepending on how long they had the condition requiring\\nsurgery and other factors.\\nNormal results\\nAfter about five days, most patients can leave the\\nhospital. They can resume all normal activities, including\\nwork, after four to six weeks of recuperation at home.\\nIn properly evaluated patients, there is a very good\\nchance that disk removal will be successful in easing\\npain. Even in patients over age 60, disk surgery has a\\n“good to excellent” result for 87% of patients. Disk\\nsurgery can relieve both back and leg pain, but the great-\\nest pain relief will occur with the leg pain.\\nResources\\nBOOKS\\nWhite III, Augustus. Your Aching Back.New York: Simon &\\nSchuster, 1990.\\nThe Surgery Book: An Illustrated Guide to 73 of the Most Com-\\nmon Operations. Ed. Robert M. Younson, et al. New York:\\nSt. Martin’s Press, 1993.\\nCarol A. Turkington\\nDiskectomy see Disk removal\\nDislocations and subluxations\\nDefinition\\nIn medicine, the terms dislocation and subluxation\\nrefer to the displacement of bones that form a joint.\\nThese conditions affecting the joint most often result\\nfrom trauma that causes adjoining bones to no longer\\nalign with each other. A partial or incomplete dislocation\\nis called a subluxation.\\nGALE ENCYCLOPEDIA OF MEDICINE 21082\\nDislocations and subluxations'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 470, 'page_label': '471'}, page_content='Description\\nIn a healthy joint, the bones are normally held\\ntogether with tough, fibrous bands called ligaments.\\nThese ligaments are attached to each bone along with a\\nfibrous sac surrounding the joint called the articular cap-\\nsule or joint capsule. The ligaments and joint capsule are\\nrelatively strong and nonelastic but permit movement\\nwithin normal limits for each particular joint. In the event\\nof a dislocation, one of the bones making up the joint is\\nforced out of its natural alignment from excessive\\nstretching and tearing of the joint ligaments and capsule.\\nMuscles and tendons surrounding the joint are usually\\nstretched and injured to some degree.\\nCauses and symptoms\\nA violent movement at the joint that exceeds normal\\nlimits usually causes a joint dislocation. Although dislo-\\ncations often result from trauma, they sometimes occur\\nas a result of disease affecting the joint structures. In the\\nprocess of the dislocation, there is tearing of the liga-\\nments and the articular capsule, which are vital structures\\nfor connecting the bone. Following a dislocation, the\\nbones affected are often immobile and the affected limb\\nmay be locked in an abnormal position; fractures are\\nalso a concern with severe dislocations.\\nImportant factors in recognizing a dislocation or\\nsubluxation include a history of experiencing a fall or\\nreceiving a blow in a particular joint followed by the sud-\\nden onset of loss of function to the involved limb. Imme-\\ndiately after the dislocation, the joint almost always\\nswells significantly and feels painful when pressure is\\napplied (point tenderness). If trauma to the joint causing\\nthe dislocation or subluxation is violent in nature, small\\nchips of bone can be torn away with the supporting struc-\\ntures. Chronic recurrent dislocations may take place\\nwithout severe pain because of the somewhat slack con-\\ndition of the surrounding muscles and other supporting\\ntissues. A first-time dislocation is considered and treated\\nas a possible fracture. Risk factors that can increase sus-\\nceptibility of joint dislocation and subluxation are shal-\\nlow or abnormally formed joint surfaces present at birth\\n(congenital) and/or other diseases of ligaments and tissue\\naround a joint. Some infants are born with a hip disloca-\\ntion. Both sexes and all ages are affected.\\nDiagnosis\\nA thorough medical history and physical exam by a\\nphysician is the first step in the correct diagnosis of dis-\\nlocations and subluxations. X rays of the joint and adja-\\ncent bones can locate and help determine the extent of\\ndislocated joints\\nTreatment\\nImmediately after the dislocation, the application of\\nice is helpful to control swelling and decrease pain. If the\\npatient needs to be transported, it is important to prevent\\nthe joint from moving (immobilization). At times, a cast\\nor splint may be used to immobilize the joint and ensure\\nproper alignment and healing. The treatment of realign-\\ning bones following a dislocation is called reduction.\\nThis may include simple maneuvers that manipulate the\\njoint to reposition the bones or surgical procedures to\\nrestore the joint to its normal position. A general anesthe-\\nsia or muscle relaxant may be used to help make joint\\nreduction possible by relaxing surrounding muscles in\\nspasm. Acetaminophen or aspirin are sometimes used\\nto control moderate pain, and narcotics may be pre-\\nscribed by the physician if the pain is severe. Recurring\\ndislocation may require surgical reconstruction or\\nreplacement of the joint. It is not recommended to\\nattempt to reset a dislocated joint outside of a medical\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1083\\nDislocations and subluxations\\nThis x ray shows the dislocation between two bones in a\\nfinger. (Photo Researchers, Inc. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 471, 'page_label': '472'}, page_content='environment with experienced medical personnel,\\nbecause a fracture may be present.\\nAlternative treatment\\nChiropractic care has been shown to be effective\\nfor joint subluxation and dislocation, especially in the\\nspine. Swelling can be addressed using botanical thera-\\npies. Bromelain, a pineapple enzyme, and tumeric ( Cur-\\ncuma longa ) are the most potent botanical remedies for\\nthis purpose. Acute homeopathic care with arnica ( Arni-\\nca montana ) can reduce the trauma to the body. Liga-\\nment and tendon strengthening can be assisted both\\nbotanically and homeopathically.\\nPrognosis\\nJoint ligaments have poor blood supply and, there-\\nfore, heal slowly. This healing process continues long\\nafter the symptoms of the dislocation injury have\\ndiminished. Once a joint has been either subluxated or\\ncompletely dislocated, the connective tissue binding or\\nholding it in correct alignment is stretched to such an\\nextent that the joint becomes extremely vulnerable to\\nrepeated dislocations. However, this chance of recur-\\nrent dislocation and subluxation will decrease if a\\nproper rehabilitation program is implemented to\\nstrengthen surrounding muscles of the joint. Most joint\\ndislocations are curable with prompt treatment. After\\nthe dislocation has been corrected, the joint may\\nrequire immobilization with a cast or sling for two to\\neight weeks.\\nPrevention\\nWhen an individual is involved in strenuous\\nsports or heavy work, involved joints may be protect-\\ned by elastic bandage wraps, tape wraps, knee and\\nshoulder pads, or special support stockings. Keeping\\nthe muscles surrounding the joint strong will also\\nhelp prevent dislocations. Long-term problems may\\nalso be prevented by allowing an adequate amount of\\ntime for an injured joint to rest and heal prior to\\nresuming full activity.\\nGALE ENCYCLOPEDIA OF MEDICINE 21084\\nDislocations and subluxations Anterior temporal \\nmandibular dislocation\\nPosterior dislocation of hip Dislocation of thumb\\nSubcoracoid \\ndislocation (shoulder)\\nDislocations and subluxations refer to the displacement of bones that form a joint. Such conditions most often result from\\ntrauma causing adjoining bones to no longer touch each other. A partial or incomplete dislocation is called a subluxation.\\nThe illustrations above indicate dislocation of the jaw bone, shoulder blade, hip bone, and the thumb.(Illustration by Electronic\\nIllustrators Group.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 472, 'page_label': '473'}, page_content='Resources\\nBOOKS\\nArnheim, Daniel D. Modern Principals of Athletic Training.St.\\nLouis: Times Mirror/Mosby College Publishing Co.,\\n1989.\\nMagee, David J. Orthopedic Physical Assessment. Philidel-\\nphia: W. B. Saunders Co., 1992.\\nScully, Rosemary M., and Marylou R. Barnes. Physical Thera-\\npy. Philadelphia: J. B. Lippincott Co., 1989.\\nPERIODICALS\\nGorden, Everett J. “Fractures and Dislocations: An Overview.”\\nTrauma 37, no. 5 (Feb. 1996): 5-36.\\nOTHER\\nGriffith, H. Winter. “Dislocations or Subluxation.”ThriveOnline.\\n1998. 25 Mar. 1998 .\\nJeffrey P. Larson, RPT\\nDisopyramide see Antiarrhythmic drugs\\nDisproportionate dwarfism see\\nAchondroplasia\\nDissecting aneurysm see Aortic dissection\\nDissecting hematoma see Aortic dissection\\nDisseminated lupus erythematosus see\\nSystemic lupus erythematosus\\nDissociative disorders\\nDefinition\\nThe dissociative disorders are a group of mental dis-\\norders that affect consciousness are defined as causing\\nsignificant interference with the patient’s general func-\\ntioning, including social relationships and employment.\\nKEY TERMS\\nArticular capsule—An envelope of tissue that sur-\\nrounds a free moving joint, composed of an exter-\\nnal layer of white fibrous tissue and an external\\nsynovial membrane that secretes a lubricant into\\nthe joint.\\nDescription\\nIn order to have a clear picture of these disorders,\\ndissociation should first be understood. Dissociation is a\\nmechanism that allows the mind to separate or compart-\\nmentalize certain memories or thoughts from normal\\nconsciousness. These split-off mental contents are not\\nerased. They may resurface spontaneously or be trig-\\ngered by objects or events in the person’s environment.\\nDissociation is a process that occurs along a spec-\\ntrum of severity. It does not necessarily mean that a per-\\nson has a dissociative disorder or other mental illness. A\\nmild degree of dissociation occurs with some physical\\nstressors; people who have gone without sleep for a long\\nperiod of time, have had “laughing gas” for dental\\nsurgery, or have been in a minor accident often have\\nbrief dissociative experiences. Another commonplace\\nexample of dissociation is a person becoming involved\\nin a book or movie so completely that the surroundings\\nor the passage of time are not noticed. Another example\\nmight be driving on the highway and taking several exits\\nwithout noticing or remembering. Dissociation is related\\nto hypnosis in that hypnotic trance also involves a tem-\\nporarily altered state of consciousness. Most patients\\nwith dissociative disorders are highly hypnotizable.\\nPeople in other cultures sometimes have dissociative\\nexperiences in the course of religious (in certain trance\\nstates) or other group activities. These occurrences\\nshould not be judged in terms of what is considered “nor-\\nmal” in the United States.\\nModerate or severe forms of dissociation are caused\\nby such traumatic experiences as childhood abuse, com-\\nbat, criminal attacks, brainwashing in hostage situations,\\nor involvement in a natural or transportation disaster.\\nPatients with acute stress disorder , post-traumatic\\nstress disorder (PTSD), or conversion disorder and\\nsomatization disorder may develop dissociative symp-\\ntoms. Recent studies of trauma indicate that the human\\nbrain stores traumatic memories in a different way than\\nnormal memories. Traumatic memories are not\\nprocessed or integrated into a person’s ongoing life in\\nthe same fashion as normal memories. Instead they are\\ndissociated, or “split off,” and may erupt into conscious-\\nness from time to time without warning. The affected\\nperson cannot control or “edit” these memories. Over a\\nperiod of time, these two sets of memories, the normal\\nand the traumatic, may coexist as parallel sets without\\nbeing combined or blended. In extreme cases, different\\nsets of dissociated memories may alter subpersonalities\\nof patients with dissociative identity disorder ( multiple\\npersonality disorder).\\nThe dissociative disorders vary in their severity and\\nthe suddenness of onset. It is difficult to give statistics\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1085\\nDissociative disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 473, 'page_label': '474'}, page_content='for their frequency in the United States because they are\\na relatively new category and are often misdiagnosed.\\nAnd, criterion for diagnosis require significant impair-\\nment in social or vocational functioning.\\nDissociative amnesia\\nDissociative amnesia is a disorder in which the\\ndistinctive feature is the patient’s inability to remem-\\nber important personal information to a degree that\\ncannot be explained by normal forgetfulness. In many\\ncases, it is a reaction to a traumatic accident or wit-\\nnessing a violent crime. Patients with dissociative\\namnesia may develop depersonalization or trance\\nstates as part of the disorder, but they do not experi-\\nence a change in identity.\\nDissociative fugue\\nDissociative fugue is a disorder in which a person\\ntemporarily loses his or her sense of personal identity and\\ntravels to another location where he or she may assume a\\nnew identity. Again, this condition usually follows a\\nmajor stressor or trauma. Apart from inability to recall\\ntheir past or personal information, patients with dissocia-\\ntive fugue do not behave strangely or appear disturbed to\\nothers. Cases of dissociative fugue are more common in\\nwartime or in communities disrupted by a natural disaster.\\nDepersonalization disorder\\nDepersonalization disorder is a disturbance in\\nwhich the patient’s primary symptom is a sense of\\ndetachment from the self. Depersonalization as a symp-\\ntom (not as a disorder) is quite common in college-age\\npopulations. It is often associated with sleep deprivation\\nor “recreational” drug use. It may be accompanied by\\n“derealization” (where objects in an environment appear\\naltered). Patients sometimes describe depersonalization\\nas feeling like a robot or watching themselves from the\\noutside. Depersonalization disorder may also involve\\nfeelings of numbness or loss of emotional “aliveness.”\\nDissociative identity disorder (DID)\\nDissociative identity disorder (DID) is the newer\\nname for multiple personality disorder (MPD). DID is\\nconsidered the most severe dissociative disorder and\\ninvolves all of the major dissociative symptoms.\\nDissociative disorder not otherwise specified\\n(DDNOS)\\nDDNOS is a diagnostic category ascribed to patients\\nwith dissociative symptoms that do not meet the full cri-\\nteria for a specific dissociative disorder.\\nCauses and symptoms\\nThe moderate to severe dissociation that occurs in\\npatients with dissociative disorders is understood to\\nresult from a set of causes:\\n• an innate ability to dissociate easily\\n• repeated episodes of severe physical or sexual abuse in\\nchildhood\\n• the lack of a supportive or comforting person to coun-\\nteract abusive relative(s)\\n• the influence of other relatives with dissociative symp-\\ntoms or disorders\\nThe relationship of dissociative disorders to child-\\nhood abuse has led to intense controversy and lawsuits\\nconcerning the accuracy of childhood memories. The\\nbrain’s storage, retrieval, and interpretation of memories\\nare still not fully understood. Controversy also exists\\nregarding how much individuals presenting dissociative\\ndisorders have been influenced by books and movies to\\ndescribe a certain set of symptoms (scripting).\\nThe major dissociative symptoms are:\\nAmnesia\\nAmnesia in a dissociative disorder is marked by\\ngaps in a patient’s memory for long periods of time or for\\ntraumatic events. Doctors can distinguish this type of\\namnesia from loss of memory caused by head injuries or\\ndrug intoxication, because the amnesia is “spotty” and\\nrelated to highly charged events and feelings.\\nDepersonalization\\nDepersonalization is a dissociative symptom in\\nwhich the patient feels that his or her body is unreal, is\\nchanging, or is dissolving. Some patients experience\\ndepersonalization as being outside their bodies or watch-\\ning a movie of themselves.\\nDerealization\\nDerealization is a dissociative symptom in which the\\nexternal environment is perceived as unreal. The patient\\nmay see walls, buildings, or other objects as changing in\\nshape, size, or color. In some cases, the patient may feel\\nthat other persons are machines or robots, though the\\npatient is able to acknowledge the unreality of this feeling.\\nIdentity disturbances\\nPatients with dissociative fugue, DDNOS, or DID\\noften experience confusion about their identities or\\neven assume new identities. Identity disturbances result\\nfrom the patient having split off entire personality traits\\nGALE ENCYCLOPEDIA OF MEDICINE 21086\\nDissociative disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 474, 'page_label': '475'}, page_content='or characteristics as well as memories. When a stressful\\nor traumatic experience triggers the reemergence of\\nthese dissociated parts, the patient may act differently,\\nanswer to a different name, or appear confused by his or\\nher surroundings.\\nDiagnosis\\nWhen a doctor is evaluating a patient with dissocia-\\ntive symptoms, he or she will first rule out physical con-\\nditions that sometimes produce amnesia, depersonaliza-\\ntion, or derealization. These physical conditions include\\nepilepsy, head injuries, brain disease, side effects of med-\\nications, substance abuse, intoxication, AIDS, dementia\\ncomplex, or recent periods of extreme physical stress\\nand sleeplessness. In some cases, the doctor may give the\\npatient an electroencephalogram (EEG) to exclude\\nepilepsy or other seizure disorders.\\nIf the patient appears to be physically normal, the\\ndoctor will rule out psychotic disturbances, including\\nschizophrenia . In addition, doctors can use some psy-\\nchological tests to narrow the diagnosis. One is a screen-\\ner, the Dissociative Experiences Scale (DES). If the\\npatient has a high score on this test, he or she can be eval-\\nuated further with the Dissociative Disorders Interview\\nSchedule (DDIS) or the Structured Clinical Interview for\\nDSM-IV Dissociative Disorders (SCID-D). It is also pos-\\nsible for doctors to measure a patient’s hypnotizability as\\npart of a diagnostic evaluation.\\nTreatment\\nTreatment of the dissociative disorders often com-\\nbines several methods.\\nPsychotherapy\\nPatients with dissociative disorders often require\\ntreatment by a therapist with some specialized under-\\nstanding of dissociation. This background is particularly\\nimportant if the patient’s symptoms include identity\\nproblems. Many patients with dissociative disorders are\\nhelped by group as well as individual treatment.\\nMedications\\nSome doctors will prescribe tranquilizers or antide-\\npressants for the anxiety and/or depression that often\\naccompany dissociative disorders. Patients with dissocia-\\ntive disorders are, however, at risk for abusing or becom-\\ning dependent on medications. As of 2001, there is no\\ndrug that can reliably counteract dissociation itself.\\nHypnosis\\nHypnosis is frequently recommended as a method of\\ntreatment for dissociative disorders, partly because hyp-\\nKEY TERMS\\nAmnesia —A general medical term for loss of\\nmemory that is not due to ordinary forgetfulness.\\nAmnesia can be caused by head injuries, brain\\ndisease, or epilepsy, as well as by dissociation.\\nDepersonalization —A dissociative symptom in\\nwhich the patient feels that his or her body is unre-\\nal, is changing, or is dissolving.\\nDerealization —A dissociative symptom in which\\nthe external environment is perceived as unreal.\\nDissociation —A psychological mechanism that\\nallows the mind to split off traumatic memories or\\ndisturbing ideas from conscious awareness.\\nFugue—A dissociative experience during which a\\nperson travels away from home, has amnesia for\\ntheir past, and may be confused about their identi-\\nty but otherwise appear normal.\\nHypnosis—The means by which a state of extreme\\nrelaxation and suggestibility is induced: used to\\ntreat amnesia and identity disturbances that occur\\nin dissociative disorders.\\nMultiple personality disorder (MPD) —An older\\nterm for dissociative identity disorder (DID).\\nTrauma—A disastrous or life-threatening event\\nthat can cause severe emotional distress, includ-\\ning dissociative symptoms and disorders.\\nnosis is related to the process of dissociation. Hypnosis\\nmay help patients recover repressed ideas and memories.\\nTherapists treating patients with DID sometimes use\\nhypnosis in the process of “fusing” the patient’s alternate\\npersonalities.\\nPrognosis\\nPrognoses for dissociative disorders vary. Recovery\\nfrom dissociative fugue is usually rapid. Dissociative\\namnesia may resolve quickly, but can become a chronic\\ndisorder in some patients. Depersonalization disorder,\\nDDNOS, and DID are usually chronic conditions. DID\\nusually requires five or more years of treatment for\\nrecovery.\\nPrevention\\nSince the primary cause of dissociative disorders is\\nthought to involve extended periods of humanly inflicted\\ntrauma, prevention depends on the elimination of child\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1087\\nDissociative disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 475, 'page_label': '476'}, page_content='abuse and psychological abuse of adult prisoners or\\nhostages.\\nResources\\nBOOKS\\n“Dissociative Disorders.” In Diagnostic and Statistical Manual\\nof Mental Disorders. 4th ed. Washington, DC: The Ameri-\\ncan Psychiatric Association, 1994.\\nEisendrath, Stuart J. “Psychiatric Disorders.” In Current Med-\\nical Diagnosis and Treatment, 1998.37th ed. Ed. Stephen\\nMcPhee, et al. Stamford: Appleton & Lange, 1997.\\nKolb, Lawrence C., and Keith H. Brodie. Modern Clinical Psy-\\nchiatry. Philadelphia: W. B. Saunders Co., 1982.\\nNapier, Nancy J. Getting Through The Day: Strategies for\\nAdults Hurt as Children. New York and London: W. W.\\nNorton & Co., 1994.\\nNemiah, John C. “Psychoneurotic Disorders.” In The New Har-\\nvard Guide to Psychiatry, ed. Armand M. Nicholi Jr.\\nCambridge, MA: The Belknap Press of Harvard Universi-\\nty Press, 1988.\\nNoll, Richard. The Encyclopedia of Schizophrenia and the Psy-\\nchotic Disorders. New York: Facts On File, 1992.\\nPascuzzi, Robert M., and Mary C. Weber. “Conversion Disor-\\nders, Malingering, and Dissociative Disorders.” In Cur-\\nrent Diagnosis. V ol. 9. Ed. Rex B. Conn, et al. Philadel-\\nphia: W. B. Saunders Co., 1997.\\n“Psychiatric Disorders: Hysterical Neurosis.” In The Merck\\nManual of Diagnosis and Therapy.16th ed. Ed. Robert\\nBerkow. Rahway, NJ: Merck Research Laboratories, 1992.\\nvan der Kolk, Bessel A., and Onno van der Hart. “The Intrusive\\nPast: The Flexibility of Memory and the Engraving of Trau-\\nma.” In Trauma: Explorations in Memory, ed. Cathy Caruth.\\nBaltimore: The Johns Hopkins University Press, 1995.\\nRebecca J. Frey\\nDissociative identity disorder see Multiple\\npersonality disorder\\nDiuretics\\nDefinition\\nDiuretics are medicines that help reduce the amount\\nof water in the body.\\nPurpose\\nDiuretics are used to treat the buildup of excess fluid\\nin the body that occurs with some medical conditions\\nsuch as congestive heart failure, liver disease, and kid-\\nney disease. Some diuretics are also prescribed to treat\\nhigh blood pressure. These drugs act on the kidneys to\\nincrease urine output. This reduces the amount of fluid in\\nthe bloodstream, which in turn lowers blood pressure.\\nDescription\\nThere are several types of diuretics, also called water\\npills:\\n• Loop diuretics, such as bumetanide (Bumex) and\\nfurosemide (Lasix), get their name from the loop-\\nshaped part of the kidneys where they have their effect.\\n• Thiazide diuretics include such commonly used diuret-\\nics as hydrochlorothiazide (HydroDIURIL, Esidrix),\\nchlorothiazide (Diuril), and chlorthalidone (Hygroton).\\n• Potassium-sparing diuretics prevent the loss of potassi-\\num, which is a problem with other types of diuretics.\\nExamples of potassium-sparing diuretics are amiloride\\n(Midamor) and triamterene (Dyrenium).\\nIn addition, some medicines contain combinations\\nof two diuretics. The brands Dyazide and Maxzide, for\\nexample, contain the thiazide diuretic hydrochloroth-\\niazide with the potassium-sparing diuretic triamterene.\\nSome nonprescription (over-the-counter) medicines\\ncontain diuretics. However, the medicines described\\nhere cannot be bought without a physician’s prescrip-\\ntion. They are available in tablet, capsule, liquid, and\\ninjectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\ndiuretic and may be different for different patients.\\nCheck with the physician who prescribed the drug or the\\npharmacist who filled the prescription for the correct\\ndosage, and take the medicine exactly as directed.\\nPrecautions\\nSeeing a physician regularly while taking a diuretic\\nis important. The physician will check to make sure the\\nmedicine is working as it should and will watch for\\nunwanted side effects.\\nSome people feel unusually tired when they first\\nstart taking diuretics. This effect usually becomes less\\nnoticeable over time, as the body adjusts to the medicine.\\nBecause diuretics increase urine output, people who\\ntake this medicine may need to urinate more often, even\\nduring the night. Health care professionals can help\\npatients schedule their doses to avoid interfering with\\ntheir sleep or regular activities.\\nGALE ENCYCLOPEDIA OF MEDICINE 21088\\nDiuretics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 476, 'page_label': '477'}, page_content='For patients taking the kinds of diuretics that rob\\npotassium from the body, physicians may recommend\\nadding potassium-rich foods or drinks, such as citrus fruits\\nand juices, to the diet. Or they may suggest taking a potas-\\nsium supplement or taking another medicine that keeps the\\nbody from losing too much potassium. If the physician\\nrecommends any of these measures, be sure to closely fol-\\nlow his or her directions. Do not make other diet changes\\nwithout checking with the physician. People who are tak-\\ning potassium-sparing diuretics should not add potassium\\nto their diets, as too much potassium may be harmful.\\nPeople who take diuretics may lose too much water\\nor potassium when they get sick, especially if they have\\nsevere vomiting and diarrhea . They should check with\\ntheir physicians if they become ill.\\nThese medicines make some people feel lighthead-\\ned, dizzy, or faint when they get up after sitting or lying\\ndown. Older people are especially likely to have this\\nproblem. Drinking alcohol, exercising, standing for long\\nperiods, or being in hot weather may make the problem\\nworse. To lessen the problem, get up gradually and hold\\nonto something for support if possible. Avoid drinking\\ntoo much alcohol and be careful in hot weather or when\\nexercising or standing for a long time.\\nAnyone who is taking a diuretic should be sure to\\ntell the health care professional in charge before having\\nsurgical or dental procedures, medical tests or emergency\\ntreatment.\\nSome diuretics make the skin more sensitive to sun-\\nlight. Even brief exposure to sun can cause a severe sun-\\nburn, itching , a rash, redness, or other changes in skin\\ncolor. While being treated with this medicine, avoid\\nbeing in direct sunlight, especially between 10 a.m. and 3\\np.m.; wear a hat and tightly woven clothing that covers\\nthe arms and legs; use a sunscreen with a skin protection\\nfactor (SPF) of at least 15; protect the lips with a sun\\nblock lipstick; and do not use tanning beds, tanning\\nbooths, or sunlamps. People with fair skin may need to\\nuse a sunscreen with a higher skin protection factor.\\nSpecial conditions\\nPeople who have certain medical conditions or who\\nare taking certain other medicines may have problems if\\nthey take diuretics. Before taking these drugs, be sure to\\nlet the physician know about any of these conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to diuretics or sulfonamides (sulfa drugs) in the\\npast should let his or her physician know before using\\na diuretic. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other sub-\\nstances.\\nPREGNANCY. Diuretics will not help the swelling of\\nhands and feet that some women have during\\npregnancy. In general, pregnant women should not use\\ndiuretics unless a physician recommends their use.\\nAlthough studies have not been done on pregnant\\nwomen, studies of laboratory animals show that some\\ndiuretics can cause harmful effects when taken during\\npregnancy.\\nBREASTFEEDING. Some diuretics pass into breast\\nmilk, but no reports exist of problems in nursing babies\\nwhose mothers use this medicine. However, thiazide\\ndiuretics may decrease the flow of breast milk. Women\\nwho are breastfeeding and need to use a diuretic should\\ncheck with their physicians.\\nOTHER MEDICAL CONDITIONS. Side effects of\\nsome diuretics may be more likely in people who have\\nhad a recent heart attack or who have liver disease or\\nsevere kidney disease. Other diuretics may not work\\nproperly in people with liver disease or severe kidney\\ndisease. Diuretics may worsen certain medical condi-\\ntions, such as gout, kidney stones , pancreatitis , lupus\\nerythematosus, and hearing problems. In addition, peo-\\nple with diabetes should be aware that diuretics may\\nincrease blood sugar levels. People with heart or blood\\nvessel disease should know that some diuretics increase\\ncholesterol or triglyceride levels. The risk of an allergic\\nreaction to certain diuretics is greater in people with\\nbronchial asthma. Before using diuretics, people with\\nany of these medical problems should make sure their\\nphysicians are aware of their conditions. Also, people\\nwho have trouble urinating or who have high potassium\\nlevels in their blood may not be able to take diuretics and\\nshould check with a physician before using them.\\nUSE OF CERTAIN MEDICINES. Taking diuretics with\\ncertain other drugs may affect the way the drugs work or\\nmay increase the chance of side effects.\\nSide effects\\nSome side effects, such as loss of appetite, nausea\\nand vomiting, stomach cramps, diarrhea and dizziness,\\nusually lessen or go away as the body adjusts to the med-\\nicine. These problems do not need medical attention\\nunless they continue or interfere with normal activities.\\nPatients taking potassium-sparing diuretics should\\nknow the signs of too much potassium and should check\\nwith a physician as soon as possible if any of these symp-\\ntoms occur:\\n• irregular heartbeat\\n• breathing problems\\n• numbness or tingling in the hands, feet, or lips\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1089\\nDiuretics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 477, 'page_label': '478'}, page_content='• confusion or nervousness\\n• unusual tiredness or weakness\\n• weak or heavy feeling in the legs\\nPatients taking diuretics that cause potassium loss\\nshould know the signs of too little potassium and should\\ncheck with a physician as soon as possible if they have\\nany of these symptoms:\\n• fast or irregular heartbeat\\n• weak pulse\\n• nausea or vomiting\\n• dry mouth\\n• excessive thirst\\n• muscle cramps or pain\\n• unusual tiredness or weakness\\n• mental or mood changes\\nInteractions\\nDiuretics may interact with other medicines. When\\nthis happens, the effects of one or both of the drugs may\\nchange or the risk of side effects may be greater. Anyone\\nwho takes a diuretic should let the physician know all\\nother medicines he or she is taking and should ask whether\\nthe possible interactions can interfere with drug therapy.\\nAmong the drugs that may interact with diuretics are:\\nKEY TERMS\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nLupus erythematosus —A chronic disease that\\naffects the skin, joints, and certain internal organs.\\nPancreas—A gland located beneath the stomach.\\nThe pancreas produces juices that help break\\ndown food.\\nPotassium —A mineral found in whole grains,\\nmeat, legumes, and some fruits and vegetables.\\nPotassium is important for many body processes,\\nincluding proper functioning of the nerves and\\nmuscles.\\nTriglyceride—A substance formed in the body from\\nfat in the diet. Triglycerides are the main fatty mate-\\nrials in the blood. Together with protein, they make\\nup high- and low-density lipoproteins (HDLs and\\nLDLs). Triglyceride levels are important in the diag-\\nnosis and treatment of many diseases including\\nhigh blood pressure, diabetes, and heart disease.\\n• Angiotensin-converting enzyme (ACE) inhibitors, such\\nas benazepril (Lotensin), captopril (Capoten), and\\nenalapril (Vasotec), used to treat high blood pressure.\\nTaking these drugs with potassium-sparing diuretics\\nmay cause levels of potassium in the blood to be too\\nhigh, increasing the chance of side effects.\\n• Cholesterol-lowering drugs such as cholestyramine\\n(Questran) and colestipol (Colestid). Taking these\\ndrugs with combination diuretics such as Dyazide and\\nMaxzide may keep the diuretic from working. Take the\\ndiuretic at least one hour before or four hours after the\\ncholesterol-lowering drug.\\n• Cyclosporine (Sandimmune), a medicine that suppress-\\nes the immune system. Taking this medicine with\\npotassium-sparing diuretics may increase the chance of\\nside effects by causing levels of potassium in the blood\\nto be too high.\\n• Potassium supplements, other medicines containing\\npotassium, or salt substitutes that contain potassium.\\nTaking these with potassium-sparing diuretics may lead\\nto too much potassium in the blood, increasing the\\nchance of side effects.\\n• Lithium, used to treat bipolar disorder (manic-depres-\\nsive illness). Using this medicine with potassium-spar-\\ning diuretics may allow lithium to build up to poiso-\\nnous levels in the body.\\n• Digitalis heart drugs, such as digoxin (Lanoxin). Using\\nthis medicine with combination diuretics such as tri-\\namterene-hydrocholorthiazide (Dyazide, Maxzide) may\\ncause blood levels of the heart medicine to be too high,\\nmaking side effects such as changes in heartbeat more\\nlikely.\\nThe list above does not include every drug that may\\ninteract with diuretics. Check with a physician or phar-\\nmacist before combining diuretics with any other pre-\\nscription or nonprescription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nDiverticulitis see Diverticulosis and\\ndiverticulitis\\nDiverticulosis and\\ndiverticulitis\\nDefinition\\nDiverticulosis refers to a condition in which the\\ninner, lining layer of the large intestine (colon) bulges\\nGALE ENCYCLOPEDIA OF MEDICINE 21090\\nDiverticulosis and diverticulitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 478, 'page_label': '479'}, page_content='out (herniates) through the outer, muscular layer. These\\noutpouchings are called diverticula. Diverticulitis refers\\nto the development of inflammation and infection in one\\nor more diverticula.\\nDescription\\nDiverticula tend to occur most frequently in the\\nlast segment of the large intestine, the sigmoid colon.\\nThey occur with decreasing frequency as one examines\\nfurther back toward the beginning of the large intes-\\ntine. The chance of developing diverticula increases\\nwith age, so that by the age of 50, about 20–50% of all\\npeople will have some diverticula. By the age of 90,\\nvirtually everyone will have developed some diverticu-\\nla. Most diverticula measure about 3 mm to just over 3\\ncm in diameter. Larger diverticula, termed giant diver-\\nticula, are quite infrequent, but may measure as large\\nas 15 cm in diameter.\\nCauses and symptoms\\nDiverticula are believed to be caused by overly\\nforceful contractions of the muscular wall of the large\\nintestine. As areas of this wall spasm, they become weak-\\ner and weaker, allowing the inner lining to bulge through.\\nThe anatomically weakest areas of the intestinal wall\\noccur next to blood vessels which course through the\\nwall, so diverticula commonly occur in this location.\\nDiverticula are most common in the developed\\ncountries of the West (North America, Great Britain,\\nnorthern and western Europe). This is thought to be due\\nto the diet of these countries, which tends to be quite low\\nin fiber. A diet low in fiber results in the production of\\nsmaller volumes of stool. In order to move this smaller\\nstool along the colon and out of the rectum, the colon\\nmust narrow itself significantly, and does so by contract-\\ning down forcefully. This causes an increase in pressure,\\nwhich, over time, weakens the muscular wall of the intes-\\ntine and allows diverticular pockets to develop.\\nThe origin of giant diverticula development is not\\ncompletely understood, although one theory involves gas\\nrepeatedly entering and becoming trapped in an already-\\nexisting diverticulum, causing stretching and expansion\\nof that diverticulum.\\nThe great majority of people with diverticulosis will\\nremain symptom-free. Many diverticula are quite acci-\\ndentally discovered during examinations for other condi-\\ntions of the intestinal tract.\\nSome people with diverticulosis have symptoms such\\nas constipation , cramping, and bloating. It is unclear\\nwhether these symptoms are actually caused by the diver-\\nticula themselves, or whether some other gastrointestinal\\ncondition (such as irritable bowel syndrome ) might be\\nresponsible. A complication of diverticulosis occurs\\nbecause many diverticula develop in areas very near\\nblood vessels. Therefore, one serious risk of diverticulosis\\ninvolves bleeding. Although an infrequent complication,\\nthe bleeding can be quite severe. Seventy-five percent of\\nsuch bleeding episodes occur due to diverticula located on\\nthe right side of the colon. About 50% of the time, such\\nbleeding will stop on its own.\\nOne of the most common and potentially serious\\ncomplications of diverticulosis is inflammation and infec-\\ntion of a particular diverticulum, called diverticulitis.\\nDiverticulitis is three times more likely to occur in\\nthe left side of the large intestine. Since most diverticula\\nare located in the sigmoid colon (the final segment of the\\nlarge intestine which empties into the rectum), most\\ndiverticulitis also takes place in the sigmoid. The elderly\\nhave the most serious complications from diverticulitis,\\nalthough very severe infections can also occur in patients\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1091\\nDiverticulosis and diverticulitis\\nA barium study x ray showing colonic diverticulosis.(Cus-\\ntom Medical Stock Photo. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 479, 'page_label': '480'}, page_content='under the age of 50. Men are three times as likely as\\nwomen to be stricken with diverticulitis.\\nDiverticulitis is believed to occur when a hardened\\npiece of stool, undigested food, and bacteria (called a\\nfecalith) becomes lodged in a diverticulum. This block-\\nage interferes with the blood supply to the area, and\\ninfection sets in.\\nAn individual with diverticulitis will experience pain\\n(especially in the lower left side of the abdomen) and fever.\\nIn response to the infection and the irritation of nearby tis-\\nsues within the abdomen, the abdominal muscles may\\nbegin to spasm. About 25% of all patients with diverticuli-\\ntis will have some rectal bleeding, although this rarely\\nbecomes severe. Walled-off pockets of infection, called\\nabscesses, may appear within the wall of the intestine, or\\neven on the exterior surface of the intestine. When a diver-\\nticulum weakens sufficiently, and is filled to bulging with\\ninfected pus, a perforation in the intestinal wall may devel-\\nop. When the infected contents of the intestine spill out into\\nthe abdomen, the severe infection called peritonitis may\\noccur. Peritonitis is an infection and inflammation of the\\nlining of the abdominal cavity, the peritoneum. Other com-\\nplications of diverticulitis include the formation of abnor-\\nmal connections between two organs that normally do not\\nconnect (fistulas; for example, the intestine and the blad-\\nder), and scarring outside of the intestine which squeezes\\noff a portion of the intestine, obstructing it.\\nDiagnosis\\nAs mentioned, the majority of diverticula do not\\ncause any symptoms, and are often found by coincidence\\nduring an examination being performed for some other\\nmedical condition.\\nWhen diverticula are suspected because a patient\\nbegins to have sudden rectal bleeding, the location of the\\nbleeding can be studied by performing an angiography.\\nAngiography involves inserting a tiny tube through an\\nartery in the leg, and moving it up into one of the major\\narteries of the gastrointestinal system. A particular chem-\\nical (contrast medium) which will show up on x-ray\\nfilms is injected, and the area of bleeding is located by\\nlooking for an area where the contrast is leaking into the\\ninterior (lumen) of the intestine.\\nA procedure called endoscopy provides another\\nmethod for examining the colon and locating the site of\\nbleeding. In endoscopy, a small, flexible scope (endo-\\nscope) is inserted through the rectum and into the intes-\\ntine. The scope usually bears a fiber-optic camera, which\\nallows the view through this endoscope to be projected\\nonto a television screen. The operator can introduce the\\nendoscope further and further through the intestine to\\nfind the location of the bleeding.\\nDiagnosis of diverticulitis is not difficult in\\npatients with previously diagnosed diverticulosis. The\\npresence of abdominal pain and fever in such an indi-\\nvidual would make the suspicion of diverticulitis quite\\nhigh. Examination of the abdomen will usually reveal\\ntenderness to touch, with the patient’s abdominal mus-\\ncles contracting strongly to protect the tender area.\\nDuring a rectal exam (performed by inserting a finger\\ninto the rectum), a doctor may be able to feel an\\nabnormal mass. Touching this mass may prove painful\\nto the patient.\\nWhen a practitioner is suspicious of diverticulitis as\\nthe cause for the patient’s symptoms, he or she will most\\nlikely avoid the types of tests usually used to diagnose\\ngastrointestinal disorders. These include barium enema\\nand endoscopy. The concern is that the increased pres-\\nsure exerted on the intestine during these exams may\\nincrease the likelihood of intestinal perforation. After\\nmedical treatment for the diverticulitis, these examina-\\ntions may be performed in order to learn the extent of the\\npatient’s disease.\\nTreatment\\nOnly about 20% of patients with diverticulosis ever\\nhave symptoms which lead them to seek medical help.\\nMost people never know that they have diverticula. For\\nthose individuals who have cramping pain and constipa-\\ntion believed to be due to diverticulosis, the usual pre-\\nscription involves increasing the fiber in the diet. This\\ncan be done by adding special diet supplements of bran\\nor psyllium seed, which increase stool volume. Bleeding\\ndiverticula can usually be treated by bed rest, with blood\\ntransfusion needed for more severe bleeding (hemor-\\nrhaging). In cases of very heavy hemorrhaging, medica-\\ntions which encourage clotting can be injected during the\\ncourse of a diagnostic angiography.\\nWhile there are almost no situations when uncom-\\nplicated diverticulosis requires surgery, giant diverticula\\nalways require removal. This is due to the very high\\nchance of infection and perforation of these diverticula.\\nWhen giant diverticula are diagnosed, the usual treat-\\nment involves removing that portion of the intestine.\\nTreatment for uncomplicated diverticulitis usually\\nrequires hospitalization. “Resting the bowel” is a main-\\nstay of treatment, and involves keeping the patient from\\neating or sometimes even drinking anything by mouth.\\nTherefore, the patient will need to receive fluids through\\na needle in the vein (intravenous or IV fluids). Antibi-\\notics will also be administered through the IV . Some\\nphysicians will agree to try treatment at home for very\\nmildly ill patients. These patients will be put on a liquid\\ndiet and receive oral antibiotics.\\nGALE ENCYCLOPEDIA OF MEDICINE 21092\\nDiverticulosis and diverticulitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 480, 'page_label': '481'}, page_content='The various complications of diverticulitis need to\\nbe treated aggressively, because the death rate from such\\nthings as perforation and peritonitis is quite high.\\nAbscesses can be drained of their infected contents by\\ninserting a needle through the skin of the abdomen and\\ninto the abscess. When this is unsuccessful, open abdom-\\ninal surgery will be required to remove the piece of the\\nintestine containing the abscess. Fistulas require surgical\\nrepair, including the removal of the length of intestine\\ncontaining the origin of the fistula, followed by immedi-\\nate reconnection of the two free ends of intestine. Peri-\\ntonitis requires open surgery. The entire abdominal cavi-\\nty is cleaned by being irrigated (washed) with a warmed\\nsterile saltwater solution, and the damaged piece of\\nintestine is removed. Obstructions require immediate\\nsurgery to prevent perforation. Massive, uncontrollable\\nbleeding, while rare, may require removal of part or all\\nof the large intestine.\\nDuring any of these types of operations, the surgeon\\nmust make an important decision regarding the quantity\\nof intestine which must be removed. When the amount of\\nintestine removed is great, it may be necessary to per-\\nform a colostomy. A colostomy involves pulling the end\\nof the remaining intestine through the abdominal wall, to\\nthe outside. This bit of intestine is then fashioned so that\\na bag can be fit over it. The patient’s waste (feces) collect\\nin the bag, because the intestine no longer connects with\\nthe rectum. This colostomy may be temporary, in which\\ncase another operation will be required to reconnect the\\nintestine, after some months of substantial healing has\\noccurred. Other times, the colostomy will need to be per-\\nmanent, and the patient will have to adjust to living per-\\nmanently with the colostomy bag. Most people with\\ncolostomies are able to go on with a very active life.\\nOccasionally, a patient will have such severe diver-\\nticular disease that a surgeon recommends planning\\nahead, and schedules removal of a portion of the colon.\\nThis is done to avoid the high risk of surgery performed\\nafter a complication has set in. Certain developments in a\\npatient will identify those patients who are at very high\\nrisk of experiencing dangerous complications. Such elec-\\ntive surgery may be recommended:\\n• when an older individual has had several attacks of\\ndiverticulitis\\n• when someone under the age of 50 has had even one\\nattack\\n• when treatment does not get rid of a painful mass\\n• when the intestine appears to be narrowing on x-ray\\nexamination (this could suggest the presence of cancer)\\n• when certain patients begin to regularly experience\\npainful urination or urinary infections (this suggests\\nKEY TERMS\\nAngiography —An x-ray study of the arteries in a\\nparticular part of the body. Angiography is often\\nperformed in order to localize internal bleeding.\\nBowel obstruction —A blockage in the intestine\\nwhich prevents the normal flow of waste down the\\nlength of the intestine.\\nColostomy—A procedure performed when a large\\nquantity of intestine is removed. The end piece of\\nthe intestine leading to the rectum is closed.\\nDiverticula—Outpouchings in the large intestine\\ncaused when the inner, lining layer of the large\\nintestine (colon) bulges out (herniates) through the\\nouter, muscular layer.\\nEndoscopy —Examination of an area of the gas-\\ntrointestinal tract by putting a lighted scope, usual-\\nly bearing a fiber-optic camera, into the rectum,\\nand passing it through the intestine.\\nFistula—An abnormal connection formed between\\ntwo organs that usually have no connection what-\\nsoever.\\nSigmoid colon —The final portion of the large\\nintestine that empties into the rectum.\\nthat there may be a connection between the intestine\\nand the bladder)\\n• when there is any question of cancer\\n• when the diverticular disease appears to be progressing\\nrapidly\\nPrognosis\\nThe prognosis for people with diverticula is excel-\\nlent, with only 20% of such patients ever seeking any\\nmedical help for their condition.\\nWhile diverticulitis can be a difficult and painful dis-\\nease, it is usually quite treatable. Prognosis is worse for\\nindividuals who have other medical problems, particular-\\nly those requiring the use of steroid medications, which\\nincrease the chances of developing a serious infection.\\nPrognosis is also worse in the elderly.\\nPrevention\\nWhile there is no absolutely certain way to prevent\\nthe development of diverticula, it is believed that high-\\nfiber diets are of help. Foods that are recommended for\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1093\\nDiverticulosis and diverticulitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 481, 'page_label': '482'}, page_content='their high fiber content include whole grain breads and\\ncereals, and all types of fruits and vegetables. Most\\nexperts suggest that individuals take in about 0.71–1.23\\noz (20–35 g) of fiber daily. If this is not possible to\\nachieve through a person’s diet, there are fiber products\\nwhich can be mixed into 8 oz (.237 l) of water or juice,\\nand which provide about 0.13–19 oz (4–6 g) of fiber.\\nResources\\nBOOKS\\nIsselbacher, Kurt J., and Alan Epstein. “Diverticular, Vascular,\\nand Other Disorders of the Intestine and Peritoneum.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nPERIODICALS\\nCerda, James J., et al. “Diverticulitis: Current Management\\nStrategies.”Patient Care31, no. 12 (15 July 1997): 170+.\\nCunningham, Mark A., et al. “Medical Versus Surgical Manage-\\nment of Diverticulitis in Patients Under Age 40.”American\\nJournal of Surgery174, no. 6 (Dec. 1997): 733+.\\n“Diet and Diverticular Disease in Men.”Nutrition Research\\nNewsletter 14, no. 2 (Nov. 1994): 28.\\n“Diet for Diverticulosis.”Consumer Reports on Health 8, no.\\n11 (Nov. 1996): 132.\\n“Keeping Diverticulosis Silent.”Berkeley Wellness Letter12,\\nno. 4 (Jan. 1996): 6+.\\nMunson, Marty, and Teresa Yeykal. “Outrun Trouble: Running\\nand Bran Cereal in the Prevention of Diverticular Dis-\\nease.” Prevention, 47, no. 9 (Sept. 1995): 38+.\\nORGANIZATIONS\\nNational Digestive Diseases Information Clearinghouse. 2 Infor-\\nmation Way, Bethesda, MD 20892-3570. (800) 891-5389.\\n.\\nRosalyn Carson-DeWitt, MD\\nDizziness\\nDefinition\\nAs a disorder, dizziness is classified into three cate-\\ngories—vertigo, syncope, and nonsyncope nonvertigo.\\nEach category has a characteristic set of symptoms, all\\nrelated to the sense of balance. In general, syncope is\\ndefined by a brief loss of consciousness ( fainting) or by\\ndimmed vision and feeling uncoordinated, confused, and\\nlightheaded. Many people experience a sensation like\\nsyncope when they stand up too fast. Vertigo is the feeling\\nthat either the individual or the surroundings are spinning.\\nThis sensation is like being on a spinning amusement\\npark ride. Individuals with nonsyncope nonvertigo dizzi-\\nness feel as though they cannot keep their balance. This\\nfeeling may become worse with movement.\\nDescription\\nThe brain coordinates information from the eyes, the\\ninner ear, and the body’s senses to maintain balance. If\\nany of these information sources is disrupted, the brain\\nmay not be able to compensate. For example, people\\nsometimes experience motion sickness because the\\ninformation from their body tells the brain that they are\\nsitting still, but information from the eyes indicates that\\nthey are moving. The messages don’t correspond and\\ndizziness results.\\nVision and the body’s senses are the most important\\nsystems for maintaining balance, but problems in the\\ninner ear are the most frequent cause of dizziness. The\\ninner ear, also called the vestibular system, contains fluid\\nthat helps fine tune the information the brain receives\\nfrom the eyes and the body. When fluid volume or pres-\\nsure in one inner ear changes, information about balance\\nis altered. The discrepancy gives conflicting messages to\\nthe brain about balance and induces dizziness.\\nCertain medical conditions can cause dizziness,\\nbecause they affect the systems that maintain balance.\\nFor example, the inner ear is very sensitive to changes in\\nblood flow. Because medical conditions such as high\\nblood pressure or low blood sugar can affect blood flow,\\nthese conditions are frequently accompanied by dizzi-\\nness. Circulation disorders are the most common causes\\nof dizziness. Other causes are head injury, ear infection,\\nallergies, and nervous system disorders.\\nDizziness often disappears without treatment or with\\ntreatment of the underlying problem, but it can be long\\nterm or chronic. According to the National Institutes of\\nHealth, 42% of Americans will seek medical help for\\ndizziness at some point in their lives. The costs may\\nexceed a billion dollars and account for five million doc-\\ntor visits annually. Episodes of dizziness increase with\\nage. Among people aged 75 or older, dizziness is the\\nmost frequent reason for seeing a doctor.\\nCauses and symptoms\\nCareful attention to symptoms can help determine\\nthe underlying cause of the dizziness. Underlying prob-\\nlems may be benign and easily treated or they may be\\ndangerous and in need of intensive therapy. Not all cases\\nof dizziness can be linked to a specific cause. More than\\none type of dizziness can be experienced at the same\\ntime and symptoms may be mixed. Episodes of dizziness\\nmay last for a few seconds or for days. The length of an\\nepisode is related to the underlying cause.\\nThe symptoms of syncope include dimmed vision,\\nloss of coordination, confusion, lightheadedness, and\\nsweating. These symptoms can lead to a brief loss of con-\\nGALE ENCYCLOPEDIA OF MEDICINE 21094\\nDizziness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 482, 'page_label': '483'}, page_content='sciousness or fainting. They are related to a reduced flow\\nof blood to the brain; they often occur when a person is\\nstanding up and can be relieved by sitting or lying down.\\nVertigo is characterized by a sensation of spinning or turn-\\ning, accompanied by nausea, vomiting, ringing in the ears,\\nheadache, or fatigue. An individual may have trouble\\nwalking, remaining coordinated, or keeping balance. Non-\\nsyncope nonvertigo dizziness is characterized by a feeling\\nof being off balance that becomes worse if the individual\\ntries moving or performing detail-intense tasks.\\nA person may experience dizziness for many rea-\\nsons. Syncope is associated with low blood pressure,\\nheart problems, and disorders in the autonomic nervous\\nsystem, the system of involuntary functions such as\\nbreathing. Syncope may also arise from emotional dis-\\ntress, pain, and other reactions to outside stressors. Non-\\nsyncope nonvertigo dizziness may be caused by rapid\\nbreathing, low blood sugar, or migraine headache ,a s\\nwell as by more serious medical conditions.\\nVertigo is often associated with inner ear problems\\ncalled vestibular disorders. A particularly intense vestibular\\ndisorder, Méniére’s disease, interferes with the volume of\\nfluid in the inner ear. This disease, which affects approxi-\\nmately one in every 1,000 people, causes intermittent verti-\\ngo over the course of weeks, months, or years. Méniére’s\\ndisease is often accompanied by ringing or buzzing in the\\near, hearing loss , and a feeling that the ear is blocked.\\nDamage to the nerve that leads from the ear to the brain can\\nalso cause vertigo. Such damage can result from head\\ninjury or a tumor. An acoustic neuroma, for example, is a\\nbenign tumor that wraps around the nerve. Vertigo can also\\nbe caused by disorders of the central nervous system and\\nthe circulatory system, such as hardening of the arteries\\n(arteriosclerosis),stroke, or multiple sclerosis.\\nSome medications cause changes in blood pressure\\nor blood flow. These medications can cause dizziness in\\nsome people. Prescription medications carry warnings\\nof such side effects, but common drugs, such as caf-\\nfeine or nicotine can also cause dizziness. Certain\\nantibiotics can damage the inner ear and cause hearing\\nloss and dizziness.\\nDiet may cause dizziness. The role of diet may be\\ndirect, as through alcohol intake. It may be also be indi-\\nrect, as through arteriosclerosis caused by a high-fat diet.\\nSome people experience a slight dip in blood sugar and\\nmild dizziness if they miss a meal, but this condition is\\nrarely dangerous unless the person is diabetic. Food sen-\\nsitivities or allergies can also be a cause of dizziness.\\nChronic conditions, such as heart disease, and serious\\nacute problems, such as seizures and strokes, can cause\\ndizziness. However, such conditions usually exhibit other\\ncharacteristic symptoms.\\nDiagnosis\\nDuring the initial medical examination, an individ-\\nual with dizziness should provide a detailed description\\nof the type of dizziness experienced, when it occurs, and\\nhow often each episode lasts. A diary of symptoms may\\nhelp track this information. Report any symptoms that\\naccompany the dizziness, such as a ringing in the ear or\\nnausea, any recent injury or infection, and any medica-\\ntion taken.\\nBlood pressure, pulse, respiration, and body temper-\\nature are checked, and the ear, nose, and throat are scruti-\\nnized. The sense of balance is assessed by moving the\\nindividual’s head to various positions or by tilt-table test-\\ning. In tilt-table testing, the person lies on a table that can\\nbe shifted into different positions and reports any dizzi-\\nness that occurs.\\nFurther tests may be indicated by the initial exami-\\nnation. Hearing tests help assess ear damage. x rays,\\ncomputed tomography scan (CT scan), and magnetic\\nresonance imaging (MRI) can pinpoint evidence of\\nnerve damage, tumor, or other structural problems. If a\\nvestibular disorder is suspected, a technique called\\nelectronystagmography (ENG) may be used. ENG mea-\\nsures the electrical impulses generated by eye move-\\nments. Blood tests can determine diabetes, high choles-\\nterol, and other diseases. In some cases, a heart evalua-\\ntion may be useful. Despite thorough testing, an underly-\\ning cause cannot always be determined.\\nTreatment\\nTreatment is determined by the underlying cause. If\\nan individual has a cold or influenza, a few days of bed\\nrest is usually adequate to resolve dizziness. Other caus-\\nes of dizziness, such as mild vestibular system damage,\\nmay resolve without medical treatment.\\nIf dizziness continues, drug therapy may prove\\nhelpful. Because circulatory problems often cause dizzi-\\nness, medication may be prescribed to control blood\\npressure or to treat arteriosclerosis. Sedatives may be\\nuseful to relieve the tension that can trigger or aggravate\\ndizziness. Low blood sugar associated with diabetes\\nsometimes causes dizziness and is treated by controlling\\nblood sugar levels. An individual may be asked to avoid\\ncaffeine, nicotine, alcohol, and any substances that\\ncause allergic reactions. A low-salt diet may also help\\nsome people.\\nWhen other measures have failed, surgery may be\\nsuggested to relieve pressure on the inner ear. If the\\ndizziness is not treatable by drugs, surgery, or other\\nmeans, physical therapy may be used and the patient may\\nbe taught coping mechanisms for the problem.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1095\\nDizziness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 483, 'page_label': '484'}, page_content='Alternative treatment\\nBecause dizziness may arise from serious conditions,\\nit is advisable to seek medical treatment. Alternative treat-\\nments can often be used alongside conventional medicine\\nwithout conflict. Relaxation techniques, such as yoga and\\nmassage therapythat focus on relieving tension, are pop-\\nularly recommended methods for reducing stress. Aro-\\nmatherapists recommend a warm bath scented with essen-\\ntial oils of lavender, geranium, and sandalwood.\\nHomeopathic therapies can work very effectively\\nfor dizziness, and are especially applicable when no\\norganic cause can be identified. An osteopath or chiro-\\npractor may suggest adjustments of the head, jaw, neck,\\nand lower back to relieve pressure on the inner ear.\\nAcupuncturists also offer some treatment options for\\nacute and chronic cases of dizziness. Nutritionists may\\nbe able to offer advice and guidance in choosing dietary\\nsupplements, identifying foods to avoid, and balancing\\nnutritional needs.\\nKEY TERMS\\nAcoustic neuroma—A benign tumor that grows on\\nthe nerve leading from the inner ear to the brain.\\nAs the tumor grows, it exerts pressure on the inner\\near and causes severe vertigo.\\nArteriosclerosis—Hardening of the arteries caused\\nby high blood cholesterol and high blood pressure.\\nAutonomic nervous system —The part of the ner-\\nvous system that controls involuntary functions\\nsuch as breathing and heart beat.\\nComputed tomography (CT) —An imaging tech-\\nnique in which cross-sectional x rays of the body\\nare compiled to create a three-dimensional image\\nof the body’s internal structures.\\nElectronystagmography—A method for measuring\\nthe electricity generated by eye movements. Elec-\\ntrodes are placed on the skin around the eye and\\nthe individual is subjected to a variety of stimuli so\\nthat the quality of eye movements can be assessed.\\nMagnetic resonance imaging (MRI) —An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\nVestibular system —The area of the inner ear that\\nhelps maintain balance.\\nPrognosis\\nOutcome depends on the cause of dizziness. Control-\\nling or curing the underlying factors usually relieves dizzi-\\nness. In some cases, dizziness disappears without treat-\\nment. In a few cases, dizziness can become a permanent\\ndisabling condition and a person’s options are limited.\\nPrevention\\nMost people learn through experience that certain\\nactivities will make them dizzy and they learn to avoid\\nthem. For example, if reading in a car produces motion\\nsickness, an individual leaves reading materials for after\\nthe trip. Changes to the diet can also cut down on\\nepisodes of dizziness in susceptible people. Relaxation\\ntechniques can help ward off tension and anxiety that\\ncan cause dizziness.\\nThese techniques can help minimize or even prevent\\ndizziness for people with chronic diseases. For example,\\npersons with Méniére’s disease may avoid episodes of\\nvertigo by leaving salt, alcohol, and caffeine out of their\\ndiets. Reducing blood cholesterol can help diminish arte-\\nriosclerosis and indirectly treat dizziness.\\nSome cases of dizziness cannot be prevented.\\nAcoustic neuromas, for example, are not predictable or\\npreventable. When the underlying cause of dizziness can-\\nnot be discovered, it may be difficult to recommend pre-\\nventive measures. Alternative approaches designed to\\nrebalance the body’s energy flow, such as acupuncture\\nand constitutional homeopathy, may be helpful in cases\\nwhere the cause of dizziness cannot be pinpointed.\\nResources\\nBOOKS\\nYardley, Lucy. Vertigo and Dizziness.New York: Routledge, 1994.\\nPERIODICALS\\nBowen, James. “Dizziness: A Diagnostic Puzzle.”Hospital\\nMedicine 34, no.1 (1998): 39.\\nRuckenstein, Michael J. “A Practical Approach to Dizziness.”\\nPostgraduate Medicine 97, no.3 (Mar. 1995): 70.\\nORGANIZATIONS\\nMéniére’s Network. 1817 Patterson St., Nashville, TN 37203.\\n(800) 545-4327. .\\nThe Vestibular Disorders Association. PO Box 4467, Portland,\\nOR 97208-4467. (503) 229-7705. .\\nJulia Barrett\\nDKA see Diabetic ketoacidosis\\nDLE see Discoid lupus erythematosus\\nGALE ENCYCLOPEDIA OF MEDICINE 21096\\nDizziness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 484, 'page_label': '485'}, page_content='Domestic violence see Abuse\\nDonovanosis see Granuloma inguinale\\nDoppler echocardiography see\\nEchocardiography\\nDoppler ultrasonography\\nDefinition\\nDoppler ultrasonography is a non-invasive diagnos-\\ntic procedure that changes sound waves into an image\\nthat can be viewed on a monitor.\\nPurpose\\nDoppler ultrasonography can detect the direction,\\nvelocity, and turbulence of blood flow. It is frequently\\nused to detect problems with heart valves or to measure\\nblood flow through the arteries. Specifically, it is useful\\nin the work up of stroke patients, in assessing blood flow\\nin the abdomen or legs, and in viewing the heart to moni-\\ntor carotid artery diseases.\\nPrecautions\\nThe test is widely used because it is noninvasive,\\nuses no x rays, and gives excellent images. It is harmless,\\npainless, and widely available.\\nDescription\\nDoppler ultrasonography makes use of two different\\nprinciples. The ultrasound principle is this: when a high-\\nfrequency sound is produced and aimed at a target, it will\\nbe reflected by its target and the reflected sound can be\\ndetected back at its origin. In addition, it is known that\\ncertain crystals (called piezoelectric crystals) produce an\\nelectrical pulse when vibrated by a returning sound.\\nThe Doppler principle is simply that sound pitch\\nincreases as the source moves toward the listener and\\ndecreases as it moves away.\\nMedical science utilizes these two principles in the\\nfollowing way. A transducer (sometimes called a probe)\\ncontaining piezoelectric crystals sends a series of short\\nsound pulses into the body and pauses between each\\npulse to listen for the returning sounds. The machine\\nthen determines the direction and depth of each returning\\nsound and coverts this into a point of light on a television\\nmonitor. Thousands of these pulses are computed and\\ndisplayed every second to produce an image of the organ\\nbeing studied. The image allows the doctor to see the\\norgan functioning in real time.\\nThe newest addition to this test is the addition of\\ncolor. Adding color to the image shows the direction and\\nrate of blood flow more clearly.\\nDuring a Doppler ultrasonography procedure the\\ntechnician will apply a gel to the skin, then place the\\ntransducer against the skin at various angles. The trans-\\nducer sends the information it receives to a television\\nmonitor that shows a moving image of the organ being\\nstudied. The technician can save these images either on\\nvideo tape, paper, or x-ray film for further study.\\nPreparation\\nThere is no special preparation needed for this test.\\nThe ultrasound technician may apply a clear gel to the skin\\nin order to help the transducer more freely over the body.\\nAftercare\\nNo aftercare is necessary.\\nNormal results\\nA Doppler ultrasonography test showing no restrict-\\ned blood flow, is a normal finding.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1097\\nDoppler ultrasonography\\nUltrasound doppler \\ntransducer\\nCarotid artery\\nDoppler ultrasonography can detect the direction, velocity,\\nand turbulence of blood flow. Because it is non-invasive and\\nuses no x rays, doppler ultrasongraphy is widely used for\\nnumerous diagnostic procedures.(Illustration by Electronic\\nIllustrators Group.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 485, 'page_label': '486'}, page_content='Abnormal results\\nDisrupted or obstructed blood flow through the neck\\narteries may indicate the person is a risk of having a\\nstroke. (Narrowed arterial flow in the legs does not nec-\\nessarily indicate a risk of stroke.)\\nResources\\nBOOKS\\nMcGoon, Michael D., ed. Mayo Clinic Heart Book: The Ulti-\\nmate Guide to Heart Health. New York: William Morrow\\nand Co., Inc., 1993.\\nOffice Practice of Neurology.Ed. Martin Samuels and Steven\\nFeske. New York: Churchill Livingstone, 1996.\\nvon Reutern, G. M., and H. J. von Budingen. Ultrasound Diag-\\nnosis of Cerebrovascular Disease.New York: Georg\\nThieme Verlag, 1993.\\nDorothy Elinor Stonely\\nDown syndrome\\nDefinition\\nDown syndrome is the most common cause of men-\\ntal retardation and malformation in a newborn. It\\noccurs because of the presence of an extra chromosome.\\nDescription\\nChromosomes are the units of genetic information\\nthat exist within every cell of the body. Twenty-three dis-\\ntinctive pairs, or 46 total chromosomes, are located with-\\nin the nucleus (central structure) of each cell. When a\\nbaby is conceived by the combining of one sperm cell\\nwith one egg cell, the baby receives 23 chromosomes\\nfrom each parent, for a total of 46 chromosomes. Some-\\ntimes, an accident in the production of a sperm or egg\\ncell causes that cell to contain 24 chromosomes. This\\nKEY TERMS\\nDoppler effect —The principle that the sound of\\nan object moving toward you has a higher pitch\\nthan the sound when it’s moving away from you.\\nTransducer—The part of a machine that changes\\nsignals in one form into another form.\\nUltrasound—Sound that is too high for the human\\near to hear.\\nevent is referred to as nondisjunction. When this defec-\\ntive cell is involved in the conception of a baby, that baby\\nwill have a total of 47 chromosomes. The extra chromo-\\nsome in Down syndrome is labeled number 21. For this\\nreason, the existence of three such chromosomes is\\nsometimes referred to as Trisomy 21.\\nIn a very rare number of Down syndrome cases\\n(about 1–2%), the original egg and sperm cells are com-\\npletely normal. The problem occurs sometime shortly\\nafter fertilization; during the phase where cells are divid-\\ning rapidly. One cell divides abnormally, creating a line\\nof cells with an extra chromosome 21. This form of\\ngenetic disorder is called a mosaic. The individual with\\nthis type of Down syndrome has two types of cells: those\\nwith 46 chromosomes (the normal number), and those\\nwith 47 chromosomes (as occurs in Down syndrome).\\nSome researchers have suggested that individuals with\\nthis type of mosaic form of Down syndrome have less\\nsevere signs and symptoms of the disorder.\\nAnother relatively rare genetic accident which can\\ncause Down syndrome is called translocation. During cell\\ndivision, the number 21 chromosome somehow breaks. A\\npiece of the 21 chromosome then becomes attached to\\nanother chromosome. Each cell still has 46 chromosomes,\\nbut the extra piece of chromosome 21 results in the signs\\nand symptoms of Down syndrome. Translocations occur\\nin about 3–4% of cases of Down syndrome.\\nDown syndrome occurs in about one in every\\n800–1,000 births. It affects an equal number of boys and\\ngirls. Less than 25% of Down syndrome cases occur due\\nto an extra chromosome in the sperm cell. The majority\\nof cases of Down syndrome occur due to an extra chro-\\nmosome 21 within the egg cell supplied by the mother\\n(nondisjunction). As a woman’s age (maternal age)\\nincreases, the risk of having a Down syndrome baby\\nincreases significantly. For example, at younger ages, the\\nrisk is about one in 4,000. By the time the woman is age\\n35, the risk increases to one in 400; by age 40 the risk\\nincreases to one in 110; and by age 45 the risk becomes\\none in 35. There is no increased risk of either mosaicism\\nor translocation with increased maternal age.\\nCauses and symptoms\\nWhile Down syndrome is a chromosomal disorder, a\\nbaby is usually identified at birth through observation of\\na set of common physical characteristics. Babies with\\nDown syndrome tend to be overly quiet, less responsive,\\nwith weak, floppy muscles. Furthermore, a number of\\nphysical signs may be present. These include:\\n• flat appearing face\\n• small head\\nGALE ENCYCLOPEDIA OF MEDICINE 21098\\nDown syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 486, 'page_label': '487'}, page_content='• flat bridge of the nose\\n• smaller than normal, low-set nose\\n• small mouth, which causes the tongue to stick out and\\nto appear overly large\\n• upward slanting eyes\\n• extra folds of skin located at the inside corner of each\\neye, near the nose (called epicanthal folds)\\n• rounded cheeks\\n• small, misshapen ears\\n• small, wide hands\\n• an unusual, deep crease across the center of the palm\\n(called a simian crease)\\n• a malformed fifth finger\\n• a wide space between the big and the second toes\\n• unusual creases on the soles of the feet\\n• overly-flexible joints (sometimes referred to as being\\ndouble-jointed)\\n• ahorter than normal height\\nOther types of defects often accompany Down syn-\\ndrome. About 30–50% of all children with Down syn-\\ndrome are found to have heart defects. A number of dif-\\nferent heart defects are common in Down syndrome,\\nincluding abnormal openings (holes) in the walls that\\nseparate the heart’s chambers (atrial septal defect, ven-\\ntricular septal defect). These result in abnormal patterns\\nof blood flow within the heart. The abnormal blood flow\\noften means that less oxygen is sent into circulation\\nthroughout the body. Another heart defect that occurs in\\nDown syndrome is called Tetralogy of Fallot. Tetralogy\\nof Fallot consists of a hole in the heart, along with three\\nother major heart defects.\\nMalformations of the gastrointestinal tract are pre-\\nsent in about 5–7% of children with Down syndrome.\\nThe most common malformation is a narrowed, obstruct-\\ned duodenum (the part of the intestine into which the\\nstomach empties). This disorder, called duodenal atresia,\\ninterferes with the baby’s milk or formula leaving the\\nstomach and entering the intestine for digestion. The\\nbaby often vomits forcibly after feeding, and cannot gain\\nweight appropriately until the defect is repaired.\\nOther medical conditions that occur in patients with\\nDown syndrome include an increased chance of develop-\\ning infections, especially ear infections and pneumonia;\\ncertain kidney disorders; thyroid disease (especially low\\nor hypothyroid); hearing loss; vision impairment requir-\\ning glasses (corrective lenses); and a 20-times greater\\nchance of developing leukemia (a blood disorder).\\nDevelopment in a baby and child with Down syn-\\ndrome occurs at a much slower than normal rate.\\nBecause of weak, floppy muscles (hypotonia), babies\\nlearn to sit up, crawl, and walk much later than their nor-\\nmal peers. Talking is also quite delayed. The level of\\nmental retardation is considered to be mild-to-moderate\\nin Down syndrome. The actual IQ range of Down syn-\\ndrome children is quite varied, but the majority of such\\nchildren are in what is sometimes known as the trainable\\nrange. This means that most people with Down syn-\\ndrome can be trained to do regular self-care tasks, func-\\ntion in a socially appropriate manner in a normal home\\nenvironment, and even hold simple jobs.\\nAs people with Down syndrome age, they face an\\nincreased chance of developing the brain disease called\\nAlzheimer’s (sometimes referred to as dementia or\\nsenility). Most people have a six in 100 risk of develop-\\ning Alzheimer’s, but people with Down syndrome have a\\n25 in 100 chance of the disease. Alzheimer’s disease\\ncauses the brain to shrink and to break down. The num-\\nber of brain cells decreases, and abnormal deposits and\\nstructural arrangements occur. This process results in a\\nloss of brain functioning. People with Alzheimer’s have\\nstrikingly faulty memories. Over time, people with\\nAlzheimer’s disease will lapse into an increasingly unre-\\nsponsive state. Some researchers have shown that even\\nDown syndrome patients who do not appear to have\\nAlzheimer’s disease have the same changes occurring to\\nthe structures and cells of their brains.\\nAs people with Down syndrome age, they also have\\nan increased chance of developing a number of other ill-\\nnesses, including cataracts, thyroid problems, diabetes,\\nand seizure disorders.\\nDiagnosis\\nDiagnosis is usually suspected at birth, when the\\ncharacteristic physical signs of Down syndrome are\\nnoted. Once this suspicion has been raised, genetic test-\\ning (chromosome analysis) can be undertaken in order to\\nverify the presence of the disorder. This testing is usually\\ndone on a blood sample, although chromosome analysis\\ncan also be done on other types of tissue, including skin.\\nThe cells to be studied are prepared in a laboratory.\\nChemical stain is added to make the characteristics of the\\ncells and the chromosomes stand out. Chemicals are\\nadded to prompt the cells to go through normal develop-\\nment, up to the point where the chromosomes are most\\nvisible, prior to cell division. At this point, they are\\nexamined under a microscope and photographed. The\\nphotograph is used to sort the different sizes and shapes\\nof chromosomes into pairs. In most cases of Down syn-\\ndrome, one extra chromosome 21 will be revealed. The\\nfinal result of such testing, with the photographed chro-\\nmosomes paired and organized by shape and size, is\\ncalled the individual’s karyotype.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1099\\nDown syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 487, 'page_label': '488'}, page_content='Treatment\\nNo treatment is available to cure Down syndrome.\\nTreatment is directed at addressing the individual con-\\ncerns of a particular patient. For example, heart defects\\nwill many times require surgical repair, as will duodenal\\natresia. Many Down syndrome patients will need to wear\\nglasses to correct vision. Patients with hearing impair-\\nment benefit from hearing aids.\\nA new drug, referred to as a “smart drug,” has been\\nreceiving some attention in the treatment of Down syn-\\ndrome patients. This drug, piracetam, has not been\\nproven to increase intellectual ability, despite testimoni-\\nals that have been receiving attention on television and\\nthe Internet. Piracetam has not been approved for use in\\nthe United States, although it is being sold via the Inter-\\nnet. The National Down Syndrome Society and the\\nNational Down Syndrome Congress do not recommend\\nthe use of this drug as of 2001.\\nWhile some decades ago, all Down syndrome chil-\\ndren were quickly placed into institutions for lifelong\\ncare. Research shows very clearly that the best outlook\\nfor children with Down syndrome is a normal family life\\nin their own home. This requires careful support and edu-\\ncation of the parents and the siblings. It is a life-changing\\nevent to learn that a new baby has a permanent condition\\nthat will effect essentially all aspects of his or her devel-\\nopment. Some community groups exist to help families\\ndeal with the emotional effects of this new information,\\nand to help plan for the baby’s future. Schools are\\nrequired to provide services for children with Down syn-\\ndrome, sometimes in separate special education class-\\nrooms, and sometimes in regular classrooms (this is\\ncalled mainstreaming or inclusion).\\nPrognosis\\nThe prognosis in Down syndrome is quite variable,\\ndepending on the types of complications (heart defects,\\nsusceptibility to infections, development of leukemia) of\\neach individual baby. The severity of the retardation can\\nalso vary significantly. Without the presence of heart\\ndefects, about 90% of children with Down syndrome live\\ninto their teens. People with Down syndrome appear to\\ngo through the normal physical changes of aging more\\nrapidly, however. The average age of death for an indi-\\nvidual with Down syndrome is about 50–55 years.\\nStill, the prognosis for a baby born with Down syn-\\ndrome is better than ever before. Because of modern\\nmedical treatments, including antibiotics to treat infec-\\ntions and surgery to treat heart defects and duodenal atre-\\nsia, life expectancy has greatly increased. Community\\nand family support allows people with Down syndrome\\nto have rich, meaningful relationships. Because of educa-\\ntional programs, some people with Down syndrome are\\nable to hold jobs.\\nMen with Down syndrome appear to be uniformly\\nsterile (meaning that they are unable to have offspring).\\nWomen with Down syndrome, however, are fully capa-\\nble of having babies. About 50% of these babies, howev-\\ner, will also be born with Down syndrome.\\nPrevention\\nEfforts at prevention of Down syndrome are aimed\\nat genetic counseling of couples who are preparing to\\nhave babies. A counselor needs to inform a woman that\\nher risk of having a baby with Down syndrome increases\\nwith her increasing age. Two types of testing is available\\nduring a pregnancy to determine if the baby being car-\\nried has Down syndrome.\\nScreening tests are used to estimate the chance that\\nan individual woman will have a baby with Down syn-\\ndrome. At 14–17 weeks of pregnancy, measurements of a\\nsubstance called AFP (alpha-fetoprotein) can be per-\\nformed. AFP is normally found circulating in the blood\\nof a pregnant woman, but may be unusually high or low\\nwith certain disorders. Carrying a baby with Down syn-\\ndrome often causes AFP to be lower than normal. This\\ninformation alone, or along with measurements of two\\nother hormones, is considered along with the mother’s\\nage to calculate the risk of the baby being born with\\nDown syndrome. These results are only predictions, and\\nare only correct about 60% of the time.\\nThe only way to definitively establish (with about\\n98–99% accuracy) the presence or absence of Down syn-\\ndrome in a developing baby, is to test tissue from the\\npregnancy itself. This is usually done either by amnio-\\ncentesis or chorionic villus sampling (CVS). In amnio-\\ncentesis, a small amount of the fluid in which the baby is\\nfloating is withdrawn with a long, thin needle. In chori-\\nonic villus sampling, a tiny tube is inserted into the open-\\ning of the uterus to retrieve a small sample of the placen-\\nta (the organ that attaches the growing baby to the moth-\\ner via the umbilical cord, and provides oxygen and\\nnutrition ). Both amniocentesis and CVS allow the\\nbaby’s own karyotype to be determined. A couple must\\nthen decide whether to use this information in order to\\nbegin to prepare for the arrival of a baby with Down syn-\\ndrome, or to terminate the pregnancy.\\nOnce a couple has had one baby with Down syn-\\ndrome, they are often concerned about the likelihood of\\nfuture offspring also being born with the disorder. Most\\nresearch indicates that this chance remains the same as\\nfor any woman at a similar age. However, when the baby\\nGALE ENCYCLOPEDIA OF MEDICINE 21100\\nDown syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 488, 'page_label': '489'}, page_content='with Down syndrome has the type that results from a\\ntranslocation, it is possible that one of the two parents is\\na carrier of that defect. A carrier “carries” the genetic\\ndefect, but does not actually have the disorder. When\\none parent is a carrier of a translocation, the chance of\\nfuture offspring having Down syndrome is greatly\\nincreased. The specific risk will have to be calculated by\\na genetic counselor.\\nResources\\nBOOKS\\nCarey, John C. “Chromosomal Disorders.” In Rudolph’s Pedi-\\natrics, ed. Abraham M. Rudolph. Stamford: Appleton &\\nLange, 1998.\\nShapiro, Larry J. “Human Genetics.” In Nelson Textbook of\\nPediatrics, ed. Richard Behrman. Philadelphia: W. B.\\nSaunders Co., 1998.\\nStray-Gunderson, K. Babies with Down Syndrome: A New Par-\\nents’ Guide.Kensington: Woodbine House, 1986.\\nKEY TERMS\\nChromosome —The structures that carry genetic\\ninformation. Chromosomes are located within\\nevery cell, and are responsible for directing the\\ndevelopment and functioning of all the cells in the\\nbody. The normal number is 46 (23 pairs).\\nKaryotype—The specific chromosomal makeup of\\na particular cell.\\nMental retardation —A condition where an indi-\\nvidual has a lower-than-normal IQ, and thus is\\ndevelopmentally delayed.\\nMosaic—A term referring to a genetic situation, in\\nwhich an individual’s cells do not have the exact\\nsame composition of chromosomes. In Down syn-\\ndrome, this may mean that some of the individ-\\nual’s cells have a normal 46 chromosomes, while\\nother cells have an abnormal 47 chromosomes.\\nNondisjunction —A genetic term referring to an\\nevent which takes place during cell division, in\\nwhich a genetic accident causes an egg or sperm\\ncell to have 24 chromosomes, rather than the nor-\\nmal 23.\\nTranslocation—A genetic term referring to a situa-\\ntion during cell division in which a piece of one\\nchromosome breaks off and sticks to another chro-\\nmosome.\\nTrisomy—The condition of having three identical\\nchromosomes, instead of the normal two.\\nTingey, C. Down Syndrome: A Resource Handbook.Boston:\\nLittle, Brown, Inc., 1988.\\nTierney, Lawrence, et. al. Current Medical Diagnosis and\\nTreatment. Los Altos: Lange Medical Publications, 2001.\\nPERIODICALS\\nCarlson, Tucker, and Jason Cowley. “When a Life is Worth\\nLiving: Down’s Syndrome Children.”The Times, 29 Nov.\\n1996, 18+.\\n“Medical and Surgical Care for Children with Down Syn-\\ndrome.” The Exceptional Parent25, no. 11 (Nov. 1995):\\n78+.\\nRoan, Shari. “Elixir of Hope?”Los Angeles Times6 Mar. 1996,\\nE1.\\nTanner, Lindsey. “Study: Drug May Hurt Syndrome Kids.”\\nChicago: Associated Press, 12 Apr. 2001.\\nORGANIZATION\\nNational Down Syndrome Congress. 1605 Chantilly Drive,\\nSuite 250, Atlanta, GA 30324-3269. (800) 232-6372.\\nNational Down Syndrome Society. 666 Broadway, 8th Floor,\\nNew York, NY 10012-2317. (800) 221-4602. .\\nKim A. Sharp, M.Ln.\\nDown’s syndrome see Down syndrome\\nDoxazosin see Alpha1-adrenergic blockers\\nDoxepin see Antidepressants, tricyclic\\nDoxycycline see Tetracyclines\\nDracontiasis see Guinea worm infection\\nDracunculiasis see Guinea worm infection\\nDrooping eyelid see Ptosis\\nDrowning see Near-drowning\\nDrug abuse see Substance abuse and\\ndependence\\nDrug addiction see Substance abuse and\\ndependence\\nDrug dependence see Substance abuse and\\ndependence\\nDrug metabolism/interactions\\nDefinition\\nDrug metabolism is the process by which the body\\nbreaks down and converts medication into active chemi-\\ncal substances.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1101\\nDrug metabolism/interactions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 489, 'page_label': '490'}, page_content='Precautions\\nDrugs can interact with other drugs, foods, and bev-\\nerages. Interactions can lessen or magnify the desired\\ntherapeutic effect of a drug, or may cause unwanted or\\nunexpected side effects. There are thousands of possible\\ndrug-to-drug and drug-to-food interactions, and many\\nmedications and supplements are contraindicated (not\\nrecommended) under certain conditions or in patients\\nwith specific diseases and disorders. This is why it is\\nimperative that patients always keep their physician fully\\ninformed about all drugs and dietary supplements\\n(including herbal remedies) they are taking.\\nDescription\\nThe primary site of drug metabolism is the liver, the\\norgan that plays a major role in metabolism, digestion,\\ndetoxification, and elimination of substances from the\\nbody. Enzymes in the liver are responsible for chemically\\nchanging drug components into substances known as\\nmetabolites. Metabolites are then bound to other sub-\\nstances for excretion through the lungs, or bodily fluids\\nsuch as saliva, sweat, breast milk, and urine, or through\\nreabsorption by the intestines. The primary mode of\\nexcretion is through the kidneys.\\nThe family of liver isoenzymes known as cytochrome\\nP-450 are crucial to drug metabolism. These enzymes\\n(labeled CYP1A2, CYP2C9, CYP2C19, CYP2D6, and\\nCYP3A4) have a catabolic action on substances, breaking\\nthem down into metabolites. Consequently, they also act to\\nlower the concentration of medication in the bloodstream.\\nDrug interactions can occur when one drug inhibits\\nor induces a P-450 that acts on another drug. An exam-\\nple is nicotine, a drug contained in tobacco, and known\\nto induce P-450s. Individuals with liver disease (e.g.,\\ncirrhosis ) may also have insufficient levels of P-450\\nenzymes. As a result, the concentration of drugs metab-\\nolized by these enzymes (e.g., amprenavir and other\\nprotease inhibitors ) remains high and can build up to\\ntoxic levels in the bloodstream. In addition, certain\\nmedications and foods, such as grapefruit juice, can\\ninactivate or lessen the metabolic activity of P-450s.\\nChanging the drug dosage can alleviate the problem in\\nsome cases.\\nThe metabolic rate can vary significantly from per-\\nson to person, and drug dosages that work quickly and\\neffectively in one individual may not work well for\\nanother. Factors such as genetics, environment, nutri-\\ntion and age also influence drug metabolism; infants\\nand elderly patients may have a reduced capacity to\\nmetabolize certain drugs, and may require adjustments\\nin dosage.\\nCauses and symptoms\\nDrugs that commonly interact with other medica-\\ntions include:\\n•Diuretics . Diuretics such as hydrochlorothiazide can\\nreduce serum potassium and sodium electrolyte levels\\nwhen taken with digoxin and lithium, respectively.\\n• Monoamine oxidase inhibitors (MAOIs). MAOI antide-\\npressants can cause convulsions and other serious side\\neffects when used with tricyclic antidepressants (e.g.,\\nImipramine, Nortriptyline), selective serotonin reup-\\ntake inhibitors (SSRIs), or sympathomimetic drugs\\n(e.g., amphetamines).\\n•Antibiotics . Antibiotics may reduce the efficiency of\\noral contraceptives.\\n• Metals. Medications containing metals, such as\\nantacids with aluminum additives and iron supple-\\nments, can reduce the absorption of tetracyclines and\\nfluoroquinolones.\\n• Drugs that inhibit liver enzyme function. Drugs that\\nslow drug metabolism include ciprofloxacin, ery-\\nthromycin, fluoxetine, nefazodone, paroxetine, and\\nritonavir. The therapeutic effect of other medications\\ntaken with these drugs may be amplified. Warfarin, a\\nblood thinner, should be used with great caution in indi-\\nviduals taking these drugs.\\nFoods and beverages that may interact with drugs\\ninclude:\\n• Grapefruit juice. Grapefruit juice inhibits the metabo-\\nlism of many medications, including cyclosporine,\\nfelodipine, nifedipine, nitrendipine, nisoldipine, carba-\\nmazepine, triazolam, and midazolam.\\n• Foods and beverages with tyramines. Red wine, malted\\nbeers, smoked foods (e.g., fish and meats), dried fruits,\\nand aged cheeses may contain tyramines, and can cause\\na severe and dangerous elevation in blood pressure\\nwhen taken with MAOI inhibitors (a class of antide-\\npressants).\\n• Dairy products. Milk, cream, and other dairy products\\ncontaining calcium can prevention the absorption of\\nantibiotics such as tetracycline, doxycycline, and\\nciprofloxacin when they are taken with the drug. In\\naddition, whole milk with vitamin D can cause milk-\\nalkali syndrome in patients taking aluminum hydroxide\\nantacids.\\n• Caffeinated beverages. The caffeine contained in cof-\\nfee and colas can influence drug metabolism.\\n• Alcohol. Alcohol is a central nervous system depressant,\\nand should not be taken with other CNS depressants\\nGALE ENCYCLOPEDIA OF MEDICINE 21102\\nDrug metabolism/interactions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 490, 'page_label': '491'}, page_content='(e.g., antipsychotics, antihistamines). In addition, cer-\\ntain fermented beverages may contain tyramines \\nThis list is not all-inclusive and individuals should\\nalways let their doctor and pharmacist know when they\\nare taking other medications, herbal remedies, or dietary\\nsupplements. Anyone who experiences a serious reaction\\nto a drug that is not consistent with its product labelling\\nshould report the event to their doctor and/or the Med-\\nWatch adverse event reporting system of the United\\nStates Food and Drug Administration (FDA).\\nAlternative treatment\\nThe growing use of herbal supplements has also\\nincreased the opportunity for adverse drug and herbal\\ninteractions. In 2000, the FDA issued a warning on the\\npopular herb St. John’s wort (Hypericum perforatum ).\\nThe supplement was found to inhibit the effect of indi-\\nnavir, a protease inhibitor used in the treatment of HIV . It\\nmay also affect the action of cyclosporine and other pro-\\ntease inhibitors (e.g., amprenavir, ritonavir). Further clin-\\nical studies are still necessary to determine the full meta-\\nbolic effects of the herb.\\nOther herbs which may interact with allopathic med-\\nications include gingko bilboa, ginseng, and garlic, which\\nmay all heighten the blood thinning effect of the anticoagu-\\nlant warfarin. Because herbs are regulated by the FDA as\\ndietary supplements, they do not require the same extensive\\nclinical trials and premarket testing as drugs do before they\\nare cleared for sale in the United States As such, there is still\\nmuch to learn about the potential interactions and adverse\\nKEY TERMS\\nCatabolism —A process of metabolism that breaks\\ndown complex substances into simple ones.\\nCirrhosis—Liver disease characterized by the wide-\\nspread disruption of the normal liver structure and\\nfunction.\\nCNS depressant —Anything that depresses, or\\nslows, the sympathetic impulses of the central ner-\\nvous system (i.e., respiratory rate, heart rate).\\nDrug interaction —A chemical or physiological\\nreaction that can occur when two different drugs\\nare taken together.\\nEnzymes—Organic substances (proteins) composed\\nof amino acids that trigger and regulate chemical\\nreactions in the body. There are over 700 identified\\nhuman enzymes.\\nLiver—A solid organ located on the right in the\\nupper abdomen. It plays a major role in metabo-\\nlism, digestion, detoxification, and elimination of\\nsubstances from the body.\\nMetabolism —The sum of all the physical and\\nchemical processes occurring in the body to orga-\\nnize and maintain life.\\nMetabolites—Substances produced by metabolism\\nor by a metabolic process.\\nMilk-alkali syndrome—Elevated blood calcium lev-\\nels and alkalosis caused by excessive intake of milk\\nand alkalis. Usually occurs in the treatment of pep-\\ntic ulcer.\\neffects associated with herbal supplements. Individuals who\\nexperience serious side effects from dietary supplements\\nshould report them to FDA’s MedWatch program.\\nDiagnosis\\nDrug interactions can be difficult to detect. In some\\ncases, adverse reactions may closely resemble the symp-\\ntoms of the disease or condition the medication was pre-\\nscribed to treat. Patients who take a number of medications\\nor self-treat with over-the-counter drugs and/or herbal\\nremedies may not be able to determine which drug actually\\ntriggered the interaction. A 2001 study by University of\\nFlorida researchers found that less than half of the women\\nparticipating disclosed their use of herbal therapies to their\\nhealthcare providers. In cases where a serious drug or herb\\ninteraction occurs, withholding this information can delay\\ndiagnosis and put the patient at increased risk.\\nTreatment\\nTreatment of a drug interaction is dependant on a\\nnumber of factors, including the medication(s) or supple-\\nments used and the medical history of the patient. A\\ndosage adjustment may reverse the effects of some inter-\\nactions. Serious or life-threatening interactions will\\nrequire more aggressive therapies.\\nPrevention\\nPatients with chronic health conditions, particularly\\nthose with liver disorders, should always inform their\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1103\\nDrug metabolism/interactions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 491, 'page_label': '492'}, page_content='healthcare professional before taking any over-the-\\ncounter (OTC) medications or dietary supplements.\\nBecause of the risk for a drug-to-drug interaction, individ-\\nuals should also let their doctor know if they are taking\\ndrugs prescribed by other physicians. Individuals should\\nclosely follow instructions for use and package directions\\non both prescription and over-the-counter drugs. Consult-\\ning with a pharmacist and/or physician may be beneficial\\nif package directions are unclear to the patient.\\nAs a rule, grapefruit juice should not be taken with\\nmedication unless recommended by a doctor. Patients\\ntaking MAOI inhibitors should always check food and\\nbeverage labels to ensure tyramines aren’t included, and\\nshould avoid all fermented drinks.\\nResources\\nBOOKS\\nBeers, Mark H., and Robert Berkow. The Merck Manual of\\nDiagnosis and Therapy, 17th ed.Whitehouse Station, NJ:\\nMerck & Co., Inc., 1999.\\nMedical Economics Company. The Physicians Desk Reference\\n(PDR). 55th edition. Montvale, NJ: Medical Economics\\nCompany, 2001.\\nPERIODICALS\\nHardy, Mary L. “Herb-Drug Interactions: An Evidence-Based\\nTable.”Internal Medicine Alert 23 (January 29, 2001): 1.\\nORGANIZATION\\nUnited States Food and Drug Administration (FDA). Med-\\nWatch Adverse Events Reporting Program. 5600 Fishers\\nLane, Rockville, MD 20852-9787. 800-FDA-1088.\\n.\\nPaula Anne Ford-Martin\\nDrug overdose\\nDefinition\\nA drug overdose is the accidental or intentional use\\nof a drug or medicine in an amount that is higher than is\\nnormally used.\\nDescription\\nAll drugs have the potential to be misused, whether\\nlegally prescribed by a doctor, purchased over-the-\\ncounter at the local drug store, or bought illegally on the\\nstreet. Taken in combination with other drugs or with\\nalcohol, even drugs normally considered safe can cause\\ndeath or serious long term consequences. Children are\\nparticularly at risk for accidental overdose, accounting\\nfor over one million poisonings each year from drugs,\\nalcohol, and other chemicals and toxic substances. Peo-\\nple who suffer from depression and who have suicidal\\nthoughts are also at high risk for drug overdose.\\nCauses and symptoms\\nAccidental drug overdose may be the result of mis-\\nuse of prescription medicines or commonly used medica-\\ntions like pain relievers and cold remedies. Symptoms\\ndiffer depending on the drug taken. Some of the drugs\\ncommonly involved in overdoses are listed below along\\nwith symptoms and outcomes.\\nAcetaminophen is the generic name for the com-\\nmonly used pain reliever Tylenol. Overdose of this drug\\ncauses liver damage with symptoms that include loss of\\nappetite, tiredness, nausea and vomiting , paleness, and\\nsweating. The next stage of symptoms indicates liver\\nfailure and includes abdominal pain and tenderness,\\nswelling of the liver, and abnormal blood tests for liver\\nenzymes. In the last stage of this poisoning, liver failure\\nadvances and the patient becomes jaundiced, with yel-\\nlowing of the skin and whites of the eyes. They may also\\nexperience kidney failure, bleeding disorders, and\\nencephalopathy (swelling of the brain).\\nAnticholinergic drugs (drugs that block the action of\\nacetylcholine, a neurotransmitter) like atropine, scopo-\\nlamine, belladonna, antihistamines , and antipsychotic\\nagents cause the skin and moist tissues (like in the mouth\\nand nose) to become dry and flushed. Dilated pupils, an\\ninability to urinate, and mental disturbances are also\\nsymptoms. Severe toxicity can lead to seizures, abnormal\\nheart rhythms, extremely high blood pressure, and coma.\\nAntidepressant drugs like amitriptyline, desi-\\npramine, and nortriptyline can cause irregular heart rate,\\nvomiting, low blood pressure, confusion, and seizures. An\\noverdose of antidepressants also causes symptoms similar\\nto those seen with anticholinergic drug overdoses.\\nCholinergic drugs (drugs that stimulate the\\nparasympathetic nervous system) like carbamate and\\npilocarpine cause nausea, diarrhea, increased secretion\\nof body fluids (sweat, tears, saliva, and urine), fatigue ,\\nand muscle weakness. Convulsions are possible. Death\\ncan occur due to respiratory failure and heart failure.\\nCocaine and crack cocaine overdoses cause seizures,\\nhigh blood pressure, increased heart rate, paranoia, and\\nother changes in behavior. Heart attack or stroke are\\nserious risks within three days after cocaine overdose.\\nDepressant drugs (tranquilizers, antianxiety drugs,\\nsleeping pills) cause sleepiness, slowed or slurred speech,\\ndifficulty walking or standing, blurred vision, impaired\\nability to think, disorientation, and mood changes. Over-\\nGALE ENCYCLOPEDIA OF MEDICINE 21104\\nDrug overdose'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 492, 'page_label': '493'}, page_content='dose symptoms can include slowed breathing, very low\\nblood pressure, stupor, coma,shock, and death.\\nDigoxin, a drug used to regulate the heart, can cause\\nirregular heart beats, nausea, confusion, loss of appetite,\\nand blurred vision.\\nNarcotics or opiates are drugs like heroin, morphine,\\nand codeine. Clonidine and diphenoxylate (Lomotil) are\\nalso in this category. Overdose with opiate drugs causes\\nsedation (sleepiness), low blood pressure, slowed heart\\nrate, and slowed breathing. Pinpoint pupils, where the\\nblack centers of the eyes become smaller than normal,\\nare common in opiate overdose. However, if other drugs\\nare taken at the same time as the opiates, they may coun-\\nteract this effect on the pupils. A serious risk is that the\\npatient will stop breathing.\\nSalicylates are found in aspirin and some creams or\\nointments used for muscle and joint pain (like Ben-Gay),\\nand creams for psoriasis, a skin condition. Initial symp-\\ntoms are gastrointestinal irritation, fever, and vomiting,\\npossibly with blood in the vomit. This overdose will\\ncause metabolic acidosisand respiratory alkalosis, con-\\nditions where the body’s acid/base balance is malfunc-\\ntioning. Symptoms include rapid heart beat and fast\\nbreathing. Nervous system symptoms include confusion,\\nhallucinations , tiredness, and ringing in the ears. An\\nincreased tendency to bleed is also common. Serious\\ncomplications include acute renal failure, coma, and heart\\nfailure. Acute salicylate poisoning can lead to death.\\nDiagnosis\\nDiagnosis of a drug overdose may be based on the\\nsymptoms that develop, however, the drug may do exten-\\nsive damage to the body before significant symptoms\\ndevelop. If the patient is conscious, he or she may be able\\nto tell what drugs were taken and in what amounts. The\\npatient’s recent medical and social history may also help\\nin a diagnosis. For example, a list of medications that the\\npatient takes, whether or not alcohol was consumed\\nrecently, even if the patient has eaten in the last few hours\\nbefore the overdose, can be valuable in determining what\\nwas taken and how fast it will be absorbed into the system.\\nDifferent drugs have varying effects on the body’s\\nacid/base balance and on certain elements in the blood\\nlike potassium and calcium. Blood tests can be used to\\ndetect changes in body chemistry that may give clues to\\nwhat drugs were taken. Blood can also be screened for\\nvarious drugs in the system. Once the overdose drug is\\nidentified, blood tests can be used to monitor how fast\\nthe drug is being cleared out of the body. Urine tests can\\nalso be used to screen for some drugs and to detect\\nchanges in the body’s chemistry. Blood and urine tests\\nmay show if there is damage to the liver or kidneys as a\\nresult of the overdose.\\nTreatment\\nImmediate care\\nIf a drug overdose is discovered or suspected, and\\nthe person is unconscious, having convulsions, or is not\\nbreathing, call for emergency help immediately. If the\\nperson who took the drug is not having symptoms, don’t\\nwait to see if symptoms develop; call a poison control\\ncenter immediately. Providing as much information as\\npossible to the poison control center can help determine\\nwhat the next course of action should be.\\nThe poison control center, paramedics, and emer-\\ngency room staff will want to know:\\n• what drug(s) were taken—try to locate the drug’s con-\\ntainer.\\n• how much of the drug was taken\\n• when was the drug taken\\n• was the drug taken with alcohol or any other drugs or\\nchemicals\\n• what is the age of the patient\\n• what symptoms are the patient experiencing\\n• is the patient conscious\\n• is the patient breathing\\nThe poison control center may recommend trying to\\nget the patient to vomit. A liquid called ipecac syrup,\\nwhich is used to induce vomiting, is available from phar-\\nmacies without a prescription. Pediatricians may recom-\\nmend that families keep ipecac syrup on hand in house-\\nholds with children. This medication should be used only\\non the advice of a medical professional. V omiting should\\nnot be induced if the patient is unconscious.\\nEmergency care\\nEmergency medical treatment may include:\\n• Assessment of the patient’s airway and breathing to\\nmaking sure that the trachea, the passage to the lungs, is\\nnot blocked. If needed, a tube may be inserted through\\nthe mouth and into the trachea to help the patient\\nbreath. This procedure is called intubation.\\n• Assessment of the patient’s heart rate, blood pressure,\\nbody temperature, and other physical signs that might\\nindicate the effects of the drug.\\n• Blood and urine samples may be collected to test for\\nthe presence of the suspected overdose drug, and any\\nother drugs or alcohol that might be present.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1105\\nDrug overdose'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 493, 'page_label': '494'}, page_content='• Elimination of the drug that has not yet been absorbed is\\nattempted. V omiting may be induced using ipecac syrup\\nor other drugs that cause vomiting. Ipecac syrup should\\nnot be given to patients who overdosed with tricyclic\\nantidepressants, theophylline, or any drug that causes a\\nsignificant change in mental status. If a patient vomits\\nwhile unconscious, there is a serious risk of choking.\\n• Gastric lavage, or washing out the stomach, may be\\nattempted. For this procedure a tube flexible tube is\\ninserted through the nose, down the throat, and into the\\nstomach. The contents of the stomach are then suc-\\ntioned out through the tube. A solution of saline (salt\\nwater) is injected into the tube to rinse out the stomach.\\nThis solution is then suctioned out. This is the process\\nused when someone has his/her stomach pumped.\\n• Activated charcoal is sometimes given to absorb the\\ndrug.\\n• Medication to stimulate urination or defecation may be\\ngiven to try to flush the excess drug out of the body\\nfaster.\\n• Intravenous (IV) fluids may be given. An intravenous\\nline, a needle inserted into a vein, may be put into the\\narm or back of the hand. Fluids, either sterile saline\\n(salt water solution) or dextrose (sugar water solution),\\ncan be administered through this line. Increasing fluids\\ncan help to flush the drug out of the system and to\\nreestablish balance of fluids and minerals in the body.\\nThe pH (acid/base balance) of the body may need to be\\ncorrected by administering electrolytes like sodium,\\npotassium, and bicarbonate through this IV line. If\\ndrugs need to be administered quickly, they can also be\\ninjected directly into the IV line.\\n• Hemodialysis is a procedure where blood is circulated\\nout of the body, pumped through a dialysis machine,\\nthen reintroduced back into the body. This process can\\nbe used to filter some drugs out of the blood. It may\\nKEY TERMS\\nGastric lavage—Also called a stomach pump. For\\nthis procedure, a flexible tube is inserted through\\nthe nose, down the throat, and into the stomach\\nand the contents of the stomach are suctioned out.\\nThe inside of the stomach is rinsed with a saline\\n(salt water) solution.\\nIntubation—A procedure where a tube is inserted\\nthrough the mouth and into the trachea keep the\\nairway open and to help the patient breathe.\\nalso be used temporarily or long term if the kidneys are\\ndamaged due to the overdose.\\n• Antidotes are available for some drug overdoses. An\\nantidote is another drug that counteracts or blocks the\\noverdose drug. For example, acetaminophen overdose\\ncan be treated with an oral medication, N-acetylcys-\\nteine (Mucomyst), if the level of acetaminophen found\\nin the blood is extremely high. Naloxone is an anti-nar-\\ncotic drug that is given to counteract narcotic poison-\\ning. Nalmefen or methadone may also be used.\\n• Psychiatric evaluation may be recommended if the drug\\noverdose was taken deliberately.\\nPrognosis\\nWhile many victims of drug overdose recover with-\\nout long term effects, there can be serious consequences.\\nSome drug overdoses cause the failure of major organs\\nlike the kidneys or liver, or failure of whole systems like\\nthe respiratory or circulatory systems. Patients who sur-\\nvive drug overdose may need kidney dialysis, kidney or\\nliver transplant, or ongoing care as a result of heart fail-\\nure, stroke, or coma. Death can occur in almost any drug\\noverdose situation, particularly if treatment is not started\\nimmediately.\\nPrevention\\nTo protect children from accidental drug overdose,\\nall medications should be stored in containers with child\\nresistant caps. All drugs should be out of sight and out of\\nreach of children, preferably in a locked cabinet. Pre-\\nscription medications should be used according to direc-\\ntions and only by the person whose name is on the label.\\nThreats of suicide need to be taken seriously and appro-\\npriate help sought for people with depression or other\\nmental illness that may lead to suicide.\\nResources\\nBOOKS\\nClinical Manual of Poisoning and Drug Overdose.Paramus:\\nAppleton-Century-Crofts and Fleschner Publishing Co.,\\n1994.\\nDeglin, Judith Hopfer, and April Hazard Vallerand. Davis’s\\nDrug Guide for Nurses. 5th ed. Philadelphia: F. A. Davis\\nCo., 1996.\\nEllerhorn, Matthew J. Ellerhorn’s Medical Toxicology: Diag-\\nnosis and Treatment of Human Poisoning. 2nd ed. Balti-\\nmore: Williams & Wilkins, 1996.\\nHaddad, Lester M. Clinical Management of Poisoning and\\nDrug Overdose. 3rd ed. Philadelphia: W. B. Saunders Co.,\\n1998.\\n“Poisoning.” In The Merck Manual. 16th ed. Rahway: Merck,\\n1992.\\nGALE ENCYCLOPEDIA OF MEDICINE 21106\\nDrug overdose'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 494, 'page_label': '495'}, page_content='PERIODICALS\\n“Recognition and Treatment of Serious Antipsychotic Drug\\nOverdose.”Drugs & Therapy Perspectives11 (1998): 13-\\n16.\\nOTHER\\n“Drug Overdose.”American Institute of Preventative Medicine.\\n.\\nGraber, Mark A., and Rhea Allen.”Emergency Medicine: Over-\\ndose and Toxindromes.”University of Iowa Family Prac-\\ntice Handbook. .\\nAltha Roberts Edgren\\nDrug therapy monitoring\\nDefinition\\nDrug therapy monitoring, also known as Therapeutic\\nDrug Monitoring (TDM), is a means of monitoring drug\\nlevels in the blood.\\nPurpose\\nTDM is employed to measure blood drug levels so\\nthat the most effective dosage can be determined, with\\ntoxicity prevented. TDM is also utilized to identify non-\\ncompliant patients (those patients who, for whatever rea-\\nson, either cannot or will not comply with drug dosages\\nas prescribed by the physician).\\nPrecautions\\nBecause so many different factors influence blood\\ndrug levels, the following points should be taken into\\nconsideration during TDM: the age and weight of the\\npatient; the route of administration of the drug; the drug’s\\nabsorption rate, excretion rate, delivery rate, and dosage;\\nother medications the patient is taking; other diseases the\\npatient has; the patient’s compliance regarding the drug\\ntreatment regimen; and the laboratory methods used to\\ntest for the drug.\\nDescription\\nTDM is a practical tool that can help the physician\\nprovide effective and safe drug therapy in patients who\\nneed medication. Monitoring can be used to confirm a\\nblood drug concentration level that is above or below the\\ntherapeutic range, or if the desired therapeutic effect of\\nthe drug is not as expected. If this is the case, and\\ndosages beyond normal then have to be prescribed, TDM\\ncan minimize the time that elapses.\\nTDM is important for patients who have other dis-\\neases that can affect drug levels, or who take other medi-\\ncines that may affect drug levels by interacting with the\\ndrug being tested. As an example, without drug monitor-\\ning, the physician cannot be sure if a patient’s lack of\\nresponse to an antibiotic reflects bacterial resistance, or\\nis the result of failure to reach the proper therapeutic\\nrange of antibiotic concentration in the blood. In cases of\\nlife-threatening infections, timing of effective antibiotic\\ntherapy is critical to success. It is equally crucial to avoid\\ntoxicity in a seriously ill patient. Therefore, if toxic\\nsymptoms appear with standard dosages, TDM can be\\nused to determine changes in dosing.\\nDrawn blood, used for TDM, demonstrates a drug\\naction in the body at any specific time, whereas drug lev-\\nels examined from urine samples reflect the presence of a\\ndrug over many days (depending on the rate of excre-\\ntion). Therefore, blood testing is the procedure of choice\\nwhen definite data are required. However, for adequate\\nabsorption and therapeutic levels to be accurate, it is\\nimportant to allow for sufficient time to pass between the\\nadministration of the medication and the collection of the\\nblood sample.\\nBlood specimens for drug monitoring can be taken\\nat two different times: during the drug’s highest thera-\\npeutic concentration (“peak” level), or its lowest\\n(“trough” level). Occasionally called residual levels,\\ntrough levels show sufficient therapeutic levels; whereas\\npeak levels show poisoning (toxicity). Peak and trough\\nlevels should fall within the therapeutic range.\\nPreparation\\nIn preparing for this test, the following guidelines\\nshould be observed:\\n• Depending on the drug to be tested, the physician\\nshould decide if the patient is to be fasting (nothing\\nto eat or drink for a specified period of hours) before\\nthe test.\\n• For patients suspected of symptoms of drug toxicity,\\nthe best time to draw the blood specimen is when the\\nsymptoms are occurring.\\n• If there is a question as to whether an adequate dose of\\nthe drug is being achieved, it is best to obtain trough\\n(lowest therapeutic concentration) levels.\\n• Peak (highest concentration) levels are usually obtained\\none to two hours after oral intake, approximately one\\nhour after intramuscular (IM) administration (a shot in\\nthe muscle), and approximately 30 minutes after intra-\\nvenous (IV) administration. Residual, or trough, levels\\nare usually obtained within 15 minutes of the next\\nscheduled dose.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1107\\nDrug therapy monitoring'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 495, 'page_label': '496'}, page_content='Risks\\nRisks for this test are minimal, but may include\\nslight bleeding from the blood-drawing site, fainting or\\nfeeling lightheaded after blood is drawn, or accumulation\\nof blood under the puncture site (hematoma).\\nResources\\nBOOKS\\nLane, Keryn A. G. The Merck Manual of Medical Information.\\nMerck Research Laboratories, 1997.\\nPagana, Kathleen Deska. Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nDrugs used in labor\\nDefinition\\nThese drugs are used to induce (start) or continue labor.\\nPurpose\\nThe drug decribed here, oxytocin, makes the uterus\\n(womb) contract. Physicians use it to deliberately start\\nlabor. Because there are some risks with using oxytocin,\\nthis should be done only when there are good medical\\nreasons. Any woman who is being given oxytocin should\\nmake sure she has discussed the benefits and risks with\\nher physician.\\nOxytocin also may be used to control bleeding after\\ndelivery or to help make the milk flow in women who are\\nbreastfeeding their babies.\\nDescription\\nOxytocin is a hormone and is available only with a\\nphysician’s prescription. When used to start or continue\\nlabor, it is slowly injected into a vein. A nasal spray form\\nis used to increase milk flow in breastfeeding. Some com-\\nmonly used brand names are Pitocin and Syntocinon.\\nRecommended dosage\\nThe dosages given here are average doses. However,\\ndoses may be different for different patients. Follow the\\norders of the physician who prescribed the drug.\\nFor increasing milk production:\\nOne spray into one or both nostrils, two to three\\nminutes before nursing or using a breast pump.\\nFor starting or continuing labor:\\nThe physician in charge will determine the appropri-\\nate dose.\\nPrecautions\\nOxytocin does not help increase or continue labor in\\nall patients. When it does not help, the physician may\\ndeliver the baby by cesarean section.\\nGALE ENCYCLOPEDIA OF MEDICINE 21108\\nDrugs used in labor\\nTherapeutic Drug Monitoring: Therapeutic And Toxic Range\\nDrug Level* Use Therapeutic Level* Toxic\\nAceteminophen mg/ml Analgesic, antipyretic Depends on use >250\\nAmikacin mg/ml Antibiotic 12–25 mg/ml** >25\\nAminophylline ng/ml Bronchodilator 10–20 mg/ml >20\\nAmitriptyline ng/ml Antidepressant 120–150 ng/ml >500\\nCarbamazepine mg/ml Anticonvulsant 5–12 mg/ml >12\\nChloramphenicol mg/ml Antibiotic 10–20 mg/ml >25\\nDigoxin ng/ml Cardiotonic 0.8–2.0 ng/ml >2.4\\nGentamicin Antibiotic 4–12 mg/L >12 mg/L\\nLidocaine Antiarrhythmic 1.5–5.0 mg/ml >5 mg/ml\\nLithium mEq/L Antimanic 0.7–2.0 mEq/L >2.0\\nNortriptyline ng/ml Antidepressant 50–150 ng/ml >500\\nPhenobarbital mg/ml Anticonvulsant 10–30 mg/ml >40\\nPhenytoin mg/ml Anticonvulsant 7–20 mg/ml >30\\nProcainamide mg/ml Antiarrhythmic 4–8 mg/ml >16\\nPropranolol ng/ml Antiarrhythmic 50–100 ng/ml >150\\nQuinidine mg/ml Antiarrhytmic 1–4 mg/ml >10\\nTheophylline mg/ml Bronchodilator 10–20 mg/ml >20\\nTobramycin mg/ml Antibiotic 4–12 mg/ml** >12\\nValproic acid mg/ml Anticonvulsant 50–100 mg/ml >100\\n* Values are laboratory-specific\\n**Concentration obtained 30 minutes after the end of a 30–minute infusion.'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 496, 'page_label': '497'}, page_content='In women who are especially sensitive to oxytocin,\\nthe drug may cause contractions to become too strong.\\nThis could tear the uterus or deprive the fetus of blood\\nand oxygen during labor.\\nOxytocin does not help improve milk flow in all\\nwomen who are breastfeeding. Check with a physician if\\nthe drug does not seem to be working.\\nWomen with heart disease, high blood pressure, or\\nkidney disease should let their physicians know about\\nthese conditions before taking oxytocin. Also, anyone\\nwho has had an unusual reaction to oxytocin in the past\\nshould inform their physician.\\nSide effects\\nOxytocin has caused irregular heartbeat and increased\\nbleeding in some women after delivery. It may also cause\\njaundice (yellowing of the eyes and skin) in newborns.\\nOther side effects are rare, but may include nausea,\\nvomiting, confusion, dizziness , convulsions, breathing\\nproblems, headache, hives, skin rash, itching, pelvic or\\nabdominal pain, and weakness. The nasal spray form\\nmay cause watery eyes or irritation of the nose.\\nInteractions\\nAnyone who takes oxytocin should let the physician\\nknow all other medicines she is taking.\\nNancy Ross-Flanigan\\nDry mouth\\nDefinition\\nDry mouth, known medically as xerostomia, is the\\nabnormal reduction of saliva due to medication, disease,\\nor medical therapy.\\nKEY TERMS\\nCesarean section—The delivery of a baby through\\na surgical procedure.\\nFetus—A developing baby inside the womb.\\nHormone —A substance that is produced in one\\npart of the body, then travels through the blood-\\nstream to another part of the body where it has its\\neffect.\\nDescription\\nDry mouth due to the lack of saliva can be a serious\\nmedical problem. Decreased salivation can make swal-\\nlowing difficult, can decrease taste sensation, and can\\npromote tooth decay.\\nCauses and symptoms\\nDry mouth, resulting from thickened or reduced\\nsalvia flow, can be caused by a number of factors: med-\\nications, both prescription and over-the-counter; sys-\\ntemic diseases, such as anemia or diabetes, manifesta-\\ntions of Sjögren’s syndrome (as rheumatoid arthritis ,\\nlupus, chronic hardening and thickening of the skin, or\\nchronic and progressive inflammation of sketal muscles);\\ninfections of the salivary glands; blockage of the salivary\\nducts caused by stones or tumors forming in the ducts\\nthrough which the saliva passes; dehydration ; medical\\ntherapies, such as local surgery or radiation; secretion\\nreduction normally involved in the aging proces; and\\nemotional stress.\\nDiagnosis\\nThe diagnosis of dry mouth is not difficult. The\\npatient will state that his or her saliva is very thick or\\nnon-existent. Finding the cause of the dry mouth may be\\nmore difficult and require some laboratory testing. Sali-\\nvary gland biopsy for stones or tumors should be per-\\nformed if indicated.\\nTreatment\\nThe treatment of dry mouth involves the manage-\\nment of the condition causing it. If dry mouth is caused\\nby medication, the medication should be changed. If dry\\nmouth is caused by blockage of the salivary ducts, the\\ncause of the blockage should be investigated. When sys-\\ntemic diseases, such as diabetes and anemia, are brought\\nunder control dry mouth problems may decrease.\\nThe use of caffeine-containing beverages, alcoholic\\nbeverages, and mouthwashes containing alcohol should\\nbe minimized. The drinking of water and fruit juices will\\ndecrease dry mouth problems. Chewing gum and lemon\\ndrops can be used to stimulate saliva flow. Bitters also\\ncan initiate salivary flow as long as the salivary glands\\nand ducts are functional. Commercial saliva substitutes\\nare available without prescription and can be used as fre-\\nquently as needed. Use of a humidifier in the bedroom\\nreduces nighttime oral dryness.\\nPrognosis\\nThe prognosis for patients with xerostomia due to\\nmedication problems is good, if the offending agent can\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1109\\nDry mouth'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 497, 'page_label': '498'}, page_content='be changed. Dry mouth due to systemic problems may be\\neliminated or improved once the disease causing the dry\\nmouth is under control. Persistent xerostomia can be\\nmanaged well with saliva substitutes.\\nPrevention\\nA patient needs to ask his or her health care\\nprovider if any medication to be prescribed will cause\\ndry mouth. Patients with persistent xerostomia need to\\npractice good oral hygiene and visit a dentist on a regu-\\nlar basis; the lack of adequate saliva can cause severe\\ndental decay. The salivary glands are very sensitive to\\nradiation, so any patient scheduled for radiation thera-\\npy of the head and neck needs to discuss with the radia-\\ntion therapist ways to minimize exposure of the salivary\\nglands to radiation.\\nResources\\nBOOKS\\nConn’s Current Therapy, 1996.Ed. Robert E. Rakel. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nEssential Otolaryngology. 6th ed. Ed. K. Lee. Norwalk, CT:\\nAppleton & Lange.\\nORGANIZATIONS\\nAmerican Dental Association. 211 E. Chicago Ave., Chicago,\\nIL 60611. (312) 440-2500. .\\nAmerican Medical Association. 515 N. State St., Chicago, IL\\n60612. (312) 464-5000. .\\nJoseph Knight, PA\\nDry skin see Ichthyosis\\nDual energy x-ray absorptiometry (DXA)\\nscan see Bone density test\\nDUB see Dysfunctional uterine bleeding\\nDuchenne muscular dystrophy see\\nMuscular dystrophy\\nDuodenal atresia see Duodenal obstruction\\nKEY TERMS\\nSalivary duct —Tube through which saliva is car-\\nried from the salivary gland to the mouth.\\nSalivary gland—Gland in which saliva forms. \\nDuodenal obstruction\\nDefinition\\nDuodenal obstruction is a failure of food to pass out of\\nthe stomach either from a complete or partial obstruction.\\nDescription\\nThe duodenum is the first part of the intestine, into\\nwhich the stomach, the gall bladder, and the pancreas\\nempty their contents. The pylorus connects the duode-\\nnum with the stomach and contains the valve that regu-\\nlates stomach emptying. Obstruction usually occurs right\\nat this outlet, so that the gall bladder and pancreas are\\nunable to drain their secretions without hindrance.\\nCauses and symptoms\\nObstruction of the duodenum occurs in adults and\\ninfants, each for a different set of reasons. In adults, the\\nusual cause is a peptic ulcer of such antiquity that repeat-\\ned cycles of injury and scarring have narrowed the pas-\\nsageway. Medical treatment of ulcers has progressed to\\nthe point where such obstinate ulcer disease is rarely\\nseen any more. In infants, the conditions are congeni-\\ntal—either the channel is underdeveloped or the pylorus\\nis overdeveloped. The first type is called duodenal\\nhypoplasia and the second is termed hypertrophic\\npyloric stenosis. In rare cases, the channel may be miss-\\ning altogether, a condition called duodenal atresia. To say\\nthat these anomalies are congenital is not to say their\\ncause is understood. As with most birth defects, the spe-\\ncific cause is not known.\\nFood that cannot exit the stomach in the forward\\ndirection will return whence it came. V omiting is the\\nconstant symptom of duodenal obstruction. It may be\\npreceded by indigestion and nausea as the stomach\\nattempts to squeeze its contents through an ever narrow-\\ning outlet.\\nHypertrophic pyloric stenosis appears soon after\\nbirth. The infant will vomit feedings, lose weight, and be\\nrestless and irritable.\\nDiagnosis\\nX rays taken with contrast material in the stomach\\nreadily demonstrate the site of the blockage and often the\\nulcer that caused it. Gastroscopy is another way to evalu-\\nate the problem. In infants, x rays may not be necessary to\\ndetect pyloric stenosis. It is often possible to feel the\\nenlarged pylorus, like an olive, deep under the ribs and see\\nthe stomach rippling as it labors to force food through.\\nGALE ENCYCLOPEDIA OF MEDICINE 21110\\nDuodenal obstruction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 498, 'page_label': '499'}, page_content='Treatment\\nBowel obstruction requires a surgeon, sometimes\\nimmediately. Newer surgical techniques constantly\\nimprove the outcome, but obstruction is a mechanical\\nproblem that needs a mechanical solution. Most adults\\nwho come to surgery for obstruction have suffered for\\nyears from peptic ulcer disease. They will usually benefit\\nfrom ulcer surgery at the same time their obstruction is\\nrelieved. The surgeon will therefore select a procedure\\nthat combines relief of obstruction with remedy for ulcer\\ndisease. There are many choices. In fact, even without\\nobstruction, functional considerations require ulcer\\nsurgery to include enhancement of stomach emptying.\\nTo treat an infant with hypertrophic pyloric stenosis,\\nsome surgeons have had success with forceful balloon\\ndilation of the pylorus done through a gastroscope, but\\nthe standard procedure is to cut across the overdeveloped\\ncircular muscle that is constricting the stomach outlet.\\nThere are reports of infant hypertrophic pyloric stenosis\\nremitting without surgery following a very careful feed-\\ning schedule, but mortality is unacceptably high.\\nPrognosis\\nA functioning and unrestricted intestine is a prereq-\\nuisite for living independent of the most advanced and\\ncontinuous medical care available. Achieving this desir-\\nable goal is the rule with surgery for duodenal obstruc-\\ntions of all types. The bowel is so malleable that there is\\na rearrangement to suit every occasion. The variety of\\npossible configurations is limited only by the surgeon’s\\nimagination.\\nPrevention\\nPrompt and effective treatment of peptic ulcers will\\nprevent chronic scarring and narrowing. Drugs devel-\\noped over the past few decades have all but eliminated\\nthe need for ulcer surgery.\\nResources\\nBOOKS\\nBarker, L. Randol, ed., et al. Principles of Ambulatory Medi-\\ncine. Baltimore: Williams & Wilkins, 1995.\\nBennett, J. Claude, and Fred Plum, eds. Cecil Textbook of Med-\\nicine. Philadelphia: W. B. Saunders Co., 1996.\\nHay, William W., ed., et al. Current Pediatric Diagnosis and\\nTreatment. Stamford: Appleton & Lange, 1997.\\nMcGuigan, James E. “Peptic Ulcer and Gastritis. In Harrison’s\\nPrinciples of Internal Medicine, ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1997.\\nMcQuaid, Kenneth R. “Alimentary Tract.” In Current Medical\\nDiagnosis and Treatment, 1996.35th ed. Ed. Stephen\\nMcPhee, et al. Stamford: Appleton & Lange, 1995.\\nKEY TERMS\\nAtresia—Failure to develop; complete absence.\\nContrast agent—A substance that produces shad-\\nows on an x ray so that hollow structures can be\\nmore easily seen.\\nGastroscopy —Looking into the stomach with a\\nflexible viewing instrument called a gastroscope.\\nHypoplasia—Incomplete development.\\nPeptic ulcer—A wound in the lower stomach and\\nduodenum caused by stomach acid and a newly\\ndiscovered germ called Helicobacter pylori.\\n“Pyloric Stenosis and Other Congenital Abnormalities of the\\nStomach.” In Nelson Textbook of Pediatrics, ed. Richard\\nE. Behrman. Philadelphia: W. B. Saunders Co., 1996.\\nRedel, Carol A., and R. Jeff Zeiwner. “Anatomy and Anomalies\\nof the Stomach and Duodenum.” In Sleisenger & Ford-\\ntran’s Gastrointestinal and Liver Disease, ed. Mark Feld-\\nman, et al. Philadelphia: W. B. Saunders Co., 1997.\\nWyllie, Robert. “Intestinal Atresia, Stenosis and Malrotation.”\\nIn Nelson Textbook of Pediatrics, ed. Richard E. Behrman.\\nPhiladelphia: W. B. Saunders Co., 1996.\\nJ. Ricker Polsdorfer, MD\\nDuodenal stenosis see Duodenal\\nobstruction\\nDuodenal ulcers see Ulcers (digestive)\\nDuodenum x rays see Hypotonic\\nduodenography\\nDuplicated ureter see Congenital ureter\\nanomalies\\nDwarfism see Achondroplasia; Pituitary\\ndwarfism\\nDysfunctional uterine\\nbleeding\\nDefinition\\nDysfunctional uterine bleeding is irregular, abnor-\\nmal uterine bleeding that is not caused by a tumor, infec-\\ntion, or pregnancy.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1111\\nDysfunctional uterine bleeding'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 499, 'page_label': '500'}, page_content='Description\\nDysfunctional uterine bleeding (DUB) is a disorder\\nthat occurs most frequently in women at the beginning\\nand end of their reproductive lives. About half the cases\\noccur in women over 45 years of age, and about one fifth\\noccur in women under age 20.\\nDysfunctional uterine bleeding is diagnosed when\\nother causes of uterine bleeding have been eliminated.\\nFailure of the ovary to release an egg during the menstru-\\nal cycle occurs in about 70% of women with DUB. This\\nis probably related to a hormonal imbalance.\\nDUB is common in women who have polycystic\\novary syndrome (cysts on the ovaries). Women who are\\non dialysis may also have heavy or prolonged periods. So\\ndo some women who use an intrauterine device ( IUD)\\nfor birth control.\\nDUB is similar to several other types of uterine bleed-\\ning disorders and sometimes overlaps these conditions.\\nMenorrhagia\\nMenorrhagia, sometimes called hypermenorrhea, is\\nanother term for abnormally long, heavy periods. This\\ntype of period can be a symptom of DUB, or many other\\ndiseases or disorders. In menorrhagia, menstrual periods\\noccur regularly, but last more than seven days, and blood\\nloss exceeds 3 oz (88.7 ml). Passing blood clots is com-\\nmon. Between 15–20% of healthy women experience\\ndebilitating menorrhagia that interferes with their normal\\nactivities. Menorrhagia may or may not signify a serious\\nunderlying problem.\\nMetrorrhagia\\nMetrorrhagia is bleeding between menstrual periods.\\nBleeding is heavy and irregular as opposed to ovulatory\\nspotting which is light bleeding, in mid-cycle, at the time\\nof ovulation.\\nPolymenorrhea\\nPolymenorrhea describes the condition of having\\ntoo frequent periods. Periods occur more often than\\nevery 21 days, and ovulation usually does not occur dur-\\ning the cycle.\\nCauses and symptoms\\nDysfunctional uterine bleeding often occurs when\\nthe endometrium, or lining of the uterus, is stimulated to\\ngrow by the hormone estrogen. When exposure to estro-\\ngen is extended, or not balanced by the presence of prog-\\nesterone, the endometrium continues to grow until it out-\\ngrows its blood supply. Then it sloughs off, causing\\nirregular bleeding. If the bleeding is heavy enough and\\nfrequent enough, anemia can result.\\nMenorrhagia is representative of DUB. It is caused\\nby many conditions including some outside the repro-\\nductive system. Causes of menorrhagia include:\\n• adenomyosis (a benign condition characterized by\\ngrowths in the area of the uterus)\\n• imbalance between the hormones estrogen and proges-\\nterone\\n• fibroid tumors\\n• pelvic infection\\n•endometrial cancer (cancer of the inner mucous\\nmembrane of the uterus)\\n• endometrial polyps\\n•endometriosis (a condition in which endometrial or\\nendrometrial-like tissue appears outside of its normal\\nplace in the uterus)\\n• use of an intrauterine device (IUD) for contraception\\n• hypothyroidism\\n• blood clotting problems (rare)\\n• lupus erythematosus\\n• pelvic inflammatory disease\\n• steroid therapy\\n• advanced liver disease\\n• renal (kidney) disease\\n• chemotherapy (cancer treatment with chemicals)\\nTo diagnose dysfunctional uterine bleeding, many of\\nthe potential causes mentioned above must be eliminat-\\ned. When all potential causes connected with pregnancy,\\ninfection, and tumors (benign or malignant) are eliminat-\\ned, then menorrhagia is presumed to be caused by dys-\\nfunctional uterine bleeding.\\nDiagnosis\\nDiagnosis of any menstrual irregularity begins with\\nthe patient herself. The doctor will ask for a detailed\\ndescription of the problem, and take a history of how\\nlong it has existed, and any patterns the patient has\\nobserved. A woman can assist the doctor in diagnosing\\nthe cause of abnormal uterine bleeding by keeping a\\nrecord of the time, frequency, length, and quantity of\\nbleeding. She should also tell the doctor about any ill-\\nnesses, including long-standing conditions, like diabetes\\nmellitus. The doctor will also inquire about sexual activ-\\nity, use of contraceptives, current medications, and past\\nsurgical procedures.\\nGALE ENCYCLOPEDIA OF MEDICINE 21112\\nDysfunctional uterine bleeding'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 500, 'page_label': '501'}, page_content='Laboratory tests\\nAfter taking the woman’s history, the gynecologist\\nor family practitioner does a pelvic examination and Pap\\nsmear. To rule out specific causes of abnormal bleeding,\\nthe doctor may also do a pregnancy test and blood tests\\nto check the level of thyroid hormone. Based on the ini-\\ntial test results, the doctor may want to do tests to deter-\\nmine the level of other hormones that play a role in\\nreproduction. A test of blood clotting time and an adrenal\\nfunction test are also commonly done.\\nImaging\\nImaging tests are important diagnostic tools for eval-\\nuating abnormal uterine bleeding. Ultrasound examina-\\ntion of the pelvic and abdominal area is used to help\\nlocate uterine fibroids, also called uterine leiomyoma, a\\ntype of tumor. Visual examination through hysterscopy—\\nwhere a camera inside a thin tube is inserted directly into\\nthe uterus so that the doctor can see the uterine lining—is\\nalso used to assess the condition of the uterus.\\nHystersalpingography can help outline endometrial\\npolyps and fibroids and help detect endometrial cancer.\\nIn this procedure an x ray is taken after contrast media\\nhas been injected into the cervix. Magnetic resonance\\nimaging (MRI) of the pelvic region can also be used to\\nlocate fibroids and tumors.\\nInvasive procedures\\nEndometrial biopsy (the removal and examination\\nof endometrial tissue) is the most important testing proce-\\ndure. It allows the doctor to sample small areas of the uter-\\nine lining, while cervical biopsy allows the cervix to be\\nsampled. Tissues are then examined for any abnormalities.\\nDilation and curettage (D & C), once common is\\nrarely done today for diagnosis of DUB. It is done while\\nthe patient is under either general or regional anesthesia.\\nWomen over 30 are more likely to need a D & C, as part\\nof the diagnostic procedure, than younger women.\\nBecause DUB is diagnosed by eliminating other\\npossible disorders, diagnosis can take a long time and\\ninvolve many tests and procedures. Older women are\\nlikely to need more extensive tests than adolescents\\nbecause the likelihood of reproductive cancers is greater\\nin this age group, and therefore must be definitively\\neliminated before treating bleeding symptoms.\\nTreatment\\nTreatment of DUB depends on the cause of the\\nbleeding and the age of the patient. When the underlying\\ncause of the disorder is known, that disorder is treated.\\nKEY TERMS\\nDilation and curettage (D & C) —A procedure\\nperformed under anesthesia during which the\\ncervix is dilated, and tissue lining the uterus is\\nscraped out with a metal spoon-shaped instrument\\nor a suction tube. The procedure can be either\\ndiagnostic, or to remove polyps.\\nEndometrial biopsy —The removal of tissue either\\nby suction or scraping of samples of tissue from\\nthe uterus. The cervix is not dilated. The procedure\\nhas a lower rate of diagnostic accuracy than a D &\\nC, but can be done as an office procedure under\\nlocal anesthesia.\\nEndometrial cancer—Cancer of the inner mucous\\nmembrane of the uterus.\\nFibroids, or fibroid tumors —Fibroid tumors are\\nnon-cancerous (benign) growths in the uterus.\\nThey occur in 30–40% of women over age 40,\\nand do not need to be removed unless they are\\ncausing symptoms that interfere with a woman’s\\nnormal activities.\\nHypothyroidism—A disorder in which the thyroid\\ngland produces too little thyroid hormone causing\\na decrease in the rate of metabolism with associat-\\ned effects on the reproductive system.\\nLupus erythematosus —A chronic inflammatory\\ndisease in which inappropriate immune system\\nreactions cause abnormalities in the blood vessels\\nand connective tissue.\\nProgesterone —A hormone naturally secreted by\\nthe ovary, or manufactured synthetically, that\\nprepares the uterus for implantation of a fertil-\\nized egg.\\nProstaglandins —A group of chemicals that medi-\\nate, or determine the actions of other chemicals in\\nthe cell or body.\\nOtherwise the goal of treatment is to relieve the symp-\\ntoms to a degree that uterine bleeding does not interfere\\nwith a woman’s normal activities or cause anemia.\\nGenerally the first approach to controlling DUB is to\\nuse oral contraceptives that provide a balance between\\nthe hormones estrogen and progesterone. Oral contracep-\\ntives are often very effective in adolescents and young\\nwomen in their twenties. NSAIDs ( nonsteroidal anti-\\ninflammatory drugs ), like Naprosyn and Motrin, are\\nalso used to treat DUB.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1113\\nDysfunctional uterine bleeding'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 501, 'page_label': '502'}, page_content='When bleeding cannot be controlled by hormone\\ntreatment, surgery may be necessary. Dilation and curet-\\ntage sometimes relieves the symptoms of DUB. If that\\nfails, endometrial ablation removes the uterine lining, but\\npreserves a woman’s uterus. This procedure is sometimes\\nbe used instead of hysterectomy. However, as it affects\\nthe uterus, it can only be used when a woman has com-\\npleted her childbearing years. The prescription of iron is\\nalso important to decrease the risk of enemia.\\nUntil the 1980s, hysterectomy often was used to\\ntreat heavy uterine bleeding. Today hysterectomy is used\\nless frequently to treat DUB, and then only after other\\nmethods of controlling the symptoms have failed. A hys-\\nterectomy leaves a woman unable to bear children, and,\\ntherefore, is limited largely to women who are unable to,\\nor uninterested in, bearing children. Still, hysterectomy\\nis a common treatment for long-standing DUB in women\\ndone with childbearing.\\nAlternative treatment\\nAlternative practitioners concentrate on good nutri-\\ntion as a way to prevent heavy periods that are not caused\\nby uterine fibroids, endometrial polyps, endometriosis, or\\ncancer. Iron supplementation (100 mg per day) not only\\nhelps prevent anemia, but also appears to reduce menor-\\nrhagia in many women. Other recommended dietary sup-\\nplements include vitamins A and C. Vitamin C improves\\ncapillary fragility and enhances iron uptake.\\nVitamin E and bioflavonoid supplements are also\\nrecommended. Vitamin E can help reduce blood flow,\\nand bioflavonoids help strengthen the capillaries. Vita-\\nmin K is known to play a role in clotting and is helpful in\\nsituations where heavy bleeding may be due to clotting\\nabnormalities\\nBotanical medicines used to assist in treating abnor-\\nmal bleeding include spotted cranesbill (Geranium macu-\\nlatum), birthroot ( Trillium pendulum ), blue cohosh\\n(Caulophyllum thalictroides ), witch hazel ( Hamamelis\\nvirginiana), shepherd’s purse (Capsella bursa-pastoris ),\\nand yarrow ( Achillea millifolia ). These are all stiptic\\nherbs that act to tighten blood vessels and tissue. Hor-\\nmonal balance can also be addressed with herbal formula-\\ntions containing phytoestrogens and phytoprogesterone.\\nPrognosis\\nResponse to treatment for DUB is highly individual\\nand is not easy to predict. The outcome depends largely\\non the woman’s medical condition and her age. Many\\nwomen, especially adolescents, are successfully treated\\nwith hormones (usually oral contraceptives). As a last\\nresort, hysterectomy removes the source of the problem\\nby removing the uterus, but this operation is not without\\nrisk, or the possibility of complications.\\nPrevention\\nDysfunctional uterine bleeding is not a preventable\\ndisorder.\\nResources\\nBOOKS\\nDeCherney, Alan H., and Martin L. Peroll. “Complications of\\nMenstruation.” In Current Obstetric and Gynecologic\\nDiagnosis and Treatment.8th ed. Norwalk, CT: Appleton\\n& Lange, 1994.\\nMurray, Michael T., and Joseph E. Pizzorno. “Heavy Periods.”\\nIn An Encyclopedia of Natural Medicine. Rocklin, CA:\\nPrima Publishing, 1991.\\nOTHER\\n“Menorrhagia.”The wellness web .\\nTish Davidson\\nDyslexia\\nDefinition\\nDyslexia is a learning disability characterized by\\nproblems in reading, spelling, writing, speaking, or lis-\\ntening. In many cases, dyslexia appears to be inherited.\\nDescription\\nThe word dyslexia is derived from the Greek word,\\ndys (meaning poor or inadequate) and the word lexis\\n(meaning words or language).\\nThe National Institutes of Health estimates that\\nabout 15% of the United States population is affected\\nby learning disabilities, mostly with problems in lan-\\nguage and reading. The condition appears in all ages,\\nraces, and income levels. Dyslexia is not a disease, but\\ndescribes rather a different kind of mind that learns in a\\ndifferent way from other people. Many people with the\\ncondition are gifted and very productive; dyslexia is not\\nat all linked to low intelligence. In fact, intelligence has\\nnothing to do with dyslexia.\\nDyslexic children seem to have trouble learning\\nearly reading skills, problems hearing individual sounds\\nin words, analyzing whole words in parts, and blending\\nsounds into words. Letters such as “d” and “b” may be\\nconfused.\\nGALE ENCYCLOPEDIA OF MEDICINE 21114\\nDyslexia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 502, 'page_label': '503'}, page_content='When a person is dyslexic, there is often an unexpect-\\ned difference between achievement and aptitude. However,\\neach person with dyslexia has different strengths and weak-\\nnesses, although many have unusual talents in art, athletics,\\narchitecture, graphics, drama, music, or engineering. These\\nspecial talents are often in areas that require the ability to\\nintegrate sight, spatial skills, and coordination.\\nOften, a person with dyslexia has a problem translat-\\ning language into thought (such as in listening or read-\\ning), or translating thought into language (such as in\\nwriting or speaking).\\nCommon characteristics include problems with:\\n• identifying single words\\n• understanding sounds in words, sound order, or rhymes\\n• spelling\\n• transposing letters in words\\n• handwriting\\n• reading comprehension\\n• delayed spoken language\\n• confusion with directions, or right/left handedness\\n• confusion with opposites (up/down, early/late, and so on)\\n• mathematics\\nCauses and symptoms\\nThe underlying cause of dyslexia is not known,\\nalthough research suggests the condition is often inherit-\\ned. In 1999, The Centre for Reading Research in Norway\\npresented the first research to study the largest family\\nwith reading problems ever known. By studying the read-\\ning and writing abilities of close to 80 family members\\nacross four generations the researchers reported, for the\\nfirst time, that chromosome 2 can be involved in the\\ninheritability of dyslexia. When a fault occurs on this\\ngene it leads to difficulties in processing written lan-\\nguage. Previous studies have pointed out linkages of other\\npotential dyslexia genes to chromosome 1, chromosome\\n15 (DYX1 gene), and to chromosome 6 (DYX2 gene).\\nThe researchers who pinpointed the newly localized gene\\non chromosome 2 (DYX3) hope that this finding will lead\\nto earlier and more precise diagnoses of dyslexia.\\nNew research suggests a possible link with a subtle\\nvisual problem that affects the speed with which affected\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1115\\nDyslexia\\nA student with dyslexia has difficulty copying words.(Photograph by Will & Deni McIntyre, Photo Researchers, Inc. Reproduced\\nby permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 503, 'page_label': '504'}, page_content='people can read. Other experts believe that dyslexia is\\nrelated to differences in the structure and function of the\\nbrain that manifests differently in different people.\\nDiagnosis\\nAnyone who is suspected to have dyslexia should\\nhave a comprehensive evaluation, including hearing,\\nvision, and intelligence testing. The test should include\\nall areas of learning and learning processes, not just\\nreading.\\nAs further research pinpoints the genes responsible\\nfor some cases of dyslexia, there is a possibility that ear-\\nlier testing will be established to allow for timely inter-\\nventions to prevent the onset of the condition and to treat\\nit when it does occur.\\nUnfortunately, in many schools, a child is not identi-\\nfied as having dyslexia until after repeated failures.\\nTreatment\\nIf a child is diagnosed with dyslexia, the parents\\nshould find out from the school or the diagnostician\\nexactly what the problem is, and what method of teach-\\ning is recommended and why. No single method will\\nwork with every child, and experts often disagree as to\\nthe best method to use.\\nThe primary focus of treatment is aimed at helping\\nthe specific learning problem of each affected person.\\nMost often, this may include modifying teaching meth-\\nods and the educational environment, since traditional\\neducational methods will not always work with a dyslex-\\nic child.\\nPeople with dyslexia need a structured language pro-\\ngram, with direct instruction in the letter-sound system.\\nTeachers must give the rules governing written language.\\nMost experts agree that the teacher should emphasize the\\nassociation between simple phonetic units with letters or\\nletter groups, rather than an approach that stresses mem-\\norizing whole words.\\nIt is important to teach these students using all the\\nsenses: hearing, touching, writing, and speaking, provid-\\ned by an instructor who is specifically trained in a pro-\\ngram that is effective for dyslexic students.\\nKEY TERMS\\nSpatial skills—The ability to locate objects in three\\ndimensional world using sight or touch.\\nPrognosis\\nMany successful and even famous people have\\ndyslexia. How well a person with dyslexia functions in\\nlife depends on the way the disability affects that person.\\nThere is a great deal of variation among different people\\nwith dyslexia, producing different symptoms and differ-\\nent degrees of severity.\\nPrognosis is usually good if the condition is diag-\\nnosed early, and if the person has a strong self image\\nwith supportive family, friends, and teachers. It is imper-\\native for a good outcome that the person be involved in a\\ngood remedial program.\\nResources\\nBOOKS\\nDavis, Ronald D., and Eldon M. Braun. The Gift of Dyslexia:\\nWhy Some of the Smartest People Can’t Read and How\\nThey Can Learn. New York: Perigee, 1997.\\nGuyer, Barbara P., and Sally E. Shaywitz. The Pretenders:\\nGifted People Who Have Difficulty Learning.Homewood:\\nHigh Tide Press, 1997.\\nPERIODICALS\\nAmerican Academy of Pediatrics, et al. “Learning Disabilities,\\nDyslexia and Vision.”Pediatrics 90 no.1 (1992): 124-126.\\nRumsey, J. M. “The Biology of Developmental Dyslexia.”\\nJournal of the American Medical Association268 no.7\\n(Aug. 19, 1992): 912-915.\\nFagerheim, Toril, et al. “A New Gene (DYX3) for Dyslexia is\\nLocated on Chromosome 2.”Journal of Medical Genetics\\n36: (Sept. 1999): 664-669.\\nORGANIZATION\\nInternational Dyslexia Association (formerly the Orton Dyslex-\\nia Society). 8600 LaSalle Rd., Chester Bldg., Ste. 382,\\nBaltimore, MD 21286. (800) ABC-D123.\\nLearning Disabilities Association. 4156 Library Rd., Pitts-\\nburgh, PA 15234. (412) 341-1515.\\nBeth Kapes\\nDyslipidemia see Hyperlipoproteinemia\\nDysmenorrhea\\nDefinition\\nDysmenorrhea is the occurrance of painful cramps\\nduring menstruation.\\nDescription\\nMore than half of all girls and women suffer from\\ndysmenorrhea (cramps), a dull or throbbing pain that\\nGALE ENCYCLOPEDIA OF MEDICINE 21116\\nDysmenorrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 504, 'page_label': '505'}, page_content='usually centers in the lower mid-abdomen, radiating\\ntoward the lower back or thighs. Menstruating women of\\nany age can experience cramps.\\nWhile the pain may be only mild for some women,\\nothers experience severe discomfort that can significant-\\nly interfere with everyday activities for several days each\\nmonth.\\nCauses and symptoms\\nDysmenorrhea is called “primary” when there is no\\nspecific abnormality, and “secondary” when the pain is\\ncaused by an underlying gynecological problem. It is\\nbelieved that primary dysmenorrhea occurs when hor-\\nmone-like substances called “prostaglandins” produced\\nby uterine tissue trigger strong muscle contractions in the\\nuterus during menstruation. However, the level of\\nprostaglandins doesn’t seem to have anything to do with\\nhow strong a woman’s cramps are. Some women have\\nhigh levels of prostaglandins and no cramps, whereas\\nother women with low levels have severe cramps. This is\\nwhy experts assume that cramps must also be related to\\nother things (such as genetics, stress, and different body\\ntypes) in addition to prostaglandins. The first year or two of\\na girl’s periods are not usually very painful. However, once\\novulation begins, the blood levels of the prostaglandins\\nrise, leading to stronger contractions.\\nSecondary dysmenorrhea may be caused by endo-\\nmetriosis, fibroid tumors, or an infection in the pelvis.\\nThe likelihood that a woman will have cramps\\nincreases if she:\\n• has a family history of painful periods\\n• leads a stressful life\\n• doesn’t get enough exercise\\n• uses caffeine\\n• has pelvic inflammatory disease\\nSymptoms include a dull, throbbing cramping in the\\nlower abdomen that may radiate to the lower back and\\nthighs. In addition, some women may experience nausea\\nand vomiting, diarrhea, irritability, sweating, or dizzi-\\nness. Cramps usually last for two or three days at the\\nbeginning of each menstrual period. Many women often\\nnotice their painful periods disappear after they have\\ntheir first child, probably due to the stretching of the\\nopening of the uterus or because the birth improves the\\nuterine blood supply and muscle activity.\\nDiagnosis\\nA doctor should perform a thorough pelvic exam\\nand take a patient history to rule out an underlying condi-\\ntion that could cause cramps.\\nKEY TERMS\\nEndometriosis —The growth of uterine tissue out-\\nside the uterus.\\nHormone —A chemical messenger secreted by a\\ngland and released into the blood, which allows it\\nto travel to distant cells where it exerts an effect.\\nOvary—One of the two almond-shaped glands in\\nthe female body that produces the hormones\\nestrogen and progesterone.\\nOvulation —The monthly release of an egg from\\nan ovary.\\nProgesterone —The hormone produced by the\\novary after ovulation that prepares the uterine lin-\\ning for a fertilized egg.\\nUterus—The female reproductive organ that con-\\ntains and nourishes a fetus from implantation until\\nbirth.\\nTreatment\\nSecondary dysmenorrhea is controlled by treating\\nthe underlying disorder.\\nSeveral drugs can lessen or completely eliminate\\nthe pain of primary dysmenorrhea. The most popular\\nchoice are the nonsteroidal anti-inflammatory drugs\\n(NSAIDs), which prevent or decrease the formation of\\nprostaglandins. These include aspirin , ibuprofen\\n(Advil), and naproxen (Aleve). For more severe pain,\\nprescription strength ibuprofen (Motrin) is available.\\nThese drugs are usually begun at the first sign of the\\nperiod and taken for a day or two. There are many dif-\\nferent types of NSAIDs, and women may find that one\\nworks better for them than the others.\\nIf an NSAID is not available, acetaminophen\\n(Tylenol) may also help ease the pain. Heat applied to the\\npainful area may bring relief, and a warm bath twice a\\nday also may help. While birth control pills will ease the\\npain of dysmenorrhea because they lead to lower hor-\\nmone levels, they are not usually prescribed just for pain\\nmanagement unless the woman also wants to use them\\nas a birth control method. This is because these pills may\\ncarry other more significant side effects and risks.\\nNew studies of a drug patch containing glyceryl\\ntrinitrate to treat dysmenorrhea suggest that it also may\\nhelp ease pain. This drug has been used in the past to\\nease preterm contractions in pregnant women.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1117\\nDysmenorrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 505, 'page_label': '506'}, page_content='Alternative treatment\\nSimply changing the position of the body can help\\nease cramps. The simplest technique is assuming the\\nfetal position, with knees pulled up to the chest while\\nhugging a heating pad or pillow to the abdomen. Like-\\nwise, several yoga positions are popular ways to ease\\nmenstrual pain. In the “cat stretch,” position, the woman\\nrests on her hands and knees, slowly arching the back.\\nThe pelvic tilt is another popular yoga position, in which\\nthe woman lies with knees bent, and then lifts the pelvis\\nand buttocks.\\nDietary recommendations to ease cramps include\\nincreasing fiber, calcium, and complex carbohydrates,\\ncutting fat, red meat, dairy products, caffeine, salt, and\\nsugar. Smoking also has been found to worsen cramps.\\nRecent research suggests that vitamin B supplements,\\nprimarily vitamin B\\n6 in a complex, magnesium, and fish\\noil supplements (omega-3 fatty acids) also may help\\nrelieve cramps.\\nOther women find relief through visualization, con-\\ncentrating on the pain as a particular color and gaining\\ncontrol of the sensations. Aromatherapy and massage\\nmay ease pain for some women. Others find that imagin-\\ning a white light hovering over the painful area can actu-\\nally lessen the pain for brief periods.\\nExercise may be a way to reduce the pain of men-\\nstrual cramps through the brain’s production of endor-\\nphins, the body’s own painkillers. And orgasm can make\\na woman feel more comfortable by releasing tension in\\nthe pelvic muscles.\\nAcupuncture and Chinese herbs are another popu-\\nlar alternative treatments for cramps.\\nPrognosis\\nMedication should lessen or eliminate pain.\\nPrevention\\nNSAIDs taken a day before the period begins should\\neliminate cramps for some women.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie Eisenstat, and Terra Ziporyn. The\\nHarvard Guide to Women’s Health.Cambridge, MA: Har-\\nvard University Press, 1996.\\nPERIODICALS\\nHale, Ellen. “Taming Menstrual Cramps.”FDA Consumer 25,\\nno. 5 (June 1991): 26-29.\\nHarel, Z., et al. “Supplementation with Omega-3 Polyunsatu-\\nrated Fatty Acids in the Management of Dysmenorrhea in\\nAdolescents.” American Journal of Obstetrics and Gyne-\\ncology 174 (Apr. 1996): 335-8.\\nMcDonald, Claire, and Susan McDonald. “A Woman’s Guide\\nto Self-care.”Natural Health (Jan. Feb. 1998): 121-142.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th Street, S.W., PO Box 96920\\nFederation of Feminist Women’s Health Centers.1469 Hum-\\nboldt Rd, Suite 200, Chico, CA 96928. (530) 891-1911.\\nNational Women’s Health Network. 514 10th St. NW, Suite\\n400, Washington, DC 20004. (202) 628-7814. .\\nCarol A. Turkington\\nDysmetria see Movement disorders\\nDyspepsia\\nDefinition\\nDyspepsia can be defined as painful, difficult, or dis-\\nturbed digestion, which may be accompanied by symp-\\ntoms such as nausea and vomiting , heartburn , bloat-\\ning, and stomach discomfort.\\nCauses and symptoms\\nThe digestive problems may have an identifiable\\ncause, such as bacterial or viral infection, peptic ulcer,\\ngallbladder, or liver disease. The bacteria Helicobacter\\npylori is often found in those individuals suffering from\\nduodenal or gastric ulcers. Investigation of recurrent\\nindigestion should rule out these possible causes.\\nOften, there is no organic cause for the problem, in\\nwhich case dyspepsia is classified as functional or nonul-\\ncer dyspepsia. There is evidence that functional dyspepsia\\nmay be related to abnormal motility of the upper gastroin-\\ntestinal tract (a state known as dysmotility in which the\\nesophagus, stomach, and upper intestine behave abnor-\\nmally). These patients may respond to a group of drugs\\ncalled prokinate agents. A review of eating habits (e.g.\\nchewing with the mouth open, gulping food, or talking\\nwhile chewing) may reveal a tendency to swallow air. This\\nmay contribute to feeling bloated, or to excessive belching.\\nSmoking, caffeine, alcohol, or carbonated beverages may\\ncontribute to the discomfort. When there is sensitivity or\\nallergy to certain food substances, eating those foods may\\ncause gastrointestinal distress. Some medications are asso-\\nciated with indigestion. Stomach problems may also be a\\nresponse to stress or emotional unrest.\\nGALE ENCYCLOPEDIA OF MEDICINE 21118\\nDyspepsia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 506, 'page_label': '507'}, page_content='Diagnosis\\nA physical examination by a health care profes-\\nsional may reveal mid-abdominal pain. A rectal exami-\\nnation may be done to rule out bleeding. If blood is\\nfound on rectal exam, laboratory studies, including a\\nblood count may be ordered. Endoscopy and barium\\nstudies may be used to rule out underlying gastrointesti-\\nnal disease. Upper gastrointestinal x-ray studies using\\nbarium may allow for visualization of abnormalities.\\nEndoscopy permits collection of tissue and culture speci-\\nmens which may be used to further confirm a diagnosis.\\nTreatment\\nThe treatment of dyspepsia is based on assessment\\nof symptoms and suspected causative factors. Clinical\\nevaluation is aimed at distinguishing those patients who\\nrequire immediate diagnostic work-ups from those who\\ncan safely benefit from more conservative initial treat-\\nment. Some of the latter may require only reassurance,\\ndietary modifications, or antacid use. Medications to\\nblock production of stomach acids, prokinate agents, or\\nantibiotic treatment may be considered. Further diagnos-\\ntic investigation is indicated if there is severe abdominal\\npain, pain radiating to the back, unexplained weight loss,\\ndifficulty swallowing, a palpable mass, or anemia. Addi-\\ntional work-up is also indicated if a patient does not\\nrespond to prescribed medications.\\nPrognosis\\nStatistics show an average of 20% of patients with\\ndyspepsia have duodenalor gastric ulcer disease, 20%\\nKEY TERMS\\nAnemia—Diagnosed through laboratory study of\\nthe blood, a deficiency in hemoglobin or red\\nblood cells, often associated with paleness or loss\\nof energy.\\nEndoscopy—A diagnostic procedure using a light-\\ned instrument to examine a body cavity or internal\\norgan. Endoscopy permits collection of tissue and\\nculture specimens.\\nhave irritable bowel syndrome , fewer than 1% of\\npatients had cancer, and the range for functional, or non-\\nulcer dyspepsia ( gastritis or superficial erosions), was\\nfrom 5–40%.\\nResources\\nBOOKS\\nSuddarth, Doris. The Lippincott Manual of Nursing Practice.\\nPhiladelphia: J. B. Lippincott, 1991.\\nPERIODICALS\\nGoldfinger, S. E. “Sensitive Stomachs: Non-ulcer Dyspepsia.”\\nHarvard Health Letter (Jan. 1992): 4-5.\\nTalley, N. J. “Non-ulcer Dyspepsia: Current Approaches to\\nDiagnosis and Management.”American Family Physician\\n(May 1993): 1407-1416.\\nOTHER\\n“Clinical Economics: Gastrointestinal Disease in Primary\\nCare.” 23 Apr. 1998 .\\n“Endoscopy for Dyspepsia.” 4 Apr. 1998 .\\nGraber, Mark A., and Rhea Allen. University of Iowa Family\\nPractice Handbook. 23 Apr. 1998 .\\nKathleen D. Wright, RN\\nDysphasia see Aphasia\\nDyspnea see Shortness of breath\\nDysthymic disorder see Depressive\\ndisorders\\nDystonia see Movement disorders\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1119\\nDyspepsia\\nA false-color gamma scan of a human stomach with dys-\\npepsia, or indigestion, during tests to study its rate of emp-\\ntying. (Photograph by Jean-Perrin, Custom Medical Stock\\nPhoto. Reproduced by permission.)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 507, 'page_label': '508'}, page_content='E. coli see Escherichia coli\\nE. coli infection see Enterobacterial\\ninfections\\nE. coli O157:H7 infection see Escherichia\\ncoli\\nEar canal infection see Otitis externa\\nEar exam with an otoscope\\nDefinition\\nAn otoscope is a hand-held instrument with a tiny\\nlight and a cone-shaped attachment called an ear specu-\\nlum, which is used to examine the ear canal. An ear\\nexamination is a normal part of most physical examina-\\ntions by a doctor or nurse. It is also done when an ear\\ninfection or other type of ear problem is suspected.\\nPurpose\\nAn otoscope is used to look into the ear canal to see\\nthe ear drum. Redness or fluid in the eardrum can indi-\\ncate an ear infection. Some otoscopes can deliver a small\\npuff of air to the eardrum to see if the eardrum will\\nvibrate (which is normal). This type of ear examination\\nwith an otoscope can also detect a build up of wax in the\\near canal, or a rupture or puncture of the eardrum.\\nPrecautions\\nNo special precautions are required. However, if an\\near infection is present, an ear examination may cause\\nsome discomfort or pain.\\nDescription\\nAn ear examination with an otoscope is usually done\\nby a doctor or a nurse as part of a complete physical\\nexamination . The ears may also be examined if an ear\\ninfection is suspected due to fever, ear pain, or hearing\\nloss. The patient will often be asked to tip the head\\nslightly toward the shoulder so the ear to be examined is\\npointing up. The doctor or nurse may hold the ear lobe as\\nthe speculum is inserted into the ear, and may adjust the\\nposition of the otoscope to get a better view of the ear\\ncanal and eardrum. Both ears are usually examined, even\\nif there seems to be a problem with just one ear.\\nPreparation\\nNo special preparation is required prior to an ear\\nexamination with an otoscope. The ear speculum, which\\nis inserted into the ear, is cleaned and sanitized before it\\nis used. The speculums come in various sizes, and the\\ndoctor or nurse will select the size that will be most com-\\nfortable for the patient’s ear.\\nAftercare\\nIf an ear infection is diagnosed, the patient may\\nrequire treatment with antibiotics. If there is a buildup of\\nwax in the ear canal, it might be rinsed or scraped out.\\nRisks\\nThis type of ear examination is simple and generally\\nharmless. Caution should always be used any time an\\nobject is inserted into the ear. This process could irritate\\nan infected external ear canal and could rupture an\\neardrum if performed improperly or if the patient moves.\\nNormal results\\nThe ear canal is normally skin-colored and is cov-\\nered with tiny hairs. It is normal for the ear canal to have\\nsome yellowish-brown earwax. The eardrum is typically\\nthin, shiny, and pearly-white to light gray in color. The\\ntiny bones in the middle ear can be seen pushing on the\\nE\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1121\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1121'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 508, 'page_label': '509'}, page_content='eardrum membrane like tent poles. The light from the\\notoscope will reflect off of the surface of the ear drum.\\nAbnormal results\\nAn ear infection will cause the eardrum to look red\\nand swollen. In cases where the eardrum has ruptured,\\nthere may be fluid draining from the middle ear. A doctor\\nmay also see scarring, retraction of the eardrum, or\\nbulging of the eardrum.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Otolaryngology-Head and Neck\\nSurgery, Inc. One Prince St., Alexandria V A 22314-3357.\\n(703) 836-4444. .\\nEar Foundation. 1817 Patterson St., Nashville, TN 37203.\\n(800) 545-4327. .\\nHearing Health Information. 2100 W. 3rd St., Los Angeles, CA\\n90057. (213) 483-4431.\\nNational Institute on Deafness and Other Communication Dis-\\norders. National Institutes of Health, 31 Center Drive,\\nMSC 2320, Bethesda, MD USA 20892-2320. (800) 241-\\n1044. .\\nOTHER\\n“Ear Test.”HealthAnswers.com..\\nAltha Roberts Edgren\\nEar surgery\\nDefinition\\nEar surgery is the treatment of diseases, injuries, or\\ndeformations of the ear by operation with instruments.\\nPurpose\\nEar surgery is performed to correct certain types of\\nhearing loss , and to treat diseases of, injuries to, or\\nKEY TERMS\\nEar speculum —A cone- or funnel-shaped attach-\\nment for an otoscope which is inserted into the ear\\ncanal to examine the eardrum.\\nOtoscope —A hand-held instrument with a tiny\\nlight and a funnel-shaped attachment called an\\near speculum, which is used to examine the ear\\ncanal and eardrum.\\ndeformities of the ear’s auditory tube, middle ear, inner\\near, and auditory and vestibular systems. Ear surgery is\\ncommonly performed to treat conductive hearing loss,\\npersistent ear infections, unhealed perforated eardrums,\\ncongenital ear defects, and tumors.\\nEar surgery is performed on children and adults. In\\nsome cases, surgery is the only treatment; in others, it is\\nused only when more conservative medical treatment fails.\\nPrecautions\\nThe precautions vary, depending on the type ofear\\nsurgery under consideration. For example, stapedecto-\\nmy (removal of parts of the middle ear and insertion of\\nprosthesis parts) should not be performed on people with\\nexternal or middle ear infection or inner ear disease. For\\npeople with complete hearing loss in the other ear, it\\nshould be performed cautiously. Microsurgery for the\\nremoval of a cholesteatoma (a cyst-like mass of cells in\\nthe middle ear) should not be performed on patients who\\nare extremely ill or have other medical conditions. Tym-\\npanoplasty (any surgical procedure on the eardrum or\\nmiddle ear) should not be performed on patients with\\nchronic sinus or nasal problems or in some patients with\\nmedical problems such as poorly controlled diabetes and\\nheart disease. Surgery for congenital microtia and atresia\\n(abscense of normal bodily openings, such as the outer\\near canal) should not be performed if the middle ear\\nspace is totally or almost totally absent.\\nDescription\\nMost ear surgery is microsurgery, performed with an\\noperating microscope to enable the surgeon to view the\\nvery small structures of the ear. The use of minimally\\ninvasive laser surgery for middle ear procedures is\\ngrowing. Laser surgery reduces the amount of trauma\\ndue to vibration, enhances coagulation, and enables sur-\\ngeons to access hard to reach places in the middle ear.\\nLaser surgery can be performed in an office operating\\nsuite. Types of ear surgery include stapedectomy, tym-\\npanoplasty, myringotomy and ear tube surgery, ear\\nsurgery to repair a perforated eardrum , cochlear\\nimplants, and tumor removal.\\nStapedectomy\\nTo restore hearing loss, which is usually due to oto-\\nsclerosis, stapedectomy is performed. Stapedectomy is\\nthe removal of all or part of the stapes, one of the bones in\\nthe middle ear, and replacement with a tiny prosthesis. An\\nincision is made in the middle ear, the small bones are\\nidentified, and the stapes is removed. The stainless steel\\nwire and cellulose sponge prosthesis is inserted, blood\\nGALE ENCYCLOPEDIA OF MEDICINE 21122\\nEar surgery\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1122'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 509, 'page_label': '510'}, page_content='and fluid are drained, and the wound is closed. Performed\\nin a hospital or outpatient surgical facility under local or\\ngeneral anesthetic, full recovery takes about three weeks\\nbut hearing should improve immediately.\\nTympanoplasty\\nTympanoplasty is performed to reconstruct the\\neardrum after partial or total conductive hearing loss,\\nusually caused by chronic middle ear infections, or per-\\nforations that do not heal. This is usually a same day\\nsurgery, performed under either local or general anesthe-\\nsia. After making an incision in the ear to view the perfo-\\nration, the ear drum is elevated away from the ear canal\\nand lifted forward. If the bones of hearing (ossicular\\nchain) are functioning, tissue is taken from the ear and\\ngrafted to the eardrum to close the perforation. A thin\\nsheet of silastic and Gelfoam hold the graft in place. The\\near is stitched together, and a sterile patch is placed on\\nthe outside of the ear canal. Tympanoplasty is successful\\nin over 90% of all cases. The need for ossicular recon-\\nstruction (reconstruction of tiny bones of the middle ear)\\nis sometimes known before surgery and and even when\\nidentified during surgery, can usually be done while\\nreconstructing the eardrum. If the gap between the anvil\\nbone and the stapes is small, a small piece of bone or car-\\ntilage from the patient can be inserted; if is is large, the\\nincus bone is removed, modelled into a prosthesis, and\\nreinserted between the stapes and the malleus. Recon-\\nstruction could also be achieved by inserting a strut made\\nfrom artificial bone. For tympanoplasty with ossicular\\nreconstruction, the patient usually stays in the hospital\\novernight. The recovery period is about four weeks.\\nMyringotomy and ear tube surgery\\nMyringotomy and ear tube surgery is performed to\\ndrain ear fluid and prevent ear infections when antibi-\\notics don’t work or when ear infections are chronic. The\\nprocess normalizes pressure in the middle ear and\\ndecreases fluid accumulation. It is most commonly per-\\nformed on infants and children, in whom ear infections\\nare most frequent, and may be done on one or both ears.\\nThe surgeon makes a small hole in the ear drum, then\\nuses suction to remove fluid. A small ear tube of metal or\\nplastic is inserted into the ear drum to allow continual\\ndrainage. The tube prevents infections as long as it stays\\nin place, which varies from six months to three years.\\nWhen the tube falls out, the hole grows over. As many of\\n25% of children under the age of two who need ear tubes\\nmay need them again. Myringotomy and ear tube surgery\\nis performed in a hospital, using a general anesthetic for\\nmost children and a local anesthetic for older children or\\nadults. No anesthetic may be used for infants. The proce-\\ndure usually takes about two hours. Most patients can go\\nhome the same day; children under three years of age and\\nthose with chronic diseases usually stay overnight.\\nEar surgery for a perforated eardrum\\nEar surgery for a perforated eardrum is only per-\\nformed in rare cases where it does not heal on its own. In\\nmost cases, this is performed in a surgeon’s office using a\\ntopical anesthetic. The surgeon scratches the undersur-\\nface of the eardrum, stimulating the skin to heal and the\\neardrum to close. A thin patch placed on the eardrum’s\\nouter surface allows the skin under the eardrum to heal.\\nCochlear implants\\nCochlear implants stimulate nerve ends within the\\ninner ear, enabling deaf children to hear. The device has a\\nmicrophone that remains outside the ear, a processor that\\nselects and codes speech sounds, and a receiver/stimulator\\nto convert the coded sounds to electric signals that stimulate\\nthe hearing nerve and are recognized by the brain as sound.\\nDuring surgery, an incision is made behind and slightly\\nabove the ear. A circular hole is drilled in the bone to receive\\nthe device’s internal coil. The mastoid bone leading to the\\nmiddle ear is opened to receive the electrodes. The internal\\ncoil is inserted and secured, followed by the electrodes. The\\nwound is stitched up and when it heals, an external unit\\ncomprised of a stimulator with a microphone is worn\\nbehind the ear. Performed in a hospital under general anes-\\nthesia, the operation takes about two hours and usually\\nrequires a hospital stay overnight. The patient can resume\\nnormal activities in two to three weeks.\\nEar surgery for tumors\\nSome ear tumors can be very serious and should be\\nremoved surgically. For a tumor on the skin of the ear\\ncanal, the skin is removed surgically, the bone beneath it\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1123\\nEar surgery\\nMicrosurgery being performed in the inner ear.(Photograph\\nby Hans Halberstadt, Photo Researchers, Inc. Reproduced by\\npermission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1123'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 510, 'page_label': '511'}, page_content='is drilled away, and a skin graft is placed in the ear canal.\\nIf the tumor is near the eardrum, the skin of the ear canal\\nand the eardrum are removed along with the bone sur-\\nrounding the ear canal. A skin graft is placed on the bare\\nbone. For basal cell cancers and low grade glandular\\nmalignancies, surgical resection of the ear canal is ade-\\nquate. Squamous cell carcinoma, a serious form of can-\\ncer, of the external ear canal requires radical surgery, fol-\\nlowed by radiation therapy . Cholesteatoma, a benign\\ntumor caused by an infection in a perforated eardrum that\\ndid not heal properly and can destroy the bones of hear-\\ning, is removed with microsurgery. Mastoidectomy is\\nperformed for mastoiditis , an inflammation of the mid-\\ndle ear, if medical therapy does not work. Petrous apicec-\\ntomy is performed to drain the petrous apicitis, the bone\\nbetween the middle ear and the clivis.\\nEar surgery for congenital ear defects\\nCongenital atresia, the absence of the external ear\\ncanal, and congenital microtia, abnormal growth of the\\nexternal ear, often occur together, although atresia can\\noccur without microtia. Surgery to reconstruct the ear\\nusually takes place when the child is four or five years old\\nand may require several operations. A facial plastic sur-\\ngeon and an ear surgeon work together, repairing the\\nmicrotia first and then the atresia. During surgery, a bony\\nopening is created over the bones of hearing. The surfaces\\nof the bony ear canal are then relined with a skin graft\\nfrom the thigh or abdomen. Tissue from behind the\\neardrum is used to create a new eardrum. In many cases,\\nthe middle ear will also need to be reconstructed. Surgery\\nis performed in a hospital under general anesthesia.\\nOther types of ear surgery\\nSurgery may also be appropriate to remove multiple\\nbony overgrowths of the ear canal or in rare cases of\\ncompromised auditory tube function, to narrow the tube.\\nKEY TERMS\\nAuditory—Relating to the sense of the organs of\\nhearing.\\nCholesteatoma—A cystic mass of cells in the mid-\\ndle ear, occurring as a congential defect or as a\\nserious complication of a disease or traumtic con-\\ndition of the ear.\\nOtologic —Relating to the study, diagnosis, and\\ntreatment of diseases of the ear and related struc-\\ntures.\\nPreparation\\nThe preparation depends upon the type of ear\\nsurgery performed. For many procedures, blood and\\nurine studies and hearing tests are conducted.\\nAftercare\\nThe type of aftercare depends upon the type of\\nsurgery performed. In most cases, the ear(s) should be\\nkept dry and warm. Non-prescription drugs such as\\nacetaminophen can be used for pain.\\nRisks\\nThe type of risk depends on the type of surgery per-\\nformed. Total hearing loss is rare.\\nResources\\nBOOKS\\n“Ear, Nose & Throat.” In Current Medical Diagnosis and\\nTreatment, 1996. 35th ed. Ed. Stephen McPhee, et al.\\nStamford: Appleton & Lange, 1995.\\nPERIODICALS\\n“Avoiding Ear Surgery.”Mothering (July/Aug. 1997): 44.\\nNissen, Alan J. “Laser Applications in Otologic Surgery.”Ear,\\nNose & Throat Journal74 (July 1995): 477.\\nSilverstein, Herbert, and Seth I. Rosenberg. Ear, Nose &\\nThroat Journal 76 (Sept. 1997): 674.\\nORGANIZATIONS\\nAmerican Academy of Otolaryngology-Head and Neck\\nSurgery, Inc. One Prince St., Alexandria V A 22314-3357.\\n(703) 836-4444. .\\nAmerican Hearing Research Foundation. 55 E. Washington St.,\\nSuite 2022, Chicago, IL 60602. (312) 726-9670. .\\nAmerican Speech-Language-Hearing Association. 10801\\nRockville Pike, Rockville, MD 20852. (800) 638-8255.\\n.\\nOTHER\\n“Ears: Entrance to the Everyday World of Hearing and Bal-\\nance.” The Ear Surgery Information Center.31 May 1998\\n.\\n“Ear Infections and Ear Tube Surgery.”KidsHealth.org. 1997.\\n31 May 1998 .\\n“Myringotomy; Ear Infection, Middle (Otitis Media); Eardrum,\\nRuptured; Staples Removal; Tympanoplasty; and\\nCochlear Implant.” ThriveOnline. 28 May 1998 .\\nLori De Milto\\nEar tubes see Myringotomy and ear tubes\\nEar wax impaction see Cerumen impaction\\nGALE ENCYCLOPEDIA OF MEDICINE 21124\\nEar surgery\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1124'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 511, 'page_label': '512'}, page_content='Eardrum perforation see Perforated eardrum\\nEastern equine encephalitis see Arbovirus\\nencephalitis\\nEating disorders see Anorexia nervosa;\\nBulimia nervosa\\nEaton agent pneumonia see Mycoplasma\\ninfections\\nEbola virus infection see Hemorrhagic fevers\\nEcchymosis see Bruises\\nECG see Electrocardiography\\nEchinacea\\nDefinition\\nEchinacea, or purple coneflower, is a perennial herb\\nof the Composite family, commonly known as the daisy\\nfamily. Most often referred to as the purple coneflower,\\nthis hardy plant also known as Sampson root, Missouri\\nsnakeroot, and rudbeckia. The prominent, bristly seed\\nhead inspired the generic name of the plant, taken from\\nthe Greek word echinos meaning hedgehog.\\nDescription\\nEchinacea is a North American prairie native, abun-\\ndant in the Midwest, and cultivated widely in ornamental\\nand medicinal gardens. The purple-pink rays of the blos-\\nsom droop downward from a brassy hued center cone\\ncomposed of many small, tubular florets. The conspicu-\\nous flowers bloom singly on stout, prickly stems from\\nmid-summer to autumn. Flower heads may grow to 4 in\\n(10.16 cm) across. The dark green leaves are opposite,\\nentire, lanceolate, toothed, and hairy with three promi-\\nnent veins. The narrow upper leaves are attached to the\\nstem with stalks. The lower leaves are longer, emerging\\nfrom the stem without a leaf stalk, and growing to 8 in\\n(20.32 cm) in length. The plant develops deep, slender,\\nblack roots. Echinacea propagates easily from seed or by\\nroot cuttings. However, due to its increasing popularity\\nas an herbal supplement, echinacea is numbered among\\nthe 19 medicinal plants considered at risk by the Vermont\\nnonprofit organization, United Plant Savers.\\nPurpose\\nThree species of echinacea are useful medicinally:\\nEchinacea augustifolia, Echinacea purpurea , and Echi-\\nnacea pallida . The entire plant has numerous medicinal\\nproperties that act synergistically to good effect. Echi-\\nnacea is most often used to boost the immune system and\\nfight infection. Research has shown that echinacea\\nincreases production of interferon in the body. It is anti-\\nseptic and antimicrobial, with properties that act to\\nincrease the number of white blood cells available to\\ndestroy bacteria and slow the spread of infection. As a\\ndepurative, the herbal extract cleanses and purifies the\\nbloodstream, and has been used effectively to treat boils.\\nEchinacea is vulnerary, promoting wound healing through\\nthe action of a chemical substance in the root known as\\ncaffeic acid glycoside. As an alterative and an immuno-\\nmodulator, echinacea acts gradually to promote beneficial\\nchange in the entire system. It has also been used to treat\\nurinary infection and Candida albicans infections. Echi-\\nnacea is a febrifuge, useful in reducing fevers. It is also\\nuseful in the treatment of hemorrhoids. A tincture, or a\\nstrong decoction of echinacea serves as an effective\\nmouthwash for the treatment of pyorrhea and gingivitis.\\nNative American plains Indians relied on echinacea\\nas an all-purpose antiseptic. The Sioux tribe valued the\\nroot as a remedy for snake bite, the Cheyenne tribe\\nchewed the root to quench thirst, and another tribe\\nwashed their hands in a decoction of echinacea to\\nincrease their tolerance of heat. European settlers learned\\nof the North American herb’s many uses, and soon\\nnumerous echinacea-based remedies were commercially\\navailable from pharmaceutical companies in the United\\nStates. Echinacea was a popular remedy in the United\\nStates through the 1930s. It was among many medicinal\\nherbs listed in the U.S. Pharmacopoeia, the official Unit-\\ned States government listing of pharmaceutical raw\\nmaterials and recipes. The herb fell out of popular use in\\nthe United States with the availability of antibiotics . In\\nWest Germany, over 200 preparations are made from the\\nspecies E. purpurea. Commercially prepared salves, tinc-\\ntures, teas, and extracts are marketed using standardized\\nextracts. Echinacea is regaining its status in the United\\nStates as a household medicine-chest staple in many\\nhomes. It is one of the best-selling herbal supplements in\\nUnited States health food stores.\\nClinical studies have found that the entire plant pos-\\nsesses medicinal properties with varying levels of effec-\\ntiveness. Echinacea is of particular benefit in the treatment\\nof upper respiratory tract infections. Some research has\\nshown that echinacea activates the macrophages that\\ndestroy cancer cells and pathogens. When taken after can-\\ncer treatments, an extract of the root has been found to\\nincrease the body’s production of white blood cells. Echi-\\nnacea has been shown to be most effective when taken at\\nthe first sign of illness, rather than when used as a daily\\npreventative. Other research has demonstrated the signifi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1125\\nEchinacea\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1125'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 512, 'page_label': '513'}, page_content='cant effect of E. purpurea root on reducing the duration\\nand severity of colds and flu. Some herbal references list\\nonly the root as the medicinal part, others include the aeri-\\nal parts of the plant, particularly the leaf. But research\\nstudies in Europe and the United States have concluded\\nthat the entire plant is medicinally effective. Most research\\nhas been done on the species E. pallida and E. purpurea.\\nAll three species of echinacea are rich in vitamins and\\nminerals. Echinacea is an herbal source of niacin, chromi-\\num, iron, manganese, selenium, silicon, and zinc.\\nPreparations\\nThe quality of any herbal supplement depends great-\\nly on the conditions of weather and soil where the herb\\nwas grown, the timing and care in harvesting, and the\\nmanner of preparation and storage.\\nDecoction is the best method to extract the mineral\\nsalts and other healing components from the coarser herb\\nmaterials, such as the root, bark, and stems. It is prepared\\nby adding 1 oz (28.4 g) of the dried plant materials, or 2\\noz (56.7 g) of fresh plant parts, to 1 pt (0.47 l) of pure,\\nunchlorinated, boiled water in a non-metallic pot. Sim-\\nmer for about one half hour. Strain and cover. A decoc-\\ntion may be refrigerated for up to two days and retain its\\nhealing qualities.\\nAn infusion is the method used to derive benefits\\nfrom the leaves, flowers, and stems in the form of an\\nherbal tea. Use twice as much fresh, chopped herb as\\nKEY TERMS\\nAlterative—A medicinal substance that acts grad-\\nually to nourish and improve the system.\\nAntimicrobial —A plant substance that acts to\\ninhibit the growth of harmful microorganisms, or\\nacts to destroy them.\\nFebrifuge—A plant substance that acts to prevent\\nor reduce fever.\\nGlycoside —An herbal carbohydrate that exerts\\npowerful effect on hormone-producing tissues.\\nThe glycoside breaks down into a sugar and a\\nnon-sugar component.\\nLanceolate —Narrow, leaf shape that is longer\\nthan it is wide, and pointed at the end.\\nMacrophage—Specialized cells present throughout\\nthe lymphoid tissues of the body that circulate in the\\nbloodstream. Macrophages have a surface marker\\nthat stimulates other cells to react to an antigen.\\ndried herb. Steep in 1 pt (0.47 l) of boiled, unchlorinated\\nwater for 10–15 minutes. Strain and cover. Drink warm,\\nsweetened with honey if desired. A standard dose is three\\ncups per day. An infusion will keep for up to two days in\\nthe refrigerator and retain its healing qualities.\\nA tincture is the usual method to prepare a concen-\\ntrated form of the herbal remedy. Tinctures, properly pre-\\npared and stored, will retain medicinal potency for two\\nyears or more. Combine 4 oz (114 g) of finely cut fresh\\nor powdered dry herb with 1 pt (0.47 l) of brandy, gin, or\\nvodka in a glass container. The alcohol should be enough\\nto cover the plant parts and have a 50/50 ratio of alcohol\\nto water. Place the mixture away from light for about two\\nweeks, shaking several times each day. Strain and store\\nin a tightly capped, dark glass bottle. A standard dose is\\n0.14 oz (4 ml ) of the tincture three times a day.\\nPrecautions\\nEchinacea is considered safe in recommended doses.\\nPregnant or lactating women, however, are advised not to\\ntake echinacea in injection form. Because the plant has\\nproven immuno-modulating properties, individuals with\\nsystemic lupus erythmatosus, rheumatoid arthritis ,\\ntuberculosis , leukemia, multiple sclerosis , or AIDS\\nshould consult their physician before using echinacea.\\nEchinacea should not be given to children under two\\nyears of age, and it should only be given to children over\\ntwo in consultation with a physician. Research indicates\\nthat echinacea is most effective when taken at first onset\\nof symptoms of cold or flu, and when usage is continued\\nno longer than eight weeks. There is some indication that\\nthe herb loses its effectiveness when used over a long\\nperiod of time. It is necessary to interrupt use for a mini-\\nmum of several weeks in order to give the body’s\\nimmune system the opportunity to rest and adjust.\\nSide effects\\nNo side effects are reported with oral administration\\nof echinacea, either in tincture, capsule, or as a tea, when\\ntaken according to recommended doses. Chills, fever,\\nand allergic reactions have been reported in some\\nresearch studies using an injection of the plant extract.\\nInteractions\\nNone reported. When used in combination with\\nother herbs, dosage should be lowered.\\nResources\\nBOOKS\\nFoster, Steven, and James A. Duke. A Field Guide to Medicinal\\nPlants. New York: The Peterson Field Guide Series,\\nHoughton Mifflin Company, 1990.\\nGALE ENCYCLOPEDIA OF MEDICINE 21126\\nEchinacea\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1126'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 513, 'page_label': '514'}, page_content='Hoffmann, David. The New Holistic Herbal. Massachusetts:\\nElement Books Inc., 1986.\\nKowalchik, Claire, and William H. Hylton, eds. Rodale’s Illus-\\ntrated Encyclopedia of Herbs. Pennsylvania: Rodale Press\\nInc., 1987.\\nMcIntyre, Anne. The Medicinal Garden. Henry Holt and Com-\\npany Inc., 1997.\\nOfficial Proceedings. Medicines from the Earth, Protocols for\\nBotanical Healing. Massachusetts: Gaia Herbal Research\\nInstitute, 1996.\\nOndra, Nancy, ed. “200 Herbal Remedies.” In The Complete\\nBook of Natural & Medicinal Cures.Pennsylvania:\\nRodale Press Inc., 1994.\\nWeed, Susun S. Wise Woman Ways, Menopausal Years.New\\nYork: Ash Tree Publishing, 1992.\\nPERIODICALS\\nDeneen, Sally, and Tracey C. Rembert. “Stalking Medicinal\\nPlants, An International Trade Imperils Wild Herbs.”E\\nMagazine (July/Aug. 1999).\\nOTHER\\nHerb World News Online, Research Reviews.1999. Herb\\nResearch Foundation. .\\nClare Hanrahan\\nEchinococcosis\\nDefinition\\nEchinococcosis (Hydatid disease) refers to human\\ninfection by the immature (larval) form of tapeworm,\\nEchinococcus . One of three forms of the Echinococcus\\nspp., E. granulosus , lives on dogs and livestock, and\\ninfects humans through contact with these animals. Aller-\\ngic reactions and damage to various organs from cyst for-\\nmation are the most common forms of disease in humans.\\nDescription\\nE. granulosus is found in many areas of Africa,\\nChina, South America, Australia, New Zealand, and\\nMediterranean and eastern Europe, as well as in parts of\\nthe western United States. The parasite lives in regions\\nwhere dogs and livestock cohabitate. Direct exposure to\\ninfectious dogs as well as parasitic eggs released into the\\nenvironment during shedding are both sources of human\\ninfection.\\nIn humans, cysts containing the larvae develop after\\ningestion of eggs. Cysts form primarily in the lungs and\\nliver. Cysts developing in the liver are responsible for\\nabout two-thirds of echinococcosis cases. Echinococco-\\nsis is a significant public health problem in many areas of\\nKEY TERMS\\nAllergenic —A substance capable of causing an\\nallergic reaction.\\nCholangitis—Infection or inflammation of the bile\\nducts; often causes abdominal pain, fever, and\\njaundice.\\nComputed tomography (CT) scan —A specialized\\nx-ray procedure in which cross-sections of the\\narea in question can be examined in detail.\\nCyst—A protective sac that includes either fluid or\\nthe cell of an organism. The cyst enables many\\norganisms to survive in the environment for long\\nperiods of time without need for food or water.\\nEmbryo—The very beginning stages of develop-\\nment of an organism.\\nJaundice —The yellow-greenish coloring of the\\nskin and eyes due to the presence of bile pig-\\nments. The presence of jaundice is usually, but not\\nalways, a sign of liver disease.\\nTapeworm—An intestinal parasite that attaches to\\nthe intestine or travels to other organs such as the\\nliver and lungs.\\nUltrasound —A noninvasive procedure based on\\nchanges in sound waves of a frequency that can-\\nnot be heard, but respond to changes in tissue\\ncomposition.\\nthe world, but control programs have decreased the rate\\nof infection in some regions. In Kenya alone, the num-\\nbers of persons infected each year is as high as 220 per\\n100,000 population.\\nCauses and symptoms\\nAfter ingestion, the eggs develop into embryos with-\\nin the intestines and then travel to the liver and lungs\\nthrough major blood vessels. The embryos then begin to\\nform cysts within the liver and lungs, causing damage as\\nthey enlarge over a period of five to 20 years. Cysts may\\nbecome over 8 in (20.3 cm)or more in size and contain a\\nhuge amount of highly allergenic fluid. Studies show that\\nwhile the liver is most often targeted, lungs, brain, heart,\\nand bone can also be affected.\\nThe major symptoms are due to compression dam-\\nage, blockage of vessels and ducts (such as the bile\\nducts), and leakage of fluid from cysts. The following\\nsymptoms are frequent.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1127\\nEchinococcosis\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1127'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 514, 'page_label': '515'}, page_content='• Liver involvement causes pain and eventually jaundice\\nor cholangitis due to blockage of bile ducts. Infection\\nof cysts leads to abscesses in up to 20%.\\n• Lung cysts cause cough and chest pain.\\n• Bone cysts cause fractures and damage to bone tissue.\\n• Heart involvement leads to irregularities of heart beat\\nand inflammation of the covering of the heart (peri-\\ncardium).\\n• Allergic reactions occur from leakage of cyst fluid that\\ncontains antigens. Itching , fever, and rashes are fre-\\nquent, and fatal allergic reactions ( anaphylaxis ) have\\nbeen reported. Eosinophils, which are blood cells\\ninvolved in allergic reactions, are increased in many\\npatients.\\nDiagnosis\\nX rays, computed tomography scans (CT scans),\\nand ultrasound are very helpful in detecting cysts. Some\\ncysts will develop characteristic hardening of organ tis-\\nsues from calcium deposits (calcifications). Blood tests\\nto detect antibodies are useful when positive, but up to\\n50% of patients have negative results. Examination of\\naspirated cyst fluid for parasites can be diagnostic, but\\ncarries the danger of a fatal allergic reaction. Treatment\\nwith anti-parasitic medications before aspiration is\\nreported to decrease allergic complications and decrease\\nthe risk of spread during the procedure.\\nTreatment\\nTreatment depends on the size and location of cysts,\\nas well as the symptoms they are producing. Surgical\\nremoval of cysts and/or surrounding tissue is the accept-\\ned method of treatment, but carries a risk of cyst rupture\\nwith spread or allergic reactions. Recent studies using\\nmedication alongside aspiration and drainage of cysts\\ninstead of surgery are very encouraging.\\nThe medication albenzadole can be taken before or\\nafter surgery or alone without surgery. However, its\\neffectiveness as a single treatment is still not known.\\nMultiple courses of medication are often necessary,\\nwith cure rates of only about 30%. Response to treat-\\nment is best monitored by serial CT scans or similar x-\\nray studies.\\nPrevention\\nGood hand washing, treating infected dogs, and pre-\\nventing dogs access to slaughter houses discourage\\nspread of the disease. Limiting the population of stray\\ndogs has also been helpful.\\nResources\\nBOOKS\\nChung, Raymond T., and Lawrence S. Friedman. “Echinococ-\\ncus.” In Sleisenger & Fordtran’s Gastrointestinal and\\nLiver Disease, ed. Mark Feldman, et al. Philadelphia: W.\\nB. Saunders Co., 1997.\\nNutman, Thomas B., and Peter F. Weller. “Echinococcosis.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nPERIODICALS\\nAmmann, Rudolph W., and Johannes Eckert. “Echinococcus.”\\nGastroenterology Clinics of North America(Sept. 1996):\\n655-689.\\nKhuroo, Mohammad, et al. “Percutaneous Drainage Compared\\nwith Surgery for Hepatic Hydatid Cysts.”New England\\nJournal of Medicine 337 (25 Sept. 1997): 881-87.\\nGALE ENCYCLOPEDIA OF MEDICINE 21128\\nEchinococcosis\\nSucker\\nEchinococcus granulosus\\nUterus with eggs\\nInfection with the larva of Echinococcus granulosus (shown above) is responsible for the disease echinococcosis.(Illustra-\\ntion by Electronic Illustrators Group.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1128'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 515, 'page_label': '516'}, page_content='OTHER\\n“Alveolar Hydatid Disease (Echinococcosis).”Centers for Dis-\\nease Control. 28 May 1998 .\\n“Percutaneous Drainage Compared with Surgery for Hepatic\\nHydatid Cysts.” New England Journal of Medicine\\nOnline. .\\nDavid Kaminstein, MD\\nEchinococcus granulosus infection see\\nEchinococcosis\\nEchocardiography\\nDefinition\\nEchocardiography is a diagnostic test that uses ultra-\\nsound waves to create an image of the heart muscle.\\nUltrasound waves that rebound or echo off the heart can\\nshow the size, shape, and movement of the heart’s valves\\nand chambers as well as the flow of blood through the\\nheart. Echocardiography may show such abnormalities\\nas poorly functioning heart valves or damage to the heart\\ntissue from a past heart attack.\\nPurpose\\nEchocardiography is used to diagnose certain cardio-\\nvascular diseases. In fact, it is one of the most widely used\\ndiagnostic tests for heart disease. It can provide a wealth\\nof helpful information, including the size and shape of the\\nheart, its pumping strength, and the location and extent of\\nany damage to its tissues. It is especially useful for assess-\\ning diseases of the heart valves. It not only allows doctors\\nto evaluate the heart valves, but it can detect abnormalities\\nin the pattern of blood flow, such as the backward flow of\\nblood through partly closed heart valves, known as regur-\\ngitation. By assessing the motion of the heart wall,\\nechocardiography can help detect the presence and assess\\nthe severity of coronary artery disease , as well as help\\ndetermine whether any chest pain is related to heart dis-\\nease. Echocardiography can also help detect hypertrophic\\ncardiomyopathy, in which the walls of the heart thicken\\nin an attempt to compensate for heart muscle weakness.\\nThe biggest advantage to echocardiography is that it is\\nnoninvasive (doesn’t involve breaking the skin or entering\\nbody cavities) and has no known risks or side effects.\\nPrecautions\\nEchocardiography is an extremely safe procedure\\nand no special precautions are required.\\nDescription\\nEchocardiography creates an image of the heart\\nusing ultra-high-frequency sound waves—sound waves\\nthat are too high in frequency to be heard by the human\\near. The technique is very similar to ultrasound scanning\\ncommonly used to visualize the fetus during pregnancy.\\nAn echocardiography examination generally lasts\\nbetween 15–30 minutes. The patient lies bare-chested on\\nan examination table. A special gel is spread over the\\nchest to help the transducer make good contact and slide\\nsmoothly over the skin. The transducer, a small hand-held\\ndevice at the end of a flexible cable, is placed against the\\nchest. Essentially a modified microphone, the transducer\\ndirects ultrasound waves into the chest. Some of the\\nwaves get echoed (or reflected) back to the transducer.\\nSince different tissues and blood all reflect ultrasound\\nwaves differently, these sound waves can be translated\\ninto a meaningful image of the heart, which can be dis-\\nplayed on a monitor or recorded on paper or tape. The\\npatient does not feel the sound waves, and the entire pro-\\ncedure is painless. In fact, there are no known side effects.\\nOccasionally, variations of the echocardiography\\ntest are used. For example, Doppler echocardiography\\nemploys a special microphone that allows technicians to\\nmeasure and analyze the direction and speed of blood\\nflow through blood vessels and heart valves. This makes\\nit especially useful for detecting and evaluating regurgi-\\ntation through the heart valves. By assessing the speed of\\nblood flow at different locations around an obstruction, it\\ncan also help to precisely locate the obstruction.\\nAn exercise echocardiogram is an echocardiogram\\nperformed during exercise, when the heart muscle must\\nwork harder to supply blood to the body. This allows\\ndoctors to detect heart problems that might not be evi-\\ndent when the body is at rest and needs less blood. For\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1129\\nEchocardiography\\nA patient getting an EKG. (Photo Researchers. Reproduced by\\npermission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1129'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 516, 'page_label': '517'}, page_content='patients who are unable to exercise, certain drugs can be\\nused to mimic the effects of exercise by dilating the\\nblood vessels and making the heart beat faster.\\nPreparation\\nThe patient removes any clothing and jewelry above\\nthe chest.\\nAftercare\\nNo special measures need to be taken following\\nechocardiography.\\nRisks\\nThere are no known risks associated with the use of\\nechocardiography.\\nNormal results\\nA normal echocardiogram shows a normal heart\\nstructure and the normal flow of blood through the heart\\nchambers and heart valves. However, a normal echocar-\\ndiogram does not rule out the possibility of heart disease.\\nAbnormal results\\nAn echocardiogram may show a number of abnor-\\nmalities in the structure and function of the heart, such as:\\n• thickening of the wall of the heart muscle (especially\\nthe left ventricle)\\n• abnormal motion of the heart muscle\\n• blood leaking backward through the heart valves\\n(regurgitation)\\n• decreased blood flow through a heart valve (stenosis)\\nKEY TERMS\\nNoninvasive —Pertaining to a diagnostic proce-\\ndure or treatment that does not require the skin to\\nbe broken or a body cavity to be entered.\\nRegurgitation—Backward flow of blood through a\\npartly closed heart valve.\\nTransducer—A device that converts electrical sig-\\nnals into ultrasound waves and ultrasound waves\\nback into electrical impulses.\\nUltrasound—Sound waves at a frequency of over\\n20,000 kHz, often used for diagnostic imaging.\\nResources\\nBOOKS\\nFaculty Members of the Yale University School of Medicine.\\nThe Patient’s Book of Medical Tests.Boston: Houghton\\nMifflin Co., 1997.\\nPERIODICALS\\nRose, Verna L. “American College of Cardiology and American\\nHeart Association Address the Use of Echocardiography.\\nAmerican Family Physician56 (1 Oct. 1997): 1489-90.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nRobert Scott Dinsmoor\\nEchovirus infections see Enterovirus\\ninfections\\nEclampsia see Preeclampsia and eclampsia\\nECT see Electroconvulsive therapy\\nEctopic orifice of the ureter see Congenital\\nureter anomalies\\nEctopic pregnancy\\nDefinition\\nIn an ectopic pregnancy, the fertilized egg implants in\\na location outside the uterus and tries to develop there. The\\nword ectopic means “in an abnormal place or position.” The\\nmost common site is the fallopian tube, the tube that nor-\\nmally carries eggs from the ovary to the uterus. However,\\nectopic pregnancy can also occur in the ovary, the abdomen,\\nand the cervical canal (the opening from the uterus to the\\nvaginal canal). The phrases tubal pregnancy, ovarian preg-\\nnancy, cervical pregnancy, and abdominal pregnancy refer\\nto the specific area of an ectopic pregnancy.\\nDescription\\nOnce a month, an egg is produced in a woman’s ovary\\nand travels down the fallopian tube where it meets the\\nmale’s sperm and is fertilized. In a normal pregnancy the\\nfertilized egg, or zygote, continues on its passage down the\\nfallopian tube and enters the uterus in three to five days.\\nThe zygote continues to grow, implanting itself securely in\\nthe wall of the uterus. The zygote’s cells develop into the\\nembryo (the organism in its first two months of develop-\\nGALE ENCYCLOPEDIA OF MEDICINE 21130\\nEctopic pregnancy\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1130'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 517, 'page_label': '518'}, page_content='ment) and placenta (a spongy structure that lines the uterus\\nand nourishes the developing organism).\\nIn a tubal ectopic pregnancy, the fertilized egg can-\\nnot make it all the way down the tube because of scarring\\nor obstruction. The fallopian tube is too narrow for the\\ngrowing zygote. Eventually the thin walls of the tube\\nstretch and may burst (rupture), resulting in severe bleed-\\ning and possibly the death of the mother. More than 95%\\npercent of all ectopic pregnancies occur in the fallopian\\ntube. Only 1.5% develop in the abdomen; less than 1%\\ndevelop in the ovary or the cervix.\\nCauses and symptoms\\nAs many as 50% of women with ectopic pregnancies\\nhave a history of pelvic inflammatory disease (PID).\\nThis is an infection of the fallopian tubes (salpingitis)\\nthat can spread to the uterus or ovaries. It is most com-\\nmonly caused by the organisms Gonorrhea and Chlamy-\\ndia and is usually transmitted by sexual intercourse.\\nOther conditions also increase the risk of ectopic\\npregnancy. They include:\\n• Endometriosis . A condition in which the tissue that\\nnormally lines the uterus is found outside the uterus,\\nand can block a fallopian tube.\\n• Exposure to diethylsilbestrol (DES) as a fetus. If a\\nwoman’s mother took DES (a synthetic version of the\\nhormone estrogen) during pregnancy, the woman may\\nhave abnormalities in her fallopian tubes that can make\\nectopic pregnancy more likely.\\n• Taking hormones. Estrogen and progesterone are hor-\\nmones that regulate the menstrual cycle and may be in\\nmedications prescribed by a doctor for birth control or\\nother reasons. Taking these hormones can affect the inte-\\nrior lining of the fallopian tubes and slow the movement\\nof the fertilized egg down the tube. Women who become\\npregnant in spite of taking some progesterone-only con-\\ntraceptives have a greater chance of an ectopic pregnan-\\ncy. Ectopic pregnancy is also more likely when the\\novaries are artificially stimulated with hormones to pro-\\nduce eggs for in vitro fertilization(a procedure in which\\neggs are taken from a woman’s body, fertilized, and then\\nplaced in the uterus in an attempt to conceive a child).\\n• Use of an intrauterine device ( IUD). These contracep-\\ntive devices are designed to prevent fertilized eggs from\\nbecoming implanted in the uterus, but they have only a\\nminimal effect on preventing ectopic pregnancies.\\nTherefore, if a woman becomes pregnant while using\\nan IUD for contraception , the fertilized egg is more\\nlikely to be implanted someplace other than the uterus.\\nFor example, among women who become pregnant\\nwhile using a progesterone-bearing IUD, about 15%\\nhave ectopic pregnancies.\\n• Surgery on a fallopian tube. The risk of ectopic preg-\\nnancy can be as high as 60% after undergoing elective\\ntubal sterilization, a procedure in which the fallopian\\ntubes are severed to prevent pregnancy. Women who\\nhave successful surgery to reverse the procedure are\\nalso more likely to have an ectopic pregnancy.\\nEarly symptoms\\nIn an ectopic pregnancy all the hormonal changes\\nassociated with a normal pregnancy may occur. The early\\nsymptoms include:fatigue; nausea; a missed period; breast\\ntenderness; low back pain; mild cramping on one side of\\nthe pelvis; and abnormal vaginal bleeding, usually spotting.\\nLater symptoms\\nAs the embryo grows too large for the confined\\nspace in the tube, the first sign that something is wrong\\nmay be a stabbing pain in the pelvis or abdomen. If the\\ntube has ruptured, blood may irritate the diaphragm and\\ncause shoulder pain. Other warning signs are lighthead-\\nedness and fainting.\\nDiagnosis\\nTo confirm an early diagnosis of ectopic pregnancy,\\nthe doctor must determine first that the patient is preg-\\nnant and that the location of the embryo is outside the\\nuterus. If an ectopic pregnancy is suspected, the doctor\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1131\\nEctopic pregnancy\\nOvary\\nVagina\\nUterus\\nFallopian tube\\nEmbryo\\nIn an ectopic pregnancy, the fertilized egg implants in a\\nlocation outside the uterus and attempts to develop at that\\nsite.The most common site of an ectopic pregnancy is the\\nfallopian tube, but it can occur in the ovary, the abdomen,\\nand the cervical wall. More than 95% of all ectopic pregnan-\\ncies occur in the fallopian tube. (Illustration by Electronic Illus-\\ntrators Group.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1131'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 518, 'page_label': '519'}, page_content='will perform a pelvic examination to locate the source of\\npain and to detect a mass in the abdomen.\\nSeveral laboratory tests of the patient’s blood pro-\\nvide information for diagnosis. Measurement of the\\nhuman chorionic gonadotropin (hCG) level in the\\npatient’s blood serum is the most useful laboratory test in\\nthe early stages. In a normal pregnancy, the level of this\\nhormone doubles about every two days during the first\\n10 weeks. In an ectopic pregnancy, the rate of the\\nincrease is much slower and the low hCG for the stage of\\nthe pregnancy is a strong indication that the pregnancy is\\nabnormal. (It could also represent a miscarriage in\\nprogress.) The level is usually tested several times over a\\nperiod of days to determine whether or not it is increas-\\ning at a normal rate.\\nProgesterone levels in the blood are also measured.\\nLower than expected levels can indicate that the pregnan-\\ncy is not normal.\\nAn ultrasound examination may provide information\\nabout whether or not the pregnancy is ectopic. A device\\nKEY TERMS\\nEmbryo—In humans, the developing organism\\nfrom conception until approximately the end of\\nthe second month.\\nFallopian tube—The tube that carries the egg from\\nthe ovary to the uterus.\\nHuman chorionic gonadotropin (hCG) —A hor-\\nmone excreted during the development of an\\nembryo or fetus.\\nLaparoscopy—Examination of the contents of the\\nabdominal cavity with a fiberoptic tube inserted\\nthrough a small incision.\\nLaparotomy—Surgical incision into the abdomen\\nto locate, repair, and/or remove injured or dis-\\neased tissues.\\nPelvic inflammatory disease (PID) —Acute or\\nchronic inflammation in the pelvic cavity, particu-\\nlarly inflammation of the fallopian tubes (salpingi-\\ntis) and its complications.\\nRupture—A breaking apart of an organ or tissue.\\nSalpingitis—Inflammation of the fallopian tube.\\nTubal pregnancy—Pregnancy in one of the fallopi-\\nan tubes.\\nZygote—The fertilized egg.\\ncalled a transducer, which emits high frequency sound\\nwaves, is moved over the surface of the patient’s\\nabdomen or inserted into the vagina. The sound waves\\nbounce off of the internal organs and create an image on\\na screen. The doctor should be able to see whether or not\\nthere is a fetus developing in the uterus after at least five\\nweeks of gestation. Before that point, a normal pregnan-\\ncy is too small to see.\\nA culdocentesis may also help confirm a diagnosis.\\nIn this procedure a needle is inserted into the space at the\\ntop of the vagina, behind the uterus and in front of the\\nrectum. Blood in this area may indicate bleeding from a\\nruptured fallopian tube.\\nA laparoscopy will enable the doctor to see the\\npatient’s reproductive organs and examine an ectopic\\npregnancy. In this technique, a hollow tube with a light\\non one end is inserted through a small incision in the\\nabdomen. Through this instrument the internal organs\\ncan be observed.\\nTreatment\\nEctopic pregnancy requires immediate treatment.\\nThe earlier the condition is treated, the better the chance\\nto preserve the fallopian tube intact for future normal\\npregnancies.\\nMedical\\nIf the ectopic pregnancy is discovered in a very early\\nstage of development, the drug methotrexate may be\\ngiven. The best results are obtained when the pregnancy\\nis less than six weeks old and the tubal mass is no more\\nthan 1.4 in (3.5 cm) in diameter. Methotrexate, which has\\nbeen used successfully since 1987, works by inhibiting\\nthe growth of rapidly growing cells. (It is also used to\\ntreat some cancers.) Most side effects are mild and tem-\\nporary, but the patient must be monitored after treatment.\\nUsually the medication is injected into the muscle in a\\nsingle dose, but may also be given intravenously or\\ninjected directly into the fallopian tube to dissolve the\\nembryonic tissue. Methotrexate has also been used to\\ntreat ovarian, abdominal, and cervical pregnancies that\\nare discovered in the early stages.\\nSurgical\\nWhen a laparoscopy is done to visualize the ectopic\\npregnancy, the scope can be fitted with surgical tools and\\nused to remove the ectopic mass immediately after it is\\nidentified. The affected fallopian tube can be repaired or\\nremoved as necessary. This procedure can be done with-\\nout requiring the patient to stay in the hospital overnight.\\nWhen the pregnancy has ruptured, a surgical inci-\\nsion into the abdomen, or laparotomy, is performed to\\nGALE ENCYCLOPEDIA OF MEDICINE 21132\\nCatch Word\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1132'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 519, 'page_label': '520'}, page_content='stop the immediate loss of blood and to remove the\\nembryo. This usually requires general anesthesia and a\\nhospital stay. Every effort is made to preserve and repair\\nthe injured fallopian tube. However, if the fallopian tube\\nhas already ruptured, repair is extremely difficult and the\\ntube is usually removed.\\nAlternative treatment\\nEctopic pregnancy was first described in the eleventh\\ncentury and was a potentially fatal condition until the\\nadvent of surgery and blood transfusions in the early\\ntwentieth century. The sophisticated diagnostic tools and\\nsurgical procedures developed since the 1970s have\\nequipped modern medicine with the tools to not only save\\na woman’s life, but also to preserve her future fertility.\\nAlthough there are herbal remedies for the tempo-\\nrary relief of the common symptoms of anxiety and\\nabdominal discomfort, prompt medical treatment is the\\nonly sure remedy for ectopic pregnancy.\\nPrognosis\\nEctopic pregnancies are the leading cause of preg-\\nnancy-related deaths in the first trimester and account for\\n9% of all pregnancy-related deaths in the United States.\\nMore than 1% of pregnancies are ectopic, and they are\\nbecoming more common. The reason for this increase is\\nnot clearly understood, though it is thought that the dra-\\nmatic increase in sexually transmitted diseases (STD)\\nis at least partly responsible.\\nThe earlier an ectopic pregnancy is diagnosed and\\ntreated, the better the outcome. The chances of having a\\nsuccessful pregnancy are lower after an ectopic pregnan-\\ncy, but depend on the extent of permanent fallopian tube\\ndamage. If the tube has been spared, chances are as high\\nas 60%. The chances of a successful pregnancy after the\\nremoval of one tube are 40%.\\nPrevention\\nMany forms of ectopic pregnancy cannot be prevent-\\ned. However, tubal pregnancies, which make up the major-\\nity of ectopic pregnancies, may be prevented by avoiding\\nconditions that cause damage to the fallopian tubes. Since\\nhalf of all women who experience ectopic pregnancy have\\na history of PID, avoiding this infection or getting early\\ndiagnosis and treatment for sexually transmitted diseases\\nwill decrease the risk of a future problem.\\nResources\\nBOOKS\\nCunningham, F. Gary, et al. “Ectopic Pregnancy.” In Williams\\nObstetrics. Appleton & Lange, 1997.\\nStabile, Isabel. Ectopic Pregnancy: Diagnosis and Manage-\\nment. Cambridge University Press, 1996.\\nPERIODICALS\\nMaiolatesi, C. R. “Methotrexate for Nonsurgical Treatment of\\nEctopic Pregnancy: Nursing Implications.”Journal of\\nObstetrical Gynecological Neonatal Nursing (Mar./Apr.\\n1996): 205-208.\\nORGANIZATIONS\\nResolve. 1310 Broadway, Somerville, MA 02144-1731. (617)\\n623-0744. .\\nKaren Ericson, RN\\nEczema see Dermatitis\\nED see Impotence\\nEdema\\nDefinition\\nEdema is a condition of abnormally large fluid vol-\\nume in the circulatory system or in tissues between the\\nbody’s cells (interstitial spaces).\\nDescription\\nNormally the body maintains a balance of fluid in\\ntissues by ensuring that the same of amount of water\\nentering the body also leaves it. The circulatory system\\ntransports fluid within the body via its network of blood\\nvessels. The fluid, which contains oxygen and nutrients\\nneeded by the cells, moves from the walls of the blood\\nvessels into the body’s tissues. After its nutrients are used\\nup, fluid moves back into the blood vessels and returns to\\nthe heart. The lymphatic system (a network of channels\\nin the body that carry lymph, a colorless fluid containing\\nwhite blood cells to fight infection) also absorbs and\\ntransports this fluid. In edema, either too much fluid\\nmoves from the blood vessels into the tissues, or not\\nenough fluid moves from the tissues back into the blood\\nvessels. This fluid imbalance can cause mild to severe\\nswelling in one or more parts of the body.\\nCauses and symptoms\\nMany ordinary factors can upset the balance of fluid\\nin the body to cause edema, including:\\n• Immobility. The leg muscles normally contract and\\ncompress blood vessels to promote blood flow with\\nwalking or running. When these muscles are not used,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1133\\nEdema\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1133'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 520, 'page_label': '521'}, page_content='blood can collect in the veins, making it difficult for\\nfluid to move from tissues back into the vessels.\\n• Heat. Warm temperatures cause the blood vessels to\\nexpand, making it easier for fluid to cross into sur-\\nrounding tissues. High humidity also aggravates this\\nsituation.\\n• Medications. Certain drugs, such as steroids, hormone\\nreplacements, nonsteroidal anti-inflammatory drugs\\n(NSAIDs), and some blood pressure medications may\\naffect how fast fluid leaves blood vessels.\\n• Intake of salty foods. The body needs a constant con-\\ncentration of salt in its tissues. When excess salt is\\ntaken in, the body dilutes it by retaining fluid.\\n• Menstruation and pregnancy . The changing levels of\\nhormones affect the rate at which fluid enters and\\nleaves the tissues.\\nSome medical conditions may also cause edema,\\nincluding:\\n• Heart failure . When the heart is unable to maintain\\nadequate blood flow throughout the circulatory system,\\nthe excess fluid pressure within the blood vessels can\\ncause shifts into the interstitial spaces. Left-sided heart\\nfailure can cause pulmonary edema, as fluid shifts into\\nthe lungs. The patient may develop rapid, shallow res-\\npirations, shortness of breath , and a cough. Right-\\nsided heart failure can cause pitting edema, a swelling\\nin the tissue under the skin of the lower legs and feet.\\nPressing this tissue with a finger tip leads to a notice-\\nable momentary indentation.\\n• Kidney disease. The decrease in sodium and water\\nexcretion can result in fluid retention and overload.\\n• Thyroid or liver disease. These conditions can change\\nthe concentration of protein in the blood, affecting fluid\\nmovement in and out of the tissues. In advanced liver\\ndisease, the liver is enlarged and fluid may build-up in\\nthe abdomen.\\n• Malnutrition. Protein levels are decreased in the blood,\\nand in an effort to maintain a balance of concentrations,\\nfluid shifts out of the vessels and causes edema in tissue\\nspaces.\\nSome conditions that may cause swelling in just one\\nleg include:\\nGALE ENCYCLOPEDIA OF MEDICINE 21134\\nEdema\\nGross lymphedema in the arm of an elderly woman following radiotherapy treatment for breast cancer.(Photograph by Dr. P .\\nMarazzi. Photo Researchers, Inc. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1134'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 521, 'page_label': '522'}, page_content='• Blood clots. Clots can cause pooling of fluid and may\\nbe accompanied by discoloration and pain. In some\\ninstances, clots may cause no pain.\\n• Weakened veins. Varicose veins, or veins whose walls\\nor valves are weak, can allow blood to pool in the legs.\\nThis is a common condition.\\n• Infection and inflammation. Infection in leg tissues can\\ncause inflammation and increasing blood flow to the\\narea. Inflammatory diseases, such as gout or arthritis,\\ncan also result in swelling.\\n• Lymphedema. Blocked lymph channels may be caused\\nby infection, scar tissue, or hereditary conditions.\\nLymph that can’t drain properly results in edema. Lym-\\nphedema may also occur after cancer treatments, when\\nthe lymph system is impaired by surgery, radiation, or\\nchemotherapy.\\n• Tumor. Abnormal masses can compress leg vessels and\\nlymph channels, affecting the rate of fluid movement.\\nSymptoms vary depending on the cause of edema. In\\ngeneral, weight gain, puffy eyelids, and swelling of the\\nlegs may occur as a result of excess fluid volume. Pulse\\nrate and blood pressure may be elevated. Hand and neck\\nveins may be observed as fuller.\\nDiagnosis\\nEdema is a sign of an underlying problem, rather\\nthan a disease unto itself. A diagnostic explanation\\nshould be sought. Patient history and presenting symp-\\ntoms, along with laboratory blood studies, if indicated,\\nassist the health professional in determining the cause of\\nthe edema.\\nTreatment\\nTreatment of edema is based on the cause. Simple\\nsteps to lessen fluid build-up may include:\\n• Reducing sodium intake. A high sodium level causes or\\naggravates fluid retention.\\n• Maintaining proper weight. Being overweight slows\\nbody fluid circulation and puts extra pressure on the\\nveins.\\n• Exercise. Regular exercise stimulates circulation.\\n• Elevation of the legs. Placing the legs at least 12 in\\n(30.5 cm) above the level of the heart for 10–15 min-\\nutes, three to four times a day, stimulates excess fluid\\nre-entry into the circulatory system.\\n• Use of support stocking. Elastic stockings, available at\\nmost medical supply or drug stores, will compress the\\nleg vessels, promoting circulation and decreasing pool-\\ning of fluid due to gravity.\\nKEY TERMS\\nDigitalis—A naturally occuring compound used in\\nthe preparation of the medication, digoxin, pre-\\nscribed to increase the heart rate and strengthen\\nthe force of the heart’s contractions.\\nDiuretics —Medications used in the treatment of\\nfluid overload, to promote excretion of sodium\\nand water.\\nInterstitial spaces —Areas of the body occuring\\noutside the vessels or organs, between the cells.\\nPitting edema—A swelling in the tissue under the\\nskin, resulting from fluid accumulation, that is\\nmeasured by the depth of indentation made by fin-\\nger pressure over a boney prominence.\\n• Massage. Massaging the body part can help to stimu-\\nlate the release of excess fluids, but should be avoided\\nif the patient has blood clots in the veins.\\n• Travel breaks. Sitting for long periods will increase\\nswelling in the feet and ankles. Standing and/or walk-\\ning at least every hour or two will help stimulate blood\\nflow.\\nThe three “Ds”—diuretics, digitalis, and diet—are\\nfrequently prescribed for medical conditions that result\\nin excess fluid volume. Diuretics are medications that\\npromote urination of sodium and water. Digoxin is a dig-\\nitalis preparation that is sometimes needed to decrease\\nheart rate and increase the strength of the heart’s contrac-\\ntions. Dietary recommendations include less sodium in\\norder to decrease fluid retention. Consideration of ade-\\nquate protein intake is also made.\\nFor patients with lymphedema, a combination of\\ntherapies may prove effective. Combined decongestive\\ntherapy includes the use of manual lymph drainage\\n(MLD), compression bandaging, garments and pumps,\\nand physical therapy. MLD involves the use of light\\nmassage of the subcutaneous tissue where the lymph\\nvessels predominate. Massage begins in an area of the\\nbody trunk where there is normal lymph function and\\nproceeds to areas of lymphatic insufficiency, in an\\neffort to stimulate new drainage tract development.\\n(MLD should not be used for patients with active can-\\ncer, deep vein clots, congestive heart failure, or cel-\\nlulitis.) MLD sessions are followed by application of\\ncompression garments or pumps. Physical therapy is\\naimed at strengthening the affected limb and increas-\\ning joint mobility.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1135\\nEdema\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1135'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 522, 'page_label': '523'}, page_content='Alternative treatment\\nDietary changes, in addition to cutting back the\\namount of sodium eaten, may also help reduce edema.\\nFoods that worsen edema, such as alcohol, caffeine,\\nsugar, dairy products, soy sauce, animal protein, choco-\\nlate, olives, and pickles, should be avoided. Diuretic herbs\\ncan also help relieve edema. One of the best herbs for this\\npurpose is dandelion (Taraxacum mongolicum), since, in\\naddition to its diuretic action, it is a rich source of potassi-\\num. (Diuretics flush potassium from the body and it must\\nbe replaced to avoid potassium deficiency.) Hydrothera-\\npy using daily contrast applications of hot and cold\\n(either compresses or immersion) may also be helpful.\\nResources\\nBOOKS\\nMonahan, Frances D., and Marianne Neighbors. Medical-Sur-\\ngical Nursing: Foundation for Clinical Practice.2nd ed.\\nPhiladelphia: W. B. Saunders Co., 1998.\\nORGANIZATIONS\\nLymphedema and Wound Care Clinic of Austin. 5750 Balcones\\nDr., Ste. 110, Austin, TX 78731. (512) 453-1930.\\nKathleen D. Wright, RN\\nEdrophonium test see Tensilon test\\nEdwards’ syndrome\\nDefinition\\nEdwards’ syndrome is caused by an extra copy of\\nchromosome 18. For this reason, it is also called trisomy 18\\nsyndrome. The extra chromosome is lethal for most babies\\nborn with this condition. It causes major physical abnor-\\nmalities and severe mental retardation, and very few chil-\\ndren afflicted with this disease survive beyond a year.\\nDescription\\nHumans normally have 23 pairs of chromosomes.\\nChromosomes are numbered 1–22, and the 23rd pair is\\ncomposed of the sex chromosomes, X and Y . A person\\ninherits one set of 23 chromosomes from each parent.\\nOccasionally, a genetic error occurs during egg or\\nsperm cell formation. A child conceived with such an\\negg or sperm cell may inherit an incorrect number of\\nchromosomes.\\nIn the case of Edwards’ syndrome, the child inherits\\nthree, rather than two, copies of chromosome 18. Trisomy\\n18 occurs in approximately one in every 3,000 newborns\\nand affects girls more often than boys. Women older than\\ntheir early thirties have a greater risk of conceiving a child\\nwith trisomy 18, but it can occur in younger women.\\nCauses and symptoms\\nA third copy of chromosome 18 causes numerous\\nabnormalities. Most children born with Edwards’ syn-\\ndrome appear weak and fragile, and they are often under-\\nweight. The head is unusually small and the back of the\\nhead is prominent. The ears are malformed and low-set,\\nand the mouth and jaw are small. The baby may also\\nhave a cleft lip or cleft palate. Frequently, the hands are\\nclenched into fists, and the index finger overlaps the\\nother fingers. The child may have clubfeet and toes may\\nbe webbed or fused.\\nNumerous problems involving the internal organs\\nmay be present. Abnormalities often occur in the lungs\\nand diaphragm (the muscle that controls breathing), and\\nheart defects and blood vessel malformations are com-\\nmon. The child may also have malformed kidneys and\\nabnormalities of the urogenital system.\\nDiagnosis\\nPhysical abnormalities point to Edwards’ syndrome,\\nbut definitive diagnosis relies on karyotyping. Karyotyp-\\ning involves drawing the baby’s blood or bone marrow\\nfor a microscopic examination of the chromosomes.\\nUsing special stains and microscopy, individual chromo-\\nsomes are identified, and the presence of an extra chro-\\nmosome 18 is revealed.\\nTrisomy 18 can be detected before birth. If a preg-\\nnant woman is older than 35, has a family history of\\ngenetic abnormalities, has previously conceived a child\\nwith a genetic abnormality, or has suffered earlier miscar-\\nriages, she may undergo tests to determine whether her\\nchild carries genetic abnormalities. Potential tests include\\nmaternal serum analysis or screening, ultrasonography,\\namniocentesis, and chorionic villus sampling.\\nTreatment\\nThere is no cure for Edwards’ syndrome. Since tri-\\nsomy 18 babies frequently have major physical abnor-\\nmalities, doctors and parents face difficult choices\\nregarding treatment. Abnormalities can be treated to a\\ncertain degree with surgery, but extreme invasive proce-\\ndures may not be in the best interests of an infant whose\\nlifespan is measured in days or weeks. Medical therapy\\noften consists of supportive care with the goal of making\\nthe infant comfortable, rather than prolonging life.\\nGALE ENCYCLOPEDIA OF MEDICINE 21136\\nEdwards’ syndrome\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1136'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 523, 'page_label': '524'}, page_content='Prognosis\\nMost children born with trisomy 18 die within their\\nfirst year of life. The average lifespan is less than two\\nmonths for 50% of the children, and 90–95% die before\\ntheir first birthday. The 5–10% of children who survive\\ntheir first year are severely mentally retarded. They need\\nsupport to walk, and learning is limited. Verbal commu-\\nnication is also limited, but they can learn to recognize\\nand interact with others.\\nPrevention\\nEdwards’ syndrome cannot be prevented.\\nResources\\nBOOKS\\nGardner, R. J. McKinlay, and Grant R. Sutherland. Chromo-\\nsome Abnormalities and Genetic Counseling. New York:\\nOxford University Press, 1996.\\nJones, Kenneth Lyons. Smith’s Recognizable Patterns of\\nHuman Malformation. 5th ed. W. B. Saunders Co., 1997.\\nORGANIZATIONS\\nThe Chromosome 18 Registry & Research Society. 6302 Fox\\nHead, San Antonio, TX 78247. (210) 657-4968. .\\nKEY TERMS\\nAminocentesis —A procedure in which a needle is\\ninserted through a pregnant woman’s abdomen and\\ninto her uterus to withdraw a small sample of amni-\\notic fluid. The amniotic fluid can be examined for\\nsigns of disease or other problems afflicting the fetus.\\nChorionic villus sampling —A medical test that is\\nbest done during weeks 10–12 of a pregnancy. The\\nprocedure involves inserting a needle into the pla-\\ncenta and withdrawing a small amount of the chori-\\nonic membrane for analysis.\\nChromosome —A structure composed of deoxyri-\\nbonucleic acid (DNA) contained within a cell’s\\nnucleus (center) in where genetic information is\\nstored. Human have 23 pairs of chromosomes, each\\nof which has recognizable characteristics (such as\\nlength and staining patterns) that allow individual\\nchromosomes to be identified. Identification is\\nassigned by number (1–22) or letter (X or Y).\\nKaryotyping —A laboratory test used to study an\\nindividual’s chromosome make-up. Chromosomes\\nare separated from cells, stained, and arranged in\\norder from largest to smallest so that their number\\nand structure can be studied under a microscope.\\nMaternal serum analyte screening—A medical pro-\\ncedure in which a pregnant woman’s blood is\\ndrawn and analyzed for the levels of certain hor-\\nmones and proteins. These levels can indicate\\nwhether there may be an abnormality in the unborn\\nchild. This test is not a definitive indicator of a prob-\\nlem and is followed by more specific testing such as\\namniocentesis or chorionic villus sampling.\\nTrisomy—A condition in which a third copy of a\\nchromosome is inherited. Normally only two copies\\nshould be inherited.\\nUltrasound—A medical test that is also called ultra-\\nsonography. Sound waves are directed against inter-\\nnal structures in the body. As sound waves bounce\\noff the internal structure, they create an image on a\\nvideo screen. An ultrasound of a fetus at weeks\\n16–20 of a pregnancy can be used to determine\\nstructural abnormalities.\\nSupport Organization for Trisomy 18, 13, and Related Disor-\\nders (SOFT). 2982 South Union St., Rochester, NY\\n14624. (800) 716-7638. .\\nJulia Barrett\\nEEG see Electroencephalography\\nEgyptian conjunctivitis see Trachoma\\nEhlers-Danlos syndrome\\nDefinition\\nThe Ehlers-Danlos syndromes (EDS) refer to a\\ngroup of inherited disorders that affect collagen structure\\nand function. Genetic abnormalities in the manufacturing\\nof collagen within the body affect connective tissues,\\ncausing them to be abnormally weak.\\nDescription\\nCollagen is a strong, fibrous protein that lends\\nstrength and elasticity to connective tissues such as the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1137\\nEhlers-Danlos syndrome\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1137'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 524, 'page_label': '525'}, page_content='skin, tendons, organ walls, cartilage, and blood vessels.\\nEach of these connective tissues requires collagen tai-\\nlored to meet its specific purposes. The many roles of\\ncollagen are reflected in the number of genes dedicated\\nto its production. There are at least 28 genes in humans\\nthat encode at least 19 different types of collagen. Muta-\\ntions in these genes can affect basic construction as well\\nas the fine-tuned processing of the collagen.\\nEDS was originally described by Dr. Van Meekeren\\nin 1682. Dr. Ehlers and Dr. Danlos further characterized\\nthe disease in 1901 and 1908, respectively. Today,\\naccording to the Ehlers-Danlos National Foundation, one\\nin 5,000 to one in 10,000 people are affected by some\\nform of EDS.\\nEDS is a group of genetic disorders that usually\\naffects the skin, ligaments, joints, and blood vessels. Clas-\\nsification of EDS types was revised in 1997. The new\\nclassification involves categorizing the different forms of\\nEDS into six major sub-types, including classical, hyper-\\nmobility, vascular, kyphoscoliosis, arthrochalasia, and\\ndermatosparaxis, and a collection of rare or poorly\\ndefined varieties. This new classification is simpler and\\nbased more on descriptions of the actual symptoms.\\nClassical type\\nUnder the old classification system, EDS classical\\ntype was divided into two separate types: type I and type\\nII. The major symptoms involved in EDS classical type\\nare the skin and joints. The skin has a smooth, velvety\\ntexture and bruises easily. Affected individuals typically\\nhave extensive scaring, particularly at the knees, elbows,\\nforehead, and chin. The joints are hyperextensible, giving\\na tendency towards dislocation of the hip, shoulder,\\nelbow, knee, or clavicle. Due to decreased muscle tone,\\naffected infants may experience a delay in reaching motor\\nmilestones. Children may have a tendency to develop her-\\nnias or other organ shifts within the abdomen. Sprains and\\npartial or complete joint dilocations are also common.\\nSymptoms can range from mild to severe. EDS classical\\ntype is inherited in an autosomal dominant manner.\\nThere are three major clinical diagnostic criteria for\\nEDS classical type. These include skin hyperextensibili-\\nty, unusually wide scars, and joint hypermobility. At this\\ntime there is no definitive test for the diagnosis of classi-\\ncal EDS. Both DNA and biochemical studies have been\\nused to help identify affected individuals. In some cases,\\na skin biopsy has been found to be useful in confirming\\na diagnosis. Unfortunately, these tests are not sensitive\\nenough to identify all individuals with classical EDS. If\\nthere are multiple affected individuals in a family, it may\\nbe possible to perform prenatal diagnosis using a DNA\\ninformation technique known as a linkage study.\\nHypermobility type\\nExcessively loose joints are the hallmark of this EDS\\ntype, formerly known as EDS type III. Both large joints,\\nsuch as the elbows and knees, and small joints, such as\\ntoes and fingers, are affected. Partial and total joint dislo-\\ncations are common, and particularly involve the jaw,\\nknee, and shoulder. Many individuals experience chronic\\nlimb and joint pain, although x rays of these joints appear\\nnormal. The skin may also bruise easily. Osteoarthritis is\\na common occurrence in adults. EDS hypermobility type\\nis inherited in an autosomal dominant manner.\\nThere are two major clinical diagnostic criteria for\\nEDS hypermobility type. These include skin involvement\\n(either hyperextensible skin or smooth and velvety skin)\\nand generalized joint hypermobility. At this time there is\\nno test for this form of EDS.\\nV ascular type\\nFormerly called EDS type IV , EDS vascular type is\\nthe most severe form. The connective tissue in the\\nintestines, arteries, uterus, and other hollow organs may\\nbe unusually weak, leading to organ or blood vessel rup-\\nture. Such ruptures are most likely between ages 20 and\\n40, although they can occur any time, and may be life-\\nthreatening.\\nThere is a classic facial appearance associated with\\nEDS vascular type. Affected individuals tend to have\\nlarge eyes, a thin pinched nose, thin lips, and a slim body.\\nThe skin is thin and translucent, with veins dramatically\\nvisible, particularly across the chest.\\nThe large joints have normal stability, but small\\njoints in the hands and feet are loose, showing hyperex-\\ntensibility. The skin bruises easily. Other complications\\nmay include collapsed lungs, premature aging of the skin\\non the hands and feet, and ruptured arteries and veins.\\nAfter surgery there tends to be poor wound healing, a\\ncomplication that tends to be frequent and severe. Preg-\\nnancy also carries the risk complications. During and\\nafter pregnancy there is an increased risk of the uterus\\nrupturing and of arterial bleeding. Due to the severe com-\\nplications associated with EDS type IV , death usually\\noccurs before the fifth decade. A study of 419 individuals\\nwith EDS vascular type, completed in 2000, found that\\nthe median survival rate was 48 years, with a range of six\\nto 73 years. EDS vascular type is inherited in an autoso-\\nmal dominant manner.\\nThere are four major clinical diagnostic criteria for\\nEDS vascular type. These include thin translucent skin,\\narterial/intestinal/uterine fragility or rupture, extensive\\nbruising, and characteristic facial appearance. EDS vascu-\\nlar type is caused by a change in the gene COL3A1,\\nGALE ENCYCLOPEDIA OF MEDICINE 21138\\nEhlers-Danlos syndrome\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1138'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 525, 'page_label': '526'}, page_content='which codes for one of the collagen chains used to build\\nCollage type III. Laboratory testing is available for this\\nform of EDS. A skin biopsy may be used to demonstrate\\nthe structurally abnormal collagen. This type of biochem-\\nical test identifies more than 95% of individuals with EDS\\nvascular type. Laboratory testing is recommended for\\nindividuals with two or more of the major criteria.\\nDNA analysis may als be used to identify the change\\nwithin the COL3A1 gene. This information may be help-\\nful for genetic counseling purposes. Prenatal testing is\\navailable for pregnancies in which an affected parent has\\nbeen identified and their DNA mutation is known or their\\nbiochemical defect has been demonstrated.\\nKyphoscoliosis type\\nThe major symptoms of kyphoscoliosis type, for-\\nmerly called EDS type VI, are general joint looseness. At\\nbirth, the muscle tone is poor, and motor skill develop-\\nment is subsequently delayed. Also, infants with this type\\nof EDS have an abnormal curvature of the spine ( scolio-\\nsis). The scoliosis becomes progressively worse with\\nage, with affected individuals usually unable to walk by\\nage 20. The eyes and skin are fragile and easily damaged,\\nand blood vessel involvement is a possibility. The bones\\nmay also be affected as demonstrated by a decrease in\\nbone mass. Kyphoscoliosis type is inherited in an autoso-\\nmal recessive manner.\\nThere are four major clinical diagnostic criteria for\\nEDS kyphoscoliosis type. These include generaly loose\\njoints, low muscle tone at birth, scoliosis at birth (which\\nworsens with age), and a fragility of the eyes, which may\\ngive the white area of the eye a blue tint or cause the eye\\nto rupture. This form of EDS is caused by a change in the\\nPLOD gene on chromosome 1, which encodes the\\nenzyme lysyl hydroxylase. A laboratory test is available\\nin which urinary hydroxylysyl pryridinoline is measured.\\nThis test, performed on urine is extremely senstive and\\nspecific for EDS kyphoscolios type. Laboratory testing is\\nrecommended for infants with three or more of the major\\ndiagnostic criteria.\\nPrenatal testing is available if a pregnancy is known\\nto be at risk and an identified affected family member has\\nhad positive laboratory testing. An amniocentesis may\\nbe performed in which fetal cells are removed from the\\namniotic fluid and enzyme activity is measured.\\nArthrochalasia type\\nDislocation of the hip joint typically accompanies\\narthrochalasia type EDS, formerly called EDS type VIIB.\\nOther joints are also unusually loose, leading to recurrent\\npartial and total dislocations. The skin has a high degree\\nof stretchability and bruises easily. Individuals with this\\ntype of EDS may also experience mildly diminished\\nbone mass, scoliosis, and poor muscle tone. Arthrochala-\\nsia type is inherited in an autosomal dominant manner.\\nThere are two major clinical diagnostic criteria for\\nEDS arthrochalasia type. These include sever general-\\nized joing hypermobility and bilateral hip dislocation\\npresent at birth. This form of EDS is caused by a change\\nin either of two components of Collage type I, called\\nproa1(I) type A and proa2(I) type B. A skin biopsy may\\nbe preformed to demonstrate an abnormality in either\\ncomponents. Direct DNA testing is also available.\\nDermatosparaxis type\\nIndividuals with this type of EDS, once called type\\nVIIC, have extremely fragile skin that bruises easily but\\ndoes not scar excessively. The skin is soft and may sag,\\nleading to an aged appearance even in young adults. Indi-\\nviduals may also experience hernias. Dermatosparaxis\\ntype is inherited in an autosomal recessive manner.\\nThere are two major clinical diagnostic criteria for\\nEDS dematosparaxis type. These include severe skin\\nfragility and sagging or aged appearing skin. This form of\\nEDS is caused by a change in the enzyme called procolla-\\ngen I N-terminal peptidase. A skin biopsy may be pre-\\nformed for a definitive diagnosis of Dermatosparaxis type.\\nOther types\\nThere are several other forms of EDS that have not\\nbeen as clearly defined as the aforementioned types.\\nForms of EDS within this category may present with\\nsoft, mildly stretchable skin, shortened bones, chronic\\ndiarrhea , joint hypermobility and dislocation, bladder\\nrupture, or poor wound healing. Inheritance patterns\\nwithin this group include X-linked recessive, autosomal\\ndominant, and autosomal recessive.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1139\\nEhlers-Danlos syndrome\\nElasticity of the skin is one characteristic of this rare disor-\\nder. (Photograph by Biophoto Associates, Photo Researchers,\\nInc. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1139'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 526, 'page_label': '527'}, page_content='Causes and symptoms\\nThere are numerous types of EDS, all caused by\\nchanges in one of several genes. The manner in which EDS\\nis inherited depends on the specific gene involved. There\\nare three patterns of inheritance for EDS: autosomal domi-\\nnant, autosomal recessive, and X-linked (extremely rare).\\nChromosomes are made up of hundreds of small\\nunits known as genes, which contain the genetic material\\nnecessary for an individual to develop and function.\\nHumans have 46 chromosomes, which are matched into\\n23 pairs. Because chromosomes are inherited in pairs,\\neach individual receives two copies of each chromosome\\nand likewise two copies of each gene.\\nChanges or mutations in genes can cause genetic\\ndiseases in several different ways, many of which are\\nrepresented within the spectrum of EDS. In autosomal\\ndominant EDS, only one copy of a specific gene must be\\nchanged for a person to have EDS. In autosomal reces-\\nsive EDS, both copies of a specific gene must be changed\\nfor a person to have EDS. If only one copy of an autoso-\\nmal recessive EDS gene is changed the person is referred\\nto as a carrier, meaning they do not have any of the signs\\nor symptoms of the disease itself, but carry the possibili-\\nKEY TERMS\\nArthrochalasia—Excessive loosness of the joints.\\nBlood vessels—General term for arteries, veins, and\\ncapillaries that transport blood throughout the body.\\nCartilage—Supportive connective tissue that cush-\\nions bone at the joints or which connects muscle to\\nbone.\\nCollagen—The main supportive protein of cartilage,\\nconnective tissue, tendon, skin, and bone.\\nConnective tissue —A group of tissues responsible\\nfor support throughout the body; includes cartilage,\\nbone, fat, tissue underlying skin, and tissues that\\nsupport organs, blood vessels, and nerves through-\\nout the body.\\nDermatosparaxis —Skin fragility caused by abnor-\\nmal collagen.\\nHernia—A rupture in the wall of a body cavity,\\nthrough which an organ may protrude.\\nHomeopathic —A holistic and natural approach to\\nhealthcare.\\nHyperextensibility —The ability to extend a joint\\nbeyond the normal range.\\nHypermobility —Unusual flexibility of the joints,\\nallowing them to be bent or moved beyond their\\nnormal range of motion.\\nJoint dislocation—The displacement of a bone.\\nKyphoscoliosis—Abnormal front-to-back and side-\\nto-side curvature of the spine.\\nLigament —A type of connective tissue that con-\\nnects bones or cartilage and provides support and\\nstrength to joints.\\nOsteoarthritis —A degenerative joint disease that\\ncauses pain and stiffness.\\nScoliosis —An abnormal, side-to-side curvature of\\nthe spine.\\nTendon—A strong connective tissue that connects\\nmuscle to bone.\\nUterus—A muscular, hollow organ of the female\\nreproductive tract. The uterus contains and nourish-\\nes the embryo and fetus from the time the fertilized\\negg is implanted until birth.\\nVascular—Having to do with blood vessels.\\nty of passing on the disorder to a future child. In X-\\nlinked EDS a specific gene on the X chromosome must\\nbe changed. However, this affects males and females dif-\\nferently because males and females have a different num-\\nber of X chromosomes.\\nAs of 2001 the few X-linked forms of EDS fall under\\nthe category of X-linked recessive. As with autosomal\\nrecessive, this implies that both copies of a specific gene\\nmust be changed for a person to be affected. However,\\nbecause males only have one X-chromosome, they are\\naffected if an X-linked recessive EDS gene is changed on\\ntheir single X-chromosome. That is, they are affected\\neven though they have only one changed copy. On the\\nother hand, that same gene must be changed on both of\\nthe X-chromosomes in a female for her to be affected.\\nAlthough there is much information regarding the\\nchanges in genes that cause EDS and their various inheri-\\ntance patterns, the exact gene mutation for all types of\\nEDS is not known.\\nDiagnosis\\nClinical symptoms such as extreme joint looseness\\nand unusual skin qualities, along with family history, can\\nGALE ENCYCLOPEDIA OF MEDICINE 21140\\nEhlers-Danlos syndrome\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1140'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 527, 'page_label': '528'}, page_content='lead to a diagnosis of EDS. Specific tests, such as skin\\nbiopsies are available for diagnosis of certain types of\\nEDS, including vascular, arthrochalasia, and der-\\nmatosparaxis types. A skin biopsy involves removing a\\nsmall sample of skin and examining its microscopic struc-\\nture. A urine test is available for the Kyphoscoliosis type.\\nManagement of all types of EDS may include genet-\\nic counseling to help the affected individual and their\\nfamily understand the disorder and its impact on other\\nfamily members and future children.\\nIf a couple has had a child diagnosed with EDS the\\nchance that they will have another child with the same\\ndisorder depends on with what form of EDS the child has\\nbeen diagnosed and if either parent is affected by the\\nsame disease or not.\\nIndividuals diagnosed with an autosomal dominant\\nform of EDS have a 50% chance of passing the same disor-\\nder on to a child in each pregnancy. Individuals diagnosed\\nwith an autosomal recessive form of EDS have an extreme-\\nly low risk of having a child with the same disorder.\\nX-linked recessive EDS is accompanied by a slight-\\nly more complicated pattern of inheritance. If a father\\nwith an X-linked recessive form of EDS passes a copy of\\nhis X chromosome to his children, the sons will be unaf-\\nfected and the daughters will be carriers. If a mother is a\\ncarrier for an X-linked recessive form of EDS, she may\\nhave affected or unaffected sons, or carrier or unaffected\\ndaughters, depending on the second sex chromosome\\ninherited from the father.\\nPrenatal diagnosis is available for specific forms of\\nEDS, including kyphosocliosis type and vascular type.\\nHowever, prenatal testing is only a possibility in these\\ntypes if the underlying defect has been found in another\\nfamily member.\\nTreatment\\nMedical therapy relies on managing symptoms and\\ntrying to prevent further complications. There is no cure\\nfor EDS.\\nBraces may be prescribed to stabilize joints, although\\nsurgery is sometimes necessary to repair joint damage\\ncaused by repeated dislocations. Physical therapy teaches\\nindividuals how to strengthen muscles around joints and\\nmay help to prevent or limit damage. Elective surgery is\\ndiscouraged due to the high possibility of complications.\\nAlternative treatment\\nThere are anecdotal reports that large daily doses\\n0.04–0.14 oz (1–4 g) of vitamin C may help decrease\\nbruising and aid in wound healing. Constitutional home-\\nopathic treatment may be helpful in maintaining optimal\\nhealth in persons with a diagnosis of EDS. An individual\\nwith EDS should discuss these types of therapies with\\ntheir doctor before beginning them on their own. Thera-\\npy that does not require medical consultation involves\\nprotecting the skin with sunscreen and avoiding activities\\nthat place stress on the joints.\\nPrognosis\\nThe outlook for individuals with EDS depends on\\nthe type of EDS with which they have been diagnosed.\\nSymptoms vary in severity, even within one sub-type,\\nand the frequency of complications changes on an indi-\\nvidual basis. Some individuals have negligible symptoms\\nwhile others are severely restricted in their daily life.\\nExtreme joint instability and scoliosis may limit a per-\\nson’s mobility. Most individuals will have a normal lifes-\\npan. However, those with blood vessel involvement, par-\\nticularly those with EDS vascular type, have an increased\\nrisk of fatal complications.\\nEDS is a lifelong condition. Affected individuals\\nmay face social obstacles related to their disease on a\\ndaily basis. Some people with EDS have reported living\\nwith fears of significant and painful skin ruptures,\\nbecoming pregnant (especially those with EDS vascular\\ntype), their condition worsening, becoming unemployed\\ndue to physical and emotional burdens, and social\\nstigmatization in general.\\nConstant bruises, skin wounds, and trips to the hos-\\npital take their toll on both affected children and their\\nparents. Prior to diagnosis parents of children with EDS\\nhave found themselves under suspicion of child abuse.\\nSome people with EDS are not diagnosed until well\\ninto adulthood and, in the case of EDS vascular type,\\noccasionally not until after death due to complications of\\nthe disorder. Not only may the diagnosis itself be devas-\\ntating to the family, but in many cases other family mem-\\nbers find out for the first time they are at risk for being\\naffected.\\nAlthough individuals with EDS face significant\\nchallenges, it is important to remember that each person\\nis unique with their own distinguished qualities and\\npotential. Persons with EDS go on to have families, to\\nhave careers, and to be accomplished citizens, surmount-\\ning the challenges of their disease.\\nResources\\nPERIODICALS\\n“Clinical and Genetic Features of Ehlers-Danlos Syndrome\\nType IV , the Vascular Type.”The New England Journal of\\nMedicine 342, no. 10 (2000).\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1141\\nEhlers-Danlos syndrome\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1141'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 528, 'page_label': '529'}, page_content='“Ehlers-Danlos Syndromes: Revised Nosology, Villefranche,\\n1997.” American Journal of Medical Genetics 77 (1998):\\n31–37.\\n“Living a Restricted Life with Ehlers-Danlos Syndrome.”\\nInternational Journal of Nursing Studies 37 (2000):\\n111–118.\\nORGANIZATIONS\\nElhers-Danlos National Foundation. 6399 Wilshire Blvd., Ste\\n203, Los Angeles, CA 90048 (323) 651-3038. Fax: (323)\\n651-1366. .\\nEhlers-Danlos Support Group- UK. PO Box 335, Farnham,\\nSurrey, GU10 1XJ. UK. .\\nOTHER\\nGeneClinics. .\\nJava O. Solis, MS\\nEhrlichiosis\\nDefinition\\nEhrlichiosis is a bacterial infection that is spread by\\nticks. Symptoms include fever, chills, headache, muscle\\naches, and tiredness.\\nDescription\\nEhrlichiosis is a tick-borne disease caused by infec-\\ntion with Ehrlichia bacteria. Ticks are small, blood-suck-\\ning arachnids. Although some ticks carry disease-causing\\norganisms, most do not. When an animal or person is bit-\\nten by a tick that carries bacteria, the bacteria are passed\\nto that person or animal during the tick’s feeding process.\\nIt is believed that the tick must remain attached to the\\nperson or animal for at least 24 hours to spread the infec-\\ntion.\\nThere are two forms of ehrlichiosis in the United\\nStates; human monocytic ehrlichiosis and human gran-\\nulocytic ehrlichiosis. Monocytic ehrlichiosis is caused\\nby Ehrlichia chaffeensis , which is spread by the Lone\\nStar tick, Amblyomma americanum . As of early 1998,\\nabout 400 cases of monocytic ehrlichiosis had been\\nreported in 30 states, primarily in the southeastern and\\nsouth central United States. The bacteria that causes\\ngranulocytic ehrlichiosis is not known, but suspected to\\nbe either Ehrlichia equi or Ehrlichia phagocytophila .\\nGranulocytic ehrlichiosis is probably spread by the\\nblacklegged tick Ixodes scapularis (which also spreads\\nLyme disease ). About 100 cases of granulocytic ehrli-\\nchiosis have been reported in Connecticut, Massachu-\\nsetts, Rhode Island, Minnesota, New York, and Wiscon-\\nsin.\\nCauses and symptoms\\nBoth forms of ehrlichiosis have similar symptoms,\\nand the illnesses can range from mild to severe and life-\\nthreatening. Risk factors include old age and exposure to\\nticks through work or recreation. Symptoms occur seven\\nto 21 days following a tick bite although patients may not\\nrecall being bitten. Fever, tiredness, headache, muscle\\naches, chills, loss of appetite, confusion, nausea, and\\nvomiting are common to both diseases. A rash may\\noccur.\\nDiagnosis\\nEhrlichiosis may be diagnosed and treated by doc-\\ntors who specialize in blood diseases (hematologists) or\\nan infectious disease specialist. Because ehrlichiosis is\\nnot very common and the symptoms are not unique, it\\nmay be misdiagnosed. A recent history of a tick bite is\\nhelpful in the diagnosis. Blood tests will be done to look\\nfor antibodies to Ehrlichia . Staining and microscopic\\nexamination of the blood sample may show Ehrlichia\\nbacteria inside white blood cells. Another test, called\\npolymerase chain reaction (PCR), is a very sensitive\\nassay to detect bacteria in the blood sample, but it is not\\nalways available.\\nTreatment\\nAntibiotic treatment should begin immediately if\\nehrlichiosis is suspected, even if laboratory results are\\nnot available. Treatment with either tetracycline\\n(Sumycin, Achromycin V) or doxycycline (Monodox,\\nVibramycin) is recommended. Many patients with ehrli-\\nchiosis are admitted to the hospital for treatment.\\nPrognosis\\nFor otherwise healthy people, a full recovery is\\nexpected following treatment for ehrlichiosis. Elderly\\npatients are at a higher risk for severe disease, which may\\nbe fatal. Serious complications include lung or gastroin-\\ntestinal bleeding. Two to 10 patients out of 100 die from\\nthe disease.\\nPrevention\\nThe only prevention for ehrlichiosis is to minimize\\nexposure to ticks by staying on the trail when walking\\nthrough the woods, avoiding tall grasses, wearing long\\nsleeves and tucking pant legs into socks, wearing insect\\nGALE ENCYCLOPEDIA OF MEDICINE 21142\\nEhrlichiosis\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1142'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 529, 'page_label': '530'}, page_content='repellent, and checking for ticks after an outing. Remove\\na tick as soon as possible by grasping the tick with\\ntweezers and gently pulling.\\nResources\\nBOOKS\\nMcDade, Joseph E., and James G. Olsen. “Ehrlichiosis, Q\\nFever, Typhus, Rickettsialpox, and Other Rickettsioses.”\\nIn Infectious Diseases. 2nd ed. Philadelphia: W. B. Saun-\\nders Co., 1998.\\nOTHER\\nMayo Clinic Online.5 Mar. 1998 .\\nBelinda Rowland, PhD\\nEKG see Electrocardiography\\nElder abuse see Abuse\\nElectric shock injuries\\nDefinition\\nElectric shock injuries are caused by lightning or\\nelectric current from a mechanical source passing\\nthrough the body.\\nDescription\\nElectric shocks are responsible for about 1,000\\ndeaths in the United States each year, or about 1% of all\\naccidental deaths.\\nCauses and symptoms\\nThe severity of injury depends on the current’s pres-\\nsure (voltage), the amount of current (amperage), the\\ntype of current (direct vs. alternating), the body’s resis-\\ntance to the current, the current’s path through the body,\\nand how long the body remains in contact with the cur-\\nrent. The interplay of these factors can produce effects\\nranging from barely noticeable tingling to instant death;\\nevery part of the body is vulnerable. Although the severi-\\nKEY TERMS\\nTick-borne disease —A disease that is spread to\\nanimals by the bite of an infected tick.\\nty of injury is determined primarily by the voltage, low\\nvoltage can be just as dangerous as high voltage under\\nthe right circumstances. People have been killed by\\nshocks of just 50 volts.\\nHow electric shocks affect the skin is determined by\\nthe skin’s resistance, which in turn is dependent upon the\\nwetness, thickness, and cleanliness of the skin. Thin or wet\\nskin is much less resistant than thick or dry skin. When\\nskin resistance is low, the current may cause little or no\\nskin damage but severely burn internal organs and tissues.\\nConversely, high skin resistance can produce severe skin\\nburns but prevent the current from entering the body.\\nThe nervous system (the brain, spinal cord, and\\nnerves) is particularly vulnerable to injury. In fact, neuro-\\nlogical problems are the most common kind of nonlethal\\nharm suffered by electric shock victims. Some neurological\\ndamage is minor and clears up on its own or with medical\\ntreatment, but some is severe and permanent. Neurological\\nproblems may be apparent immediately after the accident,\\nor gradually develop over a period of up to three years.\\nDamage to the respiratory and cardiovascular systems\\nis most acute at the moment of injury. Electric shocks can\\nparalyze the respiratory system or disrupt heart action,\\ncausing instant death. Also at risk are the smaller veins and\\narteries, which dissipate heat less easily than the larger\\nblood vessels and can develop blood clots. Damage to the\\nsmaller vessels is probably one reason why amputation is\\noften required following high-voltage injuries.\\nMany other sorts of injuries are possible after an\\nelectric shock, including cataracts , kidney failure, and\\nsubstantial destruction of muscle tissue. The victim may\\nsuffer a fall or be hit by debris from exploding equip-\\nment. An electric arc may set clothing or nearby flamma-\\nble substances on fire. Strong shocks are often accompa-\\nnied by violent muscle spasms that can break and dislo-\\ncate bones. These spasms can also freeze the victim in\\nplace and prevent him or her from breaking away from\\nthe source of the current.\\nDiagnosis\\nDiagnosis relies on gathering information about the\\ncircumstances of the accident, a thorough physical exami-\\nnation, and monitoring of cardiovascular and kidney activ-\\nity. The victim’s neurological condition can fluctuate rapid-\\nly and requires close observation. A computed tomography\\nscan (CT scan) or magnetic resonance imaging (MRI)\\nmay be necessary to check for brain injury.\\nTreatment\\nWhen an electric shock accident happens at home or\\nin the workplace, the main power should immediately be\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1143\\nElectric shock injuries\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1143'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 530, 'page_label': '531'}, page_content='shut off. If that cannot be done, and current is still flowing\\nthrough the victim, the alternative is to stand on a dry, non-\\nconducting surface such as a folded newspaper, flattened\\ncardboard carton, or plastic or rubber mat and use a non-\\nconducting object such as a wooden broomstick (never a\\ndamp or metallic object) to push the victim away from the\\nsource of the current. The victim and the source of the cur-\\nrent must not be touched while the current is still flowing,\\nfor this can electrocute the rescuer. Emergency medical\\nhelp should be summoned as quickly as possible. People\\nwho are trained to perform cardiopulmonary resuscita-\\ntion (CPR) should, if appropriate, begin first aid while\\nwaiting for emergency medical help to arrive.\\nBurn victims usually require treatment at a burn cen-\\nter. Fluid replacement therapy is necessary to restore lost\\nfluids and electrolytes. Severely injured tissue is repaired\\nsurgically, which can involve skin grafting or amputa-\\ntion. Antibiotics and antibacterial creams are used to\\nprevent infection. Victims may also require treatment for\\nkidney failure. Following surgery, physical therapy to\\nfacilitate recovery, and psychological counseling to cope\\nwith disfigurement, may be necessary.\\nPrognosis\\nElectric shocks cause death in 3–15% of cases. Many\\nsurvivors require amputation or are disfigured by their\\nburns. Injuries from household appliances and other low-\\nvoltage sources are less likely to produce extreme damage.\\nKEY TERMS\\nAntibiotics—Substances used against microorgan-\\nisms that cause infection.\\nCataract —Clouding of the lens of the eye or its\\ncapsule (surrounding membrane).\\nComputed tomography scan (CT scan) —A\\nprocess that uses x rays to create three-dimension-\\nal images of structures inside the body.\\nElectrolytes —Substances that conduct electric\\ncurrent within the body and are essential for sus-\\ntaining life.\\nMagnetic resonance imaging (MRI) —The use of\\nelectromagnetic energy to create images of struc-\\ntures inside the body.\\nSkin grafting —A technique in which a piece of\\nhealthy skin from the patient’s body (or a donor’s)\\nis used to cover another part of the patient’s body\\nthat has lost its skin.\\nPrevention\\nParents and other adults need to be alert to possible\\nelectric dangers in the home. Damaged electric appliances,\\nwiring, cords, and plugs should be repaired or replaced.\\nElectrical repairs should be attempted only by people with\\nthe proper training. Hair dryers, radios, and other electric\\nappliances should never be used in the bathroom or any-\\nwhere else they might accidentally come in contact with\\nwater. Young children need to be kept away from electric\\nappliances and should be taught about the dangers of elec-\\ntricity as soon as they are old enough. Electric outlets\\nrequire safety covers in homes with young children.\\nDuring thunderstorms, people should go indoors\\nimmediately, even if no rain is falling, and boaters should\\nreturn to shore as rapidly as possible. People who cannot\\nreach indoor shelter should move away from metallic\\nobjects such as golf clubs and fishing rods and lie down in\\nlow-ground areas. Standing or lying under or next to tall or\\nmetallic structures is unsafe. An automobile is appropriate\\ncover, as long as the radio is off. Telephones, computers,\\nhair dryers, and other appliances that can act as conduits\\nfor lightning should not be used during thunderstorms.\\nResources\\nBOOKS\\nDimick, Alan R. “Electrical Injuries.” In Harrison’s Principles\\nof Internal Medicine, ed. Anthony S. Fauci, et al. New\\nYork: McGraw-Hill, 1997.\\nHoward Baker\\nElectrical nerve stimulation\\nDefinition\\nElectrical nerve stimulation, also called transcuta-\\nneous electrical nerve stimulation (TENS), is a noninva-\\nsive, drug-free pain management technique. By sending\\nelectrical signals to underlying nerves, the battery-pow-\\nered TENS device can relieve a wide range of chronic\\nand acute pain.\\nPurpose\\nTENS is used to relieve pain caused by a variety of\\nchronic conditions, including:\\n• neck and lower back pain\\n• headache/migraine\\n• arthritis\\n• post-herpetic neuralgia (lingering chronic pain after an\\nattack of shingles)\\nGALE ENCYCLOPEDIA OF MEDICINE 21144\\nElectrical nerve stimulation\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1144'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 531, 'page_label': '532'}, page_content='• sciatica (pain radiating from lower back, through the\\nlegs, to the foot)\\n• temporomandibular joint pain\\n• osteoarthritis\\n• amputation (phantom limb)\\n• fibromyalgia (a condition causing aching and stiffness\\nthroughout the body)\\nThe device is also effective against short-term pain,\\nsuch as:\\n• shingles (painful skin eruptions along the nerves)\\n• bursitis (inflammation of tissue surrounding a joint)\\n• childbirth\\n• post-surgical pain\\n• fractures\\n• muscle and joint pain\\n• sports injuries\\n• menstrual cramps\\nPrecautions\\nBecause TENS may interfere with pacemaker func-\\ntion, patients with pacemakers should consult a cardiol-\\nogist before using a TENS unit. Patients should also\\navoid electrical stimulation in the front of the neck,\\nwhich can be hazardous. The safety of the device during\\npregnancy has not been established.\\nTENS doesn’t cure any condition; it simply eases\\npain. Patients who are not sure what is causing their pain\\nshould consult a physician before using TENS.\\nDescription\\nThe TENS device is a small battery-powered stimu-\\nlator that produces low-intensity electrical signals through\\nelectrodes on or near a painful area, producing a tingling\\nsensation that reduces pain. There is no dosage limitation,\\nand the patient controls the amount of pain relief.\\nSome experts believe TENS works by blocking pain\\nsignals in the spinal cord, or by delivering electrical\\nimpulses to underlying nerve fibers that lessen the expe-\\nrience of pain. Others suspect that the electrical stimula-\\ntion triggers the release of natural painkillers in the body.\\nPatients can rent a TENS unit before buying one, to\\nsee if it is effective against their pain.\\nPreparation\\nAfter TENS has been prescribed, a doctor will refer\\nthe patient to a TENS specialist, who will explain how to\\nuse the machine. The specialist works with the patient to\\ndetermine the settings and electrode placements for the\\nbest pain relief.\\nKEY TERMS\\nFibromyalgia —A condition characterized by\\naching and stiffness, fatigue and poor sleep, as\\nwell as tenderness at various sites on the body.\\nOsteoarthritis—A painful joint disease aggravated\\nby mechanical stress.\\nPhantom limb—The perception that a limb is pre-\\nsent (and throbbing with pain) after it has been\\namputated.\\nPost-herpetic neuralgia —Lingering pain that can\\nlast for years after an attack of shingles.\\nSciatica —Pain that radiates along the sciatic\\nnerve, extending from the buttock down the leg to\\nthe foot.\\nTemporomandibular joint pain (TMJ) —Pain and\\nother symptoms affecting the head, jaw, and face\\nthat are caused when the jaw joints and muscles\\ncontrolling them don’t work together correctly.\\nRisks\\nTENS is nonaddictive and completely safe. The only\\nside effect may be a slight skin irritation or redness in\\nsome people, which can be prevented by using different\\ngels or electrodes.\\nNormal results\\nThe amount of relief a person gets using TENS\\ndepends on the underlying cause of the pain, a person’s\\nmental state, and whether or not medication is also used.\\nAt least one study found that both a real TENS machine\\nand a placebo were equally effective in reducing pain.\\nThis suggests that at least part of its effectiveness may be\\ndue to the patient’s belief in its ability to ease pain.\\nCarol A. Turkington\\nElectrical stimulation of \\nthe brain\\nDefinition\\nElectrical stimulation of the brain (ESB) is a rela-\\ntively new technique used to treat chronic pain and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1145\\nElectrical stimulation of the brain\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1145'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 532, 'page_label': '533'}, page_content='tremors associated with Parkinson disease . ESB is\\nadministered by passing an electrical current through an\\nelectrode implanted in the brain.\\nPurpose\\nWhile the implantation of electrodes in the brain is\\nused to treat or diagnose several disorders, the term ESB\\nis limited here to the treatment of tremors, and as a pain\\nmanagement tool for patients suffering from back prob-\\nlems and other chronic injuries and illnesses.\\nPrecautions\\nAn ESB tremor control device, used in treating\\nParkinson patients, may interfere with or be affected by\\ncardiac pacemakers and other medical equipment. As a\\nresult, patients with other implanted medical equipment\\nmay not be good candidates for the therapy.\\nDescription\\nElectrical stimulation of the brain, or deep brain\\nstimulation, is effective in treating tremors in up to 88%\\nof Parkinson disease patients. An electrode is implanted\\ninto the thalamus (part of the brain) of the patient, and\\nattached to an electric pulse generator via an extension\\nwire. The pulse generator is implanted into the patient’s\\npectoral, or chest area, and the extension wire is tunneled\\nunder the skin. The pulse generator sends out intermit-\\ntent electrical stimulation to the electrode in the thala-\\nmus, which inhibits or partially relieves the tremor. The\\ngenerator can be turned on and off with a magnet, and\\nneeds to be replaced every three to five years.\\nSimilar methods have been used to treat chronic pain\\nthat responded unfavorably to conventional therapies. A\\nremote transmitter allows these patients to trigger elec-\\nKEY TERMS\\nInfarction —A sudden insuffiency of local blood\\nsupply.\\nNeuralgia —Pain extending along one or more\\nnerves.\\nNeuropathy—A functional disturbance or change\\nin the nervous system.\\nParkinson disease—A chronic neurological illness\\nthat causes tremors, stiffness, and difficulty in mov-\\ning and walking.\\ntric stimulation to relieve their symptoms on an as-need-\\ned basis. Patients with failed back syndrome, trigeminal\\nneuropathy (pertaining to the fifth cranial nerve), and\\nperipheral neuropathy fared well for pain control with\\nthis treatment, while patients with spinal cord injury\\nand postherpetic neuralagia (pain along the nerves fol-\\nlowing herpes) did poorly.\\nPreparation\\nThe patient should be free of any type of infection\\nbefore undergoing an ESB procedure. He or she may be\\nadvised to discontinue any medication for a prescribed\\nperiod of time before surgery.\\nAftercare\\nAfter neurosurgery, patients should undergo regular\\nhead dressing changes, minimize exposure to others, and\\npractice good personal hygiene in order to prevent a\\nbrain infection. The head may also be kept elevated for a\\nprescribed period of time in order to decrease swelling of\\nthe brain.\\nRisks\\nThe implantation of electrodes into the brain carries\\nrisks of hemorrhage, infarction, infection, and cerebral\\nedema. These complications could cause irreversible\\nneurological damage.\\nPatients with an implanted ESB tremor control\\ndevice may experience headaches, disequilibrium (a dis-\\nturbance of the sense of balance), burning or tingling of\\nthe skin, or partial paralysis.\\nNormal results\\nESB is effective in pain control for specific condi-\\ntions. It can provide long-term pain relief with few side\\neffects or complications.\\nFor the control of tremors a deep brain stimulator\\ndoes provide some relief. It is recommended for patients\\nwith tremors severe enough to affect their quality of life.\\nResources\\nPERIODICALS\\nDewar, Sandra, et al. “Intracranial Electrode Monitoring for\\nSeizure Localization: Indications, Methods and Preven-\\ntion of Complications.”Journal of Neuroscience Nursing\\n28, no. 5 (Oct. 1996):. 280 8.\\nKumar, K., C. Toth, and R. K. Nath. “Deep Brain Stimulation\\nfor Intractable Pain: A 15-Year Experience.”Neurosurgery\\n40, no. 4 (Apr. 1997): 736 46.\\nGALE ENCYCLOPEDIA OF MEDICINE 21146\\nElectrical stimulation of the brain\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1146'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 533, 'page_label': '534'}, page_content='Oostra, K., M. Van Laere, and B. Scheirlinck. “Use of Electri-\\ncal Stimulation in Brain-Injured Patients: A Case Report.”\\nBrain Injury 11, no. 10 (Oct. 1997): 761 4.\\nOTHER\\nThe Parkinson’s Web..\\nUniversity of Southern California. The ANGEL Neurosurgical\\nInformation Resource. .\\nPaula Anne Ford-Martin\\nElectrocardiography\\nDefinition\\nElectrocardiography is a commonly used, non-inva-\\nsive procedure for recording electrical changes in the\\nheart. The record, which is called an electrocardiogram\\n(ECG or EKG), shows the series of waves that relate to\\nthe electrical impulses which occur during each beat of\\nthe heart. The results are printed on paper or displayed\\non a monitor. The waves in a normal record are named P,\\nQ, R, S, and T and follow in alphabetical order. The num-\\nber of waves may vary, and other waves may be present.\\nPurpose\\nElectrocardiography is a starting point for detecting\\nmany cardiac problems. It is used routinely in physical\\nexaminations and for monitoring the patient’s condition\\nduring and after surgery, as well as during intensive care.\\nIt is the basic measurement used for tests such as exercise\\ntolerance. It is used to evaluate causes of symptoms such\\nas chest pain, shortness of breath, and palpitations.\\nPrecautions\\nNo special precautions are required.\\nDescription\\nThe patient disrobes from the waist up, and elec-\\ntrodes (tiny wires in adhesive pads) are applied to specif-\\nic sites on the arms, legs, and chest. When attached, the\\nelectrodes are called leads; three to 12 leads may be\\nemployed.\\nMuscle movement may interfere with the recording,\\nwhich lasts for several beats of the heart. In cases where\\nrhythm disturbances are suspected to be infrequent, the\\npatient may wear a small Holter monitor in order to\\nrecord continuously over a 24-hour period; this is known\\nas ambulatory monitoring.\\nPreparation\\nThe skin is cleaned to obtain good electrical contact\\nat the electrode positions.\\nAftercare\\nTo avoid skin irritation from the salty gel used to\\nobtain good electrical contact, the skin should be thor-\\noughly cleaned after removal of the electrodes.\\nRisks\\nNo complications from this procedure have been\\nobserved.\\nNormal results\\nWhen the heart is operating normally, each part con-\\ntracts in a specific order. Contraction of the muscle is\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1147\\nElectrocardiography\\nAn EKG strip indicting atrial flutter.(Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nThis EKG strip shows evidence of Wolff-Parkinson-White\\nsyndrome. (Custom Medical Stock Photo. Reproduced by per-\\nmission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1147'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 534, 'page_label': '535'}, page_content='triggered by an electrical impulse. These electrical\\nimpulses travel through specialized cells that form a con-\\nduction system. Following this pathway ensures that con-\\ntractions will occur in a coordinated manner.\\nWhen the presence of all waves is observed in the\\nelectrocardiogram and these waves follow the order\\ndefined alphabetically, the heart is said to show a normal\\nsinus rhythm, and impulses may be assumed to be fol-\\nlowing the regular conduction pathway.\\nThe heart is described as showing arrhythmia or dys-\\nrhythmia when time intervals between waves, the order,\\nor the number of waves do not fit this pattern. Other fea-\\ntures that may be altered include the direction of wave\\ndeflection and wave widths.\\nIn the normal heart, electrical impulses—at a rate of\\n60–100 times per minute—originate in the sinus node.\\nThe sinus node is located in the first chamber, known as\\nthe right atrium, where blood re-enters the heart. After\\ntraveling down to the junction between the upper and\\nlower chambers, the signal stimulates the atrioventricular\\nnode. From here, after a delay, it passes by specialized\\nroutes through the lower chambers or ventricles. In many\\ndisease states, the passage of the electrical impulse can\\nbe interrupted in a variety of ways, causing the heart to\\nperform less efficiently.\\nAbnormal results\\nSpecial training is required for interpretation of the\\nelectrocardiogram. To summarize the features used in inter-\\npretations in the simplest manner, the P wave of the electro-\\ncardiogram is associated with the contraction of the atria.\\nThe QRS series of waves, or QRS complex, is associated\\nwith ventricular contraction, with the T wave coming after\\nthe contraction. Finally, the P-Q or P-R interval gives a\\nvalue for the time taken for the electrical impulse to travel\\nfrom the atria to the ventricle (normally less than 0.2 sec).\\nThe cause of dysrhythmia is ectopic beats. Ectopic\\nbeats are premature heart beats that arise from a site\\nother than the sinus node—commonly from the atria,\\natrioventricular node, or the ventricle. When these dys-\\nrhythmias are only occasional, they may produce no\\nsymptoms, or a feeling of the heart turning over or “flip-\\nflopping” may be experienced. These occasional dys-\\nrhythmias are common in healthy people, but they also\\ncan be an indication of heart disease.\\nThe varied sources of dysrhythmias provide a wide\\nrange of alterations in the form of the electrocardiogram.\\nEctopic beats that start in the ventricle display an abnor-\\nmal QRS complex. This can indicate disease associated\\nwith insufficient blood supply to the muscle (myocardial\\nischemia). Multiple ectopic sites lead to rapid and unco-\\nordinated contractions of the atria or ventricles. This con-\\ndition is known as fibrillation. In atrial fibrillation, P\\nwaves are absent, and the QRS complex appears at errat-\\nic intervals, or “irregularly irregular.”\\nWhen the atrial impulse fails to reach the ventricle, a\\ncondition known as heart block results. If this is partial,\\nthe P-R interval (the time for the impulse to reach the ven-\\ntricle) is prolonged. If complete, the ventricles beat inde-\\npendently of the atria at about 40 beats per minute, and\\nthe QRS complex is mostly dissociated from the P wave.\\nResources\\nBOOKS\\nAtwood, Sandra, et al. Introduction to Basic Cardiac Dysrhyth-\\nmias. St. Louis: Mosby, 1990.\\nGALE ENCYCLOPEDIA OF MEDICINE 21148\\nElectrocardiography\\nA patient undergoing electrocardiography.(Russell Curtis,\\nPhoto Researchers. Reproduced by permission.)\\nKEY TERMS\\nAmbulatory monitoring —ECG recording over a\\nprolonged period during which the patient can\\nmove around.\\nArrhythmia or dysrhythmia—Abnormal rhythm in\\nhearts that contract in an irregular way.\\nECG or EKG—A record of the waves that relate to\\nthe electrical impulses produced at each beat of\\nthe heart.\\nElectrodes —Tiny wires in adhesive pads that are\\napplied to the body for ECG measurement.\\nFibrillation —Rapid, uncoordinated contractions\\nof the upper or the lower chambers of the heart.\\nLead—Name given the electrode when it is\\nattached to the skin.\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1148'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 535, 'page_label': '536'}, page_content='Conover, Mary Boudreau. Understanding Electrocardiogra-\\nphy. St. Louis: Mosby, 1996.\\nWalter, John B. Introduction to the Principles of Disease.\\nPhiladelphia: W. B. Saunders Co., 1992.\\nPERIODICALS\\nMorton, Patricia Gonce. “Using the 12-Lead ECG to Detect\\nIschemia, Injury, and Infarction.”Critical Care Nurse\\n(Apr. 1996): 85-95.\\nVan Riper, Sharon, and Ann Luciano. “Basic Cardiac Arrhyth-\\nmias: A Review for Postanesthesia Care Unit Nurses.”\\nJournal of Postanesthesia Nursing(Feb. 1994): 2-13.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nAlison M. Grant\\nElectroconvulsive therapy\\nDefinition\\nElectroconvulsive therapy (ECT) is a medical treat-\\nment for severe mental illness in which a small, carefully\\ncontrolled amount of electricity is introduced into the\\nbrain. This electrical stimulation, used in conjunction with\\nanesthesia and muscle relaxant medications, produces a\\nmild generalized seizure or convulsion. While used to treat\\na variety of psychiatric disorders, it is most effective in the\\ntreatment of severe depression, and provides the most\\nrapid relief currently available for this illness.\\nPurpose\\nThe purpose of electroconvulsive therapy is to provide\\nrelief from the signs and symptoms of mental illnesses\\nsuch as severe depression, mania, and schizophrenia.\\nECT is indicated when patients need rapid improvement\\nbecause they are suicidal, self-injurious, refuse to eat or\\ndrink, cannot or will not take medication as prescribed, or\\npresent some other danger to themselves. Antidepressant\\nmedications, while effective in many cases, may take two\\nto six weeks to produce a therapeutic effect. Antipsychotic\\nmedications used to treat mania and schizophrenia have\\nmany uncomfortable and sometimes dangerous side\\neffects, limiting their use. In addition, some patients devel-\\nop allergiesand therefore are unable to take their medicine.\\nPrecautions\\nThe most common risks associated with ECT are\\ndisturbances in heart rhythm. Broken or dislocated bones\\noccur very rarely.\\nDescription\\nThe treatment of severe mental illness, such as\\nschizophrenia, using electroconvulsive therapy was\\nintroduced in 1938 by two Italian doctors named Cerletti\\nand Bini. In those days many doctors believed that con-\\nvulsions were incompatible with schizophrenia since,\\naccording to their obervations, this disease rarely\\noccurred in individuals suffering from epilepsy. They\\nconcluded, therefore, that if convulsions could be artifi-\\ncally produced in patients with schizophrenia, the illness\\ncould be cured. Some doctors were already using a vari-\\nety of chemicals to produce seizures, but many of their\\npatients died or suffered severe injuries because the\\nstrength of the convulsions could not be well controlled.\\nElectroconvulsive therapy is among the most contro-\\nversial of all procedures used to treat mental illness.\\nWhen it was first introduced, many people were fright-\\nened simply because it was called “shock treatment.”\\nMany assumed the procedure would be painful, others\\nthought it was a form of electrocution, and still others\\nbelieved it would cause brain damage. Unfortunately,\\nunfavorable publicity in newspapers, magazines, and\\nmovies added to these fears.\\nIndeed, in those early years, patients and families\\nwere rarely educated by doctors and nurses regarding this\\nor other forms of psychiatric treatment. In addition, no\\nanesthesia or muscle relaxants were used. As a result,\\npatients had violent seizures, and even though they did\\nnot remember them, the procedure itself was frightening.\\nThe way these treatments are given today is very dif-\\nferent from the procedures used in the past. Currently,\\nECT is offered on both an inpatient and outpatient basis.\\nHospitals have specially equipped rooms with oxygen,\\nsuction, and cardiopulmonary resuscitation (CPR) in\\norder to deal with the rare emergency.\\nThe treatment is carried out as follows: approxi-\\nmately 30 minutes before the scheduled treatment time,\\nthe patient may receive an injection of a medication\\n(such as atropine) that keeps the pulse rate from decreas-\\ning too much during the convulsion. Next, the patient is\\nplaced on a cot and hooked up to a machine that automat-\\nically takes and displays vital signs (temperature, pulse,\\nrespiration, and blood pressure) on a television-like mon-\\nitor. A mild anesthetic is then injected into a vein, fol-\\nlowed by a medication (such a Anectine) that relaxes all\\nof the muscles in the body so that the seizure is mild, and\\nthe risk of broken bones is virtually eliminated.\\nWhen the patient is both relaxed and asleep, an air-\\nway is placed in the mouth to aid with breathing. Elec-\\ntrodes are placed on the sides of the head in the temple\\nareas. An electric current is passed through the brain by\\nmeans of a machine specifically designed for this pur-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1149\\nElectroconvulsive therapy\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1149'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 536, 'page_label': '537'}, page_content='KEY TERMS\\nMania—A mood disorder in which a person expe-\\nriences prolonged elation or irritability character-\\nized by overactivity that can lead to exhaustion\\nand medical emergencies.\\nRelapse —A return of the signs and symptoms of\\nan illness.\\nSchizophrenia —A severe mental illness in which\\na person has difficulty distinguishing what is real\\nfrom what is not real. It is often characterized by\\nhallucinations, delusions, and withdrawal from\\npeople and social activities.\\npose. The usual dose of electricity is 70–150 volts for\\n0.1–0.5 seconds. In the first stage of the seizure (tonic\\nphase), the muscles in the body that have not been para-\\nlyzed by medication contract for a period of five to 15\\nseconds. This is followed by the second stage (clonic\\nphase) that is characterized by twitching movements,\\nusually visible only in the toes or in a non-paralyzed arm\\nor leg. These are caused by alternating contraction and\\nrelaxation of these same muscles. This stage lasts\\napproximately 10–60 seconds. The entire procedure,\\nfrom beginning to end, lasts about 30 minutes.\\nThe total number of treatments a patient will receive\\ndepends upon many factors such as age, diagnosis, the\\nhistory of illness, family support, and response to thera-\\npy. Patients with depression, for example, usually require\\nsix to 12 treatments. Treatments are usually administered\\nevery other day, three times a week.\\nThe electrodes may be placed on both sides of the\\nhead (bilateral) or one side (unilateral). While bilateral\\nECT appears to be somewhat more effective, unilateral\\nECT is preferred for individuals who experience pro-\\nlonged confusion or forgetfulness following treatment.\\nMany doctors begin treatment with unilateral ECT, then\\nchange to bilateral if the patient is not improving.\\nPost-treatment confusion and forgetfulness are com-\\nmon, though disturbing symptoms associated with ECT.\\nDoctors and nurses must be patient and supportive by\\nproviding patients with factual information about recov-\\nery. Elderly patients, for example, may become increas-\\ningly confused and forgetful as the treatments continue.\\nThese symptoms usually subside with time, but a small\\nminority of patients state that they have never fully\\nrecovered from these effects.\\nWith the introduction of antipsychotics in the 1950s, the\\nuse of ECT became less frequent. These new medications\\nprovided relief for untold thousands of patients who suffered\\ngreatly from their illness. However, there are a number of\\nside effects associated with these drugs, some of which are\\nirreversible. Another drawback is that some medications do\\nnot produce a therapeutic effect for two to six weeks. During\\nthis time the patient may present a danger to himself or oth-\\ners. In addition, there are patients who do not respond to\\nmedicine or who have severe allergic reactions. For these\\nindividuals, ECT may be the only treatment that will help.\\nPreparation\\nPatients and relatives are prepared for ECT by being\\nshown video tapes that explain both the procedure and the\\nrisks involved. The physician then answers any questions\\nthese individuals may have, and the patient is asked to\\nsign an “Informed Consent Form.” This gives the doctor\\nand the hospital permission to administer the treatment.\\nOnce the form is signed, the doctor performs a com-\\nplete physical examination , and orders a number of\\ntests that can help identify any potential problem. These\\ntests may include a chest x ray , an electrocardiogram\\n(ECG), urinalysis , spinal x ray, brain wave (EEG), and\\ncomplete blood count (CBC).\\nSome medications, such as lithium and a type of anti-\\ndepressant known as monoamine oxidase inhibitors ,\\nshould be discontinued for some time before treatment.\\nPatients are instructed not to eat or drink for at least eight\\nhours prior to the procedure in order to reduce the possi-\\nbility of vomiting and choking.\\nAftercare\\nAfter the treatment, patients are moved to a recovery\\narea. Vital signs are recorded every five minutes until the\\npatient is fully awake, which may take 15–30 minutes.\\nSome initial confusion may be present but usually disap-\\npears in a matter of minutes. There may be complaints of\\nheadache, muscle pain, or back pain. Such discomfort is\\nquickly relieved by mild medications such as aspirin.\\nRisks\\nAdvanced medical technology has substantially\\nreduced the complications associated with ECT. These\\ninclude slow heart beat (bradycardia), rapid heart beat\\n(tachycardia), memory loss, and confusion. Persons at\\nhigh risk for ECT include those with recent heart\\nattack, uncontrolled blood pressure, brain tumors, and\\nprevious spinal injuries.\\nNormal results\\nECT often produces dramatic improvement in the\\nsigns and symptoms of major depression, especially in\\nGALE ENCYCLOPEDIA OF MEDICINE 21150\\nElectroconvulsive therapy\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1150'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 537, 'page_label': '538'}, page_content='elderly individuals, sometimes during the first week of\\ntreatment. While it is estimated that 50% of these\\npatients will experience a future return of symptoms, the\\nprognosis for each episode of illness is good. Mania also\\noften responds well to treatment. The picture is not as\\nbright for schizophrenia, which is more difficult to treat\\nand is characterized by frequent relapses.\\nA few patients are placed on maintenance ECT. This\\nmeans they return to the hospital every one to two\\nmonths, as needed, for an additional treatment. These\\nindividuals are thus able to keep their illness under con-\\ntrol and lead a normal and productive life.\\nResources\\nBOOKS\\nAntai-Otong, Deborah. Psychiatric Nursing: Biological and\\nBehavioral Concepts. Philadelphia: W. B. Saunders Co.,\\n1995.\\nHaber, Judith, et al. Comprehensive Psychiatric Nursing. St.\\nLouis: Mosby-Year Book, Inc., 1997.\\nStuart, Gail W., and Michele T. Laraia. Principles and Practice\\nof Psychiatric Nursing. St. Louis: Mosby-Year Book, Inc.,\\n1998.\\nTownsend, Mary C. Psychiatric Mental Health Nursing: Con-\\ncepts of Care. Philadelphia: F. A. Davis Co., 1996.\\nORGANIZATIONS\\nNational Institutes of Health. 5600 Fishers Lane. Room 7CO2,\\nRockville, MD 20857. (301) 496-4000. .\\nDonald G. Barstow, RN\\nElectrocution see Electric shock injuries\\nElectroencephalography\\nDefinition\\nElectroencephalography, or EEG, is a neurological\\ntest that uses an electronic monitoring device to measure\\nand record electrical activity in the brain.\\nPurpose\\nThe EEG is a key tool in the diagnosis and manage-\\nment of epilepsy and other seizure disorders. It is also used\\nto assist in the diagnosis of brain damage and disease (e.g.,\\nstroke, tumors, encephalitis), mental retardation, sleep\\ndisorders, degenerative diseases such as Alzheimer’s dis-\\nease and Parkinson’s disease, and certain mental disor-\\nders (e.g.,alcoholism, schizophrenia, autism).\\nAn EEG may also be used to monitor brain activity\\nduring surgery and to determine brain death.\\nPrecautions\\nElectroencephalography should be administered and\\ninterpreted by a trained medical professional only. Data\\nfrom an EEG is only one element of a complete medical\\nand/or psychological patient assessment, and should\\nnever be used alone as the sole basis for a diagnosis.\\nDescription\\nBefore the EEG begins, a nurse or technician attach-\\nes approximately 16–20 electrodes to the patient’s scalp\\nwith a conductive, washable paste. Depending on the\\npurpose for the EEG, implantable or invasive electrodes\\nare occasionally used. Implantable electrodes include\\nsphenoidal electrodes, which are fine wires inserted\\nunder the zygomatic arch, or cheekbone; and depth elec-\\ntrodes, which are surgically-implanted into the brain.\\nThe EEG electrodes are painless, and are used to mea-\\nsure the electrical activity in various regions of the brain.\\nFor the test, the patient lies on a bed, padded table,\\nor comfortable chair and is asked to relax and remain still\\nduring the EEG testing period. An EEG usually takes no\\nmore than one hour. During the test procedure, the\\npatient may be asked to breathe slowly or quickly; visual\\nstimuli such as flashing lights or a patterned board may\\nbe used to stimulate certain types of brain activity.\\nThroughout the procedure, the electroencephalograph\\nmachine makes a continuous graphic record of the\\npatient’s brain activity, or brainwaves, on a long strip of\\nrecording paper or on a computer screen. This graphic\\nrecord is called an electroencephalogram.\\nThe sleep EEG uses the same equipment and proce-\\ndures as a regular EEG. Patients undergoing a sleep EEG\\nare encouraged to fall asleep completely rather than just\\nrelax. They are typically provided a bed and a quiet room\\nconducive to sleep. A sleep EEG lasts up to three hours.\\nIn an ambulatory EEG, patients are hooked up to a\\nportable cassette recorder. They then go about their nor-\\nmal activities, and take their normal rest and sleep for a\\nperiod of up to 24 hours. During this period, the patient\\nand patient’s family record any symptoms or abnormal\\nbehaviors, which can later be correlated with the EEG to\\nsee if they represent seizures.\\nMany insurance plans provide reimbursement for\\nEEG testing. Costs for an EEG range from $100 to more\\nthan $500, depending on the purpose and type of test\\n(i.e., asleep or awake, and invasive or non-invasive elec-\\ntrodes). Because coverage may be dependent on the dis-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1151\\nElectroencephalography\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1151'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 538, 'page_label': '539'}, page_content='order or illness the EEG is evaluating, patients should\\ncheck with their individual insurance plan.\\nPreparation\\nFull instructions should be given to EEG patients\\nwhen they schedule their test. Typically, individuals on\\nmedications that affect the central nervous system, such\\nas anticonvulsants, stimulants, or antidepressants, are\\ntold to discontinue their prescription for a short time\\nprior to the test (usually one to two days). Patients may\\nbe asked to avoid food and beverages that contain caf-\\nfeine, a central nervous system stimulant. However, any\\nsuch request should be cleared by the treating physician.\\nPatients may also be asked to arrive for the test with\\nclean hair free of spray or other styling products.\\nPatients undergoing a sleep EEG may be asked to\\nremain awake the night before their test. They may be\\ngiven a sedative prior to the test to induce sleep.\\nAftercare\\nIf the patient has suspended regular medication for\\nthe test, the EEG nurse or technician should advise him\\nwhen he can begin taking it again.\\nRisks\\nBeing off medication for one to two days may trigger\\nseizures. Certain procedures used during EEG may trig-\\nger seizures in patients with epilepsy. Those procedures\\ninclude flashing lights and deep breathing. If the EEG is\\nbeing used as a diagnostic for epilepsy (i.e., to determine\\nthe type of seizures an individual is suffering from), this\\nmay be a desired effect, although the patient needs to be\\nmonitored closely so that the seizure can be aborted if\\nnecessary. This type of test is known as an ictal EEG.\\nNormal results\\nIn reading and interpreting brainwave patterns, a\\nneurologist or other physician will evaluate the type of\\nbrainwaves and the symmetry, location, and consistency\\nof brainwave patterns. He will also look at the brain-\\nwave response to certain stimuli presented during the\\nEEG test (such as flashing lights or noise). There are\\nfour basic types of brainwaves: alpha, beta, theta, and\\ndelta. “Normal” brainwave patterns vary widely,\\ndepending on factors of age and activity. For example,\\nawake and relaxed individuals typically register an alpha\\nwave pattern of eight to 13 cycles per second. Young\\nGALE ENCYCLOPEDIA OF MEDICINE 21152\\nElectroencephalography\\nThis woman is undergoing an electroencephalogram (EEG) to diagnose Alzheimer’s disease. On the computer screen at the\\nright are the colored scans of the electrical activity in her brain. Alzheimer’s patients show a specific abnormality in their\\nEEGs. (Photograph by Catherine Pouedras, Photo Researchers, Inc. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1152'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 539, 'page_label': '540'}, page_content='children and sleeping adults may have a delta wave pat-\\ntern of under four cycles per second.\\nAbnormal results\\nThe EEG readings of patients with epilepsy or other\\nseizure disorders display bursts or spikes of electrical activ-\\nity. In focal epilepsy, spikes are restricted to one hemi-\\nsphere of the brain. If spikes are generalized to both hemi-\\nspheres of the brain, multifocal epilepsy may be present.\\nThe diagnostic brainwave patterns of other disorders\\nvaries widely. The appearance of excess theta waves\\n(four to eight cycles per second) may indicate brain\\ninjury. Brain wave patterns in patients with brain disease,\\nmental retardation, and brain injury show overall slow-\\ning. A trained medical specialist should interpret EEG\\nresults in the context of the patient’s medical history, and\\nother pertinent medical test results.\\nResources\\nBOOKS\\nNiedermeyer, E., and F. Lopes da Silva, eds. Electroen-\\ncephalography: Basic Principles, Clinical Applications\\nand Related Fields. 3rd ed. Baltimore: Williams &\\nWilkins, 1993.\\nRestak, Richard M. Brainscapes: An Introduction to What Neu-\\nroscience Has Learned About the Structure, Function, and\\nAbilities of the Brain. New York: Hyperion, 1995.\\nPaula Anne Ford-Martin\\nElectrolyte disorders\\nDefinition\\nAn electrolyte disorder is an imbalance of certain\\nionized salts (i.e., bicarbonate, calcium, chloride, magne-\\nsium, phosphate, potassium, and sodium) in the blood.\\nDescription\\nElectrolytes are ionized molecules found throughout\\nthe blood, tissues, and cells of the body. These mole-\\ncules, which are either positive (cations) or negative\\n(anions), conduct an electric current and help to balance\\npH and acid-base levels in the body. Electrolytes also\\nfacilitate the passage of fluid between and within cells\\nthrough a process known as osmosis and play a part in\\nregulating the function of the neuromuscular, endocrine,\\nand excretory systems.\\nThe serum electrolytes include:\\n• Sodium (Na). A positively charged electrolyte that\\nhelps to balance fluid levels in the body and facilitates\\nneuromuscular functioning.\\n• Potassium (K). A main component of cellular fluid, this\\npositive electrolyte helps to regulate neuromuscular\\nfunction and osmotic pressure.\\n• Calcium (Ca). A cation, or positive electrolyte, that\\naffects neuromuscular performance and contributes to\\nskeletal growth and blood coagulation.\\n• Magnesium (Mg). Influences muscle contractions and\\nintracellular activity. A cation.\\n• Chloride (CI). An anion, or negative electrolyte, that\\nregulates blood pressure.\\n• Phosphate (HPO4). Negative electrolyte that impacts\\nmetabolism and regulates acid-base balance and calci-\\num levels.\\n• Bicarbonate (HCO3). A negatively charged electrolyte\\nthat assists in the regulation of blood pH levels. Bicar-\\nbonate insufficiencies and elevations cause acid-base\\ndisorders (i.e., acidosis, alkalosis).\\nMedications, chronic diseases, and trauma (i.e.,\\nburns, fractures, etc. ) may cause the concentration of\\ncertain electrolytes in the body to become too high\\n(hyper-) or too low (hypo-). When this happens, an elec-\\ntrolyte imbalance, or disorder, results.\\nCauses and symptoms\\nSodium\\nHYPERNATREMIA. Sodium helps the kidneys to regu-\\nlate the amount of water the body retains or excretes.\\nConsequently, individuals with elevated serum sodium\\nlevels also suffer from a loss of fluids, or dehydration .\\nHypernatremia can be caused by inadequate water\\nintake, excessive fluid loss (i.e., diabetes insipidus, kid-\\nney disease, severe burns, and prolonged vomiting or\\ndiarrhea), or sodium retention (caused by excessive sodi-\\num intake or aldosteronism). In addition, certain drugs,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1153\\nElectrolyte disorders\\nKEY TERMS\\nEpilepsy —A neurological disorder characterized\\nby recurrent seizures with or without a loss of con-\\nsciousness.\\nIctal EEG—Used to measure brain activity during\\na seizure. May be useful in learning more about\\npatients who aren’t responding to conventional\\ntreatments.\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1153'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 540, 'page_label': '541'}, page_content='including loop diuretics, corticosteroids, and antihyper-\\ntensive medications may cause elevated sodium levels.\\nSymptoms of hypernatremia include:\\n• thirst\\n• orthostatic hypotension\\n• dry mouth and mucous membranes\\n• dark, concentrated urine\\n• loss of elasticity in the skin\\n• irregular heartbeat (tachycardia)\\n• irritability\\n• fatigue\\n• lethargy\\n• heavy, labored breathing\\n• muscle twitching and/or seizures\\nHYPONATREMIA. Up to 1% of all hospitalized\\npatients develop hyponatremia , making it one of the\\nmost common electrolyte disorders. Diuretics, certain\\npsychoactive drugs (i.e., fluoxetine, sertraline, haloperi-\\ndol), specific antipsychotics (lithium), vasopressin,\\nchlorpropamide, the illicit drug “ecstasy”, and other\\npharmaceuticals can cause decreased sodium levels, or\\nhyponatremia. Low sodium levels may also be triggered\\nby inadequate dietary intake of sodium, excessive perspi-\\nration, water intoxication, and impairment of adrenal\\ngland or kidney function.\\nSymptoms of hyponatremia include:\\n• nausea, abdominal cramping, and/or vomiting\\n• headache\\n• edema (swelling)\\n• muscle weakness and/or tremor\\n• paralysis\\n• disorientation\\n• slowed breathing\\n• seizures\\n• coma\\nPotassium\\nHYPERKALEMIA. Hyperkalemia may be caused by\\nketoacidosis (diabetic coma), myocardial infarction\\n(heart attack ), severe burns, kidney failure, fasting ,\\nbulimia nervosa , gastrointestinal bleeding, adrenal\\ninsufficiency, or Addison’s disease . Diuretic drugs,\\ncyclosporin, lithium, heparin, ACE inhibitors, beta\\nblockers, and trimethoprim can increase serum potassi-\\num levels, as can heavy exercise. The condition may also\\nbe secondary to hypernatremia (low serum concentra-\\ntions of sodium). Symptoms may include:\\n• weakness\\n• nausea and/or abdominal pain\\n• irregular heartbeat (arrhythmia)\\n• diarrhea\\n• muscle pain\\nHYPOKALEMIA. Severe dehydration, aldosteronism,\\nCushing’s syndrome, kidney disease, long-term diuretic\\ntherapy, certain penicillins , laxative abuse, congestive\\nheart failure , and adrenal gland impairments can all\\ncause depletion of potassium levels in the bloodstream. A\\nsubstance known as glycyrrhetinic acid, which is found\\nin licorice and chewing tobacco, can also deplete potassi-\\num serum levels. Symptoms of hypokalemia include:\\n• weakness\\n• paralysis\\n• increased urination\\n• irregular heartbeat (arrhythmia)\\n• orthostatic hypotension\\n• muscle pain\\n• tetany\\nCalcium\\nHYPERCALCEMIA. Blood calcium levels may be ele-\\nvated in cases of thyroid disorder, multiple myeloma ,\\nmetastatic cancer, multiple bone fractures, milk-alkali\\nsyndrome, and Paget’s disease. Excessive use of calci-\\num-containing supplements and certain over-the-counter\\nmedications (i.e., antacids ) may also cause hypercal-\\ncemia. Symptoms include:\\n• fatigue\\n• constipation\\n• depression\\n• confusion\\n• muscle pain\\n• nausea and vomiting\\n• dehydration\\n• increased urination\\n• irregular heartbeat (arrhythmia)\\nHYPOCALCEMIA. Thyroid disorders, kidney failure,\\nsevere burns, sepsis, vitamin D deficiency, and medica-\\ntions such as heparin and glucogan can deplete blood cal-\\ncium levels. Lowered levels cause:\\n• muscle cramps and spasms\\n• tetany and/or convulsions\\n• mood changes (depression, irritability)\\n• dry skin\\nGALE ENCYCLOPEDIA OF MEDICINE 21154\\nElectrolyte disorders\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1154'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 541, 'page_label': '542'}, page_content='• brittle nails\\n• facial twitching\\nMagnesium\\nHYPERMAGNESEMIA. Excessive magnesium levels\\nmay occur with end-stage renal disease, Addison’s dis-\\nease, or an overdose of magnesium salts. Hypermagne-\\nsemia is characterized by:\\n• lethargy\\n• hypotension\\n• decreased heart and respiratory rate\\n• muscle weakness\\n• diminished tendon reflexes\\nHYPOMAGNESEMIA. Inadequate dietary intake of\\nmagnesium, often caused by chronic alcoholism or mal-\\nnutrition , is a common cause of hypomagnesemia.\\nOther causes include malabsorption syndromes, pancre-\\natitis, aldosteronism, burns, hyperparathyroidism ,\\ndigestive system disorders, and diuretic use. Symptoms\\nof low serum magnesium levels include:\\n• leg and foot cramps\\n• weight loss\\n• vomiting\\n• muscle spasms, twitching, and tremors\\n• seizures\\n• muscle weakness\\n• arrthymia\\nChloride\\nHYPERCHLOREMIA. Severe dehydration, kidney fail-\\nure, hemodialysis, traumatic brain injury, and aldostero-\\nnism can also cause hyperchloremia. Drugs such as boric\\nacid and ammonium chloride and the intravenous (IV)\\ninfusion of sodium chloride can also boost chloride lev-\\nels, resulting in hyperchloremic metabolic acidosis .\\nSymptoms include:\\n• weakness\\n• headache\\n• nausea\\n• cardiac arrest\\nHYPOCHLOREMIA. Hypochloremia usually occurs\\nas a result of sodium and potassium depletion (i.e.,\\nhyponatremia, hypokalemia). Severe depletion of serum\\nchloride levels causes metabolic alkalosis. This alkaliza-\\ntion of the bloodstream is characterized by:\\n• mental confusion\\n• slowed breathing\\n• paralysis\\n• muscle tension or spasm\\nPhosphate\\nHYPERPHOSPHATEMIA. Skeletal fractures or dis-\\nease, kidney failure, hypoparathyroidism , hemodialy-\\nsis, diabetic ketoacidosis , acromegaly, systemic infec-\\ntion, and intestinal obstruction can all cause phosphate\\nretention and build-up in the blood. The disorder occurs\\nconcurrently with hypocalcemia . Individuals with mild\\nhyperphosphatemia are typically asymptomatic, but\\nsigns of severe hyperphosphatemia include:\\n• tingling in hands and fingers\\n• muscle spasms and cramps\\n• convulsions\\n• cardiac arrest\\nHYPOPHOSPHATEMIA. Serum phosphate levels of 2\\nmg/dL or below may be caused by hypomagnesemia and\\nhypokalemia. Severe burns, alcoholism, diabetic ketoaci-\\ndosis, kidney disease, hyperparathyroidism, hypothy-\\nroidism, Cushing’s syndrome, malnutrition, hemodialy-\\nsis, vitamin D deficiency, and prolonged diuretic therapy\\ncan also diminish blood phosphate levels. There are typi-\\ncally few physical signs of mild phosphate depletion.\\nSymptoms of severe hypophosphatemia include:\\n• muscle weakness\\n• weight loss\\n• bone deformities (osteomalacia)\\nDiagnosis\\nDiagnosis is performed by a physician or other quali-\\nfied healthcare provider who will take a medical history,\\ndiscuss symptoms, perform a complete physical exami-\\nnation, and prescribe appropriate laboratory tests.\\nBecause electrolyte disorders commonly affect the neuro-\\nmuscular system, the provider will test reflexes. If a calci-\\num imbalance is suspected, the physician will also check\\nfor Chvostek’s sign, a reflex test that triggers an involun-\\ntary facial twitch, and Trousseau’s sign, a muscle spasm\\nthat occurs in response to pressure on the upper arm.\\nSerum electrolyte imbalances can be detected\\nthrough blood tests. Blood is drawn from a vein on the\\nback of the hand or inside of the elbow by a medical\\ntechnician, or phlebotomist, and analyzed at a lab.\\nNormal levels of electrolytes are:\\n• Sodium. 135–145 mEq/L (serum)\\n• Potassium. 3.5–5.5 mEq/L (serum)\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1155\\nElectrolyte disorders\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1155'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 542, 'page_label': '543'}, page_content='• Calcium. 8.8–10.4 mg/dL (total Ca; serum); 4.7–5.2\\nmg/dL (unbound Ca; serum)\\n• Magnesium. 1.4–2.1 mEq/L (plasma)\\n• Chloride. 100–108 mEq/L (serum)\\n• Phosphate. 2.5–4.5 mg/dL (plasma; adults)\\nStandard ranges for test results may vary due to dif-\\nfering laboratory standards and physiological variances\\n(i.e., gender, age, and other factors). Other blood tests\\nthat determine pH levels and acid-base balance may also\\nbe performed.\\nTreatment\\nTreatment of electrolyte disorders depends on the\\nunderlying cause of the problem and the type of elec-\\nKEY TERMS\\nAcid-base balance —A balance of acidity and\\nalkalinity of fluids in the body that keeps the pH\\nlevel of blood around 7.35–7.45.\\nAldosteronism —A condition defined by high\\nserum levels of aldosterone, a hormone secreted\\nby the adrenal gland that is responsible for\\nincreasing sodium reabsorption in the kidneys.\\nAddison’s disease—A disease characterized by a\\ndeficiency in adrenocortical hormones due to\\ndestruction of the adrenal gland.\\nBulimia nervosa —An eating disorder character-\\nized by binging and purging (self-induced vomit-\\ning) behaviors.\\nMilk-alkali syndrome— Elevated blood calcium\\nlevels and alkalosis caused by excessive intake of\\nmilk and alkalis. Usually occurs in the treatment\\nof peptic ulcer.\\nOrthostatic hypotension —A drop in blood pres-\\nsure that causes faintness or dizziness and occurs\\nwhen one rises to a standing position. Also known\\nas postural hypotension.\\nOsmotic pressure— Pressure that occurs when two\\nsolutions of differing concentrations are separated\\nby a semipermeable membrane, such as a cellular\\nwall, and the lower concentration solute is drawn\\nacross the membrane into the higher concentra-\\ntion solute (osmosis).\\nTetany—A disorder of the nervous system charac-\\nterized by muscle cramps, spasms of the arms and\\nlegs, and numbness of the extremities.\\ntrolyte involved. If the disorder is caused by poor diet or\\nimproper fluid intake, nutritional changes may be pre-\\nscribed. If medications such as diuretics triggered the\\nimbalance, discontinuing or adjusting the drug therapy\\nmay effectively treat the condition. Fluid and electrolyte\\nreplacement therapy, either intravenously or by mouth,\\ncan reverse electrolyte depletion.\\nHemodialysis treatment may be required to reduce\\nserum potassium levels in hyperkalemic patients with\\nimpaired kidney function. It may also be recommended\\nfor renal patients suffering from severe hypermagnesemia.\\nPrognosis\\nA patient’s long-term prognosis depends upon the\\nroot cause of the electrolyte disorder. However, when\\ntreated quickly and appropriately, electrolyte imbalances\\nin and of themselves are usually effectively reversed.\\nWhen they are mild, some electrolyte imbalances\\nhave few to no symptoms and may pass unnoticed. For\\nexample, transient hyperphosphatemia is usually fairly\\nbenign. However, long-term elevations of blood phos-\\nphate levels can lead to potentially fatal soft tissue and\\nvascular calcifications and bone disease, and severe\\nserum phosphate deficiencies (hypophosphatemia) can\\ncause encephalopathy, coma, and death.\\nSevere hypernatremia has a mortality rate of\\n40–60%. Death is commonly due to cerebrovascular\\ndamage and hemorrhage resulting from dehydration and\\nshrinkage of the brain cells.\\nPrevention\\nPhysicians should use caution when prescribing\\ndrugs known to affect electrolyte levels and acid-base\\nbalance. Individuals with kidney disease, thyroid prob-\\nlems, and other conditions that may place them at risk for\\ndeveloping an electrolyte disorder should be educated on\\nthe signs and symptoms.\\nResources\\nBOOKS\\nPost, Theodore, and Burton Rose. Clinical Physiology of Acid-\\nBase and Electrolyte Disorders, 5th ed.New York:\\nMcGraw-Hill Professional, 2001.\\nPERIODICALS\\nCohn, Jay N., et al. “New Guidelines for Potassium Replacement\\nin Clinical Practice: A Contemporary Review by the Nation-\\nal Council on Potassium in Clinical Practice.”Archives of\\nInternal Medicine160, no.16 (Sept. 11, 2000): 2429 36.\\nKumar, Sumit and Tomas Berl. “Sodium.”The Lancet 352, no.\\n9123 (18, July 1998): 220.\\nPaula Ford-Martin\\nGALE ENCYCLOPEDIA OF MEDICINE 21156\\nElectrolyte disorders\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1156'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 543, 'page_label': '544'}, page_content='Electrolyte tests\\nDefinition\\nElectrolytes are positively and negatively charged\\nmolecules, called ions, that are found within cells,\\nbetween cells, in the bloodstream, and in other fluids\\nthroughout the body. Electrolytes with a positive charge\\ninclude sodium, potassium, calcium, and magnesium; the\\nnegative ions are chloride, bicarbonate, and phosphate.\\nThe concentrations of these ions in the bloodstream\\nremain fairly constant throughout the day in a healthy\\nperson. Changes in the concentration of one or more of\\nthese ions can occur during various acute and chronic\\ndisease states and can lead to serious consequences.\\nPurpose\\nTests that measure the concentration of electrolytes\\nare useful in the emergency room and to obtain clues for\\nthe diagnosis of specific diseases. Electrolyte tests are\\nused for diagnosing dietary deficiencies, excess loss of\\nnutrients due to urination, vomiting, and diarrhea ,o r\\nabnormal shifts in the location of an electrolyte within\\nthe body. When an abnormal electrolyte value is detect-\\ned, the physician may either act to immediately correct\\nthe imbalance directly (in the case of an emergency) or\\nrun further tests to determine the underlying cause of the\\nabnormal electrolyte value. Electrolyte disturbances can\\noccur with malfunctioning of the kidney (renal failure),\\ninfections that produce severe and continual diarrhea or\\nvomiting, drugs that cause loss of electrolytes in the\\nurine (diuretics), poisoning due to accidental consump-\\ntion of electrolytes, or diseases involving hormones that\\nregulate electrolyte concentrations.\\nPrecautions\\nElectrolyte tests are performed from routine blood\\ntests. The techniques are simple, automated, and fairly\\nuniform throughout the United States. During the prepa-\\nration of blood plasma or serum, health workers must\\ntake care not to break the red blood cells, especially\\nwhen testing for serum potassium. Because the concen-\\ntration of potassium within red blood cells is much high-\\ner than in the surrounding plasma or serum, broken cells\\nwould cause falsely elevated potassium levels.\\nDescription\\nElectrolyte tests are typically conducted on blood\\nplasma or serum, urine, and diarrheal fluids. Electrolytes\\ncan be classified in at least five different ways. One way\\nis that some electrolytes tend to exist mostly inside cells,\\nor are intracellular, while others tend to be outside cells,\\nor are extracellular. Potassium, phosphate, and magne-\\nsium occur at much greater levels inside the cell than\\noutside, while sodium and chloride occur at much greater\\nlevels extracellularly. A second classification distinguish-\\nes those electrolytes that participate directly in the trans-\\nmission of nerve impulses and those that do not. Sodium,\\npotassium, and calcium are the important electrolytes\\ninvolved in nerve impulses, and disorders affecting them\\nare most closely associated with neurological disorders.\\nA third classification focuses on electrolytes that are able\\nto form a tight union, or complex, with one another. Cal-\\ncium and phosphate have the greatest tendency to form\\ncomplexes with each other. Disorders that cause an\\nincrease in either plasma calcium or phosphate can result\\nin the deposit of calcium-phosphate crystals in the soft\\ntissues of the body. A fourth classification concerns those\\nelectrolytes that influence the acidity or alkalinity of the\\nbloodstream, also known as the pH. The pH of the blood-\\nstream is normally in the range of 7.35–7.45. A decrease\\nbelow this range is called acidosis, while a pH above this\\nrange is called alkalosis. The electrolytes most closely\\nassociated with the pH of the bloodstream are bicarbon-\\nate, chloride, and phosphate.\\nPreparation\\nAll electrolyte tests can be performed on plasma or\\nserum. Plasma is prepared by withdrawing a blood sam-\\nple and placing it in a test tube containing a chemical that\\nprevents blood from clotting (an anticoagulant). Serum is\\nprepared by withdrawing a blood sample, placing it in a\\ntest tube, and allowing it to clot. The blood spontaneously\\nclots within a minute of withdrawing the blood from a\\nvein. The serum or plasma is then rapidly spun with a\\ncentrifuge in order to remove the blood cells or clot.\\nNormal results\\nElectrolyte concentrations are similar whether mea-\\nsured in serum or plasma. Values can be expressed in\\nterms of weight per unit volume (mg/deciliter; mg/dL) or\\nin the number of molecules in a volume, or molarity\\n(moles or millimoles/liter; M or mM). The range of nor-\\nmal values sometimes varies slightly between different\\nage groups, for males and females, and between different\\nanalytical laboratories.\\nThe normal level of serum sodium is in the range of\\n136–145 mM. The normal levels of serum potassium are\\n3.5–5.0 mM. Note that sodium occurs at a much higher\\nconcentration than potassium. The normal concentration\\nof total serum calcium (bound calcium plus free calcium)\\nis in the range of 8.8–10.4 mg/dL. About 40% of the total\\ncalcium in the plasma is loosely bound to proteins; this\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1157\\nElectrolyte tests\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1157'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 544, 'page_label': '545'}, page_content='calcium is referred to as bound calcium. The normal range\\nof free calcium is 4.8–5.2 mg/dL. The normal concentra-\\ntion of serum magnesium is in the range of 2.0–3.0 mg/dL.\\nThe normal concentration range of chloride is\\n350–375 mg/dL or 98–106 mM. The normal level of\\nphosphate, as expressed as the concentration of phospho-\\nrus, is 2.0–4.3 mg/dL. Bicarbonate is an electrolyte that\\nis freely and spontaneously interconvertable with carbon-\\nic acid and carbon dioxide. The normal concentration of\\ncarbonic acid (H\\n2CO3) is about 1.35 mM. The normal\\nconcentration of bicarbonate (HCO 3\\n/H11002\\n) is about 27 mM.\\nThe concentration of total carbon dioxide is the sum of\\ncarbonic acid and bicarbonate; this sum is normally in\\nthe range of 26–28 mM. The ratio of bicarbonate/carbon-\\nic acid is more significant than the actual concentrations\\nof these two forms of carbon dioxide. Its normal value is\\n27/1.35 (equivalent to 20/1).\\nAbnormal results\\nPositively charged electrolytes\\nHigh serum sodium levels (hypernatremia) occur at\\nsodium concentrations over 145 mM, with severe hyper-\\nnatremia over 152 mM. Hypernatremia is usually caused\\nby diseases that cause excessive urination. In these cases,\\nwater is lost, but sodium is still retained in the body. The\\nsymptoms include confusion and can lead to convulsions\\nand coma. Low serum sodium levels (hyponatremia) are\\nbelow 130 mM, with severe hyponatremia at or below 125\\nmM. Hyponatremia often occurs with severe diarrhea,\\nwith losses of both water and sodium, but with sodium\\nloss exceeding water loss. Hyponatremia provokes clinical\\nproblems only if serum sodium falls below 125 mM, espe-\\ncially if this has occurred rapidly. The symptoms can be as\\nmild as tiredness but may lead to convulsions and coma.\\nHigh serum potassium ( hyperkalemia) occurs at\\npotassium levels above 5.0 mM; it is considered severe\\nover 8.0 mM. Hyperkalemia is relatively uncommon, but\\nsometimes occurs in patients with kidney failure who take\\npotassium supplements. Hyperkalemia can result in abnor-\\nmal beating of the heart (cardiac arrhythmias). Low\\nserum potassium ( hypokalemia) occurs when serum\\npotassium falls below 3.0 mM. It can result from low\\ndietary potassium, as during starvation or in patients with\\nanorexia nervosa; from excessive losses via the kidneys,\\nas caused by diuretic drugs; or by diseases of the adrenal\\nor pituitary glands. Mild hypokalemia causes muscle\\nweakness, while severe hypokalemia can cause paralysis,\\nthe inability to breathe, and cardiac arrhythmias.\\nHigh levels of calcium ions ( hypercalcemia) occur\\nat free calcium ion concentrations over 5.2 mg/dL or\\ntotal serum calcium above 10.4 mg/dL. Hypercalcemia\\nusually occurs when the body dissolves bone at an abnor-\\nmally fast rate, increasing both serum calcium and serum\\nphosphate. Sudden hypercalcemia can cause vomiting\\nand coma, while prolonged and moderate hypercalcemia\\nresults in the deposit of calcium phosphate crystals in the\\nkidneys and eye. Hypocalcemia occurs when serum free\\ncalcium ions fall below 4.4 mg/dL, or when total serum\\ncalcium falls below 8.8 mg/dL. Hypocalcemia can result\\nfrom hypoparathyroidism (low parathyroid hormone),\\nfrom failure to produce 1,25-dihydroxyvitamin D, from\\nlow levels of plasma magnesium, and from phosphate\\npoisoning (the phosphate enters the bloodstream and\\nforms a complex with the free serum calcium). Hypocal-\\ncemia can cause depression and muscle spasms.\\nHypermagnesemia occurs at serum magnesium lev-\\nels over 25 mM (60 mg/dL). Hypermagnesemia is rare\\nbut can occur with the excessive consumption of magne-\\nsium salts. Hypomagnesemia occurs when serum magne-\\nsium levels fall below 0.8 mM, and can result from poor\\nnutrition . Chronic alcoholism is the most common\\ncause of hypomagnesemia, in part because of poor diet.\\nMagnesium levels below 0.5 mM (1.2 mg/dL) cause\\nserum calcium levels to decline. Some of the symptoms\\nof hypomagnesemia, including twitching and convul-\\nsions, actually result from the concurrent hypocalcemia.\\nHypomagnesemia can also result in hypokalemia and\\nthereby cause cardiac arrhythmias.\\nNegatively charged electrolytes\\nSerum chloride levels sometimes increase to abnor-\\nmal levels as an undesirable side effect of medical treat-\\nment with sodium chloride or ammonium chloride. The\\ntoxicity of chloride results not from the chloride itself, but\\nfrom the fact that the chloride occurs as the acid, hydro-\\ngen chloride (more commonly known as hydrochloric\\nacid, or HCl). An overdose of chloride may cause the\\naccumulation of hydrochloric acid in the bloodstream,\\nwith consequent acidosis. Renal tubular acidosis, one of\\nmany kidney diseases, involves the failure to release acid\\ninto the urine. The acidosis produces weakness,\\nheadache, nausea, and cardiac arrest. Low plasma chlo-\\nride leads to the opposite situation: a decline in the acid\\ncontent of the bloodstream. This is known as alkalization\\nof the bloodstream, or alkalosis. Hydrochloric acid, origi-\\nnally from extracellular fluids, can be lost by vomiting. At\\nits most severe, alkalosis results in paralysis (tetany).\\nHyperphosphatemia occurs at serum phosphate levels\\nabove 5 mg/dL. It can result from the failure of the kidneys\\nto excrete phosphate into the urine, causing phosphate to\\naccumulate in the bloodstream. Hyperphosphatemia can\\nalso be caused by the impaired action of parathyroid hor-\\nmone and by phosphate poisoning. Severe hyperphos-\\nGALE ENCYCLOPEDIA OF MEDICINE 21158\\nElectrolyte tests\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1158'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 545, 'page_label': '546'}, page_content='phatemia can cause paralysis, convulsions, and cardiac\\narrest. These symptoms result because the phosphate,\\noccurring in elevated levels, complexes with free serum\\ncalcium, resulting in hypocalcemia. Tests for heart func-\\ntion (an electrocardiogram) and parathyroid hormone lev-\\nels are used in the diagnosis of hyperphosphatemia.\\nHypophosphatemia occurs if serum phosphorus falls to\\n2.0 mg/dL or lower. It often results from a shift of inorgan-\\nic phosphate from the bloodstream to various organs and\\ntissues. This shift can be caused by a rise in pH (alkaliza-\\ntion) of the bloodstream, which can occur during hyper-\\nventilation, a reaction in various disease states. A shift in\\nphosphate to intracellular tissues may draw calcium away\\nfrom the bloodstream via the formation of insoluble calci-\\num phosphate crystals within cells, with consequent\\nhypocalcemia. Thus, tests for abnormalities in phosphate\\nmetabolism also involve tests for serum calcium.\\nBicarbonate metabolism involves several com-\\npounds. When dietary starches, sugars, and fats are bro-\\nken down for energy production, carbon dioxide is creat-\\ned. Much of this carbon dioxide (CO\\n2) spontaneously\\nconverts to carbonic acid (H 2CO3), and some of the car-\\nbonic acid spontaneously converts to bicarbonate\\n(HCO\\n3\\n/H11002\\n) plus a hydrogen ion (H\\n+\\n). Eventually, almost\\nevery molecule of carbon dioxide produced in the body,\\nwhether in the form of carbon dioxide, carbonic acid, or\\nbicarbonate, must convert back to carbon dioxide in\\norder to leave via the lungs during normal breathing.\\nIf one holds one’s breath, carbon dioxide cannot\\nescape from the lungs, but continues to be generated with-\\nin the body. This results in an increase in production of\\ncarbonic acid. A portion of the carbonic acid breaks apart\\n(dissociates), causing an increase in hydrogen ions in the\\nplasma, with a resulting acidosis. Tests for serum bicar-\\nbonate levels are accompanied by tests for acidosis (pH\\ntest). Conversely, when one breathes too rapidly (hyper-\\nventilation), the carbon dioxide is drawn off from the\\nbloodstream and expelled in the breath at an increased\\nrate. This results in an increase in the rate of combination\\nof bicarbonate with hydrogen ions, resulting in alkalosis.\\nAcidosis and alkalosis can be produced by means other\\nthan by altering the rate of breathing. The carbonic acid\\nand bicarbonate in the bloodstream minimize (or buffer)\\nany trend to acidosis or alkalosis. Tests for bicarbonate\\nare generally accompanied by tests for blood pH and pos-\\nsibly tests for kidney malfunction, abnormal hormone\\nfunction, or gastrointestinal disorders.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nKlahr, S. “Acid-base and Fluid and Electrolyte Disorders.” In\\nTextbook of Primary Care Medicine, ed. J. Noble. St.\\nLouis: Mosby, 1996.\\nPERIODICALS\\nFried, L. F., and P. M. Palevsky. “Hyponatremia and hyperna-\\ntremia.” Medical Clinics of North America 81 (1997):\\n585-609.\\nSutters, M., C. L. Gaboury, and W. M. Bennett. “Severe Hyper-\\nphosphatemia and Hypocalcemia: a Dilemma in Patient\\nManagement.” Journal of the American Society of\\nNephrology 7 (1996): 2056-2061.\\nTom Brody, PhD\\nElectromyography\\nDefinition\\nElectromyography (EMG) is an electrical recording\\nof muscle activity that aids in the diagnosis of neuromus-\\ncular disease.\\nPurpose\\nMuscles are stimulated by signals from nerve cells\\ncalled motor neurons. This stimulation causes electrical\\nactivity in the muscle, which in turn causes contraction.\\nThis electrical activity is detected by a needle electrode\\ninserted into the muscle and connected to a recording\\ndevice. Together, the electrode and recorder are called an\\nelectromyography machine. EMG can determine whether\\na particular muscle is responding appropriately to stimu-\\nlation, and whether a muscle remains inactive when not\\nstimulated.\\nEMG is performed most often to help diagnose dif-\\nferent diseases causing weakness. Although EMG is a\\ntest of the motor system, it may help identify abnormali-\\nties of nerves or spinal nerve roots that may be associated\\nwith pain or numbness. Other symptoms for which EMG\\nmay be useful include numbness, atrophy, stiffness, fas-\\nciculation, cramp, deformity, and spasticity. EMG results\\ncan help determine whether symptoms are due to a mus-\\ncle disease or a neurological disorder, and, when com-\\nbined with clinical findings, usually allow a confident\\ndiagnosis.\\nEMG can help diagnose many muscle and nerve dis-\\norders, including:\\n• muscular dystrophy\\n• congenital myopathies\\n• mitochondrial myopathies\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1159\\nElectromyography\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1159'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 546, 'page_label': '547'}, page_content='• metabolic myopathies\\n• myotonias\\n• peripheral neuropathies\\n• radiculopathies\\n• nerve lesions\\n• amyotrophic lateral sclerosis\\n• polio\\n• spinal muscular atrophy\\n• guillain-Barré syndrome\\n• ataxias\\n• myasthenias\\nPrecautions\\nNo special precautions are needed for this test.\\nPatients with a history of bleeding disorder should con-\\nsult with their treating physician before the test. If a mus-\\ncle biopsy is planned as part of the diagnostic work-up,\\nEMG should not be performed at the same site, as it may\\neffect the microscopic appearance of the muscle.\\nDescription\\nDuring an EMG test, a fine needle is inserted into\\nthe muscle to be tested. This may cause some discomfort,\\nsimilar to that of an injection. Recordings are made while\\nthe muscle is at rest, and then during the contraction. The\\nperson performing the test may move the limb being test-\\ned, and direct the patient to move it with various levels of\\nforce. The needle may be repositioned in the same mus-\\ncle for further recording. Other muscles may be tested as\\nwell. A typical session lasts from 30–60 minutes.\\nA slightly different test, the nerve conduction veloci-\\nty test, is often performed at the same time with the same\\nequipment. In this test, stimulating and recording elec-\\ntrodes are used, and small electrical shocks are applied to\\nmeasure the ability of the nerve to conduct electrical sig-\\nnals. This test may cause mild tingling and discomfort\\nKEY TERMS\\nMotor neurons—Nerve cells that transmit signals\\nfrom the brain or spinal cord to the muscles.\\nMotor unit action potentials —Spikes of electrical\\nactivity recorded during an EMG that reflect the\\nnumber of motor units (motor neurons and the\\nmuscle fibers they transmit signals to) activated\\nwhen the patient voluntarily contracts a muscle.\\nsimilar to a mild shock from static electricity. Evoked\\npotentials may also be performed for additional diagnos-\\ntic information. Nerve conduction velocity and evoked\\npotential testing are especially helpful when pain or sen-\\nsory complaints are more prominent than weakness.\\nPreparation\\nNo special preparation is needed. The doctor super-\\nvising and interpreting the test should be given informa-\\ntion about the symptoms, medical conditions, suspected\\ndiagnosis, neuroimaging studies, and other test results.\\nAftercare\\nMinor pain and bleeding may continue for several\\nhours after the test. The muscle may be tender for a day\\nor two.\\nRisks\\nThere are no significant risks to this test, other than\\nthose associated with any needle insertion (pain, bleed-\\ning, bruising, or infection).\\nNormal results\\nThere should be some brief EMG activity during\\nneedle insertion. This activity may be increased in dis-\\neases of the nerve and decreased in long-standing muscle\\ndisorders where muscle tissue is replaced by fibrous tis-\\nsue or fat. Muscle tissue normally shows no EMG activi-\\nty when at rest or when moved passively by the examin-\\ner. When the patient actively contracts the muscle, spikes\\n(motor unit action potentials) should appear on the\\nrecording screen, reflecting the electrical activity within.\\nAs the muscle is contracted more forcefully, more groups\\nof muscle fibers are recruited or activated, causing more\\nEMG activity.\\nAbnormal results\\nThe interpretation of EMG results is not a simple\\nmatter, requiring analysis of the onset, duration, ampli-\\ntude, and other characteristics of the spike patterns.\\nElectrical activity at rest is abnormal; the particular\\npattern of firing may indicate denervation (for example, a\\nnerve lesion, radiculopathy, or lower motor neuron\\ndegeneration), myotonia, or inflammatory myopathy.\\nDecreases in the amplitude and duration of spikes\\nare associated with muscle diseases, which also show\\nfaster recruitment of other muscle fibers to compensate\\nfor weakness. Recruitment is reduced in nerve disorders.\\nGALE ENCYCLOPEDIA OF MEDICINE 21160\\nElectromyography\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1160'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 547, 'page_label': '548'}, page_content='Resources\\nBOOKS\\nBasmajian, J., and C. DeLuca. Muscles Alive: Their Function\\nRevealed by Electromyography.5th ed. Baltimore:\\nWilliams & Wilkins, 1985.\\nOTHER\\nFalck, B., E. Stalberg, and L. Korpinen. The Expert Elec-\\ntromyographer..\\nRichard Robinson\\nElectronic fetal monitoring\\nDefinition\\nElectronic fetal monitoring (EFM) is a method for\\nexamining the condition of a baby in the uterus by noting\\nany unusual changes in its heart rate. Electronic fetal moni-\\ntoring is performed late in pregnancyor continuously dur-\\ning labor to ensure normal delivery of a healthy baby. EFM\\ncan be utilized either externally or internally in the womb.\\nPurpose\\nThe heart rate of a fetus undergoes constant adjust-\\nment as it responds to its environment and other stimuli.\\nThe fetal monitor records an unborn baby’s heart rate and\\ngraphs it on a piece of paper. Electronic fetal monitoring\\nis usually advised for high-risk pregnancies, when the\\nbaby is in danger of distress. Specific reasons for EFM\\ninclude: babies in a breech position, premature labor ,\\nand induced labor, among others.\\nWhen electronic fetal monitoring was originally\\nintroduced in the 1960s and 1970s, the hope was that it\\nwould help physicians diagnose fetal hypoxia, or lack of\\noxygen, in time to prevent damage to the baby. This lack\\nof oxygen, also known as perinatal asphyxia or birth\\nasphyxia, is an important cause of stillbirth and newborn\\ndeaths. It occurs when there are less than normal\\namounts of oxygen delivered to the body or an organ and\\nthere is build-up of carbon dioxide in the body or tissue.\\nA lack of blood flow to an organ can cause asphyxia.\\nPerinatal asphyxia can occur a long time before birth,\\nshortly before birth, during delivery, or after birth. If the\\ninterruption to the supply of oxygen is short, the baby\\nmay recover without any damage. If the time is longer,\\nthere may be some injury that is reversible. If the time\\nperiod without oxygen is very long, there may be perma-\\nnent injury to one or more organs of the body. It is impor-\\ntant, to detect any signs of asphyxia as soon as possible.\\nOne of the signs is an abnormal heart rate and rhythm in\\nthe unborn baby, which can be detected by electronic\\nfetal monitoring.\\nThe fetal monitor is a more intricate version of the\\nmachine that a health care provider uses to listen to a baby’s\\nheartbeat. The monitor that is used during prenatal visits just\\npicks up the sound of the baby’s heart beating. The fetal\\nmonitor also keeps a continuous paper record of the heart\\nrate. In addition, the fetal monitor can record uterine con-\\ntractions on the lower part of the paper strip. This helps the\\ndoctor or midwife determine how a baby is handling the\\nstress of contractions. The normal pattern is for the baby’s\\nheartbeat to drop slightly during a contraction and then go\\nback to normal after the contraction is over. EFM looks for\\nany changes from this normal pattern, particularly if there is\\na drastic drop in the baby’s heart beat or if the heart rate\\ndoes not recover immediately after a contraction.\\nBecause it is an indirect test, it is not perfect. When\\nan adult complains to a provider about not feeling well,\\nchecking the heart rate is only one of many things that\\nthe doctor will do. With an unborn baby, however, check-\\ning the heart rate is basically the only thing that a doctor\\nor midwife can do.\\nFetal monitoring can be helpful in a variety of differ-\\nent situations. During pregnancy, fetal monitoring can be\\nused as a part of antepartum testing . If the practitioner\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1161\\nElectronic fetal monitoring\\nPubic bone\\nUmbilical cord\\nIntrauterine\\npressure catheter\\nVagina\\nElectronic fetal monitoring (EFM) is performed late in preg-\\nnancy or continuously during labor to ensure normal deliv-\\nery of a healthy baby. EFM can be utilized either externally\\nor internally in the womb.The illustration above shows the\\ninternal procedure, in which an electrode is attached direct-\\nly to the baby’s scalp to monitor the heart rate. Uterine con-\\ntractions are recorded using an intrauterine pressure\\ncatheter which is inserted through the cervix into the\\nuterus. (Illustration by the Electronic Illustrators Group.)\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1161'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 548, 'page_label': '549'}, page_content='feels that a baby may be at increased risk of problems\\ntoward the end of pregnancy, a baby can be checked\\nevery week or every other week with a non-stress test. In\\nthis test, changes in the baby’s heart rate are measured\\nalong with the fetus’ own movements. The heart rate of a\\nhealthy baby should go up whenever she or he moves.\\nFetal monitoring is used on and off during early\\nlabor. As labor progresses, more monitoring is often\\nneeded. Usually, as the time for delivery nears, the moni-\\ntor is left on continuously since the end of labor tends to\\nbe the most stressful time for the baby.\\nA baby who is having trouble in labor will show char-\\nacteristic changes in heart rate after a contraction (late\\ndecelerations). If a baby is not receiving enough oxygen to\\nwithstand the stress of labor and delivery is many hours\\naway, a cesarean section(C-section) may be necessary.\\nDescription\\nUsing the external fetal monitor is simple and painless.\\nTwo elastic belts are placed around the mother’s abdomen.\\nOne belt holds a listening device in place while the other\\nbelt holds the contraction monitor. The nurse or midwife\\nadjusts the belts to get the best readings from each device.\\nSometimes, it is difficult to hear the baby’s heartbeat\\nwith the external monitoring device. Other times, the\\nmonitor may show subtle signs of a developing problem.\\nIn either case, the doctor or midwife may recommend that\\nthe external belt be replaced with an internal monitor.\\nThe internal monitor is an electronic wire that rests\\ndirectly on the baby’s head. The provider can place it on\\nthe baby’s head during an internal exam. The internal\\nmonitor can only be used when the cervix is already\\nopen. This device provides a more accurate record of the\\nbaby’s heart rate.\\nPreparation\\nThere are no special preparations needed for fetal\\nmonitoring.\\nKEY TERMS\\nBreech presentation —Fetal position in which the\\nbuttocks come first.\\nA cesarean section—delivery of a baby through an\\nincision in the mother’s abdomen instead of\\nthrough the vagina.\\nHypoxia—An oxygen deficiency.\\nRisks\\nExternal EFM poses no direct risks to the baby. How-\\never, because of being connected to the machine, the\\nmother cannot walk around. This inactivity may prolong\\nlabor and reduce oxygen levels in the mother’s blood, both\\nof which can be detrimental to the unborn baby. Another\\nproblem is that electronic fetal monitoring seems to be\\nassociated with an increase in caesarian deliveries. There\\nis a concern that EFM can give false alarms of distress in\\nthe baby, and that this can lead to unneeded caesarians.\\nWith internal monitoring, there is a higher risk for infec-\\ntion. For these and other reasons, the United States Pre-\\nventive Services Task Force states that there is some evi-\\ndence that using electronic fetal monitoring on low-risk\\nwomen in labor might not be indicated. Many physicians,\\nhowever, continue to use EFM routinely, and believe it to\\nbe of value in both low-risk and high-risk labors.\\nNormal results\\nAn unborn baby’s heart rate normally ranges from\\n120–160 beats per minute (bpm). A baby who is receiv-\\ning enough oxygen through the placenta will move\\naround. The monitor strip will show the baby’s heart rate\\nrising briefly as he/she moves (just as an adult’s heart\\nrate rises when he/she moves).\\nThe baby’s monitor strip is considered to be reactive\\nwhen the baby’s heart rate rises at least 20 bpm above the\\nbaseline heart rate for at least 20 seconds. This must\\noccur at least twice in a 20-minute period. A reactive\\nheart rate tracing (also known as a reactive non-stress\\ntest) is considered a sign of the baby’s well being.\\nAbnormal results\\nIf the baby’s heart rate drops very low or rises very\\nhigh, this signals a serious problem. In either of these\\ncases it is obvious that the baby is in distress and must be\\ndelivered soon. However, many babies who are having\\nproblems do not give such clear signs.\\nDuring a contraction, the flow of oxygen (from the\\nmother) through the placenta (to the baby) is temporarily\\nstopped. It is as if the baby has to hold its breath during\\neach contraction. Both the placenta and the baby are\\ndesigned to withstand this condition. Between contrac-\\ntions, the baby should be receiving more than enough\\noxygen to do well during the contraction.\\nThe first sign that a baby is not getting enough oxy-\\ngen between contractions is often a drop in the baby’s\\nheart rate after the contraction (late deceleration). The\\nbaby’s heart rate recovers to a normal level between con-\\ntractions, only to drop again after the next contraction.\\nThis is also a more subtle sign of distress.\\nGALE ENCYCLOPEDIA OF MEDICINE 21162\\nElectronic fetal monitoring\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1162'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 549, 'page_label': '550'}, page_content='These babies will do fine if they are delivered in a\\nshort period of time. Sometimes, these signs develop\\nlong before delivery is expected. In that case, a C-section\\nmay be necessary.\\nResources\\nPERIODICALS\\nSweha, Amir, et al. “Interpretation of the Electronic Fetal Heart\\nRate During Labor” American Family Physician (May 1,\\n1999).\\nKripke, Clarissa C. “Why Are We Using Electronic Fetal Mon-\\nitoring?” American Family Physician (May 1, 1999).\\nDeanna M. Swartout-Corbeil, R.N.\\nElectrophysiology study of \\nthe heart\\nDefinition\\nAn electrophysiology (EP) study of the heart is a\\nnonsurgical analysis of the electrical conduction system\\n(normal or abnormal) of the heart. The test employs car-\\ndiac catheters and sophisticated computers to generate\\nelectrocardiogram (EKG) tracings and electrical mea-\\nsurements with exquisite precision from within the heart\\nchambers.\\nThe EP study can be performed solely for diagnostic\\npurposes. It also is performed to pinpoint the exact loca-\\ntion of electrical signals (cardiac mapping) in conjunction\\nwith a therapeutic procedure called catheter ablation.\\nThe test is simple, not painful, and performed in a\\nspecial laboratory under controlled clinical circum-\\nstances by cardiologists and nurses who subspecialize in\\nelectrophysiology.\\nPurpose\\nA cardiologist may recommend an EP study when\\nthe standard EKG, Holter monitor, event recorder, stress\\ntest, echocardiogram, or angiogram cannot provide\\nenough information to evaluate an abnormal heart\\nrhythm, called an arrhythmia.\\nAn EP study also may be beneficial in diagnosing a\\nsuspected arrhythmia in a patient who shows symptoms\\nof an arrhythmia but in whom it could not be detected\\nfrom other tests.\\nThe purpose and great value of an EP study is that it\\noffers more detailed information to the doctor about the\\nelectrical activity in the heart than the aforementioned\\nnoninvasive tests because electrodes are placed directly\\non heart tissue. This allows the electrophysiologist to\\ndetermine the specific location of an arrhythmia and,\\noftentimes, correct it during the same procedure. This\\ncorrective treatment is permanent and considered a cure,\\nand, in many cases, the patient may not need to take heart\\nmedications.\\nEP studies may be helpful in assessing:\\n• certain tachycardias or bradycardias of unknown\\ncause.\\n• patients who have been resuscitated after experiencing\\nsudden cardiac death.\\n• various symptoms of unknown cause, such as chest\\npain, shortness of breath , fatigue, or syncope (dizzi-\\nness/fainting).\\n• response to anti-arrhythmic therapy.\\nPrecautions\\nPregnant patients should not undergo an EP study\\nbecause of exposure to radiation during the study, which\\nmay be harmful to the growing baby.\\nPatients who have coronary artery disease may\\nneed to have that treated before having an EP study.\\nDescription\\nThe rhythmic pumping action of the heart, which is\\nessentially a muscle, is the result of electrical impulses\\ntraveling throughout the walls of the four heart cham-\\nbers. These impulses originate in the sinoatrial (SA)\\nnode, which are specialized cells situated in the top right\\nchamber of the heart: the right atrium. Normally, the SA\\nnode, acting like a spark plug, spontaneously generates\\nthe impulses, which travel through specific pathways\\nthroughout the atria to the atrioventricular (A V) node.\\nThe A V node is a relay station, sending the impulses to\\nmore specialized muscle fibers throughout the bottom\\nchambers of the heart: the ventricles. If these pathways\\nbecome damaged or blocked or if extra (abnormal) path-\\nways exist, the heart’s rhythm may be altered (perhaps\\ntoo slow, too fast, or irregular), which can seriously\\naffect the heart’s pumping ability.\\nThe patient is transported to the x-ray table in the EP\\nlab and connected to various monitors. Sterile sheets are\\nplaced over him or her. A minimum of two catheters are\\ninserted into the right femoral (thigh) vein in the groin\\narea. Depending on the type of arrhythmia, the number\\nof catheters used in an EP test and their route to the heart\\nmay vary. For certain tachycardias, two more catheters\\nmay be inserted in the left groin and one in the internal\\njugular (neck) vein or in the subclavian (below the clavi-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1163\\nElectrophysiology study of the heart\\nGEM -1121 to 1274 - E 10/22/03 6:14 PM Page 1163'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 550, 'page_label': '551'}, page_content='cle) vein. The catheters are about 0.08 in (2 mm) in\\ndiameter, about the size of a spaghetti noodle. The\\ncatheters used in catheter ablation are slightly larger.\\nWith the help of fluoroscopy (x rays on a television\\nscreen), all the catheters are guided to several specific\\nlocations in the heart. Typically, four to 10 electrodes are\\nlocated on the end of the catheters, which have the ability\\nto send electrical signals to stimulate the heart (called\\npacing) and to receive electrical signals from the heart—\\nbut not at the same time (just as a walkie-talkie cannot\\nsend and receive messages at the same time).\\nFirst, the electrodes are positioned to receive signals\\nfrom inside the heart chambers. This allows the doctor to\\nmeasure how fast the electrical impulses travel currently\\nin the patient’s heart. These measurements are called the\\npatient’s baseline measurements. Next, the electrodes are\\npositioned to pace: The EP team actually tries to induce\\n(sometimes in combination with various heart drugs) the\\narrhythmia that the patient has previously experienced so\\nthe team can observe it in a controlled environment,\\ncompare it to the patient’s clinical or spontaneous\\narrhythmia, and decide how to treat it.\\nOnce the arrhythmia is induced and the team deter-\\nmines it can be treated with catheter ablation, cardiac\\nmapping is performed to locate precisely the origin and\\nroute of the abnormal pathway. When this is accom-\\nplished, the ablating electrode catheter is positioned\\ndirectly against the abnormal pathway, and high radio-\\nfrequency energy is delivered through the electrode to\\ndestroy (burn) the tissue in this area.\\nPreparation\\nThe following preparations are made for an EP\\nstudy:\\nGALE ENCYCLOPEDIA OF MEDICINE 21164\\nElectrophysiology study of the heart\\nAn electrophysiologist nurse monitors a patient’s heart rhythm during an electrophysiology study for tachycardia.(Photo-\\ngraph by Collette Placek. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1164'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 551, 'page_label': '552'}, page_content='• the patient may be advised to stop taking certain med-\\nications, especially heart drugs, that may interfere with\\nthe test results.\\n• blood tests usually are ordered the week before the test.\\n• the patient undergoes conscious sedation (awake but\\nrelaxed) during the test. This is accomplished quite\\noften with the anesthetic drugs VersedR (Roche labora-\\ntories) and fentanyl.\\n• a local anesthetic is injected at the site of catheter inser-\\ntion.\\nAftercare\\nThe patient needs to rest flat in bed for several hours\\nafter the procedure to allow healing at the catheter inser-\\ntion sites.\\nThe patient often returns home either the same day\\nof the test or the next day. Someone should drive him or\\nher home.\\nThe doctor may prescribe drugs and/or insert an\\nAFCD to treat the arrhythmia and may do a possible fol-\\nlow-up EP study.\\nRisks\\nThe EP diagnostic study and catheter ablation are low-\\nrisk procedures. There is a small risk of bleeding and/or\\ninfection at the site of catheter insertion, but this occurs less\\nthan 1% of the time. Blood clot formation occurs only two\\nin 1,000 instances and is minimized with blood thinner\\nmedications administered during the procedure. Vascular\\ninjuries causing hemorrhage or thrombophlebitisare pos-\\nsible but occur less than 0.7% of the time. Cardiac perfora-\\ntions occur only in one or two per 1,000 instances. If the\\nright internal jugular vein is accessed, the small possibility\\nof puncturing the lung with the catheter exists, which, at\\nworst, could cause a collapsed lung.\\nBecause ventricular tachycardia or fibrillation\\n(lethal arrhythmias) may be induced in the patient, the\\nEP lab personnel must be prepared to defibrillate the\\npatient as necessary.\\nNormal results\\nThe heart initiates and conducts electrical impulses\\nnormally.\\nAbnormal results\\nConfirmation of arrhythmias, such as:\\n• supraventricular tachycardias\\n• ventricular arrhythmias\\nKEY TERMS\\nAblation—Remove or destroy, such as by burning\\nor cutting.\\nAngiogram —X ray of a blood vessel after special\\nx-ray dye has been injected into it.\\nBradycardia—Slow heartbeat.\\nCardiac catheter—Long, thin, flexible tube, that is\\nthreaded into the heart through a blood vessel.\\nCardiologist—Doctor who specializes in diagnos-\\ning and treating heart diseases.\\nEchocardiogram—Ultrasound image of the heart.\\nElectrocardiogram —Tracing of the electrical\\nactivity of the heart.\\nElectrode —Medium for conducting an electrical\\ncurrent—in this case, platinum wires.\\nElectrophysiology—Study of how electrical signals\\nin the body relate to physiologic function.\\nEvent recorder —A small machine, worn by a\\npatient usually for several days or weeks, that is\\nactivated by the patient to record his or her EKG\\nwhen a symptom is detected.\\nFibrillation—Rapid, random contraction (quivering).\\nHolter monitor —A small machine, worn by a\\npatient usually for 24 hours, that continuously\\nrecords the patient’s EKG during usual daily activity.\\nStress test —Recording a patient’s EKG during\\nexercise.\\nSupraventricular tachycardia —A fast heart beat\\nthat originates above the ventricles.\\nTachycardia—Fast heartbeat.\\nVascular—Pertaining to blood vessels.\\n• accessory (extra) pathways\\n• bradycardias\\nResources\\nBOOKS\\nGrubb, Blair P., and Brian Olshansky. Syncope: Mechanisms\\nand Management. Armonk, NY: Futura Publishing, 1997.\\nHorovitz, Emmanuel. Heartbeat: A Complete Guide to Under-\\nstanding and Preventing Heart Disease.Los Angeles:\\nHealth Trend Publishing, 1988.\\nSinger, Igor. Interventional Electrophysiology.Baltimore:\\nWilliams & Wilkins, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1165\\nElectrophysiology study of the heart\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1165'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 552, 'page_label': '553'}, page_content='ORGANIZATIONS\\nCardiac Arrhythmia Research and Education Foundation\\n(C.A.R.E.). 2082 Michelson Dr. #301 Irvine, CA 92612\\n(800)-404-9500. .\\nMedtronics Manufacturer of Therapeutic Devices. 710\\nMedtronic Parkway NE, Minneapolis, MN 55432-5604.\\n(800) 328-2518. .\\nMidwest Heart Specialists. Physician Office Building, 3825\\nHighland Ave., Tower 2, Ste. 400, Downers Grove, IL\\n60515. (630) 719-4799. .\\nUnited States Catheter Instruments (USCI). 129 Concord Road\\nBillerica, MA 01821. (800) 826-2273.\\nCollette L. Placek\\nElectroshock therapy see Electroconvulsive\\ntherapy\\nElephantiasis\\nDefinition\\nThe word elephantiasis is a vivid and accurate term\\nfor the syndrome it describes: the gross (visible) enlarge-\\nment of the arms, legs, or genitals to elephantoid size.\\nDescription\\nTrue elephantiasis is the result of a parasitic infec-\\ntion caused by three specific kinds of round worms. The\\nlong, threadlike worms block the body’s lymphatic sys-\\ntem—a network of channels, lymph nodes, and organs\\nthat helps maintain proper fluid levels in the body by\\ndraining lymph from tissues into the bloodstream. This\\nblockage causes fluids to collect in the tissues, which can\\nlead to great swelling, called “lymphedema.” Limbs can\\nswell so enormously that they resemble an elephant’s\\nforeleg in size, texture, and color. This is the severely dis-\\nfiguring and disabling condition of elephantiasis.\\nThere are a few different causes of elephantiasis, but\\nthe agents responsible for most of the elephantiasis in the\\nworld are filarial worms: white, slender round worms\\nfound in most tropical and subtropical places. They are\\ntransmitted by particular kinds (species) of mosquitoes,\\nthat is, bloodsucking insects. Infection with these worms\\nis called “lymphatic filariasis” and over a long period of\\ntime can cause elephantiasis.\\nLymphatic filariasis is a disease of underdeveloped\\nregions found in South America, Central Africa, Asia, the\\nPacific Islands, and the Caribbean. It is a disease that has\\nbeen present for centuries, as ancient Persian and Indian\\nwritings clearly described elephant-like swellings of the\\narms, legs, and genitals. It is estimated that 120 million\\npeople in the world have lymphatic filariasis, as of 1997.\\nThe disease appears to be spreading, in spite of decades\\nof research in this area.\\nOther terms for elephantiasis are Barbados leg, ele-\\nphant leg, morbus herculeus, mal de Cayenne, and\\nmyelolymphangioma.\\nOther situations that can lead to elephantiasis are:\\n• a protozoan disease called leishmaniasis\\n• a repeated streptococcal infection\\n• the surgical removal of lymph nodes (usually to prevent\\nthe spread of cancer)\\n• a hereditary birth defect\\nCauses and symptoms\\nThree kinds of round worms cause elephantiasis filar-\\niasis: Wuchereria bancrofti, Brugia malayi , and Brugia\\ntimori. Of these three,W. bancroftimakes up about 90% of\\nthe cases. Man is the only known host of W. bancrofti.\\nCulex, Aedes, and Anopheles mosquitoes are the car-\\nriers of W. bancrofti. Anopheles and Mansonia mosqui-\\ntoes are the carriers of B. malayi. In addition, Anopheles\\nmosquitoes are the carriers of B. timori.\\nInfected female mosquitoes take a blood meal from\\na human, and, in doing so, introduce larval forms of the\\nparticular parasite they carry to the person. These larvae\\nmigrate toward a lymphatic channel, then travel to vari-\\nous places within the lymphatic system, usually position-\\ning themselves in or near lymph nodes throughout the\\nbody. During this time, they mature into more developed\\nlarvae and eventually into adult worms. Depending upon\\nthe species of round worm, this development can take a\\nfew months or more than a year. The adult worms grow\\nto about 1 in (2.5 cm) to 4 in (10 cm) long.\\nThe adult worms can live from about three to eight\\nyears. Some have been known to live to 20 years, and in\\none case 40 years. The adult worms begin reproducing\\nnumerous live embryos, called microfilariae. The micro-\\nfilariae travel to the bloodstream, where they can be\\ningested by a mosquito when it takes a blood meal from\\nthe infected person. If they are not ingested by a mosqui-\\nto, the microfilariae die within about 12 months. If they\\nare ingested by a mosquito, they continue to mature.\\nThey are totally dependent on their specific species of\\nmosquito to develop further. The cycle continues when\\nthe mosquito takes another blood meal.\\nMost of the symptoms an infected person experi-\\nences are due to the blockage of the lymphatic system by\\nthe adult worms and due to the substances (excretions\\nand secretions) produced by the worms.\\nGALE ENCYCLOPEDIA OF MEDICINE 21166\\nElephantiasis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1166'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 553, 'page_label': '554'}, page_content='The body’s allergic reactions may include repeated\\nepisodes of fever, shaking chills, sweating, headaches,\\nvomiting, and pain. Enlarged lymph nodes, swelling of\\nthe affected area, skin ulcers, bone and joint pain, tired-\\nness, and red streaks along the arm or leg also may occur.\\nAbscesses can form in lymph nodes or in the lymphatic\\nvessels. They may appear at the surface of the skin as well.\\nLong-term infection with lymphatic filariasis can\\nlead to lymphedema, hydrocele (a buildup of fluid in any\\nsaclike cavity or duct) in the scrotum, and elephantiasis of\\nthe legs, scrotum, arms, penis, breasts, and vulvae. The\\nmost common site of elephantiasis is the leg. It typically\\nbegins in the ankle and progresses to the foot and leg. At\\nfirst the swollen leg may feel soft to the touch but eventu-\\nally becomes hard and thick. The skin may appear dark-\\nened or warty and may even crack, allowing bacteria to\\ninfect the leg and complicate the disease. The microfilari-\\nae usually don’t cause injury. In some instances, they\\ncause “eosinophilia,” an increased number of eosinophils\\n(a type of white blood cells) in the blood.\\nThis disease is more intense in people who never\\nhave been exposed to lymphatic filariasis than it is in the\\nnative people of tropical areas where the disease occurs.\\nThis is because many of the native people often are\\nimmunologically tolerant.\\nDiagnosis\\nThe only sure way to diagnose lymphatic filariasis is\\nby detecting the parasite itself, either the adult worms or\\nthe microfilariae.\\nMicroscopic examination of the person’s blood may\\nreveal microfilariae. But many times, people who have\\nbeen infected for a long time do not have microfilariae in\\ntheir bloodstream. The absence of them, therefore, does\\nnot mean necessarily that the person is not infected. In\\nthese cases, examining the urine or hydrocele fluid or\\nperforming other clinical tests is necessary.\\nCollecting blood from the individual for microscopic\\nexamination should be done during the night when the\\nmicrofilariae are more numerous in the bloodstream.\\n(Interestingly, this is when mosquitoes bite most frequent-\\nly.) During the day microfilariae migrate to deeper blood\\nvessels in the body, especially in the lung. If it is decided\\nto perform the blood test during the day, the infected indi-\\nvidual may be given a “provocative” dose of medication\\nto provoke the microfilariae to enter the bloodstream.\\nBlood then can be collected an hour later for examination.\\nDetecting the adult worms can be difficult because\\nthey are deep within the lymphatic system and difficult to\\nget to. Biopsies usually are not performed because they\\nusually don’t reveal much information.\\nTreatment\\nThe drug of choice in treating lymphatic filariasis is\\ndiethylcarbamazine (DEC). The trade name in the United\\nStates is Hetrazan.\\nThe treatment schedule is typically 2 mg/kg per day,\\nthree times a day, for three weeks. The drug is taken in\\ntablet form.\\nDEC kills the microfilariae quickly and injures or\\nkills the adult worms slowly, if at all. If all the adult\\nworms are not killed, remaining paired males and\\nfemales may continue to produce more larvae. There-\\nfore, several courses of DEC treatment over a long\\ntime period may be necessary to rid the individual of\\nthe parasites.\\nDEC has been shown to reduce the size of enlarged\\nlymph nodes and, when taken long-term, to reduce ele-\\nphantiasis. In India, DEC has been given in the form of a\\nmedicated salt, which helps prevent spread of the disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1167\\nElephantiasis\\nMan suffering from elephantiasis. (Photograph by C. James\\nWebb, Phototake NYC. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1167'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 554, 'page_label': '555'}, page_content='The side effects of DEC almost all are due to the\\nbody’s natural allergic reactions to the dying parasites\\nrather than to the DEC itself. For this reason, DEC must\\nbe given carefully to reduce the danger to the individual.\\nSide effects may include fever, chills, headache, dizzi-\\nness, nausea and vomiting , itching , and joint pain.\\nThese side effects usually occur within the first few days\\nof treatment. These side effects usually subside as the\\nindividual continues taking the drug.\\nThere is an alternate treatment plan for the use of\\nDEC. This plan is designed to kill the parasites slowly (to\\nreduce allergic reactions to the dead microfilariae and\\ndying adult worms within the body). Lower doses of DEC\\nare taken for the first few days, followed by the higher\\ndose of 2 mg/kg per day for the remaining three weeks. In\\naddition, steroids may be prescribed to prevent the indi-\\nvidual’s body from reacting severely to the dead worms.\\nAnother drug used is Ivermectin. Early research\\nstudies of Ivermectin show that it is excellent in killing\\nKEY TERMS\\nAntigen —Any substance (usually a protein) that\\ncauses an immune response by the body to pro-\\nduce antibodies.\\nFilarial —Threadlike. The word “filament” is\\nformed from the same root word.\\nHost—A person or animal in which a parasite\\nlives, is nourished, grows, and reproduces.\\nLymph—A watery substance that collects in the\\ntissues and organs of the body and eventually\\ndrains into the bloodstream.\\nLymphatic system —A network composed of ves-\\nsels, lymph nodes, the tonsils, the thymus gland,\\nand the spleen. It is responsible for transporting\\nfluid and nutrients to the bloodstream and for\\nmaturing certain blood cells that are part of the\\nbody’s immune system.\\nLymphedema—The unnatural accumulation of\\nlymph in the tissues of the body, which results in\\nswelling in that area.\\nProtozoa —(Plural form of protozoan) Single-\\ncelled organisms (not bacteria) of which about 30\\nkinds cause disease in humans.\\nStreptococcal —Pertaining to any of the Strepto-\\ncoccus bacteria. These organisms can cause pneu-\\nmonia, skin infections, and many other diseases.\\nmicrofilariae, but the effects of this drug on the adult\\nworms are still being investigated. It is probable that\\npatients will need to continue using DEC to kill the adult\\nworms. Mild side effects of Ivermectin include headache,\\nfever, and myalgia.\\nOther means of managing lymphatic filariasis are\\npressure bandages to wrap the swollen limb and elastic\\nstockings to help reduce the pressure. Exercising and ele-\\nvating a bandaged limb also can help reduce its size.\\nSurgery can be performed to reduce elephantiasis by\\nremoving excess fatty and fibrous tissue, draining the\\nswelled area, and removing the dead worms.\\nPrognosis\\nWith DEC treatment, the prognosis is good for early\\nand mild cases of lymphatic filariasis. The prognosis is\\npoor, however, for heavy parasitic infestations.\\nPrevention\\nThe two main ways to control this disease are to take\\nDEC preventively, which has shown to be effective, and\\nto reduce the number of carrier insects in a particular area.\\nAvoiding mosquito bites with insecticides and insect\\nrepellents is helpful, as is wearing protective clothing\\nand using bed netting.\\nMuch effort has been made in cleaning the breeding\\nsites (stagnant water) of mosquitoes near people’s homes\\nin areas where filariasis is found.\\nBefore visiting countries where lymphatic filariasis\\nis found, it would be wise to consult a travel physician to\\nlearn about current preventative measures.\\nResources\\nBOOKS\\nAsh, Laurence R. Atlas of Human Parasitology.4th ed. Chica-\\ngo: ASCP Press, 1997.\\nConn’s Current Therapy, 1996.Ed. Robert E. Rakel. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nCurrent Medical Diagnosis and Treatment, 1996.35th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange,\\n1995.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nWeatherall, D. J. Oxford Textbook of Medicine.3rd ed. Oxford,\\nEngland: Oxford University Press, 1996.\\nZatouroff, Michael. Diagnosis in Color: Physical Signs in\\nGeneral Medicine. 2nd ed. London: Mosby-Wolfe, 1996.\\nPERIODICALS\\nBandyopadhyay, Lalita. “Lymphatic Filariasis and the Women\\nof India.” Social Science and Medicine 42, no.10 (May\\n1996): 1401-1410.\\nGALE ENCYCLOPEDIA OF MEDICINE 21168\\nElephantiasis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1168'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 555, 'page_label': '556'}, page_content='Eberhard, Mark L. “A Survey of Knowledge, Attitudes, and\\nPerceptions (KAPs) of Lymphatic Filariasis, Elephantia-\\nsis, and Hydrocele Among Residents in an Endemic Area\\nin Haiti.” American Journal of Tropical Medicine and\\nHygiene 54, no. 3 (Mar. 1996): 299-303.\\nRajan, T. V . “Immunopathogenetic Aspects of Disease Induced\\nby Helminth Parasites.”Chemical Immunology 66 (1997):\\n125-158.\\nORGANIZATIONS\\nNational Institute of Allergies and Infectious Diseases, Divi-\\nsion of Microbiology and Infectious Diseases. Building\\n31, Room. 7A-50, 31 Center Drive MSC 2520, Bethesda,\\nMD 20892. .\\nNational Lymphedema Network (NLN). 2211 Post St., Suite\\n404, San Francisco, CA 94115. (800) 541-3259. .\\nNational Organization for Rare Disorders. PO Box 8923, New\\nFairfield, CT 06812-8923. (800) 999-6673. .\\nCollette L. Placek\\nEnzyme-linked Immunosorbant (ELISA) see\\nAIDS tests\\nEmbolism\\nDefinition\\nAn embolism is an obstruction in a blood vessel due\\nto a blood clot or other foreign matter that gets stuck\\nwhile traveling through the bloodstream. The plural of\\nembolism is emboli.\\nDescription\\nEmboli have moved from the place where they were\\nformed through the bloodstream to another part of the\\nbody, where they obstruct an artery and block the flow of\\nblood. The emboli are usually formed from blood clots\\nbut are occasionally comprised of air, fat, or tumor tis-\\nsue. Embolic events can be multiple and small, or single\\nand massive. They can be life-threatening and require\\nimmediate emergency medical care. There are three gen-\\neral categories of emboli: arterial, gas, and pulmonary.\\nPulmonary emboli are the most common.\\nArterial embolism\\nIn arterial emboli, blood flow is blocked at the junc-\\ntion of major arteries, most often at the groin, knee, or\\nthigh. Arterial emboli are generally a complication of\\nheart disease. An arterial embolism in the brain (cere-\\nbral embolism) causes stroke, which can be fatal. An\\nestimated 5–14% of all strokes are caused by cerebral\\nemboli. Arterial emboli to the extremities can lead to tis-\\nsue death and amputation of the affected limb if not\\ntreated effectively within hours. Intestines and kidneys\\ncan also suffer damage from emboli.\\nGas embolism\\nGas emboli result from the compression of respira-\\ntory gases into the blood and other tissues due to rapid\\nchanges in environmental pressure, for example, while\\nflying or scuba diving. As external pressure decreases,\\ngases (like nitrogen) that are dissolved in the blood and\\nother tissues become small bubbles that can block blood\\nflow and cause organ damage.\\nPulmonary embolism\\nIn a pulmonary embolism, a common illness, blood\\nflow is blocked at a pulmonary artery. When emboli block\\nthe main pulmonary artery, and in cases where there are\\nno initial symptoms, a pulmonary embolism can quickly\\nbecome fatal. According to the American Heart Associa-\\ntion, an estimated 600,000 Americans develop pulmonary\\nemboli annually and 60,000 die from it.\\nA pulmonary embolism is difficult to diagnose. Less\\nthan 10% of patients who die from a pulmonary\\nembolism were diagnosed with the condition. More than\\n90% of cases of pulmonary emboli are complications of\\ndeep vein thrombosis , blood clots in the deep vein of\\nthe leg or pelvis.\\nCauses and symptoms\\nArterial emboli are usually a complication of heart\\ndisease where blood clots form in the heart’s chambers.\\nGas emboli are caused by rapid changes in environmen-\\ntal pressure that could happen when flying or scuba div-\\ning. A pulmonary embolism is caused by blood clots that\\ntravel through the blood stream to the lungs and block a\\npulmonary artery. More than 90% of the cases of pul-\\nmonary embolism are a complication of deep vein\\nthrombosis, which typically occurs in patients who have\\nhad orthopedic surgery and patients with cancer or\\nother chronic illnesses like congestive heart failure.\\nRisk factors for arterial and pulmonary emboli\\ninclude: prolonged bed rest, surgery, childbirth , heart\\nattack, stroke, congestive heart failure, cancer,obesity,a\\nbroken hip or leg, oral contraceptives , sickle cell ane-\\nmia, chest trauma, certain congenital heart defects, and\\nold age. Risk factors for gas emboli include: scuba div-\\ning, amateur plane flight, exercise, injury, obesity, dehy-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1169\\nEmbolism\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1169'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 556, 'page_label': '557'}, page_content='dration, excessive alcohol, colds, and medications such\\nas narcotics and antihistamines.\\nCommon symptoms of a pulmonary embolism\\ninclude:\\n• labored breathing, sometimes accompanied by chest\\npain\\n• a rapid pulse\\n•a cough that may produce sputum\\n• a low-grade fever\\n• fluid build-up in the lungs\\nLess common symptoms include:\\n• coughing up blood\\n• pain caused by movement or breathing\\n• leg swelling\\n• bluish skin\\n• fainting\\n• swollen neck veins\\nSymptoms of an arterial embolism include:\\n• severe pain in the area of the embolism\\n• pale, bluish cool skin\\n• numbness\\n• tingling\\n• muscular weakness or paralysis\\nDiagnosis\\nAn embolism can be diagnosed through the patient’s\\nhistory, a physical exam, and diagnostic tests. For arterial\\nemboli, cardiac ultrasound and/or arteriography are\\nordered. For a pulmonary embolism, a chest x ray, lung\\nscan, pulmonary angiography , electrocardiography ,\\narterial blood gas measurements, and venography or\\nvenous ultrasound could be ordered.\\nDiagnosing an arterial embolism\\nUltrasound uses sound waves to create an image of\\nthe heart, organs, or arteries. The technician applies gel\\nto a hand-held transducer then presses it against the\\npatient’s body. The ultrasound’s sound waves arteries are\\nconverted into an image that can be displayed on a moni-\\ntor. Performed in an outpatient diagnostic laboratory, the\\ntest takes 30–60 minutes.\\nAn arteriogram is an x ray in which a contrast medi-\\num is injected to make the arteries visible on the x ray. It\\ncan be performed in a radiology unit, outpatient clinic, or\\ndiagnostic center of a hospital.\\nDiagnosing a pulmonary embolism\\nA chest x ray can show fluid build-up and detect\\nother respiratory diseases. The perfusion lung scan shows\\npoor flow of blood in areas beyond blocked arteries. The\\npatient inhales a small amount of radiopharmaceutical\\nand pictures of airflow into the lungs are taken with a\\ngamma camera. Then a different radiopharmaceutical is\\ninjected into an arm vein and lung blood flow is scanned.\\nA normal result essentially rules out a pulmonary\\nembolism. A lung scan can be performed in a hospital or\\nan outpatient facility and takes about 45 minutes.\\nPulmonary angiography is the most reliable test for\\ndiagnosing a pulmonary embolism but it is not used often\\nbecause it is expensive, invasive, and not readily available\\nin most hospitals. Pulmonary angiography is a radiographic\\ntest which involves injection of a radio contrast agent to\\nshow the pulmonary arteries. A cinematic camera records\\nthe blood flow through the patient, who lies on a table. Pul-\\nmonary angiography is usually performed in a hospital’s\\nradiology medicine department and takes 30–60 minutes.\\nAn electrocardiograph shows the heart’s electrical\\nactivity and helps distinguish a pulmonary embolism\\nfrom a heart attack. Electrodes covered with conducting\\njelly are placed on the patient’s chest, arms, and legs.\\nImpulses of the heart’s activity are traced on paper. The\\ntest takes about 10 minutes.\\nArterial blood gas measurements are sometimes\\nhelpful but, alone, they are not diagnostic for pulmonary\\nembolism. Blood is taken from an artery instead of a\\nvein, usually in the wrist.\\nVenography is used to look for the most likely\\nsource of a pulmonary embolism, deep vein thrombosis.\\nIt is very accurate, but it is not used often, because it is\\npainful, expensive, exposes the patient to a fairly high\\ndose of radiation, and can cause complications. Venogra-\\nGALE ENCYCLOPEDIA OF MEDICINE 21170\\nEmbolism\\nA close up view of a pulmonary embolism.(Custom Medical\\nStock Photo. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1170'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 557, 'page_label': '558'}, page_content='phy identifies the location, extent, and degree of attach-\\nment of the blood clots and enables the condition of the\\ndeep leg veins to be assessed. A contrast solution is\\ninjected into a foot vein through a catheter. The physician\\nobserves the movement of the solution through the vein\\nwith a fluoroscope while a series of x rays are taken.\\nVenography takes between 30–45 minutes and can be\\ndone in a physician’s office, a laboratory, or a hospital.\\nRadionuclide venography, in which a radioactive isotope\\nis injected, is occasionally used, especially if a patient\\nhas had reactions to contrast solutions. Venous ultra-\\nsound is the preferred evaluation of leg veins.\\nTreatment\\nPatients with emboli require immediate hospitaliza-\\ntion. They are generally treated with clot-dissolving\\nand/or clot-preventing drugs. Thrombolytic therapy to\\ndissolve blood clots is the definitive treatment for a very\\nsevere pulmonary embolism. Streptokinase, urokinase,\\nand recombinant tissue plasminogen activator (TPA) are\\nused. Heparin is the anticoagulant drug of choice for pre-\\nventing formation of blood clots. Warfarin, an oral anti-\\ncoagulant, is sometimes used concurrently and is usually\\ncontinued after the hospitalization.\\nIn the case of an arterial embolism, the affected limb\\nis placed in a dependent position and kept warm.\\nEmbolectomy is the treatment of choice in the majority\\nof early cases of arterial emboli in the extremities. In this\\nprocedure, a balloon-tipped catheter is inserted into the\\nartery to remove thromboembolic matter.\\nWith a pulmonary embolism, oxygen therapy is\\noften used to maintain normal oxygen concentrations.\\nFor people who can’t take anticoagulants and in some\\nother cases, surgery may be needed to insert a device that\\nfilters blood returning to the heart and lungs.\\nPrognosis\\nOf patients hospitalized with an arterial embolism,\\n25–30% die, and 5–25% require amputation of a limb.\\nAbout 10% of patients with a pulmonary embolism die\\nsuddenly within the first hour of onset of the condition.\\nThe outcome for all other patients is generally good; only\\n3% of patients die who are properly diagnosed early and\\ntreated. In cases of an undiagnosed pulmonary\\nembolism, about 30% of patients die.\\nPrevention\\nEmbolism can be prevented in high risk patients\\nthrough antithrombotic drugs such as heparin, venous\\ninterruption, gradient elastic stockings, and intermittent\\npneumatic compression of the legs. The combination of\\nKEY TERMS\\nAnticoagulants —Drugs that suppress, delay, or\\nprevent blood clots. Anticoagulants are used to\\ntreat embolisms.\\nArtery—A blood vessel that carries blood from the\\nheart to other body tissues. Embolisms obstruct\\narteries.\\nDeep vein thrombosis —A blood clot in the calf’s\\ndeep vein. This frequently leads to pulmonary\\nembolism if untreated.\\nEmboli—Clots or other substances that travel\\nthrough the blood stream and get stuck in an\\nartery, blocking circulation.\\nThrombolytics —Drugs that dissolve blood clots.\\nThrombolytics are used to treat embolisms.\\ngraduated compression stockings and low-dose heparin is\\nsignificantly more effective than low-dose heparin alone.\\nGradient elastic stockings, also called anti-embolism\\nstockings, decrease the risk of blood clots by compress-\\ning superficial leg veins and forcing blood into the deep\\nveins. They can be knee-, thigh-, or waist-length. Many\\nphysicians order the use of stockings before surgery and\\nuntil there is no longer an elevated risk of developing\\nblood clots. The risk of deep vein thrombosis after\\nsurgery is reduced 50% with the use of these stockings.\\nThe American Heart Association recommends that the\\nuse of graduated compression stockings be considered\\nfor all high-risk surgical patients.\\nIntermittent pneumatic compression involves wrap-\\nping knee- or thigh-high cuffs around the legs to prevent\\nblood clots. The cuffs are connected to a pump which\\ninflates and deflates, mimicking the heart’s normal pump-\\ning action and reducing the pooling of blood. Intermittent\\npneumatic compression can be used during surgery and\\nrecovery and continues until there is no longer an elevated\\nrisk of developing blood clots. The American Heart Asso-\\nciation recommends the use of intermittent pneumatic\\ncompression for patients who cannot take anticoagulants,\\nfor example, spinal cord and brain trauma patients.\\nResources\\nBOOKS\\n“Arterial Occlusive Disease.” In Professional Guide to Diseases.\\n5th ed. Springhouse, PA: Springhouse Corporation, 1995.\\nDeBakey, M. E., and A. M. Gotto. “Invasive Diagnostic Proce-\\ndures.” In The New Living Heart. Holbrook, MA: Adams\\nMedia Corporation, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1171\\nEmbolism\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1171'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 558, 'page_label': '559'}, page_content='“Disorders of the Pulmonary Circulation,” “Arterial\\nEmbolism,” and “Other Disorders Due to Physical\\nAgents.” In Current Medical Diagnosis and Treatment,\\n1996. 35th ed. Ed. Stephen McPhee, et al. Stamford:\\nAppleton & Lange, 1995.\\nNoble, John, ed. “Arterial Emboli and Acute Thrombosis.” In\\nTextbook of Primary Care Medicine.2nd ed. St. Louis:\\nMosby, 1996.\\nTexas Heart Institute. “Diseases of the Peripheral Arteries and\\nVeins.” In Texas Heart Institute’s Heart Owner’s Hand-\\nbook. New York: John Wiley & Sons, 1996.\\nPERIODICALS\\nACCP Consensus Committee on Pulmonary Embolism. “Opin-\\nions Regarding the Diagnosis of Venous Thromboembolic\\nDisease.” Chest 113, no. 2 (Feb. 1998): 499-503.\\nCharland, Scott L., and Dawn Klinter. “Low-Molecular Weight\\nHeraprins in the Treatment of Pulmonary Embolism.”The\\nAnnals of Pharmacotherapy 32 (Feb. 1998): 258-263.\\nTapson, Victor F. “Pulmonary Embolism-New Diagnostic\\nApproaches.” The New England Journal of Medicine 336,\\nno. 20 (15 May 1997): 1449-1451.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nOTHER\\n“Management of Deep Vein Thrombosis and Pulmonary\\nEmbolism.” and “Stroke (Brain Attack).”American Heart\\nAssociation. 3 Mar. 1998 .\\n“Warfin and Compression Treatment Prevents Coagulation in\\nKnee ReplacementsAmerican.” Academy of Orthopaedic\\nSurgeons Online. 15 Feb. 1997. 22 Apr. 1998 .\\nLori De Milto\\nEMG see Electromyography\\nEmollient bath see Therapeutic baths\\nEmphysema\\nDefinition\\nEmphysema is a chronic respiratory disease where\\nthere is over-inflation of the air sacs (alveoli) in the\\nlungs, causing a decrease in lung function, and often,\\nbreathlessness.\\nDescription\\nEmphysema is the most common cause of death\\nfrom respiratory disease in the United States, and is the\\nfourth most common cause of death overall. There are\\n1.8 million Americans with the disease, which ranks fif-\\nteenth among chronic conditions that cause limitations of\\nactivity. The disease is usually caused by smoking, but a\\nsmall number of cases are caused by an inherited defect.\\nNormally functioning lungs are elastic, efficiently\\nexpanding and recoiling as air passes freely through the\\nbronchus to the alveoli, where oxygen is moved into the\\nblood and carbon dioxide is filtered out. When a person\\ninhales cigarette smoke or certain other irritants, his or\\nher immune system responds by releasing substances\\nthat are meant to defend the lungs against the smoke.\\nThese substances can also attack the cells of the lungs,\\nbut the body normally inhibits such action with the\\nrelease of other substances. In smokers and those with\\nthe inherited defect, however, no such prevention occurs\\nand the lung tissue is damaged in such a way that it loses\\nits elasticity. The small passageways (bronchioles) lead-\\ning to the alveoli collapse, trapping air within the alveoli.\\nThe alveoli, unable to recoil efficiently and move the air\\nout, over expand and rupture. As the disease progresses,\\ncoughing and shortness of breath occur. In the later\\nstages, the lungs cannot supply enough oxygen to the\\nblood. Emphysema often occurs with other respiratory\\ndiseases, particularly chronic bronchitis. These two dis-\\neases are often referred to as one disorder called chronic\\nobstructive pulmonary disease (COPD).\\nEmphysema is most common among people aged 50\\nand older. Those with inherited emphysema may experience\\nthe onset as early as their thirties or fourties Men are more\\nlikely than women to develop emphysema, but female cases\\nare increasing as the number of female smokers rises.\\nCauses and symptoms\\nHeavy cigarette smoking causes about 80–90% of\\nall emphysema cases. However a few cases are the result\\nof an inherited deficiency of a substance called alpha-1-\\nantitrypsin (AAT). The number of Americans with this\\ndeficiency is relatively small, probably no greater than\\n70,000. Pipe, cigar, and marijuana smoking can also\\ndamage the lungs. While a person may be less likely to\\ninhale cigar and pipe smoke, these types of smoke can\\nalso impair lung function. Marijuana smoke may be even\\nmore damaging because it is inhaled deeply and held in\\nby the smoker.\\nThe symptoms of emphysema develop gradually\\nover many years. It is a common occurrence for many\\nemphysema patients to have lost over half of their func-\\ntioning lung tissue before they become aware that some-\\nthing is wrong. Shortness of breath, a chronic mild cough\\n(which may be productive of large amounts of dark, thick\\nsputum, and often dismissed as “smoker’s cough”), and\\nsometimes weight loss are associated with emphysema.\\nGALE ENCYCLOPEDIA OF MEDICINE 21172\\nEmphysema\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1172'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 559, 'page_label': '560'}, page_content='Initially, a patient may only notice shortness of breath\\nwhen he or she is exercising. However, as the disease pro-\\ngresses, it will occur with less exertion or no exertion at\\nall. Emphysema patients may also develop an enlarged, or\\n“barrel,” chest. Other symptoms may be skipped breaths,\\ndifficulty sleeping, morning headaches, increased diffi-\\nculty breathing while lying down, chronic fatigue, and\\nswelling of the feet, ankles, or legs. Those with emphyse-\\nma are at risk for a variety of other complications result-\\ning from weakened lung function, including pneumonia.\\nDiagnosis\\nA variety of pulmonary function tests may be\\nordered. In the early stages of emphysema, the only\\nresult may be dysfunction of the small airways. Patients\\nwith emphysema may show an increase in the total\\namount of air that is in the lungs (total lung capacity), but\\na decrease in the amount of air that can be breathed out\\nafter taking a deep breath (vital capacity). With severe\\nemphysema, vital capacity is substantially below normal.\\nSpirometry, a procedure that measures air flow and lung\\nvolume, helps in the diagnosis of emphysema.\\nA chest x ray is often ordered to aid in the diagnosis\\nof emphysema, though patients in the early stages of the\\ndisease may have normal findings. Abnormal findings on\\nthe chest x ray include over-inflation of the lungs and an\\nabnormally increased chest diameter. The diaphragm may\\nappear depressed or flattened. In addition, patients with\\nadvanced emphysema may show a smaller or vertical\\nheart. The physician may observe blisters in the lungs and\\nbulging of the accessory muscles of the respiratory sys-\\ntem. Late in the disease, an EKG will show signs of right\\nventricular failure in the heart and increased hemoglobin\\ndue to lower levels of oxygen in the patient’s blood.\\nTreatment\\nTreatment methods for emphysema do not cure or\\nreverse the damage to the lungs. However, they may slow\\nthe progression of the disease, relieve symptoms, and\\nhelp control possibly fatal complications. The first step\\nin treatment for smokers is to quit, so as to prevent any\\nfurther deterioration of breathing ability. Smoking cessa-\\ntion programs may be effective. Consistent encourage-\\nment along with the help of health care professionals as\\nwell as family and friends can help increase the success\\nrate of someone attempting to quit.\\nIf the patient and the health care team develop and\\nmaintain a complete program of respiratory care, disabil-\\nity can be decreased, acute episodes of illness may be\\nprevented, and the number of hospitalizations reduced.\\nHowever, only quitting smoking has been shown to slow\\ndown the progression of the disease, and among all other\\ntreatments, only oxygen therapy has shown an increase\\nin the survival rate.\\nHome oxygen therapy may improve the survival\\ntimes in those patients with advanced emphysema who\\nalso have low blood oxygen levels. It may improve the\\npatient’s tolerance of exercise, as well as improve their\\nperformance in certain aspects of brain function and\\nmuscle coordination. The functioning of the heart may\\nalso improve with an increased concentration of oxygen\\nin the blood. Oxygen may also decrease insomnia and\\nheadaches. Some patients may only receive oxygen at\\nnight, but studies have illustrated that it is most effective\\nwhen administered at least 18, but preferably 24 hours\\nper day. Portable oxygen tanks prescribed to patients\\ncarry a limited supply and must be refilled on a regular\\nbasis by a home health provider. Medicare and most\\ninsurance companies cover a large proportion of the cost\\nof home oxygen therapy. Patients should be instructed\\nregarding special safety issues involving the transport\\nand presence of oxygen in the home.\\nA variety of medications may be used in the treat-\\nment of emphysema. Usually the patient responds best to\\na combination of medicines, rather than one single drug.\\nBronchodilators are sometimes used to help alle-\\nviate the patient’s symptoms by relaxing and opening\\nthe airways. They can be inhaled, taken by mouth, or\\ninjected. Another category of medication often used is\\ncorticosteroids or steroids. These help to decrease the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1173\\nEmphysema\\nA scanning electron microscopy (SEM) of lung tissue indi-\\ncating emphysema. (Photograph by Hossler, Ph.D., Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1173'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 560, 'page_label': '561'}, page_content='inflammation of the airway walls. They are occasional-\\nly used if bronchodilators are ineffective in preventing\\nairway obstruction. Some patients’ lung function\\nimproves with corticosteroids, and inhaled steroids may\\nbe beneficial to patients with few side effects. A variety\\nof antibiotics are frequently given at the first sign of a\\nrespiratory infection, such as increased amounts of spu-\\ntum, or if there has been a change in the color of the\\nsputum. Expectorants can help to loosen respiratory\\nsecretions, enabling the patient to more easily expel\\nthem from the airways.\\nMany of the medications prescribed involve the use\\nof a metered dose inhaler (MDI) that may require special\\ninstruction to be used correctly. MDIs are a convenient\\nand safe method of delivering medication to the lungs.\\nHowever, if they are used incorrectly the medication will\\nnot get to the right place. Proper technique is essential\\nfor the medication to be effective.\\nFor some patients, surgical treatment may be the\\nbest option. Lung volume reduction surgery is a surgical\\nprocedure in which the most diseased parts of the lung\\nare removed to enable the remaining lung and breathing\\nmuscles to work more efficiently. Preliminary studies\\nsuggest improved survival rates and better functioning\\nwith the surgery. Another surgical procedure used for\\nemphysema patients is lung transplantation . Trans-\\nplantation may involve one or both lungs. However, it is\\na risky and expensive procedure, and donor organs may\\nnot be available.\\nFor those patients with advanced emphysema, keep-\\ning the air passages reasonably clear of secretions can\\nprove difficult. Some common methods for mobilizing\\nand removing secretions include:\\n• Postural drainage. This helps to remove secretions from\\nthe airways. The patient lies in a position that allows\\ngravity to aid in draining different parts of the lung.\\nThis is often done after the patient inhales an aerosol\\nmedication. The basic position involves the patient\\nlying on the bed with his chest and head over the side\\nand the forearms resting on the floor.\\n• Chest percussion. This technique involves lightly clap-\\nping the back and chest, and may help to loosen thick\\nsecretions.\\n• Coughing and deep breathing. These techniques may\\naid the patient in bringing up secretions.\\n• Aerosol treatments. These treatments may involve solu-\\ntions of saline, often mixed with a bronchodilator,\\nwhich are then inhaled as an aerosol. The aerosols thin\\nand loosen secretions. A treatment normally takes 10 to\\n15 minutes, and is given three or four times a day.\\nPatients with COPD can learn to perform a variety\\nof self-help measures that may help improve their symp-\\ntoms and their ability to participate in everyday activi-\\nties. These measures include:\\n• Avoiding any exposure to dusts and fumes.\\n• Avoiding air pollution, including the cigarette smoke of\\nothers.\\n• Avoiding other people who have infections like the cold\\nor flu. Get a pneumonia vaccination and a yearly flu\\nshot.\\n• Drinking plenty of fluids. This helps to loosen respira-\\ntory secretions so they can be brought up more easily\\nthrough coughing.\\n• Avoiding extreme temperatures of heat or cold. Also\\navoiding high altitudes. (Special precautions can be\\ntaken that may enable the emphysema patient to fly on\\na plane.)\\n• Maintaining adequate nutritional intake. Normally a\\nhigh protein diet taken in many small feedings is rec-\\nommended.\\nAlternative treatment\\nMany patients are interested in whether any alterna-\\ntive treatments for emphysema are available. Some prac-\\ntitioners recommend supplements of antioxidant nutri-\\nents. There have also been some studies indicating a cor-\\nrelation between a low Vitamin A levels and COPD, with\\nsuggestions that supplements of vitamin A might be ben-\\nGALE ENCYCLOPEDIA OF MEDICINE 21174\\nEmphysema\\nX ray showing emphysema in the lungs.(Photo Researchers.\\nReproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1174'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 561, 'page_label': '562'}, page_content='eficial. Aromatherapists have used essential oils like\\neucalyptus, lavender, pine, and rosemary to help relieve\\nnasal congestion and make breathing easier. The herb\\nelecampane may act as an expectorant to help patients\\nclear mucus from the lungs. The patient should discuss\\nthese remedies with their health care practitioner prior to\\ntrying them, as some may interact with the more tradi-\\ntional treatments that are already being used.\\nPrognosis\\nEmphysema is a serious and chronic disease that\\ncannot be reversed. If detected early, the effects and\\nprogression can be slowed, particularly if the patient\\nstops smoking immediately. Complications of emphy-\\nsema include higher risks for pneumonia and acute\\nbronchitis. Overall, the prognosis for patients with\\nemphysema is poor, with a survival rate for all those\\nwith COPD of four years, and even less for emphyse-\\nma. However, individual cases vary and many patients\\ncan live much longer with supplemental oxygen and\\nother treatment measures.\\nPrevention\\nThe best way to prevent emphysema is to avoid\\nsmoking. Even patients with inherited emphysema\\nshould avoid smoking, as it especially worsens the onset\\nand severity. If patients quit smoking as soon as evidence\\nof small airway obstruction begins, they can significantly\\nimprove their prognosis.\\nResources\\nBOOKS\\nBeers, Mark H., and Robert Berkow, eds. The Merck Manual of\\nDiagnosis and Therapy, 17th ed.Whitehouse Station, NJ:\\nMerck and Company, Inc., 1999.\\nPERIODICALS\\n“Data Mounting on Merits of Lung V olume Reduction\\nSurgery.”Family Practice News(February 15, 2001): 5.\\nLewis, Laurie. “Optimal Treatment for COPD.”Patient Care\\n(May 30, 2000): 60.\\nKEY TERMS\\nAlveoli—Small cells or cavities. In the lungs, these\\nare air sacs where oxygen enters the blood and\\ncarbon dioxide is filtered out.\\nPulmonary —Related to or associated with the\\nlungs.\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway New York, NY\\n10019. (212) 315-8700. .\\nThe National Emphysema Foundation. 15 Stevens St. Norwalk,\\nCT 06856. .\\nThe National Heart, Lung and Blood Institute. .\\nDeanna Swartout-Corbeil, RN\\nEmpyema\\nDefinition\\nEmpyema is a condition in which pus and fluid from\\ninfected tissue collects in a body cavity. The name comes\\nfrom the Greek word empyein meaning pus-producing\\n(suppurate). Empyema is most often used to refer to col-\\nlections of pus in the space around the lungs (pleural cav-\\nity), but sometimes refers to similar collections in the\\ngall bladder or the pelvic cavity. Empyema in the pleural\\ncavity is sometimes called empyema thoracis, or empye-\\nma of the chest, to distinguish it from empyema else-\\nwhere in the body.\\nDescription\\nEmpyema may have a number of causes but is most\\nfrequently a complication of pneumonia . Its develop-\\nment can be divided into three phases: an acute phase in\\nwhich the body cavity fills with a thin fluid containing\\nsome pus; a second stage in which the fluid thickens and\\na fibrous, coagulation protein (fibrin) begins to accumu-\\nlate within the cavity; and a third or chronic stage in\\nwhich the lung or other organ is encased within a thick\\ncovering of fibrous material.\\nCauses and symptoms\\nEmpyema thoracis can be caused by a number of dif-\\nferent organisms, including bacteria, fungi, and amebas, in\\nconnection with pneumonia, chest wounds, chest surgery,\\nlung abscesses, or a ruptured esophagus. The infective\\norganism can get into the pleural cavity either through the\\nbloodstream or other circulatory system, in secretions\\nfrom lung tissue, or on the surfaces of surgical instruments\\nor objects that cause open chest wounds. The most com-\\nmon organisms that cause empyema are the following bac-\\nteria: Streptococcus pneumoniae, Haemophilus influenzae,\\nand Staphylococcus aureus. S. aureusis the most common\\ncause in all age groups, accounting for 90% of cases of\\nempyema in infants and children. Pelvic empyema in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1175\\nEmpyema\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1175'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 562, 'page_label': '563'}, page_content='women is most often caused by Bacteroides strains or\\nPseudomonas aeruginosa . In elderly, chronically ill, or\\nalcoholic patients, empyema is often caused by Klebsiella\\npneumoniae species of bacteria.\\nWhen the disease organisms arrive in the cavity sur-\\nrounding the lungs, they infect the tissues that cover the\\nlungs and line the chest wall. As the body attempts to\\nfight off the infection, the cavity fills up with tissue fluid,\\npus, and dead tissue cells. Empyema of the gall bladder\\nor pelvis results from similar reactions to infection in\\nthose parts of the body.\\nThe signs and symptoms of empyema vary some-\\nwhat according to the location of the infection and its\\nseverity. In empyema thoracis, patients usually exhibit\\nsymptoms of pneumonia, including fever, cough,\\nfatigue, shortness of breath, and chest pain. They may\\nKEY TERMS\\nAbscess —An area of inflamed and injured body\\ntissue that fills with pus.\\nDecortication —Surgical removal of the fibrous\\npeel that covers the lungs in third-stage empyema.\\nEmpyema—The collection of pus in a body cavity,\\nparticularly the lung or pleural cavity.\\nFibrin—A fibrous blood protein vital to coagula-\\ntion and blood clot formation.\\nPercussion—A diagnostic technique in which the\\nback, chest, or abdomen is tapped to determine\\nwhether body cavities contain abnormal fluid.\\nPleural cavity—The space surrounding the lungs,\\nincluding the membranes covering the lungs and\\nlining the inside of the chest wall.\\nPneumonia —Inflammation of the lungs usually\\ncaused by a virus, bacteria, or other organism.\\nResection —The surgical removal of part of an\\norgan or body structure, as in rib resection.\\nSuppurate—To produce or discharge pus.\\nThoracentesis —A procedure in which fluid is\\nwithdrawn from the pleural cavity through a nee-\\ndle inserted between the ribs. The fluid may be\\nwithdrawn either for diagnostic tests or to drain\\nthe cavity.\\nVideo-assisted thoracic surgery (VATS) —A tech-\\nnique used to aid in the placement of chest tubes\\nor when performing decortications when treating\\nadvanced empyema.\\nprefer to lie on the side of the body affected by the\\nempyema. Family members may notice bad breath . In\\nsevere cases, the patient may become dehydrated, cough\\nup blood or greenish-brown sputum, run a fever as high\\nas 105°F (40.6°C), or fall into a coma.\\nPatients with thoracic empyema may develop poten-\\ntially life-threatening complications if the condition is\\nnot treated. The infected tissues may develop large col-\\nlections of pus (abscesses) that can rupture into the\\npatient’s airway, or the infection may spread to the tis-\\nsues surrounding the heart. In extreme cases the empye-\\nma may spread to the brain by means of bacteria carried\\nin the bloodstream.\\nIn pelvic empyema, the infection produces large\\namounts of thick, foul-smelling pus that is rapidly\\nreplaced even after drainage. Empyema of the gallblad-\\nder is marked by intense pain on the upper right side of\\nthe abdomen, high fever, and rigidity of the muscles over\\nthe infected area.\\nDiagnosis\\nA physician may consider the possibility of empye-\\nma thoracis in patients with pneumonia or other symp-\\ntoms of lung infection. When listening to sounds within\\nthe patient’s chest with a stethoscope, the sounds of\\nbreathing will be partly muffled and harder to hear in the\\npatients with empyema. The area of the chest over the\\ninfection will sound dull when tapped or thumped (per-\\ncussed). On an x ray, empyema thoracis will appear as a\\ncloudy or opaque area. The amount of fluid present in the\\npleural cavity can be estimated using an ultrasound\\nimaging procedure. The diagnosis of empyema, however,\\nhas to be confirmed with laboratory tests because its\\nsymptoms can be caused by other disease conditions.\\nThe diagnosis of empyema is usually confirmed by\\nanalyzing a sample of fluid taken from the pleural cavity.\\nThe sample is obtained by a procedure called thoracente-\\nsis. In this procedure, the patient is given a local anesthet-\\nic, a needle is inserted into the pleural cavity through the\\nback between the ribs on the infected side, and a sample\\nof fluid is withdrawn. If the patient has empyema, there\\nwill be a very high level of one particular kind of immune\\ncell (white blood cells), a high level of protein, and a very\\nlow level of blood sugar. The fluid can also be tested for\\nthe specific disease organism by staining or tissue cul-\\ntures. In some cases, the color, smell, or consistency of\\nthe tissue fluid also helps to confirm the diagnosis.\\nTreatment\\nEmpyema is treated using a combination of medica-\\ntions and surgical techniques. Treatment with medication\\ninvolves intravenously administering a two-week course\\nGALE ENCYCLOPEDIA OF MEDICINE 21176\\nEmpyema\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1176'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 563, 'page_label': '564'}, page_content='of antibiotics. It is important to give antibiotics as soon\\nas possible to prevent first-stage empyema from progress-\\ning to its later stages. The antibiotics most commonly\\nused are penicillin and vancomycin. Patients experiencing\\ndifficulty breathing are also given oxygen therapy.\\nSurgical treatment of empyema has two goals:\\ndrainage of the infected fluid and closing up of the space\\nleft in the pleural cavity. If the infection is still in its early\\nstages, the fluid can be drained by thoracentesis. In sec-\\nond-stage empyema, the surgeon will insert a chest tube in\\nthe patient’s rib cage or remove part of a rib (rib resection)\\nin order to drain the fluid. In third-stage empyema, the sur-\\ngeon may cut or peel away the thick fibrous layer coating\\nthe lung. This procedure is called decortication. When the\\nfibrous covering is removed, the lung will expand to fill\\nthe space in the chest cavity. The doctor can use video-\\nassisted thoracic surgery (V ATS) techniques to position\\nthe chest tube or to perform a limited decortication. The\\nV ATS technique allows a physician to see within the body\\nduring certain surgical procedures. Empyema of the gall-\\nbladder is a serious condition that is treated with intra-\\nvenous antibiotics and surgical removal of the gallbladder.\\nPrognosis\\nThe prognosis for recovery is generally good, except\\nin those cases with complications, such as a brain\\nabscess or blood poisoning , or cases caused by certain\\ntypes of streptococci.\\nResources\\nBOOKS\\n“Bedside Procedures: Thoracentesis.” In Surgery On Call,e d .\\nLeonard G. Gomella and Alan T. Lefor. Stamford: Apple-\\nton & Lange, 1996.\\nChambers, Henry F. “Infectious Diseases: Bacterial & Chlamy-\\ndial.” In Current Medical Diagnosis and Treatment, 1998.\\n37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton\\n& Lange, 1997.\\nLarsen, Gary L., et al. “Respiratory Tract & Mediastinum.” In\\nCurrent Pediatric Diagnosis & Treatment, ed. William W.\\nHay Jr., et al. Stamford: Appleton & Lange, 1997.\\nNakeeb, Attila, and Keith D. Lillemoe. “Cholelithiasis and\\nCholecystitis.” In Conn’s Current Therapy, 1996,e d .\\nRobert E. Rakel. Philadelphia: W. B. Saunders Co., 1996.\\nStauffer, John L. “Lung.” In Current Medical Diagnosis and\\nTreatment, 1998. 37th ed. Ed. Stephen McPhee, et al.\\nStamford: Appleton & Lange, 1997.\\nTurley, Kevin. “Thoracic Wall, Pleura, Mediastinum, and Lung.”\\nIn Current Surgical Diagnosis and Treatment. 10th ed. Ed.\\nLawrence W. Way. Stamford: Appleton & Lange, 1994.\\nWhyte, Richard I. “Pleural Effusion and Empyema Thoracis.”\\nIn Conn’s Current Therapy, 1996, ed. Robert E. Rakel.\\nPhiladelphia: W. B. Saunders Co., 1996.\\nRebecca J. Frey\\nEnalapril see Angiotensin-converting\\nenzyme inhibitors\\nEncephalitis\\nDefinition\\nEncephalitis is an inflammation of the brain, usually\\ncaused by a direct viral infection or a hypersensitivity\\nreaction to a virus or foreign protein. Brain inflammation\\ncaused by a bacterial infection is sometimes called\\ncerebritis. When both the brain and spinal cord are\\ninvolved, the disorder is called encephalomyelitis. An\\ninflammation of the brain’s covering, or meninges, is\\ncalled meningitis.\\nDescription\\nEncephalitis is an inflammation of the brain. The\\ninflammation is a reaction of the body’s immune system\\nto infection or invasion. During the inflammation, the\\nbrain’s tissues become swollen. The combination of the\\ninfection and the immune reaction to it can cause\\nheadache and a fever, as well as more severe symptoms\\nin some cases.\\nApproximately 2,000 cases of encephalitis are\\nreported to the Centers for Disease Control in Atlanta,\\nGA each year. The viruses causing primary encephalitis\\ncan be epidemic or sporadic. The polio virus is an epi-\\ndemic cause. Arthropod-borne viral encephalitis is\\nresponsible for most epidemic viral encephalitis. The\\nviruses live in animal hosts and mosquitos that transmit\\nthe disease. The most common form of non-epidemic or\\nsporadic encephalitis is caused by the herpes simplex\\nvirus, type 1 (HSV-1) and has a high rate of death.\\nMumps is another example of a sporadic cause.\\nCauses and symptoms\\nCauses\\nThere are more than a dozen viruses that can cause\\nencephalitis, spread by either human-to human contact or\\nby animal bites. Encephalitis may occur with several\\ncommon viral infections of childhood. Viruses and viral\\ndiseases that may cause encephalitis include:\\n• chickenpox\\n• measles\\n• mumps\\n• Epstein-Barr virus (EBV)\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1177\\nEncephalitis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1177'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 564, 'page_label': '565'}, page_content='• cytomegalovirus infection\\n• HIV\\n• herpes simplex\\n• herpes zoster (shingles)\\n• herpes B\\n• polio\\n• rabies\\n• mosquito-borne viruses (arboviruses)\\nPrimary encephalitis is caused by direct infection by\\nthe virus, while secondary encephalitis is due to a post-\\ninfectious immune reaction to viral infection elsewhere in\\nthe body. Secondary encephalitis may occur with measles,\\nchickenpox, mumps, rubella, and EBV . In secondary\\nencephalitis, symptoms usually begin five to 10 days after\\nthe onset of the disease itself and are related to the break-\\ndown of the myelin sheath that covers nerve fibers.\\nIn rare cases, encephalitis may follow vaccination\\nagainst some of the viral diseases listed above.\\nCreutzfeldt-Jakob disease , a very rare brain disorder\\ncaused by an infectious particle called a prion, may also\\ncause encephalitis.\\nMosquitoes spread viruses responsible for equine\\nencephalitis (eastern and western types), St. Louis\\nencephalitis, California encephalitis, and Japanese\\nencephalitis . Lyme disease, spread by ticks, can cause\\nencephalitis, as can Colorado tick fever. Rabies is most\\noften spread by animal bites from dogs, cats, mice, rac-\\ncoons, squirrels, and bats and may cause encephalitis.\\nEquine encephalitis is carried by mosquitoes that do\\nnot normally bite humans but do bite horses and birds. It\\nis occasionally picked up from these animals by mosqui-\\ntoes that do bite humans. Japanese encephalitis and St.\\nLouis encephalitis are also carried by mosquitoes. The\\nrisk of contracting a mosquito-borne virus is greatest in\\nmid- to late summer, when mosquitoes are most active,\\nin those rural areas where these viruses are known to\\nexist. Eastern equine encephalitis occurs in eastern and\\nsoutheastern United States; western equine and Califor-\\nnia encephalitis occur throughout the West; and St. Louis\\nencephalitis occurs throughout the country. Japanese\\nencephalitis does not occur in the United States, but is\\nfound throughout much of Asia. The viruses responsible\\nfor these diseases are classified as arbovirus and these\\ndiseases are collectively called arbovirus encephalitis.\\nHerpes simplex encephalitis, the most common form\\nof sporadic encephalitis in western countries, is a disease\\nwith significantly high mortality. It occurs in children and\\nadults and both sides of the brain are affected. It is theo-\\nrized that brain infection is caused by the virus moving\\nfrom a peripheral location to the brain via two nerves, the\\nolfactory and the trigeminal (largest nerves in the skull).\\nHerpes simplex encephalitis is responsible for 10%\\nof all encephalitis cases and is the main cause of spo-\\nradic, fatal encephalitis. In untreated patients, the rate of\\ndeath is 70% while the mortality is 15–20% in patients\\nwho have been treated with acyclovir. The symptoms of\\nherpes simplex encephalitis are fever, rapidly disintegrat-\\ning mental state, headache, and behavioral changes.\\nSymptoms\\nThe symptoms of encephalitis range from very mild\\nto very severe and may include:\\n• headache\\n•f e v e r\\n• lethargy (sleepiness, decreased alertness, and fatigue)\\n• malaise\\n• nausea and vomiting\\n• visual disturbances\\n• tremor\\n• decreased consciousness (drowsiness, confusion, delir-\\nium, and unconsciousness)\\n• stiff neck\\n• seizures\\nSymptoms may progress rapidly, changing from\\nmild to severe within several days or even several hours.\\nDiagnosis\\nDiagnosis of encephalitis includes careful question-\\ning to determine possible exposure to viral sources. Tests\\nthat can help confirm the diagnosis and rule out other\\ndisorders include:\\n• Blood tests. These are to detect antibodies to viral anti-\\ngens, and foreign proteins.\\n• Cerebrospinal fluid analysis (spinal tap). This detects\\nviral antigens, and provides culture specimens for the\\nvirus or bacteria that may be present in the cere-\\nbrospinal fluid.\\n• Electroencephalogram (EEG).\\n• CT and MRI scans.\\nA brain biopsy (surgical gathering of a small tissue\\nsample) may be recommended in some cases where\\ntreatment to date has been ineffective and the cause of\\nthe encephalitis is unclear. Definite diagnosis by biopsy\\nmay allow specific treatment that would otherwise be\\ntoo risky.\\nGALE ENCYCLOPEDIA OF MEDICINE 21178\\nEncephalitis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1178'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 565, 'page_label': '566'}, page_content='Treatment\\nChoice of treatment for encephalitis will depend on\\nthe cause. Bacterial encephalitis is treated with antibi-\\notics. Viral encephalitis is usually treated with antiviral\\ndrugs including acyclovir, ganciclovir, foscarnet, ribo-\\nvarin, and AZT. Viruses that respond to acyclovir include\\nherpes simplex, the most common cause of sporadic\\n(non-epidemic) encephalitis in the United States.\\nThe symptoms of encephalitis may be treated with a\\nnumber of different drugs. Corticosteroids , including\\nprednisone and dexamethasone, are sometimes pre-\\nscribed to reduce inflammation and brain swelling. Anti-\\nconvulsant drugs, including dilantin and phenytoin, are\\nused to control seizures. Fever may be reduced with\\nacetaminophen or other fever-reducing drugs.\\nA person with encephalitis must be monitored care-\\nfully, since symptoms may change rapidly. Blood tests\\nmay be required regularly to track levels of fluids and\\nsalts in the blood.\\nPrognosis\\nEncephalitis symptoms may last several weeks.\\nMost cases of encephalitis are mild, and recovery is usu-\\nally quick. Mild encephalitis usually leaves no residual\\nneurological problems. Overall, approximately 10% of\\nthose with encephalitis die from their infections or com-\\nplications such as secondary infection. Some forms of\\nencephalitis have more severe courses, including herpes\\nencephalitis, in which mortality is 15–20% with treat-\\nment, and 70–80% without. Antiviral treatment is inef-\\nfective for eastern equine encephalitis, and mortality is\\napproximately 30%.\\nPermanent neurological consequences may follow\\nrecovery in some cases. Consequences may include per-\\nsonality changes, memory loss, language difficulties,\\nseizures, and partial paralysis.\\nPrevention\\nBecause encephalitis is due to infection, it may be\\nprevented by avoiding the infection. Minimizing contact\\nwith others who have any of the viral illness listed above\\nmay reduce the chances of becoming infected. Most\\ninfections are spread by hand-to-hand or hand-to-mouth\\ncontact; frequent hand washing may reduce the likeli-\\nhood of infection if contact cannot be avoided.\\nMosquito-borne viruses may be avoided by prevent-\\ning mosquito bites. Mosquitoes are most active at dawn\\nand dusk, and are most common in moist areas with\\nstanding water. Minimizing exposed skin and use of\\nmosquito repellents on other areas can reduce the\\nchances of being bitten.\\nKEY TERMS\\nCerebrospinal fluid analysis —A analysis that is\\nimportant in diagnosing diseases of the central\\nnervous system. The fluid within the spine will\\nindicate the presence of viruses, bacteria, and\\nblood. Infections such as encephalitis will be indi-\\ncated by an increase of cell count and total pro-\\ntein in the fluid.\\nComputerized tomography (CT) Scan —A test to\\nexamine organs within the body and detect evi-\\ndence of tumors, blood clots, and accumulation of\\nfluids.\\nElectroencephalagram (EEG)—A chart of the brain\\nwaves picked up by the electrodes placed on the\\nscalp. Changes in brain wave activity can be an\\nindication of nervous system disorders.\\nInflammation—A response from the immune sys-\\ntem to an injury. The signs are redness, heat,\\nswelling, and pain.\\nMagnetic Resonance Imaging (MRI)—MRI is diag-\\nnostic radiography using electromagnetic energy\\nto create an image of the central nervous system\\n(CNS), blood system, and musculoskeletal system.\\nVaccine—A prepartation containing killed or\\nweakened microorganisms used to build immuni-\\nty against infection from that microorganism.\\nVirus—A very small organism that can only live\\nwithin a cell. They are unable to reproduce out-\\nside that cell.\\nVaccines are available against some viruses, includ-\\ning polio, herpes B, Japanese encephalitis, and equine\\nencephalitis. Rabies vaccine is available for animals; it is\\nalso given to people after exposure. Japanese encephalitis\\nvaccine is recommended for those traveling to Asia and\\nstaying in affected rural areas during transmission season.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nHurst, J. Willis. Medicine for the Practicing Physician. Stam-\\nford: Appleton & Lange, 1988.\\nOffice Practice of Neurology.Ed. Martin Samuels and Steven\\nFeske. New York: Churchill Livingstone, 1996.\\nThe Merck Manual. Whitehouse Station, NJ: Merck and Co.\\nInc., 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1179\\nEncephalitis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1179'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 566, 'page_label': '567'}, page_content='In this procedure, surgeons are removing plaque from the\\ncarotid artery.(Custom Medical Stock Photo. Reproduced by\\npermission.)\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nRichard Robinson\\nEncephalocele see Congenital brain defects\\nEndarterectomy\\nDefinition\\nEndarterectomy is an operation to remove or bypass\\nthe fatty deposits, or blockage, in an artery narrowed by\\nthe buildup of fatty tissue (atherosclerosis).\\nPurpose\\nRemoving the fatty deposits restores normal blood\\nflow to the part of the body supplied by the artery. An\\nendarterectomy is performed to treat cerebrovascular dis-\\nease in which there is a serious reduction of blood supply\\nto the brain (carotid endarterectomy), or to treat periph-\\neral vascular disease(impaired blood supply to the legs).\\nEndarterectomy is most often performed on one of\\nthe two main arteries in the neck (the carotids) opening\\nthe narrowed arteries leading to the brain. When per-\\nformed by an experienced surgeon, the practice is\\nextremely effective, reducing the risk of stroke by up to\\n70%. Recent studies indicate it is effective in preventing\\nstroke, even among those patients who had no warning\\nsigns except narrowed arteries detected by their doctors\\non a routine exam.\\nPrecautions\\nBefore the surgery, a full medical exam is usually\\ndone to assess any specific health problems, such as dia-\\nbetes, high blood pressure, heart disease, or stroke. If\\npossible, reversible health problems, such as cigarette\\nsmoking or being overweight, should be corrected.\\nDescription\\nCarotid artery disease\\nEvery person has four carotid arteries (the internal\\nand external carotids on each side of the neck) through\\nwhich blood from the heart moves into the brain. If one\\nof these arteries becomes blocked by fat and cholesterol,\\nthe patient may have a range of symptoms, including:\\n• weakness in one arm, leg, half of the face, or one entire\\nside of the body\\n• numbness tingling\\n• paralysis of an arm, leg, or face\\n• slurred speech\\n• dizziness\\n• confusion,fainting, or coma\\n• stroke\\nRemoving this fatty buildup, or bypassing a blocked\\nsegment, may restore blood flow to the brain, eliminate\\nor decrease the symptoms, and lessen the risk of a stroke.\\nPeripheral vascular disease\\nWhen the blood vessels in the legs (and sometimes\\nthe arms) become narrowed, this can restrict blood flow\\nand cause pain in the affected area. In severe cases, the\\ntissue may die, requiring amputation.\\nThe narrowing is usually caused by buildup of fatty\\nplaques in the vessels, often as the result of smoking,\\nhigh blood pressure, or poorly-controlled diabetes melli-\\ntus. The vessels usually narrow slowly, but it’s possible\\nfor a blood clot to form quickly, causing sudden severe\\npain in the affected leg or arm.\\nProcedure\\nEndarterectomy is a delicate operation that may\\nrequire several hours. The surgeon begins by making an\\nGALE ENCYCLOPEDIA OF MEDICINE 21180\\nEndarterectomy\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1180'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 567, 'page_label': '568'}, page_content='incision over the blocked artery and inserting a tube\\nabove and below the blockage to redirect the blood flow\\nwhile the artery is opened.\\nNext, the surgeon removes the fat and cholesterol\\nbuildup, along with any blood clots that have formed,\\nwith a blunt dissecting instrument. Then the surgeon\\nbathes the clean wall in salt solution combined with\\nheparin, an anticoagulant. Then the surgeon stitches the\\nartery just enough so that the bypass shunt tube can be\\nremoved, and then he/she stitches the artery completely\\nclosed. After checking to make sure no blood is leaking,\\nthe surgeon next closes the skin incision with stitches.\\nThe operation should improve symptoms, although\\nits long-term effects may be more limited, since arterial\\nnarrowing is rarely confined to one area of one artery. If\\nnarrowing is a problem throughout the body, arterial\\nreconstructive surgery may be required.\\nThe total cost of an endarterectomy, including diag-\\nnostic tests, surgery, hospitalization, and follow-up care,\\nwill vary according to hospital, doctor, and area of the\\ncountry where the operation is performed, but a patient\\ncan expect to pay in the range of $15,000. Patients who\\nare very young, very old, or very ill, or who need more\\nextensive surgery, may require more expensive treatment.\\nPreparation\\nBefore surgery, the doctor pinpoints the location of\\nthe narrowed artery with an x-ray procedure called\\nangiography . For surgery to be effective, the degree of\\nnarrowing should be at least 70%, but it should not be\\ntotal. Patients undergoing angiography are given a local\\nanesthetic, but the endarterectomy itself requires the use\\nof a general anesthesia.\\nAftercare\\nAfter the surgery, the patient spends the first two\\ndays lying flat in bed. Patients who have had carotid\\nendarterectomy should not bend the neck sharply during\\nthis time. Because the blood flow to the brain is now\\ngreatly increased, patients may experience a brief but\\nsevere headache , or lightheadedness. There may be a\\nslight loss of sensation in the skin, or maybe a droop in\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1181\\nEndarterectomy\\nPlaque\\nClamp\\nCarotid\\nartery\\nPlaque is removed from the carotid artery by clamping the artery, cutting the plaque out, and closing the opening back up.\\n(Illustration by Argosy Inc.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1181'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 568, 'page_label': '569'}, page_content='the mouth, if any of the nerves in the neck were lightly\\nbruised during surgery. In time, this should correct itself.\\nRisks\\nThe amount of risk depends on the hospital, the skill\\nof the surgeon, and the severity of underlying disease.\\nPatients who have just had an acute stroke are at greatest\\nrisk. During carotid artery surgery, blood flow is inter-\\nrupted through the artery, so that paralysis and other\\nstroke symptoms may occur. These may resolve after\\nsurgery, or may result in permanent stroke. Paralysis is\\nusually one-sided; other stroke symptoms may include\\nloss of half the field of vision, loss of sensation, double\\nvision, speech problems, and personality changes. Risks\\nof endarterectomy to treat either carotid artery or periph-\\neral vascular disease include:\\n• reactions to anesthesia\\n• bleeding\\n• infection\\n• blood clots\\nNormal results\\nThe results after successful surgery are usually strik-\\ning. The newly opened artery should help to restore nor-\\nmal blood flow. In carotid endarterectomy, surgery should\\nprevent the risk of brain damage and stroke. However, the\\nKEY TERMS\\nCarotid arteries—The four principal arteries of the\\nneck and head. There are two common carotid\\narteries, each of which divides into the two main\\nbranches (internal and external).\\nDiabetes mellitus —A disorder in which the pan-\\ncreas doesn’t produce enough (or any) insulin. As\\na result, the blood levels of sugar become very\\nhigh. Among other things, diabetes can lead to the\\nbreakdown of small blood vessels and a high risk\\nof atherosclerosis and high blood pressure.\\nStroke—Damage to the part of the brain caused\\nby an interruption of the blood supply. In some\\ncases, small pieces of plaque in the carotid artery\\nmay break loose and block an artery in the brain.\\nA narrowed carotid artery also can be the source\\nof blood clots travelling to the brain, or the artery\\ncan become completely clogged, blocking all\\nblood flow to the brain.\\nbuildup of fat and cholesterol usually affects all arteries,\\nnot just the one that was operated on. Affected arteries in\\nother parts of the body may be equally clogged and poten-\\ntially dangerous. Even arteries that were operated elec-\\ntively will likely, begin to clog up again after the surgery.\\nFor this reason, lifestyle changes (no smoking, low\\nfat, low cholesterol diet) are important, especially if diet\\nand lifestyle contributed to the development of the prob-\\nlem in the first place.\\nResources\\nBOOKS\\n“Carotid Endarterectomy.” In The Surgery Book: An Illustrated\\nGuide to 73 of the Most Common Operations, ed. Robert\\nM. Younson, et al. New York: St. Martin’s Press, 1993.\\nPERIODICALS\\n“Better Blood Flow: Surgery May Strike Down Stroke Risk.”\\nPrevention 47 (1 Feb. 1995): 50-52.\\nORGANIZATIONS\\nNational Institute of Neurological Disorders and Stroke. PO\\nBox 5801, Bethesda, MD 20824. (800) 352-9424. .\\nNational Institute of Neurological Disorders at the Neurology\\nInstitute. PO Box 5801, Bethesda, MD 20824.\\nCarol A. Turkington\\nEndemic syphilis see Bejel\\nEndocardial resection see Myocardial\\nresection\\nEndocarditis\\nDefinition\\nThe endocardium is the inner lining of the heart\\nmuscle, which also covers the heart valves. When the\\nendocardium becomes damaged, bacteria from the blood\\nstream can become lodged on the heart valves or heart\\nlining. The resulting infection is known as endocarditis.\\nDescription\\nThe endocardium lines all four chambers of the\\nheart—two at the top (the right and left atria) and two at\\nthe bottom (the right and left ventricles)—through which\\nblood passes as the heart beats. It also covers the four\\nvalves (the tricuspid valve, the pulmonary valve, the\\nmitral valve, and the aortic valve), which normally open\\nGALE ENCYCLOPEDIA OF MEDICINE 21182\\nEndocarditis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1182'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 569, 'page_label': '570'}, page_content='and close to allow the blood to flow in only one direction\\nthrough the heart during each contraction.\\nFor the heart to pump blood efficiently, the four\\nchambers must contract and relax, and the four valves\\nmust open and close, in a well coordinated fashion. By\\ndamaging the valves or the walls of the heart chambers,\\nendocarditis can interfere with the ability of the heart to\\ndo its job.\\nEndocarditis rarely occurs in people with healthy,\\nnormal hearts. Rather, it most commonly occurs when\\nthere is damage to the endocardium. The endocardium\\nmay be affected by a congenital heart defect, such as\\nmitral valve prolapse , in which blood leaks through a\\npoorly functioning mitral valve back into the heart. It\\nmay also be damaged by a prior scarring of the heart\\nmuscle, such as rheumatic fever , or replacement of a\\nheart valve. Any of these conditions can damage the\\nendocardium and make it more susceptible to infection.\\nBacteria can get into the blood stream (a condition\\nknown as bacteremia) in a number of different ways: It\\nmay spread from a localized infection such as a urinary\\ntract infection, pneumonia, or skin infection or get into\\nthe blood stream as a result of certain medical condi-\\ntions, such as severe periodontal disease, colon cancer,\\nor inflammatory bowel disease. It can enter the blood\\nstream during minor procedures, such as periodontal\\nsurgery, tooth extractions, teeth cleaning, tonsil removal,\\nprostate removal, or endoscopic examination. It can also\\nbe introduced through in-dwelling catheters, which are\\nused for intravenous medications, intravenous feeding, or\\ndialysis. In people who use intravenous drugs, the bacte-\\nria can enter the blood stream through unsterilized, cont-\\naminated needles and syringes. (People who are prone to\\nendocarditis generally need to take prescribed antibi-\\notics before certain surgical or dental procedures to help\\nprevent this infection.)\\nIf not discovered and treated, infective endocarditis\\ncan permanently damage the heart muscle, especially the\\nvalves. For the heart to work properly, all four valves\\nmust be functioning well, opening at the right time to let\\nblood flow in the right direction and closing at the right\\ntime to keep the blood from flowing in the wrong direc-\\ntion. If the valve is damaged, this may allow blood to flow\\nbackward—a condition known as regurgitation. As a\\nresult of a poorly functioning valve, the heart muscle has\\nto work harder to pump blood and may become weak-\\nened, leading to heart failure. Heart failure is a chronic\\ncondition in which the heart is unable to pump blood well\\nenough to supply blood adequately to the body.\\nAnother danger associated with endocarditis is that\\nthe vegetation formed by bacteria colonizing on heart\\nvalves may break off, forming emboli. These emboli\\nmay travel through the circulation and become lodged in\\nblood vessels. By blocking the flow of blood, emboli\\ncan starve various tissues of nutrients and oxygen, dam-\\naging them. For instance, an embolus lodged in the\\nblood vessels of the lungs may cause pneumonia-like\\nsymptoms. An embolus may also affect the brain, dam-\\naging nerve tissue, or the kidneys, causing kidney dis-\\nease. Emboli may also weaken the tiny blood vessels\\ncalled capillaries, causing hemorrhages (leaking blood\\nvessels) throughout the body.\\nCauses and symptoms\\nMost cases of infective endocarditis occur in people\\nbetween the ages of 15 and 60, with a median age at\\nonset of about 50 years. Men are affected about twice as\\noften as women are. Other factors that put people at\\nincreased risk for endocarditis are congenital heart prob-\\nlems, heart surgery, previous episodes of endocarditis,\\nand intravenous drug use.\\nWhile there is no single specific symptom of endo-\\ncarditis, a number of symptoms may be present. The\\nmost common symptom is a mild fever, which rarely\\ngoes above 102°F (38.9°C). Other symptoms include\\nchills, weakness, cough, trouble breathing, headaches,\\naching joints, and loss of appetite.\\nEmboli may also cause a variety of symptoms,\\ndepending on their location. Emboli throughout the\\nbody may cause Osler’s nodes, small, reddish, painful\\nbumps most commonly found on the inside of fingers\\nand toes. Emboli may also cause petechiae, tiny purple\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1183\\nEndocarditis\\nA close-up view of an infected artificial heart valve showing\\nbacterial endocarditis (the granulated tissue at center of\\nimage). When infection occurs early after surgery, it is likely\\nthat organisms have gained entry during the operative peri-\\nod.This type of infection is usually caused by Staphylococ-\\ncus epidermidis and S. aureus and is treated with antibiotic\\ndrugs. (Photograph by Dr. E. Walker, Photo Researchers, Inc.\\nReproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1183'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 570, 'page_label': '571'}, page_content='or red spots on the skin, resulting from hemorrhages\\nunder the skin’s surface. Tiny hemorrhages resembling\\nsplinters may also appear under the fingernails or toe-\\nnails. If emboli become lodged in the blood vessels of\\nthe lungs, they may cause coughing or shortness of\\nbreath . Emboli lodged in the brain may cause symp-\\ntoms of a mini-stroke, such as numbness, weakness, or\\nparalysis on one side of the body or sudden vision loss\\nor double vision. Emboli may also damage the kidneys,\\ncausing blood to appear in the urine. Sometimes the cap-\\nillaries on the surface of the spleen rupture, causing the\\nspleen to become enlarged and tender to the touch. Any-\\none experiencing any of these symptoms should seek\\nmedical help immediately.\\nDiagnosis\\nDoctors begin the diagnosis by taking a history, ask-\\ning the patient about the symptoms mentioned above.\\nDuring a physical examination , the doctor may also\\nuncover signs such as fever, an enlarged spleen, signs of\\nkidney disease, or hemorrhaging. Listening to the\\npatient’s chest with a stethoscope, the doctor may also\\nhear a heart murmur. A heart murmur may indicate\\nabnormal flow of blood through one of the heart cham-\\nbers or valves.\\nDoctors take a sample of the patient’s blood to test it\\nfor bacteria and other microorganisms that may be caus-\\ning the infection. They usually also use a test called\\nechocardiography , which uses ultrasound waves to\\nmake images of the heart, to check for abnormalities in\\nthe structure of the heart wall or valves. One of the tell-\\ntale signs they look for in echocardiography is vegeta-\\ntion, the abnormal growth of tissue around a valve com-\\nposed of blood platelets, bacteria, and a clotting protein\\ncalled fibrin. Another tell-tale sign is regurgitation, or the\\nbackward flow of blood, through one of the heart valves.\\nA normal echocardiogram does not exclude the possibili-\\nty of endocarditis, but an abnormal echocardiogram can\\nconfirm its presence. If an echocardiogram cannot be\\ndone or its results are inconclusive, a modified technique\\ncalled transesophageal echocardiography is some-\\ntimes performed. Transesophageal echocardiography\\ninvolves passing an ultrasound device into the esophagus\\nto get a clearer image of the heart.\\nTreatment\\nWhen doctors suspect infective endocarditis, they\\nwill admit the patient to a hospital and begin treating the\\ninfection before they even have the results of the blood\\nculture. Their choice of antibiotics depends on what the\\nmost likely infecting microorganism is. Once the results\\nof the blood culture become available, the doctor can\\nadjust the medications, using specific antibiotics known\\nto be effective against the specific microorganism\\ninvolved.\\nUnfortunately, in recent years, the treatment of\\nendocarditis has become more complicated as a result of\\nantibiotic resistance. Over the past few years, especially\\nas antibiotics have been overprescribed, more and more\\nstrains of bacteria have become increasingly resistant to\\na wider range of antibiotics. For this reason, doctors may\\nneed to try a few different types of antibiotics—or even a\\ncombination of antibiotics—to successfully treat the\\ninfection. Antibiotics are usually given for about one\\nmonth, but may need to be given for an even longer peri-\\nod of time if the infection is resistant to treatment.\\nOnce the fever and the worst of the symptoms have\\ngone away, the patient may be able to continue antibiotic\\ntherapy at home. During this time, the patient should\\nmake regular visits to the health care team for further\\ntesting and physical examination to make sure that the\\nantibiotic therapy is working, that it is not causing\\nadverse side effects, and that there are no complications\\nsuch as emboli or heart failure. The patient should alert\\nthe health-care team to any symptoms that could indicate\\nserious complications: For instance, trouble breathing or\\nswelling in the legs could indicate congestive heart fail-\\nure. Headache, joint pain, blood in the urine, or stroke\\nsymptoms could indicate an embolus, and fever and\\nchills could indicate that the treatment is not working and\\nthe infection is worsening. Finally, diarrhea, rash, itch-\\ning, or joint pain may suggest a bad reaction to the\\nantibiotics. Anyone experiencing any of these symptoms\\nshould alert the health care team immediately.\\nIn some cases, surgery may be needed. These\\ninclude cases of congestive heart failure, recurring\\nGALE ENCYCLOPEDIA OF MEDICINE 21184\\nEndocarditis\\nThis echocardiogram shows an aortic regurgitation due to\\nendocarditis, an infection of the lining membrane of the car-\\ndiac chambers. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1184'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 571, 'page_label': '572'}, page_content='emboli, infection that doesn’t respond to treatment, poor-\\nly functioning heart valves, and endocarditis involving\\nprosthetic (artificial) valves. The most common surgical\\ntreatment involves cutting away (debriding) damaged tis-\\nsue and replacing the damaged valve.\\nPrognosis\\nIf left untreated, infective endocarditis continues to\\nprogress and is always fatal. However, if it is diagnosed\\nand properly treated within the first six weeks of infec-\\ntion, the infection can be completely cured in about 90%\\nof the cases. The prognosis depends on a number of fac-\\ntors, such as the patient’s age and overall physical condi-\\ntion, the severity of the diseases involved, the exact site\\nof the infection, how vulnerable the microorganisms are\\nto antibiotics, and what kind of complications the endo-\\ncarditis may be causing.\\nPrevention\\nSome people are especially prone to endocarditis.\\nThese include people with past episodes of endocarditis,\\nthose with congenital heart problems or heart damage\\nfrom rheumatic fever, and those with artificial heart\\nvalves. Intravenous drug users are also at increased risk.\\nKEY TERMS\\nAortic valve —The valve between the left ventricle\\nof the heart and the aorta.\\nBacteremia—An infection caused by bacteria in the\\nblood.\\nCongestive heart failure—A condition in which the\\nheart muscle cannot pump blood as efficiently as it\\nshould.\\nEchocardiography—A diagnostic test using reflect-\\ned sound waves to study the structure and motion of\\nthe heart muscle.\\nEmbolus —A bit of foreign material, such as gas, a\\npiece of tissue, or tiny clot, that travels in the circu-\\nlation until it becomes lodged in a blood vessel.\\nEndocardium—The inner wall of the heart muscle,\\nwhich also covers the heart valves.\\nMitral valve—The valve between the left atrium and\\nthe left ventricle of the heart.\\nOsler’s nodes—Small, raised, reddish, tender areas\\nassociated with endocarditis, commonly found\\ninside the fingers or toes.\\nPetechiae —Tiny purple or red spots on the skin\\nassociated with endocarditis, resulting from hemor-\\nrhages under the skin’s surface.\\nPulmonary valve—The valve between the right ven-\\ntricle of the heart and the pulmonary artery.\\nTransducer—A device that converts electrical sig-\\nnals into ultrasound waves and ultrasound waves\\nback into electrical impulses.\\nTransesophageal echocardiography —A diagnostic\\ntest using an ultrasound device, passed into the\\nesophagus of the patient, to create a clear image of\\nthe heart muscle.\\nTricuspid valve —The valve between the right atri-\\num and the right ventricle of the heart.\\nVegetation—An abnormal growth of tissue around\\na valve, composed of blood platelets, bacteria, and\\na protein involved in clotting.\\nAnyone who falls into a high-risk category should alert\\nhis or her health-care professionals before undergoing\\nany surgical or dental procedures. High-risk patients\\nmust be treated in advance with antibiotics before these\\nprocedures to minimize the risk of infection.\\nResources\\nBOOKS\\nThe Patient’s Guide to Medical Tests.Ed. Barry L. Zaret, et al.\\nBoston: Houghton Mifflin, 1997.\\nPERIODICALS\\nAuten, Gramce M., and Victor Del Bene. “Endocarditis: Cur-\\nrent Guidelines on Prophylaxis, Diagnosis, and Treat-\\nment.” Consultant 36 (May 1996): 973-78.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas, TX\\n75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nRobert Scott Dinsmoor\\nEndocrine pancreatic cancer see Pancreatic\\ncancer, endocrine\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1185\\nEndocarditis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1185'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 572, 'page_label': '573'}, page_content='Endometrial biopsy\\nDefinition\\nEndometrial biopsy is a procedure in which a sam-\\nple of the endometrium (tissue lining the inside of the\\nuterus) is removed for microscopic examination.\\nPurpose\\nThe test is most often performed to find out the\\ncause of abnormal uterine bleeding. Abnormal bleeding\\nincludes bleeding between menstrual periods, excessive\\nbleeding during a menstrual period, or bleeding after\\nmenopause . Since abnormal uterine bleeding can indi-\\ncate cancer, an endometrial biopsy is done to rule out\\nendometrial cancer or hyperplasia (a potentially pre-\\ncancerous condition).\\nEndometrial biopsies are also done as a screening\\ntest for endometrial cancer in postmenopausal women on\\nhormone replacement therapy . Hormone replacement\\ntherapy usually requires a woman to take estrogen and\\nprogesterone. An endometrial biopsy is particularly use-\\nful in cases where postmenopausal women take estrogen,\\nbut cannot take progesterone. Estrogen in the system\\nwithout the balancing effect of progesterone has been\\nlinked to an increased risk of endometrial cancer.\\nAn endometrial biopsy can also be used as part of an\\ninfertility exam to rule out problems with the develop-\\nment of the endometrium. This condition is called luteal\\nphase defect and can cause the endometrium to not sup-\\nport a pregnancy. An endometrial biopsy can also be used\\nto evaluate the problem of repeated early miscarriages.\\nPrecautions\\nIf the endometrial biopsy is being done to investigate\\nwhy a woman is unable to get pregnant, the test must be\\nperformed at a specific time during the menstrual cycle.\\nSince the test evaluates whether the endometrium is\\ndeveloped adequately to support implantation and growth\\nof a fertilized egg, it is critical to perform the test approxi-\\nmately three days before the expected menstrual period.\\nDescription\\nThe test is performed by a doctor who specializes in\\nwomen’s reproductive health (an obstetrician/gynecolo-\\ngist). The test is performed either in the doctor’s office or\\nin a local hospital. The patient may be asked to take pain\\nmedication (like Motrin or Aleve) an hour or so before\\nthe procedure. A local anesthetic may be injected into the\\ncervix in order to decrease pain and discomfort during\\nthe procedure.\\nThe woman will be asked to lie on her back with\\nknees apart and feet in stirrups. The doctor will first con-\\nduct a thorough exam of the pelvic region, including the\\nvulva (the external genitals), vagina, and uterus. A specu-\\nlum (an instrument that is used to hold the walls of the\\nvagina open) will be inserted into the vagina. A small,\\nhollow plastic tube is then passed into the uterine cavity.\\nA small piece of the uterine lining is sucked out with a\\nplunger that is attached to the tube. Once the sample is\\nobtained, the instruments are removed. The sample is\\nsent to the laboratory for microscopic examination.\\nThe patient may experience some pain when the\\ncervix is grasped. The patient may also feel some cramp-\\ning, pressure, and discomfort when the instruments are\\ninserted into the uterus and the tissue sample is collected.\\nPreparation\\nFor the small number of endometrial biopsies that\\nare done as part of infertility testing, a pregnancy test is\\nalso often performed before the procedure. Since the\\nbiopsy is performed late in the menstrual cycle, it is pos-\\nsible that the woman may be pregnant.\\nAftercare\\nThe biopsy may cause a small amount of bleeding\\n(spotting). The woman can resume normal activities right\\naway. If cramping becomes severe, heavy bleeding\\noccurs, or the woman develops a high temperature, the\\ndoctor should be notified immediately.\\nIf the test is being done to determine the cause of\\ninfertility, the onset of the menstrual period following the\\nbiopsy should be reported to the doctor. This will allow\\nthe doctor to correctly predict if the endometrium has\\nbeen developing at the expected rate.\\nGALE ENCYCLOPEDIA OF MEDICINE 21186\\nEndometrial biopsy\\nKEY TERMS\\nBiopsy—The surgical removal and microscopic\\nexamination of living tissue for diagnostic purposes.\\nCervix—The opening of the uterus extending into\\nthe vagina.\\nEndometrium—The layer lining the inner cavity of\\nthe uterus; this layer changes daily throughout the\\nmenstrual cycle.\\nUterus—The hollow, muscular female organ that\\nsupports the development and nourishment of the\\nunborn baby during pregnancy.\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1186'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 573, 'page_label': '574'}, page_content='Risks\\nThe risks of an endometrial biopsy are very small.\\nThere is a possibility that prolonged bleeding may occur\\nafter the procedure. There is also a slight chance of an\\ninfection. Very rarely, there are instances when the uterus\\nis pierced (perforated) or the cervix is torn because of the\\nbiopsy.\\nNormal results\\nMost biopsies are done to rule out endometrial cancer\\nor endometrial hyperplasia. A normal result shows no can-\\ncerous or precancerous cells. Normal results also show\\nthat the uterine lining is changing at the proper rate. If it is,\\nthen the results of the biopsy are said to be “in-phase”\\nbecause the tissue looks appropriate and has developed\\nnormally for the late phase of the menstrual cycle.\\nAbnormal results\\nIf the endometrium is not developing at the appro-\\npriate rate, the results are said to be “out-of-phase” or\\nabnormal. The endometrium has not developed appropri-\\nately and cannot support a pregnancy. This condition is\\ncalled luteal phase defect and may need to be treated\\nwith progesterone.\\nAbnormal appearance of the cells forming the uter-\\nine tissue could also indicate uterine cancer, or the pres-\\nence of fibroids or polyps in the uterus.\\nResources\\nBOOKS\\nThe Merck Manual of Diagnosis and Therapy.16th ed. Ed. Robert\\nBerkow. Rahway, NJ: Merck Research Laboratories, 1992.\\nPiotrowski, Nancy A., ed. “Endometrial Biopsy.” In Magill’s\\nMedical Guide Health and Illness Supplement.V ol. 4.\\nPasadena: Salem Press, 1996.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nCancer Research Institute. 681 Fifth Ave., New York, NY\\n10022. (800) 992-2623. .\\nGynecologic Cancer Foundation. 401 North Michigan Ave.,\\nChicago, IL 60611. (800) 444-4441.\\nNational Cancer Institute. Building 31, Room 10A31, 31 Cen-\\nter Drive, MSC 2580, Bethesda, MD 20892-2580. (800)\\n422-6237. .\\nLata Cherath, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1187\\nEndometrial biopsy\\nUterus\\nVagina\\nCatheter\\nA catheter is inserted into the uterus to remove uterine cells for further examination.(Illustration by Argosy Inc.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1187'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 574, 'page_label': '575'}, page_content='Endometrial cancer\\nDefinition\\nEndometrial cancer develops when the cells that\\nmake up the inner lining of the uterus (the endometrium)\\nbecome abnormal and grow uncontrollably.\\nDescription\\nEndometrial cancer (also called uterine cancer) is\\nthe fourth most common type of cancer among women\\nand the most common gynecologic cancer. Approximate-\\nly 34,000 women are diagnosed with endometrial cancer\\neach year. In 1998, approximately 6,300 women died\\nfrom this cancer. Although endometrial cancer generally\\noccurs in women who have gone through menopause\\nand are 45 years of age or older, 30% of the women with\\nendometrial cancer are younger than 40 years of age. The\\naverage age at diagnosis is 60 years old.\\nThe uterus, or womb, is the hollow female organ that\\nsupports the development of the unborn baby during\\npregnancy. The uterus has a thick muscular wall and an\\ninner lining called the endometrium. The endometrium is\\nvery sensitive to hormones and it changes daily during\\nthe menstrual cycle. The endometrium is designed to\\nprovide an ideal environment for the fertilized egg to\\nimplant and begin to grow. If pregnancy does not occur,\\nthe endometrium is shed causing the menstrual period.\\nMore than 95% of uterine cancers arise in the\\nendometrium. The most common type of uterine cancer\\nis adenocarcinoma. It arises from an abnormal multipli-\\ncation of endometrial cells (atypical adenomatous hyper-\\nplasia) and is made up of mature, specialized cells (well-\\ndifferentiated). Less commonly, endometrial cancer aris-\\nes without a preceding hyperplasia and is made up of\\npoorly differentiated cells. The more common of these\\ntypes are the papillary serous and clear cell carcinomas.\\nPoorly differentiated endometrial cancers are often asso-\\nciated with a less promising prognosis.\\nThe highest incidence of endometrial cancer in the\\nUnited States is in Caucasians, Hawaiians, Japanese, and\\nAfrican Americans. American Indians, Koreans, and\\nVietnamese have the lowest incidence. African American\\nand Hawaiian women are more likely to be diagnosed\\nwith advanced cancer and, therefore, have a higher risk\\nof dying from the disease.\\nCauses and symptoms\\nAlthough the exact cause of endometrial cancer is\\nunknown, it is clear that high levels of estrogen, when\\nnot balanced by progesterone, can lead to abnormal\\ngrowth of the endometrium. Factors that increase a\\nwoman’s risk of developing endometrial cancer are:\\n• Age. The risk is considerably higher in women who are\\nover the age of 50 and have gone through menopause.\\n• Obesity. Being overweight is a very strong risk factor\\nfor this cancer. Fatty tissue can change other normal\\nbody chemicals into estrogen, which can promote\\nendometrial cancer.\\n• Estrogen replacement therapy. Women receiving estro-\\ngen supplements after menopause have a 12 times high-\\ner risk of getting endometrial cancer if progesterone is\\nnot taken simultaneously.\\n• Diabetes. Diabetics have twice the risk of getting this\\ncancer as nondiabetic women. It is not clear if this risk\\nis due to the fact that many diabetics are also obese and\\nhypertensive. One 1998 study found that women who\\nwere obese and diabetic were three times more likely to\\ndevelop endometrial cancer than women who were\\nobese but nondiabetic. This study also found that\\nnonobese diabetics were not at risk of developing\\nendometrial cancer.\\n• Hypertension . High blood pressure (or hypertension)\\nis also considered a risk factor for uterine cancer.\\n• Irregular menstrual periods. During the menstrual\\ncycle, there is interaction between the hormones estro-\\ngen and progesterone. Women who do not ovulate regu-\\nlarly are exposed to high estrogen levels for longer peri-\\nods of time. If a woman does not ovulate regularly, this\\ndelicate balance is upset and may increase her chances\\nof getting uterine cancer.\\n• Early first menstruation or late menopause. Having\\nthe first period at a young age (the mean age of\\nmenses is 12.16 years in African American girls and\\n12.88 years in caucasian girls) or going through\\nmenopause at a late age (over age 51) seem to put\\nwomen at a slightly higher risk for developing\\nendometrial cancer.\\n• Tamoxifen. This drug, which is used to treat or prevent\\nbreast cancer, increases a woman’s chance of develop-\\ning endometrial cancer. Tamoxifen users tend to have\\nmore advanced endometrial cancer with an associated\\npoorer survival rate than those who do not take the\\ndrug. In many cases, however, the value of tamoxifen\\nfor treating breast cancer and for preventing the cancer\\nfrom spreading far outweighs the small risk of getting\\nendometrial cancer.\\n• Family history. Some studies suggest that endometrial\\ncancer runs in certain families. Women with inherited\\nmutations in the BRCA1 and BRCA2 genes are at a\\nhigher risk of developing breast, ovarian, and other\\ngynecologic cancers. Those with the hereditary non-\\nGALE ENCYCLOPEDIA OF MEDICINE 21188\\nEndometrial cancer\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1188'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 575, 'page_label': '576'}, page_content='polyposis colorectal cancer gene have a higher risk of\\ndeveloping endometrial cancer.\\n• Breast, ovarian, or colon cancer . Women who have a\\nhistory of these other types of cancer are at an increased\\nrisk of developing endometrial cancer.\\n• Low parity or nulliparity. Endometrial cancer is more\\ncommon in women who have born few (low parity) or\\nno (nulliparity) children. The high levels of proges-\\nterone produced during pregnancy has a protective\\neffect against endometrial cancer. The results of one\\nstudy suggest that nulliparity is associated with a lower\\nsurvival rate.\\n• Infertility. Risk is increased due to nulliparity or the use\\nof fertility drugs.\\n• Polycystic ovary syndrome. The increased level of\\nestrogen associated with this abnormality raises the risk\\nof cancers of the breast and endometrium.\\nThe most common symptom of endometrial cancer\\nis unusual vaginal spotting, bleeding, or discharge. In\\nwomen who are near menopause (perimenopausal),\\nsymptoms of endometrial cancer could include bleeding\\nbetween periods (intermenstrual bleeding), heavy bleed-\\ning that lasts for more than seven days, or short menstru-\\nal cycles (fewer than 21 days). For women who have\\ngone through menopause, any vaginal bleeding or abnor-\\nmal discharge is suspect. Pain in the pelvic region and\\nthe presence of a lump (mass) are symptoms that occur\\nlate in the disease.\\nDiagnosis\\nIf endometrial cancer is suspected, a series of tests\\nwill be conducted to confirm the diagnosis. The first\\nstep will involve taking a complete personal and family\\nmedical history. A physical examination , which will\\ninclude a thorough pelvic examination, will also be\\ndone.\\nThe doctor may order an endometrial biopsy . This\\nis generally performed in the doctor’s office and does not\\nrequire anesthesia. A thin, flexible tube is inserted\\nthrough the cervix and into the uterus. A small piece of\\nendometrial tissue is removed. The patient may experi-\\nence some discomfort, which can be minimized by tak-\\ning an anti-inflammatory medication (like Advil or\\nMotrin) an hour before the procedure.\\nIf an adequate amount of tissue was not obtained by\\nthe endometrial biopsy, or if the biopsy tissue looks\\nabnormal but confirmation is needed, the doctor may per-\\nform a dilatation and curettage(D & C). This procedure\\nis done in the outpatient surgery department of a hospital\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1189\\nEndometrial cancer\\nCancer located in the uterus. (Illustration by Argosy Inc.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1189'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 576, 'page_label': '577'}, page_content='and takes about an hour. The patient may be given general\\nanesthesia. The doctor dilates the cervix and uses a spe-\\ncial instrument to scrape tissue from inside the uterus.\\nThe tissue that is obtained from the biopsy or the D &\\nC is sent to a laboratory for examination. If cancer is found,\\nthen the type of cancer will be determined. The treatment\\nand prognosis depends on the type and stage of the cancer.\\nTrans-vaginal ultrasound may be used to measure the\\nthickness of the endometrium. For this painless procedure,\\na wand-like ultrasound transducer is inserted into the vagi-\\nna to enable visualization and measurement of the uterus,\\nthe thickness of the uterine lining, and other pelvic organs.\\nOther possible diagnostic procedures include sono-\\nhysterography and hysteroscopy. For sonohysteroscopy,\\na small tube is passed through the cervix and into the\\nuterus. A small amount of a salt water (saline) solution is\\ninjected through the tube to open the space within the\\nuterus and allow ultrasound visualization of the\\nendometrium. For hysteroscopy, a wand-like camera is\\npassed through the cervix to allow direct visualization of\\nthe endometrium. Both of these procedures cause dis-\\ncomfort, which may be reduced by taking an anti-inflam-\\nmatory medication prior to the procedure.\\nTreatment\\nClinical staging\\nThe International Federation of Gynecology and\\nObstetrics (FIGO) has adopted a staging system for\\nKEY TERMS\\nAdjuvant therapy—A treatment done when there is\\nno evidence of residual cancer in order to aid the\\nprimary treatment. Adjuvant treatments for endome-\\ntrial cancer are radiation therapy, chemotherapy,\\nand hormone therapy.\\nAtypical adenomatous hyperplasia —The over-\\ngrowth of the endometrium. This precancerous con-\\ndition is estimated to progress to cancer in one third\\nof the cases.\\nDilation and curettage (D & C) —A procedure in\\nwhich the doctor opens the cervix and uses a spe-\\ncial instrument to scrape tissue from the inside of\\nthe uterus.\\nEndometrial biopsy —A procedure in which a sam-\\nple of the endometrium is removed and examined\\nunder a microscope.\\nEndometrium —The mucosal layer lining the inner\\ncavity of the uterus. The endometrium’s structure\\nchanges with age and with the menstrual cycle.\\nEstrogen—A female hormone responsible for stimu-\\nlating the development and maintenance of female\\nsecondary sexual characteristics.\\nEstrogen replacement therapy (ERT) —A treatment\\nin which estrogen is used therapeutically during\\nmenopause to alleviate certain symptoms such as\\nhot flashes. ERT has also been shown to reduce the\\nrisk of osteoporosis and heart disease in women.\\nProgesterone —A female hormone that acts on the\\ninner lining of the uterus and prepares it for implan-\\ntation of the fertilized egg.\\nProgestins—A female hormone, like progesterone,\\nthat acts on the inner lining of the uterus.\\nendometrial cancer. The stage of cancer is determined after\\nsurgery. Endometrial cancer is categorized into four stages\\n(I, II, III, and IV) that are subdivided (A, B, and possibly C)\\nbased on the depth or spread of cancerous tissue. Seventy\\npercent of all uterine cancers are stage I, 10–15% are stage\\nII, and the remainder are stages III and IV . The cancer is\\nalso graded (G1, G2, and G3) based upon microscopic\\nanalysis of the aggressiveness of the cancer cells.\\nThe FIGO stages for endometrial cancer are:\\n• Stage I. Cancer is limited to the uterus.\\n• Stage II. Cancer involves the uterus and cervix.\\n• Stage III. Cancer has spread out of the uterus but is\\nrestricted to the pelvic region.\\n• Stage IV . Cancer has spread to the bladder, bowel, or\\nother distant locations.\\nThe mainstay of treatment for most stages of\\nendometrial cancer is surgery. Radiation therapy , hor-\\nmonal therapy, and chemotherapy are additional treat-\\nments (called adjuvant therapy). The necessity of adju-\\nvant therapy is a controversial topic which should be dis-\\ncussed with the patient’s treatment team.\\nSurgery\\nMost women with endometrial cancer, except those\\nwith stage IV disease, are treated with a hysterectomy. A\\nsimple hysterectomy involves the removal of the uterus.\\nIn a bilateral salpingo-oophorectomy with total hys-\\nterectomy, the ovaries, fallopian tubes, and uterus are\\nGALE ENCYCLOPEDIA OF MEDICINE 21190\\nEndometrial cancer\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1190'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 577, 'page_label': '578'}, page_content='removed. This may be necessary because endometrial\\ncancer often spreads to the ovaries first. The lymph nodes\\nin the pelvic region may also be biopsied or removed to\\ncheck for metastasis. Hysterectomy is traditionally per-\\nformed through an incision in the abdomen (laparotomy),\\nhowever, endoscopic surgery (laparoscopy) with vaginal\\nhysterectomy is also being used. Women with stage I dis-\\nease may require no further treatment. However, those\\nwith higher grade disease will receive adjuvant therapy.\\nRadiation therapy\\nThe decision to use radiation therapy depends on the\\nstage of the disease. Radiation therapy may be used\\nbefore surgery (preoperatively) and/or after surgery\\n(postoperatively). Radiation given from a machine that is\\noutside the body is called external radiation therapy.\\nSometimes applicators containing radioactive com-\\npounds are placed inside the vagina or uterus. This is\\ncalled internal radiation therapy or brachytherapy and\\nrequires hospitalization.\\nSide effects are common with radiation therapy. The\\nskin in the treated area may become red and dry.\\nFatigue, upset stomach, diarrhea , and nausea are also\\ncommon complaints. Radiation therapy in the pelvic area\\nmay cause the vagina to become narrow (vaginal steno-\\nsis), making intercourse painful. Premature menopause\\nand some problems with urination may also occur.\\nChemotherapy\\nChemotherapy is usually reserved for women with\\nstage IV or recurrent disease because this therapy is not a\\nvery effective treatment for endometrial cancer. The\\nanticancer drugs are given by mouth or intravenously.\\nSide effects include stomach upset, vomiting, appetite\\nloss, hair loss, mouth or vaginal sores, fatigue, menstrual\\ncycle changes, and premature menopause. There is also\\nan increased chance of infections.\\nHormonal therapy\\nHormonal therapy uses drugs like progesterone to\\nslow the growth of endometrial cells. These drugs are\\nusually available as pills. This therapy is usually reserved\\nfor women with advanced or recurrent disease. Side\\neffects include fatigue, fluid retention, and appetite and\\nweight changes.\\nAlternative treatment\\nAlthough alternative and complementary therapies are\\nused by many cancer patients, very few controlled studies\\non the effectiveness of such therapies exist. Mind-body\\ntechniques, such as prayer, biofeedback, visualization,\\nmeditation, and yoga, have not shown any effect in reduc-\\ning cancer, but they can reduce stress and lessen some of\\nthe side effects of cancer treatments. Clinical studies of\\nhydrazine sulfate found that it had no effect on cancer and\\neven worsened the health and well-being of the study sub-\\njects. One clinical study of the drug amygdalin (Laetrile)\\nfound that it had no effect on cancer. Laetrile can be toxic\\nand has caused deaths. Shark cartilage, although highly\\ntouted as an effective cancer treatment, is an improbable\\ntherapy that has not been the subject of clinical study.\\nThe American Cancer Society has found that the\\n“metabolic diets” pose serious risk to the patient. The\\neffectiveness of the macrobiotic, Gerson, and Kelley diets\\nand the Manner metabolic therapy has not been scientifi-\\ncally proven. The FDA was unable to substantiate the anti-\\ncancer claims made about the popular Cancell treatment.\\nThere is no evidence for the effectiveness of most\\nover-the-counter herbal cancer remedies. Some herbals\\nhave shown an anticancer effect. As shown in clinical\\nstudies, Polysaccharide krestin, from the mushroom\\nCoriolus versicolor, has significant effectiveness against\\ncancer. In a small study, the green alga Chlorella\\npyrenoidosa has been shown to have anticancer activity.\\nIn a few small studies, evening primrose oil has shown\\nsome benefit in the treatment of cancer.\\nPrognosis\\nBecause it is possible to detect endometrial cancer\\nearly, the chances of curing it are excellent. The five year\\nsurvival rates for endometrial cancer by stage are: 90%,\\nstage I; 60%, stage II; 40%, stage III; and 5%, stage IV .\\nEndometrial cancer most often spreads to the lungs, liver,\\nbones, brain, vagina, and certain lymph nodes.\\nPrevention\\nWomen (especially postmenopausal women) should\\nreport any abnormal vaginal bleeding or discharge to the\\ndoctor. Controlling obesity, blood pressure, and diabetes\\ncan help to reduce the risk of this disease. Women on\\nestrogen replacement therapy have a substantially\\nreduced risk of endometrial cancer if progestins are taken\\nsimultaneously. Long term use of birth control pills has\\nbeen shown to reduce the risk of this cancer. Women who\\nhave irregular periods may be prescribed birth control\\npills to help prevent endometrial cancer. Women who are\\ntaking tamoxifen and those who carry the hereditary non-\\npolyposis colorectal cancer gene should be screened reg-\\nularly, receiving annual pelvic examinations.\\nResources\\nBOOKS\\nBruss, Katherine, Christina Salter, and Esmeralda Galan, eds.\\nAmerican Cancer Society’s Guide to Complementary and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1191\\nEndometrial cancer\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1191'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 578, 'page_label': '579'}, page_content='Alternative Cancer Methods. Atlanta: American Cancer\\nSociety, 2000.\\nBurke, Thomas, Patricia Eifel, and Muggia Franco. “Cancers\\nof the Uterine Body.” In Cancer: Principles & Practice of\\nOncology, ed. Vincent DeVita, Samuel Hellman, and\\nSteven Rosenberg. Philadelphia: Lippincott Williams &\\nWilkins, 2001, 1573– 86.\\nLong, Harry. “Carcinoma of the Endometrium.” In Current\\nTherapy in Cancer, ed. John Foley, Julie V ose, and James\\nArmitage. Philadelphia: W. B. Saunders Company, 1999,\\n162–66.\\nPrimack, Aron. “Complementary/Alternative Therapies in the\\nPrevention and Treatment of Cancer.” In Complemen-\\ntary/Alternative Medicine: An Evidence- Based Approach,\\ned. John Spencer and Joseph Jacobs. St. Louis: Mosby,\\n1999, 123–69.\\nPERIODICALS\\nBristow, Robert. “Endometrial Cancer.”Current Opinion in\\nOncology 11 (Sept. 1999): 388–393.\\nCanavan, Timothy and Nipa Doshi. “Endometrial Cancer.”\\nAmerican Family Physician 59 (June 1999): 3069–3077.\\nElit, Laurie. “Endometrial Cancer: Prevention, Detection, Man-\\nagement, and Follow up.”Canadian Family Physician 46\\n(Apr. 2000): 887–892.\\nHogberg, Thomas, Margareta Fredstorp, and Anuja Jhingran.\\n“Indications for Adjuvant Radiotherapy in Endometrial\\nCarcinoma.” Hematology/Oncology Clinics of North\\nAmerica: Current Therapeutic Issues in Gynecologic\\nCancer 13 (Feb. 1999): 189–209.\\nORGANIZATIONS\\nAmerican Cancer Society, National Headquarters. 1599 Clifton\\nRd. NE, Atlanta, GA 30329. (800) 227-2345. .\\nCancer Research Institute, National Headquarters. 681 Fifth\\nAve., New York, NY 10022. (800) 992-2623. .\\nGynecologic Cancer Foundation. 401 North Michigan Ave.,\\nChicago, IL 60611. (800) 444-4441. .\\nNational Cancer Institute, National Institutes of Health. 9000\\nRockville Pike, Bethesda, MD 20892. (800) 422-6237.\\n.\\nOTHER\\n“Cancer of the Uterus.”Cancernet. Dec. 2000. 13 Mar. 2001\\n.\\nLata Cherath\\nBelinda Rowland, Ph.D.\\nEndometriosis\\nDefinition\\nEndometriosis is a condition in which bits of the tis-\\nsue similar to the lining of the uterus (endometrium) grow\\nin other parts of the body. Like the uterine lining, this tis-\\nsue builds up and sheds in response to monthly hormonal\\ncycles. However, there is no natural outlet for the blood\\ndiscarded from these implants. Instead, it falls onto sur-\\nrounding organs, causing swelling and inflammation. This\\nrepeated irritation leads to the development of scar tissue\\nand adhesions in the area of the endometrial implants.\\nDescription\\nEndometriosis is estimated to affect 7% of women of\\nchildbearing age in the United States. It most commonly\\nstrikes between the ages of 25 and 40. Endometriosis can\\nalso appear in the teen years, but never before the start of\\nmenstruation. It is seldom seen in postmenopausal\\nwomen.\\nEndometriosis was once called the “career woman’s\\ndisease” because it was thought to be a product of\\ndelayed childbearing. The statistics defy such a narrow\\ngeneralization; however, pregnancy may slow the\\nprogress of the condition. A more important predictor of\\na woman’s risk is if her female relatives have endome-\\ntriosis. Another influencing factor is the length of a\\nwoman’s menstrual cycle. Women whose periods last\\nlonger than a week with an interval of less than 27 days\\nbetween them seem to be more prone to the condition.\\nEndometrial implants are most often found on the\\npelvic organs—the ovaries, uterus, fallopian tubes, and in\\nthe cavity behind the uterus. Occasionally, this tissue\\ngrows in such distant parts of the body as the lungs, arms,\\nand kidneys. Newly formed implants appear as small\\nbumps on the surfaces of the organs and supporting liga-\\nments and are sometimes said to look like “powder burns.”\\nOvarian cysts may form around endometrial tissue\\n(endometriomas) and may range from pea to grapefruit\\nsize. Endometriosis is a progressive condition that usually\\nadvances slowly, over the course of many years. Doctors\\nrank cases from minimal to severe based on factors such as\\nthe number and size of the endometrial implants, their\\nappearance and location, and the extent of the scar tissue\\nand adhesions in the vicinity of the growths.\\nCauses and symptoms\\nAlthough the exact cause of endometriosis is\\nunknown, a number of theories have been put forward.\\nSome of the more popular ones are:\\n• Implantation theory. Originally proposed in the 1920s,\\nthis theory states that a reversal in the direction of men-\\nstrual flow sends discarded endometrial cells into the\\nbody cavity where they attach to internal organs and\\nseed endometrial implants. There is considerable evi-\\ndence to support this explanation. Reversed menstrual\\nGALE ENCYCLOPEDIA OF MEDICINE 21192\\nEndometriosis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1192'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 579, 'page_label': '580'}, page_content='flow occurs in 70–90% of women and is thought to be\\nmore common in women with endometriosis. However,\\nmany women with reversed menstrual flow do not\\ndevelop endometriosis.\\n• Vascular-lymphatic theory. This theory suggests that\\nthe lymph system or blood vessels (vascular system) is\\nthe vehicle for the distribution of endometrial cells out\\nof the uterus.\\n• Coelomic metaplasia theory. According to this hypothe-\\nsis, remnants of tissue left over from prenatal develop-\\nment of the woman’s reproductive tract transforms into\\nendometrial cells throughout the body.\\n• Induction theory. This explanation postulates that an\\nunidentified substance found in the body forces cells\\nfrom the lining of the body cavity to change into\\nendometrial cells.\\nIn addition to these theories, the following factors are\\nthought to influence the development of endometriosis:\\n• Heredity. A woman’s chance of developing endometrio-\\nsis is seven times greater if her mother or sisters have\\nthe disease.\\n• Immune system function. Women with endometriosis\\nmay have lower functioning immune systems that have\\ntrouble eliminating stray endometrial cells. This would\\nexplain why a high percentage of women experience\\nreversed menstrual flow while relatively few develop\\nendometriosis.\\n• Dioxin exposure. Some research suggests a link\\nbetween the exposure to dioxin (TCCD), a toxic chemi-\\ncal found in weed killers, and the development of\\nendometriosis.\\nWhile many women with endometriosis suffer debil-\\nitating symptoms, others have the disease without know-\\ning it. Paradoxically, there does not seem to be any rela-\\ntion between the severity of the symptoms and the extent\\nof the disease. The most common symptoms are:\\n• Menstrual pain. Pain in the lower abdomen that begins\\na day or two before the menstrual period starts and con-\\ntinues through to the end is typical of endometriosis.\\nSome women also report lower back aches and pain\\nduring urination and bowel movement, especially dur-\\ning their periods.\\n• Painful sexual intercourse. Pressure on the vagina and\\ncervix causes severe pain for some women.\\n• Abnormal bleeding. Heavy menstrual periods, irregular\\nbleeding, and spotting are common features of\\nendometriosis.\\n• Infertility . There is a strong association between\\nendometriosis and infertility, although the reasons for\\nthis have not been fully explained. It is thought that\\nthe build up of scar tissue and adhesions blocks the\\nfallopian tubes and prevents the ovaries from releasing\\neggs. Endometriosis may also affect fertility by caus-\\ning hormonal irregularities and a higher rate of early\\nmiscarriage.\\nDiagnosis\\nIf a doctor suspects endometriosis, the first step will\\nbe to perform a pelvic exam to try to feel if implants are\\npresent. Very often there is no strong evidence of\\nendometriosis from a physical exam. The only way to\\nmake a definitive diagnosis is through minor surgery\\ncalled a laparoscopy. A laparoscope, a slender scope with\\na light on the end, is inserted into the woman’s abdomen\\nthrough a small incision near her belly button. This allows\\nthe doctor to examine the internal organs for endometriotic\\ngrowths. Often, a sample of tissue is taken for later exami-\\nnation in the laboratory. Endometriosis is sometimes dis-\\ncovered when a woman has abdominal surgery for another\\nreason such as tubal ligationor hysterectomy.\\nVarious imaging techniques such as ultrasound,\\ncomputed tomography scan (CT scan), or magnetic res-\\nonance imaging (MRI) can offer additional information\\nbut aren’t useful in making the initial diagnosis. A blood\\ntest may also be ordered because women with\\nendometriosis have higher levels of the blood protein\\nCA125. Testing for this substance before and after treat-\\nment can predict a recurrence of the disease, but the test\\nis not reliable as a diagnostic tool.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1193\\nEndometriosis\\nAn endoscopic view of endometriosis on pelvic wall.(Cus-\\ntom Medical Stock Photo. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1193'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 580, 'page_label': '581'}, page_content='Treatment\\nHow endometriosis is treated depends on the\\nwoman’s symptoms, her age, the extent of the disease,\\nand her personal preferences. The condition cannot be\\nfully eradicated without surgery. Conservative treatment\\nfocuses on managing the pain, preserving fertility, and\\ndelaying the progress of the condition.\\nPain relief\\nOver-the-counter pain relievers such as aspirin\\nand acetaminophen (Tylenol) are useful for mild\\ncramping and menstrual pain. Prescription-strength\\nand over-the-counter nonsteroidal anti-inflammatory\\ndrugs (NSAIDs), such as ibuprofen (Motrin, Advil)\\nand naproxen (Naprosyn), are also effective. If pain is\\nsevere, a doctor may prescribe narcotic medications,\\nalthough these can be addicting and are rarely used.\\nHormonal treatments\\nHormonal therapies effectively tame endometriosis\\nbut also act as contraceptives. A woman who is hoping to\\nbecome pregnant would take these medications for a\\nperiod of time, then try to conceive within several\\nmonths of discontinuing treatment.\\n• Oral contraceptives. Continuously taking estrogen-\\nprogestin pills tricks the body into thinking it is preg-\\nnant. This state of pseudopregnancy means reduced\\npelvic pain and a temporary withering of endometrial\\nimplants.\\n• Danazol (Danocrine) and gestrinone are synthetic male\\nhormones that lower estrogen levels, prevent menstrua-\\ntion, and shrink endometrial tissues. On the downside,\\nthey lead to weight gain and menopause-like symp-\\ntoms, and cause some women to develop masculine\\ncharacteristics.\\n• Progestins. Medroxyprogesterone (Depo-Provera) and\\nrelated drugs may also be used in treating endometrio-\\nsis. They have been proven effective in minimizing pain\\nand halting the progress of the condition, but are rarely\\nused because of the high rate of side effects.\\n• Gonadotropin-releasing hormone (GnHR) agonists.\\nThese estrogen-inhibiting drugs successfully limit pain\\nand prevent the growth of endometrial implants. They\\ncan cause menopause symptoms, however, and doses\\nhave to be regulated to prevent bone loss associated\\nwith low estrogen levels.\\nSurgery\\nRemoving the uterus, ovaries, and fallopian tubes is\\nthe only permanent method of eliminating endometrio-\\nsis. This is an extreme measure that deprives a woman of\\nher ability to bear children and forces her body into\\nmenopause. Endometrial implants and ovarian cysts can\\nbe removed with laser surgery performed through a\\nlaparoscope. For women with minimal endometriosis,\\nthis technique is usually successful in reducing pain and\\nslowing the condition’s progress. It may also help infer-\\ntile women increase their chances of becoming pregnant.\\nAlternative treatment\\nAlthough severe endometriosis should not be self-\\ntreated, many women find they can help their condition\\nthrough alternative therapies. Taking vitamin B complex\\ncombined with vitamins C, E, and the minerals calcium,\\nmagnesium, and selenium can help the depression and\\nlack of energy that may accompany endometriosis. B vit-\\namins also counteract the side effects of hormonal drugs.\\nOther women have found relief when they turned to a\\nmacrobiotic diet. Less extreme diets that cut out sugar,\\nsalt, and processed foods are sometimes helpful as well.\\nMind-body therapies such as relaxation and visualization\\nhelp women cope with pain. Other avenues to combat\\npain include acupuncture and biofeedback techniques.\\nStill other women report positive results after being treat-\\ned by chiropractors or homeopathic doctors.\\nPrognosis\\nMost women who have endometriosis have minimal\\nsymptoms and do well. Overall, endometriosis symp-\\ntoms come back in an average of 40% of women over the\\nfive years following treatment. With hormonal therapy,\\npain returned after five years in 37% of patients with\\nminimal symptoms and 74% of those with severe cases.\\nThe highest success rate from conservative treatment fol-\\nlowed complete removal of implants using laser surgery.\\nEighty percent of these women were still pain-free five\\nyears later. In cases that don’t respond to these treat-\\nments, a woman and her doctor may consider surgery to\\nremove her reproductive organs.\\nPrevention\\nThere is no proven way to prevent endometriosis.\\nOne study, however, indicated that girls who begin par-\\nticipating in aerobic exercise at a young age are less like-\\nly to develop the condition.\\nResources\\nBOOKS\\nBreitkopf, Lyle J. Coping With Endometriosis.Prentice Hall,\\n1988.\\nD’Hooghe, Thomas M., and Joseph A. Hill. “Endometriosis.”\\nIn Novak’s Gynecology.12th ed. Ed. Jonathan S. Berek, et\\nal. Baltimore: Lippincott, 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 21194\\nEndometriosis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1194'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 581, 'page_label': '582'}, page_content='The Endometriosis Sourcebook. Ed. Mary Lou Ballweg, et al.\\nChicago: Congdon & Weed, 1995.\\nOvercoming Endometriosis. Ed. Mary Lou Ballweg, et al.\\nChicago: Congdon & Weed, 1987.\\nORGANIZATIONS\\nEndometriosis Association International Headquarters. 8585\\nNorth 76th Place, Milwaukee, WI 53223. (800) 992-3636.\\n.\\nStephanie Slon\\nEndometritis see Pelvic inflammatory disease\\nEndorectal ultrasound\\nDefinition\\nEndorectal ultrasound (ERUS) is a procedure where\\na probe is inserted into the rectum and high frequency\\nKEY TERMS\\nAdhesions—Web-like scar tissue that may develop\\nas a result of endometriosis and bind organs to\\none another.\\nDioxin—A toxic chemical found in weed killers\\nthat has been linked to the development of\\nendometriosis.\\nEndometrial implants —Growths of endometrial\\ntissue that attach to organs, primarily in the pelvic\\ncavity.\\nEndometrium —The tissue lining the uterus that\\ngrows and sheds each month during a woman’s\\nmenstrual cycle.\\nEstrogen —A female hormone that promotes the\\ngrowth of endometrial tissue.\\nHormonal therapy—Use of hormone medications\\nto inhibit menstruation and relieve the symptoms\\nof endometriosis.\\nLaparoscopy —A diagnostic procedure for endo-\\nmetriosis performed by inserting a slender, wand-\\nlike instrument through a small incision in the\\nwoman’s abdomen.\\nMenopause —The end of a woman’s menstrual\\nperiods when the body stops making estrogen.\\nRetrograde menstruation —Menstrual flow that\\ntravels into the body cavity rather than being\\nexpelled through the uterus.\\nsound waves (ultrasound waves) are generated. The pat-\\ntern of echoes as they bounce off tissues is converted into\\na picture (sonogram) on a television screen.\\nPurpose\\nERUS is used as a diagnostic procedure in rectal\\ncancer to determine stage of the tumor and as a postradi-\\nation, presurgical examination to assess extent of tumor\\nshrinkage. ERUS can also be used in cases of anal fistula\\n(an abnormal passage) and problems with the anal\\nsphincter muscles (muscles that control the opening and\\nclosing of the anus).\\nPrecautions\\nNormal precautions should be taken with any diag-\\nnostic procedure. Since the population in which this pro-\\ncedure is normally done is elderly, the imaging staff\\nshould be extra cautious about stressing the patient. The\\nprocedure is invasive and may be embarrassing to some.\\nOther patients may be anxious about their medical condi-\\ntion since endorectal ultrasounds are not routine. This\\nplaces an added burden on already stressed hearts and\\nnervous systems. Physicians, nurses, and technicians\\nmay need to be prepared for stress reactions that could\\ninclude the heart, asthma, or anxious behaviors.\\nDescription\\nERUS has been used as a means to determine the\\ndepth of rectal cancers and to assess whether the tumor\\nhas affected surrounding tissues. This pre-treatment pro-\\ncedure has proven to be an accurate tool for tailoring\\nsurgery for patients.\\nProblems with interpretation of the sonograms after\\nradiation and before surgery have resulted in tumors\\nbeing identified that were merely the formation of\\nfibrous tissues that remained after the tumors had been\\neliminated by the radiation. Yet, some of the fibrous\\nareas actually hid residual tumors. Rectal anatomy itself\\ncan affect the accuracy of ultrasound reading. This\\nmakes ERUS problematic in determining the amount of\\ntumor reduction a patient has after radiation therapy.\\nPreparation\\nThe patient must evacuate the bowels completely\\nbefore the procedure is done. This usually is assisted\\nthough the use of several enemas. The patient may be\\ntold to adhere to a liquid diet the day prior to doing this\\nprocedure. The probe is inserted, usually with little dis-\\ncomfort for the patient since it will only be examining\\nthe first few inches of the colon.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1195\\nEndorectal ultrasound\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1195'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 582, 'page_label': '583'}, page_content='Aftercare\\nSince ERUS is a minor invasive procedure, there is\\nno aftercare.\\nRisks\\nThere are no risks to having an ultrasound.\\nNormal results\\nNormal results after an endorectal ultrasound are\\nnormal, healthy tissues.\\nAbnormal results\\nAbnormal results range from any number of congen-\\nital deformities in the lining of the rectum to serious rec-\\ntal cancers.\\nResources\\nBOOKS\\nJohnston, Lorraine. Colon and Rectal Cancer: A Comprehen-\\nsive Guide for Patients and Families.Sebastopol, CA:\\nO’Reilly, 2000.\\nLevin, Bernard. Colorectal Cancer: A Thorough and Compas-\\nsionate Resource for Patients and Their Families.New\\nYork: Villard, 1999.\\nPERIODICALS\\nGavioli, M. A. Bagni, I. Piccagli, S. Fundaro, and G. Natalini.\\n“Usefulness of Endorectal Ultrasound after Preoperative\\nRadiotherapy in Rectal Cancer: Comparison between\\nSonographic and Histopathologic Changes.”Dis Colon\\nRectum (August 2000): 1075-83.\\nOTHER\\nAmerican Society of Colon and Rectal Surgeons. “Practice\\nParameters for the Treatment of Rectal Carcinoma.” 9 May\\n2001. .\\nNational Cancer Institute. “NCI/PDQ Patient Statement: Rectal\\nCancer Updated 11/2000.”OncoLink. 9 May 2001.\\nKEY TERMS\\nAnal sphincter muscles—Muscles that control the\\nopening and closing of the anus.\\nFistula—An abnormal passage.\\nSonogram—The picture formed by the pattern of\\nechoes from an ultra sound.\\nUltrasound waves—High frequency sound waves.\\n.\\nJanie F. Franz\\nEndoscopic retrograde\\ncholangiopancreatography\\nDefinition\\nEndoscopic retrograde cholangiopancreatography\\n(ERCP) is a technique in which a hollow tube called an\\nendoscope is passed through the mouth and stomach to\\nthe duodenum (the first part of the small intestine). This\\nprocedure was developed to examine abnormalities of\\nthe bile ducts, pancreas, and gallbladder. It was devel-\\noped during the late 1960s and is used today to diagnose\\nand treat blockages of the bile and pancreatic ducts.\\nThe term has three parts to its definition:\\n• endoscopic refers to the use of an endoscope\\n• retrograde refers to the injection of dye up into the bile\\nducts in a direction opposing, or against, the normal\\nflow of bile down the ducts\\n• cholangiopancreatography means visualization of the\\nbile ducts (cholangio) and pancreas (pancreato)\\nPurpose\\nUntil the 1970s, methods to visualize the bile ducts\\nproduced images that were of relatively poor quality and\\noften misleading; in addition, the pancreatic duct could\\nnot be examined at all. Patients with symptoms related to\\nthe bile ducts or pancreatic ducts frequently needed\\nsurgery to diagnose and treat their conditions.\\nUsing ERCP, physicians can obtain high-quality x\\nrays of these structures and identify areas of narrowing\\n(strictures), cancers, and gallstones. This procedure can\\nhelp determine whether bile or pancreatic ducts are\\nblocked; it also identifies where they are blocked along\\nwith the cause of the blockage. ERCP may then be used\\nto relieve the blockage. For patients requiring surgery or\\nadditional procedures for treatment, ERCP outlines the\\nanatomical changes for the surgeon.\\nPrecautions\\nThe most important precaution is that the examina-\\ntion should be performed by an experienced physician.\\nThe procedure is much more technically difficult than\\nmany other gastrointestinal endoscopic studies. Patients\\nGALE ENCYCLOPEDIA OF MEDICINE 21196\\nEndoscopic retrograde cholangiopancreatography\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1196'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 583, 'page_label': '584'}, page_content='should seek physicians with experience performing\\nERCP. Patients should inform the physician about any\\nallergies (including allergies to contrast dyes, iodine, or\\nshellfish), medication use, and medical problems. Occa-\\nsionally, patients may need to be admitted to the hospital\\nafter the procedure.\\nDescription\\nAfter sedation , a specially adapted endoscope is\\npassed through the mouth, through the stomach, then into\\nthe duodenum. The opening to ducts that empty from the\\nliver and pancreas is identified, and a plastic tube or\\ncatheter is placed into the orifice (opening). Contrast dye\\nis then injected into the ducts, and with the assistance of\\na radiologist, pictures are taken.\\nPreparation\\nThe upper intestinal tract must be empty for the pro-\\ncedure, so patients should not eat or drink for at least six to\\n12 hours before the exam. Patients should ask the physi-\\ncian about taking their medications before the procedure.\\nAftercare\\nSomeone should be available to take the person\\nhome after the procedure and stay with them for a while;\\npatients will not be able to drive themselves because they\\nundergo sedation during this test. Pain or any other\\nunusual symptoms should be reported to the physician.\\nRisks\\nERCP-related complications can be broken down\\ninto those related to medications used during the proce-\\ndure, the diagnostic part of the procedure, and those\\nrelated to endoscopic therapy. The overall complication\\nrate is 5–10%; most of those occur when diagnostic\\nERCP is combined with a therapeutic procedure. During\\nthe exam, the endoscopist can cut or stretch structures\\n(such as the muscle leading to the bile duct) to treat the\\ncause of the patient’s symptoms. Although the use of\\nsedatives carries a risk of decreasing cardiac and respira-\\ntory function, it is very difficult to perform these proce-\\ndures without these drugs.\\nThe major complications related to diagnostic ERCP\\nare pancreatitis (inflammation of the pancreas) and\\ncholangitis (inflammation of the bile ducts). Bacteremia\\n(the passage of bacteria into the blood stream) and perfo-\\nration (hole in the intestinal tract) are additional risks.\\nNormal results\\nBecause certain standards have been set for the nor-\\nmal diameter or width of the pancreatic duct and bile\\nKEY TERMS\\nEndoscope, endoscopy—An endoscope used in the\\nfield of gastroenterology is a hollow, thin, flexible\\ntube that uses a lens or miniature camera to view\\nvarious areas of the gastrointestinal tract. When the\\nprocedure is performed to examine the bile ducts or\\npancreas, the organs are not viewed directly, but\\nrather indirectly through the injection of contrast.\\nThe performance of an exam using an endoscope is\\nreferred to as endoscopy. Diagnosis through biop-\\nsies or other means and therapeutic procedures can\\nalso be done using these instruments.\\nVisualization—The process of making an internal\\norgan visible. A radiopaque substance is intro-\\nduced into the body, then an x-ray picture of the\\ndesired area is taken.\\nducts, measurements using x rays are taken to determine\\nif the ducts are too large (dilated) or too narrow (stric-\\ntured). The ducts and gallbladder should be free of stones\\nor tumors.\\nAbnormal results\\nWhen areas in the pancreatic or bile ducts (including\\nthose in the liver) are too wide or too narrow compared\\nwith the standard, the test is considered abnormal. Once\\nthese findings are demonstrated using ERCP, symptoms\\nare usually present; they generally do not change without\\ntreatment. Stones, identified as opaque or solid structures\\nwithin the ducts, are also considered abnormal. Masses\\nor tumors may also be seen, but sometimes the diagnosis\\nis made not by direct visualization of the tumor, but by\\nindirect signs, such as a single narrowing of one of the\\nducts. Overall, ERCP has an excellent record in diagnos-\\ning these abnormalities.\\nResources\\nBOOKS\\nOstroff, James W., and Jeanne M. LaBerge. “Endoscopic and\\nRadiologic Treatment of Biliary Disease.” In Sleisenger &\\nFordtran’s Gastrointestinal and Liver Disease.Ed. by\\nMark Feldman, et al. Philadelphia: W.B. Saunders Com-\\npany, 1997.\\nPERIODICALS\\nAliperti, Giuseppe. “Complications Related to Diagnostic and\\nTherapeutic Endoscopic Retrograde Cholangiopancre-\\natography” Gastrointestinal Endoscopy Clinics of North\\nAmerica (Apr. 1996): 379–407.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1197\\nEndoscopic retrograde cholangiopancreatography\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1197'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 584, 'page_label': '585'}, page_content='Baillie, John. “Treatment of Acute Biliary Pancreatitis.”New\\nEngland Journal of Medicine 336, no. 4 (1997): 286.\\nWigton, Robert S. “Measuring Procedural Skills.”Annals of\\nInternal Medicine 125 (1996): 1003–4.\\nOTHER\\nEndoscopic Retrograde Cholangiopancreatography.21 June\\n2001 .\\nMeasuring Procedural Skills. 21 June 2001 .\\nTreatment of Acute Biliary Pancreatitis.21 June 2001 .\\nDavid S. Kaminstein\\nEndoscopic sclerotherapy see Sclerotherapy\\nfor esophageal varices\\nEndoscopic sphincterotomy\\nDefinition\\nEndoscopic sphincterotomy or endoscopic retrograde\\nsphincterotomy (ERS) is a relatively new endoscopic\\ntechnique developed to examine and treat abnormalities\\nof the bile ducts, pancreas and gallbladder. The procedure\\nwas developed as an extension to the diagnostic examina-\\ntion, ERCP (endoscopic retrograde cholangiopancre-\\natography); with the addition of “sphincterotomy,”\\nabnormalities found during the study could be treated at\\nthe same time without the need for invasive surgery.\\nThe term ERS has three parts to its definition;\\n• endoscopic refers to the use of an endoscope\\n• retrograde refers to the insertion of the endoscope up\\ninto the ducts in a direction opposite to or against the\\nnormal flow of bile down the ducts\\n• sphincterotomy, which means cutting of the sphincter\\nor muscle that lies at the juncture of the intestine with\\nboth the bile and pancreatic ducts\\nPurpose\\nUntil the 1970s, patients with symptoms related to\\ndisease of the bile ducts or pancreas frequently needed\\nsurgery to diagnose the cause and treat any abnormali-\\nties. ERCP allowed physicians for the first time to obtain\\nhigh quality x rays of the common bile and pancreatic\\nducts, and detect areas of narrowing (strictures), stones,\\nand tumors. ERCP was not initially designed for treat-\\nment. ERS was developed shortly after and enabled\\nphysicians to treat the abnormalities identified by the\\ninjection of dye and x rays.\\nThe revolutionary technique made possible the\\nendoscopic removal of stones and stretching of areas of\\nnarrowing (strictures). It has since been expanded to\\ninclude drainage of bile from blocked ducts and treat-\\nment of various abnormalities of the pancreas.\\nPrecautions\\nThe most important precaution related to both ERCP\\nand ERS is to have the procedure performed by an expe-\\nrienced physician. ERS is technically more difficult than\\nmany other gastrointestinal endoscopic studies, including\\nERCP. Patients should inquire as to the physician’s expe-\\nrience with the procedure. The physician should also be\\ninformed of any allergies , medication use, and medical\\nproblems.\\nDescription\\nERS is generally performed only after ERCP has\\nbeen successfully accomplished and detail of the anato-\\nmy and abnormalities is known. During ERS, a number\\nof various instruments are inserted through the endo-\\nscope in order to “cut” or stretch the sphincter. Once this\\nis done, additional instruments are passed that enable the\\nremoval of stones and the stretching of narrowed regions\\nof the ducts. Drains (stents) can also be used to prevent a\\nnarrowed area from rapidly returning to its previously\\nnarrowed state.\\nPreparation\\nThe upper intestinal tract must be empty for the pro-\\ncedure, so patients must not eat or drink for at least six to\\n12 hours before the exam. Patients need to inquire about\\ntaking their medications before the procedure. Some\\npatients may require antibiotics before and/or after the\\nprocedure. When possible, aspirin or NSAIDS should\\nnot be taken within several days before the procedure,\\nbecause they interfere with blood clotting.\\nAftercare\\nWhen ERS is performed, physicians will usually\\nwant to observe the patient closely for several hours to\\nensure that there are no signs of complications. Pain or\\nany other unusual symptoms should be reported. Admis-\\nsion to the hospital may be advised.\\nRisks\\nERS complications are related either to the drugs\\nused during the procedure, or the results of dye injection\\nor cutting of tissue. The overall complication rate is\\n5–10%. During the exam, the endoscopist can cut or\\nGALE ENCYCLOPEDIA OF MEDICINE 21198\\nEndoscopic sphincterotomy\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1198'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 585, 'page_label': '586'}, page_content='stretch structures (such as the muscle leading to the bile\\nduct) to treat the cause of the patient’s symptoms. Cut-\\nting or stretching of these structures can sometimes cause\\na hole or perforation. The use of sedatives also carries a\\nrisk of decreasing cardiac and respiratory function, how-\\never, it is very difficult to perform these procedures with-\\nout these drugs.\\nOther major complications related to ERCP or ERS\\nare pancreatitis (inflammation of the pancreas) and\\ncholangitis (inflammation of the bile ducts). Bacteremia\\n(the passage of bacteria into the blood stream) and bleed-\\ning are also risks.\\nNormal results\\nCertain standards have been set for the diameter or\\nwidth of the pancreatic and bile ducts. Measurements by\\nx ray are used to determine if the ducts are too large\\n(dilated) or too narrow (strictured). Lastly, the ducts and\\ngallbladder should be free of any solid particles, such as\\nstones, and free of areas of narrowing.\\nResources\\nBOOKS\\nOstroff, James W., and Jeanne M. Laberge. “Endoscopic and\\nRadiologic Treatment of Biliary Disease.” In Sleisenger &\\nKEY TERMS\\nEndoscope, Endoscopy—An endoscope as used in\\nthe field of gastroenterology is a thin flexible tube\\nwhich uses a lens or miniature camera to view\\nvarious areas of the gastrointestinal tract. When\\nthe procedure is performed to examine certain\\norgans such as the bile ducts or pancreas, the\\norgans are not viewed directly, but rather indirect-\\nly through the injection of x-ray dye. The perfor-\\nmance of an exam using an endoscope is referred\\nby the general term endoscopy. Diagnosis through\\nbiopsies or other means and therapeutic proce-\\ndures can be done with these instruments.\\nNSAIDS—This abbreviation stands for non-\\nsteroidal anti-inflammatory drugs, which are med-\\nications such as Ibufprofen that are used to control\\npain and inflammation. Most may be purchased\\nover the counter. One of their major side effects is\\nthat they decrease the effect of the normal blood\\nclotting factors in blood. In patients undergoing\\nsurgical or endoscopic procedures, this can lead\\nto an increased risk of bleeding.\\nFordtran’s Gastrointestinal and Liver Disease, ed. Mark\\nFeldman, et al. Philadelphia: W. B. Saunders Company.\\n1997.\\nPERIODICALS\\nAliperti, Giuseppe. “Complications Related to Diagnostic and\\nTherapeutic Endoscopic Retrograde Cholangiopancre-\\natography.”Gastrointestinal Endoscopy Clinics of North\\nAmerica (Apr. 1996): 379-407.\\nBaillie, John. “Treatment of Acute Biliary Pancreatitis.”New\\nEngland Journal of Medicine 336, no. 4 (1997): 286.\\nCotton, Peter B., and Hawes, Robert H. “Therapeutic Biliary\\nEndoscopy.”Gastrointestinal Endoscopy Clinics of North\\nAmerica (Jan. 1996): 1-263.\\nWigton, Robert S. “Measuring Procedural Skills.”Annals of\\nInternal Medicine 125 (1996): 1003-1004.\\nOTHER\\n“Endoscopic Retrograde Cholangiopancreatography.”Ameri-\\ncan Society for Gastrointestinal Endoscopy..\\n“Treatment of Acute Biliary Pancreatitis.”New England Jour-\\nnal of Medicine Online. .\\nDavid Kaminstein, MD\\nEnemas\\nDefinition\\nAn enema is the insertion of a solution into the rec-\\ntum and lower intestine.\\nPurpose\\nEnemas may be given for the following purposes:\\n• to remove feces when an individual is constipated or\\nimpacted,\\n• to remove feces and cleanse the rectum in preparation\\nfor an examination,\\n• to remove feces prior to a surgical procedure to prevent\\ncontamination of the surgical area,\\n• to administer drugs or anesthetic agents.\\nPrecautions\\nThe rectal tube used for infusion of the enema solu-\\ntion should be smooth and flexible to decrease the possi-\\nbility of damage to the mucous membrane that lines the\\nrectum. Tap water is commonly used for adults but\\nshould not be used for infants because of the danger of\\nelectrolyte (substance that conducts electric current\\nwithin the body and is essential for sustaining life)\\nimbalance. The colon absorbs water, and repeated tap\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1199\\nEnemas\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1199'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 586, 'page_label': '587'}, page_content='water enemas can cause cardiovascular overload and\\nelectrolyte imbalance. Similarly, repeated saline enemas\\ncan cause increased absorption of fluid and electrolytes\\ninto the bloodstream, resulting in overload. Individuals\\nreceiving frequent enemas should be observed for over-\\nload symptoms that include dizziness , sweating, or\\nvomiting.\\nSoap suds and saline used for cleansing enemas can\\ncause irritation of the lining of the bowel, with repeated\\nuse or a solution that is too strong. Only white soap\\nshould be used; the bar should not have been previously\\nused, to prevent infusing undesirable organisms into the\\nindividual receiving the enema. Common household\\ndetergents are considered too strong for the rectum and\\nbowel. The commercially prepared castile soap is pre-\\nferred, and should be used in concentration no greater\\nthan 5 cc soap to 1,000 cc of water.\\nDescription\\nCleansing enemas act by stimulation of bowel activ-\\nity through irritation of the lower bowel, and by disten-\\ntion with the volume of fluid instilled. When the enema\\nis administered, the individual is usually lying on the left\\nside, which places the sigmoid colon (lower portion of\\nbowel) below the rectum and facilitates infusion of fluid.\\nThe length of time it takes to administer an enema\\ndepends on the amount of fluid to be infused. The\\namount of fluid administered will vary depending on the\\nage and size of the person receiving the enema, however\\ngeneral guidelines would be:\\n• Infant: 250 cc or less\\n• Toddler and preschooler: 500 cc or less\\n• School-aged child: 500–1,000 cc\\n• Adult: 750–1,000 cc\\nSome may differentiate between high and low ene-\\nmas. A high enema, given to cleanse as much of the large\\nbowel as possible, is usually administered at higher pres-\\nsure and with larger volume (1,000 cc), and the individ-\\nual changes position several times in order for the fluid\\nto flow up into the bowel. A low enema, intended to\\ncleanse only the lower bowel, is administered at lower\\npressure, using about 500 cc of fluid.\\nOil retention enemas serve to lubricate the rectum\\nand lower bowel, and soften the stool. For adults, about\\n150–200 cc of oil is instilled, while in small children,\\n75–150 cc of oil is considered adequate. Salad oil or liq-\\nuid petrolatum are commonly used at a temperature of\\n91°F (32.8°C). There are also commercially prepared oil\\nretention enemas. The oil is usually retained for one to\\nthree hours before it is expelled.\\nThe rectal tube used for infusion of the solution,\\nusually made of rubber or plastic, has two or more\\nopenings at the end through which the solution can flow\\ninto the bowel. The distance to which the tube must be\\ninserted is dependent upon the age and size of the\\npatient. For adult, insertion is usually 3–4 in (7.5–10\\ncm); for children, approximately 2–3 in (5–7.5 cm); and\\nfor infants, only 1–1.5 in (2.5–3.75 cm). The rectal tube\\nis lubricated before insertion with a water soluble lubri-\\ncant to ease insertion and decrease irritation to the rec-\\ntal tissues.\\nThe higher the container of solution is placed, the\\ngreater the force in which the fluid flows into the patient.\\nRoutinely, the container should be no higher than 12 in\\n(30 cm) above the level of the bed; for a high cleansing\\nenema, the container may be 12–18 in (30–45 cm) above\\nthe bed level, because the fluid is to be instilled higher\\ninto the bowel.\\nPreparation\\nThe solution used in the procedure is measured,\\nmixed, and warmed before administration of the enema.\\nAftercare\\nIf necessary, a specimen will be collected for diag-\\nnostic evaluation. If the enema was given to alleviate\\nconstipation , the better approach to combatting consti-\\nGALE ENCYCLOPEDIA OF MEDICINE 21200\\nEnemas Colon Rectum\\nEnemas may be given for the following purposes: to remove\\nfeces when an individual is constipated, or to remove feces\\nand cleanse the rectum in preparation for an examination,\\nor prior to surgery to prevent contamination.There are two\\ntypes of enemas: the high enema, given to cleanse the large\\nbowel, and the low enema, to cleanse only the lower bowel.\\n(Illustration by Electronic Illustrators Group.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1200'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 587, 'page_label': '588'}, page_content='pation in the future is with a high fiber diet (five to six\\nservings of whole grain foods) and adequate fluid\\nintake (seven to eight glasses of water per day). Regular\\nexercise and going to the bathroom when necessary\\nwill also help. If constipation is a chronic problem,\\nmedical help should be consulted to determine if there\\nis underlying disorder.\\nRisks\\nHabitual use of enemas as a means to combat consti-\\npation can make the problem even more severe when\\ntheir use is discontinued. Enemas should be used only as\\na last resort for treatment of constipation and with a doc-\\ntor’s recommendation. Enemas should not be adminis-\\ntered to individuals who have recently had colon or rectal\\nsurgery, a heart attack, or who suffer from an unknown\\nabdominal condition or an irregular heartbeat.\\nResources\\nOTHER\\nEller, D. “Spring Cleaning from the Inside Out.”Remedy May/\\nJune 1997. 28 May 1998 .\\nWeiss, R. “Enhancing the process of elimination.”Washington\\nPost Health. 29 Nov. 1994. 28 May 1998 .\\nKathleen D. Wright, RN\\nEnlarged prostate\\nDefinition\\nA non-cancerous condition that affects many men\\npast 50 years of age, enlarged prostate makes urinating\\nKEY TERMS\\nElectrolyte —A substance that conducts electric\\ncurrent within the body and is essential for sus-\\ntaining life.\\nIntestine—Also called the bowels and divided into\\nlarge and small intestine, they extend from the\\nstomach to the anus, where waste products exit the\\nbody. The small intestine is about 20 ft (6.1 m) long\\nand the large intestine, about 5 ft (1.5 m) long.\\nRectum—The portion of bowel just before the anus.\\nThe prefix recto is used with a variety of words in\\nrelation to conditions that affect the rectum.\\nmore difficult by narrowing the urethra, a tube running\\nfrom the bladder through the prostate gland. It can be\\neffectively treated by surgery and, today, by certain\\ndrugs.\\nDescription\\nThe common term for enlarged prostate is BPH,\\nwhich stands for benign (non-cancerous) prostatic\\nhyperplasia or hypertrophy. Hyperplasia means that the\\nprostate cells are dividing too rapidly, increasing the\\ntotal number of cells, and, therefore, the size of the\\norgan itself. Hypertrophy simply means “enlargement.”\\nBPH is part of the aging process. The actual changes in\\nthe prostate may start as early as the 30s but take place\\nvery gradually, so that significant enlargement and\\nsymptoms usually do not appear until after age 50. Past\\nthis age the chances of the prostate enlarging and caus-\\ning urinary symptoms become progressively greater.\\nMore than 40% of men in their 70s have an enlarged\\nprostate. Symptoms generally appear between ages\\n55–75. About 10% of all men eventually will require\\ntreatment for BPH.\\nBPH has been viewed as a rare condition in African,\\nChinese and other Asian peoples for reasons that are not\\nclear.\\nCauses and symptoms\\nThe cause of BPH is a mystery, but age-related\\nchanges in the levels of hormones circulating in the\\nblood may be a factor. Whatever the cause, an enlarging\\nprostate gradually narrows the urethra and obstructs the\\nflow of urine. Even though the muscle in the bladder wall\\nbecomes stronger in an attempt to push urine through the\\nsmaller urethra, in time, the bladder fails to empty com-\\npletely at each urination. The urine that collects in the\\nbladder can become infected and lead to stone formation.\\nThe kidneys themselves may be damaged by infection or\\nby urine constantly “backing up.”\\nWhen the enlarging prostate gland narrows the ure-\\nthra, a man will have increasing trouble starting the urine\\nstream. Because some urine remains behind in the blad-\\nder, he will have to urinate more often, perhaps two or\\nthree times at night (nocturia). The need to urinate can\\nbecome very urgent and, in time, urine may dribble out\\nto stain a man’s clothing. Other symptoms of BPH are a\\nweak and sometimes a split stream and general aching or\\npain in the perineum (the area between the scrotum and\\nanus). Some men may have considerable enlargement of\\nthe prostate before even mild symptoms develop.\\nIf a man must strain hard to force out the urine,\\nsmall veins in the bladder wall and urethra may rupture,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1201\\nEnlarged prostate\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1201'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 588, 'page_label': '589'}, page_content='causing blood to appear in the urine. If the urinary stream\\nbecomes totally blocked, the urine collecting in the blad-\\nder may cause severe discomfort, a condition called\\nacute urinary retention. Urine that stagnates in the blad-\\nder can easily become infected. A burning feeling during\\nurination and fever are clues that infection may have\\ndeveloped. Finally, if urine backs up long enough it may\\nincrease pressure in the kidneys, though this rarely caus-\\nes permanent kidney damage.\\nDiagnosis\\nWhen a man’s symptoms point to BPH, the first\\nthing the physician will want to do is a digital rectal\\nexamination , inserting a finger into the anus to feel\\nwhether—and how much—the prostate is enlarged. A\\nsmooth prostate surface suggests BPH, whereas a dis-\\ntinct lump in the gland might mean prostate cancer .\\nThe next step is a blood test for a substance called\\nprostate-specific antigen or PSA. Between 30–50% of\\nmen with BPH have an elevated PSA level. This does\\nnot mean cancer by any means, but other measures\\nare needed to make sure that the prostate enlargement\\nis in fact benign. An ultrasound exam of the prostate,\\nwhich is entirely safe and delivers no radiation, can\\nshow whether it is enlarged and may show that cancer\\nis present.\\nIf digital or ultrasound examination of the prostate\\nraises the suspicion of cancer, most urologists will rec-\\nommend that a prostatic tissue biopsy be performed. This\\nis usually done using a lance-like instrument that is\\ninserted into the rectum. It pierces the rectal wall and,\\nguided by the physcian’s finger, obtains six to eight\\npieces of prostatic tissue that are sent to the laboratory\\nfor microscopic examination. If cancer is present, the\\nprognosis and treatment are changed accordingly.\\nA catheter placed through the urethra and into the\\nbladder can show how much urine remains in the bladder\\nafter the patient urinates—a measure of how severe the\\nobstruction is. Another and very simple test for obstruc-\\ntion is to have the man urinate into a uroflowmeter,\\nwhich measures the rate of urine flow. A very certain—\\nthough invasive—way of confirming obstruction from an\\nenlarged prostate is to pass a special viewing instrument\\ncalled a cystoscope into the bladder, but this is not often\\nnecessary.\\nIt is routine to check a urine sample for an increased\\nnumber of white blood cells, which may mean there is\\ninfection of the bladder or kidneys. The same sample\\nmay be cultured to show what type of bacterium is caus-\\ning the infection, and which antibiotics will work best.\\nThe state of the kidneys may be checked in two ways:\\nimaging by either ultrasound or injecting a dye (the intra-\\nGALE ENCYCLOPEDIA OF MEDICINE 21202\\nEnlarged prostate\\nEnlarged \\nprostate\\ngland\\nUreter\\nProstate\\ngland\\nUrine retention in bladder\\nConstricted\\nurethra\\nNormal sized prostate gland Enlarged prostate gland\\nAn enlarged prostate is a non-cancerous condition in which the narrowing of the urethra makes the elimination of urine more\\ndifficult. It most often occurs in men over age 50.(Illustration by Electronic Illustrators Group.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1202'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 589, 'page_label': '590'}, page_content='venous urogram, or pyelogram); or a blood test for crea-\\ntinine, which collects in the blood when the kidneys can-\\nnot eliminate it.\\nTreatment\\nDrugs\\nA class of drugs called alpha-adrenergic blockers,\\nwhich includes phenoxybenzamine and doxazosin, relax\\nthe muscle tissue surrounding the bladder outlet and lin-\\ning the wall of the urethra to permit urine to flow more\\nfreely. These drugs improve obstructive symptoms, but do\\nnot keep the prostate from enlarging. Other drugs (finas-\\nteride is a good example) do shrink the prostate and may\\ndelay the need for surgery. Symptoms may not, however,\\nimprove until the drug has been used for three months or\\nlonger. Antibiotic drugs are given promptly whenever\\ninfection is diagnosed. Some medications, including anti-\\nhistamines and some decongestants , can make the\\nsymptoms of BPH suddenly worse and even cause acute\\nurinary retention, and therefore should be avoided.\\nIntermediate treatments\\nWhen drugs have failed to control symptoms of\\nBPH but the physician does not believe that conventional\\nsurgery is yet needed, a procedure called transurethral\\nneedle ablation may be tried. In the office and using local\\nanesthesia, a needle is inserted into the prostate and\\nradiofrequency energy is applied to destroy the tissue\\nthat is obstructing urine flow. Another new approach is\\nmicrowave hyperthermia, using a device called the\\nProstatron to deliver microwave energy to the prostate\\nthrough a catheter. This procedure is done at an outpa-\\ntient surgery center.\\nSurgery\\nFor many years the standard operation for BPH has\\nbeen transurethral resection (TUR) of the prostate. Under\\ngeneral or spinal anesthesia, a cystoscope is passed\\nthrough the urethra and prostate tissue surrounding the\\nurethra is removed using either a cutting instrument or a\\nheated wire loop. The small pieces of prostate tissue are\\nwashed out through the scope. No incision is needed for\\nTUR. There normally is some blood in the urine for a\\nfew days following the procedure. In a few men—less\\nthan 5% of all those having TUR—urine will continue to\\nescape unintentionally. Other uncommon complications\\ninclude a temporary rise in blood pressure with mental\\nconfusion, which is treated by giving salt solution. Impo-\\ntence—the inability to achieve lasting penile erections—\\ndoes occur, but probably in fewer than 10% of patients. A\\nnarrowing or stricture rarely develops in the urethra, but\\nthis can be treated fairly easily.\\nKEY TERMS\\nCatheter—A rubber or plastic tube placed through\\nthe urethra into the bladder to remove excess\\nurine when the flow of urine is cut off, or to pre-\\nvent urinary infection.\\nCreatinine —One of the “waste” substances nor-\\nmally excreted by the kidneys into the urine.\\nWhen urine flow is slowed, creatinine may collect\\nin the blood and cause toxic effects.\\nHyperplasia —A condition where cells, such as\\nthose making up the prostate gland, rapidly divide\\nabnormally and cause the organ to become\\nenlarged.\\nHypertrophy—A technical term for enlargement,\\nas in BPH (benign prostatic hypertrophy).\\nUrethra—In males, the tube that conducts urine\\nfrom the bladder through the penis to the outside\\nof the body. When narrowed by an enlarging\\nprostate, symptoms of BPH develop.\\nUrinary retention —The result of progressive\\nobstruction of the urethra by an enlarging prostate,\\ncausing urine to remain in the bladder even after\\nurination.\\nAlternatives to TUR, some only recently introduced,\\ninclude:\\n• Laser ablation of the prostate. Laser energy is applied\\nto the prostate through a special fiber passed through a\\ncystoscope. The procedure is done in an operating\\nroom, and several patients have retained urine postoper-\\natively.\\n• Transurethral incision of the prostate. Less invasive\\nthan standard TUR, an incision is made through the\\nprostate to open up the part of the urethra passing\\nthrough it. This may work well in men whose prostate\\nis not grossly enlarged.\\n• Transurethral vaporization. A small roller ball is used to\\nbreak up and vaporize the obstructing prostatic tissue,\\nrather than cutting it away as in standard TUR. This is\\nequally successful but patients usually can leave the\\nhospital within 24 hours, and there is less blood loss.\\n• If the prostate is greatly enlarged—as is the case in\\nabout 5–10% of those diagnosed, an incision is made to\\nperform an open prostatectomy , removing the entire\\ngland under direct vision.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1203\\nEnlarged prostate\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1203'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 590, 'page_label': '591'}, page_content='Alternative treatment\\nAn extract of the saw palmetto (Serenoa repens or\\nS. serrulata ) has been shown to stop or decrease the\\nhyperplasia of the prostate. Symptoms of BPH will\\nimprove after taking the herb for one to two months, but\\ncontinued use is recommended.\\nPrognosis\\nIn a man without symptoms whose prostate is\\nenlarged, it is hard to predict when urinary symptoms\\nwill develop and how rapidly they will progress. For this\\nreasons some specialists (urologists) advise a period of\\n“watchful waiting.” When BPH is treated by convention-\\nal TUR, there is a small risk of complications but, in the\\ngreat majority of men, urinary symptoms will be relieved\\nand their quality of life will be much enhanced. In the\\nfuture, it is possible that the less invasive forms of surgi-\\ncal treatment will be increasingly used to achieve results\\nas good as those of the standard operation. It also is pos-\\nsible that new medications will be developed that shrink\\nthe prostate and eliminate obstructive symptoms so that\\nsurgery can be avoided altogether.\\nPrevention\\nWhether or not BPH is caused by hormonal changes\\nin aging men, there is no known way of preventing it.\\nOnce it does develop and symptoms are present that\\ninterfere seriously with the patient’s life, timely medical\\nor surgical treatment will reliably prevent symptoms\\nfrom getting worse. Also, if the condition is treated\\nbefore the prostate has become grossly enlarged, the risk\\nof complications is minimal. One of the potentially most\\nserious complications of BPH, urinary infection (and\\npossible infection of the kidneys), can be prevented by\\nusing a catheter to drain excess urine out of the bladder\\nso that it does not collect, stagnate, and become infected.\\nResources\\nBOOKS\\nRous, Stephen N. The Prostate Book: Sound Advice on Symptoms\\nand Treatment.2nd ed. New York: W. W. Norton, 1995.\\nSelmans, Sandra. Prostate: Questions You Have...Answers You\\nNeed. Allentown, PA: People’s Medical Society, 1996.\\nWalsh, Patrick C., and Janet F. Worthington. The Prostate: A\\nGuide for Men and the Women Who Love Them.New\\nYork: Warner Books, 1997.\\nORGANIZATIONS\\nProstate Health Council. American Foundation for Urologic\\nDisease. 1128 N. Charles St., Baltimore, MD 21201.\\n(800) 242-AFUD.\\nDavid A. Cramer, MD\\nEntamoeba histolytica infection see\\nAmebiasis\\nEnteric fever see Typhoid fever\\nEnterically transmitted non-A non-B see\\nHepatitis E\\nEnterobacterial infections\\nDefinition\\nEnterobacterial infections are disorders of the diges-\\ntive tract and other organ systems produced by a group of\\ngram-negative, rod-shaped bacteria called Enterobacteri-\\naceae. Gram-negative means that the organisms do not\\nretain the violet color of the dye used to make Gram\\nstains. The most troublesome organism in this group is\\nEscherichia coli. Other enterobacteria are species of Sal-\\nmonella , Shigella , Klebsiella , Enterobacter , Serratia ,\\nProteus, and Yersinia.\\nDescription\\nEnterobacterial infections can be produced by bacte-\\nria that normally live in the human digestive tract without\\ncausing serious disease, or by bacteria that enter from the\\noutside. In many cases these infections are nosocomial,\\nwhich means that they can be acquired in the hospital.\\nKlebsiella and Proteus sometimes cause pneumonia, ear\\nand sinus infections, and urinary tract infections. Enter-\\nobacter and Serratia often cause bacterial infection of\\nthe blood ( bacteremia ), particularly in patients with\\nweakened immune systems.\\nDiarrhea caused by enterobacteria is a common\\nproblem in the United States. It is estimated that each\\nperson in the general population has an average of 1.5\\nepisodes of diarrhea each year, with higher rates in chil-\\ndren, institutionalized people, and Native Americans.\\nThis type of enterobacterial infection can range from a\\nminor nuisance to a life-threatening disorder, especially\\nin infants, elderly persons, AIDS patients, and malnour-\\nished people. Enterobacterial infections are one of the\\ntwo leading killers of children in developing countries.\\nCauses and symptoms\\nCauses\\nEnterobacterial infections in the digestive tract typi-\\ncally start when the organisms invade the mucous tissues\\nthat line the digestive tract. They may be bacteria that are\\nGALE ENCYCLOPEDIA OF MEDICINE 21204\\nEnterobacterial infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1204'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 591, 'page_label': '592'}, page_content='already present in the stomach and intestines, or they\\nmay be transmitted by contaminated food and water. It is\\nalso possible for enterobacterial infections to spread by\\nperson-to-person contact. The usual incubation period is\\n12–72 hours.\\nESCHERICHIA COLI INFECTIONS. E. coli infections\\ncause most of the enterobacterial infections in the United\\nStates. The organisms are categorized according to\\nwhether they are invasive or noninvasive. Noninvasive\\ntypes of E. coli include what are called enteropathogenic\\nE. coli, or EPEC, and enterotoxigenic E. coli, or ETEC.\\nEPEC and ETEC types produce a bacterial poison (toxin)\\nin the stomach that interacts with the digestive juices and\\ncauses the patient to lose large amounts of water through\\nthe intestines.\\nThe invasive types of E. coli are called enterohemor-\\nrhagic E. coli , or EHEC, and enteroinvasive E. coli, or\\nEIEC. These subtypes invade the stomach tissues direct-\\nly, causing tissue destruction and bloody stools. EHEC\\ncan produce complications leading to hemolytic-uremic\\nsyndrome (HUS), a potentially fatal disorder marked by\\nthe destruction of red blood cells and kidney failure.\\nEHEC has become a growing problem in the United\\nStates because of outbreaks caused by contaminated\\nfood. A particular type of EHEC known as O157:H7 has\\nbeen identified since 1982 in undercooked hamburgers,\\nunpasteurized milk, and apple juice. Between 2–7% of\\ninfections caused by O157:H7 develop into HUS.\\nSymptoms\\nThe symptoms of enterobacterial infections are\\nsometimes classified according to the type of diarrhea\\nthey produce.\\nWATERY DIARRHEA. Patients infected with ETEC,\\nEPEC, some types of Salmonella, and some types of\\nShigella develop a watery diarrhea. These infections are\\nlocated in the small intestine, result from bacterial toxins\\ninteracting with digestive juices, do not produce inflamma-\\ntion, and do not usually need treatment with antibiotics.\\nBLOODY DIARRHEA (DYSENTERY). Bloody diarrhea\\nis sometimes called dysentery. It is produced by EHEC,\\nEIEC, some types of Salmonella, some types of Shigella,\\nand Yersinia. In dysentery, the infection is located in the\\ncolon, cells and tissues are destroyed, inflammation is\\npresent, and antibiotic therapy is usually required.\\nNECROTIZING ENTEROCOLITIS (NEC). Necrotizing\\nenterocolitis (NEC) is a disorder that begins in newborn\\ninfants shortly after birth. Although NEC is not yet fully\\nunderstood, it is thought that it results from a bacterial or\\nviral invasion of damaged intestinal tissues. The disease\\norganisms then cause the death (necrosis) of bowel tis-\\nsue or gangrene of the bowel. NEC is primarily a disease\\nof prematurity ; 60–80% of cases occur in high-risk\\npreterm infants. NEC is responsible for 2–5% of cases in\\nnewborn intensive care units (NICU). Enterobacteriaceae\\nthat have been identified in infants with NEC include\\nSalmonella, E. coli, Klebsiella, and Enterobacter.\\nDiagnosis\\nPatient history\\nThe diagnosis of enterobacterial infections is com-\\nplicated by the fact that viruses, protozoa, and other\\ntypes of bacteria can also cause diarrhea. In most cases\\nof mild diarrhea, it is not critical to identify the organism\\nbecause the disorder is self-limiting. Some groups of\\npatients, however, should have stool tests. They include:\\n• patients with bloody diarrhea,\\n• patients with watery diarrhea who have become dehy-\\ndrated,\\n• patients with watery diarrhea that has lasted longer than\\nthree days without decreasing in amount,\\n• patients with disorders of the immune system.\\nThe patient history is useful for public health reasons\\nas well as helping the doctor determine what type of\\nenterobacterium may be causing the infection. The doctor\\nwill ask about the frequency and appearance of the diar-\\nrhea as well as other digestive symptoms. If the patient is\\nnauseated and vomiting, the infection is more likely to be\\nlocated in the small intestine. If the patient is running a\\nfever, a diagnosis of dysentery is more likely. The doctor\\nwill also ask if anyone else in the patient’s family or\\nworkplace is sick. Some types of enterobacteriaceae are\\nmore likely to cause group outbreaks than others. Other\\nquestions include the patient’s food intake over the last\\nfew days and whether he or she has recently traveled to\\ncountries with typhoid fever or cholera outbreaks.\\nPhysical examination\\nThe most important parts of the physical examina-\\ntion are checking for signs of severe fluid loss and exam-\\nining the abdomen to rule out typhoid fever. The doctor\\nwill look at the inside of the patient’s mouth and evaluate\\nthe skin for signs of dehydration. The presence of a skin\\nrash and an enlarged spleen suggests typhoid rather than a\\nbacterial infection. If the patient’s abdomen hurts when the\\ndoctor examines it, a diagnosis of dysentery is more likely.\\nLaboratory tests\\nThe most common test that is used to identify the\\ncause of diarrhea is the stool test. Examining a stool sam-\\nple under a microscope can help to rule out parasitic and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1205\\nEnterobacterial infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1205'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 592, 'page_label': '593'}, page_content='KEY TERMS\\nDysentery —A type of diarrhea caused by infec-\\ntion and characterized by mucus and blood in the\\nstools.\\nEmpirical treatment —Medical treatment that is\\ngiven on the basis of the doctor’s observations and\\nexperience.\\nEscherichia coli —A type of enterobacterium that\\nis responsible for most cases of severe bacterial\\ndiarrhea in the United States.\\nHemolytic-uremic syndrome (HUS)—A potential-\\nly fatal complication of E. coli infections character-\\nized by kidney failure and destruction of red blood\\ncells.\\nNecrotizing enterocolitis (NEC) —A disorder in\\nnewborns caused by bacterial or viral invasion of\\nvulnerable intestinal tissues.\\nNosocomial infections —Infections acquired in\\nhospitals.\\nToxin—A poison produced by certain types of\\nbacteria.\\nprotozoal infections. Routine stool cultures, however,\\ncannot be used to identify any of the four types of E. coli\\nthat cause intestinal infections. ETEC, EPEC, and EIEC\\nare unusual in the United States and can usually be iden-\\ntified only by specialists in research laboratories.\\nBecause of concern about EHEC outbreaks, however,\\nmost laboratories in the United States can now screen for\\nO157:H7 with a test that identifies its characteristic\\ntoxin. All patients with bloody diarrhea should have a\\nstool sample tested for E. coli O157:H7.\\nTreatment\\nThe initial treatment of enterobacterial diarrhea is\\nusually empiric. Empiric means that the doctor treats the\\npatient on the basis of the visible symptoms and profes-\\nsional experience in treating infections, without waiting\\nfor laboratory test results. Since the results of stool cul-\\ntures can take as long as two days, it is important to pre-\\nvent dehydration. The patient will be given fluids to\\nrestore the electrolyte balance and paregoric to relieve\\nabdominal cramping.\\nNewborn infants and patients with immune system\\ndisorders will be given antibiotics intravenously once the\\norganism has been identified. Gentamicin, tobramycin,\\nand amikacin are being used more frequently to treat\\nenterobacterial infections because many of the organisms\\nare becoming resistant to ampicillin and cephalosporin\\nantibiotics.\\nAlternative treatment\\nAlternative treatments for diarrhea are intended to\\nrelieve the discomfort of abdominal cramping. Most\\nalternative practitioners advise consulting a medical doc-\\ntor if the patient has sunken eyes, dry eyes or mouth, or\\nother signs of dehydration.\\nHerbal medicine\\nHerbalists may recommend cloves taken as an infu-\\nsion or ginger given in drop doses to control intestinal\\ncramps, eliminate gas, and prevent vomiting. Peppermint\\n(Mentha piperita ) or chamomile ( Matricaria recutita )\\ntea may also ease cramps and intestinal spasms.\\nHomeopathy\\nHomeopathic practitioners frequently recommend\\nArsenicum album for diarrhea caused by contaminated\\nfood, and Belladonna for diarrhea that comes on sudden-\\nly with mucus in the stools. Veratrum album would be\\ngiven for watery diarrhea, and Podophyllum for diarrhea\\nwith few other symptoms.\\nPrognosis\\nThe prognosis for most enterobacterial infections is\\ngood; most patients recover in about a week or 10 days\\nwithout needing antibiotics. HUS, on the other hand, has\\na mortality rate of 3–5% even with intensive care. About\\na third of the survivors have long-term problems with\\nkidney function, and another 8% develop high blood\\npressure, seizure disorders, and blindness.\\nPrevention\\nThe World Health Organization (WHO) offers the\\nfollowing suggestions for preventing enterobacterial\\ninfections, including E. coli O157:H7 dysentery:\\n• Cook ground beef or hamburgers until the meat is thor-\\noughly done. Juices from the meat should be complete-\\nly clear, not pink or red. All parts of the meat should\\nreach a temperature of 70°C (158°F) or higher.\\n• Do not drink unpasteurized milk or use products made\\nfrom raw milk.\\n• Wash hands thoroughly and frequently, especially after\\nusing the toilet.\\n• Wash fruits and vegetables carefully, or peel them.\\nKeep all kitchen surfaces and serving utensils clean.\\nGALE ENCYCLOPEDIA OF MEDICINE 21206\\nEnterobacterial infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1206'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 593, 'page_label': '594'}, page_content='• If drinking water is not known to be safe, boil it or\\ndrink bottled water.\\n• Keep cooked foods separate from raw foods, and avoid\\ntouching cooked foods with knives or other utensils that\\nhave been used with raw meat.\\nResources\\nBOOKS\\nBennish, Michael L., and Carlos Seas. “Bacterial Diarrheas.”\\nIn Current Diagnosis. V ol. 9. Ed. Rex B. Conn, et al.\\nPhiladelphia: W. B. Saunders Co., 1997.\\n“Escherichia coli and Other Enterobacteriaceae Infections.” In\\nProfessional Guide to Diseases, ed. Stanley Loeb, et al.\\nSpringhouse, PA: Springhouse Corporation, 1991.\\n“Infectious Disease: Enterobacteriaceae Infections.” In The\\nMerck Manual of Diagnosis and Therapy.16th ed. Ed.\\nRobert Berkow. Rahway, NJ: Merck Research Laborato-\\nries, 1992.\\n“Necrotizing Enterocolitis.” In Neonatology: Management,\\nProcedures, On-Call Problems, Diseases and Drugs,e d .\\nTricia Lacy Gomella, et al. Norwalk, CT: Appleton &\\nLange, 1994.\\nOgle, John W. “Infections: Bacterial & Spirochetal.” In Current\\nPediatric Diagnosis & Treatment, ed. William W. Hay Jr.,\\net al. Stamford: Appleton & Lange, 1997.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nOTHER\\n“Escherichia coli O157:H7.”World Health Organization.7\\nJune 1998 .\\n“Escherichia coli O157:H7.”Medscape Today7 June 1998\\n.\\n“Preventing foodborne illness.”Centers for Disease Control.7\\nJune 1998 .\\nRebecca J. Frey\\nEnterobiasis\\nDefinition\\nEnterobiasis, or pinworm infection as it is common-\\nly called, is an intestinal infection caused by the parasitic\\nroundworm called Enterobius vermicularis . The most\\ncommon symptom of this irritating, but not particularly\\ndangerous, disease is itching around the anal area.\\nDescription\\nEnterobiasis is also called seatworm infection or\\noxyuriasis. In the United States, enterobiasis is the most\\ncommon worm infection, and some estimate that approx-\\nimately 10% of the United States population is infected.\\nWorldwide, approximately 200 million people are infect-\\ned. Enterobiasis can affect people of any age, but is most\\ncommon among children ages 5–14 and particularly\\naffects those in the daycare setting.\\nCauses and symptoms\\nThe disease is highly contagious and is caused by a\\nparasitic worm called Enterobius vermicularis. The adult\\nfemale worm is about the size of a staple (approximately\\n0.4 in [1 cm] long and 0.02 in [0.5 mm] wide) and has a\\npointed tip. The disease is transmitted by ingesting the\\neggs of the pinworm. These eggs travel to the small intes-\\ntine where, after approximately one month, they hatch\\nand mature into adult worms. During the night, the\\nfemale adult worms travel to the area around the anus\\nand deposit eggs in the folds of the anal area. A single\\nfemale pinworm can lay 10,000 eggs and, after laying\\neggs, dies. The eggs are capable of causing infection\\nafter six hours at body temperature.\\nSignificant itching in the anal region is caused by the\\nmovement of the adult worm as the eggs are deposited.\\nWhen an individual scratches the anal region, the tiny eggs\\nget under the finger nails and in the underwear and night\\nclothes. Anything the individual touches with the contami-\\nnated fingers, for example, toys, bedding, blankets, bath-\\nroom door knobs, or sinks, becomes contaminated. The\\neggs are very hardy and can live on surfaces for two to\\nthree weeks. Anyone touching these contaminated sur-\\nfaces can ingest the eggs and become infected. An individ-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1207\\nEnterobiasis\\nThe pinworm of the genus Enterobius pictured above is the\\nsource of this infestation occurring in children.(Photo\\nResearchers, Inc. Reproduced by permission.)\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1207'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 594, 'page_label': '595'}, page_content='ual can also become infected by inhaling and swallowing\\nthe eggs, for example, when the bedcovers are shaken.\\nMany individuals with enterobiasis exhibit no symp-\\ntoms. When present, however, symptoms of the infection\\nbegin approximately two weeks after ingesting the pin-\\nworm eggs. The main symptom is itching around the\\nanus. Because the itching intensifies at night, when the\\nfemale worms comes to the anus to lay eggs, it often\\nleads to disrupted sleep and irritability. Poor sleeping at\\nnight in small children can be related to pinworms. Occa-\\nsionally, the itching causes some bleeding and bruising\\nin the region, and secondary bacterial infections can\\noccur. In females, the itching may spread to the vagina\\nand sometimes causes an infection of the vaginal region\\n(vaginitis). Enterobiasis usually lasts one to two months.\\nDiagnosis\\nFirst, a physician will rule out other potential causes\\nof the itching, such as hemorrhoids , lice, or fungal or\\nbacterial infection. Once these have been ruled out, an\\naccurate diagnosis of enterobiasis will require that either\\nthe eggs or the adult worms are detected. Rarely, the adult\\nworms are seen as thin, yellowish-white threads, about\\n0.4 in (1 cm) long, in the stools of the infected person.\\nUsually, an hour or so after the individual goes to sleep,\\nthe adult female worms may be seen moving around lay-\\ning eggs if a flashlight is shone at the rectal area.\\nAn easier method is to observe the eggs under the\\nmicroscope. In order to collect a specimen for laboratory\\ndiagnosis, the physician may provide a paddle with a\\nsticky adhesive on one side, or an individual may be\\ninstructed to place a piece of shiny cellophane tape sticky\\nside down against the anal opening. The best time to per-\\nform this test is at night or as soon as the individual\\nwakes up in the morning, before having a bowel move-\\nment or taking a bath or shower. The pinworm eggs will\\nstick to the tape, which can then be placed on a specimen\\nKEY TERMS\\nAnus—The opening through which feces are elim-\\ninated.\\nHemorrhoid —An area around the anus where\\nveins become dilated and the tissue swells, caus-\\ning itching and pain.\\nRectum—The end of the large intestine in which\\nfeces collects for elimination through the anus.\\nVaginitis—Inflammation of the vagina.\\nslide. When under a microscope in the laboratory, the\\neggs will be clearly visible.\\nTreatment\\nIn order to treat the disease, either mebendazole\\n(Vermox) or pyrantel pamoate (Pin-X) will be given in\\ntwo oral doses spaced two weeks apart. These medica-\\ntions eradicate the infection in approximately 90% of\\ncases. Re-infection is common and several treatments\\nmay be required. Because the infection is easily spread\\nthrough contact with contaminated clothing or surfaces,\\nit is recommended that all family members receive the\\ntherapeutic dose. Sometimes a series of six treatments\\nare given, each spaced two weeks apart. If family mem-\\nbers continue to be infected, a source outside the house\\nmay be responsible.\\nTo relieve the rectal itching, a shallow warm bath\\nwith either half a cup of table salt, or Epsom salts is rec-\\nommended. Also, application of an ointment containing\\nzinc oxide or regular petroleum jelly can be used to\\nrelieve rectal itching.\\nPrognosis\\nPinworms cause little damage and can be easily erad-\\nicated with proper treatment. Full recovery is expected.\\nPrevention\\nThe disease can be prevented by treating all the\\ninfected cases and thus eliminating the source of infec-\\ntion. Some ways to keep from catching or spreading the\\ndisease include the following recommendations:\\n• wash hands thoroughly before handling food and eating\\n• keep finger nails short and clean\\n• avoiding scratching the anal area\\n• take early morning showers to wash away eggs deposit-\\ned overnight\\n• once the infection has been identified, and treatment is\\nstarted, change the bed linen, night clothes, and under-\\nwear daily\\n• machine wash linens in hot water and dry with heat to\\nkill any eggs\\n• open the blinds or curtains since eggs are sensitive to\\nsunlight\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 21208\\nEnterobiasis\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1208'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 595, 'page_label': '596'}, page_content='Merck Manual of Diagnosis and Therapy.16th ed. Ed. Robert\\nBerkow, et al. Rahway, NJ: Merck Research Laboratories,\\n1992.\\nZinsser, Hans. Zinsser Microbiology.19th ed. Ed. Wolfgang K.\\nJoklik, et al. Stamford: Appleton Lange, 1988.\\nLata Cherath, PhD\\nEnterohemorrhagic E. coli see Escherichia\\ncoli\\nEnterostomy\\nDefinition\\nAn enterostomy is an operation in which the surgeon\\nmakes a passage into the patient’s small intestine through\\nthe abdomen with an opening to allow for drainage or to\\ninsert a tube for feeding. The opening is called a stoma,\\nfrom the Greek word for mouth. Enterostomies may be\\neither temporary or permanent. They are classified accord-\\ning to the part of the intestine that is used to create the\\nstoma. If the ileum, which is the lowest of the three sec-\\ntions of the small intestine, is used to make the stoma, the\\noperation is called an ileostomy. If the jejunum, which is\\nthe middle section of the small intestine, is used, the oper-\\nation is called a jejunostomy. Some people use the word\\nostomy as a word that covers all types of enterostomies.\\nPurpose\\nEnterostomies are performed in order to create a\\nnew opening for the passage of fecal matter when normal\\nintestinal functioning is interrupted or when diseases of\\nthe intestines cannot be treated by medications or less\\nradical surgery. Some situations that may require entero-\\nstomies include:\\n• Healing of inflamed bowel segments. Enterostomies\\nperformed for this reason are usually temporary.\\n• Emergency treatment of gunshot or other penetrating\\nwounds of the abdomen. An enterostomy is needed to\\nprevent the contents of the intestine from causing a seri-\\nous inflammation of the inside of the abdominal cavity\\n(peritonitis ). These enterostomies are also often tem-\\nporary.\\n• Placement of a tube for enteral feeding. Enteral feeding\\nis a method for conveying nutritional solutions directly\\ninto the stomach or jejunum through a tube. Tube\\nenterostomies may be long-term but are not permanent.\\n• Removal of diseased sections of the intestines.\\nIleostomies performed for this reason are permanent.\\nThe most common disorders requiring permanent\\nileostomy are Crohn’s disease, familial polyposis, and\\nulcerative colitis . Familial polyposis and ulcerative\\ncolitis are serious health risks because they can develop\\ninto cancer.\\n• Treatment of advanced cancer or other causes of intesti-\\nnal obstruction.\\nPrecautions\\nEnterostomies are usually performed only as emer-\\ngency treatments for traumatic injuries in the abdomen or\\nas final measures for serious disorders of the intestines.\\nMost patients do not refuse to have the operation per-\\nformed when the need for it is explained to them. A small\\nminority, however, refuse enterostomies because of\\nstrong psychological reactions to personal disfigurement\\nand the need to relearn bowel habits.\\nDescription\\nIleostomy\\nIleostomies represent about 25% of enterostomies.\\nThey are performed after the surgeon removes a diseased\\ncolon and sometimes the rectum as well. The most com-\\nmon ileostomy is called a Brooke ileostomy after the\\nEnglish surgeon who developed it. In a Brooke ileosto-\\nmy, the surgeon makes the stoma in the lower right sec-\\ntion of the abdomen. The ileum is pulled through an\\nopening (incision) in the muscle layer. The surgeon then\\nturns the cut end of the intestine inside out and sews it to\\nthe edges of the hole. He or she then positions an appli-\\nance for collecting the fecal material. The appliance con-\\nsists of a plastic bag that fits over the stoma and lies flat\\nagainst the abdomen. The patient is taught to drain the\\nbag from time to time during the day. Ileostomies need to\\nbe emptied frequently because the digested food contains\\nlarge amounts of water. Shortly after the operation, the\\nileostomy produces 1–2 qt (0.9–1.91) of fluid per day;\\nafter a month or two of adjustment, the volume decreases\\nto 1–2 pt (0.5–0.9)per day.\\nKOCK POUCH (CONTINENT ILEOSTOMY). The Kock\\npouch is a variation of the basic ileostomy and is named\\nfor its Swedish inventor. In the Kock technique, the sur-\\ngeon forms a pouch inside the abdominal cavity behind\\nthe stoma that collects the fecal material. The stoma is\\nshaped into a valve to prevent fluid from leaking onto the\\npatient’s abdomen. The patient then empties the pouch\\nseveral times daily by inserting a tube (catheter) through\\nthe valve. The Kock technique is sometimes called a con-\\ntinent ileostomy because the fluid is contained inside the\\nabdomen. It is successful in 70–90% of patients who\\nhave it done.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1209\\nEnterostomy\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1209'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 596, 'page_label': '597'}, page_content='Jejunostomy\\nA jejunostomy is similar to an ileostomy except that\\nthe stoma is placed in the second section of the small\\nintestine rather than the third. Jejunostomies are per-\\nformed less frequently than ileostomies. They are almost\\nalways temporary procedures.\\nTube enterostomies\\nTube enterostomies are operations in which the sur-\\ngeon makes a stoma into the stomach itself or the\\njejunum in order to insert a tube for liquid nutrients.\\nTube enterostomies are performed in patients who need\\ntube feeding for longer than six weeks, or who have had\\nrecent mouth or nose surgery. As long as the patient’s\\nintestinal tract can function, tube feedings are consid-\\nered preferable to intravenous feeding. Enteral nutrition\\nis safer than intravenous fluids and helps to keep the\\npatient’s digestive tract functioning.\\nPreparation\\nPreoperative preparation includes both patient edu-\\ncation and physical preparation.\\nKEY TERMS\\nCrohn’s disease—A disease of the intestines that\\ncauses inflammation leading to scarring, thickening\\nof the walls of the intestine, and eventual obstruc-\\ntion.\\nDuodenum —The first of the three segments of the\\nsmall intestine. The duodenum connects the stom-\\nach and the jejunum.\\nEnteral nutrition—A technique for feeding patients\\nwith liquid formulas conveyed directly into the\\nstomach or jejunum through tubes.\\nEnterostomal therapist (ET) —A specialized coun-\\nselor, usually a registered nurse, who provides osto-\\nmy patients with education and counseling before\\nthe operation. After surgery, the ET helps the patient\\nlearn to take care of the stoma and appliance, and\\noffers long-term emotional support.\\nFamilial polyposis —A disease that runs in families\\nin which lumps of tissue (polyps) form inside the\\ncolon. Familial polyposis may develop into cancer.\\nIleum—The third segment of the small intestine,\\nconnecting the jejunum and the large intestine.\\nJejunum—The second of the three segments of the\\nsmall intestine, connecting the duodenum and the\\nileum.\\nKock pouch—A type of ileostomy in which the sur-\\ngeon forms an artificial rectum from a section of the\\nileum. A Kock pouch is sometimes called a conti-\\nnent ileostomy because it is drained with a tube.\\nOstomy—A common term for all types of enteros-\\ntomies.\\nStoma—The surgically constructed mouth or pas-\\nsage between the intestine and the outside of the\\npatient’s body.\\nTube enterostomy —An enterostomy performed to\\nallow the insertion of a feeding tube into the\\njejunum or stomach.\\nUlcerative colitis —A disease of the colon charac-\\nterized by inflammation of the mucous lining,\\nulcerated areas of tissue, and bloody diarrhea.\\nPatient education\\nIf the patient is going to have a permanent ileosto-\\nmy, the doctor will explain what will happen during the\\noperation and why it is necessary. Most patients are will-\\ning to accept an ostomy as an alternative to the chronic\\npain and diarrhea of ulcerative colitis or the risk of can-\\ncer from other intestinal disorders. The patient can also\\nmeet with an enterostomal therapist (ET) or a member of\\nthe United Ostomy Association, which is a support group\\nfor people with ostomies.\\nMedical preparation\\nThe patient is prepared for surgery with an evalua-\\ntion of his or her nutritional status, possible need for\\nblood transfusions, and antibiotics if necessary. If the\\npatient does not have an intestinal obstruction or severe\\ninflammation, he or she may be given a large quantity of\\na polyethylene glycol (PEG) solution to cleanse the\\nintestines before surgery.\\nAftercare\\nAftercare of an enterostomy is both psychological\\nand medical.\\nGALE ENCYCLOPEDIA OF MEDICINE 21210\\nEnterostomy\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1210'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 597, 'page_label': '598'}, page_content='Medical aftercare\\nIf the enterostomy is temporary, aftercare consists of\\nthe usual monitoring of surgical wounds for infection or\\nbleeding. If the patient has had a permanent ileostomy,\\naftercare includes learning to use the appliance or empty\\nthe Kock pouch; learning to keep the stoma clean; and\\nreadjusting bathroom habits. Recovery takes a long time\\nbecause major surgery is a shock to the system and the\\nintestines take several days to resume normal function-\\ning. The patient’s fluid intake and output will be checked\\nfrequently to minimize the risk of dehydration.\\nPatient education\\nIleostomy patients must learn to watch their fluid and\\nsalt intake. They are at greater risk of becoming dehydrat-\\ned in hot weather, from exercise, or from diarrhea. In\\nsome cases they may need extra bananas or orange juice\\nin the diet to keep up the level of potassium in the blood.\\nPatient education includes social concerns as well as\\nphysical self-care. Many ileostomy patients are worried\\nabout the effects of the operation on their close relationships\\nand employment. If the patient has not seen an ET before\\nthe operation, the aftercare period is a good time to find out\\nabout self-help and support groups. The ET can also evalu-\\nate the patient’s emotional reactions to the ostomy.\\nRisks\\nEnterostomies are not considered high-risk opera-\\ntions by themselves. About 40% of ileostomy patients\\nhave complications afterward, however; about 15%\\nrequire minor surgical corrections. Possible complica-\\ntions include:\\n• skin irritation caused by leakage of digestive fluids onto\\nthe skin around the stoma, irritation is the most com-\\nmon complication of ileostomies\\n• diarrhea\\n• the development of abscesses\\n• gallstones or stones in the urinary tract\\n• inflammation of the ileum\\n• odors (can often be prevented by a change in diet)\\n• intestinal obstruction\\n• a section of the bowel pushing out of the body (pro-\\nlapse)\\nNormal results\\nNormal results include recovery from the surgery\\nwith few or no complications. About 95% of people with\\nostomies recover completely, are able to return to work,\\nand consider themselves to be in good health. Many\\nileostomy patients enjoy being able to eat a full range of\\nfoods rather than living on a restricted diet. Some\\npatients, however, need to be referred to psychotherapists\\nto deal with depression or other emotional problems after\\nthe operation.\\nResources\\nBOOKS\\nAltman, Roberta, and Michael J. Sarg. The Cancer Dictionary.\\nNew York: Facts On File, Inc., 1992.\\nBaron, Robert B. “Nutrition.” In Current Medical Diagnosis\\nand Treatment, 1998.37th ed. Ed. Stephen McPhee, et al.\\nStamford: Appleton & Lange, 1997.\\n“Bowel Surgery with Ostomy.” In Everything You Need to\\nKnow about Medical Treatments, ed. Matthew Cahill, et\\nal. Springhouse, PA: Springhouse Corporation, 1996.\\n“Nutritional Management of the Surgical Patient: Determining\\nthe Route of Nutritional Support.” In Surgery On Call,e d .\\nLeonard G. Gomella and Alan T. Lefor. Stamford: Apple-\\nton & Lange, 1996.\\nSchrock, Theodore R. “Large Intestine.” In Current Surgical\\nDiagnosis and Treatment. 10th ed. Ed. Lawrence W. Way.\\nStamford: Appleton & Lange, 1994.\\nSmith, Roger. “Ileostomy and Colostomy.” In Magill’s Medical\\nGuide: Health and Illness, Supplement. V ol. 5. Ed. Nancy\\nA. Piotrowski. Pasadena, CA: Salem Press, Inc., 1996.\\nORGANIZATIONS\\nUnited Ostomy Association, Inc. (UOA). 19772 MacArthur\\nBlvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826.\\n.\\nRebecca J. Frey\\nEnterovirus infections\\nDefinition\\nEnteroviruses are so named because they reproduce\\ninitially in the gastrointestinal tract after infection occurs.\\nDespite, this, they usually do not lead to intestinal symp-\\ntoms; rather it is their spread to organs, such as the nervous\\nsystem, heart, skin, and others that causes disease.\\nEnteroviruses are part of a larger group of viruses known as\\nPicornaviruses. The word comes from the combination of\\n“pico” (Spanish, meaning “a little bit”), and RNA (ribonu-\\ncleic acid, an important component of genetic material).\\nDescription\\nThere are four groups of enteroviruses: Coxsack-\\nievirus, Echovirus, ungrouped Enterovirus, and Y\\nPoliovirus. \\nGALE ENCYCLOPEDIA OF MEDICINE 2 1211\\nEnterovirus infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1211'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 598, 'page_label': '599'}, page_content='Viruses are generally divided into those that use\\nDNA (desoxyribonucleic acid) or RNA as their genetic\\nmaterial; all enteroviruses are RNA viruses. They are\\nfound worldwide, but infection is more common in areas\\nof poor hygiene and overcrowding.\\nAlthough most cases of enterovirus do not produce\\nsymptoms, some five to 10 million individuals in the Unit-\\ned States each year suffer from one of the enteroviral dis-\\neases. Illness is more common in the very young. While\\nthere are close to seventy different strains of enteroviruses,\\nover 70% of infections are caused by only 10 types.\\nThe virus is most commonly transmitted by the\\nfecal-oral route (contamination of fingers or objects by\\nhuman waste material); in some instances transmission is\\nthrough contaminated food or water. Passage of some\\nstrains of virus by way of air droplets can lead to respira-\\ntory illness. Infection of fetuses by way of the placenta\\nhas also been documented. Breast milk contains antibod-\\nies which can protect newborns.\\nThe incubation period for most enteroviruses ranges\\nfrom two to 14 days. In areas of temperate climate, infec-\\ntions occur mainly in the summer and fall.\\nCauses and symptoms\\nEnteroviruses are believed to be the cause of at least\\n10 distinct illnesses. Once they enter the body, they mul-\\ntiply in the cells that line the gastrointestinal tract, and\\neventually reach sites of lymphatic tissue (such as the\\ntonsils). While most of these diseases are of short dura-\\ntion and do not cause significant injury, some can pro-\\nduce severe illness.\\nThe main syndromes caused by the various entero-\\nviruses are the following:\\n• Summer grippe (nonspecific febrile illness). This is the\\nmost common syndrome, and is characterized by flu-\\nlike symptoms of fever, headache, and weakness, that\\ntypically last three to four days. Many patients also\\ndevelop upper respiratory symptoms and some nausea\\nand vomiting . One of the major ways to distinguish\\nthis disease from influenza, is the fact that grippe most\\noften occurs in the summer.\\n• Generalized disease of the newborn is a potentially\\nserious infection in which infants from one week to\\nthree months of age develop a syndrome that can be\\ndifficult to distinguish from a severe bacterial infection.\\nFever, irritability, and decreased responsiveness or\\nexcessive sleepiness are the major symptoms. Inflam-\\nmation of heart muscle ( myocarditis), low blood pres-\\nsure, hepatitis, and meningitis sometimes complicate\\nthe illness.\\n• Aseptic meningitis encephalitis is a well known syn-\\ndrome caused by this group of viruses. In fact,\\nenteroviruses are responsible for over 90% of cases of\\naseptic meningitis, and most often hits children and\\nyoung adults. Headache, fever, avoidance of light, and\\neye pain are characteristic. Drowsiness may be promi-\\nnent, and other symptoms include sore throat, cough,\\nmuscle pain, and rash. Occasionally, not only the\\nmeninges—the covering around the brain and spinal\\ncord— is infected, but also brain tissue itself, produc-\\ning encephalitis. The illness resolves after about a week\\nor so, and permanent damage is unusual. Enteroviruses\\ncan also produce the Guillian-Barré syndrome, which\\ninvolves weakness and paralysis of the extremities and\\neven the muscles of respiration.\\n• Pleurodynia (Bornholm’s disease) is due to viral infec-\\ntion and inflammation of the chest and abdominal mus-\\ncles used for breathing. Pain occurs as acute episodes,\\nlasting 30 minutes or so. Coxsackie B virus is the usual\\ncause of the illness.\\n• Myocarditis and/or pericarditis involves infection of\\nthe heart muscle (myocardium) and the covering\\naround the heart (pericardium). Infants and young\\nadults are the most susceptible, and for some reason,\\nover two-thirds of cases occur in males. The disease\\nusually begins as an upper respiratory tract infection\\nwith cough, shortness of breath, and fever. Chest pain,\\nincreasing shortness of breath, irregularities of cardiac\\nrhythm, and heart failure sometimes develop. Some\\npatients wind up with long term heart failure if the heart\\nmuscle is significantly affected.\\n• Exanthems is the medical term for rashes, and\\nenterovirus is the number one cause of summer and fall\\nrashes in children. They occur anywhere on the body,\\nand often resemble diseases such as measles.\\n• Hand-foot-and-mouth disease occurs initially as a sore\\nthroat (often involving the tongue as well), and is fol-\\nlowed by a rash on the hands, and sometimes the feet.\\nThe rash often forms small blisters, which lead to\\nulcers. Symptoms generally resolve within a week. A\\nspecific Coxsackievirus (A16) is the most frequent\\ncause of this highly infectious disease.\\n• Herpangina is most often caused by one of the Cox-\\nsackie A viruses, and appears as the acute onset of fever\\nand sore throat. This last symptom is particularly\\nsevere, as the virus produces multiple ulcers in the\\nthroat. Swallowing becomes very painful; symptoms\\ncan persist for several weeks.\\n• Acute hemorrhagic conjunctivitis involves viral infec-\\ntion of the conjunctiva, which is a covering around the\\neye. Pain, blurred vision, aversion to light, and a dis-\\ncharge from the eye are the main symptoms. Headache\\nGALE ENCYCLOPEDIA OF MEDICINE 21212\\nEnterovirus infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1212'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 599, 'page_label': '600'}, page_content='and fever occur in about one in five patients. The dis-\\nease runs its course in about 10 days.\\nA number of other illnesses have been attributed to\\nenteroviruses, including pneumonia and other respirato-\\nry infections, myositis or muscle inflammation, arthritis,\\nand acute inflammation of the kidneys. It is clear then\\nthat these viruses produce a number of various illnesses,\\nmost often in younger age groups.\\nDiagnosis\\nIn the majority of cases, diagnosis is based on the\\ncharacteristic symptoms that the virus produces (such as\\nthe chest pain in pleurodynia). Rarely is it necessary to\\nidentify a specific strain of virus causing the illness. It is\\nmore important to be certain that the infection is due to a\\nvirus which does not require treatment with antibiotics.\\nCulture, or growing the organism outside of the body,\\nis helpful only when obtained from areas that tend to indi-\\ncate recent infection, such as from swollen joints, cere-\\nbrospinal fluid, or blood. Cultures from other areas, such\\nas the throat, can be misleading. This is because the virus\\nmay remain for long periods of time in places with a large\\namount of lymphatic tissue. As a rule, cultures done early\\nin the illness are more likely to identify the virus.\\nNew techniques that involve identification of viral\\ngenetic material (PCR) are useful in certain cases, but are\\nnot indicated for routine testing.\\nTreatment\\nAs noted above, enterovirus is capable of attacking\\nmany different organs and producing a variety of symp-\\ntoms. Most infections are mild and improve without\\ncomplications, and require no specific therapy. When the\\nvirus attacks critical organs however, such as the heart,\\nrespiratory muscles, nervous system, etc., then special-\\nized care is often needed.\\nAs of 2001, no effective antiviral medication for\\nenterovirus has undergone investigation in patients,\\nthough some drugs appear promising for the future. In\\nsome patients who are unable to produce antibodies\\n(hypogammaglobunemia), administrating antibodies\\nthemselves is helpful.\\nPrognosis\\nThe overall outlook for enterovirus infection\\ndepends on the organs involved, and the immune condi-\\ntion of the individual patient. Unless vital organs are\\ninvolved or immunity is abnormal, infection causes few\\nproblems. On the other hand, patients who have diseases\\nKEY TERMS\\nAntibodies—Proteins that are formed by the body\\nand play a role in defense against infection.\\nAntibiotic —A medication that is designed to kill\\nor weaken bacteria.\\nMeninges—Outer covering of the spinal cord and\\nbrain. Infection is called meningitis, which can\\nlead to damage to the brain or spinal cord and\\nlead to death.\\nthat affect antibody production can develop chronic\\ninfection of the brain or meninges.\\nPrevention\\nIn the hospital setting, the best means of avoiding\\ntransmission of infection is the use of good hand-wash-\\ning practices and other appropriate precautions (gowns\\nand gloves for hospital staff). The virus is found in feces\\nfor up to one week after infection; therefore precautions\\nthat isolate waste material (enteric precautions) will help\\ndecrease the chance of spreading the illness.\\nResources\\nBOOKS\\nCohen, Jeffrey I. “Enteroviruses and Reoviruses.” In Harri-\\nson’s Principles of Internal Medicine, ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nPERIODICALS\\nMcKenna, W. J., and M. J. Davies. “Immunosuppression for\\nMyocarditis.” New England Journal of Medicine 333, no.\\n5 (1995): 312.\\nVenditti Jr, F. J., and J. T. Fallon. “MGH Case Records (Case\\n47-1993): A 28-year-old Man with Recurrent Ventricular\\nTachycardia and Fysfunction of Multiple Organs- Case\\nRecords of the Massachusetts General Hospital.”New\\nEngland Journal of Medicine 329, no.22 (1993): 1639.\\nOTHER\\n“Hand, Foot and Mouth Disease.”The Picarnovirus Home\\nPage..\\n“Weekly Clinicopathological Exercises: Case 47- 1993: A 28-\\nYear-Old Man with Recurrent Ventricular Tachycardia and\\nDysfunction of Multiple Organs.”New England Journal\\nof Medicine Online. .\\nDavid Kaminstein, MD\\nEntropy see Eyelid disorders\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1213\\nEnterovirus infections\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1213'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 600, 'page_label': '601'}, page_content='Enuresis see Bed-wetting\\nEnvironmental medicine see Wilderness\\nmedicine\\nEnzyme therapy\\nDefinition\\nEnyzme therapy is a plan of dietary supplements of\\nplant and animal enzymes used to facilitate the digestive\\nprocess and improve the body’s ability to maintain bal-\\nanced metabolism.\\nPurpose\\nIn traditional medicine, enzyme supplements are\\noften prescribed for patients suffering from disorders\\nthat affect the digestive process, such as cystic\\nfibrosis, Gaucher’s disease, and celiac disease . A pro-\\ngram of enzyme supplementation is rarely recommend-\\ned for healthy patients. However, proponents of\\nenzyme therapy believe that such a program is benefi-\\ncial for everyone. They point to enzymes’ ability to\\npurify the blood, strengthen the immune system,\\nenhance mental capacity, cleanse the colon, and main-\\ntain proper pH balance in urine. They feel that by\\nimproving the digestive process, the body is better able\\nto combat infection and disease.\\nSome evidence exists that pancreatic enzymes\\nderived from animal sources are helpful in cancer treat-\\nment. The enzymes may be able to dissolve the coating\\non cancer cells and may make it easier for the immune\\nsystem to attack the cancer.\\nA partial list of the wide variety of complaints and\\nillnesses that can be treated by enzyme therapy includes:\\n• AIDS\\n• anemia\\n• alcohol consumption\\n• anxiety\\n• acute inflammation\\n• back pain\\n• cancer\\n• colds\\n• chronic fatigue syndrome\\n• colitis\\n• constipation\\n• diarrhea\\n• food allergies\\n• gastritis\\n• gastric duodenal ulcer\\n• gout\\n• headaches\\n• hepatitis\\n• hypoglycemia\\n• infections\\n• mucous congestion\\n• multiple sclerosis\\n• nervous disorders\\n• nutritional disorders\\n• obesity\\n• premenstrual syndrome (PMS)\\n• stress\\nDescription\\nOrigins\\nEnzymes are protein molecules used by the body to\\nperform all of its chemical actions and reactions. The\\nbody manufactures several thousands of enzymes.\\nAmong them are the digestive enzymes produced by the\\nstomach, pancreas, small intestine, and the salivary\\nglands of the mouth. Their energy-producing properties\\nare responsible for not only the digestion of nutrients, but\\ntheir absorption, transportation, metabolization, and\\nelimination as well.\\nEnzyme therapy is based on the work of Dr. Edward\\nHowell in the 1920s and 1930s. Howell proposed that\\nenzymes from foods work in the stomach to pre-digest\\nfood. He advocated the consumption of large amounts of\\nplant enzymes, theorizing that if the body had to use less\\nof its own enzymes for digestion, it could store them for\\nmaintaining metabolic harmony. Four categories of plant\\nenzymes are helpful in pre-digestion: protease, amylase,\\nlipase, and cellulase. Cellulase is particularly helpful\\nbecause the body is unable to produce it.\\nAnimal enzymes, such as pepsin extracted from the\\nstomach of pigs, work more effectively in the duodenum.\\nThey are typically used for the treatment of nondigestive\\nailments.\\nThe seven categories of food enzymes and their\\nactivities\\nGALE ENCYCLOPEDIA OF MEDICINE 21214\\nEnzyme therapy\\nGEM -1121 to 1274 - E 10/22/03 6:15 PM Page 1214'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:16:32-05:00', 'moddate': '2004-12-18T16:35:04-06:00', 'source': '../data/medical_book.pdf', 'total_pages': 759, 'page': 601, 'page_label': '602'}, page_content='• amylase breaks down starches\\n• cellulase breaks down fibers\\n• lactase breaks down dairy products\\n• lipase breaks down fats\\n• maltase breaks down grains\\n• protease breaks down proteins\\n• sucrase breaks down sugars\\nEnzyme theory generated further interest as the\\nhuman diet became more dependent on processed and\\ncooked foods. Enzymes are extremely sensitive to heat,\\nand temperatures above 118°F (48°C) destroy them. Mod-\\nern processes of pasteurization, canning, and microwaving\\nare particularly harmful to the enzymes in food.\\nEnzyme supplements are extracted from plants like\\npineapple and papaya and from the organs of cows and\\npigs. The supplements are typically given in tablet or\\ncapsule form. Pancreatic enzymes may also be given by\\ninjection. The dosage varies with the condition being\\ntreated. For nondigestive ailments, the supplements are\\ntaken in the hour before meals so that they can be quickly\\nabsorbed into the blood. For digestive ailments, the sup-\\nplements are taken immediately before meals accompa-\\nnied by a large glass of fluids. Pancreatic enzymes may\\nbe accompanied by doses of vitamin A.\\n7Preparations\\nNo special preparations are necessary before begin-\\nning enzyme therapy. However, it is always advisable to\\ntalk to a doctor or pharmacist before purchasing enzymes\\nand beginning therapy.\\nPrecautions\\nPeople with allergies to beef, pork, pineapples, and\\npapaya may suffer allergic reactions to enzyme supple-\\nments. Tablets are often coated to prevent them from\\nbreaking down in the stomach, and usually shouldn’t be\\nchewed or crushed. People who have difficulty swallow-\\ning pills can request enzyme supplements in capsule\\nform. The capsules can then be opened and the contents\\nsprinkled onto soft foods like applesauce.\\nSide effects\\nSide effects associated with enzyme therapy include\\nheartburn , nausea and vomiting , diarrhea, bloating,\\ngas, and acne. According to the principles of therapy,\\nthese are temporary cleansing symptoms. Drinking eight\\nto ten glasses of water daily and getting regular exercise\\ncan reduce the discomfort of these side effects. Individu-\\nals may also experience an increase in bowel move-\\nKEY TERMS\\nCeliac disease —A chronic disease characterized\\nby defective digestion and use of fats.\\nCystic fibrosis—A genetic disease that causes mul-\\ntiple digestive, excretion, and respiratory complica-\\ntions. Among the effects, the pancreas fails to pro-\\nvide secretions needed for the digestion of food.\\nDuodenum—The first part of the small intestine.\\nGaucher’s disease—A rare genetic disease caused\\nby a deficiency of enzymes needed for the pro-\\ncessing of fatty acids.\\nMetabolism —The system of chemical processes\\nnecessary for living cells to remain healthy.\\nments, perhaps one or two per day. This is also consid-\\nered a positive effect.\\nPlant enzymes are safe for pregnant women,\\nalthough they should always check with a doctor before\\nusing enzymes. Pregnant women should avoid animal\\nenzymes. In rare cases, extremely high doses of enzymes\\ncan result in a build up of uric acid in the blood or urine\\nand can cause a break down of proteins.\\nResearch and general acceptance\\nIn the United States, the Food and Drug Administra-\\ntion (FDA) has classified enzymes as a food. Therefore,\\nthey can be purchased without a prescription. However,\\ninsurance coverage is usually dependent upon the thera-\\npy resulting from a doctor’s orders.\\nResources\\nBOOKS\\nCassileth, Barrie R. The Alternative Medicine Handbook. New\\nYork: W.W. Norton, 1998.\\nOTHER\\nEnzyme Therapy for Your Health. 10:\n", " unique_ratio = len(set(words)) / len(words)\n", " if unique_ratio < 0.5:\n", " return False\n", " \n", " return True" ] }, { "cell_type": "markdown", "id": "e98e5e33", "metadata": {}, "source": [ "### Simple LLM Agent" ] }, { "cell_type": "code", "execution_count": 34, "id": "7b9d680a", "metadata": {}, "outputs": [], "source": [ "def LLMAgent(state: AgentState) -> AgentState:\n", " try:\n", "\n", " prompt = f\"Patient: {state['question']}\\nDoctor:\"\n", " \n", " response = llm.invoke(prompt)\n", " answer = response.content.strip()\n", "\n", " if is_good_response(answer):\n", " state[\"generation\"] = answer\n", " state[\"llm_success\"] = True\n", " state[\"source\"] = \"BioGPT Medical Knowledge\"\n", " else:\n", " state[\"llm_success\"] = False\n", " state[\"generation\"] = \"\"\n", " except Exception as e:\n", " print(f\"LLM Error: {e}\")\n", " state[\"llm_success\"] = False\n", " state[\"generation\"] = \"\"\n", "\n", " return state" ] }, { "cell_type": "markdown", "id": "9d12e65a", "metadata": {}, "source": [ "### RAG Agent" ] }, { "cell_type": "code", "execution_count": 35, "id": "5248585a", "metadata": {}, "outputs": [], "source": [ "def RAGAgent(state: AgentState) -> AgentState:\n", " try:\n", " docs = retriever.invoke(state[\"question\"])\n", " if docs and len(docs) > 0:\n", " valid_docs = [doc for doc in docs if len(doc.page_content.strip()) > 50]\n", " if valid_docs:\n", " state[\"documents\"] = valid_docs\n", " state[\"rag_success\"] = True\n", " else:\n", " state[\"documents\"] = []\n", " state[\"rag_success\"] = False\n", " else:\n", " state[\"documents\"] = []\n", " state[\"rag_success\"] = False\n", " except Exception as e:\n", " print(f\"RAG Error: {e}\")\n", " state[\"documents\"] = []\n", " state[\"rag_success\"] = False\n", "\n", " return state" ] }, { "cell_type": "markdown", "id": "7eaff5f8", "metadata": {}, "source": [ "### RAG + LLM Generator" ] }, { "cell_type": "code", "execution_count": 36, "id": "f341bff7", "metadata": {}, "outputs": [], "source": [ "def RAGGenerator(state: AgentState) -> AgentState:\n", " if not state.get(\"documents\"):\n", " return state\n", " \n", " try:\n", " # context from documents\n", " context = \"\\n\".join([doc.page_content[:300] for doc in state[\"documents\"][:2]])\n", " \n", " prompt = f\"Medical information: {context}\\n\\nPatient: {state['question']}\\nDoctor:\"\n", " \n", " response = llm.invoke(prompt)\n", " answer = response.content.strip()\n", " \n", " if is_good_response(answer):\n", " state[\"generation\"] = answer\n", " state[\"source\"] = \"Medical Database + BioGPT\"\n", " else:\n", " # Use context directly if model fails\n", " state[\"generation\"] = context[:200] + \"...\"\n", " state[\"source\"] = \"Medical Database\"\n", " \n", " except Exception as e:\n", " print(f\"RAG Generator Error: {e}\")\n", " state[\"generation\"] = state[\"documents\"][0].page_content[:200] + \"...\"\n", " state[\"source\"] = \"Medical Database\"\n", " \n", " return state" ] }, { "cell_type": "markdown", "id": "206000e8", "metadata": {}, "source": [ "### Wikipedia fallback" ] }, { "cell_type": "code", "execution_count": 37, "id": "8d6c7f94", "metadata": {}, "outputs": [], "source": [ "def WikiAgent(state: AgentState) -> AgentState:\n", " try:\n", " content = wiki.run(state[\"question\"])\n", " if content and len(content) > 100:\n", " state[\"generation\"] = content[:300] + \"...\"\n", " state[\"source\"] = \"Wikipedia\"\n", " else:\n", " state[\"generation\"] = \"Unable to find reliable information.\"\n", " state[\"source\"] = \"System\"\n", " except Exception as e:\n", " print(f\"Wiki Error: {e}\")\n", " state[\"generation\"] = \"Unable to find reliable information.\"\n", " state[\"source\"] = \"System\"\n", " \n", " return state" ] }, { "cell_type": "markdown", "id": "378aae4f", "metadata": {}, "source": [ "### Build workflow" ] }, { "cell_type": "code", "execution_count": 38, "id": "3ad5ed71", "metadata": {}, "outputs": [], "source": [ "from langgraph.graph import StateGraph, END" ] }, { "cell_type": "code", "execution_count": 39, "id": "e4c2b6fa", "metadata": {}, "outputs": [], "source": [ "workflow = StateGraph(AgentState)" ] }, { "cell_type": "code", "execution_count": 40, "id": "40d11c27", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 40, "metadata": {}, "output_type": "execute_result" } ], "source": [ "workflow.add_node(\"llm\", LLMAgent)\n", "workflow.add_node(\"rag\", RAGAgent)\n", "workflow.add_node(\"rag_gen\", RAGGenerator)\n", "workflow.add_node(\"wiki\", WikiAgent)" ] }, { "cell_type": "code", "execution_count": 41, "id": "34fec3bb", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 41, "metadata": {}, "output_type": "execute_result" } ], "source": [ "workflow.set_entry_point(\"llm\")" ] }, { "cell_type": "code", "execution_count": 42, "id": "5f0b5ffe", "metadata": {}, "outputs": [], "source": [ "def route_after_llm(state):\n", " if state.get(\"llm_success\", False):\n", " return \"done\"\n", " else:\n", " return \"rag\"" ] }, { "cell_type": "code", "execution_count": 43, "id": "0b1daf04", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 43, "metadata": {}, "output_type": "execute_result" } ], "source": [ "workflow.add_conditional_edges(\n", " \"llm\",\n", " route_after_llm,\n", " {\"done\": END, \"rag\": \"rag\"}\n", ")" ] }, { "cell_type": "code", "execution_count": 44, "id": "394c06b8", "metadata": {}, "outputs": [], "source": [ "def route_after_rag(state):\n", " if state.get(\"rag_success\", False):\n", " return \"rag_gen\"\n", " else:\n", " return \"wiki\"" ] }, { "cell_type": "code", "execution_count": 45, "id": "7c6a0402", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 45, "metadata": {}, "output_type": "execute_result" } ], "source": [ "workflow.add_conditional_edges(\n", " \"rag\",\n", " route_after_rag,\n", " {\"rag_gen\": \"rag_gen\", \"wiki\": \"wiki\"}\n", ")" ] }, { "cell_type": "code", "execution_count": 46, "id": "f311c39a", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 46, "metadata": {}, "output_type": "execute_result" } ], "source": [ "workflow.add_edge(\"rag_gen\", END)\n", "workflow.add_edge(\"wiki\", END)" ] }, { "cell_type": "code", "execution_count": 47, "id": "9d918d21", "metadata": {}, "outputs": [], "source": [ "app = workflow.compile()" ] }, { "cell_type": "markdown", "id": "93debb69", "metadata": {}, "source": [ "### Main loop" ] }, { "cell_type": "code", "execution_count": 48, "id": "720e1487", "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "======================================================================\n", "Medical AI Assistant\n", "Commands: 'exit' to quit, 'clear' to clear history\n", "======================================================================\n", "\n", "Answer: Patient: i feel some acne Doctor: she is a young woman and doctor has prescribed me for three weeks, but this does not take place right now. I am feeling that my skin turns red.\n", "Source: BioGPT Medical Knowledge\n", "\n", "──────────────────────────────────────────────────────────────────────\n", "\n", "Answer: Patient: how to prevent this Doctor: a 50 year old male, has been diagnosed with cancer of the lung and is on chemotherapy. He was taking anti-emetic drugs for that reason but now he had an acute pain in his chest at night (which started when you were about 10 pm) so I went back home after having him taken them daily as usual Hello! Thanks For your query - This seems like what happened during my work week where there are many people working day by day.\n", "Source: BioGPT Medical Knowledge\n", "\n", "──────────────────────────────────────────────────────────────────────\n", "\n", "Thank you! Take care.\n" ] } ], "source": [ "conversation_history = []\n", "\n", "print(\"=\" * 70)\n", "print(\"Medical AI Assistant\")\n", "print(\"Commands: 'exit' to quit, 'clear' to clear history\")\n", "print(\"=\" * 70)\n", "\n", "while True:\n", " query = input(\"\\nYour Question: \").strip()\n", "\n", " if query.lower() == \"exit\":\n", " print(\"\\nThank you! Take care.\")\n", " break\n", " \n", " if query.lower() == \"clear\":\n", " conversation_history = []\n", " print(\"\\nHistory cleared!\")\n", " continue\n", " \n", " if not query:\n", " continue\n", "\n", " state = {\n", " \"question\": query,\n", " \"documents\": [],\n", " \"generation\": \"\",\n", " \"source\": \"\",\n", " \"conversation_history\": conversation_history,\n", " \"llm_success\": False,\n", " \"rag_success\": False\n", " }\n", " \n", " try:\n", " result = app.invoke(state)\n", " \n", " if result.get(\"generation\"):\n", " print(f\"\\nAnswer: {result['generation']}\")\n", " print(f\"Source: {result['source']}\")\n", " \n", " conversation_history.append({\n", " 'q': query,\n", " 'a': result['generation']\n", " })\n", " else:\n", " print(\"\\nSorry, couldn't generate a response.\")\n", "\n", " print(\"\\n\" + \"─\" * 70)\n", " \n", " except Exception as e:\n", " print(f\"\\nError: {e}\")\n", " print(\"─\" * 70)" ] } ], "metadata": { "kernelspec": { "display_name": "Python 3", "language": "python", "name": "python3" }, "language_info": { "codemirror_mode": { "name": "ipython", "version": 3 }, "file_extension": ".py", "mimetype": "text/x-python", "name": "python", "nbconvert_exporter": "python", "pygments_lexer": "ipython3", "version": "3.11.9" } }, "nbformat": 4, "nbformat_minor": 5 }