{ "cells": [ { "cell_type": "code", "execution_count": 19, "id": "4045d1f8", "metadata": {}, "outputs": [], "source": [ "from langchain.document_loaders import PyPDFLoader, DirectoryLoader\n", "from langchain.text_splitter import RecursiveCharacterTextSplitter" ] }, { "cell_type": "code", "execution_count": 20, "id": "1a741ba0", "metadata": {}, "outputs": [], "source": [ "# Extract text from PDF files\n", "def load_pdf_files(data):\n", " loader = DirectoryLoader(\n", " data,\n", " glob=\"*.pdf\",\n", " loader_cls=PyPDFLoader\n", " )\n", "\n", " documents = loader.load()\n", " return documents" ] }, { "cell_type": "code", "execution_count": 21, "id": "8353925c", "metadata": {}, "outputs": [], "source": [ "%pwd # '/home/aiyub/Pictures/Fine-Tuned_LLM_Summarizer'\n", "\n", "import os \n", "os.chdir(\"../\")" ] }, { "cell_type": "code", "execution_count": 22, "id": "c6c0176c", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "'/home/aiyub/Pictures'" ] }, "execution_count": 22, "metadata": {}, "output_type": "execute_result" } ], "source": [ "pwd" ] }, { "cell_type": "code", "execution_count": 23, "id": "1c855195", "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "/home/aiyub/Pictures/Fine-Tuned_LLM_Summarizer\n" ] } ], "source": [ "cd \"Fine-Tuned_LLM_Summarizer\"" ] }, { "cell_type": "code", "execution_count": 24, "id": "680e55b7", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 0, 'page_label': '1'}, page_content=''),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 1, 'page_label': '2'}, page_content='The GALE\\nENCYCLOPEDIA\\nof MEDICINE\\nSECOND EDITION'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 2, 'page_label': '3'}, page_content='The GALE\\nENCYCLOPEDIA\\nof MEDICINE\\nSECOND EDITION\\nJACQUELINE L. LONGE, EDITOR\\nDEIRDRE S. BLANCHFIELD, ASSOCIATE EDITOR\\nVOLUME\\nA-B\\n1'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 3, 'page_label': '4'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 4, 'page_label': '5'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 5, 'page_label': '6'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 6, 'page_label': '7'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 7, 'page_label': '8'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 8, 'page_label': '9'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 9, 'page_label': '10'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 10, 'page_label': '11'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 11, 'page_label': '12'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 12, 'page_label': '13'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 13, 'page_label': '14'}, 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': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 14, 'page_label': '15'}, page_content='Abdominal aorta ultrasound see Abdominal\\nultrasound\\nAbdominal aortic aneurysm see Aortic\\naneurysm\\nAbdominal hernia see Hernia\\nAbdominal thrust see Heimlich maneuver\\nAbdominal ultrasound\\nDefinition\\nUltrasound technology allows doctors to “see”\\ninside a patient without resorting to surgery. A transmit-\\nter sends high frequency sound waves into the body,\\nwhere they bounce off the different tissues and organs to\\nproduce a distinctive pattern of echoes. A receiver\\n“hears” the returning echo pattern and forwards it to a\\ncomputer, which translates the data into an image on a\\ntelevision screen. Because ultrasound can distinguish\\nsubtle variations between soft, fluid-filled tissues, it is\\nparticularly useful in providing diagnostic images of the\\nabdomen. Ultrasound can also be used in treatment.\\nPurpose\\nThe potential medical applications of ultrasound\\nwere first recognized in the 1940s as an outgrowth of the\\nsonar technology developed to detect submarines during\\nWorld War II. The first useful medical images were pro-\\nduced in the early 1950s, and, by 1965, ultrasound quali-\\nty had improved to the point that it came into general\\nmedical use. Improvements in the technology, applica-\\ntion, and interpretation of ultrasound continue. Its low\\ncost, versatility, safety and speed have brought it into the\\ntop drawer of medical imaging techniques.\\nWhile pelvic ultrasound is widely known and com-\\nmonly used for fetal monitoring during pregnancy ,\\nultrasound is also routinely used for general abdominal\\nimaging. It has great advantage over x-ray imaging tech-\\nnologies in that it does not damage tissues with ionizing\\nradiation. Ultrasound is also generally far better than\\nplain x rays at distinguishing the subtle variations of soft\\ntissue structures, and can be used in any of several\\nmodes, depending on the need at hand.\\nAs an imaging tool, abdominal ultrasound generally\\nis warranted for patients afflicted with: chronic or acute\\nabdominal pain; abdominal trauma; an obvious or sus-\\npected abdominal mass; symptoms of liver disease, pan-\\ncreatic disease, gallstones , spleen disease, kidney dis-\\nease and urinary blockage; or symptoms of an abdominal\\naortic aneurysm. Specifically:\\n• Abdominal pain. Whether acute or chronic, pain can\\nsignal a serious problem—from organ malfunction or\\ninjury to the presence of malignant growths. Ultrasound\\nscanning can help doctors quickly sort through poten-\\ntial causes when presented with general or ambiguous\\nsymptoms. All of the major abdominal organs can be\\nstudied for signs of disease that appear as changes in\\nsize, shape and internal structure.\\n• Abdominal trauma. After a serious accident, such as a\\ncar crash or a fall, internal bleeding from injured\\nabdominal organs is often the most serious threat to\\nsurvival. Neither the injuries nor the bleeding are\\nimmediately apparent. Ultrasound is very useful as an\\ninitial scan when abdominal trauma is suspected, and it\\ncan be used to pinpoint the location, cause, and severity\\nof hemorrhaging. In the case of puncture wounds,f r o m\\na bullet for example, ultrasound can locate the foreign\\nobject and provide a preliminary survey of the damage.\\nThe easy portability and versatility of ultrasound tech-\\nnology has brought it into common emergency room\\nuse, and even into limited ambulance service.\\n• Abdominal mass. Abnormal growths—tumors, cysts,\\nabscesses, scar tissue and accessory organs—can be\\nA\\nGALE ENCYCLOPEDIA OF MEDICINE 2 1\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 1'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 15, 'page_label': '16'}, page_content='located and tentatively identified with ultrasound. In\\nparticular, potentially malignant solid tumors can be\\ndistinguished from benign fluid-filled cysts and\\nabscesses. Masses and malformations in any organ or\\npart of the abdomen can be found.\\n• Liver disease. The types and underlying causes of liver\\ndisease are numerous, though jaundice tends to be a\\ngeneral symptom. Ultrasound can differentiate between\\nmany of the types and causes of liver malfunction, and\\nis particularly good at identifying obstruction of the\\nbile ducts and cirrhosis , which is characterized by\\nabnormal fibrous growths and reduced blood flow.\\n• Pancreatic disease. Inflammation and malformation of\\nthe pancreas are readily identified by ultrasound, as are\\npancreatic stones (calculi), which can disrupt proper\\nfunctioning.\\n• Gallstones. Gallstones cause more hospital admissions\\nthan any other digestive malady. These calculi can\\ncause painful inflammation of the gallbladder and also\\nobstruct the bile ducts that carry digestive enzymes\\nfrom the gallbladder and liver to the intestines. Gall-\\nstones are readily identifiable with ultrasound.\\n• Spleen disease. The spleen is particularly prone to\\ninjury during abdominal trauma. It may also become\\npainfully inflamed when beset with infection or\\ncancer. These conditions also lend themselves well to\\nultrasonic inspection and diagnosis.\\n• Kidney disease. The kidneys are also prone to traumatic\\ninjury and are the organs most likely to form calculi,\\nwhich can block the flow of urine and cause blood poi-\\nsoning (uremia). A variety of diseases causing distinct\\nchanges in kidney morphology can also lead to com-\\nplete kidney failure. Ultrasound imaging has proven\\nextremely useful in diagnosing kidney disorders.\\n• Abdominal aortic aneurysm. This is a bulging weak\\nspot in the abdominal aorta, which supplies blood\\ndirectly from the heart to the entire lower body. These\\naneurysms are relatively common and increase in\\nprevalence with age. A burst aortic aneurysm is immi-\\nnently life-threatening. However, they can be readily\\nidentified and monitored with ultrasound before acute\\ncomplications result.\\nUltrasound technology can also be used for treat-\\nment purposes, most frequently as a visual aid during\\nsurgical procedures—such as guiding needle placement\\nto drain fluid from a cyst, or to extract tumor cells for\\nbiopsy. Increasingly, direct therapeutic applications for\\nultrasound are being developed.\\nThe direct therapeutic value of ultrasonic waves lies\\nin their mechanical nature. They are shock waves, just like\\naudible sound, and vibrate the materials through which\\nthey pass. These vibrations are mild, virtually unnotice-\\nable at the frequencies and intensities used for imaging.\\nProperly focused however, high-intensity ultrasound can\\nbe used to heat and physically agitate targeted tissues.\\nHigh-intensity ultrasound is used routinely to treat\\nsoft tissue injuries, such as strains, tears and associated\\nscarring. The heating and agitation are believed to pro-\\nmote rapid healing through increased circulation. Strong-\\nly focused, high-intensity, high-frequency ultrasound can\\nalso be used to physically destroy certain types of\\ntumors, as well as gallstones and other types of calculi.\\nDeveloping new treatment applications for ultrasound is\\nan active area of medical research.\\nPrecautions\\nProperly performed, ultrasound imaging is virtually\\nwithout risk or side effects. Some patients report feeling\\na slight tingling and/or warmth while being scanned, but\\nmost feel nothing at all. Ultrasound waves of appropriate\\nfrequency and intensity are not known to cause or aggra-\\nvate any medical condition, though any woman who\\nthinks she might be pregnant should raise the issue with\\nher doctor before undergoing an abdominal ultrasound.\\nThe value of ultrasound imaging as a medical tool,\\nhowever, depends greatly on the quality of the equipment\\nused and the skill of the medical personnel operating it.\\nImproperly performed and/or interpreted, ultrasound can\\nbe worse than useless if it indicates that a problem exists\\nwhere there is none, or fails to detect a significant condi-\\ntion. Basic ultrasound equipment is relatively inexpen-\\nsive to obtain, and any doctor with the equipment can\\nperform the procedure whether qualified or not. Patients\\nshould not hesitate to verify the credentials of techni-\\ncians and doctors performing ultrasounds, as well as the\\nquality of the equipment used and the benefits of the pro-\\nposed procedure.\\nIn cases where ultrasound is used as a treatment tool,\\npatients should educate themselves about the proposed\\nprocedure with the help of their doctors—as is appropri-\\nate before any surgical procedure. Also, any abdominal\\nultrasound procedure, diagnostic or therapeutic, may be\\nhampered by a patient’s body type or other factors, such\\nas the presence of excessive bowel gas (which is opaque\\nto ultrasound). In particular, very obese people are often\\nnot good candidates for abdominal ultrasound.\\nDescription\\nUltrasound includes all sound waves above the fre-\\nquency of human hearing—about 20 thousand hertz, or\\ncycles per second. Medical ultrasound generally uses fre-\\nquencies between one and 10 million hertz (1-10 MHz).\\nGALE ENCYCLOPEDIA OF MEDICINE 22\\nAbdominal ultrasound\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 2'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 16, 'page_label': '17'}, page_content='KEY TERMS\\nAccessory organ —A lump of tissue adjacent to an\\norgan that is similar to it, but which serves no\\nimportant purpose, if functional at all. While not\\nnecessarily harmful, such organs can cause prob-\\nlems if they grow too large or become cancerous. In\\nany case, their presence points to an underlying\\nabnormality in the parent organ.\\nBenign—In medical usage, benign is the opposite of\\nmalignant. It describes an abnormal growth that is\\nstable, treatable and generally not life-threatening.\\nBiopsy—The surgical removal and analysis of a tis-\\nsue sample for diagnostic purposes. Usually, the\\nterm refers to the collection and analysis of tissue\\nfrom a suspected tumor to establish malignancy.\\nCalculus —Any type of hard concretion (stone) in\\nthe body, but usually found in the gallbladder, pan-\\ncreas and kidneys. They are formed by the accumu-\\nlation of excess mineral salts and other organic\\nmaterial such as blood or mucous. Calculi (pl.) can\\ncause problems by lodging in and obstructing the\\nproper flow of fluids, such as bile to the intestines or\\nurine to the bladder.\\nCirrhosis—A chronic liver disease characterized by\\nthe invasion of connective tissue and the degenera-\\ntion of proper functioning—jaundice is often an\\naccompanying symptom. Causes of cirrhosis include\\nalcoholism, metabolic diseases, syphilis and conges-\\ntive heart disease.\\nCommon bile duct —The branching passage\\nthrough which bile—a necessary digestive\\nenzyme—travels from the liver and gallbladder into\\nthe small intestine. Digestive enzymes from the\\npancreas also enter the intestines through the com-\\nmon bile duct.\\nComputed tomography scan (CT scan)—A special-\\nized type of x-ray imaging that uses highly focused\\nand relatively low energy radiation to produce\\ndetailed two-dimensional images of soft tissue\\nstructures, particularly the brain. CT scans are the\\nchief competitor to ultrasound and can yield higher\\nquality images not disrupted by bone or gas. They\\nare, however, more cumbersome, time consuming\\nand expensive to perform, and they use ionizing\\nelectromagnetic radiation.\\nDoppler—The Doppler effect refers to the apparent\\nchange in frequency of sound wave echoes returning\\nto a stationary source from a moving target. If the\\nobject is moving toward the source, the frequency\\nincreases; if the object is moving away, the frequen-\\ncy decreases. The size of this frequency shift can be\\nused to compute the object’s speed—be it a car on\\nthe road or blood in an artery. The Doppler effect\\nholds true for all types of radiation, not just sound.\\nFrequency—Sound, whether traveling through air\\nor the human body, produces vibrations—mole-\\ncules bouncing into each other—as the shock wave\\ntravels along. The frequency of a sound is the num-\\nber of vibrations per second. Within the audible\\nrange, frequency means pitch—the higher the fre-\\nquency, the higher a sound’s pitch.\\nIonizing radiation—Radiation that can damage liv-\\ning tissue by disrupting and destroying individual\\ncells at the molecular level. All types of nuclear\\nradiation—x rays, gamma rays and beta rays—are\\npotentially ionizing. Sound waves physically vibrate\\nthe material through which they pass, but do not\\nionize it.\\nJaundice—A condition that results in a yellow tint\\nto the skin, eyes and body fluids. Bile retention in\\nthe liver, gallbladder and pancreas is the immediate\\ncause, but the underlying cause could be as simple\\nas obstruction of the common bile duct by a gall-\\nstone or as serious as pancreatic cancer. Ultrasound\\ncan distinguish between these conditions.\\nMalignant—The term literally means growing worse\\nand resisting treatment. It is used as a synonym for\\ncancerous and connotes a harmful condition that\\ngenerally is life-threatening.\\nMorphology—Literally, the study of form. In medi-\\ncine, morphology refers to the size, shape and\\nstructure rather than the function of a given organ.\\nAs a diagnostic imaging technique, ultrasound facil-\\nitates the recognition of abnormal morphologies as\\nsymptoms of underlying conditions.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 3\\nAbdominal ultrasound\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 3'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 17, 'page_label': '18'}, page_content='Higher frequency ultrasound waves produce more\\ndetailed images, but are also more readily absorbed and\\nso cannot penetrate as deeply into the body. Abdominal\\nultrasound imaging is generally performed at frequencies\\nbetween 2-5 MHz.\\nAn ultrasound machine consists of two parts: the\\ntransducer and the analyzer. The transducer both produces\\nthe sound waves that penetrate the body and receives the\\nreflected echoes. Transducers are built around piezoelec-\\ntric ceramic chips. (Piezoelectric refers to electricity that\\nis produced when you put pressure on certain crystals\\nsuch as quartz). These ceramic chips react to electric puls-\\nes by producing sound waves ( they are transmitting\\nwaves) and react to sound waves by producing electric\\npulses (receiving). Bursts of high frequency electric puls-\\nes supplied to the transducer causes it to produce the\\nscanning sound waves. The transducer then receives the\\nreturning echoes, translates them back into electric pulses\\nand sends them to the analyzer—a computer that orga-\\nnizes the data into an image on a television screen.\\nBecause sound waves travel through all the body’s\\ntissues at nearly the same speed—about 3,400 miles per\\nhour—the microseconds it takes for each echo to be\\nreceived can be plotted on the screen as a distance into the\\nbody. The relative strength of each echo, a function of the\\nspecific tissue or organ boundary that produced it, can be\\nplotted as a point of varying brightness. In this way, the\\nechoes are translated into a picture. Tissues surrounded\\nby bone or filled with gas (the stomach, intestines and\\nbowel) cannot be imaged using ultrasound, because the\\nwaves are blocked or become randomly scattered.\\nFour different modes of ultrasound are used in med-\\nical imaging:\\n• A-mode. This is the simplest type of ultrasound in\\nwhich a single transducer scans a line through the body\\nwith the echoes plotted on screen as a function of\\ndepth. This method is used to measure distances within\\nthe body and the size of internal organs. Therapeutic\\nultrasound aimed at a specific tumor or calculus is also\\nA-mode, to allow for pinpoint accurate focus of the\\ndestructive wave energy.\\n• B-mode. In B-mode ultrasound, a linear array of trans-\\nducers simultaneously scans a plane through the body\\nthat can be viewed as a two-dimensional image on\\nscreen. Ultrasound probes containing more than 100\\ntransducers in sequence form the basis for these most\\ncommonly used scanners, which cost about $50,000.\\n• M-Mode. The M stands for motion. A rapid sequence\\nof B-mode scans whose images follow each other in\\nsequence on screen enables doctors to see and mea-\\nsure range of motion, as the organ boundaries that\\nproduce reflections move relative to the probe. M-\\nmode ultrasound has been put to particular use in\\nstudying heart motion.\\n• Doppler mode. Doppler ultrasonography includes the\\ncapability of accurately measuring velocities of moving\\nmaterial, such as blood in arteries and veins. The prin-\\nciple is the same as that used in radar guns that measure\\nthe speed of a car on the highway. Doppler capability is\\nmost often combined with B-mode scanning to produce\\nimages of blood vessels from which blood flow can be\\ndirectly measured. This technique is used extensively to\\ninvestigate valve defects, arteriosclerosis and hyper-\\ntension, particularly in the heart, but also in the abdom-\\ninal aorta and the portal vein of the liver. These\\nmachines cost about $250,000.\\nThe actual procedure for a patient undergoing an\\nabdominal ultrasound is relatively simple, regardless of\\nthe type of scan or its purpose. Fasting for at least eight\\nhours prior to the procedure ensures that the stomach is\\nempty and as small as possible, and that the intestines\\nand bowels are relatively inactive. Fasting also allows the\\ngall bladder to be seen, as it contracts after eating and\\nmay not be seen if the stomach is full. In some cases, a\\nfull bladder helps to push intestinal folds out of the way\\nso that the gas they contain does not disrupt the image.\\nThe patient’s abdomen is then greased with a special gel\\nthat allows the ultrasound probe to glide easily across the\\nskin while transmitting and receiving ultrasonic pulses.\\nThis procedure is conducted by a doctor with the\\nassistance of a technologist skilled in operating the\\nequipment. The probe is moved around the abdomen to\\nobtain different views of the target areas. The patient will\\nlikely be asked to change positions from side to side and\\nto hold their breath as necessary to obtain the desired\\nviews. Discomfort during the procedure is minimal.\\nThe many types and uses of ultrasound technology\\nmakes it difficult to generalize about the time and costs\\ninvolved. Relatively simple imaging—scanning a suspi-\\ncious abdominal mass or a suspected abdominal aortic\\naneurysm—will take about half an hour to perform and\\nwill cost a few hundred dollars or more, depending on\\nthe quality of the equipment, the operator and other fac-\\ntors. More involved techniques such as multiple M-mode\\nand Doppler-enhanced scans, or cases where the targets\\nnot well defined in advance, generally take more time\\nand are more expensive.\\nRegardless of the type of scan used and the potential\\ndifficulties encountered, ultrasound remains faster and\\nless expensive than computed tomography scans (CT),\\nits primary rival in abdominal imaging. Furthermore, as\\nabdominal ultrasounds are generally undertaken as\\n“medically necessary” procedures designed to detect the\\npresence of suspected abnormalities, they are covered\\nGALE ENCYCLOPEDIA OF MEDICINE 24\\nAbdominal ultrasound\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 4'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 18, 'page_label': '19'}, page_content='under most types of major medical insurance. As always,\\nthough, the patient would be wise to confirm that their\\ncoverage extends to the specific procedure proposed. For\\nnonemergency situations, most underwriters stipulate\\nprior approval as a condition of coverage.\\nSpecific conditions for which ultrasound may be\\nselected as a treatment option—certain types of tumors,\\nlesions, kidney stones and other calculi, muscle and lig-\\nament injuries, etc.—are described in detail under the\\nappropriate entries in this encyclopedia.\\nPreparation\\nA patient undergoing abdominal ultrasound will be\\nadvised by their physician about what to expect and how\\nto prepare. As mentioned above, preparations generally\\ninclude fasting and arriving for the procedure with a full\\nbladder, if necessary. This preparation is particularly use-\\nful if the gallbladder, ovaries or veins are to be examined.\\nAftercare\\nIn general, no aftercare related to the abdominal\\nultrasound procedure itself is required.\\nRisks\\nAbdominal ultrasound carries with it no recognized\\nrisks or side effects, if properly performed using appropri-\\nate frequency and intensity ranges. Sensitive tissues, par-\\nticularly those of the reproductive organs, could possibly\\nsustain damage if violently vibrated by overly intense\\nultrasound waves. In general though, such damage would\\nonly result from improper use of the equipment.\\nAny woman who thinks she might be pregnant\\nshould raise this issue with her doctor before undergoing\\nan abdominal ultrasound, as a fetus in the early stages of\\ndevelopment could be injured by ultrasound meant to\\nprobe deeply recessed abdominal organs.\\nNormal results\\nAs a diagnostic imaging technique, a normal abdom-\\ninal ultrasound is one that indicates the absence of the\\nsuspected condition that prompted the scan. For example,\\nsymptoms such as a persistent cough, labored breathing,\\nand upper abdominal pain suggest the possibility of,\\namong other things, an abdominal aortic aneurysm. An\\nultrasound scan that indicates the absence of an aneurysm\\nwould rule out this life-threatening condition and point to\\nother, less serious causes.\\nAbnormal results\\nBecause abdominal ultrasound imaging is generally\\nundertaken to confirm a suspected condition, the results\\nof a scan often will prove abnormal—that is they will\\nconfirm the diagnosis, be it kidney stones, cirrhosis of\\nthe liver or an aortic aneurysm. At that point, appropriate\\nmedical treatment as prescribed by a patient’s doctor is in\\norder. See the relevant disease and disorder entries in this\\nencyclopedia for more information.\\nResources\\nBOOKS\\nHall, Rebecca. The Ultrasonic Handbook: Clinical, Etiologic\\nand Pathologic Implications of Sonographic Findings.\\nPhiladelphia: Lippincott, 1993.\\nKevles, Bettyann Holtzmann. Naked to the Bone: Medical\\nImaging in the Twentieth Century.New Brunswick, NJ:\\nRutgers University Press, 1997.\\nKremkau, Frederick W. Diagnostic Ultrasound: Principles and\\nInstruments. Philadelphia: W. B. Saunders Co., 1993.\\nShtasel, Philip. Medical Tests and Diagnostic Procedures: A\\nPatient’s Guide to Just What the Doctor Ordered.New\\nYork: Harper & Row, 1991.\\nTempkin, Betty Bates. Ultrasound Scanning: Principles and\\nProtocols. Philadelphia: W. B. Saunders Co., 1993.\\nThe Patient’s Guide to Medical Tests.Ed. Barry L. Zaret, et al.\\nBoston: Houghton Mifflin, 1997.\\nPERIODICALS\\n“Ultrasound Detects Stomach Problems.”USA Today Maga-\\nzine (October 1992): 5.\\nFreundlich, Naomi. “Ultrasound: What’s Wrong with this Pic-\\nture?” Business Week(15 September 1997): 84-5.\\nMcDonagh, D. Brian. “Ultrasound: Unsung Medical Hero.”\\nUSA Today Magazine(September 1996): 66-7.\\nMurray, Maxine. “Basics of Ultrasonography.”Student British\\nMedical Journal (August 1996): 269-72.\\nTait, N., and J. M. Little. “The Treatment of Gallstones.”\\nBritish Medical Journal (8 July 1995): 99-105.\\nORGANIZATIONS\\nAmerican College of Gastroenterology. 4900 B South 31st St.,\\nArlington, V A 22206-1656. (703) 820-7400. .\\nAmerican Institute of Ultrasound in Medicine. 14750 Sweitzer\\nLane, Suite 100, Laurel, MD 20707-5906. (800) 638-\\n5352. .\\nAmerican Society of Radiologic Technologists. 15000 Central\\nAve., SE, Albuquerque, NM 87123-3917. (505) 298-4500.\\n.\\nKurt Richard Sternlof\\nAbdominal wall defects\\nDefinition\\nAbdominal wall defects are birth (congenital)\\ndefects that allow the stomach or intestines to protrude.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 5\\nAbdominal wall defects\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 5'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 19, 'page_label': '20'}, page_content='Description\\nMany unexpected and fascinating events occur dur-\\ning the development of a fetus inside the womb. The\\nstomach and intestines begin development outside the\\nbaby’s abdomen and only later does the abdominal wall\\nenclose them. Occasionally, either the umbilical opening\\nis too large, or it develops improperly, allowing the bow-\\nels or stomach to remain outside or squeeze through the\\nabdominal wall.\\nCauses and symptoms\\nThere are many causes for birth defects that still\\nremain unclear. Presently, the cause(s) of abdominal wall\\ndefects is unknown, and any symptoms the mother may\\nhave to indicate that the defects are present in the fetus\\nare nondescript.\\nDiagnosis\\nAt birth, the problem is obvious, because the base of\\nthe umbilical cord at the navel will bulge or, in worse\\ncases, contain viscera (internal organs). Before birth, an\\nultrasound examination may detect the problem. It is\\nalways necessary in children with one birth defect to look\\nfor others, because birth defects are usually multiple.\\nTreatment\\nAbdominal wall defects are effectively treated with\\nsurgical repair. Unless there are accompanying anom-\\nalies, the surgical procedure is not overly complicated.\\nThe organs are normal, just misplaced. However, if the\\ndefect is large, it may be difficult to fit all the viscera into\\nthe small abdominal cavity.\\nPrognosis\\nIf there are no other defects, the prognosis after sur-\\ngical repair of this condition is relatively good. However,\\nKEY TERMS\\nHernia—Movement of a structure into a place it\\ndoes not belong.\\nUmbilical —Referring to the opening in the\\nabdominal wall where the blood vessels from the\\nplacenta enter.\\nViscera—Any of the body’s organs located in the\\nchest or abdomen.\\n10% of those with more severe or additional abnormali-\\nties die from it. The organs themselves are fully function-\\nal; the difficulty lies in fitting them inside the abdomen.\\nThe condition is, in fact, a hernia requiring only replace-\\nment and strengthening of the passageway through\\nwhich it occurred. After surgery, increased pressure in\\nthe stretched abdomen can compromise the function of\\nthe organs inside.\\nPrevention\\nSome, but by no means all, birth defects are pre-\\nventable by early and attentive prenatal care, good nutri-\\ntion, supplemental vitamins , diligent avoidance of all\\nunnecessary drugs and chemicals—especially tobacco—\\nand other elements of a healthy lifestyle.\\nResources\\nPERIODICALS\\nDunn, J. C., and E. W. Fonkalsrud. “Improved Survival of\\nInfants with Omphalocele.”American Journal of Surgery\\n173 (April 1997): 284-7.\\nLanger, J. C. “Gastroschisis and Omphalocele.”Seminars in\\nPediatric Surgery5 (May 1996): 124-8.\\nJ. Ricker Polsdorfer, MD\\nAbnormal heart rhythms see Arrhythmias\\nABO blood typing see Blood typing and\\ncrossmatching\\nABO incompatibility see Erythroblastosis\\nfetalis\\nAbortion, habitual see Recurrent\\nmiscarriage\\nAbortion, partial birth\\nDefinition\\nPartial birth abortion is a method of late-term abor-\\ntion that terminates a pregnancy and results in the death\\nand intact removal of a fetus. This procedure is most\\ncommonly referred to as intact dilatation and extraction\\n(D & X).\\nPurpose\\nPartial birth abortion, or D&X, is performed to end a\\npregnancy and results in the death of a fetus, typically in\\nGALE ENCYCLOPEDIA OF MEDICINE 26\\nAbortion, partial birth\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 6'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 20, 'page_label': '21'}, page_content='the late second or third trimester. Although D&X is high-\\nly controversial, some physicians argue that it has advan-\\ntages that make it a preferable procedure in some circum-\\nstances. One perceived advantage is that the fetus is\\nremoved largely intact, allowing for better evaluation and\\nautopsy of the fetus in cases of known fetal anomalies.\\nIntact removal of the fetus may also confer a lower risk\\nof puncturing the uterus or damaging the cervix. Another\\nperceived advantage is that D&X ends the pregnancy\\nwithout requiring the woman to go through labor, which\\nmay be less emotionally traumatic than other methods of\\nlate-term abortion. In addition, D&X may offer a lower\\ncost and shorter procedure time.\\nPrecautions\\nWomen considering D&X should be aware of the\\nhighly controversial nature of this procedure. A contro-\\nversy common to all late-term abortions is whether the\\nfetus is viable, or able to survive outside of the woman’s\\nbody. A specific area of controversy with D&X is that\\nfetal death does not occur until after most of the fetal\\nbody has exited the uterus. Several states have taken\\nlegal action to limit or ban D&X and many physicians\\nwho perform abortions do not perform D&X. This may\\nrestrict the availability of this procedure to women seek-\\ning late-term abortion.\\nDescription\\nIntact D&X, or partial birth abortion first involves\\nadministration of medications to cause the cervix to\\ndilate, usually over the course of several days. Next, the\\nphysician rotates the fetus to a footling breech position.\\nThe body of the fetus is then drawn out of the uterus feet\\nfirst, until only the head remains inside the uterus. Then,\\nthe physician uses an instrument to puncture the base of\\nthe skull, which collapses the fetal head. Typically, the\\ncontents of the fetal head are then partially suctioned out,\\nwhich results in the death of the fetus, and reduces the\\nsizes of the fetal head enough to allow it to pass through\\nthe cervix. The dead and otherwise intact fetus is then\\nremoved from the woman’s body.\\nPreparation\\nMedical preparation for D&X involves an outpatient\\nvisit to administer medications, such as laminaria ,t o\\ncause the cervix to begin dilating.\\nIn addition, preparation may involve fulfilling local\\nlegal requirements, such as a mandatory waiting period,\\ncounseling, or an informed consent procedure reviewing\\nstages of fetal development, childbirth, alternative abor-\\ntion methods, and adoption.\\nKEY TERMS\\nCervix—The narrow outer end of the uterus that\\nseparates the uterus from the vaginal canal.\\nFootling breech —A position of the fetus while in\\nthe uterus where the feet of the fetus are nearest\\nthe cervix would be the first part of the fetus to exit\\nthe uterus, with the head of the fetus being the last\\npart to exit the uterus.\\nLaminaria —A medical product made from a cer-\\ntain type of seaweed that is physically placed near\\nthe cervix to cause it to dilate.\\nAftercare\\nD&X typically does not require an overnight hospi-\\ntal stay, so a follow up appointment may be scheduled to\\nmonitor the woman for any complications.\\nRisks\\nWith all abortion, the later in pregnancy an abortion\\nis performed, the more complicated the procedure and\\nthe greater the risk of injury to the woman. In addition to\\nassociated emotion reactions, D&X carries the risk of\\ninjury to the woman, including heavy bleeding, blood\\nclots, damage to the cervix or uterus, pelvic infection,\\nand anesthesia-related complications. There is also a risk\\nof incomplete abortion, meaning that the fetus is not\\ndead when removed from the woman’s body. Possible\\nlong-term risks include difficulty becoming pregnant or\\ncarrying a future pregnancy to term.\\nNormal results\\nThe expected outcome of D&X is the termination of\\na pregnancy with removal of a dead fetus from the\\nwoman’s body.\\nResources\\nPERIODICALS\\nEpner, Janet E., et al. “Late-term Abortion.”JAMA 280, no. 8\\n(26 August 1998): 724-729.\\nSprang, M. LeRoy, and Neerhof, Mark G. “Rationale for Ban-\\nning Abortions Late in Pregnancy.”JAMA (26 August\\n1998): 744-747.\\nSwomley, John M. “The ‘Partial-birth’ Debate in 1998.”\\nHumanist (March/April 1998): 5-7.\\nGrimes, David A. “The Continuing Need for Late Abortion.”\\nJAMA (26 August 1998): 747-750.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 7\\nAbortion, partial birth\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 7'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 21, 'page_label': '22'}, page_content='ORGANIZATIONS\\nPlanned Parenthood Federation of America. 810 Seventh Ave.,\\nNew York, NY 10019. (212) 541-7800. FAX: (212) 245-\\n1845.\\nOTHER\\nStatus of partial-birth abortion laws in the states. Othmer Insti-\\ntute at Planned Parenthood of NYC. 2000.\\nStefanie B. N. Dugan, M.S.\\nAbortion, selective\\nDefinition\\nSelective abortion, also known as selective reduc-\\ntion, refers to choosing to abort a fetus, typically in a\\nmulti-fetal pregnancy, to decrease the health risks to the\\nmother in carrying and giving birth to more than one or\\ntwo babies, and also to decrease the risk of complications\\nto the remaining fetus(es). The term selective abortion\\nalso refers to choosing to abort a fetus for reasons such as\\nthe woman is carrying a fetus which likely will be born\\nwith some birth defect or impairment, or because the sex\\nof the fetus is not preferred by the individual.\\nPurpose\\nA woman may decide to abort for health reasons, for\\nexample, she is at higher risk for complications during preg-\\nnancy because of a disorder or disease such as diabetes.\\nHowever, selective reduction is recommended often in\\ncases of multi-fetal pregnancy, or the presence of more than\\none fetus, typically, at least three or more fetuses. In the\\ngeneral population, multi-fetal pregnancy happens in only\\nabout 1-2% of pregnant women. But multi-fetal pregnan-\\ncies occur far more often in women using fertility drugs.\\nPrecautions\\nBecause women or couples who use fertility drugs\\nhave made an extra effort to become pregnant, it is possi-\\nble that the individuals may be unwilling or uncomfort-\\nable with the decision to abort a fetus in cases of multi-\\nfetal pregnancy. Individuals engaging in fertility treat-\\nment should be made aware of the risk of multi-fetal\\npregnancy and consider the prospect of recommended\\nreduction before undergoing fertility treatment.\\nDescription\\nSelective reduction is usually performed between\\nnine and 12 weeks of pregnancy and is most successful\\nwhen performed in early pregnancy. It is a simple proce-\\ndure and can be performed on an outpatient basis. A nee-\\ndle is inserted into the woman’s stomach or vagina and\\npotassium chloride is injected into the fetus.\\nPreparation\\nIndividuals who have chosen selective reduction to\\nsafeguard the remaining fetuses should be counseled\\nprior to the procedure. Individuals should receive infor-\\nmation regarding the risks of a multi-fetal pregnancy to\\nboth the fetuses and the mother compared with the risks\\nafter the reduction.\\nIndividuals seeking an abortion for any reason\\nshould consider the ethical implications whether it be\\nbecause the fetus is not the preferred sex or because the\\nfetus would be born with a severe birth defect.\\nAftercare\\nCounseling should continue after the abortion\\nbecause it is a traumatic event. Individuals may feel\\nguilty about choosing one fetus over another. Mental\\nhealth professionals should be consulted throughout the\\nprocess.\\nRisks\\nAbout 75% of women who undergo selective reduc-\\ntion will go into premature labor . About 4-5% of\\nwomen undergoing selective reduction also miscarry one\\nor more of the remaining fetuses. The risks associated\\nwith multi-fetal pregnancy is considered higher.\\nNormal results\\nIn cases where a multi-fetal pregnancy, three or\\nmore fetuses, is reduced to two, the twin fetuses typically\\ndevelop as they would as if they were conceived as twins.\\nResources\\nBOOKS\\nKnobil, Ernst and Jimmy D. Neill, editors. “Abortion.” In\\nEncyclopedia of Reproduction. San Diego: Adademic\\nPress, 1998, pp.1-5.\\nScott, James R., editor. “Induced Abortion.” In Danforth’s\\nObstetrics and Gynecology. Philadelphia: Lippincott\\nWilliams & Wilkins, 1999, pp.567-578.\\nPERIODICALS\\nAuthor unspecified. “Multiple Pregnancy Associated With\\nInfertility Therapy.”American Society for Reproductive\\nMedicine, A Practice Committee Report (November\\n2000): 1-8.\\nGALE ENCYCLOPEDIA OF MEDICINE 28\\nAbortion, selective\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 8'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 22, 'page_label': '23'}, page_content='ORGANIZATIONS\\nThe American Society for Reproductive Medicine. 1209 Mont-\\ngomery Highway, Birmingham, AL 35216-2809. (205)\\n978-5000. .\\nThe Alan Guttmacher Institute. 120 Wall Street, New York, NY\\n10005. (212) 248-1111. .\\nMeghan M. Gourley\\nAbortion, spontaneous see Miscarriage\\nAbortion, therapeutic\\nDefinition\\nTherapeutic abortion is the intentional termination\\nof a pregnancy before the fetus can live independently.\\nAbortion has been a legal procedure in the United States\\nsince 1973.\\nPurpose\\nAn abortion may be performed whenever there is\\nsome compelling reason to end a pregnancy. Women\\nhave abortions because continuing the pregnancy would\\ncause them hardship, endanger their life or health, or\\nbecause prenatal testing has shown that the fetus will be\\nborn with severe abnormalities.\\nAbortions are safest when performed within the first\\nsix to 10 weeks after the last menstrual period. The cal-\\nculation of this date is referred to as the gestational age\\nand is used in determining the stage of pregnancy. For\\nexample, a woman who is two weeks late having her\\nperiod is said to be six weeks pregnant, because it is six\\nweeks since she last menstruated.\\nAbout 90% of women who have abortions do so\\nbefore 13 weeks and experience few complications.\\nAbortions performed between 13-24 weeks have a higher\\nKEY TERMS\\nMulti-fetal pregnancy —A pregnancy of two or\\nmore fetuses.\\nSelective reduction—Typically referred to in cases\\nof multifetal pregnancy, when one or more fetuses\\nare aborted to preserve the viability of the remain-\\ning fetuses and decrease health risks to the mother.\\nrate of complications. Abortions after 24 weeks are\\nextremely rare and are usually limited to situations where\\nthe life of the mother is in danger.\\nPrecautions\\nMost women are able to have abortions at clinics or\\noutpatient facilities if the procedure is performed early in\\npregnancy. Women who have stable diabetes, controlled\\nepilepsy, mild to moderate high blood pressure, or who\\nare HIV positive can often have abortions as outpatients\\nif precautions are taken. Women with heart disease, pre-\\nvious endocarditis, asthma, lupus erythematosus, uter-\\nine fibroid tumors, blood clotting disorders, poorly con-\\ntrolled epilepsy, or some psychological disorders usually\\nneed to be hospitalized in order to receive special moni-\\ntoring and medications during the procedure.\\nDescription\\nV ery early abortions\\nBetween five and seven weeks, a pregnancy can be\\nended by a procedure called menstrual extraction. This\\nprocedure is also sometimes called menstrual regulation,\\nmini-suction, or preemptive abortion. The contents of the\\nuterus are suctioned out through a thin (3-4 mm) plastic\\ntube that is inserted through the undilated cervix. Suction\\nis applied either by a bulb syringe or a small pump.\\nAnother method is called the “morning after” pill, or\\nemergency contraception . Basically, it involves taking\\nhigh doses of birth control pills within 24 to 48 hours of\\nhaving unprotected sex. The high doses of hormones\\ncauses the uterine lining to change so that it will not sup-\\nport a pregnancy. Thus, if the egg has been fertilized, it is\\nsimply expelled from the body.\\nThere are two types of emergency contraception.\\nOne type is identical to ordinary birth control pills, and\\nuses the hormones estrogen and progestin). This type is\\navailable with a prescription under the brand name Pre-\\nven. But women can even use their regular birth control\\npills for emergency contraception, after they check with\\ntheir doctor about the proper dose. About half of women\\nwho use birth control pills for emergency contraception\\nget nauseated and 20 percent vomit. This method cuts the\\nrisk of pregnancy 75 percent.\\nThe other type of morning-after pill contains only\\none hormone: progestin, and is available under the brand\\nname Plan B. It is more effective than the first type with\\na lower risk of nausea and vomiting. It reduces the risk\\nof pregnancy 89 percent.\\nWomen should check with their physicians regard-\\ning the proper dose of pills to take, as it depends on the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 9\\nAbortion, therapeutic\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 9'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 23, 'page_label': '24'}, page_content='brand of birth control pill. Not all birth control pills will\\nwork for emergency contraception.\\nMenstrual extractions are safe, but because the\\namount of fetal material is so small at this stage of devel-\\nopment, it is easy to miss. This results in an incomplete\\nabortion that means the pregnancy continues.\\nFirst trimester abortions\\nThe first trimester of pregnancy includes the first 13\\nweeks after the last menstrual period. In the United\\nStates, about 90% of abortions are performed during this\\nperiod. It is the safest time in which to have an abortion,\\nand the time in which women have the most choice of\\nhow the procedure is performed.\\nMEDICAL ABORTIONS. Medical abortions are brought\\nabout by taking medications that end the pregnancy. The\\nadvantages of a first trimester medical abortion are:\\n• The procedure is non-invasive; no surgical instruments\\nare used.\\n• Anesthesia is not required.\\n• Drugs are administered either orally or by injection.\\n• The procedure resembles a natural miscarriage.\\nDisadvantages of a medical abortion are:\\n• The effectiveness decreases after the seventh week.\\n• The procedure may require multiple visits to the doctor.\\n• Bleeding after the abortion lasts longer than after a sur-\\ngical abortion.\\n• The woman may see the contents of her womb as it is\\nexpelled.\\nTwo different medications can be used to bring about\\nan abortion. Methotrexate (Rheumatrex) works by stop-\\nping fetal cells from dividing which causes the fetus to die.\\nOn the first visit to the doctor, the woman receives\\nan injection of methotrexate. On the second visit, about\\na week later, she is given misoprostol (Cytotec), an\\noxygenated unsaturated cyclic fatty acid responsible for\\nvarious hormonal reactions such as muscle contraction\\n(prostaglandin), that stimulates contractions of the\\nuterus. Within two weeks, the woman will expel the\\ncontents of her uterus, ending the pregnancy. A follow-\\nup visit to the doctor is necessary to assure that the\\nabortion is complete.\\nWith this procedure, a woman will feel cramping\\nand may feel nauseated from the misoprostol. This\\ncombination of drugs is 90-96% effective in ending\\npregnancy.\\nMifepristone (RU-486), which goes by the brand\\nname Mifeprex, works by blocking the action of prog-\\nesterone, a hormone needed for pregnancy to continue,\\nthen stimulates uterine contractions thus ending the\\npregnancy. It can be taken a much as 49 days after the\\nfirst day of a woman’s last period. On the first visit to\\nthe doctor, a woman takes a mifepristone pill. Two days\\nlater she returns and, if the miscarriage has not\\noccurred, takes two misoprostol pills, which causes the\\nuterus to contract. Five percent of women won’t need to\\ntake misoprostol. After an observation period, she\\nreturns home.\\nWithin four days, 90% of women have expelled the\\ncontents of their uterus and completed the abortion.\\nWithin 14 days, 95-97% of women have completed the\\nabortion. A third follow-up visit to the doctor is neces-\\nsary to confirm through observation or ultrasound that\\nthe procedure is complete. In the event that it is not, a\\nsurgical abortion is performed. Studies show that 4.5 to 8\\npercent of women need surgery or a blood transfusion\\nafter taking mifepristone, and the pregnancy persists in\\nabout 1 percent of women. In this case, surgical abortion\\nis recommended because the fetus may be damanged.\\nSide effects include nausea, vaginal bleeding and heavy\\ncramping. The bleeding is typically heavier than a nor-\\nmal period and may last up to 16 days.\\nMifepristone is not recommended for women with\\nectopic pregnancy, an IUD, who have been taking long-\\nGALE ENCYCLOPEDIA OF MEDICINE 210\\nAbortion, therapeutic\\nUterus\\nEmbryonic\\ntissue\\nVagina Vulsellum\\nCervix\\nSpeculum\\nExtraction tube\\nBetween 5 and 7 weeks, a pregnancy can be ended by a pro-\\ncedure called menstrual extraction.The contents of the\\nuterus are suctioned out through a thin extraction tube that\\nis inserted through the undilated cervix. (Illustration by Elec-\\ntronic Illustrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 10'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 24, 'page_label': '25'}, page_content='term steroidal therapy, have bleeding abnormalities or on\\nblood-thinners such as Coumadin.\\nSurgical abortions\\nFirst trimester surgical abortions are performed\\nusing vacuum aspiration. The procedure is also called\\ndilation and evacuation (D & E), suction dilation, vacu-\\num curettage, or suction curettage.\\nAdvantages of a vacuum aspiration abortion are:\\n• It is usually done as a one-day outpatient procedure.\\n• The procedure takes only 10-15 minutes.\\n• Bleeding after the abortion lasts five days or less.\\n• The woman does not see the products of her womb\\nbeing removed.\\nDisadvantages include:\\n• The procedure is invasive; surgical instruments are used.\\n• Infection may occur.\\nDuring a vacuum aspiration, the woman’s cervix is\\ngradually dilated by expanding rods inserted into the\\ncervical opening. Once dilated, a tube attached to a suc-\\ntion pump is inserted through the cervix and the con-\\ntents of the uterus are suctioned out. The procedure is\\n97-99% effective. The amount of discomfort a woman\\nfeels varies considerably. Local anesthesia is often\\ngiven to numb the cervix, but it does not mask uterine\\ncramping. After a few hours of rest, the woman may\\nreturn home.\\nSecond trimester abortions\\nAlthough it is better to have an abortion during the\\nfirst trimester, some second trimester abortions may be\\ninevitable. The results of genetic testing are often not\\navailable until 16 weeks. In addition, women, especially\\nteens, may not have recognized the pregnancy or come to\\nterms with it emotionally soon enough to have a first\\ntrimester abortion. Teens make up the largest group hav-\\ning second trimester abortions.\\nSome second trimester abortions are performed as a\\nD & E. The procedures are similar to those used in the\\nfirst trimester, but a larger suction tube must be used\\nbecause more material must be removed. This increases\\nthe amount of cervical dilation necessary and increases\\nthe risk of the procedure. Many physicians are reluctant\\nto perform a D & E this late in pregnancy, and for some\\nwomen is it not a medically safe option.\\nThe alternative to a D & E in the second trimester is\\nan abortion by induced labor. Induced labor may require\\nan overnight stay in a hospital. The day before the proce-\\ndure, the woman visits the doctor for tests, and to either\\nKEY TERMS\\nEndocarditis —An infection of the inner mem-\\nbrane lining of the heart.\\nFibroid tumors —Fibroid tumors are non-cancer-\\nous (benign) growths in the uterus. They occur in\\n30-40% of women over age 40, and do not need\\nto be removed unless they are causing symptoms\\nthat interfere with a woman’s normal activities.\\nLupus erythematosus —A chronic inflammatory\\ndisease in which inappropriate immune system\\nreactions cause abnormalities in the blood vessels\\nand connective tissue.\\nProstaglandin —Oxygenated unsaturated cyclic\\nfatty acids responsible for various hormonal reac-\\ntions such as muscle contraction.\\nRh negative —Lacking the Rh factor, genetically\\ndetermined antigens in red blood cells that pro-\\nduce immune responses. If an Rh negative woman\\nis pregnant with an Rh positive fetus, her body will\\nproduce antibodies against the fetus’s blood, caus-\\ning a disease known as Rh disease. Sensitization to\\nthe disease occurs when the women’s blood is\\nexposed to the fetus’s blood. Rh immune globulin\\n(RhoGAM) is a vaccine that must be given to a\\nwoman after an abortion, miscarriage, or prenatal\\ntests in order to prevent sensitization to Rh disease.\\nhave rods inserted in her cervix to help dilate it or to\\nreceive medication that will soften the cervix and speed\\nup labor.\\nOn the day of the abortion, drugs, usually prosta-\\nglandins to induce contractions, and a salt water solution,\\nare injected into the uterus. Contractions begin, and with-\\nin eight to 72 hours the woman delivers the fetus.\\nSide effects of this procedure include nausea, vomit-\\ning, and diarrhea from the prostaglandins, and pain\\nfrom uterine cramps. Anesthesia of the sort used in\\nchildbirth can be given to mask the pain. Many women\\nare able to go home a few hours after the procedure.\\nVery early abortions cost between $200-$400. Later\\nabortions cost more. The cost increases about $100 per\\nweek between the thirteenth and sixteenth week. Second\\ntrimester abortions are much more costly because they\\noften involve more risk, more services, anesthesia, and\\nsometimes a hospital stay. Insurance carriers and HMOs\\nmay or may not cover the procedure. Federal law pro-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 11\\nAbortion, therapeutic\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 11'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 25, 'page_label': '26'}, page_content='hibits federal funds including Medicaid funds, from\\nbeing used to pay for an elective abortion.\\nPreparation\\nThe doctor must know accurately the stage of a\\nwoman’s pregnancy before an abortion is performed. The\\ndoctor will ask the woman questions about her menstrual\\ncycle and also do a physical examination to confirm the\\nstage of pregnancy. This may be done at an office visit\\nbefore the abortion or on the day of the abortion. Some\\nstates require a waiting period before an abortion can be\\nperformed. Others require parental or court consent for a\\nchild under age 18 to receive an abortion.\\nDespite the fact that almost half of all women in the\\nUnited States have had at least one abortion by the time\\nthey reach age 45, abortion is surrounded by controversy.\\nWomen often find themselves in emotional turmoil when\\ndeciding if an abortion is a procedure they wish to under-\\ngo. Pre-abortion counseling is important in helping a\\nwoman resolve any questions she may have about having\\nthe procedure.\\nAftercare\\nRegardless of the method used to perform the abor-\\ntion, a woman will be observed for a period of time to\\nmake sure her blood pressure is stable and that bleeding\\nis controlled. The doctor may prescribe antibiotics to\\nreduce the chance of infection. Women who are Rh nega-\\ntive (lacking genetically determined antigens in their red\\nblood cells that produce immune responses) should be\\ngiven a human Rh immune globulin (RhoGAM) after the\\nprocedure unless the father of the fetus is also Rh nega-\\ntive. This prevents blood incompatibility complications\\nin future pregnancies.\\nBleeding will continue for about five days in a surgical\\nabortion and longer in a medical abortion. To decrease the\\nrisk of infection, a woman should avoid intercourse and not\\nuse tampons and douches for two weeks after the abortion.\\nA follow-up visit is a necessary part of the woman’s\\naftercare. Contraception will be offered to women who\\nwish to avoid future pregnancies, because menstrual\\nperiods normally resume within a few weeks.\\nRisks\\nSerious complications resulting from abortions per-\\nformed before 13 weeks are rare. Of the 90% of women\\nwho have abortions in this time period, 2.5% have minor\\ncomplications that can be handled without hospitaliza-\\ntion. Less than 0.5% have complications that require a\\nhospital stay. The rate of complications increases as the\\npregnancy progresses.\\nComplications from abortions can include:\\n• uncontrolled bleeding\\n• infection\\n• blood clots accumulating in the uterus\\n• a tear in the cervix or uterus\\n• missed abortion where the pregnancy continues\\n• incomplete abortion where some material from the\\npregnancy remains in the uterus\\nWomen who experience any of the following symp-\\ntoms of post-abortion complications should call the clin-\\nic or doctor who performed the abortion immediately.\\n• severe pain\\n• fever over 100.4°F (38.2°C)\\n• heavy bleeding that soaks through more than one sani-\\ntary pad per hour\\n• foul-smelling discharge from the vagina\\n• continuing symptoms of pregnancy\\nNormal results\\nUsually the pregnancy is ended without complica-\\ntion and without altering future fertility.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra Ziporyn.\\n“Abortion.” In The Harvard Guide to Women’s Health.\\nCambridge, MA: Harvard University Press, 1996.\\nDeCherney, Alan H., and Martin L. Peroll. “Contraception and\\nFamily Planning.” In Current Obstetric and Gynecologic\\nDiagnosis and Treatment.Norwalk, CT: Appleton &\\nLange, 1994.\\nORGANIZATION\\nNational Abortion Federation. (800) 772-9100. .\\nDebra Gordon\\nAbrasions see Wounds\\nAbruptio placentae see Placental abruption\\nAbscess\\nDefinition\\nAn abscess is an enclosed collection of liquefied tis-\\nsue, known as pus, somewhere in the body. It is the result\\nof the body’s defensive reaction to foreign material.\\nGALE ENCYCLOPEDIA OF MEDICINE 212\\nAbcess\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 12'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 26, 'page_label': '27'}, page_content='Description\\nThere are two types of abscesses, septic and sterile.\\nMost abscesses are septic, which means that they are the\\nresult of an infection. Septic abscesses can occur any-\\nwhere in the body. Only a germ and the body’s immune\\nresponse are required. In response to the invading germ,\\nwhite blood cells gather at the infected site and begin\\nproducing chemicals called enzymes that attack the germ\\nby digesting it. These enzymes act like acid, killing the\\ngerms and breaking them down into small pieces that can\\nbe picked up by the circulation and eliminated from the\\nbody. Unfortunately, these chemicals also digest body\\ntissues. In most cases, the germ produces similar chemi-\\ncals. The result is a thick, yellow liquid—pus—contain-\\ning digested germs, digested tissue, white blood cells,\\nand enzymes.\\nAn abscess is the last stage of a tissue infection that\\nbegins with a process called inflammation. Initially, as\\nthe invading germ activates the body’s immune system,\\nseveral events occur:\\n• Blood flow to the area increases.\\n• The temperature of the area increases due to the\\nincreased blood supply.\\n• The area swells due to the accumulation of water, blood,\\nand other liquids.\\n• It turns red.\\n• It hurts, because of the irritation from the swelling and\\nthe chemical activity.\\nThese four signs—heat, swelling, redness, and pain—\\ncharacterize inflammation.\\nAs the process progresses, the tissue begins to turn\\nto liquid, and an abscess forms. It is the nature of an\\nabscess to spread as the chemical digestion liquefies\\nmore and more tissue. Furthermore, the spreading fol-\\nlows the path of least resistance—the tissues most easily\\ndigested. A good example is an abscess just beneath the\\nskin. It most easily continues along beneath the skin\\nrather than working its way through the skin where it\\ncould drain its toxic contents. The contents of the abscess\\nalso leak into the general circulation and produce symp-\\ntoms just like any other infection. These include chills,\\nfever, aching, and general discomfort.\\nSterile abscesses are sometimes a milder form of the\\nsame process caused not by germs but by non-living irri-\\ntants such as drugs. If an injected drug like penicillin is\\nnot absorbed, it stays where it was injected and may\\ncause enough irritation to generate a sterile abscess—\\nsterile because there is no infection involved. Sterile\\nabscesses are quite likely to turn into hard, solid lumps as\\nthey scar, rather than remaining pockets of pus.\\nCauses and symptoms\\nMany different agents cause abscesses. The most\\ncommon are the pus-forming (pyogenic) bacteria like\\nStaphylococcus aureus, which is nearly always the cause\\nof abscesses under the skin. Abscesses near the large\\nbowel, particularly around the anus, may be caused by\\nany of the numerous bacteria found within the large\\nbowel. Brain abscesses and liver abscesses can be caused\\nby any organism that can travel there through the circula-\\ntion. Bacteria, amoeba, and certain fungi can travel in\\nthis fashion. Abscesses in other parts of the body are\\ncaused by organisms that normally inhabit nearby struc-\\ntures or that infect them. Some common causes of specif-\\nic abscesses are:\\n• skin abscesses by normal skin flora\\n• dental and throat abscesses by mouth flora\\n• lung abscesses by normal airway flora, pneumonia\\ngerms, or tuberculosis\\n• abdominal and anal abscesses by normal bowel flora\\nSpecific types of abscesses\\nListed below are some of the more common and\\nimportant abscesses.\\n• Carbuncles and other boils. Skin oil glands (sebaceous\\nglands) on the back or the back of the neck are the ones\\nusually infected. The most common germ involved is\\nStaphylococcus aureus . Acne is a similar condition of\\nsebaceous glands on the face and back.\\n• Pilonidal abscess. Many people have as a birth defect a\\ntiny opening in the skin just above the anus. Fecal bac-\\nteria can enter this opening, causing an infection and\\nsubsequent abscess.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 13\\nAbcess\\nAn amoebic abscess caused by Entameoba histolytica.\\n(Phototake NYC. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 13'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 27, 'page_label': '28'}, page_content='• Retropharyngeal, parapharyngeal, peritonsillar abscess.\\nAs a result of throat infections like strep throat and\\ntonsillitis, bacteria can invade the deeper tissues of the\\nthroat and cause an abscess. These abscesses can com-\\npromise swallowing and even breathing.\\n• Lung abscess. During or after pneumonia, whether it’s\\ndue to bacteria [common pneumonia], tuberculosis,\\nfungi, parasites, or other germs, abscesses can develop\\nas a complication.\\n• Liver abscess. Bacteria or amoeba from the intestines\\ncan spread through the blood to the liver and cause\\nabscesses.\\n• Psoas abscess. Deep in the back of the abdomen on\\neither side of the lumbar spine lie the psoas muscles.\\nThey flex the hips. An abscess can develop in one of\\nthese muscles, usually when it spreads from the appen-\\ndix, the large bowel, or the fallopian tubes.\\nDiagnosis\\nThe common findings of inflammation—heat, red-\\nness, swelling, and pain—easily identify superficial\\nabscesses. Abscesses in other places may produce only\\ngeneralized symptoms such as fever and discomfort. If\\nthe patient’s symptoms and physical examination do not\\nhelp, a physician may have to resort to a battery of tests to\\nKEY TERMS\\nCellulitis—Inflammation of tissue due to infection.\\nEnzyme—Any of a number of protein chemicals\\nthat can change other chemicals.\\nFallopian tubes—Part of the internal female anato-\\nmy that carries eggs from the ovaries to the uterus.\\nFlora—Living inhabitants of a region or area.\\nPyogenic—Capable of generating pus. Streptococ-\\ncus, Staphocococcus , and bowel bacteria are the\\nprimary pyogenic organisms.\\nSebaceous glands—Tiny structures in the skin that\\nproduce oil (sebum). If they become plugged,\\nsebum collects inside and forms a nurturing place\\nfor germs to grow.\\nSepticemia —The spread of an infectious agent\\nthroughout the body by means of the blood\\nstream.\\nSinus—A tubular channel connecting one body\\npart with another or with the outside.\\nlocate the site of an abscess, but usually something in the\\ninitial evaluation directs the search. Recent or chronic dis-\\nease in an organ suggests it may be the site of an abscess.\\nDysfunction of an organ or system—for instance, seizures\\nor altered bowel function—may provide the clue. Pain\\nand tenderness on physical examination are common\\nfindings. Sometimes a deep abscess will eat a small chan-\\nnel (sinus) to the surface and begin leaking pus. A sterile\\nabscess may cause only a painful lump deep in the but-\\ntock where a shot was given.\\nTreatment\\nSince skin is very resistant to the spread of infection,\\nit acts as a barrier, often keeping the toxic chemicals of\\nan abscess from escaping the body on their own. Thus,\\nthe pus must be drained from the abscess by a physician.\\nThe surgeon determines when the abscess is ready for\\ndrainage and opens a path to the outside, allowing the\\npus to escape. Ordinarily, the body handles the remaining\\ninfection, sometimes with the help of antibiotics or other\\ndrugs. The surgeon may leave a drain (a piece of cloth or\\nrubber) in the abscess cavity to prevent it from closing\\nbefore all the pus has drained out.\\nAlternative treatment\\nIf an abscess is directly beneath the skin, it will be\\nslowly working its way through the skin as it is more\\nrapidly working its way elsewhere. Since chemicals\\nwork faster at higher temperatures, applications of hot\\ncompresses to the skin over the abscess will hasten the\\ndigestion of the skin and eventually result in its breaking\\ndown, releasing the pus spontaneously. This treatment is\\nbest reserved for smaller abscesses in relatively less dan-\\ngerous areas of the body—limbs, trunk, back of the neck.\\nIt is also useful for all superficial abscesses in their very\\nearly stages. It will “ripen” them.\\nContrast hydrotherapy , alternating hot and cold\\ncompresses, can also help assist the body in resorption of\\nthe abscess. There are two homeopathic remedies that\\nwork to rebalance the body in relation to abscess forma-\\ntion, Silica and Hepar sulphuris . In cases of septic\\nabscesses, bentonite clay packs (bentonite clay and a\\nsmall amount of Hydrastis powder) can be used to draw\\nthe infection from the area.\\nPrognosis\\nOnce the abscess is properly drained, the prognosis\\nis excellent for the condition itself. The reason for the\\nabscess (other diseases the patient has) will determine\\nthe overall outcome. If, on the other hand, the abscess\\nruptures into neighboring areas or permits the infectious\\nGALE ENCYCLOPEDIA OF MEDICINE 214\\nAbcess\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 14'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 28, 'page_label': '29'}, page_content='agent to spill into the bloodstream, serious or fatal conse-\\nquences are likely. Abscesses in and around the nasal\\nsinuses, face, ears, and scalp may work their way into the\\nbrain. Abscesses within an abdominal organ such as the\\nliver may rupture into the abdominal cavity. In either\\ncase, the result is life threatening. Blood poisoning is a\\nterm commonly used to describe an infection that has\\nspilled into the blood stream and spread throughout the\\nbody from a localized origin. Blood poisoning, known to\\nphysicians as septicemia, is also life threatening.\\nOf special note, abscesses in the hand are more seri-\\nous than they might appear. Due to the intricate structure\\nand the overriding importance of the hand, any hand\\ninfection must be treated promptly and competently.\\nPrevention\\nInfections that are treated early with heat (if superfi-\\ncial) or antibiotics will often resolve without the forma-\\ntion of an abscess. It is even better to avoid infections\\naltogether by taking prompt care of open injuries, partic-\\nularly puncture wounds. Bites are the most dangerous of\\nall, even more so because they often occur on the hand.\\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.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nJ. Ricker Polsdorfer, MD\\nAbscess drainage see Abscess incision and\\ndrainage\\nAbscess incision & drainage\\nDefinition\\nAn infected skin nodule that contains pus may need to\\nbe drained via a cut if it does not respond to antibiotics.\\nThis allows the pus to escape, and the infection to heal.\\nPurpose\\nAn abscess is a pus-filled sore, usually caused by a\\nbacterial infection. The pus is made up of both live and\\ndead organisms and destroyed tissue from the white\\nblood cells that were carried to the area to fight the infec-\\ntion. Abscesses are often found in the soft tissue under\\nthe skin, such as the armpit or the groin. However, they\\nmay develop in any organ, and are commonly found in\\nthe breast and gums. Abscesses are far more serious and\\ncall for more specific treatment if they are located in\\ndeep organs such as the lung, liver or brain.\\nBecause the lining of the abscess cavity tends to\\ninterfere with the amount of the drug that can penetrate\\nthe source of infection from the blood, the cavity itself\\nmay require draining. Once an abscess has fully formed,\\nit often does not respond to antibiotics. Even if the\\nantibiotic does penetrate into the abscess, it doesn’t func-\\ntion as well in that environment.\\nPrecautions\\nAn abscess can usually be diagnosed visually, al-\\nthough an imaging technique such as a computed tomog-\\nraphy scan may be used to confirm the extent of the\\nabscess before drainage. Such procedures may also be\\nneeded to localize internal abscesses, such as those in the\\nabdominal cavity or brain.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 15\\nAbcess incision & drainage\\nLiver\\nStomach\\nSpleen\\nColon\\nCommon sites of abscess \\nabove and below the liver\\nAlthough abscesses are often found in the soft tissue under\\nthe skin, such as the armpit or the groin, they may develop\\nin any organ, such as the liver.(Illustration by Electronic Illus-\\ntrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 15'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 29, 'page_label': '30'}, page_content='Description\\nA doctor will cut into the lining of the abscess, allow-\\ning the pus to escape either through a drainage tube or by\\nleaving the cavity open to the skin. How big the incision\\nis depends on how quickly the pus is encountered.\\nOnce the abscess is opened, the doctor will clean\\nand irrigate the wound thoroughly with saline. If it is not\\ntoo large or deep, the doctor may simply pack the\\nabscess wound with gauze for 24–48 hours to absorb the\\npus and discharge.\\nIf it is a deeper abscess, the doctor may insert a\\ndrainage tube after cleaning out the wound. Once the tube is\\nin place, the surgeon closes the incision with simple stitch-\\nes, and applies a sterile dressing. Drainage is maintained for\\nseveral days to help prevent the abscess from reforming.\\nPreparation\\nThe skin over the abscess will be cleansed by swab-\\nbing gently with an antiseptic solution.\\nAftercare\\nMuch of the pain around the abscess will be gone\\nafter the surgery. Healing is usually very fast. After the\\ntube is taken out, antibiotics may be continued for sever-\\nal days. Applying heat and keeping the affected area ele-\\nvated may help relieve inflammation.\\nRisks\\nIf there is any scarring, it is likely to become much\\nless noticeable as time goes on, and eventually almost\\ninvisible. Occasionally, an abscess within a vital organ\\n(such as the brain) damages enough surrounding tissue\\nthat there is some permanent loss of normal function.\\nNormal results\\nMost abscesses heal after drainage alone; others\\nrequire drainage and antibiotic drug treatment.\\nResources\\nBOOKS\\nTurkington, Carol A., and Jeffrey S. Dover. Skin Deep. New\\nYork: Facts on File, 1998.\\nKEY TERMS\\nWhite blood cells —Cells that protect the body\\nagainst infection.\\nORGANIZATIONS\\nNational Institute of Arthritis and Musculoskeletal and Skin\\nDiseases. 9000 Rockville Pike, Bldg. 31, Rm 9A04,\\nBethesda, MD 20892.\\nCarol A. Turkington\\nAbuse\\nDefinition\\nAbuse is defined as any thing that is harmful, injuri-\\nous, or offensive. Abuse also includes excessive and\\nwrongful misuse of anything. There are several major types\\nof abuse: physical and sexual abuse of a child or an adult,\\nsubstance abuse, elderly abuse, and emotional abuse.\\nDescription\\nPhysical abuse of a child is the infliction of injury by\\nan other person. The injuries can include punching, kick-\\ning, biting, burning, beating, or pulling the victim’s hair.\\nThe physical abuse inflicted on a child can result in\\nbruises , burns, poisoning , broken bones, and internal\\nhemorrhages. Physical assault against an adult primarily\\noccurs with women, usually in the form of domestic vio-\\nlence. It is estimated that approximately three million\\nchildren witness domestic violence every year.\\nSexual abuse of a child refers to sexual behavior\\nbetween an adult and child or between two children, one\\nof whom is dominant or significantly older. The sexual\\nbehaviors can include touching breasts, genitals, and but-\\ntocks; either dressed or undressed. The behavior can also\\ninclude exhibitionism, cunnilingus, fellatio, or penetra-\\ntion of the vagina or anus with sexual organs or objects.\\nPornographic photography is also used in sexual\\nabuse with children. Reported sex offenders are 97%\\nmale. Females are more often perpetrators in child-care\\nsettings, since children may confuse sexual abuse by a\\nfemale with normal hygiene care. Sexual abuse by step-\\nfathers is five times more common than with biological\\nfathers. Sexual abuse of daughters by stepfathers or\\nfathers is the most common form of incest.\\nSexual abuse can also take the form of rape. The\\nlegal definition of rape includes only slight penile pene-\\ntration in the victim’s outer vulva area. Complete erec-\\ntion and ejaculation are not necessary. Rape is the perpe-\\ntration of an act of sexual intercourse whether:\\n• will is overcome by force or fear (from threats or by use\\nof drugs).\\nGALE ENCYCLOPEDIA OF MEDICINE 216\\nAbuse\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 16'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 30, 'page_label': '31'}, page_content='• mental impairment renders the victim incapable of\\nrational judgment.\\n• if the victim is below the legal age established for con-\\nsent.\\nSubstance abuse is an abnormal pattern of substance\\nusage leading to significant distress or impairment. The\\ncriteria include one or more of the following occurring\\nwithin a 12-month period:\\n• recurrent substance use resulting in failure to fulfill\\nobligations at home, work, or school.\\n• using substance in situations that are physically danger-\\nous (i.e., while driving).\\n• recurrent substance-related legal problems.\\n• continued usage despite recurrent social and interper-\\nsonal problems (i.e., arguments and fights with signifi-\\ncant other).\\nAbuse in the elderly is common and occurs mostly\\nas a result of caretaker burnout, due to the high level of\\ndependency frail, elderly patients usually require. Abuse\\ncan be manifested by physical signs, fear, and delaying\\nor not reporting the need for advanced medical care.\\nElderly patients may also exhibit financial abuse (money\\nor possessions taken away) and abandonment.\\nEmotional abuse generally continues even after phys-\\nical assaults have stopped. In most cases it is a personally\\ntailored form of verbal or gesture abuse expressed to illic-\\nit a provoked response.\\nCauses and symptoms\\nChildren who have been abused usually have a variety\\nof symptoms that encompass behavioral, emotional, and\\npsychosomatic problems. Children who have been physi-\\ncally abused tend to be more aggressive, angry, hostile,\\ndepressed, and have low self-esteem. Additionally, they\\nexhibit fear,anxiety, and nightmares. Severe psychological\\nproblems may result in suicidal behavior or posttraumatic\\nstress disorder. Physically abused children may complain\\nof physical illness even in the absence of a cause. They\\nmay also suffer from eating disorders and encopresis. Chil-\\ndren who are sexually abused may exhibit abnormal sexual\\nbehavior in the form of aggressiveness and hyperarousal.\\nAdolescents may display promiscuity, sexual acting out,\\nand—in some situations—homosexual contact.\\nPhysical abuse directed towards adults can ultimately\\nlead to death. Approximately 50% of women murdered\\nin the United States were killed by a former or current\\nmale partner. Approximately one-third of emergency\\nroom consultations by women were prompted due to\\ndomestic violence. Female victims who are married also\\nhave a higher rate of internal injuries and unconscious-\\nKEY TERMS\\nEncopresis—Abnormalities relating to bowel move-\\nments that can occur as a result of stress or fear.\\nness than victims of stranger assault (mugging, robbery).\\nPhysical abuse or rape can also occur between married\\npersons and persons of the same gender. Perpetrators usu-\\nally sexually assault their victims to dominate, hurt, and\\ndebase them. It is common for physical and sexual vio-\\nlence to occur at the same time. A large percentage of sex-\\nually assaulted persons were also physically abused in the\\nform of punching, beating, or threatening the victim with\\na weapon such as a gun or knife. Usually males who are\\nhurt and humiliated tend to physical assault persons\\nwhom they are intimately involved with, such as spouses\\nand/or children. Males who assault a female tend to have\\nexperienced or witnessed violence during childhood.\\nThey also tend to abuse alcohol, to be sexually assaultive,\\nand are at increased risk for assaultive behavior directed\\nagainst children. Jealous males tend to monitor the\\nwomen’s movements and whereabouts and to isolate\\nother sources of protection and support. They interpret\\ntheir behavior as betrayal of trust and this causes resent-\\nment and explosive anger outbursts during periods of los-\\ning control. Males may also use aggression against\\nfemales in an effort to control and intimidate partners.\\nAbuse in the elderly usually occurs in the frail, elderly\\ncommunity. The caretaker is usually the perpetrator. Care-\\ntaker abuse can be suspected if there is evidence suggest-\\ning behavioral changes in the elderly person when the\\ncaretaker is present. Additionally, elderly abuse can be\\npossible if there are delays between injuries and treatment,\\ninconsistencies between injury and explanations, lack of\\nhygiene or clothing, and prescriptions no being filled.\\nDiagnosis\\nChildren who are victims of domestic violence are\\nfrequently injured attempting to protect their mother\\nfrom an abusive partner. Injuries are visible by inspection\\nor self-report. Physical abuse of an adult may be also be\\nevident by inspection with visible cuts and/or bruises or\\nself report.\\nSexual abuse of both a child and an adult can be\\ndiagnosed with a history from the victim. Victims can be\\nassessed for ejaculatory evidence from the perpetrator.\\nEjaculatory specimens can be retrieved from the mouth,\\nrectum, and clothing. Tests for sexually transmitted dis-\\neases may be performed.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 17\\nAbuse\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 17'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 31, 'page_label': '32'}, page_content='Elderly abuse can be suspected if the elderly patient\\ndemonstrates a fear from the caretaker. Additionally,\\nelderly abuse can be suspected if there are signs indicat-\\ning intentional delay of required medical care or a\\nchange in medical status.\\nSubstance abuse can be suspected in a person who\\ncontinues to indulge in their drug of choice despite recur-\\nrent negative consequences. The diagnosis can be made\\nafter administration of a comprehensive bio-psycho-\\nsocial exam and standardized chemical abuse assess-\\nments by a therapist.\\nTreatment\\nChildren who are victims of physical or sexual abuse\\ntypically require psychological support and medical atten-\\ntion. A complaint may be filed with the local family social\\nservices that will initiate investigations. The authorities\\nwill usually follow up the allegation or offense. Children\\nmay also be referred for psychological evaluation and/or\\ntreatment. The victim may be placed in foster care pending\\nthe investigation outcome. The police may also investigate\\nphysical and sexual abuse of an adult. The victim may\\nrequire immediate medical care and long-term psychologi-\\ncal treatment. It is common for children to be adversely\\naffected by domestic violence situations and the local fam-\\nily services agency may be involved.\\nSubstance abusers should elect treatment, either inpa-\\ntient or outpatient, depending on severity of addiction.\\nLong term treatment and/or medications may be utilized to\\nassist in abstinence. The patient should be encouraged to\\nparticipate in community centered support groups.\\nPrognosis\\nThe prognosis depends on the diagnosis. Usually\\nvictims of physical and sexual abuse require therapy to\\ndeal with emotional distress associated with the incident.\\nPerpetrators require further psychological evaluation and\\ntreatment. Victims of abuse may have a variety of emo-\\ntional problems including depression, acts of suicide, or\\nanxiety. Children of sexual abuse may as adults enter\\nabusive relationships or have problems with intimacy.\\nThe substance abuser may experience relapses, since the\\ncardinal feature of all addictive disorders is a tendency to\\nreturn to symptoms. Elderly patients may suffer from\\nfurther medical problems and/or anxiety, and in some\\ncases neglect may precipitate death.\\nPrevention\\nPrevention programs are geared to education and\\nawareness. Detection of initial symptoms or characteris-\\ntic behaviors may assist in some situations. In some\\ncases treatment may be sought before incident. The pro-\\nfessional treating the abused persons must develop a\\nclear sense of the relationship dynamics and the chances\\nfor continued harm.\\nResources\\nBOOKS\\nBehrman, Richard E., et al, eds. Nelson Textbook of Pediatrics.\\n16th ed. W. B. Saunders Company, 2000.\\nDuthie, Edmund H., et al, eds. Practice of Geriatrics. 3rd ed.\\nW. B. Saunders Company, 1998.\\nRosen, Peter. Emergency Medicine: Concepts and Clinical\\nPractice. 4th ed. Mosby-Year Book, Inc., 1998.\\nPERIODICALS\\nNarendra, K., and S. Lazoritz. “Physical Assessment: Evalua-\\ntion for Possible Physical and Sexual Abuse.”Pediatric\\nClinics of North America 45 (Feb. 1998).\\nStringham, P. “Mental Health: Domestic Violence.”Primary\\nCare; Clinics in Office Practice26 (June 1999).\\nORGANIZATIONS\\nNational Clearinghouse on Child Abuse and Neglect Informa-\\ntion. 330 C Street SW, Washington, DC 20447. (800) 392-\\n3366.\\nOTHER\\nElder Abuse Prevention. .\\nNational Institute on Drug Abuse. .\\nLaith Farid Gulli, M.D.\\nBilal Nasser, M.Sc.\\nAcceleration-deceleration cervical injury\\nsee Whiplash\\nACE inhibitors see Angiotensin-converting\\nenzyme inhibitors\\nAcetaminophen\\nDefinition\\nAcetaminophen is a medicine used to relieve pain\\nand reduce fever.\\nPurpose\\nAcetaminophen is used to relieve many kinds of\\nminor aches and pains—headaches, muscle aches, back-\\naches, toothaches, menstrual cramps, arthritis, and the\\naches and pains that often accompany colds.\\nGALE ENCYCLOPEDIA OF MEDICINE 218\\nAcetaminophen\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 18'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 32, 'page_label': '33'}, page_content='Description\\nThis drug is available without a prescription. Aceta-\\nminophen—or APAP—is sold under various brand\\nnames, including Tylenol, Panadol,Aspirin Free Anacin,\\nand Bayer Select Maximum Strength Headache Pain\\nRelief Formula. Many multi-symptom cold, flu, and\\nsinus medicines also contain acetaminophen. Check the\\ningredients listed on the container to see if aceta-\\nminophen is included in the product.\\nStudies have shown that acetaminophen relieves pain\\nand reduces fever about as well as aspirin. But differences\\nbetween these two common drugs exist. Acetaminophen\\nis less likely than aspirin to irritate the stomach. However,\\nunlike aspirin, acetaminophen does not reduce the red-\\nness, stiffness, or swelling that accompany arthritis.\\nRecommended dosage\\nThe usual dosage for adults and children age 12 and\\nover is 325-650 mg every 4- 6 hours as needed. No more\\nthan 4 grams (4000 mg) should be taken in 24 hours.\\nBecause the drug can potentially harm the liver, people\\nwho drink alcohol in large quantities should take consid-\\nerably less acetaminophen and possibly should avoid the\\ndrug completely.\\nFor children ages 6-11 years, the usual dose is 150-\\n300 mg, three to four times a day. Check with a physician\\nfor dosages for children under age 6 years.\\nPrecautions\\nNever take more than the recommended dosage of\\nacetaminophen unless told to do so by a physician or\\ndentist.\\nPatients should not use acetaminophen for more than\\n10 days to relieve pain (5 days for children) or for more\\nthan 3 days to reduce fever, unless directed to do so by a\\nphysician. If symptoms do not go away—or if they get\\nworse—contact a physician. Anyone who drinks three or\\nmore alcoholic beverages a day should check with a\\nphysician before using this drug and should never take\\nmore than the recommended dosage. A risk of liver dam-\\nage exists from combining large amounts of alcohol and\\nacetaminophen. People who already have kidney or liver\\ndisease or liver infections should also consult with a\\nphysician before using the drug. So should women who\\nare pregnant or breastfeeding.\\nSmoking cigarettes may interfere with the effective-\\nness of acetaminophen. Smokers may need to take higher\\ndoses of the medicine, but should not take more than the\\nrecommended daily dosage unless told by a physician to\\ndo so.\\nKEY TERMS\\nArthritis —Inflammation of the joints. The condi-\\ntion causes pain and swelling.\\nFatigue—Physical or mental weariness.\\nInflammation—A response to irritation, infection,\\nor injury, resulting in pain, redness, and swelling.\\nMany drugs can interact with one another. Consult\\na physician or pharmacist before combining aceta-\\nminophen with any other medicine. Do not use two\\ndifferent acetaminophen-containing products at the\\nsame time.\\nAcetaminophen interferes with the results of some\\nmedical tests. Before having medical tests done, check to\\nsee whether taking acetaminophen will affect the results.\\nAvoiding the drug for a few days before the tests may be\\nnecessary.\\nSide effects\\nAcetaminophen causes few side effects. The most\\ncommon one is lightheadedness. Some people may\\nexperience trembling and pain in the side or the lower\\nback. Allergic reactions do occur in some people, but\\nthey are rare. Anyone who develops symptoms such as\\na rash, swelling, or difficulty breathing after taking\\nacetaminophen should stop taking the drug and get\\nimmediate medical attention. Other rare side effects\\ninclude yellow skin or eyes, unusual bleeding or bruis-\\ning, weakness, fatigue , bloody or black stools, bloody\\nor cloudy urine, and a sudden decrease in the amount\\nof urine.\\nOverdoses of acetaminophen may cause nausea,\\nvomiting, sweating, and exhaustion. Very large overdoses\\ncan cause liver damage. In case of an overdose, get\\nimmediate medical attention.\\nInteractions\\nAcetaminophen 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. Among the drugs that may interact with\\nacetaminophen are alcohol, nonsteroidal anti-inflam-\\nmatory drugs (NSAIDs) such as Motrin, oral contra-\\nceptives, the antiseizure drug phenytoin (Dilantin), the\\nblood-thinning drug warfarin (Coumadin), the choles-\\nterol-lowering drug cholestyramine (Questran), the\\nantibiotic Isoniazid, and zidovudine (Retrovir, AZT).\\nGALE ENCYCLOPEDIA OF MEDICINE 2 19\\nAcetaminophen\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 19'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 33, 'page_label': '34'}, page_content='Check with a physician or pharmacist before combining\\nacetaminophen with any other prescription or nonpre-\\nscription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAcetylsalicylic acid see Aspirin\\nAchalasia\\nDefinition\\nAchalasia is a disorder of the esophagus that pre-\\nvents normal swallowing.\\nDescription\\nAchalasia affects the esophagus, the tube that carries\\nswallowed food from the back of the throat down into the\\nstomach. A ring of muscle called the lower esophageal\\nsphincter encircles the esophagus just above the entrance to\\nthe stomach. This sphincter muscle is normally contracted\\nto close the esophagus. When the sphincter is closed, the\\ncontents of the stomach cannot flow back into the esopha-\\ngus. Backward flow of stomach contents (reflux) can irri-\\ntate and inflame the esophagus, causing symptoms such as\\nheartburn. The act of swallowing causes a wave of\\nesophageal contraction called peristalsis. Peristalsis pushes\\nfood along the esophagus. Normally, peristalsis causes the\\nesophageal sphincter to relax and allow food into the stom-\\nach. In achalasia, which means “failure to relax,” the\\nesophageal sphincter remains contracted. Normal peristal-\\nsis is interrupted and food cannot enter the stomach.\\nCauses and symptoms\\nCauses\\nAchalasia is caused by degeneration of the nerve\\ncells that normally signal the brain to relax the\\nesophageal sphincter. The ultimate cause of this degener-\\nation is unknown. Autoimmune disease or hidden infec-\\ntion is suspected.\\nSymptoms\\nDysphagia, or difficulty swallowing, is the most com-\\nmon symptom of achalasia. The person with achalasia usu-\\nally has trouble swallowing both liquid and solid foods,\\noften feeling that food “gets stuck” on the way down. The\\nperson has chest pain that is often mistaken for angina\\npectoris (cardiac pain). Heartburn and difficulty belching\\nare common. Symptoms usually get steadily worse. Other\\nsymptoms may include nighttime cough or recurrent\\npneumoniacaused by food passing into the lower airways.\\nDiagnosis\\nDiagnosis of achalasia begins with a careful medical\\nhistory. The history should focus on the timing of symp-\\ntoms and on eliminating other medical conditions that\\nmay cause similar symptoms. Tests used to diagnose\\nachalasia include:\\n• Esophageal manometry. In this test, a thin tube is\\npassed into the esophagus to measure the pressure\\nexerted by the esophageal sphincter.\\n• X ray of the esophagus. Barium may be swallowed to\\nact as a contrast agent. Barium reveals the outlines of\\nthe esophagus in greater detail and makes it easier to\\nsee its constriction at the sphincter.\\n• Endoscopy. In this test, a tube containing a lens and a\\nlight source is passed into the esophagus. Endoscopy is\\nused to look directly at the surface of the esophagus.\\nThis test can also detect tumors that cause symptoms\\nlike those of achalasia. Cancer of the esophagus occurs\\nas a complication of achalasia in 2-7% of patients.\\nTreatment\\nThe first-line treatment for achalasia is balloon dila-\\ntion. In this procedure, an inflatable membrane or bal-\\nloon is passed down the esophagus to the sphincter and\\ninflated to force the sphincter open. Dilation is effective\\nin about 70% of patients.\\nThree other treatments are used for achalasia when\\nballoon dilation is inappropriate or unacceptable.\\n• Botulinum toxin injection. Injected into the sphincter,\\nbotulinum toxin paralyzes the muscle and allows it to\\nrelax. Symptoms usually return within one to two years.\\n• Esophagomyotomy. This surgical procedure cuts the\\nsphincter muscle to allow the esophagus to open.\\nEsophagomyotomy is becoming more popular with the\\ndevelopment of techniques allowing very small abdom-\\ninal incisions.\\n• Drug therapy. Nifedipine, a calcium-channel blocker,\\nreduces muscle contraction. Taken daily, this drug pro-\\nvides relief for about two-thirds of patients for as long\\nas two years.\\nPrognosis\\nMost patients with achalasia can be treated effective-\\nly. Achalasia does not reduce life expectancy unless\\nesophageal carcinoma develops.\\nGALE ENCYCLOPEDIA OF MEDICINE 220\\nAchalasia\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 20'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 34, 'page_label': '35'}, page_content='Prevention\\nThere is no known way to prevent achalasia.\\nResources\\nBOOKS\\nGrendell, James H., Kenneth R. McQuaid, and Scott L. Fried-\\nman, eds. Current Diagnosis and Treatment in Gastroen-\\nterology. Stamford: Appleton & Lange, 1996.\\nRichard Robinson\\nAchondroplasia\\nDefinition\\nAchondroplasia is the most common cause of\\ndwarfism, or significantly abnormal short stature.\\nKEY TERMS\\nBotulinum toxin—Any of a group of potent bacte-\\nrial toxins or poisons produced by different strains\\nof the bacterium Clostridium botulinum . The tox-\\nins cause muscle paralysis.\\nDysphagia—Difficulty in swallowing.\\nEndoscopy—A test in which a viewing device and\\na light source are introduced into the esophagus by\\nmeans of a flexible tube. Endoscopy permits visual\\ninspection of the esophagus for abnormalities.\\nEsophageal manometry —A test in which a thin\\ntube is passed into the esophagus to measure the\\ndegree of pressure exerted by the muscles of the\\nesophageal wall.\\nEsophageal sphincter —A circular band of muscle\\nthat closes the last few centimeters of the esopha-\\ngus and prevents the backward flow of stomach\\ncontents.\\nEsophagomyotomy —A surgical incision through\\nthe muscular tissue of the esophagus.\\nEsophagus—The muscular tube that leads from the\\nback of the throat to the entrance of the stomach.\\nPeristalsis —The coordinated, rhythmic wave of\\nsmooth muscle contraction that forces food\\nthrough the digestive tract.\\nReflux—An abnormal backward or return flow of\\na fluid.\\nDescription\\nAchondroplasia is one of a number of chondodystro-\\nphies, in which the development of cartilage, and there-\\nfore, bone is disturbed. The disorder appears in approxi-\\nmately one in every 10,000 births. Achondroplasia is\\nusually diagnosed at birth, owing to the characteristic\\nappearance of the newborn.\\nNormal bone growth depends on the production of\\ncartilage (a fibrous connective tissue). Over time, calci-\\num is deposited within the cartilage, causing it to hard-\\nen and become bone. In achondroplasia, abnormalities\\nof this process prevent the bones (especially those in\\nthe limbs) from growing as long as they normally\\nshould, at the same time allowing the bones to become\\nabnormally thickened. The bones in the trunk of the\\nbody and the skull are mostly not affected, although the\\nopening from the skull through which the spinal cord\\npasses (foramen magnum) is often narrower than nor-\\nmal, and the opening (spinal canal) through which the\\nspinal cord runs in the back bones (vertebrae) becomes\\nincreasingly and abnormally small down the length of\\nthe spine.\\nCauses and symptoms\\nAchondroplasia is caused by a genetic defect. It is a\\ndominant trait, meaning that anybody with the genetic\\ndefect will display all the symptoms of the disorder. A\\nparent with the disorder has a 50% chance of passing it\\nGALE ENCYCLOPEDIA OF MEDICINE 2 21\\nAchondroplasia\\nAn x-ray image of an achondroplastic person’s head and\\nchest.(Custom Medical Stock Photo. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 21'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 35, 'page_label': '36'}, page_content='on to the offspring. Although achondroplasia can be\\npassed on to subsequent offspring, the majority of cases\\noccur due to a new mutation (change) in a gene. Interest-\\ningly enough, the defect seen in achondroplasia is one of\\nonly a few defects known to increase in frequency with\\nincreasing age of the father (many genetic defects are\\nlinked to increased age of the mother).\\nPeople with achondroplasia have abnormally short\\narms and legs. Their trunk is usually of normal size, as is\\ntheir head. The appearance of short limbs and normal\\nhead size actually makes the head appear to be oversized.\\nThe bridge of the nose often has a scooped out appear-\\nance termed “saddle nose.” The lower back has an abnor-\\nmal curvature, or sway back. The face often displays an\\noverly prominent forehead, and a relative lack of devel-\\nopment of the face in the area of the upper jaw. Because\\nthe foramen magnum and spinal canal are abnormally\\nnarrowed, nerve damage may occur if the spinal cord or\\nnerves become compressed. The narrowed foramen mag-\\nnum may disrupt the normal flow of fluid between the\\nbrain and the spinal cord, resulting in the accumulation\\nof too much fluid in the brain (hydrocephalus). Children\\nwith achondroplasia have a very high risk of serious and\\nrepeated middle ear infections, which can result in hear-\\ning loss. The disease does not affect either mental capac-\\nity, or reproductive ability.\\nKEY TERMS\\nCartilage—A flexible, fibrous type of connective tis-\\nsue which serves as a base on which bone is built.\\nForamen magnum—The opening at the base of the\\nskull, through which the spinal cord and the brain-\\nstem pass.\\nHydrocephalus —An abnormal accumulation of\\nfluid within the brain. This accumulation can be\\ndestructive by pressing on brain structures, and\\ndamaging them.\\nMutation—A new, permanent change in the struc-\\nture of a gene, which can result in abnormal struc-\\nture or function somewhere in the body.\\nSpinal canal —The opening that runs through the\\ncenter of the column of spinal bones (vertebrae),\\nand through which the spinal cord passes.\\nVertebrae—The individual bones of the spinal col-\\numn which are stacked on top of each other. There\\nis a hole in the center of each bone, through\\nwhich the spinal cord passes.\\nDiagnosis\\nDiagnosis is often made at birth due to the characteris-\\ntically short limbs, and the appearance of a large head. X-\\nray examination will reveal a characteristic appearance to\\nthe bones, with the bones of the limbs appearing short in\\nlength, yet broad in width. A number of measurements of\\nthe bones in x-ray images will reveal abnormal proportions.\\nTreatment\\nNo treatment will reverse the defect present in achon-\\ndroplasia. All patients with the disease will be short, with\\nabnormally proportioned limbs, trunk, and head. Treat-\\nment of achondroplasia primarily addresses some of the\\ncomplications of the disorder, including problems due to\\nnerve compression, hydrocephalus, bowed legs, and\\nabnormal curves in the spine. Children with achondropla-\\nsia who develop middle ear infections (acute otitis\\nmedia) will require quick treatment with antibiotics and\\ncareful monitoring in order to avoid hearing loss.\\nPrognosis\\nAchondroplasia is a disease which causes consider-\\nable deformity. However, with careful attention paid to\\nthe development of dangerous complications (nerve\\ncompression, hydrocephalus), most people are in good\\nhealth, and can live a normal lifespan.\\nPrevention\\nThe only form of prevention is through genetic\\ncounseling, which could help parents assess their risk of\\nhaving a child with achondroplasia.\\nResources\\nBOOKS\\nHall, Bryan D. “Achondroplasia.” In Nelson Textbook of Pedi-\\natrics, ed. Richard E. Behrman. Philadelphia: W. B. Saun-\\nders Co., 1996.\\nHorton, W. A., and J. T. Hecht. “The Chondrodysplasias.” In\\nConnective Tissue and Its Heritable Disorders, ed. R. M.\\nRoyce and B. Steinmann. Somerset, NJ: Wiley-Liss, 1993.\\nKrane, Stephen M., and Alan L. Schiller. “Achondroplasia.” In\\nHarrison’s Principles of Internal Medicine, ed. Anthony\\nS. Fauci, et al. New York: McGraw-Hill, 1997.\\nWhyte, Michael, P. “Achondroplasia.” In Cecil Textbook of\\nMedicine, ed. J. Claude Bennett and Fred Plum. Philadel-\\nphia: W. B. Saunders Co., 1996.\\nORGANIZATIONS\\nLittle People of America, c/o Mary Carten. 7238 Piedmont\\nDrive, Dallas, TX 75227-9324. (800) 243-9273.\\nRosalyn Carson-DeWitt, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 222\\nAchondroplasia\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 22'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 36, 'page_label': '37'}, page_content='Achromatopsia see Color blindness\\nAcid indigestion see Heartburn\\nAcid phosphatase test\\nDefinition\\nAcid phosphatase is an enzyme found throughout\\nthe body, but primarily in the prostate gland. Like all\\nenzymes, it is needed to trigger specific chemical reac-\\ntions. Acid phosphatase testing is done to diagnose\\nwhether prostate cancer has spread to other parts of the\\nbody (metastasized), and to check the effectiveness of\\ntreatment. The test has been largely supplanted by the\\nprostate specific antigen test (PSA).\\nPurpose\\nThe male prostate gland has 100 times more acid\\nphosphatase than any other body tissue. When prostate\\ncancer spreads to other parts of the body, acid phos-\\nphatase levels rise, particularly if the cancer spreads to\\nthe bone. One-half to three-fourths of persons who have\\nmetastasized prostate cancer have high acid phosphatase\\nlevels. Levels fall after the tumor is removed or reduced\\nthrough treatment.\\nTissues other than prostate have small amounts of\\nacid phosphatase, including bone, liver, spleen, kidney,\\nand red blood cells and platelets. Damage to these tissues\\ncauses a moderate increase in acid phosphatase levels.\\nAcid phosphatase is very concentrated in semen.\\nRape investigations will often include testing for the\\npresence of acid phosphatase in vaginal fluid.\\nPrecautions\\nThis is not a screening test for prostate cancer. Acid\\nphosphatase levels rise only after prostate cancer has\\nmetastasized.\\nDescription\\nLaboratory testing measures the amount of acid\\nphosphatase in a person’s blood, and can determine from\\nwhat tissue the enzyme is coming. For example, it is\\nimportant to know if the increased acid phosphatase is\\nfrom the prostate or red blood cells. Acid phosphatase\\nfrom the prostate, called prostatic acid phosphatase\\n(PAP), is the most medically significant type of acid\\nphosphatase.\\nKEY TERMS\\nEnzyme—A substance needed to trigger specific\\nchemical reactions.\\nMetastasize —Spread to other parts of the body;\\nusually refers to cancer.\\nProstate gland—A gland of the male reproductive\\nsystem.\\nSubtle differences between prostatic acid phos-\\nphatase and acid phosphatases from other tissues cause\\nthem to react differently in the laboratory when mixed\\nwith certain chemicals. For example, adding the chemi-\\ncal tartrate to the test mixture inhibits the activity of pro-\\nstatic acid phosphatase but not red blood cell acid phos-\\nphatase. Laboratory test methods based on these differ-\\nences reveal how much of a person’s total acid phos-\\nphatase is derived from the prostate. Results are usually\\navailable the next day.\\nPreparation\\nThis test requires drawing about 5-10 mL of blood.\\nThe patient should not have a rectal exam or prostate\\nmassage for two to three days prior to the test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite, and the person may feel dizzy or faint. Applying\\npressure to the puncture site until the bleeding stops will\\nreduce bruising. Warm packs to the puncture site will\\nrelieve discomfort.\\nNormal results\\nNormal results vary based on the laboratory and the\\nmethod used.\\nAbnormal results\\nThe highest levels of acid phosphatase are found in\\nmetastasized prostate cancer. Diseases of the bone, such\\nas Paget’s disease or hyperparathyroidism; diseases of\\nblood cells, such as sickle cell disease or multiple\\nmyeloma; or lysosomal disorders, such as Gaucher’s dis-\\nease, will show moderately increased levels.\\nCertain medications can cause temporary increases\\nor decreases in acid phosphatase levels. Manipulation of\\nthe prostate gland through massage, biopsy, or rectal\\nexam before a test can increase the level.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 23\\nAcid phosphatase test\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 23'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 37, 'page_label': '38'}, page_content='Resources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nGarza, Diana, and Kathleen Becan-McBride. Phlebotomy\\nHandbook. 4th ed. Stamford: Appleton & Lange, 1996.\\nPERIODICALS\\nMoul, Judd W., et al. “The Contemporary Value of Pretreat-\\nment Prostatic Acid Phosphatase to Predict Pathological\\nStage and Recurrence in Radical Prostatectomy Cases.”\\nJournal of Urology (Mar. 1998): 935-940.\\nNancy J. Nordenson\\nAcid reflux see Heartburn\\nAcidosis see Respiratory acidosis; Renal\\ntubular acidosis; Metabolic acidosis\\nAcne\\nDefinition\\nAcne is a common skin disease characterized by\\npimples on the face, chest, and back. It occurs when the\\npores of the skin become clogged with oil, dead skin\\ncells, and bacteria.\\nDescription\\nAcne vulgaris, the medical term for common acne, is\\nthe most common skin disease. It affects nearly 17 million\\npeople in the United States. While acne can arise at any\\nage, it usually begins at puberty and worsens during ado-\\nlescence. Nearly 85% of people develop acne at some time\\nbetween the ages of 12-25 years. Up to 20% of women\\ndevelop mild acne. It is also found in some newborns.\\nThe sebaceous glands lie just beneath the skin’s sur-\\nface. They produce an oil called sebum, the skin’s natural\\nmoisturizer. These glands and the hair follicles within\\nwhich they are found are called sebaceous follicles.\\nThese follicles open onto the skin through pores. At\\npuberty, increased levels of androgens (male hormones)\\ncause the glands to produce too much sebum. When\\nexcess sebum combines with dead, sticky skin cells, a\\nhard plug, or comedo, forms that blocks the pore. Mild\\nnoninflammatory acne consists of the two types of come-\\ndones, whiteheads and blackheads.\\nModerate and severe inflammatory types of acne\\nresult after the plugged follicle is invaded by Propioni-\\nbacterium acnes , a bacteria that normally lives on the\\nskin. A pimple forms when the damaged follicle weakens\\nand bursts open, releasing sebum, bacteria, and skin and\\nwhite blood cells into the surrounding tissues. Inflamed\\npimples near the skin’s surface are called papules; when\\ndeeper, they are called pustules. The most severe type of\\nacne consists of cysts (closed sacs) and nodules (hard\\nswellings). Scarring occurs when new skin cells are laid\\ndown to replace damaged cells.\\nThe most common sites of acne are the face, chest,\\nshoulders, and back since these are the parts of the body\\nwhere the most sebaceous follicles are found.\\nCauses and symptoms\\nThe exact cause of acne is unknown. Several risk\\nfactors have been identified:\\n• Age. Due to the hormonal changes they experience,\\nteenagers are more likely to develop acne.\\n• Gender. Boys have more severe acne and develop it\\nmore often than girls.\\n• Disease. Hormonal disorders can complicate acne in\\ngirls.\\n• Heredity. Individuals with a family history of acne have\\ngreater susceptibility to the disease.\\n• Hormonal changes. Acne can flare up before menstrua-\\ntion, during pregnancy, and menopause.\\n• Diet. No foods cause acne, but certain foods may cause\\nflare-ups.\\n• Drugs. Acne can be a side effect of drugs including\\ntranquilizers, antidepressants, antibiotics, oral contra-\\nceptives, and anabolic steroids.\\n• Personal hygiene. Abrasive soaps, hard scrubbing, or\\npicking at pimples will make them worse.\\n• Cosmetics. Oil-based makeup and hair sprays worsen\\nacne.\\n• Environment. Exposure to oils and greases, polluted air,\\nand sweating in hot weather aggravate acne.\\n• Stress. Emotional stress may contribute to acne.\\nAcne is usually not conspicuous, although inflamed\\nlesions may cause pain, tenderness, itching, or swelling.\\nThe most troubling aspects of these lesions are the nega-\\ntive cosmetic effects and potential for scarring. Some\\npeople, especially teenagers, become emotionally upset\\nabout their condition, and have problems forming rela-\\ntionships or keeping jobs.\\nDiagnosis\\nAcne patients are often treated by family doctors.\\nComplicated cases are referred to a dermatologist, a skin\\nGALE ENCYCLOPEDIA OF MEDICINE 224\\nAcne\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 24'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 38, 'page_label': '39'}, page_content='disease specialist, or an endocrinologist, a specialist who\\ntreats diseases of the body’s endocrine (hormones and\\nglands) system.\\nAcne has a characteristic appearance and is not diffi-\\ncult to diagnose. The doctor takes a complete medical\\nhistory, including questions about skin care, diet, factors\\ncausing flare-ups, medication use, and prior treatment.\\nPhysical examination includes the face, upper neck,\\nchest, shoulders, back, and other affected areas. Under\\ngood lighting, the doctor determines what types and how\\nmany blemishes are present, whether they are inflamed,\\nwhether they are deep or superficial, and whether there is\\nscarring or skin discoloration.\\nIn teenagers, acne is often found on the forehead,\\nnose, and chin. As people get older, acne tends to appear\\ntowards the outer part of the face. Adult women may\\nhave acne on their chins and around their mouths. The\\nelderly may develop whiteheads and blackheads on the\\nupper cheeks and skin around the eyes.\\nLaboratory tests are not done unless the patient\\nappears to have a hormonal disorder or other medical\\nproblem. In this case, blood analyses or other tests may\\nbe ordered. Most insurance plans cover the costs of diag-\\nnosing and treating acne.\\nTreatment\\nAcne treatment consists of reducing sebum produc-\\ntion, removing dead skin cells, and killing bacteria with\\ntopical drugs and oral medications. Treatment choice\\ndepends upon whether the acne is mild, moderate, or\\nsevere.\\nDrugs\\nTOPICAL DRUGS. Treatment for mild noninflamma-\\ntory acne consists of reducing the formation of new\\ncomedones with topical tretinoin, benzoyl peroxide, ada-\\npalene, or salicylic acid. Tretinoin is especially effective\\nbecause it increases turnover (death and replacement) of\\nskin cells. When complicated by inflammation, topical\\nantibiotics may be added to the treatment regimen.\\nImprovement is usually seen in two to four weeks.\\nTopical medications are available as cream, gel,\\nlotion, or pad preparations of varying strengths. They\\ninclude antibiotics (agents that kill bacteria), such as ery-\\nthromycin, clindamycin (Cleocin-T), and meclocycline\\n(Meclan); comedolytics (agents that loosen hard plugs\\nand open pores) such as the vitamin A acid tretinoin\\n(Retin-A), salicylic acid, adapalene (Differin), resorci-\\nnol, and sulfur. Drugs that act as both comedolytics and\\nantibiotics, such as benzoyl peroxide, azelaic acid\\n(Azelex), or benzoyl peroxide plus erythromycin (Benza-\\nmycin), are also used. These drugs may be used for\\nmonths to years to achieve disease control.\\nAfter washing with mild soap, the drugs are applied\\nalone or in combination, once or twice a day over the\\nentire affected area of skin. Possible side effects include\\nmild redness, peeling, irritation, dryness, and an increased\\nsensitivity to sunlight that requires use of a sunscreen.\\nORAL DRUGS. Oral antibiotics are taken daily for\\ntwo to four months. The drugs used include tetracycline,\\nerythromycin, minocycline (Minocin), doxycycline, clin-\\ndamycin (Cleocin), and trimethoprim- sulfamethoxazole\\n(Bactrim, Septra). Possible side effects include allergic\\nreactions, stomach upset, vaginal yeast infections, dizzi-\\nness, and tooth discoloration.\\nThe goal of treating moderate acne is to decrease\\ninflammation and prevent new comedone formation. One\\neffective treatment is topical tretinoin along with a topical\\nGALE ENCYCLOPEDIA OF MEDICINE 2 25\\nAcne\\nAcne vulgaris affecting a woman’s face. Acne is the general\\nname given to a skin disorder in which the sebaceous\\nglands become inflamed. (Photograph by Biophoto Associ-\\nates, Photo Researchers, Inc. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 25'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 39, 'page_label': '40'}, page_content='or oral antibiotic. A combination of topical benzoyl per-\\noxide and erythromycin is also very effective. Improve-\\nment is normally seen within four to six weeks, but treat-\\nment is maintained for at least two to four months.\\nA drug reserved for the treatment of severe acne, oral\\nisotretinoin (Accutane), reduces sebum production and\\ncell stickiness. It is the treatment of choice for severe acne\\nwith cysts and nodules, and is used with or without topical\\nor oral antibiotics. Taken for four to five months, it pro-\\nvides long-term disease control in up to 60% of patients. If\\nthe acne reappears, another course of isotretinoin may be\\nneeded by about 20% of patients, while another 20% may\\ndo well with topical drugs or oral antibiotics. Side effects\\ninclude temporary worsening of the acne, dry skin, nose-\\nbleeds, vision disorders, and elevated liver enzymes, blood\\nfats and cholesterol. This drug must not be taken during\\npregnancy since it causes birth defects.\\nAnti-androgens, drugs that inhibit androgen produc-\\ntion, are used to treat women who are unresponsive to\\nother therapies. Certain types of oral contraceptives (for\\nKEY TERMS\\nAndrogens —Male sex hormones that are linked\\nwith the development of acne.\\nAntiandrogens—Drugs that inhibit the production\\nof androgens.\\nAntibiotics—Medicines that kill bacteria.\\nComedo—A hard plug composed of sebum and\\ndead skin cells. The mildest type of acne.\\nComedolytic —Drugs that break up comedones\\nand open clogged pores.\\nCorticosteroids —A group of hormones produced\\nby the adrenal glands with different functions,\\nincluding regulation of fluid balance, androgen\\nactivity, and reaction to inflammation.\\nEstrogens —Hormones produced by the ovaries,\\nthe female sex glands.\\nIsotretinoin —A drug that decreases sebum pro-\\nduction and dries up acne pimples.\\nSebaceous follicles —A structure found within the\\nskin that houses the oil-producing glands and hair\\nfollicles, where pimples form.\\nSebum—An oily skin moisturizer produced by\\nsebaceous glands.\\nTretinoin—A drug that works by increasing the\\nturnover (death and replacement) of skin cells.\\nexample, Ortho-Tri-Cyclen) and female sex hormones\\n(estrogens) reduce hormone activity in the ovaries. Other\\ndrugs, for example, spironolactone and corticosteroids,\\nreduce hormone activity in the adrenal glands. Improve-\\nment may take up to four months.\\nOral corticosteroids, or anti-inflammatory drugs, are\\nthe treatment of choice for an extremely severe, but rare\\ntype of destructive inflammatory acne called acne fulmi-\\nnans, found mostly in adolescent males. Acne congloba-\\nta, a more common form of severe inflammation, is char-\\nacterized by numerous, deep, inflammatory nodules that\\nheal with scarring. It is treated with oral isotretinoin and\\ncorticosteroids.\\nOther treatments\\nSeveral surgical or medical treatments are available\\nto alleviate acne or the resulting scars:\\n• Comedone extraction. The comedo is removed from the\\npore with a special tool.\\n• Chemical peels. Glycolic acid is applied to peel off the\\ntop layer of skin to reduce scarring.\\n• Dermabrasion. The affected skin is frozen with a chem-\\nical spray, and removed by brushing or planing.\\n• Punch grafting. Deep scars are excised and the area\\nrepaired with small skin grafts.\\n• Intralesional injection. Corticosteroids are injected\\ndirectly into inflamed pimples.\\n• Collagen injection. Shallow scars are elevated by colla-\\ngen (protein) injections.\\nAlternative treatment\\nAlternative treatments for acne focus on proper\\ncleansing to keep the skin oil-free; eating a well-bal-\\nanced diet high in fiber, zinc, and raw foods; and avoid-\\ning alcohol, dairy products, smoking , caffeine ,\\nsugar,processed foods, and foods high in iodine, such as\\nsalt. Supplementation with herbs such as burdock root\\n(Arctium lappa ), red clover ( Trifolium pratense ), and\\nmilk thistle (Silybum marianum), and with nutrients such\\nas essential fatty acids, vitamin B complex, zinc, vitamin\\nA, and chromium is also recommended. Chinese herbal\\nremedies used for acne include cnidium seed ( Cnidium\\nmonnieri) and honeysuckle flower ( Lonicera japonica ).\\nWholistic physicians or nutritionists can recommend the\\nproper amounts of these herbs.\\nPrognosis\\nAcne is not curable, although long-term control is\\nachieved in up to 60% of patients treated with\\nGALE ENCYCLOPEDIA OF MEDICINE 226\\nAcne\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 26'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 40, 'page_label': '41'}, page_content='isotretinoin. It can be controlled by proper treatment,\\nwith improvement taking two or more months. Acne\\ntends to reappear when treatment stops, but spontaneous-\\nly improves over time. Inflammatory acne may leave\\nscars that require further treatment.\\nPrevention\\nThere are no sure ways to prevent acne, but the fol-\\nlowing steps may be taken to minimize flare-ups:\\n• gentle washing of affected areas once or twice every day\\n• avoid abrasive cleansers\\n• use noncomedogenic makeup and moisturizers\\n• shampoo often and wear hair off face\\n• eat a well-balanced diet, avoiding foods that trigger\\nflare-ups\\n• unless told otherwise, give dry pimples a limited\\namount of sun exposur\\n• do not pick or squeeze blemishes\\n• reduce stress\\nResources\\nBOOKS\\nBalch, James F., and Phyllis A. Balch. “The Disorders: Acne.”\\nIn Prescription for Nutritional Healing, ed. Amy C. Teck-\\nlenburg, et al. New York: Avery Publishing Group, 1997.\\nBark, Joseph P. Your Skin: An Owner’s Guide.Englewood\\nCliffs, NJ: Prentice Hall, 1995.\\nGoldstein, Sanford M., and Richard B. Odom. “Skin &\\nAppendages: Pustular Disorders.” In Current Medical\\nDiagnosis and Treatment, 1996.35th ed. Ed. Stephen\\nMcPhee, et al. Stamford: Appleton & Lange, 1995.\\nKaptchuk, Ted J., Z’ev Rosenberg, and K’an Herb Co., Inc.\\nK’an Herbals: Formulas by Ted Kaptchuk, O.M.D.San\\nFrancisco: Andrew Miller, 1996.\\nPERIODICALS\\n“Adult Acne.”Harvard Women’s Health Watch(Mar. 1995): 4-\\n5.\\nBergfeld, Wilma F. “The Evaluation and Management of Acne:\\nEconomic Considerations.” Journal of the American\\nAcademy of Dermatology 32 (1995): S52-6.\\nBillings, Laura. “Getting Clear.”Health Magazine, Apr. 1997,\\n48-52.\\nChristiano, Donna. “Acne Treatment Meant for Grown- Ups.”\\nAmerican Health (Oct. 1994): 23-4.\\n“Clearly Better New Treatments Help Adult Acne.”Prevention\\nMagazine, Aug. 1997, 50-51.\\nLeyden, James J. “Therapy For Acne Vulgaris.”New England\\nJournal of Medicine 17 (Apr. 1997): 1156-1162.\\nNguyen, Quan H., Y . Alyssa Kim, and Robert A. Schwartz.\\n“Management of Acne Vulgaris.”American Family Physi-\\ncian (July 1994): 89-96.\\n“Pimple Control Pill?” Prevention Magazine, May 1997, 132.\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham Road,\\nP.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-\\n0230. .\\nMercedes McLaughlin\\nAcne rosacea see Rosacea\\nAcoustic neurinoma see Acoustic neuroma\\nAcoustic neuroma\\nDefinition\\nAn acoustic neuroma is a benign tumor involving\\ncells of the myelin sheath that surrounds the vestibulo-\\ncochlear nerve (eighth cranial nerve).\\nDescription\\nThe vestibulocochlear nerve extends from the inner\\near to the brain and is made up of a vestibular branch,\\noften called the vestibular nerve, and a cochlear branch,\\ncalled the cochlear nerve. The vestibular and cochlear\\nnerves lie next to one another. They also run along side\\nother cranial nerves. People possess two of each type of\\nvestibulocochlear nerve, one that extends from the left\\near and one that extends from the right ear.\\nThe vestibular nerve transmits information concern-\\ning balance from the inner ear to the brain and the cochlear\\nnerve transmits information about hearing. The vestibular\\nnerve, like many nerves, is surrounded by a cover called a\\nmyelin sheath. A tumor, called a schwannoma, can some-\\ntimes develop from the cells of the myelin sheath. A tumor\\nis an abnormal growth of tissue that results from the\\nuncontrolled growth of cells. Acoustic neuromas are often\\ncalled vestibular schwannomas because they are tumors\\nthat arise from the myelin sheath that surrounds the\\nvestibular nerve. Acoustic neuromas are considered\\nbenign (non-cancerous) tumors since they do not spread to\\nother parts of the body. They can occur anywhere along\\nthe vestibular nerve but are most likely to occur where the\\nvestibulocochlear nerve passes through the tiny bony canal\\nthat connects the brain and the inner ear.\\nAn acoustic neuroma can arise from the left vestibu-\\nlar nerve or the right vestibular nerve. A unilateral tumor\\nis a tumor arising from one nerve and a bilateral tumor\\narises from both vestibular nerves. Unilateral acoustic\\nneuromas usually occur spontaneously (by chance). Bilat-\\neral acoustic neuromas occur as part of a hereditary con-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 27\\nAcoustic neuroma\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 27'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 41, 'page_label': '42'}, page_content='dition called Neurofibromatosis Type 2 (NF2). A person\\nwith NF2 has inherited a predisposition for developing\\nacoustic neuromas and other tumors of the nerve cells.\\nAcoustic neuromas usually grow slowly and can\\ntake years to develop. Some acoustic neuromas remain\\nso small that they do not cause any symptoms. As the\\nacoustic neuroma grows it can interfere with the func-\\ntioning of the vestibular nerve and can cause vertigo and\\nbalance difficulties. If the acoustic nerve grows large\\nenough to press against the cochlear nerve, then hearing\\nloss and a ringing (tinnitus) in the affected ear will usu-\\nally occur. If untreated and the acoustic neuroma contin-\\nues to grow it can press against other nerves in the region\\nand cause other symptoms. This tumor can be life threat-\\nening if it becomes large enough to press against and\\ninterfere with the functioning of the brain.\\nCauses and symptoms\\nCauses\\nAn acoustic neuroma is caused by a change or\\nabsence of both of the NF2 tumor suppressor genes in a\\nnerve cell. Every person possesses a pair of NF2 genes in\\nevery cell of their body including their nerve cells. One\\nNF2 gene is inherited from the egg cell of the mother and\\none NF2 gene is inherited from the sperm cell of the\\nfather. The NF2 gene is responsible for helping to pre-\\nvent the formation of tumors in the nerve cells. In partic-\\nular the NF2 gene helps to prevent acoustic neuromas.\\nOnly one unchanged and functioning NF2 gene is\\nnecessary to prevent the formation of an acoustic neuro-\\nma. If both NF2 genes become changed or missing in\\none of the myelin sheath cells of the vestibular nerve\\nthen an acoustic neuroma will usually develop. Most uni-\\nlateral acoustic neuromas result when the NF2 genes\\nbecome spontaneously changed or missing. Someone\\nwith a unilateral acoustic neuroma that has developed\\nspontaneously is not at increased risk for having children\\nwith an acoustic neuroma. Some unilateral acoustic neu-\\nromas result from the hereditary condition NF2. It is also\\npossible that some unilateral acoustic neuromas may be\\ncaused by changes in other genes responsible for pre-\\nventing the formation of tumors.\\nBilateral acoustic neuromas result when someone is\\naffected with the hereditary condition NF2. A person with\\nNF2 is typically born with one unchanged and one\\nchanged or missing NF2 gene in every cell of their body.\\nSometimes they inherit this change from their mother or\\nfather. Sometimes the change occurs spontaneously when\\nthe egg and sperm come together to form the first cell of\\nthe baby. The children of a person with NF2 have a 50%\\nchance of inheriting the changed or missing NF2 gene.\\nA person with NF2 will develop an acoustic neuro-\\nma if the remaining unchanged NF2 gene becomes spon-\\ntaneously changed or missing in one of the myelin sheath\\ncells of their vestibular nerve. People with NF2 often\\ndevelop acoustic neuromas at a younger age. The mean\\nage of onset of acoustic neuroma in NF2 is 31 years of\\nage versus 50 years of age for sporadic acoustic neuro-\\nmas. Not all people with NF2, however, develop acoustic\\nneuromas. People with NF2 are at increased risk for\\ndeveloping cataracts and tumors in other nerve cells.\\nMost people with a unilateral acoustic neuroma are\\nnot affected with NF2. Some people with NF2, however,\\nonly develop a tumor in one of the vestibulocochlear\\nnerves. Others may initially be diagnosed with a unilater-\\nal tumor but may develop a tumor in the other nerve a\\nnumber of years later. NF2 should be considered in some-\\none under the age of 40 who has a unilateral acoustic neu-\\nroma. Someone with a unilateral acoustic neuroma and\\nother family members diagnosed with NF2 probably is\\naffected with NF2. Someone with a unilateral acoustic\\nneuroma and other symptoms of NF2 such as cataracts\\nand other tumors may also be affected with NF2. On the\\nother hand, someone over the age of 50 with a unilateral\\nacoustic neuroma, no other tumors and no family history\\nof NF2 is very unlikely to be affected with NF2.\\nSymptoms\\nSmall acoustic neuromas usually only interfere with\\nthe functioning of the vestibulocochlear nerve. The most\\ncommon first symptom of an acoustic neuroma is hearing\\nloss, which is often accompanied by a ringing sound (tin-\\nnitis). People with acoustic neuromas sometimes report\\ndifficulties in using the phone and difficulties in perceiving\\nthe tone of a musical instrument or sound even when their\\nhearing appears to be otherwise normal. In most cases the\\nhearing loss is initially subtle and worsens gradually over\\ntime until deafness occurs in the affected ear. In approxi-\\nmately 10% of cases the hearing loss is sudden and severe.\\nAcoustic neuromas can also affect the functioning of\\nthe vestibular branch of the vestibulocochlear nerve and\\nvan cause vertigo and dysequilibrium. Twenty percent of\\nsmall tumors are associated with periodic vertigo, which\\nis characterized by dizziness or a whirling sensation.\\nLarger acoustic neuromas are less likely to cause vertigo\\nbut more likely to cause dysequilibrium. Dysequilibrium,\\nwhich is characterized by minor clumsiness and a gener-\\nal feeling of instability, occurs in nearly 50% of people\\nwith an acoustic neuroma.\\nAs the tumor grows larger it can press on the surround-\\ning cranial nerves. Compression of the fifth cranial nerve\\ncan result in facial pain and or numbness. Compression of\\nthe seventh cranial nerve can cause spasms, weakness or\\nGALE ENCYCLOPEDIA OF MEDICINE 228\\nAcoustic neuroma\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 28'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 42, 'page_label': '43'}, page_content='paralysis of the facial muscles. Double vision is a rare\\nsymptom but can result when the 6th cranial nerve is affect-\\ned. Swallowing and/or speaking difficulties can occur if the\\ntumor presses against the 9th, 10th, or 12th cranial nerves.\\nIf left untreated, the tumor can become large enough\\nto press against and affect the functioning of the brain\\nstem. The brain stem is the stalk like portion of the brain\\nthat joins the spinal cord to the cerebrum, the thinking and\\nreasoning part of the brain. Different parts of the brain-\\nstem have different functions such as the control of breath-\\ning and muscle coordination. Large tumors that impact the\\nbrain stem can result in headaches, walking difficulties\\n(gait ataxia) and involuntary shaking movements of the\\nmuscles (tremors). In rare cases when an acoustic neuro-\\nma remains undiagnosed and untreated it can cause nau-\\nsea, vomiting, lethargy and eventually coma, respiratory\\ndifficulties and death. In the vast majority of cases, how-\\never, the tumor is discovered and treated long before it is\\nlarge enough to cause such serious manifestations.\\nDiagnosis\\nAnyone with symptoms of hearing loss should under-\\ngo hearing evaluations. Pure tone and speech audiometry\\nKEY TERMS\\nBenign tumor—A localized overgrowth of cells that\\ndoes not spread to other parts of the body.\\nChromosome—A microscopic structure, made of a\\ncomplex of proteins and DNA, that is found within\\neach cell of the body.\\nComputed tomography (CT)—An examination that\\nuses a computer to compile and analyze the images\\nproduced by x rays projected at a particular part of\\nthe body.\\nCranial nerves—The set of twelve nerves found on\\neach side of the head and neck that control the sen-\\nsory and muscle functions of a number of organs\\nsuch as the eyes, nose, tongue face and throat.\\nDNA testing—Testing for a change or changes in a\\ngene or genes.\\nGene—A building block of inheritance, made up of\\na compound called DNA (deoxyribonucleic acid)\\nand containing the instructions for the production\\nof a particular protein. Each gene is found on a spe-\\ncific location on a chromosome.\\nMagnetic resonance imaging (MRI) —A test which\\nuses an external magnetic field instead of x rays to\\nvisualize different tissues of the body.\\nMyelin sheath —The cover that surrounds many\\nnerve cells and helps to increase the speed by\\nwhich information travels along the nerve.\\nNeurofibromatosis type 2 (NF2) —A hereditary\\ncondition associated with an increased risk of bilat-\\neral acoustic neuromas, other nerve cell tumors and\\ncataracts.\\nProtein—A substance produced by a gene that is\\ninvolved in creating the traits of the human body\\nsuch as hair and eye color or is involved in control-\\nling the basic functions of the human body.\\nSchwannoma —A tumor derived from the cells of\\nthe myelin sheath that surrounds many nerve cells.\\nTinnitus—A ringing sound or other noise in the ear.\\nVertigo—A feeling of spinning or whirling.\\nVestibulocochlear nerve (Eighth cranial nerve) —\\nNerve that transmits information, about hearing and\\nbalance from the ear to the brain.\\nare two screening tests that are often used to evaluate hear-\\ning. Pure tone audiometry tests to see how well someone\\ncan hear tones of different volume and pitch and speech\\naudiometry tests to see how well someone can hear and\\nrecognize speech. An acoustic neuroma is suspected in\\nsomeone with unilateral hearing loss or hearing loss that is\\nless severe in one ear than the other ear(asymmetrical).\\nSometimes an auditory brainstem response (ABR,\\nBAER) test is performed to help establish whether\\nsomeone is likely to have an acoustic neuroma. During\\nthe ABR examination, a harmless electrical impulse is\\npassed from the inner ear to the brainstem. An acoustic\\nneuroma can interfere with the passage of this electri-\\ncal impulse and this interference can, sometimes be\\nidentified through the ABR evaluation. A normal ABR\\nexamination does not rule out the possibility of an\\nacoustic neuroma. An abnormal ABR examination\\nincreases the likelihood that an acoustic neuroma is\\npresent but other tests are necessary to confirm the\\npresence of a tumor.\\nIf an acoustic neuroma is strongly suspected then\\nmagnetic resonance imaging (MRI) is usually per-\\nformed. The MRI is a very accurate evaluation that is\\nGALE ENCYCLOPEDIA OF MEDICINE 2 29\\nAcoustic neuroma\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 29'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 43, 'page_label': '44'}, page_content='able to detect nearly 100% of acoustic neuromas. Com-\\nputerized tomography (CT scan, CAT scan)is unable to\\nidentify smaller tumors; but it can be used when an\\nacoustic neuroma is suspected and an MRI evaluation\\ncannot be performed.\\nOnce an acoustic neuroma is diagnosed, an evalua-\\ntion by genetic specialists such as a geneticist and genet-\\nic counselor may be recommended. The purpose of this\\nevaluation is to obtain a detailed family history and\\ncheck for signs of NF2. If NF2 is strongly suspected\\nthen DNA testing may be recommended. DNA testing\\ninvolves checking the blood cells obtained from a rou-\\ntine blood draw for the common gene changes associat-\\ned with NF2.\\nTreatment\\nThe three treatment options for acoustic neuroma\\nare surgery, radiation, and observation. The physician\\nand patient should discuss the pros and cons of the differ-\\nent options prior to making a decision about treatment.\\nThe patient’s, physical health, age, symptoms, tumor\\nsize, and tumor location should be considered.\\nMicrosurgery\\nThe surgical removal of the tumor or tumors is the\\nmost common treatment for acoustic neuroma. In most\\ncases the entire tumor is removed during the surgery. If\\nthe tumor is large and causing significant symptoms, yet\\nthere is a need to preserve hearing in that ear, then only\\npart of the tumor may be removed. During the procedure\\nthe tumor is removed under microscopic guidance and\\ngeneral anesthetic. Monitoring of the neighboring cranial\\nnerves is done during the procedure so that damage to\\nthese nerves can be prevented. If preservation of hearing\\nis a possibility, then monitoring of hearing will also take\\nplace during the surgery.\\nMost people stay in the hospital four to seven days\\nfollowing the surgery. Total recovery usually takes four\\nto six weeks. Most people experience fatigue and head\\ndiscomfort following the surgery. Problems with balance\\nand head and neck stiffness are also common. The mor-\\ntality rate of this type of surgery is less than 2% at most\\nmajor centers. Approximately 20% of patients experi-\\nence some degree of post-surgical complications. In most\\ncases these complications can be managed successfully\\nand do not result in long term medical problems. Surgery\\nbrings with it a risk of stroke, damage to the brain stem,\\ninfection, leakage of spinal fluid and damage to the cra-\\nnial nerves. Hearing loss and/or tinnitis often result from\\nthe surgery. A follow-up MRI is recommended one to\\nfive years following the surgery because of possible\\nregrowth of the tumor.\\nStereotactic Radiation therapy\\nDuring stereotactic radiation therapy , also called\\nradiosurgery or radiotherapy, many small beams of radia-\\ntion are aimed directly at the acoustic neuroma. The radi-\\nation is administered in a single large dose, under local\\nanesthetic and is performed on an outpatient basis. This\\nresults in a high dose of radiation to the tumor but little\\nradiation exposure to the surrounding area. This treat-\\nment approach is limited to small or medium tumors.\\nThe goal of the surgery is to cause tumor shrinkage or at\\nleast limit the growth of the tumor. The long term effica-\\ncy and risks of this treatment approach are not known.\\nPeriodic MRI monitoring throughout the life of the\\npatient is therefore recommended.\\nRadiation therapy can cause hearing loss which can\\nsometimes occurs even years later. Radiation therapy can\\nalso cause damage to neighboring cranial nerves, which\\ncan result in symptoms such as numbness, pain or paralysis\\nof the facial muscles. In many cases these symptoms are\\ntemporary. Radiation treatment can also induce the forma-\\ntion of other benign or malignant schwannomas. This type\\nof treatment may therefore be contraindicated in the treat-\\nment of acoustic neuromas in those with NF2 who are pre-\\ndisposed to developing schwannomas and other tumors.\\nObservation\\nAcoustic neuromas are usually slow growing and in\\nsome cases they will stop growing and even become\\nsmaller or disappear entirely. It may therefore be appro-\\npriate in some cases to hold off on treatment and to peri-\\nodically monitor the tumor through MRI evaluations.\\nLong-term observation may be appropriate for example\\nin an elderly person with a small acoustic neuroma and\\nfew symptoms. Periodic observation may also be indicat-\\ned for someone with a small and asymptomatic acoustic\\nneuroma that was detected through an evaluation for\\nanother medical problem. Observation may also be sug-\\ngested for someone with an acoustic neuroma in the only\\nhearing ear or in the ear that has better hearing. The dan-\\nger of an observational approach is that as the tumor\\ngrows larger it can become more difficult to treat.\\nPrognosis\\nThe prognosis for someone with a unilateral acoustic\\nneuroma is usually quite good provided the tumor is diag-\\nnosed early and appropriate treatment is instituted. Long\\nterm hearing loss and tinnitis in the affected ear are com-\\nmon, even if appropriate treatment is provided. Regrowth of\\nthe tumor is also a possibility following surgery or radiation\\ntherapy and repeat treatment may be necessary. The progno-\\nsis can be poorer for those with NF2 who have an increased\\nrisk of bilateral acoustic neuromas and other tumors.\\nGALE ENCYCLOPEDIA OF MEDICINE 230\\nAcoustic neuroma\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 30'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 44, 'page_label': '45'}, page_content='Resources\\nBOOKS\\nFilipo, R., and Barbara Maurizio Acoustic neuroma: trends and\\ncontroversies: proceedings of the Symposium Acoustic\\nNeuroma: Trends and Controversies, Rome, Italy, Novem-\\nber 13–15, 1997. The Hague, Netherlands: Kugler,1999.\\nMalis, Leonard Acoustic Neuroma New York: Elsevier, 1998.\\nRoland, Peter, and Bradley Marple. Diagnosis and Manage-\\nment of Acoustic Neuroma (Sipac).Alexandria, V A:\\nAmerican Academy of Otolaryngology—Head and Neck\\nSurvey Foundation, 1998.\\nPERIODICALS\\nBroad, R. W. “Management of Acoustic Neuroma.” In New\\nEngland Journal of Medicine. 340(14) (8 April\\n1999):1119.\\nLederman G, E. Arbit, and J. Lowry. “Management of Acoustic\\nNeuroma.” New England Journal of Medicine. 340(14) (8\\nApril 1999):1119–1120.\\nLevo H., I. Pyykko, and G. Blomstedt. “Non-surgical Treat-\\nment of Vestibular Schwannoma Patients.”Acta Oto-\\nLaryngologica 529 (1997): 56–8.\\nO’Donoghue G.M., T. Nikolopoulos and J. Thomsen. “Man-\\nagement of Acoustic Neuroma.” In New England Journal\\nof Medicine 340(14) (8 April 1999):1120–1121.\\nRigby, P. L., et al. “Acoustic Neuroma Surgery: Outcome\\nAnalysis of Patient-Perceived Disability.” In American\\nJournal of Otology 18 (July 1997): 427–35.\\nvan Roijen, L., et al. “Costs and Effects of Microsurgery versus\\nRadiosurgery in Treating Acoustic Neuroma.” In Acta\\nNeurochirurgica 139 (1997): 942–48.\\nORGANIZATIONS\\nAcoustic Neuroma Association. 600 Peachtree Pkwy, Suite\\n108, Cumming, GA 30041-6899. Phone:(770) 205-8211.\\nFax: (770) 205-0239. ANAusa@aol.com . 28 June 2001.\\nAcoustic Neuroma Association of Canada Box 369, Edmonton,\\nAB T5J 2J6. 1-800-561-ANAC(2622). (780)428-3384.\\nanac@compusmart.ab.ca. . 28 June\\n2001.\\nBritish Acoustic Neuroma Association. Oak House, Ransom\\nWood Business Park, Southwell Road West, Mansfield,\\nNottingham, NG21 0HJ. Tel: 01623 632143. Fax: 01623\\n635313. bana@btclick.com. . 28 June 2001.\\nSeattle Acoustic Neuroma Group. Emcityland@aol.com\\n. 28\\nJune 2001.\\nOTHER\\nNational Institute of Health Consensus Statement Online.\\nAcoustic Neuroma9(4)(11-13 December 1991). . (28 June 2001). \\nUniversity of California at San Francisco (UCSF). Information\\non Acoustic Neuromas (28 June 2001). .\\nLisa Andres, M.S., CGC\\nAcquired hypogammaglobulinemia see\\nCommon variable immunodeficiency\\nAcquired immunodeficiency syndrome see\\nAIDS\\nAcrocyanosis\\nDefinition\\nAcrocyanosis is a decrease in the amount of oxygen\\ndelivered to the extremities. The hands and feet turn blue\\nbecause of the lack of oxygen. Decreased blood supply\\nto the affected areas is caused by constriction or spasm of\\nsmall blood vessels.\\nDescription\\nAcrocyanosis is a painless disorder caused by constric-\\ntion or narrowing of small blood vessels in the skin of affect-\\ned patients. The spasm of the blood vessels decreases the\\namount of blood that passes through them, resulting in less\\nblood being delivered to the hands and feet. The hands may\\nbe the main area affected. The affected areas turn blue and\\nbecome cold and sweaty. Localized swelling may also occur.\\nEmotion and cold temperatures can worsen the symptoms,\\nwhile warmth can decrease symptoms. The disease is seen\\nmainly in women and the effect of the disorder is mainly\\ncosmetic. People with the disease tend to be uncomfortable,\\nwith sweaty, cold, bluish colored hands and feet.\\nCauses and symptoms\\nThe sympathetic nerves cause constriction or spasms\\nin the peripheral blood vessels that supply blood to the\\nextremities. The spasms are a contraction of the muscles\\nin the walls of the blood vessels. The contraction\\ndecreases the internal diameter of the blood vessels,\\nthereby decreasing the amount of blood flow through the\\naffected area. The spasms occur on a persistent basis,\\nresulting in long term reduction of blood supply to the\\nhands and feet. Sufficient blood still passes through the\\nblood vessels so that the tissue in the affected areas does\\nnot starve for oxygen or die. Mainly, blood vessels near\\nthe surface of the skin are affected.\\nDiagnosis\\nDiagnosis is made by observation of the main clini-\\ncal symptoms, including persistently blue and sweaty\\nhands and/or feet and a lack of pain. Cooling the hands\\nincreases the blueness, while warming the hands decreas-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 31\\nAcrocyanosis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 31'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 45, 'page_label': '46'}, page_content='es the blue color. The acrocyanosis patient’s pulse is nor-\\nmal, which rules out obstructive diseases. Raynaud’s dis-\\nease differs from acrocyanosis in that it causes white and\\nred skin coloration phases, not just bluish discoloration.\\nTreatment\\nAcrocyanosis usually isn’t treated. Drugs that block\\nthe uptake of calcium ( calcium channel blockers ) and\\nalpha-one antagonists reduce the symptoms in most\\ncases. Drugs that dilate blood vessels are only effective\\nsome of the time. Sweating from the affected areas can\\nbe profuse and require treatment. Surgery to cut the sym-\\npathetic nerves is performed rarely.\\nPrognosis\\nAcrocyanosis is a benign and persistent disease. The\\nmain concern of patients is cosmetic. Left untreated, the\\ndisease does not worsen.\\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.\\nLarsen, D. E., ed. Mayo Clinic Family Health Book.New York:\\nWilliam Morrow and Co., Inc., 1996.\\nJohn T. Lohr, PhD\\nAcromegaly and gigantism\\nDefinition\\nAcromegaly is a disorder in which the abnormal\\nrelease of a particular chemical from the pituitary gland\\nin the brain causes increased growth in bone and soft tis-\\nsue, as well as a variety of other disturbances throughout\\nthe body. This chemical released from the pituitary gland\\nis called growth hormone (GH). The body’s ability to\\nKEY TERMS\\nSympathetic nerve —A nerve of the autonomic\\nnervous system that regulates involuntary and\\nautomatic reactions, especially to stress.\\nprocess and use nutrients like fats and sugars is also\\naltered. In children whose bony growth plates have not\\nclosed, the chemical changes of acromegaly result in\\nexceptional growth of long bones. This variant is called\\ngigantism, with the additional bone growth causing\\nunusual height. When the abnormality occurs after bone\\ngrowth stops, the disorder is called acromegaly.\\nDescription\\nAcromegaly is a relatively rare disorder, occurring in\\napproximately 50 out of every one million people (50/\\n1,000,000). Both men and women are affected. Because\\nthe symptoms of acromegaly occur so gradually, diagno-\\nsis is often delayed. The majority of patients are not\\nidentified until they are middle aged.\\nCauses and symptoms\\nThe pituitary is a small gland located at the base of\\nthe brain. A gland is a collection of cells that releases\\ncertain chemicals, or hormones, which are important to\\nthe functioning of other organs or body systems. The\\npituitary hormones travel throughout the body and are\\ninvolved in a large number of activities, including the\\nregulation of growth and reproductive functions. The\\ncause of acromegaly can be traced to the pituitary’s pro-\\nduction of GH.\\nUnder normal conditions, the pituitary receives input\\nfrom another brain structure, the hypothalamus, located\\nat the base of the brain. This input from the hypothala-\\nmus regulates the pituitary’s release of hormones. For\\nexample, the hypothalamus produces growth hormone-\\nreleasing hormone (GHRH), which directs the pituitary\\nto release GH. Input from the hypothalamus should also\\ndirect the pituitary to stop releasing hormones.\\nIn acromegaly, the pituitary continues to release GH\\nand ignores signals from the hypothalamus. In the liver,\\nGH causes production of a hormone called insulin-like\\ngrowth factor 1 (IGF-1), which is responsible for growth\\nthroughout the body. When the pituitary refuses to stop\\nproducing GH, the levels of IGF-1 also reach abnormal\\npeaks. Bones, soft tissue, and organs throughout the body\\nbegin to enlarge, and the body changes its ability to\\nprocess and use nutrients like sugars and fats.\\nIn acromegaly, an individual’s hands and feet begin\\nto grow, becoming thick and doughy. The jaw line, nose,\\nand forehead also grow, and facial features are described\\nas “coarsening”. The tongue grows larger, and because\\nthe jaw is larger, the teeth become more widely spaced.\\nDue to swelling within the structures of the throat and\\nsinuses, the voice becomes deeper and sounds more hol-\\nlow, and patients may develop loud snoring. Various hor-\\nmonal changes cause symptoms such as:\\nGALE ENCYCLOPEDIA OF MEDICINE 232\\nAcromegaly and gigantism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 32'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 46, 'page_label': '47'}, page_content='• heavy sweating\\n• oily skin\\n• increased coarse body hair\\n• improper processing of sugars in the diet (and some-\\ntimes actual diabetes)\\n• high blood pressure\\n• increased calcium in the urine (sometimes leading to\\nkidney stones)\\n• increased risk of gallstones; and\\n• swelling of the thyroid gland\\nPeople with acromegaly have more skin tags, or out-\\ngrowths of tissue, than normal. This increase in skin tags\\nis also associated with the development of growths,\\ncalled polyps, within the large intestine that may eventu-\\nally become cancerous. Patients with acromegaly often\\nsuffer from headaches and arthritis. The various\\nswellings and enlargements throughout the body may\\npress on nerves, causing sensations of local tingling or\\nburning, and sometimes result in muscle weakness.\\nThe most common cause of this disorder (in 90% of\\npatients) is the development of a noncancerous tumor with-\\nin the pituitary, called a pituitary adenoma. These tumors\\nare the source of the abnormal release of GH. As these\\ntumors grow, they may press on nearby structures within the\\nbrain, causing headaches and changes in vision. As the ade-\\nnoma grows, it may disrupt other pituitary tissue, interfering\\nwith the release of other hormones. These disruptions may\\nbe responsible for changes in the menstrual cycle of\\nwomen, decreases in the sexual drive in men and women,\\nand the abnormal production of breast milk in women. In\\nrare cases, acromegaly is caused by the abnormal produc-\\ntion of GHRH, which leads to the increased production of\\nGH. Certain tumors in the pancreas, lungs, adrenal glands,\\nthyroid, and intestine produce GHRH, which in turn triggers\\nproduction of an abnormal quantity of GH.\\nDiagnosis\\nBecause acromegaly produces slow changes over\\ntime, diagnosis is often significantly delayed. In fact, the\\ncharacteristic coarsening of the facial features is often\\nnot recognized by family members, friends, or long-time\\nfamily physicians. Often, the diagnosis is suspected by a\\nnew physician who sees the patient for the first time and\\nis struck by the patient’s characteristic facial appearance.\\nComparing old photographs from a number of different\\ntime periods will often increase suspicion of the disease.\\nBecause the quantity of GH produced varies widely\\nunder normal conditions, demonstrating high levels of\\nGH in the blood is not sufficient to merit a diagnosis of\\nacromegaly. Instead, laboratory tests measuring an\\nincrease of IGF-1 (3-10 times above the normal level) are\\nuseful. These results, however, must be carefully inter-\\npreted because normal laboratory values for IGF-1 vary\\nwhen the patient is pregnant, undergoing puberty, elder-\\nly, or severely malnourished. Normal patients will show a\\ndecrease in GH production when given a large dose of\\nsugar (glucose). Patients with acromegaly will not show\\nthis decrease, and will often show an increase in GH pro-\\nduction. Magnetic resonance imaging (MRI) is useful\\nfor viewing the pituitary, and for identifying and locating\\nan adenoma. When no adenoma can be located, the search\\nfor a GHRH-producing tumor in another location begins.\\nTreatment\\nThe first step in treatment of acromegaly is removal of\\nall or part of the pituitary adenoma. Removal requires\\nsurgery, usually performed by entering the skull through\\nthe nose. While this surgery can cause rapid improvement\\nof many acromegaly symptoms, most patients will also\\nGALE ENCYCLOPEDIA OF MEDICINE 2 33\\nAcromegaly and gigantism\\nEnlarged feet is one deformity caused by acromegaly.(Cus-\\ntom Medical Stock Photo. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 33'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 47, 'page_label': '48'}, page_content='KEY TERMS\\nAdenoma —A type of noncancerous (benign)\\ntumor that often involves the overgrowth of certain\\ncells found in glands.\\nGland—A collection of cells that releases certain\\nchemicals, or hormones, that are important to the\\nfunctioning of other organs or body systems.\\nHormone —A chemical produced in one part of\\nthe body that travels to another part of the body in\\norder to exert an effect.\\nHypothalamus —A structure within the brain\\nresponsible for a large number of normal functions\\nthroughout the body, including regulating sleep,\\ntemperature, eating, and sexual development. The\\nhypothalamus also regulates the functions of the\\npituitary gland by directing the pituitary to stop or\\nstart production of its hormones.\\nPituitary—A gland located at the base of the brain\\nthat produces a number of hormones, including\\nthose that regulate growth and reproductive func-\\ntions. Overproduction of the pituitary hormone\\ncalled growth hormone (GH) is responsible for the\\ncondition known as acromegaly.\\nrequire additional treatment with medication. Bromocrip-\\ntine (Parlodel) is a medication that can be taken by mouth,\\nwhile octreotide (Sandostatin) must be injected every eight\\nhours. Both of these medications are helpful in reducing\\nGH production, but must often be taken for life and pro-\\nduce their own unique side effects. Some patients who can-\\nnot undergo surgery are treated with radiation therapyto\\nthe pituitary in an attempt to shrink the adenoma. Radiating\\nthe pituitary may take up to 10 years, however, and may\\nalso injure/destroy other normal parts of the pituitary.\\nPrognosis\\nWithout treatment, patients with acromegaly will\\nmost likely die early because of the disease’s effects on the\\nheart, lungs, brain, or due to the development of cancer in\\nthe large intestine. With treatment, however, a patient with\\nacromegaly may be able to live a normal lifespan.\\nResources\\nBOOKS\\nBiller, Beverly M. K., and Gilbert H. Daniels. “Growth Hor-\\nmone Excess: Acromegaly and Gigantism.” In Harrison’s\\nPrinciples of Internal Medicine, ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1997.\\nJameson, J. Larry. “Growth Hormone Excess: Acromegaly and\\nGigantism.” In Cecil Textbook of Medicine, ed. J. Claude\\nBennett and Fred Plum. Philadelphia: W. B. Saunders Co.,\\n1996.\\nPERIODICALS\\nJaffe, C. A. “Acromegaly: Recognition and Treatment.”Drugs\\n47, no. 3 (1994): 425+.\\nKrishna, A. Y . “Management of Acromegaly: A Review.”Ameri-\\ncan Journal of Medical Science308, no. 6 (1994): 370+.\\nMaugans, Todd, and Michael L. Coates. “Diagnosis and Treat-\\nment of Acromegaly.”American Family Physician 52, no.\\n1 (July 1995): 207+.\\nORGANIZATIONS\\nPituitary Tumor Network Association. 16350 Ventura Blvd.,\\n#231, Encino, CA 91436. (805) 499-9973.\\nRosalyn Carson-DeWitt, MD\\nACT see Alanine aminotransferase test\\nACTH test see Adrenocorticotropic\\nhormone test\\nActinomyces israelii infection see\\nActinomycosis\\nActinomycosis\\nDefinition\\nActinomycosis is an infection primarily caused by\\nthe bacterium Actinomyces israelii. Infection most often\\noccurs in the face and neck region and is characterized\\nby the presence of a slowly enlarging, hard, red lump.\\nGALE ENCYCLOPEDIA OF MEDICINE 234\\nActinomycosis\\nA comparison of the right hand of a person afflicted with\\nacromegaly (left) and the hand of a normal sized person.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 34'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 48, 'page_label': '49'}, page_content='Description\\nActinomycosis is a relatively rare infection occurring\\nin one out of 300,000(1/300,000) people per year. It is\\ncharacterized by the presence of a lump or mass that often\\nforms, draining sinus tracts to the skin surface. Fifty per-\\ncent of actinomycosis cases are of the head and neck region\\n(also called “lumpy jaw” and “cervicofacial actinomyco-\\nsis”), 15% are in the chest, 20% are in the abdomen, and\\nthe rest are in the pelvis, heart, and brain. Men are three\\ntimes more likely to develop actinomycosis than women.\\nCauses and symptoms\\nActinomycosis is usually caused by the bacterium\\nActinomyces israelii. This bacterium is normally present\\nin the mouth but can cause disease if it enters tissues fol-\\nlowing an injury. Actinomyces israelii is an anaerobic\\nbacterium which means it dislikes oxygen but grows very\\nwell in deep tissues where oxygen levels are low. Tooth\\nextraction , tooth disease, root canal treatment ,j a w\\nsurgery, or poor dental hygiene can allow Actinomyces\\nisraelii to cause an infection in the head and neck region.\\nThe main symptom of cervicofacial actinomycosis is\\nthe presence of a hard lump on the face or neck. The lump\\nmay or may not be red. Fever occurs in some cases.\\nDiagnosis\\nCervicofacial actinomycosis can be diagnosed by a fam-\\nily doctor or dentist and the patient may be referred to an oral\\nsurgeon or infectious disease specialist. The diagnosis of\\nactinomycosis is based upon several things. The presence of a\\nred lump with draining sinuses on the head or neck is strongly\\nsuggestive of cervicofacial actinomycosis. A recent history of\\ntooth extraction or signs of tooth decay or poor dental\\nhygiene aid in the diagnosis. Microscopic examination of the\\nfluid draining from the sinuses shows the characteristic “sul-\\nfur granules” (small yellow colored material in the fluid) pro-\\nduced by Actinomyces israelii. A biopsy may be performed to\\nremove a sample of the infected tissue. This procedure can be\\nperformed under local anesthesia in the doctor’s office. Occa-\\nsionally the bacteria can be cultured from the sinus tract fluid\\nor from samples of the infected tissue.\\nActinomycosis in the lungs, abdomen, pelvis, or\\nbrain can be very hard to diagnose since the symptoms\\noften mimic those of other diseases. Actinomycosis of\\nthe lungs or abdomen can resemble tuberculosis or can-\\ncer. x-ray results, the presence of draining sinus tracts,\\nand microscopic analysis and culturing of infected tissue\\nassist in the diagnosis.\\nTreatment\\nActinomycosis is difficult to treat because of its\\ndense tissue location. Surgery is often required to drain\\nKEY TERMS\\nBiopsy—The process which removes a sample of\\ntissue for microscopic examination to aid in the\\ndiagnosis of a disease.\\nSinus tract —A narrow, elongated channel in the\\nbody which allows the escape of fluid.\\nthe lesion and/or to remove the site of infection. To kill\\nthe bacteria, large doses of penicillin are given through a\\nvein daily for two to six weeks followed by six to twelve\\nmonths of penicillin taken by mouth. Tetracycline, clin-\\ndamycin, or erythromycin may be used instead of peni-\\ncillin. The antibiotic therapy must be completed to insure\\nthat the infection does not return. Hyperbaric oxygen\\n(oxygen under high pressure) therapy in combination\\nwith the antibiotic therapy has been successful.\\nPrognosis\\nComplete recovery is achieved following treatment.\\nIf left untreated, the infection may cause localized bone\\ndestruction.\\nPrevention\\nThe best prevention is to maintain good dental hy-\\ngiene.\\nResources\\nOTHER\\n“Actinomycosis.” HealthAnswers.com. 6 Feb. 1998. .\\nBelinda Rowland, PhD\\nActivated charcoal see Charcoal, activated\\nActivated partial thromboplastin time see\\nPartial thromboplastin time\\nAcupressure\\nDefinition\\nAcupressure is a form of touch therapy that utilizes\\nthe principles of acupuncture and Chinese medicine. In\\nacupressure, the same points on the body are used as in\\nacupuncture, but are stimulated with finger pressure\\nGALE ENCYCLOPEDIA OF MEDICINE 2 35\\nAcupressure\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 35'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 49, 'page_label': '50'}, page_content='instead of with the insertion of needles. Acupressure is\\nused to relieve a variety of symptoms and pain.\\nPurpose\\nAcupressure massage performed by a therapist can be\\nvery effective both as prevention and as a treatment for many\\nhealth conditions, including headaches, general aches and\\npains, colds and flu, arthritis,allergies, asthma, nervous ten-\\nsion, menstrual cramps, sinus problems, sprains, tennis\\nelbow, and toothaches, among others. Unlike acupuncture\\nwhich requires a visit to a professional, acupressure can be\\nperformed by a layperson. Acupressure techniques are fairly\\neasy to learn, and have been used to provide quick, cost-free,\\nand effective relief from many symptoms. Acupressure\\npoints can also be stimulated to increase energy and feelings\\nof well-being, reduce stress, stimulate the immune system,\\nand alleviate sexual dysfunction.\\nDescription\\nOrigins\\nOne of the oldest text of Chinese medicine is the\\nHuang Di , The Yellow Emperor’s Classic of Internal\\nMedicine, which may be at least 2,000 years old. Chi-\\nnese medicine has developed acupuncture, acupressure,\\nherbal remedies, diet, exercise , lifestyle changes, and\\nother remedies as part of its healing methods. Nearly all\\nof the forms of Oriental medicine that are used in the\\nWest today, including acupuncture, acupressure, shiatsu,\\nand Chinese herbal medicine, have their roots in Chinese\\nmedicine. One legend has it that acupuncture and acu-\\npressure evolved as early Chinese healers studied the\\npuncture wounds of Chinese warriors, noting that certain\\npoints on the body created interesting results when stim-\\nulated. The oldest known text specifically on acupunc-\\nture points, the Systematic Classic of Acupuncture, dates\\nback to 282 \\nA.D. Acupressure is the non-invasive form of\\nacupuncture, as Chinese physicians determined that\\nstimulating points on the body with massage and pres-\\nsure could be effective for treating certain problems.\\nOutside of Asian-American communities, Chinese\\nmedicine remained virtually unknown in the United\\nStates until the 1970s, when Richard Nixon became the\\nfirst U.S. president to visit China. On Nixon’s trip, jour-\\nnalists were amazed to observe major operations being\\nperformed on patients without the use of anesthetics.\\nInstead, wide-awake patients were being operated on,\\nGALE ENCYCLOPEDIA OF MEDICINE 236\\nAcupressure\\nTherapist working acupressure points on a woman’s shoulder.(Photo Researchers, Inc. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 36'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 50, 'page_label': '51'}, page_content='with only acupuncture needles inserted into them to con-\\ntrol pain. At that time, a famous columnist for the New\\nYork Times, James Reston, had to undergo surgery and\\nelected to use acupuncture for anesthesia. Later, he wrote\\nsome convincing stories on its effectiveness. Despite\\nbeing neglected by mainstream medicine and the Ameri-\\ncan Medical Association (AMA), acupuncture and Chi-\\nnese medicine became a central to alternative medicine\\npractitioners in the United States. Today, there are mil-\\nlions of patients who attest to its effectiveness, and near-\\nly 9,000 practitioners in all 50 states.\\nAcupressure is practiced as a treatment by Chinese\\nmedicine practitioners and acupuncturists, as well as by\\nmassage therapists. Most massage schools in American\\ninclude acupressure techniques as part of their bodywork\\nprograms. Shiatsu massage is very closely related to acu-\\npressure, working with the same points on the body and\\nthe same general principles, although it was developed\\nover centuries in Japan rather than in China. Reflexology\\nis a form of bodywork based on acupressure concepts.\\nJin Shin Do is a bodywork technique with an increasing\\nnumber of practitioners in America that combines acu-\\npressure and shiatsu principles with qigong, Reichian\\ntheory, and meditation.\\nAcupressure and Chinese medicine\\nChinese medicine views the body as a small part of\\nthe universe, subject to laws and principles of harmony\\nand balance. Chinese medicine does not make as sharp a\\ndestinction as Western medicine does between mind and\\nbody. The Chinese system believes that emotions and\\nmental states are every bit as influential on disease as\\npurely physical mechanisms, and considers factors like\\nwork, environment, and relationships as fundamental to a\\npatient’s health. Chinese medicine also uses very different\\nsymbols and ideas to discuss the body and health. While\\nWestern medicine typically describes health as mainly\\nphysical processes composed of chemical equations and\\nreactions, the Chinese use ideas like yin and yang, chi,\\nand the organ system to describe health and the body.\\nEverything in the universe has properties of yin and\\nyang. Yin is associated with cold, female, passive, down-\\nward, inward, dark, wet. Yang can be described as hot,\\nmale, active, upward, outward, light, dry, and so on.\\nNothing is either completely yin or yang. These two prin-\\nciples always interact and affect each other, although the\\nbody and its organs can become imbalanced by having\\neither too much or too little of either.\\nChi (pronounced chee, also spelled qi or ki in Japan-\\nese shiatsu) is the fundamental life energy. It is found in\\nfood, air, water, and sunlight, and it travels through the\\nbody in channels called meridians . There are 12 major\\nGALE ENCYCLOPEDIA OF MEDICINE 2 37\\nAcupressure\\n/K47/K6F/K76/K65/K72/K6E/K69/K6E/K67 /K76/K65/K73/K73/K65/K6C /K32/K34/K2E/K35\\n/K4C/K75/K6E/K67 /K31/K30\\n/K53/K74/K6F/K6D/K61/K63/K68 /K33/K36\\nAcupressure points to relieve hay fever, sore throat, and\\nheartburn. (Illustration by Electronic Illustrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 37'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 51, 'page_label': '52'}, page_content='meridians in the body that transport chi, corresponding to\\nthe 12 main organs categorized by Chinese medicine.\\nDisease is viewed as an imbalance of the organs and\\nchi in the body. Chinese medicine has developed intri-\\ncate systems of how organs are related to physical and\\nmental symptoms, and it has devised corresponding\\ntreatments using the meridian and pressure point net-\\nworks that are classified and numbered. The goal of acu-\\npressure, and acupuncture, is to stimulate and unblock\\nthe circulation of chi, by activating very specific points,\\ncalled pressure points or acupoints . Acupressure seeks\\nto stimulate the points on the chi meridians that pass\\nclose to the skin, as these are easiest to unblock and\\nmanipulate with finger pressure.\\nAcupressure can be used as part of a Chinese\\nphysician’s prescription, as a session of massage ther-\\napy, or as a self-treatment for common aches and ill-\\nnesses. A Chinese medicine practitioner examines a\\npatient very thoroughly, looking at physical, mental and\\nemotional activity, taking the pulse usually at the\\nwrists, examining the tongue and complexion, and\\nobserving the patient’s demeanor and attitude, to get a\\ncomplete diagnosis of which organs and meridian\\npoints are out of balance. When the imbalance is locat-\\ned, the physician will recommend specific pressure\\npoints for acupuncture or acupressure. If acupressure is\\nrecommended, the patient might opt for a series of\\ntreatments from a massage therapist.\\nIn massage therapy, acupressurists will evaluate a\\npatient’s symptoms and overall health, but a massage\\ntherapist’s diagnostic training isn’t as extensive as a\\nChinese physician’s. In a massage therapy treatment, a\\nperson usually lies down on a table or mat, with thin\\nclothing on. The acupressurist will gently feel and pal-\\npate the abdomen and other parts of the body to deter-\\nKEY TERMS\\nAcupoint —A pressure point stimulated in acu-\\npressure.\\nChi—Basic life energy.\\nMeridian—A channel through which chi travels in\\nthe body.\\nMoxibustion —An acupuncture technique that\\nburns the herb moxa or mugwort.\\nShiatsu—Japanese form of acupressure massage.\\nYin/yang—Universal characteristics used to des-\\ncribe aspects of the natural world.\\nmine energy imbalances. Then, the therapist will work\\nwith different meridians throughout the body, depend-\\ning on which organs are imbalanced in the abdomen.\\nThe therapist will use different types of finger move-\\nments and pressure on different acupoints, depending\\non whether the chi needs to be increased or dispersed at\\ndifferent points. The therapist observes and guides the\\nenergy flow through the patient’s body throughout the\\nsession. Sometimes, special herbs ( Artemesia vulgaris\\nor moxa) may be placed on a point to warm it, a process\\ncalled moxibustion. A session of acupressure is general-\\nly a very pleasant experience, and some people experi-\\nence great benefit immediately. For more chronic con-\\nditions, several sessions may be necessary to relieve\\nand improve conditions.\\nAcupressure massage usually costs from $30–70 per\\nhour session. A visit to a Chinese medicine physician or\\nacupuncturist can be more expensive, comparable to a\\nvisit to an allopathic physician if the practitioner is an\\nMD. Insurance reimbursement varies widely, and con-\\nsumers should be aware if their policies cover alternative\\ntreatment, acupuncture, or massage therapy.\\nSelf-treatment\\nAcupressure is easy to learn, and there are many\\ngood books that illustrate the position of acupoints and\\nmeridians on the body. It is also very versatile, as it can\\nbe done anywhere, and it’s a good form of treatment for\\nspouses and partners to give to each other and for parents\\nto perform on children for minor conditions.\\nWhile giving self-treatment or performing acupressure\\non another, a mental attitude of calmness and attention is\\nimportant, as one person’s energy can be used to help\\nanother’s. Loose, thin clothing is recommended. There are\\nthree general techniques for stimulating a pressure point.\\n• Tonifying is meant to strengthen weak chi, and is done\\nby pressing the thumb or finger into an acupoint with a\\nfirm, steady pressure, holding it for up to two minutes.\\n• Dispersing is meant to move stagnant or blocked chi,\\nand the finger or thumb is moved in a circular motion or\\nslightly in and out of the point for two minutes.\\n• Calming the chi in a pressure point utilizes the palm to\\ncover the point and gently stroke the area for about two\\nminutes.\\nThere are many pressure points that are easily found\\nand memorized to treat common ailments from headaches\\nto colds.\\n• For headaches, toothaches, sinus problems, and pain in\\nthe upper body, the “LI4” point is recommended. It is\\nlocated in the web between the thumb and index finger,\\non the back of the hand. Using the thumb and index fin-\\nger of the other hand, apply a pinching pressure until\\nGALE ENCYCLOPEDIA OF MEDICINE 238\\nAcupressure\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 38'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 52, 'page_label': '53'}, page_content='the point is felt, and hold it for two minutes. Pregnant\\nwomen should never press this point.\\n• To calm the nerves and stimulate digestion, find the\\n“CV12” point that is four thumb widths above the navel\\nin the center of the abdomen. Calm the point with the\\npalm, using gentle stroking for several minutes.\\n• To stimulate the immune system, find the “TH5” point\\non the back of the forearm two thumb widths above the\\nwrist. Use a dispersing technique, or circular pressure\\nwith the thumb or finger, for two minutes on each arm.\\n• For headaches, sinus congestion, and tension, locate the\\n“GB20” points at the base of the skull in the back of the\\nhead, just behind the bones in back of the ears. Disperse\\nthese points for two minutes with the fingers or thumbs.\\nAlso find the “yintang” point, which is in the middle of\\nthe forehead between the eyebrows. Disperse it with\\ngentle pressure for two minutes to clear the mind and to\\nrelieve headaches.\\nPrecautions\\nAcupressure is a safe technique, but it is not meant to\\nreplace professional health care. A physician should\\nalways be consulted when there are doubts about medical\\nconditions. If a condition is chronic, a professional should\\nbe consulted; purely symptomatic treatment can exacer-\\nbate chronic conditions. Acupressure should not be\\napplied to open wounds, or where there is swelling and\\ninflammation. Areas of scar tissue, blisters,boils, rashes,\\nor varicose veins should be avoided. Finally, certain acu-\\npressure points should not be stimulated on people with\\nhigh or low blood pressure and on pregnant women.\\nResearch and general acceptance\\nIn general, Chinese medicine has been slow to gain\\nacceptance in the West, mainly because it rests on ideas\\nvery foreign to the scientific model. For instance, West-\\nern scientists have trouble with the idea of chi, the invisi-\\nble energy of the body, and the idea that pressing on cer-\\ntain points can alleviate certain conditions seems some-\\ntimes too simple for scientists to believe.\\nWestern scientists, in trying to account for the action\\nof acupressure, have theorized that chi is actually part of\\nthe neuroendocrine system of the body. Celebrated ortho-\\npedic surgeon Robert O. Becker, who was twice nominated\\nfor the Nobel Prize, wrote a book on the subject called\\nCross Currents: The Promise of Electromedicine; The Per-\\nils of Electropollution. By using precise electrical measur-\\ning devices, Becker and his colleagues showed that the\\nbody has a complex web of electromagnetic energy, and\\nthat traditional acupressure meridians and points contained\\namounts of energy that non-acupressure points did not.\\nThe mechanisms of acupuncture and acupressure\\nremain difficult to document in terms of the biochemical\\nprocesses involved; numerous testimonials are the prima-\\nry evidence backing up the effectiveness of acupressure\\nand acupuncture. However, a body of research is growing\\nthat verifies the effectiveness in acupressure and\\nacupuncture techniques in treating many problems and in\\ncontrolling pain.\\nResources\\nBOOKS\\nJarmey, Chris and John Tindall. Acupressure for Common Ail-\\nments. London: Gaia, 1991.\\nKakptchuk, Ted. The Web That Has No Weaver: Understanding\\nChinese Medicine. New York: Congdon and Weed, 1983.\\nWarren, Frank Z., MD. Freedom From Pain Through Acupres-\\nsure. New York: Fell, 1976.\\nPERIODICALS\\nMassage Therapy Journal. 820 Davis Street, Suite 100,\\nEvanston, IL 60201-4444.\\nOTHER\\nAmerican Association of Oriental Medicine. (December 28, 2000).\\nNational Acupuncture and Oriental Medicine Alliance. (December 28, 2000).\\nDouglas Dupler\\nAcupressure, foot see Reflexology\\nAcupuncture\\nDefinition\\nAcupuncture is one of the main forms of treatment in\\ntraditional Chinese medicine . It involves the use of\\nsharp, thin needles that are inserted in the body at very\\nspecific points. This process is believed to adjust and alter\\nthe body’s energy flow into healthier patterns, and is used\\nto treat a wide variety of illnesses and health conditions.\\nPurpose\\nThe World Health Organization (WHO) recommends\\nacupuncture as an effective treatment for over forty med-\\nical problems, including allergies, respiratory conditions,\\ngastrointestinal disorders, gynecological problems, ner-\\nvous conditions, and disorders of the eyes, nose and\\nthroat, and childhood illnesses, among others. Acupunc-\\nture has been used in the treatment of alcoholism and\\nsubstance abuse. It is an effective and low-cost treatment\\nGALE ENCYCLOPEDIA OF MEDICINE 2 39\\nAcupuncture\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 39'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 53, 'page_label': '54'}, page_content='for headaches and chronic pain, associated with problems\\nlike back injuries and arthritis. It has also been used to\\nsupplement invasive Western treatments like chemother-\\napy and surgery. Acupuncture is generally most effective\\nwhen used as prevention or before a health condition\\nbecomes acute, but it has been used to help patients suf-\\nfering from cancer and AIDS. Acupuncture is limited in\\ntreating conditions or traumas that require surgery or\\nemergency care (such as for broken bones).\\nDescription\\nOrigins\\nThe original text of Chinese medicine is the Nei\\nChing, The Yellow Emperor’s Classic of Internal Medi-\\ncine, which is estimated to be at least 2,500 years old.\\nThousands of books since then have been written on the\\nsubject of Chinese healing, and its basic philosophies\\nspread long ago to other Asian civilizations. Nearly all of\\nthe forms of Oriental medicine which are used in the West\\ntoday, including acupuncture, shiatsu, acupressure mas-\\nsage, and macrobiotics, are part of or have their roots in\\nChinese medicine. Legend has it that acupuncture devel-\\noped when early Chinese physicians observed unpredict-\\ned effects of puncture wounds in Chinese warriors. The\\noldest known text on acupuncture, the Systematic Classic\\nof Acupuncture, dates back to 282 \\nA.D. Although acupunc-\\nture is its best known technique, Chinese medicine tradi-\\ntionally utilizes herbal remedies, dietary therapy, lifestyle\\nchanges and other means to treat patients.\\nIn the early 1900s, only a few Western physicians\\nwho had visited China were fascinated by acupuncture,\\nbut outside of Asian-American communities it remained\\nvirtually unknown until the 1970s, when Richard Nixon\\nbecame the first U.S. president to visit China. On Nixon’s\\ntrip, journalists were amazed to observe major operations\\nbeing performed on patients without the use of anesthetics.\\nInstead, wide-awake patients were being operated on with\\nonly acupuncture needles inserted into them to control\\npain. During that time, a famous columnist for the New\\nYork Times, James Reston, had to undergo surgery and\\nelected to use acupuncture instead of pain medication, and\\nhe wrote some convincing stories on its effectiveness.\\nToday acupuncture is being practiced in all 50 states\\nby over 9,000 practitioners, with over 4,000 MDs includ-\\ning it in their practices. Acupuncture has shown notable\\nsuccess in treating many conditions, and over 15 million\\nAmericans have used it as a therapy. Acupuncture, how-\\nGALE ENCYCLOPEDIA OF MEDICINE 240\\nAcupuncture\\nWoman undergoing facial acupuncture.(Photograph by Y oav Levy. Phototake NYC. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 40'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 54, 'page_label': '55'}, page_content='ever, remains largely unsupported by the medical estab-\\nlishment. The American Medical Association has been\\nresistant to researching it, as it is based on concepts very\\ndifferent from the Western scientific model.\\nSeveral forms of acupuncture are being used today in\\nAmerica. Japanese acupuncture uses extremely thin nee-\\ndles and does not incorporate herbal medicine in its prac-\\ntice. Auricular acupuncture uses acupuncture points only\\non the ear, which are believed to stimulate and balance\\ninternal organs. In France, where acupuncture is very pop-\\nular and more accepted by the medical establishment, neu-\\nrologist Paul Nogier developed a system of acupuncture\\nbased on neuroendocrine theory rather than on traditional\\nChinese concepts, which is gaining some use in America.\\nBasic ideas of Chinese medicine\\nChinese medicine views the body as a small part of\\nthe universe, and subject to universal laws and principles\\nof harmony and balance. Chinese medicine does not\\ndraw a sharp line, as Western medicine does, between\\nmind and body. The Chinese system believes that emo-\\ntions and mental states are every bit as influential on dis-\\nease as purely physical mechanisms, and considers fac-\\ntors like work, environment, lifestyle and relationships as\\nfundamental to the overall picture of a patient’s health.\\nChinese medicine also uses very different symbols and\\nideas to discuss the body and health. While Western med-\\nicine typically describes health in terms of measurable\\nphysical processes made up of chemical reactions, the\\nChinese use ideas like yin and yang, chi, the organ sys-\\ntem, and the five elements to describe health and the\\nbody. To understand the ideas behind acupuncture, it is\\nworthwhile to introduce some of these basic terms.\\nYIN AND YANG. According to Chinese philosophy,\\nthe universe and the body can be described by two sepa-\\nrate but complementary principles, that of yin and yang.\\nFor example, in temperature, yin is cold and yang is hot.\\nIn gender, yin is female and yang is male. In activity, yin\\nis passive and yang is active. In light, yin is dark and\\nyang is bright; in direction yin is inward and downward\\nand yang is outward and up, and so on. Nothing is ever\\ncompletely yin or yang, but a combination of the two.\\nThese two principles are always interacting, opposing,\\nand influencing each other. The goal of Chinese medi-\\ncine is not to eliminate either yin or yang, but to allow\\nthe two to balance each other and exist harmoniously\\ntogether. For instance, if a person suffers from symptoms\\nGALE ENCYCLOPEDIA OF MEDICINE 2 41\\nAcupuncture\\nConception vessel\\nStomach meridian\\nLarge intestine meridian\\nGallbladder meridian\\nGovernor vessel\\nBladder meridian\\nTriple burner meridian\\nSmall intestine meridian\\nAcupuncture sites and meridians on the face and neck.(Illustration by Hans & Cassady.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 41'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 55, 'page_label': '56'}, page_content='of high blood pressure, the Chinese system would say\\nthat the heart organ might have too much yang, and\\nwould recommend methods either to reduce the yang or\\nto increase the yin of the heart, depending on the other\\nsymptoms and organs in the body. Thus, acupuncture\\ntherapies seek to either increase or reduce yang, or\\nincrease or reduce yin in particular regions of the body.\\nCHI. Another fundamental concept of Chinese med-\\nicine is that of chi (pronounced chee, also spelled qi). Chi\\nis the fundamental life energy of the universe. It is invisi-\\nble and is found in the environment in the air, water, food\\nand sunlight. In the body, it is the invisible vital force\\nthat creates and animates life. We are all born with inher-\\nited amounts of chi, and we also get acquired chi from\\nthe food we eat and the air we breathe. The level and\\nquality of a person’s chi also depends on the state of\\nphysical, mental and emotional balance. Chi travels\\nthrough the body along channels called meridians.\\nTHE ORGAN SYSTEM. In the Chinese system, there\\nare twelve main organs: the lung, large intestine, stom-\\nach, spleen, heart, small intestine, urinary bladder, kid-\\nney, liver, gallbladder, pericardium, and the “triple\\nwarmer,” which represents the entire torso region. Each\\norgan has chi energy associated with it, and each organ\\ninteracts with particular emotions on the mental level. As\\nthere are twelve organs, there are twelve types of chi\\nwhich can move through the body, and these move\\nthrough twelve main channels or meridians. Chinese\\ndoctors connect symptoms to organs. That is, symptoms\\nare caused by yin/yang imbalances in one or more\\norgans, or by an unhealthy flow of chi to or from one\\nKEY TERMS\\nAcupressure —Form of massage using acupunc-\\nture points.\\nAuricular acupuncture —Acupuncture using only\\npoints found on the ears.\\nChi—Basic life energy.\\nMeridian —Channel through which chi travels in\\nthe body.\\nMoxibustion —Acupuncture technique which\\nburns the herb moxa or mugwort.\\nTonification—Acupuncture technique for strength-\\nening the body.\\nYin/Yang—Universal characteristics used to des-\\ncribe aspects of the natural world.\\norgan to another. Each organ has a different profile of\\nsymptoms it can manifest.\\nTHE FIVE ELEMENTS. Another basis of Chinese theo-\\nry is that the world and body are made up of five main\\nelements: wood, fire, earth, metal, and water. These ele-\\nments are all interconnected, and each element either\\ngenerates or controls another element. For instance,\\nwater controls fire and earth generates metal. Each organ\\nis associated with one of the five elements. The Chinese\\nsystem uses elements and organs to describe and treat\\nconditions. For instance, the kidney is associated with\\nwater and the heart is associated with fire, and the two\\norgans are related as water and fire are related. If the kid-\\nney is weak, then there might be a corresponding fire\\nproblem in the heart, so treatment might be made by\\nacupuncture or herbs to cool the heart system and/or\\nincrease energy in the kidney system.\\nThe Chinese have developed an intricate system of\\nhow organs and elements are related to physical and\\nmental symptoms, and the above example is a very sim-\\nple one. Although this system sounds suspect to Western\\nscientists, some interesting parallels have been observed.\\nFor instance, Western medicine has observed that with\\nsevere heart problems, kidney failure often follows, but it\\nstill does not know exactly why. In Chinese medicine,\\nthis connection between the two organs has long been\\nestablished.\\nMEDICAL PROBLEMS AND ACUPUNCTURE. In Chi-\\nnese medicine, disease as seen as imbalances in the organ\\nsystem or chi meridians, and the goal of any remedy or\\ntreatment is to assist the body in reestablishing its innate\\nharmony. Disease can be caused by internal factors like\\nemotions, external factors like the environment and\\nweather, and other factors like injuries, trauma, diet, and\\ngerms. However, infection is seen not as primarily a\\nproblem with germs and viruses, but as a weakness in the\\nenergy of the body which is allowing a sickness to occur.\\nIn Chinese medicine, no two illnesses are ever the same,\\nas each body has its own characteristics of symptoms and\\nbalance. Acupuncture is used to open or adjust the flow\\nof chi throughout the organ system, which will strength-\\nen the body and prompt it to heal itself.\\nA VISIT TO THE ACUPUNCTURIST. The first thing an\\nacupuncturist will do is get a thorough idea of a patient’s\\nmedical history and symptoms, both physical and emo-\\ntional. This is done with a long questionnaire and inter-\\nview. Then the acupuncturist will examine the patient to\\nfind further symptoms, looking closely at the tongue, the\\npulse at various points in the body, the complexion, gen-\\neral behavior, and other signs like coughs or pains. From\\nthis, the practitioner will be able to determine patterns of\\nsymptoms which indicate which organs and areas are\\nGALE ENCYCLOPEDIA OF MEDICINE 242\\nAcupuncture\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 42'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 56, 'page_label': '57'}, page_content='imbalanced. Depending on the problem, the acupunctur-\\nist will insert needles to manipulate chi on one or more\\nof the twelve organ meridians. On these twelve meridi-\\nans, there are nearly 2,000 points which can be used in\\nacupuncture, with around 200 points being most fre-\\nquently used by traditional acupuncturists. During an\\nindividual treatment, one to twenty needles may be used,\\ndepending on which meridian points are chosen.\\nAcupuncture needles are always sterilized and\\nacupuncture is a very safe procedure. The depth of inser-\\ntion of needles varies, depending on which chi channels are\\nbeing treated. Some points barely go beyond superficial\\nlayers of skin, while some acupuncture points require a\\ndepth of 1-3 in (2.5-7.5 cm) of needle. The needles general-\\nly do not cause pain. Patients sometimes report pinching\\nsensations and often pleasant sensations, as the body expe-\\nriences healing. Depending on the problem, the acupunc-\\nturist might spin or move the needles, or even pass a slight\\nelectrical current through some of them. Moxibustion may\\nbe sometimes used, in which an herbal mixture (moxa or\\nmugwort) is either burned like incense on the acupuncture\\npoint or on the end of the needle, which is believed to stim-\\nulate chi in a particular way. Also, acupuncturists some-\\ntimes use cupping, during which small suction cups are\\nplaced on meridian points to stimulate them.\\nHow long the needles are inserted also varies. Some\\npatients only require a quick in and out insertion to clear\\nproblems and provide tonification (strengthening of\\nhealth), while some other conditions might require nee-\\ndles inserted up to an hour or more. The average visit to\\nan acupuncturist takes about thirty minutes. The number\\nof visits to the acupuncturist varies as well, with some\\nconditions improved in one or two sessions and others\\nrequiring a series of six or more visits over the course of\\nweeks or months.\\nCosts for acupuncture can vary, depending on whether\\nthe practitioner is an MD. Initial visits with non-MD\\nacupuncturists can run from $50-$100, with follow-up vis-\\nits usually costing less. Insurance reimbursement also\\nvaries widely, depending on the company and state. Regu-\\nlations have been changing often. Some states authorize\\nMedicaid to cover acupuncture for certain conditions, and\\nsome states have mandated that general coverage pay for\\nacupuncture. Consumers should be aware of the provisions\\nfor acupuncture in their individual policies.\\nPrecautions\\nAcupuncture is generally a very safe procedure. If a\\npatient is in doubt about a medical condition, more than\\none physician should be consulted. Also, a patient should\\nalways feel comfortable and confident that their\\nacupuncturist is knowledgable and properly trained.\\nResearch and general acceptance\\nMainstream medicine has been slow to accept acupunc-\\nture; although more MDs are using it, the American Medical\\nAssociation does not recognize it as a specialty. The reason\\nfor this is that the mechanism of acupuncture is difficult to\\nscientifically understand or measure, such as the invisible\\nenergy of chi in the body. Western medicine, admitting that\\nacupuncture works in many cases, has theorized that the\\nenergy meridians are actually part of the nervous system and\\nthat acupuncture relieves pain by releasing endorphins, or\\nnatural pain killers, into the bloodstream. Despite the ambi-\\nguity in the biochemistry involved, acupuncture continues to\\nshow effectiveness in clinical tests, from reducing pain to\\nalleviating the symptoms of chronic illnesses, and research\\nin acupuncture is currently growing. The Office of Alterna-\\ntive Medicine of the National Institute of Health is currently\\nfunding research in the use of acupuncture for treating\\ndepression and attention-deficit disorder.\\nResources\\nBOOKS\\nFleischman, Dr. Gary F. Acupuncture: Everything You Ever\\nWanted To Know.New York: Barrytown, 1998.\\nKakptchuk, Ted. The Web That Has No Weaver: Understanding\\nChinese Medicine. New York: Congdon and Weed, 1983.\\nRequena, Yves, MD. Terrains and Pathology in Acupuncture.\\nMassachusetts: Paradigm, 1986.\\nPERIODICALS\\nAmerican Journal of Acupuncture.1840 41st Ave., Suite 102,\\nP.O. Box 610, Capitola, CA 95010.\\nOTHER\\nAmerican Association of Oriental Medicine. (December 28, 2000).\\nNorth American Society of Acupuncture and Alternative Medi-\\ncine. (December 28, 2000).\\nDouglas Dupler\\nAcute glomerulonephritis see Acute\\npoststreptococcal glomerulonephritis\\nAcute homeopathic remedies see\\nHomeopathic remedies, acute\\nprescribing\\nAcute kidney failure\\nDefinition\\nAcute kidney failure occurs when illness, infection,\\nor injury damages the kidneys. Temporarily, the kidneys\\nGALE ENCYCLOPEDIA OF MEDICINE 2 43\\nAcute kidney failure\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 43'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 57, 'page_label': '58'}, page_content='cannot adequately remove fluids and wastes from the\\nbody or maintain the proper level of certain kidney-regu-\\nlated chemicals in the bloodstream.\\nDescription\\nThe kidneys are the body’s natural filtration system.\\nThey perform the critical task of processing approximate-\\nly 200 quarts of fluid in the bloodstream every 24 hours.\\nWaste products like urea and toxins, along with excess\\nfluids, are removed from the bloodstream in the form of\\nurine. Kidney (or renal) failure occurs when kidney func-\\ntioning becomes impaired. Fluids and toxins begin to\\naccumulate in the bloodstream. As fluids build up in the\\nbloodstream, the patient with acute kidney failure may\\nbecome puffy and swollen (edematous) in the face, hands,\\nand feet. Their blood pressure typically begins to rise, and\\nthey may experience fatigue and nausea.\\nUnlike chronic kidney failure , which is long term\\nand irreversible, acute kidney failure is a temporary con-\\ndition. With proper and timely treatment, it can typically\\nbe reversed. Often there is no permanent damage to the\\nkidneys. Acute kidney failure appears most frequently as\\na complication of serious illness, like heart failure,l i v e r\\nfailure, dehydration, severe burns, and excessive bleed-\\ning (hemorrhage). It may also be caused by an obstruc-\\ntion to the urinary tract or as a direct result of kidney dis-\\nease, injury, or an adverse reaction to a medicine.\\nCauses and symptoms\\nAcute kidney failure can be caused by many differ-\\nent illnesses, injuries, and infections. These conditions\\nfall into three main categories: prerenal, postrenal, and\\nintrarenal conditions.\\nPrerenal conditions do not damage the kidney, but\\ncan cause diminished kidney function. They are the most\\ncommon cause of acute renal failure, and include:\\n• dehydration\\n• hemorrhage\\n• septicemia, or sepsis\\n• heart failure\\n• liver failure\\n• burns\\nPostrenal conditions cause kidney failure by obstruct-\\ning the urinary tract. These conditions include:\\n• inflammation of the prostate gland in men (prostatitis)\\n• enlargement of the prostate gland (benign prostatic\\nhypertrophy)\\n• bladder or pelvic tumors\\n• kidney stones (calculi)\\nIntrarenal conditions involve kidney disease or\\ndirect injury to the kidneys. These conditions include:\\n• lack of blood supply to the kidneys (ischemia)\\n• use of radiocontrast agents in patients with kidney\\nproblems\\n• drug abuse or overdose\\n• long-term use of nephrotoxic medications, like certain\\npain medicines\\n• acute inflammation of the glomeruli, or filters, of the\\nkidney (glomerulonephritis)\\n• kidney infections (pyelitis or pyelonephritis)\\nCommon symptoms of acute kidney failure include:\\n• anemia. The kidneys are responsible for producing ery-\\nthropoietin (EPO), a hormone that stimulates red blood\\ncell production. If kidney disease causes shrinking of\\nthe kidney, red blood cell production is reduced, lead-\\ning to anemia.\\n• bad breath or bad taste in mouth. Urea in the saliva may\\ncause an ammonia-like taste in the mouth.\\n• bone and joint problems. The kidneys produce vitamin\\nD, which helps the body absorb calcium and keeps\\nbones strong. For patients with kidney failure, bones\\nmay become brittle. In children, normal growth may be\\nstunted. Joint pain may also occur as a result of high\\nphosphate levels in the blood. Retention of uric acid\\nmay cause gout.\\n• edema. Puffiness or swelling in the arms, hands, feet,\\nand around the eyes.\\n• frequent urination.\\n• foamy or bloody urine. Protein in the urine may cause it\\nto 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. This\\nmakes blood pressure rise.\\n• increased fatigue. Toxic substances in the blood and the\\npresence of anemia may cause the patient to feel\\nexhausted.\\n• itching. Phosphorus, normally eliminated in the urine,\\naccumulates in the blood of patients with kidney failure.\\nAn increased phosphorus level may cause the skin to itch.\\n• lower back pain. Patients suffering from certain kidney\\nproblems (like kidney stones and other obstructions)\\nmay have pain where the kidneys are located, in the\\nsmall of the back below the ribs.\\n• nausea. Urea in the gastric juices may cause upset\\nstomach.\\nGALE ENCYCLOPEDIA OF MEDICINE 244\\nAcute kidney failure\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 44'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 58, 'page_label': '59'}, page_content='Diagnosis\\nKidney failure is diagnosed by a doctor. A nephrolo-\\ngist, a doctor that specializes in the kidney, may be con-\\nsulted to confirm the diagnosis and recommend treat-\\nment options. The patient that is suspected of having\\nacute kidney failure will have blood and urine tests to\\ndetermine the level of kidney function. A blood test will\\nassess the levels of creatinine, blood urea nitrogen\\n(BUN), uric acid, phosphate, sodium, and potassium.\\nThe kidney regulates these agents in the blood. Urine\\nsamples will also be collected, usually over a 24-hour\\nperiod, to assess protein loss and/or creatinine clearance.\\nDetermining the cause of kidney failure is critical to\\nproper treatment. A full assessment of the kidneys is neces-\\nsary to determine if the underlying disease is treatable and if\\nthe kidney failure is chronic or acute. X rays,magnetic res-\\nonance imaging(MRI), computed tomography scan (CT),\\nultrasound, renal biopsy, and/or arteriogram of the kidneys\\nmay be used to determine the cause of kidney failure and\\nlevel of remaining kidney function. X rays and ultrasound\\nof the bladder and/or ureters may also be needed.\\nTreatment\\nTreatment for acute kidney failure varies. Treatment\\nis directed to the underlying, primary medical condition\\nthat has triggered kidney failure. Prerenal conditions may\\nbe treated with replacement fluids given through a vein,\\ndiuretics, blood transfusion , or medications. Postrenal\\nconditions and intrarenal conditions may require surgery\\nand/or medication.\\nFrequently, patients in acute kidney failure require\\nhemodialysis, hemofiltration, or peritoneal dialysis to fil-\\nter fluids and wastes from the bloodstream until the pri-\\nmary medical condition can be controlled.\\nHemodialysis\\nHemodialysis involves circulating the patient’s\\nblood outside of the body through an extracorporeal cir-\\ncuit (ECC), or dialysis circuit. The ECC is made up of\\nplastic blood tubing, a filter known as a dialyzer (or arti-\\nficial kidney), and a dialysis machine that monitors and\\nmaintains blood flow and administers dialysate.\\nDialysate is a sterile chemical solution that is used to\\ndraw waste products out of the blood. The patient’s blood\\nleaves the body through the vein and travels through the\\nECC and the dialyzer, where fluid removal takes place.\\nDuring dialysis, waste products in the bloodstream\\nare carried out of the body. At the same time, electrolytes\\nand other chemicals are added to the blood. The purified,\\nchemically-balanced blood is then returned to the body.\\nKEY TERMS\\nBlood urea nitrogen (BUN)—A waste product that\\nis formed in the liver and collects in the blood-\\nstream; patients with kidney failure have high\\nBUN levels.\\nCreatinine —A protein produced by muscle that\\nhealthy kidneys filter out.\\nExtracorporeal —Outside of, or unrelated to, the\\nbody.\\nIschemia—A lack of blood supply to an organ or\\ntissue.\\nNephrotoxic—Toxic, or damaging, to the kidney.\\nRadiocontrast agents —Dyes administered to a\\npatient for the purposes of a radiologic study.\\nSepsis—A bacterial infection of the bloodstream.\\nVasopressors—Medications that constrict the blood\\nvessels.\\nA dialysis “run” typically lasts three to four hours,\\ndepending on the type of dialyzer used and the physical\\ncondition of the patient. Dialysis is used several times a\\nweek until acute kidney failure is reversed.\\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.\\nHemofiltration\\nHemofiltration, also called continuous renal replace-\\nment therapy (CRRT), is a slow, continuous blood filtra-\\ntion therapy used to control acute kidney failure in criti-\\ncally ill patients. These patients are typically very sick\\nand may have heart problems or circulatory problems.\\nThey cannot handle the rapid filtration rates of hemodial-\\nysis. They also frequently need antibiotics , nutrition ,\\nvasopressors, and other fluids given through a vein to\\ntreat their primary condition. Because hemofiltration is\\ncontinuous, prescription fluids can be given to patients in\\nkidney failure without the risk of fluid overload.\\nLike hemodialysis, hemofiltration uses an ECC. A\\nhollow fiber hemofilter is used instead of a dialyzer to\\nremove fluids and toxins. Instead of a dialysis machine, a\\nblood pump makes the blood flow through the ECC. The\\nvolume of blood circulating through the ECC in hemofil-\\ntration is less than that in hemodialysis. Filtration rates\\nare slower and gentler on the circulatory system.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 45\\nAcute kidney failure\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 45'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 59, 'page_label': '60'}, page_content='Hemofiltration treatment will generally be used until kid-\\nney failure is reversed.\\nPeritoneal dialysis\\nPeritoneal dialysis may be used if an acute kidney\\nfailure patient is stable and not in immediate crisis. In\\nperitoneal dialysis (PD), the lining of the patient’s\\nabdomen, the peritoneum, acts as a blood filter. A flexible\\ntube-like instrument (catheter) is surgically inserted into\\nthe patient’s abdomen. During treatment, the catheter is\\nused to fill the abdominal cavity with dialysate. Waste\\nproducts and excess fluids move from the patient’s blood-\\nstream into the dialysate solution. After a certain time\\nperiod, the waste-filled dialysate is drained from the\\nabdomen, and replaced with clean dialysate. There are\\nthree type of peritoneal dialysis, which vary according to\\ntreatment time and administration method.\\nPeritoneal dialysis is often the best treatment option\\nfor infants and children. Their small size can make vein\\naccess difficult to maintain. It is not recommended for\\npatients with abdominal adhesions or other abdominal\\ndefects (like a hernia) that might reduce the efficiency of\\nthe treatment. It is also not recommended for patients\\nwho suffer frequent bouts of an inflammation of the\\nsmall pouches in the intestinal tract (diverticulitis).\\nPrognosis\\nBecause many of the illnesses and underlying con-\\nditions that often trigger acute kidney failure are critical,\\nthe prognosis for these patients many times is not good.\\nStudies have estimated overall death rates for acute kid-\\nney failure at 42-88%. Many people, however, die\\nbecause of the primary disease that has caused the kid-\\nney failure. These figures may also be misleading\\nbecause patients who experience kidney failure as a\\nresult of less serious illnesses (like kidney stones or\\ndehydration) have an excellent chance of complete\\nrecovery. Early recognition and prompt, appropriate\\ntreatment are key to patient recovery.\\nUp to 10% of patients who experience acute kidney\\nfailure will suffer irreversible kidney damage. They will\\neventually go on to develop chronic kidney failure or\\nend-stage renal disease. These patients will require long-\\nterm dialysis or kidney transplantation to replace their\\nlost renal functioning.\\nPrevention\\nSince acute kidney failure can be caused by many\\nthings, prevention is difficult. Medications that may\\nimpair kidney function should be given cautiously.\\nPatients with pre-existing kidney conditions who are\\nhospitalized for other illnesses or injuries should be care-\\nfully monitored for kidney failure complications. Treat-\\nments and procedures that may put them at risk for kid-\\nney failure (like diagnostic tests requiring radiocontrast\\nagents or dyes) should be used with extreme caution.\\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. Stewart. Kidney Failure: The Facts.New York:\\nOxford University Press, 1996.\\nRoss, Linda M., ed. Kidney and Urinary Tract Diseases and\\nDisorders Sourcebook.V ol. 21. Detroit: Omnigraphics,\\nInc., 1997.\\nPERIODICALS\\nStark, June. “Dialysis Choices: Turning the Tide in Acute\\nRenal Failure.”Nursing 27, no. 2 (Feb. 1997): 41-8.\\nORGANIZATIONS\\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. .\\nPaula Anne Ford-Martin\\nAcute leukemias see Leukemias, acute\\nAcute lymphangitis\\nDefinition\\nAcute lymphangitis is a bacterial infection in the\\nlymphatic vessels which is characterized by painful, red\\nstreaks below the skin surface. This is a potentially seri-\\nous infection which can rapidly spread to the blood-\\nstream and be fatal.\\nDescription\\nAcute lymphangitis affects a critical member of the\\nimmune system—the lymphatic system. Waste materials\\nfrom nearly every organ in the body drain into the lym-\\nphatic vessels and are filtered in small organs called\\nlymph nodes. Foreign bodies, such as bacteria or viruses,\\nare processed in the lymph nodes to generate an immune\\nresponse to fight an infection.\\nGALE ENCYCLOPEDIA OF MEDICINE 246\\nAcute lymphangitis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 46'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 60, 'page_label': '61'}, page_content='In acute lymphangitis, bacteria enter the body\\nthrough a cut, scratch, insect bite, surgical wound, or\\nother skin injury. Once the bacteria enter the lymphatic\\nsystem, they multiply rapidly and follow the lymphatic\\nvessel like a highway. The infected lymphatic vessel\\nbecomes inflamed, causing red streaks that are visible\\nbelow the skin surface. The growth of the bacteria occurs\\nso rapidly that the immune system does not respond fast\\nenough to stop the infection.\\nIf left untreated, the bacteria can cause tissue\\ndestruction in the area of the infection. A pus-filled,\\npainful lump called an abscess may be formed in the\\ninfected area. Cellulitis , a generalized infection of the\\nlower skin layers, may also occur. In addition, the bacte-\\nria may invade the bloodstream and cause septicemia.\\nLay people, for that reason, often call the red streaks seen\\nin the skin “blood poisoning.” Septicemia is a very seri-\\nous illness and may be fatal.\\nCauses and symptoms\\nAcute lymphangitis is most often caused by the bac-\\nterium Streptococcus pyogenes. This potentially danger-\\nous bacterium also causes strep throat, infections of the\\nheart, spinal cord, and lungs, and in the 1990s has been\\ncalled the “flesh-eating bacterium.” Staphylococci bacte-\\nria may also cause lymphangitis.\\nAlthough anyone can develop lymphangitis, some\\npeople are more at risk. People who have had radical mas-\\ntectomy (removal of a breast and nearby lymph nodes), a\\nleg vein removed for coronary bypass surgery, or recurrent\\nlymphangitis caused by tinea pedis (a fungal infection on\\nthe foot) are at an increased risk for lymphangitis.\\nThe characteristic symptoms of acute lymphangitis\\nare the wide, red streaks which travel from the site of\\ninfection to the armpit or groin. The affected areas are red,\\nswollen, and painful. Blistering of the affected skin may\\noccur. The bacterial infection causes a fever of 100-104°F\\n(38°–40°C). In addition, a general ill feeling, muscle\\naches, headache, chills, and loss of appetite may be felt.\\nDiagnosis\\nIf lymphangitis is suspected, the person should call\\nhis or her doctor immediately or go to an emergency\\nroom. Acute lymphangitis could be diagnosed by the\\nfamily doctor, infectious disease specialist, or an emer-\\ngency room doctor. The painful, red streaks just below\\nthe skin surface and the high fever are diagnostic of acute\\nlymphangitis. A sample of blood would be taken for cul-\\nture to determine whether the bacteria have entered the\\nbloodstream. A biopsy (removal of a piece of infected\\ntissue) sample may be taken for culture to identify which\\nKEY TERMS\\nBiopsy—The process which removes a sample of\\ndiseased or infected tissue for microscopic exami-\\nnation to aid in diagnosis.\\nLymphatic system—A component of the immune\\nsystem consisting of vessels and nodes. Waste\\nmaterials from organs drain into the lymphatic\\nvessels and are filtered by the lymph nodes.\\nSepticemia—Disease caused by the presence and\\ngrowth of bacteria in the bloodstream.\\ntype of bacteria is causing the infection. Diagnosis is\\nimmediate because it is based primarily on the symp-\\ntoms. Most insurance policies should cover the expenses\\nfor the diagnosis and treatment of acute lymphangitis.\\nTreatment\\nBecause of the serious nature of this infection, treat-\\nment would begin immediately even before the bacterial\\nculture results were available. The only treatment for\\nacute lymphangitis is to give very large doses of an\\nantibiotic, usually penicillin, through the vein. Growing\\nstreptococcal bacteria are usually eliminated rapidly and\\neasily by penicillin. The antibiotic clindamycin may be\\nincluded in the treatment to kill any streptococci which\\nare not growing and are in a resting state. Alternatively, a\\n“broad spectrum” antibiotic may be used which would\\nkill many different kinds of bacteria.\\nAspirin or other medications which reduce the pain\\nand the fever may also be given. Medications which\\nreduce any inflammation of the infected region may also\\nbe provided. The patient is likely to be hospitalized to\\nadminister the antibiotic and other medications and to\\nclosely monitor his or her condition. Surgical drainage of\\nan abscess may be necessary.\\nPrognosis\\nComplete recovery is expected if antibiotic treatment\\nis begun at an early stage of the infection. However, if\\nuntreated, acute lymphangitis can be a very serious and\\neven deadly disease. Acute lymphangitis that goes untreat-\\ned can spread, causing tissue damage. Extensive tissue\\ndamage would need to be repaired by plastic surgery.\\nSpread of the infection into the bloodstream could be fatal.\\nPrevention\\nAlthough acute lymphangitis can occur in anyone, good\\nhygiene and general health may help to prevent infections.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 47\\nAcute lymphangitis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 47'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 61, 'page_label': '62'}, page_content='KEY TERMS\\nStreptococcus —A gram-positive, round or oval\\nbacteria in the genus Streptococcus . Group A\\nstreptococci cause a number of human diseases\\nincluding strep throat, impetigo, and ASPGN.\\nResources\\nPERIODICALS\\nDajer, Tony. “A Lethal Scratch.”Discover (Feb. 1998): 34-7.\\nBelinda Rowland, PhD\\nAcute pericarditis see Pericarditis\\nAcute poststreptococcal\\nglomerulonephritis\\nDefinition\\nAcute poststreptococcal glomerulonephritis\\n(APSGN) is an inflammation of the kidney tubules\\n(glomeruli) that filter waste products from the blood, fol-\\nlowing a streptococcal infection such as strep throat .\\nAPSGN is also called postinfectious glomerulonephritis.\\nDescription\\nAPSGN develops after certain streptococcal bacteria\\n(group A beta-hemolytic streptococci) have infected the\\nskin or throat. Antigens from the dead streptococci\\nclump together with the antibodies that killed them.\\nThese clumps are trapped in the kidney tubules, cause the\\ntubules to become inflamed, and impair that organs’ abil-\\nity to filter and eliminate body wastes. The onset of\\nAPSGN usually occurs one to six weeks (average two\\nweeks) after the streptococcal infection.\\nAPSGN is a relatively uncommon disease affecting\\nabout one of every 10,000 people, although four or five\\ntimes that many may actually be affected by it but show\\nno symptoms. APSGN is most prevalent among boys\\nbetween the ages of 3 and 7, but it can occur at any age.\\nCauses and symptoms\\nFrequent sore throats and a history of streptococcal\\ninfection increase the risk of acquiring APSGN. Symp-\\ntoms of APSGN include:\\n• fluid accumulation and tissue swelling (edema) initial-\\nly in the face and around the eyes, later in the legs\\n• low urine output (oliguria)\\n• blood in the urine (hematuria)\\n• protein in the urine (proteinuria)\\n• high blood pressure\\n• joint pain or stiffness\\nDiagnosis\\nDiagnosis of APSGN is made by taking the patient’s\\nhistory, assessing his/her symptoms, and performing cer-\\ntain laboratory tests. Urinalysis usually shows blood and\\nprotein in the urine. Concentrations of urea and creati-\\nnine (two waste products normally filtered out of the\\nblood by the kidneys) in the blood are often high, indi-\\ncating impaired kidney function. A reliable, inexpensive\\nblood test called the anti-streptolysin-O test can confirm\\nthat a patient has or has had a streptococcal infection. A\\nthroat culture may also show the presence of group A\\nbeta-hemolytic streptococci.\\nTreatment\\nTreatment of ASPGN is designed to relieve the\\nsymptoms and prevent complications. Some patients are\\nadvised to stay in bed until they feel better and to restrict\\nfluid and salt intake. Antibiotics may be prescribed to\\nkill any lingering streptococcal bacteria, if their presence\\nis confirmed. Antihypertensives may be given to help\\ncontrol high blood pressure and diuretics may be used to\\nreduce fluid retention and swelling. Kidney dialysis is\\nrarely needed.\\nPrognosis\\nMost children (up to 95%) fully recover from\\nAPSGN in a matter of weeks or months. Most adults (up\\nto 70%) also recover fully. In those who do not recover\\nfully, chronic or progressive problems of kidney function\\nmay occur. Kidney failure may result in some patients.\\nPrevention\\nReceiving prompt treatment for streptococcal infec-\\ntions may prevent APSGN.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nProfessional Guide to Diseases. 5th ed. Springhouse, PA:\\nSpringhouse Corporation, 1995.\\nGALE ENCYCLOPEDIA OF MEDICINE 248\\nAcute poststreptococcal glomerulonephritis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 48'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 62, 'page_label': '63'}, page_content='ORGANIZATIONS\\nAmerican Kidney Fund. 6110 Executive Boulevard, Rockville,\\nMD 20852. (800) 638-8299. .\\nNational Kidney Foundation. 30 East 33rd St., New York, NY\\n10016. (800) 622-9010. .\\nMaureen Haggerty\\nAcute respiratory distress syndrome see\\nAdult respiratory distress syndrome\\nAcute stress disorder\\nDefinition\\nAcute stress disorder (ASD) is an anxiety disorder\\ncharacterized by a cluster of dissociative and anxiety\\nsymptoms occurring within one month of a traumatic\\nevent. (Dissociation is a psychological reaction to trauma\\nin which the mind tries to cope by “sealing off” some\\nfeatures of the trauma from conscious awareness).\\nDescription\\nAcute stress disorder is a new diagnostic category\\nthat was introduced in 1994 to differentiate time-limited\\nreactions to trauma from post-traumatic stress disorder\\n(PTSD).\\nCauses and symptoms\\nAcute stress disorder is caused by exposure to trau-\\nma, which is defined as a stressor that causes intense fear\\nand, usually, involves threats to life or serious injury to\\noneself or others. Examples are rape, mugging, combat,\\nnatural disasters, etc.\\nThe symptoms of stress disorder include a combining\\nof one or more dissociative and anxiety symptoms with\\nthe avoidance of reminders of the traumatic event. Disso-\\nciative symptoms include emotional detachment, tempo-\\nrary loss of memory, depersonalization, and derealization.\\nAnxiety symptoms connected with acute stress disor-\\nder include irritability, physical restlessness, sleep prob-\\nlems, inability to concentrate, and being easily startled.\\nDiagnosis\\nDiagnosis of acute stress disorder is based on a com-\\nbination of the patient’s history and a physical examina-\\ntion to rule out diseases that can cause anxiety. The\\nKEY TERMS\\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 reaction to trauma in which the\\nmind splits off certain aspects of the trauma from\\nconscious awareness. Dissociation can affect the\\npatient’s memory, sense of reality, and sense of\\nidentity.\\nTrauma—In the context of ASD, a disastrous or\\nlife-threatening event.\\nessential feature is a traumatic event within one month of\\nthe onset of symptoms. Other diagnostic criteria include:\\n• The symptoms significantly interfere with normal\\nsocial or vocational functioning\\n• The symptoms last between two days and four weeks.\\nTreatment\\nTreatment for acute stress disorder usually includes\\na combination of antidepressant medications and short-\\nterm psychotherapy.\\nAlternative treatment\\nAcupuncture has been recommended as a treatment\\nfor acute stress disorder. Some other alternative\\napproaches, including meditation , breathing exercises,\\nand yoga, may be helpful when combined with short-\\nterm psychotherapy. Homeopathic treatment and the use\\nof herbal medicine and flower essences also can help the\\nperson with acute stress disorder rebalance on the physi-\\ncal, mental, and emotional levels.\\nPrognosis\\nThe prognosis for recovery is influenced by the sever-\\nity and duration of the trauma, the patient’s closeness to it,\\nand the patient’s previous level of functioning. Favorable\\nsigns include a short time period between the trauma and\\nonset of symptoms, immediate treatment, and appropriate\\nsocial support. If the patient’s symptoms are severe\\nenough to interfere with normal life and have lasted longer\\nthan one month, the diagnosis may be changed to PTSD.\\nIf the symptoms have lasted longer than one month but are\\nGALE ENCYCLOPEDIA OF MEDICINE 2 49\\nAcute stress disorder\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 49'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 63, 'page_label': '64'}, page_content='not severe enough to meet the definition of PTSD, the\\ndiagnosis may be changed to adjustment disorder.\\nPatients who do not receive treatment for acute\\nstress disorder are at increased risk for substance abuse\\nor major depressive disorders.\\nPrevention\\nTraumatic events cannot usually be foreseen and,\\nthus, cannot be prevented. However, in theory, profession-\\nal intervention soon after a major trauma might reduce the\\nlikelihood or severity of ASD. In addition, some symp-\\ntoms of acute stress disorder result from biochemical\\nchanges in the central nervous system, muscles, and\\ndigestive tract that are not subject to conscious control.\\nResources\\nBOOKS\\n“Acute Stress Disorder.” In Diagnostic and Statistical Manual\\nof Mental Disorders. 4th ed. Washington, DC: American\\nPsychiatric Association, 1994.\\nCorbman, Gene R. “Anxiety Disorders.” In Current Diagnosis.\\nV ol. 9. Ed. Rex B. Conn, et al. Philadelphia: W. B. Saun-\\nders Co., 1997.\\nEisendrath, Stuart J. “Psychiatric Disorders.” In Current Med-\\nical Diagnosis and Treatment, 1998.37th ed. Ed. Stephen\\nMcPhee, et al. Stamford: Appleton & Lange, 1997.\\nKabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdom\\nof Your Body and Mind to Face Stress, Pain, and Illness.\\nNew York: Bantam Doubleday Dell Publishing Group,\\nInc., 1990.\\n“On-Call Problems: Insomnia.” In Surgery On Call,e d .\\nLeonard G. Gomella and Alan T. Lefor. Stamford: Apple-\\nton & Lange, 1996.\\nRebecca J. Frey\\nAcute stress gastritis see Gastritis\\nAcute transverse myelitis see Transverse\\nmyelitis\\nAcyclovir see Antiviral drugs\\nAddiction\\nDefinition\\nAddiction is a dependence on a behavior or sub-\\nstance that a person is powerless to stop. The term has\\nbeen partially replaced by the word dependence for sub-\\nstance abuse. Addiction has been extended, however, to\\ninclude mood-altering behaviors or activities. Some\\nresearchers speak of two types of addictions: substance\\naddictions (for example, alcoholism , drug abuse, and\\nsmoking ); and process addictions (for example, gam-\\nbling, spending, shopping, eating, and sexual activity).\\nThere is a growing recognition that many addicts, such as\\npolydrug abusers, are addicted to more than one sub-\\nstance or process.\\nDescription\\nAddiction is one of the most costly public health\\nproblems in the United States. It is a progressive syn-\\ndrome, which means that it increases in severity over\\ntime unless it is treated. Substance abuse is characterized\\nby frequent relapse, or return to the abused substance.\\nSubstance abusers often make repeated attempts to quit\\nbefore they are successful.\\nIn 1995 the economic cost of substance abuse in the\\nUnited States exceeded $414 billion, with health care\\ncosts attributed to substance abuse estimated at more\\nthan $114 billion.\\nBy eighth grade, 52% of adolescents have consumed\\nalcohol, 41% have smoked tobacco, and 20% have\\nsmoked marijuana. Compared to females, males are\\nalmost four times as likely to be heavy drinkers, nearly\\none and a half more likely to smoke a pack or more of\\ncigarettes daily, and twice as likely to smoke marijuana\\nweekly. However, among adolescents these gender dif-\\nferences are decreasing. Although frequent use of tobac-\\nco, cocaine and heavy drinking appears to have remained\\nstable in the 1990s, marijuana use increased.\\nIn 1999, an estimated four million Americans over the\\nage of 12 used prescription pain relievers, sedatives, and\\nstimulants for “nonmedical” reasons during one month.\\nIn the United States, 25% of the population regularly\\nuses tobacco. Tobacco use reportedly kills 2.5 times as\\nmany people each year as alcohol and drug abuse com-\\nbined. According to 1998 data from the World Health\\nOrganization, there were 1.1 billion smokers worldwide\\nand 10,000 tobacco-related deaths per day. Furthermore,\\nin the United States, 43% of children aged 2-11 years are\\nexposed to environmental tobacco smoke, which has\\nbeen implicated in sudden infant death syndrome,l o w\\nbirth weight, asthma, middle ear disease, pneumonia ,\\ncough, and upper respiratory infection.\\nEating disorders, such as anorexia nervosa, bulim-\\nia nervosa , and binge eating, affect over five million\\nAmerican women and men. Fifteen percent of young\\nwomen have substantially disordered attitudes toward\\neating and eating behaviors. More than 1,000 women die\\neach year from anorexia nervosa.\\nGALE ENCYCLOPEDIA OF MEDICINE 250\\nAddiction\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 50'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 64, 'page_label': '65'}, page_content='A 1997 Harvard study found that an estimated 15.4\\nmillion Americans suffered from a gambling addiction.\\nOver half that number (7.9 million) were adolescents.\\nCauses and symptoms\\nAddiction to substances results from the interaction\\nof several factors:\\nDrug chemistry\\nSome substances are more addictive than others,\\neither because they produce a rapid and intense change in\\nmood; or because they produce painful withdrawal\\nsymptoms when stopped suddenly.\\nGenetic factor\\nSome people appear to be more vulnerable to addic-\\ntion because their body chemistry increases their sensi-\\ntivity to drugs. Some forms of substance abuse and\\ndependence seem to run in families; and this may be the\\nresult of a genetic predisposition, environmental influ-\\nences, or a combination of both.\\nBrain structure and function\\nUsing drugs repeatedly over time changes brain\\nstructure and function in fundamental and long-lasting\\nways. Addiction comes about through an array of\\nchanges in the brain and the strengthening of new memo-\\nry connections. Evidence suggests that those long-lasting\\nbrain changes are responsible for the distortions of cog-\\nnitive and emotional functioning that characterize\\naddicts, particularly the compulsion to use drugs.\\nAlthough the causes of addiction remain the subject of\\nongoing debate and research, many experts now consider\\naddiction to be a brain disease: a condition caused by\\npersistent changes in brain structure and function. How-\\never, having this brain disease does not absolve the\\naddict of responsibility for his or her behavior, but it does\\nexplain why many addicts cannot stop using drugs by\\nsheer force of will alone.\\nSocial learning\\nSocial learning is considered the most important sin-\\ngle factor. It includes patterns of use in the addict’s fami-\\nly or subculture, peer pressure, and advertising or media\\ninfluence.\\nAvailability\\nInexpensive or readily available tobacco, alcohol, or\\ndrugs produce marked increases in rates of addiction.\\nIndividual development\\nBefore the 1980s, the so-called addictive personality\\nwas used to explain the development of addiction. The\\naddictive personality was described as escapist, impul-\\nsive, dependent, devious, manipulative, and self-cen-\\ntered. Many doctors now believe that these character\\ntraits develop in addicts as a result of the addiction,\\nrather than the traits being a cause of the addiction.\\nDiagnosis\\nIn addition to a preoccupation with using and\\nacquiring the abused substance, the diagnosis of addic-\\ntion is based on five criteria:\\n• loss of willpower\\n• harmful consequences\\n• unmanageable lifestyle\\n• tolerance or escalation of use\\n• withdrawal symptoms upon quitting\\nGALE ENCYCLOPEDIA OF MEDICINE 2 51\\nAddiction\\nCrack users. Crack, a form of cocaine, is one of the most\\naddictive drugs. (Photograph by Roy Marsch, The Stock Mar-\\nket. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 51'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 65, 'page_label': '66'}, page_content='KEY TERMS\\nAddiction—Dependence on a habit-forming sub-\\nstance or behavior that the person is powerless to\\nstop.\\nAddictive personality —A concept that was for-\\nmerly used to explain addiction as the result of\\npre-existing character defects in individuals.\\nProcess addiction —Addiction to certain mood-\\naltering behaviors, such as eating disorders, gam-\\nbling, sexual activity, overwork, and shopping.\\nTolerance—A condition in which an addict needs\\nhigher doses of a substance to achieve the same\\neffect previously achieved with a lower dose.\\nWithdrawal—The unpleasant, sometimes life-\\nthreatening physiological changes that occur, due\\nto the discontinuation of use of some drugs after\\nprolonged, regular use.\\nTreatment\\nTreatment requires both medical and social\\napproaches. Substance addicts may need hospital treat-\\nment to manage withdrawal symptoms. Individual or\\ngroup psychotherapy is often helpful, but only after sub-\\nstance use has stopped. Anti-addiction medications, such\\nas methadone and naltrexone, are also commonly used.\\nThe most frequently recommended social form of\\noutpatient treatment is the twelve-step program. Such\\nprograms are also frequently combined with psychother-\\napy. According to a recent study reported by the Ameri-\\ncan Psychological Association (APA), anyone, regardless\\nof his or her religious beliefs or lack of religious beliefs,\\ncan benefit from participation in 12-step programs such\\nas Alcoholics Anonymous (AA) or Narcotics Anony-\\nmous (NA). The number of visits to 12-step self-help\\ngroups exceeds the number of visits to all mental health\\nprofessionals combined. There are twelve-step groups\\nfor all major substance and process addictions.\\nThe Twelve Steps are:\\n• Admit powerlessness over the addiction.\\n• Believe that a Power greater than oneself could restore\\nsanity.\\n• Make a decision to turn your will and your life over to\\nthe care of God, as you understand him.\\n• Make a searching and fearless moral inventory of self.\\n• Admit to God, yourself, and another human being the\\nexact nature of your wrongs.\\n• Become willing to have God remove all these defects\\nfrom your character.\\n• Humbly ask God to remove shortcomings.\\n• Make a list of all persons harmed by your wrongs and\\nbecome willing to make amends to them all.\\n• Make direct amends to such people, whenever possible\\nexcept when to do so would injure them or others.\\n• Continue to take personal inventory and promptly\\nadmit any future wrongdoings.\\n• Seek to improve contact with a God of the individual’s\\nunderstanding through meditation and prayer.\\n• Carry the message of spiritual awakening to others and\\npractice these principles in all your affairs.\\nAlternative treatment\\nAcupuncture and homeopathy have been used to\\ntreat withdrawal symptoms. Meditation, yoga, and reiki\\nhealing have been recommended for process addictions,\\nhowever, the success of these programs has not been well\\ndocumented through controlled studies.\\nPrognosis\\nThe prognosis for recovery from any addiction\\ndepends on the substance or process, the individual’s cir-\\ncumstances, and underlying personality structure. Poly-\\ndrug users have the worst prognosis for recovery.\\nPrevention\\nThe most effective form of prevention appears to be\\na stable family that models responsible attitudes toward\\nmood-altering substances and behaviors. Prevention edu-\\ncation programs are also widely used to inform the pub-\\nlic of the harmfulness of substance abuse.\\nResources\\nBOOKS\\n“Psychiatric Disorders: Drug Dependence.” In The Merck Man-\\nual of Diagnosis and Therapy.V ol. 1. Ed. Robert Berkow,\\net al. Rahway, N.J.: Merck Research Laboratories, 1992.\\nRobert Wood Johnson Foundation. Substance Abuse: The\\nNation’s #1 Problem.Princeton, N.J., 2001.\\nPERIODICALS\\nKalivas, Peter. “Drug Addiction: To the Cortex..and beyond”\\nThe American Journal of Psychiatry volume 158, issue 3,\\n(March 2001).\\nKelly, Timothy. “Addiction: A Booming $800 Billion Industry.\\nThe World and I(July 1, 2000).\\nLeshner, Alan. “Addiction is a Brain Disease”Issues in Science\\nand Technologyvolume 17, issue 3, (April 1, 2001).\\nMattas-Curry, L. “12-step self-help programs proved success-\\nful regardless of participants’ religious background, study\\nGALE ENCYCLOPEDIA OF MEDICINE 252\\nAddiction\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 52'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 66, 'page_label': '67'}, page_content='suggests.” APA Monitor Online.volume 30, number 11,\\n(December 1999). .\\nORGANIZATIONS\\nAl-Anon Family Groups. Box 182, Madison Square Station,\\nNew York, NY 10159. .\\nAlcoholics Anonymous World Services, Inc. Box 459, Grand\\nCentral Station, New York, NY 10163. .\\nAmerican Anorexia Bulimina Association. .\\nAmerican Psychiatric Association. .\\nCenter for On-Line Addiction. .\\neGambling: Electronic Joural of Gambling Issues. .\\nNational Center on Addiction and Substance Abuse at Colum-\\nbia University. .\\nNational Alliance on Alcoholism and Drug Dependence, Inc.\\n12 West 21st St., New York, NY 10010. (212)206-6770.\\nNational Clearinghouse for Alcohol and Drug Information.\\n.\\nNational Institute on Alcohol Abuse and Alcoholism (NIAAA)\\n6000 Executive Boulevard, Bethesda, Maryland 20892-\\n7003. .\\nBill Asenjo, MS, CRC\\nAddison’s disease\\nDefinition\\nAddison’s disease is a disorder involving disrupted\\nfunctioning of the part of the adrenal gland called the\\ncortex. This results in decreased production of two\\nimportant chemicals (hormones) normally released by\\nthe adrenal cortex: cortisol and aldosterone.\\nDescription\\nThe adrenals are two glands, each perched on the\\nupper part of the two kidneys. The outer part of the gland\\nis known as the cortex; the inner part is known as the\\nmedulla. Each of these parts of the adrenal gland is\\nresponsible for producing different types of hormones.\\nCortisol is a very potent hormone produced by the\\nadrenal cortex. It is involved in regulating the functioning\\nof nearly every type of organ and tissue throughout the\\nbody, and is considered to be one of the few hormones\\nabsolutely necessary for life. Cortisol is involved in:\\n• the very complex processing and utilization of many nutri-\\nents, including sugars (carbohydrates), fats, and proteins\\n• the normal functioning of the circulatory system and\\nthe heart\\nKEY TERMS\\nGland—A collection of cells whose function is to\\nrelease certain chemicals, or hormones, which are\\nimportant to the functioning of other, sometimes\\ndistantly located, organs or body systems.\\nHormone —A chemical produced in one part of\\nthe body, which travels to another part of the body\\nin order to exert its effect.\\n• the functioning of muscles\\n• normal kidney function\\n• production of blood cells\\n• the normal processes involved in maintaining the skele-\\ntal system\\n• proper functioning of the brain and nerves\\n• the normal responses of the immune system\\nAldosterone, also produced by the adrenal cortex,\\nplays a central role in maintaining the appropriate pro-\\nportions of water and salts in the body. When this bal-\\nance is upset, the volume of blood circulating throughout\\nthe body will fall dangerously low, accompanied by a\\ndrop in blood pressure.\\nAddison’s disease is also called primary adrenocorti-\\ncal insufficiency. In other words, some process interferes\\ndirectly with the ability of the adrenal cortex to produce\\nits hormones. Levels of both cortisol and aldosterone\\ndrop, and numerous functions throughout the body are\\ndisrupted.\\nAddison’s disease occurs in about four in every\\n100,000 people. It strikes both men and women of all ages.\\nCauses and symptoms\\nThe most common cause of Addison’s disease is the\\ndestruction and/or shrinking (atrophy) of the adrenal\\ncortex. In about 70% of all cases, this atrophy is\\nbelieved to occur due to an autoimmune disorder. In an\\nautoimmune disorder, the immune system of the body,\\nresponsible for identifying foreign invaders such as\\nviruses or bacteria and killing them, accidentally begins\\nto identify the cells of the adrenal cortex as foreign, and\\ndestroy them. In about 20% of all cases, destruction of\\nthe adrenal cortex is caused by tuberculosis . The\\nremaining cases of Addison’s disease may be caused by\\nfungal infections, such as histoplasmosis , coccidiomy-\\ncosis, and cryptococcosis , which affect the adrenal\\ngland by producing destructive, tumor-like masses\\nGALE ENCYCLOPEDIA OF MEDICINE 2 53\\nAddison’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 53'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 67, 'page_label': '68'}, page_content='called granulomas; a disease called amyloidosis ,i n\\nwhich a starchy substance called amyloid is deposited in\\nabnormal places throughout the body, interfering with\\nthe function of whatever structure it is present within; or\\ninvasion of the adrenal glands by cancer.\\nIn about 75% of all patients, Addison’s disease\\ntends to be a very gradual, slowly developing disease.\\nSignificant symptoms are not noted until about 90% of\\nthe adrenal cortex has been destroyed. The most com-\\nmon symptoms include fatigue and loss of energy,\\ndecreased appetite, nausea, vomiting, diarrhea ,\\nabdominal pain, weight loss, muscle weakness, dizzi-\\nness when standing, dehydration , unusual areas of\\ndarkened (pigmented) skin, and dark freckling. As the\\ndisease progresses, the patient may appear to have very\\ntanned, or bronzed skin, with darkening of the lining of\\nthe mouth, vagina, and rectum, and dark pigmentation\\nof the area around the nipples (aereola). As dehydration\\nbecomes more severe, the blood pressure will continue\\nto drop and the patient will feel increasingly weak and\\nlight-headed. Some patients have psychiatric symp-\\ntoms, including depression and irritability. Women lose\\npubic and underarm hair, and stop having normal men-\\nstrual periods.\\nWhen a patient becomes ill with an infection, or\\nstressed by an injury, the disease may suddenly and\\nrapidly progress, becoming life-threatening. Symptoms\\nof this “Addisonian crisis” include abnormal heart\\nrhythms, severe pain in the back and abdomen, uncon-\\ntrollable nausea and vomiting , a drastic drop in blood\\npressure, kidney failure, and unconsciousness. About\\n25% of all Addison’s disease patients are identified due\\nto the development of Addisonian crisis.\\nDiagnosis\\nMany patients do not recognize the slow progres-\\nsion of symptoms and the disease is ultimately identified\\nwhen a physician notices the areas of increased pigmen-\\ntation of the skin. Once suspected, a number of blood\\ntests can lead to the diagnosis of Addison’s disease. It is\\nnot sufficient to demonstrate low blood cortisol levels,\\nas normal levels of cortisol vary quite widely. Instead,\\npatients are given a testing dose of another hormone\\ncalled corticotropin (ACTH). ACTH is produced in the\\nbody by the pituitary gland, and normally acts by pro-\\nmoting growth within the adrenal cortex and stimulating\\nthe production and release of cortisol. In Addison’s dis-\\nease, even a dose of synthetic ACTH does not increase\\ncortisol levels.\\nTo distinguish between primary adrenocortical\\ninsufficiency (Addison’s disease) and secondary\\nadrenocortical insufficiency (caused by failure of the\\npituitary to produce enough ACTH), levels of ACTH in\\nthe blood are examined. Normal or high levels of\\nACTH indicate that the pituitary is working properly,\\nbut the adrenal cortex is not responding normally to the\\npresence of ACTH. This confirms the diagnosis of\\nAddison’s disease.\\nTreatment\\nTreatment of Addison’s disease involves replacing\\nthe missing or low levels of cortisol. In the case of Addis-\\nonian crisis, this will be achieved by injecting a potent\\nform of steroid preparation through a needle placed in a\\nvein (intravenous or IV). Dehydration and salt loss will\\nalso be treated by administering carefully balanced solu-\\ntions through the IV . Dangerously low blood pressure\\nmay require special medications to safely elevate it until\\nthe steroids take effect.\\nPatients with Addison’s disease will need to take a\\nsteroid preparation (hydrocortisone) and a replacement\\nfor aldosterone (fludrocortisone) by mouth for the rest of\\ntheir lives. When a patient has an illness which causes\\nnausea and vomiting (such that they cannot hold down\\ntheir medications), he or she will need to enter a medical\\nfacility where IV medications can be administered.\\nWhen a patient has any kind of infection or injury, the\\nnormal dose of hydrocortisone will need to be doubled.\\nPrognosis\\nPrognosis for patients appropriately treated with\\nhydrocortisone and aldosterone is excellent. These\\npatients can expect to enjoy a normal lifespan. Without\\ntreatment, or with substandard treatment, patients are\\nalways at risk of developing Addisonian crisis.\\nResources\\nBOOKS\\nWilliams, Gordon H., and Robert G. Dluhy. “Hypofunction of\\nthe Adrenal Cortex.” In Harrison’s Principles of Internal\\nMedicine, ed. Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nPERIODICALS\\nBrosnan, C. M., and N. F. C. Gowing. “Addison’s Disease.”\\nBritish Medical Journal 312, no. 7038 (27 Apr. 1996):\\n1085+.\\nOelkers, Wolfgang. “Adrenal Insufficiency.”New England\\nJournal of Medicine 335, no. 16 (17 Oct. 1996): 1206+.\\nORGANIZATIONS\\nNational Adrenal Disease Foundation. 505 Northern Boule-\\nvard, Suite 200, Great Neck, NY 11021. (516) 487-4992.\\nRosalyn Carson-DeWitt, MD\\nGALE ENCYCLOPEDIA OF MEDICINE 254\\nAddison’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 54'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 68, 'page_label': '69'}, page_content='Adenoid hyperplasia\\nDefinition\\nAdenoid hyperplasia is the overenlargement of the\\nlymph glands located above the back of the mouth.\\nDescription\\nLocated at the back of the mouth above and below\\nthe soft palate are two pairs of lymph glands. The tonsils\\nbelow are clearly visible behind the back teeth; the ade-\\nnoids lie just above them and are hidden from view by the\\npalate. Together these four arsenals of immune defense\\nguard the major entrance to the body from foreign\\ninvaders—the germs we breathe and eat. In contrast to the\\nrest of the body’s tissues, lymphoid tissue reaches its\\ngreatest size in mid-childhood and recedes thereafter. In\\nthis way children are best able to develop the immunities\\nthey need to survive in a world full of infectious diseases.\\nBeyond its normal growth pattern, lymphoid tissue\\ngrows excessively (hypertrophies) during an acute infec-\\ntion, as it suddenly increases its immune activity to fight\\noff the invaders. Often it does not completely return to its\\nformer size. Each subsequent infection leaves behind a\\nlarger set of tonsils and adenoids. To make matters\\nworse, the sponge-like structure of these hypertrophied\\nglands can produce safe havens for germs where the\\nbody cannot reach and eliminate them. Before antibi-\\notics and the reduction in infectious childhood diseases\\nover the past few generations, tonsils and adenoids\\ncaused greater health problems.\\nCauses and symptoms\\nMost tonsil and adenoid hypertrophy is simply\\ncaused by the normal growth pattern for that type of tis-\\nsue. Less often, the hypertrophy is due to repeated throat\\ninfections by cold viruses, strep throat, mononucleosis,\\nand in times gone by, diphtheria . The acute infections\\nare usually referred to as tonsillitis, the adenoids getting\\nlittle recognition because they cannot be seen without\\nspecial instruments. Symptoms include painful, bright\\nred, often ulcerated tonsils, enlargement of lymph nodes\\n(glands) beneath the jaw,fever, and general discomfort.\\nAfter the acute infection subsides, symptoms are gen-\\nerated simply by the size of the glands. Extremely large\\ntonsils can impair breathing and swallowing, although that\\nis quite rare. Large adenoids can impair nose breathing\\nand require a child to breathe through the mouth. Because\\nthey encircle the only connection between the middle ear\\nand the eustachian tube, hypertrophied adenoids can also\\nobstruct it and cause middle ear infections.\\nKEY TERMS\\nEustacian tube—A tube connecting the middle ear\\nwith the back of the nose, allowing air pressure to\\nequalize within the ear whenever it opens, such as\\nwith yawning.\\nHyperplastic—Overgrown.\\nHypertrophy—Overgrowth.\\nStrep throat—An infection of the throat caused by\\nbacteria of the Streptococcus family, which causes\\ntonsillitis.\\nUlcerated—Damaged so that the surface tissue is\\nlost and/or necrotic (dead).\\nDiagnosis\\nA simple tongue blade depressing the tongue allows\\nan adequate view of the tonsils. Enlarged tonsils may\\nhave deep pockets (crypts) containing dead tissue\\n(necrotic debris). Viewing adenoids requires a small mir-\\nror or fiberoptic scope. A child with recurring middle ear\\ninfections may well have large adenoids. A throat cul-\\nture or mononucleosis test will usually reveal the identi-\\nty of the germ.\\nTreatment\\nIt used to be standard practice to remove tonsils\\nand/or adenoids after a few episodes of acute throat or ear\\ninfection. The surgery is called tonsillectomy and ade-\\nnoidectomy(T and A). Opinion changed as it was realized\\nthat this tissue is beneficial to the development of immuni-\\nty. For instance, children without tonsils and adenoids pro-\\nduce only half the immunity to oral polio vaccine. In addi-\\ntion, treatment of ear and throat infections with antibiotics\\nand of recurring ear infections with surgical drainage\\nthrough the ear drum (tympanostomy) has greatly reduced\\nthe incidence of surgical removal of these lymph glands.\\nAlternative treatment\\nThere are many botanical/herbal remedies that can\\nbe used alone or in formulas to locally assist the tonsils\\nand adenoids in their immune function at the opening of\\nthe oral cavity and to tone these glands. Keeping the\\nEustachian tubes open is an important contribution to\\noptimal function in the tonsils and adenoids. Food aller-\\ngies are often the culprits for recurring ear infections, as\\nwell as tonsilitis and adenoiditis. Identification and\\nremoval of the allergic food(s) can greatly assist in alle-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 55\\nAdenoid hyperplasia\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 55'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 69, 'page_label': '70'}, page_content='viating the cause of the problem. Acute tonsillitis also\\nbenefits from warm saline gargles.\\nPrognosis\\nHypertrophied adenoids are a normal part of grow-\\ning up and should be respected for their important role in\\nthe development of immunity. Only when their size caus-\\nes problems by obstructing breathing or middle ear\\ndrainage do they demand intervention.\\nPrevention\\nPrevention can be directed toward prompt evaluation\\nand appropriate treatment of sore throats to prevent over-\\ngrowth of adenoid tissue. Avoiding other children with\\nacute respiratory illness will also reduce the spread of\\nthese common illnesses.\\nResources\\nBOOKS\\nBallenger, John Jacob. Disorders of the Nose, Throat, Ear,\\nHead, and Neck. Philadelphia: Lea & Febiger, 1991.\\n“Otitis Media with Effusion.” In Nelson Textbook of Pediatrics,\\ned. Richard E. Behrman. Philadelphia: W. B. Saunders\\nCo., 1996.\\n“Tonsils and Adenoids.” In Nelson Textbook of Pediatrics,e d .\\nRichard E. Behrman. Philadelphia: W. B. Saunders Co.,\\n1996.\\nWeil, Andrew. Natural Health, Natural Medicine. Boston:\\nHoughton Mifflin Co., 1995.\\nPERIODICALS\\nLaliberte, Richard. “The Tonsils Controversy.”Parents Maga-\\nzine, (Dec. 1995): 38.\\nJ. Ricker Polsdorfer, MD\\nAdenoid hypertrophy see Adenoid\\nhyperplasia\\nAdenoid removal see Tonsillectomy and\\nadenoidectomy\\nAdenoidectomy see Tonsillectomy and\\nadenoidectomy\\nAdenovirus infections\\nDefinition\\nAdenoviruses are DNA viruses (small infectious\\nagents) that cause upper respiratory tract infections, con-\\njunctivitis, and other infections in humans.\\nDescription\\nAdenoviruses were discovered in 1953. About 47 dif-\\nferent types have been identified since then, and about\\nhalf of them are believed to cause human diseases. Infants\\nand children are most commonly affected by adenovirus-\\nes. Adenovirus infections can occur throughout the year,\\nbut seem to be most common from fall to spring.\\nAdenoviruses are responsible for 3-5% of acute res-\\npiratory infections in children and 2% of respiratory ill-\\nnesses in civilian adults. They are more apt to cause\\ninfection among military recruits and other young people\\nwho live in institutional environments. Outbreaks among\\nchildren are frequently reported at boarding schools and\\nsummer camps.\\nAcquired immunity\\nMost children have been infected by at least one\\nadenovirus by the time they reach school age. Most\\nadults have acquired immunity to multiple adenovirus\\ntypes due to infections they had as children.\\nIn one mode of adenovirus infection (called lytic\\ninfection because it destroys large numbers of cells), ade-\\nnoviruses kill healthy cells and replicate up to one mil-\\nlion new viruses per cell killed (of which 1-5% are infec-\\ntious). People with this kind of infection feel sick. In\\nchronic or latent infection, a much smaller number of\\nviruses are released and healthy cells can multiply more\\nrapidly than they are destroyed. People who have this\\nkind of infection don’t seem to be sick. This is probably\\nwhy many adults have immunity to adenoviruses without\\nrealizing they have been infected.\\nChildhood infections\\nIn children, adenoviruses most often cause acute\\nupper respiratory infections with fever and runny nose.\\nAdenovirus types 1, 2, 3,5, and 6 are responsible for\\nmost of these infections. Occasionally more serious\\nlower respiratory diseases, such as pneumonia , may\\noccur.\\nAdenoviruses also cause acute pharyngoconjunctival\\nfever in children. This disease is most often caused by\\ntypes 3 and 7. Symptoms, which appear suddenly and\\nusually disappear in less than a week, include:\\n• inflammation of the lining of the eyelid (conjunctivitis)\\n•f e v e r\\n• sore throat (pharyngitis)\\n• runny nose\\n• inflammation of lymph glands in the neck (cervical\\nadenitis)\\nGALE ENCYCLOPEDIA OF MEDICINE 256\\nAdenovirus infections\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 56'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 70, 'page_label': '71'}, page_content='Adenoviruses also cause acute diarrhea in young\\nchildren, characterized by fever and watery stools. This\\ncondition is caused by adenovirus types 40 and 41 and\\ncan last as long as two weeks.\\nAs much as 51% of all hemorrhagic cystitis (inflam-\\nmation of the bladder and of the tubes that carry urine to\\nthe bladder from the kidneys) in American and Japanese\\nchildren can be attributed to adenovirus infection. A\\nchild who has hemorrhagic cystitis has bloody urine for\\nabout three days, and invisible traces of blood can be\\nfound in the urine a few days longer. The child will feel\\nthe urge to urinate frequently—but find it difficult to do\\nso—for about the same length of time.\\nAdult infections\\nIn adults, the most frequently reported adenovirus\\ninfection is acute respiratory disease (ARD, caused by\\ntypes 4 and 7) in military recruits. Influenza-like symp-\\ntoms including fever, sore throat, runny nose, and cough\\nare almost always present; weakness, chills, headache ,\\nand swollen lymph glands in the neck may also occur.\\nThe symptoms typically last three to five days.\\nEpidemic keratoconjunctivitis (EKC, caused by ade-\\nnovirus types 8, 19, and 37) was first seen in shipyard\\nworkers whose eyes had been slightly injured by chips of\\nrust or paint. This inflammation of tissues lining the eye-\\nlid and covering the front of the eyeball can also be\\ncaused by using contaminated contact lens solutions or\\nby drying the hands or face with a towel used by some-\\none who has this infection.\\nThe inflamed, sticky eyelids characteristic of con-\\njunctivitis develop 4-24 days after exposure and last\\nbetween one and four weeks. Only 5-8% of patients with\\nepidemic keratoconjunctivitis experience respiratory\\nsymptoms. One or both eyes may be affected. As symp-\\ntoms of conjunctivitis subside, eye pain and watering\\nand blurred vision develop. These symptoms of keratitis\\nmay last for several months, and about 10% of these\\ninfections spread to at least one other member of the\\npatient’s household.\\nOther illnesses associated with adenovirus include:\\n• encephalitis (inflammation of the brain) and other\\ninfections of the central nervous system (CNS)\\n• gastroenteritis (inflammation of the stomach and intes-\\ntines)\\n• acute mesenteric lymphadenitis (inflammation of\\nlymph glands in the abdomen)\\n• chronic interstitial fibrosis (abnormal growth of con-\\nnective tissue between cells)\\n• intussusception (a type of intestinal obstruction)\\nKEY TERMS\\nConjunctivitis —Inflammation of the conjunctiva,\\nthe mucous membrane lining the inner surfaces of\\nthe eyelid and the front of the eyeball.\\nVirus—A small infectious agent consisting of a\\ncore of genetic material (DNA or RNA) surround-\\ned by a shell of protein.\\n• pneumonia that doesn’t respond to antibiotic therapy\\n• whooping cough syndrome when Bordetella pertussis\\n(the bacterium that causes classic whooping cough) is\\nnot found\\nCauses and symptoms\\nSpecific adenovirus infections can be traced to par-\\nticular sources and produce distinctive symptoms. In\\ngeneral, however, adenovirus infection is caused by:\\n• inhaling airborne viruses\\n• getting the virus in the eyes by swimming in contami-\\nnated water, using contaminated eye solutions or instru-\\nments, wiping the eyes with contaminated towels, or\\nrubbing the eyes with contaminated fingers.\\n• not washing the hands after using the bathroom, and\\nthen touching the mouth or eyes\\nSymptoms common to most types of adenovirus\\ninfections include:\\n• cough\\n•f e v e r\\n• runny nose\\n• sore throat\\n• watery eyes\\nDiagnosis\\nAlthough symptoms may suggest the presence of\\nadenovirus, distinguishing these infections from other\\nviruses can be difficult. A definitive diagnosis is based on\\nculture or detection of the virus in eye secretions, spu-\\ntum, urine, or stool.\\nThe extent of infection can be estimated from the\\nresults of blood tests that measure increases in the quan-\\ntity of antibodies the immune system produces to fight it.\\nAntibody levels begin to rise about a week after infection\\noccurs and remain elevated for about a year.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 57\\nAdenovirus infections\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 57'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 71, 'page_label': '72'}, page_content='Treatment\\nTreatment of adenovirus infections is usually sup-\\nportive and aimed at relieving symptoms of the illness.\\nBed rest may be recommended along with medications to\\nreduce fever and/or pain. (Aspirin should not be given to\\nchildren because of concerns about Reye’s syndrome.)\\nEye infections may benefit from topical corticosteroids\\nto relieve symptoms and shorten the course of the dis-\\nease. Hospitalization is usually required for severe pneu-\\nmonia in infants and for EKC (to prevent blindness). No\\neffective antiviral drugs have been developed.\\nPrognosis\\nAdenovirus infections are rarely fatal. Most patients\\nrecover fully.\\nPrevention\\nPracticing good personal hygiene and avoiding peo-\\nple with infectious illnesses can reduce the risk of devel-\\noping adenovirus infection. Proper handwashing can pre-\\nvent the spread of the virus by oral-fecal transmission.\\nSterilization of instruments and solutions used in the eye\\ncan prevent the spread of EKC, as can adequate chlorina-\\ntion of swimming pools.\\nA vaccine containing live adenovirus types 4 and 7\\nis used to control disease in military recruits, but it is not\\nrecommended or available for civilian use. Vaccines pre-\\npared from purified subunits of adenovirus are under\\ninvestigation.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nMandell, Gerald L., ed., et al. Principles and Practices of Infec-\\ntious Diseases. New York: Churchill Livingstone, 1995.\\nProfessional Guide to Diseases. 5th ed. Springhouse, PA:\\nSpringhouse Corporation, 1995.\\nMaureen Haggerty\\nAdjustment disorders\\nDefinition\\nAn adjustment disorder is a debilitating reaction,\\nusually lasting less than six months, to a stressful event\\nor situation. It is not the same thing as post-traumatic\\nstress disorder (PTSD), which usually occurs in reac-\\ntion to a life-threatening event and can be longer lasting.\\nDescription\\nAn adjustment disorder usually begins within three\\nmonths of a stressful event, and ends within six months\\nafter the stressor stops. There are many different sub-\\ntypes of adjustment disorders, including adjustment dis-\\norder with:\\n• depression\\n• anxiety\\n• mixed anxiety and depression\\n• conduct disturbances\\n• mixed disturbance of emotions and conduct\\n• unspecified\\nAdjustment disorders are very common and can\\naffect anyone, regardless of gender, age, race, or lifestyle.\\nBy definition, an adjustment disorder is short-lived,\\nunless a person is faced with a chronic recurring crisis\\n(such as a child who is repeatedly abused). In such cases,\\nthe adjustment disorder may last more than six months.\\nCauses and symptoms\\nAn adjustment disorder occurs when a person can’t\\ncope with a stressful event and develops emotional or\\nbehavioral symptoms. The stressful event can be anything:\\nit might be just one isolated incident, or a string of prob-\\nlems that wears the person down. The stress might be any-\\nthing from a car accident or illness, to a divorce, or even a\\ncertain time of year (such as Christmas or summer).\\nPeople with adjustment disorder may have a wide\\nvariety of symptoms. How those symptoms combine\\ndepend on the particular subtype of adjustment disorder\\nand on the individual’s personality and psychological\\ndefenses. Symptoms normally include some (but not all)\\nof the following:\\n• hopelessness\\n• sadness\\n• crying\\n• anxiety\\n• worry\\n• headaches or stomachaches\\n• withdrawal\\n• inhibition\\n• truancy\\n• vandalism\\n• reckless driving\\n• fighting\\n• other destructive acts\\nGALE ENCYCLOPEDIA OF MEDICINE 258\\nAdjustment disorders\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 58'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 72, 'page_label': '73'}, page_content='Diagnosis\\nIt is extremely important that a thorough evaluation\\nrule out other more serious mental disorders, since the\\ntreatment for adjustment disorder may be very different\\nthan for other mental problems.\\nIn order to be diagnosed as a true adjustment disor-\\nder, the level of distress must be more severe than what\\nwould normally be expected in response to the stressor,\\nor the symptoms must significantly interfere with a per-\\nson’s social, job, or school functioning. Normal expres-\\nsion of grief, in bereavement for instance, is not consid-\\nered an adjustment disorder.\\nTreatment\\nPsychotherapy (counseling) is the treatment of\\nchoice for adjustment disorders, since the symptoms are\\nan understandable reaction to a specific stress. The type\\nof therapy depends on the mental health expert, but it\\nusually is short-term treatment that focuses on resolving\\nthe immediate problem.\\nTherapy usually will help clients:\\n• develop coping skills\\n• understand how the stressor has affected their lives\\n• develop alternate social or recreational activities\\nFamily or couples therapy may be helpful in some\\ncases. Medications are not usually used to treat adjust-\\nment disorders, although sometimes a few days or weeks\\nof an anti-anxiety drug can control anxiety or sleeping\\nproblems.\\nSelf-help groups aimed at a specific problem (such\\nas recovering from divorce or job loss) can be extremely\\nhelpful to people suffering from an adjustment disorder.\\nSocial support, which is usually an important part of self-\\nhelp groups, can lead to a quicker recovery.\\nPrognosis\\nMost people recover completely from adjustment\\ndisorders, especially if they had no previous history of\\nmental problems, and have a stable home life with strong\\nsocial support. People with progressive or cyclic disor-\\nders (such as multiple sclerosis ) may experience an\\nadjustment disorder with each exacerbation period.\\nResources\\nBOOKS\\nHorowitz, Mardi J. Stress Response Syndromes: PTSD, Grief and\\nAdjustment Disorders.Northvale, NJ: Jason Aronson, 1997.\\nLuther, Suniya G., Jacob A. Burack, and Dante Cicchetti. Develop-\\nmental Psychopathology: Perspectives on Adjustment, Risk,\\nand Disorder.London: Cambridge University Press, 1997.\\nKEY TERMS\\nMultiple sclerosis —A progressive disorder of the\\ncentral nervous system in which scattered patches\\nof the protective sheath covering the nerves is\\ndestroyed. The disease, which causes progressive\\nparalysis, is marked by periods of exacerbation\\nand remission. There is no cure.\\nPost-traumatic stress disorder (PTSD)—A specific\\nform of anxiety that begins after a life-threatening\\nevent, such as rape, a natural disaster, or combat-\\nrelated trauma.\\nPERIODICALS\\nNewcorn, Jeffrey H., and James Strain. “Adjustment Disorder\\nin Children and Adolescents.”Journal of the American\\nAcademy of Child and Adolescent Psychiatry 31 (Mar.\\n1992): 318-27.\\nCarol A. Turkington\\nAdrenal gland cancer\\nDefinition\\nAdrenal gland cancers are rare cancers occuring in\\nthe endocrine tissue of the adrenals. They are character-\\nized by overproduction of adrenal gland hormones.\\nDescription\\nCancers of the adrenal gland are very rare. The\\nadrenal gland is a hormone producing endocrine gland\\nwith two main parts, the cortex and the medulla. The\\nmain hormone of the adrenal cortex is cortisol and the\\nmain hormone of the adrenal medulla is epinephrine.\\nWhen tumors develop in the adrenal gland, they secrete\\nexcess amounts of these hormones. A cancer that arises\\nin the adrenal cortex is called an adrenocortical carcino-\\nma and can produce high blood pressure, weight gain,\\nexcess body hair, weakening of the bones and diabetes. A\\ncancer in the adrenal medulla is called a pheochromocy-\\ntoma and can cause high blood pressure, headache, pal-\\npitations, and excessive perspiration. Although these can-\\ncers can happen at any age, most occur in young adults.\\nCauses and symptoms\\nIt is not known what causes adrenal gland cancer,\\nbut some cases are associated with hereditary diseases.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 59\\nAdrenal gland cancer\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 59'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 73, 'page_label': '74'}, page_content='Symptoms of adrenal cancer are related to the specific\\nhormones produced by that tumor. An adrenocortical car-\\ncinoma typically secretes high amounts of cortisol, pro-\\nducing Cushing’s Syndrome. This syndrome produces\\nprogressive weight gain, rounding of the face, and\\nincreased blood pressure. Women can experience men-\\nstrual cycle alterations and men can experience feminiza-\\ntion. The symptoms for pheochromocytoma include\\nhypertension , acidosis, unexplained fever and weight\\nloss. Because of the hormones produced by this type of\\ntumor, anxiety is often a feature also.\\nDiagnosis\\nDiagnosis for adrenal cancer usually begins with\\nblood tests to evaluate the hormone levels. These hor-\\nmones include epinephrine, cortisol, and testosterone. It\\nalso includes magnetic resonance imaging , and com-\\nputed tomography scans to determine the extent of the\\ndisease. Urine and blood tests can be done to detect the\\nhigh levels of hormone secreted by the tumor.\\nTreatment\\nTreatment is aimed at removing the tumor by\\nsurgery. In some cases, this can be done by laparoscopy.\\nSurgery is sometimes followed by chemotherapy and/or\\nradiation therapy . Because the surgery removes the\\nsource of many important hormones, hormones must be\\nsupplemented following surgery. If adrenocortical cancer\\nrecurs or has spread to other parts of the body (metasta-\\nsized), additional surgery may be done followed by\\nchemotherapy using the drug mitotane.\\nKEY TERMS\\nCortisol —A hormone produced by the adrenal\\ncortex. It is partially responsible for regulating\\nblood sugar levels.\\nDiabetes—A disease characterized by low blood\\nsugar.\\nEpinephrine—A hormone produced by the adren-\\nal medulla. It is important in the response to stress\\nand partially regulates heart rate and metabolism.\\nIt is also called adrenaline.\\nLaparoscopy—The insertion of a tube through the\\nabdominal wall. It can be used to visualize the\\ninside of the abdomen and for surgical procedures.\\nAlternative treatment\\nAs with any form of cancer, all conventional treat-\\nment options should be considered and applied as appro-\\npriate. Nutritional support, as well as supporting the func-\\ntioning of the entire person diagnosed with adrenal gland\\ncancer through homeopathic medicine,acupuncture, vit-\\namin and mineral supplementation, and herbal medicine,\\ncan benefit recovery and enhance quality of life.\\nPrognosis\\nThe prognosis for adrenal gland cancer is variable.\\nFor localized pheochromocytomas the 5-year survival rate\\nis 95%. This rate decreases with aggressive tumors that\\nhave metastasized. The prognosis for adrenal cortical can-\\ncer is not as good with a 5-year survival rate of 10-35%.\\nPrevention\\nSince so little is known about the cause of adrenal\\ngland cancer, it is not known if it can be prevented.\\nResources\\nBOOKS\\nNorton, J. A. “Adrenal Tumors.” In Cancer, Principles and\\nPractice of Oncology. Ed. V . T. DeVita, S. Hellman, and\\nS. A. Rosenberg. Philadelphia: Lippincott-Raven, 1997.\\nOTHER\\nEndocrine Web..\\nCindy L. A. Jones, PhD\\nAdrenal gland removal see Adrenalectomy\\nAdrenal gland scan\\nDefinition\\nThe adrenal gland scan is a nuclear medicine evalua-\\ntion of the medulla (inner tissue) of the adrenal gland.\\nPurpose\\nThe adrenal glands are a pair of small organs located\\njust above the kidney, which contain two types of tissue.\\nThe adrenal cortex produces hormones that affect water\\nbalance and metabolism in the body. The adrenal medul-\\nla produces adrenaline and noradrenaline (also called\\nepinepherine and norepinepherine).\\nAn adrenal gland scan is done when too much\\nadrenaline and noradrenaline is produced in the body and\\nGALE ENCYCLOPEDIA OF MEDICINE 260\\nAdrenal gland scan\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 60'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 74, 'page_label': '75'}, page_content='a tumor in the adrenal gland is suspected. One such situa-\\ntion in which a tumor might be suspected is when high\\nblood pressure (hypertension) does not respond to med-\\nication. Tumors that secrete adrenaline and noradrenaline\\ncan also be found outside the adrenal gland. An adrenal\\ngland scan usually covers the abdomen, chest, and head.\\nPrecautions\\nAdrenal gland scans are not recommended for preg-\\nnant women because of the potential harm to the devel-\\noping fetus. A pregnant woman should discuss with her\\ndoctor the risks of the procedure against the benefits of\\nthe information it can provide in evaluating her individ-\\nual medical situation.\\nPeople who have recently undergone tests that use\\nbarium must wait until the barium has been eliminated\\nfrom their system in order to obtain accurate results from\\nthe adrenal gland scan.\\nDescription\\nThe adrenal gland scan takes several days. On the\\nfirst day, a radiopharmaceutical is injected intravenously\\ninto the patient. On the second, third, and fourth day the\\npatient is positioned under the camera for imaging. The\\nscanning time each day takes approximately 30 minutes.\\nIt is essential that the patient remain still during imaging.\\nOccasionally, the scanning process may involve\\nfewer than three days, or it may continue several days\\nlonger. The area scanned extends from the pelvis and\\nlower abdomen to the lower chest. Sometimes the upper\\nlegs, thighs, and head are also included.\\nPreparation\\nFor two days before and ten days after the injection\\nof the radiopharmaceutical, patients are given either\\nLugol’s solution or potassium iodine. This prevents the\\nthyroid from taking up radioactive iodine and interfering\\nwith the scan.\\nAftercare\\nThe patient should not feel any adverse effects of the\\ntest and can resume normal activity immediately. Follow-\\nup tests that might be ordered include a nuclear scan of\\nthe bones or kidney, a computed tomography scan (CT)\\nof the adrenals, or an ultrasound of the pelvic area.\\nRisks\\nThe main risk associated with this test is to the fetus\\nof a pregnant woman.\\nKEY TERMS\\nAdrenal cortex —The outer tissue of the adrenal\\ngland. It produces a group of chemically related\\nhormones called corticosteroids that control min-\\neral and water balance in the body and include\\naldosterone and cortisol.\\nAdrenal medulla—The inner tissue of the adrenal\\ngland. It produces the hormones adrenaline and\\nnoradrenaline.\\nLugol’s solution—A strong iodine solution.\\nNormal results\\nNormal results will show no unusual areas of hor-\\nmone secretion and no tumors.\\nAbnormal results\\nAbnormal results will show evidence of a tumor\\nwhere there is excessive secretion of adrenaline or nora-\\ndrenaline. Over 90% of these tumors are in the abdomen.\\nResources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nTish Davidson\\nAdrenal hypofunction see Addison’s disease\\nAdrenal insufficiency see Addison’s disease\\nAdrenal virilism\\nDefinition\\nAdrenal virilism is the development or premature\\ndevelopment of male secondary sexual characteristics\\ncaused by male sex hormones (androgens) excessively\\nproduced by the adrenal gland. This disorder can occur\\nbefore birth and can lead to sexual abnormalities in new-\\nborns. It can also occur in girls and women later in life.\\nDescription\\nIn the normal human body, there are two adrenal\\nglands. They are small structures that lie on top of the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 61\\nAdrenal virilism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 61'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 75, 'page_label': '76'}, page_content='kidneys. The adrenal glands produce many hormones\\nthat regulate body functions. These hormones include\\nandrogens, or male hormones. Androgens are produced\\nin normal girls and women. Sometimes, one or both of\\nthe adrenal glands becomes enlarged or overactive, pro-\\nducing more than the usual amount of androgens. The\\nexcess androgens create masculine characteristics.\\nCauses and symptoms\\nIn infants and children, adrenal virilism is usually\\nthe result of adrenal gland enlargement that is present at\\nbirth. This is called congenital adrenal hyperplasia .\\nThe cause is usually a genetic problem that leads to\\nsevere enzyme deficiencies. In rare cases, adrenal viril-\\nism is caused by an adrenal gland tumor. The tumor can\\nbe benign (adrenal adenoma) or cancerous (adrenal car-\\ncinoma). Sometimes virilism is caused by a type of\\ntumor on a woman’s ovary (arrhenoblastoma).\\nNewborn girls with adrenal virilism have external\\nsex organs that seem to be a mixture of male and female\\norgans (called female pseudohermaphrodism). Newborn\\nboys with the disorder have enlarged external sex organs,\\nand these organs develop at an abnormally rapid pace.\\nChildren with congenital adrenal hyperplasia begin\\ngrowing abnormally fast, but they stop growing earlier\\nthan normal. Later in childhood, they are typically short-\\ner than normal but have well-developed trunks.\\nWomen with adrenal virilization may develop facial\\nhair. Typically, their menstrual cycles are infrequent or\\nabsent. They may also develop a deeper voice, a more\\nprominent Adam’s apple, and other masculine signs.\\nDiagnosis\\nEndocrinologists, doctors who specialize in the\\ndiagnosis and treatment of glandular disorders, have the\\nmost expertise to deal with adrenal virilization. Some\\nKEY TERMS\\nGlucocorticoid —A hormone produced by the\\nadrenal gland; this hormone leads to an increase\\nin blood sugar and creation of sugar molecules by\\nthe liver.\\nHydrocortisone—A hormone in the group of glu-\\ncocorticoid hormones.\\nPrednisone—A drug that functions as a glucocorti-\\ncoid hormone.\\ndoctors who treat disorders of the internal organs\\n(internists) and doctors who specialize in treating the\\nreproductive system of women (gynecologists) may also\\nbe able to help patients with this disorder.\\nDiagnosis involves performing many laboratory\\ntests on blood samples from the patient. These tests mea-\\nsure the concentration of different hormones. Different\\nabnormalities of the adrenal gland produce a different\\npattern of hormonal abnormalities. These tests can also\\nhelp determine if the problem is adrenal or ovarian. If a\\ntumor is suspected, special x rays may be done to visual-\\nize the tumor in the body. Final diagnosis may depend on\\nobtaining a tissue sample from the tumor (biopsy), and\\nexamining it under a microscope in order to verify its\\ncharacteristics.\\nTreatment\\nAdrenal virilism caused by adrenal hyperplasia is\\ntreated with daily doses of a glucocorticoid. Usually\\nprednisone is the drug of choice, but in infants hydrocor-\\ntisone is usually given. Laboratory tests are usually need-\\ned from time to time to adjust the dosage. Girls with\\npseudohermaphrodism may require surgery to make their\\nexternal sex organs appear more normal. If a tumor is\\ncausing the disorder, the treatment will depend on the\\ntype and location of the tumor. Information about the\\ntumor cell type and the spread of the tumor is used to\\ndecide the best kind of treatment for a particular patient.\\nIf the tumor is cancerous, the patient will require special\\ntreatment depending on how far the cancer has\\nadvanced. Treatment can be a combination of surgery,\\nmedications used to kill cancer cells ( chemotherapy ),\\nand x rays or other high energy rays used to kill cancer\\ncells ( radiation therapy ). Sometimes the doctor must\\nremove the adrenal gland and the surrounding tissues. If\\nthe tumor is benign, then surgically removing the tumor\\nmay be the best option.\\nPrognosis\\nOngoing glucocorticoid treatment usually controls\\nadrenal virilism in cases of adrenal hyperplasia, but there\\nis no cure. If a cancerous tumor has caused the disorder,\\npatients have a better prognosis if they have an early stage\\nof cancer that is diagnosed quickly and has not spread.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nLittle, M., and D. C. Garrell. Encyclopedia of Health; The\\nEndocrine System: The Healthy Body.Chelsea House,\\n1990.\\nGALE ENCYCLOPEDIA OF MEDICINE 262\\nAdrenal virilism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 62'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 76, 'page_label': '77'}, page_content='PERIODICALS\\nWillensy, D. “The Endocrine System.”American Health (Apr.\\n1996): 92-3.\\nRichard H. Lampert\\nAdrenalectomy\\nDefinition\\nAdrenalectomy is the surgical removal of one or\\nboth of the adrenal glands. The adrenal glands are paired\\nendocrine glands, one located above each kidney, that\\nproduce hormones such as epinephrine, norepinephrine,\\nandrogens, estrogens, aldosterone, and cortisol. Adrena-\\nlectomy is usually performed by conventional (open)\\nsurgery, but in selected patients surgeons may use\\nlaparoscopy . With laparoscopy, adrenalectomy can be\\naccomplished through four very small incisions.\\nPurpose\\nAdrenalectomy is usually advised for patients with\\ntumors of the adrenal glands. Adrenal gland tumors may\\nbe malignant or benign, but all typically excrete excessive\\namounts of one or more hormones. A successful proce-\\ndure will aid in correcting hormone imbalances, and may\\nalso remove cancerous tumors that can invade other parts\\nof the body. Occasionally, adrenalectomy may be recom-\\nmended when hormones produced by the adrenal glands\\naggravate another condition such as breast cancer.\\nPrecautions\\nThe adrenal glands are fed by numerous blood ves-\\nsels, so surgeons need to be alert to extensive bleeding\\nduring surgery. In addition, the adrenal glands lie close to\\none of the body’s major blood vessels (the vena cava),\\nand to the spleen and the pancreas. The surgeon needs to\\nremove the gland(s) without damaging any of these\\nimportant and delicate organs.\\nDescription\\nOpen adrenalectomy\\nThe surgeon may operate from any of four direc-\\ntions, depending on the exact problem and the patient’s\\nbody type.\\nIn the anterior approach, the surgeon cuts into the\\nabdominal wall. Usually the incision will be horizontal,\\njust under the rib cage. If the surgeon intends to operate\\non only one of the adrenal glands, the incision will run\\nunder just the right or the left side of the rib cage. Some-\\ntimes a vertical incision in the middle of the abdomen\\nprovides a better approach, especially if both adrenal\\nglands are involved.\\nIn the posterior approach, the surgeon cuts into the\\nback, just beneath the rib cage. If both glands are to be\\nremoved, an incision is made on each side of the body.\\nThis approach is the most direct route to the adrenal\\nglands, but it does not provide quite as clear a view of the\\nsurrounding structures as the anterior approach.\\nIn the flank approach, the surgeon cuts into the\\npatient’s side. This is particularly useful in massively obese\\npatients. If both glands need to be removed, the surgeon\\nmust remove one gland, repair the surgical wound, turn the\\npatient onto the other side, and repeat the entire process.\\nThe last approach involves an incision into the chest\\ncavity, either with or without part of the incision into the\\nabdominal cavity. It is used when the surgeon anticipates\\na very large tumor, or if the surgeon needs to examine or\\nremove nearby structures as well.\\nLaparoscopic adrenalectomy\\nThis technique does not require the surgeon to open\\nthe body cavity. Instead, four small incisions (about 1/2\\nin diameter each) are made into a patient’s flank, just\\nunder the rib cage. A laparoscope, which enables the sur-\\ngeon to visualize the inside of the abdominal cavity on a\\ntelevision monitor, is placed through one of the incisions.\\nThe other incisions are for tubes that carry miniaturized\\nversions of surgical tools. These tools are designed to be\\noperated by manipulations that the surgeon makes out-\\nside the body.\\nPreparation\\nMost aspects of preparation are the same as in other\\nmajor operations. In addition, hormone imbalances are\\noften a major challenge. Whenever possible, physicians\\nwill try to correct hormone imbalances through medica-\\ntion in the days or weeks before surgery. Adrenal tumors\\nmay cause other problems such as hypertension or inad-\\nequate potassium in the blood, and these problems also\\nshould be resolved if possible before surgery is per-\\nformed. Therefore, a patient may take specific medicines\\nfor days or weeks before surgery.\\nMost adrenal tumors can be imaged very well with a\\nCT scan or MRI, and benign tumors tend to look differ-\\nent on these tests than do cancerous tumors. Surgeons\\nmay order a CT scan, MRI, or scintigraphy (viewing of\\nthe location of a tiny amount of radioactive agent) to help\\nlocate exactly where the tumor is.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 63\\nAdrenalectomy\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 63'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 77, 'page_label': '78'}, page_content='The day before surgery, patients will probably have\\nan enema to clear the bowels. In patients with lung prob-\\nlems or clotting problems, physicians may advise special\\npreparations.\\nAftercare\\nPatients stay in the hospital for various lengths of\\ntime after adrenalectomy. The longest hospital stays are\\nrequired for open surgery using an anterior approach;\\nhospital stays of about three days are indicated for open\\nsurgery using the posterior approach or for laparoscopic\\nadrenalectomy.\\nThe special concern after adrenalectomy is the\\npatient’s hormone balance. There may be several sets of\\nlab tests to define hormone problems and monitor the\\nresults of drug treatment. In addition, blood pressure\\nproblems and infections are more common after removal\\nof certain types of adrenal tumors.\\nAs with most open surgery, surgeons are also con-\\ncerned about blood clots forming in the legs and travel-\\ning to the lungs (venous thromboembolism), bowel prob-\\nlems, and postoperative pain. With laparoscopic adrena-\\nlectomy, these problems are somewhat less difficult, but\\nthey are still present.\\nRisks\\nThe special risks of adrenalectomy involve major\\nhormone imbalances, caused by the underlying disease,\\nKEY TERMS\\nLaparoscope—An instrument that enables the sur-\\ngeon to see inside the abdominal cavity by means\\nof a thin tube that carries an image to a television\\nmonitor.\\nPancreas—An organ that secretes a number of\\ndigestive hormones and also secretes insulin to\\nregulate blood sugar.\\nPheochromocytoma—A tumor of specialized cells\\nof the adrenal gland.\\nSpleen—An organ that traps and breaks down red\\nblood cells at the end of their useful life and man-\\nufactures some key substances used by the\\nimmune system.\\nVena cava—The large vein that drains directly into\\nthe heart after gathering incoming blood from the\\nentire body.\\nthe surgery, or both.These can include problems with\\nwound healing itself, blood pressure fluctuations, and\\nother metabolic problems.\\nOther risks are typical of many operations.These\\ninclude:\\n• bleeding\\n• damage to adjacent organs (spleen, pancreas)\\n• loss of bowel function\\n• blood clots in the lungs\\n• lung problems\\n• surgical infections\\n• pain\\n• extensive scarring\\nResources\\nBOOKS\\nBradley, Edward L., III. The Patient’s Guide to Surgery.\\nPhiladelphia: University of Pennsylvania Press, 1994.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nLittle, M., and D. C. Garrell. The Endocrine System: The\\nHealthy Body. Chelsea House, 1990.\\nRichard H. Lampert\\nJanis O. Flores\\nAdrenocortical insufficiency see Addison’s\\ndisease\\nAdrenocorticotropic hormone\\ntest\\nDefinition\\nAdrenocorticotropic hormone test (also known as an\\nACTH test or a corticotropin test) measures pituitary\\ngland function.\\nPurpose\\nThe pituitary gland produces the hormone ACTH,\\nwhich stimulates the outer layer of the adrenal gland (the\\nadrenal cortex). ACTH causes the release of the hormones\\nhydrocortisone (cortisol), aldosterone, and androgen. The\\nmost important of these hormones released is cortisol.\\nThe ACTH test is used to determine if too much cortisol\\nis being produced ( Cushing’s syndrome ) or if not\\nenough cortisol is being produced (Addison’s disease).\\nGALE ENCYCLOPEDIA OF MEDICINE 264\\nAdrenocorticotropic hormone test\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 64'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 78, 'page_label': '79'}, page_content='Precautions\\nACTH has diurnal variation, meaning that the levels\\nof this hormone vary according to the time of day. The\\nhighest levels occur in the morning hours. Testing for\\nnormal secretion, as well as for Cushing’s disease, may\\nrequire multiple samples. For sequential follow-up, a\\nblood sample analyzed for ACTH should always be\\ndrawn at the same time each day.\\nACTH can be directly measured by an analyzing\\nmethod (immunoassay) in many large laboratories. How-\\never, smaller laboratories are usually not equipped to per-\\nform this test and they may need to send the blood sam-\\nple to a larger laboratory. Because of this delay, results\\nmay take several days to obtain.\\nDescription\\nACTH production is partly controlled by an area in\\nthe center of the brain (the hypothalamus) and partly\\ncontrolled by the level of cortisol in the blood. When\\nACTH levels are too high, cortisol production increases\\nto suppress ACTH release from the pituitary gland. If\\nACTH levels are too low, the hypothalamus produces\\ncorticotropin-releasing hormone (CRH) to stimulate the\\npituitary gland to make more ACTH. ACTH levels rise in\\nresponse to stress, emotions, injury, infection, burns,\\nsurgery, and decreased blood pressure.\\nCushing’s syndrome\\nCushing’s syndrome is caused by an abnormally high\\nlevel of circulating hydrocortisone. The high level may be\\nthe result of an adrenal gland tumor or enlargement of\\nboth adrenal glands due to a pituitary tumor. The high\\nlevel of hydrocortisone may be the result of taking corti-\\ncosteroid drugs for a long time. Corticosteroid drugs are\\nwidely used for inflammation in disorders like rheuma-\\ntoid arthritis, inflammatory bowel disease, and asthma.\\nAddison’s disease\\nAddison’s disease is a rare disorder in which\\nsymptoms are caused by a deficiency of hydrocorti-\\nsone and aldosterone. The most common cause of this\\ndisease is an autoimmune disorder. The immune sys-\\ntem normally fights foreign invaders in the body like\\nbacteria. In an autoimmune disorder, the immune sys-\\ntems attacks the body. In this case, the immune system\\nproduces antibodies that attack the adrenal glands.\\nAddison’s disease generally progresses slowly, with\\nsymptoms developing gradually over months or years.\\nHowever, acute episodes, called Addisonian crises, are\\nbrought on by infection, injury, or other stresses. Diag-\\nnosis is generally made if the patient fails to respond to\\nKEY TERMS\\nAdrenal glands —A pair of endocrine glands that\\nlie on top of the kidneys.\\nPituitary gland —The most important of the\\nendocrine glands, glands that release hormones\\ndirectly into the bloodstream; sometimes called\\nthe master gland.\\nan injection of ACTH, which normally stimulates the\\nsecretion of hydrocortisone.\\nPreparation\\nA person’s ACTH level is determined from a blood\\nsample. The patient must fast from midnight until the test\\nthe next morning. This means that the patient cannot eat\\nor drink anything after midnight except water. The patient\\nmust also avoid radioisotope scanning tests or recently\\nadministered radioisotopes prior to the blood test.\\nRisks\\nThe risks associated with this test are minimal. They\\nmay include slight bleeding from the location where the\\nblood was drawn. The patient may feel faint or lighthead-\\ned after the blood is drawn. Sometimes the patient may\\nhave an accumulation of blood under the puncture site\\n(hematoma) after the test.\\nNormal results\\nEach laboratory will have its own set of normal val-\\nues for this test. The normal values can range from:\\nMorning (4-8 \\nA.M.) 8-100 pg/mL or 10-80 ng/L (SI units)\\nEvening (8-10 P.M.) less than 50 pg/mL or less than 50\\nng/L (SI units)\\nAbnormal results\\nIn Cushing’s syndrome, high levels of ACTH may\\nbe caused by ACTH-producing tumors. These tumors\\nmay be either in the pituitary or in another area (like\\ntumors from lung cancer or ovarian cancer ). Low\\nACTH levels may be caused by adrenal enlargement due\\nto high levels of cortisol and feedback to the pituitary.\\nIn Addison’s disease, high levels of ACTH may be\\ncaused by adrenal gland diseases. These diseases decrease\\nadrenal hormones and the pituitary attempts to increase\\nfunctioning. Low levels of ACTH may occur because of\\ndecreased pituitary function.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 65\\nAdrenocorticotropic hormone test\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 65'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 79, 'page_label': '80'}, page_content='KEY TERMS\\nAmniocentesis —The collection of amniotic fluid\\nthrough a needle inserted through the abdomen.\\nUsed to collect fetal cells for genetic analysis.\\nAtaxia—Loss of coordination of muscular move-\\nment.\\nHypertonia—Having excessive muscular tone.\\nMyelin—A layer that encloses nerve cells and\\nsome axons and is made largely of lipids and\\nlipoproteins.\\nNeuropathy —A disease or abnormality of the\\nperipheral nerves.\\nResources\\nBOOKS\\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\\nAdrenogenital syndrome see Adrenal virilism\\nAdrenoleukodystrophy\\nDefinition\\nAdrenoleukodystrophy is a rare genetic disease\\ncharacterized by a loss of myelin surrounding nerve cells\\nin the brain and progressive adrenal gland dysfunction.\\nDescription\\nAdrenoleukodystrophy (ALD) is a member of a\\ngroup of diseases, leukodystrophies, that cause damage\\nto the myelin sheath of nerve cells. Approximately one in\\n100,000 people is affected by ALD. There are three basic\\nforms of ALD: childhood, adult-onset, and neonatal. The\\nchildhood form of the disease is the classical form and is\\nthe most severe. Childhood ALD is progressive and usu-\\nally leads to total disability or death. It affects only boys\\nbecause the genetic defect is sex-linked (carried on the X\\nchromosome). Onset usually occurs between ages four\\nand ten and can include many different symptoms, not all\\nof which appear together. The most common symptoms\\nare behavioral problems and poor memory. Other symp-\\ntoms frequently seen are loss of vision, seizures, poorly\\narticulated speech, difficulty swallowing, deafness, prob-\\nlems with gait and coordination, fatigue, increased skin\\npigmentation, and progressive dementia.\\nThe adult-onset form of the disease, also called\\nadrenomyeloneuropathy, is milder, progresses slowly, is\\nusually associated with a normal life span, and usually\\nappears between ages 21-35. Symptoms may include\\nprogressive stiffness, weakness, or paralysis of the lower\\nlimbs and loss of coordination. Brain function deteriora-\\ntion may also been seen. Women who are carriers of the\\ndisease occasionally experience the same symptoms, as\\nwell as others, including ataxia, hypertonia (excessive\\nmuscle tone), mild peripheral neuropathy, and urinary\\nproblems. The neonatal form affects both male and\\nfemale infants and may produce mental retardation ,\\nfacial abnormalities, seizures, retinal degeneration, poor\\nmuscle tone, enlarged liver, and adrenal dysfunction.\\nNeonatal ALD usually progresses rapidly.\\nCauses and symptoms\\nThe genetic defect in ALD causes a decrease in the\\nability to degrade very long chain fatty acids. These build\\nup in the adrenal glands, brain, plasma, and fibroblasts.\\nThe build-up of very long chain fatty acids interferes\\nwith the ability of the adrenal gland to convert choles-\\nterol into steroids and causes demyelination of nerves in\\nthe white matter of the brain. Demyelinated nerve cells\\nare unable to function properly.\\nDiagnosis\\nDiagnosis is made based on observed symptoms, a\\nbiochemical test, and a family history. The biochemical\\ntest detects elevated levels of very long chain fatty acids\\nin samples from amniocentesis, chorionic villi, plasma,\\nred blood cells, or fibroblasts. A family history may indi-\\ncate the likelihood of ALD because the disease is carried\\non the X-chromosome by the female lineage of families.\\nTreatment\\nTreatment for all forms of ALD consists of treating\\nthe symptoms and supporting the patient with physical\\ntherapy, psychological counseling, and special education\\nin some cases. There is no cure for this disease, and there\\nare no drugs that can reverse demyelination of nerve and\\nbrain cells. Dietary measures consist of reducing the\\nintake of foods high in fat, which are a source of very\\nlong chain fatty acids. A mixture called Lorenzo’s Oil\\nhas been shown to reduce the level of long chain fatty\\nacids if used long term; however, the rate of myelin loss\\nGALE ENCYCLOPEDIA OF MEDICINE 266\\nAdrenoleukodystrophy3\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 66'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 80, 'page_label': '81'}, page_content='is unaffected. Experimental bone marrow transplanta-\\ntion has not been very effective.\\nPrognosis\\nPrognosis for childhood and neonatal ALD patients\\nis poor because of the progressive myelin degeneration.\\nDeath usually occurs between one and ten years after\\nonset of symptoms.\\nPrevention\\nSince ALD is a genetic disease, prevention is largely\\nlimited to genetic counseling and fetal monitoring\\nthrough amniocentesis or chorionic villus sampling.\\nResources\\nBOOKS\\nBerkow, Robert. Merck Manual of Medical Information.White-\\nhouse Station, NJ: Merck Research Laboratories, 1997.\\nJohn T. Lohr, PhD\\nAdrenomyeloneuropathy see Adrenoleuko-\\ndystrophy\\nAdult respiratory distress\\nsyndrome\\nDefinition\\nAdult respiratory distress syndrome (ARDS), also\\ncalled acute respiratory distress syndrome, is a type of\\nlung (pulmonary) failure that may result from any dis-\\nease that causes large amounts of fluid to collect in the\\nlungs. ARDS is not itself a specific disease, but a syn-\\ndrome, a group of symptoms and signs that make up one\\nof the most important forms of lung or respiratory fail-\\nure. It can develop quite suddenly in persons whose\\nlungs have been perfectly normal. Very often ARDS is a\\ntrue medical emergency. The basic fault is a breakdown\\nof the barrier, or membrane, that normally keeps fluid\\nfrom leaking out of the small blood vessels of the lung\\ninto the breathing sacs (the alveoli).\\nDescription\\nAnother name for ARDS is shock lung. Its formal\\nname is misleading, because children, as well as adults,\\nmay be affected. In the lungs the smallest blood vessels,\\nor capillaries, make contact with the alveoli, tiny air sacs\\nat the tips of the smallest breathing tubes (the bronchi).\\nThis is the all-important site where oxygen passes from\\nair that is inhaled to the blood, which carries it to all parts\\nof the body. Any form of lung injury that damages this\\npoint of contact, called the alveolo-capillary junction,\\nwill allow blood and tissue fluid to leak into the alveoli,\\neventually filling them so that air cannot enter. The result\\nis the type of breathing distress called ARDS. ARDS is\\none of the major causes of excess fluid in the lungs, the\\nother being heart failure.\\nAlong with fluid there is a marked increase in\\ninflamed cells in the lungs. There also is debris left over\\nfrom damaged lung cells, and fibrin, a semi-solid materi-\\nal derived from blood in the tissues. Typically these\\nmaterials join together with large molecules in the blood\\n(proteins), to form hyaline membranes. (These mem-\\nbranes are very prominent in premature infants who\\ndevelop respiratory distress syndrome; it is often called\\nhyaline membrane disease.) If ARDS is very severe or\\nlasts a long time, the lungs do not heal, but rather become\\nscarred, a process known as fibrosis. The lack of a nor-\\nmal amount of oxygen causes the blood vessels of the\\nlung to become narrower, and in time they, too, may\\nbecome scarred and filled with clotted blood. The lungs\\nas a whole become very “stiff,” and it becomes much\\nharder for the patient to breathe.\\nCauses and symptoms\\nA very wide range of diseases or toxic substances,\\nincluding some drugs, can cause ARDS. They include:\\n• Breathing in (aspiration) of the stomach contents when\\nregurgitated, or salt water or fresh water from nearly\\ndrowning.\\n• Inhaling smoke, as in a fire; toxic materials in the air,\\nsuch as ammonia or hydrocarbons; or too much oxy-\\ngen, which itself can injure the lungs.\\n• Infection by a virus or bacterium, or sepsis, a wide-\\nspread infection that gets into the blood.\\n• Massive trauma, with severe injury to any part of the\\nbody.\\n• Shock with persistently low blood pressure may not in\\nitself cause ARDS, but it can be an important factor.\\n• A blood clotting disorder called disseminated intravas-\\ncular coagulation, in which blood clots form in vessels\\nthroughout the body, including the lungs.\\n• A large amount of fat entering the circulation and trav-\\neling to the lungs, where it lodges in small blood ves-\\nsels, injuring the cells lining the vessel walls.\\n• An overdose of a narcotic drug, a sedative, or, rarely,\\naspirin.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 67\\nAdult respiratory distress syndrome\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 67'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 81, 'page_label': '82'}, page_content='• Inflammation of the pancreas ( pancreatitis ), when\\nblood proteins, called enzymes, pass to the lungs and\\ninjure lung cells.\\n• Severe burn injury.\\n• Injury of the brain, or bleeding into the brain, from any\\ncause may be a factor in ARDS for reasons that are not\\nclear. Convulsions also may cause some cases.\\nUsually ARDS develops within one to two days of the\\noriginal illness or injury. The person begins to take rapid\\nbut shallow breaths. The doctor who listens to the patient’s\\nchest with a stethoscope may hear “crackling” or wheez-\\ning sounds. The low blood oxygen content may cause the\\nskin to appear mottled or even blue. As fluid continues to\\nfill the breathing sacs, the patient may have great trouble\\nbreathing, take very rapid breaths, and gasp for air.\\nDiagnosis\\nA simple test using a device applied to the ear will\\nshow whether the blood is carrying too little oxygen, and\\nthis can be confirmed by analyzing blood taken from an\\nartery. The chest x ray may be normal in the early stages,\\nbut, in a short time, fluid will be seen where it does not\\nbelong. The two lungs are about equally affected. A heart\\nof normal size indicates that the problem actually is ARDS\\nand not heart failure. Another way a physician can distin-\\nguish between these two possibilities is to place a catheter\\nKEY TERMS\\nAlveoli—The tiny air sacs at the ends of the breath-\\ning tubes of the lung where oxygen normally is\\ntaken up by the capillaries to enter the circulation.\\nAspiration—The process in which solid food, liq-\\nuids, or secretions that normally are swallowed\\nare, instead, breathed into the lungs.\\nCapillaries —The smallest arteries which, in the\\nlung, are located next to the alveoli so that they\\ncan pick up oxygen from inhaled air.\\nFace mask—The simplest way of delivering a high\\nlevel of oxygen to patients with ARDS or other\\nlow-oxygen conditions.\\nSteroids —A class of drugs resembling normal\\nbody substances that often help control inflamma-\\ntion in the body tissues.\\nVentilator —A mechanical device that can take\\nover the work of breathing for a patient whose\\nlungs are injured or are starting to heal.\\ninto a vein and advance it into the main artery of the lung.\\nIn this way, the pressure within the pulmonary capillaries\\ncan be measured. Pressure within the pulmonary capillar-\\nies is elevated in heart failure, but normal in ARDS.\\nTreatment\\nThe three main goals in treating patients with ARDS\\nare:\\n• To treat whatever injury or disease has caused ARDS.\\nExamples are: to treat septic infection with the proper\\nantibiotics, and to reduce the level of oxygen therapy if\\nARDS has resulted from a toxic level of oxygen.\\n• To control the process in the lungs that allows fluid to\\nleak out of the blood vessels. At present there is no cer-\\ntain way to achieve this. Certain steroid hormones have\\nbeen tried because they can combat inflammation, but\\nthe actual results have been disappointing.\\n• To make sure the patient gets enough oxygen until the\\nlung injury has had time to heal. If oxygen delivered by\\na face mask is not enough, the patient is placed on a\\nventilator, which takes over breathing, and, through a\\ntube placed in the nose or mouth (or an incision in the\\nwindpipe), forces oxygen into the lungs. This treatment\\nmust be closely supervised, and the pressure adjusted\\nso that too much oxygen is not delivered.\\nPatients with ARDS should be cared for in an inten-\\nsive care unit, where experienced staff and all needed\\nequipment are available. Enough fluid must be provided,\\nby vein if necessary, to prevent dehydration . Also, the\\npatient’s nutritional state must be maintained, again by\\nvein, if oral intake is not sufficient.\\nPrognosis\\nIf the patient’s lung injury does not soon begin to\\nheal, the lack of sufficient oxygen can injure other organs,\\nsuch as the kidneys. There always is a risk that bacterial\\npneumonia will develop at some point. Without prompt\\ntreatment, as many as 90% of patients with ARDS can be\\nexpected to die. With modern treatment, however, about\\nhalf of all patients will survive. Those who do live usually\\nrecover completely, with little or no long-term breathing\\ndifficulty. Lung scarring is a risk after a long period on a\\nventilator, but it may improve in the months after the\\npatient is taken off ventilation. Whether a particular\\npatient will recover depends to a great extent on whether\\nthe primary disease that caused ARDS to develop in the\\nfirst place can be effectively treated.\\nPrevention\\nThe only way to prevent ARDS is to avoid those dis-\\neases and harmful conditions that damage the lung. For\\nGALE ENCYCLOPEDIA OF MEDICINE 268\\nAdult respiratory distress syndrome\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 68'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 82, 'page_label': '83'}, page_content='instance, the danger of aspirating stomach contents into\\nthe lungs can be avoided by making sure a patient does not\\neat shortly before receiving general anesthesia. If a patient\\nneeds oxygen therapy, as low a level as possible should be\\ngiven. Any form of lung infection, or infection anywhere\\nin the body that gets into the blood, must be treated\\npromptly to avoid the lung injury that causes ARDS.\\nResources\\nBOOKS\\nSmolley, Lawrence A., and Debra F. Bryse. Breathe Right\\nNow: A Comprehensive Guide to Understanding and\\nTreating the Most Common Breathing Disorders.New\\nYork: W. W. Norton & Co., 1998.\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Respiratory Distress Syndrome Foundation. P.O. Box\\n723, Montgomeryville, PA 18936.\\nOTHER\\n“Pulmonary Medicine.” HealthWeb.com. 5 Jan. 1998. .\\nDavid A. Cramer, MD\\nAFP test see Alpha-fetoprotein test\\nAfrican American health see Minority\\nhealth\\nAfrican sleeping sickness see Sleeping\\nsickness\\nAfrican trypanosomiasis see Sleeping\\nsickness\\nAgammaglobulinemia see Common\\nvariable immunodeficiency\\nAggression see Conduct disorder\\nAging\\nDefinition\\nStarting at what is commonly called middle age, oper-\\nations of the human body begin to be more vulnerable to\\ndaily wear and tear; there is a general decline in physical,\\nand possibly mental, functioning. In the Western countries,\\nthe length of life is often into the 70s. The upward limit of\\nthe life span, however, can be as high as 120 years. During\\nthe latter half of life, an individual is more prone to have\\nproblems with the various functions of the body and to\\ndevelop any number of chronic or fatal diseases. The car-\\ndiovascular, digestive, excretory, nervous, reproductive\\nand urinary systems are particularly affected. The most\\ncommon diseases of aging include Alzheimer’s, arthritis,\\ncancer, diabetes, depression, and heart disease.\\nDescription\\nHuman beings reach a peak of growth and develop-\\nment around the time of their mid 20s. Aging is the normal\\ntransition time after that flurry of activity. Although there\\nare quite a few age-related changes that tax the body, dis-\\nability is not necessarily a part of aging. Health and\\nlifestyle factors together with the genetic makeup of the\\nindividual, and determines the response to these changes.\\nBody functions that are most often affected by age include:\\n• Hearing, which declines especially in relation to the\\nhighest pitched tones.\\n• The proportion of fat to muscle, which may increase by\\nas much as 30%. Typically, the total padding of body\\nfat directly under the skin thins out and accumulates\\naround the stomach. The ability to excrete fats is\\nimpaired, and therefore the storage of fats increases,\\nincluding cholesterol and fat-soluble nutrients.\\n• The amount of water in the body decreases, which there-\\nfore decreases the absorption of water-soluble nutrients.\\nAlso, there is less saliva and other lubricating fluids.\\n• The liver and the kidneys cannot function as efficiently,\\nthus affecting the elimination of wastes.\\n• A decrease in the ease of digestion, with a decrease in\\nstomach acid production.\\n• A loss of muscle strength and coordination, with an\\naccompanying loss of mobility, agility, and flexibility.\\n• A decline in sexual hormones and sexual functioning.\\n• A decrease in the sensations of taste and smell.\\n• Changes in the cardiovascular and respiratory systems,\\nleading to decreased oxygen and nutrients throughout\\nthe body.\\n• Decreased functioning of the nervous system so that\\nnerve impulses are not transmitted as efficiently, reflex-\\nes are not as sharp, and memory and learning are\\ndiminished.\\n• A decrease in bone strength and density.\\n• Hormone levels, which gradually decline. The thyroid\\nand sexual hormones are particularly affected.\\n• Declining visual abilities. Age-related changes may\\nlead to diseases such as macular degeneration.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 69\\nAging\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 69'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 83, 'page_label': '84'}, page_content='• A compromised ability to produce vitamin D from sun-\\nlight.\\n• A reduction in protein formation leading to shrinkage\\nin muscle mass and decreased bone formation, possibly\\nleading to osteoporosis.\\nCauses and symptoms\\nThere are several theories as to why the aging body\\nloses functioning. It may be that several factors work\\ntogether or that one particular factor is at work more than\\nothers in a given individual.\\n• Programmed senescence, or aging clock, theory. The\\naging of the cells of each individual is programmed into\\nthe genes, and there is a preset number of possible reju-\\nvenations in the life of a given cell. When cells die at a\\nrate faster than they are replaced, organs do not func-\\ntion properly, and they are soon unable to maintain the\\nfunctions necessary for life.\\n• Genetic theory. Human cells maintain their own seed of\\ndestruction at the level of the chromosomes.\\n• Connective tissue, or cross-linking theory. Changes in\\nthe make-up of the connective tissue alter the stability\\nof body structures, causing a loss of elasticity and func-\\ntioning, and leading to symptoms of aging.\\n• Free-radical theory. The most commonly held theory of\\naging, it is based on the fact that ongoing chemical\\nreactions of the cells produce free radicals. In the pres-\\nence of oxygen, these free radicals cause the cells of the\\nbody to break down. As time goes on, more cells die or\\nlose the ability to function, and the body soon ceases to\\nfunction as a whole.\\n• Immunological theory. There are changes in the immune\\nsystem as it begins to wear out, and the body is more\\nprone to infections and tissue damage, which may finally\\ncause death. Also, as the system breaks down, the body\\nis more apt to have autoimmune reactions, in which the\\nbody’s own cells are mistaken for foreign material and\\nare destroyed or damaged by the immune system.\\nDiagnosis\\nMany problems can arise due to age-related changes\\nin the body. Although there is no one test to be given, a\\nthorough physical exam and a basic blood screening and\\nblood chemistry panel can point to areas in need of fur-\\nther attention. When older people become ill, the first\\nsigns of disease are often nonspecific. Further exams\\nshould be conducted if any of the following occur:\\n• diminished or lack of desire for food\\n• increasing confusion\\n• failure to thrive\\n• urinary incontinence\\n• dizziness\\n• weight loss\\n• falling\\nTreatment\\nFor the most part, doctors prescribe medications to\\ncontrol the symptoms and diseases of aging. In the Unit-\\ned States, about two-thirds of people 65 and over take\\nmedications for various complaints. More women than\\nmen use these medications. The most common drugs\\nused by the elderly are painkillers, diuretics or water\\npills, sedatives, cardiac drugs, antibiotics , and mental\\nhealth drugs.\\nEstrogen replacement therapy (ERT) is commonly\\nprescribed to postmenopausal women for symptoms of\\naging. It is often used in conjunction with progesterone.\\nERT functions to help keep bones strong, reduce risk of\\nheart disease, restore vaginal lubrication, and to improve\\nskin elasticity. Evidence suggests that it may also help\\nmaintain mental functions.\\nExpected results\\nAging is unavoidable, but major physical impair-\\nment is not. People can lead a healthy, disability-free life\\nwell through their later years. A well established support\\nsystem of family, friends, and health care providers,\\ntogether with focus on good nutrition and lifestyle\\nhabits and good stress management, can prevent disease\\nand lessen the impact of chronic conditions.\\nAlternative treatment\\nNutritional supplements\\nConsumption of a high–quality multivitamin is rec-\\nommended. Common nutritional deficiencies connected\\nwith aging include B vitamins , vitamins A and C, folic\\nacid, calcium, magnesium, zinc, iron, chromium, and\\ntrace minerals. Since stomach acids may be decreased, it\\nis suggested that the use of a powdered multivitamin for-\\nmula in gelatin capsules be used, as this form is the easi-\\nest to digest. Such formulas may also contain enzymes\\nfor further help with digestion.\\nAntioxidants can help to neutralize damage by the\\nfree radical actions thought to contribute to problems of\\naging. They are also helpful in preventing and treating\\ncancer and in treating cataracts and glaucoma. Supple-\\nments that serve as antioxidants include:\\nGALE ENCYCLOPEDIA OF MEDICINE 270\\nAging\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 70'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 84, 'page_label': '85'}, page_content='• Vitamin E, 400–1,000 IUs daily. Protects cell mem-\\nbranes against damage. It shows promise in prevention\\nagainst heart disease, and Alzheimer’s and Parkinson’s\\ndiseases.\\n• Selenium, 50 mg taken twice daily. Research suggests\\nthat selenium may play a role in reducing the risk of\\ncancer.\\n• Beta-carotene, 25,000–40,000 IUs daily. May help in\\ntreating cancer, colds and flu, arthritis, and immune\\nsupport.\\n• Vitamin C, 1,000–2,000 mg per day. It may cause diar-\\nrhea in large doses. If this occurs, however, all that is\\nneeded is a decrease in the dosage.\\nOther supplements that are helpful in treating age-\\nrelated problems including:\\n•B\\n12/B-complex vitamins, studies show that B12 may help\\nreduce mental symptoms, such as confusion, memory\\nloss, and depression.\\n• Coenzyme Q10 may be helpful in treating heart dis-\\nease, as up to three-quarters cardiac patients have been\\nfound to be lacking in this heart enzyme.\\nHormones\\nThe following hormone supplements may be taken\\nto prevent or to treat various age-related problems. How-\\never, caution should be taken before beginning treatment,\\nand the patient should consult his or her health care pro-\\nfessional.\\nDHEA improves brain functioning and serves as a\\nbuilding block for many other important hormones in the\\nbody. It may be helpful in restoring declining hormone\\nlevels and in building up muscle mass, strengthening the\\nbones, and maintaining a healthy heart.\\nMelatonin may be helpful for insomnia. It has also\\nbeen used to help fight viruses and bacterial infections,\\nreduce the risk of heart disease, improve sexual function-\\ning, and to protect against cancer.\\nHuman growth hormone (hGH) has been shown to\\nregulate blood sugar levels and to stimulate bone, carti-\\nlage, and muscle growth while reducing fat.\\nHerbs\\nGarlic (Allium sativa ) is helpful in preventing heart\\ndisease, as well as improving the tone and texture of\\nskin. Garlic stimulates liver and digestive system func-\\ntions, and also helps in dealing with heart disease and\\nhigh blood pressure.\\nSiberian ginseng ( Eleutherococcus senticosus ) sup-\\nports the adrenal glands and immune functions. It is\\nKEY TERMS\\nAntioxidants—Substances that reduce the damage\\nof the highly reactive free radicals that are the\\nbyproducts of the cells.\\nAlzheimer’s disease —A condition causing a\\ndecline in brain function that interferes with the\\nability to reason and to perform daily activities.\\nSenescence—Aging.\\nVata—One of the three main constitutional types\\nfound under Ayurvedic principles. Keeping one’s\\nparticular constitution in balance is considered\\nimportant in maintaining health.\\nbelieved to be helpful in treating problems related to\\nstress. Siberian ginseng also increases mental and physi-\\ncal performance, and may be useful in treating memory\\nloss, chronic fatigue, and immune dysfunction.\\nGinkgo biloba works particularly well on the brain\\nand nervous system. It is effective in reducing the symp-\\ntoms of conditions, such as Alzheimer’s, depression,\\nvisual problems, and problems of blood circulation. It\\nmay also help treat heart disease, strokes, dementia ,\\nRaynaud’s disease, head injuries, leg cramps, macular\\ndegeneration, tinnitus , impotence due to poor blood\\nflow, and diabetes-related nerve damage.\\nProanthocyanidins, or PCO, are Pycnogenol, derived\\nfrom grape seeds and skin, and from pine tree bark, and\\nmay help in the prevention of cancer and poor vision.\\nIn Ayurvedic medicine , aging is described as a\\nprocess of increased vata, in which there is a tendency to\\nbecome thinner, drier, more nervous, more restless, and\\nmore fearful, while having a loss of appetite as well as\\nsleep. Bananas, almonds, avocados, and coconuts are\\nsome of the foods used in correcting such conditions.\\nOne of the main herbs used for such conditions is gotu\\nkola (Centella asiatica ), which is used to revitalize the\\nnervous system and brain cells and to fortify the immune\\nsystem. Gotu kola is also used to treat memory loss,anx-\\niety, and insomnia.\\nIn Chinese medicine, most symptoms of aging are\\nregarded as symptoms of a yin deficiency. Moistening\\nfoods such as millet, barley soup, tofu, mung beans,\\nwheat germ, spirulina, potatoes, black sesame seeds,\\nwalnuts, and flax seeds are recommended. Jing tonics\\nmay also be used. These include deer antler, dodder\\nseeds, processed rehmannia, longevity soup, mussels,\\nand chicken.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 71\\nAging\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 71'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 85, 'page_label': '86'}, page_content='Prevention\\nPreventive health practices such as healthy diet,\\ndaily exercise , stress management, and control of\\nlifestyle habits such as smoking and drinking, can\\nlengthen the life span and improve the quality of life as\\npeople age. Exercise can improve the appetite, the health\\nof the bones, the emotional and mental outlook, and the\\ndigestion and circulation.\\nDrinking plenty of fluids aids in maintaining healthy\\nskin, good digestion, and proper elimination of wastes.\\nUp to eight glasses of water should be consumed daily,\\nalong with plenty of herbal teas, diluted fruit and veg-\\netable juices, and fresh fruits and vegetables with high\\nwater content.\\nBecause of a decrease in the sense of taste, older\\npeople often increase their intake of salt, which can con-\\ntribute to high blood pressure and nutrient loss. Use of\\nsugar is also increased. Seaweeds and small amounts of\\nhoney can be used as replacements.\\nAlcohol, nicotine, and caffeine all have potential\\ndamaging effects, and should be limited or completely\\neliminated from consumption.\\nA diet high in fiber and low in fat is recommended.\\nProcessed foods should be replaced by complex carbohy-\\ndrates, such as whole grains. If chewing becomes a prob-\\nlem, there should be an increased intake of protein drinks,\\nfreshly juiced fruits and vegetables, and creamed cereals.\\nResources\\nBOOKS\\nDarden Ph.D., Ellington. Living Longer Stronger.New York: A\\nPerigee Book, The Berkeley Publishing Group, 1995.\\nPitchford, Paul. Healing with Whole Foods.Berkeley, CA:\\nNorth Atlantic Books, 1993.\\nOTHER\\n“Anti-Aging-Nutritional Program.” (December\\n28, 2000).\\n“Effects of Hormone in the Body.” (December 28, 2000).\\n“The Elderly-Nutritional Programs.”\\n (December 28, 2000).\\n“Evaluating the Elderly Patient: the Case for Assessment Tech-\\nnology.” \\n(December 28, 2000).\\n“Herbal Phytotherapy and the Elderly.” (Decem-\\nber 28, 2000).\\n“Pharmacokinetics.” Merck & Co., Inc. (1995-2000). (December 28, 2000).\\n“To a Long and Healthy Life.” (Decem-\\nber 28, 2000).\\nPatience Paradox\\nAgoraphobia\\nDefinition\\nThe word agoraphobia is derived from Greek words\\nliterally meaning “fear of the marketplace.” The term is\\nused to describe an irrational and often disabling fear of\\nbeing out in public.\\nDescription\\nAgoraphobia is just one type of phobia, or irrational\\nfear. People with phobias feel dread or panic when they\\nface certain objects, situations, or activities. People with\\nagoraphobia frequently also experience panic attacks, but\\npanic attacks, or panic disorder , are not a requirement\\nfor a diagnosis of agoraphobia. The defining feature of\\nagoraphobia is anxiety about being in places from which\\nescape might be embarrasing or difficult, or in which\\nhelp might be unavailable. The person suffering from\\nagoraphobia usually avoids the anxiety-provoking situa-\\ntion and may become totally housebound.\\nCauses and symptoms\\nAgoraphobia is the most common type of phobia, and\\nit is estimated to affect between 5-12% of Americans within\\ntheir lifetime. Agoraphobia is twice as common in women\\nas in men and usually strikes between the ages of 15-35.\\nThe symptoms of the panic attacks which may\\naccompany agoraphobia vary from person to person, and\\nmay include trembling, sweating, heart palpitations (a\\nfeeling of the heart pounding against the chest), jitters,\\nfatigue , tingling in the hands and feet, nausea, a rapid\\npulse or breathing rate, and a sense of impending doom.\\nAgoraphobia and other phobias are thought to be the\\nresult of a number of physical and environmental factors.\\nFor instance, they have been associated with biochemical\\nimbalances, especially related to certain neurotransmit-\\nters (chemical nerve messengers) in the brain. People\\nwho have a panic attack in a given situation (e.g., a shop-\\nping mall) may begin to associate the panic with that sit-\\nuation and learn to avoid it. According to some theories,\\nirrational anxiety results from unresolved emotional con-\\nflicts. All of these factors may play a role to varying\\nextents in different cases of agoraphobia.\\nGALE ENCYCLOPEDIA OF MEDICINE 272\\nAgoraphobia\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 72'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 86, 'page_label': '87'}, page_content='Diagnosis\\nPeople who suffer from panic attacks should discuss\\nthe problem with a physician. The doctor can diagnose\\nthe underlying panic or anxiety disorder and make sure\\nthe symptoms aren’t related to some other underlying\\nmedical condition.\\nThe doctor makes the diagnosis of agoraphobia\\nbased primarily on the patient’s description of his or her\\nsymptoms. The person with agoraphobia experiences\\nanxiety in situations where escape is difficult or help is\\nunavailable—or in certain situations, such as being alone.\\nWhile many people are somewhat apprehensive in these\\nsituations, the hallmark of agoraphobia is that a person’s\\nactive avoidance of the feared situation impairs his or her\\nability to work, socialize, or otherwise function.\\nTreatment\\nTreatment for agoraphobia usually consists of both\\nmedication and psychotherapy. Usually, patients can\\nbenefit from certain antidepressants, such as amitripty-\\nline (Elavil), or selective serotonin reuptake inhibitors,\\nsuch as paroxetine (Paxil), fluoxetine (Prozac), or sertra-\\nline (Zoloft). In addition, patients may manage panic\\nattacks in progress with certain tranquilizers called ben-\\nzodiazepines , such as alprazolam (Xanax) or clon-\\nazepam (Klonipin).\\nThe mainstay of treatment for agoraphobia and other\\nphobias is cognitive behavioral therapy. A specific tech-\\nnique that is often employed is called desensitization.\\nThe patient is gradually exposed to the situation that usu-\\nally triggers fear and avoidance, and, with the help of\\nbreathing or relaxation techniques, learns to cope with\\nthe situation. This helps break the mental connection\\nbetween the situation and the fear, anxiety, or panic.\\nPatients may also benefit from psychodynamically ori-\\nented psychotherapy, discussing underlying emotional\\nconflicts with a therapist or support group.\\nPrognosis\\nWith proper medication and psychotherapy, 90% of\\npatients will find significant improvement in their symp-\\ntoms.\\nResources\\nBOOKS\\nHallowell, Edward M. Worry: Controlling It and Using It Wise-\\nly. New York: Pantheon Books, 1997.\\nPERIODICALS\\nForsyth, Sondra. “I Panic When I’m Alone.”Mademoiselle,\\nApr. 1998, 119-24.\\nHale, Anthony S. “ABC of Mental Health: Anxiety.”British\\nMedical Journal 314 (28 June 1997): 1886-9.\\nKEY TERMS\\nBenzodiazepines —A group of tranquilizers often\\nused to treat anxiety.\\nDesensitization —A treatment for phobias which\\ninvolves exposing the phobic person to the feared\\nsituation. It is often used in conjunction with\\nrelaxation techniques.\\nPhobia—An intense and irrational fear of a specif-\\nic object, activity, or situation.\\n“Panic Disorder—Panic Attacks and Agoraphobia.” American\\nFamily Physician 52, no. 7 (15 Nov. 1995): 2067-8.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW, Washing-\\nton DC 20005. (888) 357-7924. .\\nAnxiety Disorders Association of America. 11900 Park Lawn\\nDrive, Ste. 100, Rockville, MD 20852. (800) 545-7367.\\n.\\nNational Institute of Mental Health. Mental Health Public\\nInquiries, 5600 Fishers Lane, Room 15C-05, Rockville,\\nMD 20857. (888) 826-9438. .\\nRobert Scott Dinsmoor\\nAgranulocytosis see Neutropenia\\nAIDS\\nDefinition\\nAcquired immune deficiency syndrome (AIDS) is an\\ninfectious disease caused by the human immunodeficien-\\ncy virus (HIV). It was first recognized in the United States\\nin 1981. AIDS is the advanced form of infection with the\\nHIV virus, which may not cause recognizable disease for a\\nlong period after the initial exposure (latency). No vaccine\\nis currently available to prevent HIV infection. At present,\\nall forms of AIDS therapy are focused on improving the\\nquality and length of life for AIDS patients by slowing or\\nhalting the replication of the virus and treating or prevent-\\ning infections and cancers that take advantage of a per-\\nson’s weakened immune system.\\nDescription\\nAIDS is considered one of the most devastating public\\nhealth problems in recent history. In June 2000, the Centers\\nGALE ENCYCLOPEDIA OF MEDICINE 2 73\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 73'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 87, 'page_label': '88'}, page_content='for Disease Control and Prevention (CDC) reported that\\n120,223 (includes only those cases in areas that have confi-\\ndential HIV reporting) in the United States are HIV-posi-\\ntive, and 311,701 are living with AIDS (includes only those\\ncases where vital status is known). Of these patients, 44%\\nare gay or bisexual men, 20% are heterosexual intravenous\\ndrug users, and 17% are women. In addition, approximate-\\nly 1,000-2,000 children are born each year with HIV infec-\\ntion. The World Health Organization (WHO) estimates that\\n33 million adults and 1.3 million children worldwide were\\nliving with HIV/AIDS as of 1999 with 5.4 million being\\nnewly infected that year. Most of these cases are in the\\ndeveloping countries of Asia and Africa.\\nRisk factors\\nAIDS can be transmitted in several ways. The risk\\nfactors for HIV transmission vary according to category:\\n• Sexual contact. Persons at greatest risk are those who\\ndo not practice safe sex, those who are not monoga-\\nmous, those who participate in anal intercourse, and\\nthose who have sex with a partner with symptoms of\\nadvanced HIV infection and/or other sexually trans-\\nmitted diseases (STDs). In the United States and\\nEurope, most cases of sexually transmitted HIV infec-\\ntion have resulted from homosexual contact, whereas in\\nAfrica, the disease is spread primarily through sexual\\nintercourse among heterosexuals.\\n• Transmission in pregnancy. High-risk mothers include\\nwomen married to bisexual men or men who have an\\nabnormal blood condition called hemophilia and\\nrequire blood transfusions, intravenous drug users, and\\nwomen living in neighborhoods with a high rate of HIV\\ninfection among heterosexuals. The chances of trans-\\nmitting the disease to the child are higher in women in\\nadvanced stages of the disease. Breast feeding increases\\nthe risk of transmission by 10-20%. The use of zidovu-\\ndine (AZT) during pregnancy, however, can decrease\\nthe risk of transmission to the baby.\\n• Exposure to contaminated blood or blood products.\\nWith the introduction of blood product screening in the\\nmid-1980s, the incidence of HIV transmission in blood\\ntransfusions has dropped to one in every 100,000 trans-\\nfused. With respect to HIV transmission among drug\\nabusers, risk increases with the duration of using injec-\\ntions, the frequency of needle sharing, the number of\\npersons who share a needle, and the number of AIDS\\ncases in the local population.\\n• Needle sticks among health care professionals. Present\\nstudies indicate that the risk of HIV transmission by a nee-\\ndle stick is about one in 250. This rate can be decreased if\\nthe injured worker is given AZT, an anti-retroviral medica-\\ntion, in combination with other medication.\\nHIV is not transmitted by handshakes or other casu-\\nal non-sexual contact, coughing or sneezing, or by blood-\\nsucking insects such as mosquitoes.\\nAIDS in women\\nAIDS in women is a serious public health concern.\\nWomen exposed to HIV infection through heterosexual\\ncontact are the most rapidly growing risk group in the\\nUnited States population. The percentage of AIDS cases\\ndiagnosed in women has risen from 7% in 1985 to 23% in\\n1999. Women diagnosed with AIDS may not live as long\\nas men, although the reasons for this finding are unclear.\\nGALE ENCYCLOPEDIA OF MEDICINE 274\\nAIDS Risk of acquiring HIV infection by entry site\\nEntry site Risk virus reaches entry site Risk virus enters Risk inoculated\\nConjuntiva Moderate Moderate Very low\\nOral mucosa Moderate Moderate Low\\nNasal mucosa Low Low Very low\\nLower respiratory Very low Very low Very low\\nAnus Very high Very high Very high\\nSkin, intact Very low Very low Very low\\nSkin, broken Low High High\\nSexual:\\nVagina Low High High\\nPenis Low Low High\\nUlcers (STD) Medium Low Very high\\nBlood:\\nProducts High High Low\\nShared needles High High High\\nAccidental needle High Very High Low\\nTraumatic wound Modest High High\\nPerinatal High High High\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 74'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 88, 'page_label': '89'}, page_content='AIDS in children\\nSince AIDS can be transmitted from an infected moth-\\ner to the child during pregnancy, during the birth process, or\\nthrough breast milk, all infants born to HIV-positive moth-\\ners are a high-risk group. As of 2000, it was estimated that\\n87% of HIV-positive women are of childbearing age; 41%\\nof them are drug abusers. Between 15-30% of children born\\nto HIV-positive women will be infected with the virus.\\nAIDS is one of the 10 leading causes of death in chil-\\ndren between one and four years of age. The interval\\nbetween exposure to HIV and the development of AIDS is\\nshorter in children than in adults. Infants infected with HIV\\nhave a 20-30% chance of developing AIDS within a year\\nand dying before age three. In the remainder, AIDS pro-\\ngresses more slowly; the average child patient survives to\\nseven years of age. Some survive into early adolescence.\\nCauses and symptoms\\nBecause HIV destroys immune system cells, AIDS\\nis a disease that can affect any of the body’s major organ\\nsystems. HIV attacks the body through three disease\\nprocesses: immunodeficiency, autoimmunity, and ner-\\nvous system dysfunction.\\nImmunodeficiency describes the condition in which\\nthe body’s immune response is damaged, weakened, or is\\nnot functioning properly. In AIDS, immunodeficiency\\nresults from the way that the virus binds to a protein called\\nCD4, which is primarily found on the surface of certain\\nsubtypes of white blood cells called helper T cells or CD4\\ncells. After the virus has attached to the CD4 receptor, the\\nvirus-CD4 complex refolds to uncover another receptor\\ncalled a chemokine receptor that helps to mediate entry of\\nthe virus into the cell. One chemokine receptor in particu-\\nlar, CCR5, has gotten recent attention after studies showed\\nthat defects in its structure (caused by genetic mutations)\\ncause the progression of AIDS to be prevented or slowed.\\nScientists hope that this discovery will lead to the develop-\\nment of drugs that trigger an artificial mutation of the\\nCCR5 gene or target the CCR5 receptor.\\nOnce HIV has entered the cell, it can replicate intra-\\ncellularly and kill the cell in ways that are still not com-\\npletely understood. In addition to killing some lympho-\\ncytes directly, the AIDS virus disrupts the functioning of\\nGALE ENCYCLOPEDIA OF MEDICINE 2 75\\nAIDS\\nMature HIV-1 viruses (above) and the lymphocyte from which they emerged (below).Two immature viruses can be seen bud-\\nding on the surface of the lymphocyte (right of center).(Photograph by Scott Camazir, Photo Researchers, Inc. Reproduced by\\npermission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 75'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 89, 'page_label': '90'}, page_content='the remaining CD4 cells. Because the immune system\\ncells are destroyed, many different types of infections\\nand cancers that take advantage of a person’s weakened\\nimmune system (opportunistic) can develop.\\nAutoimmunity is a condition in which the body’s\\nimmune system produces antibodies that work against its\\nown cells. Antibodies are specific proteins produced in\\nresponse to exposure to a specific, usually foreign, protein\\nor particle called an antigen. In this case, the body pro-\\nduces antibodies that bind to blood platelets that are nec-\\nessary for proper blood clotting and tissue repair. Once\\nbound, the antibodies mark the platelets for removal from\\nthe body, and they are filtered out by the spleen. Some\\nAIDS patients develop a disorder, called immune-related\\nthrombocytopenia purpura (ITP), in which the number\\nof blood platelets drops to abnormally low levels.\\nAs of 2000, researchers do not know precisely how\\nHIV attacks the nervous system since the virus can cause\\ndamage without infecting nerve cells directly. One theory\\nis that, once infected with HIV , one type of immune sys-\\ntem cell, called a macrophage, begins to release a toxin\\nthat harms the nervous system.\\nThe course of AIDS generally progresses through\\nthree stages, although not all patients will follow this\\nprogression precisely:\\nAcute retroviral syndrome\\nAcute retroviral syndrome is a term used to describe\\na group of symptoms that can resemble mononucleosis\\nand that may be the first sign of HIV infection in 50-70%\\nof all patients and 45-90% of women. Most patients are\\nnot recognized as infected during this phase and may not\\nseek medical attention. The symptoms may include\\nfever, fatigue, muscle aches, loss of appetite, digestive\\ndisturbances, weight loss, skin rashes, headache , and\\nchronically swollen lymph nodes (lymphadenopathy).\\nApproximately 25-33% of patients will experience a\\nform of meningitis during this phase in which the mem-\\nbranes that cover the brain and spinal cord become\\ninflamed. Acute retroviral syndrome develops between\\none and six weeks after infection and lasts for two to\\nthree weeks. Blood tests during this period will indicate\\nthe presence of virus (viremia) and the appearance of the\\nviral p24 antigen in the blood.\\nLatency period\\nAfter the HIV virus enters a patient’s lymph nodes\\nduring the acute retroviral syndrome stage, the disease\\nbecomes latent for as many as 10 years or more before\\nsymptoms of advanced disease develop. During latency,\\nthe virus continues to replicate in the lymph nodes, where\\nit may cause one or more of the following conditions:\\nPERSISTENT GENERALIZED LYMPHADENOPATHY (PGL).\\nPersistent generalized lymphadenopathy, or PGL, is a con-\\ndition in which HIV continues to produce chronic painless\\nswellings in the lymph nodes during the latency period.\\nThe lymph nodes that are most frequently affected by PGL\\nare those in the areas of the neck, jaw, groin, and armpits.\\nPGL affects between 50-70% of patients during latency.\\nCONSTITUTIONAL SYMPTOMS. Many patients will\\ndevelop low-grade fevers, chronic fatigue, and general\\nweakness. HIV may also cause a combination of food\\nmalabsorption, loss of appetite, and increased metabo-\\nlism that contribute to the so-called AIDS wasting or\\nwasting syndrome.\\nOTHER ORGAN SYSTEMS. At any time during the\\ncourse of HIV infection, patients may suffer from a yeast\\ninfection in the mouth called thrush, open sores or ulcers,\\nor other infections of the mouth; diarrhea and other gas-\\ntrointestinal symptoms that cause malnutrition and\\nweight loss; diseases of the lungs and kidneys; and\\ndegeneration of the nerve fibers in the arms and legs.\\nHIV infection of the nervous system leads to general loss\\nof strength, loss of reflexes, and feelings of numbness or\\nburning sensations in the feet or lower legs.\\nLate-stage disease (AIDS)\\nAIDS is usually marked by a very low number of\\nCD4+ lymphocytes, followed by a rise in the frequency\\nof opportunistic infections and cancers. Doctors monitor\\nthe number and proportion of CD4+ lymphocytes in the\\npatient’s blood in order to assess the progression of the\\ndisease and the effectiveness of different medications.\\nAbout 10% of infected individuals never progress to this\\novert stage of the disease and are referred to as nonpro-\\ngressors.\\nOPPORTUNISTIC INFECTIONS. Once the patient’s\\nCD4+ lymphocyte count falls below 200 cells/mm\\n3\\n, he or\\nshe is at risk for a variety of opportunistic infections. The\\ninfectious organisms may include the following:\\n• Fungi. The most common fungal disease associated\\nwith AIDS is Pneumocystis carinii pneumonia (PCP).\\nPCP is the immediate cause of death in 15-20% of\\nAIDS patients. It is an important measure of a patient’s\\nprognosis. Other fungal infections include a yeast\\ninfection of the mouth ( candidiasis or thrush) and\\ncryptococcal meningitis.\\n• Protozoa. Toxoplasmosis is a common opportunistic\\ninfection in AIDS patients that is caused by a proto-\\nzoan. Other diseases in this category include isoporiasis\\nand cryptosporidiosis.\\n• Mycobacteria. AIDS patients may develop tuberculo-\\nsis or MAC infections. MAC infections are caused by\\nGALE ENCYCLOPEDIA OF MEDICINE 276\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 76'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 90, 'page_label': '91'}, page_content='Mycobacterium avium-intracellulare , and occur in\\nabout 40% of AIDS patients. It is rare until CD4+\\ncounts falls below 50 cells/mm\\n3\\n.\\n• Bacteria. AIDS patients are likely to develop bacterial\\ninfections of the skin and digestive tract.\\n• Viruses. AIDS patients are highly vulnerable to\\ncytomegalovirus (CMV), herpes simplex virus (HSV),\\nvaricella zoster virus (VZV), and Epstein-Barr virus\\n(EBV) infections. Another virus, JC virus, causes pro-\\ngressive destruction of brain tissue in the brain stem, cere-\\nbrum, and cerebellum (multifocal leukoencephalopathy\\nor PML), which is regarded as an AIDS-defining illness\\nby the Centers for Disease Control and Prevention.\\nAIDS DEMENTIA COMPLEX AND NEUROLOGIC COM-\\nPLICATIONS. AIDS dementia complex is usually a late\\ncomplication of the disease. It is unclear whether it is\\ncaused by the direct effects of the virus on the brain or by\\nintermediate causes. AIDS dementia complex is marked\\nby loss of reasoning ability, loss of memory, inability to\\nconcentrate, apathy and loss of initiative, and unsteadi-\\nness or weakness in walking. Some patients also develop\\nseizures. There are no specific treatments for AIDS\\ndementia complex.\\nMUSCULOSKELETAL COMPLICATIONS. Patients in\\nlate-stage AIDS may develop inflammations of the mus-\\ncles, particularly in the hip area, and may have arthritis-\\nlike pains in the joints.\\nORAL SYMPTOMS. In addition to thrush and painful\\nulcers in the mouth, patients may develop a condition\\ncalled hairy leukoplakia of the tongue. This condition is\\nalso regarded by the CDC as an indicator of AIDS. Hairy\\nleukoplakia is a white area of diseased tissue on the\\ntongue that may be flat or slightly raised. It is caused by\\nthe Epstein-Barr virus.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 77\\nAIDS\\nCENTRAL NERVOUS SYSTEM\\nMUCOCUTANEOUS\\nPNEUMONIA\\nL YMPHOPROLIFERATIVE DISEASE\\nSKIN\\nDIARRHEA \\nOPPORTUNISTIC INFECTIONS CAUSED BY AIDS\\nBecause the immune system cells are destroyed by the AIDS virus, many different types of infections and cancers can devel-\\nop, taking advantage of a person’s weakened immune system.(Illustration by Electronic Illustrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 77'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 91, 'page_label': '92'}, page_content='AIDS-RELATED CANCERS. Patients with late-stage\\nAIDS may develop Kaposi’s sarcoma (KS), a skin\\ntumor that primarily affects homosexual men. KS is the\\nmost common AIDS-related malignancy. It is character-\\nized by reddish-purple blotches or patches (brownish in\\nAfrican-Americans) on the skin or in the mouth. About\\n40% of patients with KS develop symptoms in the diges-\\ntive tract or lungs. KS may be caused by a herpes virus-\\nlike sexually transmitted disease agent rather than HIV .\\nThe second most common form of cancer in AIDS\\npatients is a tumor of the lymphatic system (lymphoma).\\nAIDS-related lymphomas often affect the central nervous\\nsystem and develop very aggressively.\\nKEY TERMS\\nAcute retroviral syndrome —A group of symptoms\\nresembling mononucleosis that often are the first\\nsign of HIV infection in 50-70% of all patients and\\n45-90% of women.\\nAIDS dementia complex—A type of brain dysfunc-\\ntion caused by HIV infection that causes difficulty\\nthinking, confusion, and loss of muscular coordi-\\nnation.\\nAntibody —A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAntigen—Any substance that stimulates the body to\\nproduce antibody.\\nAutoimmunity —A condition in which the body’s\\nimmune system produces antibodies in response to\\nits own tissues or blood components instead of for-\\neign particles or microorganisms.\\nCCR5—A chemokine receptor; defects in its struc-\\nture caused by genetic mutation cause the progres-\\nsion of AIDS to be prevented or slowed.\\nCD4—A type of protein molecule in human blood,\\nsometimes called the T4 antigen, that is present on\\nthe surface of 65% of immune cells. The HIV virus\\ninfects cells with CD4 surface proteins, and as a\\nresult, depletes the number of T cells, B cells, natur-\\nal killer cells, and monocytes in the patient’s blood.\\nMost of the damage to an AIDS patient’s immune\\nsystem is done by the virus’ destruction of CD4+\\nlymphocytes.\\nChemokine receptor—A receptor on the surface of\\nsome types of immune cells that helps to mediate\\nentry of HIV into the cell.\\nHairy leukoplakia of the tongue —A white area of\\ndiseased tissue on the tongue that may be flat or\\nslightly raised. It is caused by the Epstein-Barr virus\\nand is an important diagnostic sign of AIDS.\\nHemophilia—Any of several hereditary blood coag-\\nulation disorders occurring almost exclusively in\\nmales. Because blood does not clot properly, even\\nminor injuries can cause significant blood loss that\\nmay require a blood transfusion, with its associated\\nminor risk of infection.\\nHuman immunodeficiency virus (HIV)—A transmis-\\nsible retrovirus that causes AIDS in humans. Two\\nforms of HIV are now recognized: HIV-1, which caus-\\nes most cases of AIDS in Europe, North and South\\nAmerica, and most parts of Africa; and HIV-2, which\\nis chiefly found in West African patients. HIV-2, dis-\\ncovered in 1986, appears to be less virulent than HIV-\\n1 and may also have a longer latency period.\\nImmunodeficient—A condition in which the body’s\\nimmune response is damaged, weakened, or is not\\nfunctioning properly.\\nKaposi’s sarcoma—A cancer of the connective tis-\\nsue that produces painless purplish red (in people\\nwith light skin) or brown (in people with dark skin)\\nblotches on the skin. It is a major diagnostic marker\\nof AIDS.\\nLatent period —Also called incubation period, the\\ntime between infection with a disease-causing\\nagent and the development of disease.\\nLymphocyte—A type of white blood cell that is\\nimportant in the formation of antibodies and that\\ncan be used to monitor the health of AIDS patients.\\nInvasive cancer of the cervix (related to certain types\\nof human papilloma virus [HPV]) is an important diag-\\nnostic marker of AIDS in women.\\nDiagnosis\\nBecause HIV infection produces such a wide range\\nof symptoms, the CDC has drawn up a list of 34 condi-\\ntions regarded as defining AIDS. The physician will use\\nthe CDC list to decide whether the patient falls into one\\nof these three groups:\\n• definitive diagnoses with or without laboratory evi-\\ndence of HIV infection\\nGALE ENCYCLOPEDIA OF MEDICINE 278\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 78'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 92, 'page_label': '93'}, page_content='• definitive diagnoses with laboratory evidence of HIV\\ninfection\\n• presumptive diagnoses with laboratory evidence of\\nHIV infection\\nPhysical findings\\nAlmost all the symptoms of AIDS can occur with\\nother diseases. The general physical examination may\\nrange from normal findings to symptoms that are closely\\nassociated with AIDS. These symptoms are hairy leuko-\\nplakia of the tongue and Kaposi’s sarcoma. When the\\nKEY TERMS\\nLymphoma—A cancerous tumor in the lymphatic\\nsystem that is associated with a poor prognosis in\\nAIDS patients.\\nMacrophage—A large white blood cell, found pri-\\nmarily in the bloodstream and connective tissue,\\nthat helps the body fight off infections by ingesting\\nthe disease-causing organism. HIV can infect and\\nkill macrophages.\\nMonocyte—A large white blood cell that is formed\\nin the bone marrow and spleen. About 4% of the\\nwhite blood cells in normal adults are monocytes.\\nMycobacterium avium (MAC) infection—A type of\\nopportunistic infection that occurs in about 40% of\\nAIDS patients and is regarded as an AIDS-defining\\ndisease.\\nNon-nucleoside reverse transcriptase inhibitors —\\nThe newest class of antiretroviral drugs that work by\\ninhibiting the reverse transcriptase enzyme neces-\\nsary for HIV replication.\\nNucleoside analogues —The first group of effective\\nanti-retroviral medications. They work by interfering\\nwith the AIDS virus’ synthesis of DNA.\\nOpportunistic infection —An infection by organ-\\nisms that usually don’t cause infection in people\\nwhose immune systems are working normally.\\nPersistent generalized lymphadenopathy (PGL)—A\\ncondition in which HIV continues to produce\\nchronic painless swellings in the lymph nodes dur-\\ning the latency period.\\nPneumocystis carinii pneumonia (PCP)—An oppor-\\ntunistic infection caused by a fungus that is a major\\ncause of death in patients with late-stage AIDS.\\nProgressive multifocal leukoencephalopathy\\n(PML)—A disease caused by a virus that destroys\\nwhite matter in localized areas of the brain. It is\\nregarded as an AIDS-defining illness.\\nProtease inhibitors—The second major category of\\ndrug used to treat AIDS that works by suppressing\\nthe replication of the HIV virus.\\nProtozoan —A single-celled, usually microscopic\\norganism that is eukaryotic and, therefore, different\\nfrom bacteria (prokaryotic).\\nRetrovirus—A virus that contains a unique enzyme\\ncalled reverse transcriptase that allows it to repli-\\ncate within new host cells.\\nT cells—Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s\\nresponse to infections, including HIV. CD4 lympho-\\ncytes are a subset of T lymphocytes.\\nThrush—A yeast infection of the mouth character-\\nized by white patches on the inside of the mouth\\nand cheeks.\\nViremia—The measurable presence of virus in the\\nbloodstream that is a characteristic of acute retrovi-\\nral syndrome.\\nWasting syndrome —A progressive loss of weight\\nand muscle tissue caused by the AIDS virus.\\ndoctor examines the patient, he or she will look for the\\noverall pattern of symptoms rather than any one finding.\\nLaboratory tests for HIV infection\\nBLOOD TESTS (SEROLOGY). The first blood test for\\nAIDS was developed in 1985. At present, patients who\\nare being tested for HIV infection are usually given an\\nenzyme-linked immunosorbent assay (ELISA) test for the\\npresence of HIV antibody in their blood. Positive ELISA\\nresults are then tested with a Western blot or immunofluo-\\nrescence (IFA) assay for confirmation. The combination\\nof the ELISA and Western blot tests is more than 99.9%\\nGALE ENCYCLOPEDIA OF MEDICINE 2 79\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 79'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 93, 'page_label': '94'}, page_content='accurate in detecting HIV infection within four to eight\\nweeks following exposure. The polymerase chain reac-\\ntion (PCR) test can be used to detect the presence of viral\\nnucleic acids in the very small number of HIV patients\\nwho have false-negative results on the ELISA and West-\\nern blot tests. These tests are also used to detect viruses\\nand bacterium other than HIV and AIDS.\\nOTHER LABORATORY TESTS. In addition to diagnos-\\ntic blood tests, there are other blood tests that are used to\\ntrack the course of AIDS in patients that have already\\nbeen diagnosed. These include blood counts, viral load\\ntests, p24 antigen assays, and measurements of /H9252\\n2-\\nmicroglobulin (/H92522M).\\nDoctors will use a wide variety of tests to diagnose the\\npresence of opportunistic infections, cancers, or other dis-\\nease conditions in AIDS patients. Tissue biopsies, samples of\\ncerebrospinal fluid, and sophisticated imaging techniques,\\nsuch as magnetic resonance imaging(MRI) and computed\\ntomography scans(CT) are used to diagnose AIDS-related\\ncancers, some opportunistic infections, damage to the central\\nnervous system, and wasting of the muscles. Urine and stool\\nsamples are used to diagnose infections caused by parasites.\\nAIDS patients are also given blood tests for syphilis and\\nother sexually transmitted diseases.\\nDiagnosis in children\\nDiagnostic blood testing in children older than 18\\nmonths is similar to adult testing, with ELISA screening\\nconfirmed by Western blot. Younger infants can be diag-\\nnosed by direct culture of the HIV virus, PCR testing,\\nand p24 antigen testing.\\nIn terms of symptoms, children are less likely than\\nadults to have an early acute syndrome. They are, howev-\\ner, likely to have delayed growth, a history of frequent\\nillness, recurrent ear infections, a low blood cell count,\\nfailure to gain weight, and unexplained fevers. Children\\nwith AIDS are more likely to develop bacterial infec-\\ntions, inflammation of the lungs, and AIDS-related brain\\ndisorders than are HIV-positive adults.\\nTreatment\\nTreatment for AIDS covers four considerations:\\nTREATMENT OF OPPORTUNISTIC INFECTIONS AND\\nMALIGNANCIES. Most AIDS patients require complex\\nlong-term treatment with medications for infectious dis-\\neases. This treatment is often complicated by the devel-\\nopment of resistance in the disease organisms. AIDS-\\nrelated malignancies in the central nervous system are\\nusually treated with radiation therapy . Cancers else-\\nwhere in the body are treated with chemotherapy.\\nPROPHYLACTIC TREATMENT FOR OPPORTUNISTIC\\nINFECTIONS. Prophylactic treatment is treatment that is\\ngiven to prevent disease. AIDS patients with a history of\\nPneumocystis pneumonia; with CD4+ counts below 200\\ncells/mm\\n3\\nor 14% of lymphocytes; weight loss; or thrush\\nshould be given prophylactic medications. The three\\ndrugs given are trimethoprim-sulfamethoxazole, dap-\\nsone, or pentamidine in aerosol form.\\nANTI-RETROVIRAL TREATMENT. In recent years\\nresearchers have developed drugs that suppress HIV\\nreplication, as distinct from treating its effects on the\\nbody. These drugs fall into three classes:\\n• Nucleoside analogues. These drugs work by interfering\\nwith the action of HIV reverse transcriptase inside infect-\\ned cells, thus ending the virus’ replication process. These\\ndrugs include zidovudine (sometimes called azidothymi-\\ndine or AZT), didanosine (ddI), zalcitabine (ddC), stavu-\\ndine (d4T), lamivudine (3TC), and abacavir (ABC).\\n• Protease inhibitors. Protease inhibitors can be effective\\nagainst HIV strains that have developed resistance to\\nnucleoside analogues, and are often used in combination\\nwith them. These compounds include saquinavir, riton-\\navir, indinavir, nelfinavir, amprenavir, and lopinavir.\\n• Non-nucleoside reverse transcriptase inhibitors. This is\\na new class of antiretroviral agents. Three are available,\\nnevirapine, which was approved first, delavirdine and\\nefavirin.\\nTreatment guidelines for these agents are in constant\\nchange as new medications are developed and intro-\\nduced. Two principles currently guide doctors in working\\nout drug regimens for AIDS patients: using combinations\\nof drugs rather than one medication alone; and basing\\ntreatment decisions on the results of the patient’s viral\\nload tests.\\nSTIMULATION OF BLOOD CELL PRODUCTION.\\nBecause many patients with AIDS suffer from abnormal-\\nly low levels of both red and white blood cells, they may\\nbe given medications to stimulate blood cell production.\\nEpoetin alfa (erythropoietin) may be given to anemic\\npatients. Patients with low white blood cell counts may\\nbe given filgrastim or sargramostim.\\nTreatment in women\\nTreatment of pregnant women with HIV is particu-\\nlarly important in that anti-retroviral therapy has been\\nshown to reduce transmission to the infant by 65%.\\nAlternative treatment\\nAlternative treatments for AIDS can be grouped into\\ntwo categories: those intended to help the immune sys-\\nGALE ENCYCLOPEDIA OF MEDICINE 280\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 80'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 94, 'page_label': '95'}, page_content='tem and those aimed at pain control. Treatments that\\nmay enhance the function of the immune system include\\nChinese herbal medicine and western herbal medicine,\\nmacrobiotic and other special diets, guided imagery and\\ncreative visualization, homeopathy, and vitamin therapy.\\nPain control therapies include hydrotherapy , reiki,\\nacupuncture, meditation, chiropractic treatments, and\\ntherapeutic massage. Alternative therapies can also be\\nused to help with side effects of the medications used in\\nthe treatment of AIDS.\\nPrognosis\\nAt the present time, there is no cure for AIDS.\\nTreatment stresses aggressive combination drug\\ntherapy for those patients with access to the expensive\\nmedications and who tolerate them adequately. The use\\nof these multi-drug therapies has significantly reduced\\nthe numbers of deaths, in this country, resulting from\\nAIDS. The data is still inconclusive, but the potential\\nexists to possibly prolong life indefinitely using these\\nand other drug therapies to boost the immune system,\\nkeep the virus from replicating, and ward off opportunis-\\ntic infections and malignancies.\\nPrognosis after the latency period depends on the\\npatient’s specific symptoms and the organ systems\\naffected by the disease. Patients with AIDS-related lym-\\nphomas of the central nervous system die within two to\\nthree months of diagnosis; those with systemic lym-\\nphomas may survive for eight to ten months.\\nPrevention\\nAs of 2001, there is no vaccine effective against\\nAIDS. Several vaccines are currently being investigated,\\nhowever, both to prevent initial HIV infection and as a\\ntherapeutic treatment to prevent HIV from progressing to\\nfull-blown AIDS.\\nIn the meantime, there are many things that can be\\ndone to prevent the spread of AIDS:\\n• Be monogamous and practice safe sex. Individuals\\nmust be instructed in the proper use of condoms and\\nurged to practice safe sex. Besides avoiding the risk of\\nHIV infection, condoms are successful in preventing\\nother sexually transmitted diseases and unwanted preg-\\nnancies. Before engaging in a sexual relationship with\\nsomeone, get tested for HIV infection.\\n• Avoid needle sharing among intravenous drug users.\\n• Although blood and blood products are carefully moni-\\ntored, those individuals who are planning to undergo\\nmajor surgery may wish to donate blood ahead of time\\nto prevent a risk of infection from a blood transfusion.\\n• Healthcare professionals must taken all necessary pre-\\ncautions by wearing gloves and masks when handling\\nbody fluids and preventing needle-stick injuries.\\n• If you suspect that you may have become infected, get\\ntested for HIV infection. If treated aggressively early\\non, the development of AIDS may be postponed indefi-\\nnitely. If HIV infection is confirmed, it is also vital to\\nlet your sexual partners know so that they can be tested\\nand, if necessary, receive medical attention.\\nResources\\nBOOKS\\nEarly HIV Infection Guideline Panel. Evaluation and Manage-\\nment of Early HIV Infection. Rockville, MD: U.S. Depart-\\nment of Health and Human Services, Agency for Health\\nCare Policy and Research, 1994.\\nHuber, Jeffrey T. Dictionary of AIDS-Related Terminology.New\\nYork and London: Neal-Schuman Publishers, Inc., 1993.\\n“Infectious Diseases: Human Immunodeficiency Virus (HIV).”\\nIn Neonatology: Management, Procedures, On-Call Prob-\\nlems, Diseases and Drugs. Ed. Tricia Lacy Gomella, et al.\\nNorwalk, CT: Appleton & Lange, 1994.\\nKatz, Mitchell H., and Harry Hollander. “HIV Infection.” In\\nCurrent Medical Diagnosis & Treatment.Ed. Lawrence M.\\nTierney Jr., et al. Stamford, CT: Appleton & Lange, 1998.\\nMcFarland, Elizabeth J. “Human Immunodeficiency Virus\\n(HIV) Infections: Acquired Immunodeficiency Syndrome\\n(AIDS).” In Current Pediatric Diagnosis & Treatment.Ed.\\nWilliam W. Hay Jr., et al. Stamford, CT: Appleton &\\nLange, 1997.\\nSo, Peter, and Livette Johnson. “Acquired Immune Deficiency\\nSyndrome (AIDS).” In Conn’s Current Therapy.Ed. Robert\\nE. Rakel. Philadelphia: W. B. Saunders Company, 1997.\\nPERIODICALS\\nXiao, X., L. Wu, T. S. Stantchev, Y . R. Feng, S. Ugolini, H.\\nChen, Z. Shen, J. L. Riley, C. C. Broder, Q. J. Sattentau,\\nand D. S. Dimitrov. “Constitutive cell surface association\\nbetween CD4 and CCR5.”Proceedings of the National\\nAcademy of Sciences of the United States of America.\\n(June 1999): 7496-7501.\\nORGANIZATIONS\\nGay Men’s Health Crisis, Inc., 129 West 20th Street, New York,\\nNY 10011-0022. (212) 807-6655.\\nNational AIDS Hot Line. (800) 342-AIDS (English). (800) 344-\\nSIDA (Spanish). (800) AIDS-TTY (hearing-impaired).\\nOTHER\\n“FDA Approved Drugs for HIV Infection and AIDS-Related\\nConditions.” HIV/AIDS Treatment Information Service\\nwebsite. January 2001. .\\nRebecca J. Frey\\nAIDS serology see AIDS tests\\nGALE ENCYCLOPEDIA OF MEDICINE 2 81\\nAIDS\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 81'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 95, 'page_label': '96'}, page_content='AIDS tests\\nDefinition\\nAIDS tests, short for acquired immunodeficiency\\nsyndrome tests, cover a number of different procedures\\nused in the diagnosis and treatment of HIV patients. These\\ntests are sometimes called AIDS serology tests. Serology\\nis the branch of immunology that deals with the contents\\nand characteristics of blood serum. Serum is the clear light\\nyellow part of blood that remains liquid when blood cells\\nform a clot. AIDS serology evaluates the presence of\\nhuman immunodeficiency virus (HIV) infection in blood\\nserum and its effects on each patient’s immune system.\\nPurpose\\nAIDS serology serves several different purposes.\\nSome AIDS tests are used to diagnose patients or con-\\nfirm a diagnosis; others are used to measure the progres-\\nsion of the disease or the effectiveness of specific treat-\\nment regimens. Some AIDS tests can also be used to\\nscreen blood donations for safe use in transfusions.\\nIn order to understand the different purposes of the\\nblood tests used with AIDS patients, it is helpful to\\nunderstand how HIV infection affects human blood and\\nthe immune system. HIV is a retrovirus that enters the\\nblood stream of a new host in the following ways:\\n• by sexual contact\\n• by contact with infected body fluids (such as blood and\\nurine)\\n• by transmission during pregnancy,o r\\n• through transfusion of infected blood products\\nA retrovirus is a virus that contains a unique enzyme\\ncalled reverse transcriptase that allows it to replicate with-\\nin new host cells. The virus binds to a protein called CD4,\\nwhich is found on the surface of certain subtypes of white\\nblood cells, including helper T cells, macrophages, and\\nmonocytes. Once HIV enters the cell, it can replicate and\\nkill the cell in ways that are still not completely under-\\nstood. In addition to killing some lymphocytes directly, the\\nAIDS virus disrupts the functioning of the remaining CD4\\ncells. CD4 cells ordinarily produce a substance called\\ninterleukin-2 (IL-2), which stimulates other cells (T cells\\nand B cells) in the human immune system to respond to\\ninfections. Without the IL-2, T cells do not reproduce as\\nthey normally would in response to the HIV virus, and B\\ncells are not stimulated to respond to the infection.\\nPrecautions\\nIn some states such as New York, a signed consent\\nform is needed in order to administer an AIDS test. As\\nwith all blood tests, healthcare professionals should\\nalways wear latex gloves and to avoid being pricked by\\nthe needle used in drawing blood for the tests. Also, it\\nmay be difficult to get blood from a habitual intravenous\\ndrug user due to collapsed veins.\\nDescription\\nDiagnostic tests\\nDiagnostic blood tests for AIDS are usually given to\\npersons in high-risk populations who may have been\\nexposed to HIV or who have the early symptoms of\\nAIDS. Most persons infected with HIV will develop a\\ndetectable level of antibody within three months of infec-\\ntion. The condition of testing positive for HIV antibody\\nin the blood is called seroconversion, and persons who\\nhave become HIV-positive are called seroconverters.\\nIt is possible to diagnose HIV infection by isolating\\nthe virus itself from a blood sample or by demonstrating\\nthe presence of HIV antigen in the blood. Viral culture,\\nhowever, is expensive, not widely available, and slow—it\\ntakes 28 days to complete the viral culture test. More\\ncommon are blood tests that work by detecting the pres-\\nence of antibodies to the HIV virus. These tests are inex-\\npensive, widely available, and accurate in detecting\\n99.9% of AIDS infections when used in combination to\\nscreen patients and confirm diagnoses.\\nENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA).\\nThis type of blood test is used to screen blood for trans-\\nfusions as well as diagnose patients. An ELISA test for\\nHIV works by attaching HIV antigens to a plastic well or\\nbeads. A sample of the patient’s blood serum is added,\\nand excess proteins are removed. A second antibody cou-\\npled to an enzyme is added, followed by addition of a\\nsubstance that will cause the enzyme to react by forming\\na color. An instrument called a spectrophotometer can\\nmeasure the color. The name of the test is derived from\\nthe use of the enzyme that is coupled or linked to the sec-\\nond antibody.\\nThe latest generation of ELISA tests are 99.5% sen-\\nsitive to HIV . Occasionally, the ELISA test will be posi-\\ntive for a patient without symptoms of AIDS from a low-\\nrisk group. Because this result is likely to be a false-posi-\\ntive, the ELISA must be repeated on the same sample of\\nthe patient’s blood. If the second ELISA is positive, the\\nresult should be confirmed by the Western blot test.\\nWESTERN BLOT (IMMUNOBLOT). The Western blot\\nor immunoblot test is used as a reference procedure to\\nconfirm the diagnosis of AIDS. In Western blot testing,\\nHIV antigen is purified by electrophoresis (large protein\\nmolecules are suspended in a gel and separated from one\\nanother by running an electric current through the gel).\\nGALE ENCYCLOPEDIA OF MEDICINE 282\\nAIDS tests\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 82'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 96, 'page_label': '97'}, page_content='The HIV antigens are attached by blotting to a nylon or\\nnitrocellulose filter. The patient’s serum is reacted against\\nthe filter, followed by treatment with developing chemi-\\ncals that allow HIV antibody to show up as a colored\\npatch or blot. A commercially produced Western blot test\\nfor HIV-1 is now available. It consists of a prefabricated\\nstrip that is incubated with a sample of the patient’s blood\\nserum and the developing chemicals. About nine different\\nHIV-1 proteins can be detected in the blots.\\nWhen used in combination with ELISA testing,\\nWestern blot testing is 99.9% specific. It can, however,\\nyield false negatives in patients with very early HIV\\ninfection and in those infected by HIV-2. In some\\npatients the Western blot yields indeterminate results.\\nIMMUNOFLUORESCENCE ASSAY (IFA). This method\\nis sometimes used to confirm ELISA results instead of\\nWestern blotting. An IFA test detects the presence of\\nHIV antibody in a sample of the patient’s serum by mix-\\ning HIV antigen with a fluorescent chemical, adding the\\nblood sample, and observing the reaction under a micro-\\nscope with ultraviolet light.\\nPOLYMERASE CHAIN REACTION (PCR). This test is\\nused to evaluate the very small number of AIDS patients\\nwith false-negative ELISA and Western blot tests. These\\npatients are sometimes called antibody-negative asympto-\\nmatic (without symptoms) carriers, because they do not\\nhave any symptoms of AIDS and there is no detectable\\nquantity of antibody in the blood serum. Antibody-nega-\\ntive asymptomatic carriers may be responsible for the\\nvery low ongoing risk of HIV infection transmitted by\\nblood transfusions. It is estimated that the risk is between\\n1 in 10,000 and 1 in 100,000 units of transfused blood.\\nThe polymerase chain reaction (PCR) test can mea-\\nsure the presence of viral nucleic acids in the patient’s\\nblood even when there is no detectable antibody to HIV .\\nThis test works by amplifying the presence of HIV nucle-\\nic acids in a blood sample. Numerous copies of a gene are\\nmade by separating the two strands of DNA containing\\nthe gene segment, marking its location, using DNA poly-\\nmerase to make a copy, and then continuously replicating\\nthe copies. It is questionable whether PCR will replace\\nWestern blotting as the method of confirming AIDS diag-\\nnoses. Although PCR can detect the low number of per-\\nsons (1%) with HIV infections that have not yet generated\\nan antibody response to the virus, the overwhelming\\nmajority of infected persons will be detected by ELISA\\nscreening within one to three months of infection. In\\naddition, PCR testing is based on present knowledge of\\nthe genetic sequences in HIV . Since the virus is continual-\\nly generating new variants, PCR testing could yield a\\nfalse negative in patients with these new variants.\\nIn 1999, the U.S. Food and Drug Administration\\n(FDA) approved an HIV home testing kit. The kit contains\\nmultiple components, including material for specimen col-\\nlection, a mailing envelope to send the specimen to a labo-\\nratory for analysis, and provides pre- and post-test coun-\\nseling. It uses a finger prick process for blood collection.\\nThe results are obtained by the purchaser through a toll\\nfree telephone number using a personal identification\\nnumber (PIN). Post test counseling is provided over the\\ntelephone by a licensed counselor. The only kit approved\\nby the FDA as of 2001 was the Home Access test system.\\nPrognostic tests\\nBlood tests to evaluate patients already diagnosed\\nwith HIV infection are as important as the diagnostic\\ntests. Because AIDS has a long latency period, some per-\\nsons may be infected with the virus for 10 years or longer\\nbefore they develop symptoms of AIDS. These patients\\nare sometimes called antibody-positive asymptomatic\\ncarriers. Prognostic tests also help drug researchers eval-\\nuate the usefulness of new medications in treating AIDS.\\nBLOOD CELL COUNTS. Doctors can measure the\\nnumber or proportion of certain types of cells in an AIDS\\npatient’s blood to see whether and how rapidly the dis-\\nease is progressing, or whether certain treatments are\\nhelping the patient. These cell count tests include:\\n• Complete blood count(CBC). A CBC is a routine analy-\\nsis performed on a sample of blood taken from the\\npatient’s vein with a needle and vacuum tube. The mea-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 83\\nAIDS tests\\nA three-dimensional model of the HIV virus.(Corbis Corpora-\\ntion (New Y ork). Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 83'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 97, 'page_label': '98'}, page_content='surements taken in a CBC include a white blood cell count\\n(WBC), a red blood cell count (RBC), the red cell distribu-\\ntion width, the hematocrit(ratio of the volume of the red\\nblood cells to the blood volume), and the amount of hemo-\\nglobin (the blood protein that carries oxygen). Although\\nCBCs are used on more than just AIDS patients, they can\\nhelp the doctor determine if an AIDS patient has an\\nadvanced form of the disease. Specific AIDS-related signs\\nin a CBC include a low hematocrit, a sharp decrease in the\\nnumber of blood platelets, and a low level of a certain type\\nof white blood cell called neutrophils.\\n• Absolute CD4+ lymphocytes. A lymphocyte is a type\\nof white blood cell that is important in the formation\\nKEY TERMS\\nAntibody —A protein in the blood that identifies\\nand helps remove disease organisms or their toxins.\\nAntibodies are secreted by B cells. AIDS diagnostic\\ntests work by demonstrating the presence of HIV\\nantibody in the patient’s blood.\\nAntigen—Any substance that stimulates the body to\\nproduce antibodies.\\nB cell —A type of white blood cell derived from\\nbone marrow. B cells are sometimes called B lym-\\nphocytes. They secrete antibody and have a number\\nof other complex functions within the human\\nimmune system.\\nCD4—A type of protein molecule in human blood\\nthat is present on the surface of 65% of human T\\ncells. CD4 is a receptor for the HIV virus. When the\\nHIV virus infects cells with CD4 surface proteins, it\\ndepletes the number of T cells, B cells, natural killer\\ncells, and monocytes in the patient’s blood. Most of\\nthe damage to an AIDS patient’s immune system is\\ndone by the virus’ destruction of CD4+ lympho-\\ncytes. CD4 is sometimes called the T4 antigen.\\nComplete blood count (CBC) —A routine analysis\\nperformed on a sample of blood taken from the\\npatient’s vein with a needle and vacuum tube. The\\nmeasurements taken in a CBC include a white blood\\ncell count, a red blood cell count, the red cell distri-\\nbution width, the hematocrit (ratio of the volume of\\nthe red blood cells to the blood volume), and the\\namount of hemoglobin (the blood protein that car-\\nries oxygen). CBCs are a routine blood test used for\\nmany medical reasons and are not used only for\\nAIDS patients. They can help the doctor determine if\\na patient is in advanced stages of the disease.\\nElectrophoresis —A method of separating complex\\nprotein molecules suspended in a gel by running an\\nelectric current through the gel.\\nEnzyme-linked immunosorbent assay (ELISA) —A\\ndiagnostic blood test used to screen patients for\\nAIDS or other viruses. The patient’s blood is mixed\\nwith antigen attached to a plastic tube or bead sur-\\nface. A sample of the patient’s blood serum is\\nadded, and excess proteins are removed. A second\\nantibody coupled to an enzyme is added, followed\\nby a chemical that will cause a color reaction that\\ncan be measured by a special instrument.\\nHuman immunodeficiency virus (HIV)—A transmis-\\nsible retrovirus that causes AIDS in humans. Two\\nforms of HIV are now recognized: HIV-1, which caus-\\nes most cases of AIDS in Europe, North and South\\nAmerica, and most parts of Africa; and HIV-2, which\\nis chiefly found in West African patients. HIV-2, dis-\\ncovered in 1986, appears to be less virulent than HIV-\\n1, but may also have a longer latency period.\\nImmunofluorescent assay (IFA) —A blood test\\nsometimes used to confirm ELISA results instead of\\nusing the Western blotting. In an IFA test, HIV anti-\\ngen is mixed with a fluorescent compound and then\\nwith a sample of the patient’s blood. If HIV antibody\\nis present, the mixture will fluoresce when exam-\\nined under ultraviolet light.\\nLymphocyte—A type of white blood cell that is\\nimportant in the formation of antibodies. Doctors\\nof an immune response. Because HIV targets CD4+\\nlymphocytes, their number in the patient’s blood can\\nbe used to track the course of the infection. This blood\\ncell count is considered the most accurate indicator\\nfor the presence of an opportunistic infection in an\\nAIDS patient. The absolute CD4+ lymphocyte count\\nis obtained by multiplying the patient’s white blood\\ncell count (WBC) by the percentage of lymphocytes\\namong the white blood cells, and multiplying the\\nresult by the percentage of lymphocytes bearing the\\nCD4+ marker. An absolute count below 200-300\\nCD+4 lymphocytes in 1 cubic millimeter (mm\\n3\\n) of\\nblood indicates that the patient is vulnerable to some\\nopportunistic infections.\\nGALE ENCYCLOPEDIA OF MEDICINE 284\\nAIDS tests\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 84'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 98, 'page_label': '99'}, page_content='• CD4+ lymphocyte percentage. Some doctors think that\\nthis is a more accurate test than the absolute count\\nbecause the percentage does not depend on a manual\\ncalculation of the number of types of different white\\nblood cells. A white blood cell count that is broken\\ndown into categories in this way is called a WBC dif-\\nferential.\\nIt is important for doctors treating AIDS patients to\\nmeasure the lymphocyte count on a regular basis.\\nExperts consulted by the United States Public Health\\nService recommend the following frequency of serum\\ntesting based on the patient’s CD4+ level:\\n• CD4+ count more than 600 cells/mm\\n3\\n: Every six months.\\nKEY TERMS\\ncan monitor the health of AIDS patients by measur-\\ning the number or proportion of certain types of\\nlymphocytes in the patient’s blood.\\nMacrophage—A large white blood cell, found pri-\\nmarily in the bloodstream and connective tissue,\\nthat helps the body fight off infections by ingesting\\nthe disease organism. HIV can infect and kill\\nmacrophages.\\nMonocyte—A large white blood cell that is formed\\nin the bone marrow and spleen. About 4% of the\\nwhite blood cells in normal adults are monocytes.\\nOpportunistic infection —An infection that devel-\\nops only when a person’s immune system is weak-\\nened, as happens to AIDS patients.\\nPolymerase chain reaction (PCR)—A test performed\\nto evaluate false-negative results to the ELISA and\\nWestern blot tests. In PCR testing, numerous copies\\nof a gene are made by separating the two strands of\\nDNA containing the gene segment, marking its\\nlocation, using DNA polymerase to make a copy,\\nand then continuously replicating the copies. The\\namplification of gene sequences that are associated\\nwith HIV allows for detection of the virus by this\\nmethod.\\nRetrovirus—A virus that contains a unique enzyme\\ncalled reverse transcriptase that allows it to repli-\\ncate within new host cells.\\nSeroconversion—The change from HIV- negative to\\nHIV-positive status during blood testing. Persons\\nwho are HIV-positive are called seroconverters.\\nSerology—The analysis of the contents and proper-\\nties of blood serum.\\nSerum—The part of human blood that remains liq-\\nuid when blood cells form a clot. Human blood\\nserum is clear light yellow in color.\\nT cells—Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s\\nresponse to infections, including HIV. CD4 lympho-\\ncytes are a subset of T lymphocytes.\\nViral load test—A new blood test for monitoring the\\nspeed of HIV replication in AIDS patients. The viral\\nload test is based on PCR techniques and supple-\\nments the CD4+ cell count tests.\\nWestern blot—A technique developed in 1979 that\\nis used to confirm ELISA results. HIV antigen is puri-\\nfied by electrophoresis and attached by blotting to a\\nnylon or nitrocellulose filter. The patient’s serum is\\nreacted against the filter, followed by treatment with\\ndeveloping chemicals that allow HIV antibody to\\nshow up as a colored patch or blot. If the patient is\\nHIV-positive, there will be stripes at specific loca-\\ntions for two or more viral proteins. A negative\\nresult is blank.\\nWBC differential —A white blood cell count in\\nwhich the technician classifies the different white\\nblood cells by type as well as calculating the num-\\nber of each type. A WBC differential is necessary to\\ncalculate the absolute CD4+ lymphocyte count.\\n• CD4+ count between 200-600 cells/mm\\n3\\n: Every three\\nmonths.\\n• CD4+ count less than 200 cells/mm\\n3\\n: Every three months.\\nWhen the CD4+ count falls below 200 cells/mm\\n3\\n,\\nthe doctor will put the patient on a medication regimen to\\nprotect him or her against opportunistic infections.\\nHIV VIRAL LOAD TESTS. Another type of blood test\\nfor monitoring AIDS patients is the viral load test. It sup-\\nplements the CD4+ count, which can tell the doctor the\\nextent of the patient’s loss of immune function, but not\\nthe speed of HIV replication in the body. The viral load\\ntest is based on PCR techniques and can measure the\\nGALE ENCYCLOPEDIA OF MEDICINE 2 85\\nAIDS tests\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 85'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 99, 'page_label': '100'}, page_content='number of copies of HIV nucleic acids. Successive test\\nresults for a given patient’s viral load are calculated on a\\nbase 10 logarithmic scale.\\nBETA2-MICROGLOBULIN (/H92522M). Beta2-microglobulin\\nis a protein found on the surface of all human cells with\\na nucleus. It is released into the blood when a cell dies.\\nAlthough rising blood levels of /H9252\\n2M are found in\\npatients with cancer and other serious diseases, a rising\\n/H92522M blood level can be used to measure the progression\\nof AIDS.\\nP24 ANTIGEN CAPTURE ASSAY. Found in the viral\\ncore of HIV , p24 is a protein that can be measured by\\nthe ELISA technique. Doctors can use p24 assays to\\nmeasure the antiviral activity of the patient’s medica-\\ntions. In addition, the p24 assay is sometimes useful in\\ndetecting HIV infection before seroconversion. Howev-\\ner, p24 is consistently present in only 25% of persons\\ninfected with HIV .\\nGENOTYPIC DRUG RESISTANCE TEST. Genotypic\\ntesting can help determine whether specific gene muta-\\ntions, common in people with HIV , are causing drug\\nresistance and drug failure. The test looks for specific\\ngenetic mutations of within the virus that are known to\\ncause resistance to certain drugs used in HIV treatment.\\nFor example the drug 3TC, also known as lamivudine\\n(Epivir), is not effective against strains of HIV that have\\na mutation at a particular position on the reverse tran-\\nscriptase protein—amino acid 184—known as M184V\\n(M/L50478V , methionine to valine). So if the genotypic resis-\\ntance test shows a mutation at position M184V , it is like-\\nly that person is resistant to 3TC and not likely to\\nrespond to 3TC treatment. Genotypic tests are only\\neffective if the person is already taking antiviral medica-\\ntion and if the viral load is greater than 1,000 copies per\\nmilliliter (mL) of blood. The cost of the test, usually\\nbetween $300 and $500, is usually now covered by\\nmany insurance plans.\\nPHENOTYPIC DRUG RESISTANCE TESTING. Pheno-\\ntypic testing directly measures the sensitivity of a\\npatient’s HIV to particular drugs and drug combinations.\\nTo do this, it measures the concentration of a drug\\nrequired to inhibit viral replication in the test tube. This\\nis the same method used by researchers to determine\\nwhether a drug might be effective against HIV before\\nusing it in human clinical trials. Phenotypic testing is a\\nmore direct measurement of resistance than genotypic\\ntesting. Also, unlike genotypic testing, phenotypic test-\\ning does not require a high viral load but it is recom-\\nmended that persons already be taking antiretroviral\\ndrugs. The cost is between $700 and $900 and is now\\ncovered by many insurance plans.\\nAIDS serology in children\\nChildren born to HIV-infected mothers may acquire\\nthe infection through the mother’s placenta or during the\\nbirth process. Public health experts recommend the test-\\ning and monitoring of all children born to mothers with\\nHIV . Diagnostic testing in children older than 18 months\\nis similar to adult testing, with ELISA screening con-\\nfirmed by Western blot. Younger infants can be diagnosed\\nby direct culture of the HIV virus, PCR testing, and p24\\nantigen testing. These techniques allow a pediatrician to\\nidentify 50% of infected children at or near birth, and\\n95% of cases in infants three to six months of age.\\nPreparation\\nPreparation and aftercare are important parts of AIDS\\ndiagnostic testing. Doctors are now advised to take the\\npatient’s emotional, social, economic, and other circum-\\nstances into account and to provide counseling before and\\nafter testing. Patients are generally better able to cope with\\nthe results if the doctor has spent some time with them\\nbefore the blood test explaining the basic facts about HIV\\ninfection and testing. Many doctors now offer this type of\\ninformational counseling before performing the tests.\\nAftercare\\nIf the test results indicate that the patient is HIV- pos-\\nitive, he or she will need counseling, information, referral\\nfor treatment, and support. Doctors can either counsel the\\npatient themselves or invite an experienced HIV coun-\\nselor to discuss the results of the blood tests with the\\npatient. They will also assess the patient’s emotional and\\npsychological status, including the possibility of violent\\nbehavior and the availability of a support network.\\nRisks\\nThe risks of AIDS testing are primarily related to\\ndisclosure of the patient’s HIV status rather than to any\\nphysical risks connected with blood testing. Some\\npatients are better prepared to cope with a positive diag-\\nnosis than others, depending on their age, sex, health,\\nresources, belief system, and similar factors.\\nNormal results\\nNormal results for ELISA, Western blot, IFA, and\\nPCR testing are negative for HIV antibody.\\nNormal results for blood cell counts:\\n• WBC differential: Total lymphocytes 24-44% of the\\nwhite blood cells.\\n• Hematocrit: 40-54% in men; 37-47% in women.\\nGALE ENCYCLOPEDIA OF MEDICINE 286\\nAIDS tests\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 86'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 100, 'page_label': '101'}, page_content='• T cell lymphocytes: 644-2200/mm\\n3\\n, 60-88% of all lym-\\nphocytes.\\n• B cell lymphocytes: 82-392/mm\\n3\\n, 3-20% of all lympho-\\ncytes.\\n• CD4+ lymphocytes: 500-1200/mm\\n3\\n, 34-67% of all\\nlymphocytes.\\nAbnormal results\\nThe following results in AIDS tests indicate progres-\\nsion of the disease:\\n• Percentage of CD4+ lymphocytes: less than 20% of all\\nlymphocytes.\\n• CD4+ lymphocyte count: less than 200 cells/mm\\n3\\n.\\n• Viral load test: Levels more than 5000 copies/mL.\\n• /H9252-2-microglobulin: Levels more than 3.5 mg/dL.\\n• P24 antigen: Measurable amounts in blood serum.\\nResources\\nBOOKS\\nAvrameas, Stratis, and Therese Ternynck. “Enzyme Linked\\nImmunosorbent Assay (ELISA).” In Encyclopedia of\\nImmunology.V ol. 1. Ed. Ivan M. Roitt and Peter J. Delves.\\nLondon: Academic Press, 1992.\\nBennett, Rebecca, and Erin, Charles A. (Editors). HIV and\\nAIDS Testing, Screening, and Confidentiality: Ethics, Law,\\nand Social Policy.Oxford, England: Oxford University\\nPress, 2001.\\nEarly HIV Infection Guideline Panel. Evaluation and Manage-\\nment of Early HIV Infection. Rockville, MD: U.S. Depart-\\nment of Health and Human Services, Agency for Health\\nCare Policy and Research, 1994.\\nHuber, Jeffrey T. Dictionary of AIDS- Related Terminology.\\nNew York: Neal-Schuman Publishers, Inc., 1993.\\n“Infectious Diseases: Human Immunodeficiency Virus (HIV).”\\nIn Neonatology: Management, Procedures, On-Call Prob-\\nlems, Diseases and Drugs. Ed. Tricia Lacy Gomella et al.\\nNorwalk, CT: Appleton & Lange, 1994.\\nKatz, Mitchell H., and Harry Hollander. “HIV Infection.” In\\nCurrent Medical Diagnosis & Treatment.Ed. Lawrence\\nM. Tierney et al. Stamford, CT: Appleton & Lange, 1998.\\nMcClure, Myra. “Human Immunodeficiency Viruses.” In Ency-\\nclopedia of Immunology.V ol. 2. Ed. by Ivan M. Roitt and\\nPeter J. Delves. London: Academic Press, 1992.\\nMcFarland, Elizabeth J. “Human Immunodeficiency Virus\\n(HIV) Infections: Acquired Immunodeficiency Syndrome\\n(AIDS).” In Current Pediatric Diagnosis & Treatment.Ed.\\nWilliam W. Hay et al. Stamford, CT: Appleton & Lange,\\n1997.\\nSo, Peter, and Livette Johnson. “Acquired Immune Deficiency\\nSyndrome (AIDS).” In Conn’s Current Therapy.Ed.\\nRobert E. Rakel. Philadelphia: W. B. Saunders Company,\\n1997.\\nSpringhouse Publishing. Handbook of Diagnostic Tests.\\nSpringhouse, PA: Springhouse Publishing Co., 1999.\\nTowbin, Harry. “Western Blotting.” In Encyclopedia of\\nImmunology.V ol. 3. Ed. Ivan M. Roitt and Peter J. Delves.\\nLondon: Academic Press, 1992.\\nPERIODICALS\\nFreedberg, Kenneth A., and Samet, Jeffrey H. “Think HIV\\n(HIV Testing).”Archives of Internal Medicine (September\\n27, 1999): 1994\\nKaplan, Edward H., and Satten, Glen A. “Repeat Screening for\\nHIV: When to Test and Why.”The Journal of the Ameri-\\ncan Medical Association. (July 19, 2000): 285.\\nSieff, Elaine M., et al. “Anticipated Versus Actual Reaction to\\nHIV Test Results.”American Journal of Psychology.\\n(Summer 1999): 297-298.\\nWeinhardt, Lance S., et al. “Human Immunodeficiency Virus\\nTesting and Behavior Change.”Archives of Internal Medi-\\ncine. (May 22, 2000): 1538.\\nWoehrle, Theresa A., and Branson, Bernard. “New Tests for\\nDetecting HIV Infection.”The Western Journal of Medi-\\ncine. (December 1998): 371-372.\\nORGANIZATION\\nNational Association of People with Aids. 1413 K St.N.W.,\\nWashington, DC 20005-3442. (202) 898-0414.\\nNational Institute of Health. Office of Aids Research. (301)\\n496-0357. .\\nCenters for Disease Control and Prevention (CDC). 1600\\nClifton Rd., Atlanta, GA 30337. (404) 639-3311. .\\nOTHER\\nFood and Drug Administration (FDA). “Testing Yourself for\\nHIV-1, the Virus that Causes AIDS.” 1999. Available at\\nFDA Website: . or by calling (301)\\n827-4460.\\nKen R. Wells\\nAir embolism see Gas embolism\\nAlanine aminotransferase test\\nDefinition\\nThe alanine aminotransferase test, also known as\\nALT, is one of a group of tests known as liver function\\ntests (or LFTs) and is used to monitor damage to the liver.\\nPurpose\\nALT levels are used to detect liver abnormalities.\\nSince the alanine aminotransferase enzyme is also found\\nin muscle, tests indicating elevated AST levels might also\\nindicate muscle damage. However, other tests, such as\\nGALE ENCYCLOPEDIA OF MEDICINE 2 87\\nAlanine aminotransferase test\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 87'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 101, 'page_label': '102'}, page_content='the levels of the MB fraction of creatine kinase should\\nindicate whether the abnormal test levels are because of\\nmuscle or liver damage.\\nDescription\\nThe alanine aminotransferase test (ALT) can reveal\\nliver damage. It is probably the most specific test for\\nliver damage. However, the severity of the liver damage\\nis not necessarily shown by the ALT test, since the\\namount of dead liver tissue does not correspond to higher\\nALT levels. Also, patients with normal, or declining,\\nALT levels may experience serious liver damage without\\nan increase in ALT.\\nNevertheless, ALT is widely used, and useful,\\nbecause ALT levels are elevated in most patients with\\nliver disease. Although ALT levels do not necessarily\\nindicate the severity of the damage to the liver, they may\\nindicate how much of the liver has been damaged. ALT\\nlevels, when compared to the levels of a similar enzyme,\\naspartate aminotransferase (AST), may provide impor-\\ntant clues to the nature of the liver disease. For example,\\nwithin a certain range of values, a ratio of 2:1 or greater\\nfor AST: ALT might indicate that a patient suffers from\\nalcoholic liver disease. Other diagnostic data may be\\ngleaned from ALT tests to indicate abnormal results.\\nPreparation\\nNo special preparations are necessary for this test.\\nAftercare\\nThis test involves blood being drawn, probably from\\na vein in the patient’s elbow. The patient should keep the\\nwound from the needle puncture covered (with a ban-\\ndage) until the bleeding stops. Patients should report any\\nunusual symptoms to their physician.\\nNormal results\\nNormal values vary from laboratory to laboratory,\\nand should be available to your physician at the time of\\nthe test. An informal survey of some laboratories indi-\\ncates many laboratories find values from approximately\\nseven to 50 IU/L to be normal.\\nAbnormal results\\nLow levels of ALT (generally below 300 IU/L) may\\nindicate any kind of liver disease. Levels above 1,000\\nIU/L generally indicate extensive liver damage from tox-\\nins or drugs, viral hepatitis, or a lack of oxygen (usually\\nresulting from very low blood pressure or a heart\\nattack). A briefly elevated ALT above 1,000 IU/L that\\nresolves in 24-48 hours may indicate a blockage of the\\nbile duct. More moderate levels of ALT (300-1,000IU/L)\\nmay support a diagnosis of acute or chronic hepatitis.\\nIt is important to note that persons with normal liv-\\ners may have slightly elevated levels of ALT. This is a\\nnormal finding.\\nMichael V . Zuck, PhD\\nAlanine aminotransferase test see Liver\\nfunction tests\\nAlbers-Schönberg disease see\\nOsteopetroses\\nAlbinism\\nDefinition\\nAlbinism is an inherited condition present at birth,\\ncharacterized by a lack of pigment that normally gives\\ncolor to the skin, hair, and eyes. Many types of albinism\\nexist, all of which involve lack of pigment in varying\\ndegrees. The condition, which is found in all races, may\\nbe accompanied by eye problems and may lead to skin\\ncancer later in life.\\nDescription\\nAlbinism is a rare disorder found in fewer than five\\npeople per 100,000 in the United States and Europe.\\nOther parts of the world have a much higher rate; for\\nexample, albinism is found in about 20 out of every\\n100,000 people in southern Nigeria.\\nThere are 10 types of the most common form of the\\ncondition, known as “oculocutaneous albinism,” which\\naffects the eyes, hair, and skin. In its most severe form,\\nhair and skin remain pure white throughout life. People\\nwith a less severe form are born with white hair and\\nskin, which turn slightly darker as they age. Everyone\\nwith oculocutaneous albinism experiences abnormal\\nflickering eye movements ( nystagmus ) and sensitivity\\nto bright light. There may be other eye problems as\\nwell, including poor vision and crossed or “lazy” eyes\\n(strabismus).\\nThe second most common type of the condition is\\nknown as “ocular” albinism, in which only the eyes lack\\ncolor; skin and hair are normal. There are five forms of\\nocular albinism; some types cause more problems—\\nespecially eye problems—than others.\\nGALE ENCYCLOPEDIA OF MEDICINE 288\\nAlbinism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 88'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 102, 'page_label': '103'}, page_content='Causes and symptoms\\nEvery cell in the body contains a matched pair of\\ngenes, one inherited from each parent. These genes act as a\\nsort of “blueprint” that guides the development of a fetus.\\nAlbinism is an inherited problem caused by a flaw in\\none or more of the genes that are responsible for direct-\\ning the eyes and skin to make melanin (pigment). As a\\nresult, little or no pigment is made, and the child’s skin,\\neyes and hair may be colorless.\\nIn most types of albinism, a recessive trait, the child\\ninherits flawed genes for making melanin from both par-\\nents. Because the task of making melanin is complex,\\nthere are many different types of albinism, involving a\\nnumber of different genes.\\nIt’s also possible to inherit one normal gene and one\\nalbinism gene. In this case, the one normal gene provides\\nenough information in its cellular blueprint to make\\nsome pigment, and the child will have normal skin and\\neye color. They “carry” one gene for albinism. About one\\nin 70 people are albinism carriers, with one flawed gene\\nbut no symptoms; they have a 50% chance of passing the\\nalbinism gene to their child. However, if both parents are\\nKEY TERMS\\nAmino acids —Natural substances that are the\\nbuilding blocks of protein. The body breaks down\\nthe protein in food into amino acids, and then uses\\nthese amino acids to create other proteins. The body\\nalso changes amino acids into melanin pigment.\\nAstigmatism —An eye condition in which the lens\\ndoesn’t focus light evenly on the retina, leading to\\nproblems with visual sharpness.\\nCarrier —A person with one normal gene and one\\nfaulty gene, who can pass on a condition to others\\nwithout actually having symptoms.\\nDNA—The abbreviation for “deoxyribonucleic\\nacid,” the primary carrier of genetic information\\nfound in the chromosomes of almost all organisms.\\nThe entwined double structure allows the chromo-\\nsomes to be copied exactly during cell division.\\nDOPA—The common name for a natural chemical\\n(3,4-dihydroxyphenylalanine) made by the body\\nduring the process of making melanin.\\nEnzyme—A protein that helps the body convert one\\nchemical substance to another.\\nGene—The basic unit of genetic material carried in\\na particular place on a chromosome. Genes are\\npassed on from parents to child when the sperm\\nand egg unite during conception.\\nHairbulb —The root of a strand of hair from which\\nthe color develops.\\nHermansky-Pudlak Syndrome (HPS) —A rare type\\nof albinism characterized by a problem with blood\\nclotting and a buildup of waxy material in lungs\\nand intestines.\\nMelanin—Pigment made in the hair, skin and eyes.\\nNystagmus—An involuntary back-and-forth move-\\nment of the eyes that is often found in albinism.\\nStrabismus—Crossed or “lazy” eyes, often found in\\nalbinism.\\nTyrosine—A protein building block found in a wide\\nvariety of foods that is used by the body to make\\nmelanin.\\nTyrosinase—An enzyme in a pigment cell which\\nhelps change tyrosine to DOPA during the process\\nof making melanin.\\ncarriers with one flawed gene each, they have a 1 in 4\\nchance of passing on both copies of the flawed gene to\\nthe child, who will have albinism. (There is also a type of\\nocular albinism that is carried on the X chromosome and\\noccurs almost exclusively in males because they have\\nonly one X chromosome and, therefore, no other gene for\\nthe trait to override the flawed one.)\\nSymptoms of albinism can involve the skin, hair,\\nand eyes. The skin, because it contains little pigment,\\nappears very light, as does the hair.\\nAlthough people with albinism may experience a vari-\\nety of eye problems, one of the myths about albinism is that\\nit causes people to have pink or red eyes. In fact, people\\nwith albinism can have irises varying from light gray or\\nblue to brown. (The iris is the colored portion of the eye\\nthat controls the size of the pupil, the opening that lets light\\ninto the eye.) If people with albinism seem to have reddish\\neyes, it’s because light is being reflected from the back of\\nthe eye (retina) in much the same way as happens when\\npeople are photographed with an electronic flash.\\nPeople with albinism may have one or more of the\\nfollowing eye problems:\\nGALE ENCYCLOPEDIA OF MEDICINE 2 89\\nAlbinism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 89'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 103, 'page_label': '104'}, page_content='• They may be very far-sighted or near-sighted, and may\\nhave other defects in the curvature of the lens of the eye\\n(astigmatism) that cause images to appear unfocused.\\n• They may have a constant, involuntary movement of\\nthe eyeball called nystagmus.\\n• They may have problems in coordinating the eyes in fix-\\ning and tracking objects (strabismus), which may lead to\\nan appearance of having “crossed eyes” at times. Stra-\\nbismus may cause some problems with depth percep-\\ntion, especially at close distances.\\n• They may be very sensitive to light (photophobia)\\nbecause their irises allow “stray” light to enter their eyes.\\nIt’s a common misconception that people with albinism\\nshouldn’t go out on sunny days, but wearing sunglasses\\ncan make it possible to go outside quite comfortably.\\nIn addition to the characteristically light skin and\\neye problems, people with a rare form of albinism called\\nHermansky-Pudlak Syndrome (HPS) also have a greater\\ntendency to have bleeding disorders, inflammation of the\\nlarge bowel (colitis), lung (pulmonary) disease, and kid-\\nney (renal) problems.\\nDiagnosis\\nIt’s not always easy to diagnose the exact type of\\nalbinism a person has; there are two tests available that\\ncan identify only two types of the condition. Recently, a\\nblood test has been developed that can identify carriers\\nof the gene for some types of albinism; a similar test dur-\\ning amniocentesis can diagnose some types of albinism\\nin an unborn child. A chorionic villus sampling test dur-\\ning the fifth week of pregnancy may also reveal some\\ntypes of albinism.\\nThe specific type of albinism a person has can be\\ndetermined by taking a good family history and examin-\\ning the patient and several close relatives.\\nThe “hairbulb pigmentation test” is used to identify\\ncarriers by incubating a piece of the person’s hair in a\\nsolution of tyrosine, a substance in food which the body\\nuses to make melanin. If the hair turns dark, it means the\\nhair is making melanin (a “positive” test); light hair\\nmeans there is no melanin. This test is the source of the\\nnames of two types of albinism: “ty-pos” and “ty-neg.”\\nThe tyrosinase test is more precise than the hairbulb\\npigmentation test. It measures the rate at which hair con-\\nGALE ENCYCLOPEDIA OF MEDICINE 290\\nAlbinism\\nA man with albinism stands with his normally pigmented father.(Photograph by Norman Lightfoot, Photo Researchers, Inc.\\nReproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 90'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 104, 'page_label': '105'}, page_content='verts tyrosine into another chemical (DOPA), which is\\nthen made into pigment. The hair converts tyrosine with\\nthe help of a substance called “tyrosinase.” In some types\\nof albinism, tyrosinase doesn’t do its job, and melanin\\nproduction breaks down.\\nTreatment\\nThere is no treatment that can replace the lack of\\nmelanin that causes the symptoms of albinism. Doctors\\ncan only treat, not cure, the eye problems that often\\naccompany the lack of skin color. Glasses are usually\\nneeded and can be tinted to ease pain from too much\\nsunlight. There is no cure for involuntary eye movements\\n(nystagmus), and treatments for focusing problems\\n(surgery or contact lenses) are not effective in all cases.\\nCrossed eyes (strabismus) can be treated during\\ninfancy, using eye patches, surgery or medicine injec-\\ntions. Treatment may improve the appearance of the\\neye, but it can do nothing to cure the underlying con-\\ndition.\\nPatients with albinism should avoid excessive expo-\\nsure to the sun, especially between 10 \\nA.M. and 2 P.M.I f\\nexposure can’t be avoided, they should use UV A-UVB\\nsunblocks with an SPF of at least 20. Taking beta-\\ncarotene may help provide some skin color, although it\\ndoesn’t protect against sun exposure.\\nPrognosis\\nIn the United States, people with this condition\\ncan expect to have a normal lifespan. People with\\nalbinism may experience some social problems\\nbecause of a lack of understanding on the part of oth-\\ners. When a member of a normally dark-skinned ethnic\\ngroup has albinism, he or she may face some very\\ncomplex social challenges.\\nOne of the greatest health hazards for people with\\nalbinism is excessive exposure to sun without protec-\\ntion, which could lead to skin cancer. Wearing opaque\\nclothes and sunscreen rated SPF 20, people with\\nalbinism can safely work and play outdoors safely even\\nduring the summer.\\nPrevention\\nGenetic counseling is very important to prevent fur-\\nther occurrences of the condition.\\nResources\\nBOOKS\\nNational Association for the Visually Handicapped. Larry: A\\nBook for Children with Albinism Going to School.New\\nYork: National Association for the Visually Handicapped.\\nWitkop Jr., C. J., W. C. Quevedo Jr., T. B. Fitzpatrick, and R. A\\nKing. “Albinism.” In The Metabolic Basis of Inherited\\nDisease. 6th ed. Ed. C. R. Scriver, et al. New York:\\nMcGraw-Hill, 1989.\\nPERIODICALS\\nCampbell, Maude. “Gene Found for Albinism, Other Pigment\\nDisorders.” Dermatology Times (1 Apr. 1995): 1.\\nSiegel-Itzkovich, Judy. “Early-warning Test for Albinism.”\\nJerusalem Post(4 Dec. 1994).\\nORGANIZATIONS\\nAlbinism World Alliance. .\\nAmerican Foundation for the Blind. 15 W. 16th St., New York,\\nNY 10011. (800) AFB-LIND.\\nHermansky-Pudlak Syndrome Network, Inc. One South Road,\\nOyster Bay, NY 11771-1905. (800) 789-9477. .\\nNational Organization for Albinism and Hypopigmentation\\n(NOAH). 1530 Locust St., #29, Philadelphia, PA 19102-\\n4415. (800) 473-2310. .\\nCarol A. Turkington\\nAlbuterol see Bronchodilators\\nAlcohol-related \\nneurologic disease\\nDefinition\\nAlcohol, or ethanol, is a poison with direct toxic\\neffects on nerve and muscle cells. Depending on which\\nnerve and muscle pathways are involved, alcohol can\\nhave far-reaching effects on different parts of the brain,\\nperipheral nerves, and muscles, with symptoms of mem-\\nory loss, incoordination, seizures, weakness, and senso-\\nry deficits. These different effects can be grouped in\\nthree main categories: (1) intoxication due to the acute\\neffects of ethanol, (2) withdrawal syndrome from sud-\\ndenly stopping drinking, and (3) disorders related to\\nlong-term or chronic alcohol abuse. Alcohol-related\\nneurologic disease includes Wernicke-Korsakoff dis-\\nease, alcoholic cerebellar degeneration, alcoholic\\nmyopathy, alcoholic neuropathy, alcohol withdrawal\\nsyndrome with seizures and delirium tremens, and fetal\\nalcohol syndrome.\\nDescription\\nAcute excess intake of alcohol can cause drunken-\\nness (intoxication) or even death, and chronic or long-\\nterm abuse leads to potentially irreversible damage to\\nvirtually any level of the nervous system. Any given\\nGALE ENCYCLOPEDIA OF MEDICINE 2 91\\nAlbinism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 91'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 105, 'page_label': '106'}, page_content='patient with long-term alcohol abuse may have no neu-\\nrologic complications, a single alcohol-related disease,\\nor multiple conditions, depending on the genes they\\nhave inherited, how well nourished they are, and other\\nenvironmental factors, such as exposure to other drugs\\nor toxins.\\nNeurologic complications of alcohol abuse may also\\nresult from nutritional deficiency, because alcoholics\\ntend to eat poorly and may become depleted of thiamine\\nor other vitamins important for nervous system function.\\nPersons who are intoxicated are also at higher risk for\\nhead injury or for compression injuries of the peripheral\\nnerves. Sudden changes in blood chemistry, especially\\nsodium, related to alcohol abuse may cause central pon-\\ntine myelinolysis, a condition of the brainstem in which\\nnerves lose their myelin coating. Liver disease compli-\\ncating alcoholic cirrhosis may cause dementia , deliri-\\num, and movement disorder.\\nCauses and symptoms\\nWhen a person drinks alcohol, it is absorbed by\\nblood vessels in the stomach lining and flows rapidly\\nthroughout the body and brain, as ethanol freely crosses\\nthe blood-brain barrier that ordinarily keeps large mole-\\ncules from escaping from the blood vessel to the brain\\ntissue. Drunkenness, or intoxication, may occur at blood\\nethanol concentrations of as low as 50-150 mg per dL in\\npeople who don’t drink. Sleepiness, stupor, coma,o r\\neven death from respiratory depression and low blood\\npressure occur at progressively higher concentrations.\\nAlthough alcohol is broken down by the liver, the\\ntoxic effects from a high dose of alcohol are most likely a\\ndirect result of alcohol itself rather than of its breakdown\\nproducts. The fatal dose varies widely because people\\nwho drink heavily develop a tolerance to the effects of\\nalcohol with repeated use. In addition, alcohol tolerance\\nresults in the need for higher levels of blood alcohol to\\nachieve intoxicating effects, which increases the likeli-\\nhood that habitual drinkers will be exposed to high and\\npotentially toxic levels of ethanol. This is particularly\\ntrue when binge drinkers fail to eat, because fasting\\ndecreases the rate of alcohol clearance and causes even\\nhigher blood alcohol levels.\\nWhen a chronic alcoholic suddenly stops drinking,\\nwithdrawal of alcohol leads to a syndrome of increased\\nexcitability of the central nervous system, called deliri-\\num tremens or “DTs.” Symptoms begin six to eight\\nhours after abstinence, and are most pronounced 24-72\\nhours after abstinence. They include body shaking\\n(tremulousness), insomnia , agitation, confusion, hear-\\ning voices or seeing images that are not really there\\n(such as crawling bugs), seizures, rapid heart beat, pro-\\nfuse sweating, high blood pressure, and fever. Alcohol-\\nrelated seizures may also occur without withdrawal,\\nsuch as during active heavy drinking or after more than a\\nweek without alcohol.\\nWernicke-Korsakoff syndrome is caused by defi-\\nciency of the B-vitamin thiamine, and can also be seen in\\npeople who don’t drink but have some other cause of thi-\\namine deficiency, such as chronic vomiting that prevents\\nthe absorption of this vitamin. Patients with this condi-\\ntion have the sudden onset of Wernicke encephalopathy;\\nthe symptoms include marked confusion, delirium, dis-\\norientation, inattention, memory loss, and drowsiness.\\nExamination reveals abnormalities of eye movement,\\nincluding jerking of the eyes ( nystagmus ) and double\\nvision. Problems with balance make walking difficult.\\nPeople may have trouble coordinating their leg move-\\nments, but usually not their arms. If thiamine is not given\\npromptly, Wernicke encephalopathy may progress to stu-\\npor, coma, and death.\\nIf thiamine is given and death averted, Korsakoff’s\\nsyndrome may develop in some patients, who suffer\\nfrom memory impairment that leaves them unable to\\nremember events for a period of a few years before the\\nonset of illness (retrograde amnesia) and unable to learn\\nnew information (anterograde amnesia). Most patients\\nhave very limited insight into their memory dysfunction\\nand have a tendency to make up explanations for events\\nthey have forgotten (confabulation).\\nSevere alcoholism can cause cerebellar degenera-\\ntion, a slowly progressive condition affecting portions of\\nthe brain called the anterior and superior cerebellar ver-\\nmis, causing a wide-based gait, leg incoordination, and\\nan inability to walk heel-to-toe in tightrope fashion. The\\ngait disturbance usually develops over several weeks, but\\nmay be relatively mild for some time, and then suddenly\\nworsen after binge drinking or an unrelated illness.\\nFetal alcohol syndrome occurs in infants born to\\nalcoholic mothers when prenatal exposure to ethanol\\nretards fetal growth and development. Affected infants\\noften have a distinctive appearance with a thin upper lip,\\nflat nose and mid-face, short stature and small head size.\\nAlmost half are mentally retarded, and most others are\\nmildly impaired intellectually or have problems with\\nspeech, learning, and behavior.\\nAlcoholic myopathy, or weakness secondary to\\nbreakdown of muscle tissue, is also known as alcoholic\\nrhabdomyolysis or alcoholic myoglobinuria. Males are\\naffected by acute (sudden onset) alcoholic myopathy\\nfour times as often as females. Breakdown of muscle tis-\\nsue (myonecrosis), can come on suddenly during binge\\ndrinking or in the first days of alcohol withdrawal. In its\\nmildest form, this breakdown may cause no noticeable\\nGALE ENCYCLOPEDIA OF MEDICINE 292\\nAlcohol-related neurologic disease\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 92'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 106, 'page_label': '107'}, page_content='symptoms, but may be detected by a temporary elevation\\nin blood levels of an enzyme found predominantly in\\nmuscle, the MM fraction of creatine kinase.\\nThe severe form of acute alcoholic myopathy is\\nassociated with the sudden onset of muscle pain,\\nswelling, and weakness; a reddish tinge in the urine\\ncaused by myoglobin, a breakdown product of muscle\\nexcreted in the urine; and a rapid rise in muscle enzymes\\nin the blood. Symptoms usually worsen over hours to a\\nfew days, and then improve over the next week to 10\\ndays as the patient is withdrawn from alcohol. Muscle\\nsymptoms are usually generalized, but pain and swelling\\nmay selectively involve the calves or other muscle\\ngroups. The muscle breakdown of acute alcoholic\\nmyopathy may be worsened by crush injuries, which\\nmay occur when people drink so much that they com-\\npress a muscle group with their body weight for a long\\ntime without moving, or by withdrawal seizures with\\ngeneralized muscle activity.\\nIn patients who abuse alcohol over many years,\\nchronic alcoholic myopathy may develop. Males and\\nfemales are equally affected. Symptoms include pain-\\nless weakness of the limb muscles closest to the trunk\\nand the girdle muscles, including the thighs, hips,\\nshoulders, and upper arms. This weakness develops\\ngradually, over weeks or months, without symptoms of\\nacute muscle injury. Muscle atrophy, or decreased bulk,\\nmay be striking. The nerves of the extremities may also\\nbegin to break down, a condition known as alcoholic\\nperipheral neuropathy , which can add to the person’s\\ndifficulty in moving.\\nThe way in which alcohol destroys muscle tissue is\\nstill not well understood. Proposed mechanisms include\\nmuscle membrane changes affecting the transport of cal-\\ncium, potassium, or other minerals ; impaired muscle\\nenergy metabolism; and impaired protein synthesis.\\nAlcohol is metabolized or broken down primarily by the\\nliver, with a series of chemical reactions in which ethanol\\nis converted to acetate. Acetate is metabolized by skeletal\\nmuscle, and alcohol-related changes in liver function\\nmay affect skeletal muscle metabolism, decreasing the\\namount of blood sugar available to muscles during pro-\\nlonged activity. Because not enough sugar is available to\\nsupply needed energy, muscle protein may be broken\\ndown as an alternate energy source. However, toxic\\neffects on muscle may be a direct result of alcohol itself\\nrather than of its breakdown products.\\nAlthough alcoholic peripheral neuropathy may con-\\ntribute to muscle weakness and atrophy by injuring the\\nmotor nerves controlling muscle movement, alcoholic\\nneuropathy more commonly affects sensory fibers.\\nInjury to these fibers can cause tingling or burning pain\\nin the feet, which may be severe enough to interfere with\\nwalking. As the condition worsens, pain decreases but\\nnumbness increases.\\nDiagnosis\\nThe diagnosis of alcohol-related neurologic disease\\ndepends largely on finding characteristic symptoms and\\nsigns in patients who abuse alcohol. Other possible\\ncauses should be excluded by the appropriate tests,\\nwhich may include blood chemistry, thyroid function\\ntests, brain MRI ( magnetic resonance imaging ) or CT\\n(computed tomography scan), and/or cerebrospinal\\nfluid analysis.\\nAcute alcoholic myopathy can be diagnosed by\\nfinding myoglobin in the urine and increased creatine\\nkinase and other blood enzymes released from injured\\nmuscle. The surgical removal of a small piece of muscle\\nfor microscopic analysis (muscle biopsy) shows the\\nscattered breakdown and repair of muscle fibers. Doc-\\ntors must rule out other acquired causes of muscle\\nbreakdown, which include the abuse of drugs such as\\nheroin, cocaine , or amphetamines; trauma with crush\\ninjury; the depletion of phosphate or potassium; or an\\nunderlying defect in the metabolism of carbohydrates or\\nlipids. In chronic alcoholic myopathy, serum creatine\\nkinase often is normal, and muscle biopsy shows atro-\\nphy, or loss of muscle fibers. Electromyography\\n(EMG) may show features characteristic of alcoholic\\nmyopathy or neuropathy.\\nTreatment\\nAcute management of alcohol intoxication, delirium\\ntremens, and withdrawal is primarily supportive, to mon-\\nitor and treat any cardiovascular or respiratory failure\\nthat may develop. In delirium tremens, fever and sweat-\\ning may necessitate treatment of fluid loss and secondary\\nlow blood pressure. Agitation may be treated with ben-\\nzodiazepines such as chlordiazepoxide, beta-adrenergic\\nantagonists such as atenolol, or alpha 2-adrenergic ago-\\nnists such as clonidine. Because Wernicke’s syndrome is\\nrapidly reversible with thiamine, and because death may\\nintervene if thiamine is not given promptly, all patients\\nadmitted for acute complications of alcohol, as well as\\nall patients with unexplained encephalopathy, should be\\ngiven intravenous thiamine.\\nWithdrawal seizures typically resolve without spe-\\ncific anti-epileptic drug treatment, although status epilep-\\nticus (continual seizures occurring without interruption)\\nshould be treated vigorously. Acute alcoholic myopathy\\nwith myoglobinuria requires monitoring and mainte-\\nnance of kidney function, and correction of imbalances\\nGALE ENCYCLOPEDIA OF MEDICINE 2 93\\nAlcohol-related neurologic disease\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 93'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 107, 'page_label': '108'}, page_content='in blood chemistry including potassium, phosphate, and\\nmagnesium levels.\\nChronic alcoholic myopathy and other chronic con-\\nditions are treated by correcting associated nutritional\\ndeficiencies and maintaining a diet adequate in protein\\nand carbohydrate. The key to treating any alcohol-related\\ndisease is helping the patient overcome alcohol addic-\\ntion. Behavioral measures and social supports may be\\nneeded in patients who develop broad problems in their\\nthinking abilities (dementia) or remain in a state of con-\\nfusion and disorientation (delirium). People with walk-\\ning disturbances may benefit from physical therapy and\\nassistive devices. Doctors may also prescribe drugs to\\ntreat the pain associated with peripheral neuropathy.\\nPrognosis\\nComplete recovery from Wernicke’s syndrome may\\nfollow prompt administration of thiamine. However,\\nrepeated episodes of encephalopathy or prolonged alco-\\nhol abuse may cause persistent dementia or Korsakoff\\npsychosis . Most patients recover fully from acute alco-\\nholic myopathy within days to weeks, but severe cases\\nmay be fatal from acute kidney failure and disturbances\\nin heart rhythm secondary to increased potassium levels.\\nRecovery from chronic alcoholic myopathy may occur\\nKEY TERMS\\nAbstinence —Refraining from the use of alcoholic\\nbeverages.\\nAtrophy—A wasting or decrease in size of a muscle\\nor other tissue.\\nCerebellum—The part of the brain involved in coor-\\ndination of movement, walking, and balance.\\nDegeneration —Gradual, progressive loss of nerve\\ncells.\\nDelirium —Sudden confusion with decreased or\\nfluctuating level of consciousness.\\nDelirium tremens —A complication that may\\naccompany alcohol withdrawal. The symptoms\\ninclude body shaking (tremulousness), insomnia,\\nagitation, confusion, hearing voices or seeing\\nimages that are not really there (hallucinations),\\nseizures, rapid heart beat, profuse sweating, high\\nblood pressure, and fever.\\nDementia—Loss of memory and other higher func-\\ntions, such as thinking or speech, lasting six months\\nor more.\\nMyoglobinuria—Reddish urine caused by excretion\\nof myoglobin, a breakdown product of muscle.\\nMyopathy—A disorder that causes weakening of\\nmuscles.\\nNeuropathy—A condition affecting the nerves sup-\\nplying the arms and legs. Typically, the feet and\\nhands are involved first. If sensory nerves are\\ninvolved, numbness, tingling, and pain are promi-\\nnent, and if motor nerves are involved, the patient\\nexperiences weakness.\\nThiamine —A B vitamin essential for the body to\\nprocess carbohydrates and fats. Alcoholics may suf-\\nfer complications (including Wernike-Korsakoff syn-\\ndrome) from a deficiency of this vitamin.\\nWernicke-Korsakoff syndrome —A combination of\\nsymptoms, including eye-movement problems,\\ntremors, and confusion, that is caused by a lack of\\nthe B vitamin thiamine and may be seen in alco-\\nholics.\\nover weeks to months of abstinence from alcohol and\\ncorrection of malnutrition. Cerebellar degeneration and\\nalcoholic neuropathy may also improve to some extent\\nwith abstinence and balanced diet, depending on the\\nseverity and duration of the condition.\\nPrevention\\nPrevention requires abstinence from alcohol. Per-\\nsons who consume small or moderate amounts of alcohol\\nmight theoretically help prevent nutritional complica-\\ntions of alcohol use with dietary supplements including\\nB vitamins. However, proper nutrition cannot protect\\nagainst the direct toxic effect of alcohol or of its break-\\ndown products. Patients with any alcohol-related symp-\\ntoms or conditions, pregnant women, and patients with\\nliver or neurologic disease should abstain completely.\\nPersons with family history of alcoholism or alcohol-\\nrelated conditions may also be at increased risk for neu-\\nrologic complications of alcohol use.\\nResources\\nPERIODICALS\\nDiamond, I., and R. O. Messing. “Neurologic Effects of Alco-\\nholism.” Western Journal of Medicine161 (1994): 279-87.\\nGALE ENCYCLOPEDIA OF MEDICINE 294\\nAlcohol-related neurologic disease\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 94'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 108, 'page_label': '109'}, page_content='Neiman, J., et al. “Movement Disorders in Alcoholism: A\\nReview.”Neurology 40 (1990): 741-6.\\nSaitz, R. “Individualized Treatment for Alcohol Withdrawal. A\\nRandomized Double-Blind Controlled Trial.”Journal of\\nthe American Medical Association 272 (1994): 557-8.\\nVictor, M. “Alcoholic Dementia.”Candian Journal of Neuro-\\nlogical Science 21 (1994): 88-99.\\nORGANIZATIONS\\nNational Institute on Alcohol Abuse and Alcoholism. 6000\\nExecutive Boulevard, Willco Building, Bethesda, MD\\n20892-7003. .\\nLaurie Barclay, MD\\nAlcohol abuse see Alcoholism\\nAlcohol dependence see Alcoholism\\nAlcohol withdrawal see Withdrawal\\nsyndromes\\nAlcoholic cerebellar disease see Alcohol-\\nrelated neurologic disease\\nAlcoholic hepatitis see Hepatitis, alcoholic\\nAlcoholic rose gardener’s disease see\\nSporotrichosis\\nAlcoholism\\nDefinition\\nThe essential feature of alcohol abuse is the mal-\\nadaptive use of alcohol with recurrent and significant\\nadverse consequences related to its repeated use. Alco-\\nholism is the popular term for two disorders, alcohol\\nabuse and alcohol dependence. The hallmarks of both\\nthese disorders involve repeated life problems that can be\\ndirectly attributed to the use of alcohol. Both these disor-\\nders can have serious consequences, affecting an individ-\\nual’s health and personal life, as well as having an impact\\non society at large.\\nDescription\\nThe effects of alcoholism are quite far-reaching.\\nAlcohol affects every body system, causing a wide range\\nof health problems. Some such problems include poor\\nnutrition, memory disorders, difficulty with balance and\\nwalking, liver disease (including cirrhosis and hepatitis),\\nhigh blood pressure, muscle weakness (including the\\nheart), heart rhythm disturbances, anemia, clotting disor-\\nders, decreased immunity to infections, gastrointestinal\\ninflammation and irritation, acute and chronic problems\\nwith the pancreas, low blood sugar, high blood fat con-\\ntent, interference with reproductive fertility, and weak-\\nened bones.\\nOn a personal level, alcoholism results in marital\\nand other relationship difficulties, depression, unemploy-\\nment, child abuse, and general family dysfunction.\\nAlcoholism causes or contributes to a variety of\\nsevere social problems including homelessness, murder,\\nsuicide, injury, and violent crime. Alcohol is a contribut-\\ning factor in at least 50% of all deaths from motor vehi-\\ncle accidents. In fact, about 100,000 deaths occur each\\nyear due to the effects of alcohol, of which 50% are due\\nto injuries of some sort. According to a recent special\\nreport prepared for the U.S. Congress by the National\\nInstitute on Alcohol Abuse and Alcoholism, the impact\\nof alcohol on society, including violence, traffic acci-\\ndents, lost work productivity, and premature death, costs\\nour nation an estimated $185 billion annually. In addi-\\ntion, it is estimated that approximately one in four chil-\\ndren (19 million children or 29 percent of children up to\\n17 years of age) is exposed at some time to familial alco-\\nhol abuse, alcohol dependence, or both. Furthermore, it\\nhas been estimated that approximately 18 percent of\\nadults experience an episode of alcohol abuse or depen-\\ndence a some time during their lives.\\nCauses and symptoms\\nThere are probably a number of factors that work\\ntogether to cause a person to become an alcoholic.\\nRecent genetic studies have demonstrated that close rel-\\natives of an alcoholic are four times more likely to\\nbecome alcoholics themselves. Furthermore, this risk\\nholds true even for children who were adopted away\\nfrom their biological families at birth and raised in a\\nnon-alcoholic adoptive family, with no knowledge of\\ntheir biological family’s difficulties with alcohol. More\\nresearch is being conducted to determine if genetic fac-\\ntors could account for differences in alcohol metabo-\\nlism that may increase the risk of an individual becom-\\ning an alcoholic.\\nThe symptoms of alcoholism can be broken down\\ninto two major categories: symptoms of acute alcohol\\nuse and symptoms of long-term alcohol use.\\nImmediate (acute) effects of alcohol use\\nAlcohol exerts a depressive effect on the brain. The\\nblood-brain barrier does not prevent alcohol from enter-\\ning the brain, so the brain alcohol level will quickly\\nbecome equivalent to the blood alcohol level. Alcohol’s\\ndepressive effects result in difficulty walking, poor bal-\\nance, slurring of speech, and generally poor coordination\\nGALE ENCYCLOPEDIA OF MEDICINE 2 95\\nAlcoholism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 95'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 109, 'page_label': '110'}, page_content='(accounting in part for the increased likelihood of\\ninjury). The affected person may also have impairment of\\nperiperal vision. At higher alcohol levels, a person’s\\nbreathing and heart rates will be slowed, and vomiting\\nmay occur (with a high risk of the vomit being breathed\\ninto the lungs, resulting in severe problems, including the\\npossibility of pneumonia ). Still higher alcohol levels\\nmay result in coma and death.\\nEffects of long-term (chronic) alcoholism\\nLong-term use of alcohol affects virtually every\\norgan system of the body:\\n• Nervous system. An estimated 30-40% of all men in\\ntheir teens and twenties have experienced alcoholic\\nblackout, which occurs when drinking a large quantity\\nof alcohol results in the loss of memory of the time\\nsurrounding the episode of drinking. Alcohol is well-\\nknown to cause sleep disturbances, so that overall\\nsleep quality is affected. Numbness and tingling may\\noccur in the arms and legs. Two syndromes, which can\\noccur together or separately, are known as Wernicke’s\\nand Korsakoff’s syndromes. Both are due to the low\\nthiamine (a form of vitamin B complex) levels found\\nin alcoholics. Wernicke’s syndrome results in disor-\\ndered eye movements, very poor balance and difficulty\\nwalking, while Korsakoff’s syndrome severely\\naffects one’s memory, preventing new learning from\\ntaking place.\\n• Gastrointestinal system. Alcohol causes loosening of\\nthe muscular ring that prevents the stomach’s contents\\nfrom re-entering the esophagus. Therefore, the acid\\nfrom the stomach flows backwards into the esopha-\\ngus, burning those tissues, and causing pain and\\nbleeding. Inflammation of the stomach can also result\\nin bleeding and pain, and decreased desire to eat. A\\nmajor cause of severe, uncontrollable bleeding (hem-\\norrhage) in an alcoholic is the development of\\nenlarged (dilated) blood vessels within the esophagus,\\nwhich are called esophageal varices. These varices are\\nactually developed in response to liver disease, and\\nare extremely prone to bursting and hemorrhaging.\\nDiarrhea is a common symptom, due to alcohol’s\\neffect on the pancreas. In addition, inflammation of\\nthe pancreas ( pancreatitis ) is a serious and painful\\nproblem in alcoholics. Throughout the intestinal tract,\\nalcohol interferes with the absorption of nutrients,\\ncreating a malnourished state. Because alcohol is bro-\\nken down (metabolized) within the liver, that organ is\\nseverely affected by constant levels of alcohol. Alco-\\nhol interferes with a number of important chemical\\nprocesses that also occur in the liver. The liver begins\\nto enlarge and fill with fat ( fatty liver ), fibrous scar\\ntissue interferes with the liver’s normal structure and\\nfunction (cirrhosis), and the liver may become\\ninflamed (hepatitis).\\n• Blood. Alcohol can cause changes to all the types of\\nblood cells. Red blood cells become abnormally\\nlarge. White blood cells (important for fighting infec-\\ntions) decrease in number, resulting in a weakened\\nimmune system. This places alcoholics at increased\\nrisk for infections, and is thought to account in part\\nfor the increased risk of cancer faced by alcoholics\\n(ten times increased over normal). Platelets and blood\\nclotting factors are affected, causing an increased risk\\nof bleeding.\\n• Heart. Small amounts of alcohol cause a drop in blood\\npressure, but with increased use, alcohol begins to\\nincrease blood pressure into a dangerous range. High\\nlevels of fats circulating in the bloodstream increase the\\nrisk of heart disease. Heavy drinking results in an\\nincrease in heart size, weakening of the heart muscle,\\nabnormal heart rhythms, a risk of blood clots forming\\nwithin the chambers of the heart, and a greatly\\nincreased risk of stroke (due to a blood clot from the\\nheart entering the circulatory system, going to the\\nbrain, and blocking a brain blood vessel).\\n• Reproductive system. Heavy drinking has a negative\\neffect on fertility in both men and women, by decreas-\\ning testicle and ovary size, and interfering with both\\nsperm and egg production. When pregnancy is\\nachieved in an alcoholic woman, the baby has a great\\nrisk of being born with fetal alcohol syndrome, which\\ncauses distinctive facial defects, lowered IQ, and\\nbehavioral problems.\\nDiagnosis\\nTwo different types of alcohol-related difficulties\\nhave been identified. The first is called alcohol depen-\\ndence, which refers to a person who literally depends on\\nthe use of alcohol. Three of the following traits must be\\npresent to diagnose alcohol dependence:\\n• tolerance, meaning that a person becomes accustomed\\nto a particular dose of alcohol, and must increase the\\ndose in order to obtain the desired effect\\n• withdrawal, meaning that a person experiences\\nunpleasant physical and psychological symptoms when\\nhe or she does not drink alcohol\\n• the tendency to drink more alcohol than one intends\\n(once an alcoholic starts to drink, he or she finds it dif-\\nficult to stop)\\n• being unable to avoid drinking or stop drinking once\\nstarted\\nGALE ENCYCLOPEDIA OF MEDICINE 296\\nAlcoholism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 96'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 110, 'page_label': '111'}, page_content='• having large blocks of time taken up by alcohol use\\n• choosing to drink at the expense of other important\\ntasks or activities\\n• drinking despite evidence of negative effects on one’s\\nhealth, relationships, education, or job\\nAlcohol abuse requires that one of the following four\\ncriteria is met. Because of drinking, a person repeatedly:\\n• fails to live up to his or her most important responsibili-\\nties\\n• physically endangers him or herself, or others (for\\nexample, by drinking when driving)\\n• gets into trouble with the law\\n• experiences difficulties in relationships or jobs\\nDiagnosis is sometimes brought about when family\\nmembers call an alcoholic’s difficulties to the attention\\nof a physician. A clinician may begin to be suspicious\\nwhen a patient suffers repeated injuries or begins to\\nexperience medical problems related to the use of alco-\\nhol. In fact, some estimates suggest that about 20% of a\\nphysician’s patients will be alcoholics.\\nDiagnosis is aided by administering specific psycho-\\nlogical assessments that try to determine what aspects of\\na person’s life may be affected by his or her use of alco-\\nhol. Determining the exact quantity of alcohol that a per-\\nson drinks is of much less importance than determining\\nhow his or her drinking affects relationships, jobs, educa-\\ntional goals, and family life. In fact, because the metabo-\\nlism of alcohol (how the body breaks down and process-\\nes alcohol) is so individual, the quantity of alcohol con-\\nsumed is not part of the criteria list for diagnosing either\\nalcohol dependence or alcohol abuse.\\nOne very simple tool for beginning the diagnosis of\\nalcoholism is called the CAGE questionnaire. It consists\\nof four questions, with the first letters of each key word\\nspelling out the word CAGE:\\n• Have you ever tried to Cut down on your drinking?\\n• Have you ever been Annoyed by anyone’s comments\\nabout your drinking?\\n• Have you ever felt Guilty about your drinking?\\n• Do you ever need an Eye-opener (a morning drink of\\nalcohol) to start the day)?\\nOther, longer lists of questions exist to help deter-\\nmine the severity and effects of a person’s alcohol use.\\nGiven the recent research pointing to a genetic basis\\nfor alcoholism, it is important to ascertain whether\\nanyone else in the person’s family has ever suffered\\nfrom alcoholism.\\nPhysical examination may reveal signs suggestive\\nof alcoholism: evidence of old injuries; a visible network\\nof enlarged veins just under the skin around the navel\\n(called caput medusae); fluid in the abdomen ( ascites);\\nyellowish-tone to the skin; decreased testicular size in\\nmen; and poor nutritional status. Lab work may reveal an\\nincrease in the size of the red blood cells; abnormalities\\nin the white blood cells (cells responsible for fighting\\ninfection) and platelets (particles responsible for clot-\\nting); and an increase in certain liver enzymes.\\nTreatment\\nTreatment of alcoholism has two parts. The first step\\nin the treatment of alcoholism, called detoxification,\\ninvolves helping the person stop drinking and ridding his\\nor her body of the harmful (toxic) effects of alcohol.\\nBecause the person’s body has become accustomed to\\nalcohol, the person will need to be supported through\\nwithdrawal. Withdrawal will be different for different\\npatients, depending on the severity of the alcoholism, as\\nmeasured by the quantity of alcohol ingested daily and the\\nlength of time the patient has been an alcoholic. With-\\ndrawal symptoms can range from mild to life-threatening.\\nMild withdrawal symptoms include nausea, achiness, diar-\\nrhea, difficulty sleeping, sweatiness, anxiety, and trem-\\nbling. This phase is usually over in about three to five\\ndays. More severe effects of withdrawal can include hallu-\\ncinations (in which a patient sees, hears, or feels some-\\nthing that is not actually real), seizures, an unbearable\\ncraving for more alcohol, confusion,fever, fast heart rate,\\nhigh blood pressure, and delirium (a fluctuating level of\\nconsciousness). Patients at highest risk for the most severe\\nsymptoms of withdrawal (referred to as delirium tremens)\\nare those with other medical problems, including malnu-\\ntrition, liver disease, or Wernicke’s syndrome. Delirium\\nGALE ENCYCLOPEDIA OF MEDICINE 2 97\\nAlcoholism\\nSymptoms Of Co-Alcohol Dependence\\nPsychological distress manifested in symptoms such as anxiety, aggression, anorexia nervosa, bulimia, depression, insomnia, hyperactivity, and suicidal tendency\\nPsychosomatic illness (ailments that have no biological basis and clear up after the co-alcoholism clears up)\\nFamily violence or neglect\\nAlcoholism or other drug abuse\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 97'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 111, 'page_label': '112'}, page_content='tremens usually begin about three to five days after the\\npatient’s last drink, progressing from the more mild symp-\\ntoms to the more severe, and may last a number of days.\\nPatients going through only mild withdrawal are sim-\\nply monitored carefully to make sure that more severe\\nsymptoms do not develop. No medications are necessary,\\nhowever. Treatment of a patient suffering the more severe\\neffects of withdrawal may require the use of sedative med-\\nications to relieve the discomfort of withdrawal and to\\navoid the potentially life-threatening complications of high\\nblood pressure, fast heart rate, and seizures. Drugs called\\nbenzodiazapines are helpful in those patients suffering\\nfrom hallucinations. Because of the patient’s nausea, fluids\\nmay need to be given through a vein (intravenously), along\\nwith some necessary sugars and salts. It is crucial that thi-\\namine be included in the fluids, because thiamine is usually\\nquite low in alcoholic patients, and deficiency of thiamine\\nis responsible for the Wernicke-Korsakoff syndrome.\\nAfter cessation of drinking has been accomplished,\\nthe next steps involve helping the patient avoid ever tak-\\ning another drink. This phase of treatment is referred to\\nas rehabilitation . The best programs incorporate the\\nfamily into the therapy, because the family has undoubt-\\nedly been severely affected by the patient’s drinking.\\nSome therapists believe that family members, in an effort\\nto deal with their loved one’s drinking problem, some-\\ntimes develop patterns of behavior that accidentally sup-\\nport or “enable” the patient’s drinking. This situation is\\nreferred to as “co-dependence,” and must be addressed in\\norder to successfully treat a person’s alcoholism.\\nSessions led by peers, where recovering alcoholics\\nmeet regularly and provide support for each other’s\\nrecoveries, are considered some of the best methods of\\npreventing a return to drinking (relapse). Perhaps the\\nmost well-known such group is called Alcoholics\\nAnonymous, which uses a “12-step” model to help peo-\\nple avoid drinking. These steps involve recognizing the\\ndestructive power that alcohol has held over the alco-\\nholic’s life, looking to a higher power for help in over-\\ncoming the problem, and reflecting on the ways in\\nwhich the use of alcohol has hurt others and, if possi-\\nble, making amends to those people. According to a\\nrecent study reported by the American Psychological\\nAssociation (APA), anyone, regardless of his or her\\nreligious beliefs or lack of religious beliefs, can benefit\\nfrom participation in 12-step programs such as Alco-\\nholics Anonymous (AA) or Narcotics Anonymous\\n(NA). The number of visits to 12-step self-help groups\\nexceeds the number of visits to all mental health profes-\\nsionals combined.\\nThere are also medications that may help an alco-\\nholic avoid returning to drinking. These have been used\\nwith variable success. Disulfiram (Antabuse) is a drug\\nwhich, when mixed with alcohol, causes unpleasant reac-\\ntions including nausea, vomiting, diarrhea, and trembling.\\nNaltrexone, along with a similar compound, Nalmefene,\\ncan be helpful in limiting the effects of a relapse. Acam-\\nprosate is helpful in preventing relapse. None of these\\nmedications would be helpful unless the patient was also\\nwilling to work very hard to change his or her behavior.\\nAlternative treatment\\nAlternative treatments can be a helpful adjunct for the\\nalcoholic patient, once the medical danger of withdrawal\\nhas passed. Because many alcoholics have very stressful\\nlives (whether because of or leading to the alcoholism is\\nsometimes a matter of debate), many of the treatments for\\nalcoholism involve dealing with and relieving stress. These\\ninclude massage, meditation, and hypnotherapy. The\\nmalnutrition of long-term alcohol use is addressed by nutri-\\ntion-oriented practitioners with careful attention to a\\nhealthy diet and the use of nutritional supplements such as\\nvitamins A, B complex, and C, as well as certain fatty\\nacids, amino acids, zinc, magnesium, and selenium. Herbal\\ntreatments include milk thistle(Silybum marianum), which\\nis thought to protect the liver against damage. Other herbs\\nare thought to be helpful for the patient suffering through\\nwithdrawal. Some of these include lavender ( Lavandula\\nofficinalis), skullcap (Scutellaria lateriflora), chamomile\\n(Matricaria recutita ), peppermint ( Mentha piperita )\\nyarrow ( Achillea millefolium ), and valerian ( Valeriana\\nofficinalis). Acupuncture is believed to both decrease\\nwithdrawal symptoms and to help improve a patient’s\\nchances for continued recovery from alcoholism.\\nPrognosis\\nRecovery from alcoholism is a life-long process. In\\nfact, people who have suffered from alcoholism are encour-\\naged to refer to themselves ever after as “a recovering alco-\\nholic,” never a recovered alcoholic. This is because most\\nresearchers in the field believe that since the potential for\\nalcoholism is still part of the individual’s biological and\\npsychological makeup, one can never fully recover from\\nalcoholism. The potential for relapse (returning to illness)\\nis always there, and must be acknowledged and respected.\\nStatistics suggest that, among middle-class alcoholics in\\nstable financial and family situations who have undergone\\ntreatment, 60% or more can be successful at an attempt to\\nstop drinking for at least a year, and many for a lifetime.\\nPrevention\\nPrevention must begin at a relatively young age\\nsince the first instance of intoxication (drunkenness) usu-\\nGALE ENCYCLOPEDIA OF MEDICINE 298\\nAlcoholism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 98'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 112, 'page_label': '113'}, page_content='ally occurs during the teenage years. It is particularly\\nimportant that teenagers who are at high risk for alco-\\nholism—those with a family history of alcoholism, an\\nearly or frequent use of alcohol, a tendency to drink to\\ndrunkenness, alcohol use that interferes with school\\nwork, a poor family environment, or a history of domes-\\ntic violence—receive education about alcohol and its\\nlong-term effects. How this is best achieved, without irri-\\ntating the youngsters and thus losing their attention, is\\nthe subject of continuing debate and study.\\nResources\\nBOOKS\\nAmerican Psychiatric Association. Diagnostic and Statistical\\nManual of Mental Disorders. 4th ed.Washington, D.C.:\\nAmerican Psychiatric Association, 1994.\\nNational Institute on Alcohol Abuse and Alcoholism. 10th Spe-\\ncial Report to the U.S. Congress on Alcohol and Health.\\nNational Institute of Health, 2000.\\nSchuckit, Marc A. “Alcohol and Alcoholism.” In Harrison’s\\nPrinciples of Internal Medicine. Ed. Anthony S. Fauci, et\\nal. New York: McGraw-Hill, 1998.\\nPERIODICALS\\nMattas-Curry, L. “12-step self-help programs proved success-\\nful regardless of participants’ religious background, study\\nKEY TERMS\\nBlood-brain barrier —A network of blood vessels\\ncharacterized by closely spaced cells that prevents\\nmany potentially toxic substances from penetrat-\\ning the blood vessel walls to enter the brain. Alco-\\nhol is able to cross this barrier.\\nDetoxification —The phase of treatment during\\nwhich a patient stops drinking and is monitored\\nand cared for while he or she experiences with-\\ndrawal from alcohol.\\nRelapse—A return to a disease state, after recovery\\nappeared to be occurring; in alcoholism, relapse\\nrefers to a patient beginning to drink alcohol again\\nafter a period of avoiding alcohol.\\nTolerance—A phenomenon during which a drinker\\nbecomes physically accustomed to a particular\\nquantity of alcohol, and requires ever-increasing\\nquantities in order to obtain the same effects.\\nWithdrawal—Those signs and symptoms experi-\\nenced by a person who has become physically\\ndependent on a drug, experienced upon decreas-\\ning the drug’s dosage or discontinuing its use.\\nsuggests.” APA Monitor Online.volume 30, number 11,\\nDecember 1999. .\\nORGANIZATIONS\\nAl-Anon, Alanon Family Group, Inc. P.O. Box 862, Midtown\\nStation, New York, NY 10018-0862. (800)356-9996.\\n.\\nAlcoholics Anonymous. Grand Central Station, Box 459, New\\nYork, NY 10163. .\\nNational Alliance on Alcoholism and Drug Dependence, Inc.\\n12 West 21st St., New York, NY 10010. (212)206-6770.\\nNational Clearinghouse for Alcohol and Drug Information.\\n.\\nNational Institute on Alcohol Abuse and Alcoholism (NIAAA)\\n6000 Executive Boulevard, Bethesda, Maryland 20892-\\n7003. .\\nBill Asenjo, MS, CRC\\nALD see Adrenoleukodystrophy\\nAldolase test\\nDefinition\\nAldolase is an enzyme found throughout the body,\\nparticularly in muscles. Like all enzymes, it is needed to\\ntrigger specific chemical reactions. Aldolase helps mus-\\ncle turn sugar into energy. Testing for aldolase is done to\\ndiagnose and monitor skeletal muscle diseases.\\nPurpose\\nSkeletal muscle diseases increase the aldolase level\\nfound in a person’s blood. Skeletal muscles are those\\nmuscles attached to bones and whose contractions make\\nthose bones move. When the muscles are diseased or\\ndamaged, such as in muscular dystrophy, the cells dete-\\nriorate and break open. The contents of the cells, includ-\\ning aldolase, spill into the bloodstream. Measuring the\\namount of aldolase in the blood indicates the degree of\\nmuscle damage.\\nAs muscles continue to deteriorate, aldolase levels\\ndecrease and eventually fall below normal. Less muscle\\nmeans fewer cells and less aldolase.\\nMuscle weakness may be caused by neurologic as\\nwell as muscular problems. The measurement of aldolase\\nlevels can help pinpoint the cause. Aldolase levels will be\\nnormal where muscle weakness is caused by neurologi-\\ncal disease, such as poliomyelitis or multiple sclerosis ,\\nbut aldolase levels will be elevated in cases of muscular\\ndisease, such as muscular dystrophy.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 99\\nAlcoholism\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 99'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 113, 'page_label': '114'}, page_content='KEY TERMS\\nAldolase —An enzyme, found primarily in the\\nmuscle, that helps convert sugar into energy.\\nEnzyme—A substance needed to trigger specific\\nchemical reactions.\\nNeurologic —Having to do with the nervous sys-\\ntem.\\nSkeletal muscle —Muscle connected to, and nec-\\nessary for the movement of, bones.\\nAldolase is also found in the liver and cardiac mus-\\ncle of the heart. Damage or disease to these organs, such\\nas chronic hepatitis or a heart attack, will also increase\\naldolase levels in the blood, but to a lesser degree.\\nDescription\\nAldolase is measured by mixing a person’s serum\\nwith a substance with which aldolase is known to trigger\\na reaction. The end product of this reaction is measured,\\nand, from that measurement, the amount of aldolase in\\nthe person’s serum is determined.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available the next day.\\nPreparation\\nTo collect the 5-10 ml of blood needed for this test, a\\nhealthcare worker ties a tourniquet on the patient’s upper\\narm, locates a vein in the inner elbow region, and inserts\\na 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.\\nThe patient should avoid strenuous exercise and\\nhave nothing to eat or drink, except water, for eight to ten\\nhours before this test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite and the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops will reduce\\nbruising. Warm packs to the puncture site will relieve\\ndiscomfort.\\nNormal results\\nNewborns have the highest normal aldolase levels\\nand adults the lowest. Normal values will vary based on\\nthe laboratory and the method used.\\nAbnormal results\\nAs noted, aldolase is elevated in skeletal muscle dis-\\neases, such as muscular dystrophies. Duchenne’s muscu-\\nlar dystrophy, the most common type of muscular dystro-\\nphy, will increase the aldolase level more than any other\\ndisease.\\nNondisease conditions that affect the muscle, such\\nas injury, gangrene, or an infection, can also increase the\\naldolase level. Also, strenuous exercise can temporarily\\nincrease a person’s aldolase level.\\nCertain medications can increase the aldolase level,\\nwhile others can decrease it. To interpret what the results\\nof the aldolase test mean, a physician will evaluate the\\nresult, the person’s clinical symptoms, and other tests\\nthat are more specific for muscle damage and disease.\\nResources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nGarza Diana, and Kathleen Becan-McBride. Phlebotomy\\nHandbook. 4th ed. Stamford: Appleton & Lange, 1996.\\nHenry, John B., ed. Clinical Diagnosis and Management by\\nLaboratory Methods. 19th ed. Philadelphia: W. B. Saun-\\nders Co., 1996.\\nMayo Medical Laboratories. Interpretive Handbook.\\nRochester, MN: Mayo Medical Laboratories, 1997.\\nNancy J. Nordenson\\nAldosterone assay\\nDefinition\\nThis test measures the levels of aldosterone, a hor-\\nmone produced by the outer part (cortex) of the two\\nadrenal glands, organs which sit one on top of each of\\nthe kidneys. Aldosterone regulates the amounts of sodi-\\num and potassium in the blood. This helps maintain\\nwater balance and blood volume, which, in turn, affects\\nblood pressure.\\nPurpose\\nAldosterone measurement is useful in detecting a\\ncondition called aldosteronism, which is caused by\\nexcess secretion of the hormone from the adrenal glands.\\nGALE ENCYCLOPEDIA OF MEDICINE 2100\\nAldosterone assay\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 100'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 114, 'page_label': '115'}, page_content='There are two types of aldosteronism: primary and sec-\\nondary. Primary aldosteronism is most commonly caused\\nby an adrenal tumor, as in Conn’s syndrome. Idiopathic\\n(of unknown cause) hyperaldosteronism is another type\\nof primary aldosteronism. Secondary aldosteronism is\\nmore common and may occur with congestive heart fail-\\nure, cirrhosis with fluid in the abdominal cavity\\n(ascites ), certain kidney diseases, excess potassium,\\nsodium-depleted diet, and toxemia of pregnancy.\\nTo differentiate primary aldosteronism from sec-\\nondary aldosteronism, a plasma renin test should be per-\\nformed at the same time as the aldosterone assay. Renin,\\nan enzyme produced in the kidneys, is high in secondary\\naldosteronism and low in primary aldosteronism.\\nDescription\\nAldosterone testing can be performed on a blood\\nsample or on a 24-hour urine specimen. Several factors,\\nincluding diet, posture (upright or lying down), and time\\nof day that the sample is obtained can cause aldosterone\\nlevels to fluctuate. Blood samples are affected by short-\\nterm fluctuations. A urine specimen collected over an\\nentire 24-hour period lessens the effects of those inter-\\nfering factors and provides a more reliable aldosterone\\nmeasurement.\\nPreparation\\nFasting is not required for either the blood sample\\nor urine collection, but the patient should maintain a nor-\\nmal sodium diet (approximately 0.1 oz [3 g] /day) for at\\nleast two weeks before either test. The doctor should\\ndecide if drugs that alter sodium, potassium, and fluid\\nbalance (e.g., diuretics, antihypertensives, steroids, oral\\ncontraceptives ) should be withheld. The test will be\\nmore accurate if these are suspended at least two weeks\\nbefore the test. Renin inhibitors (e.g., propranolol)\\nshould not be taken one week before the test, unless per-\\nmitted by the physician. The patient should avoid licorice\\nfor at least two weeks before the test, because of its\\naldosterone-like effect. Strenuous exercise and stress\\ncan increase aldosterone levels as well. Because the test\\nis usually performed by a method called radioimmunoas-\\nsay, recently administered radioactive medications will\\naffect test results.\\nSince posture and body position affect aldosterone,\\nhospitalized patients should remain in an upright position\\n(at least sitting) for two hours before blood is drawn.\\nOccasionally blood will be drawn again before the\\npatient gets out of bed. Nonhospitalized patients should\\narrive at the laboratory in time to maintain an upright\\nposition for at least two 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 results are laboratory-specific and also vary\\nwith sodium intake, with time of day, source of specimen\\n(e.g., peripheral vein, adrenal vein, 24-hour urine), age,\\nsex, and posture.\\nReference ranges for blood include:\\n• supine (lying down): 3-10 ng/dL\\n• upright (sitting for at least two hours): Female: 5-\\n30ng/dL; Male: 6-22 ng/dL\\nReference ranges for urine: 2-80 mg/24 hr.\\nAbnormal results\\nIncreased levels of aldosterone are found in Conn’s\\ndisease (aldosterone-producing adrenal tumor), and in\\ncases of Bartter’s syndrome (a condition in which the\\nkidneys overexcrete potassium, sodium and chloride,\\nresulting in low blood levels of potassium and high blood\\nlevels of aldosterone and renin). Among other condi-\\ntions, elevated levels are also seen in secondary aldos-\\nteronism, stress, and malignant hypertension.\\nDecreased levels of aldosterone are found in aldos-\\nterone deficiency, steroid therapy, high-sodium diets,\\ncertain antihypertensive therapies, and Addison’s dis-\\nease (an autoimmune disorder).\\nResources\\nBOOKS\\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 2 101\\nAldosterone assay\\nKEY TERMS\\nAldosteronism—A condition in which the adrenal\\nglands secrete excessive levels of the hormone\\naldosterone.\\nRenin—An enzyme produced in the kidneys that\\ncontrols the activation of the hormone angiotensin,\\nwhich stimulates the adrenal glands to produce\\naldosterone.\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 101'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 115, 'page_label': '116'}, page_content='Alemtuzumab\\nDefinition\\nAlemtuzumab is sold as Campath in the United\\nStates. Alemtuzumab is a humanized monoclonal anti-\\nbody that selectively binds to CD52, a protein found on\\nthe surface of normal and malignant B and T cells, that is\\nused to reduce the numbers of circulating malignant cells\\nof patients who have B-cell chronic lymphocytic\\nleukemia (B-CLL).\\nPurpose\\nAlemtuzumab is a monoclonal antibody used to treat\\nB-CLL, one of the most prevalent forms of adult chronic\\nleukemia. It specifically binds CD52, a protein found on\\nthe surface of essentially all B and T cells of the immune\\nsystem. By binding the CD52 protein on the malignant B\\ncells, the antibody targets it for removal from the circula-\\ntion. Scientists believe that alemtuzumab triggers anti-\\nbody-mediated lysis of the B cells, a method that the\\nimmune system uses to eliminate foreign cells.\\nAlemtuzumab has been approved by the FDA for\\ntreatment of refractory B-CLL. For a patient’s disease to\\nbe classified as refractory, both alkylating agents and flu-\\ndarabine treatment must have been tried and failed. Thus,\\nthis drug gives patients who have tried all approved treat-\\nments for B-CLL another option. As most patients with\\nB-CLL are in stage III or IV by the time both alkylating\\nagents and fludarabine have been tried, the experience\\nwith alemtuzumab treatment are primarily with those\\nstages of the disease. In clinical trials, about 30% of\\npatients had a partial response to the drug, with 2% of\\nthese being complete responses.\\nThis antibody has been tested with limited success\\nin the treatment of non-Hodgkin’s lymphoma (NHL) and\\nfor the preparation of patients with various immune cell\\nmalignancies for bone marrow transplantation. There is\\nalso a clinical trial ongoing to test the ability of this anti-\\nbody to prevent rejection in kidney transplantation.\\nDescription\\nAlemtuzumab is produced in the laboratory using\\ngenetically engineered single clones of B-cells. Like all\\nantibodies, it is a Y-shaped molecule can bind one partic-\\nular substance, the antigen for that monoclonal antibody.\\nFor alemtuzumab, the antigen is CD52, a protein found\\non the surface of normal and malignant B and T cells as\\nwell as other cells of the immune and male reproductive\\nsystems. Alemtuzumab is a humanized antibody, mean-\\ning that the regions that bind CD52, located on the tips of\\nthe Y branches, are derived from rat antibodies, but the\\nrest of the antibody is human sequence. The presence of\\nthe human sequences helps to reduce the immune\\nresponse by the patient against the antibody itself, a\\nproblem seen when complete mouse antibodies are used\\nfor cancer therapies. The human sequences also help to\\nensure that the various cell-destroying mechanisms of\\nthe human immune system are properly triggered with\\nbinding of the antibody.\\nAlemtuzumab was approved in May of 2001 for the\\ntreatment of refractory B-CLL. It is approved for use\\nalone but clinical trials have tested the ability of the anti-\\nbody to be used in combination with the purine analogs\\npentostatin, fludarabine, and cladribine, and rituximab, a\\nmonoclonal antibody specific for the CD20 antigen,\\nanother protein found on the surface of B cells.\\nRecommended dosage\\nThis antibody should be administered in a gradually\\nescalating pattern at the start of treatment and any time\\nadministration is interrupted for seven or more days. The\\nrecommended beginning dosage for B-CLL patients is a\\ndaily dose of 3 mg of Campath administered as a two-\\nhour IV infusion. Once this amount is tolerated, the dose\\nis increased to 10 mg per day. After tolerating this dose,\\nit can be increased to 30 mg, administered three days a\\nweek. Acetominophen and diphenhydramine hydro-\\nchoride are given thirty to sixty minutes before the infu-\\nsion to help reduce side effects.\\nAdditionally, patients generally receive anti-infec-\\ntive medication before treatment to help minimize the\\nserious opportunistic infections that can result from this\\ntreatment. Specifically, trimethoprim/sulfamethoxazole\\n(to prevent bacterial infections) and famciclovir (to pre-\\nvent viral infections) were used during the clinical trial to\\ndecrease infections, although they were not eliminated.\\nPrecautions\\nBlood studies should be done on a weekly basis\\nwhile patients are receiving the alemtuzumab treat-\\nment. Vaccination during the treatment session is not\\nrecommended, given the T cell depletion that occurs\\nduring treatment. Furthermore, given that antibodies\\nlike alumtuzumab can pass through the placenta to the\\ndeveloping fetus and in breast milk, use during preg-\\nnancy and breastfeeding is not recommended unless\\nclearly needed.\\nSide effects\\nA severe side effect of alemtuzumab treatment is the\\npossible depletion of one or more types of blood cells.\\nGALE ENCYCLOPEDIA OF MEDICINE 2102\\nAlemtuzumab\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 102'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 116, 'page_label': '117'}, page_content='Because CD52 is expressed on a patient’s normal B and\\nT cells, as well as on the surface of the abnormal B cells,\\nthe treatment eliminates both normal and cancerous\\ncells. The treatment also seems to trigger autoimmune\\nreactions against various other blood cells. This results in\\nsevere reduction of the many circulating blood cells\\nincluding red blood cells (anemia), white blood cells\\n(neutropenia), and clotting cells (thrombopenia). These\\nconditions are treated with blood transfusions. The great\\nmajority of patients treated exhibit some type of blood\\ncell depletion.\\nA second serious side effect of this drug is the preva-\\nlence of opportunistic infections that occurs during the\\ntreatment. Serious, and sometimes fatal bacterial, viral,\\nfungal, and protozoan infections have been reported.\\nTreatments to prevent pneumonia and herpes infections\\nreduce, but do not eliminate these infections.\\nThe majority of other side effects occur after or dur-\\ning the first infusion of the drug. Some common side\\neffects of this drug include fever and chills, nausea and\\nvomiting, diarrhea, shortness of breath, skin rash, and\\nunusual fatigue. This drug can also cause low blood pres-\\nsure (hypotension).\\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 chemotherapeutic agent to treat\\nB-CLL.\\nAntibody —A protective protein made by the\\nimmune system in response to an antigen, also\\ncalled an immunoglobulin.\\nAutoimmune —An immune reaction of a patient\\nagainst their own cells.\\nHumanization —Fusing the constant and variable\\nframework region of one or more human\\nimmunoglobulins with the binding region of an\\nanimal immunoglobulin, done to reduce human\\nreaction against the fusion antibody.\\nMonoclonal —Genetically engineered antibodies\\nspecific for one antigen.\\nTumor lysis syndrome —A side effect of some\\nimmunotherapies, like monoclonal antibodies,\\nthat lyse the tumor cells, due to the toxicity of\\nflooding the bloodstream with such a quantity of\\ncellular contents.\\nIn patients with high tumor burden (a large number\\nof circulating malignant B cells) this drug can cause a\\nside effect called tumor lysis syndrome. Thought to be\\ndue to the release of the lysed cells’ contents into the\\nblood stream, it can cause a misbalance of urea, uric\\nacid, phosphate, potassium, and calcium in the urine and\\nblood. Patients at risk for this side effect must keep\\nhydrated and can be given allopurinol before infusion.\\nInteractions\\nThere have been no formal drug interaction studies\\ndone for alemtuzumab.\\nMichelle Johnson, M.S., J.D.\\nAlendronate see Bone disorder drugs\\nAlexander technique\\nDefinition\\nThe Alexander technique is a somatic method for\\nimproving physical and mental functioning. Excessive\\ntension, which Frederick Alexander, the originator, rec-\\nognized as both physical and mental, restricts movement\\nand creates pressure in the joints, the spine, the breathing\\nmechanism, and other organs. The goal of the technique\\nis to restore freedom and expression to the body and\\nclear thinking to the mind.\\nPurpose\\nBecause the Alexander technique helps students\\nimprove overall functioning, both mental and physical, it\\noffers a wide range of benefits. Nikolaas Tinbergen, in his\\n1973 Nobel lecture, hailed the “striking improvements in\\nsuch diverse things as high blood pressure, breathing,\\ndepth of sleep, overall cheerfulness and mental alertness,\\nresilience against outside pressures, and the refined skill\\nof playing a musical instrument.” He went on to quote a\\nlist of other conditions helped by the Alexander tech-\\nnique: “rheumatism, including various forms of arthritis,\\nthen respiratory troubles, and even potentially lethal asth-\\nma; following in their wake, circulation defects, which\\nmay lead to high blood pressure and also to some danger-\\nous heart conditions; gastrointestinal disorders of many\\ntypes, various gynecological conditions, sexual failures,\\nmigraines and depressive states.”\\nLiterature in the 1980s and 1990s went on to include\\nimprovements in back pain, chronic pain, postural prob-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 103\\nAlexander technique\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 103'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 117, 'page_label': '118'}, page_content='lems, repetitive strain injury, benefits during pregnancy\\nand childbirth , help in applying physical therapy and\\nrehabilitative exercises, improvements in strain caused by\\ncomputer use, improvements in the posture and perfor-\\nmance of school children, and improvements in vocal and\\ndramatic performance among the benefits offered by the\\ntechnique.\\nDescription\\nOrigins\\nFrederick Matthias Alexander was born in 1869 in\\nTasmania, Australia. He became an actor and Shake-\\nspearean reciter, and early in his career he began to suffer\\nfrom strain on his vocal chords. He sought medical atten-\\ntion for chronic hoarseness, but after treatment with a\\nrecommended prescription and extensive periods of rest,\\nhis problem persisted.\\nAlexander realized that his hoarseness began about\\nan hour into a dramatic performance and reasoned that it\\nwas something he did in the process of reciting that\\ncaused him to lose his voice. Returning to his medical\\ndoctor, Alexander told him of his observation. When the\\ndoctor admitted that he didn’t know what Alexander was\\ndoing to injure his vocal chords, Alexander decided to try\\nand find out for himself.\\nThus began a decade of self-observation and discov-\\nery. Using as many as three mirrors to observe himself in\\nthe act of reciting, normal speaking, and later standing,\\nwalking, and sitting, Alexander managed to improve his\\ncoordination and to overcome his vocal problems. One of\\nhis most startling discoveries was that in order to change\\nthe way he used his body he had to change the way he\\nwas thinking, redirecting his thoughts in such a way that\\nhe did not produce unnecessary tension when he attempt-\\ned speech or movement. After making this discovery at\\nthe end of the nineteenth century, Alexander became a\\npioneer in body-mind medicine.\\nAt first, performers and dancers sought guidance\\nfrom Alexander to overcome physical complaints and\\nto improve the expression and spontaneity of their\\nperformances. Soon a great number of people sought\\nhelp from his teaching for a variety of physical and\\nmental disorders.\\nThe Alexander technique is primarily taught one-\\non-one in private lessons. Introductory workshops or\\nworkshops for special applications of the technique\\n(e.g.,workshops for musicians) are also common. Pri-\\nvate lessons range from a half-hour to an hour in length,\\nand are taught in a series. The number of lessons varies\\naccording to the severity of the student’s difficulties\\nwith coordination or to the extent of the student’s inter-\\nest in pursuing the improvements made possible by con-\\ntinued study. The cost of lessons ranges from $40-80 per\\nhour. Insurance coverage is not widely available, but\\ndiscounts are available for participants in some comple-\\nmentary care insurance plans. Pre-tax Flexible Spending\\nAccounts for health care cover Alexander technique\\nlessons if they are prescribed by a physician.\\nIn lessons teachers guide students through simple\\nmovements (while students are dressed in comfortable\\nclothing) and use their hands to help students identify\\nand stop destructive patterns of tension. Tensing arises\\nfrom mental processes as well as physical, so discussions\\nof personal reactions or behavior are likely to arise in the\\ncourse of a lesson.\\nThe technique helps students move with ease and\\nimproved coordination. At the beginning of a move-\\nment (the lessons are a series of movements), most\\npeople pull back their heads, raise their shoulders\\ntoward their ears, over-arch their lower backs, tighten\\ntheir legs, and otherwise produce excessive tension in\\ntheir bodies. Alexander referred to this as misuse of\\nthe body.\\nAt any point in a movement, proper use can be\\nestablished. If the neck muscles are not over-tensed, the\\nhead will carry slightly forward of the spine, simply\\nbecause it is heavier in the front. When the head is out of\\nbalance in the forward direction, it sets off a series of\\nstretch reflexes in the extensor muscles of the back. It is\\nskillful use of these reflexes, along with reflex activity in\\nthe feet and legs, the arms and hands, the breathing\\nmechanism, and other parts of the body, that lessons in\\nthe technique aim to develop.\\nAlexander found that optimal functioning of the\\nbody was very hard to maintain, even for the short period\\nof time it took to complete a single movement. People,\\nespecially adults, have very strong tension habits associ-\\nated with movement. Chronic misuse of the muscles is\\ncommon. It may be caused by slouching in front of tele-\\nvisions or video monitors, too much sitting or driving\\nand too little walking, or by tension associated with past\\ntraumas and injuries. Stiffening the neck after a\\nwhiplash injury or favoring a broken or sprained leg\\nlong after it has healed are examples of habitual tension\\ncaused by injury.\\nThe first thing a teacher of the Alexander tech-\\nnique does is to increase a student’s sensory awareness\\nof this excessive habitual tension, particularly that in\\nthe neck and spine. Next the student is taught to inhibit\\nthe tension. If the student prepares to sit down, for\\nexample, he will tense his muscles in his habitual way.\\nIf he is asked to put aside the intention to sit and\\ninstead to free his neck and allow less constriction in\\nGALE ENCYCLOPEDIA OF MEDICINE 2104\\nAlexander technique\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 104'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 118, 'page_label': '119'}, page_content='his muscles, he can begin to change his tense habitual\\nresponse to sitting.\\nBy leaving the head resting on the spine in its natur-\\nal free balance, by keeping eyes open and focused, not\\nheld in a tense stare, by allowing the shoulders to release,\\nthe knees to unlock and the back to lengthen and widen,\\na student greatly reduces strain. In Alexander lessons stu-\\ndents learn to direct themselves this way in activity and\\nbecome skilled in fluid, coordinated movement.\\nPrecautions\\nSide effects\\nThe focus of the Alexander technique is educational.\\nTeachers use their hands simply to gently guide students\\nin movement. Therefore, both contraindications and\\npotential physiological side effects are kept to a mini-\\nmum. No forceful treatment of soft tissue or bony struc-\\nture is attempted, so damage to tissues, even in the case\\nof errors in teaching, is unlikely.\\nAs students’ sensory awareness develops in the\\ncourse of Alexander lessons, they become more acutely\\naware of chronic tension patterns. As students learn to\\nrelease excessive tension in their muscles and to sustain\\nthis release in daily activity, they may experience tight-\\nness or soreness in the connective tissue. This is caused\\nby the connective tissue adapting to the lengthened and\\nreleased muscles and the expanded range of movement\\nin the joints.\\nOccasionally students may get light-headed during a\\nlesson as contracted muscles release and effect the circu-\\nlatory or respiratory functioning.\\nForceful contraction of muscles and rigid postures\\noften indicate suppression of emotion. As muscles\\nrelease during or after an Alexander lesson, students may\\nexperience strong surges of emotion or sudden changes\\nin mood. In some cases, somatic memories surface,\\nbringing to consciousness past injury or trauma. This can\\ncause extreme anxiety, and referrals may be made by the\\nteacher for counseling.\\nResearch and general acceptance\\nAlexander became well known among the intellectu-\\nal, artistic, and medical communities in London, Eng-\\nland, during the first half of the twentieth century.\\nAmong Alexander’s supporters were John Dewey,\\nAldous Huxley, Bernard Shaw, and renowned scientists\\nRaymond Dart, G.E. Coghill, Charles Sherrington, and\\nNikolaas Tinbergen.\\nResearchers continue to study the effects and appli-\\ncations of the technique in the fields of education, pre-\\nKEY TERMS\\nDirection—Bringing about the free balance of the\\nhead on the spine and the resulting release of the\\nerector muscles of the back and legs which estab-\\nlish improved coordination.\\nHabit—Referring to the particular set of physical\\nand mental tensions present in any individual.\\nInhibition—Referring to the moment in an Alexan-\\nder lesson when the student refrains from begin-\\nning a movement in order to avoid tensing of the\\nmuscles.\\nSensory awareness—Bringing attention to the sen-\\nsations of tension and/or release in the muscles.\\nventive medicine, and rehabilitation . The Alexander\\ntechnique has proven an effective treatment for reducing\\nstress , for improving posture and performance in\\nschoolchildren, for relieving chronic pain, and for\\nimproving psychological functioning. The technique has\\nbeen found to be as effective as beta-blocker medica-\\ntions in controlling stress responses in professional\\nmusicians, to enhance respiratory function in normal\\nadults, and to mediate the effects of scoliosis in adoles-\\ncents and adults.\\nResources\\nBOOKS\\nCaplan, Deborah. Back Trouble - A new approach to prevention\\nand recovery based on the Alexander Technique.Triad\\nCommunications: 1987.\\nDimon, Theodore. THE UNDIVIDED SELF: Alexander Tech-\\nnique and the Control of Stress.North Atlantic Books:\\n1999.\\nJones, Frank Pierce. Freedom To Change - The Development\\nand Science of the Alexander Technique.Mouritz: 1997,\\nimported (First published 1976 as Body Awareness in\\nAction.)\\nPERIODICALS\\nStern, Judith C. “The Alexander Technique:An Approach to\\nPain Control.”Lifeline (Summer 1992).\\nTinbergen, Nikolaas. “Ethology and Stress Diseases.”England\\nScience 185:20-27,(1974).\\nORGANIZATIONS\\nAmerican Society for the Alexander Technique, 401 East Mar-\\nket Street (P.O. Box 835) Charlottesville, V A 22902 USA.\\n(800) 473-0620; or (804) 295-2840. Fax: 804-295-3947.\\nalexandertec@earthlink.net. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2 105\\nAlexander technique\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 105'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 119, 'page_label': '120'}, page_content='Alexander Technique International, 1692 Massachusetts\\nAve.,3rd Floor, Cambridge, MA 02138 USA. (888) 321-\\n0856. Fax: 617-497-2615. ati@ati-net.com. .\\nOTHER\\nAlexander Technique Resource Guide.(includes list of teach-\\ners) AmSAT Books, (800) 473-0620 or (804) 295-2840.\\nNielsen, Michael. “A Study of Stress Amongst Professional\\nMusicians.” STAT Books London, 1994.\\nReiser, Samuel. “Stress Reduction and Optimal Psychological\\nFunctioning.” Lecture given at Sixth International Mon-\\ntreaus Congress on Stress, 1994.\\nSandra Bain Cushman\\nAlkali-resistant hemoglobin test see Fetal\\nhemoglobin test\\nAlkaline phosphatase test\\nDefinition\\nAlkaline phosphatase is an enzyme found through-\\nout the body. Like all enzymes, it is needed, in small\\namounts, to trigger specific chemical reactions. When it\\nis present in large amounts, it may signify bone or liver\\ndisease or a tumor.\\nPurpose\\nMedical testing of alkaline phosphatase is concerned\\nwith the enzyme that is found in liver, bone, placenta,\\nand intestine. In a healthy liver, fluid containing alkaline\\nphosphate and other substances is continually drained\\naway through the bile duct. In a diseased liver, this bile\\nduct is often blocked, keeping fluid within the liver.\\nAlkaline phosphatase accumulates and eventually\\nescapes into the bloodstream.\\nThe alkaline phosphatase of the liver is produced by\\nthe cells lining the small bile ducts (ductoles) in the liver.\\nIts origin differs from that of other enzymes called\\naminotransferases. If the liver disease is primarily of an\\nobstructive nature (cholestatic), i.e. involving the biliary\\ndrainage system, the alkaline phosphatase will be the\\nfirst and foremost enzyme elevation. If, on the other\\nhand, the disease is primarily of the liver cells (hepato-\\ncytes), the aminotransferases will rise prominently.Thus,\\nthese enzymes are very useful in distinguishing the type\\nof liver disease—cholestatic or hepatocellular.\\nGrowing bones need alkaline phosphatase. Any con-\\ndition of bone growth will cause alkaline phosphatase\\nlevels to rise. The condition may be normal, such as a\\nchildhood growth spurt or the healing of a broken bone;\\nor the condition may be a disease, such as bone cancer,\\nPaget’s disease, or rickets.\\nDuring pregnancy, alkaline phosphatase is made by\\nthe placenta and leaks into the mother’s bloodstream.\\nThis is normal. Some tumors, however, start production\\nof the same kind of alkaline phosphatase produced by the\\nplacenta. These tumors are called germ cell tumors and\\ninclude testicular cancer and certain brain tumors.\\nAlkaline phosphatase from the intestine is increased\\nin a person with inflammatory bowel disease, such as\\nulcerative colitis.\\nDescription\\nAlkaline phosphatase is measured by combining the\\nperson’s serum with specific substances with which alka-\\nline phosphatase is known to react. The end product of\\nthis reaction is measured; and from that measurement,\\nthe amount of alkaline phosphatase in the person’s serum\\nis determined.\\nEach tissue—liver, bone, placenta, and intestine—\\nproduces a slightly different alkaline phosphatase. These\\nvariations are called isoenzymes. In the laboratory, alka-\\nline phosphatase is measured as the total amount or the\\namount of each of the the four isoenzymes. The isoen-\\nzymes react differently to heat, certain chemicals, and\\nother processes in the laboratory. Methods to measure\\nthem separately are based on these differences.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available the next day.\\nPreparation\\nTo collect the 5-10 ml blood needed for this test, a\\nhealthcare worker ties a tourniquet on the person’s upper\\narm, locates a vein in the inner elbow region, and inserts\\na 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.\\nA person being tested for alkaline phosphatase\\nshouldn’t have anything to eat or drink, except water, for\\neight to ten hours before the test. Some people release\\nalkaline phosphatase from the intestine into the blood-\\nstream after eating. This will temporarily increase the\\nresult of the test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture site\\nor the person may feel dizzy or faint. Pressure to the\\nGALE ENCYCLOPEDIA OF MEDICINE 2106\\nAlkaline phosphatase test\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 106'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 120, 'page_label': '121'}, page_content='puncture site until the bleeding stops will reduce bruising.\\nWarm packs to the puncture site will relieve discomfort.\\nNormal results\\nNormal results vary by age and by sex. They also\\nvary based on the laboratory and the method used.\\nAbnormal results\\nBone and liver disease increase alkaline phosphatase\\nmore than any other disease, up to five times the normal\\nlevel. Irritable bowel disease, germ cell tumors, and\\ninfections involving the liver, such as viral hepatitis and\\ninfectious mononucleosis, increase the enzyme also, but\\nto a lesser degree. Healing bones, pregnancy, and normal\\ngrowth in children also increase levels.\\nResources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nGarza, Diana, and Kathleen Becan-MacBride. Phlebotomy\\nHandbook. 4th ed. Stamford: Appleton & Lange, 1996.\\nHenry, John B., ed. Clinical Diagnosis and Management by\\nLaboratory Methods. 19th ed. Philadephia: W. B. Saun-\\nders Co., 1996.\\nLehmann, Craig A., ed. Saunders Manual of Clinical Labora-\\ntory Science. Philadelphia: W. B. Saunders Co., 1998.\\nSacher, Ronald A., Richard A. McPherson, and J. M. Campos.\\n“Transfusion Medicine.” In Widmann’s Clinical Interpre-\\ntation of Laboratory Tests.10th ed. Philadelphia: F. A.\\nDavis, 1991.\\nNancy J. Nordenson\\nAlkalosis see Metabolic alkalosis;\\nRespiratory alkalosis\\nKEY TERMS\\nAlkaline phosphatase —An enzyme found\\nthroughout the body, primarily in liver, bone, pla-\\ncenta, and intestine.\\nCholestatis—Stoppage or suppression of the flow\\nof bile.\\nEnzyme—A substance needed to trigger specific\\nchemical reactions.\\nHepatocellular—Of or pertaining to liver cells.\\nHepatocyte—A liver cell.\\nIsoenzyme—A variation of an enzyme.\\nAllergic alveolitis see Hypersensitivity\\npneumonitis\\nAllergic bronchopulmonary\\naspergillosis\\nDefinition\\nAllergic bronchopulmonary aspergillosis, or ABPA,\\nis one of four major types of infections in humans caused\\nby Aspergillus fungi. ABPA is a hypersensitivity reaction\\nthat occurs in asthma patients who are allergic to this\\nspecific fungus.\\nDescription\\nABPA is an allergic reaction to a species of\\nAspergillus called Aspergillus fumigatus. It is sometimes\\ngrouped together with other lung disorders characterized\\nby eosinophilia—an abnormal increase of a certain type\\nof white blood cell in the blood—under the heading of\\neosinophilic pneumonia. These disorders are also called\\nhypersensitivity lung diseases.\\nABPA appears to be increasing in frequency in the\\nUnited States, although the reasons for the increase are not\\nclear. The disorder is most likely to occur in adult asthmat-\\nics aged 20-40. It affects males and females equally.\\nCauses and symptoms\\nABPA develops when the patient breathes air con-\\ntaining Aspergillus spores. These spores are found\\nworldwide, especially around riverbanks, marshes, bogs,\\nforests, and wherever there is wet or decaying vegetation.\\nThey are also found on wet paint, construction materials,\\nand in air conditioning systems. ABPA is a nosocomial\\ninfection, which means that a patient can get it in a hos-\\npital. When Aspergillus spores reach the bronchi, which\\nare the branches of the windpipe that lead into the lungs,\\nthe bronchi react by contracting spasmodically. So the\\npatient has difficulty breathing and usually wheezes or\\ncoughs. Many patients with ABPA also run a low-grade\\nfever and lose their appetites.\\nComplications\\nPatients with ABPA sometimes cough up large\\namounts of blood, a condition that is called hemoptysis.\\nThey may also develop a serious long-term form of\\nbronchiectasis , the formation of fibrous tissue in the\\nlungs. Bronchiectasis is a chronic bronchial disorder\\nGALE ENCYCLOPEDIA OF MEDICINE 2 107\\nAllergic bronchopulmonary aspergillosis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 107'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 121, 'page_label': '122'}, page_content='caused by repeated inflammation of the airway, and\\nmarked by the abnormal enlargement of, or damage to,\\nthe bronchial walls. ABPA sometimes occurs as a com-\\nplication of cystic fibrosis.\\nDiagnosis\\nThe diagnosis of ABPA is based on a combination of\\nthe patient’s history and the results of blood tests, sputum\\ntests, skin tests, and diagnostic imaging. The doctor will\\nbe concerned to distinguish between ABPA and a wors-\\nening of the patient’s asthma, cystic fibrosis, or other\\nlung disorders. There are seven major criteria for a diag-\\nnosis of allergic bronchopulmonary aspergillosis:\\n• a history of asthma.\\n• an accumulation of fluid in the lung that is visible on a\\nchest x ray.\\n• bronchiectasis (abnormal stretching, enlarging, or\\ndestruction of the walls of the bronchial tubes).\\n• skin reaction to Aspergillus antigen.\\n• eosinophilia in the patient’s blood and sputum.\\n• Aspergillus precipitins in the patient’s blood. Precip-\\nitins are antibodies that react with the antigen to form a\\nsolid that separates from the rest of the solution in the\\ntest tube.\\n• a high level of IgE in the patient’s blood. IgE refers to a\\nclass of antibodies in blood plasma that activate allergic\\nreactions to foreign particles.\\nOther criteria that may be used to support the diag-\\nnosis include the presence of Aspergillus in samples of\\nthe patient’s sputum, the coughing up of plugs of brown\\nmucus, or a late skin reaction to the Aspergillus antigen.\\nLaboratory tests\\nThe laboratory tests that are done to obtain this\\ninformation include a complete blood count (CBC), a\\nsputum culture , a blood serum test of IgE levels, and\\na skin test for the Aspergillus antigen. In the skin test, a\\nsmall amount of antigen is injected into the upper layer\\nof skin on the patient’s forearm about four inches\\nbelow the elbow. If the patient has a high level of IgE\\nantibodies in the tissue, he or she will develop what is\\ncalled a “wheal and flare” reaction in about 15-20 min-\\nutes. A “wheal and flare” reaction is characterized by\\nthe eruption of a reddened, itching spot on the skin.\\nSome patients with ABPA will develop the so-called\\nlate reaction to the skin test, in which a red, sore,\\nswollen area develops about six to eight hours after the\\ninitial reaction.\\nAspergillus can sometimes be seen under a micro-\\nscope slide made from the patient’s sputum, but the diag-\\nnosis is considered definite only when the fungus is cul-\\ntured in the laboratory. Aspergillus is easy to culture, and\\ncan be identified when it is stained with periodic acid-\\nSchiff (PAS), Calcofluor, or potassium hydroxide (KOH)\\npreparations.\\nDiagnostic imaging\\nChest x rays and CT scans are used to check for the\\npresence of fluid accumulation in the lungs and signs of\\nbronchiectasis.\\nTreatment\\nABPA is usually treated with prednisone (Meti-\\ncorten) or other corticosteroids taken by mouth, and\\nwith bronchodilators.\\nAntifungal drugs are not used to treat ABPA because\\nit is caused by an allergic reaction to Aspergillus rather\\nthan by direct infection of tissue.\\nFollow-up care\\nPatients with ABPA should be given periodic\\ncheckups with chest x rays and a spirometer test. A\\nspirometer is an instrument that evaluates the patient’s\\nlung capacity.\\nPrognosis\\nMost patients with ABPA respond well to corticos-\\nteroid treatment. Others have a chronic course with grad-\\nual improvement over time. The best indicator of a good\\nprognosis is a long-term fall in the patient’s IgE level.\\nPatients with lung complications from ABPA may devel-\\nop severe airway obstruction.\\nPrevention\\nABPA is difficult to prevent because Aspergillus is a\\ncommon fungus; it can be found in the saliva and sputum\\nof most healthy individuals. Patients with ABPA can pro-\\ntect themselves somewhat by avoiding haystacks, com-\\npost piles, bogs, marshes, and other locations with wet or\\nrotting vegetation; by avoiding construction sites or\\nnewly painted surfaces; and by having their air condi-\\ntioners cleaned regularly. Some patients may be helped\\nby air filtration systems for their bedrooms or offices.\\nResources\\nBOOKS\\n“Aspergillosis.” In Professional Guide to Diseases. 5th ed.\\nSpringhouse, PA: Springhouse Corporation, 1995.\\nBeavis, Kathleen G. “Systemic Mycoses.” In Current Diagno-\\nsis. V ol. 9. Ed. Rex B. Conn, et al. Philadelphia: W. B.\\nSaunders Co., 1997.\\nGALE ENCYCLOPEDIA OF MEDICINE 2108\\nAllergic bronchopulmonary aspergillosis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 108'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 122, 'page_label': '123'}, page_content='Hamill, Richard J. “Infectious Diseases: Mycotic.” In Current\\nMedical Diagnosis and Treatment, 1998.37th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange,\\n1997.\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 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.\\nPhysicians’ Guide to Rare Diseases.Ed. Jess G. Thoene. Mont-\\nvale, NJ: Dowden Publishing Co., Inc., 1995.\\n“Pulmonary Disorders: Hypersensitivity Diseases of the\\nLungs.” In The Merck Manual of Diagnosis and Therapy.\\n17th ed. Ed. Robert Berkow. Rahway, NJ: Merck\\nResearch Laboratories, 1997.\\nStauffer, John L. “Lung.” In Current Medical Diagnosis and\\nTreatment, 1998. 37th ed. Ed. Stephen McPhee, et al.\\nStamford: Appleton & Lange, 1997.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton Rd.,\\nNE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311.\\n.\\nNational Organization for Rare Disorders. P.O. Box 8923, New\\nFairfield, CT 06812-8923. (800) 999-6673. .\\nKEY TERMS\\nAntifungal —A medicine used to treat infections\\ncaused by a fungus.\\nAntigen —A substance that stimulates the produc-\\ntion of antibodies.\\nBronchiectasis —A disorder of the bronchial tubes\\nmarked by abnormal stretching, enlargement, or\\ndestruction of the walls. Bronchiectasis is usually\\ncaused by recurrent inflammation of the airway and\\nis a diagnostic criterion of ABPA.\\nBronchodilator —A medicine used to open up the\\nbronchial tubes (air passages) of the lungs.\\nEosinophil —A type of white blood cell containing\\ngranules that can be stained by eosin (a chemical\\nthat produces a red stain).\\nEosinophilia—An abnormal increase in the number\\nof eosinophils in the blood.\\nHemoptysis—The coughing up of large amounts of\\nblood. Hemoptysis can occur as a complication of\\nABPA.\\nHypersensitivity —An excessive response by the\\nbody to a foreign substance.\\nImmunoglobulin E (IgE)—A type of protein in blood\\nplasma that acts as an antibody to activate allergic\\nreactions. About 50% of patients with allergic disor-\\nders have increased IgE levels in their blood serum.\\nNosocomial infection —An infection that can be\\nacquired in a hospital. ABPA is a nosocomial infec-\\ntion.\\nPrecipitin —An antibody in blood that combines\\nwith an antigen to form a solid that separates from\\nthe rest of the blood.\\nSpirometer—An instrument used to test a patient’s\\nlung capacity.\\n“Wheal and flare” reaction—A rapid response to a\\nskin allergy test characterized by the development\\nof a red, itching spot in the area where the allergen\\nwas injected.\\nWheezing —A whistling or musical sound caused\\nby tightening of the air passages inside the patient’s\\nchest.\\nNational Institute of Allergy and Infectious Disease. Building\\n31, Room 7A-50, 31 Center Drive MSC 2520, Bethesda,\\nMD 20892-2520. (301) 496-5717. .\\nRebecca J. Frey\\nAllergic purpura\\nDefinition\\nAllergic purpura (AP) is an allergic reaction of\\nunknown origin causing red patches on the skin and other\\nsymptoms. AP is also called Henoch-Schonlein purpura,\\nnamed after the two doctors who first described it.\\nDescription\\n“Purpura” is a bleeding disorder that occurs when\\ncapillaries rupture, allowing small amounts of blood to\\naccumulate in the surrounding tissues. In AP, this occurs\\nbecause the capillaries are blocked by protein complexes\\nGALE ENCYCLOPEDIA OF MEDICINE 2 109\\nAllergic purpura\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 109'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 123, 'page_label': '124'}, page_content='KEY TERMS\\nGlomeruli —Knots of capillaries in the kidneys\\nresponsible for filtering the blood (singular,\\nglomerulus).\\nformed during an abnormal immune reaction. The skin is\\nthe most obvious site of reaction, but the joints, gastroin-\\ntestinal tract, and kidneys are also often affected.\\nAP affects approximately 35,000 people in the Unit-\\ned States each year. Most cases are children between the\\nages of two and seven. Boys are affected more often than\\ngirls, and most cases occur from late fall to winter.\\nCauses and symptoms\\nCauses\\nAP is caused by a reaction involving antibodies, spe-\\ncial proteins of the immune system. Antibodies are\\ndesigned to bind with foreign proteins, called antigens.\\nIn some situations, antigen-antibody complexes can\\nbecome too large to remain suspended in the blood-\\nstream. When this occurs, they precipitate out and\\nbecome lodged in the capillaries. This can cause the cap-\\nillary to burst, allowing a local hemorrhage.\\nThe source of the antigen causing AP is unknown.\\nAntigens may be introduced by bacterial or viral infec-\\ntion. More than 75% of patients report having had an\\ninfection of the throat, upper respiratory tract, or gas-\\ntrointestinal system several weeks before the onset of AP.\\nOther complex molecules can act as antigens as well,\\nincluding drugs such as antibiotics or vaccines. Other-\\nwise harmless substances that stimulate an immune reac-\\ntion are known as allergens. Drug allergens that may\\ncause AP include penicillin, ampicillin, erythromycin,\\nand quinine. Vaccines possibly linked to AP include\\nthose for typhoid, measles, cholera, and yellow fever.\\nSymptoms\\nThe onset of AP may be preceded by a headache ,\\nfever, and loss of appetite. Most patients first develop an\\nitchy skin rash. The rash is red, either flat or raised, and\\nmay be small and freckle-like. The rash may also be larg-\\ner, resembling a bruise. Rashes become purple and then\\nrust colored over the course of a day, and fade after sev-\\neral weeks. Rashes are most common on the buttocks,\\nabdomen, and lower extremities. Rashes higher on the\\nbody may also occur, especially in younger children.\\nJoint pain and swelling is common, especially in\\nthe knees and ankles. Abdominal pain occurs in almost\\nall patients, along with blood in the body waste (feces).\\nAbout half of all patients show blood in the urine, low\\nurine volume, or other signs of kidney involvement.\\nKidney failure may occur due to widespread obstruction\\nof the capillaries in the filtering structures called\\nglomeruli. Kidney failure develops in about 5% of all\\npatients, and in 15% of those with elevated blood or pro-\\ntein in the urine.\\nLess common symptoms include prolonged head-\\nache, fever, and pain and swelling of the scrotum. Involve-\\nment of other organ systems may lead to heart attack\\n(myocardial infarction), inflammation of the pancreas\\n(pancreatitis), intestinal obstruction, or bowel perforation.\\nDiagnosis\\nDiagnosis of AP is based on the symptoms and their\\ndevelopment, a careful medical history, and blood and\\nurine tests. X rays or computed tomography scans (CT)\\nmay be performed to assess complications in the bowel\\nor other internal organs.\\nTreatment\\nMost cases of AP resolve completely without treat-\\nment. Nonetheless, a hospital stay is required because of\\nthe possibility of serious complications. Non-aspirin pain\\nrelievers may be given for joint pain. Corticosteroids(like\\nprednisone) are sometimes used, although not all special-\\nists agree on their utility. Kidney involvement requires\\nmonitoring and correction of blood fluids and electrolytes.\\nPatients with severe kidney complications may\\nrequire a kidney biopsy so that tissue can be analyzed.\\nEven after all other symptoms subside, elevated levels of\\nblood or protein in the urine may persist for months and\\nrequire regular monitoring. Hypertension or kidney fail-\\nure may develop months or even years after the acute\\nphase of the disease. Kidney failure requires dialysis or\\ntransplantation.\\nPlasmapheresis , which removes antibodies from\\nthe blood, has been tried for AP with mixed results.\\nPrognosis\\nMost people who develop AP become better on their\\nown after several weeks. About half of all patients have\\nat least one recurrence. Cases that do not have kidney\\ncomplications usually have the best prognosis.\\nResources\\nPERIODICALS\\nAndreoli, S. P. “Chronic Glomerulonephritis in Childhood.\\nMembranoproliferative Glomerulonephritis, Henoch-\\nGALE ENCYCLOPEDIA OF MEDICINE 2110\\nAllergic purpura\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 110'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 124, 'page_label': '125'}, page_content='Schonlein PurpuraNnephritis, and IgA Nephropathy.”\\nPediatric Clinics of North America42, no. 6 (Dec. 1995):\\n1487-1503.\\nOTHER\\n“Henoch-Schonlein Purpura.” Vanderbilt University Medical\\nCenter. .\\nRichard Robinson\\nAllergic rhinitis\\nDefinition\\nAllergic rhinitis, more commonly referred to as hay\\nfever, is an inflammation of the nasal passages caused by\\nallergic reaction to airborne substances.\\nDescription\\nAllergic rhinitis (AR) is the most common allergic\\ncondition and one of the most common of all minor\\nafflictions. It affects between 10-20% of all people in\\nthe United States, and is responsible for 2.5% of all doc-\\ntor visits. Antihistamines and other drugs used to treat\\nallergic rhinitis make up a significant fraction of both\\nprescription and over-the-counter drug sales each year.\\nThere are two types of allergic rhinitis: seasonal and\\nperennial. Seasonal AR occurs in the spring, summer,\\nand early fall, when airborne plant pollens are at their\\nhighest levels. In fact, the term hay fever is really a mis-\\nnomer, since allergy to grass pollen is only one cause of\\nsymptoms for most people. Perennial AR occurs all year\\nand is usually caused by home or workplace airborne\\npollutants. A person can be affected by one or both types.\\nSymptoms of seasonal AR are worst after being out-\\ndoors, while symptoms of perennial AR are worst after\\nspending time indoors.\\nBoth types of allergies can develop at any age,\\nalthough onset in childhood through early adulthood is\\nmost common. Although allergy to a particular substance\\nis not inherited, increased allergic sensitivity may “run in\\nthe family.” While allergies can improve on their own\\nover time, they can also become worse over time.\\nCauses and symptoms\\nCauses\\nAllergic rhinitis is a type of immune reaction. Nor-\\nmally, the immune system responds to foreign microor-\\nganisms, or particles, like pollen or dust, by producing\\nspecific proteins, called antibodies, that are capable of\\nbinding to identifying molecules, or antigens, on the for-\\neign particle. This reaction between antibody and antigen\\nsets off a series of reactions designed to protect the body\\nfrom infection. Sometimes, this same series of reactions\\nis triggered by harmless, everyday substances. This is the\\ncondition known as allergy, and the offending substance\\nis called an allergen.\\nLike all allergic reactions, AR involves a special\\nset of cells in the immune system known as mast cells.\\nMast cells, found in the lining of the nasal passages\\nand eyelids, display a special type of antibody, called\\nimmunoglobulin type E (IgE), on their surface. Inside,\\nmast cells store reactive chemicals in small packets,\\ncalled granules. When the antibodies encounter aller-\\ngens, they trigger release of the granules, which spill\\nout their chemicals onto neighboring cells, including\\nblood vessels and nerve cells. One of these chemicals,\\nhistamine, binds to the surfaces of these other cells,\\nthrough special proteins called histamine receptors.\\nInteraction of histamine with receptors on blood ves-\\nsels causes neighboring cells to become leaky, leading\\nto the fluid collection, swelling, and increased redness\\ncharacteristic of a runny nose and red, irritated eyes.\\nHistamine also stimulates pain receptors, causing the\\nitchy, scratchy nose, eyes, and throat common in aller-\\ngic rhinitis.\\nThe number of possible airborne allergens is enor-\\nmous. Seasonal AR is most commonly caused by grass\\nand tree pollens, since their pollen is produced in large\\namounts and is dispersed by the wind. Showy flowers,\\nlike roses or lilacs, that attract insects produce a sticky\\npollen which is less likely to become airborne. Different\\nplants release their pollen at different times of the year,\\nso seasonal AR sufferers may be most affected in spring,\\nsummer, or fall, depending on which plants provoke a\\nresponse. The amount of pollen in the air is reflected in\\nthe pollen count, often broadcast on the daily news dur-\\ning allergy season. Pollen counts tend to be lower after a\\ngood rain that washes the pollen out of the air and higher\\non warm, dry, windy days.\\nVirtually any type of tree or grass may cause AR. A\\nfew types of weeds that tend to cause the most trouble for\\npeople include the following:\\n• ragweed\\n• sagebrush\\n• lamb’s-quarters\\n• plantain\\n• pigweed\\n• dock/sorrel\\nGALE ENCYCLOPEDIA OF MEDICINE 2 111\\nAllergic rhinitis\\nGEM - 0001 to 0432 - A 10/22/03 1:41 PM Page 111'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 125, 'page_label': '126'}, page_content='• tumbleweed\\nPerennial AR is often triggered by house dust, a\\ncomplicated mixture of airborne particles, many of\\nwhich are potent allergens. House dust contains some or\\nall of the following:\\n• house mite body parts. All houses contain large num-\\nbers of microscopic insects called house mites. These\\nharmless insects feed on fibers, fur, and skin shed by\\nthe house’s larger occupants. Their tiny body parts easi-\\nly become airborne.\\n• animal dander. Animals constantly shed fur, skin flakes,\\nand dried saliva. Carried in the air, or transferred from\\npet to owner by direct contact, dander can cause allergy\\nin many sensitive people.\\n• mold spores. Molds live in damp spots throughout the\\nhouse, including basements, bathrooms, air ducts, air\\nconditioners, refrigerator drains, damp windowsills,\\nmattresses, and stuffed furniture. Mildew and other\\nmolds release airborne spores which circulate through-\\nout the house.\\nOther potential causes of perennial allergic rhinitis\\ninclude the following:\\n• cigarette smoke\\n• perfume\\n• cosmetics\\n• cleansers\\n• copier chemicals\\n• industrial chemicals\\n• construction material gases\\nSymptoms\\nInflammation of the nose, or rhinitis, is the major\\nsymptom of AR. Inflammation causes itching, sneezing,\\nrunny nose, redness, and tenderness. Sinus swelling can\\nconstrict the eustachian tube that connects the inner ear\\nto the throat, causing a congested feeling and “ear pop-\\nping.” The drip of mucus from the sinuses down the back\\nof the throat, combined with increased sensitivity, can\\nalso lead to throat irritation and redness. AR usually also\\ncauses redness, itching, and watery eyes. Fatigue and\\nheadache are also common.\\nDiagnosis\\nDiagnosing seasonal AR is usually easy and can\\noften be done without a medical specialist. When symp-\\ntoms appear in spring or summer and disappear with the\\nonset of cold weather, seasonal AR is almost certainly\\nthe culprit. Other causes of rhinitis, including infection,\\ncan usually be ruled out by a physical examination and\\na nasal smear, in which a sample of mucus is taken on a\\nswab for examination.\\nAllergy tests , including skin testing and provoca-\\ntion testing, can help identify the precise culprit, but\\nmay not be done unless a single source is suspected and\\nsubsequent avoidance is possible. Skin testing involves\\nplacing a small amount of liquid containing a specific\\nallergen on the skin and then either poking, scratching,\\nor injecting it into the skin surface to observe whether\\nredness and swelling occurs. Provocation testing\\ninvolves challenging an individual with either a small\\namount of an inhalable or ingestable allergen to see if a\\nresponse is elicited.\\nPerennial AR can also usually be diagnosed by care-\\nful questioning about the timing of exposure and the\\nonset of symptoms. Specific allergens can be identified\\nthrough allergy skin testing.\\nGALE ENCYCLOPEDIA OF MEDICINE 2112\\nAllergic rhinitis\\nThis illustration depicts excessive mucus production in the\\nnose after inhalation of airborne pollen. (Photo Researchers,\\nInc. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 112'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 126, 'page_label': '127'}, page_content='Treatment\\nAvoidance of the allergens is the best treatment, but\\nthis is often not possible. When it is not possible to avoid\\none or more allergens, there are two major forms of med-\\nical treatment, drugs and immunotherapy.\\nDrugs\\nANTIHISTAMINES. Antihistamines block the hista-\\nmine receptors on nasal tissue, decreasing the effect of\\nhistamine release by mast cells. They may be used after\\nsymptoms appear, though they may be even more effec-\\ntive when used preventively, before symptoms appear. A\\nwide variety of antihistamines are available.\\nOlder antihistamines often produce drowsiness as a\\nmajor side effect. Such antihistamines include the fol-\\nlowing:\\n• diphenhydramine (Benadryl and generics)\\n• chlorpheniramine (Chlor-trimeton and generics)\\n• brompheniramine (Dimetane and generics)\\n• clemastine (Tavist and generics).\\nNewer antihistamines that do not cause drowsiness\\nare available by prescription and include the following:\\n• astemizole (Hismanal)\\n• loratidine (Claritin)\\n• fexofenadine (Allegra)\\n• azelastin HCl (Astelin).\\nHismanal has the potential to cause serious heart\\narrhythmias when taken with the antibiotic ery-\\nthromycin, the antifungal drugs ketoconazole and itra-\\nconazole, or the antimalarial drug quinine. Taking more\\nthan the recommended dose of Hismanal can also cause\\narrhythimas. Seldane (terfenadine), the original non-\\ndrowsy antihistamine, was voluntarily withdrawn from\\nthe market by its manufacturers in early 1998 because of\\nthis potential and because of the availability of an equal-\\nly effective, safer alternative drug, fexofenadine.\\nDECONGESTANTS. Decongestants constrict blood\\nvessels to counteract the effects of histamine. Nasal sprays\\nare available that can be applied directly to the nasal lining\\nand oral systemic preparations are available. Decongestants\\nare stimulants and may cause increased heart rate and blood\\npressure, headaches, and agitation. Use of topical deconges-\\ntants for longer than several days can cause loss of effective-\\nness and rebound congestion, in which nasal passages\\nbecome more severely swollen than before treatment.\\nTOPICAL CORTICOSTEROIDS. Topical corticos-\\nteroids reduce mucous membrane inflammation and are\\navailable by prescription. Allergies tend to become worse\\nas the season progresses because the immune system\\nbecomes sensitized to particular antigens and can pro-\\nduce a faster, stronger response. Topical corticosteroids\\nare especially effective at reducing this seasonal sensiti-\\nzation because they work more slowly and last longer\\nthan most other medication types. As a result, they are\\nbest started before allergy season begins. Side effects are\\nusually mild, but may include headaches, nosebleeds,\\nand unpleasant taste sensations.\\nMAST CELL STABILIZERS. Cromolyn sodium prevents\\nthe release of mast cell granules, thereby preventing\\nrelease of histamine and the other chemicals contained in\\nthem. It acts as a preventive treatment if it is begun sever-\\nal weeks before the onset of the allergy season. It can be\\nused for perennial AR as well.\\nImmunotherapy\\nImmunotherapy, also known as desensitization or\\nallergy shots, alters the balance of antibody types in the\\nbody, thereby reducing the ability of IgE to cause allergic\\nreactions. Immunotherapy is preceded by allergy testing\\nto determine the precise allergens responsible. Injections\\ninvolve very small but gradually increasing amounts of\\nallergen, over several weeks or months, with periodic\\nboosters. Full benefits may take up to several years to\\nachieve and are not seen at all in about one in five\\npatients. Individuals receiving all shots will be monitored\\nclosely following each shot because of the small risk of\\nanaphylaxis , a condition that can result in difficulty\\nbreathing and a sharp drop in blood pressure.\\nAlternative treatment\\nAlternative treatments for AR often focus on modu-\\nlation of the body’s immune response, and frequently\\ncenter around diet and lifestyle adjustments. Chinese\\nherbal medicine can help rebalance a person’s system, as\\ncan both acute and constitutional homeopathic treatment.\\nVitamin C in substantial amounts can help stabilize the\\nmucous membrane response. For symptom relief, west-\\nern herbal remedies including eyebright ( Euphrasia\\nofficinalis ) and nettle ( Urtica dioica ) may be helpful.\\nBee pollen may also be effective in alleviating or elimi-\\nnating AR symptoms.\\nPrognosis\\nMost people with AR can achieve adequate relief\\nwith a combination of preventive strategies and treat-\\nment. While allergies may improve over time, they may\\nalso get worse or expand to include new allergens. Early\\ntreatment can help prevent an increased sensitization to\\nother allergens.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 113\\nAllergic rhinitis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 113'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 127, 'page_label': '128'}, page_content='Prevention\\nReducing exposure to pollen may improve symp-\\ntoms of seasonal AR. Strategies include the following:\\n• stay indoors with windows closed during the morning\\nhours, when pollen levels are highest\\n• keep car windows up while driving\\n• use a surgical face mask when outside\\n• avoid uncut fields\\n• learn which trees are producing pollen in which sea-\\nsons, and avoid forests at the height of pollen season\\n• wash clothes and hair after being outside\\n• clean air conditioner filters in the home regularly\\n• use electrostatic filters for central air conditioning\\nMoving to a region with lower pollen levels is rarely\\neffective, since new allergies often develop\\nPreventing perennial AR requires identification of\\nthe responsible allergens\\nMold spores:\\nKEY TERMS\\nAllergen —A substance that provokes an allergic\\nresponse.\\nAnaphylaxis—Increased sensitivity caused by pre-\\nvious exposure to an allergen that can result in\\nblood vessel dilation (swelling) and smooth mus-\\ncle contraction. Anaphylaxis can result in sharp\\nblood pressure drops and difficulty breathing.\\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.\\nGranules —Small packets of reactive chemicals\\nstored within cells.\\nHistamine —A chemical released by mast cells\\nthat activates pain receptors and causes cells to\\nbecome leaky.\\nMast cells —A type of immune system cell that is\\nfound in the lining of the nasal passages and eye-\\nlids, displays a type of antibody called immuno-\\nglobulin type E (IgE) on its cell surface, and partici-\\npates in the allergic response by releasing hista-\\nmine from intracellular granules.\\n• keep the house dry through ventilation and use of dehu-\\nmidifiers\\n• use a disinfectant such as dilute bleach to clean surfaces\\nsuch as bathroom floors and walls\\n• have ducts cleaned and disinfected\\n• clean and disinfect air conditioners and coolers\\n• throw out moldy or mildewed books, shoes, pillows, or\\nfurniture\\nHouse dust:\\n• vacuum frequently, and change the bag regularly. Use a\\nbag with small pores to catch extra-fine particles\\n• clean floors and walls with a damp mop\\n• install electrostatic filters in heating and cooling ducts,\\nand change all filters regularly\\nAnimal dander:\\n• avoid contact if possible\\n• wash hands after contact\\n• vacuum frequently\\n• keep pets out of the bedroom, and off furniture, rugs,\\nand other dander-catching surfaces\\n• have your pets bathed and groomed frequently\\nResources\\nBOOKS\\nAllergic and Non-Allergic Rhinitis: Clinical Aspects.Ed. N.\\nMygund and R. M. Naclerio. Philadelphia: W. B. Saun-\\nders Co., 1993.\\nLawlor, G. J. Jr., T. J. Fischer, and D. C. Adelman. Manual of\\nAllergy and Immunology.Boston: Little, Brown and Co.,\\n1995.\\nNovick, N. L. You Can Do Something About Your Allergies.\\nNew York: Macmillan, 1994.\\nWeil, A. Natural Health, Natural Medicine: A Comprehensive\\nManual for Wellness and Self-Care.New York: Houghton\\nMifflin, 1995.\\nRichard Robinson\\nAllergies\\nDefinition\\nAllergies are abnormal reactions of the immune sys-\\ntem that occur in response to otherwise harmless sub-\\nstances.\\nGALE ENCYCLOPEDIA OF MEDICINE 2114\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 114'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 128, 'page_label': '129'}, page_content='Description\\nAllergies are among the most common of medical\\ndisorders. It is estimated that 60 million Americans, or\\nmore than one in every five people, suffer from some\\nform of allergy, with similar proportions throughout\\nmuch of the rest of the world. Allergy is the single largest\\nreason for school absence and is a major source of lost\\nproductivity in the workplace.\\nAn allergy is a type of immune reaction. Normally,\\nthe immune system responds to foreign microorganisms\\nor particles by producing specific proteins called anti-\\nbodies. These antibodies are capable of binding to iden-\\ntifying molecules, or antigens, on the foreign particle.\\nThis reaction between antibody and antigen sets off a\\nseries of chemical reactions designed to protect the\\nbody from infection. Sometimes, this same series of\\nreactions is triggered by harmless, everyday substances\\nsuch as pollen, dust, and animal danders. When this\\noccurs, an allergy develops against the offending sub-\\nstance (an allergen.)\\nMast cells, one of the major players in allergic reac-\\ntions, capture and display a particular type of antibody,\\ncalled immunoglobulin type E (IgE) that binds to aller-\\ngens. Inside mast cells are small chemical-filled packets\\ncalled granules. Granules contain a variety of potent\\nchemicals, including histamine.\\nImmunologists separate allergic reactions into two\\nmain types: immediate hypersensitivity reactions, which\\nare predominantly mast cell-mediated and occur within\\nminutes of contact with allergen; and delayed hypersen-\\nsitivity reactions, mediated by T cells (a type of white\\nblood cells) and occurring hours to days after exposure.\\nInhaled or ingested allergens usually cause immedi-\\nate hypersensitivity reactions. Allergens bind to IgE anti-\\nbodies on the surface of mast cells, which spill the con-\\ntents of their granules out onto neighboring cells, includ-\\ning blood vessels and nerve cells. Histamine binds to the\\nsurfaces of these other cells through special proteins\\ncalled histamine receptors. Interaction of histamine with\\nreceptors on blood vessels causes increased leakiness,\\nleading to the fluid collection, swelling and increased\\nredness. Histamine also stimulates pain receptors, mak-\\ning tissue more sensitive and irritable. Symptoms last\\nfrom one to several hours following contact.\\nIn the upper airways and eyes, immediate hypersen-\\nsitivity reactions cause the runny nose and itchy, blood-\\nshot eyes typical of allergic rhinitis. In the gastrointesti-\\nnal tract, these reactions lead to swelling and irritation of\\nthe intestinal lining, which causes the cramping and\\ndiarrhea typical of food allergy. Allergens that enter the\\ncirculation may cause hives, angioedema, anaphylaxis,\\nor atopic dermatitis.\\nAllergens on the skin usually cause delayed hyper-\\nsensitivity reaction. Roving T cells contact the allergen,\\nsetting in motion a more prolonged immune response.\\nThis type of allergic response may develop over several\\ndays following contact with the allergen, and symptoms\\nmay persist for a week or more.\\nCauses and symptoms\\nAllergens enter the body through four main routes:\\nthe airways, the skin, the gastrointestinal tract, and the\\ncirculatory system.\\n• Airborne allergens cause the sneezing, runny nose,\\nand itchy, bloodshot eyes of hay fever (allergic rhini-\\ntis). Airborne allergens can also affect the lining of the\\nlungs, causing asthma, or the conjunctiva of the eyes,\\ncausing conjunctivitis (pink eye). Exposure to cock-\\nroach allergans have been associated with the devel-\\nopment of asthma. Airborne allergans from household\\npets are another common source of environmental\\nexposure.\\n• Allergens in food can cause itching and swelling of the\\nlips and throat, cramps, and diarrhea. When absorbed\\ninto the bloodstream, they may cause hives (urticaria)\\nor more severe reactions involving recurrent, non-\\ninflammatory swelling of the skin, mucous membranes,\\norgans, and brain (angioedema). Some food allergens\\nmay cause anaphylaxis,a potentially life-threatening\\ncondition marked by tissue swelling, airwayconstric-\\ntion, and drop in blood pressure. Allergies to foods such\\ncow’s milk, eggs, nuts, fish, and legumes (peanuts and\\nsoybeans) are common. Allergies to fruits and vegeta-\\nbles may also occur.\\n• In contact with the skin, allergens can cause redden-\\ning, itching, and blistering, called contact dermatitis .\\nSkin reactions can also occur from allergens intro-\\nduced through the airways or gastrointestinal tract.\\nThis type of reaction is known as atopic dermatitis .\\nDermatitis may arise from an allergic response (such\\nas from poison ivy), or exposure to an irritant causing\\nnonimmune damage to skin cells (such as soap, cold,\\nand chemical agents).\\n• Injection of allergens, from insect bites and stings or\\ndrug administration, can introduce allergens directly\\ninto the circulation, where they may cause system-wide\\nresponses (including anaphylaxis), as well as the local\\nones of swelling and irritation at the injection site.\\nPeople with allergies are not equally sensitive to\\nall allergens. Some may have severe allergic rhinitis\\nbut no food allergies, for instance, or be extremely sen-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 115\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 115'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 129, 'page_label': '130'}, page_content='sitive to nuts but not to any other food. Allergies may\\nget worse over time. For example, childhood ragweed\\nallergy may progress to year-round dust and pollen\\nallergy. On the other hand, a person may lose allergic\\nsensitivity. Infant or childhood atopic dermatitis disap-\\npears in almost all people. More commonly, what\\nseems to be loss of sensitivity is instead a reduced\\nexposure to allergens or an increased tolerance for the\\nsame level of symptoms.\\nWhile allergy to specific allergens is not inherited,\\nthe likelihood of developing some type of allergy seems\\nto be, at least for many people. If neither parent has\\nallergies, the chances of a child developing allergy is\\napproximately 10-20%; if one parent has allergies, it is\\n30-50%; and if both have allergies, it is 40-75%.One\\nsource of this genetic predisposition is in the ability to\\nproduce higher levels of IgE in response to allergens.\\nThose who produce more IgE will develop a stronger\\nallergic sensitivity.\\nCOMMON ALLERGENS. The most common airborne\\nallergens are the following:\\n• plant pollens\\n• animal fur and dander\\n• body parts from house mites (microscopic creatures\\nfound in all houses)\\n• house dust\\n• mold spores\\n• cigarette smoke\\n• solvents\\n• cleaners\\nCommon food allergens include the following:\\n• nuts, especially peanuts, walnuts, and brazil nuts\\n• fish, mollusks, and shellfish\\n• eggs\\n• wheat\\n• milk\\n• food additives and preservatives\\nThe following types of drugs commonly cause aller-\\ngic reactions:\\n• penicillin or other antibiotics\\n• flu vaccines\\n• tetanus toxoid vaccine\\n• gamma globulin\\nCommon causes of contact dermatitis include the\\nfollowing:\\n• poison ivy, oak, and sumac\\n• nickel or nickel alloys\\n• latex\\nInsects and other arthropods whose bites or stings\\ntypically cause allergy include the following:\\n• bees, wasps, and hornets\\n• mosquitoes\\n• fleas\\n• scabies\\nSymptoms depend on the specific type of allergic\\nreaction. Allergic rhinitis is characterized by an itchy,\\nrunny nose, often with a scratchy or irritated throat due\\nto post-nasal drip. Inflammation of the thin membrane\\ncovering the eye (allergic conjunctivitis) causes redness,\\nirritation, and increased tearing in the eyes. Asthma caus-\\nes wheezing, coughing, and shortness of breath. Symp-\\ntoms of food allergies depend on the tissues most sensi-\\ntive to the allergen and whether the allergen spread sys-\\ntemically by the circulatory system. Gastrointestinal\\nsymptoms may include swelling and tingling in the lips,\\ntongue, palate or throat; nausea; cramping; diarrhea; and\\ngas. Contact dermatitis is marked by reddened, itchy,\\nweepy skin blisters, and an eczema that is slow to heal. It\\nsometimes has a characteritic man-made pattern, such as\\na glove allergy with clear demarkation on the hands,\\nwrist, and arms where the gloves are worn, or on the ear-\\nlobes by wearing earrings.\\nWhole body or systemic reactions may occur from\\nany type of allergen, but are more common following\\ningestion or injection of an allergen. Skin reactions\\ninclude the raised, reddened, and itchy patches called\\nhives that characteristically blanch with pressure and\\nresolve within twenty-four hours. A deeper and more\\nextensive skin reaction, involving more extensive fluid\\ncollection and pain, is called angioedema. This usually\\noccurs on the extremities, fingers, toes, and parts of the\\nhead,neck,and face. Anaphylaxis is marked by airway\\nconstriction, blood pressure drop, widespread tissue\\nswelling, heart rhythm abnormalities, and in some cases,\\nloss of consciousness. Other syptoms may include, dizzi-\\nness, weakness, seizures, coughing,flushing, or cramp-\\ning. The symptoms may begin within five minutes after\\nexposure to the allergan up to one hour or more later.\\nMast cells in the tissues and basophils in the blood\\nrelease mediators that give rise to the clinical symptoms\\nof this IgE-mediated hypersensitivity reaction. Common-\\nly, this is associated with allergies to medications, foods,\\nand insect venoms. In some individuals, anaphylaxis can\\noccur with exercise , plasma exchange, hemodialysis,\\nreaction to insulin, radocontrast media used in certain\\nGALE ENCYCLOPEDIA OF MEDICINE 2116\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 116'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 130, 'page_label': '131'}, page_content=\"types of medical tests. and rarely during the administra-\\ntion of local anesthetics.\\nDiagnosis\\nAllergies can often be diagnosed by a careful med-\\nical history, matching the onset of symptoms to the\\nexposure to possible allergens. Allergy is suspected if\\nthe symptoms presented are characteristic of an allergic\\nreaction and this occurs repeatedly upon exposure to\\nthe suspected allergan. Allergy tests can be used to\\nidentify potential allergens, but these must be supported\\nby eveidence of allergic responses in the patient’s clini-\\ncal history.\\nSkin tests\\nSkin tests are performed by administering a tiny\\ndose of the suspected allergen by pricking, scratching,\\npuncturing or injecting the skin. The allergen is applied\\nto the skin as an auqeous extract, usually on the back,\\nforearms, or top of the thighs. Once in the skin, the aller-\\ngen may produce a classic immune wheal and flare\\nresponse (a skin lesion with a raise, white, compressible\\narea surrounded by a red flare). The tests usually begin\\nwith prick tests or patch tests that expose the skin to\\nsmall amounts of allergen to observe the response. A\\npositive reaction will occur on the skin even if the aller-\\ngen is at levels normally encountered in food or in the\\nairways. Reactions are usually evaluated approximately\\nfifteen minutes after exposure. Intradermal skin tests\\ninvolved injection of the allergan into the dermis of the\\nskin. These tests are more sensitive and are used for\\nallergies associated with risk of death, such as allergies\\nto antibiotics.\\nAllergen-Specific IgE Measurement\\nTests that measure allergen-specific IgE antibodies\\ngenerally follow a basic method. The allergen is bound\\nto a solid support, either in the form of a cellulose\\nsponge, microtiter plate, or paper disk. The patient’s\\nserum is prepared from a blood sample and is incubated\\nwith the solid phase. If allergen specific IgE antibodies\\nare present, they will bind to the solid phase and be\\nretained there when the rest of the serum is washed\\naway. Next, an labeled antibody against the IgE is added\\nand will bind to any IgE on the solid phase. The excess\\nis washed away and the levels of IgE are determined.\\nThe commonly used RAST test (radio allergo sorbent\\nGALE ENCYCLOPEDIA OF MEDICINE 2 117\\nAllergies\\nAllergic rhinitis is commonly triggered by\\nexposure to household dust, animal fur,\\nor pollen. The foreign substance that\\ntriggers an allergic reaction is called\\nan allergen.\\nThe presence of an allergen causes the\\nbody's lymphocytes to begin producing\\nIgE antibodies. The lymphocytes of an \\nallergy sufferer produce an unusually\\nlarge amount of IgE.\\nIgE molecules attach to mast\\ncells, which contain histamine.\\nHistamine\\nPollen grains\\nLymphocyte\\nFIRST EXPOSURE\\nIgE\\nThe allergic response. (Illustration by Hans & Cassady.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 117\"),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 131, 'page_label': '132'}, page_content='test) employed radio-labeled Anti-IgE antibodies.\\nUpdated methods now incorporate the use of enyzme-\\nlabeled antibodies in ELISA assays (enzyme-linked\\nimmunosorbent assays).\\nTotal Serum IgE\\nThe total level of IgE in the serum is commonly\\nmeasured with a two-site immunometric assay. Some\\nresearch indicates that there is a higher level of total\\nserum IgE in allergic as compared to non-allergic peo-\\nple. However, this may not always be the case as there is\\nconsiderable overlap between the two groups.This test is\\nuseful for the diagnosis of allergic fungal sinusitis and\\nbronchopulmonary aspergillosis . Other conditions that\\nare not allergic in nature may give rise to higher IgE lev-\\nels such as smoking , AIDS, infection with parasites,\\nand IgE myeloma.\\nProvocation tests\\nThese tests involve the administration of allergen to\\nellicit an immune response. Provocation tests, most com-\\nmonly done with airborne allergens, present the allergen\\ndirectly through the route normally involved. Delayed\\nallergic contact dermatitis diagnosis involves similar\\nmethods by application of a skin patch with allergen to\\ninduce an allergic skin reaction. Food allergen provoca-\\ntion tests require abstinence from the suspect allergen for\\ntwo weeks or more, followed by ingestion of a measured\\namount of the test substance administered as an opaque\\ncapsule along with a placebo control. Provocation tests\\nare not used if anaphylaxis is is a concern due to the\\npatient’s medical history.\\nFuture diagnostic methods\\nAs of 2000, attempts have been made for direct\\nmeasurement of immune mediators such as histamine,\\neosinophil cationic protein (ECP), and mast cell\\ntryptase. Another, somewhat controversial,test is elec-\\ntrodermal testing or electro-acupuncture allergy testing.\\nThis test has been used in Europe and is under investiga-\\ntion in the United States, though not approved by the\\nFood and Drug Administration. An electric potential is\\napplied to the skin, the allergen presented, and the elec-\\ntrical resistance observed for changes. This method has\\nnot been verified.\\nTreatment\\nAvoiding allergens is the first line of defense to\\nreduce the possibility of an allergic attack. It is helpful to\\navoid environmental irritants such as tobacco smoke,\\nperfumes, household cleaning agents, paints, glues, air\\nfresheners, and potpourri. Nitrogen dioxide from poorly\\nvented gas stoves, woodburing stoves, and artificial fire-\\nplaces has also been linked to poor asthma control. Dust\\nmite control is particularly important in the bedroom\\nareas by use of allergen-impermeable covers on mattress\\nand pillows, frequent washing of bedding in hot\\nwater,and removal of items that collect dust such as\\nstuffed toys. Mold growth may be reduced by reducing\\nindoor humidity, repair of house foundations to reduce\\nindoor leaks and seepage, and installation of exhaust sys-\\ntems to ventilate areas where steam is generated such as\\nthe bathroom or kitchen. Allergic individuals should\\navoid pet allergens such as saliva, body excretions, pelts,\\nurine, or feces. For those who insist on keeping a pet,\\nrestriction of the animal’s activity to certain areas of the\\nhome may be beneficial.\\nComplete environmental control is often difficult to\\naccomplish, hence therapuetic interventions may\\nbecome necessary. A large number of prescription and\\nover-the-counter drugs are available for treatment of\\nimmediate hypersensitivity reactions. Most of these\\nwork by decreasing the ability of histamine to provoke\\nsymptoms. Other drugs counteract the effects of hista-\\nmine by stimulating other systems or reducing immune\\nresponses in general.\\nAntihistamines\\nAntihistamines block the histamine receptors on\\nnasal tissue, decreasing the effect of histamine released\\nby mast cells. They may be used after symptoms appear,\\nthough they may be even more effective when used pre-\\nventively, before symptoms appear. Antihistamines are\\nhelp reduce sneezing, itching, and rhinorrhea. A wide\\nvariety of antihistamines are available.\\nOlder, first generation antihistamines often produce\\ndrowsiness as a major side effect, as well as dry mouth,\\ntachycardia, blurred vision, constipation, and lower the\\nthreshold for seizures. These medicatios also have simi-\\nlar effects to a alcohol and care should be taken when\\noperating motor vehicles, as individuals may not be\\naware that they are impared. Such antihistamines include\\nthe following:\\n• diphenhydramine (Benadryl and generics)\\n• chlorpheniramine (Chlor-trimeton and generics)\\n• brompheniramine (Dimetane and generics)\\n• clemastine (Tavist and generics)\\nNewer antihistamines that do not cause drowsiness\\nor pass the blood-brain barrier are available by prescrip-\\ntion and include the following:\\n• loratidine (Claritin)\\nGALE ENCYCLOPEDIA OF MEDICINE 2118\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 118'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 132, 'page_label': '133'}, page_content='• fexofenadine (Allegra)\\nHismanal has the potential to cause serious heart\\narrhythmias when taken with the antibiotic ery-\\nthromycin,the antifungal drugs ketoconazole and itra-\\nconazole, or the antimalarial drug quinine. Taking more\\nthan the recommended dose of Hismanal can also cause\\narrhythimas. Seldane (terfenadine), the original non-\\ndrowsy antihistamine, was voluntarily withdrawn from\\nthe market by its manufacturers in early 1998 because of\\nthis potential and because of the availability of an equal-\\nly effective, safer alternative drug, fexofenadine.\\nDecongestants\\nDecongestants constrict blood vessels to the\\nmucosa to counteract the effects of histamine. This\\ndecreases the amount of blood in the nasopahryngeal\\nand sinus mucosa and reduces swelling. Nasal sprays\\nare available that can be applied directly to the nasal lin-\\ning and oral systemicpreparations are available. Decon-\\ngestants are stimulants and may cause increased heart\\nrate and blood pressure, headaches,insomnia,agitation,\\nand difficulty emptying the bladder. Use of topical\\ndecongestants for longer than several days can cause\\nloss of effectiveness and rebound congestion, in which\\nnasal passages become more severely swollen than\\nbefore treatment.\\nTopical corticosteroids\\nTopical corticosteroids reduce mucous membrane\\ninflammationas by decreasing the amount of fluid\\nmoved from the vascular spaces into the tissues. These\\nmedications reduce the recruitment of inflammatory\\ncells as well as the synthesis of cytokines. They are\\navailable by prescription. Allergies tend to become\\nworse as the season progresses because the immune sys-\\ntem becomes sensitized to particular antigens and can\\nproduce a faster, stronger response. Topical corticos-\\nteroids are especially effective at reducing this seasonal\\nsensitization because they work more slowly and last\\nlonger than most other medication types. As a result,\\nthey are best started before allergy season begins. Side\\neffects are usually mild, but may include headaches,\\nnosebleeds, and unpleasant taste sensations.\\nBronchodilators or metered-dose inhalers (MDI)\\nBecause allergic reactions involving the lungs cause\\nthe airways or bronchial tubes to narrow, as in asthma,\\nGALE ENCYCLOPEDIA OF MEDICINE 2 119\\nAllergies\\nIn a future exposure to the same substance,\\nthe antibodies on the mast cells bind to the\\nallergens, and the cells release their histamine.Histamine travels to receptor sites in the nasal\\npassages. When histamine molecules enter the\\nsites they trigger dilation of the blood vessels,\\nswelling, irritation, and increased production\\nof mucus.\\nAntihistamine drugs block histamine molecules\\nfrom entering receptor sites, thus preventing or\\nreducing swelling, congestion and irritation.\\nAntihistamines\\nSECOND EXPOSURE\\nSecond and subsequent exposure to allergen.(Illustration by Hans & Cassady.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 119'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 133, 'page_label': '134'}, page_content='bronchodilators, which cause the smooth muscle lining\\nthe airways to open or dilate, can be very effective.\\nWhen inahlers are used, it is important that the patient\\nbe educated in the proper use of these medications.The\\ninhaler should be shaken, and the patient should breathe\\nout to expel air from the lungs. The inhaler should be\\nplace at least two fingerbreadths in front of the mouth.\\nThe medication should be aimed at the back of the\\nthroat, and the inhaler activated while breathing in quite\\nslowly 3-4 seconds. The breath should be held for at\\nleast ten seconds, and then expelled. At least thirty to\\nsixty seconds should pass before the inhaler is used\\nagain. Care should be taken to properly wash out the\\nmouth and brush the teeth following use, as residual\\nmedication remains in this area with only a small\\namount actually reaching the lungs. Some bronchodila-\\ntors used to treat acute asthma attacks include adrena-\\nline, albuterol, or other “adrenoceptor stimulants,” most\\noften administered as aerosols. Futicasone (Flovent) is\\nanother commonly prescribed inhaler. Some bron-\\nchodilators used to treat acute asthma attacks include\\nKEY TERMS\\nAllergen —A substance that provokes an allergic\\nresponse.\\nAllergic rhinitis —Inflammation of the mucous\\nmembranes of the nose and eyes in response to an\\nallergen.\\nAnaphylaxis—Increased sensitivity caused by previ-\\nous exposure to an allergen that can result in blood\\nvessel dilation and smooth muscle contraction.\\nAnaphylaxis can result in sharp blood pressure\\ndrops and difficulty breathing.\\nAngioedema—Severe non-inflammatory swelling of\\nthe skin, organs, and brain that can also be accom-\\npanied by fever and muscle pain.\\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.\\nAsthma—A lung condition in which the airways\\nbecome narrow due to smooth muscle contraction,\\ncausing wheezing, coughing, and shortness of\\nbreath.\\nAtopic dermatitis —Infection of the skin as a result\\nof exposure to airborne or food allergens.\\nConjunctivitis —Inflammation of the thin lining of\\nthe eye called the conjunctiva.\\nContact dermatitis —Inflammation of the skin as a\\nresult of contact with a substance.\\nDelayed hypersensitivity reactions —Allergic reac-\\ntions mediated by T cells that occur hours to days\\nafter exposure.\\nGranules —Small packets of reactive chemicals\\nstored within cells.\\nHistamine—A chemical released by mast cells that\\nactivates pain receptors and causes cells to become\\nleaky.\\nImmune hypersensitivity reaction —Allergic reac-\\ntions that are mediated by mast cells and occur\\nwithin minutes of allergen contact.\\nMast cells —A type of immune system cell that is\\nfound in the lining of the nasal passages and eye-\\nlids, displays a type of antibody called\\nimmunoglobulin type E (IgE) on its cell surface, and\\nparticipates in the allergic response by releasing\\nhistamine from intracellular granules.\\nT cells—Immune system cells or more specifically,\\nwhite blood cells, that stimulate cells to create and\\nrelease antibodies.\\nadrenaline, albuterol, Maxair, Proventil, or other\\n“adrenoceptor stimulants,” most often administered as\\naerosols. Another group of medications, the long-acting\\nbeta agonists, are proving useful to reduce the use of\\ninhalers.and include salmeterol xinafoate (Serevent).\\nTheophylline,naturally present in coffee and tea, is\\nanother drug that produces brochodilation.It is usually\\ntaken orally, but in a severe asthma attack is may be\\ngiven intravenously. Side effects include gastrointestinal\\ndisturbances, insomnia, headaches, and seizures.\\nAnticholinergics\\nIpratropium bromide (atrovent) and atropine sulfate\\nare achticholinergic drugs used for the treatment of asth-\\nma. Ipratropium is used for treating asthmatics in emer-\\ngency situations with a nebulizer.\\nNonsteroidal drugs\\nMAST CELL STABILIZERS. Cromolyn sodium pre-\\nvents the release of mast cell granules, thereby prevent-\\nGALE ENCYCLOPEDIA OF MEDICINE 2120\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 120'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 134, 'page_label': '135'}, page_content='ing the release of histamine and other chemicals con-\\ntained in them. It acts as a preventive treatment if it is\\nbegun several weeks before the onset of the allergy sea-\\nson. It can also be used for year round allergy preven-\\ntion. Cromolyn sodium is available as a nasal spray for\\nallergic rhinitis and in aerosol (a suspension of particles\\nin gas) form for asthma.\\nLEUKOTRIENE MODIFIERS. These medications are\\nuseful for individuals with aspirin sensitivity,sinusitis,\\npolposis, urticaria. Examples include zafirlukast (Acco-\\nlate),montelukast (Singulair), and zileuton (Zyflo).\\nWhen zileuton is used, care must be taken to measure\\nliver enzymes.\\nImmunotherapy\\nIn this form of therapy, allergen is injected into the\\nskin in increasing doses over a specific period of time.\\nThis may be helpful for patients who do not respond to\\nmedications or avoidance of allergens in the environ-\\nment. This type of therapy may reduce the need for med-\\nications.\\nTreatment of contact dermatitis\\nAn individual suffering from contact dermatitis\\nshould initially take steps to avoid possible wources of\\nexposure to the offending agent. Calamine lotion applied\\nto affected skin can reduce irritation somewhat, as can\\ncold water compresses. Side effects of topical agents\\nmay include over-drying of the skin.In the case of acute\\ncontact dermatitis, short-term oral corticosteroid therapy\\nmay be appropriate. Moderately strong coricosteroids\\ncan also be applied as a wrap for twenty-four hours.\\nHealth care workers are especially at risk for hand erup-\\ntions due to glove use.\\nTreatment of anaphylaxis\\nThe emergency condition of anaphylaxis is treated\\nwith injection of adrenaline, also known as epinephrine.\\nPeople who are prone to anaphylaxis because of food or\\ninsect allergies often carry an “Epi-pen” containing\\nadrenaline in a hypodermic needle. Other medications\\nmay be given to aid the action of the epi-pen. Prompt\\ninjection can prevent a more serious reaction from\\ndeveloping. Paticular care should be taken to assess the\\naffected individual’s airway status, and he or she should\\nbe placed in a recumbent pose and vital signs deter-\\nmined. If a reaction resulted from insect sting or an\\ninjection, a tourniquet may need to be placed proximal\\nto the area where the agent penetrated the skin. This\\nshould then be released at intervals of ten minutes at a\\ntime, for one to two minutes duration. If the individual\\ndoes not respond to such interventions, then emergency\\ntreatment is appropriate.\\nAlternative treatment\\nAny alternative treatment for allergies begins with\\nfinding the cause and then helping the patient to avoid\\nor eliminate the allergen, although this is not always\\npossible. As with any alternative therapy, a physician\\nshould be consulted before initiating a new form of\\ntreatment. Education on the use of alternative agents is\\ncritical, as they are still “drugs” even though they are\\nderived from natural sources.Various categories of\\nalternative remedies may be helpful in allergy treat-\\nment, including:\\n• antihistamines: vitamin C and the bioflavonoid hes-\\nperidin act as natural anithistamines.\\n• decongestants: vitamin C, the homeopathic remedies\\nFerrum phosphoricum and Kali muriaticum (used alter-\\nnately), and the dietary supplement N-acetylcysteine\\nare believed to have decongestant effects.\\n• mast cell stabilizers: the bioflavonoids quercetin and\\nhesperidin may help stabilize mast cells.\\n• immunotherapy: the herbs echinacea (Echinacea spp.)\\nand astragalus or milk-vetch root ( Astragalus mem-\\nbranaceus ) may possibly help to strengthen the\\nimmune system.\\n• bronchodilators: the herbal remedies ephedra (Ephedra\\nsinica, also known as ma huang in traditional Chinese\\nmedicine), khellin ( Ammi visnaga ) and cramp bark\\n(Viburnum opulus) are believed to help open the airways.\\nTreatment of contact dermatitis\\nA variety of herbal remedies, either applied topical-\\nly or taken internally, may possibly assist in the treat-\\nment of contact dermatitis. A poultice (crushed herbs\\napplied directly to the affected area) made of jewelweed\\n(Impatiens spp.) or chickweed ( Stellaria media ) may\\nsoothe the skin. A cream or wash containing calendula\\n(Calendula officinalis ), a natural antiseptic and anti-\\ninflammatory agent, may help heal the rash when\\napplied topically. Homeopathic treatment may include\\nsuch remedies as Rhus toxicodendron, Apis mellifica,o r\\nAnacardium taken internally. A qualified homeopathic\\npractitioner should be consulted to match the symptoms\\nwith the correct remedy. Care should be taken with any\\nagent taken internally.\\nPrognosis\\nAllergies can improve over time, although they often\\nworsen. While anaphylaxis and severe asthma are life-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 121\\nAllergies\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 121'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 135, 'page_label': '136'}, page_content='threatening, other allergic reactions are not. Learning to\\nrecognize and avoid allergy-provoking situations allows\\nmost people with allergies to lead normal lives.\\nPrevention\\nAvoiding allergens is the best means of limiting\\nallergic reactions. For food allergies, there is no effective\\ntreatment except avoidance. By determining the allergens\\nthat are causing reactions, most people can learn to avoid\\nallergic reactions from food, drugs, and contact allergens\\nsuch as poison ivy or latex. Airborne allergens are more\\ndifficult to avoid, although keeping dust and animal dan-\\nder from collecting in the house may limit exposure.\\nCromolyn sodium can prevent mast cell degranulation,\\nthereby limiting the allergic response.\\nImmunotherapy, also known as desensitization or\\nallergy shots, alters the balance of antibody types in\\nthe body, thereby reducing the ability of IgE to cause\\nallergic reactions. Immunotherapy is preceded by aller-\\ngy testing to determine the precise allergens responsi-\\nble. Injections involve very small but gradually\\nincreasing amounts of allergen, over several weeks or\\nmonths, with periodic boosters. Full benefits may take\\nup to several years to achieve and are not seen at all in\\nabout one in five patients. Individuals receiving all\\nshots will be monitored closely following each shot\\nbecause of the small risk of anaphylaxis, a condition\\nthat can result in difficulty breathing and a sharp drop\\nin blood pressure.\\nOther drugs, including steroids, are used to prevent\\nasthma attacks and in the long-term management of asthma.\\nResources\\nBOOKS\\nKemp, Stephen F. and Richard Lockey, editors. Diagnostic\\nTesting of Allergic Disease.New York: Marcel Dekker,\\nInc., 2000.\\nLawlor, G. J., T. J. Fischer, and D. C. Adelman. Manual of\\nAllergy and Immunology.Boston: Little, Brown and Co.,\\n1995.\\nLieberman, Phil, and Johh Anderson, editors. Allergic Dis-\\neases: Diagnosis and Treatment, 2nd edition.Totowa:\\nHumana Press, Inc., 2000.\\nNovick, N. L. You Can Do Something About Your Allergies.\\nNew York: Macmillan, 1994.\\nHans-Uwe, Simon, editor. CRC Desk Reference for Allergy and\\nAsthma. Boca Raton: CRC Press, 2000.\\nWeil, A. Natural Health, Natural Medicine: A Comprehensive\\nManual for Wellness and Self-Care.Boston: Houghton\\nMifflin, 1995.\\nRichard Robinson\\nJill Granger, MS\\nAllergy tests\\nDefinition\\nAllergy tests indicate a person’s allergic sensitivity\\nto commonly encountered environmental substances.\\nPurpose\\nAllergy is a reaction of the immune system. Nor-\\nmally, the immune system responds to foreign microor-\\nganisms and particles, like pollen or dust, by producing\\nspecific proteins called antibodies that are capable of\\nbinding to identifying molecules, or antigens, on the\\nforeign organisms. This reaction between antibody and\\nantigen sets off a series of reactions designed to protect\\nthe body from infection. Sometimes, this same series of\\nreactions is triggered by harmless, everyday substances.\\nThis is the condition known as allergy, and the offend-\\ning substance is called an allergen. Common inhaled\\nallergens include pollen, dust, and insect parts from tiny\\nhouse mites. Common food allergens include nuts, fish,\\nand milk.\\nAllergic reactions involve a special set of cells in\\nthe immune system known as mast cells. Mast cells\\nserve as guards in the tissues where the body meets the\\noutside world: the skin, the mucous membranes of the\\neyes and other areas, and the linings of the respiratory\\nand digestive systems. Mast cells display a special type\\nof antibody, called immunoglobulin type E (IgE), on\\ntheir surface. Inside, mast cells store reactive chemicals\\nin small packets, called granules. When the antibodies\\nencounter allergens, they trigger the release of granules,\\nwhich spill out their chemicals onto neighboring cells,\\nincluding blood vessels and nerve cells. One of these\\nchemicals, histamine, binds to the surfaces of these\\nother cells, through special proteins called histamine\\nreceptors. Interaction of histamine with receptors on\\nblood vessels causes neighboring cells to become leaky,\\nleading to the fluid collection, swelling, and increased\\nredness characteristic of a runny nose and red, irritated\\neyes. Histamine also stimulates pain receptors, causing\\nthe itchy, scratchy nose, eyes, and throat common in\\nallergic rhinitis.\\nThe particular allergens to which a person is sensi-\\ntive can be determined through allergy testing. Allergy\\ntests may be performed on the skin or using blood serum\\nin a test tube. During skin tests, potential allergens are\\nplaced on the skin and the reaction is observed. In radio-\\nallergosorbent allergy testing (RAST), a patient’s blood\\nserum is combined with allergen in a test tube to deter-\\nmine if serum antibodies react with the allergen. Provo-\\ncation testing involves direct exposure to a likely aller-\\nGALE ENCYCLOPEDIA OF MEDICINE 2122\\nAllergy tests\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 122'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 136, 'page_label': '137'}, page_content='gen, either through inhalation or ingestion. Positive reac-\\ntions from any of these tests may be used to narrow the\\ncandidates for the actual allergen causing the allergy.\\nIdentification of the allergenic substance may allow\\nthe patient to avoid the substance and reduce allergic\\nreactions. In addition, allergy testing may be done in\\nthose with asthma that is difficult to manage, eczema, or\\nskin rashes to determine if an allergy is causing the con-\\ndition or making it worse. Allergy tests may also be done\\nbefore allergen desensitization to ensure the safety of\\nmore extensive exposure.\\nSkin testing is the most common type of allergy test.\\nThere are two forms: percutaneous and intradermal. In\\npercutaneous or prick testing, allergen solutions are\\nplaced on the skin, and the skin is then pricked with a\\nneedle, allowing the allergen to enter the skin and\\nbecome exposed to mast cells. Scratch testing, in which\\nthe skin is scratched instead of punctured, is used less\\noften. Intradermal testing involves directly injecting\\nallergen solutions into the skin. In both tests, a reddened,\\nswollen spot develops at the injection site for each sub-\\nstance to which the person is sensitive. Skin reactivity is\\nseen for allergens regardless of whether they usually\\naffect the skin. In other words, airborne and food aller-\\ngens cause skin reactions equally well.\\nThe range of allergens used for testing is chosen to\\nreflect possible sources in the environment and may\\ninclude the following:\\n• pollen from a variety of trees, common grasses, and\\nweeds\\n• mold and fungus spores\\n• house dust\\n• house mites\\n• animal skin cells (dander) and saliva\\n• food extracts\\n• antibiotics\\n• insect venoms\\nRadio-allergosorbent testing (RAST) is a laboratory\\ntest performed when a person may be too sensitive to risk\\nskin testing or when medications or skin conditions pre-\\nvent it.\\nProvocation testing is done to positively identify\\nsuspected allergens after preliminary skin testing. A puri-\\nfied preparation of the allergen is inhaled or ingested in\\nincreasing concentrations to determine if it will provoke\\na response. Food testing is much more tedious than\\ninhalation testing, since full passage through the diges-\\ntive system may take a day or more.\\nPrecautions\\nWhile allergy tests are quite safe for most people,\\nthe possibility of a condition known as anaphylaxis does\\nexist. Anaphylaxis is a potentially dangerous condition\\nthat can result in difficulty breathing and a sharp drop in\\nblood pressure. People with a known history of anaphy-\\nlaxis should inform the testing clinician. Skin tests\\nshould never include a substance known to cause ana-\\nphylaxis in the person being tested.\\nProvocation tests may cause an allergic reaction.\\nTherefore, treatment medications should be available fol-\\nlowing the tests, to be administered, if needed.\\nDescription\\nIn prick testing, a drop of each allergen to be tested\\nis placed on the skin, usually on the forearm or the back.\\nA typical battery of tests may involve two dozen allergen\\ndrops, including a drop of saline solution that should not\\nprovoke a reaction (negative control) and a drop of hista-\\nmine that should provoke a reaction (positive control). A\\nsmall needle is inserted through the drop, and used to\\nprick the skin below. A new needle is used for each prick.\\nThe sites are examined over the next twenty minutes for\\nevidence of swelling and redness, indicating a positive\\nreaction. In some instances, a tracing of the set of reac-\\ntions may be made by placing paper over the tested area.\\nSimilarly, in intradermal testing, separate injections are\\nmade for each allergen tested. Observations are made\\nover the next twenty minutes.\\nIn RAST testing, a blood sample is taken for use in\\nthe laboratory, where the antibody- containing serum is\\nseparated from the blood cells. The serum is then\\nexposed to allergens bound to a solid medium. If a per-\\nson has antibodies to a particular allergen, those antibod-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 123\\nAllergy tests\\nThis patient is being exposed to certain allergens as part of\\nan allergy test. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 123'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 137, 'page_label': '138'}, page_content='KEY TERMS\\nAllergen —A substance that provokes an allergic\\nresponse.\\nAnaphylaxis—Increased sensitivity caused by pre-\\nvious exposure to an allergen that can result in\\nblood vessel dilation (swelling) and smooth mus-\\ncle contraction. Anaphylaxis can result in sharp\\nblood pressure drops and difficulty breathing.\\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.\\nHistamine —A chemical released by mast cells\\nthat activates pain receptors and causes cells to\\nbecome leaky.\\nMast cells —A type of immune system cell that is\\nfound in the lining of the nasal passages and eye-\\nlids, displays a type of antibody called immuno-\\nglobulin type E (IgE) on its cell surface, and partici-\\npates in the allergic response by releasing hista-\\nmine from intracellular granules.\\nies will bind to the solid medium and remain behind after\\na rinse. Location of allergen-antibody combinations is\\ndone by adding antibody-reactive antibodies, so called\\nanti-antibodies, that are chemically linked with a\\nradioactive dye. By locating radioactive spots on the\\nsolid medium, the reactive allergens are discovered.\\nProvocation testing may be performed to identify air-\\nborne or food allergens. Inhalation testing is performed\\nonly after a patient’s lung capacity and response to the\\nmedium used to dilute the allergen has been determined.\\nOnce this has been determined, the patient inhales increas-\\ningly concentrated samples of a particular allergen, fol-\\nlowed each time by measurement of the exhalation capaci-\\nty. Only one allergen is tested per day. Testing for food\\nallergies is usually done by removing the suspect food\\nfrom the diet for two weeks, followed by eating a single\\nportion of the suspect food and follow-up monitoring.\\nPreparation\\nSkin testing is preceded by a brief examination of\\nthe skin. The patient should refrain from using anti-aller-\\ngy drugs for at least 48 hours before testing. Prior to\\ninhalation testing, patients with asthma who can tolerate\\nit may be asked to stop any asthma medications. Testing\\nfor food allergies requires the person to avoid all suspect\\nfood for at least two weeks before testing.\\nAftercare\\nSkin testing does not usually require any aftercare. A\\ngeneralized redness and swelling may occur in the test\\narea, but it will usually resolve within a day or two.\\nInhalation tests may cause delayed asthma attacks,\\neven if the antigen administered in the test initially pro-\\nduced no response. Severe initial reactions may justify\\nclose professional observation for at least 12 hours after\\ntesting.\\nRisks\\nIntradermal testing may inadvertently result in the\\ninjection of the allergen into the circulation, with an\\nincreased risk of adverse reactions. Inhalation tests may\\nprovoke an asthma attack. Exposure to new or unsuspect-\\ned allergens in any test carries the risk of anaphylaxis.\\nBecause patients are monitored following allergy testing,\\nan anaphylactic reaction is usually recognized and treat-\\ned promptly. Occasionally, a delayed anaphylactic\\nresponse can occur that will require immediate care.\\nProper patient education regarding how to recognize ana-\\nphylaxis is vital.\\nNormal results\\nLack of redness or swelling on a skin test indicates\\nno allergic response. In an inhalation test, the exhalation\\ncapacity should remain unchanged. In a food challenge,\\nno symptoms should occur.\\nAbnormal results\\nPresence of redness or swelling, especially over 5\\nmm (1/4 inch) in diameter, indicates an allergic response.\\nGALE ENCYCLOPEDIA OF MEDICINE 2124\\nAllergy tests\\nA close-up of a patient’s arm after allergy testing.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 124'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 138, 'page_label': '139'}, page_content='This does not mean the substance actually causes the\\npatient’s symptoms, however, since he or she may have\\nno regular exposure to the allergen. In fact, the actual\\nallergen may not have been included in the test array.\\nFollowing allergen inhalation, reduction in exhala-\\ntion capacity of more than 20%, and for at least 10-20\\nminutes, indicates a positive reaction to the allergen.\\nGastrointestinal symptoms within 24 hours follow-\\ning the ingestion of a suspected food allergen indicates a\\npositive response.\\nResources\\nBOOKS\\nDavies, R., and S. Ollier. Allergy: The Facts.Oxford, England:\\nOxford University Press, 1989.\\nLawlor Jr., G. J., T. J. Fischer, and D. C. Adelman. Manual of\\nAllergy and Immunology.Boston: Little, Brown and Co.,\\n1995.\\nRichard Robinson\\nAllogenic transplant see Bone marrow\\ntransplantation\\nAllopurino see Gout drugs\\nAlopecia\\nDefinition\\nAlopecia simply means hair loss (baldness).\\nDescription\\nHair loss occurs for a great many reasons—from\\npulling it out to having it killed off by cancer chemo-\\ntherapy. Some causes are considered natural, while oth-\\ners signal serious health problems. Some conditions are\\nconfined to the scalp. Others reflect disease throughout\\nthe body. Being plainly visible, the skin and its compo-\\nnents can provide early signs of disease elsewhere in the\\nbody.\\nOftentimes, conditions affecting the skin of the scalp\\nwill result in hair loss. The first clue to the specific cause\\nis the pattern of hair loss, whether it be complete bald-\\nness (alopecia totalis), patchy bald spots, thinning, or\\nhair loss confined to certain areas. Also a factor is the\\ncondition of the hair and the scalp beneath it. Sometimes\\nonly the hair is affected; sometimes the skin is visibly\\ndiseased as well.\\nCauses and symptoms\\n• Male pattern baldness (androgenic alopecia) is consid-\\nered normal in adult males. It is easily recognized by\\nthe distribution of hair loss over the top and front of the\\nhead and by the healthy condition of the scalp.\\n• Alopecia areata is a hair loss condition of unknown\\ncause that can be patchy or extend to complete baldness.\\n• Fungal infections of the scalp usually cause patchy hair\\nloss. The fungus, similar to the ones that cause athlete’s\\nfoot and ringworm, often glows under ultraviolet light.\\n• Trichotillomania is the name of a mental disorder that\\ncauses a person to pull out his/her own hair.\\n• Complete hair loss is a common result of cancer\\nchemotherapy, due to the toxicity of the drugs used.\\nPlacing a tourniquet around the skull just above the ears\\nduring the intravenous infusion of the drugs may\\nreduce or eliminate hair loss by preventing the drugs\\nfrom reaching the scalp.\\n• Systemic diseases often affect hair growth either selec-\\ntively or by altering the skin of the scalp. One example\\nis thyroid disorders. Hyperthyroidism (too much thy-\\nroid hormone) causes hair to become thin and fine.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 125\\nAlopecia\\nTop of balding male’s head.(Photograph by Kelly A. Quin.\\nReproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 125'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 139, 'page_label': '140'}, page_content='Hypothyroidism (too little thyroid hormone) thickens\\nboth hair and skin.\\n• Several autoimmune diseases (when protective cells\\nbegin to attack self cells within the body) affect the\\nskin, notably lupus erythematosus.\\nDiagnosis\\nDermatologists are skilled in diagnosis by sight\\nalone. For more obscure diseases, they may have to\\nresort to a skin biopsy, removing a tiny bit of skin using\\na local anesthetic so that it can examined under a micro-\\nscope. Systemic diseases will require a complete evalua-\\ntion by a physician, including specific tests to identify\\nand characterize the problem.\\nTreatment\\nSuccessful treatment of underlying causes is most\\nlikely to restore hair growth, be it the completion of\\nchemotherapy, effective cure of a scalp fungus, or control\\nof a systemic disease. Two relatively new drugs—minox-\\nidil (Rogaine) and finasteride (Proscar)—promote hair\\ngrowth in a significant minority of patients, especially\\nthose with male pattern baldness and alopecia areata.\\nWhile both drugs have so far proved to be quite safe\\nwhen used for this purpose, minoxidil is a liquid that is\\napplied to the scalp and finasteride is the first and only\\napproved treatment in a pill form.\\nMinoxidil was approved for over-the-counter sales\\nin 1996. When used continuously for long periods of\\nKEY TERMS\\nAthlete’s foot —A fungal infection between the\\ntoes, officially known as tinea pedis.\\nAutoimmune disease—Certain diseases caused by\\nthe body’s development of an immune reaction to\\nits own tissues.\\nChemotherapy—The treatment of diseases, usual-\\nly cancer, with drugs (chemicals).\\nHair follicles—Tiny organs in the skin, each one of\\nwhich grows a single hair.\\nLupus erythematosus —An autoimmune disease\\nthat can damage skin, joints, kidneys, and other\\norgans.\\nRingworm—A fungal infection of the skin, usually\\nknown as tinea corporis.\\nSystemic—Affecting all or most parts of the body.\\ntime, minoxidil produces satisfactory results in about one\\nquarter of patients with androgenic alopecia and as many\\nas half the patients with alopecia areata. There is also an\\nover-the-counter extra-strength version of minoxidil (5%\\nconcentration) approved for use by men only. The treat-\\nment often results in new hair that is thinner and lighter\\nin color. It is important to note that new hair stops grow-\\ning soon after the use of minoxidil is discontinued.\\nOver the past few decades there have appeared a\\nmultitude of hair replacement methods performed by\\nboth physicians and non-physicians. They range from\\nsimply weaving someone else’s hair in with the remains\\nof your own to surgically transplanting thousands of hair\\nfollicles one at a time.\\nHair transplantation is completed by taking tiny\\nplugs of skin, each containing one to several hairs,\\nfrom the back side of the scalp. The bald sections are\\nthen implanted with the plugs. Research completed in\\n2000 looked at the new technique of hair grafting, and\\nfound that micrografts (one to two hairs transplanted\\nper follicle) resulted in fewer complications and the\\nbest results\\nAnother surgical procedure used to treat androgenic\\nalopecia is scalp reduction. By stretching skin the hair-\\nless scalp can be removed and the area of bald skin\\ndecreased by closing the space with hair-covered scalp.\\nHair-bearing skin can also be folded over an area of bald\\nskin with a technique called a flap.\\nPrognosis\\nThe prognosis varies with the cause. It is generally\\nmuch easier to lose hair than to regrow it. Even when it\\nreturns, it is often thin and less attractive than the original.\\nResources\\nBOOKS\\nAmerican Society of Health-System Pharmacists Inc. Ameri-\\ncan Hospital Formulary Service Drug Information.\\nBethesda, MD: American Society of Health-System Phar-\\nmacists Inc., 1998.\\nBennett, J. Claude, and Fred Plum, ed. Cecil Textbook of Medi-\\ncine. Philadelphia: W. B. Saunders, 1996.\\nThe Burton Goldberg Group. “Hair loss.” In Alternate Medi-\\ncine: The Definitive Guide. Puyallup, W A: Future Medi-\\ncine Publishing, 1993.\\nIsselbacher, Kurt, et al., ed. Harrison’s Principles of Internal\\nMedicine. New York: McGraw-Hill, 1994.\\nPERIODICALS\\nAmichai B., M. H. Grunwald, and R. Sobel. “5 Alpha-reduc-\\ntase Inhibitors—A New Hope in Dermatology?” Interna-\\ntional Journal of Dermatology, March 1997, 182-4.\\nGALE ENCYCLOPEDIA OF MEDICINE 2126\\nAlopecia\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 126'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 140, 'page_label': '141'}, page_content='Nielsen, Timothy A., and Martin Reichel. “Alopecia: Diagnosis\\nand Management.” American Family Physician.\\nOTHER\\nAndrogenetic Alopecia.com. “How can minoxidil be used to\\ntreat baldness?”. (1 May 2001).\\nHairloss Information Center. “Rogaine: Does It Really Work?”\\n1997. (19 April\\n1998).\\nHouston Academy of Medicine. “Propecia: Male Baldness\\nPill.” December 30, 1997. (19 April 1998).\\nMayo Clinic. “Alopecia” January 26, 2001. (1 May 2001).\\nWebMD Medical News. “Hair Today, Gone Tomorrow, Hair\\nAgain” 2000. (1 May 2001).\\nBeth Kapes\\nAlpha-fetoprotein test\\nDefinition\\nThe alpha-fetoprotein (AFP) test is a blood test that\\nis performed during pregnancy. This screening test mea-\\nsures the level of AFP in the mother’s blood and indi-\\ncates the probability that the fetus has one of several seri-\\nous birth defects . The level of AFP can also be deter-\\nmined by analyzing a sample of amniotic fluid. This\\nscreening test cannot diagnose a specific condition; it\\nonly indicates the increase of risk for several birth\\ndefects. Outside pregnancy, the AFP test is used to detect\\nliver disease, certain cancerous tumors, and to monitor\\nthe progress of cancer treatment.\\nPurpose\\nAlpha-fetoprotein is a substance produced by the\\nliver of a fetus. The exact function of this protein is\\nunknown. After birth, the infant’s liver stops producing\\nAFP, and an adult liver contains only trace amounts.\\nDuring pregnancy, the fetus excretes AFP in urine and\\nsome of the protein crosses the fetal membranes to enter\\nthe mother’s blood. The level of AFP can then be deter-\\nmined by analyzing a sample of the mother’s blood. By\\nanalyzing the amount of AFP found in a blood or amni-\\notic fluid sample, doctors can determine the probability\\nthat the fetus is at risk for certain birth defects. It is very\\nimportant that the doctor know precisely how old the\\nfetus is when the test is performed since the AFP level\\nchanges over the length of the pregnancy. Alone, AFP\\nscreening cannot diagnose a birth defect. The test is\\nused as an indicator of risk and then an appropriate line\\nof testing (like amniocentesis or ultrasound) follows,\\nbased on the results.\\nAbnormally high AFP may indicate that the fetus\\nhas an increased risk of a neural tube defect, the most\\ncommon and severe type of disorder associated with\\nincreased AFP. These types of defects include spinal\\ncolumn defects ( spina bifida ) and anencephaly (a\\nsevere and usually fatal brain abnormality). If the tube\\nthat becomes the brain and spinal cord does not close\\ncorrectly during fetal development, AFP may leak\\nthrough this abnormal opening and enter the amniotic\\nfluid. This leakage creates abnormally high levels of\\nAFP in amniotic fluid and in maternal blood. If the\\nscreening test indicates abnormally high AFP, ultra-\\nsound is used to diagnosis the problem.\\nOther fetal conditions that can raise AFP levels\\nabove normal include:\\n• cysts at the end of the spine\\n• blockage in the esophagus or intestines\\n• liver disease causing liver cells to die\\n• defects in the abdominal wall\\n• kidney or urinary tract defects or disease\\n• brittle bone disease\\nLevels may also be high if there is too little fluid in\\nthe amniotic sac around the fetus, more than one devel-\\noping fetus, or a pregnancy that is farther along than\\nestimated.\\nFor unknown reasons, abnormally low AFP may\\nindicate that the fetus has an increased risk of Down\\nsyndrome . Down syndrome is a condition that\\nincludes mental retardation and a distinctive physical\\nappearance linked to an abnormality of chromosome\\n21 (called trisomy 21). If the screening test indicates\\nan abnormally low AFP, amniocentesis is used to diag-\\nnosis the problem. Abnormally low levels of AFP can\\nalso occur when the fetus has died or when the mother\\nis overweight.\\nAFP is often part of a “triple check” blood test that\\nanalyzes three substances as risk indicators of possible\\nbirth defects: AFP, estriol, and human chorionic\\ngonadotropin (HCG). When all three substances are mea-\\nsured in the mother’s blood, the accuracy of the test\\nresults increases.\\nAlthough AFP in human blood gradually disappears\\nafter birth, it never disappears entirely. It may reappear in\\nliver disease, or tumors of the liver, ovaries, or testicles.\\nThe AFP test is used to screen people at high risk for\\nthese conditions. After a cancerous tumor is removed, an\\nGALE ENCYCLOPEDIA OF MEDICINE 2 127\\nAlpha-fetoprotein test\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 127'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 141, 'page_label': '142'}, page_content='AFP test can monitor the progress of treatment. Contin-\\nued high AFP levels suggest the cancer is growing.\\nPrecautions\\nIt is very important that the doctor know precisely\\nhow old the fetus is when the test is performed since the\\nAFP level considered normal changes over the length of\\nthe pregnancy. Errors in determining the age of the fetus\\nlead to errors when interpreting the test results. Since an\\nAFP test is only a screening tool, more specific tests\\nmust follow to make an accurate diagnosis. An abnormal\\ntest result does not necessarily mean that the fetus has a\\nbirth defect. The test has a high rate of abnormal results\\n(either high or low) in order to prevent missing a fetus\\nthat has a serious condition.\\nDescription\\nThe AFP test is usually performed at week 16 of\\npregnancy. Blood is drawn from a vein, usually on the\\ninside of the elbow. AFP can also be measured in the sam-\\nple of amniotic fluid taken at the time of amniocentesis.\\nTest results are usually available after about one week.\\nPreparation\\nThere is no specific physical preparation for the AFP\\ntest.\\nAftercare\\nThere is no specific aftercare involved with this\\nscreening test.\\nRisks\\nThe risks associated with drawing blood are mini-\\nmal, but may include bleeding from the puncture site,\\nfeeling faint or lightheaded after the blood is drawn, or\\nblood accumulating under the puncture site (hematoma).\\nNormal results\\nAlpha-fetoprotein is measured in nanograms per\\nmilliliter (ng/mL) and is expressed as a probability. The\\nKEY TERMS\\nAmniotic fluid —Fluid within the uterine sac in\\nwhich the fetus lives until born.\\nFetus—The stage in human development from the\\nsecond month of pregnancy until birth.\\nprobability (1:100, for example) translates into the\\nchance that the fetus has a defect (a one in 100 chance,\\nfor example).\\nWhen testing for cancer or liver diseases, AFP\\nresults are reported as nanograms per milliliter. An AFP\\nlevel less than or equal to 50 ng/mL is considered nor-\\nmal.\\nAbnormal results\\nThe doctor will inform the woman of her specific\\nincreased risk as compared to the “normal” risk of a stan-\\ndard case. If the risk of Down syndrome is greater than\\nthe standard risk for women who are 35 years old or\\nolder (one in 270), then amniocentesis is recommended.\\nAgain, the test has a high rate of showing an abnormal\\nAFP level in order to prevent missing a fetus that has\\nDown’s syndrome. This screening test only predicts risk;\\nappropriate diagnostic testing will follow after an abnor-\\nmal screening result.\\nIn tumor or liver disease testing, an AFP level\\ngreater than 50 ng/mL is considered abnormal.\\nResources\\nBOOKS\\nCunningham, Gary, et al. Williams Obstetrics. 20th ed. Stam-\\nford: Appleton & Lange, 1997.\\nEisenberg, Arlene, et al. What To Expect When You’re Expect-\\ning. 2nd ed. New York: Workman Publishing, 1996.\\nJohnson, Robert, ed. Mayo Clinic Complete Book of Pregnancy\\nand Baby’s First Year.New York: William Morrow and\\nCo., 1997.\\nPERIODICALS\\nHaddow, James, et al. “Reducing the Need for Amniocentesis\\nin Women 35 Years of Age or Older with Serum Markers\\nfor Screening.” The New England Journal Of Medicine\\n330, no. 16 (21 Apr. 1994): 1114-8.\\nKase, Lori. “Do Pregnant Women Need All Those Tests?”\\nAmerican Baby (Aug. 1994): 42-3.\\nLieberman, Adrienne. “AFP Screening: A Test for Birth\\nDefects.” American Baby (Nov. 1993): 6.\\nMcCabe, Edward, et al. “Maternal Serum Alpha-fetoprotein\\nScreening.” Pediatrics 88, no. 6 (Dec. 1991): 1282-3.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275 Mamaroneck\\nAve., White Plains, NY 10605. (914) 428-7100. .\\nNational Cancer Institute. Building 31, Room 10A31, 31 Cen-\\nter Drive, MSC 2580, Bethesda, MD 20892-2580. (800)\\n422-6237. .\\nAdrienne Massel, RN\\nAlpha-thalassemia see Thalassemia\\nGALE ENCYCLOPEDIA OF MEDICINE 2128\\nAlpha-fetoprotein test\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 128'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 142, 'page_label': '143'}, page_content='Alpha1-adrenergic blockers\\nDefinition\\nAlpha1-adrenergic blockers are drugs that work by\\nblocking the alpha1-receptors of vascular smooth muscle,\\nthus preventing the uptake of catecholamines by the\\nsmooth muscle cells. This causes vasodilation and allows\\nblood to flow more easily.\\nPurpose\\nThese drugs, called alpha blockers for short, are\\nused for two main purposes: to treat high blood pressure\\n(hypertension) and to treat benign prostatic hyperplasia\\n(BPH), a condition that affects men and is characterized\\nby an enlarged prostate gland.\\nHigh blood pressure\\nHigh blood pressure puts a strain on the heart and\\nthe arteries. Over time, hypertension can damage the\\nblood vessels to the point of causing stroke, heart fail-\\nure or kidney failure. People with high blood pressure\\nmay also be at higher risk for heart attacks. Controlling\\nhigh blood pressure makes these problems less likely.\\nAlpha blockers help lower blood pressure by causing\\nvasodilation, meaning an increase in the diameter of the\\nblood vessels, which allows blood to flow more easily.\\nBenign prostatic hyperplasia (BPH)\\nThis condition particularly affects older men. Over\\ntime, the prostate, a donut-shaped gland below the blad-\\nder, enlarges. When this happens, it may interfere with\\nthe passage of urine from the bladder out of the body.\\nMen who are diagnosed with BPH may have to urinate\\nmore often. Or they may feel that they can not complete-\\nly empty their bladders. Alpha blockers inhibit the con-\\ntraction of prostatic smooth muscle and thus relax mus-\\ncles in the prostate and the bladder, allowing urine to\\nflow more freely.\\nDescription\\nCommonly prescribed alpha blockers for hyperten-\\nsion and BPH include doxazosin (Cardura, prazosin\\n(Minipress) and terazosin (Hytrin). Prazosin is also used\\nin the treatment of heart failure. All are available only\\nwith a physician’s prescription and are sold in tablet form.\\nRecommended dosage\\nThe recommended dose depends on the patient and\\nthe type of alpha blocker and may change over the course\\nof treatment. The prescribing physician will gradually\\nincrease the dosage, if necessary. Some patients may need\\nas much as 15-20 mg per day of terazosin, 16 mg per day\\nof doxazosin, or as much as 40 mg per day of prazosin,\\nbut most people benefit from lower doses. As the dosage\\nincreases, so does the possibility of unwanted side effects.\\nAlpha blockers should be taken exactly as directed,\\neven if the medication does not seem to be working at\\nfirst. It should not be stopped even if symptoms improve\\nbecause it needs to be taken regularly to be effective.\\nPatients should avoid missing any doses, and should not\\ntake larger or more frequent doses to make up for\\nmissed doses.\\nPrecautions\\nAlpha blockers may lower blood pressure to a\\ngreater extent than desired. This can cause dizziness ,\\nlightheadedness, heart palpitations, and fainting. Activ-\\nities such as driving, using machines, or doing anything\\nelse that might be dangerous for 24 hours after taking the\\nfirst dose should be avoided. Patients should be reminded\\nto be especially careful not to fall when getting up in the\\nmiddle of the night. The same precautions are recom-\\nmended if the dosage is increased or if the drug has been\\nstopped and then started again. Anyone whose safety on\\nthe job could be affected by taking alpha blockers should\\ninform his or her physician, so that the physician can\\ntake this factor into account when increasing dosage.\\nDizziness, lightheadedness, and fainting are more like-\\nly to occur when people taking alpha blockers also drink\\nalcohol, exercise, stand for a long time, or are exposed to\\nhot weather. Extra care should be used under these condi-\\ntions and alcohol consumption should be limited.\\nSome people may feel drowsy or less alert when\\nusing these drugs. They should accordingly avoid driving\\nor performing activities that require full attention.\\nPeople diagnosed with kidney disease or liver disease\\nmay also be more sensitive to alpha blockers. They should\\ninform their physicians about these conditions if alpha\\nblockers are prescribed. Older people may also be more\\nsensitive and may be more likely to have unwanted side\\neffects, such as fainting, dizziness, and lightheadedness.\\nIt should be noted that alpha blockers do not cure\\nhigh blood pressure. They simply help to keep the condi-\\ntion under control. Similarly, these drugs will not shrink\\nan enlarged prostate gland. Although they will help\\nrelieve the symptoms of prostate enlargement, the\\nprostate may continue to grow, and it eventually may be\\nnecessary to have prostate surgery.\\nAlpha blockers may lower blood counts. Patients\\nmay need to have their blood checked regularly while\\ntaking this medicine.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 129\\nAlpha1-adrenergic blockers\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 129'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 143, 'page_label': '144'}, page_content='Anyone who has had unusual reactions to alpha\\nblockers 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.\\nThe effects of taking alpha blockers during preg-\\nnancy are not fully understood. Women who are preg-\\nnant or planning to become pregnant should inform their\\nphysicians. Breastfeeding mothers who need to take\\nalpha blockers should also talk to their physicians. These\\ndrugs can pass into breast milk and may affect nursing\\nbabies. It may be necessary to stop breastfeeding while\\nbeing treated with alpha blockers.\\nSide effects\\nThe most common side effects are dizziness, drowsi-\\nness, tiredness, headache , nervousness, irritability,\\nstuffy or runny nose, nausea, pain in the arms and legs,\\nand weakness. These problems usually go away as the\\nKEY TERMS\\nAdrenergic—Refers to neurons (nerve cells) that use\\ncatecholamines as neurotransmitters at a synapse.\\nAdrenergic receptor —There are three families of\\nadrenergic receptors, alpha 1, alpha2 and beta, and\\neach family contains three distinct subtypes. Each\\nof the nine subtypes are coded by separate genes,\\nand display specific drug specificities and regulato-\\nry properties.\\nAlpha blockers —Medications that bind alpha\\nadrenergic receptors and decrease the workload of\\nthe heart and lower blood pressure. They are com-\\nmonly used to treat hypertension, peripheral vascu-\\nlar disease, and hyperplasia.\\nArteries —Blood vessels that carry oxygenated\\nblood away from the heart to the cells, tissues, and\\norgans of the body.\\nCatecholamines—Family of neurotransmitters con-\\ntaining dopamine, norepinephrine and epineph-\\nrine, produced and secreted by cells of the adrenal\\nmedulla in the brain. Catecholamines have excita-\\ntory effects on smooth muscle cells of the vessels\\nthat supply blood to the skin and mucous mem-\\nbranes and have inhibitory effects on smooth mus-\\ncle cells located in the wall of the gut, the bronchial\\ntree of the lungs, and the vessels that supply blood\\nto skeletal muscle. There are two different main\\ntypes of receptors for these neurotransmitters,\\ncalled alpha and beta adrenergic receptors. The cat-\\necholamines are therefore are also known as adren-\\nergic neurotransmitters.\\nHyperplasia —The abnormal increase in the num-\\nber of normal cells in a given tissue.\\nHypertension—Persistently high arterial blood pres-\\nsure.\\nNeurotransmitter —Substance released from neu-\\nrons of the peripheral nervous system that travels\\nacross the synaptic clefts (gaps) of other neurons to\\nexcite or inhibit the target cell.\\nPalpitation—Rapid, forceful, throbbing, or fluttering\\nheartbeat.\\nReceptor—A molecular structure in a cell or on the\\nsurface of a cell that allows binding of a specific\\nsubstance that causes a specific physiologic\\nresponse.\\nSynapse —A connection between nerve cells, by\\nwhich nervous excitation is transferred from one\\ncell to the other.\\nVasodilation—The increase in the internal diameter\\nof a blood vessel that results from relaxation of\\nsmooth muscle within the wall of the vessel thus\\ncausing an increase in blood flow.\\nbody adjusts to the drug and do not require medical treat-\\nment. If they do not subside or if they interfere with nor-\\nmal activities, the physician should be informed.\\nIf any of the following side effects occur, the pre-\\nscribing physician should be notified as soon as possible:\\n• fainting\\n• shortness of breath or difficulty breathing\\n• fast, pounding, or irregular heartbeat\\n• swollen feet, ankles, wrists\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking alpha blockers should\\ncontact his or her physician.\\nInteractions\\nDoxazosin (Cardura) is not known to interact with\\nany other drugs. Terazosin (Hytrin) may interact with\\nnonsteroidal anti-inflammatory drugs, such as ibupro-\\nGALE ENCYCLOPEDIA OF MEDICINE 2130\\nAlpha1-adrenergic blockers\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 130'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 144, 'page_label': '145'}, page_content='fen (Motrin), and with other blood pressure drugs, such\\nas enalapril (Vasotec), and verapamil (Calan,Verelan).\\nPrazosin (Minipress) may interact with beta adrenergic\\nblocking agents such as propranolol (Inderal) and others,\\nand with verapamil (Calan, Isoptin.) When drugs inter-\\nact, the effects of one or both of the drugs may change or\\nthe risk of side effects may be greater.\\nNancy Ross-Flanigan\\nAlport syndrome\\nDefinition\\nA hereditary disease of the kidneys that primarily\\naffects men, causing blood in the urine, hearing loss and\\neye problems. Eventually, kidney dialysis or transplant\\nmay be necessary.\\nDescription\\nAlport syndrome affects about one in 5,000 Ameri-\\ncans, striking men more often and severely than women.\\nThere are several varieties of the syndrome, some occur-\\nring in childhood and others not causing symptoms until\\nmen reach their 20s or 30s. All varieties of the syndrome\\nare characterized by kidney disease that usually pro-\\ngresses to chronic kidney failure and by uremia (the\\npresence of excessive amounts of urea and other waste\\nproducts in the blood).\\nCauses and symptoms\\nAlport syndrome in most cases is caused by a defect\\nin one or more genes located on the X chromosome. It is\\nusually inherited from the mother, who is a normal carri-\\ner. However, in up to 20% of cases there is no family his-\\ntory of the disorder. In these cases, there appears to be a\\nspontaneous genetic mutation causing Alport syndrome.\\nBlood in the urine (hematuria) is a hallmark of\\nAlport syndrome. Other symptoms that may appear in\\nvarying combinations include:\\n• protein in the urine (proteinuria)\\n• sensorineural hearing loss\\n• eye problems [involuntary, rhythmic eye movements\\n(nystagmus), cataracts, or cornea problems]\\n• skin problems\\n• platelet disorders\\n• abnormal white blood cells\\n• smooth muscle tumors\\nKEY TERMS\\nAlbumin—A protein that is important in maintain-\\ning blood volume. Low albumin levels is one sign\\nof Alport syndrome.\\nDialysis—A technique of removing waste material\\nfrom the blood. It is used with patients whose kid-\\nneys have stopped functioning and can no longer\\ncleanse the blood on their own.\\nDiuretic —A drug that increases the amount of\\nurine a person produces.\\nHematuria —Blood in the urine, Hematuria is a\\nhallmark of Alport syndrome.\\nPulmonary edema —Excess fluid in the air spaces\\nof the lungs.\\nUremia—The presence of excessive amounts of\\nurea and other waste products in the blood.\\nNot all patients with Alport syndrome have hearing\\nproblems. In general, those with normal hearing have\\nless severe cases of Alport syndrome.\\nDiagnosis\\nAlport syndrome is diagnosed with a medical evalu-\\nation and family history, together with a kidney biopsy\\nthat can detect changes in the kidney typical of the condi-\\ntion. Urinalysis may reveal blood or protein in the urine.\\nBlood tests can reveal a low platelet level.\\nIn addition, tests for the Alport gene are now avail-\\nable. Although testing is fairly expensive, it is covered by\\nmany types of health insurance. DNA tests can diagnose\\naffected children even before birth, and genetic linkage\\ntests tracing all family members at risk for Alport syn-\\ndrome are also available.\\nTreatment\\nThere is no specific treatment that can “cure” Alport\\nsyndrome. Instead, care is aimed at easing the problems\\nrelated to kidney failure, such as the presence of too\\nmany waste products in the blood (uremia).\\nTo control kidney inflammation (nephritis), patients\\nshould:\\n• restrict fluids\\n• control high blood pressure\\n• manage pulmonary edema\\nGALE ENCYCLOPEDIA OF MEDICINE 2 131\\nAlport syndrome\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 131'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 145, 'page_label': '146'}, page_content='• control high blood levels of potassium\\nRarely patients with Alport syndrome may develop\\nnephrotic syndrome , a group of symptoms including\\ntoo much protein in the urine, low albumin levels, and\\nswelling. To ease these symptoms, patients should:\\n• drink less\\n• eat a salt-free diet\\n• use diuretics\\n• have albumin transfusions\\nThe treatment for chronic kidney failure is dialysis\\nor a kidney transplant.\\nPrognosis\\nWomen with this condition can lead a normal life,\\nalthough they may have slight hearing loss. An affected\\nwoman may notice blood in her urine only when under\\nstress or pregnant.\\nMen generally have a much more serious problem\\nwith the disease. Most will experience kidney disease in\\ntheir 20s or 30s, which may eventually require dialysis or\\ntransplantation, and many develop significant hearing\\nloss. Men with Alport syndrome often die of complica-\\ntions by middle age.\\nPrevention\\nAlport syndrome is a genetic disease and prevention\\nefforts are aimed at providing affected individuals and\\ntheir families with information concerning the genetic\\nmechanisms responsible for the disease. Since it is possi-\\nble to determine if a woman is a carrier, or if an unborn\\nchild has the condition, genetic counseling can provide\\nhelpful information and support for the decisions that\\naffected individuals and their families may have to make.\\nResources\\nBOOKS\\nSchrier, R. W., and C. W. Gottschalk, eds. Diseases of the Kid-\\nney. 6th ed. Boston: Little, Brown, 1996.\\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 Kidney and Urologic Disease Information Clearing-\\nhouse. 3 Information Way, Bethesda, MD 20892. (301)\\n654-4415. .\\nNational Kidney Foundation. 30 East 33rd St., New York, NY\\n10016. (800) 622-9010..\\nNational Organization for Rare Diseases. P.O. Box 8923, Fair-\\nfield, CT 06812. (213) 745-6518. .\\nOTHER\\n“Alport Syndrome.” Pediatric Database Home Page. .\\nAlport Syndrome Home Page. .\\nThe Hereditary Nephritis Foundation (HNF) Home Page.\\n.\\nCarol A. Turkington\\nAlprazolam see Benzodiazepines\\nALS see Amyotrophic lateral sclerosis\\nAlteplase see Thrombolytic therapy\\nAltitude sickness\\nDefinition\\nAltitude sickness is a general term encompassing a\\nspectrum of disorders that occur at higher altitudes.\\nSince the severity of symptoms varies with altitude, it is\\nimportant to understand the range of the different alti-\\ntudes that may be involved. High altitude is defined as\\nheight greater than 8,000 feet (2,438 m); medium altitude\\nis defined as height between 5,000 and 8,000 feet\\n(1,524–2,438 m); and extreme altitude is defined as\\nheight greater than 19,000 feet (5,791 m). The majority\\nof healthy individuals suffer from altitude sickness when\\nthey reach very high altitudes. In addition, about 20% of\\npeople ascending above 9,000 (2,743 m) feet in one day\\nwill develop altitude sickness. Children under six years\\nand women in the premenstrual part of their cycles may\\nbe more vulnerable. Individuals with preexisting medical\\nconditions—even a minor respiratory infection—may\\nbecome sick at more moderate altitudes.\\nDescription\\nThere are three major clinical syndromes that fall\\nunder the heading of altitude sickness: acute mountain\\nsickness (AMS), high-altitude pulmonary edema\\n(HAPE), and high-altitude cerebral edema (HACE).\\nThese syndromes are not separate, individual syndromes\\nas much as they are a continuum of severity, all resulting\\nfrom a decrease in oxygen in the air. AMS is the mildest,\\nand the other two represent severe, life-threatening forms\\nof altitude sickness.\\nGALE ENCYCLOPEDIA OF MEDICINE 2132\\nAltitude sickness\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 132'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 146, 'page_label': '147'}, page_content='Altitude sickness occurs because the partial pressure\\nof oxygen decreases with altitude. (Partial pressure is a\\nterm applied to gases that is similar to the way the term\\nconcentration is applied to liquid solutions.) For instance,\\nat 18,000 feet (5,486 m) the partial pressure of oxygen\\ndrops to one-half its value at sea level and, therefore, there\\nis a substantially lower amount of oxygen available for the\\nindividual to inhale. This is known as hypoxia. Further-\\nmore, since there is less oxygen to inhale, less oxygen\\nreaches the blood. This is known as hypoxemia. These two\\nconditions are the major factors that form the basis for all\\nthe medical problems associated with altitude sickness.\\nAs a person becomes hypoxemic, his natural\\nresponse is to breathe more rapidly (hyperventilate). This\\nis the body’s attempt to bring in more oxygen at a rapid\\nrate. This attempt at alleviating the effects of the hypoxia\\nat higher altitudes is known as acclimatization, and it\\noccurs during the first few days. Acclimatization is a\\nresponse that occurs in individuals who travel from lower\\nto higher altitudes. There are groups of people who have\\nlived at high altitudes (for example, in the Himalayan\\nand Andes mountains) for generations, and they are sim-\\nply accustomed to living at such altitudes, perhaps\\nthrough a genetic ability.\\nCauses and symptoms\\nAcute mountain sickness (AMS) is a mild form of\\naltitude sickness that results from ascent to altitudes higher\\ngreater than 8,000 feet (2,438 m)—even 6,500 feet (1,981\\nm) in some susceptible individuals. Although hypoxia is\\nassociated with the development of AMS, the exact mech-\\nanism by which this condition develops has yet to be con-\\nfirmed. It is important to realize that some individuals\\nacclimatize to higher altitudes more efficiently than others.\\nAs a result, under similar conditions some will suffer from\\nAMS while others will not. At present, the susceptibility\\nof otherwise healthy individuals to contracting AMS can-\\nnot be accurately predicted. Of those who do suffer from\\nAMS, the condition tends to be most severe on the second\\nor third day after reaching the high altitude, and it usually\\nabates after three to five days if they remain at the same\\naltitude. However, it can recur if the individuals travel to\\nan even higher altitude. Symptoms usually appear a few\\nhours to a few days following ascent, and they include\\ndizziness, headache, shortness of breath, nausea, vomit-\\ning, loss of appetite, and insomnia.\\nHigh-altitude pulmonary edema (HAPE) is a life-\\nthreatening condition that afflicts a small percentage of\\nthose who suffer from AMS. In this condition, fluid leaks\\nfrom within the pulmonary blood vessels into the lung\\ntissue. As this fluid begins to accumulate within the lung\\ntissue (pulmonary edema), the individual begins to\\nKEY TERMS\\nCerebral—Pertaining to the brain.\\nEdema—Accumulation of excess fluid in the tis-\\nsues of the body.\\nHypoxemia—Insufficient oxygenation of the blood.\\nHypoxia—A deficiency in the amount of oxygen\\nrequired for effective ventilation.\\nPulmonary—Pertaining to the lungs.\\nbecome more and more short of breath. HAPE is known\\nto afflict all types of individuals, regardless of their level\\nof physical fitness.\\nTypically, the individual who suffers from HAPE\\nascends quickly to a high altitude and almost immediate-\\nly develops shortness of breath, a rapid heart rate, a\\ncough productive of a large amount of sometimes bloody\\nsputum, and a rapid rate of breathing. If no medical assis-\\ntance is provided by this point, the patient goes into a\\ncoma and dies within a few hours.\\nHigh-altitude cerebral edema (HACE), the rarest and\\nmost severe form of altitude sickness, involves cerebral\\nedema, and its mechanism of development is also poorly\\nunderstood. The symptoms often begin with those of\\nAMS, but neurologic symptoms such as an altered level\\nof consciousness, speech abnormalities, severe headache,\\nloss of coordination, hallucinations , and even seizures.\\nIf no intervention is implemented, death is the result.\\nDiagnosis\\nThe diagnosis for altitude sickness may be made\\nfrom the observation of the individual’s symptoms dur-\\ning travel to higher altitudes.\\nTreatment\\nMild AMS requires no treatment other than an\\naspirin or ibuprofen for headache, and avoidance of fur-\\nther ascent. Narcotics should be avoided because they\\nmay blunt the respiratory response, making it even more\\ndifficult for the person to breathe deeply and rapidly\\nenough to compensate for the lower levels of oxygen in\\nthe environment. Oxygen may also be used to alleviate\\nsymptoms of mild AMS.\\nAs for HAPE and HACE, the most important course\\nof action is descent to a lower altitude as soon as possi-\\nble. Even a 1,000-2,000 -foot (305–610 m) descent can\\nGALE ENCYCLOPEDIA OF MEDICINE 2 133\\nAltitude sickness\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 133'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 147, 'page_label': '148'}, page_content='dramatically improve one’s symptoms. If descent is not\\npossible, oxygen therapy should be started. In addition,\\ndexamethasone (a steroid) has been suggested in order to\\nreduce cerebral edema.\\nPrognosis\\nThe prognosis for mild AMS is good, if appropriate\\nmeasures are taken. As for HAPE and HACE, the prog-\\nnosis depends upon the rapidity and distance of descent\\nand the availability of medical intervention. Descent\\noften leads to improvement of symptoms, however,\\nrecovery times vary among individuals.\\nPrevention\\nWhen individuals ascend from sea level, it is recom-\\nmended that they spend at least one night at an interme-\\ndiate altitude prior to ascending to higher elevations. In\\ngeneral, climbers should take at least two days to go\\nfrom sea level to 8,000 feet (2,438 m). After reaching\\nthat point, healthy climbers should generally allow one\\nday for each additional 2,000 feet (610 m), and one day\\nof rest should be taken every two or three days. Should\\nmild symptoms begin to surface, further ascent should be\\navoided. If the symptoms are severe, the individual\\nshould return to a lower altitude. Some reports indicate\\nthat acetazolamide (a diuretic) may be taken before\\nascent as a preventative measure for AMS.\\nPaying attention to diet can also help prevent alti-\\ntude sickness. Water loss is a problem at higher altitudes,\\nso climbers should drink ample water (enough to pro-\\nduce copious amounts of relatively light-colored or clear\\nurine). Alcohol and large amounts of salt should be\\navoided. Eating frequent small, high-carbohydrate\\nsnacks (for example, fruits, jams and starchy foods) can\\nhelp, especially in the first few days of climbing.\\nResources\\nBOOKS\\nCrystal, R. G., ed., et al. The Lung: Scientific Foundations.Lip-\\npincott-Raven Publishers, 1997.\\nKravis, T. C., C. G. Warner, and L. M. Jacobs Jr., eds. Emer-\\ngency Medicine. Raven Press, 1993.\\nRosen, Peter, ed., et al. Emergency Medicine: Concepts and\\nClinical Practice. Mosby Year Book, 1992.\\nPERIODICALS\\nCoote, J. H. “Medicine and Mechanisms in Altitude Sickness.”\\nSports Medicine 20 (Sept. 1995): 148-159.\\nKapil Gupta, MD\\nAluminum hydroxide see Antacids\\nAlzheimer’s disease\\nDefinition\\nAlzheimer’s disease (AD) is the most common form\\nof dementia, a neurologic disease characterized by loss\\nof mental ability severe enough to interfere with normal\\nactivities of daily living, lasting at least six months, and\\nnot present from birth. AD usually occurs in old age, and\\nis marked by a decline in cognitive functions such as\\nremembering, reasoning, and planning.\\nDescription\\nA person with AD usually has a gradual decline in\\nmental functions, often beginning with slight memory\\nloss, followed by losses in the ability to maintain\\nemployment, to plan and execute familiar tasks, and to\\nreason and exercise judgment. Communication ability,\\nmood, and personality may also be affected. Most people\\nwho have AD die within eight years of their diagnosis,\\nalthough that interval may be as short as one year or as\\nlong as 20 years. AD is the fourth leading cause of death\\nin adults after heart disease, cancer, and stroke.\\nBetween two and four million Americans have AD;\\nthat number is expected to grow to as many as 14 million by\\nthe middle of the 21st century as the population as a whole\\nages. While a small number of people in their 40s and 50s\\ndevelop the disease (called early-onset AD), AD predomi-\\nnantly affects the elderly. AD affects about 3% of all people\\nbetween ages 65 and 74, about 19% of those between 75\\nand 84, and about 47% of those over 85. Slightly more\\nwomen than men are affected with AD, but this may be\\nbecause women tend to live longer, and so there is a higher\\nproportion of women in the most affected age groups.\\nThe costs for caring for a person with AD is consid-\\nerable. The annual cost of caring for one AD patient in\\n1998 was estimated as about $18,400 for a patient with\\nmild AD, $30,100 for a patient with moderate AD, and\\n$36,100 for a patient with severe AD. The annual direct\\nand indirect costs of caring for AD patients in the United\\nStates was estimated to be as much as $100 billion.\\nSlightly more than half of AD patients are cared for at\\nhome, while the remainder are cared for in a variety of\\nhealth care institutions.\\nCauses and symptoms\\nCauses\\nThe cause or causes of Alzheimer’s disease are\\nunknown. Some strong leads have been found through\\nrecent research, however, and these have also given some\\ntheoretical support to several new experimental treatments.\\nGALE ENCYCLOPEDIA OF MEDICINE 2134\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 134'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 148, 'page_label': '149'}, page_content='At first AD destroys neurons (nerve cells) in parts of\\nthe brain that control memory, including the hippocam-\\npus, which is a structure deep in the deep that controls\\nshort-term memory. As these neurons in the hippocampus\\nstop functioning, the short-term memory of the person\\nfails, and the ability to perform familiar tasks decreases.\\nLater AD affects the cerebral cortex, particularly the areas\\nresponsible for language and reasoning; this language\\nskills are lost and the ability to make judgments is\\nchanged. Personality changes occur, which may include\\nemotional outbursts, wandering, and agitation. The sever-\\nity of these changes increases with the progression of the\\ndisease. Eventually many other areas of the brain become\\ninvolved, the brain regions affected atrophy (shrink and\\nlose function), and the person with AD becomes bedrid-\\nden, incontinent, helpless, and non-responsive.\\nAutopsy of a person with AD shows that the regions\\nof the brain affected by the disease become clogged with\\ntwo abnormal structures, called neurofibrillary tangles\\nand amyloid plaques. Neurofibrillary tangles are twisted\\nmasses of protein fibers inside nerve cells, or neurons. In\\nAD, tau proteins, which normally help bind and stabilize\\nparts of neurons, is changed chemically, become twisted\\nand tangled, and no longer can stabilize the neurons.\\nAmyloid plaques consist of insoluble deposits of beta-\\namyloid (a protein fragment from a larger protein called\\namyloid precursor protein (APP) mixed with parts of neu-\\nrons and non-nerve cells. Plaques are found in the spaces\\nbetween the nerve cells of the brain. While it is not clear\\nexactly how these structures cause problems, many\\nresearchers believe that their formation is responsible for\\nthe mental changes of AD, presumably by interfering\\nwith the normal communication between neurons in the\\nbrain and later leading to the death of neurons. As of\\n2000, three drugs for the treatment of AD symptoms have\\nbeen approved by the United States Food and Drug\\nAdministration (FDA). They act by increasing the level of\\nchemical signaling molecules in the brain, known as neu-\\nrotransmitters, to make up for this decreased communica-\\ntion ability. All act by inhibiting the activity of acetyl-\\ncholinesterase, which is an enzyme that breaks down\\nacetylcholine, an important neurotransmitter released by\\nneurons that is necessary for cognitive function. These\\ndrugs modestly increase cognition and improve one’s\\nability to perform normal activities of daily living.\\nWhat triggers the formation of plaques and tangles\\nand the development of AD are unknown. AD likely\\nresults from many interrelated factors, including genetic,\\nenvironmental, and others not yet identified. Two types\\nof AD exist: familial AD (FAD), which is a rare autoso-\\nmal dominant inherited disease, and sporadic AD, with\\nno obvious inheritance pattern. AD is also described in\\nterms of age at onset, with early on-set AD occurring in\\npeople younger than 65, and late-onset occurring in those\\n65 and older. Early on-set AD comprises about 5-10 of\\nAD cases and affects people aged 30 to 60. Some cases\\nof early on-set AD are inherited and are common in some\\nfamilies. Early-onset AD often progresses faster than the\\nmore common late-on-set type.\\nAll FAD, which are relatively uncommon, that have\\nbeen identified so far are the early on-set type. As many\\nas 50% of the FAD cases are known to be caused by three\\ngenes located on three different chromosomes. Some\\nfamilies have mutations in the APP gene located on chro-\\nmosome 21, which causes the production of abnormal\\nAPP protein. Others have mutations in a gene called pre-\\nsenilin 1 located on chromosome 14, which causes the\\nproduction of abnormal presenilin 1 protein, and others\\nhave mutations in a similar gene called presenilin 2 locat-\\ned on chromosome 1, which causes production of abnor-\\nmal presenilin 2. Presenilin 1 may be one of the enzymes\\nthat clips APP into beta-amyloid; it may also be important\\nin the synaptic connections between brain cells.\\nThere is no evidence that the mutated genes that\\ncause early on-set FAD also cause late on-set AD, but\\ngenetics does appear to play a role in this more common\\nform of AD. Discovered by researchers at Duke Univer-\\nsity in the early 1990s, potentially the most important\\ngenetic link to AD was on chromosome 19. A gene on\\nthis chromosome, called APOE (apolipoprotein E), codes\\nfor a protein involved in transporting lipids into neurons.\\nAPOE occurs in at least three forms (alleles), called\\nAPOE e2, APOE e3, and APOE e4. Each person inherits\\none APOE from each parent, and therefore can either\\nhave one copy of two different forms, or two copies of\\none. The relatively rare APOE e2 appears to protect some\\npeople from AD, as it seems to be associated with a\\nlower risk of AD and a later age of onset if AD does\\ndevelop. APOE e3 is the most common version found in\\nthe general population, and only appears to have a neu-\\ntral role in AD. However, APOE e4 appears to increase\\nthe risk of developing late onset AD with the inheritance\\nof one or two copies of APOE e4. Compared to those\\nwithout APOE e4, people with one copy are about three\\ntimes as likely to develop late-onset AD, and those with\\ntwo copies are almost four times as likely to do so. Hav-\\ning APOE e4 can also lower the age of onset by as much\\nas 17 years. However, APOE e4 only increases the risk of\\ndeveloping AD and does not cause it, as not everyone\\nwith APOE e4 develops AD, and people without it can\\nstill have the disease. Why APOE e4 increases the\\nchances of developing AD is not known with certainty.\\nHowever, one theory is that APOE e4 facilitates beta-\\namyloid buildup in plaques, thus contributing to the low-\\nering of the age of onset of AD; other theories involve\\ninteractions with cholesterol levels and effects on nerve\\nGALE ENCYCLOPEDIA OF MEDICINE 2 135\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 135'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 149, 'page_label': '150'}, page_content='cell death independent of its effects on plaque buildup. In\\n2000, four new AD-related regions in the human genome\\nwere identified, where one out of several hundred genes\\nin each of these regions may be a risk factor gene for AD.\\nThese genes, which are not yet identified, appear to make\\na contribution to the risk of developing late-onset AD\\nthat is at least as important as APOE e4.\\nOther non-genetic factors have also been studied in\\nrelation to the causes of AD. Inflammation of the brain\\nmay play a role in development of AD, and use of nons-\\nteroidal anti-inflammatory drugs (NSAIDs) seems to\\nreduce the risk of developing AD. Restriction of blood\\nflow may be part of the problem, perhaps accounting for\\nthe beneficial effects of estrogen, which increases blood\\nflow in the brain, among its other effects. Highly reactive\\nmolecular fragments called free radicals damage cells of\\nall kinds, especially brain cells, which have smaller sup-\\nplies of protective antioxidants thought to protect against\\nfree radical damage. Vitamin E is one such antioxidant,\\nand its use in AD may be of possible theoretical benefit.\\nWhile the ultimate cause or causes of Alzheimer’s\\ndisease are still unknown, there are several risk factors\\nthat increase a person’s likelihood of developing the dis-\\nease. The most significant one is, of course, age; older\\npeople develop AD at much higher rates than younger\\nones. There is some evidence that strokes and AD may be\\nlinked, with small strokes that go undetected clinically\\ncontributing to the injury of neurons. Blood cholesterol\\nlevels may also be important. Scientists have shown that\\nhigh blood cholesterol levels in special breeds of geneti-\\ncally engineered (transgenic) mice may increase the rate\\nof plaque deposition. There are also parallels between\\nAD and other progressive neurodegenerative disorders\\nthat cause dementia, including prion diseases, Parkin-\\nson’s disease, and Huntington’s disease.\\nNumerous epidemiological studies of populations are\\nalso being conducted to learn more about whether and to\\nwhat extent early life events, socioeconomic factors, and\\nethnicity have an impact on the development of AD. For\\nexample, results from one study indicated that rural resi-\\ndence in childhood, along with fewer than six years of\\nschooling, was associated with increased AD risk. How-\\never, the low educational attainment that was identified as\\na risk factor might be a marker or surrogate for other dele-\\nterious socioeconomic or environmental influences in\\nchildhood, thus illustrating the difficulties in interpreting\\nepidemiological findings, due to the complexity of the\\nissues and the large number of variables involved.\\nMany environmental factors have been suspected of\\ncontributing to AD, but epidemiological population stud-\\nies have not borne out these links. Among these have\\nbeen pollutants in drinking water, aluminum from com-\\nmercial products, and metal dental fillings. To date, none\\nof these factors has been shown to cause AD or increase\\nits likelihood. Further research may yet turn up links to\\nother environmental factors.\\nSymptoms\\nThe symptoms of Alzheimer’s disease begin gradu-\\nally, usually with memory lapses. Occasional memory\\nlapses are of course common to everyone, and do not by\\nthemselves signify any change in cognitive function. The\\nperson with AD may begin with only the routine sort of\\nmemory lapse—forgetting where the car keys are—but\\nprogress to more profound or disturbing losses, such as\\nforgetting that he or she can even drive a car. Becoming\\nlost or disoriented on a walk around the neighborhood\\nbecomes more likely as the disease progresses. A person\\nwith AD may forget the names of family members, or\\nforget what was said at the beginning of a sentence by\\nthe time he hears the end.\\nAs AD progresses, other symptoms appear, includ-\\ning inability to perform routine tasks, loss of judgment,\\nand personality or behavior changes. Some patients have\\ntrouble sleeping and may suffer from confusion or agita-\\ntion in the evening (“sunsetting” or Sundowner’s Syn-\\ndrome). In some cases, people with AD repeat the same\\nideas, movements, words, or thoughts, a behavior known\\nas perseveration. In the final stages people may have\\nsevere problems with eating, communicating, and con-\\ntrolling their bladder and bowel functions.\\nThe Alzheimer’s Association has developed a list of ten\\nwarning signs of AD. A person with several of these symp-\\ntoms should see a physician for a thorough evaluation:\\n• memory loss that affects job skills\\n• difficulty performing familiar tasks\\n• problems with language\\n• disorientation of time and place\\n• poor or decreased judgment\\n• problems with abstract thinking\\n• misplacing things\\n• changes in mood or behavior\\n• changes in personality\\n• loss of initiative\\nOther types of dementia, including some that are\\nreversible, can cause similar symptoms. It is important for\\nthe person with these symptoms to be evaluated by a pro-\\nfessional who can weigh the possibility that his or her\\nsymptoms may have another cause. Approximately 20% of\\nthose originally suspected of having AD turn out to have\\nsome other disorder; about half of these cases are treatable.\\nGALE ENCYCLOPEDIA OF MEDICINE 2136\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 136'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 150, 'page_label': '151'}, page_content='Diagnosis\\nDiagnosis of Alzheimer’s disease is complex, and\\nmay require office visits to several different specialists\\nover several months before a diagnosis can be made.\\nWhile a confident provisional diagnosis may be made in\\nmost cases after thorough testing, AD cannot be defini-\\ntively diagnosed until autopsy examination of the brain\\nfor plaques and neurofibrillary tangles.\\nThe diagnosis of AD begins with a thorough physi-\\ncal exam and complete medical history. Except in the\\ndisease’s earliest stages, accurate history from family\\nmembers or caregivers is essential. Since there are both\\nprescription and over-the-counter drugs that can cause\\nthe same mental changes as AD, a careful review of the\\npatient’s drug, medicine, and alcohol use is important.\\nAD-like symptoms can also be provoked by other med-\\nical conditions, including tumors, infection, and demen-\\ntia caused by mild strokes (multi-infarct dementia).\\nThese possibilities must be ruled out as well through\\nappropriate blood and urine tests, brain magnetic reso-\\nnance imaging (MRI), positron emission tomography\\n(PET) or single photon emission computed tomography\\n(SPECT) scans, tests of the brain’s electrical activity\\n(electroencephalographs or EEGs), or other tests. Several\\ntypes of oral and written tests are used to aid in the AD\\ndiagnosis and to follow its progression, including tests of\\nmental status, functional abilities, memory, and concen-\\ntration. Still, the neurologic exam is normal in most\\npatients in early stages.\\nOne of the most important parts of the diagnostic\\nprocess is to evaluate the patient for depression and\\ndelirium , since each of these can be present with AD,\\nor may be mistaken for it. (Delirium involves a\\ndecreased consciousness or awareness of one’s environ-\\nment.) Depression and memory loss are both common\\nin the elderly, and the combination of the two can often\\nbe mistaken for AD. Depression can be treated with\\ndrugs, although some antidepressants can worsen\\ndementia if it is present, further complicating both diag-\\nnosis and treatment.\\nAn early and accurate diagnosis of AD is important\\nin developing strategies for managing symptoms and for\\nhelping patients and their families planning for the future\\nand pursuing care options while the patient can still take\\npart in the decision-making process.\\nA genetic test for the APOE e4 gene is available, but\\nis not used for diagnosis, since possessing even two\\ncopies does not ensure that a person will develop AD. In\\naddition, access to genetic information could affect the\\ninsurability of a patient if disclosed, and also affect\\nemployment status and legal rights.\\nTreatment\\nAlzheimer’s disease is presently incurable, so there-\\nfore the mainstay of treatment for a person with AD is\\ngood nursing care, providing both physical and emotion-\\nal support for a person who is gradually able to do less\\nand less for himself, and whose behavior is becoming\\nmore and more erratic. Modifications of the home to\\nincrease safety and security are often necessary. The\\ncaregiver also needs support to prevent anger, despair,\\nand burnout from becoming overwhelming. Becoming\\nfamiliar with the issues likely to lie ahead, and consider-\\ning the appropriate financial and legal issues early on,\\ncan help both the patient and family cope with the diffi-\\ncult process of the disease. Regular medical care by a\\npractitioner with a non-defeatist attitude toward AD is\\nimportant so that illnesses such as urinary or respiratory\\ninfections can be diagnosed and treated properly, rather\\nthan being incorrectly attributed to the inevitable decline\\nseen in AD.\\nPeople with AD are also often depressed or anxious,\\nand may suffer from sleeplessness, poor nutrition , and\\ngeneral poor health. Each of these conditions is treatable\\nto some degree. It is important for the person with AD to\\neat well and continue to exercise. Professional advice\\nfrom a nutritionist may be useful to provide healthy,\\neasy-to-prepare meals. Finger foods may be preferable to\\nthose requiring utensils to be eaten. Regular exercise\\n(supervised if necessary for safety) promotes overall\\nhealth. A calm, structured environment with simple ori-\\nentation aids (such as calendars and clocks) may reduce\\nanxiety and increase safety. Other psychiatric symptoms,\\nsuch as depression, anxiety, hallucinations (seeing or\\nhearing things that aren’t there), and delusions (false\\nbeliefs) may be treated with drugs if necessary.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 137\\nAlzheimer’s disease\\nDiseased tissue from the brain of an Alzheimer’s patient\\nshowing senile plaques within the brain’s gray matter.(Pho-\\ntograph by Cecil Fox, Photo Researchers, Inc. Reproduced by\\npermission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 137'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 151, 'page_label': '152'}, page_content='Drugs\\nAs of 2000, only three drugs—tacrine (Cognex),\\ndonepezil hydrochloride (Aricept), and rivastigmine\\n(Exelon)—have been approved by the FDA for its treat-\\nment. Tacrine has been shown to be effective for improv-\\ning memory skills, but only in patients with mild-to-mod-\\nerate AD, and even then in less than half of those who take\\nit. Its beneficial effects are usually mild and temporary, but\\nit may delay the need for nursing home admission. The\\nmost significant side effect is an increase in a liver enzyme\\nknown as alanine aminotransferase, or ALT. Patients tak-\\ning tacrine must have a weekly blood test to monitor their\\nALT levels. Other frequent side effects include nausea,\\nvomiting, diarrhea, abdominal pain, indigestion, and\\nskin rash. The cost of tacrine was about $125 per month in\\nearly 1998, with additional costs for the weekly blood\\nmonitoring. Despite its high cost, tacrine appears to be\\ncost-effective for those who respond to it, since it may\\ndecrease the number of months a patient needs nursing\\ncare. Donepezil is the drug most commonly used to treat\\nmild to moderate symptoms of AD, although it only helps\\nsome patients for periods of time ranging from months to\\nabout two years. Donepezil has two advantages over\\ntacrine: it has fewer side effects, and it can be given once\\ndaily rather than three times daily. Donepezil does not\\nappear to affect liver enzymes, and therefore does not\\nrequire weekly blood tests. The frequency of abdominal\\nside effects is also lower. The monthly cost is approxi-\\nmately the same. Rivastigmine, approved for use in April\\nof 2000, has been shown to improve the ability of patients\\nto carry out daily activities, such as eating and dressing,\\ndecrease behavioral symptoms such as delusions and agi-\\ntation, and improve cognitive functions such as thinking,\\nmemory, and speaking. The cost is similar to those of the\\nother two drugs. However, none of these three drugs stops\\nor reverses the progression of AD.\\nEstrogen, the female sex hormone, is widely pre-\\nscribed for post-menopausal women to prevent osteo-\\nporosis. Several preliminary studies have shown that\\nwomen taking estrogen have lower rates of AD, and those\\nwho develop AD have a slower progression and less\\nsevere symptoms.However, estrogen does not appear to\\nhave a beneficial effect on women who already have AD.\\nPreliminary studies have also suggested a reduced\\nrisk for developing AD in older people who regularly use\\nnonsteroidal anti-inflammatory drugs (NSAIDs), includ-\\ning aspirin, ibuprofen, and naproxen, although not aceta-\\nminophen.Inflammation of the brain is a distinctive char-\\nacteristic of AD, but whether it is a cause or an effect of\\nthe disease is not yet known.\\nAntioxidants, which act to inhibit and protect\\nagainst oxidative damage caused by free radicals, have\\nbeen shown to inhibit toxic effects of beta-amyloid in tis-\\nsue culture. Therefore, research is being conducted to see\\nwhether antioxidants may delay or prevent AD.\\nAnother antioxidant, vitamin E, is also thought to\\ndelay AD onset. It is not yet clear whether this is due to\\nthe specific action of vitamin E on brain cells, or to an\\nincrease in the overall health of those taking it.\\nDrugs such as antidepressants, anti-psychotics, and\\nsedatives are used to treat the behavioral symptoms\\n(agitation, aggression, wandering, and sleep disorders )\\nof AD. Research is being conducted to search for better\\ntreatments, including non-drug approaches for AD\\npatients.\\nNursing care and safety\\nThe person with Alzheimer’s disease will gradually\\nlose the ability to dress, groom, feed, bathe, or use the\\ntoilet by himself; in the later stages of the disease, he\\nmay be unable to move or speak. In addition, the per-\\nson’s behavior becomes increasing erratic. A tendency to\\nwander may make it difficult to leave him unattended for\\neven a few minutes and make even the home a potentially\\ndangerous place. In addition, some patients may exhibit\\ninappropriate sexual behaviors.\\nThe nursing care required for a person with AD is\\nwell within the abilities of most people to learn. The dif-\\nficulty for many caregivers comes in the constant but\\nunpredictable nature of the demands put on them. In\\naddition, the personality changes undergone by a person\\nwith AD can be heartbreaking for family members, as a\\nloved one deteriorates, seeming to become a different\\nperson. Not all AD patients develop negative behaviors:\\nsome become quite gentle, and spend increasing amounts\\nof time in dreamlike states.\\nA loss of good grooming may be one of the early\\nsymptoms of AD. Mismatched clothing, unkempt hair,\\nand decreased interest in personal hygiene become more\\ncommon. Caregivers, especially spouses, may find these\\nchanges socially embarrassing and difficult to cope with.\\nThe caregiver will usually need to spend increasing\\namounts of time for grooming to compensate for the loss\\nof attention from the patient, although some adjustment\\nof expectations (while maintaining cleanliness) is often\\nneeded as the disease progresses.\\nProper nutrition is important for a person with AD,\\nand may require assisted feeding early on, to make sure the\\nperson is taking in enough nutrients. Later on, as move-\\nment and swallowing become difficult, a feeding tube may\\nbe placed into the stomach through the abdominal wall. A\\nfeeding tube requires more attention, but is generally easy\\nto care for if the patient is not resistant to its use.\\nGALE ENCYCLOPEDIA OF MEDICINE 2138\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 138'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 152, 'page_label': '153'}, page_content='For many caregivers, incontinence becomes the\\nmost difficult problem to deal with at home, and is a\\nprincipal reason for pursuing nursing home care. In the\\nearly stages, limiting fluid intake and increasing the fre-\\nquency of toileting can help. Careful attention to hygiene\\nis important to prevent skin irritation and infection from\\nsoiled clothing.\\nPersons with dementia must deal with six basic safe-\\nty concerns: injury from falls, injury from ingesting dan-\\ngerous substances, leaving the home and getting lost,\\ninjury to self or others from sharp objects, fire or burns,\\nand the inability to respond rapidly to crisis situations. In\\nall cases, a person diagnosed with AD should no longer\\nbe allowed to drive, because of the increased potential\\nfor accidents and the increased likelihood of wandering\\nvery far from home while disoriented. In the home, sim-\\nple measures such as grab bars in the bathroom, bed rails\\non the bed, and easily negotiable passageways can great-\\nly increase safety. Electrical appliances should be\\nunplugged and put away when not in use, and matches,\\nlighters, knives, or weapons should be stored safely out\\nof reach. The hot water heater temperature may be set\\nlower to prevent accidental scalding. A list of emergency\\nnumbers, including the poison control center and the\\nhospital emergency room, should be posted by the\\nphone. As the disease progresses, caregivers need to peri-\\nodically reevaluate the physical safety of the home and\\nintroduce new strategies for continued safety.\\nCare for the caregiver\\nFamily members or others caring for a person with\\nAD have an extremely difficult and stressful job, which\\nbecomes harder as the disease progresses. Dementia\\ncaregivers spend significantly more time on caregiving\\nthan do people providing care for those with other types\\nof illnesses. This type of caregiving also has a greater\\nimpact in terms of employment complications, caregiver\\nstrain, mental and physical health problems, time for\\nleisure and other family members, and family conflict\\nthan do other types of caregiving. It is common for AD\\ncaregivers to develop feelings of anger, resentment, guilt,\\nand hopelessness, in addition to the sorrow they feel for\\ntheir loved one and for themselves. Depression is an\\nextremely common consequence of being a full-time\\ncaregiver for a person with AD. Support groups are an\\nimportant way to deal with the stress of caregiving.\\nBecoming a member of an AD caregivers’ support group\\ncan be one of the most important things a family member\\ndoes, not only for him or herself, but for the person with\\nAD as well. The location and contact numbers for AD\\ncaregiver support groups are available from the\\nAlzheimer’s Association; they may also be available\\nthrough a local social service agency, the patient’s physi-\\ncian, or pharmaceutical companies that manufacture the\\ndrugs used to treat AD. Medical treatment for depression\\nmay be an important adjunct to group support.\\nOutside help, nursing homes, and governmental\\nassistance\\nMost families eventually need outside help to relieve\\nsome of the burden of around-the-clock care for a person\\nwith AD. Personal care assistants, either volunteer or\\npaid, may be available through local social service agen-\\ncies. Adult daycare facilities are becoming increasingly\\ncommon. Meal delivery, shopping assistance, or respite\\ncare may be available as well.\\nProviding the total care required by a person with\\nlate-stage AD can become an overwhelming burden for a\\nfamily, even with outside help. At this stage, many fami-\\nlies consider nursing home care. This decision is often one\\nof the most difficult for the family, since it is often seen as\\nan abandonment of the loved one and a failure of the fami-\\nly. Careful counseling with a sympathetic physician, cler-\\ngy, or other trusted adviser may ease the difficulties of this\\ntransition. Selecting a nursing home may require a difficult\\nbalancing of cost, services, location, and availability.\\nKeeping the entire family involved in the decision may\\nhelp prevent further stress from developing later on.\\nSeveral federal government programs may ease the\\ncost of caring for a person with AD, including Social\\nSecurity Disability, Medicare, and Supplemental Securi-\\nty Income. Each of these programs may provide some\\nassistance for care, medication, or other costs, but none\\nof them will pay for nursing home care indefinitely.\\nMedicaid is a state-funded program that may provide for\\nsome or all of the cost of nursing home care, although\\nthere are important restrictions. Details of the benefits\\nand eligibility requirements of these programs are avail-\\nable through the local Social Security or Medicaid office,\\nor from local social service agencies.\\nPrivate long-term care insurance, special “reverse\\nmortgages,” viatical insurance, and other financial devices\\nare other ways of paying for care for those with the appro-\\npriate financial situations. Further information on these\\noptions may be available through resources listed below.\\nAlternative treatment\\nSeveral substances are currently being tested for\\ntheir ability to slow the progress of Alzheimer’s disease.\\nThese include acetylcarnitine, a supplement that acts on\\nthe cellular energy structures known as mitochondria.\\nGinkgo extract, derived from the leaves of the Ginkgo\\nbiloba tree, appears to have antioxidant as well as anti-\\ninflammatory and anticoagulant properties. Ginkgo\\nGALE ENCYCLOPEDIA OF MEDICINE 2 139\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 139'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 153, 'page_label': '154'}, page_content='extract has been used for many years in China and is\\nwidely prescribed in Europe for treatment of circulatory\\nproblems. A 1997 study of patients with dementia\\nseemed to show that ginkgo extract could improve their\\nsymptoms, though the study was criticized for certain\\nflaws in its method.Large scale follow-up studies are\\nbeing conducted to determine whether Ginkgo extract\\ncan prevent or delay the development of AD. Ginkgo\\nextract is available in many health food or nutritional\\nsupplement stores. Some alternative practitioners also\\nadvise people with AD to take supplements of phos-\\nphatidylcholine, vitamin B\\n12, gotu kola, ginseng, St.\\nJohn’s Wort, rosemary, saiko-keishi-to-shakuyaku (A\\nJapanese herbal mixture), and folic acid.\\nPrognosis\\nWhile Alzheimer’s disease may not be the direct\\ncause of death, the generally poorer health of a person\\nwith AD increases the risk of life-threatening infection,\\nincluding pneumonia . In addition, other diseases com-\\nmon in old age—cancer, stroke, and heart disease—may\\nlead to more severe consequences in a person with AD.\\nOn average, people with AD live eight years past their\\ndiagnosis, with a range from one to 20 years.\\nPrevention\\nThere is currently no sure way to prevent Alzheimer’s\\ndisease, although some of the drug treatments discussed\\nabove may eventually be proven to reduce the risk of\\ndeveloping the disease. The most likely current candidates\\nare estrogen, NSAIDs, vitamin E, and ginkgo biloba ,\\nalthough this list may grow or shrink with further research.\\nKEY TERMS\\nAcetylcholine— One of the substances in the body\\nthat helps transmit nerve impulses.\\nDementia —Impaired intellectual function that\\ninterferes with normal social and work activities.\\nGinkgo—An herb from the Ginkgo biloba tree that\\nsome alternative practitioners recommend for the\\nprevention and treatment of AD.\\nNeurofibrillary tangle— Twisted masses of protein\\ninside nerve cells that develop in the brains of\\npeople with AD.\\nSenile plaque— Structures composed of parts of\\nneurons surrounding brain proteins called beta-\\namyloid deposits and found in the brains of peo-\\nple with AD.\\nResearch on the prevention of AD is focusing on\\nblocking the production of amyloid in the brain as well\\nas breaking down beta-amyloid once it is released from\\ncells but before it has a chance to aggregate into insolu-\\nble plaques. There are also promising studies being con-\\nducted to develop an AD vaccine, where immune\\nresponses may result in the elimination of the formation\\nof amyloid plaques.\\nThe Alzheimer’s Disease Research Centers (ADCs)\\nprogram promotes research, training and education,\\ntechnology transfer, and multicenter and cooperative\\nstudies in AD, other dementias, and normal brain aging.\\nEach ADC enrolls and performs studies on AD patients\\nand healthy older people. Persons can participate in\\nresearch protocols and clinical drug trials at these cen-\\nters. Data from the ADCs as well as from other sources\\nare coordinated and made available for use by\\nresearchers at the National Alzheimer’s Coordinating\\nCenter, established in 1999.\\nResources\\nBOOKS\\nCohen, Donna, and Carl Eisdorfer. The Loss of Self: A Family\\nResource for the Care of Alzheimer’s Disease and Related\\nDisorders, Revised Edition. New York: W.W. Norton &\\nCompany, 2001.\\nCohen, Elwood. Alzheimer’s Disease: Prevention, Interven-\\ntion, and Treatment.Los Angeles: Keats Publishing, 1999.\\nGeldmacher, David S. Contemporary Diagnosis and Manage-\\nment of Alzheimer’s Disease.Newtown, PA: Associates in\\nMedical Marketing Co., Inc., 2001.\\nGruetzner, Howard. Alzheimer’s: A Caregiver’s Guide and\\nSourcebook, 3rd Edition. New York: John Wiley & Sons,\\n2001.\\nMace, Nancy L., and Peter V . Rabins. The 36-Hour Day: A\\nFamily Guide for Caring with Persons with Alzheimer\\nDisease, Related Dementing Illnesses, and Memory Loss\\nin Later Life. New York: Warner Books, 2001.\\nTeitel, Rosette, and Marc L. Gordon. The Handholder’s Hand-\\nbook: A Guide for Caregivers of Alzheimer’s and other\\nDementias. New Brunswick, NJ: Rutgers University\\nPress, 2001.\\nPERIODICALS\\nGitlin, L.N., and M. Corcoran. “Making Homes Safer: Envi-\\nronmental Adaptations for People with Dementia.”\\nAlzheimer’s Care Quarterly1 (2000): 50-58.\\nHelmuth, L. “Alzheimer’s Congress: Further Progress on a B-\\nAmyloid Vaccine.”Science 289, No. 5476 (2000): 375.\\nORGANIZATIONS\\nAlzheimer’s Association. 919 North Michigan Ave., Suite 1000\\nChicago, IL 60611. (800) 272-3900. .\\nAlzheimer’s Disease Education and Referral Center. P.O. Box\\n8250, Silver Spring, MD. (800) 438-4380.Fax: (301) 495-\\n3334. adear@alzheimers.org. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2140\\nAlzheimer’s disease\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 140'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 154, 'page_label': '155'}, page_content='Alzheimer’s Research Foundation. .\\nOTHER\\nNational Institute on Aging, National Institutes of Health.\\n2000: Progress Report on Alzheimer’s Disease - Taking\\nthe Next Steps. NIH Publication No. 4859 (2000). .\\nAlzheimer’s Disease Books and Videotapes..\\nJudith Sims\\nAmbiguous genitals see Intersex states\\nAmblyopia\\nDefinition\\nAmblyopia is an uncorrectable decrease in vision in\\none or both eyes with no apparent structural abnormality\\nseen to explain it. It is a diagnosis of exclusion, meaning\\nthat when a decrease in vision is detected, other causes\\nmust be ruled out. Once no other cause is found, ambly-\\nopia is the diagnosis. Generally, a difference of two lines\\nor more (on an eye-chart test of visual acuity) between\\nthe two eyes or a best corrected vision of 20/30 or worse\\nwould be defined as amblyopia. For example, if someone\\nhas 20/20 vision with the right eye and only 20/40 with\\nthe left, and the left eye cannot achieve better vision with\\ncorrective lenses, the left eye is said to be amblyopic.\\nDescription\\nLazy eye is a common non-medical term used to\\ndescribe amblyopia because the eye with poorer vision\\ndoesn’t seem to be doing its job of seeing. Amblyopia is\\nthe most common cause of impaired vision in children,\\naffecting nearly three out of every 100 people or 2-4%\\nof the population. Vision is a combination of the clarity\\nof the images of the eyes (visual acuity) and the process-\\ning of those images by the brain. If the images produced\\nby the two eyes are substantially different, the brain may\\nnot be able to fuse the images. Instead of seeing two dif-\\nferent images or double vision (diplopia), the brain sup-\\npresses the blurrier image. This suppression can lead to\\namblyopia. During the first few years of life, preferring\\none eye over the other may lead to poor visual develop-\\nment in the blurrier eye.\\nCauses and symptoms\\nSome of the major causes of amblyopia are as follows:\\n• Strabismus. A misalignment of the eyes (strabismus) is\\nthe most common cause of functional amblyopia. The\\ntwo eyes are looking in two different directions at the\\nsame time. The brain is sent two different images and\\nthis causes confusion. Images from the misaligned or\\n“crossed” eye are turned off to avoid double vision.\\n• Anisometropia. This is another type of functional\\namblyopia. In this case, there is a difference of refrac-\\ntive states between the two eyes (in other words, a dif-\\nference of prescriptions between the two eyes). For\\nexample, one eye may be more nearsighted than the\\nother eye, or one eye may be farsighted and the other\\neye nearsighted. Because the brain cannot fuse the two\\ndissimilar images, the brain will suppress the blurrier\\nimage, causing the eye to become amblyopic.\\n• Cataract. Clouding of the lens of the eye will cause the\\nimage to be blurrier than the other eye. The brain\\n“prefers” the clearer image. The eye with the cataract\\nmay become amblyopic.\\n• Ptosis. This is the drooping of the upper eyelid. If light\\ncannot enter the eye because of the drooping lid, the\\neye is essentially not being used. This can lead to\\namblyopia.\\n• Nutrition. A type of organic amblyopia in which nutri-\\ntional deficiencies or chemical toxicity may result in\\namblyopia. Alcohol, tobacco, or a deficiency in the B\\nvitamins may result in toxic amblyopia.\\n• Heredity. Amblyopia can run in families.\\nBarring the presence of strabismus or ptosis, chil-\\ndren may or may not show signs of amblyopia. Children\\nmay hold their heads at an angle while trying to favor the\\neye with normal vision. They may have trouble seeing or\\nreaching for things when approached from the side of the\\namblyopic eye. Parents should see if one side of\\nGALE ENCYCLOPEDIA OF MEDICINE 2 141\\nAmblyopia\\nMan with a lazy eye. (Custom Medical Stock Photo. Repro-\\nduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 141'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 155, 'page_label': '156'}, page_content='approach is preferred by the child or infant. If an infant’s\\ngood eye is covered, the child may cry.\\nDiagnosis\\nBecause children with outwardly normal eyes may\\nhave amblyopia, it is important to have regular vision\\nscreenings performed for all children. While there is\\nsome controversy regarding the age children should have\\ntheir first vision examination, their eyes can, in actuality,\\nbe examined at any age, even at one day of life.\\nSome recommend that children have their vision\\nchecked by their pediatrician, family physician, ophthal-\\nmologist, or optometrist at or before six months of age.\\nOthers recommend testing by at least the child’s fourth\\nbirthday. There may be a “critical period” in the develop-\\nment of vision, and amblyopia may not be treatable after\\nage eight or nine. The earlier amblyopia is found, the better\\nthe possible outcome. Most physicians test vision as part of\\na child’s medical examination. If there is any sign of an eye\\nproblem, they may refer a child to an eye specialist.\\nThere are objective methods, such as retinoscopy, to\\nmeasure the refractive status of the eyes. This can help\\ndetermine anisometropia. In retinoscopy, a hand-held\\ninstrument is used to shine a light in the child’s (or\\ninfant’s) eyes. Using hand-held lenses, a rough prescrip-\\ntion can be obtained. Visual acuity can be determined\\nusing a variety of methods. Many different eye charts are\\navailable (e.g., tumbling E, pictures, or letters). In ambly-\\nopia, single letters are easier to recognize than when a\\nKEY TERMS\\nAnisometropia—An eye condition in which there\\nis an inequality of vision between the two eyes.\\nThere may be unequal amounts of nearsighted-\\nness, farsightedness, or astigmatism, so that one\\neye will be in focus while the other will not.\\nCataract—Cloudiness of the eye’s natural lens.\\nOcculsion therapy—A type of treatment for ambly-\\nopia in which the good eye is patched for a period\\nof time. This forces the weaker eye to be used.\\nStrabismus —A condition in which the eyes are\\nmisaligned and point in different directions. One\\neye may look straight ahead, while the other turns\\ninward, outward, upward, or downward. This is\\nalso called crossed-eyes.\\nVisual acuity —Acuity is the acuteness or sharp-\\nness of vision.\\nwhole line is shown. This is called the “crowding effect”\\nand helps in diagnosing amblyopia. Neutral density filters\\nmay also be held over the eye to aid in the diagnosis.\\nSometimes visual fields to determine defects in the area\\nof vision will be performed. Color vision testing may also\\nbe performed. Again, it must be emphasized that ambly-\\nopia is a diagnosis of exclusion. Visual or life-threatening\\nproblems can also cause a decrease in vision. An exami-\\nnation of the eyes and visual system is very important\\nwhen there is an unexplained decrease in vision.\\nTreatment\\nThe primary treatment for amblyopia is occlusion\\ntherapy. It is important to alternate patching the good eye\\n(forcing the amblyopic eye to work) and the amblyopic\\neye. If the good eye is constantly patched, it too may\\nbecome amblyopic because of disuse. The treatment plan\\nshould be discussed with the doctor to fully understand\\nhow long the patch will be on. When patched, eye exercis-\\nes may be prescribed to force the amblyopic eye to focus\\nand work. This is called vision therapy or vision training\\n(eye exercises). Even after vision has been restored in the\\nweak eye, part-time patching may be required over a peri-\\nod of years to maintain the improvement.\\nWhile patching is necessary to get the amblyopic\\neye to work, it is just as important to correct the reason\\nfor the amblyopia. Glasses may also be worn if there are\\nerrors in refraction. Surgery or vision training may be\\nnecessary in the case of strabismus. Better nutrition is\\nindicated in some toxic amblyopias. Occasionally,\\namblyopia is treated by blurring the vision in the good\\neye with eye drops or lenses to force the child to use the\\namblyopic eye.\\nPrognosis\\nThe younger the person, the better the chance for\\nimprovement with occlusion and vision therapy. Howev-\\ner, treatment may be successful in older children—even\\nadults. Success in the treatment of amblyopia also\\ndepends upon how severe the amblyopia is, the specific\\ntype of amblyopia, and patient compliance. It is impor-\\ntant to diagnose and treat amblyopia early because sig-\\nnificant vision loss can occur if left untreated. The best\\noutcomes result from early diagnosis and treatment.\\nPrevention\\nTo protect their child’s vision, parents must be aware\\nof amblyopia as a potential problem. This awareness may\\nencourage parents to take young children for vision exams\\nearly on in life—certainly before school age. Proper nutri-\\ntion is important in the avoidance of toxic amblyopia.\\nGALE ENCYCLOPEDIA OF MEDICINE 2142\\nAmblyopia\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 142'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 156, 'page_label': '157'}, page_content='Resources\\nBOOKS\\nD’Alonzo, T. L., O.D. Your Eyes! A Comprehensive Look at the\\nUnderstanding and Treatment of Vision Problems.Clifton\\nHeights, PA: Avanti, 1992.\\nNewell, Frank W. Ophthalmology: Principles and Concepts.\\n8th 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. .\\nLorraine Steefel, RN\\nAmebiasis\\nDefinition\\nAmebiasis is an infectious disease caused by a para-\\nsitic one-celled microorganism (protozoan) called Enta-\\nmoeba histolytica . Persons with amebiasis may experi-\\nence a wide range of symptoms, including diarrhea ,\\nfever, and cramps. The disease may also affect the\\nintestines, liver, or other parts of the body.\\nDescription\\nAmebiasis, also known as amebic dysentery, is one\\nof the most common parasitic diseases occurring in\\nhumans, with an estimated 500 million new cases each\\nyear. It occurs most frequently in tropical and subtropical\\nareas where living conditions are crowded, with inade-\\nquate sanitation. Although most cases of amebiasis occur\\nin persons who carry the disease but do not exhibit any\\nsymptoms (asymptomatic), as many as 100,000 people\\ndie of amebiasis each year. In the United States, between\\n1 and 5% of the general population will develop amebia-\\nsis in any given year, while male homosexuals, migrant\\nworkers, institutionalized people, and recent immigrants\\ndevelop amebiasis at a higher rate.\\nHuman beings are the only known host of the amebi-\\nasis organism, and all groups of people, regardless of age\\nor sex, can become affected. Amebiasis is primarily\\nspread in food and water that has been contaminated by\\nhuman feces but is also spread by person-to-person con-\\ntact. The number of cases is typically limited, but region-\\nal outbreaks can occur in areas where human feces are\\nused as fertilizer for crops, or in cities with water sup-\\nplies contaminated with human feces.\\nCauses and symptoms\\nRecently, it has been discovered that persons with\\nsymptom-causing amebiasis are infected with Entamoe-\\nba histolytica , and those individuals who exhibit no\\nsymptoms are actually infected with an almost identical-\\nlooking ameba called Entamoeba dispar . During their\\nlife cycles, the amebas exist in two very different forms:\\nthe infective cyst or capsuled form, which cannot move\\nbut can survive outside the human body because of its\\nprotective covering, and the disease-producing form, the\\ntrophozoite, which although capable of moving, cannot\\nsurvive once excreted in the feces and, therefore, cannot\\ninfect others. The disease is most commonly transmitted\\nwhen a person eats food or drinks water containing E.\\nhistolytica cysts from human feces. In the digestive tract\\nthe cysts are transported to the intestine where the walls\\nof the cysts are broken open by digestive secretions,\\nreleasing the mobile trophozoites. Once released within\\nthe intestine, the trophozoites multiply by feeding on\\nintestinal bacteria or by invading the lining of the large\\nintestine. Within the lining of the large intestine, the\\ntrophozoites secrete a substance that destroys intestinal\\ntissue and creates a distinctive bottle-shaped sore (ulcer).\\nThe trophozoites may remain inside the intestine, in the\\nintestinal wall, or may break through the intestinal wall\\nand be carried by the blood to the liver, lungs, brain, or\\nother organs. Trophozoites that remain in the intestines\\neventually form new cysts that are carried through the\\ndigestive tract and excreted in the feces. Under favorable\\ntemperature and humidity conditions, the cysts can sur-\\nvive in soil or water for weeks to months, ready to begin\\nthe cycle again.\\nAlthough 90% of cases of amebiasis in the United\\nStates are mild, pregnant women, children under two\\nyears of age, the elderly, malnourished individuals, and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 143\\nAmebiasis\\nA micrograph of Entameoba histolytica, a parasitic amoeba\\nwhich invades and destroys the tissues of the intestines,\\ncausing amebiasis and ulceration to the intestinal wall.\\n(Photo Researchers, Inc. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 143'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 157, 'page_label': '158'}, page_content='people whose immune systems may be compressed, such\\nas cancer or AIDS patients and those individuals taking\\nprescription medications that suppress the immune sys-\\ntem, are at a greater risk for developing a severe infection.\\nThe signs and symptoms of amebiasis vary accord-\\ning to the location and severity of the infection and are\\nclassified as follows:\\nIntestinal amebiasis\\nIntestinal amebiasis can be subdivided into several\\ncategories:\\nASYMPTOMATIC INFECTION. Most persons with\\namebiasis have no noticeable symptoms. Even though\\nthese individuals may not feel ill, they are still capable of\\ninfecting others by person-to-person contact or by conta-\\nminating food or water with cysts that others may ingest,\\nfor example, by preparing food with unwashed hands.\\nCHRONIC NON-DYSENTERIC INFECTION. Individu-\\nals may experience symptoms over a long period of time\\nduring a chronic amebiasis infection and experience\\nrecurrent episodes of diarrhea that last from one to four\\nweeks and recur over a period of years. These patients\\nmay also suffer from abdominal cramps, fatigue , and\\nweight loss.\\nAMEBIC DYSENTERY. In severe cases of intestinal\\namebiasis, the organism invades the lining of the intes-\\ntine, producing sores (ulcers), bloody diarrhea, severe\\nabdominal cramps, vomiting, chills, and fevers as high as\\n104-105°F (40-40.6°C). In addition, a case of acute ame-\\nbic dysentery may cause complications, including\\ninflammation of the appendix ( appendicitis ), a tear in\\nthe intestinal wall (perforation), or a sudden, severe\\ninflammation of the colon (fulminating colitis).\\nAMEBOMA. An ameboma is a mass of tissue in the\\nbowel that is formed by the amebiasis organism. It can\\nresult from either chronic intestinal infection or acute\\namebic dysentery. Amebomas may produce symptoms\\nthat mimic cancer or other intestinal diseases.\\nPERIANAL ULCERS. Intestinal amebiasis may pro-\\nduce skin infections in the area around the patient’s anus\\n(perianal). These ulcerated areas have a “punched-out”\\nappearance and are painful to the touch.\\nExtraintestinal amebiasis\\nExtraintestinal amebiasis accounts for approximate-\\nly 10% of all reported amebiasis cases and includes all\\nforms of the disease that affect other organs.\\nThe most common form of extraintestinal amebiasis\\nis amebic abscess of the liver. In the United States, ame-\\nbic liver abscesses occur most frequently in young His-\\npanic adults. An amebic liver abscess can result from\\ndirect infection of the liver by E. histolytica or as a com-\\nplication of intestinal amebiasis. Patients with an amebic\\nabscess of the liver complain of pain in the chest or\\nabdomen, fever, nausea, and tenderness on the right side\\ndirectly above the liver.\\nOther forms of extraintestinal amebiasis, though\\nrare, include infections of the lungs, chest cavity, brain,\\nor genitals. These are extremely serious and have a rela-\\ntively high mortality rate.\\nDiagnosis\\nDiagnosis of amebiasis is complicated, partly\\nbecause the disease can affect several areas of the body\\nand can range from exhibiting few, if any, symptoms to\\nbeing severe, or even life-threatening. In most cases, a\\nphysician will consider a diagnosis of amebiasis when a\\npatient has a combination of symptoms, in particular,\\ndiarrhea and a possible history of recent exposure to\\namebiasis through travel, contact with infected persons,\\nor anal intercourse.\\nIt is vital to distinguish between amebiasis and\\nanother disease, inflammatory bowel disease (IBD) that\\nproduces similar symptoms because, if diagnosed incor-\\nrectly, drugs that are given to treat IBD can encourage the\\ngrowth and spread of the amebiasis organism. Because of\\nthe serious consequences of misdiagnosis, potential cases\\nof IBD must be confirmed with multiple stool samples\\nand blood tests, and a procedure involving a visual\\ninspection of the intestinal wall using a thin lighted, tubu-\\nlar instrument (sigmoidoscopy) to rule out amebiasis.\\nA diagnosis of amebiasis may be confirmed by one\\nor more tests, depending on the location of the disease.\\nStool examination\\nThis test involves microscopically examining a stool\\nsample for the presence of cysts and/or trophozoites of E.\\nhistolytica and not one of the many other intestinal ame-\\nbas that are often found but that do not cause disease. A\\nseries of three stool tests is approximately 90% accurate\\nin confirming a diagnosis of amebic dysentery. Unfortu-\\nnately, however, the stool test is not useful in diagnosing\\namebomas or extraintestinal infections.\\nSigmoidoscopy\\nSigmoidoscopy is a useful diagnostic procedure in\\nwhich a thin, flexible, lighted instrument, called a sig-\\nmoidoscope, is used to visually examine the lower part of\\nthe large intestine for amebic ulcers and take tissue or\\nfluid samples from the intestinal lining.\\nGALE ENCYCLOPEDIA OF MEDICINE 2144\\nAmebiasis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 144'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 158, 'page_label': '159'}, page_content='Blood tests\\nAlthough tests designed to detect a specific protein\\nproduced in response to amebiasis infection (antibody) are\\ncapable of detecting only about 10% of cases of mild ame-\\nbiasis, these tests are extremely useful in confirming 95%\\nof dysentery diagnoses and 98% of liver abscess diag-\\nnoses. Blood serum will usually test positive for antibody\\nwithin a week of symptom onset. Blood testing, however,\\ncannot always distinguish between a current or past infec-\\ntion since the antibodies may be detectable in the blood for\\nas long as 10 years following initial infection.\\nImaging studies\\nA number of sophisticated imaging techniques, such\\nas computed tomography scans (CT), magnetic reso-\\nnance imaging (MRI), and ultrasound, can be used to\\ndetermine whether a liver abscess is present. Once locat-\\ned, a physician may then use a fine needle to withdraw a\\nsample of tissue to determine whether the abscess is\\nindeed caused by an amebic infection.\\nTreatment\\nAsymptomatic or mild cases of amebiasis may\\nrequire no treatment. However, because of the potential\\nfor disease spread, amebiasis is generally treated with a\\nmedication to kill the disease-causing amebas. More\\nsevere cases of amebic dysentery are additionally treated\\nby replacing lost fluid and blood. Patients with an ame-\\nbic liver abscess will also require hospitalization and bed\\nrest. For those cases of extraintestinal amebiasis, treat-\\nment can be complicated because different drugs may be\\nrequired to eliminate the parasite, based on the location\\nof the infection within the body. Drugs used to treat ame-\\nbiasis, called amebicides, are divided into two categories:\\nLuminal amebicides\\nThese drugs get their name because they act on\\norganisms within the inner cavity (lumen) of the bowel.\\nThey include diloxanide furoate, iodoquinol, metronida-\\nzole, and paromomycin.\\nTissue amebicides\\nTissue amebicides are used to treat infections in the\\nliver and other body tissues and include emetine, dehy-\\ndroemetine, metronidazole, and chloroquine. Because\\nthese drugs have potentially serious side effects, patients\\ngiven emetine or dehydroemetine require bed rest and\\nheart monitoring. Chloroquine has been found to be the\\nmost useful drug for treating amebic liver abscess.\\nPatients taking metronidazole must avoid alcohol\\nbecause the drug-alcohol combination causes nausea,\\nvomiting, and headache.\\nKEY TERMS\\nAmeboma—A mass of tissue that can develop on\\nthe wall of the colon in response to amebic infec-\\ntion.\\nAntibody —A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAppendicitis —Condition characterized by the\\nrapid inflammation of the appendix, a part of the\\nintestine.\\nAsymptomatic—Persons who carry a disease and\\nare usually capable of transmitting the disease but\\nwho do not exhibit symptoms of the disease are\\nsaid to be asymptomatic.\\nDysentery —Intestinal infection marked by diar-\\nrhea containing blood and mucus.\\nFulminating colitis—A potentially fatal complica-\\ntion of amebic dysentery marked by sudden and\\nsevere inflammation of the intestinal lining, severe\\nbleeding or hemorrhaging, and massive shedding\\nof dead tissue.\\nInflammatory bowel disease (IBD) —Disease in\\nwhich the lining of the intestine becomes inflamed.\\nLumen—The inner cavity or canal of a tube-\\nshaped organ, such as the bowel.\\nProtozoan—A single-celled, usually microscopic\\norganism that is eukaryotic and, therefore, differ-\\nent from bacteria (prokaryotic).\\nMost patients are given a combination of luminal and\\ntissue amebicides over a treatment period of seven to ten\\ndays. Follow-up care includes periodic stool examinations\\nbeginning two to four weeks after the end of medication\\ntreatment to check the effectiveness of drug therapy.\\nPrognosis\\nThe prognosis depends on the location of the infection\\nand the patient’s general health prior to infection. The prog-\\nnosis is generally good, although the mortality rate is high-\\ner for patients with ameboma, perforation of the bowel, and\\nliver infection. Patients who develop fulminant colitis have\\nthe most serious prognosis, with over 50% mortality.\\nPrevention\\nThere are no immunization procedures or medica-\\ntions that can be taken prior to potential exposure to pre-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 145\\nAmebiasis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 145'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 159, 'page_label': '160'}, page_content='vent amebiasis. Moreover, people who have had the dis-\\nease can become reinfected. Prevention requires effective\\npersonal and community hygiene.\\nSpecific safeguards include the following:\\n• Purification of drinking water. Water can be purified by\\nfiltering, boiling, or treatment with iodine.\\n• Proper food handling. Measures include protecting\\nfood from contamination by flies, cooking food proper-\\nly, washing one’s hands after using the bathroom and\\nbefore cooking or eating, and avoiding foods that can-\\nnot be cooked or peeled when traveling in countries\\nwith high rates of amebiasis.\\n• Careful disposal of human feces.\\n• Monitoring the contacts of amebiasis patients. The\\nstools of family members and sexual partners of infect-\\ned persons should be tested for the presence of cysts or\\ntrophozoites.\\nResources\\nBOOKS\\nAckers, John P. “Amebiasis.” In Encyclopedia of Immunology.\\nV ol. 3. Ed. Ivan M. Roitt and Peter J. Delves. London:\\nAcademic Press, 1992.\\nFriedman, Lawrence S. “Liver, Biliary Tract, & Pancreas.” In\\nCurrent Medical Diagnosis and Treatment, 1998.37th ed.\\nEd. Stephen McPhee, et al. Stamford: Appleton & Lange,\\n1997.\\nGoldsmith, Robert S. “Infectious Diseases: Protozoal &\\nHelminthic.” In Current Medical Diagnosis and Treat-\\nment, 1998. 37th ed. Ed. Stephen McPhee, et al. Stam-\\nford: Appleton & Lange, 1997.\\nHasbun, Rodrigo, and Frank J. Bia. “Amebiasis.” In Conn’s\\nCurrent Therapy, 1996, ed. Robert E. Rakel. Philadelphia:\\nW. B. Saunders Co., 1996.\\n“Infectious Disease: Parasitic Infections.” In The Merck Manu-\\nal of Diagnosis and Therapy.16th ed. Ed. Robert Berkow.\\nRahway, NJ: Merck Research Laboratories, 1992.\\nWeinberg, Adriana, and Myron J. Levin. “Infections: Parasitic\\n& Mycotic.” In Current Pediatric Diagnosis & Treatment,\\ned. William W. Hay Jr., et al. Stamford: Appleton &\\nLange, 1997.\\nRebecca J. Frey\\nAmebic dysentery see Amebiasis\\nAmenorrhea\\nDefinition\\nThe absence of menstrual periods is called amenor-\\nrhea. Primary amenorrhea is the failure to start having a\\nperiod by the age of 16. Secondary amenorrhea is more\\ncommon and refers to either the temporary or permanent\\nending of periods in a woman who has menstruated nor-\\nmally in the past. Many women miss a period occasional-\\nly. Amenorrhea occurs if a woman misses three or more\\nperiods in a row.\\nDescription\\nThe absence of menstrual periods is a symptom, not\\na disease. While the average age that menstruation begins\\nis 12, the range varies. The incidence of primary amenor-\\nrhea in the United States is just 2.5%.\\nSome female athletes who participate in rowing,\\nlong distance running, and cycling, may notice a few\\nmissed periods. Women athletes at a particular risk for\\ndeveloping amenorrhea include ballerinas and gymnasts,\\nwho typically exercise strenuously and eat poorly.\\nCauses and symptoms\\nAmenorrhea can have many causes. Primary amenor-\\nrhea can be the result of hormonal imbalances, psychi-\\natric disorders, eating disorders, malnutrition, excessive\\nthinness or fatness, rapid weight loss, body fat content too\\nlow, and excessive physical conditioning. Intense physical\\ntraining prior to puberty can delay menarche (the onset\\nof menstruation). Every year of training can delay menar-\\nche for up to five months. Some medications such as anti-\\ndepressants, tranquilizers, steroids, and heroin can induce\\namenorrhea.\\nPrimary amenorrhea\\nHowever, the main cause is a delay in the beginning\\nof puberty either from natural reasons (such as heredity or\\npoor nutrition) or because of a problem in the endocrine\\nsystem, such as a pituitary tumor or hypothyroidism. An\\nobstructed flow tract or inflammation in the uterus may\\nbe the presenting indications of an underlying metabolic,\\nendocrine, congenital or gynecological disorder.\\nTypical causes of primary amenorrhea include:\\n• excessive physical activity\\n• drastic weight loss (such as occurs in anorexia or\\nbulimia)\\n• extreme obesity\\n• drugs (antidepressants or tranquilizers)\\n• chronic illness\\n• turner’s syndrome. (A chromosomal problem in place\\nat birth, relevant only in cases of primary amenorrhea)\\n• the absence of a vagina or a uterus\\nGALE ENCYCLOPEDIA OF MEDICINE 2146\\nAmenorrhea\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 146'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 160, 'page_label': '161'}, page_content='• imperforate hymen (lack of an opening to allow the\\nmenstrual blood through)\\nSecondary amenorrhea\\nSome of the causes of primary amenorrhea can also\\ncause secondary amenorrhea—strenuous physical activi-\\nty, excessive weight loss, use of antidepressants or tran-\\nquilizers, in particular. In adolescents, pregnancy and\\nstress are two major causes. Missed periods are usually\\ncaused in adolescents by stress and changes in environ-\\nment. Adolescents are especially prone to irregular peri-\\nods with fevers, weight loss, changes in environment, or\\nincreased physical or athletic activity. However, any ces-\\nsation of periods for four months should be evaluated.\\nThe most common cause of seconardy amenorrhea is\\npregnancy. Also, a woman’s periods may halt temporarily\\nafter she stops taking birth control pills. This temporary\\nhalt usually lasts only for a month or two, though in some\\ncases it can last for a year or more. Secondary amenor-\\nrhea may also be related to hormonal problems related to\\nstress, depression, anorexia nervosa or drugs, or it may\\nbe caused by any condition affecting the ovaries, such as a\\ntumor. The cessation of menstruation also occurs perma-\\nnently after menopause or a hysterectomy.\\nPolycystic ovary syndromeis another common cause\\nof secondary amenorrhea. It is caused by ovaries contain-\\ning many fluid filled sacs (cysts) with abnormal levels of\\nmale hormones (androgens). This condition is related to\\nimproper functioning of the pituitary gland, as it releases\\nhormones necessary for pregnancy (leuteinizing hor-\\nmones), and can cause women to develop male characteris-\\ntics, such as acne and coarse body hair. If the condition is\\nnot treated, some of the androgens may convert to estrogen,\\nand chronically high levels of estrogen may increase the\\nchance of developing cancer of the uterine lining.\\nDiagnosis\\nIt may be difficult to find the cause of amenorrhea,\\nbut the exam should start with a pregnancy test; pregnan-\\ncy needs to be ruled out whenever a woman’s period is\\ntwo to three weeks overdue. Androgen excess, estrogen\\ndeficiency, or other problems with the endocrine system\\nneed to be checked. Prolactin in the blood and the thy-\\nroid stimulating hormone (TSH) should also be checked.\\nThe diagnosis usually includes a patient history and\\na physical exam (including a pelvic exam ). If a woman\\nhas missed three or more periods in a row, a physician\\nmay recommend blood tests to measure hormone levels,\\na scan of the skull to rule out the possibility of a pituitary\\ntumor, and ultrasound scans of the abdomen and pelvis to\\nrule out a tumor of the adrenal gland or ovary.\\nTreatment\\nTreatment of amenorrhea depends on the cause. Pri-\\nmary amenorrhea often requires no treatment, but it’s\\nalways important to discover the cause of the problem in\\nany case. Not all conditions can be treated, but any\\nunderlying condition that is treatable should be treated.\\nIf a hormonal imbalance is the problem, proges-\\nterone for one to two weeks every month or two may cor-\\nrect the problem. With polycystic ovary syndrome, birth\\ncontrol pills are often prescribed. A pituitary tumor is\\ntreated with bromocriptine, a drug that reduces certain\\nhormone (prolactin) secretions. Weight loss may bring\\non a period in an obese woman. Easing up on excessive\\nexercise and eating a proper diet may bring on periods in\\nteen athletes. In very rare cases, surgery may be needed\\nfor women with ovarian or uterine cysts.\\nPrognosis\\nProlonged amenorrhea can lead to infertilityand other\\nmedical problems such as osteoporosis (thinning of the\\nbones). If the halt in the normal period is caused by stress\\nor illness, periods should begin again when the stress pass-\\nes or the illness is treated. Amenorrhea that occurs with dis-\\ncontinuing birth control pills usually go away within six to\\neight weeks, although it may take up to a year.\\nThe prognosis for polycystic ovary disease depends\\non the severity of the symptoms and the treatment plan.\\nSpironolactone, a drug that blocks the production of\\nmale hormones, can help in reducing body hair. If a\\nwoman wishes to become pregnant, treatment with\\nclomiphene may be required or, on rare occasions,\\nsurgery on the ovaries.\\nPrevention\\nPrimary amenorrhea caused by a congenital condi-\\ntion cannot be prevented. In general, however, women\\nshould maintain a healthy diet, with plenty of exercise,\\nrest, and not too much stress, avoiding smoking and sub-\\nstance abuse. Female athletes should be sure to eat a bal-\\nanced diet and rest and exercise normally. However,\\nmany cases of amenorrhea cannot be prevented.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie Eisenstat, and Ziporyn Eisenstat.\\nThe Harvard Guide to Women’s Health.Cambridge, MA:\\nHarvard University Press, 1996.\\nPERIODICALS\\nHogg, Anne Cahill. “Breaking the Cycle: Often Confused and\\nFrustrated, Sufferers of Amenorrhea Now have Better\\nGALE ENCYCLOPEDIA OF MEDICINE 2 147\\nAmenorrhea\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 147'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 161, 'page_label': '162'}, page_content='Treatment Options.”American Fitness 15, no. 4 (July-\\nAug. 1997): 30-4.\\nKiningham, Robert B., Barbara Apgar, and Thomas Schwenk.\\n“Evaluation of Amenorrhea.”American Family Physician\\n53, no. 3 (Mar. 1996): 1185-95.\\nMayo editors. “Amenorrhea: Can Athletics Disrupt a Girl’s\\nMenstrual Cycle During the Growing Years?”Mayo Clin-\\nic Nutrition Letter 2, no. 9 (Sept. 1989): 4-5.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th Street, S.W., P.O. 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\\nAmikiacin see Aminoglycosides\\nAmiloride see Diuretics\\nAmino acid disorders\\nscreening\\nDefinition\\nAmino acid disorder screening checks for inherited\\ndisorders in amino acid metabolism. Tests are most com-\\nmonly done on newborns. Two tests are available, one\\nusing a blood sample and the other a urine sample.\\nPurpose\\nAmino acid disorder screening is done in newborns,\\nand sometimes children and adults, to detect inborn\\nerrors in metabolism of amino acids. Twenty of the 100\\nknown amino acids are the main building blocks for\\nhuman proteins. Proteins regulate every aspect of cellular\\nKEY TERMS\\nHymen—Membrane that stretches across the\\nopening of the vagina.\\nHypothyroidism—Underactive thyroid gland.\\nHysterectomy—Surgical removal of the uterus.\\nTurner’s syndrome —A condition in which one\\nfemale sex chromosome is missing.\\nfunction. Of these 20 amino acids, ten are not made by\\nthe body and must be acquired through diet. Congenital\\n(present at birth) enzyme deficiencies that affect amino\\nacid metabolism or congenital abnormalities in the\\namino acid transport system of the kidneys creates a con-\\ndition called aminoaciduria.\\nScreening is especially important in newborns.\\nSome congenital amino acid metabolic defects cause\\nmental retardation that can prevented with prompt\\ntreatment of the newborn. One of the best known exam-\\nples of this is phenylketonuria (PKU). This is an genetic\\nerror in metabolism of phenylalanine, an amino acid\\nfound in milk. Individuals with PKU do not produce the\\nenzyme necessary to break down phenylalanine.\\nPKU occurs in about one out of 16,000 live births in\\nthe United States, but is more prevalent in caucasians and\\nless prevalent in Ashkenazi Jews and African Americans.\\nNewborns in the United States are routinely screened for\\nPKU by a blood test.\\nThere are two types of aminoacidurias. Primary or\\noverflow aminoaciduria results from deficiencies in the\\nenzymes necessary to metabolize amino acids. Overflow\\naminoaciduria is best detected by a blood plasma test.\\nSecondary or renal aminoaciduria occurs because of\\na congenital defect in the amino acid transport system in\\nthe tubules of the kidneys. This produces increased\\namino acids in the urine. Blood and urine test in combi-\\nnation are used to determine if the aminoaciduria is of\\nthe overflow or renal type. Urine tests are also used to\\nmonitor specific amino acid disorders.\\nNewborns are screened for amino acid disorders.\\nYoung children with acidosis (accumulation of acid in\\nthe body), severe vomiting and diarrhea , or urine with\\nan abnormal color or odor, are also screened with a urine\\ntest for specific amino acid levels.\\nPrecautions\\nBoth blood and urine tests are simple tests that can\\nbe done in a doctor’s office or clinic. These tests can be\\ndone on even the youngest patients.\\nDescription\\nTwo types of amino acid screening tests are used\\ntogether to diagnose amino acid disorders.\\nBlood plasma screening\\nIn the blood test, a medical technician draws a small\\namount of blood from a baby’s heel. The procedure is\\nrapid and relatively painless. Total time for the test is less\\nthan ten minutes. The blood is sent to a laboratory where\\nresults will be available in about two days.\\nGALE ENCYCLOPEDIA OF MEDICINE 2148\\nAmino acid disorders screening\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 148'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 162, 'page_label': '163'}, page_content='Urine test\\nIn the urine test, the patient is asked to urinate into a\\ncollecting cup. For an infant, the urine is collected in a pedi-\\natric urine collector. The process is painless. The length of\\ntime the test takes is determined by how long it takes the\\npatient to urinate. Results also take about two days.\\nBoth these tests use thin layer chromatography to\\nseparate the amino acids present. Using this technique,\\nthe amino acids form a characteristic patterns on a glass\\nplate coated with a thin layer of silica gel. This pattern is\\nthen compared to the normal pattern to determine if there\\nare abnormalities.\\nPreparation\\nBefore the blood test, the patient must not eat or\\ndrink for four hours. Failure to fast will alter the results\\nof the test.\\nThe patient should eat and drink normally before the\\nurine test. Some drugs may affect the results of the urine\\ntest. The technician handling the urine sample should be\\ninformed of any medications the patient is taking. Moth-\\ners of breastfeeding infants should report any medica-\\ntions they are taking, since these can pass from mother to\\nchild in breast milk.\\nAftercare\\nThe blood screening is normally done first. Depend-\\ning on the results, it is followed by the urine test. It takes\\nboth tests to distinguish between overflow and renal\\naminoaciduria. Also, if the results are abnormal, a 24-\\nhour urine test is performed along with other tests to\\ndetermine the levels of specific amino acids. In the event\\nof abnormal results, there are many other tests that will\\nbe performed to determine the specific amino acid\\ninvolved in the abnormality.\\nRisks\\nThere are no particular risks associated with either\\nof these tests. Occasionally minor bruising may occur at\\nthe site where the blood was taken.\\nNormal results\\nThe pattern of amino acid banding on the thin layer\\nchromatography plates will be normal.\\nAbnormal results\\nThe blood plasma amino acid pattern is abnormal in\\noverflow aminoaciduria and is normal in renal\\naminoaciduria. The pattern is abnormal in the urine test,\\nsuggesting additional tests need to be done to determine\\nKEY TERMS\\nAmino acid—An organic compound composed of\\nboth an amino group and an acidic carboxyl\\ngroup; amino acids are the basic building blocks\\nof proteins.\\nAminoaciduria—The abnormal presence of amino\\nacids in the urine.\\nChromatography —A family of laboratory tech-\\nniques that separate mixtures of chemicals into\\ntheir individual components.\\nEnzyme—A biological catalyst that increases the\\nrate of a chemical reaction without being used up\\nin the reaction.\\nMetabolism—The sum of all the chemical and\\nenergy reactions that take place in the human body.\\nwhich amino acids are involved. In addition to PKU, a\\nvariety of other amino acid metabolism disorders can be\\ndetected by these tests, including tyrosinosis, histidine-\\nmia, maple syrup urine disease, hypervalinemia, hyper-\\nprolinemia, and homocystinuria.\\nResources\\nBOOKS\\nEverything You Need to Know About Medical Tests.Ed.\\nMichael Shaw, et al. Springhouse, PA: Springhouse Cor-\\nporation, 1996.\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nORGANIZATIONS\\nAssociation for Neuro-Metabolic Disorders. 5223 Brookfield\\nLane, Sylvania, OH 43560-1809. (419) 885-1497.\\nChildren’s PKU Network (CPN). 3790 Via De La Valle, Ste\\n120, Del Mar, CA 92014. (800) 377-6677. .\\nNational Phenylketonuria Foundation. 6301 Tejas Drive,\\nPasadena, TX 77503. (713) 487-4802.\\nTish Davidson\\nAminoglycosides\\nDefinition\\nAminoglycosides are a group of antibiotics that are\\nused to treat certain bacterial infections. This group of\\nGALE ENCYCLOPEDIA OF MEDICINE 2 149\\nAminoglycosides\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 149'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 163, 'page_label': '164'}, page_content='antibiotics includes at least eight drugs: amikacin, gen-\\ntamicin, kanamycin, neomycin, netilmicin, paro-\\nmomycin, streptomycin, and tobramycin. All of these\\ndrugs have the same basic chemical structure.\\nPurpose\\nAminoglycosides are primarily used to combat infec-\\ntions due to aerobic, Gram-negative bacteria. These bacte-\\nria can be identified by their reaction to Gram’s stain. In\\nGram’s staining, a film of material containing the possible\\nbacteria is placed on a glass slide and dried. The slide is\\nstained with crystal violet for one minute, cleaned off with\\nwater and then placed into a solution of Gram’s iodine\\nsolution for one minute. The iodine solution is rinsed off\\nand the slide is immersed in 95% ethyl alcohol. The slide is\\nthen stained again with reddish carbolfuchsin or safranine\\nfor 30 seconds, rinsed in water, dried and examined. Gram-\\npositive bacteria retain the violet purple stain. Gram-nega-\\ntive bacteria accept the red stain. Bacteria that can success-\\nfully be combated with aminoglycosides include\\nPseudomonas, Acinetobacter, and Enterobacter species,\\namong others. Aminoglycosides are also effective against\\nmycobacteria, the bacteria responsible for tuberculosis.\\nThe aminoglycosides can be used against certain\\nGram-positive bacteria, but are not typically employed\\nbecause other antibiotics are more effective and have\\nfewer side effects. Aminoglycosides are ineffective\\nagainst anaerobic bacteria (bacteria that cannot grow in\\nthe presence of oxygen), viruses, and fungi. And only\\none aminoglycoside, paromomycin, is used against para-\\nsitic infection.\\nLike all other antibiotics, aminoglycosides are not\\neffective against influenza , the common cold , or other\\nviral infections.\\nPrecautions\\nPre-existing medical conditions—such as kidney dis-\\nease, eighth cranial nerve disease,myasthenia gravis, and\\nParkinson’s disease—should be discussed prior to taking\\nany aminoglycosides. Pregnant women are usually advised\\nagainst taking aminoglycosides, because their infants may\\nsuffer damage to their hearing, kidneys, or sense of bal-\\nance. However, those factors need to be considered along-\\nside the threat to the mother’s health and life in cases of\\nserious infection. Aminoglycosides do not pass into breast\\nmilk to any great extent, so nursing mothers may be pre-\\nscribed aminoglycosides without injuring their infants.\\nDescription\\nStreptomycin, the first aminoglycoside, was isolated\\nfrom Streptomyces griseusin the mid-1940s. This antibiot-\\nic was very effective against tuberculosis. One of the main\\ndrawbacks to streptomycin is its toxicity, especially to cells\\nin the inner and middle ear and the kidney. Furthermore,\\nsome strains of tuberculosis are resistant to treatment with\\nstreptomycin. Therefore, medical researchers have put con-\\nsiderable effort into identifying other antibiotics with strep-\\ntomycin’s efficacy, but without its toxicity.\\nAminoglycosides are absorbed very poorly from the\\ngastrointestinal tract; in fact, aminoglycosides taken oral-\\nly are excreted virtually unchanged and undiminished in\\nquantity. The route of drug administration depends on the\\ntype and location of the infection being treated. The typi-\\ncal routes of administration are by intramuscular (injec-\\ntion into a muscle) or intravenous injection (injection into\\na vein), irrigation, topical skin application, or inhalation.\\nIf the infection being treated involves the central nervous\\nsystem, the drug can be injected into the spinal canal.\\nThe bactericidal ability of aminoglycosides has not\\nbeen fully explained. It is known that the drug attaches to\\na bacterial cell wall and is drawn into the cell via chan-\\nnels made up of the protein, porin. Once inside the cell,\\nthe aminoglycoside attaches to the cell’s ribosomes.\\nRibosomes are the intracellular structures responsible for\\nmanufacturing proteins. This attachment either shuts\\ndown protein production or causes the cell to produce\\nabnormal, ineffective proteins. The bacterial cell cannot\\nsurvive with this impediment.\\nAntibiotic treatment using aminoglycosides may\\npair the drug with a second type of antibiotic, usually a\\nbeta-lactam or vancomycin, administered separately.\\nBeta-lactams disrupt the integrity of the bacteria cell\\nwall, making it more porous. The increased porosity\\nallows more of the aminoglycoside into the bacteria cell.\\nTraditionally, aminoglycosides were administered at\\neven doses given throughout the day. It was thought that\\na steady plasma concentration was necessary to combat\\ninfection. However, this administration schedule is time\\nand labor intensive. Furthermore, administering a single\\ndaily dose can be as effective, or more effective, than\\nseveral doses throughout the day.\\nDosage depends on the patient’s age, weight, gender,\\nand general health. Since the drug is cleared by the kid-\\nneys, it is important to assess any underlying problems\\nwith kidney function. Kidney function is assessed by\\nmeasuring the blood levels of creatinine, a protein nor-\\nmally found in the body. If these levels are high, it is an\\nindication that the kidneys may not be functioning at an\\noptimal rate and dosage will be lowered accordingly.\\nRisks\\nAminoglycosides have been shown to be toxic to cer-\\ntain cells in the ears and in the kidneys. Approximately 5-\\nGALE ENCYCLOPEDIA OF MEDICINE 2150\\nAminoglycosides \\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 150'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 164, 'page_label': '165'}, page_content='10% of the people who are treated with aminoglycosides\\nexperience some side effect, affecting their hearing, sense\\nof balance, or kidneys. However, in most cases the dam-\\nage is minor and reversible once medication is stopped.\\nIf cells in the inner ear are damaged or destroyed, an\\nindividual may experience a loss of balance and feelings\\nof dizziness . Damage to the middle ear may result in\\nhearing loss or tinnitus . Neomycin, kanamycin, and\\namikacin are the most likely to cause problems with\\nhearing, and streptomycin and gentamicin carry the\\ngreatest risk of causing vertigo and loss of balance. Kid-\\nney damage, apparent with changes in urination frequen-\\ncy or urine production, is most likely precipitated by\\nneomycin, tobramycin, and gentamicin.\\nYoung children and the elderly are at the greatest\\nrisk of suffering side effects. Excessive dosage or poor\\nclearance of the drug from the body can be injurious at\\nany age.\\nLess common side effects include skin rashes and\\nitching. Very rarely, certain aminoglycosides may cause\\ndifficulty in breathing, weakness, or drowsiness. Gen-\\ntamicin, when injected, may cause leg cramps, skin rash,\\nfever, or seizures.\\nIf side effects linger or become worse after medica-\\ntion is stopped, it is advisable to seek medical advice.\\nSide effects that may be of concern include tinnitus or\\nloss of hearing, dizziness or loss of balance, changes in\\nurination frequency or urine production, increased thirst,\\nappetite loss, and nausea or vomiting.\\nNormal results\\nAt the proper dosage and in the presence of gram-\\nnegative enteric (intestinal) bacteria, aminoglycosides\\nare very effective in treating an infection.\\nAbnormal results\\nIn some cases, bacteria are resistant to antibiotics\\nthat would normally kill them. This resistance becomes\\napparent after repeated exposure to the antibiotic and\\narises from a mutation that alters the bacteria’s suscepti-\\nbility to the drug. Various degrees of resistance have been\\nobserved in bacteria that normally would be destroyed by\\naminoglycosides. In general, though, aminoglycoside\\neffectiveness has held up well over time.\\nResources\\nBOOKS\\nChambers, Henry F., W. Keith Hadley, and Ernest Jawetz.\\n“Aminoglycosides & Spectinomycin.” In Basic and Clini-\\ncal Pharmacology. 7th ed. Ed. Bertram G. Katzung. Stam-\\nford: Appleton & Lange, 1998.\\nKEY TERMS\\nAerobic bacteria—Bacteria which require oxygen\\nin order to grow and survive.\\nAnaerobic bacteria—Bacteria which cannot grow\\nor reproduce in the presence of oxygen.\\nEighth cranial nerve disease—A disorder affecting\\nthe eighth cranial nerve, characterized by a loss of\\nhearing and/or balance.\\nGram-negative —Referring to a bacteria that take\\non a pink color when exposed to Gram’s stain.\\nGram-positive—Referring to a bacteria that takes\\non a purplish- black color when exposed to\\nGram’s stain.\\nGram’s stain—A stain used in microbiology to\\nclassify bacteria and help identify the species to\\nwhich they belong. This identification aids in\\ndetermining treatment.\\nKidney disease —Any disorder which impairs the\\nkidney’s ability to remove waste and toxins from\\nthe body.\\nMyasthenis gravis —A neuromuscular disease\\ncharacterized by muscle weakness in the limbs\\nand face.\\nParkinson’s disease —A neurological disorder\\ncaused by deficiency of dopamine, a neurotrans-\\nmitter, that is a chemical that assists in transmitting\\nmessages between the nerves within the brain. It is\\ncharacterized by muscle tremor or palsy and rigid\\nmovements.\\nLerner, Stephen A., Robert P. Gaynes, and Lisbeth Nördstrom-\\nLerner. “Aminoglycosides.” In Infectious Diseases. 2nd\\ned. Ed. Sherwood L. Gorbach, John G. Bartlett, and Neil\\nR. Blacklow. Philadelphia: W. B. Saunders Co., 1998.\\nJulia Barrett\\nAmitriptyline see Antidepressants, tricyclic\\nAmlodipine see Calcium channel blockers\\nAmnesia\\nDefinition\\nAmnesia refers to the loss of memory. Memory loss\\nmay result from two-sided (bilateral) damage to parts of\\nGALE ENCYCLOPEDIA OF MEDICINE 2 151\\nAmnesia\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 151'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 165, 'page_label': '166'}, page_content='the brain vital for memory storage, processing, or recall\\n(the limbic system, including the hippocampus in the\\nmedial temporal lobe).\\nDescription\\nAmnesia can be a symptom of several neurodegen-\\nerative diseases; however, people whose primary symp-\\ntom is memory loss (amnesiacs), typically remain lucid\\nand retain their sense of self. They may even be aware\\nthat they suffer from a memory disorder.\\nPeople who experience amnesia have been instrumen-\\ntal in helping brain researchers determine how the brain\\nprocesses memory. Until the early 1970s, researchers\\nviewed memory as a single entity. Memory of new experi-\\nences, motor skills, past events, and previous conditioning\\nwere grouped together in one system that relied on a spe-\\ncific area of the brain.\\nIf all memory were stored in the same way, it would\\nbe reasonable to deduce that damage to the specific brain\\narea would cause complete memory loss. However, stud-\\nies of amnesiacs counter that theory. Such research\\ndemonstrates that the brain has multiple systems for pro-\\ncessing, storing, and drawing on memory.\\nCauses and symptoms\\nAmnesia has several root causes. Most are traceable\\nto brain injury related to physical trauma, disease, infec-\\ntion, drug and alcohol abuse, or reduced blood flow to\\nthe brain (vascular insufficiency). In Wernicke-Korsakoff\\nsyndrome, for example, damage to the memory centers\\nof the brain results from the use of alcohol or malnutri-\\ntion. Infections that damage brain tissue, including\\nencephalitis and herpes, can also cause amnesia. If the\\namnesia is thought to be of psychological origin, it is\\ntermed psychogenic.\\nThere are at least three general types of amnesia:\\n• Anterograde. This form of amnesia follows brain trau-\\nma and is characterized by the inability to remember\\nnew information. Recent experiences and short-term\\nmemory disappear, but victims can recall events prior\\nto the trauma with clarity.\\n• Retrograde. In some ways, this form of amnesia is the\\nopposite of anterograde amnesia: the victim can recall\\nevents that occurred after a trauma, but cannot remem-\\nber previously familiar information or the events pre-\\nceding the trauma.\\n• Transient global amnesia. This type of amnesia has no\\nconsistently identifiable cause, but researchers have\\nsuggested that migraines or transient ischemic attacks\\nmay be the trigger. (A transient ischemic attack ,\\nsometimes called “a small stroke,” occurs when a\\nblockage in an artery temporarily blocks off blood sup-\\nply to part of the brain.) A victim experiences sudden\\nconfusion and forgetfulness. Attacks can be as brief as\\n30-60 minutes or can last up to 24 hours. In severe\\nattacks, a person is completely disoriented and may\\nexperience retrograde amnesia that extends back sever-\\nal years. While very frightening for the patient, tran-\\nsient global amnesia generally has an excellent progno-\\nsis for recovery.\\nDiagnosis\\nIn diagnosing amnesia and its cause, doctors look at\\nseveral factors. During a physical examination, the doc-\\ntor inquires about recent traumas or illnesses, drug and\\nmedication history, and checks the patient’s general\\nhealth. Psychological exams may be ordered to deter-\\nmine the extent of amnesia and the memory system\\naffected. The doctor may also order imaging tests such as\\nmagnetic resonance imaging (MRI) to reveal whether\\nthe brain has been damaged, and blood work to exclude\\ntreatable metabolic causes or chemical imbalances.\\nTreatment\\nTreatment depends on the root cause of amnesia and\\nis handled on an individual basis. Regardless of cause,\\ncognitive rehabilitation may be helpful in learning\\nstrategies to cope with memory impairment.\\nGALE ENCYCLOPEDIA OF MEDICINE 2152\\nAmnesia\\nAmygdalaHippocampus\\nMemory loss may result from bilateral damage to the limbic\\nsystem of the brain responsible for memory storage, pro-\\ncessing, and recall.(Illustration by Electronic Illustrators Group).\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 152'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 166, 'page_label': '167'}, page_content='Prognosis\\nSome types of amnesia, such as transient global\\namnesia, are completely resolved and there is no perma-\\nnent loss of memory. Others, such as Korsakoff syn-\\ndrome, associated with prolonged alcohol abuse or\\namnesias caused by severe brain injury, may be perma-\\nnent. Depending on the degree of amnesia and its cause,\\nvictims may be able to lead relatively normal lives.\\nAmnesiacs can learn through therapy to rely on other\\nmemory systems to compensate for what is lost.\\nPrevention\\nAmnesia is only preventable in so far as brain injury\\ncan be prevented or minimized. Common sense approach-\\nes include wearing a helmet when bicycling or participat-\\ning in potentially dangerous sports, using automobile seat\\nbelts, and avoiding excessive alcohol or drug use. Brain\\ninfections should be treated swiftly and aggressively to\\nminimize the damage due to swelling. Victims of strokes,\\nbrain aneurysms, and transient ischemic attacks should\\nseek immediate medical treatment.\\nResources\\nBOOKS\\nCohen, Neal J., and Howard Eichenbaum. Memory, Amnesia,\\nand the Hippocampal System. Cambridge, MA: MIT\\nPress, 1993.\\nKEY TERMS\\nClassical conditioning —The memory system that\\nlinks perceptual information to the proper motor\\nresponse. For example, Ivan Pavlov conditioned a\\ndog to salivate when a bell was rung.\\nEmotional conditioning —The memory system that\\nlinks perceptual information to an emotional\\nresponse. For example, spotting a friend in a crowd\\ncauses a person to feel happy.\\nExplicit memory —Conscious recall of facts and\\nevents that is classified into episodic memory\\n(involves time and place) and semantic memory\\n(does not involve time and place). For example, an\\namnesiac may remember he has a wife (semantic\\nmemory), but cannot recall his last conversation\\nwith her (episodic memory).\\nLimbic system —The brain structures involved in\\nmemory.\\nMagnetic resonance imaging (MRI) —MRI uses a\\nlarge circular magnet and radio waves to generate\\nsignals from atoms in the body. These signals are\\nused to construct images of internal structures.\\nMotor skill learning —This memory system is asso-\\nciated with physical movement and activity. For\\nexample, learning to swim is initially difficult, but\\nonce an efficient stroke is learned, it requires little\\nconscious effort.\\nNeurodegenerative disease —A disease in which\\nthe nervous system progressively and irreversibly\\ndeteriorates.\\nPriming memory —The memory system that joins\\nperceptual and conceptual representations.\\nTransient ischemic attack —A sudden and brief\\nblockage of blood flow in the brain.\\nWorking memory—The memory system that relates\\nto the task at hand and coordinates recall of memo-\\nries necessary to complete it.\\nPERIODICALS\\nKaufman, Leslie. “The Forgetting People: Amnesiacs.”Health\\n9, no. 6 (Oct. 1995): 86.\\nSquire, Larry R., and Stuart M. Zola. “Amnesia, Memory and\\nBrain Systems.” Philosophical Transactions of the Royal\\nSociety of London, Series B 352 (1997): 1663.\\n“The Man Who Lost Himself.”World Press Review44, no. 6\\n(June 1997): 36. (Reprinted from Der Spiegel 17 Mar.\\n1997.)\\nJulia Barrett\\nAmniocentesis\\nDefinition\\nAmniocentesis is a procedure used to diagnose fetal\\ndefects in the early second trimester of pregnancy . A\\nsample of the amniotic fluid, which surrounds a fetus in\\nthe womb, is collected through a pregnant woman’s\\nabdomen using a needle and syringe. Tests performed on\\nfetal cells found in the sample can reveal the presence of\\nmany types of genetic disorders, thus allowing doctors\\nand prospective parents to make important decisions\\nabout early treatment and intervention.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 153\\nAmniocentesis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 153'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 167, 'page_label': '168'}, page_content='Purpose\\nSince the mid-1970s, amniocentesis has been used\\nroutinely to test for Down syndrome , by far the most\\ncommon, nonhereditary, genetic birth defect, afflicting\\nabout one in every 1,000 babies. By 1997, approximately\\n800 different diagnostic tests were available, most of\\nthem for hereditary genetic disorders such as Tay-Sachs\\ndisease, sickle cell anemia, hemophilia, muscular dys-\\ntrophy and cystic fibrosis.\\nAmniocentesis, often called amnio, is recommended\\nfor women who will be older than 35 on their due-date. It\\nis also recommended for women who have already borne\\nchildren with birth defects, or when either of the parents\\nhas a family history of a birth defect for which a diagnos-\\ntic test is available. Another reason for the procedure is to\\nconfirm indications of Down syndrome and certain other\\ndefects which may have shown up previously during rou-\\ntine maternal blood screening.\\nThe risk of bearing a child with a nonhereditary\\ngenetic defect such as Down syndrome is directly relat-\\ned to a woman’s age—the older the woman, the greater\\nthe risk. Thirty-five is the recommended age to begin\\namnio testing because that is the age at which the risk of\\ncarrying a fetus with such a defect roughly equals the\\nrisk of miscarriage caused by the procedure—about\\none in 200. At age 25, the risk of giving birth to a child\\nwith this type of defect is about one in 1,400; by age 45\\nit increases to about one in 20. Nearly half of all preg-\\nnant women over 35 in the United States undergo\\namniocentesis and many younger women also decide to\\nhave the procedure. Notably, some 75% of all Down\\nsyndrome infants born in the United States each year are\\nto women younger than 35.\\nOne of the most common reasons for performing\\namniocentesis is an abnormal alpha-fetoprotein (AFP)\\ntest. Alpha-fetoprotein is a protein produced by the fetus\\nand present in the mother’s blood. A simple blood\\nscreening, usually conducted around the 15th week of\\npregnancy, can determine the AFP levels in the mother’s\\nblood. Levels that are too high or too low may signal\\npossible fetal defects. Because this test has a high false-\\npositive rate, another test such as amnio is recommended\\nwhenever the AFP levels fall outside the normal range.\\nAmniocentesis is generally performed during the\\n16th week of pregnancy, with results usually available\\nwithin three weeks. It is possible to perform an amnio as\\nearly as the 11th week but this is not usually recommend-\\ned because there appears to be an increased risk of mis-\\ncarriage when done at this time. The advantage of early\\namnio and speedy results lies in the extra time for deci-\\nsion making if a problem is detected. Potential treatment\\nof the fetus can begin earlier. Important, also, is the fact\\nthat elective abortions are safer and less controversial the\\nearlier they are performed.\\nPrecautions\\nAs an invasive surgical procedure, amnio poses a real,\\nalthough small, risk to the health of a fetus. Parents must\\nweigh the potential value of the knowledge gained, or\\nindeed the reassurance that all is well, against the small risk\\nof damaging what is in all probability a normal fetus. The\\nserious emotional and ethical dilemmas that adverse test\\nresults can bring must also be considered. The decision to\\nundergo amnio is always a matter of personal choice.\\nDescription\\nThe word amniocentesis literally means “puncture\\nof the amnion,” the thin-walled sac of fluid in which a\\ndeveloping fetus is suspended during pregnancy. During\\nthe sampling procedure, the obstetrician inserts a very\\nfine needle through the woman’s abdomen into the uterus\\nand amniotic sac and withdraws approximately one\\nounce of amniotic fluid for testing. The relatively pain-\\nless procedure is performed on an outpatient basis, some-\\ntimes using local anesthesia.\\nThe physician uses ultrasound images to guide nee-\\ndle placement and collect the sample, thereby minimiz-\\ning the risk of fetal injury and the need for repeated nee-\\ndle insertions. Once the sample is collected, the woman\\ncan return home after a brief observation period. She\\nmay be instructed to rest for the first 24 hours and to\\navoid heavy lifting for two days.\\nThe sample of amniotic fluid is sent to a laboratory\\nwhere fetal cells contained in the fluid are isolated and\\ngrown in order to provide enough genetic material for\\ntesting. This takes about seven to 14 days. The material is\\nthen extracted and treated so that visual examination for\\ndefects can be made. For some disorders, like Tay-Sachs,\\nthe simple presence of a telltale chemical compound in\\nthe amniotic fluid is enough to confirm a diagnosis.\\nDepending on the specific tests ordered, and the skill of\\nthe lab conducting them, all the results are available\\nbetween one and four weeks after the sample is taken.\\nCost of the procedure depends on the doctor, the lab,\\nand the tests ordered. Most insurers provide coverage for\\nwomen over 35, as a follow-up to positive maternal\\nblood screening results, and when genetic disorders run\\nin the family.\\nAn alternative to amnio, now in general use, is chori-\\nonic villus sampling, or CVS, which can be performed as\\nearly as the eighth week of pregnancy. While this allows\\nfor the possibility of a first trimester abortion, if warrant-\\ned, CVS is apparently also riskier and is more expensive.\\nGALE ENCYCLOPEDIA OF MEDICINE 2154\\nAmniocentesis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 154'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 168, 'page_label': '169'}, page_content='The most promising area of new research in prenatal test-\\ning involves expanding the scope and accuracy of mater-\\nnal blood screening as this poses no risk to the fetus.\\nPreparation\\nIt is important for a woman to fully understand the\\nprocedure and to feel confident in the obstetrician per-\\nforming it. Evidence suggests that a physician’s experi-\\nence with the procedure reduces the chance of mishap.\\nAlmost all obstetricians are experienced in performing\\namniocentesis. The patient should feel free to ask ques-\\ntions and seek emotional support before, during and after\\nthe amnio is performed.\\nAftercare\\nNecessary aftercare falls into two categories, physi-\\ncal and emotional.\\nPhysical aftercare\\nDuring and immediately following the sampling\\nprocedure, a woman may experience dizziness, nausea, a\\nrapid heartbeat, and cramping. Once past these immedi-\\nate hurdles, the physician will send the woman home\\nwith instructions to rest and to report any complications\\nrequiring immediate treatment, including:\\n• vaginal bleeding. The appearance of blood could signal\\na problem.\\n• premature labor . Unusual abdominal pain and/or\\ncramping may indicate the onset of premature labor.\\nMild cramping for the first day or two following the\\nprocedure is normal.\\n• signs of infection. Leaking of amniotic fluid or unusual\\nvaginal discharge, and fever could signal the onset of\\ninfection.\\nEmotional aftercare\\nOnce the procedure has been safely completed, the\\nanxiety of waiting for the test results can prove to be the\\nworst part of the process. A woman should seek and\\nreceive emotional support from family and friends, as\\nwell as from her obstetrician and family doctor. Profes-\\nsional counseling may also prove necessary, particularly\\nif a fetal defect is discovered.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 155\\nAmniocentesis\\nA physician uses an ultrasound monitor (left) to position the needle for insertion into the amnion when performing amnio-\\ncentesis. (Photograph by Will and Deni McIntyre, Photo Researchers, Inc. Reproduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 155'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 169, 'page_label': '170'}, page_content='Risks\\nMost of the risks and short-term side effects associ-\\nated with amniocentesis relate to the sampling procedure\\nand have been discussed above. A successful amnio sam-\\npling results in no long-term side effects. Risks include:\\n• maternal/fetal hemorrhaging. While spotting in preg-\\nnancy is fairly common, bleeding following amnio\\nshould always be investigated.\\n• infection. Infection, although rare, can occur after\\namniocentesis. An unchecked infection can lead to\\nsevere complications.\\n• fetal injury. A very slight risk of injury to the fetus\\nresulting from contact with the amnio needle does exist.\\n• miscarriage. The rate of miscarriage occurring during\\nstandard, second trimester amnio appears to be approx-\\nimately 0.5%. This compares to a miscarriage rate of\\nKEY TERMS\\nAlpha-fetoprotein (AFP) —A protein normally pro-\\nduced by the liver of a fetus and detectable in\\nmaternal blood samples. AFP screening measures\\nthe amount of alpha-fetoprotein in the blood. Levels\\noutside the norm may indicate fetal defects.\\nAnencephaly —A hereditary defect resulting in the\\npartial to complete absence of a brain and spinal\\ncord. It is fatal.\\nChorionic villus sampling (CVS)—A procedure simi-\\nlar to amniocentesis, except that cells are taken from\\nthe chorionic membrane for testing. These cells,\\ncalled chorionic villus cells, eventually become the\\nplacenta. The samples are collected either through\\nthe abdomen, as in amnio, or through the vagina.\\nCVS can be done earlier in the pregnancy than\\namnio, but carries a somewhat higher risk.\\nChromosome —Chromosomes are the strands of\\ngenetic material in a cell that occur in nearly identi-\\ncal pairs. Normal human cells contain 23 chromo-\\nsome pairs—one in each pair inherited from the\\nmother, and one from the father. Every human cell\\ncontains the exact same set of chromosomes.\\nDown syndrome—The most prevalent of a class of\\ngenetic defects known as trisomies, in which cells\\ncontain three copies of certain chromosomes rather\\nthan the usual two. Down syndrome, or trisomy 21,\\nusually results from three copies of chromosome 21.\\nGenetic—The term refers to genes, the basic units\\nof biological heredity, which are contained on the\\nchromosomes, and contain chemical instructions\\nwhich direct the development and functioning of an\\nindividual.\\nHereditary—Something which is inherited—passed\\ndown from parents to offspring. In biology and\\nmedicine, the word pertains to inherited genetic\\ncharacteristics.\\nMaternal blood screening—Maternal blood screen-\\ning is normally done early in pregnancy to test for a\\nvariety of conditions. Abnormal amounts of certain\\nproteins in a pregnant woman’s blood raise the\\nprobability of fetal defects. Amniocentesis is recom-\\nmended if such a probability occurs.\\nTay-Sachs disease—An inherited disease prevalent\\namong the Ashkenazi Jewish population of the\\nUnited States. Infants with the disease are unable to\\nprocess a certain type of fat which accumulates in\\nnerve and brain cells, causing mental and physical\\nretardation, and death by age four.\\nUltrasound—A technique which uses high-frequen-\\ncy sound waves to create a visual image (a sono-\\ngram) of soft tissues. The technique is routinely used\\nin prenatal care and diagnosis.\\n1% for CVS. Many fetuses with severe genetic defects\\nmiscarry naturally during the first trimester.\\n• the trauma of difficult family-planning decisions. The\\nthreat posed to parental and family mental health from\\nthe trauma accompanying an abnormal test result can\\nnot be underestimated.\\nNormal results\\nNegative results from an amnio analysis indicate\\nthat everything about the fetus appears normal and the\\npregnancy can continue without undue concern. A nega-\\ntive result for Down syndrome means that it is 99% cer-\\ntain that the disease does not exist.\\nAn overall “normal” result does not, however, guar-\\nantee that the pregnancy will come to term, or that the\\nfetus does not suffer from some other defect. Laboratory\\ntests are not 100% accurate at detecting targeted condi-\\ntions, nor can every possible fetal condition be tested for.\\nGALE ENCYCLOPEDIA OF MEDICINE 2156\\nAmniocentesis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 156'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 170, 'page_label': '171'}, page_content='Abnormal results\\nPositive results on an amnio analysis indicate the\\npresence of the fetal defect being tested for, with an\\naccuracy approaching 100%. Prospective parents are\\nthen faced with emotionally and ethically difficult choic-\\nes regarding treatment options, the prospect of dealing\\nwith a severely affected newborn, and the option of elec-\\ntive abortion. At this point, the parents need expert med-\\nical advice and counseling.\\nResources\\nBOOKS\\nElias, Sherman, and Joe Leigh Simpson. “Techniques for Pre-\\nnatal Diagnosis—Amniocentesis.” In Essentials of Prena-\\ntal Diagnosis. Ed. Joe Leigh Simpson and Sherman Elias.\\nNew York: Churchill Livingstone, 1993.\\nGenetic Disorders and the Fetus: Diagnosis, Prevention and\\nTreatment. Ed. Aubrey Milunsky. Baltimore: Johns Hop-\\nkins University Press, 1992.\\nKolker, Aliza. Prenatal Testing: A Sociological Perspective.\\nWestport, CT: Bergin & Garvey, 1994.\\nRapp, Rayna. “The Power of Positive Diagnosis: Medical and\\nMaternal Discourses on Amniocentesis.” In Repre-senta-\\ntions of Motherhood, ed. Donna Bassin, et al. New Haven,\\nCT: Yale University Press, 1994.\\nWomen and Prenatal Testing: Facing the Challenges of Genetic\\nTechnology.Ed. Karen H. Rothenberg and Elizabeth J.\\nThomson. Columbus, OH: Ohio State University Press,\\n1994.\\nPERIODICALS\\nBonner, John. “Simple Blood Test May Replace Amniocente-\\nsis.” New Scientist (5 Oct. 1996): 26.\\nBoss, Judith A. “First Trimester Prenatal Diagnosis: Earlier is\\nNot Necessarily Better.”Journal of Medical Ethics 20\\n(Sept. 1994): 146-151.\\n“Complications Associated with Early Amniocentesis.”Ameri-\\ncan Family Physician 54 (1 Oct. 1996): 1716.\\nDreisbach, Shaun. “Amnio Alternative.”Working Mother, Mar.\\n1997, 11.\\nJosephson, N. F. “What You May Not Know About Pregnancy\\nTests and What They Tell Your Doctor About Your Baby’s\\nHealth.” Parents, Apr. 1996, 77-8.\\nMarble, Michelle. “Testing During First Trimester Proves\\nRisky.”Women’s Health Weekly, 8 July 1996, 12.\\nSher, Emil. “Everything is Perfectly Normal.”Chatelaine, June\\n1996, 22.\\nStranc, Leonie C., et al. “Chorionic Villus Sampling and\\nAmniocentesis for Prenatal Diagnosis.”The Lancet (8\\nMar. 1997): 711-4.\\nSundberg, K., et al. “Randomized Study of Risk of Fetal Loss\\nRelated to Early Amniocentesis versus Chorionic Villus\\nSampling.” The Lancet (6 Sept. 1997): 697-703.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th Street, S.W., P.O. Box 96920\\nOTHER\\nHolbrook Jr., Harold R. Stanford University School of Medi-\\ncine Web Home Page. Feb. 2001 .\\nKurt Richard Sternlof\\nAmniotic fluid analysis see Amniocentesis\\nAmoxicillin see Penicillins\\nAmphetamines see Central nervous system\\nstimulants\\nAmphotericin B see Antifungal drugs,\\nsystemic\\nAmputation\\nDefinition\\nAmputation is the intentional surgical removal of a\\nlimb or body part. It is performed to remove diseased tis-\\nsue or relieve pain.\\nPurpose\\nArms, legs, hands, feet, fingers, and toes can all be\\namputated. Most amputations involve small body parts\\nsuch as a finger, rather than an entire limb. About 65,000\\namputations are performed in the United States each year.\\nAmputation is performed for the following reasons:\\n• to remove tissue that no longer has an adequate blood\\nsupply\\n• to remove malignant tumors\\n• because of severe trauma to the body part\\nThe blood supply to an extremity can be cut off\\nbecause of injury to the blood vessel, hardening of the\\narteries, arterial embolism , impaired circulation as a\\ncomplication of diabetes mellitus, repeated severe infec-\\ntion that leads to gangrene, severe frostbite, Raynaud’s\\ndisease, or Buerger’s disease.\\nMore than 90% of amputations performed in the\\nUnited States are due to circulatory complications of dia-\\nbetes. Sixty to eighty percent of these operations involve\\nthe legs.\\nPrecautions\\nAmputations cannot be performed on patients with\\nuncontrolled diabetes mellitus, heart failure , or infec-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 157\\nAmputation\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 157'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 171, 'page_label': '172'}, page_content='tion. Patients with blood clotting disorders are also not\\ngood candidates for amputation.\\nDescription\\nAmputations can be either planned or emergency\\nprocedures. Injury and arterial embolisms are the main\\nreasons for emergency amputations. The operation is\\nperformed under regional or general anesthesia by a gen-\\neral or orthopedic surgeon in a hospital operating room.\\nDetails of the operation vary slightly depending on\\nwhat part is to be removed. The goal of all amputations is\\ntwofold: to remove diseased tissue so that the wound will\\nheal cleanly, and to construct a stump that will allow the\\nattachment of a prosthesis or artificial replacement part.\\nThe surgeon makes an incision around the part to be\\namputated. The part is removed, and the bone is smoothed.\\nA flap is constructed of muscle, connective tissue, and\\nskin to cover the raw end of the bone. The flap is closed\\nover the bone with sutures (surgical stitches) that remain\\nin place for about one month. Often, a rigid dressing or\\ncast is applied that stays in place for about two weeks.\\nPreparation\\nBefore an amputation is performed, extensive testing\\nis done to determine the proper level of amputation. The\\ngoal of the surgeon is to find the place where healing is\\nmost likely to be complete, while allowing the maximum\\namount of limb to remain for effective rehabilitation.\\nThe greater the blood flow through an area, the more\\nlikely healing is to occur. These tests are designed to mea-\\nsure blood flow through the limb. Several or all of them\\ncan be done to help choose the proper level of amputation.\\n• measurement of blood pressure in different parts of the\\nlimb\\n• xenon 133 studies, which use a radiopharmaceutical to\\nmeasure blood flow\\n• oxygen tension measurements in which an oxygen elec-\\ntrode is used to measure oxygen pressure under the skin\\nGALE ENCYCLOPEDIA OF MEDICINE 2158\\nAmputation\\nFigure DFigure B\\nFigure A\\nFemur\\nSkin flapExposed\\nmuscle\\nFigure C\\nSciatic\\nnerve\\nAmputation of leg. Figure A: After the surgeon creates two flaps of skin and tissue, the muscle is cut and the main artery and\\nveins of the femur bone are exposed. Figure B:The surgeon severs the main artery and veins. New connections are formed\\nbetween them, restoring blood circulation.The sciatic nerve is then pulled down, clamped and tied, and severed. Figure C:\\nThe surgeon saws through the exposed femur bone. Figure D:The muscles are closed and sutured over the bone.The\\nremaining skin flaps are then sutured together, creating a stump.(Illustration by Electronic Illustrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 158'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 172, 'page_label': '173'}, page_content='If the pressure is 0, the healing will not occur. If the\\npressure reads higher than 40mm Hg (40 milliliters of\\nmercury), healing of the area is likely to be satisfactory.\\n• laser Doppler measurements of the microcirculation of\\nthe skin\\n• skin fluorescent studies that also measure skin micro-\\ncirculation\\n• skin perfusion measurements using a blood pressure\\ncuff and photoelectric detector\\n• infrared measurements of skin temperature\\nNo one test is highly predictive of healing, but taken\\ntogether, the results give the surgeon an excellent idea of\\nthe best place to amputate.\\nAftercare\\nAfter amputation, medication is prescribed for pain,\\nand patients are treated with antibiotics to discourage\\ninfection. The stump is moved often to encourage good\\ncirculation. Physical therapy and rehabilitation are started\\nas soon as possible, usually within 48 hours. Studies have\\nshown that there is a positive relationship between early\\nrehabilitation and effective functioning of the stump and\\nprosthesis. Length of stay in the hospital depends on the\\nseverity of the amputation and the general health of the\\namputee, but ranges from several days to two weeks.\\nRehabilitation is a long, arduous process, especially\\nfor above the knee amputees. Twice daily physical thera-\\npy is not uncommon. In addition, psychological counsel-\\ning is an important part of rehabilitation. Many people\\nfeel a sense of loss and grief when they lose a body part.\\nOthers are bothered by phantom limb syndrome, where\\nthey feel as if the amputated part is still in place. They\\nmay even feel pain in this limb that does not exist. Many\\namputees benefit from joining self-help groups and\\nmeeting others who are also living with amputation.\\nAddressing the emotional aspects of amputation often\\nspeeds the physical rehabilitation process.\\nRisks\\nAmputation is major surgery. All the risks associated\\nwith the administration of anesthesia exist, along with\\nthe possibility of heavy blood loss and the development\\nof blood clots. Infection is of special concern to\\namputees. Infection rates in amputations average 15%. If\\nthe stump becomes infected, it is necessary to remove the\\nprosthesis and sometimes to amputate a second time at a\\nhigher level.\\nFailure of the stump to heal is another major compli-\\ncation. Nonhealing is usually due to an inadequate blood\\nsupply. The rate of nonhealing varies from 5-30%\\nKEY TERMS\\nArterial embolism —A blood clot arising from\\nanother location that blocks an artery.\\nBuerger’s disease—An episodic disease that caus-\\nes inflammation and blockage of the veins and\\narteries of the limbs. It tends to be present almost\\nexclusively on men under age 40 who smoke, and\\nmay require amputation of the hand or foot.\\nDiabetes mellitus—A disease in which insufficient\\ninsulin is made by the body to metabolize sugars.\\nRaynaud’s disease —A disease found mainly in\\nyoung women that causes decreased circulation to\\nthe hands and feet. Its cause is unknown.\\ndepending on the facility. Centers that specialize in ampu-\\ntation usually have the lowest rates of complication.\\nPersistent pain in the stump or pain in the phantom\\nlimb is experienced by most amputees to some degree.\\nTreatment of phantom limb pain is difficult. One final\\ncomplication is that many amputees give up on the reha-\\nbilitation process and discard their prosthesis. Better fit-\\nting prosthetics and earlier rehabilitation have decreased\\nthe incidence of this problem.\\nNormal results\\nThe five year survival rate for all lower extremity\\namputees is less than 50%. For diabetic amputees, the\\nrate is less than 40%. Up to 50% of people who have\\none leg amputated because of diabetes will lose the\\nother within five years. Amputees who walk using a\\nprosthesis have a less stable gait. Three to five percent\\nof these people fall and break bones because of this\\ninstability. Although the fractures can be treated, about\\nhalf the amputees who suffer them then remain wheel-\\nchair bound.\\nResources\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard Street,\\nAlexandria, V A 22311. (800) 342-2383. .\\nOTHER\\nAmputation Prevention Global Resource Center Page. Feb.\\n2001. .\\nTish Davidson\\nGALE ENCYCLOPEDIA OF MEDICINE 2 159\\nAmputation\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 159'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 173, 'page_label': '174'}, page_content='Amylase tests\\nDefinition\\nAmylase is a digestive enzyme made primarily by\\nthe pancreas and salivary glands. Enzymes are sub-\\nstances made and used by the body to trigger specific\\nchemical reactions. The primary function of the enzyme\\namylase is to break down starches in food so that they\\ncan be used by the body. Amylase testing is usually done\\nto determine the cause of sudden abdominal pain.\\nPurpose\\nAmylase testing is performed to diagnose a number\\nof diseases that elevate amylase levels. Pancreatitis, for\\nexample, is the most common reason for a high amylase\\nlevel. When the pancreas is inflamed, amylase escapes\\nfrom the pancreas into the blood. Within six to 48 hours\\nafter the pain begins, amylase levels in the blood start to\\nrise. Levels will stay high for several days before gradu-\\nally returning to normal.\\nThere are other causes of increased amylase. An\\nulcer that erodes tissue from the stomach and goes into\\nthe pancreas will cause amylase to spill into the blood.\\nDuring a mumps infection, amylase from the inflamed\\nsalivary glands increases. Amylase is also found in the\\nliver, fallopian tubes, and small intestine; inflammation of\\nthese tissues also increases levels. Gall bladder disease,\\ntumors of the lung or ovaries, alcohol poisoning, ruptured\\naortic aneurysm, and intestinal strangulation or perfora-\\ntion can also cause unusually high amylase levels.\\nPrecautions\\nThis is not a screening test for future pancreatic dis-\\nease.\\nDescription\\nAmylase testing is done on both blood and urine.\\nThe laboratory may use any of several testing methods\\nthat involve mixing the blood or urine sample with a sub-\\nstance with which amylase is known to react. By measur-\\ning the end-product or the reaction time, technicians can\\ncalculate the amount of amylase present in the sample.\\nMore sophisticated methods separately measure the amy-\\nlase made by the pancreas and the amylase made by the\\nsalivary glands.\\nUrine testing is a better long-term monitor of amy-\\nlase levels. The kidneys quickly move extra amylase\\nfrom the blood into the urine. Urine levels rise six to 10\\nhours after blood levels and stay high longer. Urine is\\nusually collected throughout a 2- or 24-hour time period.\\nResults are usually available the same day.\\nPreparation\\nIn most cases, no special preparation is necessary for\\na person undergoing an amylase blood test. Patients taking\\nlonger term urine amylase tests will be given a container\\nand instructions for collecting the urine at home. The urine\\nshould be refrigerated until it is brought to the laboratory.\\nAftercare\\nDiscomfort or bruising may occur at the puncture site\\nor the person may feel dizzy or faint. Pressure to the punc-\\nture site until the bleeding stops reduces bruising. Apply-\\ning warm packs to the puncture site relieves discomfort.\\nNormal results\\nNormal results vary based on the laboratory and the\\nmethod used.\\nAbnormal results\\nEight out of ten persons with acute pancreatitis will\\nhave high amylase levels, up to four times the normal\\nlevel. Other causes of increased amylase, such as\\nmumps, kidney failure, pregnancy occurring in the\\nabdomen but outside the uterus ( ectopic pregnancy ),\\ncertain tumors, a penetrating ulcer, certain complications\\nof diabetes, and advanced pancreatic cancer, are further\\ninvestigated based on the person’s symptoms, medical\\nhistory, and the results of other tests.\\nIn kidney disease, the kidneys are not as efficient at\\nremoving amylase from the blood. Amylase rises in the\\nblood, but stays at normal levels in the urine.\\nPeople with macroamylasia have large clumps of\\namylase in their blood. These clumps are too large to\\nmove through the kidney, so they stay in the blood. Amy-\\nlase levels in the blood will be high; levels in the urine\\nwill be low.\\nAmylase levels may be low in severe liver disease\\n(including hepatitis), conditions in which the pancreas\\nfails to secrete enough enzyme for proper digestions\\n(pancreatic insufficiency), when toxic materials build up\\nin the blood during pregnancy (pre-eclampsia), following\\nburns, in thyroid disorders, and in advanced cystic\\nfibrosis. Some medications can raise or lower levels.\\nResources\\nBOOKS\\nA Manual of Laboratory and Diagnostic Tests.5th ed. Ed.\\nFrancis Fishback. Philadelphia: Lippincott, 1996.\\nGALE ENCYCLOPEDIA OF MEDICINE 2160\\nAmylase tests\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 160'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 174, 'page_label': '175'}, page_content='Henry, John B., ed. Clinical Diagnosis and Management by\\nLaboratory Methods. 19th ed. Philadelphia: W. B. Saun-\\nders Co., 1996.\\nLehman, Craig A. Saunders Manual of Clinical Laboratory\\nScience. Philadelphia: W. B. Saunders Co., 1998.\\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\\nAmyloidosis\\nDefinition\\nAmyloidosis is a progressive, incurable, metabolic\\ndisease characterized by abnormal deposits of protein in\\none or more organs or body systems.\\nDescription\\nAmyloid proteins are manufactured by malfunction-\\ning bone marrow. Amyloidosis, which occurs when accu-\\nmulated amyloid deposits impair normal body function,\\ncan cause organ failure or death. It is a rare disease,\\noccurring in about eight of every 1,000,000 people. It\\naffects males and females equally and usually develops\\nafter the age of 40. At least 15 types of amyloidosis have\\nbeen identified. Each one is associated with deposits of a\\ndifferent kind of protein.\\nTypes of amyloidosis\\nThe major forms of this disease are primary sys-\\ntemic, secondary, and familial or hereditary amyloidosis.\\nThere is also another form of amyloidosis associated\\nwith Alzheimer’s disease.\\nPrimary systemic amyloidosis usually develops\\nbetween the ages of 50 and 60. With about 2,000 new\\ncases diagnosed annually, primary systemic amyloidosis\\nKEY TERMS\\nAmylase—A digestive enzyme made primarily by\\nthe pancreas and salivary glands.\\nEnzyme—A substance made and used by the body\\nto trigger specific chemical reactions.\\nPancreatitis—Inflammation of the pancreas.\\nis the most common form of this disease in the United\\nStates. Also known as light-chain-related amyloidosis, it\\nmay also occur in association with multiple myeloma\\n(bone marrow cancer).\\nSecondary amyloidosis is a result of chronic infec-\\ntion or inflammatory disease. It is often associated with:\\n• familial Mediterranean fever (a bacterial infection\\ncharacterized by chills, weakness, headache , and\\nrecurring fever)\\n• granulomatous ileitis (inflammation of the small intes-\\ntine)\\n• Hodgkin’s disease (cancer of the lymphatic system)\\n• leprosy\\n• osteomyelitits (bacterial infection of bone and bone\\nmarrow)\\n• rheumatoid arthritis\\nFamilial or hereditary amyloidosis is the only inher-\\nited form of the disease. It occurs in members of most\\nethnic groups, and each family has a distinctive pattern\\nof symptoms and organ involvement. Hereditary amyloi-\\ndosis is though to be autosomal dominant, which means\\nthat only one copy of the defective gene is necessary to\\ncause the disease. A child of a parent with familial amy-\\nloidosis has a 50-50 chance of developing the disease.\\nAmyloidosis can involve any organ or system in the\\nbody. The heart, kidneys, gastrointestinal system, and\\nnervous system are affected most often. Other common\\nsites of amyloid accumulation include the brain, joints,\\nliver, spleen, pancreas, respiratory system, and skin.\\nCauses and symptoms\\nThe cause of amyloidosis is unknown. Most patients\\nhave gastrointestinal abnormalities, but other symptoms\\nvary according to the organ(s) or system(s) affected by\\nthe disease. Usually the affected organs are rubbery, firm,\\nand enlarged.\\nHeart\\nBecause amyloid protein deposits can limit the\\nheart’s ability to fill with blood between beats, even the\\nslightest exertion can cause shortness of breath . If the\\nheart’s electrical system is affected, the heart’s rhythm\\nmay become erratic. The heart may also be enlarged and\\nheart murmurs may be present. Congestive heart fail-\\nure may result.\\nKidneys\\nThe feet, ankles, and calves swell when amyloidosis\\ndamages the kidneys. The kidneys become small and\\nGALE ENCYCLOPEDIA OF MEDICINE 2 161\\nAmyloidosis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 161'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 175, 'page_label': '176'}, page_content='hard, and kidney failure may result. It is not unusual for a\\npatient to lose 20-25 pounds and develop a distaste for\\nmeat, eggs, and other protein-rich foods. Cholesterol ele-\\nvations that don’t respond to medication and protein in\\nthe urine (proteinuria) are common.\\nNervous system\\nNervous system symptoms often appear in patients\\nwith familial amyloidosis. Inflammation and degenera-\\ntion of the peripheral nerves ( peripheral neuropathy )\\nmay be present. One of four patients with amyloidosis\\nhas carpal tunnel syndrome , a painful disorder that\\ncauses numbness or tingling in response to pressure on\\nnerves around the wrist. Amyloidosis that affects nerves\\nto the feet can cause burning or numbness in the toes and\\nsoles and eventually weaken the legs. If nerves control-\\nling bowel function are involved, bouts of diarrhea\\nalternate with periods of constipation . If the disease\\naffects nerves that regulate blood pressure, patients may\\nfeel dizzy or faint when they stand up suddenly.\\nLiver and spleen\\nThe most common symptoms are enlargement of\\nthese organs. Liver function is not usually affected until\\nquite late in the course of the disease. Protein accumula-\\ntion in the spleen can increase the risk of rupture of this\\norgan due to trauma.\\nGastrointestinal system\\nThe tongue may be inflammed, enlarged, and stiff.\\nIntestinal movement (motility) may be reduced. Absorp-\\ntion of food and other nutrients may be impaired (and\\nmay lead to malnutrition), and there may also be bleed-\\ning, abdominal pain, constipation, and diarrhea.\\nSkin\\nSkin symptoms occur in about half of all cases of\\nprimary and secondary amyloidosis and in all cases\\nwhere there is inflammation or degeneration of the\\nperipheral nerves. Waxy-looking raised bumps (papules)\\nKEY TERMS\\nAmyloid—A waxy, starch-like protein.\\nPeripheral nerves—Nerves that carry information\\nto and from the spinal cord.\\nStem cells—Parent cells from which other cells are\\nmade.\\nmay appear on the face and neck, in the groin, armpits, or\\nanal area, and on the tongue or in the ear canals.\\nSwelling, hemorrhage beneath the skin (purpura), hair\\nloss, and dry mouth may also occur.\\nRespiratory system\\nAirways may be obstructed by amyloid deposits in\\nthe nasal sinus, larynx and traches (windpipe).\\nDiagnosis\\nBlood and urine tests can reveal the presence of\\namyloid protein, but tissue or bone-marrow biopsy is\\nnecessary to positively diagnose amyloidosis. Once the\\ndiagnosis has been confirmed, additional laboratory tests\\nand imaging procedures are performed to determine:\\n• which type of amyloid protein is involved\\n• which organ(s) or system(s) have been affected\\n• how far the disease has progressed\\nTreatment\\nThe goal of treatment is to slow down or stop pro-\\nduction of amyloid protein, eliminate existing amyloid\\ndeposits, alleviate underlying disorders (that give rise to\\nsecondary amyloidosis), and relieve symptoms caused by\\nheart or kidney damage. Specialists in cardiology, hema-\\ntology (the study of blood and the tissues that form it),\\nnephrology (the study of kidney function and abnormali-\\nties), neurology (the study of the nervous system), and\\nrheumatology (the study of disorders characterized by\\ninflammation or degeneration of connective tissue) work\\ntogether to assess a patient’s medical status and evaluate\\nthe effects of amyloidosis on every part of the body.\\nColchicine (Colebenemid, Probeneaid), prednisone,\\n(Prodium), and other anti-inflammatory drugs can slow\\nor stop disease progression. Bone-marrow and stem-cell\\ntransplants can enable patients to tolerate higher and\\nmore effective doses of melphalan (Alkeran) and other\\nchemotherapy drugs prescribed to combat this non-\\nmalignant disease. Surgery can relieve nerve pressure\\nand may be performed to correct other symptom-produc-\\ning conditions. Localized amyloid deposits can also be\\nremoved surgically. Dialysis or kidney transplantation\\ncan lengthen and improve the quality of life for patients\\nwhose amyloidosis results in kidney failure. Heart trans-\\nplants are rarely performed.\\nSupportive measures\\nAlthough no link has been established between diet\\nand development of amyloid proteins, a patient whose\\nheart or kidneys have been affected by the disease may\\nbe advised to use a diuretic or follow a low-salt diet.\\nGALE ENCYCLOPEDIA OF MEDICINE 2162\\nAmyloidosis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 162'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 176, 'page_label': '177'}, page_content='Prognosis\\nMost cases of amyloidosis are diagnosed after the\\ndisease has reached an advanced stage. The course of\\neach patient’s illness is unique but death, usually a result\\nof heart disease or kidney failure, generally occurs within\\na few years. Amyloidosis associated by multiple myelo-\\nma usually has a poor prognosis. Most patients with both\\ndiseases die within one to two years.\\nPrevention\\nGenetic counseling may be helpful for patients with\\nhereditary amyloidosis and their families. Use of\\ncholchicine in patients with familial Mediterranean fever\\nhas successfully prevented amyloidosis.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nORGANIZATIONS\\nAmyloidosis Network International. 7118 Cole Creek Drive,\\nHouston, TX 77092-1421. (888) 1AMYLOID. .\\nNational Organization for Rare Disorders. P.O. Box 8923, New\\nFairfield, CT 06812-8923. (800) 999-6673. .\\nOTHER\\nMayo Clinic Online.5 March 1998. .\\nMaureen Haggerty\\nAmyotrophic lateral sclerosis\\nDefinition\\nAmyotrophic lateral sclerosis (ALS) is a disease that\\nbreaks down tissues in the nervous system (a neurode-\\ngenerative disease) of unknown cause that affects the\\nnerves responsible for movement. It is also known as\\nmotor neuron disease and Lou Gehrig’s disease, after the\\nbaseball player whose career it ended.\\nDescription\\nALS is a disease of the motor neurons, those nerve\\ncells reaching from the brain to the spinal cord (upper\\nmotor neurons) and the spinal cord to the peripheral\\nnerves (lower motor neurons) that control muscle move-\\nment. In ALS, for unknown reasons, these neurons die,\\nleading to a progressive loss of the ability to move virtual-\\nly any of the muscles in the body. ALS affects “volun-\\ntary” muscles, those controlled by conscious thought,\\nsuch as the arm, leg, and trunk muscles. ALS, in and of\\nitself, does not affect sensation, thought processes, the\\nheart muscle, or the “smooth” muscle of the digestive sys-\\ntem, bladder, and other internal organs. Most people with\\nALS retain function of their eye muscles as well. Howev-\\ner, various forms of ALS may be associated with a loss of\\nintellectual function (dementia) or sensory symptoms.\\n“Amyotrophic” refers to the loss of muscle bulk, a\\ncardinal sign of ALS. “Lateral” indicates one of the\\nregions of the spinal cord affected, and “sclerosis”\\ndescribes the hardened tissue that develops in place of\\nhealthy nerves. ALS affects approximately 30,000 people\\nin the United States, with about 5,000 new cases each\\nyear. It usually begins between the ages of 40 and 70,\\nalthough younger onset is possible. Men are slightly\\nmore likely to develop ALS than women.\\nALS progresses rapidly in most cases. It is fatal\\nwithin three years for 50% of all people affected, and\\nwithin five years for 80%. Ten percent of people with\\nALS live beyond eight years.\\nCauses and symptoms\\nCauses\\nThe symptoms of ALS are caused by the death of\\nmotor neurons in the spinal cord and brain. Normally, these\\nneurons convey electrical messages from the brain to the\\nmuscles to stimulate movement in the arms, legs, trunk,\\nneck, and head. As motor neurons die, the muscles they\\nenervate cannot be moved as effectively, and weakness\\nresults. In addition, lack of stimulation leads to muscle\\nwasting, or loss of bulk. Involvement of the upper motor\\nneurons causes spasms and increased tone in the limbs, and\\nabnormal reflexes. Involvement of the lower motor neurons\\ncauses muscle wasting and twitching (fasciculations).\\nAlthough many causes of motor neuron degenera-\\ntion have been suggested for ALS, none has yet been\\nproven responsible. Results of recent research have\\nimplicated toxic molecular fragments known as free radi-\\ncals. Some evidence suggests that a cascade of events\\nleads to excess free radical production inside motor neu-\\nrons, leading to their death. Why free radicals should be\\nproduced in excess amounts is unclear, as is whether this\\nexcess is the cause or the effect of other degenerative\\nprocesses. Additional agents within this toxic cascade\\nmay include excessive levels of a neurotransmitter\\nknown as glutamate, which may over-stimulate motor\\nneurons, thereby increasing free-radical production, and\\na faulty detoxification enzyme known as SOD-1, for\\nGALE ENCYCLOPEDIA OF MEDICINE 2 163\\nAmyotrophic lateral sclerosis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 163'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 177, 'page_label': '178'}, page_content='superoxide dismutase type 1. The actual pathway of\\ndestruction is not known, however, nor is the trigger for\\nthe rapid degeneration that marks ALS. Further research\\nmay show that other pathways are involved, perhaps ones\\neven more important than this one. Autoimmune factors\\nor premature aging may play some role, as could viral\\nagents or environmental toxins.\\nTwo major forms of ALS are known: familial and\\nsporadic. Familial ALS accounts for about 10% of all ALS\\ncases. As the name suggests, familial ALS is believed to be\\ncaused by the inheritance of one or more faulty genes.\\nAbout 15% of families with this type of ALS have muta-\\ntions in the gene for SOD-1. SOD-1 gene defects are dom-\\ninant, meaning only one gene copy is needed to develop\\nthe disease. Therefore, a parent with the faulty gene has a\\n50% chance of passing the gene along to a child.\\nSporadic ALS has no known cause. While many\\nenvironmental toxins have been suggested as causes, to\\ndate no research has confirmed any of the candidates\\ninvestigated, including aluminum and mercury and lead\\nfrom dental fillings. As research progresses, it is likely\\nthat many cases of sporadic ALS will be shown to have a\\ngenetic basis as well.\\nA third type, called Western Pacific ALS, occurs in\\nGuam and other Pacific islands. This form combines\\nsymptoms of both ALS and Parkinson’s disease.\\nSymptoms\\nThe earliest sign of ALS is most often weakness in\\nthe arms or legs, usually more pronounced on one side\\nthan the other at first. Loss of function is usually more\\nGALE ENCYCLOPEDIA OF MEDICINE 2164\\nAmyotrophic lateral sclerosis\\nNormal nerve fiber\\nNORMAL SPINAL NEURON DISEASED SPINAL NEURON\\nNormal skeletal muscle Wasted skeletal muscle\\nAffected nerve fiber\\nAmyotrophic lateral sclerosis (ALS) is caused by the degeneration and death of motor neurons in the spinal cord and brain.\\nThese neurons convey electrical messages from the brain to the muscles to stimulate movement in the arms, legs, trunk,\\nneck, and head. As motor neurons degenerate, the muscles are weakened and cannot move as effectively, leading to muscle\\nwasting. (Illustration by Electronic Illustrators Group.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 164'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 178, 'page_label': '179'}, page_content='rapid in the legs among people with familial ALS and in\\nthe arms among those with sporadic ALS. Leg weakness\\nmay first become apparent by an increased frequency of\\nstumbling on uneven pavement, or an unexplained diffi-\\nculty climbing stairs. Arm weakness may lead to difficul-\\nty grasping and holding a cup, for instance, or loss of\\ndexterity in the fingers.\\nLess often, the earliest sign of ALS is weakness in\\nthe bulbar muscles, those muscles in the mouth and\\nthroat that control chewing, swallowing, and speaking. A\\nperson with bulbar weakness may become hoarse or tired\\nafter speaking at length, or speech may become slurred.\\nIn addition to weakness, the other cardinal signs of\\nALS are muscle wasting and persistent twitching (fascic-\\nulation). These are usually seen after weakness becomes\\nobvious. Fasciculation is quite common in people without\\nthe disease, and is virtually never the first sign of ALS.\\nWhile initial weakness may be limited to one region,\\nALS almost always progresses rapidly to involve virtually\\nall the voluntary muscle groups in the body. Later symp-\\ntoms include loss of the ability to walk, to use the arms and\\nhands, to speak clearly or at all, to swallow, and to hold the\\nhead up. Weakness of the respiratory muscles makes\\nbreathing and coughing difficult, and poor swallowing con-\\ntrol increases the likelihood of inhaling food or saliva (aspi-\\nration). Aspiration increases the likelihood of lung infec-\\ntion, which is often the cause of death. With a ventilator\\nand scrupulous bronchial hygiene, a person with ALS may\\nlive much longer than the average, although weakness and\\nwasting will continue to erode any remaining functional\\nabilities. Most people with ALS continue to retain function\\nof the extraocular muscles that move their eyes, allowing\\nsome communication to take place with simple blinks or\\nthrough use of a computer-assisted device.\\nDiagnosis\\nThe diagnosis of ALS begins with a complete med-\\nical history and physical exam, plus a neurological exam-\\nination to determine the distribution and extent of weak-\\nness. An electrical test of muscle function, called an elec-\\ntromyogram, or EMG, is an important part of the diag-\\nnostic process. Various other tests, including blood and\\nurine tests, x rays, and CT scans, may be done to rule out\\nother possible causes of the symptoms, such as tumors of\\nthe skull base or high cervical spinal cord, thyroid dis-\\nease, spinal arthritis, lead poisoning , or severe vitamin\\ndeficiency. ALS is rarely misdiagnosed following a care-\\nful review of all these factors.\\nTreatment\\nThere is no cure for ALS, and no treatment that can\\nsignificantly alter its course. There are many things\\nKEY TERMS\\nAspiration—Inhalation of food or liquids into the\\nlungs.\\nBulbar muscles—Muscles of the mouth and throat\\nresponsible for speech and swallowing.\\nFasciculations—Involuntary twitching of muscles.\\nMotor neuron —A nerve cell that controls a mus-\\ncle.\\nRiluzole (Rilutek) —The first drug approved in the\\nUnited States for the treatment of ALS.\\nVoluntary muscle —A muscle under conscious\\ncontrol; contrasted with smooth muscle and heart\\nmuscle which are not under voluntary control.\\nwhich can be done, however, to help maintain quality of\\nlife and to retain functional ability even in the face of\\nprogressive weakness.\\nAs of early 1998, only one drug had been approved\\nfor treatment of ALS. Riluzole (Rilutek) appears to pro-\\nvide on average a three-month increase in life expectancy\\nwhen taken regularly early in the disease, and shows a\\nsignificant slowing of the loss of muscle strength. Rilu-\\nzole acts by decreasing glutamate release from nerve ter-\\nminals. Experimental trials of nerve growth factor have\\nnot demonstrated any benefit. No other drug or vitamin\\ncurrently available has been shown to have any effect on\\nthe course of ALS.\\nA physical therapist works with an affected person\\nand family to implement exercise and stretching pro-\\ngrams to maintain strength and range of motion, and to\\npromote general health. Swimming may be a good\\nchoice for people with ALS, as it provides a low-impact\\nworkout to most muscle groups. One result of chronic\\ninactivity is contracture, or muscle shortening. Contrac-\\ntures limit a person’s range of motion, and are often\\npainful. Regular stretching can prevent contracture. Sev-\\neral drugs are available to reduce cramping, a common\\ncomplaint in ALS.\\nAn occupational therapist can help design solutions\\nto movement and coordination problems, and provide\\nadvice on adaptive devices and home modifications.\\nSpeech and swallowing difficulties can be mini-\\nmized or delayed through training provided by a speech-\\nlanguage pathologist. This specialist can also provide\\nadvice on communication aids, including computer-\\nassisted devices and simpler word boards.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 165\\nAmyotrophic lateral sclerosis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 165'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 179, 'page_label': '180'}, page_content='Nutritional advice can be provided by a nutritionist.\\nA person with ALS often needs softer foods to prevent\\njaw exhaustion or choking . Later in the disease, nutri-\\ntion may be provided by a gastrostomy tube inserted\\ninto the stomach.\\nMechanical ventilation may be used when breathing\\nbecomes too difficult. Modern mechanical ventilators are\\nsmall and portable, allowing a person with ALS to main-\\ntain the maximum level of function and mobility. Ventila-\\ntion may be administered through a mouth or nose piece,\\nor through a tracheostomy tube. This tube is inserted\\nthrough a small hole made in the windpipe. In addition to\\nproviding direct access to the airway, the tube also\\ndecreases the risk aspiration. While many people with\\nrapidly progressing ALS choose not to use ventilators for\\nlengthy periods, they are increasingly being used to pro-\\nlong life for a short time.\\nThe progressive nature of ALS means that most per-\\nsons will eventually require full-time nursing care. This\\ncare is often provided by a spouse or other family mem-\\nber. While the skills involved are not difficult to learn,\\nthe physical and emotional burden of care can be over-\\nwhelming. Caregivers need to recognize and provide for\\ntheir own needs as well as those of people with ALS, to\\nprevent depression, burnout, and bitterness.\\nThroughout the disease, a support group can provide\\nimportant psychological aid to affected persons and their\\ncaregivers as they come to terms with the losses ALS\\ninflicts. Support groups are sponsored by both the ALS\\nSociety and the Muscular Dystrophy Association.\\nAlternative treatment\\nGiven the grave prognosis and absence of tradition-\\nal medical treatments, it is not surprising that a large\\nnumber of alternative treatments have been tried for\\nALS. Two studies published in 1988 suggested that\\namino-acid therapies may provide some improvement\\nfor some people with ALS. While individual reports\\nclaim benefits for megavitamin therapy, herbal medi-\\ncine, and removal of dental fillings, for instance, no evi-\\ndence suggests that these offer any more than a brief\\npsychological boost, often followed by a more severe\\nletdown when it becomes apparent the disease has con-\\ntinued unabated. However, once the causes of ALS are\\nbetter understood, alternative therapies may be more\\nintensively studied. For example, if damage by free radi-\\ncals turns out to be the root of most of the symptoms,\\nantioxidant vitamins and supplements may be used\\nmore routinely to slow the progression of ALS. Or, if\\nenvironmental toxins are implicated, alternative thera-\\npies with the goal of detoxifying the body may be of\\nsome use.\\nPrognosis\\nALS usually progresses rapidly, and leads to death\\nfrom respiratory infection within three to five years in\\nmost cases. The slowest disease progression is seen in\\nthose who are young and have their first symptoms in the\\nlimbs. About 10% of people with ALS live longer than\\neight years.\\nPrevention\\nThere is no known way to prevent ALS or to alter its\\ncourse.\\nResources\\nBOOKS\\nAdams, Raymond D, Victor, Maurice and Ropper, Allan H.\\nAdam’s & Victor’s Principles of Neurology, 6th ed. New\\nYork, McGraw Hill, 1997.\\nBrown, Robert H. “The motor neuron diseases.” In Harrison’s\\nPrinciples of Internal Medicine, 14th ed., edited by\\nAnthony S. Fauci, et al. New York: McGraw-Hill, 1998,\\n2368-2372.\\nFeldman, Eva L. “Motor neuron diseases.” In Cecil Textbook of\\nMedicine, 21st ed., edited by Goldman, Lee and Bennett,\\nJ. Claude. Philadelphia: W.B. Saunders, 2000, 2089-2092.\\nKimura, Jun and Kaji, Ryuji. Physiology of ALS and Related\\nDiseases. Amsterdam, Elsevier Science, 1997.\\nMitsumoto, Hiroshi, Chad, David A, Pioro, Erik and Gilman,\\nSid. Amyotrophic Lateral Sclerosis.New York, Oxford\\nUniversity Press, 1997.\\nPERIODICALS\\nAnsevin CF. Treatment of ALS with pleconaril.Neurology,\\n56(5): 691-692, 2001.\\nEisen A, Weber M. The motor cortex and amyotrophic lateral\\nsclerosis. Muscle and Nerve, 24(4): 564-573, 2001.\\nGelanis DF. Respiratory Failure or Impairment in Amyotrophic\\nLateral Sclerosis. Current treatment options in neurology,\\n3(2): 133-138, 2001.\\nLudolph AC. Treatment of amyotrophic lateral sclerosis—what\\nis the next step? Journal of Neurology, 246 Suppl 6:13-18,\\n2000.\\nPasetti C, Zanini G. The physician-patient relationship in amy-\\notrophic lateral sclerosis.Neurological Science, 21(5):\\n318-323, 2000.\\nRobberecht W. Genetics of amyotrophic lateral sclerosis.Jour-\\nnal of Neurology, 246 Suppl 6: 2-6, 2000.\\nRobbins RA, Simmons Z, Bremer BA, Walsh SM, Fischer S.\\nQuality of life in ALS is maintained as physical function\\ndeclines. Neurology, 56(4): 442-444, 2001.\\nORGANIZATIONS\\nALS Association of America. 27001 Agoura Road, Suite 150,\\nCalabasas Hills, CA 91301-5104. (800) 782-4747 (Infor-\\nmation and Referral Service) or (818) 880-9007. Fax:\\n(818) 880-9006. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2166\\nAmyotrophic lateral sclerosis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 166'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 180, 'page_label': '181'}, page_content='American Academy of Family Physicians. 11400 Tomahawk\\nCreek Parkway, Leawood, KS 66211-2672. (913) 906-\\n6000, . fp@aafp.org.\\nAmerican Academy of Neurology. 1080 Montreal Avenue, St.\\nPaul, Minnesota 55116. (651) 695-1940. Fax: (651) 695-\\n2791. . info@aan.org.\\nAmerican Medical Association. 515 N. State Street, Chicago,\\nIL 60610. (312) 464-5000. .\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRoad, Atlanta, GA 30333. (404) 639-3534 or (800) 311-\\n3435. . http://www.cdc.gov/ netinfo.htm.\\nMuscular Dystrophy Association. 3300 East Sunrise Drive, Tuc-\\nson AZ 85718-3208. (520) 529-2000 or (800) 572-1717.\\nFax: (520) 529-5300. .\\nOTHER\\nALS Society of Canada: .\\nALS Survival Guide: .\\nAmerican Academy of Family Physicians: .\\nNational Institute of Neurological Disorders and Stroke:\\n.\\nNational Library of Medicine: .\\nNational Organization for Rare Diseases: .\\nWorld Federation of Neurology: .\\nL. Fleming Fallon, Jr., MD, DrPH\\nAnaerobic infections\\nDefinition\\nAn anaerobic infection is an infection caused by\\nbacteria (called anaerobes) which cannot grow in the\\npresence of oxygen. Anaerobic bacteria can infect deep\\nwounds, deep tissues, and internal organs where there is\\nlittle oxygen. These infections are characterized by\\nabscess formation, foul-smelling pus, and tissue\\ndestruction.\\nDescription\\nAnaerobic means “life without air.” Anaerobic bac-\\nteria grow in places which completely, or almost com-\\npletely, lack oxygen. They are normally found in the\\nmouth, gastrointestinal tract, and vagina, and on the skin.\\nCommonly known diseases caused by anaerobic bacteria\\ninclude gas gangrene, tetanus, and botulism. Nearly all\\ndental infections are caused by anaerobic bacteria.\\nAnaerobic bacteria can cause an infection when a\\nnormal barrier (such as skin, gums, or intestinal wall)\\nis damaged due to surgery, injury, or disease. Usually,\\nthe immune system kills any invading bacteria, but\\nsometimes the bacteria are able to grow and cause an\\ninfection. Body sites that have tissue destruction\\n(necrosis) or a poor blood supply are low in oxygen\\nand favor the growth of anaerobic bacteria. The low\\noxygen condition can result from blood vessel disease,\\nshock, injury, and surgery.\\nAnaerobic bacteria can cause infection practically\\nanywhere in the body. For example:\\n• Mouth, head, and neck. Infections can occur in the root\\ncanals, gums (gingivitis), jaw, tonsils, throat, sinuses,\\nand ears.\\n• Lung. Anaerobic bacteria can cause pneumonia , lung\\nabscesses, infecton of the lining of the lung ( empye-\\nma), and dilated lung bronchi (bronchiectasis).\\n• Intraabdominal. Anaerobic infections within the\\nabdomen include abscess formation, peritonitis , and\\nappendicitis.\\n• Female genital tract. Anaerobic bacteria can cause\\npelvic abscesses, pelvic inflammatory disease ,\\ninflammation of the uterine lining (endometritis), and\\npelvic infections following abortion, childbirth , and\\nsurgery.\\n• Skin and soft tissue. Anaerobic bacteria are common\\ncauses of diabetic skin ulcers, gangrene, destructive\\ninfection of the deep skin and tissues (necrotizing fasci-\\ntis), and bite wound infections.\\n• Central nervous system. Anaerobic bacteria can cause\\nbrain and spinal cord abscesses.\\n• Bloodstream. Anaerobic bacteria can be found in the\\nbloodstream of ill patients (a condition called bac-\\nteremia).\\nCauses and symptoms\\nPeople who have experienced shock, injury, or\\nsurgery, and those with blood vessel disease or tumors\\nare at an increased risk for infection by anaerobic bacte-\\nria. There are many different kinds of anaerobic bacteria\\nwhich can cause an infection. Indeed, most anaerobic\\ninfections are “mixed infections” which means that\\nthere is a mixture of different bacteria growing. The\\nanaerobic bacteria that most frequently cause infections\\nare Bacteroides fragilis , Peptostreptococcus , and\\nClostridium species.\\nThe signs and symptoms of anaerobic infection\\ncan vary depending on the location of the infection. In\\ngeneral, anaerobic infections result in tissue destruc-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 167\\nAnaerobic infections\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 167'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 181, 'page_label': '182'}, page_content='tion, an abscess which drains foul-smelling pus, and\\npossibly fever . Symptoms for specific infections are\\nas follows:\\n• Tooth and gum infections. Swollen, tender bleeding\\ngums, bad breath , and pain. Severe infections may\\nproduce oozing sores.\\n• Throat infection. An extremely sore throat, bad breath,\\na bad taste in the mouth, fever, and a sense of choking.\\n• Lung infection. Chest pain, coughing, difficulty breath-\\ning, fever, foul-smelling sputum, and weight loss.\\n• Intraabdominal infection. Pain, fever, and possibly, if fol-\\nlowing surgery, foul- smelling drainage from the wound.\\n• Pelvic infection. Foul-smelling pus or blood draining\\nfrom the uterus, general or localized pelvic pain, fever,\\nand chills.\\n• Skin and soft tissue infection. Infected wounds are red,\\npainful, swollen, and may drain a foul-smelling pus.\\nSkin infection causes localized swelling, pain, redness,\\nand possibly a painful, open sore (ulcer) which drains\\nfoul-smelling pus. Severe skin infections may cause\\nextensive tissue destruction (necrosis).\\n• Bloodstream. Bloodstream invasion causes high fever\\n(up to 105°F [40.6°C]), chills, a general ill feeling, and\\nis potentially fatal.\\nDiagnosis\\nThe diagnosis of anaerobic infection is based pri-\\nmarily on symptoms, the patient’s medical history, and\\nlocation of the infection. A foul-smelling infection or\\ndrainage from an abscess is diagnostic of anaerobic\\ninfection. This foul smell is produced by anaerobic bac-\\nteria and occurs in one third to one half of patients late in\\nthe infection. Other clues to anaerobic infection include\\ntissue necrosis and gas production at the infection site. A\\nsample from the infected site may be obtained, using a\\nswab or a needle and syringe, to determine which bacte-\\nria is (are) causing the infection. Because these bacteria\\ncan be easily killed by oxygen, they rarely grow in the\\nlaboratory cultures of tissue or pus samples.\\nKEY TERMS\\nAbscess—A lump filled with pus resulting from an\\ninfection.\\nAnaerobic—Living and growing in the absence of\\noxygen.\\nNecrosis—Tissue death and destruction resulting\\nfrom infection or disease.\\nThe recent medical history of the patient is helpful\\nin diagnosing anaerobic infection. A patient who has or\\nrecently had surgery, dental work, tumors, blood vessel\\ndisease, or injury are susceptible to this infection. The\\nfailure to improve following treatment with antibiotics\\nthat aren’t able to kill anaerobes is another clue that the\\ninfection is caused by anaerobes. The location and type\\nof infection also help in the diagnosis.\\nDiagnostic tests may include blood tests to see if\\nbacteria are in the bloodstream and x rays to look at\\ninternal infections.\\nTreatment\\nSerious infections may require hospitalization for\\ntreatment. Immediate antibiotic treatment of anaerobic\\ninfections is necessary. Laboratory testing may identify\\nthe bacteria causing the infection and also which antibi-\\notic will work best. Every antibiotic does not work\\nagainst all anaerobic bacteria but nearly all anaerobes are\\nkilled by chloramphenicol (Chloromycetin), metronida-\\nzole (Flagyl or Protostat), and imipenem (Primaxin).\\nOther antibiotics which may be used are clindamycin\\n(Cleocin) or cefoxitin (Mefoxin).\\nSurgical removal or drainage of the abscess is\\nalmost always required. This may involve drainage by\\nneedle and syringe to remove the pus from a skin abscess\\n(called “aspiration”). The area would be numbed prior to\\nthe aspiration procedure. Also, some internal abscesses\\ncan be drained using this procedure with the help of\\nultrasound (a device which uses sound waves to visualize\\ninternal organs). This type of abscess drainage may be\\nperformed in the doctor’s office.\\nPrognosis\\nComplete recovery should be achieved with the\\nappropriate surgery and antibiotic treatment. Untreated\\nor uncontrolled infections can cause severe tissue and\\nbone destruction, which would require plastic surgery to\\nrepair. Serious infections can be life threatening.\\nPrevention\\nAlthough anaerobic infections can occur in anyone,\\ngood hygiene and general health may help to prevent\\ninfections.\\nResources\\nBOOKS\\nHarrison’s Principles of Internal Medicine.Ed. Anthony S.\\nFauci, et al. New York: McGraw-Hill, 1997.\\nBelinda Rowland, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 2168\\nAnaerobic infections\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 168'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 182, 'page_label': '183'}, page_content='Anaerobic myositis see Gangrene\\nAnal atresia\\nDefinition\\nThe anus is either not present or it is in the wrong\\nplace.\\nDescription\\nThere are basically two kinds of anal atresia. In boys\\nwith high anal atresia, there may be a channel (fistula)\\nconnecting the large intestine to either the urethra (which\\ndelivers urine from the bladder) or the bladder itself. In\\ngirls, the channel may connect with the vagina. Sixty\\npercent of children with high anal atresia have other\\ndefects, including problems with the esophagus, urinary\\ntract, and bones. In low anal atresia, the channel may\\nopen in front of the circular mass of muscles that con-\\nstrict to close the anal opening (anal sphincter) or, in\\nboys, below the scrotum. Occasionally, the intestine ends\\njust under the skin. It is estimated that overall abnormali-\\nties of the anus and rectum occur in about one in every\\n5,000 births and are slightly more common among boys.\\nA mother who has one child with these kind of condi-\\ntions has a 1% chance of having another child who suf-\\nfers from this ailment.\\nCause and symptoms\\nAnal atresia is a defect in the development of the\\nfetus. The cause is unknown, but genetics seem to play a\\nminor role.\\nDiagnosis\\nUsually a physician can make an obvious visual\\ndiagnosis of anal atesia right after birth. Occasionally,\\nhowever, anal atresia is missed until the baby is fed and\\nsigns of intestinal obstruction appear. At the end of the\\nfirst or second day, the abdomen swells and there is vom-\\niting of fecal material. To determine the type of anal atre-\\nsia and the exact position, x rays will be taken which\\ninclude injecting opaque dye into the opening. Magnetic\\nresonance imaging (MRI) or computed tomography\\nscans (CT), as well as ultrasound, are the imaging tech-\\nniques used to determine the type and size of the anal\\natresia. Ultrasound uses sound waves, CT scans pass x\\nrays through the body at different angles, and an MRI\\nuses a magnetic field and radio waves.\\nKEY TERMS\\nAnus—The canal at the end of the large intestine\\nthrough which waste is excreted to the outside of\\nthe body.\\nBowel obstruction—Anything that prevents waste\\nfrom moving normally to the anal opening.\\nColostomy —An operation where the large intes-\\ntine is diverted through an opening in the\\nabdomen and waste is excreted.\\nFeces—Bodily waste material that normally passes\\nthrough the anus.\\nFistula—An abnormal channel that connects two\\norgans or connects an organ to the skin.\\nTreatment\\nSurgery is the only treatment for anal atresia. For\\nhigh anal atresia, immediately after the diagnosis is made,\\na surgical incision is made in the large intestine to make a\\ntemporary opening ( colostomy ) in the abdomen where\\nwaste is excreted. Several months later, the intestine is\\nmoved into the ring of muscle (sphincter) that is part of\\nthe anus and a hole is made in the skin. The colostomy is\\nclosed several weeks later. In low anal atresia, immediate-\\nly after diagnosis, a hole is made in the skin to open the\\narea where the anus should be. If the channel is in the\\nwrong place, the intestine is moved into the correct posi-\\ntion sometime during the child’s first year. After surgery,\\nthe pediatric surgeon uses an instrument to dilate or\\nwiden the rectum and teaches the parents how to do this\\ndaily at home to prevent scar tissue from contracting.\\nPrognosis\\nWith high anal atresia, many children have problems\\ncontrolling bowel function. Most also become constipat-\\ned. With low anal atresia, children generally have good\\nbowel control, but they may still become constipated.\\nPrevention\\nThere is no known way to prevent anal atresia.\\nResources\\nBOOKS\\nFreeman, Neill V . “Anorectal Malformations.” In Surgery of the\\nNewborn. Edinburgh: Churchill Livingstone, 1994.\\nPaidas, Charles N., and Alberto Pena. “Rectum and Anus.” In\\nSurgery of Infants and Children.Philadelphia: Lippincott-\\nRaven, 1997.\\nJeanine Barone, Physiologist\\nGALE ENCYCLOPEDIA OF MEDICINE 2 169\\nAnal atresia\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 169'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 183, 'page_label': '184'}, page_content='Anal cancer\\nDefinition\\nAnal cancer is an uncommon form of cancer affect-\\ning the anus. The anus is the inch-and-a-half-long end\\nportion of the large intestine, which opens to allow solid\\nwastes to exit the body. Other parts of the large intestine\\ninclude the colon and the rectum.\\nDescription\\nDifferent cancers can develop in different parts of\\nthe anus, part of which is inside the body and part of\\nwhich is outside. Sometimes abnormal changes of the\\nanus are harmless in their early stages but may later\\ndevelop into cancer. Some anal warts, for example, con-\\ntain precancerous areas and can develop into cancer.\\nTypes of anal cancer include:\\n• Squamous Cell Carcinomas. Approximately half of\\nanal cancers are squamous cell carcinomas, which arise\\nfrom the cells lining the anal margin and the anal canal.\\nThe anal margin is the part of the anus that is half inside\\nand half outside the body, and the anal canal is the part\\nof the anus that is inside the body. The earliest form of\\nsquamous cell carcinoma is known as carcinoma in\\nsitu, or Bowen’s disease.\\n• Cloacogenic Carcinomas. Approximately one-fourth to\\none-third of anal tumors are cloacogenic carcinomas.\\nThese tumors develop in the transitional zone, or cloa-\\nca, which is a ring of tissue between the anal canal and\\nthe rectum.\\n• Adenocarcinomas. About 15% of anal cancers are ade-\\nnocarcinomas, which affect glands in the anal area. One\\ntype of adenocarcinoma that can occur in the anal area\\nis called Paget’s disease, which can also affect the\\nvulva, breasts, and other areas of the body.\\n• Skin cancers. A small percentage of anal cancers are\\neither basal cell carcinomas, or malignant melanomas,\\ntwo types of skin cancer. Malignant melanomas, which\\ndevelop from skin cells that produce the brown pigment\\ncalled melanin, are far more common on areas of the\\nbody exposed to the sun.\\nApproximately 3,500 Americans will be diagnosed\\nwith anal cancer in 2001, and an estimated 500 individu-\\nals will die of the disease during this same interval,\\naccording to the American Cancer Society. Anal cancers\\nare fairly rare: they make up only 1% to 2% of cancers\\naffecting the digestive system. The disease affects\\nwomen somewhat more often than men, although the\\nnumber of cases among men, particularly homosexual\\nmen, seems to be increasing.\\nCauses and symptoms\\nThe exact cause of most anal cancers is unknown,\\nalthough certain individuals appear to have a higher risk\\nof developing the disease. Smokers are at higher risk, as\\nare individuals with certain types of the human papillo-\\nmavirus (HPV), and those with long-term problems in\\nthe anal area, such as abnormal openings known as fistu-\\nlas. Since it increases the risk of HPV infection, the prac-\\ntice of anal sex appears to increase the risk of anal\\ncancer—male homosexuals who practice anal sex are\\nabout 33 times more likely to have anal cancers than het-\\nerosexual men. Those with weakened immune systems,\\nsuch individuals with HIV , or transplant patients taking\\nimmunosuppressant drugs , are also at higher risk.\\nMost individuals with anal cancer are over the age of 50.\\nSymptoms of anal cancer resemble those found in\\nother harmless conditions. They include pain, itching\\nand bleeding, straining during a bowel movement,\\nchange in bowel habits, change in the diameter of the\\nstool, discharge from the anus, and swollen lymph nodes\\nin the anal or groin area.\\nDiagnosis\\nAnal cancer is sometimes diagnosed during routine\\nphysicals, or during minor procedures such as hemorrhoid\\nremoval. It may also be diagnosed during a digital rectal\\nexamination (DRE), when a physician inserts a gloved,\\nlubricated finger into the anus to feel for unusual growths.\\nIndividuals over the age of 50 who have no symptoms\\nshould have a digital rectal examination (DRE) every five\\nto 10 years, according to American Cancer Society (ACS)\\nguidelines for early detection of colorectal cancer.\\nOther diagnostic procedures for anal cancer include:\\nAnoscopy. A procedure that involves use of a special\\ndevice to examine the anus. Proctoscopy. A procedure that\\ninvolves use of a lighted scope to see the anal canal. Tran-\\nsrectal ultrasound. A procedure in which sound waves are\\nused to create an image of the anus and nearby tissues.\\nA biopsy is performed on any suspicious growths;\\nthat is, a tiny piece of the growth is examined under a\\nmicroscope for cancer cells. The physician may also per-\\nform a procedure called a fine needle aspiration biopsy,\\nin which a needle is used to withdraw fluid from lymph\\nnodes located near the growth, to make sure the cancer\\nhasn’t spread to these nodes.\\nAnal cancer severity is categorized by the following\\nstages:\\n• Stage 0 anal cancer is found only in the top layer of\\nanal tissue.\\n• Stage I anal cancer has spread beyond the top layer of\\nanal tissue, but is less than 1 inch in diameter.\\nGALE ENCYCLOPEDIA OF MEDICINE 2170\\nAnal cancer\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 170'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 184, 'page_label': '185'}, page_content='• Stage II anal cancer has spread beyond the top layer of\\nanal tissue and is larger than 1 inch in diameter, but has\\nnot spread to nearby organs or lymph nodes.\\n• Stage IIIA anal cancer has spread to the lymph nodes\\naround the rectum or to nearby organs such as the vagi-\\nna or bladder.\\n• Stage IIIB anal cancer has spread to lymph nodes in the\\nmid-abdomen or groin, or to nearby organs and the\\nlymph nodes around the rectum.\\n• Stage IV anal cancer has spread to distant lymph nodes\\nwithin the abdomen or to distant organs.\\nTreatment\\nAnal cancer is treated using three methods, used\\neither in concert or individually: surgery,radiation ther-\\napy, and chemotherapy.\\nTwo types of surgery may be performed. A local\\nresection, performed if the cancer has not spread,\\nremoves the tumor and an area of tissue around the tumor.\\nAn abdominoperineal resection is a more complex proce-\\ndure in which the anus and the lower rectum are removed,\\nand an opening called a colostomy is created for body\\nwastes to exit. This procedure is fairly uncommon today\\nbecause radiation and chemotherapy are just as effective.\\nRadiation therapy uses high-energy rays to fight\\ncancer cells. It is usually delivered via a machine outside\\nthe body, but may also be delivered via surgically\\nimplanted radioactive pellets. This latter method is called\\ninternal radiation, brachytherapy, or interstitial radiation.\\nSide effects of radiation may include tiredness, skin dam-\\nage resembling sunburn, and damage to anal tissues.\\nChemotherapy fights cancer using drugs, which may\\nbe delivered via pill or needle. Some chemotherapy types\\nkill cancer cells directly, while others act indirectly by\\nmaking cancer cells more vulnerable to radiation. The\\nmain drugs used to treat anal cancer are 5-fluorouracil (5-\\nFU) and mitomycin or 5-FU and cisplatin. Side effects of\\nchemotherapy, which damages normal cells in addition to\\ncancer cells, may include nausea and vomiting , hair\\nloss, loss of appetite, diarrhea, mouth sores, fatigue,\\nshortness of breath, and a weakened immune system.\\nAlternative treatment\\nResearch suggests acupuncture can help manage\\nchemotherapy-related nausea and vomiting and control\\npain associated with surgery.\\nPrognosis\\nAnal cancer is often curable. The chance of recovery\\ndepends on the cancer stage and the patient’s general health.\\nKEY TERMS\\nBiopsy—A procedure in which a small piece of\\nbody tissue is removed and examined under a\\nmicroscope for cancer.\\nChemotherapy —A cancer treatment in which\\ndrugs delivered into the blood stream kill cancer\\ncells or make them more vulnerable to radiation\\ntherapy.\\nHuman papillomavirus (HPV)—A virus with many\\nsubtypes, some of which cause cell changes that\\nincrease the risk of certain cancers.\\nHuman immunodeficiency virus (HIV)—The virus\\nthat causes acquired immune deficiency syn-\\ndrome (AIDS).\\nLymph nodes —Bean-shaped structures found\\nthroughout the body that produce and store infec-\\ntion-fighting cells.\\nRadiation therapy —A cancer treatment that uses\\nhigh-energy rays to kill or weaken cancer cells.\\nRadiation may be delivered externally or internal-\\nly via surgically implanted pellets.\\nPrevention\\nReducing the risks of the sexually transmitted dis-\\neases HPV and HIV also reduces the risk of anal cancer. In\\naddition, quitting smokinglowers the risk of anal cancer.\\nResources\\nBOOKS\\nAmerican Joint Committee on Cancer: AJCC Cancer Staging\\nManual. Philadelphia, Pa: Lippincott-Raven Publishers,\\n1997.\\nPERIODICALS\\nMurakami, M, KJ Gurski and MA Steller. “Human Papillo-\\nmavirus Vaccines For Cervical Cancer.”Journal of\\nImmunotherapy 1999, 22(3):212-8.\\nORGANIZATIONS\\nAmerican Cancer Society. (800) ACS-2345. .\\nAmerican College of Gastroenterology. .\\nAmerican Gastroenterological Association. 7910 Woodmont\\nAve., Seventh Floor, Bethesda, MD 20814. (301) 654-\\n2055. .\\nAmerican Society of Colon and Rectal Surgeons. 85 W. Algo-\\nnquin Road, Suite 550, Arlington Heights, IL 60005.\\n(847)290-9184.\\nThe NCI Office of Cancer Complementary and Alternative\\nMedicine. .\\nGALE ENCYCLOPEDIA OF MEDICINE 2 171\\nAnal cancer\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 171'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 185, 'page_label': '186'}, page_content='National Cancer Institute. 31 Center Drive, MSC 2580, Bethes-\\nda, MD 20892-2580. (800) 4-CANCER. .\\nNational Coalition for Cancer Survivorship. 1010 Wayne\\nAvenue, 5th Floor, Suite 300, Silver Spring, MD 20910.\\n(888) 650-9127.\\nThe NIH National Center for Complementary and Alternative\\nMedicine. Post Office Box 8218, Silver Spring, MD\\n20907-8218. (888) 644-6226. .\\nUnited Ostomy Association. (800) 826-0826. .\\nAnn Quigley\\nAnal fissure see Anorectal disorders\\nAnal warts\\nDefinition\\nAnal warts, also known as condyloma acuminata,\\nare small warts that can occur in the rectum.\\nDescription\\nInitially appear as tiny blemishes that can be as\\nsmall as the head of a pin or grow into larger cauliflower-\\nlike protuberances. They can be yellow, pink, or light\\nbrown in color, and only rarely are painful or uncomfort-\\nable. In fact, infected individuals often are unaware that\\nthey exist. Most cases are caused by sexual transmission.\\nMost individuals have between one to 10 genital\\nwarts thtat range in size from roughly 0.5–1.9 cm\\n2\\n. Some\\nwill complain of painless bumps or itching , but often,\\nthese warts can remain completely unnoticed.\\nCauses and symptoms\\nCondyloma acuminatum is one of the most common\\nsexually transmitted disease (STD) in the United States.\\nYoung adults aged 17 to 33 years are at greatest risk.\\nRisk factors include smoking , using oral contracep-\\ntives, having multiple sexual partners, and an early coital\\nage. In addition, individuals who have a history of\\nimmunosuppression or anal intercourse are also at risk.\\nRoughly 90% of all anal warts are caused by the\\nhuman papilloma virus (HPV) types 6 and 11, which are\\nthe least likely of over 60 types of HPV to become can-\\ncerous. Anal warts are usually transmitted through direct\\nsexual contact with someone who is infected with condy-\\nloma acuminata anywhere in the genital area, including\\nthe penis and vagina. Studies have shown that roughly\\n75% of those who engage in sexual contact with some-\\none infected with condyloma acuminata will develop\\nthese warts within three months.\\nTreatment\\nAccording to guidelines from the Centers for Dis-\\nease Control (CDC), the treatment of all genital warts,\\nincluding anal warts, should be conducted according to\\nthe methods preferred by the patient, the medications or\\nprocedures most readily available, and the experience of\\nthe patient’s physician in removing anal warts.\\nTreatment options include electrical cautery, surgi-\\ncal removal, or both. Warts that appear inside the anal\\ncanal will almost always be treated with cauterization or\\nsurgical removal. Surgical removal, also known as exci-\\nsion, has the highest success rates and lowest recurrence\\nrates. Indeed, studies have shown that initial cure rates\\nrange from 63–91%.\\nUnfortunately, most cases require numerous treat-\\nments because the virus that causes the warts can live in\\nthe surrounding tissue. The area may seem normal and\\nwart-free for six months or longer before another wart\\ndevelops.\\nLaser surgery is another possibility, but requires\\nlocal, general, or spinal anesthesia, depending on the\\nnumber warts and where they are.\\nElectrocoagulation, a technique that uses electrical\\nenergy to destroy the warts, is usually the most painful of\\nthe procedures done to eliminate condyloma acuminata\\nof the anus, and is usually reserved for larger warts. It is\\ndone with local anesthesia, and may cause discharge or\\nbleeding from the anus.\\nFollow-up visits to the physician are necessary to\\nmake sure that the warts have not recurred. It is recom-\\nmended that these patients see their physicians every\\nthree to six months for up to 1.5 years, which is how long\\nthe incubation period is for the HPV virus.\\nCarbon dioxide laser treatment and electrodesicca-\\ntion are other options, but these are usually reserved for\\nextensive warts or those that continue to recur despite\\nnumerous treatments. However, because HPV virus can\\nbe transmitted via the smoke caused by these procedures,\\nthey are usually reserved for the worst infections.\\nFor small warts that affect only the skin around the\\nanus, several medications are available, which can be\\napplied directly to the surface of the warts by a physician\\nor by the patients themselves.\\nSuch medications include podophyllum resin\\n(Podocon-25, Pod-Ben-25), a substance made from the\\ncytotoxic extracts of several plants. This agent offers a\\nGALE ENCYCLOPEDIA OF MEDICINE 2172\\nAnal warts\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 172'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 186, 'page_label': '187'}, page_content='cure rate of 20–50% when used alone, and is applied by\\nthe physician weekly and then washed off 6 hours later\\nby the patient.\\nPodofilox (Condylox) is another agent, and is avail-\\nable for patients to use at home. It can be applied twice\\ndaily for up to 4 weeks. Podofilox offers a slightly higher\\ncure rate than podophyllin, and can also be used to pre-\\nvent warts.\\nTrichloroacetic and bichloroacetic acids are avail-\\nable in several concentrations up to 80% for the treat-\\nment of condyloma acuminata. These acids work to cau-\\nterize the skin, and are quite caustic. Nevertheless, they\\ncause less irritation and overall body effects than the\\nother agents mentioned above. Recurrence, however, is\\nhigher with these acids.\\nBleomycin (Blenoxane) is another treatment option,\\nbut it has several drawbacks. First, it must be adminis-\\ntered by a physician into each lesion via injection, but is\\ncan have a host of side effects, and patients must be fol-\\nlowed carefully by their physician.\\nImiquimod 5% cream is also available for patients to\\napply themselves. It is to be applied three times weekly,\\nfor up to 16 weeks, and has been shown to clear warts\\nwithin eight to 10 weeks.\\nFinally, the interferon drugs, which are naturally\\noccurring proteins that have antiviral and antitumor\\neffects, are available. These include interferon alfa 2a\\nand 2b (Roferon, Intron A), which are to be injected into\\neach lesion twice a week for up to eight weeks.\\nPrognosis\\nOnce a diagnosis of anal warts has been made, fur-\\nther outbreaks can be controlled or sometimes prevented\\nwith proper care. Unfortunately, many cases of anal warts\\neither fail to respond to treatment or recur. Patients have\\nto undergo roughly six to nine treatments over several\\nmonths to assure that the warts are completely eradicated.\\nRecurrence rates have been estimated to be over 50%\\nafter one year and may be due to the long incubation of\\nHPV (up to 1.5 years), deep lesions, undetected lesions,\\nvirus present in surrounding skin that is not treated.\\nPrevention\\nSexual abstinence and monogamous relationships can\\nbe the most effective form of prevention, and condoms\\nmay also decrease the chances of transmission of condylo-\\nma acuminata. Abstinence from sexual relations with peo-\\nple who have anal or genital warts can prevent infection.\\nUnfortunately, since many people may not be aware that\\nthey have this condition, this is not always possible.\\nKEY TERMS\\nElectrocoagulation —a technique using electrical\\nenergy to destroy the warts. Usually done for warts\\nwithin the anus with a local anesthesia, electroco-\\nagulation is most painful form of therapy, and can\\ncause both bleeding and discharge from the anus.\\nIndividuals infected with anal warts should have fol-\\nlow-up checkups every few weeks after their initial treat-\\nment, after which self-exams can be done.\\nSexual partners of people who have anal warts\\nshould also be examined, as a precautionary preventive\\nmeasure.\\nFinally, 5-flourouracil (Adrucil, Efudex, Fluoroplex)\\nmay be useful to prevent recurrence once the warts have\\nbeen removed. Treatment must, however, be initiated\\nwithin 1 month of wart removal.\\nResources\\nPERIODICALS\\nMaw, Raymond, and Geo von Krogh. “The Management of\\nAnal Warts.”British Medical Journal, no. 321 (October\\n14, 2000):910-11.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention, Sexually Trans-\\nmitted Diseases Hotline: (800) 227-8922.\\nOTHER\\n.\\n.\\n.\\n.\\nLiz Meszaros\\nAnalgesics\\nDefinition\\nAnalgesics are medicines that relieve pain.\\nPurpose\\nAnalgesics are those drugs whose primary purpose\\nis pain relief. The primary classes of analgesics are the\\nnarcotics, including additional agents that are chemically\\nGALE ENCYCLOPEDIA OF MEDICINE 2 173\\nAnalgesics\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 173'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 187, 'page_label': '188'}, page_content='based on the morphine molecule but have minimal abuse\\npotential; nonsteroidal anti-inflammatory drugs\\n(NSAIDs) including the salicylates; and\\nacetaminophen . Other drugs, notably the tricyclic anti-\\ndepressants and anti-epileptic agents such as gabapentin,\\nhave been used to relieve pain, particularly neurologic\\npain, but are not routinely classified as analgesics. Anal-\\ngesics provide symptomatic relief, but have no effect on\\ncausation, although clearly the NSAIDs, by virtue of\\ntheir dual activity, may be beneficial in both regards.\\nDescription\\nPain has been classified as “productive” pain and\\n“non-productive” pain. While this distinction has no\\nphysiologic meaning, it may serve as a guide to treat-\\nment. “Productive” pain has been described as a warning\\nof injury, and so may be both an indication of need for\\ntreatment and a guide to diagnosis. “Non-productive”\\npain by definition serves no purpose either as a warning\\nor diagnostic tool.\\nAlthough pain syndromes may be dissimilar, the\\ncommon factor is a sensory pathway from the affected\\norgan to the brain. Analgesics work at the level of the\\nnerves, either by blocking the signal from the peripheral\\nnervous system, or by distorting the interpretation by the\\ncentral nervous system. Selection of an appropriate anal-\\ngesic is based on consideration of the risk-benefit factors\\nof each class of drugs, based on type of pain, severity of\\npain, and risk of adverse effects. Traditionally, pain has\\nbeen divided into two classes, acute and chronic,\\nalthough severity and projected patient survival are other\\nfactors that must be considered in drug selection.\\nAcute pain\\nAcute pain is self limiting in duration, and includes\\npost-operative pain, pain of injury, and childbirth .\\nBecause pain of these types is expected to be short term,\\nthe long-term side effects of analgesic therapy may rou-\\ntinely be ignored. Thus, these patients may safely be\\ntreated with narcotic analgesics without concern for their\\naddictive potential, or NSAIDs with only limited concern\\nfor their ulcerogenic risks. Drugs and doses should be\\nadjusted based on observation of healing rate, switching\\npatients from high to low doses, and from narcotic anal-\\ngesics to non-narcotics when circumstances permit.\\nAn important consideration of pain management in\\nsevere pain is that patients should not be subject to the\\nreturn of pain. Analgesics should be dosed adequately to\\nassure that the pain is at least tolerable, and frequently\\nenough to avoid the anxiety that accompanies the antici-\\npated return of pain. Analgesics should never be dosed on\\na “prn” (as needed) basis, but should be administered often\\nenough to assure constant blood levels of analgesic. This\\napplies to both the narcotic and non-narcotic analgesics.\\nChronic pain\\nChronic pain, pain lasting over three months and\\nsevere enough to impair function, is more difficult to\\ntreat, since the anticipated side effects of the analgesics\\nare more difficult to manage. In the case of narcotic anal-\\ngesics this means the addiction potential, as well as res-\\npiratory depression and constipation . For the NSAIDs,\\nthe risk of gastric ulcers may be dose limiting. While\\nsome classes of drugs, such as the narcotic agonist/antag-\\nonist drugs bupronophine, nalbuphine and pentazocine,\\nand the selective COX-2 inhibitors celecoxib and rofe-\\ncoxib represent advances in reduction of adverse effects,\\nthey are still not fully suitable for long-term management\\nof severe pain. Generally, chronic pain management\\nrequires a combination of drug therapy, life-style modifi-\\ncation, and other treatment modalities.\\nNarcotic analgesics\\nThe narcotic analgesics, also termed opioids, are all\\nderived from opium. The class includes morphine,\\ncodeine, and a number of semi-synthetics including\\nmeperidine (Demerol), propoxyphen (Darvon) and oth-\\ners. The narcotic analgesics vary in potency, but all are\\neffective in treatment of visceral pain when used in ade-\\nquate doses. Adverse effects are dose related. Because\\nthese drugs are all addictive, they are controlled under\\nfederal and state laws. A variety of dosage forms are\\navailable, including oral solids, liquids, intravenous and\\nintrathecal injections, and transcutaneous patches.\\nNSAIDs, non-steroidal anti-inflammatory drugs, are\\neffective analgesics even at doses too low to have any\\nanti-inflammatory effects. There are a number of chemi-\\ncal classes, but all have similar therapeutic effects and\\nside effects. Most are appropriate only for oral adminis-\\ntration; however ketorolac (Toradol) is appropriate for\\ninjection and may be used in moderate to severe pain for\\nshort periods.\\nAcetaminophen is a non-narcotic analgesic with no\\nanti-inflammatory properties. It is appropriate for mild to\\nmoderate pain. Although the drug is well tolerated in nor-\\nmal doses, it may have significant toxicity at high doses.\\nBecause acetaminophen is largely free of side effects at\\ntherapeutic doses, it has been considered the first choice\\nfor mild pain, including that of osteoarthritis.\\nRecommended dosage\\nAppropriate dosage varies by drug, and should con-\\nsider the type of pain, as well as other risks associated\\nGALE ENCYCLOPEDIA OF MEDICINE 2174\\nAnalgesics\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 174'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 188, 'page_label': '189'}, page_content='with patient age and condition. For example, narcotic\\nanalgesics should usually be avoided in patients with a\\nhistory of substance abuse, but may be fully appropriate\\nin patients with cancer pain. Similarly, because narcotics\\nare more rapidly metabolized in patients who have used\\nthese drugs for a long period, higher than normal doses\\nmay be needed to provide adequate pain management.\\nNSAIDs, although comparatively safe in adults, repre-\\nsent an increased risk of gastrointestinal bleeding in\\npatients over the age of 60.\\nPrecautions\\nNarcotic analgesics may be contraindicated in\\npatients with respiratory depression. NSAIDS may be\\nhazardous to patients with ulcers or an ulcer history.\\nThey should be used with care in patients with renal\\ninsufficiency or coagulation disorders . NSAIDs are\\ncontraindicated in patients allergic to aspirin.\\nSide effects\\nReview adverse effects of each drug individually.\\nDrugs within a class may vary in their frequency and\\nseverity of adverse effects.\\nThe primary adverse effects of the narcotic anal-\\ngesics are addiction, constipation, and respiratory\\ndepression. Because narcotic analgesics stimulate the\\nproduction of enzymes that cause the metabolism of\\nthese drugs, patients on narcotics for a prolonged period\\nmay require increasing doses. This is not the same thing\\nas addiction, and is not a reason for withholding medica-\\ntion from patients in severe pain.\\nNSAIDs are ulcerogenic and may cause kidney\\nproblems. Gastrointestinal discomfort is common,\\nalthough in some cases, these drugs may cause ulcers\\nKEY TERMS\\nAcute pain —Pain that is usually temporary and\\nresults from something specific, such as a surgery,\\nan injury, or an infection.\\nAnalgesic—Medicine used to relieve pain.\\nChronic pain —Pain that lasts more than three\\nmonths and threatens to disrupt daily life.\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nOsteoarthritis —Joint pain resulting from damage\\nto the cartilage.\\nwithout the prior warning of gastrointestinal distress.\\nPlatelet aggregation problems may occur, although not to\\nthe same extent as if seen with aspirin.\\nInteractions\\nInteractions depend on the specific type of anal-\\ngesic. See specific references.\\nSamuel Uretsky, PharmD\\nAnalgesics, opioid\\nDefinition\\nOpioid analgesics , also known as narcotic anal-\\ngesics, are pain relievers that act on the central nervous\\nsystem. Like all narcotics, they may become habit-form-\\ning if used over long periods.\\nPurpose\\nOpioid analgesics are used to relieve pain from a\\nvariety of conditions. Some are used before or during\\nsurgery (including dental surgery) both to relieve pain and\\nto make anesthetics work more effectively. They may also\\nbe used for the same purposes during labor and delivery.\\nDescription\\nOpioid analgesics relieve pain by acting directly on\\nthe central nervous system. However, this can also lead\\nto unwanted side effects, such as drowsiness, dizziness,\\nbreathing problems, and physical or mental dependence.\\nAmong the drugs in this category are codeine, pro-\\npoxyphene (Darvon), propoxyphene and acetaminophen\\n(Darvocet N), meperidine (Demerol), hydromorphone\\n(Dilaudid), morphine, oxycodone, oxycodone and aceta-\\nminophen (Percocet, Roxicet), and hydrocodone and\\nacetaminophen (Lortab, Anexsia). These drugs come in\\nmany forms—tablets, syrups, suppositories, and injec-\\ntions, and are sold only by prescription. For some, a new\\nprescription is required for each new supply—refills are\\nprohibited according to federal regulations.\\nRecommended dosage\\nRecommended doses vary, depending on the type of\\nopioid analgesic and the form in which it is being used.\\nDoses may be different for different patients. Check with\\nthe physician who prescribed the drug or the pharmacist\\nGALE ENCYCLOPEDIA OF MEDICINE 2 175\\nAnalgesics, opioid\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 175'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 189, 'page_label': '190'}, page_content='who filled the prescription for correct dosages, and make\\nsure to understand how to take the drug.\\nAlways take opioid analgesics exactly as directed.\\nNever take larger or more frequent doses, and do not take\\nthe drug for longer than directed. Do not stop taking the\\ndrug suddenly without checking with the physician or\\ndentist who prescribed it. Gradually tapering the dose\\nmay the chance of withdrawal symptoms.\\nPrecautions\\nAnyone who uses opioid analgesics—or any narcot-\\nic—over a long time may become physically or mentally\\ndependent on the drug. Physical dependence may lead to\\nwithdrawal symptoms when the person stops taking the\\nmedicine. Building tolerance to these drugs is also possi-\\nble when they are used for a long period. Over time, the\\nbody needs larger and larger doses to relieve pain.\\nTake these drugs exactly as directed. Never take\\nmore than the recommended dose, and do not take the\\ndrugs more often than directed. If the drugs do not seem\\nto be working, consult your physician. Do not share these\\nor any other prescription drugs with others because the\\ndrug may have a completely different effect on the per-\\nson for whom it was not prescribed.\\nChildren and older people are especially sensitive to\\nopioid analgesics and may have serious breathing prob-\\nGALE ENCYCLOPEDIA OF MEDICINE 2176\\nAnalgesics, opioid\\nOpioid analgesics\\nRoute of Onset of Time to Duration of\\nDrug administration action (min) peak effect (min) action (h)\\nStrong agonists\\nFentanyl (Sublimaze) IM 7–15 20–30 1–2\\nIV 1–2 3–5 0.5–1\\nHydromorphone (Dilaudid) Oral 30 90–120 4\\nIM 15\\nIV 10–15 30–60 2–3\\nSub-Q 30 15–30\\nLevorphanol (Levo-Dromoran) Oral 10–60 90–120 4–5\\nIM\\nIV — 60 4–5\\nSub-Q 10–60 within 20\\nMeperidine (Demerol) Oral 15 60–90 2–4\\nIM 10–15\\nIV 30–50 2–4\\nSub-Q 1\\nMethadone (Dolophine) Oral 30–60 90–120 4–6\\nIM\\nIV 10–20 60–120 4–5\\nMorphine (many trade names) Oral — 60–120 4–5\\nIM 10–30\\nIV 30–60 4–5\\nSub-Q —\\nEpidural 10–30 20 4–5\\nOxymorphone (Numorphan) IM 10–15 30–90 3–6\\nIV\\nSub-Q 5–10 15–30 3–4\\nRectal\\nMild-to-moderate agonists\\nCodiene (many trade names) Oral 30–40 60–120 4\\nIm 10–30 30–60 4\\nSub-Q 10–30 4\\nHydrocodone (Hycodan) Oral 10–30 30–60 4–6\\nOxycodone (Percodan) Oral — 60 3–4\\nPropoxyphene (Darvon, Dolene) Oral 15–60 120 4–6\\nButophanol (Stadol) IM 10–30 30–60 3–4\\nIV 2–3 30 2–4\\nNalbuphine (Nubian) IM within 15 60 3–6\\nIV 2–3 30 3–4\\nSub-Q within 15 — 3–6\\nPentazocine (Talwin) Oral 15–30 60–90 3\\nIM 15–20 30–60 2–3\\nIV 2–3 15–30 2–3\\nSub-Q 15–20 30–60 2–3\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 176'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 190, 'page_label': '191'}, page_content='lems after taking them. Children may also become\\nunusually restless or agitated when given these drugs.\\nOpioid analgesics increase the effects of alcohol.\\nAnyone taking these drugs should not drink alcoholic\\nbeverages.\\nSome of these drugs may also contain aspirin, caf-\\nfeine, or acetaminophen. Refer to the entries on each of\\nthese drugs for additional precautions.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if they\\ntake opioid analgesics. Before taking these drugs, be sure\\nto let the physician know about any of these conditions.\\nALLERGIES. Let the physician know about any aller-\\ngies to foods, dyes, preservatives, or other substances\\nand about any previous reactions to opioid analgesics.\\nPREGNANCY. Women who are pregnant or plan to\\nbecome pregnant while taking opioid analgesics should\\nlet their physicians know. No evidence exists that these\\ndrugs cause birth defects in people, but some do cause\\nbirth defects and other problems when given to pregnant\\nanimals in experiments. Babies can become dependent\\non opioid analgesics if their mothers use too much during\\npregnancy. This can cause the baby to go through with-\\ndrawal symptoms after birth. If taken just before deliv-\\nery, some opioid analgesics may cause serious breathing\\nproblems in the newborn.\\nBREAST FEEDING. Some opioid analgesics can pass\\ninto breast milk. Women who are breast feeding should\\ncheck with their physicians about the safety of taking\\nthese drugs.\\nOTHER MEDICAL CONDITIONS. These conditions\\nmay influence the effects of opioid analgesics:\\n• head injury. The effects of some opioid analgesics may\\nbe stronger and may interfere with recovery in people\\nwith head injuries.\\n• history of convulsions. Some of these drugs may trigger\\nconvulsions.\\n• asthma,emphysema, or any chronic lung disease\\n• heart disease\\n• kidney disease\\n• liver disease\\n• underactive thyroid. The chance of side effects may be\\ngreater.\\n• addison’s disease (a disease of the adrenal glands)\\n• colitis\\n• gallbladder disease or gallstones . Side effects can be\\ndangerous in people with these conditions.\\n• enlarged prostate or other urinary problems\\n• current or past alcohol abuse\\n• current or past drug abuse, especially narcotic abuse\\n• current or past emotional problems. The chance of side\\neffects may be greater.\\nUSE OF CERTAIN MEDICINES. Taking opioid nar-\\ncotics with certain other drugs may increase the chances\\nof serious side effects.\\nSide effects\\nSome people experience drowsiness, dizziness, light-\\nheadedness, or a false sense of well-being after taking opi-\\noid analgesics. Anyone who takes these drugs should not\\ndrive, use machines, or do anything else that might be dan-\\ngerous until they know how the drug affects them. Nausea\\nand vomiting are common side effects, especially when\\nfirst beginning to take the medicine. If these symptoms do\\nnot go away after the first few doses, check with the physi-\\ncian or dentist who prescribed the medicine.\\nDry mouth is another common side effect. Dry\\nmouth can be relieved by sucking on sugarless hard\\ncandy or ice chips or by chewing sugarless gum. Saliva\\nsubstitutes, which come in liquid or tablet forms, also\\nmay help. Patients who must use opioid analgesics over\\nlong periods and who have dry mouth should see their\\ndentists, as the problem can lead to tooth decay and\\nother dental problems.\\nThe following side effects are less common. They\\nusually do not need medical attention and will go away\\nafter the first few doses. If they continue or interfere with\\nnormal activity, check with the physician who prescribed\\nthe medicine.\\n• headache\\n• loss of appetite\\n• restlessness or nervousness\\n• nightmares, unusual dreams, or problems sleeping\\n• weakness or tiredness\\n• mental sluggishness\\n• stomach pain or cramps\\n• blurred or double vision or other vision problems\\n• problems urinating, such as pain, difficulty urinating,\\nfrequent urge to urinate, or decreased amount of urine\\n• constipation.\\nOther side effects may be more serious and may\\nrequire quick medical attention. These symptoms could\\nGALE ENCYCLOPEDIA OF MEDICINE 2 177\\nAnalgesics, opioid\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 177'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 191, 'page_label': '192'}, page_content='be signs of an overdose. Get emergency medical care\\nimmediately.\\n• cold, clammy skin\\n• bluish discoloration of the skin\\n• extremely small pupils\\n• serious difficulty breathing or extremely slow breathing\\n• extreme sleepiness or unresponsiveness\\n• severe weakness\\n• confusion\\n• severe dizziness\\n• severe drowsiness\\n• slow heartbeat\\n• low blood pressure\\n• severe nervousness or restlessness\\nIn addition, these less common side effects do not\\nrequire emergency medical care, but should have medical\\nattention as soon as possible:\\n• hallucinations or a sense of unreality\\n• depression or other mood changes\\n• ringing or buzzing in the ears\\n• pounding or unusually fast heartbeat\\n• itching,hives, or rash\\n• facial swelling\\n• trembling or twitching\\n• dark urine, pale stools, or yellow eyes or skin (after tak-\\ning propoxyphene)\\n• increased sweating, red or flushed face (more common\\nafter taking hydrocodone and meperidine)\\nInteractions\\nAnyone taking these drugs should notify his or her\\nphysician before taking opioid analgesics:\\n• Central nervous system (CNS) depressants, such as anti-\\nhistamines and other medicines for allergies, hay fever,\\nor colds; tranquilizers; some other prescription pain\\nrelievers; seizure medicines; muscle relaxants; sleeping\\npills; some anesthetics (including dental anesthetics).\\n• Monoamine oxidase (MAO) inhibitors, such as phenel-\\nzine (Nardil) and tranylcypromine (Parnate). The com-\\nbination of the opioid analgesic meperidine (Demerol)\\nand MAO inhibitors is especially dangerous.\\n• Tricyclic antidepressants, such as amitriptyline (Elavil).\\n• Anti-seizure medicines, such as carbamazepine (Tegre-\\ntol). May lead to serious side effects, including coma,\\nwhen combined with propoxyphene and acetaminophen\\n(Darvocet-N) or propoxyphene (Darvon).\\nKEY TERMS\\nAnalgesic—Medicine used to relieve pain.\\nCentral nervous system —The brain, spinal cord\\nand nerves throughout the body.\\nColitis—Inflammation of the colon (large bowel)\\nHallucination —A false or distorted perception of\\nobjects, sounds, or events that seems real. Halluci-\\nnations usually result from drugs or mental disor-\\nders.\\nInflammation —Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nNarcotic —A drug derived from opium or com-\\npounds similar to opium. Such drugs are potent\\npain relievers and can affect mood and behavior.\\nLong-term use of narcotics can lead to depen-\\ndence and tolerance.\\nTolerance—A decrease in sensitivity to a drug.\\nWhen tolerance occurs, a person must take more\\nand more of the drug to get the same effect.\\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• Muscle relaxants, such as cyclobenzaprine (Flexeril).\\n• Sleeping pills, such as triazolam (Halcion).\\n• Blood-thinning drugs, such as warfarin (Coumadin).\\n• Naltrexone (Trexan, Revia). Cancels the effects of opi-\\noid analgesics.\\n• Rifampin (Rifadin).\\n• Zidovudine (AZT, Retrovir). Serious side effects when\\ncombined with morphine.\\nNancy Ross-Flanigan\\nAnaphylactic shock see Anaphylaxis\\nAnaphylactoid purpura see Allergic purpura\\nAnaphylaxis\\nDefinition\\nAnaphylaxis is a rapidly progressing, life-threaten-\\ning allergic reaction.\\nGALE ENCYCLOPEDIA OF MEDICINE 2178\\nAnaphylaxis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 178'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 192, 'page_label': '193'}, page_content='Description\\nAnaphylaxis is a type of allergic reaction, in which\\nthe immune system responds to otherwise harmless sub-\\nstances from the environment. Unlike other allergic\\nreactions, however, anaphylaxis can kill. Reaction may\\nbegin within minutes or even seconds of exposure, and\\nrapidly progress to cause airway constriction, skin and\\nintestinal irritation, and altered heart rhythms. In severe\\ncases, it can result in complete airway obstruction,\\nshock, and death.\\nCauses and symptoms\\nCauses\\nLike the majority of other allergic reactions, anaphy-\\nlaxis is caused by the release of histamine and other\\nchemicals from mast cells. Mast cells are a type of white\\nblood cell and they are found in large numbers in the tis-\\nsues that regulate exchange with the environment: the\\nairways, digestive system, and skin.\\nOn their surfaces, mast cells display antibodies\\ncalled IgE (immunoglobulin type E). These antibodies\\nare designed to detect environmental substances to\\nwhich the immune system is sensitive. Substances from\\na genuinely threatening source, such as bacteria or\\nviruses, are called antigens. A substance that most peo-\\nple tolerate well, but to which others have an allergic\\nresponse, is called an allergen. When IgE antibodies\\nbind with allergens, they cause the mast cell to release\\nhistamine and other chemicals, which spill out onto\\nneighboring cells.\\nThe interaction of these chemicals with receptors on\\nthe surface of blood vessels causes the vessels to leak\\nfluid into surrounding tissues, causing fluid accumula-\\ntion, redness, and swelling. On the smooth muscle cells\\nof the airways and digestive system, they cause constric-\\ntion. On nerve endings, they increase sensitivity and\\ncause itching.\\nIn anaphylaxis, the dramatic response is due both to\\nextreme hypersensivity to the allergen and its usually\\nsystemic distribution. Allergens are more likely to cause\\nanaphylaxis if they are introduced directly into the circu-\\nlatory system by injection. However, exposure by inges-\\ntion, inhalation, or skin contact can also cause anaphy-\\nlaxis. In some cases, anaphylaxis may develop over time\\nfrom less severe allergies.\\nAnaphylaxis is most often due to allergens in foods,\\ndrugs, and insect venom. Specific causes include:\\n• fish, shellfish, and mollusks\\n• nuts and seeds\\n• stings of bees, wasps, or hornets\\n• papain from meat tenderizers\\n• vaccines, including flu and measles vaccines\\n• penicillin\\n• cephalosporins\\n• streptomycin\\n• gamma globulin\\n• insulin\\n• hormones (ACTH, thyroid-stimulating hormone)\\n• aspirin and other NSAIDs\\n• latex, from exam gloves or condoms, for example\\nExposure to cold or exercise can trigger anaphylaxis\\nin some individuals.\\nSymptoms\\nSymptoms may include:\\n• urticaria (hives)\\n• swelling and irritation of the tongue or mouth\\n• swelling of the sinuses\\n• difficulty breathing\\n• wheezing\\n• cramping, vomiting, or diarrhea\\n• anxiety or confusion\\n• strong, very rapid heartbeat (palpitations)\\n• loss of consciousness\\nNot all symptoms may be present.\\nDiagnosis\\nAnaphylaxis is diagnosed based on the rapid devel-\\nopment of symptoms in response to a suspect allergen.\\nIdentification of the culprit may be done with RAST test-\\ning, a blood test that identifies IgE reactions to specific\\nallergens. Skin testing may be done for less severe ana-\\nphylactic reactions.\\nTreatment\\nEmergency treatment of anaphylaxis involves injec-\\ntion of adrenaline (epinephrine) which constricts blood\\nvessels and counteracts the effects of histamine. Oxygen\\nmay be given, as well as intravenous replacement fluids.\\nAntihistamines may be used for skin rash, and amino-\\nphylline for bronchial constriction. If the upper airway is\\nobstructed, placement of a breathing tube or tracheosto-\\nmy tube may be needed.\\nGALE ENCYCLOPEDIA OF MEDICINE 2 179\\nAnaphylaxis\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 179'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 193, 'page_label': '194'}, page_content='Prognosis\\nThe rapidity of symptom development is an indica-\\ntion of the likely severity of reaction: the faster symp-\\ntoms develop, the more severe the ultimate reaction.\\nPrompt emergency medical attention and close monitor-\\ning reduces the likelihood of death. Nonetheless, death is\\npossible from severe anaphylaxis. For most people who\\nreceive rapid treatment, recovery is complete.\\nPrevention\\nAvoidance of the allergic trigger is the only reliable\\nmethod of preventing anaphylaxis. For insect allergies,\\nthis requires recognizing likely nest sites. Preventing food\\nallergies requires knowledge of the prepared foods or\\ndishes in which the allergen is likely to occur, and careful\\nquestioning about ingredients when dining out. Use of a\\nMedic-Alert tag detailing drug allergies is vital to prevent\\ninadvertent administration during a medical emergency.\\nPeople prone to anaphylaxis should carry an “Epi-\\npen” or “Ana-kit,” which contain an adrenaline dose\\nready for injection.\\nResources\\nBOOKS\\nHolgate, Stephen T., and Martin K. Church. Allergy. New York:\\nGower Medical Publishing, 1993.\\nLawlor Jr., G. J., T. J. Fischer, and D. C. Adelman. Manual of Aller-\\ngy and Immunology.Boston: Little, Brown and Co., 1995.\\nNovick, N. L. You Can Do Something About Your Allergies.\\nNew York: Macmillan, 1994.\\nOTHER\\nThe Merck Page.20 Feb. 1998. .\\nRichard Robinson\\nKEY TERMS\\nACTH—Adrenocorticotropic hormone, a hor-\\nmone normally produced by the pituitary gland,\\nsometimes taken as a treatment for arthritis and\\nother disorders.\\nAntibody —An immune system protein which\\nbinds to a substance from the environment.\\nNSAIDs—Non-steroidal antiinflammatory drugs,\\nincluding aspirin and ibuprofen.\\nTracheostomy tube—A tube which is inserted into\\nan incision in the trachea (tracheostomy) to relieve\\nupper airway obstruction.\\nAnemias\\nDefinition\\nAnemia is a condition characterized by abnormally\\nlow levels of healthy red blood cells or hemoglobin (the\\ncomponent of red blood cells that delivers oxygen to tis-\\nsues throughout the body).\\nDescription\\nThe tissues of the human body need a regular supply\\nof oxygen to stay healthy. Red blood cells, which contain\\nhemoglobin that allows them to deliver oxygen throughout\\nthe body, live for only about 120 days. When they die, the\\niron they contain is returned to the bone marrow and used\\nto create new red blood cells. Anemia develops when\\nheavy bleeding causes significant iron loss or when some-\\nthing happens to slow down the production of red blood\\ncells or to increase the rate at which they are destroyed.\\nTypes of anemia\\nAnemia can be mild, moderate, or severe enough to\\nlead to life-threatening complications. More than 400\\ndifferent types of anemia have been identified. Many of\\nthem are rare.\\nIRON DEFICIENCY ANEMIA. Iron deficiency ane-\\nmia is the most common form of anemia in the world. In\\nthe United States, iron deficiency anemia affects about\\n240,000 toddlers between one and two years of age and\\n3.3 million women of childbearing age. This condition is\\nless common in older children and in adults over 50 and\\nrarely occurs in teenage boys and young men.\\nThe onset of iron deficiency anemia is gradual and,\\nat first, there may not be any symptoms. The deficiency\\nbegins when the body loses more iron than it derives\\nfrom food and other sources. Because depleted iron\\nstores cannot meet the red blood cell’s needs, fewer red\\nblood cells develop. In this early stage of anemia, the red\\nblood cells look normal, but they are reduced in number.\\nThen the body tries to compensate for the iron deficiency\\nby producing more red blood cells, which are character-\\nistically small in size. Symptoms develop at this stage.\\nFOLIC ACID DEFICIENCY ANEMIA. Folic acid defi-\\nciency anemia is the most common type of megaloblas-\\ntic anemia (in which red blood cells are bigger than nor-\\nmal). It is caused by a deficiency of folic acid, a vitamin\\nthat the body needs to produce normal cells.\\nFolic acid anemia is especially common in infants\\nand teenagers. Although this condition usually results\\nfrom a dietary deficiency, it is sometimes due to inability\\nto absorb enough folic acid from such foods as:\\nGALE ENCYCLOPEDIA OF MEDICINE 2180\\nAnemias\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 180'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 194, 'page_label': '195'}, page_content='• cheese\\n• eggs\\n• fish\\n• green vegetables\\n• meat\\n• milk\\n• mushrooms\\n• yeast\\nSmoking raises the risk of developing this condition\\nby interfering with the absorption of Vitamin C, which the\\nbody needs to absorb folic acid. Folic acid anemia can be\\na complication of pregnancy, when a woman’s body\\nneeds eight times more folic acid than it does otherwise.\\nVITAMIN B12 DEFICIENCY ANEMIA. Less common in\\nthis country than folic acid anemia, vitamin B 12 deficien-\\ncy anemia is another type of megaloblastic anemia that\\ndevelops when the body doesn’t absorb enough of this\\nnutrient. Necessary for the creation of red blood cells, B\\n12\\nis found in meat and vegetables.\\nLarge amounts of B 12 are stored in the body, so this\\ncondition may not become apparent until as much as four\\nyears after B\\n12 absorption stops or slows down. The\\nresulting drop in red blood cell production can cause:\\n• loss of muscle control\\n• loss of sensation in the legs, hands, and feet\\n• soreness or burning of the tongue\\n• weight loss\\n• yellow-blue color blindness\\nThe most common form of B 12 deficiency is perni-\\ncious anemia . Since most people who eat meat or eggs\\nget enough B12 in their diets, a deficiency of this vitamin\\nusually means that the body is not absorbing it properly.\\nThis can occur among people who have had intestinal\\nsurgery or among those who do not produce adequate\\namounts of intrinsic factor, a chemical secreted by the\\nstomach lining that combines with B\\n12 to help its absorp-\\ntion in the small intestine.\\nPernicious anemia usually strikes between the ages\\nof 50–60. Eating disorders or an unbalanced diet increas-\\nes the risk of developing pernicious anemia. So do:\\n• diabetes mellitus\\n• gastritis, stomach cancer, or stomach surgery\\n• thyroid disease\\n• family history of pernicious anemia\\nVITAMIN C DEFICIENCY ANEMIA. A rare disorder\\nthat causes the bone marrow to manufacture abnormally\\nsmall red blood cells, Vitamin C deficiency anemia\\nresults from a severe, long-standing dietary deficiency.\\nHEMOLYTIC ANEMIA. Some people are born with\\nhemolytic anemia . Some acquire this condition, in\\nwhich infection or antibodies destroy red blood cells\\nmore rapidly than bone marrow can replace them.\\nHemolytic anemia can enlarge the spleen, accelerat-\\ning the destruction of red blood cells (hemolysis). Other\\ncomplications of hemolytic anemia include:\\n• pain\\n• shock\\n• gallstones and other serious health problems\\nTHALASSEMIAS. An inherited form of hemolytic\\nanemia, thalassemia stems from the body’s inability to\\nmanufacture as much normal hemoglobin as it needs.\\nThere are two categories of thalassemia, depending on\\nwhich of the amino acid chains is affected. (Hemoglobin\\nis composed of four chains of amino acids.) In alpha-tha-\\nlassemia, there is an imbalance in the production of the\\nalpha chain of amino acids; in beta-thalassemia, there is\\nan imbalance in the beta chain. Alpha-thalassemias most\\ncommonly affect blacks (25% have at least one gene);\\nbeta-thalassemias most commonly affect people of\\nMediterranean ancestry and Southeast Asians.\\nCharacterized by production of red blood cells that\\nare unusually small and fragile, thalassemia only affects\\npeople who inherit the gene for it from each parent (auto-\\nsomal recessive inheritance).\\nAUTOIMMUNE HEMOLYTIC ANEMIAS. Warm anti-\\nbody hemolytic anemia is the most common type of this\\ndisorder. This condition occurs when the body produces\\nautoantibodies that coat red blood cells. The coated cells\\nare destroyed by the spleen, liver, or bone marrow.\\nWarm antibody hemolytic anemia is more common\\nin women than in men. About one-third of patients who\\nhave warm antibody hemolytic anemia also have lym-\\nphoma, leukemia, lupus, or connective tissue disease.\\nIn cold antibody hemolytic anemia, the body attacks\\nred blood cells at or below normal body temperature. The\\nacute form of this condition frequently develops in peo-\\nple who have had pneumonia, mononeucleosis, or other\\nacute infections. It tends to be mild and short-lived, and\\ndisappears without treatment.\\nChronic cold antibody hemolytic anemia is most\\ncommon in women and most often affects those who are\\nover 40 and who have arthritis. This condition usually\\nlasts for a lifetime, generally causing few symptoms.\\nHowever, exposure to cold temperatures can accelerate\\nGALE ENCYCLOPEDIA OF MEDICINE 2 181\\nAnemias\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 181'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 195, 'page_label': '196'}, page_content='red blood cell destruction, causing fatigue, joint aches,\\nand discoloration of the arms and hands.\\nSICKLE CELL ANEMIA. Sickle cell anemia is a chron-\\nic, incurable condition that causes the body to produce\\ndefective hemoglobin, which forces red blood cells to\\nassume an abnormal crescent shape. Unlike normal oval\\ncells, fragile sickle cells can’t hold enough hemoglobin\\nto nourish body tissues. The deformed shape makes it\\nhard for sickle cells to pass through narrow blood ves-\\nsels. When capillaries become obstructed, a life-threaten-\\ning condition called sickle cell crisis is likely to occur.\\nSickle cell anemia is hereditary. It almost always\\naffects blacks and people of Mediterranean descent. A\\nchild who inherits the sickle cell gene from each parent\\nwill have the disease. A child who inherits the sickle cell\\ngene from only one parent carries the sickle cell trait, but\\ndoes not have the disease.\\nAPLASTIC ANEMIA. Sometimes curable by bone\\nmarrow transplant, but potentially fatal, aplastic anemia\\nis characterized by decreased production of red and\\nwhite blood cells and platelets (disc-shaped cells that\\nallow the blood to clot). This disorder may be inherited\\nor acquired as a result of:\\n• recent severe illness\\n• long-term exposure to industrial chemicals\\n• use of anticancer drugs and certain other medications\\nANEMIA OF CHRONIC DISEASE. Cancer, chronic\\ninfection or inflammation, and kidney and liver disease\\noften cause mild or moderate anemia. Chronic liver fail-\\nure generally produces the most severe symptoms.\\nCauses and symptoms\\nAnemia is caused by bleeding, decreased red blood\\ncell production, or increased red blood cell destruction.\\nPoor diet can contribute to vitamin deficiency and iron\\ndeficiency anemias in which fewer red blood cells are\\nproduced. Hereditary disorders and certain diseases can\\ncause increased blood cell destruction. However, exces-\\nsive bleeding is the most common cause of anemia, and\\nthe speed with which blood loss occurs has a significant\\neffect on the severity of symptoms. Chronic blood loss is\\nusually a consequence of:\\n• cancer\\n• gastrointestinal tumors\\n• diverticulosis\\n• polyposis\\n• heavy menstrual flow\\n• hemorrhoids\\n• nosebleeds\\n• stomach ulcers\\n• long-standing alcohol abuse\\nAcute blood loss is usually the result of:\\n• childbirth\\n• injury\\n• a ruptured blood vessel\\n• surgery\\nWhen a lot of blood is lost within a short time, blood\\npressure and the amount of oxygen in the body drop sud-\\ndenly. Heart failure and death can follow.\\nLoss of even one-third of the body’s blood volume in\\nthe space of several hours can be fatal. More gradual blood\\nloss is less serious, because the body has time to create\\nnew red blood cells to replace those that have been lost.\\nSymptoms\\nWeakness, fatigue, and a run-down feeling may be\\nsigns of mild anemia. Skin that is pasty or sallow, or lack\\nof color in the creases of the palm, gums, nail beds, or\\nlining of the eyelids are other signs of anemia. Someone\\nwho is weak, tires easily, is often out of breath, and feels\\nfaint or dizzy may be severely anemic.\\nOther symptoms of anemia are:\\n• angina pectoris (chest pain, often accompanied by a\\nchoking sensation that provokes severe anxiety)\\n• cravings for ice, paint, or dirt\\n• headache\\n• inability to concentrate, memory loss\\n• inflammation of the mouth ( stomatitis ) or tongue\\n(glossitis)\\n• insomnia\\n• irregular heartbeat\\n• loss of appetite\\n• nails that are dry, brittle, or ridged\\n• rapid breathing\\n• sores in the mouth, throat, or rectum\\n• sweating\\n• swelling of the hands and feet\\n• thirst\\n• tinnitus (ringing in the ears)\\n• unexplained bleeding or bruising\\nIn pernicious anemia, the tongue feels unusually\\nslick. A patient with pernicious anemia may have:\\nGALE ENCYCLOPEDIA OF MEDICINE 2182\\nAnemias\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 182'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 196, 'page_label': '197'}, page_content='• problems with movement or balance\\n• tingling in the hands and feet\\n• confusion, depression, and memory loss\\nPernicious anemia can damage the spinal cord. A\\ndoctor should be notified whenever symptoms of this\\ncondition occur.\\nA doctor should also be notified if a patient who has\\nbeen taking iron supplements develops:\\n• diarrhea\\n• cramps\\n• vomiting\\nDiagnosis\\nPersonal and family health history may suggest the\\npresence of certain types of anemia. Laboratory tests that\\nmeasure the percentage of red blood cells or the amount\\nof hemoglobin in the blood are used to confirm diagnosis\\nand determine which type of anemia is responsible for a\\npatient’s symptoms. X rays and examinations of bone\\nmarrow may be used to identify the source of bleeding.\\nTreatment\\nAnemia due to nutritional deficiencies can usually\\nbe treated at home with iron supplements or self adminis-\\ntered injections of vitamin B\\n12. People with folic acid\\nanemia should take oral folic acid replacements. Vitamin\\nC deficiency anemia can be cured by taking one vitamin\\nC tablet a day.\\nSurgery may be necessary to treat anemia caused by\\nexcessive loss of blood. Transfusions of red blood cells\\nmay be used to accelerate production of red blood cells.\\nMedication or surgery may also be necessary to con-\\ntrol heavy menstrual flow, repair a bleeding ulcer, or\\nremove polyps (growths or nodules) from the bowels.\\nPatients with thalassemia usually do not require\\ntreatment. However people with a severe form may\\nrequire periodic hospitalization for blood transfusions\\nand/or bone marrow transplantation.\\nSICKLE CELL ANEMIA. Treatment for sickle cell ane-\\nmia involves regular eye examinations, immunizations\\nfor pneumonia and infectious diseases, and prompt treat-\\nment for sickle cell crises and infections of any kind.\\nPsychotherapy or counseling may help patients deal with\\nthe emotional impact of this condition.\\nVITAMIN B12 DEFICIENCY ANEMIA. A life-long regi-\\nmen of B12 shots is necessary to control symptoms of per-\\nnicious anemia. The patient may be advised to limit phys-\\nical activity until treatment restores strength and balance.\\nAPLASTIC ANEMIA. People who have aplastic ane-\\nmia are especially susceptible to infection. Treatment for\\naplastic anemia may involve blood transfusions and bone\\nmarrow transplant to replace malfunctioning cells with\\nhealthy ones.\\nANEMIA OF CHRONIC DISEASE. There is no specific\\ntreatment for anemia associated with chronic disease, but\\ntreating the underlying illness may alleviate this condi-\\ntion. This type of anemia rarely becomes severe. If it\\ndoes, transfusions or hormone treatments to stimulate red\\nblood cell production may be prescribed.\\nHEMOLYTIC ANEMIA. There is no specific treatment\\nfor cold-antibody hemolytic anemia. About one-third of\\npatients with warm-antibody hemolytic anemia respond\\nwell to large doses of intravenous and oral corticos-\\nteroids, which are gradually discontinued as the patient’s\\ncondition improves. Patients with this condition who\\ndon’t respond to medical therapy must have the spleen\\nsurgically removed. This operation controls anemia in\\nabout half of the patients on whom it’s performed.\\nImmune-system suppressants are prescribed for patients\\nwhose surgery is not successful.\\nSelf-care\\nAnyone who has anemia caused by poor nutrition\\nshould modify his or her diet to include more vitamins,\\nminerals, and iron. Vitamin C can stimulate iron absorp-\\ntion. The following foods are also good sources of iron:\\n• almonds\\n• broccoli\\nGALE ENCYCLOPEDIA OF MEDICINE 2 183\\nAnemias\\nAn illustration of normal red blood cells (left) and those in\\nthree different types of anemia (from left), iron-deficiency\\nanemia, megaloblastic anemia, and sickle cell anemia.(Illus-\\ntration by John Bavosi, Custom Medical Stock Photo. Repro-\\nduced by permission.)\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 183'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 197, 'page_label': '198'}, page_content='• dried beans\\n• dried fruits\\n• enriched breads and cereals\\n• lean red meat\\n•l i v e r\\n• potatoes\\n• poultry\\n• rice\\n• shellfish\\n• tomatoes\\nBecause light and heat destroy folic acid, fruits and\\nvegetables should be eaten raw or cooked as little as pos-\\nsible.\\nAlternative treatment\\nAs is the case in standard medical treatment, the\\ncause of the specific anemia will determine the alterna-\\ntive treatment recommended. If the cause is a deficiency,\\nfor example iron deficiency, folic acid deficiency, B\\n12\\ndeficiency, or vitamin C deficiency, supplementation is\\nthe treatment. For extensive blood loss, the cause should\\nbe identified and corrected. Other types of anemias\\nshould be addressed on a deep healing level with crisis\\nintervention when necessary.\\nMany alternative therapies for iron-deficiency ane-\\nmia focus on adding iron-rich foods to the diet or on\\ntechniques to improve circulation and digestion. Iron\\nsupplementation, especially with iron citrate (less likely\\nto cause constipation), is used by alternative practition-\\ners. This can be given in combination with herbs that are\\nrich in iron. Some examples of iron-rich herbs are dande-\\nlion ( Taraxacum officinale ), parsley ( Petroselinum\\ncrispum ), and nettle ( Urtica dioica ). The homeopathic\\nremedy ferrum phosphoricum can also be helpful.\\nAn iron-rich herbal tonic can also me made using\\nthe following recipe:\\n• soak 1/2 oz of yellow dock root and 1/2 oz dandelion\\nroot in 1 qt of boiled water for four to 8 hours\\n• strain and simmer until the amount of liquid is reduced\\nto 1 cup\\n• remove from heat and add 1/2 cup black strap molasses,\\nmixing well\\n• store in refrigerator; take 1 tsp-2 Tbsp daily\\nOther herbal remedies used to treat iron-deficiency\\nanemia aim to improve the digestion. Gentian ( Gentiana\\nlutea) is widely used in Europe to treat anemia and other\\nnutritionally based disorders. The bitter qualities of gen-\\ntian help stimulate the digestive system, making iron and\\nother nutrients more available for absorption. This bitter\\nherb can be brewed into tea or purchased as an alcoholic\\nextract (tincture).\\nOther herbs recommended to promote digestion\\ninclude:\\n• anise (Pimpinella anisum)\\n• caraway (Carum carvi)\\n• cumin (Cuminum cyminum)\\n• linden (Tilia spp.)\\n• licorice (Glycyrrhiza glabra)\\nTraditional Chinese treatments for anemia include:\\n• acupuncture to stimulate a weakened spleen\\n• asian ginseng (Panax ginseng) to restore energy\\n• dong quai ( Angelica sinensis ) to control heavy men-\\nstrual bleeding\\n• a mixture of dong quai and Chinese foxglove(Rehman-\\nnia glutinosa) to clear a sallow complexion\\nPrognosis\\nFolic-acid and iron-deficiency anemias\\nIt usually takes three to six weeks to correct folic\\nacid or iron deficiency anemia. Patients should continue\\ntaking supplements for another six months to replenish\\niron reserves and should have periodic blood tests to\\nmake sure the bleeding has stopped and the anemia has\\nnot recurred.\\nPernicious anemia\\nAlthough pernicious anemia is considered incurable,\\nregular B\\n12 shots will alleviate symptoms and reverse\\ncomplications. Some symptoms will disappear almost as\\nsoon as treatment begins.\\nAplastic anemia\\nAplastic anemia can sometimes be cured by bone\\nmarrow transplantation. If the condition is due to\\nimmunosuppressive drugs, symptoms may disappear\\nafter the drugs are discontinued.\\nSickle cell anemia\\nAlthough sickle cell anemia cannot be cured, effec-\\ntive treatments enable patients with this disease to enjoy\\nlonger, more productive lives.\\nThalassemia\\nPeople with mild thalassemia (alpha thalassemia\\ntrait or beta thalassemia minor) lead normal lives and do\\nGALE ENCYCLOPEDIA OF MEDICINE 2184\\nAnemias\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 184'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 198, 'page_label': '199'}, page_content='not require treatment. Those with severe thalassemia\\nmay require bone marrow transplantation. Genetic thera-\\npy is is being investigated and may soon be available.\\nHemolytic anemia\\nAcquired hemolytic anemia can generally be cured\\nwhen the cause is removed.\\nPrevention\\nInherited anemias cannot be prevented. Genetic\\ncounseling can help parents cope with questions and\\nconcerns about transmitting disease-causing genes to\\ntheir children.\\nAvoiding excessive use of alcohol, eating a balanced\\ndiet that contains plenty of iron-rich foods, and taking a\\ndaily multivitamin can help prevent anemia.\\nMethods of preventing specific types of anemia\\ninclude:\\n• avoiding lengthy exposure to industrial chemicals and\\ndrugs known to cause aplastic anemia\\n• not taking medication that has triggered hemolytic ane-\\nmia and not eating foods that have caused hemolysis\\n(breakdown of red blood cells)\\n• receiving regular B\\n12 shots to prevent pernicious anemia\\nresulting from gastritis or stomach surgery\\nResources\\nBOOKS\\nBerkow, Robert, ed. The Merck Manual of Medical Informa-\\ntion: Home Edition. Whitehouse Station, NJ: Merck &\\nCo., Inc., 1997.\\nKEY TERMS\\nAplastic —Exhibiting incomplete or faulty devel-\\nopment.\\nDiabetes mellitus —A disorder of carbohydrate\\nmetabolism brought on by a combination of\\nhereditary and enviornmental factors.\\nHemoglobin—An iron-containing pigment of red\\nblood cells composed of four amino acid chains\\n(alpha, beta, gamma, delta) that delivers oxygen\\nfrom the lungs to the tissues of the body.\\nMegaloblast —A large erythroblast (a red marrow\\ncell that synthesizes hemoglobin).\\nCurrent Medical Diagnosis and Treatment, 1998.37th ed. Ed.\\nStephen McPhee, et al. Stamford: Appleton & Lange, 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.\\nOTHER\\n“Aplastic Anemia.” ThriveOnline. 2 June 1998 .\\n“Folic Acid Deficiency Anemia.” ThriveOnline. 2 June 1998\\n.\\n“Hemolytic Anemia.” ThriveOnline. 2 June 1998 .\\n“Iron Deficiency Anemia.” ThriveOnline. 2 June 1998 .\\n“Pernicious Anemia.” ThriveOnline. 3 June 1998 .\\n“Prevalence of Iron Deficiency in the United States.” ThriveOn-\\nline. 2 June 1998 .\\n“Sickle Cell Anemia & Sickle Cell Trait.” ThriveOnline. 2 June\\n1995 .\\n“Thalassemia.” ThriveOnline. 2 June 1998 .\\nMaureen Haggerty\\nAnencephaly see Congenital brain defects\\nAnesthesia, general\\nDefinition\\nGeneral anesthesia is the induction of a state of uncon-\\nsciousness with the absence of pain sensation over the\\nentire body, through the administration of anesthetic drugs.\\nIt is used during certain medical and surgical procedures.\\nPurpose\\nGeneral anesthesia has many purposes including:\\n• pain relief (analgesia)\\n• blocking memory of the procedure (amnesia)\\n• producing unconsciousness\\n• inhibiting normal body reflexes to make surgery safe\\nand easier to perform\\n• relaxing the muscles of the body\\nDescription\\nAnesthesia performed with general anesthetics\\noccurs in four stages which may or may not be observ-\\nable because they can occur very rapidly:\\nGALE ENCYCLOPEDIA OF MEDICINE 2 185\\nAnesthesia, general\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 185'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 199, 'page_label': '200'}, page_content='• Stage One: Analgesia. The patient experiences analge-\\nsia or a loss of pain sensation but remains conscious\\nand can carry on a conversation.\\n• Stage Two: Excitement. The patient may experience\\ndelirium or become violent. Blood pressure rises and\\nbecomes irregular, and breathing rate increases. This\\nstage is typically bypassed by administering a barbitu-\\nrate, such as sodium pentothal, before the anesthesia.\\n• Stage Three: Surgical Anesthesia. During this stage, the\\nskeletal muscles relax, and the patient’s breathing\\nbecomes regular. Eye movements slow, then stop, and\\nsurgery can begin.\\n• Stage Four: Medullary Paralysis . This stage occurs if\\nthe respiratory centers in the medulla oblongata of the\\nbrain that control breathing and other vital functions\\ncease to function. Death can result if the patient cannot\\nbe revived quickly. This stage should never be reached.\\nCareful control of the amounts of anesthetics adminis-\\ntered prevent this occurrence.\\nAgents used for general anesthesia may be either\\ngases or volatile liquids that are vaporized and inhaled\\nwith oxygen, or drugs delivered intravenously. A combi-\\nnation of inhaled anesthetic gases and intravenous drugs\\nare usually delivered during general anesthesia; this\\npractice is called balanced anesthesia and is used because\\nit takes advantage of the beneficial effects of each anes-\\nthetic agent to reach surgical anesthesia. If necessary, the\\nextent of the anesthesia produced by inhaling a general\\nanesthetic can be rapidly modified by adjusting the con-\\ncentration of the anesthetic in the oxygen that is breathed\\nby the patient. The degree of anesthesia produced by an\\nintravenously injected anesthesic is fixed and cannot be\\nchanged as rapidly. Most commonly, intravenous anes-\\nthetic agents are used for induction of anesthesia and\\nthen followed by inhaled anesthetic agents.\\nGeneral anesthesia works by altering the flow of\\nsodium molecules into nerve cells (neurons) through the\\ncell membrane. Exactly how the anesthetic does this is\\nnot understood since the drug apparently does not bind to\\nany receptor on the cell surface and does not seem to\\naffect the release of chemicals that transmit nerve\\nimpulses (neurotransmitters) from the nerve cells. It is\\nknown, however, that when the sodium molecules do not\\nget into the neurons, nerve impulses are not generated\\nand the brain becomes unconscious, does not store mem-\\nories, does not register pain impulses from other areas of\\nthe body, and does not control involuntary reflexes.\\nAlthough anesthesia may feel like deep sleep, it is not the\\nsame. In sleep, some parts of the brain speed up while\\nothers slow down. Under anesthesia, the loss of con-\\nsciousness is more widespread.\\nWhen general anesthesia was first introduced in\\nmedical practice, ether and chloroform were inhaled with\\nthe physician manually covering the patient’s mouth.\\nSince then, general anesthesia has become much more\\nsophisticated. During most surgical procedures, anesthet-\\nic agents are now delivered and controlled by computer-\\nized equipment that includes anesthetic gas monitoring\\nas well as patient monitoring equipment. Anesthesiolo-\\ngists are the physicians that specialize in the delivery of\\nanesthetic agents. Currently used inhaled general anes-\\nthetics include halothane, enflurane, isoflurane, desfluo-\\nrane, sevofluorane, and nitrous oxide.\\n• Halothane (Fluothane) is a powerful anesthetic and can\\neasily be overadministered. This drug causes uncon-\\nsciousness but little pain relief so it is often used with\\nother agents to control pain. Very rarely, it can be toxic\\nto the liver in adults, causing death. It also has the\\npotential for causing serious cardiac dysrhythmias.\\nHalothane has a pleasant odor, and was frequently the\\nanesthetic of choice for use with children, but since the\\nintroduction of sevofluorane in the 1990s, halothane\\nuse has declined.\\n• Enflurane (Ethrane) is less potent and results in a\\nmore rapid onset of anesthesia and faster awakening\\nthan halothane. In addition, it acts as an enhancer of\\nparalyzing agents. Enflurane has been found to\\nincrease intracranial pressure and the risk of seizures;\\ntherefore, its use is contraindicated in patients with\\nseizure disorders.\\n• Isoflurane (Forane) is not toxic to the liver but can\\ncause some cardiac irregularities. Isofluorane is often\\nused in combination with intravenous anesthetics for\\nanesthesia induction. Awakening from anesthesia is\\nfaster than it is with halothane and enfluorane.\\n• Desfluorane (Suprane) may increase the heart rate and\\nshould not be used in patients with aortic valve steno-\\nsis; however, it does not usually cause heart arrhyth-\\nmias. Desflurane may cause coughing and excitation\\nduring induction and is therefore used with intravenous\\nanesthetics for induction. Desflurane is rapidly elimi-\\nnated and awakening is therefore faster than with other\\ninhaled agents.\\n• Sevofluorane (Ultane) may also cause increased heart\\nrate and should not be used in patients with narrowed\\naortic valve (stenosis); however, it does not usually\\ncause heart arrhythmias. Unlike desfluorane, sevofluo-\\nrane does not cause any coughing or other related side\\neffects, and can therefore be used without intravenous\\nagents for rapid induction. For this reason, sevofluorane\\nis replacing halothane for induction in pediatric\\npatients. Like desfluorane, this agent is rapidly elimi-\\nnated and allows rapid awakening.\\nGALE ENCYCLOPEDIA OF MEDICINE 2186\\nAnesthesia, general\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 186'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 200, 'page_label': '201'}, page_content='• Nitrous oxide (laughing gas) is a weak anesthetic and is\\nused with other agents, such as thiopental, to produce\\nsurgical anesthesia. It has the fastest induction and\\nrecovery and is the safest because it does not slow\\nbreathing or blood flow to the brain. However, it diffus-\\nes rapidly into air-containing cavities and can result in a\\ncollapsed lung ( pneumothorax ) or lower the oxygen\\ncontents of tissues (hypoxia).\\nCommonly administered intravenous anesthetic\\nagents include ketamine, thiopental, opioids, and propofol.\\n• Ketamine (Ketalar) affects the senses, and produces a\\ndissociative anesthesia (catatonia, amnesia, analgesia)\\nin which the patient may appear awake and reactive, but\\ncannot respond to sensory stimuli. These properties\\nmake it especially useful for use in developing coun-\\ntries and during warfare medical treatment. Ketamine is\\nfrequently used in pediatric patients because anesthesia\\nand analgesia can be achieved with an intramuscular\\ninjection. It is also used in high-risk geriatric patients\\nand in shock cases, because it also provides cardiac\\nstimulation.\\n• Thiopental (Pentothal) is a barbiturate that induces a\\nrapid hypnotic state of short duration. Because thiopen-\\ntal is slowly metabolized by the liver, toxic accumula-\\ntion can occur; therefore, it should not be continuously\\ninfused. Side effects include nausea and vomiting\\nupon awakening.\\n• Opioids include fentanyl, sufentanil, and alfentanil, and\\nare frequently used prior to anesthesia and surgery as a\\nsedative and analgesic, as well as a continuous infusion\\nfor primary anesthesia. Because opioids rarely affect\\nthe cardiovascular system, they are particularly useful\\nfor cardiac surgery and other high-risk cases. Opioids\\nact directly on spinal cord receptors, and are freqently\\nused in epidurals for spinal anesthesia. Side effects may\\ninclude nausea and vomiting, itching, and respiratory\\ndepression.\\n• Propofol (Diprivan) is a nonbarbiturate hypnotic agent\\nand the most recently developed intravenous anesthetic.\\nIts rapid induction and short duration of action are iden-\\ntical to thiopental, but recovery occurs more quickly\\nand with much less nausea and vomiting. Also, propo-\\nfol is rapidly metabolized in the liver and excreted in\\nthe urine, so it can be used for long durations of anes-\\nthesia, unlike thiopental. Hence, propofol is rapidly\\nreplacing thiopental as an intravenous induction agent.\\nIt is used for general surgery , cardiac surgery, neuro-\\nsurgery, and pediatric surgery.\\nGeneral anesthetics are given only by anesthesiolo-\\ngists, the medical professionals trained to use them. These\\nspecialists consider many factors, including a patient’s\\nage, weight, medication allergies, medical history, and\\ngeneral health, when deciding which anesthetic or combi-\\nnation of anesthetics to use. General anesthetics are usual-\\nly inhaled through a mask or a breathing tube or injected\\ninto a vein, but are also sometimes given rectally.\\nGeneral anesthesia is much safer today than it was in\\nthe past. This progress is due to faster-acting anesthetics,\\nimproved safety standards in the equipment used to\\ndeliver the drugs, and better devices to monitor breath-\\ning, heart rate, blood pressure, and brain activity during\\nsurgery. Unpleasant side effects are also less common.\\nRecommended dosage\\nThe dosage depends on the type of anesthetic, the\\npatient’s age and physical condition, the type of surgery\\nor medical procedure being done, and other medication\\nthe patient takes before, during, or after surgery.\\nPrecautions\\nAlthough the risks of serious complications from\\ngeneral anesthesia are very low, they can include heart\\nattack, stroke, brain damage, and death. Anyone sched-\\nuled to undergo general anesthesia should thoroughly\\ndiscuss the benefits and risks with a physician. The risks\\nof complications depend, in part, on a patient’s age, sex,\\nweight, allergies, general health, and history of smoking,\\ndrinking alcohol, or drug use. Some of these risks can be\\nminimized by ensuring that the physician and anesthesi-\\nologist are fully informed of the detailed health condition\\nof the patient, including any drugs that he or she may be\\nusing. Older people are especially sensitive to the effects\\nof certain anesthetics and may be more likely to experi-\\nence side effects from these drugs.\\nPatients who have had general anesthesia should not\\ndrink alcoholic beverages or take medication that slow\\ndown the central nervous system (such as antihista-\\nmines, sedatives, tranquilizers, sleep aids, certain pain\\nrelievers, muscle relaxants, and anti-seizure medication)\\nfor at least 24 hours, except under a doctor’s care.\\nSpecial conditions\\nPeople with certain medical conditions are at greater\\nrisk of developing problems with anesthetics. Before\\nundergoing general anesthesia, anyone with the follow-\\ning conditions should absolutely inform their doctor.\\nALLERGIES. Anyone who has had allergic or other\\nunusual reactions to barbiturates or general anesthetics\\nin the past should notify the doctor before having general\\nanesthesia. In particular, people who have had malignant\\nhyperthermia or whose family members have had malig-\\nnant hyperthermia during or after being given an anes-\\nGALE ENCYCLOPEDIA OF MEDICINE 2 187\\nAnesthesia, general\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 187'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 201, 'page_label': '202'}, page_content='thetic should inform the physician. Signs of malignant\\nhyperthermia include rapid, irregular heartbeat, breath-\\ning problems, very high fever, and muscle tightness or\\nspasms. These symptoms can occur following the admin-\\nistration of general anesthesia using inhaled agents, espe-\\ncially halothane. In addition, the doctor should also be\\ntold about any allergies to foods, dyes, preservatives, or\\nother substances.\\nPREGNANCY. The effects of anesthetics on pregnant\\nwomen and fetuses vary, depending on the type of drug. In\\ngeneral, giving large amounts of general anesthetics to the\\nmother during labor and delivery may make the baby slug-\\ngish after delivery. Pregnant women should discuss the use\\nof anesthetics during labor and delivery with their doctors.\\nPregnant women who may be given general anesthesia for\\nother medical procedures should ensure that the treating\\nphysician is informed about the pregnancy.\\nBREASTFEEDING. Some general anesthetics pass into\\nbreast milk, but they have not been reported to cause prob-\\nlems in nursing babies whose mothers were given the drugs.\\nOTHER MEDICAL CONDITIONS. Before being given\\na general anesthetic, a patient who has any of the follow-\\ning conditions should inform his or her doctor:\\n• neurological conditions, such as epilepsy or stroke\\n• problems with the stomach or esophagus, such as ulcers\\nor heartburn\\n• eating disorders\\n• loose teeth, dentures, bridgework\\n• heart disease or family history of heart problems\\n• lung diseases, such as emphysema or asthma\\n• history of smoking\\n• immune system diseases\\n• arthritis or any other conditions that affect movement\\n• diseases of the endocrine system, such as diabetes or\\nthyroid problems\\nSide effects\\nBecause general anesthetics affect the central ner-\\nvous system, patients may feel drowsy, weak, or tired\\nfor as long as a few days after having general anesthesia.\\nFuzzy thinking, blurred vision, and coordination prob-\\nlems are also possible. For these reasons, anyone who\\nhas had general anesthesia should not drive, operate\\nmachinery, or perform other activities that could endan-\\nger themselves or others for at least 24 hours, or longer\\nif necessary.\\nMost side effects usually disappear as the anesthetic\\nwears off. A nurse or doctor should be notified if these or\\nother side effects persist or cause problems, such as:\\n• Headache\\n• vision problems, including blurred or double vision\\n• shivering or trembling\\n• muscle pain\\n• dizziness, lightheadedness, or faintness\\n• drowsiness\\n• mood or mental changes\\n• nausea or vomiting\\n• sore throat\\n• nightmares or unusual dreams\\nA doctor should be notified as soon as possible if\\nany of the following side effects occur within two weeks\\nof having general anesthesia:\\n• severe headache\\n• pain in the stomach or abdomen\\n• back or leg pain\\n• severe nausea\\n• black or bloody vomit\\n• unusual tiredness or weakness\\n• weakness in the wrist and fingers\\n• weight loss or loss of appetite\\nGALE ENCYCLOPEDIA OF MEDICINE 2188\\nAnesthesia, general\\nAnesthetics: How They Work\\nType Name(s) Administered Affect\\nGeneral Halothane, Enflurane Isoflurane, Intravenously, Inhalation Produces total unconsciousness affecting the\\nKetamine, Nitrous Oxide, Thiopental entire body\\nRegional Mepivacaine, Chloroprocaine, Lidocaine Intravenously Temporarily interrupts transmission of nerve impuls-\\nes (temperature, touch, pain) and motor functions in\\na large area to be treated; does not produce uncon-\\nsciousness\\nLocal Procaine, Lidocaine, Tetracaine, Bupivacaine Intravenously Temporarily blocks transmission of nerve impulses\\nand motor functions in a specific area; does not pro-\\nduce unconsciousness\\nTopical Benzocaine, Lidocaine Dibucaine, Demal (Sprays, Drope, Ointments, Temporarily blocks nerve endings in skin and\\nPramoxine, Butamben, Tetracaine Creams, Gels) mucous membranes; does not produce uncon-\\nsciousness\\nGEM - 0001 to 0432 - A 10/22/03 1:42 PM Page 188'),\n", " Document(metadata={'producer': 'PDFlib+PDI 5.0.0 (SunOS)', 'creator': 'PyPDF', 'creationdate': '2004-12-18T17:00:02-05:00', 'moddate': '2004-12-18T16:15:31-06:00', 'source': 'data/Medical_book.pdf', 'total_pages': 637, 'page': 202, 'page_label': '203'}, page_content='• increase or decrease in amount of urine\\n• pale skin\\n• yellow eyes or skin\\nInteractions\\nGeneral anesthetics may interact with other medi-\\ncines. When this happens, the effects of one or both of\\nthe drugs may be altered or the risk of side effects may\\nbe greater. Anyone scheduled to undergo general anes-\\nthesia should inform the doctor about all other medica-\\ntion that he or she is taking. This includes prescription\\ndrugs, nonprescription medicines, and street drugs. Seri-\\nous and possibly life-threatening reactions may occur\\nwhen general anesthetics are given to people who use\\nstreet drugs, such as cocaine, marijuana, phencyclidine\\n(PCP or angel dust), amphetamines (uppers), barbiturates\\n(downers), heroin, or other narcotics. Anyone who uses\\nthese drugs should make sure their doctor or dentist\\nknows what they have taken.\\nResources\\nBOOKS\\nDobson, Michael B. Anaesthesia at the District Hospital. 2nd\\ned. World Health Organization, 2000.\\nU.S. Pharmacopeia Staff. Complete Drug Reference. 1997 ed.\\nYonkers, NY: Consumer Reports Books, 1997.\\nKEY TERMS\\nAmnesia—The loss of memory.\\nAnalgesia —A state of insensitivity to pain even\\nthough the person remains fully conscious.\\nAnesthesiologist—A medical specialist who admin-\\nisters an anesthetic to a patient before he is treated.\\nAnesthetic—A drug that causes unconsciousness or\\na loss of general sensation.\\nArrhythmia— Abnormal heart beat.\\nBarbiturate —A drug with hypnotic and sedative\\neffects.\\nCatatonia—Psychomotor disturbance characterized\\nby muscular rigidity, excitement or stupor.\\nHypnotic agent —A drug capable of inducing a\\nhypnotic state.\\nHypnotic state —A state of heightened awareness\\nthat can be used to modulate the perception of\\npain.\\nHypoxia—Reduction of oxygen supply to the tis-\\nsues.\\nMalignant hyperthermia—A type of reaction (prob-\\nably with a genetic origin) that can occur during\\ngeneral anesthesia and in which the patient experi-\\nences a high fever, muscle rigidity, and irregular\\nheart rate and blood pressure.\\nMedulla oblongata —The lowest section of the\\nbrainstem, located next to the spinal cord. The\\nmedulla is the site of important cardiac and respira-\\ntory regulatory centers.\\nOpioid—Any morphine-like synthetic narcotic that\\nproduces the same effects as drugs derived from the\\nopium poppy (opiates), such as pain relief, seda-\\ntion, constipation and respiratory depression.\\nPneumothorax—A collapse of the lung.\\nStenosis—A narrowing or constriction of the diame-\\nter of a passage or orifice, such as a blood vessel.\\nPERIODICALS\\nAdachi, Y .U. K. Watanabe, H. Higuchi, and T. Satoh. “The\\nDeterminants of Propofol Induction of Anesthesia Dose.\\nAnesthesia and Analgesia, 92 (2001): 656-661.\\nMarcus, Mary Brophy. “How Does Anesthesia Work? A State\\nThat Is Nothing Like Sleep: No Memory, No Fight-or-\\nFlight Response, No Pain.”U.S. News & World Report\\n123 (August 18, 1997): 66.\\nORGANIZATION\\nAmerican Society of Anesthesiologists. “Anesthesia and You.”\\n1999. .\\nOTHER\\nWenker, O. “Review of Currently Used Inhalation Anesthetics\\nPart I.”(1999) The Internet Journal of Anesthesiology\\n