{ "cells": [ { "cell_type": "code", "execution_count": 1, "id": "4a6268b0", "metadata": {}, "outputs": [ { "name": "stdout", "output_type": "stream", "text": [ "ok\n" ] } ], "source": [ "print(\"ok\")" ] }, { "cell_type": "code", "execution_count": 2, "metadata": {}, "outputs": [ { "data": { "text/plain": [ "'c:\\\\Users\\\\manai\\\\Desktop\\\\My Docs\\\\LLM\\\\Med-Chatbot\\\\Final\\\\Medical-Chatbot\\\\research'" ] }, "execution_count": 2, "metadata": {}, "output_type": "execute_result" } ], "source": [ "%pwd" ] }, { "cell_type": "code", "execution_count": 14, "id": "593c408d", "metadata": {}, "outputs": [], "source": [ "import os\n", "os.chdir(\"../\")" ] }, { "cell_type": "code", "execution_count": 15, "metadata": {}, "outputs": [], "source": [ "from langchain.document_loaders import PyPDFLoader, DirectoryLoader\n", "from langchain.text_splitter import RecursiveCharacterTextSplitter" ] }, { "cell_type": "code", "execution_count": 16, "id": "b220441e", "metadata": {}, "outputs": [], "source": [ "def load_pdf_files(data):\n", " loader = DirectoryLoader(\n", " data,\n", " glob=\"*.pdf\", \n", " loader_cls=PyPDFLoader,\n", " show_progress=True\n", " )\n", " \n", " documents = loader.load()[:637]\n", " return documents" ] }, { "cell_type": "code", "execution_count": 6, "id": "e8d432b8", "metadata": {}, "outputs": [ { "name": "stderr", "output_type": "stream", "text": [ "100%|██████████| 1/1 [00:53<00:00, 53.97s/it]" ] }, { "ename": "KeyboardInterrupt", "evalue": "", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mKeyboardInterrupt\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[6], line 1\u001b[0m\n\u001b[1;32m----> 1\u001b[0m extracted_data\u001b[38;5;241m=\u001b[39m \u001b[43mload_pdf_files\u001b[49m\u001b[43m(\u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43mdata\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m)\u001b[49m\n", "Cell \u001b[1;32mIn[5], line 9\u001b[0m, in \u001b[0;36mload_pdf_files\u001b[1;34m(data)\u001b[0m\n\u001b[0;32m 1\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mload_pdf_files\u001b[39m(data):\n\u001b[0;32m 2\u001b[0m loader \u001b[38;5;241m=\u001b[39m DirectoryLoader(\n\u001b[0;32m 3\u001b[0m data,\n\u001b[0;32m 4\u001b[0m glob\u001b[38;5;241m=\u001b[39m\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124m*.pdf\u001b[39m\u001b[38;5;124m\"\u001b[39m, \n\u001b[0;32m 5\u001b[0m loader_cls\u001b[38;5;241m=\u001b[39mPyPDFLoader,\n\u001b[0;32m 6\u001b[0m show_progress\u001b[38;5;241m=\u001b[39m\u001b[38;5;28;01mTrue\u001b[39;00m\n\u001b[0;32m 7\u001b[0m )\n\u001b[1;32m----> 9\u001b[0m documents \u001b[38;5;241m=\u001b[39m \u001b[43mloader\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mload\u001b[49m\u001b[43m(\u001b[49m\u001b[43m)\u001b[49m[:\u001b[38;5;241m637\u001b[39m]\n\u001b[0;32m 10\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m documents\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_community\\document_loaders\\directory.py:117\u001b[0m, in \u001b[0;36mDirectoryLoader.load\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 115\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mload\u001b[39m(\u001b[38;5;28mself\u001b[39m) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m List[Document]:\n\u001b[0;32m 116\u001b[0m \u001b[38;5;250m \u001b[39m\u001b[38;5;124;03m\"\"\"Load documents.\"\"\"\u001b[39;00m\n\u001b[1;32m--> 117\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28;43mlist\u001b[39;49m\u001b[43m(\u001b[49m\u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mlazy_load\u001b[49m\u001b[43m(\u001b[49m\u001b[43m)\u001b[49m\u001b[43m)\u001b[49m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_community\\document_loaders\\directory.py:195\u001b[0m, in \u001b[0;36mDirectoryLoader.lazy_load\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 193\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[0;32m 194\u001b[0m \u001b[38;5;28;01mfor\u001b[39;00m i \u001b[38;5;129;01min\u001b[39;00m items:\n\u001b[1;32m--> 195\u001b[0m \u001b[38;5;28;01myield from\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_lazy_load_file(i, p, pbar)\n\u001b[0;32m 197\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m pbar:\n\u001b[0;32m 198\u001b[0m pbar\u001b[38;5;241m.\u001b[39mclose()\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_community\\document_loaders\\directory.py:223\u001b[0m, in \u001b[0;36mDirectoryLoader._lazy_load_file\u001b[1;34m(self, item, path, pbar)\u001b[0m\n\u001b[0;32m 221\u001b[0m loader \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mloader_cls(\u001b[38;5;28mstr\u001b[39m(item), \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mloader_kwargs)\n\u001b[0;32m 222\u001b[0m \u001b[38;5;28;01mtry\u001b[39;00m:\n\u001b[1;32m--> 223\u001b[0m \u001b[38;5;28;01mfor\u001b[39;00m subdoc \u001b[38;5;129;01min\u001b[39;00m loader\u001b[38;5;241m.\u001b[39mlazy_load():\n\u001b[0;32m 224\u001b[0m \u001b[38;5;28;01myield\u001b[39;00m subdoc\n\u001b[0;32m 225\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mNotImplementedError\u001b[39;00m:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_community\\document_loaders\\pdf.py:305\u001b[0m, in \u001b[0;36mPyPDFLoader.lazy_load\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 303\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[0;32m 304\u001b[0m blob \u001b[38;5;241m=\u001b[39m Blob\u001b[38;5;241m.\u001b[39mfrom_path(\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mfile_path)\n\u001b[1;32m--> 305\u001b[0m \u001b[38;5;28;01myield from\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mparser\u001b[38;5;241m.\u001b[39mlazy_parse(blob)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_community\\document_loaders\\parsers\\pdf.py:408\u001b[0m, in \u001b[0;36mPyPDFParser.lazy_parse\u001b[1;34m(self, blob)\u001b[0m\n\u001b[0;32m 398\u001b[0m all_text \u001b[38;5;241m=\u001b[39m _merge_text_and_extras(\n\u001b[0;32m 399\u001b[0m [images_from_page], text_from_page\n\u001b[0;32m 400\u001b[0m )\u001b[38;5;241m.\u001b[39mstrip()\n\u001b[0;32m 401\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mmode \u001b[38;5;241m==\u001b[39m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mpage\u001b[39m\u001b[38;5;124m\"\u001b[39m:\n\u001b[0;32m 402\u001b[0m \u001b[38;5;28;01myield\u001b[39;00m Document(\n\u001b[0;32m 403\u001b[0m page_content\u001b[38;5;241m=\u001b[39mall_text,\n\u001b[0;32m 404\u001b[0m metadata\u001b[38;5;241m=\u001b[39m_validate_metadata(\n\u001b[0;32m 405\u001b[0m doc_metadata\n\u001b[0;32m 406\u001b[0m \u001b[38;5;241m|\u001b[39m {\n\u001b[0;32m 407\u001b[0m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mpage\u001b[39m\u001b[38;5;124m\"\u001b[39m: page_number,\n\u001b[1;32m--> 408\u001b[0m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mpage_label\u001b[39m\u001b[38;5;124m\"\u001b[39m: \u001b[43mpdf_reader\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mpage_labels\u001b[49m[page_number],\n\u001b[0;32m 409\u001b[0m }\n\u001b[0;32m 410\u001b[0m ),\n\u001b[0;32m 411\u001b[0m )\n\u001b[0;32m 412\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[0;32m 413\u001b[0m single_texts\u001b[38;5;241m.\u001b[39mappend(all_text)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\_doc_common.py:1066\u001b[0m, in \u001b[0;36mPdfDocCommon.page_labels\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 1058\u001b[0m \u001b[38;5;129m@property\u001b[39m\n\u001b[0;32m 1059\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mpage_labels\u001b[39m(\u001b[38;5;28mself\u001b[39m) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m List[\u001b[38;5;28mstr\u001b[39m]:\n\u001b[0;32m 1060\u001b[0m \u001b[38;5;250m \u001b[39m\u001b[38;5;124;03m\"\"\"\u001b[39;00m\n\u001b[0;32m 1061\u001b[0m \u001b[38;5;124;03m A list of labels for the pages in this document.\u001b[39;00m\n\u001b[0;32m 1062\u001b[0m \n\u001b[0;32m 1063\u001b[0m \u001b[38;5;124;03m This property is read-only. The labels are in the order that the pages\u001b[39;00m\n\u001b[0;32m 1064\u001b[0m \u001b[38;5;124;03m appear in the document.\u001b[39;00m\n\u001b[0;32m 1065\u001b[0m \u001b[38;5;124;03m \"\"\"\u001b[39;00m\n\u001b[1;32m-> 1066\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m [page_index2page_label(\u001b[38;5;28mself\u001b[39m, i) \u001b[38;5;28;01mfor\u001b[39;00m i \u001b[38;5;129;01min\u001b[39;00m \u001b[38;5;28mrange\u001b[39m(\u001b[38;5;28mlen\u001b[39m(\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mpages))]\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\_doc_common.py:1066\u001b[0m, in \u001b[0;36m\u001b[1;34m(.0)\u001b[0m\n\u001b[0;32m 1058\u001b[0m \u001b[38;5;129m@property\u001b[39m\n\u001b[0;32m 1059\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mpage_labels\u001b[39m(\u001b[38;5;28mself\u001b[39m) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m List[\u001b[38;5;28mstr\u001b[39m]:\n\u001b[0;32m 1060\u001b[0m \u001b[38;5;250m \u001b[39m\u001b[38;5;124;03m\"\"\"\u001b[39;00m\n\u001b[0;32m 1061\u001b[0m \u001b[38;5;124;03m A list of labels for the pages in this document.\u001b[39;00m\n\u001b[0;32m 1062\u001b[0m \n\u001b[0;32m 1063\u001b[0m \u001b[38;5;124;03m This property is read-only. The labels are in the order that the pages\u001b[39;00m\n\u001b[0;32m 1064\u001b[0m \u001b[38;5;124;03m appear in the document.\u001b[39;00m\n\u001b[0;32m 1065\u001b[0m \u001b[38;5;124;03m \"\"\"\u001b[39;00m\n\u001b[1;32m-> 1066\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m [\u001b[43mpage_index2page_label\u001b[49m\u001b[43m(\u001b[49m\u001b[38;5;28;43mself\u001b[39;49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mi\u001b[49m\u001b[43m)\u001b[49m \u001b[38;5;28;01mfor\u001b[39;00m i \u001b[38;5;129;01min\u001b[39;00m \u001b[38;5;28mrange\u001b[39m(\u001b[38;5;28mlen\u001b[39m(\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mpages))]\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\_page_labels.py:179\u001b[0m, in \u001b[0;36mindex2label\u001b[1;34m(reader, index)\u001b[0m\n\u001b[0;32m 177\u001b[0m number_tree \u001b[38;5;241m=\u001b[39m cast(DictionaryObject, root[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124m/PageLabels\u001b[39m\u001b[38;5;124m\"\u001b[39m]\u001b[38;5;241m.\u001b[39mget_object())\n\u001b[0;32m 178\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124m/Nums\u001b[39m\u001b[38;5;124m\"\u001b[39m \u001b[38;5;129;01min\u001b[39;00m number_tree:\n\u001b[1;32m--> 179\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[43mget_label_from_nums\u001b[49m\u001b[43m(\u001b[49m\u001b[43mnumber_tree\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mindex\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 180\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124m/Kids\u001b[39m\u001b[38;5;124m\"\u001b[39m \u001b[38;5;129;01min\u001b[39;00m number_tree \u001b[38;5;129;01mand\u001b[39;00m \u001b[38;5;129;01mnot\u001b[39;00m \u001b[38;5;28misinstance\u001b[39m(number_tree[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124m/Kids\u001b[39m\u001b[38;5;124m\"\u001b[39m], NullObject):\n\u001b[0;32m 181\u001b[0m \u001b[38;5;66;03m# number_tree = {'/Kids': [IndirectObject(7333, 0, 140132998195856), ...]}\u001b[39;00m\n\u001b[0;32m 182\u001b[0m \u001b[38;5;66;03m# Limit maximum depth.\u001b[39;00m\n\u001b[0;32m 183\u001b[0m level \u001b[38;5;241m=\u001b[39m \u001b[38;5;241m0\u001b[39m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\_page_labels.py:140\u001b[0m, in \u001b[0;36mget_label_from_nums\u001b[1;34m(dictionary_object, index)\u001b[0m\n\u001b[0;32m 138\u001b[0m \u001b[38;5;28;01mwhile\u001b[39;00m i \u001b[38;5;241m<\u001b[39m \u001b[38;5;28mlen\u001b[39m(nums):\n\u001b[0;32m 139\u001b[0m start_index \u001b[38;5;241m=\u001b[39m nums[i]\n\u001b[1;32m--> 140\u001b[0m value \u001b[38;5;241m=\u001b[39m \u001b[43mnums\u001b[49m\u001b[43m[\u001b[49m\u001b[43mi\u001b[49m\u001b[43m \u001b[49m\u001b[38;5;241;43m+\u001b[39;49m\u001b[43m \u001b[49m\u001b[38;5;241;43m1\u001b[39;49m\u001b[43m]\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mget_object\u001b[49m\u001b[43m(\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 141\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m i \u001b[38;5;241m+\u001b[39m \u001b[38;5;241m2\u001b[39m \u001b[38;5;241m==\u001b[39m \u001b[38;5;28mlen\u001b[39m(nums):\n\u001b[0;32m 142\u001b[0m \u001b[38;5;28;01mbreak\u001b[39;00m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\generic\\_base.py:376\u001b[0m, in \u001b[0;36mIndirectObject.get_object\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 375\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mget_object\u001b[39m(\u001b[38;5;28mself\u001b[39m) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m Optional[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mPdfObject\u001b[39m\u001b[38;5;124m\"\u001b[39m]:\n\u001b[1;32m--> 376\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mpdf\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mget_object\u001b[49m\u001b[43m(\u001b[49m\u001b[38;5;28;43mself\u001b[39;49m\u001b[43m)\u001b[49m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\pypdf\\_reader.py:394\u001b[0m, in \u001b[0;36mPdfReader.get_object\u001b[1;34m(self, indirect_reference)\u001b[0m\n\u001b[0;32m 392\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;28misinstance\u001b[39m(indirect_reference, \u001b[38;5;28mint\u001b[39m):\n\u001b[0;32m 393\u001b[0m indirect_reference \u001b[38;5;241m=\u001b[39m IndirectObject(indirect_reference, \u001b[38;5;241m0\u001b[39m, \u001b[38;5;28mself\u001b[39m)\n\u001b[1;32m--> 394\u001b[0m retval \u001b[38;5;241m=\u001b[39m \u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mcache_get_indirect_object\u001b[49m\u001b[43m(\u001b[49m\n\u001b[0;32m 395\u001b[0m \u001b[43m \u001b[49m\u001b[43mindirect_reference\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mgeneration\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mindirect_reference\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43midnum\u001b[49m\n\u001b[0;32m 396\u001b[0m \u001b[43m\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 397\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m retval \u001b[38;5;129;01mis\u001b[39;00m \u001b[38;5;129;01mnot\u001b[39;00m \u001b[38;5;28;01mNone\u001b[39;00m:\n\u001b[0;32m 398\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m retval\n", "\u001b[1;31mKeyboardInterrupt\u001b[0m: " ] } ], "source": [ "extracted_data= load_pdf_files(\"data\")" ] }, { "cell_type": "code", "execution_count": null, "id": "d9dbc4f5", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 0, 'page_label': 'i'}, page_content=''),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 1, 'page_label': 'ii'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 2, 'page_label': 'iii-1'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n1\\nA-B\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 3, 'page_label': 'iii-2'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n2\\nC-F\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 4, 'page_label': 'iii-3'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n3\\nG-M\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 5, 'page_label': 'iii-4'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n4\\nN-S\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 6, 'page_label': 'iii-5'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n5\\nT-Z\\nORGANIZATIONS\\nGENERAL INDEX\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 7, 'page_label': 'iv'}, page_content='THE GALE ENCYCLOPEDIA OF MEDICINE, THIRD EDITION\\nª 2006 Thomson Gale, a part of The Thomson\\nCorporation.\\nThomson and Star Logo are trademarks and\\nGale is a registered trademark used herein\\nunder license.\\nFor more information, contact\\nThe Gale Group, Inc.\\n27500 Drake Rd.\\nFarmington Hills, MI 48331-3535\\nOr you can visit our Internet site at\\nhttp://www.gale.com\\nALL RIGHTS RESERVED\\nNo part of this work covered by the copyright\\nhereon may be reproduced or used in any\\nform or by any means—graphic, electronic, or\\nmechanical, including photocopying, record-\\ning, taping, Web distribution, or information\\nstorage retrieval systems—without the written\\npermission of the publisher.\\nThis publication is a creative work fully pro-\\ntected by all applicable copyright laws, as well\\nas by misappropriation, trade secret, unfair\\ncondition, and other applicable laws. The\\nauthors and editors of this work have added\\nvalue to the underlying factual material herein\\nthrough one or more of the following: coordi-\\nnation, expression, arrangement, and classifi-\\ncation of the information.\\nFor permission to use material from this pro-\\nduct, submit your request via the web at http://\\nwww.gale-edit.com/permission or you may\\ndownload our Permissions Request form and\\nsubmit your request by fax of mail to:\\nPermissions\\nThomson Gale\\n27500 Drake Rd.\\nFarmington Hills, MI 48331-3535\\nPermissions Hotline:\\n248-699-8006 or 800-877-4253, ext. 8006\\nFax: 248-699-8074 or 800-762-4058\\nSince this page cannot legibly accommodate all\\ncopyright notices, the acknowledgments con-\\nstitute an extension of the copyright notice.\\nWhile every effort has been made to ensure\\nthe reliability of the information presented in\\nthis publication, Thomson Gale does not\\nguarantee the accuracy of the data contained\\nherein. Thomson Gale accepts no payment for\\nlisting; and inclusion in the publication of any\\norganization, agency, institution, publication,\\nservice, or individual does not imply endorse-\\nment of the editors or publisher. Errors brought\\nto the attention of the publisher and verified to\\nthe satisfaction of the publisher will be cor-\\nrected in future editions.\\nLIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA\\nThe Gale encyclopedia of medicine / Jacqueline L. Longe, editor.– 3rd ed.\\np. ; cm.\\nIncludes bibliographical references and index.\\nISBN 1-4144-0368-2 (set hardcover : alk. paper) – ISBN 1-4144-0369-0 (v. 1 : hardcover\\n: alk. paper) – ISBN 1-4144-0370-4 (v. 2 : hardcover : alk. paper) – ISBN 1-4144-0371-2\\nv. 3 : hardcover : alk. paper) – ISBN 1-4144-0372-0 (v. 4 : hardcover : alk. paper) –\\nISBN 1-4144-0373-9 (v. 5 : hardcover : alk. paper)\\n1. Internal medicine–Encyclopedias.\\n[DNLM: 1. Internal Medicine–Encyclopedias–English. 2. Complementary Therapies–\\nEncyclopedias–English. WB 13 G151 2005] I. Title: Encyclopedia of medicine. II. Longe,\\nJacqueline L. III. Gale Group.\\nRC41.G35 2006\\n616’.003–dc22\\n2005011418\\nThis title is also available as an e-book\\nISBN 1-4144-0485-9 (set)\\nContact your Gale sales representative for ordering information.\\nISBN 1-4144-0368-2 (set)\\n1-4144-0369-0 (Vol. 1)\\n1-4144-0370-4 (Vol. 2)\\n1-4144-0371-2 (Vol. 3)\\n1-4144-0372-0 (Vol. 4)\\n1-4144-0373-9 (Vol. 5)\\nPrinted in China\\n1 0987654321\\nProject Editor\\nJacqueline L. Longe\\nEditorial\\nShirelle Phelps, Laurie Fundukian, Jeffrey\\nLehman, Brigham Narins\\nEditorial Support Services\\nLuann Brennan, Grant Eldridge, Andrea Lopeman\\nRights Acquisition Management\\nShalice Caldwell-Shah\\nImaging\\nRandy Bassett, Lezlie Light, Dan Newell,\\nChristine O’Bryan, Robyn V. Young\\nProduct Design\\nTracey Rowens\\nComposition and Electronic Prepress\\nEvi Seoud, Mary Beth Trimper\\nManufacturing\\nWendy Blurton, Dorothy Maki\\nIndexing\\nFactiva'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 8, 'page_label': 'v'}, page_content='CONTENTS\\nList of Entries............................................ vii\\nIntroduction.............................................. xxi\\nAdvisory Board....................................... xxiii\\nContributors ............................................ xxv\\nEntries\\nVolume 1: A-B............................................ 1\\nVolume 2: C-F......................................... 693\\nVolume 3: G-M...................................... 1533\\nVolume 4: N-S....................................... 2569\\nVolume 5: T-Z....................................... 3621\\nOrganizations......................................... 4037\\nGeneral Index........................................ 4061\\nGALE ENCYCLOPEDIA OF MEDICINE V'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 9, 'page_label': 'vii'}, page_content='LIST OF ENTRIES\\nA\\nAbdominal ultrasound\\nAbdominal wall defects\\nAbortion, partial birth\\nAbortion, selective\\nAbortion, therapeutic\\nAbscess incision & drainage\\nAbscess\\nAbuse\\nAcetaminophen\\nAchalasia\\nAchondroplasia\\nAcid phosphatase test\\nAcne\\nAcoustic neuroma\\nAcrocyanosis\\nAcromegaly and gigantism\\nActinomycosis\\nAcupressure\\nAcupuncture\\nAcute kidney failure\\nAcute lymphangitis\\nAcute poststreptococcal\\nglomerulonephritis\\nAcute stress disorder\\nAddiction\\nAddison’s disease\\nAdenoid hyperplasia\\nAdenovirus infections\\nAdhesions\\nAdjustment disorders\\nAdrenal gland cancer\\nAdrenal gland scan\\nAdrenal virilism\\nAdrenalectomy\\nAdrenocorticotropic hormone test\\nAdrenoleukodystrophy\\nAdult respiratory distress syndrome\\nAging\\nAgoraphobia\\nAIDS tests\\nAIDS\\nAlanine aminotransferase test\\nAlbinism\\nAlcoholism\\nAlcohol-related neurologic disease\\nAldolase test\\nAldosterone assay\\nAlemtuzumab\\nAlexander technique\\nAlkaline phosphatase test\\nAllergic bronchopulmonary\\naspergillosis\\nAllergic purpura\\nAllergic rhinitis\\nAllergies\\nAllergy tests\\nAlopecia\\nAlpha\\n1-adrenergic blockers\\nAlpha-fetoprotein test\\nAlport syndrome\\nAltitude sickness\\nAlzheimer’s disease\\nAmblyopia\\nAmebiasis\\nAmenorrhea\\nAmino acid disorders screening\\nAminoglycosides\\nAmnesia\\nAmniocentesis\\nAmputation\\nAmylase tests\\nAmyloidosis\\nAmyotrophic lateral sclerosis\\nAnabolic steroid use\\nAnaerobic infections\\nAnal atresia\\nAnal cancer\\nAnal warts\\nAnalgesics, opioid\\nAnalgesics\\nAnaphylaxis\\nAnemias\\nAnesthesia, general\\nAnesthesia, local\\nAneurysmectomy\\nAngina\\nAngiography\\nAngioplasty\\nAngiotensin-converting enzyme\\ninhibitors\\nAngiotensin-converting enzyme\\ntest\\nAnimal bite infections\\nAnkylosing spondylitis\\nAnorectal disorders\\nAnorexia nervosa\\nAnoscopy\\nAnosmia\\nAnoxia\\nAntacids\\nAntenatal testing\\nAntepartum testing\\nAnthrax\\nAntiacne drugs\\nAntiandrogen drugs\\nAntianemia drugs\\nAntiangina drugs\\nAntiangiogenic therapy\\nAntianxiety drugs\\nAntiarrhythmic drugs\\nAntiasthmatic drugs\\nAntibiotic-associated colitis\\nAntibiotics, ophthalmic\\nAntibiotics, topical\\nAntibiotics\\nAnticancer drugs\\nAnticoagulant and antiplatelet\\ndrugs\\nAnticonvulsant drugs\\nAntidepressant drugs, SSRI\\nGALE ENCYCLOPEDIA OF MEDICINE vii'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 10, 'page_label': 'viii'}, page_content='Antidepressant drugs\\nAntidepressants, tricyclic\\nAntidiabetic drugs\\nAntidiarrheal drugs\\nAntidiuretic hormone (ADH) test\\nAntifungal drugs, systemic\\nAntifungal drugs, topical\\nAntigas agents\\nAntigastroesophageal reflux\\ndrugs\\nAntihelminthic drugs\\nAntihemorrhoid drugs\\nAntihistamines H-2 blockers\\nAntihistamines\\nAntihypertensive drugs\\nAnti-hyperuricemic drugs\\nAnti-insomnia drugs\\nAnti-itch drugs\\nAntimalarial drugs\\nAntimigraine drugs\\nAntimyocardial antibody test\\nAntinausea drugs\\nAntinuclear antibody test\\nAntiparkinson drugs\\nAntiprotozoal drugs\\nAntipsychotic drugs, atypical\\nAntipsychotic drugs\\nAnti-rejection drugs\\nAntiretroviral drugs\\nAntirheumatic drugs\\nAntiseptics\\nAntispasmodic drugs\\nAntituberculosis drugs\\nAntiulcer drugs\\nAntiviral drugs\\nAnxiety disorders\\nAnxiety\\nAortic aneurysm\\nAortic dissection\\nAortic valve insufficiency\\nAortic valve stenosis\\nApgar testing\\nAphasia\\nAplastic anemia\\nAppendectomy\\nAppendicitis\\nAppetite-enhancing drugs\\nApraxia\\nArbovirus encephalitis\\nAromatherapy\\nArrhythmias\\nArt therapy\\nArterial embolism\\nArteriovenous fistula\\nArteriovenous malformations\\nArthrography\\nArthroplasty\\nArthroscopic surgery\\nArthroscopy\\nAsbestosis\\nAscites\\nAspartate aminotransferase test\\nAspergillosis\\nAspirin\\nAsthma\\nAstigmatism\\nAston-Patterning\\nAtaxia-telangiectasia\\nAtelectasis\\nAtherectomy\\nAtherosclerosis\\nAthlete’s foot\\nAthletic heart syndrome\\nAtkins diet\\nAtopic dermatitis\\nAtrial ectopic beats\\nAtrial fibrillation and flutter\\nAtrial septal defect\\nAttention-deficit/Hyperactivity disor-\\nder (ADHD)\\nAudiometry\\nAuditory integration training\\nAutism\\nAutoimmune disorders\\nAutopsy\\nAviation medicine\\nAyurvedic medicine\\nB\\nBabesiosis\\nBacillary angiomatosis\\nBacteremia\\nBacterial vaginosis\\nBad breath\\nBalance and coordination tests\\nBalanitis\\nBalantidiasis\\nBalloon valvuloplasty\\nBarbiturate-induced coma\\nBarbiturates\\nBariatric surgery\\nBarium enema\\nBartholin’s gland cyst\\nBartonellosis\\nBattered child syndrome\\nBedsores\\nBed-wetting\\nBehcet’s syndrome\\nBejel\\nBence Jones protein test\\nBender-Gestalt test\\nBenzodiazepines\\nBereavement\\nBeriberi\\nBerylliosis\\nBeta blockers\\nBeta\\n2-microglobulin test\\nBile duct cancer\\nBiliary atresia\\nBinge-eating disorder\\nBiofeedback\\nBipolar disorder\\nBird flu\\nBirth defects\\nBirthmarks\\nBites and stings\\nBlack lung disease\\nBladder cancer\\nBladder stones\\nBladder training\\nBlastomycosis\\nBleeding time\\nBleeding varices\\nBlepharoplasty\\nBlood clots\\nBlood count\\nBlood culture\\nBlood donation and registry\\nBlood gas analysis\\nBlood sugar tests\\nBlood typing and crossmatching\\nBlood urea nitrogen test\\nBlood-viscosity reducing drugs\\nBody dysmorphic disorder\\nBoils\\nBone biopsy\\nBone density test\\nBone disorder drugs\\nBone grafting\\nBone growth stimulation\\nBone marrow aspiration and\\nbiopsy\\nBone marrow transplantation\\nBone nuclear medicine scan\\nBone x rays\\nBotulinum toxin injections\\nBotulism\\nBowel preparation\\nBowel resection\\nBowel training\\nviii\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 11, 'page_label': 'ix'}, page_content='Brain abscess\\nBrain biopsy\\nBrain tumor\\nBreast biopsy\\nBreast cancer\\nBreast implants\\nBreast reconstruction\\nBreast reduction\\nBreast self-examination\\nBreast ultrasound\\nBreech birth\\nBronchiectasis\\nBronchiolitis\\nBronchitis\\nBronchodilators\\nBronchoscopy\\nBrucellosis\\nBruises\\nBruxism\\nBudd-Chiari syndrome\\nBuerger’s disease\\nBulimia nervosa\\nBundle branch block\\nBunion\\nBurns\\nBursitis\\nByssinosis\\nC\\nCaffeine\\nCalcium channel blockers\\nCampylobacteriosis\\nCancer therapy, definitive\\nCancer therapy, palliative\\nCancer therapy, supportive\\nCancer\\nCandidiasis\\nCanker sores\\nCarbohydrate intolerance\\nCarbon monoxide poisoning\\nCarcinoembryonic antigen test\\nCardiac blood pool scan\\nCardiac catheterization\\nCardiac rehabilitation\\nCardiac tamponade\\nCardiomyopathy\\nCardiopulmonary resuscitation\\n(CPR)\\nCardioversion\\nCarotid sinus massage\\nCarpal tunnel syndrome\\nCataract surgery\\nCataracts\\nCatatonia\\nCatecholamines tests\\nCatheter ablation\\nCat-scratch disease\\nCeliac disease\\nCell therapy\\nCellulitis\\nCentral nervous system depressants\\nCentral nervous system infections\\nCentral nervous system stimulants\\nCephalosporins\\nCerebral amyloid angiopathy\\nCerebral aneurysm\\nCerebral palsy\\nCerebrospinal fluid (CSF) analysis\\nCerumen impaction\\nCervical cancer\\nCervical conization\\nCervical disk disease\\nCervical spondylosis\\nCervicitis\\nCesarean section\\nChagas’ disease\\nChancroid\\nCharcoal, activated\\nCharcot Marie Tooth disease\\nCharcot’s joints\\nChelation therapy\\nChemonucleolysis\\nChemotherapy\\nChest drainage therapy\\nChest physical therapy\\nChest x ray\\nChickenpox\\nChild abuse\\nChildbirth\\nChildren’s health\\nChiropractic\\nChlamydial pneumonia\\nChoking\\nCholangitis\\nCholecystectomy\\nCholecystitis\\nCholera\\nCholestasis\\nCholesterol test\\nCholesterol, high\\nCholesterol-reducing drugs\\nCholinergic drugs\\nChondromalacia patellae\\nChoriocarcinoma\\nChorionic villus sampling\\nChronic fatigue syndrome\\nChronic granulomatous disease\\nChronic kidney failure\\nChronic obstructive lung disease\\nCircumcision\\nCirrhosis\\nCleft lip and palate\\nClenched fist injury\\nClub drugs\\nClubfoot\\nCluster headache\\nCoagulation disorders\\nCoarctation of the aorta\\nCocaine\\nCoccidioidomycosis\\nCoccyx injuries\\nCochlear implants\\nCognitive-behavioral therapy\\nCold agglutinins test\\nCold sore\\nColic\\nColon cancer\\nColonic irrigation\\nColonoscopy\\nColor blindness\\nColostomy\\nColposcopy\\nComa\\nCommon cold\\nCommon variable immunodeficiency\\nComplement deficiencies\\nComputed tomography scans\\nConcussion\\nCondom\\nConduct disorder\\nCongenital adrenal hyperplasia\\nCongenital amputation\\nCongenital bladder anomalies\\nCongenital brain defects\\nCongenital heart disease\\nCongenital hip dysplasia\\nCongenital lobar emphysema\\nCongenital ureter anomalies\\nCongestive cardiomyopathy\\nConjunctivitis\\nConstipation\\nContact dermatitis\\nContraception\\nContractures\\nCooling treatments\\nCoombs’ tests\\nCor pulmonale\\nCorneal abrasion\\nCorneal transplantation\\nCorneal ulcers\\nGALE ENCYCLOPEDIA OF MEDICINE ix\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 12, 'page_label': 'x'}, page_content='Corns and calluses\\nCoronary artery bypass graft surgery\\nCoronary artery disease\\nCoronary stenting\\nCorticosteroids systemic\\nCorticosteroids, dermatologic\\nCorticosteroids, inhaled\\nCorticosteroids\\nCortisol tests\\nCosmetic dentistry\\nCostochondritis\\nCough suppressants\\nCough\\nCouvade syndrome\\nCox-2 inhibitors\\nCraniosacral therapy\\nCraniotomy\\nC-reactive protein\\nCreatine kinase test\\nCreatinine test\\nCreutzfeldt-Jakob disease\\nCri du chat syndrome\\nCrohn’s disease\\nCroup\\nCryoglobulin test\\nCryotherapy\\nCryptococcosis\\nCryptosporidiosis\\nCT-guided biopsy\\nCulture-fair test\\nCushing’s syndrome\\nCutaneous larva migrans\\nCutaneous T-cell lymphoma\\nCutis laxa\\nCyanosis\\nCyclic vomiting syndrome\\nCyclosporiasis\\nCystectomy\\nCystic fibrosis\\nCystinuria\\nCystitis\\nCystometry\\nCystoscopy\\nCytomegalovirus antibody screening\\ntest\\nCytomegalovirus infection\\nD\\nDacryocystitis\\nDeath\\nDebridement\\nDecompression sickness\\nDecongestants\\nDeep vein thrombosis\\nDefibrillation\\nDehydration\\nDelayed hypersensitivity skin test\\nDelirium\\nDelusions\\nDementia\\nDengue fever\\nDental trauma\\nDepo-Provera/Norplant\\nDepressive disorders\\nDermatitis\\nDermatomyositis\\nDES exposure\\nDetoxification\\nDeviated septum\\nDiabetes insipidus\\nDiabetes mellitus\\nDiabetic foot infections\\nDiabetic ketoacidosis\\nDiabetic neuropathy\\nDialysis, kidney\\nDiaper rash\\nDiaphragm (birth control)\\nDiarrhea\\nDiets\\nDiffuse esophageal spasm\\nDiGeorge syndrome\\nDigitalis drugs\\nDilatation and curettage\\nDiphtheria\\nDiscoid lupus erythematosus\\nDisk removal\\nDislocations and subluxations\\nDissociative disorders\\nDiuretics\\nDiverticulosis and diverticulitis\\nDizziness\\nDoppler ultrasonography\\nDown syndrome\\nDrug metabolism/interactions\\nDrug overdose\\nDrug therapy monitoring\\nDrugs used in labor\\nDry mouth\\nDuodenal obstruction\\nDysentery\\nDysfunctional uterine bleeding\\nDyslexia\\nDysmenorrhea\\nDyspepsia\\nDysphasia\\nE\\nEar exam with an otoscope\\nEar surgery\\nEchinacea\\nEchinococcosis\\nEchocardiography\\nEctopic pregnancy\\nEdema\\nEdwards’ syndrome\\nEhlers-Danlos syndrome\\nEhrlichiosis\\nElder Abuse\\nElectric shock injuries\\nElectrical nerve stimulation\\nElectrical stimulation of the brain\\nElectrocardiography\\nElectroconvulsive therapy\\nElectroencephalography\\nElectrolyte disorders\\nElectrolyte supplements\\nElectrolyte tests\\nElectromyography\\nElectronic fetal monitoring\\nElectrophysiology study of the heart\\nElephantiasis\\nEmbolism\\nEmergency contraception\\nEmphysema\\nEmpyema\\nEncephalitis\\nEncopresis\\nEndarterectomy\\nEndocarditis\\nEndometrial biopsy\\nEndometrial cancer\\nEndometriosis\\nEndorectal ultrasound\\nEndoscopic retrograde\\ncholangiopancreatography\\nEndoscopic sphincterotomy\\nEnemas\\nEnlarged prostate\\nEnterobacterial infections\\nEnterobiasis\\nEnterostomy\\nEnterovirus infections\\nEnzyme therapy\\nEosinophilic pneumonia\\nEpidermolysis bullosa\\nEpididymitis\\nEpiglottitis\\nEpisiotomy\\nx\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 13, 'page_label': 'xi'}, page_content='Epstein-Barr virus test\\nErectile dysfunction treatment\\nErectile dysfunction\\nErysipelas\\nErythema multiforme\\nErythema nodosum\\nErythroblastosis fetalis\\nErythrocyte sedimentation rate\\nErythromycins\\nErythropoietin test\\nEscherichia coli\\nEsophageal atresia\\nEsophageal cancer\\nEsophageal disorders\\nEsophageal function tests\\nEsophageal pouches\\nEsophagogastroduodenoscopy\\nEvoked potential studies\\nExercise\\nExophthalmos\\nExpectorants\\nExternal sphincter electromyography\\nExtracorporeal membrane\\noxygenation\\nEye and orbit ultrasounds\\nEye cancer\\nEye examination\\nEye glasses and contact lenses\\nEye muscle surgery\\nEyelid disorders\\nF\\nFace lift\\nFactitious disorders\\nFailure to thrive\\nFainting\\nFamilial Mediterranean fever\\nFamilial polyposis\\nFamily therapy\\nFanconi’s syndrome\\nFasciotomy\\nFasting\\nFatigue\\nFatty liver\\nFecal incontinence\\nFecal occult blood test\\nFeldenkrais method\\nFemale genital mutilation\\nFemale sexual arousal disorder\\nFetal alcohol syndrome\\nFetal hemoglobin test\\nFever evaluation tests\\nFever of unknown origin\\nFever\\nFibrin split products\\nFibrinogen test\\nFibroadenoma\\nFibrocystic condition of the breast\\nFibromyalgia\\nFifth disease\\nFilariasis\\nFinasteride\\nFingertip injuries\\nFish and shellfish poisoning\\nFistula\\nFlesh-eating disease\\nFlower remedies\\nFluke infections\\nFluoroquinolones\\nFolic acid deficiency anemia\\nFolic acid\\nFollicle-stimulating hormone test\\nFolliculitis\\nFood allergies\\nFood poisoning\\nFoot care\\nForeign objects\\nFracture repair\\nFractures\\nFragile X syndrome\\nFriedreich’s ataxia\\nFrostbite and frostnip\\nFugu poisoning\\nG\\nGalactorrhea\\nGalactosemia\\nGallbladder cancer\\nGallbladder nuclear medicine scan\\nGallbladder x rays\\nGallium scan of the body\\nGallstone removal\\nGallstones\\nGammaglobulin\\nGanglion\\nGangrene\\nGas embolism\\nGastrectomy\\nGastric acid determination\\nGastric emptying scan\\nGastrinoma\\nGastritis\\nGastroenteritis\\nGastrostomy\\nGaucher disease\\nGay and lesbian health\\nGender identity disorder\\nGender reassignment surgery\\nGene therapy\\nGeneral adaptation syndrome\\nGeneral surgery\\nGeneralized anxiety disorder\\nGenetic counseling\\nGenetic testing\\nGenital herpes\\nGenital warts\\nGestalt therapy\\nGestational diabetes\\nGI bleeding studies\\nGiardiasis\\nGinkgo biloba\\nGinseng, Korean\\nGlaucoma\\nGlomerulonephritis\\nGlucose-6-phosphate dehydrogenase\\ndeficiency\\nGlycogen storage diseases\\nGlycosylated hemoglobin test\\nGoiter\\nGonorrhea\\nGoodpasture’s syndrome\\nGout drugs\\nGout\\nGraft-vs.-host disease\\nGranuloma inguinale\\nGroup therapy\\nGrowth hormone tests\\nGuided imagery\\nGuillain-Barre´syndrome\\nGuinea worm infection\\nGulf War syndrome\\nGynecomastia\\nH\\nHair transplantation\\nHairy cell leukemia\\nHallucinations\\nHammertoe\\nHand-foot-and-mouth disease\\nHantavirus infections\\nHaptoglobin test\\nHartnup disease\\nHatha yoga\\nHead and neck cancer\\nHead injury\\nHeadache\\nGALE ENCYCLOPEDIA OF MEDICINE xi\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 14, 'page_label': 'xii'}, page_content='Hearing aids\\nHearing loss\\nHearing tests with a tuning fork\\nHeart attack\\nHeart block\\nHeart failure\\nHeart murmurs\\nHeart surgery for congenital defects\\nHeart transplantation\\nHeart valve repair\\nHeart valve replacement\\nHeartburn\\nHeat disorders\\nHeat treatments\\nHeavy metal poisoning\\nHeel spurs\\nHeimlich maneuver\\nHeliobacteriosis\\nHellerwork\\nHematocrit\\nHemochromatosis\\nHemoglobin electrophoresis\\nHemoglobin test\\nHemoglobinopathies\\nHemolytic anemia\\nHemolytic-uremic syndrome\\nHemophilia\\nHemophilus infections\\nHemoptysis\\nHemorrhagic fevers\\nHemorrhoids\\nHepatitis A\\nHepatitis B\\nHepatitis C\\nHepatitis D\\nHepatitis E\\nHepatitis G\\nHepatitis virus tests\\nHepatitis, alcoholic\\nHepatitis, autoimmune\\nHepatitis, drug-induced\\nHerbalism, traditional Chinese\\nHerbalism, Western\\nHereditary fructose intolerance\\nHereditary hemorrhagic\\ntelangiectasia\\nHernia repair\\nHernia\\nHerniated disk\\nHiccups\\nHigh-risk pregnancy\\nHirschsprung’s disease\\nHirsutism\\nHistiocytosis X\\nHistoplasmosis\\nHives\\nHodgkin’s disease\\nHolistic medicine\\nHolter monitoring\\nHoltzman ink blot test\\nHomeopathic medicine, acute\\nprescribing\\nHomeopathic medicine, constitu-\\ntional prescribing\\nHomeopathic medicine\\nHomocysteine\\nHookworm disease\\nHormone replacement therapy\\nHospital-acquired infections\\nHuman bite infections\\nHuman chorionic gonadotropin\\npregnancy test\\nHuman leukocyte antigen test\\nHuman-potential movement\\nHuntington disease\\nHydatidiform mole\\nHydrocelectomy\\nHydrocephalus\\nHydronephrosis\\nHydrotherapy\\nHyperaldosteronism\\nHyperbaric Chamber\\nHypercalcemia\\nHypercholesterolemia\\nHypercoagulation disorders\\nHyperemesis gravidarum\\nHyperhidrosis\\nHyperkalemia\\nHyperlipoproteinemia\\nHypernatremia\\nHyperopia\\nHyperparathyroidism\\nHyperpigmentation\\nHypersensitivity pneumonitis\\nHypersplenism\\nHypertension\\nHyperthyroidism\\nHypertrophic cardiomyopathy\\nHyphema\\nHypnotherapy\\nHypocalcemia\\nHypochondriasis\\nHypoglycemia\\nHypogonadism\\nHypokalemia\\nHypolipoproteinemia\\nHyponatremia\\nHypoparathyroidism\\nHypophysectomy\\nHypopituitarism\\nHypospadias and epispadias\\nHypotension\\nHypothermia\\nHypothyroidism\\nHypotonic duodenography\\nHysterectomy\\nHysteria\\nHysterosalpingography\\nHysteroscopy\\nHysterosonography\\nI\\nIchthyosis\\nIdiopathic infiltrative lung diseases\\nIdiopathic primary renal hematuric/\\nproteinuric syndrome\\nIdiopathic thrombocytopenic\\npurpura\\nIleus\\nImmobilization\\nImmune complex test\\nImmunodeficiency\\nImmunoelectrophoresis\\nImmunoglobulin deficiency\\nsyndromes\\nImmunologic therapies\\nImmunosuppressant drugs\\nImpacted tooth\\nImpedance phlebography\\nImpetigo\\nImplantable cardioverter-defibrillator\\nImpotence\\nImpulse control disorders\\nIn vitro fertilization\\nInclusion conjunctivitis\\nIncompetent cervix\\nIndigestion\\nIndium scan of the body\\nInduction of labor\\nInfant massage\\nInfection control\\nInfectious arthritis\\nInfectious mononucleosis\\nInfertility drugs\\nInfertility therapies\\nInfertility\\nInfluenza\\nInhalation therapies\\nInsecticide poisoning\\nInsomnia\\nxii GALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 15, 'page_label': 'xiii'}, page_content='Insulin resistance\\nIntermittent claudication\\nIntermittent explosive disorder\\nIntersex states\\nInterstitial microwave thermal\\ntherapy\\nIntestinal obstructions\\nIntestinal polyps\\nIntrauterine growth retardation\\nIntravenous rehydration\\nIntravenous urography\\nIntussusception\\nIpecac\\nIron deficiency anemia\\nIron tests\\nIrritable bowel syndrome\\nIschemia\\nIsolation\\nItching\\nIUD\\nJ\\nJapanese encephalitis\\nJaundice\\nJaw wiring\\nJet lag\\nJock itch\\nJoint biopsy\\nJoint fluid analysis\\nJoint replacement\\nJuvenile arthritis\\nK\\nKaposi’s sarcoma\\nKawasaki syndrome\\nKeloids\\nKeratitis\\nKeratosis pilaris\\nKidney biopsy\\nKidney cancer\\nKidney disease\\nKidney function tests\\nKidney nuclear medicine scan\\nKidney stones\\nKidney transplantation\\nKidney, ureter, and bladder x-ray\\nstudy\\nKinesiology, applied\\nKlinefelter syndrome\\nKnee injuries\\nKneecap removal\\nKOH test\\nKorsakoff’s syndrome\\nKyphosis\\nL\\nLabyrinthitis\\nLaceration repair\\nLacrimal duct obstruction\\nLactate dehydrogenase isoenzymes\\ntest\\nLactate dehydrogenase test\\nLactation\\nLactic acid test\\nLactose intolerance\\nLaparoscopy\\nLaryngeal cancer\\nLaryngectomy\\nLaryngitis\\nLaryngoscopy\\nLaser surgery\\nLaxatives\\nLead poisoning\\nLearning disorders\\nLeeches\\nLegionnaires’ disease\\nLeishmaniasis\\nLeprosy\\nLeptospirosis\\nLesch-Nyhan syndrome\\nLeukemia stains\\nLeukemias, acute\\nLeukemias, chronic\\nLeukocytosis\\nLeukotriene inhibitors\\nLice infestation\\nLichen planus\\nLichen simplex chronicus\\nLife support\\nLipase test\\nLipidoses\\nLipoproteins test\\nLiposuction\\nListeriosis\\nLithotripsy\\nLiver biopsy\\nLiver cancer\\nLiver disease\\nLiver encephalopathy\\nLiver function tests\\nLiver nuclear medicine scan\\nLiver transplantation\\nLow back pain\\nLower esophageal ring\\nLumpectomy\\nLung abscess\\nLung biopsy\\nLung cancer, non-small cell\\nLung cancer, small cell\\nLung diseases due to gas or chemical\\nexposure\\nLung perfusion and ventilation scan\\nLung surgery\\nLung transplantation\\nLuteinizing hormone test\\nLyme disease\\nLymph node biopsy\\nLymphadenitis\\nLymphangiography\\nlymphedema\\nLymphocyte typing\\nLymphocytic choriomeningitis\\nLymphocytopenia\\nLymphogranuloma venereum\\nLysergic acid diethylamide (LSD)\\nM\\nMacular degeneration\\nMagnesium imbalance\\nMagnetic field therapy\\nMagnetic resonance imaging\\nMalabsorption syndrome\\nMalaria\\nMalignant lymphomas\\nMalignant melanoma\\nMalingering\\nMallet finger\\nMallory-Weiss syndrome\\nMalnutrition\\nMalocclusion\\nMALT lymphoma\\nMammography\\nMania\\nMarfan syndrome\\nMarijuana\\nMarriage counseling\\nMarshall-Marchetti-Krantz\\nprocedure\\nMassage therapy\\nMastectomy\\nMastitis\\nMastocytosis\\nMastoidectomy\\nMastoiditis\\nGALE ENCYCLOPEDIA OF MEDICINE xiii\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 16, 'page_label': 'xiv'}, page_content='Maternal to fetal infections\\nMaxillofacial trauma\\nMeasles\\nMeckel’s diverticulum\\nMediastinoscopy\\nMeditation\\nMedullary sponge kidney\\nMelioidosis\\nMe´nie` re’s disease\\nMeningitis\\nMeningococcemia\\nMenopause\\nMen’s health\\nMenstrual disorders\\nMental retardation\\nMental status examination\\nMesothelioma\\nMetabolic acidosis\\nMetabolic alkalosis\\nMethadone\\nMethemoglobinemia\\nMicrophthalmia and anophthalmia\\nMifepristone\\nMigraine headache\\nMineral deficiency\\nMineral toxicity\\nMinerals\\nMinnesota multiphasic personality\\ninventory (MMPI-2)\\nMinority health\\nMinoxidil\\nMiscarriage\\nMitral valve insufficiency\\nMitral valve prolapse\\nMitral valve stenosis\\nMoles\\nMonkeypox\\nMonoamine oxidase inhibitors\\nMood disorders\\nMotion sickness\\nMovement disorders\\nMovement therapy\\nMucopolysaccharidoses\\nMucormycosis\\nMultiple chemical sensitivity\\nMultiple endocrine neoplasia\\nsyndromes\\nMultiple myeloma\\nMultiple personality disorder\\nMultiple pregnancy\\nMultiple sclerosis\\nMultiple-gated acquisition (MUGA)\\nscan\\nMumps\\nMunchausen syndrome\\nMuscle relaxants\\nMuscle spasms and cramps\\nMuscular dystrophy\\nMushroom poisoning\\nMusic therapy\\nMutism\\nMyasthenia gravis\\nMycetoma\\nMycobacterial infections, atypical\\nMycoplasma infections\\nMyelodysplastic syndrome\\nMyelofibrosis\\nMyelography\\nMyers-Briggs type indicator\\nMyocardial biopsy\\nMyocardial resection\\nMyocarditis\\nMyoglobin test\\nMyomectomy\\nMyopathies\\nMyopia\\nMyositis\\nMyotonic dystrophy\\nMyringotomy and ear tubes\\nMyxoma\\nN\\nNail removal\\nNail-patella syndrome\\nNarcolepsy\\nNarcotics\\nNasal irrigation\\nNasal packing\\nNasal papillomas\\nNasal polyps\\nNasal trauma\\nNasogastric suction\\nNasopharyngeal culture\\nNaturopathic medicine\\nNausea and vomiting\\nNear-drowning\\nNecrotizing enterocolitis\\nNeonatal jaundice\\nNephrectomy\\nNephritis\\nNephrotic syndrome\\nNephrotoxic injury\\nNeuralgia\\nNeuroblastoma\\nNeuroendocrine\\ntumorsNeurofibromatosis\\nNeurogenic bladder\\nNeurolinguistic programming\\nNeurologic exam\\nNeutropenia\\nNight terrors\\nNitrogen narcosis\\nNocardiosis\\nNongonococcal urethritis\\nNon-nucleoside reverse transcriptase\\ninhibitors\\nNonsteroidal anti-inflammatory\\ndrugs\\nNoroviruses\\nNosebleed\\nNumbness and tingling\\nNutrition through an intravenous line\\nNutrition\\nNutritional supplements\\nNystagmus\\nO\\nObesity surgery\\nObesity\\nObsessive-compulsive disorder\\nObstetrical emergencies\\nOccupational asthma\\nOligomenorrhea\\nOmega-3 Fatty Acids\\nOnychomycosis\\nOophorectomy\\nOphthalmoplegia\\nOppositional defiant disorder\\nOptic atrophy\\nOptic neuritis\\nOral contraceptives\\nOral hygiene\\nOrbital and periorbital cellulitis\\nOrchitis\\nOrthopedic surgery\\nOrthostatic hypotension\\nOsteoarthritis\\nOsteochondroses\\nOsteogenesis imperfecta\\nOsteomyelitis\\nOsteopathy\\nOsteopetroses\\nOsteoporosis\\nOstomy\\nOtitis externa\\nOtitis media\\nOtosclerosis\\nOtotoxicity\\nxiv\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 17, 'page_label': 'xv'}, page_content='Ovarian cancer\\nOvarian cysts\\nOvarian torsion\\nOveractive bladder\\nOverhydration\\nOxygen/ozone therapy\\nP\\nPacemakers\\nPaget’s disease of bone\\nPaget’s disease of the breast\\nPain management\\nPain\\nPalpitations\\nPancreas transplantation\\nPancreatectomy\\nPancreatic cancer, endocrine\\nPancreatic cancer, exocrine\\nPancreatitis\\nPanic disorder\\nPap test\\nPapilledema\\nParacentesis\\nParalysis\\nParanoia\\nParathyroid hormone test\\nParathyroid scan\\nParathyroidectomy\\nParatyphoid fever\\nParkinson disease\\nParotidectomy\\nParoxysmal atrial tachycardia\\nParrot fever\\nPartial thromboplastin time\\nParuresis\\nPatau syndrome\\nPatent ductus arteriosus\\nPellagra\\nPelvic exam\\nPelvic fracture\\nPelvic inflammatory disease\\nPelvic relaxation\\nPelvic ultrasound\\nPenicillins\\nPenile cancer\\nPenile prostheses\\nPercutaneous transhepatic\\ncholangiography\\nPerforated eardrum\\nPerforated septum\\nPericardiocentesisPericarditis\\nPerinatal infection\\nPeriodic paralysis\\nPeriodontal disease\\nPeripheral neuropathy\\nPeripheral vascular disease\\nPeritonitis\\nPernicious anemia\\nPeroxisomal disorders\\nPersonality disorders\\nPervasive developmental disorders\\nPet therapy\\nPeyronie’s disease\\nPharmacogenetics\\nPhenylketonuria\\nPheochromocytoma\\nPhimosis\\nPhlebotomy\\nPhobias\\nPhosphorus imbalance\\nPhotorefractive keratectomy and\\nlaser-assisted in-situ keratomileusis\\nPhotosensitivity\\nPhototherapy\\nPhysical allergy\\nPhysical examination\\nPica\\nPickwickian syndrome\\nPiercing and tattoos\\nPilates\\nPinguecula and pterygium\\nPinta\\nPituitary dwarfism\\nPituitary tumors\\nPityriasis rosea\\nPlacenta previa\\nPlacental abruption\\nPlague\\nPlasma renin activity\\nPlasmapheresis\\nPlastic, cosmetic, and reconstructive\\nsurgery\\nPlatelet aggregation test\\nPlatelet count\\nPlatelet function disorders\\nPleural biopsy\\nPleural effusion\\nPleurisy\\nPneumococcal pneumonia\\nPneumocystis pneumonia\\nPneumonia\\nPneumothorax\\nPoison ivy and poison oak\\nPoisoning\\nPolarity therapy\\nPolio\\nPolycystic kidney disease\\nPolycystic ovary syndrome\\nPolycythemia vera\\nPolydactyly and syndactyly\\nPolyglandular deficiency syndromes\\nPolyhydramnios and\\noligohydramnios\\nPolymyalgia rheumatica\\nPolymyositis\\nPolysomnography\\nPorphyrias\\nPortal vein bypass\\nPositron emission tomography\\n(PET)\\nPost-concussion syndrome\\nPostmenopausal bleeding\\nPostpartum depression\\nPostpolio syndrome\\nPost-traumatic stress disorder\\nPrader-Willi syndrome\\nPrecocious puberty\\nPreeclampsia and eclampsia\\nPregnancy\\nPremature ejaculation\\nPremature labor\\nPremature menopause\\nPremature rupture of membranes\\nPrematurity\\nPremenstrual dysphoric disorder\\nPremenstrual syndrome\\nPrenatal surgery\\nPrepregnancy counseling\\nPresbyopia\\nPriapism\\nPrickly heat\\nPrimary biliary cirrhosis\\nProctitis\\nProgressive multifocal\\nleukoencephalopathy\\nProgressive supranuclear palsy\\nProlactin test\\nProlonged QT syndrome\\nProphylaxis\\nProstate biopsy\\nProstate cancer\\nProstate ultrasound\\nProstatectomy\\nProstate-specific antigen test\\nProstatitis\\nProtease inhibitors\\nProtein components test\\nProtein electrophoresis\\nProtein-energy malnutrition\\nProthrombin time\\nGALE ENCYCLOPEDIA OF MEDICINE xv\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 18, 'page_label': 'xvi'}, page_content='Proton Pump Inhibitors\\nPseudogout\\nPseudomonas infections\\nPseudoxanthoma elasticum\\nPsoriasis\\nPsoriatic arthritis\\nPsychiatric confinement\\nPsychoanalysis\\nPsychological tests\\nPsychosis\\nPsychosocial disorders\\nPsychosurgery\\nPtosis\\nPuberty\\nPuerperal infection\\nPulmonary alveolar proteinosis\\nPulmonary artery catheterization\\nPulmonary edema\\nPulmonary embolism\\nPulmonary fibrosis\\nPulmonary function test\\nPulmonary hypertension\\nPulmonary valve insufficiency\\nPulmonary valve stenosis\\nPyelonephritis\\nPyloric stenosis\\nPyloroplasty\\nPyruvate kinase deficiency\\nQ\\nQ fever\\nQigong\\nR\\nRabies\\nRadial keratotomy\\nRadiation injuries\\nRadiation therapy\\nRadical neck dissection\\nRadioactive implants\\nRape and sexual assault\\nRashes\\nRat-bite fever\\nRaynaud’s disease\\nRecompression treatment\\nRectal cancer\\nRectal examination\\nRectal polyps\\nRectal prolapse\\nRecurrent miscarriage\\nRed blood cell indices\\nReflex sympathetic dystrophy\\nReflex tests\\nReflexology\\nRehabilitation\\nReiki\\nReiter’s syndrome\\nRelapsing fever\\nRelapsing polychondritis\\nRenal artery occlusion\\nRenal artery stenosis\\nRenal tubular acidosis\\nRenal vein thrombosis\\nRenovascular hypertension\\nRespiratory acidosis\\nRespiratory alkalosis\\nRespiratory distress syndrome\\nRespiratory failure\\nRespiratory syncytial virus\\ninfection\\nRestless legs syndrome\\nRestrictive cardiomyopathy\\nReticulocyte count\\nRetinal artery occlusion\\nRetinal detachment\\nRetinal hemorrhage\\nRetinal vein occlusion\\nRetinitis pigmentosa\\nRetinoblastoma\\nRetinopathies\\nRetrograde cystography\\nRetrograde ureteropyelography\\nRetrograde urethrography\\nReye’s syndrome\\nRheumatic fever\\nRheumatoid arthritis\\nRhinitis\\nRhinoplasty\\nRiboflavin deficiency\\nRickets\\nRickettsialpox\\nRingworm\\nRocky Mountain spotted fever\\nRolfing\\nRoot canal treatment\\nRosacea\\nRoseola\\nRoss River Virus\\nRotator cuff injury\\nRotavirus infections\\nRoundworm infections\\nRubella test\\nRubella\\nS\\nSacroiliac disease\\nSalivary gland scan\\nSalivary gland tumors\\nSalmonella food poisoning\\nSalpingectomy\\nSalpingo-oophorectomy\\nSarcoidosis\\nSarcomas\\nSaw palmetto\\nScabies\\nScarlet fever\\nScars\\nSchistosomiasis\\nSchizoaffective disorder\\nSchizophrenia\\nSciatica\\nScleroderma\\nSclerotherapy for esophageal varices\\nScoliosis\\nScrotal nuclear medicine scan\\nScrotal ultrasound\\nScrub typhus\\nScurvy\\nSeasonal affective disorder\\nSeborrheic dermatitis\\nSecondary polycythemia\\nSedation\\nSeizure disorder\\nSelective serotonin reuptake\\ninhibitors\\nSelf-mutilation\\nSemen analysis\\nSeniors’ health\\nSensory integration disorder\\nSepsis\\nSeptic shock\\nSeptoplasty\\nSerum sickness\\nSevere acute respiratory syndrome\\n(SARS)\\nSevere combined immunodeficiency\\nSex hormones tests\\nSex therapy\\nSexual dysfunction\\nSexual perversions\\nSexually transmitted diseases\\nSexually transmitted diseases cultures\\nShaken baby syndrome\\nShiatsu\\nShigellosis\\nShin splints\\nxvi\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 19, 'page_label': 'xvii'}, page_content='Shingles\\nShock\\nShortness of breath\\nShy-Drager syndrome\\nShyness\\nSick sinus syndrome\\nSickle cell disease\\nSideroblastic anemia\\nSigmoidoscopy\\nSildenafil citrate\\nSilicosis\\nSinus endoscopy\\nSinusitis\\nSitus inversus\\nSitz bath\\nSjo¨gren’s syndrome\\nSkin biopsy\\nSkin cancer, non-melanoma\\nSkin culture\\nSkin grafting\\nSkin lesion removal\\nSkin lesions\\nSkin pigmentation disorders\\nSkin resurfacing\\nSkull x rays\\nSleep apnea\\nSleep disorders\\nSleeping sickness\\nSmall intestine biopsy\\nSmallpox\\nSmelling disorders\\nSmoke inhalation\\nSmoking\\nSmoking-cessation drugs\\nSnoring\\nSomatoform disorders\\nSore throat\\nSouth American blastomycosis\\nSpeech disorders\\nSpina bifida\\nSpinal cord injury\\nSpinal cord tumors\\nSpinal instrumentation\\nSpinal stenosis\\nSplenectomy\\nSplenic trauma\\nSporotrichosis\\nSports injuries\\nSprains and strains\\nSputum culture\\nSt. John’s wort\\nStanford-Binet intelligence scales\\nStapedectomy\\nStaphylococcal infections\\nStaphylococcal scalded skin\\nsyndrome\\nStarvation\\nStem cell transplantation\\nStillbirth\\nStockholm syndrome\\nStomach cancer\\nStomach flushing\\nStomatitis\\nStool culture\\nStool fat test\\nStool O & P test\\nStrabismus\\nStrep throat\\nStreptococcal antibody tests\\nStreptococcal infections\\nStress reduction\\nStress test\\nStress\\nStridor\\nStroke\\nStuttering\\nSubacute sclerosing panencephalitis\\nSubarachnoid hemorrhage\\nSubdural hematoma\\nSubstance abuse and dependence\\nSudden cardiac death\\nSudden infant death syndrome\\nSuicide\\nSulfonamides\\nSunburn\\nSunscreens\\nSuperior vena cava syndrome\\nSurfactant\\nSwallowing disorders\\nSydenham’s chorea\\nSympathectomy\\nSyphilis\\nSystemic lupus erythematosus\\nT\\nTai chi\\nTapeworm diseases\\nTardive dyskinesia\\nTarsorrhaphy\\nTay-Sachs disease\\nTechnetium heart scan\\nTeeth whitening\\nTemporal arteritis\\nTemporomandibular joint disorders\\nTendinitis\\nTennis elbow\\nTensilon test\\nTension headache\\nTesticular cancer\\nTesticular self-examination\\nTesticular surgery\\nTesticular torsion\\nTetanus\\nTetracyclines\\nTetralogy of Fallot\\nThalassemia\\nThallium heart scan\\nThematic apperception test\\nTherapeutic baths\\nTherapeutic touch\\nThoracentesis\\nThoracic outlet syndrome\\nThoracic surgery\\nThoracoscopy\\nThreadworm infection\\nThroat culture\\nThrombocytopenia\\nThrombocytosis\\nThrombolytic therapy\\nThrombophlebitis\\nThymoma\\nThyroid biopsy\\nThyroid cancer\\nThyroid function tests\\nThyroid hormones\\nThyroid nuclear medicine scan\\nThyroid ultrasound\\nThyroidectomy\\nThyroiditis\\nTilt table test\\nTinnitus\\nTissue typing\\nTonsillectomy and adenoidectomy\\nTonsillitis\\nTooth decay\\nTooth extraction\\nTooth replacements and restorations\\nToothache\\nTopical Anesthesia\\nTORCH test\\nTorticollis\\nTotal parenteral nutrition\\nTourette syndrome\\nToxic epidermal necrolysis\\nToxic shock syndrome\\nToxoplasmosis\\nTrabeculectomy\\nTracheoesophageal fistula\\nTracheotomy\\nTrachoma\\nGALE ENCYCLOPEDIA OF MEDICINE xvii\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 20, 'page_label': 'xviii'}, page_content='Traction\\nTraditional Chinese medicine\\nTrager psychophysical integration\\nTranscranial Doppler\\nultrasonography\\nTransesophageal echocardiography\\nTransfusion\\nTranshepatic biliary catheterization\\nTransient ischemic attack\\nTransposition of the great arteries\\nTransurethral bladder resection\\nTransvaginal ultrasound\\nTransverse myelitis\\nTraumatic amputations\\nTraveler’s diarrhea\\nTremors\\nTrench fever\\nTrichinosis\\nTrichomoniasis\\nTricuspid valve insufficiency\\nTricuspid valve stenosis\\nTrigeminal neuralgia\\nTrigger finger\\nTriglycerides test\\nTriple screen\\nTropical spastic paraparesis\\nTroponins test\\nTubal ligation\\nTube compression of the esophagus\\nand stomach\\nTube feedings\\nTuberculin skin test\\nTuberculosis\\nTularemia\\nTumor markers\\nTumor removal\\nTurner syndrome\\n2,3-diphosphoglycerate test\\nTyphoid fever\\nTyphus\\nTzanck preparation\\nU\\nUlcer surgery\\nUlcerative colitis\\nUlcers (digestive)\\nUltraviolet light treatment\\nUmbilical cord blood banking\\nUndescended testes\\nUpper GI exam\\nUreteral stenting\\nUrethritis\\nUric acid tests\\nUrinalysis\\nUrinary anti-infectives\\nUrinary catheterization\\nUrinary diversion surgery\\nUrinary incontinence\\nUrine culture\\nUrine flow test\\nUterine fibroid embolization\\nUterine fibroids\\nUveitis\\nV\\nVaccination\\nVaginal pain\\nVagotomy\\nValsalva maneuver\\nValvular heart disease\\nVaricose veins\\nVasculitis\\nVasectomy\\nVasodilators\\nVegetarianism\\nVegetative state\\nVelopharyngeal insufficiency\\nVena cava filter\\nVenography\\nVenous access\\nVenous insufficiency\\nVentricular aneurysm\\nVentricular assist device\\nVentricular ectopic beats\\nVentricular fibrillation\\nVentricular septal defect\\nVentricular shunt\\nVentricular tachycardia\\nVesicoureteral reflux\\nVibriosis\\nVision training\\nVisual impairment\\nVitamin A deficiency\\nVitamin B\\n6 deficiency\\nVitamin D deficiency\\nVitamin E deficiency\\nVitamin K deficiency\\nVitamin tests\\nVitamin toxicity\\nVitamins\\nVitiligo\\nVitrectomy\\nVocal cord nodules and polyps\\nVocal cord paralysis\\nvon Willebrand disease\\nVulvar cancer\\nVulvodynia\\nVulvovaginitis\\nW\\nWaldenstrom’s macroglobulinemia\\nWarts\\nWechsler intelligence test\\nWegener’s granulomatosis\\nWeight loss drugs\\nWest Nile Virus\\nWheezing\\nWhiplash\\nWhite blood cell count and\\ndifferential\\nWhooping cough\\nWilderness medicine\\nWilms’ tumor\\nWilson disease\\nWiskott-Aldrich syndrome\\nWithdrawal syndromes\\nWolff-Parkinson-White\\nsyndrome\\nWomen’s health\\nWound culture\\nWound flushing\\nWounds\\nX\\nX-linked agammaglobulinemia\\nX rays of the orbit\\nY\\nYaws\\nYellow fever\\nYersinosis\\nYoga\\nZ\\nZoonosis\\nxviii GALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 21, 'page_label': 'xix'}, page_content='PLEASE READ—IMPORTANT INFORMATION\\nThe Gale Encyclopedia of Medicineis a medical\\nreference product designed to inform and educate\\nreaders about a wide variety of disorders, conditions,\\ntreatments, and diagnostic tests. Thomson Gale believes\\nthe product to be comprehensive, but not necessarily\\ndefinitive. It is intended to supplement, not replace,\\nconsultation with a physician or other healthcare practi-\\ntioner. While Thomson Gale has made substantial\\nefforts to provide information that is accurate, compre-\\nhensive, and up-to-date, Thomson Gale makes no\\nrepresentations or warranties of any kind, including\\nwithout limitation, warranties of merchantability or fit-\\nness for a particular purpose, nor does it guarantee the\\naccuracy, comprehensiveness, or timeliness of the infor-\\nmation contained in this product. Readers should be\\naware that the universe of medical knowledge is con-\\nstantly growing and changing, and that differences of\\nmedical opinion exist among authorities. Readers are\\nalso advised to seek professional diagnosis and treat-\\nment for any medical condition, and to discuss informa-\\ntion obtained from this book with their healthcare\\nprovider.\\nGALE ENCYCLOPEDIA OF MEDICINE xix'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 22, 'page_label': 'xxi'}, page_content='INTRODUCTION\\nThe third edition of the Gale Encyclopedia of\\nMedicine (GEM3) is a one-stop source for medical\\ninformation on over 1,750 common medical disorders,\\nconditions, tests, and treatments, including high-\\nprofile diseases such as AIDS, Alzheimer’s disease,\\ncancer, and heart attack. This encyclopedia avoids\\nmedical jargon and uses language that laypersons\\ncan understand, while still providing thorough cover-\\nage of each topic. TheGale Encyclopedia of Medicine 3\\nfills a gap between basic consumer health resources,\\nsuch as single-volume family medical guides, and\\nhighly technical professional materials.\\nSCOPE\\nMore than 1,750 full-length articles are included\\nin theGale Encyclopedia of Medicine 3, including dis-\\norders/conditions, tests/procedures, and treatments/\\ntherapies. Many common drugs are also covered,\\nwith generic drug names appearing first and brand\\nnames following in parentheses, eg. acetaminophen\\n(Tylenol). Throughout the Gale Encyclopedia of\\nMedicine 3, many prominent individuals are high-\\nlighted as sidebar biographies that accompany the\\nmain topical essays. Articles follow a standardized\\nformat that provides information at a glance.\\nRubrics 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\\ninterest in holistic medicine that emphasizes the\\nconnection between mind and body. Aimed at achiev-\\ning and maintaining good health rather than just elim-\\ninating disease, this approach has come to be known\\nas alternative medicine. The Gale Encyclopedia of\\nMedicine 3 includes a number of essays on alterna-\\ntive therapies, ranging from traditional Chinese\\nmedicine to homeopathy and from meditation\\nto aromatherapy. In addition to full essays on alter-\\nnative therapies, the encyclopedia features specific\\nAlternative treatment sections for diseases and con-\\nditions that may be help ed by complementary\\ntherapies.\\nINCLUSION CRITERIA\\nA preliminary list of diseases, disorders, tests\\nand treatments was compiled from a wide variety of\\nsources, including professional medical guides and\\ntextbooks as well as consumer guides and encyclope-\\ndias. The general advisory board, made up of public\\nlibrarians, medical librarians and consumer health\\nexperts, evaluated the topics and made suggestions\\nfor inclusion. The list was sorted by category and\\nsent toGEM3 medical advisers, for review. Final selec-\\ntion of topics to include was made by the medical\\nadvisors in conjunction with the Thomson Gale\\neditor.\\nABOUT THE CONTRIBUTORS\\nThe essays were compiled by experienced medical\\nwriters, including physicians, pharmacists, nurses,\\nand other health care professionals.GEM3 medical\\nadvisors reviewed the completed essays to insure\\nthat they are appropriate, up-to-date, and medically\\naccurate.\\nHOW TO USE THIS BOOK\\nThe Gale Encyclopedia of Medicine 3 has been\\ndesigned with ready reference in mind.\\nGALE ENCYCLOPEDIA OF MEDICINE xxi'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 23, 'page_label': 'xxii'}, page_content='/C15Straight alphabetical arrangement allows users to\\nlocate information quickly.\\n/C15Bold faced terms function asprint hyperlinks that\\npoint the reader to related entries in the encyclopedia.\\n/C15Cross-references placed throughout the encyclope-\\ndia direct readers to where information on subjects\\nwithout entries can be found. Synonyms are also\\ncross-referenced.\\n/C15A list ofkey termsare provided where appropriate\\nto define unfamiliar terms or concepts.\\n/C15Valuable contact information for organizations\\nandsupport groups is included with each entry.\\nThe appendix contains an extensive list of organiza-\\ntions arranged in alphabetical order.\\n/C15Resources sectiondirects users to additional sources\\nof medical information on a topic.\\n/C15A comprehensive general index allows users to\\neasily target detailed aspects of any topic, including\\nLatin names.\\nGRAPHICS\\nThe Gale Encyclopedia of Medicine 3is enhanced\\nwith over 675 illustrations, including photos, charts,\\ntables, and customized line drawings.\\nxxii GALE ENCYCLOPEDIA OF MEDICINE\\nIntroduction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 24, 'page_label': 'xxiii'}, page_content='ADVISORS\\nA number of experts in the library and medical communities provided invaluable assistance in the formulation of this\\nencyclopedia. Our advisory board performed a myriad of duties, from defining the scope of coverage to reviewing\\nindividual entries for accuracy and accessibility. The editor would like to express her appreciation to them.\\nMEDICAL ADVISORS\\nRosalyn Carson-DeWitt, M.D.\\nDurham, NC\\nLarry I. Lutwick M.D., F.A.C.P.\\nDirector, Infectious Diseases\\nVA Medical Center\\nBrooklyn, NY\\nSamuel Uretsky, Pharm.D.\\nPharmacist\\nWantagh, NY\\nGALE ENCYCLOPEDIA OF MEDICINE xxiii'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 25, 'page_label': 'xxv'}, page_content='CONTRIBUTORS\\nMargaret Alic, Ph.D.\\nScience Writer\\nEastsound, WA\\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, Ph.D.\\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, VA\\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\\nCounseling\\nIndianapolis, IN\\nLinda K. Bennington, C.N.S.\\nScience Writer\\nVirginia Beach, VA\\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.,\\nC.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\\nGALE ENCYCLOPEDIA OF MEDICINE xxv'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 26, 'page_label': 'xxvi'}, page_content='Geoffrey N. Clark, D.V.M.\\nEditor\\nCanine Sports Medicine\\nUpdate\\nNewmarket, NH\\nRhonda 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.,\\nB.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\\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\\nJason Fryer\\nMedical Writer\\nSan Antonio, TX\\nRon Gasbarro, Pharm.D.\\nMedical Writer\\nNew Milford, PA\\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\\nxxvi GALE ENCYCLOPEDIA OF MEDICINE\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 27, 'page_label': 'xxvii'}, page_content='Kapil Gupta, M.D.\\nMedical Writer\\nWinston-Salem, NC\\nMaureen Haggerty\\nMedical Writer\\nAmbler, PA\\nClare Hanrahan\\nMedical Writer\\nAsheville, NC\\nAnn 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.,\\nC.G.C.\\nGenetic Counselor\\nThe Children’s Mercy Hospital\\nKansas City, MO\\nDawn A. Jacob, M.S.\\nGenetic Counselor\\nObstetrix Medical Group of\\nTexas\\nFort Worth, TX\\nSally J. Jacobs, Ed.D.\\nMedical Writer\\nLos Angeles, CA\\nMichelle L. Johnson, M.S., J.D.\\nPatent Attorney and Medical\\nWriter\\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\\nWest Chester, PA\\nBeth A. Kapes\\nMedical Writer\\nBay Village, OH\\nJanet M. Kearney\\nFreelance writer\\nOrlando, FL\\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, WA\\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, VA\\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\\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\\nVA 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\\nPathology\\nDemarest, NJ\\nAdrienne Massel, R.N.\\nMedical Writer\\nBeloit, WI\\nRuth E. Mawyer, R.N.\\nMedical Writer\\nCharlottesville, VA\\nRichard A. McCartney M.D.\\nFellow, American College of\\nSurgeons\\nDiplomat American Board of\\nSurgery\\nRichland, WA\\nGALE ENCYCLOPEDIA OF MEDICINE xxvii\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 28, 'page_label': 'xxviii'}, page_content='Bonny 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\\nBetty Mishkin\\nMedical Writer\\nSkokie, IL\\nBarbara J. Mitchell\\nMedical Writer\\nHallstead, PA\\nMark A. Mitchell, M.D.\\nMedical Writer\\nSeattle, WA\\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 Odle\\nMedical Writer\\nAlbaquerque, NM\\nLisa Papp, R.N.\\nMedical Writer\\nCherry Hill, NJ\\nLee Ann Paradise\\nMedical Writer\\nSan Antonio, TX\\nPatience Paradox\\nMedical Writer\\nBainbridge Island, WA\\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\\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\\nMetabolic Genetics\\nThe Hospital for Sick Children\\nToronto, ON, Canada\\nAnn Quigley\\nMedical Writer\\nNew York, NY\\nRobert Ramirez, B.S.\\nMedical Student\\nUniversity of Medicine &\\nDentistry of 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\\nAnnaRovidSpickler,D.V.M.,Ph.D.\\nMedical Writer\\nMoorehead, KY\\nBelinda Rowland, Ph.D.\\nMedical Writer\\nVoorheesville, 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\\nxxviii GALE ENCYCLOPEDIA OF MEDICINE\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 29, 'page_label': 'xxix'}, page_content='Kristen 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\\nJennifer 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\\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\\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\\nGALE ENCYCLOPEDIA OF MEDICINE xxix\\nContributors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 30, 'page_label': '1'}, page_content='A\\nAbdominal 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 trans-\\nmitter sends high frequency sound waves into the body,\\nwhere they bounce off the different tissues and organs\\nto produce 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\\nthe sonar technology developed to detect submarines\\nduring World War II. The first useful medical images\\nwere produced in the early 1950s, and, by 1965, ultra-\\nsound quality had improved to the point that it came\\ninto general medical use. Improvements in the tech-\\nnology, application, and interpretation of ultrasound\\ncontinue. Its low cost, versatility, safety and speed\\nhave brought it into the top drawer of medical imaging\\ntechniques.\\nWhile pelvic ultrasoundis widely known and com-\\nmonly used for fetal monitoring duringpregnancy,\\nultrasound is also routinely used for general abdom-\\ninal imaging. It has great advantage over x-ray ima-\\nging technologies in that it does not damage tissues\\nwith ionizing radiation. Ultrasound is also generally\\nfar better than plain x rays at distinguishing the subtle\\nvariations of soft tissue structures, and can be used in\\nany of several modes, depending on the need at hand.\\nAs an imaging tool, abdominal ultrasound gener-\\nally is warranted for patients afflicted with: chronic or\\nacute abdominalpain; abdominal trauma; an obvious\\nor suspected abdominal mass; symptoms ofliver dis-\\nease, pancreatic disease,gallstones, spleen disease,kid-\\nney diseaseand urinary blockage; or symptoms of an\\nabdominal aortic aneurysm. Specifically:\\n/C15Abdominal pain. Whether acute or chronic, pain can\\nsignal a serious problem–from organ malfunction or\\ninjury to the presence of malignant growths.\\nUltrasound scanning can help doctors quickly sort\\nthrough potential causes when presented with gen-\\neral or ambiguous symptoms. All of the major\\nabdominal organs can be studied for signs of disease\\nthat appear as changes in size, shape and internal\\nstructure.\\n/C15Abdominal trauma. After a serious accident, such as\\na car 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\\nan initial scan when abdominal trauma is suspected,\\nand it can be used to pinpoint the location, cause,\\nand severity of hemorrhaging. In the case of punc-\\nture wounds, from a bullet for example, ultrasound\\ncan locate the foreign object and provide a prelimin-\\nary survey of the damage. The easy portability and\\nversatility of ultrasound technology has brought it\\ninto common emergency room use, and even into\\nlimited ambulance service.\\nGALE ENCYCLOPEDIA OF MEDICINE 1'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 31, 'page_label': '2'}, page_content='/C15Abdominal mass. Abnormal growths–tumors, cysts,\\nabscesses, scar tissue and accessory organs–can be\\nlocated 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\\nor part of the abdomen can be found.\\n/C15Liver disease. The types and underlying causes of\\nliver disease are numerous, though jaundice tends\\nto be a general symptom. Ultrasound can differenti-\\nate between many of the types and causes of liver\\nmalfunction, and is particularly good at identifying\\nobstruction of the bile ducts andcirrhosis, which is\\ncharacterized by abnormal fibrous growths and\\nreduced blood flow.\\n/C15Pancreatic disease. Inflammation and malformation\\nof the pancreas are readily identified by ultrasound,\\nas are pancreatic stones (calculi), which can disrupt\\nproper functioning.\\n/C15Gallstones. Gallstones cause morehospital admissions\\nthan any other digestive malady. These calculi can\\ncause painful inflammation of the gallbladder and\\nalso obstruct the bile ducts that carry digestive enzymes\\nfrom the gallbladder and liver to the intestines.\\nGallstones are readily identifiable with ultrasound.\\n/C15Spleen 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\\nto ultrasonic inspection and diagnosis.\\n/C15Kidney disease. The kidneys are also prone to trau-\\nmatic injury and are the organs most likely to form\\ncalculi, which can block the flow of urine and cause\\nbloodpoisoning(uremia). A variety of diseases causing\\ndistinct changes in kidney morphology can also lead to\\ncomplete kidney failure. Ultrasound imaging has pro-\\nven extremely useful in diagnosing kidney disorders.\\n/C15Abdominal aortic aneurysm. This is a bulging weak\\nspot in the abdominal aorta, which supplies blood\\ndirectly from the heart to the entire lower body.\\nThese aneurysms are relatively common and increase\\nin prevalence with age. A burst aortic aneurysm is\\nimminently life-threatening. However, they can be\\nreadily identified and monitored with ultrasound\\nbefore acute complications 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\\nfor ultrasound are being developed.\\nThe direct therapeutic value of ultrasonic waves\\nlies in their mechanical nature. They are shock waves,\\njust like audible sound, and vibrate the materials\\nthrough which they pass. These vibrations are mild,\\nvirtually unnoticeable at the frequencies and intensi-\\nties used for imaging. Properly focused however, high-\\nintensity ultrasound can be used to heat and physically\\nagitate targeted tissues.\\nHigh-intensity ultrasound is used routinely to treat\\nsoft tissue injuries, such asstrains,t e a r sa n da s s o c i a t e d\\nscarring. The heating and agitation are believed to\\npromote rapid healing through increased circulation.\\nStrongly focused, high-intensity, high-frequency ultra-\\nsound can also be used to physically destroy certain\\ntypes of tumors, as well as gallstones and other types\\nof calculi. Developing new treatment applications\\nfor ultrasound is an active area of medical research.\\nPrecautions\\nProperly performed, ultrasound imaging is vir-\\ntually without risk or side effects. Some patients report\\nfeeling a slight tingling and/or warmth while being\\nscanned, but most feel nothing at all. Ultrasound\\nwaves of appropriate frequency and intensity are not\\nknown to cause or aggravate any medical condition,\\nthough any woman who thinks she might be pregnant\\nshould raise the issue with her doctor before under-\\ngoing an abdominal ultrasound.\\nThe value of ultrasound imaging as a medical tool,\\nhowever, depends greatly on the quality of the equip-\\nment used and the skill of the medical personnel oper-\\nating it. Improperly performed and/or interpreted,\\nultrasound can be worse than useless if it indicates\\nthat a problem exists where there is none, or fails to\\ndetect a significant condition. Basic ultrasound equip-\\nment is relatively inexpensive to obtain, and any doc-\\ntor with the equipment can perform the procedure\\nwhether qualified or not. Patients should not hesitate\\nto verify the credentials of technicians and doctors\\nperforming ultrasounds, as well as the quality of the\\nequipment used and the benefits of the proposed\\nprocedure.\\nIn cases where ultrasound is used as a treatment\\ntool, patients should educate themselves about the\\nproposed procedure with the help of their doctors–as\\nis appropriate before any surgical procedure. Also,\\nany abdominal ultrasound procedure, diagnostic or\\ntherapeutic, may be hampered by a patient’s body\\ntype or other factors, such as the presence of excessive\\nbowel gas (which is opaque to ultrasound). In parti-\\ncular, very obese people are often not good candidates\\nfor abdominal ultrasound.\\n2 GALE ENCYCLOPEDIA OF MEDICINE\\nAbdominal ultrasound'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 32, 'page_label': '3'}, page_content='Description\\nUltrasound includes all sound waves above the\\nfrequency of human hearing–about 20 thousand\\nhertz, or cycles per second. Medical ultrasound gener-\\nally uses frequencies between one and 10 million hertz\\n(1-10 MHz). Higher frequency ultrasound waves pro-\\nduce more detailed images, but are also more readily\\nabsorbed and so cannot penetrate as deeply into the\\nbody. Abdominal ultrasound imaging is generally per-\\nformed at frequencies between 2-5 MHz.\\nKEY TERMS\\nAccessory organ— A lump of tissue adjacent to an\\norgan that is similar to it, but which serves no impor-\\ntant purpose, if functional at all. While not necessa-\\nrily harmful, such organs can cause problems if they\\ngrow too large or become cancerous. In any case,\\ntheir presence points to an underlying abnormality in\\nthe 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\\ntissue 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 the\\nbody, but usually found in the gallbladder, pancreas\\nand kidneys. They are formed by the accumulation of\\nexcess mineral salts and other organic material such\\nas blood or mucous. Calculi (pl.) can cause problems\\nby lodging in and obstructing the proper flow of fluids,\\nsuch as bile to the intestines or urine 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 through\\nwhich bile–a necessary digestive enzyme–travels\\nfrom the liver and gallbladder into the small intes-\\ntine. Digestive enzymes from the pancreas also enter\\nthe intestines through the common bile duct.\\nComputed tomography scan (CT scan)— As p e c i a -\\nlized type of x-ray imaging that uses highly focused\\nand relatively low energy radiation to produce detailed\\ntwo-dimensional images of soft tissue structures, parti-\\ncularly the brain. CT scans are the chief competitor to\\nultrasound and can yield higher quality images not\\nd i s r u p t e db yb o n eo rg a s .T h e ya r e ,h o w e v e r ,m o r e\\ncumbersome, time consuming and expensive to per-\\nform, and they use ionizing electromagnetic 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 fre-\\nquency decreases. The size of this frequency shift\\ncan be used to compute the object’s speed–be it a\\ncar on the road or blood in an artery. The Doppler\\neffect holds true for all types of radiation, not just\\nsound.\\nFrequency— Sound, whether traveling through air or\\nthe human body, produces vibrations–molecules\\nbouncing into each other–as the shock wave travels\\nalong. The frequency of a sound is the number of\\nvibrations per second. Within the audible range,\\nfrequency means pitch–the higher the frequency,\\nthe 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 to\\nthe skin, eyes and body fluids. Bile retention in the\\nliver, 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 struc-\\nture rather than the function of a given organ. As a\\ndiagnostic imaging technique, ultrasound facilitates\\nthe recognition of abnormal morphologies as symp-\\ntoms of underlying conditions.\\nGALE ENCYCLOPEDIA OF MEDICINE 3\\nAbdominal ultrasound'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 33, 'page_label': '4'}, page_content='An ultrasound machine consists of two parts: the\\ntransducer and the analyzer. The transducer both pro-\\nduces the sound waves that penetrate the body and\\nreceives the reflected echoes. Transducers are built\\naround piezoelectric ceramic chips. (Piezoelectric\\nrefers to electricity that is produced when you put\\npressure on certain crystals such as quartz). These\\nceramic chips react to electric pulses by producing\\nsound waves ( they are transmitting waves) and react\\nto sound waves by producing electric pulses (receiv-\\ning). Bursts of high frequency electric pulses supplied\\nto the transducer causes it to produce the scanning\\nsound waves. The transducer then receives the return-\\ning 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\\nthe body. The relative strength of each echo, a func-\\ntion of the specific tissue or organ boundary that\\nproduced it, can be plotted as a point of varying\\nbrightness. In this way, the echoes are translated into\\na picture. Tissues surrounded by bone or filled with\\ngas (the stomach, intestines and bowel) cannot be\\nimaged using ultrasound, because the waves are\\nblocked or become randomly scattered.\\nFour different modes of ultrasound are used in\\nmedical imaging:\\n/C15A-mode. This is the simplest type of ultrasound in\\nwhich a single transducer scans a line through the\\nbody with the echoes plotted on screen as a function\\nof depth. This method is used to measure distances\\nwithin the body and the size of internal organs.\\nTherapeutic ultrasound aimed at a specific tumor\\nor calculus is also A-mode, to allow for pinpoint\\naccurate focus of the destructive wave energy.\\n/C15B-mode. In B-mode ultrasound, a linear array of\\ntransducers simultaneously scans a plane through\\nthe body that can be viewed as a two-dimensional\\nimage on screen. Ultrasound probes containing more\\nthan 100 transducers in sequence form the basis for\\nthese most commonly used scanners, which cost\\nabout $50,000.\\n/C15M-Mode. The M stands for motion. A rapid\\nsequence of B-mode scans whose images follow\\neach other in sequence on screen enables doctors to\\nsee and measure range of motion, as the organ\\nboundaries that produce reflections move relative\\nto the probe. M-mode ultrasound has been put to\\nparticular use in studying heart motion.\\n/C15Doppler mode.Doppler ultrasonographyincludes the\\ncapability of accurately measuring velocities of mov-\\ning material, such as blood in arteries and veins. The\\nprinciple is the same as that used in radar guns that\\nmeasure the speed of a car on the highway. Doppler\\ncapability is most often combined with B-mode scan-\\nning to produce images of blood vessels from which\\nblood flow can be directly measured. This technique\\nis used extensively to investigate valve defects, arter-\\niosclerosis and hypertension, particularly in the\\nheart, but also in the abdominal aorta and the portal\\nvein of the liver. These machines cost about\\n$250,000.\\nThe actual procedure for a patient undergoing an\\nabdominal ultrasound is relatively simple, regardless\\nof the type of scan or its purpose.Fasting for at least\\neight hours prior to the procedure ensures that the\\nstomach is empty and as small as possible, and that\\nthe intestines and bowels are relatively inactive.\\nFasting also allows the gall bladder to be seen, as it\\ncontracts after eating and may not be seen if the sto-\\nmach is full. In some cases, a full bladder helps to push\\nintestinal folds out of the way so that the gas they\\ncontain does not disrupt the image. The patient’s\\nabdomen is then greased with a special gel that allows\\nthe ultrasound probe to glide easily across the skin\\nwhile 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\\nto obtain different views of the target areas. The\\npatient will likely be asked to change positions from\\nside to side and to hold their breath as necessary to\\nobtain the desired views. Discomfort during the pro-\\ncedure is minimal.\\nThe many types and uses of ultrasound technol-\\nogy makes it difficult to generalize about the time and\\ncosts involved. Relatively simple imaging–scanning a\\nsuspicious abdominal mass or a suspected abdominal\\naortic aneurysm–will take about half an hour to per-\\nform and will cost a few hundred dollars or more,\\ndepending on the quality of the equipment, the\\noperator and other factors. More involved techniques\\nsuch as multiple M-mode and Doppler-enhanced\\nscans, or cases where the targets not well defined in\\nadvance, generally take more time and are more\\nexpensive.\\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\\n4 GALE ENCYCLOPEDIA OF MEDICINE\\nAbdominal ultrasound'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 34, 'page_label': '5'}, page_content='‘‘medically necessary’’ procedures designed to detect the\\npresence of suspected abnormalities, they are covered\\nunder mosttypes of major medical insurance. As always,\\nthough, the patient would be wise to confirm that their\\ncoverage extends to the specific procedure proposed.\\nFor nonemergency situations, most underwriters stipu-\\nlate prior 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\\nligament injuries, etc.–are described in detail under\\nthe appropriate entries in this encyclopedia.\\nPreparation\\nA patient undergoing abdominal ultrasound will\\nbe advised by their physician about what to expect and\\nhow to prepare. As mentioned above, preparations\\ngenerally include fasting and arriving for the proce-\\ndure with a full bladder, if necessary. This preparation\\nis particularly useful if the gallbladder, ovaries or veins\\nare to be examined.\\nAftercare\\nIn general, no aftercare related to the abdominal\\nultrasound procedure itself is required.\\nRisks\\nAbdominal ultrasound carries with it no recog-\\nnized risks or side effects, if properly performed using\\nappropriate frequency and intensity ranges. Sensitive\\ntissues, particularly those of the reproductive organs,\\ncould possibly sustain damage if violently vibrated by\\noverly intense ultrasound waves. In general though,\\nsuch damage would only result from improper use of\\nthe equipment.\\nAny woman who thinks she might be pregnant\\nshould raise this issue with her doctor before under-\\ngoing an abdominal ultrasound, as a fetus in the early\\nstages of development could be injured by ultrasound\\nmeant to probe deeply recessed abdominal organs.\\nNormal results\\nAs a diagnostic imaging technique, a normal\\nabdominal ultrasound is one that indicates the absence\\nof the suspected condition that prompted the scan.\\nFor example, symptoms such as a persistentcough,\\nlabored breathing, and upper abdominal pain suggest\\nthe possibility of, among other things, an abdominal\\naortic aneurysm. An ultrasound scan that indicates\\nthe absence of an aneurysm would rule out this life-\\nthreatening condition and point to other, less serious\\ncauses.\\nAbnormal results\\nBecause abdominal ultrasound imaging is gener-\\nally undertaken to confirm a suspected condition, the\\nresults of a scan often will prove abnormal–that is they\\nwill confirm the diagnosis, be it kidney stones, cirrho-\\nsis of the liver or an aortic aneurysm. At that point,\\nappropriate medical treatment as prescribed by a\\npatient’s doctor is in order. See the relevant disease\\nand disorder entries in this encyclopedia for more\\ninformation.\\nResources\\nPERIODICALS\\nFreundlich, Naomi. ‘‘Ultrasound: What’s Wrong with this\\nPicture?’’ Business Week September 15, 1997:84-5.\\nORGANIZATIONS\\nAmerican College of Gastroenterology. 4900 B South 31st\\nSt., Arlington, VA 22206-1656. (703) 820-7400.\\n.\\nAmerican Institute of Ultrasound in Medicine. 14750\\nSweitzer Lane, Suite 100, Laurel, MD 20707-5906.\\n(800) 638-5352. .\\nAmerican Society of Radiologic Technologists. 15000\\nCentral Ave., SE, Albuquerque, NM 87123-3917. (505)\\n298-4500. .\\nKurt Richard Sternlof\\nAbdominal wall defects\\nDefinition\\nAbdominal wall defects are birth (congenital)\\ndefects that allow the stomach or intestines to\\nprotrude.\\nDescription\\nMany unexpected and fascinating events occur\\nduring the development of a fetus inside the womb.\\nThe stomach and intestines begin development outside\\nthe baby’s abdomen and only later does the abdominal\\nwall enclose them. Occasionally, either the umbilical\\nopening is too large, or it develops improperly, allow-\\ning the bowels or stomach to remain outside or\\nsqueeze through the abdominal wall.\\nGALE ENCYCLOPEDIA OF MEDICINE 5\\nAbdominal wall defects'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 35, 'page_label': '6'}, page_content='Causes and symptoms\\nThere are many causes forbirth defects that still\\nremain unclear. Presently, the cause(s) of abdominal\\nwall defects is unknown, and any symptoms the\\nmother may have to indicate that the defects are pre-\\nsent in the fetus are nondescript.\\nDiagnosis\\nAt birth, the problem is obvious, because the base\\nof the umbilical cord at the navel will bulge or, in\\nworse cases, contain viscera (internal organs). Before\\nbirth, an ultrasound examination may detect the pro-\\nblem. It is always necessary in children with one birth\\ndefect to look for others, because birth defects are\\nusually multiple.\\nTreatment\\nAbdominal wall defects are effectively treated\\nwith surgical repair. Unless there are accompanying\\nanomalies, the surgical procedure is not overly com-\\nplicated. The organs are normal, just misplaced.\\nHowever, if the defect is large, it may be difficult to\\nfit all the viscera into the small abdominal cavity.\\nPrognosis\\nIf there are no other defects, the prognosis after\\nsurgical repair of this condition is relatively good.\\nHowever, 10% of those with more severe or additional\\nabnormalities die from it. The organs themselves\\nare fully functional; the difficulty lies in fitting them\\ninside the abdomen. The condition is, in fact, ahernia\\nrequiring only replacement and strengthening of the\\npassageway through which it occurred. After surgery,\\nincreased pressure in the stretched abdomen can com-\\npromise the function of the organs inside.\\nPrevention\\nSome, but by no means all, birth defects are pre-\\nventable by early and attentive prenatal care, good\\nnutrition, supplemental vitamins, diligent avoidance\\nof all unnecessary drugs and chemicals–especially\\ntobacco–and other elements of a healthy lifestyle.\\nResources\\nPERIODICALS\\nDunn, J. C., and E. W. Fonkalsrud. ‘‘Improved Survival of\\nInfantswith Omphalocele.’’American Journal of\\nSurgery 173 (April 1997): 284-7.\\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\\n(after 20 weeks) abortion that terminates apregnancy\\nand results in thedeath and intact removal of a fetus.\\nThis procedure is most commonly referred to as intact\\ndilatation and extraction (D & X). It occurs in a rare\\npercentage of pregnancies.\\nPurpose\\nPartial birth abortion, or D&X, is performed to\\nend a pregnancy and results in the death of a fetus,\\ntypically in the late second or third trimester.\\nAlthough D&X is highly controversial, some physi-\\ncians argue that it has advantages that make it a pre-\\nferable procedure in some circumstances. One\\nperceived advantage is that the fetus is removed\\nlargely intact, allowing for better evaluation and\\nautopsy of the fetus in cases of known fetal abnormal-\\nities. Intact removal of the fetus also may carry a lower\\nrisk of puncturing the uterus or damaging the cervix.\\nAnother perceived advantage is that D&X ends the\\npregnancy without requiring the woman to go\\nthrough labor, which may be less emotionally trau-\\nmatic than other methods of late-term abortion. In\\nKEY TERMS\\nHernia— Movement of a structure into a place it\\ndoes not belong.\\nUmbilical— Referring to the opening in the abdom-\\ninal wall where the blood vessels from the placenta\\nenter.\\nViscera— Any of the body’s organs located in the\\nchest or abdomen.\\n6 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, partial birth'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 36, 'page_label': '7'}, page_content='addition, D&X may offer a lower cost and shorter\\nprocedure time.\\nPrecautions\\nWomen considering D&X should be aware of the\\nhighly controversial nature of this procedure. A con-\\ntroversy common to all late-term abortions is whether\\nthe fetus is viable, or able to survive outside of the\\nwoman’s body. A specific area of controversy with\\nD&X is that fetal death does not occur until after\\nmost of the fetal body has exited the uterus. Several\\nstates have taken legal action to limit or ban D&X and\\nmany physicians who perform abortions do not per-\\nform D&X. This may restrict the availability of this\\nprocedure to women seeking late-term abortions.\\nIn March 2003, the United States Senate passed a\\nbill banning partial birth abortions and implementing\\nfines or maximum two-year jail terms for physicians\\nwho perform them. In June 2003, the House approved\\na ban as well. President George W. Bush signed the\\nlegislation into law, but a federal judge declared the\\nlaw unconstitutional, so that the government had not\\nbeen able to enforce it. One of the opponents’ claims\\nwas the legislation did not provide for exceptions for\\ncases in which the procedure was needed to protect the\\nmother’s health.\\nDescription\\nIntact D&X, or partial birth abortion first\\ninvolves administration of medications to cause the\\ncervix to dilate, usually over the course of several\\ndays. Next, the physician rotates the fetus to a footling\\nbreech position. The body of the fetus is then drawn\\nout of the uterus feet first, until only the head remains\\ninside the uterus. Then, the physician uses an instru-\\nment to puncture the base of the skull, which collapses\\nthe fetal head. Typically, the contents of the fetal head\\nare then partially suctioned out, which results in the\\ndeath of the fetus and reduces the size of the fetal head\\nenough to allow it to pass through the cervix. The dead\\nand otherwise intact fetus is then removed from the\\nwoman’s body.\\nPreparation\\nMedical preparation for D&X involves an out-\\npatient visit to administer medications, such aslami-\\nnaria, to cause the cervix to begin dilating.\\nIn addition, preparation may involve fulfilling\\nlocal legal requirements, such as a mandatory waiting\\nperiod, counseling, or an informed consent procedure\\nreviewing stages of fetal development,childbirth, alter-\\nnative abortion methods, and adoption.\\nAftercare\\nD&X typically does not require an overnight hos-\\npital stay, so a follow up appointment may be sched-\\nuled to monitor the woman for any complications.\\nRisks\\nWith all abortion, the later in pregnancy an abor-\\ntion is performed, the more complicated the procedure\\nand the greater the risk of injury to the woman. In\\naddition to associated emotional reactions, D&X car-\\nries the risk of injury to the woman, including heavy\\nbleeding, blood clots, damage to the cervix or uterus,\\npelvic infection, and anesthesia-related complications.\\nThere also is a risk of incomplete abortion, meaning\\nthat the fetus is not dead when removed from the\\nwoman’s body. Possible long-term risks include diffi-\\nculty becoming pregnant or carrying a future preg-\\nnancy to term.\\nNormal results\\nThe expected outcome of D&X is the termination\\nof a pregnancy with removal of a dead fetus from the\\nwoman’s body.\\nResources\\nPERIODICALS\\n‘‘Court Rules Abortion Ban Unconstitutional.’’Medicine &\\nHealth (June 7, 2004): 4–6.\\n‘‘House Approves Partial Birth Abortion Ban.’’Medicine\\nand Health (June 16, 2003): 5.\\n‘‘Partial-birth Abortion Ban Approved by Senate.’’Medical\\nEthics Advisor (April 2003): 47.\\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 the\\ncervix and will be the first part of the fetus to exit the\\nuterus, with the head of the fetus being the last part\\nto 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 7\\nAbortion, partial birth'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 37, 'page_label': '8'}, page_content='ORGANIZATIONS\\nPlanned Parenthood Federation of America, Inc.. 810\\nSeventh Ave., New York, NY 10019. (800) 669-0156.\\n.\\nOTHER\\nStatus of partial-birth abortion laws in the states. Othmer\\nInstitute at Planned Parenthood of NYC. 2000.\\nStefanie B. N. Dugan, M.S.\\nTeresa G. Odle\\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\\nthe mother in carrying and giving birth to more than\\none or two babies, and also to decrease the risk of\\ncomplications to the remaining fetus(es). The term\\nselective abortion also refers to choosing to abort a\\nfetus for reasons such as the woman is carrying a fetus\\nwhich likely will be born with some birth defect or\\nimpairment, or because the sex of the fetus is not\\npreferred by the individual.\\nPurpose\\nA woman may decide to abort for health reasons,\\nfor example, she is at higher risk for complications\\nduring pregnancy because of a disorder or disease\\nsuch as diabetes. A 2004 case reported on an embryo\\nembedded in acesarean sectionscar. Although rare, it\\ncan be life threatening to the mother. In this care,\\nselective abortion was successful at saving the mother\\nand the remaining embryos.\\nHowever, selective reduction is recommended\\noften in cases of multi-fetal pregnancy, or the presence\\nof more than one fetus, typically, at least three or more\\nfetuses. In the general population, multi-fetal preg-\\nnancy happens in only about 1-2% of pregnant\\nwomen. But multi-fetal pregnancies occur far more\\noften in women using fertility drugs.\\nPrecautions\\nBecause women or couples who use fertility drugs\\nhave made an extra effort to become pregnant, it is\\npossible that the individuals may be unwilling or\\nuncomfortable with the decision to abort a fetus in\\ncases of multi-fetal pregnancy. Individuals engaging in\\nfertility treatment should be made aware of the risk of\\nmulti-fetal pregnancy and consider the prospect of\\nrecommended reduction before undergoing fertility\\ntreatment.\\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\\nprocedure and can be performed on an outpatient\\nbasis. A needle is inserted into the woman’s stomach\\nor vagina and potassium chloride is injected into the\\nfetus.\\nPreparation\\nIndividuals who have chosen selective reduction\\nto safeguard the remaining fetuses should be coun-\\nseled prior to the procedure. Individuals should\\nreceive information regarding the risks of a multi-\\nfetal pregnancy to both the fetuses and the mother\\ncompared with the risks after 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\\nthe process.\\nRisks\\nAbout 75% of women who undergo selective\\nreduction will go intopremature labor. About 4-5%\\nof women undergoing selective reduction also\\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.\\n8 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, selective'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 38, 'page_label': '9'}, page_content='miscarry one or more of the remaining fetuses. The\\nrisks associated with multi-fetal pregnancy are consid-\\nered higher.\\nNormal results\\nIn cases where a multi-fetal pregnancy of three or\\nmore fetuses is reduced to two fetuses, the remaining\\ntwin fetuses typically develop as they would if they had\\nbeen conceived as twins.\\nResources\\nPERIODICALS\\n‘‘Multiple Pregnancy Associated With Infertility Therapy.’’\\nAmerican Society for Reproductive Medicine, A Practice\\nCommittee Report (November 2000): 1-8.\\n‘‘Selective Reduction Eleiminates an Emryo Embedded\\nin a Cesarean Scar.’’WomenÆs Health Weekly (April 8,\\n2004): 117.\\nORGANIZATIONS\\nThe Alan Guttmacher Institute. 120 Wall Street, New York,\\nNY 10005. (212) 248-1111. .\\nThe American Society for Reproductive Medicine. 1209\\nMontgomery Highway, Birmingham, AL 35216-2809.\\n(205) 978-5000. .\\nMeghan M. Gourley\\nTeresa G. Odle\\nAbortion, spontaneous see Miscarriage\\nAbortion, therapeutic\\nDefinition\\nTherapeutic abortion is the intentional termina-\\ntion of apregnancy before the fetus can live indepen-\\ndently. Abortion has been a legal procedure in the\\nUnited States since 1973.\\nPurpose\\nAn abortion may be performed whenever there is\\nsome compelling reason to end a pregnancy. Women\\nhave abortions because continuing the pregnancy\\nwould cause them hardship, endanger their life or\\nhealth, or because prenatal testing has shown that\\nthe fetus will be born with severe abnormalities.\\nAbortions are safest when performed within the\\nfirst six to 10 weeks after the last menstrual period.\\nThe calculation of this date is referred to as the\\ngestational age and is used in determining the stage\\nof pregnancy. For example, a woman who is two\\nweeks late having her period is said to be six weeks\\npregnant, because it is six weeks since she last\\nmenstruated.\\nAbout 90% of women who have abortions do so\\nbefore 13 weeks and experience few complications.\\nAbortions performed between 13-24 weeks have a\\nhigher rate of complications. Abortions after 24\\nweeks are extremely rare and are usually limited to\\nsituations where the life of the mother is in danger.\\nPrecautions\\nMost women are able to have abortions at clinics\\nor outpatient facilities if the procedure is performed\\nearly in pregnancy. Women who have stable diabetes,\\ncontrolled epilepsy, mild to moderate high blood pres-\\nsure, or who are HIV positive can often have abortions\\nas outpatients if precautions are taken. Women with\\nheart disease, previous endocarditis, asthma,l u p u s\\nerythematosus, uterine fibroid tumors, blood clotting\\ndisorders, poorly controlled epilepsy, or some psycho-\\nlogical disorders usually need to be hospitalized in\\norder to receive special monitoring and medications\\nduring the procedure.\\nDescription\\nVery early abortions\\nBetween five and seven weeks, a pregnancy can be\\nended by a procedure called menstrual extraction.\\nThis procedure is also sometimes called menstrual\\nregulation, mini-suction, or preemptive abortion.\\nThe contents of the uterus are suctioned out through\\na thin (3-4 mm) plastic tube that is inserted through the\\nundilated cervix. Suction is applied either by a bulb\\nsyringe or a small pump.\\nAnother method is called the ‘‘morning after’’ pill,\\nor emergency contraception. Basically, it involves tak-\\ning high doses of birth control pills within 24 to 48\\nhours of having unprotected sex. The high doses of\\nhormones causes the uterine lining to change so that it\\nwill not support a pregnancy. Thus, if the egg has been\\nfertilized, it is simply expelled from the body.\\nThere are two types of emergencycontraception.\\nOne type is identical to ordinary birth control pills,\\nand uses the hormones estrogen and progestin). This\\ntype is available with a prescription under the brand\\nname Preven. But women can even use their regular\\nbirth control pills for emergency contraception, after\\nthey check with their doctor about the proper dose.\\nAbout half of women who use birth control pills for\\nGALE ENCYCLOPEDIA OF MEDICINE 9\\nAbortion, therapeutic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 39, 'page_label': '10'}, page_content='emergency contraception get nauseated and 20 percent\\nvomit.Thismethodcutstheriskofpregnancy75percent.\\nThe other type of morning-after pill contains only\\none hormone: progestin, and is available under the\\nbrand name Plan B. It is more effective than the first\\ntype with a lower risk ofnausea and vomiting. It\\nreduces the risk of pregnancy 89 percent.\\nWomen should check with their physicians\\nregarding the proper dose of pills to take, as it depends\\non the brand of birth control pill. Not all birth control\\npills will work for emergency contraception.\\nMenstrual extractions are safe, but because the\\namount of fetal material is so small at this stage of\\ndevelopment, it is easy to miss. This results in an incom-\\nplete abortion that means the pregnancy continues.\\nFirst trimester abortions\\nThe first trimester of pregnancy includes the first\\n13 weeks after the last menstrual period. In the United\\nStates, about 90% of abortions are performed during\\nthis period. It is the safest time in which to have an\\nabortion, and the time in which women have the most\\nchoice of how the procedure is performed.\\nMEDICAL ABORTIONS. Medical abortions are\\nbrought about by taking medications that end the\\npregnancy. The advantages of a first trimester medical\\nabortion are:\\nUterus\\nEmbryonic\\ntissue\\nVagina Vulsellum\\nCervix\\nSpeculum\\nExtraction tube \\nBetween 5 and 7 weeks, a pregnancy can be ended by a procedure called menstrual extraction. The contents of the uterus are\\nsuctioned out through a thin extraction tube that is inserted through the undilated cervix.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nEndocarditis— An infection of the inner membrane\\nlining of the heart.\\nFibroid tumors— Fibroid tumors are non-cancerous\\n(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 produce\\nimmune responses. If an Rh negative woman is\\npregnant 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.\\n10 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, therapeutic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 40, 'page_label': '11'}, page_content='/C15The procedure is non-invasive; no surgical instru-\\nments are used.\\n/C15Anesthesia is not required.\\n/C15Drugs are administered either orally or by injection.\\n/C15The procedure resembles a naturalmiscarriage.\\nDisadvantages of a medical abortion are:\\n/C15The effectiveness decreases after the seventh week.\\n/C15The proceduremay requiremultiple visits to the doctor.\\n/C15Bleeding after the abortion lasts longer than after a\\nsurgical abortion.\\n/C15The woman may see the contents of her womb as it is\\nexpelled.\\nTwo different medications can be used to bring\\nabout an abortion. Methotrexate (Rheumatrex) works\\nby stopping fetal cells from dividing which causes the\\nfetus to die.\\nOn the first visit to the doctor, the woman receives\\nan injection of methotrexate. On the second visit,\\nabout a week later, she is given misoprostol\\n(Cytotec), an oxygenated unsaturated cyclic fatty\\nacid responsible for various hormonal reactions such\\nas muscle contraction (prostaglandin), that stimulates\\ncontractions of the uterus. Within two weeks, the\\nwoman will expel the contents of her uterus, ending\\nthe pregnancy. A follow-up visit to the doctor is neces-\\nsary to assure that the abortion 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 pro-\\ngesterone, a hormone needed for pregnancy to con-\\ntinue, then stimulates ulerine contractions thus ending\\nthe pregnancy. It can be taken as much as 49 days after\\nthe first day of a woman’s last period. On the first visit\\nto the doctor, a woman takes a mifepristone pill. Two\\ndays later 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\\nto take misoprostol. After an observation period, she\\nreturns home.\\nWithin four days, 90% of women have expelled\\nthe contents of their uterus and completed the abor-\\ntion. Within 14 days, 95-97% of women have com-\\npleted the abortion. A third follow-up visit to the\\ndoctor is necessary to confirm through observation\\nor ultrasound that the procedure is complete. In the\\nevent that it is not, a surgical abortion is performed.\\nStudies show that 4.5 to 8 percent of women need\\nsurgery or a bloodtransfusion after taking mifepris-\\ntone, and the pregnancy persists in about 1 percent of\\nwomen. In this case, surgical abortion is recom-\\nmended because the fetus may be damanged. Side\\neffects include nausea, vaginal bleeding and heavy\\ncramping. The bleeding is typically heavier than a\\nnormal period and may last up to 16 days.\\nMifepristone is not recommended for women with\\nectopic pregnancy, an IUD, who have been taking\\nlong-term steroidal therapy, have bleeding abnormal-\\nities or on blood-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,\\nvacuum curettage, or suction curettage.\\nAdvantages of a vacuum aspiration abortion are:\\n/C15It is usually done as a one-day outpatient procedure.\\n/C15The procedure takes only 10-15 minutes.\\n/C15Bleeding after the abortion lasts five days or less.\\n/C15The woman does not see the products of her womb\\nbeing removed.\\nDisadvantages include:\\n/C15The procedure is invasive; surgical instruments are\\nused.\\n/C15Infection may occur.\\nDuring a vacuum aspiration, the woman’s cervix\\nis gradually dilated by expanding rods inserted into\\nthe cervical opening. Once dilated, a tube attached to a\\nsuction pump is inserted through the cervix and the\\ncontents of the uterus are suctioned out. The proce-\\ndure is 97-99% effective. The amount of discomfort a\\nwoman feels varies considerably.Local anesthesia is\\noften given to numb the cervix, but it does not mask\\nuterine cramping. After a few hours of rest, the woman\\nmay return home.\\nSecond trimester abortions\\nAlthough it is better to have an abortion during\\nthe first trimester, some second trimester abortions\\nmay be inevitable. The results ofgenetic testing are\\noften not available until 16 weeks. In addition,\\nwomen, especially teens, may not have recognized\\nthe pregnancy or come to terms with it emotionally\\nsoon enough to have a first trimester abortion. Teens\\nmake up the largest group having second trimester\\nabortions.\\nGALE ENCYCLOPEDIA OF MEDICINE 11\\nAbortion, therapeutic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 41, 'page_label': '12'}, page_content='Some second trimester abortions are performed\\nas a D & E. The procedures are similar to those used\\nin the first trimester, but a larger suction tube must be\\nused because more material must be removed. This\\nincreases the amount of cervical dilation necessary and\\nincreases the risk of the procedure. Many physicians are\\nreluctant to perform a D & E this late in pregnancy, and\\nfor some women is it not a medically safe option.\\nThe alternative to a D & E in the second trimester\\nis an abortion by induced labor. Induced labor may\\nrequire an overnight stay in a hospital. The day before\\nthe procedure, the woman visits the doctor for tests,\\nand to either have rods inserted in her cervix to help\\ndilate it or to receive medication that will soften the\\ncervix and speed up labor.\\nOn the day of the abortion, drugs, usually pros-\\ntaglandins to induce contractions, and a salt water\\nsolution, are injected into the uterus. Contractions\\nbegin, and within eight to 72 hours the woman delivers\\nthe fetus.\\nSide effects of this procedure include nausea,vomit-\\ning,a n ddiarrhea from the prostaglandins, andpain\\nfrom uterine cramps. Anesthesia of the sort used in\\nchildbirthcan 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.\\nLater abortions cost more. The cost increases about\\n$100 per week between the thirteenth and sixteenth\\nweek. Second trimester abortions are much more\\ncostly because they often involve more risk, more\\nservices, anesthesia, and sometimes a hospital stay.\\nInsurance carriers and HMOs may or may not cover\\nthe procedure. Federal law prohibits federal funds\\nincluding Medicaid funds, from being used to pay for\\nan elective abortion.\\nPreparation\\nThe doctor must know accurately the stage of a\\nwoman’s pregnancy before an abortion is performed.\\nThe doctor will ask the woman questions about her\\nmenstrual cycle and also do a physical examination to\\nconfirm the stage of pregnancy. This may be done at\\nan office visit before the abortion or on the day of the\\nabortion. Some states require a waiting period before\\nan abortion can be performed. Others require parental\\nor court consent for a child under age 18 to receive an\\nabortion.\\nDespite the fact that almost half of all women\\nin the United States have had at least one abortion\\nby the time they reach age 45, abortion is surrounded\\nby controversy. Women often find themselves in\\nemotional turmoil when deciding if an abortion is\\na procedure they wish to undergo. Pre-abortion coun-\\nseling is important in helping a woman resolve any\\nquestions she may have about having the procedure.\\nAftercare\\nRegardless of the method used to perform the\\nabortion, a woman will be observed for a period of\\ntime to make sure her blood pressure is stable and\\nthat bleeding is controlled. The doctor may prescribe\\nantibiotics to reduce the chance of infection. Women\\nwho are Rh negative (lacking genetically determined\\nantigens in their red blood cells that produce immune\\nresponses) should be given a human Rh immune\\nglobulin (RhoGAM) after the procedure unless the\\nfather of the fetus is also Rh negative. This prevents\\nblood incompatibility complications in future\\npregnancies.\\nBleeding will continue for about five days in a\\nsurgical abortion and longer in a medical abortion.\\nTo decrease the risk of infection, a woman should\\navoid intercourse and not use tampons and douches\\nfor two weeks after the abortion.\\nA follow-up visit is a necessary part of the\\nwoman’s aftercare. Contraception will be offered to\\nwomen who wish to avoid future pregnancies, because\\nmenstrual periods normally resume within a few\\nweeks.\\nRisks\\nSerious complications resulting from abortions\\nperformed before 13 weeks are rare. Of the 90% of\\nwomen who have abortions in this time period, 2.5%\\nhave minor complications that can be handled without\\nhospitalization. Less than 0.5% have complications\\nthat require a hospital stay. The rate of complications\\nincreases as the pregnancy progresses.\\nComplications from abortions can include:\\n/C15uncontrolled bleeding\\n/C15infection\\n/C15blood clots accumulating in the uterus\\n/C15a tear in the cervix or uterus\\n/C15missed abortion where the pregnancy continues\\n/C15incomplete abortion where some material from the\\npregnancy remains in the uterus\\nWomen who experience any of the following\\nsymptoms of post-abortion complications should call\\nthe clinic or doctor who performed the abortion\\nimmediately.\\n12 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, therapeutic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 42, 'page_label': '13'}, page_content='/C15severe pain\\n/C15fever over 100.48F (38.28C)\\n/C15heavy bleeding that soaks through more than one\\nsanitary pad per hour\\n/C15foul-smelling discharge from the vagina\\n/C15continuing symptoms of pregnancy\\nNormal results\\nUsually the pregnancy is ended without compli-\\ncation and without altering future fertility.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra\\nZiporyn. ‘‘Abortion.’’ InThe Harvard Guide to\\nWomen’s Health. Cambridge, MA: Harvard University\\nPress, 1996.\\nDebra Gordon\\nAbrasions see Wounds\\nAbruptio placentae see Placental abruption\\nAbscess\\nDefinition\\nAn abscess is an enclosed collection of liquefied\\ntissue, known as pus, somewhere in the body. It is the\\nresult of the body’s defensive reaction to foreign\\nmaterial.\\nDescription\\nThere are two types of abscesses, septic and sterile.\\nMost abscesses are septic, which means that they are\\nthe result of an infection. Septic abscesses can occur\\nanywhere in the body. Only a germ and the body’s\\nimmune response are required. In response to the\\ninvading germ, white blood cells gather at the infected\\nsite and begin producing chemicals called enzymes\\nthat attack the germ by digesting it. These enzymes\\nact like acid, killing the germs and breaking them\\ndown into small pieces that can be picked up by\\nthe circulation and eliminated from the body.\\nUnfortunately, these chemicals also digest body tis-\\nsues. In most cases, the germ produces similar chemi-\\ncals. The result is a thick, yellow liquid–pus–\\ncontaining digested germs, digested tissue, white\\nblood cells, and enzymes.\\nAn abscess is the last stage of a tissue infection\\nthat begins with a process called inflammation.\\nInitially, as the invading germ activates the body’s\\nimmune system, several events occur:\\n/C15Blood flow to the area increases.\\n/C15The temperature of the area increases due to the\\nincreased blood supply.\\n/C15The area swells due to the accumulation of water,\\nblood, and other liquids.\\n/C15It turns red.\\n/C15It hurts, because of the irritation from the swelling\\nand the chemical activity.\\nThese four signs–heat, swelling, redness, and\\npain–characterize 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\\nfollows the path of least resistance–the tissues most\\neasily digested. A good example is an abscess just\\nbeneath the skin. It most easily continues along\\nbeneath the skin rather than working its way through\\nthe skin where it could drain its toxic contents. The\\ncontents of the abscess also leak into the general cir-\\nculation and produce symptoms just like any other\\ninfection. These include chills, fever, aching, and\\ngeneral discomfort.\\nSterile abscesses are sometimes a milder form\\nof the same process caused not by germs but by non-\\nliving irritants such as drugs. If an injected drug\\nlike penicillin is not absorbed, it stays where it was\\nAn amoebic abscess caused by Entameoba histolytica .\\n(Phototake NYC. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 13\\nAbscess'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 43, 'page_label': '14'}, page_content='injected and may cause enough irritation to generate\\na sterile abscess–sterile because there is no infection\\ninvolved. Sterile abscesses are quite likely to turn into\\nhard, solid lumps as they scar, rather than remaining\\npockets 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\\ncause of abscesses under the skin. Abscesses near\\nthe large bowel, particularly around the anus, may\\nbe caused by any of the numerous bacteria found\\nwithin the large bowel. Brain abscesses and liver\\nabscesses can be caused by any organism that can\\ntravel there through the circulation. Bacteria,\\namoeba, and certain fungi can travel in this fashion.\\nAbscesses in other parts of the body are caused by\\norganisms that normally inhabit nearby structures or\\nthat infect them. Some common causes of specific\\nabscesses are:\\n/C15skin abscesses by normal skin flora\\n/C15dental and throat abscesses by mouth flora\\n/C15lung abscesses by normal airway flora,pneumonia\\ngerms, or tuberculosis\\n/C15abdominal and anal abscesses by normal bowel\\nflora\\nSpecific types of abscesses\\nListed below are some of the more common and\\nimportant abscesses.\\n/C15Carbuncles and otherboils. Skin oil glands (sebac-\\neous glands) on the back or the back of the neck\\nare the ones usually infected. The most common\\ngerm involved is Staphylococcus aureus . Acne is a\\nsimilar condition of sebaceous glands on the face\\nand back.\\n/C15Pilonidal abscess. Many people have as a birth defect\\na tiny opening in the skin just above the anus. Fecal\\nbacteria can enter this opening, causing an infection\\nand subsequent abscess.\\n/C15Retropharyngeal, parapharyngeal, peritonsillar\\nabscess. As a result of throat infections like strep\\nthroat andtonsillitis, bacteria can invade the deeper\\ntissues of the throat and cause an abscess. These\\nabscesses can compromise swallowing and even\\nbreathing.\\n/C15Lung abscess. During or after pneumonia, whether\\nit’s due to bacteria [common pneumonia], tubercu-\\nlosis, fungi, parasites, or other germs, abscesses can\\ndevelop as a complication.\\n/C15Liver abscess. Bacteria or amoeba from the intestines\\ncan spread through the blood to the liver and cause\\nabscesses.\\n/C15Psoas 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\\nappendix, 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\\nonly generalized symptoms such as fever and discom-\\nfort. If the patient’s symptoms and physical examina-\\ntion do not help, a physician may have to resort to a\\nbattery of tests to locate the site of an abscess, but\\nusually something in the initial evaluation directs the\\nsearch. Recent or chronic disease in an organ suggests\\nit may be the site of an abscess. Dysfunction of an\\norgan or system–for instance, seizures or altered bowel\\nfunction–may provide the clue.Pain and tenderness\\non physical examination are common findings.\\nSometimes a deep abscess will eat a small channel\\n(sinus) to the surface and begin leaking pus. A sterile\\nabscess may cause only a painful lump deep in the\\nbuttock where a shot was given.\\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 anat-\\nomy that carries eggs from the ovaries to the uterus.\\nFlora— Living inhabitants of a region or area.\\nPyogenic— Capable of generating pus.Streptococcus,\\nStaphocococcus, and bowel bacteria are the primary\\npyogenic 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 stream.\\nSinus— A tubular channel connecting one body\\npart with another or with the outside.\\n14 GALE ENCYCLOPEDIA OF MEDICINE\\nAbscess'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 44, 'page_label': '15'}, page_content='Treatment\\nSince skin is very resistant to the spread of infec-\\ntion, it acts as a barrier, often keeping the toxic\\nchemicals of an abscess from escaping the body on\\ntheir own. Thus, the pus must be drained from the\\nabscess by a physician. The surgeon determines when\\nthe abscess is ready for drainage and opens a path to\\nthe outside, allowing the pus to escape. Ordinarily, the\\nbody handles the remaining infection, sometimes with\\nthe help ofantibiotics or other drugs. The surgeon may\\nleave a drain (a piece of cloth or rubber) in the abscess\\ncavity to prevent it from closing before all the pus has\\ndrained 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\\nhot compresses to the skin over the abscess will hasten\\nthe digestion of the skin and eventually result in its\\nbreaking down, releasing the pus spontaneously. This\\ntreatment is best reserved for smaller abscesses in rela-\\ntively less dangerous areas of the body–limbs, trunk,\\nback of the neck. It is also useful for all superficial\\nabscesses in their very early stages. It will ‘‘ripen’’\\nthem.\\nContrast hydrotherapy, alternating hot and\\ncold compresses, can also help assist the body in\\nresorption of the abscess. There are two homeo-\\npathic remedies that work to rebalance the body in\\nrelation to abscess formation, Silica and Hepar\\nsulphuris . In cases of septic abscesses, bentonite\\nclay packs (bentonite clay and a small amount of\\nHydrastis powder) can be used to draw the infection\\nfrom the area.\\nPrognosis\\nOnce the abscess is properly drained, the prog-\\nnosis is excellent for the condition itself. The reason\\nfor the abscess (other diseases the patient has) will\\ndetermine the overall outcome. If, on the other\\nhand, the abscess ruptures into neighboring areas or\\npermits the infectious agent to spill into the blood-\\nstream, serious or fatal consequences are likely.\\nAbscesses in and around the nasal sinuses, face, ears,\\nand scalp may work their way into the brain.\\nAbscesses within an abdominal organ such as the\\nliver may rupture into the abdominal cavity. In either\\ncase, the result is life threatening. Bloodpoisoning is a\\nterm commonly used to describe an infection that has\\nspilled into the blood stream and spread throughout\\nthe body from a localized origin. Blood poisoning,\\nknown to physicians as septicemia, is also life\\nthreatening.\\nOf special note, abscesses in the hand are more\\nserious than they might appear. Due to the intricate\\nstructure and the overriding importance of the hand,\\nany hand infection must be treated promptly and\\ncompetently.\\nPrevention\\nInfections that are treated early with heat (if\\nsuperficial) or antibiotics will often resolve without\\nthe formation of an abscess. It is even better to avoid\\ninfections altogether by taking prompt care of open\\ninjuries, particularly puncture wounds. Bites are the\\nmost dangerous of all, even more so because they\\noften occur on the hand.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles\\nof Internal Medicine. New York: McGraw-Hill,\\n1997.\\nJ. Ricker Polsdorfer, MD\\nAbscess drainage see Abscess incision and\\ndrainage\\nAbscess incision & drainage\\nDefinition\\nAn infected skin nodule that contains pus may\\nneed to be drained via a cut if it does not respond to\\nantibiotics. This allows the pus to escape, and the\\ninfection 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\\ninfection. Abscesses are often found in the soft tissue\\nunder the skin, such as the armpit or the groin.\\nGALE ENCYCLOPEDIA OF MEDICINE 15\\nAbscess incision & drainage'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 45, 'page_label': '16'}, page_content='However, they may develop in any organ, and are\\ncommonly found in the breast and gums. Abscesses\\nare far more serious and call for more specific treat-\\nment if they are located in deep organs such as the\\nlung, liver or brain.\\nBecause the lining of the abscess cavity tends\\nto interfere with the amount of the drug that can\\npenetrate the source of infection from the blood, the\\ncavity itself may require draining. Once an abscess has\\nfully formed, it often does not respond to antibiotics.\\nEven if the antibiotic does penetrate into the abscess, it\\ndoesn’t function as well in that environment.\\nPrecautions\\nAn abscess can usually be diagnosed visually,\\nalthough an imaging technique such as a computed\\ntomography scan may be used to confirm the extent of\\nthe abscess before drainage. Such procedures may also\\nbe needed to localize internal abscesses, such as those\\nin the abdominal cavity or brain.\\nDescription\\nA doctor will cut into the lining of the abscess,\\nallowing the pus to escape either through a drainage\\ntube or by leaving the cavity open to the skin. How big\\nthe incision is depends on how quickly the pus is\\nencountered.\\nOnce the abscess is opened, the doctor will clean\\nand irrigate the wound thoroughly with saline. If it is\\nnot too large or deep, the doctor may simply pack the\\nabscess wound with gauze for 24–48 hours to absorb\\nthe pus and discharge.\\nIf it is a deeper abscess, the doctor may insert a\\ndrainage tube after cleaning out the wound. Once the\\nLiver\\nStomach\\nSpleen\\nColon\\nCommon sites of abscess \\nabove and below the liver\\nAlthough abscesses are often found in the soft tissue under the skin, such as the armpit or the groin, they may develop in any\\norgan, such as the liver. (Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nWhite blood cells— Cells that protect the body\\nagainst infection.\\n16 GALE ENCYCLOPEDIA OF MEDICINE\\nAbscess incision & drainage'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 46, 'page_label': '17'}, page_content='tube is in place, the surgeon closes the incision with\\nsimple stitches, and applies a sterile dressing. Drainage\\nis maintained for several days to help prevent the\\nabscess from reforming.\\nPreparation\\nThe skin over the abscess will be cleansed by\\nswabbing gently with an antiseptic solution.\\nAftercare\\nMuch of thepain 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\\nseveral days. Applying heat and keeping the affected\\narea elevated 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.\\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 anything that is harmful,\\ninjurious, or offensive. Abuse also includes excessive\\nand wrongful misuse of a substance. There are several\\nmajor types of abuse: physical and sexual abuse of a\\nchild or an adult,substance abuse, elderly abuse, and\\nemotional abuse.\\nDescription\\nPhysical abuse of a child is the infliction of injury\\nby another person. The injuries can include punching,\\nkicking, biting, burning, beating, or pulling the vic-\\ntim’s hair. The physical abuse inflicted on a child can\\nresult inbruises, burns, poisoning, broken bones, and\\ninternal hemorrhages. Physical assault against an\\nadult primarily occurs with women, usually in the\\nform of domestic violence. It is estimated that approxi-\\nmately three million children witness domestic vio-\\nlence every year.\\nSexual abuse of a child refers to sexual behavior\\nbetween an adult and child or between two children,\\none of whom is dominant or significantly older. The\\nsexual behaviors can include touching breasts, geni-\\ntals, and buttocks; either dressed or undressed. The\\nbehavior also can include exhibitionism, cunnilingus,\\nfellatio, or penetration of the vagina or anus with\\nsexual organs or objects.\\nPornographic photography also is used in sexual\\nabuse with children. Reported sex offenders are 97%\\nmale. Reports of child pornography have increased\\nsince with the popularity of the Internet. Females\\nmore often are perpetrators in child-care settings,\\nsince children may confuse sexual abuse by a female\\nwith normal hygiene care. The 1990s and early 2000s\\nwere rocked by reports of sexual abuse of children\\ncommitted by Catholic priests. Most of the abuse\\nappeared to have occurred during the 1970s and a\\nprominent report released early in 2004 stated that as\\nmany as 10.667 children were sexually abused by more\\nthan 4,300 priests. Sexual abuse by stepfathers is five\\ntimes more common than with biological fathers.\\nSexual abuse of daughters by stepfathers or fathers is\\nthe most common form of incest.\\nSexual abuse also can take the form ofrape. The\\nlegal definition of rape includes only slight penile\\npenetration in the victim’s outer vulva area.\\nComplete erection and ejaculation are not necessary.\\nRape is the perpetration of an act of sexual intercourse\\nwhether:\\n/C15will is overcome by force or fear (from threats or by\\nuse of drugs).\\n/C15mental impairment renders the victim incapable of\\nrational judgment.\\n/C15if the victim is below the legal age established for\\nconsent.\\nSubstance abuse is an abnormal pattern of sub-\\nstance usage leading to significant distress or impair-\\nment. The criteria include one or more of the following\\noccurring within a 12-month period:\\nGALE ENCYCLOPEDIA OF MEDICINE 17\\nAbuse'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 47, 'page_label': '18'}, page_content='/C15recurrent substance use resulting in failure to fulfill\\nobligations at home, work, or school.\\n/C15using substance in situations that are physically dan-\\ngerous (i.e., while driving).\\n/C15recurrent substance-related legal problems.\\n/C15continued usage despite recurrent social and inter-\\npersonal problems (i.e., arguments and fights with\\nsignificant other).\\nAbuse of the elderly is common and occurs mostly\\nas a result of caretaker burnout, due to the high level\\nof dependency frail, elderly patients usually require.\\nAbuse can be manifested by physical signs, fear, and\\ndelaying or not reporting the need for advanced med-\\nical care. Elderly patients also may exhibit financial\\nabuse (money or possessions taken away) and\\nabandonment.\\nEmotional abuse generally continues even after\\nphysical assaults have stopped. In most cases it is a\\npersonally tailored form of verbal or gesture abuse\\nexpressed to illicit a provoked response.\\nCauses and symptoms\\nChildren who have been abused usually have a\\nvariety of symptoms that encompass behavioral, emo-\\ntional, and psychosomatic problems (body problems\\ncaused by emotional or mental disturbance). Children\\nwho have been physically abused tend to be more\\naggressive, angry, hostile, depressed, and have low\\nself-esteem. Additionally, they exhibit fear,anxiety,\\nand nightmares. Severe psychological problems may\\nresult in suicidal behavior or posttraumatic stress dis-\\norder. Physically abused children may complain of\\nphysical illness even in the absence of a cause. They\\nalso may suffer from eating disorders andencopresis,\\nor involuntary defecation caused or psychic origin.\\nChildren who are sexually abused may exhibit abnor-\\nmal sexual behavior in the form of aggressiveness and\\nhyperarousal. Adolescents may display promiscuity,\\nsexual acting out, and—in some situations—homo-\\nsexual contact.\\nPhysical abuse directed towards adults can ulti-\\nmately lead todeath. Approximately 50% of women\\nmurdered in the United States were killed by a former\\nor current male partner. Approximately one-third of\\nemergency room consultations by women were\\nprompted due to domestic violence. Female victims\\nwho are married also have a higher rate of internal\\ninjuries and unconsciousness than victims of stranger\\nassault (mugging, robbery). Physical abuse or rape\\nalso can occur between married persons and persons\\nof the same gender. Perpetrators usually sexually\\nassault their victims to dominate, hurt, and debase\\nthem. It is common for physical and sexual violence\\nto occur at the same time. A large percentage of sexu-\\nally assaulted persons were also physically abused in\\nthe form of punching, beating, or threatening the vic-\\ntim with a weapon such as a gun or knife. Usually\\nmales who are hurt and humiliated tend to physically\\nassault people whom they are intimately involved\\nwith, such as spouses and/or children. Males who\\nassault a female tend to have experienced or witnessed\\nviolence during childhood. They also tend to abuse\\nalcohol, to be sexually assaultive, and are at increased\\nrisk for assaultive behavior directed against children.\\nJealous males tend to monitor a women’s movements\\nand whereabouts and to isolate other sources of pro-\\ntection and support. They interpret their behavior as\\nbetrayal of trust and this causes resentment and explo-\\nsive anger outbursts during periods of losing control.\\nMales also may use aggression against females in an\\neffort to control and intimidate partners.\\nAbuse in the elderly usually occurs in the frail,\\nelderly community. The caretaker is usually the perpe-\\ntrator. Caretaker abuse can be suspected if there is\\nevidence suggesting behavioral changes in the elderly\\nperson when the caretaker is present. Additionally,\\nelderly abuse can be possible if there are delays\\nbetween injuries and treatment, inconsistencies\\nbetween injury and explanations, lack of hygiene or\\nclothing, and prescriptions not being filled.\\nDiagnosis\\nChildren who are victims of domestic violence\\nfrequently are injured attempting to protect their\\nmother from an abusive partner. Injuries are visible\\nby inspection or self-report. Physical abuse of an adult\\nmay also be evident by inspection with visible cuts\\nand/or bruises or self-report.\\nSexual abuse of both a child and an adult can be\\ndiagnosed with a history from the victim. Victims can\\nbe assessed for signs of ejaculatory evidence from the\\nperpetrator. Ejaculatory specimens can be retrieved\\nfrom the mouth, rectum, and clothing. Tests for sexu-\\nally transmitted diseases may be performed.\\nKEY TERMS\\nEncopresis— Abnormalities relating to bowel\\nmovements that can occur as a result of stress or\\nfear.\\n18 GALE ENCYCLOPEDIA OF MEDICINE\\nAbuse'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 48, 'page_label': '19'}, page_content='Elderly abuse can be suspected if the elderly patient\\ndemonstrates a fear of 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\\nrecurrent negative consequences. The diagnosis can\\nbe made after administration of a comprehensive\\nexam and standardized chemical abuse assessments\\nby a therapist.\\nTreatment\\nChildren who are victims of physical or sexual\\nabuse typically require psychological support and\\nmedical attention. A complaint may be filed with the\\nlocal family social services agency that will initiate\\ninvestigations. The authorities usually will follow up\\nthe allegation or offense. Children may also be\\nreferred for psychological evaluation and/or treat-\\nment. The victim also may be placed in foster care\\npending the investigation outcome. The police also\\nmay investigate physical and sexual abuse of an\\nadult. The victim may require immediate medical\\ncare and long-term psychological treatment. It is com-\\nmon for children to be adversely affected by domestic\\nviolence situations and the local family services agency\\nmay be involved.\\nSubstance abusers should elect treatment, either\\ninpatient or outpatient, depending on severity of\\naddiction. Long term treatment and/or medications\\nmay be utilized to assist in abstinence. The patient\\nshould be encouraged to participate in community\\ncentered support groups.\\nPrognosis\\nThe prognosis depends on the diagnosis.\\nUsually victims of physical and sexual abuse require\\ntherapy to deal with emotional distress associated\\nwith the incident. Perpetrators require further psy-\\nchological evaluation and treatment. Victims of\\nabuse may have a variety of emotional problems\\nincluding depression, acts of suicide,o ra n x i e t y .\\nChildren of sexual abuse may enter abusive rela-\\ntionships or have problems with intimacy as adults.\\nThe substance abuser may experience relapses, since\\nthe cardinal feature of all addictive disorders is a\\ntendency to return to symptoms. Elderly patients\\nmay suffer from further medical problems and/or\\nanxiety, and in some cases neglect may precipitate\\ndeath.\\nPrevention\\nPrevention programs are geared to education and\\nawareness. Detection of initial symptoms or charac-\\nteristic behaviors may assist in some situations. In\\nsome cases treatment may be sought before incident.\\nThe professional treating the abused persons must\\ndevelop a clear sense of the relationship dynamics\\nand the chances for continued harm.\\nResources\\nBOOKS\\nBehrman, Richard E., et al, editors.Nelson Textbook of\\nPediatrics. 16th ed. W. B. Saunders Company, 2000.\\nPERIODICALS\\nPlante, Thomas G. ‘‘Another Aftershock: What Have We\\nLearned from the John Jay Report?.’’America (March\\n22, 2004): 10.\\nORGANIZATIONS\\nNational Clearinghouse on Child Abuse and Neglect\\nInformation. 330 C Street SW, Washington, DC 20447.\\n(800) 392-3366.\\nOTHER\\nElder Abuse Prevention. .\\nNational Institute on Drug Abuse. .\\nLaith Farid Gulli, M.D.\\nBilal Nasser, M.Sc.\\nTeresa G. Odle\\nAcceleration-deceleration cervical injurysee\\nWhiplash\\nACE inhibitors see Angiotensin-converting\\nenzyme inhibitors\\nAcetaminophen\\nDefinition\\nAcetaminophen is a medicine used to relievepain\\nand reducefever.\\nPurpose\\nAcetaminophen is used to relieve many kinds of\\nminor aches and pains—headaches, muscle aches,\\nbackaches, toothaches, menstrual cramps, arthritis,\\nand the aches and pains that often accompany colds.\\nGALE ENCYCLOPEDIA OF MEDICINE 19\\nAcetaminophen'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 49, 'page_label': '20'}, page_content='Description\\nThis drug is available without a prescription.\\nAcetaminophen is sold under various brand names,\\nincluding Tylenol, Panadol,Aspirin Free Anacin, and\\nBayer Select Maximum StrengthHeadache Pain Relief\\nFormula. Many multi-symptom cold, flu, and sinus\\nmedicines also contain acetaminophen. The ingredi-\\nents listing on the container should state if acetamino-\\nphen is included in the product.\\nStudies have shown that acetaminophen relieves\\npain and reduces fever about as well as aspirin. But\\ndifferences between these two common drugs exist.\\nAcetaminophen is less likely than aspirin to irritate\\nthe stomach. However, unlike aspirin, acetaminophen\\ndoes not reduce the redness, stiffness, or swelling that\\naccompany arthritis.\\nRecommended dosage\\nThe usual dosage for adults and children age 12\\nand over is 325-650 mg every four to six hours as\\nneeded. No more than 4 grams (4000 mg) should be\\ntaken in 24 hours. Because the drug can potentially\\nharm the liver, people who drink alcohol in large\\nquantities should take considerably less acetamino-\\nphen and possibly should avoid the drug completely.\\nFor children ages 6-11 years, the usual dose is 150-\\n300 mg, three to four times a day. A physician should\\nrecommend doses for children under age 6 years.\\nPrecautions\\nIn 2004, the U.S. Food and Drug Administration\\n(FDA) launched an advertising campaign aimed at\\neducating consumers about proper use of acetamino-\\nphen and other over-the-counter pain killers. Often,\\nacetaminophen is hidden in many cold and flu products\\nand people unexpectedly overdose on the medicine.\\nSome cases have led toliver transplantationor death.\\nMore than the recommended dosage of acetaminophen\\nshould not be taken unless told to do so by a physician\\nor dentist.\\nPatients should not use acetaminophen for more\\nthan 10 days to relieve pain (five days for children) or\\nfor more than three days to reduce fever, unless direc-\\nted to do so by a physician. If symptoms do not go\\naway—or if they get worse— a physician should be\\ncontacted. Anyone who drinks three or more alcoholic\\nbeverages a day should check with a physician before\\nusing this drug and should never take more than the\\nrecommended dosage. A risk of liver damage exists\\nfrom combining large amounts of alcohol and\\nacetaminophen. People who already have kidney or\\nliver diseaseor liver infections should also consult with\\na physician before using the drug. So should women\\nwho are pregnant or breastfeeding.\\nMany drugs can interact with one another. A\\nphysician or pharmacist should be consulted before\\ncombining acetaminophen with any other medicine.\\nTwo different acetaminophen-containing products\\nshould not be used at the same time.\\nAcetaminophen interferes with the results of some\\nmedical tests. Avoiding the drug for a few days before\\nthe tests may be necessary.\\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\\nlower back. Allergic reactions occur in some people,\\nbut 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 causenausea,\\nvomiting, sweating, and exhaustion. Very large over-\\ndoses can cause liver damage. In case of an overdose,\\nimmediate medical attention should be sought. In\\n2004, researchers announced that an injection to coun-\\nteract the liver injury caused by acetaminophen over-\\ndose has been approved by the FDA.\\nInteractions\\nAcetaminophen may interact with a variety of\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side\\neffects may be greater. Among the drugs that may\\ninteract with acetaminophen are alcohol, nonsteroidal\\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.\\n20 GALE ENCYCLOPEDIA OF MEDICINE\\nAcetaminophen'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 50, 'page_label': '21'}, page_content='anti-inflammatory drugs (NSAIDs) such as Motrin,\\noral contraceptives, the antiseizure drug phenytoin\\n(Dilantin), the blood-thinning drug warfarin\\n(Coumadin), the cholesterol-lowering drug cholesty-\\nramine (Questran), the antibiotic Isoniazid, and zido-\\nvudine (Retrovir, AZT). A physician or pharmacist\\nshould be consulted before combining acetaminophen\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine.\\nResources\\nPERIODICALS\\n‘‘Antidote Cleared for Acetiminophen Overdose.’’Drug\\nTopics February 23, 2004: 12.\\nMechcatie, Elizabeth. ‘‘FDA Launches Campaign About\\nOTC Drug Risks: NSAIDs, Acetaminophen.’’Family\\nPractice News March 15, 2004: 8l\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAcetylsalicylic acid see Aspirin\\nAchalasia\\nDefinition\\nAchalasia is a disorder of the esophagus that\\nprevents normal swallowing.\\nDescription\\nAchalasia affects the esophagus, the tube that\\ncarries swallowed food from the back of the throat\\ndown into the stomach. A ring of muscle called the\\nlower esophageal sphincter encircles the esophagus\\njust above the entrance to the stomach. This sphincter\\nmuscle is normally contracted to close the esophagus.\\nWhen the sphincter is closed, the contents of the sto-\\nmach cannot flow back into the esophagus. Backward\\nflow of stomach contents (reflux) can irritate and\\ninflame the esophagus, causing symptoms such as\\nheartburn. The act of swallowing causes a wave of\\nesophageal contraction called peristalsis. Peristalsis\\npushes food along the esophagus. Normally, peristal-\\nsis causes the esophageal sphincter to relax and allow\\nfood into the stomach. In achalasia, which means\\n‘‘failure to relax,’’ the esophageal sphincter remains\\ncontracted. Normal peristalsis is interrupted and food\\ncannot 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\\ndegeneration is unknown. Autoimmune disease or\\nhidden infection is suspected.\\nSymptoms\\nDysphagia, or difficulty swallowing, is the most\\ncommon symptom of achalasia. The person with\\nachalasia usually has trouble swallowing both liquid\\nand solid foods, often feeling that food ‘‘gets stuck’’\\non the way down. The person has chestpain that\\nis often mistaken forangina pectoris (cardiac pain).\\nHeartburn and difficulty belching are common.\\nSymptoms usually get steadily worse. Other symptoms\\nmay include nighttimecough or recurrentpneumonia\\ncaused by food passing into the lower airways.\\nDiagnosis\\nDiagnosis of achalasia begins with a careful med-\\nical history. The history should focus on the timing of\\nsymptoms and on eliminating other medical condi-\\ntions that may cause similar symptoms. Tests used to\\ndiagnose achalasia include:\\n/C15Esophageal manometry. In this test, a thin tube is\\npassed into the esophagus to measure the pressure\\nexerted by the esophageal sphincter.\\n/C15X 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/C15Endoscopy. 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\\ndilation. In this procedure, an inflatable membrane\\nor balloon is passed down the esophagus to the sphinc-\\nter and inflated to force the sphincter open. Dilation is\\neffective in about 70% of patients.\\nThree other treatments are used for achalasia when\\nballoon dilation is inappropriate or unacceptable.\\nGALE ENCYCLOPEDIA OF MEDICINE 21\\nAchalasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 51, 'page_label': '22'}, page_content='/C15Botulinum toxin injection. Injected into the sphinc-\\nter, botulinum toxin paralyzes the muscle and allows\\nit to relax. Symptoms usually return within one to\\ntwo years.\\n/C15Esophagomyotomy. This surgical procedure cuts the\\nsphincter muscle to allow the esophagus to open.\\nEsophagomyotomy is becoming more popular with\\nthe development of techniques allowing very small\\nabdominal incisions.\\n/C15Drug therapy. Nifedipine, a calcium-channel blocker,\\nreduces muscle contraction. Taken daily, this drug\\nprovides relief for about two-thirds of patients for as\\nlong as two years.\\nPrognosis\\nMost patients with achalasia can be treated effec-\\ntively. Achalasia does not reduce life expectancy\\nunless esophageal carcinoma develops.\\nPrevention\\nThere is no known way to prevent achalasia.\\nResources\\nBOOKS\\nGrendell, James H., Kenneth R. McQuaid, and Scott L.\\nFriedman, editors.Current Diagnosis and Treatment in\\nGastroenterology. Stamford: Appleton& Lange, 1996.\\nRichard Robinson\\nAchondroplasia\\nDefinition\\nAchondroplasia is the most common cause of\\ndwarfism, or significantly abnormal short stature.\\nDescription\\nAchondroplasia is one of a number of chondo-\\ndystrophies, in which the development of cartilage,\\nand therefore, bone is disturbed. The disorder\\nappears in approximately one in every 10,000\\nbirths. Achondroplasia is usually diagnosed at birth,\\nowing to the characteristic appearance of the\\nnewborn.\\nNormal bone growth depends on the produc-\\ntion of cartilage (a fibrous connective tissue). Over\\ntime, calcium is deposited within the cartilage,\\ncausing it to harden and become bone. In achon-\\ndroplasia, abnormalities of this process prevent the\\nbones (especially those in the limbs) from growing\\nas long as they normally should, at the same time\\nallowing the bones to become abnormally thick-\\nened. The bones in the trunk of the body and the\\nskull are mostly not affected, although the opening\\nfrom the skull through which the spinal cord\\npasses (foramen magnum) is often narrower than\\nnormal, and the opening (spinal canal) through\\nwhich the spinal cord runs in the back bones (ver-\\ntebrae) becomes increasingly and abnormally small\\ndown the length of the spine.\\nCauses and symptoms\\nAchondroplasia is caused by a genetic defect. It is\\na dominant trait, meaning that anybody with\\nthe genetic defect will display all the symptoms of\\nthe disorder. A parent with the disorder has a 50%\\nKEY TERMS\\nBotulinum toxin— Any of a group of potent bacter-\\nial toxins or poisons produced by different strains of\\nthe bacterium Clostridium botulinum . The toxins\\ncause muscle paralysis.\\nDysphagia— Difficulty in swallowing.\\nEndoscopy— A test in which a viewing device\\nand a light source are introduced into the esopha-\\ngus by means of a flexible tube. Endoscopy per-\\nmits visual inspection of the esophagus for\\nabnormalities.\\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 a\\nfluid.\\n22 GALE ENCYCLOPEDIA OF MEDICINE\\nAchondroplasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 52, 'page_label': '23'}, page_content='chance of passing it on to the offspring. Although\\nachondroplasia can be passed on to subsequent\\noffspring, the majority of cases occur due to a new\\nmutation (change) in a gene. Interestingly enough,\\nthe defect seen in achondroplasia is one of only a\\nfew 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\\nshort arms and legs. Their trunk is usually of normal\\nsize, as is their head. The appearance of short limbs\\nand normal head size actually makes the head\\nappear to be oversized. The bridge of the nose\\noften has a scooped out appearance termed ‘‘saddle\\nnose.’’ The lower back has an abnormal curvature,\\nor sway back. The face often displays an overly\\nprominent forehead, and a relative lack of develop-\\nment of the face in the area of the upper jaw. Because\\nthe foramen magnum and spinal canal are abnor-\\nmally narrowed, nerve damage may occur if the\\nspinal cord or nerves become compressed. The nar-\\nrowed foramen magnum may disrupt the normal\\nflow of fluid between the brain and the spinal cord,\\nresulting in the accumulation of too much fluid in\\nthe brain (hydrocephalus ). Children with achondro-\\nplasia have a very high risk of serious and repeated\\nmiddle ear infections, which can result in hearing\\nloss. The disease does not affect either mental capa-\\ncity, or reproductive ability.\\nDiagnosis\\nDiagnosis is often made at birth due to the char-\\nacteristically short limbs, and the appearance of a\\nlarge head. X-ray examination will reveal a character-\\nistic appearance to the bones, with the bones of the\\nlimbs appearing short in length, yet broad in width. A\\nnumber of measurements of the bones in x-ray images\\nwill reveal abnormal proportions.\\nTreatment\\nNo treatment will reverse the defect present in\\nachondroplasia. All patients with the disease will be\\nshort, with abnormally proportioned limbs, trunk,\\nand head. Treatment of achondroplasia primarily\\naddresses some of the complications of the disorder,\\nincluding problems due to nerve compression, hydro-\\ncephalus, bowed legs, and abnormal curves in the\\nspine. Children with achondroplasia who develop\\nmiddle ear infections (acuteotitis media) will require\\nquick treatment withantibiotics and careful monitor-\\ning in order to avoid hearing loss.\\nPrognosis\\nAchondroplasia is a disease which causes consid-\\nerable deformity. However, with careful attention\\nKEY TERMS\\nCartilage— A flexible, fibrous type of connective\\ntissue which serves as a base on which bone is\\nbuilt.\\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 which\\nthe spinal cord passes.\\nAn x-ray image of an achondroplastic person’s head\\nand chest. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 23\\nAchondroplasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 53, 'page_label': '24'}, page_content='paid to the development of dangerous complications\\n(nerve compression, hydrocephalus), most people are\\nin good health, and can live a normal lifespan.\\nPrevention\\nThe only form of prevention is throughgenetic\\ncounseling, which could help parents assess their risk\\nof having a child with achondroplasia.\\nResources\\nBOOKS\\nKrane, Stephen M., and Alan L. Schiller.\\n‘‘Achondroplasia.’’ InHarrison’s Principles of Internal\\nMedicine, edited by Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nORGANIZATIONS\\nLittle People of America, c/o Mary Carten. 7238 Piedmont\\nDrive, Dallas, TX 75227-9324. (800) 243-9273.\\nRosalyn Carson-DeWitt, MD\\nAchromatopsia 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\\nthe body (metastasized), and to check the effectiveness\\nof treatment. The test has been largely supplanted by\\nthe prostate specific antigen test (PSA).\\nPurpose\\nT h em a l ep r o s t a t eg l a n dh a s1 0 0t i m e sm o r e\\nacid phosphatase than any other body tissue.\\nWhen prostate cancer s p r e a d st oo t h e rp a r t so ft h e\\nbody, acid phosphatase levels rise, particularly if\\nthe cancer spreads to the bone. One-half to three-\\nfourths of persons who have metastasized prostate\\ncancer have high acid phosphatase levels. Levels fall\\nafter the tumor is removed or reduced through\\ntreatment.\\nTissues other than prostate have small amounts\\nof acid phosphatase, including bone, liver, spleen,\\nkidney, and red blood cells and platelets. Damage to\\nthese tissues causes a moderate increase in acid phos-\\nphatase 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.\\nAcid phosphatase levels rise only after prostate cancer\\nhas metastasized.\\nDescription\\nLaboratory testing measures the amount of acid\\nphosphatase in a person’s blood, and can determine\\nfrom what tissue the enzyme is coming. For example, it\\nis important to know if the increased acid phosphatase\\nis from the prostate or red blood cells. Acid phospha-\\ntase from the prostate, called prostatic acid phospha-\\ntase (PAP), is the most medically significant type of\\nacid phosphatase.\\nSubtle differences between prostatic acid phos-\\nphatase and acid phosphatases from other tissues\\ncause them to react differently in the laboratory\\nwhen mixed with certain chemicals. For example,\\nadding the chemical tartrate to the test mixture inhi-\\nbits the activity of prostatic acid phosphatase but not\\nred blood cell acid phospha tase. Laboratory test\\nmethods based on these differences reveal how\\nmuch of a person’s total acid phosphatase is derived\\nfrom the prostate. Results are usually available the\\nnext 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.\\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.\\n24 GALE ENCYCLOPEDIA OF MEDICINE\\nAcid phosphatase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 54, 'page_label': '25'}, page_content='Aftercare\\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\\nwill reduce bruising. Warm packs to the puncture site\\nwill relieve discomfort.\\nNormal results\\nNormal results vary based on the laboratory and\\nthe method used.\\nAbnormal results\\nThe highest levels of acid phosphatase are found\\nin metastasized prostate cancer. Diseases of the\\nbone, such as Paget’s disease orhyperparathyroidism;\\ndiseases of blood cells, such assickle cell diseaseor\\nmultiple myeloma; or lysosomal disorders, such as\\nGaucher’s disease, will show moderately increased\\nlevels.\\nCertain medications can cause temporary increases\\nor decreases in acid phosphatase levels. Manipulation\\nof the prostate gland through massage, biopsy, or rectal\\nexam before a test can increase the level.\\nResources\\nPERIODICALS\\nMoul, Judd W., et al. ‘‘The Contemporary Value of\\nPretreatment Prostatic Acid Phosphatase to Predict\\nPathological Stage and Recurrence in Radical\\nProstatectomy Cases.’’Journal of Urology (March\\n1998): 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\\nthe pores of the skin become clogged with oil, dead\\nskin cells, and bacteria.\\nDescription\\nAcne vulgaris, the medical term for common acne,\\nis the most common skin disease. It affects nearly 17\\nmillion people in the United States. While acne can\\narise at any age, it usually begins atpuberty and wor-\\nsens during adolescence. Nearly 85% of people\\ndevelop acne at some time between the ages of 12-25\\nyears. Up to 20% of women develop mild acne. It is\\nalso found in some newborns.\\nThe sebaceous glands lie just beneath the skin’s\\nsurface. They produce an oil called sebum, the skin’s\\nnatural moisturizer. These glands and the hair follicles\\nwithin which they are found are called sebaceous\\nfollicles. These follicles open onto the skin through\\npores. At puberty, increased levels of androgens\\n(male hormones) cause the glands to produce too\\nmuch sebum. When excess sebum combines with\\ndead, sticky skin cells, a hard plug, or comedo, forms\\nthat blocks the pore. Mild noninflammatory acne con-\\nsists of the two types of comedones, whiteheads and\\nblackheads.\\nModerate and severe inflammatory types of acne\\nresult after the plugged follicle is invaded by\\nPropionibacterium acnes , a bacteria that normally\\nlives on the skin. A pimple forms when the damaged\\nfollicle weakens and bursts open, releasing sebum,\\nbacteria, and skin and white blood cells into the sur-\\nrounding tissues. Inflamed pimples near the skin’s sur-\\nface are called papules; when deeper, they are called\\npustules. The most severe type of acne consists of cysts\\n(closed sacs) and nodules (hard swellings). Scarring\\noccurs when new skin cells are laid down to replace\\ndamaged cells.\\nThe most common sites of acne are the face, chest,\\nshoulders, and back since these are the parts of the\\nbody where the most sebaceous follicles are found.\\nCauses and symptoms\\nThe exact cause of acne is unknown. Several risk\\nfactors have been identified:\\n/C15Age. Due to the hormonal changes they experience,\\nteenagers are more likely to develop acne.\\n/C15Gender. Boys have more severe acne and develop it\\nmore often than girls.\\n/C15Disease. Hormonal disorders can complicate acne in\\ngirls.\\n/C15Heredity. Individuals with a family history of acne\\nhave greater susceptibility to the disease.\\n/C15Hormonal changes. Acne can flare up before men-\\nstruation, duringpregnancy,a n dmenopause.\\nGALE ENCYCLOPEDIA OF MEDICINE 25\\nAcne'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 55, 'page_label': '26'}, page_content='/C15Diet. No foods cause acne, but certain foods may\\ncause flare-ups.\\n/C15Drugs. Acne can be a side effect of drugs including\\ntranquilizers, antidepressants, antibiotics,oral con-\\ntraceptives, and anabolic steroids.\\n/C15Personal hygiene. Abrasive soaps, hard scrubbing, or\\npicking at pimples will make them worse.\\n/C15Cosmetics. Oil-based makeup and hair sprays wor-\\nsen acne.\\n/C15Environment. Exposure to oils and greases, polluted\\nair, and sweating in hot weather aggravate acne.\\n/C15Stress. Emotional stress may contribute to acne.\\nAcne is usually not conspicuous, although infla-\\nmed lesions may causepain, tenderness, itching,o r\\nswelling. The most troubling aspects of these lesions\\nare the negative cosmetic effects and potential for\\nscarring. Some people, especially teenagers, become\\nemotionally upset about their condition, and have\\nproblems forming relationships or keeping jobs.\\nDiagnosis\\nAcne patients are often treated by family doctors.\\nComplicated cases are referred to a dermatologist, a\\nskin disease specialist, or an endocrinologist, a specia-\\nlist who treats diseases of the body’s endocrine (hor-\\nmones and glands) system.\\nAcne has a characteristic appearance and is not\\ndifficult to diagnose. The doctor takes a complete\\nmedical history, including questions about skin care,\\ndiet, factors causing flare-ups, medication use, and\\nprior treatment. Physical examination includes the\\nface, upper neck, chest, shoulders, back, and other\\naffected areas. Under good lighting, the doctor deter-\\nmines what types and how many blemishes are pre-\\nsent, whether they are inflamed, whether they are deep\\nor superficial, and whether there is scarring or skin\\ndiscoloration.\\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 produc-\\ntion 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.\\nAcne vulgaris affecting a woman’s face. Acne is the general\\nname given to a skin disorder in which the sebaceous glands\\nbecome inflamed. (Photograph by Biophoto Associates, Photo\\nResearchers, Inc. Reproduced by permission.)\\n26 GALE ENCYCLOPEDIA OF MEDICINE\\nAcne'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 56, 'page_label': '27'}, page_content='In teenagers, acne is often found on the forehead,\\nnose, and chin. As people get older, acne tends to\\nappear towards the outer part of the face. Adult\\nwomen may have acne on their chins and around\\ntheir mouths. The elderly may develop whiteheads\\nand blackheads on the upper cheeks and skin around\\nthe 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\\nmay be ordered. Most insurance plans cover the\\ncosts of diagnosing and treating acne.\\nTreatment\\nAcne treatment consists of reducing sebum pro-\\nduction, removing dead skin cells, and killing bacteria\\nwith topical drugs and oral medications. Treatment\\nchoice depends upon whether the acne is mild, mod-\\nerate, or severe.\\nDrugs\\nTOPICAL DRUGS. Treatment for mild noninflam-\\nmatory acne consists of reducing the formation of new\\ncomedones with topical tretinoin, benzoyl peroxide,\\nadapalene, or salicylic acid. Tretinoin is especially\\neffective because it increases turnover (death and\\nreplacement) of skin cells. When complicated by\\ninflammation, topical antibioticsmay be added to the\\ntreatment regimen. Improvement is usually seen in\\ntwo to four weeks.\\nTopical medications are available as cream, gel,\\nlotion, or pad preparations of varying strengths.\\nThey include antibiotics (agents that kill bacteria),\\nsuch as erythromycin, clindamycin (Cleocin-T), and\\nmeclocycline (Meclan); comedolytics (agents that\\nloosen hard plugs and open pores) such as the vitamin\\nA acid tretinoin (Retin-A), salicylic acid, adapalene\\n(Differin), resorcinol, and sulfur. Drugs that act as\\nboth comedolytics and antibiotics, such as benzoyl\\nperoxide, azelaic acid (Azelex), or benzoyl peroxide\\nplus erythromycin (Benzamycin), are also used.\\nThese drugs may be used for months to years to\\nachieve disease control.\\nAfter washing with mild soap, the drugs are\\napplied alone or in combination, once or twice a day\\nover the entire affected area of skin. Possible side\\neffects include mild redness, peeling, irritation, dry-\\nness, and an increased sensitivity to sunlight that\\nrequires 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,\\nclindamycin (Cleocin), and trimethoprim- sulfamethox-\\nazole (Bactrim, Septra). Possible side effects include\\nallergic reactions, stomach upset, vaginal yeast infec-\\ntions, dizziness, and tooth discoloration.\\nThe goal of treating moderate acne is to decrease\\ninflammation and prevent new comedone formation.\\nOne effective treatment is topical tretinoin along with\\na topical or oral antibiotic. A combination of topical\\nbenzoyl peroxide and erythromycin is also very effec-\\ntive. Improvement is normally seen within four to six\\nweeks, but treatment is maintained for at least two to\\nfour months.\\nA drug reserved for the treatment of severe\\nacne, oral isotretinoin (Accutane), reduces sebum\\nproduction and cell stickiness. It is the treatment\\nof choice for severe acne with cysts and nodules,\\nand is used with or without topical or oral antibio-\\ntics. Taken for four to five months, it provides long-\\nterm disease control in up to 60% of patients. If the\\nacne reappears, another course of isotretinoin may\\nbe needed by about 20% of patients, while another\\n20% may do well with topical drugs or oral anti-\\nbiotics. Side effects include temporary worsening of\\nthe acne, dry skin, nosebleeds, vision disorders, and\\nelevated liver enzymes, blood fats and cholesterol.\\nThis drug must not be taken during pregnancy since\\nit causes birth defects.\\nAnti-androgens, drugs that inhibit androgen pro-\\nduction, are used to treat women who are unrespon-\\nsive to other therapies. Certain types of oral\\ncontraceptives (for example, Ortho-Tri-Cyclen) and\\nfemale sex hormones (estrogens) reduce hormone\\nactivity in the ovaries. Other drugs, for example, spir-\\nonolactone and corticosteroids, reduce hormone\\nactivity in the adrenal glands. Improvement may\\ntake up to four months.\\nOral corticosteroids, or anti-inflammatory drugs,\\nare the treatment of choice for an extremely severe,\\nbut rare type of destructive inflammatory acne called\\nacne fulminans, found mostly in adolescent males.\\nAcne conglobata, a more common form of severe\\ninflammation, is characterized by numerous, deep,\\ninflammatory nodules that heal with scarring. It is\\ntreated with oral isotretinoin and corticosteroids.\\nOther treatments\\nSeveral surgical or medical treatments are avail-\\nable to alleviate acne or the resulting scars:\\n/C15Comedone extraction. The comedo is removed from\\nthe pore with a special tool.\\nGALE ENCYCLOPEDIA OF MEDICINE 27\\nAcne'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 57, 'page_label': '28'}, page_content='/C15Chemical peels. Glycolic acid is applied to peel off\\nthe top layer of skin to reduce scarring.\\n/C15Dermabrasion. The affected skin is frozen with a\\nchemical spray, and removed by brushing or planing.\\n/C15Punch grafting. Deepscars are excised and the area\\nrepaired with small skin grafts.\\n/C15Intralesional injection. Corticosteroids are injected\\ndirectly into inflamed pimples.\\n/C15Collagen injection. Shallow scars are elevated by\\ncollagen (protein) injections.\\nAlternative treatment\\nAlternative treatments for acne focus on proper\\ncleansing to keep the skin oil-free; eating a well-\\nbalanced diet high in fiber, zinc, and raw foods; and\\navoiding alcohol, dairy products, smoking,caffeine,\\nsugar, processed foods, and foods high in iodine,\\nsuch as salt. Supplementation with herbs such as\\nburdock root (Arctium lappa ), red clover (Trifolium\\npratense) ,a n dm i l kt h i s t l e(Silybum marianum ), and\\nwith nutrients such as essential fatty acids, vitamin B\\ncomplex, zinc, vitamin A, and chromium is also\\nrecommended. Chinese herbal remedies used for\\nacne include cnidium seed (Cnidium monnieri )a n d\\nhoneysuckle flower ( Lonicera japonica ). Wholistic\\nphysicians or nutritionists can recommend the proper\\namounts of these herbs.\\nPrognosis\\nAcne is not curable, although long-term control is\\nachieved in up to 60% of patients treated with isotre-\\ntinoin. It can be controlled by proper treatment, with\\nimprovement taking two or more months. Acne tends\\nto reappear when treatment stops, but spontaneously\\nimproves over time. Inflammatory acne may leave\\nscars that require further treatment.\\nPrevention\\nThere are no sure ways to prevent acne, but the\\nfollowing steps may be taken to minimize flare-ups:\\n/C15gentle washing of affected areas once or twice every\\nday\\n/C15avoid abrasive cleansers\\n/C15use noncomedogenic makeup and moisturizers\\n/C15shampoo often and wear hair off face\\n/C15eat a well-balanced diet, avoiding foods that trigger\\nflare-ups\\n/C15unless told otherwise, give dry pimples a limited\\namount of sun exposure\\n/C15do not pick or squeeze blemishes\\n/C15reduce stress\\nResources\\nPERIODICALS\\nBillings, Laura. ‘‘Getting Clear.’’Health Magazine (April\\n1997): 48-52.\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham\\nRoad, P.O. Box 4014, Schaumburg, IL 60168-4014.\\n(847) 330-0230. Fax: (847) 330-0050. .\\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 vestibu-\\nlocochlear nerve (eighth cranial nerve).\\nDescription\\nThe vestibulocochlear nerve extends from the\\ninner ear to the brain and is made up of a vestibular\\nbranch, often called the vestibular nerve, and a\\ncochlear branch, called the cochlear nerve. The vestib-\\nular and cochlear nerves lie next to one another. They\\nalso run along side other cranial nerves. People possess\\ntwo of each type of vestibulocochlear nerve, one that\\nextends from the left ear and one that extends from the\\nright ear.\\nThe vestibular nerve transmits information con-\\ncerning balance from the inner ear to the brain and the\\ncochlear nerve transmits information about hearing.\\nThe vestibular nerve, like many nerves, is surrounded\\nby a cover called a myelin sheath. A tumor, called\\na schwannoma, can sometimes develop from the cells\\nof the myelin sheath. A tumor is an abnormal growth\\nof tissue that results from the uncontrolled growth of\\ncells. Acoustic neuromas are often called vestibular\\nschwannomas because they are tumors that arise\\n28 GALE ENCYCLOPEDIA OF MEDICINE\\nAcoustic neuroma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 58, 'page_label': '29'}, page_content='from the myelin sheath that surrounds the vestibular\\nnerve. Acoustic neuromas are considered benign\\n(non-cancerous) tumors since they do not spread\\nto other parts of the body. They can occur any-\\nwhere along the vestibular nerve but are most likely\\nto occur where the vestibulocochlear nerve passes\\nthrough the tiny bony canal that connects the brain\\nand the inner ear.\\nAn acoustic neuroma can arise from the left\\nvestibular nerve or the right vestibular nerve. A uni-\\nlateral tumor is a tumor arising from one nerve and\\na bilateral tumor arises from both vestibular nerves.\\nUnilateral acoustic neuromas usually occur sponta-\\nneously (by chance). Bilateral acoustic neuromas\\noccur as part of a hereditary condition called\\nNeurofibromatosis Type 2 (NF2). A person with\\nNF2 has inherited a pred isposition for develop-\\ning acoustic neuromas and other tumors of the\\nnerve cells.\\nAcoustic neuromas usu ally grow slowly and\\ncan take years to develop. Some acoustic neuromas\\nremain so small that they do not cause any symp-\\ntoms. As the acoustic neuroma grows it can inter-\\nfere with the functioning of the vestibular nerve\\nand can cause vertigo and balance difficulties. If\\nthe acoustic nerve grows large enough to press\\nagainst the cochlear nerve, then hearing loss and\\na ringing (tinnitus) in the affected ear will usually\\noccur. If untreated and the acoustic neuroma con-\\ntinues to grow it can press against other nerves in\\nthe region and cause other symptoms. This tumor\\ncan be life threatening if it becomes large enough\\nto press against and interfere with the functioning\\nof the brain.\\nCauses and symptoms\\nCauses\\nAn acoustic neuroma is caused by a change or\\nabsence of both of the NF2 tumor suppressor genes\\nin a nerve cell. Every person possesses a pair of NF2\\ngenes in every cell of their body including their nerve\\ncells. One NF2 gene is inherited from the egg cell of the\\nmother and one NF2 gene is inherited from the sperm\\ncell of the father. The NF2 gene is responsible for\\nhelping to prevent the formation of tumors in the\\nnerve cells. In particular the NF2 gene helps to prevent\\nacoustic neuromas.\\nOnly one unchanged and functioning NF2 gene\\nis necessary to prevent the formation of an acoustic\\nneuroma. If both NF2 genes become changed or\\nmissing in one of the myelin sheath cells of the\\nvestibular nerve then an acoustic neuroma will usually\\ndevelop. Most unilateral acoustic neuromas result\\nwhen the NF2 genes become spontaneously changed\\nor missing. Someone with a unilateral acoustic\\nKEY TERMS\\nBenign tumor— A localized overgrowth of cells\\nthat does 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\\nthat uses a computer to compile and analyze the\\nimages produced by x rays projected at a particular\\npart of the body.\\nCranial nerves— The set of twelve nerves found on\\neach side of the head and neck that control the\\nsensory 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\\nof a compound called DNA (deoxyribonucleic\\nacid) and containing the instructions for the pro-\\nduction of a particular protein. Each gene is found\\non a specific 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\\nand cataracts.\\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\\nand balance from the ear to the brain.\\nGALE ENCYCLOPEDIA OF MEDICINE 29\\nAcoustic neuroma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 59, 'page_label': '30'}, page_content='neuroma that has developed spontaneously is not at\\nincreased risk for having children with an acoustic\\nneuroma. Some unilateral acoustic neuromas result\\nfrom the hereditary condition NF2. It is also possible\\nthat some unilateral acoustic neuromas may be caused\\nby changes in other genes responsible for preventing\\nthe formation of tumors.\\nBilateral acoustic neuromas result when some-\\none is affected with the hereditary condition NF2.\\nAp e r s o nw i t hN F 2i st y p i c a l l yb o r nw i t ho n e\\nunchanged and one changed or missing NF2 gene\\nin every cell of their body. Sometimes they inherit\\nthis change from their mother or father. Sometimes\\nthe change occurs spontaneously when the egg and\\nsperm come together to form the first cell of the\\nbaby. The children of a person with NF2 have a\\n50% chance of inheriting the changed or missing\\nNF2 gene.\\nA person with NF2 will develop an acoustic neu-\\nroma if the remaining unchanged NF2 gene becomes\\nspontaneously changed or missing in one of the myelin\\nsheath cells of their vestibular nerve. People with NF2\\noften develop acoustic neuromas at a younger age.\\nThe mean age of onset of acoustic neuroma in NF2\\nis 31 years of age versus 50 years of age for sporadic\\nacoustic neuromas. Not all people with NF2, however,\\ndevelop acoustic neuromas. People with NF2 are at\\nincreased risk for developingcataracts and tumors in\\nother nerve cells.\\nMost people with a unilateral acoustic neuroma\\nare not affected with NF2. Some people with NF2,\\nhowever, only develop a tumor in one of the vestibu-\\nlocochlear nerves. Others may initially be diagnosed\\nwith a unilateral tumor but may develop a tumor in the\\nother nerve a number of years later. NF2 should be\\nconsidered in someone under the age of 40 who has a\\nunilateral acoustic neuroma. Someone with a unilat-\\neral acoustic neuroma and other family members\\ndiagnosed with NF2 probably is affected with NF2.\\nSomeone with a unilateral acoustic neuroma and\\nother symptoms of NF2 such as cataracts and other\\ntumors may also be affected with NF2. On the other\\nhand, someone over the age of 50 with a unilateral\\nacoustic neuroma, no other tumors and no family\\nhistory of NF2 is very unlikely to be affected\\nwith NF2.\\nRecent studies in Europe have suggested a possi-\\nble connection between the widespread use of mobile\\nphones and an increased risk of developing acoustic\\nneuromas. Some observers, however, question\\nwhether mobile phones have been in use long enough\\nto be an identifiable risk factor.\\nSymptoms\\nSmall acoustic neuromas usually only interfere\\nwith the functioning of the vestibulocochlear nerve.\\nThe most common first symptom of an acoustic neu-\\nroma ishearing loss, which is often accompanied by a\\nringing sound (tinnitis). People with acoustic neuro-\\nmas sometimes report difficulties in using the phone\\nand difficulties in perceiving the tone of a musical\\ninstrument or sound even when their hearing appears\\nto be otherwise normal. In most cases the hearing loss\\nis initially subtle and worsens gradually over time\\nuntil deafness occurs in the affected ear. In approxi-\\nmately 10% of cases the hearing loss is sudden and\\nsevere.\\nAcoustic neuromas can also affect the function-\\ning of the vestibular branch of the vestibulocochlear\\nnerve and van cause vertigo and dysequilibrium.\\nTwenty percent of small tumors are associated with\\nperiodic vertigo, which is characterized bydizziness\\nor a whirling sensation. Larger acoustic neuromas are\\nless likely to cause vertigo but more likely to cause\\ndysequilibrium. Dysequilibrium, which is character-\\nized by minor clumsiness and a general feeling of\\ninstability, occurs in nearly 50% of people with an\\nacoustic neuroma.\\nAs the tumor grows larger it can press on the\\nsurrounding cranial nerves. Compression of the fifth\\ncranial nerve can result in facialpain and or numb-\\nness. Compression of the seventh cranial nerve can\\ncause spasms, weakness or paralysis of the facial\\nmuscles. Double vision is a rare symptom but can\\nresult when the 6th cranial nerve is affected.\\nSwallowing and/or speaking difficulties can occur if\\nthe tumor presses against the 9th, 10th, or 12th cra-\\nnial nerves.\\nIf left untreated, the tumor can become large\\nenough to press against and affect the functioning\\nof the brain stem. The brain stem is the stalk like\\nportion of the brain that joins the spinal cord to the\\ncerebrum, the thinking and reasoning part of the\\nbrain. Different parts of the brainstem have different\\nfunctions such as the control of breathing and muscle\\ncoordination. Large tumors that impact the brain\\nstem can result in headaches, walking difficulties\\n(gait ataxia) and involuntary shaking movements of\\nthe muscles (tremors). In rare cases when an acoustic\\nneuroma remains undiagnosed and untreated it can\\ncause nausea, vomiting, lethargy and eventually\\ncoma, respiratory difficulties and death. In the vast\\nmajority of cases, however, the tumor is discovered\\nand treated long before it is large enough to cause\\nsuch serious manifestations.\\n30 GALE ENCYCLOPEDIA OF MEDICINE\\nAcoustic neuroma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 60, 'page_label': '31'}, page_content='Diagnosis\\nAnyone with symptoms of hearing loss should\\nundergo hearing evaluations. Pure tone and speech\\naudiometry are two screening tests that are often\\nused to evaluate hearing. Pure tone audiometry\\ntests to see how well someone can hear tones of\\ndifferent volume and pitch and speech audiometry\\ntests to see how well someone can hear and recog-\\nnize speech. An acoustic neuroma is suspected in\\nsomeone with unilateral hearing loss or hearing loss\\nthat is less severe in one ear than the other ear\\n(asymmetrical).\\nSometimes an auditory brainstem response (ABR,\\nBAER) test is performed to help establish whether\\nsomeone is likely to have an acoustic neuroma.\\nDuring the ABR examination, a harmless electrical\\nimpulse is passed from the inner ear to the brainstem.\\nAn acoustic neuroma can interfere with the passage of\\nthis electrical impulse and this interference can, some-\\ntimes be identified through the ABR evaluation.\\nA normal ABR examination does not rule out the\\npossibility of an acoustic neuroma. An abnormal\\nABR examination increases the likelihood that an\\nacoustic neuroma is present but other tests are neces-\\nsary to confirm the presence 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\\nis able to detect nearly 100% of acoustic neuromas.\\nComputerized tomography (CT scan, CAT scan)is\\nunable to identify smaller tumors; but it can be used\\nwhen an acoustic neuroma is suspected and an MRI\\nevaluation cannot be performed.\\nOnce an acoustic neuroma is diagnosed, an eva-\\nluation by genetic specialists such as a geneticist and\\ngenetic counselor may be recommended. The purpose\\nof this evaluation is to obtain a detailed family history\\nand check for signs of NF2. If NF2 is strongly sus-\\npected then DNA testing may be recommended. DNA\\ntesting involves checking the blood cells obtained from\\na routine blood draw for the common gene changes\\nassociated 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\\nthe different options prior to making a decision\\nabout treatment. The patient’s, physical health, age,\\nsymptoms, tumor size, and tumor location should be\\nconsidered.\\nMicrosurgery\\nThe surgical removal of the tumor or tumors is the\\nmost common treatment for acoustic neuroma. In\\nmost cases the entire tumor is removed during the\\nsurgery. If the tumor is large and causing significant\\nsymptoms, yet there is a need to preserve hearing\\nin that ear, then only part of the tumor may be\\nremoved. During the procedure the tumor is removed\\nunder microscopic guidance and general anesthetic.\\nMonitoring of the neighboring cranial nerves is done\\nduring the procedure so that damage to these nerves\\ncan be prevented. If preservation of hearing is a possi-\\nbility, then monitoring of hearing will also take place\\nduring the surgery.\\nMost people stay in the hospital four to seven days\\nfollowing the surgery. Total recovery usually takes\\nfour to six weeks. Most people experiencefatigue and\\nhead discomfort following the surgery. Problems with\\nbalance and head and neck stiffness are also common.\\nThe mortality rate of this type of surgery is less than\\n2% at most major centers. Approximately 20% of\\npatients experience some degree of post-surgical com-\\nplications. In most cases these complications can be\\nmanaged successfully and do not result in long term\\nmedical problems. Surgery brings with it a risk of\\nstroke, damage to the brain stem, infection, leakage\\nof spinal fluid and damage to the cranial nerves.\\nHearing loss and/or tinnitis often result from the sur-\\ngery. A follow-up MRI is recommended one to five\\nyears following the surgery because of possible\\nregrowth of the tumor.\\nStereotactic radiation therapy\\nDuring stereotacticradiation therapy, also called\\nradiosurgery or radiotherapy, many small beams of\\nradiation are aimed directly at the acoustic neuroma.\\nThe radiation is administered in a single large dose,\\nunder local anesthetic and is performed on an out-\\npatient basis. This results in a high dose of radiation\\nto the tumor but little radiation exposure to the\\nsurrounding area. This treatment approach is limited\\nto small or medium tumors. The goal of the surgery is\\nto cause tumor shrinkage or at least limit the growth\\nof the tumor. The long-term efficacy and risks of this\\ntreatment approach are not known; however, as of\\nthe early 2000s, more and more patients diagnosed\\nwith acoustic neuromas are choosing this form of\\ntherapy. Periodic MRI monitoring throughout the\\nlife of the patient is therefore recommended.\\nRadiation therapy can cause hearing loss which\\ncan sometimes occurs even years later. Radiation ther-\\napy can also cause damage to neighboring cranial\\nGALE ENCYCLOPEDIA OF MEDICINE 31\\nAcoustic neuroma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 61, 'page_label': '32'}, page_content='nerves, which can result in symptoms such asnumb-\\nness, pain or paralysis of the facial muscles. In many\\ncases these symptoms are temporary. Radiation treat-\\nment can also induce the formation of other benign or\\nmalignant schwannomas. This type of treatment may\\ntherefore be contraindicated in the treatment of acous-\\ntic neuromas in those with NF2 who are predisposed\\nto developing schwannomas and other tumors.\\nObservation\\nAcoustic neuromas are usually slow growing and\\nin some cases they will stop growing and even become\\nsmaller or disappear entirely. It may therefore be\\nappropriate in some cases to hold off on treatment\\nand to periodically monitor the tumor through MRI\\nevaluations. Long-term observation may be appropri-\\nate for example in an elderly person with a small\\nacoustic neuroma and few symptoms. Periodic obser-\\nvation may also be indicated for someone with a small\\nand asymptomatic acoustic neuroma that was\\ndetected through an evaluation for another medical\\nproblem. Observation may also be suggested for some-\\none with an acoustic neuroma in the only hearing ear\\nor in the ear that has better hearing. The danger of an\\nobservational approach is that as the tumor grows\\nlarger it can become more difficult to treat.\\nPrognosis\\nThe prognosis for someone with a unilateral\\nacoustic neuroma is usually quite good provided the\\ntumor is diagnosed early and appropriate treatment is\\ninstituted. Long term-hearing loss and tinnitis in the\\naffected ear are common, even if appropriate treat-\\nment is provided. Many patients also experience\\nfacial weakness, balance problems, and headaches.\\nRegrowth of the tumor is also a possibility following\\nsurgery or radiation therapy and repeat treatment may\\nbe necessary. The prognosis can be poorer for those\\nwith NF2 who have an increased risk of bilateral\\nacoustic neuromas and other tumors.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Acoustic Neuroma.’’ Section 7, Chapter 85 InThe\\nMerck Manual of Diagnosis and Therapy. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nPERIODICALS\\nKondziolka, D., L. D. Lundsford, and J. C. Flickinger.\\n‘‘Acoustic Neuroma Radiosurgery. Origins,\\nContemporary Use and Future Expectations.’’\\nNeurochirurgie 50 (June 2004): 427–435.\\nKundi, M., K. Mild, L. Hardell, and M. O. Mattsson.\\n‘‘Mobile Telephones and Cancer—A Review of\\nEpidemiological Evidence.’’Journal of Toxicology and\\nEnvironmental Health, Part B, Critical Reviews 7\\n(September-October 2004): 351–384.\\nRyzenman, J. M., M. L. Pensak, and J. M. Tew, Jr. ‘‘Patient\\nPerception of Comorbid Conditions After Acoustic\\nNeuroma Management: Survey Results from the\\nAcoustic Neuroma Association.’’Laryngoscope 114\\n(May 2004): 814–820.\\nORGANIZATIONS\\nAcoustic Neuroma Association. 600 Peachtree Pkwy, Suite\\n108, Cumming, GA 30041-6899. (770) 205-8211. Fax:\\n(770) 205-0239. ANAusa@aol.com. [cited June 28,\\n2001]. .\\nAcoustic Neuroma Association of Canada Box 369,\\nEdmonton, AB T5J 2J6. 1-800-561-ANAC(2622).\\n(780)428-3384. anac@compusmart.ab.ca. [cited June\\n28, 2001]. .\\nSeattle Acoustic Neuroma Group. Emcityland@aol.com.\\n[cited June 28, 2001]. .\\nOTHER\\nNational Institute of Health Consensus Statement Online.\\nAcoustic Neuroma 9, no. 4 (December 11-13, 1991).\\n[cited June 28, 2001]. .\\nUniversity of California at San Francisco (UCSF).\\nInformation on Acoustic Neuromas. March 18, 1998.\\n[cited June 28, 2001]. .\\nLisa Andres, MS, CGC\\nRebecca J. Frey, PhD\\nAcquired hypogammaglobulinemia see\\nCommon variable immunodeficiency\\nAcquired immunodeficiency syndrome see\\nAIDS\\nAcrocyanosis\\nDefinition\\nAcrocyanosis is a decrease in the amount of\\noxygen delivered to the extremities. The hands and\\nfeet turn blue because of the lack of oxygen.\\nDecreased blood supply to the affected areas is caused\\nby constriction or spasm of small blood vessels.\\n32 GALE ENCYCLOPEDIA OF MEDICINE\\nAcrocyanosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 62, 'page_label': '33'}, page_content='Description\\nAcrocyanosis is a painless disorder caused by con-\\nstriction or narrowing of small blood vessels in the\\nskin of affected patients. The spasm of the blood\\nvessels decreases the amount of blood that passes\\nthrough them, resulting in less blood being delivered\\nto the hands and feet. The hands may be the main area\\naffected. The affected areas turn blue and become cold\\nand sweaty. Localized swelling may also occur.\\nEmotion and cold temperatures can worsen the symp-\\ntoms, while warmth can decrease symptoms. The dis-\\nease is seen mainly in women and the effect of the\\ndisorder is mainly cosmetic. People with the disease\\ntend to be uncomfortable, with sweaty, cold, bluish\\ncolored hands and feet.\\nCauses and symptoms\\nThe sympathetic nerves cause constriction or\\nspasms in the peripheral blood vessels that supply\\nblood to the extremities. The spasms are a contraction\\nof the muscles in the walls of the blood vessels. The\\ncontraction decreases the internal diameter of the\\nblood vessels, thereby decreasing the amount of\\nblood flow through the affected area. The spasms\\noccur on a persistent basis, resulting in long term\\nreduction of blood supply to the hands and feet.\\nSufficient blood still passes through the blood vessels\\nso that the tissue in the affected areas does not starve\\nfor oxygen or die. Mainly, blood vessels near the sur-\\nface of the skin are affected.\\nDiagnosis\\nDiagnosis is made by observation of the main\\nclinical symptoms, including persistently blue and\\nsweaty hands and/or feet and a lack ofpain. Cooling\\nthe hands increases the blueness, while warming the\\nhands decreases the blue color. The acrocyanosis\\npatient’s pulse is normal, which rules out obstructive\\ndiseases. Raynaud’s diseasediffers from acrocyanosis\\nin that it causes white and red skin coloration phases,\\nnot just bluish discoloration.\\nTreatment\\nAcrocyanosis usually isn’t treated. Drugs that\\nblock the uptake of calcium (calcium channel blockers)\\nand alpha-one antagonists reduce the symptoms in\\nmost cases. Drugs that dilate blood vessels are\\nonly effective some of the time. Sweating from the\\naffected areas can be profuse and require treatment.\\nSurgery to cut the sympathetic nerves is performed\\nrarely.\\nPrognosis\\nAcrocyanosis is a benign and persistent disease.\\nThe main concern of patients is cosmetic. Left\\nuntreated, the disease does not worsen.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nAcromegaly and gigantism\\nDefinition\\nAcromegaly is a disorder in which the abnor-\\nmal release of a particular chemical from the pitui-\\nt a r yg l a n di nt h eb r a i nc a u s e si n c r e a s e dg r o w t hi n\\nbone and soft tissue, as well as a variety of other\\ndisturbances throughout the body. This chemical\\nreleased from the pituitary gland is called growth\\nhormone (GH). The body’s ability to process and\\nuse nutrients like fats and sugars is also altered. In\\nchildren whose bony growth plates have not closed,\\nthe chemical changes of acromegaly result in\\nexceptional growth of long bones. This variant is\\ncalled gigantism, with the additional bone growth\\ncausing unusual height. When the abnormality occurs\\nafter bone growth stops, the disorder is called\\nacromegaly.\\nDescription\\nAcromegaly is a relatively rare disorder, occurring\\nin approximately 50 out of every one million people\\n(50/1,000,000). Both men and women are affected.\\nBecause the symptoms of acromegaly occur so gradu-\\nally, diagnosis is often delayed. The majority of patients\\nare not identified until they are middle aged.\\nKEY TERMS\\nSympathetic nerve— A nerve of the autonomic ner-\\nvous system that regulates involuntary and auto-\\nmatic reactions, especially to stress.\\nGALE ENCYCLOPEDIA OF MEDICINE 33\\nAcromegaly and gigantism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 63, 'page_label': '34'}, page_content='Causes 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\\nto the functioning of other organs or body systems.\\nThe pituitary hormones travel throughout the body\\nand are involved in a large number of activities,\\nincluding the regulation of growth and reproductive\\nfunctions. The cause of acromegaly can be traced to\\nthe pituitary’s production of GH.\\nUnder normal conditions, the pituitary receives\\ninput from another brain structure, the hypothalamus,\\nlocated at the base of the brain. This input from the\\nhypothalamus regulates the pituitary’s release of hor-\\nmones. For example, the hypothalamus produces\\ngrowth hormone-releasing hormone (GHRH), which\\ndirects the pituitary to release GH. Input from the\\nhypothalamus should also direct the pituitary to stop\\nreleasing hormones.\\nIn acromegaly, the pituitary continues to release\\nGH and ignores signals from the hypothalamus. In the\\nliver, GH causes production of a hormone called insu-\\nlin-like growth factor 1 (IGF-1), which is responsible\\nfor growth throughout the body. When the pituitary\\nrefuses to stop producing GH, the levels of IGF-1 also\\nreach abnormal peaks. Bones, soft tissue, and organs\\nthroughout the body begin to enlarge, and the body\\nchanges its ability to process and use nutrients like\\nsugars 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\\nand sinuses, the voice becomes deeper and sounds\\nmore hollow, and patients may develop loudsnoring.\\nVarious hormonal changes cause symptoms such as:\\n/C15heavy sweating\\n/C15oily skin\\n/C15increased coarse body hair\\n/C15improper processing of sugars in the diet (and some-\\ntimes actual diabetes)\\nKEY TERMS\\nAdenoma— A type of noncancerous (benign) tumor\\nthat often involves the overgrowth of certain cells\\nfound 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 the\\nbody that travels to another part of the body in order\\nto 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.\\nEnlarged feet is one deformity caused by acromegaly.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\n34 GALE ENCYCLOPEDIA OF MEDICINE\\nAcromegaly and gigantism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 64, 'page_label': '35'}, page_content='/C15high blood pressure\\n/C15increased calcium in the urine (sometimes leading to\\nkidney stones)\\n/C15increased risk ofgallstones;a n d\\n/C15swelling of the thyroid gland\\nPeople with acromegaly have more skin tags, or\\noutgrowths of tissue, than normal. This increase in\\nskin tags is also associated with the development of\\ngrowths, called polyps, within the large intestine that\\nmay eventually become cancerous. Patients with acro-\\nmegaly often suffer from headaches and arthritis. The\\nvarious swellings and enlargements throughout the\\nbody may press on nerves, causing sensations of local\\ntingling or burning, and sometimes result in muscle\\nweakness.\\nThe most common cause of this disorder (in 90%\\nof patients) is the development of a noncancerous\\ntumor within the pituitary, called a pituitary adenoma.\\nThese tumors are the source of the abnormal release of\\nGH. As these tumors grow, they may press on nearby\\nstructures within the brain, causing headaches and\\nchanges in vision. As the adenoma grows, it may dis-\\nrupt other pituitary tissue, interfering with the release\\nof other hormones. These disruptions may be respon-\\nsible for changes in the menstrual cycle of women,\\ndecreases in the sexual drive in men and women, and\\nthe abnormal production of breast milk in women.\\nIn rare cases, acromegaly is caused by the abnormal\\nproduction of GHRH, which leads to the increased\\nproduction of GH. Certain tumors in the pancreas,\\nlungs, adrenal glands, thyroid, and intestine produce\\nGHRH, which in turn triggers production of an\\nabnormal quantity of GH.\\nDiagnosis\\nBecause acromegaly produces slow changes over\\ntime, diagnosis is often significantly delayed. In fact,\\nthe characteristic coarsening of the facial features is\\noften not recognized by family members, friends, or\\nlong-time family physicians. Often, the diagnosis is\\nsuspected by a new physician who sees the patient for\\nthe first time and is struck by the patient’s character-\\nistic facial appearance. Comparing old photographs\\nfrom a number of different time periods will often\\nincrease suspicion of the disease.\\nBecause the quantity of GH produced varies\\nwidely under normal conditions, demonstrating high\\nlevels of GH in the blood is not sufficient to merit a\\ndiagnosis of acromegaly. Instead, laboratory tests mea-\\nsuring an increase of IGF-1 (3-10 times above the\\nnormal level) are useful. These results, however, must\\nbe carefully interpreted because normal laboratory\\nvalues for IGF-1 vary when the patient is pregnant,\\nundergoing puberty, elderly, or severely malnourished.\\nNormal patients will show a decrease in GH produc-\\ntion when given a large dose of sugar (glucose). Patients\\nwith acromegaly will not show this decrease, and will\\noften show an increase in GH production. Magnetic\\nresonance imaging (MRI) is useful for viewing the\\npituitary, and for identifying and locating an adenoma.\\nWhen no adenoma can be located, the search for a\\nGHRH-producing tumor in another location begins.\\nTreatment\\nThe first step in treatment of acromegaly is\\nremoval of all or part of the pituitary adenoma.\\nRemoval requires surgery, usually performed by\\nentering the skull through the nose. While this surgery\\ncan cause rapid improvement of many acromegaly\\nsymptoms, most patients will also require additional\\ntreatment with medication. Bromocriptine (Parlodel)\\nis a medication that can be taken by mouth, while\\noctreotide (Sandostatin) must be injected every eight\\nhours. Both of these medications are helpful in redu-\\ncing GH production, but must often be taken for life\\nand produce their own unique side effects. Some\\npatients who cannot undergo surgery are treated\\nwith radiation therapy to the pituitary in an attempt\\nto shrink the adenoma. Radiating the pituitary may\\ntake up to 10 years, however, and may also injure/\\ndestroy other normal parts of the pituitary.\\nPrognosis\\nWithout treatment, patients with acromegaly will\\nmost likely die early because of the disease’s effects on\\nA comparison of the right hand of a person afflicted\\nwith acromegaly (left) and the hand of a normal sized person.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 35\\nAcromegaly and gigantism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 65, 'page_label': '36'}, page_content='the heart, lungs, brain, or due to the development of\\ncancer in the large intestine. With treatment, however,\\na patient with acromegaly may be able to live a normal\\nlifespan.\\nResources\\nBOOKS\\nBiller, Beverly M. K., and Gilbert H. Daniels. ‘‘Growth\\nHormone Excess: Acromegaly and Gigantism.’’ In\\nHarrison’s Principles of Internal Medicine , edited by\\nAnthony S. Fauci, et al. New York: McGraw-Hill,\\n1997.\\nORGANIZATIONS\\nPituitary Tumor Network Association. 16350 Ventura\\nBlvd., #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\\noften occurs in the face and neck region and is char-\\nacterized by the presence of a slowly enlarging, hard,\\nred lump.\\nDescription\\nActinomycosis is a relatively rare infection\\noccurring in one out of 300,000(1/300,000) people\\nper year. It is characterized by the presence of a\\nlump or mass that often forms, draining sinus tracts\\nto the skin surface. Fiftypercent of actinomycosis\\ncases are of the head and neck region (also called\\n‘‘lumpy jaw’’ and ‘‘cervico facial actinomycosis’’),\\n15% are in the chest, 20% are in the abdomen, and\\nthe rest are in the pelvis, heart, and brain. Men are\\nthree times more likely to develop actinomycosis than\\nwomen.\\nCauses and symptoms\\nActinomycosis is usually caused by the bacterium\\nActinomyces israelii . This bacterium is normally pre-\\nsent in the mouth but can cause disease if it enters\\ntissues following an injury.Actinomyces israelii is an\\nanaerobic bacterium which means it dislikes oxygen\\nbut grows very well in deep tissues where oxygen levels\\nare low. Tooth extraction, tooth disease, root canal\\ntreatment, jaw surgery, or poor dental hygiene can\\nallow Actinomyces israelii to cause an infection in the\\nhead and neck region.\\nThe main symptom of cervicofacial actinomycosis\\nis the presence of a hard lump on the face or neck. The\\nlump may or may not be red.Fever occurs in some\\ncases.\\nDiagnosis\\nCervicofacial actinomycosis can be diagnosed by\\na family doctor or dentist and the patient may be\\nreferred to an oral surgeon or infectious disease\\nspecialist. The diagnosis of actinomycosis is based\\nupon several things. The presence of a red lump with\\ndraining sinuses on the head or neck is strongly\\nsuggestive of cervicofacial actinomycosis. A recent\\nhistory of tooth extraction or signs oftooth decayor\\npoor dental hygiene aid in the diagnosis. Microscopic\\nexamination of the fluid draining from the sinuses\\nshows the characteristic ‘‘sulfur Granules’’ (small\\nyellow colored material in the fluid) produced by\\nActinomyces israelii . A biopsy may be performed to\\nremove a sample of the infected tissue. This procedure\\ncan be performed underlocal anesthesiain the doctor’s\\noffice. Occasionally the bacteria can be cultured\\nfrom the sinus tract fluid or from samples of the\\ninfected 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\\nKEY TERMS\\nBiopsy— The process that removes a sample of tis-\\nsue for microscopic examination to aid in the diag-\\nnosis of a disease.\\nSinus tract— A narrow, elongated channel in the\\nbody that allows the escape of fluid.\\n36 GALE ENCYCLOPEDIA OF MEDICINE\\nActinomycosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 66, 'page_label': '37'}, page_content='of the lungs or abdomen can resembletuberculosis\\nor cancer. Diagnostic x-ray results, the presence of\\ndraining sinus tracts, and microscopic analysis\\nand culturing of infected tissue assist in the diagnosis.\\nTreatment\\nActinomycosis is difficult to treat because of its\\ndense tissue location. Surgery is often required to\\ndrain the lesion and/or to remove the site of infec-\\ntion. To kill the bacteria, standard therapy has\\nincluded large doses of penicillin given through a\\nvein daily for two to six weeks followed by six to\\ntwelve months of penicillin taken by mouth.\\nTetracycline, clindamycin, or erythromycin may be\\nused instead of penicillin. The antibiotic therapy\\nmust be completed to ensure that the infection\\ndoes not return. However, a report in 2004 on\\nseveral cases of actinomyc osis said that therapy\\ndepends on the individual case and that many\\npatients today will be diagnosed in earlier stages\\nof the disease. Sometimes, shorter courses of anti-\\nbiotic treatment are effective, with close diagnostic\\nx-ray monitoring. Hyperbaric oxygen (oxygen\\nunder high pressure) therapy in combination with\\nthe antibiotic therapy has been successful.\\nPrognosis\\nComplete recovery is achieved following treat-\\nment. If left untreated, the infection may cause loca-\\nlized bone destruction.\\nPrevention\\nThe best prevention is to maintain good dental\\nhygiene.\\nResources\\nPERIODICALS\\nSudhaker, Selvin S., and John J. Rose. ‘‘Short-term\\nTreatment of Actinomycosis: two Cases and a\\nReview.’’ Clinical Infectious Diseases (February 1,\\n2004): 444–448.\\nBelinda Rowland, PhD\\nTeresa G. Odle\\nActivated charcoal see Charcoal, activated\\nActivated partial thromboplastin time see\\nPartial thromboplastin time\\nAcupressure\\nDefinition\\nAcupressure is a form of touch therapy that\\nutilizes the principles of acupuncture and Chinese\\nmedicine. In acupressure, the same points on the\\nbody are used as in acupuncture, but are stimulated\\nwith finger pressure instead of with the insertion of\\nneedles. Acupressure is used to relieve a variety of\\nsymptoms andpain.\\nPurpose\\nAcupressure massage performed by a therapist\\ncan be very effective both as prevention and as a\\ntreatment for many health conditions, including\\nheadaches, general aches and pains, colds and flu,\\narthritis, allergies, asthma, nervous tension, men-\\nstrual cramps, sinus problems,sprains, tennis elbow,\\nand toothaches, among others. Unlike acupuncture\\nwhich requires a visit to a professional, acupressure\\ncan be performed by a layperson. Acupressure tech-\\nniques are fairly easy to learn, and have been used to\\nprovide quick, cost-free, and effective relief from\\nmany symptoms. Acupressure points can also be\\nstimulated to increase energy and feelings of well-\\nbeing, reduce stress, stimulate the immune system,\\nand alleviatesexual 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.\\nChinese medicine has developed acupuncture, acupres-\\nsure, herbal remedies, diet,exercise, lifestyle changes,\\nand other remedies as part of its healing methods.\\nNearly all of the forms of Oriental medicine that are\\nused in the West today, including acupuncture, acu-\\npressure, shiatsu, and Chinese herbal medicine, have\\ntheir roots in Chinese medicine. One legend has it that\\nacupuncture and acupressure evolved as early Chinese\\nhealers studied the puncturewounds of Chinese war-\\nriors, noting that certain points on the body created\\ninteresting results when stimulated. The oldest known\\ntext specifically on acupuncture points, theSystematic\\nClassic of Acupuncture , dates back to 282\\nA.D.\\nAcupressure is the non-invasive form of acupuncture,\\nas Chinese physicians determined that stimulating\\npoints on the body with massage and pressure could\\nbe effective for treating certain problems.\\nGALE ENCYCLOPEDIA OF MEDICINE 37\\nAcupressure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 67, 'page_label': '38'}, page_content='Outside of Asian-American communities, Chinese\\nmedicine remained virtually unknown in the United\\nStates until the 1970s, when Richard Nixon became\\nthe first U.S. president to visit China. On Nixon’s trip,\\njournalists were amazed to observe major operations\\nbeing performed on patients without the use of anes-\\nthetics. Instead, wide-awake patients were being oper-\\nated on, with only acupuncture needles inserted into\\nthem to control pain. At that time, a famous columnist\\nfor the New York Times , James Reston, had to\\nundergo surgery and elected to use acupuncture for\\nanesthesia. Later, he wrote some convincing stories\\non its effectiveness. Despite being neglected by\\nmainstream medicine and the American Medical\\nAssociation (AMA), acupuncture and Chinese medi-\\ncine became a central to alternative medicine practi-\\ntioners in the United States. Today, there are millions\\nof patients who attest to its effectiveness, and nearly\\n9,000 practitioners in all 50 states.\\nAcupressure is practiced as a treatment by Chinese\\nmedicine practitioners and acupuncturists, as well as\\nby massage therapists. Most massage schools in\\nAmerican include acupressure techniques as part of\\ntheir bodywork programs. Shiatsu massage is very\\nclosely related to acupressure, working with the same\\npoints on the body and the same general principles,\\nalthough it was developed over centuries in Japan\\nrather than in China.Reflexology is a form of body-\\nwork based on acupressure concepts. Jin Shin Do is a\\nbodywork technique with an increasing number of\\npractitioners in America that combines acupressure\\nand shiatsu principles withqigong, Reichian theory,\\nand meditation.\\nAcupressure and Chinese medicine\\nChinese medicine views the body as a small part\\nof the universe, subject to laws and principles of\\nharmony and balance. Chinese medicine does not\\nmake as sharp a destinction as Western medicine\\ndoes between mind and body. The Chinese system\\nbelieves that emotions and mental states are every\\nbit as influential on disease as purely physical\\nmechanisms, and considers factors like work, envi-\\nronment, and relationships as fundamental to a\\npatient’s health. Chinese medicine also uses very dif-\\nferent symbols and ideas to discuss the body and\\nTherapist working acupressure points on a woman’s shoulder.(Photo Researchers, Inc. Reproduced by permission.)\\n38 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupressure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 68, 'page_label': '39'}, page_content='health. While Western medicine typically describes\\nhealth as mainly physical processes composed of che-\\nmical equations and reactions, the Chinese use ideas\\nlike yin and yang, chi, and the organ system to\\ndescribe health and the body.\\nEverything in the universe has properties of\\nyin and yang. Yin is associated with cold, female,\\npassive, downward, inward, dark, wet. Yang can be\\ndescribed as hot, male, active, upward, outward, light,\\ndry, and so on. Nothing is either completely yin or\\nyang. These two principles always interact and affect\\neach other, although the body and its organs can\\nbecome imbalanced by having either too much or too\\nlittle of either.\\nChi (pronounced chee, also spelled qi or ki in\\nJapanese shiatsu) is the fundamental life energy. It is\\nfound in food, air, water, and sunlight, and it travels\\nthrough the body in channels calledmeridians. There\\nare 12 major meridians in the body that transport chi,\\ncorresponding to the 12 main organs categorized by\\nChinese medicine.\\nDisease is viewed as an imbalance of the organs\\nand chi in the body. Chinese medicine has developed\\nintricate systems of how organs are related to physical\\nand mental symptoms, and it has devised correspond-\\ning treatments using the meridian and pressure point\\nnetworks that are classified and numbered. The goal\\nKEY TERMS\\nAcupoint— A pressure point stimulated in\\nacupressure.\\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\\ndescribe aspects of the natural world.\\nPress on point governing vessel 24.5, the top of the bridge of\\nthe nose, lightly for two minutes to relieve hay fever symptoms.\\nPress on lung 10, the center of the thumb pad, for one minute to\\nalleviate a sore throat. To ease heartburn, apply pressure to\\nstomach 36, four finger-widths below the kneecap outside the\\nshinbone. Use on both legs.(Illustration by Electronic Illustrators\\nGroup.)\\nGoverning vessel 24.5\\nLung 10\\nStomach 36\\nGALE ENCYCLOPEDIA OF MEDICINE 39\\nAcupressure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 69, 'page_label': '40'}, page_content='of acupressure, and acupuncture, is to stimulate and\\nunblock the circulation of chi, by activating very spe-\\ncific points, called pressure points or acupoints.\\nAcupressure seeks to stimulate the points on the chi\\nmeridians that pass close to the skin, as these are\\neasiest to unblock and manipulate with finger\\npressure.\\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\\nand emotional activity, taking the pulse usually at the\\nwrists, examining the tongue and complexion, and\\nobserving the patient’s demeanor and attitude, to get\\na complete diagnosis of which organs and meridian\\npoints are out of balance. When the imbalance is\\nlocated, the physician will recommend specific pres-\\nsure points for acupuncture or acupressure. If acupres-\\nsure is recommended, the patient might opt for a series\\nof treatments 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\\npalpate the abdomen and other parts of the body to\\ndetermine energy imbalances. Then, the therapist will\\nwork with different meridians throughout the body,\\ndepending on which organs are imbalanced in the\\nabdomen. The therapist will use different types of\\nfinger movements and pressure on different acupoints,\\ndepending on whether the chi needs to be increased\\nor dispersed at different points. The therapist observes\\nand guides the energy flow through the patient’s body\\nthroughout the session. Sometimes, special herbs\\n(Artemesia vulgaris or moxa) may be placed on a\\npoint to warm it, a process calledmoxibustion. A ses-\\nsion of acupressure is generally a very pleasant experi-\\nence, and some people experience great benefit\\nimmediately. For more chronic conditions, several\\nsessions may be necessary to relieve and improve\\nconditions.\\nAcupressure massage usually costs from $30–70\\nper hour session. A visit to a Chinese medicine physi-\\ncian or acupuncturist can be more expensive, compar-\\nable to a visit to an allopathic physician if the\\npractitioner is an MD. Insurance reimbursement var-\\nies widely, and consumers should be aware if their\\npolicies cover alternative treatment, acupuncture, or\\nmassage therapy.\\nSelf-treatment\\nAcupressure is easy to learn, and there are many\\ngood books that illustrate the position of acupoints\\nand meridians on the body. It is also very versatile, as\\nit can be done anywhere, and it’s a good form of\\ntreatment for spouses and partners to give to each\\nother and for parents to perform on children for\\nminor conditions.\\nWhile giving self-treatment or performing acu-\\npressure on another, a mental attitude of calmness\\nand attention is important, as one person’s energy\\ncan be used to help another’s. Loose, thin clothing is\\nrecommended. There are three general techniques for\\nstimulating a pressure point.\\n/C15Tonifying is meant to strengthen weak chi, and is\\ndone by pressing the thumb or finger into an acu-\\npoint with a firm, steady pressure, holding it for up to\\ntwo minutes.\\n/C15Dispersing is meant to move stagnant or blocked\\nchi, and the finger or thumb is moved in a circular\\nmotion or slightly in and out of the point for two\\nminutes.\\n/C15Calming the chi in a pressure point utilizes the palm\\nto cover the point and gentlystroke the area for\\nabout two minutes.\\nThere are many pressure points that are easily\\nfound and memorized to treat common ailments\\nfrom headaches to colds.\\n/C15For headaches, toothaches, sinus problems, and\\npain in the upper body, the ‘‘LI4’’ point is recom-\\nmended. It is located in the web between the thumb\\nand index finger, on the back of the hand. Using the\\nthumb and index finger of the other hand, apply a\\npinching pressure until the point is felt, and hold it\\nfor two minutes. Pregnant women should never\\npress this point.\\n/C15To calm the nerves and stimulate digestion, find the\\n‘‘CV12’’ point that is four thumb widths above the\\nnavel in the center of the abdomen. Calm the point\\nwith the palm, using gentle stroking for several\\nminutes.\\n/C15To stimulate the immune system, find the ‘‘TH5’’\\npoint on the back of the forearm two thumb widths\\nabove the wrist. Use a dispersing technique, or cir-\\ncular pressure with the thumb or finger, for two\\nminutes on each arm.\\n/C15For headaches, sinus congestion, and tension, locate\\nthe ‘‘GB20’’ points at the base of the skull in the\\nback of the head, just behind the bones in back of\\n40 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupressure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 70, 'page_label': '41'}, page_content='the ears. Disperse these points for two minutes with\\nthe fingers or thumbs. Also find the ‘‘yintang’’ point,\\nwhich is in the middle of the forehead between the\\neyebrows. Disperse it with gentle pressure for two\\nminutes to clear the mind and to relieve headaches.\\nPrecautions\\nAcupressure is a safe technique, but it is not meant\\nto replace professional health care. A physician should\\nalways be consulted when there are doubts about\\nmedical conditions. If a condition is chronic, a profes-\\nsional should be consulted; purely symptomatic treat-\\nment can exacerbate chronic conditions. Acupressure\\nshould not be applied to open wounds, or where there\\nis swelling and inflammation. Areas of scar tissue,\\nblisters, boils, rashes, or varicose veins should be\\navoided. Finally, certain acupressure points should\\nnot be stimulated on people with high or low blood\\npressure and on pregnant women.\\nResearch and general acceptance\\nIn general, Chinese medicine has been slow to\\ngain acceptance in the West, mainly because it rests\\non ideas very foreign to the scientific model. For\\ninstance, Western scientists have trouble with the\\nidea of chi, the invisible energy of the body, and the\\nidea that pressing on certain points can alleviate\\ncertain conditions seems sometimes too simple for\\nscientists to believe.\\nWestern scientists, in trying to account for the\\naction of acupressure, have theorized that chi is actu-\\nally part of the neuroendocrine system of the body.\\nCelebrated orthopedic surgeon Robert O. Becker,\\nwho was twice nominated for the Nobel Prize, wrote\\na book on the subject called Cross Currents: The\\nPromise of Electromedicine; The Perils of Electro-\\npollution. By using precise electrical measuring\\ndevices, Becker and his colleagues showed that the\\nbody has a complex web of electromagnetic energy,\\nand that traditional acupressure meridians and points\\ncontained amounts of energy that non-acupressure\\npoints did not.\\nThe mechanisms of acupuncture and acupres-\\nsure remain difficult to document in terms of the\\nbiochemical processes involved; numerous testi-\\nmonials are the primary evidence backing up the\\neffectiveness of acupressure and acupuncture.\\nH o w e v e r ,ab o d yo fr e s e a r c hi sg r o w i n gt h a tv e r i -\\nfies the effectiveness in acupressure and acupunc-\\nture techniques in treating many problems and in\\ncontrolling pain.\\nResources\\nPERIODICALS\\nMassage Therapy Journal. 820 Davis Street, Suite100,\\nEvanston, IL 60201-4444.\\nOTHER\\nAmerican Association of Oriental Medicine.December 28,\\n2000. .\\nNational Acupuncture and Oriental Medicine Alliance.\\nDecember 28, 2000. .\\nDouglas Dupler, MA\\nAcupressure, foot see Reflexology\\nAcupuncture\\nDefinition\\nAcupuncture is one of the main forms of treat-\\nment in traditional Chinese medicine. It involves the\\nuse of sharp, thin needles that are inserted in the body\\nat very specific points. This process is believed to\\nadjust and alter the body’s energy flow into healthier\\npatterns, and is used to treat a wide variety of illnesses\\nand health conditions.\\nPurpose\\nThe World Health Organization (WHO) recom-\\nmends acupuncture as an effective treatment for over\\nforty medical problems, includingallergies,r e s p i r a -\\ntory conditions, gastrointestinal disorders, gynecolo-\\ngical problems, nervous conditions, and disorders of\\nthe eyes, nose and throat, and childhood illnesses,\\namong others. Acupuncture has been used in the\\ntreatment of alcoholism and substance abuse.I ti s\\nan effective and low-cost treatment for headaches\\nand chronic pain, associated with problems like\\nback injuries and arthritis. It has also been used\\nto supplement invasive W estern treatments like\\nchemotherapy and surgery. Acupuncture is generally\\nmost effective when used as prevention or before a\\nhealth condition becomes acute, but it has been used\\nto help patients suffering from cancer and AIDS.\\nAcupuncture is limited in treating conditions or\\ntraumas that require surgery or emergency care\\n(such as for broken bones).\\nGALE ENCYCLOPEDIA OF MEDICINE 41\\nAcupuncture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 71, 'page_label': '42'}, page_content='Description\\nOrigins\\nThe original text of Chinese medicine is theNei\\nChing, The Yellow Emperor’s Classic of Internal\\nMedicine, which is estimated to be at least 2,500 years\\nold. Thousands of books since then have been written\\non the subject of Chinese healing, and its basic philo-\\nsophies spread long ago to other Asian civilizations.\\nNearly all of the forms of Oriental medicine which are\\nused in the West today, including acupuncture,shiatsu,\\nacupressure massage, and macrobiotics, are part of or\\nhave their roots in Chinese medicine. Legend has it that\\nacupuncture developed when early Chinese physicians\\nobserved unpredicted effects of puncturewounds in\\nChinese warriors. The oldest known text on acupunc-\\nture, theSystematic Classic of Acupuncture,d a t e sb a c k\\nto 282 A.D. Although acupuncture is its best known\\ntechnique, Chinese medicine traditionally utilizes her-\\nbal remedies, dietary therapy, lifestyle changes and\\nother 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\\nremained virtually unknown until the 1970s, when\\nRichard Nixon became the first U.S. president to\\nvisit China. On Nixon’s trip, journalists were amazed\\nto observe major operations being performed on\\npatients without the use of anesthetics. Instead,\\nwide-awake patients were being operated on with\\nonly acupuncture needles inserted into them to con-\\ntrol pain. During that time, a famous columnist for\\nthe New York Times , James Reston, had to undergo\\nsurgery and elected to use acupuncture instead of\\npain medication, and he w rote some convincing\\nstories on its effectiveness.\\nToday, acupuncture is being practiced in all 50\\nstates by over 9,000 practitioners, with over 4,000\\nMDs including it in their practices. Acupuncture has\\nshown notable success in treating many conditions,\\nand over 15 million Americans have used it as a ther-\\napy. Acupuncture, however, remains largely unsup-\\nported by the medical establishment. The American\\nMedical Association has been resistant to researching\\nit, as it is based on concepts very different from the\\nWestern scientific model.\\nWoman undergoing facial acupuncture. (Photograph by Yoav Levy. Phototake NYC. Reproduced by permission.)\\n42 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupuncture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 72, 'page_label': '43'}, page_content='Several forms of acupuncture are being used\\ntoday in America. Japanese acupuncture uses extre-\\nmely thin needles and does not incorporate herbal\\nmedicine in its practice. Auricular acupuncture uses\\nacupuncture points only on the ear, which are\\nbelieved to stimulate and balance internal organs.\\nIn France, where acupuncture is very popular and\\nmore accepted by the medical establishment, neuro-\\nlogist Paul Nogier developed a system of acupuncture\\nbased on neuroendocrine theory rather than on tra-\\nditional Chinese concepts, which is gaining some use\\nin America.\\nBasic ideas of Chinese medicine\\nChinese medicine views the body as a small part\\nof the universe, and subject to universal laws and\\nprinciples of harmony and balance. Chinese medicine\\ndoes not draw a sharp line, as Western medicine does,\\nbetween mind and body. The Chinese system believes\\nthat emotions and mental states are every bit as\\ninfluential on disease as purely physical mechanisms,\\nand considers factors like work, environment, life-\\nstyle and relationships as fundamental to the overall\\npicture of a patient’s health. Chinese medicine also\\nuses very different symbols and ideas to discuss the\\nbody and health. While Western medicine typically\\ndescribes health in terms of measurable physical\\nprocesses made up of chemical reactions, the Chinese\\nuse ideas like yin and yang, chi, the organ system, and\\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.)\\nKEY TERMS\\nAcupressure— Form of massage using acupuncture\\npoints.\\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\\ndescribe aspects of the natural world.\\nGALE ENCYCLOPEDIA OF MEDICINE 43\\nAcupuncture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 73, 'page_label': '44'}, page_content='the five elements to describe health and the body. To\\nunderstand the ideas behind acupuncture, it is worth-\\nwhile to introduce some of these basic terms.\\nYIN AND YANG. According to Chinese philosophy,\\nthe universe and the body can be described by two\\nseparate but complementary principles, that of yin\\nand yang. For example, in temperature, yin is cold\\nand yang is hot. In gender, yin is female and yang is\\nmale. In activity, yin is passive and yang is active. In\\nlight, yin is dark and yang is bright; in direction yin is\\ninward and downward and yang is outward and up,\\nand so on. Nothing is ever completely yin or yang, but\\na combination of the two. These two principles are\\nalways interacting, opposing, and influencing each\\nother. The goal of Chinese medicine is not to eliminate\\neither yin or yang, but to allow the two to balance each\\nother and exist harmoniously together. For instance, if\\na person suffers from symptoms of high blood pressure,\\nthe Chinese system would say that the heart organ\\nmight have too much yang, and would recommend\\nmethods either to reduce the yang or to increase the\\nyin of the heart, depending on the other symptoms and\\norgans in the body. Thus, acupuncture therapies seek to\\neither increase or reduce yang, or increase or reduce yin\\nin particular regions of the body.\\nCHI. Another fundamental concept of Chinese\\nmedicine is that of chi (pronouncedchee, also spelled\\nqi). Chi is the fundamental life energy of the universe.\\nIt is invisible and is found in the environment in the\\nair, water, food and sunlight. In the body, it is the\\ninvisible vital force that creates and animates life.\\nWe are all born with inherited amounts of chi, and\\nwe also get acquired chi from the food we eat and the\\nair we breathe. The level and quality of a person’s chi\\nalso depends on the state of physical, mental and\\nemotional balance. Chi travels through the body\\nalong channels calledmeridians.\\nTHE ORGAN SYSTEM. In the Chinese system, there\\nare twelve main organs: the lung, large intestine, sto-\\nmach, spleen, heart, small intestine, urinary bladder,\\nkidney, liver, gallbladder, pericardium, and the ‘‘triple\\nwarmer,’’ which represents the entire torso region.\\nEach organ has chi energy associated with it, and\\neach organ interacts with particular emotions on the\\nmental level. As there are twelve organs, there are\\ntwelve types of chi which can move through the body,\\nand these move through twelve main channels or mer-\\nidians. Chinese doctors connect symptoms to organs.\\nThat is, symptoms are caused by yin/yang imbalances\\nin one or more organs, or by an unhealthy flow of chi\\nto or from one organ to another. Each organ has a\\ndifferent profile of symptoms it can manifest.\\nTHE FIVE ELEMENTS. Another basis of Chinese the-\\nory is that the world and body are made up of five\\nmain elements: wood, fire, earth, metal, and water.\\nThese elements are all interconnected, and each ele-\\nment either generates or controls another element. For\\ninstance, water controls fire and earth generates metal.\\nEach organ is associated with one of the five elements.\\nThe Chinese system uses elements and organs to\\ndescribe and treat conditions. For instance, the kidney\\nis associated with water and the heart is associated\\nwith fire, and the two organs are related as water and\\nfire are related. If the kidney is weak, then there might\\nbe a corresponding fire problem in the heart, so treat-\\nment might be made by acupuncture or herbs to cool\\nthe heart system and/or increase energy in the kidney\\nsystem.\\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\\nsimple one. Although this system sounds suspect to\\nWestern scientists, some interesting parallels have\\nbeen observed. For instance, Western medicine has\\nobserved that with severe heart problems, kidney fail-\\nure often follows, but it still does not know exactly\\nwhy. In Chinese medicine, this connection between the\\ntwo organs has long been established.\\nMEDICAL PROBLEMS AND ACUPUNCTURE. In\\nChinese medicine, disease as seen as imbalances in\\nthe organ system or chi meridians, and the goal of\\nany remedy or treatment is to assist the body in rees-\\ntablishing its innate harmony. Disease can be caused\\nby internal factors like emotions, external factors like\\nthe environment and weather, and other factors like\\ninjuries, trauma, diet, and germs. However, infection\\nis seen not as primarily a problem with germs and\\nviruses, but as a weakness in the energy of the body\\nwhich is allowing a sickness to occur. In Chinese med-\\nicine, no two illnesses are ever the same, as each body\\nhas its own characteristics of symptoms and balance.\\nAcupuncture is used to open or adjust the flow of chi\\nthroughout the organ system, which will strengthen\\nthe body and prompt it to heal itself.\\nA VISIT TO THE ACUPUNCTURIST. The first thing\\nan acupuncturist will do is get a thorough idea of a\\npatient’s medical history and symptoms, both physi-\\ncal and emotional. This is done with a long question-\\nnaire and interview. Then the acupuncturist will\\nexamine the patient to find further symptoms, look-\\ning closely at the tongue, the pulse at various points\\nin the body, the complexion, general behavior,\\nand other signs like coughs or pains. From this, the\\npractitioner will be able to determine patterns of\\n44 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupuncture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 74, 'page_label': '45'}, page_content='symptoms which indicate which organs and areas\\nare imbalanced. Depending on the problem, the acu-\\npuncturist will insert needles to manipulate chi on\\none or more of the twelve organ meridians. On these\\ntwelve meridians, there are nearly 2,000 points which\\ncan be used in acupuncture, with around 200 points\\nbeing most frequently used by traditional acupunc-\\nturists. During an individual treatment, one to\\ntwenty needles may be used, depending on which\\nmeridian points are chosen.\\nAcupuncture needles are always sterilized and\\nacupuncture is a very safe procedure. The depth of\\ninsertion of needles varies, depending on which chi\\nchannels are being treated. Some points barely go\\nbeyond superficial layers of skin, while some acupunc-\\nture points require a depth of 1-3 in (2.5-7.5 cm) of\\nneedle. The needles generally do not cause pain.\\nPatients sometimes report pinching sensations and\\noften pleasant sensations, as the body experiences\\nhealing. Depending on the problem, the acupuncturist\\nmight spin or move the needles, or even pass a slight\\nelectrical current through some of them.Moxibustion\\nmay be sometimes used, in which an herbal mixture\\n(moxa or mugwort) is either burned like incense on the\\nacupuncture point or on the end of the needle, which\\nis believed to stimulate chi in a particular way. Also,\\nacupuncturists sometimes usecupping, during which\\nsmall suction cups are placed on meridian points to\\nstimulate them.\\nHow long the needles are inserted also varies.\\nSome patients only require a quick in and out inser-\\ntion to clear problems and provide tonification\\n(strengthening of health), while some other condi-\\ntions might require needles inserted up to an hour or\\nmore. The average visit to an acupuncturist takes\\nabout thirty minutes. The number of visits to the\\nacupuncturist varies as well, with some conditions\\nimproved in one or two sessions and others requiring\\na series of six or more visits over the course of weeks\\nor months.\\nCosts for acupuncture can vary, depending\\non whether the practitioner is an MD. Initial visits\\nwith non-MD acupuncturists can run from $50-\\n$100, with follow-up visits usually costing less.\\nInsurance reimbursement also varies widely, depend-\\ning on the company and state. Regulations have been\\nchanging often. Some states authorize Medicaid to\\ncover acupuncture for certain conditions, and some\\nstates have mandated that general coverage pay\\nfor acupuncture. Consumers should be aware of\\nthe provisions for acupuncture in their individual\\npolicies.\\nPrecautions\\nAcupuncture is generally a very safe procedure. If\\na patient is in doubt about a medical condition, more\\nthan one physician should be consulted. Also, a\\npatient should always feel comfortable and confident\\nthat their acupuncturist is knowledgable and properly\\ntrained.\\nResearch and general acceptance\\nMainstream medicine has been slow to accept\\nacupuncture; although more MDs are using it, the\\nAmerican Medical Association does not recognize\\nit as a specialty. The reason for this is that the\\nmechanism of acupuncture is difficult to scientifi-\\ncally understand or measure, such as the invisible\\nenergy of chi in the body. Western medicine,\\nadmitting that acupuncture works in many cases,\\nhas theorized that the energy meridians are actu-\\nally part of the nervous system and that acupunc-\\nture relieves pain by releasing endorphins, or\\nnatural pain killers, into the bloodstream. Despite\\nthe ambiguity in the biochemistry involved, acu-\\npuncture continues to show effectiveness in clinical\\ntests, from reducing pain to alleviating the symp-\\ntoms of chronic illnesses,and research in acupunc-\\nture is currently growing. The Office of Alternative\\nMedicine of the National Institute of Health is\\ncurrently funding research in the use of acupunc-\\nture for treating depression and attention-deficit\\ndisorder.\\nResources\\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,\\n2000. .\\nNorth American Society of Acupuncture and Alternative\\nMedicine. December 28, 2000. .\\nDouglas Dupler, MA\\nAcute glomerulonephritis see Acute post-\\nstreptococcal glomerulonephritis\\nAcute homeopathic remedies see\\nHomeopathic remedies, acute prescribing\\nGALE ENCYCLOPEDIA OF MEDICINE 45\\nAcupuncture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 75, 'page_label': '46'}, page_content='Acute kidney failure\\nDefinition\\nAcute kidney failure occurs when illness, infec-\\ntion, or injury damages the kidneys. Temporarily, the\\nkidneys cannot adequately remove fluids and wastes\\nfrom the body or maintain the proper level of certain\\nkidney-regulated chemicals in the bloodstream.\\nDescription\\nThe kidneys are the body’s natural filtration\\nsystem. They perform the critical task of proces-\\nsing approximately 200 quarts of fluid in the\\nbloodstream every 24 hours. Waste products like\\nurea and toxins, along with excess fluids, are\\nremoved from the bloodstream in the form of\\nurine. Kidney (or renal) failure occurs when kidney\\nfunctioning becomes impaired. Fluids and toxins\\nbegin to accumulate in the bloodstream. As fluids\\nbuild up in the bloodstream, the patient with acute\\nkidney failure may become puffy and swollen (ede-\\nmatous) in the face, hands, and feet. Their blood\\npressure typically begins to rise, and they may\\nexperience fatigue and nausea.\\nUnlike chronic kidney failure , which is long\\nterm and irreversible, acute kidney failure is a\\ntemporary condition. With proper and timely treat-\\nment, it can typically be reversed. Often there is no\\npermanent damage to the kidneys. Acute kidney\\nfailure appears most frequently as a complication\\nof serious illness, like heart failure, liver failure,\\ndehydration, severe burns, and excessive bleeding\\n(hemorrhage). It may also be caused by an\\nobstruction to the urinary tract or as a direct result\\nof kidney disease, injury, or an adverse reaction to\\nam e d i c i n e .\\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,a n d\\nintrarenal conditions.\\nPrerenal conditions do not damage the kidney,\\nbut can cause diminished kidney function. They are\\nthe most common cause of acute renal failure, and\\ninclude:\\n/C15dehydration\\n/C15hemorrhage\\n/C15septicemia, orsepsis\\n/C15heart failure\\n/C15liver failure\\n/C15burns\\nPostrenal conditions cause kidney failure by\\nobstructing the urinary tract. These conditions\\ninclude:\\n/C15inflammation of the prostate gland in men\\n(prostatitis)\\n/C15enlargement of the prostate gland (benign prostatic\\nhypertrophy)\\n/C15bladder or pelvic tumors\\n/C15kidney stones(calculi)\\nIntrarenal conditions involve kidney disease\\nor direct injury to the kidneys. These conditions\\ninclude:\\n/C15lack of blood supply to the kidneys (ischemia)\\n/C15use of radiocontrast agents in patients with kidney\\nproblems\\n/C15drug abuse or overdose\\n/C15long-term use of nephrotoxic medications, like cer-\\ntain pain medicines\\n/C15acute inflammation of the glomeruli, or filters, of the\\nkidney (glomerulonephritis)\\n/C15kidney infections (pyelitis or pyelonephritis).\\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\\nblood vessels.\\n46 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute kidney failure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 76, 'page_label': '47'}, page_content='Common symptoms of acute kidney failure\\ninclude:\\n/C15anemia. The kidneys are responsible for producing\\nerythropoietin (EPO), a hormone that stimulates red\\nblood cell production. If kidney disease causes\\nshrinking of the kidney, red blood cell production is\\nreduced, leading to anemia.\\n/C15bad breath or bad taste in mouth. Urea in the saliva\\nmay cause an ammonia-like taste in the mouth.\\n/C15bone and joint problems. The kidneys produce\\nvitamin D, which helps the body absorb calcium\\nand keeps bones strong. For patients with kidney\\nfailure, bones may become brittle. In children,\\nnormal growth may be stunted. Joint pain may\\nalso occur as a result of high phosphate levels\\nin the blood. Retention of uric acid may cause\\ngout.\\n/C15edema. Puffiness or swelling in the arms, hands, feet,\\nand around the eyes.\\n/C15frequent urination.\\n/C15foamy or bloody urine. Protein in the urine may\\ncause it to foam significantly. Blood in the urine\\nmay indicate bleeding from diseased or obstructed\\nkidneys, bladder, or ureters.\\n/C15headaches. High blood pressure may trigger\\nheadaches.\\n/C15hypertension, or high blood pressure. The retention\\nof fluids and wastes causes blood volume to increase.\\nThis makes blood pressure rise.\\n/C15increased fatigue. Toxic substances in the blood and\\nthe presence of anemia may cause the patient to feel\\nexhausted.\\n/C15itching. Phosphorus, normally eliminated in the\\nurine, accumulates in the blood of patients with\\nkidney failure. An increased phosphorus level may\\ncause the skin to itch.\\n/C15lower back pain. Patients suffering from certain kid-\\nney problems (like kidney stones and other obstruc-\\ntions) may have pain where the kidneys are located,\\nin the small of the back below the ribs.\\n/C15nausea. Urea in the gastric juices may cause upset\\nstomach.\\nDiagnosis\\nKidney failure is diagnosed by a doctor. A\\nnephrologist, a doctor that specializes in the kid-\\nney, may be consulted to confirm the diagnosis and\\nrecommend treatment options. The patient that is\\nsuspected of having acute kidney failure will have\\nblood and urine tests to determine the level of\\nkidney function. A blood test will assess the levels\\nof creatinine, blood urea nitrogen (BUN), uric\\nacid, phosphate, sodium, and potassium. The kid-\\nney regulates these agents in the blood. Urine sam-\\nples will also be collected, usually over a 24-hour\\nperiod, to assess protein loss and/or creatinine\\nclearance.\\nDetermining the cause of kidney failure is critical\\nto proper treatment. A fullassessment of the kidneys\\nis necessary to determine if the underlying disease\\nis treatable and if the kidney failure is chronic or\\nacute. X rays, magnetic resonance imaging (MRI),\\ncomputed tomography scan (CT), ultrasound, renal\\nbiopsy, and/or arteriogram of the kidneys may be\\nused to determine the cause of kidney failure and\\nlevel of remaining kidney function. X rays and ultra-\\nsound of the bladder and/or ureters may also be\\nneeded.\\nTreatment\\nTreatment for acute kidney failure varies.\\nTreatment is directed to the underlying, primary med-\\nical condition that has triggered kidney failure.\\nPrerenal conditions may be treated with replacement\\nfluids given through a vein,diuretics, blood transfusion,\\nor medications. Postrenal conditions and intrarenal\\nconditions may require surgery and/or medication.\\nFrequently, patients in acute kidney failure\\nrequire hemodialysis , hemofiltration ,o r peritoneal\\ndialysis to filter fluids and wastes from the blood-\\nstream until the primary medical condition can be\\ncontrolled.\\nHemodialysis\\nHemodialysis involves circulating the patient’s\\nblood outside of the body through an extracorporeal\\ncircuit (ECC), or dialysis circuit. The ECC is made up\\nof plastic blood tubing, a filter known as a dialyzer (or\\nartificial kidney), and a dialysis machine that monitors\\nand maintains 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\\nblood leaves the body through the vein and travels\\nthrough the ECC and the dialyzer, where fluid\\nremoval takes place.\\nDuring dialysis, waste products in the blood-\\nstream are carried out of the body. At the same time,\\nelectrolytes and other chemicals are added to the\\nblood. The purified, chemically-balanced blood is\\nthen returned to the body.\\nGALE ENCYCLOPEDIA OF MEDICINE 47\\nAcute kidney failure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 77, 'page_label': '48'}, page_content='A 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 hemodia-\\nlysis may pose a risk for patients with heart problems.\\nPeritoneal dialysis may be the preferred treatment\\noption in these cases.\\nHemofiltration\\nHemofiltration, also called continuous renal\\nreplacement therapy (CRRT), is a slow, continuous\\nblood filtration therapy used to control acute kidney\\nfailure in critically ill patients. These patients are\\ntypically very sick and may have heart problems or\\ncirculatory problems. They cannot handle the rapid\\nfiltration rates of hemodialysis. They also frequently\\nneed antibiotics, nutrition, vasopressors, and other\\nfluids given through a vein to treat their primary\\ncondition. Because hemofiltration is continuous,\\nprescription fluids can be given to patients in kidney\\nfailure without the risk of fluid overload.\\nLike hemodialysis, hemofiltration uses an ECC.\\nA hollow fiber hemofilter is used instead of a dialyzer\\nto remove fluids and toxins. Instead of a dialysis\\nmachine, a blood pump makes the blood flow through\\nthe ECC. The volume of blood circulating through\\nthe ECC in hemofiltration is less than that in hemo-\\ndialysis. Filtration rates are slower and gentler on the\\ncirculatory system. Hemofiltration treatment will\\ngenerally be used until kidney failure is reversed.\\nPeritoneal dialysis\\nPeritoneal dialysis may be used if an acute kidney\\nfailure patient is stable and not in immediate crisis.\\nIn peritoneal dialysis (PD), the lining of the patient’s\\nabdomen, the peritoneum, acts as a blood filter.\\nA flexible tube-like instrument (catheter) is surgically\\ninserted into the patient’s abdomen. During treat-\\nment, the catheter is used to fill the abdominal cavity\\nwith dialysate. Waste products and excess fluids move\\nfrom the patient’s bloodstream into the dialysate\\nsolution. After a certain time period, the waste-filled\\ndialysate is drained from the abdomen, and replaced\\nwith clean dialysate. There are three type of peritoneal\\ndialysis, which vary according to treatment time and\\nadministration method.\\nPeritoneal dialysis is often the best treatment\\noption for infants and children. Their small size can\\nmake vein access difficult to maintain. It is not recom-\\nmended for patients with abdominal adhesions or\\nother abdominal defects (like a hernia) that might\\nreduce the efficiency of the treatment. It is also not\\nrecommended for patients who suffer frequent bouts\\nof an inflammation of the small pouches in the intest-\\ninal tract (diverticulitis).\\nPrognosis\\nBecause many of the illnesses and underlying\\nconditions that often trigger acute kidney failure\\nare critical, the prognosis for these patients many\\ntimes is not good. Studies have estimated overall\\ndeath rates for acute kidney failure at 42-88%.\\nMany people, however, die because of the primary\\ndisease that has caused the kidney failure. These\\nfigures may also be mislea ding because patients\\nwho experience kidney failure as a result of less\\nserious illnesses (like kidney stones or dehydration)\\nhave an excellent chance of complete recovery.\\nEarly recognition and prompt, appropriate treat-\\nment are key to patient recovery.\\nUp to 10% of patients who experience acute\\nkidney failure will suffer irreversible kidney damage.\\nThey will eventually go on to develop chronic kidney\\nfailure or end-stage renal disease. These patients will\\nrequire long-term dialysis or kidney transplantation to\\nreplace their lost 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\\ncarefully monitored for kidney failure complications.\\nTreatments and procedures that may put them at risk\\nfor kidney failure (like diagnostic tests requiring radio-\\ncontrast agents or dyes) should be used with extreme\\ncaution.\\nResources\\nPERIODICALS\\nStark, June. ‘‘Dialysis Choices: Turning the Tide in Acute\\nRenal Failure.’’Nursing 27, no. 2 (February 1997):\\n41-8.\\nORGANIZATIONS\\nNational Kidney Foundation. 30 East 33rd St., New York,\\nNY 10016. (800) 622-9010. .\\nPaula Anne Ford-Martin\\nAcute leukemias see Leukemias, acute\\n48 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute kidney failure'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 78, 'page_label': '49'}, page_content='Acute lymphangitis\\nDefinition\\nAcute lymphangitis is a bacterial infection in the\\nlymphatic vessels which is characterized by painful,\\nred streaks below the skin surface. This is a potentially\\nserious infection which can rapidly spread to the\\nbloodstream and be fatal.\\nDescription\\nAcute lymphangitis affects a critical member of\\nthe immune system–the lymphatic system. Waste\\nmaterials from nearly every organ in the body drain\\ninto the lymphatic vessels and are filtered in small\\norgans called lymph nodes. Foreign bodies, such as\\nbacteria or viruses, are processed in the lymph nodes\\nto generate an immune response to fight an infection.\\nIn acute lymphangitis, bacteria enter the body\\nthrough a cut, scratch, insect bite, surgical wound, or\\nother skin injury. Once the bacteria enter the lympha-\\ntic system, they multiply rapidly and follow the lym-\\nphatic vessel like a highway. The infected lymphatic\\nvessel becomes inflamed, causing red streaks that are\\nvisible below the skin surface. The growth of the bac-\\nteria occurs so rapidly that the immune system does\\nnot respond fast enough 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 anabscess may be formed in the\\ninfected area. Cellulitis, a generalized infection of\\nthe lower skin layers, may also occur. In addition,\\nthe bacteria may invade the bloodstream and cause\\nsepticemia. Lay people, for that reason, often call\\nthe red streaks seen in the skin ‘‘blood poisoning.’’\\nSepticemia is a very serious illness and may be fatal.\\nCauses and symptoms\\nAcute lymphangitis is most often caused by the\\nbacterium Streptococcus pyogenes . This potentially\\ndangerous bacterium also causes strep throat, infec-\\ntions of the heart, spinal cord, and lungs, and in the\\n1990s has been called the ‘‘flesh-eating bacterium.’’\\nStaphylococci bacteria may also cause lymphangitis.\\nAlthough anyone can develop lymphangitis, some\\npeople are more at risk. People who have had radical\\nmastectomy (removal of a breast and nearby lymph\\nnodes), a leg vein removed for coronary bypass sur-\\ngery, or recurrent lymphangitis caused by tinea pedis\\n(a fungal infection on the foot) are at an increased risk\\nfor lymphangitis.\\nThe characteristic symptoms of acute lymphangi-\\ntis are the wide, red streaks which travel from the site\\nof infection to the armpit or groin. The affected areas\\nare red, swollen, and painful. Blistering of the affected\\nskin may occur. The bacterial infection causes afever\\nof 100-1048F (38-408C). In addition, a general ill\\nfeeling, muscle aches, headache, chills, and loss of\\nappetite may be felt.\\nDiagnosis\\nIf lymphangitis is suspected, the person should\\ncall his or her doctor immediately or go to an emer-\\ngency room. Acute lymphangitis could be diagnosed\\nby the family doctor, infectious disease specialist,\\nor an emergency room doctor. The painful, red\\nstreaks just below the skin surface and the high\\nfever are diagnostic of acute lymphangitis. A sample\\nof blood would be taken for culture to determine\\nwhether the bacteria have entered the bloodstream.\\nA biopsy (removal of a pi ece of infected tissue)\\nsample may be taken for culture to identify which\\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\\nexpenses for the diagnosis and treatment of acute\\nlymphangitis.\\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. Grow-\\ning streptococcal bacteria are usually eliminated rapidly\\nand easily by penicillin. The antibiotic clindamycin may\\nbe included in the treatment to kill any streptococci\\nwhich are not growing and are in a resting state.\\nKEY TERMS\\nBiopsy— The process which removes a sample of\\ndiseased or infected tissue for microscopic exam-\\nination 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 ves-\\nsels and are filtered by the lymph nodes.\\nSepticemia— Disease caused by the presence and\\ngrowth of bacteria in the bloodstream.\\nGALE ENCYCLOPEDIA OF MEDICINE 49\\nAcute lymphangitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 79, 'page_label': '50'}, page_content='Alternatively, a ‘‘broad spectrum’’ antibiotic may be\\nused which would kill many different kinds of bacteria.\\nPrognosis\\nComplete recovery is expected if antibiotic treat-\\nment is begun at an early stage of the infection.\\nHowever, if untreated, acute lymphangitis can be a\\nvery serious and even deadly disease. Acute lymphan-\\ngitis that goes untreated can spread, causing tissue\\ndamage. Extensive tissue damage would need to be\\nrepaired by plastic surgery. Spread of the infection\\ninto the bloodstream could be fatal.\\nPrevention\\nAlthough acute lymphangitis can occur in any-\\none, good hygiene and general health may help to\\nprevent infections.\\nResources\\nPERIODICALS\\nDajer, Tony. ‘‘A Lethal Scratch.’’Discover (February 1998):\\n34-7.\\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,\\nfollowing a streptococcal infection such as strep\\nthroat. APSGN is also called postinfectious\\nglomerulonephritis.\\nDescription\\nAPSGN develops after certain streptococcal\\nbacteria (group A beta-hemolytic streptococci) have\\ninfected the skin or throat. Antigens from the dead\\nstreptococci clump together with the antibodies that\\nkilled them. These clumps are trapped in the kidney\\ntubules, cause the tubules to become inflamed, and\\nimpair that organs’ ability to filter and eliminate\\nbody wastes. The onset of APSGN usually occurs\\none to six weeks (average two weeks) after the strep-\\ntococcal infection.\\nAPSGN is a relatively uncommon disease affect-\\ning about one of every 10,000 people, although four or\\nfive times that many may actually be affected by it\\nbut show no symptoms. APSGN is most prevalent\\namong boys between the ages of 3 and 7, but it can\\noccur at any age.\\nCauses and symptoms\\nFrequent sore throats and a history of streptococ-\\ncal infection increase the risk of acquiring APSGN.\\nSymptoms of APSGN include:\\n/C15fluid accumulation and tissue swelling ( edema)\\ninitially in the face and around the eyes, later in\\nthe legs\\n/C15low urine output (oliguria)\\n/C15blood in the urine (hematuria)\\n/C15protein in the urine (proteinuria)\\n/C15high blood pressure\\n/C15joint pain or stiffness\\nDiagnosis\\nDiagnosis of APSGN is made by taking the\\npatient’s history, assessing his/her symptoms, and\\nperforming certain laboratory tests. Urinalysis\\nusually shows blood and protein in the urine.\\nConcentrations of urea and creatinine (two waste\\nproducts normally filtered out of the blood by the\\nkidneys) in the blood are often high, indicating\\nimpaired kidney function. A reliable, inexpensive\\nblood test called the anti- streptolysin-O test can\\nconfirm that a patient has or has had a streptococ-\\ncal infection. A throat culture may also show the\\npresence of group A beta-hemolytic streptococci.\\nTreatment\\nTreatment of ASPGN is designed to relieve the\\nsymptoms and prevent complications. Some patients\\nKEY TERMS\\nStreptococcus— A gram-positive, round or oval\\nbacteria in the genusStreptococcus. Group A strep-\\ntococci cause a number of human diseases includ-\\ning strep throat, impetigo, and ASPGN.\\n50 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute poststreptococcal glomerulonephritis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 80, 'page_label': '51'}, page_content='are advised to stay in bed until they feel better and\\nto restrict fluid and salt intake. Antibiotics may be\\nprescribed to kill any lingering streptococcal bacteria,\\nif their presence is confirmed. Antihypertensives may\\nbe given to help control high blood pressure and\\ndiuretics may be used to reduce fluid retention and\\nswelling. Kidney dialysisis rarely needed.\\nPrognosis\\nMost children (up to 95%) fully recover from\\nAPSGN in a matter of weeks or months. Most adults\\n(up to 70%) also recover fully. In those who do\\nnot recover fully, chronic or progressive problems of\\nkidney function may occur. Kidney failure may result\\nin some patients.\\nPrevention\\nReceiving prompt treatment for streptococcal\\ninfections may prevent APSGN.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nORGANIZATIONS\\nAmerican Kidney Fund (AKF). Suite 1010, 6110 Executive\\nBoulevard, Rockville, MD 20852. (800) 638-8299.\\n.\\nNational Kidney Foundation. 30 East 33rd St., New\\nYork, NY 10016. (800) 622-9010..\\nMaureen Haggerty\\nAcute respiratory distress syndrome see\\nAdult respiratory distress syndrome\\nAcute stress disorder\\nDefinition\\nAcute stress disorder (ASD) is ananxiety disorder\\ncharacterized by a cluster of dissociative and anxiety\\nsymptoms occurring within one month of a traumatic\\nevent. (Dissociation is a psychological reaction to\\ntrauma in which the mind tries to cope by ‘‘sealing\\noff ’’ some features of the trauma from conscious\\nawareness).\\nDescription\\nAcute stress disorder is a new diagnostic category\\nthat was introduced in 1994 to differentiate time-lim-\\nited reactions to trauma frompost-traumatic stress\\ndisorder (PTSD).\\nCauses and symptoms\\nAcute stress disorder is caused by exposure to\\ntrauma, which is defined as a stressor that causes\\nintense fear and, usually, involves threats to life or\\nserious injury to oneself or others. Examples are\\nrape, mugging, combat, natural disasters, etc.\\nThe symptoms of stress disorder include a com-\\nbining of one or more dissociative and anxiety symp-\\ntoms with the avoidance of reminders of the traumatic\\nevent. Dissociative symptoms include emotional\\ndetachment, temporary loss of memory, depersonali-\\nzation, and derealization.\\nAnxiety symptoms connected with acute stress\\ndisorder include irritability, physical restlessness,\\nsleep problems, inability to concentrate, and being\\neasily startled.\\nDiagnosis\\nDiagnosis of acute stress disorder is based on a\\ncombination of the patient’s history and aphysical\\nexamination to rule out diseases that can cause\\nanxiety. The essential feature is a traumatic event\\nwithin one month of the onset of symptoms. Other\\ndiagnostic criteria include:\\n/C15The symptoms significantly interfere with normal\\nsocial or vocational functioning\\n/C15The symptoms last between two days and four weeks.\\nKEY TERMS\\nDepersonalization— A dissociative symptom in\\nwhich the patient feels that his or her body is\\nunreal, 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 con-\\nscious awareness. Dissociation can affect the pat-\\nient’s memory, sense of reality, and sense of identity.\\nTrauma— In the context of ASD, a disastrous or\\nlife-threatening event.\\nGALE ENCYCLOPEDIA OF MEDICINE 51\\nAcute stress disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 81, 'page_label': '52'}, page_content='Treatment\\nTreatment for acute stress disorder usually\\nincludes a combination of antidepressant medications\\nand short-term psychotherapy.\\nPrognosis\\nThe prognosis for recovery is influenced by the\\nseverity and duration of the trauma, the patient’s\\ncloseness to it, and the patient’s previous level of func-\\ntioning. Favorable signs include a short time period\\nbetween the trauma and onset of symptoms, immediate\\ntreatment, and appropriate social support. If the\\npatient’s symptoms are severe enough to interfere\\nwith normal life and have lasted longer than one\\nmonth, the diagnosis may be changed to PTSD. If the\\nsymptoms have lasted longer than one month but are\\nnot 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 forsubstance abuse\\nor majordepressive disorders.\\nPrevention\\nTraumatic events cannot usually be foreseen and,\\nthus, cannot be prevented. However, in theory, profes-\\nsional intervention soon after a major trauma might\\nreduce the likelihood or severity of ASD. In addition,\\nsome symptoms of acute stress disorder result from\\nbiochemical changes in the central nervous system,\\nmuscles, and digestive tract that are not subject to\\nconscious control.\\nResources\\nBOOKS\\nCorbman, Gene R. ‘‘Anxiety Disorders.’’ InCurrent\\nDiagnosis, edited by Rex B. Conn, et al. Vol. 9.\\nPhiladelphia: W. B. Saunders Co., 1997.\\nEisendrath, Stuart J. ‘‘Psychiatric Disorders.’’ InCurrent\\nMedical Diagnosis and Treatment, 1998 , edited by\\nStephen McPhee, et al., 37th ed. Stamford: Appleton &\\nLange, 1997.\\nRebecca J. Frey, PhD\\nAcute stress gastritis see Gastritis\\nAcute transverse myelitis see Transverse\\nmyelitis\\nAcyclovir see Antiviral drugs\\nAddiction\\nDefinition\\nAddiction is a persistent, compulsive dependence\\non a behavior or substance. The term has been par-\\ntially replaced by the worddependence for substance\\nabuse. Addiction has been extended, however, to\\ninclude mood-altering behaviors or activities. Some\\nresearchers speak of two types of addictions: sub-\\nstance addictions (for example, alcoholism, drug\\nabuse,a n dsmoking); and process addictions (for\\nexample, gambling, spending, shopping, eating, and\\nsexual activity). There is a growing recognition that\\nmany addicts, such as polydrug abusers, are addicted\\nto more than one substance or process.\\nDescription\\nAddiction is one of the most costly public\\nhealth problems in the United States. It is a pro-\\ngressive syndrome, which means that it increases in\\nseverity over time unless i t is treated. Substance\\nabuse is characterized by frequent relapse, or return\\nto the abused substance. Substance abusers often\\nmake repeated attempts to quit before they are\\nsuccessful.\\nThe economic cost of substance abuse in the\\nUnited States exceeds $414 billion, with health care\\ncosts attributed to substance abuse estimated at more\\nthan $114 billion.\\nBy eighth grade, 52% of adolescents have con-\\nsumed alcohol, 41% have smoked tobacco, and 20%\\nhave smokedmarijuana. Compared to females, males\\nare almost four times as likely to be heavy drinkers,\\nnearly one and a half more likely to smoke a pack or\\nmore of cigarettes daily, and twice as likely to smoke\\nmarijuana weekly. However, among adolescents\\nthese gender differences are not as pronounced and\\ngirls are almost as likely to abuse substances such\\nas alcohol and cigarettes. Although frequent use\\nof tobacco, cocaine and heavy drinking appears\\nto remain stable in the 1990s, marijuana use has\\nincreased.\\nAn estimated four million Americans over the age\\nof 12 used prescriptionpain relievers, sedatives, and\\nstimulants for ‘‘nonmedical’’ reasons during one\\nmonth.\\nIn the United States, 25% of the population reg-\\nularly uses tobacco. Tobacco use reportedly kills 2.5\\ntimes as many people each year as alcohol and drug\\nabuse combined. According to data from the World\\n52 GALE ENCYCLOPEDIA OF MEDICINE\\nAddiction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 82, 'page_label': '53'}, page_content='Health Organization, there were 1.1 billion smokers\\nworldwide and 10,000 tobacco-related deaths per\\nday. Furthermore, in the United States, 43% of chil-\\ndren aged 2-11 years are exposed to environmental\\ntobacco smoke, which has been implicated insudden\\ninfant death syndrome, low birth weight,asthma, mid-\\ndle ear disease,pneumonia, cough, and upper respira-\\ntory infection.\\nEating disorders, such as anorexia nervosa ,\\nbulimia nervosa, and binge eating, affect more than\\nfive million American women and men. Fifteen per-\\ncent of young women have substantially disordered\\nattitudes toward eating and eating behaviors. More\\nthan 1,000 women die each year from anorexia\\nnervosa.\\nA Harvard study found that an estimated 15.4\\nmillion Americans suffered from a gambling addiction.\\nMore than one-half (7.9 million) were adolescents.\\nCauses and symptoms\\nAddiction to substances results from the interac-\\ntion of several factors:\\nDrug chemistry\\nSome substances are more addictive than others,\\neither because they produce a rapid and intense\\nchange in mood; or because they produce painful\\nwithdrawal symptoms when stopped suddenly.\\nGenetic factor\\nSome people appear to be more vulnerable to\\naddiction because their body chemistry increases\\ntheir sensitivity to drugs. Some forms ofsubstance\\nabuse and dependence seem to run in families; and\\nthis may be the result of a genetic predisposition,\\nenvironmental influences, or a combination of both.\\nBrain structure and function\\nUsing drugs repeatedly over time changes brain\\nstructure and function in fundamental and long-last-\\ning ways. Addiction comes about through an array of\\nchanges in the brain and the strengthening of new\\nmemory connections. Evidence suggests that those\\nlong-lasting brain changes are responsible for the dis-\\ntortions of cognitive and emotional functioning that\\ncharacterize addicts, particularly the compulsion to\\nuse drugs. Although the causes of addiction remain\\nthe subject of ongoing debate and research, many\\nexperts now consider addiction to be a brain disease:\\na condition caused by persistent changes in brain\\nstructure and function. However, having this brain\\nCrack users. Crack, a form of cocaine, is one of the most\\naddictive drugs. (Photograph by Roy Marsch, The Stock\\nMarket. Reproduced by permission.)\\nKEY TERMS\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 53\\nAddiction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 83, 'page_label': '54'}, page_content='disease does not absolve the addict of responsibility\\nfor his or her behavior, but it does explain why many\\naddicts cannot stop using drugs by sheer force of will\\nalone.\\nScientists may have come closer to solving the\\nbrain’s specific involvement in addiction in 2004.\\nPsychiatrists say they have found the craving center\\nof the brain that triggers relapse in addicts. The ante-\\nrior cingulated cortex in the frontal lobe of the brain is\\nthe area responsible for long-term craving in addicts.\\nKnowing the area of the brain from which long-term\\ncravings come may help scientists pinpoint therapies.\\nSocial learning\\nSocial learning is considered the most important\\nsingle factor in addiction. It includes patterns of use in\\nthe addict’s family or subculture, peer pressure, and\\nadvertising or media influence.\\nAvailability\\nInexpensive or readily available tobacco, alcohol,\\nor drugs produce marked increases in rates of\\naddiction.\\nIndividual development\\nBefore the 1980s, the so-called addictive person-\\nality was used to explain the development of addic-\\ntion. The addictive personality was described as\\nescapist, impulsive, dependent, devious, manipulative,\\nand self-centered. Many doctors now believe that\\nthese character traits develop in addicts as a result of\\nthe addiction, rather than the traits being a cause of\\nthe addiction.\\nDiagnosis\\nIn addition to a preoccupation with using and\\nacquiring the abused substance, the diagnosis of\\naddiction is based on five criteria:\\n/C15loss of willpower\\n/C15harmful consequences\\n/C15unmanageable lifestyle\\n/C15tolerance or escalation of use\\n/C15withdrawal symptoms upon quitting\\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\\nsubstance use has stopped. Anti-addiction medications,\\nsuch asmethadone and naltrexone, are also commonly\\nused. A new treatment option has been developed that\\nallows family physicians to treat heroine addiction\\nfrom their offices rather than sending patients to\\nmethadone clinics. The drug is called buprenorphine\\n(Suboxone).\\nResearchers continue to work to identify work-\\nable pharmacological treatments for various addic-\\ntions. In 2004, clinical trials were testing a number of\\ndrugs currently in use for other diseases and condi-\\ntions to see if they could be used to treat addiction.\\nThis would speed up their approval by the U.S. Food\\nand Drug Administration (FDA). For example,\\ncocaine withdrawal is eased by boosting dopamine\\nlevels in the brain, so scientists are studying drugs\\nthat boost dopamine, such as Ritalin, which is used\\nto treat attention-deficit hyperactivity disorder, and\\namantadine, a drug used for flu and Parkinson’s\\ndiease.\\nThe most frequently recommended social form of\\noutpatient treatment is the twelve-step program. Such\\nprograms are also frequently combined with psy-\\nchotherapy. According to a recent study reported\\nby the American Psychological Association (APA),\\nanyone, regardless of his or her religious beliefs or\\nlack of religious beliefs, can benefit from participation\\nin 12-step programs such as Alcoholics Anonymous\\n(AA) orNarcotics Anonymous (NA). The number of\\nvisits to 12-step self-help groups exceeds the number of\\nvisits to all mental health professionals combined.\\nThere are twelve-step groups for all major substance\\nand process addictions.\\nThe Twelve Steps are:\\n/C15Admit powerlessness over the addiction.\\n/C15Believe that a Power greater than oneself could\\nrestore sanity.\\n/C15Make a decision to turn your will and your life over\\nto the care of God, as you understand him.\\n/C15Make a searching and fearless moral inventory of\\nself.\\n/C15Admit to God, yourself, and another human being\\nthe exact nature of your wrongs.\\n/C15Become willing to have God remove all these defects\\nfrom your character.\\n/C15Humbly ask God to remove shortcomings.\\n/C15Make a list of all persons harmed by your wrongs\\nand become willing to make amends to them all.\\n54 GALE ENCYCLOPEDIA OF MEDICINE\\nAddiction'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 84, 'page_label': '55'}, page_content='/C15Make direct amends to such people, whenever possi-\\nble except when to do so would injure them or others.\\n/C15Continue to take personal inventory and promptly\\nadmit any future wrongdoings.\\n/C15Seek to improve contact with a God of the indivi-\\ndual’s understanding throughmeditation and prayer.\\n/C15Carry the message of spiritual awakening to others\\nand practice these principles in all your affairs.\\nPrognosis\\nThe prognosis for recovery from any addiction\\ndepends on the substance or process, the individual’s\\ncircumstances, and underlying personality structure.\\nPolydrug users have the worst prognosis for recovery.\\nPrevention\\nThe most effective form of prevention appears to\\nbe a stable family that models responsible attitudes\\ntoward mood-altering substances and behaviors.\\nPrevention education programs are also widely used\\nto inform the public of the harmfulness of substance\\nabuse.\\nResources\\nBOOKS\\nRobert Wood Johnson Foundation.Substance Abuse: The\\nNation’s #1 Problem. Princeton, N.J., 2001.\\nPERIODICALS\\nKalivas, Peter. ‘‘Drug Addiction: To the Cortex...a n d\\nBeyond.’’ The American Journal of Psychiatry 158, no. 3\\n(March 2001).\\nKelly, Timothy. ‘‘Addiction: A Booming $800 Billion\\nIndustry.’’ The World and I (July 1, 2000).\\nLeshner, Alan. ‘‘Addiction is a Brain Disease.’’Issues in\\nScience and Technology 17, no. 3 (April 1, 2001).\\n‘‘A New Office-based Treatment for Prescription Drug and\\nHeroin Addiction.’’Biotech Week (August 4, 2004):\\n219.\\n‘‘Research Brief: Source of Addiction Identified.’’GP (July\\n19, 2004): 4.\\n‘‘Scientists May Use Existing Drugs to Stop Addiction.’’\\nLife Science Weekly (Sepember 21, 2004): 1184.\\nORGANIZATIONS\\nAl-Anon Family Groups. Box 182, Madison Square Station,\\nNew York, NY 10159. .\\nAlcoholics Anonymous World Services, Inc. Box 459,\\nGrand Central Station, New York, NY 10163. .\\nAmerican Anorexia Bulimina Association.\\n.\\nAmerican Psychiatric Association.\\n.\\nCenter for On-Line Addiction.\\n.\\neGambling: Electronic Joural of Gambling Issues.\\n.\\nNational Alliance on Alcoholism and Drug Dependence,\\nInc. 12 West 21st St., New York, NY 10010. (212)\\n206-6770.\\nNational Center on Addiction and Substance Abuse at\\nColumbia University.\\n.\\nNational Clearinghouse for Alcohol and Drug Information.\\n.\\nNational Institute on Alcohol Abuse and Alcoholism\\n(NIAAA). 6000 Executive Boulevard, Bethesda,\\nMaryland 20892-7003. .\\nBill Asenjo, MS, CRC\\nTeresa G. Odle\\nAddison’s disease\\nDefinition\\nAddison’s disease is a disorder involving dis-\\nrupted functioning of the part of the adrenal gland\\ncalled the cortex. This results in decreased production\\nof two important chemicals (hormones) normally\\nreleased by the adrenal cortex: cortisol and\\naldosterone.\\nDescription\\nThe adrenals are two glands, each perched on the\\nupper part of the two kidneys. The outer part of the\\ngland is known as the cortex; the inner part is known\\nas the medulla. Each of these parts of the adrenal\\ngland is responsible for producing different types of\\nhormones.\\nCortisol is a very potent hormone produced by the\\nadrenal cortex. It is involved in regulating the func-\\ntioning of nearly every type of organ and tissue\\nthroughout the body, and is considered to be one of\\nthe few hormones absolutely necessary for life.\\nCortisol is involved in:\\n/C15the very complex processing and utilization of many\\nnutrients, including sugars (carbohydrates), fats, and\\nproteins\\n/C15the normal functioning of the circulatory system and\\nthe heart\\nGALE ENCYCLOPEDIA OF MEDICINE 55\\nAddison’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 85, 'page_label': '56'}, page_content='/C15the functioning of muscles\\n/C15normal kidney function\\n/C15production of blood cells\\n/C15the normal processes involved in maintaining the\\nskeletal system\\n/C15proper functioning of the brain and nerves\\n/C15the normal responses of the immune system\\nAldosterone, also produced by the adrenal cortex,\\nplays a central role in maintaining the appropriate\\nproportions of water and salts in the body. When\\nthis balance is upset, the volume of blood circulating\\nthroughout the body will fall dangerously low, accom-\\npanied by a drop in blood pressure.\\nAddison’s disease is also called primary adreno-\\ncortical insufficiency. In other words, some process\\ninterferes directly with the ability of the adrenal cortex\\nto produce its hormones. Levels of both cortisol and\\naldosterone drop, and numerous functions through-\\nout the body are disrupted.\\nAddison’s disease occurs in about four in every\\n100,000 people. It strikes both men and women of all\\nages.\\nCauses and symptoms\\nThe most common cause of Addison’s disease is\\nthe destruction and/or shrinking (atrophy) of the adre-\\nnal cortex. 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,\\nand destroy them. In about 20% of all cases, destruc-\\ntion of the adrenal cortex is caused bytuberculosis.T h e\\nremaining cases of Addison’s disease may be caused\\nby fungal infections, such ashistoplasmosis, coccidio-\\nmycosis, andcryptococcosis, which affect the adrenal\\ngland by producing destructive, tumor-like masses\\ncalled granulomas; a disease called amyloidosis,i n\\nwhich a starchy substance called amyloid is deposited\\nin abnormal places throughout the body, interfering\\nwith the function of whatever structure it is present\\nwithin; or invasion of the adrenal glands bycancer.\\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\\n90% of the adrenal cortex has been destroyed. The\\nmost common symptoms include fatigue and loss\\nof energy, decreased appetite,nausea, vomiting, diar-\\nrhea, abdominal pain, weight loss, muscle weakness,\\ndizziness when standing,dehydration, unusual areas of\\ndarkened (pigmented) skin, and dark freckling. As the\\ndisease progresses, the patient may appear to have\\nvery tanned, or bronzed skin, with darkening of the\\nlining of the mouth, vagina, and rectum, and dark\\npigmentation of the area around the nipples (aere-\\nola). As dehydration becomes more severe, the\\nblood pressure will continue to drop and the patient\\nwill feel increasingly weak and light-headed. Some\\npatients have psychiatric symptoms, including\\ndepression and irritability. Women lose pubic and\\nunderarm hair, and stop having normal menstrual\\nperiods.\\nWhen a patient becomes ill with an infection,\\nor stressed 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,\\nuncontrollable nausea and vomiting, a drastic drop in\\nblood pressure, kidney failure, and unconsciousness.\\nAbout 25% of all Addison’s disease patients are\\nidentified due to the development of Addisonian crisis.\\nDiagnosis\\nMany patients do not recognize the slow progres-\\nsion of symptoms and the disease is ultimately iden-\\ntified when a physician notices the areas of increased\\npigmentation of the skin. Once suspected, a number\\nof blood tests can lead to the diagnosis of Addison’s\\ndisease. It is not sufficient to demonstrate low blood\\ncortisol levels, as normal levels of cortisol vary quite\\nwidely. Instead, patients are given a testing dose of\\nanother hormone called corticotropin (ACTH).\\nACTH is produced in the body by the pituitary\\ngland, and normally acts by promoting growth\\nwithin the adrenal cortex and stimulating the produc-\\ntion and release of cortisol. In Addison’s disease,\\neven a dose of synthetic ACTH does not increase\\ncortisol levels.\\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 the\\nbody, which travels to another part of the body in\\norder to exert its effect.\\n56 GALE ENCYCLOPEDIA OF MEDICINE\\nAddison’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 86, 'page_label': '57'}, page_content='To distinguish between primary adrenocortical\\ninsufficiency (Addison’s disease) and secondary adre-\\nnocortical insufficiency (caused by failure of the pitui-\\ntary 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\\nto the presence of ACTH. This confirms the diagnosis\\nof Addison’s disease.\\nTreatment\\nTreatment of Addison’s disease involves replac-\\ning the missing or low levels of cortisol. In the case\\nof Addisonian crisis, this will be achieved by injecting\\na potent form of steroid preparation through a needle\\nplaced in a vein (intravenous or IV). Dehydration\\nand salt loss will also be treated by administering\\ncarefully balanced solutions through the IV.\\nDangerously low blood pressure may require special\\nmedications to safely elevate it until the steroids take\\neffect.\\nPatients with Addison’s disease will need to take a\\nsteroid preparation (hydrocortisone) and a replace-\\nment for aldosterone (fludrocortisone) by mouth for\\nthe rest of their lives. When a patient has an illness\\nwhich causes nausea and vomiting (such that they\\ncannot hold down their medications), he or she will\\nneed to enter a medical facility where IV medications\\ncan be administered. When a patient has any kind of\\ninfection or injury, the normal dose of hydrocortisone\\nwill 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\\nare always at risk of developing Addisonian crisis.\\nResources\\nBOOKS\\nWilliams, Gordon H., and Robert G. Dluhy.\\n‘‘Hypofunction of the Adrenal Cortex.’’ InHarrison’s\\nPrinciples of Internal Medicine , edited by Anthony\\nS.Fauci, et al. New York: McGraw-Hill, 1997.\\nORGANIZATIONS\\nNational Adrenal Disease Foundation. 505 Northern\\nBoulevard, Suite 200, Great Neck, NY 11021. (516)\\n487-4992.\\nRosalyn Carson-DeWitt, MD\\nAdenoid hyperplasia\\nDefinition\\nAdenoid hyperplasia is the overenlargement of\\nthe lymph glands located above the back of the mouth.\\nDescription\\nLocated at the back of the mouth above and\\nbelow the soft palate are two pairs of lymph glands.\\nThe tonsils below are clearly visible behind the back\\nteeth; the adenoids lie just above them and are hidden\\nfrom view by the palate. Together these four arsenals\\nof immune defense guard the major entrance to the\\nbody from foreign invaders–the germs we breathe and\\neat. In contrast to the rest of the body’s tissues, lym-\\nphoid tissue reaches its greatest size in mid-childhood\\nand recedes thereafter. In this way children are best\\nable to develop the immunities they need to survive in\\na world full of infectious diseases.\\nBeyond its normal growth pattern, lymphoid tis-\\nsue grows excessively (hypertrophies) during an acute\\ninfection, as it suddenly increases its immune activity\\nto fight off the invaders. Often it does not completely\\nreturn to its former size. Each subsequent infection\\nleaves behind a larger set of tonsils and adenoids. To\\nmake matters worse, the sponge-like structure of these\\nhypertrophied glands can produce safe havens for\\ngerms where the body cannot reach and eliminate\\nthem. Beforeantibiotics and the reduction in infectious\\nchildhood diseases over the past few generations, ton-\\nsils and adenoids caused greater health problems.\\nCauses and symptoms\\nMost tonsil and adenoid hypertrophy is simply\\ncaused by the normal growth pattern for that type of\\ntissue. Less often, the hypertrophy is due to repeated\\nthroat infections by cold viruses, strep throat, mono-\\nnucleosis, and in times gone by,diphtheria. The acute\\ninfections are usually referred to astonsillitis, the ade-\\nnoids getting little recognition because they cannot be\\nseen without special instruments. Symptoms include\\npainful, bright red, often ulcerated tonsils, enlarge-\\nment of lymph nodes (glands) beneath the jaw,fever,\\nand general discomfort.\\nAfter the acute infection subsides, symptoms are\\ngenerated simply by the size of the glands. Extremely\\nlarge tonsils can impair breathing and swallowing,\\nalthough that is quite rare. Large adenoids can impair\\nnose breathing and require a child to breathe through\\nthe mouth. Because they encircle the only connection\\nGALE ENCYCLOPEDIA OF MEDICINE 57\\nAdenoid hyperplasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 87, 'page_label': '58'}, page_content='between the middle ear and the eustachian tube,\\nhypertrophied adenoids can also obstruct it and\\ncause middle ear infections.\\nDiagnosis\\nA simple tongue blade depressing the tongue\\nallows an adequate view of the tonsils. Enlarged ton-\\nsils may have deep pockets (crypts) containing dead\\ntissue (necrotic debris). Viewing adenoids requires a\\nsmall mirror or fiberoptic scope. A child with recurring\\nmiddle ear infections may well have large adenoids. A\\nthroat cultureor mononucleosis test will usually reveal\\nthe identity of the germ.\\nTreatment\\nIt used to be standard practice to remove tonsils\\nand/or adenoids after a few episodes of acute throat or\\near infection. The surgery is calledtonsillectomy and\\nadenoidectomy (T and A). Opinion changed as it was\\nrealized that this tissue is beneficial to the development\\nof immunity. For instance, children without tonsils\\nand adenoids produce only half the immunity to oral\\npolio vaccine. In addition, treatment of ear and throat\\ninfections with antibiotics and of recurring ear infec-\\ntions with surgical drainage through the ear drum\\n(tympanostomy) has greatly reduced the incidence of\\nsurgical removal of these lymph glands.\\nAlternative treatment\\nThere are many botanical/herbal remedies that\\ncan be used alone or in formulas to locally assist the\\ntonsils and adenoids in their immune function at the\\nopening of the oral cavity and to tone these glands.\\nKeeping the Eustachian tubes open is an important\\ncontribution to optimal function in the tonsils and\\nadenoids. Food allergies are often the culprits for\\nrecurring ear infections, as well as tonsilitis and ade-\\nnoiditis. Identification and removal of the allergic\\nfood(s) can greatly assist in alleviating the cause of\\nthe problem. Acute tonsillitis also benefits from\\nwarm saline gargles.\\nPrognosis\\nHypertrophied adenoids are a normal part of\\ngrowing up and should be respected for their impor-\\ntant role in the development of immunity. Only when\\ntheir size causes problems by obstructing breathing or\\nmiddle ear drainage do they demand intervention.\\nPrevention\\nPrevention can be directed toward prompt evalua-\\ntion and appropriate treatment of sore throats to pre-\\nvent overgrowth of adenoid tissue. Avoiding other\\nchildren with acute respiratory illness will also reduce\\nthe spread of these common illnesses.\\nResources\\nBOOKS\\nBehman, Richard E., editor. ‘‘Tonsils and Adenoids.’’ In\\nNelson Textbook of Pediatrics. Philadelphia: W. B.\\nSaunders Co., 1996.\\nJ. Ricker Polsdorfer, MD\\nAdenoid hypertrophy see Adenoid\\nhyperplasia\\nAdenoid removal see Tonsillectomy\\nand adenoidectomy\\nAdenoidectomy see Tonsillectomy\\nand adenoidectomy\\nAdenovirus infections\\nDefinition\\nAdenoviruses are DNA viruses (small infectious\\nagents) that cause upper respiratory tract infections,\\nconjunctivitis, and other infections in humans.\\nDescription\\nAdenoviruses were discovered in 1953. About 47\\ndifferent types have been identified since then, and\\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).\\n58 GALE ENCYCLOPEDIA OF MEDICINE\\nAdenovirus infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 88, 'page_label': '59'}, page_content='about half of them are believed to cause human dis-\\neases. Infants and children are most commonly\\naffected by adenoviruses. Adenovirus infections can\\noccur throughout the year, but seem to be most com-\\nmon from fall to spring.\\nAdenoviruses are responsible for 3-5% of acute\\nrespiratory infections in children and 2% of respira-\\ntory illnesses in civilian adults. They are more apt to\\ncause infection among military recruits and other\\nyoung people who live in institutional environments.\\nOutbreaks among children are frequently reported at\\nboarding schools and summer camps. Another exam-\\nple includes an increased outbreak ofgastroenteritis\\namong cruise passengers in 2002.\\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),\\nadenoviruses kill healthy cells and replicate up to\\none million new viruses per cell killed (of which 1-5%\\nare infectious). People with this kind of infection feel\\nsick. In chronic or latent infection, a much smaller num-\\nber of viruses are released and healthy cells can multiply\\nmore rapidly than they are destroyed. People who have\\nthis kind of infection don’t seem to be sick. This is\\nprobably why many adults have immunity to adeno-\\nviruses without realizing 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 most\\nof these infections. Occasionally more serious lower\\nrespiratory diseases, such aspneumonia,m a yo c c u r .\\nAdenoviruses also cause acute pharyngoconjunc-\\ntival fever in children. This disease is most often caused\\nby types 3 and 7. Symptoms, which appear suddenly\\nand usually disappear in less than a week, include:\\n/C15inflammation of the lining of the eyelid (conjunctivitis)\\n/C15fever\\n/C15sore throat (pharyngitis)\\n/C15runny nose\\n/C15inflammation of lymph glands in the neck (cervical\\nadenitis)\\nAdenoviruses also cause acutediarrhea in young\\nchildren, characterized by fever and watery stools.\\nThis condition is caused by adenovirus types 40 and\\n41 and can last as long as two weeks.\\nAs much as 51% of all hemorrhagic cystitis\\n(inflammation of the bladder and of the tubes that\\ncarry urine to the bladder from the kidneys) in\\nAmerican and Japanese children can be attributed to\\nadenovirus infection. A child who has hemorrhagic\\ncystitis has bloody urine for about three days, and\\ninvisible traces of blood can be found in the urine a\\nfew days longer. The child will feel the urge to urinate\\nfrequently–but find it difficult to do so–for about the\\nsame length of time.\\nAdult infections\\nIn adults, the most frequently reported adeno-\\nvirus infection is acute respiratory disease (ARD,\\ncaused by types 4 and 7) in military recruits.\\nInfluenza-like symptoms including fever, sore throat,\\nrunny nose, and cough are almost always present;\\nweakness, chills,headache, and swollen lymph glands\\nin the neck also may occur. The symptoms typically\\nlast three to five days.\\nEpidemic keratoconjunctivitis (EKC, caused by\\nadenovirus types 8, 19, and 37) was first seen in ship-\\nyard workers whose eyes had been slightly injured by\\nchips of rust or paint. This inflammation of tissues\\nlining the eyelid and covering the front of the eyeball\\nalso can be caused by using contaminated contact lens\\nsolutions or by drying the hands or face with a towel\\nused by someone who has this infection.\\nThe inflamed, sticky eyelids characteristic of\\nconjunctivitis develop 4-24 days after exposure and\\nlast between one and four weeks. Only 5-8% of\\npatients with epidemic keratoconjunctivitis experience\\nrespiratory symptoms. One or both eyes may be\\naffected. As symptoms of conjunctivitis subside, eye\\npain and watering and blurred vision develop. These\\nsymptoms ofkeratitis may last for several months, and\\nabout 10% of these infections spread to at least one\\nother member of the patient’s household.\\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 core\\nof genetic material (DNA or RNA) surrounded by a\\nshell of protein.\\nGALE ENCYCLOPEDIA OF MEDICINE 59\\nAdenovirus infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 89, 'page_label': '60'}, page_content='Other illnesses associated with adenovirus include:\\n/C15encephalitis (inflammation of the brain) and other\\ninfections of the central nervous system (CNS)\\n/C15gastroenteritis (inflammation of the stomach and\\nintestines)\\n/C15acute mesenteric lymphadenitis (inflammation of\\nlymph glands in the abdomen)\\n/C15chronic interstitial fibrosis (abnormal growth of\\nconnective tissue between cells)\\n/C15intussusception (a type of intestinal obstruction)\\n/C15pneumonia that doesn’t respond to antibiotic therapy\\n/C15whooping coughsyndrome whenBordetella pertussis\\n(the bacterium that causes classic whooping cough) is\\nnot found\\nCauses and symptoms\\nSpecific adenovirus infections can be traced to\\nparticular sources and produce distinctive symptoms.\\nIn general, however, adenovirus infection is caused by:\\n/C15inhaling airborne viruses\\n/C15getting the virus in the eyes by swimming in contami-\\nnated water, using contaminated eye solutions or\\ninstruments, wiping the eyes with contaminated\\ntowels, or rubbing the eyes with contaminated fingers.\\n/C15not washing the hands after using the bathroom, and\\nthen touching the mouth or eyes\\nSymptoms common to most types of adenovirus\\ninfections include:\\n/C15cough\\n/C15fever\\n/C15runny nose\\n/C15sore throat\\n/C15watery eyes\\nDiagnosis\\nAlthough symptoms may suggest the presence of\\nadenovirus, distinguishing these infections from other\\nviruses can be difficult. A definitive diagnosis is based\\non culture or detection of the virus in eye secretions,\\nsputum, urine, or stool.\\nThe extent of infection can be estimated from the\\nresults of blood tests that measure increases in the\\nquantity of antibodies the immune system produces to\\nfight it. Antibody levels begin to rise about a week after\\ninfection occurs and remain elevated for about a year.\\nTreatment\\nTreatment of adenovirus infections is usually\\nsupportive and aimed at relieving symptoms of the\\nillness. Bed rest may be recommended along with\\nmedications to reduce fever and/or pain. (Aspirin\\nshould not be given to children because of concerns\\nabout Reye’s syndrome.) Eye infections may benefit\\nfrom topicalcorticosteroids to relieve symptoms and\\nshorten the course of the disease. Hospitalization is\\nusually required for severe pneumonia in infants and\\nfor EKC (to prevent blindness). No effectiveantiviral\\ndrugs have been developed.\\nPrognosis\\nAdenovirus infections are rarely fatal. Most\\npatients recover fully.\\nPrevention\\nPracticing good personal hygiene and avoiding\\npeople with infectious illnesses can reduce the\\nrisk of developing adenovirus infection. Proper hand-\\nwashing can prevent the spread of the virus by oral-\\nfecal transmission. Sterilization of instruments and\\nsolutions used in the eye can prevent the spread of\\nEKC, as can adequate chlorination of swimming\\npools.\\nA vaccine for pertussis has been developed\\nand is in use in combination withdiphtheria and teta-\\nnus vaccines for infants. It is shown to have nearly\\n90% efficacy. A vaccine containing live adenovirus\\ntypes 4 and 7 is used to control disease in military\\nrecruits, but it is not recommended or available for\\ncivilian use. A recent resurgence of the adenovirus\\nwas found in a military population as soon as the\\nvaccination program was halted. Vaccines prepared\\nfrom purified subunits of adenovirus are under\\ninvestigation.\\nResources\\nPERIODICALS\\nEvans, Jeff. ‘‘Viral Gastroenteritis On Board.’’Internal\\nMedicine News (January 15, 2003): 44.\\n‘‘Guard Against Pertussis.’’Contemporary Pediatrics\\n(February 2003): 87.\\nKolavic-Gray, Shellie A., et al. ‘‘Large Epidemic of\\nAdenovirus Type 4 Infection Among Military Trainees:\\nEpidemiological, Clinical, and Laboratory Studies.’’\\nClinical Infectious Diseases (October 1, 2002): 808–811.\\nMaureen Haggerty\\nTeresa G. Odle\\n60 GALE ENCYCLOPEDIA OF MEDICINE\\nAdenovirus infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 90, 'page_label': '61'}, page_content='Adhesions\\nDefinition\\nAdhesions are fibrous bands of scar tissue that\\nform between internal organs and tissues, joining\\nthem together abnormally.\\nDescription\\nAdhesions are made up of blood vessels and fibro-\\nblasts—connective tissue cells. They form as a normal\\npart of the body’s healing process and help to limit\\nthe spread of infection. However when adhesions\\ncause the wrong tissues to grow into each other,\\nmany different complex inflammatory disorders can\\narise. Worldwide millions of people sufferpain and\\ndysfunction due to adhesion disease.\\nDepending on their location, the most common\\ntypes of adhesions may called:\\n/C15abdominal adhesions\\n/C15intestinal adhesions\\n/C15intraperitoneal adhesions\\n/C15pelvic adhesions\\n/C15intrauterine adhesions or Asherman’s syndrome.\\nAdhesions can form between various tissues in the\\nbody including:\\n/C15loops of the intestines\\n/C15the intestines and other abdominal organs or the\\nabdominal wall\\n/C15abdominal organs such as the liver or bladder and\\nthe abdominal wall\\n/C15tissues of the uterus.\\nAlthough adhesions can be congenital (present at\\nbirth) or result from inflammation, injury, or infec-\\ntion, the vast majority of adhesions form following\\nsurgery. Adhesions are a major complication of\\nmany common surgical procedures and may occur in\\n55% to more than 90% of patients, depending on the\\ntype of surgery.\\nAll abdominal surgeries carry the risk of adhesion\\nformation. Abdominal adhesions are rare in people\\nwho have not had abdominal surgery and very com-\\nmon in people who have had multiple abdominal sur-\\ngeries. Adhesions are more common following\\nprocedures involving the intestines, colon, appendix,\\nor uterus. They are less common following surgeries\\ninvolving the stomach, gall bladder, or pancreas.\\nAlthough most abdominal adhesions do not cause\\nproblems, they can be painful when stretched or pulled\\nbecause the scar tissue is not elastic.\\nKEY TERMS\\nAsherman’s syndrome— The cessation of men-\\nstruation and/or infertility caused by intrauterine\\nadhesions.\\nComputed axial tomography; CT or CAT scan— A\\ncomputer reconstruction of scanned x rays used to\\ndiagnose intestinal obstructions.\\nEndometriosis— A condition in which the endome-\\ntrial tissue that lines the uterus begins to invade\\nother parts of the body.\\nEndoscope— A device with a light that is used to\\nlook into a body cavity or organ.\\nFibroblast— A connective-tissue cell.\\nGlaucoma— A group of eye diseases characterized\\nby increased pressure within the eye that can\\ndamage the optic nerve and cause gradual loss of\\nvision.\\nHysteroscopy— A procedure in which an endo-\\nscope is inserted through the cervix to view the\\ncervix and uterus.\\nHysterosalpingography; HSG— X raying of the\\nuterus and fallopian tubes following the injection\\nof a contrast dye.\\nIrido corneal endothelial syndrome; ICE— A type\\nof glaucoma in which cells from the back of the\\ncornea spread over the surface of the iris and tissue\\nthat drains the eye, forming adhesions that bind the\\niris to the cornea.\\nLaparoscopic surgery; keyhole surgery— Surgery\\nthat utilizes a laparoscope with a video camera and\\nsurgical instrumentsinserted throughsmall incisions.\\nLaparoscopy— A procedure that utilizes an endo-\\nscope to view contents of the abdominal cavity.\\nPelvic inflammatory disease; PID— Inflammation\\nof the female reproductive organs and associated\\nstructures.\\nPeritoneum— The membrane lining the walls of the\\nabdominal and pelvic cavities and enclosing their\\norgans.\\nSmall bowel obstruction; SBO— An obstruction of\\nthe small intestine that prevents the free passage of\\nmaterial; sometimes caused by postoperative\\nadhesions.\\nGALE ENCYCLOPEDIA OF MEDICINE 61\\nAdhesions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 91, 'page_label': '62'}, page_content='Postoperative intestinal adhesions are a major\\ncause of intestinal or small bowel obstruction (SBO).\\nIn a small number of people the scar tissue pulls sec-\\ntions of the small or large intestines out of place and\\npartially or completely blocks the passage of food and\\nfluids. Thus SBOs can result from abdominal surgery\\nand also are one of the most common reasons for\\nabdominal surgery. Although intestinal obstruction\\nis fatal in about 5% of patients, the mortality rate\\nassociated with SBO has decreased dramatically over\\nthe past century.\\nIntrauterine adhesions are relatively common in\\nwomen and the majority of women undergoing gyne-\\ncological surgery develop postoperative adhesions.\\nSometimes these pelvic adhesions cause chronic pelvic\\npain and/orinfertility.\\nAdhesions can cause a rare form ofglaucoma\\ncalled irido corneal endothelial (ICE) syndrome. In\\nthis disorder cells from the back surface of the cornea\\nof the eye spread over the surface of the iris and the\\ntissue that drains the eye, forming adhesions that bind\\nthe iris to the cornea and causing further blockage of\\nthe drainage channels. This blockage increases the\\npressure inside the eye, which may damage the optic\\nnerve. ICE syndrome occurs most often in light-\\nskinned females.\\nCauses and symptoms\\nPost-surgical adhesions\\nCommon causes of postoperative adhesions\\ninclude:\\n/C15abdominal surgery\\n/C15gynecological surgery\\n/C15thoracic surgery\\n/C15orthopedic surgery\\n/C15plastic surgery.\\nAbdominal adhesions most often result from sur-\\ngeries in which the organs are handled or temporarily\\nmoved. Intrauterine adhesions form after surgeries\\ninvolving the uterus, particularly curettage—the\\nscraping of the uterine contents. Surgery to control\\nuterine bleeding after giving birth also can lead to\\nintrauterine adhesions. Such adhesions can cause\\nAsherman’s syndrome, closing the uterus and prevent-\\ning menstruation.\\nOther causes of adhesions\\nAny inflammation or infection of the membranes\\nthat line the abdominal and pelvic walls and enclose\\nthe organs—the peritoneum—can cause adhesions.\\nAn example peritonitis, a severe infection that can\\nresult from appendicitis, may lead to adhesions. In\\naddition to surgery or injury, pelvic adhesions can be\\ncaused by inflammation resulting from an infection\\nsuch aspelvic inflammatory disease(PID).\\nSymptoms\\nIn the majority of people adhesions do not cause\\nsymptoms or serious problems. However in some peo-\\nple adhesions can lead to a variety of disorders. The\\nsymptoms depend on the type of adhesion and the\\ntissues that are involved. Adhesions may cause pain\\nand/or fever in some people.\\nABDOMINAL OBSTRUCTION. If a loop of intestine\\nbecomes trapped under an adhesion, the intestine may\\nbecome partially or completely blocked. The symp-\\ntoms of intestinal obstruction or SBOs due to adhe-\\nsions depend on the degree and location of the\\nobstruction. Partial or off-and-on intestinal obstruc-\\ntion due to adhesions may result in intermittent peri-\\nods of painful abdominal cramping and other\\nsymptoms, includingdiarrhea.\\nSymptoms of significant intestinal obstruction\\ndue to adhesions include:\\n/C15severe abdominal pain and cramping\\n/C15nausea and vomiting\\n/C15abdominal distension (swelling)\\n/C15constipation and the inability to pass gas\\n/C15symptoms ofdehydration.\\nSymptoms of dehydration include:\\n/C15dry mouth and tongue\\n/C15severe thirst\\n/C15infrequent urination\\n/C15dry skin\\n/C15fast heart rate\\n/C15low blood pressure.\\nIn about 10% of SBOs, part of the intestine twists\\ntightly and repeatedly around a band of adhesions,\\ncutting off the blood supply to the intestine and result-\\ning in strangulation and death of the twisted bowel.\\nThe mortality rate for strangulation of the bowel may\\nbe as high as 37%.\\nSymptoms of bowel strangulation due to adhe-\\nsions include:\\n/C15severe abdominal pain, either cramping or constant\\n62 GALE ENCYCLOPEDIA OF MEDICINE\\nAdhesions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 92, 'page_label': '63'}, page_content='/C15abdominal distension due to the inability to pass\\nstool and gas\\n/C15an extremely tender abdomen\\n/C15signs of systemic (body-wide) illness, including fever,\\nfast heart rate, and low blood pressure.\\nWhen a portion of the obstructed bowel begins to\\ndie from lack of blood flow, fluids and bacteria that\\nhelp digest food can leak out of the intestinal wall and\\ninto the abdominal cavity causing peritonitis.\\nPELVIC ADHESIONS. Pelvic adhesions can interfere\\nwith the functioning of the ovaries and fallopian tubes\\nand are among the common causes of female inferti-\\nlity. Adhesions on the ovaries or fallopian tubes can\\nprevent pregnancy by trapping the released egg.\\nAdhesions resulting from endometriosis can cause pel-\\nvic pain, particularly during menstruation, as well as\\nfertility problems.\\nDiagnosis\\nAdhesions are diagnosed based on the symptoms,\\nsurgical history, and aphysical examination. The phy-\\nsician examines the abdomen and rectum and performs\\na pelvic examination on women. Blood tests and chest\\nand abdominal x rays are taken. Sometimes explora-\\ntory surgery is used to locate the adhesions and\\nsources of pain.\\nAbdominal computed axial tomography—a CT\\nor CAT scan—is the most common diagnostic tool\\nfor SBO and intestinal strangulation due to adhesions.\\nIn this procedure a computer reconstructs a portion\\nof the abdomen from x-ray scans. Barium contrast\\nx-ray studies also may be used to locate an obstruc-\\ntion. The ingestion of a barium solution provides bet-\\nter visualization of the abdominal organs. However\\nsometimes intestinal obstruction or strangulation\\ncannot be confirmed without abdominal surgery.\\nExploratory laparoscopy may be used to detect\\neither abdominal or pelvic adhesions. This procedure\\nusually is performed in a hospital under local orgen-\\neral anesthesia. A small incision is made near the naval\\nand carbon dioxide gas is injected to raise the abdom-\\ninal wall. A tube called a trocar is inserted into the\\nabdomen. The laparascope, equipped with a light and\\na small video camera, is passed through the trocar\\nfor visualization of the peritoneal cavity and the\\nabdominal or pelvic organs.\\nPelvic adhesions also may be detected byhyste-\\nroscopy. In this procedure a uterine endoscope is\\ninserted through the cervix to visualize the cervix and\\nuterine cavity. Withhysterosalpingography (HSG) a\\nradiopaque or contrast dye is injected through a cathe-\\nter in the cervix and x rays are taken of the uterus and\\nfallopian tubes.\\nTreatment\\nAlthough the symptoms of adhesion disease\\nsometimes disappear on their own, adhesions are per-\\nmanent without a surgical procedure called adhesion\\nlysis to disrupt or remove the tissue.\\nAbdominal adhesions\\nSometimes an adhesion-trapped intestine frees\\nitself spontaneously. Surgery may be used to reposi-\\ntion the intestine to relieve symptoms. Various other\\ntechniques include using suction to decompress the\\nintestine; however untreated intestinal adhesions may\\nlead to bowel obstruction.\\nAlthough dilation with an endoscope may be used\\nto widen the region around an intestinal obstruction to\\nrelieve symptoms, SBOs caused almost always require\\nimmediate surgery. In cases of a partial obstruction or\\na complete obstruction without severe symptoms, sur-\\ngery may be delayed for 12–24 hours so that a dehy-\\ndrated patient can be treated with intravenous fluids.\\nA small suction tube may be placed through the nose\\ninto the stomach to remove the stomach contents to\\nrelieve pain and nausea and prevent further bloating.\\nIf an adhesion-related SBO disrupts the blood\\nsupply to part of the intestine, gangrene—tissue\\ndeath—can occur. Strangulation of the bowel usually\\nrequires emergency abdominal surgery to remove the\\nadhesions and restore blood flow to the intestine.\\nIntestinal obstruction repair is performed under gen-\\neral anesthesia. An incision is made in the abdomen,\\nthe obstruction is located, and the adhesions are cut\\naway, releasing the intestine. The bowel is examined\\nfor injury or tissue death. If possible, injured and dead\\nsections are removed and the healthy ends of the intes-\\ntine are stitched together (resectioned). If resectioning\\nis not possible, the ends of the intestine are brought\\nthrough an opening in the abdomen called anostomy.\\nIn some cases laparoscopic surgery can be used to\\nremoved damaged portions of the intestines. Five or\\nsix small incisions—0.2–0.4 in. (5–10 mm) in length—\\nare made in the abdomen. The laparoscope, equipped\\nwith its light and camera, and surgical instruments are\\ninserted through the incisions. The laparoscope guides\\nthe surgeon by projecting images of the abdominal\\norgans on a video monitor. However the existence of\\nmultiple adhesions may preclude the use of laparo-\\nscopic surgery.\\nGALE ENCYCLOPEDIA OF MEDICINE 63\\nAdhesions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 93, 'page_label': '64'}, page_content='Other types of adhesions\\nAdhesions caused by endometriosis may be\\nremoved by either traditional open abdominal or pel-\\nvic surgery or by laparoscopic surgery. In the latter\\ntechnique the laparoscope includes a laser for destroy-\\ning the tissue with heat. Although untreated gyneco-\\nlogical adhesions can lead to infertility, both types of\\nsurgeries also can result in adhesion formation.\\nICE-type glaucoma caused by adhesions is diffi-\\ncult to treat; however untreated ICE syndrome can\\nlead to blindness. Treatment usually includes medica-\\ntion and/or filtering surgery. Filtering microsurgery\\ninvolves cutting a tiny hole in the white of the eye\\n(the sclera) to allow fluid to drain, thereby lowering\\nthe pressure in the eye and preventing or reducing\\ndamage to the optic nerve.\\nAlternative treatment\\nIn cases where the intestines are partially blocked\\nby adhesions, a diet low in fiber—called a low-residue\\ndiet—may enable food to move more easily through\\nthe obstruction.\\nPrognosis\\nIntestinal obstruction surgery usually has a favor-\\nable outcome if the surgery is performed before tissue\\ndamage or death occurs. Surgery to remove adhesions\\nand to free or reconnect the intestine often is sufficient\\nfor reducing symptoms and returning normal function\\nto the intestine or other organ. However the risk of\\nnew adhesion formation increases with each addi-\\ntional surgery. Thus abdominal adhesions can become\\na recurring problem. Adhesions reform in 11–21% of\\npatients who have surgery to remove an adhesion-\\nrelated intestinal obstruction. The risk of recurrence\\nis particularly high among survivors of bowel\\nstrangulation.\\nPrevention\\nAbdominal and gynecological laparoscopic sur-\\ngeries—also known as ‘‘keyhole’’ surgeries—reduce\\nthe size of the incision and the amount of contact\\nwith the organs, thereby lowering the risk of adhesion\\nformation. Sometimes the intestines are fixed in place\\nduring surgery so as to promote benign adhesions that\\nwill not cause obstructions.\\nWithin five days after surgery the disturbed tissue\\nsurfaces have formed a new lining of mesothelial cells\\nthat prevent adhesions from forming. Therefore bio-\\ndegradable barrier membranes, films, gels, or sprays\\ncan be used to physically separate the tissues after\\nsurgery to prevent the formation of postoperative\\nadhesions.However these gels and other barrier agents\\nmay:\\n/C15suppress the immune system\\n/C15cause infection\\n/C15impair healing\\nSystemic anti-inflammatory medications may be\\nused to help prevent adhesion formation. Recent stu-\\ndies suggest that the common oral arthritis drug,\\nCelebrex, an anti-inflammatory COX-2 inhibitor,\\ntaken before and immediately after surgery, may\\nhelp prevent abdominal adhesions. Celebrex is\\nknown to inhibit both the formation of blood vessels\\nand fibroblast activity, which are necessary for the\\nformation of scar tissue.\\nRecent research has focused on the incorporation\\nof anti-inflammatory and anti-proliferation drugs into\\npolymeric films used for preventing and treating post-\\nsurgical adhesions. New types of gels to prevent post-\\noperative adhesions also are under development.\\nResources\\nBOOKS\\nBaerga-Varela, Y. ‘‘Small Bowel Obstruction.’’Mayo Clinic\\nGastrointestinal Surgery, edited by K. A. Kelly, et al.\\nSt. Louis, MO: Elsevier Science, 2004.\\nPERIODICALS\\n‘‘Surgical Complications; Celebrex Prevents Adhesions\\nAfter Surgery.’’Science Letter (February 15, 2005):\\n1443.\\nORGANIZATIONS\\nNational Digestive Diseases Information Clearinghouse.\\n2 Information Way, Bethesda, MD 20892-3570. 800-891-\\n5389. 301-654-3810. .\\nOTHER\\nAbdominal Adhesions. Aetna InteliHealth. February 17,\\n2004 [cited March 2, 2005]. .\\nEndometriosis. MayoClinic.com. September 11, 2003 [cited\\nMarch 2, 2005]. .\\nInfertility. MayoClinic.com. September 21, 2004 [cited\\nMarch 2, 2005]. .\\n‘‘Intestinal Adhesions.’’Digestive Diseases. National\\nDigestive Diseases Information Clearinghouse.\\nFebruary 2004 [cited February 21, 2005]. .\\nWhat is Glaucoma? Glaucoma Research Foundation. [Cited\\nMarch 4, 2005]. .\\nMargaret Alic, Ph.D.\\n64 GALE ENCYCLOPEDIA OF MEDICINE\\nAdhesions'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 94, 'page_label': '65'}, page_content='Adjustment 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\\nlasting.\\nDescription\\nAn adjustment disorder usually begins within\\nthree months of a stressful event, and ends within six\\nmonths after the stressor stops. There are many dif-\\nferent subtypes of adjustment disorders, including\\nadjustment disorder with:\\n/C15depression\\n/C15anxiety\\n/C15mixed anxiety and depression\\n/C15conduct disturbances\\n/C15mixed disturbance of emotions and conduct\\n/C15unspecified\\nAdjustment disorders are very common and can\\naffect anyone, regardless of gender, age, race, or life-\\nstyle. By definition, an adjustment disorder is short-\\nlived, unless a person is faced with a chronic recurring\\ncrisis (such as a child who is repeatedly abused). In\\nsuch cases, the adjustment disorder may last more\\nthan six months.\\nCauses and symptoms\\nAn adjustment disorder occurs when a person\\ncan’t cope with a stressful event and develops emo-\\ntional or behavioral symptoms. The stressful event can\\nbe anything: it might be just one isolated incident, or a\\nstring of problems that wears the person down. The\\nstress might be anything from a car accident or illness,\\nto a divorce, or even a certain time of year (such as\\nChristmas or summer).\\nPeople with adjustment disorder may have a wide\\nvariety of symptoms. How those symptoms combine\\ndepend on the particular subtype of adjustment dis-\\norder and on the individual’s personality and psycho-\\nlogical defenses. Symptoms normally include some\\n(but not all) of the following:\\n/C15hopelessness\\n/C15sadness\\n/C15crying\\n/C15anxiety\\n/C15worry\\n/C15headaches or stomachaches\\n/C15withdrawal\\n/C15inhibition\\n/C15truancy\\n/C15vandalism\\n/C15reckless driving\\n/C15fighting\\n/C15other destructive acts\\nDiagnosis\\nIt is extremely important that a thorough evalua-\\ntion rule out other more serious mental disorders,\\nsince the treatment for adjustment disorder may be\\nvery different than for other mental problems.\\nIn order to be diagnosed as a true adjustment\\ndisorder, the level of distress must be more severe\\nthan what would normally be expected in response to\\nthe stressor, or the symptoms must significantly inter-\\nfere with a person’s social, job, or school functioning.\\nNormal expression of grief, in bereavement for\\ninstance, is not considered an adjustment disorder.\\nTreatment\\nPsychotherapy (counseling) is the treatment of\\nchoice for adjustment disorders, since the symptoms\\nare an understandable reaction to a specific stress. The\\ntype of therapy depends on the mental health expert,\\nbut it usually is short-term treatment that focuses on\\nresolving the immediate problem.\\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 and\\nremission. 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 65\\nAdjustment disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 95, 'page_label': '66'}, page_content='Therapy usually will help clients:\\n/C15develop coping skills\\n/C15understand how the stressor has affected their lives\\n/C15develop 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\\nweeks of an anti-anxiety drug can control anxiety or\\nsleeping problems.\\nSelf-help groups aimed at a specific problem (such\\nas recovering from divorce or job loss) can be extre-\\nmely helpful to people suffering from an adjustment\\ndisorder. Social support, which is usually an impor-\\ntant part of self-help groups, can lead to a quicker\\nrecovery.\\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\\nstrong social support. People with progressive or cyclic\\ndisorders (such as multiple sclerosis) may experience an\\nadjustment disorder with each exacerbation period.\\nResources\\nBOOKS\\nLuther, Suniya G., Jacob A. Burack, and Dante Cicchetti.\\nDevelopmental Psychopathology: Perspectives on\\nAdjustment, Risk, and Disorder. London: Cambridge\\nUniversity Press, 1997.\\nCarol A. Turkington\\nAdrenal gland cancer\\nDefinition\\nAdrenal gland cancers are rare cancers occuring in\\nthe endocrine tissue of the adrenals. They are charac-\\nterized 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\\nsecrete excess amounts of these hormones. Acancer\\nthat arises in the adrenal cortex is called an adreno-\\ncortical carcinoma and can produce high blood pres-\\nsure, weight gain, excess body hair, weakening of the\\nbones and diabetes. A cancer in the adrenal medulla is\\ncalled apheochromocytoma and can cause high blood\\npressure, headache, palpitations, and excessive per-\\nspiration. Although these cancers can happen at any\\nage, 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.\\nSymptoms of adrenal cancer are related to the specific\\nhormones produced by that tumor. An adrenocortical\\ncarcinoma typically secretes high amounts of cortisol,\\nproducing Cushing’s Syndrome. This syndrome pro-\\nduces progressive weight gain, rounding of the face,\\nand increased blood pressure. Women can experience\\nmenstrual cycle alterations and men can experience\\nfeminization. The symptoms for pheochromocytoma\\ninclude hypertension, acidosis, unexplainedfever and\\nweight loss. Because of the hormones produced by this\\ntype of tumor,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.\\nIt also includesmagnetic resonance imaging, andcom-\\nputed tomography scansto determine the extent of the\\ndisease. Urine and blood tests can be done to detect\\nthe high levels of hormone secreted by the tumor.\\nTreatment\\nTreatment is aimed at removing the tumor by\\nsurgery. In some cases, this can be done bylaparo-\\nscopy. Surgery is sometimes followed bychemotherapy\\nand/or radiation therapy. Because the surgery removes\\nthe source of many important hormones, hormones\\nmust be supplemented following surgery. If adreno-\\ncortical cancer recurs or has spread to other parts of\\nthe body (metastasized), additional surgery may be\\ndone followed by chemotherapy using the drug\\nmitotane.\\nAlternative treatment\\nAs with any form of cancer, all conventional treat-\\nment options should be considered and applied as\\n66 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenal gland cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 96, 'page_label': '67'}, page_content='appropriate. Nutritional support, as well as support-\\ning the functioning of the entire person diagnosed with\\nadrenal gland cancer throughhomeopathic medicine,\\nacupuncture, vitamin and mineral supplementation,\\nand herbal medicine, can benefit recovery and enhance\\nquality of life.\\nPrognosis\\nThe prognosis for adrenal gland cancer is vari-\\nable. For localized pheochromocytomas the 5-year\\nsurvival rate is 95%. This rate decreases with aggres-\\nsive tumors that have metastasized. The prognosis for\\nadrenal cortical cancer is not as good with a 5-year\\nsurvival 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.’’ InCancer, Principles and\\nPractice of Oncology , edited by V. T. DeVita,\\nS. Hellman, and S. A. Rosenberg. Philadelphia:\\nLippincott-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 eva-\\nluation of the medulla (inner tissue) of the adrenal\\ngland.\\nPurpose\\nThe adrenal glands are a pair of small organs\\nlocated just above the kidney, which contain two\\ntypes of tissue. The adrenal cortex produces hormones\\nthat affect water balance and metabolism in the body.\\nThe adrenal medulla produces adrenaline and noradre-\\nnaline (also called epinepherine and norepinepherine).\\nAn adrenal gland scan is done when too much\\nadrenaline and noradrenaline is produced in the\\nbody and a tumor in the adrenal gland is suspected.\\nOne such situation in which a tumor might be sus-\\npected is when high blood pressure (hypertension)\\ndoes not respond to medication. Tumors that secrete\\nadrenaline and noradrenaline can also be found out-\\nside the adrenal gland. An adrenal gland scan usually\\ncovers the abdomen, chest, and head.\\nPrecautions\\nAdrenal gland scans are not recommended for\\npregnant women because of the potential harm to\\nthe developing fetus. A pregnant woman should dis-\\ncuss with her doctor the risks of the procedure against\\nthe benefits of the information it can provide in eval-\\nuating her individual 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\\nfrom the adrenal gland scan.\\nDescription\\nThe adrenal gland scan takes several days. On the\\nfirst day, a radiopharmaceutical is injected intrave-\\nnously into the patient. On the second, third, and\\nfourth day the patient is positioned under the camera\\nfor imaging. The scanning time each day takes\\napproximately 30 minutes. It is essential that the\\npatient remain still during imaging.\\nOccasionally, the scanning process may involve\\nfewer than three days, or it may continue several\\ndays longer. The area scanned extends from the pelvis\\nand lower abdomen to the lower chest. Sometimes the\\nupper legs, thighs, and head are also included.\\nKEY TERMS\\nCortisol— A hormone produced by the adrenal cor-\\ntex. It is partially responsible for regulating blood\\nsugar levels.\\nDiabetes— A disease characterized by low blood\\nsugar.\\nEpinephrine— A hormone produced by the adrenal\\nmedulla. It is important in the response to stress and\\npartially regulates heart rate and metabolism. It is\\nalso called adrenaline.\\nLaparoscopy— The insertion of a tube through\\nthe abdominal wall. It can be used to visualize\\nthe inside of the abdomen and for surgical\\nprocedures.\\nGALE ENCYCLOPEDIA OF MEDICINE 67\\nAdrenal gland scan'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 97, 'page_label': '68'}, page_content='Preparation\\nFor two days before and ten days after the injec-\\ntion of the radiopharmaceutical, patients are given\\neither Lugol’s solution or potassium iodine. This pre-\\nvents the thyroid from taking up radioactive iodine\\nand interfering with the scan.\\nAftercare\\nThe patient should not feel any adverse effects of\\nthe test and can resume normal activity immediately.\\nFollow-up tests that might be ordered include a\\nnuclear scan of the bones or kidney, a computed\\ntomography scan (CT) of the adrenals, or an ultra-\\nsound of the pelvic area.\\nRisks\\nThe main risk associated with this test is to the\\nfetus of a pregnant woman.\\nNormal results\\nNormal results will show no unusual areas of\\nhormone secretion and no tumors.\\nAbnormal results\\nAbnormal results will show evidence of a tumor\\nwhere there is excessive secretion of adrenaline or\\nnoradrenaline. Over 90% of these tumors are in the\\nabdomen.\\nResources\\nBOOKS\\nFishback, Francis, editor.A Manual of Laboratory and\\nDiagnostic Tests. 5th ed. Philadelphia: Lippincott, 1996.\\nTish Davidson, A.M.\\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\\noccur before birth and can lead to sexual abnormal-\\nities in newborns. It can also occur in girls and women\\nlater in life.\\nDescription\\nIn the normal human body, there are two adrenal\\nglands. They are small structures that lie on top of the\\nkidneys. The adrenal glands produce many hormones\\nthat regulate body functions. These hormones include\\nandrogens, or male hormones. Androgens are pro-\\nduced in normal girls and women. Sometimes, one or\\nboth of the adrenal glands becomes enlarged or over-\\nactive, producing more than the usual amount of\\nandrogens. The excess androgens create masculine\\ncharacteristics.\\nCauses and symptoms\\nIn infants and children, adrenal virilism is usually\\nthe result of adrenal gland enlargement that is present\\nat birth. This is called congenital adrenal hyperplasia.\\nThe cause is usually a genetic problem that leads to\\nsevere enzyme deficiencies. In rare cases, adrenal\\nvirilism is caused by an adrenal gland tumor. The\\ntumor can be benign (adrenal adenoma) or cancerous\\n(adrenal carcinoma). Sometimes virilism is caused by a\\ntype of tumor on a woman’s ovary (arrhenoblastoma).\\nNewborn girls with adrenal virilism have external\\nsex organs that seem to be a mixture of male and\\nfemale organs (called female pseudohermaphrodism).\\nNewborn boys with the disorder have enlarged exter-\\nnal sex organs, and these organs develop at an abnor-\\nmally rapid pace.\\nChildren withcongenital adrenal hyperplasiabegin\\ngrowing abnormally fast, but they stop growing earlier\\nthan normal. Later in childhood, they are typically\\nshorter than normal but have well-developed trunks.\\nKEY TERMS\\nAdrenal cortex— The outer tissue of the adrenal\\ngland. It produces a group of chemically related\\nhormones called corticosteroids that control\\nmineral 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.\\n68 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenal virilism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 98, 'page_label': '69'}, page_content='Women with adrenal virilization may develop\\nfacial hair. Typically, their menstrual cycles are infre-\\nquent or absent. They may also develop a deeper\\nvoice, a more prominent Adam’s apple, and other\\nmasculine signs.\\nDiagnosis\\nEndocrinologists, doctors who specialize in the\\ndiagnosis and treatment of glandular disorders, have\\nthe most expertise to deal with adrenal virilization.\\nSome doctors who treat disorders of the internal\\norgans (internists) and doctors who specialize in treat-\\ning the reproductive system of women (gynecologists)\\nmay also be able to help patients with this disorder.\\nDiagnosis involves performing many laboratory\\ntests on blood samples from the patient. These tests\\nmeasure the concentration of different hormones.\\nDifferent abnormalities of the adrenal gland produce\\na different pattern of hormonal abnormalities. These\\ntests can also help determine if the problem is adrenal\\nor ovarian. If a tumor is suspected, special x rays may\\nbe done to visualize the tumor in the body. Final\\ndiagnosis may depend on obtaining a tissue sample\\nfrom the tumor (biopsy), and examining it under a\\nmicroscope in order to verify its characteristics.\\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 hydro-\\ncortisone is usually given. Laboratory tests are usually\\nneeded from time to time to adjust the dosage. Girls\\nwith pseudohermaphrodism may require surgery to\\nmake their external sex organs appear more normal.\\nIf a tumor is causing the disorder, the treatment will\\ndepend on the type and location of the tumor.\\nInformation about the tumor cell type and the spread\\nof the tumor is used to decide the best kind of treatment\\nfor a particular patient. If the tumor is cancerous, the\\npatient will require special treatment depending on how\\nfar thecancer has advanced. Treatment can be a com-\\nbination of surgery, medications used to kill cancer cells\\n(chemotherapy), and x rays or other high energy rays\\nused to kill cancer cells (radiation therapy). Sometimes\\nthe doctor must remove the adrenal gland and the\\nsurrounding tissues. If the tumor is benign, then surgi-\\ncally removing the tumor may be the best option.\\nPrognosis\\nOngoing glucocorticoid treatment usually con-\\ntrols adrenal virilism in cases of adrenal hyperplasia,\\nbut there is no cure. If a cancerous tumor has caused\\nthe disorder, patients have a better prognosis if they\\nhave an early stage of cancer that is diagnosed quickly\\nand has not spread.\\nResources\\nPERIODICALS\\nWillensy, D. ‘‘The Endocrine System.’’AmericanHealth\\nApril 1996: 92-3.\\nRichard H. Lampert\\nAdrenalectomy\\nDefinition\\nAdrenalectomy is the surgical removal of one or\\nboth of the adrenal glands. The adrenal glands are\\npaired endocrine glands, one located above each kid-\\nney, that produce hormones such as epinephrine, nor-\\nepinephrine, androgens, estrogens, aldosterone, and\\ncortisol. Adrenalectomy is usually performed by con-\\nventional (open) surgery, but in selected patients sur-\\ngeons may use laparoscopy. With laparoscopy,\\nadrenalectomy can be accomplished through four\\nvery small incisions.\\nPurpose\\nAdrenalectomy is usually advised for patients\\nwith tumors of the adrenal glands. Adrenal gland\\ntumors may be malignant or benign, but all typically\\nexcrete excessive amounts of one or more hormones. A\\nsuccessful procedure will aid in correcting hormone\\nimbalances, and may also remove cancerous tumors\\nthat can invade other parts of the body. Occasionally,\\nadrenalectomy may be recommended when hormones\\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 gluco-\\ncorticoid hormones.\\nPrednisone— A drug that functions as a glucocorti-\\ncoid hormone.\\nGALE ENCYCLOPEDIA OF MEDICINE 69\\nAdrenalectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 99, 'page_label': '70'}, page_content='produced by the adrenal glands aggravate another\\ncondition such asbreast cancer.\\nPrecautions\\nThe adrenal glands are fed by numerous blood\\nvessels, so surgeons need to be alert to extensive bleed-\\ning during surgery. In addition, the adrenal glands lie\\nclose to one of the body’s major blood vessels (the\\nvena cava), and to the spleen and the pancreas. The\\nsurgeon needs to remove the gland(s) without dama-\\nging any of these important and delicate organs.\\nDescription\\nOpen adrenalectomy\\nThe surgeon may operate from any of four direc-\\ntions, depending on the exact problem and the\\npatient’s body type.\\nIn the anterior approach, the surgeon cuts into the\\nabdominal wall. Usually the incision will be horizon-\\ntal, just under the rib cage. If the surgeon intends to\\noperate on only one of the adrenal glands, the incision\\nwill run under just the right or the left side of the rib\\ncage. Sometimes a vertical incision in the middle of the\\nabdomen provides a better approach, especially if\\nboth adrenal glands are involved.\\nIn the posterior approach, the surgeon cuts into\\nthe back, just beneath the rib cage. If both glands are\\nto be removed, an incision is made on each side of the\\nbody. This approach is the most direct route to the\\nadrenal glands, but it does not provide quite as clear a\\nview of the surrounding structures as the anterior\\napproach.\\nIn the flank approach, the surgeon cuts into the\\npatient’s side. This is particularly useful in massively\\nobese patients. If both glands need to be removed, the\\nsurgeon must remove one gland, repair the surgical\\nwound, turn the patient onto the other side, and repeat\\nthe entire process.\\nThe last approach involves an incision into the\\nchest cavity, either with or without part of the incision\\ninto the abdominal cavity. It is used when the surgeon\\nanticipates a very large tumor, or if the surgeon needs\\nto examine or remove nearby structures as well.\\nLaparoscopic adrenalectomy\\nThis technique does not require the surgeon to\\nopen the body cavity. Instead, four small incisions\\n(about 1/2 in diameter each) are made into a patient’s\\nflank, just under the rib cage. A laparoscope, which\\nenables the surgeon to visualize the inside of the\\nabdominal cavity on a television monitor, is placed\\nthrough one of the incisions. The other incisions are\\nfor tubes that carry miniaturized versions of surgical\\ntools. These tools are designed to be operated by\\nmanipulations that the surgeon makes outside the\\nbody.\\nPreparation\\nMost aspects of preparation are the same as in\\nother major operations. In addition, hormone imbal-\\nances are often a major challenge. Whenever possible,\\nphysicians will try to correct hormone imbalances\\nthrough medication in the days or weeks before sur-\\ngery. Adrenal tumors may cause other problems such\\nas hypertension or inadequate potassium in the blood,\\nand these problems also should be resolved if possible\\nbefore surgery is performed. Therefore, a patient may\\ntake specific medicines for days or weeks before\\nsurgery.\\nMost adrenal tumors can be imaged very well with\\na CT scan or MRI, and benign tumors tend to look\\ndifferent on these tests than do cancerous tumors.\\nSurgeons may order a CT scan, MRI, or scintigraphy\\n(viewing of the location of a tiny amount of radio-\\nactive agent) to help locate exactly where the tumor is.\\nThe day before surgery, patients will probably\\nhave an enema to clear the bowels. In patients with\\nlung problems or clotting problems, physicians may\\nadvise special preparations.\\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 manu-\\nfactures some key substances used by the immune\\nsystem.\\nVena cava— The large vein that drains directly into\\nthe heart after gathering incoming blood from the\\nentire body.\\n70 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenalectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 100, 'page_label': '71'}, page_content='Aftercare\\nPatients stay in the hospital for various lengths of\\ntime after adrenalectomy. The longest hospital stays\\nare required for open surgery using an anterior\\napproach; hospital stays of about three days are indi-\\ncated for open surgery using the posterior approach or\\nfor laparoscopic adrenalectomy.\\nThe special concern after adrenalectomy is the\\npatient’s hormone balance. There may be several sets\\nof lab tests to define hormone problems and monitor\\nthe results of drug treatment. In addition, blood pres-\\nsure problems and infections are more common after\\nremoval of certain types of adrenal tumors.\\nAs with most open surgery, surgeons are also\\nconcerned about blood clots forming in the legs and\\ntraveling to the lungs (venous thromboembolism),\\nbowel problems, and postoperative pain. With laparo-\\nscopic adrenalectomy, these problems are somewhat\\nless difficult, but they are still present.\\nRisks\\nThe special risks of adrenalectomy involve major\\nhormone imbalances, caused by the underlying dis-\\nease, the surgery, or both.These can include problems\\nwith wound healing itself, blood pressure fluctuations,\\nand other metabolic problems.\\nOther risks are typical of many operations.These\\ninclude:\\n/C15bleeding\\n/C15damage to adjacent organs (spleen, pancreas)\\n/C15loss of bowel function\\n/C15blood clots in the lungs\\n/C15lung problems\\n/C15surgical infections\\n/C15pain\\n/C15extensive scarring\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nRichard H. Lampert\\nAdrenocortical insufficiency see Addison’s\\ndisease\\nAdrenocorticotropic hormone\\ntest\\nDefinition\\nAdrenocorticotropic hormone test (also known as\\nan ACTH test or a corticotropin test) measures pitui-\\ntary gland function.\\nPurpose\\nThe pituitary gland produces the hormone\\nACTH, which stimulates the outer layer of the adrenal\\ngland (the adrenal cortex). ACTH causes the release of\\nthe hormones hydrocortisone (cortisol), aldosterone,\\nand androgen. The most important of these hormones\\nreleased is cortisol. The ACTH test is used to deter-\\nmine if too much cortisol is being produced (Cushing’s\\nsyndrome) or if not enough cortisol is being produced\\n(Addison’s disease).\\nPrecautions\\nACTH has diurnal variation, meaning that the\\nlevels of this hormone vary according to the time of\\nday. The highest levels occur in the morning hours.\\nTesting for normal secretion, as well as for Cushing’s\\ndisease, may require multiple samples. For sequential\\nfollow-up, a blood sample analyzed for ACTH should\\nalways be drawn at the same time each day.\\nACTH can be directly measured by an analyzing\\nmethod (immunoassay) in many large laboratories.\\nHowever, smaller laboratories are usually not\\nequipped to perform this test and they may need to\\nsend the blood sample to a larger laboratory. Because\\nof this delay, results may take several days to obtain.\\nDescription\\nACTH production is partly controlled by an area\\nin the 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\\nthe pituitary gland to make more ACTH. ACTH levels\\nrise in response tostress, emotions, injury, infection,\\nburns, surgery, and decreased blood pressure.\\nCushing’s syndrome\\nCushing’s syndrome is caused by an abnormally\\nhigh level of circulating hydrocortisone. The high level\\nGALE ENCYCLOPEDIA OF MEDICINE 71\\nAdrenocorticotropic hormone test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 101, 'page_label': '72'}, page_content='may be the result of an adrenal gland tumor or enlar-\\ngement of both adrenal glands due to a pituitary\\ntumor. The high level of hydrocortisone may be the\\nresult of taking corticosteroid drugs for a long time.\\nCorticosteroid drugs are widely used for inflammation\\nin disorders like rheumatoid arthritis, inflammatory\\nbowel disease, andasthma.\\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\\nthis disease is an autoimmune disorder. The immune\\nsystem normally fights foreign invaders in the body\\nlike bacteria. In an autoimmune disorder, the\\nimmune systems attacks the body. In this case, the\\nimmune system produces antibodies that attack\\nthe adrenal glands. Addison’s disease generally pro-\\ngresses slowly, with symptoms developing gradually\\nover months or years. However, acute episodes,\\ncalled Addisonian crises, are brought on by infection,\\ninjury, or other stresses. Diagnosis is generally made\\nif the patient fails to respond to an injection of\\nACTH, which normally stimulates the secretion of\\nhydrocortisone.\\nPreparation\\nA person’s ACTH level is determined from a\\nblood sample. The patient must fast from midnight\\nuntil the test the next morning. This means that the\\npatient cannot eat or drink anything after midnight\\nexcept water. The patient must also avoid radioiso-\\ntope scanning tests or recently administered radioiso-\\ntopes prior to the blood test.\\nRisks\\nThe risks associated with this test are minimal.\\nThey may include slight bleeding from the location\\nwhere the blood was drawn. The patient may feel faint\\nor lightheaded after the blood is drawn. Sometimes\\nthe patient may have an accumulation of blood\\nunder the puncture site (hematoma) after the test.\\nNormal results\\nEach laboratory will have its own set of normal\\nvalues for this test. The normal values can range from:\\nMorning (4-8 A.M.) 8-100 pg/mL or 10-80 ng/L (SI\\nunits) Evening (8-10 P.M.) less than 50 pg/mL or less\\nthan 50 ng/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\\ndue to high levels of cortisol and feedback to the\\npituitary.\\nIn Addison’s disease, high levels of ACTH may be\\ncaused by adrenal gland diseases. These diseases\\ndecrease adrenal hormones and the pituitary attempts\\nto increase functioning. Low levels of ACTH may\\noccur because of decreased pituitary function.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnosticand\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAdrenogenital syndrome see Adrenal\\nvirilism\\nAdrenoleukodystrophy\\nDefinition\\nAdrenoleukodystrophy is a rare genetic disease\\ncharacterized by a loss of myelin surrounding nerve\\ncells in the brain and progressive adrenal gland\\ndysfunction.\\nDescription\\nAdrenoleukodystrophy (ALD) is a member of a\\ngroup of diseases, leukodystrophies, that cause damage\\nto the myelin sheath of nerve cells. Approximately one\\nin 100,000 people is affected by ALD. There are three\\nKEY TERMS\\nAdrenal glands— A pair of endocrine glands that lie\\non top of the kidneys.\\nPituitary gland— The most important of the endo-\\ncrine glands, glands that release hormones directly\\ninto the bloodstream; sometimes called the master\\ngland.\\n72 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenoleukodystrophy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 102, 'page_label': '73'}, page_content='basic forms of ALD: childhood, adult-onset, and\\nneonatal. The childhood form of the disease is the\\nclassical form and is the most severe. Childhood\\nALD is progressive and usually leads to total disabi-\\nlity ordeath. It affects only boys because the genetic\\ndefect is sex-linked (carried on the X chromosome).\\nOnset usually occurs between ages four and ten and\\ncan include many different symptoms, not all of\\nwhich appear together. The most common symptoms\\nare behavioral problems and poor memory. Other\\nsymptoms frequently seen are loss of vision, seizures,\\npoorly articulated speech, difficulty swallowing,\\ndeafness, problems with gait and coordination,fati-\\ngue, increased skin pigmentation, and progressive\\ndementia.\\nThe adult-onset form of the disease, also called\\nadrenomyeloneuropathy, is milder, progresses slowly,\\nis usually associated with a normal life span, and\\nusually appears between ages 21-35. Symptoms may\\ninclude progressive stiffness, weakness, orparalysis of\\nthe lower limbs and loss of coordination. Brain func-\\ntion deterioration may also been seen. Women who\\nare carriers of the disease occasionally experience the\\nsame symptoms, as well as others, including ataxia,\\nhypertonia (excessive muscle tone), mild peripheral\\nneuropathy, and urinary problems. The neonatal\\nform affects both male and female infants and may\\nproduce mental retardation, facial abnormalities, sei-\\nzures, retinal degeneration, poor muscle tone,\\nenlarged liver, and adrenal dysfunction. Neonatal\\nALD 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\\nbuild up in the adrenal glands, brain, plasma, and\\nfibroblasts. The build-up of very long chain fatty\\nacids interferes with the ability of the adrenal gland\\nto convert cholesterol into steroids and causes demye-\\nlination of nerves in the white matter of the brain.\\nDemyelinated nerve cells are unable to function\\nproperly.\\nDiagnosis\\nDiagnosis is made based on observed symptoms, a\\nbiochemical test, and a family history. The biochem-\\nical test detects elevated levels of very long chain fatty\\nacids in samples fromamniocentesis, chorionic villi,\\nplasma, red blood cells, or fibroblasts. A family his-\\ntory may indicate the likelihood of ALD because the\\ndisease is carried on the X-chromosome by the female\\nlineage of families.\\nTreatment\\nTreatment for all forms of ALD consists of treat-\\ning the symptoms and supporting the patient with\\nphysical therapy, psychological counseling, and spe-\\ncial education in some cases. There is no cure for this\\ndisease, and there are no drugs that can reverse demye-\\nlination of nerve and brain cells. Dietary measures\\nconsist of reducing the intake of foods high in fat,\\nwhich are a source of very long chain fatty acids. A\\nmixture called Lorenzo’s Oil has been shown to reduce\\nthe level of long chain fatty acids if used long term;\\nhowever, the rate of myelin loss is unaffected.\\nExperimental bone marrow transplantation has not\\nbeen very effective.\\nPrognosis\\nPrognosis for childhood and neonatal ALD\\npatients is poor because of the progressive myelin\\ndegeneration. Death usually occurs between one and\\nten years after onset of symptoms.\\nPrevention\\nSince ALD is a genetic disease, prevention is lar-\\ngely limited togenetic counselingand fetal monitoring\\nthrough amniocentesis orchorionic villus sampling.\\nResources\\nBOOKS\\nBerkow, Robert.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nJohn T. Lohr, PhD\\nAdrenomyeloneuropathy see\\nAdrenoleukodystrophy\\nKEY 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 movement.\\nHypertonia— Having excessive muscular tone.\\nMyelin— A layer that encloses nerve cells and some\\naxons and is made largely of lipids and lipoproteins.\\nNeuropathy— A disease or abnormality of the peri-\\npheral nerves.\\nGALE ENCYCLOPEDIA OF MEDICINE 73\\nAdrenoleukodystrophy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 103, 'page_label': '74'}, page_content='Adult respiratory distress\\nsyndrome\\nDefinition\\nAdult respiratory distress syndrome(ARDS), also\\ncalled acute respiratory distress syndrome, is a type\\nof lung (pulmonary) failure that may result from any\\ndisease that causes large amounts of fluid to collect\\nin the lungs. ARDS is not itself a specific disease, but a\\nsyndrome, a group of symptoms and signs that\\nmake up one of the most important forms of lung or\\nrespiratory failure. It can develop quite suddenly in\\npersons whose lungs have been perfectly normal.\\nVery often ARDS is a true medical emergency. The\\nbasic fault is a breakdown of the barrier, or mem-\\nbrane, that normally keeps fluid from leaking out of\\nthe small blood vessels of the lung into the breathing\\nsacs (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 ves-\\nsels, or capillaries, make contact with the alveoli, tiny\\nair sacs at the tips of the smallest breathing tubes (the\\nbronchi). This is the all-important site where oxygen\\npasses from air that is inhaled to the blood, which\\ncarries it to all parts of the body. Any form of lung\\ninjury that damages this point of contact, called the\\nalveolo-capillary junction, will allow blood and tissue\\nfluid to leak into the alveoli, eventually filling them so\\nthat air cannot enter. The result is the type of breath-\\ning distress called ARDS. ARDS is one of the major\\ncauses of excess fluid in the lungs, the other beingheart\\nfailure.\\nAlong with fluid there is a marked increase in\\ninflamed cells in the lungs. There also is debris left\\nover from damaged lung cells, and fibrin, a semi-\\nsolid material derived from blood in the tissues.\\nTypically these materials join together with large\\nmolecules in the blood (proteins), to form hyaline\\nmembranes. (These membranes are very prominent\\nin premature infants who develop respiratory distress\\nsyndrome; it is often called hyaline membrane dis-\\nease.) If ARDS is very severe or lasts a long time, the\\nlungs do not heal, but rather become scarred, a process\\nknown as fibrosis. The lack of a normal amount of\\noxygen causes the blood vessels of the lung to become\\nnarrower, and in time they, too, may become scarred\\nand filled with clotted blood. The lungs as a whole\\nbecome very ‘‘stiff,’’ and it becomes much harder for\\nthe patient to breathe.\\nCauses and symptoms\\nA very wide range of diseases or toxic substances,\\nincluding some drugs, can cause ARDS. They include:\\n/C15Breathing in (aspiration) of the stomach contents\\nwhen regurgitated, or salt water or fresh water from\\nnearly drowning.\\n/C15Inhaling smoke, as in a fire; toxic materials in the air,\\nsuch as ammonia or hydrocarbons; or too much\\noxygen, which itself can injure the lungs.\\n/C15Infection by a virus or bacterium, orsepsis, a wide-\\nspread infection that gets into the blood.\\n/C15Massive trauma, with severe injury to any part of the\\nbody.\\n/C15Shock with persistently low blood pressure may not\\nin itself cause ARDS, but it can be an important\\nfactor.\\n/C15A blood clotting disorder called disseminated intra-\\nvascular coagulation, in which blood clots form in\\nvessels throughout the body, including the lungs.\\n/C15A large amount of fat entering the circulation and\\ntraveling to the lungs, where it lodges in small blood\\nvessels, injuring the cells lining the vessel walls.\\n/C15An overdose of a narcotic drug, a sedative, or, rarely,\\naspirin.\\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,\\nliquids, 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 low-\\noxygen conditions.\\nSteroids— A class of drugs resembling normal body\\nsubstances that often help control inflammation in\\nthe 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.\\n74 GALE ENCYCLOPEDIA OF MEDICINE\\nAdult respiratory distress syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 104, 'page_label': '75'}, page_content='/C15Inflammation of the pancreas (pancreatitis), when\\nblood proteins, called enzymes, pass to the lungs\\nand injure lung cells.\\n/C15Severe burn injury.\\n/C15Injury of the brain, or bleeding into the brain, from\\nany cause may be a factor in ARDS for reasons that\\nare not clear. Convulsions also may cause some\\ncases.\\nUsually ARDS develops within one to two days of\\nthe original illness or injury. The person begins to take\\nrapid but shallow breaths. The doctor who listens to\\nthe patient’s chest with a stethoscope may hear\\n‘‘crackling’’ orwheezing sounds. The low blood oxy-\\ngen content may cause the skin to appear mottled or\\neven blue. As fluid continues to fill the breathing sacs,\\nthe patient may have great trouble breathing, take\\nvery 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,\\nand this can be confirmed by analyzing blood taken\\nfrom an artery. Thechest x raymay be normal in the\\nearly stages, but, in a short time, fluid will be seen\\nwhere it does not belong. The two lungs are about\\nequally affected. A heart of normal size indicates that\\nthe problem actually is ARDS and not heart failure.\\nAnother way a physician can distinguish between\\nthese two possibilities is to place a catheter into a\\nvein and advance it into the main artery of the lung.\\nIn this way, the pressure within the pulmonary capil-\\nlaries can be measured. Pressure within the pulmonary\\ncapillaries is elevated in heart failure, but normal\\nin ARDS.\\nTreatment\\nThe three main goals in treating patients with\\nARDS are:\\n/C15To treat whatever injury or disease has caused\\nARDS. Examples are: to treat septic infection with\\nthe proper antibiotics, and to reduce the level of\\noxygen therapy if ARDS has resulted from a toxic\\nlevel of oxygen.\\n/C15To control the process in the lungs that allows fluid\\nto leak out of the blood vessels. At present there\\nis no certain way to achieve this. Certain steroid\\nhormones have been tried because they can combat\\ninflammation, but the actual results have been\\ndisappointing.\\n/C15To make sure the patient gets enough oxygen until\\nthe lung injury has had time to heal. If oxygen deliv-\\nered by a face mask is not enough, the patient is\\nplaced on a ventilator, which takes over breathing,\\nand, through a tube placed in the nose or mouth (or\\nan incision in the windpipe), forces oxygen into the\\nlungs. This treatment must be closely supervised, and\\nthe pressure adjusted so that too much oxygen is not\\ndelivered.\\nPatients with ARDS should be cared for in an\\nintensive care unit, where experienced staff and all\\nneeded equipment are available. Enough fluid must\\nbe provided, by vein if necessary, to preventdehydra-\\ntion. Also, the patient’s nutritional state must be main-\\ntained, again by vein, 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\\norgans, such as the kidneys. There always is a risk\\nthat bacterial pneumonia will develop at some point.\\nWithout prompt treatment, as many as 90% of\\npatients with ARDS can be expected to die. With\\nmodern treatment, however, about half of all patients\\nwill survive. Those who do live usually recover com-\\npletely, with little or no long-term breathing difficulty.\\nLung scarring is a risk after a long period on a venti-\\nlator, 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\\nwhether the primary disease that caused ARDS to\\ndevelop in the first place can be effectively treated.\\nPrevention\\nThe only way to prevent ARDS is to avoid those\\ndiseases and harmful conditions that damage the lung.\\nFor instance, the danger of aspirating stomach con-\\ntents into the lungs can be avoided by making sure a\\npatient does not eat shortly before receivinggeneral\\nanesthesia. If a patient needsoxygen therapy,a sl o wa\\nlevel as possible should be given. Any form of lung\\ninfection, or infection anywhere in the body that gets\\ninto the blood, must be treated promptly to avoid the\\nlung injury that causes ARDS.\\nResources\\nBOOKS\\nSmolley, Lawrence A., and Debra F. Bryse.Breathe\\nRightNow: A Comprehensive Guide to Understanding\\nand Treating the Most Common Breathing Disorders.\\nNew York: W. W. Norton & Co., 1998.\\nGALE ENCYCLOPEDIA OF MEDICINE 75\\nAdult respiratory distress syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 105, 'page_label': '76'}, page_content='ORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Respiratory Distress Syndrome Foundation. P.O.\\nBox 723, Montgomeryville, PA 18936.\\nDavid A. Cramer, MD\\nAFP test see Alpha-fetoprotein test\\nAfrican American health see Minority health\\nAfrican sleeping sickness see Sleeping\\nsickness\\nAfrican trypanosomiasis see Sleeping\\nsickness\\nAgammaglobulinemia see Common variable\\nimmunodeficiency\\nAggression see Conduct disorder\\nAging\\nDefinition\\nStarting at what is commonly called middle age,\\noperations of the human body begin to be more vul-\\nnerable to daily wear and tear; there is a general\\ndecline in physical, and possibly mental, functioning.\\nIn the Western countries, the length of life is often into\\nthe 70s. The upward limit of the life span, however,\\ncan be as high as 120 years. During the latter half of\\nlife, an individual is more prone to have problems with\\nthe various functions of the body and to develop any\\nnumber of chronic or fatal diseases. The cardiovascu-\\nlar, digestive, excretory, nervous, reproductive and\\nurinary systems are particularly affected. The most\\ncommon diseases of aging include Alzheimer’s, arthri-\\ntis, cancer, diabetes, depression, and heart disease.\\nDescription\\nHuman beings reach a peak of growth and devel-\\nopment around the time of their mid 20s. Aging is the\\nnormal transition time after that flurry of activity.\\nAlthough there are quite a few age-related changes\\nthat tax the body, disability is not necessarily a part\\nof aging. Health and lifestyle factors together with\\nthe genetic makeup of the individual, and determines\\nthe response to these changes. Body functions that are\\nmost often affected by age include:\\n/C15Hearing, which declines especially in relation to the\\nhighest pitched tones.\\n/C15The proportion of fat to muscle, which may increase\\nby as much as 30%. Typically, the total padding of\\nbody fat directly under the skin thins out and accu-\\nmulates around the stomach. The ability to excrete\\nfats is impaired, and therefore the storage of fats\\nincreases, including cholesterol and fat-soluble\\nnutrients.\\n/C15The amount of water in the body decreases, which\\ntherefore decreases the absorption of water-soluble\\nnutrients. Also, there is less saliva and other lubricat-\\ning fluids.\\n/C15The liver and the kidneys cannot function as effi-\\nciently, thus affecting the elimination of wastes.\\n/C15A decrease in the ease of digestion, with a decrease in\\nstomach acid production.\\n/C15A loss of muscle strength and coordination, with an\\naccompanying loss of mobility, agility, and\\nflexibility.\\n/C15A decline in sexual hormones and sexual functioning.\\n/C15A decrease in the sensations of taste and smell.\\n/C15Changes in the cardiovascular and respiratory sys-\\ntems, leading to decreased oxygen and nutrients\\nthroughout the body.\\n/C15Decreased functioning of the nervous system so that\\nnerve impulses are not transmitted as efficiently,\\nreflexes are not as sharp, and memory and learning\\nare diminished.\\n/C15A decrease in bone strength and density.\\n/C15Hormone levels, which gradually decline. The thyr-\\noid and sexual hormones are particularly affected.\\n/C15Declining visual abilities. Age-related changes may\\nlead to diseases such asmacular degeneration.\\n/C15A compromised ability to produce vitamin D from\\nsunlight.\\n/C15A reduction in protein formation leading to shrink-\\nage in muscle mass and decreased bone formation,\\npossibly leading to osteoporosis.\\nCauses and symptoms\\nThere are several theories as to why the aging\\nbody loses functioning. It may be that several factors\\nwork together or that one particular factor is at work\\nmore than others in a given individual.\\n/C15Programmed senescence, or aging clock, theory. The\\naging of the cells of each individual is programmed\\ninto the genes, and there is a preset number of\\n76 GALE ENCYCLOPEDIA OF MEDICINE\\nAging'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 106, 'page_label': '77'}, page_content='possible rejuvenations in the life of a given cell. When\\ncells die at a rate faster than they are replaced, organs\\ndo not function properly, and they are soon unable\\nto maintain the functions necessary for life.\\n/C15Genetic theory. Human cells maintain their own seed\\nof destruction at the level of the chromosomes.\\n/C15Connective tissue, or cross-linking theory. Changes\\nin the make-up of the connective tissue alter the\\nstability of body structures, causing a loss of elasti-\\ncity and functioning, and leading to symptoms of\\naging.\\n/C15Free-radical theory. The most commonly held theory\\nof aging, it is based on the fact that ongoing chemical\\nreactions of the cells produce free radicals. In the\\npresence of oxygen, these free radicals cause the\\ncells of the body to break down. As time goes on,\\nmore cells die or lose the ability to function, and the\\nbody soon ceases to function as a whole.\\n/C15Immunological theory. There are changes in the im-\\nmune system as it begins to wear out, and the body is\\nmore prone to infections and tissue damage, which\\nmay finally causedeath. Also, as the system breaks\\ndown, the body is more apt to have autoimmune\\nreactions, in which the body’s own cells are mistaken\\nfor foreign material and are destroyed or damaged\\nby the immune system.\\nDiagnosis\\nMany problems can arise due to age-related\\nchanges in the body. Although there is no one test to\\nbe given, a thorough physical exam and a basic blood\\nscreening and blood chemistry panel can point to\\nareas in need of further attention. When older people\\nbecome ill, the first signs of disease are often nonspe-\\ncific. Further exams should be conducted if any of the\\nfollowing occur:\\n/C15diminished or lack of desire for food\\n/C15increasing confusion\\n/C15failure to thrive\\n/C15urinary incontinence\\n/C15dizziness\\n/C15weight loss\\n/C15falling\\nTreatment\\nFor the most part, doctors prescribe medications\\nto control the symptoms and diseases of aging. In the\\nUnited States, about two-thirds of people 65 and over\\ntake medications for various complaints. More\\nwomen than men use these medications. The most\\ncommon drugs used by the elderly are painkillers,\\ndiuretics or water pills, sedatives, cardiac drugs,anti-\\nbiotics, and mental health drugs.\\nEstrogen replacement therapy (ERT) is com-\\nmonly prescribed to postmenopausal women for\\nsymptoms of aging. It is often used in conjunction\\nwith progesterone. ERT functions to help keep bones\\nstrong, reduce risk of heart disease, restore vaginal\\nlubrication, and to improve skin elasticity. Evidence\\nsuggests that it may also help maintain mental\\nfunctions.\\nExpected results\\nAging is unavoidable, but major physical impair-\\nment is not. People can lead a healthy, disability-free\\nlife well through their later years. A well established\\nsupport system of family, friends, and health care\\nproviders, together with focus on goodnutrition and\\nlifestyle habits and good stress management, can\\nprevent disease and lessen the impact of chronic\\nconditions.\\nAlternative treatment\\nNutritional supplements\\nConsumption of a high–quality multivitamin is\\nrecommended. Common nutritional deficiencies con-\\nnected with aging include Bvitamins, vitamins A and\\nC, folic acid, calcium, magnesium, zinc, iron, chro-\\nmium, and traceminerals. Since stomach acids may\\nbe decreased, it is suggested that the use of a powdered\\nmultivitamin formula in gelatin capsules be used, as\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 77\\nAging'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 107, 'page_label': '78'}, page_content='this form is the easiest to digest. Such formulas may\\nalso contain enzymes for further help with digestion.\\nAntioxidants can help to neutralize damage by\\nthe free radical actions thought to contribute to pro-\\nblems of aging. They are also helpful in preventing\\nand treating cancer and in treating cataracts and\\nglaucoma. Supplements that serve as antioxidants\\ninclude:\\n/C15Vitamin E, 400–1,000 IUs daily. Protects cell mem-\\nbranes against damage. It shows promise in preven-\\ntion against heart disease, and Alzheimer’s and\\nParkinson’s diseases.\\n/C15Selenium, 50 mg taken twice daily. Research suggests\\nthat selenium may play a role in reducing the risk of\\ncancer.\\n/C15Beta-carotene, 25,000–40,000 IUs daily. May help in\\ntreating cancer, colds and flu, arthritis, and immune\\nsupport.\\n/C15Vitamin C, 1,000–2,000 mg per day. It may cause\\ndiarrhea in large doses. If this occurs, however, all\\nthat is needed is a decrease in the dosage.\\nOther supplements that are helpful in treating age-\\nrelated problems including:\\n/C15B12/B-complex vitamins, studies show that B12 may\\nhelp reduce mental symptoms, such as confusion,\\nmemory loss, and depression.\\n/C15Coenzyme Q10 may be helpful in treating heart dis-\\nease, as up to three-quarters cardiac patients have\\nbeen found to be lacking in this heart enzyme.\\nHormones\\nThe following hormone supplements may be\\ntaken to prevent or to treat various age-related pro-\\nblems. However, caution should be taken before\\nbeginning treatment, and the patient should consult\\nhis or her health care professional.\\nDHEA improves brain functioning and serves as a\\nbuilding block for many other important hormones in\\nthe body. It may be helpful in restoring declining\\nhormone levels and in building up muscle mass,\\nstrengthening the bones, and maintaining a healthy\\nheart.\\nMelatonin may be helpful forinsomnia. It has also\\nbeen used to help fight viruses and bacterial infections,\\nreduce the risk of heart disease, improve sexual func-\\ntioning, and to protect against cancer.\\nHuman growth hormone (hGH) has been shown\\nto regulate blood sugar levels and to stimulate bone,\\ncartilage, and muscle growth while reducing fat.\\nHerbs\\nGarlic (Allium sativa ) is helpful in preventing\\nheart disease, as well as improving the tone and texture\\nof skin. Garlic stimulates liver and digestive system\\nfunctions, and also helps in dealing with heart disease\\nand high blood pressure.\\nSiberian ginseng ( Eleutherococcus senticosus )\\nsupports the adrenal glands and immune functions.\\nIt is believed to be helpful in treating problems related\\nto stress. Siberian ginseng also increases mental\\nand physical performance, and may be useful in treat-\\ning memory loss, chronic fatigue, and immune\\ndysfunction.\\nProanthocyanidins, or PCO, are Pycnogenol,\\nderived from grape seeds and skin, and from pine\\ntree bark, and may help in the prevention of cancer\\nand poor vision.\\nIn Ayurvedic medicine, aging is described as a\\nprocess of increased vata, in which there is a tendency\\nto become thinner, drier, more nervous, more restless,\\nand more fearful, while having a loss of appetite\\nas well as sleep. Bananas, almonds, avocados, and\\ncoconuts are some of the foods used in correcting\\nsuch conditions. One of the main herbs used for\\nsuch conditions is gotu kola ( Centella asiatica ),\\nwhich is used to revitalize the nervous system and\\nbrain cells and to fortify the immune system. Gotu\\nkola is also used to treat memory loss,anxiety, and\\ninsomnia.\\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.\\nPrevention\\nPreventive health practices such as healthy diet,\\ndaily exercise, stress management, and control of life-\\nstyle habits such as smoking and drinking, can\\nlengthen the life span and improve the quality of life\\nas people age. Exercise can improve the appetite, the\\nhealth of the bones, the emotional and mental out-\\nlook, and the digestion and circulation.\\nDrinking plenty of fluids aids in maintaining\\nhealthy skin, good digestion, and proper elimination\\nof wastes. Up to eight glasses of water should be con-\\nsumed daily, along with plenty of herbal teas, diluted\\n78 GALE ENCYCLOPEDIA OF MEDICINE\\nAging'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 108, 'page_label': '79'}, page_content='fruit and vegetable juices, and fresh fruits and vegeta-\\nbles with high water content.\\nBecause of a decrease in the sense of taste, older\\npeople often increase their intake of salt, which can\\ncontribute to high blood pressure and nutrient loss.\\nUse of sugar is also increased. Seaweeds and small\\namounts of honey can be used as replacements.\\nAlcohol, nicotine, andcaffeine 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 car-\\nbohydrates, such as whole grains. If chewing becomes\\na problem, there should be an increased intake of\\nprotein drinks, freshly juiced fruits and vegetables,\\nand creamed cereals.\\nResources\\nOTHER\\n‘‘Anti-Aging-Nutritional Program.’’ December 28, 2000.\\n.\\n‘‘Effects of Hormone in the Body.’’ December 28, 2000.\\n.\\n‘‘The Elderly-Nutritional Programs.’’ December 28, 2000.\\n.\\n‘‘Evaluating the Elderly Patient: the Case for Assessment\\nTechnology.’’ December 28, 2000. .\\n‘‘Herbal Phytotherapy and the Elderly.’’ December 28, 2000.\\n.\\n‘‘Pharmacokinetics.’’ Merck & Co., Inc. (1995-2000).\\nDecember 28, 2000. .\\n‘‘To a Long and Healthy Life.’’ December 28, 2000. .\\nPatience Paradox\\nAgoraphobia\\nDefinition\\nThe word agoraphobia is derived from Greek\\nwords literally meaning ‘‘fear of the marketplace.’’\\nThe term is used to describe an irrational and often\\ndisabling fear of being out in public.\\nDescription\\nAgoraphobia is just one type of phobia, or irra-\\ntional fear. People withphobias feel dread or panic\\nwhen they face certain objects, situations, or activities.\\nPeople with agoraphobia frequently also experience\\npanic attacks, but panic attacks, or panic disorder,\\nare not a requirement for a diagnosis of agoraphobia.\\nThe defining feature of agoraphobia isanxiety about\\nbeing in places from which escape might be embarras-\\ning or difficult, or in which help might be unavailable.\\nThe person suffering from agoraphobia usually avoids\\nthe anxiety-provoking situation and may become\\ntotally housebound.\\nCauses and symptoms\\nAgoraphobia is the most common type of phobia,\\nand it is estimated to affect between 5-12% of\\nAmericans within their lifetime. Agoraphobia is\\ntwice as common in women as in men and usually\\nstrikes between the ages of 15-35.\\nThe symptoms of the panic attacks which may\\naccompany agoraphobia vary from person to person,\\nand may include trembling, sweating, heartpalpita-\\ntions (a feeling of the heart pounding against the\\nchest), jitters, fatigue, tingling in the hands and feet,\\nnausea, a rapid pulse or breathing rate, and a sense of\\nimpending doom.\\nAgoraphobia and other phobias are thought to be\\nthe result of a number of physical and environmental\\nfactors. For instance, they have been associated with\\nbiochemical imbalances, especially related to certain neu-\\nrotransmitters (chemical nerve messengers) in the brain.\\nPeople who have a panic attack in a given situation\\n(e.g., a shopping mall) may begin to associate the panic\\nwith that situation and learn to avoid it. According to\\nsome theories, irrational anxiety results from unresolved\\nemotional conflicts. All of these factors may play a\\nrole to varying extents in different cases of agoraphobia.\\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 specific\\nobject, activity, or situation.\\nGALE ENCYCLOPEDIA OF MEDICINE 79\\nAgoraphobia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 109, 'page_label': '80'}, page_content='Diagnosis\\nPeople who suffer from panic attacks should dis-\\ncuss the problem with a physician. The doctor can\\ndiagnose the underlying panic or anxiety disorder\\nand make sure the symptoms aren’t related to some\\nother underlying medical condition.\\nThe doctor makes the diagnosis of agoraphobia\\nbased primarily on the patient’s description of his or\\nher symptoms. The person with agoraphobia experi-\\nences anxiety in situations where escape is difficult or\\nhelp is unavailable–or in certain situations, such as\\nbeing alone. While many people are somewhat appre-\\nhensive in these situations, the hallmark of agorapho-\\nbia is that a person’s active avoidance of the feared\\nsituation impairs his or her ability to work, socialize,\\nor otherwise function.\\nTreatment\\nTreatment for agoraphobia usually consists of\\nboth medication and psychotherapy. Usually,\\npatients can benefit from certain antidepressants,\\nsuch as amitriptyline (Elavil), orselective serotonin\\nreuptake inhibitors , such as paroxetine (Paxil),\\nfluoxetine (Prozac), or sertraline (Zoloft). In addi-\\ntion, patients may manage panic attacks in progress\\nwith certain tranquilizers called benzodiazepines ,\\nsuch as alprazolam (Xanax) or clonazepam\\n(Klonipin).\\nThe mainstay of treatment for agoraphobia and\\nother phobias is cognitive behavioral therapy. A\\nspecific technique that is often employed is called\\ndesensitization. The patient is gradually exposed to\\nthe situation that usually triggers fear and avoidance,\\nand, with the help of breathing or relaxation tech-\\nniques, learns to cope with the situation. This helps\\nbreak the mental connection between the situation and\\nthe fear, anxiety, or panic. Patients may also benefit\\nfrom psychodynamically oriented psychotherapy,\\ndiscussing underlying emotional conflicts with a thera-\\npist or support group.\\nPrognosis\\nWith proper medication and psychotherapy, 90%\\nof patients will find significant improvement in their\\nsymptoms.\\nResources\\nPERIODICALS\\nForsyth, Sondra. ‘‘I Panic When I’m Alone.’’Mademoiselle\\nApril 1998: 119-24.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nAnxiety Disorders Association of America. 11900 Park\\nLawn Drive, Ste. 100, Rockville, MD 20852. (800)\\n545-7367. .\\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\\nan infectious disease caused by the humanimmunode-\\nficiency virus (HIV). It was first recognized in the\\nUnited States in 1981. AIDS is the advanced form of\\ninfection with the HIV virus, which may not cause\\nrecognizable disease for a long period after the initial\\nexposure (latency). No vaccine is currently available to\\nprevent HIV infection. At present, all forms of AIDS\\ntherapy are focused on improving the quality and\\nlength of life for AIDS patients by slowing or halting\\nthe replication of the virus and treating or preventing\\ninfections and cancers that take advantage of a per-\\nson’s weakened immune system.\\nDescription\\nAIDS is considered one of the most devastating\\npublic health problems in recent history. In June 2000,\\nthe Centers for Disease Control and Prevention\\n(CDC) reported that 120,223 (includes only those\\ncases in areas that have confidential HIV reporting)\\nin the United States are HIV-positive, and 311,701 are\\nliving with AIDS (includes only those cases where vital\\nstatus is known). Of these patients, 44% are gay or\\nbisexual men, 20% are heterosexual intravenous drug\\nusers, and 17% are women. In addition, approxi-\\nmately 1,000-2,000 children are born each year with\\nHIV infection. The World Health Organization\\n(WHO) estimates that 33 million adults and 1.3 mil-\\nlion children worldwide were living with HIV/AIDS as\\nof 1999 with 5.4 million being newly infected that year.\\nMost of these cases are in the developing countries of\\nAsia and Africa.\\n80 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 110, 'page_label': '81'}, page_content='Risk factors\\nAIDS can be transmitted in several ways. The risk\\nfactors for HIV transmissionvaryaccording to category:\\n/C15Sexual 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\\ninAfrica,thediseaseisspreadprimarilythroughsexual\\nintercourse among heterosexuals.\\n/C15Transmission in pregnancy. High-risk mothers\\ninclude women married to bisexual men or men\\nwho have an abnormal blood condition calledhemo-\\nphilia and require blood transfusions, intravenous\\ndrug users, and women living in neighborhoods\\nwith a high rate of HIV infection among heterosex-\\nuals. The chances of transmitting the disease to the\\nchild are higher in women in advanced stages of the\\ndisease. Breast feeding increases the risk of transmis-\\nsion by 10-20%. The use of zidovudine (AZT) during\\npregnancy, however, can decrease the risk of trans-\\nmission to the baby.\\n/C15Exposure to contaminated blood or blood products.\\nWith the introduction of blood product screening in\\nthe mid-1980s, the incidence of HIV transmission in\\nbloodtransfusionshasdroppedtooneinevery100,000\\ntransfused. With respect to HIV transmission among\\ndrug abusers, risk increases with the duration of using\\ninjections, the frequency of needle sharing, the num-\\nber of persons who share a needle, and the number of\\nAIDS cases in the local population.\\n/C15Needle sticks among health care professionals.\\nPresent studies indicate that the risk of HIV trans-\\nmission by a needle stick is about one in 250. This\\nrate can be decreased if the injured worker is given\\nAZT, an anti-retroviral medication, in combination\\nwith other medication.\\nHIV is not transmitted by handshakes or other\\ncasual non-sexual contact, coughing or sneezing, or by\\nbloodsucking insects such as mosquitoes.\\nAIDS in women\\nAIDS in women is a serious public health concern.\\nWomen exposed to HIV infection through hetero-\\nsexual contact are the most rapidly growing risk\\ngroup in the United States population. The percentage\\nof AIDS cases diagnosed in women has risen from 7%\\nin 1985 to 23% in 1999. Women diagnosed with AIDS\\nmay not live as long as men, although the reasons for\\nthis finding are unclear.\\nAIDS in children\\nSince AIDS can be transmitted from an infected\\nmother to the child during pregnancy, during the birth\\nprocess, or through breast milk, all infants born to\\nHIV-positive mothers are a high-risk group. As of\\n2000, it was estimated that 87% of HIV-positive\\nwomen are of childbearing age; 41% of them are\\ndrug abusers. Between 15-30% of children born to\\nHIV-positive women will be infected with the virus.\\nAIDS is one of the 10 leading causes ofdeath in\\nchildren between one and four years of age. The inter-\\nval between exposure to HIV and the development of\\nAIDS is shorter in children than in adults. Infants\\ninfected with HIV have a 20-30% chance of develop-\\ning AIDS within a year and dying before age three. In\\nthe remainder, AIDS progresses more slowly; the\\naverage child patient survives to seven years of age.\\nSome 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\\norgan systems. HIV attacks the body through three\\ndisease processes: immunodeficiency, autoimmunity,\\nand nervous system dysfunction.\\nRisk of acquiring HIV infection by entry site\\nEntry site\\nRisk virus\\nreaches entry\\nsite\\nRisk virus\\nenters\\nRisk\\ninoculated\\nConjuntiva Moderate Moderate Very low\\nOral mucosa Moderate Moderate Low\\nNasal mucosa Low Low Very low\\nLower\\nrespiratory\\nVery 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\\nPenis\\nUlcers (STD)\\nLow\\nHigh\\nHigh\\nLow\\nLow\\nHigh\\nMedium\\nLow\\nVery high\\nBlood:\\nProducts\\nShared needles\\nAccidental needle\\nHigh\\nHigh\\nLow\\nHigh\\nHigh\\nHigh\\nHigh\\nVery High\\nLow\\nTraumatic wound Modest High High\\nPerinatal High High High\\nGALE ENCYCLOPEDIA OF MEDICINE 81\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 111, 'page_label': '82'}, page_content='Immunodeficiency describes the condition in\\nwhich the body’s immune response is damaged, wea-\\nkened, or is not functioning properly. In AIDS, immu-\\nnodeficiency results from the way that the virus binds\\nto a protein called CD4, which is primarily found on\\nthe surface of certain subtypes of white blood cells\\ncalled helper T cells or CD4 cells. After the virus has\\nattached to the CD4 receptor, the virus-CD4 complex\\nrefolds to uncover another receptor called a chemo-\\nkine receptor that helps to mediate entry of the virus\\ninto the cell. One chemokine receptor in particular,\\nCCR5, has gotten recent attention after studies\\nshowed that defects in its structure (caused by genetic\\nmutations) cause the progression of AIDS to be pre-\\nvented or slowed. Scientists hope that this discovery\\nwill lead to the development of drugs that trigger an\\nartificial mutation of the CCR5 gene or target the\\nCCR5 receptor.\\nOnce HIV has entered the cell, it can replicate\\nintracellularly and kill the cell in ways that are still\\nnot completely understood. In addition to killing some\\nlymphocytes directly, the AIDS virus disrupts the\\nfunctioning of the remaining CD4 cells. Because the\\nimmune system cells are destroyed, many different\\ntypes of infections and cancers that take advantage\\nof a person’s weakened immune system (opportunis-\\ntic) can develop.\\nAutoimmunity is a condition in which the body’s\\nimmune system produces antibodies that work against\\nits own cells. Antibodies are specific proteins pro-\\nduced in response to exposure to a specific, usually\\nforeign, protein or particle called an antigen. In this\\ncase, the body produces antibodies that bind to blood\\nplatelets that are necessary for proper blood clotting\\nand tissue repair. Once bound, the antibodies mark the\\nplatelets for removal from the body, and they are\\nfiltered out by the spleen. Some AIDS patients develop\\na disorder, called immune-related thrombocytopenia\\npurpura (ITP), in which the number of blood platelets\\ndrops to abnormally low levels.\\nResearchers do not know precisely how HIV\\nattacks the nervous system since the virus can cause\\ndamage without infecting nerve cells directly. One\\ntheory is that, once infected with HIV, one type of\\nMature HIV-1 viruses (above) and the lymphocyte from which they emerged (below). Two immature viruses can be seen budding\\non the surface of the lymphocyte (right of center). (Photograph by Scott Camazir, Photo Researchers, Inc. Reproduced by\\npermission.)\\n82 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 112, 'page_label': '83'}, page_content='CENTRAL 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 develop,\\ntaking advantage of a person’s weakened immune system.(Illustration by Electronic Illustrators Group.)\\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\\ncoordination.\\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, natural\\nkiller cells, and monocytes in the patient’s blood.\\nGALE ENCYCLOPEDIA OF MEDICINE 83\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 113, 'page_label': '84'}, page_content='Most 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 coa-\\ngulation 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)— At r a n s m i s -\\nsible retrovirus that causes AIDS in humans. Two\\nforms of HIV are now recognized: HIV-1, which\\ncauses most cases of AIDS in Europe, North and\\nSouth America, and most parts of Africa; and HIV-2,\\nwhich is chiefly found in West African patients.\\nHIV-2, discovered in 1986, appears to be less virulent\\nthan HIV-1 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 tissue\\nthat produces painless purplish red (in people with\\nlight skin) or brown (in people with dark skin) blotches\\non the skin. It is a major diagnostic marker of AIDS.\\nLatent period— Also called incubation period, the\\ntime between infection with a disease-causing\\nagent and the development of disease.\\nLymphocyte— At y p eo fw h i t eb l o o dc e l lt h a ti si m p o r -\\ntant in the formation of antibodies and that can be used\\nto monitor the health of AIDS patients.\\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, that\\nhelps the body fight off infections by ingesting the\\ndisease-causing 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.\\nMycobacterium avium (MAC) infection— A type\\nof opportunistic infection that occurs in about 40%\\nof AIDS patients and is regarded as an AIDS-defining\\ndisease.\\nNon-nucleoside reverse transcriptase inhibitors—\\nThe newest class of antiretroviral drugs that work\\nby inhibiting the reverse transcriptase enzyme\\nnecessary 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 organisms\\nthat usually don’t cause infection in people whose\\nimmune systems are working normally.\\nPersistent generalized lymphadenopathy (PGL)— A\\ncondition in which HIV continues to produce\\nchronic painless swellings in the lymph nodes during\\nthe latency period.\\nPneumocystis carinii pneumonia (PCP)— An\\nopportunistic infection caused by a fungus that is a\\nmajor cause of death in patients with late-stage\\nAIDS.\\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 the\\nreplication 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 replicate\\nwithin new host cells.\\nT cells— Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s response\\nto infections, including HIV. CD4 lymphocytes are a\\nsubset of T lymphocytes.\\nThrush— A yeast infection of the mouth character-\\nized by white patches on the inside of the mouth and\\ncheeks.\\nViremia— The measurable presence of virus in the\\nbloodstream that is a characteristic of acute retroviral\\nsyndrome.\\nWasting syndrome— A progressive loss of weight\\nand muscle tissue caused by the AIDS virus.\\n84 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 114, 'page_label': '85'}, page_content='immune system cell, called a macrophage, begins to\\nrelease a toxin that 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\\ndescribe a group of symptoms that can resemble\\nmononucleosis and that may be the first sign of HIV\\ninfection in 50-70% of all patients and 45-90% of\\nwomen. Most patients are not recognized as infected\\nduring this phase and may not seek medical attention.\\nThe symptoms may include fever, fatigue, muscle\\naches, loss of appetite, digestive disturbances, weight\\nloss, skin rashes, headache, and chronically swollen\\nlymph nodes (lymphadenopathy). Approximately 25-\\n33% of patients will experience a form ofmeningitis\\nduring this phase in which the membranes that cover\\nthe brain and spinal cord become inflamed. Acute\\nretroviral syndrome develops between one and six\\nweeks after infection and lasts for two to three\\nweeks. Blood tests during this period will indicate the\\npresence 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\\nlatency, the virus continues to replicate in the lymph\\nnodes, where it may cause one or more of the following\\nconditions:\\nPERSISTENT GENERALIZED LYMPHADENOPATHY\\n(PGL). Persistent generalized lymphadenopathy, or\\nPGL, is a condition in which HIV continues to pro-\\nduce chronic painless swellings in the lymph nodes\\nduring the latency period. The lymph nodes that are\\nmost frequently affected by PGL are those in the areas\\nof the neck, jaw, groin, and armpits. PGL affects\\nbetween 50-70% of patients during latency.\\nCONSTITUTIONAL SYMPTOMS. Many patients will\\ndevelop low-grade fevers, chronicfatigue, and general\\nweakness. HIV may also cause a combination of food\\nmalabsorption, loss of appetite, and increased meta-\\nbolism that contribute to the so-called AIDS wasting\\nor wasting syndrome.\\nOTHER ORGAN SYSTEMS. At any time during the\\ncourse of HIV infection, patients may suffer from a\\nyeast infection in the mouth called thrush, open sores\\nor ulcers, or other infections of the mouth;diarrhea\\nand other gastrointestinal symptoms that causemal-\\nnutrition and weight loss; diseases of the lungs and\\nkidneys; and degeneration of the nerve fibers in the\\narms and legs. HIV infection of the nervous system\\nleads to general loss of strength, loss of reflexes, and\\nfeelings ofnumbness or burning sensations in the feet\\nor lower legs.\\nLate-stage disease (AIDS)\\nAIDS is usually marked by a very low number of\\nCD4+ lymphocytes, followed by a rise in the fre-\\nquency of opportunistic infections and cancers.\\nDoctors monitor the number and proportion of\\nCD4+ lymphocytes in the patient’s blood in order to\\nassess the progression of the disease and the effective-\\nness of different medications. About 10% of infected\\nindividuals never progress to this overt stage of the\\ndisease and are referred to as nonprogressors.\\nOPPORTUNISTIC INFECTIONS. Once the patient’s\\nCD4+ lymphocyte count falls below 200 cells/mm3,\\nhe or she is at risk for a variety of opportunistic infec-\\ntions. The infectious organisms may include the\\nfollowing:\\n/C15Fungi. The most common fungal disease associated\\nwith AIDS isPneumocystis carinii pneumonia (PCP).\\nPCP is the immediate cause of death in 15-20% of\\nAIDS patients. It is an important measure of a\\npatient’s prognosis. Other fungal infections include\\na yeast infection of the mouth (candidiasis or thrush)\\nand cryptococcal meningitis.\\n/C15Protozoa. Toxoplasmosis is a common opportunistic\\ninfection in AIDS patients that is caused by a proto-\\nzoan. Other diseases in this category include isopor-\\niasis and cryptosporidiosis.\\n/C15Mycobacteria. AIDS patients may developtubercu-\\nlosis or MAC infections. MAC infections are caused\\nby Mycobacterium avium-intracellulare , and occur in\\nabout 40% of AIDS patients. It is rare until CD4+\\ncounts falls below 50 cells/mm\\n3.\\n/C15Bacteria. AIDS patients are likely to develop bacter-\\nial infections of the skin and digestive tract.\\n/C15Viruses. AIDS patients are highly vulnerable to cyto-\\nmegalovirus (CMV), herpes simplex virus (HSV),\\nvaricella zoster virus (VZV), and Epstein-Barr virus\\n(EBV) infections. Another virus, JC virus, causes\\nprogressive destruction of brain tissue in the brain\\nstem, cerebrum, and cerebellum (multifocal leukoen-\\ncephalopathy or PML), which is regarded as an\\nAIDS-defining illness by the Centers for Disease\\nControl and Prevention.\\nGALE ENCYCLOPEDIA OF MEDICINE 85\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 115, 'page_label': '86'}, page_content='AIDS DEMENTIA COMPLEX AND NEUROLOGIC\\nCOMPLICATIONS. AIDS dementia complex is usually\\na late complication of the disease. It is unclear whether\\nit is caused by the direct effects of the virus on the\\nbrain or by intermediate causes. AIDS dementia com-\\nplex is marked by loss of reasoning ability, loss of\\nmemory, inability to concentrate, apathy and loss of\\ninitiative, and unsteadiness or weakness in walking.\\nSome patients also develop seizures. There are no\\nspecific treatments for AIDS dementia complex.\\nMUSCULOSKELETAL COMPLICATIONS. Patients in\\nlate-stage AIDS may develop inflammations of the\\nmuscles, particularly in the hip area, and may have\\narthritis-like pains in the joints.\\nORAL SYMPTOMS. In addition to thrush and pain-\\nful ulcers in the mouth, patients may develop a condi-\\ntion called hairy leukoplakia of the tongue. This\\ncondition is also regarded by the CDC as an indicator\\nof AIDS. Hairy leukoplakia is a white area of diseased\\ntissue on the tongue that may be flat or slightly raised.\\nIt is caused by the Epstein-Barr virus.\\nAIDS-RELATED CANCERS. Patients with late-stage\\nAIDS may develop Kaposi’s sarcoma (KS), a skin\\ntumor that primarily affects homosexual men. KS is\\nthe most common AIDS-related malignancy. It is\\ncharacterized by reddish-purple blotches or patches\\n(brownish in African-Americans) on the skin or in\\nthe mouth. About 40% of patients with KS develop\\nsymptoms in the digestive tract or lungs. KS may be\\ncaused by a herpes virus-like sexually transmitted dis-\\nease agent rather than HIV.\\nThe second most common form ofcancer in AIDS\\npatients is a tumor of the lymphatic system (lym-\\nphoma). AIDS-related lymphomas often affect the\\ncentral nervous system and develop very aggressively.\\nInvasive cancer of the cervix (related to certain\\ntypes of human papilloma virus [HPV]) is an impor-\\ntant diagnostic marker of AIDS in women.\\nWhile incidence of AIDS-defining cancers such as\\nKaposi’s sarcoma andcervical cancerhave decreased\\nsince increase use of antiretroviral therapy, other can-\\ncers has increased in AIDS patients. People with HIV\\nhas shown higher incidence of lung cancer, head and\\nneck cancers, Hodgkin’s lymphoma, melanoma, and\\nanorectal cancer from 1992 to 2002.\\nDiagnosis\\nBecause HIV infection produces such a wide\\nrange of symptoms, the CDC has drawn up a list\\nof 34 conditions regarded as defining AIDS. The\\nphysician will use the CDC list to decide whether the\\npatient falls into one of these three groups:\\n/C15definitive diagnoses with or without laboratory evi-\\ndence of HIV infection\\n/C15definitive diagnoses with laboratory evidence of HIV\\ninfection\\n/C15presumptive diagnoses with laboratory evidence of\\nHIV infection.\\nPhysical findings\\nAlmost all the symptoms of AIDS can occur with\\nother diseases. The generalphysical examinationmay\\nrange from normal findings to symptoms that are\\nclosely associated with AIDS. These symptoms are\\nhairy leukoplakia of the tongue and Kaposi’s sar-\\ncoma. When the doctor examines the patient, he or\\nshe will look for the overall pattern of symptoms\\nrather than any one finding.\\nLaboratory tests for HIV infection\\nBLOOD TESTS (SEROLOGY). The first blood test\\nfor AIDS was developed in 1985. At present, patients\\nwho are being tested for HIV infection are usually\\ngiven an enzyme-linked immunosorbent assay\\n(ELISA) test for the presence of HIV antibody in\\ntheir blood. Positive ELISA results are then tested\\nwith a Western blot or immunofluorescence (IFA)\\nassay for confirmation. The combination of the\\nELISA and Western blot tests is more than 99.9%\\naccurate in detecting HIV infection within four to\\neight weeks following exposure. The polymerase\\nchain reaction (PCR) test can be used to detect the\\npresence of viral nucleic acids in the very small number\\nof HIV patients who have false-negative results on the\\nELISA and Western blot tests. These tests are also\\nused to detect viruses and bacterium other than HIV\\nand AIDS.\\nOTHER LABORATORY TESTS. In addition to diag-\\nnostic blood tests, there are other blood tests that are\\nused to track the course of AIDS in patients that have\\nalready been diagnosed. These include blood counts,\\nviral load tests, p24 antigen assays, and measurements\\nof /C12\\n2-microglobulin (/C122M).\\nDoctors will use a wide variety of tests to diagnose\\nthe presence of opportunistic infections, cancers, or\\nother disease conditions in AIDS patients. Tissue\\nbiopsies, samples of cerebrospinal fluid, and sophisti-\\ncated imaging techniques, such as magnetic resonance\\nimaging (MRI) and computed tomography scans (CT)\\nare used to diagnose AIDS-related cancers, some\\nopportunistic infections, damage to the central\\n86 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 116, 'page_label': '87'}, page_content='nervous system, and wasting of the muscles. Urine and\\nstool samples are used to diagnose infections caused\\nby parasites. AIDS patients are also given blood tests\\nfor syphilis and othersexually transmitted diseases.\\nDiagnosis in children\\nDiagnostic blood testing in children older than 18\\nmonths is similar to adult testing, with ELISA screen-\\ning confirmed by Western blot. Younger infants can\\nbe diagnosed by direct culture of the HIV virus, PCR\\ntesting, and p24 antigen testing.\\nIn terms of symptoms, children are less likely than\\nadults to have an early acute syndrome. They are,\\nhowever, likely to have delayed growth, a history of\\nfrequent illness, recurrent ear infections, a low blood\\ncell count, failure to gain weight, and unexplained\\nfevers. Children with AIDS are more likely to develop\\nbacterial infections, inflammation of the lungs, and\\nAIDS-related brain disorders than are HIV-positive\\nadults.\\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\\ndiseases. This treatment is often complicated by the\\ndevelopment of resistance in the disease organisms.\\nAIDS-related malignancies in the central nervous sys-\\ntem are usually treated with radiation therapy.\\nCancers elsewhere in the body are treated with\\nchemotherapy.\\nPROPHYLACTIC TREATMENT FOR OPPORTUNISTIC\\nINFECTIONS. Prophylactic treatment is treatment that\\nis given to prevent disease. AIDS patients with a his-\\ntory ofPneumocystis pneumonia; with CD4+ counts\\nbelow 200 cells/mm\\n3 or 14% of lymphocytes; weight\\nloss; or thrush should be given prophylactic medica-\\ntions. The three drugs given are trimethoprim-\\nsulfamethoxazole, dapsone, or pentamidine in aerosol\\nform.\\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 four classes:\\n/C15Nucleotide analogues. These drugs work by interfer-\\ning with the action of HIV reverse transcriptase\\ninside infected cells, thus ending the virus’ replication\\nprocess. These drugs include zidovudine (sometimes\\ncalled azidothymidine or AZT), didanosine (ddI),\\nzalcitabine (ddC), stavudine (d4T), lamivudine\\n(3TC), and abacavir (ABC).\\n/C15Protease inhibitors. Protease inhibitors can be effec-\\ntive against HIV strains that have developed resis-\\ntance to nucleoside analogues, and are often used in\\ncombination with them. These compounds include\\nsaquinavir, ritonavir, indinavir, nelfinavir, amprena-\\nvir, and lopinavir..\\n/C15Non-nucleoside reverse transcriptase inhibitors. This\\nis a new class of antiretroviral agents. Three are\\navailable, nevirapine, which was approved first, dela-\\nvirdine and efavirin.\\n/C15Fusion inhibitors, the newest class of antiretrovirals.\\nThey block specific proteins on the surface of the\\nvirus or the CD4 cell. These proteins help the virus\\ngain entry into the cell.The only FDA approved\\nfusion inhibitor as of spring 2004 was enfuvirtide.\\nTreatment guidelines for these agents are in con-\\nstant change as new medications are developed and\\nintroduced. Two principles currently guide doctors in\\nworking out drug regimens for AIDS patients: using\\ncombinations of drugs rather than one medication\\nalone; and basing treatment decisions on the results\\nof the patient’s viral load tests.\\nSTIMULATION OF BLOOD CELL PRODUCTION.\\nBecause many patients with AIDS suffer from abnor-\\nmally low levels of both red and white blood cells,\\nthey may be given medications to stimulate blood cell\\nproduction. Epoetin alfa (erythropoietin) may be\\ngiven to anemic patients. Patients with low white\\nblood cell counts may be given filgrastim or\\nsargramostim.\\nTreatment in women\\nTreatment of pregnant women with HIV is parti-\\ncularly important in that anti-retroviral therapy\\nhas been shown to reduce transmission to the infant\\nby 65%.\\nAlternative treatment\\nAlternative treatments for AIDS can be grouped\\ninto two categories: those intended to help the immune\\nsystem and those aimed atpain control. Treatments\\nthat may enhance the function of the immune system\\ninclude Chinese herbal medicine and western herbal\\nmedicine, macrobiotic and other specialdiets, guided\\nimagery and creative visualization, homeopathy, and\\nvitamin therapy. Pain control therapies includehydro-\\ntherapy, reiki, acupuncture, meditation, chiropractic\\ntreatments, and therapeutic massage. Alternative\\nGALE ENCYCLOPEDIA OF MEDICINE 87\\nAIDS'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 117, 'page_label': '88'}, page_content='therapies can also be used to help with side effects of\\nthe medications used in the 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 expen-\\nsive medications and who tolerate them adequately.\\nThe use of these multi-drug therapies has signifi-\\ncantly reduced the numbers of deaths, in this country,\\nresulting from AIDS. The data is still inconclusive,\\nbut the potential exists to possibly prolong life\\nindefinitely using these and other drug therapies to\\nboost the immune system, keep the virus from repli-\\ncating, and ward off opportunistic infections and\\nmalignancies.\\nPrognosis after the latency period depends on the\\npatient’s specific symptoms and the organ systems\\naffected by the disease. Patients with AIDS-related\\nlymphomas of the central nervous system die within\\ntwo to three months of diagnosis; those with systemic\\nlymphomas may survive for eight to ten months.\\nPrevention\\nAs of 2005, there was no vaccine effective against\\nAIDS. Several vaccines are currently being investi-\\ngated, however, both to prevent initial HIV infection\\nand as a therapeutic treatment to prevent HIV from\\nprogressing to full-blown AIDS.\\nIn the meantime, there are many things that can\\nbe done to prevent the spread of AIDS:\\n/C15Being monogamous and practice safe sex.\\nIndividuals must be instructed in the proper use of\\ncondoms and urged to practice safe sex. Besides\\navoiding the risk of HIV infection, condoms are\\nsuccessful in preventing other sexually transmitted\\ndiseases and unwanted pregnancies. Before engaging\\nin a sexual relationship with someone, getting tested\\nfor HIV infection is recommended.\\n/C15Avoiding needle sharing among intravenous drug\\nusers.\\n/C15Although blood and blood products are carefully\\nmonitored, those individuals who are planning to\\nundergo major surgery may wish to donate blood\\nahead of time to prevent a risk of infection from a\\nblood transfusion.\\n/C15Healthcare professionals must take all necessary pre-\\ncautions by wearing gloves and masks when hand-\\nling body fluids and preventing needle-stick injuries.\\n/C15If someone suspects HIV infection, he or she\\nshould be tested for HIV. If treated aggressively\\nand early, the development of AIDS may be post-\\nponed indefinitely. If HIV infection is confirmed, it\\nis also vital to let sexual partners know so that they\\ncan be tested and, if necessary, receive medical\\nattention.\\nResources\\nPERIODICALS\\nBoschert, Sherry. ‘‘Some Ca Increasing in Post-HAART\\nEra.’’ Clinical Psychiatry News June 2004: 75.\\nGodwin, Catherine. ‘‘WhatÆs New in the Fight Against\\nAIDS.’’ RN April 2004: 46–54.\\nORGANIZATIONS\\nGay Men’s Health Crisis, Inc., 129 West 20th Street, New\\nYork, NY 10011-0022. (212) 807-6655.\\nNational AIDS Hot Line. (800) 342-AIDS (English). (800)\\n344-SIDA (Spanish). (800) AIDS-TTY (hearing-\\nimpaired).\\nOTHER\\n‘‘FDA Approved Drugs for HIV Infection and AIDS-\\nRelatedConditions.’’HIV/AIDS Treatment Information\\nService website. January 2001..\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAIDS serology see AIDS tests\\nAIDS tests\\nDefinition\\nAIDS tests, short for acquiredimmunodeficiency\\nsyndrome tests, cover a number of different proce-\\ndures used in the diagnosis and treatment of HIV\\npatients. These tests sometimes are called AIDS\\nserology tests. Serology is the branch of immunology\\nthat deals with the contents and characteristics of\\nblood serum. Serum is the clear light yellow part\\nof blood that remains liquid when blood cells form\\na clot. AIDS serology evaluates the presence of\\nhuman immunodeficiency virus (HIV) infection in\\nblood serum and its effects on each patient’s immune\\nsystem.\\nPurpose\\nAIDS serology serves several different purposes.\\nSome AIDS tests are used to diagnose patients or\\n88 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 118, 'page_label': '89'}, page_content='confirm a diagnosis; others are used to measure the\\nprogression of the disease or the effectiveness of spe-\\ncific treatment regimens. Some AIDS tests also can be\\nused to screen blood donations for safe use in\\ntransfusions.\\nIn order to understand the different purposes\\nof the blood tests used with AIDS patients, it is help-\\nful to understand how HIV infection affects human\\nblood and the immune system. HIV is a retrovirus that\\nenters the blood stream of a new host in the following\\nways:\\n/C15by sexual contact\\n/C15by contact with infected body fluids (such as blood\\nand urine)\\n/C15by transmission duringpregnancy,o r\\n/C15through transfusion of infected blood products\\nA retrovirus is a virus that contains a unique\\nenzyme called reverse transcriptase that allows it to\\nreplicate within new host cells. The virus binds to a\\nprotein called CD4, which is found on the surface of\\ncertain subtypes of white blood cells, including helper\\nT cells, macrophages, and monocytes. Once HIV\\nenters the cell, it can replicate and kill the cell in\\nways that are still not completely understood. In addi-\\ntion to killing some lymphocytes directly, the AIDS\\nvirus disrupts the functioning of the remaining CD4\\ncells. CD4 cells ordinarily produce a substance called\\ninterleukin-2 (IL-2), which stimulates other cells\\n(T cells and B cells) in the human immune system\\nto respond to infections. Without the IL-2, T cells do\\nnot reproduce as they normally would in response to the\\nHIV virus, and B cells are not stimulated to respond\\nto 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 avoid being pricked by\\nthe needle used in drawing blood for the tests. It may\\nbe difficult to get blood from a habitual intravenous\\ndrug user due to collapsed veins.\\nDescription\\nDiagnostic tests\\nDiagnostic blood tests for AIDS usually are given\\nto persons in high-risk populations who may have\\nbeen exposed to HIV or who have the early symptoms\\nof AIDS. Most persons infected with HIV will develop\\na detectable level of antibody within three months of\\ninfection. The condition of testing positive for HIV\\nantibody in the blood is called seroconversion, and\\npersons who have become HIV-positive are called\\nseroconverters.\\nIt is possible to diagnose HIV infection by isolat-\\ning the virus itself from a blood sample or by demon-\\nstrating the presence of HIV antigen in the blood.\\nViral culture, however, is expensive, not widely avail-\\nable, and slow—it takes 28 days to complete the viral\\nculture test. More common are blood tests that work\\nby detecting the presence of antibodies to the HIV\\nvirus. These tests are inexpensive, widely available,\\nand accurate in detecting 99.9% of AIDS infections\\nwhen used in combination to screen patients and\\nconfirm diagnoses.\\nENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA).\\nThis type of blood test is used to screen blood for\\ntransfusions as well as diagnose patients. An ELISA\\ntest for HIV works by attaching HIV antigens to a\\nplastic well or beads. A sample of the patient’s blood\\nserum is added, and excess proteins are removed.\\nA second antibody coupled to an enzyme is added,\\nfollowed by addition of a substance that will cause\\nthe enzyme to react by forming a color. An instru-\\nment called a spectrophotometer can measure the\\ncolor. The name of the test is derived from the use\\nof the enzyme that is coupled or linked to the second\\nantibody.\\nA three-dimensional model of the HIV virus. (Corbis\\nCorporation (New York). Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 89\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 119, 'page_label': '90'}, page_content='KEY TERMS\\nAntibody— A protein in the blood that identifies and\\nhelps 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 bone\\nmarrow. B cells are sometimes called B lympho-\\ncytes. They secrete antibody and have a number of\\nother complex functions within the human immune\\nsystem.\\nCD4— A type of protein molecule in human blood\\nthat is present on the surface of 65% of human\\nT cells. CD4 is a receptor for the HIV virus. When\\nthe HIV 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+ lymphocytes.\\nCD4 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 dis-\\ntribution width, the hematocrit (ratio of the volume\\nof the red blood cells to the blood volume), and the\\namount of hemoglobin (the blood protein that carries\\noxygen). CBCs are a routine blood test used for many\\nmedical reasons, not only for AIDS patients. They\\ncan help the doctor determine if a patient is in\\nadvanced 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 added,\\nand excess proteins are removed. A second antibody\\ncoupled to an enzyme is added, followed by a che-\\nmical that will cause a color reaction that can be\\nmeasured 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\\ncauses most cases of AIDS in Europe, North and\\nSouth America, and most parts of Africa; and\\nHIV-2, which is chiefly found in West African\\npatients. HIV-2, discovered in 1986, appears to be\\nless virulent than HIV-1, but also may have a longer\\nlatency period.\\nImmunofluorescent assay (IFA)— A blood test some-\\ntimes used to confirm ELISA results instead of using\\nthe Western blotting. In an IFA test, HIV antigen is\\nmixed with a fluorescent compound and then with a\\nsample of the patient’s blood. If HIV antibody is\\npresent, the mixture will fluoresce when examined\\nunder ultraviolet light.\\nLymphocyte— A type of white blood cell that is\\nimportant in the formation of antibodies. Doctors\\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, that\\nhelps the body fight off infections by ingesting the\\ndisease 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 develops\\nonly when a person’s immune system is weakened,\\nas 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 loca-\\ntion, using DNA polymerase to make a copy, and\\nthen continuously replicating the copies. The ampli-\\nfication of gene sequences that are associated with\\nHIV allows for detection of the virus by this method.\\nRetrovirus— A virus that contains a unique enzyme\\ncalled reverse transcriptase that allows it to replicate\\nwithin 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 liquid\\nwhen blood cells form a clot. Human blood serum is\\nclear light yellow in color.\\n90 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 120, 'page_label': '91'}, page_content='The latest generation of ELISA tests are 99.5%\\nsensitive to HIV. Occasionally, the ELISA test will be\\npositive for a patient without symptoms of AIDS from\\na low-risk group. Because this result is likely to be a\\nfalse-positive, the ELISA must be repeatedon the same\\nsample of the patient’s blood . If the second ELISA is\\npositive, the result should be confirmed by the\\nWestern 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 test-\\ning, HIV antigen is purified by electrophoresis (large\\nprotein molecules are suspended in a gel and separated\\nfrom one another by running an electric current\\nthrough the gel). The HIV antigens are attached by\\nblotting to a nylon or nitrocellulose filter. The\\npatient’s serum is reacted against the filter, followed\\nby treatment with developing chemicals that allow\\nHIV antibody to show up as a colored patch or blot.\\nA commercially produced Western blot test for HIV-1\\nis now available. It consists of a prefabricated\\nstrip that is incubated with a sample of the patient’s\\nblood serum and the developing chemicals. About\\nnine different HIV-1 proteins can be detected in\\nthe 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\\nmixing HIV antigen with a fluorescent chemical, add-\\ning the blood sample, and observing the reaction\\nunder a microscope with ultraviolet light.\\nPOLYMERASE CHAIN REACTION (PCR). This test is\\nused to evaluate the very small number of AIDS\\npatients with false-negative ELISA and Western blot\\ntests. These patients are sometimes called antibody-\\nnegative asymptomatic (without symptoms) carriers,\\nbecause they do not have any symptoms of AIDS and\\nthere is no detectable quantity of antibody in the blood\\nserum. Antibody-negative asymptomatic carriers may\\nbe responsible for the very low ongoing risk of HIV\\ninfection transmitted by blood transfusions. It is esti-\\nmated that the risk is between 1 in 10,000 and 1 in\\n100,000 units of transfused blood.\\nThe polymerase chain reaction (PCR) test can\\nmeasure the presence of viral nucleic acids in the\\npatient’s blood even when there is no detectable anti-\\nbody to HIV. This test works by amplifying the pre-\\nsence of HIV nucleic acids in a blood sample.\\nNumerous copies of a gene are made by separating\\nthe two strands of DNA containing the gene segment,\\nmarking its location, using DNA polymerase to make\\na copy, and then continuously replicating the copies. It\\nis questionable whether PCR will replace Western\\nblotting as the method of confirming AIDS diagnoses.\\nAlthough PCR can detect the low number of persons\\n(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.\\nIn addition, PCR testing is based on present knowl-\\nedge of the genetic sequences in HIV. Since the virus\\nis continually generating new variants, PCR testing\\ncould yield a false negative in patients with these\\nnew variants. In 2004, researchers reported on a new\\ntest that was more sensitive to HIV, detecting the\\ninfection in as little as 12 days after infection.\\nHowever, the manufacturer was still seeking FDA\\napproval for the test, which would cost about the\\nsame as PCR testing.\\nT cells— Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s response\\nto infections, including HIV. CD4 lymphocytes are a\\nsubset 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 pur-\\nified 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 result\\nis 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\\nnumber of each type. A WBC differential is neces-\\nsary to calculate the absolute CD4+ lymphocyte\\ncount.\\nGALE ENCYCLOPEDIA OF MEDICINE 91\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 121, 'page_label': '92'}, page_content='In 1999, the U.S. Food and Drug Administration\\n(FDA) approved an HIV home testing kit. The kit\\ncontained multiple components, including material\\nfor specimen collection, a mailing envelope to send\\nthe specimen to a laboratory for analysis, and provides\\npre- and post-test counseling. It uses a finger prick\\nprocess for blood collection. Other tests have been in\\ndevelopment that would allow patients to monitor\\ntheir own therapy in the home without sending out\\nfor results.\\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\\npersons may be infected with the virus for 10 years or\\nlonger before they develop symptoms of AIDS. These\\npatients are sometimes called antibody-positive\\nasymptomatic carriers. Prognostic tests also help\\ndrug researchers evaluate the usefulness of new medi-\\ncations in treating AIDS.\\nBLOOD CELL COUNTS. Doctors can measure the\\nnumber or proportion of certain types of cells in an\\nAIDS patient’s blood to see whether and how rapidly\\nthe disease is progressing, or whether certain treat-\\nments are helping the patient. These cell count tests\\ninclude:\\n/C15Complete blood count (CBC). A CBC is a routine\\nanalysis performed on a sample of blood taken\\nfrom the patient’s vein with a needle and vacuum\\ntube. The measurements taken in a CBC include a\\nwhite blood cell count (WBC), a red blood cell count\\n(RBC), the red cell distribution width, thehematocrit\\n(ratio of the volume of the red blood cells to the\\nblood volume), and the amount of hemoglobin (the\\nblood protein that carries oxygen). Although CBCs\\nare 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\\nsigns in a CBC include a low hematocrit, a sharp\\ndecrease in the number of blood platelets, and a\\nlow level of a certain type of white blood cell called\\nneutrophils.\\n/C15Absolute CD4+ lymphocytes. A lymphocyte is a\\ntype of white blood cell that is important in the\\nformation of an immune response. Because HIV\\ntargets CD4+ lymphocytes, their number in the\\npatient’s blood can be used to track the course of\\nthe infection. This blood cell count is considered the\\nmost accurate indicator for the presence of an oppor-\\ntunistic infection in an AIDS patient. The absolute\\nCD4+ lymphocyte count is obtained by multiplying\\nthe patient’s white blood cell count (WBC) by the\\npercentage of lymphocytes among the white blood\\ncells, and multiplying the result by the percentage\\nof lymphocytes bearing the CD4+ marker. An abso-\\nlute count below 200-300 CD+4 lymphocytes\\nin 1 cubic millimeter (mm\\n3) of blood indicates that\\nthe patient is vulnerable to some opportunistic\\ninfections.\\n/C15CD4+ lymphocyte percentage. Some doctors think\\nthat this is a more accurate test than the absolute\\ncount because the percentage does not depend on a\\nmanual calculation of the number of types of differ-\\nent white blood cells. A white blood cell count that is\\nbroken down into categories in this way is called a\\nWBC differential.\\nIt is important for doctors treating AIDS patients\\nto measure 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/C15CD4+ count more than 600 cells/mm3: Every six\\nmonths.\\n/C15CD4+ count between 200-600 cells/mm3: Every\\nthree months.\\n/C15CD4+ count less than 200 cells/mm3: Every three\\nmonths.\\nWhen the CD4+ count falls below 200 cells/mm3,\\nthe doctor will put the patient on a medication regi-\\nmen to protect him or her against opportunistic\\ninfections.\\nHIV VIRAL LOAD TESTS. Another type of blood test\\nfor monitoring AIDS patients is the viral load test. It\\nsupplements the CD4+ count, which can tell the doc-\\ntor the extent of the patient’s loss of immune function,\\nbut not the speed of HIV replication in the body. The\\nviral load test is based on PCR techniques and can\\nmeasure the number of copies of HIV nucleic acids.\\nSuccessive test results for a given patient’s viral load\\nare calculated on a base 10 logarithmic scale.\\nORAL HIV TESTS. Scientists have developed oral\\nHIV tests that can be conducted with saliva samples.\\nOne of the unintented effects of these tests is the\\nmisperception that HIV can be transmitted through\\nsaliva. Still, they present an excellent alternative to\\nblood sample testing.\\nRAPID HIV TESTS. Researchers constantly work on\\nmore rapid tests for HIV that can be done in physician\\noffices or by less skilled people and more convenient\\nlocations in developing countries. A finger-stick test\\nthat can be read quickly from a whole blood sample\\nhad shown promising results in the fall of 2003.\\n92 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 122, 'page_label': '93'}, page_content='Another test, called the VScan test kit, requires no\\nrefrigeration or electricity and can safely be stored at\\nroom temperature. Even if the positive results must be\\nconfirmed by ELISA or Western blotting, an accurate\\ninitial rapid test can help screen populations for HIV\\nantibodies.\\nIn 2004, a new three-minute test for HIV was\\nlunched in the United States under FDA approval.\\nThe hope of this test is that health care providers\\nsuch as family practice physician offices can quickly\\ntest a patient in the office and provide results while the\\npatient waits, rather than sending results to a lab.\\nBETA2-MICROGLOBULIN (BETA 2M). Beta-microglo-\\nbulin is a protein found on the surface of all human\\ncells with a nucleus. It is released into the blood when a\\ncell dies. Although rising blood levels of/C12\\n2M are found\\nin patients withcancer and other serious diseases, a\\nrising /C122M blood level can be used to measure the\\nprogression of 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\\nin detecting HIV infection before seroconversion.\\nHowever, p24 is consistently present in only 25% of\\npersons infected with HIV.\\nGENOTYPIC DRUG RESISTANCE TEST. Genotypic\\ntesting can help determine whether specific gene\\nmutations, common in people with HIV, are causing\\ndrug resistance and drug failure. The test looks for\\nspecific genetic mutations within the virus that are\\nknown to cause resistance to certain drugs used in\\nHIV treatment. For example the drug 3TC, also\\nknown as lamivudine (Epivir), is not effective against\\nstrains of HIV that have a mutation at a particular\\nposition on the reverse transcriptase protein—amino\\nacid 184—known as M184V (M!V, methionine to\\nvaline). So if the genotypic resistance test shows a\\nmutation at position M184V, it is likely the person\\nis resistant to 3TC and not likely to respond to 3TC\\ntreatment. Genotypic tests are only effective if the\\nperson is already taking antiviral medication and if\\nthe viral load is greater than 1,000 copies per milliliter\\n(mL) of blood. The cost of the test, usually between\\n$300 and $500, is usually now covered by many insur-\\nance plans.\\nPHENOTYPIC DRUG RESISTANCE TESTING.\\nPhenotypic testing directly measures the sensitivity of\\na patient’s HIV to particular drugs and drug combina-\\ntions. To do this, it measures the concentration of a\\ndrug required to inhibit viral replication in the test\\ntube. This is the same method used by researchers to\\ndetermine whether a drug might be effective against\\nHIV before using it in human clinical trials.\\nPhenotypic testing is a more direct measurement of\\nresistance than genotypic testing. Also, unlike genoty-\\npic testing, phenotypic testing does not require a high\\nviral load but it is recommended that persons already\\nbe takingantiretroviral drugs. The cost is between $700\\nand $900 and is now covered by many insurance plans.\\nAIDS serology in children\\nChildren born to HIV-infected mothers may\\nacquire the infection through the mother’s placenta\\nor during the birth process. Public health experts\\nrecommend the testing and monitoring of all children\\nborn to mothers with HIV. Diagnostic testing in chil-\\ndren older than 18 months is similar to adult testing,\\nwith ELISA screening confirmed by Western blot.\\nYounger infants can be diagnosed by direct culture\\nof the HIV virus, PCR testing, and p24 antigen testing.\\nThese techniques allow a pediatrician to identify 50%\\nof infected children at or near birth, and 95% of cases\\nin infants three to six months of age.\\nPreparation\\nPreparation and aftercare are important parts of\\nAIDS diagnostic testing. Doctors are now advised to\\ntake the patient’s emotional, social, economic, and\\nother circumstances into account and to provide coun-\\nseling before and after testing. Patients are generally\\nbetter able to cope with the results if the doctor has\\nspent some time with them before the blood test\\nexplaining the basic facts about HIV infection and\\ntesting. Many doctors now offer this type of informa-\\ntional counseling before performing the tests.\\nAftercare\\nIf the test results indicate that the patient is HIV-\\npositive, he or she will need counseling, information,\\nreferral for treatment, and support. Doctors can either\\ncounsel the patient themselves or invite an experienced\\nHIV counselor to discuss the results of the blood tests\\nwith the patient. They also will assess the patient’s\\nemotional and psychological status, including the pos-\\nsibility of violent behavior and the availability of a\\nsupport network.\\nRisks\\nThe risks of AIDS testing are primarily related to\\ndisclosure of the patient’s HIV status rather than to\\nany physical risks connected with blood testing. Some\\nGALE ENCYCLOPEDIA OF MEDICINE 93\\nAIDS tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 123, 'page_label': '94'}, page_content='patients are better prepared to cope with a positive\\ndiagnosis than others, depending on their age, sex,\\nhealth, resources, belief system, and similar factors.\\nNormal results\\nNormal results for ELISA, Western blot, IFA,\\nand PCR testing are negative for HIV antibody.\\nNormal results for blood cell counts:\\n/C15WBC differential: Total lymphocytes 24-44% of the\\nwhite blood cells.\\n/C15Hematocrit: 40-54% in men; 37-47% in women.\\n/C15T cell lymphocytes: 644-2200/mm3, 60-88% of all\\nlymphocytes.\\n/C15B cell lymphocytes: 82-392/mm 3, 3-20% of all\\nlymphocytes.\\n/C15CD4+ lymphocytes: 500-1200/mm3, 34-67% of all\\nlymphocytes.\\nAbnormal results\\nThe following results in AIDS tests indicate pro-\\ngression of the disease:\\n/C15Percentage of CD4+ lymphocytes: less than 20% of\\nall lymphocytes.\\n/C15CD4+ lymphocyte count: less than 200 cells/mm3.\\n/C15Viral load test: Levels more than 5000 copies/mL.\\n/C15/C12:-2-microglobulin: Levels more than 3.5 mg/dL.\\n/C15P24 antigen: Measurable amounts in blood serum.\\nResources\\nBOOKS\\nBennett, Rebecca, and Erin, Charles A., editors.HIV and\\nAIDS Testing, Screening, and Confidentiality: Ethics,\\nLaw, and Social Policy. Oxford, England: Oxford\\nUniversity Press, 2001.\\nPERIODICALS\\n‘‘Finger-stick Test is Accurate and Acceptable to Women in\\nThailand.’’ Drug Week (September 5, 2003): 168.\\nKaplan, Edward H., and Glen A. Satten. ‘‘Repeat Screening\\nfor HIV: When to Test and Why.’’The Journal of the\\nAmerican Medical Association.\\nMedical Devices & Surgical Technology Week (September\\n12, 2004): 102.\\n‘‘Researcher Developing Home Test Kit for HIV\\nTherapies.’’ Medical Devices & Surgical Technology\\nWeek (December 23, 2001): 2.\\n‘‘Researchers Report New Ultra-sensitive AIDS Test.’’\\nBiotech Week (July 14, 2004): 246.\\nWeinhardt, Lance S., et al. ‘‘Human Immunodeficiency\\nVirus Testing and Behavior Change.’’Archives of\\nInternal Medicine (May 22, 2000): 1538.\\nKen R. Wells\\nTeresa G. Odle\\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 asliver function\\ntests (or LFTs) and is used to monitor damage to the\\nliver.\\nPurpose\\nALT levels are used to detect liver abnormalities.\\nSince the alanine aminotransferase enzyme is also\\nfound in muscle, tests indicating elevated AST levels\\nmight also indicate muscle damage. However, other\\ntests, such as the levels of the MB fraction of creatine\\nkinase should indicate whether the abnormal test\\nlevels are because of muscle or liver damage.\\nDescription\\nThe alanine aminotransferase test (ALT) can\\nreveal liver damage. It is probably the most specific\\ntest for liver damage. However, the severity of the liver\\ndamage is not necessarily shown by the ALT test, since\\nthe amount of dead liver tissue does not correspond to\\nhigher ALT levels. Also, patients with normal, or\\ndeclining, ALT levels may experience serious liver\\ndamage without an 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\\nmay indicate how much of the liver has been damaged.\\nALT levels, when compared to the levels of a similar\\nenzyme, aspartate aminotransferase (AST), may pro-\\nvide important clues to the nature of the liver disease.\\nFor example, within a certain range of values, a ratio\\nof 2:1 or greater for AST: ALT might indicate that a\\npatient suffers from alcoholic liver disease. Other diag-\\nnostic data may be gleaned from ALT tests to indicate\\nabnormal results.\\n94 GALE ENCYCLOPEDIA OF MEDICINE\\nAlanine aminotransferase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 124, 'page_label': '95'}, page_content='Preparation\\nNo special preparations are necessary for this test.\\nAftercare\\nThis test involves blood being drawn, probably\\nfrom a vein in the patient’s elbow. The patient should\\nkeep the wound from the needle puncture covered\\n(with a bandage) until the bleeding stops. Patients\\nshould report any unusual symptoms to their\\nphysician.\\nNormal results\\nNormal values vary from laboratory to labora-\\ntory, and should be available to your physician at the\\ntime of the test. An informal survey of some labora-\\ntories indicates many laboratories find values from\\napproximately seven to 50 IU/L to be normal.\\nAbnormal results\\nLow levels of ALT (generally below 300 IU/L)\\nmay indicate any kind of liver disease. Levels above\\n1,000 IU/L generally indicate extensive liver damage\\nfrom toxins or drugs, viral hepatitis, or a lack of oxy-\\ngen (usually resulting from very low blood pressure or\\na heart attack). A briefly elevated ALT above 1,000\\nIU/L that resolves in 24-48 hours may indicate a\\nblockage of the bile duct. More moderate levels of\\nALT (300-1,000IU/L) may support a diagnosis of\\nacute or chronic hepatitis.\\nIt is important to note that persons with normal\\nlivers may have slightly elevated levels of ALT. This is\\na normal finding.\\nMichael V. Zuck, PhD\\nAlbers-Scho¨nberg disease see Osteopetroses\\nAlbinism\\nDefinition\\nAlbinism is an inherited condition present at\\nbirth, characterized by a lack of pigment that normally\\ngives color to the skin, hair, and eyes. Many types of\\nalbinism exist, all of which involve lack of pigment in\\nvarying degrees. The condition, which is found in all\\nraces, may be accompanied by eye problems and may\\nlead to skincancer later in life.\\nDescription\\nAlbinism is a rare disorder found in fewer than\\nfive people per 100,000 in the United States and\\nEurope. Other parts of the world have a much higher\\nrate; for example, albinism is found in about 20 out of\\nevery 100,000 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 skin,\\nwhich turn slightly darker as they age. Everyone with\\noculocutaneous albinism experiences abnormal flicker-\\ning eye movements (nystagmus) and sensitivity to bright\\nlight. There may be other eye problems as well, includ-\\ning poor vision and crossed or ‘‘lazy’’ eyes (strabismus).\\nThe second most common type of the condition is\\nknown as ‘‘ocular’’ albinism, in which only the eyes\\nlack color; skin and hair are normal. There are five\\nforms of ocular albinism; some types cause more pro-\\nblems–especially eye problems–than others.\\nCauses and symptoms\\nEvery cell in the body contains a matched pair of\\ngenes, one inherited from each parent. These genes act\\nas a sort of ‘‘blueprint’’ that guides the development of\\na fetus.\\nAlbinism is an inherited problem caused by a flaw\\nin one or more of the genes that are responsible for\\ndirecting the eyes and skin to make melanin (pigment).\\nAs a result, little or no pigment is made, and the child’s\\nskin, eyes and hair may be colorless.\\nIn most types of albinism, a recessive trait, the\\nchild inherits flawed genes for making melanin from\\nboth parents. Because the task of making melanin is\\ncomplex, there are many different types of albinism,\\ninvolving a number of different genes.\\nIt’s also possible to inherit one normal gene and\\none albinism gene. In this case, the one normal gene\\nprovides enough information in its cellular blueprint\\nto make some pigment, and the child will have normal\\nskin and eye color. They ‘‘carry’’ one gene for albin-\\nism. About one in 70 people are albinism carriers, with\\none flawed gene but no symptoms; they have a 50%\\nchance of passing the albinism gene to their child.\\nHowever, if both parents are carriers with one flawed\\ngene each, they have a 1 in 4 chance of passing on both\\ncopies of the flawed gene to the child, who will have\\nalbinism. (There is also a type of ocular albinism that\\nis carried on the X chromosome and occurs almost\\nexclusively in males because they have only one X\\nGALE ENCYCLOPEDIA OF MEDICINE 95\\nAlbinism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 125, 'page_label': '96'}, page_content='chromosome and, therefore, no other gene for the trait\\nto 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\\nvariety of eye problems, one of the myths about albin-\\nism is that it causes people to have pink or red eyes. In\\nfact, people with albinism can have irises varying from\\nlight gray or blue to brown. (The iris is the colored\\nportion of the eye that controls the size of the pupil,\\nthe opening that lets light into the eye.) If people with\\nalbinism seem to have reddish eyes, it’s because light is\\nbeing reflected from the back of the eye (retina) in\\nmuch the same way as happens when people are\\nphotographed with an electronic flash.\\nPeople with albinism may have one or more of the\\nfollowing eye problems:\\n/C15They may be very far-sighted or near-sighted, and\\nmay have other defects in the curvature of the lens of\\nthe eye (astigmatism) that cause images to appear\\nunfocused.\\n/C15They may have a constant, involuntary movement of\\nthe eyeball called nystagmus.\\n/C15They may have problems in coordinating the eyes in\\nfixing and tracking objects (strabismus), which may\\nlead to an appearance of having ‘‘crossed eyes’’ at\\ntimes. Strabismus may cause some problems with\\ndepth perception, especially at close distances.\\n/C15They may be very sensitive to light (photophobia)\\nbecause their irises allow ‘‘stray’’ light to enter their\\neyes. It’s a common misconception that people with\\nalbinism shouldn’t go out on sunny days, but wear-\\ning sunglasses can make it possible to go outside\\nquite comfortably.\\nA man with albinism stands with his normally pigmented father. (Photograph by Norman Lightfoot, Photo Researchers, Inc.\\nReproduced by permission.)\\n96 GALE ENCYCLOPEDIA OF MEDICINE\\nAlbinism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 126, 'page_label': '97'}, page_content='In addition to the characteristically light skin and\\neye problems, people with a rare form of albinism\\ncalled Hermansky-Pudlak Syndrome (HPS) also\\nhave a greater tendency to have bleeding disorders,\\ninflammation of the large bowel (colitis), lung (pul-\\nmonary) disease, and kidney (renal) problems.\\nDiagnosis\\nIt’s not always easy to diagnose the exact type\\nof albinism a person has; there are two tests avail-\\nable that can identify only two types of the condi-\\ntion. Recently, a blood test has been developed that\\ncan identify carriers of the gene for some types of\\nalbinism; a similar test during amniocentesis can\\ndiagnose some types of albinism in an unborn\\nchild. Achorionic villus samplingtest during the fifth\\nweek of pregnancy may also reveal some types of\\nalbinism.\\nThe specific type of albinism a person has can be\\ndetermined by taking a good family history and exam-\\nining the patient and several close relatives.\\nThe ‘‘hairbulb pigmentation test’’ is used to iden-\\ntify carriers by incubating a piece of the person’s hair\\nin a solution of tyrosine, a substance in food which the\\nbody uses to make melanin. If the hair turns dark, it\\nmeans the hair is making melanin (a ‘‘positive’’ test);\\nlight hair means there is no melanin. This test is the\\nsource of the names of two types of albinism: ‘‘ty-pos’’\\nand ‘‘ty-neg.’’\\nT h et y r o s i n a s et e s ti sm o r ep r e c i s et h a nt h e\\nhairbulb pigmentation test. It measures the rate at\\nwhich hair converts tyrosine into another chemical\\n(DOPA), which is then made into pigment. The hair\\nconverts tyrosine with the help of a substance called\\n‘‘tyrosinase.’’ In some types of albinism, tyrosinase\\ndoesn’t do its job, and melanin production breaks\\ndown.\\nTreatment\\nThere is no treatment that can replace the lack of\\nmelanin that causes the symptoms of albinism.\\nDoctors can only treat, not cure, the eye problems\\nthat often accompany the lack of skin color. Glasses\\nare usually needed and can be tinted to ease pain from\\ntoo much sunlight. There is no cure for involuntary\\neye movements (nystagmus), and treatments for\\nfocusing problems (surgery or contact lenses) are not\\neffective 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\\ncondition.\\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 organ-\\nisms. The entwined double structure allows the\\nchromosomes to be copied exactly during cell\\ndivision.\\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\\none chemical 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\\nin albinism.\\nTyrosine— A protein building block found in a\\nwide variety of foods that is used by the body to\\nmake melanin.\\nTyrosinase— An enzyme in a pigment cell which\\nhelps change tyrosine to DOPA during the process\\nof making melanin.\\nGALE ENCYCLOPEDIA OF MEDICINE 97\\nAlbinism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 127, 'page_label': '98'}, page_content='Patients with albinism should avoid excessive\\nexposure to the sun, especially between 10 a.m. and\\n2 p.m. If exposure can’t be avoided, they should use\\nUVA-UVB sunblocks with an SPF of at least 20.\\nTaking beta- carotene may help provide some skin\\ncolor, although it doesn’t protect against sun\\nexposure.\\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\\nothers. When a member of a normally dark-skinned\\nethnic group has albinism, he or she may face some\\nvery complex 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 albin-\\nism can safely work and play outdoors safely even\\nduring the summer.\\nPrevention\\nGenetic counseling is very important to prevent\\nfurther occurrences of the conditon.\\nResources\\nBOOKS\\nNational Association for the Visually Handicapped.Larry:\\nA Book for Children with Albinism Going to School. New\\nYork: National Association for the Visually\\nHandicapped.\\nORGANIZATIONS\\nAlbinism World Alliance. .\\nAmerican Foundation for the Blind. 15 W. 16th St., New\\nYork, NY 10011. (800) AFB-LIND.\\nHermansky-Pudlak Syndrome Network, Inc. One South\\nRoad, Oyster Bay, NY 11771-1905. (800) 789-9477.\\n.\\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 abuse see Alcoholism\\nAlcohol dependence see Alcoholism\\nAlcohol-related neurologic\\ndisease\\nDefinition\\nAlcohol, or ethanol, is a poison with direct toxic\\neffects on nerve and muscle cells. Depending on\\nwhich nerve and muscle pathways are involved,\\nalcohol can have far-reaching effects on different\\nparts of the brain, peripheral nerves, and muscles,\\nwith symptoms of memory loss, incoordination,\\nseizures, weakness, and sensory deficits. These differ-\\nent effects can be grouped into three main categories:\\n(1) intoxication due to the acute effects of ethanol, (2)\\nwithdrawal syndrome from suddenly stopping drink-\\ning, and (3) disorders related to long-term or chronic\\nalcohol abuse. Alcohol-related neurologic disease\\nincludes Wernicke-Korsakoff disease, alcoholic\\ncerebellar degeneration, alcoholic myopathy, alco-\\nholic neuropathy, alcohol withdrawal syndrome\\nwith seizures anddelirium tremens, andfetal alcohol\\nsyndrome.\\nDescription\\nAcute excess intake of alcohol can cause drunken-\\nness (intoxication) or evendeath, and chronic or long-\\nterm abuse leads to potentially irreversible damage to\\nvirtually any level of the nervous system. Any given\\npatient with long-term alcohol abuse may have no\\nneurologic complications, a single alcohol-related dis-\\nease, or multiple conditions, depending on the genes\\nthey have inherited, how well nourished they are, and\\nother environmental factors, such as exposure to other\\ndrugs or toxins.\\nNeurologic complications of alcohol abuse may also\\nresultfromnutritionaldeficiency,becausealcoholicstend\\nto eat poorly and may become depleted of thiamine or\\nother vitamins important for nervous system function.\\nPersons who are intoxicated are also at higher risk for\\nhead injuryor 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 diseasecomplicat-\\ning alcoholiccirrhosismay causedementia, delirium, and\\nmovement 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\\ncrosses the blood-brain barrier that ordinarily keeps\\n98 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 128, 'page_label': '99'}, page_content='large molecules from escaping from the blood vessel to\\nthe brain tissue. Drunkenness, or intoxication, may\\noccur at blood ethanol concentrations of as low as\\n50-150 mg per dL in people who don’t drink.\\nSleepiness, stupor,coma, or even death from respira-\\ntory depression and low blood pressure occur at\\nprogressively higher concentrations.\\nAlthough alcohol is broken down by the liver,\\nthe toxic effects from a high dose of alcohol are most\\nlikely a direct result of alcohol itself rather than of its\\nbreakdown products. The fatal dose varies widely\\nbecause people who drink heavily develop a toler-\\nance to the effects of alcohol with repeated use. In\\naddition, alcohol tolerance results in the need for\\nhigher levels of blood alcohol to achieve intoxicating\\neffects, which increases the likelihood that habitual\\ndrinkers will be exposed to high and potentially toxic\\nlevels of ethanol. This is particularly true when binge\\ndrinkers fail to eat, becausefasting decreases the rate\\nof alcohol clearance and causes even higher blood\\nalcohol levels.\\nWhen a chronic alcoholic suddenly stops drink-\\ning, withdrawal of alcohol leads to a syndrome of\\nincreased excitability of the central nervous system,\\ncalled delirium tremens or ‘‘DTs.’’ Symptoms begin\\nsix to eight hours after abstinence, and are most pro-\\nnounced 24-72 hours after abstinence. They include\\nbody shaking (tremulousness), insomnia, agitation,\\nconfusion, hearing voices or seeing images that are\\nnot really there (such as crawling bugs), seizures,\\nrapid heart beat, profuse sweating, high blood pres-\\nsure, and fever. Alcohol-related seizures may also\\noccur without withdrawal, such as during active\\nheavy drinking or after more than a week without\\nalcohol.\\nWernicke-Korsakoff syndrome is caused by\\ndeficiency of the B-vitamin thiamine, and can also\\nbe seen in people who don’t drink but have some\\nother cause of thiamine deficiency, such as chronic\\nvomiting that prevents the absorption of this vitamin.\\nA 2004 study demonstratedthat alcohol-dependent\\npatients admitted to adetoxification facility had con-\\nsumed significantly less thiamine than a comparison\\ngroup of healthy volunteers.Patients with this con-\\ndition have the sudden onset of Wernicke encepha-\\nlopathy; the symptoms include marked confusion,\\ndelirium, disorientation, inattention, memory loss,\\nand drowsiness. Examination reveals abnormalities\\nof eye movement, including jerking of the eyes\\n(nystagmus) and double vision. Problems with bal-\\nance make walking difficult. People may have trouble\\ncoordinating their leg movements, but usually not\\ntheir arms. If thiamine is not given promptly,\\nWernicke encephalopathy may progress to stupor,\\ncoma, 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 (retrogradeamnesia) and unable to\\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\\ncoordination 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 excre-\\ntion of 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\\nsuffer complications (including Wernike-Korsakoff\\nsyndrome) from a deficiency of this vitamin.\\nWernicke-Korsakoff syndrome— A combination of\\nsymptoms, including eye-movement problems, tre-\\nmors, and confusion, that is caused by a lack of the\\nB vitamin thiamine and may be seen in alcoholics.\\nGALE ENCYCLOPEDIA OF MEDICINE 99\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 129, 'page_label': '100'}, page_content='learn new information (anterograde amnesia). Most\\npatients have very limited insight into their memory\\ndysfunction and have a tendency to make up explana-\\ntions for events they have forgotten (confabulation).\\nSevere alcoholism can cause cerebellar degenera-\\ntion, a slowly progressive condition affecting portions\\nof the brain called the anterior and superior cerebellar\\nvermis, causing a wide-based gait, leg incoordination,\\nand an inability to walk heel-to-toe in tightrope fash-\\nion. The gait disturbance usually develops over several\\nweeks, but may be relatively mild for some time, and\\nthen suddenly worsen after binge drinking or an unre-\\nlated illness.\\nFetal alcohol syndrome occurs in infants born to\\nalcoholic mothers when prenatal exposure to ethanol\\nretards fetal growth and development. Affected\\ninfants often have a distinctive appearance with a\\nthin upper lip, flat nose and mid-face, short stature\\nand small head size. Almost half are mentally\\nretarded, and most others are mildly impaired intellec-\\ntually or have problems with speech, learning, and\\nbehavior. Fetal alcohol syndrome is the leading cause\\nof mental retardationand many physicians warn that\\nthere is no safe level of alcohol for a pregnant mother\\nto consume.\\nAlcoholic myopathy, or weakness secondary to\\nbreakdown of muscle tissue, is also known as alcoholic\\nrhabdomyolysis or alcoholic myoglobinuria. Males\\nare affected by acute (sudden onset) alcoholic myopa-\\nthy four times as often as females. Breakdown of\\nmuscle tissue (myonecrosis), can come on suddenly\\nduring binge drinking or in the first days of alcohol\\nwithdrawal. In its mildest form, this breakdown may\\ncause no noticeable symptoms, but may be detected by\\na temporary elevation in blood levels of an enzyme\\nfound predominantly in muscle, the MM fraction of\\ncreatine kinase.\\nThe severe form of acute alcoholic myopathy is\\nassociated with the sudden onset of musclepain, swel-\\nling, and weakness; a reddish tinge in the urine caused\\nby myoglobin, a breakdown product of muscle\\nexcreted in the urine; and a rapid rise in muscle\\nenzymes in the blood. Symptoms usually worsen over\\nhours to a few days, and then improve over the next\\nweek to 10 days as the patient is withdrawn from\\nalcohol. Muscle symptoms are usually generalized,\\nbut pain and swelling may selectively involve the\\ncalves or other muscle groups. The muscle breakdown\\nof acute alcoholic myopathy may be worsened by\\ncrush injuries, which may occur when people drink\\nso much that they compress a muscle group with\\ntheir body weight for a long time without moving, or\\nby withdrawal seizures with generalized muscle\\nactivity.\\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\\nof acute muscle injury. Muscle atrophy, or decreased\\nbulk, may be striking. The nerves of the extremities\\nmay also begin to break down, a condition known as\\nalcoholic peripheral neuropathy, which can add to the\\nperson’s difficulty in moving.\\nThe way in which alcohol destroys muscle tissue is\\nstill not well understood. Proposed mechanisms\\ninclude muscle membrane changes affecting the trans-\\nport of calcium, potassium, or other minerals;\\nimpaired muscle energy metabolism; and impaired\\nprotein synthesis. Alcohol is metabolized or broken\\ndown primarily by the liver, with a series of chemical\\nreactions in which ethanol is converted to acetate.\\nAcetate is metabolized by skeletal muscle, and alco-\\nhol-related changes in liver function may affect skele-\\ntal muscle metabolism, decreasing the amount of\\nblood sugar available to muscles during prolonged\\nactivity. Because not enough sugar is available to sup-\\nply 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\\ncontribute to muscle weakness and atrophy by injur-\\ning the motor nerves controlling muscle movement,\\nalcoholic neuropathy more commonly affects sensory\\nfibers. Injury to these fibers can causetingling or burn-\\ning pain in the feet, which may be severe enough to\\ninterfere with walking. As the condition worsens, pain\\ndecreases butnumbness increases.\\nDiagnosis\\nThe diagnosis of alcohol-related neurologic dis-\\nease depends largely on finding characteristic symp-\\ntoms and signs in patients who abuse alcohol. Other\\npossible causes should be excluded by the appropriate\\ntests, which may include blood chemistry, thyroid\\nfunction tests, brain MRI (magnetic resonance ima-\\nging) or CT (computed tomography scan), and/or\\ncerebrospinal fluid analysis.\\nAcute alcoholic myopathy can be diagnosed\\nby finding myoglobin in the urine and increased\\n100 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 130, 'page_label': '101'}, page_content='creatine kinase and other blood enzymes released from\\ninjured muscle. The surgical removal of a small piece\\nof muscle for microscopic analysis (muscle biopsy)\\nshows the scattered breakdown and repair of muscle\\nfibers. Doctors must rule out other acquired causes of\\nmuscle breakdown, which include the abuse of drugs\\nsuch as heroin, cocaine, or amphetamines; trauma\\nwith crush injury; the depletion of phosphate or potas-\\nsium; or an underlying defect in the metabolism of\\ncarbohydrates or lipids. In chronic alcoholic myopa-\\nthy, serum creatine kinase often is normal, and muscle\\nbiopsy shows atrophy, or loss of muscle fibers.\\nElectromyography (EMG) may show features charac-\\nteristic of alcoholic myopathy or neuropathy.\\nTreatment\\nAcute management of alcohol intoxication, delir-\\nium tremens, and withdrawal is primarily supportive,\\nto monitor and treat any cardiovascular orrespiratory\\nfailure that may develop. In delirium tremens, fever\\nand sweating may necessitate treatment of fluid loss\\nand secondary low blood pressure. Agitation may be\\ntreated withbenzodiazepines such as chlordiazepoxide,\\nbeta-adrenergic antagonists such as atenolol, or alpha\\n2-adrenergic agonists such as clonidine. Because\\nWernicke’s syndrome is rapidly reversible with thia-\\nmine, and because death may intervene if thiamine is\\nnot given promptly, all patients admitted for acute\\ncomplications of alcohol, as well as all patients with\\nunexplained encephalopathy, should be given intrave-\\nnous thiamine.\\nWithdrawal seizures typically resolve without\\nspecific anti-epileptic drug treatment, although status\\nepilepticus (continual seizures occurring without inter-\\nruption) should be treated vigorously. Acute alcoholic\\nmyopathy with myoglobinuria requires monitoring\\nand maintenance of kidney function, and correction\\nof imbalances in blood chemistry including potassium,\\nphosphate, and magnesium levels.\\nChronic alcoholic myopathy and other chronic\\nconditions are treated by correcting associated nutri-\\ntional deficiencies and maintaining a diet adequate in\\nprotein and carbohydrate. The key to treating any\\nalcohol-related disease is helping the patient overcome\\nalcohol addiction. Behavioral measures and social sup-\\nports may be needed in patients who develop broad\\nproblems in their thinking abilities (dementia) or\\nremain in a state of confusion and disorientation\\n(delirium). People with walking disturbances may\\nbenefit from physical therapy and assistive devices.\\nDoctors may also prescribe drugs to treat the pain\\nassociated with peripheral neuropathy.\\nPrognosis\\nComplete recovery from Wernicke’s syndrome\\nmay follow prompt administration of thiamine.\\nHowever, repeated episodes of encephalopathy or\\nprolonged alcohol abuse may cause persistent demen-\\ntia or Korsakoffpsychosis. Most patients recover fully\\nfrom acute alcoholic myopathy within days to weeks,\\nbut severe cases may be fatal fromacute kidney failure\\nand disturbances in heart rhythm secondary to\\nincreased potassium levels. Recovery from chronic\\nalcoholic myopathy may occur over weeks to months\\nof abstinence from alcohol and correction ofmalnutri-\\ntion. Cerebellar degeneration and alcoholic neuropa-\\nthy may also improve to some extent with abstinence\\nand balanced diet, depending on the severity and dura-\\ntion of the condition.\\nPrevention\\nPrevention requires abstinence from alcohol.\\nPersons who consume small or moderate amounts of\\nalcohol might theoretically help prevent nutritional\\ncomplications of alcohol use with dietary supplements\\nincluding B vitamins. However, propernutrition can-\\nnot protect against the direct toxic effect of alcohol or\\nof its breakdown products. Patients with any alcohol-\\nrelated symptoms or conditions, pregnant women,\\nand patients with liver or neurologic disease should\\nabstain completely. Persons with family history of\\nalcoholism or alcohol-related conditions may also be\\nat increased risk for neurologic complications of alco-\\nhol use.\\nResources\\nPERIODICALS\\n‘‘Missouri Clinics Will Diagnose and Treat Fetal Alcohol\\nSyndrome.’’ Mental Health Weekly Digeste (June 7,\\n2004): 33.\\nStacey, Philip S. ‘‘Preliminary Investigation of Thiamine and\\nAlcohol Intake in Clinical and Healthy Samples.’’\\nPsychological Reports (June 2004): 845–849.\\nORGANIZATIONS\\nNational Institute on Alcohol Abuse and Alcoholism. 6000\\nExecutive Boulevard, Willco Building, Bethesda, MD\\n20892-7003. .\\nLaurie Barclay, MD\\nTeresa G. Odle\\nAlcohol withdrawal see Withdrawal\\nsyndromes\\nAlcoholic cerebellar disease see Alcohol-\\nrelated neurologic disease\\nGALE ENCYCLOPEDIA OF MEDICINE 101\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 131, 'page_label': '102'}, page_content='Alcoholic hepatitis see Hepatitis, alcoholic\\nAlcoholic rose gardener’s diseasesee\\nSporotrichosis\\nAlcoholism\\nDefinition\\nAlcoholism is the popular term for alcoholabuse\\nand alcohol dependence. These disorders involve\\nrepeated life problems that can be directly attributed\\nto the use of alcohol. Both disorders can have serious\\nconsequences, affecting an individual’s health and per-\\nsonal life, as well as having an impact on society at large.\\nDescription\\nThe effects of alcoholism are far reaching.\\nAlcohol affects every body system, causing a wide\\nrange of health problems. Problems include poor\\nnutrition, memory disorders, difficulty with balance\\nand walking, liver disease (including cirrhosis and\\nhepatitis), high blood pressure, muscle weakness\\n(including the heart), heart rhythm disturbances,\\nanemia, clotting disorders, decreased immunity to\\ninfections, gastrointestinal inflammation and irrita-\\ntion, acute and chronic problems with the pancreas,\\nlow blood sugar, high blood fat content, interference\\nwith reproductive fertility, and weakened bones.\\nOn a personal level, alcoholism results in marital\\nand other relationship difficulties, depression, unem-\\nployment, child abuse, and general family dysfunction.\\nAlcoholism causes or contributes to a variety of\\nsevere social problems including homelessness, mur-\\nder, suicide, injury, and violent crime. Alcohol is a\\ncontributing factor in at least 50% of all deaths from\\nmotor vehicle accidents. In fact, about 100,000 deaths\\noccur each year due to the effects of alcohol, of which\\n50% are due to injuries of some sort. According to a\\nspecial report prepared for the U.S. Congress by the\\nNational Institute on Alcohol Abuse and Alcoholism,\\nthe impact of alcohol on society, including violence,\\ntraffic accidents, lost work productivity, and prema-\\nture death, costs our nation an estimated $185 billion\\nannually. In addition, it is estimated that approxi-\\nmately one in four children (19 million children or\\n29% of children up to 17 years of age) is exposed at\\nsome time to familial alcohol abuse, alcohol depen-\\ndence, or both. Furthermore, it has been estimated\\nthat approximately 18% of adults experience an\\nepisode of alcohol abuse or dependence a some time\\nduring 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\\nrelatives 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\\nfactors could account for differences in alcohol meta-\\nbolism that may increase the risk of an individual\\nbecoming 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\\nentering 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 coordina-\\ntion (accounting in part for the increased likelihood of\\ninjury). The affected person also may have impairment\\nof peripheral vision. At higher alcohol levels, a person’s\\nbreathing and heart rates will be slowed, andvomiting\\nmay occur (with a high risk of the vomit being breathed\\ninto the lungs, resulting in severe problems, including\\nthe possibility ofpneumonia). 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:\\nSymptoms Of Co-Alcohol Dependence\\nPsychological distress manifested in symptoms such as anxiety, aggression,\\nanorexia nervosa, bulimia, depression,insomnia, hyperactivity, and suicidal\\ntendency\\nPsychosomatic illness (ailments that have no biological basis and clear up\\nafter the co-alcoholism clears up)\\nFamily violence or neglect\\nAlcoholism or other drug abuse\\n102 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcoholism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 132, 'page_label': '103'}, page_content='/C15Nervous system. An estimated 30-40% of all men in\\ntheir teens and twenties have experienced alcoholic\\nblackout, which occurs when drinking a large quan-\\ntity of alcohol results in the loss of memory of the\\ntime surrounding the episode of drinking. Alcohol is\\nwell-known to cause sleep disturbances, so that over-\\nall sleep quality is affected. Numbness andtingling\\nmay occur in the arms and legs. Two syndromes,\\nwhich can occur together or separately, are known\\nas Wernicke’s and Korsakoff’s syndromes. Both are\\ndue to the low thiamine (a form of vitamin B\\ncomplex) levels found in alcoholics. Wernicke’s\\nsyndrome results in disordered eye movements, very\\npoor balance and difficulty walking, while\\nKorsakoff’s syndromeseverely affects one’s memory,\\npreventing new learning from taking place.\\n/C15Gastrointestinal system. Alcohol causes loosening of\\nthe muscular ring that prevents the stomach’s con-\\ntents from re-entering the esophagus. Therefore, the\\nacid from the stomach flows backward into the eso-\\nphagus, burning those tissues, and causingpain and\\nbleeding. Inflammation of the stomach also can\\nresult in bleeding and pain, and decreased desire to\\neat. A major cause of severe, uncontrollable bleeding\\n(hemorrhage) in an alcoholic is the development\\nof enlarged (dilated) blood vessels within the\\nesophagus, which are called esophageal varices.\\nThese varices actually are developed in response to\\nliver disease, and are extremely prone to bursting and\\nhemorrhaging. Diarrhea is a common symptom, due\\nto alcohol’s effect on the pancreas. In addition,\\ninflammation of the pancreas (pancreatitis) is a ser-\\nious and painful problem in alcoholics. Throughout\\nthe intestinal tract, alcohol interferes with the\\nabsorption of nutrients, creating a malnourished\\nstate. Because alcohol is broken down (metabolized)\\nwithin the liver, the organ is severely affected by\\nconstant levels of alcohol. Alcohol interferes with a\\nnumber of important chemical processes that also\\noccur in the liver. The liver begins to enlarge and fill\\nwith fat (fatty liver), fibrous scar tissue interferes with\\nthe liver’s normal structure and function (cirrhosis),\\nand the liver may become inflamed (hepatitis).\\n/C15Blood. 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(10 times the risk for nonalcoholics). Platelets and\\nblood clotting factors are affected, causing an\\nincreased risk of bleeding.\\n/C15Heart. Small amounts of alcohol cause a drop in\\nblood pressure, but with increased use, alcohol\\nbegins to increase blood pressure into a dangerous\\nrange. High levels of fats circulating in the blood-\\nstream increase the risk of heart disease. Heavy\\ndrinking results in an increase in heart size, weaken-\\ning of the heart muscle, abnormal heart rhythms, a\\nrisk ofblood clotsforming within the chambers of the\\nheart, and a greatly increased risk of stroke (due to a\\nblood clot from the heart entering the circulatory\\nsystem, going to the brain, and blocking a brain\\nblood vessel).\\n/C15Reproductive system. Heavy drinking has a negative\\neffect on fertility in both men and women, by\\ndecreasing testicle and ovary size, and interfering\\nwith both sperm and egg production. Whenpreg-\\nnancy is achieved in an alcoholic woman, the baby\\nhas a great risk of being born withfetal alcohol\\nsyndrome, which causes distinctive facial defects,\\nlowered IQ, and behavioral problems.\\nDiagnosis\\nTwo different types of alcohol-related difficulties\\nhave been identified. The first is calledalcohol depen-\\ndence, which refers to a person who literally depends\\nKEY TERMS\\nBlood-brain barrier— A network of blood vessels\\ncharacterized by closely spaced cells that prevents\\nmany potentially toxic substances from penetrating\\nthe blood vessel walls to enter the brain. Alcohol is\\nable 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 drin-\\nker becomes 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 decreasing\\nthe drug’s dosage or discontinuing its use.\\nGALE ENCYCLOPEDIA OF MEDICINE 103\\nAlcoholism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 133, 'page_label': '104'}, page_content='on the use of alcohol. Three of the following traits\\nmust be present to diagnose alcohol dependence:\\n/C15tolerance, meaning that a person becomes accus-\\ntomed to a particular dose of alcohol, and must\\nincrease the dose in order to obtain the desired effect\\n/C15withdrawal, meaning that a person experiences\\nunpleasant physical and psychological symptoms\\nwhen he or she does not drink alcohol\\n/C15the tendency to drink more alcohol than one intends\\n(once an alcoholic starts to drink, he or she finds it\\ndifficult to stop)\\n/C15being unable to avoid drinking or stop drinking once\\nstarted\\n/C15having large blocks of time taken up by alcohol use\\n/C15choosing to drink at the expense of other important\\ntasks or activities\\n/C15drinking despite evidence of negative effects on one’s\\nhealth, relationships, education, or job\\nDiagnosis is sometimes brought about when\\nfamily members call an alcoholic’s difficulties to the\\nattention of a physician. A clinician may begin to be\\nsuspicious when a patient suffers repeated injuries or\\nbegins to experience medical problems related to\\nthe use of alcohol. In fact, some estimates suggest\\nthat about 20% of a physician’s patients will be\\nalcoholics.\\nDiagnosis is aided by administering specific psy-\\nchological assessments that try to determine what\\naspects of a person’s life may be affected by his or\\nher use of alcohol. Determining the exact quantity of\\nalcohol that a person drinks is of much less impor-\\ntance than determining how his or her drinking affects\\nrelationships, jobs, educational goals, and family life.\\nIn fact, because the metabolism (how the body breaks\\ndown and processes) of alcohol is so individual, the\\nquantity of alcohol consumed is not part of the criteria\\nlist for diagnosing either alcohol dependence or alco-\\nhol abuse.\\nOne simple tool for beginning the diagnosis of\\nalcoholism is called the CAGE questionnaire. It con-\\nsists of four questions, with the first letters of each key\\nword spelling out the word CAGE:\\n/C15Have you ever tried toCut down on your drinking?\\n/C15Have you ever beenAnnoyed by anyone’s comments\\nabout your drinking?\\n/C15Have you ever feltGuilty about your drinking?\\n/C15Do you ever need anEye-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.\\nTreatment\\nTreatment of alcoholism has two parts. The first\\nstep in the treatment of alcoholism, called detoxifica-\\ntion, involves helping the person stop drinking and\\nridding his or her body of the harmful (toxic) effects\\nof alcohol. Because the person’s body has become\\naccustomed to alcohol, the person will need to be\\nsupported through withdrawal. Withdrawal will be\\ndifferent for different patients, depending on the sever-\\nity of the alcoholism, as measured by the quantity of\\nalcohol ingested daily and the length of time the\\npatient has been an alcoholic. Withdrawal symptoms\\ncan range from mild to life-threatening. Mild with-\\ndrawal symptoms includenausea, achiness, diarrhea,\\ndifficulty sleeping, sweatiness,anxiety, and trembling.\\nThis phase is usually over in about three to five days.\\nMore severe effects of withdrawal can includehalluci-\\nnations (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\\nrate, high blood pressure, anddelirium (a fluctuating\\nlevel of consciousness). Patients at highest risk for the\\nmost severe symptoms of withdrawal (referred to as\\ndelirium tremens) are those with other medical\\nproblems, including malnutrition, liver disease,o r\\nWernicke’s syndrome. Delirium tremens usually\\nbegin about three to five days after the patient’s last\\ndrink, progressing from the more mild symptoms to\\nthe more severe, and may last a number of days.\\nPatients going through only mild withdrawal are\\nsimply monitored carefully to make sure that more\\nsevere symptoms do not develop. No medications are\\nnecessary, however. Treatment of a patient suffering\\nthe more severe effects of withdrawal may require the\\nuse of sedative medications to relieve the discomfort of\\nwithdrawal and to avoid the potentially life-threaten-\\ning complications of high blood pressure, fast heart\\nrate, and seizures. Drugs called benzodiazapines are\\nhelpful in those patients suffering from hallucinations.\\nBecause of the patient’s nausea, fluids may need to be\\ngiven through a vein (intravenously), along with some\\nnecessary sugars and salts. It is crucial that thiamine\\nbe included in the fluids, because thiamine is usually\\nquite low in alcoholic patients, and deficiency of thia-\\nmine is responsible for the Wernicke-Korsakoff\\nsyndrome.\\n104 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcoholism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 134, 'page_label': '105'}, page_content='After cessation of drinking has been accom-\\nplished, the next steps involve helping the patient\\navoid ever taking another drink. This phase of treat-\\nment is referred to asrehabilitation. The best programs\\nincorporate the family into the therapy, because the\\nfamily has undoubtedly been severely affected by the\\npatient’s drinking. Some therapists believe that family\\nmembers, in an effort to deal with their loved one’s\\ndrinking problem, sometimes develop patterns of\\nbehavior that accidentally support or ‘‘enable’’ the\\npatient’s drinking. This situation is referred to as\\n‘‘co-dependence,’’ and must be addressed in order to\\nsuccessfully treat a person’s alcoholism.\\nSessions led by peers, where recovering alcoholics\\nmeet regularly and provide support for each other’s\\nrecoveries, are considered among 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\\npeople avoid drinking. These steps involve recognizing\\nthe destructive power that alcohol has held over\\nthe alcoholic’s life, looking to a higher power for\\nhelp in overcoming the problem, and reflecting on\\nthe ways in which the use of alcohol has hurt others\\nand, if possible, making amends to those people.\\nAccording to a recent study reported by the American\\nPsychological Association (APA), anyone, regardless\\nof his or her religious beliefs or lack of religious beliefs,\\ncan benefit from participation in 12-step programs\\nsuch as Alcoholics Anonymous (AA) or Narcotics\\nAnonymous (NA). The number of visits to 12-step\\nself-help groups exceeds the number of visits to all\\nmental health professionals combined.\\nThere are also medications that may help an alco-\\nholic avoid returning to drinking. These have been\\nused with variable success. Disulfiram (Antabuse)\\nis a drug which, when mixed with alcohol, causes\\nunpleasant reactions including nausea, vomiting,\\ndiarrhea, and trembling. Naltrexone, along with a\\nsimilar compound, Nalmefene, can be helpful in limit-\\ning the effects of a relapse. Acamprosate is helpful in\\npreventing relapse. None of these medications would\\nbe helpful unless the patient was also willing to work\\nvery hard to change his or her behavior. In 2004, a new\\ncompound was discovered that blocks actions of\\nchemicals in the brain that may lead to relapses.\\nClinical tests were still underway, but development of\\nsuch a drug could have great potential in the medical\\nmanagement of alcoholism. Another study that year\\nfound that topiramate (Topamax), an antiseizure\\nmedication, was effective in treating alcohol depen-\\ndence in 150 participants in a clinical trial. The authors\\ncalled for further study of this possible treatment.\\nAlternative treatment\\nAlternative treatments can be a helpful adjunct\\nfor the alcoholic patient, once the medical danger of\\nwithdrawal has passed. Because many alcoholics\\nhave very stressful lives (whether because of or lead-\\ning to the alcoholism is sometimes a matter of\\ndebate), many of the treatments for alcoholism\\ninvolve dealing with and relieving stress.T h e s e\\ninclude massage, meditation,a n dhypnotherapy.T h e\\nmalnutrition of long-term alcohol use is addressed by\\nnutrition-oriented practi tioners with careful atten-\\ntion to a healthy diet and the use of nutritional sup-\\nplements such asvitamins A, B complex, and C, as\\nwell as certain fatty acids, amino acids, zinc, magne-\\nsium, and selenium. Herbal treatments include milk\\nthistle (Silybum marianum ), which is thought to pro-\\ntect the liver against damage. Other herbs are thought\\nto be helpful for the patient suffering through with-\\ndrawal. Some of these include lavender (Lavandula\\nofficinalis), skullcap (Scutellaria lateriflora ), chamo-\\nmile ( Matricaria recutita ), peppermint ( Mentha\\npiperita) yarrow (Achillea millefolium ), and valerian\\n(Valeriana officinalis ). Acupuncture is believed to\\nboth decrease withdrawal symptoms and to help\\nimprove a patient’s chances for continued recovery\\nfrom alcoholism.\\nPrognosis\\nRecovery from alcoholism is a life-long process.\\nIn fact, people who have suffered from alcoholism are\\nencouraged to refer to themselves ever after as ‘‘a\\nrecovering alcoholic,’’ never a recovered alcoholic.\\nThis is because most researchers in the field believe\\nthat since the potential for alcoholism is still part of\\nthe individual’s biological and psychological makeup,\\none can never fully recover from alcoholism. The\\npotential for relapse (returning to illness) is always\\nthere, and must be acknowledged and respected.\\nStatistics suggest that, among middle-class alcoholics\\nin stable financial and family situations who have\\nundergone treatment, 60% or more can be successful\\nat an attempt to stop drinking for at least a year, and\\nmany for a lifetime.\\nPrevention\\nPrevention must begin at a relatively young age\\nsince the first instance of intoxication (drunkenness)\\nusually occurs during the teenage years. In fact, a 2004\\nstudy found that girls experimented with alcohol and\\ncigarettes at a younger age — 20% by seventh grage —\\nthan boys. It is particularly important that teenagers\\nwho are at high risk for alcoholism—those with a\\nGALE ENCYCLOPEDIA OF MEDICINE 105\\nAlcoholism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 135, 'page_label': '106'}, page_content='family history of alcoholism, an early or frequent use\\nof alcohol, a tendency to drink to drunkenness, alco-\\nhol use that interferes with school work, a poor family\\nenvironment, or a history of domestic violence —\\nreceive education about alcohol and its long-term\\neffects. How this is best achieved, without irritating\\nthe youngsters and thus losing their attention, is the\\nsubject of continuing debate and study.\\nResources\\nBOOKS\\nNational Institute on Alcohol Abuse and Alcoholism.10th\\nSpecial Report to the U.S. Congress on Alcohol and\\nHealth. National Institute of Health, 2000.\\nPERIODICALS\\nKoch Kubetin, Sally. ‘‘Girls Before Boys in Cigarette and\\nAlcohol Use: Longitudinal Study.’’Pediatric News\\n(March 2004): 29.\\n‘‘Research Findings Suggest Compound Might Help in\\nFight Against Alcoholism.’’Drug Week (January 9,\\n2004): 18.\\nWalling, Anne D. ‘‘Topiramate in the Treatment of Alcohol\\nDependence.’’ American Family Physician (January 1,\\n2004): 195.\\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,\\nNew York, NY 10163. .\\nNational Alliance on Alcoholism and Drug Dependence,\\nInc. 12 West 21st St., New York, NY 10010. (212) 206-\\n6770.\\nNational Clearinghouse for Alcohol and Drug Information.\\n11426 Rockville Pike, Suite 200, Rockville, MD. 20852.\\n(800) 729-6686. .\\nNational Institute on Alcohol Abuse and Alcoholism\\n(NIAAA). 6000 Executive Boulevard, Bethesda,\\nMaryland 20892-7003. .\\nBill Asenjo, MS, CRC\\nTeresa G. Odle\\nALD see Adrenoleukodystrophy\\nAldolase test\\nDefinition\\nAldolase is an enzyme found throughout the\\nbody, particularly in muscles. Like all enzymes, it is\\nneeded to trigger specific chemical reactions. Aldolase\\nhelps muscle turn sugar into energy. Testing for aldo-\\nlase is done to diagnose and monitor skeletal muscle\\ndiseases.\\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\\nmake those bones move. When the muscles are dis-\\neased or damaged, such as inmuscular dystrophy, the\\ncells deteriorate and break open. The contents of the\\ncells, including aldolase, spill into the bloodstream.\\nMeasuring the amount of aldolase in the blood indi-\\ncates the degree of muscle damage.\\nAs muscles continue to deteriorate, aldolase levels\\ndecrease and eventually fall below normal. Less mus-\\ncle means fewer cells and less aldolase.\\nMuscle weakness may be caused by neurologic as\\nwell as muscular problems. The measurement of\\naldolase levels can help pinpoint the cause. Aldolase\\nlevels will be normal where muscle weakness is caused\\nby neurological disease, such as poliomyelitis or\\nmultiple sclerosis, but aldolase levels will be elevated\\nin cases of muscular disease, such as muscular\\ndystrophy.\\nAldolase is also found in the liver and cardiac\\nmuscle of the heart. Damage or disease to these\\norgans, such as chronic hepatitis or aheart attack,\\nwill also increase aldolase levels in the blood, but to a\\nlesser degree.\\nDescription\\nAldolase is measured by mixing a person’s serum\\nwith a substance with which aldolase is known to\\ntrigger a reaction. The end product of this reaction is\\nmeasured, and, from that measurement, the amount of\\naldolase in the person’s serum is determined.\\nKEY TERMS\\nAldolase— An enzyme, found primarily in the mus-\\ncle, that helps convert sugar into energy.\\nEnzyme— A substance needed to trigger specific\\nchemical reactions.\\nNeurologic— Having to do with the nervous system.\\nSkeletal muscle— Muscle connected to, and neces-\\nsary for the movement of, bones.\\n106 GALE ENCYCLOPEDIA OF MEDICINE\\nAldolase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 136, 'page_label': '107'}, page_content='The 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,\\na healthcare worker ties a tourniquet on the patient’s\\nupper arm, locates a vein in the inner elbow region, and\\ninserts a needle into that vein. Vacuum action draws\\nthe blood through the needle into an attached tube.\\nCollection of the sample takes only a few minutes.\\nThe patient should avoid strenuousexercise and\\nhave nothing to eat or drink, except water, for eight to\\nten hours 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\\non the laboratory and the method used.\\nAbnormal results\\nAs noted, aldolase is elevated in skeletal muscle\\ndiseases, such as muscular dystrophies. Duchenne’s\\nmuscular dystrophy, the most common type of mus-\\ncular dystrophy, will increase the aldolase level more\\nthan any other disease.\\nNondisease conditions that affect the muscle, such\\nas injury,gangrene, or an infection, can also increase\\nthe aldolase level. Also, strenuous exercise can tem-\\nporarily increase a person’s aldolase level.\\nCertain medications can increase the aldolase\\nlevel, while others can decrease it. To interpret what\\nthe results of the aldolase test mean, a physician will\\nevaluate the result, the person’s clinical symptoms,\\nand other tests that are more specific for muscle\\ndamage and disease.\\nResources\\nBOOKS\\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\\nhormone produced by the outer part (cortex) of the\\ntwo adrenal glands, organs which sit one on top of\\neach of the kidneys. Aldosterone regulates the\\namounts of sodium and potassium in the blood. This\\nhelps maintain water balance and blood volume,\\nwhich, in turn, affects blood pressure.\\nPurpose\\nAldosterone measurement is useful in detecting a\\ncondition called aldosteronism, which is caused by\\nexcess secretion of the hormone from the adrenal\\nglands. There are two types of aldosteronism: primary\\nand secondary. Primary aldosteronism is most com-\\nmonly caused by an adrenal tumor, as in Conn’s\\nsyndrome. Idiopathic (of unknown cause)hyperaldos-\\nteronism is another type of primary aldosteronism.\\nSecondary aldosteronism is more common and may\\noccur with congestive heart failure,cirrhosis with fluid\\nin the abdominal cavity (ascites), certain kidney dis-\\neases, excess potassium, sodium-depleted diet, and\\ntoxemia ofpregnancy.\\nTo differentiate primary aldosteronism from sec-\\nondary aldosteronism, a plasma renin test should be\\nperformed at the same time as the aldosterone assay.\\nRenin, an enzyme produced in the kidneys, is high in\\nsecondary aldosteronism and low in primary\\naldosteronism.\\nDescription\\nAldosterone testing can be performed on a blood\\nsample or on a 24-hour urine specimen. Several fac-\\ntors, including diet, posture (upright or lying down),\\nand time of day that the sample is obtained can cause\\naldosterone levels to fluctuate. Blood samples are\\naffected by short-term fluctuations. A urine specimen\\ncollected over an entire 24-hour period lessens the\\neffects of those interfering factors and provides a\\nmore reliable aldosterone measurement.\\nPreparation\\nFasting is not required for either the blood sample\\nor urine collection, but the patient should maintain a\\nnormal sodium diet (approximately 0.1 oz [3g]/day)\\nfor at least two weeks before either test. The doctor\\nshould decide if drugs that alter sodium, potassium,\\nand fluid balance (e.g., diuretics, antihypertensives,\\nGALE ENCYCLOPEDIA OF MEDICINE 107\\nAldosterone assay'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 137, 'page_label': '108'}, page_content='steroids, oral contraceptives) should be withheld. The\\ntest will be more accurate if these are suspended at\\nat least two weeks before the test. Renin inhibitors\\n(e.g., propranolol) should not be taken one week\\nbefore the test, unless permitted by the physician.\\nThe patient should avoid licorice for at least two\\nweeks before the test, because of its aldosterone-like\\neffect. Strenuous exercise and stress can increase\\naldosterone levels as well. Because the test is usually\\nperformed by a method called radioimmunoassay,\\nrecently administered radioactive medications will\\naffect test results.\\nSince posture and body position affect aldoster-\\none, hospitalized patients should remain in an\\nupright position (at least sitting) for two hours\\nbefore blood is drawn. Occasionally blood will be\\ndrawn again before the patient gets out of bed.\\nNonhospitalized patients should arrive at the labora-\\ntory in time to maintain an upright position for at\\nleast two hours.\\nRisks\\nRisks for this test are minimal, but may include\\nslight bleeding from the blood-drawing site, fainting\\nor feeling lightheaded after venipuncture, or hema-\\ntoma (blood accumulating under the puncture site).\\nNormal results\\nNormal results are laboratory-specific and also\\nvary with sodium intake, with time of day, source of\\nspecimen (e.g., peripheral vein, adrenal vein, 24-hour\\nurine), age, sex, and posture.\\nReference ranges for blood include:\\n/C15supine (lying down): 3-10 ng/dL\\n/C15upright (sitting for at least two hours): Female:\\n5-30ng/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\\nblood levels of aldosterone and renin). Among other\\nconditions, elevated levels are also seen in secondary\\naldosteronism,stress, and malignanthypertension.\\nDecreased levels of aldosterone are found in\\naldosterone deficiency, steroid therapy, high-sodium\\ndiets, certain antihypertensive therapies, and\\nAddison’s disease (an autoimmune disorder).\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAlemtuzumab\\nDefinition\\nAlemtuzumab is sold as Campath in the United\\nStates. Alemtuzumab is a humanized monoclonal\\nantibody that selectively binds to CD52, a protein\\nfound on the surface of normal and malignant B and\\nT cells, that is used to reduce the numbers of circulat-\\ning malignant cells of patients who have B-cell chronic\\nlymphocytic leukemia (B-CLL).\\nPurpose\\nAlemtuzumab is a monoclonal antibody used to\\ntreat B-CLL, one of the most prevalent forms of adult\\nchronic leukemia. It specifically binds CD52, a protein\\nfound on the surface of essentially all B and T cells of\\nthe immune system. By binding the CD52 protein on\\nthe malignant B cells, the antibody targets it for\\nremoval from the circulation. Scientists believe that\\nalemtuzumab triggers antibody-mediated lysis of the\\nB cells, a method that the immune system uses to\\neliminate foreign cells.\\nAlemtuzumab has been approved by the FDA for\\ntreatment of refractory B-CLL. For a patient’s disease\\nto be classified as refractory, both alkylating agents\\nand fludarabine treatment must have been tried and\\nfailed. Thus, this drug gives patients who have tried all\\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.\\n108 GALE ENCYCLOPEDIA OF MEDICINE\\nAlemtuzumab'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 138, 'page_label': '109'}, page_content='approved treatments for B-CLL another option. As\\nmost patients with B-CLL are in stage III or IV by the\\ntime both alkylating agents and fludarabine have been\\ntried, the experience with alemtuzumab treatment are\\nprimarily with those stages of the disease. In clinical\\ntrials, about 30% of patients had a partial response to\\nthe drug, with 2% of these being complete responses.\\nThis antibody has been tested with limited suc-\\ncess in the treatment of non-Hodgkin’s lymphoma\\n(NHL) and for the preparation of patients with var-\\nious immune cell malignancies for bone marrow\\ntransplantation. There is also a clinical trial ongoing\\nto test the ability of this antibody to prevent rejection\\nin 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\\nparticular substance, the antigen for that monoclonal\\nantibody. For alemtuzumab, the antigen is CD52, a\\nprotein found on the surface of normal and malignant\\nB and T cells as well as other cells of the immune and\\nmale reproductive systems. Alemtuzumab is a human-\\nized antibody, meaning that the regions that bind\\nCD52, located on the tips of the Y branches, are\\nderived from rat antibodies, but the rest of the anti-\\nbody is human sequence. The presence of the human\\nsequences helps to reduce the immune response by the\\npatient against the antibody itself, a problem seen\\nwhen complete mouse antibodies are used forcancer\\ntherapies. The human sequences also help to ensure\\nthat the various cell-destroying mechanisms of the\\nhuman 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,\\na monoclonal antibody specific for the CD20 antigen,\\nanother protein found on the surface of B cells.\\nRecommended dosage\\nThis antibody should be administered in a gradu-\\nally escalating pattern at the start of treatment and any\\ntime administration is interrupted for seven or more\\ndays. The recommended beginning dosage for B-CLL\\npatients is a daily dose of 3 mg of Campath adminis-\\ntered as a two-hour IV infusion. Once this amount is\\ntolerated, the dose is increased to 10 mg per day. After\\ntolerating this dose, it can be increased to 30 mg, admi-\\nnistered three days a week. Acetominophen and diphen-\\nhydramine hydrochoride are given thirty to sixty\\nminutes before the infusion 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 studiesshould be done on a weekly basis while\\npatients are receiving the alemtuzumab treatment.\\nVaccination during the treatment session is not recom-\\nmended, given the T cell depletion that occurs during\\ntreatment. Furthermore, given thatantibodieslike alum-\\ntuzumab can pass through the placenta to the developing\\nfetus and in breastmilk,use duringpregnancyand breast-\\nfeeding is not recommended unless clearly needed.\\nSide effects\\nA severe side effect of alemtuzumab treatment is\\nthe possible depletion of one or more types of blood\\nKEY TERMS\\nAlkylating agent— Achemicalthataltersthecompo-\\nsition of the genetic material of rapidly dividing cells,\\nsuch as cancer cells, causing selective cell death;\\nused as a chemotherapeutic agent to treat B-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 immuno-\\nglobulins with the binding region of an animal\\nimmunoglobulin, done to reduce human reaction\\nagainst the fusion antibody.\\nMonoclonal— Genetically engineered antibodies\\nspecific for one antigen.\\nTumor lysis syndrome— A side effect of some immu-\\nnotherapies, like monoclonal antibodies, that lyse\\nthe tumor cells, due to the toxicity of flooding the\\nbloodstreamwithsuchaquantityofcellularcontents.\\nGALE ENCYCLOPEDIA OF MEDICINE 109\\nAlemtuzumab'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 139, 'page_label': '110'}, page_content='cells. Because CD52 is expressed on a patient’s normal\\nB and T cells, as well as on the surface of the abnormal\\nB cells, the treatment eliminates both normal and\\ncancerous cells. The treatment also seems to trigger\\nautoimmune reactions against various other blood\\ncells. This results in severe reduction of the many\\ncirculating blood cells including red blood cells (ane-\\nmia), white blood cells (neutropenia), and clotting cells\\n(thrombopenia). These conditions are treated with\\nblood transfusions. The great majority of patients\\ntreated exhibit some type of blood cell depletion.\\nA second serious side effect of this drug is the\\nprevalence of opportunistic infections that occurs dur-\\ning the treatment. Serious, and sometimes fatal bac-\\nterial, viral, fungal, and protozoan infections have\\nbeen reported. Treatments to preventpneumonia and\\nherpes infections reduce, but do not eliminate these\\ninfections.\\nThe majority of other side effects occur after or\\nduring the first infusion of the drug. Some common\\nside effects of this drug includefever and chills,nausea\\nand vomiting, diarrhea, shortness of breath, skin rash,\\nand unusual fatigue. This drug can also cause low\\nblood pressure (hypotension).\\nIn patients with high tumor burden (a large num-\\nber of circulating malignant B cells) this drug can\\ncause a side effect called tumor lysis syndrome.\\nThought to be due to the release of the lysed cells’\\ncontents into the blood stream, it can cause a misba-\\nlance of urea, uric acid, phosphate, potassium, and\\ncalcium in the urine and blood. Patients at risk for\\nthis side effect must keep hydrated and can be given\\nallopurinol before infusion.\\nInteractions\\nThere have been no formal drug interaction stu-\\ndies done for alemtuzumab.\\nMichelle Johnson, MS, JD\\nAlendronate see Bone disorder drugs\\nAlexander technique\\nDefinition\\nThe Alexander technique is a somatic method\\nfor improving physical and mental functioning.\\nExcessive tension, which Frederick Alexander, the\\noriginator, recognized as both physical and mental,\\nrestricts movement and creates pressure in the joints,\\nthe spine, the breathing mechanism, and other organs.\\nThe goal of the technique is to restore freedom and\\nexpression to the body and clear thinking to the mind.\\nPurpose\\nBecause the Alexander technique helps students\\nimprove overall functioning, both mental and physi-\\ncal, it offers a wide range of benefits. Nikolaas\\nTinbergen, in his 1973 Nobel lecture, hailed the ‘‘strik-\\ning improvements in such diverse things as high blood\\npressure, breathing, depth of sleep, overall cheerful-\\nness and mental alertness, resilience against outside\\npressures, and the refined skill of playing a musical\\ninstrument.’’ He went on to quote a list of other con-\\nditions helped by the Alexander technique: ‘‘rheuma-\\ntism, including various forms of arthritis, then\\nrespiratory troubles, and even potentially lethal\\nasthma; following in their wake, circulation defects,\\nwhich may lead to high blood pressure and also to\\nsome dangerous heart conditions; gastrointestinal dis-\\norders of many types, various gynecological condi-\\ntions, sexual failures, migraines and depressive states.’’\\nLiterature in the 1980s and 1990s went on to\\ninclude improvements in backpain, chronic pain, pos-\\ntural problems, repetitive strain injury, benefits during\\npregnancy and childbirth, help in applying physical\\ntherapy and rehabilitative exercises, improvements in\\nstrain caused by computer use, improvements in the\\nposture and performance of school children, and\\nimprovements in vocal and dramatic performance\\namong the benefits offered by the technique.\\nDescription\\nOrigins\\nFrederick Matthias Alexander was born in 1869 in\\nTasmania, Australia. He became an actor and\\nShakespearean reciter, and early in his career he\\nbegan to suffer from strain on his vocal chords. He\\nsought medical attention for chronic hoarseness, but\\nafter treatment with a recommended prescription and\\nextensive periods of rest, his problem persisted.\\nAlexander realized that his hoarseness began\\nabout an hour into a dramatic performance and\\nreasoned that it was something he did in the process\\nof reciting that caused him to lose his voice. Returning\\nto his medical doctor, Alexander told him of his\\nobservation. When the doctor admitted that he\\ndidn’t know what Alexander was doing to injure\\nhis vocal chords, Alexander decided to try and find\\nout for himself.\\n110 GALE ENCYCLOPEDIA OF MEDICINE\\nAlexander technique'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 140, 'page_label': '111'}, page_content='Thus 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\\nhis coordination and to overcome his vocal problems.\\nOne of his most startling discoveries was that in order to\\nchange the way he used his body he had to change the\\nway he was thinking, redirecting his thoughts in such a\\nway that he did not produce unnecessary tension\\nwhen he attempted speech or movement. After making\\nthis discovery at the end of the nineteenth century,\\nAlexander became a pioneerin 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.\\nPrivate lessons range from a half-hour to an hour in\\nlength, and are taught in a series. The number of lessons\\nvaries according to the severity of the student’s difficul-\\nties with coordination or to the extent of the student’s\\ninterest in pursuing the improvements made possible by\\ncontinued study. The cost of lessons ranges from $40-80\\nper hour. Insurance coverage is not widely available,\\nbut discounts are available for participants in some\\ncomplementary care insurance plans. Pre-tax Flexible\\nSpending Accounts for health care cover Alexander\\ntechnique lessons 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\\narises from mental processes as well as physical, so\\ndiscussions of personal reactions or behavior are likely\\nto arise in the course of a lesson.\\nT h et e c h n i q u eh e l p ss t u d e n t sm o v ew i t he a s ea n d\\nimproved coordination. At the beginning of a move-\\nment (the lessons are a series of movements), most peo-\\nple pull back their heads, raise their shoulders toward\\ntheir ears, over-arch their lower backs, tighten their legs,\\nand otherwise produce excessive tension in their bodies.\\nAlexander referred to this as misuse of the body.\\nAt any point in a movement, proper use can be\\nestablished. If the neck muscles are not over-tensed,\\nthe head will carry slightly forward of the spine, simply\\nbecause it is heavier in the front. When the head is out\\nof balance in the forward direction, it sets off a series\\nof stretch reflexes in the extensor muscles of the back.\\nIt is skillful use of these reflexes, along with reflex\\nactivity in the feet and legs, the arms and hands, the\\nbreathing mechanism, and other parts of the body,\\nthat lessons in the technique aim to develop.\\nAlexander found that optimal functioning of the\\nbody was very hard to maintain, even for the short\\nperiod of time it took to complete a single movement.\\nPeople, especially adults, have very strong tension\\nhabits associated with movement. Chronic misuse of\\nthe muscles is common. It may be caused by slouching\\nin front of televisions or video monitors, too much\\nsitting or driving and too little walking, or by tension\\nassociated with past traumas and injuries. Stiffening\\nthe neck after awhiplash injury or favoring a broken or\\nsprained leg long after it has healed are examples of\\nhabitual tension caused 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\\ninhibit the tension. If the student prepares to sit\\ndown, for example, he will tense his muscles in his\\nhabitual way. If he is asked to put aside the intention\\nto sit and instead to free his neck and allow less con-\\nstriction in his muscles, he can begin to change his\\ntense habitual response to sitting.\\nBy leaving the head resting on the spine in its\\nnatural free balance, by keeping eyes open and\\nfocused, not held in a tense stare, by allowing the\\nshoulders to release, the knees to unlock and the\\nback to lengthen and widen, a student greatly reduces\\nstrain. In Alexander lessons students learn to direct\\nthemselves this way in activity and become skilled in\\nfluid, coordinated movement.\\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 esta-\\nblish improved coordination.\\nHabit— Referring to the particular set of physical\\nand mental tensions present in any individual.\\nInhibition— Referring to the moment in an\\nAlexander lesson when the student refrains from\\nbeginning a movement in order to avoid tensing\\nof the muscles.\\nSensory awareness— Bringing attention to the sen-\\nsations of tension and/or release in the muscles.\\nGALE ENCYCLOPEDIA OF MEDICINE 111\\nAlexander technique'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 141, 'page_label': '112'}, page_content='Precautions\\nSide effects\\nThe focus of the Alexander technique is educa-\\ntional. Teachers use their hands simply to gently guide\\nstudents in movement. Therefore, both contraindica-\\ntions and potential physiological side effects are kept\\nto a minimum. No forceful treatment of soft tissue or\\nbony structure is attempted, so damage to tissues, even\\nin the case of errors in teaching, is unlikely.\\nAs students’ sensory awareness develops in the\\ncourse of Alexander lessons, they become more\\nacutely aware of chronic tension patterns. As students\\nlearn to release excessive tension in their muscles and\\nto sustain this release in daily activity, they may\\nexperience tightness or soreness in the connective tis-\\nsue. This is caused by the connective tissue adapting to\\nthe lengthened and released muscles and the expanded\\nrange of movement in the joints.\\nOccasionally students may get light-headed dur-\\ning a lesson as contracted muscles release and effect\\nthe circulatory or respiratory functioning.\\nForceful contraction of muscles and rigid pos-\\ntures often indicate suppression of emotion. As mus-\\ncles release during or after an Alexander lesson,\\nstudents may experience strong surges of emotion or\\nsudden changes in mood. In some cases, somatic mem-\\nories surface, bringing to consciousness past injury or\\ntrauma. This can cause extremeanxiety, and referrals\\nmay be made by the teacher for counseling.\\nResearch and general acceptance\\nAlexander became well known among the intel-\\nlectual, artistic, and medical communities in London,\\nEngland, during the first half of the twentieth century.\\nAmong Alexander’s supporters were John Dewey,\\nAldous Huxley, Bernard Shaw, and renowned scien-\\ntists Raymond Dart, G.E. Coghill, Charles\\nSherrington, and Nikolaas Tinbergen.\\nResearchers continue to study the effects and\\napplications of the technique in the fields of education,\\npreventive medicine, and rehabilitation. The\\nAlexander technique has proven an effective treatment\\nfor reducingstress, for improving posture and perfor-\\nmance in schoolchildren, for relieving chronic pain,\\nand for improving psychological functioning. The\\ntechnique has been found to be as effective as beta-\\nblocker medications in controlling stress responses in\\nprofessional musicians, to enhance respiratory func-\\ntion in normal adults, and to mediate the effects of\\nscoliosis in adolescents and adults.\\nResources\\nBOOKS\\nDimon, Theodore.THE UNDIVIDED SELF: Alexander\\nTechnique and the Control of Stress. North Atlantic\\nBooks: 1999.\\nORGANIZATIONS\\nAlexander Technique International, 1692 Massachusetts\\nAve., 3rd Floor, Cambridge, MA 02138 USA. (888)\\n321-0856. Fax: 617-497-2615. ati@ati-net.com.\\n.\\nOTHER\\nAlexander Technique Resource Guide. (Includes list of\\nteachers) AmSAT Books. (800) 473-0620 or (804)\\n295-2840.\\nSandra Bain Cushman\\nAlkali-resistant hemoglobin test see Fetal\\nhemoglobin test\\nAlkaline phosphatase test\\nDefinition\\nAlkaline phosphatase is an enzyme found\\nthroughout the body. Like all enzymes, it is needed,\\nin small amounts, to trigger specific chemical reac-\\ntions. When it is present in large amounts, it may\\nsignify bone orliver diseaseor a tumor.\\nPurpose\\nMedical testing of alkaline phosphatase is con-\\ncerned with the enzyme that is found in liver, bone,\\nplacenta, and intestine. In a healthy liver, fluid con-\\ntaining alkaline phosphate and other substances is\\ncontinually drained away through the bile duct. In a\\ndiseased liver, this bile duct is often blocked, keeping\\nfluid within the liver. Alkaline phosphatase accumu-\\nlates and eventually escapes 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\\nan obstructive nature (cholestatic), i.e. involving the\\nbiliary drainage system, the alkaline phosphatase will\\nbe the first and foremost enzyme elevation. If, on the\\nother hand, the disease is primarily of the liver cells\\n(hepatocytes), the aminotransferases will rise promi-\\nnently. Thus, these enzymes are very useful in\\n112 GALE ENCYCLOPEDIA OF MEDICINE\\nAlkaline phosphatase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 142, 'page_label': '113'}, page_content='distinguishing the type of liver disease–cholestatic or\\nhepatocellular.\\nGrowing bones need alkaline phosphatase. Any\\ncondition of bone growth will cause alkaline phospha-\\ntase levels to rise. The condition may be normal, such\\nas a childhood growth spurt or the healing of a broken\\nbone; or the condition may be a disease, such as bone\\ncancer, Paget’s disease, orrickets.\\nDuring pregnancy, alkaline phosphatase is made\\nby the placenta and leaks into the mother’s blood-\\nstream. This is normal. Some tumors, however, start\\nproduction of the same kind of alkaline phosphatase\\nproduced by the placenta. These tumors are called\\ngerm cell tumors and includetesticular cancer and\\ncertain brain tumors.\\nAlkaline phosphatase from the intestine is\\nincreased in a person with inflammatory bowel dis-\\nease, such asulcerative colitis.\\nDescription\\nAlkaline phosphatase is measured by combining\\nthe person’s serum with specific substances with which\\nalkaline phosphatase is known to react. The end\\nproduct of this reaction is measured; and from that\\nmeasurement, the amount of alkaline phosphatase in\\nthe person’s serum is determined.\\nEach tissue–liver, bone, placenta, and intestine–\\nproduces a slightly different alkaline phosphatase.\\nThese variations are called isoenzymes. In the labora-\\ntory, alkaline phosphatase is measured as the total\\namount or the amount of each of the the four isoen-\\nzymes. The isoenzymes react differently to heat, cer-\\ntain chemicals, and other processes in the laboratory.\\nMethods to measure them separately are based on\\nthese 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\\nupper arm, locates a vein in the inner elbow region,\\nand inserts a needle into that vein. Vacuum action\\ndraws the blood through the needle into an attached\\ntube. Collection of the sample takes only a few minutes.\\nA person being tested for alkaline phosphatase\\nshould not have anything to eat or drink, except\\nwater, for eight to ten hours before the test. Some\\npeople release alkaline phosphatase from the intestine\\ninto the bloodstream after eating. This will tempora-\\nrily increase the result of the test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or 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\\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 phospha-\\ntase more than any other disease, up to five times the\\nnormal level. Irritable bowel disease, germ cell tumors,\\nand infections involving the liver, such as viral hepa-\\ntitis andinfectious mononucleosis, increase the enzyme\\nalso, but to a lesser degree. Healing bones, pregnancy,\\nand normal growth in children also increase levels.\\nResources\\nBOOKS\\nLehmann, Craig A., editor.Saunders Manual of Clinical\\nLaboratory Science. Philadelphia: W. B. Saunders\\nCo., 1998.\\nNancy J. Nordenson\\nAlkalosis see Metabolic alkalosis;\\nRespiratory alkalosis\\nAllergic alveolitis see Hypersensitivity\\npneumonitis\\nKEY TERMS\\nAlkaline phosphatase— An enzyme found through-\\nout the body, primarily in liver, bone, placenta, and\\nintestine.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 113\\nAlkaline phosphatase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 143, 'page_label': '114'}, page_content='Allergic bronchopulmonary\\naspergillosis\\nDefinition\\nAllergic bronchopulmonary aspergillosis,o r\\nABPA, is one of four major types of infections in\\nhumans caused byAspergillus fungi. ABPA is a hyper-\\nsensitivity reaction that occurs in asthma patients who\\nare allergic to this specific fungus.\\nDescription\\nABPA is an allergic reaction to a species of\\nAspergillus called Aspergillus fumigatus .I ti ss o m e -\\ntimes grouped together with other lung disorders\\ncharacterized by eosinophilia–an abnormal increase\\nof a certain type of white blood cell in the blood–\\nunder the heading of eosinophilic pneumonia. These\\ndisorders are also call ed hypersensitivity lung\\ndiseases.\\nABPA appears to be increasing in frequency in the\\nUnited States, although the reasons for the increase\\nare not clear. The disorder is most likely to occur in\\nadult asthmatics aged 20-40. It affects males and\\nfemales equally.\\nCauses and symptoms\\nABPA develops when the patient breathes air\\ncontaining Aspergillus spores. These spores are\\nfound worldwide, especially around riverbanks,\\nmarshes, bogs, forests, and wherever there is wet or\\ndecaying vegetation. They are also found on wet\\npaint, construction materials, and in air condition-\\ning systems. ABPA is a nosocomial infection,\\nwhich means that a patient can get it in a hospital.\\nWhen Aspergillus spores reach the bronchi, which\\nare the branches of the windpipe that lead into the\\nlungs, the bronchi react by contracting spasmodi-\\ncally. So the patient has difficulty breathing and\\nusually wheezes or coughs. Many patients with\\nABPA also run a low-grade fever and lose their\\nappetites.\\nComplications\\nPatients with ABPA sometimes cough up large\\namounts of blood, a condition that is calledhemopty-\\nsis. They may also develop a serious long-term form of\\nbronchiectasis, the formation of fibrous tissue in the\\nlungs. Bronchiectasis is a chronic bronchial disorder\\ncaused by repeated inflammation of the airway, and\\nmarked by the abnormal enlargement of, or damage\\nto, the bronchial walls. ABPA sometimes occurs as a\\ncomplication of cystic fibrosis.\\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\\nand is 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\\nblood plasma that acts as an antibody to activate\\nallergic reactions. About 50% of patients with aller-\\ngic disorders have increased IgE levels in their\\nblood serum.\\nNosocomial infection— An infection that can be\\nacquired in a hospital. ABPA is a nosocomial\\ninfection.\\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.\\n114 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic bronchopulmonary aspergillosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 144, 'page_label': '115'}, page_content='Diagnosis\\nThe diagnosis of ABPA is based on a combination\\nof the patient’s history and the results of blood tests,\\nsputum tests, skin tests, and diagnostic imaging. The\\ndoctor will be concerned to distinguish between ABPA\\nand a worsening of the patient’sasthma,cystic fibrosis,o r\\nother lung disorders. There are seven major criteria for\\na diagnosis of allergic bronchopulmonary aspergillosis:\\n/C15a history of asthma.\\n/C15an accumulation of fluid in the lung that is visible on\\na chest x ray.\\n/C15bronchiectasis (abnormal stretching, enlarging, or\\ndestruction of the walls of the bronchial tubes).\\n/C15skin reaction toAspergillus antigen.\\n/C15eosinophilia in the patient’s blood and sputum.\\n/C15Aspergillus precipitins in the patient’s blood.\\nPrecipitins are antibodies that react with the antigen\\nto form a solid that separates from the rest of the\\nsolution in the test tube.\\n/C15a high level of IgE in the patient’s blood. IgE refers to\\na class of antibodies in blood plasma that activate\\nallergic reactions to foreign particles.\\nOther criteria that may be used to support the\\ndiagnosis include the presence ofAspergillus in sam-\\nples of the patient’s sputum, the coughing up of plugs\\nof brown mucus, or a late skin reaction to the\\nAspergillus antigen.\\nLaboratory tests\\nThe laboratory tests that are done to obtain this\\ninformation include a completeblood count(CBC), a\\nsputum culture, a blood serum test of IgE levels, and\\na skin test for theAspergillus antigen. In the skin test, a\\nsmall amount of antigen is injected into the upper\\nlayer of skin on the patient’s forearm about four\\ninches below the elbow. If the patient has a high\\nlevel of IgE antibodies in the tissue, he or she will\\ndevelop what is called a ‘‘wheal and flare’’ reaction\\nin about 15-20 minutes. A ‘‘wheal and flare’’ reaction\\nis characterized by the eruption of a reddened,itching\\nspot on the skin. Some patients with ABPA will\\ndevelop the so-called late reaction to the skin test, in\\nwhich a red, sore, swollen area develops about six to\\neight hours after the initial reaction.\\nDiagnostic imaging\\nChest x rays and CT scans are used to check for\\nthe presence of fluid accumulation in the lungs and\\nsigns of bronchiectasis.\\nTreatment\\nABPA is usually treated with prednisone\\n(Meticorten) or othercorticosteroids taken by mouth,\\nand withbronchodilators.\\nAntifungal drugs are not used to treat ABPA\\nbecause it is caused by an allergic reaction to\\nAspergillus rather than by direct infection of tissue.\\nFollow-up care\\nPatients with ABPA should be given periodic check-\\nupswith chestx rays and a spirometertest.Aspirometer is\\nan instrument that evaluates the patient’s lung capacity.\\nPrognosis\\nMost patients with ABPA respond well to corti-\\ncosteroid treatment. Others have a chronic course with\\ngradual improvement over time. The best indicator of\\na good prognosis is a long-term fall in the patient’s IgE\\nlevel. Patients with lung complications from ABPA\\nmay develop severe airway obstruction.\\nPrevention\\nABPA is difficult to prevent becauseAspergillus is\\na common fungus; it can be found in the saliva and\\nsputum of most healthy individuals. Patients with\\nABPA can protect themselves somewhat by avoiding\\nhaystacks, compost piles, bogs, marshes, and other\\nlocations with wet or rotting vegetation; by avoiding\\nconstruction sites or newly painted surfaces; and by\\nhaving their air conditioners cleaned regularly. Some\\npatients may be helped by air filtration systems for\\ntheir bedrooms or offices.\\nResources\\nBOOKS\\nStauffer, John L. ‘‘Lung.’’ InCurrent Medical Diagnosis and\\nTreatment, 1998, edited by Stephen McPhee, et al., 37th\\ned. Stamford: Appleton & Lange,1997.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nNational Institute of Allergy and Infectious Disease.\\nBuilding 31, Room 7A-50, 31 Center Drive MSC 2520,\\nBethesda, MD 20892-2520. (301) 496-5717. .\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nRebecca J. Frey, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 115\\nAllergic bronchopulmonary aspergillosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 145, 'page_label': '116'}, page_content='Allergic purpura\\nDefinition\\nAllergic purpura (AP) is an allergic reaction of\\nunknown origin causing red patches on the skin and\\nother symptoms. AP is also called Henoch-Schonlein\\npurpura, named after the two doctors who first\\ndescribed it.\\nDescription\\n‘‘Purpura’’ is a bleeding disorder that occurs when\\ncapillaries rupture, allowing small amounts of blood\\nto accumulate in the surrounding tissues. In AP, this\\noccurs because the capillaries are blocked by protein\\ncomplexes formed during an abnormal immune reac-\\ntion. The skin is the most obvious site of reaction, but\\nthe joints, gastrointestinal tract, and kidneys are also\\noften affected.\\nAP affects approximately 35,000 people in the\\nUnited States each year. Most cases are children\\nbetween the ages of two and seven. Boys are affected\\nmore often than girls, and most cases occur from late\\nfall to winter.\\nCauses and symptoms\\nCauses\\nAP is caused by a reaction involving antibodies,\\nspecial 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\\ncapillary to burst, allowing a local hemorrhage.\\nThe source of the antigen causing AP is unknown.\\nAntigens may be introduced by bacterial or viral\\ninfection. More than 75% of patients report having had\\nan infection of the throat, upper respiratory tract, or\\ngastrointestinal system several weeks before the onset\\nof AP. Other complex molecules can act as antigens\\nas well, including drugs such asantibioticsor vaccines.\\nOtherwise harmless substances that stimulate an immune\\nreaction 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,a n dyellow fever.\\nSymptoms\\nThe onset of AP may be preceded by aheadache,\\nfever, and loss of appetite. Most patients first develop\\nan itchy skin rash. The rash is red, either flat or raised,\\nand may be small and freckle-like. The rash may also\\nbe larger, resembling a bruise.Rashes become purple\\nand then rust colored over the course of a day, and\\nfade after several weeks. Rashes are most common on\\nthe buttocks, abdomen, and lower extremities. Rashes\\nhigher on the body may also occur, especially in\\nyounger children.\\nJoint pain and swelling is common, especially\\nin the knees and ankles. Abdominal pain occurs in\\nalmost all patients, along with blood in the body\\nwaste (feces). About half of all patients show blood\\nin the urine, low urine volume, or other signs of kidney\\ninvolvement. Kidney failure may occur due to wide-\\nspread obstruction of the capillaries in the filtering\\nstructures called glomeruli. Kidney failure develops\\nin about 5% of all patients, and in 15% of those with\\nelevated blood or protein in the urine.\\nLess common symptoms include prolonged head-\\nache, fever, and pain and swelling of the scrotum.\\nInvolvement of other organ systems may lead to\\nheart attack (myocardial infarction), inflammation of\\nthe pancreas (pancreatitis), intestinal obstruction, or\\nbowel perforation.\\nDiagnosis\\nDiagnosis of AP is based on the symptoms and\\ntheir development, a careful medical history, and\\nblood and urine tests. X rays or computed tomogra-\\nphy scans (CT) may be performed to assess complica-\\ntions in the bowel or other internal organs.\\nTreatment\\nMost cases of AP resolve completely without\\ntreatment. Nonetheless, a hospital stay is required\\nbecause of the possibility of serious complications.\\nNon-aspirin pain relievers may be given for joint\\npain. Corticosteroids (like prednisone) are sometimes\\nused, although not all specialists agree on their utility.\\nKidney involvement requires monitoring and correc-\\ntion 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\\nKEY TERMS\\nGlomeruli— Knots of capillaries in the kidneys\\nresponsible for filtering the blood (singular,\\nglomerulus).\\n116 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic purpura'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 146, 'page_label': '117'}, page_content='of blood or protein in the urine may persist for months\\nand require regular monitoring. Hypertension or kid-\\nney failure may develop months or even years after the\\nacute phase of the disease. Kidney failure requires\\ndialysis or transplantation.\\nPrognosis\\nMost people who develop AP become better on\\ntheir own after several weeks. About half of all\\npatients have at least one recurrence. Cases that do\\nnot have kidney complications usually have the best\\nprognosis.\\nResources\\nPERIODICALS\\nAndreoli, S. P. ‘‘Chronic Glomerulonephritis in\\nChildhood. Membranoproliferative\\nGlomerulonephritis, Henoch-Schonlein\\nPurpuraNnephritis, and IgA Nephropathy.’’Pediatric\\nClinics of North America 42, no. 6 (December 1995):\\n1487-1503.\\nOTHER\\n‘‘Henoch-Schonlein Purpura.’’ Vanderbilt University\\nMedical Center. .\\nRichard Robinson\\nAllergic rhinitis\\nDefinition\\nAllergic rhinitis, more commonly referred to as\\nhay fever, is an inflammation of the nasal passages\\ncaused by allergic 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 the\\nUnited States, and is responsible for 2.5% of all doctor\\nvisits.Antihistaminesand other drugs used to treat aller-\\ngic 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\\nand perennial. Seasonal AR occurs in the spring, sum-\\nmer, and early fall, when airborne plant pollens are at\\ntheir highest levels. In fact, the term hayfever is really\\na misnomer, since allergy to grass pollen is only one\\ncause of symptoms for most people. Perennial AR\\noccurs all year and is usually caused by home or work-\\nplace airborne pollutants. A person can be affected\\nby one or both types. Symptoms of seasonal AR are\\nworst after being outdoors, while symptoms of peren-\\nnial AR are worst after spending time indoors.\\nBoth types ofallergies can develop at any age,\\nalthough onset in childhood through early adulthood\\nis most common. Although allergy to a particular\\nsubstance is not inherited, increased allergic sensitivity\\nmay ‘‘run in the family.’’ While allergies can improve\\non their own over time, they can also become worse\\nover time.\\nCauses and symptoms\\nCauses\\nAllergic rhinitis is a type of immune reaction.\\nNormally, the immune system responds to foreign\\nThis illustration depicts excessive mucus production in the\\nnose after inhalation of airborne pollen. (Photo Researchers,\\nInc. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 117\\nAllergic rhinitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 147, 'page_label': '118'}, page_content='microorganisms, or particles, like pollen or dust, by\\nproducing specific proteins, called antibodies, that are\\ncapable of binding to identifying molecules, or antigens,\\non the foreign particle. This reaction between antibody\\nand antigen sets off a series of reactions designed to\\nprotect the body from infection. Sometimes, this same\\nseries of reactions is triggered by harmless, everyday\\nsubstances. This is the condition known as allergy,\\nand the offending substance is 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\\nallergens, they trigger release of the granules, which\\nspill out their chemicals onto neighboring cells, includ-\\ning 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\\nleaky, leading to the fluid collection, swelling, and\\nincreased redness characteristic of a runny nose and\\nred, irritated eyes. Histamine also stimulates pain\\nreceptors, causing the itchy, scratchy nose, eyes, and\\nthroat common in allergic rhinitis.\\nThe number of possible airborne allergens is\\nenormous. Seasonal AR is most commonly caused\\nby grass and tree pollens, since their pollen is produced\\nin large amounts and is dispersed by the wind. Showy\\nflowers, like roses or lilacs, that attract insects produce\\na sticky pollen that is less likely to become airborne.\\nDifferent plants release their pollen at different times\\nof the year, so seasonal AR sufferers may be most\\naffected in spring, summer, or fall, depending on\\nwhich plants provoke a response. The amount of pollen\\nin the air is reflected in the pollen count, often broad-\\ncast on the daily news during allergy season. Pollen\\ncounts tend to be lower after a good rain that washes\\nthe pollen out of the air and higher on warm, dry,\\nwindy days.\\nVirtually any type of tree or grass may cause AR.\\nA few types of weeds that tend to cause the most\\ntrouble for people include the following:\\n/C15ragweed\\n/C15sagebrush\\n/C15lamb’s-quarters\\n/C15plantain\\n/C15pigweed\\n/C15dock/sorrel\\n/C15tumbleweed\\nPerennial AR is often triggered by house dust, a\\ncomplicated mixture of airborne particles, many of\\nwhich are potent allergens. House dust contains\\nsome or all of the following:\\n/C15house 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\\neasily become airborne.\\n/C15animal dander. Animals constantly shed fur, skin\\nflakes, and dried saliva. Carried in the air, or trans-\\nferred from pet to owner by direct contact, dander\\ncan cause allergy in many sensitive people.\\n/C15mold spores. Molds live in damp spots throughout\\nthe house, including basements, bathrooms, air\\nducts, air conditioners, refrigerator drains, damp\\nwindowsills, mattresses, and stuffed furniture.\\nMildew and other molds release airborne spores\\nthat circulate throughout the house.\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAnaphylaxis— Increased sensitivity caused by pre-\\nvious exposure to an allergen1 that can result in\\nblood vessel dilation (swelling) and smooth muscle\\ncontraction. Anaphylaxis can result in sharp blood\\npressure 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 that\\nactivates pain receptors and causes cells to become\\nleaky.\\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 immunoglo-\\nbulin type E (IgE) on its cell surface, and participates\\nin the allergic response by releasing histamine from\\nintracellular granules.\\n118 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic rhinitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 148, 'page_label': '119'}, page_content='Other potential causes of perennial allergic rhini-\\ntis include the following:\\n/C15cigarette smoke\\n/C15perfume\\n/C15cosmetics\\n/C15cleansers\\n/C15copier chemicals\\n/C15industrial chemicals\\n/C15construction material gases\\nSymptoms\\nInflammation of the nose, or rhinitis, is the\\nmajor symptom of AR. Inflammation causes itching,\\nsneezing, runny nose, redness, and tenderness. Sinus\\nswelling can constrict the eustachian tube that con-\\nnects the inner ear to the throat, causing a congested\\nfeeling and ‘‘ear popping.’’ The drip of mucus from the\\nsinuses down the back of the throat, combined with\\nincreased sensitivity, can also lead to throat irritation\\nand redness. AR usually also causes redness,itching,\\nand watery eyes. Fatigue and headache are also\\ncommon.\\nDiagnosis\\nDiagnosing seasonal AR is usually easy and can\\noften be done without a medical specialist. When\\nsymptoms appear in spring or summer and disappear\\nwith the onset of cold weather, seasonal AR is almost\\ncertainly the culprit. Other causes of rhinitis, includ-\\ning infection, can usually be ruled out by aphysical\\nexamination and a nasal smear, in which a sample of\\nmucus is taken on a swab for examination.\\nAllergy tests, including skin testing and provo-\\ncation testing, can help identify the precise culprit,\\nbut may not be done unless a single source is\\nsuspected and subsequent avoidance is possible.\\nSkin testing involves placing a small amount of\\nliquid containing a specific allergen on the skin and\\nthen either poking, scratching, or injecting it into\\nthe skin surface to observe whether redness and\\nswellings occurs. Provocation testing involves chal-\\nlenging an individual with either a small amount of\\nan inhalable or ingestable allergen to see if a response\\nis elicited.\\nPerennial AR can also usually be diagnosed by\\ncareful questioning about the timing of exposure\\nand the onset of symptoms. Specific allergens can be\\nidentified through allergy skin testing.\\nTreatment\\nAvoidance of the allergens is the best treatment,\\nbut this is often not possible. When it is not possible to\\navoid one or more allergens, there are two major forms\\nof medical 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\\neffective when used preventively, before symptoms\\nappear. A wide variety of antihistamines are available.\\nOlder antihistamines often produce drowsiness as\\na major side effect. Such antihistamines include the\\nfollowing:\\n/C15diphenhydramine (Benadryl and generics)\\n/C15chlorpheniramine (Chlor-trimeton and generics)\\n/C15brompheniramine (Dimetane and generics)\\n/C15clemastine (Tavist and generics).\\nNewer antihistamines that do not cause drowsi-\\nness are available by prescription and include the\\nfollowing:\\n/C15astemizole (Hismanal)\\n/C15fexofenadine (Allegra)\\n/C15cetirizine (Zyrtec)\\n/C15azelastin HCl (Astelin).\\nLoratidine (Claritin) was available only by pre-\\nscription but was released to over-the-counter status\\nby the FDA.\\nHismanal has the potential to cause serious heart\\narrhythmias when taken with the antibiotic erythro-\\nmycin, the antifungal drugs ketoconazole and itracona-\\nzole, orthe antimalarialdrugquinine.Taking morethan\\nthe 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\\nof this potential and because of the availability of an\\nequally effective, safer alternative drug, fexofenadine.\\nLEUKOTRIENE RECEPTOR ANTAGONISTS. Leuko-\\ntriene receptor antagonists (montelukast or Singulair\\nand zafirlukast or Accolate) are a newer class of drugs\\nused daily to help preventasthma. They’ve also become\\napproved in the United States to treat allergic rhinitis.\\nDECONGESTANTS. Decongestants constrict blood\\nvessels to counteract the effects of histamine. This\\ndecreases the amount of blood in the nasopahryngeal\\nGALE ENCYCLOPEDIA OF MEDICINE 119\\nAllergic rhinitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 149, 'page_label': '120'}, page_content='and sinus mucosa and reduces swelling. Nasal sprays\\nare available that can be applied directly to the nasal\\nlining and oral systemic preparations are available.\\nDecongestants are stimulants and may cause increased\\nheart rate and blood pressure, headaches, isomnia,\\nagitation and difficulty emptying the bladder. Use of\\ntopical decongestants for longer than several days can\\ncause loss of effectiveness and rebound congestion, in\\nwhich nasal passages become more severely swollen\\nthan before treatment.\\nTOPICAL CORTICOSTEROIDS. Topical corticoster-\\noids reduce mucous membrane inflammation and are\\navailable by prescription. Allergies tend to become\\nworse as the season progresses because the immune\\nsystem becomes sensitized to particular antigens and\\ncan produce a faster, stronger response. Topical\\ncorticosteroids are especially effective at reducing this\\nseasonal sensitization because they work more slowly\\nand last longer than most other medication types. As\\na result, they are best started before allergy season\\nbegins. Side effects are usually mild, but may include\\nheadaches, nosebleeds, and unpleasant taste sensations.\\nMAST CELL STABILIZERS. Cromolyn sodium pre-\\nvents the release of mast cell granules, thereby pre-\\nventing release of histamine and the other chemicals\\ncontained in them. It acts as a preventive treatment if it\\nis begun several weeks before the onset of the allergy\\nseason. It can be used for perennial AR as well.\\nImmunotherapy\\nImmunotherapy, also known as desensitization or\\nallergy shots, alters the balance of antibody types in the\\nbody,therebyreducingtheabilityofIgEtocauseallergic\\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 moni-\\ntored closely following each shot because of the small\\nrisk ofanaphylaxis, a condition that can result in diffi-\\nculty breathing and a sharp drop in blood pressure.\\nAlternative treatment\\nAlternative treatments for AR often focus on mod-\\nulation of the body’s immune response, and\\nfrequently center around diet and lifestyle adjustments.\\nChinese herbal medicine can help rebalance a person’s\\nsystem, as can both acute and constitutional homeo-\\npathic treatment. Vitamin C in substantial amounts can\\nhelp stabilize the mucous membrane response. For\\nsymptom relief, western herbal remedies including eyeb-\\nright(Euphrasiaofficinalis)andnettle( Urticadioica)may\\nbe helpful. Bee pollen may also be effective in alleviating\\nor eliminating AR symptoms. A 2004 report said that\\nphototherapy(treatment with a combination of ultravio-\\nlet and visible light) decreased the symptoms of allergic\\nrhinitis in a majority of patients who did not respond well\\nto traditional drug treatment.\\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\\nmay also get worse or expand to include new allergens.\\nEarly treatment can help prevent an increased sensiti-\\nzation to other allergens.\\nPrevention\\nReducing exposure to pollen may improve symp-\\ntoms of seasonal AR. Strategies include the following:\\n/C15stay indoors with windows closed during the morn-\\ning hours, when pollen levels are highest\\n/C15keep car windows up while driving\\n/C15use a surgical face mask when outside\\n/C15avoid uncut fields\\n/C15learn which trees are producing pollen in which sea-\\nsons, and avoid forests at the height of pollen season\\n/C15wash clothes and hair after being outside\\n/C15clean air conditioner filters in the home regularly\\n/C15use electrostatic filters for central air conditioning\\nMoving to a region with lower pollen levels is\\nrarely effective, since new allergies often develop\\nPreventing perennial AR requires identification of\\nthe responsible allergens.\\nMold spores:\\n/C15keep the house dry through ventilation and use of\\ndehumidifiers\\n/C15use a disinfectant such as dilute bleach to clean\\nsurfaces such as bathroom floors and walls\\n/C15have ducts cleaned and disinfected\\n/C15clean and disinfect air conditioners and coolers\\n/C15throw out moldy or mildewed books, shoes, pillows,\\nor furniture\\nHouse dust:\\n/C15vacuum frequently, and change the bag regularly. Use\\na bag with small pores to catch extra-fine particles\\n120 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic rhinitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 150, 'page_label': '121'}, page_content='/C15clean floors and walls with a damp mop\\n/C15install electrostatic filters in heating and cooling\\nducts, and change all filters regularly\\nAnimal dander:\\n/C15avoid contact if possible\\n/C15wash hands after contact\\n/C15vacuum frequently\\n/C15keep pets out of the bedroom, and off furniture, rugs,\\nand other dander-catching surfaces\\n/C15have your pets bathed and groomed frequently\\nResources\\nPERIODICALS\\nFinn, Robert. ‘‘Rhinoohototherapy Targets Allergic\\nRhinitis.’’ Skin & Allergy News (July 2004): 62.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nRichard Robinson\\nTeresa G. Odle\\nAllergies\\nDefinition\\nAllergies are abnormal reactions of the immune\\nsystem that occur in response to otherwise harmless\\nsubstances.\\nDescription\\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\\nlargest reason for school absence and is a major source\\nof lost productivity in the workplace.\\nAn allergy is a type of immune reaction. Normally,\\nthe immune system responds to foreign microorgan-\\nisms or particles by producing specific proteins called\\nantibodies. These antibodies are capable of binding\\nto identifying molecules, or antigens, on the foreign\\nparticle. This reaction between antibody and antigen\\nsets off a series of chemical reactions designed to pro-\\ntect the body from infection. Sometimes, this same\\nseries of reactions is triggered by harmless, everyday\\nsubstances such as pollen, dust, and animal danders.\\nWhen this occurs, an allergy develops against the\\noffending substance (an allergen.)\\nMast cells, one of the major players in allergic\\nreactions, capture and display a particular type of\\nantibody, called immunoglobulin type E (IgE) that\\nbinds to allergens. Inside mast cells are small chemi-\\ncal-filled packets called granules. Granules contain a\\nvariety of potent chemicals, including histamine.\\nImmunologists separate allergic reactions into\\ntwo main types: immediate hypersensitivity reactions,\\nwhich are predominantly mast cell-mediated and\\noccur within minutes of contact with allergen; and\\ndelayed hypersensitivity reactions, mediated by\\nT cells (a type of white blood cells) and occurring\\nhours to days after exposure.\\nInhaled or ingested allergens usually cause\\nimmediate hypersensitivity reactions. Allergens bind\\nto IgE antibodies on the surface of mast cells, which\\nspill the contents of their granules out onto neighbor-\\ning cells, including blood vessels and nerve cells.\\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 increased leakiness, leading to the fluid\\ncollection, swelling and increased redness. Histamine\\nalso stimulates pain receptors, making tissue more\\nsensitive and irritable. Symptoms last from one to\\nseveral hours following contact.\\nIn the upper airways and eyes, immediate hyper-\\nsensitivity reactions cause the runny nose and itchy,\\nbloodshot eyes typical ofallergic rhinitis. In the gas-\\ntrointestinal tract, these reactions lead to swelling and\\nirritation of the intestinal lining, which causes the\\ncramping and diarrhea typical of food allergy.\\nAllergens that enter the circulation may causehives,\\nangioedema, anaphylaxis,o ratopic dermatitis.\\nAllergens on the skin usually cause delayed hyper-\\nsensitivity reaction. Roving T cells contact the aller-\\ngen, setting in motion a more prolonged immune\\nresponse. This type of allergic response may develop\\nover several days following contact with the allergen,\\nand symptoms may persist for a week or more.\\nCauses and symptoms\\nAllergens enter the body through four main\\nroutes: the airways, the skin, the gastrointestinal\\ntract, and the circulatory system.\\n/C15Airborne allergens cause the sneezing, runny nose,\\nand itchy, bloodshot eyes of hay fever (allergicrhini-\\ntis). Airborne allergens can also affect the lining of\\nthe lungs, causing asthma, or conjunctivitis (pink\\nGALE ENCYCLOPEDIA OF MEDICINE 121\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 151, 'page_label': '122'}, page_content=\"Allergic 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.)\\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\\nreducin\\ng swelling, congestion and irritation.\\nAntihistamines\\nSECOND EXPOSURE\\nSecond and subsequent exposure to allergen.(Illustration by Hans & Cassady.)\\n122 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies\"),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 152, 'page_label': '123'}, page_content='eye). Exposure to cockroach allergens has been asso-\\nciated with the development of asthma. Airborne\\nallergens from household pets are another common\\nsource of environmental exposure.\\n/C15Allergens in food can causeitching and swelling of\\nthe lips and throat, cramps, and diarrhea. When\\nabsorbed into the bloodstream, they may cause\\nhives (urticaria) or more severe reactions involving\\nrecurrent, non-inflammatory swelling of the skin,\\nmucous membranes, organs, and brain (angioe-\\ndema). Some food allergens may cause anaphylaxis,\\na potentially life-threatening condition marked by\\ntissue swelling, airway constriction, and drop in\\nblood pressure. Allergies to foods such as cow’s\\nmilk, eggs, nuts, fish, and legumes (peanuts and soy-\\nbeans) are common. Allergies to fruits and vegeta-\\nbles may also occur.\\n/C15In contact with the skin, allergens can cause redden-\\ning, itching, and blistering, called contactdermatitis.\\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 caus-\\ning nonimmune damage to skin cells (such as soap,\\ncold, and chemical agents).\\n/C15Injection of allergens, from insectbites and stingsor\\ndrug administration, can introduce allergens directly\\ninto the circulation, where they may cause system-\\nwide responses (including anaphylaxis), as well as\\nthe local ones of swelling and irritation at the injec-\\ntion 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\\nsensitive to nuts but not to any other food. Allergies\\nmay get worse over time. For example, childhood rag-\\nweed allergy may progress to year-round dust and\\npollen allergy. On the other hand, a person may lose\\nallergic sensitivity. Infant or childhood atopic derma-\\ntitis disappears in almost all people. More commonly,\\nwhat seems to be loss of sensitivity is instead a reduced\\nexposure to allergens or an increased tolerance for the\\nsame level of symptoms.\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAllergic rhinitis— Inflammation of the mucous mem-\\nbranes of the nose and eyes in response to an\\nallergen.\\nAnaphylaxis— Increased sensitivity caused by pre-\\nvious exposure to an allergen that can result in\\nblood vessel dilation and smooth muscle contrac-\\ntion. Anaphylaxis 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 reacts\\nby 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 of\\nexposure 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 eyelids,\\ndisplays a type of antibody called immunoglobulin\\ntype E (IgE) on its cell surface, and participates in the\\nallergic response by releasing histamine from intra-\\ncellular granules.\\nT cells— Immune system cells or more specifically,\\nwhite blood cells, that stimulate cells to create and\\nrelease antibodies.\\nGALE ENCYCLOPEDIA OF MEDICINE 123\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 153, 'page_label': '124'}, page_content='While allergy to specific allergens is not inherited, the\\nlikelihood of developing sometype of allergy seems to be,\\nat least for many people. If neither parent has allergies,\\nthe chances of a child developing allergy is approximately\\n10-20%; if one parent has allergies, it is 30-50%; and if\\nboth have allergies, it is 40-75%. One source of this\\ngenetic predisposition is in the ability to produce higher\\nlevels of IgE in response to allergens. Those who produce\\nmore IgE will develop a stronger allergic sensitivity.\\nCOMMON ALLERGENS. The most common air-\\nborne allergens are the following:\\n/C15plant pollens\\n/C15animal fur and dander\\n/C15body parts from house mites (microscopic creatures\\nfound in all houses)\\n/C15house dust\\n/C15mold spores\\n/C15cigarette smoke\\n/C15solvents\\n/C15cleaners\\nCommon food allergens include the following:\\nThe following types of drugs commonly cause\\nallergic reactions:\\n/C15penicillin or otherantibiotics\\n/C15flu vaccines\\n/C15tetanus toxoid vaccine\\n/C15gamma globulin\\nCommon causes ofcontact dermatitisinclude the\\nfollowing:\\n/C15poison ivy, oak, and sumac\\n/C15nickel or nickel alloys\\n/C15latex\\nInsects and other arthropods whose bites or stings\\ntypically cause allergy include the following:\\n/C15bees, wasps, and hornets\\n/C15mosquitoes\\n/C15fleas\\n/C15scabies\\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\\ndue to post-nasal drip. Inflammation of the thin mem-\\nbrane covering the eye (allergicconjunctivitis) causes\\nredness, irritation, and increased tearing in the eyes.\\nAsthma causeswheezing, coughing, and shortness of\\nbreath. Symptoms of food allergies depend on the\\ntissues most sensitive to the allergen and whether the\\nallergen was spread systemically by the circulatory\\nsystem. Gastrointestinal symptoms may include swel-\\nling andtingling in the lips, tongue, palate or throat;\\nnausea; cramping; diarrhea; and gas. Contact derma-\\ntitis is marked by reddened, itchy, weepy skin blisters,\\nand an eczema that is slow to heal. It sometimes has a\\ncharacteritic man-made pattern, such as a glove\\nallergy with clear demarkation on the hands, wrist,\\nand arms where the gloves are worn, or on the earlobes\\nby 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\\ncases, loss of consciousness. Other syptoms may\\ninclude, dizziness, weakness, seizures, coughing, flush-\\ning, or cramping. The symptoms may begin within five\\nminutes after exposure to the allergen up to one hour\\nor more later. Mast cells in the tissues and basophils in\\nthe blood release mediators that give rise to the clinical\\nsymptoms of this IgE-mediated hypersensitivity reac-\\ntion. Commonly, this is associated with allergies to\\nmedications, foods, and insect venoms. In some indivi-\\nduals, anaphylaxis can occur withexercise,p l a s m a\\nexchange, hemodialysis, reaction to insulin, contrast\\nmedia used in certain types of medical tests, and rarely\\nduring the administration 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 aller-\\ngic reaction and this occurs repeatedly upon exposure\\nto the suspected allergen.Allergy testscan be used to\\nidentify potential allergens, but these must be sup-\\nported by eveidence of allergic responses in the\\npatient’s clinical history.\\nSkin tests\\nSkin tests are performed by administering a tiny\\ndose of the suspected allergen by pricking, scratching,\\n124 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 154, 'page_label': '125'}, page_content='puncturing or injecting the skin. The allergen is\\napplied to the skin as an auqeous extract, usually on\\nthe back, forearms, or top of the thighs. Once in the\\nskin, the allergen may produce a classic immune wheal\\nand flare response (a skin lesion with a raised, white,\\ncompressible area surrounded by a red flare). The tests\\nusually begin with prick tests or patch tests that expose\\nthe skin to small amounts of allergen to observe the\\nresponse. A positive reaction will occur on the skin\\neven if the allergen is at levels normally encountered in\\nfood or in the airways. Reactions are usually evaluated\\napproximately fifteen minutes after exposure.\\nIntradermal skin tests involved injection of the aller-\\ngen into the dermis of the skin. These tests are more\\nsensitive and are used for allergies associated with risk\\nof death, such as allergies to antibiotics.\\nAllergen-Specific IgE Measurement\\nTests that measure allergen-specific IgE antibo-\\ndies generally follow a basic method. The allergen is\\nbound to a solid support, either in the form of a\\ncellulose sponge, microtiter plate, or paper disk. The\\npatient’s serum is prepared from a blood sample and is\\nincubated with the solid phase. If allergen specific IgE\\nantibodies are present, they will bind to the solid phase\\nand be retained there when the rest of the serum is\\nwashed away. Next, an labeled antibody against the\\nIgE is added and will bind to any IgE on the solid\\nphase. The excess is washed away and the levels of IgE\\nare determined. The commonly used RAST test (radio\\nallergo sorbent test) employed radio-labeled Anti-IgE\\nantibodies. Updated methods now incorporate the use\\nof enyzme-labeled antibodies in ELISA assays\\n(enzyme-linked immunosorbent 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\\npeople. However, this may not always be the case as\\nthere is considerable overlap between the two groups.\\nThis test is useful for the diagnosis of allergic fungal\\nsinusitis and bronchopulmonaryaspergillosis. Other\\nconditions that are not allergic in nature may give\\nrise to higher IgE levels such assmoking, AIDS, infec-\\ntion with parasites, and IgE myeloma.\\nProvocation tests\\nThese tests involve the administration of allergen to\\nelicit an immune response. Provocation tests, most com-\\nmonly done with airborne allergens, present the allergen\\ndirectly through the routenormally involved. Delayed\\nallergic contact dermatitis diagnosis involves similar\\nmethods by application of a skin patch with allergen\\nto induce an allergic skin reaction. Food allergen provo-\\ncation tests require abstinence from the suspect allergen\\nf o rt w ow e e k so rm o r e ,f o l l o w e db yi n g e s t i o no fa\\nmeasured amount of the test substance administered as\\nan opaque capsule along with a placebo control.\\nProvocation tests are not used if anaphylaxis is is a\\nconcern due to the patient’s medical history.\\nFuture diagnostic methods\\nAttempts have been made for direct measurement\\nof immune mediators such as histamine, eosinophil\\ncationic protein (ECP), and mast cell tryptase.\\nAnother, somewhat controversial,test is electrodermal\\ntesting or electro-acupuncture allergy testing. This test\\nhas been used in Europe and is under investigation in\\nthe United States, though not approved by the Food\\nand Drug Administration. An electric potential is\\napplied to the skin, the allergen presented, and the\\nelectrical resistance observed for changes. This\\nmethod has not been verified.\\nTreatment\\nAvoiding allergens is the first line of defense to\\nreduce the possibility of an allergic attack. It is helpful\\nto avoid environmental irritants such as tobacco\\nsmoke, perfumes, household cleaning agents, paints,\\nglues, air fresheners, and potpourri. Nitrogen dioxide\\nfrom poorly vented gas stoves, woodburning stoves,\\nand artificial fireplaces has also been linked to poor\\nasthma control. Dust mite control is particularly\\nimportant in the bedroom areas by use of allergen-\\nimpermeable covers on mattress and pillows, frequent\\nwashing of bedding in hot water, and removal of items\\nthat collect dust such as stuffed toys. Mold growth may\\nbe reduced by lowering indoor humidity, repair of\\nhouse foundations to reduce indoor leaks and seepage,\\nand installing exhaust systems to ventilate areas where\\nsteam is generated such as the bathroom or kitchen.\\nAllergic individuals should avoid pet allergens such as\\nsaliva, body excretions, pelts, urine, or feces. For those\\nwho insist on keeping a pet, restriction of the animal’s\\nactivity to certain areas of the home may be beneficial.\\nComplete environmental control is often difficult\\nto accomplish, hence therapuetic interventions may\\nbecome necessary. A large number of prescription\\nand over-the-counter drugs are available for treatment\\nof immediate hypersensitivity reactions. Most of these\\nwork by decreasing the ability of histamine to provoke\\nsymptoms. Other drugs counteract the effects of\\nGALE ENCYCLOPEDIA OF MEDICINE 125\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 155, 'page_label': '126'}, page_content='histamine by stimulating other systems or reducing\\nimmune responses 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\\npreventively, before symptoms appear. Antihistamines\\nhelp reduce sneezing, itching, and rhinorrhea. A wide\\nvariety of antihistamines are available.\\nOlder, first generation antihistamines often pro-\\nduce drowsiness as a major side effect, as well asdry\\nmouth, tachycardia, blurred vision,constipation, and\\nlower the threshold for seizures. These medications\\nalso have similar effects to a alcohol and care should\\nbe taken when operating motor vehicles, as individuals\\nmay not be aware that they are impaired. Such anti-\\nhistamines include the following:\\n/C15diphenhydramine (Benadryl and generics)\\n/C15chlorpheniramine (Chlor-trimeton and generics)\\n/C15brompheniramine (Dimetane and generics)\\n/C15clemastine (Tavist and generics)\\nNewer antihistamines that do not cause drowsi-\\nness or pass the blood-brain barrier are available by\\nprescription and include the following:\\n/C15loratidine (Claritin)\\n/C15cetirizine (Zyrtec)\\n/C15fexofenadine (Allegra)\\nDesloratadine (Clarinex) was approved in 2004 in\\nsyrup form for children two years and older for seaso-\\nnal allergies and for hives of unknown cause in chil-\\ndren as young as six months. It is the only nonsedating\\nantihistamine approved as of 2004 for children as\\nyoung as six months.\\nHismanal has the potential to cause serious heart\\narrhythmiaswhen taken with the antibiotic erythromy-\\ncin, the antifungal drugs ketoconazole and itraconazole,\\nor the antimalarial drug quinine. Taking more than the\\nrecommended 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\\nequally 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\\nlining and oral systematic preparations are available.\\nDecongestants are stimulants and may cause increased\\nheart rate and blood pressure, headaches,insomnia,\\nagitation, and difficulty emptying the bladder. Use of\\ntopical decongestants for longer than several days can\\ncause loss of effectiveness and rebound congestion,\\nin which nasal passages become more severely swollen\\nthan before treatment.\\nTopical corticosteroids\\nTopical corticosteroids reduce mucous membrane\\ninflammation by decreasing the amount of fluid moved\\nfrom the vascular spaces into the tissues. These medica-\\ntions reduce the recruitment of inflammatory cells as\\nwell as the synthesis of cytokines. They are available by\\nprescription. Allergies tend to become worse as the\\nseason progresses because the immune system becomes\\nsensitized to particular antigens and can produce a\\nfaster, stronger response. Topical corticosteroids are\\nespecially effective at reducing this seasonal sensitiza-\\ntion because they work more slowly and last longer\\nthan most other medication types. As a result, they\\nare 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\\ncause the airways or bronchial tubes to narrow, as in\\nasthma, bronchodilators, which cause the smooth mus-\\ncle lining the airways to open or dilate, can be very\\neffective. When inhalers are used, it is important that\\nthe patient be educated in the proper use of these\\nmedications. The inhaler should be shaken, and the\\npatient should breathe out to expel air from the lungs.\\nThe inhaler should be placed at least two finger-\\nbreadths in front of the mouth. The medication should\\nbe aimed at the back of the throat, and the inhaler\\nactivated while breathing in quite slowly 3-4 seconds.\\nThe breath should be held for at least ten seconds, and\\nthen expelled. At least thirty to sixty seconds should\\npass before the inhaler is used again. Care should be\\ntaken to properly wash out the mouth and brush the\\nteeth following use, as residual medication remains in\\nthis area with only a small amount actually reaching\\nthe lungs. Some bronchodilators used to treat acute\\nasthma attacks include adrenaline, albuterol, Maxair,\\nProventil, or other ‘‘adrenoceptor stimulants,’’ most\\noften administered as aerosols. Successfully managing\\nasthma and allergies can reduce the use of inhalers.\\n126 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 156, 'page_label': '127'}, page_content='This is done through good communication between\\nthe physician and patient, self-management with writ-\\nten action plans, avoiding allergy triggers, and\\nthrough the use of preventive medications such as\\nmontelukast.\\nAnticholinergics\\nIpratropium bromide (atrovent) and atropine sul-\\nfate are achticholinergic drugs used for the treatment\\nof asthma. Ipratropium is used for treating asthmatics\\nin emergency situations with a nebulizer.\\nNonsteroidal drugs\\nMAST CELL STABILIZERS. Cromolyn sodium pre-\\nvents the release of mast cell granules, thereby pre-\\nventing the release of histamine and other chemicals\\ncontained in them. It acts as a preventive treatment if it\\nis begun several weeks before the onset of the allergy\\nseason. It can also be used for year round allergy\\nprevention. Cromolyn sodium is available as a nasal\\nspray for allergic rhinitis and in aerosol (a suspension\\nof particles in gas) form for asthma.\\nLEUKOTRIENE MODIFIERS. These medications are\\nuseful for individuals with aspirin sensitivity,sinusitis,\\npolposis, urticaria. Examples include zafirlukast\\n(Accolate), montelukast (Singulair), and zileuton\\n(Zyflo). When zileuton is used, care must be taken to\\nmeasure liver 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\\nmedications. A 2004 study recommended that children\\nwho have severe reactions to insect sting receive immu-\\nnotherapy to protect them against future stings.\\nTreatment of contact dermatitis\\nAn individual suffering from contact dermatitis\\nshould initially take steps to avoid possible sources of\\nexposure to the offending agent. Calamine lotion\\napplied to affected skin can reduce irritation somewhat,\\nas can cold water compresses. Side effects of topical\\nagents may include over-drying of the skin. In the case\\nof acute contact dermatitis, short-term oral corticoste-\\nroid therapy may be appropriate. Moderately strong\\ncoricosteroids can also be applied as a wrap for twenty-\\nfour hours. Health care workers are especially at risk\\nfor hand eruptions due to glove use.\\nTreatment of anaphylaxis\\nThe emergency condition of anaphylaxis is treated\\nwith injection of adrenaline, also known as epinephr-\\nine. People who are prone to anaphylaxis because\\nof food or insect allergies often carry an ‘‘Epi-pen’’\\ncontaining adrenaline in a hypodermic needle. Other\\nmedications may be given to aid the action of the epi-\\npen. Prompt injection can prevent a more serious\\nreaction from developing. Particular care should be\\ntaken to assess the affected individual’s airway status,\\nand he or she should be placed in a recumbent pose\\nand vital signs determined. If a reaction resulted from\\ninsect sting or an injection, a tourniquet may need\\nto be placed proximal to the area where the agent\\npenetrated the skin. This should then be released at\\nintervals of ten minutes at a time, for one to two\\nminutes duration. If the individual does not respond\\nto such interventions, then emergency treatment is\\nappropriate.\\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\\nis critical, as they are still ‘‘drugs’’ even though they\\nare derived from natural sources. Various categories\\nof alternative remedies may be helpful in allergy treat-\\nment, including:\\n/C15antihistamines: vitamin C and the bioflavonoid\\nhesperidin act as natural anithistamines.\\n/C15decongestants: vitamin C, the homeopathic reme-\\ndies Ferrum phosphoricum and Kali muriaticum\\n(used alternately), and the dietary supplement\\nN-acetylcysteine are believed to have deconge-\\nstant effects.\\n/C15mast cell stabilizers: the bioflavonoids quercetin and\\nhesperidin may help stabilize mast cells.\\n/C15immunotherapy: the herbs echinacea (Echinacea\\nspp.) and astragalus or milk-vetch root (Astragalus\\nmembranaceus) may possibly help to strengthen the\\nimmune system.\\n/C15bronchodilators: the herbal remedies ephedra\\n(Ephedra sinica , also known as ma huang in tradi-\\ntional Chinese medicine), khellin (Ammi visnaga) and\\ncramp bark (Viburnum opulus ) are believed to help\\nopen the airways.\\nGALE ENCYCLOPEDIA OF MEDICINE 127\\nAllergies'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 157, 'page_label': '128'}, page_content='Treatment of contact dermatitis\\nA variety of herbal remedies, either applied topi-\\ncally or taken internally, may possibly assist in the\\ntreatment of contact dermatitis. A poultice (crushed\\nherbs applied directly to the affected area) made of\\njewelweed (Impatiens spp.) or chickweed (Stellaria\\nmedia) may soothe the skin. A cream or wash contain-\\ning calendula (Calendula officinalis), a natural antisep-\\ntic and anti-inflammatory agent, may help heal the\\nrash when applied topically. Homeopathic treatment\\nmay include such remedies as Rhus toxicodendron ,\\nApis mellifica ,o r Anacardium taken internally. A\\nqualified homeopathic practitioner should be con-\\nsulted to match the symptoms with the correct remedy.\\nCare should be taken with any agent taken internally.\\nPrognosis\\nAllergies can improve over time, although they\\noften worsen. While anaphylaxis and severe asthma\\nare life-threatening, other allergic reactions are not.\\nLearning to recognize and avoid allergy-provoking\\nsituations allows most people with allergies to lead\\nnormal 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 aller-\\ngens that are causing reactions, most people can learn to\\navoid allergic reactions from food, drugs, and contact\\nallergens such as poison ivy or latex. The government\\nwill help now, since passing the Food Allergen Labeling\\nand Consumer Protection Act in 2004. Beginning\\nJanuary 1, 2006, food manufacturers will be required\\nto clearly state if a product contains any of the eight\\nmajor food allergens that are responsible for more than\\n90% of allergic reactions to foods. These are milk,\\neggs, peanuts, tree nuts, fish, shellfish, wheat, and soy.\\nAirborne allergens are more difficult to avoid,\\nalthough keeping dust and animal dander from col-\\nlecting in the house may limit exposure. Cromolyn\\nsodium can prevent mast cell degranulation, thereby\\nlimiting 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\\nallergy testing to determine the precise allergens\\nresponsible. Injections involve very small but gradu-\\nally increasing amounts of allergen, over several weeks\\nor months, with periodic boosters. Full benefits may\\ntake up to several years to achieve and are not seen at\\nall in about one in five patients. Individuals receiving\\nall shots 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, such as leukotriene modifiers, are\\nused to prevent asthma attacks and in the long-term\\nmanagement of allergies and asthma.\\nResources\\nBOOKS\\nHans-Uwe, Simon, editor.CRC Desk Reference for Allergy\\nand Asthma. Boca Raton: CRC Press, 2000.\\nKemp, Stephen F., and Richard Lockey, editors.Diagnostic\\nTesting of Allergic Disease. New York: Marcel Dekker,\\nInc., 2000.\\nLieberman, Phil, and Johh Anderson, editors.Allergic\\nDiseases: Diagnosis and Treatment. 2nd ed. Totowa:\\nHumana Press, Inc., 2000.\\nPERIODICALS\\n‘‘Children With Serious Insect-sting Allergies Should Get\\nShots.’’ Drug Week (September 3, 2004): 19.\\n‘‘FDA Approves Clarinex Syrup for Allergies and Hives in\\nChildren.’’ Biotech Week (September 29, 2004): 617.\\n‘‘President Bush Signs Bill that Will Benefit Millions With\\nFood Allergies.’’Immunotherapy Weekly (September 1,\\n2004): 50.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nRichard Robinson\\nJill Granger, MS\\nTeresa G. Odle\\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.\\nNormally, the immune system responds to foreign\\nmicroorganisms and particles, like pollen or dust,\\nby producing specific proteins called antibodies that\\nare capable of binding to identifying molecules, or\\nantigens, on the foreign organisms. This reaction\\nbetween antibody and antigen sets off a series of\\nreactions designed to protect the body from infec-\\ntion. Sometimes, this sam e series of reactions is\\n128 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergy tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 158, 'page_label': '129'}, page_content='triggered by harmless, everyday substances. This is\\nthe condition known as allergy, and the offending\\nsubstance is called an allergen. Common inhaled\\nallergens include pollen,dust, and insect parts from\\ntiny house mites. Common food allergens include\\nnuts, fish, and milk.\\nAllergic reactions involve a special set of cells\\nin the immune system known as mast cells. Mast\\ncells serve as guards in the tissues where the body\\nmeets the outside world: the skin, the mucous\\nmembranes of the eyes and other areas, and the lin-\\nings of the respiratory and digestive systems. Mast\\ncells display a special typeof antibody, called immu-\\nnoglobulin 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 the release of 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\\nvessels causes neighboring cells to become leaky,\\nleading to the fluid collection, swelling, and increased\\nredness characteristic of a runny nose and red, irri-\\ntated eyes. Histamine also stimulatespain receptors,\\ncausing the itchy, scratchy nose, eyes, and throat\\ncommon inallergic rhinitis.\\nThe particular allergens to which a person is sen-\\nsitive can be determined through allergy testing.\\nAllergy tests may be performed on the skin or using\\nblood serum in a test tube. During skin tests, potential\\nallergens are placed on the skin and the reaction\\nis observed. In radio-allergosorbent allergy testing\\n(RAST), a patient’s blood serum is combined\\nwith allergen in a test tube to determine if serum anti-\\nbodies react with the allergen. Provocation testing\\ninvolves direct exposure to a likely allergen, either\\nthrough inhalation or ingestion. Positive reactions\\nfrom any of these tests may be used to narrow the\\ncandidates for the actual allergen causing the allergy.\\nIdentification of the allergenic substance may\\nallow the patient to avoid the substance and reduce\\nallergic reactions. In addition, allergy testing may\\nbe done in those with asthma that is difficult to\\nmanage, eczema, or skin rashes to determine if an\\nallergy is causing the condition or making it worse.\\nAllergy tests may also be done before allergen desensi-\\ntization to ensure the safety of more 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\\nThis patient is being exposed to certain allergens as part of\\nan allergy test. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAnaphylaxis— Increased sensitivity caused by\\nprevious exposure to an allergen that can result\\nin blood vessel dilation (swelling) and smooth\\nmuscle contraction. Anaphylaxis can result in\\nsharp blood pressure drops and difficulty\\nbreathing.\\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 that\\nactivates pain receptors and causes cells to become\\nleaky.\\nMast cells— A type of immune system cell that\\nis found in the lining of the nasal passages and\\neyelids, displays a type of antibody called immu-\\nnoglobulin type E (IgE) on its cell surface, and par-\\nticipates in the allergic response by releasing\\nhistamine from intracellular granules.\\nGALE ENCYCLOPEDIA OF MEDICINE 129\\nAllergy tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 159, 'page_label': '130'}, page_content='substance to which the person is sensitive. Skin reactivity\\nis seen 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/C15pollen from a variety of trees, common grasses, and\\nweeds\\n/C15mold and fungus spores\\n/C15house dust\\n/C15house mites\\n/C15animal skin cells (dander) and saliva\\n/C15food extracts\\n/C15antibiotics\\n/C15insect venoms\\nRadio-allergosorbent testing (RAST) is a labora-\\ntory test performed when a person may be too sensi-\\ntive to risk skin testing or when medications or skin\\nconditions prevent it.\\nProvocation testing is done to positively identify\\nsuspected allergens after preliminary skin testing.\\nA purified preparation of the allergen is inhaled or\\ningested in increasing concentrations to determine if\\nit will provoke a response. In 2004, scientists intro-\\nduced an optical method to continuously measure the\\nchanges in nasal mucosa (lining) changes with an\\ninfrared light to help improve the accuracy of provo-\\ncation testing. 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 asanaphylaxis\\nexists. Anaphylaxis is a potentially dangerous condi-\\ntion that can result in difficulty breathing and a sharp\\ndrop in blood pressure. People with a known history\\nof anaphylaxis should inform the testing clinician.\\nSkin tests should never include a substance known to\\ncause anaphylaxis in the person being tested.\\nProvocation tests may cause an allergic reaction.\\nTherefore, treatment medications should be available\\nfollowing 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\\nnot provoke a reaction (negative control) and a drop of\\nhistamine that should provoke a reaction (positive con-\\ntrol). A small needle is inserted through the drop, and\\nused to prick the skin below. A new needle is used for\\neach prick. The sites are examined over the next 20 min-\\nutes for evidence of swelling and redness, indicating a\\npositive reaction. In some instances, a tracing of the set\\nof reactions may be made by placing paper over\\nthe tested area. Similarly, in intradermal testing, sepa-\\nrate injections are made for each allergen tested.\\nObservations are made over the next 20 minutes.\\nIn RAST testing, a blood sample is taken for use in\\nthe laboratory, where the antibody- containing serum\\nis separated from the blood cells. The serum is then\\nexposed to allergens bound to a solid medium. If a\\nperson has antibodies to a particular allergen, those\\nantibodies will bind to the solid medium and remain\\nbehind after a rinse. Location of allergen-antibody com-\\nbinations is done by adding antibody-reactive antibo-\\ndies, so called anti-antibodies, that are chemically linked\\nwith a radioactive dye. By locating radioactive spots on\\nthe solid medium, the reactive allergens are discovered.\\nProvocation testing may be performed to identify\\nairborne or food allergens. Inhalation testing is per-\\nformed only after a patient’s lung capacity and\\nresponse to the medium used to dilute the allergen\\nhas been determined. Once this has been determined,\\nthe patient inhales increasingly concentrated samples\\nof a particular allergen, followed each time by mea-\\nsurement of the exhalation capacity. Only one allergen\\nis tested per day. Testing forfood allergies is usually\\ndone by removing the suspect food from the diet for\\ntwo weeks, followed by eating a single portion of the\\nsuspect food and follow-up monitoring.\\nA close-up of a patient’s arm after allergy testing. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\n130 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergy tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 160, 'page_label': '131'}, page_content='Preparation\\nSkin testing is preceded by a brief examination of\\nthe skin. The patient should refrain from using anti-\\nallergy drugs for at least 48 hours before testing. Prior\\nto inhalation testing, patients with asthma who can\\ntolerate it may be asked to stop any asthma medications.\\nTesting for foodallergies requires the person to avoid\\nall suspect food for at least two weeks before testing.\\nAftercare\\nSkin testing does not usually require any aftercare.\\nA generalized 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\\nattacks, even if the antigen administered in the test\\ninitially produced no response. Severe initial reactions\\nmay justify close professional observation for at least\\n12 hours after testing.\\nRisks\\nIntradermal testing may inadvertently result in\\nthe injection of the allergen into the circulation, with\\nan increased risk of adverse reactions. Inhalation tests\\nmay provoke an asthma attack. Exposure to new or\\nunsuspected allergens in any test carries the risk of\\nanaphylaxis. Because patients are monitored follow-\\ning allergy testing, an anaphylactic reaction is usually\\nrecognized and treated promptly. Occasionally, a\\ndelayed anaphylactic response can occur that will\\nrequire immediate care. Proper patient education\\nregarding how to recognize anaphylaxis is vital.\\nNormal results\\nLack of redness or swelling on a skin test indicates\\nno allergic response. In an inhalation test, the exhala-\\ntion capacity should remain unchanged. In a food\\nchallenge, no symptoms should occur.\\nAbnormal results\\nPresence of redness or swelling, especially over\\n5 mm (1/4 inch) in diameter, indicates an allergic\\nresponse. This does not mean the substance actually\\ncauses the patient’s symptoms, however, since he or\\nshe may have no regular exposure to the allergen. In\\nfact, the actual allergen may not have been included in\\nthe 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\\nfollowing the ingestion of a suspected food allergen\\nindicates a positive response.\\nResources\\nPERIODICALS\\nHampel, U., et al. ‘‘Optical Measurements of Nasal\\nSwellings.’’ IEEE Transactions on Biomedical\\nEngineering (September 2004): 1673–1680.\\nRichard Robinson\\nTeresa G. Odle\\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\\nconditions that make people literally pull it out to\\ncomplete hair loss caused by the toxicity of cancer\\nchemotherapy. Some causes are considered natural,\\nwhile others signal serious health problems. Some\\nconditions are confined to the scalp. Others reflect\\ndisease throughout the body. Being plainly visible,\\nthe skin and its components can provide early signs\\nof disease elsewhere in the body.\\nOftentimes, conditions affecting the skin of the\\nscalp will result in hair loss. The first clue to the specific\\ncause is the pattern of hair loss, whether it be complete\\nbaldness (alopecia totalis), patchy bald spots, thinning,\\nor hair loss confined to certain areas. Also a factor is\\nthe condition of the hair and the scalp beneath it.\\nSometimes only the hair is affected; sometimes the\\nskin is visibly diseased as well.\\nCauses and symptoms\\n/C15Male pattern baldness (androgenic alopecia) is con-\\nsidered normal in adult males. It is easily recognized\\nby the distribution of hair loss over the top and front\\nof the head and by the healthy condition of the scalp.\\nGALE ENCYCLOPEDIA OF MEDICINE 131\\nAlopecia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 161, 'page_label': '132'}, page_content='/C15Alopecia areata is a hair loss condition of unknown\\ncause that can be patchy or extend to complete\\nbaldness.\\n/C15Fungal infections of the scalp usually cause patchy\\nhair loss. The fungus, similar to the ones that cause\\nathlete’s footand ringworm, often glows under ultra-\\nviolet light.\\n/C15Trichotillomania is the name of a mental disorder\\nthat causes a person to pull out his or her own hair.\\n/C15Complete hair loss is a common result ofcancer\\nchemotherapy, due to the toxicity of the drugs used.\\n/C15Systemic diseases often affect hair growth either\\nselectively or by altering the skin of the scalp. One\\nexample is thyroid disorders. Hyperthyroidism\\n(too much thyroid hormone) causes hair to become\\nthin and fine. Hypothyroidism (too little thyroid\\nhormone) thickens both hair and skin.\\n/C15Several autoimmune diseases (when protective cells\\nbegin to attack self cells within the body) affect the\\nskin, notably lupus erythemematosus.\\n/C15In 2004, a report a the annual meeting of the\\nAmerican Academy of Dermatology said that alope-\\ncia was becoming nearly epidemic among black\\nwomen as a result of some hairstyles that pull too\\ntightly on the scalp and harsh chemical treatments\\nthat damage the hair shaft and follicles.\\nDiagnosis\\nDermatologists are skilled in diagnosis by sight\\nalone. For more obscure diseases, they may have to\\nresort to askin biopsy, removing a tiny bit of skin using\\na local anesthetic so that it can be examined under a\\nmicroscope. Systemic diseases will require a complete\\nevaluation by a physician, including specific tests to\\nidentify and characterize the problem.\\nTreatment\\nS u c c e s s f u lt r e a t m e n to fu n d e r l y i n gc a u s e si sm o s t\\nlikely to restore hair growth, be it the completion of\\nchemotherapy, effective cure of a scalp fungus, or con-\\ntrol of a systemic disease. Two relatively new drugs–\\nminoxidil (Rogaine) andfinasteride(Proscar)–promote\\nhair growth in a significant minority of patients,\\nespecially those with male pattern baldness and alope-\\ncia areata. While both drugs have so far proved to be\\nquite safe when used for this purpose,minoxidil is a\\nliquid that is applied to the scalp and finasteride is\\nthe first and only approved treatment in a pill form.\\nMinoxidil was approved for over-the-counter\\nsales in 1996. When used continuously for long peri-\\nods of time, minoxidil produces satisfactory results in\\nabout one-fourth of patients with androgenic alopecia\\nand as many as half the patients with alopecia areata.\\nThere is also an over-the-counter extra-strength\\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, usually\\ncancer, with drugs (chemicals).\\nHair follicles— Tiny organs in the skin, each one of\\nwhich grows a single hair.\\nLupus erythematosus— An autoimmune disease that\\ncan damage skin, joints, kidneys, and other organs.\\nRingworm— A fungal infection of the skin, usually\\nknown as tinea corporis.\\nSystemic— Affecting all or most parts of the body.\\nTop of balding male’s head. (Photograph by Kelly A. Quin.\\nReproduced by permission.)\\n132 GALE ENCYCLOPEDIA OF MEDICINE\\nAlopecia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 162, 'page_label': '133'}, page_content='version of minoxidil (5% concentration) approved for\\nuse by men only. The treatment often results in new\\nhair that is thinner and lighter in color. It is important\\nto note that new hair stops growing soon after the use\\nof minoxidil is discontinued.\\nOver the past few decades a multitude of hair\\nreplacement methods have been performed by physi-\\ncians and non-physicians. They range from simply\\nweaving someone else’s hair in with the remains of\\none’s own to surgically transplanting thousands of\\nhair follicles 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 or two hairs transplanted\\nper follicle) resulted in fewer complications and the\\nbest results.\\nAnother surgical procedure used to treat andro-\\ngenic alopecia is scalp reduction. By stretching skin,\\nthe hairless scalp can be removed and the area of bald\\nskin decreased by closing the space with hair-covered\\nscalp. Hair-bearing skin can also be folded over an\\narea of bald skin with a technique called a flap.\\nStem cell research is generating new hope for\\nbaldness. Scientists know that a part of the hair follicle\\ncalled the bulge contains stem cells that can give rise to\\nnew hair and help heal skinwounds. Early research\\nwith mice in 2004 showed promise for identifying the\\ngenes that cause baldness and to identify drugs that\\ncan reverse the process.\\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\\noriginal.\\nResources\\nPERIODICALS\\nCohen, Philip. ‘‘Stem Cells Generate Hair and Hope for the\\nBald.’’ New Scientist (March 20, 2004): 17.\\nLohr, Elizabeth. ‘‘Alopecia Nearly Epidemic Among Black\\nWomen.’’ Clinical Psychiatry News (March 2004): 96.\\nNielsen, Timothy A., and Martin Reichel. ‘‘Alopecia:\\nDiagnosis and Management.’’American Family Physician.\\nOTHER\\nAndrogenetic Alopecia.com. ‘‘How can minoxidil be used to\\ntreat baldness?’’ May1, 2001. .\\nMayo Clinic. ‘‘Alopecia’’ January 26, 2001. [cited May 1,\\n2001]. .\\nWebMD Medical News. ‘‘Hair Today, Gone Tomorrow,\\nHair Again’’ 2000. [cited May 1, 2001]. .\\nBeth A. Kapes\\nTeresa G. Odle\\nAlpha-fetoprotein test\\nDefinition\\nThe alpha-fetoprotein (AFP) test is a blood test\\nthat is performed duringpregnancy. This screening\\ntest measures the level of AFP in the mother’s blood\\nand indicates the probability that the fetus has one\\nof several serious birth defects. The level of AFP can\\nalso be determined by analyzing a sample of amniotic\\nfluid. This screening test cannot diagnose a specific\\ncondition; it only indicates increased risk for several\\nbirth defects. Outside pregnancy, the AFP test is used\\nto detectliver disease, certain cancerous tumors, and\\nto monitor the 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\\nenter the mother’s blood. The level of AFP can then\\nbe determined by analyzing a sample of the mother’s\\nblood. By analyzing the amount of AFP found in a\\nblood or amniotic fluid sample, doctors can determine\\nthe probability that the fetus is at risk for certain birth\\ndefects. It is very important that the doctor know\\nprecisely how old the fetus is when the test is performed\\nsince the AFP level changes over the length of the\\npregnancy. Alone, AFP screening cannot diagnose a\\nbirth defect. The test is used as an indicator of risk and\\nthen an appropriate line of testing (such asamniocent-\\nesis or ultrasound) follows, based on the results.\\nAbnormally high AFP may indicate that the\\nfetus has an increased risk of a neural tube defect,\\nthe most common and severe type of disorder\\nassociated with increased AFP. These types of defects\\ninclude spinal column defects ( spina bifida )a n d\\nanencephaly (a severe and usually fatal brain\\nabnormality). If the tube that becomes the brain\\nGALE ENCYCLOPEDIA OF MEDICINE 133\\nAlpha-fetoprotein test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 163, 'page_label': '134'}, page_content='and spinal cord does not close correctly during fetal\\ndevelopment, AFP may leak through this abnormal\\nopening and enter the amniotic fluid. This leakage\\ncreates abnormally high levels of AFP in amniotic\\nfluid and in maternal blood. If the screening test\\nindicates abnormally high AFP, ultrasound is used\\nto diagnose the problem.\\nOther fetal conditions that can raise AFP levels\\nabove normal include:\\n/C15cysts at the end of the spine\\n/C15blockage in the esophagus or intestines\\n/C15liver disease causing liver cells to die\\n/C15defects in the abdominal wall\\n/C15kidney or urinary tract defects or disease\\n/C15brittle bone disease\\nLevels may also be high if there is too little fluid in\\nthe amniotic sac around the fetus, more than one\\ndeveloping fetus, or a pregnancy that is farther along\\nthan estimated.\\nFor unknown reasons, abnormally low AFP may\\nindicate that the fetus has an increased risk ofDown\\nsyndrome. Down syndrome is a condition that includes\\nmental retardation and a distinctive physical appearance\\nlinked to an abnormality ofchromosome 21 (called\\ntrisomy 21). If the screening test indicates an abnormally\\nlow AFP, amniocentesis is used to diagnose the problem.\\nAbnormally low levels of AFP can also occur when\\nthe fetus has died or when the mother is overweight.\\nAFP is often part of a ‘‘triple check’’ blood test\\nthat analyzes three substances as risk indicators of\\npossible birth defects: AFP, estriol, and human chor-\\nionic gonadotropin (HCG). When all three substances\\nare measured in the mother’s blood, the accuracy of\\nthe test results increases.\\nIn 2004, a new study showed that the risk of an\\ninfant’s death from sudden infant death syndrome\\n(SIDS) increased if levels of AFP were higher during\\nthe second trimester of the mother’s pregnancy.\\nAlthough AFP in human blood gradually disap-\\npears after birth, it never disappears entirely. It may\\nreappear in liver disease, or tumors of the liver, ovar-\\nies, or testicles. The AFP test is used to screen people\\nat high risk for these conditions. After a cancerous\\ntumor is removed, an AFP test can monitor the\\nprogress of treatment. Continued high AFP levels\\nsuggest thecancer is growing.\\nPrecautions\\nIt is very important that the doctor know precisely\\nhow old the fetus is when the test is performed since\\nthe AFP level considered normal changes over the\\nlength of the pregnancy. Errors in determining the\\nage of the fetus lead to errors when interpreting\\nthe test results. Since an AFP test is only a screening\\ntool, more specific tests must follow to make an accu-\\nrate diagnosis. An abnormal test result does not neces-\\nsarily mean that the fetus has a birth defect. The test\\nhas a high rate of abnormal results (either high or low)\\nto prevent missing a fetus that has a serious condition.\\nDescription\\nThe AFP test is usually performed at week 16 of\\npregnancy. Blood is drawn from the patient’s\\n(mother’s) vein, usually on the inside of the elbow.\\nAFP can also be measured in the sample of amniotic\\nfluid taken at the time of amniocentesis. Test results\\nare usually available after about one week.\\nPreparation\\nThere is no specific physical preparation for the\\nAFP test.\\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\\nsite, feeling faint or lightheaded after the blood is\\ndrawn, or blood accumulating under the puncture\\nsite (hematoma).\\nNormal results\\nAlpha-fetoprotein is measured in nanograms per\\nmilliliter (ng/mL) and is expressed as a probability.\\nThe probability (1:100, for example) translates into\\nthe chance that the fetus has a defect (a one in 100\\nchance, for example).\\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.\\n134 GALE ENCYCLOPEDIA OF MEDICINE\\nAlpha-fetoprotein test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 164, 'page_label': '135'}, page_content='When testing for cancer or liver diseases, AFP\\nresults are reported as nanograms per milliliter. An\\nAFP level less than or equal to 50 ng/mL is considered\\nnormal.\\nAbnormal results\\nThe doctor will inform the woman of her specific\\nincreased risk as compared to the ‘‘normal’’ risk of a\\nstandard case. If the risk of Down syndrome is greater\\nthan the standard risk for women who are 35 years old\\nor older (one in 270), 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\\nrisk; appropriate diagnostic testing will follow after an\\nabnormal screening result.\\nIn tumor or liver disease testing, an AFP level\\ngreater than 50 ng/mL is considered abnormal.\\nResources\\nPERIODICALS\\nSmith, Gordon C.S., et al. ‘‘Second-trimester Maternal\\nSerum Levels of Alpha-fetoprotein and the Subsequent\\nRisk of Sudden Infant Death Syndrome.’’New England\\nJournal of Medicine (September 2, 2004): 978.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275\\nMamaroneck Ave., White Plains, NY 10605. (914)\\n428-7100. resourcecenter@modimes.org. .\\nNational Cancer Institute. Building 31, Room 10A31, 31\\nCenter Drive, MSC 2580, Bethesda, MD 20892-2580.\\n(800) 422-6237. .\\nAdrienne Massel, RN\\nTeresa G. Odle\\nAlpha-thalassemia see Thalassemia\\nAlpha1-adrenergic blockers\\nDefinition\\nAlpha1-adrenergic blockers are drugs that work\\nby blocking the alpha1-receptors of vascular smooth\\nmuscle, thus preventing the uptake of catecholamines\\nby the smooth muscle cells. This causes vasodilation\\nand allows blood to flow more easily.\\nPurpose\\nThese drugs, called alpha blockers for short, are\\nused for two main purposes: to treat high blood pres-\\nsure (hypertension) and to treat benign prostatic\\nhyperplasia (BPH), a condition that affects men and\\nis characterized by anenlarged prostategland.\\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 causingstroke, heart fail-\\nure or kidney failure. People with high blood pressure\\nmay also be at higher risk for heart attacks.\\nControlling high blood pressure makes these problems\\nless likely. Alpha blockers help lower blood pressure\\nby causing vasodilation, meaning an increase in the\\ndiameter of the blood vessels, which allows blood to\\nflow more easily.\\nBenign prostatic hyperplasia (BPH)\\nThis condition particularly affects older men.\\nOver time, the prostate, a donut-shaped gland\\nbelow the bladder, enlarges. When this happens, it\\nmay interfere with the passage of urine from the\\nbladder out of the body. Men who are diagnosed\\nwith BPH may have to urinate more often. Or they\\nmay feel that they can not completely empty their\\nbladders. Alpha blockers inhibit the contraction of\\nprostatic smooth muscle and thus relax muscles in\\nthe prostate and the bladder, allowing urine to flow\\nmore freely.\\nDescription\\nCommonly prescribed alpha blockers for hyper-\\ntension and BPH include doxazosin (Cardura, prazo-\\nsin (Minipress) and terazosin (Hytrin). Prazosin is also\\nused in the treatment of heart failure. All are available\\nonly with a physician’s prescription and are sold in\\ntablet form.\\nRecommended dosage\\nThe recommended dose depends on the patient\\nand the type of alpha blocker and may change over\\nthe course of treatment. The prescribing physician will\\ngradually increase the dosage, if necessary. Some\\npatients may need as much as 15-20 mg per day of\\nterazosin, 16 mg per day of doxazosin, or as much as\\n40 mg per day of prazosin, but most people benefit\\nfrom lower doses. As the dosage increases, so does the\\npossibility of unwanted side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 135\\nAlpha1-adrenergic blockers'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 165, 'page_label': '136'}, page_content='Alpha blockers should be taken exactly as direc-\\nted, even if the medication does not seem to be work-\\ning at first. It should not be stopped even if symptoms\\nimprove because it needs to be taken regularly to be\\neffective. Patients should avoid missing any doses, and\\nshould not take larger or more frequent doses to make\\nup for missed doses.\\nPrecautions\\nAlpha blockers may lower blood pressure to a\\ngreater extent than desired. This can cause dizziness,\\nlightheadedness, heart palpitations,a n d fainting.\\nActivities such as driving, using machines, or doing\\nanything else that might be dangerous for 24 hours\\nafter taking the first dose should be avoided. Patients\\nshould be reminded to be especially careful not to\\nfall when getting up in the middle of the night. The\\nsame precautions are recommended if the dosage\\nis increased or if the drug has been stopped and\\nthen started again. Anyone whose safety on the job\\ncould be affected by taking alpha blockers should\\ninform his or her physician, so that the physician\\ncan take this factor into account when increasing\\ndosage.\\nSome people may feel drowsy or less alert when\\nusing these drugs. They should accordingly avoid\\ndriving or performing activities that require full\\nattention.\\nPeople diagnosed withkidney diseaseor liver dis-\\nease may also be more sensitive to alpha blockers.\\nThey should inform their physicians about these con-\\nditions if alpha blockers are prescribed. Older people\\nmay also be more sensitive and may be more likely to\\nhave unwanted side effects, such as fainting, dizziness,\\nand lightheadedness.\\nIt should be noted that alpha blockers do not cure\\nhigh blood pressure. They simply help to keep the\\ncondition under control. Similarly, these drugs will\\nnot shrink an enlarged prostate gland. Although they\\nwill help relieve the symptoms of prostate enlarge-\\nment, the prostate may continue to grow, and it even-\\ntually may be necessary to have prostate surgery.\\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 of\\nthe nine subtypes are coded by separate genes, and\\ndisplay specific drug specificities and regulatory\\nproperties.\\nAlpha blockers— Medications that bind alpha adre-\\nnergic receptors and decrease the workload of the\\nheart and lower blood pressure. They are commonly\\nused to treat hypertension, peripheral vascular dis-\\nease, and hyperplasia.\\nArteries— Blood vessels that carry oxygenated blood\\naway from the heart to the cells, tissues, and organs\\nof the body.\\nCatecholamines— Family of neurotransmitters con-\\ntaining dopamine, norepinephrine and epinephrine,\\nproduced and secreted by cells of the adrenal\\nmedulla in the brain. Catecholamines have excita-\\ntory effects on smooth muscle cells of the vessels that\\nsupply blood to the skin and mucous membranes\\nand have inhibitory effects on smooth muscle cells\\nlocated in the wall of the gut, the bronchial tree of the\\nlungs, and the vessels that supply blood to skeletal\\nmuscle. There are two different main types of recep-\\ntors for these neurotransmitters, called alpha and beta\\nadrenergic receptors. The catecholamines are there-\\nfore are also known as adrenergic neurotransmitters.\\nHyperplasia— The abnormal increase in the number\\nof normal cells in a given tissue.\\nHypertension— Persistently high arterial blood\\npressure.\\nNeurotransmitter— Substance released from neurons\\nof the peripheral nervous system that travels across\\nthe synaptic clefts (gaps) of other neurons to excite or\\ninhibit 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 response.\\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.\\n136 GALE ENCYCLOPEDIA OF MEDICINE\\nAlpha1-adrenergic blockers'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 166, 'page_label': '137'}, page_content='Alpha blockers may lower blood counts. Patients\\nmay need to have their blood checked regularly while\\ntaking this medicine.\\nAnyone who has had unusual reactions to alpha\\nblockers in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nThe effects of taking alpha blockers duringpreg-\\nnancy are not fully understood. Women who are preg-\\nnant or planning to become pregnant should inform\\ntheir physicians. Breastfeeding mothers who need to\\ntake alpha blockers should also talk to their physi-\\ncians. These drugs can pass into breast milk and may\\naffect nursing babies. It may be necessary to stop\\nbreastfeeding while being treated with alpha blockers.\\nSide effects\\nT h em o s tc o m m o ns i d ee f f e c t sa r ed i z z i n e s s ,d r o w -\\nsiness, tiredness, headache, nervousness, irritability,\\nstuffy or runny nose,nausea, pain in the arms and legs,\\nand weakness. These problems usually go away as the\\nbody adjusts to the drug and do not require medical\\ntreatment. If they do not subside or if they interfere with\\nnormal 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/C15fainting\\n/C15shortness of breath or difficulty breathing\\n/C15fast, pounding, or irregular heartbeat\\n/C15swollen 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\\nwith any other drugs. Terazosin (Hytrin) may interact\\nwith nonsteroidal anti-inflammatory drugs, such as\\nibuprofen (Motrin), and with other blood pressure\\ndrugs, such as enalapril (Vasotec), and verapamil\\n(Calan,Verelan). Prazosin (Minipress) may interact\\nwith beta adrenergic blocking agents such as propra-\\nnolol (Inderal) and others, and with verapamil (Calan,\\nIsoptin.) When drugs interact, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay 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\\nand eye problems. Eventually,kidney dialysisor trans-\\nplant may be necessary.\\nDescription\\nAlport syndrome affects about one in 5,000\\nAmericans, striking men more often and severely\\nthan women. There are several varieties of the syn-\\ndrome, some occurring in childhood and others not\\ncausing symptoms until men reach their 20s or 30s. All\\nvarieties of the syndrome are characterized bykidney\\ndisease that usually progresses to chronic kidney fail-\\nure and by uremia (the presence of excessive amounts\\nof urea and other waste products in the blood).\\nCauses and symptoms\\nAlport syndrome in most cases is caused by a\\ndefect in one or more genes located on the X chromo-\\nsome. It is usually inherited from the mother, who is a\\nnormal carrier. However, in up to 20% of cases there is\\nno family history of the disorder. In these cases, there\\nappears to be a spontaneous genetic mutation causing\\nAlport syndrome.\\nBlood in the urine (hematuria) is a hallmark of\\nAlport syndrome. Other symptoms that may appear in\\nvarying combinations include:\\n/C15protein in the urine (proteinuria)\\n/C15sensorineural hearing loss\\n/C15eye problems [involuntary, rhythmic eye movements\\n(nystagmus), cataracts, or cornea problems]\\n/C15skin problems\\n/C15platelet disorders\\n/C15abnormal white blood cells\\n/C15smooth muscle tumors\\nNot all patients with Alport syndrome have hear-\\ning problems. In general, those with normal hearing\\nhave less severe cases of Alport syndrome.\\nDiagnosis\\nAlport syndrome is diagnosed with a medical eva-\\nluation and family history, together with a kidney\\nbiopsy that can detect changes in the kidney typical of\\nGALE ENCYCLOPEDIA OF MEDICINE 137\\nAlport syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 167, 'page_label': '138'}, page_content='the condition.Urinalysismay reveal blood or protein in\\nthe urine. Blood tests can reveal a low platelet level.\\nIn addition, tests for the Alport gene are now\\navailable. Although testing is fairly expensive, it is\\ncovered by many types of health insurance. DNA\\ntests can diagnose affected children even before birth,\\nand genetic linkage tests tracing all family members at\\nrisk for Alport syndrome are also available.\\nTreatment\\nThere is no specific treatment that can ‘‘cure’’\\nAlport syndrome. Instead, care is aimed at easing the\\nproblems related to kidney failure, such as the presence\\nof too many waste products in the blood (uremia).\\nTo control kidney inflammation ( nephritis),\\npatients should:\\n/C15restrict fluids\\n/C15control high blood pressure\\n/C15manage pulmonary edema\\n/C15control 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/C15drink less\\n/C15eat a salt-free diet\\n/C15use diuretics\\n/C15have albumin transfusions\\nThe treatment forchronic kidney failureis dialysis\\nor a kidney transplant.\\nPrognosis\\nWomen with this condition can lead a normal life,\\nalthough they may have slight hearing loss. An\\naffected woman may notice blood in her urine only\\nwhen understress or pregnant.\\nMen generally have a much more serious problem\\nwith the disease. Most will experience kidney disease\\nin their 20s or 30s, which may eventually require dia-\\nlysis or transplantation, and many develop significant\\nhearing loss. Men with Alport syndrome often die of\\ncomplications by middle age.\\nPrevention\\nAlport syndrome is a genetic disease and preven-\\ntion efforts are aimed at providing affected individuals\\nand their families with information concerning the\\ngenetic mechanisms responsible for the disease. Since\\nit is possible to determine if a woman is a carrier, or if\\nan unborn child has the condition,genetic counseling\\ncan provide helpful information and support for the\\ndecisions that affected individuals and their families\\nmay have to make.\\nResources\\nORGANIZATIONS\\nAmerican Association of Kidney Patients. 100 S. Ashley Dr.,\\n#280, Tampa, FL 33602. (800) 749-2257. .\\nAmerican Kidney Fund (AKF). Suite 1010, 6110 Executive\\nBoulevard, Rockville, MD 20852. (800) 638-8299.\\n.\\nNational Kidney and Urologic Disease Information\\nClearinghouse. 3 Information Way, Bethesda, MD\\n20892. (301) 654-4415. .\\nNational Kidney Foundation. 30 East 33rd St., New York,\\nNY 10016. (800) 622-9010. .\\nNational Organization for Rare Diseases. P.O. Box 8923,\\nFairfield, CT 06812. (213) 745-6518. .\\nOTHER\\nAlport Syndrome Home Page. .\\n‘‘Alport Syndrome.’’ Pediatric Database Home Page.\\n.\\nThe Hereditary Nephritis Foundation (HNF) Home Page.\\n.\\nCarol A. Turkington\\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 of\\nthe lungs.\\nUremia— The presence of excessive amounts of\\nurea and other waste products in the blood.\\n138 GALE ENCYCLOPEDIA OF MEDICINE\\nAlport syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 168, 'page_label': '139'}, page_content='Alprazolam 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\\nis important to understand the range of the different\\naltitudes that may be involved. High altitude is defined\\nas height greater than 8,000 feet (2,438m); medium\\naltitude is defined as height between 5,000 and 8,000\\nfeet (1,524-2,438m); 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%\\nof people ascending above 9,000 feet (2,743m) in one\\nday will develop altitude sickness. Children under six\\nyears and women in the premenstrual part of their cycles\\nmay be more vulnerable. Individuals with preexisting\\nmedical conditions–even a minor respiratory infection–\\nmay become 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 cerebraledema (HACE).\\nThese syndromes are not separate, individual syn-\\ndromes as much as they are a continuum of severity,\\nall resulting from a decrease in oxygen in the air. AMS\\nis the mildest, and the other two represent severe, life-\\nthreatening forms of altitude sickness.\\nAltitude sickness occurs because the partial pres-\\nsure of oxygen decreases with altitude. (Partial pres-\\nsure is a term applied to gases that is similar to the way\\nthe term concentration is applied to liquid solutions.)\\nFor instance, at 18,000 feet (5,486 m) the partial pres-\\nsure of oxygen drops to one-half its value at sea level\\nand, therefore, there is a substantially lower amount of\\noxygen available for the individual to inhale. This is\\nknown as hypoxia. Furthermore, since there is less\\noxygen to inhale, less oxygen reaches the blood. This\\nis known as hypoxemia. These two conditions are the\\nmajor factors that form the basis for all the medical\\nproblems associated with altitude sickness.\\nAs a person becomes hypoxemic, his natural\\nresponse is to breathe more rapidly (hyperventilate).\\nThis is the body’s attempt to bring in more oxygen at\\na rapid rate. This attempt at alleviating the effects of the\\nhypoxia at higher altitudes is known as acclimatization,\\nand it occurs during the first few days. Acclimatization\\nis a response that occurs in individuals who travel from\\nlower to higher altitudes. There are groups of people\\nwho have lived at high altitudes (for example, in the\\nHimalayan and Andes mountains) for generations, and\\nthey are simply accustomed to living at such altitudes,\\nperhaps through a genetic ability.\\nCauses and symptoms\\nAcute mountain sickness (AMS) is a mild form of\\naltitude sickness that results from ascent to altitudes\\nhigher greater than 8,000 feet (2,438m)–even 6,500 feet\\n(1,981 m) in some susceptible individuals. Although\\nhypoxia is associated with the development of AMS,\\nthe exact mechanism by which this condition develops\\nhas yet to be confirmed. It is important to realize that\\nsome individuals acclimatize to higher altitudes more\\nefficiently than others. As a result, under similar condi-\\ntions some will suffer from AMS while others will not.\\nAt present, the susceptibility of otherwise healthy indi-\\nviduals to contracting AMS cannot be accurately pre-\\ndicted. Of those who do suffer from AMS, the condition\\ntends to be most severe on the second or third day after\\nreaching the high altitude, and it usually abates after\\nthree to five days if they remain at the same\\naltitude. However, it can recur if the individuals travel\\nto an even higher altitude. Symptoms usually appear a\\nfew hours to a few days following ascent, and they\\ninclude dizziness, headache, shortness of breath, nausea,\\nvomiting,l o s so fa p p e t i t e ,a n dinsomnia.\\nHigh-altitude pulmonary edema(HAPE) is a life-\\nthreatening condition that afflicts a small percentage\\nof those who suffer from AMS. In this condition, fluid\\nleaks from within the pulmonary blood vessels into the\\nlung tissue. As this fluid begins to accumulate within\\nKEY TERMS\\nCerebral— Pertaining to the brain.\\nEdema— Accumulation of excess fluid in the tissues\\nof 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 139\\nAltitude sickness'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 169, 'page_label': '140'}, page_content='the lung tissue (pulmonary edema), the individual\\nbegins to become more and more short of breath.\\nHAPE is known to afflict all types of individuals,\\nregardless of their level of physical fitness.\\nTypically, the individual who suffers from HAPE\\nascends quickly to a high altitude and almost imme-\\ndiately develops shortness of breath, a rapid heart\\nrate, acough productive of a large amount of some-\\ntimes bloody sputum, and a rapid rate of breathing.\\nIf no medical assistance is provided by this point,\\nthe patient goes into a coma and dies within a few\\nhours.\\nHigh-altitude cerebral edema (HACE), the rarest\\nand most severe form of altitude sickness, involves\\ncerebral edema, and its mechanism of development is\\nalso poorly understood. The symptoms often begin\\nwith those of AMS, but neurologic symptoms such\\nas an altered level of consciousness, speech abnormal-\\nities, severe headache, loss of coordination,hallucina-\\ntions, and even seizures. If no intervention is\\nimplemented, death is the result.\\nDiagnosis\\nThe diagnosis for altitude sickness may be made\\nfrom the observation of the individual’s symptoms\\nduring travel to higher altitudes.\\nTreatment\\nMild AMS requires no treatment other than an\\naspirin or ibuprofen for headache, and avoidance of\\nfurther ascent. Narcotics should be avoided because\\nthey may blunt the respiratory response, making\\nit even more difficult for the person to breathe deeply\\nand rapidly enough to compensate for the lower levels\\nof oxygen in the environment. Oxygen may also be\\nused to alleviate symptoms of mild AMS.\\nAs for HAPE and HACE, the most important\\ncourse of action is descent to a lower altitude as soon\\nas possible. Even a 1,000-2,000-foot (305-610 m) des-\\ncent can dramatically improve one’s symptoms. If\\ndescent is not possible, oxygen therapy should be\\nstarted. In addition, dexamethasone (a steroid) has\\nbeen suggested in order to reduce cerebral edema.\\nPrognosis\\nThe prognosis for mild AMS is good, if appro-\\npriate measures are taken. As for HAPE and HACE,\\nthe prognosis depends upon the rapidity and distance\\nof descent and the availability of medical intervention.\\nDescent often leads to improvement of symptoms,\\nhowever, recovery times vary among individuals.\\nPrevention\\nWhen individuals ascend from sea level, it is recom-\\nmended that they spend at least one night at\\nan intermediate altitude prior to ascending to higher\\nelevations. In general, climbers should take at least two\\ndays to go from sea level to 8,000 feet (2,438m). After\\nreaching that point, healthy climbers should generally\\nallow one day for each additional 2,000 feet (610m), and\\none day of rest should be taken every two or three days.\\nShould mild symptoms begin to surface, further ascent\\nshould be avoided. If the symptoms are severe, the indi-\\nvidual should return to a lower altitude. Some reports\\nindicate that acetazolamide (a diuretic) may be taken\\nbefore ascent as a preventative measure for AMS.\\nPaying attention to diet can also help prevent alti-\\ntude sickness. Water loss is a problem at higher alti-\\ntudes, so climbers should drink ample water (enough to\\nproduce copious amounts of relatively light-colored or\\nclear urine). Alcohol and large amounts of salt should\\nbe avoided. Eating frequent small, high-carbohydrate\\nsnacks (for example, fruits, jams and starchy foods)\\ncan help, especially in the first few days of climbing.\\nResources\\nBOOKS\\nCrystal, R. G., et al., editors.The Lung: Scientific\\nFoundations. Lippincott-Raven Publishers, 1997.\\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,\\nand is 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 andexercise judgment. Communication ability,\\n140 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 170, 'page_label': '141'}, page_content='mood, and personality also may be affected. Most\\npeople who have AD die within eight years of their\\ndiagnosis, although the interval may be as short as one\\nyear or as long as 20 years. AD is the fourth leading\\ncause ofdeath in adults after heart disease,cancer,a n d\\nstroke.\\nBetween two and four million Americans have\\nAD; that number is expected to grow to as many as\\n14 million by the middle of the 21st century as the\\npopulation ages. While a small number of people in\\ntheir 40s and 50s develop the disease (called early-\\nonset AD), AD predominantly affects the elderly.\\nAD affects about 3% of all people between ages 65\\nand 74, about 19% of those between 75 and 84, and\\nabout 47% of those over 85. Slightly more women\\nthan men are affected with AD, but this may be\\nbecause women tend to live longer, leaving a higher\\nproportion of women in the most affected age groups.\\nThe cost of caring for a person with AD is con-\\nsiderable. The annual cost of caring for one AD\\npatient in 1998 was estimated as about $18,400 for a\\npatient with mild AD, $30,100 for a patient with mod-\\nerate AD, and $36,100 for a patient with severe AD.\\nThe annual direct and indirect costs of caring for AD\\npatients in the United States was estimated to be as\\nmuch as $100 billion. Slightly more than half of people\\nwith AD are cared for at home, while the remainder\\nare cared for in a variety of health care institutions.\\nCauses and symptoms\\nCauses\\nThe cause or causes of Alzheimer’s disease are lar-\\ngely unknown, though some forms have genetic links.\\nSome strong leads have been found through recent\\nresearch, however, and these have given some theoreti-\\ncal support to several new experimental treatments.\\nAt first AD destroys neurons (nerve cells) in parts\\nof the brain that control memory, including the\\nhippocampus, which is a structure deep in the deep\\nthat controls short-term memory. As these neurons\\nin the hippocampus stop functioning, the person’s\\nshort-term memory fails, and the ability to perform\\nfamiliar tasks decreases. Later AD affects the cerebral\\ncortex, particularly the areas responsible for language\\nand reasoning. Many language skills are lost and the\\nability to make judgments is affected. Personality\\nchanges occur, which may include emotional out-\\nbursts, wandering, and agitation. The severity of\\nthese changes increases with disease progression.\\nEventually many other areas of the brain become\\ninvolved, the brain regions affected atrophy (shrink\\nand lose function), and the person with AD becomes\\nbedridden, incontinent, helpless, and non-responsive.\\nAutopsy of a person with AD shows that the\\nregions of the brain affected by the disease become\\nclogged with two abnormal structures, called neuro-\\nfibrillary tangles and amyloid plaques. Neurofibrillary\\ntangles are twisted masses of protein fibers inside nerve\\ncells, or neurons. In AD, tau proteins, which normally\\nhelp bind and stabilize parts of neurons, are changed\\nchemically, become twisted and tangled, and no longer\\ncan stabilize the neurons. Amyloid plaques consist of\\ninsoluble deposits of beta-amyloid, (a protein fragment\\nfrom a larger protein called amyloid precursor protein\\n(APP), mixed with parts of neurons and non-nerve\\ncells. Plaques are found in the spaces between the\\nnerve cells of the brain. While it is not clear exactly\\nA brain segment affected by Alzheimer’s disease on the right\\ncompared with a healthy brain segment (left). The diseased\\nbrain appears shrunken, and the fissures are noticeably\\nlarger. (Simon Fraser/MRC Unit, Newcastle General Hospital/\\nScience Photo Library. Photo Researchers, Inc. Reproduced by\\npermission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 141\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 171, 'page_label': '142'}, page_content='how these structures cause problems, many researchers\\nbelieve that their formation is responsible for the men-\\ntal changes of AD, presumably by interfering with the\\nnormal communication between neurons in the brain\\nand later leading to the death of neurons. By 2000,\\nthree drugs for the treatment of AD symptoms were\\napproved by the U.S. Food and Drug Administration\\n( F D A ) .T h e ya c tb yi n c r e a s i n gt h el e v e lo fc h e m i c a l\\nsignaling molecules in the brain, known as neurotrans-\\nmitters, to make up for this decreased communication\\nability. All act by inhibiting the activity of acetyl-\\ncholinesterase, which is an enzyme that breaks down\\nacetylcholine, an important neurotransmitter released\\nby neurons that is necessary for cognitive function.\\nThese drugs modestly increase cognition and improve\\none’s ability to perform normal activities of daily living.\\nExactly what triggers the formation of plaques\\nand tangles and the development of AD is unknown.\\nAD likely results from many interrelated factors,\\nincluding genetic, environmental, and others not yet\\nidentified. Two types of AD exist: familial AD (FAD),\\nwhich is a rare autosomal dominant inherited disease,\\nand sporadic AD, with no obvious inheritance pat-\\ntern. AD also is described in terms of age at onset, with\\nearly onset AD occurring in people younger than 65,\\nand late-onset occurring in those 65 and older. Early\\nonset AD comprises about 5-10 % of AD cases and\\naffects people aged 30 to 60. Some cases of early onset\\nAD are inherited and are common in some families.\\nEarly-onset AD often progresses faster than the more\\ncommon late-onset type.\\nAll cases of FAD, which is relatively uncommon,\\nthat have been identified to date are the early onset\\ntype. As many as 50% of FAD cases are known to\\nbe caused by three genes located on three different\\nchromosomes. Some families have mutations in the\\nAPP gene located on chromosome 21, which causes\\nthe production of abnormal APP protein. Others\\nhave mutations in a gene called presenilin 1 located\\non chromosome 14, which causes the production of\\nabnormal presenilin 1 protein, and others have muta-\\ntions in a similar gene called presenilin 2 located\\non chromosome 1, which causes production of abnor-\\nmal presenilin 2. Presenilin 1 may be one of the\\nenzymes that clips APP into beta-amyloid; it also\\nmay be important in the synaptic connections between\\nbrain cells.\\nThere is no evidence that the mutated genes that\\nc a u s ee a r l yo n s e tF A Da l s oc a u s el a t eo n s e tA D ,b u t\\ngenetics appears to play a role in this more common\\nform of AD. Discovered by researchers at Duke\\nUniversity in the early 1990s, potentially the most\\nimportant genetic link to AD was on chromosome 19.\\nA gene on this chromosome, called APOE (apolipo-\\nprotein E), codes for a protein involved in transporting\\nlipids into neurons. APOE occurs in at least three forms\\n(alleles), called APOE e2, APOE e3, and APOE e4.\\nEach person inherits one APOE from each parent, and\\ntherefore can either have one copy of two different\\nforms, or two copies of one. The relatively rare APOE\\ne2 appears to protect some people from AD, as it seems\\nto be associated with a lower risk of AD and a later age\\nof onset if AD develops. APOE e3 is the most common\\nversion found in the general population, and only\\nappears to have a neutral role in AD. However, APOE\\ne4 appears to increase the risk of developing late onset\\nAD with the inheritance of one or two copies of APOE\\ne4. Compared to those without APOE e4, people with\\none copy are about three times as likely to develop late-\\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 found in the brains of people\\nwith AD.\\nDiseased tissue from the brain of an Alzheimer’s patient show-\\ning senile plaques within the brain’s gray matter.(Photograph by\\nCecil Fox, Photo Researchers, Inc. Reproduced by permission.)\\n142 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 172, 'page_label': '143'}, page_content='onset AD, and those with two copies are almost four\\ntimes as likely to do so. Having APOE e4 also can lower\\nthe age of onset by as much as 17 years. However,\\nAPOE e4 only increases the risk of developing AD\\nand does not cause it, as not everyone with APOE e4\\ndevelops AD, and people without it can still have the\\ndisease. Why APOE e4 increases the chances of devel-\\noping AD is not known with certainty. However, one\\ntheory is that APOE e4 facilitates beta-amyloid buildup\\nin plaques, thus contributing to the lowering of the age\\nof onset of AD; other theories involve interactions with\\ncholesterol levels and effects on nerve cell death inde-\\npendent of its effects on plaque buildup. In 2000, four\\nnew AD-related regions in the human genome were\\nidentified, where one out of several hundred genes in\\neach of these regions may be a risk factor gene for AD.\\nThese genes, which are not yet identified, appear to\\nmake a contribution to the risk of developing late-\\nonset AD that is at least as important as APOE e4.\\nOther non-genetic factors have been studied in\\nrelation to the causes of AD. Inflammation of the\\nbrain may play a role in development of AD, and use\\nof nonsteroidal anti-inflammatory drugs (NSAIDs)\\nwere once thought to reduce the risk of developing\\nAD. Other agents once thought to reduce chances of\\ndementia are now thought to increase its risk. In 2002,\\nhormone replacement therapy(HRT), which combines\\nestrogen and progestogen, was found to double the\\nrisk of developing dementia in postmenopausal\\nwomen. Highly reactive molecular fragments called\\nfree radicals damage cells of all kinds, especially\\nbrain cells, which have smaller supplies of protective\\nantioxidants thought to protect against free radical\\ndamage. Vitamin E is one such antioxidant, and its\\nuse in AD may be of possible theoretical benefit.\\nWhile the ultimate cause or causes of Alzheimer’s\\ndisease still are unknown, there are several risk factors\\nthat increase a person’s likelihood of developing the\\ndisease. The most significant one is, of course, age;\\nolder people develop AD at much higher rates than\\nyounger ones. There is some evidence that strokes and\\nAD may be linked, with small strokes that go unde-\\ntected clinically contributing to the injury of neurons.\\nA 2003 Dutch study reported that symptomless, unno-\\nticed strokes could double the risk of AD and other\\ndementias. Blood cholesterol levels also may be\\nimportant. Scientists have shown that high blood\\ncholesterol levels in special breeds of genetically\\nengineered (transgenic) mice may increase the rate of\\nplaque deposition. There are also parallels between\\nAD and other progressive neurodegenerative disor-\\nders that cause dementia, including prion diseases,\\nParkinson’s disease, and Huntington’s disease.\\nNumerous epidemiological studies of populations\\nalso are being conducted to learn more about whether\\nand to what extent early life events, socioeconomic\\nfactors, and ethnicity have an impact on the develop-\\nment of AD. For example, a 2003 report showed that\\nthe more formal education a person has, the better his\\nor her memory is, despite presence of AD. Other stu-\\ndies have related education level or participation in\\nleisure activities such as playing cards or doing cross-\\nword puzzles to delayed onset of AD.\\nMany environmental factors have been suspected\\nof contributing to AD, but epidemiological popula-\\ntion studies have not borne out these links. Among\\nthese have been pollutants in drinking water, alumi-\\nnum from commercial products, and metal dental fill-\\nings. To date, none of these factors has been shown to\\ncause AD or increase its likelihood. Further research\\nmay yet turn up links to other environmental factors.\\nSymptoms\\nThe symptoms of Alzheimer’s disease begin gra-\\ndually, usually with memory lapses. Occasional mem-\\nory lapses are of course common to everyone, and do\\nnot by themselves signify any change in cognitive\\nfunction. The person with AD may begin with only\\nthe routine sort of memory lapse — forgetting where\\nthe car keys are — but progress to more profound or\\ndisturbing losses, such as forgetting that he or she can\\neven drive a car. Becoming lost or disoriented on a walk\\naround the neighborhood becomes more likely as the\\ndisease progresses. A person with AD may forget the\\nnames of family members, or forget what was said at\\nthe beginning of a sentence by the time he hears the end.\\nAs AD progresses, other symptoms appear,\\nincluding inability to perform routine tasks, loss of\\njudgment, and personality or behavior changes.\\nSome people with AD have trouble sleeping and may\\nsuffer from confusion or agitation in the evening\\n(‘‘sunsetting’’ or Sundowner’s Syndrome). In some\\ncases, people with AD repeat the same ideas, move-\\nments, words, or thoughts. In the final stages people\\nmay have severe problems with eating, communicat-\\ning, and controlling their bladder and bowel functions.\\nThe Alzheimer’s Association has developed a list\\nof 10 warning signs of AD. A person with several of\\nthese symptoms should see a physician for a thorough\\nevaluation:\\n/C15memory loss that affects job skills\\n/C15difficulty performing familiar tasks\\n/C15problems with language\\n/C15disorientation of time and place\\nGALE ENCYCLOPEDIA OF MEDICINE 143\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 173, 'page_label': '144'}, page_content='/C15poor or decreased judgment\\n/C15problems with abstract thinking\\n/C15misplacing things\\n/C15changes in mood or behavior\\n/C15changes in personality\\n/C15loss of initiative\\nOther types of dementia, including some that are\\nreversible, can cause similar symptoms. It is impor-\\ntant for the person with these symptoms to be evalu-\\nated by a professional who can weigh the possibility\\nthat his or her symptoms may have another cause.\\nApproximately 20% of those originally suspected of\\nhaving AD turn out to have some other disorder;\\nabout half of these cases are treatable.\\nDiagnosis\\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\\nin most cases after thorough testing, AD cannot be\\ndiagnosed definitively until autopsy examination of\\nthe brain for plaques and neurofibrillary tangles.\\nThe diagnosis of AD begins with a thorough\\nphysical exam and complete medical history. Except\\nin the disease’s earliest stages, accurate history from\\nfamily members or caregivers is essential. Since there\\nare both prescription and over-the-counter drugs\\nthat can cause the same mental changes as AD, a\\ncareful review of the patient’s drug, medicine, and\\nalcohol use is important. AD-like symptoms also\\ncan be provoked by other medical conditions, includ-\\ning tumors, infection, and dementia caused by mild\\nstrokes (multi-infarct dementia). These possibilities\\nmust be ruled out as well through appropriate blood\\nand urine tests, brain magnetic resonance imaging\\n(MRI), positron emission tomography (PET)o rs i n -\\ngle photon emission computed tomography (SPECT)\\nscans, tests of the brain’s electrical activity (electro-\\nencephalographs or EEGs), or other tests. Several\\ntypes of oral and written tests are used to aid in the\\nAD diagnosis and to follow its progression, including\\ntests of mental status, functional abilities, memory,\\nand concentration. Still, the neurologic exam is\\nnormal in most patients 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, or\\nmay be mistaken for it. (Delirium involves a decreased\\nconsciousness or awareness of one’s environment.)\\nDepression and memory loss both are common\\nin the elderly, and the combination of the often can\\nbe mistaken for AD. On the other hand, depression\\ncan be a risk factor for AD. A 2003 study showed that\\na history of depressive symptoms can be associated\\nwith nearly twice the risk of eventually developing\\nAD. Depression can be treated with drugs, although\\nsome antidepressants can worsen dementia if it is\\npresent, further complicating both diagnosis and\\ntreatment.\\nAn early and accurate diagnosis of AD is impor-\\ntant in developing strategies for managing symptoms\\nand for helping patients and their families planning\\nfor the future and pursuing care options while the\\npatient can still take part in the decision-making\\nprocess.\\nA genetic test for the APOE e4 gene is available,\\nbut is not used for diagnosis, since possessing even two\\ncopies does not ensure that a person will develop AD.\\nIn addition, access to genetic information could affect\\nthe insurability of a patient if disclosed, and also affect\\nemployment status and legal rights.\\nTreatment\\nAlzheimer’s disease is presently incurable. Recent\\nreports show that prompt intervention can slow decline\\nfrom AD. The use of medications mentioned below as\\nearly as possible in the course of AD can help people\\nwith the disease maintain independent function as long\\nas possible. The remaining treatment for a person with\\nAD is good nursing care, providing both physical and\\nemotional support for a person who is gradually able to\\ndo less and less for himself, and whose behavior is\\nbecoming more and more erratic. Modifications of the\\nhome to increase safety and security often are neces-\\nsary. The caregiver also needs support to prevent anger,\\ndespair, and burnout from becoming overwhelming.\\nBecoming familiar with the issues likely to lie ahead,\\nand considering the appropriate financial and legal\\nissues early on, can help both the patient and family\\ncope with the difficult process of the disease. Regular\\nmedical care by a practitioner with a non-defeatist\\nattitude toward AD is important so that illnesses such\\nas urinary or respiratory infections can be diagnosed\\nand treated properly, rather than being incorrectly\\nattributed to the inevitable decline seen in AD.\\nPeople with AD often are depressed or anxious,\\nand may suffer from sleeplessness, poornutrition, and\\ngeneral poor health. Each of these conditions is trea-\\ntable to some degree. It is important for the person\\nwith AD to eat well and continue to exercise.\\nProfessional advice from a nutritionist may be useful\\n144 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 174, 'page_label': '145'}, page_content='to provide healthy, easy-to-prepare meals. Finger\\nfoods may be preferable to those requiring utensils to\\nbe eaten. Regular exercise (supervised if necessary for\\nsafety) promotes overall health. A calm, structured\\nenvironment with simple orientation aids (such as\\ncalendars and clocks) may reduceanxiety and increase\\nsafety. Other psychiatric symptoms, such as depres-\\nsion, anxiety,hallucinations (seeing or hearing things\\nthat aren’t there), anddelusions (false beliefs) may be\\ntreated with drugs if necessary.\\nDrugs\\nAs of 2003, four drugs—tacrine (Cognex), done-\\npezil hydrochloride (Aricept), and rivastigmine\\n(Exelon)—have been approved by the FDA for its\\ntreatment. Tacrine has been shown to be effective for\\nimproving memory skills, but only in patients with\\nmild-to-moderate AD, and even then in less than half\\nof those who take it. Its beneficial effects are usually\\nmild and temporary, but it may delay the need for\\nnursing home admission. The most significant side\\neffect is an increase in a liver enzyme known as alanine\\naminotransferase, or ALT. Patients taking tacrine\\nmust have a weekly blood test to monitor their ALT\\nlevels. Other frequent side effects include nausea,\\nvomiting, diarrhea, abdominal pain,indigestion,a n d\\nskin rash. The cost of tacrine was about $125 per\\nmonth in early 1998, with additional costs for the\\nweekly blood monitoring. Despite its high cost, tacrine\\nappears to be cost-effective for those who respond to\\nit, since it may decrease the number of months a\\npatient needs nursing care. Donepezil is the drug\\nmost commonly used to treat mild to moderate symp-\\ntoms of AD, although it only helps some patients for\\nperiods of time ranging from months to about two\\nyears. Donepezil has two advantages over tacrine: it\\nhas fewer side effects, and it can be given once daily\\nrather than three times daily. Donepezil does not\\nappear to affect liver enzymes, and therefore does\\nnot require weekly blood tests. The frequency of\\nabdominal side effects is also lower. The monthly\\ncost is approximately the same. Rivastigmine,\\napproved for use in April of 2000, has been shown to\\nimprove the ability of patients to carry out daily activi-\\nties, such as eating and dressing, decrease behavioral\\nsymptoms such as delusions and agitation, and improve\\ncognitive functions such as thinking, memory, and\\nspeaking. The cost is similar to those of the other\\ntwo drugs. However, none of these three drugs stops\\nor reverses the progression of AD. Galantamine\\n(Reminyl) works in the early and moderates stages\\nof AD. It has fewer side effects than other drugs,\\nwith the exception of donepezil and must be taken\\ntwice a day. Three other drugs were being tested for\\nAD treatment in mid-2003.\\nEstrogen, the female sex hormone, is widely pre-\\nscribed for post-menopausal women to preventosteo-\\nporosis. Studies once showed that estrogen was\\nbeneficial to women with AD, but in 2003, a large\\nclinical trial called the Women’s Health Initiative\\nshowed dementia among other negative effects of\\ncombined estrogen therapy.\\nPreliminary studies once suggested a reduced risk\\nfor developing AD in elderly people who regularly used\\nnonsteroidal anti-inflammatory drugs (NSAIDs),\\nincluding aspirin, ibuprofen, and naproxen, although\\nnot acetaminophen. However, an important study\\npublished in 2003 showed that NSAIDs were not effec-\\ntive in preventing or slowing the progression of AD.\\nThe study authors recommended that people stop\\ntaking NSAIDs to slow dementia.\\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\\ntissue culture. Therefore, research is being conducted\\nto see whether antioxidants may delay or prevent AD.\\nAnother antioxidant, vitamin E, is also thought\\nto delay AD onset. Hoever, it is not yet clear whether\\nthis is due to the specific action of vitamin E on brain\\ncells, or to an increase in the overall health of those\\ntaking it.\\nDrugs such as antidepressants, anti-psychotics,\\nand sedatives are used to treat the behavioral symp-\\ntoms (agitation, aggression, wandering, and sleep dis-\\norders) of AD. Research is being conducted to search\\nfor better treatments, including non-drug approaches\\nfor AD patients.\\nNursing care and safety\\nThe person with Alzheimer’s disease will gradu-\\nally lose the ability to dress, groom, feed, bathe, or use\\nthe toilet by himself; in the later stages of the disease,\\nhe may be unable to move or speak. In addition, the\\nperson’s behavior becomes increasingly erratic. A\\ntendency to wander may make it difficult to leave\\nhim unattended for even a few minutes and make\\neven the home a potentially dangerous place. In\\naddition, some people with AD may exhibit inap-\\npropriate sexual behaviors.\\nThe nursing care required for a person with AD is\\nwell within the abilities of most people to learn. The\\ndifficulty for many caregivers comes in the constant\\nbut unpredictable nature of the demands put on them.\\nIn addition, the personality changes undergone by a\\nGALE ENCYCLOPEDIA OF MEDICINE 145\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 175, 'page_label': '146'}, page_content='person with AD can be heartbreaking for family mem-\\nbers as a loved one deteriorates, seeming to become a\\ndifferent person. Not all people with AD develop\\nnegative behaviors. Some become quite gentle, and\\nspend increasing amounts of 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\\nmore common. Caregivers, especially spouses, may\\nfind these changes socially embarrassing and difficult\\nto cope with. The caregiver usually will need to spend\\nincreasing amounts of time on grooming to compensate\\nfor the loss of attention from the patient, although\\nsome adjustment of expectations (while maintaining\\ncleanliness) is often needed as the disease progresses.\\nProper nutrition is important for a person with\\nAD, and may require assisted feeding early on, to\\nmake sure the person is taking in enough nutrients.\\nLater on, as movement and swallowing become diffi-\\ncult, a feeding tube may be placed into the stomach\\nthrough the abdominal wall. A feeding tube requires\\nmore attention, but is generally easy to care for if the\\npatient is not resistant to its use.\\nFor many caregivers, incontinence becomes the\\nmost difficult problem to deal with at home, and is a\\nprincipal reason for pursuing nursing home care. In\\nthe early stages, limiting fluid intake and increasing\\nthe frequency of toileting can help. Careful attention\\nto hygiene is important to prevent skin irritation and\\ninfection from soiled clothing.\\nPersons with dementia must deal with six basic\\nsafety concerns: injury from falls, injury from ingest-\\ning dangerous substances, leaving the home and get-\\nting lost, injury to self or others from sharp objects,\\nfire orburns, and the inability to respond rapidly to\\ncrisis situations. In all cases, a person diagnosed with\\nAD should no longer be allowed to drive, because of\\nthe increased potential for accidents and the increased\\nlikelihood of wandering very far from home while\\ndisoriented. In the home, simple measures such as\\ngrab bars in the bathroom, bed rails on the bed, and\\neasily negotiable passageways can greatly increase\\nsafety. Electrical appliances should be unplugged and\\nput away when not in use, and matches, lighters, kni-\\nves, or weapons should be stored safely out of reach.\\nThe hot water heater temperature may be set lower\\nto 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\\nperiodically reevaluate the physical safety of the home\\nand introduce 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\\ntypes of illnesses. This type of caregiving also has a\\ngreater impact in terms of employment complications,\\ncaregiver strain, mental and physical health problems,\\ntime for leisure and other family members, and family\\nconflict than do other types of caregiving. It is common\\nfor AD caregivers to develop feelings of anger, resent-\\nment, guilt, and hopelessness, in addition to the sorrow\\nthey feel for their loved one and for themselves.\\nDepression is an extremely common consequence of\\nbeing a full-time caregiver for a person with AD.\\nSupport groups are an important way to deal with the\\nstress of caregiving. Becoming a member of an AD\\ncaregivers’ support group can be one of the most\\nimportant things a family member does, not only for\\nhim or herself, but for the person with AD as well. The\\nlocation and contact numbers for AD caregiver sup-\\nport groups are available from the Alzheimer’s\\nAssociation; they also may be available through a\\nlocal social service agency, the patient’s physician, or\\npharmaceutical companies that manufacture the drugs\\nused 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\\nrelieve some of the burden of around-the-clock care\\nfor a person with AD. Personal care assistants, either\\nvolunteer or paid, may be available through local social\\nservice agencies. Adult daycare facilities are becoming\\nincreasingly common. Meal delivery, shopping assis-\\ntance, or respite care may be available as well.\\nP r o v i d i n gt h et o t a lc a r er e q u i r e db yap e r s o n\\nwith late-stage AD can become an overwhelming\\nburden for a family, even with outside help. At this\\nstage, many families consider nursing home care.\\nThis decision often is one of the most difficult for\\nthe family, since it is often seen as an abandonment of\\nthe loved one and a failure of the family. Careful\\ncounseling with a sympathetic physician, clergy, or\\no t h e rt r u s t e da d v i s e rm a ye a s et h ed i f f i c u l t i e so ft h i s\\ntransition. Selecting a nursing home may require a\\ndifficult balancing of cost, services, location, and\\navailability. Keeping the entire family involved in\\nthe decision may help prevent further stress from\\ndeveloping later on.\\n146 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 176, 'page_label': '147'}, page_content='Several federal government programs may ease the\\ncost of caring for a person with AD, including Social\\nSecurity Disability, Medicare, and Supplemental\\nSecurity Income. Each of these programs may provide\\nsome assistance for care, medication, or other costs,\\nbut none of them will pay for nursing home care inde-\\nfinitely. Medicaid is a state-funded program that may\\nprovide for some or all of the cost of nursing home care,\\nalthough there are important restrictions. Details of\\nthe benefits and eligibility requirements of these pro-\\ngrams are available through the local Social Security\\nor Medicaid office, or from local social service agencies.\\nPrivate long-term care insurance, special ‘‘reverse\\nmortgages,’’ viatical insurance, and other financial\\ndevices are other ways of paying for care for those\\nwith the appropriate financial situations. Further\\ninformation on these options may be available\\nthrough resources listed below.\\nAlternative treatment\\nSeveral substances are currently being tested\\nfor their ability to slow the progress of Alzheimer’s\\ndisease. These include acetylcarnitine, a supplement\\nthat acts on the cellular energy structures known as\\nmitochondria. Ginkgo extract, derived from the leaves\\nof theGinkgo biloba tree, appears to have antioxidant\\nas well as anti-inflammatory and anticoagulant pro-\\nperties. Ginkgo extract has been used for many years\\nin China and is widely prescribed in Europe for treat-\\nment of circulatory problems. A 1997 study of patients\\nwith dementia seemed to show that ginkgo extract\\ncould improve their symptoms, though the study was\\ncriticized for certain flaws in its method. Large scale\\nfollow-up studies are being conducted to determine\\nwhether Ginkgo extract can prevent or delay the\\ndevelopment of AD. Ginkgo extract is available in\\nmany health food or nutritional supplement stores.\\nSome alternative practitioners also advise people\\nwith AD to take supplements of phosphatidylcholine,\\nvitamin B\\n12, gotu kola, ginseng, St. John˜os Wort,\\nrosemary, saiko-keishi-to-shakuyaku (A Japanese\\nherbal 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 infec-\\ntion, includingpneumonia. In addition, other diseases\\ncommon in old age–cancer, stroke, and heart disease–\\nmay lead to more severe consequences in a person with\\nAD. On average, people with AD live eight years past\\ntheir diagnosis, with a range from one to 20 years.\\nPrevention\\nCurrently, there is no sure way to prevent\\nAlzheimer’s disease. treatments discussed above may\\neventually be proven to reduce the risk of developing\\nthe disease. Avoiding risks such as hormone replace-\\nment therapy may help prevent development of 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\\nfrom cells but before it has a chance to aggregate\\ninto insoluble plaques. There also are promising\\nstudies being conducted to develop an AD vaccine,\\nwhere immune responses may result in the elimination\\nof the formation of amyloid plaques.\\nThe Alzheimer’s Disease Research Centers\\n(ADCs) program promotes research, training and\\neducation, technology transfer, and multicenter and\\ncooperative studies in AD, other dementias, and nor-\\nmal brain aging. Each ADC enrolls and performs\\nstudies on AD patients and healthy older people.\\nPersons can participate in research protocols and\\nclinical drug trials at these centers. Data from the\\nADCs as well as from other sources are coordinated\\nand made available for use by researchers at the\\nNational Alzheimer’s Coor dinating Center, estab-\\nlished in 1999.\\nResources\\nBOOKS\\nCohen, Donna, and Carl Eisdorfer.The Loss of Self: A\\nFamily Resource for the Care of Alzheimer’s Disease and\\nRelated Disorders. Revised. NewYork: W.W. Norton &\\nCompany, 2001.\\nGeldmacher, David S. Contemporary Diagnosis and\\nManagement ofAlzheimer’s Disease. Newtown,\\nPA: Associates in Medical Marketing Co., Inc.,\\n2001.\\nGruetzner, Howard.Alzheimer’s: A Caregiver ˜os Guideand\\nSourcebook. 3rd ed. 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 MemoryLoss\\nin Later Life. New York: Warner Books, 2001.\\nTeitel, Rosette, and Marc L. Gordon.The Handholder ˜os\\nHandbook: A Guide for Caregivers of Alzheimer ˜os and\\nother Dementias. NewBrunswick, NJ: Rutgers\\nUniversity Press, 2001.\\nPERIODICALS\\n‘‘Alzheimer’s Could be Linked to Depression.’’GP (May 26,\\n2003): 4.\\n‘‘Alzheimer’s Could Reduced by Education.’’The Lancet\\n(June 28, 2003): 2215.\\nGALE ENCYCLOPEDIA OF MEDICINE 147\\nAlzheimer’s disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 177, 'page_label': '148'}, page_content='‘‘Contrary to Some Earlier Results, New Study Shows\\nNSAIDs Do Not Slow Progression of Alzheimer’s\\nDisease.’’ The Brown University Geriatric\\nPsychopharmacology Update (July 2003): 1.\\nGitlin, L.N., and M. Corcoran. ‘‘Making Homes Safer:\\nEnvironmental Adaptations for People with\\nDementia.’’ Alzheimer’s Care Quarterly 1 (2000): 50-58.\\nHelmuth, L. ‘‘Alzheimer’s Congress: Further Progress on aB-\\nAmyloid Vaccine.’’Science 289, no. 5476 (2000): 375.\\nJosefson, Deborah. ‘‘Latests HRT Trial Results Show Risk\\nof Dementia.’’British Medical Journal (June 7, 2003):\\n1232.\\nMcReady, Norah. ‘‘Prompt Intervention May Slow\\nAlzheimer’s Decline.’’Family Practice News (May 1,\\n2003): 32-41.\\nNaditz, Alan. ‘‘Deeply Affected: As the Nation Ages,\\nAlzheimer’s Will Strike More People Close to Us.’’\\nContemporary Long Term Care (July 2003): 20-23.\\n‘‘Researchers Believe ‘‘Silent’’ Strokes Boost Risk.’’GP\\n(April 14, 2003): 9.\\nOTHER\\nAlzheimer’s Disease Books and Videotapes. .\\nNational Institute on Aging, National Institutes of Health.\\n2000: Progress Report on Alzheimer’s Disease - Taking\\nthe Next Steps. NIH Publication No. 4859 (2000).\\n.\\nJudith Sims\\nTeresa G. Odle\\nAmbiguous genitals see Intersex states\\nAmblyopia\\nDefinition\\nAmblyopia is an uncorrectable decrease in vision in\\none or both eyes with no apparent structural abnor-\\nmality seen to explain it. It is a diagnosis of exclusion,\\nmeaning that when a decrease in vision is detected,\\nother causes must be ruled out. Once no other cause is\\nfound, amblyopia is the diagnosis. Generally, a differ-\\nence of two lines or more (on an eye-chart test of visual\\nacuity) between the two eyes or a best corrected vision\\nof 20/30 or worse would be defined as amblyopia. For\\nexample, if someone has 20/20 vision with the right eye\\nand only 20/40 with the left, and the left eye cannot\\nachieve better vision with corrective lenses, the left eye\\nis 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\\nis the most common cause of impaired vision in child-\\nren, affecting nearly three out of every 100 people or\\n2-4% of the population. Vision is a combination of the\\nclarity of the images of the eyes (visual acuity) and the\\nprocessing of those images by the brain. If the images\\nproduced by the two eyes are substantially different,\\nthe brain may not be able to fuse the images. Instead of\\nseeing two different images or double vision (diplo-\\npia), the brain suppresses the blurrier image. This\\nsuppression can lead to amblyopia. During the first\\nfew years of life, preferring one eye over the other may\\nlead to poor visual development in the blurrier eye.\\nCauses and symptoms\\nSome of the major causes of amblyopia are as\\nfollows:\\n/C15Strabismus. A misalignment of the eyes (strabismus)\\nis the most common cause of functional amblyopia.\\nThe two eyes are looking in two different directions at\\nthe same time. The brain is sent two different images\\nand this causes confusion. Images from the misaligned\\nor ‘‘crossed’’ eye are turned off to avoid double vision.\\n/C15Anisometropia. 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\\ndifference of prescriptions between the two eyes).\\nFor example, one eye may be more nearsighted than\\nthe other eye, or one eye may be farsighted and the\\nother eye nearsighted. Because the brain cannot fuse\\nthe two dissimilar images, the brain will suppress the\\nblurrier image, causing the eye to become amblyopic.\\n/C15Cataract. Clouding of the lens of the eye will cause\\nthe image to be blurrier than the other eye. The brain\\n‘‘prefers’’ the clearer image. The eye with the cataract\\nmay become amblyopic.\\n/C15Ptosis. This is the drooping of the upper eyelid. If\\nlight cannot enter the eye because of the drooping lid,\\nthe eye is essentially not being used. This can lead to\\namblyopia.\\n/C15Nutrition. A type of organic amblyopia in which\\nnutritional deficiencies or chemical toxicity may\\nresult in amblyopia. Alcohol, tobacco, or a deficiency\\nin the Bvitamins may result in toxic amblyopia.\\n/C15Heredity. Amblyopia can run in families.\\nBarring the presence of strabismus or ptosis,\\nchildren may or may not show signs of amblyopia.\\n148 GALE ENCYCLOPEDIA OF MEDICINE\\nAmblyopia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 178, 'page_label': '149'}, page_content='Children may hold their heads at an angle while trying\\nto favor the eye with normal vision. They may have\\ntrouble seeing or reaching for things when approached\\nfrom the side of the amblyopic eye. Parents should\\nsee if one side of approach is preferred by the child\\nor infant. If an infant’s good eye is covered, the child\\nmay 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\\nhave their first vision examination, their eyes can, in\\nactuality, be examined at any age, even at one day of life.\\nSome recommend that children have their vision\\nchecked by their pediatrician, family physician,\\nophthalmologist, or optometrist at or before six\\nmonths of age. Others recommend testing by at least\\nthe child’s fourth birthday. There may be a ‘‘critical\\nperiod’’ in the development of vision, and amblyopia\\nmay not be treatable after age eight or nine. The earlier\\namblyopia is found, the better the possible outcome.\\nMost physicians test vision as part of a child’s medical\\nexamination. If there is any sign of an eye problem,\\nthey may refer a child to an eye specialist.\\nThere are objective methods, such as retinoscopy,\\nto measure the refractive status of the eyes. This can\\nhelp determine anisometropia. In retinoscopy, a hand-\\nheld instrument is used to shine a light in the child’s (or\\ninfant’s) eyes. Using hand-held lenses, a rough pre-\\nscription can be obtained. Visual acuity can be deter-\\nmined using a variety of methods. Many different eye\\ncharts are available (e.g., tumbling E, pictures, or\\nletters). In amblyopia, single letters are easier to\\nrecognize than when a whole line is shown. This is\\ncalled the ‘‘crowding effect’’ and helps in diagnosing\\namblyopia. Neutral density filters may also be held\\nover the eye to aid in the diagnosis. Sometimes visual\\nfields to determine defects in the area of vision will be\\nperformed. Color vision testing may also be per-\\nformed. Again, it must be emphasized that amblyopia\\nis a diagnosis of exclusion. Visual or life-threatening\\nproblems can also cause a decrease in vision. An exam-\\nination 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\\neye (forcing the amblyopic eye to work) and the\\namblyopic eye. If the good eye is constantly patched,\\nit too may become amblyopic because of disuse. The\\ntreatment plan should be discussed with the doctor to\\nfully understand how long the patch will be on. When\\npatched, eye exercises may be prescribed to force the\\namblyopic eye to focus and work. This is called vision\\ntherapy or vision training (eye exercises). Even after\\nvision has been restored in the weak eye, part-time\\npatching may be required over a period of years to\\nmaintain 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\\nMan with a lazy eye.(Custom Medical Stock Photo. Reproduced\\nby permission.)\\nKEY TERMS\\nAnisometropia— An eye condition in which there\\nis an inequality of vision between the two eyes.\\nThere may be unequal amounts of nearsightedness,\\nfarsightedness, or astigmatism, so that one eye will\\nbe in focus while the other will not.\\nCataract— Cloudiness of the eye’s natural lens.\\nOcculsion therapy— A type of treatment for\\namblyopia in which the good eye is patched for a\\nperiod of time. This forces the weaker eye to be\\nused.\\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 sharpness\\nof vision.GALE ENCYCLOPEDIA OF MEDICINE 149\\nAmblyopia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 179, 'page_label': '150'}, page_content='are errors in refraction. Surgery or vision training may\\nbe necessary in the case of strabismus. Better nutrition\\nis indicated 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.\\nHowever, treatment may be successful in older child-\\nren–even adults. Success in the treatment of amblyo-\\npia also depends upon how severe the amblyopia is,\\nthe specific type of amblyopia, and patient compli-\\nance. It is important to diagnose and treat amblyopia\\nearly because significant vision loss can occur if left\\nuntreated. The best outcomes result from early diag-\\nnosis and treatment.\\nPrevention\\nTo protect their child’s vision, parents must be\\naware of amblyopia as a potential problem. This\\nawareness may encourage parents to take young chil-\\ndren for vision exams early on in life–certainly before\\nschool age. Proper nutrition is important in the avoid-\\nance of toxic amblyopia.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street,\\nP.O. Box 7424, San Francisco, CA 94120-7424.\\n.\\nAmerican Optometric Association. 243 North Lindbergh\\nBlvd., St. Louis, MO 63141. (314) 991-4100. .\\nLorraine Steefel, RN\\nAmebiasis\\nDefinition\\nAmebiasis is an infectious disease caused by a\\nparasitic one-celled microorganism (protozoan) called\\nEntamoeba histolytica . Persons with amebiasis may\\nexperience a wide range of symptoms, includingdiar-\\nrhea, fever, and cramps. The disease may also affect\\nthe intestines, liver, or other parts of the body.\\nDescription\\nAmebiasis, also known as amebicdysentery, 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 subtro-\\npical areas where living conditions are crowded, with\\ninadequate sanitation. Although most cases of ame-\\nbiasis occur in persons who carry the disease but do\\nnot exhibit any symptoms (asymptomatic), as many as\\n100,000 people die of amebiasis each year. In the\\nUnited States, between 1 and 5% of the general popu-\\nlation will develop amebiasis in any given year, while\\nmale homosexuals, migrant workers, institutionalized\\npeople, and recent immigrants develop amebiasis at a\\nhigher rate.\\nHuman beings are the only known host of the\\namebiasis organism, and all groups of people, regardless\\nof age or sex, can become affected. Amebiasis is primar-\\nily spread in food and water that has been contaminated\\nby human feces but is also spread by person-to-person\\ncontact. The number of cases is typically limited, but\\nregional outbreaks can occur in areas where human\\nfeces are used as fertilizer for crops, or in cities with\\nwater supplies contaminated with human feces.\\nCauses and symptoms\\nRecently, it has been discovered that persons\\nwith symptom-causing amebiasis are infected with\\nEntamoeba histolytica , and those individuals who\\nexhibit no symptoms are actually infected with an\\nalmost identical-looking ameba called Entamoeba\\ndispar. During their life cycles, the amebas exist in\\ntwo very different forms: the infective cyst or\\ncapsuled form, which cannot move but can survive\\noutside the human body because of its protective\\ncovering, and the disease-producing form, the\\ntrophozoite, which although capable of moving, can-\\nnot survive once excreted in the feces and, therefore,\\ncannot infect others. The disease is most commonly\\ntransmitted when a person eats food or drinks water\\ncontaining E. histolytica cysts from human feces. In\\nthe digestive tract the cysts are transported to the\\nintestine where the walls of the cysts are broken\\nopen by digestive secretions, releasing the mobile\\ntrophozoites. Once released within the intestine, the\\ntrophozoites multiply by feeding on intestinal bac-\\nteria or by invading the lining of the large intestine.\\nWithin the lining of the large intestine, the\\ntrophozoites secrete a substance that destroys intest-\\ninal tissue and creates a distinctive bottle-shaped\\nsore (ulcer). The trophozoites may remain inside the\\nintestine, in the intestinal wall, or may break through\\n150 GALE ENCYCLOPEDIA OF MEDICINE\\nAmebiasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 180, 'page_label': '151'}, page_content='the intestinal wall and be carried by the blood to the\\nliver, lungs, brain, or other organs. Trophozoites that\\nremain in the intestines eventually form new cysts\\nthat are carried through the digestive tract and\\nexcreted in the feces. Under favorable temperature\\nand humidity conditions, the cysts can survive in\\nsoil 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,\\nand people whose immune systems may be compressed,\\nsuch ascancer or AIDS patients and those individuals\\ntaking prescription medications that suppress the\\nimmune system, are at a greater risk for developing a\\nsevere infection.\\nThe signs and symptoms of amebiasis vary\\naccording to the location and severity of the infection\\nand are classified 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\\nof infecting others by person-to-person contact or by\\ncontaminating food or water with cysts that others\\nmay ingest, for example, by preparing food with\\nunwashed hands.\\nCHRONIC NON-DYSENTERIC INFECTION. Indivi-\\nduals may experience symptoms over a long period\\nof time during a chronic amebiasis infection and\\nexperience recurrent episodes of diarrhea that last\\nfrom one to four weeks and recur over a period of\\nyears. These patients may also suffer from abdominal\\ncramps, fatigue, and weight loss.\\nAMEBIC DYSENTERY. In severe cases of intestinal\\namebiasis, the organism invades the lining of the\\nintestine, producing sores(ulcers), bloody diarrhea,\\nsevere abdominal cramps, vomiting,c h i l l s ,a n d\\nfevers as high as 104-1058F (40-40.68C). In addition,\\nac a s eo fa c u t ea m e b i cd y s entery may cause compli-\\ncations, including inflam mation of the appendix\\n(appendicitis ), a tear in the intestinal wall (perfora-\\ntion), or a sudden, severe inflammation of the colon\\n(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 symp-\\ntoms that mimic cancer or other intestinal diseases.\\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.)\\nKEY TERMS\\nAmeboma— A mass of tissue that can develop on\\nthe wall of the colon in response to amebic\\ninfection.\\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-shaped\\norgan, such as the bowel.\\nProtozoan— A single-celled, usually microscopic\\norganism that is eukaryotic and, therefore, different\\nfrom bacteria (prokaryotic).\\nGALE ENCYCLOPEDIA OF MEDICINE 151\\nAmebiasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 181, 'page_label': '152'}, page_content='PERIANAL ULCERS. Intestinal amebiasis may pro-\\nduce skin infections in the area around the patient’s\\nanus (perianal). These ulcerated areas have a\\n‘‘punched-out’’ appearanceand are painfultothe touch.\\nExtraintestinal amebiasis\\nExtraintestinal amebiasis accounts for approxi-\\nmately 10% of all reported amebiasis cases and includes\\nall forms of the disease that affect other organs.\\nThe most common form of extraintestinal amebia-\\nsis is amebicabscess of the liver. In the United States,\\namebic liver abscesses occur most frequently in young\\nHispanic adults. An amebic liver abscess can result\\nfrom direct infection of the liver byE. histolytica or as\\na complication of intestinal amebiasis. Patients with an\\namebic abscess of the liver complain ofpain in the chest\\nor abdomen, fever,nausea, and tenderness on the right\\nside directly above the liver.\\nOther forms of extraintestinal amebiasis, though\\nrare, include infections of the lungs, chest cavity,\\nbrain, or genitals. These are extremely serious and\\nhave a relatively high mortality rate.\\nDiagnosis\\nDiagnosis of amebiasis is complicated, partly\\nbecause the disease can affect several areas of the\\nbody and can range from exhibiting few, if any, symp-\\ntoms to being severe, or even life-threatening. In most\\ncases, a physician will consider a diagnosis of amebia-\\nsis when a patient has a combination of symptoms, in\\nparticular, diarrhea and a possible history of recent\\nexposure to amebiasis through travel, contact with\\ninfected persons, or anal intercourse.\\nIt is vital to distinguish between amebiasis and\\nanother disease, inflammatory bowel disease (IBD)\\nthat produces similar symptoms because, if diagnosed\\nincorrectly, drugs that are given to treat IBD can\\nencourage the growth and spread of the amebiasis\\norganism. Because of the serious consequences of\\nmisdiagnosis, potential cases of IBD must be con-\\nfirmed with multiple stool samples and blood tests,\\nand a procedure involving a visual inspection of the\\nintestinal wall using a thin lighted, tubular instrument\\n(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\\nstool sample for the presence of cysts and/or tropho-\\nzoites ofE. histolytica and not one of the many other\\nintestinal amebas that are often found but that do not\\ncause disease. A series of three stool tests is approxi-\\nmately 90% accurate in confirming a diagnosis of\\namebic dysentery. Unfortunately, however, the stool\\ntest is not useful in diagnosing amebomas or extra-\\nintestinal infections.\\nSigmoidoscopy\\nSigmoidoscopy is a useful diagnostic procedure in\\nwhich a thin, flexible, lighted instrument, called a\\nsigmoidoscope, is used to visually examine the lower\\npart of the large intestine for amebic ulcers and take\\ntissue or fluid samples from the intestinal lining.\\nBlood tests\\nAlthough tests designed to detect a specific\\nprotein produced in response to amebiasis infection\\n(antibody) are capable of detecting only about 10%\\nof cases of mild amebiasis, these tests are extremely\\nuseful in confirming 95% of dysentery diagnoses\\nand 98% of liver abscess diagnoses. Blood serum will\\nusually test positive for antibody within a week of\\nsymptom onset. Blood testing, however, cannot\\nalways distinguish between a current or past infection\\nsince the antibodies may be detectable in the blood\\nfor as long as 10 years following initial infection.\\nImaging studies\\nA number of sophisticated imaging techniques,\\nsuch as computed tomography scans (CT), magnetic\\nresonance imaging (MRI), and ultrasound, can be\\nused to determine whether a liver abscess is present.\\nOnce located, a physician may then use a fine needle\\nto withdraw a sample of tissue to determine whether\\nthe abscess is indeed caused by an amebic infection.\\nTreatment\\nAsymptomatic or mild cases of amebiasis may\\nrequire no treatment. However, because of the\\npotential for disease spread, amebiasis is generally\\ntreated with a medication to kill the disease-causing\\namebas. More severe cases of amebic dysentery are\\nadditionally treated by replacing lost fluid and\\nblood. Patients with an amebic liver abscess will\\nalso require hospitalization and bed rest. For those\\ncases of extraintestinal amebiasis, treatment can be\\ncomplicated because different drugs may be required\\nto eliminate the parasite, based on the location of\\nthe infection within the body. Drugs used to treat\\namebiasis, called amebicides, are divided into two\\ncategories:\\n152 GALE ENCYCLOPEDIA OF MEDICINE\\nAmebiasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 182, 'page_label': '153'}, page_content='Luminal amebicides\\nThese drugs get their name because they act on\\norganisms within the inner cavity (lumen) of the\\nbowel. They include diloxanide furoate, iodoquinol,\\nmetronidazole, and paromomycin.\\nTissue amebicides\\nTissue amebicides are used to treat infections in\\nthe liver and other body tissues and include emetine,\\ndehydroemetine, metronidazole, and chloroquine.\\nBecause these drugs have potentially serious side\\neffects, patients given emetine or dehydroemetine\\nrequire bed rest and heart monitoring. Chloroquine\\nhas been found to be the most useful drug for treating\\namebic liver abscess. Patients taking metronidazole\\nmust avoid alcohol because the drug-alcohol combi-\\nnation causes nausea, vomiting, andheadache.\\nMost patients are given a combination of luminal\\nand tissue amebicides over a treatment period of seven\\nto ten days. Follow-up care includes periodic stool\\nexaminations beginning two to four weeks after the\\nend of medication treatment to check the effectiveness\\nof drug therapy.\\nPrognosis\\nThe prognosis depends on the location of the\\ninfection and the patient’s general health prior to\\ninfection. The prognosis is generally good, although\\nthe mortality rate is higher for patients with ameboma,\\nperforation of the bowel, and liver infection. Patients\\nwho develop fulminant colitis have the most serious\\nprognosis, with over 50% mortality.\\nPrevention\\nThere are no immunization procedures or medica-\\ntions that can be taken prior to potential exposure to\\nprevent amebiasis. Moreover, people who have had\\nthe disease can become reinfected. Prevention requires\\neffective personal and community hygiene.\\nSpecific safeguards include the following:\\n/C15Purification of drinking water. Water can be purified\\nby filtering, boiling, or treatment with iodine.\\n/C15Proper food handling. Measures include protecting\\nfood from contamination by flies, cooking food\\nproperly, washing one’s hands after using the bath-\\nroom and before cooking or eating, and avoiding\\nfoods that cannot be cooked or peeled when travel-\\ning in countries with high rates of amebiasis.\\n/C15Careful disposal of human feces.\\n/C15Monitoring the contacts of amebiasis patients. The\\nstools of family members and sexual partners of\\ninfected persons should be tested for the presence of\\ncysts or trophozoites.\\nResources\\nBOOKS\\nFriedman, Lawrence S. ‘‘Liver, Biliary Tract, & Pancreas.’’\\nIn Current Medical Diagnosis and Treatment, 1998 ,\\nedited by Stephen McPhee, et al., 37th ed. Stamford:\\nAppleton & Lange, 1997.\\nRebecca J. Frey, PhD\\nAmebic dysentery see Amebiasis\\nAmenorrhea\\nDefinition\\nThe absence of menstrual periods is called ame-\\nnorrhea. Primary amenorrhea is the failure to start\\nhaving a period by the age of 16. Secondary amenor-\\nrhea is more common and refers to either the tempor-\\nary or permanent ending of periods in a woman who\\nhas menstruated normally in the past. Many women\\nmiss a period occasionally. Amenorrhea occurs if a\\nwoman misses three or more periods in a row.\\nDescription\\nThe absence of menstrual periods is a symptom,\\nnot a disease. While the average age that menstruation\\nbegins is 12, the range varies. The incidence of primary\\namenorrhea 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 gym-\\nnasts, who typically exercise strenuously and eat poorly.\\nCauses and symptoms\\nAmenorrhea can have many causes. Primary ame-\\nnorrhea can be the result of hormonal imbalances,\\npsychiatric disorders, eating disorders, malnutrition,\\nexcessive thinness or fatness, rapid weight loss, body\\nfat content too low, and excessive physical condition-\\ning. Intense physical training prior topuberty can delay\\nmenarche (the onset of menstruation). Every year of\\ntraining can delay menarche for up to five months.\\nGALE ENCYCLOPEDIA OF MEDICINE 153\\nAmenorrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 183, 'page_label': '154'}, page_content='Some medications such as anti-depressants, tranquili-\\nzers, steroids, and heroin can induce amenorrhea.\\nPrimary amenorrhea\\nHowever, the main cause is a delay in the begin-\\nning of puberty either from natural reasons (such as\\nheredity or poornutrition) or because of a problem in\\nthe endocrine system, such as a pituitary tumor or\\nhypothyroidism. An obstructed flow tract or inflam-\\nmation in the uterus may be the presenting indications\\nof an underlying metabolic, endocrine, congenital or\\ngynecological disorder.\\nTypical causes of primary amenorrhea include:\\n/C15excessive physical activity\\n/C15drastic weight loss (such as occurs in anorexia or\\nbulimia)\\n/C15extreme obesity\\n/C15drugs (antidepressants or tranquilizers)\\n/C15chronic illness\\n/C15turner’s syndrome. (A chromosomal problem in place\\nat birth, relevant only in cases of primary amenorrhea)\\n/C15the absence of a vagina or a uterus\\n/C15imperforate hymen (lack of an opening to allow the\\nmenstrual blood through)\\nSecondary amenorrhea\\nSome of the causes of primary amenorrhea can\\nalso cause secondary amenorrhea – strenuous physical\\nactivity, excessive weight loss, use of antidepressants\\nor tranquilizers, in particular. In adolescents,preg-\\nnancy and stress are two major causes. Missed periods\\nare usually caused in adolescents by stress and changes\\nin environment. Adolescents are especially prone to\\nirregular periods with fevers, weight loss, changes in\\nenvironment, or increased physical or athletic activity.\\nHowever, any cessation of periods for four months\\nshould be evaluated.\\nThe most common cause of seconardy amenor-\\nrhea is pregnancy. Also, a woman’s periods may halt\\ntemporarily after she stops taking birth control pills.\\nThis temporary halt usually lasts only for a month or\\ntwo, though in some cases it can last for a year or\\nmore. Secondary amenorrhea may also be related to\\nhormonal problems related to stress, depression,anor-\\nexia nervosa or drugs, or it may be caused by any\\ncondition affecting the ovaries, such as a tumor. The\\ncessation of menstruation also occurs permanently\\nafter menopause or ahysterectomy.\\nDiagnosis\\nIt may be difficult to find the cause of amenor-\\nrhea, but the exam should start with a pregnancy test;\\npregnancy needs to be ruled out whenever a woman’s\\nperiod is two to three weeks overdue. Androgen\\nexcess, estrogen deficiency, or other problems with\\nthe endocrine system need to be checked. Prolactin in\\nthe blood and the thyroid stimulating hormone (TSH)\\nshould also be checked.\\nThe diagnosis usually includes a patient history\\nand a physical exam (including a pelvic exam). If a\\nwoman has missed three or more periods in a row, a\\nphysician may recommend blood tests to measure\\nhormone levels, a scan of the skull to rule out the\\npossibility of a pituitary tumor, and ultrasound scans\\nof the abdomen and pelvis to rule out a tumor of the\\nadrenal gland or ovary.\\nTreatment\\nTreatment of amenorrhea depends on the cause.\\nPrimary amenorrhea often requires no treatment, but\\nit’salwaysimportanttodiscoverthecauseoftheproblem\\nin any case. Not all conditions can be treated, but any\\nunderlying condition that is treatable should be treated.\\nIf a hormonal imbalance is the problem, progester-\\none for one to two weeks every month or two may\\ncorrect the problem. With polycystic ovary syndrome,\\nbirth control pills are often prescribed. A pituitary\\ntumor is treated with bromocriptine, a drug that reduces\\ncertain hormone (prolactin) secretions. Weight loss may\\nbring on a period in an obese woman. Easing up on\\nexcessive exercise and eating a proper diet may bring\\non periods in teen athletes. In very rare cases, surgery\\nmay be needed for women with ovarian or uterine cysts.\\nPrognosis\\nProlonged amenorrhea can lead toinfertility and\\nother medical problems such asosteoporosis (thinning\\nof the bones). If the halt in the normal period is caused\\nKEY TERMS\\nHymen— Membrane that stretches across the open-\\ning 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.\\n154 GALE ENCYCLOPEDIA OF MEDICINE\\nAmenorrhea'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 184, 'page_label': '155'}, page_content='by stress or illness, periods should begin again when\\nthe stress passes or the illness is treated. Amenorrhea\\nthat occurs with discontinuing birth control pills\\nusually go away within six to eight weeks, although it\\nmay take up to a year.\\nThe prognosis for polycystic ovary disease\\ndepends on the severity of the symptoms and the\\ntreatment plan. Spironolactone, a drug that blocks\\nthe production of male hormones, can help in reducing\\nbody hair. If a woman wishes to become pregnant,\\ntreatment with clomiphene may be required or, on\\nrare occasions, surgery 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, avoidingsmoking and\\nsubstance abuse. Female athletes should be sure to eat a\\nbalanced diet and rest and exercise normally. However,\\nmany cases of amenorrhea cannot be prevented.\\nResources\\nPERIODICALS\\nHogg, Anne Cahill. ‘‘Breaking the Cycle: Often Confused\\nand Frustrated, Sufferers of Amenorrhea Now have\\nBetter Treatment Options.’’American Fitness 15, no. 4\\n(July-August 1997): 30-4.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nFederation of Feminist Women’s Health Centers.1469\\nHumboldt Rd, Suite 200, Chico, CA 96928. (530)\\n891-1911.\\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\\ncommonly done on newborns. Two tests are available,\\none using a blood sample and the other a urine sample.\\nPurpose\\nAmino acid disorder screening is done in new-\\nborns, and sometimes children and adults, to detect\\ninborn errors in metabolism of amino acids. Twenty of\\nthe 100 known amino acids are the main building\\nblocks for human proteins. Proteins regulate every\\naspect of cellular function. Of these 20 amino acids,\\nten are not made by the body and must be acquired\\nthrough diet. Congenital (present at birth) enzyme defi-\\nciencies that affect amino acid metabolism or congenital\\nabnormalities in the amino acid transport system of\\nthe kidneys creates a condition 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\\nexamples of this isphenylketonuria (PKU). This is an\\ngenetic error in metabolism of phenylalanine, an\\namino acid found in milk. Individuals with PKU do\\nnot produce the enzyme necessary to break down\\nphenylalanine.\\nPKU occurs in about one out of 16,000 live births\\nin the United States, but is more prevalent in cauca-\\nsians and less prevalent in Ashkenazi Jews and African\\nAmericans. Newborns in the United States are routi-\\nnely screened for PKU by a blood test.\\nThere are two types of aminoacidurias. Primary\\nor overflow aminoaciduria results from deficiencies in\\nthe enzymes necessary to metabolize amino acids.\\nOverflow aminoaciduria is best detected by a blood\\nplasma test.\\nSecondary or renal aminoaciduria occurs because\\nof a congenital defect in the amino acid transport\\nsystem in the tubules of the kidneys. This produces\\nincreased amino acids in the urine. Blood and urine\\ntest in combination are used to determine if the ami-\\nnoaciduria is of the overflow or renal type. Urine tests\\nare also used to monitor specific amino acid disorders.\\nNewborns are screened for amino acid disorders.\\nYoung children with acidosis (accumulation of acid\\nin the body), severevomiting and diarrhea, or urine\\nwith an abnormal color or odor, are also screened\\nwith a urine test for specific amino acid levels.\\nPrecautions\\nBoth blood and urine tests are simple tests that\\ncan be done in a doctor’s office or clinic. These tests\\ncan be done on even the youngest patients.\\nGALE ENCYCLOPEDIA OF MEDICINE 155\\nAmino acid disorders screening'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 185, 'page_label': '156'}, page_content='Description\\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\\nsmall amount of blood from a baby’s heel. The proce-\\ndure is rapid and relatively painless. Total time for the\\ntest is less than ten minutes. The blood is sent to a\\nlaboratory where results will be available in about\\ntwo days.\\nUrine test\\nIn the urine test, the patient is asked to urinate\\ninto a collecting cup. For an infant, the urine is col-\\nlected in a pediatric urine collector. The process is\\npainless. The length of time the test takes is determined\\nby how long it takes the patient to urinate. Results also\\ntake about two days.\\nBoth these tests use thin layer chromatography to\\nseparate the amino acids present. Using this techni-\\nque, the amino acids form a characteristic patterns on\\na glass plate coated with a thin layer of silica gel. This\\npattern is then compared to the normal pattern to\\ndetermine if there are abnormalities.\\nPreparation\\nBefore the blood test, the patient must not eat or\\ndrink for four hours. Failure to fast will alter the\\nresults of the test.\\nThe patient should eat and drink normally before\\nthe urine test. Some drugs may affect the results of the\\nurine test. The technician handling the urine sample\\nshould be informed of any medications the patient is\\ntaking. Mothers of breastfeeding infants should report\\nany medications they are taking, since these can pass\\nfrom mother to child in breast milk.\\nAftercare\\nThe blood screening is normally done first.\\nDepending on the results, it is followed by the urine\\ntest. It takes both tests to distinguish between over-\\nflow and renal aminoaciduria. Also, if the results are\\nabnormal, a 24-hour urine test is performed along\\nwith other tests to determine the levels of specific\\namino acids. In the event of abnormal results, there\\nare many other tests that will be performed to determine\\nthe specific amino acid involved in the abnormality.\\nRisks\\nThere are no particular risks associated with\\neither of these tests. Occasionally minor bruising may\\noccur at the site where the blood was taken.\\nNormal results\\nThe pattern of amino acid banding on the thin\\nlayer chromatography plates will be normal.\\nAbnormal results\\nThebloodplasmaaminoacidpatternisabnormalin\\noverflow aminoaciduria and is normal in renal amino-\\naciduria. The pattern is abnormal in the urine test,\\nsuggesting additional tests need to be done to determine\\nwhich amino acids are involved. In addition to PKU, a\\nvariety of other amino acid metabolism disorders can\\nbe detected by these tests, including tyrosinosis, histi-\\ndinemia, maple syrup urine disease, hypervalinemia,\\nhyperprolinemia, and homocystinuria.\\nResources\\nORGANIZATIONS\\nAssociation for Neuro-Metabolic Disorders. 5223\\nBrookfield Lane, Sylvania, OH 43560-1809. (419)\\n885-1497.\\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, A.M.\\nKEY TERMS\\nAmino acid— An organic compound composed of\\nboth an amino group and an acidic carboxyl group;\\namino acids are the basic building blocks of\\nproteins.\\nAminoaciduria— The abnormal presence of amino\\nacids in the urine.\\nChromatography— A family of laboratory techni-\\nques that separate mixtures of chemicals into their\\nindividual 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.\\n156 GALE ENCYCLOPEDIA OF MEDICINE\\nAmino acid disorders screening'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 186, 'page_label': '157'}, page_content='Aminoglycosides\\nDefinition\\nAminoglycosides are a group ofantibiotics that\\nare used to treat certain bacterial infections. This\\ngroup of antibiotics includes at least eight drugs:\\namikacin, gentamicin, kanamycin, neomycin, netil-\\nmicin, paromomycin, streptomycin, and tobramycin.\\nAll of these drugs have the same basic chemical\\nstructure.\\nPurpose\\nAminoglycosides are primarily used to combat\\ninfections due to aerobic, Gram-negative bacteria.\\nThese bacteria can be identified by their reaction to\\nGram’s stain. In Gram’s staining, a film of material\\ncontaining the possible bacteria is placed on a glass\\nslide and dried. The slide is stained with crystal violet\\nfor one minute, cleaned off with water and then placed\\ninto a solution of Gram’s iodine solution for one\\nminute. The iodine solution is rinsed off and the slide\\nis immersed in 95% ethyl alcohol. The slide is then\\nstained again with reddish carbolfuchsin or safranine\\nfor 30 seconds, rinsed in water, dried and examined.\\nGram-positive bacteria retain the violet purple stain.\\nGram-negative bacteria accept the red stain. Bacteria\\nthat can successfully be combated with aminoglyco-\\nsides include Pseudomonas, Acinetobacter, and\\nEnterobacter species, among others. Aminoglycosides\\nare also effective against mycobacteria, the bacteria\\nresponsible fortuberculosis.\\nThe aminoglycosides can be used against certain\\nGram-positive bacteria, but are not typically\\nemployed because other antibiotics are more effective\\nand have fewer side effects. Aminoglycosides are inef-\\nfective against anaerobic bacteria (bacteria that can-\\nnot grow in the presence of oxygen), viruses, and\\nfungi. And only one aminoglycoside, paromomycin,\\nis used against parasitic infection.\\nLike all other antibiotics, aminoglycosides are not\\neffective againstinfluenza, thecommon cold, or other\\nviral infections.\\nPrecautions\\nPre-existing medical conditions–such as kidney\\ndisease, eighth cranial nerve disease, myasthenia\\ngravis, and Parkinson’s disease–should be discussed\\nprior to taking any aminoglycosides. Pregnant\\nwomen are usually advised against taking aminogly-\\ncosides, because their infants may suffer damage to\\ntheir hearing, kidneys, or sense of balance. However,\\nthose factors need to be considered alongside the\\nthreat to the mother’s health and life in cases of\\nserious infection. Aminoglycosides do not pass into\\nbreast milk to any great extent, so nursing mothers\\nmay be prescribed aminoglycosides without injuring\\ntheir infants.\\nDescription\\nStreptomycin, the first aminoglycoside, was\\nisolated fromStreptomyces griseus in the mid-1940s.\\nThis antibiotic was very effective against tuberculosis.\\nOne of the main drawbacks to streptomycin is its\\ntoxicity, especially to cells in the inner and middle ear\\nand the kidney. Furthermore, some strains of tubercu-\\nlosis are resistant to treatment with streptomycin.\\nTherefore, medical researchers have put considerable\\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 Gram’s\\nstain.\\nGram’s stain—A stain used in microbiology to clas-\\nsify bacteria and help identify the species to which\\nthey belong. This identification aids in determining\\ntreatment.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 157\\nAminoglycosides'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 187, 'page_label': '158'}, page_content='effort into identifying other antibiotics with strep-\\ntomycin’s efficacy, but without its toxicity.\\nAminoglycosides are absorbed very poorly from\\nthe gastrointestinal tract; in fact, aminoglycosides\\ntaken orally are excreted virtually unchanged and\\nundiminished in quantity. The route of drug admin-\\nistration depends on the type and location of the\\ninfection being treated. The typical routes of admin-\\nistration are by intramuscular (injection into a mus-\\ncle) or intravenous injection (injection into a vein),\\nirrigation, topical skin application, or inhalation.\\nIf the infection being treated involves the central\\nnervous system, the drug can be injected into the\\nspinal canal.\\nThe bactericidal ability of aminoglycosides has\\nnot been fully explained. It is known that the drug\\nattaches to a bacterial cell wall and is drawn into the\\ncell via channels made up of the protein, porin. Once\\ninside the cell, the aminoglycoside attaches to the cell’s\\nribosomes. Ribosomes are the intracellular structures\\nresponsible for manufacturing proteins. This attach-\\nment either shuts down protein production or causes\\nthe cell to produce abnormal, ineffective proteins. The\\nbacterial cell cannot survive with this impediment.\\nAntibiotic treatment using aminoglycosides may\\npair the drug with a second type of antibiotic, usually\\na beta-lactam or vancomycin, administered sepa-\\nrately. Beta-lactams disrupt the integrity of the bac-\\nteria cell wall, making it more porous. The increased\\nporosity allows more of the aminoglycoside into the\\nbacteria cell.\\nTraditionally, aminoglycosides were administered\\nat even doses given throughout the day. It was thought\\nthat a steady plasma concentration was necessary to\\ncombat infection. However, this administration sche-\\ndule is time and labor intensive. Furthermore, admin-\\nistering a single daily dose can be as effective, or more\\neffective, than several doses throughout the day.\\nDosage depends on the patient’s age, weight, gen-\\nder, and general health. Since the drug is cleared by the\\nkidneys, it is important to assess any underlying pro-\\nblems with kidney function. Kidney function is\\nassessed by measuring the blood levels of creatinine,\\na protein normally found in the body. If these levels\\nare high, it is an indication that the kidneys may not be\\nfunctioning at an optimal rate and dosage will be\\nlowered accordingly.\\nRisks\\nAminoglycosides have been shown to be toxic\\nto certain cells in the ears and in the kidneys.\\nApproximately 5-10% of the people who are\\ntreated with aminoglycosides experience some side\\neffect, affecting their hearing, sense of balance, or\\nkidneys. However, in most cases the damage is minor\\nand reversible once medication is stopped.\\nIf cells in the inner ear are damaged or destroyed,\\nan individual may experience a loss of balance and\\nfeelings of dizziness. Damage to the middle ear may\\nresult inhearing lossor tinnitus. Neomycin, kanamycin,\\nand amikacin are the most likely to cause problems with\\nhearing, and streptomycin and gentamicin carry the\\ngreatest risk of causing vertigo and loss of balance.\\nKidney damage, apparent with changes in urination\\nfrequency or urine production, is most likely precipi-\\ntated by neomycin, 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 skinrashes and\\nitching. Very rarely, certain aminoglycosides may\\ncause difficulty in breathing, weakness, or drowsiness.\\nGentamicin, when injected, may cause leg cramps,\\nskin rash,fever, or seizures.\\nIf side effects linger or become worse after medi-\\ncation is stopped, it is advisable to seek medical advice.\\nSide effects that may be of concern includetinnitus or\\nloss of hearing, dizziness or loss of balance, changes in\\nurination frequency or urine production, increased\\nthirst, appetite loss, andnausea 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\\nbecomes apparent after repeated exposure to the anti-\\nbiotic and arises from a mutation that alters the bac-\\nteria’s susceptibility to the drug. Various degrees of\\nresistance have been observed in bacteria that nor-\\nmally would be destroyed by aminoglycosides. In gen-\\neral, though, aminoglycoside effectiveness has held\\nup well over time.\\nResources\\nBOOKS\\nChambers, Henry F., W. Keith Hadley, and Ernest Jawetz.\\n‘‘Aminoglycosides & Spectinomycin.’’ InBasic and\\n158 GALE ENCYCLOPEDIA OF MEDICINE\\nAminoglycosides'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 188, 'page_label': '159'}, page_content='Clinical Pharmacology, edited by Bertram G. Katzung,\\n7th ed. Stamford: Appleton & Lange, 1998.\\nJulia Barrett\\nAmitriptyline see Antidepressants, tricyclic\\nAmlodipine see Calcium channel blockers\\nAmnesia\\nDefinition\\nAmnesia refers to the loss of memory. Memory\\nloss may result from two-sided (bilateral) damage to\\nparts of the brain vital for memory storage, proces-\\nsing, or recall (the limbic system, including the hippo-\\ncampus in the medial temporal lobe).\\nDescription\\nAmnesia can be a symptom of several neurode-\\ngenerative diseases; however, people whose primary\\nsymptom is memory loss (amnesiacs), typically remain\\nlucid and retain their sense of self. They may even be\\naware that they suffer from a memory disorder.\\nPeople who experience amnesia have been instru-\\nmental in helping brain researchers determine how\\nthe brain processes memory. Until the early 1970s,\\nresearchers viewed memory as a single entity.\\nMemory of new experiences, motor skills, past events,\\nand previous conditioning were grouped together in\\none system that relied on a specific area of the brain.\\nIf all memory were stored in the same way, it would\\nbe reasonable to deduce that damage to the specific\\nbrain area would cause complete memory loss. How-\\never, studies of amnesiacs counter that theory. Such\\nresearch demonstrates that the brain has multiple sys-\\ntems for processing, storing, and drawing on memory.\\nCauses and symptoms\\nAmnesia has several root causes. Most are trace-\\nable to brain injury related to physical trauma, disease,\\ninfection, drug and alcoholabuse, or reduced blood\\nflow to the brain (vascular insufficiency). In Wernicke-\\nKorsakoff syndrome, for example, damage to the\\nmemory centers of the brain results from the use of\\nalcohol ormalnutrition. Infections that damage brain\\ntissue, including encephalitis and herpes, can also\\ncause amnesia. If the amnesia is thought to be of\\npsychological origin, it is termed psychogenic.\\nThere are at least three general types of amnesia:\\n/C15Anterograde. This form of amnesia follows brain\\ntrauma and is characterized by the inability to\\nremember new information. Recent experiences and\\nshort-term memory disappear, but victims can recall\\nevents prior to the trauma with clarity.\\n/C15Retrograde. In some ways, this form of amnesia is\\nthe opposite of anterograde amnesia: the victim can\\nrecall events that occurred after a trauma, but cannot\\nremember previously familiar information or the\\nevents preceding the trauma.\\n/C15Transient global amnesia. This type of amnesia has\\nno consistently identifiable cause, but researchers\\nhave suggested that migraines or transient ischemic\\nattacks may be the trigger. (A transient ischemic\\nattack, sometimes called ‘‘a small stroke,’’ occurs\\nwhen a blockage in an artery temporarily blocks\\noff blood supply to part of the brain.) A victim\\nexperiences sudden confusion and forgetfulness.\\nAttacks can be as brief as 30-60 minutes or can\\nlast up to 24 hours. In severe attacks, a person is\\ncompletely disoriented and may experience retro-\\ngrade amnesia that extends back several years.\\nWhile very frightening for the patient, transient\\nglobal amnesia generally has an excellent prognosis\\nfor recovery.\\nAmygdalaHippocampus\\nMemory loss may result from bilateral damage to the limbic\\nsystem of the brain responsible for memory storage, proces-\\nsing, and recall. (Illustration by Electronic Illustrators Group).\\nGALE ENCYCLOPEDIA OF MEDICINE 159\\nAmnesia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 189, 'page_label': '160'}, page_content='Diagnosis\\nIn diagnosing amnesia and its cause, doctors look\\nat several factors. During aphysical examination,t h e\\ndoctor inquires about recent traumas or illnesses, drug\\nand medication 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\\nas magnetic 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\\nand is handled on an individual basis. Regardless of\\ncause, cognitiverehabilitationmay be helpful in learning\\nstrategies to cope with memory impairment.\\nPrognosis\\nSome types of amnesia, such as transient global\\namnesia, are completely resolved and there is no per-\\nmanent loss of memory. Others, such as Korsakoff\\nsyndrome, associated with prolonged alcohol abuse\\nor amnesias caused by severe brain injury, may be\\npermanent. Depending on the degree of amnesia and\\nits cause, victims may be able to lead relatively normal\\nlives. Amnesiacs can learn through therapy to rely on\\nother memory systems to compensate for what is lost.\\nPrevention\\nAmnesia is only preventable in so far as brain\\ninjury can be prevented or minimized. Common\\nsense approaches include wearing a helmet when bicy-\\ncling or participating in potentially dangerous sports,\\nusing automobile seat belts, and avoiding excessive\\nalcohol or drug use. Brain infections should be treated\\nswiftly and aggressively to minimize the damage due\\nto swelling. Victims of strokes, brain aneurysms, and\\ntransient ischemic attacks should seek immediate\\nmedical treatment.\\nResources\\nPERIODICALS\\nSquire, Larry R., and Stuart M. Zola. ‘‘Amnesia,\\nMemory and Brain Systems.’’Philosophical\\nTransactions of the Royal Society of London, Series B\\n352 (1997): 1663.\\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\\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\\ncrowd causes 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,\\nan amnesiac may remember he has a wife (seman-\\ntic memory), 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\\nrelates to the task at hand and coordinates recall\\nof memories necessary to complete it.\\n160 GALE ENCYCLOPEDIA OF MEDICINE\\nAmniocentesis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 190, 'page_label': '161'}, page_content='in the womb, is collected through a pregnant woman’s\\nabdomen using a needle and syringe. Tests performed\\non fetal cells found in the sample can reveal the presence\\nof many types of genetic disorders, thus allowing\\ndoctors and prospective parents to make important\\ndecisions about early treatment and intervention.\\nPurpose\\nSince the mid-1970s, amniocentesis has been used\\nroutinely to test forDown syndrome, by far the most\\ncommon, nonhereditary, genetic birth defect, afflict-\\ning about one in every 1,000 babies. By 1997, approxi-\\nmately 800 different diagnostic tests were available,\\nmost of them for hereditary genetic disorders such\\nas Tay-Sachs disease, sickle cell anemia,hemophilia,\\nmuscular dystrophyand cystic fibrosis.\\nAmniocentesis, often called amnio, is recom-\\nmended for women who will be older than 35 on\\ntheir due-date. It is also recommended for women\\nwho have already borne children with birth defects,\\nor when either of the parents has a family history of a\\nbirth defect for which a diagnostic test is available.\\nAnother reason for the procedure is to confirm indica-\\ntions of Down syndrome and certain other defects\\nwhich may have shown up previously during routine\\nmaternal blood screening.\\nThe risk of bearing a child with a nonhereditary\\ngenetic defect such as Down syndrome is directly\\nrelated to a woman’s age–the older the woman, the\\ngreater the risk. Thirty-five is the recommended age to\\nbegin amnio testing because that is the age at which the\\nrisk of carrying a fetus with such a defect roughly\\nequals the risk of miscarriage caused by the proce-\\ndure–about one in 200. At age 25, the risk of giving\\nbirth to a child with this type of defect is about one in\\n1,400; by age 45 it increases to about one in 20. Nearly\\nhalf of all pregnant women over 35 in the United States\\nundergo amniocentesis and many younger women also\\ndecide to have the procedure. Notably, some 75% of all\\nDown syndrome infants born in the United States each\\nyear are to women younger than 35.\\nOne of the most common reasons for performing\\namniocentesis is an abnormal alpha-fetoprotein\\n(AFP) test. Alpha-fetoprotein is a protein produced\\nA physician uses an ultrasound monitor (left) to position the needle for insertion into the amnion when performing amniocent-\\nesis. (Photograph by Will and Deni McIntyre, Photo Researchers, Inc. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 161\\nAmniocentesis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 191, 'page_label': '162'}, page_content='by the fetus and present in the mother’s blood. A\\nsimple blood screening, usually conducted around\\nthe 15th week of pregnancy, can determine the AFP\\nlevels in the mother’s blood. Levels that are too high or\\ntoo low may signal possible fetal defects. Because this\\ntest has a high false-positive rate, another test such as\\namnio is recommended whenever the AFP levels fall\\noutside the normal range.\\nAmniocentesis is generally performed during the\\n16th week ofpregnancy, with results usually available\\nwithin three weeks. It is possible to perform an amnio\\nas early as the 11th week but this is not usually\\nrecommended because there appears to be an\\nincreased risk of miscarriage when done at this time.\\nThe advantage of early amnio and speedy results lies\\nin the extra time for decision making if a problem is\\ndetected. Potential treatment of the fetus can begin\\nearlier. Important, also, isthe fact that elective abor-\\ntions are safer and less controversial the earlier they\\nare performed.\\nPrecautions\\nAs an invasive surgical procedure, amnio poses a\\nreal, although small, risk to the health of a fetus.\\nParents must weigh the potential value of the knowl-\\nedge gained, or indeed the reassurance that all is well,\\nagainst the small risk of damaging what is in all pro-\\nbability a normal fetus. The serious emotional and\\nethical dilemmas that adverse test results can bring\\nmust also be considered. The decision to undergo\\namnio 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.\\nDuring the sampling procedure, the obstetrician inserts\\na very fine needle through the woman’s abdomen into\\nthe uterus and amniotic sac and withdraws appro-\\nximately one ounce of amniotic fluid for testing. The\\nKEY TERMS\\nAlpha-fetoprotein (AFP)— A protein normally pro-\\nduced by the liver of a fetus and detectable in mater-\\nnal blood samples. AFP screening measures the\\namount 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\\nsimilar to amniocentesis, except that cells are\\ntaken from the chorionic membrane for testing.\\nThese cells, called chorionic villus cells, eventually\\nbecome the placenta. The samples are collected\\neither through the abdomen, as in amnio, or\\nthrough the vagina. CVS can be done earlier in the\\npregnancy than amnio, but carries a somewhat\\nhigher risk.\\nChromosome— Chromosomes are the strands of\\ngenetic material in a cell that occur in nearly\\nidentical pairs. Normal human cells contain 23\\nchromosome pairs–one in each pair inherited\\nfrom the mother, and one from the father. Every\\nhuman cell contains the exact same set of\\nchromosomes.\\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 of\\nbiological heredity, which are contained on the\\nchromosomes, and contain chemical instructions\\nwhich direct the development and functioning of\\nan individual.\\nHereditary— Something which is inherited–passed\\ndown from parents to offspring. In biology and med-\\nicine, 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 prob-\\nability 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-\\nfrequency sound waves to create a visual image (a\\nsonogram) of soft tissues. The technique is routinely\\nused in prenatal care and diagnosis.\\n162 GALE ENCYCLOPEDIA OF MEDICINE\\nAmniocentesis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 192, 'page_label': '163'}, page_content='relatively painless procedure is performed on an out-\\npatient basis, sometimes usinglocal anesthesia.\\nThe physician uses ultrasound images to guide\\nneedle placement and collect the sample, thereby\\nminimizing the risk of fetal injury and the need for\\nrepeated needle insertions. Once the sample is col-\\nlected, the woman can return home after a brief\\nobservation period. She may be instructed to rest\\nfor the first 24 hours and to avoid heavy lifting for\\ntwo days.\\nThe sample of amniotic fluid is sent to a labora-\\ntory where fetal cells contained in the fluid are isolated\\nand grown in order to provide enough genetic material\\nfor testing. This takes about seven to 14 days. The\\nmaterial is then extracted and treated so that visual\\nexamination for defects can be made. For some dis-\\norders, like Tay-Sachs, the simple presence of a telltale\\nchemical compound in the amniotic fluid is enough to\\nconfirm a diagnosis. Depending on the specific tests\\nordered, and the skill of the lab conducting them, all\\nthe results are available between one and four weeks\\nafter the sample is taken.\\nCost of the procedure depends on the doctor, the\\nlab, and the tests ordered. Most insurers provide cov-\\nerage for women over 35, as a follow-up to positive\\nmaternal blood screening results, and when genetic\\ndisorders run in the family.\\nAn alternative to amnio, now in general use, is\\nchorionic villus sampling, or CVS, which can be per-\\nformed as early as the eighth week of pregnancy.\\nWhile this allows for the possibility of a first trimester\\nabortion, if warranted, CVS is apparently also riskier\\nand is more expensive. The most promising area of\\nnew research in prenatal testing involves expanding\\nthe scope and accuracy of maternal blood screening\\nas this poses no risk to the fetus.\\nPreparation\\nIt is important for a woman to fully understand\\nthe procedure and to feel confident in the obstetrician\\nperforming it. Evidence suggests that a physician’s\\nexperience with the procedure reduces the chance of\\nmishap. Almost all obstetricians are experienced in\\nperforming amniocentesis. The patient should feel\\nfree to ask questions and seek emotional support\\nbefore, during and after the amnio is performed.\\nAftercare\\nNecessary aftercare falls into two categories,\\nphysical and emotional.\\nPhysical aftercare\\nDuring and immediately following the sampling\\nprocedure, a woman may experience dizziness,nausea,\\na rapid heartbeat, and cramping. Once past these\\nimmediate hurdles, the physician will send the\\nwoman home with instructions to rest and to report\\nany complications requiring immediate treatment,\\nincluding:\\n/C15vaginal bleeding. The appearance of blood could\\nsignal a problem.\\n/C15premature 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/C15signs of infection. Leaking of amniotic fluid or unu-\\nsual vaginal discharge, and fever could signal the\\nonset of infection.\\nEmotional aftercare\\nOnce the procedure has been safely completed, the\\nanxiety of waiting for the test results can prove to be\\nthe worst part of the process. A woman should seek\\nand receive emotional support from family and\\nfriends, as well as from her obstetrician and family\\ndoctor. Professional counseling may also prove neces-\\nsary, particularly if a fetal defect is discovered.\\nRisks\\nMost of the risks and short-term side effects asso-\\nciated with amniocentesis relate to the sampling pro-\\ncedure and have been discussed above. A successful\\namnio sampling results in no long-term side effects.\\nRisks include:\\n/C15maternal/fetal hemorrhaging. While spotting in\\npregnancy is fairly common, bleeding following\\namnio should always be investigated.\\n/C15infection. Infection, although rare, can occur after\\namniocentesis. An unchecked infection can lead to\\nsevere complications.\\n/C15fetal injury. A very slight risk of injury to the fetus\\nresulting from contact with the amnio needle does exist.\\n/C15miscarriage. The rate of miscarriage occurring\\nduring standard, second trimester amnio appears to\\nbe approximately 0.5%. This compares to a miscarri-\\nage rate of 1% for CVS. Many fetuses with severe\\ngenetic defects miscarry naturally during the first\\ntrimester.\\n/C15the trauma of difficult family-planning decisions.\\nThe threat posed to parental and family mental\\nGALE ENCYCLOPEDIA OF MEDICINE 163\\nAmniocentesis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 193, 'page_label': '164'}, page_content='health from the trauma accompanying an abnormal\\ntest result can not be underestimated.\\nNormal results\\nNegative results from an amnio analysis indicate\\nthat everything about the fetus appears normal and\\nthe pregnancy can continue without undue concern. A\\nnegative result for Down syndrome means that it is\\n99% certain that the disease does not exist.\\nAn overall ‘‘normal’’ result does not, however,\\nguarantee that the pregnancy will come to term, or\\nthat the fetus does not suffer from some other defect.\\nLaboratory tests are not 100% accurate at detecting\\ntargeted conditions, nor can every possible fetal con-\\ndition be tested for.\\nAbnormal 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\\nchoices regarding treatment options, the prospect of\\ndealing with a severely affected newborn, and the\\noption of elective abortion. At this point, the parents\\nneed expert medical advice and counseling.\\nResources\\nPERIODICALS\\nDreisbach, Shaun. ‘‘Amnio Alternative.’’Working Mother\\n(March 1997): 11.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nOTHER\\nHolbrook Jr., Harold R. Stanford University School of\\nMedicineWeb Home Page. February 2001.\\n.\\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\\na limb or body part. It is performed to remove diseased\\ntissue or relievepain.\\nPurpose\\nArms, legs, hands, feet, fingers, and toes can be\\namputated. Most amputations involve small body\\nparts such as a finger, rather than an entire limb.\\nAbout 65,000 amputations are performed in the\\nUnited States each year.\\nAmputation is performed for the following reasons:\\n/C15to remove tissue that no longer has an adequate\\nblood supply\\n/C15to remove malignant tumors\\n/C15because 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\\nthe arteries, arterial embolism, impaired circulation\\nas a complication ofdiabetes mellitus, repeated severe\\ninfection that leads to gangrene, severe frostbite,\\nRaynaud’s disease, or Buerger’s disease.\\nMore than 90% of amputations performed in the\\nUnited States are due to circulatory complications of\\ndiabetes. Sixty to eighty percent of these operations\\ninvolve the legs or feet. Although attempts have been\\nmade in the United States to better manage diabetes\\nand the foot ulcers that can be complications of the\\ndisease, the number of resulting amputations has not\\ndecreased.\\nPrecautions\\nAmputations cannot be performed on patients\\nwith uncontrolled diabetes mellitus, heart failure, or\\ninfection. Patients with blood clotting disorders are\\nalso not good candidates for amputation.\\nDescription\\nAmputations can be either planned or emergency\\nprocedures. Injury and arterial embolisms are the\\nmain reasons for emergency amputations. The opera-\\ntion is performed under regional or general anesthesia\\nby a general or orthopedic surgeon in a hospital oper-\\nating room.\\nDetails of the operation vary slightly depending\\non what part is to be removed. The goal of all\\n164 GALE ENCYCLOPEDIA OF MEDICINE\\nAmputation'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 194, 'page_label': '165'}, page_content='amputations is twofold: to remove diseased tissue so\\nthat the wound will heal cleanly, and to construct a\\nstump that will allow the attachment of a prosthesis or\\nartificial replacement part.\\nThe surgeon makes an incision around the part to\\nbe amputated. The part is removed, and the bone is\\nsmoothed. A flap is constructed of muscle, connective\\ntissue, and skin to cover the raw end of the bone. The\\nflap is closed over the bone with sutures (surgical\\nstitches) that remain in place for about one month.\\nOften, a rigid dressing or cast is applied that stays in\\nplace for about two weeks.\\nPreparation\\nBefore an amputation is performed, extensive\\ntesting is done to determine the proper level of\\namputation. The goal of the surgeon is to find the\\nplace where healing is most likely to be complete,\\nwhile allowing the maximum amount of limb to\\nremain for effectiverehabilitation.\\nThe greater the blood flow through an area, the\\nmore likely healing is to occur. These tests are designed\\nto measure blood flow through the limb. Several or all\\nof them can be done to help choose the proper level of\\namputation.\\n/C15measurement of blood pressure in different parts of\\nthe limb\\n/C15xenon 133 studies, which use a radiopharmaceutical\\nto measure blood flow\\n/C15oxygen tension measurements in which an oxygen elec-\\ntrode is used to measure oxygen pressure under the skin.\\nIf the pressure is 0, the healing will not occur. If the\\nFigure DFigure C\\nFigure A\\nFemur\\nSkin flapExposed\\nmuscle\\nFigure B\\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: The\\nsurgeon saws through the exposed femur bone. Figure D: The muscles are closed and sutured over the bone. The remaining\\nskin flaps are then sutured together, creating a stump.(Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 165\\nAmputation'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 195, 'page_label': '166'}, page_content='pressure reads higher than 40mm Hg (40 milliliters of\\nmercury), healing of the area is likely to be satisfactory.\\n/C15laser Doppler measurements of the microcirculation\\nof the skin\\n/C15skin fluorescent studies that also measure skin\\nmicrocirculation\\n/C15skin perfusion measurements using a blood pressure\\ncuff and photoelectric detector\\n/C15infrared measurements of skin temperature\\nNo single test is highly predictive of healing, but\\ntaken together, the results give the surgeon an excel-\\nlent idea of the best place to amputate.\\nAftercare\\nAfter amputation, medication is prescribed for\\npain, and patients are treated with antibiotics to\\ndiscourage infection. The stump is moved often to\\nencourage good circulation. Physical therapy and\\nrehabilitation are startedas soon as possible, usually\\nwithin 48 hours. Studies have shown that there is a\\npositive relationship betwe en early rehabilitation\\nand effective functioning of the stump and prosthe-\\nsis. Length of stay in the hospital depends on the\\nseverity of the amputation and the general health\\nof the amputee, but ranges from several days to\\ntwo weeks.\\nRehabilitation is a long, arduous process, espe-\\ncially for above the knee amputees. Twice daily physical\\ntherapy is not uncommon. In addition, psychological\\ncounseling is an important part of rehabilitation.\\nMany people feel a sense of loss and grief when they\\nlose a body part. Others are bothered by phantom\\nlimb syndrome, where they feel as if the amputated\\npart is still in place. They may even feel pain in the limb\\nthat does not exist. Many amputees benefit from join-\\ning self-help groups and meeting others who are also\\nliving with amputation. Addressing the emotional\\naspects of amputation often speeds the physical reha-\\nbilitation process.\\nRisks\\nAmputation is major surgery. All the risks asso-\\nciated with the administration of anesthesia exist,\\nalong with the possibility of heavy blood loss and\\nthe development of blood clots. Infection is of spe-\\ncial concern to amputees. Infection rates in amputa-\\ntions average 15%. If the stump becomes infected, it\\nis necessary to remove the prosthesis and sometimes\\nto amputate a second time at a higher level.\\nFailure of the stump to heal is another major\\ncomplication. Nonhealing is usually due to an inade-\\nquate blood supply. The rate of nonhealing varies\\nfrom 5-30% depending on the facility. Centers that\\nspecialize in amputation usually have the lowest rates\\nof complication.\\nPersistent pain in the stump or pain in the phan-\\ntom limb is experienced by most amputees to some\\ndegree. Treatment of phantom limb pain is difficult.\\nFinally, many amputees give up on the rehabilitation\\nprocess and discard their prosthesis. Better fitting\\nprosthetics and earlier rehabilitation have decreased\\nthe incidence of this problem. Researchers and pros-\\nthetic manufacturers continue to refine the materials\\nand methods used to try to improve the comfort\\nand function of prosthetic devices for amputees.\\nFor example, a 2004 study showed that a technique\\ncalled the bone bridge amputation technique helped\\nimprove comfort and stability for transtibial\\namputees.\\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,\\nabout one-half of amputees who suffer them then\\nremain wheelchair bound.\\nKEY TERMS\\nArterial embolism— A blood clot arising from\\nanother location that blocks an artery.\\nBuerger’s disease— An episodic disease that\\ncauses inflammation and blockage of the veins\\nand arteries of the limbs. It tends to be present\\nalmost exclusively on men under age 40 who\\nsmoke, and may require amputation of the hand\\nor 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\\nto the hands and feet. Its cause is unknown.\\n166 GALE ENCYCLOPEDIA OF MEDICINE\\nAmputation'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 196, 'page_label': '167'}, page_content='Resources\\nPERIODICALS\\nEdwards, Anthony R. ‘‘Study Helps Build Functional\\nBridges for Amputee Patients.’’Biomechanics (May 1,\\n2004): 17.\\nJeffcoat, William. ‘‘Incidence of Amputation is a Poor\\nMeasure of the Quality of Ulcer Care.’’The Diabetic\\nFoot Summer (2004): 70–74.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard\\nStreet, Alexandria, VA 22311. (800) 342-2383.\\n.\\nOTHER\\nAmputation Prevention Global Resource Center Page.\\nFebruary 2001. .\\nTish Davidson, A.M.\\nTeresa G. Odle\\nAmylase 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\\nenzyme amylase is to break down starches in food so\\nthat they can be used by the body. Amylase testing\\nis usually done to determine the cause of sudden\\nabdominal pain.\\nPurpose\\nAmylase testing is performed to diagnose a num-\\nber of diseases that elevate amylase levels. Pancreatitis,\\nfor example, is the most common reason for a high\\namylase level. When the pancreas is inflamed, amylase\\nescapes from the pancreas into the blood. Within six to\\n48 hours after thepain begins, amylase levels in the\\nblood start to rise. Levels will stay high for several days\\nbefore gradually returning to normal.\\nThere are other causes of increased amylase. An\\nulcer that erodes tissue from the stomach and goes\\ninto the pancreas will cause amylase to spill into the\\nblood. During amumps infection, amylase from the\\ninflamed salivary glands increases. Amylase is also\\nfound in the liver, fallopian tubes, and small intestine;\\ninflammation of these tissues also increases levels. Gall\\nbladder disease, tumors of the lung or ovaries, alcohol\\npoisoning, ruptured aortic aneurysm, and intestinal\\nstrangulation or perforation can also cause unusually\\nhigh amylase levels.\\nPrecautions\\nThis is not a screening test for future pancreatic\\ndisease.\\nDescription\\nAmylase testing is done on both blood and\\nurine. The laboratory may use any of several testing\\nmethods that involve mixing the blood or urine sam-\\nple with a substance with which amylase is known to\\nreact. By measuring the end-product or the reaction\\ntime, technicians can calculate the amount of amy-\\nlase present in the sample. More sophisticated meth-\\nods separately measure the amylase made by the\\npancreas and the amylase made by the salivary\\nglands.\\nUrine testing is a better long-term monitor of\\namylase levels. The kidneys quickly move extra\\namylase from the blood into the urine. Urine levels\\nrise six to 10 hours after blood levels and stay high\\nlonger. Urine is usually collected throughout a 2- or\\n24-hour time period. Results are usually available the\\nsame day.\\nPreparation\\nIn most cases, no special preparation is necessary\\nfor a person undergoing an amylase blood test.\\nPatients taking longer term urine amylase tests will\\nbe given a container and instructions for collecting\\nthe urine at home. The urine should be refrigerated\\nuntil it is brought to the laboratory.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 167\\nAmylase tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 197, 'page_label': '168'}, page_content='bruising. Applying warm packs to the puncture site\\nrelieves discomfort.\\nNormal results\\nNormal results vary based on the laboratory and\\nthe method used.\\nAbnormal results\\nEight out of ten persons with acutepancreatitis\\nwill have high amylase levels, up to four times the\\nnormal level. Other causes of increased amylase, such\\nas mumps, kidney failure, pregnancy occurring in\\nthe abdomen but outside the uterus (ectopicpreg-\\nnancy), certain tumors, a penetrating ulcer, certain\\ncomplications of diabetes, and advanced pancreatic\\ncancer, are further investigated based on the person’s\\nsymptoms, medical history, and the results of other\\ntests.\\nIn kidney disease, the kidneys are not as efficient\\nat removing amylase from the blood. Amylase rises in\\nthe blood, 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.\\nAmylase levels in the blood will be high; levels in the\\nurine will be low.\\nAmylase levels may be low in severeliver disease\\n(including hepatitis), conditions in which the pancreas\\nfails to secrete enough enzyme for proper digestions\\n(pancreatic insufficiency), when toxic materials build\\nup in the blood during pregnancy (pre-eclampsia),\\nfollowing burns, in thyroid disorders, and in advanced\\ncystic fibrosis. Some medications can raise or lower\\nlevels.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnosticand\\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\\nin one or more organs or body systems.\\nDescription\\nAmyloid proteins are manufactured by malfunc-\\ntioning bone marrow. Amyloidosis, which occurs\\nwhen accumulated amyloid deposits impair normal\\nbody function, can cause organ failure ordeath.I t\\nis a rare disease, occurring in about eight of every\\n1,000,000 people. It affects males and females equally\\nand usually develops after the age of 40. At least 15\\ntypes of amyloidosis have been identified. Each one\\nis associated with deposits of a different kind of\\nprotein.\\nTypes of amyloidosis\\nThe major forms of this disease are primary sys-\\ntemic, secondary, and familial or hereditary amyloi-\\ndosis. There is also another form of amyloidosis\\nassociated withAlzheimer’s disease.\\nPrimary systemic amyloidosis usually develops\\nbetween the ages of 50 and 60. With about 2,000 new\\ncases diagnosed annually, primary systemic amyloido-\\nsis is the most common form of this disease in the\\nUnited States. Also known as light-chain-related amy-\\nloidosis, it may also occur in association withmultiple\\nmyeloma (bone marrowcancer).\\nSecondary amyloidosis is a result of chronic infec-\\ntion or inflammatory disease. It is often associated\\nwith:\\n/C15familial Mediterranean fever (a bacterial infection\\ncharacterized by chills, weakness, headache, and\\nrecurring fever)\\n/C15granulomatous ileitis (inflammation of the small\\nintestine)\\n/C15Hodgkin’s disease (cancer of the lymphatic system)\\n/C15leprosy\\n/C15osteomyelitits (bacterial infection of bone and bone\\nmarrow)\\n/C15rheumatoid arthritis\\nFamilial or hereditary amyloidosis is the only\\ninherited form of the disease. It occurs in members of\\nmost ethnic groups, and each family has a distinctive\\npatternofsymptoms andorganinvolvement. Hereditary\\namyloidosis is though to be autosomal dominant,\\nwhich means that only one copy of the defective gene\\nis necessary to cause the disease. A child of a parent\\nwith familial amyloidosis has a 50-50 chance of devel-\\noping the disease.\\nAmyloidosis can involve any organ or system in\\nthe body. The heart, kidneys, gastrointestinal system,\\nand nervous system are affected most often. Other\\n168 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyloidosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 198, 'page_label': '169'}, page_content='common sites of amyloid accumulation include the\\nbrain, joints, liver, spleen, pancreas, respiratory system,\\nand skin.\\nCauses and symptoms\\nThe cause of amyloidosis is unknown. Most\\npatients have gastrointestinal abnormalities, but\\nother symptoms vary according to the organ(s) or\\nsystem(s) affected by the disease. Usually the affected\\norgans are rubbery, firm, and enlarged.\\nHeart\\nBecause amyloid protein deposits can limit the\\nheart’s ability to fill with blood between beats, even\\nthe slightest exertion can causeshortness of breath.I f\\nthe heart’s electrical system is affected, the heart’s\\nrhythm may become erratic. The heart may also be\\nenlarged and heart murmurs may be present.\\nCongestive heart failure may result.\\nKidneys\\nThe feet, ankles, and calves swell when amyloidosis\\ndamages the kidneys. The kidneys become small and\\nhard, and kidney failure may result. It is not unusual for\\na patient to lose 20-25 pounds and develop a distaste for\\nmeat, eggs, and other protein-rich foods. Cholesterol\\nelevations that don’t respond to medication and protein\\nin the urine (proteinuria) are common.\\nNervous system\\nNervous system symptoms often appear in\\npatients with familial amyloidosis. Inflammation and\\ndegeneration of the peripheral nerves (peripheral neu-\\nropathy) may be present. One of four patients with\\namyloidosis has carpal tunnel syndrome, a painful\\ndisorder that causesnumbness or tingling in response\\nto pressure on nerves around the wrist. Amyloidosis\\nthat affects nerves to the feet can cause burning or\\nnumbness in the toes and soles and eventually weaken\\nthe legs. If nerves controlling bowel function are\\ninvolved, bouts ofdiarrhea alternate with periods of\\nconstipation. If the disease affects nerves that regulate\\nblood pressure, patients may feel dizzy or faint when\\nthey stand up suddenly.\\nLiver and spleen\\nThe most common symptoms are enlargement of\\nthese organs. Liver function is not usually affected\\nuntil quite late in the course of the disease. Protein\\naccumulation in the spleen can increase the risk of\\nrupture of this organ due to trauma.\\nGastrointestinal system\\nThe tongue may be inflammed, enlarged, and stiff.\\nIntestinal movement (motility) may be reduced.\\nAbsorption of food and other nutrients may be\\nimpaired (and may lead tomalnutrition), and there\\nmay also be bleeding, abdominalpain, constipation,\\nand diarrhea.\\nSkin\\nSkin symptoms occur in about half of all cases\\nof primary and secondary amyloidosis and in all\\ncases where there is inflammation or degeneration of\\nthe peripheral nerves. Waxy-looking raised bumps\\n(papules) may appear on the face and neck, in the\\ngroin, armpits, or anal area, and on the tongue or in\\nthe ear canals. Swelling, hemorrhage beneath the skin\\n(purpura), hair loss, 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\\nis necessary to positively diagnose amyloidosis. Once\\nthe diagnosis has been confirmed, additional labora-\\ntory tests and imaging procedures are performed to\\ndetermine:\\n/C15which type of amyloid protein is involved\\n/C15which organ(s) or system(s) have been affected\\n/C15how far the disease has progressed\\nTreatment\\nThe goal of treatment is to slow down or stop\\nproduction of amyloid protein, eliminate existing\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 169\\nAmyloidosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 199, 'page_label': '170'}, page_content='amyloid deposits, allevi ate underlying disorders\\n(that give rise to secondary amyloidosis), and relieve\\nsymptoms caused by heart or kidney damage.\\nSpecialists in cardiology, hematology (the study of\\nblood and the tissues that form it), nephrology (the\\nstudy of kidney function and abnormalities), neuro-\\nlogy (the study of the nervous system), and rheuma-\\ntology (the study of disorders characterized by\\ninflammation or degeneration of connective tissue)\\nwork together to assess a patient’s medical status and\\nevaluate the effects of amyloidosis on every part of\\nthe body.\\nColchicine (Colebenemid, Probeneaid), predni-\\nsone, (Prodium), and other anti-inflammatory drugs\\ncan slow or stop disease progression. Bone-marrow\\nand stem-cell transplants can enable patients to toler-\\nate higher and more effective doses of melphalan\\n(Alkeran) and other chemotherapy drugs prescribed\\nto combat this non-malignant disease. Surgery can\\nrelieve nerve pressure and may be performed to correct\\nother symptom-producing conditions. Localized amy-\\nloid deposits can also be removed surgically. Dialysis\\nor kidney transplantation can lengthen and improve\\nthe quality of life for patients whose amyloidosis\\nresults in kidney failure. Heart transplants are rarely\\nperformed.\\nSupportive measures\\nAlthough no link has been established between\\ndiet and development of amyloid proteins, a patient\\nwhose heart or kidneys have been affected by the\\ndisease may be advised to use a diuretic or follow a\\nlow-salt diet.\\nPrognosis\\nMost cases of amyloidosis are diagnosed after\\nthe disease has reached an advanced stage. The course\\nof each patient’s illness is unique but death, usually\\na result of heart disease or kidney failure, generally\\noccurs within a few years. Amyloidosis associated\\nby multiple myeloma usually has a poor prognosis.\\nMost patients with both diseases die within one to\\ntwo years.\\nPrevention\\nGenetic couselingmay be helpful for patients with\\nhereditary amyloidosis and their families. Use of\\nCholchicine in patients with familial Mediterranean\\nfever has successfully prevented amyloidosis.\\nResources\\nORGANIZATIONS\\nAmyloidosis Network International. 7118 Cole Creek Drive,\\nHouston, TX 77092-1421. (888) 1AMYLOID.\\n.\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nMaureen Haggerty\\nAmyotrophic lateral sclerosis\\nDefinition\\nAmyotrophic lateral sclerosis (ALS) is a disease\\nthat breaks down tissues in the nervous system\\n(a neurodegenerative disease) of unknown cause that\\naffects the nerves responsible for movement. It is also\\nknown as motor neuron disease and Lou Gehrig’s\\ndisease, after the baseball 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\\nmovement. In ALS, for unknown reasons, these\\nneurons die, leading to a progressive loss of the ability\\nto move virtually any of the muscles in the body. ALS\\naffects ‘‘voluntary’’ muscles, those controlled by con-\\nscious thought, such as the arm, leg, and trunk mus-\\ncles. ALS, in and of itself, does not affect sensation,\\nthought processes, the heart muscle, or the ‘‘smooth’’\\nmuscle of the digestive system, bladder, and other\\ninternal organs. Most people with ALS retain function\\nof their eye muscles as well. However, various forms\\nof ALS may be associated with a loss of intellectual\\nfunction (dementia) or sensory symptoms.\\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,\\n170 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 200, 'page_label': '171'}, page_content='these neurons convey electrical messages from the\\nbrain to the muscles to stimulate movement in the\\narms, legs, trunk, neck, and head. As motor neurons\\ndie, the muscles they enervate cannot be moved as\\neffectively, and weakness results. In addition, lack of\\nstimulation leads to muscle wasting, or loss of bulk.\\nInvolvement of the upper motor neurons causes\\nspasms and increased tone in the limbs, and abnormal\\nreflexes. 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\\nradicals. Some evidence suggests that a cascade of\\nevents leads to excess free radical production inside\\nmotor neurons, leading to their death. Why free radi-\\ncals should be produced in excess amounts is unclear,\\nas is whether this excess is the cause or the effect of\\nother degenerative processes. Additional agents\\nwithin this toxic cascade may include excessive levels\\nof a neurotransmitter known as glutamate, which may\\nover-stimulate motor neurons, thereby increasing\\nfree-radical production, and a faulty detoxification\\nenzyme known as SOD-1, for superoxide dismutase\\ntype 1. The actual pathway of destruction is not\\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, neck,\\nand head. As motor neurons degenerate, the muscles are weakened and cannot move as effectively, leading to muscle wasting.\\n(Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 171\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 201, 'page_label': '172'}, page_content='known, however, nor is the trigger for the rapid degen-\\neration that marks ALS. Further research may show\\nthat other pathways are involved, perhaps ones even\\nmore important than this one. Autoimmune factors or\\npremature 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\\nALS cases. As the name suggests, familial ALS is\\nbelieved to be caused by the inheritance of one or\\nmore faulty genes. About 15% of families with this\\ntype of ALS have mutations in the gene for SOD-1.\\nSOD-1 gene defects are dominant, meaning only one\\ngene copy is needed to develop the disease. Therefore,\\na parent with the faulty gene has a 50% chance of\\npassing the gene along to a child.\\nSporadic ALS has no known cause. While many\\nenvironmental toxins have been suggested as causes,\\nto date no research has confirmed any of the candi-\\ndates investigated, including aluminum and mercury\\nand lead from dental fillings. As research progresses, it\\nis likely that many cases of sporadic ALS will be\\nshown to have a genetic basis as well.\\nA third type, called Western Pacific ALS, occurs\\nin Guam and other Pacific islands. This form com-\\nbines symptoms 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\\nrapid in the legs among people with familial ALS and\\nin the arms among those with sporadic ALS. Leg\\nweakness may first become apparent by an increased\\nfrequency of stumbling on uneven pavement, or an\\nunexplained difficulty climbing stairs. Arm weakness\\nmay lead to difficulty grasping and holding a cup, for\\ninstance, or loss of dexterity 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 speak-\\ning. A person with bulbar weakness may become\\nhoarse or tired after speaking at length, or speech\\nmay become slurred.\\nIn addition to weakness, the other cardinal signs\\nof ALS are muscle wasting and persistent twitching\\n(fasciculation). These are usually seen after weakness\\nbecomes obvious. Fasciculation is quite common in\\npeople without the disease, and is virtually never the\\nfirst sign of ALS.\\nWhile initial weakness may be limited to one\\nregion, ALS almost always progresses rapidly to\\ninvolve virtually all the voluntary muscle groups in\\nthe body. Later symptoms include loss of the ability\\nto walk, to use the arms and hands, to speak clearly or\\nat all, to swallow, and to hold the head up. Weakness\\nof the respiratory muscles makes breathing and\\ncoughing difficult, and poor swallowing control\\nincreases the likelihood of inhaling food or saliva\\n(aspiration). Aspiration increases the likelihood of\\nlung infection, which is often the cause of death.\\nWith a ventilator and scrupulous bronchial hygiene,\\nap e r s o nw i t hA L Sm a yl i v em u c hl o n g e rt h a nt h e\\naverage, although weakness and wasting will con-\\ntinue to erode any remaining functional abilities.\\nMost people with ALS continue to retain function\\nof the extraocular muscles that move their eyes,\\nallowing some communication to take place with\\nsimple blinks or through use of a computer-assisted\\ndevice.\\nDiagnosis\\nThe diagnosis of ALS begins with a complete\\nmedical history and physical exam, plus a neurological\\nexamination to determine the distribution and extent\\nof weakness. An electrical test of muscle function,\\ncalled an electromyogram, or EMG, is an important\\npart of the diagnostic process. Various other tests,\\nincluding blood and urine tests, x rays, and CT\\nscans, may be done to rule out other possible causes\\nof the symptoms, such as tumors of the skull base or\\nhigh cervical spinal cord, thyroid disease, spinal\\narthritis, lead poisoning, or severe vitamin deficiency.\\nALS is rarely misdiagnosed following a careful review\\nof all these factors.\\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\\nmuscle.\\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.\\n172 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 202, 'page_label': '173'}, page_content='Treatment\\nThere is no cure for ALS, and no treatment that\\ncan significantly alter its course. There are many\\nthings which can be done, however, to help maintain\\nquality of life and to retain functional ability even in\\nthe face of progressive weakness.\\nAs of the early 2000s, only one drug had been\\napproved for treatment of ALS. Riluzole (Rilutek)\\nappears to provide on average a three-month increase\\nin life expectancy when taken regularly early in the\\ndisease, and shows a significant slowing of the loss of\\nmuscle strength. Riluzole acts by decreasing gluta-\\nmate release from nerve terminals. Experimental\\ntrials of nerve growth factor have not demonstrated\\nany benefit. No other drug or vitamin currently avail-\\nable has been shown to have any effect on the course\\nof ALS.\\nA physical therapist works with an affected\\nperson and family to implementexercise and stretch-\\ning programs to maintain strength and range of\\nmotion, and to promote general health. Swimming\\nmay be a good choice for people with ALS, as it\\nprovides a low-impact workout to most muscle\\ngroups. One result of chronic inactivity is contrac-\\nture, or muscle shortening.Contractures limit a per-\\nson’s range of motion, and are often painful. Regular\\nstretching can prevent contracture. Several drugs are\\navailable to reduce cramping, a common complaint\\nin ALS.\\nAn occupational therapist can help design solu-\\ntions to movement and coordination problems, and\\nprovide advice on adaptive devices and home\\nmodifications.\\nSpeech and swallowing difficulties can be mini-\\nmized or delayed through training provided by a\\nspeech-language pathologist. This specialist can also\\nprovide advice on communication aids, including\\ncomputer-assisted devices and simpler word boards.\\nNutritional advice can be provided by a nutrition-\\nist. A person with ALS often needs softer foods to\\nprevent jaw exhaustion or choking. Later in the\\ndisease, nutrition may be provided by agastrostomy\\ntube inserted into the stomach.\\nMechanical ventilation may be used when breath-\\ning becomes too difficult. Modern mechanical venti-\\nlators are small and portable, allowing a person with\\nALS to maintain the maximum level of function and\\nmobility. Ventilation may be administered through a\\nmouth or nose piece, or through a tracheostomy tube.\\nThis tube is inserted through a small hole made in the\\nwindpipe. In addition to providing direct access to the\\nairway, the tube also decreases the risk aspiration.\\nWhile many people with rapidly progressing ALS\\nchoose not to use ventilators for lengthy periods,\\nthey are increasingly being used to prolong life for a\\nshort time.\\nThe progressive nature of ALS means that most\\npersons will eventually require full-time nursing care.\\nThis care is often provided by a spouse or other family\\nmember. While the skills involved are not difficult\\nto learn, the physical and emotional burden of care\\ncan be overwhelming. Caregivers need to recognize\\nand provide for their own needs as well as those of\\npeople with ALS, to prevent depression, burnout, and\\nbitterness.\\nThroughout the disease, a support group can pro-\\nvide important psychological aid to affected persons\\nand their caregivers as they come to terms with the\\nlosses ALS inflicts. Support groups are sponsored by\\nboth the ALS Society and the Muscular Dystrophy\\nAssociation.\\nAlternative treatment\\nGiven the grave prognosis and absence of tradi-\\ntional medical treatments, it is not surprising that a\\nlarge number of alternative treatments have been\\ntried for ALS. Two studies published in 1988 sug-\\ngested that amino-acid therapies may provide some\\nimprovement for some people with ALS. While indi-\\nvidual reports claim benefits for megavitamin the-\\nrapy, herbal medicine, and removal of dental fillings,\\nfor instance, no evidence suggests that these offer\\nany more than a brief psychological boost, often\\nfollowed by a more severe letdown when it becomes\\napparent the disease has continued unabated.\\nHowever, once the causes of ALS are better under-\\nstood, alternative therapies may be more intensively\\nstudied. For example, if damage by free radicals\\nturns out to be the root of most of the symptoms,\\nantioxidant vitamins and supplements may be used\\nmore routinely to slow theprogression of ALS. Or, if\\nenvironmental toxins are implicated, alternative\\ntherapies with the goal of detoxifying the body may\\nbe of some use.\\nPrognosis\\nALS usually progresses rapidly, and leads to\\ndeath from respiratory infection within three to five\\nyears in most cases. The slowest disease progression is\\nseen in those who are young and have their first symp-\\ntoms in the limbs. About 10% of people with ALS live\\nlonger than eight years.\\nGALE ENCYCLOPEDIA OF MEDICINE 173\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 203, 'page_label': '174'}, page_content='Prevention\\nThere is no known way to prevent ALS or to alter\\nits course.\\nResources\\nBOOKS\\nFeldman, Eva L. ‘‘Motor neuron diseases.’’ InCecil\\nTextbook of Medicine, edited by Lee Goldman\\nand J. Claude Bennett, 21st ed. Philadelphia:\\nW.B. Saunders, 2000, pp. 2089-2092.\\nPERIODICALS\\nAnsevin CF. ‘‘Treatment of ALS with pleconaril.’’\\nNeurology 56, no. 5 (2001): 691-692.\\nEisen, A., and M. Weber. ‘‘The motor cortex and amyotro-\\nphiclateral sclerosis.’’Muscle and Nerve 24, no. 4\\n(2001): 564-573.\\nGelanis DF. ‘‘Respiratory Failure or Impairment in\\nAmyotrophic Lateral Sclerosis.’’Current treatment\\noptions in neurology 3, no. 2 (2001): 133-138.\\nLudolph AC. ‘‘Treatment of amyotrophic lateral sclerosis–\\nwhat is the next step?’’Journal of Neurology 246,\\nSupplement 6 (2000): 13-18.\\nPasetti, C., and G. Zanini. ‘‘The physician-patient relationship\\ninamyotrophic lateral sclerosis.’’Neurological Science21,\\nno. 5 (2000): 318-323.\\nRobberecht W. ‘‘Genetics of amyotrophic lateral sclerosis.’’\\nJournal of Neurology 246, Supplement 6 (2000): 2-6.\\nRobbins, R.A., Z. Simmons, B.A. Bremer, S.M. Walsh, and\\nS. Fischer. ‘‘Quality of life in ALS is maintained as\\nphysical function declines.’’Neurology 56, no. 4 (2001):\\n442-444.\\nORGANIZATIONS\\nAmerican Medical Association. 515 N. State Street,\\nChicago, IL 60610. (312) 464-5000. .\\nMuscular Dystrophy Association. 3300 East Sunrise Drive,\\nTucson AZ 85718-3208. (520) 529-2000 or (800)\\n572-1717. .\\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\\nAnabolic steroid use\\nDefinition\\nAnabolic steroids are drugs containing hormones,\\nor hormone-like substances, that are used to increase\\nstrength and promote muscle growth.\\nDescription\\nSteroids are a synthetic version of the human\\nhormone called testosterone. Testosterone stimulates\\nand maintains the male sexual organs. It also stimu-\\nlates development of bones and muscle, promotes\\nskin and hair growth, and can influence emotions\\nand energy levels. In males, testosterone is produced\\nby the testicles and the adrenal gland. Women have\\nonly the amount of testosterone produced by the\\nadrenal gland—much less than men have. This is\\nwhy testosterone is often called a ‘‘male’’ hormone.\\nThere are more than 100 different types of anabolic\\nsteroids that have been developed, and each requires\\nap r e s c r i p t i o nt ob eu s e dl e g a l l yi nt h eU n i t e dS t a t e s .\\nThe average adult male naturally produces 2.5 to 11\\nmilligrams of testosterone daily. The average steroid\\nabuser often takes more than 100 mg a day, through\\n‘‘stacking’’ or combining several different brands of\\nsteroids.\\nMedical uses\\nAnabolic steroids were first developed in the\\n1930s in Europe, in part to increase the physical\\nstrength of German soldiers. Anabolic steroids were\\ntried by physicians for many other purposes in the\\n1940s and 1950s with varying success. Disadvantages\\noutweighed benefits for most purposes, and during the\\nlater decades of the twentieth century medical use in\\nNorth America and Europe was restricted to a few\\nconditions. These include:\\n/C15Bone marrow stimulation: During the second half of\\nthe twentieth century anabolic steroids were the\\nmainstay of therapy for hypoplastic anemia not due\\nto nutrient deficiency, especially aplastic anemia.\\nAnabolic steroids were slowly replaced by synthetic\\nprotein hormones that selectively stimulate growth\\nof blood cell precursors.\\n/C15Growth stimulation: Anabolic steroids were used\\nheavily by pediatric endocrinologists for children\\nwith growth failure from the 1960s through the\\n1980s. Availability of synthetic growth hormone\\nand increasing social stigmatization of anabolic ste-\\nroids led to reduction of this use.\\n174 GALE ENCYCLOPEDIA OF MEDICINE\\nAnabolic steroid use'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 204, 'page_label': '175'}, page_content='/C15Stimulation of appetite and preservation of muscle\\nmass: Anabolic steroids have been given to people\\nwith chronic wasting conditions such ascancer and\\nHIV/AIDS.\\n/C15Induction of malepuberty: Androgens are given to\\nmany boys distressed about extreme delay of pub-\\nerty. Testosterone is as of 2005 nearly the only andro-\\ngen used for this purpose, but synthetic anabolic\\nsteroids were often used prior to the 1980s.\\n/C15To treat certain kinds ofbreast cancerin some women.\\n/C15To treat angioedema, which causes swelling of the face,\\narms, legs, throat, windpipe, bowels, or sexual organs.\\nAbuse of steroids\\nThe controversy surrounding steroidabuse began\\nin the 1950s during the Olympic Games when the\\nathletic community discovered that athletes from\\nRussia and some East European nations, which had\\ndominated the games, had taken large doses of ster-\\noids. Many of the male athletes developed such large\\nprostate glands (a gland located near the bladder and\\nurethra that aids in semen production) that they\\nneeded a tube inserted in order to urinate. Some of\\nthe female athletes developed so many male character-\\nistics chromosome tests were necessary to prove that\\nthey were still women. Competitive weightlifters also\\nbegan using steroids in the 1950s as a way to increase\\ntheir athletic performance. Use gradually spread\\nthroughout the world among athletes in other sports.\\nConcerns over the growing illicit market and the\\nprevalence of abuse, combined with the possibility of\\nharmful long-term effects of steroids use, led the U.S.\\nCongress in 1991 to place anabolic steroids in\\nSchedule III of the Controlled Substances Act\\n(CSA). The CSA defines anabolic steroids as any\\ndrug or hormonal substance chemically and pharma-\\ncologically related to testosterone (other than estro-\\ngens, progestins, and corticosteroids) that promotes\\nmuscle growth. Most illicit anabolic steroids are sold\\nat gyms, bodybuilding competitions, and through the\\nmail and Internet. For the most part, these substances\\nare smuggled into the United States. Anabolic steroids\\ncommonly encountered on the illicit market include:\\nboldenone (Equipoise), ethlestrenol (Maxibolin),\\nfluoxymesterone (Halotestin), methandriol, methan-\\ndrostenolone (Dianabol), methyltestosterone, nan-\\ndrolone (Durabolin, DecaDurabolin), oxandrolone\\n(Anavar), oxymetholone (Anadrol), stanozolol\\n(Winstrol), testosterone (including sustanon), and\\ntrenbolone (Finajet). In addition, a number of coun-\\nterfeit products are sold as anabolic steroids.\\nKEY TERMS\\nAdrenal gland— An endocrine gland located\\nabove each kidney. The inner part of each gland\\nsecretes epinephrine and the outer part secretes\\nsteroids.\\nAndrogen— A natural or artificial steroid that acts\\nas a male sex hormone. Androgens are responsible\\nfor the development of male sex organs and sec-\\nondary sexual characteristics. Testosterone and\\nandrosterone are androgens.\\nAndrostenedione— Also called ‘‘andro,’’ this hor-\\nmone occurs naturally during the making of testos-\\nterone and estrogen.\\nCatabolic— A metabolic process in which energy is\\nreleased through the conversion of complex mole-\\ncules into simpler ones.\\nCorticosteroids— A steroid hormone produced by\\nthe adrenal gland and involved in metabolism and\\nimmune response.\\nEndocrinologist— A medical specialist who treats\\nendocrine (glands that secrete hormones intern-\\nally directly into the lymph or bloodstream)\\ndisorders.\\nEstrogen— Any of several steroid hormones, pro-\\nduced mainly in the ovaries, that stimulate estrus\\nand the development of female secondary sexual\\ncharacteristics.\\nHormone— A chemical substance produced in the\\nbody’s endocrine glands or certain other cells that\\nexerts a regulatory or stimulatory effect, for exam-\\nple, in metabolism.\\nHypoplastic anemia— Anemia that is characterized\\nby defective function of the blood-forming organs\\n(such as bone marrow) and is caused by toxic\\nagents such as chemicals or x rays. Anemia is a\\nblood condition in which there are too few red\\nblood cells or the red blood cells are deficient in\\nhemoglobin.\\nProgestins— A female steroid sex hormone.\\nProhormones— A physiologically inactive precur-\\nsor of a hormone.\\nProstate gland— An O-shaped gland in males that\\nsecretes a fluid into the semen that acts to improve\\nthe movement and viability of sperm.\\nTestosterone— A male steroid hormone produced\\nin the testicles and responsible for the development\\nof secondary sex characteristics.\\nGALE ENCYCLOPEDIA OF MEDICINE 175\\nAnabolic steroid use'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 205, 'page_label': '176'}, page_content='In 2004, federal health officials initiated a crack-\\ndown on companies that manufacture, market, or\\ndistribute products containing androstenedione, or\\n‘‘andro,’’ due to concerns about the safety of the sub-\\nstance. Widely marketed to athletes and body\\nbuilders, androstenedione has been advertised to pro-\\nmote muscle growth, improve muscular strength,\\nreduce fat, and slowaging. Androstenedione acts like\\na steroid once it is metabolized by the body and can\\npose similar kinds of health risks. People produce\\nandrostenedione naturally during the making of tes-\\ntosterone and estrogen. When people consume\\nandrostenedione, it is converted into testosterone\\nand estrogen. Scientific evidence shows that when\\nandrostenedione is taken over time and in sufficient\\nquantities, it may increase the risk of serious and life-\\nthreatening diseases, including liver failure.\\nOn January 20, 2005, the Anabolic Steroid Control\\nAct of 2004 took effect, amending the Controlled\\nSubstance Act by placing both anabolic steroids and\\nprohormones on a list of controlled substances, making\\npossession of the banned substances a federal crime.\\nAlso in 2005, Major League Baseball (MLB), amid\\nlong-time rumors of anabolic steroid abuse among\\nplayers, was rocked by the publication ofJuiced by\\nformer Oakland Athletics outfielder Jose Canseco\\nwho alleged steroid abuse was wide-spread in profes-\\nsional baseball. In response, Congress held hearings in\\nMarch 2005 on steroid abuse in the MLB, subpoenaing\\nsuch baseball superstars as home run champion Mark\\nMcGwire (now retired), Sammy Sosa, and Curt\\nSchilling to testify. In response, MLB officials promised\\na crackdown on anabolic steroid use among players.\\nIt has been estimated that at least one in 15 male\\nhigh school seniors in the United States—more than\\n500,000 boys—has used steroids. Some are athletes\\nattempting to increase their strength and size; others\\nare simply youths attempting to speed up their growth\\nto keep pace with their peers. In some countries, ana-\\nbolic steroids are available over the counter. In the\\nUnited States, a doctor’s prescription is necessary.\\nCauses and symptoms\\nWhile the effects of steroids can seem desirable at\\nfirst, there are serious side effects. Excessive use can\\ncause a harmful imbalance in the body’s normal hor-\\nmonal balance and body chemistry. Heart attacks,\\nwater retention leading to high blood pressure and\\nstroke, and liver and kidney tumors all are possible.\\nYoung people may developacne, sometimes severe,\\nand a halting of bone growth. Males may experience\\nshrinking testicles, falling sperm counts, enlarged\\nbreasts, and enlarged prostate glands. Women fre-\\nquently show signs of masculinity and may be at higher\\nrisk for certain types of cancer and the possibility of\\nbirth defects in their children. Steroids fool the body\\ninto thinking that testosterone is being produced. The\\nbody, sensing an excess of testosterone, shuts down\\nbodily functions involving testosterone, such as bone\\ngrowth. The ends of long bones fuse together and stop\\ngrowing, resulting in stunted growth.\\nThe psychological effects of steroid use are also\\nalarming: drastic mood swings, inability to sleep,\\ndepression, and feelings of hostility. Steroids may\\nalso be psychologically addictive. Once started,\\nusers—particularly athletes—enjoy the physical so-\\ncalled benefits of increased size, strength, and endur-\\nance so much that they are reluctant to stop even when\\ntold about the risks.\\nIn addition to these dangerous side effects, steroid\\nabuse brings other risks, some of which are connected\\nto the way some steroids are manufactured and dis-\\ntributed. The drugs are often made in motel rooms and\\nwarehouses in Mexico, Europe, and other countries\\nand then smuggled into the United States. The\\npotency, purity, and strength of the steroids produced\\nthis way are not regulated; therefore, users cannot\\nknow how much they are taking. Counterfeit steroids\\nare also sold as the real thing. So it is often impossible\\nto tell exactly what some products contain.\\nMost data on the long-term effects of anabolic\\nsteroids on humans come from case reports rather\\nthan formal scientific studies. From the case reports,\\nthe incidence of life-threatening effects appears to be\\nlow, but serious adverse effects may be under-recog-\\nnized or under-reported. Data from animal studies\\nseem to support this possibility. One study found\\nthat exposing male mice for one-fifth of their lifespan\\nto steroid doses comparable to those taken by human\\nathletes caused a high percentage of premature deaths.\\nMost effects of anabolic steroid use are reversible if\\nthe abuser stops taking the drugs, but some can be\\npermanent.\\nDiagnosis\\nAnyone who is using anabolic steroids without a\\nprescription and not under the direction of a physician\\nis considered abusing the drug and should seek medi-\\ncal help in stopping the use.\\nTreatment\\nFew studies of treatments for anabolic steroid\\nabuse have been conducted. Knowledge as of 2005 is\\n176 GALE ENCYCLOPEDIA OF MEDICINE\\nAnabolic steroid use'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 206, 'page_label': '177'}, page_content='based largely on the experiences of a small number of\\nphysicians who have worked with patients undergoing\\nsteroid withdrawal. The physicians have found that\\nsupportive therapy is sufficient in some cases. Patients\\nare educated about what they may experience during\\nwithdrawal and are evaluated for suicidal thoughts. If\\nsymptoms are severe or prolonged, medications or\\nhospitalization may be needed.\\nSome medications that have been used for treating\\nsteroid withdrawal restore the hormonal system after\\nits disruption by steroid abuse. Other medications tar-\\nget specific withdrawal symptoms, for example, antide-\\npressants to treat depression, and analgesics (pain\\nkillers, such asaspirin and ibuprofen) for headaches\\nand muscle and joint pains. Some patients require assis-\\ntance beyond simple treatment of withdrawal symp-\\ntoms and are treated with behavioral therapies.\\nAlternative treatment\\nThere is little data on alternative medicines or\\ntreatments for anabolic steroid abuse. However, ana-\\nbolic steroid manufacturers recommendsaw palmetto\\nto be taken in conjunction with androstenedione as it\\ncan help reduce associated hair loss and is useful in\\ncontrolling prostate enlargement.\\nPrognosis\\nAnabolic steroid abuse is a treatable condition\\nand can be stopped. Teenagers and adults can over-\\ncome the problem with the help of parents and other\\nfamily members, support groups, psychotherapy,\\nmedication, treatment programs, and family counsel-\\ning. These programs are customized to help teens and\\nadults lead productive and normal lives. However,\\nheavy steroid use—even if it is stopped after a few\\nyears—may increase the risk ofliver cancer. A steroid\\nuser who quits may suffer a side effect commonly linked\\nto low testosterone—severe depression—which can\\nlead to suicidal thoughts and evensuicide. The risk of\\ndepression and suicide is highest among teens.\\nSome physicians recommend that athletes using\\nsteroids avoid sudden discontinuance of all steroids at\\nthe same time because their bodies may enter an\\nimmediate catabolic (sudden release of energy)\\nphase. The cortisone receptors will be free and in\\ncombination with the low testosterone and androgen\\nlevels, a considerable loss of strength and mass, and an\\nincrease of fat and water, and often breast enlarge-\\nment in males can occur. Breast enlargement is possi-\\nble because the suddenly low androgen level shifts the\\nrelationship in favor of the estrogens which suddenly\\nbecome the domineering hormone.\\nPrevention\\nThe best prevention is education to alert young\\npeople to the dangers, both medical and legal, in the\\nillegal use of anabolic steroids. In its effort to alert\\nteenagers to the dangers of steroid abuse, the U.S.\\nFood and Drug Administration (FDA) developed a\\nseries of pamphlets, posters, and public service\\nannouncements. Much of this information is available\\non-line at . Anabolic steroids\\nare in the same regulatory category ascocaine, heroin,\\nLSD, and other habit-forming drugs. This means that,\\nin addition to the FDA, the Drug Enforcement Agency\\n(DEA) helps to enforce laws relating to their abuse.\\nAthletic organizations have joined the fight. The\\nOlympic Games are now closely monitored to prevent\\nathletes who use steroids from participating. The\\nNational Football League has a strict testing policy\\nin its training camps; it delivers fines and suspensions\\nto those who test positive and bans repeat offenders.\\nThe National Collegiate Athletic Association, too, has\\nestablished stricter measures for testing and disciplin-\\ning steroid users.\\nResources\\nBOOKS\\nAretha, David.Steroids and Other Performance-Enhancing\\nDrugs. Berkeley Heights, NJ: MyReportLinks.com,\\n2005.\\nCanseco, Jose.Juiced: Wild Times, Rampant ‘Roids, Smash\\nHits, and How Baseball Got Big. New York City: Regan\\nBooks, 2005.\\nLevert, Suzanne.The Facts about Steroids. New York:\\nBenchmark Books, 2004.\\nTaylor, William N.Anabolic Therapy in Modern Medicine.\\nJefferson, NC: McFarland & Company, 2002.\\nPERIODICALS\\nAdler, Jerry. ‘‘Toxic Strength: The Headlines about Illegal\\nSteroids Have Focused on Professional and Olympic\\nAthletes. But the Most Vulnerable Users May Be Kids\\nin Your Neighborhood, High-Schoolers Who Are\\nRisking an Array of Frightful Side Effects that Can\\nLead to Death.’’Newsweek (December 20, 2004): 44.\\nBates, Betsy. ‘‘Elite Athletes Not Alone in Anabolic Steroid\\nAbuse: Missed by Drug Testing.’’Internal Medicine\\nNews (February 1, 2004): 38.\\nBrown, Tim. ‘‘McGwire Appears to Suffer Lasting Damage\\nto Credibility after Refusing to Discuss Steroids, and\\nBaseball Will Tinker with Details of Its Drug Policy.’’\\nLos Angeles Times (March 19, 2005): D–1.\\nGoodlad, Terry. ‘‘Dancing with the Dark Side: So, You\\nThink You’re Ready for Your First Steroid Cycle?’’\\nFlex (April 2004): 90–96.\\nIngram, Scott. ‘‘Buff Enough? More Teens Are Using\\nSteroids to Look Pumped and Do Better at Sports. Do\\nGALE ENCYCLOPEDIA OF MEDICINE 177\\nAnabolic steroid use'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 207, 'page_label': '178'}, page_content='they Know the Terrible Risk They’re Taking?’’Current\\nScience (September 24, 2004): 4–8.\\nPoniewozik, James. ‘‘This Is Your Nation on Steroids: Why\\nDoes a Performance-Enhanced Society Scorn\\nPerformance-Enhanced Athletes?’’Time (December 20,\\n2004): 168.\\nORGANIZATIONS\\nNational Center for Drug Free Sport Inc. 810 Baltimore St.,\\nKansas City, MO 64105. (816) 474-7329. .\\nNational Institute on Drug Abuse. 6001 Executive Blvd.,\\nBethesda, MD 20892. (301)443-1124. . .\\nOTHER\\nDrug Enforcement Administration.Steroid Abuse in\\nToday’s Society, March 2004. [cited March 21, 2005].\\n.\\nFocus Adolescent Service.Teens and Anabolic Steroids ,\\n2005. [cited March 21, 2005]. .\\nKen R. Wells\\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\\ndeep wounds, deep tissues, and internal organs where\\nthere is little oxygen. These infections are character-\\nized byabscess formation, foul-smelling pus, and tis-\\nsue destruction.\\nDescription\\nAnaerobic means ‘‘life without air.’’ Anaerobic\\nbacteria grow in places which completely, or almost\\ncompletely, lack oxygen. They are normally found in\\nthe mouth, gastrointestinal tract, and vagina, and on\\nthe skin. Commonly known diseases caused by anae-\\nrobic bacteria include gasgangrene, tetanus,a n dbotu-\\nlism. Nearly all dental infections are caused by\\nanaerobic 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/C15Mouth, head, and neck. Infections can occur in the\\nroot canals, gums (gingivitis), jaw, tonsils, throat,\\nsinuses, and ears.\\n/C15Lung. Anaerobic bacteria can causepneumonia,l u n g\\nabscesses, infecton of the lining of the lung\\n(empyema), and dilated lung bronchi (bronchiectasis).\\n/C15Intraabdominal. Anaerobic infections within the\\nabdomen include abscess formation,peritonitis, and\\nappendicitis.\\n/C15Female genital tract. Anaerobic bacteria can cause\\npelvic abscesses,pelvic inflammatory disease, inflam-\\nmation of the uterine lining (endometritis), and pelvic\\ninfections following abortion,childbirth, and surgery.\\n/C15Skin and soft tissue. Anaerobic bacteria are common\\ncauses of diabetic skin ulcers, gangrene, destructive\\ninfection of the deep skin and tissues (necrotizing\\nfascitis), and bite wound infections.\\n/C15Central nervous system. Anaerobic bacteria can\\ncause brain and spinal cord abscesses.\\n/C15Bloodstream. Anaerobic bacteria can be found in the\\nbloodstream of ill patients (a condition called\\nbacteremia).\\nCauses and symptoms\\nPeople who have experienced shock, injury, or\\nsurgery, and those with blood vessel disease or\\ntumors are at an increased risk for infection by anae-\\nrobic bacteria. There are many different kinds of\\nanaerobic bacteria which can cause an infection.\\nIndeed, most anaerobic infections are ‘‘mixed infec-\\ntions’’ which means that there is a mixture of differ-\\nent bacteria growing. The anaerobic bacteria that\\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.\\n178 GALE ENCYCLOPEDIA OF MEDICINE\\nAnaerobic infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 208, 'page_label': '179'}, page_content='most frequently ca use infections are Bacteroides\\nfragilis, Peptostreptococcus ,a n dClostridium species.\\nThe signs and symptoms of anaerobic infection can\\nvary depending on the location of the infection. In gen-\\neral, anaerobic infections result in tissue destruction, an\\nabscess which drains foul-smelling pus, and possibly\\nfever. Symptoms for specific infections are as follows:\\n/C15Tooth and gum infections. Swollen, tender bleeding\\ngums, bad breath,a n dpain. Severe infections may\\nproduce oozing sores.\\n/C15Throat infection. An extremely sore throat, bad\\nbreath, a bad taste in the mouth, fever, and a sense\\nof choking.\\n/C15Lung infection. Chest pain, coughing, difficulty brea-\\nthing, fever, foul-smelling sputum, and weight loss.\\n/C15Intraabdominal infection. Pain, fever, and possibly,\\nif following surgery, foul- smelling drainage from the\\nwound.\\n/C15Pelvic infection. Foul-smelling pus or blood draining\\nfrom the uterus, general or localized pelvic pain,\\nfever, and chills.\\n/C15Skin and soft tissue infection. Infected wounds are\\nred, painful, swollen, and may drain a foul-smelling\\npus. Skin infection causes localized swelling, pain,\\nredness, and possibly a painful, open sore (ulcer)\\nwhich drains foul-smelling pus. Severe skin infections\\nmay cause extensive tissue destruction (necrosis).\\n/C15Bloodstream. Bloodstream invasion causes high\\nfever (up to 1058F [40.68C]), chills, a general ill feel-\\ning, and is potentially fatal.\\nDiagnosis\\nThe diagnosis of anaerobic infection is based pri-\\nmarily on symptoms, the patient’s medical history,\\nand location of the infection. A foul-smelling infection\\nor drainage from an abscess is diagnostic of anaerobic\\ninfection. This foul smell is produced by anaerobic\\nbacteria and occurs in one third to one half of patients\\nlate in the infection. Other clues to anaerobic infection\\ninclude tissue necrosis and gas production at the infection\\nsite. A sample from the infected site may be obtained,\\nu s i n gas w a bo ran e e d l ea n ds y r i n g e ,t od e t e r m i n ew h i c h\\nbacteria is (are) causing the infection. Because these bac-\\nteria can be easily killed by oxygen, they rarely grow in\\nthe laboratory cultures of tissue or pus samples.\\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 withantibiotics\\nthat aren’t able to kill anaerobes is another clue that\\nthe infection is caused by anaerobes. The location and\\ntype of 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 anti-\\nbiotic will work best. Every antibiotic does not work\\nagainst all anaerobic bacteria but nearly all anaerobes\\nare killed by chloramphenicol (Chloromycetin), metro-\\nnidazole (Flagyl or Protostat), and imipenem\\n(Primaxin). Other antibiotics which may be used are\\nclindamycin (Cleocin) or cefoxitin (Mefoxin).\\nSurgical removal or drainage of the abscess is\\nalmost always required. This may involve drainage\\nby needle and syringe to remove the pus from a skin\\nabscess (called ‘‘aspira tion’’). The area would be\\nnumbed prior to the aspiration procedure. Also,\\nsome internal abscesses can be drained using this\\nprocedure with the help of ultrasound (a device\\nwhich uses sound waves to visualize internal organs).\\nThis type of abscess drainage may be performed in\\nthe doctor’s office.\\nPrognosis\\nComplete recovery should be achieved with the\\nappropriate surgery and antibiotic treatment.\\nUntreated or uncontrolled infections can cause severe\\ntissue and bone destruction, which would requireplas-\\ntic surgery to repair. Serious infections can be life\\nthreatening.\\nPrevention\\nAlthough anaerobic infections can occur in any-\\none, good hygiene and general health may help to\\nprevent infections.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nBelinda Rowland, PhD\\nAnaerobic myositis see Gangrene\\nGALE ENCYCLOPEDIA OF MEDICINE 179\\nAnaerobic infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 209, 'page_label': '180'}, page_content='Anal 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\\nboys with high anal atresia, there may be a channel\\n(fistula) connecting the large intestine to either the\\nurethra (which delivers urine from the bladder) or\\nthe bladder itself. In girls, the channel may connect\\nwith the vagina. Sixty percent of children with high\\nanal atresia have other defects, including problems\\nwith the esophagus, urinary tract, and bones. In low\\nanal atresia, the channel may open in front of the\\ncircular mass of muscles that constrict to close the\\nanal opening (anal sphincter) or, in boys, below\\nthe scrotum. Occasionally, the intestine ends just\\nunder the skin. It is estimated that overall abnormal-\\nities of the anus and rectum occur in about one in every\\n5,000 births and are slightly more common among\\nboys. A mother who has one child with these kind of\\nconditions has a 1% chance of having another child\\nwho suffers from this ailment.\\nCauses and symptoms\\nAnal atresia is a defect in the development of the\\nfetus. The cause is unknown, but genetics seem to play\\na minor 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\\nvomiting of fecal material. To determine the type of\\nanal atresia and the exact position, x rays will be taken\\nwhich include injecting opaque dye into the opening.\\nMagnetic resonance imaging (MRI) orcomputed tomo-\\ngraphy scans(CT), as well as ultrasound, are the ima-\\nging techniques used to determine the type and size of\\nthe anal atresia. Ultrasound uses sound waves, CT\\nscans pass x rays through the body at different angles,\\nand an MRI uses a magnetic field and radio waves.\\nTreatment\\nSurgery is the only treatment for anal atresia. For\\nhigh anal atresia, immediately after the diagnosis is\\nmade, a surgical incision is made in the large intestine\\nto make a temporary opening (colostomy) in the abdo-\\nmen where waste is excreted. Several months later, the\\nintestine is moved into the ring of muscle (sphincter)\\nthat is part of the anus and a hole is made in the skin.\\nThe colostomy is closed several weeks later. In low anal\\natresia, immediately after diagnosis, a hole is made in\\nthe skin to open the area where the anus should be. If\\nthe channel is in the wrong place, the intestine is\\nmoved into the correct position sometime during the\\nchild’s first year. After surgery, the pediatric surgeon\\nuses an instrument to dilate or widen the rectum and\\nteaches the parents how to do this daily at home to\\nprevent scar tissue from contracting.\\nPrognosis\\nWith high anal atresia, many children have pro-\\nblems controlling bowel function. Most also become\\nconstipated. With low anal atresia, children generally\\nhave good bowel control, but they may still become\\nconstipated.\\nPrevention\\nThere is no known way to prevent anal atresia.\\nResources\\nBOOKS\\nPaidas, Charles N., and Alberto Pena. ‘‘Rectum and Anus.’’\\nIn Surgery of Infants and Children. Philadelphia:\\nLippincott-Raven, 1997.\\nJeanine Barone, Physiologist\\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 abdomen\\nand 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.\\n180 GALE ENCYCLOPEDIA OF MEDICINE\\nAnal atresia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 210, 'page_label': '181'}, page_content='Anal cancer\\nDefinition\\nAnal cancer is an uncommon form of cancer\\naffecting the anus. The anus is the inch-and-a-half-\\nlong end portion of the large intestine, which opens\\nto allow solid wastes to exit the body. Other parts of\\nthe large intestine include 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. Someanal warts, for example,\\ncontain precancerous areas and can develop into can-\\ncer. Types of anal cancer include:\\n/C15Squamous Cell Carcinomas. Approximately half of\\nanal cancers are squamous cell carcinomas, which\\narise from the cells lining the anal margin and the\\nanal canal. The anal margin is the part of the anus\\nthat is half inside and half outside the body, and the\\nanal canal is the part of the anus that is inside the\\nbody. The earliest form of squamous cell carcinoma\\nis known as carcinoma in situ, or Bowen’s disease.\\n/C15Cloacogenic Carcinomas. Approximately one-\\nfourth to one-third of anal tumors are cloacogenic\\ncarcinomas. These tumors develop in the transitional\\nzone, or cloaca, which is a ring of tissue between the\\nanal canal and the rectum.\\n/C15Adenocarcinomas. About 15% of anal cancers are\\nadenocarcinomas, which affect glands in the anal\\narea. One type of adenocarcinoma that can occur in\\nthe anal area is called Paget’s disease, which can also\\naffect the vulva, breasts, and other areas of the body.\\n/C15Skin cancers. A small percentage of anal cancers are\\neither basal cell carcinomas, or malignant melano-\\nmas, two types of skin cancer. Malignant melano-\\nmas, which develop from skin cells that produce the\\nbrown pigment called melanin, are far more common\\non areas of the body exposed to the sun.\\nApproximately 3,500 Americans will be diag-\\nnosed with anal cancer in 2001, and an estimated 500\\nindividuals will die of the disease during this same\\ninterval, according to the American Cancer Society.\\nAnal cancers are fairly rare: they make up only 1% to\\n2% of cancers affecting the digestive system. The dis-\\nease affects women somewhat more often than men,\\nalthough the number of cases among men, particularly\\nhomosexual men, seems to be increasing.\\nCauses and symptoms\\nThe exact cause of most anal cancers is unknown,\\nalthough certain individuals appear to have a higher\\nrisk of developing the disease. Smokers are at higher\\nrisk, as are individuals with certain types of the human\\npapillomavirus (HPV), and those with long-term pro-\\nblems in the anal area, such as abnormal openings\\nknown as fistulas. Since it increases the risk of HPV\\ninfection, the practice of anal sex appears to increase\\nthe risk of anal cancer—male homosexuals who prac-\\ntice anal sex are about 33 times more likely to have\\nanal cancers than heterosexual men. Those with wea-\\nkened immune systems, such individuals with HIV, or\\ntransplant patients taking immunosuppressant drugs,\\nare also at higher risk. Most individuals with anal\\ncancer 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\\nnodes in the anal or groin area.\\nDiagnosis\\nAnal cancer is sometimes diagnosed during rou-\\ntine physicals, or during minor procedures such as\\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 drugs\\ndelivered into the blood stream kill cancer cells or\\nmake them more vulnerable to radiation therapy.\\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 syndrome\\n(AIDS).\\nLymph nodes— Bean-shaped structures found\\nthroughout the body that produce and store\\ninfection-fighting cells.\\nRadiation therapy— A cancer treatment that uses\\nhigh-energy rays to kill or weaken cancer cells.\\nRadiation may be delivered externally or internally\\nvia surgically implanted pellets.\\nGALE ENCYCLOPEDIA OF MEDICINE 181\\nAnal cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 211, 'page_label': '182'}, page_content='hemorrhoid removal. It may also be diagnosed during\\na digital rectal examination (DRE), when a physician\\ninserts a gloved, lubricated finger into the anus to\\nfeel for unusual growths. Individuals over the age of\\n50 who have no symptoms should have a digitalrectal\\nexamination (DRE) every five to 10 years, according\\nto American Cancer Society (ACS) guidelines for early\\ndetection of colorectal cancer.\\nOther diagnostic procedures for anal cancer\\ninclude: Anoscopy. A procedure that involves use of a\\nspecial device to examine the anus. Proctoscopy. A\\nprocedure that involves use of a lighted scope to see\\nthe anal canal. Transrectal ultrasound. A procedure in\\nwhich sound waves are used to create an image of the\\nanus 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\\nperform a procedure called a fine needle aspiration\\nbiopsy, in which a needle is used to withdraw fluid\\nfrom lymph nodes located near the growth, to make\\nsure the cancer has not spread to these nodes.\\nAnal cancer severity is categorized by the follow-\\ning stages:\\n/C15Stage 0 anal cancer is found only in the top layer of\\nanal tissue.\\n/C15Stage I anal cancer has spread beyond the top layer\\nof anal tissue, but is less than 1 inch in diameter.\\n/C15Stage II anal cancer has spread beyond the top layer\\nof anal tissue and is larger than 1 inch in diameter,\\nbut has not spread to nearby organs or lymph nodes.\\n/C15Stage IIIA anal cancer has spread to the lymph nodes\\naround the rectum or to nearby organs such as the\\nvagina or bladder.\\n/C15Stage IIIB anal cancer has spread to lymph nodes in\\nthe mid-abdomen or groin, or to nearby organs and\\nthe lymph nodes around the rectum.\\n/C15Stage IV anal cancer has spread to distant lymph\\nnodes within the abdomen or to distantorgans.\\nTreatment\\nAnal cancer is treated using three methods, used\\neither in concert or individually: surgery, radiation\\ntherapy, andchemotherapy.\\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\\nthe tumor. An abdominoperineal resection is a more\\ncomplex procedure in which the anus and the lower\\nrectum are removed, and an opening called acolost-\\nomy is created for body wastes to exit. This procedure\\nis fairly uncommon today because radiation and\\nchemotherapy are just as effective.\\nChemotherapy fights cancer using drugs, which\\nmay be delivered via pill or needle. Some chemother-\\napy types kill cancer cells directly, while others act\\nindirectly by making cancer cells more vulnerable to\\nradiation. The main drugs used to treat anal cancer\\nare 5-fluorouracil (5-FU) and mitomycin or 5-FU\\nand cisplatin. Side effects of chemotherapy, which\\ndamages normal cells in addition to cancer cells, may\\ninclude nausea and vomiting, hair loss, loss of appetite,\\ndiarrhea, mouth sores, fatigue, shortness of breath,\\nand a weakened immune system.\\nAlternative treatment\\nResearch suggests acupuncture can help manage\\nchemotherapy-related nausea and vomiting and con-\\ntrol pain associated with surgery.\\nPrognosis\\nAnalcancer isoftencurable.Thechanceof recovery\\ndepends on the cancer stage and the patient’s general\\nhealth.\\nPrevention\\nReducing the risks of thesexually transmitted dis-\\neases HPV and HIV also reduces the risk of anal\\ncancer. In addition, quittingsmoking lowers the risk\\nof anal cancer.\\nResources\\nPERIODICALS\\nM u r a k a m i ,M ,K .J .G u r s k i ,a n dM .A .S t e l l e r\\n‘‘Human Papillomavirus Vaccines For Cervical Cancer.’’\\nJournal of Immunotherapy 22, no. 3 (1999): 212-8.\\nORGANIZATIONS\\nAmerican Cancer Society 1599 Clifton Road, NE, Atlanta,\\nGA 30329. (404) 320-3333 or (800) ACS-2345. Fax:\\n(404) 329-7530. .\\nAmerican College of Gastroenterology. 4900 B South 31st\\nSt., Arlington, VA 22206-1656. (703) 820-7400.\\n.\\nAmerican Gastroenterological Association. 7910\\nWoodmont Ave., Seventh Floor, Bethesda, MD 20814.\\n(301) 654-2055. .\\nAmerican Society of Colon and Rectal Surgeons. 85 W.\\nAlgonquin Road, Suite 550, Arlington Heights, Illinois\\n60005. (847) 290-9184.\\n182\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAnal cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 212, 'page_label': '183'}, page_content='National Cancer Institute (National Institutes of Health).\\n9000 Rockville Pike, Bethesda, MD 20892. (800) 422-\\n6237. .\\nNational Coalition for Cancer Survivorship. 1010 Wayne\\nAvenue, 5th Floor, Suite 300, Silver Spring, MD 20910.\\n(888) 650-9127.\\nNCI Office of Cancer Complementary and Alternative\\nMedicine. .\\nNIH 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 cauli-\\nflower-like protuberances. They can be yellow, pink,\\nor light brown in color, and only rarely are painful or\\nuncomfortable. In fact, infected individuals often are\\nunaware that they exist. Most cases are caused by\\nsexual transmission.\\nMost individuals have between one to 10 genital\\nwarts thtat range in size from roughly 0.5–1.9 cm\\n2.\\nSome will complain of painless bumps oritching, but\\noften, these warts can remain completely unnoticed.\\nCauses and symptoms\\nCondyloma acuminatum is one of the most com-\\nmon sexually transmitted disease (STD) in the United\\nStates. Young adults aged 17 to 33 years are at greatest\\nrisk. Risk factors include smoking, using oral contra-\\nceptives, having multiple sexual partners, and an early\\ncoital age. 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\\nare the least likely of over 60 types of HPV to become\\ncancerous. Anal warts are usually transmitted through\\ndirect sexual contact with someone who is infected with\\ncondyloma acuminata anywhere in the genital area,\\nincluding the penis and vagina. Studies have shown\\nthat roughly 75% of those who engage in sexual con-\\ntact with someone infected with condyloma acuminata\\nwill develop these warts within three months.\\nTreatment\\nAccordingtoguidelinesfromtheCentersforDisease\\nControl (CDC), the treatment ofallgenital warts,includ-\\ning anal warts, should be conducted according to the\\nmethods preferred by the patient, the medications or\\nprocedures most readily available, and the experience\\nof the patient’s physician in removing anal warts.\\nTreatment options include electrical cautery, sur-\\ngical removal, or both. Warts that appear inside the\\nanal canal will almost always be treated with cauter-\\nization or surgical removal. Surgical removal, also\\nknown as excision, has the highest success rates and\\nlowest recurrence rates. Indeed, studies have shown\\nthat initial cure rates range from 63–91%.\\nUnfortunately, most cases require numerous\\ntreatments because the virus that causes the warts\\ncan live in the surrounding tissue. The area may seem\\nnormal and wart-free for six months or longer before\\nanother wart develops.\\nElectrocoagulation, a technique that uses electri-\\ncal energy to destroy the warts, is usually the most\\npainful of the procedures done to eliminate condy-\\nloma acuminata of the anus, and is usually reserved\\nfor larger warts. It is done withlocal anesthesia, and\\nmay cause discharge or bleeding from the anus.\\nFollow-up visits to the physician are necessary to\\nmake sure that the warts have not recurred. It is\\nrecommended that these patients see their physicians\\nevery three to six months for up to 1.5 years, which is\\nhow long the 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\\nKEY TERMS\\nElectrocoagulation— at e c h n i q u eu s i n ge l e c t r i c a l\\nenergy to destroy the warts. Usually done for warts\\nwithin the anus with a local anesthesia, electrocoa-\\ngulation is most painful form of therapy, and can\\ncause both bleeding and discharge from the anus.\\nGALE ENCYCLOPEDIA OF MEDICINE 183\\nAnal warts'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 213, 'page_label': '184'}, page_content='be transmitted via the smoke caused by these proce-\\ndures, they are usually reserved for the worst infections.\\nFor small warts that affect only the skin around\\nthe anus, several medications are available, which can\\nbe applied directly to the surface of the warts by a\\nphysician or by the patients themselves.\\nSuch medications include podophyllum resin\\n(Podocon-25, Pod-Ben-25), a substance made from\\nthe cytotoxic extracts of several plants. This agent\\noffers a cure rate of 20–50% when used alone, and is\\napplied by the physician weekly and then washed off\\n6 hours later by the patient.\\nPodofilox (Condylox) is another agent, and is\\navailable for patients to use at home. It can be applied\\ntwice daily for up to 4 weeks. Podofilox offers a\\nslightly higher cure rate than podophyllin, and can\\nalso be used to prevent 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\\ncauterize the skin, and are quite caustic. Nevertheless,\\nthey cause less irritation and overall body effects than\\nthe other agents mentioned above. Recurrence, how-\\never, is higher with these acids.\\nBleomycin (Blenoxane) is another treatment\\noption, but it has several drawbacks. First, it must be\\nadministered by a physician into each lesion via injec-\\ntion, but is can have a host of side effects, and patients\\nmust be followed carefully by their physician.\\nImiquimod 5% cream is also available for patients\\nto apply themselves. It is to be applied three times\\nweekly, for up to 16 weeks, and has been shown to\\nclear warts within 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\\ninto each lesion twice a week for up to eight weeks.\\nPrognosis\\nOnce a diagnosis of anal warts has been made,\\nfurther outbreaks can be controlled or sometimes pre-\\nvented with proper care. Unfortunately, many cases of\\nanal warts either fail to respond to treatment or recur.\\nPatients have to undergo roughly six to nine treat-\\nments over several months to assure that the warts\\nare completely eradicated.\\nRecurrence rates have been estimated to be over\\n50%afteroneyearandmaybeduetothelongincubation\\nofHPV(upto1.5years),deeplesions,undetectedlesions,\\nvirus present in surrounding skin that is not treated.\\nPrevention\\nSexual abstinence and monogamous relationships\\ncan be the most effective form of prevention, and\\ncondoms may also decrease the chances of transmis-\\nsion of condyloma acuminata. Abstinence from sexual\\nrelations with people who have anal orgenital warts\\ncan prevent infection. Unfortunately, since many peo-\\nple may not be aware that they have this condition,\\nthis is not always possible.\\nIndividuals infected with anal warts should have\\nfollow-up checkups every few weeks after their initial\\ntreatment, after which self-exams can be done.\\nSexual partners of people who have anal warts\\nshould also be examined, as a precautionary preven-\\ntive measure.\\nFinally, 5-flourouracil (Adrucil, Efudex, Fluoro-\\nplex) may be useful to prevent recurrence once the\\nwarts have been removed. Treatment must, however,\\nbe initiated within 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\\nTransmitted Diseases Hotline: (800) 227-8922.\\nOTHER\\n.\\n.\\n.\\n.\\nLiz Meszaros\\nAnalgesics\\nDefinition\\nAnalgesics are medicines that relievepain.\\nPurpose\\nAnalgesics are those drugs that mainly provide\\npain relief. The primary classes of analgesics are the\\n184 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 214, 'page_label': '185'}, page_content='narcotics, including additional agents that are chemi-\\ncally based on the morphine molecule but have mini-\\nmal abuse potential; nonsteroidal anti-inflammatory\\ndrugs (NSAIDs) including the salicylates; andacetami-\\nnophen. Other drugs, notably thetricyclic antidepres-\\nsants and anti-epileptic agents such as gabapentin, have\\nbeen used to relieve pain, particularly neurologic pain,\\nbut are not routinely classified as analgesics. Analgesics\\nprovide symptomatic relief, but have no effect on the\\ncause, although clearly the NSAIDs, by virtue of their\\ndual activity, may be beneficial in both regards.\\nDescription\\nPain has been classified as ‘‘productive’’ pain and\\n‘‘non-productive’’ pain. While this distinction has\\nno physiologic meaning, it may serve as a guide to\\ntreatment. ‘‘Productive’’ pain has been described as a\\nwarning of injury, and so may be both an indication of\\nneed for treatment and a guide to diagnosis. ‘‘Non-\\nproductive’’ pain by definition serves no purpose\\neither as a warning or 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 periph-\\neral nervous system, or by distorting the interpretation\\nby the central nervous system. Selection of an appro-\\npriate analgesic is based on consideration of the risk-\\nbenefit factors of each class of drugs, based on type of\\npain, severity of pain, and risk of adverse effects.\\nTraditionally, pain has been divided into two classes,\\nacute and chronic, although severity and projected\\npatient survival are other factors that must be consid-\\nered in drug selection.\\nAcute pain\\nAcute pain is self limiting in duration, and\\nincludes post-operative pain, pain of injury, andchild-\\nbirth. Because pain of these types is expected to be\\nshort term, the long-term side effects of analgesic ther-\\napy may routinely be ignored. Thus, these patients\\nmay safely be treated with narcotic analgesics without\\nconcern about possible addiction, or NSAIDs with\\nonly limited concern for the risk of ulcers. Drugs and\\ndoses should be adjusted based on observation of\\nhealing rate, switching patients from high to low\\ndoses, and from narcotic analgesics to non-narcotics\\nwhen circumstances permit.\\nAn important consideration ofpain management\\nin severe pain is that patients should not be subject to\\nthe return of pain. Analgesics should be dosed\\nadequately to ensure that the pain is at least tolerable,\\nand frequently enough to avoid the anxiety that\\naccompanies the anticipated return of pain.\\nAnalgesics should never be dosed on an as needed\\nbasis, but should be administered often enough to\\nassure constant blood levels of analgesic. This applies\\nto 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\\nanalgesics this means the addiction potential, as well\\nas respiratory depression and constipation.F o rt h e\\nNSAIDs, the risk of gastric ulcers limit dose. While\\nsome classes of drugs, such as the narcotic agonist/\\nantagonist drugs bupronophine, nalbuphine and penta-\\nzocine, and the selectiveCOX-2 inhibitorscelecoxib and\\nrofecoxib represent advances in reduction of adverse\\neffects, they are still not fully suitable for long-term\\nmanagement of severe pain. Generally, chronic pain\\nmanagement requires a combination of drug therapy,\\nlife-style modification, and other treatment modalities.\\nNarcotic analgesics\\nThe narcotic analgesics, also termed opioids, are\\nall derived from opium. The class includes morphine,\\ncodeine, and a number of semi-synthetics including\\nmeperidine (Demerol), propoxyphen (Darvon) and\\nothers. The narcotic analgesics vary in potency, but all\\nare effective in treatment of visceral pain when used\\nin adequate doses. Adverse effects are dose related.\\nBecause these drugs are all addictive, they are controlled\\nunder federal and state laws. A variety of dosage forms\\nare available, including oral solids, liquids, intravenous\\nand intrathecal injections, and transcutaneous patches.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 185\\nAnalgesics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 215, 'page_label': '186'}, page_content='NSAIDs are effective analgesics even at doses too\\nlow to have any anti-inflammatory effects. There are a\\nnumber of chemical classes, but all have similar ther-\\napeutic effects and side effects. Most are appropriate\\nonly for oral administration; however ketorolac\\n(Toradol) is appropriate for injection and may be\\nused in moderate to severe pain for short periods.\\nAcetaminophen is a non-narcotic analgesic with no\\nanti-inflammatory properties. It is appropriate for mild\\nto moderate pain. Although the drug is well tolerated in\\nnormal doses, it may have significant toxicity at high\\ndoses. Because acetaminophen is largely free of side\\neffects at therapeutic doses, it has been considered the\\nfirst choice for mild pain, including that ofosteoarthritis.\\nTopical analgesics (topical being those that are\\napplied on the skin) have become much more popular\\nin recent years. Those applied for local effect include\\ncapsaicin, methylsalicylate, and transdermal lidocaine.\\nTransdermal fentanyl may be applied for systemic (the\\nentire body in general) effect. In some cases, these\\ntopical agents reduce the need for drug therapy. Sales\\nof pain relief patches have increased substantially in\\nrecent years. They are particularly useful for elderly\\npatients who may not want to take a lot of tablets.\\nRecommended dosage\\nAppropriate dosage varies by drug, and should\\nconsider the type of pain, as well as other risks asso-\\nciated with patient age and condition. For example,\\nnarcotic analgesics should usually be avoided in\\npatients with a history ofsubstance abuse, but may be\\nfully appropriate in patients withcancerpain. Similarly,\\nbecause narcotics are more rapidly metabolized in\\npatients who have used these drugs for a long period,\\nhigher than normal doses may be needed to provide\\nadequate pain management. NSAIDs, although com-\\nparatively safe in adults, represent an increased risk of\\ngastrointestinal bleeding in patients over the age of 60.\\nPrecautions\\nNarcotic analgesics may be contraindicated in\\npatients with respiratory depression. NSAIDS may\\nbe hazardous to patients with ulcers or an ulcer his-\\ntory. They should be used with care in patients with\\nrenal insufficiency orcoagulation disorders. NSAIDs\\nare contraindicated in patients allergic toaspirin.\\nSide effects\\nEach drug’s adverse effects should be reviewed\\nindividually. Drugs within a class may vary in their\\nfrequency and severity of adverse effects.\\nT h ep r i m a r ya d v e r s ee f f e c t so ft h en a r c o t i c\\nanalgesics are addiction, constipation, and respira-\\ntory depression. Because narcotic analgesics stimu-\\nlate the production of enzymes that cause the\\nmetabolism of these drugs,patients on narcotics for\\na prolonged period may require increasing doses.\\nThis is not the same thing as addiction, and is not a\\nreason for withholding medication from patients in\\nsevere pain.\\nNSAIDs can lead to ulcers and may cause kid-\\nney problems. Gastrointestinal discomfort is com-\\nmon, although in some cases, these drugs may\\ncause ulcers without the prior warning of gastroin-\\ntestinal distress. Platelet aggregation problems may\\noccur, although not to the same extent as is seen\\nwith aspirin.\\nInteractions\\nInteractions depend on the specific type of\\nanalgesic.\\nResources\\nPERIODICALS\\n‘‘Analgesics: No Pain, No Gain.’’Chemist & Druggist\\n(September 11, 2004): 38.\\nKuritzky, Louis.‘‘Topical Capsaicin for Chronic Pain.’’\\nInternal Medicine Alert (September 29, 2004): 144.\\n‘‘Pain Relief Patches Are Flying Off Store Shelves.’’Chain\\nDrug Review (August 16, 2004): 15.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnalgesics, opioid\\nDefinition\\nOpioid analgesics, also known as narcotic analge-\\nsics, arepain relievers that act on the central nervous\\nsystem. Like all narcotics, they may become habit-\\nforming 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\\nand to make anesthetics work more effectively. They\\n186 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics, opioid'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 216, 'page_label': '187'}, page_content='may also be used for the same purposes during labor\\nand delivery.\\nOpioids are also given to relieve the pain of terminal\\ncancer, diabetic neuropathy, lower back pain, and other\\nchronic diseases or disorders. The World Health\\nOrganization (WHO) has established a three-stage\\n‘‘ladder’’ for the use of opioids in managing cancer pain.\\nDescription\\nOpioid analgesics relieve pain by acting directly\\non the central nervous system. However, this can also\\nlead to unwanted side effects, such as drowsiness,\\ndizziness, breathing problems, and physical or mental\\ndependence.\\nAmong the drugs in this category are codeine,\\npropoxyphene (Darvon), propoxyphene andacetami-\\nnophen (Darvocet N), meperidine (Demerol), hydro-\\nmorphone (Dilaudid), morphine, oxycodone,\\noxycodone and acetaminophen (Percocet, Roxicet),\\nand hydrocodone and acetaminophen (Lortab,\\nAnexsia). These drugs come in many forms—tablets,\\nsyrups, suppositories, and injections, and are sold only\\nby prescription. For some, a new prescription is\\nrequired for each new supply—refills are prohibited\\naccording to federal regulations.\\nOpioid analgesics\\nDrug\\nRoute of\\nadministration\\nOnset of\\naction (min)\\nTime to peak\\neffect (min)\\nDuration of\\naction (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\\nGALE ENCYCLOPEDIA OF MEDICINE 187\\nAnalgesics, opioid'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 217, 'page_label': '188'}, page_content='Recommended 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 pharm-\\nacist who filled the prescription for correct dosages, and\\nmake sure to understand how to take the drug.\\nAlways take opioid analgesics exactly as directed.\\nNever take larger or more frequent doses, and do not\\ntake the drug for longer than directed. Do not stop\\ntaking the drug suddenly without checking with the\\nphysician or dentist who prescribed it. Gradually\\ntapering the dose may the chance of withdrawal\\nsymptoms.\\nPrecautions\\nAnyone who uses opioid analgesics—or any nar-\\ncotic—over a long time may become physically or\\nmentally dependent on the drug. Physical dependence\\nmay lead to withdrawal symptoms when the person\\nstops taking the medicine. Building tolerance to these\\ndrugs is also possible when they are used for a long\\nperiod. Over time, the body needs larger and larger\\ndoses 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\\nseem to be working, consult your physician. Do not\\nshare these or any other prescription drugs with others\\nbecause the drug may have a completely different\\neffect on the person for whom it was not prescribed.\\nChildren and older people are especially sensitive\\nto opioid analgesics and may have serious breathing\\nproblems after taking them. Children may also\\nbecome unusually restless or agitated when given\\nthese drugs.\\nOpioid analgesics increase the effects of alcohol.\\nAnyone taking these drugs should not drink alcoholic\\nbeverages.\\nSome of these drugs may also containaspirin,\\ncaffeine, or acetaminophen. Refer to the entries on\\neach of these drugs for additional precautions.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if they\\ntakeopioidanalgesics.Beforetakingthesedrugs,besure\\nto let the physician know about any of these conditions.\\nALLERGIES. Let the physician know about anyaller-\\ngies to foods, dyes, preservatives, or other substances\\nand about any previous reactions to opioid analgesics.\\nPREGNANCY. Women who are pregnant or plan\\nto become pregnant while taking opioid analgesics\\nshould let their physicians know. No evidence exists\\nthat these drugs causebirth defectsin people, but some\\ndo cause birth defects and other problems when given to\\npregnant animals in experiments. Babies can become\\ndependent on opioid analgesics if their mothers use\\ntoo much duringpregnancy. This can cause the baby\\nto go through withdrawal symptoms after birth. If\\ntaken just before delivery, some opioid analgesics\\nmay cause serious breathing problems in the newborn.\\nBREAST FEEDING. Some opioid analgesics can pass\\ninto breast milk. Women who are breast feeding\\nshould check with their physicians about the safety\\nof taking these drugs.\\nOTHER MEDICAL CONDITIONS. These conditions\\nmay influence the effects of opioid analgesics:\\n/C15head injury. The effects of some opioid analgesics\\nmay be stronger and may interfere with recovery in\\npeople with head injuries.\\n/C15history of convulsions. Some of these drugs may\\ntrigger convulsions.\\n/C15asthma, emphysema, or any chronic lung disease\\nKEY TERMS\\nAnalgesic— Medicine used to relieve pain.\\nCentral nervous system—The brain and spinal cord.\\nColitis— Inflammation of the colon (large bowel)\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\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 dependence\\nand 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.\\n188 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics, opioid'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 218, 'page_label': '189'}, page_content='/C15heart disease\\n/C15kidney disease\\n/C15liver disease\\n/C15HIV infection. Patients undergoing highly active\\nantiretroviral therapy, or HAART, are at increased\\nrisk for adverse effects from opioid analgesics.\\n/C15underactive thyroid. The chance of side effects may\\nbe greater.\\n/C15Addison’s disease (a disease of the adrenal glands)\\n/C15colitis\\n/C15gallbladder disease orgallstones. Side effects can be\\ndangerous in people with these conditions.\\n/C15enlarged prostate or other urinary problems\\n/C15current or past alcoholabuse\\n/C15current or past drug abuse, especially narcotic abuse\\n/C15current or past emotional problems. The chance of\\nside effects may be greater.\\nUSE OF CERTAIN MEDICINES. Taking opioid narco-\\ntics with certain other drugs may increase the chances\\nof serious side effects.\\nSide effects\\nSome people experience drowsiness, dizziness,\\nlightheadedness, or a false sense of well-being after\\ntaking opioid analgesics. Anyone who takes these\\ndrugs should not drive, use machines, or do anything\\nelse that might be dangerous until they know how the\\ndrug affects them.Nausea and vomitingare common\\nside effects, especially when first beginning to take the\\nmedicine. If these symptoms do not go away after the\\nfirst few doses, check with the physician or dentist who\\nprescribed 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\\nover long periods and who have dry mouth should\\nsee their dentists, as the problem can lead totooth\\ndecay and other 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\\nwith normal activity, check with the physician who\\nprescribed the medicine.\\n/C15headache\\n/C15loss of appetite\\n/C15restlessness or nervousness\\n/C15nightmares, unusual dreams, or problems sleeping\\n/C15weakness or tiredness\\n/C15mental sluggishness\\n/C15stomach pain or cramps\\n/C15blurred or double vision or other vision problems\\n/C15problems urinating, such as pain, difficulty urinat-\\ning, frequent urge to urinate, or decreased amount of\\nurine\\n/C15constipation.\\nOther side effects may be more serious and may\\nrequire quick medical attention. These symptoms\\ncould be signs of an overdose. Get emergency medical\\ncare immediately.\\n/C15cold, clammy skin\\n/C15bluish discoloration of the skin\\n/C15extremely small pupils\\n/C15serious difficulty breathing or extremely slow\\nbreathing\\n/C15extreme sleepiness or unresponsiveness\\n/C15severe weakness\\n/C15confusion\\n/C15severe dizziness\\n/C15severe drowsiness\\n/C15slow heartbeat\\n/C15low blood pressure\\n/C15severe nervousness or restlessness\\nIn addition, these less common side effects do\\nnot require emergency medical care, but should have\\nmedical attention as soon as possible:\\n/C15hallucinations or a sense of unreality\\n/C15depression or other mood changes\\n/C15ringing or buzzing in the ears\\n/C15pounding or unusually fast heartbeat\\n/C15itching, hives, or rash\\n/C15facial swelling\\n/C15trembling or twitching\\n/C15dark urine, pale stools, or yellow eyes or skin (after\\ntaking propoxyphene)\\n/C15increased sweating, red or flushed face (more com-\\nmon after taking hydrocodone and meperidine)\\nGALE ENCYCLOPEDIA OF MEDICINE 189\\nAnalgesics, opioid'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 219, 'page_label': '190'}, page_content='Interactions\\nAnyone taking these drugs should notify his or her\\nphysician before taking opioid analgesics:\\n/C15Central nervous system (CNS) depressants, such as\\nantihistamines and other medicines for allergies, hay\\nfever, or colds; tranquilizers; some other prescription\\npain relievers; seizure medicines;muscle relaxants;\\nsleeping pills; some anesthetics (including dental\\nanesthetics).\\n/C15Monoamine oxidase (MAO) inhibitors, such as phe-\\nnelzine (Nardil) and tranylcypromine (Parnate). The\\ncombination of the opioid analgesic meperidine\\n(Demerol) and MAO inhibitors is especially\\ndangerous.\\n/C15Tricyclic antidepressants, such as amitriptyline\\n(Elavil).\\n/C15Anti-seizure medicines, such as carbamazepine\\n(Tegretol). May lead to serious side effects, including\\ncoma, when combined with propoxyphene and acet-\\naminophen (Darvocet-N) or propoxyphene\\n(Darvon).\\n/C15Muscle relaxants, such as cyclobenzaprine (Flexeril).\\n/C15Sleeping pills, such as triazolam (Halcion).\\n/C15Blood-thinning drugs, such as warfarin (Coumadin).\\n/C15Naltrexone (Trexan, Revia). Cancels the effects of\\nopioid analgesics.\\n/C15Rifampin (Rifadin).\\n/C15Zidovudine (AZT, Retrovir). Serious side effects\\nwhen combined with morphine.\\nOpioids may also interact with certain herbal pre-\\nparations sold as dietary supplements. Among the\\nherbs known to interact with opioids are valerian\\n(Valeriana officinalis ), ginseng (Panax ginseng ), kava\\nkava (Piper methysticum), and chamomile (Matricaria\\nchamomilla). As of early 2004 the National Center for\\nComplementary and Alternative Medicine (NCCAM)\\nis beginning a study of the possible interactions\\nbetween St. John’s wort (Hypericum perforatum ,a\\nherb frequently used to relieve symptoms of depres-\\nsion, and the opioid analgesics fentanyl and oxyco-\\ndone. It is just as important for patients to inform their\\ndoctor of herbal remedies that they take on a regular\\nbasis as it is to give the doctor a list of their other\\nprescription medications.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Pain.’’ Section 14, Chapter 167 InThe Merck Manual\\nof Diagnosis and Therapy. Whitehouse Station, NJ:\\nMerck Research Laboratories, 2002.\\nPelletier, Dr. Kenneth R.The Best Alternative Medicine,\\nPart I: Western Herbal Medicine. New York: Simon\\nand Schuster, 2002.\\nWilson, Billie Ann, RN, PhD, Carolyn L. Stang, PharmD,\\nand Margaret T. Shannon, RN, PhD.Nurses Drug\\nGuide 2000. Stamford, CT: Appleton and Lange, 1999.\\nPERIODICALS\\nCampbell, D. C. ‘‘Parenteral Opioids for Labor Analgesia.’’\\nClinical Obstetrics and Gynecology 46 (September\\n2003): 616–622.\\nCompton, P., and P. Athanasos. ‘‘Chronic Pain, Substance\\nAbuse and Addiction.’’Nursing Clinics of North\\nAmerica 38 (September 2003): 525–537.\\nFaragon, J. J., and P. J. Piliero. ‘‘Drug Interactions\\nAssociated with HAART: Focus on Treatments for\\nAddiction and Recreational Drugs.’’AIDS Reader 13\\n(September 2003): 433–450.\\nMarkowitz, J. S., J. L. Donovan, C. L. DeVane, et al. ‘‘Effect\\nof St John’s Wort on Drug Metabolism by Induction of\\nCytochrome P450 3A4 Enzyme.’’Journal of the\\nAmerican Medical Association 290 (September 17,\\n2003): 1500–1504.\\nSoares, L. G., M. Marins, and R. Uchoa. ‘‘Intravenous\\nFentanyl for Cancer Pain: A ‘Fast Titration’ Protocol\\nfor the Emergency Room.’’Journal of Pain and\\nSymptom Management 26 (September 2003): 876–881.\\nWatson, C. P., D. Moulin, J. Watt-Watson, et al.\\n‘‘Controlled-Release Oxycodone Relieves Neuropathic\\nPain: A Randomized Controlled Trial in Painful\\nDiabetic Neuropathy.’’Pain 105 (September 2003):\\n71–78.\\nORGANIZATIONS\\nNational Center for Complementary and Alternative\\nMedicine (NCCAM) Clearinghouse. P.O. Box 7923,\\nGaithersburg, MD 20898-7923. (888) 644-6226.\\n.\\nU. S. Food and Drug Administration (FDA). 5600 Fishers\\nLane, Rockville, MD 20857. (888) 463-6332. .\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAnaphylactic shock see Anaphylaxis\\nAnaphylactoid purpura see Allergic purpura\\nAnaphylaxis\\nDefinition\\nAnaphylaxis is a rapidly progressing, life-threa-\\ntening allergic reaction.\\n190 GALE ENCYCLOPEDIA OF MEDICINE\\nAnaphylaxis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 220, 'page_label': '191'}, page_content='Description\\nAnaphylaxis is a type of allergic reaction, in which\\nthe immune system responds to otherwise harmless\\nsubstances from the environment. Unlike other aller-\\ngic reactions, however, anaphylaxis can kill. Reaction\\nmay begin within minutes or even seconds of exposure,\\nand rapidly progress to cause airway constriction, skin\\nand intestinal irritation, and altered heart rhythms. In\\nsevere cases, it can result in complete airway obstruc-\\ntion, shock,a n ddeath.\\nCauses and symptoms\\nCauses\\nLike the majority of other allergic reactions, ana-\\nphylaxis is caused by the release of histamine and\\nother chemicals from mast cells. Mast cells are a type\\nof white blood cell and they are found in large num-\\nbers in the tissues that regulate exchange with the\\nenvironment: the airways, 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\\nfrom a genuinely threatening source, such as bacteria\\nor viruses, are called antigens. A substance that most\\npeople tolerate well, but to which others have an aller-\\ngic response, is called an allergen. When IgE antibo-\\ndies bind with allergens, they cause the mast cell to\\nrelease histamine and other chemicals, which spill out\\nonto neighboring cells.\\nThe interaction of these chemicals with receptors\\non the surface of blood vessels causes the vessels to\\nleak fluid into surrounding tissues, causing fluid accu-\\nmulation, redness, and swelling. On the smooth mus-\\ncle cells of the airways and digestive system, they cause\\nconstriction. On nerve endings, they increase sensitiv-\\nity and causeitching.\\nIn anaphylaxis, the dramatic response is due both\\nto extreme hypersensivity to the allergen and its usually\\nsystemic distribution. Allergens are more likely to cause\\nanaphylaxis if they are introduced directly into the\\ncirculatory system by injection. However, exposure by\\ningestion, inhalation, or skin contact can also cause\\nanaphylaxis. In some cases, anaphylaxis may develop\\nover time from less severeallergies.\\nAnaphylaxis is most often due to allergens in foods,\\ndrugs, and insect venom. Specific causes include:\\n/C15Fish, shellfish, and mollusks\\n/C15Nuts and seeds\\n/C15Stings of bees, wasps, or hornets\\n/C15Papain from meat tenderizers\\n/C15Vaccines, including flu andmeasles vaccines\\n/C15Penicillin\\n/C15Cephalosporins\\n/C15Streptomycin\\n/C15Gamma globulin\\n/C15Insulin\\n/C15Hormones (ACTH, thyroid-stimulating hormone)\\n/C15Aspirin and other NSAIDs\\n/C15Latex, from exam gloves or condoms, for example.\\nExposure to cold orexercise can trigger anaphy-\\nlaxis in some individuals.\\nSymptoms\\nSymptoms may include:\\n/C15Urticaria (hives)\\n/C15Swelling and irritation of the tongue or mouth\\n/C15Swelling of the sinuses\\n/C15Difficulty breathing\\n/C15Wheezing\\n/C15Cramping, vomiting,o rdiarrhea\\n/C15Anxiety or confusion\\n/C15Strong, very rapid heartbeat (palpitations)\\n/C15Loss of consciousness.\\nNot all symptoms may be present.\\nKEY TERMS\\nACTH— Adrenocorticotropic hormone, a hormone\\nnormally produced by the pituitary gland, some-\\ntimes taken as a treatment for arthritis and other\\ndisorders.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 191\\nAnaphylaxis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 221, 'page_label': '192'}, page_content='Diagnosis\\nAnaphylaxis is diagnosed based on the rapid\\ndevelopment of symptoms in response to a suspect\\nallergen. Identification of the culprit may be done\\nwith RAST testing, a blood test that identifies IgE\\nreactions to specific allergens. Skin testing may be\\ndone for less severe anaphylactic reactions.\\nTreatment\\nEmergency treatment of anaphylaxis involves\\ninjection of adrenaline (epinephrine) which constricts\\nblood vessels and counteracts the effects of hista-\\nmine. Oxygen may be given, as well as intravenous\\nreplacement fluids. Antihistamines may be used for\\nskin rash, and aminophylline for bronchial constric-\\ntion. If the upper airway is obstructed, placement\\nof a breathing tube or tracheostomy tube may be\\nneeded.\\nPrognosis\\nThe rapidity of symptom development is an indi-\\ncation of the likely severity of reaction: the faster\\nsymptoms develop, the m ore severe the ultimate\\nreaction. Prompt emergency medical attention and\\nclose monitoring reduces the likelihood of death.\\nNonetheless, death is possible from severe anaphy-\\nlaxis. For most people who receive rapid treatment,\\nrecovery is complete.\\nPrevention\\nAvoidance of the allergic trigger is the only\\nreliable method of preven ting anaphylaxis. For\\ninsect allergies, this requires recognizing likely\\nnest sites. Preventing food allergies requires know-\\nledge of the prepared foods or dishes in which the\\nallergen is likely to occur, and careful questioning\\nabout ingredients when dining out. Use of a Medic-\\nAlert tag detailing drug allergies is vital to prevent\\ninadvertent administr ation during a medical\\nemergency.\\nPeople prone to anaphylaxis should carry an\\n‘‘Epi-pen’’ or ‘‘Ana-kit,’’ which contain an adrenaline\\ndose ready for injection.\\nResources\\nOTHER\\nThe Meck Page. February 20, 1998. .\\nRichard Robinson\\nAnemias\\nDefinition\\nAnemia is a condition characterized by abnor-\\nmally low levels of healthy red blood cells or hemoglo-\\nbin (the component of red blood cells that delivers\\noxygen to tissues throughout the body).\\nDescription\\nThe tissues of the human body need a regular\\nsupply of oxygen to stay healthy. Red blood cells,\\nwhich contain hemoglobin that allows them to deliver\\noxygen throughout the body, live for only about 120\\ndays. When they die, the iron they contain is returned\\nto the bone marrow and used to create new red blood\\ncells. Anemia develops when heavy bleeding causes\\nsignificant iron loss or when something happens to\\nslow down the production of red blood cells or to\\nincrease the rate at which they are destroyed.\\nTypes of anemia\\nAnemia can be mild, moderate, or severe enough\\nto lead to life-threatening complications. More than\\n400 different types of anemia have been identified.\\nMany of them are rare.\\nIRON DEFICIENCY ANEMIA. The onset of iron defi-\\nciency anemia is gradual and, at first, there may not be\\nany symptoms. The deficiency begins when the body\\nloses more iron than it derives from food and other\\nsources. Because depleted iron stores cannot meet the\\nred blood cell’s needs, fewer red blood cells develop. In\\nthis early stage of anemia, the red blood cells look\\nnormal, but they are reduced in number. Then the\\nbody tries to compensate for the iron deficiency by\\nproducing more red blood cells, which are character-\\nistically small in size. Symptoms develop at this stage.\\nFOLIC ACID DEFICIENCY ANEMIA. Folic acid ane-\\nmia is especially common in infants and teenagers.\\nAlthough this condition usually results from a dietary\\ndeficiency, it is sometimes due to inability to absorb\\nenough folic acid from such foods as:\\n/C15cheese\\n/C15eggs\\n/C15fish\\n/C15green vegetables\\n/C15meat\\n/C15milk\\n/C15mushrooms\\n/C15yeast\\n192 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 222, 'page_label': '193'}, page_content='Smoking raises the risk of developing this condi-\\ntion by interfering with the absorption of Vitamin C,\\nwhich the body needs to absorb folic acid. Folic acid\\nanemia can be a complication ofpregnancy, when a\\nwoman’s body needs eight times more folic acid than it\\ndoes otherwise.\\nVITAMIN B12 DEFICIENCY ANEMIA. Less common in\\nthis country than folic acid anemia, vitamin B12 defi-\\nciency anemia is another type of megaloblastic anemia\\nthat develops when the body doesn’t absorb enough of\\nthis nutrient. Necessary for the creation of red blood\\ncells, B\\n12 is found in meat and vegetables.\\nLarge amounts of B12 are stored in the body, so this\\ncondition may not become apparent until as much as\\nfour years after B\\n12 absorption stops or slows down. The\\nresulting drop in red blood cell production can cause:\\n/C15loss of muscle control\\n/C15loss of sensation in the legs, hands, and feet\\n/C15soreness or burning of the tongue\\n/C15weight loss\\n/C15yellow-blue color blindness\\nThe most common form of B12 deficiency isperni-\\ncious anemia. Since most people who eat meat or eggs\\nget enough B12 in theirdiets, a deficiency of this vita-\\nmin usually means that the body is not absorbing it\\nproperly. This can occur among people who have had\\nintestinal surgery or among those who do not produce\\nadequate amounts of intrinsic factor, a chemical\\nsecreted by the stomach lining that combines with\\nB\\n12 to help its absorption in the small intestine.\\nPernicious anemia usually strikes between the ages\\nof 50–60. Eating disorders or an unbalanced diet\\nincreasethe riskof developingperniciousanemia. Sodo:\\n/C15diabetes mellitus\\n/C15gastritis, stomach cancer, or stomach surgery\\n/C15thyroid disease\\n/C15family history of pernicious anemia\\nVITAMIN C DEFICIENCY ANEMIA. Ar a r ed i s o r d e r\\nthat causes the bone marrow to manufacture abnor-\\nmallysmall redblood cells, Vitamin C deficiencyanemia\\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, acceler-\\nating the destruction of red blood cells (hemolysis).\\nOther complications of hemolytic anemia include:\\n/C15pain\\n/C15shock\\n/C15gallstones and other serious health problems\\nTHALASSEMIAS. An inherited form of hemolytic\\nanemia, thalassemia stems from the body’s inability\\nto manufacture as much normal hemoglobin as it\\nneeds. There are two categories of thalassemia,\\ndepending on which of the amino acid chains is\\naffected. (Hemoglobin is composed of four chains of\\namino acids.) In alpha-thalassemia, there is an imbal-\\nance in the production of the alpha chain of amino\\nacids; in beta-thalassemia, there is an imbalance in the\\nbeta chain. Alpha-thalassemias most commonly affect\\nblacks (25% have at least one gene); beta-thalassemias\\nmost commonly affect people of Mediterranean ances-\\ntry and Southeast Asians.\\nKEY TERMS\\nAplastic— Exhibiting incomplete or faulty\\ndevelopment.\\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).\\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.\\n(Illustration by John Bavosi, Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 193\\nAnemias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 223, 'page_label': '194'}, page_content='Characterized by production of red blood cells\\nthat are unusually small and fragile, thalassemia only\\naffects people who inherit the gene for it from each\\nparent (autosomal recessive inheritance).\\nAUTOIMMUNE HEMOLYTIC ANEMIAS. Warm anti-\\nbody hemolytic anemia is the most common type of\\nthis disorder. This condition occurs when the body\\nproduces autoantibodies that coat red blood cells.\\nThe coated cells are destroyed by the spleen, liver, or\\nbone marrow.\\nWarm antibody hemolytic anemia is more com-\\nmon in women than in men. About one-third of\\npatients who have warm antibody hemolytic anemia\\nalso have lymphoma, leukemia, lupus, or connective\\ntissue disease.\\nIn cold antibody hemolytic anemia, the body\\nattacks red blood cells at or below normal body tem-\\nperature. The acute form of this condition frequently\\ndevelops in people who have hadpneumonia, mono-\\nneucleosis, or other acute infections. It tends to be\\nmild and short-lived, and disappears without\\ntreatment.\\nChronic cold antibody hemolytic anemia is most\\ncommon in women and most often affects those who\\nare over 40 and who have arthritis. This condition\\nusually lasts for a lifetime, generally causing few symp-\\ntoms. However, exposure to cold temperatures can\\naccelerate red blood cell destruction, causingfatigue,\\njoint aches, and discoloration of the arms and hands.\\nSICKLE CELL ANEMIA. Sickle cell anemia is a\\nchronic, incurable condition that causes the body to\\nproduce defective hemoglobin, which forces red blood\\ncells to assume an abnormal crescent shape. Unlike\\nnormal oval cells, fragile sickle cells can’t hold enough\\nhemoglobin to nourish body tissues. The deformed\\nshape makes it hard for sickle cells to pass through\\nnarrow blood vessels. When capillaries become\\nobstructed, a life-threatening condition called sickle\\ncell 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\\ncell gene from only one parent carries the sickle cell\\ntrait, but does not have the disease.\\nAPLASTIC ANEMIA. Sometimes curable by bone\\nmarrow transplant, but potentially fatal,aplastic ane-\\nmia is characterized by decreased production of red\\nand white blood cells and platelets (disc-shaped cells\\nthat allow the blood to clot). This disorder may be\\ninherited or acquired as a result of:\\n/C15recent severe illness\\n/C15long-term exposure to industrial chemicals\\n/C15use ofanticancer drugsand certain other medications\\nANEMIA OF CHRONIC DISEASE. Cancer, chronic\\ninfection or inflammation, and kidney andliver dis-\\nease often cause mild or moderate anemia. Chronic\\nliver failure generally produces the most severe symp-\\ntoms. People infected with the Humanimmunodefi-\\nciency virus (HIV) that causesAIDS often face severe\\nfatigue.\\nCauses and symptoms\\nAnemia is caused by bleeding, decreased red\\nblood cell production, or increased red blood cell\\ndestruction. Poor diet can contribute to vitamin defi-\\nciency and iron deficiency anemias in which fewer red\\nblood cells are produced. Hereditary disorders and\\ncertain diseases can cause increased blood cell destruc-\\ntion. However, excessive bleeding is the most common\\ncause of anemia, and the speed with which blood loss\\noccurs has a significant effect on the severity of symp-\\ntoms. Chronic blood loss is usually a consequence of:\\n/C15cancer\\n/C15gastrointestinal tumors\\n/C15diverticulosis\\n/C15polyposis\\n/C15heavy menstrual flow\\n/C15hemorrhoids\\n/C15nosebleeds\\n/C15stomach ulcers\\n/C15long-standing alcohol abuse\\nAcute blood loss is usually the result of:\\n/C15childbirth\\n/C15injury\\n/C15a ruptured blood vessel\\n/C15surgery\\nWhen a lot of blood is lost within a short time,\\nblood pressure and the amount of oxygen in the body\\ndrop suddenly.Heart failureand death can follow.\\nLoss of even one-third of the body’s blood volume\\nin the space of several hours can be fatal. More gra-\\ndual blood loss is less serious, because the body has\\ntime to create new red blood cells to replace those that\\nhave been lost.\\n194 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 224, 'page_label': '195'}, page_content='Symptoms\\nWeakness, fatigue, and a run-down feeling may be\\nsigns of mild anemia. Skin that is pasty or sallow, or\\nlack of color in the creases of the palm, gums, nail\\nbeds, or lining of the eyelids are other signs of anemia.\\nSomeone who is weak, tires easily, is often out of\\nbreath, and feels faint or dizzy may be severely anemic.\\nOther symptoms of anemia are:\\n/C15angina pectoris (chest pain, often accompanied by a\\nchoking sensation that provokes severeanxiety)\\n/C15cravings for ice, paint, or dirt\\n/C15headache\\n/C15inability to concentrate, memory loss\\n/C15inflammation of the mouth (stomatitis) or tongue\\n(glossitis)\\n/C15insomnia\\n/C15irregular heartbeat\\n/C15loss of appetite\\n/C15nails that are dry, brittle, or ridged\\n/C15rapid breathing\\n/C15sores in the mouth, throat, or rectum\\n/C15sweating\\n/C15swelling of the hands and feet\\n/C15thirst\\n/C15tinnitus (ringing in the ears)\\n/C15unexplained bleeding or bruising\\nIn pernicious anemia, the tongue feels unusually\\nslick. A patient with pernicious anemia may have:\\n/C15problems with movement or balance\\n/C15tingling in the hands and feet\\n/C15confusion, 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\\nhas been taking iron supplements develops:\\n/C15diarrhea\\n/C15cramps\\n/C15vomiting\\nDiagnosis\\nPersonal and family health history may suggest\\nthe presence of certain types of anemia. Laboratory\\ntests that measure the percentage of red blood cells or\\nthe amount of hemoglobin in the blood are used to\\nconfirm diagnosis and determine which type of anemia\\nis responsible for a patient’s symptoms. X rays and\\nexaminations of bone marrow may be used to identify\\nthe source of bleeding.\\nTreatment\\nAnemia due to nutritional deficiencies can usually\\nbe treated at home with iron supplements or self admi-\\nnistered injections of vitamin B\\n12. People with folic\\nacid anemia should take oral folic acid replacements.\\nVitamin C deficiency anemia can be cured by taking\\none vitamin C tablet a day.\\nSurgery may be necessary to treat anemia caused\\nby excessive loss of blood. Transfusions of red blood\\ncells may be used to accelerate production of red blood\\ncells.\\nMedication or surgery may also be necessary to\\ncontrol heavy menstrual flow, repair a bleeding ulcer,\\nor remove polyps (growths or nodules) from the\\nbowels.\\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\\nanemia involves regular eye examinations, immuni-\\nzations for pneumonia and infectious diseases, and\\nprompt treatment for sickle cell crises and infections\\nof any kind. Psychotherapy or counseling may help\\npatients deal with the emotional impact of this\\ncondition.\\nVITAMIN B12 DEFICIENCY ANEMIA. A life-long regi-\\nmen of B12 shots is necessary to control symptoms of\\npernicious anemia. The patient may be advised to limit\\nphysical activity until treatment restores strength and\\nbalance.\\nAPLASTIC ANEMIA. People who have aplastic ane-\\nmia are especially susceptible to infection. Treatment\\nfor aplastic anemia may involve blood transfusions\\nand bone marrow transplant to replace malfunction-\\ning cells with healthy ones.\\nANEMIA OF CHRONIC DISEASE. There is no specific\\ntreatment for anemia associated with chronic disease,\\nbut treating the underlying illness may alleviate this\\ncondition. Erythropoietin is a hormone that stimu-\\nlates production of red blood cells. It is sometimes\\nused to treat anemia fromkidney disease or cancer\\nchemotherapy. This type of anemia rarely becomes\\nsevere. If it does, transfusions or hormone treatments\\nGALE ENCYCLOPEDIA OF MEDICINE 195\\nAnemias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 225, 'page_label': '196'}, page_content='to stimulate red blood cell production may be pre-\\nscribed. A working group met in 2004 to address the\\nspecific management of anemia in patients infected\\nwith HIV.\\nHEMOLYTIC ANEMIA. There is no specific treat-\\nment for cold-antibody hemolytic anemia. About\\none-third of patients with warm-antibody hemolytic\\nanemia respond well to large doses of intravenous and\\noral corticosteroids, which are gradually discontinued\\nas the patient’s condition improves. Patients with this\\ncondition who don’t respond to medical therapy must\\nhave the spleen surgically removed. This operation\\ncontrols anemia in about one-half of the patients on\\nwhom it’s performed. Immune-system suppressants\\nare prescribed for patients whose surgery is not\\nsuccessful.\\nSelf-care\\nAnyone who has anemia caused by poornutrition\\nshould modify his or her diet to include morevitamins,\\nminerals, and iron. Vitamin C can stimulate iron\\nabsorption. The following foods are also good sources\\nof iron:\\n/C15almonds\\n/C15broccoli\\n/C15dried beans\\n/C15dried fruits\\n/C15enriched breads and cereals\\n/C15lean red meat\\n/C15liver\\n/C15potatoes\\n/C15poultry\\n/C15rice\\n/C15shellfish\\n/C15tomatoes\\nBecause light and heat destroy folic acid, fruits\\nand vegetables should be eaten raw or cooked as little\\nas possible.\\nAlternative treatment\\nAs is the case in standard medical treatment, the\\ncause of the specific anemia will determine the alter-\\nnative treatment recommended. If the cause is a defi-\\nciency, for example iron deficiency, folic acid\\ndeficiency, B\\n12 deficiency, or vitamin C deficiency,\\nsupplementation is the treatment. For extensive\\nblood loss, the cause should be identified and cor-\\nrected. Other types of anemias should be addressed\\non a deep healing level with crisis intervention when\\nnecessary.\\nMany alternative therapies for iron-deficiency\\nanemia focus on adding iron-rich foods to the\\ndiet or on techniques to improve circulation and\\ndigestion. Iron supplementation, especially with\\niron citrate (less likely to cause constipation ), is\\nused by alternative practitioners. This can be given\\nin combination with herbs that are rich in iron.\\nSome examples of iron-ri ch herbs are dandelion\\n(Taraxacum officinale ), parsley ( Petroselinum\\ncrispum ), and nettle (Urtica dioica ). The homeo-\\npathic remedy ferrum phosphoricum can also be\\nhelpful.\\nAn iron-rich herbal tonic can also me made using\\nthe following recipe:\\n/C15soak 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/C15strain and simmer until the amount of liquid is\\nreduced to 1 cup\\n/C15remove from heat and add 1/2 cup black strap\\nmolasses, mixing well\\n/C15store in refrigerator; take 1 tsp-2 Tbsp daily\\nOther herbal remedies used to treat iron-\\ndeficiency anemia aim to improve the digestion.\\nGentian (Gentiana lutea ) is widely used in Europe to\\ntreat anemia and other nutritionally based disorders.\\nThe bitter qualities of gentian help stimulate the diges-\\ntive system, making iron and other nutrients more\\navailable for absorption. This bitter herb can be\\nbrewed into tea or purchased as an alcoholic extract\\n(tincture).\\nOther herbs recommended to promote digestion\\ninclude:\\n/C15anise (Pimpinella anisum )\\n/C15caraway (Carum carvi )\\n/C15cumin (Cuminum cyminum )\\n/C15linden (Tilia spp.)\\n/C15licorice (Glycyrrhiza glabra )\\nTraditional Chinese treatments for anemia\\ninclude:\\n/C15acupuncture to stimulate a weakened spleen\\n/C15asian ginseng (Panax ginseng ) to restore energy\\n/C15dong quai (Angelica sinensis ) to control heavy men-\\nstrual bleeding\\n/C15a mixture of dong quai and Chinese foxglove\\n(Rehmannia glutinosa ) to clear a sallow complexion\\n196 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 226, 'page_label': '197'}, page_content='Prognosis\\nFolic-acid and iron-deficiency anemias\\nIt usually takes three to six weeks to correct folic\\nacid or iron deficiency anemia. Patients should con-\\ntinue taking supplements for another six months to\\nreplenish iron reserves. They should have periodic\\nblood tests to make sure the bleeding has stopped\\nand the anemia has not recurred.\\nPernicious anemia\\nAlthough pernicious anemia is considered incur-\\nable, regular B\\n12 shots will alleviate symptoms and\\nreverse complications. Some symptoms will disappear\\nalmost as soon 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,\\neffective treatments enable patients with this disease\\nto enjoy longer, more productive lives.\\nThalassemia\\nPeople with mild thalassemia (alpha thalassemia\\ntrait or beta thalassemia minor) lead normal lives and\\ndo not require treatment. Those with severe thalassemia\\nmay require bone marrow transplantation. Genetic ther-\\napy is is being investigated and may soon be available.\\nHemolytic anemia\\nAcquired hemolytic anemia can generally be\\ncured when 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\\na daily multivitamin can help prevent anemia.\\nMethods of preventing specific types of anemia\\ninclude:\\n/C15avoiding lengthy exposure to industrial chemicals\\nand drugs known to cause aplastic anemia\\n/C15not taking medication that has triggered hemolytic\\nanemia and not eating foods that have caused hemo-\\nlysis (breakdown of red blood cells)\\n/C15receiving regular B12 shots to prevent pernicious\\nanemia resulting from gastritis or stomach surgery\\nResources\\nPERIODICALS\\n‘‘Biopharmaceuitcal Company Announces Manufacturing\\nAgreement for Anemia Drug.’’Obesity, Wellness, &\\nFitness Week (September 4, 2004): 406.\\n‘‘Management Strategy for Anemia in HIV Infection\\nElucidated.’’ Immunotherapy Weekly (July 7, 2004): 75.\\nMaureen Haggerty\\nTeresa G. Odle\\nAnencephaly see Congenital brain defects\\nAnesthesia, general\\nDefinition\\nGeneral anesthesia is the induction of a state of\\nunconsciousness with the absence ofpain sensation\\nover the entire body, through the administration of\\nanesthetic drugs. It is used during certain medical and\\nsurgical procedures.\\nPurpose\\nGeneral anesthesia has many purposes including:\\n/C15pain relief (analgesia)\\n/C15blocking memory of the procedure (amnesia)\\n/C15producing unconsciousness\\n/C15inhibiting normal body reflexes to make surgery safe\\nand easier to perform\\n/C15relaxing the muscles of the body\\nDescription\\nAnesthesia performed with general anesthetics\\noccurs in four stages which may or may not be obser-\\nvable because they can occur very rapidly:\\n/C15Stage One: Analgesia. The patient experiences\\nanalgesia or a loss of pain sensation but remains\\nconscious and can carry on a conversation.\\n/C15Stage Two: Excitement. The patient may experience\\ndelirium or become violent. Blood pressure rises and\\nGALE ENCYCLOPEDIA OF MEDICINE 197\\nAnesthesia, general'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 227, 'page_label': '198'}, page_content='becomes irregular, and breathing rate increases.\\nThis stage is typically bypassed by administering a\\nbarbiturate, such as sodium pentothal, before the\\nanesthesia.\\n/C15Stage Three: Surgical Anesthesia. During this stage,\\nthe skeletal muscles relax, and the patient’s breathing\\nbecomes regular. Eye movements slow, then stop,\\nand surgery can begin.\\n/C15Stage Four: MedullaryParalysis. This stage occurs if\\nthe respiratory centers in the medulla oblongata of\\nthe brain that control breathing and other vital func-\\ntions cease to function.Death can result if the patient\\ncannot be revived quickly. This stage should never be\\nreached. Careful control of the amounts of anes-\\nthetics administered 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 com-\\nbination of inhaled anesthetic gases and intravenous\\ndrugs are usually delivered during general anesthesia;\\nthis practice is called balanced anesthesia and is used\\nbecause it takes advantage of the beneficial effects of\\neach anesthetic agent to reach surgical anesthesia. If\\nnecessary, the extent of the anesthesia produced by\\ninhaling a general anesthetic can be rapidly modified\\nby adjusting the concentration of the anesthetic in the\\noxygen that is breathed by the patient. The degree of\\nanesthesia produced by an intravenously injected\\nanesthesic is fixed and cannot be changed as rapidly.\\nMost commonly, intravenous anesthetic agents are\\nused for induction of anesthesia and then followed\\nby inhaled anesthetic agents.\\nGeneral anesthesia works by altering the flow of\\nsodium molecules into nerve cells (neurons) through\\nthe cell membrane. Exactly how the anesthetic does\\nthis is not understood since the drug apparently does\\nANESTHETICS: HOW THEY WORK\\nType Name(s) Administered Affect\\nGeneral Halothane,\\nEnflurane\\nIsoflurane,\\nKetamine,\\nNitrous Oxide,\\nThiopental\\nIntravenously,\\nInhalation\\nProduces total\\nunconsciousness\\naffecting the entire\\nbody\\nRegional Mepivacaine,\\nChloroprocaine,\\nLidocaine\\nIntravenously Temporarily inter-\\nrupts transmission\\nof nerve impulses\\n(temperature,\\ntouch, pain) and\\nmotor functions in\\na large area to be\\ntreated; does not\\nproduce\\nunconsciousness\\nLocal Procaine,\\nLidocaine,\\nTetracaine,\\nBupivacaine\\nIntravenously Temporarily blocks\\ntransmission of\\nnerve impulses and\\nmotor functions in\\na specific area;\\ndoes not produce\\nunconsciousness\\nTopical Benzocaine,\\nLidocaine\\nDibucaine,\\nPramoxine,\\nButamben,\\nTetracaine\\nDemal\\n(Sprays,\\nDrope,\\nOintments,\\nCreams, Gels)\\nTemporarily blocks\\nnerve endings in\\nskin and mucous\\nmembranes; does\\nnot produce\\nunconsciousness\\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\\nor a loss of general sensation.\\nArrhythmia — Abnormal heart beat.\\nBarbiturate— A drug with hypnotic and sedative\\neffects.\\nCatatonia— Psychomotor disturbance character-\\nized by 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 pain.\\nHypoxia— Reduction of oxygensupply tothe tissues.\\nMalignant hyperthermia— A type of reaction\\n(probably with a genetic origin) that can occur\\nduring general anesthesia and in which the patient\\nexperiences a high fever, muscle rigidity, and irre-\\ngular heart 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 dia-\\nmeter of a passage or orifice, such as a blood vessel.\\n198 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, general'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 228, 'page_label': '199'}, page_content='not bind to any receptor on the cell surface and does\\nnot seem to affect the release of chemicals that trans-\\nmit nerve impulses (neurotransmitters) from the nerve\\ncells. It is known, however, that when the sodium\\nmolecules do not get into the neurons, nerve impulses\\nare not generated and the brain becomes unconscious,\\ndoes not store memories, does not register pain\\nimpulses from other areas of the body, and does not\\ncontrol involuntary reflexes. Although anesthesia may\\nfeellike deep sleep,itisnotthe same. Insleep, someparts\\nof the brain speed up while others slow down. Under\\nanesthesia, the lossofconsciousnessismorewidespread.\\nWhen general anesthesia was first introduced in\\nmedical practice, ether and chloroform were inhaled\\nwith the physician manually covering the patient’s\\nmouth. Since then, general anesthesia has become much\\nmore sophisticated. During most surgical procedures,\\nanesthetic agents are now delivered and controlled by\\ncomputerized equipment that includes anesthetic gas\\nmonitoring as well as patient monitoring equipment.\\nAnesthesiologists are the physicians that specialize in\\nthe delivery of anesthetic agents. Currently used inhaled\\ngeneral anesthetics include halothane, enflurane, isoflur-\\nane, desfluorane, sevofluorane, and nitrous oxide.\\n/C15Halothane (Fluothane) is a powerful anesthetic and\\ncan easily be overadministered. This drug causes\\nunconsciousness but little pain relief so it is often\\nused with other agents to control pain. Very rarely,\\nit can be toxic to the liver in adults, causing death. It\\nalso has the potential for causing serious cardiac\\ndysrhythmias. Halothane has a pleasant odor, and\\nwas frequently the anesthetic of choice for use with\\nchildren, but since the introduction of sevofluorane\\nin the 1990s, halothane use has declined.\\n/C15Enflurane (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/C15Isoflurane (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/C15Desfluorane (Suprane) may increase the heart rate\\nand should not be used in patients withaortic valve\\nstenosis; however, it does not usually cause heart\\narrhythmias. Desflurane may cause coughing and exci-\\ntation during induction and is therefore used with\\nintravenous anesthetics for induction. Desflurane is\\nrapidly eliminated and awakening is therefore faster\\nthan with other inhaled agents.\\n/C15Sevofluorane (Ultane) m ay also cause increased\\nheart rate and should not be used in patients with\\nnarrowed aortic valve (stenosis); however, it does\\nnot usually cause heart arrhythmias. Unlike des-\\nfluorane, sevofluorane does not cause any coughing\\nor other related side effects, and can therefore be\\nused without intravenous agents for rapid induc-\\ntion. For this reason, sevofluorane is replacing\\nhalothane for induction in pediatric patients. Like\\ndesfluorane, this agent is rapidly eliminated and\\nallows rapid awakening.\\n/C15Nitrous oxide (laughing gas) is a weak anesthetic and\\nis used with other agents, such as thiopental, to\\nproduce surgical anesthesia. It has the fastest induc-\\ntion and recovery and is the safest because it does not\\nslow breathing or blood flow to the brain. However,\\nit diffuses rapidly into air-containing cavities and can\\nresult in a collapsed lung (pneumothorax) or lower\\nthe oxygen contents of tissues (hypoxia).\\nCommonly administered intravenous anesthetic\\nagents include ketamine, thiopental, opioids, and\\npropofol.\\n/C15Ketamine (Ketalar) affects the senses, and produces\\na dissociative anesthesia (catatonia, amnesia, analge-\\nsia) in which the patient may appear awake and\\nreactive, but cannot respond to sensory stimuli.\\nThese properties make it especially useful for use in\\ndeveloping countries and during warfare medical\\ntreatment. Ketamine is frequently used in pediatric\\npatients because anesthesia and analgesia can be\\nachieved with an intramuscular injection. It is also\\nused in high-risk geriatric patients and inshock cases,\\nbecause it also provides cardiac stimulation.\\n/C15Thiopental (Pentothal) is a barbiturate that induces\\na rapid hypnotic state of short duration. Because\\nthiopental is slowly metabolized by the liver, toxic\\naccumulation can occur; therefore, it should not be\\ncontinuously infused. Side effects includenausea and\\nvomiting upon awakening.\\n/C15Opioids include fentanyl, sufentanil, and alfentanil,\\nand are frequently used prior to anesthesia and sur-\\ngery as a sedative and analgesic, as well as a continu-\\nous infusion for primary anesthesia. Because opioids\\nrarely affect the cardiovascular system, they are par-\\nticularly useful for cardiac surgery and other high-\\nrisk cases. Opioids act directly on spinal cord recep-\\ntors, and are freqently used in epidurals for spinal\\nanesthesia. Side effects may include nausea and\\nvomiting, itching, and respiratory depression.\\nGALE ENCYCLOPEDIA OF MEDICINE 199\\nAnesthesia, general'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 229, 'page_label': '200'}, page_content='/C15Propofol (Diprivan) is a nonbarbiturate hypnotic\\nagent and the most recently developed intravenous\\nanesthetic. Its rapid induction and short duration of\\naction are identical to thiopental, but recovery\\noccurs more quickly and with much less nausea and\\nvomiting. Also, propofol is rapidly metabolized in\\nthe liver and excreted in the urine, so it can be used\\nfor long durations of anesthesia, unlike thiopental.\\nHence, propofol is rapidly replacing thiopental as an\\nintravenous induction agent. It is used forgeneral\\nsurgery, cardiac surgery, neurosurgery, and pediatric\\nsurgery.\\nGeneral anesthetics are given only by anesthesio-\\nlogists, the medical professionals trained to use them.\\nThese specialists consider many factors, including a\\npatient’s age, weight, medication allergies, medical\\nhistory, and general health, when deciding which anes-\\nthetic or combination of anesthetics to use. General\\nanesthetics are usually inhaled through a mask or a\\nbreathing tube or injected into a vein, but are also\\nsometimes given rectally.\\nGeneralanesthesiaismuchsafertodaythanitwasin\\nthepast.Thisprogress isdue tofaster-actinganesthetics,\\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 includeheart\\nattack, stroke, brain damage, and death. Anyone\\nscheduled to undergo general anesthesia should thor-\\noughly discuss the benefits and risks with a physician.\\nThe risks of complications depend, in part, on a\\npatient’s age, sex, weight, allergies, general health,\\nand history of smoking, drinking alcohol, or drug\\nuse. Some of these risks can be minimized by ensuring\\nthat the physician and anesthesiologist are fully\\ninformed of the detailed health condition of the\\npatient, including any drugs that he or she may be\\nusing. Older people are especially sensitive to the\\neffects of certain anesthetics and may be more likely\\nto experience side effects from these drugs.\\nPatients who have had general anesthesia should\\nnot drink alcoholic beverages or take medication that\\nslow down the central nervous system (such asantihis-\\ntamines, sedatives, tranquilizers, sleep aids, certain pain\\nrelievers, muscle relaxants, and anti-seizure medica-\\ntion) for 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 tobarbituratesor general anesthetics\\nin the past should notify the doctor before having gen-\\neral anesthesia. In particular, people who have had\\nmalignant hyperthermia or whose family members\\nhave had malignant hyperthermia during or after\\nbeing given an anesthetic should inform the physician.\\nSigns of malignant hyperthermia include rapid, irregu-\\nlar heartbeat, breathing problems, very highfever,a n d\\nmuscle tightness or spasms. These symptoms can occur\\nfollowing the administration of general anesthesia\\nusing inhaled agents, especially halothane. In addition,\\nthe doctor should also be told about any allergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. The effects of anesthetics on preg-\\nnant women and fetuses vary, depending on the type\\nof drug. In general, giving large amounts of general\\nanesthetics to the mother during labor and delivery\\nmay make the baby sluggish after delivery. Pregnant\\nwomen should discuss the use of anesthetics during\\nlabor and delivery with their doctors. Pregnant women\\nwho may be given general anesthesia for other medical\\nprocedures should ensure that the treating physician is\\ninformed about thepregnancy.\\nBREASTFEEDING. Some general anesthetics pass\\ninto breast milk, but they have not been reported to\\ncause problems in nursing babies whose mothers were\\ngiven the drugs.\\nOTHER MEDICAL CONDITIONS. Before being given\\na general anesthetic, a patient who has any of the\\nfollowing conditions should inform his or her doctor:\\n/C15neurological conditions, such as epilepsy or stroke\\n/C15problems with the stomach or esophagus, such as\\nulcers orheartburn\\n/C15eating disorders\\n/C15loose teeth, dentures, bridgework\\n/C15heart disease or family history of heart problems\\n/C15lung diseases, such asemphysema or asthma\\n/C15history of smoking\\n/C15immune system diseases\\n200 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, general'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 230, 'page_label': '201'}, page_content='/C15arthritis or any other conditions that affect\\nmovement\\n/C15diseases 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 anesthe-\\nsia. Fuzzy thinking, blurred vision, and coordination\\nproblems are also possible. For these reasons, anyone\\nwho has had general anesthesia should not drive,\\noperate machinery, or perform other activities that\\ncould endanger themselves or others for at least 24\\nhours, or longer if necessary.\\nMost side effects usually disappear as the anes-\\nthetic wears off. A nurse or doctor should be notified if\\nthese or other side effects persist or cause problems,\\nsuch as:\\n/C15Headache\\n/C15vision problems, including blurred or double vision\\n/C15shivering or trembling\\n/C15muscle pain\\n/C15dizziness, lightheadedness, or faintness\\n/C15drowsiness\\n/C15mood or mental changes\\n/C15nausea or vomiting\\n/C15sore throat\\n/C15nightmares or unusual dreams\\nA doctor should be notified as soon as possible if\\nany of the following side effects occur within two\\nweeks of having general anesthesia:\\n/C15severe headache\\n/C15pain in the stomach or abdomen\\n/C15back or leg pain\\n/C15severe nausea\\n/C15black or bloody vomit\\n/C15unusual tiredness or weakness\\n/C15weakness in the wrist and fingers\\n/C15weight loss or loss of appetite\\n/C15increase or decrease in amount of urine\\n/C15pale skin\\n/C15yellow 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\\nanesthesia should inform the doctor about all other\\nmedication that he or she is taking. This includes pre-\\nscription drugs, nonprescription medicines, and street\\ndrugs. Serious and possibly life-threatening reactions\\nmay occur when general anesthetics are given to peo-\\nple who use street drugs, such ascocaine, marijuana,\\nphencyclidine (PCP or angel dust), amphetamines\\n(uppers), barbiturates (downers), heroin, or othernar-\\ncotics. Anyone who uses these drugs should make sure\\ntheir doctor or dentist knows what they have taken.\\nResources\\nBOOKS\\nDobson, Michael B.Anaesthesia at the District Hospital.\\n2nd ed. World Health Organization, 2000.\\nPERIODICALS\\nAdachi, Y.U., K. Watanabe, H. Higuchi, and T. Satoh.\\n‘‘The Determinants of Propofol Induction of\\nAnesthesia Dose.’’Anesthesia and Analgesia 92 (2001):\\n656-661.\\nOTHER\\nWenker, O. ‘‘Review of Currently Used Inhalation\\nAnesthetics Part I.’’ ‘‘The Internet Journal of\\nAnesthesiology.’’ 1999. .\\nJennifer Sisk\\nAnesthesia, local\\nDefinition\\nLocal or regional anesthesia involves the injection\\nor application of an anesthetic drug to a specific area\\nof the body, as opposed to the entire body and brain as\\noccurs duringgeneral anesthesia.\\nPurpose\\nLocal anesthetics are used to prevent patients\\nfrom feeling pain during medical, surgical, or dental\\nprocedures. Over-the-counter local anesthetics are\\nalso available to provide temporary relief from pain,\\nirritation, and itching caused by various conditions,\\nGALE ENCYCLOPEDIA OF MEDICINE 201\\nAnesthesia, local'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 231, 'page_label': '202'}, page_content='such as cold sores,canker sores, sore throats,sunburn,\\ninsect bites, poison ivy, and minor cuts and scratches.\\nTypes of surgery or medical procedures that reg-\\nularly make use of local or regional anesthesia include\\nthe following:\\n/C15biopsies in which skin or tissue samples are taken for\\ndiagnostic procedures\\n/C15childbirth\\n/C15surgeries on the arms, hands, legs, or feet\\n/C15eye surgery\\n/C15surgeries involving the urinary tract or sexual organs\\nSurgeries involving the chest and abdomen are\\nusually performed under general anesthesia.\\nLocal and regional anesthesia have advantages\\nover general anesthesia in that patients can avoid\\nsome unpleasant side effects, can receive longer lasting\\npain relief, have reduced blood loss, and maintain a\\nsense of psychological comfort by not losing\\nconsciousness.\\nDescription\\nRegional anesthesia typically affects a larger area\\nthan local anesthesia, for example, everything below\\nthe waist. As a result, regional anesthesia may be used\\nfor more involved or complicated surgical or medical\\nprocedures. Regional anesthetics are injected. Local\\nanesthesia involves the injection into the skin or mus-\\ncle or application to the skin of an anesthetic directly\\nwhere pain will occur. Local anesthesia can be divided\\ninto four groups: injectable, topical, dental (non-\\ninjectable), and ophthalmic.\\nLocal and regional anesthesia work by altering the\\nflow of sodium molecules into nerve cells or neurons\\nthrough the cell membrane. Exactly how the anes-\\nthetic does this is not understood, since the drug\\napparently does not bind to any receptor on the cell\\nsurface and does not seem to affect the release of\\nchemicals that transmit nerve impulses (neurotrans-\\nmitters) from the nerve cells. It is known, however,\\nthat when the sodium molecules do not get into the\\nneurons, nerve impulses are not generated and pain\\nimpulses are not transmitted to the brain. The dura-\\ntion of action of an anesthetic depends on the type and\\namount of anesthetic administered.\\nRegional anesthesia\\nTypes of regional anesthesia include:\\n/C15Spinal anesthesia. Spinal anesthesia involves the\\ninjection of a small amount of local anesthetic\\ndirectly into the cerebrospinal fluid surrounding the\\nspinal cord (the subarachnoid space). Blood pressure\\ndrops are common but are easily treated.\\n/C15Epidural anesthesia. Epidural anesthesia involves\\nthe injection of a large volume of local anesthetic\\ndirectly into the space surrounding the spinal fluid\\nsac (the epidural space), not into the spinal fluid.\\nPain relief occurs more slowly but is less likely to\\nproduce blood pressure drops. Also, the block can be\\nmaintained for long periods, even days.\\n/C15Nerve blocks. Nerve blocks involve the injection of\\nan anesthetic into the area around a nerve that sup-\\nplies a particular region of the body, preventing the\\nnerve from carrying nerve impulses to the brain.\\nAnesthetics may be administered with another\\ndrug, such as epinephrine (adrenaline), which decreases\\nbleeding, and sodium bicarbonate to decrease the acid-\\nity of a drug so that it will work faster. In addition,\\ndrugs may be administered to help a patient remain\\ncalm and more comfortable or to make them sleepy.\\nLocal anesthesia\\nINJECTABLE LOCAL ANESTHETICS. These medicines\\nare given by injection to numb and provide pain relief\\nto some part of the body during surgery, dental pro-\\ncedures, or other medical procedures. They are given\\nonly by a trained health care professional and only in a\\ndoctor’s office or a hospital. Some commonly used\\ninjectable local anesthetics are procaine (Novocain),\\nlidocaine (Dalcaine, Dilocaine, L-Caine, Nervocaine,\\nKEY TERMS\\nCanker sore— A painful sore inside the mouth.\\nCold sore— A small blister on the lips or face,\\ncaused by a virus. Also called a fever blister.\\nEpidural space— The space surrounding the spinal\\nfluid sac.\\nMalignant hyperthermia— A type of reaction\\n(probably with a genetic basis) that can occur dur-\\ning general anesthesia in which the patient experi-\\nences a high fever, the muscles become rigid, and\\nthe heart rate and blood pressure fluctuate.\\nSubarachnoid space— The space surrounding the\\nspinal cord that is filled with cerebrospinal fluid.\\nTopical— Not ingested; applied to the outside of\\nthe body, for example to the skin, eye, or mouth.\\n202 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, local'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 232, 'page_label': '203'}, page_content='Xylocaine, and other brands), and tetracaine\\n(Pontocaine).\\nTOPICAL ANESTHETICS. Topical anesthetics, such\\nas benzocaine, lidocaine, dibucaine, pramoxine,\\nbutamben, and tetracaine, relieve pain and itching by\\ndeadening the nerve endings in the skin. They are\\ningredients in a variety of nonprescription products\\nthat are applied to the skin to relieve the discomfort of\\nsunburn, insect bites or stings, poison ivy, and minor\\ncuts, scratches, andburns. These products are sold as\\ncreams, ointments, sprays, lotions, and gels.\\nDENTAL ANESTHETICS (NON-INJECTABLE). Some\\nlocal anesthetics are intended for pain relief in the\\nmouth or throat. They may be used to relieve throat\\npain, teething pain, painful canker sores, toothaches,\\nor discomfort from dentures, braces, or bridgework.\\nSome dental anesthetics are available only with a doc-\\ntor’s prescription. Others may be purchased without a\\nprescription, including products such as Num-Zit,\\nOrajel, Chloraseptic lozenges, and Xylocaine.\\nOPHTHALMIC ANESTHETICS. Other local anes-\\nthetics are designed for use in the eye. The ophthalmic\\nanesthetics proparacaine and tetracaine are used to\\nnumb the eye before certain eye examinations. Eye\\ndoctors may also use these medicines before measur-\\ning eye pressure or removing stitches orforeign objects\\nfrom the eye. These drugs are to be given only by a\\ntrained health care professional.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nlocal anesthetic and the purpose for which it is being\\nused. When using a nonprescription local anesthetic,\\nfollow the directions on the package. Questions con-\\ncerning how to use a product should be referred to a\\nmedical doctor, dentist, or pharmacist.\\nPrecautions\\nPeople who strongly feel that they cannot psycho-\\nlogically cope with being awake and alert during cer-\\ntain procedures may not be good candidates for local\\nor regional anesthesia. Other medications may be\\ngiven in conjunction with the anesthetic, however, to\\nrelieve anxiety and help the patient relax.\\nLocal anesthetics should be used only for the con-\\nditions for which they are intended. For example, a\\ntopical anesthetic meant to relieve sunburn pain\\nshould not be used on cold sores. Anyone who has\\nhad an unusual reaction to any local anesthetic in the\\npast should check with a doctor before using any type\\nof local anesthetic again. The doctor should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nOlder people may be more sensitive to the effects\\nof local anesthetics, especially lidocaine. This\\nincreased sensitivity may increase the risk of side\\neffects. Older people who use nonprescription local\\nanesthetics should be especially careful not to use\\nmore than the recommended amount. Children also\\nmay be especially sensitive to the effects of some local\\nanesthetics, which may increase the chance of side\\neffects. Anyone using these medicines on a child\\nshould be careful not to use more than the amount\\nthat is recommended for children. Certain types of\\nlocal anesthetics should not be used at all young chil-\\ndren. Follow package directions carefully and check\\nwith a doctor of pharmacist if there are any questions.\\nRegional anesthetics\\nSerious, possibly life-threatening, side effects may\\noccur when anesthetics are given to people who use\\nstreet drugs. Anyone who uses cocaine, marijuana,\\namphetamines, barbiturates, phencyclidine (PCP, or\\nangel dust), heroin, or other street drugs should\\nmake sure their doctor or dentist knows what they\\nhave used.\\nPatients who have had a particular kind of reac-\\ntion called malignant hyperthermia (or who have one\\nor more family members who have had this problem)\\nduring or just after receiving a general anesthetic\\nshould inform their doctors before receiving any kind\\nof anesthetic. Signs of malignant hyperthermia include\\nfast and irregular heartbeat, very highfever, breathing\\nproblems, andmuscle spasmsor tightness.\\nAlthough problems are rare, some unwanted side\\neffects may occur when regional anesthetics are used\\nduring labor and delivery. These anesthetics can pro-\\nlong labor and increase the risk ofCesarean section.\\nPregnant women should discuss with their doctors the\\nrisks and benefits of being given these drugs.\\nPatients should not drive or operate other\\nmachinery immediately following a procedure invol-\\nving regional anesthesia, due tonumbness and weak-\\nness, or if local anesthesia also included drugs to make\\nthe patient sleep or strong pain medications. Injection\\nsites should be kept clean, dry, and uncovered to pre-\\nvent infection.\\nInjectable local anesthetics\\nUntil the anesthetic wears off, patients should be\\ncareful not to injure the numbed area. If the anesthetic\\nGALE ENCYCLOPEDIA OF MEDICINE 203\\nAnesthesia, local'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 233, 'page_label': '204'}, page_content='was used in the mouth, do not eat or chew gum until\\nfeeling returns.\\nTopical anesthetics\\nUnless advised by a doctor, topical anesthetics\\nshould not be used on or near any part of the body\\nwith large sores, broken or scraped skin, severe injury,\\nor infection. They should also not be used on large\\nareas of skin. Some topical anesthetics contain alcohol\\nand should not be used near an open flame, or while\\nsmoking.\\nAnyone using a topical anesthetic should be care-\\nful not to get this medication in the eyes, nose, or\\nmouth. When using a spray form of this medication,\\ndo not spray it directly on the face, but apply it to the\\nface with a cotton swab or sterile gauze pad. After\\nusing a topical anesthetic on a child, make sure the\\nchild does not get the medicine in his or her mouth.\\nTopical anesthetics are intended for the tempor-\\nary relief of pain and itching. They should not be used\\nfor more than a few days at a time. Check with a\\ndoctor if:\\n/C15the discomfort continues for more than seven days\\n/C15the problem gets worse\\n/C15the treated area becomes infected\\n/C15new signs of irritation, such as skin rash, burning,\\nstinging, or swelling appear\\nDental anesthetics (non-injectable)\\nDental anesthetics should not be used if certain\\nkinds of infections are present. Check package direc-\\ntions or check with a dentist or medical doctor if\\nuncertain. Dental anesthetics should be used only for\\ntemporary pain relief. If problems such astoothache,\\nmouth sores, or pain from dentures or braces con-\\ntinue, check with a dentist. Check with a doctor if\\nsore throat pain is severe, lasts more than two days,\\nor is accompanied by other symptoms such as fever,\\nheadache, skin rash, swelling,nausea,o rvomiting.\\nPatients should not eat or chew gum while the\\nmouth is numb from a dental anesthetic. There is a\\nrisk of accidently biting the tongue or the inside of the\\nmouth. Also nothing should be eaten or drunk for one\\nhour after applying a dental anesthetic to the back of\\nthe mouth or throat, since the medicine may interfere\\nwith swallowing and may causechoking. If normal\\nfeeling does not return to the mouth within a few\\nhours after receiving a dental anesthetic or if it is\\ndifficult to open the mouth, check with a dentist.\\nOphthalmic anesthetics\\nWhen anesthetics are used in the eye, it is impor-\\ntant not to rub or wipe the eye until the effect of the\\nanesthetic has worn off and feeling has returned.\\nRubbing the eye while it is numb could cause injury.\\nSide effects\\nSide effects of regional or local anesthetics vary\\ndepending on the type of anesthetic used and the way it\\nis administered. Anyone who has unusual symptoms\\nfollowing the use of an anesthetic should get in touch\\nwith his or her doctor immediately.\\nThere is a small risk of developing a severe head-\\nache called a spinal headache following a spinal or\\nepidural block. This headache is severe when the\\npatient is upright and hardly felt when the patient\\nlies down. Though rare, it can occur and can be\\ntreated by performing a blood patch, in which a\\nsmall amount of the patient’s own blood is injected\\ninto the area in the back where the anesthetic was\\ninjected. The blood clots and closes up any area that\\nmay have been leaking spinal fluid. Relief is almost\\nimmediate. Finally, blood clots orabscess can form in\\nthe back, but these are also readily treatable and so\\npose little risk.\\nA physician should be notified immediately if any\\nof these symptoms occur:\\n/C15large swellings that look likehives on the skin, in the\\nmouth, or in the throat\\n/C15severe headache\\n/C15blurred or double vision\\n/C15dizziness or lightheadedness\\n/C15drowsiness\\n/C15confusion\\n/C15anxiety, excitement, nervousness, or restlessness\\n/C15convulsions (seizures)\\n/C15feeling hot, cold, or numb\\n/C15ringing or buzzing in the ears\\n/C15shivering or trembling\\n/C15sweating\\n/C15pale skin\\n/C15slow or irregular heartbeat\\n/C15breathing problems\\n/C15nusual weakness or tiredness\\n204 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, local'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 234, 'page_label': '205'}, page_content='Interactions\\nSome anesthetic drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who receives a regional or\\nlocal anesthetic should let the doctor know all other\\ndrugs he or she is taking including prescription drugs,\\nnonprescription drugs, and street drugs (such as\\ncocaine, marijuana, and heroin).\\nResources\\nBOOKS\\nHarvey, Richard A., et al., editors. ‘‘Anesthetics.’’ In\\nLippincott’s Illustrated Reviews: Pharmacology.\\nPhiladelphia: J.B. Lippincott & Co., 1992.\\nNancy Ross-Flanigan\\nAneurysmectomy\\nDefinition\\nAneurysmectomy is a surgical procedure per-\\nformed to repair a weak area in the aorta. The aorta\\nis the largest artery in the body and the main blood\\nvessel leading away from the heart.\\nPurpose\\nThe purpose of aneurysmectomy is to repair an\\naortic aneurysmthat is likely to rupture if left in place.\\nAneurysmectomy is indicated for an aortic aneurysm\\nthat grows to at least 2 in(5 cm) or for an aortic\\naneurysm of any size that is symptomatic, tender, or\\nenlarging rapidly.\\nPrecautions\\nAneurysmectomy may not be appropriate for\\npatients with severely debilitating diseases such as\\ncancer, emphysema, andheart failure.\\nDescription\\nAn aortic aneurysm is a bulge in the wall of the\\naorta that is usually due to arteriosclerosis orathero-\\nsclerosis. People who are 50-80 years old are most\\nlikely to develop an aortic aneurysm, with men four\\ntimes more likely to develop one than women.\\nAn aortic aneurysm develops and grows slowly. It\\nrarely produces symptoms and is usually only diag-\\nnosed by accident during a routine physical exam or\\non an x ray or ultrasound done for another reason. As\\nthe aneurysm grows larger, the risk of bursting with no\\nwarning, which causes catastrophic bleeding, rises. A\\nruptured aortic aneurysm can cause sudden loss of a\\nfatal amount of blood within minutes or it can leak in\\na series of small bleeds that lead within hours or days\\nto massive bleeding. A leaking aortic aneurysm that is\\nnot treated is always fatal.\\nAneurysmectomy is performed to repair the two\\nmost common types of aortic aneurysms: abdominal\\naortic aneurysms that occur in the abdomen below\\nthe kidneys, and thoracic aortic aneurysms that occur\\nin the chest. It is major surgery performed in a hospital\\nunder general anesthesiaand involves removing debris\\nand then implanting a flexibletube (graft) to replace the\\nenlarged artery. Aneurysmectomy for an aneurysm of\\nthe ascending aorta (the firstpart of the aorta that travels\\nupward from the heart) requires the use of a heart-lung\\nmachine that temporarily stops the heart while the\\naneurysm is repaired. Aneurysmectomy requires a\\none-week hospital stay; the recovery period is five weeks.\\nDuring surgery, the site of the aneurysm (either\\nthe abdomen or the chest) is opened with an incision to\\nexpose the aneurysm. The aorta is clamped above and\\nbelow the aneurysm to stop the flow of blood. Then,\\nKEY TERMS\\nAneurysm— A weakening in the muscular walls of\\na part of the artery which causes the damaged\\nsection to enlarge or sag, giving it a balloon-like\\nappearance.\\nAorta— The main blood vessel that leads away\\nfrom the heart and the body’s largest artery. The\\naorta carries blood from the heart through the chest\\nand abdomen, providing major branches to all of\\nthe organs in the body.\\nArteriosclerosis— Hardening of the arteries that\\noccurs as part of the aging process.\\nArtery— A blood vessel that carries blood from the\\nheart to the body’s tissues.\\nAtherosclerosis— A form of arteriosclerosis in\\nwhich cholesterol-containing fatty deposits accu-\\nmulate in the inner most walls of the heart’s\\narteries.\\nThoracic— Relating to the chest.\\nGALE ENCYCLOPEDIA OF MEDICINE 205\\nAneurysmectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 235, 'page_label': '206'}, page_content='an incision is made in the aneurysm. An artificial\\nDacron tube is sewn in place above and below the\\nopened aneurysm, but the aneurysm is not removed.\\nPlaque or clotted blood are cleaned from the diseased\\ntissue. The clamps are removed and blood flow is re-\\nestablished through the graft. The wall of the aneur-\\nysm is wrapped around the graft to protect it and the\\nskin of the abdomen or chest is sewn up.\\nAneurysmectomy can be performed as elective or\\nemergency surgery. Elective aneurysmectomy takes\\nabout an hour and is far safer than emergency aneur-\\nysmectomy, with a mortality rate of 3-5% for elective\\nabdominal aneurysmectomy and 5-10% for elective\\nthoracic aneurysmectomy. When an aneurysm\\nruptures, 62% of patients die before they reach the\\nhospital. Of those who make it into emergency aneur-\\nysmectromy, 50% die. After a successful aneurysmect-\\nomy, the patient has nearly the same life expectancy as\\nother people of the same age.\\nPreparation\\nBefore elective aneurysmectomy, blood studies, a\\nchest x ray, cardiac catherization, electrocardiogram\\n(ECG), and ultrasound are performed.\\nAftercare\\nAfter aneurysmectomy, the patient is monitored\\nin an Intensive Care Unit for the first 24–48 hours.\\nFollow-up tests include ECG, chest x ray, and\\nultrasound.\\nRisks\\nElective aneurysmectomy has a 5-10% rate of\\ncomplications, such as bleeding, kidney failure,\\nrespiratory complications,heart attack, stroke, infec-\\ntion, limb loss, bowelischemia, andimpotence. These\\ncomplications are many times more common in emer-\\ngency aneurysmectomy.\\nResources\\nPERIODICALS\\nDonaldson, M. C., M. Belkin, and A. D. Whittemore.\\n‘‘Mesenteric Revascularization During\\nAneurysmectomy.’’ Surgery Clinic of North America 77\\n(April 1997): 443-459.\\nLori De Milto\\nAneurysms see Aneurysmectomy; Cerebral\\naneurysm; Ventricular aneurysm\\nAngina\\nDefinition\\nAngina is pain, ‘‘discomfort,’’ or pressure loca-\\nlized in the chest that is caused by an insufficient\\nsupply of blood (ischemia) to the heart muscle. It is\\nalso sometimes characterized by a feeling ofchoking,\\nsuffocation, or crushing heaviness. This condition is\\nalso called angina pectoris.\\nDescription\\nOften described as a muscle spasm and choking\\nsensation, the term ‘‘angina’’ is used primarily to\\ndescribe chest (thoracic) pain originating from insuffi-\\ncient oxygen to the heart muscle. An episode of angina\\nis not an actualheart attack, but rather pain that results\\nfrom the heart muscle temporarily receiving too little\\nblood. This temporary condition may be the result of\\ndemanding activities such asexercise and does not\\nnecessarily indicate that the heart muscle is experienc-\\ning permanent damage. In fact, episodes of angina\\nseldom cause permanent damage to heart muscle.\\nAngina can be subdivided further into two cate-\\ngories: angina of effort and variant angina.\\nAngina of effort\\nAngina of effort is a common disorder caused by\\nthe narrowing of the arteries (atherosclerosis) that\\nsupply oxygen-rich blood to the heart muscle. In the\\ncase of angina of effort, the heart (coronary) arteries\\ncan provide the heart muscle (myocardium) adequate\\nblood during rest but not during periods of exercise,\\nstress, or excitement–any of which may precipitate\\npain. The pain is relieved by resting or by administer-\\ning nitroglycerin, a medication that reduces ischemia\\nof the heart. Patients with angina of effort have an\\nincreased risk of heart attack (myocardial infarction).\\nVariant angina\\nVariant angina is uncommon and occurs indepen-\\ndently of atherosclerosis which may, however, be pre-\\nsent as an incidental finding. Variant angina occurs at\\nrest and is not related to excessive work by the heart\\nmuscle. Research indicates that variant angina is\\ncaused by coronary artery muscle spasm of insufficient\\nduration or intensity to cause an actual heart attack.\\nCauses and symptoms\\nAngina causes a pressing pain or sensation of\\nheaviness, usually in the chest area under the breast\\n206 GALE ENCYCLOPEDIA OF MEDICINE\\nAngina'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 236, 'page_label': '207'}, page_content='bone (sternum). It occasionally is experienced in the\\nshoulder, arm, neck, or jaw regions. Because episodes\\nof angina occur when the heart’s need for oxygen\\nincreases beyond the oxygen available from the\\nblood nourishing the heart, the condition is often pre-\\ncipitated by physical exertion. In most cases, the symp-\\ntoms are relieved within a few minutes by resting or by\\ntaking prescribed angina medications. Emotional\\nstress, extreme temperatures, heavy meals, cigarette\\nsmoking, and alcohol can also cause or contribute to\\nan episode of angina.\\nDiagnosis\\nPhysicians can usually diagnose angina based on\\nthe patient’s symptoms and the precipitating factors.\\nHowever, other diagnostic testing is often required to\\nconfirm or rule out angina, or to determine the sever-\\nity of the underlying heart disease.\\nElectrocardiogram (ECG)\\nAn electrocardiogram is a test that records elec-\\ntrical impulses from the heart. The resulting graph of\\nelectrical activity can show if the heart muscle isn’t\\nfunctioning properly as a result of a lack of oxygen.\\nElectrocardiograms are also useful in investigating\\nother possible abnormal features of the heart.\\nStress test\\nFor many individuals with angina, the results of\\nan electrocardiogram while at rest will not show any\\nabnormalities. Because the symptoms of angina occur\\nduring stress, the functioning of the heart may need to\\nbe evaluated under the physical stress of exercise. The\\nstress testrecords information from the electrocardio-\\ngram before, during, and after exercise in search of\\nstress-related abnormalities. Blood pressure is also\\nmeasured during the stress test and symptoms are\\nnoted. A more involved and complex stress test (for\\nexample, thallium scanning) may be used in some\\ncases to picture the blood flow in the heart muscle\\nduring the most intense time of exercise and after rest.\\nAngiogram\\nThe angiogram, which is basically an x ray of the\\ncoronary artery, has been noted to be the most accu-\\nrate diagnostic test to indicate the presence and extent\\nof coronary disease. In this procedure, a long, thin,\\nflexible tube (catheter) is maneuvered into an artery\\nlocated in the forearm or groin. This catheter is passed\\nfurther through the artery into one of the two major\\ncoronary arteries. A dye is injected at that time to help\\nthe x rays ‘‘see’’ the heart and arteries more clearly.\\nMany brief x rays are made to create a ‘‘movie’’ of\\nblood flowing through the coronary arteries, which\\nwill reveal any possible narrowing that causes a\\ndecrease in blood flow to the heart muscle and asso-\\nciated symptoms of angina.\\nTreatment\\nConservative treatment\\nArtery disease causing angina is addressed initi-\\nally by controlling existing factors placing the indivi-\\ndual at risk. These risk factors include cigarette\\nsmoking, high blood pressure,high cholesterollevels,\\nand obesity. Angina is often controlled by medication,\\nmost commonly with nitroglycerin. This drug relieves\\nsymptoms of angina by increasing the diameter of the\\nblood vessels carrying blood to the heart muscle.\\nNitroglycerin is taken whenever discomfort occurs or\\nis expected. It may be taken by mouth by placing the\\ntablet under the tongue or transdermally by placing a\\nmedicated patch directly on the skin. In addition,beta\\nblockers or calcium channel blockersmay be prescribed\\nto also decrease the demand on the heart by decreasing\\nthe rate and workload of the heart.\\nSurgical treatment\\nWhen conservative treatments are not effective in\\nthe reduction of angina pain and the risk of heart\\nattack remains high, physicians may recommend\\nangioplasty or surgery. Coronary artery bypass sur-\\ngery is an operation in which a blood vessel (often a\\nlong vein surgically removed from the leg) is grafted\\nonto the blocked artery to bypass the blocked portion.\\nThis newly formed pathway allows blood to flow ade-\\nquately to the heart muscle.\\nAnother procedure used to improve blood flow to\\nthe heart is balloon angioplasty. In this procedure, the\\nKEY TERMS\\nIschemia — Decreased blood supply to an organ or\\nbody part, often resulting in pain.\\nMyocardial infarction — A blockage of a coronary\\nartery that cuts off the blood supply to part of the\\nheart. In most cases, the blockage is caused by fatty\\ndeposits.\\nMyocardium — The thick middle layer of the heart\\nthat forms the bulk of the heart wall and contracts\\nas the organ beats.\\nGALE ENCYCLOPEDIA OF MEDICINE 207\\nAngina'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 237, 'page_label': '208'}, page_content='physician inserts a catheter with a tiny balloon at the\\nend into a forearm or groin artery. The catheter is then\\nthreaded up into the coronary arteries and the balloon\\nis inflated to open the vessel in narrowed sections.\\nOther techniques using laser and mechanical devices\\nare being developed and applied, also by means of\\ncatheters.\\nAlternative treatment\\nDuring an angina episode, relief has been noted by\\napplying massage or kinesiological methods, but these\\ntechniques are not standard recommendations by phy-\\nsicians. For example, one technique places the palm\\nand fingers of either hand on the forehead while simul-\\ntaneously firmly massaging the sternum (breast bone)\\nup and down its entire length using the other hand.\\nThis is followed by additional massaging by the fin-\\ngertip and thumb next to the sternum, on each side.\\nOnce the angina has subsided, the cause should be\\ndetermined and treated. Atherosclerosis, a major asso-\\nciated cause, requires diet and lifestyle adjustments,\\nprimarily including regular exercise, reduction of diet-\\nary sugar and saturated fats, and increase of dietary\\nfiber. Both conventional and alternative medicine\\nagree that increasing exercise and improving diet are\\nimportant steps to reduce high cholesterol levels.\\nAlternative medicine has proposed specific choles-\\nterol-lowering treatments, with several gaining the\\nattention and interest of the public. One of the most\\nrecent popular treatments is garlic (Allium sativum ).\\nSome studies have shown that adequate dosages of\\ngarlic can reduce total cholesterol by about 10%,\\nLDL (bad) cholesterol by 15%, and raise HDL\\n(good) cholesterol by 10%. Other studies have not\\nshown significant benefit. Although its effect on cho-\\nlesterol is not as great as that achieved by medications,\\ngarlic may possibly be of benefit in relatively mild\\ncases of high cholesterol, without causing the side\\neffects associated with cholesterol-reducing drugs .\\nOther herbal remedies that may help lower cholesterol\\ninclude alfalfa ( Medicago sativa ), fenugreek\\n(Trigonella foenum-graecum ), Asian ginseng (Panax\\nginseng), and tumeric (Curcuma longa ).\\nAntioxidants, including vitamin A (beta carotene),\\nvitamin C, vitamin E, and selenium, can limit the oxi-\\ndative damage to the walls of blood vessels that may\\nbe a precursor of atherosclerotic plaque formation.\\nPrognosis\\nThe prognosis for a patient with angina depends\\non its origin, type, severity, and the general health of\\nthe individual. A person who has angina has the best\\nprognosis if he or she seeks prompt medical attention\\nand learns the pattern of his or her angina, such as\\nwhat causes the attacks, what they feel like, how long\\nepisodes usually last, and whether medication relieves\\nthe attacks. If patterns of the symptoms change sig-\\nnificantly, or if symptoms resemble those of a heart\\nattack, medical help should be sought immediately.\\nPrevention\\nIn most cases, the best prevention involves chan-\\nging one’s habits to avoid bringing on attacks of\\nangina. If blood pressure medication has been pre-\\nscribed, compliance is a necessity and should be a\\npriority as well. Many healthcare professionals–\\nincluding physicians, dietitians, and nurses–can pro-\\nvide valuable advice on proper diet, weight control,\\nblood cholesterol levels, and blood pressure. These\\nprofessionals also offer suggestions about current\\ntreatments and information to help stop smoking. In\\ngeneral, the majority of those with angina adjust their\\nlives to minimize episodes of angina, by taking neces-\\nsary precautions and using medications if recom-\\nmended and necessary.Coronary artery diseaseis the\\nunderlying problem that should be addressed.\\nResources\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nOTHER\\n‘‘Angina.’’ Healthtouch Online Page. Sepember 1997. [cited\\nMay 21, 1998]. .\\nJeffrey P. Larson, RPT\\nAngioedema see Hives\\nAngiogram see Angiography\\nAngiography\\nDefinition\\nAngiography is the x-ray study of the blood\\nvessels. An angiogram uses a radiopaque substance,\\nor dye, to make the blood vessels visible under x ray.\\nArteriography is a type of angiography that involves\\nthe study of the arteries.\\n208 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiography'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 238, 'page_label': '209'}, page_content='Purpose\\nAngiography is used to detect abnormalities or\\nblockages in the blood vessels (called occlusions)\\nthroughout the circulatorysystem and in some organs.\\nTheprocedureiscommonlyusedtoidentify atherosclero-\\nsis; to diagnose heart disease; to evaluate kidneyfunction\\nand detect kidney cysts or tumors; to detect an aneurysm\\n(an abnormal bulge of an artery that can rupture leading\\nto hemorrhage), tumor, blood clot, orarteriovenous mal-\\nformations (abnormals tangles of arteries and veins) in\\nthe brain; and to diagnose problems with the retina of the\\neye. It is also used to give surgeons an accurate ‘‘map’’ of\\ntheheart priortoopen-heart surgery,orofthebrainprior\\nto neurosurgery.\\nPrecautions\\nPatients withkidney diseaseor injury may suffer\\nfurther kidney damage from the contrast mediums\\nused for angiography. Patients who have blood clot-\\nting problems, have a known allergy to contrast med-\\niums, or are allergic to iodine, a component of some\\ncontrast mediums, may also not be suitable candidates\\nfor an angiography procedure. Because x rays carry\\nAn angiogram of a coronary artery.(Phototake NYC. Reproduced\\nby permission.)\\nKEY TERMS\\nArteriosclerosis— A chronic condition characterized\\nby thickening and hardening of the arteries and\\nthe build-up of plaque on the arterial walls.\\nArteriosclerosis can slow or impair blood circulation.\\nCarotid artery— An artery located in the neck.\\nCatheter— A long, thin, flexible tube used in angio-\\ngraphy to inject contrast material into the arteries.\\nCirrhosis— A condition characterized by the destruc-\\ntion of healthy liver tissue. A cirrhotic liver is scarred\\nand cannot break down the proteins in the blood-\\nstream.Cirrhosisisassociated with portalhypertension.\\nEmbolism— A blood clot, air bubble, or clot of foreign\\nmaterial that travels and blocks the flow of blood in an\\nartery. When blood supply to a tissue or organ is\\nblocked by an embolism, infarction, or death of the\\ntissue the artery feeds, occurs. Without immediate\\nand appropriate treatment, an embolism can be fatal.\\nFemoral artery— An artery located in the groin area\\nthat is the most frequently accessed site for arterial\\npuncture in angiography.\\nFluorescein dye— An orange dye used to illuminate the\\nblood vessels of the retina in fluorescein angiography.\\nFluoroscopic screen— A fluorescent screen which\\ndisplays ‘‘moving x-rays’’ of the body. Fluoroscopy\\nallows the radiologist to visualize the guide wire and\\ncatheter he is moving through the patient’s artery.\\nGuide wire— A wire that is inserted into an artery to\\nguides a catheter to a certain location in the body.\\nIscehmia— A lack of normal blood supply to a organ\\nor body part because of blockages or constriction of\\nthe blood vessels.\\nNecrosis— Cellular or tissue death; skin necrosis\\nmay be caused by multiple, consecutive doses of\\nradiation from fluoroscopic or x-ray procedures.\\nPlaque— Fatty material that is deposited on the\\ninside of the arterial wall.\\nPortal hypertension— A condition caused by cirrhosis\\nof the liver. It is characterized by impaired or reversed\\nblood flow from the portal vein to the liver, an enlarged\\nspleen, and dilated veins in the esophagus and stomach.\\nPortal vein thrombosis— The development of a\\nblood clot in the vein that brings blood into the\\nliver. Untreated portal vein thrombosis causes portal\\nhypertension.\\nGALE ENCYCLOPEDIA OF MEDICINE 209\\nAngiography'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 239, 'page_label': '210'}, page_content='risks of ionizing radiation exposure to the fetus, preg-\\nnant women are also advised to avoid this procedure.\\nDescription\\nAngiography is usually performed at a hospital by\\na trained radiologist and assisting technician or nurse.\\nIt takes place in an x-ray or fluoroscopy suite, and for\\nmost types of angiograms, the patient’s vital signs will\\nbe monitored throughout the procedure.\\nAngiographyrequiresthe injectionofacontrastdye\\nthat makes the blood vessels visible to x ray. The dye is\\ninjectedthroughaprocedureknownas arterialpuncture.\\nThe puncture is usually made in the groin area, armpit,\\ninside elbow, or neck. The site is cleaned with an anti-\\nseptic agent and injected with a local anesthetic. First, a\\nsmall incision is made in the skin to help the needle pass.\\nA needle containing an inner wire called a stylet is\\ninserted through the skin into the artery. When the radi-\\nologist has punctured the artery with the needle, the\\nstylet is removed and replaced with another long wire\\ncalled a guide wire. It is normal for blood to spout out of\\nthe needle before the guide wire is inserted.\\nThe guide wire is fed through the outer needle into\\nthe artery and to the area that requires angiographic\\nstudy. A fluoroscopic screen that displays a view of the\\npatient’s vascular system is used to pilot the wire to the\\ncorrect location. Once it is in position, the needle is\\nremoved and a catheter is slid over the length of the\\nguide wire until it to reaches the area of study. The\\nguide wire is removed and the catheter is left in place in\\npreparation for the injection of the contrast medium,\\nor dye.\\nDepending on the type of angiography procedure\\nbeing performed, the contrast medium is either injected\\nby hand with a syringe or is mechanically injected with\\nan automatic injector connected to the catheter. An\\nautomatic injector is used frequently because it is able\\nto propel a large volume of dye very quickly to the\\nangiogram site. The patient is warned that the injection\\nwill start, and instructed to remain very still. The injec-\\ntion causes some mild to moderate discomfort. Possible\\nside effects or reactions includeheadache, dizziness,\\nirregular heartbeat, nausea, warmth, burning sensa-\\ntion, and chestpain, but they usually last only momen-\\ntarily. To view the area of study from different angles\\nor perspectives, the patient may be asked to change\\npositions several times, and subsequent dye injections\\nmay be administered. During any injection, the patient\\nor the camera may move.\\nThroughout the dye injection procedure, x-ray\\npictures and/or fluoroscopic pictures (or moving\\nx rays) will be taken. Because of the high pressure of\\narterial blood flow, the dye will dissipate through the\\npatient’s system quickly, so pictures must be taken in\\nrapid succession. An automatic film changer is used\\nbecause the manual changing of x-ray plates can eat up\\nvaluable time.\\nOnce the x rays are complete, the catheter is slowly\\nand carefully removed from the patient. Pressure is\\napplied to the site with a sandbag or other weight for\\n10-20 minutes in order for clotting to take place and\\nthe arterial puncture to reseal itself. A pressure ban-\\ndage is then applied.\\nMost angiograms follow the general procedures\\noutlined above, but vary slightly depending on the\\narea of the vascular system being studied. A variety\\nof common angiography procedures are outlined\\nbelow:\\nCerebral angiography\\nCerebral angiography is used to detect aneurysms,\\nblood clots, and other vascular irregularities in the\\nbrain. The catheter is inserted into the femoral or\\ncarotid artery and the injected contrast medium tra-\\nvels through the blood vessels on the brain. Patients\\nfrequently experience headache, warmth, or a burning\\nsensation in the head or neck during the injection\\nportion of the procedure. A cerebral angiogram\\ntakes two to four hours to complete.\\nCoronary angiography\\nCoronary angiography is administered by a car-\\ndiologist with training in radiology or, occasionally,\\nby a radiologist. The arterial puncture is typically\\ngiven in the femoral artery, and the cardiologist uses\\na guide wire and catheter to perform a contrast injec-\\ntion and x-ray series on the coronary arteries. The\\ncatheter may also be placed in the left ventricle to\\nexamine the mitral and aortic valves of the heart. If\\nthe cardiologist requires a view of the right ventricle of\\nthe heart or of the tricuspid or pulmonic valves, the\\ncatheter will be inserted through a large vein and\\nguided into the right ventricle. The catheter also serves\\nthe purpose of monitoring blood pressures in these\\ndifferent locations inside the heart. The angiogram\\nprocedure takes several hours, depending on the com-\\nplexity of the procedure.\\nPulmonary angiography\\nPulmonary, or lung, angiography is performed to\\nevaluate blood circulation to the lungs. It is also con-\\nsidered the most accurate diagnostic test for detecting\\na pulmonary embolism. The procedure differs from\\n210 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiography'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 240, 'page_label': '211'}, page_content='cerebral and coronary angiograms in that the guide\\nwire and catheter are inserted into a vein instead of an\\nartery, and are guided up through the chambers of the\\nheart and into the pulmonary artery. Throughout the\\nprocedure, the patient’s vital signs are monitored to\\nensure that the catheter doesn’t causearrhythmias,o r\\nirregular heartbeats. The contrast medium is then\\ninjected into the pulmonary artery where it circulates\\nthrough the lung capillaries. The test typically takes up\\nto 90 minutes.\\nKidney angiography\\nPatients with chronic renal disease or injury can\\nsuffer further damage to their kidneys from the con-\\ntrast medium used in a kidney angiogram, yet they\\noften require the test to evaluate kidney function.\\nThese patients should be well-hydrated with a intrave-\\nnous saline drip before the procedure, and may benefit\\nfrom available medications (e.g., dopamine) that help\\nto protect the kidney from further injury due to con-\\ntrast agents. During a kidney angiogram, the guide\\nwire and catheter are inserted into the femoral artery\\nin the groin area and advanced through the abdominal\\naorta, the main artery in the abdomen, and into the\\nrenal arteries. The procedure will take approximately\\none hour.\\nFluorescein angiography\\nFluorescein angiography is used to diagnose ret-\\ninal problems and circulatory disorders. It is typically\\nconducted as an outpatient procedure. The patient’s\\npupils are dilated with eye drops and he rests his chin\\nand forehead against a bracing apparatus to keep it\\nstill. Sodium fluorescein dye is then injected with a\\nsyringe into a vein in the patient’s arm. The dye will\\ntravel through the patient’s body and into the blood\\nvessels of the eye. The procedure does not require\\nx rays. Instead, a rapid series of close-up photographs\\nof the patient’s eyes are taken, one set immediately\\nafter the dye is injected, and a second set approxi-\\nmately 20 minutes later once the dye has moved\\nthrough the patient’s vascular system. The entire\\nprocedure takes up to one hour.\\nCeliac and mesenteric angiography\\nCeliac and mesenteric angiography involves x-ray\\nexploration of the celiac and mesenteric arteries, arter-\\nial branches of the abdominal aorta that supply blood\\nto the abdomen and digestive system. The test is com-\\nmonly used to detect aneurysm, thrombosis, and signs\\nof ischemia in the celiac and mesenteric arteries, and to\\nlocate the source of gastrointestinal bleeding. It is also\\nused in the diagnosis of a number of conditions,\\nincluding portalhypertension, andcirrhosis. The pro-\\ncedure can take up to three hours, depending on the\\nnumber of blood vessels studied.\\nSplenoportography\\nA splenoportograph is a variation of an angio-\\ngram that involves the injection of contrast medium\\ndirectly into the spleen to view the splenic and portal\\nveins. It is used to diagnose blockages in the splenic\\nvein and portal vein thrombosis and to assess the\\nstrength and location of the vascular system prior to\\nliver transplantation.\\nMost angiography procedures are typically paid\\nfor by major medical insurance. Patients should check\\nwith their individual insurance plans to determine\\ntheir coverage.\\nPreparation\\nPatients undergoing an angiogram are advised to\\nstop eating and drinking eight hours prior to the pro-\\ncedure. They must remove all jewelry before the pro-\\ncedure and change into a hospital gown. If the arterial\\npuncture is to be made in the armpit or groin area,\\nshaving may be required. A sedative may be adminis-\\ntered to relax the patient for the procedure. An IV line\\nwill also be inserted into a vein in the patient’s arm\\nbefore the procedure begins in case medication or\\nblood products are required during the angiogram.\\nPrior to the angiography procedure, patients will\\nbe briefed on the details of the test, the benefits and\\nrisks, and the possible complications involved, and\\nasked to sign an informed consent form.\\nAftercare\\nBecause life-threatening internal bleeding is a pos-\\nsible complication of an arterial puncture, an over-\\nnight stay in the hospital is sometimes recommended\\nfollowing an angiography procedure, particularly with\\ncerebral and coronary angiograms. If the procedure is\\nperformed on an outpatient basis, the patient is typi-\\ncally kept under close observation for a period of at six\\nto 12 hours before being released. If the arterial punc-\\nture was performed in the femoral artery, the patient\\nwill be instructed to keep his leg straight and relatively\\nimmobile during the observation period. The patient’s\\nblood pressure and vital signs will be monitored and\\nthe puncture site observed closely. Pain medication\\nmay be prescribed if the patient is experiencing dis-\\ncomfort from the puncture, and a cold pack is applied\\nto the site to reduce swelling. It is normal for the\\nGALE ENCYCLOPEDIA OF MEDICINE 211\\nAngiography'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 241, 'page_label': '212'}, page_content='puncture site to be sore and bruised for several weeks.\\nThe patient may also develop a hematoma, a hard\\nmass created by the blood vessels broken during the\\nprocedure. Hematomas should be watched carefully,\\nas they may indicate continued bleeding of the arterial\\npuncture site.\\nAngiography patients are also advised to enjoy\\ntwo to three days of rest and relaxation after the\\nprocedure in order to avoid placing any unduestress\\non the arterial puncture. Patients who experience con-\\ntinued bleeding or abnormal swelling of the puncture\\nsite, sudden dizziness, or chest pains in the days fol-\\nlowing an angiography procedure should seek medical\\nattention immediately.\\nPatients undergoing a fluorescein angiography\\nshould not drive or expose their eyes to direct sunlight\\nfor 12 hours following the procedure.\\nRisks\\nBecause angiography involves puncturing an\\nartery, internal bleeding or hemorrhage are possible\\ncomplications of the test. As with any invasive proce-\\ndure, infection of the puncture site or bloodstream is\\nalso a risk, but this is rare.\\nA stroke or heart attack may be triggered by an\\nangiogram if blood clots or plaque on the inside of the\\narterial wall are dislodged by the catheter and form a\\nblockage in the blood vessels or artery. The heart may\\nalso become irritated by the movement of the catheter\\nthrough its chambers during pulmonary and coronary\\nangiography procedures, and arrhythmias may develop.\\nPatients who develop an allergic reaction to the\\ncontrast medium used in angiography may experience\\na variety of symptoms, including swelling, difficulty\\nbreathing, heart failure, or a sudden drop in blood\\npressure. If the patient is aware of the allergy before\\nthe test is administered, certain medications can be\\nadministered at that time to counteract the reaction.\\nAngiography involves minor exposure to radia-\\ntion through the x rays and fluoroscopic guidance\\nused in the procedure. Unless the patient is pregnant,\\nor multiple radiological or fluoroscopic studies are\\nrequired, the small dose of radiation incurred during\\na single procedure poses little risk. However, multiple\\nstudies requiring fluoroscopic exposure that are con-\\nducted in a short time period have been known to\\ncause skin necrosis in some individuals. This risk can\\nbe minimized by careful monitoring and documenta-\\ntion of cumulative radiation doses administered to\\nthese patients.\\nNormal results\\nThe results of an angiogram or arteriogram\\ndepend on the artery or organ system being exam-\\nined. Generally, test results should display a normal\\nand unimpeded flow of blood through the vascular\\nsystem. Fluorescein angiography should result in no\\nleakage of fluorescein dye through the retinal blood\\nvessels.\\nAbnormal results\\nAbnormal results of an angiography may display\\na restricted blood vessel or arterial blood flow (ische-\\nmia) or an irregular placement or location of blood\\nvessels. The results of an angiography vary widely by\\nthe type of procedure performed, and should be inter-\\npreted and explained to the patient by a trained\\nradiologist.\\nResources\\nBOOKS\\nBaum, Stanley, and Michael J. Pentecost, editors.Abrams’\\nAngiography. 4th ed. Philadelphia: Lippincott-Raven,\\n1996.\\nPaula Anne Ford-Martin\\nAngiomas see Birthmarks\\nAngioplasty\\nDefinition\\nAngioplasty is a term describing a procedure used\\nto widen vessels narrowed by stenoses or occlusions.\\nThere are various types of these procedures and their\\nnames are associated with the type of vessel entry and\\nequipment used. For example, percutaneous trans-\\nluminal angioplasty (PTA) describes entry through\\nthe skin (percutaneous) and navigates to the area of\\nthe vessel of interest through the same vessel or one\\nthat communicates with it (transluminal). In the case\\nof a procedure involving the coronary arteries, the\\npoint of entry could be the femoral artery in the\\ngroin and the catheter/guidewire system is passed\\nthrough the aorta to the heart and the origin of the\\ncoronary arteries at the base of the aorta just outside\\nthe aortic valve.\\n212 GALE ENCYCLOPEDIA OF MEDICINE\\nAngioplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 242, 'page_label': '213'}, page_content='Purpose\\nIn individuals with an occulsive vascular disease\\nsuch asatherosclerosis, blood flow is impaired to an\\norgan (such as the heart) or to a distal body part ( such\\nas the lower leg) by the narrowing of the vessel’s lumen\\ndue to fatty deposits or calcium accumulation. This\\nnarrowing may occur in any vessel but may occur\\nanywhere. Once the vessel has been widened, adequate\\nblood flow is returned. The vessel may narrow again\\nover time at the same location and the procedure could\\nbe repeated.\\nPrecautions\\nAngioplasty procedures are performed on hos-\\npital inpatients in facilities for proper monitoring\\nand recovery. If the procedure is to be performed\\nin a coronary artery, the patient’s care is likely to\\nbe provided by specially trained physicians, nurses,\\nand vascular specialists. Typically, patients are\\ngiven anticoagulants prior to the procedure to\\nassist in the prevention of thromboses (blood clots).\\nAdministration of anticoagulants, however, may\\nimpede the sealing of the vascular entry point. The\\nprocedure will be performed using fluoroscopic gui-\\ndance and contrast media. Since the decision to per-\\nform angioplasty may have been made following a\\ndiagnostic angiogram, the patient’s sensitivity to iodi-\\nnated contrast media is likely to known. The proce-\\ndure may then require the use of non-ionic contrast\\nagents.\\nDescription\\nAngioplasty was originally performed by dilating\\nthe vessel with the introduction of larger and larger\\nstiff catheters through the narrowed space.\\nComplications of this procedure caused researchers\\nto develop means of widening the vessel using a mini-\\nmally sized device. Today, catheters contain balloons\\nthat are inflated to widen the vessel and stents to\\nprovide structural support for the vessel. Lasers may\\nbe used to assist in the break up of the fat or calcium\\nplaque. Catheters may also be equipped with spinning\\nwires or drill tips to clean out the plaque.\\nAngioplasty may be performed while the patient is\\nsedated or anesthetized, depending on the vessels\\ninvolved. If a percutaneous transluminal coronary\\nangioplasty (PTCA) is to be performed, the patient\\nBefore After\\nAngioplasty\\nGuidewire\\nInadequate\\nflow\\nPlaque\\nLumen\\nImproved\\nflow\\nInflated\\nballoon\\nIn balloon angioplasty, plaque is pushed out of the clogged artery by the inflation of the balloon device.(Illustration by Argosy Inc.)\\nKEY TERMS\\nplaque— In atherosclerosis, a swollen area in the\\nlining of an artery formed by fatty deposits.\\ncardiac catheterization— A procedure to pass a\\ncatheter to the heart and its vessels for the purpose\\nof diagnosing coronary artery disease, assessing injury\\nor disease of the aorta, or evaluating cardiac function.\\nEKG— Electrocardiogram, used to study and record\\nthe electrical activity of the heart.\\nGALE ENCYCLOPEDIA OF MEDICINE 213\\nAngioplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 243, 'page_label': '214'}, page_content='will be kept awake to report on discomfort andcough\\nif required. PTCA procedures are performed incar-\\ndiac catheterizationlabs with sophisticated monitoring\\ndevices. If angioplasty is performed in the radiology\\ndepartment’s angiographic suite, the patient may be\\nsedated for the procedure and a nurse will monitor\\nthe patient’s vital signs during the procedure. If per-\\nformed by a vascular surgeon, the angioplasty proce-\\ndure will be performed in an operating room or\\nspecially designed vascular procedure suite.\\nThe site of the introduction of the angioplasty\\nequipment is prepared as a sterile surgical site.\\nAlthough many procedures are performed by punctur-\\ning the vessel through skin, many procedures are also\\nperformed by surgically exposing the site of entry.\\nDirect view of the vessel’s puncture site aids in mon-\\nitoring damage to the vessel or excessive bleeding at\\nthe site. Once the vessel is punctured and the guidewire\\nis introduced, fluoroscopy is used to monitor small\\ninjections of contrast media used to visualize the path\\nthrough the vessel. If the fluoroscopy system has a\\nfeature called ‘roadmap’, the amount of contrast\\nmedia injected will be greater in order to define the full\\nroute the guidewire will take. The fluoroscopy system\\nwill then superimpose subsequent images over the road-\\nmap while the vessel is traversed, that is, the physician\\nmoves the guidewire along the map to the destination.\\nHaving reached the area of stenosis, the physician\\nwill inflate the balloon on the catheter that has been\\npassed along the guidewire. Balloons are inflated in size\\nand duration depending on the size and location of the\\nv e s s e l .I ns o m ec a s e s ,t h eu s eo fas t e n t( am e s ho fw i r e\\nthat resembles a Chinese finger puzzle) may also be\\nused. The vessel may be widened before, during, or\\nafter the deployment of the stent. Procedures for deploy-\\ning stents are dependent on the type of stent used. In\\nc a s e sw h e r et h ev e s s e li st o r t u o u so ra ti n t e r s e c t i o n so f\\nvessels, the use of a graph may be necessary to provide\\nstructural strength to the vessel. Stents, graphs, and\\nballoon dilation may all be used together or separately.\\nThe procedure is verified using fluoroscopy and\\ncontrast media to produce an angiogram or by using\\nintravascular ultrasound or both. All equipment is\\nwithdrawn from the vessel and the puncture site\\nrepaired.\\nRisks\\nDuring the procedure there is a danger of punc-\\nturing the vessel with the guidewire. This is a very\\nsmall risk. Patients must be monitored for hematoma\\nor hemorrhage at the puncture site. There is also a\\nsmall risk of heart attack, emboli, and although\\nunlikely death. Hospitalization will vary in length by\\nthe patient’s overall condition, any complications, and\\navailability of home care.\\nResources\\nPERIODICALS\\n‘‘The angioplasty correct follow up strategy after stent\\nimplantation.’’ Heart 84, no. 4 (April, 2001): 363.\\nCarnall, Douglas. ‘‘Angioplasty.’’The Western Journal of\\nMedicine 173, no. 3 (September 2000): 201.\\n‘‘New Imaging Technique Could Improve Outcome of\\nPopular Heart Procedure.’’Heart Disease Weekly May\\n13, 2001: 3.\\n‘‘Success clearing clogged arteries.’’Science News 159, no. 5\\n(February 3, 2001): 72.\\nOTHER\\n‘‘Cardiovascular System’’ Miami Heart Research\\nInstitute 2001. [cited July 5, 2001]. .\\n‘‘Coronary angioplasty: Opening clogged arteries’’\\nMayoClinic.com, Condition Centers, Treatments and\\nTests. 2000. [cited July 5, 2001]. .\\n‘‘Heart American Heart Association online. 2000. [cited July\\n5, 2001]. .\\n‘‘STS Patient Information: What to Expect after your Heart\\nSurgery.’’ Society of Thoracic Surgeons online. 2000.\\n[cited July 5, 2001]. .\\n‘‘When you need to have Angioplast: A patient guide’’ Heart\\nInformation Network. 2000. [cited July 5, 2001].\\n.\\nElaine R. Proseus, MBA/TM, BSRT, RT(R)\\nAngiotensin-converting\\nenzyme inhibitors\\nDefinition\\nAngiotensin-converting enzyme inhibitors (also\\ncalled ACE inhibitors) are medicines that block the\\nconversion of the chemical angiotensin I to a substance\\nthat increases salt and water retention in the body.\\nPurpose\\nACE inhibitors are used in the treatment of high\\nblood pressure. They may be used alone or in combi-\\nnation with other medicines for high blood pressure.\\n214 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 244, 'page_label': '215'}, page_content='They work by preventing a chemical in the blood,\\nangiotensin I, from being converted into a substance\\nthat increases salt and water retention in the body.\\nIncreased salt and water retention lead to high blood\\npressure. ACE inhibitors also make blood vessels\\nrelax, which helps lower blood pressure and allows\\nmore oxygen-rich blood to reach the heart.\\nTreating high blood pressure is important because\\nthe condition puts a burden on the heart and the\\narteries, which can lead to permanent damage over\\ntime. If untreated, high blood pressure increases the\\nrisk of heart attacks,heart failure, stroke, or kidney\\nfailure.\\nACE inhibitors may also be prescribed for other\\nconditions. For example, captopril (Capoten) is used\\nto treat kidney problems in people who take insulin to\\ncontrol diabetes. Captopril and lisinopril are also\\ngiven to some patients after aheart attack. Heart\\nattacks damage and weaken the heart muscle, and\\nthe damage continues even after a person recovers\\nfrom the attack. This medicine helps slow down\\nfurther damage to the heart. ACE inhibitors also\\nmay be used to treat congestive heart failure.\\nDescription\\nACE inhibitors are available only with a physi-\\ncian’s prescription and come in tablet, capsule, and\\ninjectable forms. Some commonly used ACE inhibi-\\ntors are benazepril (Lotensin), captopril (Capoten),\\nenalapril (Vasotec), fosinopril (Monopril), lisinopril\\n(Prinivil, Zestril), moexipril (Univasc), perindopril\\n(Aceon), quinapril (Accupril), ramipril (Altace) and\\ntrandolapril (Mavik).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nACE inhibitor and the medical condition for which\\nit is being taken. Check with the physician who\\nprescribed the drug or the pharmacist who filled the\\nprescription for the correct dosage.\\nThis medicine may take weeks to noticeably lower\\nblood pressure. Take it exactly as directed.\\nDo not stop taking this medicine without check-\\ning with the physician who prescribed it.\\nPrecautions\\nA person taking an ACE inhibitor should see a\\nphysician regularly. The physician will check the\\nblood pressure to make sure the medicine is working\\nas it should and will note any unwanted side effects.\\nPeople who have high blood pressure often feel per-\\nfectly fine. However, they should continue to see their\\nphysicians even when they feel well so that the physi-\\ncian can keep a close watch on their condition. It is\\nalso important for patients to keep taking their med-\\nicine even when they feel fine.\\nACE inhibitors will not cure high blood pressure,\\nbut will help control the condition. To avoid the ser-\\nious health problems that high blood pressure can\\ncause, patients may have to take medicine for the rest\\nof their lives. Furthermore, medicine alone may not be\\nenough. Patients with high blood pressure may also\\nneed to avoid certain foods, such as salty snacks, and\\nkeep their weight under control. The health care pro-\\nfessional who is treating the condition can offer advice\\non what measures may be necessary. Patients being\\ntreated for high blood pressure should not change\\ntheir diets without consulting their physicians.\\nAnyone taking this medicine for high blood pres-\\nsure should not take any other prescription or over-\\nthe-counter (OTC) medicine without first checking\\nwith his or her physician. Some medicines, such as\\ncertain cold remedies, may increase blood pressure.\\nSome people feel dizzy or lightheaded after taking\\nthe first dose of an ACE inhibitor, especially if they\\nhave been taking a water pill (diuretic). Anyone who\\ntakes these drugs should not drive, use machines or do\\nKEY TERMS\\nArteries— Blood vessels that carry blood away from\\nthe heart to the cells, tissues, and organs of the\\nbody.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gradu-\\nally and involve slow changes.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nFetus— A developing baby inside the womb.\\nScleroderma— A disease that first affects the skin\\nand later affects certain internal organs. The first\\nsymptoms are the hardening, thickening, and\\nshrinking of the skin.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease that affects the skin, joints, and certain\\ninternal organs.\\nVenom— A poisonous substance secreted by an\\nanimal, usually delivered through a bite or a sting.\\nGALE ENCYCLOPEDIA OF MEDICINE 215\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 245, 'page_label': '216'}, page_content='anything else that might be dangerous until they have\\nfound out how the drugs affect them. Such symptoms\\nshould be reported to the physician or pharmacist if\\nthey do not subside within a day or so. For the first one\\nor two days of taking an ACE inhibitor, patients may\\nbecome lightheaded when arising from bed in the\\nmorning. Patienst should rise slowly to a sitting posi-\\ntion before standing up.\\nWhile a goal of treatment with an ACE inhibitor\\nis to lower the blood pressure, patients must be careful\\nnot to let their blood pressure get too low. Low blood\\npressure can lead to dizziness, lightheadedness and\\nfainting. To prevent the blood pressure from getting\\ntoo low, observe these precautions:\\n/C15Do not drink alcohol without checking with the\\nphysician who prescribed this medicine.\\n/C15Captopril and moexipril should be taken one hour\\nbefore meals. Other ACE inhinbitors may be taken\\nwith or without meals.\\n/C15Avoid overheating when exercising or in hot\\nweather. The loss of water from the body through\\nheavy sweating can cause low blood pressure.\\n/C15Check with a physician right away if illness occurs\\nwhile taking an ACE inhibitor. This is especially true\\nif the illness involves severenausea, vomiting,o rdiar-\\nrhea. Vomiting and diarrhea can cause the loss of too\\nmuch water from the body, which can lead to low\\nblood pressure.\\nAnyone who is taking ACE inhibitors should be\\nsure to tell the health care professional in charge\\nbefore having any surgical or dental procedures or\\nreceiving emergency treatment.\\nSome ACE inhibitors may change the results of\\ncertain medical tests, such as blood or urine tests.\\nBefore having medical tests, anyone taking this medi-\\ncine should alert the health care professional in charge.\\nDo not use a potassium supplement or a salt sub-\\nstitute that contains potassium without first checking\\nwith the physician who prescribed the ACE inhibitor.\\nPatients who are being treated with bee or wasp\\nvenom to prevent allergic reactions to stings may have\\na severe allergic reaction to certain ACE inhibitors.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take ACE inhibitors. Before taking these drugs,\\nbe sure to let the physician know about any of these\\nconditions.\\nALLERGIES. Anyone who has had unusual reac-\\ntions to an ACE inhibitor in the past should let his\\nor her physician know before taking this type of med-\\nicine again. The physician should also be told about\\nany allergies to foods, dyes, preservatives, or other\\nsubstances.\\nPREGNANCY. The use of ACE inhibitors inpreg-\\nnancy can cause serious problems and evendeath in the\\nfetus or newborn. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians before using this medicine. Women who become\\npregnant while taking this medicine should check with\\ntheir physicians immediately.\\nBREASTFEEDING. Some ACE inhibitors pass into\\nbreast milk. Women who are breastfeeding should\\ncheck with their physicians before using ACE\\ninhibitors.\\nOTHER MEDICAL CONDITIONS. Before using ACE\\ninhibitors, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15diabetes\\n/C15heart or blood vessel disease\\n/C15recent heart attack or stroke\\n/C15liver disease\\n/C15kidney disease\\n/C15kidney transplant\\n/C15scleroderma\\n/C15systemic lupus erythematosus (SLE)\\nUSE OF CERTAIN MEDICINES. Taking ACE inhibi-\\ntors with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side\\neffects.\\nSide effects\\nThe most common side effect is a dry, continuing\\ncough. This usually does not subside unless the medi-\\ncation is stopped. Ask the physician if the cough can\\nbe treated. Less common side effects, such ashead-\\nache, loss of taste, unusual tiredness, and nausea or\\ndiarrhea also may occur and do not need medical\\nattention unless they are severe or they interfere with\\nnormal activities.\\nMore serious side effects are rare, but may occur.\\nIf any of the following side effects occur, check with a\\nphysician immediately:\\n/C15swelling of the face, lips, tongue, throat, arms, legs,\\nhands, or feet\\n216 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 246, 'page_label': '217'}, page_content='/C15itchy skin\\n/C15sudden breathing or swallowing problems\\n/C15chest pain\\n/C15hoarseness\\n/C15sore throat\\n/C15fever and chills\\n/C15stomach pain\\n/C15yellow eyes or skin\\nIn addition, anyone who has any of the follow-\\ning symptoms while taking an ACE inhibitor\\nshould check with his or her physician as soon as\\npossible:\\n/C15dizziness, lightheadedness, fainting\\n/C15confusion\\n/C15nervousness\\n/C15fever\\n/C15joint pain\\n/C15numbness ortingling in hands, feet, or lips\\n/C15weak or heavy feeling in the legs\\n/C15skin rash\\n/C15irregular heartbeat\\n/C15shortness of breath or other breathing problems\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking an ACE inhibitor\\nshould get in touch with his or her physician.\\nInteractions\\nACE inhibitors may interact with certain foods\\nand other medicines. For example, captopril\\n(Capoten) interacts with food and should be taken\\none hour before meals. Anyone who takes ACE inhi-\\nbitors should let the physician know all other medi-\\ncines he or she is taking and should ask about foods\\nthat should be avoided. Among the foods and drugs\\nthat may interact with ACE inhibitors are:\\n/C15water pills (diuretics)\\n/C15lithium, used to treat bipolar disorder\\n/C15tetracycline, an antibiotic\\n/C15medicines or supplements that contain potassium\\n/C15salt substitutes that contain potassium\\nThe list above may not include everything that\\ninteracts with ACE inhibitors. Be sure to check with\\na physician or pharmacist before combining ACE\\ninhibitors with any other prescription or nonprescrip-\\ntion (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAngiotensin-converting\\nenzyme test\\nDefinition\\nThis test measures blood levels of angiotensin-\\nconverting enzyme (ACE), also known as Serum\\nAngiotensin-Converting Enzyme (SASE). The pri-\\nmary function of ACE is to help regulate arterial\\npressure by converting angiotensin I to angiotensin II.\\nPurpose\\nThe ACE test is used primarily to detect and\\nmonitor the clinical course ofsarcoidosis (a disease\\nthat affects many organs, especially the lungs), to differ-\\nentiate between sarcoidosis and similar diseases, and to\\ndelineate between active and inactive sarcoid disease.\\nElevated ACE levels are also found in a number of\\nother conditions, including Gaucher’s disease (a rare\\nfamilial disorder of fat metabolism) andleprosy.\\nPrecautions\\nIt should be noted that people under 20 years of\\nage normally have very high ACE levels. Decreased\\nlevels may be seen in the condition of excess fat in the\\nblood (hyperlipidemia). Drugs that may cause\\ndecreased ACE levels include ACE inhibitor antihy-\\npertensives and steroids.\\nDescription\\nACE plays an important role in the renin/aldos-\\nterone mechanism which controls blood pressure by\\nconverting angiotensin I to angiotensin II, two pro-\\nteins involved in regulating blood pressure.\\nAngiotensin I by itself is inactive, but when converted\\nby ACE to the active form, angiotensin II, it causes\\nnarrowing of the small blood vessels in tissues, result-\\ning in an increase in blood pressure. Angiotensin II\\nalso stimulates the hormone aldosterone, which causes\\nan increase in blood pressure. Certain kidney disor-\\nders increase the production of angiotensin II, another\\ncause ofhypertension. Despite the action of ACE on\\nblood pressure regulation, determination of this\\nGALE ENCYCLOPEDIA OF MEDICINE 217\\nAngiotensin-converting enzyme test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 247, 'page_label': '218'}, page_content='enzyme is not very helpful in the evaluation of hyper-\\ntension (high blood pressure).\\nPreparation\\nDetermination of ACE levels requires a blood\\nsample. The patient need not befasting.\\nRisks\\nRisks for this test are minimal, but may include\\nslight bleeding from the puncture site, fainting or\\nfeeling lightheaded after venipuncture, or hematoma\\n(blood accumulating under the puncture site).\\nNormal results\\nNormal ranges for this test are laboratory-specific\\nbut can range from 8-57 U/ml for patients over\\n20 years of age.\\nAbnormal results\\nSerum ACE levels are elevated in approximately\\n80-90% of patients with active sarcoidosis. Thyroid hor-\\nmone may have an effect on ACE activity, as hypothyr-\\noid (low thyroid) patients, as well as patients with\\nanorexia nervosawithassociatedfindingsof hypothyroid-\\nism, may have low serum ACE activity. ACE can also be\\ndecreased in lungcancer(bronchogenic carcinoma).\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAnimal bite infections\\nDefinition\\nThe most common problem following an animal\\nbite is simple infection. The saliva of dogs, cats, ferrets,\\nand rabbits is known to contain a wide variety of\\nbacteria. According to one recent study, bacteria or\\nother pathogens show up in about 85 percent of bites.\\nWhen an animal bites, it can then transmit pathogens\\ninto the wound. These microorganisms may grow\\nwithin the wound and cause an infection. The conse-\\nquences of infection range from mild discomfort to\\nlife-threatening complications.\\nDescription\\nTwo to 4.5 million animal bites occur each year in\\nthe United States; about 1% of these bites require\\nhospitalization. Animal bites result in 334,000 emer-\\ngency room visits per year, which represents approxi-\\nmately 1% of all emergency hospital visits, at an\\nannual cost of $100 million dollars in health care\\nexpenses and lost income. Children are the most fre-\\nquent victims of dog bites, with 5–9 year-old boys\\nhaving the highest incidence. Men are more often\\nbitten by dogs than are women (3:1), whereas women\\nare more often bitten by cats (3:1).\\nDog bites make up 80–85% of all reported inci-\\ndents. Cats account for about 10% of reported bites,\\nand other animals (including hamsters, ferrets, rab-\\nbits, horses, raccoons, bats, skunks, and monkeys)\\nmake up the remaining 5–10%. Cat bites become\\ninfected more frequently than dog bites. A dog’s\\nmouth is rich in bacteria, but only 15–20% of dog\\nbites become infected. In contrast, approximately\\n30–50% of cat bites become infected.\\nMany factors contribute to the infection rates,\\nincluding the type of wound inflicted, the location of\\nthe wound, pre-existing health conditions in the bitten\\nperson, the extent of delay before treatment, patient\\ncompliance and the presence of a foreign body in the\\nwound. Dogs usually inflict crush injuries because\\nthey have rounded teeth and strong jaws; thus, the\\nbite of an adult dog can exert up to 200 pounds per\\nsquare inch of pressure. This pressure usually results in\\na crushing injury, causing damage to such deep struc-\\ntures as bones, blood vessels, tendons, muscles, and\\nnerves. The canine teeth in a dog’s mouth are also\\nsharp and strong, often inflicting lacerations. Cats,\\nwith their needle-like incisors and carnassial teeth,\\ntypically cause puncture wounds. Puncture wounds\\nappear innocuous on the surface, but the underlying\\ninjury goes deep. Cat teeth essentially inject bacteria\\ninto the bite, and the deep, narrow wound is difficult\\nto clean. Persons with impaired immunocompe-\\ntence—for example, individuals with HIV infec-\\ntion—are especially vulnerable to infection from cat\\nbites. Lastly, bites or stings from marine creatures\\nKEY TERMS\\nSarcoidosis— Sarcoidosis is a rare disease of\\nunknown cause in which inflammation occurs in\\nlymph nodes and other tissues throughout the\\nbody, usually the lungs, skin, liver, and eyes.\\n218 GALE ENCYCLOPEDIA OF MEDICINE\\nAnimal bite infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 248, 'page_label': '219'}, page_content='(sharks, rays, eels, etc.) require immediate medical\\nattention as these bites may contain disease organisms\\nunique to the ocean environment as well as causing\\nsevere loss of blood.\\nThe bacterial species most commonly found\\nin bite wounds include Pasteurella multocida ,\\nStaphylococcus aureus , Pseudomonas sp ,a n d\\nStreptococcus sp . P. multocida , the root cause of pas-\\nteurellosis, is especially prominent in cat bite infec-\\ntions. Other infectious diseases from animal bites\\ninclude cat-scratch disease, tetanus and rabies.\\nDoctors are increasingly aware of the importance\\nof checking animal bite wounds for anaerobic organ-\\nisms, which are microbes that can live and multiply in\\nthe absence of air or oxygen. A study published in 2003\\nreported that about two-thirds of animal bite wounds\\ncontain anaerobes. These organisms can produce such\\ncomplications as septic arthritis, tenosynovitis,menin-\\ngitis, and infections of the lymphatic system.\\nWith regard to the most common types of domes-\\ntic pets, it is useful to note that biting and other\\naggressive behavior has different causes in dogs and\\ncats. To some extent these differences are rooted in\\nThis snake breeder shows the scar from his surgery after he\\nwas bitten by a venomous West African Gabon viper. His arm\\nwas cut open in order to relieve swelling from the snake bite\\nin his middle finger. (Photograph by Joe Crocetta, AP/Wide\\nWorld Photo. Reproduced by permission.)\\nKEY TERMS\\nAnaerobic— Referring to an organism that can live\\nin the absence of air or oxygen. About two-thirds of\\nanimal bites are found to contain anaerobic dis-\\nease-producing organisms.\\nCanines— The two sharp teeth located next to the\\nfront incisor teeth in mammals that are used to grip\\nand tear.\\nCarnassials— The last upper premolar teeth in the\\nmouths of cats and other carnivores, adapted to\\nshear or puncture food. Carnassial teeth often\\ncause puncture wounds when a cat bites a human.\\nCulture— A laboratory procedure in which a sam-\\nple from a wound, the blood or other body fluid is\\nt a k e nf r o ma ni n f e c t e dp e r s o n .T h es a m p l ei sp l a c e d\\nin conditions under which bacteria can grow. If\\nbacteria grow, identification tests are done to deter-\\nmine the bacteria species causing the infection.\\nImmunocompetence— An individual’s ability to\\nfight off infection.\\nMicroorganisms— Microscopic organisms, such as\\nbacteria, viruses, algae and fungi.\\nPasteurellosis— A bacterial infection caused by\\nPasteurella multocida . Pasteurellosis is characte-\\nrized by inflammation around the wound site and\\nmay be accompanied by bacteria in the blood-\\nstream and infection in tissues and organs.\\nPathogen— Any disease-producing microorganism.\\nPostexposure prophylaxis (PEP)— Any treatment\\ngiven after exposure to a disease to try to prevent\\nthe disease from occurring. In the case of rabies, PEP\\ninvolves a series of vaccines given to an individual\\nwho has been bitten by an unknown animal or one\\nthat is potentially infected with the rabies virus.\\nTenosynovitis— Inflammation of the sheath of tis-\\nsue that surrounds a tendon. Tenosynovitis is a\\ncommon complication of animal bites containing\\nanaerobic bacteria.\\nZoonosis (plural, zoonoses)— Any disease of ani-\\nmals that can be transmitted to humans. Rabies is\\nan example of a zoonosis.\\nGALE ENCYCLOPEDIA OF MEDICINE 219\\nAnimal bite infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 249, 'page_label': '220'}, page_content='divergent evolutionary pathways, but they have also\\nbeen influenced by human interference through selec-\\ntive breeding. Dogs were first domesticated by humans\\nas early as 10,000\\nB.C. for hunting and as guard or\\nattack dogs. Many species travel in packs or groups\\nin the wild, and many human fatalities resulting from\\ndog bites involve a large group of dogs attacking one\\nor two persons. In addition, dogs typically relate to\\nhumans according to a hierarchical model of domi-\\nnance and submission, and many of the techniques of\\ndog training are intended to teach the dog to respect\\nhuman authority. Certain breeds of dogs are much\\nmore likely to attack humans than others; those most\\noften involved in fatal attacks are pit bulls, Rottweilers,\\nGerman shepherds, huskies, and mastiffs. According to\\nthe Centers for Disease Control (CDC), there are\\nbetween 15 and 20 fatal dog attacks on humans in the\\nUnited States each year. There are several assessment\\nor evaluation scales that veterinarians or animal trai-\\nners can use to score individual or mixed-breed dogs\\nfor dominant or aggressive behavior.\\nUnlike dogs, cats were not domesticated until\\nabout 3000\\nB.C., and were important to ancient civili-\\nzations as rodent catchers and household companions\\nrather than as protectors or hunters of wild game.\\nBiologists classify cats as solitary predators rather\\nthan as pack or herd animals; as a result, cats do not\\nrelate to humans as authority figures in the same way\\nthat dogs do, and they do not form groups that attack\\nhumans when threatened or provoked. In addition,\\ndomestic cats have been selectively bred for appear-\\nance rather than for fierceness or aggression. Most cat\\nbites are the result of fear on the cat’s part (as when\\nbeing placed in a carrier for a trip to the vet) or a\\nphenomenon known as petting-induced aggression.\\nPetting-induced aggression is a behavior in which a\\ncat that has been apparently enjoying contact with a\\nhuman suddenly turns on the human and bites. This\\nbehavior appears to be more common in cats that had\\nno contact with humans during their first seven weeks\\nof life. In other cats, this type of aggression appears to\\nbe related to a hypersensitive nervous system; petting\\nor cuddling that was pleasurable to the cat for a few\\nseconds or minutes becomes irritating, and the cat\\nbites as a way of indicating that it has had enough.\\nIn older cats, petting-induced aggression is often a sign\\nthat the cat feelspain from touching or pressure on\\narthritic joints in its neck or back.\\nCauses and symptoms\\nThe most common sign of infection from an ani-\\nmal bite is inflammation. The skin around the wound\\nis red and feels warm, and the wound may exude pus.\\nNearby lymph glands may be swollen. Complications\\ncan arise if the infection is not treated and spreads into\\ndeeper structures or into the bloodstream. If the bite is\\ndeep or occurs on the hand or at a joint, complications\\nare more likely.\\nLive disease-causing bacteria within the blood-\\nstream and tissues cause complications far from the\\nwound site. Such complications include meningitis,\\nbrain abscesses, pneumonia and lung abscesses, and\\nheart infections, among others. These complications\\ncan be fatal. Deep bites or bites near joints can damage\\njoints and bones, causing inflammation of the bone\\nand bone marrow or septic arthritis.\\nCat-scratch disease is caused by Bartonella\\nhenselae, a bacterium that is carried in cat saliva;\\ninfection may be transmitted by a bite or scratch.\\nApproximately 22,000 cases are reported each year in\\nthe United States; worldwide, nine out of every\\n100,000 individuals become infected. More than 80%\\nof reported cases occur in persons under the age of 21.\\nThe disease is not normally severe in individuals with\\nhealthy immune systems. Symptoms may become ser-\\nious, however, in immunocompromised individuals,\\nsuch as those with acquired immune deficiency\\nsyndrome (AIDS) or those undergoingchemotherapy.\\nCommon symptoms include an inflamed sore in the\\narea of the bite or scratch, swollen lymph nodes,fever,\\nfatigue, and rash.\\nRabies is caused by a virus that is transmitted\\nthrough the bite of an animal that is already\\ninfected. It is classified as a zoonosis,w h i c hi sa\\nterm that refers to any disease of animals that can\\nbe transmitted to humans. More than 90% of animal\\nrabies cases occur in such wild animals as skunks,\\nbats, and raccoons, with such domestic animals as\\ndogs and cats accounting for fewer than 10% of\\ncases. The World Health Organization (WHO) esti-\\nmates that between 35,000 and 50,000 individuals\\nworldwide die each year as a result of rabies. The\\nhighest incidence of rabies occurs in Asia where, in\\n1997, over 33,000 deaths were noted, most occurring\\nin India. Rabies is nowadays rare in the United\\nStates, as a result of good animal control practices.\\nOnset is delayed, usually weeks to months after the\\nperson has been bitten. Early symptoms of rabies\\ninclude fever, headache, and flu-like symptoms.\\nThese progress to anxiety, hallucinations , muscle\\nspasms,p a r t i a lparalysis, fear of water (hydropho-\\nbia), and other neurological symptoms as the virus\\nspreads to the central nervous system. Medical treat-\\nment must be sought soon after exposure because\\ndeath invariably follows once the infection becomes\\nestablished.\\n220 GALE ENCYCLOPEDIA OF MEDICINE\\nAnimal bite infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 250, 'page_label': '221'}, page_content='Most deaths from rabies in the United States\\nresult from bat bites; the most recent victim was a\\n66-year-old man in California who died in September\\n2003 after failing to report a bat bite.\\nDiagnosis\\nA medical examination involves taking the history\\nof the injury and assessing the wound type and\\ndamage. Tetanus immunization and general health\\nstatus are checked. An x ray may be ordered to assess\\nbone damage and to check forforeign objects in the\\nwound. Wound cultures are done for infected bites if\\nthe victim is at high risk for complications or if the\\ninfection does not respond to treatment. Evaluation of\\npossible exposure to rabies is also important. A biting\\nanimal suspected of having rabies is usually appre-\\nhended, tested, and observed for a period of time for\\nevidence of pre-existing infection.\\nTreatment\\nTreatment depends on the wound type, its site,\\nand risk factors for infection. All wounds are\\ncleaned and disinfected as thoroughly as possible.\\nBites to the head and face usually receive sutures, as\\ndo severe lacerations elsewhere. Puncture wounds\\nare left open. Ifabscess formation occurs, the phy-\\nsician may perform an incision so as to drain the\\nabscess.\\nIf infection occurs, antibiotics are prescribed.\\nAntibiotics may also be used for infection preven-\\ntion. Since a single bite wound may contain many\\ndifferent types of bacteria, no single antibiotic is\\nalways effective. Commonly prescribed antibiotics\\nare penicillin or a combination of amoxicillin and\\nclavulanate potassium. Aztreonam has been\\nreported to be effective in treating infections caused\\nby P. multocida .\\nBecause rabies is caused by a virus, antibiotics\\nare not effective. In addition, as of 2003, there is no\\nknown cure for the disease once symptoms become\\napparent. It is therefore recommended that indivi-\\nduals with a high risk of contracting the disease\\n(veterinarians, animal handlers, some laboratory\\nworkers) receive preexposurevaccination. Individuals\\nbitten by an unknown or potentially rapid animal\\nshould receive postexposure vaccination, also called\\npostexposure prophylaxis (PEP). The PEP regimen\\nconsists of one dose of vaccine given at the initial visit\\nas well as one dose of human immune globulin.\\nAdditional doses of vaccine are given on days 3, 7, 14,\\nand 28.\\nPrognosis\\nOnce a bacterial infection is halted, the bite victim\\nusually recovers fully. There is no known cure for\\nrabies once symptoms become evident and death is\\nalmost certain. WHO reports that 114 rabies deaths\\noccurred in the Americas in 1997, with only four\\ndeaths occurring that year in the United States, thus\\nemphasizing the importance of good animal control\\npractice and postexposure prophylaxis.\\nPrevention\\nPreventing bites obviously prevents subsequent\\ninfections. With regard to domestic pets, parents\\nshould inform themselves about the aggression level\\nand other characteristics of a particular breed before\\nbringing a purebred pet dog into the family, and\\nconsider having a specific dog evaluated by a veter-\\ninarian or animal behaviorist before adopting it. In\\naddition, parents should make sure that the dog has\\nbeen neutered or spayed, since intact dogs of either\\nsex are more likely to bite than those that have been\\naltered. Cat bites can oftenbe prevented by learning\\nabout a cat’s body language and recognizing the signs\\nof petting-induced aggression. These include dilating\\npupils, a low growl, stiffening of the body, twitching\\nof the tail, and flattening the ears backward against\\nthe head.\\nChildren under 12 years of age are at a higher risk\\nfor bites due to their small size and their inexperience\\nwith animals; therefore, they should be supervised\\nwith animals and taught to act appropriately around\\nthem. In particular, children should be taught not to\\ntease a dog by pulling its fur or tail; to leave a dog\\nalone while it is eating; and to avoid running or\\nscreaming in the presence of a dog, as the animal is\\nmore likely to chase a moving object. Direct eye con-\\ntact with a threatening dog should be avoided, as the\\ndog may interpret that as aggression. It is best to\\nstand still if at all possible, with feet together and\\narms against the chest; most dogs will lose interest\\nin an object that is not moving, and will eventually go\\naway.\\nA wild animal that is unusually aggressive or\\nbehaving strangely (e.g. a raccoon or bat that is active\\nduring the daytime or is physically uncoordinated)\\nshould be avoided and reported to the local animal\\ncontrol authorities; it may be infected with the rabies\\nvirus. Wild animals should not be taken in as pets, and\\ngarbage or pet food that might attract wild animals\\nshould not be left outside the home or camp site.\\nPeople should also avoid trying to break up fights\\nbetween animals and should as a rule approach\\nGALE ENCYCLOPEDIA OF MEDICINE 221\\nAnimal bite infections'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 251, 'page_label': '222'}, page_content='unknown cats and dogs very cautiously, especially on\\ntheir territory. Finally, animals should not be trained\\nto fight.\\nDomestic pets should be vaccinated against\\nrabies; people should cons ult a veterinarian for\\nadvice about the frequency of booster vaccinations\\nfor the area in which they live. In addition, people\\nwho are traveling to countries where rabies is ende-\\nmic should consider vaccination before leaving the\\nUnited States.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Central Nervous System Viral Diseases: Rabies\\n(Hydrophobia).’’ Section 13, Chapter 162 InThe Merck\\nManual of Diagnosis and Therapy. Whitehouse Station,\\nNJ: Merck Research Laboratories, 1999.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Infections of Bones and Joints.’’ Section 5, Chapter 54\\nIn The Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1999.\\nDodman, Nicholas H., DVM.If Only They Could Speak:\\nStories About Pets and Their People . New York and\\nLondon: W. W. Norton and Company, 2002. Contains\\nseveral useful appendices about aggression in various\\ndog breeds and a sample assessment form for evaluating\\na dog’s potential for biting.\\nGarvey, Michael S., DVM, Ann E. Hohenhaus, DVM,\\nKatherine A. Houpt, VMD, PhD, et al.The\\nVeterinarians’ Guide to Your Cat’s Symptoms . New\\nYork: Villard, 1999.\\nPERIODICALS\\nBrook, I. ‘‘Microbiology and Management of Human and\\nAnimal Bite Wound Infections.’’Primary Care 30\\n(March 2003): 25–39.\\nFooks, A. R., N. Johnson, S. M. Brookes, et al. ‘‘Risk\\nFactors Associated with Travel to Rabies Endemic\\nCountries.’’ Journal of Applied Microbiology 94,\\nSupplement (2003): 31S–36S.\\nGarcia Triana, M., M. A. Fernandez Echevarria, R. L.\\nAlvaro, et al. ‘‘Pasteurella multocida Tenosynovitis of\\nthe Hand: Sonographic Findings.’’Journal of Clinical\\nUltrasound 31 (March-April 2003): 159–162.\\n‘‘Human Death Associated with Bat Rabies—California,\\n2003.’’ Morbidity and Mortality Weekly Report 53\\n(January 23, 2004): 33–35.\\nLe Moal, G., C. Landron, G. Grollier, et al. ‘‘Meningitis Due\\nto Capnocytophaga canimorsus After Receipt of a Dog\\nBite: Case Report and Review of the Literature.’’Clinical\\nInfectious Diseases 36 (February 1, 2003): 42–46.\\nMessenger, S. L., J. S. Smith, L. A. Orciari, et al. ‘‘Emerging\\nPattern of Rabies Deaths and Increased Viral\\nInfectivity.’’ Emerging Infectious Diseases 9 (February\\n2003): 151–154.\\nPerkins, R. A., and S. S. Morgan. ‘‘Poisoning,\\nEnvenomation, and Trauma from Marine Creatures.’’\\nAmerican Family Physician 69 (February 15, 2004):\\n885–890.\\nSacks, Jeffrey J., MD, MPH, Leslie Sinclair, DVM, Julie\\nGilchrist, MD, et al. ‘‘Special Report: Breeds of Dogs\\nInvolved in Fatal Human Attacks in the United States\\nBetween 1979 and 1998.’’Journal of the American\\nVeterinary Medical Association 217 (September 15,\\n2000): 836–840.\\nWeiss, R. A. ‘‘Cross-Species Infections.’’Current Topics in\\nMicrobiology and Immunology 278 (2003): 47–71.\\nWinner, J. S., C. A. Gentry, L. J. Machado, and P. Cornea.\\n‘‘Aztreonam Treatment ofPasteurella multocida\\nCellulitis and Bacteremia.’’Annals of Pharmacotherapy\\n37 (March 2003): 392–394.\\nORGANIZATIONS\\nAmerican Academy of Emergency Medicine (AAEM). 555\\nEast Wells Street, Suite 1100, Milwaukee, WI 53202.\\n(800) 884-2236. Fax: (414) 276-3349. .\\nAmerican Veterinary Medical Association (AVMA). 1931\\nNorth Meacham Road, Suite 100, Schaumburg, IL\\n60173-4360. .\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nOTHER\\nNational Association of State Public Health Veterinarians,\\nInc. ‘‘Compendium of Animal Rabies Prevention and\\nControl, 2003.’’Morbidity and Mortality Weekly\\nReport Recommendations and Reports 52 (March 21,\\n2003) (RR-5): 1–6.\\n‘‘Rabies Situation and Trends.’’ Paris: World Health\\nOrganization. 2001. .\\nJulia Barrett\\nRebecca J. Frey, PhD\\nAnkylosing spondylitis\\nDefinition\\nAnkylosing spondylitis (AS) refers to inflamma-\\ntion of the joints in the spine. AS is also known as\\nrheumatoid spondylitis or Marie-Stru¨ mpell disease\\n(among other names).\\nDescription\\nA form of arthritis, AS is characterized by chronic\\ninflammation, causingpain and stiffness of the back,\\n222 GALE ENCYCLOPEDIA OF MEDICINE\\nAnkylosing spondylitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 252, 'page_label': '223'}, page_content='progressing to the chest and neck. Eventually, the\\nwhole back may become curved and inflexible if the\\nbones fuse (this is known as ‘‘bamboo spine’’). AS is a\\nsystemic disorder that may involve multiple organs,\\nsuch as the:\\n/C15eye (causing an inflammation of the iris, or iritis)\\n/C15heart (causing aortic valve disease)\\n/C15lungs\\n/C15skin (causing a scaly skin condition, or psoriasis)\\n/C15gastrointestinal tract (causing inflammation within\\nthe small intestine, called ileitis, or inflammation of\\nthe large intestine, called colitis)\\nLess than 1% of the population has AS; however,\\n20% of AS sufferers have a relative with the disorder.\\nCauses and symptoms\\nGenetics play an important role in the disease, but\\nthe cause of AS is still unknown. More than 90% of\\npatients have a gene called HLA-B27, but only\\n10-15% of those who inherit the gene develop the\\ndisease. Symptoms of AS include:\\n/C15low back and hip pain and stiffness\\n/C15difficulty expanding the chest\\n/C15pain in the neck, shoulders, knees, and ankles\\n/C15low-grade fever\\n/C15fatigue\\n/C15weight loss\\nAS is seen most commonly in males 30 years old\\nand older. Initial symptoms are uncommon after\\nthe age of 30, although the diagnosis may not be\\nestablished until after that age. The incidence of AS\\nin Afro-Americans is about 25% of the incidence in\\nCaucasians.\\nDiagnosis\\nDoctors usually diagnose the disease simply by\\nthe patient’s report of pain and stiffness. Doctors\\nalso review spinal and pelvic x rays since involvement\\nof the hip and pelvic joints is common and may be the\\nfirst abnormality seen on the x ray. The doctor may\\nalso order a blood test to determine the presence of\\nHLA-B27 antigen. When a diagnosis is made, patients\\nmay be referred to a rheumatologist, a doctor who\\nspecializes in treating arthritis. Patients may also be\\nreferred to an orthopedic surgeon, a doctor who can\\nsurgically correct joint or bone disorders.\\nTreatment\\nPhysical therapists prescribe exercises to prevent a\\nstooped posture and breathing problems when\\nthe spine starts to fuse and ribs are affected. Back\\nbraces may be used to prevent continued deformity\\nof the spine and ribs. Only in severe cases of deformity\\nis surgery performed to straighten and realign the\\nspine, or to replace knee, shoulder, or hip joints.\\nAlternative treatment\\nTo reduce inflammation various herbal remedies,\\nincluding white willow (Salix alba ), yarrow (Achillea\\nmillefolium), and lobelia (Lobelia inflata ), may be\\nhelpful. Acupuncture, performed by a trained profes-\\nsional, has helped some patients manage their pain.\\nHomeopathic practitione rs may prescribe such\\nremedies as Bryonia and Rhus toxicodendron for\\npain relief.\\nPrognosis\\nThere is no cure for AS, and the course of the\\ndisease is unpredictable. Generally, AS progresses for\\nabout 10 years and then its progression levels off.\\nMost patients can lead normal lives with treatment\\nto control symptoms.\\nPrevention\\nThere is no known way to prevent AS.\\nResources\\nORGANIZATIONS\\nArthritis Foundation.1300 W. Peachtree St., Atlanta, GA\\n30309. (800) 283-7800. .\\nNational Institute of Arthritis and Musculoskeletal and Skin\\nDiseases Information Clearinghouse. 1 AMS Circle,\\nBethesda, MD 29892-3675. (301) 495-4484.\\nKEY TERMS\\nAnkylosing— When bones of a joint are fused, stiff,\\nor rigid.\\nHLA-B27— An antigen or protein marker on cells\\nthat may indicate ankylosing spondylitis.\\nImmune suppressing— Anything that reduces the\\nactivity of the immune system.\\nInflammation— A reaction of tissues to disease or\\ninjury, often associated with pain and swelling.\\nSpondylitis— An inflammation of the spine.\\nGALE ENCYCLOPEDIA OF MEDICINE 223\\nAnkylosing spondylitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 253, 'page_label': '224'}, page_content='Spondylitis Association of America. P.O. Box 5872,\\nSherman Oaks, CA 91413. (800) 777-8189.\\nOTHER\\nMatsen III, Frederick, ed. ‘‘Ankylosing Spondylitis.’’\\nUniversity of Washington Orthopaedics and Sports\\nMedicine. .\\nJeanine Barone, Physiologist\\nAnorectal abscess see Anorectal disorders\\nAnorectal disorders\\nDefinition\\nAnorectal disorders are a group of medical disor-\\nders that occur at the junction of the anal canal and the\\nrectum.\\nDescription\\nThe anal canal, also called the anus, is the opening\\nat the bottom end of the digestive tract and is a com-\\nbination of external skin and tissue from the digestive\\ntract. It has many sensory nerves and is sensitive to\\npain. The rectum is the last section of the digestive\\ntract and has a mucus layer as its inside surface. It\\nhas very few sensory nerves and is, therefore, relatively\\ninsensitive to pain. The anal canal has a ring of muscle,\\ncalled the anal sphincter, which keeps the anus closed.\\nThere are a number of different anorectal disorders.\\nCauses and symptoms\\nAn anal fissure is a tear in the lining of the anus\\nthat is usually caused by a hard bowel movement.\\nFissures are painful and bleed when the tissue is\\nstressed during bowel movements.\\nAnorectal abscesses are characterized by pus-\\nforming infections in the anorectal region. Painful\\nabscesses form under the skin.\\nAn anorectal fistula is an abnormal opening or\\nchannel from the anorectal area to another part of\\nthe body. Typically, the channel leads to pockets of\\nskin near the anus. When seen in infants, anorectal\\nfistulas are considered birth defects. These are seen\\nmore frequently in boys than in girls. Fistulas are\\nalso seen more frequently in people who have other\\ndiseases, including Crohn’s disease , tuberculosis,\\ncancer, and diverticulitis. Anorectal fistulas also\\noccur following anorectal abscesses or other injury\\nto the anal area. Fistulas are usually painful and\\ndischarge pus.\\nDiagnosis\\nDiagnosis is made by visual inspection of the skin\\naround the anus. Also, the doctor may probe the\\nrectum with a gloved finger. An anoscope is a short\\ninstrument that allows the physician to view the inside\\nof the anus. A proctoscope is a longer, rigid viewing\\ntube of approximately six to ten inches in length,\\nwhich may be used to look for anorectal disorders.\\nA sigmoidoscope is a longer, flexible tube, that\\nallows the physician to view up to about two feet of\\nthe inside of the large intestine. Tissue samples and\\nmaterial for microbial culture may be obtained during\\nthe examination.\\nTreatment\\nTreatment usually isn’t required for hemorrhoids.\\nMost hemorrhoids will heal if the patient takes stool\\nsofteners to relieve the constipation. Enlarged blood\\nvesselscanbeeliminatedbysurgeryiftheyareconsidered\\na severe problem. In the case of fissures, treatment\\ninvolves stool softeners that eliminatestress on the\\nfissureduring bowelmovements,which allows the fissure\\nto heal. If the fissure doesn’t heal, surgery is required.\\nTreatment for anorectal abscesses consists of cutting the\\nabscess and draining the pus. Fistulas are treated by\\nsurgery.The usual treatment for proctitis isantibiotics.\\nResources\\nBOOKS\\nBerkow, Robert, editor.Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nJohn T. Lohr, PhD\\nAnorectal fistula see Anorectal disorders\\nAnorexia nervosa\\nDefinition\\nAnorexia nervosa is an eating disorder character-\\nized by unrealistic fear of weight gain, self-starvation,\\nand conspicuous distortion of body image. The name\\ncomes from two Latin words that mean nervous\\ninability to eat. In females who have begun to\\n224 GALE ENCYCLOPEDIA OF MEDICINE\\nAnorexia nervosa'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 254, 'page_label': '225'}, page_content='menstruate, anorexia nervosa is usually marked by\\namenorrhea, or skipping at least three menstrual peri-\\nods in a row. The fourth edition of theDiagnostic and\\nStatistical Manual of Mental Disorders ,o r DSM-IV\\n(1994), defines two subtypes of anorexia nervosa–a\\nrestricting type, characterized by strict dieting and\\nexercise without binge eating; and a binge-eating/pur-\\nging type, marked by episodes of compulsive eating\\nwith or without self-inducedvomiting and the use of\\nlaxatives or enemas. DSM-IV defines a binge as a\\ntime-limited (usually under two hours) episode of\\ncompulsive eating in which the individual consumes\\na significantly larger amount of food than most people\\nwould eat in similar circumstances.\\nDescription\\nAnorexia nervosa was not officially classified as a\\npsychiatric disorder until the third edition ofDSM in\\n1980. It is, however, a growing problem among ado-\\nlescent females. Its incidence in the United States has\\ndoubled since 1970. The rise in the number of reported\\ncases reflects a genuine increase in the number of\\npersons affected by the disorder, and not simply earlier\\nor more accurate diagnosis. Estimates of the incidence\\nof anorexia range between 0.5–1% of caucasian female\\nadolescents. Over 90% of patients diagnosed with the\\ndisorder as of 1998 are female. It was originally thought\\nthat only 5% of anorexics are male, but that estimate is\\nbeing revised upward. The peak age range for onset of\\nthe disorder is 14-18 years, although there are patients\\nwho develop anorexia as late as their 40s. In the 1970s\\nand 1980s, anorexia was regarded as a disorder of\\nupper- and middle-class women, but that generalization\\nis also changing. More recent studies indicate that\\nanorexia is increasingly common among women of all\\nraces and social classes in the United States.\\nAnorexia nervosa is a serious public health\\nproblem not only because of its rising incidence, but\\nalso because it has one of the highest mortality rates\\nof any psychiatric disorder. Moreover, the disorder\\nmay cause serious long-term health complications,\\nincluding congestive heart failure , sudden death,\\ngrowth retardation, dental problems, constipation,\\nstomach rupture, swelling of the salivary glands, ane-\\nmia and other abnormalities of the blood, loss of\\nkidney function, andosteoporosis.\\nCauses and symptoms\\nAnorexia is a disorder that results from the inter-\\naction of cultural and interpersonal as well as biologi-\\ncal factors. While the precise cause of the disease is not\\nknown, it has been linked to the following:\\nSocial influences\\nThe rising incidence of anorexia is thought to\\nreflect the present idealization of thinness as a badge\\nof upper-class status as well as of female beauty. In\\naddition, the increase in cases of anorexia includes\\n‘‘copycat’’ behavior, with some patients developing\\nthe disorder from imitating other girls.\\nThe onset of anorexia in adolescence is attributed\\nto a developmental crisis caused by girls’ changing\\nbodies coupled with society’s overemphasis on\\nwomen’s looks. The increasing influence of the mass\\nmedia in spreading and reinforcing gender stereotypes\\nhas also been noted.\\nOccupational goals\\nThe risk of developing anorexia is higher among\\nadolescents preparing for careers that require atten-\\ntion to weight and/or appearance. These high-risk\\ngroups include dancers, fashion models, professional\\nathletes (including gymnasts, skaters, long-distance\\nrunners, and jockeys), and actresses.\\nGenetic and biological influences\\nWomen whose biological mothers or sisters have\\nthe disorder appear to be at increased risk.\\nKEY TERMS\\nAmenorrhea— Absence of the menses in a female\\nwho has begun to have menstrual periods.\\nBinge eating— A pattern of eating marked by epi-\\nsodes of rapid consumption of large amounts of\\nfood; usually food that is high in calories.\\nBody dysmorphic disorder— A psychiatric disorder\\nmarked by preoccupation with an imagined physi-\\ncal defect.\\nHyperalimentation— A method of refeeding anor-\\nexics by infusing liquid nutrients and electrolytes\\ndirectly into central veins through a catheter.\\nLanugo— A soft, downy body hair that develops on\\nthe chest and arms of anorexic women.\\nPurging— The use of vomiting, diuretics, or laxatives\\nto clear the stomach and intestines after a binge.\\nRussell’s sign—Scraped or raw areas on the patient’s\\nknuckles, caused by self-induced vomiting.\\nSuperior mesenteric artery syndrome— A condi-\\ntion in which a person vomits after meals due to\\nblockage of the blood supply to the intestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 225\\nAnorexia nervosa'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 255, 'page_label': '226'}, page_content='Psychological factors\\nA number of theories have been advanced to\\nexplain the psychological aspects of the disorder. No\\nsingle explanation covers all cases. Anorexia nervosa\\nhas been interpreted as:\\n/C15A rejection of female sexual maturity. This rejection\\nis variously interpreted as a desire to remain a child,\\nor as a desire to resemble men as closely as possible.\\n/C15A reaction to sexualabuse or assault.\\n/C15A desire to appear as fragile and nonthreatening as\\npossible. This hypothesis reflects the idea that female\\npassivity and weakness are attractive to men.\\n/C15Overemphasis on control, autonomy, and indepen-\\ndence. Some anorexics come from achievement-\\noriented families that stress physical fitness and\\ndieting. Many anorexics are perfectionistic and\\n‘‘driven’’ about schoolwork and other matters in\\naddition to weight control.\\n/C15Evidence of family dysfunction. In some families, a\\ndaughter’s eating disorder serves as a distraction\\nfrom marital discord or other family tensions.\\n/C15Inability to interpret the body’s hunger signals accu-\\nrately due to early experiences of inappropriate\\nfeeding.\\nMale anorexics\\nAlthough anorexia nervosa is still considered a\\ndisorder that largely affects women, its incidence in\\nthe male population is rising. Less is known about the\\ncauses of anorexia in males, but some risk factors are\\nthe same as for females. These include certain occupa-\\ntional goals and increasing media emphasis on exter-\\nnal appearance in men. Moreover, homosexual males\\nare under pressure to conform to an ideal body weight\\nthat is about 20 pounds lighter than the standard\\n‘‘attractive’’ weight for heterosexual males.\\nDiagnosis\\nDiagnosis of anorexia nervosa is complicated by a\\nnumber of factors. One is that the disorder varies\\nsomewhat in severity from patient to patient. A second\\nfactor is denial, which is regarded as an early sign of\\nthe disorder. Most anorexics deny that they are ill and\\nare usually brought to treatment by a family member.\\nMost anorexics are diagnosed by pediatricians or\\nfamily practitioners. Anorexics develop emaciated\\nbodies, dry or yellowish skin, and abnormally low\\nblood pressure. There is usually a history of amenor-\\nrhea (failure to menstruate) in females, and sometimes\\nof abdominal pain, constipation, or lack of energy.\\nThe patient may feel chilly or have developed lanugo,\\na growth of downy body hair. If the patient has been\\nvomiting, she may have eroded tooth enamel or\\nRussell’s sign (scars on the back of the hand). The\\nsecond step in diagnosis is measurement of the\\npatient’s weight loss.DSM-IV specifies a weight loss\\nleading to a body weight 15% below normal, with\\nsome allowance for body build and weight history.\\nThe doctor will need to rule out other physical\\nconditions that can cause weight loss or vomiting\\nafter eating, including metabolic disorders, brain\\ntumors (especially hypothalamus and pituitary gland\\nlesions), diseases of the digestive tract, and a condition\\ncalled superior mesenteric artery syndrome. Persons\\nwith this condition sometimes vomit after meals\\nbecause the blood supply to the intestine is blocked.\\nThe doctor will usually order blood tests, an electro-\\ncardiogram, urinalysis, and bone densitometry (bone\\ndensity test) in order to exclude other diseases and to\\nassess the patient’s nutritional status.\\nThe doctor will also need to distinguish between\\nanorexia and other psychiatric disorders, including\\ndepression, schizophrenia, social phobia, obsessive-\\ncompulsive disorder, and body dysmorphic disorder.\\nTwo diagnostic tests that are often used are the\\nEating Attitudes Test (EAT) and the Eating Disorder\\nInventory (EDI).\\nTreatment\\nTreatment of anorexia nervosa includes both\\nshort- and long-term measures, and requires assessment\\nby dietitians and psychiatrists as well as medical specia-\\nlists. Therapy is often complicated by the patient’s\\nresistance or failure to carry out treatment plan.\\nHospital treatment\\nHospitalization is recommended for anorexics\\nwith any of the following characteristics:\\n/C15weight of 40% or more below normal; or weight loss\\nover a three-month period of more than 30 pounds\\n/C15severely disturbed metabolism\\n/C15severe binging and purging\\n/C15signs ofpsychosis\\n/C15severe depression or risk ofsuicide\\n/C15family in crisis\\nHospital treatment includes individual andgroup\\ntherapy as well as refeeding and monitoring of the\\npatient’s physical condition. Treatment usually\\n226 GALE ENCYCLOPEDIA OF MEDICINE\\nAnorexia nervosa'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 256, 'page_label': '227'}, page_content='requires two to four months in the hospital. In extreme\\ncases, hospitalized patients may be force-fed through a\\ntube inserted in the nose (nasogastric tube) or by over-\\nfeeding (hyperalimentation techniques).\\nOutpatient treatment\\nAnorexics who are not severely malnourished can\\nbe treated by outpatient psychotherapy. The types of\\ntreatment recommended are supportive rather than\\ninsight-oriented, and include behavioral approaches\\nas well as individual or group therapy.Family therapy\\nis often recommended when the patient’s eating dis-\\norder is closely tied to family dysfunction. Self-help\\ngroups are often useful in helping anorexics find social\\nsupport and encouragement. Psychotherapy with\\nanorexics is a slow and difficult process; about 50%\\nof patients continue to have serious psychiatric pro-\\nblems after their weight has stabilized.\\nMedications\\nAnorexics have been treated with a variety of\\nmedications, including antidepressants, antianxiety\\ndrugs, selective serotonin reuptake inhibitors , and\\nlithium carbonate. The effectiveness of medications\\nin treatment regimens is still debated. However, at\\nleast one study of Prozac showed it helped the patient\\nmaintain weight gained while in the hospital.\\nPrognosis\\nFigures for long-term recovery vary from study to\\nstudy, but the most reliable estimates are that 40-60%\\nof anorexics will make a good physical and social\\nrecovery, and 75% will gain weight. The long-term\\nmortality rate for anorexia is estimated at around\\n10%, although some studies give a lower figure of\\n3-4%. The most frequent causes of death associated\\nwith anorexia are starvation, electrolyte imbalance,\\nheart failure, and suicide.\\nPrevention\\nShort of major long-term changes in the larger\\nsociety, the best strategy for prevention of anorexia\\nis the cultivation of healthy attitudes toward food,\\nweight control, and beauty (or body image) within\\nfamilies.\\nResources\\nBOOKS\\nBaron, Robert B. ‘‘Nutrition.’’ InCurrent Medical Diagnosis\\nand Treatment, 1998 , edited by Stephen McPhee, et al.,\\n37th ed. Stamford: Appleton & Lange, 1997.\\nORGANIZATIONS\\nAmerican Anorexia/Bulimia Association. 418 East 76th St.,\\nNew York, NY 10021. (212) 734-1114.\\nNational Institute of Mental Health Eating Disorders\\nProgram. Building 10, Room 3S231. 9000 Rockville\\nPike, Bethesda, MD 20892. (301) 496-1891.\\nRebecca J. Frey, PhD\\nAnoscopy\\nDefinition\\nAn anoscopy is an examination of the rectum in\\nwhich a small tube is inserted into the anus to screen,\\ndiagnose, and evaluate problems of the anus and anal\\ncanal.\\nPurpose\\nThis test may be ordered for the evaluation of\\nperianal or anal pain, hemorrhoids, rectal prolapse,\\ndigital rectal examinationthat shows a mass, perianal\\nabscess and condyloma (a wart-like growth). An ana-\\nscopy may be performed to check for abnormal open-\\nings between the anus and the skin, or anal fissures.\\nThe test is also used to diagnoserectal cancer.\\nPrecautions\\nAnoscopy should not be performed on patients\\nwith acute cardiovascular problems due to the vaso-\\nvagal reaction it may cause. This test is also not recom-\\nmended for patients with acute abdominal problems\\nand those with a constricted or narrowed anal canal.\\nDescription\\nAnoscopy views the anus and anal canal by using\\nan anoscope. An anoscope is a plastic, tube-shaped\\nspeculum that is a smaller version of a sigmoidscope.\\nBefore the anoscope is used, the doctor completes a\\ndigital rectal examination with a lubricated, gloved\\nindex finger. The anoscope is then lubricated and\\ngently inserted a few inches into the rectum. This\\nprocedure enlarges the rectum to allow the doctor to\\nview the entire anal canal with a light. If any suspicious\\nareas are noticed, a piece of tissue can be biopsied.\\nDuring the anoscopy procedure there may be a\\nfeeling of pressure or the need to go to the bathroom.\\nIf a biopsy is taken, the patient may feel a slight pinch.\\nGALE ENCYCLOPEDIA OF MEDICINE 227\\nAnoscopy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 257, 'page_label': '228'}, page_content='The procedure is performed on an out-patient basis,\\nand takes approximately an hour to complete.\\nPreparation\\nThe patient will be instructed to clear their rectum\\nof stool before the procedure. This may be done by\\ntaking a laxative, enema, or other preparation that\\nmay help with the evacuation.\\nAftercare\\nIf a biopsy is needed during an anoscopy, there may\\nbe slight anal bleeding for less than two days following\\nthe procedure. The patient may be instructed to sit in a\\nbathtub of warm water for 10 to 15 minutes, three\\ntimes a day, to help decrease the pain and swelling.\\nRisks\\nA simple anoscopy procedure offers minimal\\nrisks. There is a limited risk of bleeding and mild\\npain is a biopsy is performed.\\nNormal results\\nNormal values to look for during an anoscopy\\ninclude an anal canal that appears healthy in size,\\ncolor, and shape. The test also looks for no evidence of\\nbleeding, polyps, hemorrhoids or other abnormalities.\\nAbnormal results\\nWhile an anoscopy is typically performed to\\ndetermine is hemorrhoids are present, other abnormal\\nfinding could include polyps, abscesses, inflammation,\\nfissures, colorectal polyps, orcancer.\\nResources\\nBOOKS\\nAltman, Roberta, and Michael J. Sarg. ‘‘Anoscopy.’’The\\nCancer Dictionary. Checkmark Books, 2000, p. 18.\\nPERIODICALS\\nColyar, Margaret. ‘‘Anascopy Basics.’’The Nurse\\nPractitioner (October 2000): 91.\\nOTHER\\nDiscovery Health. ‘‘Medical Tests: Anoscopy.’’ May 5,\\n2001. .\\nLycos Health with WebMD. ‘‘Anoscopy.’’ May 5, 2001.\\n.\\nBeth A. Kapes\\nAnosmia\\nDefinition\\nThe term anosmia means lack of the sense of\\nsmell. It may also refer to a decreased sense of smell.\\nAgeusia, a companion word, refers to a lack of taste\\nsensation. Patients who actually have anosmia may\\ncomplain wrongly of ageusia, although they retain\\nthe ability to distinguish salt, sweet, sour, and bitter–\\nhumans’ only taste sensations.\\nDescription\\nOf the five senses, smell ranks fourth in importance\\nfor humans, although it is much more pronounced in\\nother animals. Bloodhounds, for example, can smell an\\nodor a thousand times weaker than humans. Taste,\\nconsidered the fifth sense, is mostly the smell of food\\nin the mouth. The sense of smell originates from the\\nfirst cranial nerves (the olfactory nerves), which sit at\\nthe base of the brain’s frontal lobes, right behind the\\neyes and above the nose. Inhaled airborne chemicals\\nstimulate these nerves.\\nThere are other aberrations of smell beside a\\ndecrease. Smells can be distorted, intensified, or hallu-\\ncinated. These changes usually indicate a malfunction\\nof the brain.\\nCauses and symptoms\\nThe most common cause of anosmia is nasal\\nocclusion caused by rhinitis (inflammation of the\\nKEY TERMS\\nAnal fissure— An ulcer on the margin of the anus.\\nDigital rectal examination— An examination\\nwhere a gloved, lubricated index finger is inserted\\ninto the rectum to check for any abnormalities.\\nPolyps— A tumor with a small flap that attaches\\nitself to the wall of various vascular organs such as\\nthe nose, uterus and rectum. Polyps bleed easily,\\nand if they are suspected to be cancerous they\\nshould be surgically removed.\\nVasovagal reaction— Regarding the action of\\nstimuli from the vagus nerve on blood vessels.\\n228 GALE ENCYCLOPEDIA OF MEDICINE\\nAnosmia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 258, 'page_label': '229'}, page_content='nasal membranes). If no air gets to the olfactory\\nnerves, smell will not happen. In turn, rhinitis and\\nnasal polyps(growths on nasal membranes) are caused\\nby irritants such as allergens, infections, cigarette\\nsmoke, and other air pollutants. Tumors such as\\nnasal polyps can also block the nasal passages and\\nthe olfactory nerves and cause anosmia.Head injury\\nor, rarely, certain viral infections can damage or\\ndestroy the olfactory nerves.\\nDiagnosis\\nIt is difficult to measure a loss of smell, and no one\\ncomplains of loss of smell in just one nostril. So a\\nphysician usually begins by testing each nostril sepa-\\nrately with a common, non-irritating odor such as\\nperfume, lemon, vanilla, or coffee. Polyps and rhinitis\\nare obvious causal agents a physician looks for.\\nImaging studies of the head may be necessary in\\norder to detect brain injury, sinus infection, or tumor.\\nTreatment\\nCessation ofsmoking is the first step. Many smo-\\nkers who quit discover new tastes so enthusiastically\\nthat they immediately gain weight. Attention to redu-\\ncing exposure to other nasal irritants and treatment of\\nrespiratory allergies or chronic upper respiratory\\ninfections will be beneficial.Corticosteroids are parti-\\ncularly helpful.\\nAlternative treatment\\nFinding and treating the cause of the loss of smell\\nis the first approach innaturopathic medicine. If rhini-\\ntis is the cause, treating acute rhinitis with herbal mast\\ncell stabilizers and herbaldecongestants can offer some\\nrelief as the body heals. If chronic rhinitis is present,\\nthis is often related to an environmental irritant or to\\nfood allergies. Removal of the causative factors is the\\nfirst step to healing. Nasal steams with essential oils\\noffer relief of the blockage and tonification of the\\nmembranes. Blockages can sometimes be resolved\\nthrough naso-specific therapy–a way of realigning\\nthe nasal cavities. Polyp blockage can be addressed\\nthrough botanical medicine treatment as well as\\nhydrotherapy. Olfactory nerve damage may not be\\nregenerable. Some olfactory aberrations, like intensi-\\nfied sense of smell, can be resolved usinghomeopathic\\nmedicine.\\nPrognosis\\nIf nasal inflammation is the cause of anosmia, the\\nchances of recovery are excellent. However, if nerve\\ndamage is the cause of the problem, the recovery of\\nsmell is much more difficult.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nJ. Ricker Polsdorfer, MD\\nAnoxemia see Anoxia\\nAnoxia\\nDefinition\\nAnoxia is a condition characterized by an absence\\nof oxygen supply to an organ or a tissue.\\nDescription\\nAnoxia results when oxygen is not being delivered\\nto a part of the body. If the condition does not involve\\ntotal oxygen deprivation, it is often called hypoxia,\\nalthough the two terms have been used interchange-\\nably. A related condition, anoxemia, occurs when the\\nblood circulates but contains a below normal amount\\nof oxygen.\\nThe five types of anoxia or hypoxia include\\nhypoxemic, anemic, affinity, stagnant, and histotoxic.\\nHypoxemic anoxia happens when the oxygen pressure\\noutside the body is so low that the hemoglobin, the\\nchemical which carries oxygen in the red blood cells\\n(RBCs), is unable to become fully loaded with the gas.\\nThis results in too little oxygen reaching the tissues\\nand can occur in suffocation when a person is at high\\nKEY TERMS\\nAllergen— Any substance that irritates only those\\nwho are sensitive (allergic) to it.\\nCorticosteroids— Cortisone, prednisone, and\\nrelated drugs that reduce inflammation.\\nRhinitis— Inflammation and swelling of the nasal\\nmembranes.\\nNasal polyps— Drop-shaped overgrowths of the\\nnasal membranes.\\nGALE ENCYCLOPEDIA OF MEDICINE 229\\nAnoxia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 259, 'page_label': '230'}, page_content='altitude, where the pressure of oxygen in the air is\\nmuch less than at sea level.\\nAnemic anoxia results from a decrease in the\\namount of hemoglobin or RBCs in the blood, which\\nreduces the ability to get oxygen to the tissues. Anemia\\nmay result from lack of production of red blood cells\\n(iron deficiency), blood loss (hemorrhage), or shor-\\ntened lifespan of red blood cells (autoimmune disease).\\nAffinity anoxia involves a defect in the chemistry\\nof the blood such that the hemoglobin can no longer\\npick up as much oxygen from the air, even though the\\nquantities are normal, reducing how much is delivered\\nto the tissues.\\nStagnant anoxia occurs when there is interference\\nwith the blood flow, although the blood and its\\noxygen-carrying abilities are normal. A common\\ncause of general stagnant anoxia is heart disease or\\ninterference with the return of blood flow through the\\nveins. Examples of local stagnant anoxia include expo-\\nsure to cold, diseases that restrict circulation to the\\nextremities, and ergotpoisoning. When the tissue or\\norgan itself has a reduced ability to accept and use the\\noxygen, it is called histotoxic anoxia. The classic exam-\\nple is cyanide poisoning, where the chemical inacti-\\nvates a cellular enzyme necessary for the cell to use\\noxygen. Thus, tissue exposed to cyanide cannot use the\\noxygen even though it is in normal amounts in the\\nbloodstream. Histotoxic anoxia can also be caused\\nby exposure tonarcotics, alcohol, formaldehyde, acet-\\none, toluene, and certain anesthetic agents.\\nCauses and symptoms\\nAnoxia and hypoxia can be caused by any number\\nofdiseasestatesoftheblood,lungs,heartandcirculation\\nincluding heart attack,s e v e r easthma,o r emphysema.\\nIt can also result from smoke or carbon monoxide inha-\\nlation, improper exposure to anesthesia, poisoning,\\nstrangulation,near-drowning, or high altitude exposure\\nthrough mountain climbing or travel in an insufficiently\\npressurized airplane. Anoxia, and the resultant brain\\ndamage, is a particular problem with newborns during\\ndifficult births.\\nNo matter what the cause of anoxia, the symp-\\ntoms are similar. In severe cases, the patient is often\\nconfused and commonly stuperous or comatose (in a\\nstate of unconsciousness). Depending on the severity\\nof the injury to the brain, the organ most sensitive to\\nreduced oxygen intake, this condition can persist for\\nhours, days, weeks, or even months or years. Seizures,\\nmyoclonic jerks (involuntary muscle spasms or\\ntwitches), and neck stiffness are some other symptoms\\nof the anoxic condition.\\nSymptoms of more localized or less complete oxy-\\ngen deprivation (hypoxia) include increased breathing\\nrate, lightheadedness,dizziness, tingling or warm sen-\\nsation, sweating, reduced field of vision, sleepiness, a\\nbluish tint to skin, particularly the fingertips and lips,\\nand behavior changes, often an inappropriate sense of\\neuphoria.\\nDiagnosis\\nDiagnosis of anoxia and hypoxia is commonly\\nmade through the appearance of clinical symptoms.\\nHowever, suspected reduction in oxygen reaching the\\ntissues can be confirmed using laboratory tests. The\\nexact test that is performed is dependent on the sus-\\npected cause of the anoxia. One systemic measure of\\ntissue anoxia is the serum lactate (lactic acid) test.\\nWhen cells are forced to produce energy without oxy-\\ngen, as would happen during anoxia, lactic acid is one\\nof the byproducts. Thus, an increase in lactic acid in\\nthe blood would indicate that tissues were starved for\\noxygen and are using non-oxygen pathways to pro-\\nduce energy. Normally, the blood contains less than\\n2mmol/L of lactic acid. However, some forms of\\nanoxia do not increase lactic acid concentrations in\\nthe blood and some increases in lactic acid levels are\\nnot associated with anoxia, so an elevated value for\\nthis test is only suggestive of an anoxic or hypoxic\\ncondition.\\nTreatment\\nThe exact treatment for anoxia is dependent on\\nthe cause of the reduced oxygen reaching the tissues.\\nHowever, immediate restoration of tissue oxygen\\nlevels through supplementing the patient’s air supply\\nwith 100% oxygen is a common first step. Secondary\\nsteps often include support of the cardiovascular sys-\\ntem through drugs or other treatment, treatment of\\nKEY TERMS\\nAmnesia— Loss of memory often traceable to brain\\ntissue damage.\\nAnoxemia— An extreme lack of oxygen in the blood.\\nHemoglobin— A chemical found in red blood cells\\nthat transports oxygen.\\nMyoclonus— Involuntary contractions of a muscle\\nor group of muscles.\\n230 GALE ENCYCLOPEDIA OF MEDICINE\\nAnoxia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 260, 'page_label': '231'}, page_content='lung disease, transfusions, or administration of anec-\\ndotes for poisoning, as appropriate.\\nPrognosis\\nA good prognosis is dependent on the ability to\\ntreat the underlying cause of the low oxygen levels. If\\ncardiovascular and respiratory systems can be sup-\\nported adequately, recovery from the injury to the\\ntissue is possible, although extent of injury to the\\nbrain can be difficult to assess. The exact amount of\\nrecovery varies with the amount of injury sustained,\\nwhere significant injury brings a poorer prognosis. As\\nrecovery occurs, both psychological and neurological\\nabnormalities may appear, persist, and can improve.\\nSome problems seen after anoxia include mental con-\\nfusion, personality changes,amnesia or other types of\\nmemory loss,hallucinations, and persistent myoclonus\\n(involuntary contractions of the muscles).\\nPrevention\\nHypoxemic anoxia can be avoided by utilizing\\nsupplemental oxygen when in high altitudes and\\nbeing aware of the early symptoms ofaltitude sick-\\nness and reducing altitude once recognized. Iron sup-\\nplements can avoid anemic hypoxia, although more\\nsevere anemic states are usually caused by disease or\\nbleeding. Maintaining g ood cardiovascular health\\nthrough proper diet andexercise is a good first step\\nto avoiding the most common cause of stagnant\\nanoxia. Avoiding exposure to the toxic chemicals\\nthat cause the condition can prevent histotoxic\\nanoxia.\\nResources\\nPERIODICALS\\nGutierrez, Guillermo. ‘‘Metabolic Assessement of Tissue\\nOxygenation’’ Seminars in Respiratory and Critical\\nCare Medicine 20 (January 1999): 11–15.\\nORGANIZATIONS\\nBrain Injury Association. 105 N. Alfred St. Alexandria, VA\\n22314. (800) 444-6443. .\\nPhoenix Project/Head Injury Hotline. Box 84151, Seattle,\\nWA 98124. (206) 621-8558. .\\nOTHER\\nBorron, Stephen W. ‘‘Lactic Acidosis.’’eMedicine.February 7,\\n2001. [cited May 13, 2001]. .\\nNINDS Anoxia/Hypoxia Information Page. The National\\nInstitute of Neurological Disorders and Stroke\\n(NINDS). January 22, 2001. [cited May 13, 2001].\\n.\\nMichelle Johnson, MS, JD\\nAntacids\\nDefinition\\nAntacidsaremedicinesthatneutralizestomachacid.\\nPurpose\\nAntacids are used to relieve acidindigestion, upset\\nstomach, sour stomach, and heartburn. Additional\\ncomponents of some formulations include dimethi-\\ncone, to reduce gas pains (flatulence) and alginic\\nacid, which, in combination with antacids, may help\\nmanage GERD (gastro-esophageal reflux disease).\\nAntacids should not be confused with gastric acid\\ninhibitors, such as the H-2 receptor blockers (cimeti-\\ndine, ranitide and others) or theproton pump inhibitors\\n(lansoprazole, omeprazole and others). Although all\\nthree classes of drugs act to reduce the levels of gastric\\nacid, their mechanisms are different, and this affects\\nthe appropriate use of the drug. Antacids have a rapid\\nonset and short duration of action, and are most\\nappropriate for rapid relief of gastric discomfort for\\na short period of time.\\nAntacids may be divided into two classes, those\\nthat work by chemical neutralization of gastric acid,\\nmost notably sodium bicarbonate; and those that act\\nby adsorption of the acid (non-absorbable antacids),\\nsuch as calcium and magnesium salts.\\nThe chemical antacids show the most rapid onset\\nof action, but may cause ‘‘acid rebound,’’ a condition\\nin which the gastric acid returns in greater concentra-\\ntion after the drug effect has stopped. Also, since\\nthese antacids may contain high concentrations of\\nsodium, they may be inappropriate in patients with\\nhypertension.\\nCalcium and magnesium salts act by adsorption\\nof the acid, and are less prone to the rebound effect,\\nbut may have other significant disadvantages. These\\nantacids are particularly prone todrug interactions,\\nand patients taking other medications must often\\navoid simultaneous administration of the medica-\\ntions. These antacids are more effective in liquid for-\\nmulations than in tablet or capsule form, and so may\\nbe inconvenient for routine dosing.\\nGALE ENCYCLOPEDIA OF MEDICINE 231\\nAntacids'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 261, 'page_label': '232'}, page_content='The non-absorbable antacids may have additional\\nuses beyond control of hyperacidity. Calcium salts\\nmay be used as diet supplements in prevention of\\nosteoporosis. Aluminum carbonate is useful for bind-\\ning phosphate, and has been effective in treatment and\\ncontrol of hyperphosphatemia or for use with a low\\nphosphate diet to prevent formation of phosphate\\nurinary stones. This application is particularly valu-\\nable in patients with chronic renal failure. Antacids\\nwith aluminum and magnesium hydroxides or alumi-\\nnum hydroxide alone effectively prevent significant\\nstress ulcer bleeding in post-operative patients or\\nthose with severeburns.\\nRecommended dosage\\nThe dose depends on the type of antacid. Consult\\nspecific references.\\nWhen using antacids in chewable tablet form,\\nchew the tablet well before swallowing. Drink a glass\\nof water after taking chewable aluminum hydroxide.\\nLozenges should be allowed to dissolve completely in\\nthe mouth. Liquid antacids should be shaken well\\nbefore using.\\nPrecautions\\nAntacids should be avoided if any signs ofappen-\\ndicitis or inflamed bowel are present. These include\\ncramping, pain, and soreness in the lower abdomen,\\nbloating, andnausea and vomiting.\\nAntacids may affect the results of some medical\\ntests, such as those that measure how much acid\\nthe stomach produces. Health care providers and\\npatients should keep this in mind when scheduling a\\nmedical test.\\nAntacids that contain magnesium may causediar-\\nrhea. Other types of antacids may causeconstipation.\\nAvoid taking antacids containing sodium bicar-\\nbonate when the stomach is uncomfortably full from\\neating or drinking.\\nAntacids should not be given to children under six\\nyears of age.\\nAntacids that contain calcium or sodium bicarbo-\\nnate may cause side effects, such asdizziness, nausea,\\nand vomiting, in people who consume large amounts\\nof calcium (from dairy products or calcium supple-\\nments). In some cases, this can lead to permanent\\nkidney damage. Before combining antacids with\\nextra calcium, check with a physician.\\nSome antacids contain large amounts of sodium,\\nparticularly sodium bicarbonate (baking soda).\\nAnyone who is on a low-sodium diet should check\\nthe list of ingredients or check with a physician or\\npharmacist before taking an antacid product.\\nExcessive use of antacids may cause or increase\\nthe severity or kidney problems. Calcium based anta-\\ncids may lead to renal stone formation.\\nPREGNANCY. Antacids are not classified under\\nthe pregnancy safety categories A, B, C, D and X.\\nOccasional use of antacids in small amounts during\\npregnancy is considered safe. However, pregnant\\nwomen should check with their physicians before using\\nantacids or any other medicines. Pregnant women\\nwho are consuming extra calcium should be aware\\nthat using antacids that contain sodium bicarbonate or\\ncalcium can lead to serious side effects.\\nBREASTFEEDING. Some antacids may pass into\\nbreast milk. However, no evidence exists that the\\ningestion of antacids through breast milk causes pro-\\nblems for nursing babies whose mothers use antacids\\noccasionally.\\nSide effects\\nSide effects are very rare when antacids are taken\\nas directed. They are more likely when the medicine is\\ntaken in large doses or over a long time. Minor side\\neffects include a chalky taste, mild constipation or\\ndiarrhea, thirst, stomach cramps, and whitish or\\nspeckled stools. These symptoms do not need medical\\nKEY TERMS\\nAcid indigestion— Indigestion that results from too\\nmuch acid in the stomach.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nHeartburn— A burning sensation, usually in the\\ncenter of the chest, near the breastbone.\\nIndigestion— A feeling of discomfort or illness that\\nresults from the inability to properly digest food.\\nInflamed bowel— Irritation of the intestinal tract.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nPregnancy safety categories— A system for report-\\ning the known safety issues of drugs for use during\\npregnancy, The ratings range from A, proven safe\\nby well controlled studies, to X, proven harmful.\\n232 GALE ENCYCLOPEDIA OF MEDICINE\\nAntacids'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 262, 'page_label': '233'}, page_content='attention unless they do not go away or they interfere\\nwith normal activities.\\nOther uncommon side effects may occur. Anyone\\nwho has unusual symptoms after taking antacids\\nshould get in touch with his or her health care provider.\\nInteractions\\nAntacids have multiple drug interactions, usually\\ndue to inhibition of absorption of other medications.\\nIn rare cases, the absorbable antacids may alter the\\npH of the stomach contents or urine sufficiently to\\nalter drug absoprtion or excretion. Consult specific\\nreferences.\\nSamuel D. Uretsky, PharmD\\nAntegrade pyelography see Intravenous\\nurography\\nAntenatal testing\\nDefinition\\nAntenatal testing includes any diagnostic proce-\\ndures performed before the birth of a baby.\\nPurpose\\nThese tests and exams are essential for protecting\\nthe health of a pregnant woman and her developing\\nchild.\\nPrecautions\\nSome tests, such as amniocentisis, carry a small\\nrisk of amiscarriage or other complications that could\\nharm the mother or baby.\\nDescription\\nWomen who become pregnant undergo a wide\\nvariety of tests throughout the nine months before\\ndelivery. In the early stages, physicians order blood\\ntests to screen for possible disorders or infections, such\\nas human immunodeficiency virus (HIV), which can\\npass from the mother to the fetus. Later, the focus\\nshifts to checking on fetal well-being with a variety of\\ntechnological tools such as ultrasound scans.\\nDescriptions of the most common tests and proce-\\ndures used duringpregnancy are listed below.\\nWhen a woman first learns she is pregnant, her\\nphysician will run a series of routine urine and blood\\ntests to determine her blood type, check for anemia\\nand gestational diabetes, make sure she is immune to\\nrubella (German measles) and check for infectious\\ndiseases like HIV, hepatitis, chlamydia or syphilis.\\nPhysicians also usually dopelvic exam to screen for\\ncervical cancerand check the patient’s blood pressure.\\nAs the pregnancy progresses, more tests will follow.\\nUltrasound\\nUltrasound is a device that records sound waves\\nas they bounce off the developing fetus to create an\\nimage, which is projected onto a large computer\\nscreen. Physicians order an ultrasound scan to listen\\nfor a fetal heartbeat, determine a woman’s precise due\\ndate and check for twins, among other uses. An ultra-\\nsound scan also is known as a sonogram. The proce-\\ndure takes a few minutes, is painless and usually is\\ncovered by health insurance.\\nThe ultrasound technician will ask the pregnant\\nwoman to remove her clothes and change into a gown.\\nThe technician may rub some gel on the woman’s stom-\\nach, which helps the hand-held device pick up sound\\nwaves better. In certain cases, the technician may insert\\na plastic probe into the woman’s vaginal canal to get a\\nclearer picture of the fetus. Early in pregnancy, the\\ntest may need to be done with a full bladder.\\nKEY TERMS\\nUltrasound — A device that records sound waves\\nas they bounce off a developing fetus to create an\\nimage, which is projected onto a large computer\\nscreen\\nBreech position— When a child is oriented feet\\nfirst in the mother’s uterus just before delivery.\\nAlpha fetoprotein screen — A test that measures\\nthe level of alpha fetoprotein, a substance pro-\\nduced by a fetus with birth defects, in the mother’s\\nblood.\\nAmniocentesis— An invasive procedure that\\nallows physicians to check for birth defects by col-\\nlecting a sample of fetal cells from inside the\\namniotic sac.\\nGBS— Group B streptococci are a type of bacteria\\nthat, if passed to a can cause inflammation of the\\nbrain, spinal cord, blood or lungs. In some cases, it\\ncan result in infant death\\nGALE ENCYCLOPEDIA OF MEDICINE 233\\nAntenatal testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 263, 'page_label': '234'}, page_content='Unlike x rays, ultrasound is safe to use during\\npregnancy. It does not cause any known side-effects\\nthat would harm the mother or baby.\\nPregnant women usually will have their first ultra-\\nsound anytime between 8 and 12 weeks of gestation. In\\nnormal cases, the technician is able to identify a fetal\\nheartbeat, which appears as a flashing light on the\\nscreen. Closer to the due date, physicians use ultra-\\nsound to make sure the fetus is in the correct position\\nto exit the birth canal head first.\\nSometimes an ultrasound will show that a fetus\\nhas stopped growing, or a gestational sac has formed\\nwithout a fetus, and a miscarriage has occurred. Later\\nin pregnancy, it also may show that the child is in a\\nbreech position, oriented feet first, which can cause a\\ndifficult labor.\\nTests for birth defects\\nMost obstetricians offer parents a variety of ways\\nto find out if their developing child might havebirth\\ndefects such asspina bifida and Down Syndrome.A n\\nalpha fetoprotein screen can be done through a simple\\nblood test in the doctor’s office between the 16th and\\n18th week of gestation. It tells the odds that their child\\nwill have a severe congenital anomaly. The test works\\nby measuring the level of alpha fetoprotein, a sub-\\nstance produced by a fetus with birth defects. Low\\nlevels of alpha fetoprotein in the mother’s blood may\\nindicate Down’s Syndrome. In that case, the next step\\nfor most couples isamniocentesis because the alpha\\nfetoprotein test can give false-positive results.\\nAmniocentesis is a more accurate test, but it also has\\nhigher risks of complications.\\nThis procedure typically is used to diagnose Down\\nsyndrome while a developing child is still in the womb,\\nat 15-28 weeks.\\nDuring amniocentesis, a doctor inserts a needle\\nthrough a woman’s vaginal canal and inside her cer-\\nvix. Using ultrasound as a guide, the doctor pierces the\\nuterus to withdraw a sample of fluid from the amniotic\\nsac. Afterwards, tiny cells shed by the fetus can be\\nstudied in the laboratory. Scientists can analyze\\nDNA samples to determine if the fetus has Down\\nsyndrome or other genetic conditions. Amniocentesis\\nalso can determine the sex of the fetus.\\nWomen who have a history of recurring miscar-\\nriages may not want to have this procedure.\\nAmniocentesis is usually performed in a doctor’s\\noffice on an outpatient basis.\\nCommon side effects include cramping and\\nbleeding.\\nIn about one out of every 1,000 cases, amniocen-\\ntesis causes a needle to puncture the uterine wall,\\nwhich could result in miscarriage.\\nIn most cases, couples find out their baby does not\\nhave a birth defect.\\nIf the results come back positive for Down’s\\nSyndrome or other serious conditions, the couple\\nmust decide if they want to end the pregnancy.\\nOthers use the knowledge to plan and prepare any\\nspecial care needed for their future child.\\nGroup B Strep\\nThis test is for Group B streptococci (GBS)\\ninfection.\\nBy testing for GBS, physicians can determine if\\na woman is at risk of passing this infection along to\\nher child.\\nWomen who have had a prior child with GBS, or\\nwho have afever or prolonged or premature rupture of\\nthe amniotic sac may be at higher risk for this type of\\ninfection.\\nGBS is a type of bacteria commonly found in the\\nvagina and rectum. Unlike regularstrep throat, GBS\\ncan be present in a person’s body without causing any\\nsymptoms, so many women do not realize they are\\ninfected with it.\\nTo test for the presence of GBS, doctors may take\\na urine sample. They also may collect samples from the\\nvagina or rectum, which are then analyzed in a lab.\\nThis test is usually performed late in pregnancy, at\\n35-37 weeks of gestation.\\nThis is a routine urine test or pelvic exam with no\\nside effects.\\nIn many cases, doctors do not find any evidence of\\nthis type of infection.\\nIf a woman is found to be infected with Group B\\nstrep, physicians usually wait to treat it until just\\nbefore labor begins. At that time, they may give the\\nmother antibiotics so the baby is not born with the\\ninfection. Newborns who are exposed to Group B\\nstrep can have inflammation of the brain, spinal\\ncord, blood or lungs. In some cases, this serious com-\\nplication can result in infantdeath.\\nResources\\nBOOKS\\nPlanning your Pregnancy and Birth. Washington, DC: The\\nAmerican College of Obstetricians and Gynecologists,\\n2000.\\n234 GALE ENCYCLOPEDIA OF MEDICINE\\nAntenatal testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 264, 'page_label': '235'}, page_content='PERIODICALS\\nParkey, Paula. ‘‘Birth Defects: Is Prenatal Screening\\nAdvisable?’’ CBS HealthWatch April, 2000. .\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nMarch of Dimes Birth Defects Foundation. 275\\nMamaroneck Avenue, White Plains, NY 10605. (888)\\n663-4637. .\\nMelissa Knopper\\nAntepartum testing\\nDefinition\\nAntepartum testing consists of a variety of tests\\nperformed late inpregnancy to verify fetal well-being,\\nas judged by the baby’s heart rate and other character-\\nistics. Antepartum tests include the nonstress test\\n(NST), biophysical profile, and contraction stress\\ntest (CST).\\nPurpose\\nAntepartum testing is performed after 32 weeks of\\npregnancy so that the couple and the doctor can be\\nwarned of any problems that may necessitate further\\ntesting or immediate delivery. The results reflect the\\nadequacy of blood flow (and oxygen delivery) to the\\nfetus from the placenta.\\nAntepartum tests are usually done in pregnancies\\nat high risk for fetal complications. Various reasons\\ninclude:\\n/C15any chronic illness in the mother, such as high blood\\npressure or diabetes\\n/C15problems with previous pregnancies, such as\\nstillbirth\\n/C15fetal complications, such asintrauterine growth retar-\\ndation (a slowing of growth of the fetus) orbirth\\ndefects\\n/C15problems in the current pregnancy, includingpree-\\nclampsia (serious pregnancy-induced high blood\\npressure), gestational (pregnancy-related) diabetes,\\npremature rupture of the membranes, excessive\\namniotic fluid (the liquid that surrounds the fetus),\\nvaginal bleeding, orplacenta previa (a condition in\\nwhich the placenta is positioned over the cervix\\ninstead of near the top of the uterus)\\n/C15twins or other multiple fetuses\\nOne of the most common indications for antepar-\\ntum testing is post-term pregnancy. A pregnancy\\nshould not be allowed to continue past 42 weeks.\\n(The usual pregnancy is 40 weeks in duration).\\nBabies should be monitored with antepartum testing\\nstarting at 41 weeks. After 41 weeks, there is an\\nincreasing risk that the placenta cannot meet the grow-\\ning baby’s needs for oxygen andnutrition. This may be\\nreflected in decreased movements of the baby,\\ndecreased amniotic fluid, and changes in the heart\\nrate pattern of the baby.\\nDescription\\nTechnology\\nThe NST and CST use a technique calledelectro-\\nnic fetal monitoringto evaluate the heartbeat of the\\nfetus. The biophysical profile is an ultrasound\\nexamination.\\nNST\\nThe NST is usually the first antepartum test used to\\nverify fetal well-being. It is based on the principle that\\nwhen the fetus moves, its heartbeat normally speeds up.\\nThe NST assesses fetal health through monitoring\\naccelerations of the heart rate in response to the\\nbaby’s own movements, i.e., in the absence ofstress.\\nKEY TERMS\\nAmniotic fluid— The liquid that surrounds the baby\\nwithin the amniotic sac. Because it is composed\\nmostly of fetal urine, a low amount of fluid can indi-\\ncate inadequate placental blood flow to the fetus.\\nDeceleration— A decrease in the fetal heart rate\\nthat can indicate inadequate blood flow through\\nthe placenta.\\nOxytocin— A natural hormone that produces uter-\\nine contractions.\\nUltrasound— A procedure in which high-\\nfrequency sound waves are used to create a picture\\nof the baby, used alone or with antepartum tests.\\nVibroacoustic stimulation— In the biophysical pro-\\nfile, use of an artificial larynx to produce a loud\\nnoise to ‘‘awaken’’ the fetus.\\nGALE ENCYCLOPEDIA OF MEDICINE 235\\nAntepartum testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 265, 'page_label': '236'}, page_content='The mother lays down or sits, and an electronic\\nfetal monitor is placed on her abdomen to monitor the\\nfetal heart rate. The doctor records the baby’s heart-\\nbeat on a graph or ‘‘tracing’’ to determine whether it\\ndemonstrates correct reactivity, or acceleration of the\\nheart rate. To record fetal movements on the tracing,\\nthe mother presses a button every time she feels the\\nbaby move. If the baby is inactive, the mother may be\\nasked to rub her abdomen to ‘‘awaken’’ it. Sometimes\\nan instrument is used to produce a loud noise to arouse\\nthe fetus (vibroacoustic stimulation). The test usually\\ntakes between 20–45 minutes.\\nA baby who is receiving enough oxygen should\\nmove at least twice in a 20 minute period. The baby’s\\nheart rate should increase at least 20 beats per minute\\nfor at least 20 seconds during these movements. The\\nNST is the simplest and cheapest antepartum test.\\nBiophysical profile\\nThe biophysical profile is an ultrasound exam that\\ncan add additional information to the NST. During\\nthe biophysical profile, the examiner checks for var-\\nious characteristics of the baby to evaluate its overall\\nhealth. These include: fetal movement, fetal tone,\\nbreathing movements, and the amniotic fluid volume.\\nAmniotic fluid volume is important because a\\ndecreased amount raises the possibility that the baby\\nmay be under stress. The five components of the test\\n(NST is also included) are each given a score of 2 for\\nnormal (or present), 1 if decreased, and 0 for abnor-\\nmal. The highest possible score is 10. The ‘‘modified’’\\nbiophysical profile is another option; this includes\\nonly the NST and amniotic fluid volume.\\nCST\\nThe CST is like the NST, except that the fetus is\\nevaluated in response to contractions of the mother’s\\nuterus. Because it is a more complicated test, it is often\\nused after an abnormal NST to confirm the results.\\nUterine contractions produce ‘‘stress’’ in the fetus\\nbecause they temporarily stop the flow of blood and\\noxygen. The CST is used to confirm that the fetus does\\nnot respond to this stress by a decrease in the heart rate.\\nThe CST is performed with the same equipment as\\nthe NST. Maternal blood pressure and fetal heart rate\\nare recorded along with the onset, relative intensity,\\nand duration of any spontaneous contractions. For an\\naccurate test, the contractions should be of sufficient\\nduration and frequency. If uterine activity does not\\noccur naturally, a drug called oxytocin may be given to\\nthe mother intravenously (hence the test’s alternate\\nname, the oxytocin challenge test) to provoke\\ncontractions. Another option is self-stimulation of\\nthe mother’s nipples, because this releases natural\\noxytocin. The fetal heart rate is observed until, ideally,\\nthree moderate contractions occur within 10 minutes.\\nPreparation\\nThe mother should eat just before the antepartum\\ntests to help stimulate fetal activity.\\nRisks\\nThere are no appreciable risks from the NST or\\nthe biophysical profile. Ultrasound used for the bio-\\nphysical profile is painless and safe because it uses no\\nharmful radiation, and no evidence has been found\\nthat sound waves cause any adverse effects on the\\nmother or fetus.\\nThe frequency of antepartum testing depends on\\nthe reason for its use. All of the tests occasionally give\\nincorrect results, which may prompt an unnecessary\\nearly delivery or cesarean. Repeat testing is important\\nto double-check any abnormal findings.\\nNormal results\\nIn general, ‘‘negative’’ or normal results on ante-\\npartum testing provide reassurance that the baby is\\nhealthy and should remain so for perhaps a week, with\\nno need for immediate delivery. Unfortunately, the\\ntests cannot guarantee that there are no problems,\\nbecause falsely normal results can occur, though this\\nis unusual. Even if all test results are normal, it is\\nimportant to realize that this does not guarantee a\\n‘‘perfect’’ baby.\\nThe NST is normal (‘‘reactive’’) if two or more\\ndistinct fetal movements occur in association with\\nappropriate accelerations of the fetal heart rate within\\n20 minutes. A biophysical profile score of 8-10 is con-\\nsidered reassuring. The CST is normal if the fetus\\nshows no decelerations in heart rate in response to\\nthree uterine contractions within 10 minutes.\\nAbnormal results\\nA ‘‘positive’’ result suggests that the baby is not\\nreceiving enough oxygen for some reason. However, it\\nis quite possible that the test result was falsely abnor-\\nmal. To confirm or monitor a suspected disorder,\\nfollow-up testing with the same or an alternate test\\nwill probably be performed at least weekly.\\nThe NST is abnormal (‘‘nonreactive’’) if the fetal\\nheart rate fails to speed up by at least 20 beats per\\n236 GALE ENCYCLOPEDIA OF MEDICINE\\nAntepartum testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 266, 'page_label': '237'}, page_content='minute at least two times during a 20-minute period.\\nAbnormal decreases in the heart rate (decelerations)\\nare also a cause for concern.\\nA biophysical profile score of 6 is considered a\\ncause for concern and should be followed by further\\ntesting. Scores of 4 or less may require immediate\\ndelivery of the fetus.\\nAbnormal results on the CST include late decel-\\nerations, or abnormal slowing of the fetal heart rate\\nafter the uterine contractions. This can suggest that\\nthe baby is not receiving enough oxygen and may have\\ndifficulty withstanding the stress of labor and vaginal\\ndelivery. Cesarean section might be necessary so the\\nbaby can be spared the stress of labor. With either\\nNST or CST, a severe deceleration (a period of very\\nslow heartbeat) can also suggest fetal distress.\\nThe ultimate outcome will depend on the woman’s\\nindividual situation. In some cases, delivery can be post-\\nponed while medication is given to the mother (e.g., for\\nhigh blood pressure) or the fetus (e.g., to speed up lung\\nmaturitybeforedelivery).Dependinguponthereadiness\\nof the mother’s cervix, the doctor may decide to induce\\nlabor. The extra-large fetus of a diabetic woman may\\nrequire cesarean delivery; severe preeclampsia also may\\nnecessitate induction of laboror cesarean section. The\\ndoctor will determine the most prudent course of action.\\nResources\\nPERIODICALS\\nSmith-Levitin, Michelle, Boris Petrikovsky, and Elizabeth P.\\nSchneider. ‘‘Practical Guidelines for Antepartum Fetal\\nSurveillance.’’ American Family Physician 56\\n(November 15, 1997): 1981-1988.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nNational Institute of Child Health and Human\\nDevelopment. Bldg 31, Room 2A32, MSC 2425, 31\\nCenter Drive, Bethesda, MD 20892-2425. (800) 505-\\n2742. .\\nLaura J. Ninger\\nAnthrax\\nDefinition\\nAnthrax is an infection caused by the bacterium\\nBacillus anthracis that primarily affects livestock but\\nthat can occasionally spread to humans, affecting\\neither the skin, intestines, or lungs. In humans, the\\ninfection can often be treated, but it is almost always\\nfatal in animals.\\nDescription\\nAnthrax is most often found in the agricultural\\nareas of South and Central America, southern and\\neastern Europe, Asia, Africa, the Caribbean, and the\\nMiddle East. In the United States, anthrax is rarely\\nreported; however, cases of animal infection with\\nanthrax are most often reported in Texas, Louisiana,\\nMississippi, Oklahoma, and South Dakota. The bac-\\nterium and its associated disease get their name from\\nthe Greek word meaning ‘‘coal’’ because of the char-\\nacteristic coal-black sore that is the hallmark of the\\nmost common form of the disease.\\nDuring the 1800s, in England and Germany,\\nanthrax was known either as ‘‘wool-sorter’s’’ or ‘‘rag-\\npicker’s’’ disease because workers contracted the dis-\\nease from bacterial spores present on hides and in\\nwool or fabric fibers. Spores are the small, thick-\\nwalled dormant stage of some bacteria that enable\\nthem to survive for long periods of time under adverse\\nconditions. The first anthrax vaccine was perfected in\\n1881 by Louis Pasteur.\\nThe largest outbreak ever recorded in the United\\nStates occurred in 1957 when nine employees of a goat\\nhair processing plant became ill after handling a con-\\ntaminated shipment from Pakistan. Four of the five\\npatients with the pulmonary form of the disease died.\\nOther cases appeared in the 1970s when contaminated\\ngoatskin drumheads from Haiti were brought into the\\nU.S. as souvenirs.\\nHumans suffering from anthrax often develop ulcerating\\nnodules on the body. Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 237\\nAnthrax'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 267, 'page_label': '238'}, page_content='Today, anthrax is rare, even among cattle, largely\\nbecause of widespread animalvaccination. However,\\nsome serious epidemics continue to occur among ani-\\nmal herds and in human settlements in developing\\ncountries due to ineffective control programs. In\\nhumans, the disease is almost always an occupational\\nhazard, contracted by those who handle animal hides\\n(farmers, butchers, and veterinarians) or sort wool.\\nThere are no reports of the disease spreading from\\none person to another.\\nAnthrax as a weapon\\nThere has been a great deal of recent concern\\nthat the bacteria that cause anthrax may be used as\\na type of biological warfare, since it is possible to\\nbecome infected simply by inhaling the spores, and\\ninhaled anthrax is the most serious form of the\\ndisease. The bacteria can be grown in laboratories,\\nand with a great deal of expertise and special equip-\\nment, the bacteria can be altered to be usable as a\\nweapon.\\nThe largest-ever documented outbreak of human\\nanthrax contracted through spore inhalation occurred\\nin Russia in 1979, when anthrax spores were acciden-\\ntally released from a military laboratory, causing a\\nregional epidemic that killed 69 of its 77 victims. In\\nthe United States in 2001, terrorists converted anthrax\\nspores into a powder that could be inhaled and mailed\\nit to intended targets, including news agencies and\\nprominent individuals in the federal government.\\nBecause the United States government considers\\nanthrax to be of potential risk to soldiers, the\\nDepartment of Defense has begun systematic vaccina-\\ntion of all military personnel against anthrax.\\nFor civilians in the United States, the government\\nhas instituted a program called the National\\nPharmaceutical Stockpile program in whichantibio-\\ntics and other medical materials to treat two million\\npeople are located so that they could be received any-\\nwhere in the country within twelve hours following a\\ndisaster or terrorist attack.\\nCauses and symptoms\\nThe naturally occurring bacterium Bacillus\\nanthracis produces spores that can remain dormant\\nfor years in soil and on animal products, such as\\nhides, wool, hair, or bones. The disease is often fatal\\nto cattle, sheep, and goats, and their hides, wool, and\\nbones are often heavily contaminated.\\nThe bacteria are found in many types of soil, all\\nover the world, and usually do not pose a problem for\\nhumans because the spores stay in the ground. In\\norder to infect a human, the spores have to be released\\nfrom the soil and must enter the body. They can enter\\nthe body through a cut in the skin, through consuming\\ncontaminated meat, or through inhaling the spores.\\nOnce the spores are in the body, and if antibiotics are\\nnot administered, the spores become bacteria that\\nmultiply and release a toxin that affects the immune\\nsystem. In the inhaled form of the infection, the\\nimmune system can become overwhelmed and the\\nbody can go intoshock.\\nSymptoms vary depending on how the disease was\\ncontracted, but the symptoms usually appear within\\none week of exposure.\\nCutaneous anthrax\\nIn humans, anthrax usually occurs when the\\nspores enter a cut or abrasion, causing a skin (cuta-\\nneous) infection at the site. Cutaneous anthrax, as this\\ninfection is called, is the mildest and most common\\nform of the disease. At first, the bacteria cause an\\nitchy, raised area like an insect bite. Within one to\\ntwo days, inflammation occurs around the raised\\narea, and a blister forms around an area of dying tissue\\nthat becomes black in the center. Other symptoms may\\ninclude shivering and chills. In most cases, the bacteria\\nKEY TERMS\\nAntibody— A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAntitoxin— An antibody that neutralizes a toxin.\\nBronchitis— Inflammation of the mucous mem-\\nbrane of the bronchial tubes of the lung that can\\nmake it difficult to breathe.\\nCutaneous— Pertaining to the skin\\nMeningitis— Inflammation of the membranes cov-\\nering the brain and spinal cord called the\\nmeninges.\\nPulmonary— Having to do with the lungs or\\nrespiratory system.\\nSpore— A dormant form assumed by some bac-\\nteria, such as anthrax, that enable the bacterium\\nto survive high temperatures, dryness, and lack of\\nnourishment for long periods of time. Under proper\\nconditions, the spore may revert to the actively\\nmultiplying form of the bacteria.\\n238 GALE ENCYCLOPEDIA OF MEDICINE\\nAnthrax'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 268, 'page_label': '239'}, page_content='remain within the sore. If, however, they spread to the\\nnearest lymph node (or, in rare cases, escape into the\\nbloodstream), the bacteria can cause a form of blood\\npoisoning that rapidly proves fatal.\\nInhalation anthrax\\nInhaling the bacterial spores can lead to a rare,\\noften-fatal form of anthrax known as pulmonary or\\ninhalation anthrax that attacks the lungs and sometimes\\nspreads to the brain. Inhalation anthrax begins with flu-\\nlike symptoms, namelyfever, fatigue, headache,m u s c l e\\naches, andshortness of breath. As early as one day after\\nthese initial symptoms appear, and as long as two weeks\\nlater, the symptoms suddenly worsen and progress to\\nbronchitis. The patient experiences difficulty breath-\\ning, and finally, the patient enters a state of shock.\\nThis rare form of anthrax is often fatal, even if treated\\nwithin one or two days after the symptoms appear.\\nIntestinal anthrax\\nIntestinal anthrax is a rare, often-fatal form of the\\ndisease, caused by eating meat from an animal that\\ndied of anthrax. Intestinal anthrax causes stomach\\nand intestinal inflammation and sores or lesions\\n(ulcers), much like the sores that appear on the skin\\nin the cutaneous form of anthrax. The first signs of the\\ndisease arenausea and vomiting, loss of appetite, and\\nfever, followed by abdominalpain, vomiting of blood,\\nand severe bloodydiarrhea.\\nDiagnosis\\nAnthrax is diagnosed by detectingB. anthracis in\\nsamples taken from blood, spinal fluid,skin lesions,o r\\nrespiratory secretions. The bacteria may be positively\\nidentified using biochemical methods or using a tech-\\nnique whereby, if present in the sample, the anthrax\\nbacterium is made to fluoresce. Blood samples will\\nalso indicate elevated antibody levels or increased\\namounts of a protein produced directly in response\\nto infection with the anthrax bacterium. Polymerase\\nchain reaction (PCR) tests amplify trace amounts of\\nDNA to show that the anthrax bacteria are present.\\nAdditional DNA-based tests are also currently being\\nperfected.\\nTreatment\\nIn the early stages, anthrax is curable by adminis-\\ntering high doses of antibiotics, but in the advanced\\nstages, it can be fatal. If anthrax is suspected, health\\ncare professionals may begin to treat the patient with\\nantibiotics even before the diagnosis is confirmed\\nbecause early intervention is essential. The antibiotics\\nused include penicillin, doxycycline, and ciprofloxa-\\ncin. Because inhaled spores can remain in the body for\\na long time, antibiotic treatment for inhalation\\nanthrax should continue for 60 days. In the case of\\ncutaneous anthrax, the infection may be cured follow-\\ning a single dose of antibiotic, but it is important to\\ncontinue treatment so as to avoid potential serious\\ncomplications, such as inflammation of the mem-\\nbranes covering the brain and spinal cord (meningitis).\\nIn the setting of potential bioterrorism, cutaneous\\nanthrax should be treated with a 60-day dose of\\nantibiotics.\\nResearch is ongoing to develop new antibiotics\\nand antitoxins that would work against the anthrax\\nbacteria and the toxins they produce. One Harvard\\nprofessor, Dr. R. John Collier, and his team have been\\ntesting two possible antitoxins on rats. A Stanford\\nmicrobiologist and a Penn State chemist have also\\nbeen testing their new antibiotic against the bacteria\\nthat cause brucellosis and tularemia, as well as\\nthe bacteria that cause anthrax. All of these drugs\\nare still in early investigational stages, however, and\\nit is still unknown how these drugs would affect\\nhumans.\\nPrognosis\\nUntreated anthrax is often fatal, butdeath is far\\nless likely with appropriate care. Ten to twenty per-\\nc e n to fp a t i e n t sw i l ld i ef r o ma n t h r a xo ft h es k i n\\n(cutaneous anthrax) if it is not properly treated. All\\npatients with inhalation (pulmonary) anthrax will\\ndie if untreated. Intestinal anthrax is fatal 25-75%\\nof the time.\\nPrevention\\nAnthrax is relatively rare in the United States\\nbecause of widespread animal vaccination and prac-\\ntices used to disinfect hides or other animal products.\\nAnyone visiting a country where anthrax is common\\nor where herd animals are not often vaccinated should\\navoid contact with livestock or animal products and\\navoid eating meat that has not been properly prepared\\nand cooked.\\nOther means of preventing the spread of infection\\ninclude carefully handling dead animals suspected of\\nhaving the disease, burning (instead of burying) con-\\ntaminated carcasses, and providing good ventilation\\nwhen processing hides, fur, wool, or hair.\\nIn the event that exposure to anthrax spores is\\nknown, such as in the aftermath of a terrorist attack,\\nGALE ENCYCLOPEDIA OF MEDICINE 239\\nAnthrax'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 269, 'page_label': '240'}, page_content='a course of antibiotics can prevent the disease from\\noccurring.\\nIn the case of contaminated mail, as was the case in\\nthe 2001 attacks, the U.S. postal service recommends\\ncertain precautions. These precautions include\\ninspecting mail from an unknown sender for excessive\\ntape, powder, uneven weight or lumpy spots, restrictive\\nendorsements such as ‘‘Personal,’’ or ‘‘Confidential,’’ a\\npostmark different from the sender’s address, or a\\nsender’s address that seems false or that cannot be\\nverified. Handwashing is also recommended after\\nhandling mail. In order to decontaminate batches of\\nmail before being opened, machines that use bacteria-\\nkilling radiation could be used to sterilize the mail.\\nThese machines are similar to systems already in place\\non assembly lines for sterile products, such as bandages\\nand medical devices, but this technique would not be\\npractical for large quantities of mail. In addition, the\\nradiation could damage some of the mail’s contents,\\nsuch as undeveloped photographic film. Microwave\\nradiation or the heat from a clothes iron is not powerful\\nenough to kill the anthrax bacteria.\\nFor those in high-risk professions, an anthrax\\nvaccine is available that is 93% effective in protecting\\nagainst infection. To provide this immunity, an indi-\\nvidual should be given an initial course of three injec-\\ntions, given two weeks apart, followed by booster\\ninjections at six, 12, and 18 months and an annual\\nimmunization thereafter.\\nApproximately 30% of those who have been\\nvaccinated against anthrax may notice mild local reac-\\ntions, such as tenderness at the injection site.\\nInfrequently, there may be a severe local reaction\\nwith extensive swelling of the forearm, and a few\\nvaccine recipients may have a more general flu-like\\nreaction to the shot, including muscle and joint\\naches, headache, and fatigue. Reactions requiring hos-\\npitalization are very rare. However, this vaccine is only\\navailable to people who are at high risk, including\\nveterinary and laboratory workers, livestock handlers,\\nand military personnel. The vaccine is not recom-\\nmended for people who have previously recovered\\nfrom an anthrax infection or for pregnant women.\\nWhether this vaccine would protect against anthrax\\nused as a biological weapon is, as yet, unclear.\\nResources\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nNational Institute of Allergies and Infectious Diseases,\\nDivision of Microbiology and Infectious Diseases.\\nBuilding 31, Room. 7A-50, 31 Center Drive MSC 2520,\\nBethesda, MD 20892. .\\nWorld Health Organization, Division of Emerging and\\nOther Communicable Diseases Surveillance and\\nControl. Avenue Appia 20, 1211 Geneva 27,\\nSwitzerland. (+00 41 22) 791 21 11. .\\nOTHER\\n‘‘Anthrax.’’ New York State Department of Health\\nCommunicable Disease Fact Sheet. .\\n‘‘Bacillus anthracis (Anthrax).’’ .\\nBegley, Sharon and Karen Springen. ‘‘Anthrax: What\\nYou Need to Know: Exposure doesn’t guarantee disease,\\nand the illness is treatable.’’Newsweek October 29,\\n2001: 40.\\nCenters for Disease Control. .\\nKolata, Gina. ‘‘Antibiotics and Antitoxins.’’New York\\nTimes October 23, 2001: Section D, page 4, second\\ncolumn.\\nPark, Alice. ‘‘Anthrax: A Medical Guide.’’Time 158, no. 19\\n(October 29, 2001): 44.\\nShapiro, Bruce. ‘‘Anthrax Anxiety.’’The Nation 273, no. 4\\n(November 5, 2001): 4.\\nWade, Nicholas. ‘‘How a Patient Assassin Does Its Deadly\\nWork.’’ New York Times October 23, 2001: Section D,\\npage 1.\\nCarol A. Turkington\\nAntiacne drugs\\nDefinition\\nAntiacne drugs are medicines that help clear up\\npimples, blackheads, whiteheads, and more severe\\nforms ofacne.\\nPurpose\\nDifferent types of antiacne drugs are used for\\ndifferent purposes. For example, lotions, soaps, gels,\\nand creams containing benzoyl peroxide or tretinoin\\nmay be used to clear up mild to moderately severe\\nacne. Isotretinoin (Accutane) is prescribed only for\\nvery severe, disfiguring acne.\\nAcne is a skin condition that occurs when pores or\\nhair follicles become blocked. This blockage allows a\\nwaxy material called sebum to collect inside the pores\\nor follicles. Normally, sebum flows out onto the skin\\n240 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiacne drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 270, 'page_label': '241'}, page_content='and hair to form a protective coating, but when it\\ncannot get out, small swellings develop on the skin\\nsurface. Bacteria and dead skin cells can also collect\\nthat can cause inflammation. Swellings that are small\\nand not inflamed are whiteheads or blackheads. When\\nthey become inflamed, they turn into pimples. Pimples\\nthat fill with pus are called pustules.\\nThe severity of acne is often influenced by seaso-\\nnal changes; it is typically less severe in summer than in\\nwinter. In addition, acne in girls is often affected by the\\nmenstrual cycle.\\nAcne cannot be cured, but acne drugs can help\\nclear the skin. Benzoyl peroxide and tretinoin work\\nby mildly irritating the skin. This encourages skin\\ncells to slough off, which helps open blocked pores.\\nBenzoyl peroxide also kills bacteria, which helps pre-\\nvent whiteheads and blackheads from turning into\\npimples. Isotretinoin shrinks the glands that produce\\nsebum.\\nDescription\\nBenzoyl peroxide is found in many over-the-counter\\nacne products that are applied to the skin, such\\nas Benoxyl, Clear By Design, Neutrogena Acne,\\nPanOxyl, and some formulations of Clean & Clear,\\nClearasil, and Oxy. Some benzoyl peroxide products\\nare available without a physician’s prescription; others\\nrequire a prescription. Tretinoin (Retin-A) is available\\nonly with a physician’s prescription and comes in\\nliquid, cream, and gel forms, which are applied to the\\nskin. Isotretinoin (Accutane), which is taken by mouth\\nin capsule form, is available only with a physician’s\\nprescription. Only physicians who have experience\\nin diagnosing and treating severe acne, such as derma-\\ntologists, should prescribe isotretinoin.\\nSome newer antiacne preparations combine\\nbenzoyl peroxide with antibiotics. One combination\\nof benzoyl peroxide with clindamycin is sold under\\nthe trade name BenzaClin.\\nMany antiacne preparations contain compounds\\nderived from plants that have anti-inflammatory\\nproperties. One group of researchers listed thirty-\\neight different plants that are beneficial in treating\\nacne and other inflammatory skin conditions.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiacne drug. These drugs usually come with written\\ndirections for patients and should be used only as\\ndirected. Patients who have questions about how to\\nuse the medicine should check with a physician or\\npharmacist.\\nPatients who use isotretinoin usually take the\\nmedicine for a few months, then stop for at least two\\nmonths. Their acne may continue to improve even\\nAnti-Acne Drugs\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\nAccutane (isotretinoin) Dry skin, dry mouth, conjunctivitis\\nBenzamycin Dry and itchy skin\\nCleocin T(clindamycin\\nphosphate)\\nDry skin\\nDesquam-E(benzoyl peroxide) Itching, red and peeling skin\\nErythromycin topical (A/T/S,\\nerycette, t-stat)\\nBurning, dry skin, hives, red and\\npeeling skin\\nMinocin (minocycline\\nhydrochloride)\\nHeadache, hives, diarrhea, peeling\\nskin, vomiting\\nRetin-A (tretinoin) Darkening of the skin, blistering,\\ncrusted, or puffy skin\\nKEY TERMS\\nAcne— A skin condition in which raised bumps,\\npimples, and cysts form on the face, neck,\\nshoulders and upper back.\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nBowel— The intestine; a tube-like structure that\\nextends from the stomach to the anus. Some diges-\\ntive processes are carried out in the bowel before\\nfood passes out of the body as waste.\\nCyst— An abnormal sac or enclosed cavity in the\\nbody, filled with liquid or partially solid material.\\nDermatologist— A doctor who specializes in treat-\\ning diseases and disorders of the skin.\\nEczema— Inflammation of the skin with itching and\\na rash. The rash may have blisters that ooze and\\nform crusts.\\nPimple— A small, red swelling of the skin.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nPus— Thick, whitish or yellowish fluid that forms in\\ninfected tissue.\\nTriglyceride— A substance formed in the body from\\nfat in the diet.\\nGALE ENCYCLOPEDIA OF MEDICINE 241\\nAntiacne drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 271, 'page_label': '242'}, page_content='after they stop taking the medicine. If the condition is\\nstill severe after several months of treatment and a\\ntwo-month break, the physician may prescribe a\\nsecond course of treatment.\\nPrecautions\\nIsotretinoin\\nIsotretinoin can cause seriousbirth defects, includ-\\ning mental retardation and physical deformities. This\\nmedicine should not be used during pregnancy.\\nWomen who are able to bear children should not use\\nisotretinoin unless they have very severe acne that has\\nnot cleared up with the use of other antiacne drugs. In\\nthat case, a woman who uses this drug must have a\\npregnancy test two weeks before beginning treatment\\nand each month they are taking the drug. Another\\npregnancy test must be done one month after treat-\\nment ends. The woman must use an effective birth\\ncontrol method for one month before treatment begins\\nand must continue using it throughout treatment and\\nfor one month after treatment ends. Women who are\\nable to bear children and who want to use this medi-\\ncine should discuss this information with their health\\ncare providers. Before using the medicine, they will\\nbe asked to sign a consent form stating that they\\nunderstand the danger of taking isotretinoin during\\npregnancy and that they agree to use effective birth\\ncontrol.\\nDo not donate blood to a blood bank while taking\\nisotretinoin or for 30 days after treatment with the\\ndrug ends. This will help reduce the chance of a preg-\\nnant woman receiving blood containing isotretinoin,\\nwhich could cause birth defects.\\nIsotretinoin may cause a sudden decrease in night\\nvision. If this happens, do not drive or do anything else\\nthat could be dangerous until vision returns to normal.\\nLet the physician know about the problem.\\nThis medicine may also make the eyes, nose, and\\nmouth dry. Ask the physician about using special eye\\ndrops to relieve eye dryness. To temporarily relieve\\nthe dry mouth, chew sugarless gum, suck on sugarless\\ncandy or ice chips, or use saliva substitutes, which\\ncome in liquid and tablet forms and are available\\nwithout a prescription. Ifthe problem continues for\\nmore than two weeks, check with a physician or\\ndentist. Mouth dryness that continues over a long\\ntime may contribute totooth decay and other dental\\nproblems.\\nIsotretinoin may increase sensitivity to sunlight.\\nPatients being treated with this medicine should avoid\\nexposure to the sun and should not use tanning beds,\\ntanning booths, or sunlamps until they know how the\\ndrug affects them.\\nIn the early stages of treatment with isotretinoin,\\nsome people’s acne seems to get worse before it starts\\ngetting better. If the condition becomes much worse or\\nif the skin is very irritated, check with the physician\\nwho prescribed the medicine.\\nBenzoyl peroxide and tretinoin\\nWhen applying antiacne drugs to the skin, be\\ncareful not to get the medicine in the eyes, mouth, or\\ninside of the nose. Do not put the medicine on skin\\nthat is wind burned, sunburned, or irritated, and do\\nnot apply it to openwounds.\\nBecause such antiacne drugs as benzoyl peroxide\\nand tretinoin irritate the skin slightly, avoid doing\\nanything that might cause further irritation. Wash\\nthe face with mild soap and water only two or three\\ntimes a day, unless the physician says to wash it more\\noften. Avoid using abrasive soaps or cleansers and\\nproducts that might dry the skin or make it peel,\\nsuch as medicated cosmetics, cleansers that contain\\nalcohol, or other acne products that contain resorci-\\nnol, sulfur or salicylic acid.\\nIf benzoyl peroxide or tretinoin make the skin too\\nred or too dry or cause too much peeling, check with a\\nphysician. Using the medicine less often or using a\\nweaker strength may be necessary.\\nTretinoin may increase sensitivity to sunlight.\\nWhile being treated with this medicine, avoid exposure\\nto the sun and do not use tanning beds, tanning\\nbooths, or sunlamps. If it is not possible to avoid\\nbeing in the sun, use a sunscreen with a skin protection\\nfactor (SPF) of at least 15 or wear protective clothing\\nover the treated areas. The skin may also become\\nmore sensitive to cold and wind. People who use this\\nmedicine should protect their skin from cold and wind\\nuntil they know how the medicine affects them.\\nBenzoyl peroxide may discolor hair or colored\\nfabrics.\\nSpecial conditions\\nPeople who have certain medical conditions or\\nwho are taking certain other medicines may have pro-\\nblems if they use antiacne drugs. Before using these\\nproducts, be sure to let the physician know about any\\nof these conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto etretinate, isotretinoin, tretinoin, vitamin A prepara-\\ntions, or benzoyl peroxide in the past should let his or\\n242 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiacne drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 272, 'page_label': '243'}, page_content='her physician know before using an antiacne drug. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Women who are pregnant or who\\nmay become pregnant should check with a physician\\nbefore using tretinoin or benzoyl peroxide.Isotretinoin\\ncauses birth defects in humans and must not be used\\nduring pregnancy.\\nBREASTFEEDING. No problems have been reported\\nin nursing babies whose mothers used tretinoin or\\nbenzoyl peroxide. Women who are breastfeeding\\nbabies should not take isotretinoin, however, as it\\nmay cause problems in nursing babies.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nacne drugs applied to the skin, people with any of these\\nmedical problems should make sure their physicians\\nare aware of their conditions:\\n/C15eczema. Antiacne drugs that are applied to the skin\\nmay make this condition worse.\\n/C15sunburn or raw skin. Antiacne drugs that are applied\\nto the skin may increase thepain and irritation of\\nthese conditions.\\nIn people with certain medical conditions, iso-\\ntretinoin may increase the amount of triglyceride\\n(a fatty-substance) in the blood. This may lead to\\nheart or blood vessel problems. Before using isotreti-\\nnoin, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15alcoholism or heavy drinking, now or in the past\\n/C15diabetes (or family history of diabetes). Isotretinoin\\nmay also change blood sugar levels.\\n/C15family history of high triglyceride levels in the blood\\n/C15severe weight problems.\\nUSE OF CERTAIN MEDICINES. Using antiacne drugs\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nIsotretinoin\\nMinor discomforts such as dry mouth or nose,\\ndry eyes, dry skin, oritching usually go away as the\\nbody adjusts to the drug and do not require medical\\nattention unless they continue or are bothersome.\\nOther side effects should be brought to a physi-\\ncians attention. These include:\\n/C15burning, redness, or itching of the eyes\\n/C15nosebleeds\\n/C15signs of inflammation of the lips, such as peeling,\\nburning, redness or pain\\nBowel inflammation is not a common side effect,\\nbut it may occur. If any of the following signs of bowel\\ninflammation occur, stop taking isotretinoin immedi-\\nately and check with a physician:\\n/C15pain in the abdomen\\n/C15bleeding from the rectum\\n/C15severe diarrhea\\nBenzoyl peroxide and tretinoin\\nThe most common side effects of antiacne drugs\\napplied to the skin are slight redness, dryness, peeling,\\nand stinging, and a warm feeling to the skin. These\\nproblems usually go away as the body adjusts to the\\ndrug and do not require medical treatment.\\nOther side effects should be brought to a physi-\\ncian’s attention. Check with a physician as soon as\\npossible if any of the following side effects occur:\\n/C15blistering, crusting or swelling of the skin\\n/C15severe burning or redness of the skin\\n/C15darkening or lightening of the skin. (This effect will\\neventually go away after treatment with an antiacne\\ndrug ends.)\\n/C15skin rash\\nOther side effects are possible with any type of\\nantiacne drug. Anyone who has unusual symptoms\\nwhile using antiacne drugs should get in touch with\\nhis or her physician.\\nInteractions\\nPatients using antiacne drugs on their skin should\\ntell their physicians if they are using any other pre-\\nscription or nonprescription (over-the-counter) medi-\\ncine that they apply to the skin in the same area.\\nIsotretinoin may interact with other medicines.\\nWhen this happens, the effects of one or both drugs\\nmay change or the risk of side effects may be greater.\\nAnyone who takes isotretinoin should let the physi-\\ncian know about all other medicines he or she is taking\\nand should ask whether the possible interactions can\\ninterfere with drug therapy. Among the drugs that\\nmay interact with isotretinoin are:\\n/C15etretinate (Tegison), used to treat severepsoriasis.\\nUsing this medicine with isotretinoin increases side\\neffects.\\n/C15tretinoin (Retin-A, Renova). Using this medicine\\nwith isotretinoin increases side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 243\\nAntiacne drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 273, 'page_label': '244'}, page_content='/C15vitamin A or any medicine containing vitamin A.\\nUsing any vitamin A preparations with isotretinoin\\nincreases side effects. Do not take vitamin supple-\\nments containing vitamin A while taking isotretinoin.\\n/C15tetracyclines (used to treat infections). Using these\\nmedicines with isotretinoin increases the chance of\\nswelling of the brain. Make sure the physician knows\\nif tetracycline is being used to treat acne or another\\ninfection.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Acne.’’ Section 10, Chapter 116 InThe Merck\\nManual of Diagnosis and Therapy. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Warts (Verrucae).’’ Section 10, Chapter 115 In\\nThe Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nWilson, Billie Ann, Margaret T. Shannon, and Carolyn L.\\nStang. Nurse’s Drug Guide 2003. Upper Saddle River,\\nNJ: Prentice Hall, 2003.\\nPERIODICALS\\nBreneman, D., R. Savin, C. Van dePol, et al. ‘‘Double-Blind,\\nRandomized, Vehicle-Controlled Clinical Trial of\\nOnce-Daily Benzoyl Peroxide/Clindamycin Topical Gel\\nin the Treatment of Patients with Moderate to Severe\\nRosacea.’’ International Journal of Dermatology 43\\n(May 2004): 381–387.\\nDarshan, S., and R. Doreswamy. ‘‘Patented\\nAntiinflammatory Plant Drug Development from\\nTraditional Medicine.’’Phytotherapy Research 18 (May\\n2004): 343–357.\\nHalder, R. M., and G. M. Richards. ‘‘Topical Agents Used\\nin the Management of Hyperpigmentation.’’Skin\\nTherapy Letter 9 (June-July 2004): 1–3.\\nKligman, D. E., and Z. D. Draelos. ‘‘High-Strength\\nTretinoin for Rapid Retinization of Photoaged\\nFacial Skin.’’ Dermatologic Surgery 30 (June 2004):\\n864–866.\\nLeyden, J. J., D. Thiboutot, and A. Shalita. ‘‘Photographic\\nReview of Results from a Clinical Study Comparing\\nBenzoyl Peroxide 5%/Clindamycin 1% Topical Gel\\nwith Vehicle in the Treatment of Rosacea.’’Cutis 73,\\nSupplement 6 (June 2004): 11–17.\\nORGANIZATIONS\\nAmerican Academy of Dermatology (AAD). P. O. Box\\n4014, Schaumburg, IL 60168-4014. (847) 330-0230.\\n.\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888)\\nINFO-FDA. .\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAntiandrogen drugs\\nDefinition\\nAntiandrogen drugs are a diverse group of medi-\\ncations given to counteract the effects of androgens\\n(male sex hormones) on various body organs and\\ntissues. Some medications in this category work by\\nlowering the body’s production of androgens while\\nothers work by blocking the body’s ability to make\\nuse of the androgens that are produced. The first\\ngroup of antiandrogens includes such medications as\\nleuprolide (Lupron, Viadur, or Eligard), goserelin\\n(Zoladex), triptorelin (Trelstar Depot), and abarelix\\n(Plenaxis). The second group includes flutamide\\n(Eulexin), nilutamide (Nilandron), cyproterone acet-\\nate (Cyprostat, Androcur, Cyproterone), and bicalu-\\ntamide (Casodex). Flutamide, nilutamide, and\\nbicalutamide are nonsteroidal antiandrogen drugs\\nwhile cyproterone acetate is a steroidal medication.\\nSome drugs that were originally developed to treat\\nother conditions are sometimes categorized as antian-\\ndrogens because their off-label uses include some of\\nthe disorders listed below. These drugs include\\nmedroxyprogesterone (Depo-Provera), a derivative of\\nthe female sex hormone progesterone that is used as a\\ncontraceptive and treatment for abnormal uterine\\nbleeding; ketoconazole (Nizoral), an antifungal drug;\\nand spironolactone (Aldactone), a diuretic.\\nPurpose\\nAntiandrogen drugs may be given for any of\\nseveral conditions or disorders, ranging from skin\\nproblems to mental disorders:\\n/C15Prostate cancer. Antiandrogen medications may be\\nused to treat both early-stage and advanced prostate\\ncancer by lowering or blocking the supply of male sex\\nhormones that encourage the growth and spread of\\nthe cancer.\\n/C15Androgenetic alopecia. Androgenetic alopecia is a\\ntype of hair loss that is genetically determined and\\n244 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 274, 'page_label': '245'}, page_content='affects both men and women. It is sometimes called\\npattern baldness.\\n/C15Acne. Acne is the end result of several factors, one of\\nwhich is excessive production of sebum, a whitish\\nsemiliquid greasy substance produced by certain\\nglands in the skin. Antiandrogens may help to clear\\nacne by slowing down the secretion of sebum, which\\ndepends on androgen production.\\n/C15Amenorrhea. Amenorrhea, or the absence of men-\\nstrual periods in females of childbearing age, is some-\\ntimes caused by excessively high levels of androgens\\nin the blood. Antiandrogen medications may help to\\nrestore normal menstrual periods.\\n/C15Hirsutism. Hirsutism is a condition in which women\\ndevelop excessive facial and body hair in a distribu-\\ntion pattern usually associated with adult males.\\nIt results from abnormally high levels of androgens\\nin the bloodstream or from increased sensitivity of\\nthe hair follicles to normal levels of androgens.\\nHirsutism may be a sign ofpolycystic ovary syn-\\ndrome (PCOS), a condition in which the ovaries\\ndevelop multiple large cysts and produce too\\nmuch androgen.\\n/C15Gender reassignment. Antiandrogen drugs are often\\nprescribed for male-to-female (MTF) transsexuals as\\npart of the hormonal treatment that precedes gender\\nreassignment surgery.\\n/C15Paraphilias. Paraphilias are a group of mental dis-\\norders characterized by intense and recurrent sexual\\nurges or behaviors involving nonhuman objects, chil-\\ndren or nonconsenting adults, orpain and humilia-\\ntion. Antiandrogen drugs have been prescribed for\\nmen diagnosed with paraphilias in order to lower\\nblood serum levels of testosterone and help them\\ncontrol their sexual urges.\\n/C15Virilization. Virilization is an extreme form of hyper-\\nandrogenism in females, marked by such changes\\nas development of male pattern baldness, voice\\nchanges, and overdevelopment of the skeletal mus-\\ncles. Antiandrogens may be given to correct this\\ncondition.\\nDescription\\n/C15Leuprolide. Leuprolide is classified as a luteinizing\\nhormone-releasing hormone (LHRH) agonist,\\nwhich means that it resembles a chemical produced\\nby the hypothalamus (a gland located in the brain)\\nthat lowers the level of testosterone in the blood-\\nstream. It also reduces levels of estrogen in girls\\na n dw o m e n ,a n dm a yb eu s e dt ot r e a tendome-\\ntriosis or tumors in the uterus. It is presently\\nunder investigation as a possible treatment for\\nthe paraphilias.\\n/C15Goserelin. Goserelin is also an LHRH agonist, and\\nworks in the same way as leuprolide.\\n/C15Triptorelin. Triptorelin is an LHRH agonist, and\\nworks in the same way as leuprolide. It is not usually\\ngiven to women, however.\\n/C15Abarelix. Abarelix is a newer drug that works by\\nblocking hormone receptors in the pituitary gland.\\nIt is recommended for the treatment of prostate can-\\ncer in men with advanced disease who refuse surgery,\\ncannot take other hormonal treatments, or are poor\\ncandidates for surgery.\\n/C15Ketoconazole. Ketoconazole is an antifungal drug\\navailable in tablets to be taken by mouth. Its use in\\ntreating hirsutism is off-label.\\n/C15Flutamide. Flutamide is a nonsteroidal antiandro-\\ngen medication that blocks the use of androgen by\\nthe body.\\n/C15Nilutamide. Nilutamide is another nonsteroidal anti-\\nandrogen drug that works by blocking the body’s use\\nof androgens.\\n/C15Bicalutamide. Bicalutamide is a nonsteroidal antian-\\ndrogen medication that works in the same way as\\nflutamide.\\n/C15Cyproterone acetate. Cyproterone acetate is a steroi-\\ndal antiandrogen drug that works by lowering testo-\\nsterone production as well as blocking the body’s use\\nof androgens.\\n/C15Medroxyprogesterone. Medroxyprogesterone is a\\nsynthetic derivative of progesterone that prevents\\novulation and keeps the lining of the uterus from\\nbreaking down, thus preventing uterine bleeding.\\n/C15Spironolactone. Spironolactone is a potassium-\\nsparing diuretic that may be given to treat androgen\\nexcess in women.\\nRecommended dosage\\n/C15Leuprolide. Leuprolide is available in an injectable\\nform and as an implant. The implant form, used to\\ntreat prostate cancer, contains 22.5 mg of leuprolide\\nand is inserted under the skin every three months.\\nThis type of slow-release medication is called depot\\nform. A longer-acting implant that lasts 12 months\\nis also available. Injectable leuprolide is injected\\nonce a day in a 1-mg dose to treat prostate cancer.\\nThe dosage for endometriosis or uterine tumors is\\n3.75 mg injected into a muscle once a month for three\\nto six months.\\nGALE ENCYCLOPEDIA OF MEDICINE 245\\nAntiandrogen drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 275, 'page_label': '246'}, page_content='/C15Goserelin. Goserelin is implanted under the skin of\\nthe upper abdomen. The dosage for treating cancer\\nof the prostate is one 3.6-mg implant every 28 days\\nor one 10.8-mg implant every 12 weeks. For treating\\nendometriosis, the dosage is one 3.6-mg implant\\nevery 28 days for six months.\\n/C15Triptorelin. Triptorelin is given as a long-lasting\\ninjection for treatment of prostate cancer or\\nparaphilias. The usual dose for either condition is\\n3.75 mg, injected into a muscle once a month.\\n/C15Abarelix. Abarelix is given in 100-mg doses by deep\\ninjection into the muscles of the buttocks. It is given\\non days 1, 15, and 29 of treatment, then every four\\nweeks for a total treatment duration of 12 weeks.\\n/C15Ketoconazole. For treatment of hirsutism, 400 mg by\\nmouth once per day.\\n/C15Flutamide. Flutamide is available in capsule as\\nwell as tablet form. For treatment of prostate cancer,\\n250 mg by mouth three times a day. For virilization\\nor hyperandrogenism in women, 250 mg by mouth\\nthree times a day. It should be used in women, how-\\never, only when other treatments have proved\\nineffective.\\n/C15Nilutamide. To treat prostate cancer, nilutamide is\\ntaken in a single 300-mg daily dose by mouth for the\\nfirst 30 days of therapy, then a single daily dose of\\n150 mg..\\n/C15Bicalutamide. Bicalutamide is taken by mouth in a\\nsingle daily dose of 50 mg to treat prostate cancer.\\n/C15Cyproterone acetate. Cyproterone is taken by mouth\\nthree times a day in 100-mg doses to treat prostate\\ncancer. The dose for treating hyperandrogenism or\\nvirilization in women is one 50-mg tablet by mouth\\neach day for the first ten days of the menstrual cycle.\\nCyproterone acetate given to treat acne is usually\\ngiven in the form of an oral contraceptive (Diane-\\n35) that combines the drug (2 mg) with ethinyl estra-\\ndiol (35 mg). Diane-35 is also taken as hormonal\\ntherapy by MTF transsexuals. The dose for treating\\nparaphilias is 200–400 mg by injection in depot form\\nevery 1–2 weeks, or 50–200 mg by mouth daily.\\n/C15Medroxyprogesterone. For the treatment of para-\\nphilias, given as an intramuscular 150-mg injection\\ndaily, weekly, or monthly, depending on the patient’s\\nserum testosterone levels, or as an oral dose of 100–\\n400 mg daily. As hormonal therapy for MTF trans-\\nsexuals, 10–40 mg per day. For polycystic ovary\\nsyndrome, 10 mg daily for 10 days.\\n/C15Spironolactone. For hyperandrogenism in women,\\n100–200 mg per day by mouth; for polycystic ovary\\nsyndrome, 50–200 mg per day. For the treatment of\\nacne, 200 mg per day. For hormonal therapy for\\nMTF transsexuals, 200–400 mg per day. A topical\\nform of spironolactone is available for the treatment\\nof androgenetic alopecia.\\nPrecautions\\n/C15Leuprolide. Leuprolide should not be used by preg-\\nnant or nursing women, by patients diagnosed with\\nspinal compression, or by patients allergic to the\\ndrug. Women taking leuprolide should not try to\\nbecome pregnant, and should use methods of birth\\ncontrol that do not contain hormones.\\n/C15Goserelin. Goserelin should not be used duringpreg-\\nnancy or lactation, or by patients known to be allergic\\nto it. As with leuprolide, women taking goserelin\\nshould use methods of contraception that do not\\ncontain hormones.\\n/C15Triptorelin. Patients using triptorelin should see their\\ndoctor at regular intervals for monitoring of side\\neffects.\\n/C15Abarelix. Abarelix should not be given to children or\\nwomen. Because of the severity of this drug’s possible\\nside effects, doctors who prescribe it for men must be\\ncertified following successful completion of a safety\\nprogram for its proper use.\\n/C15Ketoconazole. Ketoconazole should not be given\\nto alcoholic patients or those allergic to the drug. In\\naddition, patients using ketoconazole should have\\ntheir liver function monitored by their doctor.\\n/C15Flutamide. Flutamide should not be used by preg-\\nnant women. Patients taking flutamide should have\\ntheir liver function monitored carefully. They should\\nnotify their doctor at once if they have pain in the\\nupper right side of the abdomen or a yellowish dis-\\ncoloration of the eyes and skin, as these are signs of\\nliver damage. In addition, patients using this drug\\nshould not discontinue taking it without telling their\\ndoctor.\\n/C15Nilutamide. This drug should not be given to\\npatients who are allergic to it, have severe respiratory\\nproblems, or have been diagnosed with a liver dis-\\norder. Patients taking this drug should discontinue\\nusing alcoholic beverages while they are being trea-\\nted with it.\\n/C15Bicalutamide. The precautions while using this drug\\nare the same as those for flutamide.\\n/C15Cyproterone acetate. This drug has not been\\napproved by the Food and Drug Administration\\n(FDA) for use in the United States, but is approved\\nfor use in Canada and the United Kingdom. It\\n246 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 276, 'page_label': '247'}, page_content='should not be used during pregnancy or lactation, or\\nby patients withliver disease. Men who are taking\\nthis drug for treatment of paraphilias should not use\\nalcohol.\\n/C15Medroxyprogesterone. This drug should not be\\ngiven to patients with a history of blood clot forma-\\ntion in their blood vessels. It should be used with\\ncaution in patients withasthma, seizure disorders,\\nmigraine headaches, liver or kidney disorders, or\\nheart disease.\\n/C15Spironolactone. This drug should not be given to\\npatients with overly high levels of potassium in\\nthe blood or to patients with liver disease or kidney\\nfailure. It should also not be given to pregnant or\\nlactating women.\\nSide effects\\n/C15Leuprolide. Side effects of leuprolide in men may\\ninclude pains in the chest, groin, or legs; hot flashes,\\nloss of interest in sex, orimpotence; bone pain; sleep\\ndisturbances; and mood changes. Side effects in\\nwomen may include amenorrhea or light and irregu-\\nlar menstrual periods; loss of bone density; mood\\nchanges; burning oritching sensations in the vagina;\\nor pelvic pain.\\n/C15Goserelin. The side effects of goserelin may include\\nnausea and vomiting; they are otherwise the same as\\nfor leuprolide.\\n/C15Triptorelin. Side effects of triptorelin include pain in\\nthe bladder, difficulty urinating, or bloody or cloudy\\nurine; pain in the side or lower back; hot flashes or\\nheadache; loss of interest in sex or impotence;vomit-\\ning or diarrhea; unusual bleeding or bruising; pain at\\nthe injection site; unusual tiredness or sleep distur-\\nbances; depression or rapid mood changes. It may\\nalso cause a temporary enlargement of the tumor;\\nthis side effect is known as tumor flare.\\n/C15Abarelix. This drug may cause immediate life-threa-\\ntening allergic reactions following any dose. May\\nalso cause a loss of bone mineral density, irregular\\nheartbeat, hot flashes, sleep disturbances,gyneco-\\nmastia, or pain in the breasts and nipples.\\n/C15Ketoconazole. The side effects of ketoconazole\\ninclude nausea and vomiting, loss of appetite,\\nabdominal pain, skin rash or itching, uterine bleed-\\ning, breast pain, gynecomastia, hair loss, loss of\\ninterest in sex, and decline in sperm production.\\n/C15Flutamide. Flutamide has been reported to cause\\nbreast tenderness and gynecomastia in men as well\\nas fatigue, nausea, flu-like symptoms, and runny\\nnose; darkened urine; indigestion, constipation,\\ndiarrhea, or gas; bluish-colored or dry skin;dizziness;\\nand liver damage. These side effects may be intensi-\\nfied in patients who smoke.\\n/C15Nilutamide. The side effects of nilutamide are the\\nsame as those for flutamide. In addition, this drug\\nmay affect the ability of the eyes to adjust to sudden\\nchanges in light intensity or may make the eyes un-\\nusually sensitive to light. Another potential side effect\\nis difficulty breathing; this is more likely to occur in\\nAsian patients taking this drug than in Caucasians.\\n/C15Bicalutamide. The side effects of this drug are the\\nsame as those for flutamide.\\n/C15Cyproterone acetate. Cyproterone has been reported\\nto cause gynecomastia, impotence, loss of interest in\\nsex, deep venous thrombosis, and possible damage to\\nthe cardiovascular system.\\n/C15Medroxyprogesterone. The side effects of this drug\\ninclude high blood pressure, headache, nausea and\\nvomiting, changes in menstrual flow, breakthrough\\nbleeding, puffy skin (edema), weight gain, and sore or\\nswollen breasts.\\n/C15Spironolactone. Spironolactone may cause fatigue,\\nheadache, and drowsiness; gynecomastia and impo-\\ntence in men; abdominal cramps, nausea, vomiting,\\ndiarrhea, or loss of appetite; and skin rashes or\\nitching.\\nInteractions\\n/C15Leuprolide. No interactions with other medications\\nhave been reported.\\n/C15Goserelin. No interactions have been reported.\\n/C15Triptorelin. No interactions have been reported.\\n/C15Abarelix. Abarelix may interact with other medica-\\ntions that affect heart rhythm, including procaina-\\nmide, amiodarone, sotalol, and dofetilde.\\n/C15Ketoconazole. Ketoconazole interacts with a number\\nof drugs, including rifampin, warfarin, phenytoin,\\nantacids, cyclosporine, terfenadine, and astemizole.\\nIt may cause a sunburn-like skin reaction if used\\ntogether with alcohol.\\n/C15Flutamide. This drug has been reported to intensify\\nthe effects of warfarin (Coumadin) and other blood-\\nthinning medications. It has also been reported to\\nintensify the effects of phenytoin (Dilantin), a drug\\ngiven to control seizures.\\n/C15Nilutamide. Reported interactions are the same as for\\nflutamide; in addition, nilutamide has been reported\\nto intensify the effects of theophylline (Theo-Dur), a\\ndrug given to treat asthma.\\nGALE ENCYCLOPEDIA OF MEDICINE 247\\nAntiandrogen drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 277, 'page_label': '248'}, page_content='/C15Bicalutamide. Reported interactions are the same as\\nfor flutamide.\\n/C15Cyproterone acetate. Patients taking oral medica-\\ntions to control diabetes may require dosage adjust-\\nments while taking this drug.\\n/C15Medroxyprogesterone. Patients taking phenobarbi-\\ntal, phenothiazine tranquilizers (chlorpromazine,\\nperphenazine, fluphenazine, etc.), or oral medica-\\ntions to control diabetes should consult their doctor\\nabout dosage adjustments.\\n/C15Spironolactone. Spironolactone is reported to\\ndecrease the effectiveness ofaspirin and anticoagu-\\nlants (blood thinners). It may also interact with potas-\\nsium supplements to increase the patient’s blood\\npotassium level.\\nResources\\nBOOKS\\n‘‘Amenorrhea.’’ Section 18, Chapter 235 inThe Merck\\nManual of Diagnosis and Therapy ,e d i t e db yM a r kH .\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders , 4th edition, text revision.\\nWashington, DC: American Psychiatric Association,\\n2000.\\n‘‘Paraphilias.’’ Section 15, Chapter 192 inThe Merck\\nManual of Diagnosis and Therapy ,e d i t e db yM a r k\\nH. Beers, MD, and Robert Berkow, MD.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2005.\\n‘‘Prostate Cancer.’’ Section 17, Chapter 233 inThe Merck\\nManual of Diagnosis and Therapy , edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nPERIODICALS\\nBradford, J. M. ‘‘The Neurobiology, Neuropharmacology,\\nand Pharmacological Treatment of the Paraphilias and\\nCompulsive Sexual Behavior.’’Canadian Journal of\\nPsychiatry 46 (February 2001): 26–34.\\nBrannon, Guy E., MD. ‘‘Paraphilias.’’eMedicine,1 7\\nOctober 2002. .\\nFeinstein, Robert, MD. ‘‘Androgenetic Alopecia.’’\\neMedicine, 2 October 2003. .\\nHarper, Julie C., MD, and James Fulton, Jr., MD. ‘‘Acne\\nVulgaris.’’ eMedicine, 29 July 2004. .\\nHunter, Melissa H., MD, and Peter J. Carek, MD.\\n‘‘Evaluation and Treatment of Women with\\nHirsutism.’’ American Family Physician 67 (June 15,\\n2003): 2565–2572.\\nHyperandrogenic Disorders Task Force. ‘‘American\\nAssociation of Clinical Endocrinologists Medical\\nGuidelines for Clinical Practice for the Diagnosis and\\nTreatment of Hyperandrogenic Disorders.’’Endocrine\\nPractice 7 (March-April 2001): 120–135.\\nKrueger, R. B., and M. S. Kaplan. ‘‘Depot-Leuprolide\\nAcetate for Treatment of Paraphilias: A Report of\\nTwelve Cases.’’Archives of Sexual Behavior 30 (August\\n2001): 409–422.\\nOriel, Kathleen A., MD, MS. ‘‘Medical Care of Transsexual\\nPatients.’’ Journal of the Gay and Lesbian Medical\\nAssociation 4 (April 2000): 185–194.\\nPatel, Vipul, MD, and Raymond J. Leveille, MD. ‘‘Prostate\\nCancer: Neoadjuvant Androgen Deprivation.’’\\neMedicine, 10 March 2005. .\\nRichardson, Marilyn R., MD. ‘‘Current Perspectives in\\nPolycystic Ovary Syndrome.’’American Family\\nPhysician 68 (August 15, 2003): 697–704.\\nThorneycroft, Ian, MD, PhD. ‘‘Androgen Excess.’’\\neMedicine, 28 February 2004. .\\nORGANIZATIONS\\nAmerican Academy of Dermatology (AAD). P. O. Box\\n4014, Schaumburg, IL 60168-4014. (847) 330-0230.\\nFax: (847) 330-0050. .\\nAmerican Association of Clinical Endocrinologists\\n(AACE). 1000 Riverside Avenue, Suite 205,\\nJacksonville, FL 32204. (904) 353-7878. Fax: (904)\\n353-8185. .\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nHarry Benjamin International Gender Dysphoria\\nAssociation, Inc. (HBIGDA). 1300 South Second\\nStreet, Suite 180, Minneapolis, MN 55454. (612)\\n624-9397. Fax: (612) 624-9541.\\n.\\nNational Cancer Institute (NCI). NCI Public Inquiries\\nOffice, Suite 3036A, 6116 Executive Boulevard,\\nMSC8332, Bethesda, MD 20892-8322. (800)\\n4-CANCER or (800) 332-8615 (TTY).\\n.\\nNational Institute of Mental Health (NIMH). 6001\\nExecutive Boulevard, Room 8184, MSC 9663,\\nBethesda, MD 20892-9663. (301) 443-4513 or (886)\\n615-NIMH. \\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888)\\nINFO-FDA. .\\nOTHER\\nNational Cancer Institute (NCI).Prostate Cancer (PDQ /C226):\\nTreatment, Health Professional version. .\\nRebecca J. Frey, PhD\\n248 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 278, 'page_label': '249'}, page_content='Antianemia drugs\\nDefinition\\nAntianemia drugs are therapeutic agents which\\nincrease either the number of red cells or the amount\\nof hemoglobin in the blood.\\nPurpose\\nAnemia is a general term for a large number of\\nconditions marked by a reduction in the oxygen-\\ncarrying capacity of blood. Red blood cells carry\\noxygen in hemoglobin, so that anemia may be caused\\nby a deficiency of blood or red blood cells or of hemo-\\nglobin. These conditions may be caused by a variety\\nof other conditions. Injury can cause blood loss, which\\nin turn can cause anemia. Nutritional deficiency,\\ninadequate amounts of some of the vitamins and\\nminerals that are needed for hemoglobin production,\\nmay also cause anemia. Because hemoglobin is the\\npigment that makes blood cells red, a lack of hemo-\\nglobin will cause the cells to be a paler color, leading\\nto the term hypochromic, lacking in color.\\nOther conditions can also cause anemia. For\\nexample, certain diseases cause the condition. These\\ncan include infections andkidney disease, in which\\nthere is a deficiency of erythropoietin, a material pro-\\nduced in the kidneys which is essential for the produc-\\ntion of red blood cells. Certain genetic conditions\\naffect the absorption of nutrients and may lead to\\nanemia. In sickle cell anemia, a genetic condition in\\nwhich the red cells are curved rather than flat, the red\\ncells have reduced ability to carry oxygen.\\nThe Merck Manualreduces all types of anemia to\\nthree classes:\\n/C15blood loss\\n/C15inadequate production of blood\\n/C15excessive breakdown of blood cells\\nAnemia may be caused by one or a combination\\nof these three factors. Drug therapy is available for\\nmany types of anemia; however, the selection of the\\ndrug depends on proper diagnosis of the cause of the\\nanemia.\\nDescription\\nAnemia caused by blood loss is normally treated\\nwith either blood volume expanders such as plasma or\\nwith related blood products. More severe blood loss\\nmay require transfusions of red blood cells.\\nIn some cases, blood loss may be due to ulcers of\\nthe stomach or intestines. In these cases, treatment of\\nthe underlying cause will normally correct the anemia.\\nIron deficiency\\nThe most common cause of anemia in adults is\\niron deficiency. Although the typical American diet\\ncontains enough iron to meet normal needs, individuals\\nwho are less able to absorb and store iron may experi-\\nence inadequate hemoglobin production. Although the\\nbest way to meet daily iron requirements is through\\nimproved diet, iron supplements are widely used.\\nIron is normally taken in the form of ferrous\\nsulfate. Although other iron salts are commercially\\navailable and make claims of fewer or less severe side\\neffects, these benefits may be related to the fact that\\nother preparations cont a i nl e s si r o nb yw e i g h t .\\nFerrous sulfate contains about 37% iron, while fer-\\nrous gluconate contains only about 13% iron. People\\nwho have trouble with the side effects of ferrous\\nsulfate may benefit from some of the specialty pre-\\nparations available, but fe rrous sulfate normally\\noffers the greatest amount of iron of all commercial\\nproducts.\\nKEY TERMS\\nAnabolic steroid— Drugs, derived from the male\\nsex hormones, which increase the rate of tissue\\ngrowth. They are best known for increasing the\\nrate of muscle development.\\nAnemia— Any condition in which the amount of\\nhemoglobin in red cells, the number of red cells,\\nor the size of the red cells in blood is reduced from\\nthe normal.\\nCrohn’s disease— Chronic inflammation of the\\nintestine.\\nHemochromatosis— A disorder of iron metabolism\\ncharacterized by excessive absorption of iron from\\nfood.\\nHemoglobin— The red protein found in blood cells\\nwhich carries oxygen from the lungs to the tissues.\\nHemolytic anemia— A type of anemia marked by\\nthe breakdown of red blood cells causing the\\nrelease of hemoglobin.\\nSickle cell anemia— An inherited condition,\\nmarked by crescent-shaped red blood cells and\\nred cell breakdown.\\nGALE ENCYCLOPEDIA OF MEDICINE 249\\nAntianemia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 279, 'page_label': '250'}, page_content='Recommended dosage\\nDosage should be calculated by iron needs, based\\non laboratory tests. Manufacturers recommend one\\ntablet a day, containing 65 mg of iron, as a supplement\\nfor patients over the age of 12 years.\\nPrecautions\\nIron can lead to lethalpoisoning in children. All\\niron supplements should be kept carefully out of reach\\nof children.\\nSome types of anemia do not respond to iron\\ntherapy, and the use of iron should be avoided in\\nthese cases. People with acquiredhemolytic anemia,\\nautoimmune hemolytic anemia, hemochromatosis,\\nhemolytic anemia and hemosiderosis should not take\\niron supplements. Hemolytic anemia is caused by\\nthe increased breakdown of red blood cells.\\nHemochromatosis and hemosiderosis and are condi-\\ntions in which there is too much, rather than too little,\\nabsorption of iron.\\nIron supplements should also be avoided by peo-\\nple who have gastric or intestinal ulcers,ulcerative\\ncolitis,o r Crohn’s disease. These conditions marked\\nby inflammation of the digestive tract, which would be\\nmade worse by use of iron.\\nSide effects\\nThe most common side effects of iron consump-\\ntion are stomach and intestinal problems, including\\nstomach upset with cramps, constipation, diarrhea,\\nnausea, and vomiting. At least 25% of patients have\\none or more of these side effects. The frequency and\\nseverity of the side effects increases with the dose of\\niron. Less frequent side effects includeheartburn and\\nurine discoloration.\\nInteractions\\nIron supplements should not be taken at the same\\ntime asantibiotics of either the tetracycline or quino-\\nlone types. The iron will reduce the effectiveness of the\\nantibiotic. Also, iron supplements reduces the effec-\\ntiveness of levodopa, which is used in treatment of\\nParkinson’s disease.\\nIron supplements should not be used with magne-\\nsium trisilicate, an antacid, or with penicillamine,\\nwhich is used for some types of arthritis.\\nTaking iron with vitamin C increases the absorp-\\ntion of iron, with no increase in side effects.\\nFolic acid\\nFolic acid is found in many common foods,\\nincluding liver, dried peas, lentils, oranges, whole-\\nwheat products, asparagus, beets, broccoli, brussel\\nsprouts, and spinach. However, in some cases, patients\\nhave difficulty absorbing folic acid or in converting it\\nfrom the form found in foods to the form that is active\\nin blood formation. In these cases, folic acid tablets are\\nappropriate for use.\\nRECOMMENDED DOSAGE. For treatment of ane-\\nmia, a daily dose of 1 mg is generally used. Patients\\nwho have trouble absorbing folic acid may require\\nhigher doses.\\nMaintenance doses are:\\n/C15infants: 0.1 mg/day\\n/C15children (under 4 years of age): up to 0.3 mg/day\\n/C15children (over 4 years of age) and adults: 0.4 mg/day\\n/C15pregnant and lactating women: 0.8 mg/day\\nPRECAUTIONS. Before treating an anemia with\\nfolic acid, diagnostic tests must be performed to verify\\nthe cause of the anemia.Pernicious anemiacaused by\\nlack of vitamin B12 shows symptoms that are very\\nsimilar to those of folic acid deficiency but also causes\\nnerve damage which shows up as atingling sensation\\nand feelings ofnumbness. Giving folic acid to patients\\nwith B\\n12 deficiency anemia improves the blood cell\\ncount, but the nerve damage continues to progress.\\nSIDE EFFECTS. Folic acid is considered extremely\\nsafe, and there are no predictable side effects. Where\\nside effects have been reported, they have been among\\npatients taking many times more than the normal\\ntherapeutic dose of the drug.\\nOn rare occasions allergic reactions to folic acid\\nhave been reported.\\nINTERACTIONS. Phenytoins, used to treat seizure\\ndisorders, interact with folic acid with a reduction in\\nphenytoin effectiveness and an increased risk of\\nseizures. If the two drugs must be used together, phe-\\nnytoin blood levels should be monitored, and the dose\\nmay have to be increased.\\nTrimethoprim (an antibacterial) and methotrex-\\nate (originally an anti-cancer drug, which is also used\\nfor arthritis andpsoriasis) act by reducing the meta-\\nbolism of folic acid. Regular blood monitoring is\\nrequired, and dose adjustments may be needed.\\nVitamin B\\n12\\nVitamin B12 is also known as cyanocobalamine\\nand hydroxocobalamine. Cyanocobalamine may be\\n250 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianemia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 280, 'page_label': '251'}, page_content='given by mouth, while hydroxocobalamine must be\\ninjected. The vitamin has many functions in the\\nbody, including maintaining the nervous system, but\\nin treatment of anemia B\\n12 is needed for the metabo-\\nlism of folic acid. Lack of B12 causes pernicious ane-\\nmia, a type of anemia which is marked by a low red cell\\ncount and lack of hemoglobin. There are many other\\nsymptoms of pernicious anemia, including a feeling of\\ntingling or numbness, shortness of breath, muscle\\nweakness, faintness, and a smooth tongue. If perni-\\ncious anemia is left untreated for more than three\\nmonths, permanent damage to the nerves of the spinal\\ncord may result.\\nRECOMMENDED DOSAGE. While vitamin B12 can\\nbe given by mouth for mild vitamin deficiency states,\\npernicious anemia should always be treated with injec-\\ntions, either under the skin (subcutaneous) or into\\nmuscle (intramuscular). Hydroxocobalamine should\\nonly be injected into muscle. Intravenous injections\\nare not used because the vitamin is eliminated from\\nthe body too quickly when given this way. Elderly\\npatients, whose ability to absorb vitamin B\\n12 through\\nthe stomach may be impaired, should also be treated\\nwith injections only.\\nThe normal dose of cyanocobalamine is 100 mcg\\n(micrograms) daily for six to seven days. If improve-\\nment is seen, the dose may be reduced to 100 mcg every\\nother day for seven doses and then 100 mcg every three\\nto four days for two to three weeks. After that,\\nmonthly injections may be required for life.\\nPRECAUTIONS. Although vitamin B12 has a very\\nhigh level of safety, commercial preparations may\\ncontain preservatives which may cause allergic\\nresponses.\\nIn patients with pernicious anemia, treatment\\nwith vitamin B\\n12 may lead to loss of potassium.\\nPatients should be monitored for their potassium\\nlevels.\\nSIDE EFFECTS. Diarrhea and itching of the skin\\nhave been reported on rare occasions. Moreover,\\nthere have been reports of severe allergic reactions to\\ncyanocobalamine.\\nINTERACTIONS. Aminosalicylic acid may reduce\\nthe effectiveness of vitamin B12. Also, colchicine, a\\ndrug used for gout, may reduce the effectiveness\\nof vitamin B12. Other, infrequently used drugs and\\nexcessive use of alcohol may also affect the efficacy\\nof vitamin B12. Patients being treated for anemia\\nshould discuss all medications, both prescription\\nand nonprescription, with their physician or\\npharmacist.\\nAnabolic steroids\\nThe anabolic steroids (nandrolone, oxymetho-\\nlone, oxandrolone, and stanzolol) are the same drugs\\nthat are used improperly by body builders to increase\\nmuscle mass. Two of these drugs, nandrolone and\\noxymetholone, are approved for use in treatment of\\nanemia. Nandrolone is indicated for treatment of ane-\\nmia caused by kidney failure, while oxymetholone\\nmay be used to treat anemia caused by insufficient\\nred cell production, such asaplastic anemia.\\nAll anabolic steroids are considered to be drugs of\\nabuse under United States federal law.\\nRECOMMENDED DOSAGE. The information that\\nfollows is specific only to oxymetholone; however,\\nthe warnings and precautions apply to all drugs in\\nthe class of anabolic steroids.\\nThe dosage of oxymetholone must be individual-\\nized. The most common dose is 1 to 2 mg per kilogram\\nof body weight per day, although doses as high as 5 mg\\nper kilogram per day have been used. The response to\\nthese drugs is slow, and it may take several months to\\nsee if there is any benefit.\\nPRECAUTIONS. All anabolic steroids are danger-\\nous. The following warnings represent the most\\nsignificant hazards of these drugs. For a complete\\nlist, patients should consult the manufacturer’s pack-\\nage insert.\\n/C15Peliosis hepatitis, a condition in which liver and\\nsometimes spleen tissue is replaced with blood-filled\\ncysts, has occurred in patients receiving androgenic\\nanabolic steroids. Although this condition is usually\\nreversible by discontinuing the drug, if it is left unde-\\ntected and untreated, it may lead to life-threatening\\nliver failure or bleeding.\\n/C15Liver tumors may develop. Although most of these\\ntumors are benign and will go away when the drug is\\ndiscontinued, liver cancers may also result.\\n/C15Anabolic steroids may cause changes in blood lipids,\\nleading toatherosclerosis with greatly increased risk\\nof heart attack.\\n/C15Because anabolic steroids are derived from male sex\\nhormones, masculinization may occur when they are\\nused by women.\\n/C15Elderly men who use these drugs may be at increased\\nrisk of prostate enlargement and prostatecancer.\\n/C15Increased water retention due to anabolic steroids\\nmay lead to heart failure.\\n/C15Anabolic steroids should not be used during\\npregnancy, since this may cause masculinization of\\nthe fetus.\\nGALE ENCYCLOPEDIA OF MEDICINE 251\\nAntianemia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 281, 'page_label': '252'}, page_content='/C15Anabolic steroids should be used in children only if\\nthere is no possible alternative. These drugs may\\ncause the long bones of the legs to stop growing\\nprematurely, leading to reduction in adult height.\\nRegular monitoring is essential.\\n/C15In patients with epilepsy, the frequency of seizures\\nmay be increased.\\n/C15In patients with diabetes, glucose tolerance may be\\naltered. Careful monitoring is essential.\\nSIDE EFFECTS. The list of side effects associated\\nwith anabolic steroids is extremely long. The following\\nlist covers only the most commonly observed effects:\\n/C15acne\\n/C15increased urinary frequency\\n/C15breast growth in males\\n/C15breast pain\\n/C15persistent, painful erections\\n/C15masculinization in women\\nINTERACTIONS. Anabolic steroids should not be\\nused in combination with anticoagulants such as war-\\nfarin. Anabolic steroids increase the effects of the\\nanticoagulant, possibly leading to bleeding. If the\\ncombination cannot be avoided, careful monitoring\\nis essential.\\nEpoetin alfa\\nEpoetin alfa is a synthetic form of a protein pro-\\nduced by the kidneys that stimulates the production\\nand release of red blood cells. A similar drug, dare-\\npoetin alpha, is available with the same properties, but\\nit remains active longer and so requires fewer injec-\\ntions each week. Because epoetin alfa is approved for\\nmore types of anemia than darepoetin, this discussion\\ndeals only with the older drug.\\nEpoetin alpha is approved by the Food and Drug\\nAdministration for the following uses:\\n/C15anemia associated with chronic renal failure\\n/C15anemia related to zidovudine therapy in HIV-\\ninfected patients\\n/C15anemia in cancer patients on chemotherapy\\n/C15reduction in blood transfusions in surgical patients\\nIn addition, epoetin alpha may be useful in ane-\\nmia from many other causes. These include but are not\\nlimited to anemia ofprematurity, sickle cell anemia,\\nand the anemia associated withrheumatoid arthritis.\\nThe drug has been abused by athletes due to the\\ntheory that increasing the red blood cell count\\nimproves athletic performance. The potential benefits\\nof misuse of the drug are limited, and the risks are\\nsignificant. The United States and International\\nOlympic Committees and the National Collegiate\\nAthletic Association consider the use of epoetin alfa\\nto enhance athletic ergogenic potential inappropriate\\nand unacceptable because its use by athletes is con-\\ntrary to the rules and ethical principles of athletic\\ncompetition. As of the early 200s, tests to detect the\\nmisuse of epoetin alfa by athletes are increasingly\\nreliable.\\nRECOMMENDED DOSAGE. Dosing schedules may\\nvary with the cause of the anemia. All doses should\\nbe individualized. In general, epoetin alpha dosing\\nin adults is started at 50 to 100 units per kilogram\\ngiven three times a week, either by vein or sub-\\ncutaneously.\\nThe dose should be reduced if the hemoglobin\\nlevel reaches 12 grams per decaliter or if the hemoglo-\\nbin level increases by more than 1 gram per decaliter in\\nany two-week period. The drug should be interrupted\\nif hemoglobin levels reach 13 grams or more per\\ndecaliter.\\nThe dose should be increased if the hemoglobin\\nlevel does not increase by at least 2 grams per decaliter\\nafter eight weeks of treatment.\\nMaintenance doses, if required, should be indivi-\\ndualized to keep the hemoglobin levels within the\\nrange of 10 to 12 grams per decaliter.\\nPRECAUTIONS. Epoetin alpha should not be given\\nto patients with severe, uncontrolledhypertension.\\nOther conditions in which epoetin alpha should be\\nused only when the benefits clearly outweigh the risks\\nare as follows:\\n/C15constitutional aplastic anemia\\n/C15hypertension\\n/C15thromboembolism\\nSide effects\\nThe most common adverse effects of erythopoetin\\nalpha are:\\n/C15joint pain\\n/C15chest pain\\n/C15diarrhea\\n/C15swelling\\n/C15fatigue\\n/C15fever\\n/C15weakness\\n252 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianemia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 282, 'page_label': '253'}, page_content='/C15headache\\n/C15high blood pressure\\n/C15irritation at injection site\\n/C15nausea\\n/C15vomiting\\n/C15rapid heart beat\\nA large number of additional adverse effects have\\nbeen reported. Patients should consult the manufac-\\nturer’s package insert for the full list.\\nInteractions\\nAccording to the manufacturer, as of 2004 no\\nevidence of interaction of epoetin alfa with other\\ndrugs was observed.\\nResources\\nBOOKS\\nBeers, Mark H., ed.Merck Manual of Medical Information:\\nHome Edition.Riverside, NJ: Simon & Schuster, 2004.\\nGreer John P., et al., eds.Wintrobe’s Clinical Hematology.\\nBaltimore, MD: Lippincott Williams & Wilkins, 2003.\\nPhysicians’ Desk Reference 2005.Montvale, NJ: Thomson\\nHealthcare, 2004.\\nPERIODICALS\\nSharma, N., et al. ‘‘Vitamin supplementation: what the gas-\\ntroenterologist needs to know.’’Journal of Clinical\\nGastroenterology 38, no. 10 (November/December\\n2004): 844–54.\\nSamuel D. Uretsky, PharmD\\nAntiangina drugs\\nDefinition\\nAntiangina drugs are medicines that relieve the\\nsymptoms ofangina pectoris (severe chestpain).\\nPurpose\\nThe dull, tight chest pain of angina occurs when the\\nheart’s muscular wall is not getting enough oxygen. By\\nrelaxing the blood vessels, antiangina drugs reduce the\\nheart’s work load and increase the amount of oxygen-\\nrich blood that reaches the heart. These drugs come in\\ndifferent forms, and are used in three main ways:\\n/C15taken regularly over a long period, they reduce the\\nnumber of angina attacks.\\n/C15taken just before some activity that usually brings on\\nan attack, such as climbing stairs, they prevent attacks.\\n/C15taken when an attack begins, they relieve the pain\\nand pressure.\\nNot every form of antiangina drug can be used in\\nevery way. Some work too slowly to prevent attacks\\nthat are about to begin or to relieve attacks that have\\nalready started. These forms can be used only to\\nreduce the number of attacks. Be sure to understand\\nhow and when to use the type of antiangina drug that\\nhas been prescribed.\\nDescription\\nAntiangina drugs, also known as nitrates, come in\\nmany different forms: tablets and capsules that are\\nswallowed; tablets that are held under the tongue,\\ninside the lip, or in the cheek until they dissolve;\\nstick-on patches; ointment; and in-the-mouth sprays.\\nCommonly used antiangina drugs include isosorbide\\ndinitrate (Isordil, Sorbitrate, and other brands) and\\nnitroglycerin (Nitro-Bid, Nitro-Dur, Nitrolingual\\nSpray, Nitrostat Tablets, Transderm-Nitro, and\\nother brands). These medicines are available only\\nwith a physician’s prescription.\\nAntiangina Drugs\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\nCalan (calan SR, isoptin, isoptin\\nSR, verelan)\\nConstipation, dizziness, fatigue,\\nheadache, fluid retention, low blood\\npressure, nausea\\nCardene (nicardipine\\nhydrochloride)\\nDizziness, headache, indigestion,\\nnausea, rapid heartbeat, sleepiness,\\nswelling of feet, flushing\\nCardizem (diltiazem\\nhydrochloride)\\nDizziness, fluid retention, headache,\\nnausea, rash\\nCorgard (nadolol) Behaviorial changes, dizziness,\\ndrowsiness, tiredness\\nImdur, Ismo, Monoket\\n(isosorbide mononitrate)\\nHeadache\\nIsordil (isosorbide dinitrate) Headache, dizziness, low blood\\npressure\\nLopressor (metroprolol tartrate) Depression, diarrhea, itching, rash,\\ntiredness\\nNitro-Bid, Nitro-Dur, Nitrolingual\\nSpray, Nitrostat Tables,\\nTransderm-Nitro (nitroglycerin)\\nDizziness, flushing, headache\\nNorvasc (amlodipine besylate) Dizziness, fatigue, fluid retention,\\nheadache, palpitations\\nProcardia, Procardia XL, Adalat\\n(nifedipine)\\nConstipation, dizziness, hearburn,\\nlow blood pressure, moodiness,\\nnausea, swelling\\nTenormin (atenolol) Dizziness, fatigue, nausea, slowed\\nheartbeat\\nGALE ENCYCLOPEDIA OF MEDICINE 253\\nAntiangina drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 283, 'page_label': '254'}, page_content='Recommended dosage\\nThe recommended dosage depends on the type\\nand form of antiangina drug and may be different\\nfor different patients. Check with the physician who\\nprescribed the drug or the pharmacist who filled the\\nprescription for the correct dosage.\\nAlways take antiangina drugs exactly as directed.\\nThe medicine will not work if it is not taken correctly.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more, as this could cause\\nangina attacks to return. If it is necessary to stop taking\\nthe drug, check with the physician who prescribed it\\nfor instructions on how to taper down gradually.\\nPrecautions\\nRemember that some forms of antiangina drugs\\nwork too slowly to relieve attacks that have already\\nstarted. Check with the physician who prescribed the\\nmedicine for instructions on how to use the type that\\nhas been prescribed. Patients who are using slower-\\nacting forms to make attacks less frequent may want\\nto ask their physicians to prescribe a fast-acting type to\\nrelieve attacks. Another method of treating the fre-\\nquency of attacks is to increase the dosage of the long-\\nacting antiangina drug. Do this only with the approval\\nof a physician.\\nThese medicines make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting\\nor lying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nAntiangina drugs may also causedizziness, lighthead-\\nedness, orfainting in hot weather or when people stand\\nfor a long time orexercise. Use caution in all these\\nsituations. Drinking alcohol while taking antiangina\\ndrugs may cause the same problems. Anyone who\\ntakes this medicine should limit the amount of alcohol\\nconsumed.\\nBecause these drugs may cause dizziness, be care-\\nful when driving, using machines, or doing anything\\nelse that could be dangerous.\\nIf the person is taking the form of nitroglycerin\\nthat is placed under the tongue and symptoms are not\\nrelieved within three doses taken about 5 minutes\\napart, the person should go to the hospital emergency\\nroom as soon as possible. Aheart attack may be in\\nprogress.\\nSome people develop tolerance to antiangina\\ndrugs over time. That is, the drug no longer produces\\nthe desired effects. Anyone who seems to be develop-\\ning a tolerance to this medicine should check with his\\nor her physician.\\nAnyone who has had unusual reactions to anti-\\nangina drugs in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nWomen who are pregnant or breastfeeding or who\\nmay become pregnant should check with their physi-\\ncians before using antiangina drugs.\\nOlder people may be especially sensitive to the\\neffects of antiangina drugs and thus more likely to\\nhave side effects such as dizziness and lightheadedness.\\nBefore using antiangina drugs, people with any of\\nthese medical problems should make sure their physi-\\ncians are aware of their conditions:\\n/C15recent heart attack orstroke\\n/C15kidney disease\\n/C15liver disease\\n/C15severe anemia\\n/C15overactive thyroid\\n/C15glaucoma\\n/C15recent head injury\\nSide effects\\nA common side effect is aheadache just after\\ntaking a dose of the medicine. These headaches usually\\nbecome less noticeable as the body adjusts to the drug.\\nCheck with a physician if they are severe or they con-\\ntinue even after taking the medicine for a few weeks.\\nUnless a physician says to do so, do not change the\\ndose to avoid headaches. Other common side effects\\ninclude dizziness, lightheadedness, fast pulse, flushed\\nface and neck,nausea or vomiting, and restlessness.\\nThese problems do not need medical attention unless\\nthey do not go away or they interfere with normal\\nactivities.\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking an antiangina drug\\nshould get in touch with his or her physician.\\nKEY TERMS\\nAngina pectoris— A feeling of tightness, heaviness,\\nor pain in the chest, caused by a lack of oxygen in\\nthe muscular wall of the heart.\\n254 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiangina drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 284, 'page_label': '255'}, page_content='Interactions\\nAntiangina drugs may interact with other medi-\\ncines. This may increase the risk of side effects or\\nchange the effects of one or both drugs. Anyone who\\ntakes antiangina drugs should let the physician know\\nall other medicines he or she is taking. Among the\\ndrugs that may interact with antiangina drugs are:\\n/C15other heart medicines\\n/C15blood pressure medicines\\n/C15aspirin\\n/C15alcohol\\n/C15ergot alkaloids used in migraine headaches\\nNancy Ross-Flanigan\\nAntiangiogenic therapy\\nDefinition\\nAntiangiogenesis therapy is one of two types of\\ndrugs in a new class of medicines that restores health\\nby controlling blood vessel growth. The other medica-\\ntion is called pro-angiogenic therapy.\\nPurpose\\nAntiangiogenic therapy inhibits the growth of new\\nblood vessels. Because new blood vessel growth plays a\\ncritical role in many disease conditions, including\\ndisorders that cause blindness, arthritis, and\\ncancer, angiogenesis inhibition is a ‘‘common denomina-\\ntor’’ approach to treating these diseases. Antiangiogenic\\ndrugsexerttheirbeneficialeffectsinanumberofways:by\\ndisabling the agents that activate and promote cell\\ngrowth, or by directly blocking the growing blood vessel\\ncells. Angiogenesis inhibitory properties have been dis-\\ncoveredinmorethan300substances,rangingfrommole-\\ncules produced naturally in animals and plants, such as\\ngreen tea extract, to new chemicals synthesized in the\\nlaboratory. A number of medicines already approved\\nby the U.S. Food and Drug Administration (FDA)\\nhave also been found to possess antiangiogenic proper-\\nties, including celecoxib (Celebrex), bortezomib\\n(Velcade), and interferon. Many inhibitors are currently\\nbeing tested in clinical trials for a variety of diseases in\\nhuman patients, and some in veterinary settings.\\nThese diseases include:\\n/C15Eye disease—Excessive new blood vessels growing in\\nthe eye can cause vision loss and lead to blindness.\\nAntiangiogenic treatments may prevent progressive\\nloss of vision or even improve eyesight in patients.\\n/C15Arthritis—Blood vessels that invade the joint release\\nenzymes that destroy cartilage and other tissues in\\narthritis. Antiangiogenic drugs may relieve the arthritic\\npain and prevent bone joint destruction caused by\\nthese pathological and destructive blood vessels.\\n/C15Cancer—Tumors recruit their own private blood\\nsupply to obtain oxygen and nourishment for cancer\\ncells. By cutting off tumor vasculature (the arrange-\\nment of blood vessels in the body or in a particular\\norgan or tissue), antiangiogenesis therapies may lit-\\nerally starve tumors, and prevent their growth and\\nspread. Antiangiogenesis may also prove to be useful\\nwhen combined with conventionalchemotherapy or\\nradiation therapy, as part of a ‘‘multiple warhead’’\\napproach to attack cancer via different strategies\\nsimultaneously.\\nCurrently, more than 80 antiangiogenic drugs are\\nbeing tested worldwide in human clinical trials\\nsponsored by biotechnology and pharmaceutical com-\\npanies, top medical centers, and the U.S. National\\nCancer Institute. The Angiogenesis Foundation is\\nleading the application of antiangiogenic therapy in\\nveterinary medicine, for treatment of certain condi-\\ntions in dogs, cats, and exotic animal species.\\nPro-angiogenic therapy works the opposite way as\\nantiangiogenic therapy by using angiogenic growth\\nfactors or gene therapy to stimulate blood vessel\\ngrowth in tissues that require an improved blood\\nsupply. A number of angiogenic growth factors and\\ngene therapies are currently undergoing clinical trials\\nin human patients suffering from the following condi-\\ntions: ischemic heart disease,stroke, peripheral vascu-\\nlar disease, and chronicwounds.\\nPrecautions\\nSince antiangiogenic therapy is still experimental,\\nonly people enrolled in a clinical trial of a particular\\ndrug therapy can use it. The only FDA-approved\\ndrug, bevacizumab (Avastin), is prescribed to treat\\ncolon-rectal cancer. Avastin can result in intestinal\\nperforation and can cause wounds that have been\\nstitched to break open, sometimes causing death.\\nIntestinal perforation, sometimes associated with\\nabscesses inside the abdomen, occurred throughout\\ntreatment with Avastin. Symptoms included abdom-\\ninal pain associated withconstipation and vomiting.\\nAvastin therapy should be permanently discontinued\\nin patients with intestinal perforation or wound\\nbreaks requiring medical intervention. Serious, and\\nGALE ENCYCLOPEDIA OF MEDICINE 255\\nAntiangiogenic therapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 285, 'page_label': '256'}, page_content='in some cases fatal,hemoptysis (coughing up of blood\\nor mucus containing blood) has occurred in patients\\nwith non-small cell lung cancertreated with chemother-\\napy and Avastin.\\nDescription\\nIn the late 1990s, many medical researchers believed\\nthat the Holy Grail of cancer treatment had been found.\\nAntiangiogenesis therapy was safe, elegant, and at first\\napparently effective. But the clinical results soon fell\\nshort of expectations. The tumors, it seemed, had\\nfound a way to circumvent even this most ingenious of\\ntreatment approaches. Despite the setbacks, however,\\nangiogenesis remains a very tempting target, and\\nresearchers are exploring new agents and approaches\\nto maximize the effects of antiangiogenic therapies.\\nNewer studies have demonstrated that in addition\\nto differences in the regulation of new blood vessel for-\\nmation in cancer compared with normal tissues, the\\nactual blood vessels that are ‘‘created’’ in cancers are\\ndifferent from those created in normal tissues. These\\ndifferences have allowed a number of antiangiogenic\\ndrugs to be developed that specifically damage tumor-\\nassociated blood vessels and not normal vessels. The\\ngoal of these drugs is to attack cancers by damaging\\ntheir blood supply. Many antiangiogenic agents also\\nappear to hasten the death of tumor-associated blood\\nvessels.\\nWith the success of targeted agents such as the\\nbiotechnology company Genentech’s Avastin, the\\nonly antiangiogenic drug approved by the FDA to\\ntreat cancer, new efforts are underway to widen and\\noptimize the field of antiangiogenic agents. As oncol-\\nogy (the study of cancer) drug development accelerates,\\nnew indications are beginning to emerge for diseases\\nsuch as ocular neovascularization and evenobesity.\\nAntiangiogenic therapy represents a novel, poten-\\ntially effective, and non-toxic treatment for cancer. It\\nis likely that these drugs will provide the next major\\nbreakthrough in the management of people and pets\\nwith cancer. Antiangiogenic therapy will likely\\nbecome part of the conventional treatment of cancer\\nand will be used in combination with surgery, radia-\\ntion therapy and chemotherapy. These agents are\\ncurrently in clinical trials and may become available\\nto both people and pets in the near future.\\nAntiangiogenic therapy offers a number of advant-\\nages over traditional therapies for cancer:\\n/C15Tumor cells often mutate and become resistant to\\nchemotherapy. Because antiangiogenic drugs only\\ntarget normal endothelial cells (a layer of cells that\\nlines the inside of certain body cavities, such as blood\\nvessels), these cells are less likely to develop acquired\\ndrug resistance.\\n/C15All tumors rely upon host vessels. Antiangiogenic\\nagents are therefore effective against a broad range\\nof cancers.\\n/C15Conventional chemotherapy and radiotherapy indis-\\ncriminately attacks all dividing cells in the body,\\nleading to side effects such asdiarrhea, mouth ulcers,\\nhair loss, and weakened immunity. Antiangiogenic\\ndrugs selectively target dividing blood vessels and\\ncause fewer side effects.\\n/C15Antiangiogenic drugs are relatively nontoxic and\\nwork at levels well below the maximum tolerated\\ndose, so may be given in lower doses over longer\\nperiods of time.\\n/C15Antiangiogenic treatment may take weeks or even\\nmonths to exhibit its full beneficial effect, but this\\nallows for continuous, chronic control of disease.\\n/C15Antiangiogenic drugs may also serve as a powerful\\nsupplement to traditional chemotherapy or radiation\\ntherapy.\\nKEY TERMS\\nAngiogenesis— The formation of new blood ves-\\nsels, for example, as a result of a tumor.\\nChemotherapy— The use of chemical agents to\\ntreat diseases, infections, or other disorders, espe-\\ncially cancer.\\nEndothelial— A layer of cells that lines the inside of\\ncertain body cavities, for example, blood vessels.\\nEpidermal— Referring to the thin outermost layer of\\nthe skin, itself made up of several layers, that covers\\nand protects the underlying dermis (skin).\\nFibroblast— A large flat cell that secretes the\\nproteins that form collagen and elastic fibers and\\nthe substance between the cells of connective\\ntissue.\\nIschemic— An inadequate supply of blood to a part\\nof the body, caused by partial or total blockage of\\nan artery.\\nOcular neovascularization— Abnormal or exces-\\nsive formation of blood vessels in the eye.\\nPeripheral vascular disease— A disease affecting\\nblood vessels, especially in the arms, legs, hands,\\nand feet.\\nVascular— Relating to blood vessels.\\n256 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiangiogenic therapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 286, 'page_label': '257'}, page_content='Preparation\\nSince antiangiogenic drugs are either injected or\\nadministered orally, little or no preparation is needed.\\nFor injections, the site should be first swabbed with\\nalcohol.\\nAftercare\\nLittle or no aftercare is needed following the\\nadministering of antiangiogenic therapy, except for a\\nsmall bandage on the injection site.\\nAlthough many of these agents are currently being\\ntested in clinical trials, no reliable way to monitor the\\neffects of many, if not most, of these therapeutic\\nagents on the inhibition of the complicated process\\nof angiogenesis exists. However, in late 2004, scientists\\nuncovered critical information that may lead to an\\nurgently needed method for effectively monitoring\\nantiangiogenic cancer therapies. The research is likely\\nto facilitate development of new antiangiogenic drugs\\nor treatment strategies and allow for accurate deter-\\nmination of the optimal drug doses to use for such\\ntherapies. The researchers found that measuring per-\\nipheral blood cells can be used as a reliable way to\\nmonitor antiangiogenic drug activity, which can be\\nused to help establish the optimal biologic dose of\\nsuch drugs.\\nRisks\\nIn general, early research has found the side\\neffects of antiangiogenesis agents to be mostly mini-\\nmal. Because these drugs use proteins that are pro-\\nduced in the human body, there is less likelihood that\\nthey will produce the bad side effects common in\\nradiation treatments and chemotherapy. Still, one\\ncancer study found that 6 of the 99 patients taking\\nan antiangiogenesis drug experienced severe bleeding\\nin the tumors being treated. Four of those patients\\ndied from this complication.\\nSince antiangiogenesis drugs could affect a\\ndeveloping fetus, they will probably not be used\\nfor pregnant women or women who might become\\npregnant. They may also need to be stopped before\\nsurgery, since blood vessels that are cut at such\\ntimes need to repair themselves. Also, people who\\nhave damaged blood vessels (such as those with\\nheart disease or stroke) may not be able to take\\nthese drugs. Other side effects in people are being\\ndetermined. Doctors, sci entists and specialists at\\nthe FDA will be monitoring these other side effects\\nto better understand the toxicity and risks of these\\ndrugs.\\nNormal results\\nSince all antiangiogenic therapies are still experi-\\nmental and in clinical trials, it is difficult to determine\\nwhat normal results should be. The goal of antiangio-\\ngenic drugs is to stop the development and spread of\\ncertain diseases, especially some cancers. At least four\\nmajor proteins and their receptors and signaling path-\\nways commonly govern angiogenesis in solid tumors:\\nplatelet-derived growth factor, epidermal growth fac-\\ntor, vascular endothelial growth factor (VEGF), and\\nfibroblast growth factor (basic and acidic). Therapies\\nthat either target these molecules or block their signal-\\ning pathways should be effective in preventing solid\\ntumor growth and spread of the cancer by preventing\\nthe formation of new blood vessels.\\nResources\\nBOOKS\\nCooke, Robert.Dr. Folkman’s War: Angiogenesis and the\\nStruggle to Defeat CancerCollingdale, PA: Diane\\nPublishing Co., 2003.\\nTeicher, Beverly A.Antiangiogenic Agents in Cancer Therapy\\nTotowa, NJ: Humana Press, 1999.\\nPERIODICALS\\nFrankish, Helen. ‘‘Researchers Target Tumour Blood\\nVessels With Antiangiogenic Gene Therapy.’’The\\nLancet (June 29, 2002): 2256.\\nGuttman, Cheryl. ‘‘Anti-Angiogenic Therapy Explored for\\nRetinoblastoma.’’ Ophthalmology Times(September 1,\\n2004): 11.\\nMarch, Keith. ‘‘New Approach for Easing Angina.’’\\nMedical Update(December 2003): 6.\\nSullivan. Michele G. ‘‘Experimental Antiangiogenic\\n(Therapy) May Battle Drug-Resistant Tumors.’’\\nFamily Practice News(February 15, 2003): 42.\\nORGANIZATION\\nThe Angiogenesis Foundation. P.O. Box 382111,\\nCambridge, MA 02139. (617) 576-5708. patienthel-\\np@angio.org. or (for veterinary information) vetme-\\nd@angio.org. http://www.angio.org.\\nKen R. Wells\\nAntianxiety drugs\\nDefinition\\nAntianxiety drugs are medicines that calm and\\nrelax people with excessiveanxiety, nervousness, or\\ntension, or for short-term control of social phobia\\ndisorder or specific phobia disorder.\\nGALE ENCYCLOPEDIA OF MEDICINE 257\\nAntianxiety drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 287, 'page_label': '258'}, page_content='Purpose\\nAntianxiety agents, or anxiolytics, may be used to\\ntreat mild transient bouts of anxiety as well as more\\npronounced episodes of social phobia and specific\\nphobia. Clinically significant anxiety is marked by\\nseveral symptoms. The patient experiences marked\\nor persistent fear of one or more social or performance\\nsituations in which he or she is exposed to unfamiliar\\npeople or possible scrutiny by others, and may react in\\na humiliating or embarrassing way. The exposure to\\nthe feared situation produces an anxiety attack. Fear\\nof these episodes of anxiety leads to avoidance beha-\\nvior, which impairs normal social functioning, includ-\\ning working or attending classes. The patient is aware\\nthat these fears are unjustified.\\nDescription\\nIn psychiatric practice, treatment of anxiety has\\nlargely turned from traditional antianxiety agents,\\nanxiolytics, to antidepressant therapies. In current\\nuse, thebenzodiazepines, the best known class of anxio-\\nlytics, have been largely supplanted byselective seroto-\\nnin reuptake inhibitors(SSRIs). Among the preferred\\nSSRIs forgeneralized anxiety disorderare paroxetine\\n(Paxil), escitalopram (Lexapro), and venlafaxine\\n(Effexor), which also has norepinephrine. Other\\nSSRIs are fluoxetine (Prozac) and sertraline (Zoloft).\\nVenlafaxine and Paroxetine have been shown particu-\\nlarly effective in relieving symptoms of social anxiety.\\nHowever, traditional anxiolytics remain useful for\\npatients who need a rapid onset of action, or whose\\nfrequency of exposure to anxiety provoking stimuli is\\nlow enough to eliminate the need for continued treat-\\nment. While SSRIs may require three to five weeks to\\nshow any effects, and must be taken continuously,\\nbenzodiazepines may produce a response within 30\\nminutes, and may be dosed on an as-needed basis.\\nThe intermediate action benzodiazepines, alprazo-\\nlam (Xanax), and lorazepam (Ativan) are the appropri-\\nate choice for treatment of mild anxiety and social\\nphobia. Diazepam (Valium) is still widely used for anxi-\\nety, but its active metabolite, desmethyldiazepam, which\\nhas a long half-life, may make this a poorer choice than\\nother drugs in its class. There is considerable variation\\nbetween individuals in metabolism of benzodiazepines,\\nso patient response may not be predictable. As a class,\\nbenzodiazepines are used not only as anxiolytics, but\\nalso as sedatives,muscle relaxants, and in treatment of\\nepilepsy andalcoholism. The distinctions between these\\nuses are largely determined by onset and duration of\\naction, and route of administration.\\nBuspirone (BuSpar), which is not chemically\\nrelated to other classes of central nervous system\\nAntianxiety Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nAtarax (hydroxyzine\\nhydrochloride)\\nDrowsiness, dry mouth\\nAtivan (lorazepam) Dizziness, excessive calm, weakness\\nBuSpar, Buspirone (bus-\\npirone hydrochloride)\\nDry mouth, dizziness, headache, fatigue,\\nnausea\\nCentrax (pazepam) Decreased coordination, dizziness,\\ndrowsiness, fatigue, weakness\\nLibrium, Libritabs\\n(chlordiazepoxide)\\nConstipation, drowsiness, nausea,\\nswelling\\nMiltown, Equanil\\n(meprobamate)\\nDiarrhea, bruising, fever, headache,\\nnausea, rash, slurred speech\\nSerax (oxazepam) Dizziness, fainting, headache, liver\\nproblems, decreased coordination,\\nnausea, swelling, vertigo\\nStelazine (trifluoperazine\\nhydrochloride)\\nAbnormal glucose in urine, allergic\\nreactions, blurred vision, constipation, eye\\nspasms, fluid retention and swelling\\nTranxene, Tranxene-SD\\n(clorazepate dipotassium)\\nDrowsiness\\nValium (diazepam) Decreased coordination, drowsiness,\\nlight-headedness\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or ima-\\ngined stress, danger, or dreaded situations. Physical\\nreactions, such as fast pulse, sweating, trembling, fati-\\ngue, and weakness may accompany anxiety.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nPanic disorder— An disorder in which people have\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nPhobia— An intense, abnormal, or illogical fear of\\nsomething specific, such as heights or open spaces.\\nPregnancy category B— Animal studies indicate no\\nfetal risk, but no human studies; or adverse effects in\\nanimals, but not in well-controlled human studies.\\nPregnancy category C— No adequate human or\\nanimal studies; or adverse fetal effects in animal\\nstudies, but no available human data.\\nSeizure— A sudden attack, spasm, or convulsion.\\n258 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianxiety drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 288, 'page_label': '259'}, page_content='drugs, is also a traditional anxiolytic, although it is\\nnow considered either a third line or adjunctive agent\\nfor use after trials of SSRIs and benzodiazepines. It is\\nappropriate for use in patients who have either failed\\ntrials of other treatments, or who should not receive\\nbenzodiazepines because of a history of substance\\nabuse problems. Buspirone, in common with antide-\\npressants, requires a two to three week period before\\nthere is clinical evidence of improvement, and must be\\ncontinuously dosed to maintain its effects.\\nBenzodiazepines are controlled drugs under fede-\\nral law. The number of U.S. drug-abuse related trips\\nto emergency departments involving benzodiazepine\\nmedications exceeded 100,000 in 2002. Buspirone is\\nnot a controlled substance and has no established\\nabuse potential.\\nRecommended dosage\\nBenzodiazepines should be administered 30 to 60\\nminutes before exposure to the anticipated stress.\\nDosage should be individualized to minimizesedation.\\nThe normal dose of alprazolam is 0.25–0.5 mg. The\\nusual dose of lorazepam is 2–3 mg. Doses may be\\nrepeated if necessary.\\nBuspirone is initially dosed at 5 mg three times a\\nday. Patients should increase the dosage 5 mg/day, at\\nintervals of two to three days, as needed and should\\nnot exceed 60 mg/day. Two to three weeks may be\\nrequired before a satisfactory response is seen.\\nPrecautions\\nBenzodiazepines should not be used in patients with\\npsychosis, acute narrow angleglaucoma,o rliver disease.\\nThe drugs can act as respiratory depressants and should\\nbe avoided in patients with respiratory conditions.\\nBenzodiazepines are potentially addictive and should\\nnot be administered to patients with substance abuse\\ndisorders. Because benzodiazepines are sedative, they\\nshould be avoided in patients who must remain alert.\\nTheir use for periods over four months has not been\\ndocumented. These drugs should not be used during the\\nsecond and third trimester ofpregnancy, although use\\nduring the first trimester appears to be safe. They should\\nnot be taken while breastfeeding. Physicians and\\npharmacists should be consulted about use in children.\\nBuspirone is metabolized by the liver and excreted\\nby the kidney, and should be used with care in patients\\nwith hepatic or renal disease. The drug is classified as\\nschedule B during pregnancy, but should not be taken\\nduring breastfeeding. Its use in children under the age\\nof 18 years has not been studied.\\nIn 2004, the FDA cautioned revealed that certain\\nSSRIs could lead to increased risk ofsuicide in child-\\nren and adolescents who took them for depression.\\nParents should check with physicians to receive more\\ninformation on SSRIs when they are prescribed for\\nteens and children with anxiety.\\nSide effects\\nThe most common side effects of benzodiazepines\\nare secondary to their C NS effects and include\\nsedation and sleepiness; depression; lethargy; apathy;\\nfatigue; hypoactivity; lightheadedness; memory impair-\\nment; disorientation; anterogradeamnesia; restlessness;\\nconfusion; crying or sobbing;delirium; headache;s l u r -\\nred speech; aphonia; dysarthria; stupor; seizures;coma;\\nsyncope; rigidity; tremor; dystonia; vertigo;dizziness;\\neuphoria; nervousness; irritability; difficulty in concen-\\ntration; agitation; inability to perform complex mental\\nfunctions; akathisia; hemiparesis; hypotonia; unsteadi-\\nness; ataxia; incoordination; weakness; vivid dreams;\\npsychomotor retardation; ‘‘glassy-eyed’’ appearance;\\nextrapyramidal symptoms; paradoxical reactions.\\nOther reactions include changes in heart rate and blood\\npressure, changes in bowel function, severe skin rash and\\nchanges in genitourinary function. Other adverse\\neffects have been reported.\\nBuspirone has a low incidence of side effects.\\nDizziness and drowsiness are the most commonly\\nreported adverse effects. Other CNS effects include\\ndream disturbances; depersonalization, dysphoria,\\nnoise intolerance, euphoria, akathisia, fearfulness,\\nloss of interest, disassociative reaction,hallucinations,\\nsuicidal ideation, seizures; feelings of claustrophobia,\\ncold intolerance, stupor and slurred speech, psychosis.\\nRarely, heart problems, including congestive heart\\nfailure and myocardial infarction, have been reported.\\nOther adverse effects have been reported.\\nInteractions\\nThe metabolism of alprazolam may be increased\\nby: cimetidine, oral contraceptives, disulfiram, fluox-\\netine, isoniazid, ketoconazole, metoprolol, propoxy-\\nphene, propranolol and valproic acid. The absorption\\nof all benzodiazepines is inhibited by concomitant use\\nof antacids. Benzodiazepines may increase blood\\nlevels of digoxin, and reduce the efficacy of levodopa.\\nOther drug interactionshave been reported.\\nBuspirone levels will be increased by concomitant\\nuse of erythromycin, itraconazole, and nefazadone.\\nDoses should be adjusted based on clinical response.\\nUse of buspirone at the same time as mono-amine\\nGALE ENCYCLOPEDIA OF MEDICINE 259\\nAntianxiety drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 289, 'page_label': '260'}, page_content='oxidase inhibitors (MAOIs, phenelzine, tranycypro-\\nmine) may cause severe blood pressure elevations.\\nUse of buspirone with MAOIs should be avoided.\\nResources\\nPERIODICALS\\n‘‘Abuse of Anti-anxiety Drugs Up, Study of ER Visits\\nShows.’’ Drug Week(September 17, 2004): 225.\\nFinn, Robert. ‘‘Venlafaxine and Paroxetine Both Relieve\\nSocial Anxiety.’’Clinical Psychiatry News(September\\n2004): 41.\\nSherman, Carl. ‘‘GAD Patients Often Require Combined\\nTherapy.’’Clinical Psychiatry News(August 2004): 12–14.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntiarrhythmic drugs\\nDefinition\\nAntiarrhythmic drugs are medicines that correct\\nirregular heartbeats and slow down hearts that beat\\ntoo fast.\\nPurpose\\nNormally, the heart beats at a steady, even pace.\\nThe pace is controlled by electrical signals that begin in\\none part of the heart and quickly spread through the\\nwhole heart. If something goes wrong with this control\\nsystem, the result may be an irregular heartbeat, or an\\narrhythmia. Antiarrhythmic drugs correct irregular\\nheartbeats, restoring the normal rhythm. If the heart\\nis beating too fast, these drugs will slow it down. By\\ncorrecting these problems, antiarrhythmic drugs help\\nthe heart work more efficiently.\\nDescription\\nAntiarrhythmic drugs are available only with a\\nphysician’s prescription and are sold in capsule (regu-\\nlar and extended release), tablet (regular and\\nextended-release), and injectable forms. Commonly\\nused antiarrhythmic drugs are disopyramide\\n(Norpace, Norpace CR), procainamide (Procan SR,\\nPronestyl, Pronestyl-SR), and quinidine (Cardioquin,\\nDuraquin, Quinidex, and other brands).Do not con-\\nfuse quinidine with quinine, which is a related medicine\\nwith different uses, such as relieving leg cramps.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiarrhythmic drug and other factors. Doses may be\\ndifferent for different patients. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage.\\nAlways take antiarrhythmic drugs exactly as\\ndirected. Never take larger or more frequent doses.\\nDo not stop taking this medicine without checking\\nwith the physician who prescribed it. Stopping it sud-\\ndenly could lead to a serious change in heart function.\\nAntiarrhythmic drugs work best when they are at\\nconstant levels in the blood. To help keep levels con-\\nstant, take the medicine in doses spaced evenly through\\nthe day and night. Do not miss any doses. If taking\\nmedicine at night interferes with sleep, or if it is difficult\\nto remember to take the medicine during the day, check\\nwith a health care professional for suggestions.\\nPrecautions\\nPersons who take these drugs should see their\\nphysician regularly. The physician will check to make\\nsure the medicine is working as it should and will note\\nany unwanted side effects.\\nSome people feel dizzy, lightheaded, or faint when\\nusing these drugs. This medicine may cause blurred\\nvision or other vision problems. Because of these pos-\\nsible problems, anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them. If the medicine does cause vision pro-\\nblems, wait until vision is clear before driving or\\nengaging in other activities that require normal vision.\\nAntiarrhythmic drugs make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting or\\nlying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nAnyone taking this medicine should not drink\\nalcohol without his or her physician’s approval.\\nSome antiarrhythmic drugs may change the\\nresults of certain medical tests. Before having medical\\ntests, anyone taking this medicine should alert the\\nhealth care professional in charge.\\nAnyone who is taking antiarrhythmic drugs\\nshould be sure to tell the health care professional in\\ncharge before having any surgical or dental proce-\\ndures or receiving emergency treatment.\\nAntiarrhythmic drugs may cause low blood sugar\\nin some people. Anyone who experiences symptoms of\\nlow blood sugar should eat or drink a food that\\n260 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiarrhythmic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 290, 'page_label': '261'}, page_content='contains sugar and call a physician immediately. Signs\\nof low blood sugar are:\\n/C15anxiety\\n/C15confusion\\n/C15nervousness\\n/C15shakiness\\n/C15unsteady walk\\n/C15extreme hunger\\n/C15headache\\n/C15nausea\\n/C15drowsiness\\n/C15unusual tiredness or weakness\\n/C15fast heartbeat\\n/C15pale, cool skin\\n/C15chills\\n/C15cold sweats\\nAntiarrhythmic drugs may causedry mouth.T o\\ntemporarily relieve the discomfort, chew sugarless gum,\\nsuck on sugarless candy or ice chips, or use saliva sub-\\nstitutes, which come in liquid and tablet forms and are\\navailable without a prescription. If the problem con-\\nt i n u e sf o rm o r et h a n2w e e k s ,c h e c kw i t hap h y s i c i a no r\\ndentist. Mouth dryness that continues over a long time\\nmay contribute totooth decayand other dental problems.\\nPeople taking antiarrhythmic drugs may sweat\\nless, which can cause the body temperature to rise.\\nAnyone who takes this medicine should be careful\\nnot to become overheated during exercise or hot\\nweather and should avoid hot baths, hot tubs, and\\nsaunas. Overheating could lead to heatstroke.\\nOlder people may be especially sensitive to the\\neffects of antiarrhythmic drugs. This may increase\\nthe risk of certain side effects, such as dry mouth,\\ndifficult urination, anddizziness or lightheadedness.\\nThe antiarrhythmic drug procainamide can cause\\nserious blood disorders. Anyone taking this medicine\\nshould have regular blood counts and should check\\nwith a physician if any of the following symptoms occur:\\n/C15joint or musclepain\\n/C15muscle weakness\\n/C15pain in the chest or abdomen\\n/C15tremors\\n/C15wheezing\\n/C15cough\\n/C15palpitations\\n/C15rash, sores, or pain in the mouth\\n/C15sore throat\\n/C15fever and chills\\n/C15loss of appetite\\n/C15diarrhea\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or\\nimagined stress, danger, or dreaded situations.\\nPhysical reactions, such as fast pulse, sweating, trem-\\nbling, fatigue, and weakness may accompany anxiety.\\nArrhythmia— Abnormal heart rhythm.\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nEmphysema— A lung disease in which breathing\\nbecomes difficult.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHeat stroke— A severe condition caused by pro-\\nlonged exposure to high heat. Heat stroke interferes\\nwith the body’s temperature regulating abilities and\\ncan lead to collapse and coma.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMyasthenia gravis— A chronic disease with symp-\\ntoms that include muscle weakness and sometimes\\nparalysis.\\nPalpitation— Rapid, forceful, throbbing, or flutter-\\ning heartbeat.\\nProstate— A donut-shaped gland below the bladder\\nin men that contributes to the production of semen.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease that affects the skin, joints, and certain\\ninternal organs.\\nTourette syndrome— A condition in which a per-\\nson has tics and other involuntary behavior, such as\\nbarking, sniffing, swearing, grunting, and making\\nuncontrollable movements.\\nTremor— Shakiness or trembling.\\nGALE ENCYCLOPEDIA OF MEDICINE 261\\nAntiarrhythmic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 291, 'page_label': '262'}, page_content='/C15dark urine\\n/C15yellow skin or eyes\\n/C15unusual bleeding or bruising\\n/C15dizziness\\n/C15hallucinations\\n/C15depression\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines may have problems if\\nthey take antiarrhythmic drugs. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to an antiarrhythmic drug in the past should let\\nhis or her physician know before taking this type of\\nmedicine again. Patients taking procainamide should\\nlet their physicians know if they have ever had an\\nunusual or allergic reaction to procaine or any other\\n‘‘caine-type’’ medicine, such as xylocaine or lidocaine.\\nPatients taking quinidine should mention any pre-\\nvious reactions to quinine. The physician should also\\nbe told about anyallergies to foods, dyes, preserva-\\ntives, or other substances.\\nCONGESTIVE HEART DISEASE. Antiarrhythmic\\ndrugs may cause low blood sugar, which can be a\\nparticular problem for people with congestive heart\\ndisease. Anyone with congestive heart disease should\\nbe familiar with the signs of low blood sugar (listed\\nabove) and should check with his or her physician\\nabout what to do if such symptoms occur.\\nDIABETES. Antiarrhythmic drugs may cause low\\nblood sugar, which can be a particular problem for\\npeople with diabetes. Anyone with diabetes should be\\nfamiliar with the signs of low blood sugar (listed\\nabove) and should check with his or her physician\\nabout what to do if such symptoms occur.\\nPREGNANCY. The effects of taking antiarrhythmic\\ndrugs inpregnancyhave not been studied in humans. In\\nstudies of laboratory animals, this medicine increased\\nthe risk ofmiscarriage. In addition, some women who\\nhave taken these drugs while pregnant have had con-\\ntractions of the uterus (womb). Women who are preg-\\nnant or who may become pregnant should check with\\ntheir physicians before taking this medicine. Women\\nwho become pregnant while taking this medicine\\nshould let their physicians know right away.\\nBREASTFEEDING. Antiarrhythmic drugs pass into\\nbreast milk. Women who are breastfeeding should\\ncheck with their physicians before taking this medicine.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\narrhythmic drugs, people with any of these medical\\nproblems should make sure their physicians are aware\\nof their conditions:\\n/C15heart disorders such as structural heart disease or\\ninflammation of the heart muscle\\n/C15congestive heart failure\\n/C15kidney disease\\n/C15liver disease\\n/C15diseases of the blood\\n/C15asthma oremphysema\\n/C15enlarged prostate or difficulty urinating\\n/C15overactive thyroid\\n/C15low blood sugar\\n/C15psoriasis\\n/C15glaucoma\\n/C15myasthenia gravis\\n/C15systemic lupus erythematosus\\nUSE OF CERTAIN MEDICINES.Taking antiarrhythmic\\ndrugs with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects are dry mouth and\\nthroat, diarrhea, and loss of appetite. These problems\\nusually go away as the body adjusts to the drug and do\\nnot require medical treatment. Less common side\\neffects, such as dizziness, lightheadedness, blurred\\nvision, dry eyes and nose, frequent urge to urinate,\\nbloating, constipation, stomach pain, and decreased\\nsexual ability, also may occur and do not need medical\\nattention unless they do not go away or they interfere\\nwith normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15fever and chills\\n/C15difficult urination\\n/C15swollen or painful joints\\n/C15pain when breathing\\n/C15skin rash or itching\\nPeople who are especially sensitive to quinidine\\nmay have a reaction to the first dose or doses. If any of\\nthese side effects occur after taking quinidine, check\\nwith a physician immediately:\\n262 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiarrhythmic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 292, 'page_label': '263'}, page_content='/C15dizziness\\n/C15ringing in the ears\\n/C15breathing problems\\n/C15vision changes\\n/C15fever\\n/C15headache\\n/C15skin rash\\nOther rare side effects may occur with any anti-\\narrhythmic drug. Anyone who has unusual symptoms\\nafter taking antiarrhythmic drugs should get in touch\\nwith his or her physician.\\nInteractions\\nAntiarrhythmic drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes antiarrhythmic\\ndrugs should let the physician know all other medi-\\ncines he or she is taking. Among the drugs that may\\ninteract with antiarrhythmic drugs are:\\n/C15other heart medicines, including other antiarrhyth-\\nmic drugs\\n/C15blood pressure medicine\\n/C15blood thinners\\n/C15pimozide (Orap), used to treat Tourette’s syndrome\\nThe list above does not include every drug that\\nmay interact with antiarrhythmic drugs. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning antiarrhythmic drugs with any other prescription\\nor nonprescription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntiasthmatic drugs\\nDefinition\\nAntiasthmatic drugs are medicines that treat or\\nprevent asthma attacks.\\nPurpose\\nFor people with asthma, the simple act of breath-\\ning can be a struggle. Their airways become inflamed\\nand blocked with mucus during asthma attacks, nar-\\nrowing the opening through which air passes. This is\\nnot such a problem when the person breathes in,\\nbecause the airways naturally expand when a person\\ntakes a breath. The real problem arises when the per-\\nson with asthma tries to breathe out. The air cannot\\nget out through the blocked airways, so it stays\\ntrapped in the lungs. With each new breath, the person\\ncan take in only a little more air, so breathing becomes\\nshallow and takes more and more effort.\\nAsthma attacks can be caused byallergies to pol-\\nlen, dust, pets or other things, but people without\\nknown allergies may also have asthma.Exercise, stress,\\nintense emotions, exposure to cold, certain medicines\\nand some medical conditions also can bring on attacks.\\nThe two main approaches to dealing with asthma\\nare avoiding substances and situations that trigger\\nattacks and using medicines that treat or prevent the\\nsymptoms. With a combination of the two, most peo-\\nple with asthma can find relief and live normal lives.\\nDescription\\nThree types of drugs are used in treating and pre-\\nventing asthma attacks:\\n/C15Bronchodilators relax the smooth muscles that line\\nthe airway. This makes the airways open wider, let-\\nting more air pass through them. These drugs are\\nused mainly to relieve sudden asthma attacks or to\\nprevent attacks that might come on after exercise.\\nThey may be taken by mouth, injected or inhaled.\\nBronchodilators may be taken in pill or liquid form,\\nbut normally are used as inhalers, which go directly\\nto the lungs and result in fewer side effects.\\n/C15Corticosteroids block the inflammation that narrows\\nthe airways. Used regularly, these drugs will help pre-\\nvent asthma attacks. Those attacks that do occur will\\nbe less severe. However, corticosteroids cannot stop\\nan attack that is already underway. These drugs may\\nbe taken by mouth, injected or inhaled.\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nInhalant— Medicine that is breathed into the lungs.\\nMucus— Thick fluid produced by the moist mem-\\nbranes that line many body cavities and structures.\\nNebulizer— A device that turns liquid forms of\\nmedicine into a fine spray that can be inhaled.\\nGALE ENCYCLOPEDIA OF MEDICINE 263\\nAntiasthmatic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 293, 'page_label': '264'}, page_content='/C15Leukotriene modifiers (montelukast and zafirlukast)\\nare a new type of drug that can be used in place of\\nsteroids, for older children or adults who have a mild\\ndegree of asthma that persists. They work by coun-\\nteracting leukotrienes, which are substances released\\nby white blood cells in the lung that cause the air\\npassages to constrict and promote mucus secretion.\\nLeukotriene modifiers also fight off some forms of\\nrhinitis, an added bonus for people with asthma.\\nHowever, they are not proven effective in fighting\\nseasonal allergies.\\n/C15Cromolyn also is taken regularly to prevent asthma\\nattacks and may be used alone or with other asthma\\nmedicines. It cannot stop an attack that already has\\nstarted. The drug works by preventing certain cells in\\nthe body from releasing substances that cause aller-\\ngic reactions or asthma symptoms. One brand of this\\ndrug, Nasalcrom, comes in capsule and nasal spray\\nforms and is used to treat hayfever and other aller-\\ngies. The inhalation form of the drug, Intal, is used\\nfor asthma. It comes in aerosol canisters, in capsules\\nthat are inserted into an inhaler, and in liquid form\\nthat is used in a nebulizer.\\nPrecautions\\nUsing antiasthmatic drugs properly is important.\\nBecause bronchodilators provide quick relief, some peo-\\nple may be tempted to overuse them. However, with\\nsome kinds of bronchodilator s ,t h i sc a nl e a dt os e r i o u s\\nand possibly life-threatening complications. In the long\\nrun, patients are better off using bronchodilators only as\\nd i r e c t e da n da l s ou s i n gc o r t i costeroids, which eventually\\nwill reduce their need for bronchodilators. However, a\\n2004 Canadian study has questioned a standard practice\\nof increasing steroids aftera s t h m aa t t a c k so rw o r s e n e d\\nsymptoms. Also, research in 2004 showed that people\\nwith asthma who worked closely with their physicians to\\nself-manage their asthma had fewer attacks, which\\nreduces the need for bronchodilators. Carefully mana-\\nging asthma also reduces visits to the emergency depart-\\nment and hospitalizations.\\nCorticosteroids are powerful drugs that may\\ncause serious side effects when used over a long time.\\nHowever, these problems are much less likely with the\\ninhalant forms than with the oral and injected forms.\\nWhile the oral and injected forms generally should be\\nused only for one to two weeks, the inhalant forms\\nmay be used for long periods.\\nIt is important to remember that leukotriene modi-\\nfiers are used to prevent and manage asthma, not to\\nstop an attack. A physician or pharmacist can advise\\npatients on possible interactions with other drugs.\\nPatients who are using their antiasthmatic drugs\\ncorrectly but feel their asthma is not under control\\nshould see their physicians. The physician can either\\nincrease the dose, switch to another medicine or add\\nanother medicine to the regimen. A 2004 survey\\nshowed that 70% of people with mild to moderate\\nasthma were not taking the correct dose of asthma\\nmedication.\\nWhen used to prevent asthma attacks, cromolyn\\nmust be taken as directed every day. The drug may\\ntake as long as four weeks to start working. Unless\\ntold to do so by a physician, patients should not stop\\ntaking the drug just because it does not seem to be\\nworking. When symptoms do begin to improve,\\npatients should continue taking all medicines that\\nhave been prescribed, unless a physician directs\\notherwise.\\nSide effects\\nInhalant forms of antiasthmatic drugs may cause\\ndryness or irritation in the throat,dry mouth,o ra n\\nunpleasant taste in the mouth. To help prevent these\\nproblems, gargling and rinsing the mouth or taking a\\nsip of water after each dose is recommended.\\nMore serious side effects are not common when\\nthese medicines are used properly. However, anyone\\nwho has unusual or bothersome symptoms after tak-\\ning an antiasthmatic drug should get in touch with a\\nphysician.\\nInteractions\\nA physician or pharmacist should be consulted\\nbefore combining antiasthmatic drugs with any other\\nprescription or nonprescription (over-the-counter)\\nmedicine.\\nResources\\nPERIODICALS\\n‘‘Many People With Asthma Areno´ t Taking the Right\\nAmount of Medication.’’Obesity, Fitness & Wellness\\nWeek (September 25, 2004): 87.\\n‘‘Study Calls Standard Asthma Management Into Doubt.’’\\nDoctor (July 15, 2004): 4.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntibacterial bath see Therapeutic baths\\n264 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiasthmatic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 294, 'page_label': '265'}, page_content='Antibiotic-associated colitis\\nDefinition\\nAntibiotic-associated colitis is an inflammation of\\nthe intestines that sometimes occurs following antibio-\\ntic treatment and is caused by toxins produced by the\\nbacterium Clostridium difficile.\\nDescription\\nAntibiotic-associated colitis, also called antibiotic-\\nassociated enterocolitis, can occur following antibiotic\\ntreatment. The bacteriaClostridia difficileare normally\\nfound in the intestines of 5% of healthy adults, but\\npeople can also pick up the bacteria while they are in a\\nhospital or nursing home. In a healthy person, harmless\\nresident intestinal bacteria compete with each other for\\nfood and places to ‘‘sit’’ along the inner intestinal wall.\\nWhen antibioticsare given, most of the resident bacteria\\nare killed. With fewer bacteria to compete with, the\\nnormally harmlessClostridia difficilegrow rapidly and\\nproduce toxins. These toxins damage the inner wall of\\nthe intestines and cause inflammation anddiarrhea.\\nAlthough all antibiotics can cause this disease, it is\\nmost commonly caused by clindamycin (Cleocin), ampi-\\ncillin (Omnipen), amoxicillin (Amoxil, Augmentin, or\\nWymox), and any in the cephalosporin class (such as\\ncefazolin or cephalexin). Symptoms of the condition can\\noccur during antibiotic treatment or within four weeks\\nafter the treatment has stopped.\\nIn approximately half of cases of antibiotic-asso-\\nciated colitis, the condition progresses to a more severe\\nform of colitis called pseudomembranous enterocolitis\\nin which pseudomembranes are excreted in the stools.\\nPseudomembranes are membrane-like collections of\\nwhite blood cells, mucus, and the protein that causes\\nblood to clot (fibrin) that are released by the damaged\\nintestinal wall.\\nCauses and symptoms\\nAntibiotic-associated colitis is caused by toxins\\nproduced by the bacteriumClostridium difficile after\\ntreatment with antibiotics. When most of the other\\nintestinal bacteria have been killed,Clostridium diffi-\\ncile grows rapidly and releases toxins that damage the\\nintestinal wall. The disease and symptoms are caused\\nby these toxins, not by the bacterium itself.\\nSymptoms of antibiotic-associated colitis usually\\nbegin four to ten days after antibiotic treatment has\\nbegun. The early signs and symptoms of this disease\\ninclude lower abdominal cramps, an increased need to\\npass stool, and watery diarrhea. As the disease pro-\\ngresses, the patient may experience a general ill feeling,\\nfatigue, abdominalpain, andfever. If the disease pro-\\nceeds to pseudomembranous enterocolitis, the patient\\nmay also experiencenausea, vomiting, large amounts\\nof watery diarrhea, and a very high fever (104-1058F/\\n40-40.5 8C). Complications of antibiotic-associated\\ncolitis include severe dehydration, imbalances in\\nblood minerals, low blood pressure, fluid accumula-\\ntion in deep skin (edema), enlargement of the large\\nintestine (toxic megacolon), and the formation of a\\ntear (perforation) in the wall of the large intestine.\\nThe Clostridium difficile toxin is found in the\\nstools of persons older than 60 years of age 20-100\\ntimes more frequently than in the stools of persons\\nwho are 10-20 years old. As a result, the elderly are\\nmuch more prone to developing antibiotic-associated\\ncolitis than younger individuals.\\nDiagnosis\\nAntibiotic-associated colitis can be diagnosed by\\nthe symptoms and recent medical history of the\\npatient, by a laboratory test for the bacterial toxin,\\nand/or by using a procedure called endoscopy.\\nIf the diarrhea and related symptoms occurred after\\nthe patient received antibiotics, antibiotic-associated\\ncolitis may be suspected. A stool sample may be analyzed\\nfor the presence of theClostridium difficiletoxin. This\\ntoxin test is the preferred diagnostic test for antibiotic-\\nassociated colitis. One frequently used test for the toxin\\ninvolves adding the processed stool sample to a human\\ncell culture. If the toxin is present in the stool sample, the\\ncells die. It may take up to two days to get the results\\nKEY TERMS\\nColitis— Inflammation of the colon.\\nEdema— Fluid accumulation in a tissue.\\nEndoscopy— A procedure in which a thin, lighted\\ninstrument is inserted into the interior of a hollow\\norgan, such as the rectum and used to visually\\ninspect the inner intestinal lining.\\nFibrin— A fibrous blood protein vital to coagulation\\nand blood clot formation.\\nRectum— The last part of the intestine. Stool passes\\nthrough the rectum and out through the anal\\nopening.\\nToxic megacolon— Acute enlargement or dilation\\nof the large intestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 265\\nAntibiotic-associated colitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 295, 'page_label': '266'}, page_content='from this test. A simpler test, which provides results in\\ntwo to three hours, is also available. Symptoms and toxin\\ntest results are usually enough to diagnose the disease.\\nAnother tool that may be useful in the diagnosis\\nof antibiotic-associated colitis, however, is a proce-\\ndure called an endoscopy that involves inserting a\\nthin, lighted tube into the rectum to visually inspect\\nthe intestinal lining. Two different types of endoscopy\\nprocedures, the sigmoidoscopy and the colonoscopy,\\nare used to view different parts of the large intestine.\\nThese procedures are performed in a hospital or doc-\\ntor’s office. Patients are sedated during the procedure\\nto make them more comfortable and are allowed to go\\nhome after recovering from thesedation.\\nTreatment\\nDiarrhea, regardless of the cause, is always treated\\nby encouraging the individual to replace lost fluids and\\nprevent dehydration. One method to treat antibiotic-\\nassociated colitis is to simply stop taking the antibiotic\\nthat caused the disease. This allows the normal intest-\\ninal bacteria to repopulate the intestines and inhibits\\nthe overgrowth ofClostridium difficile.M a n yp a t i e n t s\\nwith mild disease respond well to this and are free from\\ndiarrhea within two weeks. It is important, however, to\\nmake sure that the original disease for which the anti-\\nbiotics were prescribed is treated.\\nBecause of the potential seriousness of this disease,\\nmost patients are given another antibiotic to control the\\ngrowth of theClostridium difficile, usually vancomycin\\n(Vancocin) or metronidazole (Flagyl or Protostat). Both\\nare designed to be taken orally four times a day for 10-14\\ndays. Upon finishing antibiotic treatment, approxi-\\nmately 15-20% of patients will experience a relapse of\\ndiarrhea within one to five weeks. Mild relapses can go\\nuntreated with great success, however, severe relapses of\\ndiarrhea require another round of antibiotic treatment.\\nInstead of further antibiotic treatment, a cholestyramine\\nresin (Questran or Prevalite) may be given. The bacterial\\ntoxins produced in the intestine stick to the resin and are\\npassed out with the resin in the stool. Unfortunately,\\nhowever, vancomycin also sticks to the resin, so these\\ntwo drugs cannot be taken at the same time. Serious\\ndisease may require hospitalization so that the patient\\ncan be monitored, treated, and rehydrated.\\nAlternative treatment\\nThe goal of alternative treatment for antibiotic-\\nassociated enterocolitis is to repopulate the intestinal\\nenvironment with microorganisms that are normal and\\nhealthy for the intestinal tract. These microorgansisms\\nthen compete for space and keep the Clostridium\\ndifficile from over-populating.\\nSeveral types of supplements can be used.\\nSupplements containingLactobacillus acidophilus,t h e\\nbacteria commonly found in yogurt and some types of\\nmilk, Lactobacillus bifidus,a n dStreptococcus faecium,\\nare available in many stores in powder, capsule, tablet,\\nand liquid form.Acidophilus also acts as a mild anti-\\nbiotic, which helps it to reestablish itself in the intestine,\\nand all may aid in the production of some Bvitamins\\nand vitamin K. These supplements can be taken indivi-\\ndually and alternated weekly or together following one\\nor more courses of antibiotics.\\nPrognosis\\nWith appropriate treatment and replenishment of\\nfluids, the prognosis is generally excellent. One or more\\nrelapses can occur. Very severe colitis can cause a tear\\n(perforation) in the wall of thelarge intestine that would\\nrequire major surgery. Perforation of the intestine can\\ncause a serious abdominal infection. Antibiotic-asso-\\nciated colitis can be fatal in people who are elderly\\nand/or have a serious underlying illness, such ascancer.\\nPrevention\\nThere are no specific preventative measures for this\\ndisease. Good general health can reduce the chance of\\ndeveloping a bacterial infection that would require anti-\\nbiotic treatment and the chance of picking up the\\nClostridia bacteria. Maintaining good general health\\ncan also reduce the seriousness and length of the con-\\ndition, should it develop following antibiotic therapy.\\nResources\\nOTHER\\nMayo Clinic Online.March 5, 1998. .\\nBelinda Rowland, PhD\\nAntibiotic prophylaxis see Prophylaxis\\nAntibiotics\\nDefinition\\nAntibiotics may be informally defined as the sub-\\ngroup of anti-infectives that are derived from bacterial\\nsources and are used to treat bacterial infections.\\nOther classes of drugs, most notably thesulfonamides,\\n266 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 296, 'page_label': '267'}, page_content='may be effective antibacterials. Similarly, some anti-\\nbiotics may have secondary uses, such as the use of\\ndemeclocycline (Declomycin, a tetracycline deriva-\\ntive) to treat the syndrome of inappropriate antidiure-\\ntic hormone (SIADH) secretion. Other antibiotics\\nmay be useful in treating protozoal infections.\\nPurpose\\nAntibiotics are used for treatment or prevention\\nof bacterial infection.\\nDescription\\nClassifications\\nAlthough there are several classification schemes\\nfor antibiotics, based on bacterial spectrum (broad\\nversus narrow) or route of administration (injectable\\nversus oral versus topical), or type of activity (bacter-\\nicidal vs. bacteriostatic), the most useful is based on\\nchemical structure. Antibiotics within a structural\\nclass will generally show similar patterns of effective-\\nness, toxicity, and allergic potential.\\nPENICILLINS. The penicillins are the oldest class of\\nantibiotics, and have a common chemical structure\\nwhich they share with the cephalopsorins. The two\\ngroups are classed as the beta-lactam antibiotics, and\\nare generally bacteriocidal—that is, they kill bacteria\\nrather than inhibiting growth. The penicillins can be\\nfurther subdivided. The natural pencillins are based on\\nthe original penicillin G structure; penicillinase-resistant\\npenicillins, notably methicillin and oxacillin, are active\\neven in the presence of the bacterial enzyme that inacti-\\nvates most natural penicillins. Aminopenicillins such as\\nampicillin and amoxicillin have an extended spectrum\\nof action compared with the natural penicillins;\\nextended spectrum penicillins are effective against a\\nwider range of bacteria. These generally include cover-\\nage forPseudomonas aeruginaosaand may provide the\\npenicillin in combination with a penicillinase inhibitor.\\nCEPHALOSPORINS. Cephalosporins and the closely\\nrelated cephamycins and carbapenems, like the pencil-\\nlins, contain a beta-lactam chemical structure.\\nConsequently, there are patterns of cross-resistance\\nand cross-allergenicity among the drugs in these\\nclasses. The ‘‘cepha’’ drugs are among the most diverse\\nclasses of antibiotics, and are themselves subgrouped\\ninto 1st, 2nd and 3rd generations. Each generation has\\na broader spectrum of activity than the one before. In\\naddition, cefoxitin, a cephamycin, is highly active\\nagainst anaerobic bacteria, which offers utility in treat-\\nment of abdominal infections. The 3rd generation\\ndrugs, cefotaxime, ceftizoxime, ceftriaxone and others,\\ncross the blood-brain barrier and may be used to treat\\nmeningitis and encephalitis. Cephalopsorins are the\\nusually preferred agents for surgicalprophylaxis.\\nFLUROQUINOLONES. The fluroquinolones are syn-\\nthetic antibacterial agents,and not derived from bacteria.\\nThey are included here because they can be readily inter-\\nchanged with traditional antibiotics. An earlier, related\\nclass of antibacterial agents, the quinolones, were not\\nwell absorbed, and could be used only to treat urinary\\ntract infections. The fluroquinolones, which are based\\non the older group, are broad-spectrum bacteriocidal\\ndrugs that are chemically unrelated to the penicillins or\\nthe cephaloprosins. They are well distributed into bone\\ntissue, and so well absorbed that in general they are as\\neffective by the oral route as by intravenous infusion.\\nTETRACYCLINES. Tetracyclines got their name\\nbecause they share a chemical structure that has four\\nrings. They are derived from a species ofStreptomyces\\nbacteria. Broad-spectrum bacteriostatic agents, the tetra-\\ncyclines may be effective against a wide variety of micro-\\norganisms, including rickettsia and amoebic parasites.\\nMACROLIDES. The macrolide antibiotics are\\nderived from Streptomyces bacteria, and got their\\nname because they all have a macrocyclic lactone\\nchemical structure. Erythromycin, the prototype of\\nthis class, has a spectrum and use similar to penicillin.\\nNewer members of the group, azithromycin and\\nclarithyromycin, are particularly useful for their high\\nA penicillin culture. (Photograph by P. Barber, Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 267\\nAntibiotics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 297, 'page_label': '268'}, page_content='level of lung penetration. Clarithromycin has been\\nwidely used to treat Helicobacter pylori infections,\\nthe cause of stomach ulcers.\\nOTHERS. Other classes of antibiotics include the\\naminoglycosides, which are particularly useful for\\ntheir effectiveness in treatingPseudomonas aeruginosa\\ninfections; the lincosamindes, clindamycin and linco-\\nmycin, which are highly active against anaerobic\\npathogens. There are other, individual drugs which\\nmay have utility in specific infections.\\nRecommended dosage\\nDosage varies with drug, route of administration,\\npathogen, site of infection, and severity. Additional\\nconsiderations include renal function, age of patient,\\nand other factors. Consult manufacturers’ recommen-\\ndations for dose and route.\\nSide effects\\nAll antibiotics cause risk of overgrowth by non-\\nsusceptible bacteria. Manufacturers list other major\\nhazards by class; however, the health care provider\\nshould review each drug individually to assess the degree\\nof risk. Generally, breastfeeding is not recommended\\nwhile taking antibiotics because of risk of alteration to\\nAntibiotic\\nWater enters Cell deteriorates\\nCell is destroyed\\nDifferent antibiotics destroy bacteria in different ways. Some short-circuit the processes by which bacteria receive energy.\\nOthers disturb the structure of the bacterial cell wall, as shown in the illustration above. Still others interfere with the production\\nof essential proteins. (Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMeningitis— Inflammation of tissues that surround\\nthe brain and spinal cord.\\nMicroorganism— An organism that is too small to\\nbe seen with the naked eye.\\nOrganism— A single, independent unit of life, such\\nas a bacterium, a plant or an animal.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\n268 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 298, 'page_label': '269'}, page_content='infant’s intestinal flora, and risk of masking infection in\\nthe infant. Excessive or inappropriate use may promote\\ngrowth of resistant pathogens.\\nPenicillins: Hypersensitivity may be common, and\\ncross allergenicity with cephalosporins has been reported.\\nPenicillins are classed as category B duringpregnancy.\\nCephalopsorins: Several cephalopsorins and\\nrelated compounds have been associated with seizures.\\nCefmetazole, cefoperazone, cefotetan and ceftriaxone\\nmay be associated with a fall in prothrombin activity\\nand coagulation abnormalities. Pseudomembranous\\ncolitis has been reported with cephalosporins and\\nother broad spectrum antibiotics. Some drugs in this\\nclass may cause renal toxicity. Pregnancy category B.\\nFluroquinolones: Lomefloxacin has been associated\\nwithincreasedphotosensitivity.Alldrugsinthisclasshave\\nbeen associated with convulsions. Pregnancy category C.\\nTetracyclines: Demeclocycline may cause increased\\nphotosensitivity. Minocycline may cause dizziness.\\nDo not use tetracyclines in children under the age of\\neight, and specifically avoid during periods of tooth\\ndevelopment. Oral tetracyclines bind to anions such as\\ncalcium and iron. Although doxycycline and minocy-\\ncline may be taken with meals, patients must be advised\\nto take other tetracycline antibiotics on an empty sto-\\nmach, and not to take the drugs with milk or other\\ncalcium-rich foods. Expired tetracycline should never\\nbe administered. Pregnancy category D. Use during\\npregnancy may cause alterations in bone development.\\nMacrolides: Erythromycin may aggravate the weak-\\nness of patients withmyasthenia gravis.A z i t h r o m y c i n\\nhas, rarely, been associated with allergic reactions,\\nincluding angioedema,anaphylaxis, and dermatologic\\nreactions, including Stevens-Johnson syndrome and\\ntoxic epidermal necrolysis.O r a le r y t h r o m y c i nm a yb e\\nhighly irritating to the stomach and when given by\\ninjection may cause severe phlebitis. These drugs should\\nbe used with caution in patients with liver dysfunction.\\nPregnancy category B: Azithromycin, erythro-\\nmycin. Pregnancy category C: Clarithromycin, dirithro-\\nmycin, troleandomycin.\\nAminoglycosides: This class of drugs causes kid-\\nney and ototoxicity. These problems can occur even\\nwith normal doses. Dosing should be based on renal\\nfunction, with periodic testing of both kidney function\\nand hearing. Pregnancy category D.\\nRecommended usage\\nTo minimize risk of adverse reactions and develop-\\nment of resistant strains of bacteria, antibiotics should\\nbe restricted to use in cases where there is either known\\nor a reasonable presumption of bacterial infection. The\\nuse of antibiotics in viral infections is to be avoided.\\nAvoid use of fluroquinolones for trivial infections.\\nIn severe infections, presumptive therapy with a\\nbroad-spectrum antibiotic such as a 3rd generation\\ncephalosporin may be appropriate. Treatment should\\nbe changed to a narrow spectrum agent as soon as the\\npathogen has been identified. After 48 hours of treat-\\nment, if there is clinical improvement, an oral antibio-\\ntic should be considered.\\nResources\\nPERIODICALS\\n‘‘Consumer Alert: Antibiotic Resistance Is Growing!’’\\nPeople’s Medical Society Newsletter16 (August 1997): 1.\\nSamuel D. Uretsky, PharmD\\nAntibiotics, ophthalmic\\nDefinition\\nOphthalmic antibiotics are medicines that kill bac-\\nteria that cause eye infections.\\nPurpose\\nOphthalmic antibiotics are applied to the eye, or\\nundertheeyelid,totreateyeinf ectionscausedbybacteria.\\nDescription\\nThe medicine described here, tobramycin\\n(Tobrex), comes in the form of eye drops or ointment.\\nIt is available only with a physician’s prescription.\\nRecommended dosage\\nThe dosages given here are typical doses. Physicians\\nmay adjust the number of doses per day, the time\\nbetween doses, and the length of treatment with the\\nmedicine, depending on the patient’s particular medical\\nproblem. If the physician’s directions are different\\nfrom those given here, follow the physician’s directions.\\nAdults\\nEYE DROPS. Formildtomoderateinfections,useone\\nto two drops in the affected eye or eyes every four hours.\\nFor severe infections, use two drops in the affected\\neye or eyes every two hours until the condition improves.\\nGALE ENCYCLOPEDIA OF MEDICINE 269\\nAntibiotics, ophthalmic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 299, 'page_label': '270'}, page_content='At that time, the physician will determine how much\\nto use until the infection is completely cleared up.\\nOINTMENT. For mild to moderate infections,\\nsqueeze a half-inch ribbon of ointment into the\\naffected eye or eyes two or three times a day. Do not\\nlet the tip of the ointment tube touch the eye.\\nFor severe infections, squeeze a half-inch ribbon\\nof ointment into the affected eye or eyes every three to\\nfour hours until the condition improves. At that time,\\nthe physician will determine how much to use until the\\ninfection is completely cleared up.\\nChildren\\nThe child’s physician should determine the proper\\ndose.\\nPrecautions\\nUse this drug as often as directed, for as long as\\ndirected. Although the symptoms may have disap-\\npeared, the infection may not clear up completely if\\nthe drug is stopped too soon. Therefore, the medica-\\ntion may be prescribed for several days after the infec-\\ntion appears to have cleared. However, it is just as\\nimportant to use the drug foronly as long as directed.\\nUsing it for too long may lead to the growth of bac-\\nteria that do not respond to the drug. These bacteria\\nmay then cause infections that can be very difficult to\\ntreat. Make sure the physician or pharmacist specifies\\nhow long the medication is to be used.\\nAnyone who has had an allergic reaction to tobra-\\nmycin or any other ingredients of Tobrex should not\\nuse this medicine. Be sure to tell the physician about\\nany past reactions to the drug or its ingredients.\\nAnyone who has an allergic reaction to tobramycin\\nshould stop using it immediately and call a physician.\\nWomen who are pregnant or breastfeeding or who\\nplan to become pregnant should check with their phy-\\nsicians before using tobramycin.\\nSide effects\\nThe main side effects of this medicine areitching,\\nredness, and swelling of the eye or eyelid. Allergic\\nreactions also are possible. If any of these symptoms\\noccur, call the physician who prescribed the medicine.\\nInteractions\\nPatients who are using any other prescription or\\nnonprescription (over-the-counter) medicines in their\\neyes should check with their physicians before using\\ntobramycin.\\nNancy Ross-Flanigan\\nAntibiotics, topical\\nDefinition\\nTopical antibiotics are medicines applied to the\\nskin to kill bacteria.\\nPurpose\\nTopical antibiotics help prevent infections caused\\nby bacteria that get into minor cuts, scrapes, and\\nburns. Treating minorwounds with antibiotics allows\\nquicker healing. If the wounds are left untreated, the\\nbacteria will multiply, causingpain, redness, swelling,\\nitching, and oozing. Untreated infections can even-\\ntually spread and become much more serious.\\nDifferent kinds of topical antibiotics kill different\\nkinds of bacteria. Many antibiotic first-aid products\\ncontain combinations of antibiotics to make them\\neffective against a broad range of bacteria.\\nWhen treating a wound, it is not enough to simply\\napply a topical antibiotic. The wound must first be\\ncleaned with soap and water and patted dry. After the\\nantibiotic is applied, the wound should be covered\\nwith a dressing, such as a bandage or a protective gel\\nor spray. For many years, it was thought that wounds\\nheal best when exposed to the air. But now most\\nexperts say it is best to keep wounds clean and moist\\nwhile they heal. The covering should still allow some\\nair to reach the wound, however.\\nDescription\\nSome topical antibiotics are available without a\\nprescription and are sold in many forms, including\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nOintment— A thick, spreadable substance that con-\\ntains medicine and is meant to be used on the skin,\\nor, if it is specifically an ophthalmic, or ‘‘eye’’ oint-\\nment, in the eye\\n270 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics, topical'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 300, 'page_label': '271'}, page_content='creams, ointments, powders, and sprays. Some widely\\nused topical antibiotics are bacitracin, neomycin,\\nmupirocin, and polymyxin B. Among the products\\nthat contain one or more of these ingredients are\\nBactroban (a prescription item), Neosporin,\\nPolysporin, and Triple Antibiotic Ointment or Cream.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\ntopical antibiotic. Follow the directions on the pack-\\nage label or ask a pharmacist for directions.\\nIn general, topical antibiotics should be applied\\nwithin four hours after injury. Do not use more than\\nthe recommended amount and do not apply it more\\noften than three times a day. Do not apply the medi-\\ncine over large areas of skin or on open wounds.\\nPrecautions\\nMany public health experts are concerned about\\nantibiotic resistance, a problem that can develop when\\nantibiotics are overused. Over time, bacteria develop\\nnew defenses against antibiotics that once were effective\\nagainst them. Because bacteria reproduce so quickly,\\nthese defenses can be rapidly passed on through gen-\\nerations of bacteria until almost all are immune to the\\neffects of a particular antibiotic. The process happens\\nfaster than new antibiotics can be developed. To help\\ncontrol the problem, many experts advise people to use\\ntopical antibiotics only for short periods, that is, until\\nthe wound heals, and only as directed. For the topical\\nantibiotic to work best, it should be used only to pre-\\nvent infection in a fresh wound, not to treat an infection\\nthat has already started. Wounds that are not fresh may\\nneed the attention of a physician to prevent complica-\\ntions such as bloodpoisoning.\\nTopical antibiotics are meant to be used only on\\nthe skin and only for only a few days at a time. If the\\nwound has not healed in five days, stop using the\\nantibiotic and call a doctor.\\nDo not use topical antibiotics on large areas of skin\\nor on open wounds. These products should not be used\\nto treatdiaper rashin infants or incontinence rash in\\nadults.\\nOnly minor cuts, scrapes, and burns should be\\ntreated with topical antibiotics. Certain kinds of inju-\\nries may need medical care and should not be self-\\ntreated with topical antibiotics. These include:\\n/C15large wounds\\n/C15deep cuts\\n/C15cuts that continue bleeding\\n/C15cuts that may need stitches\\n/C15burns any larger than a few inches in diameter\\n/C15scrapes imbedded with particles that won’t wash\\naway\\n/C15animal bites\\n/C15deep puncture wounds\\n/C15eye injuries\\nNever use regular topical antibiotics in the eyes.\\nSpecial antibiotic products are available for treating\\neye infections.\\nAlthough topical antibiotics control infections\\ncaused by bacteria, they may allow fungal infections\\nto develop. The use of other medicines to treat the\\nfungal infections may be necessary. Check with the\\nphysician or pharmacist.\\nSome people may be allergic to one or more ingre-\\ndients in a topical antibiotic product. If an allergic\\nreaction develops, stop using the product immediately\\nand call a physician.\\nNo harmful or abnormal effects have been\\nreported in babies whose mothers used topical anti-\\nbiotics while pregnant or nursing. However, pregnant\\nwomen generally are advised not to use any drugs\\nduring the first 3 months after conception. A woman\\nwho is pregnant or breastfeeding or who plans to\\nbecome pregnant should check with her physician\\nbefore using a topical antibiotic.\\nUnless a physician says to do so, do not use topi-\\ncal antibiotics on children under two years of age.\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nConception— The union of egg and sperm to form a\\nfetus.\\nFungal— Caused by a fungus.\\nFungus— A member of a group of simple organisms\\nthat are related to yeast and molds.\\nIncontinence— The inability to control the bladder\\nor bowel.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nGALE ENCYCLOPEDIA OF MEDICINE 271\\nAntibiotics, topical'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 301, 'page_label': '272'}, page_content='Side effects\\nThe most common minor side effects are itching\\nor burning. These problems usually do not require\\nmedical treatment unless they do not go away or they\\ninterfere with normal activities.\\nIf any of the following side effects occur, check\\nwith a doctor as soon as possible:\\n/C15rash\\n/C15swelling of the lips and face\\n/C15sweating\\n/C15tightness or discomfort in the chest\\n/C15breathing problems\\n/C15fainting ordizziness\\n/C15low blood pressure\\n/C15nausea\\n/C15diarrhea\\n/C15hearing loss or ringing in the ears\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after using a topical antibio-\\ntic should get in touch with the physician who pre-\\nscribed or the pharmacist who recommedned the\\nmedication.\\nInteractions\\nUsing certain topical antibiotics at the same time\\nas hydrocortisone (a topical corticosteroid used to\\ntreat inflammation) may hide signs of infection or\\nallergic reaction. Do not use these two medicines at\\nthe same time unless told to do so by a health care\\nprovider.\\nAnyone who is using any other type of prescrip-\\ntion or nonprescription (over-the-counter) medicine\\non the skin should check with a doctor before using a\\ntopical antibiotic.\\nResources\\nPERIODICALS\\nFarley, Dixie. ‘‘Help for Cuts, Scrapes and Burns.’’FDA\\nConsumer May 1996:12.\\nNancy Ross-Flanigan\\nAntibody screening see Blood typing and\\ncrossmatching\\nAnticancer drugs\\nDefinition\\nAnticancer, or antineoplastic, drugs are used to\\ntreat malignancies, or cancerous growths. Drug\\ntherapy may be used alone, or in combination with\\nother treatments such as surgery orradiation therapy.\\nPurpose\\nAnticancer drugs are used to control the growth of\\ncancerous cells. Cancer is commonly defined as the\\nuncontrolled growth of cells, with loss of differentia-\\ntion and commonly, with metastasis, spread of the\\ncancer to other tissues and organs. Cancers are malign-\\nant growths. In contrast, benign growths remain\\nencapsulated and grow within a well-defined area.\\nAlthough benign tumors may be fatal if untreated,\\ndue to pressure on essential organs, as in the case of a\\nbenign brain tumor, surgery or radiation are the pre-\\nferred methods of treating growths which have a well\\ndefined location. Drug therapy is used when the tumor\\nhas spread, or may spread, to all areas of the body.\\nDescription\\nSeveral classes of drugs may be used in cancer\\ntreatment, depending on the nature of the organ\\ninvolved. For example, breast cancers are commonly\\nstimulated by estrogens, and may be treated with\\ndrugs that inactivate the sex hormones. Similarly,\\nprostate cancermay be treated with drugs that inacti-\\nvate androgens, the male sex hormone. However, the\\nmajority of antineoplastic drugs act by interfering\\nwith cell growth. Since cancerous cells grow more\\nrapidly than other cells, the drugs target those cells\\nthat are in the process of reproducing themselves. As a\\nresult, antineoplastic drugs will commonly affect not\\nonly the cancerous cells, but others cells that com-\\nmonly reproduce quickly, including hair follicles,\\novaries and testes, and the blood-forming organs.\\nNewer methods of antineoplastic drug therapy\\nhave taken different approaches, including angiogen-\\nesis—the inhibition of formation of blood vessels feed-\\ning the tumor and contributing to tumor growth.\\nAlthough these approaches hold promise, they are\\nnot yet in common use. Developing new anticancer\\ndrugs is the work of ongoing research. In 2003, a new\\ntechnique was developed to streamline the search for\\neffective drugs. Researchers pumped more than 23,000\\nchemical compounds through a screening technique to\\nidentify those that help fight cancer while leaving\\n272 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticancer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 302, 'page_label': '273'}, page_content='healthy cells unharmed. The system identified nine\\ncompounds matching the profile, including one pre-\\nviously unidentified drug for fighting cancer. They\\nhave expanded their research to determine how the\\ndrug might be developed. This was an important step\\nAnti Cancer Drugs\\nGeneric (Brand Name) Clinical Uses\\nCommon Side\\nEffects To Drug\\nAltretamine(Hexalen) Treatment of\\nadvanced ovarian\\ncancer\\nBone marrow\\ndepression, nausea\\nand vomiting\\nAsparaginase(Elspar) Commonly used in\\ncombination with\\nother drugs; refrac-\\ntory acute lymphocy-\\ntic leukemia\\nLiver, kidney,\\npancreas, CNS\\nabnormalities,\\nBleomycin(Blenoxane) Lymphomas,\\nHodgkin’s disease,\\ntesticular cancer\\nHair loss, stomatitis,\\npulmonary toxicity,\\nhyperpigmentation\\nof skin\\nBusulfan(Myleran) Chronic granulocytic\\nleukemia\\nBone marrow\\ndepression,\\npulmonary toxicity\\nCarboplatin(Paraplatin) Pallilation of ovarian\\ncancer\\nBone marrow\\ndepression, nausea\\nand vomiting\\nCarmustine Hodgkin’s disease,\\nbrain tumors, multi-\\nple myeloma, malig-\\nnant melonoma\\nBone marrow\\ndepression, nausea\\nand vomiting, toxic\\ndamage to liver\\nChlorambucil(Leukeran) Chronic lymphocytic\\nleukemia, non-\\nHodgkin’s\\nlymphomas, breast\\nand ovarian cancer\\nBone marrow\\ndepression, excess\\nuric acid in blood\\nCisplatin(Platinol) Treatment of bladder,\\novarian,\\nuterine, testicular,\\nhead and neck\\ncancers\\nRenal toxicity and\\nototoxicity\\nCladribine(Leustatin) Hairy cell leukemia Bone marrow\\ndepression, nausea\\nand vomiting, fever\\nCyclophosphamide\\n(Cytoxan)\\nHodgkin’s disease,\\nnon-Hodgkin’s lym-\\nphomas, neuroblas-\\ntoma. Often used\\nwith other drugs for\\nbreast, ovarian, and\\nlung cancers; acute\\nlymphoblastic leuke-\\nmia in children; mul-\\ntiple myeloma\\nBone marrow\\ndepression, hair loss,\\nnausea and vomiting,\\ninflammation of the\\nbladder\\nCytarabine(Cytosar-U) Leukemias occurring\\nin adults and children\\nBone marrow\\ndepression, nausea\\nand vomiting,\\ndiarrhea, stomatitis\\nDacarbazine(DTIC-\\nDome)\\nHodgkin’s disease,\\nmalignant melanoma\\nBone marrow\\ndepression, nausea\\nand vomiting\\nDiethylstilbestrol (DES)\\n(Stilbestrol)\\nBreast cancer in\\npost-menopausal\\nwomen, prostate\\ncancer\\nHair loss, nausea and\\nvomiting, edema,\\nexcess calcium in\\nblood; feminizing\\neffects in men\\nEthinyl\\nestradiol(Estinyl)\\nAdvanced breast\\ncancer in post-\\nmenopausal women,\\nprostate cancer\\nExcess calcium in\\nblood, anorexia,\\nedema, nausea and\\nvomiting; feminizing\\neffects in men\\nEtoposide(VePesid) Acute leukemias,\\nlymphomas, testicu-\\nlar cancer\\nBone marrow\\ndepression, nausea\\nand vomiting, hair loss\\nAnti Cancer Drugs (continued)\\nGeneric (Brand Name) Clinical Uses\\nCommon Side\\nEffects To Drug\\nMitomycin (Mutamycin) Bladder, breast,\\ncolon, lung,\\npancreas, rectum\\ncancers, head and\\nneck cancer, malig-\\nnant melanoma\\nBone marrow\\ndepression, nausea\\nand vomiting,\\ndiarrhea, stomatitis,\\npossible tissue\\ndamage\\nMitotane (Lysodren) Cancer of the adrenal\\ncortex (inoperable)\\nDamage to adrenal\\ncortex, nausea,\\nanorexia\\nMitoxantrone (Novantrone) Acute nonlymphocy-\\ntic leukemia\\nCardiac arrhythmias,\\nlabored breating,\\nnausea and vomiting,\\ndiarrhea, fever,\\ncongestive heart\\nfailure\\nPaclitaxel (Taxol) Advanced ovarian\\ncancer\\nBone marrow\\ndepression, hair loss,\\nnausea and vomiting,\\nhypotension, allergic\\nreactions, slow heart\\naction, muscle and\\njoint pain\\nPentastatin (Nipent) Hairy cell leukemia\\nunresponsive to\\nalpha-interferon\\nBone marrow\\ndepression, fever,\\nskin rash, liver\\ndamage, nausea and\\nvomiting\\nPipobroman (Vercyte) Chronic granulocytic\\nleukemia\\nBone marrow\\ndepression\\nPlicamycin (Mithracin) Testucular tumors Toxicity/damage\\nto bone marrow,\\nkidneys, and liver\\nPrednisone (Meticorten) Used in adjunct ther-\\napy for palliation of\\nsymptoms in lympho-\\nmas, acute leukemia\\nHodgkin’s disease\\nMay be toxic to all\\nbody systems\\nProcarbazine (Matulane) Hodgkin’s disease Bone marrow\\ndepression, nausea\\nand vomiting\\nStreptozocin (Zanosar) Islet cell carcinoma of\\npancreas\\nNausea and vomiting,\\ntoxicity to kidneys\\nTamoxifen (Nolvadex) Advanced breast can-\\ncer in post\\nmenopausal\\nNausea and vomiting,\\nocular toxicity, hot\\nflashes\\nTeniposide (Vumon) Acute lymphocytic\\nleukemia in children\\nSee Etoposide\\nVinblastine (Velban) Breast cancer,\\nHodgkin’s disease,\\nmetastatic testicular\\ncancer\\nBone marrow\\ndepression,\\nneurotoxicity\\nVincristine (Oncovin) Acute leukemia,\\nHodgkin’s disease,\\nlymphomas\\nConstipation,\\nneurotoxicity,\\npossible tissue\\nnecrosis\\nGALE ENCYCLOPEDIA OF MEDICINE 273\\nAnticancer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 303, 'page_label': '274'}, page_content='in identifying anticancer dugs that are not completely\\ntoxic to healthy cells.\\nAntineoplastic drugs may be divided into two\\nclasses: cycle specific and non-cycle specific. Cycle\\nspecific drugs act only at specific points of the cell’s\\nduplication cycle, such as anaphase or metaphase,\\nwhile non-cycle specific drugs may act at any point in\\nthe cell cycle. In order to gain maximum effect, anti-\\nneoplastic drugs are commonly used in combinations.\\nPrecautions\\nBecause antineoplastic agents do not target spe-\\ncific cell types, they have a number of common\\nadverse side effects. Hair loss is common due to the\\neffects on hair follicles, and anemia, immune system\\nimpairment, and clotting problems are caused by\\ndestruction of the blood-forming organs, leading to\\na reduction in the number of red cells, white cells, and\\nplatelets. Because of the frequency and severity of\\nthese side effects, it is common to administerche-\\nmotherapy in cycles, allowing time for recovery from\\nthe drug effects before administering the next dose.\\nDoses are often calculated, not on the basis of weight,\\nbut rather based on blood counts, in order to avoid\\ndangerous levels of anemia (red cell depletion),neu-\\ntropenia (white cell deficiency), orthrombocytopenia\\n(platelet deficiency.)\\nThe health professional has many responsibilities\\nin dealing with patients undergoing chemotherapy.\\nThe patient must be well informed of the risks and\\nbenefits of chemotherapy, and must be emotionally\\nprepared for the side effects. These may be permanent,\\nand younger patients should be aware of the high risk\\nof sterility after chemotherapy.\\nThe patient must also know which side effects\\nshould be reported to the practitioner, since many\\nadverse effects do not appear until several days after\\na dose of chemotherapy. When chemotherapy is self-\\nadministered, the patien tm u s tb ef a m i l i a rw i t h\\nproper use of the drugs, including dose scheduling\\nand avoidance of drug-drug and food-drug\\ninteractions.\\nAppropriate steps should be taken to minimize\\nside effects. These may include administration of anti-\\nnauseant medications to reducenausea and vomiting,\\nmaintaining fluid levels to reduce drug toxicity, parti-\\ncularly to the kidneys, or application of a scalp tour-\\nniquet to reduce blood flow to the scalp and minimize\\nhair loss due to drug therapy.\\nPatients receiving chemotherapy also are at risk of\\ninfections due to reduced white blood counts. While\\nprophylactic antibiotics may be useful, the health care\\nprofessional should also be sure to use standard pre-\\ncautions, including gowns and gloves when appropri-\\nate. Patients should be alerted to avoid risks of viral\\ncontamination, and live virus immunizations are con-\\ntraindicated until the patient has fully recovered from\\nthe effects of chemotherapy. Similarly, the patient\\nshould avoid contact with other people who have\\nrecently had live virus immunizations.\\nOther precautions which should be emphasized\\nare the risks to pregnant or nursing women. Because\\nantineoplastic drugs are commonly harmful to the\\nfetus, women of childbearing potential should be cau-\\ntioned to use two effective methods of birth control\\nwhile receiving cancer chemotherapy. This also applies\\nif the woman’s male partner is receiving chemother-\\napy. Breastfeeding should be avoided while the mother\\nis being treated.\\nBefore prescribing or administering anticancer\\ndrugs, health care providers should inquire whether\\nthe patient has any of the following conditions:\\n/C15chickenpox or recent exposure to someone with\\nchickenpox\\n/C15shingles (Herpes zoster)\\n/C15mouth sores\\n/C15current or past seizures\\n/C15head injury\\n/C15nerve or muscle disease\\n/C15hearing problems\\n/C15infection of any kind\\n/C15gout\\n/C15colitis\\n/C15intestine blockage\\n/C15stomach ulcer\\n/C15kidney stones\\n/C15kidney disease\\n/C15liver disease\\n/C15current or past alcoholabuse\\nKEY TERMS\\nCataract— Clouding of the lens of the eye, leading\\nto poor vision or blindness.\\nImpotent— Unable to achieve or maintain an erec-\\ntion of the penis.\\n274 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticancer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 304, 'page_label': '275'}, page_content='/C15immune system disease\\n/C15cataracts or other eye problems\\n/C15high cholesterol\\nOther precautions\\nThe anticancer drug methotrexate has additional\\nprecautions. Patients should be given advice on the\\neffects of sun exposure and the use of alcohol andpain\\nrelievers.\\nSide effects\\nTamoxifen\\nThe anticancer drug tamoxifen (Nolvadex) increases\\nt h er i s ko fc a n c e ro ft h eu t e r u si ns o m ew o m e n .I ta l s o\\ncauses cataracts and other eye problems. Women taking\\nthis drug may have hot flashes, menstrual changes, geni-\\ntal itching, vaginal discharge, and weight gain. Men who\\ntake tamoxifen may lose interest in sex or become impo-\\ntent. Health care providers should keep in close contact\\nwith patients to assess the individual risks associated\\nwith taking this powerful drug.\\nOther anticancer drugs\\nThese side effects are not common, but could be a\\nsign of a serious problem. Health care providers\\nshould immediately be consulted if any of the follow-\\ning occur:\\n/C15black, tarry, or bloody stools\\n/C15blood in the urine\\n/C15diarrhea\\n/C15fever or chills\\n/C15cough or hoarseness\\n/C15wheezing orshortness of breath\\n/C15sores in the mouth or on the lips\\n/C15unusual bleeding or bruising\\n/C15swelling of the face\\n/C15red ‘‘pinpoint’’ spots on the skin\\n/C15redness, pain, or swelling at the point where an inject-\\nable anticancer drug is given\\n/C15pain in the side or lower back\\n/C15problems urinating or painful urination\\n/C15dizziness or faintness\\n/C15fast or irregular heartbeat\\nOther side effects do not need immediate care, but\\nshould have medical attention. They are:\\n/C15joint pain\\n/C15skin rash\\n/C15hearing problems or ringing in the ears\\n/C15numbness ortingling in the fingers or toes\\n/C15trouble walking or balance problems\\n/C15swelling of the feet or lower legs\\n/C15unusual tiredness or weakness\\n/C15loss of taste\\n/C15seizures\\n/C15dizziness\\n/C15confusion\\n/C15agitation\\n/C15headache\\n/C15dark urine\\n/C15yellow eyes or skin\\n/C15flushing of the face\\nIn addition, there are other possible side effects\\nthat do not need medical attention unless they persist\\nor interfere with normal activities. These include\\nchanges in menstrual period, itchy skin, nausea and\\nvomiting, and loss of appetite.\\nOther rare side effects may occur. Anyone who has\\nunusual symptoms after taking anticancer drugs should\\ncontact the physician who prescribed the medication.\\nInteractions\\nAnticancer drugs may interact with a number of\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side effects\\nmaybegreater.Thehealthcareprovidershouldbeaware\\nof all other prescription or non-prescription (over-the-\\ncounter) medicines a patient is taking. The primary care\\nprovidershouldalsobetoldifthepatienthasbeentreated\\nwith radiation or has taken other anticancer drugs.\\nResources\\nPERIODICALS\\n‘‘Technique Streamlines Search for Anticancer Drugs.’’\\nCancer WeeklyApril 15, 2003: 62.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnticholinergic drugsseeAntiparkinson drugs\\nAnticlotting drugs see Anticoagulant and\\nantiplatelet drugs\\nGALE ENCYCLOPEDIA OF MEDICINE 275\\nAnticancer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 305, 'page_label': '276'}, page_content='Anticoagulant and antiplatelet\\ndrugs\\nDefinition\\nAnticoagulants are drugs used to prevent clot for-\\nmation or to prevent a clot that has formed from enlarg-\\ning. They inhibit clot formation by blocking the action\\nof clotting factors or platelets. Anticoagulant drugs fall\\ninto three categories: inhibitors of clotting factor synth-\\nesis, inhibitors of thrombin and antiplatelet drugs.\\nPurpose\\nAnticoagulant drugs reduce the ability of the blood\\nto form clots. Although blood clotting is essential to\\nprevent serious bleeding in the case of skin cuts, clots\\ninside the blood vessels block the flow of blood to major\\norgans and cause heart attacks and strokes. Although\\nthese drugs are sometimes called blood thinners, they\\ndo not actually thin the blood. Furthermore, this type\\nof medication will not dissolve clots that already have\\nformed, although the drug stops an existing clot from\\nworsening. However, another type of drug, used in\\nthrombolytic therapy, will dissolve existing clots.\\nAnticoagulant drugs are used for a number of con-\\nditions. For example, they may be given to preventblood\\nclotsfrom forming after the replacement of a heart valve\\nor to reduce the risk of astroke or anotherheart attack\\nafter a first heart attack. They are also used to reduce the\\nchance of blood clots forming during open heart surgery\\nor bypass surgery. Low doses of these drugs may be\\ng i v e nt op r e v e n tb l o o dc l o t si np a t i e n t sw h om u s ts t a yi n\\nbed for a long time after certain types of surgery.\\nBecause anticoagulants affect the blood’s ability\\nto clot, they can increase the risk of severe bleeding\\nand heavy blood loss. It is thus essential to take these\\ndrugs exactly as directed and to see a physician regu-\\nlarly as long as they are prescribed.\\nDescription\\nAnticoagulant drugs, also called anticlotting drugs\\nor blood thinners, are available only with a physician’s\\nprescription. They come in tablet and injectable forms.\\nThey fall into three groups:\\n/C15Inhibitors of clotting factor synthesis. These anti-\\ncoagulants inhibit the production of certain clotting\\nfactors in the liver. One example is warfarin (brand\\nname: coumadin).\\n/C15Inhibitors of thrombin. Thrombin inhibitors interfere\\nwith blood clotting by blocking the activity of throm-\\nbin. They include heparin, lepirudin (Refludan).\\n/C15Antiplatelet drugs. Antiplatelet drugs interact with\\nplatelets, which is a type of blood cell, to block plate-\\nlets from aggregating into harmful clots. They include:\\naspirin, ticlopidine (Ticlid), clopidogrel (Plavix), tiro-\\nfiban (Aggrastat), and eptifibatide (Integrilin).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nanticoagulant drug and the medical condition for\\nwhich it is prescribed. The prescribing physician or\\nthe pharmacist who filled the prescription can provide\\ninformation concerning the correct dosage. Usually,\\nthe physician will adjust the dose after checking the\\npatient’s clotting time.\\nAnticoagulant drugs must be taken exactly as direc-\\nted by the physician. Larger or more frequent doses\\nshould not be taken, and the drug should also not be\\ntaken for longer than prescribed.Taking too much of this\\nmedication can cause severe bleeding.Anticoagulants\\nshould also be taken on schedule. A record of each\\ndose should be kept as it is taken. If a dose is missed, it\\nKEY TERMS\\nAnticoagulant— Drug used to prevent clot forma-\\ntion or to prevent a clot that has formed from enlar-\\nging. Anticoagulant drugs inhibit clot formation by\\nblocking the action of clotting factors or platelets.\\nAnticoagulant drugs fall into three groups: inhibi-\\ntors of clotting factor synthesis, inhibitors of throm-\\nbin and antiplatelet drugs.\\nAntiplatelet drug— Drug that inhibits platelets from\\naggregating to form a plug. They are used to prevent\\nclotting and alter the natural course of atherosclerosis.\\nAtherosclerosis— Condition characterized by\\ndeposits of fatty plaque in the arteries.\\nClot— A soft, semi-solid mass that forms when\\nblood gels.\\nPlatelet— A small, disk-shaped body in the blood\\nthat has an important role in blood clotting: they\\nform the initial plug at the rupture site of a blood\\nvessel.\\nThrombin— Thrombin is a protein produced by the\\nbody. It is a specific clotting factor that plays an\\nimportant role in the blood clotting process.\\nThrombin inhibitor— Thrombin inhibitors are one\\ntype of anticoagulant medication, used to help pre-\\nvent formation of harmful blood clots in the body\\nby blocking the activity of thrombin.\\n276 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticoagulant and antiplatelet drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 306, 'page_label': '277'}, page_content='should be taken as soon as possible followed by the\\nregular dose schedule. However, a patient who forgets\\nto take a missed dose until the next day should not take\\nthe missed dose at all and should not double the next\\ndose, as this could lead to bleeding. A record of all\\nmissed doses should be kept for the prescribing physi-\\ncian who should be informed at the scheduled visits.\\nPrecautions\\nPersons who take anticoagulants should see a phy-\\nsician regularly while taking these drugs, particularly at\\nthe beginning of therapy. The physician will order peri-\\nodic blood tests to check the blood’s clotting ability. The\\nresults of these tests will help the physician determine the\\nproper amount of medication to be taken each day.\\nTime is required for normal clotting ability to\\nreturn after anticoagulant treatment. During this per-\\niod, patients must observe the same precautions they\\nobserved while taking the drug. The length of time\\nneeded for the blood to return to normal depends on\\nthe type of anticoagulant drug that was taken. The\\nprescribing physician will advise as to how long the\\nprecautions should be observed.\\nPeople who are taking anticoagulant drugs should\\ntell all physicians, dentists, pharmacists, and other\\nmedical professionals who provide medical treatments\\nor services to them that they are taking such a medica-\\ntion. They should also carry identification stating that\\nthey are using an anticoagulant drug.\\nOther prescription drugs or over-the-counter\\nmedicine–especially aspirin–should be not be taken\\nwithout the prescribing physician being informed.\\nBecause of the risk of heavy bleeding, anyone who\\ntakes an anticoagulant drug must take care to avoid\\ninjuries. Sports and other potentially hazardous activ-\\nities should be avoided. Any falls, blows to the body or\\nhead, or other injuries should be reported to a physician,\\nas internal bleeding may occur without any obvious\\nsymptoms. Special care should be taken in shaving\\nand in brushing and flossing the teeth. Soft tooth-\\nbrushes should be used and the flossing should be very\\ngentle. Electric razors should be used instead of a blade.\\nAlcohol can change the way anticoagulant drugs\\naffect the body. Anyone who takes this medicine\\nshould not have more than one to two drinks at any\\ntime and should not drink alcohol every day.\\nSpecial conditions\\nPeople with specific medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take anticoagulant drugs. Before taking these\\ndrugs, the prescribing physician should be informed\\nabout any of these conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to anticoagulants in the past should let his or\\nher physician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nbeef, pork, or other foods; dyes; preservatives; or other\\nsubstances.\\nPREGNANCY. Anticoagulants may cause many\\nserious problems if taken during pregnancy. Birth\\ndefects, severe bleeding in the fetus, and other pro-\\nblems that affect the physical or mental development\\nof the fetus or newborn are possible. The mother may\\nalso experience severe bleeding if she takes anticoagu-\\nlants during pregnancy, during delivery, or even\\nshortly after delivery. Women should not take start\\ntaking anticoagulants during pregnancy and should not\\nbecome pregnant while taking it. Any woman who\\nbecomes pregnant or suspects that she has become preg-\\nnant while taking an anticoagulant should check with\\nher physician immediately.\\nBREASTFEEDING. Some anticoagulant drugs may\\npass into breast milk. Blood tests can be done on\\nnursing babies to see whether the drug is causing any\\nproblems. If it is, other medication may be prescribed\\nto counteract the effects of the anticoagulant drug.\\nOTHER MEDICAL CONDITIONS. Before using antic-\\noagulant drugs, people should inform their physician\\nabout any medical problems they have. They should\\nalso let the physician who prescribed the medicine\\nknow if they are being treated by any other medical\\nphysician or dentist. In addition, people who will be\\ntaking anticoagulant drugs should let their physician\\nknow if they have recently had any of the following:\\n/C15fever lasting more than one to two days\\n/C15severe or continuingdiarrhea\\n/C15childbirth\\n/C15heavy or unusual menstrual bleeding\\n/C15insertion of an intrauterine contraceptive device\\n(IUD)\\n/C15falls, injuries, or blows to the body or head\\n/C15any type of surgery, including dental surgery\\n/C15spinal anesthesia\\n/C15radiation treatment\\nUSE OF CERTAIN FOODS AND MEDICINES. Many\\nfoods and drugs may affect the way the anticoagulant\\ndrugs work or may increase the risk of side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 277\\nAnticoagulant and antiplatelet drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 307, 'page_label': '278'}, page_content='Side effects\\nThe most common minor side effects are bloating or\\ngas. These problems usually go away as the body adjusts\\nto the drug and do not require medical treatment.\\nMore serious side effects may occur, especially if\\nexcessive anticoagulant is taken. If any of the follow-\\ning side effects occur, a physician should be notified\\nimmediately:\\n/C15bleeding gums\\n/C15sores or white spots in the mouth or throat\\n/C15unusual bruises or purplish areas on the skin\\n/C15unexplained nosebleeds\\n/C15unusually heavy bleeding or oozing fromwounds\\n/C15unexpected or unusually menstrual bleeding\\n/C15blood in the urine\\n/C15cloudy or dark urine\\n/C15painful or difficult urination or sudden decrease in\\namount of urine\\n/C15black, tarry, or bloody stools\\n/C15coughing up blood\\n/C15vomiting blood or something that looks like coffee\\ngrounds\\n/C15constipation\\n/C15pain or swelling in the stomach or abdomen\\n/C15back pain\\n/C15stiff, swollen, or painful joints\\n/C15painful, bluish or purplish fingers or toes\\n/C15puffy or swollen eyelids, face, feet, or lower legs\\n/C15changes in the color of the face\\n/C15skin rash,itching,o rhives\\n/C15yellow eyes or skin\\n/C15severe or continuingheadache\\n/C15sore throat and fever, with or without chills\\n/C15breathing problems orwheezing\\n/C15tightness in the chest\\n/C15dizziness\\n/C15unusual tiredness or weakness\\n/C15weight gain.\\nIn addition, patients taking anticoagulant drugs\\nshould check with their physicians as soon as possible\\nif any of these side effects occur:\\n/C15nausea or vomiting\\n/C15diarrhea\\n/C15stomach pain or cramps.\\nOther side effects may occur. Anyone who has\\nunusual symptoms while taking anticoagulant drugs\\nshould get in touch with his or her physician.\\nInteractions\\nAnticoagulants may interact with many other med-\\nications. When this happens, the effects of one or both\\nof the drugs may change or the risk of side effects may\\nbe increased.Anyone who takes anticoagulants should\\ninform the prescribing physician about other prescription\\nor nonprescription (over-the-counter medicines) he or she\\nis taking–even aspirin, laxatives, vitamins, and antacids.\\nDiet also affects the way anticoagulant drugs work\\nin the body. A normal, balanced diet should be followed\\nevery day while taking such medication. No dietary\\nchanges should be made without informing first the\\nprescribing physician, who should also be told of any\\nillness or other condition interfering with the ability to\\neat normally. Diet is a very important consideration\\nbecause the amount of vitamin K in the body affects\\nhow anticoagulant drugs work. Dicoumarol and war-\\nfarin act by reducing the effects of vitamin K. Vitamin K\\nis found in meats, dairy products, leafy, green vegeta-\\nbles, and some multiplevitamins and nutritional supple-\\nments. For the drugs to work properly, it is best to have\\nthe same amount of vitamin K in the body all the time.\\nFoods containing vitamin K in the diet should not be\\nincreased or decreased without consulting with the pre-\\nscribing physician. If the patient takes vitamin supple-\\nments, he should check the label to see if it contains\\nvitaminK.BecausevitaminK isalsoproducedbyintest-\\ninal bacteria, a severe case of diarrhea or the use of\\nlaxativesmay also alter a person’s vitamin K levels.\\nNancy Ross-Flanigan\\nAnticonvulsant drugs\\nDefinition\\nAnticonvulsant drugs are medicines used to pre-\\nvent or treat convulsions (seizures).\\nPurpose\\nAnticonvulsant drugs are used to control seizures\\nin people with epilepsy. Epilepsy is not a single dis-\\nease—it is a set of symptoms that may have different\\n278 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticonvulsant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 308, 'page_label': '279'}, page_content='causes in different people. The common thread is an\\nimbalance in the brain’s electrical activity. This imbal-\\nance causes seizures that may affect part or all of the\\nbody and may or may not cause a loss of conscious-\\nness. Anticonvulsant drugs act on the brain to reduce\\nthe frequency and severity of seizures.\\nSome cases of epilepsy are brought on by head\\ninjuries, brain tumors or infections, or metabolic pro-\\nblems such as low blood sugar. But in some people\\nwith epilepsy, the cause is not clear.\\nAnticonvulsant drugs are an important part of the\\ntreatment program for epilepsy. Different kinds of\\ndrugs may be prescribed for different types of seizures.\\nIn addition to taking medicine, patients with epilepsy\\nshould get enough rest, avoidstress, and practice good\\nhealth habits.\\nSome physicians believe that giving the drugs to\\nchildren with epilepsy may prevent the condition from\\ngetting worse in later life. However, others say the\\neffects are the same, whether treatment is started\\nearly or later in life. Determining when treatment\\nbegins depends on the physician and his assessment\\nof the patient’s symptoms.\\nPhysicians also prescribe certain anticonvulsant\\ndrugs for other conditions, includingbipolar disorder\\nand migraine headaches.\\nDescription\\nAnticonvulsant drugs may be divided into several\\nclasses. The hydantoins include pheytoin (Dilantin) and\\nmephenytoin (Mesantoin.) Ther succimides include\\nethosuximide (Zarontin) and methsuccimide (Celontin.)\\nThe benzodiazepines, which are better known for their\\nuse as tranquilizers and sedatives, include clonazepam\\n(Klonopin), clorazepate (Tranxene) and diazepam\\n(Valium.) There are also a large number of other drugs\\nwhich are not related to larger groups. These include\\ncarbamazepine (Tegretol), valproic acid (Depakote,\\nDepakene) gabapentin (Neurontin), topiramate\\n(Topamax), felbamate (Felbatol) and several others.\\nPhenobarbital has been used as an anticonvulsant, and\\nis still useful for some patients. The drugs are available\\nonly with a physician’s prescription and come in tablet,\\ncapsule, liquid, and ‘‘sprinkle’’ forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nanticonvulsant, its strength, and the type of seizures\\nfor which it is being taken. Check with the physician\\nwho prescribed the drug or the pharmacist who filled\\nthe prescription for the correct dosage.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more. Gradually tapering\\nthe dose may reduce the chance of withdrawal effects.\\nDo not change brands or dosage forms of this\\nmedicine without checking with a pharmacist or phy-\\nsician. If a prescription refill does not look like the\\noriginal medicine, check with the pharmacist who\\nfilled the prescription.\\nPrecautions\\nPatients on anticonvulsant drugs should see a\\nphysician regularly while on therapy, especially during\\nthe first few months. The physician will check to make\\nsure the medicine is working as it should and will note\\nunwanted side effects. The physician may also need to\\nadjust the dosage during this period.\\nValproic acid can cause serious liver damage,\\nespecially in the first 6 months of treatment. Children\\nare particularly at risk, but anyone taking this medi-\\ncine should see their physician regularly for tests of\\nliver function and should be alert to symptoms of liver\\ndamage, such as yellow skin and eyes, facial swelling,\\nKEY TERMS\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings, such as chlorophyll which makes plants\\ngreen or hemoglobin which makes blood red.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease with many symptoms, including weakness,\\nfatigue, joint pain, sores on the skin, and problems\\nwith the kidneys, spleen, and other organs.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 279\\nAnticonvulsant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 309, 'page_label': '280'}, page_content='loss of appetite, general feeling of illness, loss of appe-\\ntite, andvomiting. If liver problems are suspected, call\\na physician immediately.\\nFelbatol has caused serious liver damage and\\naplastic anemia, a condition in which the bone mar-\\nrow stops producing blood cells. Patients taking this\\ndrug should have regular blood counts, and should\\nstop taking the drug if there are too few red blood\\ncells.\\nWhile taking anticonvulsant drugs, do not start or\\nstop taking any other medicines without checking with\\na physician. The other medicines may affect the way\\nthe anticonvulsant medicine works.\\nBecause anticonvulsant drugs work on the central\\nnervous system, they may add to the effects of alcohol\\nand other drugs that slow down the central nervous\\nsystem, such asantihistamines, cold medicine, allergy\\nmedicine, sleep aids, other medicine for seizures, tran-\\nquilizers, some pain relievers, and muscle relaxants.\\nAnyone taking anticonvulsant drugs should check with\\nhis or her physician before drinking alcohol or taking\\nany medicines that slow the central nervous system.\\nAnticonvulsant drugs may interact with medicines\\nused during surgery, dental procedures, or emergency\\ntreatment. These interactions could increase the\\nchance of side effects. Anyone who is taking antic-\\nonvulsant drugs should be sure to tell the health care\\nprofessional in charge before having any surgical or\\ndental procedures or receiving emergency treatment.\\nSome people feel drowsy, dizzy, lightheaded, or\\nless alert when using these drugs, especially when they\\nfirst begin taking them or when their dosage is\\nincreased. Anyone who takes anticonvulsant drugs\\nshould not drive, use machines or do anything else\\nthat might be dangerous until they have found out\\nhow the drugs affect them.\\nAnticonvulsant drugs may affect the results of\\ncertain medical tests. Before having medical tests, peo-\\nple who take anticonvulsant drugs should make sure\\nthat the medical professional in charge knows what\\nthey are taking.\\nChildren may be more likely to have certain side\\neffects from anticonvulsant drugs, such as behavior\\nchanges; tender, bleeding, or swollen gums; enlarged\\nfacial features; and excessive hair growth. Problems\\nwith the gums may be prevented by regularly brushing\\nand flossing, massaging the gums, and having the teeth\\ncleaned every 3 months whether the patient is a child\\nor an adult.\\nChildren who take high doses of this medicine for\\na long time may have problems in school.\\nOlder people may be more sensitive to the effects\\nof anticonvulsant drugs. This may increase the chance\\nof side effects and overdoses.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take anticonvulsant drugs. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to anticonvulsant drugs or totricyclic antidepres-\\nsants such as imipramine (Tofranil) or desipramine\\n(Norpramin) in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nPREGNANCY. Some anticonvulsant drugs taken\\nduring pregnancy may cause bleeding problems in the\\nmother during delivery and in the baby after delivery.\\nThis problem can be avoided by giving vitamin K to the\\nmother during delivery and to the baby after birth.\\nPregnancy may affect the way the body absorbs\\nanticonvulsant drugs. Women who are prone to sei-\\nzures may have more seizures during pregnancy, even\\nthough they are taking their medicine regularly. If this\\nhappens, they should check with their physicians\\nabout whether the dose needs to be increased.\\nBREASTFEEDING. Some anticonvulsant drugs pass\\ninto breast milk and may cause unwanted effects in babies\\nwhose mothers take the medicine. Women who are\\nbreastfeeding should check with their physicians about\\nthe benefits and risks of using anticonvulsant drugs.\\nDIABETES. Anticonvulsant drugs may affect blood\\nsugar levels. Patients with diabetes who notice changes\\nin the results of their urine or blood tests should check\\nwith their physicians.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nconvulsant drugs, people with any of these medical\\nproblems should make sure their physicians are\\naware of their conditions:\\n/C15liver disease\\n/C15kidney disease\\n/C15thyroid disease\\n/C15heart or blood vessel disease\\n/C15blood disease\\n/C15brain disease\\n/C15problems with urination\\n/C15current or past alcoholabuse\\n280 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticonvulsant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 310, 'page_label': '281'}, page_content='/C15behavior problems\\n/C15diabetes mellitus\\n/C15glaucoma\\n/C15porphyria\\n/C15systemic lupus erythematosus\\n/C15fever higher than 1018F (38.38C) for more than\\n24 hours\\nUSE OF CERTAIN MEDICINES. Taking anticonvul-\\nsant drugs with certain other drugs may affect the\\nway the drugs work or may increase the chance of\\nside effects.\\nSide effects\\nThe most common side effects areconstipation,\\nmild nausea or vomiting, and milddizziness, drowsi-\\nness, or lightheadedness. These problems usually go\\naway as the body adjusts to the drug and do not\\nrequire medical treatment. Less common side effects,\\nsuch asdiarrhea, sleep problems, aching joints or mus-\\ncles, increased sensitivity to sunlight, increased sweat-\\ning, hair loss, enlargement of facial features, excessive\\nhair growth, muscle twitching, and breast enlargement\\nin males also may occur and do not need medical\\nattention unless they persist or are troublesome.\\nOther side effects may need medical attention. If\\nany of these side effects occur, check with a physician\\nas soon as possible:\\n/C15clumsiness or unsteadiness\\n/C15slurred speech or stuttering\\n/C15trembling\\n/C15unusual excitement, irritability, or nervousness\\n/C15uncontrolled eye movements\\n/C15blurred or double vision\\n/C15mood or mental changes\\n/C15confusion\\n/C15increase in seizures\\n/C15bleeding, tender, or swollen gums\\n/C15skin rash or itching\\n/C15enlarged glands in neck or armpits\\n/C15muscle weakness or pain\\n/C15fever\\nOther side effects are possible. Anyone who has\\nunusual symptoms after taking anticonvulsant drugs\\nshould get in touch with his or her physician.\\nInteractions\\nSome anticonvulsant drugs should not be taken\\nwithin two to three hours of takingantacids or medi-\\ncine for diarrhea. These medicines may make the\\nanticonvulsant drugs less effective. Ask the pharma-\\ncist or physician for more information.\\nBirth control pills may not work properly when\\nanticonvulsant drugs are being taken. To prevent\\npregnancy, ask the physician or pharmacist if addi-\\ntional methods of birth control should be used while\\ntaking anticonvulsant drugs.\\nAnticonvulsant drugs may interact with many\\nother medicines. When this happens, the effects of\\none or both of the drugs may change or the risk of\\nside effects may be greater. Anyone who takes antic-\\nonvulsant drugs should let the physician know all\\nother medicines he or she is taking. Among the\\ndrugs that may interact with certain anticonvulsant\\ndrugs are:\\n/C15airway opening drugs (bronchodilators) such as amino-\\nphylline, theophylline (Theo-Dur and other brands),\\nand oxtriphylline (Choledyl and other brands)\\n/C15medicines that contain calcium, such as antacids and\\ncalcium supplements\\n/C15blood thinning drugs\\n/C15caffeine\\n/C15antibiotics such as clarithromycin (Biaxin),erythro-\\nmycins, andsulfonamides (sulfa drugs)\\n/C15disulfiram (Antabuse), used to treat alcohol abuse\\n/C15fluoxetine (Prozac)\\n/C15monoamine oxidase inhibitors (MAO inhibitors)\\nsuch as phenelzine (Nardil) or tranylcypromine\\n(Parnate), used to treat conditions including depres-\\nsion and Parkinson’s disease\\n/C15tricyclic antidepressants such as imipramine (Tofranil)\\nor desipramine (Norpramin)\\n/C15corticosteroids\\n/C15acetaminophen (Tylenol)\\n/C15aspirin\\n/C15female hormones (estrogens)\\n/C15male hormones (androgens)\\n/C15cimetidine (Tagamet)\\n/C15central nervous system (CNS) depressants such as medi-\\ncine for allergies, colds, hay fever, andasthma;s e d a t i v e s ;\\ntranquilizers; prescription pain medicine; muscle relax-\\nants; medicine for seizures; sleep aids;barbiturates;a n d\\nanesthetics\\nGALE ENCYCLOPEDIA OF MEDICINE 281\\nAnticonvulsant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 311, 'page_label': '282'}, page_content='/C15alcohol\\n/C15other anticonvulsant drugs\\nThe list above does not include every drug that\\nmay interact with anticonvulsant drugs. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning anticonvulsant drugs with any other prescription\\nor nonprescription (over-the-counter) medicine.\\nResources\\nPERIODICALS\\nReynolds, E.H. ‘‘Do Anticonvulsant Drugs Alter the\\nNatural Course of Epilepsy? Treatment Should Be\\nStarted as Early as Possible.’’British Medical Journal\\n310 (January 21, 1995): 176.\\nORGANIZATIONS\\nAmerican Epilepsy Society. 638 Prospect Avenue, Hartford,\\nCT 06105. (203) 232-4825.\\nEpilepsy Foundation of America. 4351 Garden City Drive,\\n#406, Landover, MD 20785. (800) 332-1000.\\nNational Institute of Neurological Disorders and Stroke.\\nP.O. Box 5801, Bethesda, MD 20824. (301) 496-5751.\\nNancy Ross-Flanigan\\nAntidepressant drugs\\nDefinition\\nAntidepressant drugs are medicines that relieve\\nsymptoms ofdepressive disorders.\\nPurpose\\nDepressive disorders may either be unipolar\\n(depression alone) or bipolar (depression alternating\\nwith periods of extreme excitation). The formal diag-\\nnosis requires a cluster of symptoms, lasting at least\\ntwo weeks. These symptoms include, but are not limi-\\nted to, mood changes, insomnia or hypersomnia, and\\ndiminished interest in daily activities. The symptoms\\nare not caused by any medical condition, drug side\\neffect, or adverse life event. The condition is severe\\nenough to cause clinically significant distress or\\nimpairment in social, occupational, or other import-\\nant areas of functioning.\\nSecondary depression, or depression caused by\\nunfavorable life events, is normally self limiting, and\\nmay best be treated with cognitive/behavioral therapy\\nrather than drugs.\\nDescription\\nAntidepressant agents act by increasing the levels\\nof excitatory neurostransmitters, or nerve cell chemicals\\nthat act as messengers in the brain’s nervous system. In\\n2003, a report showed that in addition to treating\\ndepression, use of antidepressant drugs may protect\\nthe brain from damage depressive episodes cause to\\nthe hippocampus, the area of the brain involved in\\nlearning and memory. Antidepressant drugs may be\\nprescribed as a first-line treatment for depression, or\\nin conjunction with other methods of controlling\\ndepression, such as behavioral therapy andexercise.\\nThe main types of antidepressant drugs in use\\ntoday are listed below, though the drugs available\\nchange frequently. For example, in mid-2003, the\\nmanufacturer of Wellbutrin released Wellbutrin XL,\\nthe only once-daily norepinephrine and dopamine\\nreuptake inhibitor for treating depression in adults.\\n/C15tricyclic antidepressants, such as amitriptyline (Elavil),\\nimipramine (Tofranil), nortriptyline (Pamelor)\\n/C15selective serotonin reuptake inhibitors (SSRIs or\\nserotonin boosters), such as fluoxetine (Prozac), par-\\noxetine (Paxil), and sertraline (Zoloft)\\n/C15monoamine oxidase inhibitors(MAO inhibitors), such\\nas phenelzine (Nardil), and tranylcypromine (Parnate)\\nKEY TERMS\\nCognitive behavioral therapy— A type of psy-\\nchotherapy in which people learn to recognize\\nand change negative and self-defeating patterns of\\nthinking and behavior.\\nDepression— A mental condition in which people\\nfeel extremely sad and lose interest in life. People\\nwith depression also may have sleep problems and\\nloss of appetite and may have trouble concentrat-\\ning and carrying out everyday activities.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\n282 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 312, 'page_label': '283'}, page_content='/C15tetracyclic compounds and atypical antidepressants\\nwhich do not fall into any of the above categories\\nSelective serotonin reuptake inhibitors maintain\\nlevels of the excitatory neurohormone serotonin in the\\nbrain. They do not alter levels of norepinephrine. These\\nhave become the drugs of choice for a variety of psy-\\nchiatric disorders, primarily because of their low inci-\\nd e n c eo fs e v e r es i d ee f f e c t sa sc o m p a r e dw i t ho t h e rd r u g s\\nin this therapeutic class. SSRIs show similar actions and\\nside effect profiles, but may vary in duration of action.\\nTricyclic compounds, identified by their chemical\\nstructure containing three carbon rings, are an older\\nclass of antidepressants. Although generally effective,\\nthey have a high incidence of anticholinergic effects,\\nnotably dry mouth and dry eyes, which can cause\\ndiscomfort. They also cause cardiac arrythmias.\\nBecause tricyclics act on both serotonin and norepi-\\nnephrine, they may have some value in treatment of\\npatients who fail to respond to SSRIs. Drugs in this\\nclass often are available at low prices, which may be\\nsignificant when cost is a major factor in treatment.\\nThey also have been found useful in control of some\\nneurologic pain syndromes.\\nTricyclic antidepressants are similar, but may vary\\nin severity of side effects, most notably the degree of\\nsedation and the extent of the anticholinergic effects.\\nTetracyclic compounds and atypical antidepres-\\nsants are chemically distinct from both the major\\ngroups and each other. Although maprotilene (no\\nbrand name, marketed in generic form only) and mir-\\ntazepine (Remeron) are similar in chemical structures,\\nthey differ in their balance of activity on serotonine\\nand norepinephrine levels.\\nMonoamine oxidase inhibitors (phenelzine\\n[Nardil], tranylcypromine [Parnate]) have largely\\nbeen supplanted in therapy because of their high risk\\nof severe adverse effects, most notably severehyper-\\ntension. They act by inhibiting the enzyme monoamine\\noxidase, which is responsible for the metabolism of the\\nstimulatory neurohormones norepinephrine, epi-\\nnephrine, dopamine, and serotonin. The MAOIs are\\nnormally reserved for patients who are resistant to\\nsafer drugs. Two drugs, eldepryl (Carbex, used in\\ntreatment of Parkinson’s disease) and the herb,\\nSt. John’s wort, have some action against mono-\\namine oxidase B, and have shown some value as anti-\\ndepressants. They do not share the same risks as the\\nnon-selective MAO inhibitors.\\nAll antidepressant agents, regardless of their\\nstructure, have a slow onset of action, typically three\\nto five weeks. Although adverse effects may be seen as\\nearly as the first dose, significant therapeutic\\nimprovement is always delayed. Similarly, the effects\\nof antidepressants will continue for a similar length of\\ntime after the drugs have been discontinued.\\nRecommended dosage\\nDose varies with the specific drug and patient.\\nSpecialized references or a physician should be consulted.\\nPrecautions\\nAntidepressants have many significant cautions\\nand adverse effects. Although a few are listed here,\\nspecific references should be consulted for more com-\\nplete information.\\nSSRIs. The most common side effect of SSRIs is\\nexcitation and insomnia. Excitation has been reported\\nin over 20% of patients, and insomnia in 33%.\\nSignificant weight loss has been frequently reported,\\nbut most commonly in patients who are already\\nunderweight. A 2003 report showed that SSRIs also\\nincrease the risk of upper gastrointestinal tract bleed-\\ning. SSRIs may cause some sedation, and patients\\nshould be cautioned not to perform tasks requiring\\nalertness until they have evaluated the effects of these\\ndrugs. SSRIs arepregnancy category C drugs. In 2003,\\na new report demonstrated that late-term (third trime-\\nster) use of these drugs could cause neurological symp-\\ntoms in newborns, including tremor, restlessness and\\nrigidity. Most SSRIs are excreted in breast milk, and\\nthere have been anecdotal reports of drowsiness in\\ninfants whose mothers were taking SSRIs while\\nbreastfeeding.\\nMost notably, a joint panel of the U.S. Food and\\nDrug Administration (FDA) issued strong warnings\\nto parents and physicians in 2004 about the risk of\\nsuicidal behavior in children and adolescents taking\\nSSRIs.\\nTricyclic antidepressants. Amoxepine (not mar-\\nketed by brand, generic available), although a tricyclic\\nantidepressant rather than a neuroleptic (major tran-\\nquilizer), displays some of the more serious effects of\\nthe neuroleptics, including tardive dyskinesias (drug\\ninduced involuntary movements) and neuroleptic\\nmalignant syndrome, a potentially fatal syndrome\\nwith symptoms including high fever, altered mental\\nstatus, irregular pulse or blood pressure, and changes\\nin heart rate. These adverse effects have not been\\nreported with other tricyclic antidepressants.\\nThe most common adverse effects of tricyclic anti-\\ndepressants are sedation and the anticholinergic\\neffects, such as dry mouth, dry eyes, and difficult\\nurination. Alterations in heartbeat also are common,\\nGALE ENCYCLOPEDIA OF MEDICINE 283\\nAntidepressant drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 313, 'page_label': '284'}, page_content='and may progress to congestiveheart failure, stroke,\\nand suddendeath.\\nTricyclic antidepressants are in pregnancy cate-\\ngories C or D, although there have been no formal\\nstudies of the drugs on fetal development. There are no\\nstudies of effects on newborns, but some anecdotal\\nreports of malformations have resulted from animal\\nstudies. The drugs are excreted in breast milk.\\nMonoamine oxidase inhibitors. The greatest risk\\nassociated with these drugs is a hypertensive crisis\\nwhich may be fatal and most often occurs when the\\ndrugs are taken with interacting foods or drugs. More\\ncommon adverse reactions may include low blood\\npressure and slowing of heartbeat. Sedation and gas-\\ntrointestinal disturbances also are common. MAOIs\\nare in pregnancy category C. Safety in breast feeding\\nhas not been established.\\nTetracyclics and atypicals. Because these drugs\\nare individual, there are no group patterns of adverse\\nreactions. Specific references should be consulted.\\nInteractions\\nThe antidepressants have manydrug interactions,\\nsome severe. Although a few are listed here, specific\\nreferences should be consulted for more complete\\ninformation.\\nSSRIs should not be administered with MAOIs.\\nA wash-out period of about four weeks should be\\nallowed before switching from one class of drugs to\\nthe other, five weeks if switching from fluoxetine\\n(Prozac) to an MAOI.\\nMAOIs have many interactions, however the best\\nknown are those with foods containing the amino acid\\ntyramine. These include aged cheese, chianti wine, and\\nmany others. Patients and providers should review the\\nMAOI diet restrictions before using or prescribing\\nthese drugs. Because of the severity of MAOI interac-\\ntions, all additions to the patient’s drug regimen\\nshould be reviewed with care.\\nTricyclic compounds have many interactions, and\\nspecialized references should be consulted.\\nSpecifically, it is best to avoid other drugs with antic-\\nholinergic effects. Tricyclics should not be taken with\\nthe antibiotics grepafloxacin and sprafloxacin, since\\nthe combination may cause serious heart arrythmias.\\nTricyclic compounds should not be taken with the\\ngastric acid inhibitor cimetidine (Tagamet), since this\\nincreases the blood levels of the tricyclic compound.\\nOther acid inhibiting drugs do not share this\\ninteraction.\\nSSRIs interact with a number of other drugs that\\nact on the central nervous system. Care should be used\\nin combining these drugs with major or minor tran-\\nquilizers, or with anti-epileptic agents such as pheny-\\ntoin (Dilantin) or carbamazepine (Tegretol). In 2003,\\none of the biggest concerns regarding new prescrip-\\ntions for tricyclic antidepressants was data concerning\\noverdoses from these drugs. Information in Great\\nBritain showed that this class of antidepressants was\\nresponsible for more than 90% of all deaths from\\nantidepressant overdose. Physicians were being\\nadvised to prescribe SSRIs in new patients, but not\\nto change the course of those who had taken tricyclics\\nfor years with success.\\nResources\\nPERIODICALS\\n‘‘Antidepressant Drugs May Protect Brain from Damage.’’\\nMental Health Weekly Digest(August 18, 2003): 2.\\n‘‘FDA Approves Once-daily Supplement.’’Biotech Week\\n(September 24, 2003): 6.\\n‘‘FDA Panel Urges Stronger Warnings of Child Suicide.’’\\nSCRIP World Pharmaceutical News(February 6,\\n2004): 24.\\n‘‘GPs Told Not to Prescribe Tricyclics.’’Pulse (October 13,\\n2003): 1.\\n‘‘Late-term Exposure to SSRIs May Cause Neurological\\nSymptoms in Babies.’’Drug Week(August 8, 2003):\\n255.\\n‘‘SSRIs Increase the Risk of Upper GI Bleeding.’’\\nPsychiatric Times(July 1, 2003): 75.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntidepressant drugs, SSRI\\nDefinition\\nPurpose\\nSSRIs are prescribed primarily to treat mental\\ndepression. Because they are as effective as other\\ntypes of antidepressants and have less serious side\\neffects, SSRIs have become the most commonly pre-\\nscribed antidepressants for all age groups, including\\nchildren and adolescents.\\nIn addition to treating depression, some SSRIs\\nhave been approved by the U.S. Food and Drug\\nAdministration (FDA) for the treatment of other dis-\\norders including:\\n284 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 314, 'page_label': '285'}, page_content='/C15obsessive-compulsive disorder(OCD)\\n/C15generalized anxiety disorder\\n/C15panic disorder\\n/C15social anxiety disorder or social phobia\\n/C15premenstrual dysphoric disorder (PMDD) or\\npremenstrual syndrome(PMS)\\n/C15post-traumatic stress disorder (PTSD)\\n/C15bulimia nervosa, an eating disorder.\\nSSRIs often are prescribed for other ‘‘off-label’’\\nuses including:\\n/C15various mental disorders including schizophrenia\\n/C15mania\\n/C15menopause-related symptoms such as hot flashes\\n/C15geriatric depression\\n/C15loss of mental abilities in the elderly\\n/C15nicotine withdrawal\\n/C15alcoholism\\n/C15premature ejaculation\\nThe advantages of SSRIs over other types of anti-\\ndepressants include:\\n/C15Most SSRIs can be taken in one daily dose as com-\\npared with three to six daily pills.\\n/C15Because they lessen cravings for carbohydrates,\\nSSRIs usually do not cause weight gain.\\n/C15Since SSRIs do not appear to affect the cardiovas-\\ncular system, they can be prescribed for people with\\nhigh blood pressure or heart conditions.\\n/C15Since SSRIs are not particularly dangerous even in high\\ndoses and are unlikely to cause permanent damage if\\nmisused, they may be prescribed for suicidal adults.\\nSSRIs are mood enhancers only in depressed indi-\\nviduals. They have little effect on people who are not\\nclinically depressed. However some experts believe\\nthat SSRIs are over-prescribed and should be reserved\\nfor those with major disabling depression.\\nDescription\\nTypes of SSRIs\\nAs of 2005, six brand-name SSRIs and generic\\nequivalents were available in the United States:\\n/C15Celexa (citalopram hydrobromide) for treating\\ndepression\\n/C15Lexapro (escitalopram oxalate) for treating depres-\\nsion and generalized anxiety disorder\\n/C15Luvox (fluvoxamine) for treating OCD\\n/C15Paxil (paroxetine hydrochloride) for treating\\ndepression, generalized anxiety disorder, OCD,\\nKEY TERMS\\nCitalopram hydrobromide— Celexa; a SSRI that is\\nhighly specific for serotonin reuptake.\\nDopamine— A neurotransmitter and the precursor\\nof norepinephrine.\\nEscitalopram oxalate— Lexapro; a SSRI that is very\\nsimilar to Celexa but contains only the active che-\\nmical form.\\nFluoxetine— Prozac; the first SSRI; marketed as\\nSarafem for treating PMDD.\\nFluvoxamine— Luvox; a SSRI that is used to treat\\nobsessive-compulsive disorder as well as other\\nconditions.\\nMonoamine oxidase inhibitor (MAOI)— An older\\nclass of antidepressants.\\nNeurotransmitter— A substance that helps transmit\\nimpulses between two nerve cells or between a\\nnerve cell and a muscle.\\nNorepinephrine— A hormone released by nerve\\ncells and the adrenal medulla that causes constric-\\ntion of blood vessels.\\nObsessive-compulsive disorder (OCD)— An anxi-\\nety disorder characterized by obsessions, such as\\nrecurring thoughts or impulses, and compulsions,\\nsuch as repetitive behaviors.\\nOff-label use— A drug that is prescribed for uses,\\nperiods of time, or at dosages that are not FDA-\\napproved.\\nParoxetine hydrochloride— Paxil; a SSRI that is\\nused to treat mental depression, OCD, and various\\nother disorders.\\nPremenstrual dysphoric disorder (PMDD)—\\nPremenstrual syndrome (PMS); symptoms includ-\\ning back and abdominal pain, nervousness and\\nirritability, headache, and breast tenderness that\\noccur the week before menstruation.\\nSerotonin— 5-Hydroxytryptamine; a substance\\nthat occurs throughout the body with numerous\\neffects including neurotransmission.\\nSerotonin syndrome— A group of symptoms caused\\nby severely elevated serotonin levels in the body.\\nSertraline— Zoloft; a SSRI that is used to treat men-\\ntal depression and a variety of other disorders.\\nGALE ENCYCLOPEDIA OF MEDICINE 285\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 315, 'page_label': '286'}, page_content='panic disorder, social anxiety disorder, PMDD, and\\nPTSD\\n/C15Prozac and Prozac Weekly (fluoxetine) for treating\\ndepression, OCD, and bulimia nervosa; marketed as\\nSarafem for treating PMDD\\n/C15Zoloft (sertraline) for treating depression, OCD,\\npanic disorder, social anxiety disorder, PMDD, and\\nPTSD.\\nWhen Prozac first became available in 1988, it was\\nhailed as a new wonder drug and quickly became the most\\npopular antidepressant everprescribed. Many millions\\nof Americans have taken Prozac and more than 70%\\nof them claim to have benefited from it. Within a few\\nyears other SSRIs became available and, by 2000, Zoloft\\nprescriptions outnumbered those for Prozac.\\nLexapro is the newest SSRI. Celexa and Lexapro\\nare very similar, with chemical structures unrelated to\\nother SSRIs. Celexa is a mixture of two isomers—\\nforms of the same chemical—whereas Lexapro is the\\nactive isomer alone. They appear to be highly selective\\nfor serotonin, only minimally inhibiting the reuptake\\nof the neurotransmitters norepinephrine and dopa-\\nmine. Paxil is structurally unrelated to other SSRIs\\nand is more selective for serotonin than Luvox,\\nProzac, or Zoloft, but less selective than Celexa and\\nLexapro. Paxil becomes distributed widely through-\\nout body tissues and the CNS, with only 1% remain-\\ning in the circulatory system.\\nMode of action\\nMental depression is believed to be related to the\\nlow activity of one or more neurotransmitters in the\\nbrain—the chemical messengers that cross the gap or\\nsynapse between nerve cells. Although it is not under-\\nstood exactly how most SSRIs work, they are designed\\nto increase the level of serotonin in the brain. This can\\nreduce the symptoms of depression and other psycho-\\nlogical disorders.\\nSerotonin is released by nerve cells and then—in a\\nprocess called reuptake—is reabsorbed by the cells to\\nbe used again. SSRIs interfere with reuptake by block-\\ning the serotonin reuptake sites on the surfaces of\\nnerve cells, thereby making more serotonin available\\nfor brain activity. Paxil inhibits the transporter mole-\\ncule that moves serotonin back into the cell. SSRIs are\\nsaid to selectively interfere with the reuptake of sero-\\ntonin, without affecting the uptake or activities of\\nother neurotransmitters. In contrast, older antidepres-\\nsants such astricyclic antidepressantsand monoamine\\noxidase inhibitors (MAOIs) affect numerous neuro-\\ntransmitters, brain cell receptors, and brain processes,\\nincreasing the likelihood of serious side effects.\\nHowever it is becoming clear that the serotonin\\nneurotransmitter system is far more complex and wide-\\nspread throughout the body than was thought initially.\\nAlthough serotonin receptors are particularly common\\nin areas of the brain that control emotion, it is known\\nnow that there are at least six different types of serotonin\\nreceptors that send different signals to different parts of\\nthe brain. Serotonin also appears to affect other neuro-\\ntransmitter systems—including dopamine—to at least\\nsome extent. Thus increasing the levels of serotonin may\\nnot be the only reason why SSRIs relieve depression.\\nEffectiveness\\nSSRIs are not effective for treating anxiety or\\ndepression in 20–40% of patients. However some\\nresearch suggests that the use of SSRIs in the early stages\\nof depression can prevent majordepressive disorders.\\nAlthough different SSRIs appear to be equally\\neffective, individuals respond differently to different\\nSSRIs and side effects may vary. Thus finding the best\\nSSRI for an individual may be a matter of trial-and-\\nerror. It usually takes two to four weeks after starting an\\nSSRI before symptoms begin to improve. Luvox may\\ntake one to two months for noticeable improvement.\\nPaxil may take as long as several months, although\\nsleeping often improves within one or two weeks of\\nbeginning the medication. If there is no response after\\na few weeks or if side effects occur, the patient may be\\nswitched to another SSRI. Prozac is the most commonly\\nprescribed SSRI for children, in part because it is avail-\\nable in liquid form that is easier to swallow.\\nAlthough Luvox is the only SSRI that is FDA-\\napproved for use in children—and only for obsessive-\\ncompulsive behavior—thousands of young people\\nhave been treated with SSRIs for:\\n/C15depression\\n/C15anxiety\\n/C15OCD\\n/C15panic\\n/C15attention deficit/hyperactivity disorder (ADHD)\\nA 2004 study found that among depressed adoles-\\ncents, 60% improved with Prozac alone, whereas 75%\\nreported improvement with Prozac combined with\\ncognitive behavioral therapy.\\nSSRIs sometimes are prescribed to relieve depres-\\nsion accompanying alcoholism. A recent study found\\nthat, although type A alcoholics responded to Zoloft\\nin conjunction with a 12-step individual therapy pro-\\ngram, type B alcoholics—those with the most severe\\n286 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 316, 'page_label': '287'}, page_content='drinking problems—did not benefit from Zoloft and,\\nin some cases, increased their alcohol intake.\\nRecommended dosage\\nUsually SSRIs are started with a low dosage that\\nmay be gradually increased. In older adults SSRIs\\nremain in the body longer than in younger adults.\\nThe blood levels of Paxil can be 70–80% higher in\\nthe elderly as compared with younger patients.\\nTherefore lower doses usually are prescribed for\\nolder people. Older patients with other medical con-\\nditions or who are taking many different drugs also\\nmay need smaller or less frequent doses. The dosage\\nof an SSRI also varies according to the individual\\nand the condition that is being treated. SSRIs may be\\ntaken with or without food, on a full or empty\\nstomach. However taking SSRIs with food or drink\\nmay lessen side effects such as stomach upset or\\nnausea.\\nCelexa is supplied as tablets or as an oral solution\\nequivalent to 2 mg per ml (0.03 oz.), taken once per\\nday in the morning or evening:\\n/C15adults: 20 mg per day, increasing to 40 mg if neces-\\nsary, to a maximum of 60 mg per day\\n/C15older adults: 20 mg per day to a maximum of 40 mg\\nLexapro is supplied as 5-, 10-, or 20-mg tablets or\\nas a 1 mg per ml (0.03 oz.) liquid. The recommended\\ndose is 10 mg per day, with a possible increase to 20 mg\\nper day after at least one week.\\nAverage dosages of Luvox for treating OCD and\\ndepression are:\\n/C15adults: one 50-mg tablet at bedtime; may be\\nincreased up to a maximum of 300 mg daily; dosages\\nof more than 100 mg per day should be divided into\\ntwo doses, one taken in the evening and one in the\\nmorning\\n/C15children aged 8–17: initially one 25-mg tablet at\\nbedtime; may be gradually increased by 25 mg\\nper day every four to seven days, up to a maxi-\\nmum of 200 mg per day; daily dosages of more\\nthan 50 mg should be divided into two daily\\ndoses.\\nAverage doses of Paxil for treating depression are:\\n/C15adults: 20 mg (10 ml, 0.3 oz.) of oral suspension, one\\n20-mg tablet, or one 25-mg extended-release tablet,\\nonce a day in the morning, increased by 10 mg per\\nweek to a maximum of 50 mg—25 ml (0.75 oz.) of\\noral suspension—or a 62.5-mg extended-release\\ntablet\\n/C15older adults: 10 mg (5 ml, 0.15 oz.) of oral suspension\\nor a 10-mg tablet daily, increased to a maximum of\\n40 mg (20 ml, 0.6 oz.); one 12.5-mg extended-release\\ntablet daily, increased to a maximum of 50 mg\\nBecause of its sedating effect, Paxil may be taken\\nin the evening rather than in the morning as usually\\nrecommended. Oral suspensions need to be shaken\\nwell before measuring with a small measuring cup or\\nmeasuring spoon. Extended-release tablets should be\\nswallowed whole, not broken or chewed. Dosages may\\nbe different for treating disorders other than\\ndepression.\\nTypical dosages of Prozac are:\\n/C15one 10–20-mg daily capsule or solution taken in the\\nmorning; increased up to as much as 40 mg daily if\\nthere is no improvement in one month, up to an\\n80-mg maximum\\n/C15one 90-mg capsule per week of Prozac Weekly once\\nthe depression is under control\\n/C15one 20-mg capsule of Sarafem per day, taken in the\\nmorning, every day or for only 14 days of a men-\\nstrual cycle; maximum of 80 mg per day; Sarafem is\\nsupplied in seven-day blister packs to help keep track\\nof the days\\n/C15children: initially one 5–10-mg capsule or solution\\nper day.\\nZoloft is available as capsules, oral solutions, or\\ntablets:\\n/C15adults: 50 mg daily, taken in the morning or evening,\\nup to a maximum of 200 mg daily for severely\\ndepressed individuals\\n/C15older adults: 12.5–25 mg per day, taken in the morn-\\ning or evening; may be increased gradually\\n/C15for treating OCD in children aged 6–12: 25 mg per\\nday, taken in the morning or evening; may be\\nincreased gradually to a maximum of 200 mg per day\\n/C15children aged 13–17: initially 50 mg per day, in the\\nmorning or evening, may be increased gradually to a\\nmaximum of 200 mg per day.\\nZoloft oral concentrate should be mixed with 4 oz\\n(133 ml) of water, ginger ale, lemon-lime soda, lemon-\\nade, or orange juice and taken immediately.\\nMissed doses of SSRIs are handled differently\\ndepending on the SSRI and the number of doses\\nper day. An effective SSRI may be prescribed for\\nsix months or more. Some experts recommend continu-\\ning on the SSRI indefinitely to prevent the recurrence\\nof depression.\\nGALE ENCYCLOPEDIA OF MEDICINE 287\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 317, 'page_label': '288'}, page_content='Precautions\\nMedical conditions\\nMedical conditions that may affect the use or\\ndosage of at least some SSRIs include:\\n/C15drug allergies or allergies to other substances in\\nmedications\\n/C15mania\\n/C15manic-depressive (bipolar) disorder\\n/C15brain disease or mental retardation\\n/C15seizures or epilepsy\\n/C15Parkinson s disease\\n/C15liver or severe kidney disease\\n/C15abnormal bleeding problems\\n/C15diabetes mellitus\\n/C15heart disease\\n/C15a recent heart attack\\n/C15glaucoma\\nSSRI use duringpregnancy may not be safe, parti-\\ncularly during the third trimester. Exposure of fetuses\\nto Celexa and other SSRIs during the late third trime-\\nster have led to very serious complications, including\\nserotonin syndrome—a condition in which high sero-\\ntonin levels cause severe problems. Symptoms in a new-\\nborn may be the result of a direct toxic effect of the\\nSSRI or withdrawal from the drug. SSRIs pass into\\nbreast milk and may negatively affect a baby.\\nSuicidal tendencies\\nA possible link between SSRIs and suicide\\nattempts in depressed adults remains controversial.\\nThree studies in early 2005 drew conflicting conclu-\\nsions concerning an association between suicidal\\nbehavior and the use of SSRIs. However a February\\n2005 study found a close correlation between the dra-\\nmatic decrease in suicides in the United States and\\nEurope and the introduction of SSRIs.\\nIn October 2004, the FDA concluded that anti-\\ndepressants, including SSRIs, increased the risk of\\nsuicidal thoughts and behaviors in children and ado-\\nlescents who suffered from depression and other psy-\\nchiatric disorders. They recommended extreme\\ncaution in prescribing SSRIs for children. In the last\\nthree months of 2004, SSRI prescriptions for children\\nand adolescents fell by 10%.\\nSymptoms that may lead to suicidal tendencies\\ncan develop very suddenly in children and adolescents\\ntaking SSRIs; they may include:\\n/C15new or worsening depression\\n/C15severe worrying\\n/C15irritability\\n/C15agitation\\n/C15extreme restlessness\\n/C15frenzied excitement\\n/C15panic attacks\\n/C15insomnia\\n/C15impulsive behavior\\n/C15aggressive behavior\\n/C15thinking about, planning, or attempting to harm\\none’s self\\nWithdrawal\\nSSRIs remain in the body for some time after the\\nmedication is stopped:\\n/C15Celexa for at least three days\\n/C15Luvox for at least 32 hours\\n/C15Paxil for at least 42 hours\\n/C15Prozac for up to five weeks\\n/C15Zoloft for at least three to five days\\nSSRIs can cause what the manufacturers refer to\\nas ‘‘discontinuation syndrome’’ when the medication\\nis stopped. Since this occurs most often when the drug\\nis stopped abruptly, usually the dose is gradually\\nreduced before stopping the drug completely. The\\noccurrence of discontinuation syndrome depends on\\nthe SSRI, the dosage, and the length of time that the\\ndrug was used. Paxil appears to induce more serious\\nwithdrawal symptoms than other SSRIs. Symptoms of\\nPaxil withdrawal appear within 1 to 10 days of stop-\\nping the drug. Because of its long half-life in the body,\\nProzac rarely causes withdrawal symptoms, although\\nsymptoms have been known to appear within 5 to 42\\ndays of stopping Prozac.\\nWithdrawal symptoms may include:\\n/C15generally feeling sick\\n/C15dry mouth\\n/C15runny nose\\n/C15dizziness or lightheadedness\\n/C15nausea and vomiting\\n/C15diarrhea\\n/C15headache\\n/C15sweating\\n/C15muscle pain\\n288 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 318, 'page_label': '289'}, page_content='/C15weakness or fatigue\\n/C15nervousness or anxiety\\n/C15restlessness or agitation\\n/C15trembling or shaking\\n/C15insomnia\\n/C15fast heart rate\\n/C15breathing difficulties\\n/C15chest pain\\n/C15confusion\\nAlthough withdrawal symptoms usually wear off,\\nin some patients some symptoms appear to continue\\nindefinitely.\\nOther precautions\\nOther precautions concerning SSRIs include:\\n/C15a 50% chance that an episode of depression will recur\\nat some point after stopping the drug\\n/C15a 90% risk of recurrence following two episodes of\\ndepression\\n/C15reports of patients developing tolerance to an SSRI,\\nrequiring increased dosages for effectiveness\\n/C15the long-term effects of SSRIs are unknown\\n/C15SSRIs are expensive: at least $2–$3 per pill; over $150\\nfor 4 oz. (133 ml) of liquid Prozac\\n/C15some insurance plans to not cover mental health\\nmedications.\\nSide effects\\nCommon side effects\\nThe most common side effects of SSRIs include:\\n/C15dry mouth\\n/C15dizziness\\n/C15sour or acid stomach or gas\\n/C15heartburn\\n/C15decreased appetite\\n/C15stomach upset\\n/C15nausea\\n/C15diarrhea\\n/C15sweating\\n/C15headache\\n/C15weakness or fatigue\\n/C15drowsiness\\n/C15insomnia\\n/C15nervousness or anxiety\\n/C15tremors\\n/C15sexual problems\\nMost common side effects disappear as the body\\nadjusts to the drug. Nausea may be relieved by taking\\nthe medication with meals or temporarily dividing the\\ndose in half.\\nCertain side effects occur more frequently depend-\\ning on the SSRI:\\n/C15Side effects of Celexa usually are mild and disappear\\nas the body adjusts.\\n/C15Luvox and Zoloft are more likely to cause gastroin-\\ntestinal upset, including stomach irritation, nausea,\\nand diarrhea.\\n/C15Paxil is more likely to cause dry mouth,constipation,\\nand drowsiness. Paxil is significantly more sedating\\nthan other SSRIs, which may benefit patients with\\ninsomnia.\\n/C15The most common side effect of Prozac is nausea\\nduring the first two weeks on the drug; nervousness\\nand anxiety also are common with Prozac.\\n/C15Paxil, Prozac, and Zoloft often reduce appetite.\\n/C15Up to 30% of those on Zoloft suffer headaches and\\n20% suffer from insomnia.\\nStudies with Luvox have found that children may\\nexperience different side effects than adults, the most\\ncommon being:\\n/C15dry mouth\\n/C15a stuffy or bloody nose\\n/C15sweating\\n/C15drowsiness\\n/C15restlessness\\n/C15muscle twitching or tics\\n/C15tremors\\n/C15thinning hair\\n/C15abnormal thinking\\nSexual side effects\\nAny SSRI can affect sexual interest or perfor-\\nmance. Side effects include increased or, more often,\\ndecreased sexual interest, difficulty reaching orgasm\\nor ejaculation, andimpotence.\\nAlthough manufacturers initially reported that\\nsexual problems were very rare side effects of\\nSSRIs, most patients in clinical trials were never\\nGALE ENCYCLOPEDIA OF MEDICINE 289\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 319, 'page_label': '290'}, page_content='asked specifically about sex and were reluctant to\\nraise the issue. After a few years it became apparent\\nthat sexual problems were commonplace among\\nSSRI users, affecting as many as 70%. Among\\nmen taking Paxil, 23% report problems with ejacu-\\nlation. Between 40% and 70% of those taking\\nProzac report negative sexual side effects, especially\\nloss of interest.\\nLess common or rare side effects\\nLess common—but potentially serious—side\\neffects of at least some SSRIs may include:\\n/C15flu-like symptoms\\n/C15sneezing\\n/C15nasal congestion or a runny nose\\n/C15sore throat\\n/C15skin rash\\n/C15itching ortingling, burning, or prickling of the skin\\n/C15fever\\n/C15chills\\n/C15body aches or pain\\n/C15muscle or joint pain\\n/C15abdominal cramps or pain\\n/C15vomiting\\n/C15decreased or increased appetite\\n/C15weight loss\\n/C15weight gain, especially after a year on an SSRI\\n/C15mouth watering\\n/C15increased frequency or amount of urination\\n/C15constipation\\n/C15menstrual changes or pain\\n/C15chest congestion or pain\\n/C15difficulty breathing\\n/C15taste changes, including a metallic taste in the mouth\\n/C15blurred vision or other visual changes\\n/C15loss of voice\\n/C15teeth grinding\\n/C15trembling or shaking\\n/C15hair loss\\n/C15sensitivity to sunlight\\n/C15anxiety or agitation\\n/C15abnormal dreams\\n/C15confusion\\n/C15lack of emotion, apathy\\n/C15memory loss\\nRare side effects that may occur with some SSRIs\\ninclude:\\n/C15symptoms of low blood sugar or sodium\\n/C15bleeding gums or nosebleeds\\n/C15unusual bruising\\n/C15irregular or slow heartbeat (less than 50 beats per\\nminute)\\n/C15fainting\\n/C15painful urination or other difficulties with urination\\n/C15purple or red spots on the skin\\n/C15skin conditions\\n/C15red or irritated eyes\\n/C15inability to move the eyes\\n/C15swelling of the face, ankles, or hands\\n/C15increased or decreased body movements\\n/C15clumsiness\\n/C15tics or other sudden or unusual body or facial move-\\nments or postures\\n/C15changes in the breasts, including leakage of milk\\n/C15seizures\\n/C15irritability\\n/C15increased depression\\n/C15mood or mental changes\\n/C15abnormal behaviors\\n/C15difficulty concentrating\\n/C15lethargy or stupor\\n/C15hallucinations\\n/C15suicidal thoughts or tendencies\\nVarious other SSRI side effects have been\\nobserved in clinical practice although their incidence\\nis not known.\\nSymptoms of overdose\\nAlthough overdose rarely occurs with SSRIs,\\nsymptoms include two or more severe side effects\\noccurring together. More common symptoms of\\nSSRI overdose include:\\n/C15flushing of the face\\n/C15enlarged pupils\\n/C15fast heart rate\\n/C15upset stomach\\n290 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 320, 'page_label': '291'}, page_content='/C15nausea and vomiting\\n/C15sweating\\n/C15dizziness\\n/C15irritability\\n/C15drowsiness\\n/C15insomnia\\n/C15trembling or shaking\\nRare symptoms of SSRI overdose include:\\n/C15deep or fast breathing with dizziness\\n/C15fainting\\n/C15muscle pain\\n/C15weakness\\n/C15difficulty urinating\\n/C15bluish skin or lips\\n/C15fast, slow, or irregular heartbeat\\n/C15low blood pressure\\n/C15confusion\\n/C15memory loss\\n/C15seizures\\n/C15coma\\nInteractions\\nSSRIs interact with many other drugs, often in\\nsimilar ways. Alcohol may increase SSRI-induced\\ndrowsiness and should not be used when taking some\\nSSRIs. Luvox appears to cause the most seriousdrug\\ninteractions, whereas Celexa has relatively few interac-\\ntions. A combination of Luvox and Clozaril can cause\\nlow blood pressure and seizures.\\nThe interaction of SSRIs with MAOIs can be\\nfatal. In addition to antidepressant MAOIs, the\\nantibiotic linezolid (Zyvox) is an MAOI. There\\nmust be at least a two-week interval between stop-\\nping one drug and starting the other. There should\\nbe at least a three-week interval between an MAOI\\nand either Paxil or Zoloft, if either type of antide-\\npressant was taken for more than three months.\\nBecause of its long half-life in the body, it is neces-\\nsary to wait five to six weeks after stopping Prozac\\nbefore starting on an MAOI.\\nSome of the drugs that can interact negatively\\nwith SSRIs include:\\n/C15other antidepressants\\n/C15antihistamines\\n/C15various medications for anxiety, mental illness, or\\nseizures\\n/C15sedatives and tranquilizers\\n/C15sleeping pills\\n/C15St. John’s wort\\nDrugs that may cause severe heart problems if\\ntaken in conjunction with some SSRIs include:\\n/C15astemizole (Hismanal)\\n/C15cisapride (Propulsid)\\n/C15terfenadine (Seldane)\\n/C15thioridazine (Mellaril), which should not be taken\\nfor at least five weeks after stopping Prozac\\nDrugs that may affect the blood levels of an SSRI\\nor the length of time that an SSRI remains in the body\\ninclude:\\n/C15antifungal drugs\\n/C15cimetidine (Tagamet)\\n/C15erythromycin\\n/C15tricyclic antidepressants\\n/C15Dilantin and phenobarbitol, which may decrease the\\nblood levels of Paxil\\nSome SSRIs may cause higher blood levels of\\nother medications including:\\n/C15alprazolam (Xanax and others)\\n/C15anticoagulants or blood-thinners such as warfarin\\n(Coumadin)—SSRIs can increase warfarin blood\\nlevels dramatically\\n/C15aspirin and other nonsteroidal anti-inflammatory\\ndrugs (NSAIDs) including ibuprofen and\\nnaproxen\\n/C15caffeine\\n/C15carbamazepine (Tegretol)\\n/C15diazepam (Valium)\\n/C15digitalis glycosides (heart medicines)\\n/C15lithium\\n/C15methadone\\n/C15phenytoin (Dilantin and others)\\n/C15propanolol (Ineral and others)\\n/C15theophylline or theophylline-containing drugs\\n/C15triazolam (Halcion and others)\\n/C15tricyclic antidepressants\\nGALE ENCYCLOPEDIA OF MEDICINE 291\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 321, 'page_label': '292'}, page_content='Serotonin syndrome\\nRarely, some drugs may interact with an SSRI to\\ncause serotonin syndrome including:\\n/C15buspirone (BuSpar)\\n/C15bromocriptine (Parlodel)\\n/C15dextromethorphan (coughmedicine such as Robitussin\\nDM)\\n/C15levodopa (Sinemet)\\n/C15lithium (Eskalith)\\n/C15meperidine (Demerol)\\n/C15moclobemide (Manerex)\\n/C15nefazodone (Serzone)\\n/C15pentazocine (Talwin)\\n/C15other SSRIs\\n/C15street drugs\\n/C15sumatriptan (Imitrex)\\n/C15tramadol (Ultram)\\n/C15trazodone (Desyrel)\\n/C15tryptophan\\n/C15venlafaxine (Effexor)\\nSerotonin syndrome may occur shortly after the\\ndose of a drug is increased.\\nSerotonin syndrome may be suspected when at\\nleast three of the following symptoms occur\\ntogether:\\n/C15diarrhea\\n/C15fever\\n/C15shivering\\n/C15sweating\\n/C15restlessness\\n/C15agitation\\n/C15uncontrollable excitement\\n/C15poor coordination\\n/C15twitching\\n/C15trembling or shaking\\n/C15rigidity\\n/C15confusion\\n/C15mental changes\\n/C15fluctuating vital signs\\nCombined treatments\\nIncreasingly physicians are combining an SSRI\\nwith other medications, either to increase effectiveness\\nor to counteract side effects. Prozac sometimes is pre-\\nscribed along with:\\n/C15an anti-anxiety drug such as Valium (diazepam)\\n/C15Desyrel (trazodone), a different type of antidepres-\\nsant, for patients with insomnia\\n/C15lithium\\nResources\\nBOOKS\\nGlenmullen, Joseph.Prozac Backlash: Overcoming the\\nDangers of Prozac, Zoloft, Paxil, and Other\\nAntidepressants with Safe, Effective Alternatives.New\\nYork: Simon & Schuster, 2000.\\nPreskorn, Sheldon H., and Renato D. Alarco´ n, editors.\\nAntidepressants: Past, Present, and Future.New York:\\nSpringer, 2004.\\nTrigoboff, Eileen.Psychiatric Drug Guide.Upper Saddle\\nRiver, NJ: Pearson/Prentice Hall, 2005.\\nPERIODICALS\\nJonsson, Patrik. ‘‘Zoloft Defense Tests Whether Pills Are\\nGuilty; A Murder Trial Highlights Evolving Legal\\nDebate Over Whether Antidepressants Limit Personal\\nAccountability.’’ Christian Science MonitorFebruary\\n11, 2005: 3.\\nSanz, Emilio J., et al. ‘‘Selective Serotonin Reuptake\\nInhibitors in Pregnant Women and Neonatal\\nWithdrawal Syndrome: A Database Analysis.’’Lancet\\n365, no. 9458 (February 5, 2005): 482–7.\\nTreatment for Adolescents With Depression Study (TADS)\\nTeam. ‘‘Fluoxetine, Cognitive-Behavioral Therapy,\\nand Their Combination for Adolescents with\\nDepression.’’ Journal of the American Medical\\nAssociation 292, no. 7 (August 18, 2004): 807–20.\\nWhittington, Craig, J., et al. ‘‘Selective Serotonin Reuptake\\nInhibitors in Childhood Depression: Systematic Review\\nof Published Versus Unpublished Data.’’Lancet 363,\\nno. 9418 (April 24, 2004): 1341–5.\\nORGANIZATIONS\\nNational Institute of Mental Health. Office of\\nCommunications, 6001 Executive Boulevard, Room\\n8184, MSC 9663, Bethesda, MD 20892-9663. 866-\\n615-6464. 301-443-4513. .\\nU.S. Food and Drug Administration. 5600 Fishers Lane,\\nRockville, MD 20857-0001. 1-888-INFO-FDA\\n(1-888-463-6332). .\\nOTHER\\nCelexaTM. Forest Pharmaceuticals, Inc. January 2004 [cited\\nMarch 6, 2005]. .\\n292 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 322, 'page_label': '293'}, page_content='Edelson, Ed. ‘‘Suicide Risk from Antidepressants Remains\\nUnclear.’’ HealthDayNews. National Health\\nInformation Center, U.S. Department of Health and\\nHuman Services. February 17, 2005 [cited March 6,\\n2005]. .\\nLexaproTM. Forest Pharmaceuticals, Inc. December 2003\\n[cited March 6, 2005]. .\\nMedications. National Institute of Mental Health. April 9,\\n2004 [cited March 13, 2005]. .\\nMundell, E. J. ‘‘Study: Benefits of Antidepressants\\nOutweigh Risks.’’HealthDayNews. National Health\\nInformation Center, U.S. Department of Health and\\nHuman Services. February 2, 2005 [cited March 25,\\n2005]. .\\nTurkington, Carol, and Eliot F. Kaplan.Selective Serotonin\\nReuptake Inhibitors (SSRIs).WebMD Medical\\nReference. 2001 [cited March 23, 2005]. .\\nMargaret Alic, Ph.D.\\nAntidepressants, tricyclic\\nDefinition\\nTricyclic antidepressants are medicines that\\nrelieve mental depression.\\nPurpose\\nSince their discovery in the 1950s, tricyclic anti-\\ndepressants have been used to treat mental depression.\\nLike otherantidepressant drugs, they reduce symptoms\\nsuch as extreme sadness, hopelessness, and lack of\\nenergy. Some tricyclic antidepressants are also used\\nto treat bulimia,cocaine withdrawal, panic disorder,\\nobsessive-compulsive disorders, certain types of\\nchronic pain, andbed-wetting in children.\\nDescription\\nNamed for their three-ring chemical structure,\\ntricyclic antidepressants work by correcting chemical\\nimbalances in the brain. But because they also affect\\nother chemicals throughout the body, these drugs may\\nproduce many unwanted side effects.\\nTricyclic antidepressants are available only with a\\nphysician’s prescription and are sold in tablet, capsule,\\nliquid, and injectable forms. Some commonly used\\ntricyclic antidepressants are amitriptyline (Elavil),\\ndesipramine (Norpramin), imipramine (Tofranil),\\nnortriptyline (Pamelor), and protriptyline (Vivactil).\\nDifferent drugs in this family have different effects,\\nand physicians can choose the drug that best fits the\\npatient’s symptoms. For example, a physician might\\nprescribe Elavil for a person with depression who has\\ntrouble sleeping, because this drug is more likely to\\nmake people feel calm and sleepy. Other tricyclic anti-\\ndepressants might be more appropriate for depressed\\npeople with low energy.\\nRecommended dosage\\nThe recommended dosage depends on many fac-\\ntors, including the patient’s age, weight, general health\\nand symptoms. The type of tricyclic antidepressant\\nand its strength also must be considered. Check with\\nthe physician who prescribed the drug or the pharma-\\ncist who filled the prescription for the correct dosage.\\nAlways take tricyclic antidepressants exactly as\\ndirected. Never take larger or more frequent doses,\\nand do not take the drug for longer than directed.\\nDo not stop taking the medicine just because it does\\nnot seem to be working. Several weeks may be needed\\nfor its effects to be felt. Visit the physician as often as\\nrecommended so that the physician can check to see if\\nthe drug is working and to note for side effects.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more. Gradually taper-\\ning the dose may be necessary to reduce the chance of\\nwithdrawal symptoms.\\nTaking this medicine with food may prevent upset\\nstomach.\\nPrecautions\\nThe effects of this medicine may continue for three\\nto seven days after patients stop taking it. All precau-\\ntions should be observed during this period, as well as\\nthroughout treatment with tricyclic antidepressants.\\nSome people feel drowsy, dizzy, or lightheaded,\\nwhen taking these drugs. The drugs may also cause\\nblurred vision. Anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them.\\nBecause tricyclic antidepressants work on the cen-\\ntral nervous system, they may add to the effects of\\nalcohol and other drugs that cause drowsiness, such\\nas antihistamines, cold medicine, allergy medicine,\\nGALE ENCYCLOPEDIA OF MEDICINE 293\\nAntidepressants, tricyclic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 323, 'page_label': '294'}, page_content='sleep aids, medicine for seizures, tranquilizers, some\\npain relievers, andmuscle relaxants. Anyone taking\\ntricyclic antidepressants should check with his or her\\nphysician before drinking alcohol or taking any drugs\\nthat cause drowsiness.\\nThese medicines make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting\\nor lying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nTricyclic antidepressants may interact with medi-\\ncines used during surgery, dental procedures, or emer-\\ngency treatment. These interactions could increase the\\nchance of side effects. Anyone who is taking tricyclic\\nantidepressants should be sure to tell the health care\\nprofessional in charge before having any surgical or\\ndental procedures or receiving emergency treatment.\\nThese drugs may also change the results of medi-\\ncal tests. Before having medical tests, anyone taking\\nthis medicine should alert the health care professional\\nin charge.\\nThis medicine may increase sensitivity to sunlight.\\nEven brief exposure to sun can cause a severesunburnor\\na rash. While being treated with this tricyclic antide-\\npressants, avoid being in direct sunlight, especially\\nbetween 10 A.M. and 3 P.M.; wear a hat and tightly\\nwoven clothing that covers the arms and legs; use a\\nsunscreen with a skin protection factor (SPF) of at\\nleast 15; protect the lips with a sun block lipstick; and\\ndo not use tanning beds, tanning booths, or sunlamps.\\nTricyclic antidepressants may causedry mouth.T o\\ntemporarily relieve the discomfort, chew sugarless\\ngum, suck on sugarless candy or ice chips, or use saliva\\nsubstitutes, which come in liquid and tablet forms and\\nare available without a prescription.\\nChildren and older people are especially sensitive to\\nthe effects of tricyclic antidepressants. This increased\\nsensitivity may increase the chance of side effects.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take tricyclic antidepressants. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to tricyclic antidepressants or to carbamazepine\\n(Tegretol), maprotiline (Ludiomil), or trazodone\\n(Desyrel) in the past should let his or her physician\\nknow before taking tricyclic antidepressants. The phy-\\nsician should also be told about anyallergies to foods,\\ndyes, preservatives, or other substances.\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBulimia— An eating disorder in which a person\\nbinges on food and then induces vomiting, uses\\nlaxatives, or goes without food for some time.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nDelusion— An abnormal mental state characterized\\nby the acceptance of something as true that is actually\\nfalse orunreal,such asthebeliefthatoneisJesus Christ.\\nDepression— A mental condition in which a person\\nfeels extremely sad and loses interest in life. A\\nperson with depression may also have sleep pro-\\nblems and loss of appetite and may have trouble\\nconcentrating and carrying out everyday activities.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nObsessive-compulsive disorder— An anxiety disor-\\nder in which a person cannot prevent himself from\\ndwelling on unwanted thoughts, acting on urges, or\\nperforming repetitious rituals, such as washing his\\nhands or checking to make sure he turned off the lights.\\nPanic disorder— An disorder in which a person has\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nProstate— A donut-shaped gland in males below the\\nbladder that contributes to the production of semen.\\nSchizophrenia— A severe mental disorder in which\\na person loses touch with reality and may have\\nillogical thoughts, delusions, hallucinations, beha-\\nvioral problems and other disturbances.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSerotonin— A natural chemical found in the brain\\nand other parts of the body, that carries signals\\nbetween nerve cells.\\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.\\n294 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressants, tricyclic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 324, 'page_label': '295'}, page_content='PREGNANCY. Problems have been reported in\\nbabies whose mothers took tricyclic antidepressants\\njust before delivery. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians about the safety of using tricyclic antidepressants.\\nBREASTFEEDING. Tricyclic antidepressants pass\\ninto breast milk and may cause drowsiness in nursing\\nbabies whose mothers take the drugs. Women who are\\nbreastfeeding should check with their physicians\\nbefore using tricyclic antidepressants.\\nDIABETES. Tricyclic antidepressants may affect\\nblood sugar levels. Diabetic patients who notice\\nchanges in blood or urine test results while taking\\nthis medicine should check with their physicians.\\nOTHER MEDICAL CONDITIONS. Before using tri-\\ncyclic antidepressants, people with any of these medi-\\ncal problems should make sure their physicians are\\naware of their conditions:\\n/C15current or past alcohol or drugabuse\\n/C15bipolar disorder (manic-depressive illness)\\n/C15schizophrenia\\n/C15seizures (convulsions)\\n/C15heart disease\\n/C15high blood pressure\\n/C15kidney disease\\n/C15liver disease\\n/C15overactive thyroid\\n/C15stomach or intestinal problems\\n/C15enlarged prostate\\n/C15problems urinating\\n/C15glaucoma\\n/C15asthma\\nUSE OF CERTAIN MEDICINES. Taking tricyclic anti-\\ndepressants with certain other drugs may affect the way\\nthe drugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, drow-\\nsiness, dry mouth, unpleasant taste,headache, nausea,\\nmild tiredness or weakness, increased appetite or crav-\\ning for sweets, and weight gain. These problems\\nusually go away as the body adjusts to the drug and\\ndo not require medical treatment. Less common side\\neffects, such as diarrhea, vomiting, sleep problems,\\nsweating, and heartburn also may occur and do not\\nneed medical attention unless they do not go away or\\nthey interfere with normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15blurred vision\\n/C15eye pain\\n/C15confusion\\n/C15hallucinations\\n/C15fainting\\n/C15loss of balance\\n/C15swallowing problems\\n/C15difficulty speaking\\n/C15mask-like face\\n/C15shakiness or trembling\\n/C15nervousness or restlessness\\n/C15movement problems, such as shuffling walk, stiff\\narms and legs, or slow movement\\n/C15decreased sexual ability\\n/C15fast or irregular heartbeat\\n/C15constipation\\n/C15problems urinating\\nSome side effects may continue after treatment\\nwith tricyclic antidepressants has ended. Check with\\na physician if these symptoms occur:\\n/C15headache\\n/C15nausea, vomiting, or diarrhea\\n/C15sleep problems, including vivid dreams\\n/C15unusual excitement, restlessness, or irritability\\nInteractions\\nLife-threatening reactions, such as extrememly high\\nblood pressure, may occur when tricyclic antidepres-\\nsants are taken with other antidepressants called mono-\\namine oxidase (MAO) inhibitors (such as Nardil\\nand Parnate).Do not take tricyclic antidepressants within\\n2 weeks of taking a MAO inhibitor. However, a patient\\ncan take an MAO inhibitor immediately after tricyclic\\nantidepressant therapy is stopped by the physician.\\nTricyclic antidepressants may interact with many\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side\\neffects may be greater. Anyone who takes tricyclic\\nantidepressants should let the physician know all\\nother medicines he or she is taking. Among the drugs\\nthat may interact with tricyclic antidepressants are:\\nGALE ENCYCLOPEDIA OF MEDICINE 295\\nAntidepressants, tricyclic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 325, 'page_label': '296'}, page_content='/C15Central nervous system (CNS) depressants such as\\nmedicine for allergies, colds, hayfever, and asthma;\\nsedatives; tranquilizers; prescription pain medicine;\\nmuscle relaxants; medicine for seizures; sleep aids;\\nbarbiturates; and anesthetics.\\n/C15diet pills\\n/C15amphetamines\\n/C15blood thinning drugs\\n/C15medicine for overactive thyroid\\n/C15cimetidine (Tagamet)\\n/C15other antidepressant drugs, including MAO inhibi-\\ntors (such as Nardil and Parnate) and antidepres-\\nsants that raise serotonin levels (such as Prozac and\\nZoloft)\\n/C15blood pressure medicines such as clonidine (Catapres)\\nand guanethidine monosulfate (Ismelin)\\n/C15disulfiram (Antabuse), used to treat alcohol abuse\\n/C15major tranquilizers such as thioridazine (Mellaril)\\nand chlorpromazine (Thorazine)\\n/C15antianxiety drugs such as chlordiazepoxide (Librium)\\nand alprazolam (Xanax)\\n/C15antiseizure medicines such as carbamazaepine\\n(Tegretol) and phenytoin (Dilantin)\\nThe list above does not include every drug that\\nmay interact with tricyclic antidepressants. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning tricyclic antidepressants with any other prescrip-\\ntion or nonprescription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntidiabetic drugs\\nDefinition\\nAntidiabetic drugs are medicines that help control\\nblood sugar levels in people with diabetes mellitus\\n(sugar diabetes).\\nPurpose\\nDiabetes may be divided into type I and type II,\\nformerly termed juvenile onset or insulin-dependent,\\nand maturity onset or non insulin-dependent. Type I is\\ncaused by a deficiency of insulin production, while\\ntype II is characterized byinsulin resistance.\\nT r e a t m e n to ft y p eId i a b e t e si sl i m i t e dt oi n s u l i n\\nreplacement, while type II diabetes is treatable by a\\nnumber of therapeutic approaches. Many cases of insu-\\nlin resistance are asymptomatic due to normal increases\\nin insulin secretion, and others may be controlled by\\ndiet andexercise. Drug therapy may be directed toward\\nincreasing insulin secretion, increasing insulin sensitiv-\\nity, or increasing insulin penetration of the cells.\\nDescription\\nAntidiabetic drugs may be subdivided into six\\ngroups: insulin, sufonylureas, alpha-glucosidase inhibi-\\ntors, biguanides, meglitinides, and thiazolidinediones.\\nInsulin (Humulin, Novolin) is the hormone respon-\\nsible for glucose utilization. It is effective in both types\\nof diabetes, since, even in insulin resistance, some sen-\\nsitivity remains and the condition can be treated with\\nKEY TERMS\\nBlood sugar— The concentration of glucose in the\\nblood.\\nGlucose— A simple sugar that serves as the body’s\\nmain source of energy.\\nHormone— A substance that is produced in one part\\nof the body, then travels through the bloodstream to\\nanother part of the body where it has its effect.\\nMetabolism— All the physical and chemical changes\\nthat occur in cells to allow growth and maintain\\nbody functions. These include processes that break\\ndown substances to yield energy and processes\\nthat build up other substances necessary for life.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nSalicylates— A group of drugs that includes aspirin\\nand related compounds. Salicylates are used to\\nrelieve pain, reduce inflammation, and lower fever.\\nSeizure— A sudden attack, spasm, or convulsion.\\n296 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiabetic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 326, 'page_label': '297'}, page_content='larger doses of insulin. Most insulins are now produced\\nby recombinant DNA techniques, and are chemically\\nidentical to natural human insulin. Isophane insulin\\nsuspension, insulin zinc suspension, and other formula-\\ntions are intended to extend the duration of insulin\\naction, and permit glucose control over longer periods\\nof time. In 2003, research suggested that inhaled forms\\nof insulin offered advantages to injected types, but\\nfurther study was needed on its long-term effects on\\nthe lungs and cost-effectiveness.\\nSulfonylureas (chlorpropamide [Diabinese], tola-\\nzamide [Tolinase], glipizide [Glucotrol] and others) act\\nby increasing insulin release from the beta cells of the\\npancrease. Glimepiride (Amaryl), a member of this\\nclass, appears to have a useful secondary action in\\nincreasing insulin sensitivity in peripheral cells.\\nAlpha-glucosidase inhibitors (acarbose [Precose],\\nmiglitol [Glyset]) do not enhance insulin secretion.\\nRather, they inhibit the conversion of disaccharides and\\ncomplex carbohydrates to glucose. This mechanism does\\nnot prevent conversion, but only delays it, reducing the\\npeak blood glucose levels. Alpha-glucosidase inhibitors\\nare useful for either monotherapy or in combination\\ntherapywithsulfonylureas orotherhypoglycemicagents.\\nMetformin (Glucophage) is the only available mem-\\nber of the biguanide class. Metformin decreases hepatic\\n(liver) glucose production, decreases intestinal absorp-\\ntion of glucose and increases peripheral glucose uptake\\nand use. Metformin may be used as monotherapy\\n(alone), or in combination therapy with a sulfonylurea.\\nThere are two members of the meglitinide class:\\nrepaglinide (Prandin) and nateglitinide (Starlix). The\\nmechanism of action of the meglitinides is to stimulate\\ninsulin production. This activity is both dose dependent\\nand dependent on the presence of glucose, so that the\\ndrugs have reduced effectiveness in the presence of low\\nblood glucose levels. The meglitinides may be used alone,\\nor in combination with metformin. The manufacturer\\nwarns that nateglitinide should not be used in combina-\\ntion with other drugs that enhance insulin secretion.\\nRosiglitazone (Avandia) and pioglitazone (Actos)\\nare members of the thiazolidinedione class. They act\\nby both reducing glucose production in the liver, and\\nincreasing insulin dependent glucose uptake in muscle\\ncells. They do not increase insulin production. These\\ndrugs may be used in combination with metformin or\\na sulfonylurea.\\nRecommended dosage\\nDosage must be highly individualized for all anti-\\ndiabetic agents and is based on blood glucose levels\\nwhich must be taken regularly. Patients should review\\nspecific literature that comes with antidiabetic medica-\\ntions for complete dosage information.\\nPrecautions\\nInsulin. The greatest short term risk of insulin is\\nhypoglycemia, which may be the result of either a\\ndirect overdose or an imbalance between insulin injec-\\ntion and level of exercise and diet. This also may occur\\nin the presence of other conditions which reduce the\\nglucose load, such as illness withvomiting and diar-\\nrhea. Treatment is with glucose in the form of glucose\\ntablets or liquid, although severe cases may require\\nintravenous therapy. Allergic reactions and skin reac-\\ntions also may occur. Insulin is classified as category B\\nin pregnancy, and is considered the drug of choice for\\nglucose control during pregnancy. Insulin glargine\\n(Lantus), an insulin analog which is suitable for\\nonce-daily dosing, is classified as category C, because\\nthere have been reported changes in the hearts of new-\\nborns in animal studies of this drug. The reports are\\nessentially anecdotal, and no cause and effect relation-\\nship has been determined. Insulin is not recommended\\nduring breast feeding because either low or high\\ndoses of insulin may inhibit milk production. Insulin\\nadministered orally is destroyed in the GI tract, and\\nrepresents no risk to the newborn.\\nSulonylureas. All sulfonylurea drugs may cause\\nhypoglycemia. Most patients become resistant to these\\ndrugs over time, and may require either dose adjust-\\nments or a switch to insulin. The list of adverse reactions\\nis extensive, and includes central nervous system pro-\\nblems and skin reactions, among others. Hematologic\\nreactions, although rare,may be severe and include\\naplastic anemiaand hemolytic anemia.T h ea d m i n i s t r a -\\ntion of oral hypoglycemic drugs has been associated\\nwith increased cardiovascular mortality as compared\\nwith treatment with diet alone or diet plus insulin. The\\nsulfonylureas are classified as category C during preg-\\nnancy, based on animal studies, although glyburide has\\nnot shown any harm to the fetus and is classified as\\ncategory B. Because there may be significant alterations\\nin blood glucose levels during pregnancy, it is recom-\\nmended that patients be switched to insulin. These drugs\\nhave not been fully studied during breast feeding, but it\\nis recommended that becausetheir presence in breast\\nmilk might cause hypoglycemia in the newborn, breast\\nfeeding be avoided while taking sulfonylureas.\\nAlpha-glucosidase inhibitors are generally well\\ntolerated, and do not cause hypoglycemia. The most\\ncommon adverse effects are gastrointestinal problems,\\nincluding flatulence, diarrhea, and abdominalpain.\\nGALE ENCYCLOPEDIA OF MEDICINE 297\\nAntidiabetic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 327, 'page_label': '298'}, page_content='These drugs are classified as category B in pregnancy.\\nAlthough there is no evidence that the drugs are harm-\\nful to the fetus, it is important that rigid blood glucose\\ncontrol be maintained during pregnancy, and preg-\\nnant women should be switched to insulin. Alpha-\\nglucosidase inhibitors may be excreted in small\\namounts in breast milk, and it is recommended that\\nthe drugs not be administered to nursing mothers.\\nMetformin causes gastrointestinal (stomach and\\ndigestive) reactions in about a third of patients. A rare,\\nbut very serious, reaction to metformin is lactic acido-\\nsis, which is fatal in about 50% of cases. Lactic acido-\\nsis occurs in patients with multiple medical problems,\\nincluding renal (kidney-related) insufficiency. The risk\\nmay be reduced with careful renal monitoring, and\\ncareful dose adjustments to metformin. Metformin is\\ncategory B during pregnancy. There have been no\\ncarefully controlled studies of the drug during preg-\\nnancy, but there is no evidence of fetal harm from\\nanimal studies. It is important that rigid blood glucose\\ncontrol be maintained during pregnancy, and preg-\\nnant women should be switched to insulin. Animal\\nstudies show that metformin is excreted in milk. It is\\nrecommended that metformin not be administered to\\nnursing mothers.\\nMeglitinides. These drugs are generally well tol-\\nerated, with an adverse event profile similar to pla-\\ncebo. The drugs are classified as category C during\\npregnancy, based on fetal abnormalities in rabbits\\ngiven about 40 times the normal human dose. It is\\nimportant that rigid blood glucose control be main-\\ntained during pregnancy, and pregnant women\\nshould be switched to insulin. It is not known\\nwhether the meglitinides are excreted in human\\nmilk, but it is recommended that these drugs not be\\ngiven to nursing mothers.\\nThiazolidinediones. These drugs were generally\\nwell tolerated in early trials, but they are structurally\\nrelated to an earlier drug, troglitazone, which was\\nassociated with liver function problems. However, in\\n2003, researchers reported that these drugs, which are\\nused by more than 6 million Americans, may lead to\\nserious side effects. Research showed that after one to\\n16 months of therapy with pioglitazone or rosiglita-\\nzone, some patients developed seriousedema and signs\\nof congestive heart failure. Additional studies were\\nunderway in late 2003 to determine how these drugs\\ncaused fluid build-up and if the symptoms occurred\\nmore frequently in certain age groups. The mean age\\nof patients in the 2003 study was 69 years.\\nIt is strongly recommended that all patients treated\\nwith pioglitazone or rosiglitazone have regular liver\\nfunction monitoring. The drugs are classified as preg-\\nnancy category C, based on evidence of inhibition of\\nfetal growth in rats given more than four times the\\nnormal human dose. It is important that rigid blood\\nglucose control be maintained during pregnancy, and\\npregnant women should be switched to insulin. It is not\\nknown whether the thiazolidinediones are excreted in\\nhuman milk, however they have been identified in the\\nmilk of lactating rats. It is recommended that these\\ndrugs not be administered to nursing mothers.\\nInteractions\\nThe sulfonylureas have a particularly long list of\\ndrug interactions, several of which may be severe.\\nPatients should review specific literature for these drugs.\\nThe actions of oral hypoglycemic agents may be\\nstrengthened by highly protein bound drugs, including\\nNSAIDs, salicylates, sulfonamides, chloramphenicol,\\ncoumarins, probenecid, MAOIs, andbeta blockers.\\nThe literature that accompanies each medication\\nshould list possible drug-drug or food-drug interactions.\\nResources\\nPERIODICALS\\n‘‘Inhaled Insulin Means Better Quality of Life.’’Health &\\nMedicine Week(September 16, 2003): 189.\\n‘‘Two Common Diabetes Drugs May Cause Heart Failure\\nand Fluid Buildup.’’Cardiovascular Week(September\\n29, 2003): 26.\\nORGANIZATIONS\\nAmerican Diabetes Association. ADA National Service\\nCenter, 1660 Duke Street, Alexandria, VA 22314.\\n(800)232-3472. .\\nNational Diabetes Information Clearinghouse. 1\\nInformation Way, Bethesda, MD 20892-3560.\\n(301)654-3327. ndic@info.niddk.nih.gov.\\nOTHER\\nNational Institute of Diabetes and Digestive and Kidney\\nDiseases. .\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntidiarrheal drugs\\nDefinition\\nAntidiarrheal drugs are medicines that relieve\\ndiarrhea.\\n298 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiarrheal drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 328, 'page_label': '299'}, page_content='Purpose\\nAntidiarrheal drugs help control diarrhea and some\\nof the symptoms that go along with it. An average,\\nhealthy person has anywhere from three bowel move-\\nments a day to three a week, depending on that person’s\\ndiet. Normally the stool (the material that is passed in a\\nbowel movement) has a texture something like clay.\\nWithdiarrhea,bowelmovementsmaybemorefrequent,\\nandthetextureofthestool isthinandsometimes watery.\\nDiarrhea is not a disease, but a symptom of some\\nother problem. The symptom may be caused by eating\\nor drinking food or water that is contaminated with\\nbacteria, viruses, or parasites, or by eating something\\nthat is difficult to digest. People who have trouble\\ndigesting lactose (milk sugar), for example, may get\\ndiarrhea if they eat dairy products. Some cases of\\ndiarrhea are caused bystress, while others are brought\\non by taking certain medicines.\\nDescription\\nAntidiarrheal drugs work in several ways. The\\ndrug loperamide, found in Imodium A-D, for example,\\nslows the passage of stools through the intestines. This\\nallows more time for water and salts in the stools to be\\nabsorbed back into the body. Adsorbents, such as atta-\\npulgite (found in Kaopectate) pull diarrhea-causing\\nsubstances from the digestive tract. However, they\\nmay also pull out substances that the body needs,\\nsuch as enzymes and nutrients. Bismuth subsalicylate,\\nthe ingredient in Pepto-Bismol, decreases the secretion\\nof fluid into the intestine and inhibits the activity of\\nbacteria. It not only controls diarrhea, but relieves the\\ncramps that often accompany diarrhea.\\nThese medicines come in liquid, tablet, caplet, and\\nchewable tablet forms and can be bought without a\\nphysician’s prescription.\\nRecommended dosage\\nThe dose depends on the type of antidiarrheal\\ndrug. Read and follow the directions on the product\\nlabel. For questions about dosage, check with a phy-\\nsician or pharmacist. Never take larger or more fre-\\nquent doses, and do not take the drug for longer than\\ndirected.\\nPrecautions\\nDiarrhea usually improves within 24-48 hours. If\\nthe problem lasts longer or if it keeps coming back,\\ndiarrhea could be a sign of a more serious problem.\\nAnyone who has any of the symptoms listed below\\nshould get medical attention as soon as possible:\\n/C15diarrhea that lasts more than two days or gets worse\\n/C15fever\\n/C15blood in the stool\\n/C15vomiting\\n/C15cramps or tenderness in the abdomen\\n/C15signs of dehydration, such as decreased urination,\\ndizziness or lightheadedness, dry mouth, increased\\nthirst, or wrinkled skin\\nDo not use antidiarrheal drugs for more than two\\ndays unless told to do so by a physician.\\nSevere, long-lasting dia r r h e ac a nl e a dt od e h y -\\ndration. In such cases, lost fluids and salts, such as\\ncalcium, sodium, and potassium, must be replaced.\\nPeople older than 60 should not use attapulgite\\n(Kaopectate, Donnagel, Parepectolin), but may use\\nother kinds of antidiarrheal drugs. However, people\\nin this age group may be more likely to have side\\neffects, such as severeconstipation, from bismuth sub-\\nsalicylate. Ask the pharmacist for more information.\\nBismuth subsalicylate may cause the tongue or the\\nstool to temporarily darken. This is harmless.\\nHowever, do not confuse this harmless darkening of\\nthe stool with the black, tarry stools that are a sign of\\nbleeding in the intestinal tract.\\nChildren with flu or chicken pox should not be\\ngiven bismuth subsalicylate. It can lead toReye’s syn-\\ndrome, a life-threatening condition that affects the\\nliver and central nervous system. To be safe, never\\ngive bismuth subsalicylate to a child under 16 years\\nwithout consulting a physician. Children may have\\nunpredictable reactions to other antidiarrheal drugs.\\nLoperamide should not be given to children under six\\nyears and attapulgite should not be given to children\\nunder three years unless directed by a physician.\\nKEY TERMS\\nColitis— Inflammation of the colon (large bowel).\\nDehydration— Excessive loss of water from the\\nbody.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nNutrient— A food substance that provides energy or\\nis necessary for growth and repair. Examples of nutri-\\nents are vitamins, minerals, carbohydrates, fats, and\\nproteins.\\nGALE ENCYCLOPEDIA OF MEDICINE 299\\nAntidiarrheal drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 329, 'page_label': '300'}, page_content='Anyone who has a history ofliver diseaseor who\\nhas been takingantibiotics should check with his or her\\nphysician before taking the antidiarrheal drug loper-\\namide. A physician should also be consulted before\\nanyone with acuteulcerative colitisor anyone who has\\nbeen advised to avoid constipation uses the drug.\\nLoperamide should not be used by people whose\\ndiarrhea is caused by certain infections, such as sal-\\nmonella or shigella. To be safe, check with a physician\\nbefore using this drug.\\nAnyone who has a medical condition that causes\\nweakness should check with a physician about the best\\nway to treat diarrhea.\\nSpecial conditions\\nBefore taking antidiarrheal drugs, be sure to let\\nthe physician know about any of these conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto aspirin or other drugs containing salicylates should\\ncheck with a physician before taking bismuth subsali-\\ncylate. Anyone who has developed a rash or other\\nunusual reactions after taking loperamide should not\\ntake that drug again without checking with a physician.\\nThe physician should also be told about anyallergiesto\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY AND BREASTFEEDING. Women who\\nare pregnant or breastfeeding should check with their\\nphysicians before using antidiarrheal drugs. They should\\nalso ask advice on how to replace lost fluids and salts.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\ndiarrheal drugs, people with any of these medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15dysentery\\n/C15gout\\n/C15hemophilia or other bleeding problems\\n/C15kidney disease\\n/C15stomach ulcer\\n/C15severe colitis\\n/C15liver disease\\nUSE OF CERTAIN MEDICINES. Taking antidiarrheal\\ndrugs with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects of attapulgite\\nare constipation, bloating, and fullness. Bismuth\\nsubsalicylate may cause ringing in the ears, but\\nthat side effect is rare. Possible side effects from\\nloperamide include skin rash, constipation, drowsi-\\nness, dizziness, tiredness, dry mouth,nausea,v o m i t -\\ning, and swelling, pain, and discomfort in the\\nabdomen. Some of these symptoms are the same\\nas those that occur with diarrhea, so it may be\\ndifficult to tell if the medicine is causing the pro-\\nblems. Children may be more sensitive than adults\\nto certain side effects of loperamide, such as drow-\\nsiness and dizziness.\\nOther rare side effects may occur with any anti-\\ndiarrheal medicine. Anyone who has unusual symp-\\ntoms after taking an antidiarrhea drug should get in\\ntouch with his or her physician.\\nInteractions\\nAttapulgite can decrease the effectiveness of other\\nmedicines taken at the same time. Changing the times\\nat which the other medicines are taken may be neces-\\nsary. Check with a physician or pharmacist to work\\nout the proper dose schedule.\\nBismuth subsalicylate should not be taken with\\naspirin or any other medicine that contains salicylate.\\nThis drug may also interact with other drugs, such as\\nblood thinners (warfarin, for example), methotrexate,\\nthe antigout medicine probenecid, and the antidia-\\nbetes drug tolbutamide. In addition, bismuth subsali-\\ncylate may interact with any drug that interacts with\\naspirin. Anyone taking these drugs should check with\\na physician or pharmacist before taking bismuth\\nsubsalicylate.\\nNancy Ross-Flanigan\\nAntidiuretic hormone (ADH)\\ntest\\nDefinition\\nAntidiuretic hormone (ADH) test, also called the\\nVasopressin test, is a test for the antidiuretic hormone,\\nwhich is released from the pituitary gland and acts on\\nthe kidneys to increase their reabsorption of water into\\nthe blood.\\nPurpose\\nAn ADH test is used to aid in the diagnosis of\\ndiabetes insipidus or the syndrome of inappropriate\\nADH called SIADH.\\n300 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiuretic hormone (ADH) test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 330, 'page_label': '301'}, page_content='Precautions\\nCertain drugs can either increase or decrease\\nADH levels. Drugs that increase ADH levels include\\nacetaminophen, barbiturates, cholinergic agents, estro-\\ngen, nicotine, oralhypoglycemia agents, somediuretics\\n(e.g., thiazides), cyclophosphamide,narcotics, andtri-\\ncyclic antidepressants. Drugs that decrease ADH levels\\ninclude alcohol, beta-adrenergic agents, morphine\\nantagonists, and phenytoin (Dilantin).\\nDescription\\nThe purpose of ADH is to control the amount of\\nwater reabsorbed by the kidneys. Water is continu-\\nally being taken into the body in food and drink, as\\nwell as being produced by chemical reactions in cells.\\nWater is also continually lost in urine, sweat, feces,\\nand in the breath as water vapor. ADH release helps\\nmaintain the optimum amount of water in the body\\nwhen there is an increase in the concentration of the\\nblood serum or a decrease in blood volume. Physical\\nstress, surgery, and high levels ofanxiety can also\\nstimulate ADH.\\nVarious factors can affect ADH production,\\nthereby disturbing the body’s water balance. For\\nexample, alcohol consumption reduces ADH pro-\\nduction by direct action on the brain, resulting in a\\ntemporarily increased production of urine. This may\\nalso occur in diabetes insipidus, when the pituitary\\ngland produces insufficient ADH, or rarely, when the\\nkidneys fail to respond to ADH. The reverse effect of\\nwater retention can result from temporarily\\nincreased ADH production after a major operation\\nor accident. Water retention may also be caused by\\nthe secretion of ADH by some tumors, especially of\\nthe lung.\\nPreparation\\nThe test requires collection of a blood sample. The\\npatient must befasting (nothing to eat or drink) for\\n12 hours, be adequately hydrated, and limit physical\\nactivity for 10-12 hours before the test.\\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\\nADH normal ranges are laboratory-specific but\\ncan range from 1-5 pg/ml or 1.5 ng/L (SI units).\\nAbnormal results\\nPatients who are dehydrated, who have a decreased\\namount of blood in the body (hypovolemia), or who are\\nundergoing severe physical stress (e.g., trauma,pain or\\nprolonged mechanical ventilation) may exhibit increased\\nADH levels. Patients who are overly hydrated or who\\nhave an increased amount of blood in the body (hyper-\\nvolemia) may have decreased ADH levels.\\nOther conditions that cause increased levels\\ninclude SIADH, central nervous system tumors or\\ninfection, orpneumonia.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAntiemetic drugs see Antinausea drugs\\nAntiepileptic drugs see Anticonvulsant drugs\\nAntifungal drugs, systemic\\nDefinition\\nSystemic antifungal drugs are medicines taken by\\nmouth or by injection to treat deep infections caused\\nby a fungus.\\nKEY TERMS\\nDiabetes insipidus— A metabolic disorder in which\\nthe pituitary gland producesinadequate amounts of\\nantidiuretic hormone (ADH) or the kidneys are unable\\nto respond to release of the hormone. Primary symp-\\ntoms are excessive urination and constant thirst.\\nPituitary gland— The pituitary gland is sometimes\\nreferred to as the ‘‘master gland.’’ As the most impor-\\ntant of the endocrine glands (glands which release\\nhormones directly into the bloodstream), it regulates\\nand controls not only the activities of other endo-\\ncrine glands but also many body processes.\\nGALE ENCYCLOPEDIA OF MEDICINE 301\\nAntifungal drugs, systemic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 331, 'page_label': '302'}, page_content='Purpose\\nSystemic antifungal drugs are used to treat\\ninfections in various parts of the body that are\\ncaused by a fungus. A fungus is an organism that\\ncan be either one-celled or filamentous. Unlike a\\nplant, which makes its own food, or an animal,\\nwhich eats plants or other animals, a fungus sur-\\nvives by invading and living off other living things.\\nFungi thrive in moist, dark places, including some\\nparts of the body.\\nFungal infections can either be systemic, meaning\\nthat the infection is deep, or topical (dermatophytic),\\nmeaning that the infection is superficial and occurs on\\nthe skin. Additionally, yeast infections can affect the\\nmucous membranes of the body. Fungal infections on\\nthe skin are usually treated with creams or ointments\\n(topical antifungal drugs). However, systemic infec-\\ntions, yeast infections or topical infections that do\\nnot clear up after treatment with creams or ointments\\nmay need to be treated with systemic antifungal drugs.\\nThese drugs are used, for example, to treat common\\nfungal infections such as tinea (ringworm), which\\noccurs on the skin orcandidiasis (a yeast infection,\\nalso known as trush), which can occur in the throat,\\nin the vagina, or in other parts of the body. They are\\nalso used to treat other deep fungal infections such as\\nhistoplasmosis, blastomycosis, andaspergillosis, which\\ncan affect the lungs and other organs. They are some-\\ntimes used to prevent or treat fungal infections in\\npeople whose immune systems are weakened, such as\\nbone marrow or organ transplant patients and people\\nwith AIDS.\\nDescription\\nAntifungal drugs are categorized depending on\\ntheir route or site of action, their mechanism of action\\nand their chemical nature.\\nSystemic antifungal drugs, such as capsofungin\\n(Cancidas), flucytosine, fluconazole (Diflucan), itra-\\nconazole (Sporanox), ketoconazole (Nizoral), and\\nmiconazole (Monistat I.V.) are available only by pre-\\nscription. They are available in tablet, capsule, liquid,\\nand injectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantifungal drug and the nature and extent of fungal\\ninfection being treated. Doses may also be different for\\ndifferent patients. The prescribing physician or the\\npharmacist can provide dosage information.\\nSystemic antifungal drugs must be taken exactly as\\ndirected. Itraconazole and ketoconazole should be\\ntaken with food.\\nFungal infections can take a long time to clear up,\\nso it may be necessary to take the medication for several\\nmonths, or even for a year or longer. It is very import-\\nant to keep taking the medicine for as long as the\\nphysician says to take it, even if symptoms seem to\\nimprove. If the drug is stopped too soon, the symptoms\\nmay return.\\nSystemic antifungal drugs work best when their\\namount is kept constant in the body, meaning that\\nthey have to be taken regularly, at the same time\\nevery day, and without missing any doses.\\nPatients taking the liquid form of ketoconazole\\nshould use a specially marked medicine spoon or other\\nmedicine measuring device to make sure they take the\\ncorrect amount. A regular household teaspoon may\\nnot hold the right amount of medicine. Ask the phar-\\nmacists about ways to accurately measure the dose of\\nthese drugs.\\nPrecautions\\nIf symptoms do not improve within a few weeks,\\nthe prescribing physician should be informed.\\nWhile taking this medicine, regular medical visits\\nshould be scheduled. The physician needs to keep\\nchecking for side effects throughout the antifungal\\ntherapy.\\nSome people feel drowsy or dizzy while taking\\nsystemic antifungal drugs. Anyone who takes these\\ndrugs should not drive, use machines or do anything\\nKEY TERMS\\nElixir— A sweetened liquid that contains alcohol,\\nwater, and medicine.\\nFetus— A developing baby inside the womb.\\nFungus— A unicellular to filamentous organism\\nthat causes parasitic infections.\\nOintment— A thick substance that contains medi-\\ncine and is meant to be spread on the skin, or if an\\nophthalmic ointment, in the eye.\\nSystemic— At e r mu s e dt od e s c r i b eam e d i c i n e\\nthat has effects throughout the body, as opposed\\nto topical drugs that work on the skin. Most med-\\nicines that are taken by mouth or by injection are\\nsystemic drugs.\\n302 GALE ENCYCLOPEDIA OF MEDICINE\\nAntifungal drugs, systemic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 332, 'page_label': '303'}, page_content='else that might be dangerous until they have found out\\nhow the drugs affect them.\\nLiver problems, stomach problems and other pro-\\nblems may occur in people who drink alcohol while\\ntaking systemic antifungal drugs. Alcohol and pre-\\nscription or nonprescription (over-the-counter) drugs\\nthat contain alcohol should be avoided while taking\\nantifungal drugs. (Medicines that may contain alcohol\\ninclude some cough syrups, tonics, and elixirs.)\\nAlcohol should be avoided for at least a day after\\ntaking an antifungal drug.\\nThe antifungal drug ketoconazole may make the\\neyes unusually sensitive to light. Wearing sunglasses\\nand avoiding exposure to bright light may help.\\nSpecial conditions\\nPeople with certain medical conditions or who\\nare taking certain other medicines can have pro-\\nblems if they take systemic antifungal drugs.\\nBefore taking these drugs, the prescribing physician\\nshould be informed about any of the following\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to systemic antifungal drugs in the past should\\nlet his or her physician know about the problem before\\ntaking the drugs again. The physician should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nPREGNANCY. In laboratory studies of animals,\\nsystemic antifungal drugs have causedbirth defects\\nand other problems in the mother and fetus.\\nStudies have not been done on pregnant women,\\nso it is not known whether these drugs cause simi-\\nlar effects in people. Women who are pregnant or\\nwho plan to become pregnant should check with\\ntheir physicians before taking systemic antifungal\\ndrugs. Any woman who becomes pregnant while\\ntaking these drugs should let her physician know\\nimmediately.\\nBREASTFEEDING. Systemic antifungal drugs pass\\ninto breast milk. Women who are breastfeeding\\nshould check with their physicians before using sys-\\ntemic antifungal drugs.\\nOTHER MEDICAL CONDITIONS. People who have\\nmedical conditions that deplete stomach acid (achlor-\\nhydria) or decrease stomach acid (hypochlorhydria)\\nshould be sure to inform their physicians about their\\ncondition before they use a systemic antifungal drug.\\nThese drugs are not active in their natural form, but\\nmust be converted to the active form by an acid. If\\nthese is not enough stomach acid, the drugs will be\\nineffective. For people with insufficient stomach acid,\\nit may help to take the medicine with an acidic drink,\\nsuch as a cola. The patient’s health care provider can\\nsuggest the best way to take the medicine.\\nBefore using systemic antifungal drugs, people\\nwith any of these medical problems should also make\\nsure their physicians are aware of their conditions:\\n/C15current or past alcoholabuse\\n/C15liver disease\\n/C15kidney disease\\nUSE OF CERTAIN MEDICINES. Taking systemic anti-\\nfungal drugs with certain other drugs may affect the\\nway the drugs work or may increase the chance of side\\neffects.\\nSide effects\\nFluconazole\\nAlthough rare, severe allergic reactions to this\\nmedicine have been reported. Call a physician imme-\\ndiately if any of these symptoms develop after taking\\nfluconazole (Diflucan):\\n/C15hives, itching, or swelling\\n/C15breathing or swallowing problems\\n/C15sudden drop in blood pressure\\n/C15diarrhea\\n/C15abdominal pain\\nKetoconazole\\nKetoconazole has caused anaphylaxis (a life-\\nthreatening allergic reaction) in some people after\\ntheir first dose. This is a rare reaction.\\nSystemic antifungal drugs in general\\nSystemic antifungal drugs may cause serious and\\npossibly life-threatening liver damage. Patients who\\ntake these drugs should haveliver function testsbefore\\nthey start taking the medicine and as often as their\\nphysician recommends while they are taking it. The\\nphysician should be notified immediately if any of\\nthese symptoms develop:\\n/C15loss of appetite\\n/C15nausea or vomiting\\n/C15yellow skin or eyes\\n/C15unusual fatigue\\n/C15dark urine\\n/C15pale stools\\nGALE ENCYCLOPEDIA OF MEDICINE 303\\nAntifungal drugs, systemic'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 333, 'page_label': '304'}, page_content='The most common minor side effects of systemic\\nantifungal drugs are constipation, diarrhea, nausea,\\nvomiting, headache, drowsiness,dizziness, and flush-\\ning of the face or skin. These problems usually go\\naway as the body adjusts to the drug and do not\\nrequire medical treatment. Less common side effects,\\nsuch as menstrual problems in women, breast enlar-\\ngement in men, and decreased sexual ability in men\\nalso may occur and do not need medical attention\\nunless they do not improve in a reasonable amount\\nof time.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nimmediately:\\n/C15fever and chills\\n/C15skin rash or itching\\n/C15high blood pressure\\n/C15pain, redness, or swelling at site of injection (for\\ninjectable miconazole)\\nOther rare side effects are possible. Anyone who\\nhas unusual symptoms after taking systemic antifun-\\ngal drugs should get in touch with his or her physician.\\nInteractions\\nSerious and possibly life-threatening side effects\\ncan result if the oral forms of itraconazole or ketoco-\\nnazole or the injectable form of miconazole are taken\\nwith certain drugs. Do not take those types of\\nsystemic antifungal drugs with any of the following\\ndrugs unless the physician approves of the therapy:\\n/C15astemizole (Hismanal)\\n/C15cisapride (Propulsid)\\n/C15antacids\\n/C15theophylline-containing anti-wheezing medications\\nTaking an acid blocker such as cimetidine\\n(Tagamet), famotidine (Pepcid), nizatidine (Axid),\\nomeprazole (Prilosec), or ranitidine (Zantac) at the\\nsame time as a systemic antifungal drug may prevent\\nthe antifungal drug from working properly. For best\\nresults, take the acid blocker at least 2 hours after\\ntaking the antifungal drug.\\nIn addition, systemic antifungal drugs may inter-\\nact with many other medicines. When this happens,\\nthe effects of one or both of the drugs may change or\\nthe risk of side effects may be greater.Anyone who\\ntakes systemic antifungal drugs should inform the pre-\\nscribing physician about all other prescription and non-\\nprescription (over-the-counter) medicines he or she is\\ntaking. Among the drugs that may interact with sys-\\ntemic antifungal drugs are:\\n/C15acetaminophen (Tylenol)\\n/C15birth control pills\\n/C15male hormones (androgens)\\n/C15female hormones (estrogens)\\n/C15medicine for other types of infections\\n/C15antidepressants\\n/C15antihistamines\\n/C15muscle relaxants\\n/C15medicine for diabetes, such as tolbutamide (Orinase),\\nglyburide (DiaBeta), and glipizide (Glucotrol)\\n/C15blood-thinning medicine, such as warfarin (Coumadin)\\nThe list above does not include every drug that\\nmay interact with systemic antifungal drugs. Be sure\\nto check with a physician or pharmacist before com-\\nbining systemic antifungal drugs with any other\\nmedicine.\\nNancy Ross-Flanigan\\nAntifungal drugs, topical\\nDefinition\\nTopical antifungal drugs are medicines applied to\\nthe skin to treat skin infections caused by a fungus.\\nPurpose\\nDermatologic fungal infections are usually\\ndescribed by their location on the body: tinea pedis\\n(infection of the foot), tinea unguium (infection of the\\nnails), tinia capitis (infection of the scalp.) Three types\\nof fungus are involved in most skin infections:\\nTrichophyton, Epidermophyton, and Microsporum.\\nMild infections are usually susceptible to topical\\ntherapy, however severe or resistant infections may\\nrequire systemic treatment.\\nDescription\\nThere are a large number of drugs currently\\navailable in topical form for fungal infections.\\nOther than the imidazoles, (miconazole [Micatin,\\nMiconazole], clotrimazole [Lotrimin], econazole\\n[Spectazole], ketoconazole [Nizoral], oxiconazole\\n[Oxistat], sulconazole [Exelderm]) and the\\n304 GALE ENCYCLOPEDIA OF MEDICINE\\nAntifungal drugs, topical'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 334, 'page_label': '305'}, page_content='allylamine derivatives (butenafine [Mentax], nafti-\\nfine [Naftin], terbinafine [Lamisil]), the drugs in\\nthis therapeutic class are chemically distinct from\\neach other. All drugs when applied topically have\\na good margin of safety, and most show a high\\ndegree of effectiveness. There are no studies com-\\nparing drugs on which to base a recommendation\\nfor drugs of choice. Although some of the topical\\nantifungals are available over-the-counter, they\\nmay be as effective as prescription drugs for this\\npurpose.\\nTraditional antifungal drugs such as undecylinic\\nacid (Cruex, Desenex) and gentian violet (also known\\nas crystal violet) remain available, but have a lower\\ncure rate (complete eradication of fungus) than the\\nnewer agents and are not recommended. Tolnaftate\\n(Tinactin) has a lower cure rate than the newer drugs,\\nbut may be used prophylactically to prevent\\ninfection.\\nRecommended dosage\\nAll drugs are applied topically. Consult individual\\nproduct information for specific application\\nrecommendations.\\nAs with all topical products, selection of the\\ndosage form may be as important as proper drug\\nselection. Consider factors such as presence or\\nabsence of hair on the affected area, and type of\\nskin to which the medication is to be applied. Thin\\nliquids may preferable for application to hairy areas,\\ncreams for the hands and face, and ointments may be\\npreferable for the trunk and legs. Other dosage forms\\navailable include shampoos and sprays. Ciclopirox\\nand triacetin are available in formulations for topical\\ntreatment of nail fungus as well as skin infections\\n(ciclopirox as Penlac Nail Lacquer and triacetin as\\nOny-Clear Nail).\\nMost topical antifungal drugs require four weeks\\nof treatment. Infections insome areas, particularly\\nthe spaces between toes, may take up to six weeks\\nfor cure.\\nPrecautions\\nMost topical antifungal agents are well tolerated.\\nThe most common adverse effects are localized irrita-\\ntion caused by the vehicle or its components. This may\\ninclude redness, itch, and a burning sensation. Some\\ndirect allergic reactions are possible.\\nTopical antifungal drugs should only be applied in\\naccordance with labeled uses. They are not intended or\\nophthalmic (eye) or otic (ear) use. Application to\\nmucous membranes should be limited to appropriate\\nformulations.\\nThe antifungal drugs have not been evaluated for\\nsafety in pregnancy and lactation on topical applica-\\ntion under the pregnancy risk category system.\\nAlthough systemic absorption is probably low, review\\nspecific references. Gentian violet is labeled with a\\nwarning against use in pregnancy.\\nInteractions\\nTopical antifungal drugs have no recognized\\ndrug-drug or food-drug interactions.\\nSamuel D. Uretsky, PharmD\\nAntigas agents\\nDefinition\\nAntigas agents are medicines that relieve the\\nuncomfortable symptoms of too much gas in the sto-\\nmach and intestines.\\nPurpose\\nExcess gas can build up in the stomach and intes-\\ntines for a number of reasons. Eating high-fiber foods,\\nsuch as beans, grains, and vegetables is one cause.\\nSome people unconsciously swallow air when they\\nKEY TERMS\\nCream— A spreadable substance, similar to an oint-\\nment, but not as thick. Creams may be more appro-\\npriate than ointments for application to exposed\\nskin areas such as the face and hands.\\nOintment— A thick, spreadable substance that\\ncontains medicine and is meant to be used on the\\nskin, or if a vaginal preparation, in the vagina.\\nOphthalmic— Pertaining to the eye.\\nOtic— Pertaining to the ear.\\nTopical— A term used to describe medicine that\\nhas effects only in a specific area, not throughout\\nthe body, particularly medicine that is put directly\\non the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 305\\nAntigas agents'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 335, 'page_label': '306'}, page_content='eat, drink, chew gum, or smoke cigarettes, which can\\nlead to uncomfortable amounts of gas in the digestive\\nsystem. Surgery and certain medical conditions, such\\nas irritable colon, peptic ulcer, anddiverticulosis, can\\nalso lead to gas build-up. Certain intestinal parasites\\ncan contribute to the production of severe gas - these\\nparasites need to be treated separately with special\\ndrugs. Abdominalpain, pressure, bloating, and flatu-\\nlence are signs of too much gas. Antigas agents help\\nrelieve the symptoms by preventing the formation of\\ngas pockets and breaking up gas that already is\\ntrapped in the stomach and intestines.\\nDescription\\nAntigas agents are sold as capsules, liquids, and\\ntablets (regular and chewable) and can be bought with-\\nout a physician’s prescription. Some commonly used\\nbrands are Gas-X, Flatulex, Mylanta Gas Relief,\\nDi-Gel, and Phazyme. The ingredient that helps relieve\\nexcess gas is simethicone. Simethicone does not relieve\\nacid indigestion, but some products also containanta-\\ncids for that purpose. Check the label of the product or\\nask the pharmacist for more information.\\nRecommended dosage\\nCheck the product container for dosing informa-\\ntion. Typically, the doses should be taken after meals\\nand at bedtime. Chewable forms should be chewed\\nthoroughly.\\nCheck with a physician before giving this medi-\\ncine to children under age 12 years.\\nPrecautions\\nSome anti-gas medicines may contain sugar,\\nsodium, or other ingredients. Anyone who is on a\\nspecial diet or is allergic to any foods, dyes,\\npreservatives, or other substances should check with\\nhis or her physician or pharmacist before using any of\\nthese products.\\nAnyone who has had unusual reactions to\\nsimethicone – the active ingredient in antigas medi-\\ncines – should check with his or her physician before\\ntaking these drugs.\\nSide effects\\nNo common or serious side effects have been\\nreported in people who use this medicine. However,\\nanyone who has unusual symptoms after taking an\\nantigas agent should get in touch with his or her\\nphysician.\\nInteractions\\nAntigas agents are not known to interact with any\\nother drugs.\\nSamuel D. Uretsky, PharmD\\nAntigastroesophageal reflux\\ndrugs\\nDefinition\\nThese drugs are used to treat gastroesophageal\\nreflux, the backward flow of stomach contents into\\nthe esophagus.\\nPurpose\\nThe drug discussed here, cisapride (Propulsid), is\\nused to treat nighttimeheartburn resulting from gas-\\ntroesophageal reflux disease (GERD). In this condi-\\ntion, food and stomach juices flow backward from the\\nstomach into the esophagus, the part of the digestive\\ntract through which food passes on its way from the\\nmouth to the stomach. Normally, a muscular ring\\ncalled the lower esophageal sphincter (LES) opens to\\nallow food into the stomach and then closes to prevent\\nthe stomach’s contents from flowing back into the\\nesophagus. In people with GERD, this muscular ring\\nis either weak or it relaxes at the wrong times. The\\nmain symptom is heartburn – a burning sensation\\ncentered behind the breastbone and spreading upward\\ntoward the neck and throat.\\nCisapride works by strengthening the lower eso-\\nphageal sphincter and making the stomach empty\\nKEY TERMS\\nDigestive tract— The stomach, intestines, and\\nother parts of the body through which food passes.\\nDiverticulosis— A condition in which the colon\\n(large intestine) develops a number of outpouch-\\nings or sacs.\\nFlatulence— Excess gas in the digestive tract.\\nIrritable colon— An intestinal disorder often\\naccompanied by abdominal pain and diarrhea.\\n306 GALE ENCYCLOPEDIA OF MEDICINE\\nAntigastroesophageal reflux drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 336, 'page_label': '307'}, page_content='more quickly. This shortens the amount of time that the\\nesophagus comes in contact with the stomach contents.\\nOther drugs, such as H2-blockers are sometimes pre-\\nscribed to reduce the amount of acid in the stomach.\\nDescription\\nCisapride is available only with a physician’s pre-\\nscription. Cisapride is sold in tablet and liquid forms.\\nRecommended dosage\\nThe dose depends on the patient. The average\\ndose for adults and children age 12 and over is 5-20 mg\\ntaken two to four times a day. The medicine should be\\ntaken 15 minutes before meals and at bedtime. For\\nchildren under 12, the dose is based on body weight\\nand should be determined by the child’s physician.\\nPrecautions\\nThis medicine is effective in treating only night-\\ntime heartburn, not daytime heartburn.\\nCisapride may increase the effects of alcohol and\\ntranquilizers.\\nCisapride has caused dangerous irregular heart-\\nbeats in a few people who took it with other medicines.\\nAnyone who takes this drug should let the physician\\nknow all other medicines he or she is taking. Patients\\nwith heart problems should check with their physi-\\ncians before taking cisapride.\\nAnyone who has bleeding, blockage, or leakage in\\nthe stomach or intestines should not take cisapride.\\nCisapride should not be used by anyone who has had\\nan unusual reaction to the drug in the past. In addi-\\ntion, people with any of the following medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15Epilepsy or history of seizures\\n/C15Kidney disease\\n/C15Liver disease.\\nThe effects of taking cisapride duringpregnancy\\nhave not been fully studied. Women who are preg-\\nnant or plan to become pregnant should check with\\ntheir physicians before taking Cisapride. The drug\\npasses into breast milk and may affect nursing\\nbabies. Women who are breastfeeding and need to\\ntake this medicine should check with their physi-\\ncians. Avoiding breastfeeding while taking the drug\\nmay be necessary.\\nSide effects\\nThe most common side effects are abdominal\\npain, bloating, gas, diarrhea, constipation, nausea,\\nupper respiratory infections, inflammation of the\\nnasal passages and sinuses, headache,a n dv i r a l\\ninfections. Other side effects may occur. Anyone\\nwho has unusual or troublesome symptoms after\\ntaking this drug should get in touch with his or her\\nphysician.\\nInteractions\\nCisapride may interact with a variety of other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes Cisapride should\\nlet the physician know all other medicines he or she is\\ntaking. Among the drugs that may interact with cisa-\\npride are:\\n/C15Antifungal drugs such as ketoconazole (Nizoral),\\nmiconazole (Monistat), and fluconazole (Diflucan)\\n/C15Antibiotics such as clarithromycin (Biaxin) and ery-\\nthromycin (E-Mycin, ERYC)\\n/C15Blood-thinners such as warfarin (Coumadin)\\n/C15H2-blockers such as cimetidine (Tagamet) and rani-\\ntidine (Zantac)\\n/C15Tranquilizers such as chlordiazepoxide (Librium),\\ndiazepam (Valium), and alprazolam (Xanax).\\nThe list above does not include every drug that\\nmay interact with cisapride. Be sure to check with a\\nphysician or pharmacist before combining cisapride\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine.\\nResources\\nORGANIZATIONS\\nNational Digestive Diseases Information Clearinghouse. 2\\nInformation Way, Bethesda, MD 20892-3570. (800)\\n891-5389. .\\nKEY TERMS\\nEsophagus— The part of the digestive tract between\\nthe pharynx and the stomach. (The pharynx is the\\nspace just behind the mouth.)\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nGALE ENCYCLOPEDIA OF MEDICINE 307\\nAntigastroesophageal reflux drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 337, 'page_label': '308'}, page_content='Pediatric/Adolescent Gastroesophageal Reflux Association,\\nInc. P.O. Box 1153, Germantown, MD 20875-1153.\\n(301) 601-9541. .\\nOTHER\\n‘‘GERD Information Center.’’Pharmaceutical Information\\nNetwork. .\\nGERD Information Resource Center..\\nNancy Ross-Flanigan\\nAntihelminthic drugs\\nDefinition\\nAntihelminthic drugs are used to treat parasitic\\ninfestations.\\nPurpose\\nParasitic infestations are caused by protozoa or\\nworms gaining entry into the body. Most of these\\norganisms cause infections by being ingested in the\\nform of eggs or larvae, usually present on contaminated\\nfood or clothing, while others gain entry through skin\\nabrasions. Common parasitic infestations includeame-\\nbiasis, malaria, giardiasis, hookworm, pinworm,\\nthreadworm, whipworm and tapeworm infestations.\\nOnce in the body, parasitic worms may go unnoticed\\nif they cause no severe symptoms. However, if they\\nmultiply rapidly and spread to a major organ, they\\ncan cause very serious and even life-threatening condi-\\ntions. Antihelminthic drugs are prescribed to treat these\\ninfestations. They function either by destroying the\\nworms on contact or by paralyzing them, or by altering\\nthe permeability of their plasma membranes. The dead\\nworms then pass out of the body in the feces.\\nDescription\\nAntihelminthic drugs are available only with a\\nprescription and are available as liquids, tablets or cap-\\nsules. Some commonly used antihelminthics include:\\nalbendazole (Albenza), mebendazole (Vermox), niclosa-\\nmide (Niclocide), oxamniquine (Vansil), praziquantel\\n(Biltricide), pyrantel (Antiminth), pyantel pamoate\\n(Antiminth) and thiabendazole (Mintezol). Some types\\nof parasitic infestations are rarely seen in the United\\nStates, thus, the corresponding antihelminthic drugs are\\nn o tw i d e l yd i s t r i b u t e da n dn e e dt ob eo b t a i n e df r o mt h e\\nUnited States Center for Disease Control (CDC) when\\nrequired. These include for example bitional and iver-\\nm e c t i n ,u s e dt ot r e a to n c h o c e rciasis infestations. Other\\nantihelminthic drugs, such as diethylcarbamazepine\\ncitrate (Hetrezan), used for treatment of roundworms\\nand other parasites, is supplied directly by its manufac-\\nturer when needed.\\nMost antihelminthic drugs are only active against\\nspecific parasites, some are also toxic. Before treat-\\nment, the parasites must therefore be identified using\\ntests that look for parasites, eggs or larvae in feces,\\nurine, blood, sputum, or tissues. Thus, niclosamide is\\nused against tapeworms, but will not be effective for\\nthe treatment of pinworm or roundworm infestations,\\nbecause it acts by inhibiting ATP production in tape-\\nworm cells. Thiabendazole (Mintezole) is the drug\\nusually prescribed for treatment of threadworm, but\\na similar drug, mebendazole (Vermox) works better on\\nwhipworm by disrupting the microtubules of this\\nworm. Praziquantel is another drug that acts by alter-\\ning the membrane permeability of the worms.\\nPreparation\\nDosage is established depending on the patient’s\\ngeneral health status and age, the type of antihel-\\nminthic drug used, and the type of parasitic infestation\\nbeing treated. The number of doses per day, the time\\nbetween doses, and the length of treatment will also\\ndepend on these factors.\\nAntihelminthic drugs must be taken exactly as\\ndirected to completely rid the body of the parasitic\\ninfestation, and for as long as directed. A second\\nround of treatment may be required to ensure that\\nthe infection has completely cleared.\\nPrecautions\\nSome antihelminthic drugs work best when ingested\\nalong with fatty foods, such as milk or ice cream. Oral\\ndrugs should be taken with water during or after meals.\\nThe prescribing physician should be informed if the\\npatient has a low-fat or other special diet.\\nSome antihelminthic drugs, such as praziquantel,\\ncome in chewable form. These tablets should not be\\nchewed or kept in the mouth, but should swallowed\\nwhole because their bitter taste may cause gagging or\\nvomiting.\\nAntihelminthic drugs sometimes need to be taken\\nwith other medications. For example, steroids such as\\nprednisone are also prescribed together with the anti-\\nhelminthic drug for tapeworm to reduce the inflam-\\nmation that the worm may cause.\\n308 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihelminthic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 338, 'page_label': '309'}, page_content='When required, pre- or post-treatment purges are\\nalso performed with magnesium or sodium sulfate.\\nRegular medical visits are recommended for peo-\\nple affected by parasitic infestations. The physician\\nmonitors whether the infection is clearing or not and\\nalso keeps track of unwanted side effects. The pre-\\nscribing physician should be informed if symptoms\\ndo not disappear or if they get worse.\\nHookworm or whipworm infections are also trea-\\nted with iron supplements along with the antihel-\\nminthic prescription.\\nSome types of parasitic infestations (e.g. pin-\\nworms) can be passed from one person to another. It\\nis then often recommended that everyone in the house-\\nhold of an infected person be asked to also take the\\nprescribed antihelminthic drug.\\nKEY TERMS\\nAmebiasis— Parasitic infestation caused by amebas,\\nespecially by Entamoeba histolytica.\\nColitis— Inflammation of the colon (large intestine).\\nFeces— The solid waste that is left after digestion.\\nFeces form in the intestines and leave the body\\nthrough the anus.\\nFlukes— Parasite worms that look like leeches. They\\nusually have one or more suckers for attaching to the\\ndigestive mucosa of the host. Liver flukes infest the\\nliver, destroying liver tissue and impairing bile pro-\\nduction and drainage.\\nGiardiasis— Parasitic infestation caused by a flagel-\\nlate protozoan of the genus Giardia, especially by\\nG. lamblia.\\nHallucination— A false or distorted perception of\\nobjective reality. Imaginary objects, sounds, and\\nevents are perceived as real.\\nHookworm— Parasitic intestinal infestation caused\\nby any of several parasitic nematode worms of the\\nfamily Ancylostomatidae. These worms have strong\\nbuccal hooks that attach to the host’s intestinal\\nlining.\\nLarva— The immature, early form of an organism\\nthat at birth or hatching is not like its parent and\\nhas to undergo metamorphosis before assuming\\nadult features.\\nMalaria— Disease caused by the presence of\\nsporozoan parasites of the genus Plasmodium in\\nthe red blood cells, transmitted by the bite\\nof anopheline mosquitoes, and characterized\\nby severe and recurring attacks of chills and\\nfever).\\nMicrotubules— Slender, elongated anatomical\\nchannels in worms.\\nNematode— Roundworm.\\nOrganism— A single, independent life form, such as\\na bacterium, a plant or an animal.\\nParasite— An organism that lives in or with another\\norganism, called the host, in parasitism, a type of\\nassociation characterized by the parasite obtaining\\nbenefits from the host, such as food, and the host\\nbeing injured as a result.\\nParasitic— Of, or relating to a parasite.\\nPinworm— Enterobius vermicularis, a nematode\\nworm of the family Oxyuridae that causes para-\\nsitic infestation of the intestines and cecum.\\nPinworm is endemic in both temperate and tro-\\npical regions and common especially in school\\nage children.\\nOnchocerciasis— Parasitic infestation caused by\\nfilamentous worms of the genus Onchocerca,\\nespecially O. volvulus, that is found in tropical\\nAmerica and is transmitted by several types of\\nblackflies.\\nProtozoan— Any unicellular or multicellular organ-\\nism containing nuclei and organelles (eukaryotic) of\\nthe subkingdom Protozoa.\\nRoundworm— Any round-bodied unsegmented\\nworm as distinguished from a flatworm. Also called\\na nematode, they look similar to the common\\nearthworm.\\nTapeworm— Flat and very long (up to 30 meters)\\nintestinal parasitic worms, similar to a long piece of\\ntape. Common tapeworms include: T. saginata (beef\\ntapeworm), T. solium (pork tapeworm) D. latum (fish\\ntapeworm), H. Nana (dwarf tapeworm) and E. gran-\\nulosus (dog tapeworm). General symptoms are\\nvague abdominal discomfort, nausea, vomiting,\\ndiarrhea and weight loss.\\nThreadworm— Any long, thin nematode worm.\\nTrematode— Any parasitic flatworm of the class\\nTrematoda, as the liver fluke.\\nWhipworm— A nematode worm of the family\\nTrichuridae with a body that is thick at one end and\\nvery long and slender at the other end.\\nGALE ENCYCLOPEDIA OF MEDICINE 309\\nAntihelminthic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 339, 'page_label': '310'}, page_content='Risks\\nPeople with the following medical conditions may\\nhave adverse reactions to antihelminthic drugs. The\\nprescribing physician should accordingly be informed\\nif any of these conditions are present:\\n/C15Allergies. Anyone who has had adverse reactions to\\nantihelminthic drugs should inform the prescribing\\nphysician before taking the drugs again. The physi-\\ncian should also be informed about any other pre-\\nexisting allergies.\\n/C15Ulcers. Antihelminthic drugs are also contraindi-\\ncated for persons diagnosed with ulcers of the diges-\\ntive tract, especiallyulcerative colitis.\\n/C15Pregnancy. There is research evidence reporting that\\nsome antihelminthic drugs causebirth defectsor mis-\\ncarriage in animal studies. No human birth defects\\nhave been reported, but antihelminthic drugs are\\nusually not recommended for use during pregnancy.\\nPregnant women should accordingly inform the pre-\\nscribing physician.\\n/C15Breastfeeding. Some antihelminthic drugs can pass\\ninto breast milk. Breastfeeding may have to be dis-\\ncontinued until the antihelminthic treatment has\\nended and breastfeeding mothers must also inform\\nthe prescribing physician.\\n/C15Other risk conditions. Any of the following medical\\nconditions should also be reported to the prescribing\\nphysician: Crohn’s disease, liver disease, kidney dis-\\nease and worm cysts in the eyes.\\nCommon side effects of antihelminthic drugs\\ninclude dizziness, drowsiness,headache, sweating, dry-\\nness of the mouth and eyes, and ringing in the ears.\\nAnyone taking these drugs should accordingly avoid\\ndriving, operating machines or other activities that\\nmay be dangerous until they know how they are\\naffected by the drugs. Side effects usually wear off as\\nthe body adjusts to the drug and do not usually require\\nmedical treatment. Thiabendazole may cause the urine\\nto have an unusual odor that can last for a day after\\nthe last dose. Other side effects of antihelminthic\\ndrugs, such as loss of appetite,diarrhea, nausea, vomit-\\ning, or abdominal cramps are less common. If they\\noccur, they are usually mild and do not require med-\\nical attention.\\nMore serious side effects, such asfever, chills,\\nconfusion, extreme weakness, hallucinations, severe\\ndiarrhea, nausea or vomiting, skinrashes, low back\\npain, dark urine, blurred vision, seizures, andjaundice\\nhave been reported in some cases. The patient’s phy-\\nsician should be informed immediately if any should\\ndevelop. As a rule, anyone who has unusual symptoms\\nafter starting treatment with antihelminthic drugs\\nshould notify the prescribing physician.\\nAntihelminthic drugs may interact with each\\nother or with other drugs, whether prescribed or not.\\nFor example, it has been reported that use of the\\nantihelminthic drugs pyrantel and piperazine together\\nlowers the efficiency of pyrantel. Similarly, combining\\na given antihelminthic drug with another medication\\nmay increase the risk of side effects from either drug.\\nNancy Ross-Flanigan\\nAntihemorrhoid drugs\\nDefinition\\nAntihemorrhoid drugs are medicines that reduce\\nthe swelling and relieve the discomfort ofhemorrhoids\\n(swellings in the area around the anus).\\nPurpose\\nHemorrhoids are bulges in the veins that supply\\nblood to the skin and membranes of the area around\\nthe anus. They may form for various reasons.\\nFrequent heavy lifting, sitting for long periods, or\\nstraining to have bowel movements may putstress\\non anal tissues, which can lead to hemorrhoids.\\nSome women develop hemorrhoids duringpregnancy\\nas the expanding uterus puts pressure on the anal\\ntissues. The strain of labor and delivery can also\\ncause hemorrhoids or make existing hemorrhoids\\nworse. Hemorrhoids sometimes result from certain\\nmedical problems, such as tumors pressing on the\\nlower bowel.\\nThe main symptoms of hemorrhoids are bleeding\\nfrom the rectum, especially after a bowel movement,\\nand itching, burning,pain, and general discomfort in\\nthe anal area. Over-the-counter antihemorrhoid pro-\\nducts can relieve many of these symptoms. The pro-\\nducts contain combinations of four main types of\\ningredients:\\n/C15Local anesthetics, such as benzocaine, lidocaine and\\ntetracaine, to temporarily relieve the pain\\n/C15Vasoconstrictors, such as epinephrine base, epinephr-\\nine hydrochloride, ephedrine sulfate and phenylephr-\\nine hydrochloride that reduce swelling and relieve\\nitching and discomfort by tightening blood vessels\\n/C15Astringents (drying agents), such as witch hazel, cala-\\nmine, and zinc oxide. These help shrink hemorrhoids\\n310 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihemorrhoid drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 340, 'page_label': '311'}, page_content='by pulling water out of the swollen tissue. This, in\\nturn, helps relieve itching, burning, and irritation.\\n/C15Protectants, such as cocoa butter, lanolin, glycerin,\\nmineral oil, and shark liver oil which soothe irritated\\ntissues and form a protective barrier to prevent\\nfurther irritation.\\nDescription\\nAntihemorrhoid drugs are available as creams,\\nointments and suppositories. Most can be bought\\nwithout a physician’s prescription.\\nRecommended dosage\\nFollow package instructions for using these pro-\\nducts. Do not use more than the recommended\\namount of this medicine every day. For explanations\\nor further information about how to use antihemor-\\nrhoid drugs, check with a physician or pharmacist.\\nPrecautions\\nDo not use antihemorrhoid drugs for more than\\nseven days in a row. If the problem gets worse or does\\nnot improve, check with a physician.\\nIf rectal bleeding continues, check with a physi-\\ncian. This could be a sign of a condition that needs\\nmedical attention.\\nSide effects\\nSide effects are rare, however, if a rash or any\\nother sign of an allergic reaction occurs, stop using\\nthe medicine.\\nInteractions\\nSome antihemorrhoid drugs should not be used\\nby people who are taking or have recently takenmono-\\namine oxidase inhibitors (MAO inhibitors), such as\\nphenelzine (Nardil) or tranylcypromine (Parnate),\\nused to treat conditions including depression and\\nParkinson’s disease. Anyone who is not sure if he or\\nshe has taken this type of drug should check with a\\nphysician or pharmacist before using an antihemor-\\nrhoid drug. People who are taking antidepressants or\\nmedicine for high blood pressure also should not use\\ncertain antihemorrhoid drugs. Check with a pharma-\\ncist for a list of drugs that may interact with specific\\nantihemorrhoid drugs.\\nNancy Ross-Flanigan\\nAntihistamines\\nDefinition\\nAntihistamines are drugs that block the action of\\nhistamine (a compound released in allergic inflamma-\\ntory reactions) at the H1 receptor sites, responsible for\\nimmediate hypersensitivity reactions such as sneezing\\nand itching. Members of this class of drugs may also be\\nused for their side effects, includingsedation and anti-\\nemesis (prevention ofnausea and vomiting).\\nPurpose\\nAntihistamines provide their primary action by\\nblocking histamine H1 at the receptor site. They have\\nno effect on rate of histamine release, nor do they\\ninactivate histamine. By inhibiting the activity of\\nhistamine, they can reduce capillary fragility, which\\nproduces the erythema, or redness, associated with\\nallergic reactions. They will also reduce histamine-\\ninduced secretions, including excessive tears and\\nsalivation. Additional effects vary with the indivi-\\ndual drug used. Several of the older drugs, called\\nfirst-generation antihistamines, bind non-selectively\\nto H1 receptors in the central nervous system as\\nwell as to peripheral receptors, and can produce\\nsedation, inhibition of nausea and vomiting,a n d\\nreduction ofmotion sickness. The second-generation\\nantihistamines bind only to peripheral H1 receptors,\\nand reduce allergic res ponse with little or no\\nsedation.\\nThe first-generation antihistamines may be\\ndivided into several chemical classes. The side effect\\nprofile, which also determines the uses of the drugs,\\nwill vary by chemical class. The alkylamines include\\nbrompheniramine (Dimetapp) and chlorpheniramine\\nKEY TERMS\\nAnus— The opening at the end of the intestine\\nthrough which solid waste (stool) passes as it leaves\\nthe body.\\nRectum— The end of the intestine closest to the\\nanus.\\nUterus— A hollow organ in a female in which a\\nfetus develops until birth.\\nGALE ENCYCLOPEDIA OF MEDICINE 311\\nAntihistamines'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 341, 'page_label': '312'}, page_content='(Chlor-Trimeton.) These agents cause relatively little\\nsedation, and are used primarily for treatment of aller-\\ngic reactions. Promethazine (Phenergan), in contrast,\\nis a phenothiazine, chemically related to the major\\ntranquilizers, and while it is used for treatment ofaller-\\ngies, may also be used as a sedative, the relieve anxiety\\nprior to surgery, as an anti-nauseant, and for control of\\nmotion sickness. Diphenhydramine (Benadryl) is che-\\nmically an ethanolamine, and in addition to its role in\\nreducing allergic reactions, may be used as a nighttime\\nsedative, for control of drug-induced Parkinsonism,\\nand, in liquid form, for control of coughs. Consult\\nmore detailed references for further information.\\nThe second generation antihistamines have no\\ncentral action, and are used only for treatment of\\nallergic reactions. These are divided into two chemical\\nclasses. Cetirizine (Zyrtec) is a piperazine derivative,\\nand has a slight sedative effect. Loratidine (Claritin)\\nand fexofenadine (Allegra) are members of the piper-\\nadine class and are essentially non-sedating.\\nRecommended dosage\\nDosage varies with drug, patient and intended\\nuse. Consult more detailed references for further\\ninformation.\\nWhen used for control of allergic reactions, anti-\\nhistamines should be taken on a regular schedule,\\nrather than on an as-needed basis, since they have no\\neffect on histamine itself, nor on histamine already\\nbound to the receptor site.\\nEfficacy is highly variable from patient to patient. If\\nan antihistamine fails to provide adequate relief, switch\\nto a drug from a different chemical class. Individual\\ndrugs may be effective in no more than 40% of patients,\\nand provide 50% relief of allergic symptoms.\\nSide effects\\nThe frequency and severity of adverse effects will\\nvary between drugs. Not all adverse reactions will\\napply to every member of this class.\\nCentral nervous system reactions include drowsiness,\\nsedation, dizziness, faintness, disturbed coordination, las-\\nsitude,confusion,restlessness,excitation,tremor,seizures,\\nheadache,insomnia, euphoria, blurred vision,hallucina-\\ntions, disorientation, disturbingdreams/nightmares, schi-\\nzophrenic-like reactions, weakness, vertigo,hysteria,\\nnerve pain, and convulsions. Overdoses may cause invo-\\nluntary movements. Other problems have been reported.\\nGastrointestinal problems include increased\\nappetite, decreased appetite, nausea, vomiting,diar-\\nrhea, andconstipation.\\nHematologic reactions are rare, but may be\\nsevere. These include anemia, or breakdown of red\\nANTIHISTAMINES\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\n*Atarax (hydroxyzine\\nhydrochloride)\\nDrowsiness, dry mouth\\nBenadryl (diphenhydramine\\nhydrochloride)\\nDizziness, sleepiness, upset stomach,\\ndecreased coordination\\nHismanal (astemiozole) Drowsiness, dry mouth, fatigue, weight\\ngain\\nPBZ-SR (tripelennamine\\nhydrochloride)\\nDizziness, drowsiness, dry mouth and\\nthroat, chest congestion, decreased\\ncoordination, upset stomach\\nPeriactin (cyproheptadine\\nhydrochloride)\\nChest congestion, dizziness, fluttery\\nheartbeat, loss of appetite, hives, slee-\\npiness, vision problems\\nPhenergan (promethazine\\nhydrochloride)\\nChanges in blood pressure, dizziness,\\nblurred vision, nausea, rash\\nPolaramine (dexchlorphenira-\\nmine maleate)\\nDrowiness\\nSeldane, Seldane-D\\n(terfenadine)\\nUpset stomach, nausea, drowiness,\\nheadache, fatigue\\nTavist (clemastine fumarate) Decreased coordination, dizziness,\\nupset stomach\\nTrinalin Repetabs (azatadine\\nmaleate, pseudoephedrine\\nsulfate)\\nAbdominal cramps, chest pain, dry\\nmouth, headache\\n*Also used in the treatment of\\nanxiety\\nD A N I E L E B O V E T (1907–1992)\\nA gifted researcher in therapeutic chemistry,\\nDaniele Bovet was born in Neuchatel, Switzerland, one\\nof four children of a professor of experimental education.\\nBovet studied zoology and comparative anatomy at the\\nUniversity of Geneva, receiving his doctor of science\\ndegree in 1929. He then joined the Pasteur Institute in\\nParis, becoming director of the Laboratory of Therapeutic\\nChemistry in 1936.\\nBovet investigated histamine, thought to cause\\nallergy symptoms. No antagonist of histamine was\\nknown, so Bovet—with his research student Anne-Marie\\nStaub—began studying substances that blocked hormones\\nsimilar to histamine. By 1937 he had produced the first\\nantihistamine, thymoxydiethylamine. Since this substance\\nwas too toxic for human use, Bovet and Staub performed\\nthousands more experiments seeking less toxic antihista-\\nmines. This work formed the basis for the development of\\nsubsequent clinically useful antihistamines.\\n312\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAntihistamines'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 342, 'page_label': '313'}, page_content='blood cells; reduced platelets; reduced white cells; and\\nbone marrow failure.\\nA large number of additional reactions have been\\nreported. Not all apply to every drug, and some reac-\\ntions may not be drug related. Some of the other adverse\\neffects are chest tightness;wheezing; nasal stuffiness; dry\\nmouth, nose and throat;sore throat; respiratory depres-\\nsion; sneezing; and a burning sensation in the nose.\\nWhen taking antihistamines during pregnancy,\\nChlorpheniramine (Chlor-Trimeton), dexchlorphenir-\\namine (Polaramine), diphenhydramine (Benadryl),\\nbrompheniramine (Dimetapp), cetirizine (Zyrtec),\\ncyproheptadine (Periactin), clemastine (Tavist), azata-\\ndine (Optimine), loratadine (Claritin) are all listed\\nas category B. Azelastine (Astelin), hydroxyzine\\n(Atarax), promethazine (Phenergan) are category C.\\nRegardless of chemical class of the drug, it is\\nrecommended that mothers not breast feed while\\ntaking antihistamines.\\nContraindications\\nThe following are absolute or relative contraindi-\\ncations to use of antihistamines. The significance of\\nthe contraindication will vary with the drug and dose.\\n/C15glaucoma\\n/C15hyperthyroidism (overactive thyroid)\\n/C15high blood pressure\\n/C15enlarged prostate\\n/C15heart disease\\n/C15ulcers or other stomach problems\\n/C15stomach or intestinal blockage\\n/C15liver disease\\n/C15kidney disease\\n/C15bladder obstruction\\n/C15diabetes\\nInteractions\\nMonoamine oxidase inhibitor antidepressants\\n(phenelzine [Nardil], tranylcypromine [Parnate]) may\\nprolong and increase the effects of some antihista-\\nmines. When used with promethazine (Phenergan)\\nthis may cause reduced blood pressure and involun-\\ntary movements.\\nResources\\nORGANIZATIONS\\nAllergy and Asthma Network. 3554 Chain Bridge Road,\\nSuite 200. (800) 878-4403.\\nAmerican Academy of Allergy, Asthma, and Immunology.\\n611 East Wells St, Milwaukee, WI 53202. (800) 822-\\n2762. .\\nAsthma and Allergy Foundation of America. 1125 15th\\nStreet NW, Suite 502, Washington, DC 20005.\\n(800)727-8462.\\nSamuel D. Uretsky, PharmD\\nAntihyperlipidemic drugs see Cholesterol-\\nreducing drugs\\nAntihypertensive drugs\\nDefinition\\nAntihypertensive drugs are medicines that help\\nlower blood pressure.\\nPurpose\\nThe overall class of antihypertensive agents lowers\\nblood pressure, although the mechanisms of action vary\\ngreatly. In 2003, a Joint National Committee on\\nKEY TERMS\\nAllergen— A substance that causes an allergy.\\nAnaphylaxis— A sudden, life-threatening allergic\\nreaction.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHistamine— A chemical released from cells in the\\nimmune system as part of an allergic reaction.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nGALE ENCYCLOPEDIA OF MEDICINE 313\\nAntihypertensive drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 343, 'page_label': '314'}, page_content='Prevention, Detection, Evaluation, and Treatment of\\nHigh Blood Pressure report said that recent clinical trials\\nshow that antihypertensive treatment can reduce inci-\\ndence of stroke by 35-40%,heart attack by 20-25%,\\nand onset of newheart failureby 50%. Within this ther-\\napeutic class, there are several subgroups of drugs. There\\nare a large number of drugs used to controlhypertension,\\nand the drugs listed below are representative, but not the\\nonly members of their classes.\\nThe calcium channel blocking agents, also called\\nslow channel blockers or calcium antagonists, inhibit\\nthe movement of ionic calcium acrossthe cell membrane.\\nThis reduces the force of contraction of muscles of the\\nheart and arteries. Although thecalcium channel blockers\\nare treated as a group, there are four different chemical\\nclasses, leading to significant variations in the activity of\\nindividual drugs. Nifedipine (Adalat, Procardia) has the\\ngreatest effect on the blood vessels, while verapamil\\n(Calan, Isoptin) and diltiazem (Cardizem) have a greater\\neffect on the heart muscle itself.\\nPeripheral vasodilators such as hydralazine\\n(Apresoline), isoxuprine (Vasodilan), and minoxidil\\n(Loniten) act by relaxing blood vessels.\\nThere are several groups of drugs that act by\\nreducing adrenergic nerve stimulation, the excitatory\\nnerve stimulation that causes contraction of the mus-\\ncles in the arteries, veins, and heart. These drugs\\ninclude the beta-adrenergic blockers and alpha/beta\\nadrenergic blockers. There are also non-specific adre-\\nnergic blocking agents.\\nBeta-adrenergic blocking agents include propra-\\nnolol (Inderal), atenolol (Tenormin), and pindolol\\n(Visken). Propranolol acts on the beta-adrenergic\\nreceptors anywhere in the body, and has been used as\\na treatment for emotional anxiety and rapid heart\\nAntihypertensive Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nAccupril (quinapril\\nhydrochloride)\\nHeadache, dizziness\\nAldatazide Diarrhea, fever, headache, decreased\\ncoordination\\nAldactone\\n(spironolactone)\\nCramps, drowsiness, stomach disorders\\nAldomet (methyldopa) Fluid retention, headache, weak feeling\\nAltace (ramipril) Headache, cough\\nCalan, Calan SR (vera-\\npamil hydrochloride)\\nConstipation, fatigue, decreased blood\\npressure\\nCapoten (captopril) Decreased sense of taste, decreased blood\\npressure tiching, rash\\nCardene (nicardipine\\nHydrochloride)\\nDizziness, headache, indigestion and nausea,\\nincreased heartbeat\\nCardizem (diltiazem\\nhydrochloride)\\nDizziness, fluid retention, headache, nausea,\\nskin rash\\nCardura (doxazosin\\nmesylate)\\nDizziness, fatigue, drowsiness, headache\\nCatapres Dry mouth, drowsiness, dizziness, constipation\\nCorgard (nadolol) Behaviorial changes, dizziness, decreased\\nheartbeat, tiredness\\nCorzide Dizziness, decreased heartbeat, fatigue, cold\\nhands and feet\\nDiuril (chlorothiazide) Cramps, constipation or diarrhea, dizziness,\\nfever, increased glocose level in urine\\nDyazide Blurred vision, muscle and abdominal pain,\\nfatigue\\nDynaCirc (isradipine) Chest pain, fluid retention, headache, fatigue\\nHydroDIURIL\\n(hydrochlorothiazide)\\nUpset stomach, headache, cramps, loss of\\nappetite\\nHygroton\\n(chlorthalidone)\\nAnemia, constipation or diarrhea, cramps,\\nitching\\nHytrin (terazosin\\nhydrochloride)\\nDizziness, labored breathing, nausea, swelling\\nInderal (propranolol\\nhydrochloride)\\nConstipation or diarrhea, tingling sensation,\\nnausea and vomiting\\nInderide Blurred vision, cramps, fatigue, loss of appetite\\nLasix (furosemide) Back and muscle pain, indigestion, nausea\\nLopressor (metoprolol\\ntartrate)\\nDiarrhea, itching/rash, tiredness\\nLotensin (benazepril\\nhydrochloride)\\nNausea, dizziness, fatigue, headache\\nAlozol (indapamide) Anxiety, headache, loss of energy, muscle\\ncramps\\nMaxzide Cramps, labored breathing, drowsiness,\\nirritated stomach\\nMinipress (prazosin\\nhdrochloride)\\nHeadache, nausea, weakness, dizziness\\nModuretic Diarrhea, fatigue, itching, loss of appetite\\nMonopril (fosinopril\\nsodium)\\nNausea and vomiting, headache, cough\\nNormodyne (labetalol\\nhydrochloride)\\nFatigue, nausea, stuffy nose\\nPlendil (felodipine) Pain in back, chest, muscles, joints, and\\nabdomen, itching, dry mouth, respiratory\\nproblems\\nProcardia, Procardia X\\n(nifedipine)\\nSwelling, constipation, decreased blood\\npressure, nausea, fatigue\\nSectral (acebutolol\\nhydrochloride)\\nConstipation or diarrhea, gas, chest and joint\\npain\\nSer-Ap-Es Blurred vision, cramps, muscle pain, dizziness\\nTenex (guanfacine\\nhydrochloride)\\nHeadache, constipation, dry mouth, weakness\\nTenoretic Decreased heartbeat, fatigue, nausea\\nTenormin (atenolol) Nausea, fatigue, dizziness\\nVeseretic Diarrhea, muscle cramps, rash\\nAntihypertensive Drugs (continued)\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nVasotec (enalapril\\nmaleate)\\nChest pain, blurred vision, constipation or diar-\\nrhea, hives, nausea\\nVisken (pindolol) Muscle cramps, labored breathing, nausea, fluid\\nretention\\nWytensin (guanabenz\\nacetate)\\nHeadache, drowsiness, dizziness\\nZaroxolyn (metolazone) Constipation or diarrhea, chest pain, spasms,\\nnausea\\nZestoretic (lisinopril\\nhydrochlorothiazide)\\nFatigue, headache, dizziness\\nZestril (lisinopril) Labored breathing, abdominal and chest pain,\\nnausea, decreased blood pressure\\n314 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihypertensive drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 344, 'page_label': '315'}, page_content='beat. Atenolol and acebutolol (Sectral) act specifically\\non the nerves of the heart and circulation.\\nThere are two alpha/beta adrenergic blockers,\\nlabetolol (Normodyne, Trandate) and carvedilol\\n(Coreg). These work similarly to thebeta blockers.\\nThe ACE II inhibitors, losartan (Cozaar), cande-\\nsartan (Atacand), irbesartan (Avapro), telmisartan\\n(Micardis), valsartan (Diovan) and eprosartan\\n(Teveten) directly inhibit the effects of ACE II rather\\nthan blocking its production. Their actions are similar\\nto the ACE inhibitors, but they appear to have a more\\nfavorable side effect and safety profile.\\nIn addition to these drugs, other classes of drugs\\nhave been used to lower blood pressure, most\\nnotably the thiazidediuretics. There are 12 thiazide\\ndiuretics marketed in the United States, including\\nhydrochlorothiazide (Hydrodiuril, Esidrex), indapa-\\nmide (Lozol), polythiazide (Renese), and hydroflu-\\nmethiazide (Diucardin). The drugs in this class\\nappear to lower blood pressure through several\\nmechanisms. By promoting sodium loss they lower\\nblood volume. At the same time, the pressure of the\\nwalls of blood vessels, the peripheral vascular resis-\\ntance, is lowered. Thiazide diuretics are commonly\\nused as the first choice for reduction of mild hyper-\\ntension, and may be used in combination with other\\nantihypertensive drugs.\\nDebate continued in 2003 as to the best drugs to\\nlower blood pressure. One study seemed to prove\\nthat diuretics were the best initial choice, but a\\nstudy from Australia said that ACE inhibitors\\nwere a superior choice. However, many physicians\\nagreed that the best treatment for a particular\\npatient depends on his or her particular age, eco-\\nnomic situation, genetic factors and other existing\\nillnesses and conditions.\\nWhile designed to lower cholesterol rather than\\nblood pressure, a large clinical trial reported in 2003\\nthat people with high blood pressure may one day\\nbenefit from taking them. In the trial, participants\\nwith increased risk for heart disease, even if it was not\\nfrom high cholesterol, benefited from taking statins.\\nRecommended dosage\\nRecommended dosage varies with patient, drug,\\nseverity of hypertension, and whether the drug is being\\nused alone or in combination with other drugs.\\nSpecialized references can be consulted for further\\ninformation.\\nPrecautions\\nBecause of the large number of classes and indivi-\\ndual drugs in this group, specialized references offer\\nmore complete information.\\nPeripheral vasodilators may causedizziness and\\northostatic hypotension—a rapid lowering of blood\\npressure when the patient stands up in the morning.\\nPatients taking these drugs must be instructed to rise\\nfrom bed slowly.Pregnancy risk factors for this group\\nare generally category C. Hydralazine has been shown to\\ncausecleft palatein animal studies, but there is no human\\ndata available. Breastfeeding is not recommended.\\nACE inhibitors generally are well tolerated, but\\nrarely may cause dangerous reactions including laryn-\\ngospasm and angioedema. Persistent cough is a\\nKEY TERMS\\nAdrenergic— Activated by adrenalin (norepinephr-\\nine), loosely applied to the sympathetic nervous\\nsystem responses.\\nAngioedema— An allergic skin disease character-\\nized by patches of confined swelling involving the\\nskin the layers beneath the skin, the mucous mem-\\nbranes, and sometimes the viscera—called also\\nangioneurotic edema, giant urticaria, Quincke’s\\ndisease, or Quincke’s edema.\\nArteries— Blood vessels that carry blood away from\\nthe heart to the cells, tissues, and organs of the body.\\nLaryngospasm — Spasmodic closure of the larynx.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies;\\nor adverse effects in animals, but not in well--\\ncontrolled human studies. Category C: No adequate\\nhuman or animal studies; or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nSympathetic nervous system— The part of the auto-\\nnomic nervous system that is concerned especially\\nwith preparing the body to react to situations of\\nstress or emergency; it contains chiefly adrenergic\\nfibers and tends to depress secretion, decrease the\\ntone and contractility of smooth muscle, and\\nincrease heart rate.\\nGALE ENCYCLOPEDIA OF MEDICINE 315\\nAntihypertensive drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 345, 'page_label': '316'}, page_content='common side effect. ACE inhibitors should not be\\nused in pregnancy. When used in pregnancy during\\nthe second and third trimesters, angiotension-convert-\\ning inhibitors (ACEIs) can cause injury to and even\\ndeath in the developing fetus. When pregnancy is\\ndetected, discontinue the ACE inhibitor as soon as\\npossible. Breastfeeding is not recommended.\\nACE II inhibitors are generally well tolerated and\\ndo not cause cough. Pregnancy risk factor is category C\\nduring the first trimester and category D during the\\nsecond and third trimesters. Drugs that act directly on\\nthe renin-angiotensin system can cause fetal and\\nneonatal morbidity and death when administered to\\npregnant women. Several dozen cases have been\\nreported in patients who were taking ACE inhibitors.\\nWhen pregnancy is detected, AIIRAs should be dis-\\ncontinued as soon as possible. Breastfeeding is not\\nrecommended.\\nThiazide diuretics commonly cause potassium\\ndepletion. Patients should have potassium supplemen-\\ntation either through diet or potassium supplements.\\nPregnancy risk factor is category B (chlorothiazide,\\nchlorthalidone, hydrochlorothiazide, indapamide,\\nmetolazone) or category C (bendroflume-\\nthiazide, benzthiazide, hydroflumethiazide, methy-\\nclothiazide, trichlormethiazide). Routine use during\\nnormal pregnancy is inappropriate. Thiazides are\\nfound in breast milk. Breastfeeding is not recommended.\\nBeta blockers may cause a large number of adverse\\nreactions including dangerous heart rate abnormalities.\\nPregnancy risk factor is category B (acebutolol, pindo-\\nlol, sotalol) or category C (atenolol, labetalol, esmolol,\\nmetoprolol, nadolol, timolol, propranolol, penbutolol,\\ncarteolol, bisoprolol). Breastfeeding is not recom-\\nmended. In 2003, a report announced that adavances in\\npharmacogenetics mean that in the future, physicians\\nmay be able to use a patients genetic information to\\nmake certain prescribing decisions for antihypertensives.\\nInteractions\\nSpecific drug references should be consulted, since\\ninteractions vary for antihypertensive drugs.\\nResources\\nPERIODICALS\\nBelden, Heidi. ‘‘Debate Continues Over Best Drug for\\nHypertension.’’ Drug Topics (April 21, 2003): 32.\\nMechcatie, Elizabeth. ‘‘Genetics Will Guide Prescribing for\\nHypertension: Genotype Predicts Response to Drug.’’\\nInternal Medicine News(July 1, 2003): 48-51.\\n‘‘New Hypertension Guidelines: JNC-7.’’Clinical\\nCardiology Alert (July 2003): 54-63.\\n‘‘Studies Show Thata´ Statins Benefits People With High\\nBlood Pressure.’’ Harvard Health Letter(June 2003).\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnti-hyperuricemic drugs\\nDefinition\\nAnti-hyperuricemic drugs are used to treat hyper-\\nuricemia, the state of having too much uric acid in the\\nblood.\\nPurpose\\nAnti-hyperuricemic drugs decrease the levels\\nof uric acid in the blood, either by increasing\\nthe rate at which uric acid is excreted in the\\nurine, or by preventing the formation of excess\\nuric acid.\\nPrecautions\\nBefore taking any medication, patients should\\nnotify their physician of all other medications that\\nthey are currently taking. Patients should also notify\\ntheir physician of any health problems they are cur-\\nrently experiencing. Patients must notify physicians if\\nthey have kidney problems, since this might affect the\\ntype of drug administered. Patients must also notify\\ntheir physician if they are allergic to any of the medi-\\ncations used to treat acute or long-termgout. Since all\\nof these factors contribute to the disease, patients\\nsuffering from gout should attempt to lose weight,\\navoid excess alcohol consumption, and avoid foods\\nhigh in purines, such as asparagus, sardines, lobster,\\navocado, and peas.\\nDescription\\nGout and hyperuricemia\\nPersons with high levels of uric acid (hyperurice-\\nmia) may experience gout. Commonly gout occurs in\\nmales in their 40s and 50s. Gout is defined by the\\nattacks of (arthritic) painful, reddened joints, and is\\noften accompanied by hard lumps in the painful joints.\\nThe most common joint affected is the big toe.Kidney\\nstones, and/or poor kidney function may also be asso-\\nciated with hyperuricemia, but may not be considered\\ngout if the patient does not have painful joints. In\\npersons with gout (and associated symptoms), uric\\n316 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-hyperuricemic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 346, 'page_label': '317'}, page_content='acid forms crystals, which then cause the aforemen-\\ntioned symptoms. Although uric acid levels must be\\nhigh in order for patients to have crystals form, and\\ntherefore have gout, most persons with high uric acid\\nlevels don’t ever have symptoms. Thus, recent criteria\\nfor use of anti-hyperuricemic agents suggest that\\npatients who have never experienced symptoms of\\ngout should not receive drug therapy, unless their\\nhyperuricemia is associated withcancer (may lead to\\nkidney damage) or certain rare genetic disorders\\n(McGill, Rheumatologist, University of Sydney,\\nAustralia, 2000).\\nAcute gout attacks\\nWhen patients experience acute attacks of\\ngout, drugs that lower the levels of uric acid can\\ncause an acute gout attack or cause an attack to\\nbecome more severe. Thus, drugs that lower uric\\nacid levels and are used to treat gout in the long\\nterm are not used in the short term. Medications\\nused in acute gout attacks include non-steroidal\\nanti-inflammatory drugs (such as indomethacin),\\ncolchicine, and corticosteroids . Colchicine causes\\nside effects in a large number of individuals\\n(usually diarhhea). The most important factor in\\nthe effective treatment of gout may not be the drug\\nused, but how quickly it is administered after an\\nacute attack has begun.\\nLong-term treatment\\nLong-term treatment of gout or hyperuricemia\\nusually involves one of four drugs: allopurinol,\\nprobenicid, sulphinpyrazone, or benzbromarone\\n(as of 2001, benzbromarone was not available for\\nuse in the United States). While allopurinol\\ndecreases the amount of uric acid that is produced\\n(and may help prevent acute attacks of gout), the\\nother drugs all increase the rate at which uric acid\\nis excreted in the urine. As previously mentioned,\\nlowering the concentration of uric acid can cause\\ngout attacks. Thus, patients taking these medica-\\ntions should have the dose slowly increased (and\\nuric acid levels slowly lowered) to prevent acute\\nattacks of gout. Patients may also be treated with\\ncolchicine or non-steroi dal anti-inflammatory\\ndrugs to prevent acute attacks of gout (corticoster-\\noids are not used in this scenario because over the\\nlong term corticosteroids have deleterious side\\neffects). In 2004, the FDA was seeking trial data\\non a new drug called oxypurinol (Oxyprim) for\\ntreating chronic gout. These medications may\\nhave to be taken for life to prevent further gout\\nattacks.\\nResources\\nPERIODICALS\\nCoghill, Kim. ‘‘FDA Panel Discusses Endpoints for Approval\\nof Gout Products.’’Bioworld TodayJune 3, 2004.\\nMichael V Zuck, PhD\\nTeresa G. Odle\\nAnti-insomnia drugs\\nDefinition\\nAnti-insomnia drugs are medicines that help\\npeople fall asleep or stay asleep.\\nPurpose\\nPhysicians prescribe anti-insomnia drugs for short-\\nterm treatment of insomnia—a sleep problem in which\\npeople have trouble falling asleep or staying asleep or\\nwake up too earlyand can’t go back to sleep. These drugs\\nshould be used only for occasional treatment of tempor-\\narysleepproblemsandshouldnotbetakenformorethan\\na week or two at a time. People whose sleep problems last\\nlonger than this should see a physician. Their sleep pro-\\nblems could be a sign of another medical problem.\\nDescription\\nThe anti-insomnia drug described here, zolpidem\\n(Ambien), is a classified as a central nervous system\\n(CNS) depressant. CNS depressants are medicines\\nthat slow the nervous system. Physicians also prescribe\\nmedicines in the benzodiazepine family, such as flura-\\nzepam (Dalmane), quazepam (Doral), triazolam\\n(Halcion), estazolam (ProSom), and temazepam\\n(Restoril), for insomnia. Benzodiazepine drugs are\\ndescribed in the essay onantianxiety drugs. Zaleplon\\n(Sonata) is another anti-insomnia drug that is not\\nrelated to other drugs with the same effect. Thebarbi-\\nturates, such as pentobarbital (Nembutal) and secobar-\\nbital (Seconal) are no longer commonly used to treat\\ninsomnia because they are too dangerous if they are\\ntaken in overdoses. For patients with mild insomnia,\\nsome antihistamines, such as diphenhydramine\\n(Benadryl) or hydroxyzine (Atarax) may be used,\\nsince these also cause sleepiness.\\nZolpidem is available only with a physician’s\\nprescription and comes in tablet form.\\nGALE ENCYCLOPEDIA OF MEDICINE 317\\nAnti-insomnia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 347, 'page_label': '318'}, page_content='Recommended dosage\\nThe recommended dose for adults is 5-10 mg just\\nbefore bedtime. The medicine works quickly, often\\nwithin 20 minutes, so it should be taken right before\\ngoing to bed.\\nFor older people and others who may be more\\nsensitive to the drug’s effects, the recommended start-\\ning dosage is 5 mg just before bedtime.\\nZolpidem may be taken with food or on an\\nempty stomach, but it may work faster when taken\\non an empty stomach. Check with a physician or\\npharmacists for instructions on how to take the\\nmedicine.\\nPrecautions\\nZolpidem is meant only for short-term treatment\\nof insomnia. If sleep problems last more than seven to\\n10 days, check with a physician. Longer-lasting sleep\\nproblems could be a sign of another medical problem.\\nAlso, this drug may lose its effectiveness when taken\\nevery night for more than a few weeks.\\nSome people feel drowsy, dizzy, confused, light-\\nheaded, or less alert the morning after they have taken\\nzolpidem. The medicine may also cause clumsiness,\\nunsteadiness, double vision, or other vision problems\\nthe next day. For these reasons, anyone who takes\\nthese drugs should not drive, use machines or do any-\\nthing else that might be dangerous until they have\\nfound out how zolpidem affects them.\\nThis medicine has caused cause behavior changes\\nin some people, similar to those seen in people whose\\nbehavior changes when they drink alcohol. Examples\\ninclude giddiness and rage. More extreme changes,\\nsuch as confusion, agitation, andhallucinations, also\\nare possible. Anyone who starts having strange or\\nunusual thoughts or behavior while taking this medi-\\ncine should get in touch with his or her physician.\\nZolpidem and other sleep medicines may cause a\\nspecial type of temporary memory loss, in which the\\nperson does not remember what happens between the\\ntime they take the medicine and the time its effects\\nwear off. This is usually not a problem, because people\\ngo to sleep right after taking the medicine and stay\\nasleep until its effects wear off. But it could be a\\nproblem for anyone who has to wake up before getting\\na full night’s sleep (seven to eight hours). In particular,\\ntravelers should not take this medicine on airplane\\nflights of less than seven to eight hours.\\nBecause zolpidem works work on the central\\nnervous system, it may add to the effects of alcohol\\nand other drugs that slow down the central nervous\\nsystem, such as antihistamines, cold medicine,\\nallergy medicine, medicine for seizures, tranquili-\\nzers, some pain relievers, and muscle relaxants .\\nZolpidem may also add to the effects of anesthetics,\\nincluding those used for dental procedures. The\\ncombined effects of zolpidem and alcohol or other\\nCNS depressants (drugs that slow the central ner-\\nvous system) can be very dangerous, leading to\\nunconsciousness or even death. People who take\\nzolpidem should not drink alcohol and should\\ncheck with their physicians before taking any other\\nCNS depressant. Anyone who shows signs of an\\noverdose or of the effects of combining zolpidem\\ndrugs with alcohol or other drugs should have\\nimmediate emergency help. Warning signs include\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBronchitis— Inflammation of the air passages of the\\nlungs.\\nEmphysema— A lung disease in which breathing\\nbecomes difficult.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nSleep apnea— A condition in which a person tem-\\nporarily stops breathing during sleep.\\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.\\nAnti-Insomnia Drugs\\nBrand Name (Generic\\nName)\\nPossible Common Side Effects Include:\\nAmbien (zolpidem tartrate) Daytime drowsiness, dizziness, headache\\nDalmane (flurazepam\\nhydrochloride)\\nDecreased coordination, lightheadedness,\\ndizziness\\nDoral (quazepam) Daytime drowsiness, headache, dry mouth,\\nfatigue\\nHalcion (triazolam) Decreased coordination, chest pain, mem-\\nory impairment\\nProSom (estazolam) Dizziness, headache, nausea, weakness\\nRestoril (temazepam) Dizziness, fatigue, nausea, headache,\\nsluggishness\\n318 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-insomnia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 348, 'page_label': '319'}, page_content='severe drowsiness, severenausea or vomiting,b r e a t h -\\ning problems, and staggering.\\nAnyone who takes zolpidem for more than 1–2\\nweeks should not stop taking it without first checking\\nwith a physician. Stopping the drug abruptly may\\ncause rebound insomnia; increased difficulty falling\\nasleep for the first one of two nights after the drug\\nhas been discontinued. In rare cases, withdrawal\\nsymptoms, such as vomiting, cramps, and unpleasant\\nfeelings may occur. Gradual tapering may be\\nnecessary.\\nOlder people may be more sensitive to the effects\\nof zolpidem. This may increase the chance of side\\neffects, such as confusion, and may also increase the\\nrisk of falling.\\nIn people with breathing problems, zolpidem may\\nworsen the symptoms.\\nSpecial conditions\\nPeople with certain other medical conditions or\\nwho are taking certain other medicines can have pro-\\nblems if they take zolpidem. Before taking this medi-\\ncine, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to zolpidem in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians about the safety of using zolpidem during\\npregnancy.\\nBREASTFEEDING. Women who are breastfeeding\\nshould check with their physicians before using\\nzolpidem.\\nOTHER MEDICAL CONDITIONS. Before using zolpi-\\ndem, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15Chronic lung diseases ( emphysema, asthma,o r\\nchronic bronchitis)\\n/C15Liver disease\\n/C15Kidney disease\\n/C15Current or past alcohol or drug abuse\\n/C15Depression\\n/C15Sleep apnea\\nUSE OF CERTAIN MEDICINES. Taking zolpidem with\\ncertain other drugs may affect the way the drugs work\\nor may increase the chance of side effects.\\nSide effects\\nThe most common minor side effects are daytime\\ndrowsiness or a ‘‘drugged’’ feeling, vision problems,\\nmemory problems, nightmares or unusual dreams,\\nvomiting, nausea, abdominal or stomach pain,diar-\\nrhea, dry mouth, headache, and general feeling of dis-\\ncomfort or illness. These problems usually go away as\\nthe body adjusts to the drug and do not require med-\\nical treatment.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15Confusion\\n/C15Depression\\n/C15Clumsiness or unsteadiness\\nPatients who take zolpidem may notice side\\neffects for several weeks after they stop taking the\\ndrug. They should check with their physicians if\\nthese or other troublesome symptoms occur:\\n/C15Agitation, nervousness, feelings of panic\\n/C15Uncontrolled crying\\n/C15Worsening of mental or emotional problems\\n/C15Seizures\\n/C15Tremors\\n/C15Lightheadedness\\n/C15Sweating\\n/C15Flushing\\n/C15Nausea or abdominal or stomach cramps\\n/C15Muscle cramps\\n/C15Unusual tiredness or weakness\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking zolpidem should\\nget in touch with his or her physician.\\nInteractions\\nZolpidem may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Anyone who takes zolpidem should let the\\nphysician know all other medicines he or she is\\nGALE ENCYCLOPEDIA OF MEDICINE 319\\nAnti-insomnia drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 349, 'page_label': '320'}, page_content='taking. Among the drugs that may interact with zol-\\npidem are:\\n/C15Other central nervous system (CNS) depressants\\nsuch as medicine for allergies, colds, hayfever, and\\nasthma; sedatives; tranquilizers; prescription pain\\nmedicine; muscle relaxants; medicine for seizures;\\nbarbiturates; and anesthetics.\\n/C15The major tranquilizer chlorpromazine (Thorazine).\\n/C15Tricyclic antidepressants such as imipramine\\n(Tofranil) and amitriptyline (Elavil).\\nNancy Ross-Flanigan\\nAnti-itch drugs\\nDefinition\\nAnti-itch drugs are medicines taken by mouth or\\nby injection to relieveitching.\\nPurpose\\nThe medicine described here, hydroxyzine, is a\\ntype of antihistamine used to relieve itching caused\\nby allergic reactions. An allergic reaction occurs\\nwhen the body is unusually sensitive to some sub-\\nstance, such as pollen, dust, mold, or certain foods or\\nmedicine. The body reacts by releasing a chemical\\ncalled histamine that causes itching and other symp-\\ntoms, such as sneezing and watery eyes.Antihistamines\\nreduce the symptoms by blocking the effects of\\nhistamine.\\nHydroxyzine is also prescribed foranxiety and to\\nhelp people relax before or after having general\\nanesthesia.\\nDescription\\nAnti-itch drugs, also called antipruritic drugs, are\\navailable only with a physician’s prescription and\\ncome in tablet and injectable forms. Some commonly\\nused brands of the anti-itch drug hydroxyzine are\\nAtarax and Vistaril.\\nRecommended dosage\\nWhen prescribed for itching, the usual dosage for\\nadults is 25 mg, three to four times a day. For children\\nover six years of age, the usual dosage 50-100 mg per\\nday, divided into several small doses. The usual dosage\\nfor children under six years of age is 50 mg per day,\\ndivided into several small doses.\\nThe dosage may be different for different people.\\nCheck with the physician who prescribed the drug\\nor the pharmacist who filled the prescription for the\\ncorrect dosage, and take the medicine exactly as\\ndirected.\\nPrecautions\\nThis medicine should not be used for more than\\nfour months at a time because its effects can wear off.\\nSee a physician regularly while taking the medicine to\\ndetermine whether it is still needed.\\nHydroxyzine may add to the effects of alcohol and\\nother drugs that slow down the central nervous sys-\\ntem, such as other antihistamines, cold medicine,\\nallergy medicine, sleep aids, medicine for seizures,\\ntranquilizers, some pain relievers, and muscle relax-\\nants. Anyone taking hydroxyzine should not drink\\nalcohol and should check with his or her physician\\nbefore taking any of the above.\\nSome people feel drowsy or less alert when using\\nthis medicine. Anyone who takes it should not drive,\\nuse machines, or do anything else that might be\\ndangerous until they have found out how the drugs\\naffect them.\\nAnyone who has had unusual reactions to hydro-\\nxyzine in the past should let his or her physician know\\nbefore taking the medicine again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nA woman who is pregnant or who may become\\npregnant should check with her physician before tak-\\ning this medicine. In studies of laboratory animals,\\nhydroxyzine has causedbirth defectswhen taken du-\\nring pregnancy. Although the drug’s effects on preg-\\nnant women have not been fully studied, physicians\\nadvise against taking it in early pregnancy.\\nKEY TERMS\\nAnesthesia— Treatment with medicine that causes\\na loss of feeling, especially pain. Local anesthesia\\nnumbs only part of the body; general anesthesia\\ncauses loss of consciousness.\\nAntihistamine— Medicine that prevents or relieves\\nallergy symptoms.\\n320 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-itch drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 350, 'page_label': '321'}, page_content='BREASTFEEDING. Women who are breastfeeding\\nshould also check with their physicians before using\\nhydroxyzine. The medicine may pass into breast milk\\nand may cause problems in nursing babies whose\\nmothers take it.\\nSide effects\\nThe most common side effect, drowsiness, usually\\ngoes away as the body adjusts to the drug. If it does\\nnot, reducing the dosage may be necessary. Other side\\neffects, such asdry mouth, also may occur and do not\\nneed medical attention unless they continue.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15Twitches ortremors\\n/C15Convulsions (seizures).\\nInteractions\\nHydroxyzine may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Anyone who takes hydroxyzine should let the\\nphysician know all other medicines he or she is taking.\\nAmong the drugs that may interact with hydroxyzine are:\\n/C15Barbiturates such as phenobarbital and secobarbital\\n(Seconal)\\n/C15Opioid (narcotic) pain medicines such as meperidine\\n(Demerol) and oxycodone (Percocet)\\n/C15Non-narcotic pain medicines such asacetaminophen\\n(Tylenol) and ibuprofen (Motrin, Advil).\\nThe list above may not include every drug that\\ninteracts with hydroxyzine. Be sure to check with a\\nphysician or pharmacist before combining hydroxy-\\nzine with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntimalarial drugs\\nDefinition\\nAntimalarial drugs are medicines that prevent or\\ntreat malaria.\\nPurpose\\nAntimalarial drugs treat or prevent malaria, a\\ndisease that occurs in tropical, subtropical, and\\nsome temperate regions of the world. The disease\\nis caused by a parasite,Plasmodium, which belongs\\nto a group of one-celled organisms known as proto-\\nzoa. The only way to get malaria is to be bitten by a\\ncertain type of mosquito that has bitten someone\\nwho has the disease. Thanks to mosquito control\\nprograms, malaria has been eliminated in the\\nUnited States, almost all of Europe, and large\\nparts of Central and South America. However, mos-\\nquito control has not worked well in other parts\\nof the world, and malaria continues to be a\\nmajor health problem in parts of Africa, Southeast\\nAsia, Latin America, Haiti, the Dominican Republic,\\nand some Pacific Islands. Every year, some\\n30,000 Americans and Europeans who travel to\\nthese areas get malaria. People planning to travel to\\nthe tropics are often advised to take antimalarial\\ndrugs before, during, and after their trips, to help\\nthem avoid getting the disease and bringing it home\\nwith them. These drugs killPlasmodium or prevent\\nits growth.\\nIn recent years, some strains of Plasmodium\\nhave become resistant to antimalarial drugs, and\\nmedical researchers have stepped up efforts to\\ndevelop a malaria vaccine. In early 1997, research-\\ners reported encouraging results from a small study\\nof one vaccine and planned to test the vaccine\\nin Africa.\\nKEY TERMS\\nGlucose— A simple sugar that serves as the body’s\\nmain source of energy.\\nHypoglycemia— Abnormally low levels of glucose\\nin the blood.\\nOrganism— An individual of some type of life form,\\nsuch as a plant or an animal.\\nParasite— An organism that lives and feeds in or on\\nanother organism (the host) and does nothing to\\nbenefit the host.\\nProtozoa— Animal-like, one-celled organisms,\\nsome of which cause diseases in people.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nPurpura— A spotty or patchy purplish rash caused\\nby bleeding under the surface of the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 321\\nAntimalarial drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 351, 'page_label': '322'}, page_content='Description\\nAntimalarial drugs are available only with a phy-\\nsician’s prescription. They come in tablet, capsule, and\\ninjectable forms. Among the commonly used antima-\\nlarial drugs are chloroquine (Aralen), mefloquine\\n(Lariam), primaquine, pyrimethamine (Daraprim),\\nand quinine. Other drugs are constantly in develop-\\nment. In early 2004, scientists were researching pro-\\nmising new agents called beat-amino hydroxamates\\nand amino acid-conjugated quinolinamines.\\nRecommended dosage\\nRecommended dosage depends on the type of\\nantimalarial drug, its strength, and the form in which\\nit is being used (such as tablet or injection). The dosage\\nmay also be different for different people. The physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription can recommend the correct\\ndosage. This medicine should be taken exactly as\\ndirected and for the full time of treatment. If the\\ndrug is being taken to treat malaria, it should not be\\nstopped just because symptoms begin to improve.\\nSymptoms may return if the drug is stopped too\\nsoon. Larger or more frequent doses than the physi-\\ncian has ordered should never be taken, nor should the\\ndrug be taken for longer than directed.\\nTravelers taking this medicine to prevent malaria\\nmay be told to take it for one to two weeks before their\\ntrip and for four weeks afterward, as well as for the\\nwhole time they are away. It is important to follow\\nthese directions.\\nAntimalarial drugs work best when they are taken\\non a regular schedule. When taken once a week to\\nprevent malaria, they should be taken on the same day\\nevery week. When taken daily or several times a day to\\ntreat malaria, they should be taken at the same time\\nevery day. Doses should not be missed or skipped.\\nSome antimalarial drugs should be taken with\\nmeals or with milk to prevent upset stomach. Others\\nmust be taken with a full glass of water. It is important\\nto follow directions along with the prescription.\\nPrecautions\\nAntimalarial drugs may cause lightheadedness,\\ndizziness, blurred vision and other vision changes.\\nAnyone who takes these drugs should not drive, use\\nmachines or do anything else that might be dangerous\\nuntil they have found out how the drugs affect them.\\nThe antimalarial drug mefloquine (Lariam) has\\nreceived attention because of reports that it causes\\npanic attacks, hallucinations, anxiety, depression,\\nparanoia, and other mental and mood changes, some-\\ntimes lasting for months after the last dose. In fact, the\\nU.S. Food and Drug Administration (FDA) began\\nrequiring warnings with Lariam beginning in July\\n2003 because of serious psychiatric effects caused by\\nthe drug. Pharmacists are required to include a 2,000-\\nword medication guide detailing the warnings.\\nAnyone who has unexplained anxiety, depression,\\nrestlessness, confusion, or other troubling mental or\\nmood changes after taking mefloquine should call a\\nphysician right away. Switching to a different antima-\\nlarial drug may be an alternative and can allow the side\\neffects to stop.\\nAnyone taking antimalarial drugs to prevent\\nmalaria who develops afever or flu-like symptoms\\nwhile taking the medicine or within 2-3 months after\\ntraveling to an area where malaria is common should\\ncall a physician immediately.\\nIf the medicine is being taken to treat malaria, and\\nsymptoms stay the same or get worse, The patient\\nshould check with the physician who prescribed the\\nmedicine.\\nPatients who take this medicine over a long period\\nof time need to have a physician check them periodi-\\ncally for unwanted side effects.\\nBabies and children are especially sensitive to the\\nantimalarial drug chloroquine. Not only are they more\\nlikely to have side effects from the medicine, but they\\nare also at greater risk of being harmed by an over-\\ndose. A single 300-mg tablet could kill a small child.\\nThis medicine should be kept out of the reach of children\\nand safety vials should be used.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take antimalarial drugs. Before taking these\\ndrugs, the physician should know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to antimalarial drugs or related medicines in\\nthe past should let his or her physician know before\\ntaking the drugs again. The physician should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nPREGNANCY. In laboratory animal studies, some\\nantimalarial drugs causebirth defects. But it is also\\nrisky for a pregnant woman to get malaria. Untreated\\nmalaria can cause premature birth, stillbirth, and\\nmiscarriage. When given in low doses to prevent\\nmalaria, antimalarial drugs have not been reported\\n322 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimalarial drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 352, 'page_label': '323'}, page_content='to cause birth defects in humans. If possible, pregnant\\nwomen should avoid traveling to areas where they\\ncould get malaria. If travel is necessary, women who\\nare pregnant or who may become pregnant should\\ncheck with their physicians about the use of antima-\\nlarial drugs.\\nBREASTFEEDING. Some antimalarial drugs pass\\ninto breast milk. Although no problems have been\\nreported in nursing babies whose mothers took anti-\\nmalarial drugs, babies and young children are particu-\\nlarly sensitive to some of these drugs. Women who are\\nbreastfeeding should check with their physicians\\nbefore using antimalarial drugs.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nmalarial drugs, people who have any of these medi-\\ncal problems (or have had them in the past) should\\nmake sure their physicians are aware of their\\nconditions:\\n/C15Blood disease\\n/C15Liver disease\\n/C15Nerve or brain disease or disorder, including seizures\\n(convulsions)\\n/C15Past or current mental disorder\\n/C15Stomach or intestinal disease\\n/C15Deficiency of the enzyme glucose-6-phosphate dehy-\\ndrogenase (G6PD), which is important in the break-\\ndown of sugar in the body\\n/C15Deficiency of the enzyme nicotinamide adenine dinu-\\ncleotide (NADH) methemoglobin reductase\\n/C15Psoriasis\\n/C15Heart disease\\n/C15Family or personal history of the genetic condition\\nfavism (a hereditary allergic condition)\\n/C15Family or personal history ofhemolytic anemia,a\\ncondition in which red blood cells are destroyed\\n/C15Purpura\\n/C15Hypoglycemia (low blood sugar)\\n/C15Blackwater fever (a serious complication of one type\\nof malaria)\\n/C15Myasthenia gravis (a disease of the nerves and\\nmuscles).\\nUSE OF CERTAIN MEDICINES. Taking antimalarial\\ndrugs with certain other drugs may affect the way\\nthe drugs work or may increase the chance of side\\neffects.\\nSide effects\\nHigh doses of the antimalarial drug pyrimetha-\\nmine may cause blood problems that can interfere with\\nhealing and increase the risk of infection. People tak-\\ning this drug should be careful not to injure their gums\\nwhen brushing or flossing their teeth or using tooth-\\npicks. If possible, dental work should be postponed\\nuntil treatment is complete and the blood has returned\\nto normal.\\nThe most common side effects of antimalarial\\ndrugs are diarrhea, nausea or vomiting, stomach\\ncramps or pain, loss of appetite, headache, itching,\\ndifficulty concentrating, dizziness, lightheadedness,\\nand sleep problems. These problems usually go away\\nas the body adjusts to the drug and do not require\\nmedical treatment. Less common side effects, such as\\nhair loss or loss of color in the hair; skin rash; or blue-\\nblack discoloration of the skin, fingernails, or inside of\\nthe mouth also may occur and do not need medical\\nattention unless they are long-lasting.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\nthe physician who prescribed the medicine should be\\ncontacted immediately:\\n/C15Blurred vision or any other vision changes\\n/C15Convulsions (seizures)\\n/C15Mood or mental changes\\n/C15Hallucinations\\n/C15Anxiety\\n/C15Confusion\\n/C15Weakness or unusual tiredness\\n/C15Unusual bruising or bleeding\\n/C15Hearing loss or ringing or buzzing in the ears\\n/C15Fever, with or without sore throat\\n/C15Slow heartbeat\\n/C15Pain in the back or legs\\n/C15Dark urine\\n/C15Pale skin\\n/C15Taste changes\\n/C15Soreness, swelling, or burning sensation in the\\ntongue.\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking anantimalarial\\ndrug should get in touch with his or her physician.\\nGALE ENCYCLOPEDIA OF MEDICINE 323\\nAntimalarial drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 353, 'page_label': '324'}, page_content='Interactions\\nSome antimalarial drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes antimalarial drugs\\nshould let the physician know all other medicines he or\\nshe is taking. Among the drugs that interact with some\\nantimalarial drugs are:\\n/C15Beta blockers such as atenolol (Tenormin), propra-\\nnolol (Inderal), and metoprolol (Lopressor)\\n/C15Calcium channel blockers such as diltiazem\\n(Cardizem), nicardipene (Cardene), and nifedipine\\n(Procardia)\\n/C15Other antimalarial drugs\\n/C15Quinidine, used to treat abnormal heart rhythms\\n/C15Antiseizure medicines such as vaproic acid deriva-\\ntives (Depakote or Depakene)\\n/C15Oral typhoid vaccine\\n/C15Diabetes medicines taken by mouth\\n/C15Sulfonamides (sulfa drugs)\\n/C15Vitamin K\\n/C15Anticancer drugs\\n/C15Medicine for overactive thyroid\\n/C15Antiviral drugs such as zidovudine (Retrovir).\\nThe list above does not include every medicine\\nthat may interact with every antimalarial drug. It is\\nadvised to check with a physician or pharmacist before\\ncombining an antimalarial drug with any other\\nprescription or nonprescription (over-the-counter)\\nmedicine.\\nResources\\nPERIODICALS\\n‘‘Amino Acid-conjugated Quinolinamines Are Potent\\nAntimalarials.’’ Drug Week(March 12, 2004): 142.\\n‘‘FDA Requires Warnings on Anti-malaria Drug Lariam.’’\\nConsumer Reports(January 2004): 45.\\n‘‘Glycosylated Beta-amino Hydroxamates Show Promise as\\nAntimalarials.’’ Malaria Weekly(February 2, 2004): 2.\\nOTHER\\n‘‘Should You Take Lariam?’’Travel Health Information\\nPage. .\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntimicrobial agents see Antibiotics\\nAntimigraine drugs\\nDefinition\\nAntimigraine drugs are medicines used to prevent\\nor reduce the severity of migraine headaches.\\nPurpose\\nMigraine headaches usually cause a throbbing\\npain on one side of the head.Nausea, vomiting, dizzi-\\nness, increased sensitivity to light and sound, and\\nother symptoms may accompany the pain. The attacks\\nmay last for several hours or for a day or more and\\nmay come as often as several times a week. Some\\npeople who get migraine headaches have warning sig-\\nnals before the headaches begin, such as restlessness,\\ntingling in an arm or leg, or seeing patterns of flashing\\nlights. This set of signals is called an aura. The anti-\\nmigraine drugs discussed in this section are meant to\\nbe taken as soon as the pain begins, to relieve the pain\\nand other symptoms. Other types of drugs, such as\\nantiseizure medicines, antidepressants,calcium chan-\\nnel blockers and beta blockers, are sometimes pre-\\nscribed to prevent attacks in people with very severe\\nor frequent migraines.\\nDescription\\nMigraine is thought to be caused by electrical and\\nchemical imbalances in certain parts of the brain.\\nThese imbalances affect the blood vessels in the\\nbrain – first tightening them up, then widening them.\\nAs the blood vessels widen, they stimulate the release\\nof chemicals that increase sensitivity to pain and cause\\ninflammation and swelling. Antimigraine drugs are\\nbelieved to work by correcting the imbalances and by\\ntightening the blood vessels.\\nExamples of drugs in this group are ergotamine\\n(Cafergot), naratriptan (Amerge), sumatriptan\\n(Imitrex), rizatriptan (Maxalt), almotriptan (Axert),\\nand zolmitriptan (Zomig). Methysergide maleate\\n(Sansert) may be used by patients whose headaches\\nare not controlled by other drugs, while some patients\\ndo well on other drugs. For example, combinations\\nor ergotamine and caffeine may be very effective.\\nThe caffeine acts by constricting blood vessels to\\nrelieve the headache. Sometimes, an analgesic such\\nas acetaminophen, caffeine, and a barbiturate which\\nacts as a sedative, are combined, as in Fioricet and\\nsimilar compounds. These medicines are available\\nonly with a physician’s prescription and come in\\nseveral forms. Ergotamine is available as tablets\\n324 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimigraine drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 354, 'page_label': '325'}, page_content='and rectal suppositories; sumatriptan as tablets,\\ninjections, and nasal spray; and zolmitriptan as\\ntablets.\\nAntimigraine drugs are used to treat headaches\\nonce they have started. These drugs should not be\\ntaken to prevent headaches.\\nSome patients are given anti-epileptic drugs,\\nwhich are also known as anticonvulsants, to treat\\nmigraine headaches. As of 2003, sodium valproate\\n(Epilim) is the only anticonvulsant approved by the\\nFood and Drug Administration (FDA) for preven-\\ntion of migraine. Such newer anticonvulsants as\\ngabapentin (Neurontin) and topiramate (Topamax)\\nare being evaluated as migraine preventives as of\\nearly 2004.\\nRecommended dosage\\nRecommended dosage depends on the type of\\ndrug. Typical recommended dosages for adults are\\ngiven below for each type of drug.\\nErgotamine\\nTake at the first sign of a migraine attack. Patients\\nwho get warning signals (aura) may take the drug as\\nsoon as they know a headache is coming.\\nTABLETS. No more than 6 tablets for any single\\nattack.\\nNo more than 10 tablets per week.\\nSUPPOSITORIES. No more than 2 suppositories for\\nany single attack.\\nNo more than 5 suppositories per week.\\nNaratriptan\\nTake as soon as pain or other migraine symptoms\\nbegin. Also effective if taken any time during an\\nattack. Do not take the drug until the pain actually\\nstarts as not all auras result in a migraine.\\nTABLETS. Usual dose is one 1-mg tablet taken with\\nwater or other liquid.\\nDoses of 2.5-mg may be used, but they may cause\\nmore side effects.\\nIf the headache returns or if there is only partial\\nresponse, the dose may be repeated once after 4 hours,\\nfor a maximum dose of 5 mg in a 24-hour period.\\nLarger doses do not seem to offer any benefit.\\nSumatriptan\\nTake as soon as pain or other migraine symptoms\\nbegin. Also effective if taken any time during an\\nattack. Do not take the drug until the pain actually\\nstarts as not all auras result in a migraine.\\nTABLETS. Usual dose is one 25-mg tablet, taken\\nwith water or other liquid.\\nDoses should be spaced at least 2 hours apart.\\nAnyone with liver disease should consult with a\\nphysician for proper dosing.\\nINJECTIONS. No more than 6 mg per dose, injected\\nunder the skin.\\nNo more than two 6-mg injections per day. These\\ndoses should be taken at least 1 hour apart.\\nZolmitriptan\\nTake as soon as symptoms begin.\\nTABLETS. Usual dose is 1–5 mg. Additional doses\\nmay be taken at 2-hour intervals.\\nNo more than 10 mg per 24 hour period.\\nKEY TERMS\\nAnticonvulsant— A type of drug given to prevent\\nseizures. Some patients with migraines can be\\ntreated effectively with an anticonvulsant.\\nAura— A set of warning symptoms, such as seeing\\nflashing lights, that some people have 10–30\\nminutes before a migraine attack.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nStatus migrainosus— The medical term for an acute\\nmigraine headache that lasts 72 hours or longer.\\nAntimigraine Drugs\\nBrand Name\\n(Generic Name) Possible Common Side Effects Include:\\nCafergot Nausea, increased blood pressure, fluid\\nretention, numbness, increased heart rate,\\ntingling sensation\\nImitrex (sumatriptan\\nsuccinate)\\nBurning, flushing, neck pain, inflammation at\\ninjection site, sore throat, tingling sensation\\nInderal (propranolol\\nhydrochloride)\\nConstipation or diarrhea, headache, nausea, rash\\nMidrin Dizziness, rash\\nGALE ENCYCLOPEDIA OF MEDICINE 325\\nAntimigraine drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 355, 'page_label': '326'}, page_content='General dosage advice\\nAlways take antimigraine drugs exactly as direc-\\nted. Never take larger or more frequent doses, and do\\nnot take the drug for longer than directed.\\nIf possible, lie down and relax in a dark, quiet\\nroom for a few hours after taking the medicine.\\nPrecautions\\nThese drugs should be used only to treat the type\\nof headache for which they were prescribed. Patients\\nshould not use them for other headaches, such as those\\ncaused bystress or too much alcohol, unless directed\\nto do so by a physician.\\nAnyone whose headache is unlike any previous\\nheadache should check with a physician before taking\\nthese drugs. If the headache is far worse than any\\nother, emergency medical treatment should be sought\\nimmediately.\\nTaking too much of the antimigraine drug ergota-\\nmine (Cafergot), can lead to ergotpoisoning. Symptoms\\ninclude headache, muscle pain,numbness, coldness, and\\nunusually pale fingers and toes. If not treated, the con-\\ndition can lead togangrene(tissue death).\\nSumatriptan (Imitrex), naratriptan (Amerge),\\nrizatriptan (Maxalt) and zolmitriptan (Zomig) may\\ninteract with ergotamine. These drugs should not be\\ntaken within 24 hours of taking any drug containing\\nergotamine.\\nSome antimigraine drugs work by tightening\\nblood vessels in the brain. Because these drugs also\\naffect blood vessels in other parts of the body, people\\nwith coronary heart disease, circulatory problems, or\\nhigh blood pressure should not take these medicines\\nunless directed to do so by their physicians.\\nAbout 40% of all migraine attacks do not\\nrespond to treatment with triptans or any other\\nmedication. If the headache lasts longer than 72\\nhours—a condition known as status migrainosus—\\nthe patient may be given narcotic medications to\\nbring on sleep and stop the attack. Patients with\\nstatus migrainosus are often hospitalized because\\nthey are likely to be dehydrated from severenausea\\nand vomiting.\\nSpecial conditions\\nPeople with certain other medical conditions or\\nwho are taking certain other medicines can have pro-\\nblems if they take antimigraine drugs. Before taking\\nthese drugs, be sure to let the physician know about\\nany of these conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to ergotamine, caffeine, sumatriptan, zolmitrip-\\ntan, or other antimigraine drugs in the past should let\\nhis or her physician know before taking the drugs\\nagain. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other\\nsubstances.\\nPREGNANCY. Women who are pregnant should\\nnot take ergotamine (Cafergot). The effects of other\\nantimigraine drugs duringpregnancy have not been\\nwell studied. Any woman who is pregnant or plans to\\nbecome pregnant should let her physician know before\\nan antimigraine drug is prescribed.\\nBREASTFEEDING. Some antimigraine drugs can\\npass into breast milk and may cause serious problems\\nin nursing babies. Women who are breastfeeding\\nshould check with their physicians about whether to\\nstop breastfeeding while taking the medicine.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nmigraine drugs, people with any of these medical pro-\\nblems should make sure their physicians know about\\ntheir conditions:\\n/C15Coronary heart disease\\n/C15Angina (crushing chest pain)\\n/C15Circulatory problems or blood vessel disease\\n/C15High blood pressure\\n/C15Liver problems\\n/C15Kidney problems\\n/C15Any infection\\n/C15Eye problems.\\nUSE OF CERTAIN MEDICINES. Taking antimigraine\\ndrugs certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects are fluid reten-\\ntion, flushing; high blood pressure; unusually fast\\nor slow heart rate; numbness; tingling; itching;\\nnausea; vomiting; weakness; neck or jaw pain and\\nstiffness; feelings of tightness, heaviness, warmth,\\nor coldness; sore throat ; and discomfort of the\\nmouth and tongue.\\nMore serious side effects are not common, but\\nthey may occur. If any of the following side effects\\noccur, call a physician immediately:\\n/C15Tightness in the chest\\n/C15Bluish tinge to the skin\\n/C15Cold arms and legs\\n326 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimigraine drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 356, 'page_label': '327'}, page_content='/C15Signs of gangrene, such as coldness, dryness, and a\\nshriveled or black appearance of a body part\\n/C15Dizziness\\n/C15Drowsiness\\n/C15Shortness of breath orwheezing\\n/C15Skin rash\\n/C15Swelling of the eyelids or face.\\nPossible side effects with anticonvulsants include\\ndizziness, drowsiness, emotional upset, skin rash, tem-\\nporary hair loss, nausea, and irregular menstrual\\nperiods.\\nOther side effects may occur with any antimi-\\ngraine drug. Anyone who has unusual symptoms\\nafter taking this medicine should get in touch with\\nhis or her physician.\\nAlternative treatments\\nThere are two herbal remedies that are reported to\\nbe effective as alternative treatments for migraine. One\\nis feverfew (Tanacetum parthenium), an herb related to\\nthe daisy that is traditionally used in England to pre-\\nvent migraines. Published studies indicate that fever-\\nfew can reduce the frequency and intensity of\\nmigraines. It does not, however, relieve pain once the\\nheadache has begun. The other herbal remedy is but-\\nterbur root (Petasites hybridus). Petadolex is a natural\\npreparation made from butterbur root that has been\\nsold in Germany since the 1970s as a migraine preven-\\ntive. Petadolex has been available in the United States\\nsince December 1998.\\nInteractions\\nAntimigraine drugs may interact with other med-\\nicines. When this happens, the effects of one or both of\\nthe drugs may change, or the risk of side effects may be\\ngreater. Anyone who takes these drugs should let the\\nphysician know all other medicines he or she is taking.\\nAmong the drugs that may interact with antimigraine\\ndrugs are:\\n/C15Beta blockers such as atenolol (Tenormin) and pro-\\npranolol (Inderal)\\n/C15Drugs that tighten blood vessels such as epinephrine\\n(EpiPen) and pseudoephedrine (Sudafed)\\n/C15Nicotine such as cigarettes or Nicoderm, Habitrol,\\nand othersmoking-cessation drugs\\n/C15Certain antibiotics, such as erythromycin and clari-\\nthromycin (Biaxin)\\n/C15Monoamine oxidase inhibitors such as phenelzine\\n(Nardil) and tranylcypromine (Parnate)\\n/C15Certain antidepressants, such as sertraline (Zoloft),\\nfluoxetine (Prozac), and paroxetine (Paxil)\\n/C15Fluvoxamine (Luvox), prescribed for obsessive com-\\npulsive disorder or chronic pain.\\nAnticonvulsants should not be taken together\\nwith aspirin, alcohol, or tranquilizers.\\nRemember naratriptan, sumatriptan, rizatriptan\\nand zolmitriptan may interact with ergotamine. These\\ndrugs should not be taken within 24 hours of taking\\nany drug containing ergotamine.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders.4th ed., revised.\\nWashington, DC: American Psychiatric Association,\\n2000.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Headache.’’ Section 14, Chapter 168 InThe Merck\\nManual of Diagnosis and Therapy.Whitehouse Station,\\nNJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Psychogenic Pain Syndromes.’’ Section 14, Chapter\\n167 InThe Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nPelletier, Kenneth R., MD.The Best Alternative Medicine,\\nPart II. ‘‘CAM Therapies for Specific Conditions:\\nHeadache.’’ New York: Simon & Schuster, 2002.\\nPERIODICALS\\nCeballos Hernansanz, M. A., R. Sanchez Roy, A. Cano\\nOrgaz, et al. ‘‘Migraine Treatment Patterns and Patient\\nSatisfaction with Prior Therapy: A Substudy of a\\nMulticenter Trial of Rizatriptan Effectiveness.’’\\nClinical Therapeutics25 (July 2003): 2053–2069.\\nCorbo, J. ‘‘The Role of Anticonvulsants in Preventive\\nMigraine Therapy.’’Current Pain and Headache\\nReports 7 (February 2003): 63–66.\\nDodick, D. W. ‘‘A Review of the Clinical Efficacy and\\nTolerability of Almotriptan in Acute Migraine.’’Expert\\nOpinion in Pharmacotherapy4 (July 2003): 1157–1163.\\nDowson, A. J., and B. R. Charlesworth. ‘‘Patients with\\nMigraine Prefer Zolmitriptan Orally Disintegrating\\nTablet to Sumatriptan Conventional Oral Tablet.’’\\nInternational Journal of Clinical Practice57 (September\\n2003): 573–576.\\nJohannessen, C. U., and S. I. Johannessen. ‘‘Valproate: Past,\\nPresent, and Future.’’CNS Drug Review9 (Summer\\n2003): 199–216.\\nSahai, Soma, MD, Robert Cowan, MD, and David Y. Ko,\\nMD. ‘‘Pathophysiology and Treatment of Migraine\\nand Related Headache.’’eMedicine April 30, 2002.\\nGALE ENCYCLOPEDIA OF MEDICINE 327\\nAntimigraine drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 357, 'page_label': '328'}, page_content='Tepper, S. J., and D. Millson. ‘‘Safety Profile of the\\nTriptans.’’ Expert Opinion on Drug Safety2 (March\\n2003): 123–132.\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAntimyocardial antibody test\\nDefinition\\nTesting for antimyocardial antibodies is done\\nwhen evaluating a person for heart damage or heart\\ndisease.\\nPurpose\\nAntimyocardial antibodies are autoantibodies.\\nNormal antibodies are special proteins built by the\\nbody as a defense against foreign material entering the\\nbody. Autoantibodies are also proteins built by the body,\\nbut instead of attacking foreign material, they inappro-\\npriatelyattackthebody’s owncells. Antimyocardial anti-\\nbodies attack a person’s heart muscle, or myocardium.\\nThis test may be done on a person who recently\\nhad trauma to the heart, such as heart surgery or a\\nmyocardial infarction (heart attack). It also may be\\ndone on someone with heart disease, such ascardio-\\nmyopathy or rheumatic fever.\\nAlthough the presence of antimyocardial antibo-\\ndies does not diagnose heart damage or disease, there is\\na connection between the presence of these antibodies\\nand damage to the heart. The amount of damage, how-\\never, cannot be predicted by the amount of antibodies.\\nThese antibodies usually appear after heart surgery\\northebeginningofdisease,buttheymaybepresentbefore\\nsurgery or the onset of disease. In 30% of people with\\nmyocardial infarction and 70% of people having heart\\nsurgery, antimyocardial antibodies will appear within\\ntwo to three weeks and stay for three to eight weeks.\\nDescription\\nA 5-10 mL sample of venous blood is drawn from\\nthe patient’s arm in the region of the inner elbow.\\nAntimyocardial antibodies are detected by combining\\na patient’s serum (clear, thin, sticky fluid in blood)\\nwith cells from animal heart tissue, usually that of a\\nmonkey. Antimyocardial antibodies in the serum bind\\nto the heart tissue cells. A fluorescent dye is then added\\nto the mixture. This dye will attach to any antibodies\\nand heart tissue cells bound together. The final mix-\\nture is studied under a microscope that is designed to\\nshow fluorescence. If fluorescent cells are seen under\\nthe microscope, the test is positive.\\nWhen the test is positive, the next step is to find\\nout how much antibody is present. The patient’s\\nserum is diluted, or titered, and the test is done\\nagain. The serum is then further diluted and the test\\nrepeated until the serum is so dilute that fluorescence is\\nno longer seen. The last dilution that showed fluores-\\ncence is the titer reported.\\nPreparation\\nNo fasting or special prepartion is needed. Before\\nthe test is done it should be explained to the patient.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite after the blood is drawn or the person may feel\\ndizzy or faint. Pressure to the puncture site until the\\nbleeding stops reduces bruising. Warm packs on the\\npuncture site relieve discomfort.\\nNormal results\\nAntimyocardial antibodies are not normally seen\\nin healthy individuals.\\nKEY TERMS\\nAntibody— A special protein built by the body as\\na defense against foreign material entering the\\nbody.\\nAntimyocardial antibody— An autoantibody that\\nattacks a person’s own heart muscle, or\\nmyocardium.\\nAutoantibody— An antibody that attacks the\\nbody’s own cells or tissues.\\nMyocardial infarction— A block in the blood sup-\\nply to the heart, resulting in what is commonly\\ncalled a heart attack.\\nMyocardium— The muscular middle layer of the\\nheart.\\nTiter— A dilution of a substance with an exact\\nknown amount of fluid. For example, one part of\\nserum diluted with four parts of saline is a titer\\nof 1:4.\\n328 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimyocardial antibody test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 358, 'page_label': '329'}, page_content='Abnormal results\\nA positive result means that antimyocardial antibo-\\ndiesarepresentandthatheartdiseaseordamageislikely.\\nFurther testing may be needed as other autoantibodies\\ncould also be present, causing a false abnormal test.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nNancy J. Nordenson\\nAntinausea drugs\\nDefinition\\nAntinausea drugs are medicines that control nau-\\nsea—a feeling of sickness or queasiness in the stomach\\nwith an urge to vomit. These drugs also prevent or stop\\nvomiting. Drugs that control vomiting are called antie-\\nmetic drugs.\\nPurpose\\nAntinausea drugs such as prochlorperazine\\n(Compazine), usually control bothnausea and vomit-\\ning. Prochlorperazine is also sometimes prescribed for\\nsymptoms of mental disorders, such asschizophrenia.\\nAnother commonly prescribed antinausea drug is\\npromethazine (Phenergan). Promethazine also may be\\nprescribed to relieve allergy symptoms and apprehen-\\nsion, as well asmotion sickness.\\nDescription\\nProchlorperazine is available only with a physi-\\ncian’s prescription. It is sold in syrup, capsule, tablet,\\ninjection, and suppository forms.\\nRecommended dosage\\nTo control nausea and vomiting in adults, the\\nusual dose is:\\n/C15Tablets—one 5-mg or 10-mg tablet three to four\\ntimes a day\\n/C15Extended-release capsules—one 15-mg capsule first\\nthing in the morning or one 10-mg capsule every\\n12 hours\\n/C15Suppository—25 mg, twice a day\\n/C15Syrup—5-10 mg three to four times a day\\n/C15Injection—5-10 mg injected into a muscle three to\\nfour times a day.\\nDoses for children must be determined by a\\nphysician.\\nPromethazine may be administered in pill, syrup,\\nchewable tablet, or extended release capsule form by\\nprescription only. For severe nausea, it may be admi-\\nnistered by injection or via a suppository. The physician\\nrecommends dose depending on the patient’s condition.\\nPrecautions\\nProchlorperazine may cause a movement disorder\\ncalled tardive dyskinesia. Signs of this disorder are\\ninvoluntary twitches and muscle spasms in the face\\nand body and jutting or rolling movements of the\\ntongue. The condition may be permanent. Older people,\\nespecially women, are particularly at risk of developing\\nthis problem when they take prochlorperazine.\\nAntinausea Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nCompazine\\n(phochlorperazine)\\nInvoluntary muscle spasms, dizziness,\\njitteriness, puckering of the mouth\\nPhenergan (prometha-\\nzine hydrochloride)\\nDizziness, dry mouth, nausea and vomiting,\\nrash\\nReglan (metoclopramide\\nhydrochloride)\\nFatigue, drowsiness, restlessness\\nTigan (trimethobenza-\\nmide hydrochloride)\\nBlurred vision, diarrhea, cramps, headache\\nZofan (ondansetron\\nhydrochloride)\\nConstipation, headache, fatigue, abdominal\\npain\\nKEY TERMS\\nAnesthetic— Medicine that causes a loss of feeling,\\nespecially pain. Some anesthetics also cause a loss\\nof consciousness.\\nAntihistamine— Medicine that prevents or relieves\\nallergy symptoms.\\nCentral nervous system— The brain and spinal cord.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles.\\nTranquilizer— Medicine that has a calming effect\\nand is used to treat anxiety and mental tension.\\nGALE ENCYCLOPEDIA OF MEDICINE 329\\nAntinausea drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 359, 'page_label': '330'}, page_content='Some people feel drowsy, dizzy, lightheaded, or less\\nalert when using this medicine. The drug may also cause\\nblurred vision, and movement problems. For these rea-\\nsons, anyone who takes this drug should not drive, use\\nmachines or do anything else that might be dangerous\\nuntil they have found out how the drug affects them.\\nProchlorperazine makes some people sweat less,\\nwhich can allow the body to overheat. The drug may\\nalso make the skin and eyes more sensitive to the sun.\\nPeople who are taking prochlorperazine should try to\\navoid extreme heat and exposure to the sun. When\\ngoing outdoors, they should wear protective clothing,\\na hat, a sunscreen with a skin protection factor (SPF)\\nof at least 15, and sunglasses that block ultraviolet\\n(UV) light. Saunas, sunlamps, tanning booths, tan-\\nning beds, hot baths, and hot tubs should be avoided\\nwhile taking this medicine. Anyone who must be\\nexposed to extreme heat while taking the drug should\\ncheck with his or her physician.\\nThis medicine adds to the effects of alcohol and\\nother drugs that slow down the central nervous sys-\\ntem, such asantihistamines, cold and flu medicines,\\ntranquilizers, sleep aids, anesthetics, somepain medi-\\ncines, and muscle relaxants. Drinking alcohol while\\ntaking prochlorperazine is not advised and patients\\nshould check with the physician who prescribed the\\ndrug before combining it with any other medicines.\\nDo not stop taking this medicine without checking\\nwith the physician who prescribed it. Stopping the drug\\nsuddenly can causedizziness, nausea, vomiting,tremors,\\nand other side effects. When stopping the medicine, it\\nmay be necessary to taper down the dose gradually.\\nProchlorperazine may cause falsepregnancy tests.\\nWomen who are pregnant (or planning to become\\npregnant) or breast feeding should check with their\\nphysicians before using antinausea medicines.\\nBefore using prochlorperazine, people with any of\\nthe medical problems should make sure their physi-\\ncians are aware of their conditions:\\n/C15Previous sensitivity or allergic reaction to\\nprochlorperazine\\n/C15Heart disease\\n/C15Glaucoma\\n/C15Brain tumor\\n/C15Intestinal blockage\\n/C15Abnormal blood conditions, such as leukemia\\n/C15Exposure to pesticides.\\nSome people may experience side effects from\\npromethazine including:\\n/C15dry mouth\\n/C15drowsiness\\n/C15confusion\\n/C15fatigue\\n/C15difficulty coordinating movements\\n/C15stuffy nose.\\nA physician should be contacted immediately if a\\npatient experiences the following effects while taking\\npromethazine:\\n/C15vision problems\\n/C15ringing in the ears\\n/C15tremors\\n/C15insomnia\\n/C15excitement\\n/C15restlessness\\n/C15yellowing of the skin or eyes\\n/C15skin rash.\\nSide effects\\nMany side effects are possible with prochlorpera-\\nzine, including, but not limited to,constipation, dizzi-\\nness, drowsiness, decreased sweating, dry mouth, stuffy\\nnose, movementproblems,changes inmenstrualperiod,\\nincreased sensitivity to sun, and swelling or pain in\\nbreasts. Anyone who has unusual or troublesome symp-\\ntoms after taking prochlorperazine should get in touch\\nwith his or her physician.\\nSide effects associated with promethazine include\\nthose listed above and interactions with various med-\\nications that may cause complications or lessen the\\neffects of the drug. A physician should be notified of\\nother medications the patient is on when taking\\npromethazine.\\nInteractions\\nProchlorperazine may interact with other medi-\\ncines. When this happens, the effects of one or both of\\nthe drugs may change or the risk of side effects may be\\ngreater. Among the drugs that may interact with pro-\\nchlorperazine are antiseizure drugs such as phenytoin\\n(Dilantin) and carbamazepine (Tegretol), anticoagu-\\nlants such as warfarin (Coumadin), and drugs that\\nslow the central nervous system such as alprazolam\\n(Xanax), diazepam (Valium), and secobarbital\\n(Seconal). Not every drug that interacts with prochlor-\\nperazine is listed here. A physician or pharmacist can\\nadvise patients about prescription or nonprescription\\n330 GALE ENCYCLOPEDIA OF MEDICINE\\nAntinausea drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 360, 'page_label': '331'}, page_content='(over-the-counter) drugs that might interact with\\nProchlorperazine.\\nResources\\nPERIODICALS\\nFlake, Zachary A., Robert D. Scalley, and Austin G. Bailey.\\n‘‘Practical Selection of Antiemetics.’’American Family\\nPhysician March 1, 2004: 1169.\\nOTHER\\n‘‘Promethazine’’ Medline Plus Drug Information..\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntinuclear antibody test\\nDefinition\\nThe antinuclear antibody (ANA) test is a test done\\nearly in the evaluation of a person for autoimmune or\\nrheumatic disease, particularlysystemic lupus erythe-\\nmatosus (SLE).\\nPurpose\\nIn autoimmune diseases, the body makes antibo-\\ndies that work against its own cells or tissues.\\nRheumatic diseases (diseases that affect connective\\ntissue, including the joints, bone, and muscle) are\\nalso associated with these antibodies. Autoantibodies\\nare proteins built by the body, but instead of guarding\\nagainst foreign material (including bacteria, viruses,\\nand fungi) as normal antibodies do, they attack the\\nbody’s own cells.\\nAutoimmune and rheumatic diseases can be diffi-\\ncult to diagnose. People with the same disease can\\nhave very different symptoms. A helpful strategy in\\nthe diagnosis of these diseases is to find and identify an\\nautoantibody in the person’s blood.\\nThe antinuclear antibody test looks for a\\ngroup of autoantibodies that attack substances\\nfound in the center (nucleus) of all cells. It is useful\\nas a screen for many autoantibodies associated\\nwith diseases that affect the entire body (systemic\\ndiseases).\\nThis test is particularly useful when diagnosing a\\nperson with symptoms of SLE, an illness that affects\\nmany body organs and tissues. If the test is negative, it\\nis unlikely that the person has SLE; if the test is positive,\\nmore tests are done to confirm whether the person has\\nSLE or another related disease. Other diseases, such as\\nscleroderma, Sjo¨gren’s syndrome, Raynaud’s disease,\\nrheumatoid arthritis,a n dautoimmune hepatitis, often\\nhave a positive test for antinuclear antibodies.\\nDescription\\nFive to 10 mL of blood is needed for this test. The\\nantinuclear antibody test is done by adding a person’s\\nserum to commercial cells mounted on a microscope\\nslide. If antinuclear antibodies are in the serum, they\\nbind to the nuclei of cells on the slide. Next, a second\\nantibody is added to the mixture. This antibody is\\n‘‘tagged’’ with a fluorescent dye so that it can be\\nseen. The second antibody attaches to any antibodies\\nand cells bound together and, because of the fluores-\\ncent ‘‘tag,’’ the areas with antinuclear antibodies seem\\nto glow, or fluoresce, when the slide is viewed under an\\nultraviolet microscope.\\nIf fluorescent cells are seen, the test is positive.\\nWhen positive, the serum is diluted, or titered, and\\nthe test done again. These steps are repeated until the\\nserum is so dilute it no longer gives a positive result.\\nThe last dilution that shows fluorescence is the titer\\nreported.\\nThe pattern of fluorescence within the cells gives\\nthe physician clues as to what the disease might be.\\nThe test result includes the titer and the pattern.\\nThis test is also called the fluorescent antinuclear\\nantibody test or FANA. Results are available within\\none to three days.\\nKEY TERMS\\nAntibody— A special protein built by the immune\\nsystem as a defense against foreign material enter-\\ning the body.\\nAutoantibody— An antibody that attacks the body’s\\nown cells or tissues.\\nAntinuclear antibodies—Autoantibodies that attack\\nsubstances found in the center, or nucleus, of all\\ncells.\\nAutoimmune disease— Disease in which the body\\nmakes antibodies against its own cells or tissues.\\nTiter— A dilution of a substance with an exact\\nknown amount of fluid. For example, one part of\\nserum diluted with four parts of saline is a titer of 1:4.\\nGALE ENCYCLOPEDIA OF MEDICINE 331\\nAntinuclear antibody test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 361, 'page_label': '332'}, page_content='Preparation\\nNo special preparations or diet changes are\\nrequired before a person undergoes an antinuclear\\nantibody test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces bruis-\\ning. Warm packs relieve discomfort.\\nNormal results\\nNormal results will be negative, showing no anti-\\nnuclear antibodies.\\nAbnormal results\\nA positive test in a person with symptoms of an\\nautoimmune or rheumatic disease helps the physician\\nmake a diagnosis. More than 95% of people with SLE\\nhave a positive ANA test. Scleroderma has a 60-71%\\npositive rate; Sjo¨ gren’s disease, 50-60%, and rheuma-\\ntoid arthritis, 25-30%.\\nSeveral factors must be considered when inter-\\npreting a positive test. Diseases other than autoim-\\nmune diseases can cause autoantibodies. Some\\nhealthy people have a positive test. More testing\\nis done after a positive test to identify individual\\nautoantibodies associated with the various diseases.\\nResources\\nBOOKS\\nLehman, Craig A.Saunders Manual of Clinical Laboratory\\nScience. Philadelphia: W. B. Saunders Co., 1998.\\nNancy J. Nordenson\\nAntiparkinson drugs\\nDefinition\\nAntiparkinson drugs are medicines that relieve the\\nsymptoms of Parkinson’s disease and other forms of\\nparkinsonism.\\nPurpose\\nAntiparkinson drugs are used to treat symptoms of\\nparkinsonism, a group of disorders that share four\\nmain symptoms: tremor or trembling in the hands,\\narms, legs, jaw, and face; stiffness or rigidity of the\\narms, legs, and trunk; slowness of movement (bradyki-\\nnesia); and poor balance and coordination. Parkinson’s\\ndisease is the most common form of parkinsonism and\\nis seen more frequently with advancing age. Other\\nforms of the disorder may result from viral infections,\\nenvironmental toxins,carbon monoxide poisoning,a n d\\nthe effects of treatment withantipsychotic drugs.\\nThe immediate cause of Parkinson’s disease or\\nParkinsonian-like syndrome is the lack of the neuro-\\ntransmitter dopamine in the brain. Drug therapy may\\ntake several forms, including replacement of dopa-\\nmine, inhibition of dopamine metabolism to increase\\nthe effects of the dopamine already present, or sensi-\\ntization of dopamine receptors. Drugs may be used\\nsingly or in combination.\\nDescription\\nLevodopa (Larodopa) is the mainstay of\\nParkinson’s treatment. The drug crosses the blood-\\nbrain barrier, and is converted to dopamine. The drug\\nmay be administered alone, or in combination with\\ncarbidopa (Lodosyn) which inhibits the enzyme respon-\\nsible for the destruction of levodopa. The limitation of\\nlevodopa or levodopa-carbidopa therapy is that after\\napproximately two years of treatment, the drugs cease\\nto work reliably. This has been termed the ‘‘on-off phe-\\nnomenon.’’ Additional treatment strategies have been\\ndeveloped to retard the progression of Parkinsonism,\\nor to find alternative approaches to treatment.\\nAnticholinergic drugs reduce some of the symp-\\ntoms of Parkinsonism, and reduce the reuptake of\\ndopamine, thereby sustaining the activity of the nat-\\nural neurohormone. They may be effective in all stages\\nof the disease. All drugs with anticholinergic\\nAntiparkinson Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nArtane (trihexyphenidyl\\nhydrochloride)\\nDry mouth, nervousness, blurred vision,\\nnausea\\nBenadryl (diephenhydra-\\nmine hydrochloride)\\nDizziness, sleepiness, upset stomach,\\ndecreased coordination\\nCogentin (benztropine\\nmesylate)\\nConstipation, dry mouth, nausea and\\nvomiting, rash\\nEldepryl (selegiline\\nhydrochloride)\\nAbdominal and back pain, drowsiness,\\ndecreased coordination\\nParlodel (bromocriptine\\nmesylate)\\nConstipation, decreased blood pressure,\\nabdominal cramps\\nSinemet CR Involuntary body movements, confusion,\\nnausea, hallucinations\\n332 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiparkinson drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 362, 'page_label': '333'}, page_content='properties, the naturally occurring belladonna alka-\\nloids (atropine, scopolamine, hyoscyamine), some\\nantihistamines with anticholinergic properties, and\\nsynthetics such as benztropin (Cogentin), procyclidine\\n(Kemadrin) and biperiden (Akineton) are members of\\nthisgroup.Althoughtheanticholinergicdrugshaveonly\\nlimited activity against Parkinson’s disease, they are\\nuseful in the early stages, and may be adjuncts to levo-\\ndopa as the disease progresses.\\nAmantadine (Symmetrel), was developed for pre-\\nvention of influenza virus infection, but has anti-\\nParkinsonian properties. Its mechanism of action is\\nnot known.\\nBromocriptine (Parlodel) is a prolactin inhibitor,\\nwhich is used for a variety of indications including\\namenorrhea/galactorrhea, femaleinfertility, and acro-\\nmegaly. It appears to work by direct stimulation of the\\ndopamine receptors. Bromocriptine is used as a late\\nadjunct to levodopa therapy, and may permit reduc-\\ntion in levodopa dosage. Pergolide (Permax) is similar\\nto bromocriptine, but has not been studied as exten-\\nsively in Parkinson’s disease.\\nEntacapone (Comtan) appears to act by main-\\ntaining levels of dopamine through enzyme inhibi-\\ntion. It is used as an adjunct to levodopa was the\\npatient is beginning to experience the on-off effect.\\nTolcapone (Tasmar) is a similar agent, but has\\ndemonstrated the potential for inducing severe\\nliver failure. As such, tolcapone is reserved for\\ncases where all other adjunctive therapies have\\nfailed or are contraindicated.\\nSelegeline (Carbex, Eldepryl) is a selective mono-\\namine oxidase B (MAO-B) inhibitor, however its\\nmechanism of action in Parkinsonism is unclear,\\nsince other drugs with MAO-B inhibition have failed\\nto show similar anti-Parkinsonian effects. Selegeline is\\nused primarily as an adjunct to levodopa, although\\nsome studies have indicated that the drug may be\\nuseful in the early stages of Parkinsonism, and may\\ndelay the progression of the disease.\\nPramipexole (Mirapex) and ropinirole (Requip)\\nare believed to act by direct stimulation of the dopa-\\nmine receptors in the brain. They may be used alone in\\nearly Parkison’s disease, or as adjuncts to levodopa in\\nadvanced stages.\\nRecommended dosage\\nDosages of anti-Parkinsonian medications must\\nbe highly individualized. All doses must be carefully\\ntitrated. Consult specific references.\\nPrecautions\\nThere are a large number of drugs and drug\\nclasses used to treat Parkinson’s disease, and indivi-\\ndual references should be consulted.\\nKEY TERMS\\nAnorexia— Lack or loss of appetite.\\nAnticholigerginc— An agent that blocks the para-\\nsympathetic nerves and their actions.\\nBradykinesia— Extremely slow movement.\\nBruxism— Compulsive grinding or clenching of the\\nteeth, especially at night.\\nCarbon monoxide— A colorless, odorless, highly\\npoisonous gas.\\nCentral nervous system— The brain and spinalcord.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nHallucination— A false or distorted perception\\nof objects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHeat stroke— A severe condition caused by pro-\\nlonged exposure to high heat. Heat stroke interferes\\nwith the body’s temperature regulating abilities and\\ncan lead to collapse and coma.\\nParkinsonism— A group of conditions that all have\\nthese typical symptoms in common: tremor, rigi-\\ndity, slow movement, and poor balance and\\ncoordination.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category\\nB: Animal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles.\\nTremor— Shakiness or trembling.\\nGALE ENCYCLOPEDIA OF MEDICINE 333\\nAntiparkinson drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 363, 'page_label': '334'}, page_content='The anticholinergics have a large number of\\nadverse effects, all related to their primary mode of\\nactivity. Their cardiovascular effects include tachycar-\\ndia, palpitations, hypotension, postural hypotension,\\nand mild bradycardia. They may also cause a wide\\nrange of central nervous system effects, including\\ndisorientation, confusion, memory loss,hallucinations,\\npsychoses, agitation, nervousness,delusions, delirium,\\nparanoia, euphoria, excitement, lightheadedness,\\ndizziness, headache, listlessness, depression, drowsiness,\\nweakness, and giddiness. Dry mouth, dry eyes and\\ngastrointestinal distress are common problems.\\nSedation has been reported with some drugs in this\\ngroup, but this may be beneficial in patients who suffer\\nfrom insomnia. Pregnancy risk factor is C. Because\\nanticholinergic drugs may inhibit milk production,\\ntheir use during breastfeeding is not recommended.\\nPatients should be warned that anticholinergic medica-\\ntions will inhibit perspiration, and soexercise during\\nperiods of high temperature should be avoided.\\nLevodopa has a large number of adverse effects.\\nAnorexia, loss of appetite, occurs in roughly half the\\npatients using this drug. Symptoms of gastrointestinal\\nupset, such asnausea and vomiting, have been reported\\nin 80% of cases. Other reported effects include\\nincreased hand tremor; headache; dizziness;numbness;\\nweakness and faintness; bruxism; confusion; insom-\\nnia; nightmares; hallucinations and delusions; agita-\\ntion and anxiety; malaise; fatigue and euphoria.\\nLevodopa has not been listed under the pregnancy\\nrisk factor schedules, but should be used with caution.\\nBreastfeeding is not recommended.\\nAmantadine is generally well tolerated, but may\\ncause dizziness andnausea. It is classified as pregnancy\\nschedule C. Since amantadine is excreted in breast\\nmilk, breastfeeding while taking amantidine is not\\nrecommended.\\nPergolide and bromocriptine have been generally\\nwell tolerated. Orthostatic hypotension are common\\nproblems, and patients must be instructed to risk\\nslowly from bed. This problem can be minimized by\\nlow initial doses with small dose increments.\\nHallucinations may be a problem. Bromocriptine has\\nnot been evaluated for pregnancy risk, while pergolide\\nis category B. Since both drugs may inhibitlactation,\\nbreastfeeding while taking these drugs is not\\nrecommended.\\nPramipexole and ropinirole cause orthostatic\\nhypotension, hallucinations and dizziness. The two\\ndrugs are in pregnancy category C. In animals, ropi-\\nnirole has been shown to have adverse effects on\\nembryo-fetal development, including teratogenic\\neffects, decreased fetal body weight, increased fetal\\ndeath and digital malformation. Because these drugs\\ninhibit prolactin secretion, they should not be taken\\nwhile breastfeeding.\\nSide effects\\nThe most common side effects are associated with\\nthe central nervous system, and include dizziness,\\nlightheadedness, mood changes and hallucinations.\\nGastrointestinal problems, including nausea and\\nvomiting, are also common.\\nInteractions\\nAll anti-Parkinsonian regimens should be care-\\nfully reviewed for possible drug interactions. Note\\nthat combination therapy with anti-Parkinsonian\\ndrugs is, in itself, use of additive and potentiating\\ninteractions between drugs, and so careful dose adjust-\\nment is needed whenever a drug is added or\\nwithdrawn.\\nSamuel D. Uretsky, PharmD\\nAntiplatelet drugs see Anticoagulant\\nand antiplatelet drugs\\nAntiprotozoal drugs\\nDefinition\\nAntiprotozoal drugs are medicines that treat\\ninfections caused by protozoa.\\nPurpose\\nAntiprotozoal drugs are used to treat a variety of\\ndiseases caused by protozoa. Protozoa are animal-\\nlike, one-celled animals, such as amoebas. Some are\\nparasites that cause infections in the body. African\\nsleeping sickness, giardiasis, amebiasis, Pneumocystis\\ncarinii pneumonia (PCP), andmalaria are examples of\\ndiseases caused by protozoa.\\nDescription\\nAntiprotozoal drugs come in liquid, tablet, and\\ninjectable forms and are available only with a doctor’s\\nprescription. Some commonly used antiprotozoal\\ndrugs are metronidazole (Flagyl), eflornithine\\n334 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiprotozoal drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 364, 'page_label': '335'}, page_content='(Ornidyl), furazolidone (Furoxone), hydroxychloro-\\nquine (Plaquenil), iodoquinol (Diquinol, Yodoquinol,\\nYodoxin), and pentamidine (Pentam 300).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiprotozoal drug, its strength, and the medical pro-\\nblem for which it is being used. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage. Always\\ntake antiprotozoal drugs exactly as directed.\\nPrecautions\\nSome people feel dizzy, confused, lightheaded, or\\nless alert when using these drugs. The drugs may also\\ncause blurred vision and other vision problems. For\\nthese reasons, anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them.\\nThe antiprotozoal drug furazolidone may cause\\nvery dangerous side effects when taken with certain\\nfoods or beverages. Likewise, metronidazole (Flagyl)\\ncan cause serious liver damage if taken with alcohol.\\nCheck with the physician who prescribed the drug or\\nthe pharmacist who filled the prescription for a list of\\nproducts to avoid while taking these medicines.\\nAnyone who has ever had unusual reactions to\\nantiprotozoal drugs or related medicines should let his\\nor her physician know before taking the drugs again.\\nThe physician should also be told about anyallergies\\nto foods, dyes, preservatives, or other substances.\\nSome antiprotozoal drugs may cause problems with\\nthe blood. This can increase the risk of infection or\\nexcessive bleeding. Patientstaking these drugs shouldbe\\ncareful not to injure their gums when brushing or floss-\\ning their teeth or using a toothpick. They shouldcheck\\nwith the physician before having any dentalwork done.\\nCare should also be taken to avoidcuts from razors, nail\\nclippers, or kitchen knives, orhousehold tools. Anyone\\nwho has any of these symptoms while taking antiproto-\\nzoal drugs should call the physician immediately:\\n/C15Fever or chills\\n/C15Signs of cold or flu\\n/C15Signs of infection, such as redness, swelling, or\\ninflammation\\n/C15Unusual bruising or bleeding\\n/C15Black, tarry stools\\n/C15Blood in urine or stools\\n/C15Pinpoint red spots on the skin\\n/C15Unusual tiredness or weakness.\\nAnyone taking this medicine should also check with\\na physician immediately if any of these symptoms occur:\\n/C15Blurred vision or other vision changes\\n/C15Skin rash,hives,o ritching\\n/C15Swelling of the neck\\n/C15Clumsiness or unsteadiness\\n/C15Numbness, tingling, pain, or weakness in the hands\\nor feet\\n/C15Decrease in urination.\\nChildren are especially sensitive to the effects of\\nsome antiprotozoal drugs.Never give this medicine to a\\nchild unless directed to do so by a physician, and always\\nkeep this medicine out of the reach of children. Use\\nsafety vials.\\nThe effects of antiprotozoal drugs on pregnant\\nwomen have not been studied. However, in experi-\\nments with pregnant laboratory animals, some anti-\\nprotozoal drugs cause birth defects or death of the\\nfetus. Women who are pregnant or who plan to\\nbecome pregnant should check with their physicians\\nbefore taking antiprotozoal drugs. Mothers who are\\nbreastfeeding should also check with their physicians\\nabout the safety of taking these drugs.\\nBefore using antiprotozoal drugs, people with any\\nof these medical problems should make sure their\\nphysicians are aware of their conditions:\\nKEY TERMS\\nAmebiasis— An infection caused by an ameba,\\nwhich is a type of protozoan.\\nFetus— A developing baby inside the womb.\\nGiardiasis— A condition in which the intestines are\\ninfected with Giardia lamblia, a type of protozoan.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nParasite— An organism that lives and feeds in or on\\nanother organism (the host) and does nothing to\\nbenefit the host.\\nPneumocystis carinii pneumonia— A severe\\nlung infection caused by a parasitic protozoan.\\nThe disease mainly affects people with weakened\\nimmune systems, such as people with AIDS.\\nGALE ENCYCLOPEDIA OF MEDICINE 335\\nAntiprotozoal drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 365, 'page_label': '336'}, page_content='/C15Anemia or other blood problems\\n/C15Kidney disease\\n/C15Heart disease\\n/C15Low blood pressure\\n/C15Diabetes\\n/C15Hypoglycemia (low blood sugar)\\n/C15Liver disease\\n/C15Stomach or intestinal disease\\n/C15Nerve or brain disease or disorder, including convul-\\nsions (seizures)\\n/C15Psoriasis (a skin condition)\\n/C15Hearing loss\\n/C15Deficiency of the enzyme glucose-6-phosphate dehy-\\ndrogenase (G6PD)\\n/C15Eye or vision problems\\n/C15Thyroid disease.\\nSide effects\\nThe most common side effects arediarrhea, nau-\\nsea, vomiting, and stomach pain. These problems\\nusually go away as the body adjusts to the drug and\\ndo not require medical treatment.\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking an antiproto-\\nzoal drug should get in touch with his or her\\nphysician.\\nInteractions\\nAntiprotozoal drugs may interact with other med-\\nicines. When this happens, the effects of one or both of\\nthe drugs may change or the risk of side effects may be\\ngreater. Anyone who takes antiprotozoal drugs should\\nlet the physician know all other medicines he or she is\\ntaking. Among the drugs that may interact with anti-\\nprotozoal drugs are:\\n/C15Alcohol\\n/C15Anticancer drugs\\n/C15Medicine for overactive thyroid\\n/C15Antiviral drugs such as zidovudine (Retrovir)\\n/C15Antibiotics\\n/C15Medicine used to relieve pain or inflammation\\n/C15Amphetamine\\n/C15Diet pills (appetite suppressants)\\n/C15Monoamine oxidase inhibitors (MAO inhibitors)\\nsuch as phenelzine (Nardil) and tranylcypromine\\n(Parnate), used to treat conditions including depres-\\nsion and Parkinson’s disease.\\n/C15Tricyclic antidepressants such as amitriptyline\\n(Elavil) and imipramine (Tofranil)\\n/C15Decongestants such as phenylephrine (Neo-\\nSynephrine) and pseudoephedrine (Sudafed)\\n/C15Other antiprotozoal drugs.\\nThe list above does not include every medicine\\nthat may interact with an antifungal drug. Be sure\\nto check with a physician or pharmacist before\\ncombining antifungal drugs with any other pre-\\nscription or nonprescripti on (over-the-counter)\\nmedicine.\\nNancy Ross-Flanigan\\nAntipruritic drugs see Anti-itch drugs\\nAntipsychotic drugs\\nDefinition\\nAntipsychotic drugs are a class of medicines used\\nto treat psychosis and other mental and emotional\\nconditions.\\nPurpose\\nPsychosis is defined as ‘‘a serious mental disorder\\n(as schizophrenia) characterized by defective or lost\\ncontact with reality often withhallucinations or delu-\\nsions.’’ Psychosis is an end-stage condition arising\\nfrom a variety of possible causes. Anti-psychotic\\ndrugs control the symptoms of psychosis, and in\\nmany cases are effective in controlling the symptoms\\nof other disorders that may lead to psychosis, includ-\\ning bipolar mood disorder (formerly termed manic-\\ndepressive), in which the patient cycles from severe\\ndepression to feelings of extreme excitation. This\\nclass of drugs is primarily composed of the major\\ntranquilizers; however, lithium carbonate, a drug\\nthat is largely specific to bipolar mood disorder, is\\ncommonly classified among the antipsychotic agents.\\nDescription\\nThe antipsychotic agents may be divided by che-\\nmical class. The phenothiazines are the oldest group,\\nand include chlorpromazine (Thorazine), mesoridazine\\n336 GALE ENCYCLOPEDIA OF MEDICINE\\nAntipsychotic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 366, 'page_label': '337'}, page_content='(Serentil), prochlorperazine (Compazine), and thiori-\\ndazine (Mellaril). These drugs are essentially similar in\\naction and adverse effects. They may also be used as\\nanti-emetics, although prochlorperazine is the drug\\nmost often used for this indication.\\nThe phenylbutylpiperadines are haloperidol\\n(Haldol) and pimozide (Orap). They find primary\\nuse in control of Tourette’s syndrome. Haloperidol\\nhas been extremely useful in controlling aggressive\\nbehavior.\\nThe debenzapine derivatives, clozapine (Clozaril),\\nloxapine (Loxitane), olanzapine (Zyprexa) and quetia-\\npine (Seroquel), have been effective in controlling psy-\\nchotic symptoms that have not been responsive to\\nother classes of drugs.\\nThe benzisoxidil group is composed of resperidone\\n(Resperidal) and ziprasidone (Geodon). Resperidone\\nhas been found useful for controlling bipolar mood\\ndisorder, while ziprasidone is used primarily as sec-\\nond-line treatment for schizophrenia.\\nIn addition to these drugs, the class of antipsycho-\\ntic agents includes lithium carbonate (Eskalith,\\nLithonate), which is used for control of bipolar\\nmood disorder, and thiothixene (Navane), which is\\nused in the treatment of psychosis.\\nNewer agents\\nSome newer antipsychotic drugs have been\\napproved by the Food and Drug administration\\n(FDA) in the early 2000s. These drugs are sometimes\\ncalled second-generation antipsychotics or SGAs.\\nAripiprazole (Abilify), which is classified as a partial\\ndopaminergic agonist, received FDA approval in\\nAugust 2003. Two drugs that are still under investiga-\\ntion, a neurokinin antagonist and a serotonin 2A/2C\\nantagonist respectively, show promise in the treatment\\nof schizophrenia andschizoaffective disorder.\\nRecommended dosage\\nDose varies with the drug, condition being trea-\\nted, and patient response. See specific references.\\nPrecautions\\nNeuroleptic malignant syndrome (NMS). NMS is\\na rare, idiosyncratic combination of extra-pyramidal\\nsymptoms (EPS), hyperthermia, and autonomic dis-\\nturbance. Onset may be hours to months after drug\\ninitiation, but once started, proceeds rapidly over\\n24 to 72 hours. It is most commonly associated with\\nhaloperidol, long-acting fluphenazine, but has occurred\\nwith thiothixene, thioridazine, and clozapine, and may\\nAntipsychotic Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nClozaril (clozapine) Seizures, agranulocytosis, dizziness,\\nincreased blood pressure\\nCompazine\\n(prochlorperazine)\\nInvoluntary muscle spasms, dizziness,\\njitteriness, puckering of the mouth\\nHaldol (haloperidol) Involuntary muscle spasms, blurred vision,\\ndehydration, headache, puckering of the\\nmouth\\nMellaril (thioridazine) Involuntary muscle spasms, constipation and\\ndiarrhea, sensitivity to light\\nNavane (thiothixene) Involuntary muscle spasms, dry mouth, rash,\\nhives\\nRisperdal\\n(risperidone)\\nInvoluntary muscle spasms, abdominal and\\nchest pain, fever, headache\\nStelazine (trifluopera-\\nzine hydrochloride)\\nInvoluntary muscle spasms, drowsiness,\\nfatigue\\nThorazine\\n(chlorpromazine)\\nInvoluntary muscle spasms, labored breathing,\\nfever, puckering of the mouth\\nTriavil Involuntary muscle spasms, disorientation,\\nexcitability, lightheadedness\\nKEY TERMS\\nAgranulocytosis— An acute condition marked by\\nsevere depression of the bone marrow, which pro-\\nduces white blood cells, and by prostration, chills,\\nswollen neck, and sore throat sometimes with local\\nulceration. Aalso called agranulocytic angina or\\ngranulocytopenia.\\nAnticholinergic— Blocking the action of the neuro-\\nhormone acetylcholine. The most obvious effects\\ninclude dry mouth and dry eyes.\\nAnticonvulsants— A class of drugs given to control\\nseizures.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies,\\nor adverse effects in animals, but not in well-con-\\ntrolled human studies. Category C: No adequate\\nhuman or animal studies, or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nGALE ENCYCLOPEDIA OF MEDICINE 337\\nAntipsychotic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 367, 'page_label': '338'}, page_content='occur with other agents. NMS is potentially fatal, and\\nrequires intensive symptomatic treatment and immedi-\\nate discontinuation of neuroleptic treatment. There is\\nno established treatment. Most patients who develop\\nNMS will have the same problem if the drug is\\nrestarted.\\nAgranulocytosis has been associated with cloza-\\npine. This is a potentially fatal reaction, but can be\\nprevented with careful monitoring of the whiteblood\\ncount. There are no well-established risk factors for\\ndeveloping agranulocytosis, and so all patients treated\\nwith this drug must follow the clozapine Patient\\nManagement System. For more information, the\\nreader should call 1-800-448-5938.\\nAnticholinergic effects, particularly dry mouth,\\nhave been reported with all of the phenothiazines,\\nand can be severe enough to cause patients to discon-\\ntinue their medication.\\nPhotosensitization is a common reaction to chlor-\\npromazine. Patients must be instructed to use precau-\\ntions when exposed to sunlight.\\nLithium carbonate commonly causes increased\\nfrequency of urination.\\nThe so-called atypical antipsychotics are asso-\\nciated with a substantial increase in the risk of devel-\\noping diabetes mellitus. A study done at the University\\nof Rochester (New York) reported in 2004 that 15.2%\\nof patients receiving atypical antipsychotics developed\\ndiabetes, compared with 6.3% of patients taking other\\nantipsychotic medications.\\nAntipsychotic drugs are pregnancy category C.\\n(Clozapine is category B.) The drugs in this class\\nappear to be generally safe for occasional use at low\\ndoses during pregnancy, but should be avoided near\\ntime of delivery. Although the drugs do not appear\\nto be teratogenic, when used near term, they may\\ncross the placenta and have adverse effects on the\\nnewborn infant, including causing involuntary\\nmovements. There is no information about safety\\nin breast feeding.\\nAs a class, the antipsychotic drugs have a large\\nnumber of potential side effects, many of them serious.\\nBecause of the potential severity of side effects, these\\ndrugs must be used with special caution in children.\\nSpecific references should be consulted.\\nInteractions\\nBecause the phenothiazines have anticholinergic\\neffects, they should not be used in combination with\\nother drugs that may have similar effects.\\nBecause the drugs in this group may causehypo-\\ntension, or low blood pressure, they should be used\\nwith extreme care in combination with blood pressure-\\nlowering drugs.\\nThe antipsychotic drugs have a large number of\\ndrug interactions. Consult specific references.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Childhood Psychosis.’’ Section 19, Chapter 274 InThe\\nMerck Manual of Diagnosis and Therapy.Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Psychiatric Emergencies.’’ Section 15, Chapter 194\\nIn The Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nWilson, Billie Ann, Margaret T. Shannon, and Carolyn L.\\nStang. Nurse’s Drug Guide 2003.Upper Saddle River,\\nNJ: Prentice Hall, 2003.\\nPERIODICALS\\nDeLeon, A., N. C. Patel, and M. L. Crismon. ‘‘Aripiprazole:\\nA Comprehensive Review of Its Pharmacology, Clinical\\nEfficacy, and Tolerability.’’Clinical Therapeutics26\\n(May 2004): 649–666.\\nEmsley, R., H. J. Turner, J. Schronen, et al. ‘‘A Single-Blind,\\nRandomized Trial Comparing Quetiapine and\\nHaloperidol in the Treatment of Tardive Dyskinesia.’’\\nJournal of Clinical Psychiatry65 (May 2004): 696–701.\\nLamberti, J. S., J. F. Crilly, K. Maharaj, et al. ‘‘Prevalence of\\nDiabetes Mellitus among Outpatients withSevere Mental\\nDisorders Receiving Atypical Antipsychotic Drugs.’’\\nJournal of Clinical Psychiatry65 (May 2004): 702–706.\\nMeltzer, H. Y., L. Arvanitis, D. Bauer, et al. ‘‘Placebo-\\nControlled Evaluation of Four Novel Compounds for\\nthe Treatment of Schizophrenia and Schizoaffective\\nDisorder.’’ American Journal of Psychiatry161 (June\\n2004): 975–984.\\nStahl, S. M. ‘‘Anticonvulsants as Mood Stabilizers and\\nAdjuncts to Antipsychotics: Valproate, Lamotrigine,\\nCarbamazepine, and Oxcarbazepine and Actions at\\nVoltage-Gated Sodium Channels.’’Journal of Clinical\\nPsychiatry 65 (June 2004): 738–739.\\nORGANIZATIONS\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888) INFO-\\nFDA. .\\nSamuel D. Uretsky, PharmD\\nRebecca J. Frey, PhD\\n338 GALE ENCYCLOPEDIA OF MEDICINE\\nAntipsychotic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 368, 'page_label': '339'}, page_content='Antipsychotic drugs, atypical\\nDefinition\\nThe atypical antipsychotic agents, sometimes\\ncalled the ‘‘novel’’ antipsychotic agents are a group\\nof drugs which are different chemically from the older\\ndrugs used to treat psychosis. The ‘‘conventional’’\\nantipsychotic drugs are classified by their chemical\\nstructures as the phenothiazines, thioxanthines\\n(which are chemically very similar to the phenothia-\\nzines), butyrophenones, diphenylbutylpiperadines\\nand the indolones. All of the atypical antipsychotic\\nagents are chemically classified as dibenzepines. They\\nare considered atypical or novel because they have\\ndifferent side effects from the conventional antipsy-\\nchotic agents. The atypical drugs are far less likely to\\ncause extra-pyrammidal side-effects(EPS), drug\\ninduced involuntary movements, than are the older\\ndrugs. The atypical antipsychotic drugs may also be\\neffective in some cases that are resistant to older drugs.\\nThe drugs in this group are clozapine (Clozaril),\\nloxapine (Loxitane), olanzapine (Zyprexa), and que-\\ntiapine (Seroquel).\\nPurpose\\nThe antipsychotic drugs are used to treat severe\\nemotional disorders. Although there may be different\\nnames for these disorders, depending on severity and\\nhow long the symptoms last, psychotic disorders all\\ncause at least one of the following symptoms:\\nLoxapine has also been used to treatanxiety with\\nmental depression.\\nRecommended dosage\\nThe recommended dose depends on the drug, the\\npatient, and the condition being treated. The normal\\npractice is to start each patient at a low dose, and\\ngradually increase the dose until a satisfactory\\nresponse is achieved. The odse should be held at the\\nlowest level that gives satisfactory results.\\nClozapine usually requires doses between 300 and\\n600 milligrams a day, but some people require as much\\nas 900 milligrams/day. Doses higher than 900 mill-\\ngrams/day are not recommended.\\nLoxapine is usually effective at doses of 60-100\\nmilligrams/day, but may be used in doses as high as\\n250 mg/day if needed.\\nOlanzapine doses vary with the condition being\\ntreated. The usual maximum dose is 20 milligrams/day.\\nQuetiapine may be dosed anywhere from 150-750\\nmilligrams/day, depending on how well the patient\\nresponds.\\nPrecautions\\nAlthough the atypical antipsychotics are generally\\nsafe, clozapine has been associated with severe agra-\\nnulocytosis, a shortage of white blood cells. For this\\nreason, people who may be treated with clozapine\\nshould have blood counts before starting the drug,\\nblood counts every week for as long as they are using\\nclozapine, and blood counts every week for the first\\n4 weeks after they stop taking clozapine. If there is any\\nevidence of a drop in the whiteblood countwhile using\\nclozapine, the drug should be stopped.\\nAtypical antipsychotics should not be used in\\npatients with liver damage, brain or circulatory pro-\\nblems, or some types of blood problems.\\nAllergies\\nPeople who have had an allergic reaction to one of\\nthe atypical antipsychotics should not use that\\nKEY TERMS\\nAnxiety— An abnormal and overwhelming sense of\\napprehension and fear often marked by physiological\\nsigns (as sweating, tension, and increased pulse), by\\ndoubt concerning the reality and nature of the threat,\\nand by self-doubt about one’s capacity to cope with it.\\nDelusions— A false belief regarding the self or per-\\nsons or objects outside the self that persists despite\\nthe facts.\\nDepression— A state of being depressed marked\\nespecially by sadness, inactivity, difficulty with\\nthinking and concentration, a significant increase or\\ndecrease in appetite and time spent sleeping, feelings\\nof dejection and hopelessness, and sometimes suici-\\ndal thoughts or an attempt to commit suicide.\\nGlucocorticoid— Any of a group of corticosteroids\\n(as hydrocortisone or dexamethasone) that are anti-\\ninflammatory and immunosuppressive, and that\\nare used widely in medicine (as in the alleviation\\nof the symptoms of rheumatoid arthritis).\\nPsychosis— A serious mental disorder character-\\nized by defective or lost contact with reality often\\nwith hallucinations or delusions.\\nGALE ENCYCLOPEDIA OF MEDICINE 339\\nAntipsychotic drugs, atypical'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 369, 'page_label': '340'}, page_content='medication again. However, sometimes it is possible to\\nuse a different drug from the same group safely.\\nPregnancy\\nThe atypical antipsychotics have not been proved\\nsafe in pregnancy. They should be used only when\\nclearly needed and when potential benefits outweigh\\npotential hazards to the fetus. These drugs have not\\nbeen reported in human milk.\\nSide effects\\nAlthough the atypical antipsychotics are less\\nlikely to cause involuntary movements than the older\\nantipsychotic drugs, they still have a large number of\\nadverse effects. The following list is not complete.\\nReview each drug individually for a full list of possible\\nadverse effects.\\nInteractions\\nTaking atypical antipsychotic medications with\\ncertain other drugs may affect the way the drugs work\\nor may increase the chance of side effects. While taking\\nantipsychotic drugs, do not take any other prescription\\nor nonprescription (over-the-counter) drugs without\\nfirst checking with a physician.\\nBecause the atypical antipsychotics may cause\\nlowering of blood pressure, care should be used when\\nthese drugs are taken at the same time as other drugs\\nwhich lower blood pressure.\\nQuetiapine has many interactions. Doses should\\nbe carefully adjusted when quetiapine is used with\\nketoconazole, itraconazole, fluconazole, erythromy-\\ncin, carbamazepine, barbiturates, rifampin or gluco-\\ncorticoids including prednisone, dexamethasone and\\nmethylprednisolone.\\nThese drugs will also require dose adjustments\\nwhen used with anti-Parkinson medications.\\nResources\\nBOOKS\\nBrain Basics: An Integrated Biological Approach to\\nUnderstanding and Assessing Human Behavior.Phoenix:\\nBiological-Psychiatry-Institute, June 1999.\\nPERIODICALS\\nMcDougle, C. J. ‘‘A double-blind, placebo-controlled study\\nof risperidone addition in serotonin reuptake inhibitor-\\nrefractory obsessive-compulsive disorder.’’Archives of\\nGeneral PsychiatryAugust 2000: 794.\\nSamuel D. Uretsky, PharmD\\nAnti-rejection drugs\\nDefinition\\nAnti-rejection drugs are daily medications taken by\\norgan transplant patients to prevent organ rejection.\\nPurpose\\nAnti-rejection drugs, which are also called immuno-\\nsuppressants, help to suppress the immune system’s\\nresponse to a new organ. When a new organ is placed\\ninside a patient s body, the patient’s immune system\\nrecognizes the organ as foreign tissue and tries to reject it.\\nDescription\\nWhen a physician prescribes anti-rejection drugs,\\nthe patient’s risk of rejection and susceptibility to side\\neffects are considered. The most common drugs pre-\\nscribed to prevent organ rejection are cyclosporine,\\nprednisone, azathioprine, tacrolimus or FK506,\\nmycophenolate mofetil, sirolimus, and OKT3, as well\\nas ATGAM and Thymoglobulin. As is true with all\\nmedications, each of these drugs has benefits and\\ndrawbacks. Cyclosporine, which is one of the most\\nfrequently used anti-rejection drugs, is usually com-\\nbined with prednisone. An extremely powerful medi-\\ncine, cyclosporine is usually taken by a patient over the\\ncourse of his or her lifetime. Cortisol, which is the\\nnaturally produced form of prednisone in a person’s\\nbody, helps the body managestress, such as infections\\nor organ rejection. Taking prednisone results in less\\ncortisol production in a person’s body, thus minimizing\\nthe risk of rejection. Azathioprine, which needs to be\\ntaken with food to avoid stomach upset, is frequently\\ncombined with cyclosporine, prednisone, or tacrolimus.\\nMycophenolate mofetil is a relatively new immunosup-\\npressant that is similar to azathioprine; therefore, the\\ntwo drugs should not be taken together. It is preferable\\nto take mycophenolate mofetil on an empty stomach;\\nhowever, like azathioprine, it can be taken with food\\nbecause it, too, can cause stomach problems, such as\\nheartburn and nausea. Like azathioprine, mycopheno-\\nlate mofetil is not a stand-alone drug; instead, it must be\\nused, in combination with other medications. This is\\nalso the case with regard to sirolimus.\\nPhysicians prescribe either mycophenolate mofetil\\nor azathioprine (in combination with otherimmuno-\\nsuppressant drugs) to help patients cope with acute\\nbouts of organ rejection. The medications work by\\ninterfering with the multiplication process of white\\nblood cells, which is part of the body’s natural defense\\n340 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-rejection drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 370, 'page_label': '341'}, page_content='system when foreign invaders, such as a new organ, are\\ndetected. However, researchers at Duke University\\nand the University of Florida found that mycopheno-\\nlate mofetil doesn’t work any better than azathioprine,\\nbut costs significantly more. Aside from cost, another\\nconsideration also needs to be the type of organ trans-\\nplanted, because acute rejection rates differ. For\\nexample, six months after surgery, approximately\\n15% of kidney recipients will have an acute rejection\\nepisode as compared to approximately 60% of lung\\nrecipients. And because study results vary depending\\non the organ transplanted, more research is needed\\nwith regard to the success of mycophenolate mofetil as\\ncompared to azathioprine.\\nOKT3 prevents is prescribed to prevent organ rejec-\\ntion immediately after surgery and is also used to treat\\nacute rejection episodes; ATGAM and Thymoglobulin,\\nwhich are similar to OKT3, are used for the same rea-\\nsons. All three drugs are given intravenously.\\nTacrolimus, which is also known as FK506, is a\\nfairly new drug that is considered by many experts to\\nbe as effective as cyclosporine. An alternative drug\\nchoice for patients that cannot tolerate cyclosporine,\\ntacrolimus has been the subject of much research in\\nrecent years. Used to treat rejection episodes that are\\nacute or chronic in nature, tacrolimus is being studied\\nto see if using it will allow patients to reduce their\\ndosage of prednisone without organ rejection.\\nIn a presentation at the 2003 American\\nTransplant Congress, surgeons from the University\\nof Pittsburgh reported that an innovative clinical pro-\\ntocol developed by Dr. Thomas E. Starzl was imple-\\nmented, which reduced the dosage of tacrolimus\\nneeded by lung transplant patients with excellent suc-\\ncess. Patients required lower doses of prednisone as\\nwell. In fact, in some cases, patients were taking tacro-\\nlimus only once a day (rather than twice a day) or only\\nfour times a week. Over the long-term, physicians\\nhope that there will be less risk of lung recipients\\ndeveloping the kinds of complications normally asso-\\nciated with high levels of immunosuppressants, such\\nas kidney dysfunction, which is a common problem\\nfaced by lung transplant patients.\\nDr. Thomas E. Strazl, the renowned physician\\noften referred to as the modern-day father of transplan-\\ntation, developed the protocol based on the knowledge\\nthat some of his patients had stopped taking their daily\\npills with no ill effects. Starzl theorized that giving sev-\\neral drugs to a patient immediately after surgery, which\\nwas the normal practice, might inhibit the immune sys-\\ntem from developing a tolerance for the new organ.\\nTherefore, his new protocol embraced a different\\napproach. Shortly before the transplantation, patients\\nwere given a drug that killed their T-cells and after the\\noperation, patients received only one anti-rejection\\nmedicine rather than the multi-pill cocktail normally\\nprescribed. In an article published byLancet in 2003,\\nStarzl and colleagues reported the results of their pilot\\nstudy involving 82 two kidney, liver, pancreas or small\\nbowel transplant patients treated according to the new\\ndrug protocol. Out of the 72 patients with successful\\ntransplants after one year, over half the patients were\\ntaking anti-rejection medication either every other day,\\nthree times per week or twice per week. Amazingly, 11 of\\nthe patients were taking only one pill a week and they\\nexhibited no signs of organ rejection or complications.\\nCertainly more research needs to be conducted, but\\nthese results are very promising.\\nRecommended dosage\\nThe dosages vary depending on the drug or drug\\ncombination being taken by the patient. In general,\\ncyclosporine is taken every 12 hours in liquid or capsule\\nform. Tacrolimus is generally taken every 12 hours as\\nw e l l .T h el e v e lo fe i t h e rd r u gi nap a t i e n t ’ sb l o o di s\\nmonitored carefully and doses are adjusted accordingly\\nin order to not only prevent reject, but also unpleasant\\nside effects. Azathioprine is taken once a day in tablet\\nform, whereas mycophenolate mofetil is generally taken\\nevery 12 hours. High doses of prednisone are usually\\ngiven at first and then tapered down slowly.\\nPrecautions\\nPatients should discuss proper storage methods\\nwith regard to their medications. Sirolimus, for exam-\\nple, should be stored at room temperature with special\\ncare taken to keep it out of excessive heat and humidity.\\nAlthough pregnant women taking anti-rejection\\ndrugs have delivered healthy babies, women planning\\non becoming pregnant while taking anti-rejection\\ndrugs should talk with their physicians regarding any\\npossible complications. For example, the safety of\\ntaking mycophenolate mofetil during pregnancy or\\nwhile breastfeeding is questionable and not advised.\\nSide effects\\nSide effects vary depending on the individual and\\nthe drug therapy chosen. Patients should talk with\\ntheir doctors regarding the various side effects they\\ncan expect and under what conditions emergency\\nmedical care needs to be sought.\\nInteractions\\nIt is essential that patients talk with their pharma-\\ncist and transplant team before taking any medications,\\nGALE ENCYCLOPEDIA OF MEDICINE 341\\nAnti-rejection drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 371, 'page_label': '342'}, page_content='regardless of whether they are prescription or over-the-\\ncounter drugs to ensure that the combinations will\\nnot interact. For example,antacids can diminish the\\neffectiveness of mycophenolate mofetil and drugs used\\nto treat high cholesterol may increase the potency of\\nsirolimus. In addition, certain food products can also\\nalter the potency of some anti-rejection drugs. For\\nexample, grapefruit and grapefruit juice can cause\\ncyclosporine blood levels to increase.\\nResources\\nPERIODICALS\\nMazariegos, G. V., Zahorchak, A. F., Reyes, J., et al.\\n‘‘Dendritic cell subset ratio in peripheral blood\\ncorrelates with successful withdrawal of\\nimmunosuppression in liver transplant patients.’’\\nAmerican Journal of Transplantation3 (2003): 689–696.\\nStarzl, T. E., Murase, N., Abu-Elmagd, K., et al.\\n‘‘Tolerogenic immunosuppression for organ\\ntransplantation.’’ Lancet 361 (2003): 1502–1510.\\nOTHER\\nRoss, Melanie Fridl ‘‘Duke/UF Researchers compare\\nanti-rejection medicines in lung transplant patients.’’\\nUniversity of Florida9 Aug 2001 University of Florida\\nNews. 22 Feb 2005 .\\nRossi, Lisa ‘‘Studies of liver transplant patients off\\nanti-rejection drugs have altered cell profile.’’\\nUniversity of Pittsburgh Medical Center2 June 2003\\nUniversity of Pittsburgh Medical Center. 22 Feb 2005\\n.\\nSrikameswaran, Anita ‘‘Protocol reduces transplant patients\\nneed for anti-rejection drugs.’’Post-Gazette.com Health\\nand Science 2 May 2003 PG Publishing Company, Inc.\\n22 Feb 2005 .\\nUniversity of Pittsburgh Medical Center ‘‘Our Experts:\\nThomas E. Starzl, M.D., Ph.D.’’University of\\nPittsburgh Medical Center2005 University of\\nPittsburgh Medical Center. 22 Feb 2005 .\\nLee Ann Paradise\\nAntiretroviral drugs\\nDefinition\\nAntiretroviral drugs inhibit the reproduction of\\nretroviruses—viruses composed of RNA rather than\\nDNA. The best known of this group is HIV, human\\nimmunodeficiency virus, the causative agent ofAIDS.\\nPurpose\\nAntiretroviral agents are virustatic agents which\\nblock steps in the replication of the virus. The drugs\\nare not curative; however continued use of drugs,\\nparticularly in multi-drug regimens, significantly\\nslows disease progression.\\nDescription\\nThere are three main types of antiretroviral drugs,\\nalthough only two steps in the viral replication process\\nare blocked. Nucleoside analogs, or nucleoside reverse\\ntranscriptase inhibitors (NRTIs), such as didanosine\\n(ddI, Videx), lamivudine (3TC, Epivir), stavudine\\n(d4T, Zerit), zalcitabine (ddC, Hivid), and zidovudine\\n(AZT, Retrovir), act by inhibiting the enzyme reverse\\ntranscriptase. Because a retrovirus is composed of\\nRNA, the virus must make a DNA strand in order to\\nreplicate itself. Reverse transcriptase is an enzyme that\\nis essential to making the DNA copy. The nucleoside\\nreverse transcriptase inhibitors are incorporated into\\nthe DNA strand. This is a faulty DNA molecule that is\\nincapable of reproducing.\\nThe non-nucleoside reverse transcriptase inhibitors\\n(NNRTIs), such as delavirdine (Rescriptor), loviride,\\nand nevirapine (Viramune) act by binding directly to\\nthe reverse transcriptase molecule, inhibiting its\\nactivity.\\nA fourth class of drugs was under clinical trials in\\n2003. Called fusion inhibitors, they block HIV from\\nfusing with healthy cells. The first to receive FDA\\napproval will likely be a drug called Enfurvitide.\\nBecause HIV mutates readily, the virus can\\ndevelop resistance to single drug therapy. However,\\ntreatment with drug combinations appears to produce\\na durable response. Proper treatment appears to\\nslow the progression of HIV infections and reduce\\nthe frequency of opportunistic infections. One of the\\nmost notable advances in recent years has been the\\nsuccess of highly active antiretroviral therapy\\n(HAART). This multidrug approach reduced the\\nrisk of opportunistic infections in persons with HIV/\\nAIDS and slowed the progression of the disease and\\ndeath. Usually, patients receive triple combination\\ntherapy, however research in 2003 showed a new\\nonce-daily regimen of quadruple therapy effective.\\nThe combination included adefovir, lamivudine,\\ndidanosine, and efavirenz. In short, the scientific com-\\nmunity continues to make rapid advancements in\\ndeveloping and evaluating antiretroviral drug therapy.\\nIt is best to keep well informed and frequently check\\nwith a physician.\\n342 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiretroviral drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 372, 'page_label': '343'}, page_content='Recommended dosage\\nDoses must be individualized based on the patient\\nand use of interacting drugs. The optimum combina-\\ntions of antiretroviral drugs have not been determined,\\nnor is there agreement on the stage of infection at\\nwhich to start treatment. In fact, starting treatment\\ntoo early has led to unwanted side effects in some\\npatients or problems with patient readiness to comply.\\nTreatment should begin when the time and circum-\\nstances are right.\\nPrecautions\\nAlthough the antiretroviral drugs fall into several\\ngroups, each drug has a unique pattern of adverse\\neffects anddrug interactions. Since the drugs are used\\nin various combinations, the frequency and severity\\nof adverse effects will vary with the combination.\\nAlthough most drug combinations show a higher\\nrate of adverse events than single drug therapy,\\nsome patterns are not predictable. For example, indi-\\nnavir has been reported to causeinsomnia in 3% of\\npatients, however, when used in combination with\\nzidovudine, only 1.5% of patients complained of\\nsleep difficulties.\\nThe most severe adverse effects associated with\\nthe protease inhibitors are kidney and liver toxicity.\\nPatients also have reported a syndrome of abdominal\\ndistention (selling and expansion) and increased body\\nodor, which may be socially limiting. Hemophilic\\npatients have reported increased bleeding tendencies\\nwhile taking protease inhibitors. The drugs arepreg-\\nnancy category B. There have been no controlled stu-\\ndies of safety in pregnancy. HIV-infected mothers are\\nadvised not to breast feed in order to prevent transmis-\\nsion of the virus to the newborn.\\nThe nucleoside reverse transcriptase inhibitors\\nhave significant levels of toxicity. Lactic acidosis in\\nthe absence of hypoxemia and severe liver enlargement\\nwith fatty degeneration have been reported with zido-\\nvudine and zalcitabine, and are potentially fatal. Rare\\ncases of liver failure, considered possibly related to\\nunderlying hepatitis B and zalcitabine monotherapy,\\nhave been reported.\\nAbacavir has been associated with fatal hyper-\\nsensitivity reactions. Didanosine has been associated\\nwith severe pancreatitis . Nucleoside reverse tran-\\nscriptase inhibitors are pregnancy category C.\\nThere is limited information regarding safety during\\npregnancy. Zidovudine has been used during preg-\\nnancy to reduce the risk of HIV infection to the\\ninfant. HIV-infected mothers are advised not to\\nbreast feed in order to prevent transmission of the\\nvirus to the newborn.\\nEfavirenz has been associated with a high fre-\\nquency of skin rash, 27% in adults and 40% in child-\\nren. Nevirapine has been associated with severe liver\\ndamage and skin reactions. All of the non-nucleoside\\nreverse transcriptase inhibitors are pregnancy cate-\\ngory C, based on animal studies.\\nUsing antiretroviral drugs in combination also\\nhelps lower risk of developing viral resistance. Fifty\\npercent of patients who fail antiretroviral therapy are\\nKEY TERMS\\nAntiviral drugs— Medicines that cure or control\\nvirus infections.\\nBioavailability— A measure of the amount of drug\\nthat is actually absorbed from a given dose.\\nHypoxemia— Lower than normal oxygenation of\\narterial blood.\\nImmune system— The body’s natural defenses\\nagainst disease and infection.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nPancreas— A gland located beneath the stomach.\\nThe pancreas produces juices that help break down\\nfood and secretes insulin that helps the body use\\nsugar for energy.\\nInsomnia— A sleep disorder characterized by\\ninability to either fall asleep or to stay asleep.\\nMutates— Undergoes a spontaneous change in the\\nmake-up of genes or chromosomes.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nRetrovirus— A virus composed of ribonucleic acid\\n(RNA) instead of deoxynucleic acid (DNA).\\nVirus— A tiny, disease-causing particle that can\\nreproduce only in living cells.\\nGALE ENCYCLOPEDIA OF MEDICINE 343\\nAntiretroviral drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 373, 'page_label': '344'}, page_content='resistant to one class of drug. Recent research into\\nmultiple drugs and combinations is promising.\\nInteractions\\nBecause of the high frequency of drug interactions\\nassociated with AIDS therapy, specialized references\\nshould be consulted. Use of recreational drugs while\\non antriretroviral therapy can trigger potentially lethal\\nside effects or negate the positive effects of the therapy.\\nSaquinavir is marketed in both hard and soft\\ngelatin capsules. Because saquinavir in the hard gela-\\ntin capsule formulation (Invirase) has poor bioavail-\\nability, it is recommended that this formulation only\\nbe used in combination with other drugs which inter-\\nact to raise saquinavir blood levels. Saquinavir soft\\ngelatin capsules (Fortovase) are the preferred dosage\\nform of this drug.\\nResources\\nPERIODICALS\\n‘‘Grant Awarded for Evaluation of Once-Daily\\nAntiretroviral.’’ Virus Weekly(November 26, 2002): 12.\\nIsaac, A., and D. Pillay. ‘‘New Drugs for Treating Drug\\nResistant HIV–1: Clinical Management of Virological\\nFailure Remains an Important and Difficult Issue for\\nHIV Physicians.’’Sexualy Transmitted Diseases(June\\n2003): 176–183.\\n‘‘New Therapy Strategies Focusing on Long Term: DrugsÆ\\nImpact on Heart is Debated.’’AIDS AlertApril 2003: 45.\\n‘‘Once-Daily Quadruple Regimen Safe, Effective.’’AIDS\\nWeekly (October 7, 2003): 4.\\n‘‘Recreational Drugs can Reduce Safety, Efficacy of\\nAntiretroviral Agents.’’AIDS Weekly(December 16,\\n2003): 3.\\nThanker, H.K., and M.H. Snow. ‘‘HIV Viral Suppression in\\nthe Era of Antiretroviral Therapy.’’Postgraduate\\nMedical Journal(January 2003): 36.\\nORGANIZATIONS\\nProject Inform. 205 13th Street, #2001, San Francisco, CA\\n94103. (415) 558-8669. .\\nOTHER\\nAIDS Clinical Trials Information Service website and tele-\\nphone information line. Sponsored by Centers for\\nDisease Control and Prevention, Food and Drug\\nAdministration, National Institute of Allergy and\\nInfectious Diseases, and National Library of Medicine.\\n(800) TRIALS-A or (800) 874-2572. .\\nHIV/AIDS Treatment Information Service website and\\ntelephone information line. Sponsored by Agency for\\nHealth Care Policy and Research, Centers for Disease\\nControl and Prevention, Health Resources and Services\\nAdministration, Indian Health Service, National\\nInstitutes of Health, and Substance Abuse and Mental\\nHealth Services Administration. (800) HIV-0440 (800)\\n448-0440. .\\nProject Inform National HIV/AIDS Treatment Hotline.\\n(800) 822-7422.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntirheumatic drugs\\nDefinition\\nAntirheumatic drugs are drugs used to treatrheu-\\nmatoid arthritis.\\nPurpose\\nRheumatoid arthritis is a progressive form of\\narthritis that has devastating effects on joints and\\ngeneral health. It is classified as an auto-immune dis-\\nease, because the disease is caused by the body’s own\\nimmune system acting against the body itself.\\nSymptoms include painful, stiff, swollen joints,fever,\\nfatigue, and loss of appetite.\\nIn recent years, there has been a change in attitude\\nconcerning the treatment of rheumatoid arthritis.\\nPhysicians now use Disease Modifying Anti-Rheumatic\\nDrugs (DMARDs) early in the history of the disease and\\na r el e s si n c l i n e dt ow a i tf o rc rippling stages before resort-\\ning to the more potent drugs. Fuller understanding of the\\nside-effects of non-steroidal anti-inflammatory drugs\\n(NSAIDs) has also stimulatedr e l i a n c eo no t h e rt y p e s\\nof antirheumatic drugs.\\nDescription\\nThe major classes of antirheumatic drugs include:\\n/C15Nonsteroidal Anti-Inflammatory Drugs (NSAIDs.\\nDrugs belonging to this class bring symptomatic\\nrelief of both inflammation andpain, but have a\\nlimited effect on the progressive bone and cartilage\\nloss associated with rheumatoid arthritis. They act\\nby slowing the body’s production of prostaglandins.\\nCommon NSAIDs include: ibuprofen (Motrin,\\nNuprin or Advil), naproxen (Naprosyn, Aleve) and\\nindomethacin (Indocin).\\n/C15Corticosteroids. These drugs are very powerful anti-\\ninflammatory agents. They are the synthetic analogs\\nof cortisone, produced by the body. Corticosteroids\\nare used to reduce inflammation and suppress\\n344 GALE ENCYCLOPEDIA OF MEDICINE\\nAntirheumatic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 374, 'page_label': '345'}, page_content='activity of the immune system. The most commonly\\nprescribed are prednisone and dexamethasone.\\n/C15Disease Modifying Anti-Rheumatic Drugs\\n(DMARDs). DMARDs influence the disease process\\nitself and do not only treat symptoms, hence their\\nname. DMARDs also have anti-inflammatory effects,\\nand most were borrowed from the treatment of other\\ndiseases, such ascancer and malaria. Antimalarials\\nDMARDs include chloroquine (Aralen) and hydroxy-\\nchloroquine (Plaquenil). Powerful DMARDs include:\\nmethotrexate (Rheumatrex), sulfasalazine, cyclospor-\\nine, azathioprine (Imuran) and cyclophosphamide\\n(Cytoxan), azathioprine, sulfasalazine, penicillamine,\\nand organic gold compounds such as aurothioglucose\\n(Solganol), gold sodium thiomalate (Aurolate) and\\nauranofin (Ridaura).\\n/C15Slow-Acting Antirheumatic Drugs (SAARDs).\\nSAARDs are a special class of DMARDs and the\\neffect of these drugs is slow acting and not so quickly\\napparent as that of the NSAIDs. Examples are\\nhydroxychloroquine and aurothioglucose.\\n/C15Immunosuppresive cytotoxic drugs. This class of\\ndrugs is used if treatment with NSAIDs and\\nSAARDs have no effect. Immunosuppresive drugs\\nhave a stabilizing effect on the immune system.\\nSince the inflammation associated with chronic\\narthritis is due to malfunctions of the immune\\nsystem, use of this class of drugs has been shown\\nto be beneficial for the treatment of rheumatoid\\narthritis as well. Examples are: methotrexate,\\nmechlorethamine, cyclophosphamide, chlorambu-\\ncil, and azathioprine.\\nKEY TERMS\\nAnti-inflammatory drugs— A class of drugs that\\nlower inflammation and that includes NSAIDs and\\ncorticosteroids.\\nArthritis— A painful condition that involves inflam-\\nmation of one or more joints.\\nConception— The union of egg and sperm to form a\\nfetus.\\nCorticosteroids— A class of drugs that are synthetic\\nversions of the cortisone produced by the body. They\\nrank among the most powerful anti-inflammatory\\nagents.\\nCortisone— Glucocorticoid produced by the adrenal\\ncortex in response to stress. Cortisone is a steroid and\\nhas anti-inflammatory and immunosuppressive\\nproperties.\\nCytotoxic drugs— Drugs that function by destroying\\ncells.\\nDisease Modifying Anti-Rheumatic Drugs\\n(DMARDs)— A class of antirheumatic drugs, includ-\\ning chloroquine, methotrexate, cyclosporine, and\\ngold compounds, that influence the disease process\\nitself and do not only treat its symptoms.\\nInflammation— A process occurring in body tissues,\\ncharacterized by increased circulation and the accu-\\nmulation of white blood cells. Inflammation also occurs\\nin disorders such as arthritis and causes harmful effects.\\nInflammatory— Pertaining to inflammation.\\nImmune response— Physiological response of the\\nbody controlled by the immune system that involves\\nthe production of antibodies to fight off specific for-\\neign substances or agents (antigens).\\nImmune system— The sum of the defence mechan-\\nisms of the body that protects it against foreign sub-\\nstances and organisms causing infection.\\nImmunosuppressive— Any agent that suppresses the\\nimmune response of an individual.\\nImmunosuppresive cytotoxic drugs— A class of\\ndrugs that function by destroying cells and suppres-\\nsing the immune response.\\nMethotrexate— A drug that interferes with cell\\ngrowth and is used to treat rheumatoid arthritis as\\nwell as various types of cancer. Side-effects may\\ninclude mouth sores, digestive upsets, skin rashes,\\nand hair loss.\\nNon steroidal— Not containing steroids or cortisone.\\nUsually refers to a class of drugs called Non Steroidal\\nAnti-Inflammatory Drugs (NSAID).\\nNonsteroidal Anti-Inflammatory Drugs (NSAIDs)—\\nA class of drugs that is used to relieve pain, and\\nsymptoms of inflammation, such as ibuprofen and\\nketoprofen.\\nOsteoarthritis— A form of arthritis that occurs\\nmainly in older people and involves the gradual\\ndegeneration of the cartilage of the joints.\\nProstaglandins— Prostaglandins are produced by\\nthe body and are responsible for inflammation\\nfeatures, such as swelling, pain, stiffness, redness\\nand warmth.\\nGALE ENCYCLOPEDIA OF MEDICINE 345\\nAntirheumatic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 375, 'page_label': '346'}, page_content='Recommended dosage\\nRecommended dosage depends on the type of\\ndrug. The prescribing physician or the pharmacist\\nprovide information for the correct dosage. The\\ndrugs must be taken exactly as directed.\\nWhen taking methotrexate for rheumatoid arthri-\\ntis, it should be taken onlyonce or twice a week as\\nprescribed, not every day. Taking it every day can lead\\nto a fatal overdose.\\nPrecautions\\nMany antirheumatic drugs such as, for example,\\nazathioprine (Imuran) and methotrexate\\n(Rheumatrex), are very powerful drugs. They are\\nusually prescribed in severe cases, when all other treat-\\nments have failed. Thus, they may have serious side\\neffects, so it is important to be monitored closely by a\\nphysician while taking any of these drugs.\\nSide effects\\nHydroxychloroquine (Plaquenil) may cause vision\\nproblems. Anyone taking it should see an ophthalmol-\\nogist (a physician who specializes in treating eyes) for a\\nthorough eye examinationevery six months.\\nMethotrexate and penicillamine may causebirth\\ndefects. Women taking these drugs must stop taking\\nthem duringpregnancy and for several months before\\na planned pregnancy. Methotrexate may also cause\\nlung damage or fertility problems and should not be\\ntaken by anyone with serious kidney orliver diseaseor\\nby anyone who drinks alcohol.\\nAzathioprine may cause birth defects if either the\\nman or woman is using it at the time of conception.\\nAnyone who uses this drug and is sexually active\\nshould consult with a physician about an effective\\nbirth control method.\\nOther common side effects of antirheumatic drugs\\ninclude abdominal cramps,diarrhea, dizziness,l o s so f\\nappetite, headache, nausea, vomiting, fever and chills,\\nand mouth sores. A variety of other side effects may\\noccur. Anyone who has unusual symptoms while taking\\nantirheumatic drugs should notify the treating physician.\\nThe gold compounds may cause serious blood\\nproblems by reducing the ability of the blood forming\\norgans to produce blood cells. These drugs may\\ndecrease the number of white blood cells, red blood\\ncells, or both. Patients taking these drugs should have\\nregular blood counts.\\nEntanercept (Enbrel) may also cause blood pro-\\nblems, and some patients who received this drug have\\ndeveloped eye problems andmultiple sclerosis.I ti sn o t\\ncertain whether these reactions were caused by entaner-\\ncept, but multiple sclerosis has been seen in patients tak-\\ning other drugs which act against tumor necrosis factor.\\nInteractions\\nAntirheumatic drugs may interact with a variety of\\nother medicines or other antirheumatic drugs. When this\\nhappens, the effects of one or both of the drugs may\\nchange, or the risk of side effects may be greater. Anyone\\nwho takes this type of drug should inform the prescribing\\nphysician about any other medication he or she is taking.\\nAmong the drugs that may interact with antirheumatic\\ndrugs are phenytoin (Dilantin),aspirin, sulfa drugs such\\nas Bactrim and Gantrisin, tetracycline and some other\\nantibiotics and cimetidine (Tagamet). NSAIDs such as\\nibuprofen (Motrin, Advil)are also known to interact\\nwith other classes of antirheumatic drugs.\\nNancy Ross-Flanigan\\nAntiseptics\\nDefinition\\nAn antiseptic is a substance which inhibits the\\ngrowth and development of microorganisms. For\\npractical purposes, antiseptics are routinely thought\\nof as topical agents, for application to skin, mucous\\nmembranes, and inanimate objects, although a formal\\ndefinition includes agents which are used internally,\\nsuch as the urinary tract antiseptics.\\nPurpose\\nAntiseptics are a diverse class of drugs which are\\napplied to skin surfaces or mucous membranes for\\ntheir anti-infective effects. This may be either bacter-\\niocidal or bacteriostatic. Their uses include cleansing\\nof skin and wound surfaces after injury, preparation of\\nskin surfaces prior to injections or surgical procedures,\\nand routine disinfection of the oral cavity as part of a\\nprogram oforal hygiene. Antiseptics are also used for\\ndisinfection of inanimate objects, including instru-\\nments and furniture surfaces.\\nCommonly used antiseptics for skin cleaning\\ninclude benzalkonium chloride, chlorhexidine, hexa-\\nchlorophine, iodine compounds, mercury compounds,\\nalcohol and hydrogen peroxide. Other agents which\\nhave been used for this purpose, but have largely been\\nsupplanted by more effective or safer agents, include\\n346 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiseptics'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 376, 'page_label': '347'}, page_content='boric acid and volatile oils such as methyl salicylate\\n(oil of wintergreen.)\\nChlorhexidine shows a high margin of safety when\\napplied to mucous membranes, and has been used in\\noral rinses and preoperative total body washes.\\nBenzalkonium chloride and hexachlorophine are\\nused primarily as hand scrubs or face washes.\\nBenzalkonium may also find application is a disinfect-\\ning agent for instruments, and in low concentration as\\na preservative for drugs including ophthalmic solu-\\ntions. Benzalkonium chloride is inactivated by organic\\ncompounds, including soap, and must not be applied\\nto areas which have not been fully rinsed.\\nIodine compounds include tincture of iodine and\\npovidone iodine compounds. Iodine compounds have\\nthe broadest spectrum of all topical anti-infectives, with\\naction against bacteria, fungi, viruses, spores, protozoa,\\nand yeasts. Iodine tincture is highly effective, but its\\nalcoholic component is drying and extremely irritating\\nwhen applied to abraided (scraped or rubbed) skin.\\nPovidone iodine, an organic compound, is less irritating\\nand less toxic, but not as effective. Povidone iodine has\\nbeen used for hand scrubs and disinfection of surgical\\nsites. Aqueous solutions of iodine have also been used\\nas antiseptic agents, but are less effective than alcoholic\\nsolutions and less convenient to use that the povidone\\niodine compounds.\\nHydrogen peroxide acts through the liberation of\\noxygen gas. Although the antibacterial activity of hydro-\\ngen peroxide is relatively weak, the liberation of oxygen\\nbubbles produces an effervescent action, which may be\\nuseful for wound cleansing through removal of tissue\\ndebris. The activity of hydrogen peroxide may be\\nreduced by the presence of blood and pus. The appro-\\npriate concentration of hydrogen peroxide for antiseptic\\nuse is 3%, although higher concentrations are available.\\nThimerosol (Mersol) is a mercury compound with\\nactivity against bacteria and yeasts. Prolonged use\\nmay result in mercury toxicity.\\nRecommended dosage\\nDosage varies with product and intended use.\\nConsult individualized references.\\nPrecautions\\nPrecautions vary with individual product and use.\\nConsult individualized references.\\nHypersensitivity reactions should be considered\\nwith organic compounds such as chlorhexidine, ben-\\nzalkonium and hexachlorophine.\\nSkin dryness and irritation should be considered\\nwith all products, but particularly with those contain-\\ning alcohol.\\nSystemic toxicity may result from ingestion of\\niodine containing compounds or mercury compounds.\\nChlorhexidine should not be instilled into the ear.\\nThere is one anecdotal report of deafness following\\nuse of chlorhexidine in a patient with aperforated\\neardrum. Safety inpregnancy and breastfeeding have\\nnot been reported, however there is one anecdotal\\nreport of an infant developing slowed heartbeat\\napparently related to maternal use of chlorhexidine.\\nIodine compounds should be used sparingly\\nduring pregnancy andlactation due to risk of infant\\nabsorption of iodine with alterations in thyroid function.\\nInteractions\\nAntiseptics are not known to interact with any\\nother medicines. However, they should not be used\\ntogether with any other topical cream, solution, or\\nointment.\\nResources\\nPERIODICALS\\nFarley, Dixie. ‘‘Help for Cuts, Scrapes and Burns.’’FDA\\nConsumer May 1996: 12.\\nSamuel D. Uretsky, PharmD\\nAntispasmodic drugs\\nDefinition\\nAntispasmodic drugs relieve cramps or spasms of\\nthe stomach, intestines, and bladder.\\nKEY TERMS\\nAntibiotic— A medicine used to treat infections.\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nMucous membrane— The moist lining of a body\\ncavity or structure, such as the mouth or nose.\\nResidue— Traces that remain after most of the rest\\nof the material is gone.\\nGALE ENCYCLOPEDIA OF MEDICINE 347\\nAntispasmodic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 377, 'page_label': '348'}, page_content='Purpose\\nAntispasmodic drugs have been used to treat\\nstomach cramps. Traditionally, they were used to\\ntreat stomach ulcers, but for this purpose they have\\nlargely been replaced by the acid inhibiting\\ncompoundsa, the H-2 receptor blockers such as\\ncimetidine and ranitidine and the proton pump\\ninhibtors such as omeprazole, lansoprazole and\\nrabetazole.\\nMost of the drugs used for this purpose as ‘‘anti-\\ncholinergics’’, since they counteract the effects of the\\nneurohormone acetylcholine. Some of these drugs are\\nderived from the plant belladonna, also known as\\nDeadly Nightshade. There is also a group of drugs\\nwith similar activity, but not taken from plant sources.\\nThe anticholingergics decrease both the movements of\\nthe stomach and intestine, and also the secretions of\\nstomach acid and digestive enzymes. They may be\\nused for other purposes including treatment of\\nParkinson’s Disease, and bladder urgency. Because\\nthese drugs inhibit secretions, they causedry mouth\\nand dry eyes because of reduced salivation and tear-\\ning. Dicyclomine is an antispasmodic with very lettle\\neffect on secretions. It is used to treatirritable bowel\\nsyndrome.\\nDescription\\nDicyclomine is available only with a prescription\\nand is sold as capsules, tablets (regular and extended-\\nrelease forms), and syrup.\\nRecommended dosage\\nThe usual dosage for adults is 20 mg, four times a\\nday. However, the physician may recommend starting\\nat a lower dosage and gradually increasing the dose to\\nreduce the chance of unwanted side effects.\\nThe dosage for children depends on the child’s\\nage. Check with the child’s physician for the correct\\ndosage.\\nPrecautions\\nDicyclomine makes so me people sweat less,\\nwhich allows the body to overheat and may lead to\\nheat prostration ( fever and heat stroke). Anyone\\ntaking this drug should try to avoid extreme heat.\\nIf that is not possible, check with the physician\\nwho prescribed the drug. If heat prostration occurs,\\nstop taking the medicine and call a physician\\nimmediately.\\nThis medicine can cause drowsiness and blurred\\nor double vision. People who take this drug should not\\ndrive, use machines, or do anything else that might be\\ndangerous until they have found out how the medicine\\naffects them.\\nDicyclomine should not be given to infants or\\nchildren unless the physician decides the use of this\\ndrug is necessary. Diclyclomine should not be used by\\nwomen who are breast feeding. Women who are preg-\\nnant or plan to become pregnant should check with\\ntheir physicians before using this drug.\\nAnyone with the following medical conditions\\nshould not take dicyclomine unless directed to do so\\nby a physician:\\n/C15Previous sensitivity or allergic reaction to\\ndicyclomine\\n/C15Glaucoma\\n/C15Myasthenia gravis\\n/C15Blockage of the urinary tract, stomach, or intestines\\n/C15Severe ulcerative colitis\\n/C15Reflux esophagitis.\\nKEY TERMS\\nHeat stroke— A serious condition that results from\\nexposure to extreme heat. The body loses its ability\\nto cool itself. Severe headache, high fever, and hot,\\ndry skin may result. In severe cases, a person with\\nheat stroke may collapse or go into a coma.\\nHiatal hernia— A condition in which part of the\\nstomach protrudes through the diaphragm.\\nHyperthyroidism— Secretion of excess thyroid hor-\\nmones by the thyroid gland.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMyasthenia gravis— A condition in which certain\\nmuscles weaken and may become paralyzed.\\nReflux esophagitis— Inflammation of the lower\\nesophagus caused by the backflow of stomach\\ncontents.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles\\nUlcerative colitis— Long-lasting and repeated\\ninflammation of the colon with the development\\nof sores.\\n348 GALE ENCYCLOPEDIA OF MEDICINE\\nAntispasmodic drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 378, 'page_label': '349'}, page_content='In addition, patients with these conditions should\\ncheck with their physicians before using dicyclomine:\\n/C15Liver disease\\n/C15Kidney disease\\n/C15High blood pressure\\n/C15Heart problems\\n/C15Enlarged prostate gland\\n/C15Hiatal hernia\\n/C15Autonomic neuropathy (a nerve disorder)\\n/C15Hyperthyroidism.\\nSide effects\\nThe most common side effects aredizziness, drow-\\nsiness, lightheadedness, nausea, nervousness, blurred\\nvision, dry mouth, and weakness. Other side effects\\nmay occur. Anyone who has unusual symptoms after\\ntaking dicyclomine should get in touch with his or her\\nphysician.\\nInteractions\\nDicyclomine may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Among the drugs that may interact with\\nDicyclomine are:\\n/C15Antacids such as Maalox\\n/C15Antihistamines such as clemastine fumarate (Tavist)\\n/C15Bronchodilators (airway opening drugs) such as\\nalbuterol (Proventil, Ventolin)\\n/C15Corticosteroids such as prednisone (Deltasone)\\n/C15Monoamine oxidase inhibitors (MAO inhibitors) such\\nas phenelzine (Nardil) and tranylcypromine (Parnate)\\n/C15Tranquilizers such as diazepam (Valium) and alpra-\\nzolam (Xanax).\\nThe list above does not include every drug that\\nmay interact with dicyclomine. Be sure to check with a\\nphysician or pharmacist before combining dicyclo-\\nmine with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntistreptolysin O titer (ASO) see\\nStreptococcal antibody tests\\nAntithrombin III deficiency see\\nHypercoagulation disorders\\nAntituberculosis drugs\\nDefinition\\nAntituberculosis drugs are medicines used to treat\\ntuberculosis, an infectious disease that can affect the\\nlungs and other organs.\\nPurpose\\nTuberculosis is a disease caused by Mycobacterium\\ntuberculae, a bacteria that is passed between people\\nthrough the air. The disease can be cured with proper\\ndrug therapy, but because the bacteria may become\\nresistant to any single drug, combinations of antituber-\\nculosis drugs are used to treat tuberculosis (TB) are\\nnormally required for effective treatment. At the start\\nof the 20th Century, tuberculosis was the most common\\ncause of death in the United States, but was laregly\\neliminated with better living conditions. It is most com-\\nmon in areas of crowding and poor ventilation, suich as\\ncrowded urban areas and prisons. In some areas, the\\nAIDS epidemic has been accompanied by an increase\\nin the prevalence of tuberculosis.\\nSome antituberculosis drugs also are used to treat\\nor prevent other infections such asMycobacterium\\navium complex (MAC), which causes disease through-\\nout the bodies of people with AIDS or other diseases\\nof the immune system.\\nDescription\\nAntituberculosis drugs are available only with a\\nphysician’s prescription and come in tablet, capsule,\\nliquid and injectable forms. Some commonly used\\nantituberculosis drugs are cycloserine (Seromycin),\\nethambutol (Myambutol), ethionamide (Trecator-\\nSC), isoniazid (Nydrazid, Laniazid), pyrazinamide,\\nrifabutin (Mycobutin), and rifampin (Rifadin,\\nRimactane).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantituberculosis drug and may be different for differ-\\nent patients. Check with the physician who prescribed\\nthe medicine or the pharmacist who filled the prescrip-\\ntion for the proper dosage. The physician may gradu-\\nally increase the dosage during treatment. Be sure to\\nfollow the physician’s orders. Patients who are infected\\nwith HIV must usually take larger combinations of\\ndrugs for a longer period of time than is needed for\\npatients with an unimpaired immune system.\\nGALE ENCYCLOPEDIA OF MEDICINE 349\\nAntituberculosis drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 379, 'page_label': '350'}, page_content='Some antituberculosis drugs must be taken with\\nother drugs. If they are taken alone, they may encou-\\nrage the bacteria that cause tuberculosis to become\\nresistant to drugs used to treat the disease. When the\\nbacteria become resistant, treating the disease\\nbecomes more difficult.\\nTo clear up tuberculosis completely, antitubercu-\\nlosis drugs must be taken for as long as directed. This\\nmay mean taking the medicine every day for a year or\\ntwo or even longer. Symptoms may improve very\\nquickly after treatment with this medicine begins.\\nHowever, they may come back if the medicine is\\nstopped too quickly. Do not stop taking the medicine\\njust because symptoms improve.\\nBecause people may neglect to take their medica-\\ntion for tuberculosis, it is common to have tuberculo-\\nsis centers develop a program of Directly Observed\\nTherapy (DOT.) In these programs, patients come to\\nthe hospital or clinic, and take their medication in\\nfront of an observer. These programs may be annoy-\\ning to the patients, but are justified by the risks to\\npublic health if tuberculosis germs which have become\\nresistant to drugs were to be spread.\\nCycloserine works best when it is at constant\\nlevels in the blood. To help keep levels constant, take\\nthe medicine in doses spaced evenly through the day\\nand night. Do not miss any doses. If taking medicine at\\nnight interferes with sleep, or if it is difficult to\\nremember to take the medicine during the day, check\\nwith a health care professional for suggestions.\\nDo not takeantacids that contain aluminum, such\\nas Maalox, within 1 hour of taking isoniazid, as this\\nmay keep the medicine from working.\\nPrecautions\\nSeeing a physician regularly while taking antitu-\\nberculosis drugs is important. The physician will check\\nto make sure the medicine is working as it should and\\nwill watch for unwanted side effects. These visits also\\nwill help the physician know if the dosage needs to be\\nchanged.\\nSymptoms should begin to improve within a few\\nweeks after treatment begins with antituberculosis\\ndrugs. If they do not, or if they become worse, check\\nwith a physician.\\nSome people feel drowsy, dizzy, confused, or less\\nalert when using these drugs. Some may also cause\\nvision changes, clumsiness, or unsteadiness. Because\\nof these possible problems, anyone who takes antitu-\\nberculosis drugs should not drive, use machines, or do\\nanything else that might be dangerous until they have\\nfound out how the medicine affects them.\\nDaily doses of pyridoxine (vitamin B\\n6) may lessen\\nor prevent some side effects of ethionamide or isoniazid.\\nIf the physician who prescribed the medicine recom-\\nmends this, be sure to take the pyridoxine every day.\\nCertain kinds of cheese (such as Swiss and\\nCheshire) and fish (such as tuna and skipjack) may\\ncause an unusual reaction in people taking isoniazid.\\nSymptoms of this reaction include fast or pounding\\nheartbeat, sweating or a hot feeling, chills or a clammy\\nfeeling,headache, lightheadedness, and red or itchy skin.\\nThis reaction is very rare. However, if any of these symp-\\ntoms occur, check with a physician as soon as possible.\\nRifabutin and rifampin will make saliva, sweat,\\ntears, urine, feces, and skin turn reddish orange to\\nreddish brown. This is nothing to worry about.\\nHowever, the discolored tears may permanently stain\\nsoft contact lenses (but not hard contact lenses). To\\navoid ruining contact lenses, do not wear soft contacts\\nwhile taking these medicines.\\nRifampin may temporarily lower the number of\\nwhite blood cells. Because the white blood cells are\\nimportant in fighting infection, this effect increases the\\nchance of getting an infection. This drug also may\\nlower the number of platelets that play an important\\nrole in clotting. To reduce the risk of bleeding and\\ninfection in the mouth while taking this medicine, be\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nFeces— (Also called stool.) The solid waste that is\\nleft after food is digested. Feces form in the intes-\\ntines and pass out of the body through the anus.\\nFetus— A developing baby inside the womb.\\nGout— A disease in which uric acid, a waste pro-\\nduct that normally passes out of the body in urine,\\ncollects in the joints and the kidneys. This causes\\narthritis and kidney stones.\\nImmune system— The body’s natural defenses\\nagainst disease and infection.\\nMicroorganism— An organism (life form) that is too\\nsmall to be seen with the naked eye.\\nPlatelets— Disk-shaped bodies in the blood that are\\nimportant in clotting.\\nSeizure— A sudden attack, spasm, or convulsion.\\n350 GALE ENCYCLOPEDIA OF MEDICINE\\nAntituberculosis drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 380, 'page_label': '351'}, page_content='especially careful when brushing and flossing the\\nteeth. Check with a physician or dentist for sugges-\\ntions on how to keep the teeth and mouth clean with-\\nout causing injuries. Put off any dental work until\\nblood counts return to normal.\\nRifampin may affect the results of some medical\\ntests. Before having medical tests, anyone taking this\\nmedicine should alert the health care professional in\\ncharge.\\nPeople who have certain medical conditions may\\nhave problems if they take antituberculosis drugs. For\\nexample:\\n/C15cycloserine or isoniazid may increase the risk of sei-\\nzures (convulsions) in people with a history of\\nseizures.\\n/C15the dosage of cycloserine may need to be adjusted for\\npeople withkidney disease.\\n/C15ethambutol or pyrazinamide may cause or worsen\\nattacks of gout in people who are prone to having\\nthem.\\n/C15ethambutol may cause or worsen eye damage.\\n/C15diabetes may be harder to control in patients who\\ntake ethionamide.\\n/C15isoniazid may cause false results on some urine sugar\\ntests, and pyrazinamide may cause false results on\\nurine ketone tests. Diabetic patients who either of\\nthese medicines should discuss the possibility of false\\ntest results with their physicians.\\n/C15people with liver disease or a history of alcohol\\nabuse may be more likely to develop hepatitis\\nwhen taking isoniazid and are more likely to have\\nside effects that affect the liver when taking\\nrifampin.\\n/C15in people with kidney disease, ethambutol, ethiona-\\nmide, or isoniazid may be more likely to cause side\\neffects.\\n/C15side effects are also more likely in people with liver\\ndisease who take pyrazinamide.\\nBefore taking antituberculosis drugs, be sure to let\\nthe physician know about these or any other medical\\nproblems.\\nIn laboratory tests of pregnant animals, high\\ndoses of some antituberculosis drugs have caused\\nbirth defectsand other problems in the fetus or new-\\nborn. However, pregnant women with tuberculosis\\nneed to take antituberculosis drugs to clear up their\\ndisease. Knowing that many women have had healthy\\nbabies after taking these drugs during pregnancy may\\nbe reassuring. Pregnant women who need to take this\\nmedicine and are worried about birth defects or other\\nproblems should talk to their physicians.\\nAnyone who has had unusual reactions to anti-\\ntuberculosis drugs or to niacin should let his or her\\nphysician know before taking any antituberculosis\\ndrug. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other\\nsubstances.\\nPatients who are on specialdiets, such as low-\\nsodium or low-sugar diets, should make sure their\\nphysicians know. Some antituberculosis medicines\\nmay contain sodium, sugar, or alcohol.\\nSide effects\\nCycloserine\\nIn some people, this medicine causes depression\\nand thoughts ofsuicide. If this happens, check with a\\nphysician immediately. Switching to another medicine\\nwill usually stop these troubling thoughts and feelings.\\nAlso let the physician know immediately about any\\nother mood or mental changes; such as nervousness,\\nnightmares, anxiety, confusion, or irritability; and\\nabout symptoms such as muscle twitches, convulsions,\\nor speech problems.\\nHeadache is a common side effect that usually\\ngoes away as the body adjusts to this medicine. This\\nproblem does not need medical attention unless it\\ncontinues or it interferes with everyday life.\\nEthambutol\\nThis medicine may cause eye pain or vision\\nchanges, including loss of vision or changes in color\\nvision. Check with a physician immediately if any of\\nthese problems develop.\\nIn addition, anyone who has any of these symp-\\ntoms while taking ethambutol should check with a\\nphysician immediately:\\n/C15painful or swollen joints, especially in the knee,\\nankle, or big toe\\n/C15a tight, hot sensation in the skin over painful or\\nswollen joints\\n/C15chills.\\nOther side effects may occur but do not need\\nmedical attention unless they are bothersome or they\\ndo not go away as the body adjusts to the medicine.\\nThese include: headache, confusion, nausea and\\nvomiting, stomach pain, and loss of appetite.\\nGALE ENCYCLOPEDIA OF MEDICINE 351\\nAntituberculosis drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 381, 'page_label': '352'}, page_content='Ethionamide\\nCheck with a physician immediately if eye pain,\\nblurred vision, or other vision changes occur while\\ntaking this medicine.\\nSymptoms such as unsteadiness, clumsiness and\\npain, numbness, tingling, or burning in the hands or\\nfeet could be the first signs of nerve problems that may\\nbecome more serious. If any of these symptoms occur,\\ncheck with a physician immediately. Other side effects\\nthat should be brought to a physician’s attention\\nimmediately include yellow eyes or skin and mood or\\nmental changes such as depression or confusion.\\nLess serious side effects such asdizziness, nausea\\nor vomiting, appetite loss, sore mouth, or metallic\\ntaste may also occur. These problems usually go\\naway as the body adjusts to the medicine. They do\\nnot need medical attention unless they continue or\\nthey interfere with normal activities.\\nIsoniazid\\nThis medicine may cause serious liver damage, espe-\\ncially in people over 40 years of age. However, taking\\nmedicine for tuberculosis is very important for people\\nwith the disease. Anyone who has tuberculosis and has\\nbeen advised to take this drug should thoroughly discuss\\ntreatment options with his or her physician.\\nRecognizing the early signs of liver and nerve\\ndamage can help prevent the problems from getting\\nworse. If any of these symptoms occur, check with a\\nphysician immediately:\\n/C15unusual tiredness or weakness\\n/C15clumsiness or unsteadiness\\n/C15pain, numbness, tingling, or burning in the hands\\nand feet\\n/C15loss of appetite\\n/C15vomiting\\nThis medicine may also cause less serious side\\neffects such asdiarrheaand stomach pain. These usually\\ngo away as the body adjusts to the medicine and do not\\nneed medical attention unless they continue.\\nIf eye pain, blurred vision, or other vision changes\\noccur while taking this medicine, check with a physi-\\ncian immediately.\\nPyrazinamide\\nCheck with a physician immediately if pain in the\\njoints occurs.\\nRifabutin\\nCheck with a physician immediately if a skin rash\\noccurs.\\nRifampin\\nStop taking rifampin and check with a physician\\nimmediately if any of the following symptoms occur.\\nThese symptoms could be early signs of problems that\\nmay become more serious. Getting prompt medical\\nattention could prevent them from getting worse.\\n/C15unusual tiredness or weakness\\n/C15nausea or vomiting\\n/C15loss of appetite\\nIn addition, anyone who has any of these symp-\\ntoms while taking rifampin should check with a phy-\\nsician immediately:\\n/C15breathing problems\\n/C15fever\\n/C15chills\\n/C15shivering\\n/C15headache\\n/C15dizziness\\n/C15itching\\n/C15skin rash or redness\\n/C15muscle and bone pain\\nOther side effects, such as diarrhea and stomach\\npain, may occur with this medicine, but should go\\naway as the body adjusts to the drug. Medical treat-\\nment is not necessary unless these problems continue.\\nOther side effects may occur with any antituber-\\nculosis drug. Anyone who has unusual symptoms\\nwhile taking an antituberculosis drug should get in\\ntouch with his or her physician.\\nInteractions\\nTaking cycloserine and ethionamide together may\\nincrease the risk of seizures and other nervous system\\nproblems. These and other side effects also are more\\nlikely in people who drink alcohol while taking cyclo-\\nserine. To avoid these problems,do not drink alcohol\\nwhile taking cycloserine and check with a physician\\nbefore combining cycloserine and ethionamide.\\nDrinking alcohol regularly may prevent isoniazid\\nfrom working properly and may increase the chance of\\nliver damage. Anyone taking this medicine should\\nstrictly limit the use of alcohol. Check with a health\\n352 GALE ENCYCLOPEDIA OF MEDICINE\\nAntituberculosis drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 382, 'page_label': '353'}, page_content='care professional for advice on the amount of alcohol\\nthat may safely be used.\\nMany drugs may interact with isoniazid or rifampin,\\nincreasing the chance of liver damage or other side effects.\\nAmong these drugs are acetaminophen (Tylenol), birth\\ncontrol pills and other drugs that contain female hor-\\nmones, and the antiseizure drugs divalproex (Depakote)\\nand valproic acid (Depakene). For a complete list of\\ndrugs that may have this effect, check with a pharmacist.\\nIsoniazid may also decrease the effects of the anti-\\nfungal drug ketoconazole (Nizoral) and the antituber-\\nculosis drug rifampin (Rifadin).\\nRifampin may make many drugs less effective.\\nAmong the drugs that may be affected are diabetes\\nmedicines taken by mouth (oral hypoglycemics), digi-\\ntalis heart drugs, many antifungal drugs, and birth\\ncontrol pills. Because it makes birth control pills less\\neffective, taking rifampin may increase the chance of\\nbecoming pregnant. Women who take this medicine\\nalong with birth control pills should use an additional\\nform of birth control. For a complete list of drugs that\\nmay be affected by rifampin, check with a pharmacist.\\nUsing rifabutin with the antiretroviral drug zido-\\nvudine (AZT, Retrovir) may make the zidovudine less\\neffective. Consult with a physician if both drugs are\\nprescribed.\\nNot every drug that may interact with an antitu-\\nberculosis drug is listed here. Be sure to check with a\\nphysician or pharmacist before combining an antitu-\\nberculosis drug with any other prescription or nonpre-\\nscription (over-the-counter) medicine.\\nResources\\nPERIODICALS\\nCornwall, Janet. ‘‘Tuberculosis: A Clinical Problem of\\nInternational Importance.’’The Lancet(August 30,\\n1997): 660.\\nNancy Ross-Flanigan\\nAntiulcer drugs\\nDefinition\\n‘Antiulcer drugs are a class of drugs, exclusive of\\nthe antibacterial agents, used to treat ulcers in the\\nstomach and the upper part of the small intestine.\\nPurpose\\nRecurrent gastric and duodenal ulcers are caused\\nby Helicobacter pylori infections, and are treated\\nwith combination treatments that incorporate anti-\\nbiotic therapy with gastric acid suppression.\\nAdditionally, bismuth compounds have been used.\\nThe primary class of drugs used for gastric acid\\nsuppression are the proton pump inhibitors, omepra-\\nzole, lansoprazole, pantoprazole and rabeprazole. The\\nH-2 receptor blocking agents, cimetidine, famotidine,\\nnizatidine, and ranitidine have been used for this\\npurpose, but are now more widely used for mainte-\\nnance therapy after treatment with the proton pump\\ninhibitors. Sucralfate, which acts by forming a protec-\\ntive coating over the ulcerate lesion, is also used in\\nulcer treatment and may be appropriate for patients in\\nwhom other classes of drugs are not indicated, or those\\nwhose gastric ulcers are caused by non-steroidal anti-\\ninflammatory drugs (NSAIDs) rather thanH. pylori\\ninfections.\\nDescription\\nThe proton pump inhibitorsblock the secretion of\\ngastric acid by the gastric parietal cells. The extent of\\ninhibition of acid secretion is dose related. In some\\ncases, gastric acid secretion is completely blocked for\\nover 24 hours on a single dose. In addition to their role\\nin treatment of gastric ulcers, the proton pump inhibi-\\ntors are used to treat syndromes of excessive acid\\nsecretion (Zollinger-Ellison Syndrome) and gastroeso-\\nphageal reflux disease (GERD).\\nAntiulcer Drugs\\nBrand Name\\n(Generic Name) Possible Common Side Effects Include:\\nAxid (nitzatidine) Diarrhea, headache, nausea and vomiting, sore\\nthroat\\nCarafate (sucralfate) Constipation, insomnia, hives, upset stomach,\\nvomiting\\nCytotec (misoprostol) Cramps, diarrhea, nausea, gas, headache,\\nmenstrual disorders (including heavy bleeding\\nand severe cramping)\\nPepcid (famotidine) Constipation or diarrhea, dizziness, fatigue,\\nfever\\nPrilosec (omeprazole) Nausea and vomiting, headache, diarrhea,\\nabdominal pain\\nTagamet (cimetidine) Headache, breast development in men, depres-\\nsion and disorientation\\nZantac (ranitidine\\nhydrochloride)\\nHeadache, constipation or diarrhea, joint pain\\nGALE ENCYCLOPEDIA OF MEDICINE 353\\nAntiulcer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 383, 'page_label': '354'}, page_content='Histamine H-2 receptor blockers stop the action\\nof histamine on the gastric parietal cells, inhibiting the\\nsecretion of gastric acid. These drugs are less effective\\nthan the proton pump inhibitors, but may achieve a\\n75–79% reduction in acid secretion. Higher rates of\\nacid inhibition may be achieved when the drug is\\nadministered by the intravenous route. The H-2 recep-\\ntor blockers may also be used to treatheartburn and\\nhypersecretory syndromes. When given before sur-\\ngery, the H-2 receptor blockers are useful in preven-\\ntion of aspirationpneumonia.\\nSucralfate (Carafate), a substituted sugar molecule\\nwith no nutritional value, does not inhibit gastric acid,\\nbut rather, reacts with existing stomach acid to form a\\nthick coating that covers the surface of an ulcer, protect-\\ning the open area from further damage. A secondary\\neffect is to act as an inhibitor of the digestive enzyme\\npepsin. Sucralfate does not bind to the normal stomach\\nlining. The drug has been used for prevention ofstress\\nulcers, the type seen in patients exposed to physical stress\\nsuch asburns and surgery. It has no systemic effects.\\nRecommended dosage\\nThe doses of the proton pump inhibitors and H-2\\nreceptor blockers vary depending on the drug and\\ncondition being treated. Consult individual references.\\nThe dose of sucralfate for acute ulcer therapy is\\n1 gram four times a day. After the ulcer has healed,\\nmaintenance treatment may continue at 1 gram two\\ntimes daily.\\nPrecautions\\nThe proton pump inhibitors are generally well\\ntolerated, and the most common adverse effects are\\ndiarrhea, itching, skin rash, dizziness and headache.\\nMuscle aches and a higher than normal rate of respira-\\ntory infections are among the other adverse reactions\\nreported. Omeprazole has an increased rate of fetal\\ndeaths in animal studies. It is not known if these drugs\\nare excreted in human milk, but because of reported\\nadverse effects to infants in animal studies, it is recom-\\nmended that proton pump inhibitors not be used by\\nnursing mothers.\\nThe H-2 receptor blockers vary widely in their\\nadverse effects. Although they are generally well tol-\\nerated, cimetidine may cause confusion in elderly\\npatients, and has an antiandrogenic effect that may\\ncause sexual dysfunction in males. Famotidine has\\nbeen reported to causeheadache in 4.7% of patients.\\nIt is advisable that mothers not take H-2 receptor\\nblockers while nursing.\\nSucralfate is well tolerated. It is poorly absorbed,\\nand its most common side effect is constipation in 2%\\nof patients. Diarrhea, nausea, vomiting, gastric dis-\\ncomfort, indigestion, flatulence, dry mouth, rash, prur-\\nitus (itching), back pain, headache, dizziness,\\nsleepiness, and vertigo have been reported, as well as\\nrare allergic responses. Because sucralfate releases\\nsmall amounts of aluminum into the system, it should\\nbe used with caution in patients with renal insuffi-\\nciency. There is no information available about sucral-\\nfate’s safety in breastfeeding.\\nInteractions\\nProton pump inhibitors may increase the pH of\\nthe stomach. This will inactivate some antifungal\\ndrugs that require an acid medium for effectiveness,\\nnotable itraconazole and ketoconazole.\\nH-2 receptor blocking agents have a large number\\nof drug interactions. Consult individualized references.\\nSucralfate should not be used with aluminum\\ncontaining antacids, because of the risk of increased\\naluminum absorption. Sucralfate may inhibit\\nabsorption and reduce blood levels of anticoagu-\\nlants, digoxin, quinidine, ketoconazole, quinolones\\nand phenytoin.\\nKEY TERMS\\nAntibiotic— Medicine used to treat infections.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nGastrointestinal tract— The stomach, small intes-\\ntine and large intestine.\\nHypersecretory— Excessive production of a bodily\\nsecretion. The most common hypersecretory\\nsyndrome of the stomach is Zollinger-Ellison\\nSyndrome, a syndrome consisting of fulminating\\nintractable peptic ulcers, gastric hypersecretion and\\nhyperacidity, and the occurrence of gastrinomas\\nof the pancreatic cells of the islets of Langerhans.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMucous— Thick fluid produced by the moist mem-\\nbranes that line many body cavities and structures.\\nNonsteroidal anti-inflammatory drug (NSAID)— A\\ntype of medicine used to relieve pain, swelling, and\\nother symptoms of inflammation, such as ibuprofen\\nor ketoprofen.\\n354 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiulcer drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 384, 'page_label': '355'}, page_content='Resources\\nORGANIZATIONS\\nDigestive Disease National Coalition. 507 Capitol Court\\nNE, Suite 200, Washington, DC 20003. (202) 544-7497.\\nNational Digestive Diseases Information Clearinghouse.\\n2 Information Way, Bethesda, MD 20892-3570.\\nnddic@aerie.com. .\\nOTHER\\nDuodenal UlcerFact sheet. Johns Hopkins Health\\nInformation Adult Health Advisor. .\\nNational Institute of Diabetes and Digestive and Kidney\\nDiseases. .\\nPharmInfoNet’s Digestive Disease Center. .\\nStomach Ulcer (Gastric Ulcer).Fact sheet. Johns Hopkins\\nHealth Information Adult Health Advisor. .\\nSamuel D. Uretsky, PharmD\\nAntiviral drugs\\nDefinition\\nAntiviral drugs are medicines that cure or control\\nvirus infections.\\nPurpose\\nAntivirals are used to treat infections caused by\\nviruses. Unlike antibacterial drugs, which may cover a\\nwide range of pathogens, antiviral agents tend to be\\nnarrow in spectrum, and have limited efficacy.\\nDescription\\nExclusive of the antiretroviral agents used in HIV\\n(AIDS) therapy, there are currently only 11 antiviral\\ndrugs available, covering four types of virus. Acyclovir\\n(Zovirax), famciclovir (Famvir), and valacyclovir\\n(Valtrex) are effective against herpesvirus, including\\nherpes zoster and herpes genitalis. They may also be of\\nvalue in either conditions caused by herpes, such as\\nchickenpox and shingles. These drugs are not curative,\\nbut may reduce thepain of a herpes outbreak and\\nshorten the period of viral shedding.\\nAmantadine (Symmetrel), oseltamivir (Tamiflu),\\nrimantidine (Flumadine), and zanamivir (Relenza) are\\nuseful in treatment ofinfluenza virus. Amantadine,\\nrimantadine, and oseltamivir may be administered\\nthroughout the flu season as preventatives for patients\\nwho cannot take influenza virus vaccine.\\nCidofovir (Vistide), foscarnet (Foscavir), and\\nganciclovir (Cytovene) have been beneficial in treat-\\nment of cytomegalovirus in immunosupressed\\npatients, primarily HIV-positive patients and trans-\\nplant recipients. Ribavirin (Virazole) is used to treat\\nKEY TERMS\\nAsthenia— Muscle weakness.\\nCytomegalovirus (CMV)— A type of virus that\\nattacks and enlarges certain cells in the body. The\\nvirus also causes a disease in infants.\\nHerpes simplex— A virus that causes sores on the\\nlips (cold sores) or on the genitals (genital herpes).\\nHIV— Acronym for human immunodeficiency\\nvirus, the virus that causes AIDS.\\nParkinsonism— A group of conditions that all have\\nthese typical symptoms in common: tremor, rigidity,\\nslowmovement,andpoorbalanceandcoordination.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies,\\nor adverse effects in animals, but not in well-\\ncontrolled human studies. Category C: No adequate\\nhuman or animal studies, or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nProphylactic— Guarding from or preventing the\\nspread or occurrence of disease or infection.\\nRetrovirus— A group of viruses that contain RNA\\nand the enzyme reverse transcriptase. Many viruses\\nin this family cause tumors. The virus that causes\\nAIDS is a retrovirus.\\nShingles— An disease caused by an infection with\\nthe Herpes zoster virus, the same virus that causes\\nchickenpox. Symptoms of shingles include pain\\nand blisters along one nerve, usually on the face,\\nchest, stomach, or back.\\nVirus— A tiny, disease-causing structure that can\\nreproduce only in living cells and causes a variety\\nof infectious diseases.\\nGALE ENCYCLOPEDIA OF MEDICINE 355\\nAntiviral drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 385, 'page_label': '356'}, page_content='respiratory syncytial virus. In combination with\\ninterferons, ribavirin has shown some efficacy\\nagainst hepatitis C, and there have been anecdotal\\nreports of utility against other types of viral\\ninfections.\\nAs a class, the antivirals are not curative, and\\nmust be used either prophylactically or early in the\\ndevelopment of an infection. Their mechanism of\\naction is typically to inactivate the enzymes needed\\nfor viral replication. This will reduce the rate of viral\\ngrowth, but will not inactive the virus already present.\\nAntiviral therapy must normally be initiated within 48\\nhours of the onset of an infection to provide any\\nbenefit. Drugs used for influenza may be used\\nthroughout the influenza season in high risk patients,\\nor within 48 hours of exposure to a known carrier.\\nAntiherpetic agents should be used at the first signs of\\nan outbreak. Anti-cytomegaloviral drugs must routi-\\nnely be used as part of a program of secondarypro-\\nphylaxis (maintenance therapy following an initial\\nresponse) in order to prevent reinfection in immuno-\\ncompromised patients.\\nRecommended dosage\\nDosage varies with the drug, patient age and con-\\ndition, route of administration, and other factors. See\\nspecific references.\\nPrecautions\\nGanciclovir is available in intravenous injection,\\noral capsules, and intraoccular inserts. The capsules\\nshould be reserved for prophylactic use in organ trans-\\nplant patients, or for HIV infected patients who can-\\nnot be treated with the intravenous drug. The toxicity\\nprofile of this drug when administered systemically\\nincludes granulocytopenia, anemia andthrombocyto-\\npenia. The drug is in pregnancy category C, but has\\ncaused significant fetal abnormalities in animal studies\\nincluding cleft palate and organ defects. Breast feeding\\nis not recommended.\\nCidofovir causes renal toxicity in 53% of patients.\\nPatients should be well hydrated, and renal function\\nshould be checked regularly. Other common adverse\\neffects are nausea and vomiting in 65% or patients,\\nasthenia in 46% and headache and diarrhea, both\\nreported in 27% of cases. The drug is category C in\\npregnancy, due to fetal abnormalities in animal\\nstudies. Breast feeding is not recommended.\\nFoscarnet is used in treatment of immunocom-\\npromised patients with cytomegalovirus infections\\na n di na c y c l o v i r - r e s i s t a n therpes simples virus. The\\nprimary hazard is renal toxicity. Alterations in elec-\\ntrolyte levels may cause seizures. Foscarnet is cate-\\ngory C during pregnancy. The drug has caused\\nskeletal abnormailities in developing fetuses. It is\\nnot known whether foscarnet is excreted in breast\\nmilk, however the drug does appear in breast milk in\\nanimal studies.\\nValaciclovir is metabolized to acyclovir, so that\\nthe hazards of the two drugs are very similar. They\\nare generally well tolerated, butnausea and headache\\nare common adverse effects. They are both preg-\\nnancy category B. Although there have been no\\nreports of fetal abnormalities attributable to either\\ndrug, the small number of reported cases makes it\\nimpossible to draw conclusions regarding safety in\\npregnancy. Acyclovir is found in breast milk, but\\nno adverse effects have been reported in the new-\\nborn. Famciclovir is similar in actions and adverse\\neffects.\\nRibavirin is used by aerosol for treatment of hos-\\npitalized infants and young children with severe lower\\nrespiratory tract infections due to respiratory syncytial\\nvirus (RSV). When administered orally, the drug has\\nbeen used in adultys to treat other viral diseases\\nincluding acute and chronic hepatitis, herpes genitalis,\\nmeasles, and Lassa fever, however there is relatively\\nlittle information about these uses. In rare cases, initia-\\ntion of ribavirin therapy has led to deterioration of\\nrespiratory function in infants. Careful monitoring is\\nessential for safe use.\\nThe anti-influenza drugs are generally well toler-\\nated. Amantadine, which is also used for treatment\\nof Parkinsonism, may show more frequent CNS\\neffects, includingsedation and dizziness. Rapid discon-\\ntinuation of amantidine may cause an increase in\\nParkinsonian symptoms in patients using the drug\\nfor that purpose. All are schedule C for pregnancy.\\nIn animal studies, they have caused fetal malforma-\\ntions in doses several times higher than the normal\\nhuman dose. Use caution in breast feeding.\\nInteractions\\nConsult specific references for information on\\ndrug interactions.\\nUse particular caution in HIV-positive patients,\\nsince these patients are commonly on multi-drug regi-\\nmens with a high frequency of interactions.\\nGanciclovir should not be used with other drugs\\nwhich cause hematologic toxicity, and cidofovir\\nshould not be used with other drugs that may cause\\nkidney damage.\\n356 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiviral drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 386, 'page_label': '357'}, page_content='Resources\\nPERIODICALS\\nGray, Mary Ann. ‘‘Antiviral Medications.’’Orthopaedic\\nNursing 15 (November-December 1996): 82.\\nSamuel D. Uretsky, PharmD\\nAnxiety\\nDefinition\\nAnxiety is a multisystem response to a perceived\\nthreat or danger. It reflects a combination of biochem-\\nical changes in the body, the patient’s personal history\\nand memory, and the social situation. As far as we\\nknow, anxiety is a uniquely human experience. Other\\nanimals clearly know fear, but human anxiety involves\\nan ability, to use memory and imagination to move\\nbackward and forward in time, that animals do\\nnot appear to have. The anxiety that occurs in post-\\ntraumatic syndromes indicates that human memory is\\na much more complicated mental function than ani-\\nmal memory. Moreover, a large portion of human\\nanxiety is produced by anticipation of future events.\\nWithout a sense of personal continuity over time,\\npeople would not have the ‘‘raw materials’’ of anxiety.\\nIt is important to distinguish between anxiety as a\\nfeeling or experience, and an anxiety disorder as a\\npsychiatric diagnosis. A person may feel anxious with-\\nout having an anxiety disorder. In addition, a person\\nfacing a clear and present danger or a realistic fear is\\nnot usually considered to be in a state of anxiety. In\\naddition, anxiety frequently occurs as a symptom in\\nother categories of psychiatric disturbance.\\nDescription\\nAlthough anxiety is a commonplace experience\\nthat everyone has from time to time, it is difficult to\\ndescribe concretely because it has so many different\\npotential causes and degrees of intensity. Doctors\\nsometimes categorize anxiety as an emotion or an\\naffect depending on whether it is being described by\\nthe person having it (emotion) or by an outside obser-\\nver (affect). The wordemotion is generally used for the\\nbiochemical changes and feeling state that underlie a\\nperson’s internal sense of anxiety.Affect is used to\\ndescribe the person’s emotional state from an obser-\\nver’s perspective. If a doctor says that a patient has an\\nanxious affect, he or she means that the patient\\nappears nervous or anxious, or responds to others in\\nan anxious way (for example, the individual is shaky,\\ntremulous, etc.).\\nAlthough anxiety is related to fear, it is not the\\nsame thing. Fear is a direct, focused response to a\\nspecific event or object, and the person is consciously\\naware of it. Most people will feel fear if someone\\npoints a loaded gun at them or if they see a tornado\\nforming on the horizon. They also will recognize that\\nthey are afraid. Anxiety, on the other hand, is often\\nunfocused, vague, and hard to pin down to a specific\\ncause. In this form it is called free-floating anxiety.\\nKEY TERMS\\nAffect— An observed emotional expression or\\nresponse. In some situations, anxiety would be\\nconsidered an inappropriate affect.\\nAnxiolytic— A type of medication that helps to\\nrelieve anxiety.\\nAutonomic nervous system (ANS)— The part of the\\nnervous system that supplies nerve endings in the\\nblood vessels, heart, intestines, glands, and smooth\\nmuscles, and governs their involuntary functioning.\\nThe autonomic nervous system is responsible for\\nthe biochemical changes involved in experiences\\nof anxiety.\\nEndocrine gland— A ductless gland, such as the\\npituitary, thyroid, or adrenal gland, that secretes\\nits products directly into the blood or lymph.\\nFree-floating anxiety— Anxiety that lacks a definite\\nfocus or content.\\nHyperarousal— A state or condition of muscular\\nand emotional tension produced by hormones\\nreleased during the fight-or-flight reaction.\\nHypothalamus— A portion of the brain that regu-\\nlates the autonomic nervous system, the release of\\nhormones from the pituitary gland, sleep cycles,\\nand body temperature.\\nLimbic system— A group of structures in the brain\\nthat includes the hypothalamus, amygdala, and\\nhippocampus. The limbic system plays an impor-\\ntant part in regulation of human moods and emo-\\ntions. Many psychiatric disorders are related to\\nmalfunctioning of the limbic system.\\nPhobia— In psychoanalytic theory, a psychological\\ndefense against anxiety in which the patient dis-\\nplaces anxious feelings onto an external object,\\nactivity, or situation.\\nGALE ENCYCLOPEDIA OF MEDICINE 357\\nAnxiety'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 387, 'page_label': '358'}, page_content='Sometimes anxiety being experienced in the present\\nmay stem from an event or person that produced\\npain and fear in the past, but the anxious individual\\nis not consciously aware of the original source of the\\nfeeling. It is anxiety’s aspect of remoteness that makes\\nit hard for people to compare their experiences of it.\\nWhereas most people will be fearful in physically dan-\\ngerous situations, and can agree that fear is an appro-\\npriate response in the presence of danger, anxiety is\\noften triggered by objects or events that are unique\\nand specific to an individual. An individual might be\\nanxious because of a unique meaning or memory\\nbeing stimulated by present circumstances, not\\nbecause of some immediate danger. Another indivi-\\ndual looking at the anxious person from the outside\\nmay be truly puzzled as to the reason for the person’s\\nanxiety.\\nCauses and symptoms\\nAnxiety can have a number of different causes. It is\\na multidimensional response to stimuli in the person’s\\nenvironment, or a response to an internal stimulus (for\\nexample, a hypochondriac’s reaction to a stomach\\nrumbling) resulting from a combination of general\\nbiological and individual psychological processes.\\nPhysical\\nIn some cases, anxiety is produced by physical\\nresponses tostress, or by certain disease processes or\\nmedications.\\nTHE AUTONOMIC NERVOUS SYSTEM (ANS).The ner-\\nvous system of human beings is ‘‘hard-wired’’ to\\nrespond to dangers or threats. These responses are\\nnot subject to conscious control, and are the same in\\nhumans as in lower animals. They represent an evolu-\\ntionary adaptation to the animal predators and other\\ndangers with which all animals, including primitive\\nhumans, had to cope. The most familiar reaction of\\nthis type is the so-called ‘‘fight-or-flight’’ response.\\nThis response is the human organism’s automatic\\n‘‘red alert’’ in a life-threatening situation. It is a state\\nof physiological and emotional hyperarousal marked\\nby high muscle tension and strong feelings of fear or\\nanger. When a person has a fight-or-flight reaction,\\nthe level of stress hormones in their blood rises. They\\nbecome more alert and attentive, their eyes dilate, their\\nheartbeat increases, their breathing rate increases, and\\ntheir digestion slows down, allowing more energy to be\\navailable to the muscles.\\nThis emergency reaction is regulated by a part\\nof the nervous system called the autonomic nervous\\nsystem, or ANS. The ANS is controlled by the\\nhypothalamus, a specialized part of the brainstem\\nthat is among a group of structures called the limbic\\nsystem. The limbic system controls human emotions\\nthrough its connections to glands and muscles; it also\\nconnects to the ANS and ‘‘higher’’ brain centers, such\\nas parts of the cerebral cortex. One problem with this\\narrangement is that the limbic system cannot tell the\\ndifference between a realistic physical threat and an\\nanxiety-producing thought or idea. The hypothalamus\\nmay trigger the release of stress hormones by the\\npituitary gland, even when there is no external and\\nobjective danger. A second problem is caused by the\\nbiochemical side effects of too many ‘‘false alarms’’ in\\nthe ANS. When a person responds to a real danger,\\nhis or her body gets rid of the stress hormones by\\nrunning away or by fighting. In modern life, however,\\npeople often have fight-or-flight reactions in situations\\nin which they can neither run away nor lash out\\nphysically. As a result, their bodies have to absorb all\\nthe biochemical changes of hyperarousal, rather\\nthan release them. These biochemical changes can\\nproduce anxious feelings, as well as muscle tension\\nand other physical symptoms associated with anxiety.\\nThey may even produce permanent changes in the\\nbrain, if the process occurs repeatedly. Moreover,\\nchronic physical disorders, such as coronary artery\\ndisease, may be worsened by anxiety, as chronic\\nhyperarousal puts undue stress on the heart, stomach,\\nand other organs.\\nDISEASES AND DISORDERS. Anxiety can be a symp-\\ntom of certain medical conditions. Some of these dis-\\neases are disorders of the endocrine system, such as\\nCushing’s syndrome (overproduction of cortisol by\\nthe adrenal cortex), and include over- or underactivity\\nof the thyroid gland. Other medical conditions that\\ncan produce anxiety includerespiratory distress syn-\\ndrome, mitral valve prolapse, porphyria, and chest\\npain caused by inadequate blood supply to the heart\\n(angina pectoris).\\nA study released in 2004 showed that people who\\nhad experienced traumatic bone injuries may have\\nunrecognized anxiety in the form ofpost-traumatic\\nstress disorder. This disorder can result from witnes-\\nsing or experiencing an event involving serious injury,\\nor threatened death (or experiencing the death or\\nthreatened death of another.)\\nMEDICATIONS AND SUBSTANCE USE. Numerous\\nmedications may cause anxiety-like symptoms as a\\nside effect. They include birth control pills; some thyr-\\noid or asthma drugs; some psychotropic agents;\\noccasionally, local anesthetics;corticosteroids; antihy-\\npertensive drugs; and nonsteroidal anti-inflammatory\\ndrugs (like flurbiprofen and ibuprofen).\\n358 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 388, 'page_label': '359'}, page_content='Although people do not usually think ofcaffeineas\\na drug, it can cause anxiety-like symptoms when con-\\nsumed in sufficient quantity. Patients who consume caf-\\nfeine rich foods and beverages, such as chocolate, cocoa,\\ncoffee, tea, or carbonated soft drinks (especially cola\\nbeverages), can sometimes lower their anxiety symptoms\\nsimply by reducing their intake of these substances.\\nWithdrawal from certain prescription drugs,\\nprimarily beta blockers and corticosteroids, can\\ncause anxiety. Withdrawal from drugs of abuse,\\nincluding LSD, cocaine, alcohol, and opiates, can\\nalso cause anxiety.\\nLearned associations\\nSome aspects of anxiety appear to be unavoidable\\nbyproducts of the human developmental process.\\nHumans are unique among animals in that they\\nspend an unusually long period of early life in a rela-\\ntively helpless condition, and a sense of helplessness\\ncan lead to anxiety. The extended period of human\\ndependency on adults means that people may remem-\\nber, and learn to anticipate, frightening or upsetting\\nexperiences long before they are capable enough to feel\\na sense of mastery over their environment. In addition,\\nthe fact that anxiety disorders often run in families\\nindicates that children can learn unhealthy attitudes\\nand behaviors from parents, as well as healthy ones.\\nAlso, recurrent disorders in families may indicate that\\nthere is a genetic or inherited component in some\\nanxiety disorders. For example, there has been found\\nto be a higher rate of anxiety disorders (panic) in\\nidentical twins than in fraternal twins.\\nCHILDHOOD DEVELOPMENT AND ANXIETY.\\nResearchers in early childhood development regard\\nanxiety in adult life as a residue of childhood mem-\\nories of dependency. Humans learn during the first\\nyear of life that they are not self-sufficient and that\\ntheir basic survival depends on the care of others. It is\\nthought that this early experience of helplessness\\nunderlies the most common anxieties of adult life,\\nincluding fear of powerlessness and fear of being\\nunloved. Thus, adults can be made anxious by sym-\\nbolic threats to their sense of competence and/or\\nsignificant relationships, even though they are no\\nlonger helpless children.\\nSYMBOLIZATION. The psychoanalytic model gives\\nconsiderable weight to the symbolic aspect of human\\nanxiety; examples include phobic disorders, obsessions,\\ncompulsions, and other forms of anxiety that are highly\\nindividualized. The length of the human maturation\\nprocess allows many opportunities for children and\\nadolescents to connect their experiences with certain\\nobjects or events that can bring back feelings in later\\nlife. For example, a person who was frightened as a child\\nb yat a l lm a nw e a r i n gg l a s s e sm a yf e e lp a n i c k yy e a r s\\nlater by something that reminds him of that person or\\nexperience without consciously knowing why.\\nFreud thought that anxiety results from a per-\\nson’s internal conflicts. According to his theory,\\npeople feel anxious when they feel torn between\\ndesires or urges toward certain actions, on the one\\nhand, and moral restrictions, on the other. In some\\ncases, the person’s anxiety may attach itself to an\\nobject that represents the inner conflict. For exam-\\nple, someone who feels anxious around money may\\nbe pulled between a desire to steal and the belief that\\nstealing is wrong. Money becomes a symbol for the\\ninner conflict between doing what is considered right\\nand doing what one wants.\\nPHOBIAS. Phobias are a special type of anxiety\\nreaction in which the person’s anxiety is concentrated\\non a specific object or situation that the person then\\ntries to avoid. In most cases, the person’s fear is out of\\nall proportion to its ‘‘cause.’’ Prior to theDiagnostic\\nand Statistical Manual of Mental Disorders,4th edition\\n(DSM-IV), these specific phobias were called simple\\nphobias. It is estimated that 10-11% of the population\\nwill develop a phobia in the course of their lives. Some\\nphobias, such asagoraphobia (fear of open spaces),\\nclaustrophobia (fear of small or confined spaces), and\\nsocial phobia, are shared by large numbers of people.\\nOthers are less common or unique to the patient.\\nSocial and environmental stressors\\nAnxiety often has a social dimension because\\nhumans are social creatures. People frequently report\\nfeelings of high anxiety when they anticipate and,\\ntherefore, fear the loss of social approval or love.\\nSocial phobia is a specific anxiety disorder that is\\nmarked by high levels of anxiety or fear of embarrass-\\nment in social situations.\\nAnother social stressor is prejudice. People who\\nbelong to groups that are targets of bias are at higher\\nrisk for developing anxiety disorders. Some experts\\nthink, for example, that the higher rates of phobias\\nand panic disorderamong women reflects their greater\\nsocial and economic vulnerability.\\nSome controversial studies indicate that the\\nincrease in violent or upsetting pictures and stories in\\nnews reports and entertainment may raise the anxiety\\nlevel of many people. Stress and anxiety management\\nprograms often suggest that patients cut down their\\nexposure to upsetting stimuli.\\nGALE ENCYCLOPEDIA OF MEDICINE 359\\nAnxiety'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 389, 'page_label': '360'}, page_content='Anxiety may also be caused by environmental or\\noccupational factors. People who must live or work\\naround sudden or loud noises, bright or flashing lights,\\nchemical vapors, or similar nuisances, which they cannot\\navoid or control, may develop heightened anxiety levels.\\nExistential anxiety\\nAnother factor that shapes human experiences of\\nanxiety is knowledge of personal mortality. Humans are\\nthe only animals that appear to be aware of their limited\\nlife span. Some researchers think that awareness of\\ndeath influences experiences of anxiety from the time\\nthat a person is old enough to understand death.\\nSymptoms of anxiety\\nIn order to understand the diagnosis and treat-\\nment of anxiety, it is helpful to have a basic under-\\nstanding of its symptoms.\\nSOMATIC. The somatic or physical symptoms of\\nanxiety include headaches,dizziness or lightheaded-\\nness, nausea and/or vomiting, diarrhea, tingling, pale\\ncomplexion, sweating,numbness, difficulty in breath-\\ning, and sensations of tightness in the chest, neck,\\nshoulders, or hands. These symptoms are produced\\nby the hormonal, muscular, and cardiovascular reac-\\ntions involved in the fight-or-flight reaction. Children\\nand adolescents withgeneralized anxiety disordershow\\na high percentage of physical complaints.\\nBEHAVIORAL. Behavioral symptoms of anxiety\\ninclude pacing, trembling, general restlessness, hyper-\\nventilation, pressured speech, hand wringing, or finger\\ntapping.\\nCOGNITIVE. Cognitive symptoms of anxiety\\ninclude recurrent or obsessive thoughts, feelings of\\ndoom, morbid or fear-inducing thoughts or ideas,\\nand confusion, or inability to concentrate.\\nEMOTIONAL. Feeling states associated with anxi-\\nety include tension or nervousness, feeling ‘‘hyper’’ or\\n‘‘keyed up,’’ and feelings of unreality, panic, or terror.\\nDEFENSE MECHANISMS. In psychoanalytic theory,\\nthe symptoms of anxiety in humans may arise from or\\nactivate a number of unconscious defense mechan-\\nisms. Because of these defenses, it is possible for a\\nperson to be anxious without being consciously\\naware of it or appearing anxious to others. These\\npsychological defenses include:\\n/C15Repression. The person pushes anxious thoughts or\\nideas out of conscious awareness.\\n/C15Displacement. Anxiety from one source is attached\\nto a different object or event. Phobias are an example\\nof the mechanism of displacement in psychoanalytic\\ntheory.\\n/C15Rationalization. The person justifies the anxious\\nfeelings by saying that any normal person would\\nfeel anxious in their situation.\\n/C15Somatization. The anxiety emerges in the form of\\nphysical complaints and illnesses, such as recurrent\\nheadaches, stomach upsets, or muscle and joint pain.\\n/C15Delusion formation. The person converts anxious\\nfeelings into conspiracy theories or similar ideas\\nwithout reality testing. Delusion formation can\\ninvolve groups as well as individuals.\\nOther theorists attribute some drugaddictionto the\\ndesire to relieve symptoms of anxiety. Most addictions,\\nthey argue, originate in the use of mood-altering sub-\\nstances or behaviors to ‘‘medicate’’ anxious feelings.\\nDiagnosis\\nThe diagnosis of anxiety is difficult and complex\\nbecause of the variety of its causes and the highly\\npersonalized and individualized nature of its symptom\\nformation. There are no medical tests that can be used\\nto diagnose anxiety by itself. When a doctor examines\\nan anxious patient, he or she will first rule out physical\\nconditions and diseases that have anxiety as a symp-\\ntom. Apart from these exclusions, thephysical exam-\\nination is usually inconclusive. Some anxious patients\\nmay have their blood pressure or pulse rate affected by\\nanxiety, or may look pale or perspire heavily, but\\nothers may appear physically completely normal.\\nThe doctor will then take the patient’s medication,\\ndietary, and occupational history to see if they are\\ntaking prescription drugs that might cause anxiety, if\\nthey are abusing alcohol or mood-altering drugs,\\nif they are consuming large amounts of caffeine, or if\\ntheir workplace is noisy or dangerous. In most cases,\\nthe most important source of diagnostic information is\\nthe patient’s psychological and social history. The\\ndoctor may administer a brief psychological test to\\nhelp evaluate the intensity of the patient’s anxiety and\\nsome of its features. Some tests that are often given\\ninclude the Hamilton Anxiety Scale and the Anxiety\\nDisorders Interview Schedule (ADIS). Many doctors\\nwill check a number of chemical factors in the blood,\\nsuch as the level of thyroid hormone and blood sugar.\\nTreatment\\nNot all patients with anxiety require treatment,\\nbut for more severe cases, treatment is recommended.\\nBecause anxiety often has more than one cause and is\\nexperienced in highly individual ways, its treatment\\n360 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 390, 'page_label': '361'}, page_content='usually requires more than one type of therapy. In\\naddition, there is no way to tell in advance how\\npatients will respond to a specific drug or therapy.\\nSometimes the doctor will need to try different medi-\\ncations or methods of treatment before finding the\\nbest combination for the particular patient. It usually\\ntakes about six to eight weeks for the doctor to evalu-\\nate the effectiveness of a treatment regimen.\\nMedications\\nMedications are often prescribed to relieve the\\nphysical and psychological symptoms of anxiety.\\nMost agents work by counteracting the biochemical\\nand muscular changes involved in the fight-or-flight\\nreaction. Some work directly on the chemicals in the\\nbrain that are thought to underlie the anxiety.\\nANXIOLYTICS. Anxiolytics are sometimes called\\ntranquilizers. Most anxiolytic drugs are eitherbenzo-\\ndiazepines or barbiturates. Barbiturates, once com-\\nmonly used, are now rarely used in clinical practice.\\nBarbiturates work by slowing down the transmission\\nof nerve impulses from the brain to other parts\\nof the body. They include such drugs as phenobarbital\\n(Luminal) and pentobarbital (Nembutal). Benzodia-\\nzepines work by relaxing the skeletal muscles and\\ncalming the limbic system. They include such drugs\\nas chlordiazepoxide (Librium) and diazepam\\n(Valium). Both barbiturates and benzodiazepines are\\npotentially habit-forming and may cause withdrawal\\nsymptoms, but benzodiazepines are far less likely than\\nbarbiturates to cause physical dependency. Both drugs\\nalso increase the effects of alcohol and should never be\\ntaken in combination with it.\\nTwo other types of anxiolytic medications\\ninclude meprobamate (Equanil), which is now\\nrarely used, and buspirone (BuSpar), a new type\\nof anxiolytic that appears to work by increasing\\nthe efficiency of the body’s own emotion-regulating\\nbrain chemicals. Buspirone has several advantages\\nover other anxiolytics. It does not cause depen-\\ndence problems, does not interact with alcohol,\\nand does not affect the patient’s ability to drive\\nor operate machinery. However, buspirone is not\\neffective against certain types of anxiety, such as\\npanic disorder.\\nANTIDEPRESSANTS AND BETA-BLOCKERS. For some\\nanxiety disorders, such as obsessive-compulsive disor-\\nder and panic type anxiety, a type of drugs used to treat\\ndepression, selective serotonin reuptake inhibitors\\n(SSRIs; such as Prozac and Paxil), are the treatment\\nof choice. A newer drug that has been shown as effec-\\ntive as Paxil is called escitalopram oxalate (Lexapro).\\nBecause anxiety often coexists with symptoms of\\ndepression, many doctors prescribe antidepressant\\nmedications for anxious/depressed patients. While\\nSSRIs are more common, antidepressants are some-\\ntimes prescribed, including tricyclic antidepressants\\nsuch as imipramine (Tofranil) ormonoamine oxidase\\ninhibitors (MAO inhibitors) such as phenelzine\\n(Nardil).\\nBeta-blockers are medications that work by\\nblocking the body’s reaction to the stress hormones\\nthat are released during the fight-or-flight reaction.\\nThey include drugs like propranolol (Inderal) or ate-\\nnolol (Tenormin). Beta-blockers are sometimes given\\nto patients with post-traumatic anxiety symptoms.\\nMore commonly, the beta-blockers are given to\\npatients with a mild form of social phobic anxiety,\\nsuch as fear of public speaking.\\nPsychotherapy\\nMost patients with anxiety will be given some\\nform of psychotherapy along with medications.\\nMany patients benefit from insight-oriented therapies,\\nwhich are designed to help them uncover unconscious\\nconflicts and defense mechanisms in order to under-\\nstand how their symptoms developed. Patients who\\nare extremely anxious may benefit from supportive\\npsychotherapy, which aims at symptom reduction\\nrather than personality restructuring.\\nTwo newer approaches that work well with\\nanxious patients are cognitive-behavioral therapy\\n(CBT), and relaxation training. In CBT, the patient\\nis taught to identify the thoughts and situations that\\nstimulate his or her anxiety, and to view them more\\nrealistically. In the behavioral part of the program, the\\npatient is exposed to the anxiety-provoking object,\\nsituation, or internal stimulus (like a rapid heart\\nbeat) in gradual stages until he or she is desensitized\\nto it. Relaxation training, which is sometimes called\\nanxiety management training, includes breathing exer-\\ncises and similar techniques intended to help the\\npatient prevent hyperventilation and relieve the mus-\\ncle tension associated with the fight-or-flight reaction.\\nBoth CBT and relaxation training can be used in\\ngroup therapy as well as individual treatment. In addi-\\ntion to CBT, support groups are often helpful to\\nanxious patients, because they provide a social net-\\nwork and lessen the embarrassment that often accom-\\npanies anxiety symptoms.\\nPsychosurgery\\nSurgery on the brain is very rarely recommended\\nfor patients with anxiety; however, some patients with\\nsevere cases of obsessive-compulsive disorder (OCD)\\nGALE ENCYCLOPEDIA OF MEDICINE 361\\nAnxiety'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 391, 'page_label': '362'}, page_content='have been helped by an operation on a part of\\nthe brain that is involved in OCD. Normally, this\\noperation is attempted after all other treatments have\\nfailed.\\nAlternative treatment\\nAlternative treatments for anxiety cover a variety\\nof approaches. Meditation and mindfulness training\\nare thought beneficial to patients with phobias and\\npanic disorder. Hydrotherapy is useful to some\\nanxious patients because it promotes general relaxa-\\ntion of the nervous system.Yoga, aikido, t’ai chi, and\\ndance therapy help patients work with the physical, as\\nwell as the emotional, tensions that either promote\\nanxiety or are created by the anxiety.\\nHomeopathy and traditional Chinese medicine\\napproach anxiety as a symptom of a systemic disorder.\\nHomeopathic practitioners select a remedy based on\\nother associated symptoms and the patient’s general\\nconstitution. Chinese medicine regards anxiety as a\\nblockage of qi, or vital force, inside the patient’s\\nbody that is most likely to affect the lung and large\\nintestine meridian flow. The practitioner of Chinese\\nmedicine choosesacupuncture point locations and/or\\nherbal therapy to move the qi and rebalance the entire\\nsystem in relation to the lung and large intestine.\\nPrognosis\\nThe prognosis for resolution of anxiety depends\\non the specific disorder and a wide variety of factors,\\nincluding the patient’s age, sex, general health, living\\nsituation, belief system, social support network, and\\nresponses to different anxiolytic medications and\\nforms of therapy.\\nPrevention\\nHumans have significant control over thoughts,\\nand, therefore, may learn ways of preventing anxiety\\nby changing irrational ideas and beliefs. Humans\\nalso have some power over anxiety arising from\\nsocial and environmental conditions. Other forms\\nof anxiety, however, are built into the human organ-\\nism and its life cycle, and cannot be prevented or\\neliminated.\\nResources\\nPERIODICALS\\n‘‘Lexapro Found to be as Effective as Paxil.’’Mental Health\\nWeekly Digest(April 12, 2004): 16.\\nMasi, Gabriele, et al. ‘‘Generalized Anxiety Disorder in\\nReferred Children and Adolescents.’’Journal of the\\nAmerican Academy of Child and Adolescent Psychiatry\\n(June 2004): 752–761.\\n‘‘Patients With Traumatic Bone Injuries Have Unrecognized\\nAnxiety.’’Health & Medicine Week(June 28, 2004): 824.\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAnxiety disorders\\nDefinition\\nThe anxiety disorders are a group of mental dis-\\nturbances characterized by anxiety as a central or core\\nsymptom. Although anxiety is a commonplace experi-\\nence, not everyone who experiences it has an anxiety\\ndisorder. Anxiety is associated with a wide range of\\nphysical illnesses, medication side effects, and other\\npsychiatric disorders.\\nThe revisions of the Diagnostic and Statistical\\nManual of Mental Disorders (DSM)that took place\\nafter 1980 brought major changes in the classification\\nof the anxiety disorders. Prior to 1980, psychiatrists\\nclassified patients on the basis of a theory that defined\\nanxiety as the outcome of unconscious conflicts in the\\npatient’s mind. DSM-III (1980), DSM-III-R (1987),\\nand DSM-IV (1994) introduced and refined a new\\nclassification that considered recent discoveries\\nabout the biochemical and post-traumatic origins\\nof some types of anxiety. The present definitions\\nare based on the external and reported symptom\\npatterns of the disorders rather than on theories\\nabout their origins.\\nDescription\\nAnxiety disorders are the most common form of\\nmental disturbance in the United States population. It is\\nestimated that 28 million people suffer from an anxiety\\ndisorder every year. These disorders are a serious pro-\\nblem for the entire society because of their interference\\nwith patients’ work, schooling, and family life. They\\nalso contribute to the high rates of alcohol and sub-\\nstance abuse in the United States. Anxiety disorders\\nare an additional problem for health professionals\\nbecause the physical symptoms of anxiety frequently\\nbring people to primary care doctors or emergency\\nrooms.\\nDSM-IV defines 12 types of anxiety disorders in\\nthe adult population. They can be grouped under\\nseven headings:\\n362 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 392, 'page_label': '363'}, page_content='/C15Panic disorders with or withoutagoraphobia. The\\nchief characteristic ofpanic disorderis the occurrence\\nof panic attacks coupled with fear of their recurrence.\\nIn clinical settings, agoraphobia is usually not a dis-\\norder byitself, but is typically associated with some\\nform of panic disorder. Patients with agoraphobia\\nare afraid of places or situations in which they might\\nhave a panic attack and be unable to leave or to find\\nhelp. About 25% of patients with panic disorder\\ndevelop obsessive-compulsive disorder(OCD).\\n/C15Phobias. These include specific phobias and social\\nphobia. A phobia is an intense irrational fear of a\\nspecific object or situation that compels the patient\\nto avoid it. Some phobias concern activities or\\nobjects that involve some risk (for example, flying\\nor driving) but many are focused on harmless ani-\\nmals or other objects. Social phobia involves a fear of\\nbeing humiliated, judged, or scrutinized. It manifests\\nitself as a fear of performing certain functions in the\\npresence of others, such as public speaking or using\\npublic lavatories.\\n/C15Obsessive-compulsive disorder (OCD). This disorder\\nis marked by unwanted, intrusive, persistent\\nthoughts or repetitive behaviors that reflect the\\npatient’s anxiety or attempts to control it. It affects\\nbetween 2-3% of the population and is much more\\ncommon than was previously thought.\\n/C15Stress disorders. These includepost-traumatic stress\\ndisorder (PTSD) and acute stress disorder. Stress\\ndisorders are symptomatic reactions to traumatic\\nevents in the patient’s life.\\n/C15Generalized anxiety disorder (GAD). GAD is the\\nmost commonly diagnosed anxiety disorder and\\noccurs most frequently in young adults.\\n/C15Anxiety disorders due to known physical causes.\\nThese include general medical conditions or sub-\\nstance abuse.\\n/C15Anxiety disorder not otherwise specified. This last\\ncategory is not a separate type of disorder, but is\\nincluded to cover symptoms that do not meet the\\nspecific DSM-IV criteria for other anxiety disorders.\\nAll DSM-IV anxiety disorder diagnoses include a\\ncriterion of severity. The anxiety must be severe\\nenough to interfere significantly with the patient’s\\noccupational or educational functioning, social activ-\\nities or close relationships, and other customary\\nactivities.\\nThe anxiety disorders vary widely in their fre-\\nquency of occurrence in the general population, age\\nof onset, family patterns, and gender distribution. The\\nstress disorders and anxiety disorders caused by\\nmedical conditions or substance abuse are less age-\\nand gender-specific. Whereas OCD affects males and\\nfemales equally, GAD, panic disorder, and specific\\nphobias all affect women more frequently than men.\\nGAD and panic disorders are more likely to develop in\\nyoung adults, while phobias and OCD can begin in\\nchildhood.\\nAnxiety disorders in children and adolescents\\nDSM-IV defines one anxiety disorder as specific\\nto children, namely, separation anxiety disorder. This\\ndisorder is defined as anxiety regarding separation\\nfrom home or family that is excessive or inappropriate\\nfor the child’s age. In some children, separation anxi-\\nety takes the form of school avoidance.\\nChildren and adolescents can also be diagnosed\\nwith panic disorder, phobias, generalized anxiety dis-\\norder, and the post-traumatic stress syndromes.\\nCauses and symptoms\\nThe causes of anxiety include a variety of indivi-\\ndual and general social factors, and may produce phy-\\nsical, cognitive, emotional, or behavioral symptoms.\\nThe patient’s ethnic or cultural background may also\\ninfluence his or her vulnerability to certain forms of\\nanxiety. Genetic factors that lead to biochemical\\nabnormalities may also play a role.\\nAnxiety in children may be caused by suffering\\nfrom abuse, as well as by the factors that cause anxiety\\nin adults.\\nKEY TERMS\\nAgoraphobia— Abnormal anxiety regarding public\\nplaces or situations from which the patient may\\nwish to flee or in which he or she would be helpless\\nin the event of a panic attack.\\nCompulsion— A repetitive or ritualistic behavior\\nthat a person performs to reduce anxiety.\\nCompulsions often develop as a way of controlling\\nor ‘‘undoing’’ obsessive thoughts.\\nObsession— A repetitive or persistent thought,\\nidea, or impulse that is perceived as inappropriate\\nand distressing.\\nPanic attack— A time-limited period of intense fear\\naccompanied by physical and cognitive symptoms.\\nPanic attacks may be unexpected or triggered by\\nspecific cues.\\nGALE ENCYCLOPEDIA OF MEDICINE 363\\nAnxiety disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 393, 'page_label': '364'}, page_content='Diagnosis\\nThe diagnosis of anxiety disorders is complicated by\\nthe variety of causes of anxiety and the range of disor-\\nders that may include anxiety as a symptom. Many\\npatients who suffer from anxiety disorders have features\\nor symptoms of more than one disorder. Patients whose\\nanxiety is accounted for by another psychic disorder,\\nsuch as schizophrenia or major depression, are not\\ndiagnosed with an anxiety disorder. A doctor examining\\nan anxious patient will usually begin by ruling out dis-\\neases that are known to cause anxiety and then proceed\\nto take the patient’s medication history, in order to\\nexclude side effects of prescription drugs. Most doctors\\nwill ask about caffeine consumption to see if the\\npatient’s dietary habits are a factor. The patient’s work\\nand family situation will also be discussed. Often, pri-\\nmary care physicians will exhaust resources looking for\\nmedical causes for general patient complaints which\\nmay indicate a physical illness. In 2004, the Anxiety\\nDisorders Association of American published guide-\\nl i n e st ob e t t e ra i dp h y s i c i a n si nd i a g n o s i n ga n dm a n a -\\nging generalized anxiety disorder. Laboratory tests for\\nblood sugar and thyroid function are also common.\\nDiagnostic testing for anxiety\\nThere are no laboratory tests that can diagnose\\nanxiety, although the doctor may order some specific\\ntests to rule out disease conditions. Although there is\\nno psychiatric test that can provide definite diagnoses\\nof anxiety disorders, there are several short-answer\\ninterviews or symptom inventories that doctors can\\nuse to evaluate the intensity of a patient’s anxiety\\nand some of its associated features. These measures\\ninclude the Hamilton Anxiety Scale and the Anxiety\\nDisorders Interview Schedule (ADIS).\\nTreatment\\nFor relatively mild anxiety disorders, psychother-\\napy alone may suffice. In general, doctors prefer to use\\na combination of medications and psychotherapy with\\nmore severely anxious patients. Most patients respond\\nbetter to a combination of treatment methods than to\\neither medications or psychotherapy in isolation.\\nBecause of the variety of medications and treatment\\napproaches that are used to treat anxiety disorders, the\\ndoctor cannot predict in advance which combination\\nwill be most helpful to a specific patient. In many cases\\nthe doctor will need to try a new medication or treat-\\nment over a six- to eight-week period in order to assess\\nits effectiveness. Treatment trials do not necessarily\\nmean that the patient cannot be helped or that the\\ndoctor is incompetent.\\nAlthough anxiety disorders are not always easy to\\ndiagnose, there are several reasons why it is important\\nfor patients with severe anxiety symptoms to get help.\\nAnxiety doesn’t always go away by itself; it often\\nprogresses to panic attacks, phobias, and episodes of\\ndepression. Untreated anxiety disorders may even-\\ntually lead to a diagnosis of major depression, or\\ninterfere with the patient’s education or ability to\\nkeep a job. In addition, many anxious patients develop\\naddictions to drugs or alcohol when they try to ‘‘med-\\nicate’’ their symptoms. Moreover, since children learn\\nways of coping with anxiety from their parents, adults\\nwho get help for anxiety disorders are in a better\\nposition to help their families cope with factors that\\nlead to anxiety than those who remain untreated.\\nAlternative treatment\\nAlternative treatments for anxiety cover a variety\\nof approaches. Meditation and mindfulness training\\nare thought beneficial to patients with phobias and\\npanic disorder. Hydrotherapy is useful to some\\nanxious patients because it promotes general relaxa-\\ntion of the nervous system.Yoga, aikido, t’ai chi, and\\ndance therapy help patients work with the physical, as\\nwell as the emotional, tensions that either promote\\nanxiety or are created by the anxiety.\\nHomeopathy and traditional Chinese medicine\\napproach anxiety as a symptom of a systemic disorder.\\nHomeopathic practitioners select a remedy based on\\nother associated symptoms and the patient’s general\\nconstitution. Chinese medicine regards anxiety as a\\nblockage of qi, or vital force, inside the patient’s\\nbody that is most likely to affect the lung and large\\nintestine meridian flow. The practitioner of Chinese\\nmedicine choosesacupuncture point locations and/or\\nherbal therapy to move the qi and rebalance the entire\\nsystem in relation to the lung and large intestine.\\nPrognosis\\nThe prognosis for recovery depends on the speci-\\nfic disorder, the severity of the patient’s symptoms, the\\nspecific causes of the anxiety, and the patient’s degree\\nof control over these causes.\\nPrevention\\nAnxiety is an unavoidable feature of human exis-\\ntence. However, humans have some power over their\\nreactions to anxiety-provoking events and situations.\\nCognitive therapy and meditation or mindfulness\\ntraining appear to be beneficial in helping people\\nlower their long-term anxiety levels.\\n364 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 394, 'page_label': '365'}, page_content='Resources\\nPERIODICALS\\n‘‘Guidelines to Assist Primary Care Physicians in Diagnosing\\nGAD.’’ Psychiatric Times( J u l y1 ,2 0 0 4 ) :1 6 .\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAnxiolytics see Antianxiety drugs\\nAortic aneurysm\\nDefinition\\nAn aneurysm is an abnormal bulging or swelling\\nof a portion of a blood vessel. The aorta, which can\\ndevelop these abnormal bulges, is the large blood\\nvessel that carries oxygen-rich blood away from the\\nheart to the rest of the body.\\nDescription\\nThe aorta carries oxygen-rich blood to the body,\\nand is therefore called an artery. Because the aorta is an\\nartery, its walls are made of up three layers; a thin inner\\nlayer, a muscular middle layer (that gives the vessel its\\nflexibility under pressure from the filling blood), and a\\nfiber-like outer layer that gives the vessel strength to not\\nburst when the heart pumps blood to the body.\\nAortic aneurysms occur when a weakness devel-\\nops in part of the wall of the aorta; three basic\\ntypes are usually found. If all three layers of the\\nvessel are affected and weakness develops along an\\nextended area of the vessel, the weakened area will\\nappear as a large, bulging region of blood vessel;\\nthis is called a fusiform aneurysm. If weakness\\ndevelops between the inner and outer layers of the\\naortic wall, a bulge results as blood from the inter-\\nior of the vessel is pushed around the damaged\\nregion in the wall and collects between these layers.\\nThis is called a dissecting aneurysm because one\\nlayer is ‘‘dissected’’ or separated from another. If\\ndamage occurs to only the middle (muscular) layer\\nof the vessel, a sack-like bulge can form; therefore,\\nthis is a saccular aneurysm.\\nCauses and symptoms\\nAortic aneurysms occur in different portions of\\nthe aorta, which begins in the chest (at the heart) and\\ntravels downward through the abdomen. Aneurysms\\nfound in the region of the aorta within the chest are\\ncalled thoracic aortic aneurysms. Aneurysms that\\noccur in the part of the aorta within the abdomen are\\ncalled abdominal aortic aneurysms.\\nThoracic aortic aneurysms do not usually pro-\\nduce any noticeable symptoms. However, as the\\naneurysm becomes larger, chest, shoulder, neck,\\nlower back, or abdominal pain can result.\\nAbdominal aortic aneurysms occur more often in\\nmen, and these aneurysms can cause pain in the\\nlower back, hips, and abdomen. A painful abdomi-\\nnal aortic aneurysm usually means that the aneurysm\\ncould burst very soon.\\nMost abdominal aortic aneurysms are caused by\\natherosclerosis, a condition caused when fat (mostly\\ncholesterol) carried in the blood builds up in the inner\\nwall of the aorta. As more and more fat attaches to the\\naortic wall, the wall itself becomes abnormally weak\\nand often results in an aneurysm or bulge.\\nAn aneurysm in progress. An aneurysm is an abnormal\\nbulging or swelling of a portion of a blood vessel. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\nSurgery being performed to correct aortic aneurysm.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 365\\nAortic aneurysm'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 395, 'page_label': '366'}, page_content='Aortic aneurysms are also caused by a breakdown\\nof the muscular middle layer of the artery wall, by high\\nblood pressure, by direct injury to the chest, and\\nalthough rare, by bacteria that can infect the aorta.\\nDiagnosis\\nSilent, stable aneurysms are often detected when a\\nperson has an x ray as part of a routine examination or\\nfor other medical reasons. Otherwise, when chest,\\nabdominal, or back pain is severe, aortic aneurysm is\\nsuspected and x-ray (radiographic) studies can con-\\nfirm or rule out that condition.\\nTreatment\\nAortic aneurysms are potentially life-threatening\\nconditions. Small aneurysms should be monitored for\\ntheir rate of growth and large aneurysms require con-\\nsideration for a surgical repair. The most common\\nAortic \\naneurysm\\nAorta\\nSubclavian artery\\nCarotid artery\\nHeart\\nHepatic artery\\nMessentric artery\\nIliac artery\\nRenal artery\\nPulmonary artery\\nLiver\\nKidney\\nAortic aneurysms occur when a weakness develops in a part of the wall of the aorta. The aorta is the large blood vessel that\\ncarries oxygen-rich blood away from the heart to the rest of the body.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nAtherosclerosis— The accumulation of fat on the\\ninner wall of an artery. This fat is largely made up\\nof cholesterol being carried in the blood.\\nDacron— A synthetic polyester fiber used to surgi-\\ncally repair damaged sections of blood vessel walls.366 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic aneurysm'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 396, 'page_label': '367'}, page_content='method of surgical repair is to cut out the bulging\\nsection of artery wall and sew a Dacron fiber material\\ninto its place in the vessel wall.\\nPrognosis\\nOnly 1-2% of people die from having surgical\\nrepair of an aortic aneurysm. However, if the aneurysm\\nis untreated and eventually ruptures, less than half of\\nthe people with ruptured aneurysms will survive. The\\nchallenge for the physician is to decide when or if to do\\nthe preventive surgery.\\nPrevention\\nAneuryms can develop in people with athero-\\nsclerosis. High blood pressure can also lead to this\\ncondition. Although no definite prevention exists, life-\\nstyle and dietary changes that help lower blood pres-\\nsure and the amount of fat in the blood stream may\\nslow the development of aneurysms.\\nResources\\nPERIODICALS\\nvan der Vleit, J. Adam, and Albert P. M. Boll. ‘‘Abdominal\\nAorticAneurysm.’’The Lancet349 (March 22, 1997): 863.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nDominic De Bellis, PhD\\nAortic dissection\\nDefinition\\nAortic dissection is a rare, but potentially fatal,\\ncondition in which blood passes through the inner\\nlining and between the layers of the aorta. The dissect-\\ning aorta usually does not burst, but has an abnormal\\nsecond channel within it.\\nDescription\\nA defect in the inner lining of the aorta allows an\\nopening or tear to develop. The aorta is the main\\nartery of the body and is an area of high blood\\npressure. When a defect develops, blood pressure can\\nforce the tear to open and allow blood to pass through.\\nSince the blood is under pressure, it eventually splits\\n(dissecting) the middle layer of the blood vessel, creat-\\ning a new channel for blood. The length of the channel\\ngrows over time and can result in the closing off of\\nconnection points to other arteries. This can lead to\\nheart attack, strokes, abdominal pain, and nerve\\ndamage. Blood may leak from the dissection and col-\\nlect in the chest an around the heart.\\nA second mechanism leading to aortic dissection\\nis medial hemorrhage. A medial hemorrhage occurs in\\nthe middle layer of the blood vessel and spills through\\nthe inner lining of the aorta wall. This opening then\\nallows blood from the aorta to enter the vessel wall\\nand begin a dissection. Approximately 2,000 cases of\\naortic dissection occur yearly in the United States.\\nCauses and symptoms\\nAortic dissection is caused by a deterioration of\\nthe inner lining of the aorta. There are a number of\\nconditions that predispose a person to develop defects\\nof the inner lining, including high blood pressure,\\nMarfan’s disease,Ehlers-Danlos syndrome, connective\\ntissue diseases, and defects of heart development\\nwhich begin during fetal development. A dissection\\ncan also occur accidentally following insertion of a\\ncatheter, trauma, or surgery. The main symptom is sud-\\nden, intense pain. The pain can be so intense as to\\nimmobilize the patient and cause him to fall to the\\nground. The pain is frequently felt in both the chest\\nand in the back, between the shoulder blades. The extent\\nof the pain isproportional tothe lengthof the dissection.\\nDiagnosis\\nThe pain experienced by the patient is the first\\nsymptom of aortic dissection and is unique. The pain is\\nusually described by the patient as ‘‘tearing, ripping, or\\nstabbing.’’ This is in contrastto the pain associated with\\nheart attacks. The patient frequently has a reduced or\\nabsent pulse in the extremities. A murmur may be heard\\nif the dissection is close to the heart. An enlarged aorta\\nwill usually appear in the chest x rays and ultrasound\\nKEY TERMS\\nDissection— A cut or divide.\\nHemorrhage— A large discharge of blood, profuse\\nbleeding.\\nGALE ENCYCLOPEDIA OF MEDICINE 367\\nAortic dissection'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 397, 'page_label': '368'}, page_content='exams of most patients. The use of a blood dye in angio-\\ngrams and/or CT scans (computed tomography scans)\\nwill aid in diagnosing and visualizing the dissection.\\nTreatment\\nBecause of the potentially fatal nature of aortic\\ndissection, patients are treated immediately. Drugs are\\nadministered to reduce the blood pressure and heart\\nrate. If the dissection is small, drug therapy alone may\\nbe used. In other cases, surgery is performed. In sur-\\ngery, damaged sections of the aorta are removed and a\\nsynthetic graft is often used to reconstruct the\\ndamaged vessel.\\nPrognosis\\nDepending on the nature and extent of the dissec-\\ntion, death can occur within a few hours of the start of\\na dissection. Approximately 75% of untreated people\\ndie within two weeks of the start of a dissection. Of\\nthose who are treated, 40% survive more than 10\\nyears. Patients are usually given long term treatment\\nwith drugs to reduce their blood pressure, even if they\\nhave had surgery.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nAortic incompetence see Aortic valve\\ninsufficiency\\nAortic regurgitation see Aortic valve\\ninsufficiency\\nAortic stenosis see Aortic valve stenosis\\nAortic valve insufficiency\\nDefinition\\nThe aortic valve separates the left ventricle of the\\nheart (the heart’s largest pumping chamber) from the\\naorta, the large artery that carries oxygen-rich blood out\\nof the left ventricle to the rest of the body. In aortic valve\\ninsufficiency, the aortic valve becomes leaky, causing\\nblood to flow backwards into the left ventricle.\\nDescription\\nAortic valve insufficie ncy occurs when this\\nvalve cannot properly close after blood that is leav-\\ning the heart’s left ventricle enters the aorta. With\\neach contraction of the heart more and more blood\\nflows back into the left ventricle, causing the ven-\\ntricle to become overfilled. This larger-than-normal\\namount of blood that collects in the left ventricle\\nputs pressure on the walls of the heart, causing the\\nheart muscle to increase in thickness (hypertrophy).\\nIf this thickening continues, the heart can be per-\\nmanently damaged.\\nAorticvalveinsufficiencyisalsoknowasaorticvalve\\nregurgitation because of the abnormal reversed flow of\\nblood leaking through the poorly functioning valve.\\nCauses and symptoms\\nThe faulty working of the aortic valve can be\\ncaused by a birth defect; by abnormal widening\\nof the aorta (which can be caused by very high blood\\npressure and a variety of other less common condi-\\ntions); by various diseases that cause large amounts of\\nswelling (inflammation) in different areas of the body,\\nlike rheumatic fever; and, although rarely, by the sexu-\\nally transmitted disease,syphilis.\\nNormal\\nblood flow\\nDiseased valve\\nBlood backflow\\nA human heart with a diseased valve that doesn’t open and\\nclose properly, allowing blood to backflow to the heart.\\n(Illustration by Argosy, Inc.)\\n368 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic valve insufficiency'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 398, 'page_label': '369'}, page_content='About 75% of people with aortic valve insuffi-\\nciency are men. Rheumatic (inflammatory) diseases\\nhave been the main cause of this condition in both\\nmen and women.\\nAortic valve insufficiency can remain unnoticed\\nfor 10 to 15 years. In cases of severe insufficiency a\\nperson may notice a variety of symptoms, including an\\nuncomfortable pounding of the heart when lying\\ndown, a very rapid or hard heart beat (palpitations),\\nshortness of breath, chest pain, and if untreated for\\nvery long times, swelling of the liver, ankles, and belly.\\nDiagnosis\\nA poorly functioning or insufficient aortic valve\\ncan be identified when a doctor listens to the heart\\nduring aphysical examination.A chest x ray,a ne l e c -\\ntrocardiogram (ECG, an electrical printout of the heart\\nbeats), as well as an echocardiogram (a test that uses\\nsound waves to create an image of the heart and its\\nvalves), can further evaluate or confirm the condition.\\nTreatment\\nAortic insufficiency is usually corrected by having\\nthe defective valve surgically replaced. However, such\\nan operation is done in severe cases. Before the condi-\\ntion worsens, certain drugs can be used to help manage\\nthis condition.\\nDrugs that remove water from the body, drugs\\nthat lower blood pressure, and drugs that help the\\nheart beat more effectively can each be used for this\\ncondition. Reducing the amount of salt in the diet also\\nhelps lower the amount of fluid the body holds and can\\nhelp the heart to work more efficiently as well.\\nIn cases of a severely malfunctioning valve that\\nhas been untreated for a long time, surgery is the\\ntreatment of choice, especially if the heart is not func-\\ntioning normally. Human heart valves can be replaced\\nwith man-made valves or with valves taken from pig\\nhearts.\\nPrognosis\\nAlthough drug treatment can help put off the need\\nfor surgical valve replacement, it is important to\\nreplace the faulty valve before the heart muscle itself\\nis damaged beyond recovery.\\nResources\\nPERIODICALS\\nCondos Jr., William R. ‘‘Decade-old Heart Drug May Have a\\nNew Use.’’San Diego Business Journal18 (21 July 1997): 24.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nDominic De Bellis, PhD\\nAortic valve stenosis\\nDefinition\\nWhen aortic valve stenosis occurs, the aortic\\nvalve, located between the aorta and left ventricle of\\nthe heart, is narrower than normal size.\\nDescription\\nA normal aortic valve, when open, allows the free\\nflow of blood from the left ventricle to the aorta. When\\nthe valve narrows, as it does with stenosis, blood flow\\nis impeded. Because it is more difficult for blood\\nto flow through the valve, there is increased strain on\\nthe heart. This can cause the left ventricle to enlarge\\nand malfunction, resulting in reduced blood supply to\\nthe heart muscle and body, as well as fluid build up in\\nthe lungs.\\nCause and symptoms\\nAortic valve stenosis can occur because of a birth\\ndefect in the formation of the valve. Calcium deposits\\nmay form on the valve withaging, causing the valve to\\nbecome stiff and narrow. Stenosis can also occur as a\\nresult of rheumatic fever. Mild aortic stenosis may\\nproduce no symptoms at all. The most common symp-\\ntoms, depending on the severity of the disease, are\\nchest pain, blackouts, and difficulty breathing.\\nKEY TERMS\\nRheumatic fever— A disease believed to be caused\\nby a bacterium named group A streptococcus. This\\nbacterium causes a sore ‘‘strep throat’’ and can also\\nresult in fever. Infection by this bacterium can also\\ndamage the heart and its valves, but how this takes\\nplace is not clearly understood.\\nGALE ENCYCLOPEDIA OF MEDICINE 369\\nAortic valve stenosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 399, 'page_label': '370'}, page_content='Diagnosis\\nUsing a stethoscope, a physician may hear a mur-\\nmur and other abnormal heart sounds. An ECG, also\\ncalled an electrocardiogram, records the electrical\\nactivity of the heart. This technique andchest x ray\\ncan show evidence that the left ventricle is enlarged.\\nAn x ray can also reveal calcium deposits on the valve,\\nas well as congestion in the lungs.Echocardiography\\ncan pick up thickening of the valve, heart size, and\\nwhether or not the valve is working properly. This is\\na procedure in which high frequency sound waves\\nharmlessly bounce off organs in the body. Cardiac\\ncatheterization, in which a contrast dye is injected in\\nan artery using a catheter, is the key tool to confirm\\nstenosis and gauge its severity.\\nTreatment\\nTreatment depends on the symptoms and how\\nthe heart’s function is affected. The valve can be\\nopened without surgery by using a balloon catheter,\\nbut this is often a temporary solution. The proce-\\ndure involves inserting a deflated balloon at the end\\nof a catheter through the arteries to the valve.\\nInflating the balloon should widen the valve. In\\nsevere stenosis, heart valve replacement is recom-\\nmended, most often involving open-heart surgery.\\nThe valve can be replaced with a mechanical valve,\\na valve from a pig, or by moving the patient’s other\\nheart valve (pulmonary) into the position of the\\naortic valve and then replacing the pulmonary\\nvalve with an mechanical one. Anyone with aortic\\nstenosis needs to take antibiotics (amoxicillin, ery-\\nthromycin, or clindamycin) before dental and some\\nother surgical procedures, to prevent a heart valve\\ninfection.\\nPrognosis\\nThe prognosis for aortic valve stenosis depends on\\nthe severity of the disease. With surgical repair, the\\ndisease is curable. Patients suffering mild stenosis can\\nusually lead a normal life; a minority of the patients\\nprogress to severe disease. Anyone with moderate\\nstenosis should avoid vigorous physical activity.\\nMost of these patients end up suffering some kind of\\ncoronary heart disease over a 10 year period. Because\\nit is a progressive disease, moderate and severe stenosis\\nwill be treated ultimately with surgery. Severe disease,\\nif left untreated, leads to death within 2 to 4 years once\\nthe symptoms start.\\nPrevention\\nThere is no way to prevent aortic stenosis.\\nResources\\nBOOKS\\nBender, Jeffrey R. ‘‘Heart Valve Disease.’’ InYale University\\nSchool of Medicine Heart Book, edited by Barry L.\\nZaret, et al. New York: HearstBooks, 1992.\\nA close-up view of a calcified stenosis of the aortic valve.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAorta— The largest artery in the body, which\\nmoves blood from the left ventricle to the rest of\\nthe body.\\nECG— Also called an electrocardiogram, it records\\nthe electrical activity of the heart.\\nEchocardiogram— A procedure in which high fre-\\nquency sound waves harmlessly bounce off organs\\nin the body providing an image so one can deter-\\nmine their structure and function.\\nCardiac catheterization— A procedure in which\\ndye is injected through a tube or catheter into an\\nartery to more easily observe valves or blood ves-\\nsels seen on an x ray.\\nLeft ventricle— One of the lower chambers of the\\nheart, which pumps blood to the aorta.\\nMurmur— An abnormal heart sound that can\\nreflect a valve dysfunction.\\nRheumatic fever— A bacterial infection that often\\ncauses heart inflammation.\\nPulmonary valve— The valve located between the\\npulmonary artery and the right ventricle, which\\nbrings blood to the lungs.\\n370 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic valve stenosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 400, 'page_label': '371'}, page_content='OTHER\\n‘‘Aortic Stenosis.’’Ochsner Heart and VascularInstitute.\\n.\\nRahimtoola, Aly. ‘‘Aortic Stenosis.’’Loyola University\\nHealth System Page..\\nJeanine Barone, Physiologist\\nApgar testing\\nDefinition\\nApgar testing is the assessment of the newborn\\nrating color, heart rate, stimulus response, muscle\\ntone, and respirations on a scale of zero to two, for a\\nmaximum possible score of 10. It is performed twice,\\nfirst at one minute and then again at five minutes after\\nbirth.\\nPurpose\\nApgar scoring was originally developed in the\\n1950s by the anesthesiologist Virginia Apgar to assist\\npractitioners attending a birth in deciding whether or\\nnot a newborn was in need of resuscitation. Using a\\nscoring method fosters consistency and standardiza-\\ntion among different practitioners. A February 2001\\nstudy published in the New England Journal of\\nMedicine investigated whether Apgar scoring con-\\ntinues to be relevant. Researchers concluded that\\n‘‘The Apgar scoring system remains as relevant for\\nthe prediction of neonatal survival today as it was\\nalmost 50 years ago.’’\\nDescription\\nThe five areas are scored as follows:\\n/C15Appearance, or color: 2 if the skin is pink all over; 1\\nfor acrocyanosis, where the trunk and head are pink,\\nbut the arms and legs are blue; and 0 if the whole\\nbody is blue. Newborns with naturally darker skin\\ncolor will not be pink. However, pallor is still notice-\\nable, especially in the soles and palms. Color is\\nrelated to the neonate’s ability to oxygenate its\\nbody and extremities, and is dependent on heart\\nrate and respirations. A perfectly healthy newborn\\nwill often receive a score of 9 because of some blue-\\nness in the hands and feet.\\n/C15Pulse (heart rate): 2 for a pulse of 100+ beats per\\nminute (bpm); 1 for a pulse below 100 bpm; 0 for no\\npulse. Heart rate is assessed by listening with a\\nstethoscope to the newborn’s heart and counting\\nthe number of beats.\\n/C15Grimace, or reflex irritability: 2 if the neonate\\ncoughs, sneezes, or vigorously cries in response to a\\nstimulus (such as the use of nasal suctioning, stroking\\nthe back to assess for spinal abnormalities, or having\\nthe foot tapped); 1 for a slight cry or grimace in\\nresponse to the stimulus; 0 for no response.\\n/C15Activity, or muscle tone: 2 for vigorous movements\\nof arms and legs; 1 for some movement; 0 for no\\nmovement, limpness.\\n/C15Respirations: 2 for visible breathing and crying; 1\\nfor slow, weak, irregular breathing; 0 for apnea,\\nor no breathing. A crying newborn can ade-\\nquately oxygenate its lungs. Respirations are best\\nassessed by watching the rise and fall of the neo-\\nnate’s abdomen, as inf ants are diaphragmatic\\nbreathers.\\nThe combined first letters in these five areas spell\\nApgar.\\nPreparation\\nNo preparation is needed to perform the test.\\nHowever, while being born the neonate may receive\\nnasal and oral suctioning to remove mucus and\\namniotic fluid. This may be done when the head of\\nthe newborn is safely out, while the mother rests\\nbefore she continues to push.\\nAftercare\\nSince the test is primarily observational in nature,\\nno aftercare is needed. However, the test may flag the\\nneed for immediate intervention or prolonged\\nobservation.\\nNormal results\\nThe maximum possible score is 10, the minimum\\nis zero. It is rare to receive a true 10, as some acrocya-\\nnosis in the newborn is considered normal, and there-\\nfore not a cause for concern. Most infants score\\nbetween 7 and 10. These infants are expected to have\\nan excellent outcome. A score of 4, 5, or 6 requires\\nimmediate intervention, usually in the form of oxygen\\nand respiratory assistance, or perhaps just suctioning\\nif breathing has been obstructed by mucus. While\\nsuctioning is being done, a source of oxygen may be\\nplaced near, but not over the newborn’s nose and\\nmouth. This form of oxygen is referred to asblow-by.\\nA score in the 4-6 range indicates that the neonate is\\nhaving some difficulty adapting to extrauterine life.\\nGALE ENCYCLOPEDIA OF MEDICINE 371\\nApgar testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 401, 'page_label': '372'}, page_content='This may be due to medications given to the mother\\nduring a difficult labor, or at the very end of labor,\\nwhen these medications have an exaggerated effect on\\nthe neonate.\\nAbnormal results\\nWith a score of 0-3, the newborn is unresponsive,\\napneic, pale, limp and may not have a pulse.\\nInterventions to resuscitate will begin immediately.\\nThe test is repeated at five minutes after birth and\\nboth scores are documented. Should the resuscitation\\neffort continue into the five-minute time period, inter-\\nventions will not stop in order to perform the test. The\\none-minute score indicates the need for intervention at\\nbirth. It addresses survival and prevention of birth-\\nrelated complications resulting from inadequate\\noxygen supply. Poor oxygenation may be due to\\ninadequate neurological and/or chemical control of\\nrespiration. The five-minute score appears to have a\\nmore predictive value for morbidity and normal devel-\\nopment, although research studies on this are incon-\\nsistent in their conclusions.\\nResources\\nBOOKS\\nFeinbloom, Richard I.Pregnancy, Birth and the EarlyMonths.\\nCambridge, MA: Perseus Publishing, 2000.\\nKEY TERMS\\nAcrocyanosis— A slight cyanosis, or blueness of the\\nhands and feet of the neonate is considered normal.\\nThis impaired ability to fully oxygenate the extre-\\nmities is due to an immature circulatory system\\nwhich is still in flux.\\nAmniotic fluid— The protective bag of fluid that\\nsurrounds the fetus while growing in the uterus.\\nNeonate— A term referring to the newborn infant,\\nfrom birth until one month of age.\\nNeonatologist— A physician who specializes in\\nproblems of newborn infants.\\nPallor— Extreme paleness in the color of the skin.\\nD R . V I R G I N I A A P G A R (1909–1974)\\n(AP/Wide World Photos. Reproduced by permission.)\\nAs one of very few female medical students at\\nColumbia University College of Physicians and Surgeons\\nin New York during the early 1930s and one of the first\\nwomen to graduate from its medical school, Apgar knew\\nthat her goal of becoming a surgeon would not be\\nachieved easily in a male-dominated profession.\\nReluctantly, she switched her medical specialty to anes-\\nthesiology, she embraced her new field with typical intel-\\nligence and energy. At this time, anesthesiology was a\\nrelatively new field, having been left by the doctors\\nmostly to the attention of nurses. Apgar realized immedi-\\nately how much in need of scientifically trained personnel\\nwas this significant part of surgery, and she set out to\\nmake anesthesiology a separate medical discipline. By\\n1937, she had become the fiftieth physician to be certified\\nas an anesthesiologist in the United States. The following\\nyear she was appointed director of anesthesiology at the\\nColumbia-Presbyterian Medical Center, becoming the\\nfirst woman to head a department at that institution.\\nAs the attending anesthesiologist who assisted in the\\ndelivery of thousands of babies during these years, Apgar\\nrealized that infants had died from respiratory or circula-\\ntory complications that early treatment could have pre-\\nvented. Apgar decided to bring her considerable research\\nskills to this childbirth dilemma, and her careful study\\nresulted in her publication of the Apgar Score System\\nin 1952.\\n372\\nGALE ENCYCLOPEDIA OF MEDICINE\\nApgar testing'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 402, 'page_label': '373'}, page_content=\"Pillitteri, Adele.Maternal & Child Nursing; Care ofthe\\nChildbearing and Childrearing Family.3rd ed.\\nPhiladelphia: Lippincott, 1999.\\nPERIODICALS\\nCasey, B. M., D. D. McIntire, and K. J. Leveno. ‘‘The\\nContinuing Value of Apgar Score for the Assessment of\\nNewborn Infants’’.NewEngland Journal of Medicine\\n344 (February 15, 2000): 467-71.\\nOTHER\\nApgar, Virginia.A Proposal for a New Method of Evaluation\\nof the Newborn Infant..\\nThe National Childbirth Trust. .\\nPregnancyWeekly.com .\\nEsther Csapo Rastegari, RN, BSN, EdM\\nAphasia\\nDefinition\\nAphasia is condition characterized by either par-\\ntial or total loss of the ability to communicate verbally\\nor using written words. A person with aphasia may\\nhave difficulty speaking, reading, writing, recognizing\\nthe names of objects, or understanding what other\\npeople have said. Aphasia is caused by a brain injury,\\nas may occur during a traumatic accident or when\\nthe brain is deprived of oxygen during astroke.I t\\nmay also be caused by abrain tumor, a disease such\\nas Alzheimer’s, or an infection, like encephalitis.\\nAphasia may be temporary or permanent. Aphasia\\ndoes not include speech impediments caused by loss\\nof muscle control.\\nDescription\\nTo understand and use language effectively, an\\nindividual draws upon word memory–stored informa-\\ntion on what certain words mean, how to put them\\ntogether, and how and when to use them properly. For\\na majority of people, these and other language func-\\ntions are located in the left side (hemisphere) of the\\nbrain. Damage to this side of the brain is most com-\\nmonly linked to the development of aphasia.\\nInterestingly, however, left-handed people appear to\\nhave language areas in both the left and right hemi-\\nspheres of the brain and, as a result, may develop\\naphasia from damage to either side of the brain.\\nStroke is the most common cause of aphasia in the\\nUnited States. Approximately 500,000 individuals suf-\\nfer strokes each year, and 20% of these individuals\\ndevelop some type of aphasia. Other causes of brain\\ndamage include head injuries, brain tumors, and infec-\\ntion. About half of the people who show signs of apha-\\nsia have what is called temporary or transient aphasia\\nand recover completely within a few days. An estimated\\none million Americans suffer from some form of per-\\nmanent aphasia. As yet, no connection between aphasia\\nand age, gender, or race has been found.\\nAphasia is sometimes confused with other condi-\\ntions that affect speech, such as dysarthria and\\napraxia. These condition affect the muscles used in\\nspeaking rather than language function itself.\\nDysarthria is a speech disturbance caused by lack of\\ncontrol over the muscles used in speaking, perhaps due\\nto nerve damage. Speech apraxia is a speech distur-\\nbance in which language comprehension and muscle\\ncontrol are retained, but the memory of how to use the\\nmuscles to form words is not.\\nBroca's area\\nWernicke's area\\nBroca’s aphasia results from damage to the frontal lobe of the\\nlanguage-dominant area of the brain. Individuals with\\nBroca’s aphasia may become mute or may be able to use\\nsingle-word statements or full sentences, although it may\\nrequire great effort. Wernicke’s aphasia is caused by damage\\nto the temporal lobe of the language-dominant area of the\\nbrain. People with this condition speak in long, uninterrupted\\nsentences, but the words used are often unnecessary and\\nunintelligible. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 373\\nAphasia\"),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 403, 'page_label': '374'}, page_content='Causes and symptoms\\nAphasia can develop after an individual sustains\\na brain injury from a stroke, head trauma, tumor, or\\ninfection, such as herpes encephalitis. As a result of\\nthis injury, the pathways for language comprehen-\\nsion or production are disrupted or destroyed. For\\nmost people, this means damage to the left hemi-\\nsphere of the brain. (In 95 to 99% of right-handed\\npeople, language centers are in the left hemisphere,\\nand up to 70% of left-handed people also have left-\\nhemisphere language dominance.) According to the\\ntraditional classification scheme, each form of\\naphasia is caused by damage to a different part of\\nthe left hemisphere of the brain. This damage affects\\none or more of the basic language functions: speech,\\nnaming (the ability to identify an object, color, or\\nother item with an appropriate word or term), repe-\\ntition (the ability to repeat words, phrases, and sen-\\ntences), hearing comprehension (the ability to\\nunderstand spoken language), reading (the ability\\nto understand written words and their meaning),\\nand writing (the ability to communicate and record\\nevents with text).\\nThe traditional classification scheme includes\\neight types of aphasia:\\n/C15Broca’s aphasia, also called motor aphasia, results\\nfrom damage to the front portion or frontal lobe of\\nthe language-dominant area of the brain. Individuals\\nwith Broca’s aphasia may be completely unable to\\nuse speech (mutism) or may be able to use single-\\nword statements or even full sentences, though\\nthese sentences may require a great deal of effort to\\nconstruct. Small words, such as conjunctions (and,\\nor, but) and articles (the, an, a), may be omitted,\\nleading to a ‘‘telegraph’’ quality in their speech.\\nHearing comprehension is usually not affected, so\\nthey are able to understand other people’s speech\\nand conversation and can follow commands. Often,\\nKEY TERMS\\nAnomic aphasia— A condition characterized by\\neither partial or total loss of the ability to recall the\\nnames of persons or things as a result of a stroke,\\nhead injury, brain tumor, or infection.\\nBroca’s aphasia—A condition characterized by either\\npartial or total loss of the ability to express oneself,\\neither through speech or writing. Hearing comprehen-\\nsion is not affected. This condition may result from a\\nstroke, head injury, brain tumor, or infection.\\nComputed tomography (CT)— An imaging techni-\\nque that uses cross-sectional x rays of the body to\\ncreate a three-dimensional image of the body’s inter-\\nnal structures.\\nConduction aphasia— A condition characterized by\\nthe inability to repeat words, sentences, or phrases as\\na result of a stroke, head injury, brain tumor, or\\ninfection.\\nFrontal lobe— The largest, most forward-facing part\\nof each side or hemisphere of the brain.\\nGlobal aphasia— A condition characterized by either\\npartial or total loss of the ability to communicate verb-\\nally or using written words as a result of widespread\\ninjury to the language areasof the brain. This condition\\nmay be caused by a stroke, head injury, brain tumor,\\nor infection. The exact language abilities affected vary\\ndepending on the location and extent of injury.\\nHemisphere— One of the two halves or sides-the left\\nand the right-of the brain.\\nMagnetic resonance imaging (MRI)— An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\nSubcortical aphasia— A condition characterized by\\neither partial or total loss of the ability to commu-\\nnicate verbally or using written words as a result of\\ndamage to non language-dominated areas of the\\nbrain. This condition may be caused by a stroke,\\nhead injury, brain tumor, or infection.\\nTemporal lobe— The part of each side or hemisphere\\nof the brain that is on the side of the head, nearest the\\nears.\\nTranscortical aphasia— A condition characterized\\nby either partial or total loss of the ability to commu-\\nnicate verbally or using written words that does not\\naffect an individual’s ability to repeat words,\\nphrases, and sentences.\\nWernicke’s aphasia— A condition characterized by\\neither partial or total loss of the ability to understand\\nwhat is being said or read. The individual maintains\\nthe ability to speak, but speech may contain unne-\\ncessary or made-up words.\\n374 GALE ENCYCLOPEDIA OF MEDICINE\\nAphasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 404, 'page_label': '375'}, page_content='they may experience weakness on the right side of\\ntheir bodies, which can make it difficult to write.\\nReading ability is impaired, and they may have diffi-\\nculty finding the right word when speaking.\\nIndividuals with Broca’s aphasia may become fru-\\nstrated and depressed because they are aware of their\\nlanguage difficulties.\\n/C15Wernicke’s aphasia is caused by damage to the side\\nportion or temporal lobe of the language-dominant\\narea of the brain. Individuals with Wernicke’s apha-\\nsia speak in long, uninterrupted sentences; however,\\nthe words used are frequently unnecessary or even\\nmade-up. They have a great deal of difficulty under-\\nstanding other people’s speech, sometimes to the\\npoint of being unable to understand spoken language\\nat all. Reading ability is diminished, and although\\nwriting ability is retained, what is written may be\\nabnormal. No physical symptoms, such as the\\nright-sided weakness seen with Broca’s aphasia, are\\ntypically observed. Also, in contrast to Broca’s apha-\\nsia, individuals with Wernicke’s aphasia are not\\naware of their language errors.\\n/C15Global aphasia is caused by widespread damage to\\nthe language areas of the left hemisphere. As a result,\\nall basic language functions are affected, but some\\nareas may be more affected than others. For exam-\\nple, an individual may have difficulty speaking but\\nmay be able to write well. The individual may experi-\\nence weakness and loss of feeling on the right side of\\ntheir body.\\n/C15Conduction aphasia, also called associative aphasia,\\nis rather uncommon. Individuals with conduction\\naphasia are unable to repeat words, sentences, and\\nphrases. Speech is fairly unbroken, although indivi-\\nduals may frequently correct themselves and words\\nmay be skipped or repeated. Although able to under-\\nstand spoken language, it may also be difficult for the\\nindividual with conduction aphasia to find the right\\nword to describe a person or object. The impact of\\nthis condition on reading and writing ability varies.\\nAs with other types of aphasia, right-sided weakness\\nor sensory loss may be present.\\n/C15Anomic or nominal aphasia primarily influences an\\nindividual’s ability to find the right name for a per-\\nson or object. As a result, an object may be described\\nrather than named. Hearing comprehension, repeti-\\ntion, reading, and writing are not affected, other than\\nby this inability to find the right name. Speech is\\nfluent, except for pauses as the individual tries to\\nrecall the right name. Physical symptoms are vari-\\nable, and some individuals have no symptoms of one-\\nsided weakness or sensory loss.\\n/C15Transcortical aphasia is caused by damage to the\\nlanguage areas of the left hemisphere outside the\\nprimary language areas. There are three types of\\naphasia: transcortical motor aphasia, transcortical\\nsensory aphasia, and mixed transcortical aphasia.\\nAll of the transcortical aphasias are distinguished\\nfrom other types by the individual’s ability to repeat\\nwords, phrases, or sentences. Other language func-\\ntions may also be impaired to varying degrees,\\ndepending on the extent and particular location of\\nbrain damage.\\nAs researchers continue to learn more about the\\nbrain’s structure and function, new types of aphasia\\nare being recognized. One newly recognized type of\\naphasia, subcortical aphasia, mimics the symptoms\\nof other traditional types of aphasia but involves\\nlanguage disorders that are not typical. This type of\\naphasia is associated with injuries to areas of the brain\\ntypically not identified with language and language\\nprocessing.\\nDiagnosis\\nFollowing brain injury, an initial bedside assess-\\nment is made to determine whether language func-\\ntion has been affected. If the individual experiences\\ndifficulty communicati ng, attempts are made to\\ndetermine whether this difficulty arises from\\nimpaired language comprehension or an impaired\\nability to speak. A typical examination involves\\nlistening to spontaneous speech and evaluating the\\nindividual’s ability to recognize and name objects,\\ncomprehend what is heard, and repeat sample words\\nand phrases. The individual may also be asked to\\nread text aloud and explain what the passage\\nmeans. In addition, writing ability is evaluated by\\nhaving the individual copy text, transcribe dictated\\ntext, and write something without prompting.\\nA speech pathologist or neuropsychologist may\\nbe asked to conduct more extensive examinations\\nusing in-depth, standardized tests. Commonly used\\ntests include the Boston Diagnostic Aphasia\\nExamination, the Western Aphasia Battery, and pos-\\nsibly, the Porch Index of Speech Ability.\\nThe results of these tests indicate the severity of\\nthe aphasia and may also provide information regard-\\ning the exact location of the brain damage. This more\\nextensive testing is also designed to provide the infor-\\nmation necessary to design an individualized speech\\ntherapy program. Further information about the loca-\\ntion of the damage is gained through the use of ima-\\nging technology, such asmagnetic resonance imaging\\n(MRI) andcomputed tomography scans(CT).\\nGALE ENCYCLOPEDIA OF MEDICINE 375\\nAphasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 405, 'page_label': '376'}, page_content='Treatment\\nInitially, the underlying cause of aphasia must be\\ntreated or stabilized. To regain language function,\\ntherapy must begin as soon as possible following the\\ninjury. Although there are no medical or surgical pro-\\ncedures currently available to treat this condition,\\naphasia resulting from stroke or head injury may\\nimprove through the use of speech therapy. For most\\nindividuals, however, the primary emphasis is placed\\non making the most of retained language abilities and\\nlearning to use other means of communication to\\ncompensate for lost language abilities.\\nSpeech therapy is tailored to meet individual\\nneeds, but activities and tools that are frequently\\nused include the following:\\n/C15Exercise and practice. Weakened muscles are exer-\\ncised by repetitively speaking certain words or mak-\\ning facial expressions, such as smiling.\\n/C15Picture cards. Pictures of everyday objects are used\\nto improve word recall and increase vocabulary. The\\nnames of the objects may also be repetitively spoken\\naloud as part of an exercise and practice routine.\\n/C15Picture boards. Pictures of everyday objects and\\nactivities are placed together, and the individual\\npoints to certain pictures to convey ideas and com-\\nmunicate with others.\\n/C15Workbooks. Reading and writing exercises are used\\nto sharpen word recall and regain reading and writ-\\ning abilities. Hearing comprehension is also redeve-\\nloped using these exercises.\\n/C15Computers. Computer software can be used to\\nimprove speech, reading, recall, and hearing compre-\\nhension by, for example, displaying pictures and\\nhaving the individual find the right word.\\nPrognosis\\nThe degree to which an individual can recover\\nlanguage abilities is highly dependent on how much\\nbrain damage occurred and the location and cause of\\nthe original brain injury. Other factors include the\\nindividual’s age, general health, motivation and will-\\ningness to participate in speech therapy, and whether\\nthe individual is left or right handed. Language areas\\nmay be located in both the left and right hemispheres\\nin left-handed individuals. Left-handed individuals\\nare, therefore, more likely to develop aphasia follow-\\ning brain injury, but because they have two language\\ncenters, may recover more fully because language abil-\\nities can be recovered from either side of the brain. The\\nintensity of therapy and the time between diagnosis\\nand the start of therapy may also affect the eventual\\noutcome.\\nPrevention\\nBecause there is no way of knowing when a\\nstroke, traumatic head injury, or disease will occur,\\nvery little can be done to prevent aphasia. The extent\\nof recovery, however, in some cases, can be affected\\nby an individual’s willingness to cooperate and parti-\\ncipate in speech therapy directly following the injury.\\nResources\\nBOOKS\\nLyon, Jon G., and Marianne B. Simpson.Coping with\\nAphasia. San Diego: Singular Publishing Group, 1998.\\nORGANIZATIONS\\nNational Aphasia Association. 156 5th Ave., Suite 707, New\\nYork, NY 10010. (800) 922-4622. .\\nJulia Barrett\\nApheres see Transfusion\\nAplastic anemia\\nDefinition\\nAplastic anemia is a disorder in which the bone\\nmarrow greatly decreases or stops production of\\nblood cells.\\nDescription\\nThe bone marrow (soft tissue that is located\\nwithin the hard outer shell of the bones) is responsible\\nfor the production of all types of blood cells. The\\nmature forms of these cells include red blood cells,\\nwhich carry oxygen throughout the body; white\\nblood cells, which fight infection; and platelets,\\nwhich are involved in clotting. In aplastic anemia,\\nthe basic structure of the marrow becomes abnormal,\\nand those cells responsible for generating blood cells\\n(hematopoietic cells) are greatly decreased in number\\nor absent. These hematopoietic cells are replaced by\\nlarge quantities of fat.\\nYearly, aplastic anemia strikes about 5-10 people\\nin every one million. Although aplastic anemia strikes\\nboth males and females of all ages, there are two age\\ngroups that have an increased risk. Both young adults\\n376 GALE ENCYCLOPEDIA OF MEDICINE\\nAplastic anemia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 406, 'page_label': '377'}, page_content='(between 15-30 years of age) and the elderly (over the\\nage of 60) have higher rates of aplastic anemia than the\\ngeneral population. While the disorder occurs world-\\nwide, young adults in Asia have a higher disease rate\\nthan do populations in North America and Europe.\\nCauses and symptoms\\nAplastic anemia falls into three basic categories,\\nbased on the origin of its cause: idiopathic, acquired,\\nand hereditary.\\nIn about 60% of cases, aplastic anemia is consid-\\nered to be idiopathic, meaning that the cause of the\\ndisorder is unknown.\\nAcquired aplastic anemia refers to those cases\\nwhere certain environmental factors and physical con-\\nditions seem to be associated with development of the\\ndisease. Acquired aplastic anemia can be associated\\nwith:\\n/C15exposure to drugs, especially anti-cancer agents,\\nantibiotics, anti-inflammatory agents, seizure\\nmedications, and antithyroid drugs (drugs given to\\nstop the functioning of an overactive thyroid)\\n/C15exposure to radiation\\n/C15chemical exposure (especially to the organic solvent\\nbenzene and certain insecticides)\\n/C15infection with certain viruses (especially those caus-\\ning viral hepatitis, as well as Epstein-Barr virus, par-\\nvovirus, and HIV, the virus that can causeAIDS)\\n/C15pregnancy\\n/C15certain other disorders, including a disease called par-\\noxysmal nocturnal hemoglobinuria, an autoimmune\\nreaction called graft-vs-host disease (which occurs\\nwhen the body’s immune system attacks and destroys\\nthe body’s own cells), and certain connective tissue\\ndiseases\\nHereditary aplastic anemia is relatively rare, but\\noccurs in Fanconi’s anemia, Shwachman-Diamond\\nsyndrome, and dyskeratosis congenita.\\nSymptoms of aplastic anemia tend to be those of\\nother anemias,i n c l u d i n gfatigue, weakness, tiny red-\\ndish-purple marks (petechiae) on the skin (evidence of\\npinpoint hemorrhages into the skin), evidence of abnor-\\nmal bruising, and bleeding from the gums, nose, intes-\\ntine, or vagina. The patient is likely to appear pale. If\\nthe anemia progresses, decreased oxygen circulating in\\nthe blood may lead to an increase in heart rate and the\\nsudden appearance of a new heart murmur.\\nDiagnosis\\nThe blood countin aplastic anemia will reveal low\\nnumbers of all formed blood cells. Red blood cells will\\nappear normal in size and coloration, but greatly\\ndecreased in number. Cells called reticulocytes (very\\nyoung red blood cells, which are usually produced in\\ngreat numbers by the bone marrow in order to com-\\npensate for a severe anemia) will be very low in num-\\nber. Platelets and white blood cells will also be\\ndecreased in number, though normal in structure.\\nA sample of the patient’s bone marrow will need\\nto be removed by needle (usually from the hip bone)\\nand examined under a microscope. If aplastic anemia\\nis present, this examination will reveal very few or no\\nhematopoietic cells, and replacement with fat.\\nTreatment\\nThe first step in the treatment of aplastic anemia\\ninvolves discontinuing exposure to any substance that\\nmay be causing the disorder. Although it would seem\\nthat blood transfusions would be helpful in this dis-\\nease, in fact, they only serve as a temporary help, and\\nmay complicate future attempts at bone marrow\\ntransplantation.\\nThe most successful treatment for aplastic anemia\\nis bone marrow transplantation. To do this, a marrow\\ndonor (often a sibling) must be identified. There are a\\nnumber of tissue markers that must be examined to\\ndetermine whether a bone marrow donation is likely to\\nbe compatible with the patient’s immune system.\\nCompatibility is necessary to avoid complications,\\nincluding the destruction of the donor marrow by the\\npatient’s own immune system.\\nKEY TERMS\\nBone marrow— A substance found in the cavities of\\nbones, especially the long bones and the sternum\\n(breast bone). The bone marrow contains those cells\\nthat are responsible for the production of the blood\\ncells (red blood cells, white blood cells, and platelets).\\nBone marrow transplant— A procedure in which a\\nquantity of bone marrow is extracted through a nee-\\ndle from a donor, and then passed into a patient to\\nreplace the patient’s diseased or absent bone marrow.\\nHematopoietic cells— Those cells that are lodged\\nwithin the bone marrow, and which are responsible\\nfor producing the cells which circulate in the blood\\n(red blood cells, white blood cells, and platelets).\\nGALE ENCYCLOPEDIA OF MEDICINE 377\\nAplastic anemia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 407, 'page_label': '378'}, page_content='Patients who cannot undergo bone marrow\\ntransplant can be treated with a number of agents,\\nincluding antithymocyte globulin (ATG), cyclopho-\\nsphamide, steroids, and cyclosporine. These agents\\nall have the potential to cause a number of trouble-\\nsome side-effects and may have a success rate of only\\n60% to 80%. Still, even among those patients who\\nhave a good response, many later suffer a relapse\\n(return) of aplastic anemia. Researchers are trying to\\nidentify the molecules in certain stem cells that the\\nimmune system targets in aplastic anemia.\\nPrognosis\\nAplastic anemia is a life-threatening illness.\\nWithout treatment, it will almost surely progress to\\ndeath. Survival depends on how severe the disease is at\\ndiagnosis, which type of treatment a patient is eligible\\nfor, and what kind of response their body has to that\\ntreatment. The worst-prognosis type of aplastic anemia\\nis one associated with very low numbers of a particular\\ntype of white blood cell. These patients have a high\\nchance of dying from overwhelming bacterial infec-\\ntions. In fact, 80% of all patients treated with blood\\ntransfusions alone die within 18 months to two years.\\nPatients who undergo bone marrow transplantation\\nh a v ea6 0 - 9 0 %c h a n c eo fb e i n gc u r e do ft h ed i s e a s e .\\nResources\\nPERIODICALS\\nMarsh, Judith C.W., Edward C. Gordon-Smith. ‘‘Insights\\nInto the Autoimmune Nature of Aplastic Anemia.’’The\\nLancet (July 24, 2004): 308.\\nORGANIZATIONS\\nAplastic Anemia Foundation of America. P.O. Box 613,\\nAnnapolis, MD 21404. (800) 747-2820. .\\nRosalyn Carson-DeWitt, MD\\nTeresa G. Odle\\nAplastic crisis see Fifth disease\\nAppendectomy\\nDefinition\\nAppendectomy is the surgical removal of the\\nappendix. The appendix is a worm-shaped hollow\\npouch attached to the cecum, the beginning of the\\nlarge intestine.\\nPurpose\\nAppendectomies are performed to treatappendi-\\ncitis, an inflamed and infected appendix.\\nPrecautions\\nSince appendicitis occurs most commonly in\\nmales between the ages of 10-14 and in females\\nbetween the ages of 15-19, appendectomy is most\\noften performed during this time. The diagnosis of\\nappendicitis is most difficult in the very young (less\\nthan two years of age) and in the elderly.\\nDescription\\nAppendectomy is considered a major surgical\\noperation. Therefore, a general surgeon must perform\\nthis operation in the operating room of a hospital. An\\nanesthesiologist is also present during the operation to\\nadminister an anesthetic. Most often the anesthesiol-\\nogist uses a general anesthetic technique whereby\\npatients are put to sleep and made pain free by\\nadministering drugs in the vein or by agents inhaled\\nthrough a tube placed in the windpipe. Occasionally a\\nspinal anesthetic may be used.\\nAfter the patient is anesthetized, the general\\nsurgeon can remove the appendix either by using\\nthe traditional open procedure (in which a 2-3 in\\n[5-7.6 cm] incision is made in the abdomen) or via\\nlaparoscopy (in which four 1 in [2.5cm] incisions are\\nmade in the abdomen).\\nTraditional open appendectomy\\nWhen the surgeon uses the open approach, he\\nmakes an incision in the lower right section of the\\nabdomen. Most incisions are less than 3 in (7.6 cm)\\nin length. The surgeon then identifies all of the organs\\nin the abdomen and examines them for other disease\\nor abnormalities. The appendix is located and brought\\nup into thewounds. The surgeon separates the appen-\\ndix from all the surrounding tissue and its attachment\\nto the cecum and then removes it. The site where the\\nappendix was previously attached, the cecum, is closed\\nand returned to the abdomen. The muscle layers and\\nthen the skin are sewn together.\\nLaproscopic appendectomy\\nWhen the surgeon conducts a laproscopic appen-\\ndectomy, four incisions, each about 1 in (2.5 cm) in\\nlength, are made. One incision is near the umbilicus, or\\nnavel, and one is between the umbilicus and the pubis.\\nTwo other incisions are smaller and are in the right\\n378 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 408, 'page_label': '379'}, page_content='side of the lower abdomen. The surgeon then passes a\\ncamera and special instruments through these inci-\\nsions. With the aid of this equipment, the surgeon\\nvisually examines the abdominal organs and identifies\\nthe appendix. Similarly, the appendix is freed from\\nall of its attachments and removed. The place where\\nthe appendix was formerly attached, the cecum, is\\nstitched. The appendix is removed through one of the\\nincisions. The instruments are removed and then all of\\nthe incisions are closed.\\nStudies and opinions about the relative advan-\\ntages and disadvantages of each method are divided.\\nA skilled surgeon can perform either one of these\\nprocedures in less than one hour. However, lapro-\\nscopic appendectomy (LA) always takes longer than\\ntraditional appendectomy (TA). The increased time\\nrequired to do a LA increases the patient’s exposure\\nto anesthetics, which increases the risk of complica-\\ntions. The increased time requirement also escalates\\nfees charged by the hospital for operating room time\\nand by the anesthesiologist. Since LA also requires\\nspecialized equipment, the fees for its use also\\nincreases the hospital charges. Patients with either\\noperation have similar pain medication needs, begin\\neating diets at comparable times, and stay in the hos-\\npital equivalent amounts of time. LA is of special\\nbenefit in women in whom the diagnosis is difficult\\nand gynecological disease (such asendometriosis,p e l -\\nvic inflammatory disease, ruptured ovarian follicles,\\nruptured ovarian cysts, and tubal pregnancies) may be\\nthe source of pain and not appendicitis. If LA is done\\nin these patients, the pelvic organs can be more thor-\\noughly examined and a definitive diagnosis made prior\\nto removal of the appendix. Most surgeons select\\nLarge intestine\\nAppendix\\nSwollen and\\ninflamed appendix\\nRectum\\nCecum\\nCecum\\nA traditional open appendectomy. After the surgeon makes an incision in the lower right section of the abdomen, he/she pulls\\nthe appendix up, separates it from the surrounding tissue and its attachment to the cecum, and then removes it.(Illustration by\\nElectronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 379\\nAppendectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 409, 'page_label': '380'}, page_content='either TA or LA based on the individual needs and\\ncircumstances of the patient.\\nInsurance plans do cover the costs of appendect-\\nomy. Fees are charged independently by the hospital\\nand the physicians. Hospital charges include fees for\\noperating and recovery room use, diagnostic and\\nlaboratory testing, as well as the normal hospital\\nroom charges. Surgical fees vary from region to region\\nand range between $250-$750. The anesthesiologist’s\\nfee depends upon the health of the patient and the\\nlength of the operation.\\nPreparation\\nOnce the diagnosis of appendicitis is made and the\\ndecision has been made to perform an appendectomy,\\nthe patient undergoes the standard preparation for an\\noperation. This usually takes only one to two hours\\nand includes signing the operative consents, patient\\nidentification procedures, evaluation by the anesthe-\\nsiologist, and moving the patient to the operating suites\\nof the hospital. Occasionally, if the patient has been ill\\nfor a prolonged period of time or has had protracted\\nvomiting, a delay of few to several hours may be neces-\\nsary to give the patient fluids and antibiotics.\\nAftercare\\nRecovery from an appendectomy is similar to\\nother operations. Patients are allowed to eat when\\nthe stomach and intestines begin to function again.\\nUsually the first meal is a clear liquid diet–broth,\\njuice, soda pop, and gelatin. If patients tolerate this\\nmeal, the next meal usually is a regular diet. Patients\\nare asked to walk and resume their normal physical\\nactivities as soon as possible. If TA was done, work\\nand physical education classes may be restricted for a\\nfull three weeks after the operation. If a LA was done,\\nmost patients are able to return to work and strenuous\\nactivity within one to three weeks after the operation.\\nRisks\\nCertain risks are present when any operation\\nrequires a general anesthetic and the abdominal cavity\\nis opened. Pneumonia and collapse of the small air-\\nways (atelectasis) often occurs. Patients who smoke\\nare at a greater risk for developing these complica-\\ntions. Thrombophlebitis, or inflammation of the\\nveins, is rare but can occur if the patient requires\\nprolonged bed rest. Bleeding can occur but rarely is a\\nblood transfusion required. Adhesions (abnormal con-\\nnections to abdominal organs by thin fibrous tissue) is\\na known complication of any abdominal procedure\\nsuch as appendectomy. Theseadhesions can lead to\\nintestinal obstruction which prevents the normal flow\\nof intestinal contents.Hernia is a complication of any\\nincision, However, they are rarely seen after appen-\\ndectomy because the abdominal wall is very strong in\\nthe area of the standard appendectomy incision.\\nThe overall complication rate of appendectomy\\ndepends upon the status of the appendix at the time\\nit is removed. If the appendix has not ruptured the\\ncomplication rate is only about 3%. However, if the\\nappendix has ruptured the complication rate rises to\\nalmost 59%. Wound infections do occur and are more\\ncommon if the appendicitis was severe, far advanced,\\nor ruptured. Anabscess may form in the abdomen as a\\ncomplication of appendicitis.\\nOccasionally, an appendix will rupture prior to its\\nremoval, spilling its contents into the abdominal cavity.\\nPeritonitis or a generalized infection in the abdomen\\nwill occur. Treatment of peritonitis as a result of a\\nruptured appendix includes removal of what remains\\nof the appendix, insertion of drains (rubber tubes that\\npromote the flow of infection inside the abdomen to\\nKEY TERMS\\nAbscess— A collection of pus buried deep in the\\ntissues or in a body cavity.\\nAnesthesiologist— A physician who has special\\ntraining and expertise in the delivery of anesthetics.\\nAnesthetics— Drugs or methodologies used to\\nmake a body area free of sensation or pain.\\nCecum— The beginning of the large intestine and\\nthe place where the appendix attaches to the intest-\\ninal tract.\\nGeneral surgeon— A physician who has special\\ntraining and expertise in performing a variety of\\noperations.\\nPelvic organs— The organs inside of the body that\\nare located within the confines of the pelvis. This\\nincludes the bladder and rectum in both sexes and\\nthe uterus, ovaries, and fallopian tubes in females.\\nPubis— The anterior portion of the pelvis located in\\nthe anterior abdomen.\\nThrombophlebitis— Inflammation of the veins,\\nusually in the legs, which causes swelling and ten-\\nderness in the affected area.\\nUmbilicus— The navel.\\n380 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 410, 'page_label': '381'}, page_content='outside of the body), andantibiotics. Fistula formation\\n(an abnormal connection between the cecum and the\\nskin) rarely occurs. It is only seen if the appendix has a\\nbroad attachment to the cecum and the appendicitis is\\nfar advanced causing destruction of the cecum itself.\\nNormal results\\nMost patients feel better immediately after an\\noperation for appendicitis. Many patients are dis-\\ncharged from the hospital within 24 hours after the\\nappendectomy. Others may require a longer stay–\\nthree to five days. Almost all patients are back to\\ntheir normal activities within three weeks.\\nThe mortality rate of appendicitis has dramatically\\ndecreased over time. Currently, the mortality rate is\\nestimated at one to two per 1,000,000 cases of appendi-\\ncitis. Death is usually due to peritonitis, intra abdom-\\ninal abscess or severe infection following rupture.\\nThe complications associated with undiagnosed,\\nmisdiagnosised, or delayed diagnosis of appendect-\\nomy are very significant. The diagnosis is of appendi-\\ncitis is difficult and never certain. This has led surgeons\\nto perform an appendectomy any time that they feel\\nappendicitis is the diagnosis. Most surgeons feel that\\nin approximately 20% of their patients, a normal\\nappendix will be removed. Rates much lower than\\nthis would seem to indicate that the diagnosis of\\nappendicitis was being frequently missed.\\nResources\\nPERIODICALS\\nMcCall, J. L., K. Sharples, and F. Jafallah. ‘‘Systematic\\nReview of Randomized Controlled Trial Comparing\\nLaproscopic with Open Appendectomy.’’British\\nJournal of Surgery84, no. 8 (August 1997): 1045-1950.\\nOTHER\\n‘‘Appendectomy.’’ ThriveOnline. .\\n‘‘The Appendix.’’ Mayo Clinic Online. .\\nMary Jeanne Krob, MD, FACS\\nAppendicitis\\nDefinition\\nAppendicitis is an inflammation of the appendix,\\nwhich is the worm-shaped pouch attached to the\\ncecum, the beginning of the large intestine. The appen-\\ndix has no known function in the body, but it can\\nbecome diseased. Appendicitis is a medical emergency,\\nand if it is left untreated the appendix may rupture and\\ncause a potentially fatal infection.\\nDescription\\nAppendicitis is the most common abdominal\\nemergency found in children and young adults. One\\nperson in 15 develops appendicitis in his or her life-\\ntime. The incidence is highest among males aged\\n10-14, and among females aged 15-19. More males\\nthan females develop appendicitis between puberty\\nand age 25. It is rare in the elderly and in children\\nunder the age of two.\\nThe hallmark symptom of appendicitis is increas-\\ningly severe abdominalpain. Since many different con-\\nditions can cause abdominal pain, an accurate\\ndiagnosis of appendicitis can be difficult. A timely\\ndiagnosis is important, however, because a delay can\\nresult in perforation, or rupture, of the appendix.\\nWhen this happens, the infected contents of the appen-\\ndix spill into the abdomen, potentially causing a ser-\\nious infection of the abdomen calledperitonitis.\\nAn extracted appendix. (Photograph by Lester V. Bergman,\\nCorbis Images. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 381\\nAppendicitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 411, 'page_label': '382'}, page_content='Other conditions can have similar symptoms,\\nespecially in women. These include pelvic inflamma-\\ntory disease, ruptured ovarian follicles, ruptured ovar-\\nian cysts, tubal pregnancies, and endometriosis.\\nVarious forms of stomach upset and bowel inflamma-\\ntion may also mimic appendicitis.\\nThe treatment for acute (sudden, severe) appendi-\\ncitis is anappendectomy, surgery to remove the appen-\\ndix. Because of the potential for a life-threatening\\nruptured appendix, persons suspected of having\\nappendicitis are often taken to surgery before the\\ndiagnosis is certain.\\nCauses and symptoms\\nThe causes of appendicitis are not well under-\\nstood, but it is believed to occur as a result of one or\\nmore of these factors: an obstruction within the\\nappendix, the development of an ulceration (an abnor-\\nmal change in tissue accompanied by the death of\\ncells) within the appendix, and the invasion of\\nbacteria.\\nUnder these conditions, bacteria may multiply\\nwithin the appendix. The appendix may become swol-\\nlen and filled with pus (a fluid formed in infected tissue,\\nconsisting of while blood cells and cellular debris), and\\nmay eventually rupture. Signs of rupture include the\\npresence of symptoms for more than 24 hours, afever,a\\nhigh white blood cell count, and a fast heart rate. Very\\nrarely, the inflammation and symptoms of appendicitis\\nmay disappear but recur again later.\\nThe distinguishing symptom of appendicitis is\\npain beginning around or above the navel. The pain,\\nwhich may be severe or only achy and uncomfortable,\\neventually moves into the right lower corner of the\\nabdomen. There, it becomes more steady and more\\nsevere, and often increases with movement, coughing,\\nand so forth. The abdomen often becomes rigid and\\ntender to the touch. Increasing rigidity and tenderness\\nindicates an increased likelihood of perforation and\\nperitonitis.\\nLoss of appetite is very common. Nausea and\\nvomiting may occur in about half of the cases and\\noccasionally there may be constipation or diarrhea.\\nThe temperature may be normal or slightly elevated.\\nThe presence of a fever may indicate that the appendix\\nhas ruptured.\\nDiagnosis\\nA careful examination is the best way to diag-\\nnose appendicitis. It is o ften difficult even for\\nexperienced physicians to distinguish the symptoms\\nof appendicitis from those of other abdominal dis-\\norders. Therefore, very specific questioning and a\\nthorough physical examination are crucial. The\\nphysician should ask questions, such as where the\\npain is centered, whether the pain has shifted, and\\nwhere the pain began. The physician should press\\non the abdomen to judge the location of the pain\\nand the degree of tenderness.\\nThe typical sequence of symptoms is present in\\nabout 50% of cases. In the other half of cases, less\\ntypical patterns may be seen, especially in pregnant\\nwomen, older patients, and infants. In pregnant\\nwomen, appendicitis is easily masked by the fre-\\nquent occurrence of mild abdominal pain and\\nnausea from other causes. Elderly patients may\\nfeel less pain and tenderness than most patients,\\nthereby delaying diagnosis and treatment, and\\nleading to rupture in 30% of cases. Infants and\\nyoung children often have diarrhea, vomiting,\\nand fever in addition to pain.\\nWhile laboratory tests cannot establish the diag-\\nnosis, an increased white cell count may point to\\nappendicitis. Urinalysis may help to rule out a urinary\\ntract infection that can mimic appendicitis.\\nPatients whose symptoms andphysical examina-\\ntion are compatible with a diagnosis of appendicitis\\nare usually taken immediately to surgery, where a\\nlaparotomy (surgical exploration of the abdomen) is\\ndone to confirm the diagnosis. In cases with a ques-\\ntionable diagnosis, other tests, such as a computed\\ntomography scan (CT) may be performed to avoid\\nunnecessary surgery. An ultrasound examination of\\nthe abdomen may help to identify an inflamed appen-\\ndix or other condition that would explain the symp-\\ntoms. Abdominal x-rays are not of much value except\\nwhen the appendix has ruptured.\\nKEY TERMS\\nAppendectomy (or appendicectomy)— Surgical\\nremoval of the appendix.\\nAppendix— The worm-shaped pouch attached to\\nthe cecum, the beginning of the large intestine.\\nLaparotomy— Surgical incision into the loin,\\nbetween the ribs and the pelvis, which offers sur-\\ngeons a view inside the abdominal cavity.\\nPeritonitis— Inflammation of the peritoneum,\\nmembranes lining the abdominal pelvic wall.\\n382 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendicitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 412, 'page_label': '383'}, page_content='Often, the diagnosis is not certain until an opera-\\ntion is done. To avoid a ruptured appendix, surgery\\nmay be recommended without delay if the symptoms\\npoint clearly to appendicitis. If the symptoms are not\\nclear, surgery may be postponed until they progress\\nenough to confirm a diagnosis.\\nWhen appendicitis is strongly suspected in a\\nwoman of child-bearing age, a diagnostic laparoscopy\\n(an examination of the interior of the abdomen) is\\nsometimes recommended before the appendectomy in\\norder to be sure that a gynecological problem, such as a\\nruptured ovarian cyst, is not causing the pain. In this\\nprocedure, a lighted viewing tube is inserted into the\\nabdomen through a small incision around the navel.\\nA normal appendix is discovered in about 10-20%\\nof patients who undergo laparotomy, because of sus-\\npected appendicitis. Sometimes the surgeon will\\nremove a normal appendix as a safeguard against\\nappendicitis in the future. During the surgery, another\\nspecific cause for the pain and symptoms of appendi-\\ncitis is found for about 30% of these patients.\\nTreatment\\nThe treatment of appendicitis is an immediate\\nappendectomy. This may be done by opening the abdo-\\nmen in the standard open appendectomy technique, or\\nthrough laparoscopy. In laparoscopy, a smaller incision\\nis made through the navel. Both methods can success-\\nfully accomplish the removal of the appendix. It is not\\ncertain that laparoscopy holds any advantage over open\\nappendectomy. When the appendix has ruptured,\\npatients undergoing a laparoscopic appendectomy may\\nhave to be switched to the open appendectomy proce-\\ndure for the successful management of the rupture. If a\\nruptured appendix is left untreated, the condition is fatal.\\nPrognosis\\nAppendicitis is usually treated successfully by\\nappendectomy. Unless there are complications, the\\npatient should recover without further problems. The\\nmortality rate in cases without complications is less\\nthan 0.1%. When an appendix has ruptured, or a\\nsevere infection has developed, the likelihood is higher\\nfor complications, with slower recovery, or death from\\ndisease. There are higher rates of perforation and\\nmortality among children and the elderly.\\nPrevention\\nAppendicitis is probably not preventable, although\\nthere is some indication that a diet high in green vege-\\ntables and tomatoes may help prevent appendicitis.\\nResources\\nPERIODICALS\\nVan Der Meer, Antonia. ‘‘Do You Know the Warning Signs\\nof Appendicitis?’’Parents Magazine(April 1997): 49.\\nCaroline A. Helwick\\nAppendix removal see Appendectomy\\nAppetite-enhancing drugs\\nDefinition\\nAppetite-enhancing drugs are a diverse group of\\nmedications given to prevent undesired weight loss in\\nthe elderly and in patients suffering from such diseases\\nas AIDS and cancer, which often result in wasting of\\nthe body’s muscle tissue as well as overall weight loss.\\nThe medical term for these drugs is orexigenic, which\\nis derived from the Greek word for ‘‘appetite’’ or\\n‘‘desire.’’ None of the orexigenic drugs in common\\nuse as of 2005, however, were originally formulated\\nor prescribed as appetite stimulants; they range from\\nantihistamines and antiemetics (drugs given to treat or\\nprevent nausea and vomiting) to antidepressants and\\nsynthetic hormones. The medications most often used\\nin the early 2000s include mirtazapine (Remeron), a\\ntetracyclic antidepressant; cyproheptadine (Periactin),\\nan antihistamine; dronabinol (Marinol, THC), an\\nantiemetic; nandrolone, oxymetholone, and oxandro-\\nlone (Anadrol-50, Durabolin, Hybolin, Oxandrin, and\\nother brand nam! es), which are anabolic steroids\\nrelated to the male sex hormone testosterone; and\\nmegestrol acetate (Megace), a synthetic derivative of\\nthe female sex hormone progesterone. In addition to\\nthese prescription drugs, fish oil (eicosapentaenoic acid\\nor EPA) has been recommended as an alternative\\nor complementary treatment for undesired weight loss.\\nPurpose\\nThe reader should note the distinction between\\nappetite and hunger in order to understand why a\\ngroup of such different medications could be used to\\nstimulate the desire for food. Hunger is defined as the\\nbody’s basic physical need for food, whether in terms\\nof calorie content or specific nutrients. Appetite, on\\nthe other hand, refers to the complex desires in\\nhumans for food and drink that are often conditioned\\nor influenced by previous experiences or cultural fac-\\ntors as well as by a person’s present health status.\\nGALE ENCYCLOPEDIA OF MEDICINE 383\\nAppetite-enhancing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 413, 'page_label': '384'}, page_content='People may have an appetite for food in the absence of\\nhunger; conversely, they may be hungry in the physical\\nsense but have little or no appetite. Loss of appetite\\nmay lead to a type ofmalnutrition known as under-\\nnutrition, which is characterized by food intake that\\nfalls below a recommended daily allowance of calories\\nor by the body’s inability to make use of the nutrients\\nin the food that is consumed.\\nPeople may become anorexic (lose their appetite\\nfor food) for a variety of physical, emotional, and\\nsocial reasons:\\n/C15Sensory changes related toaging. Elderly persons\\noften experience a partial loss of the senses of taste\\nand smell, which means that they may not enjoy their\\nmeals as much as they did when they were younger.\\nIn addition, many elderly persons feel full after eat-\\ning relatively small amounts of food. It is thought\\nthat this early feeling of fullness is caused by\\nincreased secretion of gastric hormones known as\\ncholecystokinins.\\n/C15Gastrointestinal disorders. Patients with such disor-\\nders as Crohn’s disease or gastric atonia (abnormally\\nslow emptying of the stomach) may lose their appe-\\ntite for food.\\n/C15Severe diseases that affect the entire body, particu-\\nlarly cancer and AIDS. Patients with these diseases\\nmay develop cachexia, a potentially life-threatening\\ncondition characterized by unintended weight loss\\nand wasting of lean muscle tissue. Cachexia is often\\naccompanied by loss of appetite.\\n/C15Medication side effects. In addition to the drugs used\\nin cancer chemotherapy, such drugs as fluoxetine\\n(Prozac), digoxin (Lanoxin), quinidine (Duraquin,\\nCardioquin), hydralazine (Alazine, Apresoline), cer-\\ntain antibiotics, and vitamin A may cause loss of\\nappetite.\\n/C15Emotional stress. Many people do not feel like eating\\nbefore examinations, job interviews, public speaking,\\nartistic performances, athletic competitions, or simi-\\nlar stressful situations.\\n/C15Depression and othermood disorders. Loss of appe-\\ntite is a common feature of depressive episodes as\\nwell as of major depressive disorder.\\n/C15Cultural factors. The types of food that people find\\nappetizing are influenced by their respective cultures;\\nfor example, Westerners usually find the use of cats\\nand dogs for food in China and Korea upsetting or\\ndisgusting because they regard these animals as\\ndomestic pets rather than dietary items. In addition,\\nmany people lose their appetite when they discover\\ninsects, hair, or other evidence of unsanitary\\nconditions in their food, or when they find that a\\ndish’s ingredients violate the dietary laws of their\\nreligion.\\n/C15Social isolation. Research indicates that human\\nappetite for food is stimulated by eating in the com-\\npany of others. Loss of appetite in many elderly\\npeople is associated with living alone.\\n/C15Previous experience. People who have developed\\nfood poisoning after eating contaminated or impro-\\nperly refrigerated salads, raw clams or oysters, or\\nsimilar foods may develop a long-term distaste for\\nthe food that made them sick.\\nGiven the complexity and variety of factors that\\ninfluence the desire for food in humans, doctors often\\nuse such questionnaires as the Mini Nutritional\\nAssessment or theNutrition Screening Index before\\nprescribing any appetite-enhancing drug. Many\\npatients can be successfully treated by changes in the\\ntype or dosage of medications they are taking for\\nother conditions, or by therapy directed at an under-\\nlying mood disorder or gastrointestinal disease.\\nOthers can be helped by changes in their living situa-\\ntions that allow them to share mealtimes with others\\nor by assistance in preparing foods that they particu-\\nlarly enjoy. The American Academy of Home Care\\nPhysicians (AAHCP) noted in a report published in\\nMay 2004 that the use of orexigenic drugs in the\\nelderly is ‘‘controversial and not generally FDA-\\napproved.’’\\nDescription\\nOrexigenic drugs used in the United States as of\\n2005 are classified as follows:\\n/C15Mirtazapine. Mirtazapine is a tetracyclic antidepres-\\nsant that was approved by the Food and Drug\\nAdministration (FDA) in 1996 for the treatment of\\nmajor depression. Although researchers do not fully\\nunderstand why mirtazapine relieves mood disor-\\nders, they think that it increases the levels of nora-\\ndrenaline and serotonin (chemicals that transmit\\nnerve impulses across the gaps between cells) in the\\nbrain. Mirtazapine is most often prescribed as an\\nappetite stimulant for patients who have been pre-\\nviously diagnosed with depression.\\n/C15Cyproheptadine. Cyproheptadine is an antihista-\\nmine given to relieve the symptoms of colds, nasal\\nallergies, and hayfever. It is also prescribed to relieve\\nthe itching associated with insect bites and stings,\\npoison ivy, and poison oak. It appears to be most\\neffective in treating loss of appetite in children and\\nadults diagnosed with cystic fibrosis.\\n384 GALE ENCYCLOPEDIA OF MEDICINE\\nAppetite-enhancing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 414, 'page_label': '385'}, page_content='/C15Dronabinol. Dronabinol is a synthetic version of tet-\\nrahydrocannabinol (THC), the mood-altering com-\\npound found in marijuana (Cannabis sativa ).\\nMarijuana has been known as an appetite stimulant\\nfor centuries, having been recommended for that pur-\\npose by Ayurvedic practitioners and by the Arabic\\nphysician Al Badri, who first described its orexigenic\\nproperties in 1251. Dronabinol is most commonly\\nused to treat thenausea and vomiting associated with\\nAIDS and with cancer chemotherapy.\\n/C15Anabolic steroids. These drugs are given to older per-\\nsons to increase muscle mass and strength, or to help\\npatients recovering from severe illness or injury to\\nregain lost weight.\\n/C15Megestrol acetate. Megestrol acetate was first\\napproved by the FDA in 1976 for palliative treat-\\nment of metastatic breast orendometrial cancer.I t\\nreceived additional approval in 1993 for the\\ntreatment of anorexia or unexplained weight loss in\\npatients with AIDS. Researchers do not fully under-\\nstand how the drug prevents the growth of cancer\\ncells or how it stimulates appetite.\\n/C15Fish oil. Fish oil is recommended by some practi-\\ntioners as a nutritional supplement for weight loss\\ncaused by cancer or AIDS. It is thought that the\\nomega-3 fatty acids in fish oil help to reduce the\\ninflammation associated with some forms of cancer\\ntherapy as well as helping patients regain lost weight.\\nAlthough some studies question the effectiveness of\\nfish oil as a complementary treatment for undesired\\nweight loss, the National Center for Complementary\\nand Alternative Medicine (NCCAM) is recruiting\\npatients as of April 2005 for a clinical trial of fish\\noil as a dietary supplement to maintain weight in\\npatients with pancreatic cancer. The study will be\\ncompleted in September 2007.\\nRecommended dosage\\nRecommended dosages for orexigenic drugs are\\nas follows:\\n/C15Mirtazapine. Mirtazapine is available in 15- and 30-\\nmg tablets or disintegrating tablets. The usual start-\\ning dose is 15 mg once daily, usually at bedtime. The\\ndrug can be taken with or without food, as the\\npatient prefers.\\n/C15Cyproheptadine. Cyproheptadine is taken by mouth,\\neither as tablets or in liquid form. Adults are usually\\ngiven 4 mg three or four times per day. Children\\nbetween 2 and 6 years of age are usually given 12\\nmg per day in 3–4 divided doses while older children\\nare given 16 mg per day in divided doses.\\n/C15Dronabinol. As an appetite stimulant, dronabinol is\\ngiven as a 2.5-mg capsule twice a day, before lunch\\nand dinner. Some AIDS patients may be given as\\nmuch as 10 mg per day.\\n/C15Anabolic steroids. Oxandrolone and oxymetholone\\nare available in the United States and Canada as\\ntablets, while nandrolone is given by injection. To\\nbuild up body tissues after injury or serious illness,\\nthe adult dosage of oxandrolone is a 2.5-mg tablet\\ntaken by mouth two to four times daily for a period\\nof four weeks, although the total daily dosage may be\\nraised as high as 20 mg. To treat anemia, oxymetho-\\nlone is prescribed according to the patient’s body\\nweight, usually 0.45–2.3 mg per pound of body\\nweight per day in adults and children. Nandrolone\\nis given by injection every three to four weeks for a\\nperiod of 12 weeks. The usual dosage for women and\\ngirls over 14 is 50–100 mg; for men and boys over 14,\\nKEY TERMS\\nAnabolic steroids— A group of drugs derived from\\nthe male sex hormone testosterone, most com-\\nmonly prescribed to promote growth or to help\\nthe body repair tissues weakened by severe illness\\nor aging. Some anabolic steroids are given as appe-\\ntite stimulants.\\nAnorexia— Loss of appetite for food.\\nAntiemetic— A type of medication given to relieve\\nor prevent nausea and vomiting. Some appetite-\\nenhancing drugs are also used as antiemetics.\\nAppetite— The natural instinctive desire for food. It\\nshould be distinguished from hunger, which is the\\nbody’s craving or need for food (either calories or\\nspecific nutrients).\\nCachexia— A condition of general ill health, mal-\\nnutrition, undesired weight loss, and physical\\nweakness, often associated with cancer.\\nOff-label— Referring to the use of a drug for a con-\\ndition or disorder not listed in the official FDA\\nlabeling.\\nOrexigenic— The medical term for drugs that\\nincrease or stimulate the appetite.\\nPalliative— Referring to drugs or other therapies\\nintended to relieve the symptoms of a disease rather\\nthan to cure it.\\nUndernutrition— A type of malnutrition caused by\\ninadequate food intake or the body’s inability to\\nmake use of needed nutrients.\\nGALE ENCYCLOPEDIA OF MEDICINE 385\\nAppetite-enhancing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 415, 'page_label': '386'}, page_content='50–200 mg; for children between the ages of 2 and 13,\\n15–50 mg.\\n/C15Megestrol acetate. Megestrol acetate is given as a\\nliquid suspension in 200-mg doses every 6 hours.\\n/C15Fish oil. A recommended dose for cancer-induced\\nweight loss is 12 g daily, taken by mouth. Fish oil is\\navailable in capsules as well as liquid forms.\\nPrecautions\\nPrecautions for orexigenic drugs are as follows:\\n/C15Mirtazapine. In January 2005 the FDA required\\nlabeling changes for mirtazapine to warn of the\\nincreased risk ofsuicide or self-harm in children or\\nadolescents taking this drug. Mirtazapine should not\\nbe given to children below 18 years of age, and\\nshould be used with caution in pregnant or lactating\\nwomen. Patients taking mirtazapine should not stop\\ntaking it without telling their doctor; it should not be\\ndiscontinued abruptly but taken in progressively\\nsmaller doses over a period of time. This precaution\\nis particularly important in patients who have been\\ntaking the drug for a long time.\\n/C15Cyproheptadine. This drug should not be given to\\npatients who suffer acute asthma attacks or are\\nhypersensitive to antihistamines. It should not be\\ngiven to patients who have taken phenelzine\\n(Nardil), tranylcypromine (Parnate), or other MAO\\ninhibitors within the last two weeks. Cyproheptadine\\nshould be used cautiously in the elderly and in\\npatients withglaucoma, high blood pressure, or car-\\ndiovascular disease.\\n/C15Dronabinol. Patients t aking dronabinol should\\nbe closely supervised by their doctor, as the\\ndrug may cause unpredictable changes in blood\\npressure and heart rate. In addition, it may make\\ncertain mental disorders worse. It also has a high\\npotential for abuse; for this reason, it should be\\nused cautiously in patients with a history of\\nalcohol or drug abuse. Dronabinol should not\\nbe used by nursing mothers because it passes\\ninto breast milk. It should be used with great\\ncaution in children or patients diagnosed with\\nsevere mental illness because of its effects on\\nthe mind. Patients taking dronabinol should\\nnotify their dentist or surgeon before any proce-\\ndure requiring local or general anesthesia ,a st h e\\ndrug may intensify the effects of the anesthetic.\\nIn addition, these patients should not drive a car\\nor operate dangerous machinery until they know\\nwhether dronabinol make s them dizzy, drowsy,\\nor uncoordinated.\\n/C15Anabolic steroids. Patients taking these drugs must\\nfollow a diet high in protein and calories in order to\\nbenefit from the medications, and should be carefully\\nsupervised by their doctor because of possible side\\neffects. Children or teenagers taking these drugs\\nshould have x-rays every six months to make sure\\nthey are growing normally, as anabolic steroids can\\ninterfere with growth. Patients with diabetes should\\ncheck their blood sugar levels with extra care, as\\nthese drugs may cause rapid changes in blood sugar\\nlevels.\\n/C15Megestrol acetate. This drug should not be used by\\npregnant or lactating women, or by women planning\\nto become pregnant. Women of childbearing age\\nwho are taking megestrol should use a reliable form\\nof contraception.\\n/C15Fish oil. Fish oil is not a prescription drug; however,\\npatients who choose to take cod liver oil as their fish\\noil supplement should make sure that they are not\\ngetting more than the safe maximum daily allowan-\\nces ofvitamins A and D. These vitamins tend to build\\nup in the body and may reach toxic levels. The max-\\nimum safe daily level of vitamin A for adults is 3000\\nmicrograms (mcg).\\nSide effects\\nSide effects reported for orexigenic drugs are as\\nfollows:\\n/C15Mirtazapine. Mirtazapine may cause mood changes,\\nincluding worsening depression or thoughts of sui-\\ncide. It may also cause panic attacks, irritability,\\ndifficulty with impulse control, abnormal levels of\\nexcitement, or difficulty sleeping. Physical side\\neffects may include sleepiness,dry mouth, constipa-\\ntion, nausea and vomiting, flu-like symptoms, chest\\npain, and rapid heartbeat. Patients who have any of\\nthese side effects should consult their doctor at once.\\n/C15Cyproheptadine. Side effects include drowsiness,\\nfatigue, dry mouth, skin rash, chest congestion,head-\\nache, diarrhea, nausea and vomiting, difficulty uri-\\nnating, and blurred vision. Patients who experience\\nurinary or vision problems should consult their doc-\\ntor at once.\\n/C15Dronabinol. Dronabinol may cause a variety of\\nchanges in mental status, includingdelirium, confu-\\nsion, hallucinations, memory loss,delusions, euphoria\\n(false sense of well-being), nervousness oranxiety.\\nBecause of the possibility of severe mental side\\neffects, anyone who has taken an overdose of dronabi-\\nnol needs immediate emergency medical help. The\\ndrug may also cause clumsiness or lightheadedness,\\n386 GALE ENCYCLOPEDIA OF MEDICINE\\nAppetite-enhancing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 416, 'page_label': '387'}, page_content='dry mouth, fatigue, headache, sweating, facial flush-\\ning, diarrhea or constipation, muscle pains, high\\nblood pressure, seizures, problems in urinating, red\\neyes, or vomiting.\\n/C15Anabolic steroids. These drugs have been reported to\\ncause a rare form ofliver disease; patients who notice\\nyellowing of the eyes or skin, or black, tarry stools,\\nsore throatand fever, vomiting of blood, or purplish\\nor reddish spots on the body should contact their\\ndoctor at once. Other side effects include feeling\\nchilly, diarrhea,muscle cramps, unusual increase or\\ndecrease in sexual desire,acne or oily skin, bone pain,\\nnausea, or vomiting. Women may notice deepening\\nof the voice, hair loss, unnatural hair growth (hirsut-\\nism), or irregular menstrual periods. Adult males\\nmay notice enlargement of the breasts (gynecomas-\\ntia), frequent need to urinate, or frequent erections.\\nElderly males may have difficulty urinating.\\n/C15Megestrol acetate. Side effects of megestrol acetate\\ninclude swelling of the hands, feet, or lower legs;\\nheadaches; sore breasts; or decreased sexual desire.\\nMen taking this drug may become impotent. Women\\nmay notice vaginal bleeding or abdominal pain.\\n/C15Fish oil. Some people taking fish oil as a dietary\\nsupplement experience an increased tendency to\\nburp followed by a fishy taste in the mouth.\\nInteractions\\nMost orexigenic drugs interact with a number of\\nother medications:\\n/C15Mirtazapine. Mirtazapine may cause high blood\\npressure or abnormally high body temperature if\\ntaken together with MAO inhibitors (furazolidone,\\nphenelzine, procarbazine, selegiline, or tranylcypro-\\nmine). It intensifies the sedating (sleep-inducing)\\neffects of alcohol, benzodiazepine tranquilizers, anti-\\nhistamines, tricyclic antidepressants, narcotic pain\\nrelievers, and some medications given for high\\nblood pressure.\\n/C15Cyproheptadine. Cyproheptadine intensifies and\\nprolongs the effects of other antihistamines, alcohol,\\nbarbiturates, narcotic pain relievers, benzodiazepine\\ntranquilizers, and antidepressant medications.\\n/C15Dronabinol. Dronabinol intensifies the effects of\\nalcohol and other medications that act ascentral\\nnervous system depressants. These groups of drugs\\ninclude barbiturates, benzodiazepine tranquilizers,\\ntetracyclic and tricyclic antidepressants, narcotic\\npain relievers, antiseizure medications, antihista-\\nmines, muscle relaxants, and anesthetics, including\\ndental anesthetics.\\n/C15Anabolic steroids. Anabolic steroids may intensify\\nthe effects of blood thinners (aspirin, coumadin, war-\\nfarin). They may increase the risk of liver damage in\\npatients who are taking phenothiazines, valproic\\nacid, oral contraceptives containing estrogen, gold\\nsalts, methotrexate, carbamazepine, amiodarone,\\nmercaptopurine, phenytoin, plicamycin, disulfiram,\\ndaunorubicin, chloroquine, methyldopa, or\\nnaltrexone.\\n/C15Megestrol acetate. No significant interactions with\\nother drugs have been reported. Patients taking\\nmegestrol acetate should, however, notify their phy-\\nsician of all other drugs and dietary supplements\\n(including herbal preparations) that they use on a\\nregular basis, as dosage adjustments are sometimes\\nneeded.\\n/C15Fish oil. Fish oil has been reported to intensify the\\neffects of such blood-thinning medications as cou-\\nmadin and warfarin. Persons who take these drugs\\nand wish to use fish oil as a dietary supplement\\nshould consult their doctor first.\\nResources\\nBOOKS\\n‘‘Malnutrition.’’ Section 1, Chapter 2 inThe Merck Manual\\nof Diagnosis and Therapy, edited by Mark H. Beers,\\nMD, and Robert Berkow, MD. Whitehouse Station,\\nNJ: Merck Research Laboratories, 2004.\\n‘‘Protein-Energy Undernutrition.’’ Section 8, Chapter 61 in\\nThe Merck Manual of Geriatrics, edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2004.\\nWilson, Billie A., Margaret T. Shannon, and Carolyn L.\\nStang. Nurses Drug Guide 2000, Stamford, CT:\\nAppleton & Lange, 2000.\\nPERIODICALS\\nAnttila, S. A., and E. V. Leinonen. ‘‘A Review of the\\nPharmacological and Clinical Profile of Mirtazapine.’’\\nCNS Drug Reviews7 (Fall 2001): 249–264.\\nGrinspoon, S., and K. Mulligan. ‘‘Weight Loss and Wasting\\nin Patients Infected with Human Immunodeficiency\\nVirus.’’ Clinical Infectious Diseases36 (April 1, 2003)\\n(Supplement 2): S69–S78.\\nHolder, H. ‘‘Nursing Management of Nutrition in Cancer\\nand Palliative Care.’’British Journal of Nursing12 (June\\n12–25, 2003): 667–674.\\nHomnick, D. N., B. D. Homnick, A. J. Reeves, et al.\\n‘‘Cyproheptadine Is an Effective Appetite Stimulant in\\nCystic Fibrosis.’’Pediatric Pulmonology38 (August\\n2004): 129–134.\\nJatoi, A., K. Rowland, C. L. Loprinzi, et al. ‘‘An\\nEicosapentaenoic Acid Supplement Versus Megestrol\\nAcetate Versus Both for Patients with Cancer-\\nAssociated Wasting: A North Central Cancer\\nTreatment Group and National Cancer Institute of\\nGALE ENCYCLOPEDIA OF MEDICINE 387\\nAppetite-enhancing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 417, 'page_label': '388'}, page_content='Canada Collaborative Project.’’Journal of Clinical\\nOncology 22 (June 15, 2004): 2469–2476.\\nJatoi, A., H. E. Windschitl, C. L. Loprinzi, et al.\\n‘‘Dronabinol Versus Megestrol Acetate Versus\\nCombination Therapy for Cancer-Associated\\nAnorexia: A North Central Cancer Treatment Group\\nStudy.’’ Journal of Clinical Oncology20 (January 15,\\n2002): 567–573.\\nMorley, J. E. ‘‘Orexigenic and Anabolic Agents.’’Clinics in\\nGeriatric Medicine18 (November 2002): 853–866.\\nVickers, S. P., and G. A. Kennett. ‘‘Cannabinoids and the\\nRegulation of Ingestive Behaviour.’’Current Drug\\nTargets 6 (March 2005): 215–223.\\nORGANIZATIONS\\nAmerican Academy of Home Care Physicians (AAHCP).\\nP. O. Box 1037, Edgewood, MD 21040-0337. (410) 676-\\n7966. Fax: (410) 676-7980. .\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nNational Cancer Institute (NCI). NCI Public Inquiries\\nOffice, Suite 3036A, 6116 Executive Boulevard,\\nMSC8332, Bethesda, MD 20892-8322. (800)\\n4-CANCER or (800) 332-8615 (TTY).\\n.\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888) INFO-\\nFDA. .\\nOTHER\\nFood and Drug Administration (FDA) MedWatch, January\\n2005. ‘‘Summary View: Safety Labeling Changes\\nApproved by FDA Center for Drug Evaluation and\\nResearch (CDER)—January 2005.’’ .\\nMorley, John E., David R. Thomas, and Margaret-Mary G.\\nWilson. ‘‘Appetite and Orexigenic Drugs.’’ St. Louis,\\nMO: Council for Nutrition, Clinical Strategies in Long-\\nTerm Care, 2001.\\nNational Center for Complementary and Alternative\\nMedicine (NCCAM). ‘‘Clinical Trial: A Fish Oil\\nSupplement to Maintain Body Weight in Pancreatic\\nCancer Patients.’’ .\\nTaler, George, MD, and Christine Ritchie, MD.\\n‘‘Unintended Weight Loss Guidelines.’’. Edgewood,\\nMD: American Academy of Home Care Physicians,\\n2004.\\nRebecca J. Frey, PhD\\nApplied kinesiology see Kinesiology, applied\\nApraxia\\nDefinition\\nApraxia is neurological condition characterized\\nby loss of the ability to perform activities that a person\\nis physically able and willing to do.\\nDescription\\nApraxia is caused by brain damage related to\\nconditions such as head injury, stroke, brain tumor,\\nand Alzheimer’s disease. The damage affects the\\nbrain’s ability to correctly signal instructions to the\\nbody. Forms of apraxia include the inability to say\\nsome words or make gestures.\\nVarious conditions cause apraxia, and it can affect\\npeople of all ages. A baby might be born with the\\ncondition. A car accident or fall that resulted in head\\ntrauma could lead to apraxia.\\nFrom 500,000 to 750,000 people need to be hospi-\\ntalized each year for head injuries according to the\\nAmerican Medical Association (AMA). Men between\\nthe ages of 18 and 24 form the largest group of people\\nwith head injuries. While not all severe injuries result\\nin apraxia, men in that age group are at risk.\\nRisk factors for strokes include high blood pres-\\nsure, diabetes, and heart disease. Cigarettesmoking\\nalso puts a person at risk for a stroke. Brain tumors\\nare abnormal tissue growths in the skull. They may be\\nsecondary tumors caused by the spread of cancer\\nthrough the body.\\nThere is more than one type of apraxia, and a\\nperson may have one or more form of this condition.\\nFurthermore, a milder form of apraxia is called\\ndyspraxia.\\nCauses and symptoms\\nApraxia is caused by conditions that affect parts\\nof the brain that control movements. Apraxia is a\\nresult of damage to the brain’s cerebral hemispheres.\\nThese are the two halves of the cerebrum and are the\\nlocation of brain activities such as voluntary\\nmovements.\\nApraxia causes a lapse in carrying out movements\\nthat a person knows how to do, is physically able to\\nperform, and wants to do. A person may be willing\\nand able to do something like bathe. However, the\\nbrain does not send the signals that allow the person\\nto perform the necessary sequence of activities to do\\nthis correctly.\\n388 GALE ENCYCLOPEDIA OF MEDICINE\\nApraxia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 418, 'page_label': '389'}, page_content='Types of apraxia\\nThere are several types of apraxia, and a patient\\ncould be diagnosed with one or more forms of this\\ncondition. The types of apraxia include:\\n/C15Buccofacial or orofacial apraxia is the inability of a\\nperson to follow through on commands involving\\nface and lip motions. These activities include cough-\\ning, licking the lips, whistling, and winking. Also\\nknown as facial-oral apraxia, it is the most common\\nform of apraxia, according to the National Institute\\nof Neurological Disorders and Stroke (NINDS).\\n/C15Limb-kinetic apraxia is the inability to make precise\\nmovements with an arm or leg.\\n/C15Ideomotor apraxia is the inability to make the proper\\nmovement in response to a command to pantomime\\nan activity like waving.\\n/C15Constructional apraxia is the inability to copy, draw,\\nor build simple figures.\\n/C15Ideational apraxia is the inability to do an activity\\nthat involves performing a series of movements in a\\nsequence. A person with this condition could have\\ntrouble dressing, eating, or bathing. It is also known\\nas conceptual apraxia.\\n/C15Oculomotor apraxia is characterized by difficulty\\nmoving the eyes.\\n/C15Verbal apraxia is a condition involving difficulty\\ncoordinating mouth and speech movements. It is\\nreferred to as apraxia of speech by organizations\\nincluding the American Speech Language Hearing\\nAssociation (ASHA).\\nA baby who does not coo or babble may display a\\nsymptom of apraxia of speech, according to ASHA. A\\nyoung child may only say a few consonant sounds, and\\nan older child may have difficulty imitating speech. An\\nadult also has this difficulty. Other symptoms include\\nsaying the wrong words. A person wants to say\\n‘‘kitchen,’’ but says ‘‘bipem’’ instead, according to an\\nASHA report.\\nA person diagnosed with apraxia may also have\\naphasia, a condition caused by damage to the brain’s\\nspeech centers. This results in difficulty reading, wit-\\nting, speaking, and understanding when others speak.\\nPost-apraxia changes\\nA person with apraxia could experience frustra-\\ntion about difficulty communicating or trouble per-\\nforming tasks. In some cases, the condition could\\naffect the person’s ability to live independently.\\nDiagnosis\\nDiagnosis of apraxia could begin with testing of\\nits underlying cause. Testing for conditions like a\\nstroke or cancer includes the MRI (magnetic resonance\\nimaging) and CT scanning (computer tomography\\nscanning). Abrain biopsyis used to measure changes\\ncaused by Alzheimer’s disease. In all cases, the physi-\\ncian takes a family history. Head trauma that could\\ncause apraxia is first treated in the emergency room.\\nOther diagnostic treatment is related to identify-\\ning the type of apraxia. For example, the physician\\nmay ask the patient to demonstrate how to blow out a\\ncandle, wave, use a fork, or use a toothbrush.\\nAssessment for speech apraxia in children\\nincludes a hearing evaluation to determine if difficulty\\nin speaking is related to ahearing loss. If the condition\\nappears related to apraxia, a speech-language pathol-\\nogist examines muscle development in the jaw, lips,\\nand tongue. The examination of adults and children\\nincludes an evaluation of how words are pronounced\\nindividually and in conversation. The pathologist\\nobserves how the patient breathes when speaking\\nand the ability to perform actions like smiling.\\nThe costs of diagnosis vary because the process\\ncould include examinations and diagnostic screening\\nrelated to the underlying cost of the apraxia. Insurance\\ngenerally covers part of these costs.\\nTreatment\\nThe treatment for apraxia usually involvesreha-\\nbilitation through speech-language therapy, physical\\ntherapy, or occupational therapy. In addition, treat-\\nment such as chemotherapy is administered for the\\ncondition that caused the apraxia.\\nFamily education is an important component of\\napraxia treatment. The rehabilitation process takes\\ntime, and relatives can offer encouragement and support\\nto the patient. They may be asked to help the patient\\nwith in-home exercises. Furthermore, family members\\ns o m e t i m e sn e e dt ot a k eo nt h er o l eo fc a r e g i v e r s .\\nKEY TERMS\\nCT scanning— Computer tomography scanning is a\\ndiagnostic imaging tool that uses x rays sent\\nthrough the body at different angles.\\nMRI— Magnetic resonance imaging is a diagnostic\\nimaging tool that utilizes an electromagnetic field\\nand radio waves.\\nGALE ENCYCLOPEDIA OF MEDICINE 389\\nApraxia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 419, 'page_label': '390'}, page_content='Speech-language therapy\\nSpeech-language therapy focuses on helping the\\npatients learn or regain communication skills.\\nTherapists teach exercises to strengthen facial muscles\\nused in speech. Other exercises concentrate on patients\\nlearning to correctly pronounce sounds and then turn\\nthose sounds into words.\\nIn cases where apraxia limits the ability to speak,\\ntherapists help patients develop alternate means of\\ncommunication. These alternatives range from gestur-\\ning to using a portable computer that writes and pro-\\nduces speech, according to ASHA.\\nOccupational and physical therapies\\nOccupational and physical therapies focus on\\nhelping patients regain the skills impaired by apraxia.\\nPhysical therapy exercises concentrate on areas such\\nas mobility and balance. Occupational therapy helps\\npatients relearn daily living skills.\\nTreatment costs\\nThe costs of therapy vary by the type of treatment,\\nregional location, and where the therapy is offered.\\nFees can range for $40 per hour for in-office speech\\ntherapy for a child to $85 per hour for in-home physi-\\ncal or occupational therapy for a senior citizen. Part of\\ntherapy costs may be covered by insurance.\\nAlternative treatment\\nMost alternative treatments target Alzheimer’s\\ndisease and other conditions that cause apraxia.\\nHerbal remedies thought to help people with\\nAlzheimer’s include ginkgo biloba, a plant extract.\\nHowever, organizations including the Alzheimer’s\\nAssociation caution that the effectiveness and safety\\nof this herbal remedy has not been evaluated by the\\nU.S. Food and Drug Administration. The government\\ndoes not require a review of supplements like ginkgo.\\nFurthermore, there is a risk of internal bleeding if\\nginkgo is taken in combination with aspirin and\\nblood-thinning medications.\\nPrognosis\\nThe prognosis for apraxia depends on factors such\\nas what caused the condition. While Alzheimer’s is a\\ndegenerative condition, a child with verbal apraxia or\\na stroke patient could make progress.\\nIn some cases, treatment helps a person to relearn\\nor acquire skills needed to function. A caregiver may\\nbe required, and some people withdementia require\\nsupervised, longterm care.\\nPrevention\\nThe methods of preventing apraxia focus on pre-\\nventing the underlying causes of this condition. This\\nmay not be entirely possible when there is a family\\nhistory of conditions such as stroke, dementia, and\\ncancer. However, a person at risk by not smoking,\\nexercising, and eating a diet based on the American\\nHeart Association guidelines.\\nHead injury can be prevented by wearing a helmet\\nwhen participating in activities like sports and bicy-\\ncling. Wearing a seatbelt when in a vehicle also helps\\nreduce the risk of head injury.\\nResources\\nBOOKS\\nPERIODICALS\\nORGANIZATIONS\\nAmerican Speech Language Hearing Association. 10801\\nRockville Pike, Rockville, MD 20852-3279. 800-638-\\n8255. .\\nAlzheimer’s Association. 225 North Michigan Avenue,\\nFloor 17, Chicago, IL 60601. 800-272-3900. .\\nNational Institute of Neurological Disorders and Stroke,\\nNIH Neurological Institute. P.O. Box 5801, Bethesda,\\nMD 20824. 800-352-9424..\\nNational Rehabilitation Information Center. 4200 Forbes\\nBoulevard Suite 202, Lanham, MD 20706-4829. 800-\\n346-2742. .\\nNational Stroke Association. 9707 East Easter Lane,\\nEnglewood, CO 80112. 1-800-787-6537. .\\nOTHER\\n‘‘Apraxia in Adults.’’ American Speech Language Hearing\\nAssociation. 2005. [cited March 29, 2005]. .\\n‘‘Childhood Apraxia of Speech.’’ American Speech\\nLanguage Hearing Association. 2005. [cited March 29,\\n2005]. .\\nJacobs, Daniel H., M.D.‘‘Apraxia and Related Syndromes.’’\\ne-medicine. October 27, 2004 [cited March 29, 2005].\\n.\\n‘‘NINDS Apraxia Information Page.’’ National Institute of\\nNeurological Disorders and Stroke February 09, 2005\\n[cited March 29, 2005]. .\\nLiz Swain,\\n390 GALE ENCYCLOPEDIA OF MEDICINE\\nApraxia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 420, 'page_label': '391'}, page_content='APSGN see Acute poststreptococcal\\nglomerulonephritis\\nAPTT see Partial thromboplastin time\\nArachnodactyly see Marfan syndrome\\nArbovirus encephalitis\\nDefinition\\nEncephalitis is a serious inflammation of the\\nbrain, Arbovirus encephalitis is caused by a virus\\nfrom the Arbovirus group. The termarbovirus stands\\nfor Arthro-pod-borne virus because these viruses are\\npassed to humans by members of the phylum\\nArthropoda (which includes insects and spiders).\\nDescription\\nOf the huge number of arboviruses known to\\nexist, about 80 types are responsible for human dis-\\nease. In addition to the virus, there are usually two\\nother types of living creatures involved in the cycle\\nleading to human disease. When large quantities of\\nvirus are present in an arthropod (often a tick or\\nmosquito), the viruses are passed to a bird or small\\nmammal when the arthropod attempts to feed on the\\nblood of that creature. The virus thrives within the\\nnew host, sometimes causing illness, sometimes not.\\nMore ticks or mosquitoes are infected with the virus\\nwhen they feed on the host’s blood. Eventually, a tick\\nor mosquito bites a human, and the virus is passed\\nalong. Just a few types of arboviruses cycle only\\nbetween arthropods and humans, with no intermedi-\\nate stop in a bird or small mammal.\\nBecause the arboviruses require an arthropod to\\npass them along to humans, the most common times\\nof year for these illnesses include summer and fall,\\nwhen mosquitoes and ticks are most prevalent.\\nDamp environments favor large populations of mos-\\nquitoes, and thus also increase the risk of arbovirus\\ninfections.\\nThe major causes of arbovirus encephalitis\\ninclude the members of the viral families alphavirus\\n(causing Eastern equine encephalitis, Western equine\\nencephalitis, and Venezuelan equine encephalitis), fla-\\nvivirus (responsible for St. Louis encephalitis,\\nJapanese encephalitis , Tick-borne encephalitis,\\nMurray Valley encephalitis, Russian spring-summer\\nencephalitis, and Powassan), and bunyavirus (causing\\nCalifornia encephalitis).\\nIn the United States, the most important types of\\narbovirus encephalitis include Western equine ence-\\nphalitis (WEE), Eastern equine encephalitis (EEE),\\nSt. Louis encephalitis, and California encephalitis.\\nWEE strikes young infants in particular, with a 5%\\nchance ofdeath from the illness. Of those who survive,\\nabout 60% suffer permanent brain damage. EEE\\nstrikes infants and children, with a 20% chance of\\ndeath, and a high rate of permanent brain damage\\namong survivors. St. Louis encephalitis tends to strike\\nadults older than 40 years of age, and older patients\\ntend to have higher rates of death and long-term dis-\\nability from the infection. California virus primarily\\nstrikes 5-18 year olds, with a lower degree of perma-\\nnent brain damage.\\nCauses and symptoms\\nEncephalitis occurs because specific arboviruses\\nhave biochemical characteristics which cause them to\\nbe particularly attracted to the cells of the brain and the\\nnerves. The virus causes cell death and inflammation,\\nwith fever and swelling within the brain and nerves. The\\nmembranous coverings of the brain and spinal cord\\n(the meninges) may also become inflamed, a condition\\ncalled meningitis. The brain is swollen, and patches of\\nbleeding occur throughout the brain and spinal cord.\\nPatients with encephalitis suffer from headaches,\\nfever, nausea and vomiting, stiff neck, and sleepiness.\\nAs the disease progresses, more severe symptoms\\ndevelop, including tremors, confusion, seizures,\\ncoma, and paralysis. Loss of function occurs when\\nspecific nerve areas are damaged and/or killed.\\nDiagnosis\\nEarly in the disease, laboratory testing of blood\\nmay reveal the presence of the arbovirus. The usual\\ntechnique used to verify the presence of arbovirus\\ninvolves injecting the patient’s blood into the brain\\nof a newborn mouse, then waiting to see if the mouse\\ndevelops encephalitis. Diagnosis is usually based on\\nthe patient’s symptoms, history of tick or mosquito\\nbites, and knowledge that the patient has been in an\\narea known to harbor the arbovirus.\\nKEY TERMS\\nArthropods— A phylum name referring to certain\\ninsects (including mosquitoes and ticks) and spiders.\\nEncephalitis— A condition in which the brain swells.\\nGALE ENCYCLOPEDIA OF MEDICINE 391\\nArbovirus encephalitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 421, 'page_label': '392'}, page_content='Treatment\\nTreatment is mostly supportive, meaning it is\\ndirected at improving the symptoms, but does not\\nshorten the course of the illness. The main concerns\\nof treatment involve lowering fever, treating pain,\\navoiding dehydration or other chemical imbalances,\\nand decreasing swelling in the brain with steroids.\\nPrognosis\\nPrognosis depends on the particular type of arbo-\\nvirus causing disease, and on the age and prior health\\nstatus of the patient. Death rates range all the way up\\nto 20% for arbovirus encephalitis, and the rates of\\nlifelong effects due to brain damage reach 60% for\\nsome types of arboviruses.\\nPrevention\\nPrevention involves avoiding contact with\\narthropods which carry these viruses. This means\\nwearing appropriate insect repellents, and dressing\\nproperly in areas known to be infested. Insecticides\\nand the avoidance of collections of standing water\\n(which are good breeding ground for arthropods) is\\nalso effective at decreasing arthropod populations.\\nThere are immunizations available against EEE\\nand WEE. These have primarily been used to safe-\\nguard laboratory workers who have regular exposure\\nto these viruses.\\nResources\\nBOOKS\\nStoffman, Phyllis.The Family Guide to Preventing and\\nTreating 100 Infectious Diseases.New York: John\\nWiley & Sons, 1995.\\nRosalyn Carson-DeWitt, MD\\nARDS see Adult respiratory distress\\nsyndrome\\nAromatherapy\\nDefinition\\nAromatherapy is the therapeutic use of plant-\\nderived, aromatic essential oils to promote physical\\nand psychological well-being. It is sometimes used in\\ncombination with massage and other therapeutic tech-\\nniques as part of a holistic treatment approach.\\nPurpose\\nAromatherapy offers diverse physical and psy-\\nchological benefits, depending on the essential oil or\\noil combination and method of application used.\\nSome common medicinal properties of essential oils\\nused in aromatherapy include: analgesic, antimicro-\\nbial, antiseptic, anti-inflammatory, astringent, seda-\\ntive, antispasmodic, expectorant, diuretic, and\\nsedative. Essential oils are used to treat a wide range\\nof symptoms and conditions, including, but not limi-\\nted to, gastrointestinal discomfort, skin conditions,\\nmenstrual pain and irregularities, stress-related condi-\\ntions, mood disorders, circulatory problems, respira-\\ntory infections, andwounds.\\nAromatherapy Oils\\nName Description Conditions treated\\nBay laurel Antiseptic, diuretic,\\nsedative, etc.\\nDigestive problems,\\nbronchitis, common cold,\\ninfluenza, and scabies\\nand lice. CAUTION: Don’t\\nuse if pregnant.\\nClary sage Relaxant, anticonvulsive,\\nantiinflammatory, and\\nantiseptic\\nMenstrual and menopausal\\nsymptoms, burns, eczema,\\nand anxiety. CAUTION:\\nDon’t use if pregnant.\\nEucalyptus Antiseptic, antibacterial,\\nastringent, expectorant,\\nand analgesic\\nBoils, breakouts, cough,\\ncommon cold, influenza,\\nand sinusitis. CAUTION:\\nNot to be taken orally.\\nChamomile Sedative,\\nantiinflammatory,\\nantiseptic, and pain\\nreliever\\nHay fever, burns, acne,\\narthritis, digestive\\nproblems, sunburn, and\\nmenstrual an menopausal\\nsymptoms.\\nLavender Analgesic, antiseptic,\\ncalming/soothing\\nHeadache, depression,\\ninsomnia, stress, sprains,\\nand nausea.\\nPeppermint Pain reliever Indigestion, nausea,\\nheadache, motion\\nsickness, and muscle\\npain.\\nRosemary Antiseptic, stimulant,\\nand diuretic\\nIndigestion, gas, bronchitis,\\nfluid retention, and\\ninfluenza. CAUTION: Don’t\\nuse if pregnant or have\\nepilepsy or hypertension.\\nTarragon Diuretic, laxative,\\nantispasmodic, and\\nstimulant\\nMenstrual and menopausal\\nsymptoms, gas, and\\nindigestion. CAUTION:\\nDon’t use if pregnant.\\nTea tree Antiseptic and soothing Common cold, bronchitis,\\nabscesses, acne, vaginitis,\\nand burns.\\nThyme Stimulant, antiseptic,\\nantibacterial, and\\nantispasmodic\\nCough, laryngitis,\\ndiarrhea, gas, and\\nintestinal worms.\\nCAUTION: Don’t use if\\npregnant or have\\nhypertension.392 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 422, 'page_label': '393'}, page_content='Description\\nOrigins\\nAromatic plants have been employed for their\\nhealing, preservative, and pleasurable qualities\\nthroughout recorded history in both the East and\\nWest. As early as 1500 B.C. the ancient Egyptians\\nused waters, oils, incense, resins, and ointments\\nscented with botanicals for their religious ceremonies.\\nThere is evidence that the Chinese may have\\nrecognized the benefits of herbal and aromatic reme-\\ndies much earlier than this. The oldest known herbal\\ntext, Shen Nung’sPen Ts’ao(c. 2700-3000\\nB.C.) cata-\\nlogs over 200 botanicals. Ayurveda, a practice of tra-\\nditional Indian medicine that dates back over 2,500\\nyears, also used aromatic herbs for treatment.\\nThe Romans were well-known for their use of\\nfragrances. They bathed with botanicals and integrated\\nthem into their state and religious rituals. So did the\\nGreeks, with a growing awareness of the medicinal\\nproperties of herbs, as well. Greek physician and sur-\\ngeon Pedanios Dioscorides, whose renown herbal text\\nDe Materia Medica(60\\nA.D.) was the standard textbook\\nfor Western medicine for 1,500 years, wrote extensively\\non the medicinal value of botanical aromatics. The\\nMedica contained detailed information on over 500\\nplants and 4,740 separate medicinal uses for them,\\nincluding an entire section on aromatics.\\nWritten records of herbal distillation are found as\\nearly as the first century\\nA.D., and around 1000A.D.,\\nthe noted Arab physician and naturalist Avicenna\\ndescribed the distillation of rose oil from rose petals,\\nand the medicinal properties of essential oils in his\\nwritings. However, it wasn’t until 1937, when French\\nchemist Rene ´ -Maurice Gattefosse ´ published\\nAromatherapie: Les Huiles essentielles, hormones ve´ge´\\ntales, that aromatherapie, or aromatherapy, was\\nintroduced in Europe as a medical discipline.\\nGattefosse´ , who was employed by a French perfu-\\nmeur, discovered the healing properties of lavender\\noil quite by accident when he suffered a severe burn\\nwhile working and used the closest available liquid,\\nlavender oil, to soak it in.\\nIn the late 20th century, French physician Jean\\nValnet used botanical aromatics as a front line\\nAromatic substances\\nNasal cavity\\nOlfactory bulb\\nOlfactory\\nneurons\\nLimbic system of the brain\\nAs a holistic therapy, aromatherapy is believed to benefit both the mind and body. Here, the aromatic substances from a flower\\nstimulates the olfactory bulb and neurons. The desired emotional response (such as relaxation) is activated from the limbic\\nsystem of the brain. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 393\\nAromatherapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 423, 'page_label': '394'}, page_content='treatment for wounded soldiers in World War II. He\\nwrote about his use of essential oils and their healing\\nand antiseptic properties, in his 1964 book\\nAromatherapie, traitement des maladies par les essences\\ndes plantes, which popularized the use of essential oils\\nfor medical and psychiatric treatment throughout\\nFrance. Later, French biochemist Mauguerite Maury\\npopularized the cosmetic benefits of essential oils, and\\nin 1977 Robert Tisserand wrote the first English lan-\\nguage book on the subject,The Art of Aromatherapy,\\nwhich introduced massage as an adjunct treatment to\\naromatherapy and sparked its popularity in the\\nUnited Kingdom.\\nIn aromatherapy, essential oils are carefully\\nselected for their medicinal properties. As essential oils\\nare absorbed into the bloodstream through application\\nto the skin or inhalation, their active components trig-\\nger certain pharmalogical effects (e.g., pain relief ).\\nIn addition to physical benefits, aromatherapy\\nhas strong psychological benefits. The volatility of an\\noil, or the speed at which it evaporates in open air, is\\nthought to be linked to the specific psychological effect\\nof an oil. As a rule of thumb, oils that evaporate\\nquickly are considered emotionally uplifting, while\\nslowly-evaporating oils are thought to have a calming\\neffect.\\nEssential oils commonly used in aromatherapy\\ntreatment include:\\n/C15Roman chamomile (Chamaemelum nobilis). An anti-\\ninflammatory and analgesic. Useful in treatingotitis\\nmedia (earache), skin conditions, menstrual pains,\\nand depression.\\n/C15Clary sage (Salvia sclarea). This natural astringent is\\nnot only used to treat oily hair and skin, but is also\\nsaid to be useful in regulating the menstrual cycle,\\nimproving mood, and controlling high blood pres-\\nsure. Clary sage should not be used by pregnant\\nwomen.\\n/C15Lavender (Lavandula officinalis). A popular aro-\\nmatherapy oil which mixes well with most essential\\noils, lavender has a wide range of medicinal and\\ncosmetic applications, including treatment of insect\\nbites, burns, respiratory infections, intestinal discom-\\nfort, nausea, migraine, insomnia, depression, and\\nstress.\\n/C15Myrtle (Myrtus communis). Myrtle is a fungicide,\\ndisinfectant, and antibacterial. It is often used in\\nsteam aromatherapy treatments to alleviate the\\nsymptoms ofwhooping cough, bronchitis, and other\\nrespiratory infections.\\n/C15Neroli (bitter orange), (Citrus aurantium). Citrus oil\\nextracted from bitter orange flower and peel and\\nused to treatsore throat, insomnia, and stress and\\nanxiety-related conditions.\\n/C15Sweet orange (Citrus sinensis). An essential oil used\\nto treat stomach complaints and known for its\\nreported ability to lift the mood while relieving stress.\\n/C15Peppermint (Mentha piperita). Relaxes and soothes\\nthe stomach muscles and gastrointestinal tract.\\nPeppermint’s actions as an anti-inflammatory, anti-\\nseptic, and antimicrobial also make it an effective\\nskin treatment, and useful in fighting cold and flu\\nsymptoms.\\nKEY TERMS\\nAntiseptic— Inhibits the growth of microorganisms.\\nBactericidal— An agent that destroys bacteria (e.g.,\\nStaphylococci aureus, Streptococci pneumoniae,\\nEscherichia coli, Salmonella enteritidis).\\nCarrier oil— An oil used to dilute essential oils for\\nuse in massage and other skin care applications.\\nContact dermatitis— Skin irritation as a result of con-\\ntact with a foreign substance.\\nEssential oil— A volatile oil extracted from the\\nleaves, fruit, flowers, roots, or other components of\\na plant and used in aromatherapy, perfumes, and\\nfoods and beverages.\\nHolistic— A practice of medicine that focuses on the\\nwhole patient, and addresses the social, emotional,\\nand spiritual needs of a patient as well as their phy-\\nsical treatment.\\nPhototoxic— Causes a harmful skin reaction when\\nexposed to sunlight.\\nRemedy antidote— Certain foods, beverages, pre-\\nscription medications, aromatic compounds, and\\nother environmental elements that counteract the\\nefficacy of homeopathic remedies.\\nSteam distillation— A process of extracting essential\\noils from plant products through a heating and eva-\\nporation process.\\nVolatile— Something that vaporizes or evaporates\\nquickly when exposed to air.\\n394 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 424, 'page_label': '395'}, page_content='/C15Rosemary ( Rosmarinus officinalis ). Stimulating\\nessential oil used to treat muscular and rheumatic\\ncomplaints, as well as low blood pressure, gastroin-\\ntestinal problems, and headaches.\\n/C15Tea tree (Melaleuca alternifolia). Has bactericidal,\\nvirucidal, fungicidal, and anti-inflammatory proper-\\nties that make it a good choice for fighting infection.\\nRecommended for treating sore throat and respira-\\ntory infections, vaginal and bladder infections,\\nwounds, and a variety of skin conditions.\\n/C15Ylang ylang (Cananga odorata). A sedative essential\\noil sometimes used to treat hypertension and\\ntachycardia.\\nEssential oils contain active agents that can have\\npotent physical effects. While some basic aromather-\\napy home treatments can be self-administered, medi-\\ncal aromatherapy should always be performed under\\nthe guidance of an aromatherapist, herbalist, massage\\ntherapist, nurse, or physician.\\nInhalation\\nThe most basic method of administering aroma-\\ntherapy is direct or indirect inhalation of essential\\noils. Several drops of an essential oil can be applied\\nto a tissue or handkerchief and gently inhaled. A\\nsmall amount of essential oil can also be added to a\\nbowl of hot water and used as a steam treatment.\\nThis technique is recommended when aromatherapy\\nis used to treat respiratory and/or skin conditions.\\nAromatherapy steam devices are also available com-\\nmercially. A warm bath containing essential oils can\\nhave the same effect as steam aromatherapy, with\\nthe added benefit of promoting relaxation. When\\nused in a bath, water should be lukewarm rather\\nthan hot to slow the evaporation of the oil.\\nEssential oil diffusers, vaporizers, and light bulb\\nrings can be used to disperse essential oils over a large\\narea. These devices can be particularly effective in\\naromatherapy that uses essential oils to promote a\\nhealthier home environment. For example, eucalyptus\\nand tea tree oil are known for their antiseptic qualities\\nand are frequently used to disinfect sickrooms, and\\ncitronella and geranium can be useful in repelling\\ninsects.\\nDirect application\\nBecause of their potency, essential oils are diluted\\nin a carrier oil or lotion before being applied to the\\nskin to prevent an allergic skin reaction. The carrier oil\\ncan be a vegetable or olive based one, such as wheat\\ngerm or avocado. Light oils, such as safflower, sweet\\nalmond, grapeseed, hazelnut, apricot seed, or peach\\nkernel, may be absorbed more easily by the skin.\\nStandard dilutions of essential oils in carrier oils\\nrange from 2–10%. However, some oils can be used\\nat higher concentrations, and others should be diluted\\nfurther for safe and effective use. The type of carrier\\noil used and the therapeutic use of the application\\nmay also influence how the essential oil is mixed.\\nIndividuals should seek guidance from a healthcare\\nprofessional and/or aromatherapist when diluting\\nessential oils.\\nMassage is a common therapeutic technique\\nused in conjunction with aromatherapy to both\\nrelax the body and thoroughly administer the essen-\\ntial oil treatment. Essential oils can also be used in\\nhot or cold compresses and soaks to treat muscle\\naches and pains (e.g., lavender and ginger). As a\\nsore throat remedy, antiseptic and soothing essential\\noils (e.g., tea tree and sage) can be thoroughly\\nmixed with water and used as a gargle or\\nmouthwash.\\nInternal use\\nSome essential oils can be administered internally\\nin tincture, infusion, or suppository form to treat cer-\\ntain symptoms or conditions; however, this treatment\\nshould never be self-administered. Essential oils\\nshould only be taken internally under the supervision\\nof a qualified healthcare professional.\\nAs non-prescription botanical preparations, the\\nessential oils used in aromatherapy are typically not\\npaid for by health insurance. The self-administered\\nnature of the therapy controls costs to some degree.\\nAromatherapy treatmen t sessions from a profes-\\nsional aromatherapist are not covered by health\\ninsurance in most cases, although aromatherapy per-\\nformed in conjunction with physical therapy, nur-\\nsing, therapeutic massage,or other covered medical\\nservices may be. Individuals should check with their\\ninsurance provider to find out about their specific\\ncoverage.\\nThe adage ‘‘You get what you pay for’’ usually\\napplies when purchasing essential oils, as bargain oils\\nare often adulterated, diluted, or synthetic. Pure essen-\\ntial oils can be expensive; and the cost of an oil will\\nvary depending on its quality and availability.\\nPreparations\\nThe method of extracting an essential oil varies by\\nplant type. Common methods include water or steam\\ndistillation and cold pressing. Quality essential oils\\nGALE ENCYCLOPEDIA OF MEDICINE 395\\nAromatherapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 425, 'page_label': '396'}, page_content='should be unadulterated and extracted from pure\\nbotanicals. Many aromatherapy oils on the market\\nare synthetic and/or diluted, contain solvents, or are\\nextracted from botanicals grown with pesticides or\\nherbicides. To ensure best results, essential oils should\\nbe made from pure organic botanicals and labeled by\\ntheir full botanical name. Oils should always be stored\\ndark bottles out of direct light.\\nBefore using essential oils on the skin, indivi-\\nduals should perform a skin patch test by applying\\na small amount of the diluted oil behind the wrist\\nand covering it with a bandage or cloth for up to\\n12 hours. If redness or irri tation occurs, the oil\\nshould be diluted further and a second skin test\\nperformed, or it should be avoided altogether.\\nIndividuals should never apply undiluted essential\\noils to the skin unless advised to do so by a trained\\nhealthcare professional.\\nPrecautions\\nIndividuals should only take essential oils\\ninternally under the guidance and close supervision\\nof a health-care professional. Some oils, such as\\neucalyptus, wormwood, and sage, should never be\\ntaken internally. Many essential oils are highly\\ntoxic and should never be used at all in aromather-\\napy. These include (but are not limited to) bitter\\nalmond, pennyroyal, mustard, sassafras, rue, and\\nmugwort.\\nCitrus-based essential oils, including bitter and\\nsweet orange, lime, lemon, grapefruit, and tangerine,\\nare phototoxic, and exposure to direct sunlight should\\nbe avoided for at least four hours after their\\napplication.\\nOther essential oils, such as cinnamon leaf,\\nblack pepper, juniper, lemon, white camphor,\\neucalyptus blue gum, ginger, peppermint, pine\\nneedle, and thyme can be extremely irritating to\\nthe skin if applied in high enough concentration\\nor without a carrier oil or lotion. Caution should\\nalways be exercised when applying essential oils\\ntopically. Individuals should never apply undi-\\nluted essential oils to the skin unless directed to\\ndo so by a trained healthcare professional and/or\\naromatherapist.\\nIndividuals taking homeopathic remedies should\\navoid black pepper, camphor, eucalyptus, and pepper-\\nmint essential oils. These oils may act as a remedy\\nantidote to the homeopathic treatment.\\nChildren should only receive aromatherapy treat-\\nment under the guidance of a trained aromatherapist\\nor healthcare professional. Some essential oils may not\\nbe appropriate for treating children, or may require\\nadditional dilution before use on children.\\nCertain essential oils should not be used by preg-\\nnant or nursing women or by people with specific ill-\\nnesses or physical conditions. Individuals suffering\\nfrom any chronic or acute health condition should\\ninform their healthcare provider before starting treat-\\nment with any essential oil.\\nAsthmatic individuals should not use steam inha-\\nlation for aromatherapy, as it can aggravate their\\ncondition.\\nEssential oils are flammable, and should be kept\\naway from heat sources.\\nSide effects\\nSide effects vary by the type of essential oil used.\\nCitrus-based essential oils can cause heightened sensi-\\ntivity to sunlight. Essential oils may also causecontact\\ndermatitis, an allergic reaction characterized by red-\\nness and irritation. Anyone experiencing an allergic\\nreaction to an essential oil should discontinue its use\\nand contact their healthcare professional for further\\nguidance. Individuals should do a small skin patch test\\nwith new essential oils before using them extensively\\n(see ‘‘Preparations’’ above).\\nResearch and general acceptance\\nThe antiseptic and bactericidal qualities of some\\nessential oils (such as tea tree and peppermint) and\\ntheir value in fighting infection has been detailed\\nextensively in both ancient and modern medical\\nliterature.\\nRecent research in mainstream medical literature\\nhas also shown that aromatherapy has a positive\\npsychological impact on patients, as well. Several\\nclinical studies involvin g both post-operative and\\nchronically ill subjects showed that massage with\\nessential oils can be helpful in improving emotional\\nwell-being, and consequently, promoting the healing\\nprocess.\\nToday, the use of holistic aromatherapy is widely\\naccepted in Europe, particularly in Great Britain,\\nwhere it is commonly used in conjunction with mas-\\nsage as both a psychological and physiological healing\\ntool. In the United States, where aromatherapy is\\noften misunderstood as solely a cosmetic treatment,\\nthe mainstream medical community has been slower\\nto accept it.\\n396 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 426, 'page_label': '397'}, page_content='Resources\\nBOOKS\\nSchnaubelt, Kurt.Medical Aromatherapy: Healing With\\nEssential Oils.Berkeley, CA: Frog Ltd, 1999.\\nORGANIZATIONS\\nNational Association of Holistic Aromatherapy. 836 Hanley\\nIndustrial Court, St. Louis, MO 63144. (888) ASK-\\nNAHA. .\\nPaula Anne Ford-Martin\\nArrhythmias\\nDefinition\\nAn arrhythmia is an abnormality in the heart’s\\nrhythm, or heartbeat pattern. The heartbeat can be\\ntoo slow, too fast, have extra beats, skip a beat, or\\notherwise beat irregularly.\\nDescription\\nArrhythmias are deviations from the normal\\ncadence of the heartbeat, which cause the heart to\\npump improperly. The normal heartbeat starts in the\\nright atrium, where the heart’s natural pacemaker (the\\nsinus node) sends an electrical signal to the center of\\nthe heart to the atrioventricular node. The atrioven-\\ntricular node then sends signals into the main pumping\\nchamber to make the ventricle contract. Arrhythmias\\noccur when the heartbeat starts in a part of the heart\\nother than the sinus node, an abnormal rate or rhythm\\ndevelops in the sinus node, or a heart conduction\\n‘‘block’’ prevents the electrical signal from traveling\\ndown the normal pathway.\\nMore than four million Americans have arrhyth-\\nmias, most of which are h armless. Middle-aged\\nadults commonly experience arrhythmias. As people\\nage, the probability of experiencing an arrhythmia\\nincreases. Arrhythmias often occur in people who\\ndo not have heart disease. In people with heart dis-\\nease, it is usually the heartdisease which is danger-\\nous, not the arrhythmia. Arrhythmias often occur\\nduring and after heart attacks. Some types of\\narrhythmias, such as ventricular tachycardia ,a r e\\nserious and even life threatening. In the United\\nStates, arrhythmias are the primary cause ofsudden\\ncardiac death , accounting for more than 350,000\\ndeaths each year.\\nSlow heart rates (less than 60 beats per minute) are\\ncalled bradycardias, while fast heart rates (more than\\n100 beats per minute) are called tachycardias.\\nBradycardia can result in poor circulation of blood,\\nand, hence, a lack of oxygen throughout the body,\\nespecially the brain. Tachycardias also can compro-\\nmise the heart’s ability to pump effectively because the\\nventricles do not have enough time to completely fill.\\nArrhythmias are characterized by their site of\\norigin: the atria or the ventricles. Supraventricular\\narrhythmias occur in the upper areas of the heart and\\nare less serious than ventricular arrhythmias.\\nVentricular fibrillationis the most serious arrhythmia\\nand is fatal unless medical help is immediate.\\nCauses and symptoms\\nIn many cases, the cause of an arrhythmia is\\nunknown. Known causes of arrhythmias include\\nheart disease, stress, caffeine, tobacco, alcohol, diet\\npills, anddecongestants in cough and cold medicines.\\nSymptoms of an arrhythmia include a fast heart-\\nbeat, pounding or fluttering chest sensations, skipping\\na heartbeat, ‘‘flip-flops,’’dizziness, faintness,shortness\\nof breath, and chest pains.\\nDiagnosis\\nExamination with a stethoscope, electrocardio-\\ngrams, and electrophysiologic studies is used to diag-\\nnose arrhythmias. Sometimes arrhythmias can be\\nidentified by listening to the patient’s heart through\\na stethoscope, but, sincearrhythmias are not always\\npresent, they may not occur during the physical\\nexam.\\nKEY TERMS\\nBradycardia— A slow heart rate. Bradycardia is one\\nof the two types of arrhythmia\\nElectrocardiogram— A test which uses electric sen-\\nsors placed on the body to monitor the heartbeat.\\nElectrophysiology study— A test using cardiac\\ncatheterization to stimulate an electrical current\\nto provoke an arrhythmia. The test identifies the\\norigin of arrhythmias and is used to test the effec-\\ntiveness of antiarrhythmic drugs.\\nTachycardia— A fast heart rate. Tachycardia is one\\nof the two types of arrhythmia.\\nGALE ENCYCLOPEDIA OF MEDICINE 397\\nArrhythmias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 427, 'page_label': '398'}, page_content='An electrocardiogram (ECG) shows the heart’s\\nactivity and may reveal a lack of oxygen from poor\\ncirculation (ischemia). Electrodes covered with con-\\nducting jelly are placed on the patient’s chest, arms,\\nand legs. They send impulses of the heart’s activity\\nthrough an electrical activity monitor (oscilloscope)\\nto a recorder that traces them on paper. The test\\ntakes about 10 minutes and is performed in a physi-\\ncian’s office. Another type of ECG, commonly known\\nas theexercise stress test, measures how the heart and\\nblood vessels respond to exertion while the patient is\\nexercising on a treadmill or a stationary bike. This test\\nis performed in a physician’s office or an exercise\\nlaboratory and takes 15-30 minutes. Other types of\\nECGs include 24-hour ECG monitoring and trans-\\ntelephonic monitoring. In 24-hour ECG (Holter)\\nmonitoring, the patient wears a small, portable tape\\nrecorder connected to disks on his/her chest that\\nrecord the heart’s rhythm during daily activities.\\nTranstelephonic monitoring can identify arrhythmias\\nthat occur infrequently. Similar toHolter monitoring,\\ntranstelephonic monitoring can continue for days or\\nweeks, and it enables patients to send the ECG via\\ntelephone to a monitoring station when an arrhythmia\\nis felt, or the patient can store the information in the\\nrecorder and transmit it later.\\nElectrophysiologic studies are invasive proce-\\ndures performed in a hospital to identify the origin of\\nserious arrhythmias and responses to various treat-\\nments. They involvecardiac catheterization, in which\\ncatheters tipped with electrodes are passed from a vein\\nin the arm or leg through the blood vessels into the\\nheart. The electrodes record impulses in the heart,\\nhighlighting where the arrhythmia starts. During the\\nprocedure, physicians can test the effects of various\\ndrugs by provoking an arrhythmia through the elec-\\ntrodes and trying different drugs. The procedure takes\\none to three hours, during which the patient is awake\\nbut mildly sedated. Local anesthetic is injected at the\\ncatheter insertion sites.\\nTreatment\\nMany arrhythmias do not require any treatment.\\nFor serious arrhythmias, treating the underlying heart\\ndisease sometimes controls the arrhythmia. In some\\ncases, the arrhythmia itself is treated with drugs, elec-\\ntrical shock (cardioversion), automatic implantable\\ndefibrillators, artificialpacemakers, catheter ablation,\\nor surgery. Supraventricular arrhythmias often can be\\ntreated with drug therapy. Ventricular arrhythmias\\nare more complex to treat.\\nDrug therapy can manage many arrhythmias, but\\nfinding the right drug and dose requires care and can\\ntake some time. Common drugs for suppressing\\narrhythmias include beta-blockers, calcium channel\\nblockers, quinidine, digitalis preparations, and procai-\\nnamide. Because of their potential serious side effects,\\nstronger, desensitizing drugs are used only to treat life-\\nthreatening arrhythmias. All of the drugs used to treat\\narrhythmias have possible side effects, ranging from\\nmild complications with beta-blockers and calcium\\nchannel blockers to more serious effects of desensitiz-\\ning drugs that can, paradoxically, cause arrhythmias\\nor make them worse. Response to drugs is usually\\nmeasured by ECG, Holter monitor, or electrophysio-\\nlogic study.\\nIn emergency situations, cardioversion ordefibril-\\nlation (the application of an electrical shock to the\\nchest wall) is used. Cardioversion restores the heart\\nto its normal rhythm. It is followed by drug therapy to\\nprevent recurrence of the arrhythmia.\\nArtificial pacemakers that send electrical signals\\nto make the heart beat properly can be implanted\\nunder the skin during a simple operation. Leads from\\nthe pacemaker are anchored to the right side of the\\nheart. Pacemakers are used to correct bradycardia and\\nare sometimes used after surgical or catheter ablation.\\nAutomatic implantable defibrillators correct life-\\nthreatening ventricular arrhythmias by recognizing\\nthem and then restoring a normal heart rhythm by\\npacing the heart or giving it an electric shock. They\\nare implanted within the chest wall without major\\nsurgery and store information for future evaluation\\nby physicians. Automatic implantable defibrillators\\nhave proven to be more effective in saving lives than\\ndrugs alone. They often are used in conjunction with\\ndrug therapy.\\nAblation, a procedure to alter or remove the\\nheart tissue causing the arrhythmia in order to pre-\\nvent a recurrence, can be performed through a cathe-\\nt e ro rs u r g e r y .S u p r a v e n t r i c u l a rt a c h y c a r d i ac a nb e\\ntreated successfully with ablation. Catheter ablation\\nis performed in a catheterization laboratory with the\\npatient under sedation. A catheter equipped with a\\ndevice that maps the heart’s electrical pathways is\\ninserted into a vein and is threaded into the heart.\\nHigh-frequency radio waves are then used to remove\\nthe pathway(s) causing the arrhythmia. Surgical\\nablation is similar in principle but it is performed in\\na hospital, using a cold probe instead of radio waves\\nto destroy tissue. Ablation treatments are used when\\nmedications fail.\\nMaze surgery treats atrial fibrillation by making\\nmultiple incisions through the atrium to allow electri-\\ncal impulses to move effectively. This is often\\n398 GALE ENCYCLOPEDIA OF MEDICINE\\nArrhythmias'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 428, 'page_label': '399'}, page_content='recommended for patients who have not responded to\\ndrugs or cardioversion.\\nAlternative treatment\\nSince some arrhythmias can be life threatening, a\\nconventional medical doctor should always be con-\\nsulted first. Acupuncture can correct an insignificant\\nnumber (1.5%) of atrial fibrillation cases. For new,\\nminor arrhythmias, acupuncture may be effective in\\nup to 70% of cases, but this figure may not differ\\nmuch from placebo thera py. Both western and\\nChinese herbal remedies are also used in the treat-\\nment of arrhythmias. Since hawthorn (Crataegus lae-\\nvigata) dilates the blood vessels and stimulates the\\nheart muscle, it may help to stabilize arrhythmias. It\\nis gentle and appropriate for home use, unlike fox-\\nglove (Digitalis purpurea), an herb whose action on\\nthe heart is too potent for use without supervision by\\na qualified practitioner. Homeopathic practitioners\\nmay prescribe remedies such asLachesis and aconite\\nor monkshood ( Aconitum napellus ) to treat mild\\narrhythmias.\\nPrognosis\\nAdvances in diagnostic techniques, new drugs,\\nand medical technology have extended the lives of\\nmany patients with serious arrhythmias. Diagnostic\\ntechniques enable physicians to accurately identify\\narrhythmias, while new drugs, advances in pacemaker\\ntechnology, the development of implantable defibril-\\nlators, and progress in ablative techniques offer effec-\\ntive treatments for many types of arrhythmia.\\nPrevention\\nSome arrhythmias can be prevented by managing\\nstress, controllinganxiety, and avoiding caffeine, alco-\\nhol, decongestants,cocaine, and cigarettes.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nArt therapy\\nDefinition\\nArt therapy, sometimes called creative arts ther-\\napy or expressive arts therapy, encourages people to\\nexpress and understand emotions through artistic\\nexpression and through the creative process.\\nPurpose\\nArt therapy provides the client-artist with critical\\ninsight into emotions, thoughts, and feelings. Key\\nbenefits of the art therapy process include:\\n/C15Self-discovery. At its most successful, art therapy\\ntriggers an emotional catharsis.\\n/C15Personal fulfillment. The creation of a tangible\\nreward can build confidence and nurture feelings of\\nself-worth. Personal fulfillment comes from both the\\ncreative and the analytical components of the artistic\\nprocess.\\n/C15Empowerment. Art therapy can help people visually\\nexpress emotions and fears that they cannot express\\nthrough conventional means, and can give them\\nsome sense of control over these feelings.\\n/C15Relaxation and stress relief. Chronic stress can be\\nharmful to both mind and body. Stress can weaken\\nand damage the immune system, can causeinsomnia\\nand depression, and can trigger circulatory problems\\n(like high blood pressure and irregular heartbeats).\\nWhen used alone or in combination with other\\nrelaxation techniques such as guided imagery, art\\ntherapy can effectively relieve stress.\\n/C15Symptom relief and physicalrehabilitation. Art the-\\nrapy can also help patients cope withpain. This\\ntherapy can promote physiological healing when\\npatients identify and work through anger, resent-\\nment, and other emotional stressors. It is often\\nprescribed to accompany pain control therapy for\\nchronically and terminally ill patients.\\nDescription\\nOrigins\\nHumans have expressed themselves with symbols\\nthroughout history. Masks, ritual pottery, costumes,\\nother objects used in rituals, cave drawings, Egyptian\\nhieroglyphics, and Celtic art and symbols are all visual\\nrecords of self-expression and communication\\nthrough art. Art has also been associated spiritual\\npower, and artistic forms such as the Hindu and\\nGALE ENCYCLOPEDIA OF MEDICINE 399\\nArt therapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 429, 'page_label': '400'}, page_content='Buddhist mandala and Native American sand paint-\\ning are considered powerful healing tools.\\nIn the late nineteenth century, French psychia-\\ntrists Ambrose Tardieu and Paul-Max Simon both\\npublished studies on the similar characteristics of and\\nsymbolism in the artwork of the mentally ill. Tardieu\\nand Simon viewed art therapy as an effective diagnos-\\ntic tool to identify specific types of mental illness or\\ntraumatic events. Later, psychologists would use this\\ndiagnostic aspect to develop psychological drawing\\ntests (the Draw-A-Man test, the Draw-A-Person\\nQuestionnaire [DAP.Q]) and projective personality\\ntests involving visual symbol recognition (e.g., the\\nRorschach Inkblot Test, the Thematic Apperception\\nTest [TAT], and the Holtzman Inkblot Test [HIT]).\\nThe growing popularity of milieu therapies at\\npsychiatric institutions in the twentieth century was\\nan important factor in the development of art therapy\\nin the United States. Milieu therapies (or environmen-\\ntal therapy) focus on putting the patient in a controlled\\ntherapeutic social setting that provides the patient\\nwith opportunities to gain self-confidence and interact\\nwith peers in a positive way. Activities that encourage\\nself-discovery and empowerment such as art, music,\\ndance, and writing are important components of this\\napproach.\\nEducator and therapist Margaret Naumburg was\\na follower of both Freud and Jung, and incorporated\\nart into psychotherapy as a means for her patients to\\nvisualize and recognize the unconscious. She founded\\nthe Walden School in 1915, where she used students’\\nartworks in psychological counseling. She published\\nextensively on the subject and taught seminars on the\\ntechnique at New York University in the 1950s.\\nToday, she is considered the founder of art therapy\\nin the United States.\\nIn the 1930s, Karl, William, and Charles Menninger\\nintroduced an art therapy program at their Kansas-\\nbased psychiatric hospital, the Menninger Clinic. The\\nMenninger Clinic employed a number of artists in resi-\\ndence in the following years, and the facility was also\\nconsidered a leader in the art therapy movement\\nthrough the 1950s and 60s. Other noted art therapy\\npioneers who emerged in the 50s and 60s include Edith\\nKramer, Hanna Yaxa Kwiatkowska (National Institute\\nof Mental Health), and Janie Rhyne.\\nArt therapy, sometimes called expressive art or art\\npsychology, encourages self-discovery and emotional\\ngrowth. It is a two part process, involving both the\\ncreation of art and the discovery of its meaning.\\nRooted in Freud and Jung’s theories of the subcon-\\nscious and unconscious, art therapy is based on the\\nassumption that visual symbols and images are the\\nmost accessible and natural form of communication\\nto the human experience. Patients are encouraged to\\nvisualize, and then create, the thoughts and emotions\\nthat they cannot talk about. The resulting artwork is\\nthen reviewed and its meaning interpreted by the\\npatient.\\nThe ‘‘analysis’’ of the artwork produced in art\\ntherapy typically allows patients to gain some level of\\ninsight into their feelings and lets them to work\\nthrough these issues in a constructive manner. Art\\ntherapy is typically practiced with individual, group,\\nor family psychotherapy (talk therapy). While a thera-\\npist may provide critical guidance for these activities, a\\nkey feature of effective art therapy is that the patient/\\nartist, not the therapist, directs the interpretation of\\nthe artwork.\\nArt therapy can be a particularly useful treatment\\ntool for children, who frequently have limited lan-\\nguage skills. By drawing or using other visual means\\nto express troublesome feelings, younger patients\\ncan begin to address these issues, even if they cannot\\nidentify or label these emotions with words. Art\\ntherapy is also valuable for adolescents and adults\\nwho are unable or unwilling to talk about thoughts\\nand feelings.\\nBeyond its use in mental health treatment, art\\ntherapy is also used with traditional medicine to\\ntreat organic diseases and conditions. The connec-\\ntion between mental and physical health is well\\ndocumented, and art therapy can promote healing\\nby relieving stress and allowing the patient to\\ndevelop coping skills.\\nArt therapy has traditionally centered on visual\\nmediums, like paintings, sculptures, and drawings.\\nSome mental healthcare providers have now\\nKEY TERMS\\nCatharsis— Therapeutic discharge of emotional\\ntension by recalling past events.\\nMandala— A design, usually circular, that appears\\nin religion and art. In Buddhism and Hinduism, the\\nmandala has religious ritual purposes and serves as\\na yantra (a geometric emblem or instrument of\\ncontemplation).\\nOrganic illness— A physically, biologically based\\nillness.\\n400 GALE ENCYCLOPEDIA OF MEDICINE\\nArt therapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 430, 'page_label': '401'}, page_content='broadened the definition to include music, film, dance,\\nwriting, and other types of artistic expression.\\nArt therapy is often one part of a psychiatric\\ninpatient or outpatient treatment program, and can\\ntake place in individual or group therapy sessions.\\nGroup art therapy sessi ons often take place in\\nhospital, clinic, shelter, and community program\\nsettings. These group therapy sessions can have\\nthe added benefits of positive social interaction,\\nempathy, and support from peers. The client-artist\\ncan learn that others have similar concerns and\\nissues.\\nPreparations\\nBefore starting art therapy, the therapist may\\nhave an introductory session with the client-artist to\\ndiscuss art therapy techniques and give the client the\\nopportunity to ask questions about the process. The\\nclient-artist’s comfort with the artistic process is criti-\\ncal to successful art therapy.\\nThe therapist ensures that appropriate materials\\nand space are available for the client-artist, as well as\\nan adequate amount of time for the session. If the\\nindividual artist is exploring art as therapy without\\nthe guidance of a trained therapist, adequate materi-\\nals, space, and time are still important factors in a\\nsuccessful creative experience.\\nThe supplies used in art therapy are limited only\\nby the artist’s (and/or therapist’s) imagination. Some\\nof the materials often used include paper, canvas,\\nposter board, assorted paints, inks, markers, pencils,\\ncharcoals, chalks, fabrics, string, adhesives, clay,\\nwood, glazes, wire, bendable metals, and natural\\nitems (like shells, leaves, etc.). Providing artists with\\na variety of materials in assorted colors and textures\\ncan enhance their interest in the process and may\\nresult in a richer, more diverse exploration of their\\nemotions in the resulting artwork. Appropriate tools\\nsuch as scissors, brushes, erasers, easels, supply trays,\\nglue guns, smocks or aprons, and cleaning materials\\nare also essential.\\nAn appropriate workspace should be available for\\nthe creation of art. Ideally, this should be a bright,\\nquiet, comfortable place, with large tables, counters,\\nor other suitable surfaces. The space can be as simple\\nas a kitchen or office table, or as fancy as a specialized\\nartist’s studio.\\nThe artist should have adequate time to become\\ncomfortable with and explore the creative process.\\nThis is especially true for people who do not consider\\nthemselves ‘‘artists’’ and may be uncomfortable with\\nthe concept. If performed in a therapy group or one-\\non-one session, the art therapist should be available to\\nanswer general questions about materials and/or the\\ncreative process. However, the therapist should be\\ncareful not to influence the creation or interpretation\\nof the work.\\nPrecautions\\nArt materials and techniques should match the\\nage and ability of the client. People with impairments,\\nsuch as traumatic brain injury or an organic neurolo-\\ngical condition, may have difficulties with the self-\\ndiscovery portion of the art therapy process depending\\non their level of functioning. However, they may still\\nbenefit from art therapy through the sensory stimula-\\ntion it provides and the pleasure they get from artistic\\ncreation.\\nWhile art is accessible to all (with or without a\\ntherapist to guide the process), it may be difficult to\\ntap the full potential of the interpretive part of art\\ntherapy without a therapist to guide the process.\\nWhen art therapy is chosen as a therapeutic tool\\nto cope with a physical condition, it should be\\ntreated as a supplemental therapy and not as a\\nsubstitute for conventional medical treatments.\\nResearch and general acceptance\\nA wide body of literature supports the use of art\\ntherapy in a mental health capacity. And as the mind-\\nbody connection between psychological well-being\\nand physical health is further documented by studies\\nin the field, art therapy gains greater acceptance by\\nmainstream medicine as a therapeutic technique for\\norganic illness.\\nResources\\nBOOKS\\nGanim, Barbara.Art and Healing: Using expressive art\\ntoheal your body, mind, and spirit.New York: Three\\nRivers Press, 1999.\\nORGANIZATIONS\\nAmerican Art Therapy Association.1202 Allanson Rd.,\\nMundelein, IL 60060-3808. 888-290-0878 or 847-949-\\n6064. Fax: 847-566-4580. E-mail: arttherapy@ntr.net\\n.\\nPaula Anne Ford-Martin\\nArterial blood gas analysis see Blood gas\\nanalysis\\nGALE ENCYCLOPEDIA OF MEDICINE 401\\nArt therapy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 431, 'page_label': '402'}, page_content='Arterial embolism\\nDefinition\\nAn embolus is a blood clot, bit of tissue or\\ntumor, gas bubble, or other foreign body that cir-\\nculates in the blood stream until it becomes stuck in\\na blood vessel.\\nDescription\\nWhen a blood clot develops in an artery and\\nremains in place, it is called a thrombosis. If all or\\npart of the blockage breaks away and lodges in\\nanother part of the artery, it is called anembolism.\\nBlockage of an artery in this manner can be the result\\nof a blood clot, fat cells, or an air bubble.\\nWhen an embolus blocks the flow of blood\\nin an artery, the tissues beyond the plug are\\ndeprived of normal blood flow and oxygen. This\\ncan cause severe damage and even death of the\\ntissues involved.\\nEmboli can affect any part of the body. The most\\ncommon sites are the legs and feet. When the brain is\\naffected, it is called a stroke. When the heart is\\ninvolved, it is called a heart attack or myocardial\\ninfarction (MI).\\nCauses and symptoms\\nA common cause of embolus is when an artery\\nwhose lining has become thickened or damaged,\\nusually with age, allows cholesterol to build up\\nmore easily than normal on the artery wall. If\\nsome of the cholesterol breaks off, it forms an\\nembolus. Emboli also commonly form from blood\\nclots in a heart that has been damaged from heart\\nattack or when the heart contracts abnormally from\\natrial fibrillation.\\nOther known causes are fat cells that enter the\\nblood after a major bone fracture, infected blood\\ncells, cancer cells that enter the blood stream, and\\nsmall gas bubbles.\\nSymptoms of an embolus can begin suddenly or\\nbuild slowly over time, depending on the amount of\\nblocked blood flow.\\nIf the embolus is in an arm or leg, there will be\\nmuscle pain, numbness or tingling, pale skin color,\\nlower temperature in the limb, and weakness or loss\\nof muscle function. If it occurs in an internal organ,\\nthere is usually pain and/or loss of the organ’s\\nfunction.\\nDiagnosis\\nThe following tests can be used to confirm the\\npresence of an arterial embolism:\\n/C15Electrocardiogram, also known as an EKG or ECG.\\nFor this test, patches that detect electrical impulses\\nfrom the heart are attached to the chest and extremi-\\nties. The information is displayed on a monitor\\nscreen or a paper tape in the form of waves.\\nReduced blood and oxygen supply to the heart\\nshows as a change in the shape of the waves.\\n/C15Noninvasive vascular tests. These involve measuring\\nblood pressure in various parts of the body and\\ncomparing the results from each location. When\\nthere is a decrease in blood pressure beyond what is\\nnormal between two points, a blockage is presumed\\nto be present.\\n/C15Angiography. In this procedure, a colored liquid\\nmaterial (a dye, or contrast material) that can be\\nseen with x rays is injected into the blood stream\\nthrough a small tube called a catheter. As the dye\\nfills the arteries, they are easily seen on x ray motion\\npictures. If there is a blockage in the artery, it shows\\nup as a sudden cut off in the movement of contrast\\nmaterial. Angiography is an expensive procedure\\nand does carry some risk. The catheter may cause\\na blood clot to form, blocking blood flow. There is\\nalso the risk of poking the catheter through the artery\\nor heart muscle. Some people may be allergic to the\\ndye. The risk of any of these injuries occurring is\\nsmall.\\nTreatment\\nArterial embolism can be treated with medication\\nor surgery, depending on the extent and location of the\\nblockage.\\nMedication to dissolve the clot is usually given\\nthrough a catheter directly into the affected artery. If\\nthe embolus was caused by a blood clot, medications\\nthat thin the blood will help reduce the risk of another\\nembolism.\\nKEY TERMS\\nAtrial fibrillation— An arrhythmia; chaotic quiver-\\ning of the arteries.\\nThrombosis— A blockage in a blood vessel that\\nbuilds and remains in one place.\\n402 GALE ENCYCLOPEDIA OF MEDICINE\\nArterial embolism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 432, 'page_label': '403'}, page_content='A surgeon can remove an embolus by making an\\nincision in the artery above the blockage and, using a\\ncatheter inserted past the embolus, drag it out through\\nthe incision.\\nIf the condition is severe, a surgeon may elect to\\nbypass the blocked vessel by grafting a new vessel in its\\nplace.\\nPrognosis\\nAn arterial embolism is serious and should be\\ntreated promptly to avoid permanent damage to the\\naffected area. The outcome of any treatment depends\\non the location and seriousness of the embolism. New\\narterial emboli can form even after successful treat-\\nment of the first event.\\nPrevention\\nPrevention may include diet changes to reduce\\ncholesterol levels, medications to thin the blood, and\\npracticing an active, healthy lifestyle.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nOTHER\\n‘‘Arterial Embolism.’’ HealthAnswers.com. .\\nDorothy Elinor Stonely\\nArteriogram see Angiography\\nArteriography see Angiography\\nArteriosclerosis see Atherosclerosis\\nArteriovenous fistula\\nDefinition\\nAn arteriovenousfistula is an abnormal channel\\nor passage between an artery and a vein.\\nDescription\\nAn arteriovenous fistula is a disruption of the nor-\\nmal blood flow pattern. Normally, oxygenated blood\\nflows to the tissue through arteries and capillaries.\\nFollowing the release of oxygen in the tissues, the\\nblood returns to the heart in veins. An arteriovenous\\nfistula is an abnormal connection of an artery and a\\nvein. The blood bypasses the capillaries and tissues, and\\nreturns to the heart. Arterial blood has a higher blood\\npressure than veins and causes swelling of veins\\ninvolved in a fistula. Although both the artery and the\\nvein retain their normal connections, the new opening\\nbetween the two will cause some arterial blood to shunt\\ninto the vein because of the blood pressure difference.\\nCauses and symptoms\\nThere are two types of arteriovenous fistulas, con-\\ngenital and acquired. A congenital arteriovenous fis-\\ntula is one that formed during fetal development. It is a\\nbirth defect. In congenital fistulas, blood vessels of the\\nlower extremity are more frequently involved than\\nother areas of the body. Congenital fistulas are not\\ncommon. An acquired arteriovenous fistula is one that\\ndevelops after a person is born. It usually occurs when\\nan artery and vein that are side-by-side are damaged\\nand the healing process results in the two becoming\\nlinked. After catheterizations, arteriovenous fistulas\\nmay occur as a complication of the arterial puncture\\nin the leg or arm. Fistulas also form without apparent\\ncause. In the case of patients on hemodialysis, physi-\\ncians perform surgery to create a fistula. These\\npatients receive many needle sticks to flush their\\nblood through dialysis machines and for routine\\nblood analysis testing. The veins used may scar and\\nbecome difficult to use. Surgery is used to connect an\\nartery and vein so that arterial blood pressure and flow\\nrate widens the vein and decreases the chance ofblood\\nclots forming inside the vein.\\nThe main symptoms of arteriovenous fistulas near\\nthe surface of the skin are bulging and discolored\\nveins. In some cases, the bulging veins can be mistaken\\nfor varicose veins. Other fistulas can cause more seri-\\nous problems depending on their location and the\\nblood vessels involved.\\nDiagnosis\\nUsing a stethoscope, a physician can detect the\\nsound of a pulse in the affected vein (bruit). The sound\\nis a distinctive to-and-fro sound. Dye into the blood can\\nbe tracked by x ray to confirm the presence of a fistula.\\nTreatment\\nSmall arteriovenous fistulas can be corrected by\\nsurgery. Fistulas in the brain or eye are very difficult to\\ntreat. If surgery is not possible or very difficult, injec-\\ntion therapy may be used. Injection therapy is the\\nGALE ENCYCLOPEDIA OF MEDICINE 403\\nArteriovenous fistula'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 433, 'page_label': '404'}, page_content='injection of substances that cause the blood to clot at\\nthe site of the injection. In the case of an arteriovenous\\nfistula, the blood clot should stop the passage of blood\\nfrom the artery to the vein. Surgery is usually used to\\ncorrect acquired fistulas once they are diagnosed.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, eds.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nBerkow, Robert, ed.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nBraunwald, E.Heart Disease.Philadelphia: W. B. Saunders\\nCo., 1997.\\nJohn T. Lohr, PhD\\nArteriovenous malformations\\nDefinition\\nArteriovenous malformations are blood vessel\\ndefects that occur before birth when the fetus is grow-\\ning in the uterus (prenatal development). The blood\\nvessels appear as a tangled mass of arteries and veins.\\nThey do not possess the capillary (very fine blood\\nvessels) bed which normally exists in the common\\narea where the arteries and veins lie in close proximity\\n(artery-vein interface). An arteriovenous malforma-\\ntion (AVM) may hemorrhage, or bleed, leading to\\nserious complications that can be life-threatening.\\nDescription\\nAVMs represent an abnormal interface between\\narteries and veins. Normally, arteries carry oxyge-\\nnated blood to the body’s tissues through progres-\\nsively smaller blood vessels. The smallest are\\ncapillaries, which form a web of blood vessels (the\\ncapillary bed) through the body’s tissues. The arterial\\nblood moves through tissues by these tiny pathways,\\nexchanging its load of oxygen and nutrients for carbon\\ndioxide and other waste products produced by the\\nbody cells (cellular wastes). The blood is carried\\naway by progressively larger blood vessels, the veins.\\nAVMs lack a capillary bed and arterial blood is moved\\n(shunted) directly from the arteries into the veins.\\nAVMs can occur anywhere in the body and have\\nbeen found in the arms, hands, legs, feet, lungs, heart,\\nliver, and kidneys. However, 50% of these malforma-\\ntions are located in the brain, brainstem, and spinal\\ncord. Owing to the possibility of hemorrhaging, such\\nAVMs carry the risk of stroke,paralysis, and the loss\\nof speech, memory, or vision. An AVM that hemor-\\nrhages can be fatal.\\nApproximately three of every 100,000 people have\\na cerebral AVM and roughly 40-80% of them will\\nexperience some bleeding from the abnormal blood\\nvessels at some point. The annual risk of an AVM\\nbleeding is estimated at about 1-4%. After age 55, the\\nrisk of bleeding decreases. Pre-existing high blood pres-\\nsure or intense physical activity do not seem to be\\nassociated with AVM hemorrhage, butpregnancy and\\nlabor could cause a rupture or breaking open of a blood\\nvessel. An AVM hemorrhage is not as dangerous as an\\naneurysmal rupture. (An aneurysm is a swollen, blood\\nfilled vessel where the pressure of the blood causes the\\nwall to bulge outward.) There is an approximate 10%\\nfatality rate associated with AVM hemorrhage, com-\\npared to a 50% fatality rate for ruptured aneurysms.\\nAlthough AVMs are congenital defects, meaning\\na person is born with them, they are rarely discovered\\nbefore age 20. A genetic link has been proposed for\\nsome AVMs, but studies are only suggestive, not posi-\\ntive. The majority of AVMs are discovered in people\\nage 20-40. Medical researchers estimate that the mal-\\nformations are created during days 45-60 of fetal\\ndevelopment. A second theory suggests that AVMs\\nare primitive structures that are left over from the\\nKEY TERMS\\nCongenital— Present at the time of birth.\\nArteriovenous malformations. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n404 GALE ENCYCLOPEDIA OF MEDICINE\\nArteriovenous malformations'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 434, 'page_label': '405'}, page_content='period when fetal blood circulating systems began to\\ndevelop.\\nHowever they form, AVMs have blood vessels\\nthat are abnormally fragile. The arteries that feed\\ninto the malformation are unusually swollen and thin\\nwalled. They lack the usual amount of smooth muscle\\ntissue and elastin, a fibrous connective tissue. These\\nblood vessels commonly accumulate deposits of cal-\\ncium salts and hyalin. The venous part of the malfor-\\nmation receives blood directly from the artery.\\nWithout the intervening capillary bed, the veins\\nreceive blood at a higher pressure than they were\\ndesigned to handle. This part of the malformation is\\nalso swollen (dilated) and thin walled. There is a mea-\\nsurable risk of an aneurysm forming near an AVM,\\nincreasing the threat of hemorrhage, brain damage,\\nand death. Approximately 10-15% of AVMs are\\naccompanied by saccular aneurysms, a type of aneur-\\nysm that looks like a small sac attached to the outer\\nwall of the blood vessel.\\nAlthough the malformation itself lacks capillaries,\\nthere is often an abnormal proliferation of capillaries\\nnext to the defect. These blood vessels feed into the\\nmalformation, causing it to grow larger in some cases.\\nAs the AVM receives more blood through this ‘‘steal,’’\\nadjacent brain tissue does not receive enough. These\\nareas show abnormal nerve cell growth, cell death,\\nand deposits of calcium in that area (calcification).\\nNerve cells within the malformation may demons-\\ntrate abnormal growth and are believed to be\\nnonfunctional.\\nCauses and symptoms\\nMost people do not realize that they have an\\nAVM unless it hemorrhages enough to produce symp-\\ntoms. Small AVMs are more likely to hemorrhage. If a\\nhemorrhage occurs, it produces a sudden, severehead-\\nache. The headache may be focused in one specific\\narea or it may be more general. It can be mistaken\\nfor a migraine in some cases. The headache is accom-\\npanied by other symptoms, such asvomiting, a stiff\\nneck, sleepiness, lethargy, confusion, irritability, or\\nweakness anywhere in the body. Seizures occur in\\nabout a quarter of AVM cases. A person may experi-\\nence decreased, double, or blurred vision.\\nHemorrhaging from an AVM is generally less danger-\\nous than hemorrhaging from an aneurysm, with a\\nsurvival rate of 80-90%.\\nOther symptoms occur less frequently, but some-\\ntimes appear alongside major symptoms such as the\\nsudden severe headache. Additional warning signs of a\\nbleeding AVM are impaired speech or smell,fainting,\\nfacial paralysis, a drooping eyelid, dizziness, and ring-\\ning or buzzing in the ears.\\nAlthough large AVMs are less likely to hemor-\\nrhage, they can induce symptoms based on their mass\\nalone. Large AVMs exert pressure against brain tissue,\\ncause abnormal development in the surrounding brain\\ntissue, and slow down or block blood flow.\\nHydrocephalus, a swelling of brain tissue caused by\\naccumulated fluids, may develop. The warning signs\\nassociated with a large non-bleeding AVM are similar\\nto the symptoms of a small malformation that is bleed-\\ning. Unexplained headaches, seizures, dizziness, and\\nneurological symptoms, such as sensory changes, are\\nsignals that demand medical attention.\\nDiagnosis\\nBased on the clinical symptoms such as severe\\nheadache and neurological problems, and after a com-\\nplete neurologic exam, a computed tomography scan\\n(CT) of the head will be done. In some cases, a\\nwhooshing sound from arteries in the neck or over\\nthe eye or jaw (called a bruit), can be heard with a\\nstethoscope. The CT scan will reveal whether there has\\nbeen bleeding in the brain and can identify AVMs\\nlarger than 1 inch (2.5 cm).Magnetic resonance ima-\\nging (MRI) is also used to identify an AVM. A lumbar\\npuncture, or spinal tap, may follow the MRI or CT\\nscan. A lumbar puncture involves removing a small\\namount of cerebrospinal fluid from the lower part of\\nthe spine. Blood cells or blood breakdown products in\\nthe cerebrospinal fluid indicate bleeding.\\nKEY TERMS\\nAneurysm— A weak point in a blood vessel where\\nthe pressure of the blood causes the vessel wall to\\nbulge outwards.\\nAngiography— A mapping of the brain’s blood\\nvessels, using x-ray imaging.\\nCapillary bed— A dense network of tiny blood ves-\\nsels that enables blood to fill a tissue or organ.\\nHydrocephalus— Swelling of the brain caused by\\nan accumulation of fluid.\\nLumbar puncture— A diagnostic procedure in\\nwhich a needle is inserted into the lower spine to\\nwithdraw a small amount of cerebrospinal fluid.\\nThis fluid is examined to assess trauma to the brain.\\nSaccular aneurysm— A type of aneurysm that\\nresembles a small sack of blood attached to the\\nouter surface of a blood vessel by a thin neck.\\nGALE ENCYCLOPEDIA OF MEDICINE 405\\nArteriovenous malformations'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 435, 'page_label': '406'}, page_content='To pinpoint where the blood is coming from, a\\ncerebral angiography is done. This procedure uses\\nx rays to map out the blood vessels in the brain,\\nincluding the vessels that feed into the malformation.\\nThe information gained from angiography comple-\\nments the MRI and helps distinguish the precise\\nlocation of the AVM.\\nTreatment\\nNeurosurgeons consider several factors before\\ndeciding on a treatment option. There is some debate\\nover whether or not to treat AVMs that have not\\nruptured and are not causing any symptoms. The\\nrisks and benefits of proceeding with treatment need\\nto be measured on an individual basis, taking into\\naccount factors such as the person’s age and general\\nhealth, as well as the AVM’s size and location. Several\\ntreatment options are available, both for symptomatic\\nor asymptomatic AVMs. These treatment options\\nmay be used alone or in combination.\\nSurgery\\nRemoving the AVM is the surest way of preventing\\nit from causing future problems. Both small and large\\nAVMs can be handled in surgery. Surgery is recom-\\nmended for superficial AVMs, but may be too danger-\\nous for deep or very large AVMs. Unless it is\\nan emergency situation, an AVM that has hemorrhaged\\nis treated conservatively for several weeks. Conservative\\ntreatment consists of managing the immediate symp-\\ntoms and allowing the patient’s condition to stabilize.\\nSurgery requiresgeneral anesthesiaand a longer period\\nof recuperation than any other treatment option.\\nRadiation\\nRadiation is particularly useful to treat small\\n(under 1 in) malformations that are deep within the\\nbrain. Ionizing radiation is directed at the malforma-\\ntion, destroying the AVM without damaging the sur-\\nrounding tissue. Radiation treatment is accomplished\\nin a single session and it is not necessary to open the\\nskull. However, success can only be measured over\\nthe course of the following two years. A year after\\nthe procedure, 50-75% of treated AVMs are comple-\\ntely blocked; two years after radiation treatment, the\\npercentage increases to 85-95%.\\nEmbolization\\nEmbolization involves plugging up access to the\\nmalformation. This technique does not require open-\\ning the skull to expose the brain and can be used to\\ntreat deep AVMs. Using x-ray images as a guide, a\\ncatheter is threaded through the artery in the thigh\\n(femoral artery) to the affected area. The patient\\nremains awake during the procedure and medications\\ncan be administered to prevent discomfort. The blood\\nvessel leading into the AVM is assessed for its impor-\\ntance to the rest of the brain before a balloon or other\\nblocking agent is inserted via the catheter. The block\\nchokes off the blood supply to the malformation.\\nThere may be a mild headache ornausea associated\\nwith the procedure, but patients may resume normal\\nactivities after leaving the hospital. At least two to\\nthree embolization procedures are usually necessary\\nat intervals of two to six weeks. At least a three-day\\nhospital stay is associated with each embolization.\\nPrognosis\\nApproximately 10% of AVM cases are fatal.\\nSeizures and neurological changes may be permanent\\nin another 10-30% cases of AVM rupture. If an AVM\\nbleeds once, it is about 20% likely to bleed again in the\\nnext year. As time passes from the initial hemorrhage,\\nthe risk for further bleeding drops to about 3-4%. If\\nthe AVM has not bled, it is possible, but not guaran-\\nteed, that it never will. Untreated AVMs can grow\\nlarger over time and rarely go away by themselves.\\nOnce an AVM is removed and a person has recovered\\nfrom the procedure, there should be no further symp-\\ntoms associated with that malformation.\\nResources\\nPERIODICALS\\nHenning, Mast. ‘‘Risk of Spontaneous Hemorrhage after\\nDiagnosis of Cerebral Arteriovenous Malformation.’’\\nThe Lancet350 (October 11, 1997): 1065.\\nORGANIZATIONS\\nAmerican Chronic Pain Association. PO Box 850, Rocklin,\\nCA 95677-0850. (916) 632-0922. .\\nArteriovenous Malformation Support Group. 168\\nSix Mile Canyon Road, Dayton, NV 89403. (702)\\n246-0682.\\nNational Chronic Pain Outreach Association, Inc. P.O. Box\\n274, Millboro, VA 24460. (540) 997-5004.\\nJulia Barrett\\nArthritis see Juvenile arthritis;\\nOsteoarthritis; Psoriatic arthritis;\\nRheumatoid arthritis\\nArthrocentesis see Joint fluid analysis\\nArthrogram see Arthrography\\n406 GALE ENCYCLOPEDIA OF MEDICINE\\nArteriovenous malformations'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 436, 'page_label': '407'}, page_content='Arthrography\\nDefinition\\nArthrograpy is a procedure involving multiple\\nx rays of a joint using a fluoroscope, or a special\\npiece of x-ray equipment which shows an immediate\\nx-ray image. A contrast medium (in this case, a con-\\ntrast iodine solution) injected into the joint area helps\\nhighlight structures of the joint.\\nPurpose\\nFrequently, arthrography is ordered to determine\\nthe cause of unexplained jointpain. This fluoroscopic\\nprocedure can show the internal workings of specific\\njoints and outline soft tissue structures. The procedure\\nmay also be conducted to identify problems with the\\nligaments, cartilage, tendons, or the joint capsule of\\nthe hip, shoulder, knee, ankle or wrist. An arthrogra-\\nphy procedure may locate cysts in the joint area, eval-\\nuate problems with the joint’s arrangement and\\nfunction, or indicate the need forjoint replacement\\n(prostheses). The most commonly studied joints are\\nthe knee and shoulder.\\nPrecautions\\nPatients who are pregnant or may be pregnant\\nshould not have this procedure unless the benefits of\\nthe findings outweigh the risk of radiation exposure.\\nPatients who are known to be allergic to iodine need to\\ndiscuss this complication with their physician. Patients\\nwho have a known allergy to shellfish are more likely\\nto be allergic to iodine contrast.\\nDescription\\nArthrograpy may be referred to as ‘‘joint radio-\\ngraphy’’ or ‘‘x rays of the joint.’’ The term arthrogram\\nmay be used interchangeably with arthrography. The\\njoint area will be cleaned and a local anesthetic\\nwill be injected into the tissues around the joint\\nto reduce pain. Next, if fluids are present in the\\njoint, the physician may suction them out (aspi-\\nrate) with a needle. These fluids may be sent to a\\nlaboratory for further study. Contrast agents are\\nthen injected into the joint through the same loca-\\ntion by attaching the aspirating needle to a syringe\\ncontaining the contrast medium. The purpose of\\ncontrast agents in x-ray procedures is to help high-\\nlight details of areas under study by making them\\nopaque. Agents for arthrography are generally air\\nand water-soluble dyes, the most common\\ncontaining iodine. Air and iodine may be used\\ntogether or independent ly. After the contrast\\nagent is administered, the site of injection will be\\nsealed and the patient may be asked to move the\\njoint around to distribute the contrast.\\nBefore the contrast medium can be absorbed by\\nthe joint itself, several films will be quickly taken\\nunder the guidance of the fluoroscope. The patient\\nwill be asked to move the joint into a series of\\npositions, keeping still between positioning.\\nSometimes, the patient will experience sometingling\\nor discomfort during the procedure, which is\\nAn x-ray image of the knees of a patient with cysts caused by\\nrheumatoid arthritis. The cysts appear as dark areas just\\nbelow the knee joints. (Custom Medical Stock Photo.\\nReproduced by permission.)\\nKEY TERMS\\nAspirate— Remove fluids by suction, often through\\na needle.\\nContrast (agent, medium)— A substance injected\\ninto the body that illuminates certain structures\\nthat would otherwise be hard to see on the radio-\\ngraph (film).\\nFluoroscope— A device used in some radiology\\nprocedures that provides immediate images and\\nmotion on a screen much like those seen at airport\\nbaggage security stations.\\nRadiologist— A medical doctor specially trained in\\nradiology (x ray) interpretation and its use in the\\ndiagnosis of diseases and injuries.\\nX ray— A form of electromagnetic radiation with\\nshorter wavelengths than normal light. X rays can\\npenetrate most structures.\\nGALE ENCYCLOPEDIA OF MEDICINE 407\\nArthrography'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 437, 'page_label': '408'}, page_content='normal and due to the contrast. Following fluoro-\\nscopic tracking of the contrast, standard x rays of\\nthe area may also be taken. The entire procedure\\nwill last about one hour.\\nPreparation\\nIt is important to discuss any known sensitivity to\\nlocal anesthetics or iodine prior to this procedure. A\\nphysician should explain the procedure and the risks\\nassociated with contrast agents and ask the patient to\\nsign an informed consent. If iodine contrast will be\\nadministered, the patient may be instructed not to eat\\nbefore the exam. The timeframe offasting may extend\\nfrom only 90 minutes prior to the exam up to the night\\nbefore. There is no other preparation necessary.\\nAftercare\\nThe affected joint should be rested for appro-\\nximately 12 hours following the procedure. The joint\\nmay be wrapped in an elastic bandage and the patient\\nshould receive instructions on the care and changing of\\nt h eb a n d a g e .N o i s e si nt h ej o i n ts u c ha sc r a c k i n g\\nor clicking are normal for a few days following arthro-\\ngraphy. These noises are the result of liquid in the joints.\\nSwelling may also occur and can be treated with appli-\\ncation of ice or cold packs. A mild pain reliever can be\\nused to lessen pain in the first few days. However, if any\\nof these symptoms persist for more than a few days,\\npatients are advised to contact their physician.\\nRisks\\nIn some patients iodine can cause allergic reactions,\\nranging from mildnausea to severe cardiovascular or\\nnervous system complications. Since the contrast dye is\\nput into a joint, rather than into a vein, allergic reactions\\nare rare. Facilities licensed to perform contrast exams\\nshould meet requirements for equipment, supplies and\\nstaff training to handle a possible severe reaction.\\nInfection or joint damage are possible, although not\\nfrequent, complications of arthrography.\\nNormal results\\nA normal arthrography exam will show proper pla-\\ncement of the dye or contrast medium throughout the\\njoint structures, joint space, cartilage and ligaments.\\nAbnormal results\\nThe abnormal placement of dye may indicate\\nrheumatoid arthritis, cysts, joint dislocation, rupture\\nof the rotator cuff, tears in the ligament and other\\nconditions. The entire lining of the joint becomes opa-\\nque from the technique, which allows the radiologist\\nto see abnormalities in the intricate workings of the\\njoint. In the case of recurrent shoulderdislocations,\\narthrography results can be used to evaluate damage.\\nPatients with hip prostheses may receive arthrography\\nto evaluate proper placement or function of their\\nprostheses.\\nResources\\nORGANIZATIONS\\nAmerican College of Radiology. 1891 Preston White Drive,\\nReston, VA 22091. (800) 227-5463. .\\nArthritis Foundation. 1300 W. Peachtree St., Atlanta, GA\\n30309. (800) 283-7800. .\\nTeresa Odle\\nArthroplasty\\nDefinition\\nArthroplasty is surgery to relievepain and restore\\nrange of motion by realigning or reconstructing a joint.\\nPurpose\\nThe goal of arthroplasty is to restore the function\\nof a stiffened joint and relieve pain. Two types of\\narthroplastic surgery exist. Joint resection involves\\nremoving a portion of the bone from a stiffened\\njoint, creating a gap between the bone and the socket,\\nto improve the range of motion. Scar tissue eventually\\nfills the gap. Pain is relieved and motion is restored,\\nbut the joint is less stable.\\nInterpositional reconstruction is surgery to\\nreshape the joint and add a prosthetic disk between\\nthe two bones forming the joint. The prosthesis can\\nbe made of plastic and metal or from body tissue\\nsuch as fascia and skin. When interpositional\\nreconstruction fails, total joint replacement may be\\nnecessary. Joint replacement is also called total\\njoint arthroplasty.\\nIn recent years, joint replacement has become the\\noperation of choice for most knee and hip problems.\\nElbow, shoulder, ankle, and finger joints are more\\nlikely to be treated with joint resection or interposi-\\ntional reconstruction.\\n408 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 438, 'page_label': '409'}, page_content='Arthroplasty is performed on people suffering\\nfrom severe pain and disabling joint stiffness that\\nresult from osteoarthritis or rheumatoid arthritis .\\nJoint resection, rather than joint replacement, is\\nmore likely to be performed on people with rheuma-\\ntoid arthritis, especially when the elbow joint is\\ninvolved. Total joint replacement is usually reserved\\nfor people over the age of 60.\\nPrecautions\\nIf both the bone and socket of a joint are\\ndamaged, joint replacement is usually the preferred\\ntreatment.\\nDescription\\nArthroplasty is performed under general or regio-\\nnal anesthesia in a hospital, by an orthopedic surgeon.\\nCertain medical centers specialize in joint surgery and\\ntend to have higher success rates than less specialized\\ncenters.\\nIn joint resection, the surgeon makes an incision\\nat the joint, then carefully removes minimum amount\\nof bone necessary to allow free motion. The more bone\\nthat remains, the more stable the joint. Ligament\\nattachments are preserved as much as possible. In\\ninterpositional reconstruction, both bones of the\\njoint are reshaped, and a disk of material is placed\\nbetween the bones to prevent their rubbing together.\\nLength of hospital stay depends on which joint is\\ntreated, but is normally only a few days.\\nPreparation\\nPrior to arthroplasty, allthe standard preopera-\\ntive blood and urine tests are performed. The patient\\nmeets with the anesthesiologist to discuss any\\nspecial conditions that affect the administration of\\nanesthesia.\\nAftercare\\nPatients who have undergone arthroplasty must\\nbe careful not to overstress or destabilize the joint.\\nPhysical therapy is begun immediately.Antibiotics are\\ngiven to prevent infection.\\nRisks\\nJoint resection and interpositional reconstruction\\ndo not always produce successful results, especially in\\npatients with rheumatoid arthritis. Repeat surgery or\\ntotal joint replacement may be necessary. As with any\\nmajor surgery, there is always a risk of an allergic\\nreaction to anesthesia or thatblood clots will break\\nloose and obstruct the arteries.\\nNormal results\\nMost patients recover with improved range of\\nmotion in the joint and relief from pain.\\nResources\\nBOOKS\\n‘‘Joint Replacement.’’ InEverything You Need to Know\\nAbout Medical Treatments.Springhouse, PA:\\nSpringhouse Corp., 1996.\\nOTHER\\n‘‘Darrach’s Procedure.’’Wheeless’ Textbook of Orthopaedics\\nPage. .\\nTish Davidson, A.M.\\nArthroscopic surgery\\nDefinition\\nArthroscopic surgery is a procedure to visualize,\\ndiagnose, and treat joint problems. The name is\\nderived from the Greek wordsarthron, which means\\njoint, and skopein, which meansto look at.\\nPurpose\\nArthroscopic surgery is used to identify, monitor,\\nand diagnose joint injuries and disease; or to remove\\nbone or cartilage or repair tendons or ligaments.\\nDiagnostic arthroscopic surgery is performed when\\nmedical history, physical exam, x rays, and other\\ntests such as MRIs or CTs don’t provide a definitive\\ndiagnosis.\\nKEY TERMS\\nFascia— Thin connective tissue covering or separ-\\nating the muscles and internal organs of the\\nbody.\\nRheumatoid arthritis— A joint disease of\\nunknown origins that may begin at an early age,\\ncausing deformity and loss of function in the\\njoints.\\nGALE ENCYCLOPEDIA OF MEDICINE 409\\nArthroscopic surgery'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 439, 'page_label': '410'}, page_content='Precautions\\nDiagnostic arthroscopic surgery should not be\\nperformed unless conservative treatment does not fix\\nthe problem.\\nDescription\\nIn arthroscopic surgery, an orthopedic surgeon\\nuses an arthroscope, a fiber-optic instrument, to see\\nt h ei n s i d eo faj o i n t .A f t e rm a k i n ga ni n c i s i o na b o u t\\nthe size of a buttonhole in the patient’s skin, a sterile\\nsodium chloride solution is injected to distend the joint.\\nThe arthroscope, an instrument the size of a pencil, is\\nthen inserted into the joint. The arthroscope has a lens\\nand a lighting system through which the structures\\ninside the joint are transmitted to a miniature television\\ncamera attached to the end of the arthroscope. The\\nsurgeon uses irrigation and suction to remove blood\\nand debris from the joint before examining it. Other\\nincisions may be made in order to see other parts of the\\njoint or to insert additional instruments. Looking at the\\ninterior of the joint on the television screen, the surgeon\\ncan then determine the amount or type of injury and, if\\nnecessary, take a biopsy specimen or repair or correct\\nthe problem. Arthroscopic surgery can be used to\\nremove floating bits of cartilage and treat minor tears\\nand other disorders. When the procedure is finished,\\nthe arthroscope is removed and the joint is irrigated.\\nThe site of the incision is bandaged.\\nArthroscopic surgery is used to diagnose and treat\\njoint problems, most commonly in the knee, but also\\nin the shoulder, elbow, ankle, wrist, and hip. Some of\\nthe most common joint problems seen with an arthro-\\nscope are:\\n/C15inflammation in the knee, shoulder, elbow, wrist, or\\nankle\\n/C15injuries to the shoulder (rotator cuff tendon tears,\\nimpingement syndrome, and recurrent dislocations),\\nknee (cartilage tears, wearing down of or injury to the\\ncartilage cushion, and anterior cruciate ligament tears\\nwith instability), and wrist (carpal tunnel syndrome)\\nCamera\\nTelescope\\nAn arthroscope uses optical fibers to form an image of the damged cartilage, which it sends to a television monitor that helps the\\nsurgeon perform surgery. (Illustration by Argosy Inc.)\\n410 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroscopic surgery'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 440, 'page_label': '411'}, page_content='/C15loose bodies of bone and/or cartilage in the knee,\\nshoulder, elbow, ankle, or wrist\\nCorrective arthroscopic surgery is performed with\\ninstruments that are inserted through additional inci-\\nsions. Arthritis can sometimes be treated with arthro-\\nscopic surgery. Some problems are treated with a\\ncombination of arthroscopic and standard surgery.\\nAlso calledarthroscopy, the procedure is performed\\nin a hospital or outpatient surgical facility. The type of\\nanesthesia (local, spinal, or general) and the length of\\nthe procedure depends on the joint operated on and the\\ncomplexity of the suspected problem. Arthroscopic sur-\\ngery rarely takes more than an hour. Most patients who\\nhave arthroscopic surgery are released that same day;\\nsome patients stay in the hospital overnight.\\nConsidered the most important orthopedic devel-\\nopment in the 20th century, arthroscopic surgery is\\nwidely used. The use of arthroscopic surgery on famous\\nathletes has been well publicized. It is estimated that\\n80% of orthopedic surgeons practice arthroscopic sur-\\ngery. Arthroscopic surgery was initially a diagnostic\\ntool used prior to open surgery, but as better instru-\\nments and techniques were developed, it began to be\\nused to actually treat a variety of joint problems. New\\ntechniques currently under development are likely to\\nlead to other joints being treated with arthroscopic\\nsurgery in the future. Recently, lasers were introduced\\nin arthroscopic surgery and other new energy sources\\nare being explored. Lasers and electromagnetic radia-\\ntion can repair rather than resect injuries and may be\\nmore cost effective than instruments.\\nPreparation\\nBefore the procedure, blood and urine studies and\\nx rays of the joint will be conducted.\\nAftercare\\nImmediately after the procedure, the patient will\\nspend several hours in the recovery room. An ice pack\\nwill be put on the joint that was operated on for up to\\n48 hours after the procedure. Pain medicine, prescrip-\\ntion or non-prescription, will be given. The morning\\nafter the surgery, the dressing can be removed and\\nreplaced by adhesive strips. The patient should call\\nhis/her doctor upon experiencing an increase inpain,\\nswelling, redness, drainage or bleeding at the site of the\\nsurgery, signs of infection (headache, muscle aches,\\ndizziness, fever), ornausea or vomiting.\\nIt takes several days for the puncture wounds\\nto heal, and several weeks for the joint to fully recover.\\nMany patients can resume their daily activities, includ-\\ning going back to work, within a few days of the\\nprocedure. Arehabilitation program, including physi-\\ncal therapy, may be suggested to speed recovery and\\nimprove the future functioning of the joint.\\nRisks\\nComplications are rare in arthroscopic surgery,\\noccurring in less than 1% of patients. These include\\ninfection and inflammation, blood vessel clots, damage\\nto blood vessels or nerves, and instrument breakage.\\nResources\\nPERIODICALS\\nWilkinson, Todd. ‘‘Pop, Crackle, Snap.’’Women’s Sports &\\nFitness (April 1998): 68.\\nLori De Milto\\nArthroscopy\\nDefinition\\nArthroscopy is the examination of a joint, specifi-\\ncally, the inside structures. The procedure is performed\\nby inserting a specifically designed illuminated device\\ninto the joint through a small incision. This instrument\\nis called an arthroscope. The procedure of arthroscopy\\nis primarily associated with the process of diagnosis.\\nHowever, when actual repair is performed, the proce-\\ndure is calledarthroscopic surgery.\\nPurpose\\nArthroscopy is used primarily by doctors who\\nspecialize in treating disorders of the bones and\\nKEY TERMS\\nJoint— The point where bones meet. Arthroscopic\\nsurgery is used on joint problems.\\nLaser— A device that concentrates electromagnetic\\nradiation into a narrow beam and treats tissue\\nquickly without heating surrounding areas.\\nOrthopedics— The medical specialty that deals\\nwith preserving, restoring, and developing form\\nand function in the extremities, spine, and other\\nstructures using medical, surgical, and physical\\nmethods. Arthroscopic surgery is performed by\\northopedic surgeons.\\nGALE ENCYCLOPEDIA OF MEDICINE 411\\nArthroscopy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 441, 'page_label': '412'}, page_content='related structures (orthopedics) to help diagnose\\njoint problems. Once described as essential for those\\nwho primarily care for athletic injuries, arthroscopy\\nis now a technique commonly used by orthopedic\\nsurgeons for the treatment of patients of all ages.\\nThis procedure is most commonly used to diagnose\\nknee and shoulder problems, although the elbow,\\nhip, wrist, and ankle may also be examined with an\\narthroscope.\\nA joint is a complex system. Within a joint, liga-\\nments attach bones to other bones, tendons attach\\nmuscles to bones, cartilage lines and helps protect the\\nends of bones, and a special fluid (synovial fluid)\\ncushions and lubricates the structures. Looking inside\\nthe joint allows the doctors to see exactly which struc-\\ntures are damaged. Arthroscopy also permits earlier\\ndiagnosis of many types of joint problems which had\\nbeen difficult to detect in previous years.\\nPrecautions\\nMost arthroscopic procedures today are per-\\nformed in same-day surgery centers where the patient\\nis admitted just before surgery. A few hours following\\nthe procedure, the patient is allowed to return home,\\nArthroscope\\nSuperolateral Superomedial\\nCommon entry sites for the arthroscope\\nInferomedial\\nCentral\\nMedialLateral\\nInferolateral\\nArthroscopy is primarily used to help diagnose joint problems. This procedure, most commonly associated with knee and\\nshoulder problems, allows accurate examination and diagnosis of damaged joint ligaments, surfaces, and other related joint\\nstructures. The illustration above indicates the most common entry sites, or portals, in knee arthroscopy. (Illustration by\\nElectronic Illustrators Group.)\\n412 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroscopy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 442, 'page_label': '413'}, page_content='although usually someone else must drive. Depending\\non the type of anesthesia used, the patient may be told\\nnot to eat for several hours before arriving. Before the\\nprocedure, the anesthesiologist will ask if the patient\\nhas any knownallergies to local or general anesthetics.\\nAirway obstruction is always possible in any patient\\nwho receives a general anesthesia. Because of this,\\noxygen, suction, and monitoring equipment must be\\navailable. The patient’s cardiac status should always\\nbe monitored in the event that any cardiac abnormal-\\nities arise during the arthroscopy.\\nDescription\\nThe arthroscope is an instrument used to look\\ndirectly into the joint. It contains magnifying lenses\\nand glass-coated fibers that send concentrated light\\ninto the joint. A camera attached to the arthroscope\\nallows the surgeon to see a clear image of the joint.\\nThis image is then transferred to a monitor located in\\nthe operating room at the time of the arthroscopy.\\nThis video technology is also important for docu-\\nmentation of the arthroscopic procedure. For exam-\\nple, if the surgeon decides after the arthroscopic\\nexamination that a conventional approach to surgi-\\ncally expose or ‘‘open’’ the joint (arthrotomy) must\\nbe used, a good photographic record will be useful\\nwhen the surgeon returns to execute the final surgical\\nplan.\\nThe procedure requires the surgeon to make sev-\\neral small incisions (portals) through the skin’s surface\\ninto the joint. Through one or two of the portals, a\\nlarge-bore needle, called a cannula, is attached to tub-\\ning and inserted into the joint. The joint is inflated\\nwith a sterile saline solution to expand the joint and\\nensure clear arthroscopic viewing. Often, following a\\nrecent traumatic injury to a joint, the joint’s natural\\nfluid may be cloudy, making interior viewing of the\\njoint difficult. In this condition, a constant flow of the\\nsaline solution is necessary. This inflow of saline solu-\\ntion may be through the cannula with the outflow\\nthrough the arthroscope, or the positions may be\\nreversed. The arthroscope is placed through one of\\nthe portals to view and evaluate the condition of the\\njoint.\\nPreparation\\nBefore an arthroscopy can take place, the surgeon\\ncompletes a thorough medical history and evaluation.\\nImportant for the accuracy of this diagnostic\\nprocedure, a medical history and evaluation may dis-\\ncover other disorders of the joint or body parts, prov-\\ning the procedure unnecessary. This is always\\nan important preliminary step, because pain can\\noften be referred to a joint from another area of\\nthe body. Anatomical models and pictures are\\nuseful aids to explain to the patient the proposed\\narthroscopy and what the surgeon may be looking at\\nspecifically.\\nProper draping of the body part is important to\\nprevent contamination from instruments used in\\narthroscopy, such as the camera, light cords, and\\ninflow and outflow drains placed in the portals.\\nDraping packs used in arthroscopy include disposable\\npaper gowns and drapes with adhesive backing. The\\nsurgeon may also place a tourniquet above the joint to\\ntemporarily block blood flow to the area during the\\narthroscopic exam.\\nGeneral or local anesthesia may be used during\\narthroscopy. Local anesthesia is usually used\\nbecause it reduces the risk of lung and heart com-\\nplications and allows the patient to go home sooner.\\nThe local anesthetic may be injected in small\\namounts in multiple locations in skin and joint\\ntissues in a process called infiltration. In other\\ncases, the anesthetic is injected into the spinal cord\\nor a main nerve supplying the area. This process is\\ncalled a ‘‘block,’’ and it blocks all sensation below\\nthe main trunk of the nerve. For example, a femoral\\nblock anesthetizes the leg from the thigh down (its\\nname comes from femur, the thighbone). Most\\npatients are comfortable once the skin, muscles,\\nand other tissues around the joint are numbed by\\nthe anesthetic; however, some patients are also\\ngiven a sedative if they express anxiety about the\\nprocedure. (It’s important for the patient to remain\\nstill during the arthroscopic examination.)\\nGeneral anesthesia, in which the patient becomes\\nunconcious, may be used if the procedure may be\\nunusually complicated or painful. For example,\\npeople who have relatively ‘‘tight’’ joints may be can-\\ndidates for general anesthesia because the procedure\\nmay take longer and cause more discomfort.\\nKEY TERMS\\nHemarthrosis— A condition of blood within a joint.\\nPulmonary embolus— Blockage of an artery of the\\nlung by foreign matter such as fat, tumor, tissue, or\\na clot originating from a vein.\\nThrombophlebitis— Inflamation of a vein with the\\nformation of a thrombus or clot.\\nGALE ENCYCLOPEDIA OF MEDICINE 413\\nArthroscopy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 443, 'page_label': '414'}, page_content='Aftercare\\nThe portals are closed by small tape strips or\\nstitches and covered with dressings and a bandage.\\nThe patient spends a short amount of time in the\\nrecovery room after arthroscopy. Most patients can\\ngo home after about an hour in the recovery room.\\nPain medication may be prescribed for a short period;\\nhowever, many patients find various over-the-counter\\npain relievers sufficient.\\nFollowing the surgical procedure, the patient\\nneeds to be aware of the signs of infection, which\\ninclude redness, warmth, excessive pain, and swelling.\\nThe risk of infection increases if the incisions become\\nwet too early following surgery. Because of this, it is\\ngood practice to cover the joint with plastic (for exam-\\nple, a plastic bag) while showering after arthroscopy.\\nThe use of crutches is commonplace after arthro-\\nscopy, with progression to independent walking on an\\n‘‘as tolerated’’ basis by the patient. Generally, areha-\\nbilitation program, supervised by a physical therapist,\\nfollows shortly after the arthroscopy to help the\\npatient regain mobility and strength of the affected\\njoint and limb.\\nRisks\\nThe incidence of complications is low compared\\nto the high number of arthroscopic procedures per-\\nformed every year. Possible complications include\\ninfection, swelling, damage to the tissues in the joint,\\nblood clotsin the leg veins (thrombophlebitis), leakage\\nof blood into the joint (hemarthrosis), blood clots that\\nmove to the lung (pulmonary embolus), and injury to\\nthe nerves around the joint.\\nNormal results\\nThe goal of arthroscopy is to diagnose a joint\\nproblem causing pain and/or restrictions in normal\\njoint function. For example, arthroscopy can be a\\nuseful tool in locating a tear in the joint surface of\\nthe knee or locating a torn ligament of the shoulder.\\nArthroscopic examination is often followed by arthro-\\nscopic surgery performed to repair the problem with\\nappropriate arthroscopic tools. The final result is to\\ndecrease pain, increase joint mobility, and thereby\\nimprove the overall quality of the patient’s activities\\nof daily living.\\nAbnormal results\\nLess optimal results that may require further treat-\\nment include adhesive capsulitis. In this condition, the\\njoint capsule that naturally forms around the joint\\nbecomes thickened, formingadhesions.T h i sr e s u l t si n\\na stiff and less mobile joint. This problem is frequently\\ncorrected by manipulation and mobilization of the\\njoint with the patient placed under general anesthesia.\\nResources\\nPERIODICALS\\nGlassman, Scott. ‘‘Advances in Treating Shoulder Injuries.’’\\nAdvanced Magazine for Physical Therapists(December\\n1997): 10-12.\\nJeffrey P. Larson, RPT\\nArtificial insemination see Infertility\\ntherapies\\nAsbestosis\\nDefinition\\nAsbestosis is chronic, progressive inflammation of\\nthe lung. It is not contagious.\\nDescription\\nAsbestosis is a consequence of prolonged expo-\\nsure to large quantities of asbestos, a material once\\nwidely used in construction, insulation, and manufac-\\nturing. When asbestos is inhaled, fibers penetrate the\\nbreathing passages and irritate, fill, inflame, and scar\\nlung tissue. In advanced asbestosis,, the lungs shrink,\\nstiffen, and become honeycombed (riddled with tiny\\nholes).\\nLegislation has reduced use of asbestos in the\\nUnited States, but workers who handle automobile\\nbrake shoe linings, boiler insulation, ceiling acoustic\\ntiles, electrical equipment, and fire-resistant materials\\nare still exposed to the substance. Asbestos is used in\\nthe production of paints and plastics. Significant\\namounts can be released into the atmosphere when\\nold buildings or boats are razed or remodeled.\\nAsbestosis is most common in men over 40 who\\nhave worked in asbestos-related occupations.\\nSmokers or heavy drinkers have the greatest risk of\\ndeveloping this disease. Between 1968 and 1992,\\nmore than 10,000 Americans over the age of 15 died\\nas a result of asbestosis. Nearly 25% of those who\\ndied lived in California or New Jersey, and most of\\nthem had worked in the construction or shipbuilding\\ntrades.\\n414 GALE ENCYCLOPEDIA OF MEDICINE\\nAsbestosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 444, 'page_label': '415'}, page_content='Causes and symptoms\\nOccupational exposure is the most common cause\\nof asbestosis, but the condition also strikes people who\\ninhale asbestos fiber or who are exposed to waste\\nproducts from plants near their homes. Family mem-\\nbers can develop the disease as a result of inhaling\\nparticles of asbestos dust that cling to workers’\\nclothes.\\nIt is rare for asbestosis to develop in anyone who\\nhasn’t been exposed to large amounts of asbestos on a\\nregular basis for at least 10 years. Symptoms of the\\ndisease do not usually appear until 15–20 years after\\ninitial exposure to asbestos.\\nThe first symptom of asbestosis is usually short-\\nness of breath following exercise or other physical\\nactivity. The early stages of the disease are also char-\\nacterized by a drycough and a generalized feeling of\\nillness.\\nAs the disease progresses and lung damage\\nincreases, shortness of breath occurs even when\\nthe patient is at rest. Recurrent respiratory infec-\\ntions and coughing up blood are common. So is\\nswelling of the feet, ankles, or hands. Other symp-\\ntoms of advanced asbestosis include chest pain,\\nhoarseness, and restless sleep. Patients who have\\nasbestosis often have clubbed (widened and thick-\\nened) fingers. Other potential complications\\ninclude heart failure, collapsed (deflated) lung,\\nand pleurisy (inflammation of the membrane that\\nprotects the lung).\\nDiagnosis\\nScreening of at-risk workers can reveal lung\\ninflammation and lesions characteristic of asbestosis.\\nPatients’ medical histories can identify occupations,\\nhobbies, or other situations likely to involve exposure\\nto asbestos fibers.\\nX rays can show shadows or spots on the lungs\\nor an indistinct or shaggy outline of the heart that\\nsuggests the presence of asbestosis. Blood tests are\\nused to measure concentrations of oxygen and carbon\\ndioxide. Pulmonary function tests can be used to\\nassess a patient’s ability to inhale and exhale, and a\\ncomputed tomography scan (CT) of the lungs can\\nshow flat, raised patches associated with advanced\\nasbestosis.\\nTreatment\\nThe goal of treatment is to help patients breathe\\nmore easily, prevent colds and other respiratory infec-\\ntions, and control complications associated with\\nadvanced disease. Ultrasonic, cool-mist humidifiers\\nor controlled coughing can loosen bronchial\\nsecretions.\\nRegular exercise helps maintain and improve lung\\ncapacity. Although temporary bed rest may be recom-\\nmended, patients are encouraged to resume their reg-\\nular activities as soon as they can.\\nAnyone who develops symptoms of asbestosis\\nshould see a family physician or lung disease specialist.\\nA doctor should be notified if someone who has been\\ndiagnosed with asbestosis:\\n/C15coughs up blood\\n/C15continues to lose weight\\n/C15is short of breath\\n/C15has chestpain\\n/C15develops a suddenfever of 1018F (38.38C) or higher\\n/C15develops unfamiliar, unexplained symptoms\\nPrognosis\\nAsbestosis can’t be cured, but its symptoms\\ncan be controlled. Doctors don’t know why the\\nMicrograph of asbestos fibers embedded in lung tissue.\\n(Photograph by Dr. E. Walker, Custom Medical Stock Photo.\\nReproduced by permission.)\\nKEY TERMS\\nAsbestos— A silicate (containing silica) mineral\\nthat occurs in a variety of forms; it is characterized\\nby a fibrous structure and resistance to fire.\\nGALE ENCYCLOPEDIA OF MEDICINE 415\\nAsbestosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 445, 'page_label': '416'}, page_content='health of some patients deteriorates and the condi-\\ntion of others remain the same, but believe the\\ndifference may be due to varying exposures of\\nasbestos. People with asbestosis who smoke, parti-\\ncularly those who smoke more than one pack of\\ncigarettes each day, are at increased risk for devel-\\noping lung cancer and should be strongly advised\\nto quit smoking.\\nPrevention\\nWorkers in asbestosis-related industries should\\nhave regular x rays to determine whether their\\nlungs are healthy. A person whose lung x ray\\nshows a shadow should eliminate asbestos expo-\\nsure even if no symptoms of the condition have\\nappeared.\\nAnyone who works with asbestos should wear a\\nprotective mask or a hood with a clean-air supply and\\nobey recommended procedures to control asbestos\\ndust. Anyone who is at risk of developing asbestosis\\nshould:\\n/C15not smoke\\n/C15be vaccinated againstinfluenza and pneumonia\\n/C15exercise regularly to maintain cardiopulmonary\\nfitness\\n/C15avoid crowds and people who have respiratory\\ninfections\\nA person who has asbestosis should exercise\\nregularly, relax, and conserve energy whenever\\nnecessary.\\nResources\\nBOOKS\\nBurton, George G., John E. Hodgkin, and Jeffrey J. Ward,\\neditors. Respiratory Care: A Guide to Clinical Practice.\\n4th ed. Philadelphia: Lippincott, 1997.\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York,\\nNY 10019. (800) 586-4872. .\\nMaureen Haggerty\\nAscariasis see Roundworm infections\\nAscending cholangitis see Cholangitis\\nAscending contrast phlebography see\\nVenography\\nAscites\\nDefinition\\nAscites is an abnormal accumulation of fluid in\\nthe abdomen.\\nDescription\\nRapidly developing (acute) ascites can occur as a\\ncomplication of trauma, perforated ulcer, appendici-\\ntis, or inflammation of the colon or other tube-shaped\\norgan (diverticulitis). This condition can also develop\\nwhen intestinal fluids, bile, pancreatic juices, or bacteria\\ninvade or inflame the smooth, transparent membrane\\nthat lines the inside of the abdomen (peritoneum).\\nHowever, ascites is more often associated withliver\\ndisease and other long-lasting (chronic) conditions.\\nTypes of ascites\\nCirrhosis, which is responsible for 80% of all\\ninstances of ascities in the United States, triggers a\\nseries of disease-producing changes that weaken the\\nkidney’s ability to excrete sodium in the urine.\\nPancreatic ascites develops when a cyst that has\\nthick, fibrous walls (pseudocyst) bursts and permits\\npancreatic juices to enter the abdominal cavity.\\nChylous ascites has a milky appearance caused by\\nlymph that has leaked into the abdominal cavity.\\nAlthough chylous ascites is sometimes caused by\\ntrauma, abdominal surgery,tuberculosis, or another\\nperitoneal infection, it is usually a symptom of lym-\\nphoma or some othercancer.\\nCancer causes 10% of all instances of ascites in the\\nUnited States. It is most commonly a consequence of\\ndisease that originates in the peritoneum (peritoneal\\ncarcinomatosis) or of cancer that spreads (metasta-\\nsizes) from another part of the body.\\nEndocrine and renal ascites are rare disorders.\\nEndocrine ascites, sometimes a symptom of an endo-\\ncrine system disorder, also affects women who are\\ntaking fertility drugs. Renal ascites develops when\\nblood levels of albumin dip below normal. Albumin\\nis the major protein in blood plasma. It functions to\\nkeep fluid inside the blood vessels.\\nCauses and symptoms\\nCauses\\nThe two most important factors in the production\\nof ascites due to chronic liver disease are:\\n416 GALE ENCYCLOPEDIA OF MEDICINE\\nAscites'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 446, 'page_label': '417'}, page_content='/C15Low levels of albumin in the blood that cause a\\nchange in the pressure necessary to prevent fluid\\nexchange (osmotic pressure). This change in pressure\\nallows fluid to seep out of the blood vessels.\\n/C15An increase in the pressure within the branches of\\nthe portal vein that run through liver (portal\\nhypertension). Portal hypertension is caused by\\nthe scarring that occurs in cirrhosis. Blood that\\ncannot flow through the liver because of the\\nincreased pressure leaks into the abdomen and\\ncauses ascites.\\nOther conditions that contribute to ascites devel-\\nopment include:\\n/C15hepatitis\\n/C15heart or kidney failure\\n/C15inflammation and fibrous hardening of the sac that\\ncontains the heart (constrictive pericarditis)\\nPersons who have systemic lupus erythematosus\\nbut do not have liver disease or portal hypertension\\noccasionally develop ascites. Depressed thyroid\\nactivity sometimes causes pronounced ascites, but\\ninflammation of the pancreas (pancreatitis) rarely\\ncauses significant accumulations of fluid.\\nSymptoms\\nSmall amounts of fluid in the abdomen do not\\nusually produce symptoms. Massive accumulations\\nmay cause:\\n/C15rapid weight gain\\n/C15abdominal discomfort and distention\\n/C15shortness of breath\\n/C15swollen ankles\\nDiagnosis\\nSkin stretches tightly across an abdomen that con-\\ntains large amounts of fluid. The navel bulges or lies\\nflat, and the fluid makes a dull sound when the doctor\\ntaps the abdomen. Ascitic fluid may cause the flanks\\nto bulge.\\nPhysical examinationgenerally enables doctors to\\ndistinguish ascities from pregnancy, intestinal gas,\\nobesity, or ovarian tunors. Ultrasound orcomputed\\ntomography scans (CT)can detect even small amounts\\nof fluid. Laboratory analysis of fluid extracted by\\ninserting a needle through the abdominal wall (diag-\\nnostic paracentesis) can help identify the cause of the\\naccumulation.\\nA computed tomography (CT) scan of an axial section\\nthrough the abdomen, showing ascites. At right is the liver\\noccupying much of the abdomen; the stomach and spleen are\\nalso seen. Around these organs is fluid giving rise to this\\ncondition. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nKEY TERMS\\nComputed tomography scan (CT)— An imaging\\ntechnique in which cross-sectional x rays of the\\nbody are compiled to create a three-dimensional\\nimage of the body’s internal structures.\\nInterferon— A protein formed when cells are\\nexposed to a virus. Interferon causes other nonin-\\nfected cells to develop translation inhibitory\\nprotein (TIP). TIP blocks viruses from infecting\\nnew cells.\\nParacentesis— A procedure in which fluid is\\ndrained from a body cavity by means of a catheter\\nplaced through an incision in the skin.\\nSystemic lupus erythematosus— An inflammatory\\ndisease that affects many body systems, including\\nthe skin, blood vessels, kidneys, and nervous sys-\\ntem. It is characterized, in part, by arthritis, skin\\nrash, weakness, and fatigue.\\nUltrasonography— A test using sound waves to\\nmeasure blood flow. Gel is applied to a hand-held\\ntransducer that is pressed against the patient’s\\nbody. Images are displayed on a monitor.\\nGALE ENCYCLOPEDIA OF MEDICINE 417\\nAscites'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 447, 'page_label': '418'}, page_content='Treatment\\nReclining minimizes the amount of salt the kid-\\nneys absorb, so treatment generally starts with bed rest\\nand a low-salt diet. Urine-producing drugs (diuretics)\\nmay be prescribed if initial treatment is ineffective.\\nThe weight and urinary output of patients using diure-\\ntics must be carefully monitored for signs of :\\n/C15hypovolemia (massive loss of blood or fluid)\\n/C15azotemia (abnormally high blood levels of nitrogen-\\nbearing materials)\\n/C15potassium imbalance\\n/C15high sodium concentration. If the patient consumes\\nmore salt than the kidneys excrete, increased doses of\\ndiuretics should be prescribed\\nModerate-to-severe accumulations of fluid are\\ntreated by draining large amounts of fluid (large-\\nvolume paracentesis) from the patient’s abdomen.\\nThis procedure is safer than diuretic therapy. It\\ncauses fewer complications and requires a shorter\\nhospital stay.\\nLarge-volume paracentesis is also the preferred\\ntreatment for massive ascites. Diuretics are sometimes\\nused to prevent new fluid accumulations, and the pro-\\ncedure may be repeated periodically.\\nAlternative treatment\\nDietary alterations, focused on reducing salt\\nintake, should be a part of the treatment. In less severe\\ncases, herbal diuretics like dandelion (Taraxacum offi-\\ncinale) can help eliminate excess fluid and provide\\npotassium. Potassium-rich foods like low-fat yogurt,\\nmackerel, cantaloupe, and baked potatoes help bal-\\nance excess sodium intake.\\nPrognosis\\nThe prognosis depends upon the condition that is\\ncausing the ascites. Carcinomatous ascites has a very\\nbad prognosis. However, salt restriction and diuretics\\ncan control ascites caused byliver disease in many cases.\\nTherapy should also be directed towards the\\nunderlying disease that produces the ascites.\\nCirrhosis should be treated by abstinence from alcohol\\nand appropriate diet. The new interferon agents\\nmaybe helpful in treating chronic hepatitis.\\nPrevention\\nModifying or restricting use of salt can prevent\\nmost cases of recurrent ascites.\\nResources\\nBOOKS\\nBerkow, Robert, editor.The Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nOTHER\\n‘‘Hepatic and Liver Disorders.’’The Meck Page.April 20,\\n1998. .\\nMaureen Haggerty\\nAscorbic acid deficiency see Scurvy\\nASD see Atrial septal defect\\nAsian American health see Minority health\\nAsian flu see Influenza\\nAspartate aminotransferase test\\nDefinition\\nThe Aspartate aminotransferase test measures\\nlevels of AST, an enzyme released into the blood\\nwhen certain organs or tissues, particularly the liver\\nand heart, are injured. Aspartate aminotransferase\\n(AST) is also known as serum glutamic oxaloacetic\\ntransaminase (SGOT).\\nPurpose\\nThe determination of AST levels aids primarily in\\nthe diagnosis ofliver disease. In the past, the AST test\\nwas used to diagnoseheart attack(myocardial infarc-\\ntion or MI) but more accurate blood tests have largely\\nreplaced it for cardiac purposes.\\nDescription\\nAST is determined by analysis of a blood sample,\\nusually from taken from a venipuncture site at the\\nbend of the elbow.\\nAST is found in the heart, liver, skeletal muscle,\\nkidney, pancreas, spleen, lung, red blood cells, and\\nbrain tissue. When disease or injury affects these\\ntissues, the cells are destroyed and AST is released\\ninto the bloodstream. Theamount of AST is directly\\n418 GALE ENCYCLOPEDIA OF MEDICINE\\nAspartate aminotransferase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 448, 'page_label': '419'}, page_content='related to the number of cells affected by the disease\\nor injury, but the level of elevation depends on the\\nlength of time that the blood is tested after the\\ninjury. Serum AST levels become elevated eight\\nhours after cell injury, peak at 24-36 hours, and\\nreturn to normal in three to seven days. If the\\ncellular injury is chronic (ongoing), AST levels will\\nremain elevated.\\nOne of the most important uses for AST determi-\\nnation has formerly been in the diagnosis of a heart\\nattack, or MI. AST can assist in determining the\\ntiming and extent of a recent MI, although it is less\\nspecific than creatine phosphokinase (CPK), CKMB,\\nmyglobin, troponins, and lactic dehydrogenase\\n(LDH). Assuming no further cardiac injury occurs,\\nthe AST level rises within 6-10 hours after an acute\\nattack, peaks at 12-48 hours, and returns to normal\\nin three to four days. Myocardial injuries such as\\nangina (chest pain)o r pericarditis (inflammation of\\nthe pericardium, the membrane around the heart) do\\nnot increase AST levels.\\nAST is also a valuable aid in the diagnosis of liver\\ndisease. Although not specific for liver disease, it can\\nbe used in combination with other enzymes to monitor\\nthe course of various liver disorders. Chronic, silent\\nhepatitis (hepatitis C) is sometimes the cause of ele-\\nvated AST. Inalcoholic hepatitis, caused by excessive\\nalcohol ingestion, AST values are usually moderately\\nelevated; in acute viral hepatitis, AST levels can rise to\\nover 20 times normal. Acute extrahepatic (outside the\\nliver) obstruction (e.g. gallstone), produces AST levels\\nthat can quickly rise to 10 times normal, and then\\nrapidly fall. In cases of cirrhosis, the AST level is\\nrelated to the amount of active inflammation of the\\nliver. Determination of AST also assists in early recog-\\nnition of toxic hepatitis that results from exposure to\\ndrugs toxic to the liver, like acetaminophen and\\ncholesterol lowering medications.\\nOther disorders or diseases in which the AST\\ndetermination can be valuable include acute\\npancreatitis, muscle disease, trauma, severe burn, and\\ninfectious mononucleosis.\\nPreparation\\nThe physician may require discontinuation of any\\ndrugs that might affect the test. These types include\\nsuch drugs as antihypertensives (for treatment of\\nhigh blood pressure), coumarin-type anticoagulants\\n(blood-thinning drugs), digitalis, erythromycin (an\\nantibiotic), oral contraceptives, and opiates, among\\nothers. The patient may also need to cut back on\\nstrenuous activities temporarily, becauseexercise can\\nalso elevate AST for a day or two.\\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 ranges for the AST are laboratory-\\nspecific, but can range from 3-45 units/L (units per\\nliter).\\nAbnormal results\\nStriking elevations of AST (400-4000 units/L) are\\nfound in almost all forms of acute hepatic necrosis,\\nsuch as viral hepatitis and carbon tetrachloridepoison-\\ning. In alcoholics, even moderate doses of the analgesic\\nacetaminophen have caused extreme elevations\\n(1, 960-29, 700 units/L). Moderate rises of AST are\\nseen injaundice, cirrhosis, and metastatic carcinoma.\\nApproximately 80% of patients with infectious mono-\\nnucleosis show elevations in the range of 100-600\\nunits/L.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAsperger’s syndromesee Pervasive develop-\\nmental disorders\\nAspergilloma see Aspergillosis\\nKEY TERMS\\nCirrhosis— Disease of the liver caused by chronic\\ndamage to its cells.\\nMyocardial infarction— Commonly known as a\\nheart attack. Sudden death of part of the heart\\nmuscle, characterized, in most cases, by severe,\\nunremitting chest pain.\\nGALE ENCYCLOPEDIA OF MEDICINE 419\\nAspartate aminotransferase test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 449, 'page_label': '420'}, page_content='Aspergillosis\\nDefinition\\nAspergillosis refers to several forms of disease\\ncaused by a fungus in the genus Aspergillus.\\nAspergillosis fungal infections can occur in the ear\\ncanal, eyes, nose, sinus cavities, and lungs. In some\\nindividuals, the infection can even invade bone and the\\nmembranes that enclose the brain and spinal cord\\n(meningitis).\\nDescription\\nAspergillosis is primarily an infection of the lungs\\ncaused by the inhalation of airborne spores of the\\nfungus Aspergillus. Spores are the small particles that\\nmost fungi use to reproduce. Although virtually every-\\none is exposed to this fungus in their daily environ-\\nment, it rarely causes disease. WhenAspergillus does\\ncause disease, however, it usually occurs in those\\nindividuals with weakened immune systems (immuno-\\ncompromised) or who have a history of respiratory\\nailments. Because it does not present distinctive symp-\\ntoms, aspergillosis is generally thought to be under-\\ndiagnosed and underreported. Furthermore, many\\npatients with the more severe forms of aspergillosis\\ntend to have multiple, complex health problems, such\\nas AIDS or a blood disorder like leukemia, which can\\nfurther complicate diagnosis and treatment.\\nOnce considered particularly rare, the incidence of\\nreported aspergillosis has risen somewhat with the\\ndevelopment of more sophisticated methods of diag-\\nnosis and advances made in other areas of medicine,\\nsuch as with the increased use of certain chemother-\\napeutic and corticosteroid drugs that are extremely\\nuseful in treating various types ofcancer but that\\ndecrease the individual’s immune response, making\\nthem more susceptible to other diseases like\\naspergillosis.\\nOur advanced ability to perform tissue and organ\\ntransplants has also increased the number of people\\nvulnerable to fungal infections. Transplant recipients,\\nparticularly those receiving bone marrow or heart\\ntransplants, are highly susceptible to Aspergillus,\\nwhich may be circulating in the hospital air.\\nAspergillosis can be a serious, potentially deadly\\nthreat for two primary reasons:\\n/C15Aspergillosis usually occurs in those individuals who\\nare already ill or have weakened immune systems,\\nsuch as patients who have undergonechemotherapy\\nfor cancer.\\nAspergillus\\nAspergillosis is an infection of the lungs caused by inhala-\\ntion of airborne spores of the fungusAspergillus. (Illustration\\nby Electronic Illustrators Group).\\nKEY TERMS\\nAntibody— A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAspergilloma— A ball or mass made of Aspergillus\\nfungi that can form in the lungs of patients with\\nsuppressed immune systems.\\nBronchial lavage— A procedure that involves\\nrepeatedly washing the inside of the bronchial\\ntubes of the lung.\\nHemoptysis— Spitting up blood from the lungs or\\nsputum stained with blood.\\nImmunocompromised— A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nMeningitis— Inflammation of the membranes cover-\\ning the brain and spinal cord, called the meninges.\\nNebulizer— A device that produces an extremely\\nfine mist that is readily inhalable.\\nSpores— The small, thick-walled reproductive\\nstructures of fungi.\\nSputum— Mucus and other matter coughed up\\nfrom the airways.\\n420 GALE ENCYCLOPEDIA OF MEDICINE\\nAspergillosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 450, 'page_label': '421'}, page_content='/C15None of the currently available antifungal drugs are\\nreliably effective againstAspergillus.\\nCauses and symptoms\\nAirborne Aspergillus spores enter the body pri-\\nmarily through inhalation but can also lodge in the\\near or eye. Normally functioning immune systems are\\ngenerally able to cope without consequent develop-\\nment of aspergillosis.\\nIt is important to make distinctions between the\\nvarious forms of aspergillosis, as the treatment and\\nprognosis varies considerably among types.\\nAspergillosis as a diagnosis refers to three general\\nforms:\\n/C15Allergic bronchopulmonary aspergillosis (ABPA) is\\nseen in patients with long-standing asthma, particu-\\nlarly in patients taking oralcorticosteroids for a long\\nperiod of time. This is usually the least serious and\\nmost treatable form.\\n/C15Aspergilloma refers to the mass formed when fungal\\nspores settle into or colonize areas of the lung that\\nhave been pitted and scarred as a result of tubercu-\\nlosis or priorpneumonia. There are several available\\ntreatments, although the success rate varies with each\\ntreatment.\\n/C15Invasive fungal infection refers to rare cases in which\\nthe fungus spreads throughout the body via the\\nblood stream and invades other organ systems.\\nOnce established, invasive fungal infections are\\nextremely difficult to cure and, as a result, the asso-\\nciated death rate is extremely high.\\nDiagnosis\\nAspergillosis can be quite difficult to diagnose\\nbecause the symptoms, such as coughing andwheezing,\\nif present at all, are common to many respiratory\\ndisorders. Furthermore, blood and sputum cultures\\nare not very helpful. The presence ofAspergillus is\\nso common, even in asthmatics, that a positive culture\\nalone is insufficient for a diagnosis. Other, potentially\\nmore useful, screening tools include examining the\\nsample obtained after repeatedly washing the bronchial\\ntubes of the lung with water (bronchial lavage), but\\nexamining a tissue sample (biopsy) is the most reliable\\ndiagnostic tool. Researchers are currently attempting\\nto develop a practical, specific, and rapid blood test\\nthat would confirmAspergillus infection.\\nSigns of ABPA include a worsening of bronchial\\nasthmaaccompanied by a low-grade fever. Brown flecks\\nor clumps may be seen in the sputum. Pulmonary\\nfunction tests may show decreased blood flow, suggest-\\ning an obstruction within the lungs. Elevated blood levels\\nof an antibody produced in response toAspergillusand\\nof certain immune system cells may indicate a specific\\nallergic-type immune system response.\\nA fungal mass (aspergilloma) in the lung usually\\ndoes not produce clear symptoms and is generally diag-\\nnosed when seen on chest x rays. However, 70% or\\nmore of patients spit up blood from the lungs (hemop-\\ntysis) at least once, and this may become repetitive and\\nserious. Hemoptysis, then, is another indication that\\nthe patient may be suffering from an aspergilloma.\\nIn patients with lowered immune systems who are\\nat risk for developing invasive aspergillosis, the physi-\\ncian may use a combination of blood culture with\\nvisual diagnostic techniques, such as computed tomo-\\ngraphy scans (CT) and radiography, to arrive at a\\nlikely diagnosis.\\nTreatment\\nThe treatment method selected depends on the\\nform of aspergillosis. ABPA can usually be treated\\nwith many of the same drugs used to treat asthma,\\nsuch as systemic steroids. Long-term therapy may be\\nrequired, however, to prevent recurrence. Antifungal\\nagents are not recommended in the treatment of\\nABPA. In cases of aspergilloma, it may become neces-\\nsary to surgically remove or reduce the size of a fungal\\nmass, especially if the patient continues to spit up\\nblood. In aspergillosis cases affecting the nose and\\nnasal sinuses, surgery may also be required.\\nIn non-ABPA cases, the use of antifungal drugs\\nmay be indicated. In such cases, amphotericin B\\n(Fungizone) is the first-line therapy. The prescribed\\ndose will depend on the patient’s condition but usually\\nbegins with a small test dose and then escalates. Less\\nthan one-third of patients are likely to respond to\\namphotericin B, and its side effects often limit its use.\\nFor patients who do not respond to oral amphotericin\\nB, another option is a different formulation of the\\nsame drug called liposomal amphotericin B.\\nFor patients who fail to respond or who cannot\\ntolerate amphotericin B, another drug called itracona-\\nzole (Sporanox), given 400-600 mg daily, has also been\\napproved. Treatment generally lasts about 3 months.\\nGiving itraconazole can produce adverse reactions if\\nprescribed in combination with certain other drugs by\\nincreasing the concentrations of both drugs in the\\nblood and creating a potentially life-threatening situa-\\ntion. Even antacids can significantly affect itracona-\\nzole levels. As a result, drug levels must be continually\\nGALE ENCYCLOPEDIA OF MEDICINE 421\\nAspergillosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 451, 'page_label': '422'}, page_content='monitored to ensure that absorption is occurring at\\nacceptable levels.\\nTwo other methods of treatment are being\\nstudied: direct instillat ion of an antifungal agent\\ninto the lungs and administration of antifungals\\nusing a nebulizer. Instilling or injecting amphoter-\\nicin B or itraconazole directly into the lung cavity\\nor into the fungal ball (aspergilloma) itself has\\nbeen helpful in stopping episodes of hemoptysis,\\nbut not in preventing future recurrences.\\nFurthermore, many patients with aspergillomas\\nare poor risks for surgery because their lung func-\\ntion is already compromise d .A sar e s u l t ,i n s t i l l a -\\ntion of a fungal agent should only be considered in\\nthose who have significant hempotysis.\\nA popular method of treating some respiratory\\ndisorders is to add a liquid drug to another carrier liquid\\nand aerosolize or produce a fine mist that can be inhaled\\ninto the lungs through a device called a nebulizer.\\nHowever, this has not yet been shown to improve the\\npatient’s condition in cases of aspergillosis, possibly\\nbecause the drug is not reaching the aspergilloma.\\nAt this point, preventative therapy for aspergillo-\\nsis is not suggested for susceptible individuals, primar-\\nily because overuse of the drugs used to fight fungal\\ninfections may lead to the development of drug-\\nresistant aspergillosis against which current antifungal\\ndrugs are no longer effective.\\nPrognosis\\nThe likelihood of recovery from aspergillosis\\ndepends on any underlying medical conditions, the\\npatient’s general health, and the specific type of asper-\\ngillosis. If the problem is based on an allergic response,\\nas in ABPA, the patient will likely respond well to\\nsystemic steroids.\\nPatients who requirelung surgery, especially those\\nwho have problems with coughing up blood, have a\\nmortality rate of about 7-14%, and complications or\\nrecurrence may result in a higher overall death rate.\\nHowever, by treating aspergilloma with other, non-\\nsurgical methods, that risk rises to 26%, making sur-\\ngery a better option in some cases.\\nUnfortunately, the prognosis for the most serious\\nform, invasive aspergillosis, is quite poor, largely\\nbecause these patients have little resilience due to\\ntheir underlying disorders. Death rates have ranged\\nfrom about 50% in some studies to as high as 95% for\\nbone-marrow recipients and patients with AIDS. The\\ncourse of the illness can be rapid, resulting in death\\nwithin a few months of diagnosis.\\nPrevention\\nFungal infection byAspergillus presents a major\\nchallenge, particularly in the patient with a suppressed\\nimmune system (immunocompr omised). Hospitals\\nand government health agencies continually seek\\nways to minimize exposure for hospitalized patients.\\nPractical suggestions are minimal but include moving\\nleaf piles away from the house. Unfortunately, overall\\navoidance of this fungus is all but impossible because\\nit is present in the environment virtually everywhere.\\nResearch efforts are being directed at enhancing\\npatients’ resistance toAspergillus rather than trying\\nto eliminate exposure to the fungus. Given the grow-\\ning number of people with immune disorders or whose\\nimmune systems have been suppressed in the course of\\ntreating another disease, research and clinical trials\\nfor new antifungal agents will be increasingly impor-\\ntant in the future.\\nResources\\nORGANIZATIONS\\nAmerican College of Allergy, Asthma, and Immunology.\\n85 West Algonquin Road, Suite 550, Arlington Heights,\\nIL 60005. .\\nOTHER\\n‘‘Lung, Allergic and Immune Diseases: Mold Allergy:\\nPrevention Techniques.’’ National Jewish Medical and\\nResearch..\\nOffice of Rare Diseases (ORD) at National Institutes\\nof Health, Bldg. 31,1BO3, Bethesda, MD 20892-\\n2082. (301) 402-4336.\\nJill S. Lasker\\nAspirin\\nDefinition\\nAspirin is a medicine that relievespain and reduces\\nfever.\\nPurpose\\nAspirin is used to relieve many kinds of minor\\naches and pains–headaches, toothaches, muscle pain,\\nmenstrual cramps, the joint pain from arthritis, and\\naches associated with colds and flu. Some people take\\naspirin daily to reduce the risk of stroke, heart attack,\\nor other heart problems.\\n422 GALE ENCYCLOPEDIA OF MEDICINE\\nAspirin'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 452, 'page_label': '423'}, page_content='Description\\nAspirin–also known as acetylsalicylic acid–is sold\\nover the counter and comes in many forms, from the\\nfamiliar white tablets to chewing gum and rectal sup-\\npositories. Coated, chewable, buffered, and extended\\nrelease forms are available. Many other over-the-\\ncounter medicine contain aspirin. Alka-Seltzer\\nOriginal Effervescent Antacid Pain Reliever, for\\nexample, contains aspirin for pain relief and sodium\\nbicarbonate to relieve acid indigestion, heartburn, and\\nsour stomach.\\nAspirin belongs to a group of drugs called salicy-\\nlates. Other members of this group include sodium\\nsalicylate, choline salicylate, and magnesium salicy-\\nlate. These drugs are more expensive and no more\\neffective than aspirin. However, they are a little easier\\non the stomach. Aspirin is quickly absorbed into the\\nbloodstream and provides quick and relatively long-\\nlasting pain relief. Aspirin also reduces inflammation.\\nResearchers believe these effects come about because\\naspirin blocks the production of pain-producing che-\\nmicals called prostaglandins.\\nIn addition to relieving pain and reducing inflam-\\nmation, aspirin also lowersfever by acting on the part\\nof the brain that regulates temperature. The brain then\\nsignals the blood vessels to widen, which allows heat to\\nleave the body more quickly.\\nRecommended dosage\\nAdults\\nTO RELIEVE PAIN OR REDUCE FEVER. One to two\\ntablets every three to four hours, up to six times per day.\\nTO REDUCE THE RISK OF STROKE. One tablet four\\ntimes a day or two tablets twice a day.\\nTO REDUCE THE RISK OF HEART ATTACK.Check with\\na physician for the proper dose and number of times\\nper week aspirin should, if at all, be taken.\\nChildren\\nCheck with a physician.\\nPrecautions\\nAspirin–even children’s aspirin–should never be\\ngiven to children or teenagers with flu-like symptoms\\nor chickenpox. Aspirin can causeReye’s syndrome,a\\nlife-threatening condition that affects the nervous sys-\\ntem and liver. As many as 30% of children and teen-\\nagers who develop Reye’s syndrome die. Those who\\nsurvive may have permanent brain damage.\\nCheck with a physician before giving aspirin to a\\nchild under 12 years for arthritis, rheumatism, or any\\ncondition that requires long-term use of the drug.\\nNo one should take aspirin for more than 10 days\\nin a row unless told to do so by a physician. Anyone\\nwith fever should not take aspirin for more than 3 days\\nwithout a physician’s consent. Do not to take more\\nthan the recommended daily dosage.\\nPeople in the following categories should not use\\naspirin without first checking with their physician:\\n/C15Pregnant women. Aspirin can cause bleeding pro-\\nblems in both the mother and the developing fetus.\\nAspirin can also cause the infant’s weight to be too\\nlow at birth.\\n/C15Women who are breastfeeding. Aspirin can pass into\\nbreast milk and may affect the baby.\\nKEY TERMS\\nDiuretic— Medicine that increases the amount of\\nurine produced and relieves excess fluid buildup in\\nbody tissues. Diuretics may be used in treating high\\nblood pressure, lung disease, premenstrual syn-\\ndrome, and other conditions.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nNSAIDs— Nonsteroidal anti-inflammatory drugs.\\nDrugs such as ketoprofen and ibuprofen which\\nrelieve pain and reduce inflammation.\\nPolyp— A lump of tissue protruding from the lining\\nof an organ, such as the nose, bladder, or intestine.\\nPolyps can sometimes block the passages in which\\nthey are found.\\nProstaglandin— A hormonelike chemical produced\\nin the body. Prostaglandins have a wide variety of\\neffects, and may be responsible for the production\\nof some types of pain and inflammation.\\nReye’s syndrome— A life-threatening disease that\\naffects the liver and the brain and sometimes occurs\\nafter a viral infection, such as flu or chickenpox.\\nChildren or teenagers who are given aspirin for flu\\nor chickenpox are at increased risk of developing\\nReye’s syndrome.\\nRhinitis— Inflammation of the membranes inside\\nthe nose.\\nSalicylates— A group of drugs that includes aspirin\\nand related compounds. Salicylates are used to\\nrelieve pain, reduce inflammation, and lower fever.\\nGALE ENCYCLOPEDIA OF MEDICINE 423\\nAspirin'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 453, 'page_label': '424'}, page_content='/C15People with a history of bleeding problems.\\n/C15People who are taking blood-thinning drugs, such as\\nwarfarin (Coumadin).\\n/C15People with a history of ulcers.\\n/C15People with a history ofasthma, nasal polyps, or\\nboth. These people are more likely to be allergic to\\naspirin.\\n/C15People who are allergic to fenoprofen, ibuprofen,\\nindomethacin, ketoprofen, meclofenamate sodium,\\nnaproxen, sulindac, tolmetin, or the orange food-\\ncoloring tartrazine. They may also be allergic to\\naspirin.\\n/C15People withAIDS or AIDS-related complex who are\\ntaking AZT (zidovudine). Aspirin can increase the\\nrisk of bleeding in these patients.\\n/C15People taking certain other drugs (discussed in\\nInteractions).\\n/C15People with liver damage or severe kidney failure.\\nAspirin should not be taken before surgery, as it\\ncan increase the risk of excessive bleeding. Anyone\\nwho is scheduled for surgery should check with his or\\nher surgeon to find out how long before surgery to\\navoid taking aspirin.\\nAspirin can cause stomach irritation. To reduce\\nthe likelihood of that problem, take aspirin with food\\nor milk or drink a full 8-oz glass of water with it.\\nTaking coated or buffered aspirin can also help. Be\\naware that drinking alcohol can make the stomach\\nirritation worse.\\nStop taking aspirin immediately and call a physi-\\ncian if any of these symptoms develop:\\n/C15ringing or buzzing in the ears\\n/C15hearing loss\\n/C15dizziness\\n/C15stomach pain that does not go away\\nDo not take aspirin that has a vinegary smell.\\nThat is a sign that the aspirin is too old and ineffective.\\nFlush such aspirin down the toilet.\\nBecause aspirin can increase the risk of exces-\\nsive bleeding, do not take aspirin daily over long\\nperiods–to reduce the risk of stroke or heart\\nattack, for example–unless advised to do so by a\\nphysician.\\nSide effects\\nThe most common side effects include stomach-\\nache, heartburn, loss of appetite, and small amounts of\\nblood in stools. Less common side effects are rashes,\\nhives, fever, vision problems, liver damage, thirst, sto-\\nmach ulcers, and bleeding. People who are allergic to\\naspirin or those who have asthma,rhinitis, or polyps in\\nthe nose may have trouble breathing after taking\\naspirin.\\nInteractions\\nAspirin may increase, decrease, or change the\\neffects of many drugs. Aspirin can make drugs such\\nas methotrexate (Rheumatrex) and valproic acid\\n(Depakote, Depakene) more toxic. If taken with\\nblood-thinning drugs, such as warfarin (Coumadin)\\nand dicumarol, aspirin can increase the risk of\\nexcessive bleeding. Aspirin counteracts the effects\\nof other drugs, such as angiotensin-converting\\nenzyme (ACE) inhibitors and beta blockers, which\\nlower blood pressure, and medicines used to treat\\ngout (probenecid and sulfinpyrazone). Blood pres-\\nsure may drop unexpectedly and cause fainting or\\ndizziness if aspirin is taken along with nitroglycerin\\ntablets. Aspirin may also interact with diuretics,\\ndiabetes medicines, other nonsteroidal anti-inflam-\\nmatory drugs (NSAIDs), seizure medications, and\\nsteroids. Anyone who is taking these drugs should\\nask his or her physician whether they can safely\\ntake aspirin.\\nResources\\nPERIODICALS\\n‘‘What’s the Best Pain Reliever? Depends on Your Pain.’’\\nConsumer ReportsMay 1996: 62.\\nNancy Ross-Flanigan\\nAST see Aspartate aminotransferase test\\nAstemizole see Antihistamines\\nAsthma\\nDefinition\\nAsthma is a chronic (long-lasting) inflammatory\\ndisease of the airways. In those susceptible to asthma,\\nthis inflammation causes the airways to narrow peri-\\nodically. This, in turn, produceswheezing and breath-\\nlessness, sometimes to the point where the patient\\ngasps for air. Obstruction to air flow either stops\\nspontaneously or responds to a wide range of treat-\\nments, but continuing inflammation makes the\\n424 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 454, 'page_label': '425'}, page_content='airways hyper-responsive to stimuli such as cold air,\\nexercise, dust mites, pollutants in the air, and even\\nstress and anxiety.\\nDescription\\nBetween 17 million and 26 million Americans\\nhave asthma, and the number seems to be increasing.\\nIn about 1992, the number with asthma was about\\n10 million, and had risen 42% from 1982, just 10 years\\nprior. Not only is asthma becoming more frequent,\\nbut it also is a more severe disease than before, despite\\nmodern drug treatments. Asthma accounts for almost\\n500,000 hospitalizations, two million emergency\\ndepartment visits, and 5,000 deaths in the United\\nStates each year.\\nThe changes that take place in the lungs of asth-\\nmatic persons makes the airways (the ‘‘breathing\\ntubes,’’ orbronchi and the smallerbronchioles) hyper-\\nreactive to many different types of stimuli that don’t\\naffect healthy lungs. In an asthma attack, the muscle\\ntissue in the walls of bronchi go into spasm, and the\\ncells lining the airways swell and secrete mucus into the\\nair spaces. Both these actions cause the bronchi to\\nbecome narrowed (bronchoconstriction). As a result,\\nan asthmatic person has to make a much greater effort\\nto breathe in air and to expel it.\\nCells in the bronchial walls, called mast cells,\\nrelease certain substances that cause the bronchial\\nmuscle to contract and stimulate mucus formation.\\nThese substances, which include histamine and a\\nIn normal bronchioles the airway\\nis open and unobstructed.\\nDuring an attack, the bronchioles of an\\nasthma sufferer are constricted by bands\\nof muscle around them. They may be\\nfurther obstructed by increased mucus\\nproduction and tissue inflammation.\\nA comparison of normal bronchioles and those of an asthma sufferer.(Illustration by Hans & Cassady.)\\nGALE ENCYCLOPEDIA OF MEDICINE 425\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 455, 'page_label': '426'}, page_content='group of chemicals called leukotrienes, also bring\\nwhite blood cells into the area, which is a key part of\\nthe inflammatory response. Many patients with\\nasthma are prone to react to such ‘‘foreign’’ sub-\\nstances as pollen, house dust mites, or animal dander;\\nthese are called allergens. On the other hand, asthma\\naffects many patients who are not allergic in this way.\\nAsthma usually begins in childhood or adoles-\\ncence, but it also may first appear during adult years.\\nWhile the symptoms may be similar, certain important\\naspects of asthma are different in children and adults.\\nChild-onset asthma\\nNearly one-third on the 17 to 26 million\\nAmericans with asthma are children. When asthma\\nbegins in childhood, it often does so in a child who is\\nlikely, for genetic reasons, to become sensitized to\\ncommon allergens in the environment (atopic person).\\nWhen these children are exposed to house-dust mites,\\nanimal proteins, fungi, or other potential allergens,\\nthey produce a type of antibody that is intended to\\nengulf and destroy the foreign materials. This has the\\neffect of making the airway cells sensitive to particular\\nmaterials. Further exposure can lead rapidly to an\\nasthmatic response. This condition of atopy is present\\nin at least one-third and as many as one-half of the\\ngeneral population. When an infant or young child\\nwheezes during viral infections, the presence of allergy\\n(in the child or a close relative) is a clue that asthma\\nmay well continue throughout childhood.\\nAdult-onset asthma\\nAllergenic materials may also play a role when\\nadults become asthmatic. Asthma can actually start\\nat any age and in a wide variety of situations. Many\\nadults who are not allergic have conditions such as\\nsinusitis or nasal polyps, or they may be sensitive to\\naspirin and related drugs. Another major source of\\nadult asthma is exposure at work to animal products,\\ncertain forms of plastic, wood dust, or metals.\\nCauses and symptoms\\nIn most cases, asthma is caused by inhaling an\\nallergen that sets off the chain of biochemical and\\ntissue changes leading to airway inflammation,\\nbronchoconstriction, and wheezing. Because avoiding\\n(or at least minimizing) exposure is the most effective\\nway of treating asthma, it is vital to identify which\\nallergen or irritant is causing symptoms in a particular\\npatient. Once asthma is present, symptoms can be set\\noff or made worse if the patient also has rhinitis\\n(inflammation of the lining of the nose) or sinusitis.\\nWhen, for some reason, stomach acid passes back up\\nthe esophagus (acid reflux), this can also make asthma\\nworse. A viral infection of the respiratory tract can\\nalso inflame an asthmatic reaction. Aspirin and a type\\nof drug called beta-blockers, often used to treat high\\nblood pressure, can also worsen the symptoms of\\nasthma.\\nThe most important inhaled allergens giving rise\\nto attacks of asthma are:\\n/C15animal dander\\n/C15mites in house dust\\n/C15fungi (molds) that grow indoors\\n/C15cockroach allergens\\n/C15pollen\\n/C15occupational exposure to chemicals, fumes, or parti-\\ncles of industrial materials in the air\\nInhaling tobacco smoke, either by smoking or\\nbeing near people who are smoking, can irritate the\\nairways and trigger an asthmatic attack. Air pollu-\\ntants can have a similar effect. In addition, there are\\nthree important factors that regularly produce attacks\\nin certain asthmatic patients, and they may sometimes\\nbe the sole cause of symptoms. They are:\\n/C15inhaling cold air (cold-induced asthma)\\n/C15exercise-induced asthma (in certain children, asthma\\nis caused simply by exercising)\\n/C15stress or a high level of anxiety\\nKEY TERMS\\nAllergen— A foreign substance, such as mites in\\nhouse dust or animal dander which, when inhaled,\\ncauses the airways to narrow and produces symp-\\ntoms of asthma.\\nAtopy— A state that makes persons more likely to\\ndevelop allergic reactions of any type, including\\nthe inflammation and airway narrowing typical of\\nasthma.\\nHypersensitivity— The state where even a tiny\\namount of allergen can cause the airways to con-\\nstrict and bring on an asthmatic attack.\\nSpirometry— A test using an instrument called a\\nspirometer that shows how difficult it is for an asth-\\nmatic patient to breathe. Used to determine the\\nseverity of asthma and to see how well it is respond-\\ning to treatment.\\n426 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 456, 'page_label': '427'}, page_content='Wheezing is often obvious, but mild asthmatic\\nattacks may be confirmed when the physician listens\\nto the patient’s chest with a stethoscope. Besides\\nwheezing and being short of breath, the patient\\nmay cough and may report a feeling of ‘‘tightness’’\\nin the chest. Children may have itching on their\\nback or neck at the start of an attack. Wheezing is\\noften loudest when the patient breathes out, in an\\nattempt to expel used air through the narrowed\\nairways. Some asthmatics are free of symptoms\\nmost of the time but may occasionally be short of\\nbreath for a brief time. Others spend much of their\\ndays (and nights) coughing and wheezing, until\\nproperly treated. Crying or even laughing may\\nbring on an attack. Severe episodes are often seen\\nwhen the patient gets a viral respiratory tract infec-\\ntion or is exposed to a heavy load of an allergen or\\nirritant. Asthmatic attacks may last only a few min-\\nutes or can go on for hours or even days (a condi-\\ntion called status asthmaticus).\\nBeing short of breath may cause a patient to\\nbecome very anxious, sit upright, lean forward, and\\nuse the muscles of the neck and chest wall to help\\nbreathe. The patient may be able to say only a few\\nwords at a time before stopping to take a breath.\\nConfusion and a bluish tint to the skin are clues\\nthat the oxygen supply is much too low, and that\\nemergency treatment is needed. In a severe attack\\nthat lasts for some time, some of the air sacs in the\\nlung may rupture so that air collects within the\\nchest. This makes it even harder to breathe in\\nenough air.\\nDiagnosis\\nApart from listening to the patient’s chest, the\\nexaminer should look for maximum chest expansion\\nwhile taking in air. Hunched shoulders and contract-\\ning neck muscles are other signs of narrowed airways.\\nNasal polypsor increased amounts of nasal secretions\\nare often noted in asthmatic patients. Skin changes,\\nlike atopic dermatitis or eczema, are a tipoff that the\\npatient has allergic problems.\\nInquiring about a family history of asthma or\\nallergies can be a valuable indicator of asthma. The\\ndiagnosis may be strongly suggested when typical\\nsymptoms and signs are present. A test called spiro-\\nmetry measures how rapidly air is exhaled and how\\nmuch is retained in the lungs. Repeating the test after\\nthe patient inhales a drug that widens the air passages\\n(a bronchodilator) will show whether the airway nar-\\nrowing is reversible, which is a very typical finding in\\nasthma. Often patients use a related instrument, called\\na peak flow meter, to keep track of asthma severity\\nwhen at home.\\nOften, it is difficult to determine what is triggering\\nasthma attacks. Allergy skin testing may be used,\\nalthough an allergic skin response does not always\\nmean that the allergen being tested is causing the\\nasthma. Also, the body’s immune system produces\\nantibody to fight off the allergen, and the amount of\\nantibody can be measured by a blood test. This will\\nshow how sensitive the patient is to a particular aller-\\ngen. If the diagnosis is still in doubt, the patient can\\ninhale a suspect allergen while using a spirometer to\\ndetect airway narrowing. Spirometry can also be\\nrepeated after a bout of exercise if exercise-induced\\nasthma is a possibility. A chest x ray will help rule\\nout other disorders.\\nTreatment\\nPatients should be periodically examined and\\nhave their lung function measured by spirometry to\\nmake sure that treatment goals are being met. These\\ngoals are to prevent troublesome symptoms, to main-\\ntain lung function as close to normal as possible, and\\nto allow patients to pursue their normal activities\\nincluding those requiring exertion. The best drug ther-\\napy is that which controls asthmatic symptoms while\\ncausing few or no side-effects.\\nDrugs\\nMETHYLXANTHINES. The chief methylxanthine\\ndrug is theophylline. It may exert some anti-inflam-\\nmatory effect, and is especially helpful in controlling\\nnighttime symptoms of asthma. When, for some rea-\\nson, a patient cannot use an inhaler to maintain long-\\nterm control, sustained-release theophylline is a good\\nalternative. The blood levels of the drug must be mea-\\nsured periodically, as too high a dose can cause an\\nabnormal heart rhythm or convulsions.\\nBETA-RECEPTOR AGONISTS. These drugs, which\\nare bronchodilators , are the best choice for relieving\\nsudden attacks of asthma and for preventing attacks\\nfrom being triggered by exercise. Some agonists, such\\nas albuterol, act mainly in lung cells and have little\\neffect on other organs, such as the heart. These\\ndrugs generally start acting within minutes, but\\ntheir effects last only four tosix hours. Longer-acting\\nbrochodilators have been developed. They may last\\nup to 12 hours. Bronchodilators may be taken in pill\\nor liquid form, but normally are used as inhalers,\\nwhich go directly to the lungs and result in fewer\\nside effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 427\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 457, 'page_label': '428'}, page_content='STEROIDS. These drugs, which resemble natural\\nbody hormones, block inflammation and are extre-\\nmely effective in relieving symptoms of asthma.\\nWhen steroids are taken by inhalation for a long\\nperiod, asthma attacks become less frequent as the\\nairways become less sensitive to allergens. This is\\nthe strongest medicine for asthma, and can control\\neven severe cases over the long term and maintain\\ngood lung function. Steroids can cause numerous\\nside-effects, however, including bleeding from the\\nstomach, loss of calcium from bones, cataracts in\\nthe eye, and a diabetes-like state. Patients using\\nsteroids for lengthy periods may also have problems\\nwith wound healing, may gain weight, and may\\nsuffer mental problems. In children, growth may\\nbe slowed. Besides being inhaled, steroids may be\\ntaken by mouth or injected, to rapidly control\\nsevere asthma.\\nLEUKOTRIENE MODIFIERS. Leukotriene modifiers\\n(montelukast and zafirlukast) are a new type of\\ndrug that can be used in place of steroids, for\\nolder children or adults who have a mild degree of\\nasthma that persists. They work by counteracting\\nleukotrienes, which are substances released by white\\nblood cells in the lung that cause the air passages to\\nconstrict and promote mucus secretion. Leukotriene\\nmodifiers also fight off some forms of rhinitis, an\\nadded bonus for people with asthma. However, they\\nare not proven effective in fighting seasonal\\nallergies.\\nOTHER DRUGS. Cromolyn and nedocromil are\\nanti-inflammatory drugs that are often used as\\ninitial treatment to prevent asthmatic attacks over\\nthe long term in children. They can also prevent\\nattacks when given before exercise or when expo-\\nsure to an allergen cannot be avoided. These are\\nsafe drugs but are expensive, and must be taken\\nregularly even if there are no symptoms. Anti-cho-\\nlinergic drugs, such as atropine, are useful in con-\\ntrolling severe attacks when added to an inhaled\\nbeta-receptor agonist. They help widen the airways\\nand suppress mucus production.\\nIf a patient’s asthma is caused by an allergen that\\ncannot be avoided and it has been difficult to control\\nsymptoms by drugs, immunotherapy may be worth\\ntrying. Typically, increasing amounts of the allergen\\nare injected over a period of three to five years, so that\\nthe body can build up an effective immune response.\\nThere is a risk that this treatment may itself cause the\\nairways to become narrowed and bring on an asth-\\nmatic attack. Not all experts are enthusiastic about\\nimmunotherapy, although some studies have shown\\nthat it reduces asthmatic symptoms caused by\\nexposure to house-dust mites, ragweed pollen, and\\ncat dander.\\nManaging asthmatic attacks\\nA severe asthma attack should be treated as\\nquickly as possible. It is most important for a patient\\nsuffering an acute attack to be given extra oxygen.\\nRarely, it may be necessary to use a mechanical venti-\\nlator to help the patient breathe. A beta-receptor ago-\\nnist is inhaled repeatedly or continuously. If the\\npatient does not respond promptly and completely, a\\nsteroid is given. A course of steroid therapy, given\\nafter the attack is over, will make a recurrence less\\nlikely.\\nMaintaining control\\nLong-term asthma treatment is based on inhaling\\na beta-receptor agonist using a special inhaler that\\nmeters the dose. Patients must be instructed in proper\\nuse of an inhaler to be sure that it will deliver the right\\namount of drug. Once asthma has been controlled for\\nseveral weeks or months, it is worth trying to cut down\\non drug treatment, but this must be done gradually.\\nThe last drug added should be the first to be reduced.\\nPatients should be seen every one to six months,\\ndepending on the frequency of attacks.\\nStarting treatment at home, rather than in a hos-\\npital, makes for minimal delay and helps the patient to\\ngain a sense of control over the disease. All patients\\nshould be taught how to monitor their symptoms so\\nthat they will know when an attack is starting, and\\nthose with moderate or severe asthma should know\\nh o wt ou s eaf l o wm e t e r .T h e ys h o u l da l s oh a v ea\\nwritten ‘‘action plan’’ to follow if symptoms suddenly\\nbecome worse, including how to adjust their medica-\\ntion and when to seek medical help. A 2004 report said\\nthat a review of medical studies revealed that patients\\nwith self-management written action plans had fewer\\nhospitalizations, fewer emergency department visits,\\nand improved lung function. They also had a 70%\\nlower mortality rate. If more intense treatment is neces-\\nsary, it should be continued for several days. Over-the-\\ncounter ‘‘remedies’’ should be avoided. When deciding\\nwhether a patient should be hospitalized, the past his-\\ntory of acute attacks, severity of symptoms, current\\nmedication, and whether good support is available at\\nhome all must be taken into account.\\nReferral to an asthma specialist should be consid-\\nered if:\\n/C15there has been a life-threatening asthma attack or\\nsevere, persistent asthma\\n428 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 458, 'page_label': '429'}, page_content='/C15treatment for three to six months has not met its\\ngoals\\n/C15some other condition, such as nasal polyps or\\nchronic lung disease, is complicating asthma\\n/C15special tests, such as allergy skin testing or an aller-\\ngen challenge, are needed\\n/C15intensive steroid therapy has been necessary\\nSpecial populations\\nINFANTS AND YOUNG CHILDREN. It is especially\\nimportant to closely watch the course of asthma in\\nyoung patients. Treatment is cut down when possible\\nand if there is no clear improvement, some other treat-\\nment should be tried. If a viral infection leads to severe\\nasthmatic symptoms, steroids may help. The health\\ncare provider should write out an asthma treatment\\nplan for the child’s school. Asthmatic children often\\nneed medication at school to control acute symptoms\\nor to prevent exercise-induced attacks. Proper man-\\nagement will usually allow a child to take part in play\\nactivities. Only as a last resort should activities be\\nlimited.\\nTHE ELDERLY. Older persons often have other\\ntypes of obstructive lung disease, such as chronic\\nbronchitis or emphysema. This makes it important\\nto know to what extent the symptoms are caused\\nby asthma. Giving steroids for two to three weeks\\ncan help determine this. Side-effects from beta-\\nreceptor agonist drugs (including a speeding heart\\nand tremor) may be more common in older\\npatients. These patients may benefit from receiving\\nan anti-cholinergic drug,along with the beta-recep-\\ntor agonist. If theophylline is given, the dose\\nshould be limited, as older patients are less able\\nto clear this drug from their blood. Steroids should\\nbe avoided, as they often make elderly patients\\nconfused and agitated. Steroids may also further\\nweaken the bones.\\nPrognosis\\nMost patients with asthma respond well when\\nthe best drug or combination of drugs is found, and\\nthey are able to lead relatively normal lives. More\\nthan one-half of affected children stop having\\nattacks by the time they reach 21 years of age.\\nMany others have less frequent and less severe\\nattacks as they grow older. Urgent measures to\\ncontrol asthma attacks and ongoing treatment to\\nprevent attacks are equally important. A small min-\\nority of patients will have progressively more trou-\\nble breathing and run a risk of going into\\nrespiratory failure, for which they must receive\\nintensive treatment.\\nPrevention\\nMinimizing exposure to allergens\\nThere are a number of ways to cut down exposure\\nto the common allergens and irritants that provoke\\nasthmatic attacks, or to avoid them altogether:\\n/C15If the patient is sensitive to a family pet, removing the\\nanimal or at least keeping it out of the bedroom (with\\nthe bedroom door closed), as well as keeping the pet\\naway from carpets and upholstered furniture and\\nRemoving hair and feathers.\\n/C15To reduce exposure to house dust mites, removing\\nwall-to-wall carpeting, keeping humidity down, and\\nusing special pillows and mattress covers. Cutting\\ndown on stuffed toys, and washing them each week\\nin hot water.\\n/C15If cockroach allergen is causing asthma attacks, kill-\\ning the roaches (using poison, traps, or boric acid\\nrather than chemicals). Taking care not to leave food\\nor garbage exposed.\\n/C15Keeping indoor air clean by vacuuming carpets\\nonce or twice a week (with the patient absent),\\navoiding using humidifiers. Using air conditioning\\nduring warm weather (so that the windows can be\\nclosed).\\n/C15Avoiding exposure to tobacco smoke.\\n/C15Not exercising outside when air pollution levels are\\nhigh.\\n/C15When asthma is related to exposure at work, taking\\nall precautions, including wearing a mask and, if\\nnecessary, arranging to work in a safer area.\\nMore than 80% of people with asthma have\\nrhinitis and recent research emphasizes that treating\\nrhinitis helps benefit ashtma. Prescription nasal ster-\\noids and other methods to control rhinitis (in addit-\\nion to avoiding known allergens) can help prevent\\nasthma attacks. It is also important for patients to\\nkeep open communication with physicians to ensure\\nthat the correcnt amount of medication is being\\ntaken.\\nResources\\nPERIODICALS\\n‘‘Many People With Asthma ArenÆt Taking the Right\\nAmount of Medication.’’Obesity, Fitness & Wellness\\nWeek (September 25, 2004): 87.\\nGALE ENCYCLOPEDIA OF MEDICINE 429\\nAsthma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 459, 'page_label': '430'}, page_content='Mintz, Matthew. ‘‘Asthma Update: Part 1. Diagnosis,\\nMonitoring, and Prevention of Disease Progression.’’\\nAmerican Family PhysicianSeptember 1, 2004: 893.\\nSolomon, Gina, Elizabeth H. Humphreys, and Mark D.\\nMiller. ‘‘Asthma and the Environment: Connecting the\\nDots: What Role do Environmental Exposures Play in\\nthe Rising Prevalence and Severity of Asthma?’’\\nContemporary PeditatricsAugust 2004: 73–81.\\n‘‘WhatÆs New in: Asthma and Allergic Rhinitis.’’Pulse\\nSeptember 20, 2004: 50.\\nORGANIZATIONS\\nAsthma and Allergy Foundation of America. 1233 20th\\nStreet, NW, Suite 402, Washington, DC 20036. (800)\\n727-8462. .\\nMothers of Asthmatics, Inc. 3554 Chain Bridge Road, Suite\\n200, Fairfax, VA 22030. (800) 878-4403.\\nNational Asthma Education Program. 4733 Bethesda Ave.,\\nSuite 350, Bethesda, MD 20814. (301) 495-4484.\\nNational Jewish Medical and Research Center. 1400\\nJackson St., Denver, CO 80206. (800) 222-LUNG.\\nDavid A. Cramer, MD\\nTeresa G. Odle\\nAstigmatism\\nDefinition\\nAstigmatism is the result of an inability of the\\ncornea to properly focus an image onto the retina.\\nThe result is a blurred image.\\nDescription\\nThe cornea is the outermost part of the eye. It is a\\ntransparent layer that covers the colored part of the eye\\n(iris), pupil, and lens. The cornea bends light and helps\\nto focus it onto the retina where specialized cells (photo\\nreceptors) detect light and transmit nerve impulses via\\nthe optic nerve to the brain where the image is formed.\\nThe cornea is dome shaped. Any incorrect shaping of\\nthe cornea results in an incorrect focusing of the light\\nthat passes through that part of the cornea. The bending\\nof light is called refraction and focusing problems with\\nthe cornea are called diseases of refraction or refractive\\ndisorders. Astigmatism is an image distortion that\\nresults from an improperly shaped cornea. Usually the\\ncornea is spherically shaped, like a baseball. However, in\\nastigmatism the cornea is elliptically shaped, more like a\\nfootball. There is a long meridian and a short meridian.\\nThese two meridians generally have a constant curva-\\nture and are generally perpendicular to each other\\n(regular astigmatism). Irregular astigmatism may have\\nmore than two meridians of focus and they may not be\\n908 apart. A point of light, therefore, going through an\\nastigmatic cornea will have two points of focus, instead\\nof one nice sharp image on the retina. This will cause the\\nperson to have blurry vision. What the blur looks like\\nwill depend upon the amount and the direction of the\\nastigmatism. A person with nearsightedness (myopia)o r\\nfarsightedness (hyperopia) may see a dot as a blurred\\ncircle. A person with astigmatism may see the same dot\\nas a blurred oval or frankfurter-shaped blur.\\nSome cases of astigmatism are caused by problems\\nin the lens of the eye. Minor variations in the curvature\\nof the lens can produce minor degrees of astigmatism\\n(lenticular astigmatism). In these patients, the cornea is\\nusually normal in shape. Infants, as a group, have the\\nleast amount of astigmatism. Astigmatism may increase\\nduring childhood, as the eye is developing.\\nCornea\\nLens\\nLight\\nRetina\\nHorizontal line out of focus\\nAstigmatism corrected by lens\\nLight\\nAstigmatism can be treated by the use of cylindrical lenses.\\nThe lenses are shaped to counteract the shape of the sec-\\ntions of the cornea that are causing the difficulty.(Illustration\\nby Electronic Illustrators Group.)\\n430 GALE ENCYCLOPEDIA OF MEDICINE\\nAstigmatism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 460, 'page_label': '431'}, page_content='Causes and symptoms\\nThe main symptom of astigmatism is blurring.\\nPeople can also experience headaches and eyestrain.\\nParents can notice that a child may have astigma-\\ntism when the child can see some part of a pattern\\nor picture more clearly than others. For example,\\nlines going across may seem clearer than lines going\\nup and down.\\nRegular astigmatism can be caused by the weight\\nof the upper eyelid resting on the eyeball creating\\ndistortion, surgical incisions in the cornea, trauma or\\nscarring to the cornea, the presence of tumors in the\\neyelid, or a developmental factor. Irregular astigma-\\ntism can be caused by scarring or keratoconus.\\nKeratoconus is a condition in which the cornea thins\\nand becomes cone shaped. It usually occurs around\\npuberty and is more common in women. Although the\\ncauses of keratoconus are unknown, it may be heredi-\\ntary or a result of chronic eye rubbing, as in people\\nwith allergies. The center of the cone may not be in line\\nwith the center of the cornea. Diabetes can play a role\\nin the development of astigmatism. High blood sugar\\nlevels can cause shape changes in the lens of the eye.\\nThis process usually occurs slowly and, often, is only\\nnoticed when the diabetic has started treatment to\\ncontrol their blood sugar. The return to a more normal\\nblood sugar allows the lens to return to normal and\\nthis change is sometimes noticed by the patient as\\nfarsightedness. Because of this, diabetics should wait\\nuntil their blood sugar is under control for at least one\\nmonth to allow vision to stabilize before being mea-\\nsured for eyeglasses.\\nDiagnosis\\nPatients seek treatment because of blurred vision.\\nA variety of tests can be used to detect astigmatism\\nduring the eye exam. The patient may be asked to\\ndescribe the astigmatic dial, a series of lines that radi-\\nate outward from a center. People with astigmatism\\nwill see some of the lines more clearly than others.\\nOne diagnostic instrument used is the keratometer.\\nThis measures the curvature of the central cornea.\\nIt measures the amount and direction of the curvature.\\nA corneal topographer can measure a larger area of\\nthe cornea. It can measure the central area and\\nmid-periphery of the cornea. A keratoscope projects\\na series of concentric light rings onto the cornea.\\nMisshapen areas of the cornea are revealed by noting\\nareas of the light pattern that do not appear con-\\ncentric on the cornea. Because these instruments are\\nmeasuring the cornea, it is also important to have a\\nrefraction in case the lens is also contributing to the\\nastigmatism. The refraction measures the optics or\\nvisual status of the eye and the result is the eyeglass\\nprescription. The refraction is when the patient is look-\\ning at an eye chart and the doctor is putting different\\nlenses in front of the patient’s eyes and asks which one\\nlooks better.\\nTreatment\\nAstigmatism can be treated by the use of cylind-\\nrical lenses. They can be in eyeglasses or contact lenses.\\nThe unit of measure describing the power of the lens\\nsystem or lens is called the diopter (D). The lenses are\\nshaped to counteract the shape of the sections of\\ncornea that are causing the difficulty. Because the\\ncorrection is in one direction, it is written in terms of\\nthe axis the correction is in. On a prescription, for\\nexample, it may say-1.00 /C21808. Cylinders correct\\nastigmatism, minus spheres correct myopia, and plus\\nspheres correct hyperopia.\\nThere is some debate as to whether people with\\nvery small amounts of astigmatism should be treated.\\nGenerally, if visual acuity is good and the patient\\nexperiences no overt symptoms, treatment is not\\nnecessary. When treating larger amounts of astigma-\\ntism, or astigmatism for the first time, the doctor may\\nnot totally correct the astigmatism. The cylindrical\\ncorrection in the eyeglasses may make the floor appear\\nto tilt, thus making it difficult for the patient at first.\\nGenerally, the doctor will place lenses in a trial frame\\nto allow the patient to try the prescription at the exam.\\nIt may take a week or so to get used to the glasses,\\nhowever, if the patient is having a problem they should\\ncontact their doctor, who might want to recheck the\\nprescription.\\nContact lenses that are used to correct astigma-\\ntism are called toric lenses. When a person blinks, the\\ncontact lens rotates. In toric lenses, it is important for\\nKEY TERMS\\nMeridian— A section of a sphere. For example,\\nlongitude or latitude on the globe. Or, on a clock, a\\nsection going through 12:00-6:00 or 3:00-9:00, etc.\\nRefraction— The turning or bending of light waves\\nas the light passes from one medium or layer to\\nanother. In the eye it means the ability of the eye\\nto bend light so that an image is focused onto the\\nretina.\\nGALE ENCYCLOPEDIA OF MEDICINE 431\\nAstigmatism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 461, 'page_label': '432'}, page_content='the lens to return to the same position each time.\\nLenses have thin zones, or cut-off areas (truncated),\\nor have other ways to rotate and return to the correct\\nposition. Soft toric lenses are available in a variety of\\nprescriptions, materials, and even in tints. Patients\\nshould ask their doctors about the possibility of toric\\nlenses.\\nIn 1997, the Food and Drug Administration\\n(FDA) approved laser treatment of astigmatism.\\nPatients considering this should make sure the surgeon\\nhas a lot of experience in the procedure and discuss the\\npossible side effects or risks with the doctor. In the\\ncase of keratoconus, a corneal transplant is performed\\nif the astigmatism can not be corrected with hard\\ncontact lenses.\\nPrognosis\\nAstigmatism is a condition that may be present at\\nbirth. It may also be acquired if something is distorting\\nthe cornea. Vision can generally be corrected with\\neyeglasses or contact lenses. The major risks of surgery\\n(aside from the surgical risks) are over and under\\ncorrection of the astigmatism. There is no cure for\\nover correction. Under correction can be solved by\\nrepeating the operation.\\nResources\\nBOOKS\\nBerkow, Robert, editor.Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nJohn T. Lohr, PhD\\nAston-Patterning\\nDefinition\\nAston-Patterning is an integrated system of move-\\nment education, bodywork, ergonomic adjustments,\\nand fitness training that recognizes the relationship\\nbetween the body and mind for well being. It helps\\npeople who seek a remedy from acute or chronicpain\\nby teaching them to improve postural and movement\\npatterns.\\nPurpose\\nAston-Patterning assists people in finding more\\nefficient and less stressful ways of performing the\\nsimple movements of everyday life to dissipate tension\\nin the body. This is done through massage, alteration\\nof the environment, and fitness training.\\nDescription\\nSeeking to solve movement problems, Aston-\\nPatterning helps make the most of their own unique\\nbody types rather than trying to force them to conform\\nto an ideal. UnlikeRolfing, it doesn’t strive for linear\\nsymmetry. Rather it works with asymmetry in the\\nhuman body to develop patterns of alignment and\\nmovement that feel right to the individual. Aston\\nalso introduced the idea of working in a three-dimen-\\nsional spinal pattern. Aston-Patterning sessions have\\nfour general components. They are:\\n/C15A personal history that helps the practitioner assess\\nthe client’s needs.\\n/C15Pre-testing, in which the practitioner and the client\\nexplore patterns of movement and potential for\\nimprovement.\\n/C15Movement education and bodywork, including mas-\\nsage, myofacial release, and arthrokinetics, to help\\nreleasetensionandmakenewmovementpatternseasier.\\nJUDITH ASTON\\nJudith Aston was born in Long Beach, California. She\\ngraduated from University of California at Los Angeles\\nwith a B.A. and a M.F.A. in dance. Her interest in move-\\nment arose from working as a dancer. In 1963 Aston\\nestablished her first movement education program for\\ndancers, actors, and athletes at Long Beach City College.\\nFive years later, while recovering from injuries sus-\\ntained during two consecutive automobile accidents,\\nAston met Ida Rolf, the developer of Rolfing. Aston\\nbegan working for Rolf, teaching a movement education\\nprogram called Rolf-Aston Structural Patterning that\\nemphasized using the body with minimum effort and\\nmaximum precision.\\nIn time, Rolf and Aston’s views on movement diverged,\\nand the partnership was dissolved in 1977. Aston formed her\\nown company called the Aston Paradigm Corporation in\\nLake Tahoe, California. This company provides training\\nand certification for Aston practitioners. She also began\\nexploring how environmental conditions affect body\\nmovement, foreshadowing the ergonomic movement in\\nthe workplace that developed in the 1990s. Over time,\\nAston has expanded her movement work to include a\\nfitness program for older adults. Today, Judith Aston\\nserves as director of Aston Paradigm Corporation.\\n432\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAston-Patterning'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 462, 'page_label': '433'}, page_content='/C15Post-testing, when pre-testing movements are\\nrepeated, allowing the client to feel the changes that\\nhave taken place and integrate them into daily life.\\nAston-Patterning requires more participation\\nfrom the client than many bodywork techniques. The\\nmassage aspect of Aston-Patterning is designed\\naround a three-dimensional, non-compressive touch\\nthat releases patterns of tension in the body. It is\\ngentler than Rolfing. Myokinetics uses touch to\\nrelease tension in the face and neck. Arthrokinetics\\naddresses tension at bones and joints. This massage\\nis accompanied by education about how new move-\\nment patterns may be established.\\nIn addition to Aston-Patterning sessions, clients\\nare also helped to examine their environment for fac-\\ntors, such as seating or sleeping arrangements, that\\nmay limit their body function and introduce tension.\\nFinally, they may choose to participate in the Aston\\nfitness training program that includes loosening tech-\\nniques based on self-massage, toning, stretching, and\\ncardiovascular fitness.\\nPreparations\\nNo special preparation need be taken.\\nPrecautions\\nNo special precautions are necessary when\\nparticipating.\\nSide effects\\nNo undesirable side effects are reported. Usually\\nclients report a diminution of tension, improved body\\nmovement, and an enhanced feeling of well being.\\nResearch and general acceptance\\nAston-Patterning is an outgrowth of Rolfing,\\nwhich has been shown to be of benefit in a limited\\nnumber of controlled studies. Little controlled\\nresearch has been done on the either benefits or\\nlimitations of Aston-Patterning. Its claims have been\\nneither proven nor disproved, although anecdotally\\nmany clients report relief from pain and tension and\\nalso improved body movement.\\nResources\\nORGANIZATIONS\\nAston Training Center. P. O. Box 3568, Incline Village, NV\\n89450. (775) 831-8228. Astonpat@aol.com .\\nTish Davidson, A.M.\\nAstrocytoma see Brain tumor\\nAtaxia-telangiectasia\\nDefinition\\nAtaxia-telangiectasia (A-T), also called Louis-Bar\\nsyndrome, is a rare, genetic neurological disorder of\\nchildhood that progressively destroys part of the\\nmotor control area of the brain, leading to a lack of\\nbalance and coordination. A-T also affects the\\nimmune system and increases the risk of leukemia\\nand lymphoma in affected individuals.\\nDescription\\nThe disorder first appeared in the medical litera-\\nture in the mid-1920s, but was not named specifically\\nuntil 1957. The name is a combination of two recog-\\nnized abnormalities: ataxia (lack of muscle control)\\nand telangiectasia (abnormal dilatation of capillary\\nvessels that often result in tumors and redskin lesions).\\nHowever, A-T involves more than just the sum of\\nthese two findings. Other associated A-T problems\\ninclude immune system deficiencies, extreme sensitiv-\\nity to radiation, and blood cancers.\\nMedical researchers initially suspected that multi-\\nple genes (the units responsible for inherited features)\\nwere involved. However, in 1995, mutations in a single\\nlarge gene were identified as causing A-T. Researchers\\nnamed the gene ATM for A-T, mutated. Subsequent\\nresearch revealed that ATM has a significant role in\\nregulating cell division. The symptoms associated with\\nA-T reflect the main role of the AT gene, which is to\\ninduce several cellular responses to DNA damage,\\nsuch as preventing damaged DNA from being repro-\\nduced. When the AT gene is mutated into ATM, the\\nKEY TERMS\\nRolfing— Developed by Dr. Ida Rolf (1896–1979),\\nrolfing is a systematic approach to relieving stress\\npatterns and dysfunctions in the body’s structure\\nthrough the manipulation of the highly pliant myo-\\nfacial (connective) tissue. It assists the body in reor-\\nganizing its major segments into vertical alignment.\\nGALE ENCYCLOPEDIA OF MEDICINE 433\\nAtaxia-telangiectasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 463, 'page_label': '434'}, page_content='signaling networks are affected and the cell no longer\\nresponds correctly to minimize the damage.\\nA-T is very rare, but it occurs in every popula-\\ntion world wide, with an estimated frequency of\\nbetween 1/40,000 and 1/100,000 live births. But it\\nis believed that many A-T cases, particularly those\\nwho die at a young age, are never properly diag-\\nnosed. Therefore, this disease may actually be\\nmuch more prevalent. According to the A-T\\nProject Foundation, an estimated 1% (2.5 million\\nin the United States) of the general population\\ncarries defective A-T genes. Carriers of one copy\\nof this gene do not develop A-T, but have a sig-\\nnificantly increased risk of cancer.T h i sm a k e st h e\\nA-T gene one of the most important cancer-related\\ngenes identified to date.\\nCauses and symptoms\\nThe ATM gene is autosomal recessive, meaning\\nthe disease occurs only if a defective gene is inher-\\nited from both parents. Infants with A-T initially\\noften appear very healthy. At around age two,\\nataxia and nervous system abnormalities becomes\\napparent. The root cause of A-T-associated ataxia\\nis cell death in the brain, specifically the large\\nbranching cells of the nervous system (Purkinje’s\\ncells) which are located in the cerebellum. A tod-\\ndler becomes clumsy, loses balance easily and lacks\\nmuscle control. Speech becomes slurred and more\\ndifficult, and the symptoms progressively worsen.\\nBetween ages two and eight, telangiectases, or tiny,\\nred ‘‘spider’’ veins, appear on the cheeks and ears\\na n di nt h ee y e s .\\nB ya g e1 0 - 1 2 ,c h i l d r e nw i t hA - Tc a nn ol o n g e r\\ncontrol their muscles. Immune system deficiencies\\nbecome common, and affected individuals are extre-\\nmely sensitive to radiation. Immune system defi-\\nciencies vary between individuals but include\\nlower-than-normal levels of proteins that function\\nas antibodies (immunoglobulins) and white blood\\ncells (blood cells not containing ‘‘iron’’ proteins).\\nThe thymus gland, which aids in development of\\nthe body’s immune system, is either missing or has\\nKEY TERMS\\nAngioma— A tumor (such as a hemangioma or lym-\\nphangioma) that mainly consists of blood vessels or\\nlymphatic vessels.\\nAntibody— Any of a large number of proteins pro-\\nduced by specialized blood cells after stimulation by\\nan antigen and that act specifically against the anti-\\ngen in an immune response.\\nAntigen— Any substance (such as a toxin or enzyme)\\ncapable of stimulating an immune response in the\\nbody.\\nAtaxia— The inability to control voluntary muscle\\nmovement, most frequently resulting from disorders\\nin the brain or spinal cord.\\nAutosomal— Relating to any of the chromosomes\\nexcept for X and Y, the sex chromosomes.\\nCerebellum— The part of the brain responsible for\\ncoordination of voluntary movements.\\nGamma-globulin— An extract of human blood that\\ncontains antibodies.\\nImmune response— A response from the body to an\\nantigen that occurs when the antigen is identified as\\nforeign and that induces the production of antibodies\\nand lymphocytes capable of destroying the antigen\\nor making it harmless.\\nImmunoglobulin— A protein in the blood that is the\\ncomponent part of an antibody.\\nLeukemia— A cancer of blood cells characterized by\\nthe abnormal increase in the number of white blood\\ncells in the tissues. There are many types of leuke-\\nmias and they are classified according to the type of\\nwhite blood cell involved.\\nLymphoma— A blood cancer in which lymphocytes,\\na variety of white blood cells, grow at an unusually\\nrapid rate.\\nMutation— Any change in the hereditary material of\\ngenes.\\nPurkinje’s cells—Large branching cells of the nervous\\nsystem.\\nRecessive— Producing little or no phenotypic effect\\nwhen occurring in heterozygous condition with a\\ncontrasting allele.\\nTelangiectases— Spidery red skin lesions caused by\\ndilated blood vessels.\\nTelangiectasia— Abnormal dilation of capillary blood\\nvessels leading to the formation of telangiectases or\\nangiomas.\\nThymus— A gland located in the front of the neck that\\ncoordinates the development of the immune system.\\n434 GALE ENCYCLOPEDIA OF MEDICINE\\nAtaxia-telangiectasia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 464, 'page_label': '435'}, page_content='developed abnormally. Intelligence is normal, but\\ngrowth may be retarded owing to immune system\\nor hormonal deficiencies. Individuals with A-T are\\nalso sometimes afflicted with diabetes, prematurely\\ngraying hair, and difficulty swallowing. As the chil-\\ndren grow older, the immune system becomes\\nweaker and less capable of fighting infection. In\\nthe later stages, recurrent respiratory infections\\nand blood cancers, such as leukemia or lymphoma,\\nare common.\\nDiagnosis\\nDiagnosis relies on recognizing the hallmarks\\nof A-T: progressive ataxi a and telangiectasia.\\nHowever, this may be difficult as ataxia symptoms\\ndo appear prior to telangiectasia symptoms by sev-\\neral years. Other symptoms can vary between indi-\\nviduals; for example, 70% of individuals with A-T\\nhave a high incidence of respiratory infection, 30%\\ndo not. The identification of the ATM gene raises\\nhopes that screening, and perhaps treatment, may\\nbe possible.\\nTreatment\\nThere is currently no cure for A-T, and treatment\\nfocuses on managing the individual’s multiple symp-\\ntoms. Physical therapy and speech therapy can help\\nthe patient adjust to ataxia. Injections of gamma glo-\\nbulin, or extracts of human blood that contain anti-\\nbodies, are used to strengthen the weakened immune\\nsystem. High-dose vitamin administrations may also\\nbe prescribed. Research continues in many countries\\nto find effective treatments. Individuals and families\\nliving with this disorder may benefit from attending\\nsupport groups.\\nPrognosis\\nA-T is a fatal condition. Children with A-T\\nbecome physically disabled by their early teens and\\ntypically die by their early 20s, usually from the asso-\\nciated blood cancers and malignancies. In very rare\\ncases, individuals with A-T may experience slower\\nprogression and a slightly longer life span, surviving\\ninto their 30s. A-T carriers have a five-fold higher risk\\nthan non-carriers of developing certain cancers, espe-\\ncially breast cancer.\\nPrevention\\nMedical researchers are investigating methods for\\nscreening individuals who may be carriers of the\\ndefective gene. Prenatal testing for A-T is possible\\nbut not done routinely, because commercial screening\\ntests have yet to be developed.\\nAtaxia see Movement disorders\\nAtelectasis\\nDefinition\\nAtelectasis is a collapse of lung tissue affecting\\npart or all of one lung. This condition prevents normal\\noxygen absoption to healthy tissues.\\nDescription\\nAtelectasis can result from an obstruction (block-\\nage) of the airways that affects tiny air scas called\\nalveoli. Alveoli are very thin-walled and contain a\\nrich blood supply. They are important for lung func-\\ntion, since their purpose is the exchange of oxygen and\\ncarbon dioxide. When the airways are blocked by a\\nmucous ‘‘plug,’’ foreign object, or tumor, the alveoli\\nare unable to fill with air and collapse of lung tissue\\ncan occur in the affected area. Atelectasis is a potential\\ncomplication following surgery, especially in indivi-\\nduals who have undergone chest or abdominal opera-\\ntions resulting in associated abdominal or chestpain\\nduring breathing. Congenital atelectasis can result\\nfrom a failure of the lungs to expand at birth. This\\ncongenital condition may be localized or may affect all\\nof both lungs.\\nCauses and symptoms\\nCauses of atelectasis include insufficient attemps\\nat respiration by the newborn, bronchial obstruction,\\nor absence of surfactant (a substance secreted by\\nalveoli that maintains the stability of lung tissue by\\nreducing the surface tension of fluids that coat the\\nlung). This lack of surfactant reduces the surface\\narea available for effective gas exchange causing it to\\ncollapse if severe. Pressure on the lung from fluid or air\\ncan cause atelectasis as well as obstruction of lung air\\npassages by thick mucus resulting from various infec-\\ntions and lung diseases. Tumors and inhaled objects\\ncan also cause obstruction of the airway, leading to\\natelectasis.\\nAnyone undergoing chest or abdominal surgery\\nusing general anesthesiais at risk to develop atelecta-\\nsis, since breathing is often shallow after surgery to\\nGALE ENCYCLOPEDIA OF MEDICINE 435\\nAtelectasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 465, 'page_label': '436'}, page_content='avoid pain from the surgical incision. Any significant\\ndecrease in airflow to the alveoli contributes to pool-\\ning of secretions, which in turn can cause infection.\\nChest injuries causing shallow breathing, including\\nfractured ribs, can cause atelectasis. Common symp-\\ntoms of atelectasis include shortness of breath and\\ndecreased chest wall expansion. If atelectasis only\\nafects a small area of the lung, symptoms are ususally\\nminimal. If the condition affects a large area of the\\nlung and develops quickly, the individual may turn\\nblue (cyanotic) or pale, have extreme shortness of\\nbreath, and feel a stabbing pain on the affected side.\\nFever and increased heart rate may be present if infec-\\ntion accompanies atelectasis.\\nDiagnosis\\nTo diagnose atelectasis, a doctor starts by record-\\ning the patient’s symptoms and performing a tho-\\nrough physical examination. When the doctor listens\\nto the lungs through a stethoscope (ausculation),\\ndiminished or bronchial breath sounds may be heard.\\nBy tapping on the chest (percussion) while listening\\nthrough the stethoscope, the doctor can often tell if the\\nlung is collapsed. Achest x raythat shows an airless\\narea in the lung confirms the diagnosis of atelectasis. If\\nan obstruction of the airways is suspected, a computed\\ntomography scan (CT) or bronchoscopy may be\\nperformed to locate the cause of the blockage.\\nTreatment\\nIf atelectasis is due to obstruction of the airway,\\nthe first step in treatment is to remove the cause of\\nthe blockage. This may be done by coughing, suction-\\ning, or bronchoscopy. If a tumor is the cause of atelec-\\ntasis, surgery may be necessary to remove it.\\nAntibiotics are commonly used to fight the infection\\nthat often accompanies atelectasis. In cases where\\nrecurrent or long-lasting infection is disabling or\\nwhere significant bleeding occurs, the affected section\\nof the lung may be surgically removed.\\nPrognosis\\nIf atelectasis is caused by a thick mucus ‘‘plug’’ or\\ninhaled foreign object, the patient usually recovers com-\\npletely when the blockage is removed. If it is caused by a\\ntumor, the outcome depends on the nature of the tumor\\ninvolved. If atelectasis is a result of surgery, other post-\\noperative conditions and/or complications affect the\\nprognosis.\\nA computed tomography (CT) scan through a patient’s chest.\\nThe collapsed lung appears at the right of the image. (Photo\\nResearchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAlveoli— Tiny air sacs in the lungs where gas\\nexchange takes place between alveolar air and\\npulmonary blood within the capillaries\\nBronchial— Relating to the air passages to and from\\nthe lungs including the bronchi and the bronchioles.\\nBronchoscopy— A procedure in which a hollow,\\nflexible tube is inserted into the airway to allow\\nvisual examination of the larynx, trachea, bronchi,\\nand bronchioles. It isalso used to collect specimens for\\nbiopsyorculturingandtoremoveairwayobstructions.\\nIncentive spirometer— A breathing device that\\nprovides feedback on performance to encourage\\ndeep breathing.\\nMucus— A thin, slippery film secreted by the\\nmucous membranes and glands.\\nPostural drainage— Techniques to help expel excess\\nmucus by specific poistions of the body (that decrease\\nthe effects of gravity) combined with manual percus-\\nsion and vibration over various parts of the lung.\\nSurfactant— A substance secreted by the alveoli in\\nthe lungs that reduces the surface tension of lung\\nfluids, allowing gas exchange and helping maintain\\nthe elasticity of lung tissue.\\nTumor— Anabnormalgrowthoftissueresultingfrom\\nuncontrolled, progressive multiplication of cells.436 GALE ENCYCLOPEDIA OF MEDICINE\\nAtelectasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 466, 'page_label': '437'}, page_content='Prevention\\nWhen recovering from surgery, frequent reposition-\\ning in bed along with coughing and deep breathing are\\nimportant. Coughing and breathing deeply every one to\\ntwo hours after any surgical operation with general\\nanesthesia is recommended. Breathing exercises and the\\nuse of breathing devices, such as an incentive spirometer,\\nmay also help prevent atelectasis. Although smokers\\nhave a higher risk of developing atelectasis following\\nsurgery, stoppingsmokingsix to eight weeks before sur-\\ngery can help reduce the risk. Increasing fluid intake\\nduring respiratory illness or after surgery (by mouth or\\nintravenously) helps lung secretions to remain loose.\\nIncreasing humidity may also be beneficial.\\nPostural drainage techniques can be learned from\\na respiratory therapist or physical therapist and are a\\nuseful tool for anyone affected with a respiratiory ill-\\nness that could cause atelectasis. Because foreign\\nobjects blocking the airway can cause atelectasis, it is\\nvery important to keep small objects that might be\\ninhaled away from young children.\\nResources\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nJeffrey P. Larson, RPT\\nAtenolol see Beta blockers\\nAtherectomy\\nDefinition\\nAtherectomy is a non-surgical procedure to open\\nblocked coronary arteries or vein grafts by using a device\\non the end of a catheter to cut or shave away athero-\\nsclerotic plaque (a depositof fat and other substances\\nthat accumulate in the lining of the artery wall).\\nPurpose\\nAtherectomy is performed to restore the flow of\\noxygen-rich blood to the heart, to relieve chestpain,\\nand to prevent heart attacks. It may be done on\\npatients with chest pain who have not responded to\\nother medical therapy and on certain of those who are\\ncandidates for balloonangioplasty (a surgical proce-\\ndure in which a balloon catheter is used to flatten\\nplaque against an artery wall) or coronary artery\\nbypass graft surgery. It is sometimes performed to\\nremove plaque that has built up after acoronary artery\\nbypass graft surgery.\\nPrecautions\\nAtherectomy should not be performed when the\\nplaque is located where blood vessels divide into\\nbranches, when plaque is angular or inside an angle\\nof a blood vessel, on patients with weak vessel walls,\\non ulcerated or calcium-hardened lesions, or on\\nblockages through which a guide wire won’t pass.\\nDescription\\nAtherectomy uses a rotating shaver or other device\\nplaced on the end of a catheter to slice away or destroy\\nplaque. At the beginning of the procedure, medications\\nto control blood pressure, dilate the coronary arteries,\\nand preventblood clotsare administered. The patient is\\nawake but sedated. The catheter is inserted into an\\nartery in the groin, leg, or arm, and threaded through\\nthe blood vessels into the blocked coronary artery. The\\ncutting head is positioned against the plaque and acti-\\nvated, and the plaque is ground up or suctioned out.\\nThe types of atherectomy are rotational, direc-\\ntional, and transluminal extraction. Rotational ather-\\nectomy uses a high speed rotating shaver to grind up\\nplaque. Directional atherectomy was the first type\\napproved, but is no longer commonly used; it scrapes\\nplaque into an opening in one side of the catheter.\\nTransluminal extraction coronary atherectomy uses a\\ndevice that cuts plaque off vessel walls and vacuums it\\ninto a bottle. It is used to clear bypass grafts.\\nPerformed in acardiac catheterizationlab, atherect-\\nomy is also called removal of plaque from the coronary\\narteries. It can be used instead of, or along with, balloon\\nangioplasty. Atherectomy issuccessful about 95% of the\\ntime. Plaque forms again in 20-30% of patients.\\nPreparation\\nThe day before atherectomy, the patient takes\\nmedication to prevent blood clots and may be asked\\nto bathe and shampoo with an antiseptic skin cleaner.\\nAftercare\\nAfter the procedure, the patient spends several days\\nin the hospital’s cardiac monitoring area. For at least\\n20 minutes, pressure is applied to a dressing on the\\ninsertion site. For the first hour, an electrocardiogram\\nand close monitoring are conducted; vital signs are\\nGALE ENCYCLOPEDIA OF MEDICINE 437\\nAtherectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 467, 'page_label': '438'}, page_content='checked every 15 minutes. Pain medication is then\\nadministered. The puncture site is checked once an\\nhour or more. For most of the first 24 hours, the patient\\nremains in bed.\\nRisks\\nChest pain is the most common complication of\\natherectomy. Other common complications are injury\\nto the blood vessel lining, plaque that re-forms, blood\\nclots (hematoma), and bleeding at the site of insertion.\\nMore serious but less frequent complications are\\nblood vessel holes, blood vessel wall tears, or reduced\\nblood flow to the heart.\\nResources\\nBOOKS\\nMcPhee, Stephen, et al., editors.Current Medical Diagnosis\\nand Treatment, 1998.37th ed. Stamford: Appleton &\\nLange, 1997.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nIn this digitized ultrasound of a blood vessel, C is the catheter, D is the dissection, and F is the artherosclerotic flap. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAtherosclerotic plaque— A deposit of fat and other\\nsubstances that accumulate in the lining of the\\nartery wall.\\nBalloon angioplasty— A surgical procedure in\\nwhich a balloon catheter is used to flatten plaque\\nagainst an artery wall.\\nCoronary arteries— The two main arteries that pro-\\nvide blood to the heart. The coronary arteries sur-\\nround the heart like a crown, coming out of the\\naorta, arching down over the top of the heart, and\\ndividing into two branches. These are the arteries\\nwhere coronary artery disease occurs.\\nHematoma— A localizedcollectionofblood,usually\\nclotted, due to a break in the wall of blood vessel.\\n438 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherectomy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 468, 'page_label': '439'}, page_content='Atherosclerosis\\nDefinition\\nAtherosclerosis is the build up of a waxy plaque\\non the inside of blood vessels. In Greek,athere means\\ngruel, andskleros means hard. Atherosclerosis is often\\ncalled arteriosclerosis. Arteriosclerosis (from the\\nGreek arteria, meaning artery) is a general term for\\nhardening of the arteries. Arteriosclerosis can occur in\\nseveral forms, including atherosclerosis.\\nDescription\\nAtherosclerosis, a progressive process responsible\\nfor most heart disease, is a type of arteriosclerosis\\nor hardening of the arteries. An artery is made up of\\nseveral layers: an inner lining called the endothelium,\\nan elastic membrane that allows the artery to expand\\nand contract, a layer of smooth muscle, and a layer of\\nconnective tissue. Arteriosclerosis is a broad term that\\nincludes a hardening of the inner and middle layers of\\nthe artery. It can be caused by normalaging, by high\\nblood pressure, and by diseases such as diabetes.\\nAtherosclerosis is a type of arteriosclerosis that affects\\nonly the inner lining of an artery. It is characterized by\\nplaque deposits that block the flow of blood.\\nPlaque is made of fatty substances, cholesterol,\\nwaste products from the cells, calcium, and fibrin, a\\nstringy material that helps clot blood. The plaque for-\\nmation process stimulates the cells of the artery wall to\\nproduce substances that accumulate in the inner layer.\\nFat builds up within these cells and around them, and\\nthey form connective tissue and calcium. The inner\\nlayer of the artery wall thickens, the artery’s diameter\\nis reduced, and blood flow and oxygen delivery are\\ndecreased. Plaques can rupture or crack open, causing\\nthe sudden formation of a blood clot (thrombosis).\\nAtherosclerosis can cause aheart attackif it completely\\nblocks the blood flow in the heart (coronary) arteries. It\\ncan cause astroke if it completely blocks the brain\\n(carotid) arteries. Atherosclerosis can also occur in the\\narteries of the neck, kidneys, thighs, and arms, causing\\nkidney failure organgrene and amputation.\\nCauses and symptoms\\nAtherosclerosis can begin in the late teens, but it\\nusually takes decades to cause symptoms. Some people\\nexperience rapidly progressing atherosclerosis during\\ntheir thirties, others during their fifties or sixties.\\nAtherosclerosis is complex. Its exact cause is still\\nunknown. It is thought that atherosclerosis is caused\\nby a response to damage to the endothelium from high\\ncholesterol, high blood pressure, and cigarettesmoking.\\nA person who has all three of these risk factors is eight\\ntimes more likely to develop atherosclerosis than is a\\nperson who has none. Physical inactivity, diabetes, and\\nobesity are also risk factors for atherosclerosis. High\\nlevels of the amino acidhomocysteine and abnormal\\nlevels of protein-coated fats called lipoproteins also\\nraise the risk ofcoronary artery disease. These sub-\\nstances are the targets of much current research. The\\nrole of triglycerides, another fat that circulates in the\\nblood, in forming atherosclerotic plaques is unclear.\\nHigh levels of triglycerides are often associated with\\ndiabetes, obesity, and low levels of high-density lipo-\\nproteins (HDL cholesterol). The more HDL (‘‘good’’)\\ncholesterol, in the blood, the less likely is coronary\\nartery disease. These risk factors are all modifiable.\\nNon-modifiable risk factors are heredity, sex, and age.\\nRisk factors that can be changed:\\n/C15Cigarette/tobacco smoke–Smoking increases both\\nthe chance of developing atherosclerosis and the\\nchance of dying from coronary heart disease.\\nSecond hand smoke may also increase risk.\\n/C15High blood cholesterol–Cholesterol, a soft, waxy\\nsubstance, comes from foods such as meat, eggs,\\nand other animal products and is produced in the\\nliver. Age, sex, heredity, and diet affect cholesterol.\\nTotal blood cholesterol is considered high at levels\\nabove 240 mg/dL and borderline at 200-239 mg/dL.\\nHigh-risk levels of low-density lipoprotein (LDL\\ncholesterol) begin at 130-159 mg/dL.\\n/C15High triglycerides–Most fat in food and in the body\\ntakes the form of triglycerides. Blood triglyceride\\nlevels above 400 mg/dL have been linked to coronary\\nartery disease in some people. Triglycerides, how-\\never, are not nearly as harmful as LDL cholesterol.\\n/C15High blood pressure–Blood pressure of 140 over 90\\nor higher makes the heart work harder, and over\\ntime, both weakens the heart and harms the arteries.\\n/C15Physical inactivity–Lack of exercise increases the\\nrisk of atherosclerosis.\\n/C15Diabetes mellitus–The risk of developing atherosclero-\\nsis is seriously increased for diabetics and can be low-\\nered by keeping diabetes under control. Most diabetics\\ndie from heart attacks caused by atherosclerosis.\\n/C15Obesity–Excess weight increases the strain on the\\nheart and increases the risk of developing athero-\\nsclerosis even if no other risk factors are present.\\nRisk factors that cannot be changed:\\n/C15Heredity–People whose parents have coronary\\nartery disease, atherosclerosis, or stroke at an early\\nGALE ENCYCLOPEDIA OF MEDICINE 439\\nAtherosclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 469, 'page_label': '440'}, page_content='age are at increased risk. The high rate of severe\\nhypertension among African-Americans puts them\\nat increased risk.\\n/C15Sex–Before age 60, men are more likely to have heart\\nattacks than women are. After age 60, the risk is\\nequal among men and women.\\n/C15Age–Risk is higher in men who are 45 years of age and\\nolder and women who are 55 years of age and older.\\nSymptoms differ depending upon the location of\\nthe atherosclerosis.\\n/C15In the coronary (heart) arteries: Chestpain, heart\\nattack, or suddendeath.\\n/C15In the carotid (brain) arteries: Sudden dizziness,\\nweakness, loss of speech, or blindness.\\n/C15In the femoral (leg) arteries: Disease of the blood\\nvessels in the outer parts of the body (peripheral\\nvascular disease) causes cramping andfatigue in the\\ncalves when walking.\\n/C15In the renal (kidney) arteries: High blood pressure\\nthat is difficult to treat.\\nDiagnosis\\nPhysicians may be able to make a diagnosis of\\natherosclerosis during a physical exam by means of a\\nstethoscope and gentle probing of the arteries with the\\nhand (palpation). More definite tests areelectrocardio-\\ngraphy, echocardiography or ultrasonography of the\\narteries (for example, the carotids), radionuclide\\nscans, andangiography.\\nThe result is a fibrous \\nlesion, made up in part\\nof muscle cells, proteins, \\nand collagen, that has at \\nits center a pool of lipids \\nand dead cells. Blood \\nflow can be very nearly \\ncut off by the blockage.\\nWhen the arterial lining becomes \\nseparated over the growing mass of \\nfoam cells, platelets are attracted to the \\nsite and begin the process of clot formation.\\nPlatelets\\nHigh cholesterol levels, \\nhigh blood pressure, \\ndiabetes, obesity, viruses,\\ncigarette smoking, etc., \\ncause injuries to the \\nlining of the artery, \\ncreating areas where \\nhigher levels of lipids\\nare trapped.\\nFurther injury is inflicted by foam cells\\nattempting to remove lipids back to the\\nlungs, liver, spleen and lymph nodes\\nby again passing through the lining of\\nthe artery.\\nMonocyteLining of\\nartery\\nMuscle\\nT- c e l l\\nMonocytes (the largest of the \\nwhite blood cells) and T -cells \\nare attracted to the injury.\\nFoam cell\\nMonocytes, which become \\nmacrophages when they leave \\nthe bloodstream, and T -cells \\npenetrate the lining of the artery.\\nThe macrophages soak up lipids, \\nbecoming large foam cells and \\ndistorting the inner surface of the \\nartery. Blood flow becomes\\nrestricted.\\nThe progression of atherosclerosis. (Illustration by Hans & Cassady.)\\n440 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherosclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 470, 'page_label': '441'}, page_content='An electrocardiogram shows the heart’s activity.\\nElectrodes covered with conducting jelly are placed on\\nthe patient’s body. They send impulses of the heart to a\\nrecorder. The test takes about 10 minutes and is per-\\nformed in a physician’s office. Exercise electrocardio-\\ngraphy (stress test) is conducted while the patient\\nexercises on a treadmill or a stationary bike. It is\\nperformed in a physician’s office or an exercise labora-\\ntory and takes 15-30 minutes.\\nEchocardiography, cardiac ultrasound, uses sound\\nwaves to create an image of the heart’s chambers and\\nvalves. A technician applies gel to a hand-held transdu-\\ncer, presses it against the patient’s chest, and images are\\ndisplayed on a monitor. This technique cannot evaluate\\nthe coronary arteries directly. They are too small and\\nare in motion with the heart. Severe coronary artery\\ndisease, however, may cause abnormal heart motion\\nthat is detected by echocardiography. Performed in a\\ncardiology outpatient diagnostic laboratory, the test\\ntakes 30-60 minutes. Ultrasonography is also used to\\nassess arteries of the neck and thighs.\\nRadionuclide angiography and thallium (or ses-\\ntamibi) scanning enable physicians to see the blood\\nflow through the coronary arteries and the heart\\nchambers. Radioactive material is injected into the\\nbloodstream. A device that uses gamma rays to\\nproduce an image of the radioactive material\\n(gamma camera) records pictures of the heart.\\nRadionuclide angiography is usually performed in\\na hospital’s nuclear medicine department and takes\\n30-60 minutes. Thallium scanning is usually done\\nafter an exercise stress test or after injection of a\\nvasodilator, a drug to enlarge the blood vessels, like\\ndipyridamole (Persantine). Thallium is injected, and\\nthe scan is done then and again four hours (and\\npossibly 24 hours) later. Thallium scanning is\\nusually performed in a hospital’s nuclear medicine\\ndepartment. Each scan takes 30-60 minutes.\\nCoronary angiography is the most accurate diag-\\nnostic method and the only one that requires entering\\nthe body (invasive procedure). A cardiologist inserts a\\ncatheter equipped with a viewing device into a blood\\nvessel in the leg or arm and guides it into the heart. The\\npatient has been given a contrast dye that makes\\nthe heart visible to x rays. Motion pictures are taken\\nof the contrast dye flowing though the arteries.\\nPlaques and blockages, if present, are well defined.\\nThe patient is awake but has been given a sedative.\\nCoronary angiography is performed in a cardiac\\ncatheterization laboratory and takes from 30 minutes\\nto two hours.\\nTreatment\\nTreatment includes lifestyle changes, lipid-lower-\\ning drugs, percutaneous transluminal coronaryangio-\\nplasty, and coronary artery bypass surgery.\\nAtherosclerosis requires lifelong care.\\nPatients who have less severe atherosclerosis may\\nachieve adequate control through lifestyle changes\\nand drug therapy. Many of the lifestyle changes that\\nprevent disease progression–a low-fat, low-cholesterol\\ndiet, losing weight (if necessary), exercise, controlling\\nblood pressure, and not smoking–also help prevent the\\ndisease.\\nMost of the drugs prescribed for atherosclerosis\\nseek to lower cholesterol. Many popular lipid-lower-\\ning drugs can reduce LDL-cholesterol by an average\\nof 25-30% when combined with a low-fat, low-\\ncholesterol diet. Lipid-lowering drugs include bile\\nacid resins, ‘‘statins’’ (drugs that effect HMG-CoA\\nreductase, an enzyme that controls the processing of\\ncholesterol), niacin, and fibric acid derivatives such as\\ngemfibrozil (Lobid).Aspirin helps prevent thrombosis\\nand a variety of other medications can be used to treat\\nthe effects of atherosclerosis.\\nKEY TERMS\\nArteriosclerosis— Hardening of the arteries. It\\nincludes atherosclerosis, but the two terms are\\noften used synonymously.\\nCholesterol— A fat-like substance that is made by\\nthe human body and eaten in animal products.\\nCholesterol is used to form cell membranes and\\nprocess hormones and vitamin D. High cholesterol\\nlevels contribute to the development of\\natherosclerosis.\\nHDL Cholesterol— About one-third or one-fourth\\nof all cholesterol is high-density lipoprotein choles-\\nterol. High levels of HDL, nicknamed ‘‘good’’ cho-\\nlesterol, decrease the risk of atherosclerosis.\\nLDL Cholesterol— Low-density lipoprotein choles-\\nterol is the primary cholesterol molecule. High\\nlevels of LDL, nicknamed ‘‘bad’’ cholesterol,\\nincrease the risk of atherosclerosis\\nPlaque— A deposit of fatty and other substances\\nthat accumulates in the lining of the artery wall.\\nTriglyceride— A fat that comes from food or is\\nmade from other energy sources in the body.\\nElevated triglyceride levels contribute to the devel-\\nopment of atherosclerosis.\\nGALE ENCYCLOPEDIA OF MEDICINE 441\\nAtherosclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 471, 'page_label': '442'}, page_content='Percutaneous transluminal coronary angioplasty\\nand bypass surgery are invasive procedures that\\nimprove blood flow in the coronary arteries.\\nPercutaneous transluminal coronary angioplasty (cor-\\nonary angioplasty) is a non-surgical procedure in\\nwhich a catheter tipped with a balloon is threaded\\nfrom a blood vessel in the thigh into the blocked\\nartery. The balloon is inflated, compresses the plaque\\nto enlarge the blood vessel, and opens the blocked\\nartery. Coronary angioplasty is performed by a cardi-\\nologist in a hospital and generally requires a hospital\\nstay of one or two days. It is successful about 90% of\\nthe time, but for one-third of patients the artery nar-\\nrows again within six months. It can be repeated and a\\n‘‘stent’’ may be placed in the artery to help keep it open\\n(see below).\\nIn coronary artery bypass surgery (bypass sur-\\ngery), a detour is built around the blockage with a\\nhealthy vein or artery, which then supplies oxygen-\\nrich blood to the heart. It is major surgery appropriate\\nfor patients with blockages in two or three major\\ncoronary arteries or severely narrowed left main cor-\\nonary arteries, and for those who have not responded\\nto other treatments. It is performed in a hospital under\\ngeneral anesthesia and uses a heart-lung machine.\\nAbout 70% of patients experience full relief; about\\n20% partial relief.\\nThree other semi-experimental surgical proce-\\ndures may be used to treat atherosclerosis. In ather-\\nectomy, a cardiologist shaves off and removes strips\\nof plaque from the blocked artery. In laser angio-\\nplasty, a catheter with a laser tip is inserted to burn\\nor break down the plaque. A metal coil called a\\nstent may be permanently implanted to keep a\\nblocked artery open.\\nAlternative treatment\\nAlternative therapies that focus on diet and life-\\nstyle can help prevent, retard, or reverse atherosclero-\\nsis. Herbal therapies that may be helpful include:\\nhawthorn (Crataegus laevigata ), notoginseng root\\n(Panax notoginseng), garlic (Allium sativum), ginger\\n(Zingiber officinale), hot red or chili peppers, yarrow\\n(Achillea millefolium), and alfalfa (Medicago sativum).\\nRelaxation techniques including yoga, meditation,\\nguided imagery, biofeedback, and counseling and\\nother ‘‘talking’’ therapies may also be useful to prevent\\nor slow the progress of the disease. Dietary modifica-\\ntions focus on eating foods that are low in fats (espe-\\ncially saturated fats), cholesterol, sugar, and animal\\nproteins and high in fiber and antioxidants (found in\\nfresh fruits and vegetables). Liberal use of onions and\\ngarlic is recommended, as is eating raw and cooked\\nfish, especially cold-water fish like salmon. Smoking,\\nalcohol, and stimulants like coffee should be avoided.\\nChelation therapy, which usesanticoagulant drugsand\\nnutrients to dissolve plaque and flush it through the\\nkidneys, is controversial. Long-term remedies can be\\nprescribed by specialists in ayurvedic medicine, which\\ncombines diet, herbal remedies, relaxation and exer-\\ncise, and homeopathy, which treats a disease with\\nsmall doses of a drug that causes the symptoms of\\nthe disease.\\nPrognosis\\nAtherosclerosis can be successfully treated but not\\ncured. Recent clinical studies have shown that athero-\\nsclerosis can be delayed, stopped, and even reversed by\\naggressively lowering LDL cholesterol. New diagnos-\\ntic techniques enable physicians to identify and treat\\natherosclerosis in its earliest stages. New technologies\\nand surgical procedures have extended the lives of\\nmany patients who would otherwise have died.\\nResearch continues.\\nPrevention\\nA healthy lifestyle–eating right, regular exercise,\\nmaintaining a healthy weight, not smoking, and con-\\ntrolling hypertension–can reduce the risk of develop-\\ning atherosclerosis, help keep the disease from\\nprogressing, and sometimes cause it to regress.\\n/C15Eat right-A healthy diet reduces excess levels of LDL\\ncholesterol and triglycerides. It includes a variety of\\nfoods that are low in fat and cholesterol and high in\\nfiber; plenty of fruits and vegetables; and limited\\nsodium. Fat should comprise no more than 30%,\\nand saturated fat no more than 8-10%, of total\\ndaily calories according to the American Heart\\nAssociation. Cholesterol should be limited to about\\n300 milligrams per day and sodium to about 2,400\\nmilligrams. The ‘‘Food Guide’’ Pyramid developed\\nby the U.S. Departments of Agriculture and Health\\nand Human Services provides daily guidelines: 6-11\\nservings of bread, cereal, rice, and pasta; 3-5 servings\\nof vegetables; 2-4 servings of fruit; 2-3 servings of\\nmilk, yogurt, and cheese; and 2-3 servings of meat,\\npoultry, fish, dry beans, eggs, and nuts. Fats, oils,\\nand sweets should be used sparingly. Mono-unsatu-\\nrated oils, like olive and rapeseed (Canola) are good\\nalternatives to use for cooking.\\n/C15Exercise regularly–Aerobic exercise can lower blood\\npressure, help control weight, and increase HDL\\n(‘‘good’’) cholesterol. It may keep the blood vessels\\n442 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherosclerosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 472, 'page_label': '443'}, page_content='more flexible. Moderate to intense aerobic exercise\\nlasting about 30 minutes (or three 10-minute exercise\\nperiods) four or more times per week is recom-\\nmended, according to the Centers for Disease\\nControl and Prevention and the American College\\nof Sports Medicine. Aerobic exercise includes walk-\\ning, jogging, and cycling, active gardening, climbing\\nstairs, or brisk housework. A physician should be\\nconsulted before exercise if a person has athero-\\nsclerosis or is at increased risk for it.\\n/C15Maintain a desirable body weight–Losing weight can\\nhelp reduce total and LDL cholesterol, reduce trigly-\\ncerides, and boost HDL cholesterol. It may also\\nreduce blood pressure. Eating right and exercising\\nare two key components in maintaining a desirable\\nbody weight.\\n/C15Do not smoke or use tobacco–Smoking has many\\nadverse effects on the heart but quitting can repair\\ndamage. Ex-smokers face the same risk of heart dis-\\nease as non-smokers within five to 10 years of quit-\\nting. Smoking is the worst thing a person can do to\\ntheir heart and lungs.\\n/C15Seek treatment for hypertension–High blood pres-\\nsure can be controlled through lifestyle changes–\\nreducing sodium and fat, exercising, managing\\nstress, quitting smoking, and drinking alcohol in\\nmoderation–and medication. Drugs that provide\\neffective treatment are:diuretics, beta-blockers, sym-\\npathetic nerve inhibitors, vasodilators, angiotensin\\nconverting enzyme inhibitors, and calcium antago-\\nnists. Hypertension usually has no symptoms so it\\nmust be checked to be known. Like cholesterol,\\nhypertension is called a ‘‘silent killer.’’\\nResources\\nPERIODICALS\\nMorgan, Peggy. ‘‘What Your Heart Wishes You Knew\\nAbout Cholesterol.’’Prevention (September 1997): 96.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nAthetosis see Movement disorders\\nAthlete’s foot\\nDefinition\\nA common fungus infection between the toes in\\nwhich the skin becomes itchy and sore, cracking and\\npeeling away. Athlete’s foot (also known as tinea pedis\\nor footringworm) can be treated, but it can be tena-\\ncious and difficult to clear up completely.\\nDescription\\nAthlete’s foot is a very common condition of\\nitchy, peeling skin on the feet. In fact, it’s so common\\nthat most people will have at least one episode at least\\nonce in their lives. It’s less often found in women and\\nchildren under age 12. (Symptoms that look like ath-\\nlete’s foot in young children most probably are caused\\nby some other skin condition).\\nBecause the fungi grow well in warm, damp areas,\\nthey flourish in and around swimming pools, showers,\\nand locker rooms. Tinea pedis got its common name\\nbecause the infection was common among athletes\\nwho often used these areas.\\nCauses and symptoms\\nAthlete’s foot is caused by a fungal infection that\\nmost often affects the fourth and fifth toe webs.\\nTrichophyton rubrum , T. mentagrophytes ,a n d\\nEpidermophyton floccosum, the fungi that cause ath-\\nlete’s foot, are unusual in that they live exclusively on\\ndead body tissue (hair, the outer layer of skin, and\\nnails). The fungus grows best in moist, damp, dark\\nplaces with poor ventilation. The problem doesn’t\\noccur among people who usually go barefoot.\\nMany people carry the fungus on their skin.\\nHowever, it will only flourish to the point of causing\\nathlete’s foot if conditions are right. Many people\\nbelieve athlete’s foot is highly contagious, especially in\\npublic swimming pools and shower rooms. Research\\nhas shown, however, that it is difficult to pick up the\\ninfection simply by walking barefoot over a contami-\\nnated damp floor. Exactly why some people develop\\nthe condition and others don’t is not well understood.\\nSweaty feet, tight shoes, synthetic socks that don’t\\nabsorb moisture well, a warm climate, and not drying\\nthe feet well after swimming or bathing, all contribute\\nto the overgrowth of the fungus.\\nSymptoms of athlete’s foot include itchy, sore skin\\non the toes, with scaling, cracking, inflammation, and\\nblisters. Blisters that break, exposing raw patches of\\nGALE ENCYCLOPEDIA OF MEDICINE 443\\nAthlete’s foot'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 473, 'page_label': '444'}, page_content='tissue, can cause pain and swelling. As the infection\\nspreads, itching and burning may get worse.\\nIf it’s not treated, athlete’s foot can spread to the\\nsoles of the feet and toenails.Stubborn toenail infections\\nmay appear at the same time, with crumbling, scaling and\\nthickened nails, and nail loss. The infection can spread\\nfurther if patients scratch and then touch themselves\\nelsewhere (especially in the groin or under the arms).\\nIt’s also possible to spread the infection to other parts\\nof the body via contaminated bed sheets or clothing.\\nDiagnosis\\nNot all footrashesare athlete’s foot, which is why a\\nphysician should diagnose the condition before any\\nremedies are used. Using nonprescription products on a\\nrash that is not athlete’s foot could make the rash worse.\\nA dermatologist can diagnose the condition by\\nphysical examination and by examining a preparation\\nof skin scrapings under a microscope. This test, called\\na KOH preparation, treats a sample of tissue scraped\\nfrom the infected area with heat and potassium hydro-\\nxide (KOH). This treatment dissolves certain sub-\\nstances in the tissue sample, making it possible to see\\nthe fungi under the microscope.\\nTreatment\\nAthlete’s foot may be resistant to medication and\\nshould not be ignored. Simple cases usually respond\\nwell to antifungal creams or sprays (clotrimazole, keto-\\nconazole, miconazole nitrate, sulconazole nitrate, or\\ntolnaftate). If the infection is resistant to topical treat-\\nment, the doctor may prescribe an oral antifungal drug.\\nUntreated athlete’s foot may lead to a secondary\\nbacterial infection in the skin cracks.\\nAlternative treatment\\nA footbath containing cinnamon has been shown\\nto slow down the growth of certain molds and fungi,\\nand is said to be very effective in clearing up athlete’s\\nfoot. To make the bath:\\n/C15heat four cups of water to a boil\\n/C15add eight to 10 broken cinnamon sticks\\n/C15reduce heat and simmer five minutes\\n/C15remove and let the mixture steep for 45 minutes until\\nlukewarm\\n/C15soak feet\\nOther herbal remedies used externally to treat\\nathlete’s foot include: a foot soak or powder contain-\\ning goldenseal (Hydrastis canadensis); tea tree oil\\n(Melaleuca spp.); or calendula (Calendula officinalis)\\ncream to help heal cracked skin.\\nPrognosis\\nAthlete’s foot usually responds well to treatment,\\nbut it is important to take all medication as directed by\\na dermatologist, even if the skin appears to be free of\\nfungus. Otherwise, the infection could return. The toe-\\nnail infections that may accompany athlete’s foot,\\nhowever, are typically very hard to treat effectively.\\nPrevention\\nGood personal hygiene and a few simple precau-\\ntions can help prevent athlete’s foot. To prevent\\nspread of athlete’s foot:\\n/C15wash feet daily\\n/C15dry feet thoroughly (especially between toes)\\nAthlete’s foot fungus on toes of patient.(Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nAthlete’s foot fungus on bottom of patient’s foot. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\n444 GALE ENCYCLOPEDIA OF MEDICINE\\nAthlete’s foot'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 474, 'page_label': '445'}, page_content='/C15avoid tight shoes (especially in summer)\\n/C15wear sandals during warm weather\\n/C15wear cotton socks and change them often if they get\\ndamp\\n/C15don’t wear socks made of synthetic material\\n/C15go barefoot outdoors when possible\\n/C15wear bathing shoes in public bathing or showering\\nareas\\n/C15use a good quality foot powder\\n/C15don’t wear sneakers without socks\\n/C15wash towels, contaminated floors, and shower stalls\\nwell with hot soapy water if anyone in the family has\\nathlete’s foot.\\nResources\\nBOOKS\\nThompson, June, et al.Mosby’s Clinical Nursing.St. Louis:\\nMosby, 1998.\\nORGANIZATIONS\\nAmerican Podiatric Medical Association. 9312 Old\\nGeorgetown Road, Bethesda, MD 20814-1698. (301)\\n571-9200. .\\nCarol A. Turkington\\nAthletic heart syndrome\\nDefinition\\nAthletic heart syndrome is the adaptation of\\nan athlete’s heart in response the physiologic stresses\\nof strenuous physical training. It can be difficult to\\ndistinguish a significant medical condition from an\\nathletic heart.\\nDescription\\nThe heart adapts to physical demands by enlar-\\nging, especially the left ventricle. Enlargement increases\\nthe cardiac output, the amount of blood pumped with\\neach beat of the heart. The exact type of adaptation\\ndepends on the nature of the physical demand. There\\nare two types of demand, static and dynamic. Static\\ndemand involves smaller groups of muscles under\\nextreme resistance for brief period. An example is\\nweight lifting. Dynamic training involves larger groups\\nof muscles at lower resistance for extended periods of\\ntime. Examples are aerobic training and tennis.\\nCardiac enlargement is associated with dynamic train-\\ning. The heart’s response to static training is hypertro-\\nphy, thickening of the muscle walls of the heart. As\\nthe wall of the heart adapts, there are changes in the\\nelectrical conducting system of the heart. Because of\\nthe larger volume of blood being pumped with each\\nheart beat, the heart rate when at rest decreases\\nbelow the normal level for nonathletes.\\nSudden unexpecteddeath (SUD) is the death of an\\nathlete, usually during or shortly after physical acti-\\nvity. Often, there is no warning that the person will\\nexperience SUD, although in some cases, warning\\nsigns appear which cause the person to seek medical\\nadvice. Importantly, cases of death occurring during\\nphysical activity are not caused by athletic heart\\nsyndrome, but by undiagnosed heart disorders.\\nCauses and symptoms\\nAthletic heart syndrome is the consequence of a\\nnormal adaptation by the heart to increased physical\\nactivity. The changes in the electrical conduction sys-\\ntem of the heart may be pronounced and diagnostic,\\nbut should not cause problems. In the case of SUD,\\nother heart problems are involved. In 85-97% of the\\ncases of SUD, an underlying structural defect of the\\nheart has been noted.\\nDiagnosis\\nThe changes in the heart beat caused by the elec-\\ntrical conduction system of the heart are detectable on\\nan electrocardiogram. Many of the changes seen in\\nathletic heart syndrome mimic those of various heart\\ndiseases. Careful examination must be made to distin-\\nguish heart disease from athletic heart syndrome.\\nPrognosis\\nThe yearly rate for occurrence of SUD in people\\nless than 35 years of age is less than 7 incidents per\\n100,000. Of all SUD cases, only about 8% areexercise\\nrelated. On a national basis, this means that each year\\napproximately 25 athletes experience SUD. In persons\\nover age 35, the incidence of SUD is approximately 55\\nin 100,000, with only 3% of the cases occurring during\\nexercise.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 445\\nAthletic heart syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 475, 'page_label': '446'}, page_content='Atkins diet\\nDefinition\\nThe Atkins diet is a high-protein, high-fat, and\\nvery low-carbohydrate regimen. It emphasizes meat,\\ncheese, and eggs, while discouraging foods such as\\nbread, pasta, fruit, and sugar. It is a form of keto-\\ngenic diet.\\nPurpose\\nThe primary benefit of the diet is rapid and sub-\\nstantial weight loss. By restricting carbohydrate\\nintake, the body will burn more fat stored in the\\nbody. Since there are no limits on the amount of\\ncalories or quantities of foods allowed on the diet,\\nthere is little hunger between meals. According to\\nAtkins, the diet can alleviate symptoms of conditions\\nsuch asfatigue, irritability, headaches, depression, and\\nsome types of joint and musclepain.\\nDescription\\nThe regimen is a low-carbohydrate, or ketogenic\\ndiet, characterized by initial rapid weight loss, usually\\ndue to water loss. Drastically reducing the amount of\\ncarbohydrate intake causes liver and muscle glycogen\\nloss, which has a strong but temporary diuretic effect.\\nLong-term weight loss occurs because with a low\\namount of carbohydrate intake, the body burns stored\\nfat for energy.\\nThe four-step diet starts with a two-week induc-\\ntion program designed to rebalance an individual’s\\nmetabolism. Unlimited amounts of fat and protein\\nare allowed but carbohydrate intake is restricted to\\n20 grams per day. Foods allowed include butter, oil,\\nmeat, poultry, fish, eggs, cheese, and cream. The daily\\namount of carbohydrates allowed equals about three\\ncups of salad vegetables, such as lettuce, cucumbers,\\nand celery.\\nThe second stage is for ongoing weight loss. It\\nallows 20-40 grams of carbohydrates a day. When\\nthe individual is about 10 pounds from their desired\\nweight, they begin the pre-maintenance phase. This\\ngradually adds one to three servings a week of high\\ncarbohydrate foods, such as a piece of fruit or slice of\\nwhole-wheat bread. When the desired weight is\\nreached, the maintenance stage begins. It allows\\n40-60 grams of carbohydrates per day.\\nOpinion from the general medical community\\nremains mixed on the Atkins diet. There have been\\nno significant long-term scientific studies on the diet.\\nA number of leading medical and health organiza-\\ntions, including the American Medical Association,\\nAmerican Dietetic Association (ADA), and the\\nAmerican Heart Association oppose it. It is drastically\\ndifferent than the dietary intakes recommended by the\\nU.S. Department of Agriculture and the National\\nInstitutes of Health. Much of the opposition is because\\nthe diet is lacking in somevitamins and nutrients, and\\nbecause it is high in fat. In a hearing before the U.S.\\nCongress on February 24, 2000, an ADA representa-\\ntive called the Atkins diet ‘‘hazardous’’ and said it\\nlacked scientific credibility.\\nPreparations\\nNo advance preparation is needed to go on the\\ndiet. However, as with mostdiets, it is generally con-\\nsidered appropriate to consult with a physician and to\\nhave a physical evaluation before starting such a nutri-\\ntional regimen. The evaluation should include blood\\ntests to determine levels of cholesterol, triglycerides,\\nglucose, insulin, and uric acid. A glucose tolerance test\\nis also recommended.\\nPrecautions\\nAdherence to the Atkins diet can result in vitamin\\nand mineral deficiencies. In his books, Atkins recom-\\nmends a wide-range ofnutritional supplements, includ-\\ning a multi-vitamin. Among his recommendations,\\nAtkins suggests the following daily dosages: 300-600\\nmicrograms (mcg) of chromium picolinate, 100-400\\nmilligrams (mg) of pantetheine, 200 mcg of selenium,\\nand 450-675 mcg of biotin.\\nThe diet is not recommended for lacto-ovo vege-\\ntarians, since it cannot be done as successfully without\\nprotein derived from animal products. Also, vegans\\ncannot follow this diet, since a vegan diet is too high in\\ncarbohydrates, according to Atkins. Instead, he\\nrecommends vegetarians with a serious weight pro-\\nblem give upvegetarianism, or at least include fish in\\ntheir diet.\\nSide effects\\nAccording to Atkins, the diet causes no adverse\\nside effects. Many health care professionals dis-\\nagree. In a fact sheet for the Healthcare Reality\\nCheck Web site (), Ellen\\nColeman, a registered dietician and author, said\\nthe diet may have serious side effects for some peo-\\nple. She said complicationsassociated with the diet\\ninclude ketosis,dehydration, electrolyte loss, calcium\\ndepletion, weakness, nausea, and kidney problems.\\n446 GALE ENCYCLOPEDIA OF MEDICINE\\nAtkins diet'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 476, 'page_label': '447'}, page_content='‘‘It is certainly riskier for overweight individuals with\\nmedical problems such as heart disease,hypertension,\\nkidney disease, and diabetes than it is for overweight\\npeople with no health problems,’’ she said.\\nPeople with diabetes taking insulin are at risk of\\nbecoming hypoglycemic if they do not eat appropriate\\ncarbohydrates. Also, persons whoexercise regularly\\nmay experience low energy levels and muscle fatigue\\nfrom low carbohydrate intake.\\nResources\\nBOOKS\\nAtkins, Dr. Robert C.Dr. Atkins’ Age-Defying Diet\\nRevolution. New York: St. Martin’s Press. 1999.\\nPERIODICALS\\nCray, Dan, et al. ‘‘The Low-Carb Diet Craze.’’Time\\nNovember 1, 1999: 72-79.\\nGotthardt, Melissa Meyers. ‘‘The New Low-Carb Diet\\nCraze.’’ Cosmopolitan February 2000: 148.\\nMerrell, Woodson. ‘‘How I Became a Low-Carb Believer.’’\\nTime November 1, 1999: 80.\\nTurner, Richard. ‘‘The Trendy Diet That Sizzles.’’\\nNewsweek September 6, 1999: 60.\\nDR.ROBERT C. ATKINS (1930–2003)\\n(AP/Wide World Photos. Reproduced by permission.)\\nDr. Robert C. Atkins graduated from the University\\nof Michigan in 1951 and received his medical degree\\nfrom Cornell University Medical School in 1955 with a\\nspecialty in cardiology. As an internist and cardiologist\\nhe developed the Atkins Diet in the early 1970s. The diet is\\na ketogenic diet—a high protein, high fat, and very low\\ncarbohydrate regimen resulting in ketosis. It emphasizes\\nmeat, cheese, and eggs, while discouraging foods such as\\nbread, pasta, fruit, and sugar. It first came to public atten-\\ntion in 1972 with the publication of Dr. Atkins’ Diet\\nRevolution. The book quickly became a bestseller but\\nunlike most other fad diet books, this one has remained\\npopular. At last count, it had been reprinted 28 times and\\nsold more than 10 million copies worldwide. Since then,\\nAtkins has authored a number of other books on his diet\\ntheme, including Dr. Atkins’ New Diet Revolution(1992),\\nDr. Atkins’ Quick and Easy New Diet Cookbook (1997),\\nand The Vita-Nutrient Solution: Nature’s Answer to Drugs\\n(1998).\\nAtkins has seen about 60,000 patients in his more\\nthan 30 years of practice. He has also appeared on numer-\\nous radio and television talk shows, has his own syndi-\\ncated radio program, Your Health Choices , and authors\\nthe monthly newsletter Dr. Atkins’ Health Revelations .\\nAtkins has received the World Organization of\\nAlternative Medicine’s Recognition of Achievement\\nAward and been named the National Health Federation’s\\nMan of the Year. He was the director of the Atkins Center\\nfor Complementary Medicine which he founded in the\\nearly 1980s until his death. The center is located at 152\\nE. 55th St., New York, NY 10022.\\nKEY TERMS\\nBiotin— A B complex vitamin, found naturally in\\nyeast, liver, and egg yolks.\\nCarbohydrates— Neutral compounds of carbon,\\nhydrogen, and oxygen found in sugar, starches,\\nand cellulose.\\nHypertension— Abnormally high arterial blood\\npressure, which if left untreated can lead to heart\\ndisease and stroke.\\nKetogenic diet— A diet that supplies an abnormally\\nhigh amount of fat, and small amounts of carbohy-\\ndrates and protein.\\nKetosis— An abnormal increase in ketones in the\\nbody, usually found in people with uncontrolled\\ndiabetes mellitus.\\nPantetheine— A growth factor substance essential\\nin humans, and a constituent of coenzyme A.\\nTriglycerides— A blood fat lipid that increases the\\nrisk for heart disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 447\\nAtkins diet'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 477, 'page_label': '448'}, page_content='OTHER\\nAtkins Center for Complementary Medicine. 152 E. 55th St.,\\nNew York, NY 10022. 212-758-2110. .\\nKen R. Wells\\nAtopic dermatitis\\nDefinition\\nEczema is a general term used to describe a variety\\nof conditions that cause an itchy, inflamed skin\\nrash. Atopic dermatitis, a form of eczema, is a non-\\ncontagious disorder characterized by chronically\\ninflamed skin and sometimes intolerable itching.\\nDescription\\nAtopic dermatitis refers to a wide range of dis-\\neases that are often associated with stress and allergic\\ndisorders that involve the respiratory system, like\\nasthma and hay fever. Although atopic dermatitis\\ncan appear at any age, it is most common in children\\nand young adults. Symptoms usually abate before the\\nage of 25 and do not affect the patient’s general health.\\nAbout one in ten babies develop a form of atopic\\ndermatitis called infantile eczema. Characterized by skin\\nthatoozesand becomes encrusted, infantile eczema most\\noften occurs on the face and scalp. The condition usually\\nimproves before the child’ssecond birthday,andmedical\\nattention can keep symptoms in check until that time.\\nWhen atopic dermatitis develops after infancy,\\ninflammation, blistering, oozing, and crusting are less\\npronounced. The patient’s sores become dry, turn from\\nred to brownish-gray, and skin may thicken and become\\nscaly. In dark-skinned individuals, this condition can\\ncause the complexion to lighten or darken.Itchingasso-\\nciated with this condition is usually worst at night. It\\ncan be so intense that patients scratch until their sores\\nbleed, sometimes causing scarring and infection.\\nAtopic dermatitis affects about 3% of the popula-\\ntion of the United States, and about 80% of the people\\nwho have the condition have one or more relatives with\\nthe same condition or a similar one. Symptoms tend to\\nbe most severe in females. Atopic dermatitis can erupt on\\nany part of the skin, and crusted, thickened patches on\\nthe fingers, palms, or the soles of the feet can last for\\nyears. In teenagers and young adults, atopic dermatitis\\noften appears on one or more of the following areas:\\n/C15elbow creases\\n/C15backs of the knees\\n/C15ankles\\n/C15wrists\\n/C15face\\n/C15neck\\n/C15upper chest\\n/C15palms and between the fingers\\nCauses and symptoms\\nWhile allergic reactions often trigger atopic\\ndermatitis, the condition is thought to be the result\\nof an inherited over-active immune system or a\\ngenetic defect that causes the skin to lose abnor-\\nmally large amounts of moisture. The condition can\\nA close-up view of atopic dermatitis in the crook of the\\nelbow of a 12-year-old patient. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n448 GALE ENCYCLOPEDIA OF MEDICINE\\nAtopic dermatitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 478, 'page_label': '449'}, page_content='be aggravated by a cycle that develops in which the\\nskin itches, the patient scratches, the condition wor-\\nsens, the itching worsens, the patient scratches, etc.\\nThis cycle must be broken by relieving the itching to\\nallow the skin time to heal. If the skin becomes\\nbroken, there is also a risk of developing skin infec-\\ntions which, if not recognized and treated promptly,\\ncan become more serious.\\nSymptoms of atopic dermatitis include the\\nfollowing:\\n/C15an itchy rash and dry, thickened skin on areas of the\\nbody where moisture can be trapped\\n/C15continual scratching\\n/C15chronic fatigue, caused when itching disrupts sleep\\nInfant Adult\\nAtopic dermatitis can erupt on any part of the skin. In infants, it often appears on the face, scalp, and knees, while it develops on\\nthe elbows, neck, back of the knees, and ankles in adults.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nCorticosteroid— A steroid hormone produced by\\nthe adrenal gland or as a synthetic compound that\\nreducesinflammation, redness,rashes, andirritation.\\nDermatitis— Inflammation of the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 449\\nAtopic dermatitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 479, 'page_label': '450'}, page_content='An individual is more at-risk for developing the\\ncondition if there is a personal or family history of\\natopic dermatitis, hay fever, asthma, or other allergies.\\nExposure to any of the following can cause a flare-up:\\n/C15hot or cold temperatures\\n/C15wool and synthetic fabrics\\n/C15detergents, fabric softeners, and chemicals\\n/C15use of drugs that suppress immune-system activity\\nCertain foods, such as peanuts, cow’s milk, eggs,\\nand fish, can trigger symptoms of atopic dermatitis.\\nA small percentage of patients with atopic dermatitis\\nfind that their symptoms worsen after having been\\nexposed to dust, feather pillows, rough-textured fab-\\nrics, or other materials to which dust adheres.\\nDiagnosis\\nDiagnosis of atopic dermatitis is usually based on\\nthe patient’s symptoms and personal and family\\nhealth history. Skin tests do not generally provide\\nreliable information about this condition.\\nTreatment\\nAtopic dermatitis cannot be cured, but the sever-\\nity and duration of symptoms can be controlled.\\nA dermatologist should be consulted when symptoms\\nfirst appear, and is likely to recommend warm baths to\\nloosen encrusted skin, followed by applications of\\npetroleum jelly or vegetable shortening to prevent the\\nskin’s natural moisture from escaping.\\nExternally applied (topical) steroids or prepara-\\ntions containing coal tar can relieve minor itching, but\\ncoal tar has an unpleasant odor, stains clothes, and\\nmay increase skin-cancer risk. Excessive use of steroid\\ncreams in young children can alter growth. Pregnant\\nwomen should not use products that contain coal tar.\\nTopical steroids can cause itching, burning,acne,p e r -\\nmanent stretch marks, and thinning and spotting of\\nthe skin. Applying topical steroids to the area around\\nthe eyes can causeglaucoma.\\nOral antihistamines, such as diphenhydramine\\n(Benadryl), can relieve symptoms of allergy-related\\natopic dermatitis. More concentrated topical steroids\\nare recommended for persistent symptoms. A mild\\ntranquilizer may be prescribed to reducestress and\\nhelp the patient sleep, and antibiotics are used to\\ntreat secondary infections.\\nCortisone ointments should be used sparingly,\\nand strong preparations should never be applied\\nto the face, groin, armpits, or rectal area. Regular\\nmedical monitoring is recommended for patients\\nwho use cortisone salves or lotions to control wide-\\nspread symptoms. Oral cortisone may be prescribed\\nif the patient does not respond to other treatments,\\nbut patients who take the medication for more than\\ntwo weeks have a greater-than-average risk of devel-\\noping severe symptoms when the treatment is\\ndiscontinued.\\nAllergy shots rarely improve atopic dermatitis\\nand sometimes aggravate the symptoms. Sincefood\\nallergies may trigger atopic dermatitis, the doctor\\nmay suggest eliminating certain foods from the diet if\\nother treatments prove ineffective.\\nIf symptoms are extremely severe, ultraviolet\\nlight therapy may be prescribed, and a wet body\\nw r a pr e c o m m e n d e dt oh e l pt h es k i nr e t a i nm o i s t -\\nure. This technique, used most often with children,\\ninvolves sleeping in a warm room while wearing\\nwet pajamas under dry clothing, rain gear, or a\\nnylon sweatsuit. The patient’s face may be covered\\nwith wet gauze covered by elastic bandages, and\\nhis hands encased in wet socks covered by dry\\nones.\\nA physician should be notified if the condition is\\nwidespread or resists treatment, or the skin oozes,\\nbecomes encrusted, or smells, as this may indicate an\\ninfection.\\nAlternative treatment\\nAlternative therapies can sometimes bring relief\\nor resolution of atopic dermatitis when conventional\\ntherapies are not helping. If the condition becomes\\nincreasingly widespread or infected, a physician\\nshould be consulted.\\nHelpful alternative treatments for atopic dermati-\\ntis may include:\\n/C15Taking regular brisk walks, followed by bathing in\\nwarm water sprinkled with essential oil of lavender\\n(Lavandula officinalis); lavender oil acts as a nerve\\nrelaxant for the whole body including the skin\\n/C15Supplementing the diet daily with zinc, fish oils, vita-\\nmin A, vitamin E, and evening primrose oil (Oenothera\\nbiennis)–all good sources of nutrients for the skin\\n/C15Reducing or eliminating red meat from the diet\\n/C15Eliminating or rotating potentially allergic foods\\nsuch as cow’s milk, peanuts, wheat, eggs, and soy\\n/C15Implementing stress reduction techniques in daily\\nlife.\\nHerbal therapies also can be helpful in treating\\natopic dermatitis. Western herbal remedies used in the\\n450 GALE ENCYCLOPEDIA OF MEDICINE\\nAtopic dermatitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 480, 'page_label': '451'}, page_content='treatment of this condition include burdock (Arctium\\nlappa) andRuta (Ruta graveolens). Long-term herbal\\ntherapy requires monitoring and should be guided by\\nan experienced practitioner.\\nOther alternative techniques that may be useful in\\nthe treatment of atopic dermatitis include:\\n/C15Acupressure (acupuncture without needles) to relieve\\ntension that may trigger a flare\\n/C15Aromatherapy, using essential oils like lavender,\\nthyme (Thymus vulgaris), jasmine (Jasminum offici-\\nnale) and chamomile (Matricaria recutita) in hot\\nwater, to add a soothing fragrance to the air\\n/C15Shiatsu massage and reflexology, performed by\\nlicensed practitioners, to alleviate symptoms by\\nrestoring the body’s natural balance\\n/C15Homeopathy, which may temporarily worsen\\nsymptoms before relieving them, and should be\\nsupervised by a trained alternative healthcare\\nprofessional\\n/C15Hydrotherapy, which uses water, ice, liquid, and\\nsteam, to stimulate the immune system\\n/C15Juice therapy to purify the liver and relieve bowel\\ncongestion\\n/C15Yoga to induce a sense of serenity.\\nPrognosis\\nAtopic dermatitis is unpredictable. Although\\nsymptoms occur less often with age and sometimes\\ndisappear altogether, they can recur without warn-\\ning. Atopic dermatitis lowers resistance to infection\\nand increases the risk of developingcataracts. Sixty\\npercent of patients with atopic dermatitis will\\nexperience flares and remissions throughout their\\nlives.\\nPrevention\\nResearch has shown that babies weaned from\\nbreast milk before they are four months old are almost\\nthree times more likely than other babies to develop\\nrecurrent eczema. Feeding eggs or fish to a baby less\\nthan one year old can activate symptoms, and babies\\nshould be shielded from such irritants as mites, molds,\\npet hair, and smoke.\\nPossible ways to prevent flare-ups include the\\nfollowing:\\n/C15eliminate activities that cause sweating\\n/C15lubricate the skin frequently\\n/C15avoid wool, perfumes, fabric softeners, soaps that\\ndry the skin, and other irritants\\n/C15avoid sudden temperature changes\\nA doctor should be notified whenever any of the\\nfollowing occurs:\\n/C15fever or relentless itching develop during a flare\\n/C15an unexplained rash develops in someone who has a\\npersonal or family history of eczema or asthma\\n/C15inflammation does not decrease after seven days of\\ntreatment with an over-the-counter preparation con-\\ntaining coal tar or steroids\\n/C15a yellow, tan, or brown crust or pus-filled blisters\\nappear on top of an existing rash\\n/C15a person with active atopic dermatitis comes into\\ncontact with someone who has cold sores,genital\\nherpes, or another viral skin disease\\nResources\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham Road,\\nP.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-\\n0230. Fax: (847) 330-0050. .\\nMaureen Haggerty\\nAtrial ectopic beats\\nDefinition\\nAtrial ectopic beats (AEB) refers to a contraction\\nof the upper heart chamber which occurs before it\\nwould be expected. Atrial ectopic beats are also\\nknown as premature atrial beats, premature atrial\\ncomplex (PAC), or atrial extrasystole.\\nDescription\\nAn AEB is usually a harmless disturbance in the\\nnormal rhythm of the heart. It can occur only occa-\\nsionally, in a regular pattern, or several may occur in\\nsequence and then disappear. Most often, the person is\\nunaware of the event.\\nCauses and symptoms\\nAs people age, extra beats tend to happen more\\nfrequently even in perfectly healthy individuals. AEB\\nmay be triggered or increased bystress, caffeine, smok-\\ning, and some medicines. Cold remedies containing\\nGALE ENCYCLOPEDIA OF MEDICINE 451\\nAtrial ectopic beats'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 481, 'page_label': '452'}, page_content='ephedrine or pseudoephedrine have been known to\\nincrease the incidence of atrial ectopic beats. AEB\\nmay also be the result of an enlarged atria, lung dis-\\nease, or the result of reduced blood supply to that area\\nof the heart.\\nIf a person is aware of the event, the first symptom\\nof AEB is usually a feeling that the heart has skipped\\nor missed a beat. This is often accompanied by a\\nfeeling that the heart is thumping or pounding in the\\nchest. The thumping or pounding is caused by the fact\\nthat when there is an AEB, the pause before the next\\nbeat is usually longer than normal. The next beat must\\nbe stronger than usual to pump the accumulated blood\\nout of the chamber.\\nDiagnosis\\nDiagnosis of AEB is often suspected on the basis of\\nthe patient’s description of the occurrence. An electro-\\ncardiogram (ECG) can confirm the diagnosis. An ECG\\nshows the heart beat as three wave forms. The first wave\\nis called P, the second is called QRS, and the last is T. An\\natrial ectopic beat will show up on the ECG as a P wave\\nthat occurs closer than usual to the preceding T wave.\\nTreatment\\nAtrial ectopic beats do not usually require treat-\\nment. If treatment is necessary because the beats occur\\nfrequently and cause intolerable discomfort, the doc-\\ntor may prescribe medication.\\nPrognosis\\nOccasional AEB usually have no significance. If\\nthey increase in frequency, they can lead to atrial\\ntachycardia or fibrillation and to a decrease in cardiac\\noutput.\\nPrevention\\nAEB cannot usually be prevented. Aggravating\\nfactors can be addressed, like excessive stimulants,\\nand uncontrolled pulmonary disorders.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nDorothy Elinor Stonely\\nAtrial extrasystole see Atrial ectopic beats\\nAtrial fibrillation and flutter\\nDefinition\\nAtrial fibrillation and flutter are abnormal heart\\nrhythms in which the atria, or upper chambers of the\\nheart, are out of sync with the ventricles, or lower\\nchambers of the heart. In atrial fibrillation, the atria\\n‘‘quiver’’ chaotically and the ventricles beat irregu-\\nlarly. In atrial flutter, the atria beat regularly and\\nfaster than the ventricles.\\nDescription\\nAtrial fibrillation and flutter are two types of\\ncardiac arrhythmias, irregularities in the heart’s\\nrhythm. Nearly 2 million Americans have atrial fibril-\\nlation, according to the American Heart Association.\\nIt is the most common chronic arrhythmia. Atrial\\nflutter is less common, but both of these arrhythmias\\ncan cause a blood clot to form in the heart. This can\\nlead to astroke or a blockage carried by the blood flow\\n(an embolism) anywhere in the body’s arteries. Atrial\\nfibrillation is responsible for about 15% of strokes.\\nThe atria are the heart’s two small upper cham-\\nbers. In atrial fibrillation, the heart beat is comple-\\ntely irregular. The atrial muscles contract very\\nquickly and irregularly; the ventricles, the heart’s\\ntwo large lower chambers, beat irregularly but not\\nas fast as the atria. When the atria fibrillate, blood\\nthat is not completely pumped out can pool and\\nform a clot. In atrial flutter, the heart beat is\\nusually very fast but steady. The atria beat faster\\nthan the ventricles.\\nAtrial fibrillation often occurs in people with var-\\nious types of heart disease. Atrial fibrillation may also\\nresult from an inflammation of the heart’s covering\\n(pericarditis), chest trauma or surgery, pulmonary dis-\\nease, and certain medications. Atrial fibrillation is\\nmore common in older people; about 10% of people\\nover the age of 75 have it. Atrial flutter and fibrillation\\nusually occur in people with hypertensive or coronary\\nheart disease and other types of heart disorders.\\nCauses and symptoms\\nIn most cases, the cause of atrial fibrillation and\\nflutter can be found, but often it cannot. Causes of\\nthese heart beat abnormalities include:\\n/C15many types of heart disease\\n/C15stress and anxiety\\n/C15caffeine\\n452 GALE ENCYCLOPEDIA OF MEDICINE\\nAtrial fibrillation and flutter'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 482, 'page_label': '453'}, page_content='/C15alcohol\\n/C15tobacco\\n/C15diet pills\\n/C15some prescription and over-the-counter medications\\n/C15open heart surgery\\nSymptoms, when present, include:\\n/C15a fluttering feeling in the chest\\n/C15a pulse that feels like the heart is skipping, racing,\\njumping, or is irregular\\n/C15low energy\\n/C15a faint or dizzy feeling\\n/C15pressure or discomfort in the chest\\n/C15shortness of breath\\n/C15anxiety\\nDiagnosis\\nA doctor can sometimes hear these arrhythmias\\nusing an instrument (a stethoscope) to listen to the\\nsounds within the chest. Atrial fibrillation and flutter\\nare usually diagnosed through electrocardiography\\n(EKGs), an exercise stress test, a 24-hour Holter\\nEKG monitor, or a telephone cardiac monitor. An\\nEKG shows the heart’s activity and may reveal a\\nlack of oxygen (ischemia). Electrodes covered with\\nconducting jelly are placed on the patient’s chest,\\narms, and legs. The electrodes send impulses of the\\nheart’s activity through a monitor (called an oscillo-\\nscope) to a recorder that traces the pattern of the\\nimpulses onto paper. The test takes about 10 minutes\\nand is performed in a doctor’s office. The exercise\\nstress test measures how the heart and blood vessels\\nrespond to work when the patient is exercising on a\\ntreadmill or a stationary bike. This test is performed in\\na doctor’s office within an exercise laboratory and\\ntakes 15-30 minutes.\\nIn 24-hour EKG (Holter) monitoring, the\\npatient wears a small, portable tape recorder con-\\nnected to disks on his/her chest that record the\\nheart’s rhythm during normal activities. An EKG\\ncalled transtelephonic monitoring identifies arrhyth-\\nmias that occur infrequently. Like Holter monitor-\\ning, transtelephonic monitoring continues for days\\nor weeks and enables patients to send the EKG via\\ntelephone to a monitoring station when an arrhythmia\\nis felt, or to store the information in the recorder and\\ntransmit it later. Doctors can also use high-frequency\\nsound waves (echocardiography) to determine the\\nstructure and function of the heart. This diagnostic\\nmethod is often helpful to evaluate for underlying\\nheart disease.\\nTreatment\\nAtrial fibrillation and flutter are usually treated\\nwith medications and/or electrical shock (cardiover-\\nsion). In some cases, removal of a small portion of the\\nheart (ablation), implantation of a pacemaker or a\\ncardioverter defibrillator, or maze surgery is needed.\\nIf the heart rate cannot be quickly controlled,\\nelectrical cardioversion may be used. Cardioversion,\\nthe electric shock to the chest wall, is usually per-\\nformed emergencies. This device briefly suspends the\\nheart’s activity and allows it to return to a normal\\nrhythm.\\nAblation destroys the heart tissue that causes the\\narrhythmia. The tissue can be destroyed by catheter-\\nization or surgery. Radiofrequency catheter ablation,\\nperformed in acardiac catheterizationlaboratory, can\\ncure atrial flutter and control the heart rate in atrial\\nfibrillation. The patient is awake but sedated. A thin\\ntube called a catheter is inserted into a vein and is\\nthreaded into the heart. At the end of the catheter, a\\ndevice maps the electrical pathways of the heart. A\\ncardiologist, a doctor specializing in the heart, uses\\nthis map to identify the pathway(s) causing the\\narrhythmia, and then eliminates it (them) with bursts\\nof high-frequency radio waves. Surgical ablation is\\nperformed in an operating room under general\\nanesthesia. Computerized mapping techniques are\\ncombined with a cold probe to destroy arrhythmia-\\ncausing tissue. Ablation is generally successful. When\\nablation is used for atrial fibrillation, it is usually\\nfollowed by implantation of a pacemaker as well as\\ndrug therapy.\\nKEY TERMS\\nArrhythmia— A variation in the normal rhythm of\\nthe heart beat. Atrial fibrillation and flutter are two\\ntypes of arrhythmia.\\nAtria— The two small upper chambers of the heart\\nthat receive blood from the lungs and the body.\\nStroke— A brain attack caused by a sudden disrup-\\ntion of blood flow to the brain, in this case because\\nof a blood clot.\\nVentricles— The two large lower chambers of the\\nheart that pump blood to the lungs and to the rest of\\nthe body.\\nGALE ENCYCLOPEDIA OF MEDICINE 453\\nAtrial fibrillation and flutter'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 483, 'page_label': '454'}, page_content='A pacemaker is a battery-powered device about the\\nsize of a matchbox that is surgically implanted near the\\ncollarbone to regulate the heart beat. Lead wires\\nthreaded to the right side ofthe heart supply electrical\\nenergy to pace the atria and ventricles. The implantable\\ncardioverter defibrillator is a treatment for serious\\narrhythmias. The battery-powered device senses an\\nabnormal heart rhythm and automatically provides elec-\\ntrical shock(s). The shock(s)suspends heart activity and\\nthen allows the heart to initiate a normal rhythm. Wire\\nelectrodes on the device are attached to the heart. Some\\nof the electrodes are attached to the outside of the heart\\nand some are attached to the inside of the heart through\\nveins. The newest implantablecardioverter defibrillators\\ncan be implanted in the chest wall and do not require\\nopen chest surgery. These devices weigh less than 10 oz\\nand generally last seven or eight years. An implantable\\ncardioverter defibrillator is usually used with drug ther-\\napy, but the amount medication is reduced. In maze\\nsurgery, often the last resort, surgeons create a maze of\\nstitches (sutures) that help theheart’s electrical impulses\\ntravel effectively.\\nMost of the drugs used for treatment have poten-\\ntial side effects and should be carefully monitored by a\\ndoctor. The goal of treatment is to control the rate and\\nrhythm of the heart and to prevent the formation of\\nblood clots. If the arrhythmia is caused by heart dis-\\nease, the heart disease will also be treated. The\\nAmerican Heart Association recommends aggressive\\ntreatment.\\nA digitalis drug, most commonly digoxin, is\\nusually prescribed to control the heart rate. Digitalis\\ndrugs slow the heart’s electrical impulses, helping to\\nrestore the normal rate and rhythm. These drugs also\\nincrease the ability of the heart’s muscular layer to\\ncontract and pump properly. Beta-blockers and\\ncalcium channel blockers can also be used for this\\npurpose. Beta-blockers slow the speed of electrical\\nimpulses through the heart. Some calcium channel\\nblockers dampen the heart’s response to erratic elec-\\ntrical impulses.\\nTo prevent blood clots, aspirin or warfarin\\n(Coumadin) is administered. Warfarin, however, has\\npotential bleeding side effects, especially in older\\npatients. Amiodarone is fairly efffective for atrial flut-\\nter. This drug is often able to maintain the heart’s\\nproper rhythm and can also help control the heart\\nrate when the flutter occurs.\\nPrognosis\\nPatients with atrial fibrillation and flutter can\\nlive a normal life for many years as long as the\\narrhythmia is controlled and serious blood clots\\nare prevented.\\nPrevention\\nAtrial fibrillation and flutter can sometimes be\\nprevented when the cause can be identified and con-\\ntrolled. Depending on the cause, prevention could\\ninclude:\\n/C15treating the underlying heart disease\\n/C15reducing stress and anxiety\\n/C15reducing or stopping consumption of caffeine, alco-\\nhol, or tobacco; and/or\\n/C15discontinuing diet pills or other medications (over-\\nthe-counter or prescription)\\nResources\\nPERIODICALS\\nKosinski, Daniel, et al. ‘‘Catheter Ablation for Atrial Flutter\\nand Fibrillation: An Effective Alternative to Medical\\nTherapy.’’ Postgraduate Medicine103, no. 1 (January\\n1998): 103-110.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nAtrial flutter see Atrial fibrillation and flutter\\nAtrial septal defect\\nDefinition\\nAn atrial septal defect is an abnormal opening in\\nthe wall separating the left and right upper chambers\\n(atria) of the heart.\\nDescription\\nDuring the normal development of the fetal\\nheart, there is an opening in the wall (the septum)\\nseparating the left and right upper chambers of the\\nheart. Normally, this opening closes before birth,\\n454 GALE ENCYCLOPEDIA OF MEDICINE\\nAtrial septal defect'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 484, 'page_label': '455'}, page_content='but if it does not, the child is born with a hole\\nbetween the left and right atria. This abnormal\\nopening is called an atrial septal defect and causes\\nblood from the left atrium to flow into the right\\natrium.\\nDifferent types of atrial septal defects can\\noccur, and they are classified according to where\\nin the separating wall they are found. The most\\ncommonly found atrial septal defect occurs in the\\nmiddle of the atrial septum and accounts for about\\n70% of all atrial septal defects. Abnormal openings\\ncan form in the upper and lower parts of the atrial\\nseptum as well.\\nCauses and symptoms\\nAbnormal openings in the atrial septum occur\\nduring fetal development and are twice as common\\nin females as in males. These abnormalities can go\\nunnoticed if the opening is small, producing no\\nabnormal symptoms. If the defect is big, large\\namounts of blood flowing from the left to the\\nright atrium will cause the right atrium to swell to\\nhold the extra blood.\\nPeople born with an atrial septal defect can have\\nno symptoms through their twenties, but by age 40,\\nmost people with this condition have symptoms that\\ncan includeshortness of breath, rapid abnormal beat-\\ning of the atria (atrial fibrillation), and eventually\\nheart failure.\\nDiagnosis\\nAtrial septal defects can be identified by various\\nmethods. Abnormal changes in the sound of the\\nheart beats can be heard when a doctor listens to\\nthe heart with a stethoscope. In addition, a chest\\nxr a y, an electrocardiogram (ECG, an electrical\\nprintout of the heartbeats), and an echocardiogram\\n(a test that uses sound waves to form a detailed\\nimage of the heart) can also be used to identify\\nthis condition.\\nAn atrial septal defect can also be diagnosed by\\nusing a test calledcardiac catheterization.T h i st e s t\\ninvolves inserting a very thin tube (catheter) into the\\nheart’s chambers to measure the amount of oxygen\\npresent in the blood within the heart. If the heart\\nhas an opening between the atria, oxygen-rich blood\\nfrom the left atrium enters the right atrium.\\nThrough cardiac catheterization, doctors can detect\\nthe higher-than-normal amount of oxygen in the\\nheart’s right atrium, right ventricle, and the large\\nblood vessels that carry blood to the lungs, where\\nthe blood would normally subsequently get its\\noxygen.\\nTreatment\\nAtrial septal defects often correct themselves with-\\nout medical treatments by the age of two. If this dose\\nnot happen, surgery is done by sewing the hole closed,\\nor by sewing a patch of Dacron material or a piece of\\nthe sac that surrounds the heart (the pericardium),\\nover the opening.\\nSome patients can have the defect fixed by having\\nan clam-shaped plug placed over the opening. This\\nplug is a man-made device that is put in place through\\na catheter inserted into the heart.\\nPrognosis\\nIndividuals with small defects can live a normal\\nlife, but larger defects require surgical correction. Less\\nthan 1% of people younger than 45 years of age die\\nfrom corrective surgery. Five to ten percent of patients\\ncan die from the surgery if they are older than 40 and\\nhave other heart-related problems. When an atrial\\nseptal defect is corrected within the first 20 years of\\nlife, there is an excellent chance for the individual to\\nlive normally.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nDominic De Bellis, PhD\\nAtrioventricular block see Heart block\\nAttapulgite see Antidiarrheal drugs\\nKEY TERMS\\nCardiac catheterization— A test that involves hav-\\ning a tiny tube inserted into the heart through a\\nblood vessel.\\nDacron— A synthetic polyester fiber used to surgi-\\ncally repair damaged sections of heart muscle and\\nblood vessel walls.\\nEchocardiogram— A test that uses sound waves to\\ngenerate an image of the heart, its valves, and\\nchambers.\\nGALE ENCYCLOPEDIA OF MEDICINE 455\\nAtrial septal defect'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 485, 'page_label': '456'}, page_content='Attention-deficit/\\nHyperactivity disorder\\n(ADHD)\\nDefinition\\nAttention-deficit/hyperactivity disorder (ADHD)\\nis a developmental disorder characterized by distract-\\nibility, hyperactivity, impulsive behaviors, and the\\ninability to remain focused on tasks or activities.\\nDescription\\nADHD, also known as hyperkinetic disorder\\n(HKD) outside of the United States, is estimated to\\naffect 3-9% of children, and afflicts boys more often\\nthan girls. Although difficult to assess in infancy and\\ntoddlerhood, signs of ADHD may begin to appear as\\nearly as age two or three, but the symptom picture\\nchanges as adolescence approaches. Many symptoms,\\nparticularly hyperactivity, diminish in early adult-\\nhood, but impulsivity and inattention problems\\nremain with up to 50% of ADHD individuals\\nthroughout their adult life.\\nChildren with ADHD have short attention\\nspans, becoming easily bored and/or frustrated\\nwith tasks. Although they may be quite intelligent,\\ntheir lack of focus frequently results in poor grades\\nand difficulties in school. ADHD children act\\nimpulsively, taking action first and thinking later.\\nThey are constantly moving, running, climbing,\\nsquirming, and fidgeting, but often have trouble\\nwith gross and fine motor skills and, as a result,\\nmay be physically clumsy and awkward. Their\\nclumsiness may extend to the social arena, where\\nthey are sometimes shunned due to their impulsive\\nand intrusive behavior.\\nCauses and symptoms\\nThe causes of ADHD are not known. However,\\nit appears that heredity plays a major role in the\\ndevelopment of ADHD. Children with an ADHD\\nparent or sibling are more likely to develop the\\ndisorder themselves. In 2004, scientists reported at\\nleast 20 candidate genes that might contribute to\\nADHD, but no single gene stood out as the gene\\ncausing the condition. Before birth, ADHD children\\nmay have been exposed to poor maternalnutrition,\\nviral infections, or maternal substance abuse .I n\\nearly childhood, exposure to lead or other toxins\\ncan cause ADHD-like symptoms. Traumatic brain\\ninjury or neurological disorders may also trigger\\nADHD symptoms. Although the exact cause of\\nADHD is not known, an imbalance of certain neu-\\nrotransmitters, the chemicals in the brain that trans-\\nmit messages between nerve cells, is believed to be\\nthe mechanism behind ADHD symptoms.\\nA widely publicized study conducted by Dr. Ben\\nFeingold in the early 1970s suggested that allergies to\\ncertain foods and food additives caused the character-\\nistic hyperactivity of ADHD children. Although some\\nchildren may have adverse reactions to certain foods\\nthat can affect their behavior (for example, a rash\\nmight temporarily cause a child to be distracted from\\nother tasks), carefully controlled follow-up studies\\nhave uncovered no link betweenfood allergies and\\nADHD. Another popularly held misconception\\nabout food and ADHD is that the consumption of\\nsugar causes hyperactive behavior. Again, studies\\nhave shown no link between sugar intake and\\nADHD. It is important to note, however, that a nutri-\\ntionally balanced diet is important for normal devel-\\nopment inall children.\\nPsychologists and other mental health profes-\\nsionals typically use the criteria listed in theDiagnostic\\nand Statistical Manual of Mental Disorders, Fourth\\nDrugs Used To Treat ADHD\\nBrand Name (Generic Name) Possible Common Side Effects\\nInclude:\\nCylert (pemoline) Insomnia\\nDexedrine (dextroamphetamine\\nsulfate)\\nExcessive stimulation, restlessness\\nRitalin (methylphenidate\\nhydrochloride)\\nInsomnia, nervousness, loss of\\nappetite\\nKEY TERMS\\nConduct disorder— A behavioral and emotional\\ndisorder of childhood and adolescence. Children\\nwith a conduct disorder act inappropriately,\\ninfringe on the rights of others, and violate societal\\nnorms.\\nNervous tic— A repetitive, involuntary action, such\\nas the twitching of a muscle or repeated blinking.\\nOppositional defiant disorder— A disorder charac-\\nterized by hostile, deliberately argumentative, and\\ndefiant behavior toward authority figures.\\n456 GALE ENCYCLOPEDIA OF MEDICINE\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 486, 'page_label': '457'}, page_content='Edition (DSM-IV)as a guideline for determining the\\npresence of ADHD. For a diagnosis of ADHD,DSM-\\nIV requires the presence of at least six of the following\\nsymptoms of inattention, or six or more symptoms of\\nhyperactivity and impulsivity combined:\\nInattention:\\n/C15fails to pay close attention to detail or makes careless\\nmistakes in schoolwork or other activities\\n/C15has difficulty sustaining attention in tasks or\\nactivities\\n/C15does not appear to listen when spoken to\\n/C15does not follow through on instructions and does not\\nfinish tasks\\n/C15has difficulty organizing tasks and activities\\n/C15avoids or dislikes tasks that require sustained mental\\neffort (e.g., homework)\\n/C15is easily distracted\\n/C15is forgetful in daily activities\\nHyperactivity:\\n/C15fidgets with hands or feet or squirms in seat\\n/C15does not remain seated when expected to\\n/C15runs or climbs excessively when inappropriate (in\\nadolescents and adults, feelings of restlessness)\\n/C15has difficulty playing quietly\\n/C15is constantly on the move\\n/C15talks excessively\\nImpulsivity:\\n/C15blurts out answers before the question has been\\ncompleted\\n/C15has difficulty waiting for his or her turn\\n/C15interrupts and/or intrudes on others\\nDiagnosis\\nThe first step in determining if a child has ADHD\\nis to consult with a pediatrician. The pediatrician can\\nmake an initial evaluation of the child’s developmental\\nmaturity compared to other children in his or her age\\ngroup. The physician should also perform a compre-\\nhensive physical examination to rule out any organic\\ncauses of ADHD symptoms, such as an overactive\\nthyroid or vision or hearing problems.\\nIf no organic problem can be found, a psycholo-\\ngist, psychiatrist, neurologist, neuropsychologist, or\\nlearning specialist is typically consulted to perform a\\ncomprehensive ADHD assessment. A complete medi-\\ncal, family, social, psychiatric, and educational history\\nis compiled from existing medical and school records\\nand from interviews with parents and teachers.\\nInterviews may also be conducted with the child,\\ndepending on his or her age. Along with these inter-\\nviews, several clinical inventories may also be used,\\nsuch as the Conners Rating Scales (Teacher’s\\nQuestionnaire and Parent’s Questionnaire), Child\\nBehavior Checklist (CBCL), and the Achenbach\\nChild Behavior Rating Scales. These inventories pro-\\nvide valuable information on the child’s behavior in\\ndifferent settings and situations. In addition, the\\nWender Utah Rating Scale has been adapted for use\\nin diagnosing ADHD in adults.\\nIt is important to note that mental disorders such\\nas depression andanxiety disorder can cause symp-\\ntoms similar to ADHD. A complete and comprehen-\\nsive psychiatric assessment is critical to differentiate\\nADHD from other possible mood and behavioral dis-\\norders. Bipolar disorder, for example, may be misdiag-\\nnosed as ADHD.\\nPublic schools are required by federal law to offer\\nfree ADHD testing upon request. A pediatrician can\\nalso provide a referral to a psychologist or pediatric\\nspecialist for ADHD assessment. Parents should\\ncheck with their insurance plans to see if these services\\nare covered.\\nTreatment\\nPsychosocial therapy, usually combined with\\nmedications, is the treatment approach of choice to\\nalleviate ADHD symptoms. Psychostimulants, such\\nas dextroamphetamine (Dexedrine), pemoline\\n(Cylert), and methylphenidate (Ritalin) are commonly\\nprescribed to control hyperactive and impulsive beha-\\nvior and increase attention span. They work by stimu-\\nlating the production of certain neurotransmitters in\\nthe brain. Possible side effects of stimulants include\\nnervous tics, irregular heartbeat, loss of appetite, and\\ninsomnia. However, the medications are usually well-\\ntolerated and safe in most cases. In 2004, longer-acting\\nstimulants had been released to treat adult ADHD.\\nIn 2004, the American Academy of Child and\\nAdolescent Psychiatry listed the first nonstimulant as a\\nfirst-line therapy for ADHD. Called atomoxetine HCI\\n(Strattera), it is a norepinephrine reuptake inhibitor.\\nIn children who do not respond well to stimulant\\ntherapy, tricyclic antidepressantssuch as desipramine\\n(Norpramin, Pertofane) and amitriptyline (Elavil) are\\nsometimes recommended. Reported side effects of\\nthese drugs include persistent dry mouth, sedation,\\ndisorientation, and cardiac arrhythmia (particularly\\nGALE ENCYCLOPEDIA OF MEDICINE 457\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 487, 'page_label': '458'}, page_content='with desipramine). Other medications prescribed for\\nADHD therapy include buproprion (Wellbutrin), an\\nantidepressant; fluoxetine (Prozac), anSSRI antide-\\npressant; and carbamazepine (Tegretol, Atretol), an\\nanticonvulsant drug. Clonidine (Catapres), an antihy-\\npertensive medication, has also been used to control\\naggression and hyperactivity in some ADHD children,\\nalthough it should not be used with Ritalin. A child’s\\nresponse to medication will change with age and\\nmaturation, so ADHD symptoms should be moni-\\ntored closely and prescriptions adjusted accordingly.\\nBehavior modification therapy uses a reward sys-\\ntem to reinforce good behavior and task completion\\nand can be implemented both in the classroom and at\\nhome. A tangible reward such as a sticker may be\\ngiven to the child every time he completes a task or\\nbehaves in an acceptable manner. A chart system may\\nbe used to display the stickers and visually illustrate\\nthe child’s progress. When a certain number of stickers\\nare collected, the child may trade them in for a bigger\\nreward such as a trip to the zoo or a day at the beach.\\nThe reward system stays in place until the good beha-\\nvior becomes ingrained.\\nA variation of this technique,cognitive-behavioral\\ntherapy, works to decrease impulsive behavior by get-\\nting the child to recognize the connection between\\nthoughts and behavior, and to change behavior by\\nchanging negative thinking patterns.\\nIndividual psychotherapy can help an ADHD\\nchild build self-esteem, give them a place to discuss\\ntheir worries and anxieties, and help them gain insight\\ninto their behavior and feelings. Family therapy may\\nalso be beneficial in helping family members develop\\ncoping skills and in working through feelings of guilt\\nor anger parents may be experiencing.\\nADHD children perform better within a familiar,\\nconsistent, and structured routine with positive rein-\\nforcements for good behavior and real consequences\\nfor bad. Family, friends, and caretakers should all be\\neducated on the special needs and behaviors of the\\nADHD child. Communication between parents and\\nteachers is especially critical to ensuring an ADHD\\nchild has an appropriate learning environment.\\nAlternative treatment\\nA number of alternative treatments exist for\\nADHD. Although there is a lack of controlled studies\\nto prove their efficacy, proponents report that they are\\nsuccessful in controlling symptoms in some ADHD\\npatients. Some of the more popular alternative treat-\\nments include:\\n/C15EEG (electroencephalograph)biofeedback. By mea-\\nsuring brainwave activity and teaching the ADHD\\npatient which type of brainwave is associated with\\nattention, EEG biofeedback attempts to train\\npatients to generate the desired brainwave activity.\\n/C15Dietary therapy. Based in part on the Feingold food\\nallergy diet, dietary therapy focuses on a nutritional\\nplan that is high in protein and complex carbohy-\\ndrates and free of white sugar and salicylate-contain-\\ning foods such as strawberries, tomatoes, and grapes.\\n/C15Herbal therapy. Herbal therapy uses a variety of\\nnatural remedies to address the symptoms of\\nADHD, such as ginkgo (Gingko biloba) for memory\\nand mental sharpness and chamomile (Matricaria\\nrecutita) extract for calming. The safety of herbal\\nremedies has not been demonstrated in controlled\\nstudies. For example, it is known that gingko may\\naffect blood coagulation, but controlled studies have\\nnot yet evaluated the risk of the effect.\\n/C15Homeopathic medicine. The theory of homeopathic\\nmedicine is to treat the whole person at a core level.\\nConstitutional homeopathic care requires consulting\\nwith a well-trained homeopath who has experience\\nworking with ADD and ADHD individuals.\\nPrognosis\\nUntreated, ADHD negatively affects a child’s\\nsocial and educational performance and can seriously\\ndamage his or her sense of self-esteem. ADHD child-\\nren have impaired relationships with their peers, and\\nmay be looked upon as social outcasts. They may be\\nperceived as slow learners or troublemakers in the\\nclassroom. Siblings and even parents may develop\\nresentful feelings towards the ADHD child.\\nSome ADHD children also develop a conduct\\ndisorder problem. For those adolescents who have\\nboth ADHD and aconduct disorder, as many as 25%\\ngo on to develop antisocial personality disorder and\\nthe criminal behavior, substanceabuse, and high rate\\nof suicide attempts that are symptomatic of it.\\nChildren diagnosed with ADHD are also more likely\\nto have a learning disorder, a mood disorder such as\\ndepression, or an anxiety disorder.\\nApproximately 70-80% of ADHD patients trea-\\nted with stimulant medication experience significant\\nrelief from symptoms, at least in the short-term.\\nApproximately one-half of ADHD children seem to\\n‘‘outgrow’’ the disorder in adolescence or early adult-\\nhood; the other half will retain some or all symptoms\\nof ADHD as adults. With early identification and\\nintervention, careful compliance with a treatment\\n458 GALE ENCYCLOPEDIA OF MEDICINE\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 488, 'page_label': '459'}, page_content='program, and a supportive and nurturing home and\\nschool environment, ADHD children can flourish\\nsocially and academically.\\nResources\\nPERIODICALS\\n‘‘AACAP Guidelines Include Strattera as a First-line ADHD\\nTherapy Option.’’Drug Week(May 28, 2004): 54.\\n‘‘More Long-acting Stimulants to Treat Adult ADHD.’’\\nSCRIP World Pharmaceutical News(May 14, 2004): 101-\\n23.\\n‘‘Study Updates Genetics of ADHD.’’Drug Week(May 21,\\n2004): 55.\\nORGANIZATIONS\\nAmerican Academy of Child and Adolescent Psychiatry.\\n(AACAP). 3615 Wisconsin Ave. NW, Washington, DC\\n20016. (202) 966-7300. .\\nChildren and Adults with Attention Deficit Disorder\\n(CH.A.D.D.). 8181 Professional Place, Suite 201.\\nNational Attention Deficit Disorder Association. (ADDA).\\n9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH\\n44060. (800) 487-2282. .\\nPaula Anne Ford-Martin\\nTeresa G. Odle\\nAttention deficit disorder see Attention-defi-\\ncit/Hyperactivity disorder (ADHD)\\nAtypical mycobacterial infections see\\nMycobacterial infections, atypical\\nAtypical pneumonia see Mycoplasma\\ninfections\\nAudiometry\\nDefinition\\nAudiometry is the testing of a person’s ability to\\nhear various sound frequencies. The test is performed\\nwith the use of electronic equipment called an audio-\\nmeter. This testing is usually administered by a trained\\ntechnician called an audiologist.\\nPurpose\\nAudiometry testing is used to identify and diag-\\nnose hearing loss. The equipment is used in health\\nscreening programs, for example in grade schools, to\\ndetect hearing problems in children. It is also used in\\nthe doctor’s office or hospital audiology department\\nto diagnose hearing problems in children, adults, and\\nthe elderly. With correct diagnosis of a person’s spe-\\ncific pattern of hearing impairment, the right type of\\ntherapy, which might includehearing aids, corrective\\nsurgery, or speech therapy, can be prescribed.\\nPrecautions\\nTesting with audiometry equipment is simple and\\npainless. No special precautions are required.\\nDescription\\nA trained audiologist (a specialist in detecting\\nhearing loss) uses an audiometer to conduct audiome-\\ntry testing. This equipment emits sounds or tones, like\\nmusical notes, at various frequencies, or pitches, and\\nat differing volumes or levels of loudness. Testing is\\nusually done in a soundproof testing room.\\nThe person being tested wears a set of head-\\nphones that blocks out other distracting sounds and\\ndelivers a test tone to one ear at a time. At the sound\\nof a tone, the patient holds up a hand or finger to\\nindicate that the sound is detected. The audiologist\\nlowers the volume and repeats the sound until the\\npatient can no longer detect it. This process is\\nrepeated over a wide range of tones or frequencies\\nfrom very deep, low sounds, like the lowest note\\nplayed on a tuba, to very high sounds, like the\\npinging of a triangle. Each ear is tested separately.\\nIt is not unusual for levels of sensitivity to sound to\\ndiffer from one ear to the other.\\nA second type of audiometry testing uses a head-\\nband rather than headphones. The headband is worn\\nwith small plastic rectangles that fit behind the ears to\\nAn audiologist conducting a hearing test. (Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 459\\nAudiometry'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 489, 'page_label': '460'}, page_content='conduct sound through the bones of the skull. The\\npatient being tested senses the tones that are trans-\\nmitted as vibrations through the bones to the inner\\near. As with the headphones, the tones are repeated at\\nvarious frequencies and volumes.\\nThe results of the audiometry test may be recorded\\non a grid or graph called an audiogram. This graph is\\ngenerally set up with low frequencies or tones at one end\\nand high ones at the other end, much like a piano key-\\nboard. Low notes are graphed on the left and high notes\\non the right. The graph also charts the volume of the\\ntones used; from soft, quiet sounds at the top of the\\nchart to loud sounds at the bottom. Hearing is mea-\\nsured in units called decibels. Most of the sounds asso-\\nciated with normal speech patterns are generally spoken\\nin the range of 20-50 decibels. An adult with normal\\nhearing can detect tones between 0-20 decibels.\\nSpeech audiometry is another type of testing that\\nuses a series of simple recorded words spoken at var-\\nious volumes into headphones worn by the patient\\nbeing tested. The patient repeats each word back to\\nthe audiologist as it is heard. An adult with normal\\nhearing will be able to recognize and repeat 90-100%\\nof the words.\\nPreparation\\nThe ears may be examined with an otoscope prior\\nto audiometry testing to determine if there are any\\nblockages in the ear canal due to ear wax or other\\nmaterial.\\nNormal results\\nA person with normal hearing will be able to\\nrecognize and respond to all of the tone frequencies\\nadministered at various volumes in both ears by the\\naudiometry test. An adult with normal hearing can\\ndetect a range of low and high pitched sounds that\\nare played as softly as between nearly 0-20 decibels.\\nNormal speech is generally spoken in the range of\\n20-50 decibels.\\nAbnormal results\\nAudiometry test results are considered abnormal\\nif there is a significant or unexplained difference\\nbetween the levels of sound heard between the two\\nears, or if the person being tested is unable to hear in\\nthe normal range of frequencies and volume. The\\npattern of responses displayed on the audiogram can\\nbe used by the audiologist to identify if a significant\\nhearing loss is present and if the patient might benefit\\nfrom hearing aids or corrective surgery.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Audiology. 8201 Greensboro Drive,\\nSuite 300, McLean, VA 22102. (703) 610-9022. .\\nAudiology Awareness Campaign. 3008 Millwood Ave.,\\nColumbia, SC 29205. (800) 445-8629.\\nOTHER\\n‘‘How to Read Your Hearing Test.’’Hearing Alliance\\nofAmerica. .\\n‘‘Understanding Your Audiogram.’’The League for the\\nHard of Hearing..\\nAltha Roberts Edgren\\nAuditory integration training\\nDefinition\\nAuditory integration training, or AIT, is one spe-\\ncific type of music/auditory therapy based upon the\\nwork of French otolaryngologists Dr.Alfred Tomatis\\nand Dr. Guy Berard.\\nOrigins\\nThe premise upon which most auditory integra-\\ntion programs are based is that distortion in how\\nthings are heard contributes to commonly seen\\nbehavioral or learning disorders in children. Some\\nof these disorders includeattention deficit/hyperac-\\ntive disorder (ADHD), autism, dyslexia, and central\\nKEY TERMS\\nAudiogram— A chart or graph of the results of a hear-\\ning test conductedwith audiographic equipment. The\\nchart reflects the softest (lowest volume) sounds that\\ncan be heard at various frequencies or pitches.\\nDecibel— A unit of measure for expressing the\\nloudness of a sound. Normal speech is typically\\nspoken in the range of about 20-50 decibels.\\nOtoscope— A hand-held instrument with a tiny\\nlight and a funnel-shaped attachment called an\\near speculum, which is used to examine the ear\\ncanal and eardrum.\\n460 GALE ENCYCLOPEDIA OF MEDICINE\\nAuditory integration training'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 490, 'page_label': '461'}, page_content='auditory processing disorders (CAPD). Training the\\npatient to listen can stimulate central and cortical\\norganization.\\nAuditory integration is one facet of what audiol-\\nogists call central auditory processing. The simplest\\ndefinition of central auditory processing, or CAP, is\\nUniversity of Buffalo Professor of Audiology Jack\\nKatz’s, which is: ‘‘What we do with what we hear.’’\\nCentral auditory integration is actually the perception\\nof sound, including the ability to attend to sound, to\\nremember it, retaining it in both the long- and short-\\nterm memory, to be able to listen to sound selectively,\\nand to localize it.\\nGuy Berard developed one of the programs com-\\nmonly used. Berard’s auditory integration training\\nconsists of twenty half-hour sessions spent listening\\nto musical sounds via a stereophonic system. The\\nmusic is random, with filtered frequencies, and the\\nperson listens through earphones. These sound waves\\nvibrate andexercise structures in the middle ear. This\\nis normally done in sessions twice a day for 10 days.\\nAlfred Tomatis is also the inventor of the\\nElectronic Ear. This device operates through a series\\nof filters, and reestablishes the dominance of the right\\near in hearing. The basis of Tomatis’ work is a series of\\nprinciples that follow:\\n/C15The most important purpose of the ear is to adapt\\nsound waves into signals that charge the brain.\\n/C15Sound is conducted via both air and bone. It can be\\nconsidered something that nourishes the nervous\\nsystem, either stimulating or destimulating it.\\n/C15Just as seeing is not the same as looking, hearing is not\\nthe same as listening. Hearing is passive. Listening is\\nactive.\\n/C15A person’s ability to listen affects all language devel-\\nopment for that person. This process influences every\\naspect of self-image and social development.\\nA L F R E D T O M A T I S (1920– )\\n(Photograph by V. Brynner. Gamma Liaison. Reproduced by\\npermission.)\\nInternationally renowned French otolaryngologist,\\npsychologist, educator and inventor Alfred Tomatis per-\\nceived the importance of sound and hearing early in\\nhis career. He took his degree as a Doctor of Medicine\\nfrom the University of Paris and specialized in ear,\\nnose and throat medicine. The son of two opera sing-\\ners, Tomatis early in his career treated some of his\\nparents’ fellow opera singers. From these experiences with\\nthe sound of music, he developed the principle that has\\ncome to be known as the Tomatis Effect, i.e. that the human\\nvoice can only sing what it hears.\\nTomatis has been called the Einstein of the ear. It was\\nhis research that made the world aware that the ears of an\\ninfant in utero are already functioning at four and half\\nmonths of age. Just as the umbilical cord provides nourish-\\nment to the unborn infant’s body, Tomatis postulated that\\nthe sound of the mother’s voice is also a nutrient heard by\\nthe fetus. This sound literally charges and stimulates the\\ngrowth of the brain.\\nTomatis took this further, into the realm of language.\\nTomatis concluded that the need to communicate and to\\nbe understood are among our most basic needs. He was a\\npioneer in perceiving that language problems convert into\\nsocial problems for people. ‘‘Language is what charac-\\nterizes man and makes him different from other creatures,’’\\nTomatis is quoted as saying. The techniques he developed\\nto teach people how to listen effectively are internationally\\nrespected tools used in the treatment of autism, attention-\\ndeficit disorder, and other learning disabilities.\\nHis listening program, the invention of the Electronic\\nEar, and his work with the therapeutic use of sound and\\nmusic for the past fifty years have made Tomatis arguably\\nthe best known and most successful ear specialist in the\\nworld. There are more than two hundred Tomatis Centers\\nworldwide, treating a vast variety of problems related to\\nthe ability to hear.\\nGALE ENCYCLOPEDIA OF MEDICINE 461\\nAuditory integration training'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 491, 'page_label': '462'}, page_content='/C15The capacity to listen can be changed or improved\\nthrough auditory stimulation using musical and\\nvocal sounds at high frequencies.\\n/C15Communication begins in the womb. As early as the\\nbeginning of the second trimester, fetuses can hear\\nsounds. These sounds literally cause the brain and\\nnervous system of the baby to develop.\\nDescription\\nA quartet of CAP defects have been identified that\\ncan unfavorably alter how each person processes\\nsound. Among these are:\\n/C15Phonetic decoding, a problem that occurs when the\\nbrain incorrectly decodes what is being heard.\\nSounds are unrecognizable, often because the person\\nspeaking talks too fast.\\n/C15Tolerance-fading memory, a condition with little or\\npoor tolerance for background sounds.\\n/C15Auditory integration involves a person’s ability to\\nput together things heard with things seen.\\nCharacteristically there are long response delays\\nand trouble with phonics, or recognizing the symbols\\nfor sounds.\\n/C15The fourth problem area, often called auditory orga-\\nnization, overlaps the previous three. It is character-\\nized by disorganization in handling auditory and\\nother information.\\nCertain audiological tests are carried out to see if\\nthe person has a CAP problem, and if so, how severe it\\nis. Other tests give more specific information regard-\\ning the nature of the CAP problem. They include:\\n/C15Puretone air-conduction threshold testing, which mea-\\nsures peripheral hearing loss. If loss is found, then\\nbone-conduction testing, or evaluation of the vibra-\\ntion of small bones in the inner ear, is also carried out.\\n/C15Word discrimination scores (WDS) determines a per-\\nson’s clarity in hearing ideal speech. This is done by\\npresenting 25–50 words at 40 decibels above the\\nperson’s average sound threshold in each ear. Test\\nscores equal the percentage of words heard correctly.\\n/C15Immittance testing is made up of two parts, assessing\\nthe status of, and the protective mechanisms of the\\nmiddle ear.\\n/C15Staggered sporadic word (SSW) testing delivers 40\\ncompound words in an overlapping way at 50 deci-\\nbels above threshold to each ear of the person being\\ntested. This test provides expanded information that\\nmakes it possible to break down CAP problems into\\nthe four basic types.\\n/C15Speech in noise discrimination (SN) testing is similar\\nto Staggered Sporadic Word testing except that other\\nnoise is also added and the percentage correct in\\nquiet is compared with that correct when there is\\nadded noise.\\n/C15Phonemic synthesis (PS) determines serious learning\\nproblems. The types of errors made in sounding out\\nwritten words or associating written letters with the\\nsounds they represent help in determining the type\\nand severity of CAP problems.\\nPurpose\\nUpon completion of an auditory integration\\ntraining program, the person’s hearing should be cap-\\nable of perceiving all frequencies at, or near, the same\\nlevel. Total improvement from this therapy, in both\\nhearing and behavior, can take up to one year.\\nResearch and general acceptance\\nAuditory integration training is based upon newly\\nlearned information about the brain. Though brain\\nstructures and connections are predetermined, prob-\\nably by heredity, another factor calledplasticity also\\ncomes into play. Learning, we now know, continues\\nfrom birth todeath. Plasticity is the ability of the brain\\nto actually change its structuring and connections\\nthrough the process of learning.\\nProblems with auditory processing are now\\nviewed as having a wide–reaching ripple effect on our\\nsociety. It is estimated that 30–40% of children start-\\ning school have language-learning skills that can be\\ndescribed as poor. CAP difficulties are a factor in\\nseveral different learning disabilities. They affect not\\nonly academic success, but also nearly every aspect of\\nsocietal difficulties. One example to illustrate this is a\\n1989 University of Buffalo study where CAP problems\\nwere found to be present in a surprising 97% of youth\\ninmates in an upstate New York corrections facility.\\nResources\\nOTHER\\nCooper, Rachel. ‘‘What is Auditory Integration Training?’’\\nDecember 2000. .\\nDejean, Valerie.About the Tomatis Method, 1997.Tomatis\\nAuditory Training Spectrum Center, Bethseda, MD.\\nThe Spectrum Center. ‘‘Auditory Integration and\\nAlfredTomatis.’’ December 2000. .\\nJoan Schonbeck\\nAustralia antigen-associated hepatitis see\\nHepatitis B\\n462 GALE ENCYCLOPEDIA OF MEDICINE\\nAuditory integration training'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 492, 'page_label': '463'}, page_content='Autism\\nDefinition\\nAutism is a severe disorder of brain function\\nmarked by problems with social contact, intelligence\\nand language, together with ritualistic or compulsive\\nbehavior and bizarre responses to the environment.\\nDescription\\nAutism is a lifelong disorder that interferes with\\nthe ability to understand what is seen, heard, and\\ntouched. This can cause profound problems in perso-\\nnal behavior and in the ability to relate to others. A\\nperson with autism must learn how to communicate\\nnormally and how to relate to people, objects and\\nevents. However, not all patients suffer the same\\ndegree of impairment. There is a full spectrum of\\nsymptoms, which can range from mild to severe.\\nAutism occurs in as many as one or two per 1,000\\nchildren. It is found four times more often in boys\\n(usually the first-born) and occurs around the world\\nin all races and social backgrounds. Autism usually is\\nevident in the first three years of life, although in some\\nchildren it’s hard to tell when the problem develops.\\nSometimes the condition isn’t diagnosed until the\\nchild enters school.\\nWhile a person with autism can have symptoms\\nranging from mild to severe, about 10% have an\\nextraordinary ability in one area, such as in mathe-\\nmatics, memory, music, or art. Such children are\\nknown as ‘‘autistic savants’’ (formerly known as\\n‘‘idiot savants.’’).\\nCauses and symptoms\\nAutism is a brain disorder that affects the way the\\nbrain uses or transmits information. Studies have\\nfound abnormalities in several parts of the brain that\\nalmost certainly occurred during fetal development.\\nThe problem may be centered in the parts of the\\nbrain responsible for processing language and infor-\\nmation from the senses.\\nThere appears to be a strong genetic basis for\\nautism. Identical twins are more likely to both be\\naffected than twins who are fraternal (not genetically\\nidentical). In a family with one autistic child, the\\nchance of having another child with autism is about\\n1 in 20, much higher than in the normal population.\\nSometimes, relatives of an autistic child have mild\\nbehaviors that look very much like autism, such as\\nrepetitive behaviors and social or communication\\nproblems. Research also has found that some emo-\\ntional disorders (such as manic depression) occur\\nmore often in families of a child with autism.\\nAt least one group of researchers has found a link\\nbetween an abnormal gene and autism. The gene may\\nbe just one of at least three to five genes that interact in\\nsome way to cause the condition. Scientists suspect\\nthat a faulty gene or genes might make a person vul-\\nnerable to develop autism in the presence of other\\nfactors, such as a chemical imbalance, viruses or che-\\nmicals, or a lack of oxygen at birth.\\nIn a few cases, autistic behavior is caused by a\\ndisease such as:\\n/C15rubella in the pregnant mother\\n/C15tuberous sclerosis\\n/C15fragile X syndrome\\n/C15encephalitis\\n/C15untreated phenylketonuria\\nThe severity of the condition varies between indi-\\nviduals, ranging from the most severe (extremely unu-\\nsual, repetitive, self- injurious, and aggressive\\nbehavior) to very mild, resembling a personality dis-\\norder with some learning disability.\\nProfound problems with social interaction are the\\nmost common symptoms of autism. Infants with the\\ndisorder won’t cuddle; they avoid eye contact and\\ndon’t seem to want or need physical contact or affec-\\ntion. They may become rigid or flaccid when they are\\nheld, cry when picked up, and show little interest in\\nhuman contact. Such a child doesn’t smile or lift his\\narms in anticipation of being picked up. He forms no\\nattachment to parents nor shows any normal anxiety\\ntoward strangers. He doesn’t learn typical games of\\nchildhood, such as peek-a-boo.\\nLanguage problems\\nThe child with autism may not speak at all; if he\\ndoes, it is often in single words. He may endlessly\\nrepeat words or phrases that are addressed to him\\nand may reverse pronouns (‘‘You go sleep’’ instead\\nof ‘‘I want to go to sleep’’).\\nRestricted interests and activity\\nUsually a child with autism has many problems\\nplaying normally. He probably won’t act out adultroles\\nduring play time, and instead of enjoying fantasy play,\\nhe may simply repeatedly mimic the actions of someone\\nelse. Bizarre behavior patterns are very common among\\nautistic children and may include complex rituals,\\nscreaming fits, rhythmic rocking, arm flapping, finger\\nGALE ENCYCLOPEDIA OF MEDICINE 463\\nAutism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 493, 'page_label': '464'}, page_content='twiddling, and crying without tears. Autistic children\\nmay play with their own saliva, feces or urine.They\\nmay be self-destructive, biting their own hands, gouging\\nat their eyes, pulling their hair, or banging their head.\\nSensory problems\\nThe sensory world poses a real problem to many\\nautistic children, who seem overwhelmed by their own\\nsenses. A child with autism may ignore objects or become\\nobsessed with them, continually watching the object\\nor the movement of his fingers over it. Many of these\\nchildren may react to sounds by banging their head\\nor flapping fingers. Some high-functioning autistic\\nadults who have written books about their childhood\\nexperiences report that sounds were often excruciatingly\\npainful to them, forcing them to withdraw from their\\nenvironment or try to cope by withdrawing into their\\nown world of sensation and movement.\\nIntellectual problems\\nMost autistic children appear to be moderately\\nmentally retarded. They may giggle or cry for no\\nreason, have no fear of real danger, but exhibit terror\\nof harmless objects.\\nDiagnosis\\nThere is no medical test for autism. Because the\\nsymptoms of autism are so varied, the condition may\\ngo undiagnosed for some time (especially in those with\\nmild cases or if other handicaps are also present).\\nIt may be confused with other diseases, such as fragile\\nX syndrome, tuberous sclerosis, and untreated\\nphenylketonuria.\\nAutism is diagnosed by observing the child’s\\nbehavior, communication skills, and social interac-\\ntions. Medical tests should rule out other possible\\ncauses of autistic symptoms. Criteria that mental\\nhealth experts use to diagnose autism include:\\n/C15problems with developing friendships\\n/C15problems with make-believe or social play\\n/C15endlessly repeated words or strings of words\\n/C15difficulty in carrying on a conversation\\nThis autistic child is encouraged to interact with the guinea pig in an effort to improve his social interaction. (Helen B. Senisi.\\nPhoto Researchers, Inc. Reproduced by permission.)\\n464 GALE ENCYCLOPEDIA OF MEDICINE\\nAutism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 494, 'page_label': '465'}, page_content='/C15obsessions with rituals or restricted patterns\\n/C15preoccupation with parts of objects\\nSome children have a few of the symptoms of\\nautism, but not enough to be diagnosed with the\\n‘‘classical’’ form of the condition. Children who have\\nautistic behavior but no problems with language may\\nbe diagnosed with ‘‘Asperger syndrome.’’ Children\\nwho seem normal at first but who begin to show\\nautistic behavior as they get older might be diagnosed\\nwith ‘‘childhood disintegrative disorder’’ (CDD).\\nThese problems are sometimes called ‘‘autistic spec-\\ntrum disorders.’’ It is also important to rule out other\\nproblems that seem similar to autism.\\nTreatment\\nThere is no cure for autism. Treatments are\\naimed at reducing specific symptoms. Because the\\nsymptoms vary so widely from one person to the\\nnext, there is not a single approach that works for\\nevery person. A spectrum of interventions include\\ntraining in music, listening, vision, speech and lan-\\nguage, and senses. Specialdiets and medications may\\nalso be prescribed.\\nStudies show that people with autism can improve\\nsignificantly with proper treatment. A child with aut-\\nism can learn best with special teachers in a\\nstructured program that emphasizes individual\\ninstruction. The two most-often studied types of treat-\\nment are:\\nEducational or behavioral treatment\\nTypically, behavioral techniques are used to help\\nthe child respond and decrease symptoms. This might\\ninclude positive reinforcement (food and rewards) to\\nboost language and social skills. This training includes\\nstructured, skill-oriented instruction designed to boost\\nsocial and language abilities. Training needs to begin\\nas early as possible, since early intervention appears to\\ninfluence brain development.\\nMost experts believe that modern treatment is\\nmost effective when carried out at home, although\\ntreatment may also take place in a psychiatric hospi-\\ntal, specialized school, or day care program.\\nMedication\\nNo single medication has yet proved highly effec-\\ntive for the major features of autism. However, a\\nvariety of drugs can control self-injurious, aggressive,\\nand other of the more difficult behaviors. Drugs also\\ncan control epilepsy, which afflicts up to 20% of peo-\\nple with autism.\\nFive types of drugs are sometimes prescribed to\\nhelp the behavior problems of people with autism:\\n/C15stimulants, such as methylphenidate (Ritalin)\\n/C15antidepressants, such as fluroxamine (Luvox)\\n/C15opiate blockers, such as naltrexone (ReVia)\\nKEY TERMS\\nAntidepressants— A type of medication that is used\\nto treat depression; it is also sometimes used to treat\\nautism.\\nAsperger syndrome— Children who have autistic\\nbehavior but no problems with language.\\nEncephalitis— A rare inflammation of the brain\\ncaused by a viral infection. It has been linked to\\nthe develoment of autism.\\nFragile X syndrome— A genetic condition related to\\nthe X chromosome that affects mental, physical and\\nsensory development.\\nMajor tranquilizers— The family of drugs that\\nincludes the psychotropic or neuroleptic drugs,\\nsometimes used to help autistic people. They carry\\nsignificant risk of side effects, including Parkinsonism\\nand movement disorders, and should be prescribed\\nwith caution.\\nOpiate blockers— At y p eo fd r u gt h a tb l o c k st h e\\neffects of natural opiates in the system. This\\nmakes some people, including some people with\\nautism, appear more responsive to their\\nenvironment.\\nPhenylketonuria (PKU)— An enzyme deficiency\\npresent at birth that disrupts metabolism and causes\\nbrain damage. This rare inherited defect may be\\nlinked to the development of autism.\\nRubella— Also known as German measles. When a\\nwoman contracts rubella during pregnancy, her\\ndeveloping infant may be damaged. One of the\\nproblems that may result is autism.\\nStimulants— A class of drugs, including Ritalin,\\nused to treat people with autism. They may make\\nchildren calmer and better able to concentrate, but\\nthey also may limit growth or have other side\\neffects.\\nTuberous sclerosis— A genetic disease that causes\\nskin problems, seizures, and mental retardation. It\\nmay be confused with autism.\\nGALE ENCYCLOPEDIA OF MEDICINE 465\\nAutism'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 495, 'page_label': '466'}, page_content='/C15antipsychotics\\n/C15tranquilizers.\\nToday, most experts recommend a complex treat-\\nment regimen that begins early and continues through\\nthe teenage years. Behavioral therapies are used in\\nconjunction with medications.\\nAlternative treatment\\nMany parents report success with megavitamin\\ntherapy. Some studies have shown that vitamin B6\\nimproves eye contact and speech and lessens tantrum\\nbehavior. Vitamin B6 causes fewer side effects than\\nother medications and is considered safe when used\\nin appropriate doses. However, not many health prac-\\ntitioners advocate its use in the treatment of autism,\\nciting that the studies showing its benefit were flawed.\\nDMG (dimethylglycine)\\nThis compound, available in many health food\\nstores, is legally classified as a food, not a vitamin or\\ndrug. Some researchers claim that it improves speech\\nin children with autism. Those who respond to this\\ntreatment will usually do so within a week. Again,\\nmany doctors do not feel that the studies are adequate\\nto promote this treatment.\\nExercise\\nOne researcher found that vigorousexercise (20\\nminutes or longer, three or four days a week) seems to\\ndecrease hyperactivity, aggression, self-injury and\\nother autistic symptoms.\\nPrognosis\\nWhile there is no cure, with appropriate treatment\\nthe negative behaviors of autism may improve. Earlier\\ngenerations placed autistic children in institutions;\\ntoday, even severely disabled children can be helped in\\na less restrictive environment to develop to their highest\\npotential. Many can eventually become more respon-\\nsive to others as they learn to understand the world\\naround them, and some can lead nearly normal lives.\\nPeople with autism have a normal life expectancy.\\nSome people with autism can handle a job; they do\\nbest with structured jobs that involve a degree of\\nrepetition.\\nPrevention\\nUntil the cause of autism is discovered, prevention\\nis not possible.\\nResources\\nORGANIZATIONS\\nAutism Network International. PO Box 448, Syracuse, NY\\n13210.\\nAutism Research Institute. 4182 Adams Ave., San Diego,\\nCA 92116. (619) 281-7165.\\nAutism Society of America. 7910 Woodmont Avenue, Suite\\n300, Bethesda, Maryland 20814-3067. (800) 328-8476.\\n.\\nNational Alliance for Autism Research.\\n.\\nNational Autism Hotline. c/o Autism Services Center, PO\\nBox 507, 605 Ninth St., Huntington, WV 25710. (304)\\n525-8014.\\nNational Fragile X Foundation. PO Box 190488, San\\nFrancisco, CA 94119. (800) 688-8765. .\\nNational Institute of Neurological Disorders and Stroke. PO\\nBox 5801, Bethesda, MD 20824. (800) 352-9424.\\n.\\nOTHER\\nAutism Society of America. 7910 Woodmont Avenue.\\n.\\nNational Alliance for Autism Research (NAAR). .\\nNational Information Center for Children and Youth with\\nDisabilities. .\\nCarol A. Turkington\\nAutograft see Skin grafting\\nAutoimmune disorders\\nDefinition\\nAutoimmune disorders are conditions in which a\\nperson’s immune system attacks the body’s own cells,\\ncausing tissue destruction.\\nDescription\\nAutoimmunity is accepted as the cause of a wide\\nrange of disorders, and it is suspected to be responsible\\nfor many more. Autoimmune diseases are classified as\\neither general, in which the autoimmune reaction\\ntakes place simultaneously in a number of tissues, or\\norgan specific, in which the autoimmune reaction tar-\\ngets a single organ.\\nAutoimmune disorders include the following:\\n/C15Systemic lupus erythematosus. A general autoim-\\nmune disease in which antibodies attack a number\\n466 GALE ENCYCLOPEDIA OF MEDICINE\\nAutoimmune disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 496, 'page_label': '467'}, page_content='of different tissues. The disease recurs periodically\\nand is seen mainly in young and middle-aged women.\\n/C15Rheumatoid arthritis. Occurs when the immune sys-\\ntem attacks and destroys the tissues that line bone\\njoints and cartilage. The disease occurs throughout\\nthe body, although some joints may be more affected\\nthan others.\\n/C15Goodpasture’s syndrome. Occurs when antibodies\\nare deposited in the membranes of both the lung\\nand kidneys, causing both inflammation of kidney\\nglomerulus (glomerulonephritis) and lung bleeding. It\\nis typically a disease of young males.\\n/C15Grave’s disease. Caused by an antibody that binds to\\nspecific cells in the thyroid gland, causing them to\\nmake excessive amounts of thyroid hormone.\\n/C15Hashimoto’s thyroiditis. Caused by an antibody that\\nbinds to cells in the thyroid gland. Unlike in Grave’s\\ndisease, however, this antibody’s action results in less\\nthyroid hormone being made.\\n/C15Pemphigus vulgaris. A group of autoimmune disor-\\nders that affect the skin.\\n/C15Myasthenia gravis. A condition in which the immune\\nsystem attacks a receptor on the surface of muscle\\ncells, preventing the muscle from receiving nerve\\nimpulses and resulting in severe muscle weakness.\\n/C15Scleroderma. Also called CREST syndrome or pro-\\ngressive systemic sclerosis, scleroderma affects the\\nconnective tissue.\\n/C15Autoimmune hemolytic anemia. Occurs when the\\nbody produces antibodies that coat red blood cells.\\n/C15Autoimmune thrombocytopenic purpura. Disorder\\nin which the immune system targets and destroys\\nblood platelets.\\n/C15Polymyositis and Dermatomyositis. Immune disor-\\nders that affect the neuromuscular system.\\n/C15Pernicious anemia. Disorder in which the immune\\nsystem attacks the lining of the stomach in such a\\nway that the body cannot metabolize vitamin B\\n12.\\n/C15Sjo¨ gren’s syndrome. Occurs when the exocrine\\nglands are attacked by the immune system, resulting\\nin excessive dryness.\\n/C15Ankylosing spondylitis . Immune system induced\\ndegeneration of the joints and soft tissue of the spine.\\n/C15Vasculitis. A group of autoimmune disorders in\\nwhich the immune system attacks and destroys\\nblood vessels.\\n/C15Type Idiabetes mellitus. May be caused by an anti-\\nbody that attacks and destroys the islet cells of the\\npancreas, which produce insulin.\\n/C15Amyotrophic lateral schlerosis. Also called Lou\\nGehrig’s disease. An immune disorder that causes\\nthe death of neurons which leads to progressive loss\\nof muscular control.\\n/C15Guillain-Barre syndrome. Also called infectious\\npolyneuritis. Often occurring after an infection or\\nan immunization (specifically Swine flu), the disease\\naffects the myelin sheath, which coats nerve cells. It\\ncauses progressive muscle weakness andparalysis.\\n/C15Multiple sclerosis. An autoimmune disorder that may\\ninvolve a virus affects the central nervous system,\\ncausing loss of coordination and muscle control.\\nCauses and symptoms\\nTo further understand autoimmune disorders, it is\\nhelpful to understand the workings of the immune\\nsystem. The purpose of the immune system is to defend\\nthe body against attack by infectious microbes (germs)\\nand foreign objects. When the immune system attacks\\nan invader, it is very specific—a particular immune\\nsystem cell will only recognize and target one type of\\ninvader. To function properly, the immune system must\\nnot only develop this specialized knowledge of indivi-\\ndual invaders, but it must also learn how to recognize\\nand not destroy cells that belong to the body itself.\\nEvery cell carries protein markers on its surface that\\nidentifies it in one of two ways: what kind of cell it is\\n(e.g. nerve cell, muscle cell, blood cell, etc.) and to\\nwhom that cell belongs. These markers are called\\nmajor histocompatability complexes (MHCs). When\\nfunctioning properly, cells of the immune system will\\nnot attack any other cell with markers identifying it as\\nbelonging to the body. Conversely, if the immune sys-\\ntem cells do not recognize the cell as ‘‘self,’’ they attach\\nthemselves to it and put out a signal that the body has\\nbeen invaded, which in turn stimulates the production\\nof substances such as antibodies that engulf and destroy\\nthe foreign particles. In case of autoimmune disorders,\\nthe immune system cannot distinguish between ‘‘self’’\\ncells and invader cells. As a result, the same destructive\\noperation is carried out on the body’s own cells that\\nwould normally be carried out on bacteria, viruses, and\\nother such harmful entities.\\nThe reasons why immune systems become dys-\\nfunctional in this way is not well understood.\\nHowever, most researchers agree that a combination\\nof genetic, environmental, and hormonal factors\\nplay into autoimmunity. Researchers also speculate\\nthat certain mechanisms may trigger autoimmunity.\\nFirst, a substance that is normally restricted to one\\npart of the body, and therefore not usually exposed\\nto the immune system, is released into other areas\\nGALE ENCYCLOPEDIA OF MEDICINE 467\\nAutoimmune disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 497, 'page_label': '468'}, page_content='where it is attacked. Second, the immune system\\nmay mistake a component of the body for a similar\\nforeign component. Third, cells of the body may be\\naltered in some way, either by drugs, infection, or\\nsome other environmental factor, so that they are\\nno longer recognizable as ‘‘self’’ to the immune\\nsystem. Fourth, the immune system itself may be\\ndamaged, such as by a genetic mutation, and there-\\nfore cannot function properly.\\nThe symptoms of the above disorders include:\\n/C15Systemic lupus erythematosus. Symptoms include\\nfever, chills,fatigue, weight loss, skinrashes (particu-\\nlarly the classic ‘‘butterfly’’ rash on the face), vasculi-\\ntis, polyarthralgia, patchy hair loss, sores in the mouth\\nor nose, lymph-node enlargement, gastric problems,\\nand, in women, irregular periods. About half of those\\nwho suffer from lupus develop cardiopulmonary pro-\\nblems, and some may also develop urinary problems.\\nLupus can also effect the central nervous system,\\ncausing seizures, depression, and psychosis.\\n/C15Rheumatoid arthritis. Initially may be characterized\\nby a low-gradefever, loss of appetite, weight loss,\\nand a generalizedpain in the joints. The joint pain\\nthen becomes more specific, usually beginning in the\\nfingers, then spreading to other areas, such as the\\nwrists, elbows, knees, and ankles. As the disease\\nprogresses, joint function diminishes sharply and\\ndeformities occur, particularly the characteristic\\n‘‘swan’s neck’’ curling of the fingers.\\n/C15Goodpasture’s syndrome. Symptoms are similar to\\nthat of iron deficiency anemia, including fatigue and\\npallor. Symptoms involving the lungs may range\\nfrom a cough that produces bloody sputum to out-\\nright hemorrhaging. Symptoms involving the urin-\\nary system include blood in the urine and/or swelling.\\n/C15Grave’s disease. This disease is characterized by an\\nenlarged thyroid gland, weight loss without loss of\\nappetite, sweating, heart palpitations, nervousness,\\nand an inability to tolerate heat.\\n/C15Hashimoto’s thyroiditis. This disorder generally dis-\\nplays no symptoms.\\n/C15Pemphigus vulgaris. This disease is characterized by\\nblisters and deep lesions on the skin.\\n/C15Myasthenia gravis. Characterized by fatigue and mus-\\ncle weakness that at first may be confined to certain\\nmuscle groups, but then may progress to the point of\\nparalysis. Myasthenia gravis patients often have\\nexpressionless faces as well as difficulty chewing and\\nswallowing. If the disease progresses to the respiratory\\nsystem, artificial respiration may be required.\\n/C15Scleroderma. Disorder is usually preceded by\\nRaynaud’s phenomenon. Symptoms that follow\\ninclude pain, swelling, and stiffness of the joints,\\nand the skin takes on a tight, shiny appearance. The\\ndigestive system also becomes involved, resulting in\\nweight loss, appetite loss, diarrhea,constipation, and\\ndistention of the abdomen. As the disease progresses,\\nthe heart, lungs, and kidneys become involved, and\\nmalignant hypertension causes death in approxi-\\nmately 30% of cases.\\n/C15Autoimmune hemolytic anemia. May be acute or\\nchronic. Symptoms include fatigue and abdominal\\ntenderness due to an enlarged spleen.\\n/C15Autoimmune thrombocytopenic purpura. Character-\\nized by pinhead-size red dots on the skin, unexplained\\nbruises, bleeding from the nose and gums, and blood in\\nthe stool.\\n/C15Polymyositis and Dermatomyositis. In polymyositis,\\nsymptoms include muscle weakness, particularly in\\nthe shoulders or pelvis, that prevents the patient from\\nperforming everyday activities. In dermatomyositis,\\nthe same muscle weakness is accompanied by a rash\\nthat appears on the upper body, arms, and fingertips.\\nA rash may also appear on the eyelids, and the area\\naround the eyes may become swollen.\\n/C15Pernicious anemia. Signs of pernicious anemia\\ninclude weakness, sore tongue, bleeding gums, and\\ntingling in the extremities. Because the disease causes\\na decrease in stomach acid, nausea,vomiting, loss of\\nappetite, weight loss,diarrhea, and constipation are\\npossible. Also, because Vitamin B\\n12 is essential for\\nthe nervous system function, the deficiency of it\\nbrought on by the disease can result in a host of\\nneurological problems, including weakness, lack of\\ncoordination, blurred vision, loss of fine motor skills,\\nloss of the sense of taste, ringing in the ears, and loss\\nof bladder control.\\n/C15Sjo¨ gren’s syndrome. Characterized by excessive dry-\\nness of the mouth and eyes.\\n/C15Ankylosing spondylitis. Generally begins with lower\\nback pain that progresses up the spine. The pain may\\neventually become crippling.\\n/C15Vasculitis. Symptoms depend upon the group of\\nveins affected and can range greatly.\\nKEY TERMS\\nAutoantibody— An antibody made by a person that\\nreacts with their own tissues.\\nParesthesias— A prickly, tingling sensation.\\n468 GALE ENCYCLOPEDIA OF MEDICINE\\nAutoimmune disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 498, 'page_label': '469'}, page_content='/C15Type I diabetes mellitus. Characterized by fatigue\\nand an abnormally high level of glucose in the\\nblood (hyperglycemia).\\n/C15Amyotrophic lateral schlerosis. First signs are stum-\\nbling and difficulty climbing stairs. Later,muscle\\ncramps and twitching may be observed as well as\\nweakness in the hands making fastening buttons or\\nturning a key difficult. Speech may become slowed or\\nslurred. There may also be difficluty swallowing. As\\nrespiratory muscles atrophy, there is increased dan-\\nger of aspiration or lung infection.\\n/C15Guillain-Barre syndrome. Muscle weakness in the legs\\noccurs first, then the arms and face. Paresthesias (a\\nprickly, tingling sensation) is also felt. This disorder\\naffects both sides of the body and may involve paraly-\\nsis and the muscles that control breathing.\\n/C15Multiple sclerosis. Like Lou Gehrig’s disease, the\\nfirst symptom may be clumsiness. Weakness or\\nexhaustion is often reported, as well as blurry or\\ndouble vision. There may be dizziness, depression,\\nloss of bladder control, and muscle weakness so\\nsevere that the patient is confined to a wheelchair.\\nDiagnosis\\nA number of tests are involved in the diagnosis\\nof autoimmune diseases, depending on the particular\\ndisease; e.g. blood tests, cerebrospinal fluid analysis,\\nelectromylogram (measur es muscle function), and\\nmagnetic resonance imaging of the brain. Usually,\\nthese tests determine the location and extent of\\ndamage or involvement. They are useful in charting\\nprogress of the disease and as baselines for\\ntreatment.\\nThe principle tool, however, for authenticating\\nautoimmune disease is antibody testing. Such tests\\ninvolve measuring the level of antibodies found in\\nthe blood and determining if they react with specific\\nantigens that would give rise to an autoimmune reac-\\ntion. An elevated amount of antibodies indicates that\\na humoral immune reaction is occurring. Since ele-\\nvated antibody levels are also seen in common infec-\\ntions, they must be ruled out as the cause for the\\nincreased antibody levels.\\nAntibodies can also be typed by class. There are\\nfive classes of antibodies, and they can be separated in\\nthe laboratory. The class IgG is usually associated\\nwith autoimmune diseases. Unfortunately, IgG class\\nantibodies are also the main class of antibody seen in\\nnormal immune responses.\\nThe most useful antibody tests involve introdu-\\ncing the patient’s antibodies to samples of his or her\\nown tissue, usually thyroid, stomach, liver, and kidney\\ntissue. If antibodies bind to the ‘‘self’’ tissue, it is\\ndiagnostic for an autoimmune disorder. Antibodies\\nfrom a person without an autoimmune disorder\\nwould not react to ‘‘self ’’ tissue.\\nTreatment\\nTreatment of autoimmune diseases is specific to\\nthe disease, and usually concentrates on alleviating or\\npreventing symptoms rather than correcting the\\nunderlying cause. For example, if a gland involved in\\nan autoimmune reaction is not producing a hormone\\nsuch as insulin, administration of that hormone is\\nrequired. Administration of a hormone, however,\\nwill restore the function of the gland damaged by the\\nautoimmune disease.\\nThe other aspect of treatment is controlling the\\ninflammatory and proliferative nature of the immune\\nresponse. This is generally accomplished with two\\ntypes of drugs. Steroid compounds are used to control\\ninflammation. There are many different steroids, each\\nhaving side effects. The proliferative nature of the\\nimmune response is controlled with immunosuppres-\\nsive drugs. These drugs work by inhibiting the replica-\\ntion of cells and, therefore, also suppress non-immune\\ncells leading to side effects such as anemia.\\nSystemic enzyme therapyis a new treatment that is\\nshowing results for rheumatoid arthritis, multiple\\nsclerosis, ankylosing spondylitis, and other inflamma-\\ntory diseases. Enzymes combinations of pancreatin,\\ntrypsin, chymotrypsin, bromelain, and papain help\\nstimulate the body’s own defenses, accelerate inflam-\\nmation in order to reduce swelling and improve circu-\\nlation, and break up the immune complexes within the\\nbloodstream. Symptoms have been reduced using this\\ntreatment.\\nOther treatments that hold some promise are irra-\\ndiation of the spleen andgene therapy. Splenic irradia-\\ntion is touted to be a safe, alternative for patients with\\nautoimmune blood diseases, especially autoimmune\\nhemolytic anemia, or others with compromised\\nimmune systems, such as HIV patients and the elderly.\\nIt is reported to have few side effects and seems to be\\nworking. Cytokine and cytokine inhibitor genes\\ninjected directly into muscle tissue also appear to be\\neffective in treating Type I diabetes mellitus, systemic\\nlupus erythematosus, thyroditis, and arthritis.\\nPrognosis\\nPrognosis depends upon the pathology of each\\nautoimmune disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 469\\nAutoimmune disorders'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 499, 'page_label': '470'}, page_content='Prevention\\nMost autoimmune diseases cannot be prevented.\\nThough the mechanisms involved in how these dis-\\neases affect the body are known, it is still unclear\\nwhy the body turns on itself. Since more women than\\nmen seem to be affected by some of these disorders\\n(e.g. lupus), some researchers are looking into hor-\\nmones as a factor. This, and gene therapy, may be\\nthe preventatives of the future.\\nResources\\nPERIODICALS\\nCichoke, Anthony J. ‘‘Natural Relief for Autoimmune\\nDisorders.’’ Better Nutrition.62, no. 6 (June 2000): 24.\\nHenderson, Charles W. ‘‘Gene Therapy Uses Vectors\\nEncodingCytokines or Cytokine Inhibitors (for\\ntreatment of autoimmune disorders).’’\\nImmunotherapyWeekly September 27, 2000: pNA.\\nRiccio, Nina M. ‘‘Autoimmune Disorder: When the Body\\nAttacksItself.’’ Current Health 226, no. 5 (January\\n2000): 13.\\n‘‘Splenic Irradiation Is an Option for Patients with\\nAutoimmuneDisorders and Those with HIV.’’AIDS\\nWeekly (April 9, 2001): pNA.\\nJanie F. Franz\\nAutoimmune hepatitis see Hepatitis,\\nautoimmune\\nAutologous transfusion see Transfusion\\nAutologous transplant see Bone marrow\\ntransplantation\\nAutomatic implantable cardioverter-\\ndefibrillator see Implantable cardioverter-\\ndefibrillator\\nAutopsy\\nDefinition\\nAn autopsy is a postmortem assessment or exam-\\nination of a body to determine the cause of death. An\\nautopsy is performed by a physician trained in\\npathology.\\nPurpose\\nMost autopsies advance medical knowledge and\\nprovide evidence for legal action. Medically, autopsies\\ndetermine the exact cause and circumstances ofdeath,\\ndiscover the pathway of a disease, and provide valuable\\ninformation to be used in the care of the living. When\\nfoul play is suspected, a government coroner or medical\\nexaminer performs autopsies for legal use. This branch\\nof medical study is called forensic medicine. Forensic\\nspecialists investigate deaths resulting from violence\\nor occurring under suspicious circumstances.\\nBenefits of research from autopsies include the\\nproduction of new medical information on diseases\\nsuch as toxic shock syndrome, acquired immunodefi-\\nciency syndrome (AIDS). Organ donation, which can\\npotentially save the lives of other patients, is also\\nanother benefit of autopsies.\\nPrecautions\\nWhen performed for medical reasons, autopsies\\nrequire formal permission from family members or the\\nlegal guardian. (Autopsies required for legal reasons\\nwhen foul play is suspected do not need the consent\\nKEY TERMS\\nAcquired immunodeficiency syndrome (AIDS) —\\nA group of diseases resulting from infection with\\nthe human immunodeficiency virus (HIV). A per-\\nson infected with HIV gradually loses immune\\nfunction, becoming less able to resist aliments and\\ncancers, resulting in eventual death.\\nComputed tomography scan (CT scan) —The tech-\\nnique used in diagnostic studies of internal bodily\\nstructures in the detection of tumors or brain aneur-\\nysms. This diagnostic test consists of a computer\\nanalysis of a series of cross-sectional scans made\\nalong a single axis of a bodily structure or tissue that\\nis used to construct a three-dimensional image of\\nthat structure\\nCreutzfeld-Jakob disease— A rare, often fatal dis-\\nease of the brain, characterized by gradual demen-\\ntia and loss of muscle control that occurs most often\\nin middle age and is caused by a slow virus.\\nHepatitis— Inflammation of the liver, caused by\\ninfectious or toxic agents and characterized by jaun-\\ndice, fever, liver enlargement, and abdominal pain.\\nMagnetic resonance imaging (MRI)— A diagnostic\\ntool that utilizes nuclear magnetic energy in the\\nproduction of images of specific atoms and mole-\\ncular structures in solids, especially human cells,\\ntissues, and organs.\\nPostmortem— After death.\\n470 GALE ENCYCLOPEDIA OF MEDICINE\\nAutopsy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 500, 'page_label': '471'}, page_content='of next of kin.) During the autopsy, very concise notes\\nand documentation must be made for both medical\\nand legal reasons. Some religious groups prohibit\\nautopsies.\\nDescription\\nAn autopsy can be described as the examination\\nof a deceased human body with a detailed exam of\\nthe person’s remains. This procedure dates back to\\nthe Roman era when few human dissections were\\nperformed; autopsies were utilized, however, to\\ndetermine the cause of death in criminal cases. At\\nthe beginning of the procedure the exterior body is\\nexamined and then the internal organs are removed\\nand studied. Some pathologists argue that more\\nautopsies are performed than necessary. However,\\nrecent studies show that autopsies can detect major\\nfindings about a person’s condition that were not\\nsuspected when the person was alive. And the grow-\\ning awareness of the influence of genetic factors in\\ndisease has also emphasized the importance of\\nautopsies.\\nDespite the usefulness of autopsies, fewer autop-\\nsies have been performed in the United States during\\nthe past 10-20 years. A possible reason for this decline\\nis concern about malpractice suits on the part of the\\ntreating physician. Other possible reasons are that\\nhospitals are performing fewer autopsies because of\\nthe expense or because modern technology, such as\\nCT scans and magnetic resonance imaging, can\\noften provide sufficient diagnostic information.\\nNonetheless, federal regulators and pathology groups\\nhave begun to establish new guidelines designed to\\nincrease the number and quality of autopsies being\\nperformed.\\nMany experts are concerned that if the number of\\nautopsies increases, hospitals may be forced to charge\\nfamilies a fee for the procedure as autopies are not\\nnormally covered by insurance companies or\\nMedicare. Yet, according to several pathologists, the\\nbenefit of the procedure for families and doctors does\\njustify the cost. In medical autopsies, physicians\\nremain cautious to examine only as much of the\\nbody as permitted according to the wishes of the\\nfamily. It is important to note that autopsies can also\\nprovide peace of mind for the bereaved family in cer-\\ntain situations.\\nPreparation\\nIf a medical autopsy is being performed, written\\npermission is secured from the family of the deceased\\nAftercare\\nOnce the autopsy has been completed, the body is\\nprepared for final arrangements according to the\\nfamily’s wishes\\nRisks\\nThere are some risks of disease transmission from\\nthe deceased. In fact, some physicans may refuse to do\\nautopsies on specific patients because of a fear of\\ncontracting diseases such as AIDS, hepatitis, or\\nCreutzfeld-Jakob disease.\\nNormal results\\nIn most situations the cause of death is determined\\nfrom the procedure of an autopsy without any trans-\\nmission of disease.\\nAbnormal results\\nAbnormal results would include inconclusive\\nresults from the autopsy and transmission of infec-\\ntious disease during the autopsy.\\nResources\\nORGANIZATIONS\\nAmerican Medical Association. 515 N. State St., Chicago,\\nIL 60612. (312) 464-5000. .\\nJeffrey P. Larson, RPT\\nAviation medicine\\nDefinition\\nAlso known as aerospace medicine, flight medi-\\ncine, or space medicine, aviation medicine is a medi-\\ncal specialty that focuses on the physical and\\npsychological conditions associated with flying and\\nspace travel.\\nPurpose\\nSince flying airplanes and spacecraft involves\\ngreat risk and physical demands, such as changes in\\ngravity and oxygen, pilots and astronauts need medi-\\ncal experts to protect their safety and the public’s\\nsafety.\\nGALE ENCYCLOPEDIA OF MEDICINE 471\\nAviation medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 501, 'page_label': '472'}, page_content='Description\\nPressure changes\\nIn the United States, the Federal Aviation\\nAdministration (FAA) requires all pilots who fly\\nabove 14,500 ft (4,420 m) to be prepared for pressure\\nchanges caused by lower oxygen levels at high altitude.\\nPilots must either have a pressurized cabin or access to\\nan oxygen mask. Without these protections, they\\ncould experience hypoxia, or altitude sickness.\\nHypoxia reduces the amount of oxygen in the brain,\\ncausing such symptoms as dizziness, shortness of\\nbreath, and mental confusion. These symptoms\\ncould cause the pilot to lose control of the plane.\\nHypoxia can be treated withoxygen therapy.\\nRapid altitude increases and decreases can cause\\npain because there is an air pocket in the middle por-\\ntion of the ear. To equalize pressure in the ear, physi-\\ncians typically advise pilots and passengers to clear\\ntheir sinuses by plugging their nose and blowing until\\nthe eardrums ‘‘pop.’’ Other options include yawning,\\nswallowing or chewing gum. For people with a cold or\\na severely blocked middle ear, the use ofdecongestants,\\nantihistamines, or nasal sprays may help. Without tak-\\ning steps to equalize pressure, the tympanic membrane\\ncould rupture, causing hearing loss, vertigo, dizziness,\\nand nausea.\\nGravity’s impact\\nFighter pilots who fly high-performance jets can\\nexperience health problems during rapid acceleration\\nand when executing tight turns at high speed. During\\nthese moves, a pilot experiences extreme gravity con-\\nditions that can pull blood away from the brain and\\nheart and into the lower body. This can cause the pilot\\nto have tunnel vision or pass out. To prevent these\\npotentially deadly situations, the military requires\\nfighter pilots to wear special flight suits, or G suits,\\nwhich have compartments that fill with air or fluid to\\nkeep blood from pooling in the lower body.\\nSome pilots, like the Blue Angels, use a technique\\ncalled the Valsalva Maneuver instead of G suits to\\nprevent black outs during high-performance flying.\\nThe Valsalva Maneuver involves grunting and tigh-\\ntening the abdominal muscles to stop blood from\\ncollecting in the wrong parts of the body.\\nPREVENTIVE CARE. Since any routine health pro-\\nblem that affects a pilot could mean the loss of\\nhundreds of lives, aviation medicine specialists who\\nwork for commercial airlines and the military take\\nspecial care to educate pilots about proper diet,\\nexercise and preventive health tools. For example,\\nphysicians may frequently screen pilots for vision\\nchanges caused by glaucoma or cataracts. They\\nalso will check for hearing loss and encourage the\\npilot to wear earplugs or headphones to buffer\\nengine noise. To monitor for heart disease, physi-\\ncians will check blood pressure and may order diag-\\nnostic tests such as an ECG orstress test.\\nMotion sickness\\nMany people experience nausea, vertigo, and dis-\\norientation when they first arrive in space. This is\\ncaused by changes in the fluid in the inner ear, which\\nis sensitive to gravity and affects our sense of spatial\\norientation. The symptoms typically ease after several\\ndays, but often recur when the astronaut returns to\\nEarth. To treat this condition, physicians give astro-\\nnauts motion sicknessmedication, such as lorazepam.\\nBone and muscle loss\\nIn zero-gravity conditions, astronauts lose bone\\nand muscle mass. On earth, the natural resistance of\\ngravity helps build stronger muscles and bones during\\nnormal weight-bearing activities like walking or even\\nsitting at a desk. In space, however, astronauts must\\nwork harder to prevent bone and muscle loss. Exercise\\nis an important treatment. Crew members may use an\\nexercise cycle or resistive rubber bands to stay in\\nshape. Physicians also may give them medication to\\nprevent bone loss and prescribe nutritional supple-\\nments, such as a mixture of essential amino acids and\\ncarbohydrates, to limit muscle atrophy.\\nKEY TERMS\\nG suits— Special flight suits, worn by fighter pilots,\\nwhich have compartments that fill with air or fluid\\nto keep blood from pooling in the lower body dur-\\ning rapid acceleration and tight turns.\\nHypoxia— Hypoxia, or altitude sickness, reduces\\nthe amount of oxygen in the brain causing such\\nsymptoms as dizziness, shortness of breath, and\\nmental confusion.\\nTympanic membrane— A structure in the middle\\near that can rupture if pressure in the ear is\\nnot equalized during airplane ascents and\\ndescents.\\nValsalva Maneuver — Pilots grunt and tighten their\\nabdominal muscles to prevent black outs during\\nhigh-performance flying.\\n472 GALE ENCYCLOPEDIA OF MEDICINE\\nAviation medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 502, 'page_label': '473'}, page_content='Radiation\\nAnother health threat to space travelers is radia-\\ntion. Harmful rays can alter the DNA in human cells\\nand cause cancer. Excess radiation also can weaken\\nthe immune system. To prevent these problems, phy-\\nsicians may give astronauts nutritional supplements.\\nFor example, research has show that n-3 fatty acids\\nfound in fish oil reduce DNA damage.\\nCardiovascular issues\\nWhen astronauts return to earth after a long mis-\\nsion, they tend to feel dizzy and black out. Scientists are\\nconcerned about this dilemma because it could be dan-\\ngerous if the crew members need to make an emergency\\nexit. One way to prevent this problem, which is caused\\nby a drop in blood pressure, is to have the astronauts\\ndrink extra fluids and increase salt intake to increase\\nblood volume. Physicians also may prescribe medication\\nthat causes blood vessels to contract. As another pre-\\ncaution, astronauts also put on protective flight suits, or\\nG suits, before they re-enter the earth’s atmosphere.\\nResources\\nPERIODICALS\\nAviation, Space and Environmental Medicine.Monthly peer-\\nreviewed journal published by the Aerospace Medical\\nAssociation. Contact theeditor: 3212 Swandale Dr.,\\nSan Antonio, TX 78230-4404. (210) 342-5670.\\nASEMJournal@worldnet.att.net.\\nORGANIZATIONS\\nAerospace Medical Association. 320 S. Henry St.,\\nAlexandria, VA 22314-3579. (703) 739-2240. .\\nNational Space Biomedical Research Institute. One Baylor\\nPlaza, NA-425, Houston, TX 77030. (713) 798-7412.\\ninfo@www.nsbri.org. .\\nWright State University Aerospace Medicine Program. P.O.\\nBox 92, Dayton, Ohio 45401-0927. (937) 276-8338.\\n.\\nOTHER\\nFederal Aviation Administration Office of Aviation\\nMedicine. .\\nNational Aeronautics and Space Administration Aerospace\\nMedicine. .\\nSociety of USAF Flight Surgeons Online Catalog. .\\nMelissa Knopper\\nAVM see Arteriovenous malformations\\nAvoidant personality disorder see\\nPersonality disorders\\nAvulsions see Wounds\\nAyurvedic medicine\\nDefinition\\nAyurvedic medicine is a system of healing that ori-\\nginated in ancient India. In Sanskrit,ayur means life or\\nliving,and vedameans knowledge, soAyurveda hasbeen\\ndefined as the ‘‘knowledge of living’’ or the ‘‘science of\\nlongevity.’’ Ayurvedic medicine utilizes diet,detoxifica-\\ntion and purification techniques, herbal and mineral\\nremedies, yoga, breathing exercises, meditation,a n d\\nmassage therapyas holistic healing methods. Ayurvedic\\nmedicine is widely practiced in modern India and has\\nbeen steadily gaining followers in the West.\\nPurpose\\nAccording to the original texts, the goal of\\nAyurveda is prevention as well as promotion of the\\nbody’s own capacity for maintenance and balance.\\nAyurvedic treatment is non-invasive and non-toxic, so\\nit can be used safely as an alternative therapy or along-\\nside conventional therapies. Ayurvedic physicians\\nclaim that their methods can also help stress-related,\\nmetabolic, and chronic conditions. Ayurveda has been\\nused to treatacne, allergies, asthma, anxiety, arthritis,\\nchronic fatigue syndrome, colds, colitis, constipation,\\ndepression, diabetes, flu, heart disease,hypertension,\\nimmune problems, inflammation, insomnia, nervous\\ndisorders, obesity, skin problems, and ulcers.\\nAyurvedic physicians seek to discover the roots\\nof a disease before it gets so advanced that more\\nradical treatments are necessary. Thus, Ayurveda\\nseems to be limited in treating severely advanced\\nconditions, traumatic injuries, acutepain, and con-\\nditions and injuries requiring invasive surgery.\\nAyurvedic techniques have also been used alongside\\nchemotherapy and surgery to assist patients in\\nrecovery and healing.\\nDescription\\nOrigins\\nAyurvedic medicine originated in the early civili-\\nzations of India some 3,000-5,000 years ago. It is\\nmentioned in the Vedas, the ancient religious and\\nphilosophical texts that are the oldest surviving litera-\\nture in the world, which makes Ayurvedic medicine\\nthe oldest surviving healing system. According to the\\ntexts, Ayurveda was conceived by enlightened wise\\nmen as a system of living harmoniously and maintain-\\ning the body so that mental and spiritual awareness\\ncould be possible. Medical historians believe that\\nGALE ENCYCLOPEDIA OF MEDICINE 473\\nAyurvedic medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 503, 'page_label': '474'}, page_content='Ayurvedic ideas were transported from ancient India\\nto China and were instrumental in the development of\\nChinese medicine.\\nToday, Ayurvedic medicine is used by 80% of the\\npopulation in India. Aided by the efforts ofDeepak\\nChopra and the Maharishi, it has become an increas-\\ningly accepted alternative medical treatment in\\nAmerica during the last two decades. Chopra is an\\nM.D. who has written several bestsellers based on\\nAyurvedic ideas. He also helped develop the Center\\nfor Mind/Body Medicine in La Jolla, California, a\\nmajor Ayurvedic center that trains physicians in\\nAyurvedic principles, produces herbal remedies, and\\nconducts research and documentation of its healing\\ntechniques.\\nKey ideas\\nTo understand Ayurvedic treatment, it is necessary\\nto have an idea how the Ayurvedic system views the\\nbody. The basic life force in the body isprana,w h i c hi s\\nalso found in the elements and is similar to the Chinese\\nnotion ofchi. As Swami Vishnudevananda, a yogi and\\nexpert, put it, ‘‘Prana is in the air, but is not the oxygen,\\nnor any of its chemical constituents. It is in food, water,\\nand in the sunlight, yet it is not vitamin, heat, or light-\\nrays. Food, water, air, etc., are only the media through\\nwhich the prana is carried.’’\\nIn Ayurveda, there are five basic elements that\\ncontain prana: earth, water, fire, air, and ether.\\nThese elements interact and are further organized in\\nthe human body as three main categories or basic\\nphysiological principles in the body that govern all\\nbodily functions known as the doshas. The three\\ndoshas arevata, pitta, and kapha. Each person has a\\nunique blend of the three doshas, known as the per-\\nson’s prakriti, which is why Ayurvedic treatment is\\nalways individualized. In Ayurveda, disease is viewed\\nas a state of imbalance in one or more of a person’s\\ndoshas, and an Ayurvedic physician strives to adjust\\nand balance them, using a variety of techniques.\\nThe vata dosha is associated with air and ether,\\nand in the body promotes movement and lightness.\\nD E E P A K C H O P R A (1946– )\\n(AP/Wide World Photos. Reproduced by permission.)\\nDeepak Chopra was born in India and studied medi-\\ncine at the All India Institute of Medical Science. He left his\\nhome for the United States in 1970 and completed resi-\\ndencies in internal medicine and endocrinology. He went\\non to teaching posts at major medical institutions—Tufts\\nUniversity and Boston University schools of medicine—\\nwhile establishing a very successful private practice. By\\nthe time he was thirty-five, Chopra had become chief of\\nstaff at New England Memorial Hospital.\\nDisturbed by Western medicine’s reliance on medica-\\ntion, he began a search for alternatives and discovered one\\nin the teachings of the Maharishi Mahesh Yogi, an Indian\\nspiritualist who had gained a cult following in the late sixties\\nteaching Transcendental Meditation (TM). Chopra began\\npracticing TM fervently and eventually met the Maharishi.\\nIn 1985 Chopra established the Ayurvedic Health Center for\\nStress Management and Behavioral Medicine in Lancaster,\\nMassachusetts, where he began his practice of integrating\\nthe best aspects of Eastern and Western medicine.\\nIn 1993, he published Creating Affluence: Wealth\\nConsciousness in the Field of All Possibilities, and the enor-\\nmously successful best seller,Ageless Body, Timeless Mind.\\nIn the latter he presents his most radical thesis: that aging is\\nnot the inevitable deterioration of organs and mind that we\\nhave been traditionally taught to think of it as. It is a process\\nthat can be influenced, slowed down, and even reversed\\nwith the correct kinds of therapies, almost all of which are\\nself-administered or self-taught. He teaches that applying a\\nregimen of nutritional balance, meditation, and emotional\\nclarity characterized by such factors as learning to easily\\nand quickly express anger, for instance, can lead to\\nincreased lifespans of up to 120 years.\\n474\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAyurvedic medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 504, 'page_label': '475'}, page_content='Vata people are generally thin and light physically,\\ndry-skinned, and very energetic and mentally restless.\\nWhen vata is out of balance, there are often nervous\\nproblems, hyperactivity, sleeplessness, lower back\\npains, and headaches.\\nPitta is associated with fire and water. In the body,\\nit is responsible for metabolism and digestion. Pitta\\ncharacteristics are medium-built bodies, fair skin,\\nstrong digestion, and good mental concentration.\\nPitta imbalances show up as anger and aggression\\nand stress-related conditions like gastritis, ulcers,\\nliver problems, and hypertension.\\nThe kapha dosha is associated with water and\\nearth. People characterized as kapha are generally\\nlarge or heavy with more oily complexions. They\\ntend to be slow, calm, and peaceful. Kapha disorders\\nmanifest emotionally as greed and possessiveness, and\\nphysically as obesity, fatigue, bronchitis, and sinus\\nproblems.\\nDiagnosis\\nIn Ayurvedic medicine, disease is always seen as\\nan imbalance in the dosha system, so the diagnostic\\nprocess strives to determine which doshas are\\nunderactive or overactive in a body. Diagnosis is\\noften taken over a course of days in order for the\\nAyurvedic physician to most accurately determine\\nwhat parts of the body are being affected. To diag-\\nnose problems, Ayurvedic physicians often use\\nlong questionnaires and interviews to determine a\\nperson’s dosha patterns and physical and psycholo-\\ngical histories. Ayurvedic physicians also intricately\\nobserve the pulse, tongue, face, lips, eyes, and fin-\\ngernails for abnormalities or patterns that they\\nbelieve can indicate deeper problems in the internal\\nsystems. Some Ayurvedic physicians also use\\nlaboratory tests to assist in diagnosis.\\nTreatment\\nAyurvedic treatment seeks to re-establish balance\\nand harmony in the body’s systems. Usually the first\\nmethod of treatment involves some sort of detoxifica-\\ntion and cleansing of the body, in the belief that accu-\\nmulated toxins must be removed before any other\\nmethods of treatment will be effective. Methods of\\ndetoxification include therapeuticvomiting, laxatives,\\nmedicated enemas, fasting, and cleansing of the\\nsinuses. Many Ayurvedic clinics combine all of these\\ncleansing methods into intensive sessions known as\\npanchakarma. Panchakarma can take several days or\\neven weeks and they are more than elimination thera-\\npies. They also include herbalized oil massage and\\nherbalized heat treatments . After purification,\\nAyurvedic physicians use herbal and mineral remedies\\nto balance the body as well. Ayurvedic medicine con-\\ntains a vast knowledge of the use of herbs for specific\\nhealth problems.\\nAyurvedic medicine also emphasizes how people\\nlive their lives from day to day, believing that proper\\nlifestyles and routines accentuate balance, rest, diet,\\nand prevention. Ayurveda recommends yoga as a\\nform of exercise to build strength and health, and\\nalso advises massage therapy and self-massage as\\nways of increasing circulation and reducingstress.\\nYogic breathing techniques and meditation are also\\npart of a healthy Ayurvedic regimen, to reduce stress\\nand improve mental energy.\\nAyurvedic Body Types\\nVata Pitta Kapha\\nPhysical\\ncharacteristics\\nThin.\\nProminent\\nfeatures.\\nCool, dry\\nskin.\\nConstipation.\\nCramps.\\nAverage\\nbuild. Fair,\\nthin hair.\\nWarm, moist\\nskin. Ulcers,\\nheartburn,\\nand hemor-\\nrhoids. Acne.\\nLarge build.\\nWavy, thick\\nhair. Pale, cool,\\noily skin.\\nObesity, aller-\\ngies, and sinus\\nproblems. High\\ncholesterol.\\nEmotional\\ncharacteristics\\nMoody.\\nVivacious.\\nImaginative.\\nEnthusiastic.\\nIntuitive.\\nIntense.\\nQuick tem-\\npered.\\nIntelligent.\\nLoving.\\nArticulate.\\nRelaxed. Not\\neasily angered.\\nAffectionate.\\nTolerant.\\nCompassionate.\\nBehavioral\\ncharacteristics\\nUnscheduled\\nsleep and\\nmeal times.\\nNervous dis-\\norders.\\nAnxiety.\\nOrderly.\\nStructured\\nsleep and\\nmeal times.\\nPerfectionist.\\nSlow, graceful.\\nLong sleeper\\nand slow eater.\\nProcrastination.\\nKEY TERMS\\nDosha— One of three constitutional types, either\\nvata, pitta, or kapha, found in Ayurvedic medicine.\\nMeditation— Technique of calming the mind.\\nPanchakarma— Intensive Ayurvedic cleansing and\\ndetoxification program.\\nPrakriti— An individual’s unique dosha pattern.\\nPrana— Basic life energy found in the elements.\\nYoga— System of body and breathing exercises.\\nGALE ENCYCLOPEDIA OF MEDICINE 475\\nAyurvedic medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 505, 'page_label': '476'}, page_content='Of all treatments, though, diet is one of the most\\nbasic and widely used therapy in the Ayurvedic sys-\\ntem. An Ayurvedic diet can be a very well planned and\\nindividualized regimen. According to Ayurveda, there\\nare six basic tastes: sweet, sour, salty, pungent, bitter,\\nand astringent. Certain tastes and foods can either\\ncalm or aggravate a particular dosha. For instance,\\nsweet, sour, and salty decrease vata problems and\\nincrease kapha. Sour, salty, and pungent can increase\\npitta. After an Ayurvedic physician determines a per-\\nson’s dosha profile, they will recommend a specific\\ndiet to correct imbalances and increase health. The\\nAyurvedic diet emphasizes primarily vegetarian\\nfoods of high quality and freshness, tailored to the\\nseason and time of day. Cooling foods are eaten in\\nthe summer and heating ones in the winter, always\\nwithin a person’s dosha requirements. In daily routine,\\nthe heaviest meal of the day should be lunch, and\\ndinner should eaten well before bedtime, to allow for\\ncomplete digestion. Also, eating meals in a calm man-\\nner with proper chewing and state of mind is impor-\\ntant, as is combining foods properly and avoiding\\novereating.\\nCost\\nCosts of Ayurvedic treatments can vary, with\\ninitial consultations running anywhere from $40 to\\nover $100, with follow-up visits costing less. Herbal\\ntreatments may cost from $10 to $50 per month, and\\nare often available from health food or bulk herb\\nstores. Some clinics offer panchakarma, the intensive\\nAyurvedic detoxification treatment, which can include\\novernight stays for up to several weeks. The prices for\\nthese programs can vary significantly, depending on\\nthe services and length of stay. Insurance reimburse-\\nment may depend on whether the primary physician is\\na licensed M.D.\\nPreparations\\nAyurveda is a mind/body system of health that\\ncontains some ideas foreign to the Western scien-\\ntific model. Those people considering Ayurveda\\nshould approach it with an open mind and will-\\ningness to experiment. Also, because Ayurveda is a\\nwhole-body system of healing and health, patience\\nand discipline are helpful, as some conditions and\\ndiseases are believed to be brought on by years of\\nbad health habits and require time and effort to\\ncorrect. Finally, the Ayurvedic philosophy believes\\nthat each person has the ability to heal themselves,\\nso those considering Ayurveda should be prepared\\nto bring responsibility and participation into the\\ntreatment.\\nPrecautions\\nAn Ayurvedic practitioner should always be\\nconsulted.\\nSide effects\\nDuring Ayurvedic detoxification programs, some\\npeople report fatigue, muscle soreness, and general\\nsickness. Also, as Ayurveda seeks to release mental\\nstresses and psychological problems from the patient,\\nsome people can experience mental disturbances and\\ndepression during treatment, and psychological coun-\\nseling may be part of a sound program.\\nResearch and general acceptance\\nBecause Ayurveda had been outside the Western\\nscientific system for years, research in the United\\nStates is new. Another difficulty in documentation\\narises because Ayurvedic treatment is very individua-\\nlized; two people with the same disease but different\\ndosha patterns might be treated differently. Much\\nmore scientific research has been conducted over the\\npast several decades in India. Much research in the\\nUnited States is being supported by the Maharishi\\nAyur-Ved organization, which studies the Ayurvedic\\nproducts it sells and its clinical practices.\\nSome Ayurvedic herbal mixtures have been pro-\\nven to have high antioxidant properties, much stron-\\nger than vitamins A, C, and E, and some have also\\nbeen shown in laboratory tests to reduce or eliminate\\ntumors in mice and to inhibitcancer growth in human\\nlung tumor cells. In a 1987 study at MIT, an Ayurvedic\\nherbal remedy was shown to significantly reducecolon\\ncancer in rats. Another study was performed in the\\nNetherlands with Maharishi Ayur-Ved products. A\\ngroup of patients with chronic illnesses, including\\nasthma, chronic bronchitis, hypertension, eczema,\\npsoriasis, constipation, rheumatoid arthritis , head-\\naches, and non-insulin dependent diabetes mellitus,\\nwere given Ayurvedic treatment. Strong results were\\nobserved, with nearly 80% of the patients improving\\nand some chronic conditions being completely cured.\\nOther studies have shown that Ayurvedic therapies\\ncan significantly lower cholesterol and blood pressure in\\nstress-related problems. Diabetes, acne, and allergies\\nhave also been successfully treated with Ayurvedic reme-\\ndies. Ayurvedic products have been shown to increase\\nshort-term memory and reduce headaches. Also,\\nAyurvedic remedies have been used successfully to sup-\\nport the healing process of patients undergoing che-\\nmotherapy, as these remedies have been demonstrated\\nto increase immune system activity.\\n476 GALE ENCYCLOPEDIA OF MEDICINE\\nAyurvedic medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 506, 'page_label': '477'}, page_content='Resources\\nBOOKS\\nLad, Dr. Vasant.The Complete Book of Ayurvedic Home\\nRemedies. Minneapolis: Three Rivers Press, 1999.\\nORGANIZATIONS\\nAmerican Institute of Vedic Studies. P.O. Box 8357, Santa\\nFe, NM 87504. (505) 983-9385\\nAyurveda Holistic Center. Bayville, Long Island, NY.\\n(516)759-7731 mail@Ayurvedahc.com .\\nAyurvedic and Naturopathic Medical Clinic. 10025 NE 4th\\nStreet, Bellevue, WA 98004. (206)453-8022.\\nAyurvedic Institute. 11311 Menaul, NE Albuquerque, New\\nMexico 87112. (505) 291-9698. info@Ayurveda.com\\n.\\nBastyr University of Natural Health Sciences. 144 N.E. 54th\\nStreet, Seattle, WA 98105. (206) 523-9585.\\nCenter for Mind/Body Medicine. P.O. Box 1048, La Jolla,\\nCA 92038. (619)794-2425.\\nCollege of Maharishi Ayur-Ved, Maharishi International\\nUniversity. 1000 4th Street, Fairfield, IA 52557. (515)\\n472-7000.\\nNational Institute of Ayurvedic Medicine. (914) 278-8700.\\ndrgerson@erols.com. .\\nRocky Mountain Institute of Yoga and Ayurveda. P.O. Box\\n1091, Boulder, CO 80306. (303) 443-6923.\\nOTHER\\n‘‘Inside Ayurveda: An Independent Journal of Ayurvedic\\nHealth Care.’’ P.O. Box 3021, Quincy, CA 95971.\\n.\\nDouglas Dupler, MA\\nAzithromycin see Erythromycins\\nAZT see Antiretroviral drugs\\nGALE ENCYCLOPEDIA OF MEDICINE 477\\nAyurvedic medicine'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 507, 'page_label': '478'}, page_content=''),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 508, 'page_label': '479'}, page_content='B\\nB-cell count see Lymphocyte typing\\nBabesiosis\\nDefinition\\nBabesiosis is an infection of red blood cells caused\\nby the single-celled parasite,Babesia microti, which is\\nspread to humans by a tick bite.\\nDescription\\nBabesiosis is a rare, tick-transmitted disease that\\nis caused most often by the single-celled parasite\\nBabesia microti. By 1995, fewer than 500 cases of\\nbabesiosis had been reported in the United States.\\nThe disease occurs primarily in New England and\\nNew York, especially on the coastal islands.\\nHowever, cases have occurred in other parts of the\\nUnited States. Because of tick activity, the risk for\\nbabesiosis is highest during June and July.\\nTicks are small, blood-sucking arachnids.\\nAlthough some ticks carry diseasecausing organisms,\\nmost do not. Babesia microti is spread to humans\\nthrough the bite of the tickIxodes scapularis (also\\ncalled Ixodes dammini). Ixodes scapularis, called the\\n‘‘blacklegged deer tick,’’ usually feeds on deer and\\nmice. A tick picks up the parasites by feeding on an\\ninfected mouse and then passes them on by biting a\\nnew host, possibly a human. To pass on the parasites,\\nthe tick must be attached to the skin for 36-48 hours.\\nOnce in the bloodstream,Babesia microtienters a red\\nblood cell, reproduces by cell division, and destroys\\nthe cell, causing anemia. Humans infected with\\nBabesia microtiproduce antibodies that can be helpful\\nin diagnosing the infection.\\nCauses and symptoms\\nBabesia microti live and divide within red blood\\ncells, destroying the cells and causing anemia. The\\nmajority of people who are infected have no visible\\nsymptoms. In those who become ill, symptoms appear\\none to six weeks following the tick bite. Because the\\nticks are small, many patients have no recollection of a\\ntick bite. The symptoms are flu-like and include tired-\\nness, loss of appetite, fever, drenching sweats, and\\nmuscle pain. Nausea, vomiting, headache, shaking\\nchills, blood in the urine, and depression can occur.\\nPersons who are over 40 years old, have had their\\nspleen removed (splenectomized), and/or have a ser-\\nious disease (cancer, AIDS, etc.) are at a greater risk\\nfor severe babesiosis. In severe cases of babesiosis, up\\nto 85% of the blood cells can be infected. This causes a\\nserious, possibly fatal, blood deficiency.\\nDiagnosis\\nBabesiosis can be diagnosed by examining a blood\\nsample microscopically and detecting the presence of\\nBabesia microtiwithin the blood cells. The blood can\\nalso be checked for the presence of antibodies to the\\nparasite.\\nTreatment\\nIn serious cases, babesiosis is treated with a\\ncombination of clindamycin (Cleocin) and quinine.\\nClindamycin is given by injection and quinine is given\\norally three to four times a day for four to seven days.\\nTo reduce the number of parasites in the blood, severely\\nill patients have been treated with blood transfusions.\\nPrognosis\\nOtherwise healthy patients will recover comple-\\ntely. Babesiosis may last several months without\\nGALE ENCYCLOPEDIA OF MEDICINE 479'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 509, 'page_label': '480'}, page_content='treatment and is a severe, potentially fatal disease in\\nsplenectomized patients.\\nPrevention\\nThe only prevention for babesiosis is to minimize\\nexposure to ticks by staying on trails when walking\\nthrough the woods, avoiding tall grasses, wearing long\\nsleeves and tucking pant legs into socks, wearing insect\\nrepellent, and checking for ticks after an outing.\\nRemove a tick as soon as possible by grasping the\\ntick with tweezers and gently pulling. Splenectomized\\npeople should avoid northeastern coastal regions\\nduring the tick season.\\nResources\\nOTHER\\nMayo Clinic Online.March 5, 1998. .\\nBelinda Rowland, PhD\\nBach flower remedies see Flower remedies\\nBacillary angiomatosis\\nDefinition\\nA life-threatening but curable infection that\\ncauses an eruption of purple lesions on or under the\\nskin that resembleKaposi’s sarcoma. The infection,\\nwhich occurs almost exclusively in patients with\\nAIDS, can be a complication ofcat-scratch disease.\\nDescription\\nBacillary angiomatosis is a re-emerging bacterial\\ninfection that is identical or closely related to one\\nwhich commonly afflicted thousands of soldiers during\\nWorld War I. Today, the disease, caused by two ver-\\nsions of the same bacteria, is linked to homeless AIDS\\npatients and to those afflicted with cat-scratch disease.\\nThe infection is rarely seen today in patients who\\ndon’t have HIV. According to the U.S. Centers for\\nDisease Control and Prevention (CDC), an HIV\\npatient diagnosed with bacillary angiomatosis is con-\\nsidered to have progressed to full-blown AIDS.\\nCauses and symptoms\\nScientists have recently isolated two varieties of\\nthe Bartonella bacteria as the cause of bacillary angio-\\nmatosis: Bartonella (formerly Rochalimaea quintana)\\nand B. henselae(cause of cat-scratch disease).\\nB. quintanainfection is known popularly astrench\\nfever, and is the infection associated with body lice that\\nsickened European troops during World War I. Lice\\ncarry the bacteria, and can transmit the infection to\\nhumans. The incidence of trenchfever was believed to\\nhave faded away with the end of World War I. It was\\nnot diagnosed in the United States until 1992, when 10\\ncases were reported among homeless Seattle men.\\nThe related bacteriaB. henselae was first identi-\\nfied several years ago as the cause of cat-scratch fever.\\nIt also can lead to bacillary angiomatosis in AIDS\\npatients. Bacillary angiomatosis caused by this bac-\\nteria is transmitted to AIDS patients from cat fleas.\\nThese two different types of bacteria both cause\\nbacillary angiomatosis, a disease which is character-\\nized by wildly proliferating blood vessels that form\\ntumor-like masses in the skin and organs. The nodules\\nthat appear in bacillary angiomatosis are firm and\\ndon’t turn white when pressed. The lesions can occur\\nanywhere on the body, in numbers ranging from one\\nto 100. They are rarely found on palms of the hands,\\nsoles of the feet, or in the mouth. As the number of\\nlesions increase, the patient may develop a high fever,\\nsweats, chills, poor appetite,vomiting, and weight loss.\\nIf untreated, the infection may be fatal.\\nIn addition to the basic disease process, the two\\ndifferent types of bacteria cause some slightly different\\nsymptoms. Patients infected with B. henselae also\\nKEY TERMS\\nAnemia— A below normal number of red blood\\ncells in the bloodstream.\\nParasite— An organism that lives upon or within\\nanother organism.\\nKEY TERMS\\nCat-scratch disease— An infectious disease caused\\nby bacteria transmitted by the common cat flea that\\ncauses a self-limiting, mild infection in healthy\\npeople.\\nKaposi’s sarcoma— A malignant condition that\\nbegins as soft brown or purple lesions on the skin\\nthat occurs most often in men with AIDS.\\n480 GALE ENCYCLOPEDIA OF MEDICINE\\nBacillary angiomatosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 510, 'page_label': '481'}, page_content='experience blood-filled cysts within the liver and\\nabnormal liver function, whereasB. quintanapatients\\nmay have tumor growths in the bone.\\nDiagnosis\\nThis life-threatening but curable infection is often\\nmisdiagnosed, because it may be mistaken for other\\nconditions (such as Kaposi’s sarcoma). A blood test\\ndeveloped in 1992 by the CDC detects antibodies to\\nthe bacteria. It can be confirmed by reviewing symp-\\ntoms, history and negative tests for other diseases that\\ncause swollen lymph glands. It isn’t necessary to\\nbiopsy a small sample of the lymph node unless there\\nis a question of cancer of the lymph node or some\\nother disease.\\nTreatment\\nRecent research indicates thatantibiotics used to\\ntreat other HIV opportunistic infections can both pre-\\nvent and treat bacillary angiomatosis. Treatment is\\nusually given until the lesions disappear, which typi-\\ncally takes three or four weeks. A severely affected\\nlymph node or blister may have to be drained, and a\\nheating pad may help swollen, tender lymph glands.\\nAcetaminophen (Tylenol) may relievepain, aches, and\\nfever over 1018F (38.38C).\\nPrognosis\\nIn most cases, prompt antibiotic treatment in\\npatients with AIDS cured the infection caused by\\neither variety of the bacteria, and patients may resume\\nnormal life. Early diagnosis is crucial to a cure.\\nPrevention\\nStudies suggest that antibiotics may prevent\\nthe disease. Patients also should be sure to treat cats\\nfor fleas.\\nResources\\nPERIODICALS\\nKoehler, J. E. ‘‘Zoonoses: Cats, Fleas and Bacteria.’’\\nJournal of the American Medical Association271 (1994):\\n531-535.\\nCarol A. Turkington\\nBacillary dysentery see Shigellosis\\nBacitracin see Antibiotics, topical\\nBacteremia\\nDefinition\\nBacteremia is an invasion of the bloodstream by\\nbacteria.\\nDescription\\nBacteremia occurs when bacteria enter the\\nbloodstream. This may occur through a wound or\\ninfection, or through a surgical procedure or injec-\\ntion. Bacteremia may cause no symptoms and resolve\\nwithout treatment, or it may producefever and other\\nsymptoms of infection. In some cases, bacteremia\\nleads to septic shock, a potentially life-threatening\\ncondition.\\nCauses and symptoms\\nCauses\\nSeveral types of bacteria live on the surface of the\\nskin or colonize the moist linings of the urinary tract,\\nlower digestive tract, and other internal surfaces. These\\nbacteria are normally harmless as long as they are kept\\nin check by the body’s natural barriers and the immune\\nsystem. People in good health with strong immune\\nsystems rarely develop bacteremia. However, when\\nbacteria are introduced directly into the circulatory\\nsystem, especially in a person who is ill or undergoing\\naggressive medical treatment, the immune system may\\nnot be able to cope with the invasion, and symptoms of\\nbacteremia may develop. For this reason, bacteremia is\\nmost common in people who are already affected by or\\nbeing treated for some other medical problem. In addi-\\ntion, medical treatment may bring a person in contact\\nwith new types of bacteria that are more invasive than\\nthose already residing in that person’s body, further\\nincreasing the likelihood of bacterial infection.\\nConditions which increase the chances of devel-\\noping bacteremia include:\\n/C15immune suppression, either due to HIV infection or\\ndrug therapy\\n/C15antibiotic therapy which changes the balance of bac-\\nterial types in the body\\n/C15prolonged or severe illness\\n/C15alcoholism or other drugabuse\\n/C15malnutrition\\n/C15diseases or drug therapy that cause ulcers in the\\nintestines, e.g.chemotherapy for cancer\\nGALE ENCYCLOPEDIA OF MEDICINE 481\\nBacteremia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 511, 'page_label': '482'}, page_content='Common immediate causes of bacteremia include:\\n/C15drainage of anabscess, including an abscessed tooth\\n/C15urinary tract infection, especially in the presence of a\\nbladder catheter\\n/C15decubitus ulcers (pressure sores)\\n/C15intravenous procedures using unsterilized needles,\\nincluding IV drug use\\n/C15prolonged IV needle placement\\n/C15use ofostomy tubes, includinggastrostomy(surgically\\nmaking a new opening into the stomach), jejunostomy\\n(surgically making an opening from the abdominal\\nwall into the jejunum), and colostomy (surgically\\ncreating an articifical opening into the colon).\\nThe bacteria most likely to cause bacteremia include\\nmembers of the Staphylococcus, Streptococcus,\\nPseudomonas,Haemophilus,and Esherichia coli(E. coli)\\ngenera.\\nSymptoms\\nSymptoms of bacteremia may include:\\n/C15fever over 1018F (38.38C)\\n/C15chills\\n/C15malaise\\n/C15abdominal pain\\n/C15nausea\\n/C15vomiting\\n/C15diarrhea\\n/C15anxiety\\n/C15shortness of breath\\n/C15confusion\\nNot all of these symptoms are usually present. In\\nthe elderly, confusion may be the only prominent symp-\\ntom. Bacteremia may lead toseptic shock, whose symp-\\ntoms include decreased consciousness, rapid heart and\\nbreathing rates and multiple organ failures.\\nDiagnosis\\nBacteremia is diagnosed by culturing the blood\\nfor bacteria. Samples may need to be tested several\\ntimes over several hours. Blood analysis may also\\nreveal an elevated number of white blood cells.\\nBlood pressure is monitored closely; a decline in\\nblood pressure may indicate the onset of septicshock.\\nTreatment\\nBacteremia may cause no symptoms, but may be\\ndiscovered through a blood test for another condition.\\nIn this situation, it may not need to be treated, except\\nin patients especially at risk for infection, such as those\\nwith heart valve defects or whose immune systems are\\nsuppressed.\\nPrognosis\\nPrompt antibiotic therapy usually succeeds in clear-\\ning bacteria from the bloodstream. Recurrence may\\nindicate an undiscovered site of infection. Untreated\\nbacteria in the blood may spread, causing infection of\\nthe heart (endocarditisor pericarditis) or infection of the\\ncovering of the central nervous system (meningitis).\\nPrevention\\nBacteremia can be prevented by preventing the\\ninfections which often precede it. Good personal\\nhygiene, especially during viral illness, may reduce the\\nrisk of developing bacterial infection. Treating bacterial\\ninfections quickly and thoroughly can minimize the risk\\nof spreading infection. During medical procedures, the\\nburden falls on medical professionals to minimize the\\nnumber and duration of invasive procedures, to reduce\\npatients’ exposure to sources of bacteria when being\\ntreated, and to use scrupulous technique.\\nResources\\nOTHER\\nThe Merck Page.April 13, 1998. .\\nRichard Robinson\\nBacterial meningitis see Meningitis\\nKEY TERMS\\nColostomy— Surgical creation of an artificial anus\\non the abdominal wall by cutting into the colon and\\nbringing it up to the surface.\\nGastrostomy— Surgical creation of an artificial\\nopening into the stomach through the abdominal\\nwall to allow tube feeding.\\nJejunostomy— Surgical creation of an opening to\\nthe middle portion of the small intestine (jejunum),\\nthrough the abdominal wall.\\nSeptic shock— A life-threatening drop in blood\\npressure caused by bacterial infection.\\n482 GALE ENCYCLOPEDIA OF MEDICINE\\nBacteremia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 512, 'page_label': '483'}, page_content='Bacterial vaginosis\\nDefinition\\nBacterial vaginosis (BV) is a type of vaginal infec-\\ntion in which the normal balance of bacteria in the\\nvagina is disrupted, allowing the overgrowth of harmful\\nanaerobic bacteria at the expense of protective bacteria.\\nDescription\\nBV is the most, common and the most serious type\\nof vaginal infection in women of childbearing age. As\\nmany as 10 to 26 percent of pregnant women in the\\nUnited States have BV; BV has been found in 12 to 25\\npercent of women in routine clinic populations, and in 32\\nto 64 percent of women in clinics forsexually transmitted\\ndiseases(STDs). BV is different than vaginal yeast infec-\\ntions and requires different methods of treatment.\\nIn most cases, BV does not have lasting effects on\\nwomen. However, there can be risks associated with BV:\\nCauses and symptoms\\nBacteria that dominate the vaginal flora in a BV\\ninfection includeGardnerella vaginalisor Mobiluncus,\\nalthough other bacteria, such asEscherichia colifrom\\nthe rectum have also been shown to cause the disease.\\nThe overgrowth of these harmful bacteria are at the\\nexpense of the protective bacteria lactobacilli, which\\nsecrete a natural disinfectant, hydrogen peroxide, that\\nmaintains the healthy, normal balance of vaginal\\nmicroorganisms. The factors that upset the normal\\nbalance of bacteria in the vagina are not well-under-\\nstood; however, the following activities or behaviors\\nthat have been associated with BV include:\\n/C15having a new sex partner or multiple sex partners\\n/C15stress\\n/C15douching\\n/C15using an intrauterine device (IUD) for contraception\\nBV is not transmitted through toilet seats, bed-\\nding, swimming pools, or touching of objects. Women\\nwho have not had sexual intercourse rarely have BV.\\nHowever BV is not considered an STD, although it\\ndoes appear to act like an STD in women who have sex\\nwith women.\\nThe main symptom of BV is a thin, watery or\\nfoamy, white (milky) or gray vaginal discharge with\\nan unpleasant, foul, fish-like or musty odor. The odor\\nis sometimes stronger after a woman has sex, when the\\nsemen mixes with the vaginal secretions. Burning or\\npain during urination can also be present with BV.\\nItching on the outside of the vagina and redness can\\nalso occur, but are seen less frequently. However,\\nmany women with BV do not exhibit any symptoms.\\nDiagnosis\\nBV is diagnosed through a examination of the\\nvagina by a health care provider. A woman who sus-\\npects that she may have BV should not douche or use a\\nfeminine hygiene spray before the appointment with\\nthe health care provider. Laboratory tests are con-\\nducted on a sample of the vaginal fluid to see if the\\nbacteria present are those associated with BV. The\\nhealth care provider may also check to see if there is\\ndecreased vaginal acidity. Potassium hydroxide, when\\nadded to a vaginal discharge sample, enhances vaginal\\nodors and allows the health care provider to determine\\nif the odor is fishy or foul.\\nTreatment\\nIn a few cases, BV might clear up without treat-\\nment. However, all women with symptoms of BV\\nshould be treated to relieve symptoms and to avoid\\nthe development of complications such as pelvic inflam-\\nmatory disease (PID). In most cases, male partners are\\nnot treated, but female sexual partners should be exam-\\nined to see if they have BV and require treatment.\\nBV is treated with prescriptionantibiotics such as\\nmetronidazole or clindamycin creams or oral metronida-\\nzole (both are antibiotics that can also be used by preg-\\nnantwomen,althoughatdifferentdoses).Metronidazole\\nkills anaerobic bacteria but does not harm the protective\\nlactobacilli. Drinking alcohol should be avoided when\\ntaking metronidazole, for this medicine can cause severe\\nnausea and vomitingwhen combined with alcohol.\\nFor postmenopausal women, in addition to the\\nuse of antibiotics, the health care provider may also\\nprescribe estrogen suppositories or topical cream to\\nthicken and lubricate vaginal tissues. Sexual activity\\nshould be avoided during treatment; acondom should\\nbe used if the woman does have sexual intercourse.\\nKEY TERMS\\nAnaerobic bacteria— Bacteria that do not require\\noxgyen, found in low concentrations in the normal\\nvagina\\nVaginal discharge— discharge of secretions from the\\ncervical glands of the vagina; normally clear or white\\nGALE ENCYCLOPEDIA OF MEDICINE 483\\nBacterial vaginosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 513, 'page_label': '484'}, page_content='The woman should be tested after treatment to ensure\\nthat the infection has been cured.\\nAlternative treatment\\nSupplement therapies are available in addition to\\nthe use of prescription medicines to ease recovery.\\nHerbal therapies\\nFresh garlic (Allium sativum) has antibacterial\\nproperties and can be added to a woman’s diet. A\\nfresh, peeled garlic wrapped in gauze can also be\\ninserted into the vagina to help treat BV. The insert\\nshould be changed twice daily.\\nTo soothe itching or irritation of the vaginal tis-\\nsues, a woman can bathe the tissues in an infusion of\\nfresh chickweed (Stellaria media). The infusion is\\nmade by pouring one cup of boiling water on one to\\ntwo teaspoons of the herb, steeping for five minutes,\\nand allowing the mixture to cool before use.\\nPrognosis\\n/C15Pre gn an twome nwithB Vofte nh av eb ab ieso flo wbirth\\nweight (less than 5.5 pounds) or who are premature\\n/C15Bacteria that cause BV may also causepelvic inflam-\\nmatory disease(PID), an infection of the uterus and\\nfallopian tubes. The risk of a woman with BV devel-\\noping PID is higher after the woman undergoes sur-\\ngical procedures such as a hysterectomy or an\\nabortion. PID can result ininfertility and can also\\nincrease the risk of an ectopic pregnancy\\n/C15BV may increase the risk of a woman becoming\\ninfected with HIV, the virus that causes AIDS\\n/C15A woman with BV and HIV is more likely to pass\\nHIV to her sexual partner\\n/C15BV increases the chance that a woman will contract\\nother STDs, such as chlamydia and gonorrhea\\nBV can be successfully treated with antibiotics.\\n/C15practicing abstinence\\n/C15delaying having sex for the first time, as younger\\npeople who have sex are more likely to contract BV\\nand STDs\\n/C15limiting the number of sexual partners\\n/C15having a sexual relationship with only one partner\\nwho does not have an STD\\n/C15practicing safer sex, which means using a condom\\nevery time when having sex\\nPrevention\\nSince the development of BV often appears to be\\nassociated with sexual activities, recommended ways\\nto avoid BV include:\\nOther ways to prevent BV include:\\n/C15discontinuing the use of tampons for six months\\n/C15practicing good hygiene by wiping from front to\\nback (away from the vagina) after bowel movements\\nto avoid spreading bacteria from the rectum to the\\nvagina\\n/C15wearing cotton panties and panty-hose with a cotton\\ncrotch and avoiding tight or latex clothing to keep\\nthe vagina cool and dry\\n/C15avoiding the use of perfumed soaps and feminine\\nsprays\\n/C15lowering stress levels\\n/C15avoiding douching, as douching removes some of the\\nnormal bacteria in the vagina that protects women\\nfrom infection\\n/C15finishing the course of antibiotic treatment, even if\\nthe symptoms are relieved, to prevent reoccurrence\\nof the disease\\n/C15routinely being tested for BV during regular gyneco-\\nlogical examinations\\nSome physicians recommend that all women who\\nhave a hysterectomy or an abortion be treated for BV,\\nto reduce the risk of developing PID.\\nResources\\nBOOKS\\nIcon Health Publications.Bacterial Vaginosis - a Medical\\nDictionary, Bibliography, and Annotated Research Guide\\nto Internet References.San Diego, CA: Icon Health\\nPublications, 2003.\\nParker, James N. and Parker, Philip M., editors.The Official\\nPatient’s Sourcebook on Vaginitis.San Diego, CA: Icon\\nHealth Publications, 2002.\\nParker, James N. and Parker, Philip M., editors.The Official\\nPatient’s Sourcebook on Bacterial Vaginosis.San Diego,\\nCA: Icon Health Publications, 2003.\\nTime-Life Books.Vaginal Problems The Medical Advisor..\\nRichmond, VA: Time-Life Books, 1996.\\nPERIODICALS\\nORGANIZATIONS\\nAmerican Social Health Association, P.O. Box 13827,\\nResearch Triangle Park, NC 27709. Telephone: (919)\\n361-8400; Fax: (919) 361-8425; Web site: http://\\nwww.ashastd.org/.\\n484\\nGALE ENCYCLOPEDIA OF MEDICINE\\nBacterial vaginosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 514, 'page_label': '485'}, page_content='3M National Vaginitis Association. 3M Center, 275-3W-01,\\nP.O. Box 33275 Saint Paul, MN 55133-3275. Website:\\nwww3.3m.com/pdas-nva/\\nNational Women’s Health Information Center. U.S.\\nDepartment of Health and Human Services. Telephone:\\n(800) 994-9662: Website: www.4woman.gov\\nOTHER\\n3M National Vaginitis Association.Women’s Guide to\\nVaginal Infections.Brochure available for download:\\nwww3.3m.com/pdas-nva/cons_addresources.html\\nJudith Sims\\nBacteroides infection see Anaerobic\\ninfections\\nBad breath\\nDefinition\\nBad breath, sometimes called halitosis, is an\\nunpleasant odor of the breath.\\nDescription\\nBad breath is likely to be experienced by most\\nadults at least occasionally. Bad breath, either real or\\nimagined, can have a significant impact on a person’s\\nsocial and professional life.\\nCauses and symptoms\\nBad breath can be caused by a number of pro-\\nblems. Oral diseases, fermentation of food particles in\\nthe mouth, sinus infections, and unclean dentures can\\nall contribute to mouth odor. Many non-oral diseases,\\nsuch as lung infections, kidney failure, or severeliver\\ndisease, can also cause bad breath, though rarely.\\nMany people think that bad breath can originate in\\nthe stomach or intestines; this is extremely rare. The\\nesophagus is usually collapsed and closed, and,\\nalthough a belch may carry odor up from the stomach,\\nthe chance of bad breath being caused from air con-\\ntinually escaping from the stomach is remote.\\nCigarette smoke can cause bad breath, not only in\\nthe cigarette smoker, but also in one who is constantly\\nexposed to second-hand smoke.\\nDiagnosis\\nThe easiest way to determine if one has bad breath\\nis to ask someone who is trustworthy and discrete.\\nThis is usually not too difficult. Another, more pri-\\nvate, method of determining if one has bad breath is to\\nlick one’s wrist, wait until it dries, then smell the area.\\nScraping the rear area of the tongue with a plastic\\nspoon, then smelling the spoon, is another method\\none can use to assess bad breath.\\nTreatment\\nThe most effective treatment of bad breath is to\\ntreat the cause. Poor oral hygiene can be improved by\\nregular brushing and flossing, as well as regular dental\\ncheckups. Gentle brushing of the tongue should be\\npart of dailyoral hygiene. In addition to good oral\\nhygiene, the judicious use of mouthwashes is helpful.\\nMouth dryness, experienced at night or duringfasting,\\nor due to certain medications and medical conditions,\\ncan contribute to bad breath. Dryness can be avoided\\nby drinking adequate amounts of water. Chewing gum\\nmay be beneficial.\\nAs mentioned, some medications, such as some\\nhigh blood pressure medications, can cause dry mouth.\\nIf this problem is significant, a medication change, under\\nthe supervision of one’s health care provider, may\\nimprove the dry-mouth condition. Oral or sinus infec-\\ntions, once diagnosed, can be treated medically, usually\\nwith antibiotics. Lung infections and kidney or liver\\nproblems will, of course, need medical treatment.\\nAlternative treatment\\nDepending on the cause, a multitude of alterna-\\ntive therapeutic remedies can be used. For example,\\nsinusitis can be treated with steam inhalation of essen-\\ntial oils and/or herbs.\\nPrognosis\\nMost bad breath can be treated successfully with\\ngood oral hygiene and/or medical care. Occasionally,\\nfor patients who feel that these therapies are unsuccessful,\\nsome delusional or obsessivebehavior pattern might per-\\ntain, and mental health counseling may be appropriate.\\nResources\\nORGANIZATIONS\\nAmerican Dental Association. 211 E. Chicago Ave., Chicago,\\nIL 60611. (312) 440-2500. .\\nKEY TERMS\\nHalitosis— The medical term for bad breath.\\nGALE ENCYCLOPEDIA OF MEDICINE 485\\nBad breath'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 515, 'page_label': '486'}, page_content='American Medical Association. 515 N. State St., Chicago, IL\\n60612. (312) 464-5000. .\\nJoseph Knight, PA\\nBalance and coordination tests\\nDefinition\\nBalance is the ability to maintain a position.\\nCoordination is the capacity to move through a complex\\nset of movements. Balance and coordination depend on\\nthe interaction of multiple body organs and systems\\nincluding the eyes, ears, brain and nervous system, car-\\ndiovascular system, and muscles. Tests or examination\\nof any or all of these organs or systems may be necessary\\nto determine the causes of loss of balance,dizziness,o r\\nthe inability to coordinate movement or activities.\\nPurpose\\nTests of balance and coordination, and the exam-\\nination of the organs and systems that influence\\nbalance and coordination, can help to identify causes\\nof dizziness,fainting, falling, or incoordination.\\nPrecautions\\nTests for balance and coordination should be con-\\nducted in a safe and controlled area where patients will\\nnot experience injury if they become dizzy or fall.\\nDescription\\nAssessment of balance and coordination can\\ninclude discussion of the patient’s medical history and\\nac o m p l e t ephysical examinationincluding evaluation of\\nthe heart, head, eyes, and ears. A slow pulse or heart\\nrate, or very low blood pressure may indicate a circula-\\ntory system problem, which can cause dizziness or faint-\\ning. During the examination, the patient may be asked\\nto rotate the head from side to side while sitting up or\\nwhile lying down with the head and neck extended over\\nthe edge of the examination table. If these tests produce\\ndizziness or a rapid twitching of the eyeballs (nystag-\\nmus), the patient may have a disorder of the inner ear,\\nwhich is responsible for maintaining balance.\\nAn examination of the eyes and ears may also give\\nclues to episodes of dizziness or incoordination. The\\npatient may be asked to focus on a light or on a distant\\npoint or object, and to look up, down, left, and right\\nmoving only the eyes while the eyes are examined.\\nProblems with vision may, in themselves, contribute\\nto balance and coordination disturbances, or may\\nindicate more serious problems of the nervous system\\nor brain function.Hearing loss, fluid in the inner ear,\\nor ear infection might indicate the cause of balance\\nand coordination problems.\\nVarious physical tests may also be used. A patient\\nmay be asked to walk a straight line, stand on one foot,\\nor touch a finger to the nose to help assess balance.\\nThe patient may be asked to squeeze or push against\\nthe doctor’s hands, to squat down, to bend over, stand\\non tiptoes or stand on their heels. Important aspects of\\nthese tests include holding positions for a certain num-\\nber of seconds, successfully repeating movements a\\ncertain number of times, and repeating the test accu-\\nrately with eyes closed. The patient’s reflexes may also\\nbe tested. For example, the doctor may tap on the\\nA patient sits on a ball, working on his balance. He wears a\\nbelt so that the physical therapist can catch him if he loses\\nbalance. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\n486 GALE ENCYCLOPEDIA OF MEDICINE\\nBalance and coordination tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 516, 'page_label': '487'}, page_content='knees, ankles, and elbows with a small rubber mallet to\\ntest nervous system functioning. These tests may\\nreveal muscle weakness or nervous system problems\\nthat could contribute to incoordination.\\nPreparation\\nNo special preparation is required prior to admin-\\nistration of balance and coordination tests. The\\npatient may be asked to disrobe and put on an exam-\\nination gown to make it easier for the doctor to\\nobserve muscles and reflex responses.\\nAftercare\\nNo special aftercare is generally required, however,\\nsome of the tests may cause episodes of dizziness or\\nincoordination. Patients may need to use caution in\\nreturning to normal activities if they are experiencing\\nanysymptomsofdizziness,lightheadedness,orweakness.\\nRisks\\nThese simple tests of balance and coordination are\\ngenerally harmless.\\nNormal results\\nUnder normal conditions, these test will not cause\\ndizziness, loss of balance, or incoordination.\\nAbnormal results\\nThe presence of dizziness, lightheadedness, loss of\\ncoordination, unusual eye movements, muscle weak-\\nness, or impaired reflexes are abnormal results and\\nmay indicate the problem causing the loss of balance\\nor incoordination. In some cases, additional testing\\nmay be needed to diagnose the cause of balance or\\ncoordination problems.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Otolaryngology-Head and Neck\\nSurgery, Inc. One Prince St., Alexandria VA 22314-\\n3357. (703) 836-4444. .\\nEar Foundation. 1817 Patterson St., Nashville, TN 37203.\\n(800) 545-4327. .\\nVestibular Disorders Association (VEDA). P.O. Box 4467,\\nPortland, OR 97208-4467. (800) 837-8428 or (503) 229-\\n7705. Fax: (503) 229-8064.\\nAltha Roberts Edgren\\nBalanitis\\nDefinition\\nBalanitis is an inflammation of the head and fore-\\nskin of the penis.\\nDescription\\nBalanitis generally affects uncircumcised males.\\nThese are men who have a foreskin, which is the\\n‘‘hood’’ of soft skin that partially covers the head of\\nthe penis. In balanitis, the head and foreskin become\\nred and inflamed. (In circumcised men, who lack a\\nforeskin, these symptoms only affect the tip of the\\npenis.) The condition often occurs due to the fungus\\nCandida albicans, the same organism that causes vagi-\\nnal yeast infections in women. Balanitis (which is also\\nreferred to as balanoposthitis) can be caused by a\\nvariety of other fungal or bacterial infections, or may\\noccur due to a sensitivity reaction to common chemi-\\ncal agents.\\nUncircumcised men are more at risk for balanitis\\ndue to the presence of the foreskin. The snug fit of the\\nforeskin around the top of the penis tends to create a\\ndamp, warm environment that encourages the growth\\nof microorganisms. Most of the organisms associated\\nwith balanitis are already present on the penis, but in\\nvery small numbers. However, if the area between the\\nhead and foreskin is not cleansed thoroughly on a\\nregular basis, these organisms can multiply and lead\\nto infection.\\nDiabetes can increase the risk of developing the\\ncondition.\\nCauses and symptoms\\nBalanitis is usually a result of poor hygiene—for\\nexample, neglecting to bathe for several days. A failure\\nto properly wash (or rinse) the area between the head and\\nforeskin can lead to the development of fungal or bacter-\\nial infections that cause the condition. In other cases,\\nbalanitis may occur due to an allergic reaction: Some\\nKEY TERMS\\nMeniere’s disease—An abnormality of the inner ear\\nthat causes dizziness, ringing in the ears, and hear-\\ning loss.\\nGALE ENCYCLOPEDIA OF MEDICINE 487\\nBalanitis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 517, 'page_label': '488'}, page_content='men may be sensitive to chemicals found in harsh soaps,\\nlaundry detergents, or contraceptive creams. Men who\\ncontract a sexually transmitted disease (STD) such as\\ntrichimoniasis may also develop symptoms.\\nThe symptoms of balanitis are limited to the fore-\\nskin and head of the penis (in circumcised men, only\\nthe head is affected). These include redness, inflamma-\\ntion, pain, discharge, sore or itchy skin, and difficulty\\nretracting the foreskin.\\nDiagnosis\\nBalanitis is usually diagnosed based on a brief\\nphysical examination. This may be conducted by\\nyour regular health care provider or by a urologist,\\nthe type of doctor who specializes in such disorders.\\nThe doctor may take a sample of the discharge (if any)\\nto determine the nature of the possible infection. A\\nurine test may be recommended to evaluate glucose\\n(sugar) levels in the urine. Balanitis treatment is typi-\\ncally covered by medical insurance.\\nTreatment\\nThe treatment of balanitis depends on the specific\\ncause, which can vary from case to case. Antibiotics are\\nused to treat bacterial infections, while topical antifun-\\ngals such as clotrimazole can combat balanitis caused by\\nCandida. If an allergic reaction is causing symptoms, the\\ngoal is to identify the chemical agent responsible.\\nOintments or creams may be used to ease skin irritation.\\nNo matter what the cause, it is important to thor-\\noughly clean the penis on a daily basis in order to\\nalleviate symptoms. If the condition keeps occurring,\\nor if the inflammation is interfering with urination,\\ncircumcision may be advised.\\nAlternative treatment\\nAccording to practitioners of alternative medi-\\ncine, certain herbs may be effective in controlling or\\npreventing yeast infections–a common cause of bala-\\nnitis. These remedies include garlic, calendula, and\\ngoldenseal. Eating yogurt that contains acidophilus\\nmay also help to clear up aCandida infection.\\nPrognosis\\nMost cases go away quickly once the cause is\\nidentified and treated. However, regular bouts of bala-\\nnitis can result in urethral stricture.\\nPrevention\\nProper hygiene is the best way to avoid balanitis.\\nCircumcision is sometimes performed to prevent\\nrepeated cases.\\nResources\\nBOOKS\\nTierney, Lawrence M., et al.Current Medical Diagnosis and\\nTreatment. McGraw-Hill, 2000.\\nPERIODICALS\\nMayser, P. ‘‘Mycotic infections of the penis.’’Andrologia 31\\nSupplement 1 (1999): 13-6.\\nORGANIZATIONS\\nU.S. National Library of Medicine. 8600 Rockville Pike,\\nBethesda, MD 20894. (888) 346-3656. .\\nGreg Annussek\\nBalantidiasis\\nDefinition\\nBalantidiasis is an infectious disease produced by\\na single-celled microorganism (protozoan) called\\nBalantidium coli that infects the digestive tract. It is\\nprimarily a disease of the tropics, although it is also\\nfound in cooler, temperate climates. Most persons\\nwith balantidiasis do not exhibit any noticeable symp-\\ntoms (asymptomatic), but a few individuals will\\ndevelop diarrhea with blood and mucus and an\\ninflamed colon (colitis).\\nDescription\\nBalantidiasis is caused byBalantidium coli, a para-\\nsitic protozoan that infects the large intestine.B. coliis\\nthe largest and only protozoan, having cilia or hair-\\nlike structures, that is capable of causing disease in\\nKEY TERMS\\nAcidophilus— A bacteria believed to combat yeast\\ninfections.\\nCircumcision— The surgical removal of the\\nforeskin.\\nUrethral stricture— A narrowing of the urethra\\n(urine tube).\\n488 GALE ENCYCLOPEDIA OF MEDICINE\\nBalantidiasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 518, 'page_label': '489'}, page_content='humans. Balantidiasis occurs most commonly in areas\\nwith poor sanitation and in settings where humans live\\nin close contact with pigs, sheep, or goats.\\nCauses and symptoms\\nBalantidiasis is transmitted primarily by eating food\\nor drinking water that has been contaminated by human\\nor animal feces containingB. colicysts. During its life\\ncycle, this organism exists in two very different forms: the\\ninfective cyst or capsuled form, which cannot move but\\ncan survive outside the human body because of its thick,\\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. In the digestive tract, the cysts are trans-\\nported to the intestine where the walls of the cysts are\\nbroken open by digestive secretions, releasing the mobile\\ntrophozoites. Once released within the intestine, the tro-\\nphozoites multiply by feeding on intestinal bacteria or by\\ninvadingtheliningof the largeintestine.Within the lining\\nof the largeintestine, the trophozoites secrete a substance\\nthat destroys intestinal tissue and creates sores (ulcers) or\\nabscesses. Trophozoites eventually form new cysts that\\nare carried through the digestive tract and excreted in the\\nfeces. Under favorable temperature and humidity condi-\\ntions, the cysts can survive in soil or water for weeks to\\nmonths, ready to begin the cycle again.\\nMost individuals with balantidiasis have no\\nnoticeable symptoms. Even though these individuals\\nmay not feel ill, they are still capable of infecting\\nothers by person-to-person contact or by contaminat-\\ning food or water with cysts that others may ingest, for\\nexample, by preparing food with unwashed hands.\\nThe most common symptoms of balantidiasis are\\nchronic diarrhea or severe colitis with abdominal\\ncramps, pain, and bloody stools. Complications may\\ninclude intestinal perforation in which the intestinal\\nwall becomes torn, but the organisms do not spread to\\nother parts of the body in the blood stream.\\nDiagnosis\\nDiagnosis of balantidiasis, as with other similar\\ndiseases, can be complicated, partly because symp-\\ntoms may or may not be present. A diagnosis of\\nbalantidiasis may be considered when a patient has\\ndiarrhea combined with a possible history of recent\\nexposure to amebiasis through travel, contact with\\ninfected persons, or anal intercourse.\\nSpecifically, a diagnosis of balantidiasis is made\\nby findingB. colicysts or trophozoites in the patient’s\\nstools or by finding trophozoites in tissue samples\\n(biopsy) taken from the large bowel. A diagnostic\\nblood test has not yet been developed.\\nStool examination\\nThis test involves microscopically examining a\\nstool sample for the presence of cysts and/or tropho-\\nzoites ofB. coli.\\nSigmoidoscopy\\nTo take a tissue sample from the large intestine, a\\nprocedure called a sigmoidoscopy is performed.\\nDuring a sigmoidoscopy, a thin, flexible instrument\\nis used to visually examine the intestinal lining and\\nobtain small tissue specimens.\\nTreatment\\nPatients with balantidiasis are treated with pre-\\nscription medication, typically consisting of a ten day\\ncourse of either tetracycline or metronidazole.\\nAlternative drugs that have proven effective in treat-\\ning balantidiasis include iodoquinol or paromomycin.\\nPrognosis\\nAlthough somewhat dependent on the patient’s\\noverall health, in general, the prognosis for most\\nKEY TERMS\\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.\\nBiopsy— The removal of a tissue sample for diag-\\nnostic purposes.\\nCiliated— Covered with short, hair-like protru-\\nsions, like B. coli and certain other protozoa. The\\ncilia or hairs help the organism to move.\\nColitis— An inflammation of the large intestine that\\noccurs in some cases of balantidiasis. It is marked\\nby cramping pain and the passing of bloody mucus.\\nProtozoan— A single-celled, usually microscopic\\norganism, such as B. coli, that is eukaryotic and,\\ntherefore, different from bacteria (prokaryotic).\\nSigmoidoscopy— A procedure in which a thin, flex-\\nible, lighted instrument, called a sigmoidoscope, is\\nused to visually examine the lower part of the large\\nintestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 489\\nBalantidiasis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 519, 'page_label': '490'}, page_content='patients with balantidiasis is good. Severely infected\\npatients occasionally die as a result of a tear in the\\nintestinal wall (intestinal perforation) and consequent\\nloss of blood.\\nPrevention\\nThere are no immunization procedures or medica-\\ntions that can be taken prior to potential exposure to\\nprevent balantidiasis. Moreover, people who have had\\nthe disease can become reinfected. Prevention requires\\neffective personal and community hygiene. Specific\\nsafeguards include the following:\\n/C15Purification of drinking water. Water can be purified\\nby filtering, boiling, or treatment with iodine.\\n/C15Proper food handling. Measures include protecting\\nfood from contamination by flies, cooking food\\nproperly, washing one’s hands after using the bath-\\nroom and before cooking or eating, and avoiding\\nfoods that cannot be cooked or peeled when travel-\\ning in countries with high rates of balantidiasis.\\n/C15Careful disposal of human feces.\\n/C15Monitoring the contacts of balantidiasis patients.\\nThe stools of family members and sexual partners\\nof infected persons should be tested for the presence\\nof cysts or trophozoites.\\nResources\\nBOOKS\\nGoldsmith, Robert S. ‘‘Infectious Diseases: Protozoal &\\nHelminthic.’’ InCurrent Medical Diagnosis and\\nTreatment, 1998, edited by Stephen McPhee, et al., 37th\\ned. Stamford: Appleton & Lange, 1997.\\nRebecca J. Frey, PhD\\nBaldness see Alopecia\\nBalloon angioplasty see Angioplasty\\nBalloon valvuloplasty\\nDefinition\\nBalloon valvuloplasty is a procedure in which a\\nnarrowed heart valve is stretched open using a proce-\\ndure that does not require open heart surgery.\\nPurpose\\nThere are four valves in the heart, which are\\nlocated at the exit of each of the four chambers of\\nthe heart. They are called aortic valve, pulmonary\\nvalve, mitral valve, and tricuspid valve. The valves\\nopen and close to regulate the blood flow from one\\nchamber to the next. They are vital to the efficient\\nfunctioning of the heart.\\nIn some people the valves are too narrow (a con-\\ndition called stenosis). Balloon valvuloplasty is per-\\nformed on children and adults to improve valve\\nfunction and blood flow by enlarging the valve open-\\ning. It is a treatment for aortic, mitral, and pulmonary\\nstenosis. Balloon valvuloplasty has the best results as a\\ntreatment for narrowed pulmonary valves. Results in\\ntreating narrowing of the mitral valve are generally\\ngood. It is more difficult to perform and less successful\\nin treating narrowing of the aortic valve.\\nDescription\\nBalloon valvuloplasty is a procedure in which a\\nthin tube (catheter) that has a small deflated balloon at\\nthe tip is inserted through the skin in the groin area\\ninto a blood vessel, and then is threaded up to the\\nopening of the narrowed heart valve. The balloon is\\ninflated, which stretches the valve open. This proce-\\ndure cures many valve obstructions. It is also called\\nballoon enlargement of a narrowed heart valve.\\nThe procedure is performed in a cardiac catheteriza-\\ntion laboratory and takes up to four hours. The patient is\\nusually awake, but is givenlocal anesthesiato make the\\narea where the catheter is inserted numb. After the site\\nwhere the catheter will be inserted is prepared and\\nanesthetized, the cardiologist inserts a catheter into the\\nappropriate blood vessel, then passes a balloon-tipped\\nKEY TERMS\\nCardiac catheterization— A technique used to\\nevaluate the heart and fix certain problems.\\nCatheterization is far less invasive than traditional\\nsurgery.\\nStenosis— The narrowing of any valve, especially\\none of the heart valves or the opening into the\\npulmonary artery from the right ventricle.\\nValve— Tissue in the passageways between the\\nheart’s upper and lower chambers that controls\\npassage of blood and prevents regurgitation.\\n490 GALE ENCYCLOPEDIA OF MEDICINE\\nBalloon valvuloplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 520, 'page_label': '491'}, page_content='catheter through the first catheter. Guided by a video\\nmonitor and an x ray, the physician slowly threads the\\ncatheter into the heart. The deflated balloon is posi-\\ntioned in the valve opening, then is inflated repeatedly.\\nThe inflated balloon widens the valve’s opening by split-\\nting the valve leaflets apart. Once the valve is widened,\\nthe balloon-tipped catheter is removed. The other cathe-\\nter remains in place for 6 to 12 hours because in some\\ncases the procedure must be repeated.\\nPreparation\\nFor at least six hours before balloon valvulo-\\nplasty, the patient will have to avoid eating or drinking\\nanything. An intravenous line is inserted so that med-\\nications can be administered. The patient’s groin area\\nis shaved and cleaned with an antiseptic. About an\\nhour before the procedure, the patient is given an\\noral sedative such as diazepam (Valium).\\nAftercare\\nAfter balloon valvuloplasty, the patient is sent to\\nthe recovery room for several hours, where he or she is\\nmonitored for vital signs (such as pulse and breathing)\\nand heart sounds. An electrocardiogram, which is a\\nrecord of the electrical impulses in the heart, is done.\\nThe leg in which the catheter was inserted is tempora-\\nrily prevented from moving. The skin condition is\\nmonitored. The insertion site, which will be covered\\nby a sandbag, is observed for bleeding until the cathe-\\nter is removed. Intravenous fluids will be given to help\\neliminate the x-ray dye; intravenous blood thinners or\\nother medications to dilate the coronary arteries may\\nbe given. Pain medication is available.\\nFor at least 30 minutes after removal of the cathe-\\nter, direct pressure is applied to the site of insertion; after\\nthis a pressure dressing will be applied. Following dis-\\ncharge from the hospital, the patient can usually resume\\nnormal activities. After balloon valvuloplasty lifelong\\nfollow-up is necessary because valves sometimes degen-\\nerate or narrowing recurs, making surgery necessary.\\nRisks\\nBalloon valvuloplasty can have serious complica-\\ntions. For example, the valve can become misshapen so\\nthat it doesn’t close completely, which makes the condi-\\ntionworse. Embolism,wherepiecesofthevalvebreakoff\\nand travel to the brain or the lungs, is another possible\\nrisk. If the procedure causes severe damage to the valve\\nleaflets, immediate surgery is required. Less frequent\\ncomplications are bleeding and hematoma (a local col-\\nlection of clotted blood) at the puncture site, abnormal\\nheart rhythms, reduced blood flow, heart attack, heart\\npuncture, infection, and circulatory problems.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nLori De Milto\\nBancroftian filariasis see Elephantiasis\\nBang’s diseasesee Brucellosis\\nBarbiturate-induced coma\\nDefinition\\nA barbiturate-induced coma, or barb coma, is a\\ntemporary state of unconsciousness brought on by a\\ncontrolled dose of a barbiturate drug, usually pento-\\nbarbital or thiopental.\\nPurpose\\nBarbiturate comas are used to protect the brain\\nduring major brain surgery, such as the removal of\\narteriovenous malformationsor aneurysms. Coma may\\nalso be induced to control intracranialhypertension\\ncaused by brain injury.\\nPrecautions\\nBarbiturate-induced comas are used when con-\\nventional therapy to reduce intracranial hypertension\\nhas failed. Barbiturate dosing is geared toward burst\\nsuppression–that is, reducing brain activity as mea-\\nsured by electroencephalography. This reduction in\\nbrain activity has to be balanced against the potential\\nside effects ofbarbiturates, which include allergic reac-\\ntions and effects on the cardiovascular system.\\nDescription\\nOne of the greatest hazards associated with brain\\ninjury is intracranial hypertension. Brain injury may be\\ncaused by an accidentalhead injuryor a medical condi-\\ntion, such as stroke, tumor, or infection. When the\\nbrain is injured, fluids accumulate in the brain, causing\\nit to swell. The skull does not allow for the expansion of\\nthe brain; in effect, the brain becomes compressed.\\nGALE ENCYCLOPEDIA OF MEDICINE 491\\nBarbiturate-induced coma'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 521, 'page_label': '492'}, page_content='If the pressure does not abate, oxygenated blood\\nmay not reach all areas of the brain. Also, the brain\\ntissue may be forced against hard, bony edges on the\\ninterior of the skull. In either case, the brain tissue may\\ndie, causing permanent brain damage ordeath.\\nBarbiturates reduce the metabolic rate of brain\\ntissue, as well as the cerebral blood flow. With these\\nreductions, the blood vessels in the brain narrow,\\ndecreasing the amount of swelling in the brain. With\\nthe swelling relieved, the pressure decreases and some\\nor all brain damage may be averted.\\nControversy exists, however, over the benefits of\\nusing barbiturates to control intracranial hyperten-\\nsion. Some studies have shown that barbiturate-\\ninduced coma can reduce intracranial hypertension\\nbut does not necessarily prevent brain damage.\\nFurthermore, the reduction in intracranial hyperten-\\nsion may not be sustained.\\nPreparation\\nInducing a barbiturate coma is usually kept in\\nreserve for cases in which conventional treatments\\nfor controlling intracranial hypertension have\\nfailed. Before coma is induced, intracranial hyper-\\ntension may be treated by hyperventilation; by\\nfacilitation of blood flow from the brain; by\\ndecompressive surgical procedures, such as draining\\nexcess fluids from under the skull or from the\\nchambers within the brain (ventricles); or by drug\\ntherapy, including osmotherapy, diuretic agents, or\\nsteroids.\\nRisks\\nAn estimated 25% of barbiturate-induced\\ncomas are accompanied by severe side effects. The\\nside effects of barbiturates, especially the depres-\\nsive effect on the cardiovascular system, can be too\\nrisky for some patients. Other side effects include\\nimpaired gastrointestinal motility and impaired\\nimmune response and infection. Since barbiturates\\ndepress activity in the brain, measurements of\\nbrain activity may be unreliable. Careful monitor-\\ning of the patient is required to ensure nutritional\\nneeds are being met and to guard against compli-\\ncations, such as lung infection, fevers, or deep vein\\nblood clots.\\nNormal results\\nIn many patients who do not respond to conven-\\ntional therapy, barbiturate-induced coma can\\nachieve the necessary control of intracranial\\nhypertension.\\nResources\\nPERIODICALS\\nSchwab, Stefan, et al. ‘‘Barbiturate Coma in Severe\\nHemispheric Stroke: Useful or Obsolete?’’Neurology 48\\n(1997): 1608.\\nJulia Barrett\\nBarbiturate withdrawal see Withdrawal\\nsyndromes\\nBarbiturates\\nDefinition\\nBarbiturates are medicines that act on the central\\nnervous system and cause drowsiness and can control\\nseizures.\\nKEY TERMS\\nAneurysm— A bulge or sack-like projection from a\\nblood vessel.\\nArteriovenous malformation— An abnormal tangle\\nof arteries and veins in which the arteries feed\\ndirectly into the veins without a normal intervening\\ncapillary bed.\\nDiuretic agent— A drug which increases urine\\noutput.\\nElectroencephalography— The recording of elec-\\ntrical potentials produced by the brain. These\\npotentials indicate brain activity.\\nHyperventilation— A respiratory therapy involving\\ndeeper and/or faster breathing to keep the carbon\\ndioxide pressure in the blood below normal.\\nIntracranial hypertension— Abnormally high\\nblood pressure within the skull.\\nOsmotherapy— Intravenous injection or oral\\nadministration of an agent that induces dehydra-\\ntion. The goal of dehydration is to reduce the\\namount of accumulated fluid in the brain.\\nSteroid— A type of drug used to reduce swelling.\\n492 GALE ENCYCLOPEDIA OF MEDICINE\\nBarbiturates'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 522, 'page_label': '493'}, page_content='Purpose\\nBarbiturates are in the group of medicines known\\nas central nervous system depressants (CNS). Also\\nknown as sedative-hypnotic drugs, barbiturates make\\npeople very relaxed, calm, and sleepy. These drugs are\\nsometimes used to help patients relax before surgery.\\nSome may also be used to control seizures (convul-\\nsions). Although barbiturates have been used to treat\\nnervousness and sleep problems, they have generally\\nbeen replaced by other medicines for these purposes.\\nThese medicines may become habit forming and\\nshould not be used to relieve everydayanxiety and\\ntension or to treat sleeplessness over long periods.\\nDescription\\nBarbiturates are available only with a physician’s\\nprescription and are sold incapsule, tablet, liquid,\\nand injectable forms. Some commonly used barbitu-\\nrates are phenobarbital (Barbita) and secobarbital\\n(Seconal).\\nRecommended dosage\\nRecommended dosage depends on the type of\\nbarbiturate and other factors such as the patient’s\\nage and the condition for which the medicine is being\\ntaken. Check with the physician who prescribed the\\ndrug or the pharmacist who filled the prescription for\\nthe correct dosage.\\nAlways take barbiturates exactly as directed.\\nNever take larger or more frequent doses, and do\\nnot take the drug for longer than directed. If the\\nmedicine does not seem to be working, even after\\ntaking it for several weeks, do not increase the\\ndosage. Instead, check with the physician who pre-\\nscribed the medicine.\\nDo not stop taking this medicine suddenly with-\\nout first checking with the physician who prescribed it.\\nIt may be necessary to taper down gradually to reduce\\nthe chance of withdrawal symptoms. If it is necessary\\nto stop taking the drug, check with the physician for\\ninstructions on how to stop.\\nPrecautions\\nSee a physician regularly while taking barbitu-\\nrates. The physician will check to make sure the med-\\nicine is working as it should and will note unwanted\\nside effects.\\nBecause barbiturates work on the central nervous\\nsystem, they may add to the effects of alcohol and\\nother drugs that slow the central nervous system,\\nsuch as antihistamines, cold medicine, allergy medi-\\ncine, sleep aids, medicine for seizures, tranquilizers,\\nsome pain relievers, and muscle relaxants. They may\\nalso add to the effects of anesthetics, including those\\nused for dental procedures. The combined effects of\\nbarbiturates and alcohol or other CNS depressants\\n(drugs that slow the central nervous system) can be\\nvery dangerous, leading to unconsciousness or even\\ndeath. Anyone taking barbiturates should not drink\\nalcohol and should check with his or her physician\\nbefore taking any medicines classified as CNS\\ndepressants.\\nTaking an overdose of barbiturates or combining\\nbarbiturates with alcohol or other central nervous\\nsystem depressants can cause unconsciousness and\\neven death. Anyone who shows signs of an overdose\\nor a reaction to combining barbiturates with alcohol\\nKEY TERMS\\nAdrenal glands— Two glands located next to the\\nkidneys. The adrenal glands produce the hormones\\nepinephrine and norepinephrine and the corticos-\\nteroid (cortisone-like) hormones.\\nAnemia— A lack of hemoglobin – the compound in\\nblood that carries oxygen from the lungs through-\\nout the body and brings waste carbon dioxide from\\nthe cells to the lungs, where it is released.\\nCentral nervous system— The brain and spinal\\ncord.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHypnotic— A medicine that causes sleep.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings, such as chlorophyll, that makes plants\\ngreen and hemoglobin which makes blood red.\\nSedative— Medicine that has a calming effect and\\nmay be used to treat nervousness or restlessness.\\nSeizure— A sudden attack, spasm, or convulsion.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 493\\nBarbiturates'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 523, 'page_label': '494'}, page_content='or other drugs should get emergency medical help\\nimmediately. Signs include:\\n/C15severe drowsiness\\n/C15breathing problems\\n/C15slurred speech\\n/C15staggering\\n/C15slow heartbeat\\n/C15severe confusion\\n/C15severe weakness\\nBarbiturates may change the results of certain\\nmedical tests. Before having medical tests, anyone\\ntaking this medicine should alert the health care pro-\\nfessional in charge.\\nPeople may feel drowsy, dizzy, lightheaded, or\\nless alert when using these drugs. These effects may\\neven occur the morning after taking a barbiturate\\nat bedtime. Because of these possible effects, any-\\none who takes these drugs should not drive, use\\nmachines or do anything else that might be dan-\\ngerous until they have found out how the drugs\\naffect them.\\nBarbiturates may cause physical or mental depen-\\ndence when taken over long periods. Anyone who\\nshows these signs of dependence should check with\\nhis or her physician right away:\\n/C15the need to take larger and larger doses of the med-\\nicine to get the same effect\\n/C15a strong desire to keep taking the medicine\\n/C15withdrawal symptoms, such as anxiety,nausea or\\nvomiting, convulsions, trembling, or sleep problems,\\nwhen the medicine is stopped\\nChildren may be especially sensitive to barbitu-\\nrates. This may increase the chance of side effects such\\nas unusual excitement.\\nOlder people may also be more sensitive that\\nothers to the effects of this medicine. In older people,\\nbarbiturates may be more likely to cause confusion,\\ndepression, and unusual excitement. These effects are\\nalso more likely in people who are very ill.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take barbiturates. Before taking these drugs, be\\nsure to let the physician know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to barbiturates in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Taking barbiturates during preg-\\nnancy increases the chance ofbirth defects and may\\ncause other problems such as prolonged labor and\\nwithdrawal effects in the baby after birth. Pregnant\\nwomen who must take barbiturates for serious or life-\\nthreatening conditions should thoroughly discuss with\\ntheir physicians the benefits and risks of taking this\\nmedicine.\\nBREASTFEEDING. Barbiturates pass into breast\\nmilk and may cause problems such as drowsiness,\\nbreathing problems, or slow heartbeat in nursing\\nbabies whose mothers take the medicine. Women\\nwho are breastfeeding should check with their physi-\\ncians before using barbiturates.\\nOTHER MEDICAL CONDITIONS. Before using barbi-\\nturates, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15alcohol or drugabuse\\n/C15depression\\n/C15hyperactivity (in children)\\n/C15pain\\n/C15kidney disease\\n/C15liver disease\\n/C15diabetes\\n/C15overactive thyroid\\n/C15underactive adrenal gland\\n/C15chronic lung diseases such asasthma or emphysema\\n/C15severe anemia\\n/C15porphyria\\nUSE OF CERTAIN MEDICINES. Taking barbiturates\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, light-\\nheadedness, drowsiness, and clumsiness or unsteadiness.\\nThese problems usually go away as the body adjusts to\\nthe drug and do not require medical treatment unless\\nthey persist or interfere with normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nimmediately:\\n494 GALE ENCYCLOPEDIA OF MEDICINE\\nBarbiturates'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 524, 'page_label': '495'}, page_content='/C15fever\\n/C15muscle or joint pain\\n/C15sore throat\\n/C15chest pain or tightness in the chest\\n/C15wheezing\\n/C15skin problems, such as rash,hives, or red, thickened,\\nor scaly skin\\n/C15bleeding sores on the lips\\n/C15sores or painful white spots in the mouth\\n/C15swollen eyelids, face, or lips\\nIn addition, check with a physician as soon as\\npossible if confusion, depression, or unusual excite-\\nment occur after taking barbiturates.\\nPatients who take barbiturates for a long time or\\nat high doses may notice side effects for some time\\nafter they stop taking the drug. These effects usually\\nappear within 8-16 hours after the patient stops taking\\nthe medicine. Check with a physician if these or other\\ntroublesome symptoms occur after stopping treatment\\nwith barbiturates:\\n/C15dizziness, lightheadedness or faintness\\n/C15anxiety or restlessness\\n/C15hallucinations\\n/C15vision problems\\n/C15nausea and vomiting\\n/C15seizures (convulsions)\\n/C15muscle twitches or trembling hands\\n/C15weakness\\n/C15sleep problems, nightmares, or increased dreaming\\nOther side effects may occur. Anyone who has\\nunusual symptoms during or after treatment with bar-\\nbiturates should get in touch with his or her physician.\\nInteractions\\nBirth control pills may not work properly when\\ntaken while barbiturates are being taken. To prevent\\npregnancy, use additional or additional methods of\\nbirth control while taking barbiturates.\\nBarbiturates may also interact with other medicines.\\nWhen this happens, the effects of one or both of the drugs\\nmay change or the risk of side effects may be greater.\\nAnyone who takes barbiturates should let the physician\\nknow all other medicines he or she is taking. Among the\\ndrugs that may interact with barbiturates are:\\n/C15Other central nervous system (CNS) depressants\\nsuch as medicine for allergies, colds, hay fever, and\\nasthma; sedatives; tranquilizers; prescription pain\\nmedicine; muscle relaxants; medicine for seizures;\\nsleep aids; barbiturates; and anesthetics.\\n/C15Blood thinners.\\n/C15Adrenocorticoids (cortisone-like medicines).\\n/C15Antiseizure medicines such as valproic acid (Depakote\\nand Depakene), and carbamazepine (Tegretol).\\nThe list above does not include every drug that\\nmay interact with barbiturates. Be sure to check with\\na physician or pharmacist before combining barbitu-\\nrates with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nResources\\nPERIODICALS\\nMiller, Norman S. ‘‘Sedative-Hypnotics: Pharmacology and\\nUse.’’ Journal of Family Practice29 (December 1989):\\n665.\\nNancy Ross-Flanigan\\nBariatric surgery\\nDefinition\\nBariatric surgery promotes weight loss by chan-\\nging the digestive system’s anatomy, limiting the\\namount of food that can be eaten and digested.\\nPurpose\\nObesity normally is defined through the use of\\nbody mass index (BMI) measurement. Physician\\noffices, obesity associations, nutritionists, and others\\noffer methods for calculating BMI, which is a compar-\\nison of height to weight. Those with a BMI of 30 or\\nhigher are considered obese. However, at 40 or higher,\\nthey are considered severely obese—approximately\\nabout 100 pounds overweight for men and 80 pounds\\noverweight for women.\\nMany people who are obese struggle to lose\\nweight through diet andexercise but fail. Only after\\nthey have tried other methods of losing weight will\\nthey be candidates for bariatric surgery, which today\\nis considered a ‘‘last resort’’ for weight loss. In general,\\nguidelines agree that those with a BMI of 40 or more,\\nor a BMI of 35 to 39.9 and a serious obesity-related\\nGALE ENCYCLOPEDIA OF MEDICINE 495\\nBariatric surgery'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 525, 'page_label': '496'}, page_content='health problem, qualify for bariatric surgery. More\\nthan 23 million Americans are candidates for bariatric\\nsurgery. More than 100,000 of the procedures were\\nperformed in 2003 and the number of surgeries per-\\nformed will probably continue to rise for many years.\\nPrecautions\\nBariatric surgery is not for everyone and the\\nsurgeon and other physicians will evaluate all med-\\nical conditions before allowing a patient to pro-\\nceed. As a major surgery, there are associated\\nrisks and side effects. Women of childbearing age\\nshould be aware that rapid weight loss and nutri-\\ntional deficiency associate dw i t hb a r i a t r i cs u r g e r y\\nmay be harmful to a developing fetus. It is impor-\\ntant that a patient reveal all current medications\\nand conditions during any pre-operative discus-\\nsions or examinations. Also, the physician will\\ncarefully evaluate the patient to ensure that he or\\nshe is prepared to make a lifelong commitment to\\nthe changes in eating and lifestyle required to make\\nthe surgery successful.\\nThough many studies have shown general safety\\nassociated with the major surgeries, they are relatively\\nnew and research on long-term effects are not as wide-\\nspread as they are for many other surgeries and pro-\\ncedures. When choosing a surgeon to perform the\\noperation, patients should check with organizations\\nsuch as the American Society for Bariatric Surgery\\nfor certification. A patient also should ask about the\\nsurgeon’s experience in performing the particular\\noperation.\\nAlthough the number of obese teenagers and\\nresulting bariatric surgeries has increased, some\\nexperts are questioning the decision to perform\\nbariatric surgery on teens. There are no specific clin-\\nical guidelines for determining a safe age for the\\nprocedure, but some physicians agree that bariatric\\nsurgery is not appropriatefor children younger than\\nage 15, since they are still growing and forming\\nbones.\\nDescription\\nWhen food is chewed and swallowed, it moves\\nalong the digestive tract. In the stomach, a strong\\nacid helps break down food so it can be digested\\nand the body can absorb the food’s nutrients and\\ncalories. The stomach can hold about three pints\\nof food at one time. As digestion continues, food\\nparticles become smaller and move from the stomach\\ninto the intestine. The various parts of the small\\nintestine are nearly 20 feet long if laid out straight.\\nThose food particles not digested in the small intes-\\ntine are stored in the large intestine until they are\\neliminated as waste.\\nWhen a patient has bariatric surgery, this diges-\\ntive process is altered to help the patient lose weight.\\nThere are three main types of bariatric surgery, but\\nonly two types are commonly used today. The types\\nare restrictive, malabsorptive, and combined restric-\\ntive/malabsorptive.\\nRestrictive surgery, often referred to as ‘‘sto-\\nmach stapling’’ uses bands or staples to create a\\nsmall pouch at the top of the stomach where food\\nenters from the esophagus. This smaller pouch may\\nhold only about 1 ounce of food at first and may\\nstretch to hold about 2-3 ounces. The pouch’s\\nlower opening is made small, so that food moves\\nslowly to the lower part of the stomach, adding to\\nthe feeling of fullness. The most frequently per-\\nformed types of restrictive surgeries are vertical\\nbanded gastroplasty (VBG), gastric banding, and\\nlaparoscopic gastric ba nding. VBG is used less\\ntoday in favor of gastric banding, which involves\\nan adjustable hollow band made of silicone rubber.\\nLaparoscopic gastric banding, or Lap-band, was\\napproved by the U.S. Food and Drug Administration\\n(FDA) in 2001. Sometimes referred to as ‘‘minimally\\ninvasive’’ bariatric surgery, the surgeon uses small\\nincisions and a laparoscope, or a small, tubular instru-\\nment with a camera attached, to see inside the abdo-\\nmen and apply the band.\\nMalabsorptive procedures help patients lose\\nweight by limiting the amount of nutrients and cal-\\nories the intestine can absorb. Sometimes called intest-\\ninal bypasses, they are no longer used in the United\\nStates because they have often resulted in severe nutri-\\ntional deficiencies.\\nCombined restrictive/malabsorptive operations\\nare the most common bariatric surgeries. They work\\nKEY TERMS\\nDigestive tract— The organs that perform diges-\\ntion, or changing of food into a form that can be\\nabsorbed by the body. They are the esophagus,\\nstomach, small intestine, and large instestine.\\nEsophagus— A muscular tube about nine inches\\nlong that carries food from the throat (pharynx) to\\nthe stomach.\\n496 GALE ENCYCLOPEDIA OF MEDICINE\\nBariatric surgery'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 526, 'page_label': '497'}, page_content='by restricting both the amount of food the stomach\\ncan hold and the amount of calories and nutrients the\\nbody absorbs. The most common and successful com-\\nbined surgery in recent years is called the Roux-en-Y\\ngastric bypass (RGB). In this operation, the surgeon\\nfirst creates a small pouch at the top of the stomach.\\nNext, a Y-shaped section of the small intestine is con-\\nnected to the small pouch, allowing food to bypass the\\nlower stomach, the first part of the small intestine\\n(duodenum), and the first portion of the next section\\nof the small intestine ( jejunum). It connects into the\\nsecond half of the jejunum, reducing the amount of\\ncalories and nutrients the body absorbs. RGB may be\\nperformed with a laparoscope and a series of tiny\\nincisions or with a large abdominal incision.\\nProcedure times vary, depending on the type of\\nbariatric surgery chosen. However, most patients are\\nin surgery for about one to two hours. Though costs\\ncan be as high as $35,000, more insurance companies\\nare beginning to pay for the procedures if they are\\nproven medically necessary. In 2004, the agency that\\npays for Medicare costs recognized obesity and many\\nof its treatments as a medical cost for the first time,\\nrecognizing that obesity leads to many other medical\\nproblems.\\nPreparation\\nThe physician will first make sure that a patient is\\nmentally prepared for the surgery and the commit-\\nment to follow-up care that will be required. Patients\\nshould have a consultation appointment with the\\nsurgeon prior to the procedure to discuss risks and\\nbenefits. Pre-operative instructions will be given that\\nwill tell the patient specific preparations prior to the\\nsurgery. These may include instructions about avoid-\\ning food or liquids, certainmedications, and other\\ninstructions on the day before or the day of the pro-\\ncedure. Patients also may have several laboratory or\\nother diagnostic tests prior to the surgery.\\nAftercare\\nDepending on the type of procedure and any pos-\\nsible complications, patients can expect to stay at the\\nhospital or surgery center for about two to four days\\nfollowing the surgery. Those who have laparoscopic\\noperations typically have shorter hospital stays and\\nspeedier recovery times. The physician and nurses will\\nprovide instructions for wound care and other follow-\\nup when the patient is discharged from the hospital.\\nUsually, bariatric surgery patients can resume normal\\nactivity within about six weeks following surgery, and\\nas little as two weeks after laparoscopic procedures. It\\nis important for bariatric surgery patients to lose\\nweight at the recommended pace, takenutritional sup-\\nplements as recommended, and attend follow-up visits\\nwith physicians and nutritionists.\\nHow a patient complies with instructions from\\nphysicians following bariatric surgery is important.\\nMost patients will require lifelong use of nutritional\\nsupplements such as multivitamins, calcium, and other\\nvitamin supplements to prevent nutritional deficien-\\ncies. Because the stomach is smaller, patients will have\\nto eat small portions of food and often must avoid\\ncertain types of food such as sugar.\\nRisks\\nThe surgeon performing the procedure should\\ndiscuss its specific risks prior to surgery. Risks for\\nbariatric surgery include infection,blood clots, abdom-\\ninal hernia, gallstones, nutritional deficiencies, possi-\\nble nerve complications, anddeath. Death rates have\\nbeen reported lowest for RGB and VBG, at less than\\n1% of patients.\\nNormal results\\nWeight loss will occur gradually, as patients can\\neat less food and absorb fewer calories. When patients\\nfollow post-operative instructions, they can lead nor-\\nmal lives, eating less food and being careful to limit\\ncertain foods that may irritate their new stomach\\npouches. Most patients will lose 50–60% of their\\nexcess weight in the first year or two. With gastric\\nbypass surgery, many can lose up to two-thirds of\\nexcess weight by the second postoperative year.\\nResources\\nPERIODICALS\\n‘‘Gastric Bypass Patients Should Recognize Risk of Nerve\\nInjury Post-surgery.’’Life Science Weekly(Nov. 2,\\n2004):973.\\nMacNeil, Jane Saladoff. ‘‘Gastric Bypass Beat Medical Care\\nfor Moderate Obesity.’’Family Practice News(Jan. 15,\\n2005):60–61.\\nSantora, Marc. ‘‘Teenagers Turn to Surgery to Shrink Their\\nStomachs.’’ The New York Times(Nov. 26, 2004):B1.\\nORGANIZATION\\nAmerican Obesity Association. 1250 12th St. NW, Suite 300,\\nWashington, DC 20037. 202-776-7711. http://\\nwww.obesity.org.\\nSociety of American Gastrointestinal Endoscopic Surgeons.\\n11300 West Olympic Blvd., Suuite 600, Los Angeles,\\nCA 90064. 310-437-0544. http://www.sages.org.\\nGALE ENCYCLOPEDIA OF MEDICINE 497\\nBariatric surgery'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 527, 'page_label': '498'}, page_content='OTHER\\nGastrointestinal Surgery for Severe ObesityWeight-control\\nInformation Network, National Institutes of Health,\\n2004. http://win.niddk.nih.gov/publications/\\ngastric.htm.\\nTeresa G. Odle\\nBarium enema\\nDefinition\\nA barium enema, also known as a lower GI (gas-\\ntrointestinal) exam, is a test that uses x-ray examina-\\ntion to view the large intestine. There are two types of\\nthis test: the single-contrast technique where barium\\nsulfate is injected into the rectum in order to gain a\\nprofile view of the large intestine; and the double-\\ncontrast (or ‘‘air contrast’’) technique where air is\\ninserted into the rectum.\\nPurpose\\nA barium enema may be performed for a variety of\\nreasons, including to aid in the diagnosis of colon and\\nrectal cancer(or colorectalcancer), and inflammatory\\ndisease. Detection of polyps (a benign growth in the\\ntissue lining of the colon and rectum), diverticula (a\\npouch pushing out from the colon), and structural\\nchanges in the large intestine can also be established with\\nthis test. The double-contrast barium enema is the best\\nmethod for detecting small tumors (such as polyps), early\\ninflammatory disease, and bleeding caused by ulcers.\\nThe decision to perform a barium enema is based\\non a person’s history of altered bowel habits. These\\ncan includediarrhea, constipation, any lower abdom-\\ninal pain they are currently exhibiting, blood, mucus,\\nor pus in their stools. It is also recommended that this\\nexam be used every five to 10 years to screen healthy\\npeople for colorectal cancer, the second most deadly\\ntype of tumor in the United States. Those who have\\na close relative with colorectal cancer or have had\\na precancerous polyp are considered to be at an\\nincreased risk for the disease and should be screened\\nmore frequently to look for abnormalities.\\nPrecautions\\nWhile barium enema is an effective screening\\nmethod in the detection of symptoms and may lead\\nto a timely diagnosis of several diseases, it is not the\\nonly method to do this. As of 1997, some studies have\\nshown that thecolonoscopy procedure performed by\\nexperienced gastroenterologists is a more accurate\\ninitial diagnostic tool for detecting early signs of color-\\nectal cancer. A colonoscopy is the most accurate way\\nfor the physician to examine the entire colon and\\nrectum for polyps. If abnormalities are seen at this\\ntime the procedure is accompanied by a biopsy.\\nSome physicians use sigmoidoscopy plus a barium\\nenema instead of colonoscopy.\\nDescription\\nTo begin a barium enema, the patient will lie with\\ntheir back down on a tilting radiographic table in order\\nto have x rays of the abdomen taken. After being\\nassisted to a different position, a well-lubricated rectal\\ntube is inserted through the anus. This tube allows the\\nphysician or assistant to slowly administer the barium\\ninto the intestine. While this filling process is closely\\nmonitored, it is important for the patient to keep the\\nanus tightly contracted against the rectal tube to help\\nmaintain its position and prevent the barium from\\nleaking. This step is emphasized to the patient due to\\nthe inaccuracy that may be caused if the barium leaks.\\nA rectal balloon may also be inflated to help retain the\\nbarium. The table may be tilted or the patient moved to\\na different position to aid in the filling process.\\nKEY TERMS\\nBarium sulfate— A barium compound used during\\na barium enema to block the passage of x rays\\nduring the exam.\\nBowel lumen— The space within the intestine.\\nColonoscopy— An examination of the upper por-\\ntion of the rectum performed with a colonoscope or\\nelongated speculum.\\nDiverticula— A diverticulum of the colon is a sac or\\npouch in the colon walls which is usually asympto-\\nmatic (without symptoms) but may cause difficulty\\nif it becomes inflamed.\\nDiverticulitis— A condition of the diverticulum of\\nthe intestinal tract, especially in the colon, where\\ninflammation may cause distended sacs extending\\nfrom the colon and pain.\\nUlcerative colitis— An ulceration or erosion of the\\nmucosa of the colon.\\nProctosigmoidoscopy— A visual examination of the\\nrectum and sigmoid colon using a sigmoidoscope.\\n498 GALE ENCYCLOPEDIA OF MEDICINE\\nBarium enema'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 528, 'page_label': '499'}, page_content='As the barium fills the intestine, x rays of the abdo-\\nmen are taken to distinguish significant findings.There\\nare many ways to perform a barium enema. One way is\\nthat shortly after filling, the rectal tube is removed and\\nthe patient expels as much of the barium as possible.\\nUpon completing this, an additional x ray is taken, and\\na double-contrast enema may follow. If this is done\\nimmediately, a thin film of barium will remain in the\\nintestine, and air is then slowly injected to expand the\\nbowel lumen. Sometimes no x rays will be taken until\\nafter the air is injected.\\nPreparation\\nIn order to conduct the most accurate barium\\nenema test, the patient must follow a prescribed diet\\nand bowel preparation instructions prior to the test.\\nThis preparation commonly includes restricted intake\\nof diary products and a liquid diet for 24 hours prior to\\nthe test, in addition to drinking large amounts of water\\nor clear liquids 12–24 hours before the test. Patients\\nmay also be givenlaxatives, and asked to give them-\\nselves a cleansing enema.\\nIn addition to the prescribed diet and bowel pre-\\nparation prior to the test, the patient can expect the\\nfollowing during a barium enema:\\n/C15They will be well draped with a gown as they are\\nsecured to a tilting x-ray table.\\n/C15As the barium or air is injected into the intestine, they\\nmay experience cramping pains or the urge to defecate.\\n/C15The patient will be instructed to take slow, deep\\nbreaths through the mouth to ease any discomfort.\\nAftercare\\nPatients should follow several steps immediately\\nafter undergoing a barium enema, including:\\n/C15Drink plenty of fluids to help counteract the dehy-\\ndrating effects of bowel preparation and the test.\\n/C15Take time to rest. A barium enema and the bowel\\npreparation taken before it can be exhausting.\\n/C15A cleansing enema may be given to eliminate any\\nremaining barium. Lightly colored stools will be pre-\\nvalent for the next 24–72 hours following the test.\\nRisks\\nWhile a barium enema is considered a safe screening\\ntest used on a routine basis, it can cause complications in\\ncertain people. The following indications should be kept\\nin mind before a barium enema is performed:\\n/C15Those who have a rapid heart rate, severe ulcerative\\ncolitis, toxic megacolon, or a presumed perforation\\nin the intestine should not undergo a barium enema.\\n/C15The test can be cautiously performed if the patient\\nhas a blocked intestine, ulcerative colitis,diverticuli-\\ntis, or severe bloody diarrhea.\\n/C15Complications that may be caused by the test include\\nperforation of the colon, water intoxication, barium\\ngranulomas (inflamed nodules), and allergic reac-\\ntion. These are all very rare.\\nNormal results\\nWhen the patient undergoes a single-contrast\\nenema, their intestine is steadily filled with barium\\nto differentiate the colon’s markings. A normal result\\ndisplays uniform filling of the colon. As the barium is\\nexpelled, the intestinal walls collapse. A normal result\\non the x ray after defecation will show the intestinal\\nlining as having a standard, feathery appearance.\\nAccordingly, the double-contrast enema expands\\nthe intestine which is already lined with a thin layer of\\nbarium, but with air to display a detailed image of the\\nmucosal pattern. Varying positions taken by the\\npatient allow the barium to collect on the dependent\\nwalls of the intestine by way of gravity.\\nAbnormal results\\nA barium enema allows abnormalities to appear on\\nan x ray that may aid in the diagnosis of several different\\nconditions. Although most colon cancers occur in the\\nrectosigmoid region, or upper part of the rectum and\\nadjoining portion of the sigmoid colon, and are better\\ndetected with a different test called a proctosigmoido-\\nscopy, an enema can identify other early signs of cancer.\\nIdentification of polyps,diverticulosis, inflamma-\\ntory disease, such as diverticulitis and ulcerative colitis\\nis attainable through a barium x ray. Structural\\nchanges in the intestine, gastroenteritis, and some\\ncases of acuteappendicitis may also be apparent by\\nviewing this x ray.\\nResources\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nBeth A. Kapes\\nBarium swallow see Upper GI exam\\nBarlow’s syndromesee Mitral valve prolapse\\nGALE ENCYCLOPEDIA OF MEDICINE 499\\nBarium enema'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 529, 'page_label': '500'}, page_content='Bartholin’s gland cyst\\nDefinition\\nA Bartholin’s gland cyst is a swollen fluid-filled\\nlump that develops from a blockage of one of the\\nBartholin’s glands, which are small glands located on\\neach side of the opening to the vagina. Bartholin’s\\ngland cysts and abscesses are commonly found in\\nwomen of reproductive age, developing in approxi-\\nmately 2% of all women.\\nDescription\\nThe Bartholin’s glands are located in the lips of the\\nlabia that cover the vaginal opening. The glands (nor-\\nmally the size of a pea) provide moisture for the vulva\\narea. A Bartholin’s gland cyst may form in the gland itself\\nor in the duct draining the gland. A cyst normally does\\nnot cause pain, grows slowly, and may go away with-\\nout treatment. It usually ranges in size from 0.4-1.2 in.\\n(1–3 cm), although some may grow much larger.\\nIf infected, a Bartholin’s gland cyst can form an\\nabscess that will increase in size over several days and\\nis very painful. In order to heal, a Bartholin’s gland\\ncyst usually must be drained.\\nCauses and symptoms\\nA Bartholin’s gland cyst occurs if the duct\\nbecomes blocked for any reason, such as infection,\\ninjury, or chronic inflammation. Very rarely a cyst is\\ncaused bycancer, which usually occurs only in women\\nover the age of 40. In many cases, the cause of a\\nBartholin’s gland cyst is unknown.\\nSymptoms of an uninfected Bartholin’s gland cyst\\ninclude a painless jump on one side of the vulva area\\n(most common symptom) and redness or swelling in\\nthe vulva area.\\nSymptoms of an abscessed Bartholin’s gland\\ninclude:\\n/C15pain that occurs with walking, sitting, physical activ-\\nity, or sexual intercourse\\n/C15fever and chills\\n/C15increased swelling in the vulva area over a two- to\\nfour-day period\\n/C15drainage from the cyst, normally occurring four to\\nfive days after the swelling starts\\nAbscesses may be caused by sexually transmitted\\nbacteria, such as those causing chlamydial or gonococ-\\ncal infections, while others are caused by bacteria\\nnormally occurring in the vagina. Over 60 types of\\nbacteria have been found in Bartholin’s gland abscesses.\\nDiagnosis\\nA Bartholin’s gland cyst or abscess is diagnosed\\nby a gynecologicalpelvic exam. If the cyst appears to\\nbe infected, a culture is often performed to identify the\\ntype of bacteria causing the abscess.\\nTreatment\\nTreatment for this condition depends on the size\\nof the cyst, whether it is painful, and whether the cyst is\\ninfected.\\nIf the cyst is not infected, treatment options\\ninclude:\\n/C15watchful waiting by the woman and her health care\\nprofessional\\n/C15soaking of the genital area with warm towel\\ncompresses\\n/C15soaking of the genital area in a sitz bath\\n/C15use of non-prescription pain medication to relieve\\nmild discomfort\\nIf the Bartholin’s gland is infected, there are several\\ntreatments available to treat the abscess, including:\\n/C15soaking of the genital area in a sitz bath\\n/C15treatment withantibiotics\\n/C15useofprescriptionornon-prescriptionpainmedication\\n/C15incision and drainage, i.e., cutting into the cyst and\\ndraining the fluid (not usually successful, as the cyst\\noften reoccurs)\\nKEY TERMS\\nMarsupialization— Cutting out a wedge of the cyst\\nwall and putting in stitches so the cyst cannot reoccur.\\nSitz bath— A warm bath in which just the buttocks\\nand genital area soak in water; used to reduce pain\\nand aid healing in the genital area.\\nWindow operation— Cutting out a large oval-\\nshaped piece of the cyst wall and putting in stitches\\nto create a window so the cyst cannot reoccur.\\nWord catheter— A small rubber catheter with an\\ninflatable balloon tip that is inserted into a stab\\nincision in the cyst, after the contents of the cyst\\nhave been drained.\\n500 GALE ENCYCLOPEDIA OF MEDICINE\\nBartholin’s gland cyst'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 530, 'page_label': '501'}, page_content='/C15placement of a drain (Word catheter) in the cyst for\\ntwo to four weeks so fluid can drain and prevent\\nreoccurrence of the cyst\\n/C15marsupialization\\n/C15window operation\\n/C15use of a carbon dioxide laser to open the cyst and\\nheat the cyst wall tissue so that the cyst cannot form a\\nsac and reoccur\\n/C15incision and drainage, followed by treatment with\\nsilver nitrate to burn the cyst wall so the cyst cannot\\nform a sac and reoccur\\n/C15removal of the entire Bartholin’s gland cyst, if the\\ncyst has reoccurred several times after use of other\\ntreatment methods\\nDuring surgical treatment, the area will be numbed\\nwith a local anesthetic to reduce pain. General anesthe-\\nsia may be used for treatment of an abscess, as the\\nprocedure can be painful.\\nIn a pregnant woman, surgical treatment of cysts\\nthat are asymptomatic should be delayed until after\\ndelivery to avoid the possibility of excessive bleeding.\\nHowever, if the Bartholin’s gland is infected and must\\nbe drained, antibiotics andlocal anesthesiaare gener-\\nally considered safe.\\nIf the cyst is caused by cancer, the gland must be\\nexcised, and the woman should be under the care of a\\ngynecologist familiar with the treatment of this type of\\ncancer.\\nAlternative treatment\\nIf a Bartholin’s gland cyst has no or mild symp-\\ntoms, or has opened on its own to drain, a woman may\\ndecide to use watchful waiting, warm sitz baths, and\\nnon-prescription pain medication. If symptoms\\nbecome worse or do not improve, a health care profes-\\nsional should then be consulted.\\nInfected Bartholin’s glands should be evaluated\\nand treated by a health care professional.\\nPrognosis\\nA Bartholin’s gland cyst should respond to treat-\\nment in a few days. If an abscess requires surgery,\\nhealing may take days to weeks, depending on the\\nsize of the abscess and the type of surgical procedure\\nused. Most of the surgical procedures, except for inci-\\nsion and drainage, should be effective in preventing\\nrecurring infections.\\nPrevention\\nThere are few ways to prevent the formation of\\nBartholin’s gland cysts or abscesses. However, as a\\nBartholin’s gland abscess may be caused by a sexually\\ntransmitted disease, the practice of safe sex is recom-\\nmended. Using good hygiene, i.e., wiping front to back\\nafter a bowel movement, is also recommended to pre-\\nvent bacteria from the bowels from contaminating the\\nvaginal area.\\nResources\\nBOOKS\\nToth, P. P. ‘‘Management of Bartholin’s Gland Duct Cysts\\nand Abscesses.’’ InSaunders Manual of Medical\\nPractice. Philadelphia: W.B. Saunders, 2000.\\nJudith Sims\\nBartonella bacilliformis infection see\\nBartonellosis\\nBartonellosis\\nDefinition\\nBartonellosis is an infectious bacterial disease\\nwith an acute form (which has a sudden onset and\\nshort course) and a chronic form (which has more\\ngradual onset and longer duration). The disease is\\ntransmitted by sandflies and occurs in western South\\nAmerica. Characterized by a form of red blood cell\\ndeficiency (hemolytic anemia)a n dfever, the poten-\\ntially fatal acute form is called Oroya fever or\\nCarrion’s disease. The chronic form is identified by\\npainful skin lesions.\\nDescription\\nThe acute form of the disease gets its name from an\\noutbreak that occurred in 1871 near La Oroya, Peru.\\nMore than 7,000 people perished. Some survivors later\\ndeveloped a skin disease, called verruga peruana\\n(Peruvian warts). These skin lesions were observed\\nprior to the 1871 outbreak–perhaps as far back as the\\npre-Columbian era–but a connection to Oroya fever\\nwas unknown. In 1885, a young medical researcher,\\nDaniel Carrion, inoculated himself with blood from a\\nlesion to study the course of the skin disease. When he\\nbecame ill with Oroya fever, the connection became\\napparent. Oroya fever is often called Carrion’s disease\\nin honor of his fatal experiment.\\nGALE ENCYCLOPEDIA OF MEDICINE 501\\nBartonellosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 531, 'page_label': '502'}, page_content='The bacteria,Bartonella bacilliformis, was isolated\\nby Alberto Barton in 1909, but wasn’t identified as the\\ncause of the fever until 1940. TheBartonella genus\\nincludes at least 11 bacteria species, four of which\\ncause human diseases, including cat-scratch disease\\nand bacillary angiomatosis. However, bartonellosis\\nrefers exclusively to the disease caused byB. bacillifor-\\nmis. The disease is limited to a small area of the Andes\\nMountains in western South America; nearly all cases\\nhave been in Peru, Colombia, and Ecuador. A large\\noutbreak involving thousands of people occurred in\\n1940–41, but bartonellosis has since occurred sporadi-\\ncally. Control of sandflies, the only known disease carrier\\n(vector), has been credited with managing the disease.\\nCauses and symptoms\\nBartonellosis is transmitted by the nocturnal\\nsandfly and arises from infection withB. bacilliformis.\\nThe sandfly,Lutzomyia verrucarum, dines on human\\nblood and, in so doing, can inject bacteria into the\\nbloodstream. The sandfly is found only in certain\\nareas of the Peruvian Andes; other, as-yet-unidentified\\nvectors are suspected in Ecuador and Colombia.\\nOnce in the bloodstream, the bacteria latch onto\\nred blood cells (erythrocytes), burrow into the cells,\\nand reproduce. In the process, up to 90% of the host’s\\nerythrocytes are destroyed, causing severe hemolytic\\nanemia. The anemia is accompanied by high fever,\\nmuscle and jointpain, delirium, and possiblycoma.\\nTwo to eight weeks after the acute phase, an\\ninfected individual develops verruga peruana. However,\\nindividuals may exhibit the characteristic lesions with-\\nout ever experiencing the acute phase. Left untreated,\\nthe lesions may last months or years. These lesions\\nresemble blood-filled blisters, up to 1.6 in (4 cm) in\\ndiameter, and appear primarily on the head and limbs.\\nThey can be painful to the touch and may bleed or\\nulcerate.\\nDiagnosis\\nBartonellosis is identified by symptoms and the\\npatient’s history, such as recent travel in areas where\\nbartonellosis occurs. Isolation ofB. bacilliformisfrom\\nthe bloodstream or lesions can confirm the diagnosis.\\nTreatment\\nAntibiotics are the mainstay of bartonellosis treat-\\nment. The bacteria are susceptible to several antibiotics,\\nincluding chloramphenicol,penicillins,a n daminoglyco-\\nsides. Blood transfusions may be necessary to treat the\\nanemia caused by bartonellosis.\\nPrognosis\\nAntibiotics have dramatically decreased the fatal-\\nity associated with bartonellosis. Prior to the develop-\\nment of antibiotics, the fever was fatal in 40% of cases.\\nWith antibiotic treatment, that rate has dropped to\\n8%. Fatalities can result from complications associated\\nwith severe anemia and secondary infections. Once\\nthe infection is halted, an individual can recover fully.\\nPrevention\\nAvoiding sandfly bites is the primary means of\\nprevention. Sandfly eradication programs have been\\nhelpful in decreasing the sandfly population, and insect\\nrepellant can be effective in preventing sandfly bites.\\nResources\\nBOOKS\\nDaly, Jennifer S. ‘‘Bartonella Species.’’ InInfectious\\nDiseases, edited by Sherwood F. Gorbach, John S.\\nBartlett, and Neil R. Blacklow, 2nd ed. Philadelphia:\\nW. B. Saunders Co., 1998.\\nJulia Barrett\\nBasal cell cancer see Skin cancer,\\nnon-melanoma\\nBasal gastric secretion test see Gastric acid\\ndetermination\\nKEY TERMS\\nAcute— Referring to the course of a disease, or\\na phase of a disease, the short-term experience of\\nprominent symptoms.\\nChronic— Referring to the course of a disease, or\\na phase of a disease, the long-term experience of\\nprominent symptoms.\\nErythrocytes— Red blood cells.\\nHemolytic anemia—A form of erythrocyte deficiency\\ncaused by the destruction of the red blood cells.\\nHost— The organism that harbors or nourishes\\nanother organism (parasite). In bartonellosis, the\\nperson infected with Bartonella basilliformis.\\nVector— An organism, such as insects or rodents,\\nthat can transmit disease to humans.\\n502 GALE ENCYCLOPEDIA OF MEDICINE\\nBartonellosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 532, 'page_label': '503'}, page_content='Battered child syndrome\\nDefinition\\nBattered child syndrome refers to injuries sus-\\ntained by a child as a result of physical abuse, usually\\ninflicted by an adult caregiver. Alternative terms\\ninclude: shaken baby; shaken baby syndrome; child\\nabuse; and non-accidental trauma (NAT).\\nDescription\\nInternal injuries, cuts,burns, bruises and broken or\\nfractured bones are all possible signs of battered child\\nsyndrome. Emotional damage to a child is also often\\nthe by-product of childabuse, which can result in serious\\nbehavioral problems such assubstance abuse or the\\nphysical abuse of others. Approximately 14% of chil-\\ndren in the United States are physically abused each\\nyear, and an estimated 2,000 of those children die as a\\nresult of the abuse. Between 1994-1995, 1.1 million cases\\nof child abuse were recorded in the United States; of that\\nnumber, 55% of the victims were less than a year old.\\nCauses and symptoms\\nBattered child syndrome (BCS) is found at every\\nlevel of society, although the incidence may be higher\\nin low-income households where adult caregivers suf-\\nfer greaterstress and social difficulties, without having\\nhad the benefit of higher education. The child abuser\\nmost often injures a child in the heat of anger, and was\\noften abused as a child himself. The incessant crying of\\nan infant or child may trigger abuse. Symptoms may\\ninclude a delayed visit to the emergency room with an\\ninjured child; an implausible explanation of the cause\\nof a child’s injury; bruises that match the shape of a\\nhand, fist or belt; cigarette burns; scald marks; bite\\nmarks; black eyes; unconsciousness; bruises around\\nthe neck; and a bulging fontanel in infants.\\nDiagnosis\\nBattered child syndrome is most often diagnosed\\nby an emergency room physician or pediatrician, or by\\nteachers or social workers. Physical examination will\\ndetect bruises, burns, swelling, retinal hemorrhages.\\nX rays, and other imaging techniques, such as MRI\\nor scans may confirmfractures or other internal inju-\\nries. The presence of injuries at different stages of\\nhealing (i.e. having occurred at different times) is\\nnearly always indicative of BCS. Establishing the diag-\\nnosis is often hindered by the excessive cautiousness\\nof caregivers or by actual concealment of the true\\norigin of the childþs injuries, as a result of fear,\\nshame and avoidance or denial mechanisms.\\nTreatment\\nMedical treatment for battered child syndrome\\nwill vary according to the type of injury incurred.\\nCounseling and the implementation of an intervention\\nplan for the child’s parents or guardians is necessary.\\nThe child abuser may be incarcerated, and/or the\\nabused child removed from the home to prevent\\nfurther harm. Reporting child abuse to authorities is\\nmandatory for doctors, teachers, and childcare work-\\ners in most states as a way to prevent continued abuse.\\nBoth physical and psychological therapy are often\\nrecommended as treatment for the abused child.\\nPrognosis\\nThe prognosis for battered child syndrome will\\ndepend on the severity of injury, actions taken by the\\nauthorities to ensure the future safety of the injured\\nchild, and the willingness of parents or guardians to\\nseek counseling for themselves as well as for the child.\\nPrevention\\nRecognizing the potential for child abuse in a situa-\\ntion, and the seeking or offering of intervention and\\ncounseling before battered child syndrome occurs is the\\nbest way to prevent it. Signs that physical abuse may be\\nforthcoming include parental alcohol or substance\\nabuse; previous abuse of the child or the child’s siblings;\\nhistory of mental or emotional problems in parents;\\nparents abused as children; absence of visible parental\\nlove or concern for the child; child’s hygiene neglected.\\nResources\\nBOOKS\\nLukefahr, James L.Treatment of Child Abuse.Baltimore,\\nMD: Johns Hopkins University Press, 2000.\\nPERIODICALS\\nMulryan, Kathleen, ‘‘Protecting the Child.’’Nursing (July\\n2000).\\nKEY TERMS\\nFontanel— Soft spot on top of an infant’s skull.\\nSubdural hematoma— Bleeding over the brain.\\nMultiple retinal hemorrhages— Bleeding in the\\nback of the eye.\\nGALE ENCYCLOPEDIA OF MEDICINE 503\\nBattered child syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 533, 'page_label': '504'}, page_content='ORGANIZATIONS\\nChildhelp National Abuse Hotline. (800)422-4453.\\nMary Jane Tenerelli, MS\\nBecker muscular dystrophy see Muscular\\ndystrophy\\nBeclomethasone see Corticosteroids\\nBed-wetting\\nDefinition\\nBed-wetting is the unintentional (involuntary) dis-\\ncharge of urine during the night. Although most chil-\\ndren between the ages of three and five begin to stay\\ndry at night, the age at which children are physically\\nand emotionally ready to maintain complete bladder\\ncontrol varies. Enuresis is a technical term that refers\\nto the continued, usually involuntary, passage of urine\\nduring the night or the day after the age at which\\ncontrol is expected.\\nDescription\\nMost children wet the bed occasionally, and defi-\\nnitions of the age and frequency at which bed-wetting\\nbecomes a medical problem vary somewhat. Many\\nresearchers consider bed-wetting normal until age 6.\\nAbout 10% of 6-year-old children wet the bed about\\nonce a month. More boys than girls have this problem.\\nThe American Psychiatric Association, however,\\ndefines enuresis as repeated voiding of urine into the\\nbed or clothes at age five or older. The wetting is usually\\ninvoluntary but in some cases it is intentional. For a\\ndiagnosis of enuresis, wetting must occur twice a week\\nfor at least three months with no underlying physio-\\nlogical cause. Enuresis, both nighttime (nocturnal) and\\ndaytime (diurnal), at age five affects 7% of boys and\\n3% of girls. By age 10, it affects 3% of boys and 2% of\\ngirls; only 1% of adolescents experience enuresis.\\nEnuresis is divided into two classes. A child with\\nprimary enuresis has never established bladder con-\\ntrol. A child with secondary enuresis begins to wet\\nafter a prolonged dry period. Some children have\\nboth nocturnal and diurnal enuresis.\\nCauses and symptoms\\nThe causes of bed-wetting are not entirely known.\\nIt tends to run in families. Most children with primary\\nenuresis have a close relative–a parent, aunt, or uncle–\\nwho also had the disorder. About 70% of children\\nwith two parents who wet the bed will also wet the\\nbed. Twin studies have shown that both of a pair of\\nidentical twins experience enuresis more often than\\nboth of a pair of fraternal twins.\\nSometimes bed-wetting can be caused by a serious\\nmedical problem like diabetes, sickle-cell anemia, or\\nepilepsy. Snoring and episodes of interrupted breath-\\ning during sleep (sleep apnea) occasionally contribute\\nto bed-wetting problems. Enlarged adenoids can cause\\nthese conditions. Other physiological problems, such\\nas urinary tract infection, severeconstipation,o rspinal\\ncord injury, can cause bed-wetting.\\nChildren who wet the bed frequently may have a\\nsmaller than normal functional bladder capacity.\\nFunctional bladder capacity is the amount of urine a\\nKEY TERMS\\nAcupressure— At e c h n i q u eu s i n gp r e s s u r et ov a r -\\nious points on the body to alleviate health problems.\\nADH— Antidiuretic hormone, or the hormone that\\nhelps to concentrate urine during the night.\\nBehavior modification— Techniques used to\\nchange harmful behavior patterns.\\nBladder— The muscular sac or container that stores\\nurine until it is released from the body through the\\ntube that carries urine from the bladder to the out-\\nside of the body (urethra).\\nDDAVP— Desmopressin acetate, a drug used to\\nregulate urine production.\\nHypnosis— The technique by which a trained pro-\\nfessional relaxes the subject and then asks ques-\\ntions or gives suggestions.\\nImipramine hydrochloride— A drug used to\\nincrease bladder capacity.\\nKidneys— A pair of organs located on each side of\\nthe spine in the lower back area. They excrete, or\\nget rid of, urine.\\nNocturnal enuresis— Involuntary discharge of\\nurine during the night.\\nUrinalysis— A urine test.\\nUrine— The fluid excreted by the kidneys, stored in\\nthe bladder, then discharged from the body through\\nthe tube that carries urine from the bladder to the\\noutside of the body (urethra).\\nVoid— To empty the bladder.\\n504 GALE ENCYCLOPEDIA OF MEDICINE\\nBed-wetting'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 534, 'page_label': '505'}, page_content='person can hold in the bladder before feeling a strong\\nurge to urinate. When functional capacity is small, the\\nbladder will not hold all the urine produced during the\\nnight. Tests have shown that bladder size in these\\nchildren is normal. Nevertheless, they experience fre-\\nquent strong urges to urinate. Such children urinate\\noften during the daytime and may wet several times at\\nnight. Although a small functional bladder capacity\\nmay be caused by a developmental delay, it may also\\nbe that the child’s habit of voiding frequently slows\\nbladder development.\\nParents often report that their bed-wetting child is\\nan extremely sound sleeper and difficult to wake.\\nHowever, several research studies found that bed-\\nwetting children have normal sleep patterns and that\\nbed-wetting can occur in any stage of sleep.\\nRecent medical research has found that many\\nchildren who wet the bed may have a deficiency of\\nan important hormone known as antidiuretic hor-\\nmone (ADH). ADH helps to concentrate urine during\\nsleep hours, meaning that the urine contains less\\nwater and therefore takes up less space. This decreased\\nvolume of water usually prevents the child’s bladder\\nfrom overfilling during the night, unless the child\\ndrank a lot just before going to bed. Testing of\\nmany bed-wetting children has shown that these\\nchildren do not have the usual increase in ADH dur-\\ning sleep. Children who wet the bed, therefore, often\\nproduce more urine during the hours of sleep than\\ntheir bladders can hold. If they do not wake up, the\\nbladder releases the excess urine and the child wets\\nthe bed.\\nResearch demonstrates that in most cases bed-\\nwetting does not indicate that the child has a physical\\nor psychological problem. Children who wet the bed\\nusually have normal-sized bladders and have sleep\\npatterns that are no different from those of non-bed-\\nwetting children. Sometimes emotionalstress,s u c ha s\\nthe birth of a sibling, adeath in the family, or separa-\\ntion from the family, may be associated with the onset\\nof bed-wetting in a previously toilet-trained child.\\nDaytime wetting, however, may indicate that the pro-\\nblem has a physical cause.\\nWhile most children have no long-term problems\\nas a result of bed-wetting, some children may develop\\npsychological problems. Low self-esteem may occur\\nwhen these children, who already feel embarrassed,\\nare further humiliated by angry or frustrated parents\\nwho punish them or who are overly aggressive about\\ntoilet training. The problem can by aggravated when\\nplaymates tease or when social activities such as sleep-\\naway camp are avoided for fear of teasing.\\nDiagnosis\\nIf a child continues to wet the bed after the age of\\nsix, parents may feel the need to seek evaluation and\\ndiagnosis by the family doctor or a children’s specia-\\nlist (pediatrician). Typically, before the doctor can\\nmake a diagnosis, a thorough medical history is\\nobtained. Then the child receives aphysical examina-\\ntion, appropriate laboratory tests, including a urine\\ntest (urinalysis), and, if necessary, radiologic studies\\n(such as x rays).\\nIf the child is healthy and no physical problem is\\nfound, which is the case 90% of the time, the doctor\\nmay not recommend treatment but rather may pro-\\nvide the parents and the child with reassurance, infor-\\nmation, and advice.\\nTreatment\\nOccasionally a doctor will determine that the pro-\\nblem is serious enough to require treatment. Standard\\ntreatments for bed-wetting include bladder training\\nexercises, motivational therapy, drug therapy, psy-\\nchotherapy, and diet therapy.\\nBladder training exercises are based on the theory\\nthat those who wet the bed have small functional\\nbladder capacity. Children are told to drink a large\\nquantity of water and to try to prolong the periods\\nbetween urinations. These exercises are designed to\\nincrease bladder capacity but are only successful in\\nresolving bed-wetting in a small number of patients.\\nIn motivational therapy, parents attempt to\\nencourage the child to combat bed-wetting, but the\\nchild must want to achieve success. Positive reinforce-\\nment, such as praise or rewards for staying dry, can\\nhelp improve self-image and resolve the condition.\\nPunishment for ‘‘wet’’ nights will hamper the child’s\\nself-esteem and compound the problem.\\nThe following motivational techniques are com-\\nmonly used:\\n/C15Behavior modification. This method of therapy is\\naimed at helping children take responsibility for their\\nnighttime bladder control by teaching new behaviors.\\nFor example, children are taught to use the bathroom\\nbefore bedtime and to avoid drinking fluids after\\ndinner. While behavior modification generally pro-\\nduces good results, it is long-term treatment.\\n/C15Alarms. This form of therapy uses a sensor placed\\nin the child’s pajamas or in a bed pad. This sensor\\ntriggers an alarm that wakes the child at the first sign\\nof wetness. If the child is awakened, he or she can then\\ngo to the bathroom and finish urinating. The intention\\nGALE ENCYCLOPEDIA OF MEDICINE 505\\nBed-wetting'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 535, 'page_label': '506'}, page_content='is to condition a response to awaken when the bladder\\nis full. Bed-wetting alarms require the motivation\\nof both parents and children. They are considered\\nthe most effective form of treatment now available.\\nA number of drugs are also used to treat bed-\\nwetting. These medications are usually fast acting;\\nchildren often respond to them within the first week\\nof treatment. Among the drugs commonly used are a\\nnasal spray of desmopressin acetate (DDAVP), a sub-\\nstance similar to the hormone that helps regulate urine\\nproduction; and imipramine hydrochloride, a drug\\nthat helps to increase bladder capacity. Studies show\\nthat imipramine is effective for as many as 50% of\\npatients. However, children often wet the bed again\\nafter the drug is discontinued, and it has some side\\neffects. Some bed-wetting with an underlying physical\\ncause can be treated by surgical procedures. These\\ncauses include enlarged adenoids that cause sleep\\napnea, physical defects in the urinary system, or a\\nspinal tumor.\\nPsychotherapy is indicated when the child exhibits\\nsigns of severe emotional distress in response to events\\nsuch as a death in the family, the birth of a new child, a\\nchange in schools, or divorce. Psychotherapy is also\\nindicated if a child shows signs of persistently low self-\\nesteem or depression.\\nIn rare cases,allergies or intolerances to certain\\nfoods–such as dairy products, citrus products, or cho-\\ncolate–can cause bed-wetting. When children have food\\nsensitivities, bed-wetting may be helped by discovering\\nthe substances that trigger the allergic response and\\neliminating these substances from the child’s diet.\\nAlternative treatment\\nA number of alternative treatments are available\\nfor bed-wetting.\\nMassage\\nAccording to practitioners of this technique, pres-\\nsure applied to various points on the body may help\\nalleviate the condition.Acupressure or massage, when\\ndone by a trained therapist, may also be helpful in bed-\\nwetting caused by a neurologic problem.\\nHerbal and homeopathic remedies\\nSome herbal remedies, such as horsetail (Equisetum\\narvense) have also been used to treat bed-wetting. A\\ntrained homeopathic practitioner, working at the consti-\\ntutional level, will seek to rebalance the child’s vital force,\\neliminating the imbalanced behavior of bed-wetting.\\nCommon homeopathic remedies used in this treatment\\nincludeCausticum, Lycopodium,and Pulsatilla.\\nHypnosis\\nHypnosis is another approach that is being used\\nsuccessfully by practitioners trained in this therapy. It\\ntrains the child to awaken and go to the bathroom\\nwhen his or her bladder feels full. Hypnosis is less\\nexpensive, less time-consuming, and less dangerous\\nthan most approaches; it has virtually no side effects.\\nRecent medical studies show thathypnotherapy can\\nwork quickly–within four to six sessions.\\nPrognosis\\nOccasional bed-wetting is not a disease and it does\\nnot have a ‘‘cure.’’ If the child has no underlying\\nphysical or psychological problem that is causing the\\nbed-wetting, in most cases he or she will outgrow the\\ncondition without treatment. About 15% of bedwetters\\nbecome dry each year after age 6. If bed-wetting is\\nfrequent, accompanied by daytime wetting, or falls\\ninto the American Psychiatric Association’s diagnostic\\ndefinition of enuresis, a doctor should be consulted. If\\ntreatment is indicated, it usually successfully resolves\\nthe problem. Marked improvement is seen in about\\n75% of cases treated with wetness alarms.\\nPrevention\\nAlthough preventing a child from wetting the bed\\nis not always possible, parents can take steps to help\\nthe child keep the bed dry at night. These steps include:\\n/C15Encouraging and praising the child for staying dry\\ninstead of punishing when the child wets.\\n/C15Reminding the child to urinate before going to bed, if\\nhe or she feels the need.\\n/C15Limiting liquid intake at least two hours before\\nbedtime.\\nResources\\nORGANIZATIONS\\nAssociation for the Care of Children’s Health (ACCH). 7910\\nWoodmont Ave., Suite 300, Bethesda, MD 20814. (800)\\n808-2224.\\nNational Association for Continence. P.O. Box 8310,\\nSpartenburg, SC 29305. (800) 252-3337. .\\nNational Enuresis Society. 7777 Forest Lane, Suite C-737,\\nDallas, TX 75230-2518. (800) 697-8080. .\\nGenevieve Slomski, Ph.D.\\n506 GALE ENCYCLOPEDIA OF MEDICINE\\nBed-wetting'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 536, 'page_label': '507'}, page_content='Bedsores\\nDefinition\\nBedsores are also called decubitus ulcers, pressure\\nulcers, or pressure sores. These tender or inflamed\\npatches develop when skin covering a weight-bearing\\npart of the body is squeezed between bone and another\\nbody part, or a bed, chair, splint, or other hard object.\\nDescription\\nEach year, about one million people in the\\nUnited States develop bedsores ranging from mild\\ninflammation to deep wounds that involve muscle\\nand bone. This often painful condition usually starts\\nwith shiny red skin that quickly blisters and deterio-\\nrates into open sores that can harbor life-threatening\\ninfection.\\nBedsores are not cancerous or contagious. They\\nare most likely to occur in people who must use wheel-\\nchairs or who are confined to bed. In 1992, the federal\\nAgency for Health Care Policy and Research reported\\nthat bedsores afflict:\\n/C1510% of hospital patients\\n/C1525% of nursing home residents\\n/C1560% of quadriplegics\\nThe Agency also noted that 65% of elderly people\\nhospitalized with broken hips develop bedsores and\\nthat doctors fees for treatment of bedsores amounted\\nto $2,900 per person.\\nBedsores are most apt to develop on the:\\n/C15ankles\\n/C15back of the head\\n/C15heels\\n/C15hips\\n/C15knees\\n/C15lower back\\n/C15shoulder blades\\n/C15spine\\nPeople over the age of 60 are more likely than\\nyounger people to develop bedsores. Risk is also\\nincreased by:\\n/C15atherosclerosis (hardening of arteries)\\n/C15diabetes or other conditions that make skin more\\nsusceptible to infection\\n/C15diminished sensation or lack of feeling\\n/C15heart problems\\n/C15incontinence (inability to control bladder or bowel\\nmovements)\\n/C15malnutrition\\n/C15obesity\\n/C15paralysis or immobility\\n/C15poor circulation\\n/C15prolonged bed rest, especially in unsanitary condi-\\ntions or with wet or wrinkled sheets\\n/C15spinal cord injury\\nCauses and symptoms\\nBedsores most often develop when constant pres-\\nsure pinches tiny blood vessels that deliver oxygen and\\nnutrients to the skin. When skin is deprived of oxygen\\nand nutrients for as little as an hour, areas of tissue can\\ndie and bedsores can form.\\nSlight rubbing or friction against the skin can\\ncause minor pressure ulcers. They can also develop\\nwhen a patient stretches or bends blood vessels by\\nslipping into a different position in a bed or chair.\\nUrine, feces, or other moisture increases the risk\\nof skin infection, and people who are unable to move\\nor recognize internal cues to shift position have a\\ngreater than average risk of developing bedsores.\\nOther risk factors include:\\n/C15malnutrition\\n/C15anemia (lack of red blood cells)\\n/C15diuse atrophy (muscle loss or weakness from lack of\\nuse)\\n/C15infection\\nBedsore. (Photograph by Michael English, M.D., Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 507\\nBedsores'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 537, 'page_label': '508'}, page_content='Diagnosis\\nBedsores usually follow six stages:\\n/C15redness of skin\\n/C15redness, swelling, and possible peeling of outer layer\\nof skin\\n/C15dead skin, draining wound, and exposed layer of fat\\n/C15tissue death through skin and fat, to muscle\\n/C15inner fat and muscle death\\n/C15destruction of bone, bone, infection, fracture, and\\nblood infection\\nTreatment\\nPrompt medical attention can prevent surface\\npressure sores from deepening into more serious infec-\\ntions. For mild bedsores, treatment involves relieving\\npressure, keeping the wound clean and moist, and\\nkeeping the area around the ulcer clean and dry.\\nAntiseptics, harsh soaps, and other skin cleansers can\\ndamage new tissue, so a saline solution should be used\\nto cleanse the wound whenever a fresh non-stick dres-\\nsing is applied.\\nThe patient’s doctor may prescribe infection-\\nfighting antibiotics, special dressings or drying agents,\\nor lotions or ointments to be applied to the wound in a\\nthin film three or four times a day. Warm whirlpool\\ntreatments are sometimes recommended for sores on\\nthe arm, hand, foot, or leg.\\nIn a procedure called debriding, a scalpel may be\\nused to remove dead tissue or other debris from the\\nwound. Deep, ulcerated sores that don’t respond to\\nother therapy may require skin grafts orplastic surgery.\\nA doctor should be notified whenever a person:\\n/C15will be bedridden or immobilized for an extended time\\n/C15is very weak or unable to move\\n/C15develops bedsores\\nImmediate medical attention is required whenever:\\n/C15skin turns black or becomes inflamed, tender, swol-\\nlen, or warm to the touch.\\n/C15the patient develops afever during treatment.\\n/C15the sore contains pus or has a foul-smelling discharge.\\nWith proper treatment, bedsores should begin to\\nheal two to four weeks after treatment begins.\\nAlternative treatment\\nZinc and vitamins A, C, E, and B complex help\\nskin repair injuries and stay healthy, but large doses of\\nvitamins or minerals should never be used without a\\ndoctor’s approval.\\nA poultice made of equal parts of powdered slip-\\npery elm (Ulmus fulva), marsh mallow (Althaea officina-\\nlis), and echinacea (Echinaceaspp.) blended with a small\\namount of hot water can relieve minor inflammation.\\nAn infection-fighting rinse can be made by diluting two\\ndrops of essential tea tree oil (Melaleuca spp.) in eight\\nounces of water. An herbal tea made from the calendula\\n(Calendula officinalis) can act as an antiseptic and\\nwound healing agent. Calendula cream can also be used.\\nContrasting hot and cold local applications can\\nincrease circulation to the area and help flush out\\nwaste products, speeding the healing process. The tem-\\nperatures should be extreme (hot hot and ice cold), yet\\ntolerable to the skin. Hot compresses should be applied\\nfor three minutes, followed by 30 seconds of cold com-\\npress application, repeating the cycle three times. The\\ncycle should always end with the cold compress.\\nPrevention\\nIt is usually possible to prevent bedsores from\\ndeveloping or worsening. The patient should be\\ninspected regularly; should bathe or shower every\\nday, using warm water and mild soap; and should\\navoid cold or dry air. A bedridden patient should be\\nrepositioned at least once every two hours while\\nawake. A person who uses a wheelchair should shift\\nhis weight every 10 or 15 minutes, or be helped to\\nreposition himself at least once an hour. It is impor-\\ntant to lift, rather than drag, a person being reposi-\\ntioned. Bony parts of the body should not be\\nmassaged. Even slight friction can remove the top\\nlayer of skin and damage blood vessels beneath it.\\nIf the patient is bedridden, sensitive body parts\\ncan be protected by:\\n/C15sheepskin pads\\n/C15special cushions placed on top of a mattress\\n/C15a water-filled mattress\\n/C15a variable-pressure mattress whose sections can be\\nindividually inflated or deflated to redistribute\\npressure.\\nPillows or foam wedges can prevent a bedridden\\npatient’s ankles from irritating each other, and pillows\\nplaced under the legs from mid-calf to ankle can raise\\nthe heels off the bed. Raising the head of the bed\\nslightly and briefly can provide relief, but raising the\\nhead of the bed more than 30 degrees can cause the\\npatient to slide, thereby causing damage to skin and\\ntiny blood vessels.\\n508 GALE ENCYCLOPEDIA OF MEDICINE\\nBedsores'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 538, 'page_label': '509'}, page_content='A person who uses a wheelchair should be encour-\\naged to sit up as straight as possible. Pillows behind\\nthe head and between the legs can help prevent bed-\\nsores, as can a special cushion placed on the chair seat.\\nDonut-shaped cushions should not be used because\\nthey restrict blood flow and cause tissues to swell.\\nPrognosis\\nBedsores can usually be cured, but about 60,000\\ndeaths a year are attributed to complications caused\\nby bedsores. Bedsores can be slow to heal. Without\\nproper treatment, they can lead to:\\n/C15gangrene (tissue death)\\n/C15osteomyelitis (infection of the bone beneath the\\nbedsore)\\n/C15sepsis (tissue-destroying bacterial infection)\\n/C15other localized or systemic infections that slow the\\nhealing process, increase the cost of treatment,\\nlengthen hospital or nursing home stays, or cause\\ndeath\\nResources\\nORGANIZATIONS\\nInternational Association of Enterstomal Therapy. 27241\\nLa Paz Road, Suite 121, Laguna Niguel, CA 92656.\\n(714) 476-0268.\\nNational Pressure Ulcer Advisory Panel. SUNY at Buffalo,\\nBeck Hall, 3435 Main St., Buffalo, NY 14214. (716)\\n881-3558. .\\nMaureen Haggerty\\nBeef tapeworm infection see Tapeworm\\ndiseases\\nBehavior therapy see Cognitive-behavioral\\ntherapy\\nBehcet’s syndrome\\nDefinition\\nA group of symptoms that affect a variety of body\\nsystems, including musculoskeletal, gastrointestinal,\\nand the central nervous system. These symptoms\\ninclude ulceration of the mouth or the genital area,\\nskin lesions, and inflammation of the uvea (an area\\naround the pupil of the eye).\\nDescription\\nBehcet’s syndrome is a chronic disease that\\ninvolves multiple body systems. The disease is named\\nfor a Turkish dermatologist, Hulusi Behcet, who first\\nreported a patient with recurrent mouth and genital\\nulcers along withuveitis in 1937. The disease occurs\\nworldwide, but is most prevalent in Japan, the Middle\\nEast, and in the Mediterranean region. There is a\\nwider prevalence among males than females in a\\nratio of two to one.\\nCauses and symptoms\\nThe cause of Behcet’s syndrome is unknown.\\nSymptoms include recurring ulcers in the mouth or\\nthe genital area, skin lesions, arthritis that affects\\nmainly the knees and ankles,pain and irritation in\\nthe eyes, andfever. The mouth and genital ulcers tend\\nto occur in multiples and can be quite painful. In the\\nmouth, these ulcers are generally found on the ton-\\ngue, gums, and the inside of the lips or jaws. In the\\ngenital area, the ulcers usually occur on the penis and\\nscrotum in males and on the vulva of women. The eye\\ninflammation can lead to blindness.\\nDiagnosis\\nBecause Behcet’s syndrome is a multisystem dis-\\nease, it is difficult to diagnose. International criteria\\nhave been proposed to assist in classifying this disease.\\nThere is no one diagnostic feature of this disease, so\\ndiagnosis depends on grouping together enough\\nsymptoms in order to identify the disease. Symptoms\\nof Behcet’s syndrome also occur in other diseases, so it\\nis often necessary to rule out the other diseases before\\na definitive diagnosis can be reached.\\nTreatment\\nSome of the current drugs used to treat Behcet’s\\nsyndrome include corticosteroids, cyclosporine,\\nazathioprine, chlorambucil, interferon alpha, thali-\\ndomide, levamisole and pulse cyclophosphamide.\\nPrognosis\\nThe prognosis for Behcet’s syndrome is generally\\npoor. There has been a documented case of Behcet’s\\nlasting for 17 years. Although the disease is considered\\npainful but not fatal, when the central nervous system is\\ninvolved there is usually severe disability anddeath\\noften occurs. The condition is usually chronic, although\\nthere can be remissions during the course of the disease.\\nThere is no predictable method to determine which\\nGALE ENCYCLOPEDIA OF MEDICINE 509\\nBehcet’s syndrome'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 539, 'page_label': '510'}, page_content='patients will progress into the more serious symptoms,\\nand which might move into remission.\\nPrevention\\nThere is no known prevention for Behcet’s\\nsyndrome.\\nResources\\nBOOKS\\nRuddy, Shaun.Kelley’s Textbook of Rheumatology.\\nPhiladelphia: W.B. Saunders Company, 2001.\\nTierney, Lawrence, et al.Current Medical Diagnosis and\\nTreatment.Los Altos: Lange Medical Publications, 2001.\\nPERIODICALS\\nOkada, A. A. ‘‘Drug Therapy in Behcet’s Disease.’’\\nOcularImmunology and InflammationJune 2000: 85-91.\\nShed, L. P. ‘‘Thalomide Responsiveness in an Infant with\\nBehcet’s Syndrome.’’Pediatrics June 1999: 1295-1297.\\nORGANIZATIONS\\nAmerican Behcet’s Disease Association. P.O. Box 280240,\\nMemphis, TN 38168-0240. .\\nBehcet’s Organization Worldwide, Head Office. P.O. Box\\n27, Watchet, Somerset TA23 OYJ, United Kingdom.\\n.\\nNational Eye Institute. National Institute of Health. Bldg. 31,\\nRm. 6A32, Bethesda, MD 30892-2510. (800) 869-2020.\\n2020@nei.nih.gov. .\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nKim A. Sharp, M.Ln.\\nBejel\\nDefinition\\nBejel, also known as endemic syphilis,i sa\\nchronic but curable disease,s e e nm o s t l yi nc h i l d r e n\\nin arid regions. Unlike the better-known venereal\\nsyphilis, endemic syphilis is not a sexually trans-\\nmitted disease.\\nDescription\\nBejel has many other names depending on the\\nlocality: siti, dichuchwa, njovera, belesh, and skerljevo\\nare some of the names. It is most commonly found in\\nthe Middle East (Syria, Saudi Arabia, Iraq), Africa,\\ncentral Asia, and Australia. Bejel is related toyaws\\nand pinta, but has different symptoms.\\nCauses and symptoms\\nTreponema pallidum, the bacteria that causes\\nbejel, is very closely related to the one that causes the\\nsexually transmitted form of syphilis, but transmission\\nis very different. In bejel, transmission is by direct\\ncontact, with broken skin or contaminated hands, or\\nindirectly by sharing drinking vessels and eating uten-\\nsils. T. pallidumis passed on mostly between children\\nliving in poverty in very unsanitary environments and\\nwith poor hygiene.\\nThe skin, bones, and mucous membranes are\\naffected by bejel. Patches and ulcerated sores are com-\\nmon in the mouth, throat, and nasal passages.\\nGummy lesions may form, even breaking through\\nthe palate. Other findings may include a region of\\nswollen lymph nodes and deep bonepain in the legs.\\nEventually, bones may become deformed.\\nDiagnosis\\nT. pallidumcan be detected by microscopic study\\nof samples taken from the sores or lymph fluid.\\nHowever, since antibody tests don’t distinguish\\nbetween the types of syphilis, specific diagnosis of the\\ntype of syphilis depends on the patient’s history, symp-\\ntoms, and environment.\\nTreatment\\nLarge doses of benzathine penicillin G given by\\ninjection into the muscle can cure this disease in any\\nstage, although it may take longer and require\\nadditional doses in later stages. If penicillin cannot\\nbe given, the alternative is tetracycline. Since tetracy-\\ncline can permanently discolor new teeth still forming,\\nit is usually not prescribed for children unless no viable\\nalternative is available.\\nPrognosis\\nBejel is completely curable with antibiotic\\ntreatment.\\nKEY TERMS\\nRemission— When active symptoms of a chronic\\ndisease are absent.\\nUveitis— Inflammation of the area of the eye\\naround the pupil.\\n510 GALE ENCYCLOPEDIA OF MEDICINE\\nBejel'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 540, 'page_label': '511'}, page_content='Prevention\\nThe World Health Organization (WHO) has\\nworked with many countries to prevent this and\\nother diseases, and the number of cases has been\\nreduced somewhat. Widespread use of penicillin has\\nbeen responsible for reducing the number of existing\\ncases, but the only way to eliminate bejel is by improv-\\ning living and sanitation conditions.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine.New York: McGraw-Hill, 1997.\\nJill S. Lasker\\nBenazepril see Angiotensin-converting\\nenzyme inhibitors\\nBence Jones protein test\\nDefinition\\nBence Jones proteins are small proteins (light\\nchains of immunoblobulin) found in the urine.\\nTesting for these proteins is done to diagnose and\\nmonitor multiple myelomaand other similar diseases.\\nPurpose\\nBence Jones proteins are considered the first\\ntumor marker. A tumor marker is a substance, made\\nby the body, that is linked to a certaincancer,o r\\nmalignancy. Bence Jones proteins are made by plasma\\ncells, a type of white blood cell. The presence of these\\nproteins in a person’s urine is associated with a malig-\\nnancy of plasma cells.\\nMultiple myeloma, a tumor of plasma cells, is the\\ndisease most often linked with Bence Jones proteins.\\nThe amount of Bence Jones proteins in the urine indi-\\ncates how much tumor is present. Physicians use Bence\\nJones proteins testing to diagnose the disease as well as\\nto check how well the disease is responding to\\ntreatment.\\nOther diseases involving cancerous or excessive\\ngrowth of plasma cells or cells similar to plasma cells\\ncan cause Bence Jones proteins in the urine. These\\ndiseases include: Waldenstro¨m’s macroglobulinemia,\\nsome lymphomas and leukemias, osteogenic sarcoma,\\ncryoglobulinemia, malignant B-cell disease,amyloidosis,\\nlight chain disease, and cancer that has spread to bone.\\nDescription\\nUrine is the best specimen in which to look for\\nBence Jones proteins. Proteins are usually too large to\\nmove through a healthy kidney, from the blood into\\nthe urine. Bence Jones proteins are an exception. They\\nare small enough to move quickly and easily through\\nthe kidney into the urine.\\nA routine urinalysis will not detect Bence Jones\\nproteins. There are several methods used by labora-\\ntories to detect and measure these proteins. The classic\\nBence Jones reaction involves heating urine to 1408F\\n(608C). At this temperature, the Bence Jones proteins\\nwill clump. The clumping disappears if the urine is\\nfurther heated to boiling and reappears when the\\nurine is cooled. Other clumping procedures using\\nsalts, acids, and other chemicals are also used to detect\\nthese proteins. These types of test will reveal whether\\nor not Bence Jones proteins are present, but not how\\nmuch is present.\\nA more complex procedure is done to measure the\\nexact amount of Bence Jones proteins. This proce-\\ndure–immunoelectrophoresis–is usually done on\\nurine that has been collected for 24-hours.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available within several\\ndays.\\nPreparation\\nUrine is usually collected throughout a 24-hour\\ntime period. A person is given a large container in\\nKEY TERMS\\nEndemic disease— An infectious disease that\\noccurs frequently in a specific geographical locale.\\nThe disease often occurs in cycles. Influenza is an\\nexample of an endemic disease.\\nLymph— This is a clear, colorless fluid found in\\nlymph vessels and nodes. The lymph nodes contain\\norganisms that destroy bacteria and other disease\\ncausing organisms (also called pathogens).\\nSyphilis— This disease occurs in two forms. One is\\na sexually transmitted disease caused by a bacteria.\\nThe second form is not sexually transmitted, but\\npassed on by direct contact with the patient or\\nthrough use of shared food dishes and utensils.\\nGALE ENCYCLOPEDIA OF MEDICINE 511\\nBence Jones protein test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 541, 'page_label': '512'}, page_content='which to collect the urine. The urine should be refri-\\ngerated until it is brought to the laboratory or physi-\\ncian’s office.\\nNormal results\\nBence Jones proteins normally are not present in\\nthe urine.\\nAbnormal results\\nBence Jones proteins are present in 50–80% of\\npeople with multiple myeloma. People with other\\nmalignancies also can have a positive Bence Jones\\nproteins test, but less frequently.\\nCertain nonmalignant diseases, such asrheuma-\\ntoid arthritis , systemic lupus erythematosus , and\\nchronic renal insufficiency, can have Bence Jones pro-\\nteins in the urine. High doses of penicillin oraspirin\\nbefore collecting the urine can give a false positive\\nresult.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nNancy J. Nordenson\\nBender-Gestalt test\\nDefinition\\nThe Bender Visual Motor Gestalt test (or Bender-\\nGestalt test) is a psychological assessment used to\\nevaluate visual-motor functioning, visual-perceptual\\nskills, neurological impairment, and emotional distur-\\nbances in children and adults ages three and older.\\nPurpose\\nThe Bender-Gestalt is used to evaluate visual-\\nmotor maturity and to screen children for develop-\\nmental delays. The test is also used to assess brain\\ndamage and neurological deficits. Individuals who\\nhave suffered a traumatic brain injury may be given\\nthe Bender-Gestalt as part of a battery of neuropsy-\\nchological measures, or tests.\\nThe Bender-Gestalt is sometimes used in conjunc-\\ntion with other personality tests to determine the pre-\\nsence of emotional and psychiatric disturbances such\\nas schizophrenia.\\nPrecautions\\nPsychometric testing requires a clinically trained\\nexaminer. The Bender Visual Motor Gestalt Test\\nshould be administered and interpreted by a trained\\npsychologist or psychiatrist. The Bender-Gestalt should\\nalways be employed as only one element of a complete\\nbattery of psychological or developmental tests, and\\nshould never be used alone as the sole basis for a\\ndiagnosis.\\nDescription\\nThe original Bender Visual Motor Gestalt test was\\ndeveloped in 1938 by psychiatrist Lauretta Bender.\\nThere are several different versions of the Bender-\\nGestalt available today (i.e., the Bender-Gestalt test;\\nModified Version of the Bender-Gestalt test for\\nPreschool and Primary School Children; the Hutt\\nAdaptation of the Bender-Gestalt test; the Bender\\nVisual Motor Gestalt test for Children; the Bender-\\nGestalt test for Young Children; the Watkins Bender-\\nGestalt Scoring System; the Canter Background\\nInterference Procedure for the Bender-Gestalt test).\\nAll use the same basic test materials, but vary in their\\nscoring and interpretation methods.\\nThe standard Bender Visual Motor Gestalt test\\nconsists of nine figures, each on its own3 x 5 card. An\\nexaminer presents each figure to the test subject one at\\na time and asks the subject to copy it onto a single\\npiece of blank paper. The only instruction given to the\\nsubject is that he or she should make the best repro-\\nduction of the figure possible. The test is not timed,\\nalthough standard administration time is typically\\n10-20 minutes. After testing is complete, the results\\nare scored based on accuracy and organization.\\nInterpretation depends on the form of the test in use.\\nCommon features considered in evaluating the draw-\\nings are rotation, distortion, symmetry, and persevera-\\ntion. As an example, a patient with frontal lobe injury\\nKEY TERMS\\nBence Jones protein— Small protein, composed of\\na light chain of immunoglobulin, made by plasma\\ncells.\\nMultiple myeloma— A tumor of the plasma cells.\\nPlasma cells— A type of white blood cell.\\n512 GALE ENCYCLOPEDIA OF MEDICINE\\nBender-Gestalt test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 542, 'page_label': '513'}, page_content='may reproduce the same pattern over and over\\n(perserveration).\\nThe Bender-Gestalt can also be administered in a\\ngroup setting. In group testing, the figures are shown\\nto test subjects with a slide projector, in a test booklet,\\nor on larger versions of the individual test cards. Both\\nthe individual and group- administered Bender-\\nGestalt evaluation may take place in either an out-\\npatient or hospital setting. Patients should check\\nwith their insurance plans to determine if these or\\nother mental health services are covered.\\nNormal results\\nChildren normally improve in this test as they age,\\nbut, because of the complexity of the scoring process,\\nresults for the Bender-Gestalt should only be inter-\\npreted by a clinically trained psychologist or\\npsychiatrist.\\nResources\\nORGANIZATIONS\\nAmerican Psychological Association (APA). 750 First St.\\nNE, Washington, DC 20002-4242. (202) 336-5700.\\n.\\nERIC Clearinghouse on Assessment and Evaluation. 1131\\nShriver Laboratory (Bldg 075).\\nPaula Anne Ford-Martin\\nBends see Decompression sickness\\nBenign see Uterine fibroids\\nBenign prostatic hyperplasia see Enlarged\\nprostate\\nBenign prostatic hypertrophy see Enlarged\\nprostate\\nBenzocaine see Antiseptics\\nBenzodiazepines\\nDefinition\\nBenzodiazepines are medicines that help relieve\\nnervousness, tension, and other symptoms by slowing\\nthe central nervous system.\\nPurpose\\nBenzodiazepines are a type ofantianxiety drugs.\\nWhile anxiety is a normal response to stressful situa-\\ntions, some people have unusually high levels of anxi-\\nety that can interfere with everyday life. For these\\npeople, benzodiazepines can help bring their feelings\\nunder control. The medicine can also relieve troubling\\nsymptoms of anxiety, such as pounding heartbeat,\\nbreathing problems, irritability,nausea, and faintness.\\nPhysicians may sometimes prescribe these drugs for\\nother conditions, such asmuscle spasms, epilepsy and\\nother seizure disorders,phobias, panic disorder,w i t h d r a -\\nwal from alcohol, and sleeping problems. However,\\nthis medicine should not be used every day for sleep\\nproblems that last more than a few days. If used this\\nway, the drug loses its effectiveness within a few weeks.\\nDescription\\nThe family of antianxiety drugs known as benzo-\\ndiazepines includes alprazolam (Xanax), chlordiazep-\\noxide (Librium), diazepam (Valium), and lorazepam\\n(Ativan). These medicines take effect fairly quickly,\\nstarting to work within an hour after they are taken.\\nBenzodiazepines are available only with a physician’s\\nprescription and are available in tablet, capsule,\\nliquid, or injectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nbenzodiazepine, its strength, and the condition for\\nwhich it is being taken. Doses may be different for\\ndifferent people. Check with the physician who pre-\\nscribed the drug or the pharmacist who filled the pre-\\nscription for the correct dosage.\\nKEY TERMS\\nNeuropsychological test— A test or assessment\\ngiven to diagnose a brain disorder or disease.\\nPerserveration— The persistence of a repetitive\\nresponse after the cause of the response has been\\nremoved, or the response continues to different\\nstimuli.\\nVisual-motor skills— Hand-eye coordination; in\\nthe Bender-Gestalt test, visual-motor skills are mea-\\nsured by the subject’s ability to accurately perceive\\nand then reproduce figures.\\nVisual-perceptual skills— The capacity of the mind\\nand the eye to ‘‘see’’ something as it objectively\\nexists.\\nGALE ENCYCLOPEDIA OF MEDICINE 513\\nBenzodiazepines'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 543, 'page_label': '514'}, page_content='Always take benzodiazepines exactly as directed.\\nNever take larger or more frequent doses, and do not\\ntake the drug for longer than directed. If the medicine\\ndoes not seem to be working, check with the physician\\nwho prescribed it. Do not increase the dose or stop\\ntaking the medicine unless the physician says to do so.\\nStopping the drug suddenly may cause withdrawal\\nsymptoms, especially if it has been taken in large\\ndoses or over a long period. People who are taking\\nthe medicine for seizure disorders may have seizures\\nif they stop taking it suddenly. If it is necessary to stop\\ntaking the medicine, check with a physician for direc-\\ntions on how to stop. The physician may recommend\\ntapering down gradually to reduce the chance of with-\\ndrawal symptoms or other problems.\\nPrecautions\\nSeeing a physician regularly while taking benzo-\\ndiazepines is important, especially during the first few\\nmonths of treatment. The physician will check to make\\nsure the medicine is working as it should and will note\\nunwanted side effects.\\nPeople who take benzodiazepines to relieve ner-\\nvousness, tension, or symptoms of panic disorder\\nshould check with their physicians every two to three\\nmonths to make sure they still need to keep taking the\\nmedicine.\\nPatients who are taking benzodiazepines for sleep\\nproblems should check with their physicians if they are\\nnot sleeping better within 7-10 days. Sleep problems\\nthat last longer than this may be a sign of another\\nmedical problem.\\nPeople who take this medicine to help them sleep\\nmay have trouble sleeping when they stop taking the\\nmedicine. This effect should last only a few nights.\\nSome people, especially older people, feel\\ndrowsy, dizzy, lightheaded, or less alert when using\\nbenzodiazepines. The drugs may also cause clumsi-\\nness or unsteadiness. When the medicine is taken at\\nbedtime, these effects may even occur the next morn-\\ning. Anyone who takes these drugs should not drive,\\nuse machines or do anything else that might be\\ndangerous until they have found out how the drugs\\naffect them.\\nBenzodiazepines may also cause behavior changes\\nin some people, similar to those seen in people who act\\ndifferently when they drink alcohol. More extreme\\nchanges, such as confusion, agitation, andhallucina-\\ntions, also are possible. Anyone who starts having\\nstrange or unusual thoughts or behavior while taking\\nthis medicine should get in touch with his or her\\nphysician.\\nBecause benzodiazepines work on the central ner-\\nvous system, they may add to the effects of alcohol and\\nother drugs that slow down the central nervous\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or\\nimagined stress, danger, or dreaded situations.\\nPhysical reactions, such as fast pulse, sweating, trem-\\nbling, fatigue, and weakness may accompany anxiety.\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBronchitis— Inflammation of the air passages of the\\nlungs.\\nCentral nervous system— The brain and spinal\\ncord.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nEmphysema— An irreversible lung disease in which\\nbreathing becomes increasingly difficult.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nMyasthenia gravis— A chronic disease with symp-\\ntoms that include muscle weakness and sometimes\\nparalysis.\\nPanic disorder— A disorder in which people have\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nPhobia— An intense, abnormal, or illogical fear of\\nsomething specific, such as heights or open spaces.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSleep apnea— A condition in which a person tem-\\nporarily stops breathing during sleep.\\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.\\n514 GALE ENCYCLOPEDIA OF MEDICINE\\nBenzodiazepines'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 544, 'page_label': '515'}, page_content='system, such asantihistamines, cold medicine, allergy\\nmedicine, sleep aids, medicine for seizures, tranquili-\\nzers, somepain relievers, andmuscle relaxants. They\\nmay also add to the effects of anesthetics, including\\nthose used for dental procedures. These effects may\\nlast several days after treatment with benzodiazepines\\nends. The combined effects of benzodiazepines and\\nalcohol or other CNS depressants (drugs that slow the\\ncentral nervous system) can be very dangerous, leading\\nto unconsciousness or, rarely, even death.Anyone tak-\\ning benzodiazepines should not drink alcohol and\\nshould check with his or her physician before using\\nany CNS depressants.Taking an overdose of benzodia-\\nzepines can also cause unconsciousness and possibly\\ndeath. Anyone who shows signs of an overdose or of the\\neffects of combining benzodiazepines with alcohol or\\nother drugs should get immediate emergency help.\\nWarning signs include slurred speech or confusion,\\nsevere drowsiness, staggering, and profound weakness.\\nSome benzodiazepines may change the results of\\ncertain medical tests. Before having medical tests, any-\\none taking this medicine should alert the health care\\nprofessional in charge.\\nChildren are generally more sensitive than adults\\nto the effects of benzodiazepines. This sensitivity may\\nincrease the chance of side effects.\\nOlder people are more sensitive than younger\\nadults to the effects of this medicine and may be at\\ngreater risk for side effects. Older people who take\\nthese drugs to help them sleep may be drowsy during\\nthe day. Older people also increase their risk of falling\\nand injuring themselves when they take these drugs.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take benzodiazepines. Before taking these drugs,\\nbe sure to let the physician know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to benzodiazepines or other mood-altering\\ndrugs in the past should let his or her physician know\\nbefore taking the drugs again. The physician should\\nalso be told about anyallergies to foods, dyes, preser-\\nvatives, or other substances.\\nPREGNANCY. Some benzodiazepines increase the\\nlikelihood ofbirth defects. Using these medicines dur-\\ning pregnancy may also cause the baby to become\\ndependent on them and to have withdrawal symptoms\\nafter birth. When taken late in pregnancy or around\\nthe time of labor and delivery, these drugs can cause\\nother problems in the newborn baby, such as\\nweakness, breathing problems, slow heartbeat, and\\nbody temperature problems.\\nBREASTFEEDING. Benzodiazepines may pass into\\nbreast milk and cause problems in babies whose\\nmothers taken the medicine. These problems include\\ndrowsiness, breathing problems, and slow heartbeat.\\nWomen who are breastfeeding their babies should not\\nuse this medicine without checking with their\\nphysicians.\\nOTHER MEDICAL CONDITIONS. Before using ben-\\nzodiazepines, people with any of these medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15current or past drug or alcoholabuse\\n/C15depression\\n/C15severe mental illness\\n/C15epilepsy or other seizure disorders\\n/C15swallowing problems\\n/C15chronic lung disease such asemphysema, asthma,o r\\nchronic bronchitis\\n/C15kidney disease\\n/C15liver disease\\n/C15brain disease\\n/C15glaucoma\\n/C15hyperactivity\\n/C15myasthenia gravis\\n/C15porphyria\\n/C15sleep apnea\\nUSE OF CERTAIN MEDICINES. Taking benzodiaze-\\npines with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, light-\\nheadedness, drowsiness, clumsiness, unsteadiness, and\\nslurred speech. These problems usually go away as the\\nbody adjusts to the drug and do not require medical\\ntreatment unless they persist or they interfere with\\nnormal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15behavior changes\\n/C15memory problems\\n/C15difficulty concentrating\\nGALE ENCYCLOPEDIA OF MEDICINE 515\\nBenzodiazepines'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 545, 'page_label': '516'}, page_content='/C15confusion\\n/C15depression\\n/C15seizures (convulsions)\\n/C15hallucinations\\n/C15sleep problems\\n/C15increased nervousness, excitability, or irritability\\n/C15involuntary movements of the body, including\\nthe eyes\\n/C15low blood pressure\\n/C15unusual weakness or tiredness\\n/C15skin rash oritching\\n/C15unusual bleeding or bruising\\n/C15yellow skin or eyes\\n/C15sore throat\\n/C15sores in the mouth or throat\\n/C15fever and chills\\nPatients who take benzodiazepines for a long time\\nor at high doses may notice side effects for several\\nweeks after they stop taking the drug. They should\\ncheck with their physicians if these or other trouble-\\nsome symptoms occur:\\n/C15irritability\\n/C15nervousness\\n/C15sleep problems\\nOther rare side effects may occur. Anyone who has\\nunusual symptoms during or after treatment with benzo-\\ndiazepines should get in touch with his or her physician.\\nInteractions\\nBenzodiazepines may interact with a variety of\\nother medicines. When this happens, the effects of\\none or both of the drugs may change or the risk\\nof side effects may be greater. Anyone who takes\\nbenzodiazepines should let the physician know all\\nother medicines he or she is taking. Among the drugs\\nthat may interact with benzodiazepines are:\\n/C15Central nervous system (CNS) depressants such as\\nmedicine for allergies, colds, hay fever, and asthma;\\nsedatives; tranquilizers; prescription pain medicine;\\nmuscle relaxants; medicine for seizures; sleep aids;\\nbarbiturates; and anesthetics.\\nMedicines other than those listed above may\\ninteract with benzodiazepines. Be sure to check with\\na physician or pharmacist before combining benzodia-\\nzepines with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nResources\\nOTHER\\n‘‘Medications.’’ National Institute of Mental Health Page.\\n1995. .\\nNancy Ross-Flanigan\\nBenzoyl peroxide see Antiacne drugs\\nBenztropine see Antiparkinson drugs\\nBereavement\\nDefinition\\nBereavement refers to the period of mourning and\\ngrief following thedeath of a beloved person or ani-\\nmal. The English wordbereavement comes from an\\nancient Germanic root word meaning ‘‘to rob’’ or ‘‘to\\nseize by violence.’’Mourning is the word that is used to\\ndescribe the public rituals or symbols of bereavement,\\nsuch as holding funeral services, wearing black cloth-\\ning, closing a place of business temporarily, or low-\\nering a flag to half mast.Grief refers to one’s personal\\nexperience of loss; it includes physical symptoms as\\nwell as emotional and spiritual reactions to the loss.\\nWhile public expressions of mourning are usually\\ntime-limited, grief is a process that takes most people\\nseveral months or years to work through.\\nDescription\\nBereavement is a highly individual as well as a\\ncomplex experience. It is increasingly recognized that\\nno two people respond the same way to the losses\\nassociated with the death of a loved one. People’s\\nreactions to a death are influenced by such factors\\nas ethnic or religious traditions; personal beliefs\\nabout life after death; the type of relationship ended\\nby death (relative, friend, colleague, etc.); the cause of\\ndeath; the person’s age at death; whether the death\\nwas sudden or expected; and many others. In addi-\\ntion, the death of a loved one inevitably confronts\\nadults (and older adolescents) with the fact that they\\ntoo will die. As a result of this variety and emotional\\ncomplexity, most doctors and other counselors advise\\npeople to trust their own feelings about bereave-\\nment,0 and grieve in the way that seems most helpful\\nto them.\\nIt is also increasingly understood in the early\\n2000s that people can experience bereavement with\\nregard to other losses. Some examples of these\\n516 GALE ENCYCLOPEDIA OF MEDICINE\\nBereavement'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 546, 'page_label': '517'}, page_content='so-called ‘‘silent losses’’ include miscarriages in early\\npregnancy, the death of a child in the womb shortly\\nbefore birth, or the news that a loved one has\\nAlzheimer’s disease or another illness that slowly\\ndestroys their personality. In addition, many counse-\\nlors recognize that bereavement has two dimensions,\\nthe actual loss and the symbolic losses. For example, a\\nperson whose teenage son or daughter is killed in an\\naccident suffers a series of symbolic losses—knowing\\nthat their child will never graduate from high school,\\nget married, or have children—as well as the actual\\nloss of the adolescent to death.\\nCauses and symptoms\\nCauses\\nThe immediate cause of bereavement is usually\\nthe death of a loved friend or relative. There are a\\nnumber of situations, however, which can affect or\\nprolong the grief process:\\n/C15The relationship with the dead person was a source\\nof pain rather than love and support. Examples\\nwould include an abusive parent or spouse.\\n/C15The person died in military service or in a natural,\\ntransportation, or workplace disaster. Bereavement in\\nthese cases is often made more difficult by intrusive\\nnews reporters as well asanxiety over the loved one’s\\npossible physical or mental suffering prior to death.\\n/C15The person was murdered. Survivors of homicide\\nvictims often find the criminal justice system as well\\nas the media frustrating and upsetting.\\n/C15The person is missing and presumed dead but their\\ndeath has not been verified. As a result, friends and\\nrelatives may alternate between grief and hope that\\nthe person is still alive.\\n/C15The person committed suicide. Survivors may feel\\nguilt over their inability to foresee or prevent the\\nsuicide, shame that the death was self-inflicted, or\\nanger at the person who committed suicide.\\n/C15The relationship with the dead person cannot be\\nopenly acknowledged. This situation often leads to\\nwhat is called disenfranchised grief. The most com-\\nmon instances are homosexual or extramarital sexual\\nrelationships that have been kept secret for the sake\\nof spouses or other family members.\\n/C15The loved one was an animal rather than a human\\nbeing. Western societies are only beginning to accept\\nthat adults as well as children can grieve for a dead\\nanimal; many adults still feel that there is ‘‘some-\\nthing wrong’’ about grieving for their pet. The ques-\\ntion of euthanasia may be an additional source of\\nsorrow; even when the pet is terminally ill, many\\npeople are very uneasy about making the decision\\nto end its life.\\nSymptoms\\nBereavement typically affects a person’s physical\\nwell-being as well as emotions. Common symptoms of\\ngrief include changes in appetite and weight,fatigue,\\ninsomnia and other sleep disturbances, loss of interest\\nin sex, low energy levels,nausea and vomiting, chest or\\nthroat pain, and headache. People who have lost a\\nloved one in traumatic circumstances may have such\\nsymptoms ofpost-traumatic stress disorderas an exag-\\ngerated startle response, visual or auditoryhallucina-\\ntions, or high levels of muscular tension.\\nDoctors and other counselors have identified four\\nstages or phases in uncomplicated bereavement:\\nColumbine High School students in Littleton, Colorado,\\ngrieving for their slain classmates. (Photo by David\\nZalubowski. AP/Wide World Photos. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 517\\nBereavement'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 547, 'page_label': '518'}, page_content='/C15Shock, disbelief, feelings of numbness. This initial\\nphase lasts about two weeks, during which the\\nbereaved person finally accepts the reality of the\\nloved one’s death.\\n/C15Suffering the pain of grief. This phase typically lasts\\nfor several months. Some people undergo a mild\\ntemporary depression about six months after the\\nloved one’s death.\\n/C15Adjusting to life without the loved one. In this phase\\nof bereavement, survivors may find themselves\\ntaking on the loved one’s roles and responsibilities\\nas well as redefining their own identities.\\n/C15Moving forward with life, forming new relation-\\nships, and having positive expectations of the future.\\nMost people reach this stage within one to two years\\nafter the loved one’s death.\\nBEREAVEMENT IN CHILDREN. Children do not\\nexperience bereavement in the same way as adolescents\\nand adults. Preschool children usually do not under-\\nstand death as final and irreversible, and may talk or act\\nas if the dead pet or family member will wake up or\\ncome back. Children between the ages of five and nine\\nare better able to understand the finality of death, but\\nthey tend to assume it will not affect them or their\\nfamily. They are likely to be shocked and severely\\nupset by a death in their immediate family. In addition\\nto the physical disturbances that bereaved adults often\\nexperience, children sometimes begin to act like infants\\nagain (wanting bottle feeding, using baby talk, etc.)\\nThis pattern of returning to behaviors characteristic of\\nan earlier life stage is called regression.\\nTRAUMATIC AND COMPLICATED GRIEF. Since the\\nearly 1990s, thanatologists (doctors and other counse-\\nlors who specialize in issues related to death and\\ndying) have identified two types of grief that do not\\nresolve normally with the passage of time. Traumatic\\ngrief is defined as grief resulting from a sudden trau-\\nmatic event that involves violent suffering, mutilation,\\nand/or multiple deaths; appears to be random or pre-\\nventable; and often involves the survivor’s own brush\\nwith death. The symptoms of traumatic grief are simi-\\nlar to those of post-traumaticstress disorder (PTSD).\\nSuch events as the terrorist attacks of September 11,\\n2001, the East Asian tsunami of December 2004, and\\nairplane crashes or other transportation disasters may\\nproduce traumatic grief in survivors.\\nIn contrast to traumatic grief, complicated grief\\ndoes not necessarily result from a specific type of event\\nbut rather refers to an abnormally intense and pro-\\nlonged response to bereavement. While most people\\nare able to move through a period of bereavement and\\nrecover a sense of purpose and meaning in life, people\\nwith complicated grief feel as if their entire worldview\\nhas been shattered. They cannot stop thinking of the\\ndead person, long to be with him or her, and may feel\\nthat part of them died along with the loved one. They\\nsometimes start acting like the deceased person,\\nmimicking the symptoms of his or her illness, behav-\\ning in reckless ways, talking about ‘‘joining’’ the loved\\none, or refusing to accept the reality of the death.\\nIn general they are unable to function normally.\\nComplicated grief should not be regarded as simply\\nKEY TERMS\\nBibliotherapy— The use of books (usually self-help\\nor problem-solving works) to improve one’s under-\\nstanding of personal problems and/or to heal pain-\\nful feelings.\\nBiofield healing— A general term for a group of\\nalternative therapies based on the belief that the\\nhuman body is surrounded by an energy field (or\\naura) that reflects the condition of the person’s\\nbody and spirit. Rebalancing or repairing the\\nenergy field is thought to bring about healing in\\nmind and body. Reiki, therapeutic touch, polarity\\nbalancing, Shen therapy, and certain forms of color\\ntherapy are considered forms of biofield healing.\\nComplicated grief— An abnormal response to\\nbereavement that includes unrelieved yearning for\\nthe dead person, the complete loss of previous\\npositive beliefs or worldviews, and a general inabil-\\nity to function.\\nDisenfranchised grief— Grief that cannot be\\nopenly expressed because the death or other loss\\ncannot be publicly acknowledged.\\nEuthanasia— The act of putting a person or animal\\nto death painlessly or allowing them to die by with-\\nholding medical services, usually because of a\\npainful and incurable disease.\\nMourning— The public expression of bereavement;\\nit may include funerals and other rituals, special\\nclothing, and symbolic gestures.\\nRegression— A return to earlier, particularly infan-\\ntile, patterns of thought and behavior.\\nThanatology— The medical, psychological, or\\nlegal study of death and dying.\\nTraumatic grief— Grief resulting from the loss of a\\nloved one in a traumatic situation (natural or transpor-\\ntation disaster, act of terrorism or mass murder, etc.)\\n518 GALE ENCYCLOPEDIA OF MEDICINE\\nBereavement'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 548, 'page_label': '519'}, page_content='a subtype of clinical depression; the two conditions\\nmay coexist or overlap in some patients but are none-\\ntheless distinct entities.\\nDiagnosis\\nBereavement is considered a normal response to a\\ndeath or other loss. A doctor who suspects that a\\npatient is suffering from traumatic or complicated\\ngrief, however, may use various psychological inven-\\ntories or questionnaires to see whether the patient\\nmeets the criteria for PTSD, major depression, or\\nacute stress disorder. In addition, there are several spe-\\ncific questionnaires to help diagnose complicated grief.\\nTreatment\\nMost people do not require formal treatment\\nfor bereavement. In the early 2000s, however, many\\npeople choose to participate in support groups for\\nrecently bereaved people or hospice follow-up programs\\nfor relatives of patients who died in that hospice.\\nBereavement support groups are particularly helpful in\\nguiding members through such common but painful\\nproblems as disposing of the dead person’s possessions,\\ncelebrating holidays without the loved one, coping with\\nanniversaries, etc.\\nTraumatic grief is usually treated in the same way\\nas post-traumatic stress, with temporary use of medi-\\ncations to control sleep disturbances and anxiety\\nsymptoms along with long-term psychotherapy.\\nThose suffering from traumatic grief may also be\\nreferred to support groups of people dealing with the\\nsame type of sudden and violent loss. Some of these\\norganizations are listed below. Complicated grief is\\nusually managed with a combination of group and\\nindividual psychotherapy.\\nAlternative treatment\\nAlternative therapies that have been reported to\\nhelp with the sleep disturbances and other physical\\nsymptoms of bereavement include prayer andmedita-\\ntion; such movement therapies asyoga and tai chi;\\ntherapeutic touch, Reiki, and other forms of biofield\\nhealing; bibliotherapy and journaling;music therapy,\\nart therapy, hydrotherapy,a n dmassage therapy.\\nPrognosis\\nMost people move through the stages of the nor-\\nmal grief process within several months to two years,\\ndepending on the length and closeness of the relation-\\nship. Traumatic grief and complicated grief, however,\\nmay take three years or longer to resolve, even with\\nappropriate treatment.\\nPrevention\\nBereavement is considered a normal response to\\ndeath and loss, which are universal human experi-\\nences. It should ordinarily be allowed to run its course;\\nmost counselors maintain that trying to stifle or cut\\nshort the grief process is more likely to cause emo-\\ntional problems later on than to prevent them.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders, 4th edition, text revision.\\nWashington, DC: American Psychiatric Association,\\n2000.\\nDossey, Larry, MD.Healing Beyond the Body: Medicine and\\nthe Infinite Reach of the Mind.Boston and London:\\nShambhala, 2001. The chapters on ‘‘The Return of\\nPrayer’’ and ‘‘Immortality’’ are particularly relevant to\\nbereavement.\\n‘‘Mood Disorders.’’ Section 15, Chapter 189 inThe Merck\\nManual of Diagnosis and Therapy, edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nPERIODICALS\\nBowles, Stephen B., Larry C. James, Diane S. Solursh, et al.\\n‘‘Acute and Post-Traumatic Stress Disorder after\\nSpontaneous Abortion.’’American Family Physician61\\n(March 15, 2000): 1689–1696.\\nKersting, Karen. ‘‘A New Approach to Complicated Grief.’’\\nMonitor on Psychology35 (November 2004): 51.\\nLubit, Roy, MD. ‘‘Acute Treatment of Disaster Survivors.’’\\neMedicine, 17 June 2004. .\\nOgrodniczuk, John S., William E. Piper, Anthony S. Joyce,\\net al. ‘‘Differentiating Symptoms of Complicated Grief\\nand Depression among Psychiatric Outpatients.’’\\nCanadian Journal of Psychiatry/Revue canadienne de\\npsychiatrie 48 (March 2003): 87–93.\\nORGANIZATIONS\\nAlzheimer’s Association. 225 North Michigan Avenue, 17th\\nFloor, Chicago, IL 60601-7633. (312) 335-8700.\\n24-hour hotline: (800) 272-3900. .\\nThis website is an excellent resource for anyone with a\\nloved one suffering from Alzheimer’s or another\\ndementing illness.\\nAmerican Academy of Child and Adolescent Psychiatry.\\n3615 Wisconsin Avenue, NW, Washington, DC\\n20016-3007. (202) 966-7300. Fax: (202) 966-2891.\\n.\\nAmerican Veterinary Medical Association (AVMA). 1931\\nNorth Meacham Road, Suite 100, Schaumburg, IL\\nGALE ENCYCLOPEDIA OF MEDICINE 519\\nBereavement'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 549, 'page_label': '520'}, page_content='60173-4360. . The AVMA\\nwebsite includes links to resources about pet loss.\\nDougy Center for Grieving Children and Families. 3909 SE\\n52nd Avenue, Portland, OR 97206. (866) 775-5683 or\\n(503) 775-5683. Fax: (503) 777-3097. . Provides age-appropriate\\nsupport groups, information, and referral services for\\nbereaved children and adolescents.\\nNational Air Disaster Alliance/Foundation (NADA). 2020\\nPennsylvania Avenue #315, Washington, DC 20006-\\n1846. (888) 444-NADA. Fax: (336) 643-1394. . NADA was founded in 1995\\nfollowing the loss of USAir Flight 427 to meet the needs\\nof people who have lost loved ones in air disasters as\\nwell as work for better transportation safety standards.\\nNational Hospice and Palliative Care Organization\\n(NHPCO). 1700 Diagonal Road, Suite 625, Alexandria,\\nVA 22314. (703) 837-1500. Fax: (703) 837-1233.\\n. This website is a good source\\nof information about hospice-based bereavement ser-\\nvices and support groups.\\nNational Institute of Mental Health (NIMH). 6001\\nExecutive Boulevard, Room 8184, MSC 9663,\\nBethesda, MD 20892-9663. (301) 443-4513 or (886) 615-\\nNIMH. \\nTragedy Assistance Program for Survivors, Inc. (TAPS).\\nNational Headquarters, 1621 Connecticut Avenue NW,\\nSuite 300, Washington, DC 20009. (202) 588-TAPS.\\nHotline: (800) 959-TAPS. .\\nTAPS provides grief support for those who have lost a\\nloved one serving in the Armed Forces.\\nOTHER\\nAlzheimer’s Association.Fact Sheet: About Grief, Mourning\\nand Guilt.Chicago, IL: Alzheimer’s Association, 2004.\\nAmerican Academy of Child and Adolescent Psychiatry\\n(AACAP). Children and Grief. AACAP Facts for\\nFamilies #8. Washington, DC: AACAP, 2004.\\nAmerican Academy of Child and Adolescent Psychiatry\\n(AACAP). When a Pet Dies. AACAP Facts for\\nFamilies #78. Washington, DC: AACAP, 2000.\\nHarper, Linda R., PhD.Healing after the Loss of Your Pet.\\n.\\nNational Institute of Mental Health (NIMH).Mental Health\\nand Mass Violence: Evidence-Based Early Psychological\\nInterventions for Victims/Survivors of Mass Violence.\\nNIH Publication No. 02-5138. Washington, DC: U. S.\\nGovernment Printing Office, 2002.\\nNational Organization of Parents of Murdered Children\\n(POMC). Information Bulletin: Survivors of Homicide\\nVictims. .\\nRebecca Frey, PhD\\nBerger’s diseasesee Idiopathic primary renal\\nhematuric/proteinuric syndrome\\nBeriberi\\nDefinition\\nBeriberi is a disease caused by a deficiency of\\nthiamine (vitamin B1) that affects many systems of\\nthe body, including the muscles, heart, nerves, and\\ndigestive system. Beriberi literally means ‘‘I can’t, I\\ncan’t’’ in Singhalese, which reflects the crippling effect\\nit has on its victims. It is common in parts of southeast\\nAsia, where white rice is the main food. In the United\\nStates, beriberi is primarily seen in people with chronic\\nalcoholism.\\nDescription\\nBeriberi puzzled medical experts for years as it\\nravaged people of all ages in Asia. Doctors thought it\\nwas caused by something in food. Not until the early\\n1900s did scientists discover that rice bran, the outer\\ncovering that was removed to create the polished white\\nrice preferred by Asians, actually contained something\\nthat prevented the disease. Thiamine was the first\\nvitamin identified. In the 1920s, extracts of rice polish-\\nings were used to treat the disease.\\nIn adults, there are different forms of beriberi,\\nclassified according to the body systems most affected.\\nDry beriberi involves the nervous system; wet beriberi\\naffects the heart and circulation. Both types usually\\noccur in the same patient, with one set of symptoms\\npredominating.\\nA less common form of cardiovascular, or wet\\nberiberi, is known as ‘‘shoshin.’’ This condition\\ninvolves a rapid appearance of symptoms and acute\\nheart failure. It is highly fatal and is known to cause\\nsudden death in young migrant laborers in Asia whose\\ndiet consists of white rice.\\nCerebral beriberi, also known as Wernicke-\\nKorsakoff syndrome, usually occurs in chronic alco-\\nholics and affects the central nervous system (brain\\nand spinal cord). It can be caused by a situation that\\naggravates a chronic thiamine deficiency, like an alco-\\nholic binge or severevomiting.\\nInfantile beriberi is seen in breastfed infants of\\nthiamine-deficient mothers, who live in developing\\nnations.\\nAlthough severe beriberi is uncommon in the\\nUnited States, less severe thiamine deficiencies do\\noccur. About 25% of all alcoholics admitted to a\\nhospital in the United States show some evidence of\\nthiamine deficiency.\\n520 GALE ENCYCLOPEDIA OF MEDICINE\\nBeriberi'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 550, 'page_label': '521'}, page_content='Causes and symptoms\\nThiamine is one of the Bvitamins and plays an\\nimportant role in energy metabolism and tissue build-\\ning. It combines with phosphate to form the coenzyme\\nthiamine pyrophosphate (TPP), which is essential in\\nreactions that produce energy from glucose or that\\nconvert glucose to fat for storage in the tissues.\\nWhen there is not enough thiamine in the diet, these\\nbasic energy functions are disturbed, leading to pro-\\nblems throughout the body.\\nSpecial situations, such as an over-active meta-\\nbolism, prolonged fever, pregnancy, and breastfeed-\\ning, can increase the body’s thiamine requirements\\nand lead to symptoms of deficiency. Extended peri-\\nods ofdiarrhea or chronic liver disease can result in\\nthe body’s inability to maintain normal levels of\\nmany nutrients, including thiamine. Other persons\\nat risk are patients with kidney failure on dialysis\\nand those with severe digestive problems who are\\nunable to absorb nutrients. Alcoholics are susceptible\\nbecause they may substitute alcohol for food and\\ntheir frequent intake of alcohol decreases the body’s\\nability to absorb thiamine.\\nThe following systems are most affected by\\nberiberi:\\n/C15Gastrointestinal system. When the cells of the\\nsmooth muscles in the digestive system and glands\\ndo not get enough energy from glucose, they are\\nunable to produce more glucose from the normal\\ndigestion of food. There is a loss of appetite,indiges-\\ntion, severeconstipation, and a lack of hydrochloric\\nacid in the stomach.\\n/C15Nervous System. Glucose is essential for the central\\nnervous system to function normally. Early defi-\\nciency symptoms arefatigue, irritability, and poor\\nmemory. If the deficiency continues, there is damage\\nto the peripheral nerves that causes loss of sensation\\nand muscle weakness, which is calledperipheral neu-\\nropathy. The legs are most affected. The toes feel\\nnumb and the feet have a burning sensation; the leg\\nmuscles become sore and the calf muscles cramp. The\\nindividual walks unsteadily and has difficulty getting\\nup from a squatting position. Eventually, the muscles\\nshrink (atrophy) and there is a loss of reflexes in the\\nknees and feet; the feet may hang limp (footdrop).\\n/C15Cardiovascular system. There is a rapid heartbeat\\nand sweating. Eventually the heart muscle weakens.\\nBecause the smooth muscle in the blood vessels is\\naffected, the arteries and veins relax, causing swel-\\nling, known asedema, in the legs.\\n/C15Musculoskeletal system. There is widespread mus-\\ncle pain caused by the lack of TPP in the muscle\\ntissue.\\nInfants who are breastfed by a thiamine-\\ndeficient mother usually develop symptoms of\\ndeficiency between the second and fourth month of\\nlife. They are pale, restless, unable to sleep, prone\\nto diarrhea, and have muscle wasting and edema in\\ntheir arms and legs. They have a characteristic,\\nsometimes silent, cry and develop heart failure and\\nnerve damage.\\nDiagnosis\\nA physical examination will reveal many of the\\nearly symptoms of beriberi, such as fatigue, irrita-\\ntion, nausea, constipation, and poor memory, but\\nthe deficiency may be difficult to identify.\\nInformation about the individual’s diet and general\\nhealth is also needed.\\nThere are many biochemical tests based on thia-\\nmine metabolism or the functions of TPP that can\\ndetect a thiamine deficiency. Levels of thiamine can\\nbe measured in the blood and urine and will be\\nreduced if there is a deficiency. The urine can be\\nKEY TERMS\\nB vitamins— This family of vitamins consists of\\nthiamine (B1), riboflavin (B2), niacin (B3), pantothe-\\nnic acid (B5), pyridoxine (B6), biotin, folic acid (B9),\\nand cobalamin (B12). They are interdependent and\\ninvolved in converting glucose to energy.\\nCoenzyme— A substance needed by enzymes to\\nproduce many of the reactions in energy and pro-\\ntein metabolism in the body.\\nEdema— An excess accumulation of fluid in the\\ncells and tissues.\\nEnzyme— A protein that acts as a catalyst to pro-\\nduce chemical changes in other substances without\\nbeing changed themselves.\\nMetabolism— All the physical and chemical\\nchanges that take place within an organism.\\nPeripheral neuropathy— A disease affecting the\\nportion of the nervous system outside the brain\\nand spinal chord. One or more nerves can be\\ninvolved, causing sensory loss, muscle weakness\\nand shrinkage, and decreased reflexes.\\nThiamine pyrophosphate (TPP)— The coenzyme\\ncontaining thiamine that is essential in converting\\nglucose to energy.\\nGALE ENCYCLOPEDIA OF MEDICINE 521\\nBeriberi'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 551, 'page_label': '522'}, page_content='collected for 24 hours to measure the level of thia-\\nmine excreted. Another reliable test measures the\\neffect of TPP on red blood cell activity since all\\nforms of beriberi affect the metabolism of red blood\\ncells.\\nAn electroencephalogram (EEG), which measures\\nelectrical activity in the brain, may be done to rule out\\nother causes of neurologic changes. Observing\\nimprovements in the patient after giving thiamine\\nsupplements will also confirm the diagnosis.\\nTreatment\\nTreatment with thiamine reverses the deficiency in\\nthe body and relieves most of the symptoms. Severe\\nthiamine deficiency is treated with high doses of thia-\\nmine given by injection into a muscle (intramuscular)\\nor in a solution that goes into a vein (intravenously)\\nfor several days. Then smaller doses can be given\\neither by injection or in pill form until the patient\\nrecovers. Usually there are other deficiencies in the\\nB vitamins that will also need treatment.\\nThe cardiovascular symptoms of wet beriberi can\\nrespond to treatment within a few hours if they are\\nnot too severe. Heart failure may require additional\\ntreatment with diuretics that help eliminate excess\\nfluid and with heart-strengthening drugs like\\ndigitalis.\\nRecovery from peripheral neuropathy and other\\nsymptoms of dry beriberi may take longer and patients\\nfrequently become discouraged. They should stay\\nactive; physical therapy will also help in recovery.\\nInfantile beriberi is treated by giving thiamine to\\nboth the infant and the breast feeding mother until\\nlevels are normal.\\nIn Wernicke-Korsakoff syndrome, thiamine should\\nbe given intravenously or by injection at first because the\\nintestinal absorption of thiamine is probably impaired\\nand the patient is very ill. Most of the symptoms will be\\nrelieved by treatment, though there may be residual\\nmemory loss.\\nExcess thiamine is excreted by the body in the\\nurine, and negative reactions to too much thiamine\\nare rare. Thiamine is unstable in alkali solutions, so it\\nshould not be taken withantacids or barbiturates.\\nAlternative treatment\\nAlternative treatments for beriberi deal first with\\ncorrecting the thiamine deficiency. As in conventional\\ntreatments, alternative treatments for beriberistress\\na diet rich in foods that provide thiamine and other\\nB vitamins, such as brown rice, whole grains, raw\\nfruits and vegetables, legumes, seeds, nuts, and yogurt.\\nDrinking more than one glass of liquid with a meal\\nshould be avoided, since this may wash out the vita-\\nmins before they can be absorbed by the body.\\nThiamine should be taken daily, with the dose depend-\\ning on the severity of the disease. Additional supple-\\nments of B vitamins, a multivitamin and mineral\\ncomplex, and Vitamin C are also recommended.\\nOther alternative therapies may help relieve the per-\\nson’s symptoms after the thiamine deficiency is\\ncorrected.\\nPrognosis\\nBeriberi is fatal if not treated and the longer the\\ndeficiency exists, the sicker the person becomes. Most\\nof the symptoms can be reversed and full recovery is\\npossible when thiamine levels are returned to normal\\nand maintained with a balanced diet and vitamin sup-\\nplements as needed.\\nPrevention\\nA balanced diet containing all essential nutrients\\nwill prevent a thiamine deficiency and the develop-\\nment of beriberi. People who consume large quantities\\nof junk food like soda, pretzels, chips, candy, and high\\ncarbohydrate foods made with unenriched flours may\\nbe deficient in thiamine and other vital nutrients. They\\nmay need to take vitamin supplements and should\\nimprove theirdiets.\\nDietary Requirements\\nThe body’s requirements for thiamine are tied\\nto carbohydrate metabolism and expressed in terms\\nof total intake of calories. The current recom-\\nmended dietary allowances (RDA) are 0.5 mg for\\nevery 1000 calories, with a minimum daily intake\\nof 1 mg even for those who eat fewer than 2,000\\ncalories in a day. The RDA for children and teen-\\nagers is the same as for adults: 1.4 mg daily for\\nmales over age eleven, and 1.1 mg for females.\\nDuring pregnancy, an increase to 1.5 mg daily is\\nneeded. Because of increased energy needs and the\\nsecretion of thiamine in breast milk, breast feeding\\nmothers need 1.5 mg every day. In infants, 0.4 mg\\nis advised.\\nFood Sources\\nThe best food sources of thiamine are lean\\npork, beef, liver, brewer’s yeast, peas and beans,\\n522 GALE ENCYCLOPEDIA OF MEDICINE\\nBeriberi'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 552, 'page_label': '523'}, page_content='whole or enriched grains, and breads. The more\\nrefined the food, as in white rice, white breads,\\nand some cereals, the lower the thiamine. Many\\nfood products are enriche d with thiamine, along\\nwith riboflavin, niacin, and iron, to prevent dietary\\ndeficiency.\\nDuring the milling process, rice is polished and all\\nthe vitamins in the exterior coating of bran are lost.\\nBoiling the rice before husking preserves the vitamins\\nby distributing them throughout the kernel. Food\\nenrichment programs have eliminated beriberi in\\nJapan and the Phillipines.\\nLike all B vitamins, thiamine is water soluble,\\nwhich means it is easily dissolved in water. It will\\nleach out during cooking in water and is destroyed\\nby high heat and overcooking.\\nResources\\nPERIODICALS\\nRyan, Ruth, et al. ‘‘Beriberi Unexpected.’’Psychosomatics\\nMay-June 1997: 191-294.\\nKaren Ericson, RN\\nBerry aneurysm see Cerebral aneurysm\\nBerylliosis\\nDefinition\\nBerylliosis is lung inflammation caused by inhal-\\ning dust or fumes that contain the metallic element\\nberyllium. Found in rocks, coal, soil, and volcanic\\ndust, beryllium is used in the aerospace industry and\\nin many types of manufacturing. Berylliosis occurs in\\nboth acute and chronic forms. In some cases, appear-\\nance of the disease may be delayed as much as 20 years\\nafter exposure to beryllium.\\nDescription\\nIn the 1930s, scientists discovered that beryllium\\ncould make fluorescent light bulbs last longer. During\\nthe following decade, the hard, grayish metal was\\nidentified as the cause of a potentially debilitating,\\nsometimes deadly disease characterized byshortness\\nof breathand inflammation, swelling, and scarring of\\nthe lungs.\\nThe manufacture of fluorescent light bulbs is no\\nlonger a source of beryllium exposure, but serious\\nhealth hazards are associated with any work\\nenvironment or process in which beryllium fumes or\\nparticles become airborne. Working with pure beryl-\\nlium, beryllium compounds (e.g. beryllium oxide), or\\nberyllium alloys causes occupational exposure. So do\\njobs involving:\\n/C15electronics\\n/C15fiber optics\\n/C15manufacturing ceramics, bicycle frames, golf clubs,\\nmirrors, and microwave ovens\\n/C15mining\\n/C15nuclear weapons and reactors\\n/C15reclaiming scrap metal\\n/C15space and atomic engineering\\n/C15dental and laboratory technology\\nBeryllium dust and fumes are classified as toxic air\\npollutants by the Environmental Protection Agency\\n(EPA). It is estimated that 2–6% of workers exposed\\nto these contaminants eventually develop berylliosis.\\nCauses and symptoms\\nCoughing, shortness of breath, and weight loss\\nthat begin abruptly can be a symptom of acute ber-\\nylliosis. This condition is caused by beryllium air pol-\\nlution that inflames the lungs making them rigid; it can\\naffect the eyes and skin as well. People who have acute\\nberylliosis are usually very ill. Most recover, but some\\ndie of the disease.\\nChronic berylliosis is an allergic reaction to long-\\nterm exposure to even low levels of beryllium dust or\\nfumes. A systemic disease that causes formation of\\nabnormal lung tissue and enlargement of the lymph\\nnodes, chronic berylliosis also may affect other parts\\nof the body. The symptoms of chronic berylliosis are\\nKEY TERMS\\nBeryllium— A steel-grey, metallic mineral used in\\nthe aerospace and nuclear industries and in a vari-\\nety of manufacturing processes.\\nChelation therapy— A treatment using chelating\\nagents, compounds that surround and bind to target\\nsubstances allowing them to be excreted from the\\nbody.\\nCorticosteroids— A group of anti-inflammatory\\ndrugs.\\nGALE ENCYCLOPEDIA OF MEDICINE 523\\nBerylliosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 553, 'page_label': '524'}, page_content='largely the same as those seen in acute berylliosis, but\\nthey develop more slowly.\\nDiagnosis\\nBerylliosis is initially suspected if a patient with\\nsymptoms of the disease has a history of beryllium\\nexposure. Achest x rayshows characteristic changes\\nin the lungs. However, since these changes can resem-\\nble those caused by other lung diseases, further testing\\nmay be necessary.\\nThe beryllium lymphocyte proliferation test\\n(BeLPT), a blood test that can detect beryllium sensi-\\ntivity (i.e. an allergic reaction to beryllium), is used to\\nscreen individuals at risk of developing berylliosis.\\nWhen screening results reveal a high level of sensitiv-\\nity, BeLPT is performed on cells washed from the\\nlungs. This test is now considered the most definitive\\ndiagnostic test for berylliosis.\\nTreatment\\nIndividuals with beryllium sensitivity or early-\\nstage berylliosis should be transferred from tasks\\nthat involve beryllium exposure and regularly exam-\\nined to determine whether the disease has progressed.\\nAcute berylliosis is a serious disease that occasion-\\nally may be fatal. Ventilators can help patients with\\nacute berylliosis breathe. Prompt corticosteroid ther-\\napy is required to lessen lung inflammation.\\nChronic beryllium disease is incurable.\\nCorticosteroid therapy is often prescribed, but it is\\nnot certain that steroids can alter the progression of\\nthe disease, and they have no effect on scarring of lung\\ntissue. Cleansing the lungs of beryllium is a slow pro-\\ncess, so long-term therapy may be required.Chelation\\ntherapy is currently under investigation as a treatment\\nfor the disease.\\nPrognosis\\nMost patients with acute berylliosis recover fully\\n7–10 days after treatment begins, and the disease\\nusually causes no after effects.\\nPatients whose lungs are severely damaged by\\nchronic berylliosis may experience fatalheart failure\\nbecause of the strain placed on the heart.\\nPrevention\\nEliminating exposure to beryllium is the surest way\\nto prevent berylliosis. Screening workers who are\\nexposed to beryllium fumes or dust or who develop an\\nallergic reaction to these substances is an effective way\\nto control symptoms and prevent disease progression.\\nResources\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York,\\nNY 10019. (800) 586-4872. .\\nBeryllium Support Group. P.O. Box 2021, Broomfield, CO\\n80038-2021. (303) 412-7065. .\\nEnvironmental Health Center. 1025 Connecticut Ave., NW,\\nWashington, DC 20036. (202) 293-2270.\\nMaureen Haggerty\\nBeryllium pneumonosis see Berylliosis\\nBeryllium poisoning see Berylliosis\\nBeta-adrenergic blockers see beta blockers\\nBeta blockers\\nDefinition\\nBeta blockers are medicines that affect the body’s\\nresponse to certain nerve impulses. This, in turn,\\ndecreases the force and rate of the heart’s contrac-\\ntions, which lowers blood pressure and reduces the\\nheart’s demand for oxygen.\\nPurpose\\nThe main use of beta blockers is to treat high\\nblood pressure. Some also are used to relieve the type\\nof chestpain called angina or to prevent heart attacks\\nin people who already have had oneheart attack.\\nThese drugs may also be prescribed for other condi-\\ntions, such as migraine,tremors, and irregular heart-\\nbeat. In eye drop form, they are used to treat certain\\nkinds ofglaucoma.\\nDescription\\nBeta blockers, also known as beta-adrenergic\\nblockers, are available only with a physician’s\\nprescription. They come in capsule, tablet, liquid, and\\ninjectable forms. Some common beta blockers are\\natenolol (Tenormin), metoprolol (Lopressor), nadolol\\n(Corgard), propranolol (Inderal), and timolol\\n(Blocadren). Timolol and certain other beta blockers\\nare also sold in eye drop form for treating glaucoma.\\n524 GALE ENCYCLOPEDIA OF MEDICINE\\nBeta blockers'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 554, 'page_label': '525'}, page_content='Eye drops that contain beta blockers include betaxolol\\n(Betoptic), cartelol (Ocupress), and timolol (Timoptic).\\nRecommended dosage\\nThe recommended dosage depends on the type,\\nstrength, and form of beta blocker and the condition\\nfor which it is prescribed. The physician who pre-\\nscribed the drug or the pharmacist who filled the pre-\\nscription can recommend the correct dosage.\\nThis medicine may take several weeks to notice-\\nably lower blood pressure. Taking it exactly as direc-\\nted is important.\\nThis medicine should not be stopped without\\nchecking with the physician who prescribed it. Some\\nconditions may get worse when patients stop taking\\nbeta blockers abruptly. This may also increase the risk\\nof heart attack in some people. Because of these possi-\\nble effects, it is important to keep enough medicine on\\nhand to get through weekends, holidays, and vacations.\\nPhysicians may recommend that patients check\\ntheir pulse before and after taking this medicine. If the\\npulse becomes too slow, circulation problems may result.\\nPrecautions\\nSeeing a physician regularly while taking beta\\nblockers is important. The physician will check to\\nmake sure the medicine is working as it should and\\nwill watch for unwanted side effects. People who have\\nhigh blood pressure often feel perfectly fine. However,\\nthey should continue to see their physicians even when\\nthey feel well so that the physician can keep a close\\nwatch on their condition. Patients also need to keep\\ntaking their medicine even when they feel fine.\\nBeta blockers will not cure high blood pressure,\\nbut will help control the condition. To avoid the ser-\\nious health problems that high blood pressure can\\ncause, patients may have to take medicine for the rest\\nof their lives. Furthermore, medicine alone may not be\\nenough. Patients with high blood pressure may also\\nneed to avoid certain foods and keep their weight\\nunder control. The health care professional who is\\ntreating the condition can offer advice on what mea-\\nsures may be necessary. Patients being treated for high\\nblood pressure should not change theirdiets without\\nconsulting their physicians.\\nAnyone taking beta blockers for high blood pres-\\nsure should not take any other prescription or over-the-\\ncounter medicine without first checking with his or her\\nphysician. Some medicines may increase blood pressure.\\nAnyone who is taking beta blockers should be\\nsure to tell the health care professional in charge\\nbefore having any surgical or dental procedures or\\nreceiving emergency treatment.\\nSome beta blockers may change the results of\\ncertain medical tests. Before having medical tests, any-\\none taking this medicine should alert the health care\\nprofessional in charge.\\nSome people feel drowsy, dizzy, or lightheaded\\nwhen taking beta blockers. Anyone who takes these\\ndrugs should not drive, use machines or do anything\\nelse that might be dangerous until they have found out\\nhow the drugs affect them.\\nBeta blockers may increase sensitivity to cold,\\nespecially in older people or people who have poor\\ncirculation. Anyone who takes this medicine should\\nBlister packs of Tenormin LS (atenolol), a type of beta-recep-\\ntor blocking drug or beta blocker. This type of drug is widely\\nused to treat angina, to lower blood pressure, or to correct\\nabnormal heart rhythms. (Photograph by Adam Hart-Davis,\\nPhoto Researchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAngina pectoris— A feeling of tightness, heaviness,\\nor pain in the chest, caused by a lack of oxygen in\\nthe muscular wall of the heart.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nMigraine— A throbbing headache that usually\\naffects only one side of the head. Nausea, vomiting,\\nincreased sensitivity to light, and other symptoms\\noften accompany migraine.\\nGALE ENCYCLOPEDIA OF MEDICINE 525\\nBeta blockers'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 555, 'page_label': '526'}, page_content='dress warmly in cold weather and should be careful\\nnot to be exposed to the cold for too long.\\nPeople who usually have chest pain when they\\nexercise or exert themselves may not have the pain\\nwhen they are taking beta blockers. This could lead\\nthem to be more active than they should be. Anyone\\ntaking this medicine should ask his or her physician\\nhow much exercise and activity is safe.\\nOlder people may be unusually sensitive to the\\neffects of beta blockers. This may increase the chance\\nof side effects.\\nPhysicians may advise people taking beta blockers\\nto wear or carry medical identification indicating that\\nthey are taking this medicine.\\nSpecial conditions\\nPeople who have certain medical conditions or\\nwho are taking certain other medicines may have pro-\\nblems if they take beta blockers. Before taking these\\ndrugs, the physician should know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to beta blockers in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\ninsect stings, medicines, foods, dyes, preservatives, or\\nother substances. In people with allergies to medicines,\\nfoods, or insect stings, beta blockers may make the\\nallergic reactions more severe and harder to treat.\\nAnyone who has an allergic reaction while taking\\nbeta blockers should get medical attention right\\naway and should make sure the physician in charge\\nknows that he or she is taking this medicine.\\nBeta blockers may also cause serious reactions in\\npeople who take allergy shots. Anyone taking this\\nmedicine should be sure to alert the physician before\\nhaving any allergy shots.\\nDIABETES. Beta blockers may make blood sugar\\nlevels rise and may hide some symptoms of low\\nblood sugar. Diabetic patients should discuss these\\npossible problems with their physicians.\\nPREGNANCY. Some studies of beta blockers show\\nthat these drugs cause problems in newborns whose\\nmothers use them duringpregnancy. Other studies do\\nnot show such effects. Women who are pregnant or\\nwho may become pregnant should check with their\\nphysicians about the use of beta blockers.\\nBREASTFEEDING. Some beta blockers pass into\\nbreast milk and may cause breathing problems, slow\\nheartbeat, and low blood pressure in nursing babies\\nwhose mothers take the drugs. Women who need to\\ntake beta blockers and who want to breastfeed their\\nbabies should check with their physicians.\\nOTHER MEDICAL CONDITIONS. Beta blockers may\\nincrease breathing problems or make allergic reactions\\nmore severe in people who have allergies,bronchitis,o r\\nemphysema. However, while breathing diseases were\\nonce thought to outrule use of beta blockers, new\\nresearch in 2004 shows that this may have been a\\nlarge misconception. A clinical trial showed that\\nmore than 98% of patients with chronic obstructive\\npulmonary disease safely used beta blockers. It is\\nadvised for patients with emphysema and other ser-\\nious pulmonary disease to check with a physician and\\ndiscuss the new findings.\\nIn people with an overactive thyroid, stopping beta\\nblockers suddenly may cause an increase in symptoms.\\nAlso, taking this medicine may hide a fast heartbeat,\\nwhich is one of the symptoms of overactive thyroid.\\nEffects of these drugs may be greater in people\\nwith kidney orliver disease because the medicine is\\ncleared from the body more slowly.\\nBeta blockers may also make the following med-\\nical conditions worse:\\n/C15Heart or blood vessel disease\\n/C15Unusually slow heartbeat (bradycardia)\\n/C15Myasthenia gravis (chronic disease causing muscle\\nweakness and possiblyparalysis)\\n/C15Psoriasis (itchy, scaly, red patches of skin)\\n/C15Depression (now, or in the past).\\nBefore using beta blockers, people with any of the\\nmedical problems listed in this section should make\\nsure their physicians are aware of their conditions.\\nUSE OF CERTAIN MEDICINES. Taking beta blockers\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness,d r o w s -\\niness, lightheadedness, sleep problems, unusual tiredness\\nor weakness, and decreased sexual ability. In men, this\\ncan occur asimpotence or delayed ejaculation. These\\nproblems usually go away as the body adjusts to the\\ndrug and do not require medical treatment unless they\\npersist or they interfere with normal activities. On the\\npositive side, research in 2004 showed that use of beta\\nblockers helps reduce risk for boenfractures.\\nMore serious side effects are possible. If any of the\\nfollowing side effects occur, the physician who prescribed\\nthe medicine should be notified as soon as possible:\\n526 GALE ENCYCLOPEDIA OF MEDICINE\\nBeta blockers'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 556, 'page_label': '527'}, page_content='/C15Breathing problems\\n/C15Slow heartbeat\\n/C15Cold hands and feet\\n/C15Swollen ankles, feet, or lower legs\\n/C15Mental depression.\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking beta blockers should\\nget in touch with his or her physician.\\nInteractions\\nBeta blockers may interact with a number of other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes beta blockers\\nshould let the physician know all other medicines he\\nor she is taking. Among the drugs that may interact\\nwith beta blockers are:\\n/C15Calcium channel blockers and other blood pressure\\ndrugs. Using these drugs with beta blockers may\\ncause unwanted effects on the heart.\\n/C15Insulin and diabetes medicines taken by mouth. Beta\\nblockers cause high blood sugar or hide the symp-\\ntoms of low blood sugar.\\n/C15Monoamine oxidase inhibitors (MAO) such as phe-\\nnelzine (Nardil) or tranylcypromine (Parnate), used\\nto treat conditions including depression and\\nParkinson’s disease. Taking beta blockers at the\\nsame time or within two weeks of taking MAO inhi-\\nbitors may cause severe high blood pressure.\\n/C15Airway-opening drugs (bronchodilators) such as ami-\\nnophylline (Somophyllin), dyphylline (Lufyllin)\\noxtriphylline (Choledyl), or theophylline\\n(Somophyllin-T). When combined with beta block-\\ners, the effects of both the beta blockers and the\\nairway-opening drugs may be lessened.\\n/C15Cocaine. High blood pressure, fast heartbeat, and\\nheart problems are possible when cocaine and beta\\nblockers are combined. Also, cocaine may interfere\\nwith the effects of beta blockers.\\n/C15Allergy shots or allergy skin tests. Beta blockers may\\nincrease the chance of serious reactions to these\\nmedicines.\\nThe list above may not include every drug that\\ninteracts with beta blockers. Checking with a physi-\\ncian or pharmacist before combining beta blockers\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine is advised.\\nResources\\nPERIODICALS\\n‘‘Study Reveals Fears Over Beta Blockers in COPD\\nUnfounded.’’ Pulse September 13, 2004: 8.\\n‘‘Use of Beta Blockers Associated With Decreased Risk for\\nFractures.’’ Life Science WeeklySeptember 28, 2004:\\n944.\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nBeta-thalassemia see Thalassemia\\nBetamethasone see Corticosteroids\\nBeta2-microglobulin test\\nDefinition\\nBeta2-microglobulin is a protein found on the sur-\\nface of many cells. Testing is done primarily when\\nevaluating a person for certain kinds ofcancer affect-\\ning white blood cells including chronic lymphocytic\\nleukemia, non-Hodgkin’s lymphoma, and multiple\\nmyeloma or kidney disease.\\nPurpose\\nBeta2-microglobulin is plentiful on the surface of\\nwhite blood cells. Increased production or destruction\\nof these cells causes Beta\\n2-microglobulin levels in the\\nblood to increase. This increase is seen in people with\\ncancers involving white blood cells, but it is particu-\\nlarly meaningful in people newly diagnosed with mul-\\ntiple myeloma. Multiple myeloma is a malignancy\\n(cancer) of a certain kind of white blood cell, called a\\nplasma cell. At the time of diagnosis, the Beta\\n2-micro-\\nglobulin levels reflect how advanced the disease is and\\nthe likely prognosis for that person.\\nWhen kidney disease is suspected, comparing\\nblood and urine levels helps identify where the kidney\\nis damaged. Beta\\n2-microglobulin normally is filtered\\nout of the blood by the kidney’s glomeruli (a round\\nmass of capillary loops leading to each kidney tubule),\\nonly to be partially reabsorbed back into the blood\\nwhen it reaches the kidney’s tubules. In glomerular\\nkidney disease, the glomeruli can’t filter it out of the\\nblood, so levels increase in the blood and decrease in\\nthe urine. In tubular kidney disease, the tubules can’t\\nreabsorb it back into the blood, so urine levels rise and\\nblood levels fall. After a kidney transplant, increased\\nblood levels may be an early sign of rejection.\\nGALE ENCYCLOPEDIA OF MEDICINE 527\\nBeta2-microglobulin test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 557, 'page_label': '528'}, page_content='Increased urinary levels are found in people with\\nkidney damage caused by high exposure to the heavy\\nmetals cadmium and mercury. Periodic testing of\\nworkers exposed to these metals helps to detect begin-\\nning kidney damage.\\nBeta\\n2-microglobulin levels also rise during infec-\\ntion with some viruses, including cytomegalovirus and\\nhuman immunodeficiency virus (HIV). Studies show\\nthat as HIV disease advances, beta\\n2-microglobulin\\nlevels rise.\\nDescription\\nTesting methods vary, but most involve adding\\nthe person’s serum–the yellow, liquid part of blood–\\nor urine to one or more substances that bind to beta\\n2-\\nmicroglobulin in the serum or urine. The amount of\\nthe substance(s) bound to beta\\n2-microglobulin is mea-\\nsured and the original amount of beta2-microglobulin\\nis determined.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available the next day.\\nPreparation\\nThe blood test requires 5 mL of blood. A health-\\ncare worker ties a tourniquet on the person’s upper\\narm, locates a vein in the inner elbow region, and\\ninserts a needle into that vein. Vacuum action draws\\nthe blood through the needle into an attached tube.\\nCollection of the sample takes only a few minutes.\\nUrine may be a single collection or collected\\nthroughout a 24-hour time period. The urine should\\nbe refrigerated until it is brought to the laboratory and\\nmust not become acidic.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to the\\npuncture site until the bleeding stops reduces bruising.\\nWarm packs on the puncture site relieve discomfort.\\nNormal results\\n/C15Serum: less than or equ to 2.7 g/ml\\n/C15Urine: less than 1 mg 24 hours 0–160 g/L\\nAbnormal results\\nThe meaning of an abnormal result varies with the\\nclinical condition of the person tested. In a person with\\nmultiple myeloma, a higher level means a poorer prog-\\nnosis than a lower level. In a person with kidney dis-\\nease, an increased blood level means the problem is\\ntubular, not glomerular. In a kidney transplant\\npatient, an increase may be a sign of rejection, toxic\\namounts of antirejection medication, or a viral infec-\\ntion. An increased level in a worker exposed to cad-\\nmium or mercury may signal beginning kidney\\ndamage and in a person with HIV, advancing disease.\\nResources\\nBOOKS\\nLehmann, Craig A.Saunders Manual of Clinical Laboratory\\nScience. Philadelphia: W. B. Saunders Co., 1998.\\nNancy J. Nordenson\\nBile duct infection see Cholangitis\\nBile duct cancer\\nDefinition\\nBile duct cancer, or cholangiocarcinoma, is a\\nmalignant tumor of the bile ducts within the liver\\n(intrahepatic), or leading from the liver to the small\\nKEY TERMS\\nBeta2-microglobulin— A protein found on the sur-\\nface of many cells, particularly white blood cells.\\nChronic lymphocytic leukemia— A cancer of the\\nblood cells characterized by large numbers of can-\\ncerous, mature white blood cells and enlarged\\nlymph nodes.\\nGlomerular kidney disease— Disease of the kidney\\nthat affects the glomeruli, the part of the kidney that\\nfilters certain substances out of the blood.\\nMuliple myeloma— A malignancy (cancer) of a cer-\\ntain kind of white blood cell, called a plasma cell.\\nNon-Hodgkin’s lymphoma— Cancer that origi-\\nnates in the lymphatic system and typically spreads\\nthroughout the body.\\nTubular kidney disease— Disease of the kidney that\\naffect the tubules, the part of the kidney that allows\\ncertain substances to be reabsorbed back into the\\nblood.\\n528 GALE ENCYCLOPEDIA OF MEDICINE\\nBile duct cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 558, 'page_label': '529'}, page_content='intestine (extrahepatic). It is a rare tumor with poor\\noutcome for most patients.\\nDescription\\nBile is a substance manufactured by the liver that\\naids in the digestion of food. Bile ducts are channels\\nthat carry the bile from the liver to the small intestine.\\nLike the tributaries of a river, the small bile ducts in\\nthe liver converge into two large bile ducts called the\\nleft and right hepatic ducts. These exit the liver and\\njoin to form the common hepatic duct. The gallblad-\\nder, which concentrates and stores the bile, empties\\ninto the common hepatic duct to form the common\\nbile duct. Finally, this large duct connects to the small\\nintestine where the bile can help digest food.\\nCollectively, this network of bile ducts is called the\\nbiliary tract.\\nBile duct cancer originates from the cells that line\\nthe inner surface of the bile ducts. A tumor may arise\\nanywhere along the biliary tract, either within or out-\\nside of the liver. Bile duct tumors are typically slow-\\ngrowing tumors that spread by local invasion of neigh-\\nboring structures and by way of lymphatic channels.\\nBile duct cancer is an uncommon malignancy. In\\nthe United States, approximately one case arises per\\n100,000 people per year, but it is more common in\\nSoutheast Asia. It occurs in men only slightly more\\noften than in women and it is most commonly diag-\\nnosed in people in their 50s and 60s. In fact, about\\n65% of patients with bile duct cancer are over age 65.\\nCauses and symptoms\\nA number of risk factors are associated with the\\ndevelopment of bile duct cancer:\\n/C15Primary sclerosingcholangitis. This disease is char-\\nacterized by extensive scarring of the biliary tract,\\nsometimes associated with inflammatory bowel\\ndisease.\\n/C15Choledochal cysts. These are abnormal dilatations of\\nthe biliary tract that usually form during fetal devel-\\nopment. There is evidence that these cysts may rarely\\narise during adulthood.\\n/C15Hepatolithiasis. This is the condition of stone forma-\\ntion within the liver (not including gallbladder stones).\\n/C15Liver flukes. Parasitic infection with certain worms is\\nthought to be at least partially responsible for the\\nhigher prevalence of bile duct cancer in Southeast\\nAsia.\\n/C15Thorotrast. This is a chemical that was previously\\ninjected intravenously during certain types of x rays.\\nIt is not in use anymore. Exposure to Thorotrast has\\nbeen implicated in the development of cancer of the\\nliver as well as the bile ducts.\\nSymptoms\\nJaundice is the first symptom in 90% of patients.\\nThis occurs when the bile duct tumor causes an\\nobstruction in the normal flow of bile from the liver\\nto the small intestine. Bilirubin, a component of bile,\\nbuilds up within the liver and is absorbed into the\\nbloodstream in excess amounts. This can be detected\\nin a blood test, but it can also manifest as yellowish\\ndiscoloring of the skin and eyes. The bilirubin in the\\nbloodstream also makes the urine appear dark.\\nAdditionally, the patient may experience generalized\\nitching due to the deposition of bile components in the\\nskin. Normally, a portion of the bile is excreted in\\nstool; bile actually gives stool its brown color. But\\nwhen the biliary tract is obstructed by tumor, the\\nstools may appear pale.\\nAbdominal pain, fatigue, weight loss, and poor\\nappetite are less common symptoms. Occasionally, if\\nobstruction of the biliary tract causes the gallbladder\\nto swell enormously yet without causing pain, the\\nphysician may be able to feel the gallbladder during a\\nKEY TERMS\\nAngiography— Radiographic examination of blood\\nvessels after injection with a special dye.\\nCholangiography— Radiographic examination of\\nthe bile ducts after injection with a special dye.\\nComputed tomography— Radiographic examina-\\ntion that obtains cross-sectional images of the\\nbody.\\nJaundice— Yellowish staining of the skin and eyes\\ndue to excess bilirubin in the bloodstream.\\nLymphatic— Pertaining to lymph, the clear fluid\\nthat is collected from tissues, flows through special\\nvessels, and joins the venous circulation.\\nMetastasis— The spread of cancerous tumor cells\\nfrom one part of the body to another.\\nResection— To surgically remove a part of the body\\nStent— Slender hollow catheter or rod placed\\nwithin a vessel or duct to provide support or main-\\ntain patency.\\nUltrasound— Radiographic imaging technique uti-\\nlizing high frequency sound waves.\\nGALE ENCYCLOPEDIA OF MEDICINE 529\\nBile duct cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 559, 'page_label': '530'}, page_content='physical examination. Sometimes the biliary tract can\\nbecome infected, but this is normally a rare conse-\\nquence of invasive tests. Infection causesfever, chills,\\nand pain in the right upper portion of the abdomen.\\nDiagnosis\\nCertain laboratory tests of the blood may aid in\\nthe diagnosis. The most important one is the test for\\nelevated bilirubin levels in the bloodstream. Levels of\\nalkaline phosphatase and CA 19-9 may also be\\nelevated.\\nWhen symptoms, physical signs, and blood tests\\npoint toward an abnormality of the biliary tract, the\\nnext step involves radiographic exams. Ultrasound,\\ncomputed tomography (CT scan), andmagnetic reso-\\nnance imaging (MRI) are noninvasive and rapid. In\\nrecent years, MRI has become the favored imaging\\nchoice for initial diagnosis of cholangiocarcinoma\\nwhen the exam is available and affordable or covered\\nby insurance. These tests can often detect the actual\\ntumor as well as dilatation of the obstructed biliary\\ntract. If these tests indicate the presence of a tumor,\\ncholangiography is required. This procedure involves\\ninjecting dye into the biliary tract to obtain anatomic\\nimages of the bile ducts and the tumor. The specialist\\nthat performs this test can also insert small tubes, or\\nstents, into a partially obstructed portion of the bile\\nduct to prevent further obstruction by growth of the\\ntumor. This is vitally important since it may be the\\nonly intervention that is possible in certain patients.\\nCholangiography is an invasive test that carries a\\nsmall risk of infection of the biliary tract. The objective\\nof these radiological tests is to determine the size and\\nlocation of the tumor, as well as the extent of spread to\\nnearby structures.\\nThe treatment of bile duct tumors is usually not\\naffected by the specific type of cancer cells that com-\\nprise the tumor. For this reason, some physicians\\nforego biopsy of the tumor.\\nTreatment\\nThe treatment is with surgical resection (removal)\\nof the tumor and all involved structures. Unfortunately,\\nsometimes the cancer has already spread too far when\\nthe diagnosis is made. Thus, in the treatment of bile\\nduct cancer, the first question to answer is if the tumor\\nmay be safely resected by surgery with reasonable\\nbenefit to the patient. If the cancer involves\\ncertain blood vessels or has spread widely throughout\\nthe liver, resection may not be possible. Sometimes\\nfurther invasive testing is required.\\nAngiography can determine if the blood vessels are\\ninvolved. Laparoscopy is a surgical procedure that\\nallows the surgeon to directly assess the tumor and\\nnearby lymph nodes without making a large incision\\nin the abdomen. Only about 45% of bile duct cancers\\nare ultimately resectable.\\nIf the tumor is resectable, and the patient is\\nhealthy enough to tolerate the operation, the specific\\ntype of surgery performed depends on the location of\\nthe tumor. For tumors within the liver or high up in\\nthe biliary tract, resection of part of the liver may be\\nrequired. Tumors in the middle portion of the biliary\\ntract can be removed alone. Tumors of the lower end\\nof the biliary tract may require extensive resection of\\npart of the pancreas, small intestine, and stomach to\\nensure complete resection.\\nUnfortunately, sometimes the cancer appears\\nresectable by all the radiological and invasive tests,\\nbut is found to be unresectable during surgery. In\\nthis scenario, a bypass operation can relieve the biliary\\ntract obstruction, but does not remove the tumor\\nitself. This does not produce a cure but it can offer a\\nbetter quality of life for the patient.\\nPrognosis\\nPrognosis depends on the stage and resectability\\nof the tumor. If the patient cannot undergo surgical\\nresection, the survival rate is commonly less than one\\nyear. If the tumor is resected, the survival rate\\nimproves, with 20% of these patients surviving past\\nfive years.\\nClinical trials\\nStudies of new treatments in patients are known as\\nclinical trials. These trials seek to compare the stan-\\ndard method of care with a new method, or the trials\\nmay be trying to establish whether one treatment is\\nmore beneficial for certain patients than others.\\nSometimes, a new treatment that is not being offered\\non a wide scale may be available to patients participat-\\ning in clinical trials, but participating in the trials may\\ninvolve some risk. To learn more about clinical trials,\\npatients can call the National Cancer Institute (NCI)\\nat 1-800-4-CANCER or visit the NCI web site for\\npatients at .\\nPrevention\\nOther than the avoidance of infections caused by\\nliver flukes, there are no known preventions for this\\ncancer.\\n530 GALE ENCYCLOPEDIA OF MEDICINE\\nBile duct cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 560, 'page_label': '531'}, page_content='Resources\\nBOOKS\\nAbeloff, Martin D., editor. ‘‘Cholangiocarcinoma.’’ In\\nClinical Oncology.2nd ed. New York: Churchill\\nLivingstone, 2000, pp.1722-1723.\\nAhrendt, Steven A., and Henry A. Pitt. ‘‘Biliary Tract.’’ In\\nSabiston Textbook of Surgery, edited by Courtney\\nTownsend Jr., 16th ed. Philadelphia: W.B. Saunders\\nCompany, 2001, pp. 1076-1111.\\nPERIODICALS\\n‘‘COX–2 Promoter Enhances the Efficacy of\\nCholangiosarcoma Gene Therapy.’’Cancer Weekly\\n(May 20, 2003): 167.\\nKhan, S.A., et al. ‘‘Guidelines for the Diagnosis and\\nTreatment of Cholangiosarcoma: Consensus\\nDocument.’’ Gut (November 2002): vi1–9.\\nORGANIZATIONS\\nThe American Cancer Society. 1-800-ACS 2345. .\\nAmerican Liver Foundation.1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nNational Cancer Institute (National Institutes of Health).\\n9000 Rockville Pike, Bethesda, MD 20892. (800) 422-\\n6237. .\\nKevin O. Hwang M.D.\\nTeresa G. Odle\\nBile duct atresia see Biliary atresia\\nBile flow obstruction see Cholestasis\\nBilharziasis see Schistosomiasis\\nBiliary atresia\\nDefinition\\nBiliary atresia is the failure of a fetus to develop an\\nadequate pathway for bile to drain from the liver to the\\nintestine.\\nDescription\\nBiliary atresia is the most common lethalliver\\ndisease in children, occurring once every 10,000–\\n15,000 live births. Half of all liver transplants are\\ndone for this reason.\\nThe normal anatomy of the bile system begins\\nwithin the liver, where thousands of tiny bile ducts\\ncollect bile from liver cells. These ducts merge into\\nlarger and larger channels, like streams flowing into\\nrivers, until they all pour into a single duct that empties\\ninto the duodenum (first part of the small intestine).\\nBetween the liver and the duodenum this duct has a side\\nchannel connected to the gall bladder. The gall bladder\\nstores bile and concentrates it, removing much of its\\nwater content. Then, when a meal hits the stomach, the\\ngall bladder contracts and empties its contents.\\nBile is a mixture of waste chemicals that the liver\\nremoves from the circulation and excretes through the\\nbiliary system into the intestine. On its way out, bile\\nassists in the digestion of certain nutrients. If bile\\ncannot get out because the channels are absent or\\nblocked, it backs up into the liver and eventually into\\nthe rest of the body. The major pigment in bile is a\\nchemical called bilirubin, which is yellow. Bilirubin is a\\nbreakdown product of hemoglobin (the red chemical\\nin blood that carries oxygen). If the body accumulates\\nan excess of bilirubin, it turns yellow (jaundiced). Bile\\nalso turns the stool brown. Without it, stools are the\\ncolor of clay.\\nCauses and symptoms\\nIt is possible that a viral infection is responsible\\nfor this disease, but evidence is not yet convincing. The\\ncause remains unknown.\\nThe affected infant will appear normal at birth\\nand during the newborn period. After two weeks the\\nnormal jaundice of the newborn will not disappear,\\nand the stools will probably be clay-colored. At this\\npoint, the condition will come to the attention of a\\nphysician. If not, the child’s abdomen will begin to\\nswell, and the infant will get progressively more ill.\\nNearly all untreated children will die of liver failure\\nwithin two years.\\nDiagnosis\\nThe persistence of jaundice beyond the second\\nweek in a newborn with clay-colored stools is a sure\\nsign of obstruction to the flow of bile. An immediate\\nevaluation that includes blood tests and imaging of the\\nbiliary system will confirm the diagnosis.\\nTreatment\\nSurgery is the only treatment. Somehow the sur-\\ngeon must create an adequate pathway for bile to\\nescape the liver into the intestine. The altered anatomy\\nof the biliary system is different in every case, calling\\nupon the surgeon’s skill and experience to select and\\nexecute the most effective among several options. If\\nthe obstruction is only between the gall bladder and\\nGALE ENCYCLOPEDIA OF MEDICINE 531\\nBiliary atresia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 561, 'page_label': '532'}, page_content='the intestine, it is possible to attach a piece of intestine\\ndirectly to the gall bladder. More likely, the upper\\nbiliary system will also be inadequate, and the surgeon\\nwill attach a piece of intestine directly to the liver–the\\nKasai procedure. In its wisdom, the body will discover\\nthat the tiny bile ducts in that part of the liver are\\ndischarging their bile directly into the intestine. Bile\\nwill begin to flow in that direction, and the channels\\nwill gradually enlarge. Survival rates for the Kasai\\nprocedure are commonly 50% at five years and 15%\\nat 10 years. Persistent disease in the liver gradually\\ndestroys the organ.\\nPrognosis\\nBefore liver transplants became available, even\\nprompt and effective surgery did not cure the whole\\nproblem. Biliary drainage can usually be established,\\nbut the patients still have a defective biliary system\\nthat develops progressive disease and commonly leads\\nto an earlydeath. Transplantation now achieves up to\\n90% one-year survival rates and promises to prevent\\nthe chronic disease that used to accompany earlier\\nprocedures.\\nPrevention\\nThe specific cause of this birth defect is unknown,\\nso all that women can do is to practice the many\\ngeneral preventive measures, even before they\\nconceive.\\nLiverCystic duct\\nPyloric sphincter\\nPancreas\\nDuodenum\\nGallbladder\\nCommon bile duct\\nBiliary atresia is a congenital condition in which the pathway for bile to drain from the liver to the intestine is undeveloped. It is\\nthe most common lethal liver disease in children.(Illustration by Electronic Illustrators Group).\\nKEY TERMS\\nDuodenum— The first part of the small intestine,\\nbeginning at the outlet of the stomach.\\nHemoglobin— The red, iron-containing chemical\\nin the blood that carries oxygen to the tissues.\\nJaundice— The yellow color taken on by a patient\\nwhose liver is unable to excrete bilirubin. A normal\\ncondition in the first week of life due to the infant’s\\ndelayed ability to process certain waste products.\\nKernicterus— A potentially lethal disease of new-\\nborns caused by excessive accumulation of the bile\\npigment bilirubin.\\n532 GALE ENCYCLOPEDIA OF MEDICINE\\nBiliary atresia'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 562, 'page_label': '533'}, page_content='Biliary atresia is a congenital condition in which\\nthe pathway for bile to drain from the liver to the\\nintestine is undeveloped. It is the most common lethal\\nliver disease in children.\\nResources\\nBOOKS\\nFeldman, Mark, et al. ‘‘Diseases of the Bile Ducts.’’\\nSleisenger & Fordtran’s Gastrointestinal and Liver\\nDisease. Philadelphia: W. B. Saunders Co., 1998.\\nJ. Ricker Polsdorfer, MD\\nBiliary duct cancer see Gallbladder cancer\\nBiliary tract cancer see Bile duct cancer\\nBilirubin test see Liver function tests\\nBinge-eating disorder\\nDefinition\\nBinge eating disorder (BED) is characterized by a\\nloss of control over eating behaviors. The binge eater\\nconsumes unnaturally large amounts of food in a short\\ntime period, but unlike a bulimic, does not regularly\\nengage in any inappropriate weight-reducing beha-\\nviors (for example, excessiveexercise, vomiting, taking\\nlaxatives) following the binge episodes.\\nDescription\\nBED typically strikes individuals sometime between\\nadolescence and the early twenties. Because of the nat-\\nure of the disorder, most BED patients are overweight\\nor obese. Studies of weight loss programs have shown\\nthat an average of 30% of individuals enrolling in these\\nprograms report binge eating behavior.\\nCauses and symptoms\\nBinge eating episodes may act as a psychological\\nrelease for excessive emotionalstress. Other circum-\\nstances that may predispose an individual to BED\\ninclude heredity and affective disorders, such as\\nmajor depression. BED patients are also more likely\\nto have a comorbid, or co-existing, diagnosis of impul-\\nsive behaviors (for example, compulsive buying),post-\\ntraumatic stress disorder (PTSD), panic disorder,o r\\npersonality disorders.\\nIndividuals who develop BED often come from\\nfamilies who put an unnatural emphasis on the\\nimportance of food, for example, as a source of com-\\nfort in times of emotional distress. As children, BED\\npatients may have been taught to clean their plate\\nregardless of their appetite, or that finishing a meal\\nmade them a ‘‘good’’ girl or boy. Cultural attitudes\\ntowards beauty and thinness may also be a factor in\\nthe BED equation.\\nDuring binge episodes, BED patients experience a\\ndefinite sense of lost control over their eating. They eat\\nquickly and to the point of discomfort even if they\\naren’t hungry. They typically binge alone two or more\\ntimes a week, and often feel depressed and guilty once\\nthe episode has concluded.\\nDiagnosis\\nBinge eating disorder is usually diagnosed and\\ntreated by a psychiatrist and/or a psychologist. In\\naddition to an interview with the patient, personality\\nand behavioral inventories, such as the Minnesota\\nMultiphasic Personality Inventory (MMPI), may be\\nadministered as part of the assessment process. One\\nof several clinical inventories, or scales, may also be\\nused to assess depressive symptoms, including the\\nHamilton Depression Scale (HAM-D) or Beck\\nDepression Inventory (BDI). These tests may be admi-\\nnistered in an outpatient or hospital setting.\\nTreatment\\nMany BED individuals binge after long intervals\\nof excessive dietary restraint; therapy helps normalize\\nthis pattern. The initial goal of BED treatment is\\nto teach the patient to gain control over his eating\\nbehavior by focusing on eating regular meals and\\navoiding snacking. Cognitive-behavioral therapy ,\\ngroup therapy, or interpersonal psychotherapy may\\nbe employed to uncover the emotional motives, dis-\\ntorted thinking, and behavioral patterns behind the\\nbinge eating.\\nKEY TERMS\\nBulimia— An eating disorder characterized by\\nbinge eating and inappropriate compensatory\\nbehavior, such as vomiting, misusing laxatives, or\\nexcessive exercise.\\nCognitive behavioral therapy— A therapy that pays\\nparticular attention to a patient’s behavior and\\nthinking processes rather than underlying psycho-\\nlogical causes of an activity.\\nGALE ENCYCLOPEDIA OF MEDICINE 533\\nBinge-eating disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 563, 'page_label': '534'}, page_content='Because the prevalence of depression in BED\\npatients is high, psychopharmacological treatment\\nwith antidepressants may also be prescribed. Once\\nthe binge eating behavior is curbed and depressive\\nsymptoms are controlled, the physical symptoms\\nof BED can be addressed. The overweight BED\\npatient may be placed on a moderate exercise pro-\\ngram and a nutritionist may be consulted to educate\\nthe patient on healthy food choices and strategies for\\nweight loss.\\nPrognosis\\nThe poor dietary habits andobesity that are symp-\\ntomatic of BED can lead to serious health problems,\\nsuch as high blood pressure, heart attacks, and dia-\\nbetes, if left unchecked. BED is a chronic condition\\nthat requires ongoing medical and psychological man-\\nagement. To bring long-term relief to the BED patient,\\nit is critical to address the underlying psychological\\ncauses behind binge eating behaviors. It appears that\\nup to 50% of BED patients will stop bingeing with\\ncognitive behavioral therapy (CBT).\\nResources\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nAmerican Psychological Association (APA). 750 First St.\\nNE, Washington, DC 20002-4242. (202) 336-5700.\\n.\\nEating Disorders Awareness and Prevention. 603 Stewart\\nSt., Suite 803, Seattle, WA 98101. (206) 382-3587.\\nNational Eating Disorders Organization (NEDO). 6655\\nSouth Yale Ave., Tulsa, OK 74136. (918) 481-4044.\\nOvereaters Anonymous World Service Office. 6075 Zenith\\nCt. NE, Rio Rancho, NM 87124. (505) 891-2664.\\n.\\nPaula Anne Ford-Martin\\nBiofeedback\\nDefinition\\nBiofeedback, or applied psychophysiological\\nfeedback, is a patient-guided treatment that teaches\\nan individual to control muscle tension,pain, body\\ntemperature, brain waves, and other bodily functions\\nand processes through relaxation, visualization, and\\nother cognitive control techniques. The name\\nbiofeedback refers to the biological signals that are\\nfed back, or returned, to the patient in order for the\\npatient to develop techniques of manipulating them.\\nPurpose\\nBiofeedback has been used to successfully treat a\\nnumber of disorders and their symptoms, including\\ntemporomandibular joint disorder (TMJ), chronic\\npain, irritable bowel syndrome (IBS), Raynaud’s\\nsyndrome, epilepsy, attention-deficit hyperactivity\\ndisorder ( ADHD), migraine headaches, anxiety,\\ndepression, traumatic brain injury, andsleep disorders.\\nIllnesses that may be triggered at least in part by\\nstress are also targeted by biofeedback therapy. Certain\\ntypes of headaches, high blood pressure,bruxism (teeth\\ngrinding), post-traumatic stress disorder,e a t i n gd i s o r -\\nders, substance abuse, and someanxiety disordersmay\\nbe treated successfully by teaching patients the ability\\nto relax and release both muscle and mental tension.\\nBiofeedback is often just one part of a comprehensive\\ntreatment program for some of these disorders.\\nNASA has used biofeedback techniques to treat\\nastronauts who suffer from severe space sickness, dur-\\ning which the autonomic nervous system is disrupted.\\nScientists at the University of Tennessee have adapted\\nthese techniques to treat individuals suffering from\\nsevere nausea and vomiting that is also rooted in\\nautonomic nervous system dysfunction.\\nA patient undergoing biofeedback therapy. (Photo\\nResearchers, Inc. Reproduced by permission.)\\n534 GALE ENCYCLOPEDIA OF MEDICINE\\nBiofeedback'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 564, 'page_label': '535'}, page_content='Recent research also indicates that biofeedback may\\nbe a useful tool in helping patients withurinary incon-\\ntinence regain bladder control. Individuals learning pel-\\nvic-floor muscle strengthening exercises can gain better\\ncontrol over these muscles by using biofeedback. Sensors\\na r ep l a c e do nt h em u s c l e st ot r a i nt h ep a t i e n tw h e r et h e y\\nare and when proper contractions are taking place.\\nDescription\\nOrigins\\nIn 1961, Neal Miller, an experimental psycholo-\\ngist, suggested that autonomic nervous system\\nresponses (for instance, heart rate, blood pressure,\\ngastrointestinal activity, regional blood flow) could\\nbe under voluntary control. As a result of his experi-\\nments, he showed that such autonomic processes were\\ncontrollable. This work led to the creation of biofeed-\\nback therapy. Willer’s work was expanded by other\\nresearchers. Thereafter, research performed in the\\n1970s by UCLA researcher Dr. Barry Sterman estab-\\nlished that both cats and monkeys could be trained to\\ncontrol their brain wave patterns. Sterman then used\\nhis research techniques on human patients with epi-\\nlepsy, where he was able to reduce seizures by 60%\\nwith the use of biofeedback techniques. Throughout\\nthe 1970s, other researchers published reports of their\\nuse of biofeedback in the treatment of cardiacarrhyth-\\nmias, headaches, Raynaud’s syndrome, and excess\\nstomach acid, and as a tool for teaching deep relaxa-\\ntion. Since the early work of Miller and Sterman,\\nbiofeedback has developed into a front-line behavioral\\ntreatment for an even wider range of disorders and\\nsymptoms.\\nDuring biofeedback, special sensors are placed on\\nthe body. These sensors measure the bodily function\\nthat is causing the patient problem symptoms, such as\\nheart rate, blood pressure, muscle tension (EMG or\\nelectromyographic feedback), brain waves (EEC or elec-\\ntroencophalographic feedback), respiration, and body\\ntemperature (thermal feedback), and translates the\\ninformation into a visual and/or audible readout, such\\nas a paper tracing, a light display, or a series of beeps.\\nWhile the patient views the instantaneous feed-\\nback from the biofeedback monitors, he or she begins\\nto recognize what thoughts, fears, and mental images\\ninfluence his or her physical reactions. By monitor-\\ning this relationship between mind and body, the\\npatient can then use these same thoughts and mental\\nimages as subtle cues, as these act as reminders to\\nbecome deeply relaxed, instead of anxious. These\\nreminders also work to manipulate heart beat, brain\\nwave patterns, body temperature, and other bodily\\nfunctions. This is achieved through relaxation exer-\\ncises, mental imagery, and other cognitive therapy\\ntechniques.\\nAs the biofeedback response takes place, patients\\ncan actually see or hear the results of their efforts\\ninstantly through the sensor readout on the biofeed-\\nback equipment. Once these techniques are learned\\nand the patient is able to recognize the state of relaxa-\\ntion or visualization necessary to alleviate symptoms,\\nthe biofeedback equipment itself is no longer needed.\\nThe patient then has a powerful, portable, and self-\\nadministered treatment tool to deal with problem\\nsymptoms.\\nKEY TERMS\\nAutonomic nervous system— The part of the ner-\\nvous system that controls so-called involuntary\\nfunctions, such as heart rate, salivary gland secre-\\ntion, respiratory function, and pupil dilation.\\nBruxism— Habitual, often unconscious, grinding of\\nthe teeth.\\nEpilepsy— A neurological disorder characterized\\nby the sudden onset of seizures.\\nPlacebo effect— Placebo effect occurs when a treat-\\nment or medication with no known therapeutic\\nvalue (a placebo) is administered to a patient, and\\nthe patient’s symptoms improve. The patient\\nbelieves and expects that the treatment is going to\\nwork, so it does. The placebo effect is also a factor to\\nsome degree in clinically-effective therapies, and\\nexplains why patients respond better than others to\\ntreatment despite similar symptoms and illnesses.\\nRaynaud’s syndrome— A vascular, or circulatory\\nsystem, disorder which is characterized by abnor-\\nmally cold hands and feet. This chilling effect is\\ncaused by constriction of the blood vessels in the\\nextremities, and occurs when the hands and feet\\nare exposed to cold weather. Emotional stress can\\nalso trigger the cold symptoms.\\nSchizophrenia— Schizophrenia is a psychotic dis-\\norder that causes distortions in perception (delu-\\nsions and hallucinations), inappropriate moods\\nand behaviors, and disorganized or incoherent\\nspeech and behavior.\\nTemporomandibular joint disorder—Inflammation,\\nirritation, and pain of the jaw caused by improper\\nopening and closing of the temporomandibular\\njoint. Other symptoms include clicking of the jaw\\nand a limited range of motion.\\nGALE ENCYCLOPEDIA OF MEDICINE 535\\nBiofeedback'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 565, 'page_label': '536'}, page_content='Biofeedback that specializes in reading and alter-\\ning brain waves is sometimes calledneurofeedback.\\nThe brain produces four distinct types of brain\\nwaves—delta, theta, alpha, and beta—that all operate\\nat a different frequency. Delta, the slowest frequency\\nwave, is the brain wave pattern associated with sleep.\\nBeta waves, which occur in a normal, waking state,\\ncan range from 12-35 Hz. Problems begin to develop\\nwhen beta wave averages fall in the low end (under-\\narousal) or the high end (overarousal) of that spec-\\ntrum. Underarousal might be present in conditions\\nsuch as depression or attention-deficit disorder, and\\noverarousal may be indicative of an anxiety disorder,\\nobsessive compulsive disorder, or excessive stress.\\nBeta wave neurofeedback focuses on normalizing\\nthat beta wave pattern to an optimum value of around\\n14 Hz. A second type of neurofeedback, alpha-theta,\\nfocuses on developing the more relaxing alpha (8-13\\nHz) and theta waves (4-9 Hz) that are usually asso-\\nciated with deep, meditative states, and has been used\\nwith some success in substanceabuse treatment.\\nThrough brain wave manipulation, neurofeedback\\ncan be useful in treating a variety of disorders that are\\nsuspected or proven to impact brain wave patterns,\\nsuch as epilepsy, attention-deficit disorder, migraine\\nheadaches, anxiety, depression, traumatic brain injury,\\nand sleep disorders. The equipment used for neurofeed-\\nback usually uses a monitor as an output device. The\\nmonitor displays specific patterns that the patient\\nattempts to change by producing the appropriate type\\nof brain wave. Or, the monitor may reward the patient\\nfor producing the appropriate brain wave by producing\\na positive reinforcer, or reward. For example, children\\nmay be rewarded with a series of successful moves in a\\ndisplayed video game.\\nDepending on the type of biofeedback, individuals\\nm a yn e e du pt o3 0s e s s i o n sw i t hat r a i n e dp r o f e s s i o n a lt o\\nlearn the techniques required to control their symptoms\\non a long-term basis. Therapists usually recommend\\nthat their patients practice both biofeedback and relaxa-\\ntion techniques on their own at home.\\nPreparations\\nBefore initiating biofeedback treatment, the\\ntherapist and patient will have an initial consultation\\nto record the patients medical history and treatment\\nbackground and discuss goals for therapy.\\nBefore a neurofeedback session, an EEG is taken\\nfrom the patient to determine his or her baseline brain-\\nwave pattern.\\nBiofeedback typically is performed in a quiet and\\nrelaxed atmosphere with comfortable seating for the\\npatient. Depending on the type and goals of biofeed-\\nback being performed, one or more sensors will be\\nattached to the patient’s body with conductive gel\\nand/or adhesives. These may include:\\n/C15Electromyographic (EMG) sensors. EMG sensors\\nmeasure electrical activity in the muscles, specifically\\nmuscle tension. In treating TMJ or bruxism, these\\nsensors would be placed along the muscles of the jaw.\\nChronic pain might be treated by monitoring electri-\\ncal energy in other muscle groups.\\n/C15Galvanic skin response (GSR) sensors. These are\\nelectrodes placed on the fingers that monitor per-\\nspiration, or sweat gland, activity. These may also\\nbe called skin conductance level (SCL).\\n/C15Temperature sensors. Temperature, or thermal, sen-\\nsors measure body temperature and changes in blood\\nflow.\\n/C15Electroencephalography (EEG) sensors. These elec-\\ntrodes are applied to the scalp to measure the elec-\\ntrical activity of the brain, or brain waves.\\n/C15Heart rate sensors. A pulse monitor placed on the\\nfinger tip can monitor pulse rate.\\n/C15Respiratory sensors. Respiratory sensors monitor\\noxygen intake and carbon dioxide output.\\nPrecautions\\nIndividuals who use a pacemaker or other implan-\\ntable electrical devices should inform their biofeed-\\nback therapist before starting treatments, as certain\\ntypes of biofeedback sensors have the potential to\\ninterfere with these devices.\\nBiofeedback may not be suitable for some\\npatients. Patients must be willing to take a very active\\nrole in the treatment process. And because biofeed-\\nback focuses strictly on behavioral change, those\\npatients who wish to gain insight into their symptoms\\nby examining their past might be better served by\\npsychodynamic therapy.\\nBiofeedback may also be inappropriate for cogni-\\ntively impaired individuals, such as those patients with\\norganic brain disease or a traumatic brain injury,\\ndepending on their levels of functioning.\\nPatients with specific pain symptoms of unknown\\norigin should undergo a thorough medical examina-\\ntion before starting biofeedback treatments to rule out\\nany serious underlying disease. Once a diagnosis has\\nbeen made, biofeedback can be used concurrently with\\nconventional treatment.\\n536 GALE ENCYCLOPEDIA OF MEDICINE\\nBiofeedback'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 566, 'page_label': '537'}, page_content='Biofeedback may only be one component of a\\ncomprehensive treatment plan. For illnesses and\\nsymptoms that are manifested from an organic disease\\nprocess, such as cancer or diabetes, biofeedback\\nshould be an adjunct to (complementary to), and not\\na replacement for, conventional medical treatment.\\nSide effects\\nThere are no known side effects to properly admi-\\nnistered biofeedback or neurofeedback sessions.\\nResearch and general acceptance\\nPreliminary research published in late 1999 indi-\\ncated that neurofeedback may be a promising new tool\\nin the treatment of schizophrenia. Researchers\\nreported that schizophrenic patients had used neuro-\\nfeedback to simulate brain wave patterns that antipsy-\\nchotic medications produce in the brain. Further\\nresearch is needed to determine what impact this may\\nhave on treatment for schizophrenia.\\nThe use of biofeedback techniques to treat an array\\nof disorders has been extensively described in the med-\\nical literature. Controlled studies for some applications\\nare limited, such as for the treatment of menopausal\\nsymptoms and premenstrual disorder (PMS). There is\\nalso some debate over the effectiveness of biofeedback\\nin ADHD treatment, and the lack of controlled studies\\non that application. While many therapists, counselors,\\nand mental health professionals have reported great\\nsuccess with treating their ADHD patients with neuro-\\nfeedback techniques, some critics attribute this positive\\ntherapeutic impact to a placebo effect.\\nThere may also be some debate among mental\\nhealth professionals as to whether biofeedback should\\nbe considered a first line treatment for some mental\\nillnesses, and to what degree other treatments, such as\\nmedication, should be employed as an adjunct therapy.\\nResources\\nBOOKS\\nRobbins, Jim.A Symphony in the Brain: The Evolution of the\\nNew Brain Wave Biofeedback.Boston, MA: Atlantic\\nMonthly Press, 2000.\\nPERIODICALS\\nRobbins, Jim. ‘‘On the Track with Neurofeedback.’’\\nNewsweek 135, no. 25 (June 2000): 76.\\nORGANIZATIONS\\nAssociation for Applied Psychotherapy and Biofeedback.\\n10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO\\n80033-2840. (303) 422-8436. .\\nBiofeedback Certification Institute of America.10200 W.\\n44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303)\\n420-2902.\\nPaula Anne Ford-Martin\\nBiopsy see Bone biopsy; Bone marrow\\naspiration and biopsy; Brain biopsy;\\nBreast biopsy; Cervical conization; CT-\\nguided biopsy; Endometrial biopsy; Joint\\nbiopsy; Kidney biopsy; Liver biopsy; Lung\\nbiopsy; Lymph node biopsy; Myocardial\\nbiopsy; Pleural biopsy; Prostate biopsy;\\nSkin biopsy; Small intestine biopsy;\\nThyroid biopsy\\nBipolar disorder\\nDefinition\\nBipolar, or manic-depressive disorder, is a mood\\ndisorder that causes radical emotional changes and\\nmood swings, from manic highs to depressive lows.\\nThe majority of bipolar individuals experience alter-\\nnating episodes ofmania and depression.\\nDescription\\nIn the United States alone, more than two million\\npeople are diagnosed with bipolar disorder. Research\\nshows that as many as 10 million people might be\\naffected by bipolar disorder, which is the sixth-leading\\ncause of disability worldwide. The average age of\\nonset of bipolar disorder is from adolescence through\\nthe early twenties. However, because of the complexity\\nof the disorder, a correct diagnosis can be delayed for\\nseveral years or more. In a survey of bipolar patients\\nconducted by the National Depressive and Manic\\nDepressive Association (MDMDA), one-half of\\nrespondents reported visiting three or more profes-\\nsionals before receiving a correct diagnosis, and over\\none-third reported a wait of ten years or more before\\nthey were correctly diagnosed.\\nBipolar I disorder is characterized by manic epi-\\nsodes, the ‘‘high’’ of the manic-depressive cycle. A\\nperson with bipolar disorder experiencing mania often\\nhas feelings of self-importance, elation, talkativeness,\\nincreased sociability, and a desire to embark on goal-\\noriented activities, coupled with the characteristics of\\nirritability, impatience, impulsiveness, hyperactivity,\\nGALE ENCYCLOPEDIA OF MEDICINE 537\\nBipolar disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 567, 'page_label': '538'}, page_content='and a decreased need for sleep. Usually this manic\\nperiod is followed by a period of depression, although\\na few bipolar I individuals may not experience a major\\ndepressive episode. Mixed states, where both manic or\\nhypomanic symptoms and depressive symptoms occur\\nat the same time, also occur frequently with bipolar I\\npatients (for example, depression with the racing\\nthoughts of mania). Also, dysphoric mania is common\\n(mania characterized by anger and irritability).\\nBipolar II disorder is characterized by major\\ndepressive episodes alternating with episodes of hypo-\\nmania, a milder form of mania. Bipolar depression\\nmay be difficult to distinguish from a unipolar major\\ndepressive episode. Patients with bipolar depression\\ntend to have extremely low energy, retarded mental\\nand physical processes, and more profoundfatigue\\n(for example, hypersomnia; a sleep disorder marked\\nby a need for excessive sleep or sleepiness when awake)\\nthan unipolar depressives.\\nCyclothymia refers to the cycling of hypomanic\\nepisodes with depression that does not reach major\\ndepressive proportions. One-third of patients with\\ncyclothymia will develop bipolar I or II disorder\\nlater in life.\\nA phenomenon known as rapid cycling occurs in\\nup to 20% of bipolar I and II patients. In rapid cycling,\\nmanicanddepressiveepisodesmustalternatefrequently;\\nat least four times in 12 months; to meet the diagnostic\\ndefinition. In some cases of ‘‘ultra-rapid cycling,’’ the\\npatient may bounce between manic and depressive\\nstates several times within a 24-hour period. This con-\\ndition is very hard to distinguish from mixed states.\\nBipolar NOS is a category for bipolar states that\\ndo not clearly fit into the bipolar I, II, or cyclothymia\\ndiagnoses.\\nCauses and symptoms\\nThe source of bipolar disorder has not been\\nclearly defined. Because two-thirds of bipolar patients\\nhave a family history of affective or emotional disor-\\nders, researchers have searched for a genetic link to the\\ndisorder. Several studies have uncovered a number of\\npossible genetic connections to the predisposition for\\nbipolar disorder. A 2003 study found thatschizophre-\\nnia and bipolar disorder could have similar genetic\\ncauses that arise from certain problems with genes\\nassociated with myelin development in the central\\nnervous system. (Myelin is a white, fat-like substance\\nthat forms a sort of layer or sheath around nerve\\nfibers.) Another possible biological cause under inves-\\ntigation is the presence of an excessive calcium build-\\nup in the cells of bipolar patients. Also, dopamine and\\nother neurochemical transmitters appear to be impli-\\ncated in bipolar disorder and these are under intense\\ninvestigation.\\nOver one-half of patients diagnosed with bipolar\\ndisorder have a history ofsubstance abuse. There is a\\nKEY TERMS\\nAffective disorder— An emotional disorder invol-\\nving abnormal highs and/or lows in mood. Now\\ntermed mood disorder.\\nAnticonvulsant medication— A drug used to pre-\\nvent convulsions or seizures; often prescribed in\\nthe treatment of epilepsy. Several anticonvulsant\\nmedications have been found effective in the treat-\\nment of bipolar disorder.\\nAntipsychotic medication— A drug used to treat\\npsychotic symptoms, such as delusions or halluci-\\nnations, in which patients are unable to distinguish\\nfantasy from reality.\\nBenzodiazpines— A group of tranquilizers having\\nsedative, hypnotic, antianxiety, amnestic, anticon-\\nvulsant, and muscle relaxant effects.\\nDSM-IV— Diagnostic and Statistical Manual of\\nMental Disorders, Fourth Edition (DSM-IV). This\\nreference book, published by the American\\nPsychiatric Association, is the diagnostic standard\\nfor most mental health professionals in the United\\nStates.\\nECT— Electroconvulsive therapy sometimes is used\\nto treat depression or mania when pharmaceutical\\ntreatment fails.\\nHypomania— A milder form of mania which is\\ncharacteristic of bipolar II disorder.\\nMixed mania/mixed state— A mental state in\\nwhich symptoms of both depression and mania\\noccur simultaneously.\\nMania— An elevated or euphoric mood or irritable\\nstate that is characteristic of bipolar I disorder.\\nNeurotransmitter— A chemical in the brain that\\ntransmits messages between neurons, or nerve\\ncells. Changes in the levels of certain neurotrans-\\nmitters, such as serotonin, norepinephrine, and\\ndopamine, are thought to be related to bipolar\\ndisorder.\\nPsychomotor retardation— Slowed mental and\\nphysical processes characteristic of a bipolar\\ndepressive episode.\\n538 GALE ENCYCLOPEDIA OF MEDICINE\\nBipolar disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 568, 'page_label': '539'}, page_content='high rate of association betweencocaine abuse and\\nbipolar disorder. Some studies have shown up to 30%\\nof abusers meeting the criteria for bipolar disorder. The\\nemotional and physical highs and lows of cocaine use\\ncorrespond to the manic depression of the bipolar\\npatient, making the disorder difficult to diagnosis.\\nFor some bipolar patients, manic and depressive\\nepisodes coincide with seasonal changes. Depressive\\nepisodes are typical during winter and fall, and\\nmanic episodes are more probable in the spring and\\nsummer months.\\nSymptoms of bipolar depressive episodes include\\nlow energy levels, feelings of despair, difficulty con-\\ncentrating, extreme fatigue, and psychomotor retarda-\\ntion (slowed mental and physical capabilities). Manic\\nepisodes are characterized by feelings of euphoria,\\nlack of inhibitions, racing thoughts, diminished need\\nfor sleep, talkativeness, risk taking, and irritability. In\\nextreme cases, mania can inducehallucinations and\\nother psychotic symptoms such as grandiose illusions.\\nDiagnosis\\nBipolar disorder usually is diagnosed and treated\\nby a psychiatrist and/or a psychologist with medical\\nassistance. In addition to an interview, several clinical\\ninventories or scales may be used to assess the patient’s\\nmental status and determine the presence of bipolar\\nsymptoms. These include the Millon Clinical\\nMultiaxial Inventory III (MCMI-III), Minnesota\\nMultiphasic Personality Inventory II (MMPI-2), the\\nInternal State Scale (ISS), the Self-Report Manic\\nInventory (SRMI), and the Young Mania Rating\\nScale (YMRS). The tests are verbal and/or written\\nand are administered in both hospital and outpatient\\nsettings.\\nPsychologists and psychiatrists typically use the\\ncriteria listed in theDiagnostic and Statistical Manual\\nof Mental Disorders, Fourth Edition (DSM-IV )a s\\na guideline for diagnosis of bipolar disorder and\\nother mental illnesses. DSM-IV describes a manic\\nepisode as an abnormally elevated or irritable mood\\nlasting a period of at least one week that is distinguished\\nby at least three of the mania symptoms: inflated self-\\nesteem, decreased need for sleep, talkativeness, racing\\nthoughts, distractibility, increase in goal-directed activ-\\nity, or excessive involvement in pleasurable activities\\nthat have a high potential for painful consequences. If\\nthe mood of the patient is irritable and not elevated,\\nfour of the symptoms are required.\\nAlthough many clinicians find the criteria too\\nrigid, a hypomanic diagnosis requires a duration\\nof at least four days with at least three of the symptoms\\nindicated for manic episodes (four if mood is irritable\\nand not elevated).DSM-IV notes that unlike manic\\nepisodes, hypomanic episodes do not cause a marked\\nimpairment in social or occupational functioning, do\\nnot require hospitalization, and do not have psychotic\\nfeatures. In addition, because hypomanic episodes are\\ncharacterized by high energy and goal directed activ-\\nities and often result in a positive outcome, or are\\nperceived in a positive manner by the patient, bipolar\\nII disorder can go undiagnosed.\\nBipolar symptoms often present differently in\\nchildren and adolescents. Manic episodes in these age\\ngroups are typically characterized by more psychotic\\nfeatures than in adults, which may lead to a misdiag-\\nnosis of schizophrenia. Children and adolescents also\\ntend toward irritability and aggressiveness instead of\\nelation. Further, symptoms tend to be chronic, or\\nongoing, rather than acute, or episodic. Bipolar chil-\\ndren are easily distracted, impulsive, and hyperactive,\\nwhich can lead to a misdiagnosis of attention deficit\\nhyperactivity disorder (ADHD). Furthermore, their\\naggression often leads to violence, which may be mis-\\ndiagnosed as aconduct disorder.\\nSubstance abuse, thyroid disease, and use of\\nprescription or over-the-counter medication can mask\\nor mimic the presence of bipolar disorder. In cases of\\nsubstance abuse, the patient must ordinarily undergo a\\nperiod ofdetoxification and abstinence before a mood\\ndisorder is diagnosed and treatment begins.\\nTreatment\\nTreatment of bipolar disorder is usually achieved\\nwith medication. A combination of mood stabilizing\\nagents with antidepressants, antipsychotics, and antic-\\nonvulsants is used to regulate manic and depressive\\nepisodes.\\nMood stabilizing agents such as lithium, carba-\\nmazepine, and valproate are prescribed to regulate the\\nmanic highs and lows of bipolar disorder:\\n/C15Lithium (Cibalith-S, Eskalith, Lithane, Lithobid,\\nLithonate, Lithotabs) is one of the oldest and most\\nfrequently prescribed drugs available for the treat-\\nment of bipolar mania and depression. Because the\\ndrug takes four to ten days to reach a therapeutic\\nlevel in the bloodstream, it sometimes is prescribed in\\nconjunction with neuroleptics and/or benzodiaze-\\npines to provide more immediate relief of a manic\\nepisode. Lithium also has been shown to be effective\\nin regulating bipolar depression, but is not recom-\\nmended for mixed mania. Lithium may not be an\\nGALE ENCYCLOPEDIA OF MEDICINE 539\\nBipolar disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 569, 'page_label': '540'}, page_content='effective long-term treatment option for rapid cyclers,\\nwho typically develop a tolerance for it, or may not\\nrespond to it. Possible side effects of the drug include\\nweight gain, thirst, nausea, and hand tremors.\\nProlonged lithium use also may causehyperthyroid-\\nism (a disease of the thryoid that is marked by heart\\npalpitations, nervousness, the presence of goiter,\\nsweating, and a wide array of other symptoms.)\\n/C15Carbamazepine (Tegretol, Atretol) is an anticonvul-\\nsant drug usually prescribed in conjunction with\\nother mood stabilizing agents. The drug often is\\nused to treat bipolar patients who have not\\nresponded well to lithium therapy. Blurred vision\\nand abnormal eye movement are two possible side\\neffects of carbamazepine therapy.\\n/C15Valproate (divalproex sodium, or Depakote; valproic\\nacid, or Depakene) is one of the few drugs available\\nthat has been proven effective in treating rapid cycling\\nbipolar and mixed states patients. Valproate is pre-\\nscribed alone or in combination with carbamazepine\\nand/or lithium. Stomach cramps,indigestion, diar-\\nrhea, hair loss, appetite loss, nausea, and unusual\\nweight loss or gain are some of the common side\\neffects of valproate. Note: valproate also is approved\\nfor the treatment of mania. A 2003 study found that\\nthe risk ofdeath from suicide is about two and one-\\nhalf times higher in people with bipolar disorder\\ntaking divalproex than those taking lithium.\\nTreating the depression associated with bipolar\\ndisorder has proven more challenging. In early 2004,\\nthe first drug to treat bipolar administration was\\napproved by the U.S. Food and Drug Administration\\n(FDA). It is called Symbyax, a combination of olanzi-\\npine and fluoxetine, the active ingredient in Prozac.\\nBecause antidepressants may stimulate manic\\nepisodes in some bipolar patients, their use typically\\nis short-term. Selective serotonin reuptake inhibitors\\n(SSRIs) or, less often,monoamine oxidase inhibitors\\n(MAO inhibitors) are prescribed for episodes of bipo-\\nlar depression.Tricyclic antidepressantsused to treat\\nunipolar depression may trigger rapid cycling in bipo-\\nlar patients and are, therefore, not a preferred treat-\\nment option for bipolar depression.\\n/C15SSRIs, such as fluoxetine (Prozac), sertraline\\n(Zoloft), and paroxetine (Paxil), regulate depression\\nby regulating levels of serotonin, a neurotransmitter.\\nAnxiety, diarrhea, drowsiness, headache, sweating,\\nnausea, sexual problems, andinsomnia are all possi-\\nble side effects of SSRIs.\\n/C15MAOIs such as tranylcypromine (Parnate) and phe-\\nnelzine (Nardil) block the action of monoamine oxi-\\ndase (MAO), an enzyme in the central nervous\\nsystem. Patients taking MAOIs must cut foods high\\nin tyramine (found in aged cheeses and meats) out of\\ntheir diet to avoid hypotensive side effects.\\n/C15Bupropion (Wellbutrin) is a heterocyclic antidepres-\\nsant. The exact neurochemical mechanism of the\\ndrug is not known, but it has been effective in reg-\\nulating bipolar depression in some patients. Side\\neffects of bupropion include agitation, anxiety, con-\\nfusion, tremor,dry mouth, fast or irregular heartbeat,\\nheadache, and insomnia.\\n/C15ECT, orelectroconvulsive therapy, has a high success\\nrate for treating both unipolar and bipolar depres-\\nsion, and mania. However, because of the conveni-\\nence of drug treatment and the stigma sometimes\\nattached to ECT therapy, ECT usually is employed\\nafter all pharmaceutical treatment options have been\\nexplored. ECT is given under anesthesia and patients\\nare given a muscle relaxant medication to prevent\\nconvulsions. The treatment consists of a series of\\nelectrical pulses that move into the brain through\\nelectrodes on the patient’s head. Although the exact\\nmechanisms behind the success of ECT therapy are\\nnot known, it is believed that this electrical current\\nalters the electrochemical processes of the brain, con-\\nsequently relieving depression. Headaches, muscle\\nsoreness, nausea, and confusion are possible side\\neffects immediately following an ECT procedure.\\nTemporary memory loss has also been reported in\\nECT patients. In bipolar patients, ECT is often used\\nin conjunction with drug therapy.\\nAdjunct treatments are used in conjunction with\\na long-term pharmaceutical treatment plan:\\n/C15Long-acting benzodiazepines such as clonazepam\\n(Klonapin) and alprazolam (Xanax) are used for\\nrapid treatment of manic symptoms to calm and\\nsedate patients until mania or hypomania have\\nwaned and mood stabilizing agents can take effect.\\nSedation is a common effect, and clumsiness, light-\\nheadedness, and slurred speech are other possible\\nside effects of benzodiazepines.\\n/C15Neuroleptics such as chlorpromazine (Thorazine) and\\nhaloperidol (Haldol) also are used to control mania\\nwhile a mood stabilizer such as lithium or valproate\\ntakes effect. Because neuroleptic side effects can be\\nsevere (difficulty in speaking or swallowing,paralysis\\nof the eyes, loss of balance control,muscle spasms,\\nsevere restlessness, stiffness of arms and legs, tremors\\nin fingers and hands, twisting movements of body,\\nand weakness of arms and legs), benzodiazepines are\\ngenerally preferred over neuroleptics.\\n/C15Psychotherapy and counseling. Because bipolar dis-\\norder is thought to be biological in nature, therapy is\\n540 GALE ENCYCLOPEDIA OF MEDICINE\\nBipolar disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 570, 'page_label': '541'}, page_content='recommended as a companion to, but not a substi-\\ntute for, pharmaceutical treatment of the disease.\\nPsychotherapy, such ascognitive-behavioral therapy,\\ncan be a useful tool in helping patients and their\\nfamilies adjust to the disorder, in encouraging com-\\npliance to a medication regimen, and in reducing the\\nrisk of suicide. Also, educative counseling is recom-\\nmended for the patient and family. In fact, a 2003\\nreport revealed that people on medication for bipolar\\ndisorder had better results if they also participated in\\nfamily-focused therapy.\\nClozapine (Clozaril) is an atypical antipsychotic\\nmedication used to control manic episodes in patients\\nwho have not responded to typical mood stabilizing\\nagents. The drug has also been a useful prophylactic,\\nor preventative treatment, in some bipolar patients.\\nCommon side effects of clozapine include tachycardia\\n(rapid heart rate), hypotension, constipation,a n d\\nweight gain. Agranulocytosis, a potentially serious but\\nreversible condition in which the white blood cells that\\ntypically fight infection in the body are destroyed, is a\\npossible side effect of clozapine. Patients treated with\\nthe drug should undergo weekly blood tests to monitor\\nwhite blood cell counts.\\nRisperidone (Risperdal) is an atypical antipsycho-\\ntic medication that has been successful in controlling\\nmania when low doses were administered. In early\\n2004, the FDA approved its use for treating bipolar\\nmania. The side effects of risperidone are mild com-\\npared to many other antipsychotics (constipation,\\ncoughing, diarrhea, dry mouth, headache,heartburn,\\nincreased length of sleep and dream activity, nausea,\\nrunny nose,sore throat, fatigue, and weight gain).\\nOlanzapine (Zyprexa) is another atypical antipsy-\\nchotic approved in 2003 for use in combination with\\nlithium or valproate for treatment of acute manic\\nepisodes associated with bipolar disorder. Side effects\\ninclude hypotension (low blood pressure) associated\\nwith dizziness, rapid heartbeat, and syncope, or low\\nblood pressure to the point offainting.\\nLamotrigine (Lamictal, or LTG), an anticonvul-\\nsant medication, was found to alleviate manic symp-\\ntoms in a 1997 trial of 75 bipolar patients. The drug\\nwas used in conjunction with divalproex (divalproate)\\nand/or lithium. Possible side effects of lamotrigine\\ninclude skin rash, dizziness, drowsiness, headache,\\nnausea, andvomiting.\\nAlternative treatment\\nGeneral recommendations include maintaining a\\ncalm environment, avoiding overstimulation, getting\\nplenty of rest, regular exercise, and proper diet.\\nChinese herbs may soften mood swings.Biofeedback\\nis effective in helping some patients control symptoms\\nsuch as irritability, poor self control, racing thoughts,\\nand sleep problems. A diet low in vanadium (a mineral\\nfound in meats and other foods) and high in vitamin C\\nmay be helpful in reducing depression.\\nA surprising study in 2004 found that a rarely used\\ncombination of magnetic fields used inmagnetic reso-\\nnance imaging(MRI) scanning improved the moods of\\nsubjects with bipolar disorder. The discovery was\\nmade while scientists were using MRI to investigate\\neffectiveness of certain medications. However, they\\nfound that a particular type of echo-planar magnetic\\nfield led to reports of mood improvement. Further\\nstudies may one day lead to a smaller, more conveni-\\nent use of magnetic treatment.\\nPrognosis\\nWhile most patients will show some positive\\nresponse to treatment, response varies widely, from\\nfull recovery to a complete lack of response to all\\ndrug and/or ECT therapy. Drug therapies frequently\\nneed adjustment to achieve the maximum benefit for\\nthe patient. Bipolar disorder is a chronic recurrent\\nillness in over 90% of those afflicted, and one that\\nrequires lifelong observation and treatment after diag-\\nnosis. Patients with untreated or inadequately treated\\nbipolar disorder have a suicide rate of 15-25% and a\\nnine-year decrease in life expectancy. With proper\\ntreatment, the life expectancy of the bipolar patient\\nwill increase by nearly seven years and work produc-\\ntivity increases by ten years.\\nPrevention\\nThe ongoing medical management of bipolar dis-\\norder is critical to preventing relapse, or recurrence, of\\nmanic episodes. Even in carefully controlled treatment\\nprograms, bipolar patients may experience recurring\\nepisodes of the disorder. Patient education in the form\\nof psychotherapy or self-help groups is crucial for\\ntraining bipolar patients to recognize signs of mania\\nand depression and to take an active part in their\\ntreatment program.\\nResources\\nPERIODICALS\\n‘‘Family-focused Therapy May Reduce Relapse Rate.’’\\nHealth & Medicine Week(September 29, 2003): 70.\\n‘‘FDA Approves Medication for Bipolar Depression.’’Drug\\nWeek (January 23, 2004): 320.\\nGALE ENCYCLOPEDIA OF MEDICINE 541\\nBipolar disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 571, 'page_label': '542'}, page_content='‘‘FDA Approves Risperidone for Bipolar Mania.’’\\nPsychopharmacology Update(January 2004): 8.\\n‘‘Lithium and Risk of Suicide.’’The Lancet(September 20,\\n2003): 969.\\nRossiter, Brian. ‘‘Bipolar Disorder.’’Med Ad News(March\\n2004): 82.\\n‘‘Schizophrenia and Bipolar Disorder Could Have Similar\\nGenetic Causes.’’Genomics & Genetics Weekly\\n(September 26, 2003): 85.\\nSherman, Carl. ‘‘Bipolar’s Clinical, Financial Impact Widely\\nMissed. (Prevalence May be Greater Than Expected).’’\\nClinical Psychiatry News(August 2002): 6.\\n‘‘Unique Type of MRI Scan Shows Promise in Treating\\nBipolar Disorder.’’AScribe Health News Service\\n(January 1, 2004).\\n‘‘Zyprexa.’’ Formulary 9 (September 2003): 513.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nNational Alliance for the Mentally Ill (NAMI). Colonial\\nPlace Three, 2107 Wilson Blvd., Ste. 300, Arlington,\\nVA 22201-3042. (800) 950-6264. .\\nNational Depressive and Manic-Depressive Association\\n(NDMDA). 730 N. Franklin St., Suite 501, Chicago,\\nIL 60610. (800) 826-3632. .\\nNational Institute of Mental Health. Mental Health Public\\nInquiries, 5600 Fishers Lane, Room 15C-05, Rockville,\\nMD 20857. (888) 826-9438. .\\nPaula Anne Ford-Martin\\nTeresa G. Odle\\nBird flu\\nDefinition\\nBird flu is an infectious disease caused by strains\\nof the Type Ainfluenza viruses that ordinarily only\\ninfect birds. Avian influenza A (H5N1) virus infected\\nand caused the deaths of people.\\nDescription\\nBird flu, which is also known as avian influenza,\\nwas first identified in Italy more than 100 years ago.\\nAvian viruses occur naturally in birds, and can infect\\nbirds including chickens, ducks, geese, turkeys,\\npheasants, quail, and guinea fowl. The avian influenza\\nviruses generally do not infect humans.\\nAvian viruses are carried around the world by\\nmigratory birds. Wild ducks are natural reservoirs of\\nthe infection, according to the World Health\\nOrganization (WHO). Those wild birds generally\\ndon’t become ill, but avian flu is extremely contagious\\nand has caused some domesticated birds to become\\nvery ill and die. The casualties included chickens, tur-\\nkeys, and ducks.\\nVirus suptypes\\nReaction to the infection varies among the species\\nbecause flu viruses are constantly mutating into new\\nstrains or subgroups. Low-pathogenic viruses cause\\nfew or no symptoms in infected birds. However,\\nsome strains can mutate into highly pathogenic avian\\ninfluenza (HPAI) strains that are extremely infectious\\nand deadly to birds.\\nThe viruses are identified by a series of letters and\\nnumbers that refer to two proteins, hemagglutinin\\n(HA) and neuraminidase (NA). There are 16 HA sub-\\ntypes and nine NA subtypes of influenza A virus.\\nNumerous combinations of the two proteins are\\npossible, and each combination forms a new subtype.\\nThere are 15 different Influenza A subtypes that\\ncan infect birds, according to the United States\\nCenters for Disease Control (CDC). In comparison,\\nthere are three known subtypes of human flu virus A:\\nH1N1, H1N2, and H3N2. Avian viruses can infect\\npigs, but people are generally not affected. That chan-\\nged when there was an outbreak of H5N1 in Hong\\nKong in 1997.\\nDeadly outbreaks\\nThe highly pathogenic H5N1 virus was first isolated\\nin terns in South Africa in 1961, and then in Hong Kong\\nin 1997. Hong Kong’s avian flu outbreak coincided\\nwith 18 cases of severe respiratory disease in people.\\nThose diagnosed with bird flu had close contact with\\npoultry. Six people died, according to WHO. There\\nwas ‘‘limited transmission’’ of the virus to health care\\nworkers, but they did not become seriously ill.\\nMedical research showed that the avian virus had\\njumped from birds to people. Within three days, Hong\\nKong’s poultry population of about 1.5 million birds\\nwas destroyed to prevent further infection. There was\\nanother H5N1 outbreak in Hong Kong in February\\nof 2003. It affected two members of a family that had\\nrecently visited China. One person died, according to\\nthe WHO.\\n542 GALE ENCYCLOPEDIA OF MEDICINE\\nBird flu'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 572, 'page_label': '543'}, page_content='In the Netherlands in February of 2003, there was\\nan outbreak of another highly pathogenic avian virus,\\nH7N7. Two months later, a veterinarian died from the\\nvirus. It also caused mild illness in 83 people.\\nIn Hong Kong, the avian virus subtype H9N2\\ncaused mild cases of flu in two children in 1999 and\\none child in the middle of December of 2003, accord-\\ning to WHO. While H9N2 was not highly pathogenic\\nin birds, there was an outbreak of H5N1 in Korea in\\nmid-December of 2003. The next month, there was an\\noutbreak in Vietnam that was followed by outbreaks\\nin other Asian countries.\\nHuman bird flu cases\\nThe World Health Organization tracks bird flu out-\\nbreaks and the charts the numbers of human cases that\\nhave been confirmed by a laboratory. There were 74\\ncases and 49 deaths between January of 2004 and March\\n31, 2005. The flu caused two deaths in Cambodia. In\\nThailand, 12 of 17 people with bird flu died. In Vietnam,\\nthe flu was fatal in 35 of 55 diagnosed cases. Deaths\\nrelated to the H5N1 viruses have been caused bypneu-\\nmonia and pulmonary complications.\\nMoreover, the Democratic People’s Republic of\\nKorea (North Korea) officially reported the country’s\\nfirst outbreak of avian influenza in poultry on March 27,\\n2005. Outbreaks occurred at chicken farms, and there\\nwere no human cases at that time, according to WHO.\\nIn October 2005, an outbreak of bird flu was\\nreported at a farm near the Mongolian capital of\\nHohhot in the People’s Republic of China. The H5N1\\nstrain of the virus was detected in a parrot located in\\nBritain. The parrot contracted the disease while in quar-\\nantine with birds originating in Taiwan. In January 2006,\\nthe H5N1 strain was confirmed as the cause of death in at\\nleast two cases in Dogubeyazit, Turkey. This case, as well\\nas others documented in countries across Europe, indi-\\ncate the potential for the disease to spread worldwide.\\nPreparing for a pandemic\\nThe World Health Organization and nations\\nincluding the United States are troubled about the\\ndeadly consequences that could occur if H5N1 mutated\\ninto a new virus subtype that could be transferred from\\none human to another. That subtype would develop if\\nthe avian virus acquired human influenza genes,\\naccording to the U.S. Department of Agriculture\\n(USDA). A strain of bird flu spread by human-to-\\nhuman contact could cause an influenza pandemic.\\nA pandemic is a worldwide epidemic that is dan-\\ngerous because people have little or no immunity to\\nthe new virus strain. Historically, pandemics occur\\nthree to four times during a century when new virus\\nsubtypes appear. After World War I, the great influ-\\nenza pandemic of 1917-1918 caused from 40 to 50\\nmillion deaths globally, according to WHO. The flu\\npandemic of 1968-1969 claimed 1 to 4 million lives.\\nAccording to a 2004 WHO report, medical influ-\\nenza experts agree that another flu pandemic is ‘‘inevi-\\ntable and possibly imminent.’’ In a December 8, 2004\\nreport, WHO warned that the ‘‘best case scenario’’\\nprojection for next pandemic was that the new flu strain\\nwould kill from 2 to 7 million people. Moreover, ‘‘tens\\nof millions’’ of people would require medical attention.\\nThe appearance of H5N1 signals that the world is\\nmoving closer to a pandemic, WHO reported.\\nThe spread of H5N1 to humans increased the\\nlikelihood of a new strain emerging that could be\\ntransmitted by people. That could create a pandemic.\\nNations and the World Health Organization are\\nworking to prevent a pandemic or cause it to be less\\ndeadly. Their strategies include efforts to decrease the\\nspread of flu strains in poultry and the development of\\nvaccines to treat the virus in people.\\nCauses and symptoms\\nAvian flu is caused by an influenza virus that birds\\ncarry in their intestines. The virus spreads as infected\\nbirds excrete saliva, nasal secretions, and feces. Birds\\nvulnerable to the flu become infected when they come\\ninto contact with the excretions or surfaces contami-\\nnated by the infected matter.\\nBirds that survive the H5N1 infection can\\nexcrete the virus for at least 10 days, according to a\\nWHO report. The strain had proliferated through\\nbird-to-bird contact to flocks on farms and poultry\\nin live bird markets. The virus can also spread in\\nsurfaces including manure, bird feed, equipment,\\nvehicles, egg flats, and crates, and the clothing and\\nshoes of people who came into contact with the\\nvirus.\\nA small amount of a highly pathogenic avian\\ninfluenza virus could be deadly. One gram (0.035\\nounces) of contaminated manure could hold enough\\nvirus to infect 1 million birds, according to the USDA.\\nFrom 1997 through the spring of 2005, the viruses\\nprimarily infected people in Asia who had contact\\nwith infected birds and surfaces.\\nBird flu symptoms in people\\nIn early 2005, information about symptoms of\\nH5N1 in humans was based on the 1997 Hong Kong\\nGALE ENCYCLOPEDIA OF MEDICINE 543\\nBird flu'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 573, 'page_label': '544'}, page_content='outbreak. People experienced traditional flu symptoms\\nsuch as afever, cough, sore throat, and aching muscles.\\nOther symptoms included eye infections (conjunctivi-\\ntis), pneumonia, acute respiratory distress, viral pneu-\\nmonia, and other severe and life-threatening\\ncomplications.\\nAvian flu symptoms in birds\\nThe sudden death of a bird that had not appeared\\nill is one symptom of the highly pathogenic bird flu.\\nAccording to the USDA, infected live birds may dis-\\nplay one or more of the following symptoms: lack\\nof energy, appetite loss, nasal discharge, coughing,\\nsneezing, a lack of coordination, and diarrhea.I n\\naddition, the bird may lay fewer eggs or produce eggs\\nthat are soft-shelled or misshapen. Furthermore, there\\nmay be swelling of the head, eyelids, comb, and wat-\\ntles. Another symptom is purple discoloration on the\\ncombs, wattles, and legs.\\nIf there is an outbreak of the highly pathogenic\\nflu in birds, they are destroyed to prevent the spread of\\nthe virus.\\nVirus mixing vessels\\nInfluenza viruses undergo frequent changes and\\nform new subtypes. In addition, influenza A viruses\\ncan trade genetic materials with the viruses of other\\nspecies. Two different strains trade or merge material,\\na process known as an antigenic shift. That shift pro-\\nduces a new subtype that is different from the two\\nparent viruses. When the new subtype contains genes\\nfrom the human virus, a pandemic resulted because\\nthere was no immunity to the virus and no vaccine to\\nprotect against it.\\nThe genetic shift occurs in a ‘‘mixing vessel’’ that\\nwas susceptible to both types of flu. In the past, the\\nshift was thought to be related to people living close to\\npigs and domestic poultry. Pigs can be infected by\\navian viruses and mammalian viruses like the human\\nstrains, according to WHO. However, research into\\nthe H5N1 strain indicates that people can serve as the\\nmixing vessels. As more people become infected with\\nbird flu, the probability increases that humans would\\nserve as the mixing vessel for a new subtype that could\\nbe transmitted from one person to another.\\nDiagnosis\\nThe symptoms of avian flu and human flu are very\\nsimilar, so laboratory testing is needed to diagnose\\navian influenza. In addition to diagnosing the indivi-\\ndual, testing in 2005 was performed to determine\\nwhether the infection was spreading from birds to\\npeople or from humans to humans.\\nDiagnostic tests for human flu are rapid and reli-\\nable, according to WHO. The international organiza-\\ntion noted that laboratories within WHO’s global\\nnetwork have high-security facilities and experienced\\nstaff. Test methods include a viral culture that ana-\\nlyses a blood sample and swabbings of the nose or\\nthroat. Other testing examines respiratory secretions.\\nIn the United States, the Centers for Disease\\nControl is among the organizations preparing for a\\npossible outbreak of bird flu in humans. In addition to\\nspecifics related to diagnosing bird flu, CDC refers\\nhealthcare workers to precautions to prevent the\\nspread of flu and other respiratory infections in med-\\nical settings.\\nPrecautionary measures include directing people\\nto observe cough etiquette. People with symptoms of\\nrespiratory infection should cover their mouths or use\\nfacial tissues when coughing or sneezing. After cough-\\ning or sneezing, the person should wash their hands\\nwith a non-antimicrobial soap and water, alcohol-\\nbased hand rub, or antiseptic handwash.\\nFurthermore, people with flu-like symptoms may\\nbe given masks to wear while they are waiting to be\\nexamined by medical personnel. The healthcare work-\\ners should wear masks in some circumstances.\\nUndoubtedly, they will wear masks when working\\nwith people with symptoms of bird flu.\\nTreatment\\nAs of March of 2005, there was no vaccine to\\nprotect people from the H5N1 virus, according to the\\nCDC. However, the U.S. agency and the World\\nHealth Organization had isolated seed strains of the\\nvirus in order to make a vaccine. Safety tests were\\nscheduled to start in April of 2005 on a vaccine man-\\nufactured by Sanofi pasteur, a firm in Swiftwater,\\nPennsylvania, formerly known as Aventis Pasteur.\\nOn March 23, 2005, the National Institute of\\nAllergy and Infectious Diseases (NIAID) announced\\nthat fast-track recruitment had started for volunteers\\nto participate in an investigative study of the vaccine.\\nDuring the Phase I trial, the trial vaccine will be tested\\non 450 healthy adults between the ages of 18 to 64,\\naccording to NIAID, which is part of the National\\nInstitutes of Health.\\nStudies were to be conducted at University of\\nCalifornia at Los Angeles, University of Maryland\\nSchool of Medicine in Baltimore, and the University\\nof Rochester School of Medicine and Dentistry,\\n544 GALE ENCYCLOPEDIA OF MEDICINE\\nBird flu'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 574, 'page_label': '545'}, page_content='Rochester, New York. If the vaccine is proven safe for\\nadults, there were plans to test it in people in other age\\ngroups such as children and the elderly.\\nFurthermore, research was underway on a vaccine\\nto fight H9N2, another avian flu virus subtype.\\nTreatment with existing drugs\\nExisting anti-viral medications may sometimes be\\neffective against avian flu viruses, according to a\\nMarch 18, 2005, report from CDC. In the United\\nStates, four drugs have been approved by the U.S.\\nFood and Drug Administration (FDA) for the treat-\\nment and prevention of influenza A viruses.\\nThe medications amantadine (Symmetrel),\\nrimantadine (Flumadine), seltamivir (Tamiflu), and\\nzanamivir (Relenza) were clinically effective in the\\ntreatment of influenza A viruses in otherwise healthy\\nadults.\\nHowever, avian flu research indicated that the\\nH5N1 virus was resistant to amantadine and rimanta-\\ndine, according to CCDC. The other two drugs would\\n‘‘probably work,’’ according to CDC. However, stu-\\ndies were needed of the medication’s effectiveness.\\nDuring the 2004 human flu season in the United\\nStates, the Associated Press reported that Relenza cost\\nabout $55 for the typical 10-day treatment. Tamiflu\\ncost approximately $66 for the same course of treat-\\nment. Insurance frequently covered part of the pre-\\nscription costs.\\nFor people diagnosed with bird flu, the World\\nHealth Organization recommends that patients take\\nTamiflu twice daily for five days. Treatment should\\nbegin as soon as possible. Patients may also receive\\nmedication to lower fevers and antibiotics to fight\\nsecondary infections.\\nIn the spring of 2005, there was no H5N1 vaccine.\\nCountries including the United States were reportedly\\nstockpiling Tamiflu in the event a pandemic erupted.\\nAt that time, WHO and CDC recommended the issu-\\ning of anti-viral medication as a preventive measure to\\npeople working in poultry production. Those people,\\nalong with health care workers, would have priority\\nfor the medications.\\nAlternative treatment\\nIn March of 2005, people in South Korea began\\neating more kimchi to ward off avian flu infection,\\naccording to the reports from the British Broadcasting\\nCompany and other news organizations. The public\\nturned to the spicy vegetable dish after scientists at\\nSeoul National University announced that kimchi\\naided in the recovery of 11 out of 13 infected chickens.\\nThe scientists fed the birds an extract of kimchi, a dish\\nmade by fermenting cabbage with red peppers,\\nradishes, and large amounts of garlic and ginger. A\\nweek later, all but two birds showed signs of recovery.\\nThe researchers acknowledged that their study\\nwas unscientific. At that time, they were not sure\\nhow or why kimchi was related to the recovery.\\nHowever, the announcement led people to again\\nregard kimchi as a health remedy. In 2003, interest in\\nkimchi increased when people thought eating it helped\\nprevent SARS (severe acute respiratory syndrome).\\nNo scientific confirmation was made between kimchi\\nand SARS prevention.\\nPrognosis\\nBird flu has been fatal to people, and there was\\nconcern in 2005 about the virus mutating into a strain\\nthat could be transmittedby people. Health organi-\\nzations and government agencies focused on pre-\\nventing or reducing the risks of a pandemic caused\\nby bird flu.\\nIn the United States, research was underway on\\nvaccines to fight the flu. Other efforts include the\\nUSDA Safety’s guidelines for people working with\\npoultry. Strategies included trade restrictions on poul-\\ntry and poultry products from Asia, according to the\\nUSDA. Imported live birds and eggs were quarantined\\nfor 30 days. During that time, they were tested for bird\\nflu and exotic Newcastle disease. The United States\\nbans the import of poultry meat from Asia because\\nmeat processing plants were not approved by the\\nUSDA’s Food Safety and Inspection Service.\\nPrevention\\nIn the spring of 2005, bird flu was primarily a risk\\nfor people in the United States who worked with\\npoultry. Potentially vulnerable people included those\\nworking with poultry on farms and avian health work-\\ners like veterinarians. People working with birds in\\nlocations such as commercial poultry facilities, veter-\\ninary offices, and live bird markets should wear pro-\\ntective clothing. That equipment includes boots,\\ncoveralls, face masks, gloves, and headgear, according\\nto the USDA. If necessary, they should receive anti-\\nviral medications as a safeguard.\\nFurthermore, poultry producers should imple-\\nment security measures to prevent the outbreak of a\\nhighly pathogenic virus. Those actions include keep-\\ning flocks away from wild or migratory birds and\\nGALE ENCYCLOPEDIA OF MEDICINE 545\\nBird flu'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 575, 'page_label': '546'}, page_content='providing clothing and disinfectant facilities for\\nemployees. Plastic crates should be used at live bird\\nmarkets because they were easier to clean than wood\\ncrates. Cleaning and disinfecting areas were also\\nimportant for preventing an outbreak.\\nIf necessary birds would be quarantined or\\ndestroyed.\\nResources\\nPERIODICALS\\nAssociated Press. ‘‘Bird Flu Called Global Human Threat:\\nAsia Outbreak Poses ‘Gravest Possible Danger,’ U.N.\\nOfficial Says, Urging Controls.’’ Washington Post.\\nFebruary 24, 2005 [cited March 30, 2005] .\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRoad, Atlanta, GA 30333. 800-CDC-INFO (232-\\n5636)..\\nNational Institute of Allergy and Infectious Diseases. 6610\\nRockledge Drive, MSC 6612, Bethesda, MD 20892-\\n6612. 301-496-5717. .\\nWorld Health Organization. Regional Office for the\\nAmericas. 525, 23rd Street NW, Washington, DC\\n20037. 202-974-3000..\\nHighly Pathogenic Avian Influenza. United States\\nDepartment of Agriculture Animal and Plant\\nInspection Safety. March 2004 [Cited March 31, 2005].\\n.\\nOTHER\\nAvian Influenza. World Health Organization. Continuously\\nupdated [cited March 31, 2005]. .\\nAvian Flu Index. Centers for Disease Control and\\nPrevention. Continuously updated [cited April 1, 2005].\\n.\\nChazan, David. ‘‘Korean dish ‘may cure bird flu.’’’BBC\\nNews. March 14, 2005 [cited March 30, 2005]. .\\nFocus on the Flu. National Institute of Allergy and\\nInfectious Diseases. Continuously updated [cited\\nMarch 31, 2005]. .\\nLiz Swain\\nBirth control see Diaphragm (birth control);\\nCondom; Contraception\\nBirth control pills see Oral contraceptives\\nBirth defects\\nDefinition\\nBirth defects are physical abnormalities that are\\npresent at birth; they also are called congenital\\nabnormalities. More than 3,000 have been identified.\\nDescription\\nBirth defects are found in 2-3% of all newborn\\ninfants. This rate doubles in the first year, and reaches\\n10% by age five, as more defects become evident and\\ncan be diagnosed. Almost 20% of deaths in newborns\\nare caused by birth defects.\\nAbnormalities can occur in any major organ or\\npart of the body. Major defects are structural abnor-\\nmalities that affect the way a person looks and require\\nmedical and/or surgical treatment. Minor defects are\\nabnormalities that do not cause serious health or social\\nproblems. When multiple birth defects occur together\\nand have a similar cause, they are called syndromes. If\\ntwo or more defects tend to appear together but do not\\nshare the same cause, they are called associations.\\nCauses and symptoms\\nThe specific cause of many congenital abnormal-\\nities is unknown, but several factors associated with\\npregnancy and delivery can increase the risk of birth\\ndefects.\\nTeratogens\\nAny substance that can cause abnormal develop-\\nment of the egg in the mother’s womb is called a\\nteratogen. In the first two months after conception,\\nthe developing organism is called an embryo; develop-\\nmental stages from two months to birth are called\\nfetal. Growth is rapid, and each body organ has a\\ncritical period in which it is especially sensitive to out-\\nside influences. About 7% of all congenital defects are\\ncaused by exposure to teratogens.\\nDRUGS. Only a few drugs are known to cause birth\\ndefects, but all have the potential to cause harm.\\nFor example, in 2003, a study found that use of topical\\n(local) corticosteroidsin the first trimester of pregnancy\\nmay be associated withcleft lip. Thalidomide is known\\nto cause defects of the arms and legs; several other\\ntypes also cause problems.\\n/C15Alcohol. Drinking large amounts of alcohol while\\npregnant causes a cluster of defects calledfetal alco-\\nhol syndrome, which includes mental retardation,\\n546 GALE ENCYCLOPEDIA OF MEDICINE\\nBirth defects'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 576, 'page_label': '547'}, page_content='heart problems, and growth deficiency. In 2004,\\nexperts warned that binge drinking early in pregnancy\\nwas dangerous even if the woman quit drinking later.\\n/C15Antibiotics. Certain antibiotics are known tetrato-\\ngens. Tetracycline affects bone growth and discolors\\nthe teeth. Drugs used to treattuberculosis can lead to\\nhearing problems and damage to a nerve in the head\\n(cranial damage).\\n/C15Anticonvulsants. Drugs given to prevent seizures can\\ncause serious problems in the developing fetus,\\nincluding mental retardation and slow growth.\\nStudies in the United Kingdom and Australia have\\ntracked the percentage of birth defects caused by\\ncertain antiepileptic drugs.\\n/C15Antipsychotic and antianxiety agents. Several drugs\\ngiven for anxiety and mental illness are known to\\ncause specific defects.\\n/C15Antineoplastic agents. Drugs given to treatcancer\\ncan cause major congenital malformations, espe-\\ncially central nervous system defects. They also may\\nbe harmful to the health care worker who is giving\\nthem while pregnant.\\n/C15Hormones. Male hormones may cause masculiniza-\\ntion of a female fetus. A synthetic estrogen (DES)\\ngiven in the 1940s and 1950s caused an increased risk\\nof cancer in the adult female children of the mothers\\nwho received the drug.\\n/C15Recreational drugs. Drugs such asLSD have been\\nassociated with arm and leg abnormalities and cen-\\ntral nervous system problems in infants. Crack\\ncocaine also has been associated with birth defects.\\nSince drug abusers tend to use many drugs and have\\npoor nutrition and prenatal care, it is hard to deter-\\nmine the effects of individual drugs.\\nUnknown causes–70%\\nCytogenetic diseases–4%\\nDrugs, chemicals, radiation–2%\\nMaternal infection–2%\\nMaternal metabolic factors–1%\\nBirth trauma and uterine factors–1%\\nHereditary diseases–20%\\nThe specific cause of many birth defects is unknown, but several factors associated with pregnancy and delivery can increase\\nthe risk of birth defects. These factors include exposure to teratogens, drugs and other chemicals, exposure to radiation, and\\ninfections present in the womb. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 547\\nBirth defects'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 577, 'page_label': '548'}, page_content='CHEMICALS. Environmental chemicals such as\\nfungicides, food additives, and pollutants are sus-\\npected of causing birth defects, though this is difficult\\nto prove.\\nRADIATION. Exposure of the mother to high levels\\nof radiation can cause small skull size (microcephaly),\\nblindness, spina bifida,a n dcleft palate. How severe the\\ndefect is depends on the duration and timing of the\\nexposure.\\nINFECTIONS. Three viruses are known to harm a\\ndeveloping baby: rubella, cytomegalovirus (CMV),\\nand herpes simplex. Toxoplasma gondii, a parasite\\nthat can be contracted from undercooked meat, from\\ndirt, or from handling the feces of infected cats, causes\\nserious problems. Untreated syphilis in the mother\\nalso is harmful.\\nGenetic factors\\nA gene is a tiny, invisible unit containing informa-\\ntion (DNA) that guides how the body forms and func-\\ntions. Each individual inherits tens of thousands of\\ngenes from each parent, arranged on 46 chromosomes.\\nGenes control all aspects of the body, how it works,\\nand all its unique characteristics, including eye color\\nand body size. Genes are influenced by chemicals and\\nradiation, but sometimes changes in the genes are\\nunexplained accidents. Each child gets half of its\\ngenes from each parent. In each pair of genes one\\nwill take precedence (dominant) over the other (reces-\\nsive) in determining each trait, or characteristic. Birth\\ndefects caused by dominant inheritance include a form\\nof dwarfism called achondroplasia; high cholesterol;\\nHuntington’s disease, a progressive nervous system\\ndisorder; Marfan syndrome, which affects connective\\ntissue; some forms ofglaucoma, andpolydactyly (extra\\nfingers or toes).\\nIf both parents carry the same recessive gene,\\nthey have a one-in-four chance that the child will\\ninherit the disease. Recessive diseases are severe and\\nmay lead to an earlydeath. They include sickle cell\\nanemia, a blood disorder that affects blacks, and\\nTay-Sachs disease, which causes mental retardation\\nin people of eastern European Jewish heritage. Two\\nrecessive disorders that affect mostly whites are:\\ncystic fibrosis, a lung and digestive disorder, and\\nphenylketonuria (PKU), a metabolic disorder. If only\\nCongenital absence of three fingers. Deformities such as this\\nare usually caused by damage to the developing fetusin utero.\\n(Photograph by Dr. P. Marazzi, Photo Researchers, Inc.\\nReproduced by permission.)\\nKEY TERMS\\nChromosome— One of the bodies in the cell\\nnucleus that carries genes. There are normally 46\\nchromosomes in humans.\\nCleft lip and palate— An opening in the lip, the roof\\nof the mouth (hard palate), or the soft tissue in the\\nback of the mouth (soft palate).\\nEmbryo— The developing baby from conception to\\nthe end of the second month.\\nGene— The The functional unit of heredity that\\ndirects all growth and development of an organism.\\nEach human being has more than 100,000 genes\\nthat determine hair color, body build, and all other\\ntraits.\\nFetus— In humans, the developing organism from\\nthe end of the eighth week to the moment of birth.\\nNeural tube defects— A group of birth defects that\\naffect the backbone and sometimes the spinal chord.\\nRubella— A mild, highly contagious childhood\\nillness caused by a virus; it is also called German\\nmeasles. It causes severe birth defects if a pregnant\\nwoman is not immune and gets the illness in the\\nfirst three months of pregnancy.\\nSpina bifida— One of the more common birth\\ndefects in which the backbone never closes.\\nTrait— A distinguishing feature of an individual.\\nVirus— A very small organism that causes infection\\nand needs a living cell to reproduce.\\n548 GALE ENCYCLOPEDIA OF MEDICINE\\nBirth defects'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 578, 'page_label': '549'}, page_content='one parent passes along the genes for the disorder, the\\nnormal gene received from the other parent will\\nprevent the disease, but the child will be a carrier.\\nHaving the gene is not harmful to the carrier, but\\nthere is the 25% chance of the genetic disease showing\\nup in the child of two carriers.\\nSome disorders are linked to the sex-determining\\nchromosomes passed along by parents.Hemophilia,a\\ncondition that prevents blood from clotting, and\\nDuchenne muscular dystrophy, which causes muscle\\nweakness, are carried on the X chromosome. Genetic\\ndefects also can take place when the egg or sperm are\\nforming if the mother or father passes along some\\nfaulty gene material. This is more common in older\\nmothers. The most common defect of this kind is\\nDown syndrome, a pattern of mental retardation and\\nphysical abnormalities, often including heart defects,\\ncaused by inheriting three copies of a chromosome\\nrather than the normal pair.\\nA less understood cause of birth defects results\\nfrom the interaction of genes from one or both parents\\nplus environmental influences. These defects are\\nthought to include:\\n/C15Cleft lip and palate, which are malformations of the\\nmouth.\\n/C15Clubfoot, ankle or foot deformities.\\n/C15Spina bifida, an open spine caused when the tube\\nthat forms the brain and spinal chord does not\\nclose properly.\\n/C15Water on the brain (hydrocephalus), which causes\\nbrain damage.\\n/C15Diabetes mellitus, an abnormality in sugar metabo-\\nlism that appears later in life.\\n/C15Heart defects.\\n/C15Some forms of cancer.\\nA serious illness in the mother, such as an under-\\nactive thyroid, or diabetes mellitus, in which her body\\ncannot process sugar, also can cause birth defects in the\\nchild. In fact, in 2003, it was shown that babies of\\ndiabetic mothers are five times as likely to have struc-\\ntural heart defects as other babies. An abnormal\\namount of amniotic fluid may indicate or cause birth\\ndefects. Amniotic fluid is the liquid that surrounds and\\nprotects the unborn child in the uterus. Too little of this\\nfluid can interfere with lung or limb development. Too\\nmuch amniotic fluid can accumulate if the fetus has a\\ndisorder that interferes with swallowing. In 2003, a\\nstudy linked the mother’s weight to risk of birth defects.\\nObese women were about three times more likely to\\nhave an infant with spina bifida or omphalocele\\n(protrusion of part of the intestine through the abdom-\\ninal wall) than women of average weight. Women who\\nwere overweight or classified as obese also were twice as\\nlikely to have an infant with a heart defect or multiple\\nbirth defects than women classified as average weight.\\nDiagnosis\\nIf there is a family history of birth defects or if the\\nmother is over 35 years old, then screening tests can be\\ndone during pregnancy to gain information about\\nthe health of the baby.\\n/C15Alpha-fetoprotein test. This is a simple blood test\\nthat measures the level of a substance called alpha-\\nfetoprotein that is associated with some major birth\\ndefects. An abnormally high or low level may indi-\\ncate the need for further testing.\\n/C15Ultrasound. The use of sound waves to examine the\\nshape, function, and age of the fetus is a common\\nprocedure. It also can detect many malformations,\\nsuch as spina bifida, limb defects, and heart and\\nkidney problems. In 2003, researchers in England\\nannouncedanewcombinationofbloodtestsandultra-\\nsound to detect Down syndrome sooner and more\\naccurately than with the usual blood screenings done\\nat 20 weeks of pregnancy.\\n/C15Amniocentesis. This test usually is done between the\\n13th and 15th weeks of pregnancy. A small sample of\\namniotic fluid is withdrawn through a thin needle\\ninserted into the mother’s abdomen. Chromosomal\\nanalysis can rule out Down syndrome and other\\ngenetic conditions.\\n/C15Chorionic villus sampling (CVS). This test can be\\ndone as early as the ninth week of pregnancy to\\nidentify chromosome disorders and some genetic\\nconditions. A thin needle is inserted through the\\nabdomen or a slim tube is inserted through the\\nvagina that takes a tiny tissue sample for testing.\\nIf a birth defect is suspected after a baby is born,\\nthen confirmation of the diagnosis is very important.\\nThe patient’s medical records and medical history may\\nhold essential information. A carefulphysical exami-\\nnation and laboratory tests should be done. Special\\ndiagnostic tests also can provide genetic informa-\\ntion in some cases. In 2003, the March of Dimes, a\\nnonprofit organization, recommended that every baby\\nborn in the United States receive, at minimum, screen-\\ning for the same core group of birth defects including\\nphenylketonuria, congenital adrenal hyperplasia, con-\\ngenital hypothryroidism, biotinidase deficiency, and\\nothers. They were concerned that newborn screening\\nvaried too much from state to state.\\nGALE ENCYCLOPEDIA OF MEDICINE 549\\nBirth defects'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 579, 'page_label': '550'}, page_content='Treatment\\nTreatment depends on the type of birth defect and\\nhow serious it is. When an abnormality has been\\nidentified before birth, delivery can be planned at a\\nhealth care facility that is prepared to offer any special\\ncare needed. Some abnormalities can be corrected\\nwith surgery. Experimental procedures have been\\nused successfully in correcting some defects, like\\nexcessive fluid in the brain (hydrocephalus), even\\nbefore the baby is born. Early reports have shown\\nsuccess with fetal surgery on spina bifida patients.\\nBy operating on these fetuses while still in the womb,\\nsurgeons have prevented the need for shunts and\\nimproved outcomes at birth for many newborns.\\nHowever, long-term studies still are needed. Patients\\nwith complicated conditions usually need the help of\\nexperienced medical and educational specialists with\\nan understanding of the disorder.\\nPrognosis\\nThe prognosis for a disorder varies with the spe-\\ncific condition.\\nPrevention\\nPregnant women should eat a nutritious diet.\\nTaking folic acidsupplements before and during preg-\\nnancy reduces the risk of having a baby with serious\\nproblems of the brain or spinal chord (neural tube\\ndefects). It is important to avoid any teratogen that\\ncan harm the developing baby, including alcohol and\\ndrugs. When there is a family history of congenital\\ndefects in either parent,genetic counselingand testing\\ncan help parents plan for future children. Often, coun-\\nselors can determine the risk of a genetic condition\\noccurring and the availability of tests for it. Talking to\\na genetic counselor after a child is born with a defect\\ncan provide parents with information about medical\\nmanagement and available community resources.\\nResources\\nPERIODICALS\\n‘‘Babies of Diabetic Mothers Have Fivefold Increase in\\nStructural Heart Defects.’’Diabetes Week(October 6,\\n2003): 8.\\nBauer, Jeff. ‘‘Researchers Link Momo´s Weight to Babyo´s\\nRisk of Birth Defects.’’RN (August 2003): 97–102.\\n‘‘Fetal Alcohol Syndrome Is Still a Threat, Says\\nPublication.’’ Science Letter(September 28, 2004): 448.\\n‘‘Fetal Diagnostic Test Combo Shows Promise.’’Health &\\nMedicine Week(October 27, 2003): 224.\\n‘‘Fetal Surgery for Spina Bifida Shows Benefits in Leg\\nFunction, Fewer Shunts.’’Health & Medicine Week\\n(October 20, 2003): 608.\\n‘‘March of Dimes Pushes Newborn Screening.’’Diagnostics &\\nImaging Week(July 31, 2003): 10–11.\\n‘‘Studies Reveal Risk of Birth Defects from AEDs.’’Pharma\\nMarketletter (September 13, 2004).\\n‘‘Topical Corticosteroids Use During Pregnancy May\\nAssociate With Cleft Lip.’’Biotech Week(September\\n24, 2003): 190.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275\\nMamaroneck Ave., White Plains, NY 10605. (914) 428-\\n7100. resourcecenter@modimes.org. .\\nOTHER\\nMarch of Dimes.Public Health Education Information Sheets.\\nKaren Ericson, RN\\nTeresa G. Odle\\nBirthmarks\\nDefinition\\nBirthmarks, including angiomas and vascular\\nmalformations, are benign (noncancerous) skin\\ngrowths composed of rapidly growing or poorly\\nformed blood vessels or lymph vessels. Found at\\nbirth (congenital) or developing later in life (acquired)\\nanywhere on the body, they range from faint spots to\\ndark swellings covering wide areas.\\nDescription\\nSkin angiomas, also called vascular (pertaining to\\nvessel) nevi (marks), are composed of blood vessels\\n(hemangiomas) or lymph vessels (lymphangiomas),\\nthat lie beneath the skin’s surface. Hemangiomas,\\ncomposed of clusters of cells that line the capillaries,\\nthe body’s smallest blood vessels, are found on the face\\nand neck (60%), trunk (25%), or the arms and legs\\n(15%). Congenital hemangiomas, 90% of which\\nappear at birth or within the first month of life, grow\\nquickly, and disappear over time. They are found in 1-\\n10% of full-term infants, and 25% of premature\\ninfants. About 65% are capillary hemangiomas\\n(strawberry marks), 15% are cavernous (deep) heman-\\ngiomas, and the rest are mixtures. Hemangiomas are\\nthree times more common in girls. Usually, only one\\nhemangioma is found, in 20% two are found, while\\nfewer than 5% have three or more. Lymphangiomas\\nare skin bumps caused by enlarged lymph vessels any-\\nwhere on the body.\\n550 GALE ENCYCLOPEDIA OF MEDICINE\\nBirthmarks'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 580, 'page_label': '551'}, page_content='Vascular malformations are poorly formed blood\\nor lymph vessels that appear at birth or later in life.\\nOne type, the salmon patch (nevus simplex), a pink\\nmark composed of dilated capillaries, is found on the\\nback of the neck (also called a stork bite) in 40% of\\nnewborns, and on the forehead and eyelids (also called\\nan angel’s kiss) in 20%. Stork bites are found in 70%\\nof white and 60% of black newborns.\\nFound in fewer than 1% of newborns, port-wine\\nstains (nevus flammeus), are vascular malformations\\ncomposed of dilated capillaries in the upper and lower\\nlayers of the skin of the face, neck, arms, and legs.\\nOften permanent, these flat pink to red marks develop\\ninto dark purple bumpy areas in later life; 85% appear\\non only one side of the body.\\nAcquired hemangiomas include spider angiomas\\n(nevus araneus), commonly known as spider veins,\\nand cherry angiomas (senile angiomas or Campbell\\nde Morgan spots). Found around the eyes, cheek-\\nbones, arms, and legs, spider angiomas are red marks\\nformed from dilated blood vessels. They occur during\\npregnancy in 70% of white women and 10% of black\\nwomen, in alcoholics andliver diseasepatients, and in\\n50% of children. Cherry angiomas, dilated capillaries\\nfound mainly on the trunk, appear in the 30s, and\\nmultiply withaging.\\nCauses and symptoms\\nThere are no known causes for congenital skin\\nangiomas; they may be related to an inherited weak-\\nness of vessel walls. Exposure to estrogen causes spider\\nangiomas in pregnant women or those takingoral\\ncontraceptives. Spider angiomas tend to run in\\nfamilies, and may be associated with liver disease,\\nsun exposure, and trauma.\\nHemangiomas\\nHemangiomas first appear as single or multiple,\\nwhite or pale pink marks, ranging from 2-20 cm (aver-\\nage 2-5 cm) in size. Some are symptomless while others\\ncause pain or bleeding, or interfere with normal func-\\ntioning when they are numerous, enlarged, infected, or\\nulcerated. Vision is affected by large marks on the\\neyelids. Spider and cherry angiomas are unsightly\\nbut symptomless.\\nEach type of hemangioma has a characteristic\\nappearance:\\n/C15Capillary hemangiomas (strawberry marks). These\\nround, raised marks are bright red and bumpy like\\na strawberry, and become white or gray when fading.\\n/C15Cavernous hemangiomas. These slightly raised,\\ndome-shaped, blue or purple swellings are sometimes\\nassociated with lymphangiomas or involve the soft\\ntissues, bone, or digestive tract.\\n/C15Spider angiomas. These are symptomless, reddish\\nblue marks formed from blood-filled capillaries\\nradiating around a central arteriole (small artery) in\\nthe shape of a spider web.\\n/C15Cherry angiomas. These harmless, dilated capillaries\\nappear as tiny, bright red-to-violet colored bumps.\\n/C15Lymphangiomas. These dilated lymph vessels form\\nlight pink or yellow cysts (fluid- filled sacs) or swellings.\\nKEY TERMS\\nAngioma— A benign skin tumor composed of\\nrapidly growing, small blood or lymph vessels.\\nCapillaries— The smallest blood vessels, they con-\\nnect the arteries and veins.\\nCorticosteroids— Drugs that fight inflammation.\\nHemangioma— A benign skin tumor composed of\\nabnormal blood vessels.\\nLymph vessels— Part of the lymphatic system, these\\nvessels connect lymph capillaries with the lymph\\nnodes; they carry lymph, a thin, watery fluid resem-\\nbling blood plasma and containing white blood\\ncells.\\nLymphangioma— A benign skin tumor composed\\nof abnormal lymph vessels.\\nNevus— A mark on the skin.\\nUlcer— A red, shallow sore on the skin.\\nVascular malformation— A poorly formed blood or\\nlymph vessels.\\nA fading capillary hemangioma on the nose of a child.\\n(Photograph by Dr. P. Marazzi, Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 551\\nBirthmarks'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 581, 'page_label': '552'}, page_content='Vascular malformations\\nThese are faint, flat, pink stains that grow as the\\nchild grows into larger dark red or purple marks. Some\\nare symptomless but others bleed if enlarged or injured.\\nDisfiguring port-wine stains can cause emotional and\\nsocial problems. About 5% of port-wine stains on\\nthe forehead and eyelids increase eye pressure due to\\ninvolvement of the eye and surrounding nerves.\\nAbnormalities of the spinal cord, soft tissues, or bone\\nmay be associated with severe port-wine stains.\\nEach type has a characteristic appearance:\\n/C15Salmon patches. These symptomless, light red-to-\\npink marks usually fade with time.\\n/C15Port-wine stains. These flat, pink marks progress to\\nraised, dark red-to-purple grape-like lumps distort-\\ning the facial features, arms, or legs.\\nDiagnosis\\nPatients are treated by pediatricians (doctors who\\nspecialize in the care of children), dermatologists (skin\\ndisease specialists), plastic surgeons (doctors who spe-\\ncialize in correcting abnormalities of the appearance),\\nand ophthalmologists (eye disease specialists).\\nAngiomas and vascular malformations are not dif-\\nficult to diagnose. The doctor takes a complete medical\\nhistory and performs aphysical examinationincluding\\ninspection and palpation of the marks. The skin is\\nexamined for discoloration, scarring, bleeding, infec-\\ntion, or ulceration. The type, location, size, number,\\nand severity of the marks are recorded. The doctor may\\nempty the mark of blood by gentle pressure. Biopsies or\\nspecialized x rays or scans of the abnormal vessels and\\ntheir surrounding areas may be performed. Patients\\nwith port-wine stains near the eye may requireskull x\\nrays, computed tomography scans, and vision and\\ncentral nervous system tests. Most insurance plans\\npay for diagnosis and treatment of these conditions.\\nTreatment\\nTreatment choices for skin angiomas and vascular\\nmalformations depend on their type, location, and\\nseverity, and whether they cause symptoms, pain, or\\ndisfigurement.\\nWatchful waiting\\nNo treatment is given, but the mark is regularly\\nexamined. This continues until the mark disappears,\\nor requires treatment. This approach is particularly\\nappropriate for the treatment of hemangiomas,\\nwhich often do not require treatment, since they even-\\ntually shrink by themselves.\\nDrugs\\nCORTICOSTEROIDS. Daily doses of the anti-\\ninflammatory drugs prednisone or prednisolone are\\ngiven for up to 2 months with gradual reduction of\\nthe dose. The marks begin to subside within 7-10 days,\\nbut may take up to 2 months to fully disappear. If no\\nresponse is seen in 2 weeks, the drug is discontinued.\\nTreatment may be repeated. Side effects include growth\\nretardation, increased blood pressure and blood sugar,\\ncataracts, glandular disorders, and infection. Thecor-\\nticosteroids triamcinolone acetate and betamethasone\\nsodium phosphate or acetate are injected directly into\\nthe marks with a response usually achieved within a\\nweek; additional injections are given in 4-6 weeks. Side\\neffects include tissue damage at the injection site.\\nINTERFERON ALPHA-2A. This drug reduces cell\\ngrowth, and is used for vascular marks that affect\\nvision, and that are unresponsive to corticosteroids.\\nGiven in daily injections under the skin, a response\\nrate of 50% is achieved after about 7 months. Side\\neffects include fever, chills, muscle and joint pain,\\nvision disorders, low white and red blood cell counts,\\nfatigue, elevated liver enzymes,nausea, blood clotting\\nproblems, and nerve damage.\\nANTIBIOTICS. Oral or topical (applied to the skin)\\nantibiotics are prescribed for infected marks.\\nSurgery\\nLASER SURGERY. Lasers create intense heat that\\ndestroys abnormal blood vessels beneath the skin,\\nwithout damaging normal skin. Two types of lasers\\nare used: the flashlamp-pulsed dye laser (FPDL) and\\nthe neodymium:YAG (Nd:YAG) laser. The FPDL,\\nused mainly for strawberry marks and port-wine\\nstains, penetrates to a depth of 1.8 mm and causes\\nlittle scarring, while the Nd:YAG laser penetrates to\\na depth of 6 mm, and is used to treat deep hemangio-\\nmas. Laser surgeryis not usually painful, but can be\\nuncomfortable. Anesthetic cream is used for FPDL\\ntreatment. Treatment with the Nd:YAG laser requires\\nlocal or general anesthesia . Children are usually\\nsedated or anesthetized. Healing occurs within 2\\nweeks. Side effects include bruising, skin discolora-\\ntion, swelling, crusting, and minor bleeding.\\nSURGICAL EXCISION. Under local or general\\nanesthesia, the skin is cut with a surgical instrument,\\nand vascular marks or theirscars are removed. The cut\\nis repaired with stitches or skin clips.\\n552 GALE ENCYCLOPEDIA OF MEDICINE\\nBirthmarks'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 582, 'page_label': '553'}, page_content='CRYOSURGERY. Vascular marks are frozen with an\\nextremely cold substance sprayed onto the skin.\\nWounds heal with minimal scarring.\\nELECTRODESICCATION. Affected vessels are\\ndestroyed with the current from an electric needle.\\nOther treatments\\nThese include:\\n/C15Sclerotherapy. Injection of a special solution causes\\nblood clotting and shrinkage with little scarring. Side\\neffects include stinging, swelling, bruising, scarring,\\nmuscle cramping, and allergic reactions. This treat-\\nment is used most commonly for spider angiomas.\\n/C15Embolization. Material injected into the vessel\\nblocks blood flow which helps control blood loss\\nduring or reduces the size of inoperable growths. A\\nserious side effect,stroke, can occur if a major blood\\nvessel becomes blocked.\\n/C15Make-up. Special brands are designed to cover birth-\\nmarks (Covermark or Dermablend).\\n/C15Cleaning and compression. Bleeding marks are\\ncleaned with soap and water or hydrogen peroxide,\\nandcompressedwith asterilebandagefor 5-10minutes.\\nAlternative treatment\\nAlternative treatments for strengthening weak\\nblood vessels include eating high-fiber foods and\\nthose containing bioflavonoids, including citrus fruit,\\nblueberries, and cherries, supplementing the diet with\\nvitamin C, and taking the herbs, ginkgo (Ginkgo\\nbiloba) and bilberry (Vaccinium myrtillus.)\\nPrognosis\\nThe various types of birthmarks have different\\nprognoses:\\n/C15Capillary hemangiomas. Fewer than 10% require\\ntreatment. Without treatment, 50% disappear by\\nage 5, 70% by age 7, and 90% by age 9. No skin\\nchanges are found in half while others have some\\ndiscoloration, scarring, or wrinkling. From 30-90%\\nrespond to oral corticosteroids, and 45% respond to\\ninjected corticosteroids; 50% respond to interferon\\nAlpha-2a. About 60% improve after laser surgery.\\n/C15Cavernous hemangiomas. Some do not disappear\\nand some are complicated by ulceration or infection.\\nAbout 75% respond to Nd:YAG laser surgery but\\nhave scarring. Severe marks respond to oral corticos-\\nteroids, but some require excision.\\n/C15Spider angiomas. These fade followingchildbirth and\\nin children, but may recur. About 90% respond to\\nsclerotherapy, electrodesiccation, or laser therapy.\\n/C15Cherry angiomas. These are easily removed by\\nelectrodesiccation.\\n/C15Lymphangiomas. These require surgery.\\n/C15Salmon patches. Eyelid marks disappear by 6-12\\nmonths of age, and forehead marks fade by age 6;\\nhowever, 50% of stork bites on the neck persist into\\nadulthood.\\n/C15Port-wine stains. Some flat birthmarks are easily\\ncovered with make-up. Treatment during infancy\\nor childhood improves results. About 95% of the\\nstains respond to FPDL surgery with minimal scarring;\\n25% will completely and 70% will partially disappear.\\nFor unknown reasons, 5% show no improvement.\\nPrevention\\nCongenital hemangiomas or vascular malform-\\nations cannot be prevented, but spider angiomas\\nmay be prevented byexercise, weight control, and a\\nhigh-fiber diet, as well as avoidance of sun exposure,\\nalcohol drinking, or wearing tight hosiery.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham\\nRoad, P.O. Box 4014, Schaumburg, IL 60168-4014.\\n(847) 330-0230. Fax: (847) 330-0050. .\\nAmerican Academy of Pediatrics. 141 Northwest Point\\nBoulevard, Elk Grove Village, IL 60007-1098. (847)\\n434-4000. .\\nCongenital Nevus Support Group. 1400 South Joyce St.,\\nNumber C-1201, Arlington, VA 22202. (703) 920-3249.\\nNational Congenital Port Wine Stain Foundation. 123 East\\n63rd St., New York, NY 10021. (516) 867-5137.\\nMercedes McLaughlin\\nBismuth subsalicylate see Antidiarrheal\\ndrugs\\nBites and stings\\nDefinition\\nHumans can be injured by the bites or stings of\\nmany kinds of animals, including mammals such as\\ndogs, cats, and fellow humans; arthropods such as\\nGALE ENCYCLOPEDIA OF MEDICINE 553\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 583, 'page_label': '554'}, page_content='spiders, bees, and wasps; snakes; and marine animals\\nsuch as jellyfish and stingrays.\\nDescription\\nMammals\\nDOGS. In the United States, where the dog popula-\\ntion exceeds 50 million, dogs surpass all other mammals\\nin the number of bites inflicted on humans. However,\\nmost dog-bite injuries are minor. A telephone survey of\\nU.S. households conducted in1994 led researchers to\\nestimate that 3,737,000 dogbites not requiring medical\\nattention occurred in the United States that year, versus\\n757,000 that required medical treatment. Studies also\\nshow that most dog bites are from pets or other dogs\\nknown to the bitten person, that males are more likely\\nthan females to be bitten, and that children face a greater\\nrisk than adults. Each year, about 10-20 Americans,\\nmostly children under 10 years of age, are killed by dogs.\\nDog bites result in an estimated 340,000 emergency\\nroom visits annually throughout the United States.\\nMore than half of the bites seen by emergency depart-\\nments occur at home. Children under 10 years old,\\nespecially boys between 5 and 9 years of age, are more\\nlikely than older people to visit an emergency room for\\nbite treatment. Children under 10 years old were also\\nmuch more liable to be bitten on the face, neck, and\\nhead. Nearly all of the injuries suffered by people seek-\\ning treatment in emergency rooms were of ‘‘low sever-\\nity,’’ and most were treated and released without being\\nadmitted to the hospital or sent to another facility.\\nMany of the bites resulted from people attempting to\\nbreak up fights between animals.\\nCATS. Although cats are found in nearly a third of\\nU.S. households, cat bites are far less common than\\ndog bites. According to one study, cats inflict perhaps\\n400,000 harmful bites in the United States each year.\\nThe tissue damage caused by cat bites is usually lim-\\nited, but they carry a high risk of infection. Whereas\\nthe infection rate for dog bite injuries is 15-20%, the\\ninfection rate for cat bites is 30-40%.\\nHUMANS. Bites from mammals other than dogs\\nand cats are uncommon, with one exception—human\\nbites. There are approximately 70,000 human bites\\neach year in the United States. Because the human\\nmouth contains a multitude of potentially harmful\\nmicroorganisms, human bites are more infectious\\nthan those of most other animals.\\nArthropods\\nArthropods are invertebrates belonging to the phy-\\nlum Arthropoda, which includes insects, arachnids,\\ncrustaceans, and other subgroups. There are more than\\n700,000 species in all. The list of arthropods that bite or\\nstinghumansisextensiveandincludeslice,bedbugs,fleas,\\nmosquitoes, black flies, ants, chiggers, ticks, centipedes,\\nscorpions, and other species.Spiders, bees, and wasps are\\nthe three kinds of arthropod that most often bite people.\\nSPIDERS. In the United States, only two kinds of\\nvenomous spider are truly dangerous: widow spiders\\nand brown (violin or fiddle) spiders. The black widow,\\nwhich is found in every state but Alaska, is probably\\nthe most notorious widow spider. It prefers dark, dry\\nplaces such as barns, garages, and outhouses, and also\\nlives under rocks and logs. Disturbing a female black\\nwidow or its web may provoke a bite. Brown spiders\\nalso prefer sheltered places, including clothing, and\\nmay bite if disturbed.\\nBEES AND WASPS. Bees and wasps will sting\\nto defend their nests or if they are disturbed. Species\\nAn insect bite caused this person’s lower lip to swell.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nA close-up view of lacerations on the shin of an adult woman\\ninflicted by a Rottweiler dog. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n554 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 584, 'page_label': '555'}, page_content='common to the United States include honeybees, bum-\\nblebees, yellow jackets, bald-faced hornets, brown hor-\\nnets, and paper wasps. Of note are also Africanized bee\\nspecies, also called ‘‘killer bees’’ that have been found in\\nthe United States since 1990. More than 50 Americans\\ndie each year after being stung by a bee, wasp, or ant.\\nAlmost all of those deaths are the result of allergic\\nreactions, and not of exposure to the venom itself.\\nSnakes\\nThere are 20 species of venomous snakes in the\\nUnited States. These snakes are found in every state\\nexcept Maine, Alaska, and Hawaii. Each year about\\n8,000 Americans receive a venomous snakebite, but no\\nmore than about 15 die, mostly from rattlesnake bites.\\nThe venomous snakes of the United States are\\ndivided into two families, the Crotalidae (pit vipers)\\nand the Elapidae. Pit vipers, named after the small\\nheat-sensing pit that lies between each eye and nostril,\\nare responsible for about 99% of the venomous snake-\\nbites suffered by Americans. Rattlesnakes, copperheads,\\nand cottonmouths (also called water moccasins) are pit\\nvipers. This family of snakes delivers its venom through\\ntwo long, hinged fangs in the upper jaw. Some pit vipers\\ncarry a potent venom that can threaten the brain and\\nspinal cord. The venom of others, such as the copper-\\nheads, is less harmful.\\nThe Elapidae family includes two kinds of veno-\\nmous coral snakes indigenous to the southern and\\nwestern states. Because coral snakes are bashful crea-\\ntures that come out only at night, they almost never\\nbite humans, and are responsible for approximately 25\\nbites a year in the United States. Coral snakes also\\nhave short fangs and a small mouth, which lowers the\\nrisk of a bite actually forcing venom into a person’s\\nbody. However, their venom is quite poisonous.\\nMarine animals\\nSeveral varieties of marine animal may bite or sting.\\nJellyfish and stingrays aretwo kinds that pose a threat\\nto people who live or vacation in coastal communities.\\nCauses and symptoms\\nMammals\\nDOGS. A typical dog bite results in a laceration,\\ntear, puncture, or crush injury. Bites from large,\\npowerful dogs may even causefractures and danger-\\nous internal injuries. Also, dogs trained to attack may\\nbite repeatedly during a single episode. Infected bites\\nusually causepain, cellulitis (inflammation of the con-\\nnective tissues), and a pus-filled discharge at the\\nwound site within 8-24 hours. Most infections are\\nconfined to the wound site, but many of the micro-\\norganisms in the mouths of dogs can cause systemic\\nand possibly life-threatening infections. Examples are\\nbacteremia and meningitis, especially severe in people\\ndiagnosed with acquiredimmunodeficiency syndrome\\n(AIDS) or other health condition that increases their\\nsusceptibility to infection.Rabies is rare among pet\\ndogs in the United States, most of which have been\\nvaccinated against the disease.Tetanus is also rare but\\nTriangular head\\nPit\\nProfile and top views of typically nonpoisonous and poisonous snakes. Characteristic triangular head and pits on the side of the\\nhead are indicative of poisonous pit vipers found in the United States.(Illustration by Argosy Inc.)\\nGALE ENCYCLOPEDIA OF MEDICINE 555\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 585, 'page_label': '556'}, page_content='can be transmitted by a dog bite if the victim is not\\nimmunized.\\nCATS. T h em o u t h so fc a t sa n dd o g sc o n t a i nm a n y\\nof the same microorganisms. Cat scratches and bites are\\nalso capable of transmitting theBartonella henselae\\nbacterium, which can lead tocat-scratch disease,a n\\nunpleasant but usually not life-threatening illness.\\nCat bites are mostly found on the arms and hands.\\nSharp cat teeth typically leave behind a deep puncture\\nwound that can reach muscles, tendons, and bones,\\nwhich are vulnerable to infection because of their\\ncomparatively poor blood supply. This is why cat\\nbites are much more likely to become infected than\\ndog bites. Also, people are less inclined to view cat\\nbites as dangerous and requiring immediate attention;\\nthe risk that infection has set in by the time a medical\\nprofessional is consulted is thus greater.\\nHUMANS. Humans bites result from fights, sexual\\nactivity, medical and dental treatment, and seizures.\\nBites also raise the possibility of spousal orchild abuse.\\nYellow jacket\\nPaper wasp\\nBlack\\nwidow\\nspider\\n(underside)\\nBrown\\nrecluse\\nspider\\nLouse\\nHornet\\nFire antHoney bee\\nTypes of spiders and insects that bite and sting.(Illustration by Argosy Inc.)\\n556 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 586, 'page_label': '557'}, page_content='Children often bite other children, but those bites are\\nhardly ever severe. Human bites are capable of trans-\\nmitting a wide range of dangerous diseases, including\\nhepatitis B, syphilis,a n dtuberculosis.\\nHuman bites fall into two categories: occlusional\\n(true) bites and clenched-fist injuries. The former pre-\\nsent a lower risk of infection. The latter, which are very\\ninfectious and can permanently damage the hand,\\nusually result from a fist hitting teeth during a fight.\\nPeople often wait before seeking treatment for a\\nclenched-fist injury, with the result that about half of\\nsuch injuries are infected by the time they are seen by a\\nmedical professional.\\nArthropods\\nSPIDERS. As a rule, people rarely see a black\\nwidow bite, nor do they feel the bite as it occurs. The\\nfirst (and possibly only) evidence that a person has\\nbeen bitten may be a mild swelling of the injured area\\nand two red puncture marks. Within a short time,\\nhowever, some victims begin to experience severemus-\\ncle cramps and rigidity of the abdominal muscles.\\nOther possible symptoms include excessive sweating,\\nnausea, vomiting, headaches, and vertigo as well as\\nbreathing, vision, and speech problems.\\nA brown spider’s bite can lead to necrotic ara-\\nchnidism, in which the tissue in an area of up to several\\ninches around the bite becomes necrotic (dies), produ-\\ncing an open sore that can take months or years to\\ndisappear. In most cases, however, the bite simply\\nproduces a hard, painful, itchy, and discolored area\\nthat heals without treatment in 2-3 days. The bite may\\nalso be accompanied by a fever, chills, edema (an\\naccumulation of excess tissue fluid),nausea and vomit-\\ning, dizziness, muscle and joint pain, and a rash.\\nBEES AND WASPS. The familiar symptoms of bee\\nand wasp stings include pain, redness, swelling, and\\nitchiness in the area of the sting. Multiple stings can\\nhave much more severe consequences, such asanaphy-\\nlaxis, a life-threatening allergic reaction that occurs in\\nhypersensitive persons.\\nSnakes\\nVenomous pit viper bites usually begin to swell\\nwithin 10 minutes and sometimes are painful. Other\\nsymptoms include skin blisters and discoloration,\\nweakness, sweating, nausea, faintness, dizziness,\\nbruising, and tender lymph nodes. Severepoisoning\\ncan also lead to tingling in the scalp, fingers, and\\ntoes, muscle contractions, an elevated heart rate,\\nrapid breathing, large drops in body temperature and\\nblood pressure, vomiting of blood, andcoma.\\nMany pit viper and coral snake bites (20-60%) fail\\nto poison (envenomate) their victim, or introduce only a\\nsmall amount of venom into the victim’s body. The\\nwounds, however, can still become infected by the harm-\\nful microorganisms that snakes carry in their mouths.\\nCoral snake bites are painful but may be hard to\\nsee. One to seven hours after the bite, a bitten person\\nbegins to experience the effects of the venom, which\\ninclude tingling at the wound site, weakness, nausea,\\nvomiting, excessive salivation, and irrational beha-\\nvior. Major nerves of the body can become paralyzed\\nfor 6-14 days, causing double vision, difficulty swal-\\nlowing and speaking, respiratory failure, and other\\nKEY TERMS\\nAnaphylaxis— A life-threatening allergic reaction\\noccurring in persons hypersensitive to bites and\\nstings.\\nAntibiotics— Substances used against bacteria that\\ncause infection.\\nAntibodies— Substances created by the body to\\ncombat infection.\\nAntihistamines— Drugs used to treat allergic reac-\\ntions by acting against a substance called histamine.\\nArachnid— Large class of arthropods that includes\\nspiders, scorpions, mites, and ticks. Arachnids have\\na segmented body divided into two parts, one of\\nwhich has four pairs of legs but no antennae.\\nArachnidism— Poisoning resulting from the bite or\\nsting of an arachnid.\\nBacteremia— Bacteria in the blood.\\nBlood serum— A component of blood.\\nImmune system— The body system that fights\\ninfection and protects the body against foreign\\ninvaders and disease.\\nKiller bees— Hybrids of African bees accidentally\\nintroduced into the wild in South and North\\nAmerica in 1956 and first reported in Texas in\\n1990. They were first imported by Brazilian scien-\\ntists attempting to create a new hybrid bee to\\nimprove honey production.\\nLymph nodes— Small, kidney-shaped organs that\\nfilter a fluid called lymph and that are part of the\\nbody’s immune system.\\nPus— A thick yellowish or greenish fluid composed\\nof the remains of dead white blood cells, pathogens\\nand decomposed cellular debris.\\nGALE ENCYCLOPEDIA OF MEDICINE 557\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 587, 'page_label': '558'}, page_content='problems. Six to eight weeks may be needed before\\nnormal muscular strength is regained.\\nMarine animals\\nJELLYFISH. Jellyfish venom is delivered by barbs\\ncalled nematocysts, which are located on the crea-\\nture’s tentacles and penetrate the skin of people who\\nbrush up against them. Instantly painful and itchy\\nred lesions usually result. The pain can continue up\\nto 48 hours. Severe cases may lead to skin necrosis,\\nmuscle spasms and cramps, vomiting, nausea, diar-\\nrhea, headaches, excessive sweating, and other symp-\\ntoms. In rare instances, cardiorespiratory failure may\\nalso occur.\\nSTINGRAYS. Tail spines are the delivery mechan-\\nism for stingray venom. Deep puncture wounds result\\nthat can cause an infection if pieces of spine become\\nembedded in the wound. A typical stingray injury\\nscenario involves a person who inadvertently steps\\non a resting stingray and is lashed in the ankle by its\\ntail. Stingray venom produces immediate, excruciating\\npain that lasts several hours. Sometimes the victim\\nsuffers a severe reaction, including vomiting, diarrhea,\\nhemorrhage (bleeding), a drop in blood pressure, and\\ncardiac arrhythmia (disordered heart beat).\\nDiagnosis\\nMammals\\nDOGS. Gathering information on the circum-\\nstances of a dog attack is a crucial part of treatment.\\nMedical professionals need to know when the attack\\noccurred (the chances of infection increase dramati-\\ncally if the wound has been left untreated for more\\nthan eight hours) and what led to the attack (unpro-\\nvoked attacks are more likely to be associated with\\nrabies). A person’s general health must also be\\nassessed, including the tetanus immunization history\\nif any, as well as information concerning possible\\nallergies to medication and pre-existing health pro-\\nblems that may increase the risk of infection.\\nA physical examinationrequires careful scrutiny of\\nthe wound, with special attention to possible bone,\\njoint, ligament, muscle, tendon, nerve, or blood-vessel\\ndamage caused by deep punctures or severe crush inju-\\nries. Serious hand injuries should be evaluated by a\\nspecialized surgeon. Most of the time, laboratory tests\\nfor identifying the microorganisms in bite wounds are\\nperformed if infection is present. X rays and other\\ndiagnostic procedures may also be necessary.\\nCATS. The diagnostic procedures used for dog\\nbites also apply to cat bites.\\nHUMANS. Testing the blood of a person who has\\nbeen bitten for immunity to hepatitis B and other\\ndiseases is always necessary after a human bite.\\nIdeally, the biter should be tested as well for the pre-\\nsence of transmissible disease. Clenched-fist injuries\\noften require evaluation by a hand surgeon or orthope-\\ndist. Because many people will deny having been in a\\nfight, medical professionals usually consider lacerations\\nover the fourth and fifth knuckles—the typical result of\\na clenched-fist injury—to be evidence of a bite wound.\\nMedical professionals also look for indications of\\nspousal or childabuse when evaluating human bites.\\nArthropods\\nSPIDERS. Because bites from widow spiders and\\nbrown spiders require different treatments, capturing\\nand identifying the spider helps to establish diagnosis.\\nSnakes\\nDiagnosis relies on a physical examination of the\\nvictim, information about the circumstances of the\\nbite, and a look at the snake itself (if it can safely be\\nkilled and brought in for identification). Blood tests\\nand urinalysis supply important data on the victim’s\\ncondition. Chest x-rays and electrocardiography (a\\nprocedure for measuring heart activity) may also be\\nnecessary.\\nTreatment\\nMammals\\nDOGS. Minor dog bites can be treated at home. The\\nAmerican Academy of Family Physicians recommends\\ngently washing the wound with soap and water and then\\napplying pressure to the injured area with a clean towel\\nto stop the bleeding. The next step is to apply anti-\\nbiotic ointment and a sterile bandage to the wound.\\nTo reduce swelling and fend off infection, ice should\\nbe applied and the injured area kept elevated above\\nthe level of the heart. The wound should be cleaned\\nand covered with ointment twice a day until it heals.\\nAny dog bite that does not stop bleeding after\\n15 minutes of pressure must be seen by a medical\\nprofessional. The same is true for bites that are deep\\nor gaping; for bites to the head, hands, or feet; and for\\nbites that may have broken a bone, damaged nerves,\\nor caused a major injury of another kind. Bite victims\\nmust also watch for infection. A fever is one sign of\\ninfection, as are redness, swelling, warmth, increased\\ntenderness, and pus at the wound site. Diabetics, peo-\\nple with AIDS orcancer, individuals who have not had\\na tetanus shot in five years, and anyone else who has a\\n558 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 588, 'page_label': '559'}, page_content='medical problem that can increase susceptibility to\\ninfection should seek medical treatment no matter\\nhow minor the bite appears.\\nMedical treatment of dog bites involves washing\\nthe wound with an anti-infective solution. Removal of\\ndead and damaged tissue (under local, regional, or\\ngeneral anesthetic) may be required after the wound\\nhas been washed, and any person whose tetanus shots\\nare not up to date should receive a booster injection.\\nSome wounds are left open and allowed to heal on\\ntheir own, while others require stitches (stitching may\\nbe delayed a few days if infection is a concern). Many\\nemergency departments prescribe antibiotics for all\\npeople with dog bites, but some researchers suggest\\nthat antibiotics are usually unnecessary and should\\nbe limited to those whose injuries or other health\\nproblems make them likely candidates for infection.\\nA follow-up visit after one or two days is generally\\nrequired for anyone who has received bite treatment.\\nCATS. Because of the high risk of infection, people\\nwho are bitten by a cat should always see a doctor. Cat\\nscratches do not require professional medical treat-\\nment unless the wound appears infected or the\\nscratched person has a weakened immune system.\\nMedical treatment for cat bites generally follows\\nthe procedures used for dog bites. Experts advise,\\nhowever, that cat-bite wounds should always be left\\nopen to prevent infection. Persons who have been\\nbitten by cats generally receive antibiotics as a preven-\\ntive measure.\\nHUMANS. Human bites should always be exam-\\nined by a doctor. Such bites are usually treated with\\nantibiotics and left open because of the high risk of\\ninfection. A study released in June 2004 showed that\\nroutine use of antibiotics for human bites may not be\\nnecessary, as physicians try to minimize overuse of\\nantibiotics. Superficial wounds in low-risk areas may\\nno longer need antibiotic treatment, but more serious\\nhuman bites to high-risk areas such as the hands\\nshould be treated with antibiotics to prevent serious\\ninfection. A person who has been bitten may also\\nrequire immunization against hepatitis B and other\\ndiseases. Persons who are being treated for a\\nclenched-fist injury will require a daily follow-up\\nexamination for 3-5 days.\\nArthropods\\nSPIDERS. No spider bite should be ignored.\\nThe antidote for severe widow spider bites is a sub-\\nstance called antivenin, which contains antibodies\\ntaken from the blood serum of horses injected with\\nspider venom. Doctors exercise caution in using\\nantivenin, however, because it can trigger anaphylac-\\ntic shock, a potentially deadly (though treatable) aller-\\ngic reaction, and serum sickness, an inflammatory\\nresponse that can give rise to joint pain, a fever,rashes,\\nand other unpleasant, though rarely serious,\\nconsequences.\\nAn antivenin for brown spider bites exists as well,\\nbut it is not yet available in the United States. The drug\\ndapsone, used to treatleprosy, can sometimes stop the\\ntissue death associated with a brown spider bite.\\nNecrotic areas may need debridement (removal of\\ndead and damaged tissue) and skin grafts. Pain medica-\\ntions, antihistamines, antibiotics, and tetanus shots are\\na few of the other treatments that are sometimes neces-\\nsary after a bite from a brown spider or widow spider.\\nBEES AND WASPS. Most stings can be treated at\\nhome. A stinger that is stuck in the skin can be scraped\\noff with a blade, fingernail, credit card, or piece of\\npaper (using tweezers may push more venom out of\\nthe venom sac and into the wound). The area should\\nbe cleaned and covered with an ice pack.Aspirin and\\nother pain medications, oral antihistamines, and cala-\\nmine lotion are good for treating minor symptoms.\\nPutting meat tenderizer on the wound has no effect.\\nPersons who have been stung and experience an\\nallergic reaction, or who are at risk due to their medical\\nhistory, require immediate medical attention. The danger\\nsigns, which usually begin 10 minutes after an individual\\nis stung (though possibly not for several hours), include\\nnausea, faintness, chest pain, abdominal cramps,\\ndiarrhea, and difficulty swallowing or breathing.\\nSnakes\\nAlthough most snakes are not venomous, any sna-\\nkebite should immediately be examined at a hospital.\\nWhile waiting for emergency help to arrive, the victim\\nshould wash the wound site with soap and water, and\\nthen keep the injured area still and at a level lower than\\nthe heart. Ice should never be used on the wound site\\nnor should attempts be made to suck out the venom.\\nMaking a cut at the wound site is also dangerous. It is\\nimportant to stay calm and wait for emergency medical\\naid if it can arrive quickly. Otherwise, the victim should\\nproceed directly to a hospital.\\nWhen the victim arrives at a hospital, the medical\\nstaff must determine whether the bite was inflicted by\\na venomous snake and, if so, whether envenomation\\noccurred and how much venom the person has\\nreceived. Patients may develop low blood pressure,\\nabnormal blood clotting, or severe pain, all of which\\nrequire aggressive treatment. Fortunately, the effects\\nof some snakebites can be counteracted with\\nGALE ENCYCLOPEDIA OF MEDICINE 559\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 589, 'page_label': '560'}, page_content='antivenin. Minor rattlesnake envenomations can be\\nsuccessfully treated without antivenin, as can copper-\\nhead and water-moccasin bites. However, coral snake\\nenvenomations and the more dangerous rattlesnake\\nenvenomations require antivenin, sometimes in large\\namounts. Other treatment measures include antibiotics\\nto prevent infection and a tetanus booster injection.\\nMarine animals\\nJELLYFISH. Vinegar and other acidic substances\\nare used to neutralize jellyfish nematocysts still cling-\\ning to the skin, which are then scraped off. Anesthetic\\nointments, antihistamine creams, and steroid lotions\\napplied to the skin are sometimes beneficial. Other\\nmeasures may be necessary to counter the many harm-\\nful effects of jellyfish stings, which, if severe, require\\nemergency medical care.\\nSTINGRAYS. Stingray wounds should be washed\\nwith saltwater and then soaked in very hot water for\\n30-90 minutes to neutralize the venom. Afterwards,\\nthe wound should be examined by a doctor to ensure\\nthat no pieces of spine remain.\\nAlternative treatment\\nArthropods\\nSeveral alternative self-care approaches are used\\nto treat minor bee, wasp, and other arthropod stings,\\nincluding aromatherapy, ayurvedic medicine, flower\\nremedies, herbs, homeopathy, and nutritional therapy.\\nPrognosis\\nMammals\\nPrompt treatment and recognizing that even\\napparently minor bites can have serious consequences\\nare the keys to a good outcome after a mammal bite.\\nInfected bites can be fatal if neglected. Surgery and\\nhospitalization may be needed for severe bites.\\nArthropods\\nSPIDERS. Even without treatment, adults usually\\nrecover from black widow bites after 2-3 days. Those\\nmost at risk of dying are very young children, the\\nelderly, and people with high blood pressure. In the\\ncase of brown spider bites, the risk of death is greatest\\nfor children, though rare.\\nBEES AND WASPS. The pain and other symptoms of\\na bee or wasp sting normally fade away after a few\\nhours. People who are allergic to such stings, however,\\ncan experience severe and occasionally fatal\\nanaphylaxis.\\nSnakes\\nA snakebite victim’s chances of survival are excel-\\nlent if medical aid is obtained in time. Some bites,\\nhowever, result inamputation, permanent deformity,\\nor loss of function in the injured area.\\nMarine animals\\nSTINGRAYS. Stingray venom kills its human vic-\\ntims on rare occasions.\\nPrevention\\nMammals\\nDOGS. The risk of a dog bite injury can be reduced\\nby avoiding sick or stray dogs, staying away from\\ndogfights (people often get bitten when they try to\\nseparate the animals), and not behaving in ways that\\nmight provoke or upset dogs, such as wrestling with\\nthem or bothering them while they are sleeping, eating,\\nor looking after their puppies. Special precautions\\nneed to be taken around infants and young children,\\nwho must never be left alone with a dog. Pit bulls,\\nrottweilers, and German shepherds (responsible for\\nnearly half of all fatal dog attacks in the United\\nStates in 1997-2000) are potentially dangerous pets in\\nhouseholds where children live or visit. For all breeds\\nof dog, obedience training as well as spaying or neu-\\ntering lessen the chances of aggressive behavior.\\nCATS. Prevention involves warning children to\\nstay away from strange cats and to avoid rough play\\nand other behavior that can anger cats and cause them\\nto bite.\\nArthropods\\nSPIDERS. Common-sense precautions include\\nclearing webs out of garages, outhouses, and other\\nplaces favored by venomous spiders; keeping one’s\\nhands away from places where spiders may be lurking;\\nand, when camping or vacationing, checking clothing,\\nshoes, and sleeping areas.\\nBEES AND WASPS. When possible, it is advised to\\navoid the nests of bees and wasps and to not eat sweet\\nfood or wear bright clothing, perfumes, or cosmetics\\nthat attract bees and wasps.\\nEmergency medical kits containing self-adminis-\\ntrable epinephrine to counter anaphylactic shock are\\navailable for allergic people and should be carried by\\n560 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 590, 'page_label': '561'}, page_content='them at all times. People who suspect they are allergic\\nshould consult an allergist about shots that can reduce\\nreactions to bee and wasp venom.\\nSnakes\\nSnakes should not be kept as pets. Measures such\\nas mowing the lawn, keeping hedges trimmed, and\\nremoving brush from the yard also discourages snakes\\nfrom living close to human dwellings. Tongs should be\\nused to move brush, lumber, and firewood, to avoid\\nexposing one’s hands to snakes that might be lying\\nunderneath. Similarly, golfers should never use their\\nhands to retrieve golf balls from a water hole, since\\nsnakes can be hiding in the rocks and weeds. Caution\\nis also necessary when walking through weedy or grassy\\nareas, and children should be prevented from playing in\\nweedy, vacant lots and other places where snakes may\\nlive. Leather boots and long pants offer hikers and\\ncampers some protection from bites. Approaching a\\nsnake, even a dead one, can be dangerous, for the\\nvenom of recently killed snakes may still be active.\\nMarine animals\\nJELLYFISH. Prevention of jellyfish stings includes\\nobeying posted warning signs at the beach. Also, jelly-\\nfish tentacles may be transparent and up to 120 ft\\n(36.5 m) long, therefore great caution must be exer-\\ncised whenever a jellyfish is sighted nearby. An over-\\nthe-counter cream was being tested at the Stanford\\nUniversity School of Medicine in the summer of\\n2004. In early tests, it was effective in helping to pre-\\nvent some jellyfish contact.\\nSTINGRAYS. Shuffling while walking through shal-\\nlow areas that may be inhabited by stingrays will dis-\\nturb the water, causing the animal to move before it\\ncan be stepped on.\\nResources\\nBOOKS\\nHolve, Steve. ‘‘Envenomations.’’ InCecil Textbook of\\nMedicine, edited by Lee Goldman and J. Claude\\nBennett, 21st ed. Philadelphia: W. B. Saunders, 2000,\\npp. 2174-2178.\\nSutherland, Struan, and Tibballs, James.Australian Animal\\nToxins. 2nd ed. New York, Oxford Univ Press, 2001.\\nPERIODICALS\\n‘‘Cream May Ward Off Jellyfish.’’Drug Week(June 25,\\n2004): 553.\\n‘‘Do All Human Bite Wounds Need Antibiotics?’’\\nEmergency Medicine Alert(June 2004): 3.\\nGraudins, A., M. Padula, K. Broady, and G. M. Nicholson.\\n‘‘Red-back spider (Latrodectus hasselti) antivenom\\nprevents the toxicity of widow spider venoms.’’Annals\\nof Emergency Medicine37, no. 2 (2001): 154-160.\\nJarvis R. M., M. V. Neufeld, and C. T. Westfall. ‘‘Brown\\nrecluse spider bite to the eyelid.’’Ophthalmology 107,\\nno. 8 (2000): 1492-1496.\\nMetry, D. W., and A. A. Hebert. ‘‘Insect and arachnid\\nstings, bites, infestations, and repellents.’’Pediatric\\nAnnals 29, no. 1 (2000): 39-48.\\nSams, H. H., C. A. Dunnick, M. L. Smith, and L. E. King.\\n‘‘Necrotic arachnidism.’’Journal of the American\\nAcademy of Dermatology44, no. 4 (2001): 561-573.\\nSams, HH. ‘‘Nineteen documented cases of Loxosceles\\nreclusa envenomation.’’Journal of the American\\nAcademy of Dermatology44, no.4 (2001): 603-608.\\nORGANIZATIONS\\nAmerican Academy of Emergency Medicine. 611 East Wells\\nStreet, Milwaukee, WI 53202. (800) 884-2236. Fax:\\n(414) 276-3349. .\\nAmerican Academy of Family Physicians. 11400 Tomahawk\\nCreek Parkway, Leawood, KS 66211-2672. (913) 906-\\n6000. . fp@aafp.org.\\nAmerican Medical Association. 515 N. State Street, Chicago,\\nIL60610. (312) 464-5000..\\nOTHER\\nCity of Phoenix, Arizona..\\nSouthwestern University School of Medicine..\\nToxicology Professional Groups..\\nUniversity of Sydney, Australia..\\nVanderbilt University..\\nL. Fleming Fallon Jr., MD, PhD\\nTeresa G. Odle\\nBlack death see Plague\\nBlack lung disease\\nDefinition\\nBlack lung disease is the common name for coal\\nworkers’ pneumoconiosis (CWP) or anthracosis, a\\nlung disease of older workers in the coal industry,\\ncaused by inhalation, over many years, of small\\namounts of coal dust.\\nDescription\\nThe risk of having black lung disease is directly\\nrelated to the amount of dust inhaled over the\\nGALE ENCYCLOPEDIA OF MEDICINE 561\\nBlack lung disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 591, 'page_label': '562'}, page_content='years; the disease typically affects workers over age 50.\\nIts common name comes from the fact that the inhala-\\ntion of heavy deposits of coal dust makes miners lungs\\nlook black instead of a healthy pink. Although people\\nwho live in cities often have some black deposits in\\ntheir lungs from polluted air, coal miners have much\\nmore extensive deposits.\\nIn the years since the federal government has\\nregulated dust levels in coal mines, the number of\\ncases of black lung disease has fallen sharply. Since\\nthe Federal Coal Mine Health and Safety Act of 1969,\\naverage dust levels have fallen from 8.0 mg. per cubic\\nmeter to the current standard of 2.0 mg. per cubic\\nmeter. The 1969 law also set up a black lung disability\\nbenefits program to compensate coal miners who have\\nbeen disabled by on-the-job dust exposure.\\nDespite the technology available to control the\\nhazard, however, miners still run the risk of develop-\\ning this lung disease. The risk is much lower today,\\nhowever; fewer than 10% of coal miners have any x\\nray evidence of coal dust deposits. When there is such\\nevidence, it often shows up as only small black spots\\nless than 0.4 in (1 cm). in diameter, and may have been\\ncaused bysmoking rather than coal dust. This condi-\\ntion is called ‘‘simple CWP’’ and does not lead to\\nsymptoms or disability.\\nCauses and symptoms\\nSince the particles of fine coal dust, which a miner\\nbreathes when he is in the mines, cannot be destroyed\\nwithin the lungs or removed from them, builds up.\\nEventually, this build-up causes thickening and\\nscarring, making the lungs less efficient in supplying\\noxygen to the blood.\\nThe primary symptom of the disease isshortness\\nof breath, which gradually gets worse as the disease\\nprogresses. In severe cases, the patient may develop\\ncor pulmonale, an enlargement and strain of the right\\nside of the heart caused by chronic lung disease. This\\nmay eventually cause right-sidedheart failure.\\nSome patients developemphysema (a disease in\\nwhich the tiny air sacs in the lungs become damaged,\\nleading to shortness of breath, and respiratory and\\nheart failure) as a complication of black lung disease.\\nOthers develop a severe type of black lung disease\\ncalled progressive massive fibrosis, in which damage\\ncontinues in the upper parts of the lungs even after\\nexposure to the dust has ended. Scientists aren’t sure\\nwhat causes this serious complication. Some think\\nthat it may be due to the breathing of a mixture of\\ncoal and silica dust that is found in certain mines.\\nSilica is far more likely to lead to scarring than coal\\ndust alone.\\nDiagnosis\\nBlack lung disease can be diagnosed by checking a\\npatient’s history for exposure to coal dust, followed by\\na chest x-ray to discover if the characteristic spots in\\nthe lungs caused by coal dust are present. Apulmonary\\nfunction testmay aid in diagnosis.\\nX rays can detect black lung disease before it\\ncauses any symptoms. If exposure to the dust is\\nA light micrograph of a human lung containing particles of\\ninspired coal dust (anthracosis). The black masses shown\\nare groups of coal dust particles. (Photograph by Astrid &\\nHanns-Frieder Michler, Photo Researchers, Inc. Reproduced by\\npermission.)\\nKEY TERMS\\nEmphysema— A disease in which the tiny air sacs in\\nthe lungs become damaged, leading to shortness of\\nbreath, and respiratory and heart failure.\\nFibrosis— The growth of scar tissue, often as a\\nresponse to injury, infection, or inflammation.\\nPulmonary function test— A group of procedures\\nused to evaluate the function of the lungs and con-\\nfirm the presence of certain lung disorders.\\nSilica dust— A type of dust from silica (crystalline\\nquartz) which causes breathing problems in work-\\ners in the fields of mining, stone cutting, quarrying\\n(especially granite), blasting, road and building\\nconstruction industries that manufacture abrasives,\\nand farming. Breathing the dust causes silicosis, a\\nsevere disease that can scar the lungs.\\n562 GALE ENCYCLOPEDIA OF MEDICINE\\nBlack lung disease'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 592, 'page_label': '563'}, page_content='stopped at that point, progression of the disease may\\nbe prevented.\\nTreatment\\nThere is no treatment or cure for this condition,\\nalthough it is possible to treat complications such as\\nlung infections and cor pulmonale. Further exposure\\nto coal dust must be stopped.\\nPrognosis\\nThose miners with simple CWP can lead a normal\\nlife. However, patients who develop black lung disease\\nat an early age, or who have progressive massive\\nfibrosis, have a higher risk of prematuredeath.\\nPrevention\\nThe only way to prevent black lung disease is to\\navoid long-term exposure to coal dust. Coal mines\\nmay help prevent the condition by lowering coal dust\\nlevels and providing protective clothes to coal\\nminers.\\nA light micrograph of a human lung containing\\nparticles of inspired coal dust (anthracosis). The black\\nmasses shown are groups of coal dust particles.\\nResources\\nORGANIZATIONS\\nMine Safety and Health Administration. 4015 Wilson Blvd.\\nArlington, VA 22203. (703) 235-1910. .\\nCarol A. Turkington\\nBladder calculi see Bladder stones\\nBladder cancer\\nDefinition\\nBladder cancer is a disease in which the cells lining\\nthe urinary bladder lose the ability to regulate their\\ngrowth and start dividing uncontrollably. This abnor-\\nmal growth results in a mass of cells that form a tumor.\\nDescription\\nBladder cancer is the sixth most common cancer\\nin the United States. The American Cancer Society\\n(ACS) estimated that in 2001, approximately 54,300\\nnew cases of bladder cancer would be diagnosed\\n(about 39,200 men and 15,100 women), causing\\napproximately 12,400 deaths. The rates for men of\\nAfrican descent and Hispanic men are similar and\\nare approximately one-half of the rate among white\\nnon-Hispanic men. The lowest rate of bladder cancer\\noccurs in the Asian population. Among women, the\\nhighest rates also occur in white non-Hispanic females\\nand are approximately twice the rate for Hispanics.\\nWomen of African descent have higher rates of blad-\\nder cancer than Hispanic women.\\nThe urinary bladder is a hollow muscular organ\\nthat stores urine from the kidneys until it is excreted out\\nof the body. Two tubes called the ureters bring the urine\\nfrom the kidneys to the bladder. The urethra carries\\nthe urine from the bladder to the outside of the body.\\nBladder cancer has a very high rate of recurrence.\\nEven after superficial tumors are completely removed,\\nthere is a 75% chance that new tumors will develop\\nin other areas of the bladder. Hence, patients need\\nfrequent and thorough follow-up care.\\nCauses and symptoms\\nAlthough the exact cause of bladder cancer is not\\nknown, smokers are twice as likely as nonsmokers to get\\nthe disease. Hence,smoking is considered the greatest\\nrisk factor for bladder cancer. Workers who are exposed\\nto certain chemicals used in the dye industry and in the\\nrubber, leather, textile, and paint industries are believed\\nto be at a higher risk for bladder cancer. The disease also\\nis three times more common in men than in women;\\ncaucasians also are at an increased risk. The risk of\\nbladder cancer increases with age. Most cases are\\nfound in people who are 50–70 years old. In 2003, studies\\nshowed that hormone replacement therapy(HRT), a\\ntreatment used by many postmenopausal women, sig-\\nnificantly increased the risk of bladder and other cancers.\\nFrequent urinary infections, kidney andbladder\\nstones, and other conditions that cause long-term\\nirritation to the bladder may increase the risk of getting\\nbladder cancer. A past history of tumors in the bladder\\nalso could increase one’s risk of getting other tumors.\\nOne of the first warning signals of bladder cancer is\\nblood in the urine. Sometimes, there is enough blood to\\nchange the color of the urine to a yellow-red or a dark\\nred. At other times, the color of the urine appears\\nnormal but chemical testing of the urine reveals the\\npresence of blood cells. A change in bladder habits\\nsuch as painful urination, increased frequency of\\nurination and a feeling of needing to urinate but not\\nbeing able to do so are some of the signs of possible\\nGALE ENCYCLOPEDIA OF MEDICINE 563\\nBladder cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 593, 'page_label': '564'}, page_content='bladder cancer. All of these symptoms also may be\\ncaused by conditions other than cancer, but it is impor-\\ntant to see a doctor and have the symptoms evaluated.\\nWhen detected early and treated appropriately, patients\\nhave a very good chance of being cured completely.\\nDiagnosis\\nIf a doctor has any reason to suspect bladder can-\\ncer, several tests can help find out if the disease is\\npresent. As a first step, a complete medical history\\nwill be taken to check for any risk factors. A thorough\\nphysical examinationwill be conducted to assess all the\\nsigns and symptoms. Laboratory testing of a urine\\nsample will help to rule out the presence of a bacterial\\ninfection. In a urine cytology test, the urine is examined\\nunder a microscope to look for any abnormal or can-\\ncerous cells. A catheter (tube) can be advanced into\\nthe bladder through the urethra, and a salt solution is\\npassed through it to wash the bladder. The solution\\ncan then be collected and examined under a microscope\\nto check for the presence of cancerous cells.\\nA test known as the intravenous pyelogram (IVP)\\nis an x–ray examination that is done after a dye is\\ninjected into the blood stream through a vein in the\\narm. The dye travels through the blood stream and\\nthen reaches the kidneys to be excreted. It clearly out-\\nlines the kidneys, ureters, bladder, and urethra.\\nMultiple x rays are taken to detect any abnormality\\nin the lining of these organs.\\nThe physician may use a procedure known as a\\ncystoscopy to view the inside of the bladder. A thin\\nhollow lighted tube is introduced into the bladder\\nthrough the urethra. If any suspicious looking masses\\nare seen, a small piece of the tissue can be removed\\nfrom it using a pair of biopsy forceps. The tissue is then\\nexamined microscopically to verify if cancer is present,\\nand if so, to identify the type of cancer.\\nIf cancer is detected and there is evidence to indi-\\ncate that it has metastasized (spread) to distant sites in\\nthe body, imaging tests such as chest x rays, computed\\ntomography scans (CT), and magnetic resonance ima-\\nging (MRI) may be done to determine which organs\\nare affected. Bladder cancer generally tends to spread\\nto the lungs, liver, and bone.\\nTreatment\\nTreatment for bladder cancer depends on the\\nstage of the tumor. The patient’s medical history,\\noverall health status, and personal preferences also\\nare taken into account when deciding on an appropri-\\nate treatment plan. The three standard modes of treat-\\nment available for bladder cancer are surgery,\\nradiation therapy, and chemotherapy. In addition,\\nnewer treatment methods such as photodynamic ther-\\napy and immunotherapy also are being investigated in\\nclinical trials.\\nSurgery is considered an option only when the dis-\\nease is in its early stages. If the tumor is localized to a\\nUrethra\\nEpithalial Lining\\nMuscle\\nUreterBladder\\nCancer\\nBladder cancer on the inner lining of the bladder.(Illustration by Argosy Inc.)\\n564 GALE ENCYCLOPEDIA OF MEDICINE\\nBladder cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 594, 'page_label': '565'}, page_content='small area and has not spread to the inner layers of the\\nbladder, then the surgery is done without cutting open\\nthe abdomen. A cytoscope is introduced into the blad-\\nder through the urethra, and the tumor is removed\\nthrough it. This procedure is called a transurethral\\nresection (TUR). Passing a high-energy laser beam\\nthrough the cytoscope and burning the cancer may\\ntreat any remaining cancer. This procedure is known\\nas electrofulguration. If the cancer has invaded the walls\\nof the bladder, surgery will be done through an incision\\nin the abdomen. Cancer that is not very large can be\\nremoved by partialcystectomy, a procedure where a\\npart of the bladder is removed. If the cancer is large or\\nis present in more than one area of the bladder, a radical\\ncystectomy is done. In this operation, the entire bladder\\nand adjoining organs also may be removed. In men, the\\nprostate is removed, while in women, the uterus, ovar-\\nies, and fallopian tubes are removed.\\nIf the entire urinary bladder is removed, an alter-\\nnate place must be created for the urine to be stored\\nbefore it is excreted out of the body. To do this, a piece\\nof intestine is converted into a small bag and attached\\nto the ureters. This is then connected to an opening\\n(stoma) that is made in the abdominal wall. The pro-\\ncedure is called a urostomy. In some urostomy proce-\\ndures, the urine from the intestinal sac is routed into a\\nbag that is placed over the stoma in the abdominal\\nwall. The bag is hidden by the clothing and has to be\\nemptied occasionally by the patient. In a different\\nprocedure, the urine is collected in the intestinal sac,\\nbut there is no bag on the outside of the abdomen. The\\nintestinal sac has to be emptied by the patient, by\\nplacing a drainage tube through the stoma.\\nRadiation therapy that uses high-energy rays to\\nkill cancer cells is generally used after surgery to\\nKEY TERMS\\nBiopsy— The surgical removal and microscopic\\nexamination of living tissue for diagnostic purposes.\\nChemotherapy— Treatment with anticancer drugs.\\nComputed tomography (CT) scan— A medical pro-\\ncedure where a series of x rays are taken and put\\ntogether by a computer in order to form detailed\\npictures of areas inside the body.\\nCystoscopy— A diagnostic procedure where a hol-\\nlow lighted tube, (cystoscope) is used to look inside\\nthe bladder and the urethra.\\nElectrofulguration— A procedure where a high-\\nenergy laser beam is used to burn the cancerous tissue.\\nImmunotherapy— Treatment of cancer by stimulat-\\ning the body’s immune defense system.\\nIntravenous pyelogram (IVP)— A procedure where a\\ndye is injected into a vein in the arm. The dye travels\\nthrough the body and then concentrates in the urine\\nto be excreted. It outlines the kidneys, ureters, and\\nthe urinary bladder. An x ray of the pelvic region is\\nthen taken and any abnormalities of the urinary tract\\nare revealed.\\nMagnetic Resonance Imaging (MRI)— A medical\\nprocedure used for diagnostic purposes where pic-\\ntures of areas inside the body can be created using a\\nmagnet linked to a computer.\\nPartial cystectomy— A surgical procedure where the\\ncancerous tissue is removed by cutting out a small\\npiece of the bladder.\\nPhotodynamic therapy— A novel mode of treat-\\nment that uses a combination of special light\\nrays and drugs are used to destroy the cancerous\\ncells. First, the drugs, which make cancerous cells\\nmore susceptible to the light rays, are introduced\\ninto the bladder. Then the light is shone on the\\nbladder to kill the cells.\\nRadiation therapy— Treatment using high-energy\\nradiation from x-ray machines, cobalt, radium, or\\nother sources.\\nRadical cystectomy— A surgical procedure that is\\nused when the cancer is in more than one area of\\nthe bladder. Along with the bladder, the adjoining\\norgans also are removed. In men, the prostate is\\nremoved, while in women, the ovaries, fallopian\\ntubes and uterus may be removed.\\nStoma— An artificial opening between two cav-\\nities or between a cavity and the surface of the\\nbody.\\nTransurethral resection— A surgical procedure to\\nremove abnormal tissue from the bladder. The tech-\\nnique involves the insertion of an instrument called a\\ncytoscope into the bladder through the urethra, and\\nthe tumor is removed through it.\\nUrostomy— A surgical procedure consisting of cut-\\nting the ureters from the bladder and connecting\\nthem to an opening (see stoma) on the abdomen,\\nallowing urine to flow into a collection bag.\\nGALE ENCYCLOPEDIA OF MEDICINE 565\\nBladder cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 595, 'page_label': '566'}, page_content='destroy any remaining cancer cells that may not have\\nbeen removed during surgery. If the tumor is in a\\nlocation that makes surgery difficult, or if it is large,\\nradiation may be used before surgery to shrink the\\ntumor. In cases of advanced bladder cancer, radiation\\ntherapy is used to ease the symptoms such aspain,\\nbleeding, or blockage. Radiation can be delivered by\\nexternal beam, where a source of radiation that is\\noutside the body focuses the radiation on the area of\\nthe tumor. Occasionally, a small pellet of radioactive\\nmaterial may be placed directly into the cancer. This is\\nknown as interstitial radiation therapy.\\nChemotherapy uses anticancer drugs to destroy\\nthe cancer cells that may have migrated to distant\\nsites. The drugs are introduced into the bloodstream\\nby injecting them into a vein in the arm or taking\\nthem orally in pill form. Generally a combination of\\ndrugs is more effective than any single drug in treating\\nbladder cancer. Chemotherapy may be given follow-\\ning surgery to kill any remaining cancer cells. It also\\nmay be given even when no remaining cancer cells\\ncan be seen. This is called adjuvant chemotherapy.\\nAnticancer drugs, including thiotepa, doxorubicin,\\nand mitomycin, also may be instilled directly into\\nthe bladder (intravesicular chemotherapy) to treat\\nsuperficial tumors. In 2003, the FDA was giving fast\\ntrack designation to a form of paclitaxel, a common\\nanticancer drug, that was shown effective in treating\\nmetastatic or locally advanced bladder cancer.\\nA 2003 report stated that giving patients with blad-\\nder cancer chemotherapy followed by surgery may\\nimprove their outcomes. In the study of 307 patients,\\nthose with this combination of therapy lived two\\nyears longer than those treated with surgery only.\\nImmunotherapy, or biological therapy, uses the\\nbody’s own immune cells to fight the disease. To treat\\nsuperficial bladder cancer, bacille Calmette-Guerin\\n(BCG) may be instilled directly into the bladder. BCG\\nis a weakened (attenuated) strain of thetuberculosis\\nbacillus that stimulates the body’s immune system to\\nfight the cancer. This therapy has been shown to be\\neffective in controlling superficial bladder cancer.\\nPhotodynamic treatment is a novel mode of treat-\\nment that uses special chemicals and light to kill the\\ncancerous cells. First, a drug is introduced into the\\nbladder that makes the cancer cells more susceptible\\nto light. Following that, a special light is shone on the\\nbladder in an attempt to destroy the cancerous cells.\\nNew treatments are continuously being investi-\\ngated. Scientists have made great strides in gene map-\\nping and research in the twenty-first century. In 2003,\\na type ofgene therapy was being tested on patients\\nwith bladder cancer with success, but further enhance-\\nments were needed.\\nPrognosis\\nWhen detected in early stages, the prognosis for\\nthose with bladder cancer is excellent. At least 94% of\\npeople survive five years or more after initial diagno-\\nsis. However, if the disease has spread to the nearby\\ntissues, the survival rate drops to 49%. If it has metas-\\ntasized to distant organs such as the lung and liver,\\ncommonly only 6% of patients will survive five years\\nor more. As newer treatment methods are developed,\\nsome prognoses improve. For example, neoadjuvant\\nchemotherapy, or giving certain chemotherapy drugs\\nfollowing surgery, may help people live up to\\n31 months longer than previous treatments allowed.\\nPrevention\\nSince the exact causes of bladder cancer are not\\nknown, there is no certain way to prevent it. Avoiding\\nrisk factors whenever possible is the best alternative.\\nSince smoking doubles one’s risk of getting blad-\\nder cancer, avoiding tobacco may prevent at least half\\nthe deaths that result from bladder cancer. Taking\\nappropriate safety precautions when working with\\norganic cancer-causing chemicals is another way of\\npreventing the disease. Women should discuss the\\nrisks vs. benefits of hormone replacement therapy\\nwith their physicians.\\nIf a person has had a history of bladder cancer, or\\nhas been exposed to cancer-causing chemicals, he or\\nshe is considered to be at an increased risk of getting\\nbladder cancer. Similarly,kidney stones, frequent urin-\\nary infections, and other conditions that cause long-\\nterm irritation to the bladder also increase the chance\\nof getting the disease. In such cases, it is advisable to\\nundergo regular screening tests such as urine cytology,\\ncystoscopy and x rays of the urinary tract, so that\\nbladder cancer can be detected at its early stages and\\ntreated appropriately.\\nResources\\nPERIODICALS\\nGood, Brian. ‘‘Battle Against Bladder Cancer.’’Men’s\\nHealth 18 (December 2003): 32.\\nGrossman, H. Barton, et al. ‘‘Neoadjuvant Chemotherapy\\nPlus Cystectomy Compared With Cystectomy Alone\\nfor Locally Advanced Bladder Cancer.’’The New\\nEngland Journal of Medicine(August 28, 2003): 859.\\n‘‘HRT Increases Risk of Gallbladder, Breast, Endometrial,\\nand Bladder Cancer.’’Women’s Health Weekly(July 17,\\n2003): 31.\\n566\\nGALE ENCYCLOPEDIA OF MEDICINE\\nBladder cancer'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 596, 'page_label': '567'}, page_content='‘‘Intravesical Gene Therapy Appears Safe for Those\\nWith Local Bladder Cancer.’’Cancer Weekly(July 8,\\n2003): 144.\\n‘‘Tocosol Paclitaxel Receives Expedited Review for Bladder\\nCancer Indication.’’Biotech Week(November 26,\\n2003): 443.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta,\\nGA 30329-4251. (800) 227-2345. .\\nAmerican Foundation for Urologic Disease. 300 W. Pratt\\nSt., Suite 401. Baltimore, MD 21201. Phone: (800)-\\n828-7866.\\nCancer Research Institute. 681 Fifth Ave., New York, N.Y.\\n10022. (800) 992-2623. .\\nNational Cancer Institute. Building 31, Room 10A31, 31\\nCenter Drive, MSC 2580, Bethesda, MD 20892-2580.\\n(800) 422-6237. .\\nOncolink. University of Pennsylvania Cancer Center.\\n.\\nOTHER\\n‘‘Bladder Cancer.’’ National Cancer Institute Page..\\nLata Cherath, PhD\\nTeresa G. Odle\\nBladder removal see Cystectomy\\nBladder resection see Transurethral bladder\\nresection\\nBladder stones\\nDefinition\\nBladder stones are crystalline masses that form\\nfrom the minerals and proteins, which naturally\\noccur in urine. These types of stones are much less\\ncommon thankidney stones.\\nDescription\\nBladder stones can form anywhere in the urinary\\ntract before depositing in the bladder. They begin as tiny\\ngranules about the size of a grain of sand, but they can\\ngrow to more than an inch in diameter. These stones\\ncan block the flow of urine causingpain and difficulty\\nwith urination. They can also scratch the bladder\\nwall, which may lead to bleeding or infection.\\nCauses and symptoms\\nWhile the exact causes of the formation of bladder\\nstones are not completely understood, bladder stones\\nusually occur because of urinary tract infection (UTI),\\nobstruction of the urinary tract, enlargement of the\\nprostate gland in men, or the presence of foreign\\nbodies in the urinary tract. Diet and the amount of\\nfluid intake also appear to be important factors in the\\ndevelopment of bladder stones.\\nNinety-five percent of all bladder stones occur\\nin men, most of who have anenlarged prostategland or\\na UTI. These stones are rarely seen in children or\\nin African Americans. People withgout may deve-\\nlop bladder stones composed almost entirely of uric acid.\\nThe symptoms of bladder stones may become\\nevident when the wall of the bladder is scratched or\\nwhen the urinary tract becomes obstructed by the\\nstone. These symptoms include:\\n/C15abnormally dark colored urine\\n/C15blood in the urine\\n/C15difficulty urinating\\n/C15frequent urge to urinate\\n/C15lower abdominal pain\\n/C15pain or discomfort in the penis\\nSome people with bladder stones also may experi-\\nence an inability to control urination ( urinary\\nincontinence).\\nDiagnosis\\nThe diagnosis of bladder stones is usually made\\nafter a physical examination, which may include a\\nrectal examination to check for enlargement of the\\nprostate gland. Urine tests are then used to determine\\nKEY TERMS\\nBladder— A small organ that serves as the reservoir\\nfor urine prior to its passing from the body during\\nurination.\\nProstate gland— A small gland in the male genitals\\nthat contributes to the production of seminal fluid.\\nUrinary tract— The system of organs that produces\\nand expels urine from the body. This system begins\\nat the kidneys, where the urine is formed; passes\\nthrough the bladder; and, ends at the urethra,\\nwhere urine is expelled.\\nGALE ENCYCLOPEDIA OF MEDICINE 567\\nBladder stones'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 597, 'page_label': '568'}, page_content='if there is blood or indications of an UTI in the urine. If\\nbladder stones are suspected, bladder or pelvic x rays\\nmay be ordered. Stones that are large enough to cause\\nproblems with urinary function are almost always\\ndetectable by x ray.\\nTreatment\\nMany bladder stones can be passed out of the\\nbody in the urine. People with small bladder stones\\nwill be asked to increase their fluid intakes to at least\\nsix to eight eight-ounce glasses of water per day to\\nincrease urinary output. If the stones do not pass\\nafter two weeks, or if the patient’s symptoms become\\nworse, further medical treatment may be required.\\nA large bladder stone, or small stone that the patient\\ncannot pass in the urine, may be broken up into smaller\\nstones using ultrasound (shock waves). These smaller\\nstones may then pass in the urine. Stones that cannot\\nbe broken into pieces by these methods, or that the\\npatient cannot pass, may have to be surgically removed.\\nAlternative treatment\\nTraditional herbal remedies for bladder stones\\ninclude celery seed and horsetail. Also, because incom-\\nplete bladder emptying may cause bladder stones, many\\npatients may benefit from methods and remedies aimed\\nat improving overall bladder function. These include\\nKegel exercises, which are used to strengthen the\\nmuscles involved in urination; herbal supplements\\n(cornsilk, hydrangea, juniper berries, parsley, and uva\\nursi) used to increase urine flow and flush out sediment\\nfrom the bladder; and, the consumption of cranberry\\njuice and/or fresh, unsweetened, lemon juice.\\nCranberry juice helps to control urinary tract infection\\nand contains a chemical that coats the walls of the\\nbladder, making them more resistant to infection.\\nLemon juice helps to flush out the urinary system.\\nPrognosis\\nMost bladder stones can be, and are, passed out of\\nthe body in the urine without any permanent damage\\nto the bladder or the rest of the urinary tract.\\nHowever, most bladder stones arise from an under-\\nlying medical condition. Therefore, if this medical\\ncondition is not corrected approximately half of all\\npatients will experience a recurrence of bladder stones\\nwithin five years.\\nPrevention\\nBladder stones may, in some cases, be prevented\\nby the patient receiving prompt medical treatment for\\nan enlarged prostate gland or UTI. The consumption\\nof at least six to eight eight-ounce glasses of water per\\nday and/or the regular consumption of cranberry juice\\nmay help to prevent recurrences of bladder stones.\\nResources\\nPERIODICALS\\nSchwartz, B.F., and M.L. Stoller. ‘‘The vesical calculus.’’\\nUrologic Clinics of North America27 (May 2000):\\n333-46.\\nORGANIZATIONS\\nAmerican Foundation for Urologic Disease. 1128 North\\nCharles Street, Baltimore, Maryland 21201. (410)\\n468-1800. Fax: (410) 468-1808. .\\nOTHER\\n‘‘Bladder Stones.’’ MEDLINEplus Health Information.\\nMay 12, 2001. .\\nPaul A. Johnson, Ed.M.\\nBladder training\\nDefinition\\nBladder training is a behavioral modification treat-\\nment technique forurinary incontinencethat involves\\nplacing a patient on a toileting schedule. The time\\ninterval between urination is gradually increased in\\norder to train the patient to remain continent.\\nPurpose\\nBladder training is used to treat urinary urge\\nincontinence. Urge incontinence occurs when an\\nindividual feels a sudden need to urinate and cannot\\ncontrol the urge to do so and, as a consequence, invo-\\nluntarily loses urine before making it to the toilet.\\nPrecautions\\nIncontinence may be controlled through a num-\\nber of invasive and non-invasive treatment options,\\nincluding Kegel exercises, biofeedback, bladder\\ntraining, medication, insertable incontinence devices,\\nand surgery. Each patient should undergo a full\\ndiagnostic work-up to determine the type and cause\\nof the incontinence in order to determine the best\\ncourse of treatment.\\n568 GALE ENCYCLOPEDIA OF MEDICINE\\nBladder training'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 598, 'page_label': '569'}, page_content='Description\\nBladder training may be prescribed and implemen-\\nted by a general physician, urologist, or urogynecolo-\\ngist. A urination schedule is created for the patient.\\nThe schedule typically starts out with fairly short inter-\\nvals between bathroom breaks (e.g., an hour). As soon\\nas the patient is able to consistently remain continent\\nfor several days at a certain toileting time interval, the\\ntime span is increased. Bladder training continues until\\nthe patient regularly achieves continence at a time\\ninterval he/she feels comfortable with.\\nPreparation\\nA complete evaluation to determine the cause of\\nurinary incontinence is critical to proper treatment.\\nA thorough medical history andphysical examination\\nshould be performed on patients considering bladder\\ntraining. Diagnostic testing may include x rays, ultra-\\nsound, urine tests, and a physical examination of\\nthe pelvis. It may include a series of exams called\\nurodynamic testing that measure bladder pressure\\nand capacity and the urinary flow. The patient may\\nalso be asked to keep a diary of their urination output\\nand frequency and episodes of incontinence over a\\nperiod of several days or a week.\\nRisks\\nBladder training may not be successful in all\\npatients with urge incontinence. Patients who demon-\\nstrate a strong desire to control their continence and\\nare committed to sticking with a training program\\ntend to have the most success with bladder training.\\nNormal results\\nPatients who undergo successful bladder training\\ngain complete or improved control over their urina-\\ntion. In some cases, additional alternate treatment\\nsuch as biofeedback or pelvic muscle exercises may\\nbe recommended to supplement the progress made\\nwith bladder training.\\nResources\\nORGANIZATIONS\\nAmerican Foundation for Urologic Disease. 1128 North\\nCharles St., Baltimore, MD 21201. (800) 242-2383.\\n.\\nNational Association for Continence. P.O. Box 8310,\\nSpartanburg, SC 29305-8310. (800) 252-3337. .\\nPaula Anne Ford-Martin\\nBlastomyces dermatitidis see Blastomycosis\\nBlastomycosis\\nDefinition\\nBlastomycosis is an infection caused by inhaling\\nmicroscopic particles (spores) produced by the fungus\\nBlastomyces dermatitidis. Blastomycosis may be limited\\nto the lungs or also involve the skin and bones. In its\\nmost severe form, the infection can spread throughout\\nthe body and involve many organ systems (systemic).\\nDescription\\nBlastomycosis is a fungal infection caused by\\nBlastomyces dermatitidis. Although primarily an air-\\nborne disease, farmers and gardeners may become\\ninfected from contact with spores in the soil through\\ncuts and scrapes. The fungus that causes the disease is\\nfound in moist soil and wood in the southeastern\\nUnited States, the Mississippi River valley, southern\\nCanada, and Central America. Blastomycosis is also\\ncalled Gilchrist’s disease, Chicago disease, or North\\nAmerican blastomycosis. Another South and Central\\nAmerican disease, paracoccidioidomycosis, is some-\\ntimes called South American blastomycosis, but\\ndespite the similar name, this disease is substantially\\ndifferent from North American blastomycosis. Canine\\nblastomycosis, a common dog disease, is caused by the\\nsame fungus that infects humans. However, people do\\nnot get this disease from their dogs except only very\\nrarely through dog bites.\\nBlastomycosis is a rare disease infecting only\\nabout 4 in every 100,000 people. It is at least six\\ntimes more common in men than in women and\\ntends to more often infect children and individuals in\\nthe 30–50 year old age group. People who have\\nKEY TERMS\\nBiofeedback— Biofeedback training monitors tem-\\nperature and muscle contractions in the vagina to\\nhelp incontinent patients control their pelvic\\nmuscles.\\nPelvic muscle exercises— Exercises that tighten and\\ntone the pelvic floor, or perineal, muscles. Also\\nknown as Kegel and PC muscle exercises.\\nGALE ENCYCLOPEDIA OF MEDICINE 569\\nBlastomycosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 599, 'page_label': '570'}, page_content='diabetes mellitus or who are taking drugs that sup-\\npress the immune system (immunocompromised) are\\nmore likely to develop blastomycosis. Although peo-\\nple with AIDS can get blastomycosis because of their\\nweakened immune system, blastomycosis has not been\\none of the more common fungal infections associated\\nwith AIDS.\\nCauses and symptoms\\nOnce inhaled, the spores ofB. dermatitidis can\\nlodge in the lungs and cause a localized inflammation.\\nThis is known as primary pulmonary blastomycosis.\\nThe disease does not spread from one person to\\nanother. In the early stages, symptoms may include a\\ndry cough, fever, heavy sweating, fatigue, and a general\\nfeeling of ill health. In approximately 25% of blasto-\\nmycosis cases, only the lungs are affected. As the dis-\\nease progresses, small lesions form in the lungs causing\\nthe air sacs deep within the lungs (alveoli) to break\\ndown and form small cavities.\\nIn another 35%, the disease involves both the\\nlungs and the skin. Bumps develop on the skin,\\ngradually becoming small, white, crusted blisters\\nfilled with pus. The blisters break open, creating\\nabscesses that do not heal. Approximately 19% of\\ninfected people have skin sores without infection in\\nthe lungs.\\nThe remaining approximately 20% of the\\ninfected population has blastomycosis that has\\nspread or disseminated to other systems of the\\nbody. Symptoms may include pain and lesions on\\none or more bones, the male genitalia, and/or parts\\nof the central nervous system. The liver, spleen,\\nlymph nodes, heart, adrenal glands, and digestive\\nsystem may also be infected.\\nDiagnosis\\nA positive diagnosis of blastomycosis is made when\\nthe fungusB. dermatitidisis identified by direct micro-\\nscopic examination of body fluids such as sputum and\\nprostate fluid or in tissue samples (biopsies) from the\\nlung or skin. Another way to diagnose blastomycosis is\\nto culture and isolate the fungus from a sample of\\nsputum. Chest x rays are used to assess lung damage,\\nbut alone cannot lead to a definitive diagnosis of blas-\\ntomycosis because any damage caused by other dis-\\neases, such as by pneumonia or tuberculosis,m a y\\nappear look on the x ray. Because its symptoms vary\\nwidely, blastomycosis is often misdiagnosed.\\nTreatment\\nBlastomycosis must be treated or it will gradually\\nlead to death. Treatment with the fungicidal drug\\nketoconazole (Nizoral) taken orally is effective in\\nabout 75% of patients. Amphotericin B (Fungizone)\\ngiven intravenously is also very effective, but it has\\nmore toxic side effects than ketoconazole. Treatment\\nwith amphotericin B usually requires hospitalization,\\nand the patient may also receive other drugs to mini-\\nmize the its side effects.\\nBlastomycosis is usually attributed to contact with yeast-like\\nfungi. (Custom Medical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAbscess— An area of inflamed and injured body\\ntissue that fills with pus.\\nAcidophilus— The bacteria called Lactobacillus\\nacidophilus that is usually found in yogurt.\\nAlveoli— Small air pockets in the lungs that\\nincrease the surface area for oxygen absorption.\\nBifidobacteria— A group of bacteria normally pre-\\nsent in the intestine. Commercial supplements con-\\ntaining these bacteria are available.\\nBiopsy— The removal of a tissue sample for diag-\\nnostic purposes.\\nImmunocompromised— A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nSpores— The small, thick-walled reproductive\\nstructures of fungi.\\nSputum— Mucus and other matter coughed up\\nfrom airways.\\nSystemic— Not localized to a single area of the\\nbody but, instead, involving one or more body\\nsystems.\\n570 GALE ENCYCLOPEDIA OF MEDICINE\\nBlastomycosis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 600, 'page_label': '571'}, page_content='Alternative treatment\\nAlternative treatment for fungal infections\\nfocuses on creating an internal environment where\\nthe fungus cannot survive. This is accomplished by\\neating a diet low in dairy products, sugars, including\\nhoney and fruit juice, and foods like beer that contain\\nyeast. This is complemented by a diet consisting, in\\nlarge part, of uncooked and unprocessed foods.\\nSupplements ofvitamins C, E, A-plus, and B complex\\nmay also be useful. Lactobacillus acidophilus and\\nBifidobacterium will replenish the good bacteria in\\nthe intestines. Some antifungal herbs, like garlic\\n(Allium sativum), can be consumed in relatively large\\ndoses and for an extended period of time in order to\\nincrease effectiveness. A variety of antifungal herbs,\\nsuch as myrrh (Commiphora molmol), tea tree oil\\n(Melaleuca spp.), citrus seed extract, pau d’arco tea\\n(Tabebuia impetiginosa ), and garlic may also be\\napplied directly to the infected skin.\\nPrognosis\\nLeft untreated, blastomycosis gradually leads to\\ndeath. When treated, however, patients begin to\\nimprove within one week and, with intensive treat-\\nment, may be cured within several weeks. The highest\\nrate of recovery is among patients who only have skin\\nlesions. People with the disseminated form of the dis-\\nease are least likely to be cured and and most likely to\\nsuffer a relapse.\\nPrevention\\nBecause the fungus that causes blastomycosis is\\nairborne and microscopic, the only form of preven-\\ntion is to avoid visiting areas where it is found in the\\nsoil. For many people this is impractical. Since the\\ndisease is rare, people who maintain general good\\nhealth do not need to worry much about infection.\\nResources\\nORGANIZATIONS\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nOTHER\\n‘‘Blastomycosis.’’ Vanderbilt University Medical Center.\\n.\\nTish Davidson, A.M.\\nBleeding disorders see Coagulation\\ndisorders\\nBleeding time\\nDefinition\\nBleeding time is a crude test of hemostasis (the arrest\\nor stopping of bleeding). It indicates how well platelets\\ninteract with blood vessel walls to formblood clots.\\nPurpose\\nBleeding time is used most often to detect quali-\\ntative defects of platelets, such as Von Willebrand’s\\ndisease. The test helps identify people who have\\ndefects in their platelet function. This is the ability\\nof blood to clot following a wound or trauma.\\nNormally, platelets interact with the walls of blood\\nvessels to cause a blood clot. There are many factors\\nin the clotting mechanism, and they are initiated by\\nplatelets. The bleeding time test is usually used on\\npatients who have a history of prolonged bleeding\\nafter cuts, or who have a family history of bleeding\\ndisorders. Also, the bleeding time test is sometimes\\nperformed as a preoperative test to determine a\\npatient’s likely bleeding response during and after\\nsurgery. However, in patients with no history of\\nbleeding problems, or who are not taking anti-\\ninflammatory drugs, the bleeding time test is not\\nusually necessary.\\nPrecautions\\nBefore administering the test, patients should be\\nquestioned about what medications they may be\\ntaking. Some medications will adversely affect the\\nresults of the bleeding time test. These medications\\ninclude anticoagulants,diuretics, anticancer drugs, sul-\\nfonamides, thiazide, aspirin and aspirin-containing\\npreparations, and nonsteroidal anti-inflammatory\\ndrugs. The test may also be affected by anemia (a\\ndeficiency in red blood cells). Since the taking of\\naspirin or related drugs are the most common cause\\nof prolonged bleeding time, no aspirin should be taken\\ntwo weeks prior to the test.\\nDescription\\nThere are four methods to perform the bleeding\\ntest. The Ivy method is the traditional format for this\\ntest. In the Ivy method, a blood pressure cuff is\\nplaced on the upper arm and inflated to 40 mM\\nHg. A lancet or scalpel blade is used to make a stab\\nwound on the underside of the forearm. An auto-\\nmatic, spring-loaded blade device is most commonly\\nused to make a standard-sized cut. The area stabbed\\nGALE ENCYCLOPEDIA OF MEDICINE 571\\nBleeding time'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 601, 'page_label': '572'}, page_content='is selected so that no superficial or visible veins are\\ncut. These veins, because of their size, may have\\nlonger bleeding times, es pecially in people with\\nbleeding defects. The time from when the stab\\nwound is made until all bleeding has stopped is\\nmeasured and is called the bleeding time. Every 30\\nseconds, filter paper or a paper towel is used to draw\\noff the blood. The test is finished when bleeding has\\nstopped completely.\\nThe three other methods of performing the bleed-\\ning test are the template, modified template, and Duke\\nmethods. The template and modified template meth-\\nods are variations of the Ivy method. A blood pressure\\ncuff is used and the skin on the forearm prepared as in\\nthe Ivy method. A template is placed over the area to\\nbe stabbed and two incisions are made in the forearm\\nusing the template as a location guide. The main dif-\\nference between the template and the modified method\\nis the length of the cut made.\\nFor the Duke method, a nick is made in an ear\\nlobe or a fingertip is pricked to cause bleeding. As in\\nthe Ivy method, the test is timed from the start of\\nbleeding until bleeding is completely stopped. The\\ndisadvantage to the Duke method is that the pressure\\non the blood veins in the stab area is not constant and\\nthe results achieved are less reliable. The advantage to\\nthe Duke method is that no scar remains after the test.\\nThe other methods may result in a tiny, hairline scar\\nwhere the wound was made. However, this is largely a\\ncosmetic concern.\\nPreparation\\nThere is no special preparation required of the\\npatient for this test. The area to be stabbed should be\\nwiped clean with an alcohol pad. The alcohol should\\nbe left on the skin long enough for it to kill bacteria at\\nthe wound site. The alcohol must be removed before\\nstabbing the arm because alcohol will adversely affect\\nthe tests results by inhibiting clotting.\\nAftercare\\nIf a prolonged bleeding time is caused by unknown\\nfactors or diseases, further testing is required to identify\\nthe exact cause of the bleeding problem.\\nNormal results\\nA normal bleeding time for the Ivy method is less\\nthan five minutes from the time of the stab until all\\nbleeding from the wound stops. Some texts extend the\\nnormal range to eight minutes. Normal values for the\\ntemplate method range up to eight minutes, while for\\nthe modified template methods, up to 10 minutes is\\nconsidered normal. Normal for the Duke method is\\nthree minutes.\\nAbnormal results\\nA bleeding time that is longer than normal is an\\nabnormal result. The test should be stopped if the\\npatient hasn’t stopped bleeding by 20-30 minutes.\\nBleeding time is longer when the normal function of\\nplatelets is impaired, or there are a lower-than-normal\\nnumber of platelets in the blood.\\nA longer-than-normal bleeding time can indicate\\nthat one of several defects in hemostasis is present,\\nincluding severe thrombocytopenia, platelet dysfunc-\\ntion, vascular defects, Von Willebrand’s disease, or\\nother abnormalities.\\nResources\\nBOOKS\\nHenry, J. B.Clinical Diagnosis and Management by\\nLaboratory Methods.Philadelphia: W. B. Saunders Co.,\\n1996.\\nJohn T. Lohr, PhD\\nBleeding varices\\nDefinition\\nBleeding varices are bleeding, dilated (swollen)\\nveins in the esophagus (gullet), or the upper part of\\nthe stomach, caused byliver disease.\\nDescription\\nEngorged veins are called varices (plural of varix).\\nVarices may occur in the lining of the esophagus, the\\ntube that connects the mouth to the stomach, or in the\\nupper part of the stomach. Such varices are called\\nesophageal varices. These varices are fragile and can\\nbleed easily because veins are not designed to handle\\nhigh internal pressures.\\nKEY TERMS\\nHemostasis— The stopping of bleeding or blood\\nflow through a blood vessel or organ.\\n572 GALE ENCYCLOPEDIA OF MEDICINE\\nBleeding varices'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 602, 'page_label': '573'}, page_content='Causes and symptoms\\nLiver disease often causes an increase in the\\nblood pressure in the main veins that carry blood\\nfrom the stomach and intestines to the liver (portal\\nveins). As the pressure in the portal veins increases,\\nthe veins of the stomach and esophagus swell, until\\nthey eventually become varices. Bleeding varices are a\\nlife-threatening complication of this increase in blood\\npressure (portal hypertension). The most common\\ncause of bleeding varices is cirrhosis of the liver\\ncaused by chronic alcohol abuse or hepatitis.\\nBleeding varices occur in approximately one in\\nevery 10,000 people.\\nSymptoms of bleeding varices include:\\n/C15vomiting blood, sometimes in massive amounts\\n/C15black, tarry stools\\n/C15decreased urine output\\n/C15excessive thirst\\n/C15nausea\\n/C15vomiting\\n/C15blood in the vomit\\nIf bleeding from the varices is severe, a patient\\nmay go intoshock from the loss of blood, character-\\nized by pallor, a rapid and weak pulse, rapid and\\nshallow respiration, and lowered systemic blood\\npressure.\\nDiagnosis\\nBleeding varices may be suspected in a patient\\nwho has any of the above-mentioned symptoms, and\\nwho has either been diagnosed with cirrhosis of the\\nliver or who has a history of prolonged alcohol abuse.\\nThe definitive diagnosis is established via a specialized\\ntype of endoscopy, namely,esophagogastroduodeno-\\nscopy (EGD), a procedure that involves the visual\\nexamination of the lining of the esophagus, stomach,\\nand upper duodenum with a flexible fiberoptic\\nendoscope.\\nTreatment\\nThe objective during treatment of bleeding\\nvarices is to stop and/or prevent bleeding and to\\nrestore/maintain normal blood circulation through-\\nout the body. Patients with severe bleeding should be\\ntreated in intensive care since uncontrolled bleeding\\ncan lead todeath.\\nInitial treatment of bleeding varices begins\\nwith standard resuscitation, including intravenous\\nfluids and blood transfusions as needed. Definitive\\ntreatment is usually endoscopic, with the endo-\\nscope used to locate the sites of the bleeding. An\\ninstrument, inserted along with the endoscope, is\\nused either to inject these sites with a clotting agent\\nor to tie off the bleeding sites with tiny rubber\\nbands.\\nKEY TERMS\\nCirrhosis of the liver— A type of liver disease, most\\noften caused by chronic alcohol abuse. It is\\ncharacterized by scarring of the liver, which\\nleads to an increase in the blood pressure in the\\nportal veins.\\nEndoscopy— Medical imaging technique for visua-\\nlizing the interior of a hollow organ.\\nEsophagus— The tube in the body which takes food\\nfrom the mouth to the stomach.\\nEsophagogastroduodenoscopy (EGD)— An ima-\\nging test that involves visually examining the lining\\nof the esophagus, stomach, and upper duodenum\\nwith a flexible fiberoptic endoscope.\\nPortal hypertension— Portal hypertension forces\\nthe blood flow backward, causing the portal veins\\nto enlarge and the emergence of bleeding varices\\nacross the esophagus and stomach from the\\npressure in the portal vein. Portal hypertension is\\nmost commonly caused by cirrhosis, but can also\\nbe seen in portal vein obstruction from unknown\\ncauses.\\nPortal veins— The main veins that carry blood from\\nthe stomach and intestines to the liver.\\nShock— A state of depression of the vital processes\\nof the body characterized by pallor, a rapid and\\nweak pulse, rapid and shallow respiration, and\\nlowered blood pressure. Shock results from severe\\ntrauma, such as crushing injuries, hemorrhage,\\nburns, or major surgery.\\nTransjugular intrahepatic portosystemic shunt\\n(TIPS)— A transjugular intrahepatic portosystemic\\nshunt (TIPS) is a radiology procedure in which a\\ntubular device is inserted in the middle of the liver\\nto redirect the blood flow.\\nVarices— A type of varicose vein that develops in\\nveins in the linings of the esophagus and upper\\nstomach when these veins fill with blood and\\nswell due to an increase in blood pressure in the\\nportal veins.\\nGALE ENCYCLOPEDIA OF MEDICINE 573\\nBleeding varices'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 603, 'page_label': '574'}, page_content='Repeated endoscopic treatments (usually four/\\nsix) are generally required to eliminate the varices\\nand to prevent the recurrence of bleeding. These endo-\\nscopic techniques are successful in about 90 percent\\nof cases.\\nPatients who cannot be treated endoscopically\\nmay be considered for an alternative procedure called\\nTIPS (transjugular intrahepatic portosystemic shunt).\\nThis procedure involves placing a hollow metal\\ntube (shunt) in the liver connecting the portal veins\\nwith the hepatic veins (veins that leave the liver and\\ndrain to the heart). This shunt lowers the pressure in\\nthe portal veins and prevents bleeding and portal\\nhypertension. The TIPS procedure is performed by a\\nradiologist and has become an accepted method for\\nreducing portal vein pressure since 1992. Although the\\nprocedure continues to evolve, TIPS can routinely be\\ncreated in more than 93% of patients.\\nMedications aimed at controlling bleeding\\nmay also be prescribed. These include propanolol,\\nvasopressin, octreotide acetate, and isosorbide\\nmononitrate.\\nAlternative treatment\\nSome alternative treatments are aimed at prevent-\\ning the cirrhosis of the liver that often causes bleeding\\nvarices and most are effective. However, once a patient\\nhas reached the bleeding varice stage, standard inter-\\nvention to stop the bleeding is required or the patient\\nmay die.\\nPrognosis\\nBleeding varices represent one of the most feared\\ncomplications of portal hypertension. They contribute\\nto the estimated 32,000 deaths per year attributed to\\ncirrhosis. Half or more of patients who survive episodes\\nof bleeding varices are at risk of renewed esophageal\\nbleeding during the first one to two years. The risk of\\nrecurrence can be lowered by endoscopic and drug\\ntreatment. Prognosis is usually more related to the\\nunderlying liverdisease. Approximately 30 to 50 percent\\nof people with bleeding varices will die from this con-\\ndition within the six weeks of the first bleeding episode.\\nPrevention\\nThe best way to possibly prevent the development\\nor recurrence of bleeding varices is to eliminate the risk\\nfactors for cirrhosis of the liver. The most common\\ncause of cirrhosis is prolonged alcohol abuse, and alco-\\nhol consumption must be completely eliminated. People\\nwith hepatitis Bor hepatitis Calso have an increased\\nrisk of developing cirrhosis of the liver.Vaccination\\nagainst hepatitis B and avoidance of intravenous drug\\nusage reduce the risk of contracting hepatitis.\\nResources\\nBOOKS\\nShannon, Joyce Brennfleck, editor.Liver Disorders\\nSourcebook. Detroit, MI: Omnigraphics, Inc., 2000.\\nPERIODICALS\\nBurroughs, Andrew K. and David Patch. ‘‘Primary\\nprevention of bleeding from esophageal varices.’’New\\nEngland Journal of Medicine340 (April 1, 1999): 1033-5.\\nHegab, Ahmed M., and Velimir A. Luketic. ‘‘Bleeding\\nesophageal varices: How to treat this dreaded compli-\\ncation of portal hypertension.’’Postgraduate Medicine\\n109 (February 2001): 75-89.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nOTHER\\nGoff, John.‘‘Portal hypertensive bleeding.’’May 12, 2001.\\n.\\nPaul A. Johnson, Ed.M.\\nBlepharitis see Eyelid disorders\\nBlepharoplasty\\nDefinition\\nBlepharoplasty is a cosmetic surgical procedure\\nthat removes fat deposits, excess tissue, or muscle\\nfrom the eyelids to improve the appearance of the eyes.\\nPurpose\\nThe primary use of blepharoplasty is for improv-\\ning the cosmetic appearance of the eyes. In some older\\npatients, however, sagging and excess skin surround-\\ning the eyes can be so extensive that it limits the range\\nof vision. In those cases, blepharoplasty serves a more\\nfunctional purpose.\\nPrecautions\\nBefore performing blepharoplasty, the surgeon will\\nassess whether the patient is a good candidate for the\\n574 GALE ENCYCLOPEDIA OF MEDICINE\\nBlepharoplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 604, 'page_label': '575'}, page_content='treatment. A good medical history is important. The\\nsurgeon will want to know about any history of thyroid\\ndisease, hypertension, or eye problems, which may\\nincrease the risk of complications.\\nDescription\\nBlepharoplasty can be performed on the upper or\\nlower eyelid; it can involve the removal of excess skin\\nand fat deposits and the tightening of selected muscles\\nsurrounding the eyelids. The goal is to provide a more\\nyouthful appearance.\\nThe surgeon will begin by deciding whether excess\\nskin, fat deposits, or muscle looseness are at fault.\\nWhile the patient is sitting upright, the surgeon will\\nmark on the skin where incisions will be made. Care\\nwill be taken to hide the incision lines in the natural\\nskin folds above and below the eye. The patient then\\nreceives injections of a local anesthetic to numb the\\npain. Many surgeons also give the patient a sedative\\nintravenously during the procedure.\\nAfter a small, crescent-shaped section of eyelid\\nskin is removed, the surgeon will work to tease out\\nsmall pockets of fat that have collected in the lids. If\\nmuscle looseness is also a problem, the surgeon may\\ntrim tissue or add a stitch to pull it tighter. Then the\\nincision is closed with stitches.\\nIn some patients, fat deposits in the lower eyelid\\nmay be the only or primary problem. Such patients\\nmay be good candidates for transconjunctival ble-\\npharoplasty. In this procedure the surgeon makes no\\nincision on the surface of the eyelid, but instead enters\\nfrom behind to tease out the fat deposits from a small\\nincision. The advantage of this procedure is that there\\nis no visible scar.\\nPreparation\\nP r i o rt os u r g e r y ,p a t i e n t sm e e tw i t ht h e i rs u r -\\ngeon to discuss the procedure, clarify the results\\nthat can be achieved, and discuss the potential pro-\\nblems that might occur. Having realistic expecta-\\ntions is important in any cosmetic procedure.\\nPatients will learn, for example, that although ble-\\npharoplasty can improve the appearance of the eye-\\nlid, other procedures, such as a chemical peel, will be\\nKEY TERMS\\nEctropion— A complication of blepharoplasty, in\\nwhich the lower lid is pulled downward, exposing\\nthe surface below.\\nIntravenous sedation— A method of injecting a\\nfluid sedative into the blood through the vein\\nRetrobulbar hematoma— A rare complication of\\nblepharoplasty, in which a pocket of blood forms\\nbehind the eyeball.\\nTransconjuctival blepharoplasty— At y p eo fb l e -\\npharoplasty in which the surgeon makes no\\nincision on the surface of the eyelid, but,\\ninstead, enters from behind to tease out the fat\\ndeposits.\\nPinching the \\nredundant skin\\nCutting the skin off Closing the incisions\\nBlepharoplasty is one of the most common cosmetic surgical procedures. The illustration above depicts a procedure to\\neliminate dermochalasia, or baggy skin around the eyes. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 575\\nBlepharoplasty'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 605, 'page_label': '576'}, page_content='necessary to reduce the appearance of wrinkles\\naround the eye. Some surgeons prescribe vitamin C\\nand vitamin K for 10 days prior to surgery in the\\nbelief that this helps the healing process. Patients are\\nalso told to stopsmoking in the weeks before and\\nafter the procedure, and to refrain from alcohol and\\naspirin.\\nAftercare\\nAn antibiotic ointment is applied to the line of\\nstitches for several days after surgery. Patients also\\ntake an antibiotic several times a day to prevent\\ninfection. Ice-cold compresses are applied to the\\neyes continuously for the first day following sur-\\ngery, and several times a day for the next week or\\nso, to reduce swelling. Some swelling and discolora-\\ntion around the eyes is expected with the procedure.\\nPatients should avoid aspirin or alcoholic beverages\\nfor one week and should limit their activities,\\nincluding bending, straining, and lifting. The\\nstitches are removed a few days after surgery.\\nPatients can generally return to their usual activities\\nwithin a week to 10 days.\\nRisks\\nAs with any surgical procedure, blepharo-\\np l a s t yc a nl e a dt oi n f e c t i o na n ds c a r r i n g .G o o d\\ncare of the wound following surgery can minimize\\nthese risks. In cases where too much skin is\\nremoved from the eyelids, the patient may have\\ndifficulty closing his eyes. Dry eye syndrome may\\ndevelop, requiring the use of artificial tears to\\nlubricate the eye. In a rar e complication, called\\nretrobulbar hematoma, a pocket of blood forms\\nbehind the eyeball.\\nNormal results\\nMost patients can expect good results from ble-\\npharoplasty, with the removal of excess eyelid skin\\nand fat producing a more youthful appearance.\\nSome swelling and discoloration is expected immedi-\\nately following the procedure, but this clears in time.\\nSmall scars will be left where the surgeon has made\\nincisions; but these generally lighten in appearance\\nover several months, and, if placed correctly, will not\\nbe readily noticeable.\\nAbnormal results\\nAs noted, if too much excess skin is removed\\nfrom the upper eyelid, the patient may be unable to\\nclose his eyes completely; another surgery to correct\\nthe defect may be required. Similarly, too much skin\\ncan be removed from the lower eyelid, allowing too\\nmuch of the white of the eye (the sclera) to show. In\\nextreme cases, the lower lid may be pulled down too\\nfar, revealing the underlying tissue. Called an ectro-\\npion, this, too, may require a second, corrective\\nsurgery. The eye’s ability to make tears may also be\\ncompromised, leading to dry eye syndrome. Dry eye\\nsyndrome is potentially dangerous; in rare cases\\nit leads to damage to the cornea of the eye and\\nvision loss.\\nResources\\nORGANIZATIONS\\nAmerican Society for Dermatologic Surgery. 930 N.\\nMeacham Road, P.O. Box 4014, Schaumburg, IL\\n60168-4014. (847) 330-9830. .\\nAmerican Society of Plastic and Reconstructive Surgeons.\\n44 E. Algonquin Rd., Arlington Heights, IL 60005.\\n(847) 228-9900. .\\nRichard H. Camer\\nBlindness see Visual impairment\\nBlood-viscosity reducing drugs\\nDefinition\\nBlood-viscosity reducing drugs are medicines that\\nimprove blood flow by making the blood less viscous\\n(sticky).\\nPurpose\\nThe main use of blood-viscosity reducing drugs\\nis to relieve painful leg cramps caused by poor cir-\\nculation, a condition calledintermittent claudication.\\nPhysicians also may prescribe this medicine for other\\nconditions, including stroke, impotence, male inferti-\\nlity, Raynaud’s disease, and nerve and circulation\\nproblems caused by diabetes.\\nDescription\\nBlood-viscosity reducing drugs are available only\\nwith a physician’s prescription and come in extended-\\nrelease tablet form. Examplesof blood-viscosity reducing\\ndrugs are pentoxifylline (Trental) and oxypentifylline.\\n576 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood-viscosity reducing drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 606, 'page_label': '577'}, page_content='Recommended dosage\\nThe usual dosage for adults is 400 mg, two to three\\ntimes a day, with meals. However, the dose may be\\ndifferent for different patients. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage. Dosages\\nfor children must be determined by a physician.\\nTaking an antacid with this medicine may help\\nprevent upset stomach.\\nPrecautions\\nThis medicine may relieve legpain that results\\nfrom poor circulation, but it should not be considered\\na substitute for other treatments the physician recom-\\nmends, such as physical therapy or surgery.\\nThis medicine may take several weeks to produce\\nnoticeable results. Be sure to keep taking it as directed,\\neven if it doesn’t seem to be helping.\\nPatients being treated with this medicine should\\nnot smoke, assmoking may worsen the conditions for\\nwhich the medicine is prescribed.\\nAnyone who has had unusual reactions to pentox-\\nifylline, aminophylline,caffeine, dyphylline, ethylene-\\ndiamine (contained in aminophylline), oxtriphylline,\\ntheobromine, or theophylline in the past should let his\\nor her physician know before taking a blood-viscosity\\nreducing drug. The physician should also be told\\nabout any allergies to foods, dyes, preservatives, or\\nother substances.\\nWomen who are pregnant or breastfeeding or who\\nmay become pregnant should check with their physi-\\ncians before using a blood-viscosity reducing drug.\\nOlder people may be especially sensitive to the\\neffects of this medicine, which may increase the chance\\nof side effects.\\nBefore using blood-viscosity reducing drugs, peo-\\nple with any of these medical problems should make\\nsure their physicians are aware of their conditions:\\n/C15recent stroke\\n/C15any condition in which there is an increased chance\\nof bleeding\\n/C15kidney disease\\n/C15liver disease\\nSide effects\\nMinor discomforts, such asdizziness, headache,\\nupset stomach, nausea,o r vomiting usually go away\\nas the body adjusts to the drug and do not require\\nmedical treatment unless they persist or they interfere\\nwith normal activities.\\nMore serious side effects are rare. However, if\\nthese or any other unusual or troublesome symptoms\\noccur, check with the physician who prescribed the\\nmedicine as soon as possible:\\n/C15chest pain\\n/C15irregular heartbeat\\nInteractions\\nBlood-viscosity reducing drugs may interact\\nwith a other medicines, changing the effects of one\\nor both of the drugs or increasing the risk of side\\neffects. Anyone who takesblood-viscosity reducing\\ndrugs should let the physician know all other pre-\\nscription or nonprescrip tion (over-the-counter)\\nmedicines he or she is taking. Among the drugs\\nthat may interact with bl ood-viscosity reducing\\ndrugs are:\\n/C15anticoagulants such as warfarin (Coumadin)(also\\ncalled blood thinners or clot inhibitors)\\n/C15calcium channel blockers such as diltiazem\\n(Cardizem), used to treat high blood pressure\\n/C15angiotensin-converting enzyme (ACE) inhibitors\\nsuch as enalapril (Vasotec), used to treat high blood\\npressure\\n/C15theophylline (Theo-Dur)\\n/C15medicines such as cimetidine (Tagamet), taken for\\nulcers or heartburn\\nNancy Ross-Flanigan\\nBlood clots\\nDefinition\\nA blood clot is a thickened mass in the blood\\nformed by tiny substances called platelets. Clots form\\nto stop bleeding, such as at the site of cut. But clots\\nKEY TERMS\\nRaynaud’s disease— A blood vessel disorder in\\nwhich the fingers and toes become numb and turn\\nwhite when exposed to cold.\\nGALE ENCYCLOPEDIA OF MEDICINE 577\\nBlood clots'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 607, 'page_label': '578'}, page_content='should not form when blood is moving through the\\nbody; when clots form inside blood vessels or when\\nblood has a tendency to clot too much, serious health\\nproblems can occur.\\nDescription\\nAs soon as a blood vessel wall is damaged—by a\\ncut or similar trauma—a series of reactions normally\\ntakes place to activate platelets to stop the bleeding.\\nPlatelets are the tiny particles in the blood released\\ninto the bone marrow that gather together and form\\na barrier to further bleeding. Several proteins in the\\nbody are involved in the platelets clotting process.\\nChief among these proteins are collagen, thrombin,\\nand von Willebrand factor. Collagen and thrombin\\nhelp platelets stick together. As platelets gather at\\nthe site of injury, they change in shape from round\\nto spiny, releasing proteins and other substances\\nthat help catch more platelets and clotting proteins.\\nThis enlarges the plug that becomes a blood\\nclot. Formation of blood clots also is called\\n‘‘coagulation’’.\\nThe series of reactions that cause proteins and\\nplatelets to create blood clots also are balanced by\\nother reactions that stop the clotting process and dis-\\nsolve clots after the blood vessel has healed. If this\\ncontrol system fails, minor blood vessel injuries can\\ntrigger clotting throughout the body. The tendency to\\nclot too much is called ‘‘hypercoagulation’’. Anytime\\nclots form inside blood vessels, they can lead to serious\\ncomplications.\\nThe formation of a clot in a blood vessels may be\\ncalled thrombophlebitis. The term refers to swelling of\\none or more veins caused by a blood clot. Although\\nsome clots occur in the arms or small, surface blood\\nvessels, most occur in the lower legs. When the blood\\nclot occurs in a deep vein, it is calleddeep vein throm-\\nbosis, or DVT. As many as one of every 1,000\\nAmericans develops DVT each year. The danger of\\nDVT comes when pieces of the clot, known as emboli,\\nbreak off and travel through the bloodstream to an\\nartery.\\nA blood clot that blocks an artery to the brain can\\ncause a stroke. If the clot blocks blood flow to the\\nlungs pulmonary embolism can occur. A blood clot\\nthat blocks a coronary artery can cause aheart attack.\\nCertain people are at higher risk for blood clots than\\nothers; surgery, some injuries,childbirth and lying or\\nsitting still for extended periods of time put people at\\nhigher risk, as do inherited disorders. Once a person\\nhas a blood clot, he or she may have to take blood-\\nthinning drugs to prevent clots from recurring. Men\\nand women are at similar risk for blood clots. A recent\\nstudy in Austria found that men run a higher risk of\\nrecurring blood clots than women, though the reason\\nis unknown.\\nCauses and symptoms\\nMany causes can lead to blood clots, some\\ngenetic and some environmental. An environmental\\ncause of DVT is prolonged inactivity. For instance,\\nhaving to sit in a car or airplane for a long period of\\ntime decreases blood flowin the lower legs. Recent\\nstudies have shown that 1% of air travelers develop\\nblood clots, usually on long flights of five hours or\\nmore. However, one study in 2004 found that air\\ntravelers developed clots onf l i g h t sa ss h o r ta st h r e e\\nhours, though they often dissolved naturally and did\\nnot lead to complications. Other environmental\\ncauses of blood clots include use ofhormone replace-\\nment therapy to ease menopausal symptoms, oral\\ncontraceptives for birth control, pregnancy (and a\\nchildbirth within the past six weeks), recent surgery\\nor procedures involving use of a central venous\\naccess catheter, and cancer. Smoking also is an\\nimportant and preventable environmental risk for\\nblood clots.\\nSome people are born with a higher risk for blood\\nclots. Hypercoagulation disorders are genetic condi-\\ntions. Usually the body doesn t produce enough of\\nthe proteins involved in the clotting process, so they\\ncannot do their job to stop the clotting; in other cases,\\nthey have an extra protein that causes too much\\nclotting.\\nKEY TERMS\\nCentral venous access catheter— A tube placed\\njust beneath the skin to allow doctors and nurses\\nconstant and pain-free access to the veins, often\\nwhen a patient is in the hospital or has a chronic\\ndisease such as cancer. The doctors and nurses can\\ndraw blood and give medications and nutrients\\nthrough the catheter.\\nGenetic— A trait or condition that is acquired\\nor inherited because it was related to genes and\\nDNA.\\nPulmonary embolism— The sudden obstruction of\\na pulmonary (lung) artery or one of its branches by\\nan abnormal particle (such as a blood clot) floating\\nin the blood.\\n578 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood clots'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 608, 'page_label': '579'}, page_content='There may be no symptoms of blood clots until\\nthey grow so large that they block the flow of blood\\nthrough the vein. Then, symptoms may develop sud-\\ndenly around the area and include:\\n/C15Pain or tenderness in the affected area.\\n/C15Warmth or redness of the skin in the affected area.\\n/C15Sudden swelling in the affected limb.\\nAdditional symptoms may indicate serious com-\\nplications of blood clots such as pulmonaryembolism,\\nstroke, and heart attack. If vein swelling or pain are\\naccompanied by high fever or shortness of breath,\\nrapid pulse, or chest pain, or other symptoms that\\nmay indicate stroke, heart attack, or pulmonary\\nembolism, it is advised to go to an emergency room\\nimmediately.\\nDiagnosis\\nA physician will diagnose blood clots based on\\npatient history and one of several diagnostic imaging\\nexams. The patient’s history will help determine pos-\\nsible risk factors that may lead to suspected blood\\nclots. In addition to family history or known genetic\\ndisorders, the patient may mention an environmental\\nfactor such as recent air travel or use of high-risk\\nmediations.\\nTo help get a picture of suspected clots inside the\\nveins, the first test chosen normally is an ultrasound.\\nDoppler or duplex ultrasound uses sound waves that\\ntravel through tissue and reflect back. A computer\\ntransforms the sound waves into moving images on\\nthe screen that may show the clot, as well as blood flow\\nnear the clot and any abnormalities. Ultrasound does\\nnot use x rays and is a noninvasive method. Computed\\ntomography (CT) scans also might be used to image\\nthe blood vessels. It is similar to x rays, except the\\nimages are much like cross-section slices with greater\\ndetail that can be computerized and even viewed three-\\ndimensionally. A special dye called a contrast agent\\nmay be injected before the exam to help highlight the\\nveins. Magnetic resonanceangiography uses magnetic\\nresonance imaging(MRI) to image the blood vessels.\\nIt also may involve injection of a contrast dye.\\nVenography is less commonly used, but involves inject-\\ning a contrast and using x rays to image the vein.\\nTreatment\\nMedicines can help thin blood, making it less\\nlikely to clot. The two most common blood thin-\\nners are heparin and warfarin. Heparin works\\nright away, keeping blood clots from growing. It\\nusually is injected. In re cent years, more physi-\\ncians have been prescribing low-molecular weight\\nheparin, purified versions of the drug that can be\\ngiven with less monitoring . Warfarin (coumadin)\\noften is used for long-term treatment of blood\\nclots and is taken orally. Patients must work clo-\\nsely with their physicians to constantly monitor its\\neffects and adjust dose if necessary. Too little\\nw a r f a r i nc a nl e a dt oc l o t t i n g ,b u tt o om u c hc a n\\nthin the blood so much that causing life-threaten-\\ning bleeding can occur. The same can be true of\\nlow-molecular weight heparin when used on a\\nlong-term, at-home basis.\\nOther treatments for blood clots include injecting\\nclot busting drugs directly into the clot through a\\ncatheter, or in rare instances, installation of a filter to\\nblock a clot from lodging in the lungs. Sometimes,\\nsurgery also is needed to remove a clot blocking a\\npelvic or abdominal vein or one that is chronic and\\ndisabling. A cardiovascular surgeon or interventional\\nradiologist may perform balloonangioplasty or insert\\na stent to open a narrowed or damaged vein. In an\\nemergency situation, a drug called tissue plasminogen\\nactivator, or tPA, may be given to immediately dis-\\nsolve a life-threatening blood clot to the brain or heart.\\nIn 2004, the U.S. Food and Drug Administration\\napproved a new, small, corklike device that can be\\nused to remove blood clots from the brains of patients\\nwho cannot receive clot-busting drugs.\\nAlternative treatment\\nGarlic is thought to lower blood clotting poten-\\ntial. Less evidence suggests onions and cayenne pepper\\nmay help keep blood thin. New research from\\nAustralia adds tomato juice to the list of potential\\nblood thinners. Subjects who drank a glass of tomato\\njuice a day reduced their risk for DVT, stroke and\\ncardiovascular disease. Research has shown that a\\nnatural soy and pine product called pinokinase has\\nbeen effective in controlling DVT in air travelers.\\nPatients seeking alternative treatments for blood\\nclots should work with certified practitioners and\\nshould inform their allopathic provider about their\\nalternative care.\\nPrognosis\\nIf detected and controlled with medications,\\nblood clots can be safely managed. However, if the\\nclots become dislodged and travel to an artery, they\\ncan cause nearly instant death. For instance, more\\nthan 600,000 people have a pulmonary embolism\\neach year and more than 10% of them die from the\\nGALE ENCYCLOPEDIA OF MEDICINE 579\\nBlood clots'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 609, 'page_label': '580'}, page_content='embolism, most of them within 30 to 60 minutes after\\nsymptoms start.\\nPrevention\\nClots may be avoided by not smoking, and by not\\nusing medications that add to the risk. Clotting can be\\nprevented by following physician recommendations\\nconcerning medications. Sometimes, physicians will\\nprescribe special support stockings that prevent swel-\\nling and reduce chances of DVT. When taking an air\\nflight of six hours or longer, drinking plenty of fluids\\nto avoiddehydration, avoiding tight clothing around\\nthe waist, and stretching calves every hour can help\\nprevent DVT. It is advised that those on long flights\\nget up and move about once an hour during the flight.\\nIf not possible, moving the legs regularly while seated\\nby flexing the ankles, then pressing the feet against the\\nseat in the row ahead or on the floor can help stretch\\nthe calves. A physician may advise those at high risk of\\nDVT wear support stockings during the flight or take\\nlow-molecular weight heparin two to four hours\\nbefore departure.\\nResources\\nPERIODICALS\\n‘‘Air Travel, Especially Long Flights, May Increase the Risk\\nof Blood Clots.’’Women’s Health Weekly(Dec. 25,\\n2003):119.\\n‘‘In-flight Exercises for a Healthy Trip: Prevent\\nDangerous Blood Clots With These Three Easy\\nMoves the Next Time You Fly.’’Natural Health\\n(Jan–Feb. 2003):27.\\nStephenson, Joan. ‘‘FDA Orders Estrogen Safety Warnings:\\nAgency Offers Guidance for HRT Use.’’JAMA, The\\nJournal of the American Medical Association(Feb. 5,\\n2003):537–539.\\n‘‘Study Finds One Percent of Air Travelers Develop\\nInjurious Blood Clots.’’Heart Disease Weekly(Jan. 25,\\n2004):41.\\n‘‘Tiny Corkscrew Clears Blood Clots.’’Hematology Week\\n(Sept. 6, 2004):99.\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBehtesda, MD 20824-0105. 301-592-8573.\\nwww.nhlbi.nih.gov.\\nSociety of Interventional Radiology. 10201 Lee Highway,\\nSuite 500, Fairfax, VA 22030. 703-691-1805. http://\\nwww.sirweb.org.\\nOTHER\\nAvoid Deep Vein Thrombosis: Keep the Blood Flowing.FDA\\nWeb site, 2005. www.fda.gov/fdac/features/2004/\\n604_vein.html.\\nTeresa G. Odle\\nBlood count\\nDefinition\\nOne of the most commonly ordered clinical\\nlaboratory tests, a blood count, also called a com-\\nplete blood count (CBC), is a basic evaluation of\\nthe cells (red blood cells, white blood cells, and plate-\\nlets) suspended in the liquid part of the blood\\n(plasma). It involves determining the numbers, con-\\ncentrations, and conditions of the different types of\\nblood cells.\\nPurpose\\nThe CBC is a useful screening and diagnostic test\\nthat is often done as part of a routinephysical exam-\\nination. It can provide valuable information about the\\nblood and blood-forming tissues (especially the bone\\nmarrow), as well as other body systems. Abnormal\\nresults can indicate the presence of a variety of condi-\\ntions—including anemias, leukemias, and infections—\\nsometimes before the patient experiences symptoms of\\nthe disease.\\nDescription\\nA complete blood count is actually a series of tests\\nin which the numbers of red blood cells, white blood\\ncells, and platelets in a given volume of blood are\\ncounted. The CBC also measures the hemoglobin con-\\ntent and the packed cell volume (hematocrit) of the red\\nblood cells, assesses the size and shape of the red blood\\ncells, and determines the types and percentages of\\nwhite blood cells. Components of the complete blood\\ncount (hemoglobin, hematocrit, white blood cells,\\nplatelets, etc.) can also be tested separately, and are\\nsometimes done that way when a doctor wants to\\nmonitor a specific condition, such as the white cell\\ncount of a patient diagnosed with leukemia, or the\\nhemoglobin of a patient who has recently received a\\nblood transfusion. Because of its value, though, as an\\nindicator of a person’s overall health, the CBC pack-\\nage is most frequently ordered.\\nThe blood count is performed relatively inexpen-\\nsively and quickly. Most laboratories routinely use\\nsome type of automated equipment to dilute the\\nblood, sample a measured volume of the diluted sus-\\npension, and count the cells in that volume. In addi-\\ntion to counting actual numbers of red cells, white\\ncells, and platelets, the automated cell counters also\\nmeasure the hemoglobin and calculate the hematocrit\\nand thered blood cell indices(measures of the size and\\nhemoglobin content of the red blood cells).\\n580 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood count'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 610, 'page_label': '581'}, page_content='Technologists then examine a stained blood smear\\nunder the microscope to identify any abnormalities\\nin the appearance of the red blood cells and to report\\nthe types and percentages of white blood cells\\nobserved.\\nThe red blood cell (RBC) count determines the\\ntotal number of red cells (erythrocytes) in a sample of\\nblood. The red cells, the most numerous of the cellu-\\nlar elements, carry oxygen from the lungs to the\\nbody’s tissues. Hemoglobin (Hgb) is the protein-\\niron compound in the red blood cells that enables\\nthem to transport oxygen. Its concentration corre-\\nsponds closely to the RBC count. Also closely tied\\nto the RBC and hemoglobin values is the hematocrit\\n(Hct), which measures the percentage of red blood\\ncells in the total blood volume. The hematocrit\\n(expressed as percentage points) is normally about\\nthree times the hemoglobin concentration (reported\\nas grams per deciliter).\\nRed blood cell indices provide information\\nabout the size and hemoglobin content of the red\\ncells. They are useful in differentiating types of ane-\\nmias. The indices include four measurements that are\\ncalculated using the RBC count, hemoglobin, and\\nhematocrit results. Mean corpuscular volume\\n( M C V )i sam e a s u r e m e n to ft h ea v e r a g es i z eo ft h e\\nred blood cells and indicates whether that is small,\\nlarge or normal. The red blood cell distribution width\\n( R D W )i sa ni n d i c a t i o no ft h ev a r i a t i o ni nR B Cs i z e .\\nMean corpuscular hemoglobin (MCH) measures the\\naverage amount (weight) of hemoglobin within a red\\nblood cell. A similar measurement, mean corpuscular\\nhemoglobin concentration (MCHC), expresses the\\naverage concentration of hemoglobin in the red\\nblood cells.\\nThe white blood cell (WBC) count determines the\\ntotal number of white cells (leukocytes) in the blood\\nsample. Fewer in number than the red cells, WBCs\\nare the body’s primary means of fighting infection.\\nThere are five main types of white cells (neutrophils,\\nlymphocytes, monocytes, eosinophils, and baso-\\nphils), each of which plays a different role in respond-\\ning to the presence of foreign organisms in the body.\\nA differential white cell count is done by staining a\\nsmear of the patient’s blood with a Wright’s stain,\\nallowing the different types of white cells to be clearly\\nseen under the microscope. A technologist then\\ncounts a minimum of 100 WBCs and reports each\\ntype of white cell as a percentage of the total white\\nblood cells counted.\\nThe platelet countis an actual count of the number\\nof platelets (thrombocytes) in a given volume of blood.\\nPlatelets, the smallest of the cellular elements of blood,\\nare involved in blood clotting. Because platelets\\ncan clump together, the automated counting method\\nis subject to a certain level of error and may not\\nbe accurate enough for low platelet counts. For this\\nreason, very low platelet levels are often counted\\nmanually.\\nNormal results\\nBlood count values can vary by age and sex. The\\nnormal red blood cell count ranges from 4.2–5.4 mil-\\nlion RBCs per microliter of blood for men and 3.6–5.0\\nmillion for women. Hemoglobin values range\\nfrom 14–18 grams per deciliter of blood for men and\\n12–16 grams for women. The normal hematocrit is\\n42–54% for men and 36–48% for women. The normal\\nnumber of white blood cells for both men and women\\nis approximately 4,000–10,000 WBCs per microliter of\\nblood.\\nAbnormal results\\nAbnormal blood count results are seen in a vari-\\nety of conditions. One of the most common is ane-\\nmias, which are characterized by low RBC counts,\\nhemoglobins, and hematocrits. Infections and leuke-\\nmias are associated wit h increased numbers of\\nWBCs.\\nA white blood cell. (Photograph by Institut Pasteur, Phototake\\nNYC. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 581\\nBlood count'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 611, 'page_label': '582'}, page_content='Resources\\nBOOKS\\nBerkow, Robert, ed.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nHenry, J. B.Clinical Diagnosis and Management by Laboratory\\nMethods.New York: W. B. Saunders Co., 1996.\\nKaren A. Boyden\\nBlood crossmatching see Blood typing and\\ncrossmatching\\nBlood culture\\nDefinition\\nA blood culture is done when a person has symp-\\ntoms of a blood infection, also called bacteremia.\\nBlood is drawn from the person one or more times\\nand is tested in a laboratory to find and identify any\\nmicroorganism present and growing in the blood. If a\\nmicroorganism is found, more testing is done to deter-\\nmine theantibiotics that will be effective in treating the\\ninfection.\\nPurpose\\nBacteremia is a serious clinical condition and can\\nlead to death. To give the best chance for effective\\ntreatment and survival, a blood culture is done as\\nsoon as an infection is suspected.\\nSymptoms of bacteremia arefever, chills, mental\\nconfusion, anxiety, rapid heart beat, hyperventilation,\\nblood clotting problems, andshock. These symptoms\\nare especially significant in a person who already has\\nanother illness or infection, is hospitalized, or has\\ntrouble fighting infections because of a weak immune\\nsystem. Often, the blood infection results from an\\ninfection somewhere else in the body that has now\\nspread.\\nAdditionally, blood cultures are done to find the\\ncauses of other infections. These include bacterial\\npneumonia (an infection of the lung), and infectious\\nendocarditis (an infection of the inner layer of the\\nheart). Both of these infections leak bacteria into the\\nblood.\\nAfter a blood infection has been diagnosed, con-\\nfirmed by culture, and treated, an additional blood\\nculture may be done to make sure the infection is\\ngone.\\nDescription\\nCulture strategies\\nThere are many variables involved in performing\\na blood culture. Before the person’s blood is drawn,\\nthe physician must make several decisions based on a\\nknowledge of infections and the person’s clinical con-\\ndition and medical history.\\nSeveral groups of microorganisms, including\\nbacteria, viruses, mold, and yeast, can cause blood\\ninfections. The bacteriagroup can be further broken\\ndown into aerobes and anaerobes. Most aerobes do\\nnot need oxygen to live. They can grow with oxygen\\n(aerobic microbes) or without oxygen (anaerobic\\nmicrobes).\\nBased on the clinical condition of the patient, the\\nphysician determines what group of microorganisms\\nis likely to be causing the infection and then orders\\none or more specific types of blood culture, including\\naerobic, anaerobic, viral, or fungal (for yeasts and\\nmolds). Each specific type of culture is handled differ-\\nently by the laboratory. Most blood cultures test for\\nboth aerobic and anaerobic microbes. Fungal, viral,\\nand mycobacterial blood cultures can also be done,\\nbut are less common.\\nThe physician must also decide how many blood\\ncultures should be done. One culture is rarely\\nenough, but two to three are usually adequate.\\nFour cultures are occasionally required. Some fac-\\ntors influencing this decision are the specific micro-\\norganisms the physician expects to find based on the\\nperson’s symptoms or previous culture results, and\\nKEY TERMS\\nAerobe— Bacteria that require oxygen to live.\\nAnaerobe— Bacteria that live where there is no\\noxygen.\\nBacteremia— Bacteria in the blood.\\nContinuous bacteremia— A kind of bacteremia\\nwhere bacteria is always in the blood.\\nIntermittent bacteremia— A kind of bacteremia\\nwhere the bacteria enter the blood at various time\\nintervals.\\n582 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood culture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 612, 'page_label': '583'}, page_content='whether or not the person has had recent antibiotic\\ntherapy.\\nThe time at which the cultures are to be drawn is\\nanother decision made by the physician. During\\nmost blood infections (called intermittent bactere-\\nmia) microorganisms enter the blood at various\\ntime intervals. Blood drawn randomly may miss the\\nmicroorganisms. Since mic roorganisms enter the\\nblood 30–90 minutes bef ore the person’s fever\\nspikes, collecting the culture just after the fever\\nspike offers the best likelihood of finding the micro-\\norganism. The second and third cultures may be\\ncollected at the same time, but from different places\\non the person, or spaced at 30-minute or one-hour\\nintervals, as the physician chooses. During continu-\\nous bacteremia, such as i nfective endocarditis,\\nmicroorganisms are always in the blood and the\\ntiming of culture collection is less important. Blood\\ncultures should always be collected before antibiotic\\ntreatment has begun.\\nLaboratory analysis\\nBacteria are the most common microorganisms\\nfound in blood infections. Laboratory analysis of a\\nbacterial blood culture differs slightly from that of a\\nfungal culture and significantly from that of a viral\\nculture.\\nBlood is drawn from a person and put directly\\ninto a blood culture bottle containing a nutritional\\nbroth. After the laboratory receives the blood culture\\nbottle, several processes must be completed:\\n/C15provide an environment for the bacteria to grow\\n/C15detect the growth when it occurs\\n/C15identify the bacteria that grow\\n/C15test the bacteria against certain antibiotics to deter-\\nmine which antibiotic will be effective\\nThere are several types of systems, both manual\\nand automated, available to laboratories to carry out\\nthese processes.\\nThe broth in the blood culture bottle is the first\\nstep in creating an environment in which bacteria will\\ngrow. It contains all the nutrients that bacteria need to\\ngrow. If the physician expects anaerobic bacteria to\\ngrow, oxygen will be kept out of the blood culture\\nbottle; if aerobes are expected, oxygen will be allowed\\nin the bottle.\\nThe bottles are placed in an incubator and kept at\\nbody temperature. They are watched daily for signs of\\ngrowth, including cloudiness or a color change in the\\nbroth, gas bubbles, or clumps of bacteria. When there\\nis evidence of growth, the laboratory does a gram stain\\nand a subculture. To do the gram stain, a drop of\\nblood is removed from the bottle and placed on a\\nmicroscope slide. The blood is allowed to dry and\\nthen is stained with purple and red stains and exam-\\nined under the microscope. If bacteria are seen, the\\ncolor of stain they picked up (purple or red), their\\nshape (such as round or rectangular), and their size\\nprovide valuable clues as to what type of microorgan-\\nism they are and what antibiotics might work best. To\\ndo the subculture, a drop of blood is placed on a\\nculture plate, spread over the surface, and placed in\\nan incubator.\\nIf there is no immediate visible evidence of growth\\nin the bottles, the laboratory looks for bacteria by\\ndoing gram stains and subcultures. These steps are\\nrepeated daily for the first several days and periodi-\\ncally after that.\\nWhen bacteria grows, the laboratory identifies it\\nusing biochemical tests and the gram stain. Sensitivity\\ntesting, also called antibiotic susceptibility testing, is\\nalso done. The bacteria are tested against many differ-\\nent antibiotics to see which antibiotics can effectively\\nkill it.\\nAll information is passed on to the physician as\\nsoon as it is known. An early report, known as a\\npreliminary report, is usually available after one day.\\nThis report will tell if any bacteria have been found\\nyet, and if so, the results of the gram stain. The next\\npreliminary report may include a description of the\\nbacteria growing on the subculture. The laboratory\\nnotifies the physician immediately when an organism\\nis found and as soon as sensitivity tests are complete.\\nSensitivity tests may be complete before the bacteria\\nis completely identified. The final report may not be\\navailable for five to seven days. If bacteria was\\nfound, the report will include its complete identifica-\\ntion and a list of the antibiotics to which the bacteria is\\nsensitive.\\nOne automated system is considered one of\\nthe most important recent technical advances in\\nblood cultures. It is called continuous-monitoring\\nblood culture systems (CMCCS). The instruments\\nautomatically monitor the bottles containing the\\npatient blood for evidence of microorganisms, usually\\nevery 10 minutes. Many data points are collected daily\\nfor each bottle, and fed into a computer for analysis.\\nSophisticated mathematical calculations can deter-\\nmine when microorganisms have grown. This, com-\\nbined with more frequent blood tests, make it possible\\nGALE ENCYCLOPEDIA OF MEDICINE 583\\nBlood culture'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 613, 'page_label': '584'}, page_content='to detect microbial growth earlier. In addition, all\\nCMBCS instruments have the detection system, incu-\\nbator, and agitation unit in one unit.\\nPreparation\\nTen ml (milliliter) of blood is usually needed for\\neach blood culture bottle. First a healthcare worker\\nlocates a vein in the inner elbow region. The area of\\nskin where the blood will be drawn must be disin-\\nfected to prevent any microorganisms on a person’s\\nskin from entering the blood culture bottle and con-\\ntaminating it. The area is disinfected by wiping the\\narea with alcohol in a circular fashion, starting with\\ntiny circles at the spot where the needle will puncture\\nthe skin and enlarging the size of the circles while\\nwiping away from the puncture site. The same\\npattern of wiping is repeated using an iodine or iodo-\\nphor solution. The top of the bottle is disinfected\\nusing alcohol. After the person’s skin has been\\ndisinfected, the healthcare worker draws the blood\\nand about 10 ml of blood is injected into each\\nblood culture bottle. The type of bottles used will\\nvary based on whether the physician is looking\\nfor bacteria (aerobes or anaerobes), yeast, mold, or\\nviruses.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces bruis-\\ning. Warm packs relieve discomfort.\\nNormal results\\nNormal results will be negative. A single negative\\nculture does not rule out a blood infection. False\\nnegatives can occur if the person was started on\\nantibiotics before the blood was drawn, if the\\nenvironment for growth was not right, the timing\\nwas off, or for some unknown reason the micro-\\norganism just didn’t grow. Three negative cultures\\nmay be enough to rule out bacteremia in the case of\\nendocarditis.\\nAbnormal results\\nThe physician’s skill in interpreting the culture\\nresults and assessing the person’s clinical condition is\\nessential in distinguishing a blood culture that is posi-\\ntive because of a true infection from a culture that is\\npositive because it became contaminated. In true\\nbacteremia, the patient’s clinical condition should be\\nconsistent with a blood infection caused by the micro-\\norganism that was found. The microorganism is\\nusually found in more than one culture, it usually\\ngrows soon after the bottles are incubated, and it is\\noften the cause of an infection somewhere else in the\\nperson’s body.\\nWhen the culture is positive because of contam-\\nination, the patient’s clinical condition usually is not\\nconsistent with an infection from the identified\\nmicroorganism. In addition, the microorganism is\\noften one commonly found on skin, it rarely causes\\ninfection, it is found in only one bottle, and it may\\nappear after several days of incubation. More than\\none microorganism often grow in contaminated\\ncultures.\\nResources\\nORGANIZATIONS\\nAmerican Society of Microbiology. 1752 N Street N.W.,\\nWashington, D.C. 20036. (202) 737-3600. .\\nNancy J. Nordenson\\nBlood donation and registry\\nDefinition\\nBlood donation refers to the process of collecting,\\ntesting, preparing, and storing blood and blood com-\\nponents. Donors are most commonly unpaid volun-\\nteers, but they may also be paid by commercial\\nenterprises. Blood registry refers to the collection and\\nsharing of data about donated blood and ineligible\\ndonors.\\nPurpose\\nThe purpose of the blood collection and distribu-\\ntion system is to help ensure an adequate supply of\\nblood for accident victims, people needing surgery,\\nand people suffering from certain diseases, as well as\\nfor medical research.\\nSometimes, donors give blood specifically to\\nbenefit a particular person.People preparing for elec-\\ntive surgery may donate their own blood to be held\\nand then returned to them during surgery. This is\\nknown as autologous blood donation. Directed\\ndonor blood has been donated by someone known\\n584 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood donation and registry'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 614, 'page_label': '585'}, page_content='to the intended recipient, such as a family member or\\nfriend.\\nEach year, more than four million Americans\\nreceive blood transfusions involving more than\\n26 million units of blood (one unit equals 450 milli-\\nliters, or about one pint), or an average of about\\n32,000 units per day. All of that blood must be\\ncollected, tested, prepared, stored, and delivered\\nto the appropriate sites. Roughly eight million\\npeople in the United States donate blood each year;\\nabout half of the total amount needed is provided\\nby the 36 regional blood centers of the American\\nRed Cross.\\nWhole blood and the various blood components\\nhave many uses. Red blood cells, which carry oxygen,\\nare used to treat anemia. Platelets, which play a role in\\ncontrolling bleeding, are commonly used in the treat-\\nment of leukemia and other cancers. Fresh frozen\\nplasma is also used to control bleeding in people defi-\\ncient in certain clotting factors. Cryoprecipitated\\nAHF, made from fresh frozen plasma, contains a few\\nspecific clotting factors.\\nPrecautions\\nTo ensure the safety of the blood supply, a multi-\\ntiered process of donor screening and deferral is\\nemployed. This involves donor education, taking a\\ndetailed health history of each prospective donor, and\\ngiving potential donors a simplephysical examination\\n(which includes taking a few drops of blood to test for\\nanemia). At any point in the process, a potential donor\\nmay be ‘‘deferred,’’ or judged ineligible to donate blood.\\nThis deferral may be temporary or permanent, depend-\\ning on the reason. Potential donors are also encouraged\\nto ‘‘self-defer,’’ or voluntarily decline to donate, rather\\nthan put future blood recipients at risk.\\nAll donated blood is extensively tested before\\nbeing used. The first step is determining the blood\\ntype, which indicates who can receive the blood.\\nReceiving the wrong type of blood can cause\\ndeath. Blood is also screened for any antibodies that\\ncould cause complications for recipients. In addition,\\nblood is tested to screen out donors infected with\\nthe following diseases: Hepatitis B surface antigen\\nADD, hepatitis B core antibody, hepatitis C\\nvirus antibody, HIV-1 and HIV-2 antibody, HIV p24\\nantigen, HTLV-I and HTLV-II antibodies, and\\nsyphilis. Nucleic Acid Amplification testing is also\\nperformed, and other tests may be done if a doctor\\nrequests them.\\nIn order to detect the greatest possible number of\\ninfections, these screening tests are extremely sensi-\\ntive. For this reason, however, donors sometimes\\nreceive false positive test results. In these cases,\\nmore specific confirmatory tests are performed, to\\nhelp rule out false positive results. Blood found to\\nbe abnormal is discarded, and all items coming into\\ndirect contact with donors are used only once and\\nthen discarded. Donors of infected blood are entered\\ninto the Donor Deferral Register, a confidential\\nnational data base used to prevent deferred people\\nfrom donating blood.\\nIn general, blood donors must be at least 17 years\\nold (some states allow younger people to donate blood\\nwith their parents’ consent), must weigh at least 110\\npounds (50 kg), and must be in good health.\\nMany factors can temporarily or permanently\\ndisqualify potential donors. Most of them have to\\ndo with having engaged in behaviors that put them\\nat risk of infection or having spent time in certain\\nspecified areas. Among these factors are having had a\\ntattoo, having had sex with people in high-risk\\ngroups, having had certain diseases, and having\\nbeen raped.\\nDescription\\nThere are eight different blood types in all—four\\nABO groups, each of which may be either Rh positive\\nor Rh negative. These types, and their approximate\\ndistribution in the U.S. population, are as follows:\\nO+ (38%), O- (7%), A+ (34%), A- (6%), B+ (9%),\\nB- (2%), AB+ (3%), AB- (1%). In an emergency,\\nanyone can safely receive type O red blood cells,\\nand people with this blood type are known as\\n‘‘universal donors.’’ People with type AB blood,\\nknown as ‘‘universal recipients,’’ can receive any type\\nof red blood cells and can give plasma to all blood\\ntypes.\\nKEY TERMS\\nApheresis— Extraction of a specific component\\nfrom donated blood, with the remainder returned\\nto the donor.\\nAutologous donation— Blood donated for the\\ndonor’s own use.\\nGranulocytes— White blood cells.\\nPlasma— The liquid part of blood.\\nPlatelets— Tiny, disklike elements of plasma that\\npromote clotting.\\nGALE ENCYCLOPEDIA OF MEDICINE 585\\nBlood donation and registry'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 615, 'page_label': '586'}, page_content='Blood donations can be made in community\\nblood centers, at hospitals or in bloodmobiles, which\\nvisit schools, churches and workplaces. The actual\\nprocess of donating whole blood takes about 20\\nminutes. A sterile needle is inserted into a vein in the\\ndonor’s arm. The blood flows through plastic tubing\\ninto a blood bag. Donors may be asked to clench their\\nfist to encourage blood to flow. Usually, one unit of\\nblood is collected. Afterward, donors are escorted to\\nan observation area, given light refreshments, and\\nallowed to rest.\\nPlasma, the liquid portion of the blood in which red\\nblood cells, platelets and other elements are suspended,\\nis also collected, often by commercial enterprises that\\nsell it to companies manufacturing clotting factors and\\nother blood products. This is done using a process\\nknown as apheresis, in which whole blood is coll-\\nected, the desired blood component is removed, and\\nthe remainder is returned to the donor. Collecting\\nplasma generally takes one to two hours. Apheresis\\nmay also be used to collect other blood components,\\nsuch as platelets and granulocytes.\\nPreparation\\nOnce whole blood has been collected, it is sent to a\\nlab for testing and processing. Most donated blood is\\nseparated into its constituent components, such as red\\nblood cells, platelets, and cryoprecipitate. This enables\\nmore than one person to benefit from the same unit of\\ndonated blood.\\nDifferent blood components vary in how long\\nthey can be stored. Red blood cells can be refrigerated\\nfor up to 42 days or frozen for as much as 10 years.\\nPlatelets, stored at room temperature, may be kept for\\nup to five days. Fresh frozen plasma and cryoprecipi-\\ntated AHF can be kept for as much as one year.\\nAftercare\\nIt generally takes about 24 hours for the donor’s\\nbody to replenish the lost fluid. Replacing the lost red\\nblood cells, however, may take as much as two\\nmonths. Whole blood donors must wait a minimum\\nof eight weeks before donating again. Some states\\nplace further limits on the frequency and/or total\\nnumber of times an individual may donate blood\\nwithin a 12-month period.\\nRisks\\nThanks to the use of a multi-tiered screening\\nsystem and advances in the effectiveness of\\nscreening tests, the transmission of infectious dis-\\neases via transfusion has been significantly dimin-\\nished. Nonetheless, ther e is still a minuscule risk\\nthat blood recipients could contract HIV, Hepatitis\\nC or other infections via transfusion. Other diseases\\nthat could conceivably be contracted in this way, or\\nthat are of particular concern to blood-collection\\nagencies, include babesiosis,C h a g a sd i s e a s e ,H T L V -\\nIa n d- I I ,Creutzfeldt-Jakob disease , cytomegalo-\\nvirus, Lyme disease , malaria, and new variant\\nCreutzfeldt-Jakob disease.\\nAutologous blood donors run a tiny risk of having\\nthe wrong blood returned to them due to clerical error.\\nThere is also a faint possibility of bacterial contamina-\\ntion of the autologous blood.\\nNormal results\\nFor most donors, the process is quick and painless\\nand they leave feeling fine. They may also find satis-\\nfaction in knowing that they have contributed to the\\nnation’s blood supply and may even have helped save\\nlives.\\nAbnormal results\\nMost blood donors suffer no significant afteref-\\nfects. Occasionally, however, donors feel faint or\\ndizzy, nauseous, and/or havepain, redness, or a bruise\\nwhere the blood was taken. More serious complica-\\ntions, which rarely occur, include fainting, muscle\\nspasms, and nerve damage.\\nResources\\nPERIODICALS\\nMcKenna, C. ‘‘Blood Minded’’Nursing TimesApril 6, 2000:\\n27-28.\\nWagner, H. ‘‘Umbilical Cord Blood Banking: Insurance\\nAgainst Future Diseases?’’USA Today Magazine\\n(March 2000) : 59-61.\\nORGANIZATIONS\\nAmerican Association of Blood Banks. 8101 Glenbrook\\nRoad, Bethesda, MD 20814-2749. (301) 907-6977.\\n.\\nAmerican Red Cross. 430 17th Street NW, Washington,\\nD.C. 20006. .\\nNational Blood Data Resource Center. (301) 215-6506.\\n.\\nPeter Gregutt\\nBlood fluke infection see Schistosomiasis\\n586 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood donation and registry'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 616, 'page_label': '587'}, page_content='Blood gas analysis\\nDefinition\\nBlood gas analysis, also called arterial blood gas\\n(ABG) analysis, is a test which measures the amounts\\nof oxygen and carbon dioxide in the blood, as well as\\nthe acidity (pH) of the blood.\\nPurpose\\nAn ABG analysis evaluates how effectively the\\nlungs are delivering oxygen to the blood and how\\nefficiently they are eliminating carbon dioxide from\\nit. The test also indicates how well the lungs and\\nkidneys are interacting to maintain normal blood pH\\n(acid-base balance). Blood gas studies are usually\\ndone to assess respiratory disease and other conditions\\nthat may affect the lungs, and to manage patients\\nreceiving oxygen therapy (respiratory therapy). In\\naddition, the acid-base component of the test provides\\ninformation on kidney function.\\nDescription\\nBlood gas analysis is performed on blood from an\\nartery. It measures the partial pressures of oxygen and\\ncarbon dioxide in the blood, as well as oxygen content,\\noxygen saturation, bicarbonate content, and blood pH.\\nOxygen in the lungs is carried to the tissues through\\nthe bloodstream, but only a small amount of this oxy-\\ngen can actually dissolve in arterial blood. How much\\ndissolves depends on the partial pressure of the oxygen\\n(the pressure that the gas exerts on the walls of the\\narteries). Therefore, testing the partial pressure of oxy-\\ngen is actually measuring how much oxygen the lungs\\nare delivering to the blood. Carbon dioxide is released\\ninto the blood as a by-product of cell metabolism. The\\npartial carbon dioxide pressure indicates how well the\\nlungs are eliminating this carbon dioxide.\\nThe remainder of oxygen that is not dissolved in\\nthe blood combines with hemoglobin, a protein–iron\\ncompound found in the red blood cells. The oxygen\\ncontent measurement in an ABG analysis indicates\\nhow much oxygen is combined with the hemoglobin.\\nA related value is the oxygen saturation, which com-\\npares the amount of oxygen actually combined with\\nhemoglobin to the total amount of oxygen that the\\nhemoglobin is capable of combining with.\\nCarbon dioxide dissolves more readily in the blood\\nthan oxygen does, primarily forming bicarbonate and\\nsmaller amounts of carbonic acid. When present in\\nnormal amounts, the ratio of carbonic acid to bicar-\\nbonate creates an acid-base balance in the blood, help-\\ning to keep the pH at a level where the body’s cellular\\nfunctions are most efficient. The lungs and kidneys\\nA blood gas analyzer from Corning Corporation.(Photograph by\\nHank Morgan, Photo Researchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAcid-base balance— The condition that exists\\nwhen the body’s carbonic acid-bicarbonate buffer\\nsystem is in equilibrium, helping to maintain the\\nblood pH at a normal level of 7.35–7.45.\\nHemoglobin— A protein—iron compound in red\\nblood cells that functions primarily in carrying\\noxygen from the lungs to the tissues of the body.\\npH— A measure of the acidity of a solution. Normal\\nblood pH ranges from 7.35–7.45.\\nGALE ENCYCLOPEDIA OF MEDICINE 587\\nBlood gas analysis'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 617, 'page_label': '588'}, page_content='both participate in maintaining the carbonic acid-\\nbicarbonate balance. The lungs control the carbonic\\nacid level and the kidneys regulate the bicarbonate. If\\neither organ is not functioning properly, an acid-base\\nimbalance can result. Determination of bicarbonate\\nand pH levels, then, aids in diagnosing the cause of\\nabnormal blood gas values.\\nThe procedure\\nThe blood sample is obtained by arterial puncture\\n(usually in the wrist, although it could be in the groin\\nor arm) or from an arterial line already in place. If a\\npuncture is needed, the skin over the artery is cleaned\\nwith an antiseptic. A technician then collects the blood\\nwith a small sterile needle attached to a disposable\\nsyringe. The patient may feel a brief throbbing or\\ncramping at the site of the puncture. After the blood\\nis drawn, the sample must be transported to the\\nlaboratory as soon as possible for analysis.\\nPreparation\\nThere are no special preparations. Patients have no\\nrestrictions on drinking or eating before the test. If the\\npatient is receiving oxygen, the oxygen concentration\\nmust remain the same for 20 minutes before the test; if\\nthe test is to be taken without oxygen, the gas must be\\nturned off for 20 minutes before the test is taken. The\\npatient should breathe normally during the test.\\nAftercare\\nAfter the blood has been taken, the technician\\nor the patient applies pressure to the puncture site\\nfor 10–15 minutes to stop the bleeding, and then places\\na dressing over the puncture.The patient should rest\\nquietly while applying the pressure to the puncture\\nsite. Health care workers will observe the patient for\\nsigns of bleeding or circulation problems\\nRisks\\nRisks are very low when the test is done correctly.\\nRisks include bleeding or bruising at the site, or delayed\\nbleeding from the site. Very rarely, there may be a\\nproblem with circulation in the puncture area.\\nNormal results\\nNormal blood gas values are as follows:\\n/C15partial pressure of oxygen (PaO2): 75–100 mm Hg\\n/C15partial pressure of carbon dioxide (PaCO2): 35–45\\nmm Hg\\n/C15oxygen content (O2CT): 15–23%\\n/C15oxygen saturation (SaO2): 94–100%\\n/C15bicarbonate (HCO3): 22–26 mEq/liter\\n/C15pH: 7.35–7.45\\nAbnormal results\\nValues that differ from those listed above may\\nindicate respirat ory, metabolic, or kidney disease .\\nThese results also may be abnormal if the patient\\nhas experienced trauma that may affect breathing\\n(especially head and neck injuries). Disorders, such\\nas anemia, that affect the oxygen-carrying capacity\\nof blood, can produce an abnormally low oxygen\\ncontent value.\\nResources\\nBOOKS\\nThompson, June, et al.Mosby’s Clinical Nursing.4th ed.\\nSt. Louis: Mosby, 1997.\\nCarol A. Turkington\\nBlood poisoning see Acute lymphangitis\\nBlood registry see Blood donation and\\nregistry\\nBlood removal see Phlebotomy\\nBlood sugar tests\\nDefinition\\nBlood sugar tests include several different tests\\nthat measure the amount of sugar (glucose) in a per-\\nson’s blood. These tests are performed either on an\\nempty stomach, or after consuming a meal or pre-\\nmeasured glucose drink. Blood sugar tests are done\\nprimarily to diagnose and evaluate a person with\\ndiabetes mellitus.\\nPurpose\\nThe body uses sugar, also called glucose, to supply\\nthe energy it needs to function. People get sugar from\\ntheir diet and from their body tissues. Insulin is made\\nby the pancreas and affects the outer membrane of\\ncells, making it easy for glucose to move from the\\nblood into the cells. When insulin is active, blood\\nglucose levels fall. Sugar from body tissues is stored\\n588 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood sugar tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 618, 'page_label': '589'}, page_content='in the form of glycogen. When glycogen is active,\\nblood glucose levels rise.\\nAfter a meal, blood glucose levels rise sharply.\\nThe pancreas responds by releasing enough insulin to\\ntake care of all the newly added sugar found in the\\nbody. The insulin moves the sugar out of the blood\\nand into the cells. Only then does the blood sugar start\\nto level off and begin to fall. A person with diabetes\\nmellitus either does not make enough insulin, or\\nmakes insulin that does not work properly. The result\\nis blood sugar that remains high, a condition called\\nhyperglycemia.\\nDiabetes must be diagnosed as early as possible. If\\nleft untreated, it can damage or cause failure of the\\neyes, kidneys, nerves, heart, blood vessels, and other\\nbody organs.Hypoglycemia, or low blood sugar, also\\nmay be discovered through blood sugar testing.\\nHypoglycemia is caused by various hormone disorders\\nand liver disease, as well as by too much insulin.\\nDescription\\nThere are a variety of ways to measure a person’s\\nblood sugar.\\nWhole blood glucose test\\nWhole blood glucose testing can be performed by\\na person in his or her home, and kits are available for\\nthis purpose. The person pricks his or her finger (a\\nfinger stick) with a sterile sharp blade from the kit. A\\nsingle drop of blood is placed on a strip in a portable\\ninstrument called a glucometer. The glucometer\\nquickly determines the blood sugar and shows the\\nresults on a small screen in usually a few seconds.\\nNew technologies for monitoring glucose levels\\nwill help diabetics better control their glucose levels.\\nThese tests are particularly important for children\\nand adolescents. In mid-2002, the U.S. Food and\\nDrug Administration (FDA) approved a new home\\ntest for use by children and adolescents (it had\\nalready been approved for adults) called the Cygnus\\nGlucoWatch biographer that helped better detect\\nhypoglycemia. Studies show that more frequent\\nchecks are better; new monitors such as this allow\\nfor simpler frequent testing. Continuous monitoring\\nwas in development in early 2004, as a company\\ncalled TheraSense, Inc. received preapproval from\\nthe FDA for clinical trials on its home continuous\\nglucose monitor. The monitor was designed to pro-\\nvide users with real-time glucose data, alarms for\\nhypoglycemia and hyperglycemia and to show trends\\ni nt h e i rb l o o ds u g a rl e v e l s .\\nFasting plasma glucose test\\nThe fasting plasma glucose test is done on an\\nempty stomach. For the eight hours before the test,\\nthe person must fast (nothing to eat or drink, except\\nwater). The person’s blood is drawn from a vein by a\\nhealth care worker. The blood sample is collected into\\na tube containing an anticoagulant. Anticoagulants\\nstop the blood from clotting. In the laboratory, the\\ntube of blood spins at high speed within a machine\\ncalled a centrifuge. The blood cells sink to the bottom\\nand the liquid stays on the top. This straw-colored\\nliquid on the top is the plasma. To measure the\\nglucose, a person’s plasma is combined with other\\nsubstances. From the resulting reaction, the amount\\nof glucose in the plasma is determined.\\nOral glucose tolerance test\\nThe oral glucose tolerance test is conducted to see\\nhow well the body handles a standard amount of\\nglucose. This test measures the amount of glucose in\\na person’s plasma before and two hours after drinking\\na large premeasured beverage containing glucose. The\\nperson must eat a consistent diet, containing at least\\n5.25 oz (150g) of carbohydrates each day, for three\\ndays before this test. For eight hours before the test,\\nthe person must fast. A health care provider draws the\\nfirst sample of blood at the end of the fast to determine\\nthe glucose level at the start of the test. The health care\\nprovider then gives the person a beverage containing\\n2.6oz (75g) of glucose. Two hours later, the person’s\\nblood is drawn again. These blood samples are centri-\\nfuged and processed in the laboratory. A doctor can\\nthen compare the before and after glucose levels to see\\nhow well the patient’s body processed the sugar.\\nTwo-hour postprandial blood glucose test\\nThe two-hour postprandial blood glucose test mea-\\nsures the amount of glucose in plasma after a person eats\\na specific meal containing a certain amount of sugar.\\nAlthough the meal follows a predetermined menu, it is\\ndifficult to control many factors associated with this\\ntesting method.\\nBlood sugar tests can be used in a variety of situa-\\ntions including:\\n/C15Testing people suspected for diabetes. The American\\nDiabetic Association (ADA) recommends that either\\na fasting plasma glucose test or an oral glucose toler-\\nance test be used to diagnose diabetes. If the person\\nalready has symptoms of diabetes, a blood glucose test\\nwithout fasting (called a casual plasma glucose test)\\nmay be done. If the test result is abnormal, it must be\\nconfirmed with another test performed on another\\nGALE ENCYCLOPEDIA OF MEDICINE 589\\nBlood sugar tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 619, 'page_label': '590'}, page_content='day. The two tests can be different or they can be the\\nsame, but they must be done on different days. If the\\nsecond test also is abnormal, the person has diabetes.\\nA two-hour postprandial test is not recommended by\\nthe ADA as a test to use for the diagnosis of diabetes.\\nA doctor may order this test, and follow it with the\\noral glucose tolerance test or the fasting plasma glu-\\ncose test if the results are abnormal.\\n/C15Testing pregnant women. Diabetes that occurs dur-\\ning pregnancy (gestational diabetes) is dangerous for\\nboth the mother and the baby. Women who may be\\nat risk are screened when they are 24-28 weeks preg-\\nnant. A woman is considered at risk if she is older\\nthan 25 years, is not at her normal body weight, has a\\nparent or sibling with diabetes, or if she is in an ethnic\\ngroup that has a high rate of diabetes (Hispanics,\\nNative Americans, Asians, African Americans).\\nThe blood sugar test to screen for gestational dia-\\nbetes is a variation of the oral glucose tolerance test.\\nFasting is not required. If the result is abnormal,\\na more complete test is done on another day.\\n/C15Testing healthy people. Healthy people without\\nsymptoms of diabetes should be screened for dia-\\nbetes when they are 45 years old and again every\\nthree years. Either the fasting plasma glucose or\\noral glucose tolerance test is used for screening.\\nPeople in high risk groups should be tested before\\nthe age of 45 and tested more frequently.\\n/C15Testing of people already diagnosed with diabetes.\\nThe ADA recommends that a person with diabetes\\nkeep the amount of glucose in the blood at a normal\\nlevel as much as possible. This can be done by the\\ndiabetic person testing his or her own blood at home\\none or more times a day.\\nPreparation\\nEach blood sugar test that uses plasma requires a\\n5 mL blood sample. A healthcare worker ties a tight\\nband (tourniquet) on the person’s upper arm, locates a\\nvein in the inner elbow region, and inserts a needle into\\nthe vein. Vacuum action draws the blood through the\\nneedle into an attached tube. Collection of the sample\\ntakes only a few minutes.\\nWhen fasting is required, the person should have\\nnothing to eat or drink (except water) for eight hours\\nbefore the test and until the test or series of tests is\\ncompleted. The person should not smoke before or\\nduring the testing period because this can temporarily\\nincrease the amount of glucose in the blood. Other\\nfactors that can cause inaccurate results are a change\\nin diet before the test, illness or surgery two weeks\\nbefore the test, certain drugs, and extended bed rest.\\nThe doctor may tell a person on insulin or taking pills\\nfor diabetes to stop the medication until after the test.\\nAftercare\\nAfter the test or series of tests is completed (and\\nwith the approval of his or her doctor), the person\\nshould eat, drink, and take any medications that\\nwere stopped for the test.\\nThe patient may feel discomfort when blood is\\ndrawn from a vein. Bruising may occur at the puncture\\nsite or 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.\\nRisks\\nIf the person experiences weakness, fainting,\\nsweating, or any other unusual reaction while fasting\\nor during the test, he or she should immediately tell the\\nperson giving the test.\\nNormal results\\nNormal results are:\\n/C15fasting plasma glucose test less than 120 mg/dL\\n/C15oral glucose tolerance test, 2 hours less than 140 mg/dL\\nFor the diabetic person, the ADA recommends\\nan ongoing blood sugar goal of less than or equal to\\n120 mg/dL.\\nAbnormal results\\nThese abnormal results indicate diabetes and\\nmust be confirmed with repeat testing:\\n/C15fasting plasma glucose test less than or equal to\\n126 mg/dL\\n/C15oral glucose tolerance test, 2 hours less than or equal\\nto 200 mg/dL\\n/C15casual plasma glucose test (nonfasting, with symp-\\ntoms) less than or equal to 200 mg/dL\\n/C15gestational oral glucose tolerance test, 1 hour less\\nthan or equal to 140 mg/dL\\nBrain damage can occur from glucose levels below\\n40 mg/dL andcoma from levels above 470 mg/dL.\\nA condition known as prediabetes or impaired\\nglucose tolerance, which may lead to Type 2 diabetes,\\nusually is indicated with a reading of 100 mg/dL. Other\\nhormone disorders can cause both hyperglycemia and\\n590 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood sugar tests'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 620, 'page_label': '591'}, page_content='hypoglycemia. Abnormal results must be interpreted by\\na doctor who is aware of the person’s medical condition\\nand medical history.\\nResources\\nPERIODICALS\\n‘‘New Guidelines Set Lower Threshold for Precursor to\\nDiabetes.’’ RN (January 2004): 17.\\nPlotnick, Leslie P. ‘‘The Next Step in Blood Glucose\\nMonitoring?’’ Pediatrics (April 2003): 885.\\n‘‘Premarket Approval Application Filed for Continuous\\nGlucose Monitor.’’Medical Letter on the CDC & FDA\\n(January 4, 2004): 26.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard\\nStreet, Alexandria, VA 22311. (800) 342-2383. .\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-\\n3311. .\\nNational Diabetes Information Clearinghouse.\\n1 Information Way, Bethesda, MD 20892-3560. (800)\\n860-8747. .\\nNancy J. Nordenson\\nTeresa G. Odle\\nBlood thinners see Anticoagulant and\\nantiplatelet drugs\\nBlood transfusion see Transfusion\\nBlood typing and\\ncrossmatching\\nDefinition\\nBlood typing is a laboratory test done to deter-\\nmine a person’s blood type. If the person needs a blood\\ntransfusion, another test called crossmatching is done\\nafter the blood is typed to find blood from a donor\\nthat the person’s body will accept.\\nPurpose\\nBlood typing and crossmatching are most com-\\nmonly done to make certain that a person who needs a\\ntransfusion will receive blood that matches (is compa-\\ntible with) his own. People must receive blood of the\\nsame blood type, otherwise, a serious, even fatal,\\ntransfusion reaction can occur.\\nParents who are expecting a baby have their blood\\ntyped to diagnose and prevent hemolytic disease of the\\nnewborn (HDN), a type of anemia also known as\\nerythroblastosis fetalis. Babies who have a blood type\\ndifferent from their mothers are at risk for developing\\nthis disease. The disease is serious with certain blood\\ntype differences, but is milder with others.\\nA child inherits factors or genes from each parent\\nthat determine his blood type. This fact makes blood\\ntyping useful in paternity testing. To determine\\nwhether or not the alleged father could be the true\\nfather, the blood types of the child, mother, and\\nalleged father are compared.\\nLegal investigations may require typing of blood\\nor other body fluids, such as semen or saliva, to iden-\\ntify persons involved in crimes or other legal matters.\\nDescription\\nBlood typing and crossmatching tests are per-\\nformed in a blood bank laboratory by technologists\\ntrained in blood bank and transfusion services. The\\ntests are done on blood, after it has separated into cells\\nand serum (serum is the yellow liquid left after the\\nblood clots.) Costs for both tests are covered by insur-\\nance when the tests are determined to be medically\\nnecessary.\\nBlood bank laboratories are usually located in\\nfacilities, such as those operated by the American\\nRed Cross, that collect, process, and supply blood\\nthat is donated, as well as in facilities, such as most\\nhospitals, that prepare blood for transfusion. These\\nlaboratories are regulated by the United States Food\\nand Drug Administration (FDA) and are often\\ninspected and accredited by a professional association\\nsuch as the American Association of Blood Banks\\n(AABB).\\nBlood typing and crossmatching tests are based\\non the reaction between antigens and antibodies. An\\nantigen can be anything that causes the body to launch\\nan attack, known as an immune response, against it.\\nThe attack begins when the body builds a special\\nprotein, called an antibody, that is uniquely designed\\nto attack and make ineffective (neutralize) the specific\\nantigen that caused the attack. A person’s body nor-\\nmally doesn’t make antibodies against its own anti-\\ngens, only against antigens that are foreign to it.\\nA person’s body contains many antigens. The anti-\\ngens found on the surface of red blood cells are impor-\\ntant because they determine a person’s blood type.\\nWhen red blood cells having a certain blood type anti-\\ngen are mixed with serum containing antibodies against\\nGALE ENCYCLOPEDIA OF MEDICINE 591\\nBlood typing and crossmatching'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 621, 'page_label': '592'}, page_content='that antigen, the antibodies attack and stick to the\\nantigen. In a test tube, this reaction is observed as the\\nformation of clumps of cells (clumping).\\nWhen blood is typed, a person’s cells and serum\\nare mixed in a test tube with commercially-prepared\\nserum and cells. Clumping tells which antigens or\\nantibodies are present and reveals the person’s blood\\ntype. When blood is crossmatched, patient serum\\nis mixed with cells from donated blood that might be\\nused for transfusion. Clumping or lack of clumping\\nin the test tube tells whether or not the blood is\\ncompatible.\\nAlthough there are over 600 known red blood cell\\nantigens, organized into 22 blood group systems, rou-\\ntine blood typing and crossmatching is usually con-\\ncerned with only two systems: the ABO and Rh blood\\ngroup systems.\\nBlood typing\\nABO BLOOD GROUP SYSTEM. In 1901, Karl\\nLandsteiner, an Austrian pathologist, randomly com-\\nbined the serum and red blood cells of his colleagues.\\nFrom the reactions he observed in test tubes, he dis-\\ncovered the ABO blood group system. This discovery\\nearned him the 1930 Nobel Prize in Medicine.\\nA person’s ABO blood type–A, B, AB, or O–is\\nbased on the presence or absence of the A and B\\nantigens on his red blood cells. The A blood type has\\nonly the A antigen and the B blood type has only the\\nB antigen. The AB blood type has both A and B\\nantigens, and the O blood type has neither A nor B\\nantigen.\\nBy the time a person is six months old, he natu-\\nrally will have developed antibodies against the anti-\\ngens his red blood cells lack. That is, a person with A\\nblood type will have anti-B antibodies, and a person\\nwith B blood type will have anti-A antibodies. A per-\\nson with AB blood type will have neither antibody, but\\na person with O blood type will have both anti-A and\\nanti-B antibodies. Although the distribution of each of\\nthe four ABO blood types varies between racial\\ngroups, O is the most common and AB is the least\\ncommon.\\nABO typing is the first test done on blood when it\\nis tested for transfusion. A person must receive ABO-\\nmatched blood. ABO incompatibilities are the major\\ncause of fatal transfusion reactions. ABO antigens are\\nalso found on most body organs, so ABO compatibil-\\nity is also important for organ transplants.\\nAn ABO incompatibility between a pregnant\\nwoman and her baby is a minor cause of HDN and\\nusually causes no problem for the baby. The structure\\nof ABO antibodies makes it unlikely they will cross the\\nplacenta to attack the baby’s red blood cells.\\nPaternity testing compares the ABO blood types of\\nthe child, mother, and alleged father. The alleged father\\ncan’t be the true father if the child’s blood type requires\\na gene that neither he nor the mother have. For exam-\\nple, a child with blood type B whose mother has blood\\ntype O, requires a father with either AB or B blood type;\\na man with blood type O cannot be the true father.\\nIn some people, ABO antigens can be found in\\nbody fluids other than blood, such as saliva and\\nsemen. ABO typing of these fluids provides clues in\\nlegal investigations.\\nRH BLOOD GROUP SYSTEM. The Rh, or Rhesus,\\nsystem was first detected in 1940 by Landsteiner and\\nWiener when they injected blood from rhesus monkeys\\ninto guinea pigs and rabbits. More than 50 antigens have\\nsince been discovered belonging to this system, making\\nit the most complex red blood cell antigen system.\\nIn routine blood typing and crossmatching tests,\\nonly one of these 50 antigens, the D antigen, also\\nknown as the Rh factor or Rh\\no[D], is tested for.\\nIf the D antigen is present, that person is Rh-positive;\\nif the D antigen is absent, that person is Rh-negative.\\nOther important antigens in the Rh system are C,\\nc, E, and e. These antigens are not usually tested for in\\nroutine blood typing tests. However, testing for the\\npresence of these antigens is useful in paternity testing,\\nand when a technologist tries to identify unexpected\\nFrequency (%) Of ABO And Rh Blood Types In U.S. Population\\nRacial Group ABO Blood Type Rh Blood Type\\nO A B AB Positive Negative\\nWhites 45% 40% 11% 4% 85% 15%\\nBlacks 49% 27% 20% 4% 90% 10%\\n592 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood typing and crossmatching'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 622, 'page_label': '593'}, page_content=\"Rh antibodies or find matching blood for a person\\nwith antibodies to one or more of these antigens.\\nUnlike the ABO system, antibodies to Rh anti-\\ngens don’t develop naturally. They develop only as an\\nimmune response after a transfusion or during\\npregnancy.\\nThe incidence of the Rh blood types varies\\nbetween racial groups, but not as widely as the ABO\\nblood types: 85% of whites and 90% of blacks are\\nRh-positive; 15% of whites and 10% of blacks are\\nRh-negative.\\nIn transfusions, the Rh system is next in impor-\\ntance after the ABO system. Most Rh-negative people\\nwho receive Rh-positive blood will develop anti-D\\nantibodies. A later transfusion of Rh-positive blood\\ncould result in a severe or fatal transfusion reaction.\\nRh incompatibility is the most common and\\nsevere cause of HDN. This incompatibility can\\nhappen when an Rh-negative woman and an Rh-\\npositive man produce an Rh-positive baby. Cells\\nfrom the baby can cross the placenta and enter the\\nmother’s bloodstream, causing the mother to make\\nanti-D antibodies. Unlike ABO antibodies, the struc-\\nture of anti-D antibodies makes it likely that they will\\ncross the placenta and enter the baby’s bloodstream.\\nThere, they can destroy the baby’s red blood cells,\\ncausing severe or fatal anemia.\\nThe first step in preventing HDN is to find out\\nthe Rh types of the expectant parents. If the mother is\\nRh-negative and the father is Rh-positive, the baby is\\nat risk for developing HDN. The next step is to test the\\nmother’s serum to make sure she doesn’t already have\\nanti-D antibodies from a previous pregnancy or trans-\\nfusion. This procedure is similar to blood typing.\\nFinally, the Rh-negative mother is given an injection\\nof Rh Immunoglobulin (RhIg) at 28 weeks of gesta-\\ntion and again after delivery, if the baby is Rh positive.\\nRecipient's blood\\nABO\\nantigens\\nABO\\nantibodies\\nDonor type\\nO cells\\nDonor type\\nA cells\\nDonor type\\nB cells\\nDonor type\\nAB cells\\nABO blood\\ntype\\nO\\nA\\nB\\nAB\\nNone Anti-A\\nAnti-B\\nA Anti-B\\nB Anti-A\\nA & B None\\nCompatible Not compatible\\nReactions with donor's red blood cells\\nBlood typing is a laboratory test done to discover a person’s blood type. If the person needs a blood transfusion, cross-\\nmatching is done following blood typing to locate donor blood that the person’s body will accept. (Illustration by Electronic\\nIllustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 593\\nBlood typing and crossmatching\"),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 623, 'page_label': '594'}, page_content='The RhIg attaches to any Rh-positive cells from the\\nbaby in the mother’s bloodstream, preventing them\\nfrom triggering anti-D antibody production in the\\nmother. An Rh-negative woman should also receive\\nRhIg following a miscarriage, abortion, or ectopic\\npregnancy.\\nOTHER BLOOD GROUP SYSTEMS. Several other\\nblood group systems may be involved in HDN and\\ntransfusion reactions, although they are much less\\nfrequent than ABO and Rh. They are the Duffy,\\nKell, Kidd, MNS, and P systems. Tests for antigens\\nfrom these systems are not included in routine blood\\ntyping, but they are commonly used in paternity\\ntesting.\\nLike Rh antibodies, antibodies in these systems\\ndo not develop naturally, but as an immune response\\nafter transfusion or during pregnancy. An antibody\\nscreening test is done before a crossmatch to check\\nfor unexpected antibodies to antigens in these sys-\\ntems. A person’s serum is mixed in a test tube with\\ncommercially-prepared cells containing antigens\\nfrom these systems. If clumping occurs, the antibody\\nis identified.\\nCrossmatching\\nCrossmatching is the final step in pretransfusion\\ntesting. It is commonly referred to as compatibility\\ntesting, or ‘‘Type and Cross.’’\\nBefore blood from a donor and the recipient are\\ncrossmatched, both are ABO and Rh typed. In addi-\\ntion, antibody screening is done to look for antibo-\\ndies to certain Rh, Duffy, MNS, Kell, Kidd, and\\nP system antigens. If an antibody to one of these\\nantigens is found, only blood without that antigen\\nwill be compatible in a crossmatch. This sequence\\nmust be repeated before each transfusion a person\\nreceives.\\nTo begin the crossmatch, blood from a donor with\\nthe same ABO and Rh type as the rcipient is selected.\\nIn a test tube, serum from the patient is mixed with red\\nblood cells from the donor. If clumping occurs, the\\nblood is not compatible; if clumping does not occur,\\nthe blood is compatible. If an unexpected antibody is\\nfound in either the patient or the donor, the blood\\nbank does further testing to make sure the blood is\\ncompatible.\\nIn an emergency, when there is not enough time\\nfor blood typing and crossmatching, O red blood cells\\nmay be given, preferably Rh-negative. O blood type is\\ncalled the universal donor because it has no ABO\\nantigens for a patient’s antibodies to attack. In con-\\ntrast, AB blood type is called the universal recipient\\nbecause it has no ABO antibodies to attack the anti-\\ngens on transfused red blood cells. If there is time\\nfor blood typing, red blood cells of the recipient type\\n(type specific cells) are given. In either case, the cross-\\nmatch is continued, even though the transfusion has\\nbegun.\\nPreparation\\nTo collect the 10 mL blood needed for these tests,\\na healthcare worker ties a tourniquet above the\\npatient’s elbow, locates a vein in the inner elbow\\nregion, and inserts a needle into that vein. Vacuum\\nKEY TERMS\\nABO blood type— Blood type based on the pre-\\nsence or absence of the A and B antigens on the\\nred blood cells.\\nAntibody— A special protein made by the body as a\\ndefense against foreign material that enters the\\nbody. It is uniquely designed to attack and neutra-\\nlize the specific antigen that triggered the immune\\nresponse.\\nAntigen— Anything that causes the body to launch\\nan immune response against that antigen through\\nthe production of antibodies.\\nBlood bank— A laboratory that specializes in blood\\ntyping, antibody identification, and transfusion\\nservices.\\nBlood type— Blood categories based on the pre-\\nsence or absence of certain antigens on the red\\nblood cells.\\nCrossmatch— A laboratory test done to confirm\\nthat blood from a donor and blood from the recipi-\\nent are compatible.\\nGene— A piece of DNA, located on a chromo-\\nsome, that determines how traits such as blood\\ntype are inherited and expressed.\\nImmune response— The body’s attack against an\\nantigen that it considers foreign to itself. The attack\\nbegins with the production of antibodies against\\nthe antigen.\\nRh blood type— Blood type based on the presence\\nor absence of the D antigen on the red blood cells.\\nTransfusion— The therapeutic introduction of\\nblood or a blood component into a patient’s\\nbloodstream.\\n594 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood typing and crossmatching'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 624, 'page_label': '595'}, page_content='action draws the blood through the needle into an\\nattached tube. Collection of the sample takes only a\\nfew minutes.\\nBlood typing and crossmatching must be done\\nthree days or less before a transfusion. A person\\ndoesn’t need to change diet, medications, or activities\\nbefore these tests. He should tell his healthcare provi-\\nder if, during the last three months, he has received a\\nblood transfusion or a plasma substitute, or has had a\\nradiology procedure using intravenous contrast\\nmedia. These can give false clumping reactions in\\nboth typing and crossmatching tests.\\nAftercare\\nThe possible side effects of any blood collection\\nare discomfort or bruising at the site where the\\nneedle punctured the skin, as well asdizziness or faint-\\ning. Bruising is reduced if pressure is applied with a\\nfinger to the puncture site until the bleeding stops.\\nDiscomfort is treated with warm packs to the\\npuncture site.\\nRisks\\nThere are no risks from the blood collection or\\ntest procedures. Blood transfusions always have the\\nrisk of an unexpected transfusion reaction. A nurse\\nwatches a patient for signs of a reaction during the\\nentire transfusion.\\nNormal results\\nThere is no normal blood type. The desired result\\nof a crossmatch is that compatible donor blood is\\nfound. Compatibility testing procedures are designed\\nto provide the safest blood product possible for the\\nrecipient, but a compatible crossmatch is no guarantee\\nthat an unexpected adverse reaction will not appear\\nduring the transfusion.\\nAbnormal results\\nExcept in an emergency, a person cannot receive a\\ntransfusion without a compatible crossmatch result.\\nResources\\nORGANIZATIONS\\nAmerican Association of Blood Banks. 8101 Glenbrook\\nRoad, Bethesda, MD 20814. (301) 907-6977. .\\nNancy J. Nordenson\\nBlood urea nitrogen test\\nDefinition\\nThe blood urea nitrogen (BUN) test measures the\\nlevel of urea nitrogen in a sample of the patient’s\\nblood. Urea is a substance that is formed in the liver\\nwhen the body breaks down protein. Urea then circu-\\nlates in the blood in the form of urea nitrogen. In\\nhealthy people, most urea nitrogen is filtered out by\\nthe kidneys and leaves the body in the urine. If the\\npatient’s kidneys are not functioning properly or if the\\nbody is using large amounts of protein, the BUN level\\nwill rise. If the patient has severeliver disease, the BUN\\nwill drop.\\nPurpose\\nThe BUN level may be checked in order to assess\\nor monitor:\\n/C15the presence or progression of kidney or liver disease.\\n/C15blockage of urine flow.\\n/C15mental confusion. Patients with kidney failure are\\nsometimes disoriented and confused.\\n/C15abnormal loss of water from the body (dehydration).\\n/C15recovery from severe burns. The body uses larger\\nthan normal amounts of protein following serious\\nburns.\\nDescription\\nThe BUN test is performed on a sample of the\\npatient’s blood, withdrawn from a vein into a vacuum\\ntube. The procedure, which is called a venipuncture,\\ntakes about five minutes.\\nPreparation\\nThe doctor should check to make sure that the\\npatient is not taking any medications that can affect\\nBUN results. These drugs include theantibiotics chlor-\\namphenicol, streptomycin, amphotericin B, methicil-\\nlin, gentamicin, tobramycin, and kanamycin, as well\\nas diuretics and corticosteroids.\\nThe patient should be advised not to eat large\\namounts of meat the day before the test.\\nAftercare\\nAftercare consists of routine care of the area\\naround the venipuncture.\\nGALE ENCYCLOPEDIA OF MEDICINE 595\\nBlood urea nitrogen test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 625, 'page_label': '596'}, page_content='Risks\\nThe primary risk is the possibility of a bruise or\\nswelling in the area of the venipuncture. The patient\\ncan apply moist warm compresses.\\nNormal results\\nNormal BUN levels are 5-18 mg/dL for children;\\n7-18 mg/dL for adults; and 8-20 mg/dL in the elderly.\\nAbnormal results\\nBUN levels can be too low as well as too high.\\nAbnormally low BUN\\nLow levels of BUN may indicateoverhydration,\\nmalnutrition, celiac disease[a disease characterized by\\nthe inability ot tolerate foods containing wheat pro-\\ntein (gluten)], liver damage or disease, or use of corti-\\ncosteroids. Low BUN may also occur in early\\npregnancy.\\nAbnormally high BUN\\nHigh levels of BUN may indicatekidney diseaseor\\nfailure; blockage of the urinary tract by a kidney stone\\nor tumor; aheart attack or congestive heart failure;\\ndehydration; fever; shock; or bleeding in the digestive\\ntract. High BUN levels can sometimes occur during\\nlate pregnancy or result from eating large amounts of\\nprotein-rich foods. A BUN level higher than 100 mg/\\ndL points to severe kidney damage.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nRebecca J. Frey, PhD\\nBlood vessel scan see Doppler\\nultrasonography\\nBody dysmorphic disorder\\nDefinition\\nBody dysmorphic disorder (BDD) is defined by\\nDSM-IV-TR as a condition marked by excessive pre-\\noccupation with an imaginary or minor defect in a\\nfacial feature or localized part of the body. The diag-\\nnostic criteria specify that the condition must be suffi-\\nciently severe to cause a decline in the patient’s social,\\noccupational, or educational functioning. The most\\ncommon cause of this decline is the time lost\\nin obsessing about the ‘‘defect’’—one study found\\nthat 68 percent of patients in a sample of adolescents\\ndiagnosed with BDD spent three or more hours every\\nday thinking about the body part or facial feature of\\nconcern. DSM-IV assigns BDD to the larger category\\nof somatoform disorders, which are disorders charac-\\nterized by physical complaints that appear to be\\nmedical in origin but that cannot be explained in\\nterms of a physical disease, the results ofsubstance\\nabuse, or by another mental disorder.\\nThe earliest known case of BDD in the medical\\nliterature was reported by an Italian physician named\\nEnrique Morselli in 1886, but the disorder was not\\ndefined as a formal diagnostic category until DSM-\\nIII-R in 1987. The World Health Organization\\n(WHO) did not add BDD to the International\\nClassification of Diseases (ICD) until 1992. The\\nword dysmorphic comes from two Greek words that\\nmean ‘‘bad’’ or ‘‘ugly’’ and ‘‘shape’’ or ‘‘form.’’ BDD\\nwas previously known as dysmorphophobia.\\nDescription\\nBDD is characterized by an unusual degree of\\nworry or concern about a specific part of the face or\\nbody, rather than the general size or shape of the body.\\nIt is distinguished fromanorexia nervosaand bulimia\\nnervosa in that patients with eating disorders are\\npreoccupied with their overall weight and body\\nshape. As many as 50 percent of patients diagnosed\\nwith BDD undergo plastic surgery to correct their\\nperceived physical defects.\\nSince the publication of DSM-IV in 1994, some\\npsychiatrists have suggested that there is a subtype of\\nBDD, namely muscle dysmorphia. Muscle dysmor-\\nphia is marked by excessive concern with one’s mus-\\ncularity and/or fitness. Persons with muscle\\ndysmorphia spend unusual amounts of time working\\nout in gyms or exercising rather than dieting obses-\\nsively or seeking plastic surgery. DSM-IV-TR added\\nreferences to concern about body build and excessive\\nKEY TERMS\\nUrea— A compound containing nitrogen that\\noccurs in the urine and other body fluids as a result\\nof protein metabolism.\\n596 GALE ENCYCLOPEDIA OF MEDICINE\\nBody dysmorphic disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 626, 'page_label': '597'}, page_content='weight lifting to DSM-IV’s description of BDD in\\norder to cover muscle dysmorphia.\\nBDD and muscle dysmorphia can both be\\ndescribed as disorders resulting from the patient’s\\ndistorted body image. Body image refers to a per-\\nson’s mental picture of his or her outward appear-\\nance, including size, shape, and form. It has two\\nmajor components: how the person perceives their\\nphysical appearance, and how they feel about their\\nbody. Significant distortions in self-perception can\\nlead to intense dissatisfaction with one’s body and\\ndysfunctional behaviors aimed at improving one’s\\nappearance. Some patients with BDD are aware\\nthat their concerns are excessive, but others do\\nnot have this degree of insight; about 50 percent\\nof patients diagnosed with BDD also meet the\\ncriteria for a delusional disorder.\\nThe usual age of onset of BDD is late childhood or\\nearly adolescence; the average age of patients diag-\\nnosed with the disorder is 17. BDD has a high rate of\\ncomorbidity, which means that people diagnosed with\\nthe disorder are highly likely to have been diagnosed\\nwith another psychiatric disorder—most commonly\\nmajor depression, social phobia, orobsessive-compul-\\nsive disorder (OCD). About 29% of patients with\\nBDD eventually try to commitsuicide.\\nBDD is thought to affect 1–2 percent of the gen-\\neral population in the United States and Canada,\\nalthough some doctors think that it is underdiagnosed\\nbecause it coexists so often with depression and other\\ndisorders. In addition, patients are often ashamed of\\ngrooming rituals and other behaviors associated with\\nBDD, and may avoid telling their doctor about them.\\nBDD is thought to affect men and women equally;\\nhowever, there are no reliable data as of the early\\n2000s regarding racial or ethnic differences in the inci-\\ndence of the disorder.\\nCauses and symptoms\\nCauses\\nThe causes of BDD fall into two major categories,\\nneurobiological and psychosocial.\\nNEUROBIOLOGICAL CAUSES. Research indicates\\nthat patients diagnosed with BDD have serotonin\\nlevels that are lower than normal. Serotonin is a neu-\\nrotransmitter— a chemical produced by the brain that\\nhelps to transmit nerve impulses across the junctions\\nbetween nerve cells. Low serotonin levels are asso-\\nciated with depression and othermood disorders.\\nPSYCHOSOCIAL CAUSES. Another important fac-\\ntor in the development of BDD is the influence of the\\nmass media in developed countries, particularly the\\nrole of advertising in spreading images of physically\\n‘‘perfect’’ men and women. Impressionable children\\nand adolescents absorb the message that anything\\nshort of physical perfection is unacceptable. They\\nmay then develop distorted perceptions of their own\\nfaces and bodies.\\nA young person’s family of origin also has a power-\\nful influence on his or her vulnerability to BDD.\\nChildren whose parents are themselves obsessed with\\nappearance, dieting, and/or body building, or who are\\nKEY TERMS\\nBody image— A term that refers to a person s inner\\npicture of his or her outward appearance. It has\\ntwo components: perceptions of the appearance\\nof one’s body, and emotional responses to those\\nperceptions.\\nDelusion— A false belief that is resistant to reason\\nor contrary to actual fact. Common delusions\\ninclude delusions of persecution, delusions about\\none s importance (sometimes called delusions of\\ngrandeur), or delusions of being controlled by\\nothers. In BDD, the delusion is related to the\\npatient’s perception of his or her body.\\nDisplacement— A psychological process in which\\nfeelings originating from one source are expressed\\noutwardly in terms of concern or preoccupation\\nwith an issue or problem that the patient considers\\nmore acceptable. In some BDD patients, obsession\\nabout the body includes displaced feelings, often\\nrelated to a history of childhood abuse.\\nMuscle dysmorphia— A subtype of BDD, described\\nas excessive preoccupation with muscularity and\\nbody building to the point of interference with\\nsocial, educational, or occupational functioning.\\nSerotonin— A chemical produced by the brain that\\nfunctions as a neurotransmitter. Low serotonin\\nlevels are associated with mood disorders, particu-\\nlarly depression. Medications known as selective\\nserotonin reuptake inhibitors (SSRIs) are used to\\ntreat BDD and other disorders characterized by\\ndepressed mood.\\nSomatoform disorders— A group of psychiatric dis-\\norders in the DSM-IV-TR classification that are\\ncharacterized by external physical symptoms or\\ncomplaints. BDD is classified as a somatoform\\ndisorder.\\nGALE ENCYCLOPEDIA OF MEDICINE 597\\nBody dysmorphic disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 627, 'page_label': '598'}, page_content='highly critical of their children’s looks, are at greater\\nrisk of developing BDD.\\nAn additional factor in some young people is a\\nhistory of childhood trauma orabuse. Buried feelings\\nabout the abuse or traumatic incident may emerge\\nin the form of obsession about a part of the face or\\nbody. This ‘‘reassignment’’ of emotions from the unac-\\nknowledged true cause to another issue is called dis-\\nplacement. For example, an adolescent who frequently\\nfelt overwhelmed in childhood by physically abusive\\nparents may develop a preoccupation at the high\\nschool level with muscular strength and power.\\nSymptoms\\nThe central symptom of BDD is excessive concern\\nwith a specific facial feature or body part. Research\\nindicates that the features most likely to be the focus of\\nthe patient’s attention are (in order of frequency) com-\\nplexion flaws (acne, blemishes, scars, wrinkles); hair\\n(on the head or the body, too much or too little); and\\nfacial features (size, shape, or lack of symmetry). The\\npatient’s concerns may, however, involve other body\\nparts, and may shift over time from one feature to\\nanother.\\nOther symptoms of body dysmorphic disorder\\ninclude:\\n/C15Ritualistic behavior. Ritualistic behavior refers to\\nactions that the patient performs to manageanxiety\\nand that take up excessive amounts of his or her time.\\nPatients are typically upset if someone or something\\ninterferes with or interrupts their ritual. Ritualistic\\nbehaviors in BDD may includeexercise or makeup\\nroutines, assuming specific poses or postures in front\\nof a mirror, etc.\\n/C15Camouflaging the ‘‘problem’’ feature or body part\\nwith makeup, hats, or clothing. Camouflaging\\nappears to be the single most common symptom\\namong patients with BDD; it is reported by 94%.\\n/C15Abnormal behavior around mirrors, car bumpers,\\nlarge windows, or similar reflecting surfaces. A\\nmajority of patients diagnosed with BDD frequently\\ncheck their appearance in mirrors or spend long\\nperiods of time doing so. A minority, however,\\nreact in the opposite fashion and avoid mirrors\\nwhenever possible.\\n/C15Frequent requests for reassurance from others about\\ntheir appearance.\\n/C15Frequently comparing one’s appearance to others.\\n/C15Avoiding activities outside the home, including\\nschool and social events.\\nDiagnosis\\nThe diagnosis of BDD in children or adolescents\\nis often made by physicians in family practice because\\nthey are more likely to have developed long-term rela-\\ntionships of trust with young people. At the adult\\nlevel, it is often specialists in dermatology,cosmetic\\ndentistry, or plastic surgery who may suspect that the\\npatient suffers from BDD because of frequent requests\\nfor repeated or unnecessary procedures. Reported\\nrates of BDD among dermatology andcosmetic sur-\\ngery patients range between 6 and 15 percent. The\\ndiagnosis is made on the basis of the patient’s history\\ntogether with the physician’s observations of the\\npatient’s overall mood and conversation patterns.\\nPeople with BDD often come across to others as gen-\\nerally anxious and worried. In addition, the patient’s\\ndress or clothing styles may suggest a diagnosis of\\nBDD. It is not unusual, however, for patients with\\nBDD to take offense if their primary care doctor\\nsuggests referral to a psychiatrist.\\nSome physicians may use a self-report question-\\nnaire, such as the Multidimensional Body-Self\\nRelations Questionnaire (MBSRQ) or the short form\\nof the Situational Inventory of Body-Image Dysphoria\\n(SIBID), to evaluate patients during an office visit.\\nThere are no brain imaging studies or laboratory\\ntests as of the early 2000s that can be used to diagnose\\nBDD.\\nTreatment\\nThe standard course of treatment for body dys-\\nmorphic disorder is a combination of medications and\\npsychotherapy. Surgical, dental, or dermatologic\\ntreatments have been found to be ineffective.\\nThe medications most frequently prescribed for\\npatients with BDD are theselective serotonin reuptake\\ninhibitors, most commonly fluoxetine (Prozac) or ser-\\ntraline (Zoloft). Other SSRIs that have been used with\\nthis group of patients include fluvoxamine (Luvox)\\nand paroxetine (Paxil). In fact, it is the relatively high\\nrate of positive responses to SSRIs among BDD\\npatients that led to the hypothesis that the disorder\\nhas a neurobiological component related to serotonin\\nlevels in the body. An associated finding is that\\npatients with BDD require higher dosages ofSSRI\\nmedications than patients who are being treated for\\ndepression with these drugs.\\nThe most effective approach to psychotherapy\\nwith BDD patients is cognitive-behavioral restructur-\\ning. Since the disorder is related todelusionsabout one’s\\nappearance, cognitive-oriented therapy that challenges\\n598 GALE ENCYCLOPEDIA OF MEDICINE\\nBody dysmorphic disorder'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 628, 'page_label': '599'}, page_content='inaccurate self-perceptions is more effective than purely\\nsupportive approaches. Thought-stopping and relaxa-\\ntion techniques also work well with BDD patients\\nwhen they are combined with cognitive restructuring.\\nSome doctors recommend couples therapy or\\nfamily therapyin order to involve the patient s parents,\\nspouse, or partner in his or her treatment. This\\napproach may be particularly helpful if family mem-\\nbers are critical of the patient s looks or are reinforcing\\nhis or her unrealistic body image.\\nAlternative treatment\\nAlthough no alternative or complementary\\nform of treatment has been recommended specifi-\\ncally for BDD, such herbal remedies for depression\\nas St. John’s worthave been reported as helping some\\nBDD patients. Aromatherapy appears to be a useful\\naid to relaxation techniques as well as a pleasurable\\nphysical experience for BDD patients. Yoga has\\nhelped some persons with BDD acquire more realistic\\nperceptions of their bodies and to replace obsessions\\nabout external appearance with new respect for their\\nbody’s inner structure and functioning.\\nPrognosis\\nAs of early 2005, the prognosis of BDD is consid-\\nered good for patients receiving appropriate treat-\\nment. On the other hand, researchers do not know\\nenough about the lifetime course of body dysmorphic\\ndisorder to offer detailed statistics. DSM-IV-TR notes\\nthat the disorder ‘‘has a fairly continuous course, with\\nfew symptom-free intervals, although the intensity of\\nsymptoms may wax and wane over time.’’\\nPrevention\\nGiven the pervasive influence of the mass media in\\ncontemporary Western societies, the best preventive\\nstrategy involves challenging their unrealistic images\\nof attractive people. Parents, teachers, primary health\\ncare professionals, and other adults who work with\\nyoung people can point out and discuss the pitfalls of\\ntrying to look ‘‘perfect.’’ In addition, parents or other\\nadults can educate themselves about BDD and its\\nsymptoms, and pay attention to any warning signs in\\ntheir children’s dress or behavior.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders, 4th edition, text revision.\\nWashington,DC:AmericanPsychiatricAssociation,2000.\\n‘‘Body Dysmorphic Disorder,’’ Section 15, Chapter 186\\ninThe Merck Manual of Diagnosis and Therapy, edited\\nby Mark H. Beers, MD, and Robert Berkow, MD.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nJohnston, Joni E., Psy D.Appearance Obsession: Learning to\\nLove the Way You Look.Deerfield Beach, FL: Health\\nCommunications, Inc., 1994.\\nRodin, Judith, PhD.Body Traps: Breaking the Binds That\\nKeep You from Feeling Good About Your Body.New\\nYork: William Morrow, 1992.\\nPERIODICALS\\nArthur, Gary K., MD, and Kim Monnell, DO. ‘‘Body\\nDysmorphic Disorder.’’eMedicine, 3 September 2004.\\n.\\nCafri, G., J. K. Thompson, L. Ricciardelli, et al. ‘‘Pursuit of\\nthe Muscular Ideal: Physical and Psychological\\nConsequences and Putative Risk Factors.’’Clinical\\nPsychology Review25 (February 2005): 215–239.\\nKirchner, Jeffrey T. ‘‘Treatment of Patients with Body\\nDysmorphic Disorder.’’American Family Physician61\\n(March 2000): 1837–1843.\\nSlaughter, James R. ‘‘In Pursuit of Perfection: A Primary\\nCare Physician’s Guide to Body Dysmorphic\\nDisorder.’’ American Family Physician60 (October\\n1999): 569–580.\\nORGANIZATIONS\\nAmerican Academy of Child and Adolescent Psychiatry.\\n3615 Wisconsin Avenue, NW, Washington, DC 20016-\\n3007. (202) 966-7300. Fax: (202) 966-2891.\\n.\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nRebecca Frey, PhD\\nBody lice see Lice infestation\\nBoils\\nDefinition\\nBoils and carbuncles are bacterial infections of\\nhair follicles and surrounding skin that form pustules\\n(small blister-like swellings containing pus) around\\nthe follicle. Boils are sometimes called furuncles. A\\ncarbuncle is formed when several furuncles merge\\nto form a single deepabscess with several heads or\\ndrainage points.\\nGALE ENCYCLOPEDIA OF MEDICINE 599\\nBoils'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 629, 'page_label': '600'}, page_content='Description\\nBoils and carbuncles are firm reddish swellings\\nabout 0.2–0.4in (5-10 mm) across that are slightly raised\\nabove the skin surface. They are sore to the touch. A\\nboil usually has a visible central core of pus; a carbuncle\\nis larger and has several visible heads. Boils occur most\\ncommonly on the face, back of the neck, buttocks,\\nupper legs and groin area, armpits, and upper torso.\\nCarbuncles are less common than single boils; they are\\nmost likely to form at the back of the neck. Males are\\nmore likely to develop carbuncles.\\nBoils and carbuncles are common problems in the\\ngeneral population, particularly among adolescents\\nand adults. People who are more likely to develop\\nthese skin infections include those with:\\n/C15diabetes, especially when treated by injected insulin\\n/C15alcoholism or drugabuse\\n/C15poor personal hygiene\\n/C15crowded living arrangements\\n/C15jobs or hobbies that expose them to greasy or oily\\nsubstances, especially petroleum products\\n/C15allergies or immune system disorders, including HIV\\ninfection.\\n/C15family members with recurrent skin infections\\nCauses and symptoms\\nBoils and carbuncles are caused byStaphylococcus\\naureus, a bacterium that causes an infection in an oil\\ngland or hair follicle. Although the surface of human\\nskin is usually resistant to bacterial infection,S. aureus\\nc a ne n t e rt h r o u g hab r e a ki nthe skin surface–including\\nbreaks caused by needle punctures for insulin or drug\\ninjections. Hair follicles that are blocked by greasy\\ncreams, petroleum jelly, or similar products are\\nmore vulnerable to infection.Bacterial skin infections\\ncan be spread by shared cosmetics or washcloths, close\\nhuman contact, or by contact with pus from a boil or\\ncarbuncle.\\nAs the infection develops, an area of inflamed tis-\\nsue gradually forms a pus-filled swelling or pimple that\\nis painful to touch. As the boil matures, it forms a\\nyellowish head or point. It may either continue to\\nswell until the point bursts open and allows the pus to\\ndrain, or it may be gradually reabsorbed into the skin.\\nIt takes between one and two weeks for a boil to heal\\ncompletely after it comes to a head and discharges\\npus. The bacteria that cause the boil can spread into\\nother areas of the skin or even into the bloodstream\\nif the skin around the boil is injured by squeezing. If the\\ninfection spreads, the patient will usually develop chills\\nand fever, swollen lymph nodes (lymphadenitis), and red\\nlines in the skin running outward from the boil.\\nFurunculosis is a word that is sometimes used\\nto refer to recurrent boils. Many patients have\\nrepeated episodes of furunculosis that are difficult to\\ntreat because their nasal passages carry colonies of\\nS. aureus. These bacterial colonies make it easy for\\nthe patient’s skin to be reinfected. They are most likely\\nto develop in patients with diabetes, HIV infection, or\\nother immune system disorders.\\nCarbuncles are formed when the bacteria infect\\nseveral hair follicles that are close together.\\nCarbunculosis is a word that is sometimes used to\\nrefer to the development of carbuncles. The abscesses\\nspread until they merge with each other to form a\\nsingle large area of infected skin with several pus-filled\\nBoils often occur from a bacterial infection in a hair follicle or\\nskin gland. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nA close-up view of a carbuncle on person’s back.(Photograph\\nby John Watney, Photo Researchers, Inc. Reproduced by\\npermission.)\\n600 GALE ENCYCLOPEDIA OF MEDICINE\\nBoils'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 630, 'page_label': '601'}, page_content='heads. Patients with carbuncles may also have a low-\\ngrade fever or feel generally unwell.\\nDiagnosis\\nThe diagnosis of boils and carbuncles is usually\\nmade by the patient’s primary care doctor on the basis\\nof visual examination of the skin. In some cases invol-\\nving recurrent boils on the face, the doctor may need\\nto consider acne as a possible diagnosis, but for the\\nmost part boils and carbuncles are not difficult to\\ndistinguish from other skin disorders.\\nTreatment\\nPatient and family education\\nPatient education is an important part of the\\ntreatment of boils and carbuncles. Patients need to\\nbe warned against picking at or squeezing boils\\nbecause of the danger of spreading the infection into\\nother parts of the skin or bloodstream. It is especially\\nimportant to avoid squeezing boils around the mouth\\nor nose because infections in these areas can be carried\\nto the brain. Patients should also be advised about\\nkeeping the skin clean, washing their hands carefully\\nbefore and after touching the boil or carbuncle, avoid-\\ning the use of greasy cosmetics or creams, and keeping\\ntheir towels and washcloths separate from those of\\nother family members. Some doctors may recommend\\nan antiseptic soap or gel for washing the infected\\nareas.\\nIf the patient has had several episodes of furuncu-\\nlosis, the doctor may examine family members or close\\ncontacts to see if they are carriers ofS. aureus. In many\\ncases they also need treatment for boils or carbuncles.\\nSkin infections and reinfections involving small\\ngroups or clusters of people are being reported more\\nfrequently in the United States.\\nMedications\\nBoils are usually treated with application of antibio-\\ntic creams–usually clindamycin or polymyxin–following\\nthe application of hot compresses. The compresses help\\nthe infection to come to a head and drain.\\nCarbuncles and furunculosis are usually treated\\nwith oral antibiotics as well as antibiotic creams or\\nointments. The specific medications that are given\\nare usually dicloxacillin (Dynapen) or cephalexin\\n(Keflex). Erythromycin may be given to patients who\\nare allergic to penicillin. The usual course of oral anti-\\nbiotics is 5-10 days; however, patients with recurrent\\nfurunculosis may be given oral antibiotics for longer\\nperiods. Furunculosis is treated with a combination of\\ndicloxacillin and rifampin (Rifadin).\\nPatients with bacterial colonies in their nasal pas-\\nsages are often given mupirocin (Bactroban) to apply\\ndirectly to the lining of the nose.\\nSurgical treatment\\nBoils and carbuncles that are very large, or that\\nare not draining, may be opened with a sterile needle\\nor surgical knife to allow the pus to drain. The doctor\\nwill usually give the patient a local anesthetic if a knife\\nis used; surgical treatment of boils is painful and\\nusually leaves noticeablescars.\\nAlternative treatment\\nNaturopathic therapy\\nNaturopathic practitioners usually recommend\\nchanges in the patient’s diet as well as applying herbal\\npoultices to the infected area. The addition of zinc\\nsupplements and vitamin A to the diet is reported to\\nbe effective in treating boils. The application of a paste\\nor poultice containing goldenseal (Hydrastis canaden-\\nsis) root is recommended by naturopaths on the\\ngrounds that goldenseal helps to kill bacteria and\\nreduce inflammation.\\nHomeopathy\\nHomeopaths maintain that taking the proper\\nhomeopathic medication in the first stages of a boil\\nor carbuncle will bring about early resolution of the\\ninfection and prevent pus formation. The most likely\\nchoices areBelladonna or Hepar sulphuris. If the boil\\nKEY TERMS\\nAbscess— A localized collection of pus in the skin\\nor other body tissue.\\nCarbuncle— A large, deep skin abscess formed by a\\ngroup or cluster of boils.\\nFollicle— The small sac at the base of a hair shaft.\\nThe follicle lies below the skin surface.\\nFurunculosis— A condition in which the patient\\nsuffers from recurrent episodes of boils.\\nPustule— A small raised pimple or blister-like swel-\\nling of the skin that contains pus.\\nGALE ENCYCLOPEDIA OF MEDICINE 601\\nBoils'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 631, 'page_label': '602'}, page_content='has already formed,Mercurius vivusor Silica may be\\nrecommended to bring the pus to a head.\\nWestern herbal therapies\\nA variety of herbal remedies can be applied topically\\nto boils to fight infection. These include essential oils\\nof bergamot (Citrus bergamia), chamomile (Matricaria\\nrecutita), lavender (Lavandula officinalis), and sage\\n(Salvia officinalis), as well as tea tree oil (Melaleuca\\nspp.). Herbalists also recommend washing the skin\\nwith a mixture of goldenseal and witch hazel. To\\nfight the inflammation associated with boils, herbalists\\nsuggest marsh mallow (Althaea officinalis) ointment,\\ntinctures (herbal solutions made with alcohol) of blue\\nflag (Iris versicolor)o rm y r r h(Commiphora molmol), and\\nslippery elm (Ulmus fulva) made into a poultice.\\nPrognosis\\nThe prognosis for most boils is excellent. Some\\npatients, however, suffer from recurrent carbuncles or\\nfurunculosis. In addition, although the spread of infec-\\ntion from boils is relatively unusual, there have been\\ndeaths reported from brain infections caused by\\nsqueezing boils on the upper lip or in the tissue folds\\nat the base of the nose.\\nPrevention\\nThere are some precautions that people can take\\nto minimize the risk of developing bacterial skin\\ninfections:\\n/C15cleanse skin properly with soap and water, and take\\nshowers rather than tub baths\\n/C15do not share washcloths, towels, or facial cosmetics\\nwith others\\n/C15cut down on greasy or fatty foods and snacks\\n/C15always wash hands before touching the face\\n/C15consider using antiseptic soaps and shower gels\\n/C15consult a doctor if furunculosis is a persistent pro-\\nblem–it may indicate an underlying disease such as\\ndiabetes\\nResources\\nBOOKS\\nHacker, Steven M. ‘‘Common Bacterial and Fungal\\nInfections of the Integument.’’ InCurrent Diagnosis,\\nedited by Rex B. Conn, et al. Vol 9. Philadelphia: W. B.\\nSaunders Co., 1997.\\nRebecca J. Frey, PhD\\nBone biopsy\\nDefinition\\nBone biopsy is the removal of a piece of bone\\nfor laboratory examination and analysis.\\nPurpose\\nBone biopsy is used to distinguish between malig-\\nnant tumors and benign bone disease such asosteo-\\nporosis and osteomyelitis. This test may be ordered\\nto determine why a patient’s bones ache or feel sore,\\nor when a mass or deformity is found on an x ray,\\nCT scan, bone scan, or other diagnostic imaging\\nprocedure.\\nPrecautions\\nThe patient’s doctor and the surgeon who per-\\nforms the bone biopsy must be told about any pre-\\nscription and over-the-counter medications the\\npatient is taking, and aboutallergies or reactions the\\npatient has had to anesthetics orpain relievers. Special\\ncare must be taken with patients who have experienced\\nbleeding problems.\\nDescription\\nA bone biopsy involves using a special drill or\\nother surgical instruments to remove bone from the\\npatient’s body. The procedure usually lasts about 30\\nminutes and may be performed in the hospital, a doc-\\ntor’s office, or a surgical center.\\nA drill biopsy is generally used to obtain a small\\nspecimen. After the skin covering the bone has been\\ncleansed with an antiseptic and shaved, the patient\\nis given a local anesthetic. The doctor will not begin\\nthe procedure until the anesthetic has numbed the\\narea from which the bone is to be removed, but the\\npatient may feel pressure or mild pain when\\nthe needle pierces the bone. The surgeon turns the\\nneedle in a half-circle to extract a sample from the\\ncore, or innermost part, of the bone. The sample is\\ndrawn into the hollow stem of the biopsy needle. The\\nsample is then sent to a laboratory, where it is exam-\\nined under a microscope.\\nAn open biopsy is used when a larger specimen is\\nneeded. After the area covering the bone has been\\ncleansed with an antiseptic and shaved, the patient\\nis given a general anesthetic. After the anesthetic\\ntakes effect and the patient is unconscious, the\\n602 GALE ENCYCLOPEDIA OF MEDICINE\\nBone biopsy'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 632, 'page_label': '603'}, page_content='surgeon makes an incision and removes a bone speci-\\nmen. The specimen is sent to the laboratory for\\nimmediate analysis. Results of that analysis may\\nindicate that additional surgery should be performed\\nright away.\\nPreparation\\nNo special preparation is needed for a drill biopsy,\\nbut a patient must fast for at least 12 hours before an\\nopen biopsy.\\nAftercare\\nPain medication will be prescribed after a biopsy,\\nand vital signs will be monitored until they return to\\nnormal. Most patients can go home in about an hour.\\nIf bone was removed from the spine, the patient may\\nstay in the hospital overnight. The surgical site must be\\nkept clean and dry for 48 hours, and the patient’s\\ndoctor should be notified if any of these symptoms\\nappear:\\n/C15fever\\n/C15headache\\n/C15pain on movement\\n/C15inflammation or pus near the biopsy site\\n/C15bleeding through the bandage at the biopsy site\\nRisks\\nRisks include bone fracture, injury to nearby\\ntissue, and infection. Bleeding is a rare complication.\\nFactors that increase risk include:\\n/C15stress\\n/C15obesity\\n/C15poor nutrition\\n/C15chronic illness\\n/C15some medications\\n/C15mind-altering drugs\\nNormal results\\nNormal bone is made up of collagen fibers and\\nbone tissue.\\nAbnormal results\\nBone biopsy can reveal the presence of benign\\ndisease, infection, or malignant tumors that have\\nspread to the bone from other parts of the body.\\nResults of this test are considered reliable, but\\nmay be affected by:\\n/C15failure to fast before open biopsy\\n/C15failure to obtain an adequate specimen\\n/C15delayed microscopic examination or laboratory\\nanalysis\\nResources\\nORGANIZATIONS\\nCancer Group Institute. 1814 N.E. Miami Gardens\\nDrive, North Miami Beach, FL 33179. (305)\\n651-5070. .\\nNational Institute of Arthritis and Musculoskeletal and Skin\\nDiseases Information Clearinghouse. National\\nInstitutes of Health. 1 AMS Circle, Bethesda, MD\\n20892-3695. (301) 495-3675.\\nMaureen Haggerty\\nBone break fever see Dengue fever\\nBone cancer see Sarcomas\\nBone densitometry see Bone density test\\nBone density test\\nDefinition\\nA bone density test, or scan, is designed to check\\nfor osteoporosis, a disease that occurs when the bones\\nbecome thin and weak. Osteoporosis happens when\\nthe bones lose calcium and otherminerals that keep\\nthem strong. Osteoporosis begins aftermenopause in\\nmany women, and worsens after age 65, often result-\\ning in seriousfractures. These fractures may not only\\nKEY TERMS\\nBiopsy— Removal and examination of tissue to\\ndetermine if cancer is present.\\nOsteomyelitis— An infection of the bone that is\\nusually treated with antibiotics but sometimes\\nrequires surgery.\\nOsteoporosis— Thinning and loss of bone tissue.\\nGALE ENCYCLOPEDIA OF MEDICINE 603\\nBone density test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 633, 'page_label': '604'}, page_content='bring disability, but may affect longevity. As many as\\none-fourth of women who fracture their hip after age\\n50 die within one year.\\nMost people today will get a bone density scan\\nfrom a machine using a technology called Dual Energy\\nX-ray Absorptiometry or DEXA for short. This\\nmachine takes a picture of the bones in the spine,\\nhip, total body and wrist, and calculates their density.\\nIf a DEXA machine is not available, bone density\\nscans can also be done with dual photon absorptiome-\\ntry (measuring the spine, hip and total body) and\\nquantitative computed tomography scans (measuring\\nthe spine). Bone density scanners that use DEXA tech-\\nnology to just measure bone density in the wrist (called\\npDEXA scans) provide scans at some drugstores. Yet\\nthese tests are not as accurate as those that measure\\ndensity in the total body, spine or hip–where most\\nfractures occur.\\nPurpose\\nA bone density scan measures the strength of an\\nindividual’s bones and determines the risk of fracture.\\nAn observation of any osteoporosis present can be\\nmade.\\nDescription\\nTo take a DEXA bone density scan, the patient\\nlies on a bed underneath the scanner, a curving plastic\\narm that emits x rays. These low-dose x rays form a\\nfan beam that rotates around the patient. During the\\ntest, the scanner moves to capture images of the\\npatient’s spine, hip or entire body. A computer then\\ncompares the patient’s bone strength and risk of\\nfracture to that of other people in the United States\\nat the same age and to young people at peak bone\\ndensity. Bones reach peak density at age 30 and then\\nstart to lose mass. The test takes about 20 minutes to\\ndo and is painless. The DEXA bone scan costs about\\n$250. Some insurance companies and Medicare cover\\nthe cost. pDEXA wrist bone scans in drugstores are\\navailable for about $30.\\nPreparation\\nThe patient puts on a hospital gown and lies\\non the bed underneath the scanner. Not all doctors\\nroutinely schedule this test. If the following factors\\napply to a patient, they may need a bone density\\nscan and can discuss this with their doctor. The\\npatient:\\n/C15is at risk for osteoporosis\\n/C15is near menopause\\n/C15has broken a bone after a modest trauma\\n/C15has a family history of osteoporosis\\n/C15uses steroid or antiseizure medications\\n/C15has had a period of restricted mobility for more than\\nsix months\\nRisks\\nThe DEXA bone scan exposes the patient to only\\na small amount of radiation–about one-fiftieth that\\nof a chest x ray, or about the amount you get from\\ntaking a cross-country airplane flight.\\nComputer read-out of a bone density scan. (Photo\\nResearchers. Reproduced by permission.)\\nPatient undergoing a bone density scan. (Photo Researchers.\\nReproduced by permission.)\\n604 GALE ENCYCLOPEDIA OF MEDICINE\\nBone density test'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 634, 'page_label': '605'}, page_content='Normal results\\nThe patient, when compared with people at\\n‘‘young normal bone density’’ (called the T-score)\\nhas the same or denser bones than a healthy 30-year-\\nold. T scores above 1 mean that a patient has a healthy\\nbone mass. Scores from 0 to/C01 mean that the patient\\nhas borderline bone mass and should repeat the test in\\ntwo to five years.\\nAbnormal results\\nThe patient has two to four times the risk of a\\nbroken bone as other people in the United States at the\\nsame age and those at peak bone density. If a patient’s T\\nscore ranges from/C01t o/C02.5 they have low bone mass\\nand are at risk for osteoporosis. A T score below/C02.5\\nmeans osteoporosis is already evident. These patients\\nshould have a repeat bone density scan every year or two.\\nResources\\nORGANIZATIONS\\nNational Osteoporosis Foundation. 1150 17th St., NW,\\nSuite 500, Washington, DC 20036-4603. (800) 223-\\n9994. .\\nBarbara Boughton\\nBone disorder drugs\\nDefinition\\nBone disorder drugs are medicines used to treat\\ndiseases that weaken the bones.\\nPurpose\\nThe drugs described here are used to treat or pre-\\nvent osteoporosis (brittle bone disease) in women past\\nmenopause as well as older men. They also are used\\nprescribed for Paget’s disease, a painful condition that\\nweakens and deforms bones, and they are used to\\ncontrol calcium levels in the blood.\\nBone is living tissue. Like other tissue, bone is\\nconstantly being broken down and replaced with new\\nmaterial. Normally, there is a balance between the\\nbreakdown of old bone and its replacement with new\\nbone. But when something goes wrong with the\\nprocess, bone disorders may result.\\nOsteoporosis is a particular concern for women\\nafter menopause, as well as for older men. In osteo-\\nporosis, the inside of the bones become porous and\\nKEY TERMS\\nCalcium— A mineral that helps build bone. After\\nmenopause, when women start making less of the\\nbone-protecting hormone estrogen, they may need\\nto increase their intake of calcium.\\nDEXA bone density scan— A bone density scan\\nthat uses a rotating x-ray beam to measure the\\nstrength of an individual’s bones and his or her\\nfracture risk.\\nOsteoporosis— A disease that occurs when the\\nbones lose the calcium and structure that keep\\nthem strong. It often occurs after menopause\\n(around age 50) in women and in old age in men.\\nA bone densitometry scan of identical twins. Their bone\\ndensity is normal and identical to one another. (Photo\\nResearchers. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 605\\nBone disorder drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 635, 'page_label': '606'}, page_content='thin. Over time, this condition weakens the bones\\nand makes them more likely to break. Osteoporosis\\nis four times more common in women than in men.\\nThis is because women have less bone mass than men,\\ntend to live longer and take in less calcium, and need\\nthe female hormone estrogen to keep their bones\\nstrong. If men live long enough, they are also at risk\\nof getting osteoporosis later in life. Once total bone\\nmass has peaked–around age 35–all adults start to lose\\nit. In women, the rate of bone loss speeds up during\\nmenopause, when estrogen levels fall. Bone loss may\\nalso occur if both ovaries are removed by surgery.\\nOvaries make estrogen.Hormone replacement therapy\\nis one approach to preventing osteoporosis. However,\\nnot all people can use hormone replacement therapy.\\nBone disorder drugs are a good alternative for people\\nwho already have osteoporosis or who are at risk\\nof developing it. Risk factors include lack of regular\\nexercise, early menopause, being underweight, and a\\nstrong family history of osteoporosis.\\nDescription\\nBone disorder drugs are available only with a physi-\\ncian’s prescription and come in tablet, nasal spray, and\\ninjectable forms. Commonly used bone disorder drugs\\nare alendronate (Fosamax), calcitonin (Miacalcin,\\nCalcimar), and raloxifene (Evista). Raloxifene belongs\\nto a group of drugs known as selective estrogen recep-\\ntor modulators (SERMs), which act like estrogen in\\nsome parts of the body but not in others. This makes\\nthe drugs less likely to cause some of the harmful\\neffects that estrogen may cause. Unlike estrogen,\\nraloxifene does not increase the risk ofbreast cancer.\\nIn fact, research suggests that raloxifene may even\\nreduce that risk.\\nRecommended dosage\\nAlendronate\\nFOR OSTEOPOROSIS. The usual dose is 10 mg once\\na day. Treatment usually continues over many years.\\nFOR PAGET’S DISEASE. The usual dose is 40 mg\\nonce a day for six months.\\nThis medicine works only when it is taken with a\\nfull glass of water first thing in the morning, at least 30\\nminutes before eating or drinking anything or taking\\nany other medicine. Do not lie down for at least 30\\nminutes after taking it because the drug can irritate the\\nesophagus, the tube that delivers food form the mouth\\nto the stomach.\\nCalcitonin\\nNASAL SPRAY. The usual dose is one spray into the\\nnose once a day. Alternate nostrils, spraying the right\\nnostril one day, the left nostril the next day, and so on.\\nINJECTABLE. The recommended dosage depends\\non the condition for which the medicine is prescribed\\nand may be different for different people. Check with\\nthe physician who prescribed the medicine or the\\npharmacist who filled the prescription for the proper\\ndosage.\\nRaloxifene\\nThe usual dose is one 60-mg tablet daily.\\nPrecautions\\nAldendronate\\nPeople with low levels of calcium in their blood\\nshould not take this medicine. It also is not recom-\\nmended for women on hormone replacement therapy\\nor for anyone with kidney problems. Before using\\nalendronate, anyone who has digestive or swallowing\\nproblems should make sure that his or her physician\\nknows about the condition.\\nCalcitonin\\nCalcitonin nasal spray may cause irritation or\\nsmall sores in the nose. Check with a physician if this\\nKEY TERMS\\nEstrogen— The main sex hormone that controls\\nnormal sexual development in females. During\\nthe menstrual cycle, estrogen helps prepare the\\nbody for possible pregnancy.\\nFracture— A break or crack in a bone.\\nHormone— A substance that is produced in one\\npart of the body, then travels through the blood-\\nstream to another part of the body where it has its\\neffect.\\nMenopause— The stage in a woman’s life when the\\novaries stop producing egg cells at regular times\\nand menstruation stops.\\nOsteoporosis— A disease in which bones become\\nvery porous and weak. The bones are then more\\nlikely to fracture and take longer to heal. The con-\\ndition is most common in women after menopause\\nbut can also occur in older men.\\n606 GALE ENCYCLOPEDIA OF MEDICINE\\nBone disorder drugs'),\n", " Document(metadata={'producer': 'PDFlib+PDI 6.0.3 (SunOS)', 'creator': 'Adobe Acrobat 6.0', 'creationdate': '2006-10-16T20:19:33+02:00', 'moddate': '2016-02-07T11:23:03+07:00', 'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf', 'total_pages': 4505, 'page': 636, 'page_label': '607'}, page_content='becomes very uncomfortable or if there is bleeding\\nfrom the nose.\\nThe injectable form of calcitonin has caused ser-\\nious allergic reactions in a few people. The nasal spray\\nis not known to cause such reactions, but the possi-\\nbility exists. Before starting treatment with calcitonin,\\nthe physician who prescribes the drug may order an\\nallergy test to make sure there will not be a problem.\\nRaloxifene\\nA rare, but serious side effect of raloxifene is an\\nincreased risk ofblood clotsthat form in the veins and\\nmay break away and travel to the lungs. This is about\\nas likely in women who take raloxifene as it is in\\nwomen who take estrogen. Because of this possible\\nproblem, women with a history of blood clots in\\ntheir veins should not take raloxifene.\\nWomen who have had breastcancer or cancer of\\nthe uterus should check with their physicians about\\nwhether they can safely use raloxifene.\\nGeneral precautions for bone disorder drugs\\nTo keep bones strong, the body needs calcium and\\nvitamin D. Dairy products and fish such as salmon,\\nsardines and tuna are good sources of both calcium and\\nvitamin D. People who are taking bone disorder drugs\\nfor osteoporosis and who do not get enough of these\\nnutrients in theirdiets should check with their physi-\\ncians about taking supplements. Other important\\nbone-saving steps are avoidingsmoking and alcohol\\nand getting enough of the kind of exercise that puts\\nweight on the bones (such as walking or lifting weights).\\nPeople who are taking these drugs because they\\nhave too much calcium in their blood may need to\\nlimit the amount of calcium in their diets. Too much\\ncalcium may prevent the medicine from working prop-\\nerly. Discuss the proper diet with the physician who\\nprescribed the drug, and do not make any diet changes\\nwithout the physician’s approval.\\nAnyone who has had unusual reactions to bone\\ndisorder drugs in the past should let his or her physi-\\ncian know before taking the drugs again. The physi-\\ncian also should be told about anyallergies to foods,\\ndyes, preservatives, or other substances.\\nWomen who are pregnant or who may become\\npregnant and women who are breastfeeding should\\ncheck with their physicians before using this alendro-\\nnate or calcitonin. Raloxifene should not be used by\\nwomen who are pregnant or who may become preg-\\nnant. In laboratory studies of rats, raloxifene caused\\nbirth defects.\\nSide effects\\nAldendronate\\nCommon side effects includeconstipation, diar-\\nrhea, indigestion, nausea, pain in the abdomen, and\\npain in the muscles and bones. These problems usually\\ngo away as the body adjusts to the medicine and do not\\nneed medical attention unless they continue or they\\ninterfere with normal activities.\\nCalcitonin\\nThe most common side effects of calcitonin nasal\\nspray are nose problems, such as dryness, redness,\\nitching, sores, bleeding and general discomfort. These\\nproblems should go away as the body adjusts to the\\nmedicine, but if they do not or if they are very uncom-\\nfortable, check with a physician. Other side effects that\\nshould be brought to a physician’s attention include\\nheadache, back pain and joint pain.\\nInjectable calcitonin may cause minor side effects\\nsuch as nausea orvomiting; diarrhea; stomach pain;\\nloss of appetite; flushing of the face, ears, hands or\\nfeet; and discomfort or redness at the place on the\\nbody where it is injected. Medical attention is not\\nnecessary unless these problems persist or cause unusual\\ndiscomfort.\\nAnyone who has a skin rash orhives after taking\\ninjectable calcitonin should check with a physician as\\nsoon as possible.\\nRaloxifene\\nCommon side effects include hot flashes, leg\\ncramps, nausea and vomiting. Women who have these\\nproblems while taking raloxifene should check with\\ntheir physicians.\\nInteractions\\nAldendronate\\nTaking aspirin with alendronate may increase the\\nchance of upset stomach, especially if the dose of\\nalendronate is more than 10 mg per day. If an analge-\\nsic is necessary, switch to another drug, such asacet-\\naminophen (Tylenol) or use buffered aspirin. Ask a\\nphysician or pharmacist for the correct medication\\nto use.\\nSome calcium supplements, antacids and other\\nmedicines keep the body from absorbing alendronate.\\nTo prevent this problem, do not take any other med-\\nicine within 30 minutes of taking alendronate.\\nGALE ENCYCLOPEDIA OF MEDICINE 607\\nBone disorder drugs')]" ] }, "execution_count": 10, "metadata": {}, "output_type": "execute_result" } ], "source": [ "extracted_data" ] }, { "cell_type": "code", "execution_count": null, "id": "62e24133", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "637" ] }, "execution_count": 11, "metadata": {}, "output_type": "execute_result" } ], "source": [ "len(extracted_data)" ] }, { "cell_type": "code", "execution_count": 21, "id": "468d4ec7", "metadata": {}, "outputs": [], "source": [ "from typing import List\n", "from langchain.schema import Document\n", "\n", "def filter_to_minimal_docs(docs: List[Document]) -> List[Document]:\n", " minimal_docs : List[Document]= []\n", " for doc in docs:\n", " source = doc.metadata.get(\"source\")\n", " minimal_docs.append(\n", " Document(\n", " page_content=doc.page_content,\n", " metadata={\n", " \"source\": source}))\n", " return minimal_docs" ] }, { "cell_type": "code", "execution_count": 18, "id": "30b56884", "metadata": {}, "outputs": [ { "ename": "NameError", "evalue": "name 'extracted_data' is not defined", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mNameError\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[18], line 1\u001b[0m\n\u001b[1;32m----> 1\u001b[0m minimal_docs \u001b[38;5;241m=\u001b[39m filter_to_minimal_docs(\u001b[43mextracted_data\u001b[49m)\n", "\u001b[1;31mNameError\u001b[0m: name 'extracted_data' is not defined" ] } ], "source": [ "minimal_docs = filter_to_minimal_docs(extracted_data)" ] }, { "cell_type": "code", "execution_count": null, "id": "a1d90c45", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content=''),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n1\\nA-B\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n2\\nC-F\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n3\\nG-M\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n4\\nN-S\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The GALE\\nENCYCLOPEDIA of\\nMEDICINE\\nTHIRD EDITION\\nVOLUME\\n\\x81\\n5\\nT-Z\\nORGANIZATIONS\\nGENERAL INDEX\\nJACQUELINE L. LONGE, PROJECT EDITOR'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='THE GALE ENCYCLOPEDIA OF MEDICINE, THIRD EDITION\\nª 2006 Thomson Gale, a part of The Thomson\\nCorporation.\\nThomson and Star Logo are trademarks and\\nGale is a registered trademark used herein\\nunder license.\\nFor more information, contact\\nThe Gale Group, Inc.\\n27500 Drake Rd.\\nFarmington Hills, MI 48331-3535\\nOr you can visit our Internet site at\\nhttp://www.gale.com\\nALL RIGHTS RESERVED\\nNo part of this work covered by the copyright\\nhereon may be reproduced or used in any\\nform or by any means—graphic, electronic, or\\nmechanical, including photocopying, record-\\ning, taping, Web distribution, or information\\nstorage retrieval systems—without the written\\npermission of the publisher.\\nThis publication is a creative work fully pro-\\ntected by all applicable copyright laws, as well\\nas by misappropriation, trade secret, unfair\\ncondition, and other applicable laws. The\\nauthors and editors of this work have added\\nvalue to the underlying factual material herein\\nthrough one or more of the following: coordi-\\nnation, expression, arrangement, and classifi-\\ncation of the information.\\nFor permission to use material from this pro-\\nduct, submit your request via the web at http://\\nwww.gale-edit.com/permission or you may\\ndownload our Permissions Request form and\\nsubmit your request by fax of mail to:\\nPermissions\\nThomson Gale\\n27500 Drake Rd.\\nFarmington Hills, MI 48331-3535\\nPermissions Hotline:\\n248-699-8006 or 800-877-4253, ext. 8006\\nFax: 248-699-8074 or 800-762-4058\\nSince this page cannot legibly accommodate all\\ncopyright notices, the acknowledgments con-\\nstitute an extension of the copyright notice.\\nWhile every effort has been made to ensure\\nthe reliability of the information presented in\\nthis publication, Thomson Gale does not\\nguarantee the accuracy of the data contained\\nherein. Thomson Gale accepts no payment for\\nlisting; and inclusion in the publication of any\\norganization, agency, institution, publication,\\nservice, or individual does not imply endorse-\\nment of the editors or publisher. Errors brought\\nto the attention of the publisher and verified to\\nthe satisfaction of the publisher will be cor-\\nrected in future editions.\\nLIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA\\nThe Gale encyclopedia of medicine / Jacqueline L. Longe, editor.– 3rd ed.\\np. ; cm.\\nIncludes bibliographical references and index.\\nISBN 1-4144-0368-2 (set hardcover : alk. paper) – ISBN 1-4144-0369-0 (v. 1 : hardcover\\n: alk. paper) – ISBN 1-4144-0370-4 (v. 2 : hardcover : alk. paper) – ISBN 1-4144-0371-2\\nv. 3 : hardcover : alk. paper) – ISBN 1-4144-0372-0 (v. 4 : hardcover : alk. paper) –\\nISBN 1-4144-0373-9 (v. 5 : hardcover : alk. paper)\\n1. Internal medicine–Encyclopedias.\\n[DNLM: 1. Internal Medicine–Encyclopedias–English. 2. Complementary Therapies–\\nEncyclopedias–English. WB 13 G151 2005] I. Title: Encyclopedia of medicine. II. Longe,\\nJacqueline L. III. Gale Group.\\nRC41.G35 2006\\n616’.003–dc22\\n2005011418\\nThis title is also available as an e-book\\nISBN 1-4144-0485-9 (set)\\nContact your Gale sales representative for ordering information.\\nISBN 1-4144-0368-2 (set)\\n1-4144-0369-0 (Vol. 1)\\n1-4144-0370-4 (Vol. 2)\\n1-4144-0371-2 (Vol. 3)\\n1-4144-0372-0 (Vol. 4)\\n1-4144-0373-9 (Vol. 5)\\nPrinted in China\\n1 0987654321\\nProject Editor\\nJacqueline L. Longe\\nEditorial\\nShirelle Phelps, Laurie Fundukian, Jeffrey\\nLehman, Brigham Narins\\nEditorial Support Services\\nLuann Brennan, Grant Eldridge, Andrea Lopeman\\nRights Acquisition Management\\nShalice Caldwell-Shah\\nImaging\\nRandy Bassett, Lezlie Light, Dan Newell,\\nChristine O’Bryan, Robyn V. Young\\nProduct Design\\nTracey Rowens\\nComposition and Electronic Prepress\\nEvi Seoud, Mary Beth Trimper\\nManufacturing\\nWendy Blurton, Dorothy Maki\\nIndexing\\nFactiva'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='CONTENTS\\nList of Entries............................................ vii\\nIntroduction.............................................. xxi\\nAdvisory Board....................................... xxiii\\nContributors ............................................ xxv\\nEntries\\nVolume 1: A-B............................................ 1\\nVolume 2: C-F......................................... 693\\nVolume 3: G-M...................................... 1533\\nVolume 4: N-S....................................... 2569\\nVolume 5: T-Z....................................... 3621\\nOrganizations......................................... 4037\\nGeneral Index........................................ 4061\\nGALE ENCYCLOPEDIA OF MEDICINE V'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='LIST OF ENTRIES\\nA\\nAbdominal ultrasound\\nAbdominal wall defects\\nAbortion, partial birth\\nAbortion, selective\\nAbortion, therapeutic\\nAbscess incision & drainage\\nAbscess\\nAbuse\\nAcetaminophen\\nAchalasia\\nAchondroplasia\\nAcid phosphatase test\\nAcne\\nAcoustic neuroma\\nAcrocyanosis\\nAcromegaly and gigantism\\nActinomycosis\\nAcupressure\\nAcupuncture\\nAcute kidney failure\\nAcute lymphangitis\\nAcute poststreptococcal\\nglomerulonephritis\\nAcute stress disorder\\nAddiction\\nAddison’s disease\\nAdenoid hyperplasia\\nAdenovirus infections\\nAdhesions\\nAdjustment disorders\\nAdrenal gland cancer\\nAdrenal gland scan\\nAdrenal virilism\\nAdrenalectomy\\nAdrenocorticotropic hormone test\\nAdrenoleukodystrophy\\nAdult respiratory distress syndrome\\nAging\\nAgoraphobia\\nAIDS tests\\nAIDS\\nAlanine aminotransferase test\\nAlbinism\\nAlcoholism\\nAlcohol-related neurologic disease\\nAldolase test\\nAldosterone assay\\nAlemtuzumab\\nAlexander technique\\nAlkaline phosphatase test\\nAllergic bronchopulmonary\\naspergillosis\\nAllergic purpura\\nAllergic rhinitis\\nAllergies\\nAllergy tests\\nAlopecia\\nAlpha\\n1-adrenergic blockers\\nAlpha-fetoprotein test\\nAlport syndrome\\nAltitude sickness\\nAlzheimer’s disease\\nAmblyopia\\nAmebiasis\\nAmenorrhea\\nAmino acid disorders screening\\nAminoglycosides\\nAmnesia\\nAmniocentesis\\nAmputation\\nAmylase tests\\nAmyloidosis\\nAmyotrophic lateral sclerosis\\nAnabolic steroid use\\nAnaerobic infections\\nAnal atresia\\nAnal cancer\\nAnal warts\\nAnalgesics, opioid\\nAnalgesics\\nAnaphylaxis\\nAnemias\\nAnesthesia, general\\nAnesthesia, local\\nAneurysmectomy\\nAngina\\nAngiography\\nAngioplasty\\nAngiotensin-converting enzyme\\ninhibitors\\nAngiotensin-converting enzyme\\ntest\\nAnimal bite infections\\nAnkylosing spondylitis\\nAnorectal disorders\\nAnorexia nervosa\\nAnoscopy\\nAnosmia\\nAnoxia\\nAntacids\\nAntenatal testing\\nAntepartum testing\\nAnthrax\\nAntiacne drugs\\nAntiandrogen drugs\\nAntianemia drugs\\nAntiangina drugs\\nAntiangiogenic therapy\\nAntianxiety drugs\\nAntiarrhythmic drugs\\nAntiasthmatic drugs\\nAntibiotic-associated colitis\\nAntibiotics, ophthalmic\\nAntibiotics, topical\\nAntibiotics\\nAnticancer drugs\\nAnticoagulant and antiplatelet\\ndrugs\\nAnticonvulsant drugs\\nAntidepressant drugs, SSRI\\nGALE ENCYCLOPEDIA OF MEDICINE vii'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Antidepressant drugs\\nAntidepressants, tricyclic\\nAntidiabetic drugs\\nAntidiarrheal drugs\\nAntidiuretic hormone (ADH) test\\nAntifungal drugs, systemic\\nAntifungal drugs, topical\\nAntigas agents\\nAntigastroesophageal reflux\\ndrugs\\nAntihelminthic drugs\\nAntihemorrhoid drugs\\nAntihistamines H-2 blockers\\nAntihistamines\\nAntihypertensive drugs\\nAnti-hyperuricemic drugs\\nAnti-insomnia drugs\\nAnti-itch drugs\\nAntimalarial drugs\\nAntimigraine drugs\\nAntimyocardial antibody test\\nAntinausea drugs\\nAntinuclear antibody test\\nAntiparkinson drugs\\nAntiprotozoal drugs\\nAntipsychotic drugs, atypical\\nAntipsychotic drugs\\nAnti-rejection drugs\\nAntiretroviral drugs\\nAntirheumatic drugs\\nAntiseptics\\nAntispasmodic drugs\\nAntituberculosis drugs\\nAntiulcer drugs\\nAntiviral drugs\\nAnxiety disorders\\nAnxiety\\nAortic aneurysm\\nAortic dissection\\nAortic valve insufficiency\\nAortic valve stenosis\\nApgar testing\\nAphasia\\nAplastic anemia\\nAppendectomy\\nAppendicitis\\nAppetite-enhancing drugs\\nApraxia\\nArbovirus encephalitis\\nAromatherapy\\nArrhythmias\\nArt therapy\\nArterial embolism\\nArteriovenous fistula\\nArteriovenous malformations\\nArthrography\\nArthroplasty\\nArthroscopic surgery\\nArthroscopy\\nAsbestosis\\nAscites\\nAspartate aminotransferase test\\nAspergillosis\\nAspirin\\nAsthma\\nAstigmatism\\nAston-Patterning\\nAtaxia-telangiectasia\\nAtelectasis\\nAtherectomy\\nAtherosclerosis\\nAthlete’s foot\\nAthletic heart syndrome\\nAtkins diet\\nAtopic dermatitis\\nAtrial ectopic beats\\nAtrial fibrillation and flutter\\nAtrial septal defect\\nAttention-deficit/Hyperactivity disor-\\nder (ADHD)\\nAudiometry\\nAuditory integration training\\nAutism\\nAutoimmune disorders\\nAutopsy\\nAviation medicine\\nAyurvedic medicine\\nB\\nBabesiosis\\nBacillary angiomatosis\\nBacteremia\\nBacterial vaginosis\\nBad breath\\nBalance and coordination tests\\nBalanitis\\nBalantidiasis\\nBalloon valvuloplasty\\nBarbiturate-induced coma\\nBarbiturates\\nBariatric surgery\\nBarium enema\\nBartholin’s gland cyst\\nBartonellosis\\nBattered child syndrome\\nBedsores\\nBed-wetting\\nBehcet’s syndrome\\nBejel\\nBence Jones protein test\\nBender-Gestalt test\\nBenzodiazepines\\nBereavement\\nBeriberi\\nBerylliosis\\nBeta blockers\\nBeta\\n2-microglobulin test\\nBile duct cancer\\nBiliary atresia\\nBinge-eating disorder\\nBiofeedback\\nBipolar disorder\\nBird flu\\nBirth defects\\nBirthmarks\\nBites and stings\\nBlack lung disease\\nBladder cancer\\nBladder stones\\nBladder training\\nBlastomycosis\\nBleeding time\\nBleeding varices\\nBlepharoplasty\\nBlood clots\\nBlood count\\nBlood culture\\nBlood donation and registry\\nBlood gas analysis\\nBlood sugar tests\\nBlood typing and crossmatching\\nBlood urea nitrogen test\\nBlood-viscosity reducing drugs\\nBody dysmorphic disorder\\nBoils\\nBone biopsy\\nBone density test\\nBone disorder drugs\\nBone grafting\\nBone growth stimulation\\nBone marrow aspiration and\\nbiopsy\\nBone marrow transplantation\\nBone nuclear medicine scan\\nBone x rays\\nBotulinum toxin injections\\nBotulism\\nBowel preparation\\nBowel resection\\nBowel training\\nviii\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Brain abscess\\nBrain biopsy\\nBrain tumor\\nBreast biopsy\\nBreast cancer\\nBreast implants\\nBreast reconstruction\\nBreast reduction\\nBreast self-examination\\nBreast ultrasound\\nBreech birth\\nBronchiectasis\\nBronchiolitis\\nBronchitis\\nBronchodilators\\nBronchoscopy\\nBrucellosis\\nBruises\\nBruxism\\nBudd-Chiari syndrome\\nBuerger’s disease\\nBulimia nervosa\\nBundle branch block\\nBunion\\nBurns\\nBursitis\\nByssinosis\\nC\\nCaffeine\\nCalcium channel blockers\\nCampylobacteriosis\\nCancer therapy, definitive\\nCancer therapy, palliative\\nCancer therapy, supportive\\nCancer\\nCandidiasis\\nCanker sores\\nCarbohydrate intolerance\\nCarbon monoxide poisoning\\nCarcinoembryonic antigen test\\nCardiac blood pool scan\\nCardiac catheterization\\nCardiac rehabilitation\\nCardiac tamponade\\nCardiomyopathy\\nCardiopulmonary resuscitation\\n(CPR)\\nCardioversion\\nCarotid sinus massage\\nCarpal tunnel syndrome\\nCataract surgery\\nCataracts\\nCatatonia\\nCatecholamines tests\\nCatheter ablation\\nCat-scratch disease\\nCeliac disease\\nCell therapy\\nCellulitis\\nCentral nervous system depressants\\nCentral nervous system infections\\nCentral nervous system stimulants\\nCephalosporins\\nCerebral amyloid angiopathy\\nCerebral aneurysm\\nCerebral palsy\\nCerebrospinal fluid (CSF) analysis\\nCerumen impaction\\nCervical cancer\\nCervical conization\\nCervical disk disease\\nCervical spondylosis\\nCervicitis\\nCesarean section\\nChagas’ disease\\nChancroid\\nCharcoal, activated\\nCharcot Marie Tooth disease\\nCharcot’s joints\\nChelation therapy\\nChemonucleolysis\\nChemotherapy\\nChest drainage therapy\\nChest physical therapy\\nChest x ray\\nChickenpox\\nChild abuse\\nChildbirth\\nChildren’s health\\nChiropractic\\nChlamydial pneumonia\\nChoking\\nCholangitis\\nCholecystectomy\\nCholecystitis\\nCholera\\nCholestasis\\nCholesterol test\\nCholesterol, high\\nCholesterol-reducing drugs\\nCholinergic drugs\\nChondromalacia patellae\\nChoriocarcinoma\\nChorionic villus sampling\\nChronic fatigue syndrome\\nChronic granulomatous disease\\nChronic kidney failure\\nChronic obstructive lung disease\\nCircumcision\\nCirrhosis\\nCleft lip and palate\\nClenched fist injury\\nClub drugs\\nClubfoot\\nCluster headache\\nCoagulation disorders\\nCoarctation of the aorta\\nCocaine\\nCoccidioidomycosis\\nCoccyx injuries\\nCochlear implants\\nCognitive-behavioral therapy\\nCold agglutinins test\\nCold sore\\nColic\\nColon cancer\\nColonic irrigation\\nColonoscopy\\nColor blindness\\nColostomy\\nColposcopy\\nComa\\nCommon cold\\nCommon variable immunodeficiency\\nComplement deficiencies\\nComputed tomography scans\\nConcussion\\nCondom\\nConduct disorder\\nCongenital adrenal hyperplasia\\nCongenital amputation\\nCongenital bladder anomalies\\nCongenital brain defects\\nCongenital heart disease\\nCongenital hip dysplasia\\nCongenital lobar emphysema\\nCongenital ureter anomalies\\nCongestive cardiomyopathy\\nConjunctivitis\\nConstipation\\nContact dermatitis\\nContraception\\nContractures\\nCooling treatments\\nCoombs’ tests\\nCor pulmonale\\nCorneal abrasion\\nCorneal transplantation\\nCorneal ulcers\\nGALE ENCYCLOPEDIA OF MEDICINE ix\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Corns and calluses\\nCoronary artery bypass graft surgery\\nCoronary artery disease\\nCoronary stenting\\nCorticosteroids systemic\\nCorticosteroids, dermatologic\\nCorticosteroids, inhaled\\nCorticosteroids\\nCortisol tests\\nCosmetic dentistry\\nCostochondritis\\nCough suppressants\\nCough\\nCouvade syndrome\\nCox-2 inhibitors\\nCraniosacral therapy\\nCraniotomy\\nC-reactive protein\\nCreatine kinase test\\nCreatinine test\\nCreutzfeldt-Jakob disease\\nCri du chat syndrome\\nCrohn’s disease\\nCroup\\nCryoglobulin test\\nCryotherapy\\nCryptococcosis\\nCryptosporidiosis\\nCT-guided biopsy\\nCulture-fair test\\nCushing’s syndrome\\nCutaneous larva migrans\\nCutaneous T-cell lymphoma\\nCutis laxa\\nCyanosis\\nCyclic vomiting syndrome\\nCyclosporiasis\\nCystectomy\\nCystic fibrosis\\nCystinuria\\nCystitis\\nCystometry\\nCystoscopy\\nCytomegalovirus antibody screening\\ntest\\nCytomegalovirus infection\\nD\\nDacryocystitis\\nDeath\\nDebridement\\nDecompression sickness\\nDecongestants\\nDeep vein thrombosis\\nDefibrillation\\nDehydration\\nDelayed hypersensitivity skin test\\nDelirium\\nDelusions\\nDementia\\nDengue fever\\nDental trauma\\nDepo-Provera/Norplant\\nDepressive disorders\\nDermatitis\\nDermatomyositis\\nDES exposure\\nDetoxification\\nDeviated septum\\nDiabetes insipidus\\nDiabetes mellitus\\nDiabetic foot infections\\nDiabetic ketoacidosis\\nDiabetic neuropathy\\nDialysis, kidney\\nDiaper rash\\nDiaphragm (birth control)\\nDiarrhea\\nDiets\\nDiffuse esophageal spasm\\nDiGeorge syndrome\\nDigitalis drugs\\nDilatation and curettage\\nDiphtheria\\nDiscoid lupus erythematosus\\nDisk removal\\nDislocations and subluxations\\nDissociative disorders\\nDiuretics\\nDiverticulosis and diverticulitis\\nDizziness\\nDoppler ultrasonography\\nDown syndrome\\nDrug metabolism/interactions\\nDrug overdose\\nDrug therapy monitoring\\nDrugs used in labor\\nDry mouth\\nDuodenal obstruction\\nDysentery\\nDysfunctional uterine bleeding\\nDyslexia\\nDysmenorrhea\\nDyspepsia\\nDysphasia\\nE\\nEar exam with an otoscope\\nEar surgery\\nEchinacea\\nEchinococcosis\\nEchocardiography\\nEctopic pregnancy\\nEdema\\nEdwards’ syndrome\\nEhlers-Danlos syndrome\\nEhrlichiosis\\nElder Abuse\\nElectric shock injuries\\nElectrical nerve stimulation\\nElectrical stimulation of the brain\\nElectrocardiography\\nElectroconvulsive therapy\\nElectroencephalography\\nElectrolyte disorders\\nElectrolyte supplements\\nElectrolyte tests\\nElectromyography\\nElectronic fetal monitoring\\nElectrophysiology study of the heart\\nElephantiasis\\nEmbolism\\nEmergency contraception\\nEmphysema\\nEmpyema\\nEncephalitis\\nEncopresis\\nEndarterectomy\\nEndocarditis\\nEndometrial biopsy\\nEndometrial cancer\\nEndometriosis\\nEndorectal ultrasound\\nEndoscopic retrograde\\ncholangiopancreatography\\nEndoscopic sphincterotomy\\nEnemas\\nEnlarged prostate\\nEnterobacterial infections\\nEnterobiasis\\nEnterostomy\\nEnterovirus infections\\nEnzyme therapy\\nEosinophilic pneumonia\\nEpidermolysis bullosa\\nEpididymitis\\nEpiglottitis\\nEpisiotomy\\nx\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Epstein-Barr virus test\\nErectile dysfunction treatment\\nErectile dysfunction\\nErysipelas\\nErythema multiforme\\nErythema nodosum\\nErythroblastosis fetalis\\nErythrocyte sedimentation rate\\nErythromycins\\nErythropoietin test\\nEscherichia coli\\nEsophageal atresia\\nEsophageal cancer\\nEsophageal disorders\\nEsophageal function tests\\nEsophageal pouches\\nEsophagogastroduodenoscopy\\nEvoked potential studies\\nExercise\\nExophthalmos\\nExpectorants\\nExternal sphincter electromyography\\nExtracorporeal membrane\\noxygenation\\nEye and orbit ultrasounds\\nEye cancer\\nEye examination\\nEye glasses and contact lenses\\nEye muscle surgery\\nEyelid disorders\\nF\\nFace lift\\nFactitious disorders\\nFailure to thrive\\nFainting\\nFamilial Mediterranean fever\\nFamilial polyposis\\nFamily therapy\\nFanconi’s syndrome\\nFasciotomy\\nFasting\\nFatigue\\nFatty liver\\nFecal incontinence\\nFecal occult blood test\\nFeldenkrais method\\nFemale genital mutilation\\nFemale sexual arousal disorder\\nFetal alcohol syndrome\\nFetal hemoglobin test\\nFever evaluation tests\\nFever of unknown origin\\nFever\\nFibrin split products\\nFibrinogen test\\nFibroadenoma\\nFibrocystic condition of the breast\\nFibromyalgia\\nFifth disease\\nFilariasis\\nFinasteride\\nFingertip injuries\\nFish and shellfish poisoning\\nFistula\\nFlesh-eating disease\\nFlower remedies\\nFluke infections\\nFluoroquinolones\\nFolic acid deficiency anemia\\nFolic acid\\nFollicle-stimulating hormone test\\nFolliculitis\\nFood allergies\\nFood poisoning\\nFoot care\\nForeign objects\\nFracture repair\\nFractures\\nFragile X syndrome\\nFriedreich’s ataxia\\nFrostbite and frostnip\\nFugu poisoning\\nG\\nGalactorrhea\\nGalactosemia\\nGallbladder cancer\\nGallbladder nuclear medicine scan\\nGallbladder x rays\\nGallium scan of the body\\nGallstone removal\\nGallstones\\nGammaglobulin\\nGanglion\\nGangrene\\nGas embolism\\nGastrectomy\\nGastric acid determination\\nGastric emptying scan\\nGastrinoma\\nGastritis\\nGastroenteritis\\nGastrostomy\\nGaucher disease\\nGay and lesbian health\\nGender identity disorder\\nGender reassignment surgery\\nGene therapy\\nGeneral adaptation syndrome\\nGeneral surgery\\nGeneralized anxiety disorder\\nGenetic counseling\\nGenetic testing\\nGenital herpes\\nGenital warts\\nGestalt therapy\\nGestational diabetes\\nGI bleeding studies\\nGiardiasis\\nGinkgo biloba\\nGinseng, Korean\\nGlaucoma\\nGlomerulonephritis\\nGlucose-6-phosphate dehydrogenase\\ndeficiency\\nGlycogen storage diseases\\nGlycosylated hemoglobin test\\nGoiter\\nGonorrhea\\nGoodpasture’s syndrome\\nGout drugs\\nGout\\nGraft-vs.-host disease\\nGranuloma inguinale\\nGroup therapy\\nGrowth hormone tests\\nGuided imagery\\nGuillain-Barre´syndrome\\nGuinea worm infection\\nGulf War syndrome\\nGynecomastia\\nH\\nHair transplantation\\nHairy cell leukemia\\nHallucinations\\nHammertoe\\nHand-foot-and-mouth disease\\nHantavirus infections\\nHaptoglobin test\\nHartnup disease\\nHatha yoga\\nHead and neck cancer\\nHead injury\\nHeadache\\nGALE ENCYCLOPEDIA OF MEDICINE xi\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Hearing aids\\nHearing loss\\nHearing tests with a tuning fork\\nHeart attack\\nHeart block\\nHeart failure\\nHeart murmurs\\nHeart surgery for congenital defects\\nHeart transplantation\\nHeart valve repair\\nHeart valve replacement\\nHeartburn\\nHeat disorders\\nHeat treatments\\nHeavy metal poisoning\\nHeel spurs\\nHeimlich maneuver\\nHeliobacteriosis\\nHellerwork\\nHematocrit\\nHemochromatosis\\nHemoglobin electrophoresis\\nHemoglobin test\\nHemoglobinopathies\\nHemolytic anemia\\nHemolytic-uremic syndrome\\nHemophilia\\nHemophilus infections\\nHemoptysis\\nHemorrhagic fevers\\nHemorrhoids\\nHepatitis A\\nHepatitis B\\nHepatitis C\\nHepatitis D\\nHepatitis E\\nHepatitis G\\nHepatitis virus tests\\nHepatitis, alcoholic\\nHepatitis, autoimmune\\nHepatitis, drug-induced\\nHerbalism, traditional Chinese\\nHerbalism, Western\\nHereditary fructose intolerance\\nHereditary hemorrhagic\\ntelangiectasia\\nHernia repair\\nHernia\\nHerniated disk\\nHiccups\\nHigh-risk pregnancy\\nHirschsprung’s disease\\nHirsutism\\nHistiocytosis X\\nHistoplasmosis\\nHives\\nHodgkin’s disease\\nHolistic medicine\\nHolter monitoring\\nHoltzman ink blot test\\nHomeopathic medicine, acute\\nprescribing\\nHomeopathic medicine, constitu-\\ntional prescribing\\nHomeopathic medicine\\nHomocysteine\\nHookworm disease\\nHormone replacement therapy\\nHospital-acquired infections\\nHuman bite infections\\nHuman chorionic gonadotropin\\npregnancy test\\nHuman leukocyte antigen test\\nHuman-potential movement\\nHuntington disease\\nHydatidiform mole\\nHydrocelectomy\\nHydrocephalus\\nHydronephrosis\\nHydrotherapy\\nHyperaldosteronism\\nHyperbaric Chamber\\nHypercalcemia\\nHypercholesterolemia\\nHypercoagulation disorders\\nHyperemesis gravidarum\\nHyperhidrosis\\nHyperkalemia\\nHyperlipoproteinemia\\nHypernatremia\\nHyperopia\\nHyperparathyroidism\\nHyperpigmentation\\nHypersensitivity pneumonitis\\nHypersplenism\\nHypertension\\nHyperthyroidism\\nHypertrophic cardiomyopathy\\nHyphema\\nHypnotherapy\\nHypocalcemia\\nHypochondriasis\\nHypoglycemia\\nHypogonadism\\nHypokalemia\\nHypolipoproteinemia\\nHyponatremia\\nHypoparathyroidism\\nHypophysectomy\\nHypopituitarism\\nHypospadias and epispadias\\nHypotension\\nHypothermia\\nHypothyroidism\\nHypotonic duodenography\\nHysterectomy\\nHysteria\\nHysterosalpingography\\nHysteroscopy\\nHysterosonography\\nI\\nIchthyosis\\nIdiopathic infiltrative lung diseases\\nIdiopathic primary renal hematuric/\\nproteinuric syndrome\\nIdiopathic thrombocytopenic\\npurpura\\nIleus\\nImmobilization\\nImmune complex test\\nImmunodeficiency\\nImmunoelectrophoresis\\nImmunoglobulin deficiency\\nsyndromes\\nImmunologic therapies\\nImmunosuppressant drugs\\nImpacted tooth\\nImpedance phlebography\\nImpetigo\\nImplantable cardioverter-defibrillator\\nImpotence\\nImpulse control disorders\\nIn vitro fertilization\\nInclusion conjunctivitis\\nIncompetent cervix\\nIndigestion\\nIndium scan of the body\\nInduction of labor\\nInfant massage\\nInfection control\\nInfectious arthritis\\nInfectious mononucleosis\\nInfertility drugs\\nInfertility therapies\\nInfertility\\nInfluenza\\nInhalation therapies\\nInsecticide poisoning\\nInsomnia\\nxii GALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Insulin resistance\\nIntermittent claudication\\nIntermittent explosive disorder\\nIntersex states\\nInterstitial microwave thermal\\ntherapy\\nIntestinal obstructions\\nIntestinal polyps\\nIntrauterine growth retardation\\nIntravenous rehydration\\nIntravenous urography\\nIntussusception\\nIpecac\\nIron deficiency anemia\\nIron tests\\nIrritable bowel syndrome\\nIschemia\\nIsolation\\nItching\\nIUD\\nJ\\nJapanese encephalitis\\nJaundice\\nJaw wiring\\nJet lag\\nJock itch\\nJoint biopsy\\nJoint fluid analysis\\nJoint replacement\\nJuvenile arthritis\\nK\\nKaposi’s sarcoma\\nKawasaki syndrome\\nKeloids\\nKeratitis\\nKeratosis pilaris\\nKidney biopsy\\nKidney cancer\\nKidney disease\\nKidney function tests\\nKidney nuclear medicine scan\\nKidney stones\\nKidney transplantation\\nKidney, ureter, and bladder x-ray\\nstudy\\nKinesiology, applied\\nKlinefelter syndrome\\nKnee injuries\\nKneecap removal\\nKOH test\\nKorsakoff’s syndrome\\nKyphosis\\nL\\nLabyrinthitis\\nLaceration repair\\nLacrimal duct obstruction\\nLactate dehydrogenase isoenzymes\\ntest\\nLactate dehydrogenase test\\nLactation\\nLactic acid test\\nLactose intolerance\\nLaparoscopy\\nLaryngeal cancer\\nLaryngectomy\\nLaryngitis\\nLaryngoscopy\\nLaser surgery\\nLaxatives\\nLead poisoning\\nLearning disorders\\nLeeches\\nLegionnaires’ disease\\nLeishmaniasis\\nLeprosy\\nLeptospirosis\\nLesch-Nyhan syndrome\\nLeukemia stains\\nLeukemias, acute\\nLeukemias, chronic\\nLeukocytosis\\nLeukotriene inhibitors\\nLice infestation\\nLichen planus\\nLichen simplex chronicus\\nLife support\\nLipase test\\nLipidoses\\nLipoproteins test\\nLiposuction\\nListeriosis\\nLithotripsy\\nLiver biopsy\\nLiver cancer\\nLiver disease\\nLiver encephalopathy\\nLiver function tests\\nLiver nuclear medicine scan\\nLiver transplantation\\nLow back pain\\nLower esophageal ring\\nLumpectomy\\nLung abscess\\nLung biopsy\\nLung cancer, non-small cell\\nLung cancer, small cell\\nLung diseases due to gas or chemical\\nexposure\\nLung perfusion and ventilation scan\\nLung surgery\\nLung transplantation\\nLuteinizing hormone test\\nLyme disease\\nLymph node biopsy\\nLymphadenitis\\nLymphangiography\\nlymphedema\\nLymphocyte typing\\nLymphocytic choriomeningitis\\nLymphocytopenia\\nLymphogranuloma venereum\\nLysergic acid diethylamide (LSD)\\nM\\nMacular degeneration\\nMagnesium imbalance\\nMagnetic field therapy\\nMagnetic resonance imaging\\nMalabsorption syndrome\\nMalaria\\nMalignant lymphomas\\nMalignant melanoma\\nMalingering\\nMallet finger\\nMallory-Weiss syndrome\\nMalnutrition\\nMalocclusion\\nMALT lymphoma\\nMammography\\nMania\\nMarfan syndrome\\nMarijuana\\nMarriage counseling\\nMarshall-Marchetti-Krantz\\nprocedure\\nMassage therapy\\nMastectomy\\nMastitis\\nMastocytosis\\nMastoidectomy\\nMastoiditis\\nGALE ENCYCLOPEDIA OF MEDICINE xiii\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Maternal to fetal infections\\nMaxillofacial trauma\\nMeasles\\nMeckel’s diverticulum\\nMediastinoscopy\\nMeditation\\nMedullary sponge kidney\\nMelioidosis\\nMe´nie` re’s disease\\nMeningitis\\nMeningococcemia\\nMenopause\\nMen’s health\\nMenstrual disorders\\nMental retardation\\nMental status examination\\nMesothelioma\\nMetabolic acidosis\\nMetabolic alkalosis\\nMethadone\\nMethemoglobinemia\\nMicrophthalmia and anophthalmia\\nMifepristone\\nMigraine headache\\nMineral deficiency\\nMineral toxicity\\nMinerals\\nMinnesota multiphasic personality\\ninventory (MMPI-2)\\nMinority health\\nMinoxidil\\nMiscarriage\\nMitral valve insufficiency\\nMitral valve prolapse\\nMitral valve stenosis\\nMoles\\nMonkeypox\\nMonoamine oxidase inhibitors\\nMood disorders\\nMotion sickness\\nMovement disorders\\nMovement therapy\\nMucopolysaccharidoses\\nMucormycosis\\nMultiple chemical sensitivity\\nMultiple endocrine neoplasia\\nsyndromes\\nMultiple myeloma\\nMultiple personality disorder\\nMultiple pregnancy\\nMultiple sclerosis\\nMultiple-gated acquisition (MUGA)\\nscan\\nMumps\\nMunchausen syndrome\\nMuscle relaxants\\nMuscle spasms and cramps\\nMuscular dystrophy\\nMushroom poisoning\\nMusic therapy\\nMutism\\nMyasthenia gravis\\nMycetoma\\nMycobacterial infections, atypical\\nMycoplasma infections\\nMyelodysplastic syndrome\\nMyelofibrosis\\nMyelography\\nMyers-Briggs type indicator\\nMyocardial biopsy\\nMyocardial resection\\nMyocarditis\\nMyoglobin test\\nMyomectomy\\nMyopathies\\nMyopia\\nMyositis\\nMyotonic dystrophy\\nMyringotomy and ear tubes\\nMyxoma\\nN\\nNail removal\\nNail-patella syndrome\\nNarcolepsy\\nNarcotics\\nNasal irrigation\\nNasal packing\\nNasal papillomas\\nNasal polyps\\nNasal trauma\\nNasogastric suction\\nNasopharyngeal culture\\nNaturopathic medicine\\nNausea and vomiting\\nNear-drowning\\nNecrotizing enterocolitis\\nNeonatal jaundice\\nNephrectomy\\nNephritis\\nNephrotic syndrome\\nNephrotoxic injury\\nNeuralgia\\nNeuroblastoma\\nNeuroendocrine\\ntumorsNeurofibromatosis\\nNeurogenic bladder\\nNeurolinguistic programming\\nNeurologic exam\\nNeutropenia\\nNight terrors\\nNitrogen narcosis\\nNocardiosis\\nNongonococcal urethritis\\nNon-nucleoside reverse transcriptase\\ninhibitors\\nNonsteroidal anti-inflammatory\\ndrugs\\nNoroviruses\\nNosebleed\\nNumbness and tingling\\nNutrition through an intravenous line\\nNutrition\\nNutritional supplements\\nNystagmus\\nO\\nObesity surgery\\nObesity\\nObsessive-compulsive disorder\\nObstetrical emergencies\\nOccupational asthma\\nOligomenorrhea\\nOmega-3 Fatty Acids\\nOnychomycosis\\nOophorectomy\\nOphthalmoplegia\\nOppositional defiant disorder\\nOptic atrophy\\nOptic neuritis\\nOral contraceptives\\nOral hygiene\\nOrbital and periorbital cellulitis\\nOrchitis\\nOrthopedic surgery\\nOrthostatic hypotension\\nOsteoarthritis\\nOsteochondroses\\nOsteogenesis imperfecta\\nOsteomyelitis\\nOsteopathy\\nOsteopetroses\\nOsteoporosis\\nOstomy\\nOtitis externa\\nOtitis media\\nOtosclerosis\\nOtotoxicity\\nxiv\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Ovarian cancer\\nOvarian cysts\\nOvarian torsion\\nOveractive bladder\\nOverhydration\\nOxygen/ozone therapy\\nP\\nPacemakers\\nPaget’s disease of bone\\nPaget’s disease of the breast\\nPain management\\nPain\\nPalpitations\\nPancreas transplantation\\nPancreatectomy\\nPancreatic cancer, endocrine\\nPancreatic cancer, exocrine\\nPancreatitis\\nPanic disorder\\nPap test\\nPapilledema\\nParacentesis\\nParalysis\\nParanoia\\nParathyroid hormone test\\nParathyroid scan\\nParathyroidectomy\\nParatyphoid fever\\nParkinson disease\\nParotidectomy\\nParoxysmal atrial tachycardia\\nParrot fever\\nPartial thromboplastin time\\nParuresis\\nPatau syndrome\\nPatent ductus arteriosus\\nPellagra\\nPelvic exam\\nPelvic fracture\\nPelvic inflammatory disease\\nPelvic relaxation\\nPelvic ultrasound\\nPenicillins\\nPenile cancer\\nPenile prostheses\\nPercutaneous transhepatic\\ncholangiography\\nPerforated eardrum\\nPerforated septum\\nPericardiocentesisPericarditis\\nPerinatal infection\\nPeriodic paralysis\\nPeriodontal disease\\nPeripheral neuropathy\\nPeripheral vascular disease\\nPeritonitis\\nPernicious anemia\\nPeroxisomal disorders\\nPersonality disorders\\nPervasive developmental disorders\\nPet therapy\\nPeyronie’s disease\\nPharmacogenetics\\nPhenylketonuria\\nPheochromocytoma\\nPhimosis\\nPhlebotomy\\nPhobias\\nPhosphorus imbalance\\nPhotorefractive keratectomy and\\nlaser-assisted in-situ keratomileusis\\nPhotosensitivity\\nPhototherapy\\nPhysical allergy\\nPhysical examination\\nPica\\nPickwickian syndrome\\nPiercing and tattoos\\nPilates\\nPinguecula and pterygium\\nPinta\\nPituitary dwarfism\\nPituitary tumors\\nPityriasis rosea\\nPlacenta previa\\nPlacental abruption\\nPlague\\nPlasma renin activity\\nPlasmapheresis\\nPlastic, cosmetic, and reconstructive\\nsurgery\\nPlatelet aggregation test\\nPlatelet count\\nPlatelet function disorders\\nPleural biopsy\\nPleural effusion\\nPleurisy\\nPneumococcal pneumonia\\nPneumocystis pneumonia\\nPneumonia\\nPneumothorax\\nPoison ivy and poison oak\\nPoisoning\\nPolarity therapy\\nPolio\\nPolycystic kidney disease\\nPolycystic ovary syndrome\\nPolycythemia vera\\nPolydactyly and syndactyly\\nPolyglandular deficiency syndromes\\nPolyhydramnios and\\noligohydramnios\\nPolymyalgia rheumatica\\nPolymyositis\\nPolysomnography\\nPorphyrias\\nPortal vein bypass\\nPositron emission tomography\\n(PET)\\nPost-concussion syndrome\\nPostmenopausal bleeding\\nPostpartum depression\\nPostpolio syndrome\\nPost-traumatic stress disorder\\nPrader-Willi syndrome\\nPrecocious puberty\\nPreeclampsia and eclampsia\\nPregnancy\\nPremature ejaculation\\nPremature labor\\nPremature menopause\\nPremature rupture of membranes\\nPrematurity\\nPremenstrual dysphoric disorder\\nPremenstrual syndrome\\nPrenatal surgery\\nPrepregnancy counseling\\nPresbyopia\\nPriapism\\nPrickly heat\\nPrimary biliary cirrhosis\\nProctitis\\nProgressive multifocal\\nleukoencephalopathy\\nProgressive supranuclear palsy\\nProlactin test\\nProlonged QT syndrome\\nProphylaxis\\nProstate biopsy\\nProstate cancer\\nProstate ultrasound\\nProstatectomy\\nProstate-specific antigen test\\nProstatitis\\nProtease inhibitors\\nProtein components test\\nProtein electrophoresis\\nProtein-energy malnutrition\\nProthrombin time\\nGALE ENCYCLOPEDIA OF MEDICINE xv\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Proton Pump Inhibitors\\nPseudogout\\nPseudomonas infections\\nPseudoxanthoma elasticum\\nPsoriasis\\nPsoriatic arthritis\\nPsychiatric confinement\\nPsychoanalysis\\nPsychological tests\\nPsychosis\\nPsychosocial disorders\\nPsychosurgery\\nPtosis\\nPuberty\\nPuerperal infection\\nPulmonary alveolar proteinosis\\nPulmonary artery catheterization\\nPulmonary edema\\nPulmonary embolism\\nPulmonary fibrosis\\nPulmonary function test\\nPulmonary hypertension\\nPulmonary valve insufficiency\\nPulmonary valve stenosis\\nPyelonephritis\\nPyloric stenosis\\nPyloroplasty\\nPyruvate kinase deficiency\\nQ\\nQ fever\\nQigong\\nR\\nRabies\\nRadial keratotomy\\nRadiation injuries\\nRadiation therapy\\nRadical neck dissection\\nRadioactive implants\\nRape and sexual assault\\nRashes\\nRat-bite fever\\nRaynaud’s disease\\nRecompression treatment\\nRectal cancer\\nRectal examination\\nRectal polyps\\nRectal prolapse\\nRecurrent miscarriage\\nRed blood cell indices\\nReflex sympathetic dystrophy\\nReflex tests\\nReflexology\\nRehabilitation\\nReiki\\nReiter’s syndrome\\nRelapsing fever\\nRelapsing polychondritis\\nRenal artery occlusion\\nRenal artery stenosis\\nRenal tubular acidosis\\nRenal vein thrombosis\\nRenovascular hypertension\\nRespiratory acidosis\\nRespiratory alkalosis\\nRespiratory distress syndrome\\nRespiratory failure\\nRespiratory syncytial virus\\ninfection\\nRestless legs syndrome\\nRestrictive cardiomyopathy\\nReticulocyte count\\nRetinal artery occlusion\\nRetinal detachment\\nRetinal hemorrhage\\nRetinal vein occlusion\\nRetinitis pigmentosa\\nRetinoblastoma\\nRetinopathies\\nRetrograde cystography\\nRetrograde ureteropyelography\\nRetrograde urethrography\\nReye’s syndrome\\nRheumatic fever\\nRheumatoid arthritis\\nRhinitis\\nRhinoplasty\\nRiboflavin deficiency\\nRickets\\nRickettsialpox\\nRingworm\\nRocky Mountain spotted fever\\nRolfing\\nRoot canal treatment\\nRosacea\\nRoseola\\nRoss River Virus\\nRotator cuff injury\\nRotavirus infections\\nRoundworm infections\\nRubella test\\nRubella\\nS\\nSacroiliac disease\\nSalivary gland scan\\nSalivary gland tumors\\nSalmonella food poisoning\\nSalpingectomy\\nSalpingo-oophorectomy\\nSarcoidosis\\nSarcomas\\nSaw palmetto\\nScabies\\nScarlet fever\\nScars\\nSchistosomiasis\\nSchizoaffective disorder\\nSchizophrenia\\nSciatica\\nScleroderma\\nSclerotherapy for esophageal varices\\nScoliosis\\nScrotal nuclear medicine scan\\nScrotal ultrasound\\nScrub typhus\\nScurvy\\nSeasonal affective disorder\\nSeborrheic dermatitis\\nSecondary polycythemia\\nSedation\\nSeizure disorder\\nSelective serotonin reuptake\\ninhibitors\\nSelf-mutilation\\nSemen analysis\\nSeniors’ health\\nSensory integration disorder\\nSepsis\\nSeptic shock\\nSeptoplasty\\nSerum sickness\\nSevere acute respiratory syndrome\\n(SARS)\\nSevere combined immunodeficiency\\nSex hormones tests\\nSex therapy\\nSexual dysfunction\\nSexual perversions\\nSexually transmitted diseases\\nSexually transmitted diseases cultures\\nShaken baby syndrome\\nShiatsu\\nShigellosis\\nShin splints\\nxvi\\nGALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Shingles\\nShock\\nShortness of breath\\nShy-Drager syndrome\\nShyness\\nSick sinus syndrome\\nSickle cell disease\\nSideroblastic anemia\\nSigmoidoscopy\\nSildenafil citrate\\nSilicosis\\nSinus endoscopy\\nSinusitis\\nSitus inversus\\nSitz bath\\nSjo¨gren’s syndrome\\nSkin biopsy\\nSkin cancer, non-melanoma\\nSkin culture\\nSkin grafting\\nSkin lesion removal\\nSkin lesions\\nSkin pigmentation disorders\\nSkin resurfacing\\nSkull x rays\\nSleep apnea\\nSleep disorders\\nSleeping sickness\\nSmall intestine biopsy\\nSmallpox\\nSmelling disorders\\nSmoke inhalation\\nSmoking\\nSmoking-cessation drugs\\nSnoring\\nSomatoform disorders\\nSore throat\\nSouth American blastomycosis\\nSpeech disorders\\nSpina bifida\\nSpinal cord injury\\nSpinal cord tumors\\nSpinal instrumentation\\nSpinal stenosis\\nSplenectomy\\nSplenic trauma\\nSporotrichosis\\nSports injuries\\nSprains and strains\\nSputum culture\\nSt. John’s wort\\nStanford-Binet intelligence scales\\nStapedectomy\\nStaphylococcal infections\\nStaphylococcal scalded skin\\nsyndrome\\nStarvation\\nStem cell transplantation\\nStillbirth\\nStockholm syndrome\\nStomach cancer\\nStomach flushing\\nStomatitis\\nStool culture\\nStool fat test\\nStool O & P test\\nStrabismus\\nStrep throat\\nStreptococcal antibody tests\\nStreptococcal infections\\nStress reduction\\nStress test\\nStress\\nStridor\\nStroke\\nStuttering\\nSubacute sclerosing panencephalitis\\nSubarachnoid hemorrhage\\nSubdural hematoma\\nSubstance abuse and dependence\\nSudden cardiac death\\nSudden infant death syndrome\\nSuicide\\nSulfonamides\\nSunburn\\nSunscreens\\nSuperior vena cava syndrome\\nSurfactant\\nSwallowing disorders\\nSydenham’s chorea\\nSympathectomy\\nSyphilis\\nSystemic lupus erythematosus\\nT\\nTai chi\\nTapeworm diseases\\nTardive dyskinesia\\nTarsorrhaphy\\nTay-Sachs disease\\nTechnetium heart scan\\nTeeth whitening\\nTemporal arteritis\\nTemporomandibular joint disorders\\nTendinitis\\nTennis elbow\\nTensilon test\\nTension headache\\nTesticular cancer\\nTesticular self-examination\\nTesticular surgery\\nTesticular torsion\\nTetanus\\nTetracyclines\\nTetralogy of Fallot\\nThalassemia\\nThallium heart scan\\nThematic apperception test\\nTherapeutic baths\\nTherapeutic touch\\nThoracentesis\\nThoracic outlet syndrome\\nThoracic surgery\\nThoracoscopy\\nThreadworm infection\\nThroat culture\\nThrombocytopenia\\nThrombocytosis\\nThrombolytic therapy\\nThrombophlebitis\\nThymoma\\nThyroid biopsy\\nThyroid cancer\\nThyroid function tests\\nThyroid hormones\\nThyroid nuclear medicine scan\\nThyroid ultrasound\\nThyroidectomy\\nThyroiditis\\nTilt table test\\nTinnitus\\nTissue typing\\nTonsillectomy and adenoidectomy\\nTonsillitis\\nTooth decay\\nTooth extraction\\nTooth replacements and restorations\\nToothache\\nTopical Anesthesia\\nTORCH test\\nTorticollis\\nTotal parenteral nutrition\\nTourette syndrome\\nToxic epidermal necrolysis\\nToxic shock syndrome\\nToxoplasmosis\\nTrabeculectomy\\nTracheoesophageal fistula\\nTracheotomy\\nTrachoma\\nGALE ENCYCLOPEDIA OF MEDICINE xvii\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Traction\\nTraditional Chinese medicine\\nTrager psychophysical integration\\nTranscranial Doppler\\nultrasonography\\nTransesophageal echocardiography\\nTransfusion\\nTranshepatic biliary catheterization\\nTransient ischemic attack\\nTransposition of the great arteries\\nTransurethral bladder resection\\nTransvaginal ultrasound\\nTransverse myelitis\\nTraumatic amputations\\nTraveler’s diarrhea\\nTremors\\nTrench fever\\nTrichinosis\\nTrichomoniasis\\nTricuspid valve insufficiency\\nTricuspid valve stenosis\\nTrigeminal neuralgia\\nTrigger finger\\nTriglycerides test\\nTriple screen\\nTropical spastic paraparesis\\nTroponins test\\nTubal ligation\\nTube compression of the esophagus\\nand stomach\\nTube feedings\\nTuberculin skin test\\nTuberculosis\\nTularemia\\nTumor markers\\nTumor removal\\nTurner syndrome\\n2,3-diphosphoglycerate test\\nTyphoid fever\\nTyphus\\nTzanck preparation\\nU\\nUlcer surgery\\nUlcerative colitis\\nUlcers (digestive)\\nUltraviolet light treatment\\nUmbilical cord blood banking\\nUndescended testes\\nUpper GI exam\\nUreteral stenting\\nUrethritis\\nUric acid tests\\nUrinalysis\\nUrinary anti-infectives\\nUrinary catheterization\\nUrinary diversion surgery\\nUrinary incontinence\\nUrine culture\\nUrine flow test\\nUterine fibroid embolization\\nUterine fibroids\\nUveitis\\nV\\nVaccination\\nVaginal pain\\nVagotomy\\nValsalva maneuver\\nValvular heart disease\\nVaricose veins\\nVasculitis\\nVasectomy\\nVasodilators\\nVegetarianism\\nVegetative state\\nVelopharyngeal insufficiency\\nVena cava filter\\nVenography\\nVenous access\\nVenous insufficiency\\nVentricular aneurysm\\nVentricular assist device\\nVentricular ectopic beats\\nVentricular fibrillation\\nVentricular septal defect\\nVentricular shunt\\nVentricular tachycardia\\nVesicoureteral reflux\\nVibriosis\\nVision training\\nVisual impairment\\nVitamin A deficiency\\nVitamin B\\n6 deficiency\\nVitamin D deficiency\\nVitamin E deficiency\\nVitamin K deficiency\\nVitamin tests\\nVitamin toxicity\\nVitamins\\nVitiligo\\nVitrectomy\\nVocal cord nodules and polyps\\nVocal cord paralysis\\nvon Willebrand disease\\nVulvar cancer\\nVulvodynia\\nVulvovaginitis\\nW\\nWaldenstrom’s macroglobulinemia\\nWarts\\nWechsler intelligence test\\nWegener’s granulomatosis\\nWeight loss drugs\\nWest Nile Virus\\nWheezing\\nWhiplash\\nWhite blood cell count and\\ndifferential\\nWhooping cough\\nWilderness medicine\\nWilms’ tumor\\nWilson disease\\nWiskott-Aldrich syndrome\\nWithdrawal syndromes\\nWolff-Parkinson-White\\nsyndrome\\nWomen’s health\\nWound culture\\nWound flushing\\nWounds\\nX\\nX-linked agammaglobulinemia\\nX rays of the orbit\\nY\\nYaws\\nYellow fever\\nYersinosis\\nYoga\\nZ\\nZoonosis\\nxviii GALE ENCYCLOPEDIA OF MEDICINE\\nList of Entries'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='PLEASE READ—IMPORTANT INFORMATION\\nThe Gale Encyclopedia of Medicineis a medical\\nreference product designed to inform and educate\\nreaders about a wide variety of disorders, conditions,\\ntreatments, and diagnostic tests. Thomson Gale believes\\nthe product to be comprehensive, but not necessarily\\ndefinitive. It is intended to supplement, not replace,\\nconsultation with a physician or other healthcare practi-\\ntioner. While Thomson Gale has made substantial\\nefforts to provide information that is accurate, compre-\\nhensive, and up-to-date, Thomson Gale makes no\\nrepresentations or warranties of any kind, including\\nwithout limitation, warranties of merchantability or fit-\\nness for a particular purpose, nor does it guarantee the\\naccuracy, comprehensiveness, or timeliness of the infor-\\nmation contained in this product. Readers should be\\naware that the universe of medical knowledge is con-\\nstantly growing and changing, and that differences of\\nmedical opinion exist among authorities. Readers are\\nalso advised to seek professional diagnosis and treat-\\nment for any medical condition, and to discuss informa-\\ntion obtained from this book with their healthcare\\nprovider.\\nGALE ENCYCLOPEDIA OF MEDICINE xix'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='INTRODUCTION\\nThe third edition of the Gale Encyclopedia of\\nMedicine (GEM3) is a one-stop source for medical\\ninformation on over 1,750 common medical disorders,\\nconditions, tests, and treatments, including high-\\nprofile diseases such as AIDS, Alzheimer’s disease,\\ncancer, and heart attack. This encyclopedia avoids\\nmedical jargon and uses language that laypersons\\ncan understand, while still providing thorough cover-\\nage of each topic. TheGale Encyclopedia of Medicine 3\\nfills a gap between basic consumer health resources,\\nsuch as single-volume family medical guides, and\\nhighly technical professional materials.\\nSCOPE\\nMore than 1,750 full-length articles are included\\nin theGale Encyclopedia of Medicine 3, including dis-\\norders/conditions, tests/procedures, and treatments/\\ntherapies. Many common drugs are also covered,\\nwith generic drug names appearing first and brand\\nnames following in parentheses, eg. acetaminophen\\n(Tylenol). Throughout the Gale Encyclopedia of\\nMedicine 3, many prominent individuals are high-\\nlighted as sidebar biographies that accompany the\\nmain topical essays. Articles follow a standardized\\nformat that provides information at a glance.\\nRubrics 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\\ninterest in holistic medicine that emphasizes the\\nconnection between mind and body. Aimed at achiev-\\ning and maintaining good health rather than just elim-\\ninating disease, this approach has come to be known\\nas alternative medicine. The Gale Encyclopedia of\\nMedicine 3 includes a number of essays on alterna-\\ntive therapies, ranging from traditional Chinese\\nmedicine to homeopathy and from meditation\\nto aromatherapy. In addition to full essays on alter-\\nnative therapies, the encyclopedia features specific\\nAlternative treatment sections for diseases and con-\\nditions that may be help ed by complementary\\ntherapies.\\nINCLUSION CRITERIA\\nA preliminary list of diseases, disorders, tests\\nand treatments was compiled from a wide variety of\\nsources, including professional medical guides and\\ntextbooks as well as consumer guides and encyclope-\\ndias. The general advisory board, made up of public\\nlibrarians, medical librarians and consumer health\\nexperts, evaluated the topics and made suggestions\\nfor inclusion. The list was sorted by category and\\nsent toGEM3 medical advisers, for review. Final selec-\\ntion of topics to include was made by the medical\\nadvisors in conjunction with the Thomson Gale\\neditor.\\nABOUT THE CONTRIBUTORS\\nThe essays were compiled by experienced medical\\nwriters, including physicians, pharmacists, nurses,\\nand other health care professionals.GEM3 medical\\nadvisors reviewed the completed essays to insure\\nthat they are appropriate, up-to-date, and medically\\naccurate.\\nHOW TO USE THIS BOOK\\nThe Gale Encyclopedia of Medicine 3 has been\\ndesigned with ready reference in mind.\\nGALE ENCYCLOPEDIA OF MEDICINE xxi'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Straight alphabetical arrangement allows users to\\nlocate information quickly.\\n/C15Bold faced terms function asprint hyperlinks that\\npoint the reader to related entries in the encyclopedia.\\n/C15Cross-references placed throughout the encyclope-\\ndia direct readers to where information on subjects\\nwithout entries can be found. Synonyms are also\\ncross-referenced.\\n/C15A list ofkey termsare provided where appropriate\\nto define unfamiliar terms or concepts.\\n/C15Valuable contact information for organizations\\nandsupport groups is included with each entry.\\nThe appendix contains an extensive list of organiza-\\ntions arranged in alphabetical order.\\n/C15Resources sectiondirects users to additional sources\\nof medical information on a topic.\\n/C15A comprehensive general index allows users to\\neasily target detailed aspects of any topic, including\\nLatin names.\\nGRAPHICS\\nThe Gale Encyclopedia of Medicine 3is enhanced\\nwith over 675 illustrations, including photos, charts,\\ntables, and customized line drawings.\\nxxii GALE ENCYCLOPEDIA OF MEDICINE\\nIntroduction'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='ADVISORS\\nA number of experts in the library and medical communities provided invaluable assistance in the formulation of this\\nencyclopedia. Our advisory board performed a myriad of duties, from defining the scope of coverage to reviewing\\nindividual entries for accuracy and accessibility. The editor would like to express her appreciation to them.\\nMEDICAL ADVISORS\\nRosalyn Carson-DeWitt, M.D.\\nDurham, NC\\nLarry I. Lutwick M.D., F.A.C.P.\\nDirector, Infectious Diseases\\nVA Medical Center\\nBrooklyn, NY\\nSamuel Uretsky, Pharm.D.\\nPharmacist\\nWantagh, NY\\nGALE ENCYCLOPEDIA OF MEDICINE xxiii'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='CONTRIBUTORS\\nMargaret Alic, Ph.D.\\nScience Writer\\nEastsound, WA\\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, Ph.D.\\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, VA\\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\\nCounseling\\nIndianapolis, IN\\nLinda K. Bennington, C.N.S.\\nScience Writer\\nVirginia Beach, VA\\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.,\\nC.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\\nGALE ENCYCLOPEDIA OF MEDICINE xxv'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Geoffrey N. Clark, D.V.M.\\nEditor\\nCanine Sports Medicine\\nUpdate\\nNewmarket, NH\\nRhonda 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.,\\nB.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\\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\\nJason Fryer\\nMedical Writer\\nSan Antonio, TX\\nRon Gasbarro, Pharm.D.\\nMedical Writer\\nNew Milford, PA\\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\\nxxvi GALE ENCYCLOPEDIA OF MEDICINE\\nContributors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Kapil Gupta, M.D.\\nMedical Writer\\nWinston-Salem, NC\\nMaureen Haggerty\\nMedical Writer\\nAmbler, PA\\nClare Hanrahan\\nMedical Writer\\nAsheville, NC\\nAnn 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.,\\nC.G.C.\\nGenetic Counselor\\nThe Children’s Mercy Hospital\\nKansas City, MO\\nDawn A. Jacob, M.S.\\nGenetic Counselor\\nObstetrix Medical Group of\\nTexas\\nFort Worth, TX\\nSally J. Jacobs, Ed.D.\\nMedical Writer\\nLos Angeles, CA\\nMichelle L. Johnson, M.S., J.D.\\nPatent Attorney and Medical\\nWriter\\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\\nWest Chester, PA\\nBeth A. Kapes\\nMedical Writer\\nBay Village, OH\\nJanet M. Kearney\\nFreelance writer\\nOrlando, FL\\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, WA\\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, VA\\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\\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\\nVA 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\\nPathology\\nDemarest, NJ\\nAdrienne Massel, R.N.\\nMedical Writer\\nBeloit, WI\\nRuth E. Mawyer, R.N.\\nMedical Writer\\nCharlottesville, VA\\nRichard A. McCartney M.D.\\nFellow, American College of\\nSurgeons\\nDiplomat American Board of\\nSurgery\\nRichland, WA\\nGALE ENCYCLOPEDIA OF MEDICINE xxvii\\nContributors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Bonny 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\\nBetty Mishkin\\nMedical Writer\\nSkokie, IL\\nBarbara J. Mitchell\\nMedical Writer\\nHallstead, PA\\nMark A. Mitchell, M.D.\\nMedical Writer\\nSeattle, WA\\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 Odle\\nMedical Writer\\nAlbaquerque, NM\\nLisa Papp, R.N.\\nMedical Writer\\nCherry Hill, NJ\\nLee Ann Paradise\\nMedical Writer\\nSan Antonio, TX\\nPatience Paradox\\nMedical Writer\\nBainbridge Island, WA\\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\\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\\nMetabolic Genetics\\nThe Hospital for Sick Children\\nToronto, ON, Canada\\nAnn Quigley\\nMedical Writer\\nNew York, NY\\nRobert Ramirez, B.S.\\nMedical Student\\nUniversity of Medicine &\\nDentistry of 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\\nAnnaRovidSpickler,D.V.M.,Ph.D.\\nMedical Writer\\nMoorehead, KY\\nBelinda Rowland, Ph.D.\\nMedical Writer\\nVoorheesville, 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\\nxxviii GALE ENCYCLOPEDIA OF MEDICINE\\nContributors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Kristen 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\\nJennifer 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\\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\\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\\nGALE ENCYCLOPEDIA OF MEDICINE xxix\\nContributors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='A\\nAbdominal 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 trans-\\nmitter sends high frequency sound waves into the body,\\nwhere they bounce off the different tissues and organs\\nto produce 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\\nthe sonar technology developed to detect submarines\\nduring World War II. The first useful medical images\\nwere produced in the early 1950s, and, by 1965, ultra-\\nsound quality had improved to the point that it came\\ninto general medical use. Improvements in the tech-\\nnology, application, and interpretation of ultrasound\\ncontinue. Its low cost, versatility, safety and speed\\nhave brought it into the top drawer of medical imaging\\ntechniques.\\nWhile pelvic ultrasoundis widely known and com-\\nmonly used for fetal monitoring duringpregnancy,\\nultrasound is also routinely used for general abdom-\\ninal imaging. It has great advantage over x-ray ima-\\nging technologies in that it does not damage tissues\\nwith ionizing radiation. Ultrasound is also generally\\nfar better than plain x rays at distinguishing the subtle\\nvariations of soft tissue structures, and can be used in\\nany of several modes, depending on the need at hand.\\nAs an imaging tool, abdominal ultrasound gener-\\nally is warranted for patients afflicted with: chronic or\\nacute abdominalpain; abdominal trauma; an obvious\\nor suspected abdominal mass; symptoms ofliver dis-\\nease, pancreatic disease,gallstones, spleen disease,kid-\\nney diseaseand urinary blockage; or symptoms of an\\nabdominal aortic aneurysm. Specifically:\\n/C15Abdominal pain. Whether acute or chronic, pain can\\nsignal a serious problem–from organ malfunction or\\ninjury to the presence of malignant growths.\\nUltrasound scanning can help doctors quickly sort\\nthrough potential causes when presented with gen-\\neral or ambiguous symptoms. All of the major\\nabdominal organs can be studied for signs of disease\\nthat appear as changes in size, shape and internal\\nstructure.\\n/C15Abdominal trauma. After a serious accident, such as\\na car 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\\nan initial scan when abdominal trauma is suspected,\\nand it can be used to pinpoint the location, cause,\\nand severity of hemorrhaging. In the case of punc-\\nture wounds, from a bullet for example, ultrasound\\ncan locate the foreign object and provide a prelimin-\\nary survey of the damage. The easy portability and\\nversatility of ultrasound technology has brought it\\ninto common emergency room use, and even into\\nlimited ambulance service.\\nGALE ENCYCLOPEDIA OF MEDICINE 1'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Abdominal mass. Abnormal growths–tumors, cysts,\\nabscesses, scar tissue and accessory organs–can be\\nlocated 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\\nor part of the abdomen can be found.\\n/C15Liver disease. The types and underlying causes of\\nliver disease are numerous, though jaundice tends\\nto be a general symptom. Ultrasound can differenti-\\nate between many of the types and causes of liver\\nmalfunction, and is particularly good at identifying\\nobstruction of the bile ducts andcirrhosis, which is\\ncharacterized by abnormal fibrous growths and\\nreduced blood flow.\\n/C15Pancreatic disease. Inflammation and malformation\\nof the pancreas are readily identified by ultrasound,\\nas are pancreatic stones (calculi), which can disrupt\\nproper functioning.\\n/C15Gallstones. Gallstones cause morehospital admissions\\nthan any other digestive malady. These calculi can\\ncause painful inflammation of the gallbladder and\\nalso obstruct the bile ducts that carry digestive enzymes\\nfrom the gallbladder and liver to the intestines.\\nGallstones are readily identifiable with ultrasound.\\n/C15Spleen 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\\nto ultrasonic inspection and diagnosis.\\n/C15Kidney disease. The kidneys are also prone to trau-\\nmatic injury and are the organs most likely to form\\ncalculi, which can block the flow of urine and cause\\nbloodpoisoning(uremia). A variety of diseases causing\\ndistinct changes in kidney morphology can also lead to\\ncomplete kidney failure. Ultrasound imaging has pro-\\nven extremely useful in diagnosing kidney disorders.\\n/C15Abdominal aortic aneurysm. This is a bulging weak\\nspot in the abdominal aorta, which supplies blood\\ndirectly from the heart to the entire lower body.\\nThese aneurysms are relatively common and increase\\nin prevalence with age. A burst aortic aneurysm is\\nimminently life-threatening. However, they can be\\nreadily identified and monitored with ultrasound\\nbefore acute complications 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\\nfor ultrasound are being developed.\\nThe direct therapeutic value of ultrasonic waves\\nlies in their mechanical nature. They are shock waves,\\njust like audible sound, and vibrate the materials\\nthrough which they pass. These vibrations are mild,\\nvirtually unnoticeable at the frequencies and intensi-\\nties used for imaging. Properly focused however, high-\\nintensity ultrasound can be used to heat and physically\\nagitate targeted tissues.\\nHigh-intensity ultrasound is used routinely to treat\\nsoft tissue injuries, such asstrains,t e a r sa n da s s o c i a t e d\\nscarring. The heating and agitation are believed to\\npromote rapid healing through increased circulation.\\nStrongly focused, high-intensity, high-frequency ultra-\\nsound can also be used to physically destroy certain\\ntypes of tumors, as well as gallstones and other types\\nof calculi. Developing new treatment applications\\nfor ultrasound is an active area of medical research.\\nPrecautions\\nProperly performed, ultrasound imaging is vir-\\ntually without risk or side effects. Some patients report\\nfeeling a slight tingling and/or warmth while being\\nscanned, but most feel nothing at all. Ultrasound\\nwaves of appropriate frequency and intensity are not\\nknown to cause or aggravate any medical condition,\\nthough any woman who thinks she might be pregnant\\nshould raise the issue with her doctor before under-\\ngoing an abdominal ultrasound.\\nThe value of ultrasound imaging as a medical tool,\\nhowever, depends greatly on the quality of the equip-\\nment used and the skill of the medical personnel oper-\\nating it. Improperly performed and/or interpreted,\\nultrasound can be worse than useless if it indicates\\nthat a problem exists where there is none, or fails to\\ndetect a significant condition. Basic ultrasound equip-\\nment is relatively inexpensive to obtain, and any doc-\\ntor with the equipment can perform the procedure\\nwhether qualified or not. Patients should not hesitate\\nto verify the credentials of technicians and doctors\\nperforming ultrasounds, as well as the quality of the\\nequipment used and the benefits of the proposed\\nprocedure.\\nIn cases where ultrasound is used as a treatment\\ntool, patients should educate themselves about the\\nproposed procedure with the help of their doctors–as\\nis appropriate before any surgical procedure. Also,\\nany abdominal ultrasound procedure, diagnostic or\\ntherapeutic, may be hampered by a patient’s body\\ntype or other factors, such as the presence of excessive\\nbowel gas (which is opaque to ultrasound). In parti-\\ncular, very obese people are often not good candidates\\nfor abdominal ultrasound.\\n2 GALE ENCYCLOPEDIA OF MEDICINE\\nAbdominal ultrasound'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nUltrasound includes all sound waves above the\\nfrequency of human hearing–about 20 thousand\\nhertz, or cycles per second. Medical ultrasound gener-\\nally uses frequencies between one and 10 million hertz\\n(1-10 MHz). Higher frequency ultrasound waves pro-\\nduce more detailed images, but are also more readily\\nabsorbed and so cannot penetrate as deeply into the\\nbody. Abdominal ultrasound imaging is generally per-\\nformed at frequencies between 2-5 MHz.\\nKEY TERMS\\nAccessory organ— A lump of tissue adjacent to an\\norgan that is similar to it, but which serves no impor-\\ntant purpose, if functional at all. While not necessa-\\nrily harmful, such organs can cause problems if they\\ngrow too large or become cancerous. In any case,\\ntheir presence points to an underlying abnormality in\\nthe 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\\ntissue 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 the\\nbody, but usually found in the gallbladder, pancreas\\nand kidneys. They are formed by the accumulation of\\nexcess mineral salts and other organic material such\\nas blood or mucous. Calculi (pl.) can cause problems\\nby lodging in and obstructing the proper flow of fluids,\\nsuch as bile to the intestines or urine 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 through\\nwhich bile–a necessary digestive enzyme–travels\\nfrom the liver and gallbladder into the small intes-\\ntine. Digestive enzymes from the pancreas also enter\\nthe intestines through the common bile duct.\\nComputed tomography scan (CT scan)— As p e c i a -\\nlized type of x-ray imaging that uses highly focused\\nand relatively low energy radiation to produce detailed\\ntwo-dimensional images of soft tissue structures, parti-\\ncularly the brain. CT scans are the chief competitor to\\nultrasound and can yield higher quality images not\\nd i s r u p t e db yb o n eo rg a s .T h e ya r e ,h o w e v e r ,m o r e\\ncumbersome, time consuming and expensive to per-\\nform, and they use ionizing electromagnetic 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 fre-\\nquency decreases. The size of this frequency shift\\ncan be used to compute the object’s speed–be it a\\ncar on the road or blood in an artery. The Doppler\\neffect holds true for all types of radiation, not just\\nsound.\\nFrequency— Sound, whether traveling through air or\\nthe human body, produces vibrations–molecules\\nbouncing into each other–as the shock wave travels\\nalong. The frequency of a sound is the number of\\nvibrations per second. Within the audible range,\\nfrequency means pitch–the higher the frequency,\\nthe 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 to\\nthe skin, eyes and body fluids. Bile retention in the\\nliver, 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 struc-\\nture rather than the function of a given organ. As a\\ndiagnostic imaging technique, ultrasound facilitates\\nthe recognition of abnormal morphologies as symp-\\ntoms of underlying conditions.\\nGALE ENCYCLOPEDIA OF MEDICINE 3\\nAbdominal ultrasound'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='An ultrasound machine consists of two parts: the\\ntransducer and the analyzer. The transducer both pro-\\nduces the sound waves that penetrate the body and\\nreceives the reflected echoes. Transducers are built\\naround piezoelectric ceramic chips. (Piezoelectric\\nrefers to electricity that is produced when you put\\npressure on certain crystals such as quartz). These\\nceramic chips react to electric pulses by producing\\nsound waves ( they are transmitting waves) and react\\nto sound waves by producing electric pulses (receiv-\\ning). Bursts of high frequency electric pulses supplied\\nto the transducer causes it to produce the scanning\\nsound waves. The transducer then receives the return-\\ning 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\\nthe body. The relative strength of each echo, a func-\\ntion of the specific tissue or organ boundary that\\nproduced it, can be plotted as a point of varying\\nbrightness. In this way, the echoes are translated into\\na picture. Tissues surrounded by bone or filled with\\ngas (the stomach, intestines and bowel) cannot be\\nimaged using ultrasound, because the waves are\\nblocked or become randomly scattered.\\nFour different modes of ultrasound are used in\\nmedical imaging:\\n/C15A-mode. This is the simplest type of ultrasound in\\nwhich a single transducer scans a line through the\\nbody with the echoes plotted on screen as a function\\nof depth. This method is used to measure distances\\nwithin the body and the size of internal organs.\\nTherapeutic ultrasound aimed at a specific tumor\\nor calculus is also A-mode, to allow for pinpoint\\naccurate focus of the destructive wave energy.\\n/C15B-mode. In B-mode ultrasound, a linear array of\\ntransducers simultaneously scans a plane through\\nthe body that can be viewed as a two-dimensional\\nimage on screen. Ultrasound probes containing more\\nthan 100 transducers in sequence form the basis for\\nthese most commonly used scanners, which cost\\nabout $50,000.\\n/C15M-Mode. The M stands for motion. A rapid\\nsequence of B-mode scans whose images follow\\neach other in sequence on screen enables doctors to\\nsee and measure range of motion, as the organ\\nboundaries that produce reflections move relative\\nto the probe. M-mode ultrasound has been put to\\nparticular use in studying heart motion.\\n/C15Doppler mode.Doppler ultrasonographyincludes the\\ncapability of accurately measuring velocities of mov-\\ning material, such as blood in arteries and veins. The\\nprinciple is the same as that used in radar guns that\\nmeasure the speed of a car on the highway. Doppler\\ncapability is most often combined with B-mode scan-\\nning to produce images of blood vessels from which\\nblood flow can be directly measured. This technique\\nis used extensively to investigate valve defects, arter-\\niosclerosis and hypertension, particularly in the\\nheart, but also in the abdominal aorta and the portal\\nvein of the liver. These machines cost about\\n$250,000.\\nThe actual procedure for a patient undergoing an\\nabdominal ultrasound is relatively simple, regardless\\nof the type of scan or its purpose.Fasting for at least\\neight hours prior to the procedure ensures that the\\nstomach is empty and as small as possible, and that\\nthe intestines and bowels are relatively inactive.\\nFasting also allows the gall bladder to be seen, as it\\ncontracts after eating and may not be seen if the sto-\\nmach is full. In some cases, a full bladder helps to push\\nintestinal folds out of the way so that the gas they\\ncontain does not disrupt the image. The patient’s\\nabdomen is then greased with a special gel that allows\\nthe ultrasound probe to glide easily across the skin\\nwhile 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\\nto obtain different views of the target areas. The\\npatient will likely be asked to change positions from\\nside to side and to hold their breath as necessary to\\nobtain the desired views. Discomfort during the pro-\\ncedure is minimal.\\nThe many types and uses of ultrasound technol-\\nogy makes it difficult to generalize about the time and\\ncosts involved. Relatively simple imaging–scanning a\\nsuspicious abdominal mass or a suspected abdominal\\naortic aneurysm–will take about half an hour to per-\\nform and will cost a few hundred dollars or more,\\ndepending on the quality of the equipment, the\\noperator and other factors. More involved techniques\\nsuch as multiple M-mode and Doppler-enhanced\\nscans, or cases where the targets not well defined in\\nadvance, generally take more time and are more\\nexpensive.\\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\\n4 GALE ENCYCLOPEDIA OF MEDICINE\\nAbdominal ultrasound'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='‘‘medically necessary’’ procedures designed to detect the\\npresence of suspected abnormalities, they are covered\\nunder mosttypes of major medical insurance. As always,\\nthough, the patient would be wise to confirm that their\\ncoverage extends to the specific procedure proposed.\\nFor nonemergency situations, most underwriters stipu-\\nlate prior 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\\nligament injuries, etc.–are described in detail under\\nthe appropriate entries in this encyclopedia.\\nPreparation\\nA patient undergoing abdominal ultrasound will\\nbe advised by their physician about what to expect and\\nhow to prepare. As mentioned above, preparations\\ngenerally include fasting and arriving for the proce-\\ndure with a full bladder, if necessary. This preparation\\nis particularly useful if the gallbladder, ovaries or veins\\nare to be examined.\\nAftercare\\nIn general, no aftercare related to the abdominal\\nultrasound procedure itself is required.\\nRisks\\nAbdominal ultrasound carries with it no recog-\\nnized risks or side effects, if properly performed using\\nappropriate frequency and intensity ranges. Sensitive\\ntissues, particularly those of the reproductive organs,\\ncould possibly sustain damage if violently vibrated by\\noverly intense ultrasound waves. In general though,\\nsuch damage would only result from improper use of\\nthe equipment.\\nAny woman who thinks she might be pregnant\\nshould raise this issue with her doctor before under-\\ngoing an abdominal ultrasound, as a fetus in the early\\nstages of development could be injured by ultrasound\\nmeant to probe deeply recessed abdominal organs.\\nNormal results\\nAs a diagnostic imaging technique, a normal\\nabdominal ultrasound is one that indicates the absence\\nof the suspected condition that prompted the scan.\\nFor example, symptoms such as a persistentcough,\\nlabored breathing, and upper abdominal pain suggest\\nthe possibility of, among other things, an abdominal\\naortic aneurysm. An ultrasound scan that indicates\\nthe absence of an aneurysm would rule out this life-\\nthreatening condition and point to other, less serious\\ncauses.\\nAbnormal results\\nBecause abdominal ultrasound imaging is gener-\\nally undertaken to confirm a suspected condition, the\\nresults of a scan often will prove abnormal–that is they\\nwill confirm the diagnosis, be it kidney stones, cirrho-\\nsis of the liver or an aortic aneurysm. At that point,\\nappropriate medical treatment as prescribed by a\\npatient’s doctor is in order. See the relevant disease\\nand disorder entries in this encyclopedia for more\\ninformation.\\nResources\\nPERIODICALS\\nFreundlich, Naomi. ‘‘Ultrasound: What’s Wrong with this\\nPicture?’’ Business Week September 15, 1997:84-5.\\nORGANIZATIONS\\nAmerican College of Gastroenterology. 4900 B South 31st\\nSt., Arlington, VA 22206-1656. (703) 820-7400.\\n.\\nAmerican Institute of Ultrasound in Medicine. 14750\\nSweitzer Lane, Suite 100, Laurel, MD 20707-5906.\\n(800) 638-5352. .\\nAmerican Society of Radiologic Technologists. 15000\\nCentral Ave., SE, Albuquerque, NM 87123-3917. (505)\\n298-4500. .\\nKurt Richard Sternlof\\nAbdominal wall defects\\nDefinition\\nAbdominal wall defects are birth (congenital)\\ndefects that allow the stomach or intestines to\\nprotrude.\\nDescription\\nMany unexpected and fascinating events occur\\nduring the development of a fetus inside the womb.\\nThe stomach and intestines begin development outside\\nthe baby’s abdomen and only later does the abdominal\\nwall enclose them. Occasionally, either the umbilical\\nopening is too large, or it develops improperly, allow-\\ning the bowels or stomach to remain outside or\\nsqueeze through the abdominal wall.\\nGALE ENCYCLOPEDIA OF MEDICINE 5\\nAbdominal wall defects'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nThere are many causes forbirth defects that still\\nremain unclear. Presently, the cause(s) of abdominal\\nwall defects is unknown, and any symptoms the\\nmother may have to indicate that the defects are pre-\\nsent in the fetus are nondescript.\\nDiagnosis\\nAt birth, the problem is obvious, because the base\\nof the umbilical cord at the navel will bulge or, in\\nworse cases, contain viscera (internal organs). Before\\nbirth, an ultrasound examination may detect the pro-\\nblem. It is always necessary in children with one birth\\ndefect to look for others, because birth defects are\\nusually multiple.\\nTreatment\\nAbdominal wall defects are effectively treated\\nwith surgical repair. Unless there are accompanying\\nanomalies, the surgical procedure is not overly com-\\nplicated. The organs are normal, just misplaced.\\nHowever, if the defect is large, it may be difficult to\\nfit all the viscera into the small abdominal cavity.\\nPrognosis\\nIf there are no other defects, the prognosis after\\nsurgical repair of this condition is relatively good.\\nHowever, 10% of those with more severe or additional\\nabnormalities die from it. The organs themselves\\nare fully functional; the difficulty lies in fitting them\\ninside the abdomen. The condition is, in fact, ahernia\\nrequiring only replacement and strengthening of the\\npassageway through which it occurred. After surgery,\\nincreased pressure in the stretched abdomen can com-\\npromise the function of the organs inside.\\nPrevention\\nSome, but by no means all, birth defects are pre-\\nventable by early and attentive prenatal care, good\\nnutrition, supplemental vitamins, diligent avoidance\\nof all unnecessary drugs and chemicals–especially\\ntobacco–and other elements of a healthy lifestyle.\\nResources\\nPERIODICALS\\nDunn, J. C., and E. W. Fonkalsrud. ‘‘Improved Survival of\\nInfantswith Omphalocele.’’American Journal of\\nSurgery 173 (April 1997): 284-7.\\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\\n(after 20 weeks) abortion that terminates apregnancy\\nand results in thedeath and intact removal of a fetus.\\nThis procedure is most commonly referred to as intact\\ndilatation and extraction (D & X). It occurs in a rare\\npercentage of pregnancies.\\nPurpose\\nPartial birth abortion, or D&X, is performed to\\nend a pregnancy and results in the death of a fetus,\\ntypically in the late second or third trimester.\\nAlthough D&X is highly controversial, some physi-\\ncians argue that it has advantages that make it a pre-\\nferable procedure in some circumstances. One\\nperceived advantage is that the fetus is removed\\nlargely intact, allowing for better evaluation and\\nautopsy of the fetus in cases of known fetal abnormal-\\nities. Intact removal of the fetus also may carry a lower\\nrisk of puncturing the uterus or damaging the cervix.\\nAnother perceived advantage is that D&X ends the\\npregnancy without requiring the woman to go\\nthrough labor, which may be less emotionally trau-\\nmatic than other methods of late-term abortion. In\\nKEY TERMS\\nHernia— Movement of a structure into a place it\\ndoes not belong.\\nUmbilical— Referring to the opening in the abdom-\\ninal wall where the blood vessels from the placenta\\nenter.\\nViscera— Any of the body’s organs located in the\\nchest or abdomen.\\n6 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, partial birth'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='addition, D&X may offer a lower cost and shorter\\nprocedure time.\\nPrecautions\\nWomen considering D&X should be aware of the\\nhighly controversial nature of this procedure. A con-\\ntroversy common to all late-term abortions is whether\\nthe fetus is viable, or able to survive outside of the\\nwoman’s body. A specific area of controversy with\\nD&X is that fetal death does not occur until after\\nmost of the fetal body has exited the uterus. Several\\nstates have taken legal action to limit or ban D&X and\\nmany physicians who perform abortions do not per-\\nform D&X. This may restrict the availability of this\\nprocedure to women seeking late-term abortions.\\nIn March 2003, the United States Senate passed a\\nbill banning partial birth abortions and implementing\\nfines or maximum two-year jail terms for physicians\\nwho perform them. In June 2003, the House approved\\na ban as well. President George W. Bush signed the\\nlegislation into law, but a federal judge declared the\\nlaw unconstitutional, so that the government had not\\nbeen able to enforce it. One of the opponents’ claims\\nwas the legislation did not provide for exceptions for\\ncases in which the procedure was needed to protect the\\nmother’s health.\\nDescription\\nIntact D&X, or partial birth abortion first\\ninvolves administration of medications to cause the\\ncervix to dilate, usually over the course of several\\ndays. Next, the physician rotates the fetus to a footling\\nbreech position. The body of the fetus is then drawn\\nout of the uterus feet first, until only the head remains\\ninside the uterus. Then, the physician uses an instru-\\nment to puncture the base of the skull, which collapses\\nthe fetal head. Typically, the contents of the fetal head\\nare then partially suctioned out, which results in the\\ndeath of the fetus and reduces the size of the fetal head\\nenough to allow it to pass through the cervix. The dead\\nand otherwise intact fetus is then removed from the\\nwoman’s body.\\nPreparation\\nMedical preparation for D&X involves an out-\\npatient visit to administer medications, such aslami-\\nnaria, to cause the cervix to begin dilating.\\nIn addition, preparation may involve fulfilling\\nlocal legal requirements, such as a mandatory waiting\\nperiod, counseling, or an informed consent procedure\\nreviewing stages of fetal development,childbirth, alter-\\nnative abortion methods, and adoption.\\nAftercare\\nD&X typically does not require an overnight hos-\\npital stay, so a follow up appointment may be sched-\\nuled to monitor the woman for any complications.\\nRisks\\nWith all abortion, the later in pregnancy an abor-\\ntion is performed, the more complicated the procedure\\nand the greater the risk of injury to the woman. In\\naddition to associated emotional reactions, D&X car-\\nries the risk of injury to the woman, including heavy\\nbleeding, blood clots, damage to the cervix or uterus,\\npelvic infection, and anesthesia-related complications.\\nThere also is a risk of incomplete abortion, meaning\\nthat the fetus is not dead when removed from the\\nwoman’s body. Possible long-term risks include diffi-\\nculty becoming pregnant or carrying a future preg-\\nnancy to term.\\nNormal results\\nThe expected outcome of D&X is the termination\\nof a pregnancy with removal of a dead fetus from the\\nwoman’s body.\\nResources\\nPERIODICALS\\n‘‘Court Rules Abortion Ban Unconstitutional.’’Medicine &\\nHealth (June 7, 2004): 4–6.\\n‘‘House Approves Partial Birth Abortion Ban.’’Medicine\\nand Health (June 16, 2003): 5.\\n‘‘Partial-birth Abortion Ban Approved by Senate.’’Medical\\nEthics Advisor (April 2003): 47.\\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 the\\ncervix and will be the first part of the fetus to exit the\\nuterus, with the head of the fetus being the last part\\nto 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 7\\nAbortion, partial birth'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='ORGANIZATIONS\\nPlanned Parenthood Federation of America, Inc.. 810\\nSeventh Ave., New York, NY 10019. (800) 669-0156.\\n.\\nOTHER\\nStatus of partial-birth abortion laws in the states. Othmer\\nInstitute at Planned Parenthood of NYC. 2000.\\nStefanie B. N. Dugan, M.S.\\nTeresa G. Odle\\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\\nthe mother in carrying and giving birth to more than\\none or two babies, and also to decrease the risk of\\ncomplications to the remaining fetus(es). The term\\nselective abortion also refers to choosing to abort a\\nfetus for reasons such as the woman is carrying a fetus\\nwhich likely will be born with some birth defect or\\nimpairment, or because the sex of the fetus is not\\npreferred by the individual.\\nPurpose\\nA woman may decide to abort for health reasons,\\nfor example, she is at higher risk for complications\\nduring pregnancy because of a disorder or disease\\nsuch as diabetes. A 2004 case reported on an embryo\\nembedded in acesarean sectionscar. Although rare, it\\ncan be life threatening to the mother. In this care,\\nselective abortion was successful at saving the mother\\nand the remaining embryos.\\nHowever, selective reduction is recommended\\noften in cases of multi-fetal pregnancy, or the presence\\nof more than one fetus, typically, at least three or more\\nfetuses. In the general population, multi-fetal preg-\\nnancy happens in only about 1-2% of pregnant\\nwomen. But multi-fetal pregnancies occur far more\\noften in women using fertility drugs.\\nPrecautions\\nBecause women or couples who use fertility drugs\\nhave made an extra effort to become pregnant, it is\\npossible that the individuals may be unwilling or\\nuncomfortable with the decision to abort a fetus in\\ncases of multi-fetal pregnancy. Individuals engaging in\\nfertility treatment should be made aware of the risk of\\nmulti-fetal pregnancy and consider the prospect of\\nrecommended reduction before undergoing fertility\\ntreatment.\\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\\nprocedure and can be performed on an outpatient\\nbasis. A needle is inserted into the woman’s stomach\\nor vagina and potassium chloride is injected into the\\nfetus.\\nPreparation\\nIndividuals who have chosen selective reduction\\nto safeguard the remaining fetuses should be coun-\\nseled prior to the procedure. Individuals should\\nreceive information regarding the risks of a multi-\\nfetal pregnancy to both the fetuses and the mother\\ncompared with the risks after 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\\nthe process.\\nRisks\\nAbout 75% of women who undergo selective\\nreduction will go intopremature labor. About 4-5%\\nof women undergoing selective reduction also\\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.\\n8 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, selective'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='miscarry one or more of the remaining fetuses. The\\nrisks associated with multi-fetal pregnancy are consid-\\nered higher.\\nNormal results\\nIn cases where a multi-fetal pregnancy of three or\\nmore fetuses is reduced to two fetuses, the remaining\\ntwin fetuses typically develop as they would if they had\\nbeen conceived as twins.\\nResources\\nPERIODICALS\\n‘‘Multiple Pregnancy Associated With Infertility Therapy.’’\\nAmerican Society for Reproductive Medicine, A Practice\\nCommittee Report (November 2000): 1-8.\\n‘‘Selective Reduction Eleiminates an Emryo Embedded\\nin a Cesarean Scar.’’WomenÆs Health Weekly (April 8,\\n2004): 117.\\nORGANIZATIONS\\nThe Alan Guttmacher Institute. 120 Wall Street, New York,\\nNY 10005. (212) 248-1111. .\\nThe American Society for Reproductive Medicine. 1209\\nMontgomery Highway, Birmingham, AL 35216-2809.\\n(205) 978-5000. .\\nMeghan M. Gourley\\nTeresa G. Odle\\nAbortion, spontaneous see Miscarriage\\nAbortion, therapeutic\\nDefinition\\nTherapeutic abortion is the intentional termina-\\ntion of apregnancy before the fetus can live indepen-\\ndently. Abortion has been a legal procedure in the\\nUnited States since 1973.\\nPurpose\\nAn abortion may be performed whenever there is\\nsome compelling reason to end a pregnancy. Women\\nhave abortions because continuing the pregnancy\\nwould cause them hardship, endanger their life or\\nhealth, or because prenatal testing has shown that\\nthe fetus will be born with severe abnormalities.\\nAbortions are safest when performed within the\\nfirst six to 10 weeks after the last menstrual period.\\nThe calculation of this date is referred to as the\\ngestational age and is used in determining the stage\\nof pregnancy. For example, a woman who is two\\nweeks late having her period is said to be six weeks\\npregnant, because it is six weeks since she last\\nmenstruated.\\nAbout 90% of women who have abortions do so\\nbefore 13 weeks and experience few complications.\\nAbortions performed between 13-24 weeks have a\\nhigher rate of complications. Abortions after 24\\nweeks are extremely rare and are usually limited to\\nsituations where the life of the mother is in danger.\\nPrecautions\\nMost women are able to have abortions at clinics\\nor outpatient facilities if the procedure is performed\\nearly in pregnancy. Women who have stable diabetes,\\ncontrolled epilepsy, mild to moderate high blood pres-\\nsure, or who are HIV positive can often have abortions\\nas outpatients if precautions are taken. Women with\\nheart disease, previous endocarditis, asthma,l u p u s\\nerythematosus, uterine fibroid tumors, blood clotting\\ndisorders, poorly controlled epilepsy, or some psycho-\\nlogical disorders usually need to be hospitalized in\\norder to receive special monitoring and medications\\nduring the procedure.\\nDescription\\nVery early abortions\\nBetween five and seven weeks, a pregnancy can be\\nended by a procedure called menstrual extraction.\\nThis procedure is also sometimes called menstrual\\nregulation, mini-suction, or preemptive abortion.\\nThe contents of the uterus are suctioned out through\\na thin (3-4 mm) plastic tube that is inserted through the\\nundilated cervix. Suction is applied either by a bulb\\nsyringe or a small pump.\\nAnother method is called the ‘‘morning after’’ pill,\\nor emergency contraception. Basically, it involves tak-\\ning high doses of birth control pills within 24 to 48\\nhours of having unprotected sex. The high doses of\\nhormones causes the uterine lining to change so that it\\nwill not support a pregnancy. Thus, if the egg has been\\nfertilized, it is simply expelled from the body.\\nThere are two types of emergencycontraception.\\nOne type is identical to ordinary birth control pills,\\nand uses the hormones estrogen and progestin). This\\ntype is available with a prescription under the brand\\nname Preven. But women can even use their regular\\nbirth control pills for emergency contraception, after\\nthey check with their doctor about the proper dose.\\nAbout half of women who use birth control pills for\\nGALE ENCYCLOPEDIA OF MEDICINE 9\\nAbortion, therapeutic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='emergency contraception get nauseated and 20 percent\\nvomit.Thismethodcutstheriskofpregnancy75percent.\\nThe other type of morning-after pill contains only\\none hormone: progestin, and is available under the\\nbrand name Plan B. It is more effective than the first\\ntype with a lower risk ofnausea and vomiting. It\\nreduces the risk of pregnancy 89 percent.\\nWomen should check with their physicians\\nregarding the proper dose of pills to take, as it depends\\non the brand of birth control pill. Not all birth control\\npills will work for emergency contraception.\\nMenstrual extractions are safe, but because the\\namount of fetal material is so small at this stage of\\ndevelopment, it is easy to miss. This results in an incom-\\nplete abortion that means the pregnancy continues.\\nFirst trimester abortions\\nThe first trimester of pregnancy includes the first\\n13 weeks after the last menstrual period. In the United\\nStates, about 90% of abortions are performed during\\nthis period. It is the safest time in which to have an\\nabortion, and the time in which women have the most\\nchoice of how the procedure is performed.\\nMEDICAL ABORTIONS. Medical abortions are\\nbrought about by taking medications that end the\\npregnancy. The advantages of a first trimester medical\\nabortion are:\\nUterus\\nEmbryonic\\ntissue\\nVagina Vulsellum\\nCervix\\nSpeculum\\nExtraction tube \\nBetween 5 and 7 weeks, a pregnancy can be ended by a procedure called menstrual extraction. The contents of the uterus are\\nsuctioned out through a thin extraction tube that is inserted through the undilated cervix.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nEndocarditis— An infection of the inner membrane\\nlining of the heart.\\nFibroid tumors— Fibroid tumors are non-cancerous\\n(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 produce\\nimmune responses. If an Rh negative woman is\\npregnant 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.\\n10 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, therapeutic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15The procedure is non-invasive; no surgical instru-\\nments are used.\\n/C15Anesthesia is not required.\\n/C15Drugs are administered either orally or by injection.\\n/C15The procedure resembles a naturalmiscarriage.\\nDisadvantages of a medical abortion are:\\n/C15The effectiveness decreases after the seventh week.\\n/C15The proceduremay requiremultiple visits to the doctor.\\n/C15Bleeding after the abortion lasts longer than after a\\nsurgical abortion.\\n/C15The woman may see the contents of her womb as it is\\nexpelled.\\nTwo different medications can be used to bring\\nabout an abortion. Methotrexate (Rheumatrex) works\\nby stopping fetal cells from dividing which causes the\\nfetus to die.\\nOn the first visit to the doctor, the woman receives\\nan injection of methotrexate. On the second visit,\\nabout a week later, she is given misoprostol\\n(Cytotec), an oxygenated unsaturated cyclic fatty\\nacid responsible for various hormonal reactions such\\nas muscle contraction (prostaglandin), that stimulates\\ncontractions of the uterus. Within two weeks, the\\nwoman will expel the contents of her uterus, ending\\nthe pregnancy. A follow-up visit to the doctor is neces-\\nsary to assure that the abortion 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 pro-\\ngesterone, a hormone needed for pregnancy to con-\\ntinue, then stimulates ulerine contractions thus ending\\nthe pregnancy. It can be taken as much as 49 days after\\nthe first day of a woman’s last period. On the first visit\\nto the doctor, a woman takes a mifepristone pill. Two\\ndays later 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\\nto take misoprostol. After an observation period, she\\nreturns home.\\nWithin four days, 90% of women have expelled\\nthe contents of their uterus and completed the abor-\\ntion. Within 14 days, 95-97% of women have com-\\npleted the abortion. A third follow-up visit to the\\ndoctor is necessary to confirm through observation\\nor ultrasound that the procedure is complete. In the\\nevent that it is not, a surgical abortion is performed.\\nStudies show that 4.5 to 8 percent of women need\\nsurgery or a bloodtransfusion after taking mifepris-\\ntone, and the pregnancy persists in about 1 percent of\\nwomen. In this case, surgical abortion is recom-\\nmended because the fetus may be damanged. Side\\neffects include nausea, vaginal bleeding and heavy\\ncramping. The bleeding is typically heavier than a\\nnormal period and may last up to 16 days.\\nMifepristone is not recommended for women with\\nectopic pregnancy, an IUD, who have been taking\\nlong-term steroidal therapy, have bleeding abnormal-\\nities or on blood-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,\\nvacuum curettage, or suction curettage.\\nAdvantages of a vacuum aspiration abortion are:\\n/C15It is usually done as a one-day outpatient procedure.\\n/C15The procedure takes only 10-15 minutes.\\n/C15Bleeding after the abortion lasts five days or less.\\n/C15The woman does not see the products of her womb\\nbeing removed.\\nDisadvantages include:\\n/C15The procedure is invasive; surgical instruments are\\nused.\\n/C15Infection may occur.\\nDuring a vacuum aspiration, the woman’s cervix\\nis gradually dilated by expanding rods inserted into\\nthe cervical opening. Once dilated, a tube attached to a\\nsuction pump is inserted through the cervix and the\\ncontents of the uterus are suctioned out. The proce-\\ndure is 97-99% effective. The amount of discomfort a\\nwoman feels varies considerably.Local anesthesia is\\noften given to numb the cervix, but it does not mask\\nuterine cramping. After a few hours of rest, the woman\\nmay return home.\\nSecond trimester abortions\\nAlthough it is better to have an abortion during\\nthe first trimester, some second trimester abortions\\nmay be inevitable. The results ofgenetic testing are\\noften not available until 16 weeks. In addition,\\nwomen, especially teens, may not have recognized\\nthe pregnancy or come to terms with it emotionally\\nsoon enough to have a first trimester abortion. Teens\\nmake up the largest group having second trimester\\nabortions.\\nGALE ENCYCLOPEDIA OF MEDICINE 11\\nAbortion, therapeutic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Some second trimester abortions are performed\\nas a D & E. The procedures are similar to those used\\nin the first trimester, but a larger suction tube must be\\nused because more material must be removed. This\\nincreases the amount of cervical dilation necessary and\\nincreases the risk of the procedure. Many physicians are\\nreluctant to perform a D & E this late in pregnancy, and\\nfor some women is it not a medically safe option.\\nThe alternative to a D & E in the second trimester\\nis an abortion by induced labor. Induced labor may\\nrequire an overnight stay in a hospital. The day before\\nthe procedure, the woman visits the doctor for tests,\\nand to either have rods inserted in her cervix to help\\ndilate it or to receive medication that will soften the\\ncervix and speed up labor.\\nOn the day of the abortion, drugs, usually pros-\\ntaglandins to induce contractions, and a salt water\\nsolution, are injected into the uterus. Contractions\\nbegin, and within eight to 72 hours the woman delivers\\nthe fetus.\\nSide effects of this procedure include nausea,vomit-\\ning,a n ddiarrhea from the prostaglandins, andpain\\nfrom uterine cramps. Anesthesia of the sort used in\\nchildbirthcan 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.\\nLater abortions cost more. The cost increases about\\n$100 per week between the thirteenth and sixteenth\\nweek. Second trimester abortions are much more\\ncostly because they often involve more risk, more\\nservices, anesthesia, and sometimes a hospital stay.\\nInsurance carriers and HMOs may or may not cover\\nthe procedure. Federal law prohibits federal funds\\nincluding Medicaid funds, from being used to pay for\\nan elective abortion.\\nPreparation\\nThe doctor must know accurately the stage of a\\nwoman’s pregnancy before an abortion is performed.\\nThe doctor will ask the woman questions about her\\nmenstrual cycle and also do a physical examination to\\nconfirm the stage of pregnancy. This may be done at\\nan office visit before the abortion or on the day of the\\nabortion. Some states require a waiting period before\\nan abortion can be performed. Others require parental\\nor court consent for a child under age 18 to receive an\\nabortion.\\nDespite the fact that almost half of all women\\nin the United States have had at least one abortion\\nby the time they reach age 45, abortion is surrounded\\nby controversy. Women often find themselves in\\nemotional turmoil when deciding if an abortion is\\na procedure they wish to undergo. Pre-abortion coun-\\nseling is important in helping a woman resolve any\\nquestions she may have about having the procedure.\\nAftercare\\nRegardless of the method used to perform the\\nabortion, a woman will be observed for a period of\\ntime to make sure her blood pressure is stable and\\nthat bleeding is controlled. The doctor may prescribe\\nantibiotics to reduce the chance of infection. Women\\nwho are Rh negative (lacking genetically determined\\nantigens in their red blood cells that produce immune\\nresponses) should be given a human Rh immune\\nglobulin (RhoGAM) after the procedure unless the\\nfather of the fetus is also Rh negative. This prevents\\nblood incompatibility complications in future\\npregnancies.\\nBleeding will continue for about five days in a\\nsurgical abortion and longer in a medical abortion.\\nTo decrease the risk of infection, a woman should\\navoid intercourse and not use tampons and douches\\nfor two weeks after the abortion.\\nA follow-up visit is a necessary part of the\\nwoman’s aftercare. Contraception will be offered to\\nwomen who wish to avoid future pregnancies, because\\nmenstrual periods normally resume within a few\\nweeks.\\nRisks\\nSerious complications resulting from abortions\\nperformed before 13 weeks are rare. Of the 90% of\\nwomen who have abortions in this time period, 2.5%\\nhave minor complications that can be handled without\\nhospitalization. Less than 0.5% have complications\\nthat require a hospital stay. The rate of complications\\nincreases as the pregnancy progresses.\\nComplications from abortions can include:\\n/C15uncontrolled bleeding\\n/C15infection\\n/C15blood clots accumulating in the uterus\\n/C15a tear in the cervix or uterus\\n/C15missed abortion where the pregnancy continues\\n/C15incomplete abortion where some material from the\\npregnancy remains in the uterus\\nWomen who experience any of the following\\nsymptoms of post-abortion complications should call\\nthe clinic or doctor who performed the abortion\\nimmediately.\\n12 GALE ENCYCLOPEDIA OF MEDICINE\\nAbortion, therapeutic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15severe pain\\n/C15fever over 100.48F (38.28C)\\n/C15heavy bleeding that soaks through more than one\\nsanitary pad per hour\\n/C15foul-smelling discharge from the vagina\\n/C15continuing symptoms of pregnancy\\nNormal results\\nUsually the pregnancy is ended without compli-\\ncation and without altering future fertility.\\nResources\\nBOOKS\\nCarlson, Karen J., Stephanie A. Eisenstat, and Terra\\nZiporyn. ‘‘Abortion.’’ InThe Harvard Guide to\\nWomen’s Health. Cambridge, MA: Harvard University\\nPress, 1996.\\nDebra Gordon\\nAbrasions see Wounds\\nAbruptio placentae see Placental abruption\\nAbscess\\nDefinition\\nAn abscess is an enclosed collection of liquefied\\ntissue, known as pus, somewhere in the body. It is the\\nresult of the body’s defensive reaction to foreign\\nmaterial.\\nDescription\\nThere are two types of abscesses, septic and sterile.\\nMost abscesses are septic, which means that they are\\nthe result of an infection. Septic abscesses can occur\\nanywhere in the body. Only a germ and the body’s\\nimmune response are required. In response to the\\ninvading germ, white blood cells gather at the infected\\nsite and begin producing chemicals called enzymes\\nthat attack the germ by digesting it. These enzymes\\nact like acid, killing the germs and breaking them\\ndown into small pieces that can be picked up by\\nthe circulation and eliminated from the body.\\nUnfortunately, these chemicals also digest body tis-\\nsues. In most cases, the germ produces similar chemi-\\ncals. The result is a thick, yellow liquid–pus–\\ncontaining digested germs, digested tissue, white\\nblood cells, and enzymes.\\nAn abscess is the last stage of a tissue infection\\nthat begins with a process called inflammation.\\nInitially, as the invading germ activates the body’s\\nimmune system, several events occur:\\n/C15Blood flow to the area increases.\\n/C15The temperature of the area increases due to the\\nincreased blood supply.\\n/C15The area swells due to the accumulation of water,\\nblood, and other liquids.\\n/C15It turns red.\\n/C15It hurts, because of the irritation from the swelling\\nand the chemical activity.\\nThese four signs–heat, swelling, redness, and\\npain–characterize 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\\nfollows the path of least resistance–the tissues most\\neasily digested. A good example is an abscess just\\nbeneath the skin. It most easily continues along\\nbeneath the skin rather than working its way through\\nthe skin where it could drain its toxic contents. The\\ncontents of the abscess also leak into the general cir-\\nculation and produce symptoms just like any other\\ninfection. These include chills, fever, aching, and\\ngeneral discomfort.\\nSterile abscesses are sometimes a milder form\\nof the same process caused not by germs but by non-\\nliving irritants such as drugs. If an injected drug\\nlike penicillin is not absorbed, it stays where it was\\nAn amoebic abscess caused by Entameoba histolytica .\\n(Phototake NYC. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 13\\nAbscess'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='injected and may cause enough irritation to generate\\na sterile abscess–sterile because there is no infection\\ninvolved. Sterile abscesses are quite likely to turn into\\nhard, solid lumps as they scar, rather than remaining\\npockets 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\\ncause of abscesses under the skin. Abscesses near\\nthe large bowel, particularly around the anus, may\\nbe caused by any of the numerous bacteria found\\nwithin the large bowel. Brain abscesses and liver\\nabscesses can be caused by any organism that can\\ntravel there through the circulation. Bacteria,\\namoeba, and certain fungi can travel in this fashion.\\nAbscesses in other parts of the body are caused by\\norganisms that normally inhabit nearby structures or\\nthat infect them. Some common causes of specific\\nabscesses are:\\n/C15skin abscesses by normal skin flora\\n/C15dental and throat abscesses by mouth flora\\n/C15lung abscesses by normal airway flora,pneumonia\\ngerms, or tuberculosis\\n/C15abdominal and anal abscesses by normal bowel\\nflora\\nSpecific types of abscesses\\nListed below are some of the more common and\\nimportant abscesses.\\n/C15Carbuncles and otherboils. Skin oil glands (sebac-\\neous glands) on the back or the back of the neck\\nare the ones usually infected. The most common\\ngerm involved is Staphylococcus aureus . Acne is a\\nsimilar condition of sebaceous glands on the face\\nand back.\\n/C15Pilonidal abscess. Many people have as a birth defect\\na tiny opening in the skin just above the anus. Fecal\\nbacteria can enter this opening, causing an infection\\nand subsequent abscess.\\n/C15Retropharyngeal, parapharyngeal, peritonsillar\\nabscess. As a result of throat infections like strep\\nthroat andtonsillitis, bacteria can invade the deeper\\ntissues of the throat and cause an abscess. These\\nabscesses can compromise swallowing and even\\nbreathing.\\n/C15Lung abscess. During or after pneumonia, whether\\nit’s due to bacteria [common pneumonia], tubercu-\\nlosis, fungi, parasites, or other germs, abscesses can\\ndevelop as a complication.\\n/C15Liver abscess. Bacteria or amoeba from the intestines\\ncan spread through the blood to the liver and cause\\nabscesses.\\n/C15Psoas 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\\nappendix, 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\\nonly generalized symptoms such as fever and discom-\\nfort. If the patient’s symptoms and physical examina-\\ntion do not help, a physician may have to resort to a\\nbattery of tests to locate the site of an abscess, but\\nusually something in the initial evaluation directs the\\nsearch. Recent or chronic disease in an organ suggests\\nit may be the site of an abscess. Dysfunction of an\\norgan or system–for instance, seizures or altered bowel\\nfunction–may provide the clue.Pain and tenderness\\non physical examination are common findings.\\nSometimes a deep abscess will eat a small channel\\n(sinus) to the surface and begin leaking pus. A sterile\\nabscess may cause only a painful lump deep in the\\nbuttock where a shot was given.\\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 anat-\\nomy that carries eggs from the ovaries to the uterus.\\nFlora— Living inhabitants of a region or area.\\nPyogenic— Capable of generating pus.Streptococcus,\\nStaphocococcus, and bowel bacteria are the primary\\npyogenic 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 stream.\\nSinus— A tubular channel connecting one body\\npart with another or with the outside.\\n14 GALE ENCYCLOPEDIA OF MEDICINE\\nAbscess'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nSince skin is very resistant to the spread of infec-\\ntion, it acts as a barrier, often keeping the toxic\\nchemicals of an abscess from escaping the body on\\ntheir own. Thus, the pus must be drained from the\\nabscess by a physician. The surgeon determines when\\nthe abscess is ready for drainage and opens a path to\\nthe outside, allowing the pus to escape. Ordinarily, the\\nbody handles the remaining infection, sometimes with\\nthe help ofantibiotics or other drugs. The surgeon may\\nleave a drain (a piece of cloth or rubber) in the abscess\\ncavity to prevent it from closing before all the pus has\\ndrained 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\\nhot compresses to the skin over the abscess will hasten\\nthe digestion of the skin and eventually result in its\\nbreaking down, releasing the pus spontaneously. This\\ntreatment is best reserved for smaller abscesses in rela-\\ntively less dangerous areas of the body–limbs, trunk,\\nback of the neck. It is also useful for all superficial\\nabscesses in their very early stages. It will ‘‘ripen’’\\nthem.\\nContrast hydrotherapy, alternating hot and\\ncold compresses, can also help assist the body in\\nresorption of the abscess. There are two homeo-\\npathic remedies that work to rebalance the body in\\nrelation to abscess formation, Silica and Hepar\\nsulphuris . In cases of septic abscesses, bentonite\\nclay packs (bentonite clay and a small amount of\\nHydrastis powder) can be used to draw the infection\\nfrom the area.\\nPrognosis\\nOnce the abscess is properly drained, the prog-\\nnosis is excellent for the condition itself. The reason\\nfor the abscess (other diseases the patient has) will\\ndetermine the overall outcome. If, on the other\\nhand, the abscess ruptures into neighboring areas or\\npermits the infectious agent to spill into the blood-\\nstream, serious or fatal consequences are likely.\\nAbscesses in and around the nasal sinuses, face, ears,\\nand scalp may work their way into the brain.\\nAbscesses within an abdominal organ such as the\\nliver may rupture into the abdominal cavity. In either\\ncase, the result is life threatening. Bloodpoisoning is a\\nterm commonly used to describe an infection that has\\nspilled into the blood stream and spread throughout\\nthe body from a localized origin. Blood poisoning,\\nknown to physicians as septicemia, is also life\\nthreatening.\\nOf special note, abscesses in the hand are more\\nserious than they might appear. Due to the intricate\\nstructure and the overriding importance of the hand,\\nany hand infection must be treated promptly and\\ncompetently.\\nPrevention\\nInfections that are treated early with heat (if\\nsuperficial) or antibiotics will often resolve without\\nthe formation of an abscess. It is even better to avoid\\ninfections altogether by taking prompt care of open\\ninjuries, particularly puncture wounds. Bites are the\\nmost dangerous of all, even more so because they\\noften occur on the hand.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles\\nof Internal Medicine. New York: McGraw-Hill,\\n1997.\\nJ. Ricker Polsdorfer, MD\\nAbscess drainage see Abscess incision and\\ndrainage\\nAbscess incision & drainage\\nDefinition\\nAn infected skin nodule that contains pus may\\nneed to be drained via a cut if it does not respond to\\nantibiotics. This allows the pus to escape, and the\\ninfection 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\\ninfection. Abscesses are often found in the soft tissue\\nunder the skin, such as the armpit or the groin.\\nGALE ENCYCLOPEDIA OF MEDICINE 15\\nAbscess incision & drainage'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='However, they may develop in any organ, and are\\ncommonly found in the breast and gums. Abscesses\\nare far more serious and call for more specific treat-\\nment if they are located in deep organs such as the\\nlung, liver or brain.\\nBecause the lining of the abscess cavity tends\\nto interfere with the amount of the drug that can\\npenetrate the source of infection from the blood, the\\ncavity itself may require draining. Once an abscess has\\nfully formed, it often does not respond to antibiotics.\\nEven if the antibiotic does penetrate into the abscess, it\\ndoesn’t function as well in that environment.\\nPrecautions\\nAn abscess can usually be diagnosed visually,\\nalthough an imaging technique such as a computed\\ntomography scan may be used to confirm the extent of\\nthe abscess before drainage. Such procedures may also\\nbe needed to localize internal abscesses, such as those\\nin the abdominal cavity or brain.\\nDescription\\nA doctor will cut into the lining of the abscess,\\nallowing the pus to escape either through a drainage\\ntube or by leaving the cavity open to the skin. How big\\nthe incision is depends on how quickly the pus is\\nencountered.\\nOnce the abscess is opened, the doctor will clean\\nand irrigate the wound thoroughly with saline. If it is\\nnot too large or deep, the doctor may simply pack the\\nabscess wound with gauze for 24–48 hours to absorb\\nthe pus and discharge.\\nIf it is a deeper abscess, the doctor may insert a\\ndrainage tube after cleaning out the wound. Once the\\nLiver\\nStomach\\nSpleen\\nColon\\nCommon sites of abscess \\nabove and below the liver\\nAlthough abscesses are often found in the soft tissue under the skin, such as the armpit or the groin, they may develop in any\\norgan, such as the liver. (Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nWhite blood cells— Cells that protect the body\\nagainst infection.\\n16 GALE ENCYCLOPEDIA OF MEDICINE\\nAbscess incision & drainage'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='tube is in place, the surgeon closes the incision with\\nsimple stitches, and applies a sterile dressing. Drainage\\nis maintained for several days to help prevent the\\nabscess from reforming.\\nPreparation\\nThe skin over the abscess will be cleansed by\\nswabbing gently with an antiseptic solution.\\nAftercare\\nMuch of thepain 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\\nseveral days. Applying heat and keeping the affected\\narea elevated 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.\\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 anything that is harmful,\\ninjurious, or offensive. Abuse also includes excessive\\nand wrongful misuse of a substance. There are several\\nmajor types of abuse: physical and sexual abuse of a\\nchild or an adult,substance abuse, elderly abuse, and\\nemotional abuse.\\nDescription\\nPhysical abuse of a child is the infliction of injury\\nby another person. The injuries can include punching,\\nkicking, biting, burning, beating, or pulling the vic-\\ntim’s hair. The physical abuse inflicted on a child can\\nresult inbruises, burns, poisoning, broken bones, and\\ninternal hemorrhages. Physical assault against an\\nadult primarily occurs with women, usually in the\\nform of domestic violence. It is estimated that approxi-\\nmately three million children witness domestic vio-\\nlence every year.\\nSexual abuse of a child refers to sexual behavior\\nbetween an adult and child or between two children,\\none of whom is dominant or significantly older. The\\nsexual behaviors can include touching breasts, geni-\\ntals, and buttocks; either dressed or undressed. The\\nbehavior also can include exhibitionism, cunnilingus,\\nfellatio, or penetration of the vagina or anus with\\nsexual organs or objects.\\nPornographic photography also is used in sexual\\nabuse with children. Reported sex offenders are 97%\\nmale. Reports of child pornography have increased\\nsince with the popularity of the Internet. Females\\nmore often are perpetrators in child-care settings,\\nsince children may confuse sexual abuse by a female\\nwith normal hygiene care. The 1990s and early 2000s\\nwere rocked by reports of sexual abuse of children\\ncommitted by Catholic priests. Most of the abuse\\nappeared to have occurred during the 1970s and a\\nprominent report released early in 2004 stated that as\\nmany as 10.667 children were sexually abused by more\\nthan 4,300 priests. Sexual abuse by stepfathers is five\\ntimes more common than with biological fathers.\\nSexual abuse of daughters by stepfathers or fathers is\\nthe most common form of incest.\\nSexual abuse also can take the form ofrape. The\\nlegal definition of rape includes only slight penile\\npenetration in the victim’s outer vulva area.\\nComplete erection and ejaculation are not necessary.\\nRape is the perpetration of an act of sexual intercourse\\nwhether:\\n/C15will is overcome by force or fear (from threats or by\\nuse of drugs).\\n/C15mental impairment renders the victim incapable of\\nrational judgment.\\n/C15if the victim is below the legal age established for\\nconsent.\\nSubstance abuse is an abnormal pattern of sub-\\nstance usage leading to significant distress or impair-\\nment. The criteria include one or more of the following\\noccurring within a 12-month period:\\nGALE ENCYCLOPEDIA OF MEDICINE 17\\nAbuse'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15recurrent substance use resulting in failure to fulfill\\nobligations at home, work, or school.\\n/C15using substance in situations that are physically dan-\\ngerous (i.e., while driving).\\n/C15recurrent substance-related legal problems.\\n/C15continued usage despite recurrent social and inter-\\npersonal problems (i.e., arguments and fights with\\nsignificant other).\\nAbuse of the elderly is common and occurs mostly\\nas a result of caretaker burnout, due to the high level\\nof dependency frail, elderly patients usually require.\\nAbuse can be manifested by physical signs, fear, and\\ndelaying or not reporting the need for advanced med-\\nical care. Elderly patients also may exhibit financial\\nabuse (money or possessions taken away) and\\nabandonment.\\nEmotional abuse generally continues even after\\nphysical assaults have stopped. In most cases it is a\\npersonally tailored form of verbal or gesture abuse\\nexpressed to illicit a provoked response.\\nCauses and symptoms\\nChildren who have been abused usually have a\\nvariety of symptoms that encompass behavioral, emo-\\ntional, and psychosomatic problems (body problems\\ncaused by emotional or mental disturbance). Children\\nwho have been physically abused tend to be more\\naggressive, angry, hostile, depressed, and have low\\nself-esteem. Additionally, they exhibit fear,anxiety,\\nand nightmares. Severe psychological problems may\\nresult in suicidal behavior or posttraumatic stress dis-\\norder. Physically abused children may complain of\\nphysical illness even in the absence of a cause. They\\nalso may suffer from eating disorders andencopresis,\\nor involuntary defecation caused or psychic origin.\\nChildren who are sexually abused may exhibit abnor-\\nmal sexual behavior in the form of aggressiveness and\\nhyperarousal. Adolescents may display promiscuity,\\nsexual acting out, and—in some situations—homo-\\nsexual contact.\\nPhysical abuse directed towards adults can ulti-\\nmately lead todeath. Approximately 50% of women\\nmurdered in the United States were killed by a former\\nor current male partner. Approximately one-third of\\nemergency room consultations by women were\\nprompted due to domestic violence. Female victims\\nwho are married also have a higher rate of internal\\ninjuries and unconsciousness than victims of stranger\\nassault (mugging, robbery). Physical abuse or rape\\nalso can occur between married persons and persons\\nof the same gender. Perpetrators usually sexually\\nassault their victims to dominate, hurt, and debase\\nthem. It is common for physical and sexual violence\\nto occur at the same time. A large percentage of sexu-\\nally assaulted persons were also physically abused in\\nthe form of punching, beating, or threatening the vic-\\ntim with a weapon such as a gun or knife. Usually\\nmales who are hurt and humiliated tend to physically\\nassault people whom they are intimately involved\\nwith, such as spouses and/or children. Males who\\nassault a female tend to have experienced or witnessed\\nviolence during childhood. They also tend to abuse\\nalcohol, to be sexually assaultive, and are at increased\\nrisk for assaultive behavior directed against children.\\nJealous males tend to monitor a women’s movements\\nand whereabouts and to isolate other sources of pro-\\ntection and support. They interpret their behavior as\\nbetrayal of trust and this causes resentment and explo-\\nsive anger outbursts during periods of losing control.\\nMales also may use aggression against females in an\\neffort to control and intimidate partners.\\nAbuse in the elderly usually occurs in the frail,\\nelderly community. The caretaker is usually the perpe-\\ntrator. Caretaker abuse can be suspected if there is\\nevidence suggesting behavioral changes in the elderly\\nperson when the caretaker is present. Additionally,\\nelderly abuse can be possible if there are delays\\nbetween injuries and treatment, inconsistencies\\nbetween injury and explanations, lack of hygiene or\\nclothing, and prescriptions not being filled.\\nDiagnosis\\nChildren who are victims of domestic violence\\nfrequently are injured attempting to protect their\\nmother from an abusive partner. Injuries are visible\\nby inspection or self-report. Physical abuse of an adult\\nmay also be evident by inspection with visible cuts\\nand/or bruises or self-report.\\nSexual abuse of both a child and an adult can be\\ndiagnosed with a history from the victim. Victims can\\nbe assessed for signs of ejaculatory evidence from the\\nperpetrator. Ejaculatory specimens can be retrieved\\nfrom the mouth, rectum, and clothing. Tests for sexu-\\nally transmitted diseases may be performed.\\nKEY TERMS\\nEncopresis— Abnormalities relating to bowel\\nmovements that can occur as a result of stress or\\nfear.\\n18 GALE ENCYCLOPEDIA OF MEDICINE\\nAbuse'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Elderly abuse can be suspected if the elderly patient\\ndemonstrates a fear of 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\\nrecurrent negative consequences. The diagnosis can\\nbe made after administration of a comprehensive\\nexam and standardized chemical abuse assessments\\nby a therapist.\\nTreatment\\nChildren who are victims of physical or sexual\\nabuse typically require psychological support and\\nmedical attention. A complaint may be filed with the\\nlocal family social services agency that will initiate\\ninvestigations. The authorities usually will follow up\\nthe allegation or offense. Children may also be\\nreferred for psychological evaluation and/or treat-\\nment. The victim also may be placed in foster care\\npending the investigation outcome. The police also\\nmay investigate physical and sexual abuse of an\\nadult. The victim may require immediate medical\\ncare and long-term psychological treatment. It is com-\\nmon for children to be adversely affected by domestic\\nviolence situations and the local family services agency\\nmay be involved.\\nSubstance abusers should elect treatment, either\\ninpatient or outpatient, depending on severity of\\naddiction. Long term treatment and/or medications\\nmay be utilized to assist in abstinence. The patient\\nshould be encouraged to participate in community\\ncentered support groups.\\nPrognosis\\nThe prognosis depends on the diagnosis.\\nUsually victims of physical and sexual abuse require\\ntherapy to deal with emotional distress associated\\nwith the incident. Perpetrators require further psy-\\nchological evaluation and treatment. Victims of\\nabuse may have a variety of emotional problems\\nincluding depression, acts of suicide,o ra n x i e t y .\\nChildren of sexual abuse may enter abusive rela-\\ntionships or have problems with intimacy as adults.\\nThe substance abuser may experience relapses, since\\nthe cardinal feature of all addictive disorders is a\\ntendency to return to symptoms. Elderly patients\\nmay suffer from further medical problems and/or\\nanxiety, and in some cases neglect may precipitate\\ndeath.\\nPrevention\\nPrevention programs are geared to education and\\nawareness. Detection of initial symptoms or charac-\\nteristic behaviors may assist in some situations. In\\nsome cases treatment may be sought before incident.\\nThe professional treating the abused persons must\\ndevelop a clear sense of the relationship dynamics\\nand the chances for continued harm.\\nResources\\nBOOKS\\nBehrman, Richard E., et al, editors.Nelson Textbook of\\nPediatrics. 16th ed. W. B. Saunders Company, 2000.\\nPERIODICALS\\nPlante, Thomas G. ‘‘Another Aftershock: What Have We\\nLearned from the John Jay Report?.’’America (March\\n22, 2004): 10.\\nORGANIZATIONS\\nNational Clearinghouse on Child Abuse and Neglect\\nInformation. 330 C Street SW, Washington, DC 20447.\\n(800) 392-3366.\\nOTHER\\nElder Abuse Prevention. .\\nNational Institute on Drug Abuse. .\\nLaith Farid Gulli, M.D.\\nBilal Nasser, M.Sc.\\nTeresa G. Odle\\nAcceleration-deceleration cervical injurysee\\nWhiplash\\nACE inhibitors see Angiotensin-converting\\nenzyme inhibitors\\nAcetaminophen\\nDefinition\\nAcetaminophen is a medicine used to relievepain\\nand reducefever.\\nPurpose\\nAcetaminophen is used to relieve many kinds of\\nminor aches and pains—headaches, muscle aches,\\nbackaches, toothaches, menstrual cramps, arthritis,\\nand the aches and pains that often accompany colds.\\nGALE ENCYCLOPEDIA OF MEDICINE 19\\nAcetaminophen'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nThis drug is available without a prescription.\\nAcetaminophen is sold under various brand names,\\nincluding Tylenol, Panadol,Aspirin Free Anacin, and\\nBayer Select Maximum StrengthHeadache Pain Relief\\nFormula. Many multi-symptom cold, flu, and sinus\\nmedicines also contain acetaminophen. The ingredi-\\nents listing on the container should state if acetamino-\\nphen is included in the product.\\nStudies have shown that acetaminophen relieves\\npain and reduces fever about as well as aspirin. But\\ndifferences between these two common drugs exist.\\nAcetaminophen is less likely than aspirin to irritate\\nthe stomach. However, unlike aspirin, acetaminophen\\ndoes not reduce the redness, stiffness, or swelling that\\naccompany arthritis.\\nRecommended dosage\\nThe usual dosage for adults and children age 12\\nand over is 325-650 mg every four to six hours as\\nneeded. No more than 4 grams (4000 mg) should be\\ntaken in 24 hours. Because the drug can potentially\\nharm the liver, people who drink alcohol in large\\nquantities should take considerably less acetamino-\\nphen and possibly should avoid the drug completely.\\nFor children ages 6-11 years, the usual dose is 150-\\n300 mg, three to four times a day. A physician should\\nrecommend doses for children under age 6 years.\\nPrecautions\\nIn 2004, the U.S. Food and Drug Administration\\n(FDA) launched an advertising campaign aimed at\\neducating consumers about proper use of acetamino-\\nphen and other over-the-counter pain killers. Often,\\nacetaminophen is hidden in many cold and flu products\\nand people unexpectedly overdose on the medicine.\\nSome cases have led toliver transplantationor death.\\nMore than the recommended dosage of acetaminophen\\nshould not be taken unless told to do so by a physician\\nor dentist.\\nPatients should not use acetaminophen for more\\nthan 10 days to relieve pain (five days for children) or\\nfor more than three days to reduce fever, unless direc-\\nted to do so by a physician. If symptoms do not go\\naway—or if they get worse— a physician should be\\ncontacted. Anyone who drinks three or more alcoholic\\nbeverages a day should check with a physician before\\nusing this drug and should never take more than the\\nrecommended dosage. A risk of liver damage exists\\nfrom combining large amounts of alcohol and\\nacetaminophen. People who already have kidney or\\nliver diseaseor liver infections should also consult with\\na physician before using the drug. So should women\\nwho are pregnant or breastfeeding.\\nMany drugs can interact with one another. A\\nphysician or pharmacist should be consulted before\\ncombining acetaminophen with any other medicine.\\nTwo different acetaminophen-containing products\\nshould not be used at the same time.\\nAcetaminophen interferes with the results of some\\nmedical tests. Avoiding the drug for a few days before\\nthe tests may be necessary.\\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\\nlower back. Allergic reactions occur in some people,\\nbut 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 causenausea,\\nvomiting, sweating, and exhaustion. Very large over-\\ndoses can cause liver damage. In case of an overdose,\\nimmediate medical attention should be sought. In\\n2004, researchers announced that an injection to coun-\\nteract the liver injury caused by acetaminophen over-\\ndose has been approved by the FDA.\\nInteractions\\nAcetaminophen may interact with a variety of\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side\\neffects may be greater. Among the drugs that may\\ninteract with acetaminophen are alcohol, nonsteroidal\\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.\\n20 GALE ENCYCLOPEDIA OF MEDICINE\\nAcetaminophen'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='anti-inflammatory drugs (NSAIDs) such as Motrin,\\noral contraceptives, the antiseizure drug phenytoin\\n(Dilantin), the blood-thinning drug warfarin\\n(Coumadin), the cholesterol-lowering drug cholesty-\\nramine (Questran), the antibiotic Isoniazid, and zido-\\nvudine (Retrovir, AZT). A physician or pharmacist\\nshould be consulted before combining acetaminophen\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine.\\nResources\\nPERIODICALS\\n‘‘Antidote Cleared for Acetiminophen Overdose.’’Drug\\nTopics February 23, 2004: 12.\\nMechcatie, Elizabeth. ‘‘FDA Launches Campaign About\\nOTC Drug Risks: NSAIDs, Acetaminophen.’’Family\\nPractice News March 15, 2004: 8l\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAcetylsalicylic acid see Aspirin\\nAchalasia\\nDefinition\\nAchalasia is a disorder of the esophagus that\\nprevents normal swallowing.\\nDescription\\nAchalasia affects the esophagus, the tube that\\ncarries swallowed food from the back of the throat\\ndown into the stomach. A ring of muscle called the\\nlower esophageal sphincter encircles the esophagus\\njust above the entrance to the stomach. This sphincter\\nmuscle is normally contracted to close the esophagus.\\nWhen the sphincter is closed, the contents of the sto-\\nmach cannot flow back into the esophagus. Backward\\nflow of stomach contents (reflux) can irritate and\\ninflame the esophagus, causing symptoms such as\\nheartburn. The act of swallowing causes a wave of\\nesophageal contraction called peristalsis. Peristalsis\\npushes food along the esophagus. Normally, peristal-\\nsis causes the esophageal sphincter to relax and allow\\nfood into the stomach. In achalasia, which means\\n‘‘failure to relax,’’ the esophageal sphincter remains\\ncontracted. Normal peristalsis is interrupted and food\\ncannot 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\\ndegeneration is unknown. Autoimmune disease or\\nhidden infection is suspected.\\nSymptoms\\nDysphagia, or difficulty swallowing, is the most\\ncommon symptom of achalasia. The person with\\nachalasia usually has trouble swallowing both liquid\\nand solid foods, often feeling that food ‘‘gets stuck’’\\non the way down. The person has chestpain that\\nis often mistaken forangina pectoris (cardiac pain).\\nHeartburn and difficulty belching are common.\\nSymptoms usually get steadily worse. Other symptoms\\nmay include nighttimecough or recurrentpneumonia\\ncaused by food passing into the lower airways.\\nDiagnosis\\nDiagnosis of achalasia begins with a careful med-\\nical history. The history should focus on the timing of\\nsymptoms and on eliminating other medical condi-\\ntions that may cause similar symptoms. Tests used to\\ndiagnose achalasia include:\\n/C15Esophageal manometry. In this test, a thin tube is\\npassed into the esophagus to measure the pressure\\nexerted by the esophageal sphincter.\\n/C15X 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/C15Endoscopy. 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\\ndilation. In this procedure, an inflatable membrane\\nor balloon is passed down the esophagus to the sphinc-\\nter and inflated to force the sphincter open. Dilation is\\neffective in about 70% of patients.\\nThree other treatments are used for achalasia when\\nballoon dilation is inappropriate or unacceptable.\\nGALE ENCYCLOPEDIA OF MEDICINE 21\\nAchalasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Botulinum toxin injection. Injected into the sphinc-\\nter, botulinum toxin paralyzes the muscle and allows\\nit to relax. Symptoms usually return within one to\\ntwo years.\\n/C15Esophagomyotomy. This surgical procedure cuts the\\nsphincter muscle to allow the esophagus to open.\\nEsophagomyotomy is becoming more popular with\\nthe development of techniques allowing very small\\nabdominal incisions.\\n/C15Drug therapy. Nifedipine, a calcium-channel blocker,\\nreduces muscle contraction. Taken daily, this drug\\nprovides relief for about two-thirds of patients for as\\nlong as two years.\\nPrognosis\\nMost patients with achalasia can be treated effec-\\ntively. Achalasia does not reduce life expectancy\\nunless esophageal carcinoma develops.\\nPrevention\\nThere is no known way to prevent achalasia.\\nResources\\nBOOKS\\nGrendell, James H., Kenneth R. McQuaid, and Scott L.\\nFriedman, editors.Current Diagnosis and Treatment in\\nGastroenterology. Stamford: Appleton& Lange, 1996.\\nRichard Robinson\\nAchondroplasia\\nDefinition\\nAchondroplasia is the most common cause of\\ndwarfism, or significantly abnormal short stature.\\nDescription\\nAchondroplasia is one of a number of chondo-\\ndystrophies, in which the development of cartilage,\\nand therefore, bone is disturbed. The disorder\\nappears in approximately one in every 10,000\\nbirths. Achondroplasia is usually diagnosed at birth,\\nowing to the characteristic appearance of the\\nnewborn.\\nNormal bone growth depends on the produc-\\ntion of cartilage (a fibrous connective tissue). Over\\ntime, calcium is deposited within the cartilage,\\ncausing it to harden and become bone. In achon-\\ndroplasia, abnormalities of this process prevent the\\nbones (especially those in the limbs) from growing\\nas long as they normally should, at the same time\\nallowing the bones to become abnormally thick-\\nened. The bones in the trunk of the body and the\\nskull are mostly not affected, although the opening\\nfrom the skull through which the spinal cord\\npasses (foramen magnum) is often narrower than\\nnormal, and the opening (spinal canal) through\\nwhich the spinal cord runs in the back bones (ver-\\ntebrae) becomes increasingly and abnormally small\\ndown the length of the spine.\\nCauses and symptoms\\nAchondroplasia is caused by a genetic defect. It is\\na dominant trait, meaning that anybody with\\nthe genetic defect will display all the symptoms of\\nthe disorder. A parent with the disorder has a 50%\\nKEY TERMS\\nBotulinum toxin— Any of a group of potent bacter-\\nial toxins or poisons produced by different strains of\\nthe bacterium Clostridium botulinum . The toxins\\ncause muscle paralysis.\\nDysphagia— Difficulty in swallowing.\\nEndoscopy— A test in which a viewing device\\nand a light source are introduced into the esopha-\\ngus by means of a flexible tube. Endoscopy per-\\nmits visual inspection of the esophagus for\\nabnormalities.\\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 a\\nfluid.\\n22 GALE ENCYCLOPEDIA OF MEDICINE\\nAchondroplasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='chance of passing it on to the offspring. Although\\nachondroplasia can be passed on to subsequent\\noffspring, the majority of cases occur due to a new\\nmutation (change) in a gene. Interestingly enough,\\nthe defect seen in achondroplasia is one of only a\\nfew 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\\nshort arms and legs. Their trunk is usually of normal\\nsize, as is their head. The appearance of short limbs\\nand normal head size actually makes the head\\nappear to be oversized. The bridge of the nose\\noften has a scooped out appearance termed ‘‘saddle\\nnose.’’ The lower back has an abnormal curvature,\\nor sway back. The face often displays an overly\\nprominent forehead, and a relative lack of develop-\\nment of the face in the area of the upper jaw. Because\\nthe foramen magnum and spinal canal are abnor-\\nmally narrowed, nerve damage may occur if the\\nspinal cord or nerves become compressed. The nar-\\nrowed foramen magnum may disrupt the normal\\nflow of fluid between the brain and the spinal cord,\\nresulting in the accumulation of too much fluid in\\nthe brain (hydrocephalus ). Children with achondro-\\nplasia have a very high risk of serious and repeated\\nmiddle ear infections, which can result in hearing\\nloss. The disease does not affect either mental capa-\\ncity, or reproductive ability.\\nDiagnosis\\nDiagnosis is often made at birth due to the char-\\nacteristically short limbs, and the appearance of a\\nlarge head. X-ray examination will reveal a character-\\nistic appearance to the bones, with the bones of the\\nlimbs appearing short in length, yet broad in width. A\\nnumber of measurements of the bones in x-ray images\\nwill reveal abnormal proportions.\\nTreatment\\nNo treatment will reverse the defect present in\\nachondroplasia. All patients with the disease will be\\nshort, with abnormally proportioned limbs, trunk,\\nand head. Treatment of achondroplasia primarily\\naddresses some of the complications of the disorder,\\nincluding problems due to nerve compression, hydro-\\ncephalus, bowed legs, and abnormal curves in the\\nspine. Children with achondroplasia who develop\\nmiddle ear infections (acuteotitis media) will require\\nquick treatment withantibiotics and careful monitor-\\ning in order to avoid hearing loss.\\nPrognosis\\nAchondroplasia is a disease which causes consid-\\nerable deformity. However, with careful attention\\nKEY TERMS\\nCartilage— A flexible, fibrous type of connective\\ntissue which serves as a base on which bone is\\nbuilt.\\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 which\\nthe spinal cord passes.\\nAn x-ray image of an achondroplastic person’s head\\nand chest. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 23\\nAchondroplasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='paid to the development of dangerous complications\\n(nerve compression, hydrocephalus), most people are\\nin good health, and can live a normal lifespan.\\nPrevention\\nThe only form of prevention is throughgenetic\\ncounseling, which could help parents assess their risk\\nof having a child with achondroplasia.\\nResources\\nBOOKS\\nKrane, Stephen M., and Alan L. Schiller.\\n‘‘Achondroplasia.’’ InHarrison’s Principles of Internal\\nMedicine, edited by Anthony S. Fauci, et al. New York:\\nMcGraw-Hill, 1997.\\nORGANIZATIONS\\nLittle People of America, c/o Mary Carten. 7238 Piedmont\\nDrive, Dallas, TX 75227-9324. (800) 243-9273.\\nRosalyn Carson-DeWitt, MD\\nAchromatopsia 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\\nthe body (metastasized), and to check the effectiveness\\nof treatment. The test has been largely supplanted by\\nthe prostate specific antigen test (PSA).\\nPurpose\\nT h em a l ep r o s t a t eg l a n dh a s1 0 0t i m e sm o r e\\nacid phosphatase than any other body tissue.\\nWhen prostate cancer s p r e a d st oo t h e rp a r t so ft h e\\nbody, acid phosphatase levels rise, particularly if\\nthe cancer spreads to the bone. One-half to three-\\nfourths of persons who have metastasized prostate\\ncancer have high acid phosphatase levels. Levels fall\\nafter the tumor is removed or reduced through\\ntreatment.\\nTissues other than prostate have small amounts\\nof acid phosphatase, including bone, liver, spleen,\\nkidney, and red blood cells and platelets. Damage to\\nthese tissues causes a moderate increase in acid phos-\\nphatase 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.\\nAcid phosphatase levels rise only after prostate cancer\\nhas metastasized.\\nDescription\\nLaboratory testing measures the amount of acid\\nphosphatase in a person’s blood, and can determine\\nfrom what tissue the enzyme is coming. For example, it\\nis important to know if the increased acid phosphatase\\nis from the prostate or red blood cells. Acid phospha-\\ntase from the prostate, called prostatic acid phospha-\\ntase (PAP), is the most medically significant type of\\nacid phosphatase.\\nSubtle differences between prostatic acid phos-\\nphatase and acid phosphatases from other tissues\\ncause them to react differently in the laboratory\\nwhen mixed with certain chemicals. For example,\\nadding the chemical tartrate to the test mixture inhi-\\nbits the activity of prostatic acid phosphatase but not\\nred blood cell acid phospha tase. Laboratory test\\nmethods based on these differences reveal how\\nmuch of a person’s total acid phosphatase is derived\\nfrom the prostate. Results are usually available the\\nnext 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.\\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.\\n24 GALE ENCYCLOPEDIA OF MEDICINE\\nAcid phosphatase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aftercare\\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\\nwill reduce bruising. Warm packs to the puncture site\\nwill relieve discomfort.\\nNormal results\\nNormal results vary based on the laboratory and\\nthe method used.\\nAbnormal results\\nThe highest levels of acid phosphatase are found\\nin metastasized prostate cancer. Diseases of the\\nbone, such as Paget’s disease orhyperparathyroidism;\\ndiseases of blood cells, such assickle cell diseaseor\\nmultiple myeloma; or lysosomal disorders, such as\\nGaucher’s disease, will show moderately increased\\nlevels.\\nCertain medications can cause temporary increases\\nor decreases in acid phosphatase levels. Manipulation\\nof the prostate gland through massage, biopsy, or rectal\\nexam before a test can increase the level.\\nResources\\nPERIODICALS\\nMoul, Judd W., et al. ‘‘The Contemporary Value of\\nPretreatment Prostatic Acid Phosphatase to Predict\\nPathological Stage and Recurrence in Radical\\nProstatectomy Cases.’’Journal of Urology (March\\n1998): 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\\nthe pores of the skin become clogged with oil, dead\\nskin cells, and bacteria.\\nDescription\\nAcne vulgaris, the medical term for common acne,\\nis the most common skin disease. It affects nearly 17\\nmillion people in the United States. While acne can\\narise at any age, it usually begins atpuberty and wor-\\nsens during adolescence. Nearly 85% of people\\ndevelop acne at some time between the ages of 12-25\\nyears. Up to 20% of women develop mild acne. It is\\nalso found in some newborns.\\nThe sebaceous glands lie just beneath the skin’s\\nsurface. They produce an oil called sebum, the skin’s\\nnatural moisturizer. These glands and the hair follicles\\nwithin which they are found are called sebaceous\\nfollicles. These follicles open onto the skin through\\npores. At puberty, increased levels of androgens\\n(male hormones) cause the glands to produce too\\nmuch sebum. When excess sebum combines with\\ndead, sticky skin cells, a hard plug, or comedo, forms\\nthat blocks the pore. Mild noninflammatory acne con-\\nsists of the two types of comedones, whiteheads and\\nblackheads.\\nModerate and severe inflammatory types of acne\\nresult after the plugged follicle is invaded by\\nPropionibacterium acnes , a bacteria that normally\\nlives on the skin. A pimple forms when the damaged\\nfollicle weakens and bursts open, releasing sebum,\\nbacteria, and skin and white blood cells into the sur-\\nrounding tissues. Inflamed pimples near the skin’s sur-\\nface are called papules; when deeper, they are called\\npustules. The most severe type of acne consists of cysts\\n(closed sacs) and nodules (hard swellings). Scarring\\noccurs when new skin cells are laid down to replace\\ndamaged cells.\\nThe most common sites of acne are the face, chest,\\nshoulders, and back since these are the parts of the\\nbody where the most sebaceous follicles are found.\\nCauses and symptoms\\nThe exact cause of acne is unknown. Several risk\\nfactors have been identified:\\n/C15Age. Due to the hormonal changes they experience,\\nteenagers are more likely to develop acne.\\n/C15Gender. Boys have more severe acne and develop it\\nmore often than girls.\\n/C15Disease. Hormonal disorders can complicate acne in\\ngirls.\\n/C15Heredity. Individuals with a family history of acne\\nhave greater susceptibility to the disease.\\n/C15Hormonal changes. Acne can flare up before men-\\nstruation, duringpregnancy,a n dmenopause.\\nGALE ENCYCLOPEDIA OF MEDICINE 25\\nAcne'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Diet. No foods cause acne, but certain foods may\\ncause flare-ups.\\n/C15Drugs. Acne can be a side effect of drugs including\\ntranquilizers, antidepressants, antibiotics,oral con-\\ntraceptives, and anabolic steroids.\\n/C15Personal hygiene. Abrasive soaps, hard scrubbing, or\\npicking at pimples will make them worse.\\n/C15Cosmetics. Oil-based makeup and hair sprays wor-\\nsen acne.\\n/C15Environment. Exposure to oils and greases, polluted\\nair, and sweating in hot weather aggravate acne.\\n/C15Stress. Emotional stress may contribute to acne.\\nAcne is usually not conspicuous, although infla-\\nmed lesions may causepain, tenderness, itching,o r\\nswelling. The most troubling aspects of these lesions\\nare the negative cosmetic effects and potential for\\nscarring. Some people, especially teenagers, become\\nemotionally upset about their condition, and have\\nproblems forming relationships or keeping jobs.\\nDiagnosis\\nAcne patients are often treated by family doctors.\\nComplicated cases are referred to a dermatologist, a\\nskin disease specialist, or an endocrinologist, a specia-\\nlist who treats diseases of the body’s endocrine (hor-\\nmones and glands) system.\\nAcne has a characteristic appearance and is not\\ndifficult to diagnose. The doctor takes a complete\\nmedical history, including questions about skin care,\\ndiet, factors causing flare-ups, medication use, and\\nprior treatment. Physical examination includes the\\nface, upper neck, chest, shoulders, back, and other\\naffected areas. Under good lighting, the doctor deter-\\nmines what types and how many blemishes are pre-\\nsent, whether they are inflamed, whether they are deep\\nor superficial, and whether there is scarring or skin\\ndiscoloration.\\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 produc-\\ntion 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.\\nAcne vulgaris affecting a woman’s face. Acne is the general\\nname given to a skin disorder in which the sebaceous glands\\nbecome inflamed. (Photograph by Biophoto Associates, Photo\\nResearchers, Inc. Reproduced by permission.)\\n26 GALE ENCYCLOPEDIA OF MEDICINE\\nAcne'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In teenagers, acne is often found on the forehead,\\nnose, and chin. As people get older, acne tends to\\nappear towards the outer part of the face. Adult\\nwomen may have acne on their chins and around\\ntheir mouths. The elderly may develop whiteheads\\nand blackheads on the upper cheeks and skin around\\nthe 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\\nmay be ordered. Most insurance plans cover the\\ncosts of diagnosing and treating acne.\\nTreatment\\nAcne treatment consists of reducing sebum pro-\\nduction, removing dead skin cells, and killing bacteria\\nwith topical drugs and oral medications. Treatment\\nchoice depends upon whether the acne is mild, mod-\\nerate, or severe.\\nDrugs\\nTOPICAL DRUGS. Treatment for mild noninflam-\\nmatory acne consists of reducing the formation of new\\ncomedones with topical tretinoin, benzoyl peroxide,\\nadapalene, or salicylic acid. Tretinoin is especially\\neffective because it increases turnover (death and\\nreplacement) of skin cells. When complicated by\\ninflammation, topical antibioticsmay be added to the\\ntreatment regimen. Improvement is usually seen in\\ntwo to four weeks.\\nTopical medications are available as cream, gel,\\nlotion, or pad preparations of varying strengths.\\nThey include antibiotics (agents that kill bacteria),\\nsuch as erythromycin, clindamycin (Cleocin-T), and\\nmeclocycline (Meclan); comedolytics (agents that\\nloosen hard plugs and open pores) such as the vitamin\\nA acid tretinoin (Retin-A), salicylic acid, adapalene\\n(Differin), resorcinol, and sulfur. Drugs that act as\\nboth comedolytics and antibiotics, such as benzoyl\\nperoxide, azelaic acid (Azelex), or benzoyl peroxide\\nplus erythromycin (Benzamycin), are also used.\\nThese drugs may be used for months to years to\\nachieve disease control.\\nAfter washing with mild soap, the drugs are\\napplied alone or in combination, once or twice a day\\nover the entire affected area of skin. Possible side\\neffects include mild redness, peeling, irritation, dry-\\nness, and an increased sensitivity to sunlight that\\nrequires 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,\\nclindamycin (Cleocin), and trimethoprim- sulfamethox-\\nazole (Bactrim, Septra). Possible side effects include\\nallergic reactions, stomach upset, vaginal yeast infec-\\ntions, dizziness, and tooth discoloration.\\nThe goal of treating moderate acne is to decrease\\ninflammation and prevent new comedone formation.\\nOne effective treatment is topical tretinoin along with\\na topical or oral antibiotic. A combination of topical\\nbenzoyl peroxide and erythromycin is also very effec-\\ntive. Improvement is normally seen within four to six\\nweeks, but treatment is maintained for at least two to\\nfour months.\\nA drug reserved for the treatment of severe\\nacne, oral isotretinoin (Accutane), reduces sebum\\nproduction and cell stickiness. It is the treatment\\nof choice for severe acne with cysts and nodules,\\nand is used with or without topical or oral antibio-\\ntics. Taken for four to five months, it provides long-\\nterm disease control in up to 60% of patients. If the\\nacne reappears, another course of isotretinoin may\\nbe needed by about 20% of patients, while another\\n20% may do well with topical drugs or oral anti-\\nbiotics. Side effects include temporary worsening of\\nthe acne, dry skin, nosebleeds, vision disorders, and\\nelevated liver enzymes, blood fats and cholesterol.\\nThis drug must not be taken during pregnancy since\\nit causes birth defects.\\nAnti-androgens, drugs that inhibit androgen pro-\\nduction, are used to treat women who are unrespon-\\nsive to other therapies. Certain types of oral\\ncontraceptives (for example, Ortho-Tri-Cyclen) and\\nfemale sex hormones (estrogens) reduce hormone\\nactivity in the ovaries. Other drugs, for example, spir-\\nonolactone and corticosteroids, reduce hormone\\nactivity in the adrenal glands. Improvement may\\ntake up to four months.\\nOral corticosteroids, or anti-inflammatory drugs,\\nare the treatment of choice for an extremely severe,\\nbut rare type of destructive inflammatory acne called\\nacne fulminans, found mostly in adolescent males.\\nAcne conglobata, a more common form of severe\\ninflammation, is characterized by numerous, deep,\\ninflammatory nodules that heal with scarring. It is\\ntreated with oral isotretinoin and corticosteroids.\\nOther treatments\\nSeveral surgical or medical treatments are avail-\\nable to alleviate acne or the resulting scars:\\n/C15Comedone extraction. The comedo is removed from\\nthe pore with a special tool.\\nGALE ENCYCLOPEDIA OF MEDICINE 27\\nAcne'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Chemical peels. Glycolic acid is applied to peel off\\nthe top layer of skin to reduce scarring.\\n/C15Dermabrasion. The affected skin is frozen with a\\nchemical spray, and removed by brushing or planing.\\n/C15Punch grafting. Deepscars are excised and the area\\nrepaired with small skin grafts.\\n/C15Intralesional injection. Corticosteroids are injected\\ndirectly into inflamed pimples.\\n/C15Collagen injection. Shallow scars are elevated by\\ncollagen (protein) injections.\\nAlternative treatment\\nAlternative treatments for acne focus on proper\\ncleansing to keep the skin oil-free; eating a well-\\nbalanced diet high in fiber, zinc, and raw foods; and\\navoiding alcohol, dairy products, smoking,caffeine,\\nsugar, processed foods, and foods high in iodine,\\nsuch as salt. Supplementation with herbs such as\\nburdock root (Arctium lappa ), red clover (Trifolium\\npratense) ,a n dm i l kt h i s t l e(Silybum marianum ), and\\nwith nutrients such as essential fatty acids, vitamin B\\ncomplex, zinc, vitamin A, and chromium is also\\nrecommended. Chinese herbal remedies used for\\nacne include cnidium seed (Cnidium monnieri )a n d\\nhoneysuckle flower ( Lonicera japonica ). Wholistic\\nphysicians or nutritionists can recommend the proper\\namounts of these herbs.\\nPrognosis\\nAcne is not curable, although long-term control is\\nachieved in up to 60% of patients treated with isotre-\\ntinoin. It can be controlled by proper treatment, with\\nimprovement taking two or more months. Acne tends\\nto reappear when treatment stops, but spontaneously\\nimproves over time. Inflammatory acne may leave\\nscars that require further treatment.\\nPrevention\\nThere are no sure ways to prevent acne, but the\\nfollowing steps may be taken to minimize flare-ups:\\n/C15gentle washing of affected areas once or twice every\\nday\\n/C15avoid abrasive cleansers\\n/C15use noncomedogenic makeup and moisturizers\\n/C15shampoo often and wear hair off face\\n/C15eat a well-balanced diet, avoiding foods that trigger\\nflare-ups\\n/C15unless told otherwise, give dry pimples a limited\\namount of sun exposure\\n/C15do not pick or squeeze blemishes\\n/C15reduce stress\\nResources\\nPERIODICALS\\nBillings, Laura. ‘‘Getting Clear.’’Health Magazine (April\\n1997): 48-52.\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham\\nRoad, P.O. Box 4014, Schaumburg, IL 60168-4014.\\n(847) 330-0230. Fax: (847) 330-0050. .\\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 vestibu-\\nlocochlear nerve (eighth cranial nerve).\\nDescription\\nThe vestibulocochlear nerve extends from the\\ninner ear to the brain and is made up of a vestibular\\nbranch, often called the vestibular nerve, and a\\ncochlear branch, called the cochlear nerve. The vestib-\\nular and cochlear nerves lie next to one another. They\\nalso run along side other cranial nerves. People possess\\ntwo of each type of vestibulocochlear nerve, one that\\nextends from the left ear and one that extends from the\\nright ear.\\nThe vestibular nerve transmits information con-\\ncerning balance from the inner ear to the brain and the\\ncochlear nerve transmits information about hearing.\\nThe vestibular nerve, like many nerves, is surrounded\\nby a cover called a myelin sheath. A tumor, called\\na schwannoma, can sometimes develop from the cells\\nof the myelin sheath. A tumor is an abnormal growth\\nof tissue that results from the uncontrolled growth of\\ncells. Acoustic neuromas are often called vestibular\\nschwannomas because they are tumors that arise\\n28 GALE ENCYCLOPEDIA OF MEDICINE\\nAcoustic neuroma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='from the myelin sheath that surrounds the vestibular\\nnerve. Acoustic neuromas are considered benign\\n(non-cancerous) tumors since they do not spread\\nto other parts of the body. They can occur any-\\nwhere along the vestibular nerve but are most likely\\nto occur where the vestibulocochlear nerve passes\\nthrough the tiny bony canal that connects the brain\\nand the inner ear.\\nAn acoustic neuroma can arise from the left\\nvestibular nerve or the right vestibular nerve. A uni-\\nlateral tumor is a tumor arising from one nerve and\\na bilateral tumor arises from both vestibular nerves.\\nUnilateral acoustic neuromas usually occur sponta-\\nneously (by chance). Bilateral acoustic neuromas\\noccur as part of a hereditary condition called\\nNeurofibromatosis Type 2 (NF2). A person with\\nNF2 has inherited a pred isposition for develop-\\ning acoustic neuromas and other tumors of the\\nnerve cells.\\nAcoustic neuromas usu ally grow slowly and\\ncan take years to develop. Some acoustic neuromas\\nremain so small that they do not cause any symp-\\ntoms. As the acoustic neuroma grows it can inter-\\nfere with the functioning of the vestibular nerve\\nand can cause vertigo and balance difficulties. If\\nthe acoustic nerve grows large enough to press\\nagainst the cochlear nerve, then hearing loss and\\na ringing (tinnitus) in the affected ear will usually\\noccur. If untreated and the acoustic neuroma con-\\ntinues to grow it can press against other nerves in\\nthe region and cause other symptoms. This tumor\\ncan be life threatening if it becomes large enough\\nto press against and interfere with the functioning\\nof the brain.\\nCauses and symptoms\\nCauses\\nAn acoustic neuroma is caused by a change or\\nabsence of both of the NF2 tumor suppressor genes\\nin a nerve cell. Every person possesses a pair of NF2\\ngenes in every cell of their body including their nerve\\ncells. One NF2 gene is inherited from the egg cell of the\\nmother and one NF2 gene is inherited from the sperm\\ncell of the father. The NF2 gene is responsible for\\nhelping to prevent the formation of tumors in the\\nnerve cells. In particular the NF2 gene helps to prevent\\nacoustic neuromas.\\nOnly one unchanged and functioning NF2 gene\\nis necessary to prevent the formation of an acoustic\\nneuroma. If both NF2 genes become changed or\\nmissing in one of the myelin sheath cells of the\\nvestibular nerve then an acoustic neuroma will usually\\ndevelop. Most unilateral acoustic neuromas result\\nwhen the NF2 genes become spontaneously changed\\nor missing. Someone with a unilateral acoustic\\nKEY TERMS\\nBenign tumor— A localized overgrowth of cells\\nthat does 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\\nthat uses a computer to compile and analyze the\\nimages produced by x rays projected at a particular\\npart of the body.\\nCranial nerves— The set of twelve nerves found on\\neach side of the head and neck that control the\\nsensory 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\\nof a compound called DNA (deoxyribonucleic\\nacid) and containing the instructions for the pro-\\nduction of a particular protein. Each gene is found\\non a specific 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\\nand cataracts.\\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\\nand balance from the ear to the brain.\\nGALE ENCYCLOPEDIA OF MEDICINE 29\\nAcoustic neuroma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='neuroma that has developed spontaneously is not at\\nincreased risk for having children with an acoustic\\nneuroma. Some unilateral acoustic neuromas result\\nfrom the hereditary condition NF2. It is also possible\\nthat some unilateral acoustic neuromas may be caused\\nby changes in other genes responsible for preventing\\nthe formation of tumors.\\nBilateral acoustic neuromas result when some-\\none is affected with the hereditary condition NF2.\\nAp e r s o nw i t hN F 2i st y p i c a l l yb o r nw i t ho n e\\nunchanged and one changed or missing NF2 gene\\nin every cell of their body. Sometimes they inherit\\nthis change from their mother or father. Sometimes\\nthe change occurs spontaneously when the egg and\\nsperm come together to form the first cell of the\\nbaby. The children of a person with NF2 have a\\n50% chance of inheriting the changed or missing\\nNF2 gene.\\nA person with NF2 will develop an acoustic neu-\\nroma if the remaining unchanged NF2 gene becomes\\nspontaneously changed or missing in one of the myelin\\nsheath cells of their vestibular nerve. People with NF2\\noften develop acoustic neuromas at a younger age.\\nThe mean age of onset of acoustic neuroma in NF2\\nis 31 years of age versus 50 years of age for sporadic\\nacoustic neuromas. Not all people with NF2, however,\\ndevelop acoustic neuromas. People with NF2 are at\\nincreased risk for developingcataracts and tumors in\\nother nerve cells.\\nMost people with a unilateral acoustic neuroma\\nare not affected with NF2. Some people with NF2,\\nhowever, only develop a tumor in one of the vestibu-\\nlocochlear nerves. Others may initially be diagnosed\\nwith a unilateral tumor but may develop a tumor in the\\nother nerve a number of years later. NF2 should be\\nconsidered in someone under the age of 40 who has a\\nunilateral acoustic neuroma. Someone with a unilat-\\neral acoustic neuroma and other family members\\ndiagnosed with NF2 probably is affected with NF2.\\nSomeone with a unilateral acoustic neuroma and\\nother symptoms of NF2 such as cataracts and other\\ntumors may also be affected with NF2. On the other\\nhand, someone over the age of 50 with a unilateral\\nacoustic neuroma, no other tumors and no family\\nhistory of NF2 is very unlikely to be affected\\nwith NF2.\\nRecent studies in Europe have suggested a possi-\\nble connection between the widespread use of mobile\\nphones and an increased risk of developing acoustic\\nneuromas. Some observers, however, question\\nwhether mobile phones have been in use long enough\\nto be an identifiable risk factor.\\nSymptoms\\nSmall acoustic neuromas usually only interfere\\nwith the functioning of the vestibulocochlear nerve.\\nThe most common first symptom of an acoustic neu-\\nroma ishearing loss, which is often accompanied by a\\nringing sound (tinnitis). People with acoustic neuro-\\nmas sometimes report difficulties in using the phone\\nand difficulties in perceiving the tone of a musical\\ninstrument or sound even when their hearing appears\\nto be otherwise normal. In most cases the hearing loss\\nis initially subtle and worsens gradually over time\\nuntil deafness occurs in the affected ear. In approxi-\\nmately 10% of cases the hearing loss is sudden and\\nsevere.\\nAcoustic neuromas can also affect the function-\\ning of the vestibular branch of the vestibulocochlear\\nnerve and van cause vertigo and dysequilibrium.\\nTwenty percent of small tumors are associated with\\nperiodic vertigo, which is characterized bydizziness\\nor a whirling sensation. Larger acoustic neuromas are\\nless likely to cause vertigo but more likely to cause\\ndysequilibrium. Dysequilibrium, which is character-\\nized by minor clumsiness and a general feeling of\\ninstability, occurs in nearly 50% of people with an\\nacoustic neuroma.\\nAs the tumor grows larger it can press on the\\nsurrounding cranial nerves. Compression of the fifth\\ncranial nerve can result in facialpain and or numb-\\nness. Compression of the seventh cranial nerve can\\ncause spasms, weakness or paralysis of the facial\\nmuscles. Double vision is a rare symptom but can\\nresult when the 6th cranial nerve is affected.\\nSwallowing and/or speaking difficulties can occur if\\nthe tumor presses against the 9th, 10th, or 12th cra-\\nnial nerves.\\nIf left untreated, the tumor can become large\\nenough to press against and affect the functioning\\nof the brain stem. The brain stem is the stalk like\\nportion of the brain that joins the spinal cord to the\\ncerebrum, the thinking and reasoning part of the\\nbrain. Different parts of the brainstem have different\\nfunctions such as the control of breathing and muscle\\ncoordination. Large tumors that impact the brain\\nstem can result in headaches, walking difficulties\\n(gait ataxia) and involuntary shaking movements of\\nthe muscles (tremors). In rare cases when an acoustic\\nneuroma remains undiagnosed and untreated it can\\ncause nausea, vomiting, lethargy and eventually\\ncoma, respiratory difficulties and death. In the vast\\nmajority of cases, however, the tumor is discovered\\nand treated long before it is large enough to cause\\nsuch serious manifestations.\\n30 GALE ENCYCLOPEDIA OF MEDICINE\\nAcoustic neuroma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nAnyone with symptoms of hearing loss should\\nundergo hearing evaluations. Pure tone and speech\\naudiometry are two screening tests that are often\\nused to evaluate hearing. Pure tone audiometry\\ntests to see how well someone can hear tones of\\ndifferent volume and pitch and speech audiometry\\ntests to see how well someone can hear and recog-\\nnize speech. An acoustic neuroma is suspected in\\nsomeone with unilateral hearing loss or hearing loss\\nthat is less severe in one ear than the other ear\\n(asymmetrical).\\nSometimes an auditory brainstem response (ABR,\\nBAER) test is performed to help establish whether\\nsomeone is likely to have an acoustic neuroma.\\nDuring the ABR examination, a harmless electrical\\nimpulse is passed from the inner ear to the brainstem.\\nAn acoustic neuroma can interfere with the passage of\\nthis electrical impulse and this interference can, some-\\ntimes be identified through the ABR evaluation.\\nA normal ABR examination does not rule out the\\npossibility of an acoustic neuroma. An abnormal\\nABR examination increases the likelihood that an\\nacoustic neuroma is present but other tests are neces-\\nsary to confirm the presence 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\\nis able to detect nearly 100% of acoustic neuromas.\\nComputerized tomography (CT scan, CAT scan)is\\nunable to identify smaller tumors; but it can be used\\nwhen an acoustic neuroma is suspected and an MRI\\nevaluation cannot be performed.\\nOnce an acoustic neuroma is diagnosed, an eva-\\nluation by genetic specialists such as a geneticist and\\ngenetic counselor may be recommended. The purpose\\nof this evaluation is to obtain a detailed family history\\nand check for signs of NF2. If NF2 is strongly sus-\\npected then DNA testing may be recommended. DNA\\ntesting involves checking the blood cells obtained from\\na routine blood draw for the common gene changes\\nassociated 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\\nthe different options prior to making a decision\\nabout treatment. The patient’s, physical health, age,\\nsymptoms, tumor size, and tumor location should be\\nconsidered.\\nMicrosurgery\\nThe surgical removal of the tumor or tumors is the\\nmost common treatment for acoustic neuroma. In\\nmost cases the entire tumor is removed during the\\nsurgery. If the tumor is large and causing significant\\nsymptoms, yet there is a need to preserve hearing\\nin that ear, then only part of the tumor may be\\nremoved. During the procedure the tumor is removed\\nunder microscopic guidance and general anesthetic.\\nMonitoring of the neighboring cranial nerves is done\\nduring the procedure so that damage to these nerves\\ncan be prevented. If preservation of hearing is a possi-\\nbility, then monitoring of hearing will also take place\\nduring the surgery.\\nMost people stay in the hospital four to seven days\\nfollowing the surgery. Total recovery usually takes\\nfour to six weeks. Most people experiencefatigue and\\nhead discomfort following the surgery. Problems with\\nbalance and head and neck stiffness are also common.\\nThe mortality rate of this type of surgery is less than\\n2% at most major centers. Approximately 20% of\\npatients experience some degree of post-surgical com-\\nplications. In most cases these complications can be\\nmanaged successfully and do not result in long term\\nmedical problems. Surgery brings with it a risk of\\nstroke, damage to the brain stem, infection, leakage\\nof spinal fluid and damage to the cranial nerves.\\nHearing loss and/or tinnitis often result from the sur-\\ngery. A follow-up MRI is recommended one to five\\nyears following the surgery because of possible\\nregrowth of the tumor.\\nStereotactic radiation therapy\\nDuring stereotacticradiation therapy, also called\\nradiosurgery or radiotherapy, many small beams of\\nradiation are aimed directly at the acoustic neuroma.\\nThe radiation is administered in a single large dose,\\nunder local anesthetic and is performed on an out-\\npatient basis. This results in a high dose of radiation\\nto the tumor but little radiation exposure to the\\nsurrounding area. This treatment approach is limited\\nto small or medium tumors. The goal of the surgery is\\nto cause tumor shrinkage or at least limit the growth\\nof the tumor. The long-term efficacy and risks of this\\ntreatment approach are not known; however, as of\\nthe early 2000s, more and more patients diagnosed\\nwith acoustic neuromas are choosing this form of\\ntherapy. Periodic MRI monitoring throughout the\\nlife of the patient is therefore recommended.\\nRadiation therapy can cause hearing loss which\\ncan sometimes occurs even years later. Radiation ther-\\napy can also cause damage to neighboring cranial\\nGALE ENCYCLOPEDIA OF MEDICINE 31\\nAcoustic neuroma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='nerves, which can result in symptoms such asnumb-\\nness, pain or paralysis of the facial muscles. In many\\ncases these symptoms are temporary. Radiation treat-\\nment can also induce the formation of other benign or\\nmalignant schwannomas. This type of treatment may\\ntherefore be contraindicated in the treatment of acous-\\ntic neuromas in those with NF2 who are predisposed\\nto developing schwannomas and other tumors.\\nObservation\\nAcoustic neuromas are usually slow growing and\\nin some cases they will stop growing and even become\\nsmaller or disappear entirely. It may therefore be\\nappropriate in some cases to hold off on treatment\\nand to periodically monitor the tumor through MRI\\nevaluations. Long-term observation may be appropri-\\nate for example in an elderly person with a small\\nacoustic neuroma and few symptoms. Periodic obser-\\nvation may also be indicated for someone with a small\\nand asymptomatic acoustic neuroma that was\\ndetected through an evaluation for another medical\\nproblem. Observation may also be suggested for some-\\none with an acoustic neuroma in the only hearing ear\\nor in the ear that has better hearing. The danger of an\\nobservational approach is that as the tumor grows\\nlarger it can become more difficult to treat.\\nPrognosis\\nThe prognosis for someone with a unilateral\\nacoustic neuroma is usually quite good provided the\\ntumor is diagnosed early and appropriate treatment is\\ninstituted. Long term-hearing loss and tinnitis in the\\naffected ear are common, even if appropriate treat-\\nment is provided. Many patients also experience\\nfacial weakness, balance problems, and headaches.\\nRegrowth of the tumor is also a possibility following\\nsurgery or radiation therapy and repeat treatment may\\nbe necessary. The prognosis can be poorer for those\\nwith NF2 who have an increased risk of bilateral\\nacoustic neuromas and other tumors.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Acoustic Neuroma.’’ Section 7, Chapter 85 InThe\\nMerck Manual of Diagnosis and Therapy. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nPERIODICALS\\nKondziolka, D., L. D. Lundsford, and J. C. Flickinger.\\n‘‘Acoustic Neuroma Radiosurgery. Origins,\\nContemporary Use and Future Expectations.’’\\nNeurochirurgie 50 (June 2004): 427–435.\\nKundi, M., K. Mild, L. Hardell, and M. O. Mattsson.\\n‘‘Mobile Telephones and Cancer—A Review of\\nEpidemiological Evidence.’’Journal of Toxicology and\\nEnvironmental Health, Part B, Critical Reviews 7\\n(September-October 2004): 351–384.\\nRyzenman, J. M., M. L. Pensak, and J. M. Tew, Jr. ‘‘Patient\\nPerception of Comorbid Conditions After Acoustic\\nNeuroma Management: Survey Results from the\\nAcoustic Neuroma Association.’’Laryngoscope 114\\n(May 2004): 814–820.\\nORGANIZATIONS\\nAcoustic Neuroma Association. 600 Peachtree Pkwy, Suite\\n108, Cumming, GA 30041-6899. (770) 205-8211. Fax:\\n(770) 205-0239. ANAusa@aol.com. [cited June 28,\\n2001]. .\\nAcoustic Neuroma Association of Canada Box 369,\\nEdmonton, AB T5J 2J6. 1-800-561-ANAC(2622).\\n(780)428-3384. anac@compusmart.ab.ca. [cited June\\n28, 2001]. .\\nSeattle Acoustic Neuroma Group. Emcityland@aol.com.\\n[cited June 28, 2001]. .\\nOTHER\\nNational Institute of Health Consensus Statement Online.\\nAcoustic Neuroma 9, no. 4 (December 11-13, 1991).\\n[cited June 28, 2001]. .\\nUniversity of California at San Francisco (UCSF).\\nInformation on Acoustic Neuromas. March 18, 1998.\\n[cited June 28, 2001]. .\\nLisa Andres, MS, CGC\\nRebecca J. Frey, PhD\\nAcquired hypogammaglobulinemia see\\nCommon variable immunodeficiency\\nAcquired immunodeficiency syndrome see\\nAIDS\\nAcrocyanosis\\nDefinition\\nAcrocyanosis is a decrease in the amount of\\noxygen delivered to the extremities. The hands and\\nfeet turn blue because of the lack of oxygen.\\nDecreased blood supply to the affected areas is caused\\nby constriction or spasm of small blood vessels.\\n32 GALE ENCYCLOPEDIA OF MEDICINE\\nAcrocyanosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nAcrocyanosis is a painless disorder caused by con-\\nstriction or narrowing of small blood vessels in the\\nskin of affected patients. The spasm of the blood\\nvessels decreases the amount of blood that passes\\nthrough them, resulting in less blood being delivered\\nto the hands and feet. The hands may be the main area\\naffected. The affected areas turn blue and become cold\\nand sweaty. Localized swelling may also occur.\\nEmotion and cold temperatures can worsen the symp-\\ntoms, while warmth can decrease symptoms. The dis-\\nease is seen mainly in women and the effect of the\\ndisorder is mainly cosmetic. People with the disease\\ntend to be uncomfortable, with sweaty, cold, bluish\\ncolored hands and feet.\\nCauses and symptoms\\nThe sympathetic nerves cause constriction or\\nspasms in the peripheral blood vessels that supply\\nblood to the extremities. The spasms are a contraction\\nof the muscles in the walls of the blood vessels. The\\ncontraction decreases the internal diameter of the\\nblood vessels, thereby decreasing the amount of\\nblood flow through the affected area. The spasms\\noccur on a persistent basis, resulting in long term\\nreduction of blood supply to the hands and feet.\\nSufficient blood still passes through the blood vessels\\nso that the tissue in the affected areas does not starve\\nfor oxygen or die. Mainly, blood vessels near the sur-\\nface of the skin are affected.\\nDiagnosis\\nDiagnosis is made by observation of the main\\nclinical symptoms, including persistently blue and\\nsweaty hands and/or feet and a lack ofpain. Cooling\\nthe hands increases the blueness, while warming the\\nhands decreases the blue color. The acrocyanosis\\npatient’s pulse is normal, which rules out obstructive\\ndiseases. Raynaud’s diseasediffers from acrocyanosis\\nin that it causes white and red skin coloration phases,\\nnot just bluish discoloration.\\nTreatment\\nAcrocyanosis usually isn’t treated. Drugs that\\nblock the uptake of calcium (calcium channel blockers)\\nand alpha-one antagonists reduce the symptoms in\\nmost cases. Drugs that dilate blood vessels are\\nonly effective some of the time. Sweating from the\\naffected areas can be profuse and require treatment.\\nSurgery to cut the sympathetic nerves is performed\\nrarely.\\nPrognosis\\nAcrocyanosis is a benign and persistent disease.\\nThe main concern of patients is cosmetic. Left\\nuntreated, the disease does not worsen.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nAcromegaly and gigantism\\nDefinition\\nAcromegaly is a disorder in which the abnor-\\nmal release of a particular chemical from the pitui-\\nt a r yg l a n di nt h eb r a i nc a u s e si n c r e a s e dg r o w t hi n\\nbone and soft tissue, as well as a variety of other\\ndisturbances throughout the body. This chemical\\nreleased from the pituitary gland is called growth\\nhormone (GH). The body’s ability to process and\\nuse nutrients like fats and sugars is also altered. In\\nchildren whose bony growth plates have not closed,\\nthe chemical changes of acromegaly result in\\nexceptional growth of long bones. This variant is\\ncalled gigantism, with the additional bone growth\\ncausing unusual height. When the abnormality occurs\\nafter bone growth stops, the disorder is called\\nacromegaly.\\nDescription\\nAcromegaly is a relatively rare disorder, occurring\\nin approximately 50 out of every one million people\\n(50/1,000,000). Both men and women are affected.\\nBecause the symptoms of acromegaly occur so gradu-\\nally, diagnosis is often delayed. The majority of patients\\nare not identified until they are middle aged.\\nKEY TERMS\\nSympathetic nerve— A nerve of the autonomic ner-\\nvous system that regulates involuntary and auto-\\nmatic reactions, especially to stress.\\nGALE ENCYCLOPEDIA OF MEDICINE 33\\nAcromegaly and gigantism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes 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\\nto the functioning of other organs or body systems.\\nThe pituitary hormones travel throughout the body\\nand are involved in a large number of activities,\\nincluding the regulation of growth and reproductive\\nfunctions. The cause of acromegaly can be traced to\\nthe pituitary’s production of GH.\\nUnder normal conditions, the pituitary receives\\ninput from another brain structure, the hypothalamus,\\nlocated at the base of the brain. This input from the\\nhypothalamus regulates the pituitary’s release of hor-\\nmones. For example, the hypothalamus produces\\ngrowth hormone-releasing hormone (GHRH), which\\ndirects the pituitary to release GH. Input from the\\nhypothalamus should also direct the pituitary to stop\\nreleasing hormones.\\nIn acromegaly, the pituitary continues to release\\nGH and ignores signals from the hypothalamus. In the\\nliver, GH causes production of a hormone called insu-\\nlin-like growth factor 1 (IGF-1), which is responsible\\nfor growth throughout the body. When the pituitary\\nrefuses to stop producing GH, the levels of IGF-1 also\\nreach abnormal peaks. Bones, soft tissue, and organs\\nthroughout the body begin to enlarge, and the body\\nchanges its ability to process and use nutrients like\\nsugars 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\\nand sinuses, the voice becomes deeper and sounds\\nmore hollow, and patients may develop loudsnoring.\\nVarious hormonal changes cause symptoms such as:\\n/C15heavy sweating\\n/C15oily skin\\n/C15increased coarse body hair\\n/C15improper processing of sugars in the diet (and some-\\ntimes actual diabetes)\\nKEY TERMS\\nAdenoma— A type of noncancerous (benign) tumor\\nthat often involves the overgrowth of certain cells\\nfound 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 the\\nbody that travels to another part of the body in order\\nto 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.\\nEnlarged feet is one deformity caused by acromegaly.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\n34 GALE ENCYCLOPEDIA OF MEDICINE\\nAcromegaly and gigantism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15high blood pressure\\n/C15increased calcium in the urine (sometimes leading to\\nkidney stones)\\n/C15increased risk ofgallstones;a n d\\n/C15swelling of the thyroid gland\\nPeople with acromegaly have more skin tags, or\\noutgrowths of tissue, than normal. This increase in\\nskin tags is also associated with the development of\\ngrowths, called polyps, within the large intestine that\\nmay eventually become cancerous. Patients with acro-\\nmegaly often suffer from headaches and arthritis. The\\nvarious swellings and enlargements throughout the\\nbody may press on nerves, causing sensations of local\\ntingling or burning, and sometimes result in muscle\\nweakness.\\nThe most common cause of this disorder (in 90%\\nof patients) is the development of a noncancerous\\ntumor within the pituitary, called a pituitary adenoma.\\nThese tumors are the source of the abnormal release of\\nGH. As these tumors grow, they may press on nearby\\nstructures within the brain, causing headaches and\\nchanges in vision. As the adenoma grows, it may dis-\\nrupt other pituitary tissue, interfering with the release\\nof other hormones. These disruptions may be respon-\\nsible for changes in the menstrual cycle of women,\\ndecreases in the sexual drive in men and women, and\\nthe abnormal production of breast milk in women.\\nIn rare cases, acromegaly is caused by the abnormal\\nproduction of GHRH, which leads to the increased\\nproduction of GH. Certain tumors in the pancreas,\\nlungs, adrenal glands, thyroid, and intestine produce\\nGHRH, which in turn triggers production of an\\nabnormal quantity of GH.\\nDiagnosis\\nBecause acromegaly produces slow changes over\\ntime, diagnosis is often significantly delayed. In fact,\\nthe characteristic coarsening of the facial features is\\noften not recognized by family members, friends, or\\nlong-time family physicians. Often, the diagnosis is\\nsuspected by a new physician who sees the patient for\\nthe first time and is struck by the patient’s character-\\nistic facial appearance. Comparing old photographs\\nfrom a number of different time periods will often\\nincrease suspicion of the disease.\\nBecause the quantity of GH produced varies\\nwidely under normal conditions, demonstrating high\\nlevels of GH in the blood is not sufficient to merit a\\ndiagnosis of acromegaly. Instead, laboratory tests mea-\\nsuring an increase of IGF-1 (3-10 times above the\\nnormal level) are useful. These results, however, must\\nbe carefully interpreted because normal laboratory\\nvalues for IGF-1 vary when the patient is pregnant,\\nundergoing puberty, elderly, or severely malnourished.\\nNormal patients will show a decrease in GH produc-\\ntion when given a large dose of sugar (glucose). Patients\\nwith acromegaly will not show this decrease, and will\\noften show an increase in GH production. Magnetic\\nresonance imaging (MRI) is useful for viewing the\\npituitary, and for identifying and locating an adenoma.\\nWhen no adenoma can be located, the search for a\\nGHRH-producing tumor in another location begins.\\nTreatment\\nThe first step in treatment of acromegaly is\\nremoval of all or part of the pituitary adenoma.\\nRemoval requires surgery, usually performed by\\nentering the skull through the nose. While this surgery\\ncan cause rapid improvement of many acromegaly\\nsymptoms, most patients will also require additional\\ntreatment with medication. Bromocriptine (Parlodel)\\nis a medication that can be taken by mouth, while\\noctreotide (Sandostatin) must be injected every eight\\nhours. Both of these medications are helpful in redu-\\ncing GH production, but must often be taken for life\\nand produce their own unique side effects. Some\\npatients who cannot undergo surgery are treated\\nwith radiation therapy to the pituitary in an attempt\\nto shrink the adenoma. Radiating the pituitary may\\ntake up to 10 years, however, and may also injure/\\ndestroy other normal parts of the pituitary.\\nPrognosis\\nWithout treatment, patients with acromegaly will\\nmost likely die early because of the disease’s effects on\\nA comparison of the right hand of a person afflicted\\nwith acromegaly (left) and the hand of a normal sized person.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 35\\nAcromegaly and gigantism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the heart, lungs, brain, or due to the development of\\ncancer in the large intestine. With treatment, however,\\na patient with acromegaly may be able to live a normal\\nlifespan.\\nResources\\nBOOKS\\nBiller, Beverly M. K., and Gilbert H. Daniels. ‘‘Growth\\nHormone Excess: Acromegaly and Gigantism.’’ In\\nHarrison’s Principles of Internal Medicine , edited by\\nAnthony S. Fauci, et al. New York: McGraw-Hill,\\n1997.\\nORGANIZATIONS\\nPituitary Tumor Network Association. 16350 Ventura\\nBlvd., #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\\noften occurs in the face and neck region and is char-\\nacterized by the presence of a slowly enlarging, hard,\\nred lump.\\nDescription\\nActinomycosis is a relatively rare infection\\noccurring in one out of 300,000(1/300,000) people\\nper year. It is characterized by the presence of a\\nlump or mass that often forms, draining sinus tracts\\nto the skin surface. Fiftypercent of actinomycosis\\ncases are of the head and neck region (also called\\n‘‘lumpy jaw’’ and ‘‘cervico facial actinomycosis’’),\\n15% are in the chest, 20% are in the abdomen, and\\nthe rest are in the pelvis, heart, and brain. Men are\\nthree times more likely to develop actinomycosis than\\nwomen.\\nCauses and symptoms\\nActinomycosis is usually caused by the bacterium\\nActinomyces israelii . This bacterium is normally pre-\\nsent in the mouth but can cause disease if it enters\\ntissues following an injury.Actinomyces israelii is an\\nanaerobic bacterium which means it dislikes oxygen\\nbut grows very well in deep tissues where oxygen levels\\nare low. Tooth extraction, tooth disease, root canal\\ntreatment, jaw surgery, or poor dental hygiene can\\nallow Actinomyces israelii to cause an infection in the\\nhead and neck region.\\nThe main symptom of cervicofacial actinomycosis\\nis the presence of a hard lump on the face or neck. The\\nlump may or may not be red.Fever occurs in some\\ncases.\\nDiagnosis\\nCervicofacial actinomycosis can be diagnosed by\\na family doctor or dentist and the patient may be\\nreferred to an oral surgeon or infectious disease\\nspecialist. The diagnosis of actinomycosis is based\\nupon several things. The presence of a red lump with\\ndraining sinuses on the head or neck is strongly\\nsuggestive of cervicofacial actinomycosis. A recent\\nhistory of tooth extraction or signs oftooth decayor\\npoor dental hygiene aid in the diagnosis. Microscopic\\nexamination of the fluid draining from the sinuses\\nshows the characteristic ‘‘sulfur Granules’’ (small\\nyellow colored material in the fluid) produced by\\nActinomyces israelii . A biopsy may be performed to\\nremove a sample of the infected tissue. This procedure\\ncan be performed underlocal anesthesiain the doctor’s\\noffice. Occasionally the bacteria can be cultured\\nfrom the sinus tract fluid or from samples of the\\ninfected 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\\nKEY TERMS\\nBiopsy— The process that removes a sample of tis-\\nsue for microscopic examination to aid in the diag-\\nnosis of a disease.\\nSinus tract— A narrow, elongated channel in the\\nbody that allows the escape of fluid.\\n36 GALE ENCYCLOPEDIA OF MEDICINE\\nActinomycosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='of the lungs or abdomen can resembletuberculosis\\nor cancer. Diagnostic x-ray results, the presence of\\ndraining sinus tracts, and microscopic analysis\\nand culturing of infected tissue assist in the diagnosis.\\nTreatment\\nActinomycosis is difficult to treat because of its\\ndense tissue location. Surgery is often required to\\ndrain the lesion and/or to remove the site of infec-\\ntion. To kill the bacteria, standard therapy has\\nincluded large doses of penicillin given through a\\nvein daily for two to six weeks followed by six to\\ntwelve months of penicillin taken by mouth.\\nTetracycline, clindamycin, or erythromycin may be\\nused instead of penicillin. The antibiotic therapy\\nmust be completed to ensure that the infection\\ndoes not return. However, a report in 2004 on\\nseveral cases of actinomyc osis said that therapy\\ndepends on the individual case and that many\\npatients today will be diagnosed in earlier stages\\nof the disease. Sometimes, shorter courses of anti-\\nbiotic treatment are effective, with close diagnostic\\nx-ray monitoring. Hyperbaric oxygen (oxygen\\nunder high pressure) therapy in combination with\\nthe antibiotic therapy has been successful.\\nPrognosis\\nComplete recovery is achieved following treat-\\nment. If left untreated, the infection may cause loca-\\nlized bone destruction.\\nPrevention\\nThe best prevention is to maintain good dental\\nhygiene.\\nResources\\nPERIODICALS\\nSudhaker, Selvin S., and John J. Rose. ‘‘Short-term\\nTreatment of Actinomycosis: two Cases and a\\nReview.’’ Clinical Infectious Diseases (February 1,\\n2004): 444–448.\\nBelinda Rowland, PhD\\nTeresa G. Odle\\nActivated charcoal see Charcoal, activated\\nActivated partial thromboplastin time see\\nPartial thromboplastin time\\nAcupressure\\nDefinition\\nAcupressure is a form of touch therapy that\\nutilizes the principles of acupuncture and Chinese\\nmedicine. In acupressure, the same points on the\\nbody are used as in acupuncture, but are stimulated\\nwith finger pressure instead of with the insertion of\\nneedles. Acupressure is used to relieve a variety of\\nsymptoms andpain.\\nPurpose\\nAcupressure massage performed by a therapist\\ncan be very effective both as prevention and as a\\ntreatment for many health conditions, including\\nheadaches, general aches and pains, colds and flu,\\narthritis, allergies, asthma, nervous tension, men-\\nstrual cramps, sinus problems,sprains, tennis elbow,\\nand toothaches, among others. Unlike acupuncture\\nwhich requires a visit to a professional, acupressure\\ncan be performed by a layperson. Acupressure tech-\\nniques are fairly easy to learn, and have been used to\\nprovide quick, cost-free, and effective relief from\\nmany symptoms. Acupressure points can also be\\nstimulated to increase energy and feelings of well-\\nbeing, reduce stress, stimulate the immune system,\\nand alleviatesexual 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.\\nChinese medicine has developed acupuncture, acupres-\\nsure, herbal remedies, diet,exercise, lifestyle changes,\\nand other remedies as part of its healing methods.\\nNearly all of the forms of Oriental medicine that are\\nused in the West today, including acupuncture, acu-\\npressure, shiatsu, and Chinese herbal medicine, have\\ntheir roots in Chinese medicine. One legend has it that\\nacupuncture and acupressure evolved as early Chinese\\nhealers studied the puncturewounds of Chinese war-\\nriors, noting that certain points on the body created\\ninteresting results when stimulated. The oldest known\\ntext specifically on acupuncture points, theSystematic\\nClassic of Acupuncture , dates back to 282\\nA.D.\\nAcupressure is the non-invasive form of acupuncture,\\nas Chinese physicians determined that stimulating\\npoints on the body with massage and pressure could\\nbe effective for treating certain problems.\\nGALE ENCYCLOPEDIA OF MEDICINE 37\\nAcupressure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Outside of Asian-American communities, Chinese\\nmedicine remained virtually unknown in the United\\nStates until the 1970s, when Richard Nixon became\\nthe first U.S. president to visit China. On Nixon’s trip,\\njournalists were amazed to observe major operations\\nbeing performed on patients without the use of anes-\\nthetics. Instead, wide-awake patients were being oper-\\nated on, with only acupuncture needles inserted into\\nthem to control pain. At that time, a famous columnist\\nfor the New York Times , James Reston, had to\\nundergo surgery and elected to use acupuncture for\\nanesthesia. Later, he wrote some convincing stories\\non its effectiveness. Despite being neglected by\\nmainstream medicine and the American Medical\\nAssociation (AMA), acupuncture and Chinese medi-\\ncine became a central to alternative medicine practi-\\ntioners in the United States. Today, there are millions\\nof patients who attest to its effectiveness, and nearly\\n9,000 practitioners in all 50 states.\\nAcupressure is practiced as a treatment by Chinese\\nmedicine practitioners and acupuncturists, as well as\\nby massage therapists. Most massage schools in\\nAmerican include acupressure techniques as part of\\ntheir bodywork programs. Shiatsu massage is very\\nclosely related to acupressure, working with the same\\npoints on the body and the same general principles,\\nalthough it was developed over centuries in Japan\\nrather than in China.Reflexology is a form of body-\\nwork based on acupressure concepts. Jin Shin Do is a\\nbodywork technique with an increasing number of\\npractitioners in America that combines acupressure\\nand shiatsu principles withqigong, Reichian theory,\\nand meditation.\\nAcupressure and Chinese medicine\\nChinese medicine views the body as a small part\\nof the universe, subject to laws and principles of\\nharmony and balance. Chinese medicine does not\\nmake as sharp a destinction as Western medicine\\ndoes between mind and body. The Chinese system\\nbelieves that emotions and mental states are every\\nbit as influential on disease as purely physical\\nmechanisms, and considers factors like work, envi-\\nronment, and relationships as fundamental to a\\npatient’s health. Chinese medicine also uses very dif-\\nferent symbols and ideas to discuss the body and\\nTherapist working acupressure points on a woman’s shoulder.(Photo Researchers, Inc. Reproduced by permission.)\\n38 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupressure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='health. While Western medicine typically describes\\nhealth as mainly physical processes composed of che-\\nmical equations and reactions, the Chinese use ideas\\nlike yin and yang, chi, and the organ system to\\ndescribe health and the body.\\nEverything in the universe has properties of\\nyin and yang. Yin is associated with cold, female,\\npassive, downward, inward, dark, wet. Yang can be\\ndescribed as hot, male, active, upward, outward, light,\\ndry, and so on. Nothing is either completely yin or\\nyang. These two principles always interact and affect\\neach other, although the body and its organs can\\nbecome imbalanced by having either too much or too\\nlittle of either.\\nChi (pronounced chee, also spelled qi or ki in\\nJapanese shiatsu) is the fundamental life energy. It is\\nfound in food, air, water, and sunlight, and it travels\\nthrough the body in channels calledmeridians. There\\nare 12 major meridians in the body that transport chi,\\ncorresponding to the 12 main organs categorized by\\nChinese medicine.\\nDisease is viewed as an imbalance of the organs\\nand chi in the body. Chinese medicine has developed\\nintricate systems of how organs are related to physical\\nand mental symptoms, and it has devised correspond-\\ning treatments using the meridian and pressure point\\nnetworks that are classified and numbered. The goal\\nKEY TERMS\\nAcupoint— A pressure point stimulated in\\nacupressure.\\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\\ndescribe aspects of the natural world.\\nPress on point governing vessel 24.5, the top of the bridge of\\nthe nose, lightly for two minutes to relieve hay fever symptoms.\\nPress on lung 10, the center of the thumb pad, for one minute to\\nalleviate a sore throat. To ease heartburn, apply pressure to\\nstomach 36, four finger-widths below the kneecap outside the\\nshinbone. Use on both legs.(Illustration by Electronic Illustrators\\nGroup.)\\nGoverning vessel 24.5\\nLung 10\\nStomach 36\\nGALE ENCYCLOPEDIA OF MEDICINE 39\\nAcupressure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='of acupressure, and acupuncture, is to stimulate and\\nunblock the circulation of chi, by activating very spe-\\ncific points, called pressure points or acupoints.\\nAcupressure seeks to stimulate the points on the chi\\nmeridians that pass close to the skin, as these are\\neasiest to unblock and manipulate with finger\\npressure.\\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\\nand emotional activity, taking the pulse usually at the\\nwrists, examining the tongue and complexion, and\\nobserving the patient’s demeanor and attitude, to get\\na complete diagnosis of which organs and meridian\\npoints are out of balance. When the imbalance is\\nlocated, the physician will recommend specific pres-\\nsure points for acupuncture or acupressure. If acupres-\\nsure is recommended, the patient might opt for a series\\nof treatments 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\\npalpate the abdomen and other parts of the body to\\ndetermine energy imbalances. Then, the therapist will\\nwork with different meridians throughout the body,\\ndepending on which organs are imbalanced in the\\nabdomen. The therapist will use different types of\\nfinger movements and pressure on different acupoints,\\ndepending on whether the chi needs to be increased\\nor dispersed at different points. The therapist observes\\nand guides the energy flow through the patient’s body\\nthroughout the session. Sometimes, special herbs\\n(Artemesia vulgaris or moxa) may be placed on a\\npoint to warm it, a process calledmoxibustion. A ses-\\nsion of acupressure is generally a very pleasant experi-\\nence, and some people experience great benefit\\nimmediately. For more chronic conditions, several\\nsessions may be necessary to relieve and improve\\nconditions.\\nAcupressure massage usually costs from $30–70\\nper hour session. A visit to a Chinese medicine physi-\\ncian or acupuncturist can be more expensive, compar-\\nable to a visit to an allopathic physician if the\\npractitioner is an MD. Insurance reimbursement var-\\nies widely, and consumers should be aware if their\\npolicies cover alternative treatment, acupuncture, or\\nmassage therapy.\\nSelf-treatment\\nAcupressure is easy to learn, and there are many\\ngood books that illustrate the position of acupoints\\nand meridians on the body. It is also very versatile, as\\nit can be done anywhere, and it’s a good form of\\ntreatment for spouses and partners to give to each\\nother and for parents to perform on children for\\nminor conditions.\\nWhile giving self-treatment or performing acu-\\npressure on another, a mental attitude of calmness\\nand attention is important, as one person’s energy\\ncan be used to help another’s. Loose, thin clothing is\\nrecommended. There are three general techniques for\\nstimulating a pressure point.\\n/C15Tonifying is meant to strengthen weak chi, and is\\ndone by pressing the thumb or finger into an acu-\\npoint with a firm, steady pressure, holding it for up to\\ntwo minutes.\\n/C15Dispersing is meant to move stagnant or blocked\\nchi, and the finger or thumb is moved in a circular\\nmotion or slightly in and out of the point for two\\nminutes.\\n/C15Calming the chi in a pressure point utilizes the palm\\nto cover the point and gentlystroke the area for\\nabout two minutes.\\nThere are many pressure points that are easily\\nfound and memorized to treat common ailments\\nfrom headaches to colds.\\n/C15For headaches, toothaches, sinus problems, and\\npain in the upper body, the ‘‘LI4’’ point is recom-\\nmended. It is located in the web between the thumb\\nand index finger, on the back of the hand. Using the\\nthumb and index finger of the other hand, apply a\\npinching pressure until the point is felt, and hold it\\nfor two minutes. Pregnant women should never\\npress this point.\\n/C15To calm the nerves and stimulate digestion, find the\\n‘‘CV12’’ point that is four thumb widths above the\\nnavel in the center of the abdomen. Calm the point\\nwith the palm, using gentle stroking for several\\nminutes.\\n/C15To stimulate the immune system, find the ‘‘TH5’’\\npoint on the back of the forearm two thumb widths\\nabove the wrist. Use a dispersing technique, or cir-\\ncular pressure with the thumb or finger, for two\\nminutes on each arm.\\n/C15For headaches, sinus congestion, and tension, locate\\nthe ‘‘GB20’’ points at the base of the skull in the\\nback of the head, just behind the bones in back of\\n40 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupressure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the ears. Disperse these points for two minutes with\\nthe fingers or thumbs. Also find the ‘‘yintang’’ point,\\nwhich is in the middle of the forehead between the\\neyebrows. Disperse it with gentle pressure for two\\nminutes to clear the mind and to relieve headaches.\\nPrecautions\\nAcupressure is a safe technique, but it is not meant\\nto replace professional health care. A physician should\\nalways be consulted when there are doubts about\\nmedical conditions. If a condition is chronic, a profes-\\nsional should be consulted; purely symptomatic treat-\\nment can exacerbate chronic conditions. Acupressure\\nshould not be applied to open wounds, or where there\\nis swelling and inflammation. Areas of scar tissue,\\nblisters, boils, rashes, or varicose veins should be\\navoided. Finally, certain acupressure points should\\nnot be stimulated on people with high or low blood\\npressure and on pregnant women.\\nResearch and general acceptance\\nIn general, Chinese medicine has been slow to\\ngain acceptance in the West, mainly because it rests\\non ideas very foreign to the scientific model. For\\ninstance, Western scientists have trouble with the\\nidea of chi, the invisible energy of the body, and the\\nidea that pressing on certain points can alleviate\\ncertain conditions seems sometimes too simple for\\nscientists to believe.\\nWestern scientists, in trying to account for the\\naction of acupressure, have theorized that chi is actu-\\nally part of the neuroendocrine system of the body.\\nCelebrated orthopedic surgeon Robert O. Becker,\\nwho was twice nominated for the Nobel Prize, wrote\\na book on the subject called Cross Currents: The\\nPromise of Electromedicine; The Perils of Electro-\\npollution. By using precise electrical measuring\\ndevices, Becker and his colleagues showed that the\\nbody has a complex web of electromagnetic energy,\\nand that traditional acupressure meridians and points\\ncontained amounts of energy that non-acupressure\\npoints did not.\\nThe mechanisms of acupuncture and acupres-\\nsure remain difficult to document in terms of the\\nbiochemical processes involved; numerous testi-\\nmonials are the primary evidence backing up the\\neffectiveness of acupressure and acupuncture.\\nH o w e v e r ,ab o d yo fr e s e a r c hi sg r o w i n gt h a tv e r i -\\nfies the effectiveness in acupressure and acupunc-\\nture techniques in treating many problems and in\\ncontrolling pain.\\nResources\\nPERIODICALS\\nMassage Therapy Journal. 820 Davis Street, Suite100,\\nEvanston, IL 60201-4444.\\nOTHER\\nAmerican Association of Oriental Medicine.December 28,\\n2000. .\\nNational Acupuncture and Oriental Medicine Alliance.\\nDecember 28, 2000. .\\nDouglas Dupler, MA\\nAcupressure, foot see Reflexology\\nAcupuncture\\nDefinition\\nAcupuncture is one of the main forms of treat-\\nment in traditional Chinese medicine. It involves the\\nuse of sharp, thin needles that are inserted in the body\\nat very specific points. This process is believed to\\nadjust and alter the body’s energy flow into healthier\\npatterns, and is used to treat a wide variety of illnesses\\nand health conditions.\\nPurpose\\nThe World Health Organization (WHO) recom-\\nmends acupuncture as an effective treatment for over\\nforty medical problems, includingallergies,r e s p i r a -\\ntory conditions, gastrointestinal disorders, gynecolo-\\ngical problems, nervous conditions, and disorders of\\nthe eyes, nose and throat, and childhood illnesses,\\namong others. Acupuncture has been used in the\\ntreatment of alcoholism and substance abuse.I ti s\\nan effective and low-cost treatment for headaches\\nand chronic pain, associated with problems like\\nback injuries and arthritis. It has also been used\\nto supplement invasive W estern treatments like\\nchemotherapy and surgery. Acupuncture is generally\\nmost effective when used as prevention or before a\\nhealth condition becomes acute, but it has been used\\nto help patients suffering from cancer and AIDS.\\nAcupuncture is limited in treating conditions or\\ntraumas that require surgery or emergency care\\n(such as for broken bones).\\nGALE ENCYCLOPEDIA OF MEDICINE 41\\nAcupuncture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nOrigins\\nThe original text of Chinese medicine is theNei\\nChing, The Yellow Emperor’s Classic of Internal\\nMedicine, which is estimated to be at least 2,500 years\\nold. Thousands of books since then have been written\\non the subject of Chinese healing, and its basic philo-\\nsophies spread long ago to other Asian civilizations.\\nNearly all of the forms of Oriental medicine which are\\nused in the West today, including acupuncture,shiatsu,\\nacupressure massage, and macrobiotics, are part of or\\nhave their roots in Chinese medicine. Legend has it that\\nacupuncture developed when early Chinese physicians\\nobserved unpredicted effects of puncturewounds in\\nChinese warriors. The oldest known text on acupunc-\\nture, theSystematic Classic of Acupuncture,d a t e sb a c k\\nto 282 A.D. Although acupuncture is its best known\\ntechnique, Chinese medicine traditionally utilizes her-\\nbal remedies, dietary therapy, lifestyle changes and\\nother 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\\nremained virtually unknown until the 1970s, when\\nRichard Nixon became the first U.S. president to\\nvisit China. On Nixon’s trip, journalists were amazed\\nto observe major operations being performed on\\npatients without the use of anesthetics. Instead,\\nwide-awake patients were being operated on with\\nonly acupuncture needles inserted into them to con-\\ntrol pain. During that time, a famous columnist for\\nthe New York Times , James Reston, had to undergo\\nsurgery and elected to use acupuncture instead of\\npain medication, and he w rote some convincing\\nstories on its effectiveness.\\nToday, acupuncture is being practiced in all 50\\nstates by over 9,000 practitioners, with over 4,000\\nMDs including it in their practices. Acupuncture has\\nshown notable success in treating many conditions,\\nand over 15 million Americans have used it as a ther-\\napy. Acupuncture, however, remains largely unsup-\\nported by the medical establishment. The American\\nMedical Association has been resistant to researching\\nit, as it is based on concepts very different from the\\nWestern scientific model.\\nWoman undergoing facial acupuncture. (Photograph by Yoav Levy. Phototake NYC. Reproduced by permission.)\\n42 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupuncture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Several forms of acupuncture are being used\\ntoday in America. Japanese acupuncture uses extre-\\nmely thin needles and does not incorporate herbal\\nmedicine in its practice. Auricular acupuncture uses\\nacupuncture points only on the ear, which are\\nbelieved to stimulate and balance internal organs.\\nIn France, where acupuncture is very popular and\\nmore accepted by the medical establishment, neuro-\\nlogist Paul Nogier developed a system of acupuncture\\nbased on neuroendocrine theory rather than on tra-\\nditional Chinese concepts, which is gaining some use\\nin America.\\nBasic ideas of Chinese medicine\\nChinese medicine views the body as a small part\\nof the universe, and subject to universal laws and\\nprinciples of harmony and balance. Chinese medicine\\ndoes not draw a sharp line, as Western medicine does,\\nbetween mind and body. The Chinese system believes\\nthat emotions and mental states are every bit as\\ninfluential on disease as purely physical mechanisms,\\nand considers factors like work, environment, life-\\nstyle and relationships as fundamental to the overall\\npicture of a patient’s health. Chinese medicine also\\nuses very different symbols and ideas to discuss the\\nbody and health. While Western medicine typically\\ndescribes health in terms of measurable physical\\nprocesses made up of chemical reactions, the Chinese\\nuse ideas like yin and yang, chi, the organ system, and\\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.)\\nKEY TERMS\\nAcupressure— Form of massage using acupuncture\\npoints.\\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\\ndescribe aspects of the natural world.\\nGALE ENCYCLOPEDIA OF MEDICINE 43\\nAcupuncture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the five elements to describe health and the body. To\\nunderstand the ideas behind acupuncture, it is worth-\\nwhile to introduce some of these basic terms.\\nYIN AND YANG. According to Chinese philosophy,\\nthe universe and the body can be described by two\\nseparate but complementary principles, that of yin\\nand yang. For example, in temperature, yin is cold\\nand yang is hot. In gender, yin is female and yang is\\nmale. In activity, yin is passive and yang is active. In\\nlight, yin is dark and yang is bright; in direction yin is\\ninward and downward and yang is outward and up,\\nand so on. Nothing is ever completely yin or yang, but\\na combination of the two. These two principles are\\nalways interacting, opposing, and influencing each\\nother. The goal of Chinese medicine is not to eliminate\\neither yin or yang, but to allow the two to balance each\\nother and exist harmoniously together. For instance, if\\na person suffers from symptoms of high blood pressure,\\nthe Chinese system would say that the heart organ\\nmight have too much yang, and would recommend\\nmethods either to reduce the yang or to increase the\\nyin of the heart, depending on the other symptoms and\\norgans in the body. Thus, acupuncture therapies seek to\\neither increase or reduce yang, or increase or reduce yin\\nin particular regions of the body.\\nCHI. Another fundamental concept of Chinese\\nmedicine is that of chi (pronouncedchee, also spelled\\nqi). Chi is the fundamental life energy of the universe.\\nIt is invisible and is found in the environment in the\\nair, water, food and sunlight. In the body, it is the\\ninvisible vital force that creates and animates life.\\nWe are all born with inherited amounts of chi, and\\nwe also get acquired chi from the food we eat and the\\nair we breathe. The level and quality of a person’s chi\\nalso depends on the state of physical, mental and\\nemotional balance. Chi travels through the body\\nalong channels calledmeridians.\\nTHE ORGAN SYSTEM. In the Chinese system, there\\nare twelve main organs: the lung, large intestine, sto-\\nmach, spleen, heart, small intestine, urinary bladder,\\nkidney, liver, gallbladder, pericardium, and the ‘‘triple\\nwarmer,’’ which represents the entire torso region.\\nEach organ has chi energy associated with it, and\\neach organ interacts with particular emotions on the\\nmental level. As there are twelve organs, there are\\ntwelve types of chi which can move through the body,\\nand these move through twelve main channels or mer-\\nidians. Chinese doctors connect symptoms to organs.\\nThat is, symptoms are caused by yin/yang imbalances\\nin one or more organs, or by an unhealthy flow of chi\\nto or from one organ to another. Each organ has a\\ndifferent profile of symptoms it can manifest.\\nTHE FIVE ELEMENTS. Another basis of Chinese the-\\nory is that the world and body are made up of five\\nmain elements: wood, fire, earth, metal, and water.\\nThese elements are all interconnected, and each ele-\\nment either generates or controls another element. For\\ninstance, water controls fire and earth generates metal.\\nEach organ is associated with one of the five elements.\\nThe Chinese system uses elements and organs to\\ndescribe and treat conditions. For instance, the kidney\\nis associated with water and the heart is associated\\nwith fire, and the two organs are related as water and\\nfire are related. If the kidney is weak, then there might\\nbe a corresponding fire problem in the heart, so treat-\\nment might be made by acupuncture or herbs to cool\\nthe heart system and/or increase energy in the kidney\\nsystem.\\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\\nsimple one. Although this system sounds suspect to\\nWestern scientists, some interesting parallels have\\nbeen observed. For instance, Western medicine has\\nobserved that with severe heart problems, kidney fail-\\nure often follows, but it still does not know exactly\\nwhy. In Chinese medicine, this connection between the\\ntwo organs has long been established.\\nMEDICAL PROBLEMS AND ACUPUNCTURE. In\\nChinese medicine, disease as seen as imbalances in\\nthe organ system or chi meridians, and the goal of\\nany remedy or treatment is to assist the body in rees-\\ntablishing its innate harmony. Disease can be caused\\nby internal factors like emotions, external factors like\\nthe environment and weather, and other factors like\\ninjuries, trauma, diet, and germs. However, infection\\nis seen not as primarily a problem with germs and\\nviruses, but as a weakness in the energy of the body\\nwhich is allowing a sickness to occur. In Chinese med-\\nicine, no two illnesses are ever the same, as each body\\nhas its own characteristics of symptoms and balance.\\nAcupuncture is used to open or adjust the flow of chi\\nthroughout the organ system, which will strengthen\\nthe body and prompt it to heal itself.\\nA VISIT TO THE ACUPUNCTURIST. The first thing\\nan acupuncturist will do is get a thorough idea of a\\npatient’s medical history and symptoms, both physi-\\ncal and emotional. This is done with a long question-\\nnaire and interview. Then the acupuncturist will\\nexamine the patient to find further symptoms, look-\\ning closely at the tongue, the pulse at various points\\nin the body, the complexion, general behavior,\\nand other signs like coughs or pains. From this, the\\npractitioner will be able to determine patterns of\\n44 GALE ENCYCLOPEDIA OF MEDICINE\\nAcupuncture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='symptoms which indicate which organs and areas\\nare imbalanced. Depending on the problem, the acu-\\npuncturist will insert needles to manipulate chi on\\none or more of the twelve organ meridians. On these\\ntwelve meridians, there are nearly 2,000 points which\\ncan be used in acupuncture, with around 200 points\\nbeing most frequently used by traditional acupunc-\\nturists. During an individual treatment, one to\\ntwenty needles may be used, depending on which\\nmeridian points are chosen.\\nAcupuncture needles are always sterilized and\\nacupuncture is a very safe procedure. The depth of\\ninsertion of needles varies, depending on which chi\\nchannels are being treated. Some points barely go\\nbeyond superficial layers of skin, while some acupunc-\\nture points require a depth of 1-3 in (2.5-7.5 cm) of\\nneedle. The needles generally do not cause pain.\\nPatients sometimes report pinching sensations and\\noften pleasant sensations, as the body experiences\\nhealing. Depending on the problem, the acupuncturist\\nmight spin or move the needles, or even pass a slight\\nelectrical current through some of them.Moxibustion\\nmay be sometimes used, in which an herbal mixture\\n(moxa or mugwort) is either burned like incense on the\\nacupuncture point or on the end of the needle, which\\nis believed to stimulate chi in a particular way. Also,\\nacupuncturists sometimes usecupping, during which\\nsmall suction cups are placed on meridian points to\\nstimulate them.\\nHow long the needles are inserted also varies.\\nSome patients only require a quick in and out inser-\\ntion to clear problems and provide tonification\\n(strengthening of health), while some other condi-\\ntions might require needles inserted up to an hour or\\nmore. The average visit to an acupuncturist takes\\nabout thirty minutes. The number of visits to the\\nacupuncturist varies as well, with some conditions\\nimproved in one or two sessions and others requiring\\na series of six or more visits over the course of weeks\\nor months.\\nCosts for acupuncture can vary, depending\\non whether the practitioner is an MD. Initial visits\\nwith non-MD acupuncturists can run from $50-\\n$100, with follow-up visits usually costing less.\\nInsurance reimbursement also varies widely, depend-\\ning on the company and state. Regulations have been\\nchanging often. Some states authorize Medicaid to\\ncover acupuncture for certain conditions, and some\\nstates have mandated that general coverage pay\\nfor acupuncture. Consumers should be aware of\\nthe provisions for acupuncture in their individual\\npolicies.\\nPrecautions\\nAcupuncture is generally a very safe procedure. If\\na patient is in doubt about a medical condition, more\\nthan one physician should be consulted. Also, a\\npatient should always feel comfortable and confident\\nthat their acupuncturist is knowledgable and properly\\ntrained.\\nResearch and general acceptance\\nMainstream medicine has been slow to accept\\nacupuncture; although more MDs are using it, the\\nAmerican Medical Association does not recognize\\nit as a specialty. The reason for this is that the\\nmechanism of acupuncture is difficult to scientifi-\\ncally understand or measure, such as the invisible\\nenergy of chi in the body. Western medicine,\\nadmitting that acupuncture works in many cases,\\nhas theorized that the energy meridians are actu-\\nally part of the nervous system and that acupunc-\\nture relieves pain by releasing endorphins, or\\nnatural pain killers, into the bloodstream. Despite\\nthe ambiguity in the biochemistry involved, acu-\\npuncture continues to show effectiveness in clinical\\ntests, from reducing pain to alleviating the symp-\\ntoms of chronic illnesses,and research in acupunc-\\nture is currently growing. The Office of Alternative\\nMedicine of the National Institute of Health is\\ncurrently funding research in the use of acupunc-\\nture for treating depression and attention-deficit\\ndisorder.\\nResources\\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,\\n2000. .\\nNorth American Society of Acupuncture and Alternative\\nMedicine. December 28, 2000. .\\nDouglas Dupler, MA\\nAcute glomerulonephritis see Acute post-\\nstreptococcal glomerulonephritis\\nAcute homeopathic remedies see\\nHomeopathic remedies, acute prescribing\\nGALE ENCYCLOPEDIA OF MEDICINE 45\\nAcupuncture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Acute kidney failure\\nDefinition\\nAcute kidney failure occurs when illness, infec-\\ntion, or injury damages the kidneys. Temporarily, the\\nkidneys cannot adequately remove fluids and wastes\\nfrom the body or maintain the proper level of certain\\nkidney-regulated chemicals in the bloodstream.\\nDescription\\nThe kidneys are the body’s natural filtration\\nsystem. They perform the critical task of proces-\\nsing approximately 200 quarts of fluid in the\\nbloodstream every 24 hours. Waste products like\\nurea and toxins, along with excess fluids, are\\nremoved from the bloodstream in the form of\\nurine. Kidney (or renal) failure occurs when kidney\\nfunctioning becomes impaired. Fluids and toxins\\nbegin to accumulate in the bloodstream. As fluids\\nbuild up in the bloodstream, the patient with acute\\nkidney failure may become puffy and swollen (ede-\\nmatous) in the face, hands, and feet. Their blood\\npressure typically begins to rise, and they may\\nexperience fatigue and nausea.\\nUnlike chronic kidney failure , which is long\\nterm and irreversible, acute kidney failure is a\\ntemporary condition. With proper and timely treat-\\nment, it can typically be reversed. Often there is no\\npermanent damage to the kidneys. Acute kidney\\nfailure appears most frequently as a complication\\nof serious illness, like heart failure, liver failure,\\ndehydration, severe burns, and excessive bleeding\\n(hemorrhage). It may also be caused by an\\nobstruction to the urinary tract or as a direct result\\nof kidney disease, injury, or an adverse reaction to\\nam e d i c i n e .\\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,a n d\\nintrarenal conditions.\\nPrerenal conditions do not damage the kidney,\\nbut can cause diminished kidney function. They are\\nthe most common cause of acute renal failure, and\\ninclude:\\n/C15dehydration\\n/C15hemorrhage\\n/C15septicemia, orsepsis\\n/C15heart failure\\n/C15liver failure\\n/C15burns\\nPostrenal conditions cause kidney failure by\\nobstructing the urinary tract. These conditions\\ninclude:\\n/C15inflammation of the prostate gland in men\\n(prostatitis)\\n/C15enlargement of the prostate gland (benign prostatic\\nhypertrophy)\\n/C15bladder or pelvic tumors\\n/C15kidney stones(calculi)\\nIntrarenal conditions involve kidney disease\\nor direct injury to the kidneys. These conditions\\ninclude:\\n/C15lack of blood supply to the kidneys (ischemia)\\n/C15use of radiocontrast agents in patients with kidney\\nproblems\\n/C15drug abuse or overdose\\n/C15long-term use of nephrotoxic medications, like cer-\\ntain pain medicines\\n/C15acute inflammation of the glomeruli, or filters, of the\\nkidney (glomerulonephritis)\\n/C15kidney infections (pyelitis or pyelonephritis).\\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\\nblood vessels.\\n46 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute kidney failure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Common symptoms of acute kidney failure\\ninclude:\\n/C15anemia. The kidneys are responsible for producing\\nerythropoietin (EPO), a hormone that stimulates red\\nblood cell production. If kidney disease causes\\nshrinking of the kidney, red blood cell production is\\nreduced, leading to anemia.\\n/C15bad breath or bad taste in mouth. Urea in the saliva\\nmay cause an ammonia-like taste in the mouth.\\n/C15bone and joint problems. The kidneys produce\\nvitamin D, which helps the body absorb calcium\\nand keeps bones strong. For patients with kidney\\nfailure, bones may become brittle. In children,\\nnormal growth may be stunted. Joint pain may\\nalso occur as a result of high phosphate levels\\nin the blood. Retention of uric acid may cause\\ngout.\\n/C15edema. Puffiness or swelling in the arms, hands, feet,\\nand around the eyes.\\n/C15frequent urination.\\n/C15foamy or bloody urine. Protein in the urine may\\ncause it to foam significantly. Blood in the urine\\nmay indicate bleeding from diseased or obstructed\\nkidneys, bladder, or ureters.\\n/C15headaches. High blood pressure may trigger\\nheadaches.\\n/C15hypertension, or high blood pressure. The retention\\nof fluids and wastes causes blood volume to increase.\\nThis makes blood pressure rise.\\n/C15increased fatigue. Toxic substances in the blood and\\nthe presence of anemia may cause the patient to feel\\nexhausted.\\n/C15itching. Phosphorus, normally eliminated in the\\nurine, accumulates in the blood of patients with\\nkidney failure. An increased phosphorus level may\\ncause the skin to itch.\\n/C15lower back pain. Patients suffering from certain kid-\\nney problems (like kidney stones and other obstruc-\\ntions) may have pain where the kidneys are located,\\nin the small of the back below the ribs.\\n/C15nausea. Urea in the gastric juices may cause upset\\nstomach.\\nDiagnosis\\nKidney failure is diagnosed by a doctor. A\\nnephrologist, a doctor that specializes in the kid-\\nney, may be consulted to confirm the diagnosis and\\nrecommend treatment options. The patient that is\\nsuspected of having acute kidney failure will have\\nblood and urine tests to determine the level of\\nkidney function. A blood test will assess the levels\\nof creatinine, blood urea nitrogen (BUN), uric\\nacid, phosphate, sodium, and potassium. The kid-\\nney regulates these agents in the blood. Urine sam-\\nples will also be collected, usually over a 24-hour\\nperiod, to assess protein loss and/or creatinine\\nclearance.\\nDetermining the cause of kidney failure is critical\\nto proper treatment. A fullassessment of the kidneys\\nis necessary to determine if the underlying disease\\nis treatable and if the kidney failure is chronic or\\nacute. X rays, magnetic resonance imaging (MRI),\\ncomputed tomography scan (CT), ultrasound, renal\\nbiopsy, and/or arteriogram of the kidneys may be\\nused to determine the cause of kidney failure and\\nlevel of remaining kidney function. X rays and ultra-\\nsound of the bladder and/or ureters may also be\\nneeded.\\nTreatment\\nTreatment for acute kidney failure varies.\\nTreatment is directed to the underlying, primary med-\\nical condition that has triggered kidney failure.\\nPrerenal conditions may be treated with replacement\\nfluids given through a vein,diuretics, blood transfusion,\\nor medications. Postrenal conditions and intrarenal\\nconditions may require surgery and/or medication.\\nFrequently, patients in acute kidney failure\\nrequire hemodialysis , hemofiltration ,o r peritoneal\\ndialysis to filter fluids and wastes from the blood-\\nstream until the primary medical condition can be\\ncontrolled.\\nHemodialysis\\nHemodialysis involves circulating the patient’s\\nblood outside of the body through an extracorporeal\\ncircuit (ECC), or dialysis circuit. The ECC is made up\\nof plastic blood tubing, a filter known as a dialyzer (or\\nartificial kidney), and a dialysis machine that monitors\\nand maintains 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\\nblood leaves the body through the vein and travels\\nthrough the ECC and the dialyzer, where fluid\\nremoval takes place.\\nDuring dialysis, waste products in the blood-\\nstream are carried out of the body. At the same time,\\nelectrolytes and other chemicals are added to the\\nblood. The purified, chemically-balanced blood is\\nthen returned to the body.\\nGALE ENCYCLOPEDIA OF MEDICINE 47\\nAcute kidney failure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='A 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 hemodia-\\nlysis may pose a risk for patients with heart problems.\\nPeritoneal dialysis may be the preferred treatment\\noption in these cases.\\nHemofiltration\\nHemofiltration, also called continuous renal\\nreplacement therapy (CRRT), is a slow, continuous\\nblood filtration therapy used to control acute kidney\\nfailure in critically ill patients. These patients are\\ntypically very sick and may have heart problems or\\ncirculatory problems. They cannot handle the rapid\\nfiltration rates of hemodialysis. They also frequently\\nneed antibiotics, nutrition, vasopressors, and other\\nfluids given through a vein to treat their primary\\ncondition. Because hemofiltration is continuous,\\nprescription fluids can be given to patients in kidney\\nfailure without the risk of fluid overload.\\nLike hemodialysis, hemofiltration uses an ECC.\\nA hollow fiber hemofilter is used instead of a dialyzer\\nto remove fluids and toxins. Instead of a dialysis\\nmachine, a blood pump makes the blood flow through\\nthe ECC. The volume of blood circulating through\\nthe ECC in hemofiltration is less than that in hemo-\\ndialysis. Filtration rates are slower and gentler on the\\ncirculatory system. Hemofiltration treatment will\\ngenerally be used until kidney failure is reversed.\\nPeritoneal dialysis\\nPeritoneal dialysis may be used if an acute kidney\\nfailure patient is stable and not in immediate crisis.\\nIn peritoneal dialysis (PD), the lining of the patient’s\\nabdomen, the peritoneum, acts as a blood filter.\\nA flexible tube-like instrument (catheter) is surgically\\ninserted into the patient’s abdomen. During treat-\\nment, the catheter is used to fill the abdominal cavity\\nwith dialysate. Waste products and excess fluids move\\nfrom the patient’s bloodstream into the dialysate\\nsolution. After a certain time period, the waste-filled\\ndialysate is drained from the abdomen, and replaced\\nwith clean dialysate. There are three type of peritoneal\\ndialysis, which vary according to treatment time and\\nadministration method.\\nPeritoneal dialysis is often the best treatment\\noption for infants and children. Their small size can\\nmake vein access difficult to maintain. It is not recom-\\nmended for patients with abdominal adhesions or\\nother abdominal defects (like a hernia) that might\\nreduce the efficiency of the treatment. It is also not\\nrecommended for patients who suffer frequent bouts\\nof an inflammation of the small pouches in the intest-\\ninal tract (diverticulitis).\\nPrognosis\\nBecause many of the illnesses and underlying\\nconditions that often trigger acute kidney failure\\nare critical, the prognosis for these patients many\\ntimes is not good. Studies have estimated overall\\ndeath rates for acute kidney failure at 42-88%.\\nMany people, however, die because of the primary\\ndisease that has caused the kidney failure. These\\nfigures may also be mislea ding because patients\\nwho experience kidney failure as a result of less\\nserious illnesses (like kidney stones or dehydration)\\nhave an excellent chance of complete recovery.\\nEarly recognition and prompt, appropriate treat-\\nment are key to patient recovery.\\nUp to 10% of patients who experience acute\\nkidney failure will suffer irreversible kidney damage.\\nThey will eventually go on to develop chronic kidney\\nfailure or end-stage renal disease. These patients will\\nrequire long-term dialysis or kidney transplantation to\\nreplace their lost 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\\ncarefully monitored for kidney failure complications.\\nTreatments and procedures that may put them at risk\\nfor kidney failure (like diagnostic tests requiring radio-\\ncontrast agents or dyes) should be used with extreme\\ncaution.\\nResources\\nPERIODICALS\\nStark, June. ‘‘Dialysis Choices: Turning the Tide in Acute\\nRenal Failure.’’Nursing 27, no. 2 (February 1997):\\n41-8.\\nORGANIZATIONS\\nNational Kidney Foundation. 30 East 33rd St., New York,\\nNY 10016. (800) 622-9010. .\\nPaula Anne Ford-Martin\\nAcute leukemias see Leukemias, acute\\n48 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute kidney failure'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Acute lymphangitis\\nDefinition\\nAcute lymphangitis is a bacterial infection in the\\nlymphatic vessels which is characterized by painful,\\nred streaks below the skin surface. This is a potentially\\nserious infection which can rapidly spread to the\\nbloodstream and be fatal.\\nDescription\\nAcute lymphangitis affects a critical member of\\nthe immune system–the lymphatic system. Waste\\nmaterials from nearly every organ in the body drain\\ninto the lymphatic vessels and are filtered in small\\norgans called lymph nodes. Foreign bodies, such as\\nbacteria or viruses, are processed in the lymph nodes\\nto generate an immune response to fight an infection.\\nIn acute lymphangitis, bacteria enter the body\\nthrough a cut, scratch, insect bite, surgical wound, or\\nother skin injury. Once the bacteria enter the lympha-\\ntic system, they multiply rapidly and follow the lym-\\nphatic vessel like a highway. The infected lymphatic\\nvessel becomes inflamed, causing red streaks that are\\nvisible below the skin surface. The growth of the bac-\\nteria occurs so rapidly that the immune system does\\nnot respond fast enough 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 anabscess may be formed in the\\ninfected area. Cellulitis, a generalized infection of\\nthe lower skin layers, may also occur. In addition,\\nthe bacteria may invade the bloodstream and cause\\nsepticemia. Lay people, for that reason, often call\\nthe red streaks seen in the skin ‘‘blood poisoning.’’\\nSepticemia is a very serious illness and may be fatal.\\nCauses and symptoms\\nAcute lymphangitis is most often caused by the\\nbacterium Streptococcus pyogenes . This potentially\\ndangerous bacterium also causes strep throat, infec-\\ntions of the heart, spinal cord, and lungs, and in the\\n1990s has been called the ‘‘flesh-eating bacterium.’’\\nStaphylococci bacteria may also cause lymphangitis.\\nAlthough anyone can develop lymphangitis, some\\npeople are more at risk. People who have had radical\\nmastectomy (removal of a breast and nearby lymph\\nnodes), a leg vein removed for coronary bypass sur-\\ngery, or recurrent lymphangitis caused by tinea pedis\\n(a fungal infection on the foot) are at an increased risk\\nfor lymphangitis.\\nThe characteristic symptoms of acute lymphangi-\\ntis are the wide, red streaks which travel from the site\\nof infection to the armpit or groin. The affected areas\\nare red, swollen, and painful. Blistering of the affected\\nskin may occur. The bacterial infection causes afever\\nof 100-1048F (38-408C). In addition, a general ill\\nfeeling, muscle aches, headache, chills, and loss of\\nappetite may be felt.\\nDiagnosis\\nIf lymphangitis is suspected, the person should\\ncall his or her doctor immediately or go to an emer-\\ngency room. Acute lymphangitis could be diagnosed\\nby the family doctor, infectious disease specialist,\\nor an emergency room doctor. The painful, red\\nstreaks just below the skin surface and the high\\nfever are diagnostic of acute lymphangitis. A sample\\nof blood would be taken for culture to determine\\nwhether the bacteria have entered the bloodstream.\\nA biopsy (removal of a pi ece of infected tissue)\\nsample may be taken for culture to identify which\\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\\nexpenses for the diagnosis and treatment of acute\\nlymphangitis.\\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. Grow-\\ning streptococcal bacteria are usually eliminated rapidly\\nand easily by penicillin. The antibiotic clindamycin may\\nbe included in the treatment to kill any streptococci\\nwhich are not growing and are in a resting state.\\nKEY TERMS\\nBiopsy— The process which removes a sample of\\ndiseased or infected tissue for microscopic exam-\\nination 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 ves-\\nsels and are filtered by the lymph nodes.\\nSepticemia— Disease caused by the presence and\\ngrowth of bacteria in the bloodstream.\\nGALE ENCYCLOPEDIA OF MEDICINE 49\\nAcute lymphangitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alternatively, a ‘‘broad spectrum’’ antibiotic may be\\nused which would kill many different kinds of bacteria.\\nPrognosis\\nComplete recovery is expected if antibiotic treat-\\nment is begun at an early stage of the infection.\\nHowever, if untreated, acute lymphangitis can be a\\nvery serious and even deadly disease. Acute lymphan-\\ngitis that goes untreated can spread, causing tissue\\ndamage. Extensive tissue damage would need to be\\nrepaired by plastic surgery. Spread of the infection\\ninto the bloodstream could be fatal.\\nPrevention\\nAlthough acute lymphangitis can occur in any-\\none, good hygiene and general health may help to\\nprevent infections.\\nResources\\nPERIODICALS\\nDajer, Tony. ‘‘A Lethal Scratch.’’Discover (February 1998):\\n34-7.\\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,\\nfollowing a streptococcal infection such as strep\\nthroat. APSGN is also called postinfectious\\nglomerulonephritis.\\nDescription\\nAPSGN develops after certain streptococcal\\nbacteria (group A beta-hemolytic streptococci) have\\ninfected the skin or throat. Antigens from the dead\\nstreptococci clump together with the antibodies that\\nkilled them. These clumps are trapped in the kidney\\ntubules, cause the tubules to become inflamed, and\\nimpair that organs’ ability to filter and eliminate\\nbody wastes. The onset of APSGN usually occurs\\none to six weeks (average two weeks) after the strep-\\ntococcal infection.\\nAPSGN is a relatively uncommon disease affect-\\ning about one of every 10,000 people, although four or\\nfive times that many may actually be affected by it\\nbut show no symptoms. APSGN is most prevalent\\namong boys between the ages of 3 and 7, but it can\\noccur at any age.\\nCauses and symptoms\\nFrequent sore throats and a history of streptococ-\\ncal infection increase the risk of acquiring APSGN.\\nSymptoms of APSGN include:\\n/C15fluid accumulation and tissue swelling ( edema)\\ninitially in the face and around the eyes, later in\\nthe legs\\n/C15low urine output (oliguria)\\n/C15blood in the urine (hematuria)\\n/C15protein in the urine (proteinuria)\\n/C15high blood pressure\\n/C15joint pain or stiffness\\nDiagnosis\\nDiagnosis of APSGN is made by taking the\\npatient’s history, assessing his/her symptoms, and\\nperforming certain laboratory tests. Urinalysis\\nusually shows blood and protein in the urine.\\nConcentrations of urea and creatinine (two waste\\nproducts normally filtered out of the blood by the\\nkidneys) in the blood are often high, indicating\\nimpaired kidney function. A reliable, inexpensive\\nblood test called the anti- streptolysin-O test can\\nconfirm that a patient has or has had a streptococ-\\ncal infection. A throat culture may also show the\\npresence of group A beta-hemolytic streptococci.\\nTreatment\\nTreatment of ASPGN is designed to relieve the\\nsymptoms and prevent complications. Some patients\\nKEY TERMS\\nStreptococcus— A gram-positive, round or oval\\nbacteria in the genusStreptococcus. Group A strep-\\ntococci cause a number of human diseases includ-\\ning strep throat, impetigo, and ASPGN.\\n50 GALE ENCYCLOPEDIA OF MEDICINE\\nAcute poststreptococcal glomerulonephritis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='are advised to stay in bed until they feel better and\\nto restrict fluid and salt intake. Antibiotics may be\\nprescribed to kill any lingering streptococcal bacteria,\\nif their presence is confirmed. Antihypertensives may\\nbe given to help control high blood pressure and\\ndiuretics may be used to reduce fluid retention and\\nswelling. Kidney dialysisis rarely needed.\\nPrognosis\\nMost children (up to 95%) fully recover from\\nAPSGN in a matter of weeks or months. Most adults\\n(up to 70%) also recover fully. In those who do\\nnot recover fully, chronic or progressive problems of\\nkidney function may occur. Kidney failure may result\\nin some patients.\\nPrevention\\nReceiving prompt treatment for streptococcal\\ninfections may prevent APSGN.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nORGANIZATIONS\\nAmerican Kidney Fund (AKF). Suite 1010, 6110 Executive\\nBoulevard, Rockville, MD 20852. (800) 638-8299.\\n.\\nNational Kidney Foundation. 30 East 33rd St., New\\nYork, NY 10016. (800) 622-9010..\\nMaureen Haggerty\\nAcute respiratory distress syndrome see\\nAdult respiratory distress syndrome\\nAcute stress disorder\\nDefinition\\nAcute stress disorder (ASD) is ananxiety disorder\\ncharacterized by a cluster of dissociative and anxiety\\nsymptoms occurring within one month of a traumatic\\nevent. (Dissociation is a psychological reaction to\\ntrauma in which the mind tries to cope by ‘‘sealing\\noff ’’ some features of the trauma from conscious\\nawareness).\\nDescription\\nAcute stress disorder is a new diagnostic category\\nthat was introduced in 1994 to differentiate time-lim-\\nited reactions to trauma frompost-traumatic stress\\ndisorder (PTSD).\\nCauses and symptoms\\nAcute stress disorder is caused by exposure to\\ntrauma, which is defined as a stressor that causes\\nintense fear and, usually, involves threats to life or\\nserious injury to oneself or others. Examples are\\nrape, mugging, combat, natural disasters, etc.\\nThe symptoms of stress disorder include a com-\\nbining of one or more dissociative and anxiety symp-\\ntoms with the avoidance of reminders of the traumatic\\nevent. Dissociative symptoms include emotional\\ndetachment, temporary loss of memory, depersonali-\\nzation, and derealization.\\nAnxiety symptoms connected with acute stress\\ndisorder include irritability, physical restlessness,\\nsleep problems, inability to concentrate, and being\\neasily startled.\\nDiagnosis\\nDiagnosis of acute stress disorder is based on a\\ncombination of the patient’s history and aphysical\\nexamination to rule out diseases that can cause\\nanxiety. The essential feature is a traumatic event\\nwithin one month of the onset of symptoms. Other\\ndiagnostic criteria include:\\n/C15The symptoms significantly interfere with normal\\nsocial or vocational functioning\\n/C15The symptoms last between two days and four weeks.\\nKEY TERMS\\nDepersonalization— A dissociative symptom in\\nwhich the patient feels that his or her body is\\nunreal, 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 con-\\nscious awareness. Dissociation can affect the pat-\\nient’s memory, sense of reality, and sense of identity.\\nTrauma— In the context of ASD, a disastrous or\\nlife-threatening event.\\nGALE ENCYCLOPEDIA OF MEDICINE 51\\nAcute stress disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nTreatment for acute stress disorder usually\\nincludes a combination of antidepressant medications\\nand short-term psychotherapy.\\nPrognosis\\nThe prognosis for recovery is influenced by the\\nseverity and duration of the trauma, the patient’s\\ncloseness to it, and the patient’s previous level of func-\\ntioning. Favorable signs include a short time period\\nbetween the trauma and onset of symptoms, immediate\\ntreatment, and appropriate social support. If the\\npatient’s symptoms are severe enough to interfere\\nwith normal life and have lasted longer than one\\nmonth, the diagnosis may be changed to PTSD. If the\\nsymptoms have lasted longer than one month but are\\nnot 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 forsubstance abuse\\nor majordepressive disorders.\\nPrevention\\nTraumatic events cannot usually be foreseen and,\\nthus, cannot be prevented. However, in theory, profes-\\nsional intervention soon after a major trauma might\\nreduce the likelihood or severity of ASD. In addition,\\nsome symptoms of acute stress disorder result from\\nbiochemical changes in the central nervous system,\\nmuscles, and digestive tract that are not subject to\\nconscious control.\\nResources\\nBOOKS\\nCorbman, Gene R. ‘‘Anxiety Disorders.’’ InCurrent\\nDiagnosis, edited by Rex B. Conn, et al. Vol. 9.\\nPhiladelphia: W. B. Saunders Co., 1997.\\nEisendrath, Stuart J. ‘‘Psychiatric Disorders.’’ InCurrent\\nMedical Diagnosis and Treatment, 1998 , edited by\\nStephen McPhee, et al., 37th ed. Stamford: Appleton &\\nLange, 1997.\\nRebecca J. Frey, PhD\\nAcute stress gastritis see Gastritis\\nAcute transverse myelitis see Transverse\\nmyelitis\\nAcyclovir see Antiviral drugs\\nAddiction\\nDefinition\\nAddiction is a persistent, compulsive dependence\\non a behavior or substance. The term has been par-\\ntially replaced by the worddependence for substance\\nabuse. Addiction has been extended, however, to\\ninclude mood-altering behaviors or activities. Some\\nresearchers speak of two types of addictions: sub-\\nstance addictions (for example, alcoholism, drug\\nabuse,a n dsmoking); and process addictions (for\\nexample, gambling, spending, shopping, eating, and\\nsexual activity). There is a growing recognition that\\nmany addicts, such as polydrug abusers, are addicted\\nto more than one substance or process.\\nDescription\\nAddiction is one of the most costly public\\nhealth problems in the United States. It is a pro-\\ngressive syndrome, which means that it increases in\\nseverity over time unless i t is treated. Substance\\nabuse is characterized by frequent relapse, or return\\nto the abused substance. Substance abusers often\\nmake repeated attempts to quit before they are\\nsuccessful.\\nThe economic cost of substance abuse in the\\nUnited States exceeds $414 billion, with health care\\ncosts attributed to substance abuse estimated at more\\nthan $114 billion.\\nBy eighth grade, 52% of adolescents have con-\\nsumed alcohol, 41% have smoked tobacco, and 20%\\nhave smokedmarijuana. Compared to females, males\\nare almost four times as likely to be heavy drinkers,\\nnearly one and a half more likely to smoke a pack or\\nmore of cigarettes daily, and twice as likely to smoke\\nmarijuana weekly. However, among adolescents\\nthese gender differences are not as pronounced and\\ngirls are almost as likely to abuse substances such\\nas alcohol and cigarettes. Although frequent use\\nof tobacco, cocaine and heavy drinking appears\\nto remain stable in the 1990s, marijuana use has\\nincreased.\\nAn estimated four million Americans over the age\\nof 12 used prescriptionpain relievers, sedatives, and\\nstimulants for ‘‘nonmedical’’ reasons during one\\nmonth.\\nIn the United States, 25% of the population reg-\\nularly uses tobacco. Tobacco use reportedly kills 2.5\\ntimes as many people each year as alcohol and drug\\nabuse combined. According to data from the World\\n52 GALE ENCYCLOPEDIA OF MEDICINE\\nAddiction'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Health Organization, there were 1.1 billion smokers\\nworldwide and 10,000 tobacco-related deaths per\\nday. Furthermore, in the United States, 43% of chil-\\ndren aged 2-11 years are exposed to environmental\\ntobacco smoke, which has been implicated insudden\\ninfant death syndrome, low birth weight,asthma, mid-\\ndle ear disease,pneumonia, cough, and upper respira-\\ntory infection.\\nEating disorders, such as anorexia nervosa ,\\nbulimia nervosa, and binge eating, affect more than\\nfive million American women and men. Fifteen per-\\ncent of young women have substantially disordered\\nattitudes toward eating and eating behaviors. More\\nthan 1,000 women die each year from anorexia\\nnervosa.\\nA Harvard study found that an estimated 15.4\\nmillion Americans suffered from a gambling addiction.\\nMore than one-half (7.9 million) were adolescents.\\nCauses and symptoms\\nAddiction to substances results from the interac-\\ntion of several factors:\\nDrug chemistry\\nSome substances are more addictive than others,\\neither because they produce a rapid and intense\\nchange in mood; or because they produce painful\\nwithdrawal symptoms when stopped suddenly.\\nGenetic factor\\nSome people appear to be more vulnerable to\\naddiction because their body chemistry increases\\ntheir sensitivity to drugs. Some forms ofsubstance\\nabuse and dependence seem to run in families; and\\nthis may be the result of a genetic predisposition,\\nenvironmental influences, or a combination of both.\\nBrain structure and function\\nUsing drugs repeatedly over time changes brain\\nstructure and function in fundamental and long-last-\\ning ways. Addiction comes about through an array of\\nchanges in the brain and the strengthening of new\\nmemory connections. Evidence suggests that those\\nlong-lasting brain changes are responsible for the dis-\\ntortions of cognitive and emotional functioning that\\ncharacterize addicts, particularly the compulsion to\\nuse drugs. Although the causes of addiction remain\\nthe subject of ongoing debate and research, many\\nexperts now consider addiction to be a brain disease:\\na condition caused by persistent changes in brain\\nstructure and function. However, having this brain\\nCrack users. Crack, a form of cocaine, is one of the most\\naddictive drugs. (Photograph by Roy Marsch, The Stock\\nMarket. Reproduced by permission.)\\nKEY TERMS\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 53\\nAddiction'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='disease does not absolve the addict of responsibility\\nfor his or her behavior, but it does explain why many\\naddicts cannot stop using drugs by sheer force of will\\nalone.\\nScientists may have come closer to solving the\\nbrain’s specific involvement in addiction in 2004.\\nPsychiatrists say they have found the craving center\\nof the brain that triggers relapse in addicts. The ante-\\nrior cingulated cortex in the frontal lobe of the brain is\\nthe area responsible for long-term craving in addicts.\\nKnowing the area of the brain from which long-term\\ncravings come may help scientists pinpoint therapies.\\nSocial learning\\nSocial learning is considered the most important\\nsingle factor in addiction. It includes patterns of use in\\nthe addict’s family or subculture, peer pressure, and\\nadvertising or media influence.\\nAvailability\\nInexpensive or readily available tobacco, alcohol,\\nor drugs produce marked increases in rates of\\naddiction.\\nIndividual development\\nBefore the 1980s, the so-called addictive person-\\nality was used to explain the development of addic-\\ntion. The addictive personality was described as\\nescapist, impulsive, dependent, devious, manipulative,\\nand self-centered. Many doctors now believe that\\nthese character traits develop in addicts as a result of\\nthe addiction, rather than the traits being a cause of\\nthe addiction.\\nDiagnosis\\nIn addition to a preoccupation with using and\\nacquiring the abused substance, the diagnosis of\\naddiction is based on five criteria:\\n/C15loss of willpower\\n/C15harmful consequences\\n/C15unmanageable lifestyle\\n/C15tolerance or escalation of use\\n/C15withdrawal symptoms upon quitting\\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\\nsubstance use has stopped. Anti-addiction medications,\\nsuch asmethadone and naltrexone, are also commonly\\nused. A new treatment option has been developed that\\nallows family physicians to treat heroine addiction\\nfrom their offices rather than sending patients to\\nmethadone clinics. The drug is called buprenorphine\\n(Suboxone).\\nResearchers continue to work to identify work-\\nable pharmacological treatments for various addic-\\ntions. In 2004, clinical trials were testing a number of\\ndrugs currently in use for other diseases and condi-\\ntions to see if they could be used to treat addiction.\\nThis would speed up their approval by the U.S. Food\\nand Drug Administration (FDA). For example,\\ncocaine withdrawal is eased by boosting dopamine\\nlevels in the brain, so scientists are studying drugs\\nthat boost dopamine, such as Ritalin, which is used\\nto treat attention-deficit hyperactivity disorder, and\\namantadine, a drug used for flu and Parkinson’s\\ndiease.\\nThe most frequently recommended social form of\\noutpatient treatment is the twelve-step program. Such\\nprograms are also frequently combined with psy-\\nchotherapy. According to a recent study reported\\nby the American Psychological Association (APA),\\nanyone, regardless of his or her religious beliefs or\\nlack of religious beliefs, can benefit from participation\\nin 12-step programs such as Alcoholics Anonymous\\n(AA) orNarcotics Anonymous (NA). The number of\\nvisits to 12-step self-help groups exceeds the number of\\nvisits to all mental health professionals combined.\\nThere are twelve-step groups for all major substance\\nand process addictions.\\nThe Twelve Steps are:\\n/C15Admit powerlessness over the addiction.\\n/C15Believe that a Power greater than oneself could\\nrestore sanity.\\n/C15Make a decision to turn your will and your life over\\nto the care of God, as you understand him.\\n/C15Make a searching and fearless moral inventory of\\nself.\\n/C15Admit to God, yourself, and another human being\\nthe exact nature of your wrongs.\\n/C15Become willing to have God remove all these defects\\nfrom your character.\\n/C15Humbly ask God to remove shortcomings.\\n/C15Make a list of all persons harmed by your wrongs\\nand become willing to make amends to them all.\\n54 GALE ENCYCLOPEDIA OF MEDICINE\\nAddiction'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Make direct amends to such people, whenever possi-\\nble except when to do so would injure them or others.\\n/C15Continue to take personal inventory and promptly\\nadmit any future wrongdoings.\\n/C15Seek to improve contact with a God of the indivi-\\ndual’s understanding throughmeditation and prayer.\\n/C15Carry the message of spiritual awakening to others\\nand practice these principles in all your affairs.\\nPrognosis\\nThe prognosis for recovery from any addiction\\ndepends on the substance or process, the individual’s\\ncircumstances, and underlying personality structure.\\nPolydrug users have the worst prognosis for recovery.\\nPrevention\\nThe most effective form of prevention appears to\\nbe a stable family that models responsible attitudes\\ntoward mood-altering substances and behaviors.\\nPrevention education programs are also widely used\\nto inform the public of the harmfulness of substance\\nabuse.\\nResources\\nBOOKS\\nRobert Wood Johnson Foundation.Substance Abuse: The\\nNation’s #1 Problem. Princeton, N.J., 2001.\\nPERIODICALS\\nKalivas, Peter. ‘‘Drug Addiction: To the Cortex...a n d\\nBeyond.’’ The American Journal of Psychiatry 158, no. 3\\n(March 2001).\\nKelly, Timothy. ‘‘Addiction: A Booming $800 Billion\\nIndustry.’’ The World and I (July 1, 2000).\\nLeshner, Alan. ‘‘Addiction is a Brain Disease.’’Issues in\\nScience and Technology 17, no. 3 (April 1, 2001).\\n‘‘A New Office-based Treatment for Prescription Drug and\\nHeroin Addiction.’’Biotech Week (August 4, 2004):\\n219.\\n‘‘Research Brief: Source of Addiction Identified.’’GP (July\\n19, 2004): 4.\\n‘‘Scientists May Use Existing Drugs to Stop Addiction.’’\\nLife Science Weekly (Sepember 21, 2004): 1184.\\nORGANIZATIONS\\nAl-Anon Family Groups. Box 182, Madison Square Station,\\nNew York, NY 10159. .\\nAlcoholics Anonymous World Services, Inc. Box 459,\\nGrand Central Station, New York, NY 10163. .\\nAmerican Anorexia Bulimina Association.\\n.\\nAmerican Psychiatric Association.\\n.\\nCenter for On-Line Addiction.\\n.\\neGambling: Electronic Joural of Gambling Issues.\\n.\\nNational Alliance on Alcoholism and Drug Dependence,\\nInc. 12 West 21st St., New York, NY 10010. (212)\\n206-6770.\\nNational Center on Addiction and Substance Abuse at\\nColumbia University.\\n.\\nNational Clearinghouse for Alcohol and Drug Information.\\n.\\nNational Institute on Alcohol Abuse and Alcoholism\\n(NIAAA). 6000 Executive Boulevard, Bethesda,\\nMaryland 20892-7003. .\\nBill Asenjo, MS, CRC\\nTeresa G. Odle\\nAddison’s disease\\nDefinition\\nAddison’s disease is a disorder involving dis-\\nrupted functioning of the part of the adrenal gland\\ncalled the cortex. This results in decreased production\\nof two important chemicals (hormones) normally\\nreleased by the adrenal cortex: cortisol and\\naldosterone.\\nDescription\\nThe adrenals are two glands, each perched on the\\nupper part of the two kidneys. The outer part of the\\ngland is known as the cortex; the inner part is known\\nas the medulla. Each of these parts of the adrenal\\ngland is responsible for producing different types of\\nhormones.\\nCortisol is a very potent hormone produced by the\\nadrenal cortex. It is involved in regulating the func-\\ntioning of nearly every type of organ and tissue\\nthroughout the body, and is considered to be one of\\nthe few hormones absolutely necessary for life.\\nCortisol is involved in:\\n/C15the very complex processing and utilization of many\\nnutrients, including sugars (carbohydrates), fats, and\\nproteins\\n/C15the normal functioning of the circulatory system and\\nthe heart\\nGALE ENCYCLOPEDIA OF MEDICINE 55\\nAddison’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15the functioning of muscles\\n/C15normal kidney function\\n/C15production of blood cells\\n/C15the normal processes involved in maintaining the\\nskeletal system\\n/C15proper functioning of the brain and nerves\\n/C15the normal responses of the immune system\\nAldosterone, also produced by the adrenal cortex,\\nplays a central role in maintaining the appropriate\\nproportions of water and salts in the body. When\\nthis balance is upset, the volume of blood circulating\\nthroughout the body will fall dangerously low, accom-\\npanied by a drop in blood pressure.\\nAddison’s disease is also called primary adreno-\\ncortical insufficiency. In other words, some process\\ninterferes directly with the ability of the adrenal cortex\\nto produce its hormones. Levels of both cortisol and\\naldosterone drop, and numerous functions through-\\nout the body are disrupted.\\nAddison’s disease occurs in about four in every\\n100,000 people. It strikes both men and women of all\\nages.\\nCauses and symptoms\\nThe most common cause of Addison’s disease is\\nthe destruction and/or shrinking (atrophy) of the adre-\\nnal cortex. 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,\\nand destroy them. In about 20% of all cases, destruc-\\ntion of the adrenal cortex is caused bytuberculosis.T h e\\nremaining cases of Addison’s disease may be caused\\nby fungal infections, such ashistoplasmosis, coccidio-\\nmycosis, andcryptococcosis, which affect the adrenal\\ngland by producing destructive, tumor-like masses\\ncalled granulomas; a disease called amyloidosis,i n\\nwhich a starchy substance called amyloid is deposited\\nin abnormal places throughout the body, interfering\\nwith the function of whatever structure it is present\\nwithin; or invasion of the adrenal glands bycancer.\\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\\n90% of the adrenal cortex has been destroyed. The\\nmost common symptoms include fatigue and loss\\nof energy, decreased appetite,nausea, vomiting, diar-\\nrhea, abdominal pain, weight loss, muscle weakness,\\ndizziness when standing,dehydration, unusual areas of\\ndarkened (pigmented) skin, and dark freckling. As the\\ndisease progresses, the patient may appear to have\\nvery tanned, or bronzed skin, with darkening of the\\nlining of the mouth, vagina, and rectum, and dark\\npigmentation of the area around the nipples (aere-\\nola). As dehydration becomes more severe, the\\nblood pressure will continue to drop and the patient\\nwill feel increasingly weak and light-headed. Some\\npatients have psychiatric symptoms, including\\ndepression and irritability. Women lose pubic and\\nunderarm hair, and stop having normal menstrual\\nperiods.\\nWhen a patient becomes ill with an infection,\\nor stressed 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,\\nuncontrollable nausea and vomiting, a drastic drop in\\nblood pressure, kidney failure, and unconsciousness.\\nAbout 25% of all Addison’s disease patients are\\nidentified due to the development of Addisonian crisis.\\nDiagnosis\\nMany patients do not recognize the slow progres-\\nsion of symptoms and the disease is ultimately iden-\\ntified when a physician notices the areas of increased\\npigmentation of the skin. Once suspected, a number\\nof blood tests can lead to the diagnosis of Addison’s\\ndisease. It is not sufficient to demonstrate low blood\\ncortisol levels, as normal levels of cortisol vary quite\\nwidely. Instead, patients are given a testing dose of\\nanother hormone called corticotropin (ACTH).\\nACTH is produced in the body by the pituitary\\ngland, and normally acts by promoting growth\\nwithin the adrenal cortex and stimulating the produc-\\ntion and release of cortisol. In Addison’s disease,\\neven a dose of synthetic ACTH does not increase\\ncortisol levels.\\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 the\\nbody, which travels to another part of the body in\\norder to exert its effect.\\n56 GALE ENCYCLOPEDIA OF MEDICINE\\nAddison’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='To distinguish between primary adrenocortical\\ninsufficiency (Addison’s disease) and secondary adre-\\nnocortical insufficiency (caused by failure of the pitui-\\ntary 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\\nto the presence of ACTH. This confirms the diagnosis\\nof Addison’s disease.\\nTreatment\\nTreatment of Addison’s disease involves replac-\\ning the missing or low levels of cortisol. In the case\\nof Addisonian crisis, this will be achieved by injecting\\na potent form of steroid preparation through a needle\\nplaced in a vein (intravenous or IV). Dehydration\\nand salt loss will also be treated by administering\\ncarefully balanced solutions through the IV.\\nDangerously low blood pressure may require special\\nmedications to safely elevate it until the steroids take\\neffect.\\nPatients with Addison’s disease will need to take a\\nsteroid preparation (hydrocortisone) and a replace-\\nment for aldosterone (fludrocortisone) by mouth for\\nthe rest of their lives. When a patient has an illness\\nwhich causes nausea and vomiting (such that they\\ncannot hold down their medications), he or she will\\nneed to enter a medical facility where IV medications\\ncan be administered. When a patient has any kind of\\ninfection or injury, the normal dose of hydrocortisone\\nwill 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\\nare always at risk of developing Addisonian crisis.\\nResources\\nBOOKS\\nWilliams, Gordon H., and Robert G. Dluhy.\\n‘‘Hypofunction of the Adrenal Cortex.’’ InHarrison’s\\nPrinciples of Internal Medicine , edited by Anthony\\nS.Fauci, et al. New York: McGraw-Hill, 1997.\\nORGANIZATIONS\\nNational Adrenal Disease Foundation. 505 Northern\\nBoulevard, Suite 200, Great Neck, NY 11021. (516)\\n487-4992.\\nRosalyn Carson-DeWitt, MD\\nAdenoid hyperplasia\\nDefinition\\nAdenoid hyperplasia is the overenlargement of\\nthe lymph glands located above the back of the mouth.\\nDescription\\nLocated at the back of the mouth above and\\nbelow the soft palate are two pairs of lymph glands.\\nThe tonsils below are clearly visible behind the back\\nteeth; the adenoids lie just above them and are hidden\\nfrom view by the palate. Together these four arsenals\\nof immune defense guard the major entrance to the\\nbody from foreign invaders–the germs we breathe and\\neat. In contrast to the rest of the body’s tissues, lym-\\nphoid tissue reaches its greatest size in mid-childhood\\nand recedes thereafter. In this way children are best\\nable to develop the immunities they need to survive in\\na world full of infectious diseases.\\nBeyond its normal growth pattern, lymphoid tis-\\nsue grows excessively (hypertrophies) during an acute\\ninfection, as it suddenly increases its immune activity\\nto fight off the invaders. Often it does not completely\\nreturn to its former size. Each subsequent infection\\nleaves behind a larger set of tonsils and adenoids. To\\nmake matters worse, the sponge-like structure of these\\nhypertrophied glands can produce safe havens for\\ngerms where the body cannot reach and eliminate\\nthem. Beforeantibiotics and the reduction in infectious\\nchildhood diseases over the past few generations, ton-\\nsils and adenoids caused greater health problems.\\nCauses and symptoms\\nMost tonsil and adenoid hypertrophy is simply\\ncaused by the normal growth pattern for that type of\\ntissue. Less often, the hypertrophy is due to repeated\\nthroat infections by cold viruses, strep throat, mono-\\nnucleosis, and in times gone by,diphtheria. The acute\\ninfections are usually referred to astonsillitis, the ade-\\nnoids getting little recognition because they cannot be\\nseen without special instruments. Symptoms include\\npainful, bright red, often ulcerated tonsils, enlarge-\\nment of lymph nodes (glands) beneath the jaw,fever,\\nand general discomfort.\\nAfter the acute infection subsides, symptoms are\\ngenerated simply by the size of the glands. Extremely\\nlarge tonsils can impair breathing and swallowing,\\nalthough that is quite rare. Large adenoids can impair\\nnose breathing and require a child to breathe through\\nthe mouth. Because they encircle the only connection\\nGALE ENCYCLOPEDIA OF MEDICINE 57\\nAdenoid hyperplasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='between the middle ear and the eustachian tube,\\nhypertrophied adenoids can also obstruct it and\\ncause middle ear infections.\\nDiagnosis\\nA simple tongue blade depressing the tongue\\nallows an adequate view of the tonsils. Enlarged ton-\\nsils may have deep pockets (crypts) containing dead\\ntissue (necrotic debris). Viewing adenoids requires a\\nsmall mirror or fiberoptic scope. A child with recurring\\nmiddle ear infections may well have large adenoids. A\\nthroat cultureor mononucleosis test will usually reveal\\nthe identity of the germ.\\nTreatment\\nIt used to be standard practice to remove tonsils\\nand/or adenoids after a few episodes of acute throat or\\near infection. The surgery is calledtonsillectomy and\\nadenoidectomy (T and A). Opinion changed as it was\\nrealized that this tissue is beneficial to the development\\nof immunity. For instance, children without tonsils\\nand adenoids produce only half the immunity to oral\\npolio vaccine. In addition, treatment of ear and throat\\ninfections with antibiotics and of recurring ear infec-\\ntions with surgical drainage through the ear drum\\n(tympanostomy) has greatly reduced the incidence of\\nsurgical removal of these lymph glands.\\nAlternative treatment\\nThere are many botanical/herbal remedies that\\ncan be used alone or in formulas to locally assist the\\ntonsils and adenoids in their immune function at the\\nopening of the oral cavity and to tone these glands.\\nKeeping the Eustachian tubes open is an important\\ncontribution to optimal function in the tonsils and\\nadenoids. Food allergies are often the culprits for\\nrecurring ear infections, as well as tonsilitis and ade-\\nnoiditis. Identification and removal of the allergic\\nfood(s) can greatly assist in alleviating the cause of\\nthe problem. Acute tonsillitis also benefits from\\nwarm saline gargles.\\nPrognosis\\nHypertrophied adenoids are a normal part of\\ngrowing up and should be respected for their impor-\\ntant role in the development of immunity. Only when\\ntheir size causes problems by obstructing breathing or\\nmiddle ear drainage do they demand intervention.\\nPrevention\\nPrevention can be directed toward prompt evalua-\\ntion and appropriate treatment of sore throats to pre-\\nvent overgrowth of adenoid tissue. Avoiding other\\nchildren with acute respiratory illness will also reduce\\nthe spread of these common illnesses.\\nResources\\nBOOKS\\nBehman, Richard E., editor. ‘‘Tonsils and Adenoids.’’ In\\nNelson Textbook of Pediatrics. Philadelphia: W. B.\\nSaunders Co., 1996.\\nJ. Ricker Polsdorfer, MD\\nAdenoid hypertrophy see Adenoid\\nhyperplasia\\nAdenoid removal see Tonsillectomy\\nand adenoidectomy\\nAdenoidectomy see Tonsillectomy\\nand adenoidectomy\\nAdenovirus infections\\nDefinition\\nAdenoviruses are DNA viruses (small infectious\\nagents) that cause upper respiratory tract infections,\\nconjunctivitis, and other infections in humans.\\nDescription\\nAdenoviruses were discovered in 1953. About 47\\ndifferent types have been identified since then, and\\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).\\n58 GALE ENCYCLOPEDIA OF MEDICINE\\nAdenovirus infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='about half of them are believed to cause human dis-\\neases. Infants and children are most commonly\\naffected by adenoviruses. Adenovirus infections can\\noccur throughout the year, but seem to be most com-\\nmon from fall to spring.\\nAdenoviruses are responsible for 3-5% of acute\\nrespiratory infections in children and 2% of respira-\\ntory illnesses in civilian adults. They are more apt to\\ncause infection among military recruits and other\\nyoung people who live in institutional environments.\\nOutbreaks among children are frequently reported at\\nboarding schools and summer camps. Another exam-\\nple includes an increased outbreak ofgastroenteritis\\namong cruise passengers in 2002.\\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),\\nadenoviruses kill healthy cells and replicate up to\\none million new viruses per cell killed (of which 1-5%\\nare infectious). People with this kind of infection feel\\nsick. In chronic or latent infection, a much smaller num-\\nber of viruses are released and healthy cells can multiply\\nmore rapidly than they are destroyed. People who have\\nthis kind of infection don’t seem to be sick. This is\\nprobably why many adults have immunity to adeno-\\nviruses without realizing 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 most\\nof these infections. Occasionally more serious lower\\nrespiratory diseases, such aspneumonia,m a yo c c u r .\\nAdenoviruses also cause acute pharyngoconjunc-\\ntival fever in children. This disease is most often caused\\nby types 3 and 7. Symptoms, which appear suddenly\\nand usually disappear in less than a week, include:\\n/C15inflammation of the lining of the eyelid (conjunctivitis)\\n/C15fever\\n/C15sore throat (pharyngitis)\\n/C15runny nose\\n/C15inflammation of lymph glands in the neck (cervical\\nadenitis)\\nAdenoviruses also cause acutediarrhea in young\\nchildren, characterized by fever and watery stools.\\nThis condition is caused by adenovirus types 40 and\\n41 and can last as long as two weeks.\\nAs much as 51% of all hemorrhagic cystitis\\n(inflammation of the bladder and of the tubes that\\ncarry urine to the bladder from the kidneys) in\\nAmerican and Japanese children can be attributed to\\nadenovirus infection. A child who has hemorrhagic\\ncystitis has bloody urine for about three days, and\\ninvisible traces of blood can be found in the urine a\\nfew days longer. The child will feel the urge to urinate\\nfrequently–but find it difficult to do so–for about the\\nsame length of time.\\nAdult infections\\nIn adults, the most frequently reported adeno-\\nvirus infection is acute respiratory disease (ARD,\\ncaused by types 4 and 7) in military recruits.\\nInfluenza-like symptoms including fever, sore throat,\\nrunny nose, and cough are almost always present;\\nweakness, chills,headache, and swollen lymph glands\\nin the neck also may occur. The symptoms typically\\nlast three to five days.\\nEpidemic keratoconjunctivitis (EKC, caused by\\nadenovirus types 8, 19, and 37) was first seen in ship-\\nyard workers whose eyes had been slightly injured by\\nchips of rust or paint. This inflammation of tissues\\nlining the eyelid and covering the front of the eyeball\\nalso can be caused by using contaminated contact lens\\nsolutions or by drying the hands or face with a towel\\nused by someone who has this infection.\\nThe inflamed, sticky eyelids characteristic of\\nconjunctivitis develop 4-24 days after exposure and\\nlast between one and four weeks. Only 5-8% of\\npatients with epidemic keratoconjunctivitis experience\\nrespiratory symptoms. One or both eyes may be\\naffected. As symptoms of conjunctivitis subside, eye\\npain and watering and blurred vision develop. These\\nsymptoms ofkeratitis may last for several months, and\\nabout 10% of these infections spread to at least one\\nother member of the patient’s household.\\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 core\\nof genetic material (DNA or RNA) surrounded by a\\nshell of protein.\\nGALE ENCYCLOPEDIA OF MEDICINE 59\\nAdenovirus infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Other illnesses associated with adenovirus include:\\n/C15encephalitis (inflammation of the brain) and other\\ninfections of the central nervous system (CNS)\\n/C15gastroenteritis (inflammation of the stomach and\\nintestines)\\n/C15acute mesenteric lymphadenitis (inflammation of\\nlymph glands in the abdomen)\\n/C15chronic interstitial fibrosis (abnormal growth of\\nconnective tissue between cells)\\n/C15intussusception (a type of intestinal obstruction)\\n/C15pneumonia that doesn’t respond to antibiotic therapy\\n/C15whooping coughsyndrome whenBordetella pertussis\\n(the bacterium that causes classic whooping cough) is\\nnot found\\nCauses and symptoms\\nSpecific adenovirus infections can be traced to\\nparticular sources and produce distinctive symptoms.\\nIn general, however, adenovirus infection is caused by:\\n/C15inhaling airborne viruses\\n/C15getting the virus in the eyes by swimming in contami-\\nnated water, using contaminated eye solutions or\\ninstruments, wiping the eyes with contaminated\\ntowels, or rubbing the eyes with contaminated fingers.\\n/C15not washing the hands after using the bathroom, and\\nthen touching the mouth or eyes\\nSymptoms common to most types of adenovirus\\ninfections include:\\n/C15cough\\n/C15fever\\n/C15runny nose\\n/C15sore throat\\n/C15watery eyes\\nDiagnosis\\nAlthough symptoms may suggest the presence of\\nadenovirus, distinguishing these infections from other\\nviruses can be difficult. A definitive diagnosis is based\\non culture or detection of the virus in eye secretions,\\nsputum, urine, or stool.\\nThe extent of infection can be estimated from the\\nresults of blood tests that measure increases in the\\nquantity of antibodies the immune system produces to\\nfight it. Antibody levels begin to rise about a week after\\ninfection occurs and remain elevated for about a year.\\nTreatment\\nTreatment of adenovirus infections is usually\\nsupportive and aimed at relieving symptoms of the\\nillness. Bed rest may be recommended along with\\nmedications to reduce fever and/or pain. (Aspirin\\nshould not be given to children because of concerns\\nabout Reye’s syndrome.) Eye infections may benefit\\nfrom topicalcorticosteroids to relieve symptoms and\\nshorten the course of the disease. Hospitalization is\\nusually required for severe pneumonia in infants and\\nfor EKC (to prevent blindness). No effectiveantiviral\\ndrugs have been developed.\\nPrognosis\\nAdenovirus infections are rarely fatal. Most\\npatients recover fully.\\nPrevention\\nPracticing good personal hygiene and avoiding\\npeople with infectious illnesses can reduce the\\nrisk of developing adenovirus infection. Proper hand-\\nwashing can prevent the spread of the virus by oral-\\nfecal transmission. Sterilization of instruments and\\nsolutions used in the eye can prevent the spread of\\nEKC, as can adequate chlorination of swimming\\npools.\\nA vaccine for pertussis has been developed\\nand is in use in combination withdiphtheria and teta-\\nnus vaccines for infants. It is shown to have nearly\\n90% efficacy. A vaccine containing live adenovirus\\ntypes 4 and 7 is used to control disease in military\\nrecruits, but it is not recommended or available for\\ncivilian use. A recent resurgence of the adenovirus\\nwas found in a military population as soon as the\\nvaccination program was halted. Vaccines prepared\\nfrom purified subunits of adenovirus are under\\ninvestigation.\\nResources\\nPERIODICALS\\nEvans, Jeff. ‘‘Viral Gastroenteritis On Board.’’Internal\\nMedicine News (January 15, 2003): 44.\\n‘‘Guard Against Pertussis.’’Contemporary Pediatrics\\n(February 2003): 87.\\nKolavic-Gray, Shellie A., et al. ‘‘Large Epidemic of\\nAdenovirus Type 4 Infection Among Military Trainees:\\nEpidemiological, Clinical, and Laboratory Studies.’’\\nClinical Infectious Diseases (October 1, 2002): 808–811.\\nMaureen Haggerty\\nTeresa G. Odle\\n60 GALE ENCYCLOPEDIA OF MEDICINE\\nAdenovirus infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Adhesions\\nDefinition\\nAdhesions are fibrous bands of scar tissue that\\nform between internal organs and tissues, joining\\nthem together abnormally.\\nDescription\\nAdhesions are made up of blood vessels and fibro-\\nblasts—connective tissue cells. They form as a normal\\npart of the body’s healing process and help to limit\\nthe spread of infection. However when adhesions\\ncause the wrong tissues to grow into each other,\\nmany different complex inflammatory disorders can\\narise. Worldwide millions of people sufferpain and\\ndysfunction due to adhesion disease.\\nDepending on their location, the most common\\ntypes of adhesions may called:\\n/C15abdominal adhesions\\n/C15intestinal adhesions\\n/C15intraperitoneal adhesions\\n/C15pelvic adhesions\\n/C15intrauterine adhesions or Asherman’s syndrome.\\nAdhesions can form between various tissues in the\\nbody including:\\n/C15loops of the intestines\\n/C15the intestines and other abdominal organs or the\\nabdominal wall\\n/C15abdominal organs such as the liver or bladder and\\nthe abdominal wall\\n/C15tissues of the uterus.\\nAlthough adhesions can be congenital (present at\\nbirth) or result from inflammation, injury, or infec-\\ntion, the vast majority of adhesions form following\\nsurgery. Adhesions are a major complication of\\nmany common surgical procedures and may occur in\\n55% to more than 90% of patients, depending on the\\ntype of surgery.\\nAll abdominal surgeries carry the risk of adhesion\\nformation. Abdominal adhesions are rare in people\\nwho have not had abdominal surgery and very com-\\nmon in people who have had multiple abdominal sur-\\ngeries. Adhesions are more common following\\nprocedures involving the intestines, colon, appendix,\\nor uterus. They are less common following surgeries\\ninvolving the stomach, gall bladder, or pancreas.\\nAlthough most abdominal adhesions do not cause\\nproblems, they can be painful when stretched or pulled\\nbecause the scar tissue is not elastic.\\nKEY TERMS\\nAsherman’s syndrome— The cessation of men-\\nstruation and/or infertility caused by intrauterine\\nadhesions.\\nComputed axial tomography; CT or CAT scan— A\\ncomputer reconstruction of scanned x rays used to\\ndiagnose intestinal obstructions.\\nEndometriosis— A condition in which the endome-\\ntrial tissue that lines the uterus begins to invade\\nother parts of the body.\\nEndoscope— A device with a light that is used to\\nlook into a body cavity or organ.\\nFibroblast— A connective-tissue cell.\\nGlaucoma— A group of eye diseases characterized\\nby increased pressure within the eye that can\\ndamage the optic nerve and cause gradual loss of\\nvision.\\nHysteroscopy— A procedure in which an endo-\\nscope is inserted through the cervix to view the\\ncervix and uterus.\\nHysterosalpingography; HSG— X raying of the\\nuterus and fallopian tubes following the injection\\nof a contrast dye.\\nIrido corneal endothelial syndrome; ICE— A type\\nof glaucoma in which cells from the back of the\\ncornea spread over the surface of the iris and tissue\\nthat drains the eye, forming adhesions that bind the\\niris to the cornea.\\nLaparoscopic surgery; keyhole surgery— Surgery\\nthat utilizes a laparoscope with a video camera and\\nsurgical instrumentsinserted throughsmall incisions.\\nLaparoscopy— A procedure that utilizes an endo-\\nscope to view contents of the abdominal cavity.\\nPelvic inflammatory disease; PID— Inflammation\\nof the female reproductive organs and associated\\nstructures.\\nPeritoneum— The membrane lining the walls of the\\nabdominal and pelvic cavities and enclosing their\\norgans.\\nSmall bowel obstruction; SBO— An obstruction of\\nthe small intestine that prevents the free passage of\\nmaterial; sometimes caused by postoperative\\nadhesions.\\nGALE ENCYCLOPEDIA OF MEDICINE 61\\nAdhesions'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Postoperative intestinal adhesions are a major\\ncause of intestinal or small bowel obstruction (SBO).\\nIn a small number of people the scar tissue pulls sec-\\ntions of the small or large intestines out of place and\\npartially or completely blocks the passage of food and\\nfluids. Thus SBOs can result from abdominal surgery\\nand also are one of the most common reasons for\\nabdominal surgery. Although intestinal obstruction\\nis fatal in about 5% of patients, the mortality rate\\nassociated with SBO has decreased dramatically over\\nthe past century.\\nIntrauterine adhesions are relatively common in\\nwomen and the majority of women undergoing gyne-\\ncological surgery develop postoperative adhesions.\\nSometimes these pelvic adhesions cause chronic pelvic\\npain and/orinfertility.\\nAdhesions can cause a rare form ofglaucoma\\ncalled irido corneal endothelial (ICE) syndrome. In\\nthis disorder cells from the back surface of the cornea\\nof the eye spread over the surface of the iris and the\\ntissue that drains the eye, forming adhesions that bind\\nthe iris to the cornea and causing further blockage of\\nthe drainage channels. This blockage increases the\\npressure inside the eye, which may damage the optic\\nnerve. ICE syndrome occurs most often in light-\\nskinned females.\\nCauses and symptoms\\nPost-surgical adhesions\\nCommon causes of postoperative adhesions\\ninclude:\\n/C15abdominal surgery\\n/C15gynecological surgery\\n/C15thoracic surgery\\n/C15orthopedic surgery\\n/C15plastic surgery.\\nAbdominal adhesions most often result from sur-\\ngeries in which the organs are handled or temporarily\\nmoved. Intrauterine adhesions form after surgeries\\ninvolving the uterus, particularly curettage—the\\nscraping of the uterine contents. Surgery to control\\nuterine bleeding after giving birth also can lead to\\nintrauterine adhesions. Such adhesions can cause\\nAsherman’s syndrome, closing the uterus and prevent-\\ning menstruation.\\nOther causes of adhesions\\nAny inflammation or infection of the membranes\\nthat line the abdominal and pelvic walls and enclose\\nthe organs—the peritoneum—can cause adhesions.\\nAn example peritonitis, a severe infection that can\\nresult from appendicitis, may lead to adhesions. In\\naddition to surgery or injury, pelvic adhesions can be\\ncaused by inflammation resulting from an infection\\nsuch aspelvic inflammatory disease(PID).\\nSymptoms\\nIn the majority of people adhesions do not cause\\nsymptoms or serious problems. However in some peo-\\nple adhesions can lead to a variety of disorders. The\\nsymptoms depend on the type of adhesion and the\\ntissues that are involved. Adhesions may cause pain\\nand/or fever in some people.\\nABDOMINAL OBSTRUCTION. If a loop of intestine\\nbecomes trapped under an adhesion, the intestine may\\nbecome partially or completely blocked. The symp-\\ntoms of intestinal obstruction or SBOs due to adhe-\\nsions depend on the degree and location of the\\nobstruction. Partial or off-and-on intestinal obstruc-\\ntion due to adhesions may result in intermittent peri-\\nods of painful abdominal cramping and other\\nsymptoms, includingdiarrhea.\\nSymptoms of significant intestinal obstruction\\ndue to adhesions include:\\n/C15severe abdominal pain and cramping\\n/C15nausea and vomiting\\n/C15abdominal distension (swelling)\\n/C15constipation and the inability to pass gas\\n/C15symptoms ofdehydration.\\nSymptoms of dehydration include:\\n/C15dry mouth and tongue\\n/C15severe thirst\\n/C15infrequent urination\\n/C15dry skin\\n/C15fast heart rate\\n/C15low blood pressure.\\nIn about 10% of SBOs, part of the intestine twists\\ntightly and repeatedly around a band of adhesions,\\ncutting off the blood supply to the intestine and result-\\ning in strangulation and death of the twisted bowel.\\nThe mortality rate for strangulation of the bowel may\\nbe as high as 37%.\\nSymptoms of bowel strangulation due to adhe-\\nsions include:\\n/C15severe abdominal pain, either cramping or constant\\n62 GALE ENCYCLOPEDIA OF MEDICINE\\nAdhesions'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15abdominal distension due to the inability to pass\\nstool and gas\\n/C15an extremely tender abdomen\\n/C15signs of systemic (body-wide) illness, including fever,\\nfast heart rate, and low blood pressure.\\nWhen a portion of the obstructed bowel begins to\\ndie from lack of blood flow, fluids and bacteria that\\nhelp digest food can leak out of the intestinal wall and\\ninto the abdominal cavity causing peritonitis.\\nPELVIC ADHESIONS. Pelvic adhesions can interfere\\nwith the functioning of the ovaries and fallopian tubes\\nand are among the common causes of female inferti-\\nlity. Adhesions on the ovaries or fallopian tubes can\\nprevent pregnancy by trapping the released egg.\\nAdhesions resulting from endometriosis can cause pel-\\nvic pain, particularly during menstruation, as well as\\nfertility problems.\\nDiagnosis\\nAdhesions are diagnosed based on the symptoms,\\nsurgical history, and aphysical examination. The phy-\\nsician examines the abdomen and rectum and performs\\na pelvic examination on women. Blood tests and chest\\nand abdominal x rays are taken. Sometimes explora-\\ntory surgery is used to locate the adhesions and\\nsources of pain.\\nAbdominal computed axial tomography—a CT\\nor CAT scan—is the most common diagnostic tool\\nfor SBO and intestinal strangulation due to adhesions.\\nIn this procedure a computer reconstructs a portion\\nof the abdomen from x-ray scans. Barium contrast\\nx-ray studies also may be used to locate an obstruc-\\ntion. The ingestion of a barium solution provides bet-\\nter visualization of the abdominal organs. However\\nsometimes intestinal obstruction or strangulation\\ncannot be confirmed without abdominal surgery.\\nExploratory laparoscopy may be used to detect\\neither abdominal or pelvic adhesions. This procedure\\nusually is performed in a hospital under local orgen-\\neral anesthesia. A small incision is made near the naval\\nand carbon dioxide gas is injected to raise the abdom-\\ninal wall. A tube called a trocar is inserted into the\\nabdomen. The laparascope, equipped with a light and\\na small video camera, is passed through the trocar\\nfor visualization of the peritoneal cavity and the\\nabdominal or pelvic organs.\\nPelvic adhesions also may be detected byhyste-\\nroscopy. In this procedure a uterine endoscope is\\ninserted through the cervix to visualize the cervix and\\nuterine cavity. Withhysterosalpingography (HSG) a\\nradiopaque or contrast dye is injected through a cathe-\\nter in the cervix and x rays are taken of the uterus and\\nfallopian tubes.\\nTreatment\\nAlthough the symptoms of adhesion disease\\nsometimes disappear on their own, adhesions are per-\\nmanent without a surgical procedure called adhesion\\nlysis to disrupt or remove the tissue.\\nAbdominal adhesions\\nSometimes an adhesion-trapped intestine frees\\nitself spontaneously. Surgery may be used to reposi-\\ntion the intestine to relieve symptoms. Various other\\ntechniques include using suction to decompress the\\nintestine; however untreated intestinal adhesions may\\nlead to bowel obstruction.\\nAlthough dilation with an endoscope may be used\\nto widen the region around an intestinal obstruction to\\nrelieve symptoms, SBOs caused almost always require\\nimmediate surgery. In cases of a partial obstruction or\\na complete obstruction without severe symptoms, sur-\\ngery may be delayed for 12–24 hours so that a dehy-\\ndrated patient can be treated with intravenous fluids.\\nA small suction tube may be placed through the nose\\ninto the stomach to remove the stomach contents to\\nrelieve pain and nausea and prevent further bloating.\\nIf an adhesion-related SBO disrupts the blood\\nsupply to part of the intestine, gangrene—tissue\\ndeath—can occur. Strangulation of the bowel usually\\nrequires emergency abdominal surgery to remove the\\nadhesions and restore blood flow to the intestine.\\nIntestinal obstruction repair is performed under gen-\\neral anesthesia. An incision is made in the abdomen,\\nthe obstruction is located, and the adhesions are cut\\naway, releasing the intestine. The bowel is examined\\nfor injury or tissue death. If possible, injured and dead\\nsections are removed and the healthy ends of the intes-\\ntine are stitched together (resectioned). If resectioning\\nis not possible, the ends of the intestine are brought\\nthrough an opening in the abdomen called anostomy.\\nIn some cases laparoscopic surgery can be used to\\nremoved damaged portions of the intestines. Five or\\nsix small incisions—0.2–0.4 in. (5–10 mm) in length—\\nare made in the abdomen. The laparoscope, equipped\\nwith its light and camera, and surgical instruments are\\ninserted through the incisions. The laparoscope guides\\nthe surgeon by projecting images of the abdominal\\norgans on a video monitor. However the existence of\\nmultiple adhesions may preclude the use of laparo-\\nscopic surgery.\\nGALE ENCYCLOPEDIA OF MEDICINE 63\\nAdhesions'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Other types of adhesions\\nAdhesions caused by endometriosis may be\\nremoved by either traditional open abdominal or pel-\\nvic surgery or by laparoscopic surgery. In the latter\\ntechnique the laparoscope includes a laser for destroy-\\ning the tissue with heat. Although untreated gyneco-\\nlogical adhesions can lead to infertility, both types of\\nsurgeries also can result in adhesion formation.\\nICE-type glaucoma caused by adhesions is diffi-\\ncult to treat; however untreated ICE syndrome can\\nlead to blindness. Treatment usually includes medica-\\ntion and/or filtering surgery. Filtering microsurgery\\ninvolves cutting a tiny hole in the white of the eye\\n(the sclera) to allow fluid to drain, thereby lowering\\nthe pressure in the eye and preventing or reducing\\ndamage to the optic nerve.\\nAlternative treatment\\nIn cases where the intestines are partially blocked\\nby adhesions, a diet low in fiber—called a low-residue\\ndiet—may enable food to move more easily through\\nthe obstruction.\\nPrognosis\\nIntestinal obstruction surgery usually has a favor-\\nable outcome if the surgery is performed before tissue\\ndamage or death occurs. Surgery to remove adhesions\\nand to free or reconnect the intestine often is sufficient\\nfor reducing symptoms and returning normal function\\nto the intestine or other organ. However the risk of\\nnew adhesion formation increases with each addi-\\ntional surgery. Thus abdominal adhesions can become\\na recurring problem. Adhesions reform in 11–21% of\\npatients who have surgery to remove an adhesion-\\nrelated intestinal obstruction. The risk of recurrence\\nis particularly high among survivors of bowel\\nstrangulation.\\nPrevention\\nAbdominal and gynecological laparoscopic sur-\\ngeries—also known as ‘‘keyhole’’ surgeries—reduce\\nthe size of the incision and the amount of contact\\nwith the organs, thereby lowering the risk of adhesion\\nformation. Sometimes the intestines are fixed in place\\nduring surgery so as to promote benign adhesions that\\nwill not cause obstructions.\\nWithin five days after surgery the disturbed tissue\\nsurfaces have formed a new lining of mesothelial cells\\nthat prevent adhesions from forming. Therefore bio-\\ndegradable barrier membranes, films, gels, or sprays\\ncan be used to physically separate the tissues after\\nsurgery to prevent the formation of postoperative\\nadhesions.However these gels and other barrier agents\\nmay:\\n/C15suppress the immune system\\n/C15cause infection\\n/C15impair healing\\nSystemic anti-inflammatory medications may be\\nused to help prevent adhesion formation. Recent stu-\\ndies suggest that the common oral arthritis drug,\\nCelebrex, an anti-inflammatory COX-2 inhibitor,\\ntaken before and immediately after surgery, may\\nhelp prevent abdominal adhesions. Celebrex is\\nknown to inhibit both the formation of blood vessels\\nand fibroblast activity, which are necessary for the\\nformation of scar tissue.\\nRecent research has focused on the incorporation\\nof anti-inflammatory and anti-proliferation drugs into\\npolymeric films used for preventing and treating post-\\nsurgical adhesions. New types of gels to prevent post-\\noperative adhesions also are under development.\\nResources\\nBOOKS\\nBaerga-Varela, Y. ‘‘Small Bowel Obstruction.’’Mayo Clinic\\nGastrointestinal Surgery, edited by K. A. Kelly, et al.\\nSt. Louis, MO: Elsevier Science, 2004.\\nPERIODICALS\\n‘‘Surgical Complications; Celebrex Prevents Adhesions\\nAfter Surgery.’’Science Letter (February 15, 2005):\\n1443.\\nORGANIZATIONS\\nNational Digestive Diseases Information Clearinghouse.\\n2 Information Way, Bethesda, MD 20892-3570. 800-891-\\n5389. 301-654-3810. .\\nOTHER\\nAbdominal Adhesions. Aetna InteliHealth. February 17,\\n2004 [cited March 2, 2005]. .\\nEndometriosis. MayoClinic.com. September 11, 2003 [cited\\nMarch 2, 2005]. .\\nInfertility. MayoClinic.com. September 21, 2004 [cited\\nMarch 2, 2005]. .\\n‘‘Intestinal Adhesions.’’Digestive Diseases. National\\nDigestive Diseases Information Clearinghouse.\\nFebruary 2004 [cited February 21, 2005]. .\\nWhat is Glaucoma? Glaucoma Research Foundation. [Cited\\nMarch 4, 2005]. .\\nMargaret Alic, Ph.D.\\n64 GALE ENCYCLOPEDIA OF MEDICINE\\nAdhesions'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Adjustment 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\\nlasting.\\nDescription\\nAn adjustment disorder usually begins within\\nthree months of a stressful event, and ends within six\\nmonths after the stressor stops. There are many dif-\\nferent subtypes of adjustment disorders, including\\nadjustment disorder with:\\n/C15depression\\n/C15anxiety\\n/C15mixed anxiety and depression\\n/C15conduct disturbances\\n/C15mixed disturbance of emotions and conduct\\n/C15unspecified\\nAdjustment disorders are very common and can\\naffect anyone, regardless of gender, age, race, or life-\\nstyle. By definition, an adjustment disorder is short-\\nlived, unless a person is faced with a chronic recurring\\ncrisis (such as a child who is repeatedly abused). In\\nsuch cases, the adjustment disorder may last more\\nthan six months.\\nCauses and symptoms\\nAn adjustment disorder occurs when a person\\ncan’t cope with a stressful event and develops emo-\\ntional or behavioral symptoms. The stressful event can\\nbe anything: it might be just one isolated incident, or a\\nstring of problems that wears the person down. The\\nstress might be anything from a car accident or illness,\\nto a divorce, or even a certain time of year (such as\\nChristmas or summer).\\nPeople with adjustment disorder may have a wide\\nvariety of symptoms. How those symptoms combine\\ndepend on the particular subtype of adjustment dis-\\norder and on the individual’s personality and psycho-\\nlogical defenses. Symptoms normally include some\\n(but not all) of the following:\\n/C15hopelessness\\n/C15sadness\\n/C15crying\\n/C15anxiety\\n/C15worry\\n/C15headaches or stomachaches\\n/C15withdrawal\\n/C15inhibition\\n/C15truancy\\n/C15vandalism\\n/C15reckless driving\\n/C15fighting\\n/C15other destructive acts\\nDiagnosis\\nIt is extremely important that a thorough evalua-\\ntion rule out other more serious mental disorders,\\nsince the treatment for adjustment disorder may be\\nvery different than for other mental problems.\\nIn order to be diagnosed as a true adjustment\\ndisorder, the level of distress must be more severe\\nthan what would normally be expected in response to\\nthe stressor, or the symptoms must significantly inter-\\nfere with a person’s social, job, or school functioning.\\nNormal expression of grief, in bereavement for\\ninstance, is not considered an adjustment disorder.\\nTreatment\\nPsychotherapy (counseling) is the treatment of\\nchoice for adjustment disorders, since the symptoms\\nare an understandable reaction to a specific stress. The\\ntype of therapy depends on the mental health expert,\\nbut it usually is short-term treatment that focuses on\\nresolving the immediate problem.\\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 and\\nremission. 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 65\\nAdjustment disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Therapy usually will help clients:\\n/C15develop coping skills\\n/C15understand how the stressor has affected their lives\\n/C15develop 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\\nweeks of an anti-anxiety drug can control anxiety or\\nsleeping problems.\\nSelf-help groups aimed at a specific problem (such\\nas recovering from divorce or job loss) can be extre-\\nmely helpful to people suffering from an adjustment\\ndisorder. Social support, which is usually an impor-\\ntant part of self-help groups, can lead to a quicker\\nrecovery.\\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\\nstrong social support. People with progressive or cyclic\\ndisorders (such as multiple sclerosis) may experience an\\nadjustment disorder with each exacerbation period.\\nResources\\nBOOKS\\nLuther, Suniya G., Jacob A. Burack, and Dante Cicchetti.\\nDevelopmental Psychopathology: Perspectives on\\nAdjustment, Risk, and Disorder. London: Cambridge\\nUniversity Press, 1997.\\nCarol A. Turkington\\nAdrenal gland cancer\\nDefinition\\nAdrenal gland cancers are rare cancers occuring in\\nthe endocrine tissue of the adrenals. They are charac-\\nterized 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\\nsecrete excess amounts of these hormones. Acancer\\nthat arises in the adrenal cortex is called an adreno-\\ncortical carcinoma and can produce high blood pres-\\nsure, weight gain, excess body hair, weakening of the\\nbones and diabetes. A cancer in the adrenal medulla is\\ncalled apheochromocytoma and can cause high blood\\npressure, headache, palpitations, and excessive per-\\nspiration. Although these cancers can happen at any\\nage, 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.\\nSymptoms of adrenal cancer are related to the specific\\nhormones produced by that tumor. An adrenocortical\\ncarcinoma typically secretes high amounts of cortisol,\\nproducing Cushing’s Syndrome. This syndrome pro-\\nduces progressive weight gain, rounding of the face,\\nand increased blood pressure. Women can experience\\nmenstrual cycle alterations and men can experience\\nfeminization. The symptoms for pheochromocytoma\\ninclude hypertension, acidosis, unexplainedfever and\\nweight loss. Because of the hormones produced by this\\ntype of tumor,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.\\nIt also includesmagnetic resonance imaging, andcom-\\nputed tomography scansto determine the extent of the\\ndisease. Urine and blood tests can be done to detect\\nthe high levels of hormone secreted by the tumor.\\nTreatment\\nTreatment is aimed at removing the tumor by\\nsurgery. In some cases, this can be done bylaparo-\\nscopy. Surgery is sometimes followed bychemotherapy\\nand/or radiation therapy. Because the surgery removes\\nthe source of many important hormones, hormones\\nmust be supplemented following surgery. If adreno-\\ncortical cancer recurs or has spread to other parts of\\nthe body (metastasized), additional surgery may be\\ndone followed by chemotherapy using the drug\\nmitotane.\\nAlternative treatment\\nAs with any form of cancer, all conventional treat-\\nment options should be considered and applied as\\n66 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenal gland cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='appropriate. Nutritional support, as well as support-\\ning the functioning of the entire person diagnosed with\\nadrenal gland cancer throughhomeopathic medicine,\\nacupuncture, vitamin and mineral supplementation,\\nand herbal medicine, can benefit recovery and enhance\\nquality of life.\\nPrognosis\\nThe prognosis for adrenal gland cancer is vari-\\nable. For localized pheochromocytomas the 5-year\\nsurvival rate is 95%. This rate decreases with aggres-\\nsive tumors that have metastasized. The prognosis for\\nadrenal cortical cancer is not as good with a 5-year\\nsurvival 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.’’ InCancer, Principles and\\nPractice of Oncology , edited by V. T. DeVita,\\nS. Hellman, and S. A. Rosenberg. Philadelphia:\\nLippincott-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 eva-\\nluation of the medulla (inner tissue) of the adrenal\\ngland.\\nPurpose\\nThe adrenal glands are a pair of small organs\\nlocated just above the kidney, which contain two\\ntypes of tissue. The adrenal cortex produces hormones\\nthat affect water balance and metabolism in the body.\\nThe adrenal medulla produces adrenaline and noradre-\\nnaline (also called epinepherine and norepinepherine).\\nAn adrenal gland scan is done when too much\\nadrenaline and noradrenaline is produced in the\\nbody and a tumor in the adrenal gland is suspected.\\nOne such situation in which a tumor might be sus-\\npected is when high blood pressure (hypertension)\\ndoes not respond to medication. Tumors that secrete\\nadrenaline and noradrenaline can also be found out-\\nside the adrenal gland. An adrenal gland scan usually\\ncovers the abdomen, chest, and head.\\nPrecautions\\nAdrenal gland scans are not recommended for\\npregnant women because of the potential harm to\\nthe developing fetus. A pregnant woman should dis-\\ncuss with her doctor the risks of the procedure against\\nthe benefits of the information it can provide in eval-\\nuating her individual 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\\nfrom the adrenal gland scan.\\nDescription\\nThe adrenal gland scan takes several days. On the\\nfirst day, a radiopharmaceutical is injected intrave-\\nnously into the patient. On the second, third, and\\nfourth day the patient is positioned under the camera\\nfor imaging. The scanning time each day takes\\napproximately 30 minutes. It is essential that the\\npatient remain still during imaging.\\nOccasionally, the scanning process may involve\\nfewer than three days, or it may continue several\\ndays longer. The area scanned extends from the pelvis\\nand lower abdomen to the lower chest. Sometimes the\\nupper legs, thighs, and head are also included.\\nKEY TERMS\\nCortisol— A hormone produced by the adrenal cor-\\ntex. It is partially responsible for regulating blood\\nsugar levels.\\nDiabetes— A disease characterized by low blood\\nsugar.\\nEpinephrine— A hormone produced by the adrenal\\nmedulla. It is important in the response to stress and\\npartially regulates heart rate and metabolism. It is\\nalso called adrenaline.\\nLaparoscopy— The insertion of a tube through\\nthe abdominal wall. It can be used to visualize\\nthe inside of the abdomen and for surgical\\nprocedures.\\nGALE ENCYCLOPEDIA OF MEDICINE 67\\nAdrenal gland scan'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Preparation\\nFor two days before and ten days after the injec-\\ntion of the radiopharmaceutical, patients are given\\neither Lugol’s solution or potassium iodine. This pre-\\nvents the thyroid from taking up radioactive iodine\\nand interfering with the scan.\\nAftercare\\nThe patient should not feel any adverse effects of\\nthe test and can resume normal activity immediately.\\nFollow-up tests that might be ordered include a\\nnuclear scan of the bones or kidney, a computed\\ntomography scan (CT) of the adrenals, or an ultra-\\nsound of the pelvic area.\\nRisks\\nThe main risk associated with this test is to the\\nfetus of a pregnant woman.\\nNormal results\\nNormal results will show no unusual areas of\\nhormone secretion and no tumors.\\nAbnormal results\\nAbnormal results will show evidence of a tumor\\nwhere there is excessive secretion of adrenaline or\\nnoradrenaline. Over 90% of these tumors are in the\\nabdomen.\\nResources\\nBOOKS\\nFishback, Francis, editor.A Manual of Laboratory and\\nDiagnostic Tests. 5th ed. Philadelphia: Lippincott, 1996.\\nTish Davidson, A.M.\\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\\noccur before birth and can lead to sexual abnormal-\\nities in newborns. It can also occur in girls and women\\nlater in life.\\nDescription\\nIn the normal human body, there are two adrenal\\nglands. They are small structures that lie on top of the\\nkidneys. The adrenal glands produce many hormones\\nthat regulate body functions. These hormones include\\nandrogens, or male hormones. Androgens are pro-\\nduced in normal girls and women. Sometimes, one or\\nboth of the adrenal glands becomes enlarged or over-\\nactive, producing more than the usual amount of\\nandrogens. The excess androgens create masculine\\ncharacteristics.\\nCauses and symptoms\\nIn infants and children, adrenal virilism is usually\\nthe result of adrenal gland enlargement that is present\\nat birth. This is called congenital adrenal hyperplasia.\\nThe cause is usually a genetic problem that leads to\\nsevere enzyme deficiencies. In rare cases, adrenal\\nvirilism is caused by an adrenal gland tumor. The\\ntumor can be benign (adrenal adenoma) or cancerous\\n(adrenal carcinoma). Sometimes virilism is caused by a\\ntype of tumor on a woman’s ovary (arrhenoblastoma).\\nNewborn girls with adrenal virilism have external\\nsex organs that seem to be a mixture of male and\\nfemale organs (called female pseudohermaphrodism).\\nNewborn boys with the disorder have enlarged exter-\\nnal sex organs, and these organs develop at an abnor-\\nmally rapid pace.\\nChildren withcongenital adrenal hyperplasiabegin\\ngrowing abnormally fast, but they stop growing earlier\\nthan normal. Later in childhood, they are typically\\nshorter than normal but have well-developed trunks.\\nKEY TERMS\\nAdrenal cortex— The outer tissue of the adrenal\\ngland. It produces a group of chemically related\\nhormones called corticosteroids that control\\nmineral 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.\\n68 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenal virilism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Women with adrenal virilization may develop\\nfacial hair. Typically, their menstrual cycles are infre-\\nquent or absent. They may also develop a deeper\\nvoice, a more prominent Adam’s apple, and other\\nmasculine signs.\\nDiagnosis\\nEndocrinologists, doctors who specialize in the\\ndiagnosis and treatment of glandular disorders, have\\nthe most expertise to deal with adrenal virilization.\\nSome doctors who treat disorders of the internal\\norgans (internists) and doctors who specialize in treat-\\ning the reproductive system of women (gynecologists)\\nmay also be able to help patients with this disorder.\\nDiagnosis involves performing many laboratory\\ntests on blood samples from the patient. These tests\\nmeasure the concentration of different hormones.\\nDifferent abnormalities of the adrenal gland produce\\na different pattern of hormonal abnormalities. These\\ntests can also help determine if the problem is adrenal\\nor ovarian. If a tumor is suspected, special x rays may\\nbe done to visualize the tumor in the body. Final\\ndiagnosis may depend on obtaining a tissue sample\\nfrom the tumor (biopsy), and examining it under a\\nmicroscope in order to verify its characteristics.\\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 hydro-\\ncortisone is usually given. Laboratory tests are usually\\nneeded from time to time to adjust the dosage. Girls\\nwith pseudohermaphrodism may require surgery to\\nmake their external sex organs appear more normal.\\nIf a tumor is causing the disorder, the treatment will\\ndepend on the type and location of the tumor.\\nInformation about the tumor cell type and the spread\\nof the tumor is used to decide the best kind of treatment\\nfor a particular patient. If the tumor is cancerous, the\\npatient will require special treatment depending on how\\nfar thecancer has advanced. Treatment can be a com-\\nbination of surgery, medications used to kill cancer cells\\n(chemotherapy), and x rays or other high energy rays\\nused to kill cancer cells (radiation therapy). Sometimes\\nthe doctor must remove the adrenal gland and the\\nsurrounding tissues. If the tumor is benign, then surgi-\\ncally removing the tumor may be the best option.\\nPrognosis\\nOngoing glucocorticoid treatment usually con-\\ntrols adrenal virilism in cases of adrenal hyperplasia,\\nbut there is no cure. If a cancerous tumor has caused\\nthe disorder, patients have a better prognosis if they\\nhave an early stage of cancer that is diagnosed quickly\\nand has not spread.\\nResources\\nPERIODICALS\\nWillensy, D. ‘‘The Endocrine System.’’AmericanHealth\\nApril 1996: 92-3.\\nRichard H. Lampert\\nAdrenalectomy\\nDefinition\\nAdrenalectomy is the surgical removal of one or\\nboth of the adrenal glands. The adrenal glands are\\npaired endocrine glands, one located above each kid-\\nney, that produce hormones such as epinephrine, nor-\\nepinephrine, androgens, estrogens, aldosterone, and\\ncortisol. Adrenalectomy is usually performed by con-\\nventional (open) surgery, but in selected patients sur-\\ngeons may use laparoscopy. With laparoscopy,\\nadrenalectomy can be accomplished through four\\nvery small incisions.\\nPurpose\\nAdrenalectomy is usually advised for patients\\nwith tumors of the adrenal glands. Adrenal gland\\ntumors may be malignant or benign, but all typically\\nexcrete excessive amounts of one or more hormones. A\\nsuccessful procedure will aid in correcting hormone\\nimbalances, and may also remove cancerous tumors\\nthat can invade other parts of the body. Occasionally,\\nadrenalectomy may be recommended when hormones\\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 gluco-\\ncorticoid hormones.\\nPrednisone— A drug that functions as a glucocorti-\\ncoid hormone.\\nGALE ENCYCLOPEDIA OF MEDICINE 69\\nAdrenalectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='produced by the adrenal glands aggravate another\\ncondition such asbreast cancer.\\nPrecautions\\nThe adrenal glands are fed by numerous blood\\nvessels, so surgeons need to be alert to extensive bleed-\\ning during surgery. In addition, the adrenal glands lie\\nclose to one of the body’s major blood vessels (the\\nvena cava), and to the spleen and the pancreas. The\\nsurgeon needs to remove the gland(s) without dama-\\nging any of these important and delicate organs.\\nDescription\\nOpen adrenalectomy\\nThe surgeon may operate from any of four direc-\\ntions, depending on the exact problem and the\\npatient’s body type.\\nIn the anterior approach, the surgeon cuts into the\\nabdominal wall. Usually the incision will be horizon-\\ntal, just under the rib cage. If the surgeon intends to\\noperate on only one of the adrenal glands, the incision\\nwill run under just the right or the left side of the rib\\ncage. Sometimes a vertical incision in the middle of the\\nabdomen provides a better approach, especially if\\nboth adrenal glands are involved.\\nIn the posterior approach, the surgeon cuts into\\nthe back, just beneath the rib cage. If both glands are\\nto be removed, an incision is made on each side of the\\nbody. This approach is the most direct route to the\\nadrenal glands, but it does not provide quite as clear a\\nview of the surrounding structures as the anterior\\napproach.\\nIn the flank approach, the surgeon cuts into the\\npatient’s side. This is particularly useful in massively\\nobese patients. If both glands need to be removed, the\\nsurgeon must remove one gland, repair the surgical\\nwound, turn the patient onto the other side, and repeat\\nthe entire process.\\nThe last approach involves an incision into the\\nchest cavity, either with or without part of the incision\\ninto the abdominal cavity. It is used when the surgeon\\nanticipates a very large tumor, or if the surgeon needs\\nto examine or remove nearby structures as well.\\nLaparoscopic adrenalectomy\\nThis technique does not require the surgeon to\\nopen the body cavity. Instead, four small incisions\\n(about 1/2 in diameter each) are made into a patient’s\\nflank, just under the rib cage. A laparoscope, which\\nenables the surgeon to visualize the inside of the\\nabdominal cavity on a television monitor, is placed\\nthrough one of the incisions. The other incisions are\\nfor tubes that carry miniaturized versions of surgical\\ntools. These tools are designed to be operated by\\nmanipulations that the surgeon makes outside the\\nbody.\\nPreparation\\nMost aspects of preparation are the same as in\\nother major operations. In addition, hormone imbal-\\nances are often a major challenge. Whenever possible,\\nphysicians will try to correct hormone imbalances\\nthrough medication in the days or weeks before sur-\\ngery. Adrenal tumors may cause other problems such\\nas hypertension or inadequate potassium in the blood,\\nand these problems also should be resolved if possible\\nbefore surgery is performed. Therefore, a patient may\\ntake specific medicines for days or weeks before\\nsurgery.\\nMost adrenal tumors can be imaged very well with\\na CT scan or MRI, and benign tumors tend to look\\ndifferent on these tests than do cancerous tumors.\\nSurgeons may order a CT scan, MRI, or scintigraphy\\n(viewing of the location of a tiny amount of radio-\\nactive agent) to help locate exactly where the tumor is.\\nThe day before surgery, patients will probably\\nhave an enema to clear the bowels. In patients with\\nlung problems or clotting problems, physicians may\\nadvise special preparations.\\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 manu-\\nfactures some key substances used by the immune\\nsystem.\\nVena cava— The large vein that drains directly into\\nthe heart after gathering incoming blood from the\\nentire body.\\n70 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenalectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aftercare\\nPatients stay in the hospital for various lengths of\\ntime after adrenalectomy. The longest hospital stays\\nare required for open surgery using an anterior\\napproach; hospital stays of about three days are indi-\\ncated for open surgery using the posterior approach or\\nfor laparoscopic adrenalectomy.\\nThe special concern after adrenalectomy is the\\npatient’s hormone balance. There may be several sets\\nof lab tests to define hormone problems and monitor\\nthe results of drug treatment. In addition, blood pres-\\nsure problems and infections are more common after\\nremoval of certain types of adrenal tumors.\\nAs with most open surgery, surgeons are also\\nconcerned about blood clots forming in the legs and\\ntraveling to the lungs (venous thromboembolism),\\nbowel problems, and postoperative pain. With laparo-\\nscopic adrenalectomy, these problems are somewhat\\nless difficult, but they are still present.\\nRisks\\nThe special risks of adrenalectomy involve major\\nhormone imbalances, caused by the underlying dis-\\nease, the surgery, or both.These can include problems\\nwith wound healing itself, blood pressure fluctuations,\\nand other metabolic problems.\\nOther risks are typical of many operations.These\\ninclude:\\n/C15bleeding\\n/C15damage to adjacent organs (spleen, pancreas)\\n/C15loss of bowel function\\n/C15blood clots in the lungs\\n/C15lung problems\\n/C15surgical infections\\n/C15pain\\n/C15extensive scarring\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nRichard H. Lampert\\nAdrenocortical insufficiency see Addison’s\\ndisease\\nAdrenocorticotropic hormone\\ntest\\nDefinition\\nAdrenocorticotropic hormone test (also known as\\nan ACTH test or a corticotropin test) measures pitui-\\ntary gland function.\\nPurpose\\nThe pituitary gland produces the hormone\\nACTH, which stimulates the outer layer of the adrenal\\ngland (the adrenal cortex). ACTH causes the release of\\nthe hormones hydrocortisone (cortisol), aldosterone,\\nand androgen. The most important of these hormones\\nreleased is cortisol. The ACTH test is used to deter-\\nmine if too much cortisol is being produced (Cushing’s\\nsyndrome) or if not enough cortisol is being produced\\n(Addison’s disease).\\nPrecautions\\nACTH has diurnal variation, meaning that the\\nlevels of this hormone vary according to the time of\\nday. The highest levels occur in the morning hours.\\nTesting for normal secretion, as well as for Cushing’s\\ndisease, may require multiple samples. For sequential\\nfollow-up, a blood sample analyzed for ACTH should\\nalways be drawn at the same time each day.\\nACTH can be directly measured by an analyzing\\nmethod (immunoassay) in many large laboratories.\\nHowever, smaller laboratories are usually not\\nequipped to perform this test and they may need to\\nsend the blood sample to a larger laboratory. Because\\nof this delay, results may take several days to obtain.\\nDescription\\nACTH production is partly controlled by an area\\nin the 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\\nthe pituitary gland to make more ACTH. ACTH levels\\nrise in response tostress, emotions, injury, infection,\\nburns, surgery, and decreased blood pressure.\\nCushing’s syndrome\\nCushing’s syndrome is caused by an abnormally\\nhigh level of circulating hydrocortisone. The high level\\nGALE ENCYCLOPEDIA OF MEDICINE 71\\nAdrenocorticotropic hormone test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='may be the result of an adrenal gland tumor or enlar-\\ngement of both adrenal glands due to a pituitary\\ntumor. The high level of hydrocortisone may be the\\nresult of taking corticosteroid drugs for a long time.\\nCorticosteroid drugs are widely used for inflammation\\nin disorders like rheumatoid arthritis, inflammatory\\nbowel disease, andasthma.\\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\\nthis disease is an autoimmune disorder. The immune\\nsystem normally fights foreign invaders in the body\\nlike bacteria. In an autoimmune disorder, the\\nimmune systems attacks the body. In this case, the\\nimmune system produces antibodies that attack\\nthe adrenal glands. Addison’s disease generally pro-\\ngresses slowly, with symptoms developing gradually\\nover months or years. However, acute episodes,\\ncalled Addisonian crises, are brought on by infection,\\ninjury, or other stresses. Diagnosis is generally made\\nif the patient fails to respond to an injection of\\nACTH, which normally stimulates the secretion of\\nhydrocortisone.\\nPreparation\\nA person’s ACTH level is determined from a\\nblood sample. The patient must fast from midnight\\nuntil the test the next morning. This means that the\\npatient cannot eat or drink anything after midnight\\nexcept water. The patient must also avoid radioiso-\\ntope scanning tests or recently administered radioiso-\\ntopes prior to the blood test.\\nRisks\\nThe risks associated with this test are minimal.\\nThey may include slight bleeding from the location\\nwhere the blood was drawn. The patient may feel faint\\nor lightheaded after the blood is drawn. Sometimes\\nthe patient may have an accumulation of blood\\nunder the puncture site (hematoma) after the test.\\nNormal results\\nEach laboratory will have its own set of normal\\nvalues for this test. The normal values can range from:\\nMorning (4-8 A.M.) 8-100 pg/mL or 10-80 ng/L (SI\\nunits) Evening (8-10 P.M.) less than 50 pg/mL or less\\nthan 50 ng/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\\ndue to high levels of cortisol and feedback to the\\npituitary.\\nIn Addison’s disease, high levels of ACTH may be\\ncaused by adrenal gland diseases. These diseases\\ndecrease adrenal hormones and the pituitary attempts\\nto increase functioning. Low levels of ACTH may\\noccur because of decreased pituitary function.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnosticand\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAdrenogenital syndrome see Adrenal\\nvirilism\\nAdrenoleukodystrophy\\nDefinition\\nAdrenoleukodystrophy is a rare genetic disease\\ncharacterized by a loss of myelin surrounding nerve\\ncells in the brain and progressive adrenal gland\\ndysfunction.\\nDescription\\nAdrenoleukodystrophy (ALD) is a member of a\\ngroup of diseases, leukodystrophies, that cause damage\\nto the myelin sheath of nerve cells. Approximately one\\nin 100,000 people is affected by ALD. There are three\\nKEY TERMS\\nAdrenal glands— A pair of endocrine glands that lie\\non top of the kidneys.\\nPituitary gland— The most important of the endo-\\ncrine glands, glands that release hormones directly\\ninto the bloodstream; sometimes called the master\\ngland.\\n72 GALE ENCYCLOPEDIA OF MEDICINE\\nAdrenoleukodystrophy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='basic forms of ALD: childhood, adult-onset, and\\nneonatal. The childhood form of the disease is the\\nclassical form and is the most severe. Childhood\\nALD is progressive and usually leads to total disabi-\\nlity ordeath. It affects only boys because the genetic\\ndefect is sex-linked (carried on the X chromosome).\\nOnset usually occurs between ages four and ten and\\ncan include many different symptoms, not all of\\nwhich appear together. The most common symptoms\\nare behavioral problems and poor memory. Other\\nsymptoms frequently seen are loss of vision, seizures,\\npoorly articulated speech, difficulty swallowing,\\ndeafness, problems with gait and coordination,fati-\\ngue, increased skin pigmentation, and progressive\\ndementia.\\nThe adult-onset form of the disease, also called\\nadrenomyeloneuropathy, is milder, progresses slowly,\\nis usually associated with a normal life span, and\\nusually appears between ages 21-35. Symptoms may\\ninclude progressive stiffness, weakness, orparalysis of\\nthe lower limbs and loss of coordination. Brain func-\\ntion deterioration may also been seen. Women who\\nare carriers of the disease occasionally experience the\\nsame symptoms, as well as others, including ataxia,\\nhypertonia (excessive muscle tone), mild peripheral\\nneuropathy, and urinary problems. The neonatal\\nform affects both male and female infants and may\\nproduce mental retardation, facial abnormalities, sei-\\nzures, retinal degeneration, poor muscle tone,\\nenlarged liver, and adrenal dysfunction. Neonatal\\nALD 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\\nbuild up in the adrenal glands, brain, plasma, and\\nfibroblasts. The build-up of very long chain fatty\\nacids interferes with the ability of the adrenal gland\\nto convert cholesterol into steroids and causes demye-\\nlination of nerves in the white matter of the brain.\\nDemyelinated nerve cells are unable to function\\nproperly.\\nDiagnosis\\nDiagnosis is made based on observed symptoms, a\\nbiochemical test, and a family history. The biochem-\\nical test detects elevated levels of very long chain fatty\\nacids in samples fromamniocentesis, chorionic villi,\\nplasma, red blood cells, or fibroblasts. A family his-\\ntory may indicate the likelihood of ALD because the\\ndisease is carried on the X-chromosome by the female\\nlineage of families.\\nTreatment\\nTreatment for all forms of ALD consists of treat-\\ning the symptoms and supporting the patient with\\nphysical therapy, psychological counseling, and spe-\\ncial education in some cases. There is no cure for this\\ndisease, and there are no drugs that can reverse demye-\\nlination of nerve and brain cells. Dietary measures\\nconsist of reducing the intake of foods high in fat,\\nwhich are a source of very long chain fatty acids. A\\nmixture called Lorenzo’s Oil has been shown to reduce\\nthe level of long chain fatty acids if used long term;\\nhowever, the rate of myelin loss is unaffected.\\nExperimental bone marrow transplantation has not\\nbeen very effective.\\nPrognosis\\nPrognosis for childhood and neonatal ALD\\npatients is poor because of the progressive myelin\\ndegeneration. Death usually occurs between one and\\nten years after onset of symptoms.\\nPrevention\\nSince ALD is a genetic disease, prevention is lar-\\ngely limited togenetic counselingand fetal monitoring\\nthrough amniocentesis orchorionic villus sampling.\\nResources\\nBOOKS\\nBerkow, Robert.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nJohn T. Lohr, PhD\\nAdrenomyeloneuropathy see\\nAdrenoleukodystrophy\\nKEY 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 movement.\\nHypertonia— Having excessive muscular tone.\\nMyelin— A layer that encloses nerve cells and some\\naxons and is made largely of lipids and lipoproteins.\\nNeuropathy— A disease or abnormality of the peri-\\npheral nerves.\\nGALE ENCYCLOPEDIA OF MEDICINE 73\\nAdrenoleukodystrophy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Adult respiratory distress\\nsyndrome\\nDefinition\\nAdult respiratory distress syndrome(ARDS), also\\ncalled acute respiratory distress syndrome, is a type\\nof lung (pulmonary) failure that may result from any\\ndisease that causes large amounts of fluid to collect\\nin the lungs. ARDS is not itself a specific disease, but a\\nsyndrome, a group of symptoms and signs that\\nmake up one of the most important forms of lung or\\nrespiratory failure. It can develop quite suddenly in\\npersons whose lungs have been perfectly normal.\\nVery often ARDS is a true medical emergency. The\\nbasic fault is a breakdown of the barrier, or mem-\\nbrane, that normally keeps fluid from leaking out of\\nthe small blood vessels of the lung into the breathing\\nsacs (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 ves-\\nsels, or capillaries, make contact with the alveoli, tiny\\nair sacs at the tips of the smallest breathing tubes (the\\nbronchi). This is the all-important site where oxygen\\npasses from air that is inhaled to the blood, which\\ncarries it to all parts of the body. Any form of lung\\ninjury that damages this point of contact, called the\\nalveolo-capillary junction, will allow blood and tissue\\nfluid to leak into the alveoli, eventually filling them so\\nthat air cannot enter. The result is the type of breath-\\ning distress called ARDS. ARDS is one of the major\\ncauses of excess fluid in the lungs, the other beingheart\\nfailure.\\nAlong with fluid there is a marked increase in\\ninflamed cells in the lungs. There also is debris left\\nover from damaged lung cells, and fibrin, a semi-\\nsolid material derived from blood in the tissues.\\nTypically these materials join together with large\\nmolecules in the blood (proteins), to form hyaline\\nmembranes. (These membranes are very prominent\\nin premature infants who develop respiratory distress\\nsyndrome; it is often called hyaline membrane dis-\\nease.) If ARDS is very severe or lasts a long time, the\\nlungs do not heal, but rather become scarred, a process\\nknown as fibrosis. The lack of a normal amount of\\noxygen causes the blood vessels of the lung to become\\nnarrower, and in time they, too, may become scarred\\nand filled with clotted blood. The lungs as a whole\\nbecome very ‘‘stiff,’’ and it becomes much harder for\\nthe patient to breathe.\\nCauses and symptoms\\nA very wide range of diseases or toxic substances,\\nincluding some drugs, can cause ARDS. They include:\\n/C15Breathing in (aspiration) of the stomach contents\\nwhen regurgitated, or salt water or fresh water from\\nnearly drowning.\\n/C15Inhaling smoke, as in a fire; toxic materials in the air,\\nsuch as ammonia or hydrocarbons; or too much\\noxygen, which itself can injure the lungs.\\n/C15Infection by a virus or bacterium, orsepsis, a wide-\\nspread infection that gets into the blood.\\n/C15Massive trauma, with severe injury to any part of the\\nbody.\\n/C15Shock with persistently low blood pressure may not\\nin itself cause ARDS, but it can be an important\\nfactor.\\n/C15A blood clotting disorder called disseminated intra-\\nvascular coagulation, in which blood clots form in\\nvessels throughout the body, including the lungs.\\n/C15A large amount of fat entering the circulation and\\ntraveling to the lungs, where it lodges in small blood\\nvessels, injuring the cells lining the vessel walls.\\n/C15An overdose of a narcotic drug, a sedative, or, rarely,\\naspirin.\\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,\\nliquids, 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 low-\\noxygen conditions.\\nSteroids— A class of drugs resembling normal body\\nsubstances that often help control inflammation in\\nthe 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.\\n74 GALE ENCYCLOPEDIA OF MEDICINE\\nAdult respiratory distress syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Inflammation of the pancreas (pancreatitis), when\\nblood proteins, called enzymes, pass to the lungs\\nand injure lung cells.\\n/C15Severe burn injury.\\n/C15Injury of the brain, or bleeding into the brain, from\\nany cause may be a factor in ARDS for reasons that\\nare not clear. Convulsions also may cause some\\ncases.\\nUsually ARDS develops within one to two days of\\nthe original illness or injury. The person begins to take\\nrapid but shallow breaths. The doctor who listens to\\nthe patient’s chest with a stethoscope may hear\\n‘‘crackling’’ orwheezing sounds. The low blood oxy-\\ngen content may cause the skin to appear mottled or\\neven blue. As fluid continues to fill the breathing sacs,\\nthe patient may have great trouble breathing, take\\nvery 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,\\nand this can be confirmed by analyzing blood taken\\nfrom an artery. Thechest x raymay be normal in the\\nearly stages, but, in a short time, fluid will be seen\\nwhere it does not belong. The two lungs are about\\nequally affected. A heart of normal size indicates that\\nthe problem actually is ARDS and not heart failure.\\nAnother way a physician can distinguish between\\nthese two possibilities is to place a catheter into a\\nvein and advance it into the main artery of the lung.\\nIn this way, the pressure within the pulmonary capil-\\nlaries can be measured. Pressure within the pulmonary\\ncapillaries is elevated in heart failure, but normal\\nin ARDS.\\nTreatment\\nThe three main goals in treating patients with\\nARDS are:\\n/C15To treat whatever injury or disease has caused\\nARDS. Examples are: to treat septic infection with\\nthe proper antibiotics, and to reduce the level of\\noxygen therapy if ARDS has resulted from a toxic\\nlevel of oxygen.\\n/C15To control the process in the lungs that allows fluid\\nto leak out of the blood vessels. At present there\\nis no certain way to achieve this. Certain steroid\\nhormones have been tried because they can combat\\ninflammation, but the actual results have been\\ndisappointing.\\n/C15To make sure the patient gets enough oxygen until\\nthe lung injury has had time to heal. If oxygen deliv-\\nered by a face mask is not enough, the patient is\\nplaced on a ventilator, which takes over breathing,\\nand, through a tube placed in the nose or mouth (or\\nan incision in the windpipe), forces oxygen into the\\nlungs. This treatment must be closely supervised, and\\nthe pressure adjusted so that too much oxygen is not\\ndelivered.\\nPatients with ARDS should be cared for in an\\nintensive care unit, where experienced staff and all\\nneeded equipment are available. Enough fluid must\\nbe provided, by vein if necessary, to preventdehydra-\\ntion. Also, the patient’s nutritional state must be main-\\ntained, again by vein, 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\\norgans, such as the kidneys. There always is a risk\\nthat bacterial pneumonia will develop at some point.\\nWithout prompt treatment, as many as 90% of\\npatients with ARDS can be expected to die. With\\nmodern treatment, however, about half of all patients\\nwill survive. Those who do live usually recover com-\\npletely, with little or no long-term breathing difficulty.\\nLung scarring is a risk after a long period on a venti-\\nlator, 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\\nwhether the primary disease that caused ARDS to\\ndevelop in the first place can be effectively treated.\\nPrevention\\nThe only way to prevent ARDS is to avoid those\\ndiseases and harmful conditions that damage the lung.\\nFor instance, the danger of aspirating stomach con-\\ntents into the lungs can be avoided by making sure a\\npatient does not eat shortly before receivinggeneral\\nanesthesia. If a patient needsoxygen therapy,a sl o wa\\nlevel as possible should be given. Any form of lung\\ninfection, or infection anywhere in the body that gets\\ninto the blood, must be treated promptly to avoid the\\nlung injury that causes ARDS.\\nResources\\nBOOKS\\nSmolley, Lawrence A., and Debra F. Bryse.Breathe\\nRightNow: A Comprehensive Guide to Understanding\\nand Treating the Most Common Breathing Disorders.\\nNew York: W. W. Norton & Co., 1998.\\nGALE ENCYCLOPEDIA OF MEDICINE 75\\nAdult respiratory distress syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='ORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nNational Respiratory Distress Syndrome Foundation. P.O.\\nBox 723, Montgomeryville, PA 18936.\\nDavid A. Cramer, MD\\nAFP test see Alpha-fetoprotein test\\nAfrican American health see Minority health\\nAfrican sleeping sickness see Sleeping\\nsickness\\nAfrican trypanosomiasis see Sleeping\\nsickness\\nAgammaglobulinemia see Common variable\\nimmunodeficiency\\nAggression see Conduct disorder\\nAging\\nDefinition\\nStarting at what is commonly called middle age,\\noperations of the human body begin to be more vul-\\nnerable to daily wear and tear; there is a general\\ndecline in physical, and possibly mental, functioning.\\nIn the Western countries, the length of life is often into\\nthe 70s. The upward limit of the life span, however,\\ncan be as high as 120 years. During the latter half of\\nlife, an individual is more prone to have problems with\\nthe various functions of the body and to develop any\\nnumber of chronic or fatal diseases. The cardiovascu-\\nlar, digestive, excretory, nervous, reproductive and\\nurinary systems are particularly affected. The most\\ncommon diseases of aging include Alzheimer’s, arthri-\\ntis, cancer, diabetes, depression, and heart disease.\\nDescription\\nHuman beings reach a peak of growth and devel-\\nopment around the time of their mid 20s. Aging is the\\nnormal transition time after that flurry of activity.\\nAlthough there are quite a few age-related changes\\nthat tax the body, disability is not necessarily a part\\nof aging. Health and lifestyle factors together with\\nthe genetic makeup of the individual, and determines\\nthe response to these changes. Body functions that are\\nmost often affected by age include:\\n/C15Hearing, which declines especially in relation to the\\nhighest pitched tones.\\n/C15The proportion of fat to muscle, which may increase\\nby as much as 30%. Typically, the total padding of\\nbody fat directly under the skin thins out and accu-\\nmulates around the stomach. The ability to excrete\\nfats is impaired, and therefore the storage of fats\\nincreases, including cholesterol and fat-soluble\\nnutrients.\\n/C15The amount of water in the body decreases, which\\ntherefore decreases the absorption of water-soluble\\nnutrients. Also, there is less saliva and other lubricat-\\ning fluids.\\n/C15The liver and the kidneys cannot function as effi-\\nciently, thus affecting the elimination of wastes.\\n/C15A decrease in the ease of digestion, with a decrease in\\nstomach acid production.\\n/C15A loss of muscle strength and coordination, with an\\naccompanying loss of mobility, agility, and\\nflexibility.\\n/C15A decline in sexual hormones and sexual functioning.\\n/C15A decrease in the sensations of taste and smell.\\n/C15Changes in the cardiovascular and respiratory sys-\\ntems, leading to decreased oxygen and nutrients\\nthroughout the body.\\n/C15Decreased functioning of the nervous system so that\\nnerve impulses are not transmitted as efficiently,\\nreflexes are not as sharp, and memory and learning\\nare diminished.\\n/C15A decrease in bone strength and density.\\n/C15Hormone levels, which gradually decline. The thyr-\\noid and sexual hormones are particularly affected.\\n/C15Declining visual abilities. Age-related changes may\\nlead to diseases such asmacular degeneration.\\n/C15A compromised ability to produce vitamin D from\\nsunlight.\\n/C15A reduction in protein formation leading to shrink-\\nage in muscle mass and decreased bone formation,\\npossibly leading to osteoporosis.\\nCauses and symptoms\\nThere are several theories as to why the aging\\nbody loses functioning. It may be that several factors\\nwork together or that one particular factor is at work\\nmore than others in a given individual.\\n/C15Programmed senescence, or aging clock, theory. The\\naging of the cells of each individual is programmed\\ninto the genes, and there is a preset number of\\n76 GALE ENCYCLOPEDIA OF MEDICINE\\nAging'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='possible rejuvenations in the life of a given cell. When\\ncells die at a rate faster than they are replaced, organs\\ndo not function properly, and they are soon unable\\nto maintain the functions necessary for life.\\n/C15Genetic theory. Human cells maintain their own seed\\nof destruction at the level of the chromosomes.\\n/C15Connective tissue, or cross-linking theory. Changes\\nin the make-up of the connective tissue alter the\\nstability of body structures, causing a loss of elasti-\\ncity and functioning, and leading to symptoms of\\naging.\\n/C15Free-radical theory. The most commonly held theory\\nof aging, it is based on the fact that ongoing chemical\\nreactions of the cells produce free radicals. In the\\npresence of oxygen, these free radicals cause the\\ncells of the body to break down. As time goes on,\\nmore cells die or lose the ability to function, and the\\nbody soon ceases to function as a whole.\\n/C15Immunological theory. There are changes in the im-\\nmune system as it begins to wear out, and the body is\\nmore prone to infections and tissue damage, which\\nmay finally causedeath. Also, as the system breaks\\ndown, the body is more apt to have autoimmune\\nreactions, in which the body’s own cells are mistaken\\nfor foreign material and are destroyed or damaged\\nby the immune system.\\nDiagnosis\\nMany problems can arise due to age-related\\nchanges in the body. Although there is no one test to\\nbe given, a thorough physical exam and a basic blood\\nscreening and blood chemistry panel can point to\\nareas in need of further attention. When older people\\nbecome ill, the first signs of disease are often nonspe-\\ncific. Further exams should be conducted if any of the\\nfollowing occur:\\n/C15diminished or lack of desire for food\\n/C15increasing confusion\\n/C15failure to thrive\\n/C15urinary incontinence\\n/C15dizziness\\n/C15weight loss\\n/C15falling\\nTreatment\\nFor the most part, doctors prescribe medications\\nto control the symptoms and diseases of aging. In the\\nUnited States, about two-thirds of people 65 and over\\ntake medications for various complaints. More\\nwomen than men use these medications. The most\\ncommon drugs used by the elderly are painkillers,\\ndiuretics or water pills, sedatives, cardiac drugs,anti-\\nbiotics, and mental health drugs.\\nEstrogen replacement therapy (ERT) is com-\\nmonly prescribed to postmenopausal women for\\nsymptoms of aging. It is often used in conjunction\\nwith progesterone. ERT functions to help keep bones\\nstrong, reduce risk of heart disease, restore vaginal\\nlubrication, and to improve skin elasticity. Evidence\\nsuggests that it may also help maintain mental\\nfunctions.\\nExpected results\\nAging is unavoidable, but major physical impair-\\nment is not. People can lead a healthy, disability-free\\nlife well through their later years. A well established\\nsupport system of family, friends, and health care\\nproviders, together with focus on goodnutrition and\\nlifestyle habits and good stress management, can\\nprevent disease and lessen the impact of chronic\\nconditions.\\nAlternative treatment\\nNutritional supplements\\nConsumption of a high–quality multivitamin is\\nrecommended. Common nutritional deficiencies con-\\nnected with aging include Bvitamins, vitamins A and\\nC, folic acid, calcium, magnesium, zinc, iron, chro-\\nmium, and traceminerals. Since stomach acids may\\nbe decreased, it is suggested that the use of a powdered\\nmultivitamin formula in gelatin capsules be used, as\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 77\\nAging'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='this form is the easiest to digest. Such formulas may\\nalso contain enzymes for further help with digestion.\\nAntioxidants can help to neutralize damage by\\nthe free radical actions thought to contribute to pro-\\nblems of aging. They are also helpful in preventing\\nand treating cancer and in treating cataracts and\\nglaucoma. Supplements that serve as antioxidants\\ninclude:\\n/C15Vitamin E, 400–1,000 IUs daily. Protects cell mem-\\nbranes against damage. It shows promise in preven-\\ntion against heart disease, and Alzheimer’s and\\nParkinson’s diseases.\\n/C15Selenium, 50 mg taken twice daily. Research suggests\\nthat selenium may play a role in reducing the risk of\\ncancer.\\n/C15Beta-carotene, 25,000–40,000 IUs daily. May help in\\ntreating cancer, colds and flu, arthritis, and immune\\nsupport.\\n/C15Vitamin C, 1,000–2,000 mg per day. It may cause\\ndiarrhea in large doses. If this occurs, however, all\\nthat is needed is a decrease in the dosage.\\nOther supplements that are helpful in treating age-\\nrelated problems including:\\n/C15B12/B-complex vitamins, studies show that B12 may\\nhelp reduce mental symptoms, such as confusion,\\nmemory loss, and depression.\\n/C15Coenzyme Q10 may be helpful in treating heart dis-\\nease, as up to three-quarters cardiac patients have\\nbeen found to be lacking in this heart enzyme.\\nHormones\\nThe following hormone supplements may be\\ntaken to prevent or to treat various age-related pro-\\nblems. However, caution should be taken before\\nbeginning treatment, and the patient should consult\\nhis or her health care professional.\\nDHEA improves brain functioning and serves as a\\nbuilding block for many other important hormones in\\nthe body. It may be helpful in restoring declining\\nhormone levels and in building up muscle mass,\\nstrengthening the bones, and maintaining a healthy\\nheart.\\nMelatonin may be helpful forinsomnia. It has also\\nbeen used to help fight viruses and bacterial infections,\\nreduce the risk of heart disease, improve sexual func-\\ntioning, and to protect against cancer.\\nHuman growth hormone (hGH) has been shown\\nto regulate blood sugar levels and to stimulate bone,\\ncartilage, and muscle growth while reducing fat.\\nHerbs\\nGarlic (Allium sativa ) is helpful in preventing\\nheart disease, as well as improving the tone and texture\\nof skin. Garlic stimulates liver and digestive system\\nfunctions, and also helps in dealing with heart disease\\nand high blood pressure.\\nSiberian ginseng ( Eleutherococcus senticosus )\\nsupports the adrenal glands and immune functions.\\nIt is believed to be helpful in treating problems related\\nto stress. Siberian ginseng also increases mental\\nand physical performance, and may be useful in treat-\\ning memory loss, chronic fatigue, and immune\\ndysfunction.\\nProanthocyanidins, or PCO, are Pycnogenol,\\nderived from grape seeds and skin, and from pine\\ntree bark, and may help in the prevention of cancer\\nand poor vision.\\nIn Ayurvedic medicine, aging is described as a\\nprocess of increased vata, in which there is a tendency\\nto become thinner, drier, more nervous, more restless,\\nand more fearful, while having a loss of appetite\\nas well as sleep. Bananas, almonds, avocados, and\\ncoconuts are some of the foods used in correcting\\nsuch conditions. One of the main herbs used for\\nsuch conditions is gotu kola ( Centella asiatica ),\\nwhich is used to revitalize the nervous system and\\nbrain cells and to fortify the immune system. Gotu\\nkola is also used to treat memory loss,anxiety, and\\ninsomnia.\\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.\\nPrevention\\nPreventive health practices such as healthy diet,\\ndaily exercise, stress management, and control of life-\\nstyle habits such as smoking and drinking, can\\nlengthen the life span and improve the quality of life\\nas people age. Exercise can improve the appetite, the\\nhealth of the bones, the emotional and mental out-\\nlook, and the digestion and circulation.\\nDrinking plenty of fluids aids in maintaining\\nhealthy skin, good digestion, and proper elimination\\nof wastes. Up to eight glasses of water should be con-\\nsumed daily, along with plenty of herbal teas, diluted\\n78 GALE ENCYCLOPEDIA OF MEDICINE\\nAging'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='fruit and vegetable juices, and fresh fruits and vegeta-\\nbles with high water content.\\nBecause of a decrease in the sense of taste, older\\npeople often increase their intake of salt, which can\\ncontribute to high blood pressure and nutrient loss.\\nUse of sugar is also increased. Seaweeds and small\\namounts of honey can be used as replacements.\\nAlcohol, nicotine, andcaffeine 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 car-\\nbohydrates, such as whole grains. If chewing becomes\\na problem, there should be an increased intake of\\nprotein drinks, freshly juiced fruits and vegetables,\\nand creamed cereals.\\nResources\\nOTHER\\n‘‘Anti-Aging-Nutritional Program.’’ December 28, 2000.\\n.\\n‘‘Effects of Hormone in the Body.’’ December 28, 2000.\\n.\\n‘‘The Elderly-Nutritional Programs.’’ December 28, 2000.\\n.\\n‘‘Evaluating the Elderly Patient: the Case for Assessment\\nTechnology.’’ December 28, 2000. .\\n‘‘Herbal Phytotherapy and the Elderly.’’ December 28, 2000.\\n.\\n‘‘Pharmacokinetics.’’ Merck & Co., Inc. (1995-2000).\\nDecember 28, 2000. .\\n‘‘To a Long and Healthy Life.’’ December 28, 2000. .\\nPatience Paradox\\nAgoraphobia\\nDefinition\\nThe word agoraphobia is derived from Greek\\nwords literally meaning ‘‘fear of the marketplace.’’\\nThe term is used to describe an irrational and often\\ndisabling fear of being out in public.\\nDescription\\nAgoraphobia is just one type of phobia, or irra-\\ntional fear. People withphobias feel dread or panic\\nwhen they face certain objects, situations, or activities.\\nPeople with agoraphobia frequently also experience\\npanic attacks, but panic attacks, or panic disorder,\\nare not a requirement for a diagnosis of agoraphobia.\\nThe defining feature of agoraphobia isanxiety about\\nbeing in places from which escape might be embarras-\\ning or difficult, or in which help might be unavailable.\\nThe person suffering from agoraphobia usually avoids\\nthe anxiety-provoking situation and may become\\ntotally housebound.\\nCauses and symptoms\\nAgoraphobia is the most common type of phobia,\\nand it is estimated to affect between 5-12% of\\nAmericans within their lifetime. Agoraphobia is\\ntwice as common in women as in men and usually\\nstrikes between the ages of 15-35.\\nThe symptoms of the panic attacks which may\\naccompany agoraphobia vary from person to person,\\nand may include trembling, sweating, heartpalpita-\\ntions (a feeling of the heart pounding against the\\nchest), jitters, fatigue, tingling in the hands and feet,\\nnausea, a rapid pulse or breathing rate, and a sense of\\nimpending doom.\\nAgoraphobia and other phobias are thought to be\\nthe result of a number of physical and environmental\\nfactors. For instance, they have been associated with\\nbiochemical imbalances, especially related to certain neu-\\nrotransmitters (chemical nerve messengers) in the brain.\\nPeople who have a panic attack in a given situation\\n(e.g., a shopping mall) may begin to associate the panic\\nwith that situation and learn to avoid it. According to\\nsome theories, irrational anxiety results from unresolved\\nemotional conflicts. All of these factors may play a\\nrole to varying extents in different cases of agoraphobia.\\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 specific\\nobject, activity, or situation.\\nGALE ENCYCLOPEDIA OF MEDICINE 79\\nAgoraphobia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nPeople who suffer from panic attacks should dis-\\ncuss the problem with a physician. The doctor can\\ndiagnose the underlying panic or anxiety disorder\\nand make sure the symptoms aren’t related to some\\nother underlying medical condition.\\nThe doctor makes the diagnosis of agoraphobia\\nbased primarily on the patient’s description of his or\\nher symptoms. The person with agoraphobia experi-\\nences anxiety in situations where escape is difficult or\\nhelp is unavailable–or in certain situations, such as\\nbeing alone. While many people are somewhat appre-\\nhensive in these situations, the hallmark of agorapho-\\nbia is that a person’s active avoidance of the feared\\nsituation impairs his or her ability to work, socialize,\\nor otherwise function.\\nTreatment\\nTreatment for agoraphobia usually consists of\\nboth medication and psychotherapy. Usually,\\npatients can benefit from certain antidepressants,\\nsuch as amitriptyline (Elavil), orselective serotonin\\nreuptake inhibitors , such as paroxetine (Paxil),\\nfluoxetine (Prozac), or sertraline (Zoloft). In addi-\\ntion, patients may manage panic attacks in progress\\nwith certain tranquilizers called benzodiazepines ,\\nsuch as alprazolam (Xanax) or clonazepam\\n(Klonipin).\\nThe mainstay of treatment for agoraphobia and\\nother phobias is cognitive behavioral therapy. A\\nspecific technique that is often employed is called\\ndesensitization. The patient is gradually exposed to\\nthe situation that usually triggers fear and avoidance,\\nand, with the help of breathing or relaxation tech-\\nniques, learns to cope with the situation. This helps\\nbreak the mental connection between the situation and\\nthe fear, anxiety, or panic. Patients may also benefit\\nfrom psychodynamically oriented psychotherapy,\\ndiscussing underlying emotional conflicts with a thera-\\npist or support group.\\nPrognosis\\nWith proper medication and psychotherapy, 90%\\nof patients will find significant improvement in their\\nsymptoms.\\nResources\\nPERIODICALS\\nForsyth, Sondra. ‘‘I Panic When I’m Alone.’’Mademoiselle\\nApril 1998: 119-24.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nAnxiety Disorders Association of America. 11900 Park\\nLawn Drive, Ste. 100, Rockville, MD 20852. (800)\\n545-7367. .\\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\\nan infectious disease caused by the humanimmunode-\\nficiency virus (HIV). It was first recognized in the\\nUnited States in 1981. AIDS is the advanced form of\\ninfection with the HIV virus, which may not cause\\nrecognizable disease for a long period after the initial\\nexposure (latency). No vaccine is currently available to\\nprevent HIV infection. At present, all forms of AIDS\\ntherapy are focused on improving the quality and\\nlength of life for AIDS patients by slowing or halting\\nthe replication of the virus and treating or preventing\\ninfections and cancers that take advantage of a per-\\nson’s weakened immune system.\\nDescription\\nAIDS is considered one of the most devastating\\npublic health problems in recent history. In June 2000,\\nthe Centers for Disease Control and Prevention\\n(CDC) reported that 120,223 (includes only those\\ncases in areas that have confidential HIV reporting)\\nin the United States are HIV-positive, and 311,701 are\\nliving with AIDS (includes only those cases where vital\\nstatus is known). Of these patients, 44% are gay or\\nbisexual men, 20% are heterosexual intravenous drug\\nusers, and 17% are women. In addition, approxi-\\nmately 1,000-2,000 children are born each year with\\nHIV infection. The World Health Organization\\n(WHO) estimates that 33 million adults and 1.3 mil-\\nlion children worldwide were living with HIV/AIDS as\\nof 1999 with 5.4 million being newly infected that year.\\nMost of these cases are in the developing countries of\\nAsia and Africa.\\n80 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Risk factors\\nAIDS can be transmitted in several ways. The risk\\nfactors for HIV transmissionvaryaccording to category:\\n/C15Sexual 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\\ninAfrica,thediseaseisspreadprimarilythroughsexual\\nintercourse among heterosexuals.\\n/C15Transmission in pregnancy. High-risk mothers\\ninclude women married to bisexual men or men\\nwho have an abnormal blood condition calledhemo-\\nphilia and require blood transfusions, intravenous\\ndrug users, and women living in neighborhoods\\nwith a high rate of HIV infection among heterosex-\\nuals. The chances of transmitting the disease to the\\nchild are higher in women in advanced stages of the\\ndisease. Breast feeding increases the risk of transmis-\\nsion by 10-20%. The use of zidovudine (AZT) during\\npregnancy, however, can decrease the risk of trans-\\nmission to the baby.\\n/C15Exposure to contaminated blood or blood products.\\nWith the introduction of blood product screening in\\nthe mid-1980s, the incidence of HIV transmission in\\nbloodtransfusionshasdroppedtooneinevery100,000\\ntransfused. With respect to HIV transmission among\\ndrug abusers, risk increases with the duration of using\\ninjections, the frequency of needle sharing, the num-\\nber of persons who share a needle, and the number of\\nAIDS cases in the local population.\\n/C15Needle sticks among health care professionals.\\nPresent studies indicate that the risk of HIV trans-\\nmission by a needle stick is about one in 250. This\\nrate can be decreased if the injured worker is given\\nAZT, an anti-retroviral medication, in combination\\nwith other medication.\\nHIV is not transmitted by handshakes or other\\ncasual non-sexual contact, coughing or sneezing, or by\\nbloodsucking insects such as mosquitoes.\\nAIDS in women\\nAIDS in women is a serious public health concern.\\nWomen exposed to HIV infection through hetero-\\nsexual contact are the most rapidly growing risk\\ngroup in the United States population. The percentage\\nof AIDS cases diagnosed in women has risen from 7%\\nin 1985 to 23% in 1999. Women diagnosed with AIDS\\nmay not live as long as men, although the reasons for\\nthis finding are unclear.\\nAIDS in children\\nSince AIDS can be transmitted from an infected\\nmother to the child during pregnancy, during the birth\\nprocess, or through breast milk, all infants born to\\nHIV-positive mothers are a high-risk group. As of\\n2000, it was estimated that 87% of HIV-positive\\nwomen are of childbearing age; 41% of them are\\ndrug abusers. Between 15-30% of children born to\\nHIV-positive women will be infected with the virus.\\nAIDS is one of the 10 leading causes ofdeath in\\nchildren between one and four years of age. The inter-\\nval between exposure to HIV and the development of\\nAIDS is shorter in children than in adults. Infants\\ninfected with HIV have a 20-30% chance of develop-\\ning AIDS within a year and dying before age three. In\\nthe remainder, AIDS progresses more slowly; the\\naverage child patient survives to seven years of age.\\nSome 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\\norgan systems. HIV attacks the body through three\\ndisease processes: immunodeficiency, autoimmunity,\\nand nervous system dysfunction.\\nRisk of acquiring HIV infection by entry site\\nEntry site\\nRisk virus\\nreaches entry\\nsite\\nRisk virus\\nenters\\nRisk\\ninoculated\\nConjuntiva Moderate Moderate Very low\\nOral mucosa Moderate Moderate Low\\nNasal mucosa Low Low Very low\\nLower\\nrespiratory\\nVery 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\\nPenis\\nUlcers (STD)\\nLow\\nHigh\\nHigh\\nLow\\nLow\\nHigh\\nMedium\\nLow\\nVery high\\nBlood:\\nProducts\\nShared needles\\nAccidental needle\\nHigh\\nHigh\\nLow\\nHigh\\nHigh\\nHigh\\nHigh\\nVery High\\nLow\\nTraumatic wound Modest High High\\nPerinatal High High High\\nGALE ENCYCLOPEDIA OF MEDICINE 81\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Immunodeficiency describes the condition in\\nwhich the body’s immune response is damaged, wea-\\nkened, or is not functioning properly. In AIDS, immu-\\nnodeficiency results from the way that the virus binds\\nto a protein called CD4, which is primarily found on\\nthe surface of certain subtypes of white blood cells\\ncalled helper T cells or CD4 cells. After the virus has\\nattached to the CD4 receptor, the virus-CD4 complex\\nrefolds to uncover another receptor called a chemo-\\nkine receptor that helps to mediate entry of the virus\\ninto the cell. One chemokine receptor in particular,\\nCCR5, has gotten recent attention after studies\\nshowed that defects in its structure (caused by genetic\\nmutations) cause the progression of AIDS to be pre-\\nvented or slowed. Scientists hope that this discovery\\nwill lead to the development of drugs that trigger an\\nartificial mutation of the CCR5 gene or target the\\nCCR5 receptor.\\nOnce HIV has entered the cell, it can replicate\\nintracellularly and kill the cell in ways that are still\\nnot completely understood. In addition to killing some\\nlymphocytes directly, the AIDS virus disrupts the\\nfunctioning of the remaining CD4 cells. Because the\\nimmune system cells are destroyed, many different\\ntypes of infections and cancers that take advantage\\nof a person’s weakened immune system (opportunis-\\ntic) can develop.\\nAutoimmunity is a condition in which the body’s\\nimmune system produces antibodies that work against\\nits own cells. Antibodies are specific proteins pro-\\nduced in response to exposure to a specific, usually\\nforeign, protein or particle called an antigen. In this\\ncase, the body produces antibodies that bind to blood\\nplatelets that are necessary for proper blood clotting\\nand tissue repair. Once bound, the antibodies mark the\\nplatelets for removal from the body, and they are\\nfiltered out by the spleen. Some AIDS patients develop\\na disorder, called immune-related thrombocytopenia\\npurpura (ITP), in which the number of blood platelets\\ndrops to abnormally low levels.\\nResearchers do not know precisely how HIV\\nattacks the nervous system since the virus can cause\\ndamage without infecting nerve cells directly. One\\ntheory is that, once infected with HIV, one type of\\nMature HIV-1 viruses (above) and the lymphocyte from which they emerged (below). Two immature viruses can be seen budding\\non the surface of the lymphocyte (right of center). (Photograph by Scott Camazir, Photo Researchers, Inc. Reproduced by\\npermission.)\\n82 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='CENTRAL 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 develop,\\ntaking advantage of a person’s weakened immune system.(Illustration by Electronic Illustrators Group.)\\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\\ncoordination.\\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, natural\\nkiller cells, and monocytes in the patient’s blood.\\nGALE ENCYCLOPEDIA OF MEDICINE 83\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Most 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 coa-\\ngulation 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)— At r a n s m i s -\\nsible retrovirus that causes AIDS in humans. Two\\nforms of HIV are now recognized: HIV-1, which\\ncauses most cases of AIDS in Europe, North and\\nSouth America, and most parts of Africa; and HIV-2,\\nwhich is chiefly found in West African patients.\\nHIV-2, discovered in 1986, appears to be less virulent\\nthan HIV-1 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 tissue\\nthat produces painless purplish red (in people with\\nlight skin) or brown (in people with dark skin) blotches\\non the skin. It is a major diagnostic marker of AIDS.\\nLatent period— Also called incubation period, the\\ntime between infection with a disease-causing\\nagent and the development of disease.\\nLymphocyte— At y p eo fw h i t eb l o o dc e l lt h a ti si m p o r -\\ntant in the formation of antibodies and that can be used\\nto monitor the health of AIDS patients.\\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, that\\nhelps the body fight off infections by ingesting the\\ndisease-causing 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.\\nMycobacterium avium (MAC) infection— A type\\nof opportunistic infection that occurs in about 40%\\nof AIDS patients and is regarded as an AIDS-defining\\ndisease.\\nNon-nucleoside reverse transcriptase inhibitors—\\nThe newest class of antiretroviral drugs that work\\nby inhibiting the reverse transcriptase enzyme\\nnecessary 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 organisms\\nthat usually don’t cause infection in people whose\\nimmune systems are working normally.\\nPersistent generalized lymphadenopathy (PGL)— A\\ncondition in which HIV continues to produce\\nchronic painless swellings in the lymph nodes during\\nthe latency period.\\nPneumocystis carinii pneumonia (PCP)— An\\nopportunistic infection caused by a fungus that is a\\nmajor cause of death in patients with late-stage\\nAIDS.\\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 the\\nreplication 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 replicate\\nwithin new host cells.\\nT cells— Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s response\\nto infections, including HIV. CD4 lymphocytes are a\\nsubset of T lymphocytes.\\nThrush— A yeast infection of the mouth character-\\nized by white patches on the inside of the mouth and\\ncheeks.\\nViremia— The measurable presence of virus in the\\nbloodstream that is a characteristic of acute retroviral\\nsyndrome.\\nWasting syndrome— A progressive loss of weight\\nand muscle tissue caused by the AIDS virus.\\n84 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='immune system cell, called a macrophage, begins to\\nrelease a toxin that 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\\ndescribe a group of symptoms that can resemble\\nmononucleosis and that may be the first sign of HIV\\ninfection in 50-70% of all patients and 45-90% of\\nwomen. Most patients are not recognized as infected\\nduring this phase and may not seek medical attention.\\nThe symptoms may include fever, fatigue, muscle\\naches, loss of appetite, digestive disturbances, weight\\nloss, skin rashes, headache, and chronically swollen\\nlymph nodes (lymphadenopathy). Approximately 25-\\n33% of patients will experience a form ofmeningitis\\nduring this phase in which the membranes that cover\\nthe brain and spinal cord become inflamed. Acute\\nretroviral syndrome develops between one and six\\nweeks after infection and lasts for two to three\\nweeks. Blood tests during this period will indicate the\\npresence 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\\nlatency, the virus continues to replicate in the lymph\\nnodes, where it may cause one or more of the following\\nconditions:\\nPERSISTENT GENERALIZED LYMPHADENOPATHY\\n(PGL). Persistent generalized lymphadenopathy, or\\nPGL, is a condition in which HIV continues to pro-\\nduce chronic painless swellings in the lymph nodes\\nduring the latency period. The lymph nodes that are\\nmost frequently affected by PGL are those in the areas\\nof the neck, jaw, groin, and armpits. PGL affects\\nbetween 50-70% of patients during latency.\\nCONSTITUTIONAL SYMPTOMS. Many patients will\\ndevelop low-grade fevers, chronicfatigue, and general\\nweakness. HIV may also cause a combination of food\\nmalabsorption, loss of appetite, and increased meta-\\nbolism that contribute to the so-called AIDS wasting\\nor wasting syndrome.\\nOTHER ORGAN SYSTEMS. At any time during the\\ncourse of HIV infection, patients may suffer from a\\nyeast infection in the mouth called thrush, open sores\\nor ulcers, or other infections of the mouth;diarrhea\\nand other gastrointestinal symptoms that causemal-\\nnutrition and weight loss; diseases of the lungs and\\nkidneys; and degeneration of the nerve fibers in the\\narms and legs. HIV infection of the nervous system\\nleads to general loss of strength, loss of reflexes, and\\nfeelings ofnumbness or burning sensations in the feet\\nor lower legs.\\nLate-stage disease (AIDS)\\nAIDS is usually marked by a very low number of\\nCD4+ lymphocytes, followed by a rise in the fre-\\nquency of opportunistic infections and cancers.\\nDoctors monitor the number and proportion of\\nCD4+ lymphocytes in the patient’s blood in order to\\nassess the progression of the disease and the effective-\\nness of different medications. About 10% of infected\\nindividuals never progress to this overt stage of the\\ndisease and are referred to as nonprogressors.\\nOPPORTUNISTIC INFECTIONS. Once the patient’s\\nCD4+ lymphocyte count falls below 200 cells/mm3,\\nhe or she is at risk for a variety of opportunistic infec-\\ntions. The infectious organisms may include the\\nfollowing:\\n/C15Fungi. The most common fungal disease associated\\nwith AIDS isPneumocystis carinii pneumonia (PCP).\\nPCP is the immediate cause of death in 15-20% of\\nAIDS patients. It is an important measure of a\\npatient’s prognosis. Other fungal infections include\\na yeast infection of the mouth (candidiasis or thrush)\\nand cryptococcal meningitis.\\n/C15Protozoa. Toxoplasmosis is a common opportunistic\\ninfection in AIDS patients that is caused by a proto-\\nzoan. Other diseases in this category include isopor-\\niasis and cryptosporidiosis.\\n/C15Mycobacteria. AIDS patients may developtubercu-\\nlosis or MAC infections. MAC infections are caused\\nby Mycobacterium avium-intracellulare , and occur in\\nabout 40% of AIDS patients. It is rare until CD4+\\ncounts falls below 50 cells/mm\\n3.\\n/C15Bacteria. AIDS patients are likely to develop bacter-\\nial infections of the skin and digestive tract.\\n/C15Viruses. AIDS patients are highly vulnerable to cyto-\\nmegalovirus (CMV), herpes simplex virus (HSV),\\nvaricella zoster virus (VZV), and Epstein-Barr virus\\n(EBV) infections. Another virus, JC virus, causes\\nprogressive destruction of brain tissue in the brain\\nstem, cerebrum, and cerebellum (multifocal leukoen-\\ncephalopathy or PML), which is regarded as an\\nAIDS-defining illness by the Centers for Disease\\nControl and Prevention.\\nGALE ENCYCLOPEDIA OF MEDICINE 85\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='AIDS DEMENTIA COMPLEX AND NEUROLOGIC\\nCOMPLICATIONS. AIDS dementia complex is usually\\na late complication of the disease. It is unclear whether\\nit is caused by the direct effects of the virus on the\\nbrain or by intermediate causes. AIDS dementia com-\\nplex is marked by loss of reasoning ability, loss of\\nmemory, inability to concentrate, apathy and loss of\\ninitiative, and unsteadiness or weakness in walking.\\nSome patients also develop seizures. There are no\\nspecific treatments for AIDS dementia complex.\\nMUSCULOSKELETAL COMPLICATIONS. Patients in\\nlate-stage AIDS may develop inflammations of the\\nmuscles, particularly in the hip area, and may have\\narthritis-like pains in the joints.\\nORAL SYMPTOMS. In addition to thrush and pain-\\nful ulcers in the mouth, patients may develop a condi-\\ntion called hairy leukoplakia of the tongue. This\\ncondition is also regarded by the CDC as an indicator\\nof AIDS. Hairy leukoplakia is a white area of diseased\\ntissue on the tongue that may be flat or slightly raised.\\nIt is caused by the Epstein-Barr virus.\\nAIDS-RELATED CANCERS. Patients with late-stage\\nAIDS may develop Kaposi’s sarcoma (KS), a skin\\ntumor that primarily affects homosexual men. KS is\\nthe most common AIDS-related malignancy. It is\\ncharacterized by reddish-purple blotches or patches\\n(brownish in African-Americans) on the skin or in\\nthe mouth. About 40% of patients with KS develop\\nsymptoms in the digestive tract or lungs. KS may be\\ncaused by a herpes virus-like sexually transmitted dis-\\nease agent rather than HIV.\\nThe second most common form ofcancer in AIDS\\npatients is a tumor of the lymphatic system (lym-\\nphoma). AIDS-related lymphomas often affect the\\ncentral nervous system and develop very aggressively.\\nInvasive cancer of the cervix (related to certain\\ntypes of human papilloma virus [HPV]) is an impor-\\ntant diagnostic marker of AIDS in women.\\nWhile incidence of AIDS-defining cancers such as\\nKaposi’s sarcoma andcervical cancerhave decreased\\nsince increase use of antiretroviral therapy, other can-\\ncers has increased in AIDS patients. People with HIV\\nhas shown higher incidence of lung cancer, head and\\nneck cancers, Hodgkin’s lymphoma, melanoma, and\\nanorectal cancer from 1992 to 2002.\\nDiagnosis\\nBecause HIV infection produces such a wide\\nrange of symptoms, the CDC has drawn up a list\\nof 34 conditions regarded as defining AIDS. The\\nphysician will use the CDC list to decide whether the\\npatient falls into one of these three groups:\\n/C15definitive diagnoses with or without laboratory evi-\\ndence of HIV infection\\n/C15definitive diagnoses with laboratory evidence of HIV\\ninfection\\n/C15presumptive diagnoses with laboratory evidence of\\nHIV infection.\\nPhysical findings\\nAlmost all the symptoms of AIDS can occur with\\nother diseases. The generalphysical examinationmay\\nrange from normal findings to symptoms that are\\nclosely associated with AIDS. These symptoms are\\nhairy leukoplakia of the tongue and Kaposi’s sar-\\ncoma. When the doctor examines the patient, he or\\nshe will look for the overall pattern of symptoms\\nrather than any one finding.\\nLaboratory tests for HIV infection\\nBLOOD TESTS (SEROLOGY). The first blood test\\nfor AIDS was developed in 1985. At present, patients\\nwho are being tested for HIV infection are usually\\ngiven an enzyme-linked immunosorbent assay\\n(ELISA) test for the presence of HIV antibody in\\ntheir blood. Positive ELISA results are then tested\\nwith a Western blot or immunofluorescence (IFA)\\nassay for confirmation. The combination of the\\nELISA and Western blot tests is more than 99.9%\\naccurate in detecting HIV infection within four to\\neight weeks following exposure. The polymerase\\nchain reaction (PCR) test can be used to detect the\\npresence of viral nucleic acids in the very small number\\nof HIV patients who have false-negative results on the\\nELISA and Western blot tests. These tests are also\\nused to detect viruses and bacterium other than HIV\\nand AIDS.\\nOTHER LABORATORY TESTS. In addition to diag-\\nnostic blood tests, there are other blood tests that are\\nused to track the course of AIDS in patients that have\\nalready been diagnosed. These include blood counts,\\nviral load tests, p24 antigen assays, and measurements\\nof /C12\\n2-microglobulin (/C122M).\\nDoctors will use a wide variety of tests to diagnose\\nthe presence of opportunistic infections, cancers, or\\nother disease conditions in AIDS patients. Tissue\\nbiopsies, samples of cerebrospinal fluid, and sophisti-\\ncated imaging techniques, such as magnetic resonance\\nimaging (MRI) and computed tomography scans (CT)\\nare used to diagnose AIDS-related cancers, some\\nopportunistic infections, damage to the central\\n86 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='nervous system, and wasting of the muscles. Urine and\\nstool samples are used to diagnose infections caused\\nby parasites. AIDS patients are also given blood tests\\nfor syphilis and othersexually transmitted diseases.\\nDiagnosis in children\\nDiagnostic blood testing in children older than 18\\nmonths is similar to adult testing, with ELISA screen-\\ning confirmed by Western blot. Younger infants can\\nbe diagnosed by direct culture of the HIV virus, PCR\\ntesting, and p24 antigen testing.\\nIn terms of symptoms, children are less likely than\\nadults to have an early acute syndrome. They are,\\nhowever, likely to have delayed growth, a history of\\nfrequent illness, recurrent ear infections, a low blood\\ncell count, failure to gain weight, and unexplained\\nfevers. Children with AIDS are more likely to develop\\nbacterial infections, inflammation of the lungs, and\\nAIDS-related brain disorders than are HIV-positive\\nadults.\\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\\ndiseases. This treatment is often complicated by the\\ndevelopment of resistance in the disease organisms.\\nAIDS-related malignancies in the central nervous sys-\\ntem are usually treated with radiation therapy.\\nCancers elsewhere in the body are treated with\\nchemotherapy.\\nPROPHYLACTIC TREATMENT FOR OPPORTUNISTIC\\nINFECTIONS. Prophylactic treatment is treatment that\\nis given to prevent disease. AIDS patients with a his-\\ntory ofPneumocystis pneumonia; with CD4+ counts\\nbelow 200 cells/mm\\n3 or 14% of lymphocytes; weight\\nloss; or thrush should be given prophylactic medica-\\ntions. The three drugs given are trimethoprim-\\nsulfamethoxazole, dapsone, or pentamidine in aerosol\\nform.\\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 four classes:\\n/C15Nucleotide analogues. These drugs work by interfer-\\ning with the action of HIV reverse transcriptase\\ninside infected cells, thus ending the virus’ replication\\nprocess. These drugs include zidovudine (sometimes\\ncalled azidothymidine or AZT), didanosine (ddI),\\nzalcitabine (ddC), stavudine (d4T), lamivudine\\n(3TC), and abacavir (ABC).\\n/C15Protease inhibitors. Protease inhibitors can be effec-\\ntive against HIV strains that have developed resis-\\ntance to nucleoside analogues, and are often used in\\ncombination with them. These compounds include\\nsaquinavir, ritonavir, indinavir, nelfinavir, amprena-\\nvir, and lopinavir..\\n/C15Non-nucleoside reverse transcriptase inhibitors. This\\nis a new class of antiretroviral agents. Three are\\navailable, nevirapine, which was approved first, dela-\\nvirdine and efavirin.\\n/C15Fusion inhibitors, the newest class of antiretrovirals.\\nThey block specific proteins on the surface of the\\nvirus or the CD4 cell. These proteins help the virus\\ngain entry into the cell.The only FDA approved\\nfusion inhibitor as of spring 2004 was enfuvirtide.\\nTreatment guidelines for these agents are in con-\\nstant change as new medications are developed and\\nintroduced. Two principles currently guide doctors in\\nworking out drug regimens for AIDS patients: using\\ncombinations of drugs rather than one medication\\nalone; and basing treatment decisions on the results\\nof the patient’s viral load tests.\\nSTIMULATION OF BLOOD CELL PRODUCTION.\\nBecause many patients with AIDS suffer from abnor-\\nmally low levels of both red and white blood cells,\\nthey may be given medications to stimulate blood cell\\nproduction. Epoetin alfa (erythropoietin) may be\\ngiven to anemic patients. Patients with low white\\nblood cell counts may be given filgrastim or\\nsargramostim.\\nTreatment in women\\nTreatment of pregnant women with HIV is parti-\\ncularly important in that anti-retroviral therapy\\nhas been shown to reduce transmission to the infant\\nby 65%.\\nAlternative treatment\\nAlternative treatments for AIDS can be grouped\\ninto two categories: those intended to help the immune\\nsystem and those aimed atpain control. Treatments\\nthat may enhance the function of the immune system\\ninclude Chinese herbal medicine and western herbal\\nmedicine, macrobiotic and other specialdiets, guided\\nimagery and creative visualization, homeopathy, and\\nvitamin therapy. Pain control therapies includehydro-\\ntherapy, reiki, acupuncture, meditation, chiropractic\\ntreatments, and therapeutic massage. Alternative\\nGALE ENCYCLOPEDIA OF MEDICINE 87\\nAIDS'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='therapies can also be used to help with side effects of\\nthe medications used in the 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 expen-\\nsive medications and who tolerate them adequately.\\nThe use of these multi-drug therapies has signifi-\\ncantly reduced the numbers of deaths, in this country,\\nresulting from AIDS. The data is still inconclusive,\\nbut the potential exists to possibly prolong life\\nindefinitely using these and other drug therapies to\\nboost the immune system, keep the virus from repli-\\ncating, and ward off opportunistic infections and\\nmalignancies.\\nPrognosis after the latency period depends on the\\npatient’s specific symptoms and the organ systems\\naffected by the disease. Patients with AIDS-related\\nlymphomas of the central nervous system die within\\ntwo to three months of diagnosis; those with systemic\\nlymphomas may survive for eight to ten months.\\nPrevention\\nAs of 2005, there was no vaccine effective against\\nAIDS. Several vaccines are currently being investi-\\ngated, however, both to prevent initial HIV infection\\nand as a therapeutic treatment to prevent HIV from\\nprogressing to full-blown AIDS.\\nIn the meantime, there are many things that can\\nbe done to prevent the spread of AIDS:\\n/C15Being monogamous and practice safe sex.\\nIndividuals must be instructed in the proper use of\\ncondoms and urged to practice safe sex. Besides\\navoiding the risk of HIV infection, condoms are\\nsuccessful in preventing other sexually transmitted\\ndiseases and unwanted pregnancies. Before engaging\\nin a sexual relationship with someone, getting tested\\nfor HIV infection is recommended.\\n/C15Avoiding needle sharing among intravenous drug\\nusers.\\n/C15Although blood and blood products are carefully\\nmonitored, those individuals who are planning to\\nundergo major surgery may wish to donate blood\\nahead of time to prevent a risk of infection from a\\nblood transfusion.\\n/C15Healthcare professionals must take all necessary pre-\\ncautions by wearing gloves and masks when hand-\\nling body fluids and preventing needle-stick injuries.\\n/C15If someone suspects HIV infection, he or she\\nshould be tested for HIV. If treated aggressively\\nand early, the development of AIDS may be post-\\nponed indefinitely. If HIV infection is confirmed, it\\nis also vital to let sexual partners know so that they\\ncan be tested and, if necessary, receive medical\\nattention.\\nResources\\nPERIODICALS\\nBoschert, Sherry. ‘‘Some Ca Increasing in Post-HAART\\nEra.’’ Clinical Psychiatry News June 2004: 75.\\nGodwin, Catherine. ‘‘WhatÆs New in the Fight Against\\nAIDS.’’ RN April 2004: 46–54.\\nORGANIZATIONS\\nGay Men’s Health Crisis, Inc., 129 West 20th Street, New\\nYork, NY 10011-0022. (212) 807-6655.\\nNational AIDS Hot Line. (800) 342-AIDS (English). (800)\\n344-SIDA (Spanish). (800) AIDS-TTY (hearing-\\nimpaired).\\nOTHER\\n‘‘FDA Approved Drugs for HIV Infection and AIDS-\\nRelatedConditions.’’HIV/AIDS Treatment Information\\nService website. January 2001..\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAIDS serology see AIDS tests\\nAIDS tests\\nDefinition\\nAIDS tests, short for acquiredimmunodeficiency\\nsyndrome tests, cover a number of different proce-\\ndures used in the diagnosis and treatment of HIV\\npatients. These tests sometimes are called AIDS\\nserology tests. Serology is the branch of immunology\\nthat deals with the contents and characteristics of\\nblood serum. Serum is the clear light yellow part\\nof blood that remains liquid when blood cells form\\na clot. AIDS serology evaluates the presence of\\nhuman immunodeficiency virus (HIV) infection in\\nblood serum and its effects on each patient’s immune\\nsystem.\\nPurpose\\nAIDS serology serves several different purposes.\\nSome AIDS tests are used to diagnose patients or\\n88 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='confirm a diagnosis; others are used to measure the\\nprogression of the disease or the effectiveness of spe-\\ncific treatment regimens. Some AIDS tests also can be\\nused to screen blood donations for safe use in\\ntransfusions.\\nIn order to understand the different purposes\\nof the blood tests used with AIDS patients, it is help-\\nful to understand how HIV infection affects human\\nblood and the immune system. HIV is a retrovirus that\\nenters the blood stream of a new host in the following\\nways:\\n/C15by sexual contact\\n/C15by contact with infected body fluids (such as blood\\nand urine)\\n/C15by transmission duringpregnancy,o r\\n/C15through transfusion of infected blood products\\nA retrovirus is a virus that contains a unique\\nenzyme called reverse transcriptase that allows it to\\nreplicate within new host cells. The virus binds to a\\nprotein called CD4, which is found on the surface of\\ncertain subtypes of white blood cells, including helper\\nT cells, macrophages, and monocytes. Once HIV\\nenters the cell, it can replicate and kill the cell in\\nways that are still not completely understood. In addi-\\ntion to killing some lymphocytes directly, the AIDS\\nvirus disrupts the functioning of the remaining CD4\\ncells. CD4 cells ordinarily produce a substance called\\ninterleukin-2 (IL-2), which stimulates other cells\\n(T cells and B cells) in the human immune system\\nto respond to infections. Without the IL-2, T cells do\\nnot reproduce as they normally would in response to the\\nHIV virus, and B cells are not stimulated to respond\\nto 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 avoid being pricked by\\nthe needle used in drawing blood for the tests. It may\\nbe difficult to get blood from a habitual intravenous\\ndrug user due to collapsed veins.\\nDescription\\nDiagnostic tests\\nDiagnostic blood tests for AIDS usually are given\\nto persons in high-risk populations who may have\\nbeen exposed to HIV or who have the early symptoms\\nof AIDS. Most persons infected with HIV will develop\\na detectable level of antibody within three months of\\ninfection. The condition of testing positive for HIV\\nantibody in the blood is called seroconversion, and\\npersons who have become HIV-positive are called\\nseroconverters.\\nIt is possible to diagnose HIV infection by isolat-\\ning the virus itself from a blood sample or by demon-\\nstrating the presence of HIV antigen in the blood.\\nViral culture, however, is expensive, not widely avail-\\nable, and slow—it takes 28 days to complete the viral\\nculture test. More common are blood tests that work\\nby detecting the presence of antibodies to the HIV\\nvirus. These tests are inexpensive, widely available,\\nand accurate in detecting 99.9% of AIDS infections\\nwhen used in combination to screen patients and\\nconfirm diagnoses.\\nENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA).\\nThis type of blood test is used to screen blood for\\ntransfusions as well as diagnose patients. An ELISA\\ntest for HIV works by attaching HIV antigens to a\\nplastic well or beads. A sample of the patient’s blood\\nserum is added, and excess proteins are removed.\\nA second antibody coupled to an enzyme is added,\\nfollowed by addition of a substance that will cause\\nthe enzyme to react by forming a color. An instru-\\nment called a spectrophotometer can measure the\\ncolor. The name of the test is derived from the use\\nof the enzyme that is coupled or linked to the second\\nantibody.\\nA three-dimensional model of the HIV virus. (Corbis\\nCorporation (New York). Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 89\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='KEY TERMS\\nAntibody— A protein in the blood that identifies and\\nhelps 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 bone\\nmarrow. B cells are sometimes called B lympho-\\ncytes. They secrete antibody and have a number of\\nother complex functions within the human immune\\nsystem.\\nCD4— A type of protein molecule in human blood\\nthat is present on the surface of 65% of human\\nT cells. CD4 is a receptor for the HIV virus. When\\nthe HIV 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+ lymphocytes.\\nCD4 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 dis-\\ntribution width, the hematocrit (ratio of the volume\\nof the red blood cells to the blood volume), and the\\namount of hemoglobin (the blood protein that carries\\noxygen). CBCs are a routine blood test used for many\\nmedical reasons, not only for AIDS patients. They\\ncan help the doctor determine if a patient is in\\nadvanced 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 added,\\nand excess proteins are removed. A second antibody\\ncoupled to an enzyme is added, followed by a che-\\nmical that will cause a color reaction that can be\\nmeasured 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\\ncauses most cases of AIDS in Europe, North and\\nSouth America, and most parts of Africa; and\\nHIV-2, which is chiefly found in West African\\npatients. HIV-2, discovered in 1986, appears to be\\nless virulent than HIV-1, but also may have a longer\\nlatency period.\\nImmunofluorescent assay (IFA)— A blood test some-\\ntimes used to confirm ELISA results instead of using\\nthe Western blotting. In an IFA test, HIV antigen is\\nmixed with a fluorescent compound and then with a\\nsample of the patient’s blood. If HIV antibody is\\npresent, the mixture will fluoresce when examined\\nunder ultraviolet light.\\nLymphocyte— A type of white blood cell that is\\nimportant in the formation of antibodies. Doctors\\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, that\\nhelps the body fight off infections by ingesting the\\ndisease 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 develops\\nonly when a person’s immune system is weakened,\\nas 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 loca-\\ntion, using DNA polymerase to make a copy, and\\nthen continuously replicating the copies. The ampli-\\nfication of gene sequences that are associated with\\nHIV allows for detection of the virus by this method.\\nRetrovirus— A virus that contains a unique enzyme\\ncalled reverse transcriptase that allows it to replicate\\nwithin 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 liquid\\nwhen blood cells form a clot. Human blood serum is\\nclear light yellow in color.\\n90 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The latest generation of ELISA tests are 99.5%\\nsensitive to HIV. Occasionally, the ELISA test will be\\npositive for a patient without symptoms of AIDS from\\na low-risk group. Because this result is likely to be a\\nfalse-positive, the ELISA must be repeatedon the same\\nsample of the patient’s blood . If the second ELISA is\\npositive, the result should be confirmed by the\\nWestern 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 test-\\ning, HIV antigen is purified by electrophoresis (large\\nprotein molecules are suspended in a gel and separated\\nfrom one another by running an electric current\\nthrough the gel). The HIV antigens are attached by\\nblotting to a nylon or nitrocellulose filter. The\\npatient’s serum is reacted against the filter, followed\\nby treatment with developing chemicals that allow\\nHIV antibody to show up as a colored patch or blot.\\nA commercially produced Western blot test for HIV-1\\nis now available. It consists of a prefabricated\\nstrip that is incubated with a sample of the patient’s\\nblood serum and the developing chemicals. About\\nnine different HIV-1 proteins can be detected in\\nthe 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\\nmixing HIV antigen with a fluorescent chemical, add-\\ning the blood sample, and observing the reaction\\nunder a microscope with ultraviolet light.\\nPOLYMERASE CHAIN REACTION (PCR). This test is\\nused to evaluate the very small number of AIDS\\npatients with false-negative ELISA and Western blot\\ntests. These patients are sometimes called antibody-\\nnegative asymptomatic (without symptoms) carriers,\\nbecause they do not have any symptoms of AIDS and\\nthere is no detectable quantity of antibody in the blood\\nserum. Antibody-negative asymptomatic carriers may\\nbe responsible for the very low ongoing risk of HIV\\ninfection transmitted by blood transfusions. It is esti-\\nmated that the risk is between 1 in 10,000 and 1 in\\n100,000 units of transfused blood.\\nThe polymerase chain reaction (PCR) test can\\nmeasure the presence of viral nucleic acids in the\\npatient’s blood even when there is no detectable anti-\\nbody to HIV. This test works by amplifying the pre-\\nsence of HIV nucleic acids in a blood sample.\\nNumerous copies of a gene are made by separating\\nthe two strands of DNA containing the gene segment,\\nmarking its location, using DNA polymerase to make\\na copy, and then continuously replicating the copies. It\\nis questionable whether PCR will replace Western\\nblotting as the method of confirming AIDS diagnoses.\\nAlthough PCR can detect the low number of persons\\n(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.\\nIn addition, PCR testing is based on present knowl-\\nedge of the genetic sequences in HIV. Since the virus\\nis continually generating new variants, PCR testing\\ncould yield a false negative in patients with these\\nnew variants. In 2004, researchers reported on a new\\ntest that was more sensitive to HIV, detecting the\\ninfection in as little as 12 days after infection.\\nHowever, the manufacturer was still seeking FDA\\napproval for the test, which would cost about the\\nsame as PCR testing.\\nT cells— Lymphocytes that originate in the thymus\\ngland. T cells regulate the immune system’s response\\nto infections, including HIV. CD4 lymphocytes are a\\nsubset 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 pur-\\nified 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 result\\nis 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\\nnumber of each type. A WBC differential is neces-\\nsary to calculate the absolute CD4+ lymphocyte\\ncount.\\nGALE ENCYCLOPEDIA OF MEDICINE 91\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In 1999, the U.S. Food and Drug Administration\\n(FDA) approved an HIV home testing kit. The kit\\ncontained multiple components, including material\\nfor specimen collection, a mailing envelope to send\\nthe specimen to a laboratory for analysis, and provides\\npre- and post-test counseling. It uses a finger prick\\nprocess for blood collection. Other tests have been in\\ndevelopment that would allow patients to monitor\\ntheir own therapy in the home without sending out\\nfor results.\\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\\npersons may be infected with the virus for 10 years or\\nlonger before they develop symptoms of AIDS. These\\npatients are sometimes called antibody-positive\\nasymptomatic carriers. Prognostic tests also help\\ndrug researchers evaluate the usefulness of new medi-\\ncations in treating AIDS.\\nBLOOD CELL COUNTS. Doctors can measure the\\nnumber or proportion of certain types of cells in an\\nAIDS patient’s blood to see whether and how rapidly\\nthe disease is progressing, or whether certain treat-\\nments are helping the patient. These cell count tests\\ninclude:\\n/C15Complete blood count (CBC). A CBC is a routine\\nanalysis performed on a sample of blood taken\\nfrom the patient’s vein with a needle and vacuum\\ntube. The measurements taken in a CBC include a\\nwhite blood cell count (WBC), a red blood cell count\\n(RBC), the red cell distribution width, thehematocrit\\n(ratio of the volume of the red blood cells to the\\nblood volume), and the amount of hemoglobin (the\\nblood protein that carries oxygen). Although CBCs\\nare 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\\nsigns in a CBC include a low hematocrit, a sharp\\ndecrease in the number of blood platelets, and a\\nlow level of a certain type of white blood cell called\\nneutrophils.\\n/C15Absolute CD4+ lymphocytes. A lymphocyte is a\\ntype of white blood cell that is important in the\\nformation of an immune response. Because HIV\\ntargets CD4+ lymphocytes, their number in the\\npatient’s blood can be used to track the course of\\nthe infection. This blood cell count is considered the\\nmost accurate indicator for the presence of an oppor-\\ntunistic infection in an AIDS patient. The absolute\\nCD4+ lymphocyte count is obtained by multiplying\\nthe patient’s white blood cell count (WBC) by the\\npercentage of lymphocytes among the white blood\\ncells, and multiplying the result by the percentage\\nof lymphocytes bearing the CD4+ marker. An abso-\\nlute count below 200-300 CD+4 lymphocytes\\nin 1 cubic millimeter (mm\\n3) of blood indicates that\\nthe patient is vulnerable to some opportunistic\\ninfections.\\n/C15CD4+ lymphocyte percentage. Some doctors think\\nthat this is a more accurate test than the absolute\\ncount because the percentage does not depend on a\\nmanual calculation of the number of types of differ-\\nent white blood cells. A white blood cell count that is\\nbroken down into categories in this way is called a\\nWBC differential.\\nIt is important for doctors treating AIDS patients\\nto measure 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/C15CD4+ count more than 600 cells/mm3: Every six\\nmonths.\\n/C15CD4+ count between 200-600 cells/mm3: Every\\nthree months.\\n/C15CD4+ count less than 200 cells/mm3: Every three\\nmonths.\\nWhen the CD4+ count falls below 200 cells/mm3,\\nthe doctor will put the patient on a medication regi-\\nmen to protect him or her against opportunistic\\ninfections.\\nHIV VIRAL LOAD TESTS. Another type of blood test\\nfor monitoring AIDS patients is the viral load test. It\\nsupplements the CD4+ count, which can tell the doc-\\ntor the extent of the patient’s loss of immune function,\\nbut not the speed of HIV replication in the body. The\\nviral load test is based on PCR techniques and can\\nmeasure the number of copies of HIV nucleic acids.\\nSuccessive test results for a given patient’s viral load\\nare calculated on a base 10 logarithmic scale.\\nORAL HIV TESTS. Scientists have developed oral\\nHIV tests that can be conducted with saliva samples.\\nOne of the unintented effects of these tests is the\\nmisperception that HIV can be transmitted through\\nsaliva. Still, they present an excellent alternative to\\nblood sample testing.\\nRAPID HIV TESTS. Researchers constantly work on\\nmore rapid tests for HIV that can be done in physician\\noffices or by less skilled people and more convenient\\nlocations in developing countries. A finger-stick test\\nthat can be read quickly from a whole blood sample\\nhad shown promising results in the fall of 2003.\\n92 GALE ENCYCLOPEDIA OF MEDICINE\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Another test, called the VScan test kit, requires no\\nrefrigeration or electricity and can safely be stored at\\nroom temperature. Even if the positive results must be\\nconfirmed by ELISA or Western blotting, an accurate\\ninitial rapid test can help screen populations for HIV\\nantibodies.\\nIn 2004, a new three-minute test for HIV was\\nlunched in the United States under FDA approval.\\nThe hope of this test is that health care providers\\nsuch as family practice physician offices can quickly\\ntest a patient in the office and provide results while the\\npatient waits, rather than sending results to a lab.\\nBETA2-MICROGLOBULIN (BETA 2M). Beta-microglo-\\nbulin is a protein found on the surface of all human\\ncells with a nucleus. It is released into the blood when a\\ncell dies. Although rising blood levels of/C12\\n2M are found\\nin patients withcancer and other serious diseases, a\\nrising /C122M blood level can be used to measure the\\nprogression of 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\\nin detecting HIV infection before seroconversion.\\nHowever, p24 is consistently present in only 25% of\\npersons infected with HIV.\\nGENOTYPIC DRUG RESISTANCE TEST. Genotypic\\ntesting can help determine whether specific gene\\nmutations, common in people with HIV, are causing\\ndrug resistance and drug failure. The test looks for\\nspecific genetic mutations within the virus that are\\nknown to cause resistance to certain drugs used in\\nHIV treatment. For example the drug 3TC, also\\nknown as lamivudine (Epivir), is not effective against\\nstrains of HIV that have a mutation at a particular\\nposition on the reverse transcriptase protein—amino\\nacid 184—known as M184V (M!V, methionine to\\nvaline). So if the genotypic resistance test shows a\\nmutation at position M184V, it is likely the person\\nis resistant to 3TC and not likely to respond to 3TC\\ntreatment. Genotypic tests are only effective if the\\nperson is already taking antiviral medication and if\\nthe viral load is greater than 1,000 copies per milliliter\\n(mL) of blood. The cost of the test, usually between\\n$300 and $500, is usually now covered by many insur-\\nance plans.\\nPHENOTYPIC DRUG RESISTANCE TESTING.\\nPhenotypic testing directly measures the sensitivity of\\na patient’s HIV to particular drugs and drug combina-\\ntions. To do this, it measures the concentration of a\\ndrug required to inhibit viral replication in the test\\ntube. This is the same method used by researchers to\\ndetermine whether a drug might be effective against\\nHIV before using it in human clinical trials.\\nPhenotypic testing is a more direct measurement of\\nresistance than genotypic testing. Also, unlike genoty-\\npic testing, phenotypic testing does not require a high\\nviral load but it is recommended that persons already\\nbe takingantiretroviral drugs. The cost is between $700\\nand $900 and is now covered by many insurance plans.\\nAIDS serology in children\\nChildren born to HIV-infected mothers may\\nacquire the infection through the mother’s placenta\\nor during the birth process. Public health experts\\nrecommend the testing and monitoring of all children\\nborn to mothers with HIV. Diagnostic testing in chil-\\ndren older than 18 months is similar to adult testing,\\nwith ELISA screening confirmed by Western blot.\\nYounger infants can be diagnosed by direct culture\\nof the HIV virus, PCR testing, and p24 antigen testing.\\nThese techniques allow a pediatrician to identify 50%\\nof infected children at or near birth, and 95% of cases\\nin infants three to six months of age.\\nPreparation\\nPreparation and aftercare are important parts of\\nAIDS diagnostic testing. Doctors are now advised to\\ntake the patient’s emotional, social, economic, and\\nother circumstances into account and to provide coun-\\nseling before and after testing. Patients are generally\\nbetter able to cope with the results if the doctor has\\nspent some time with them before the blood test\\nexplaining the basic facts about HIV infection and\\ntesting. Many doctors now offer this type of informa-\\ntional counseling before performing the tests.\\nAftercare\\nIf the test results indicate that the patient is HIV-\\npositive, he or she will need counseling, information,\\nreferral for treatment, and support. Doctors can either\\ncounsel the patient themselves or invite an experienced\\nHIV counselor to discuss the results of the blood tests\\nwith the patient. They also will assess the patient’s\\nemotional and psychological status, including the pos-\\nsibility of violent behavior and the availability of a\\nsupport network.\\nRisks\\nThe risks of AIDS testing are primarily related to\\ndisclosure of the patient’s HIV status rather than to\\nany physical risks connected with blood testing. Some\\nGALE ENCYCLOPEDIA OF MEDICINE 93\\nAIDS tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='patients are better prepared to cope with a positive\\ndiagnosis than others, depending on their age, sex,\\nhealth, resources, belief system, and similar factors.\\nNormal results\\nNormal results for ELISA, Western blot, IFA,\\nand PCR testing are negative for HIV antibody.\\nNormal results for blood cell counts:\\n/C15WBC differential: Total lymphocytes 24-44% of the\\nwhite blood cells.\\n/C15Hematocrit: 40-54% in men; 37-47% in women.\\n/C15T cell lymphocytes: 644-2200/mm3, 60-88% of all\\nlymphocytes.\\n/C15B cell lymphocytes: 82-392/mm 3, 3-20% of all\\nlymphocytes.\\n/C15CD4+ lymphocytes: 500-1200/mm3, 34-67% of all\\nlymphocytes.\\nAbnormal results\\nThe following results in AIDS tests indicate pro-\\ngression of the disease:\\n/C15Percentage of CD4+ lymphocytes: less than 20% of\\nall lymphocytes.\\n/C15CD4+ lymphocyte count: less than 200 cells/mm3.\\n/C15Viral load test: Levels more than 5000 copies/mL.\\n/C15/C12:-2-microglobulin: Levels more than 3.5 mg/dL.\\n/C15P24 antigen: Measurable amounts in blood serum.\\nResources\\nBOOKS\\nBennett, Rebecca, and Erin, Charles A., editors.HIV and\\nAIDS Testing, Screening, and Confidentiality: Ethics,\\nLaw, and Social Policy. Oxford, England: Oxford\\nUniversity Press, 2001.\\nPERIODICALS\\n‘‘Finger-stick Test is Accurate and Acceptable to Women in\\nThailand.’’ Drug Week (September 5, 2003): 168.\\nKaplan, Edward H., and Glen A. Satten. ‘‘Repeat Screening\\nfor HIV: When to Test and Why.’’The Journal of the\\nAmerican Medical Association.\\nMedical Devices & Surgical Technology Week (September\\n12, 2004): 102.\\n‘‘Researcher Developing Home Test Kit for HIV\\nTherapies.’’ Medical Devices & Surgical Technology\\nWeek (December 23, 2001): 2.\\n‘‘Researchers Report New Ultra-sensitive AIDS Test.’’\\nBiotech Week (July 14, 2004): 246.\\nWeinhardt, Lance S., et al. ‘‘Human Immunodeficiency\\nVirus Testing and Behavior Change.’’Archives of\\nInternal Medicine (May 22, 2000): 1538.\\nKen R. Wells\\nTeresa G. Odle\\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 asliver function\\ntests (or LFTs) and is used to monitor damage to the\\nliver.\\nPurpose\\nALT levels are used to detect liver abnormalities.\\nSince the alanine aminotransferase enzyme is also\\nfound in muscle, tests indicating elevated AST levels\\nmight also indicate muscle damage. However, other\\ntests, such as the levels of the MB fraction of creatine\\nkinase should indicate whether the abnormal test\\nlevels are because of muscle or liver damage.\\nDescription\\nThe alanine aminotransferase test (ALT) can\\nreveal liver damage. It is probably the most specific\\ntest for liver damage. However, the severity of the liver\\ndamage is not necessarily shown by the ALT test, since\\nthe amount of dead liver tissue does not correspond to\\nhigher ALT levels. Also, patients with normal, or\\ndeclining, ALT levels may experience serious liver\\ndamage without an 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\\nmay indicate how much of the liver has been damaged.\\nALT levels, when compared to the levels of a similar\\nenzyme, aspartate aminotransferase (AST), may pro-\\nvide important clues to the nature of the liver disease.\\nFor example, within a certain range of values, a ratio\\nof 2:1 or greater for AST: ALT might indicate that a\\npatient suffers from alcoholic liver disease. Other diag-\\nnostic data may be gleaned from ALT tests to indicate\\nabnormal results.\\n94 GALE ENCYCLOPEDIA OF MEDICINE\\nAlanine aminotransferase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Preparation\\nNo special preparations are necessary for this test.\\nAftercare\\nThis test involves blood being drawn, probably\\nfrom a vein in the patient’s elbow. The patient should\\nkeep the wound from the needle puncture covered\\n(with a bandage) until the bleeding stops. Patients\\nshould report any unusual symptoms to their\\nphysician.\\nNormal results\\nNormal values vary from laboratory to labora-\\ntory, and should be available to your physician at the\\ntime of the test. An informal survey of some labora-\\ntories indicates many laboratories find values from\\napproximately seven to 50 IU/L to be normal.\\nAbnormal results\\nLow levels of ALT (generally below 300 IU/L)\\nmay indicate any kind of liver disease. Levels above\\n1,000 IU/L generally indicate extensive liver damage\\nfrom toxins or drugs, viral hepatitis, or a lack of oxy-\\ngen (usually resulting from very low blood pressure or\\na heart attack). A briefly elevated ALT above 1,000\\nIU/L that resolves in 24-48 hours may indicate a\\nblockage of the bile duct. More moderate levels of\\nALT (300-1,000IU/L) may support a diagnosis of\\nacute or chronic hepatitis.\\nIt is important to note that persons with normal\\nlivers may have slightly elevated levels of ALT. This is\\na normal finding.\\nMichael V. Zuck, PhD\\nAlbers-Scho¨nberg disease see Osteopetroses\\nAlbinism\\nDefinition\\nAlbinism is an inherited condition present at\\nbirth, characterized by a lack of pigment that normally\\ngives color to the skin, hair, and eyes. Many types of\\nalbinism exist, all of which involve lack of pigment in\\nvarying degrees. The condition, which is found in all\\nraces, may be accompanied by eye problems and may\\nlead to skincancer later in life.\\nDescription\\nAlbinism is a rare disorder found in fewer than\\nfive people per 100,000 in the United States and\\nEurope. Other parts of the world have a much higher\\nrate; for example, albinism is found in about 20 out of\\nevery 100,000 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 skin,\\nwhich turn slightly darker as they age. Everyone with\\noculocutaneous albinism experiences abnormal flicker-\\ning eye movements (nystagmus) and sensitivity to bright\\nlight. There may be other eye problems as well, includ-\\ning poor vision and crossed or ‘‘lazy’’ eyes (strabismus).\\nThe second most common type of the condition is\\nknown as ‘‘ocular’’ albinism, in which only the eyes\\nlack color; skin and hair are normal. There are five\\nforms of ocular albinism; some types cause more pro-\\nblems–especially eye problems–than others.\\nCauses and symptoms\\nEvery cell in the body contains a matched pair of\\ngenes, one inherited from each parent. These genes act\\nas a sort of ‘‘blueprint’’ that guides the development of\\na fetus.\\nAlbinism is an inherited problem caused by a flaw\\nin one or more of the genes that are responsible for\\ndirecting the eyes and skin to make melanin (pigment).\\nAs a result, little or no pigment is made, and the child’s\\nskin, eyes and hair may be colorless.\\nIn most types of albinism, a recessive trait, the\\nchild inherits flawed genes for making melanin from\\nboth parents. Because the task of making melanin is\\ncomplex, there are many different types of albinism,\\ninvolving a number of different genes.\\nIt’s also possible to inherit one normal gene and\\none albinism gene. In this case, the one normal gene\\nprovides enough information in its cellular blueprint\\nto make some pigment, and the child will have normal\\nskin and eye color. They ‘‘carry’’ one gene for albin-\\nism. About one in 70 people are albinism carriers, with\\none flawed gene but no symptoms; they have a 50%\\nchance of passing the albinism gene to their child.\\nHowever, if both parents are carriers with one flawed\\ngene each, they have a 1 in 4 chance of passing on both\\ncopies of the flawed gene to the child, who will have\\nalbinism. (There is also a type of ocular albinism that\\nis carried on the X chromosome and occurs almost\\nexclusively in males because they have only one X\\nGALE ENCYCLOPEDIA OF MEDICINE 95\\nAlbinism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='chromosome and, therefore, no other gene for the trait\\nto 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\\nvariety of eye problems, one of the myths about albin-\\nism is that it causes people to have pink or red eyes. In\\nfact, people with albinism can have irises varying from\\nlight gray or blue to brown. (The iris is the colored\\nportion of the eye that controls the size of the pupil,\\nthe opening that lets light into the eye.) If people with\\nalbinism seem to have reddish eyes, it’s because light is\\nbeing reflected from the back of the eye (retina) in\\nmuch the same way as happens when people are\\nphotographed with an electronic flash.\\nPeople with albinism may have one or more of the\\nfollowing eye problems:\\n/C15They may be very far-sighted or near-sighted, and\\nmay have other defects in the curvature of the lens of\\nthe eye (astigmatism) that cause images to appear\\nunfocused.\\n/C15They may have a constant, involuntary movement of\\nthe eyeball called nystagmus.\\n/C15They may have problems in coordinating the eyes in\\nfixing and tracking objects (strabismus), which may\\nlead to an appearance of having ‘‘crossed eyes’’ at\\ntimes. Strabismus may cause some problems with\\ndepth perception, especially at close distances.\\n/C15They may be very sensitive to light (photophobia)\\nbecause their irises allow ‘‘stray’’ light to enter their\\neyes. It’s a common misconception that people with\\nalbinism shouldn’t go out on sunny days, but wear-\\ning sunglasses can make it possible to go outside\\nquite comfortably.\\nA man with albinism stands with his normally pigmented father. (Photograph by Norman Lightfoot, Photo Researchers, Inc.\\nReproduced by permission.)\\n96 GALE ENCYCLOPEDIA OF MEDICINE\\nAlbinism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In addition to the characteristically light skin and\\neye problems, people with a rare form of albinism\\ncalled Hermansky-Pudlak Syndrome (HPS) also\\nhave a greater tendency to have bleeding disorders,\\ninflammation of the large bowel (colitis), lung (pul-\\nmonary) disease, and kidney (renal) problems.\\nDiagnosis\\nIt’s not always easy to diagnose the exact type\\nof albinism a person has; there are two tests avail-\\nable that can identify only two types of the condi-\\ntion. Recently, a blood test has been developed that\\ncan identify carriers of the gene for some types of\\nalbinism; a similar test during amniocentesis can\\ndiagnose some types of albinism in an unborn\\nchild. Achorionic villus samplingtest during the fifth\\nweek of pregnancy may also reveal some types of\\nalbinism.\\nThe specific type of albinism a person has can be\\ndetermined by taking a good family history and exam-\\nining the patient and several close relatives.\\nThe ‘‘hairbulb pigmentation test’’ is used to iden-\\ntify carriers by incubating a piece of the person’s hair\\nin a solution of tyrosine, a substance in food which the\\nbody uses to make melanin. If the hair turns dark, it\\nmeans the hair is making melanin (a ‘‘positive’’ test);\\nlight hair means there is no melanin. This test is the\\nsource of the names of two types of albinism: ‘‘ty-pos’’\\nand ‘‘ty-neg.’’\\nT h et y r o s i n a s et e s ti sm o r ep r e c i s et h a nt h e\\nhairbulb pigmentation test. It measures the rate at\\nwhich hair converts tyrosine into another chemical\\n(DOPA), which is then made into pigment. The hair\\nconverts tyrosine with the help of a substance called\\n‘‘tyrosinase.’’ In some types of albinism, tyrosinase\\ndoesn’t do its job, and melanin production breaks\\ndown.\\nTreatment\\nThere is no treatment that can replace the lack of\\nmelanin that causes the symptoms of albinism.\\nDoctors can only treat, not cure, the eye problems\\nthat often accompany the lack of skin color. Glasses\\nare usually needed and can be tinted to ease pain from\\ntoo much sunlight. There is no cure for involuntary\\neye movements (nystagmus), and treatments for\\nfocusing problems (surgery or contact lenses) are not\\neffective 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\\ncondition.\\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 organ-\\nisms. The entwined double structure allows the\\nchromosomes to be copied exactly during cell\\ndivision.\\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\\none chemical 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\\nin albinism.\\nTyrosine— A protein building block found in a\\nwide variety of foods that is used by the body to\\nmake melanin.\\nTyrosinase— An enzyme in a pigment cell which\\nhelps change tyrosine to DOPA during the process\\nof making melanin.\\nGALE ENCYCLOPEDIA OF MEDICINE 97\\nAlbinism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Patients with albinism should avoid excessive\\nexposure to the sun, especially between 10 a.m. and\\n2 p.m. If exposure can’t be avoided, they should use\\nUVA-UVB sunblocks with an SPF of at least 20.\\nTaking beta- carotene may help provide some skin\\ncolor, although it doesn’t protect against sun\\nexposure.\\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\\nothers. When a member of a normally dark-skinned\\nethnic group has albinism, he or she may face some\\nvery complex 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 albin-\\nism can safely work and play outdoors safely even\\nduring the summer.\\nPrevention\\nGenetic counseling is very important to prevent\\nfurther occurrences of the conditon.\\nResources\\nBOOKS\\nNational Association for the Visually Handicapped.Larry:\\nA Book for Children with Albinism Going to School. New\\nYork: National Association for the Visually\\nHandicapped.\\nORGANIZATIONS\\nAlbinism World Alliance. .\\nAmerican Foundation for the Blind. 15 W. 16th St., New\\nYork, NY 10011. (800) AFB-LIND.\\nHermansky-Pudlak Syndrome Network, Inc. One South\\nRoad, Oyster Bay, NY 11771-1905. (800) 789-9477.\\n.\\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 abuse see Alcoholism\\nAlcohol dependence see Alcoholism\\nAlcohol-related neurologic\\ndisease\\nDefinition\\nAlcohol, or ethanol, is a poison with direct toxic\\neffects on nerve and muscle cells. Depending on\\nwhich nerve and muscle pathways are involved,\\nalcohol can have far-reaching effects on different\\nparts of the brain, peripheral nerves, and muscles,\\nwith symptoms of memory loss, incoordination,\\nseizures, weakness, and sensory deficits. These differ-\\nent effects can be grouped into three main categories:\\n(1) intoxication due to the acute effects of ethanol, (2)\\nwithdrawal syndrome from suddenly stopping drink-\\ning, and (3) disorders related to long-term or chronic\\nalcohol abuse. Alcohol-related neurologic disease\\nincludes Wernicke-Korsakoff disease, alcoholic\\ncerebellar degeneration, alcoholic myopathy, alco-\\nholic neuropathy, alcohol withdrawal syndrome\\nwith seizures anddelirium tremens, andfetal alcohol\\nsyndrome.\\nDescription\\nAcute excess intake of alcohol can cause drunken-\\nness (intoxication) or evendeath, and chronic or long-\\nterm abuse leads to potentially irreversible damage to\\nvirtually any level of the nervous system. Any given\\npatient with long-term alcohol abuse may have no\\nneurologic complications, a single alcohol-related dis-\\nease, or multiple conditions, depending on the genes\\nthey have inherited, how well nourished they are, and\\nother environmental factors, such as exposure to other\\ndrugs or toxins.\\nNeurologic complications of alcohol abuse may also\\nresultfromnutritionaldeficiency,becausealcoholicstend\\nto eat poorly and may become depleted of thiamine or\\nother vitamins important for nervous system function.\\nPersons who are intoxicated are also at higher risk for\\nhead injuryor 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 diseasecomplicat-\\ning alcoholiccirrhosismay causedementia, delirium, and\\nmovement 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\\ncrosses the blood-brain barrier that ordinarily keeps\\n98 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='large molecules from escaping from the blood vessel to\\nthe brain tissue. Drunkenness, or intoxication, may\\noccur at blood ethanol concentrations of as low as\\n50-150 mg per dL in people who don’t drink.\\nSleepiness, stupor,coma, or even death from respira-\\ntory depression and low blood pressure occur at\\nprogressively higher concentrations.\\nAlthough alcohol is broken down by the liver,\\nthe toxic effects from a high dose of alcohol are most\\nlikely a direct result of alcohol itself rather than of its\\nbreakdown products. The fatal dose varies widely\\nbecause people who drink heavily develop a toler-\\nance to the effects of alcohol with repeated use. In\\naddition, alcohol tolerance results in the need for\\nhigher levels of blood alcohol to achieve intoxicating\\neffects, which increases the likelihood that habitual\\ndrinkers will be exposed to high and potentially toxic\\nlevels of ethanol. This is particularly true when binge\\ndrinkers fail to eat, becausefasting decreases the rate\\nof alcohol clearance and causes even higher blood\\nalcohol levels.\\nWhen a chronic alcoholic suddenly stops drink-\\ning, withdrawal of alcohol leads to a syndrome of\\nincreased excitability of the central nervous system,\\ncalled delirium tremens or ‘‘DTs.’’ Symptoms begin\\nsix to eight hours after abstinence, and are most pro-\\nnounced 24-72 hours after abstinence. They include\\nbody shaking (tremulousness), insomnia, agitation,\\nconfusion, hearing voices or seeing images that are\\nnot really there (such as crawling bugs), seizures,\\nrapid heart beat, profuse sweating, high blood pres-\\nsure, and fever. Alcohol-related seizures may also\\noccur without withdrawal, such as during active\\nheavy drinking or after more than a week without\\nalcohol.\\nWernicke-Korsakoff syndrome is caused by\\ndeficiency of the B-vitamin thiamine, and can also\\nbe seen in people who don’t drink but have some\\nother cause of thiamine deficiency, such as chronic\\nvomiting that prevents the absorption of this vitamin.\\nA 2004 study demonstratedthat alcohol-dependent\\npatients admitted to adetoxification facility had con-\\nsumed significantly less thiamine than a comparison\\ngroup of healthy volunteers.Patients with this con-\\ndition have the sudden onset of Wernicke encepha-\\nlopathy; the symptoms include marked confusion,\\ndelirium, disorientation, inattention, memory loss,\\nand drowsiness. Examination reveals abnormalities\\nof eye movement, including jerking of the eyes\\n(nystagmus) and double vision. Problems with bal-\\nance make walking difficult. People may have trouble\\ncoordinating their leg movements, but usually not\\ntheir arms. If thiamine is not given promptly,\\nWernicke encephalopathy may progress to stupor,\\ncoma, 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 (retrogradeamnesia) and unable to\\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\\ncoordination 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 excre-\\ntion of 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\\nsuffer complications (including Wernike-Korsakoff\\nsyndrome) from a deficiency of this vitamin.\\nWernicke-Korsakoff syndrome— A combination of\\nsymptoms, including eye-movement problems, tre-\\nmors, and confusion, that is caused by a lack of the\\nB vitamin thiamine and may be seen in alcoholics.\\nGALE ENCYCLOPEDIA OF MEDICINE 99\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='learn new information (anterograde amnesia). Most\\npatients have very limited insight into their memory\\ndysfunction and have a tendency to make up explana-\\ntions for events they have forgotten (confabulation).\\nSevere alcoholism can cause cerebellar degenera-\\ntion, a slowly progressive condition affecting portions\\nof the brain called the anterior and superior cerebellar\\nvermis, causing a wide-based gait, leg incoordination,\\nand an inability to walk heel-to-toe in tightrope fash-\\nion. The gait disturbance usually develops over several\\nweeks, but may be relatively mild for some time, and\\nthen suddenly worsen after binge drinking or an unre-\\nlated illness.\\nFetal alcohol syndrome occurs in infants born to\\nalcoholic mothers when prenatal exposure to ethanol\\nretards fetal growth and development. Affected\\ninfants often have a distinctive appearance with a\\nthin upper lip, flat nose and mid-face, short stature\\nand small head size. Almost half are mentally\\nretarded, and most others are mildly impaired intellec-\\ntually or have problems with speech, learning, and\\nbehavior. Fetal alcohol syndrome is the leading cause\\nof mental retardationand many physicians warn that\\nthere is no safe level of alcohol for a pregnant mother\\nto consume.\\nAlcoholic myopathy, or weakness secondary to\\nbreakdown of muscle tissue, is also known as alcoholic\\nrhabdomyolysis or alcoholic myoglobinuria. Males\\nare affected by acute (sudden onset) alcoholic myopa-\\nthy four times as often as females. Breakdown of\\nmuscle tissue (myonecrosis), can come on suddenly\\nduring binge drinking or in the first days of alcohol\\nwithdrawal. In its mildest form, this breakdown may\\ncause no noticeable symptoms, but may be detected by\\na temporary elevation in blood levels of an enzyme\\nfound predominantly in muscle, the MM fraction of\\ncreatine kinase.\\nThe severe form of acute alcoholic myopathy is\\nassociated with the sudden onset of musclepain, swel-\\nling, and weakness; a reddish tinge in the urine caused\\nby myoglobin, a breakdown product of muscle\\nexcreted in the urine; and a rapid rise in muscle\\nenzymes in the blood. Symptoms usually worsen over\\nhours to a few days, and then improve over the next\\nweek to 10 days as the patient is withdrawn from\\nalcohol. Muscle symptoms are usually generalized,\\nbut pain and swelling may selectively involve the\\ncalves or other muscle groups. The muscle breakdown\\nof acute alcoholic myopathy may be worsened by\\ncrush injuries, which may occur when people drink\\nso much that they compress a muscle group with\\ntheir body weight for a long time without moving, or\\nby withdrawal seizures with generalized muscle\\nactivity.\\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\\nof acute muscle injury. Muscle atrophy, or decreased\\nbulk, may be striking. The nerves of the extremities\\nmay also begin to break down, a condition known as\\nalcoholic peripheral neuropathy, which can add to the\\nperson’s difficulty in moving.\\nThe way in which alcohol destroys muscle tissue is\\nstill not well understood. Proposed mechanisms\\ninclude muscle membrane changes affecting the trans-\\nport of calcium, potassium, or other minerals;\\nimpaired muscle energy metabolism; and impaired\\nprotein synthesis. Alcohol is metabolized or broken\\ndown primarily by the liver, with a series of chemical\\nreactions in which ethanol is converted to acetate.\\nAcetate is metabolized by skeletal muscle, and alco-\\nhol-related changes in liver function may affect skele-\\ntal muscle metabolism, decreasing the amount of\\nblood sugar available to muscles during prolonged\\nactivity. Because not enough sugar is available to sup-\\nply 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\\ncontribute to muscle weakness and atrophy by injur-\\ning the motor nerves controlling muscle movement,\\nalcoholic neuropathy more commonly affects sensory\\nfibers. Injury to these fibers can causetingling or burn-\\ning pain in the feet, which may be severe enough to\\ninterfere with walking. As the condition worsens, pain\\ndecreases butnumbness increases.\\nDiagnosis\\nThe diagnosis of alcohol-related neurologic dis-\\nease depends largely on finding characteristic symp-\\ntoms and signs in patients who abuse alcohol. Other\\npossible causes should be excluded by the appropriate\\ntests, which may include blood chemistry, thyroid\\nfunction tests, brain MRI (magnetic resonance ima-\\nging) or CT (computed tomography scan), and/or\\ncerebrospinal fluid analysis.\\nAcute alcoholic myopathy can be diagnosed\\nby finding myoglobin in the urine and increased\\n100 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='creatine kinase and other blood enzymes released from\\ninjured muscle. The surgical removal of a small piece\\nof muscle for microscopic analysis (muscle biopsy)\\nshows the scattered breakdown and repair of muscle\\nfibers. Doctors must rule out other acquired causes of\\nmuscle breakdown, which include the abuse of drugs\\nsuch as heroin, cocaine, or amphetamines; trauma\\nwith crush injury; the depletion of phosphate or potas-\\nsium; or an underlying defect in the metabolism of\\ncarbohydrates or lipids. In chronic alcoholic myopa-\\nthy, serum creatine kinase often is normal, and muscle\\nbiopsy shows atrophy, or loss of muscle fibers.\\nElectromyography (EMG) may show features charac-\\nteristic of alcoholic myopathy or neuropathy.\\nTreatment\\nAcute management of alcohol intoxication, delir-\\nium tremens, and withdrawal is primarily supportive,\\nto monitor and treat any cardiovascular orrespiratory\\nfailure that may develop. In delirium tremens, fever\\nand sweating may necessitate treatment of fluid loss\\nand secondary low blood pressure. Agitation may be\\ntreated withbenzodiazepines such as chlordiazepoxide,\\nbeta-adrenergic antagonists such as atenolol, or alpha\\n2-adrenergic agonists such as clonidine. Because\\nWernicke’s syndrome is rapidly reversible with thia-\\nmine, and because death may intervene if thiamine is\\nnot given promptly, all patients admitted for acute\\ncomplications of alcohol, as well as all patients with\\nunexplained encephalopathy, should be given intrave-\\nnous thiamine.\\nWithdrawal seizures typically resolve without\\nspecific anti-epileptic drug treatment, although status\\nepilepticus (continual seizures occurring without inter-\\nruption) should be treated vigorously. Acute alcoholic\\nmyopathy with myoglobinuria requires monitoring\\nand maintenance of kidney function, and correction\\nof imbalances in blood chemistry including potassium,\\nphosphate, and magnesium levels.\\nChronic alcoholic myopathy and other chronic\\nconditions are treated by correcting associated nutri-\\ntional deficiencies and maintaining a diet adequate in\\nprotein and carbohydrate. The key to treating any\\nalcohol-related disease is helping the patient overcome\\nalcohol addiction. Behavioral measures and social sup-\\nports may be needed in patients who develop broad\\nproblems in their thinking abilities (dementia) or\\nremain in a state of confusion and disorientation\\n(delirium). People with walking disturbances may\\nbenefit from physical therapy and assistive devices.\\nDoctors may also prescribe drugs to treat the pain\\nassociated with peripheral neuropathy.\\nPrognosis\\nComplete recovery from Wernicke’s syndrome\\nmay follow prompt administration of thiamine.\\nHowever, repeated episodes of encephalopathy or\\nprolonged alcohol abuse may cause persistent demen-\\ntia or Korsakoffpsychosis. Most patients recover fully\\nfrom acute alcoholic myopathy within days to weeks,\\nbut severe cases may be fatal fromacute kidney failure\\nand disturbances in heart rhythm secondary to\\nincreased potassium levels. Recovery from chronic\\nalcoholic myopathy may occur over weeks to months\\nof abstinence from alcohol and correction ofmalnutri-\\ntion. Cerebellar degeneration and alcoholic neuropa-\\nthy may also improve to some extent with abstinence\\nand balanced diet, depending on the severity and dura-\\ntion of the condition.\\nPrevention\\nPrevention requires abstinence from alcohol.\\nPersons who consume small or moderate amounts of\\nalcohol might theoretically help prevent nutritional\\ncomplications of alcohol use with dietary supplements\\nincluding B vitamins. However, propernutrition can-\\nnot protect against the direct toxic effect of alcohol or\\nof its breakdown products. Patients with any alcohol-\\nrelated symptoms or conditions, pregnant women,\\nand patients with liver or neurologic disease should\\nabstain completely. Persons with family history of\\nalcoholism or alcohol-related conditions may also be\\nat increased risk for neurologic complications of alco-\\nhol use.\\nResources\\nPERIODICALS\\n‘‘Missouri Clinics Will Diagnose and Treat Fetal Alcohol\\nSyndrome.’’ Mental Health Weekly Digeste (June 7,\\n2004): 33.\\nStacey, Philip S. ‘‘Preliminary Investigation of Thiamine and\\nAlcohol Intake in Clinical and Healthy Samples.’’\\nPsychological Reports (June 2004): 845–849.\\nORGANIZATIONS\\nNational Institute on Alcohol Abuse and Alcoholism. 6000\\nExecutive Boulevard, Willco Building, Bethesda, MD\\n20892-7003. .\\nLaurie Barclay, MD\\nTeresa G. Odle\\nAlcohol withdrawal see Withdrawal\\nsyndromes\\nAlcoholic cerebellar disease see Alcohol-\\nrelated neurologic disease\\nGALE ENCYCLOPEDIA OF MEDICINE 101\\nAlcohol-related neurologic disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alcoholic hepatitis see Hepatitis, alcoholic\\nAlcoholic rose gardener’s diseasesee\\nSporotrichosis\\nAlcoholism\\nDefinition\\nAlcoholism is the popular term for alcoholabuse\\nand alcohol dependence. These disorders involve\\nrepeated life problems that can be directly attributed\\nto the use of alcohol. Both disorders can have serious\\nconsequences, affecting an individual’s health and per-\\nsonal life, as well as having an impact on society at large.\\nDescription\\nThe effects of alcoholism are far reaching.\\nAlcohol affects every body system, causing a wide\\nrange of health problems. Problems include poor\\nnutrition, memory disorders, difficulty with balance\\nand walking, liver disease (including cirrhosis and\\nhepatitis), high blood pressure, muscle weakness\\n(including the heart), heart rhythm disturbances,\\nanemia, clotting disorders, decreased immunity to\\ninfections, gastrointestinal inflammation and irrita-\\ntion, acute and chronic problems with the pancreas,\\nlow blood sugar, high blood fat content, interference\\nwith reproductive fertility, and weakened bones.\\nOn a personal level, alcoholism results in marital\\nand other relationship difficulties, depression, unem-\\nployment, child abuse, and general family dysfunction.\\nAlcoholism causes or contributes to a variety of\\nsevere social problems including homelessness, mur-\\nder, suicide, injury, and violent crime. Alcohol is a\\ncontributing factor in at least 50% of all deaths from\\nmotor vehicle accidents. In fact, about 100,000 deaths\\noccur each year due to the effects of alcohol, of which\\n50% are due to injuries of some sort. According to a\\nspecial report prepared for the U.S. Congress by the\\nNational Institute on Alcohol Abuse and Alcoholism,\\nthe impact of alcohol on society, including violence,\\ntraffic accidents, lost work productivity, and prema-\\nture death, costs our nation an estimated $185 billion\\nannually. In addition, it is estimated that approxi-\\nmately one in four children (19 million children or\\n29% of children up to 17 years of age) is exposed at\\nsome time to familial alcohol abuse, alcohol depen-\\ndence, or both. Furthermore, it has been estimated\\nthat approximately 18% of adults experience an\\nepisode of alcohol abuse or dependence a some time\\nduring 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\\nrelatives 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\\nfactors could account for differences in alcohol meta-\\nbolism that may increase the risk of an individual\\nbecoming 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\\nentering 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 coordina-\\ntion (accounting in part for the increased likelihood of\\ninjury). The affected person also may have impairment\\nof peripheral vision. At higher alcohol levels, a person’s\\nbreathing and heart rates will be slowed, andvomiting\\nmay occur (with a high risk of the vomit being breathed\\ninto the lungs, resulting in severe problems, including\\nthe possibility ofpneumonia). 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:\\nSymptoms Of Co-Alcohol Dependence\\nPsychological distress manifested in symptoms such as anxiety, aggression,\\nanorexia nervosa, bulimia, depression,insomnia, hyperactivity, and suicidal\\ntendency\\nPsychosomatic illness (ailments that have no biological basis and clear up\\nafter the co-alcoholism clears up)\\nFamily violence or neglect\\nAlcoholism or other drug abuse\\n102 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcoholism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Nervous system. An estimated 30-40% of all men in\\ntheir teens and twenties have experienced alcoholic\\nblackout, which occurs when drinking a large quan-\\ntity of alcohol results in the loss of memory of the\\ntime surrounding the episode of drinking. Alcohol is\\nwell-known to cause sleep disturbances, so that over-\\nall sleep quality is affected. Numbness andtingling\\nmay occur in the arms and legs. Two syndromes,\\nwhich can occur together or separately, are known\\nas Wernicke’s and Korsakoff’s syndromes. Both are\\ndue to the low thiamine (a form of vitamin B\\ncomplex) levels found in alcoholics. Wernicke’s\\nsyndrome results in disordered eye movements, very\\npoor balance and difficulty walking, while\\nKorsakoff’s syndromeseverely affects one’s memory,\\npreventing new learning from taking place.\\n/C15Gastrointestinal system. Alcohol causes loosening of\\nthe muscular ring that prevents the stomach’s con-\\ntents from re-entering the esophagus. Therefore, the\\nacid from the stomach flows backward into the eso-\\nphagus, burning those tissues, and causingpain and\\nbleeding. Inflammation of the stomach also can\\nresult in bleeding and pain, and decreased desire to\\neat. A major cause of severe, uncontrollable bleeding\\n(hemorrhage) in an alcoholic is the development\\nof enlarged (dilated) blood vessels within the\\nesophagus, which are called esophageal varices.\\nThese varices actually are developed in response to\\nliver disease, and are extremely prone to bursting and\\nhemorrhaging. Diarrhea is a common symptom, due\\nto alcohol’s effect on the pancreas. In addition,\\ninflammation of the pancreas (pancreatitis) is a ser-\\nious and painful problem in alcoholics. Throughout\\nthe intestinal tract, alcohol interferes with the\\nabsorption of nutrients, creating a malnourished\\nstate. Because alcohol is broken down (metabolized)\\nwithin the liver, the organ is severely affected by\\nconstant levels of alcohol. Alcohol interferes with a\\nnumber of important chemical processes that also\\noccur in the liver. The liver begins to enlarge and fill\\nwith fat (fatty liver), fibrous scar tissue interferes with\\nthe liver’s normal structure and function (cirrhosis),\\nand the liver may become inflamed (hepatitis).\\n/C15Blood. 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(10 times the risk for nonalcoholics). Platelets and\\nblood clotting factors are affected, causing an\\nincreased risk of bleeding.\\n/C15Heart. Small amounts of alcohol cause a drop in\\nblood pressure, but with increased use, alcohol\\nbegins to increase blood pressure into a dangerous\\nrange. High levels of fats circulating in the blood-\\nstream increase the risk of heart disease. Heavy\\ndrinking results in an increase in heart size, weaken-\\ning of the heart muscle, abnormal heart rhythms, a\\nrisk ofblood clotsforming within the chambers of the\\nheart, and a greatly increased risk of stroke (due to a\\nblood clot from the heart entering the circulatory\\nsystem, going to the brain, and blocking a brain\\nblood vessel).\\n/C15Reproductive system. Heavy drinking has a negative\\neffect on fertility in both men and women, by\\ndecreasing testicle and ovary size, and interfering\\nwith both sperm and egg production. Whenpreg-\\nnancy is achieved in an alcoholic woman, the baby\\nhas a great risk of being born withfetal alcohol\\nsyndrome, which causes distinctive facial defects,\\nlowered IQ, and behavioral problems.\\nDiagnosis\\nTwo different types of alcohol-related difficulties\\nhave been identified. The first is calledalcohol depen-\\ndence, which refers to a person who literally depends\\nKEY TERMS\\nBlood-brain barrier— A network of blood vessels\\ncharacterized by closely spaced cells that prevents\\nmany potentially toxic substances from penetrating\\nthe blood vessel walls to enter the brain. Alcohol is\\nable 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 drin-\\nker becomes 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 decreasing\\nthe drug’s dosage or discontinuing its use.\\nGALE ENCYCLOPEDIA OF MEDICINE 103\\nAlcoholism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='on the use of alcohol. Three of the following traits\\nmust be present to diagnose alcohol dependence:\\n/C15tolerance, meaning that a person becomes accus-\\ntomed to a particular dose of alcohol, and must\\nincrease the dose in order to obtain the desired effect\\n/C15withdrawal, meaning that a person experiences\\nunpleasant physical and psychological symptoms\\nwhen he or she does not drink alcohol\\n/C15the tendency to drink more alcohol than one intends\\n(once an alcoholic starts to drink, he or she finds it\\ndifficult to stop)\\n/C15being unable to avoid drinking or stop drinking once\\nstarted\\n/C15having large blocks of time taken up by alcohol use\\n/C15choosing to drink at the expense of other important\\ntasks or activities\\n/C15drinking despite evidence of negative effects on one’s\\nhealth, relationships, education, or job\\nDiagnosis is sometimes brought about when\\nfamily members call an alcoholic’s difficulties to the\\nattention of a physician. A clinician may begin to be\\nsuspicious when a patient suffers repeated injuries or\\nbegins to experience medical problems related to\\nthe use of alcohol. In fact, some estimates suggest\\nthat about 20% of a physician’s patients will be\\nalcoholics.\\nDiagnosis is aided by administering specific psy-\\nchological assessments that try to determine what\\naspects of a person’s life may be affected by his or\\nher use of alcohol. Determining the exact quantity of\\nalcohol that a person drinks is of much less impor-\\ntance than determining how his or her drinking affects\\nrelationships, jobs, educational goals, and family life.\\nIn fact, because the metabolism (how the body breaks\\ndown and processes) of alcohol is so individual, the\\nquantity of alcohol consumed is not part of the criteria\\nlist for diagnosing either alcohol dependence or alco-\\nhol abuse.\\nOne simple tool for beginning the diagnosis of\\nalcoholism is called the CAGE questionnaire. It con-\\nsists of four questions, with the first letters of each key\\nword spelling out the word CAGE:\\n/C15Have you ever tried toCut down on your drinking?\\n/C15Have you ever beenAnnoyed by anyone’s comments\\nabout your drinking?\\n/C15Have you ever feltGuilty about your drinking?\\n/C15Do you ever need anEye-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.\\nTreatment\\nTreatment of alcoholism has two parts. The first\\nstep in the treatment of alcoholism, called detoxifica-\\ntion, involves helping the person stop drinking and\\nridding his or her body of the harmful (toxic) effects\\nof alcohol. Because the person’s body has become\\naccustomed to alcohol, the person will need to be\\nsupported through withdrawal. Withdrawal will be\\ndifferent for different patients, depending on the sever-\\nity of the alcoholism, as measured by the quantity of\\nalcohol ingested daily and the length of time the\\npatient has been an alcoholic. Withdrawal symptoms\\ncan range from mild to life-threatening. Mild with-\\ndrawal symptoms includenausea, achiness, diarrhea,\\ndifficulty sleeping, sweatiness,anxiety, and trembling.\\nThis phase is usually over in about three to five days.\\nMore severe effects of withdrawal can includehalluci-\\nnations (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\\nrate, high blood pressure, anddelirium (a fluctuating\\nlevel of consciousness). Patients at highest risk for the\\nmost severe symptoms of withdrawal (referred to as\\ndelirium tremens) are those with other medical\\nproblems, including malnutrition, liver disease,o r\\nWernicke’s syndrome. Delirium tremens usually\\nbegin about three to five days after the patient’s last\\ndrink, progressing from the more mild symptoms to\\nthe more severe, and may last a number of days.\\nPatients going through only mild withdrawal are\\nsimply monitored carefully to make sure that more\\nsevere symptoms do not develop. No medications are\\nnecessary, however. Treatment of a patient suffering\\nthe more severe effects of withdrawal may require the\\nuse of sedative medications to relieve the discomfort of\\nwithdrawal and to avoid the potentially life-threaten-\\ning complications of high blood pressure, fast heart\\nrate, and seizures. Drugs called benzodiazapines are\\nhelpful in those patients suffering from hallucinations.\\nBecause of the patient’s nausea, fluids may need to be\\ngiven through a vein (intravenously), along with some\\nnecessary sugars and salts. It is crucial that thiamine\\nbe included in the fluids, because thiamine is usually\\nquite low in alcoholic patients, and deficiency of thia-\\nmine is responsible for the Wernicke-Korsakoff\\nsyndrome.\\n104 GALE ENCYCLOPEDIA OF MEDICINE\\nAlcoholism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='After cessation of drinking has been accom-\\nplished, the next steps involve helping the patient\\navoid ever taking another drink. This phase of treat-\\nment is referred to asrehabilitation. The best programs\\nincorporate the family into the therapy, because the\\nfamily has undoubtedly been severely affected by the\\npatient’s drinking. Some therapists believe that family\\nmembers, in an effort to deal with their loved one’s\\ndrinking problem, sometimes develop patterns of\\nbehavior that accidentally support or ‘‘enable’’ the\\npatient’s drinking. This situation is referred to as\\n‘‘co-dependence,’’ and must be addressed in order to\\nsuccessfully treat a person’s alcoholism.\\nSessions led by peers, where recovering alcoholics\\nmeet regularly and provide support for each other’s\\nrecoveries, are considered among 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\\npeople avoid drinking. These steps involve recognizing\\nthe destructive power that alcohol has held over\\nthe alcoholic’s life, looking to a higher power for\\nhelp in overcoming the problem, and reflecting on\\nthe ways in which the use of alcohol has hurt others\\nand, if possible, making amends to those people.\\nAccording to a recent study reported by the American\\nPsychological Association (APA), anyone, regardless\\nof his or her religious beliefs or lack of religious beliefs,\\ncan benefit from participation in 12-step programs\\nsuch as Alcoholics Anonymous (AA) or Narcotics\\nAnonymous (NA). The number of visits to 12-step\\nself-help groups exceeds the number of visits to all\\nmental health professionals combined.\\nThere are also medications that may help an alco-\\nholic avoid returning to drinking. These have been\\nused with variable success. Disulfiram (Antabuse)\\nis a drug which, when mixed with alcohol, causes\\nunpleasant reactions including nausea, vomiting,\\ndiarrhea, and trembling. Naltrexone, along with a\\nsimilar compound, Nalmefene, can be helpful in limit-\\ning the effects of a relapse. Acamprosate is helpful in\\npreventing relapse. None of these medications would\\nbe helpful unless the patient was also willing to work\\nvery hard to change his or her behavior. In 2004, a new\\ncompound was discovered that blocks actions of\\nchemicals in the brain that may lead to relapses.\\nClinical tests were still underway, but development of\\nsuch a drug could have great potential in the medical\\nmanagement of alcoholism. Another study that year\\nfound that topiramate (Topamax), an antiseizure\\nmedication, was effective in treating alcohol depen-\\ndence in 150 participants in a clinical trial. The authors\\ncalled for further study of this possible treatment.\\nAlternative treatment\\nAlternative treatments can be a helpful adjunct\\nfor the alcoholic patient, once the medical danger of\\nwithdrawal has passed. Because many alcoholics\\nhave very stressful lives (whether because of or lead-\\ning to the alcoholism is sometimes a matter of\\ndebate), many of the treatments for alcoholism\\ninvolve dealing with and relieving stress.T h e s e\\ninclude massage, meditation,a n dhypnotherapy.T h e\\nmalnutrition of long-term alcohol use is addressed by\\nnutrition-oriented practi tioners with careful atten-\\ntion to a healthy diet and the use of nutritional sup-\\nplements such asvitamins A, B complex, and C, as\\nwell as certain fatty acids, amino acids, zinc, magne-\\nsium, and selenium. Herbal treatments include milk\\nthistle (Silybum marianum ), which is thought to pro-\\ntect the liver against damage. Other herbs are thought\\nto be helpful for the patient suffering through with-\\ndrawal. Some of these include lavender (Lavandula\\nofficinalis), skullcap (Scutellaria lateriflora ), chamo-\\nmile ( Matricaria recutita ), peppermint ( Mentha\\npiperita) yarrow (Achillea millefolium ), and valerian\\n(Valeriana officinalis ). Acupuncture is believed to\\nboth decrease withdrawal symptoms and to help\\nimprove a patient’s chances for continued recovery\\nfrom alcoholism.\\nPrognosis\\nRecovery from alcoholism is a life-long process.\\nIn fact, people who have suffered from alcoholism are\\nencouraged to refer to themselves ever after as ‘‘a\\nrecovering alcoholic,’’ never a recovered alcoholic.\\nThis is because most researchers in the field believe\\nthat since the potential for alcoholism is still part of\\nthe individual’s biological and psychological makeup,\\none can never fully recover from alcoholism. The\\npotential for relapse (returning to illness) is always\\nthere, and must be acknowledged and respected.\\nStatistics suggest that, among middle-class alcoholics\\nin stable financial and family situations who have\\nundergone treatment, 60% or more can be successful\\nat an attempt to stop drinking for at least a year, and\\nmany for a lifetime.\\nPrevention\\nPrevention must begin at a relatively young age\\nsince the first instance of intoxication (drunkenness)\\nusually occurs during the teenage years. In fact, a 2004\\nstudy found that girls experimented with alcohol and\\ncigarettes at a younger age — 20% by seventh grage —\\nthan boys. It is particularly important that teenagers\\nwho are at high risk for alcoholism—those with a\\nGALE ENCYCLOPEDIA OF MEDICINE 105\\nAlcoholism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='family history of alcoholism, an early or frequent use\\nof alcohol, a tendency to drink to drunkenness, alco-\\nhol use that interferes with school work, a poor family\\nenvironment, or a history of domestic violence —\\nreceive education about alcohol and its long-term\\neffects. How this is best achieved, without irritating\\nthe youngsters and thus losing their attention, is the\\nsubject of continuing debate and study.\\nResources\\nBOOKS\\nNational Institute on Alcohol Abuse and Alcoholism.10th\\nSpecial Report to the U.S. Congress on Alcohol and\\nHealth. National Institute of Health, 2000.\\nPERIODICALS\\nKoch Kubetin, Sally. ‘‘Girls Before Boys in Cigarette and\\nAlcohol Use: Longitudinal Study.’’Pediatric News\\n(March 2004): 29.\\n‘‘Research Findings Suggest Compound Might Help in\\nFight Against Alcoholism.’’Drug Week (January 9,\\n2004): 18.\\nWalling, Anne D. ‘‘Topiramate in the Treatment of Alcohol\\nDependence.’’ American Family Physician (January 1,\\n2004): 195.\\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,\\nNew York, NY 10163. .\\nNational Alliance on Alcoholism and Drug Dependence,\\nInc. 12 West 21st St., New York, NY 10010. (212) 206-\\n6770.\\nNational Clearinghouse for Alcohol and Drug Information.\\n11426 Rockville Pike, Suite 200, Rockville, MD. 20852.\\n(800) 729-6686. .\\nNational Institute on Alcohol Abuse and Alcoholism\\n(NIAAA). 6000 Executive Boulevard, Bethesda,\\nMaryland 20892-7003. .\\nBill Asenjo, MS, CRC\\nTeresa G. Odle\\nALD see Adrenoleukodystrophy\\nAldolase test\\nDefinition\\nAldolase is an enzyme found throughout the\\nbody, particularly in muscles. Like all enzymes, it is\\nneeded to trigger specific chemical reactions. Aldolase\\nhelps muscle turn sugar into energy. Testing for aldo-\\nlase is done to diagnose and monitor skeletal muscle\\ndiseases.\\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\\nmake those bones move. When the muscles are dis-\\neased or damaged, such as inmuscular dystrophy, the\\ncells deteriorate and break open. The contents of the\\ncells, including aldolase, spill into the bloodstream.\\nMeasuring the amount of aldolase in the blood indi-\\ncates the degree of muscle damage.\\nAs muscles continue to deteriorate, aldolase levels\\ndecrease and eventually fall below normal. Less mus-\\ncle means fewer cells and less aldolase.\\nMuscle weakness may be caused by neurologic as\\nwell as muscular problems. The measurement of\\naldolase levels can help pinpoint the cause. Aldolase\\nlevels will be normal where muscle weakness is caused\\nby neurological disease, such as poliomyelitis or\\nmultiple sclerosis, but aldolase levels will be elevated\\nin cases of muscular disease, such as muscular\\ndystrophy.\\nAldolase is also found in the liver and cardiac\\nmuscle of the heart. Damage or disease to these\\norgans, such as chronic hepatitis or aheart attack,\\nwill also increase aldolase levels in the blood, but to a\\nlesser degree.\\nDescription\\nAldolase is measured by mixing a person’s serum\\nwith a substance with which aldolase is known to\\ntrigger a reaction. The end product of this reaction is\\nmeasured, and, from that measurement, the amount of\\naldolase in the person’s serum is determined.\\nKEY TERMS\\nAldolase— An enzyme, found primarily in the mus-\\ncle, that helps convert sugar into energy.\\nEnzyme— A substance needed to trigger specific\\nchemical reactions.\\nNeurologic— Having to do with the nervous system.\\nSkeletal muscle— Muscle connected to, and neces-\\nsary for the movement of, bones.\\n106 GALE ENCYCLOPEDIA OF MEDICINE\\nAldolase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The 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,\\na healthcare worker ties a tourniquet on the patient’s\\nupper arm, locates a vein in the inner elbow region, and\\ninserts a needle into that vein. Vacuum action draws\\nthe blood through the needle into an attached tube.\\nCollection of the sample takes only a few minutes.\\nThe patient should avoid strenuousexercise and\\nhave nothing to eat or drink, except water, for eight to\\nten hours 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\\non the laboratory and the method used.\\nAbnormal results\\nAs noted, aldolase is elevated in skeletal muscle\\ndiseases, such as muscular dystrophies. Duchenne’s\\nmuscular dystrophy, the most common type of mus-\\ncular dystrophy, will increase the aldolase level more\\nthan any other disease.\\nNondisease conditions that affect the muscle, such\\nas injury,gangrene, or an infection, can also increase\\nthe aldolase level. Also, strenuous exercise can tem-\\nporarily increase a person’s aldolase level.\\nCertain medications can increase the aldolase\\nlevel, while others can decrease it. To interpret what\\nthe results of the aldolase test mean, a physician will\\nevaluate the result, the person’s clinical symptoms,\\nand other tests that are more specific for muscle\\ndamage and disease.\\nResources\\nBOOKS\\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\\nhormone produced by the outer part (cortex) of the\\ntwo adrenal glands, organs which sit one on top of\\neach of the kidneys. Aldosterone regulates the\\namounts of sodium and potassium in the blood. This\\nhelps maintain water balance and blood volume,\\nwhich, in turn, affects blood pressure.\\nPurpose\\nAldosterone measurement is useful in detecting a\\ncondition called aldosteronism, which is caused by\\nexcess secretion of the hormone from the adrenal\\nglands. There are two types of aldosteronism: primary\\nand secondary. Primary aldosteronism is most com-\\nmonly caused by an adrenal tumor, as in Conn’s\\nsyndrome. Idiopathic (of unknown cause)hyperaldos-\\nteronism is another type of primary aldosteronism.\\nSecondary aldosteronism is more common and may\\noccur with congestive heart failure,cirrhosis with fluid\\nin the abdominal cavity (ascites), certain kidney dis-\\neases, excess potassium, sodium-depleted diet, and\\ntoxemia ofpregnancy.\\nTo differentiate primary aldosteronism from sec-\\nondary aldosteronism, a plasma renin test should be\\nperformed at the same time as the aldosterone assay.\\nRenin, an enzyme produced in the kidneys, is high in\\nsecondary aldosteronism and low in primary\\naldosteronism.\\nDescription\\nAldosterone testing can be performed on a blood\\nsample or on a 24-hour urine specimen. Several fac-\\ntors, including diet, posture (upright or lying down),\\nand time of day that the sample is obtained can cause\\naldosterone levels to fluctuate. Blood samples are\\naffected by short-term fluctuations. A urine specimen\\ncollected over an entire 24-hour period lessens the\\neffects of those interfering factors and provides a\\nmore reliable aldosterone measurement.\\nPreparation\\nFasting is not required for either the blood sample\\nor urine collection, but the patient should maintain a\\nnormal sodium diet (approximately 0.1 oz [3g]/day)\\nfor at least two weeks before either test. The doctor\\nshould decide if drugs that alter sodium, potassium,\\nand fluid balance (e.g., diuretics, antihypertensives,\\nGALE ENCYCLOPEDIA OF MEDICINE 107\\nAldosterone assay'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='steroids, oral contraceptives) should be withheld. The\\ntest will be more accurate if these are suspended at\\nat least two weeks before the test. Renin inhibitors\\n(e.g., propranolol) should not be taken one week\\nbefore the test, unless permitted by the physician.\\nThe patient should avoid licorice for at least two\\nweeks before the test, because of its aldosterone-like\\neffect. Strenuous exercise and stress can increase\\naldosterone levels as well. Because the test is usually\\nperformed by a method called radioimmunoassay,\\nrecently administered radioactive medications will\\naffect test results.\\nSince posture and body position affect aldoster-\\none, hospitalized patients should remain in an\\nupright position (at least sitting) for two hours\\nbefore blood is drawn. Occasionally blood will be\\ndrawn again before the patient gets out of bed.\\nNonhospitalized patients should arrive at the labora-\\ntory in time to maintain an upright position for at\\nleast two hours.\\nRisks\\nRisks for this test are minimal, but may include\\nslight bleeding from the blood-drawing site, fainting\\nor feeling lightheaded after venipuncture, or hema-\\ntoma (blood accumulating under the puncture site).\\nNormal results\\nNormal results are laboratory-specific and also\\nvary with sodium intake, with time of day, source of\\nspecimen (e.g., peripheral vein, adrenal vein, 24-hour\\nurine), age, sex, and posture.\\nReference ranges for blood include:\\n/C15supine (lying down): 3-10 ng/dL\\n/C15upright (sitting for at least two hours): Female:\\n5-30ng/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\\nblood levels of aldosterone and renin). Among other\\nconditions, elevated levels are also seen in secondary\\naldosteronism,stress, and malignanthypertension.\\nDecreased levels of aldosterone are found in\\naldosterone deficiency, steroid therapy, high-sodium\\ndiets, certain antihypertensive therapies, and\\nAddison’s disease (an autoimmune disorder).\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAlemtuzumab\\nDefinition\\nAlemtuzumab is sold as Campath in the United\\nStates. Alemtuzumab is a humanized monoclonal\\nantibody that selectively binds to CD52, a protein\\nfound on the surface of normal and malignant B and\\nT cells, that is used to reduce the numbers of circulat-\\ning malignant cells of patients who have B-cell chronic\\nlymphocytic leukemia (B-CLL).\\nPurpose\\nAlemtuzumab is a monoclonal antibody used to\\ntreat B-CLL, one of the most prevalent forms of adult\\nchronic leukemia. It specifically binds CD52, a protein\\nfound on the surface of essentially all B and T cells of\\nthe immune system. By binding the CD52 protein on\\nthe malignant B cells, the antibody targets it for\\nremoval from the circulation. Scientists believe that\\nalemtuzumab triggers antibody-mediated lysis of the\\nB cells, a method that the immune system uses to\\neliminate foreign cells.\\nAlemtuzumab has been approved by the FDA for\\ntreatment of refractory B-CLL. For a patient’s disease\\nto be classified as refractory, both alkylating agents\\nand fludarabine treatment must have been tried and\\nfailed. Thus, this drug gives patients who have tried all\\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.\\n108 GALE ENCYCLOPEDIA OF MEDICINE\\nAlemtuzumab'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='approved treatments for B-CLL another option. As\\nmost patients with B-CLL are in stage III or IV by the\\ntime both alkylating agents and fludarabine have been\\ntried, the experience with alemtuzumab treatment are\\nprimarily with those stages of the disease. In clinical\\ntrials, about 30% of patients had a partial response to\\nthe drug, with 2% of these being complete responses.\\nThis antibody has been tested with limited suc-\\ncess in the treatment of non-Hodgkin’s lymphoma\\n(NHL) and for the preparation of patients with var-\\nious immune cell malignancies for bone marrow\\ntransplantation. There is also a clinical trial ongoing\\nto test the ability of this antibody to prevent rejection\\nin 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\\nparticular substance, the antigen for that monoclonal\\nantibody. For alemtuzumab, the antigen is CD52, a\\nprotein found on the surface of normal and malignant\\nB and T cells as well as other cells of the immune and\\nmale reproductive systems. Alemtuzumab is a human-\\nized antibody, meaning that the regions that bind\\nCD52, located on the tips of the Y branches, are\\nderived from rat antibodies, but the rest of the anti-\\nbody is human sequence. The presence of the human\\nsequences helps to reduce the immune response by the\\npatient against the antibody itself, a problem seen\\nwhen complete mouse antibodies are used forcancer\\ntherapies. The human sequences also help to ensure\\nthat the various cell-destroying mechanisms of the\\nhuman 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,\\na monoclonal antibody specific for the CD20 antigen,\\nanother protein found on the surface of B cells.\\nRecommended dosage\\nThis antibody should be administered in a gradu-\\nally escalating pattern at the start of treatment and any\\ntime administration is interrupted for seven or more\\ndays. The recommended beginning dosage for B-CLL\\npatients is a daily dose of 3 mg of Campath adminis-\\ntered as a two-hour IV infusion. Once this amount is\\ntolerated, the dose is increased to 10 mg per day. After\\ntolerating this dose, it can be increased to 30 mg, admi-\\nnistered three days a week. Acetominophen and diphen-\\nhydramine hydrochoride are given thirty to sixty\\nminutes before the infusion 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 studiesshould be done on a weekly basis while\\npatients are receiving the alemtuzumab treatment.\\nVaccination during the treatment session is not recom-\\nmended, given the T cell depletion that occurs during\\ntreatment. Furthermore, given thatantibodieslike alum-\\ntuzumab can pass through the placenta to the developing\\nfetus and in breastmilk,use duringpregnancyand breast-\\nfeeding is not recommended unless clearly needed.\\nSide effects\\nA severe side effect of alemtuzumab treatment is\\nthe possible depletion of one or more types of blood\\nKEY TERMS\\nAlkylating agent— Achemicalthataltersthecompo-\\nsition of the genetic material of rapidly dividing cells,\\nsuch as cancer cells, causing selective cell death;\\nused as a chemotherapeutic agent to treat B-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 immuno-\\nglobulins with the binding region of an animal\\nimmunoglobulin, done to reduce human reaction\\nagainst the fusion antibody.\\nMonoclonal— Genetically engineered antibodies\\nspecific for one antigen.\\nTumor lysis syndrome— A side effect of some immu-\\nnotherapies, like monoclonal antibodies, that lyse\\nthe tumor cells, due to the toxicity of flooding the\\nbloodstreamwithsuchaquantityofcellularcontents.\\nGALE ENCYCLOPEDIA OF MEDICINE 109\\nAlemtuzumab'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='cells. Because CD52 is expressed on a patient’s normal\\nB and T cells, as well as on the surface of the abnormal\\nB cells, the treatment eliminates both normal and\\ncancerous cells. The treatment also seems to trigger\\nautoimmune reactions against various other blood\\ncells. This results in severe reduction of the many\\ncirculating blood cells including red blood cells (ane-\\nmia), white blood cells (neutropenia), and clotting cells\\n(thrombopenia). These conditions are treated with\\nblood transfusions. The great majority of patients\\ntreated exhibit some type of blood cell depletion.\\nA second serious side effect of this drug is the\\nprevalence of opportunistic infections that occurs dur-\\ning the treatment. Serious, and sometimes fatal bac-\\nterial, viral, fungal, and protozoan infections have\\nbeen reported. Treatments to preventpneumonia and\\nherpes infections reduce, but do not eliminate these\\ninfections.\\nThe majority of other side effects occur after or\\nduring the first infusion of the drug. Some common\\nside effects of this drug includefever and chills,nausea\\nand vomiting, diarrhea, shortness of breath, skin rash,\\nand unusual fatigue. This drug can also cause low\\nblood pressure (hypotension).\\nIn patients with high tumor burden (a large num-\\nber of circulating malignant B cells) this drug can\\ncause a side effect called tumor lysis syndrome.\\nThought to be due to the release of the lysed cells’\\ncontents into the blood stream, it can cause a misba-\\nlance of urea, uric acid, phosphate, potassium, and\\ncalcium in the urine and blood. Patients at risk for\\nthis side effect must keep hydrated and can be given\\nallopurinol before infusion.\\nInteractions\\nThere have been no formal drug interaction stu-\\ndies done for alemtuzumab.\\nMichelle Johnson, MS, JD\\nAlendronate see Bone disorder drugs\\nAlexander technique\\nDefinition\\nThe Alexander technique is a somatic method\\nfor improving physical and mental functioning.\\nExcessive tension, which Frederick Alexander, the\\noriginator, recognized as both physical and mental,\\nrestricts movement and creates pressure in the joints,\\nthe spine, the breathing mechanism, and other organs.\\nThe goal of the technique is to restore freedom and\\nexpression to the body and clear thinking to the mind.\\nPurpose\\nBecause the Alexander technique helps students\\nimprove overall functioning, both mental and physi-\\ncal, it offers a wide range of benefits. Nikolaas\\nTinbergen, in his 1973 Nobel lecture, hailed the ‘‘strik-\\ning improvements in such diverse things as high blood\\npressure, breathing, depth of sleep, overall cheerful-\\nness and mental alertness, resilience against outside\\npressures, and the refined skill of playing a musical\\ninstrument.’’ He went on to quote a list of other con-\\nditions helped by the Alexander technique: ‘‘rheuma-\\ntism, including various forms of arthritis, then\\nrespiratory troubles, and even potentially lethal\\nasthma; following in their wake, circulation defects,\\nwhich may lead to high blood pressure and also to\\nsome dangerous heart conditions; gastrointestinal dis-\\norders of many types, various gynecological condi-\\ntions, sexual failures, migraines and depressive states.’’\\nLiterature in the 1980s and 1990s went on to\\ninclude improvements in backpain, chronic pain, pos-\\ntural problems, repetitive strain injury, benefits during\\npregnancy and childbirth, help in applying physical\\ntherapy and rehabilitative exercises, improvements in\\nstrain caused by computer use, improvements in the\\nposture and performance of school children, and\\nimprovements in vocal and dramatic performance\\namong the benefits offered by the technique.\\nDescription\\nOrigins\\nFrederick Matthias Alexander was born in 1869 in\\nTasmania, Australia. He became an actor and\\nShakespearean reciter, and early in his career he\\nbegan to suffer from strain on his vocal chords. He\\nsought medical attention for chronic hoarseness, but\\nafter treatment with a recommended prescription and\\nextensive periods of rest, his problem persisted.\\nAlexander realized that his hoarseness began\\nabout an hour into a dramatic performance and\\nreasoned that it was something he did in the process\\nof reciting that caused him to lose his voice. Returning\\nto his medical doctor, Alexander told him of his\\nobservation. When the doctor admitted that he\\ndidn’t know what Alexander was doing to injure\\nhis vocal chords, Alexander decided to try and find\\nout for himself.\\n110 GALE ENCYCLOPEDIA OF MEDICINE\\nAlexander technique'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Thus 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\\nhis coordination and to overcome his vocal problems.\\nOne of his most startling discoveries was that in order to\\nchange the way he used his body he had to change the\\nway he was thinking, redirecting his thoughts in such a\\nway that he did not produce unnecessary tension\\nwhen he attempted speech or movement. After making\\nthis discovery at the end of the nineteenth century,\\nAlexander became a pioneerin 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.\\nPrivate lessons range from a half-hour to an hour in\\nlength, and are taught in a series. The number of lessons\\nvaries according to the severity of the student’s difficul-\\nties with coordination or to the extent of the student’s\\ninterest in pursuing the improvements made possible by\\ncontinued study. The cost of lessons ranges from $40-80\\nper hour. Insurance coverage is not widely available,\\nbut discounts are available for participants in some\\ncomplementary care insurance plans. Pre-tax Flexible\\nSpending Accounts for health care cover Alexander\\ntechnique lessons 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\\narises from mental processes as well as physical, so\\ndiscussions of personal reactions or behavior are likely\\nto arise in the course of a lesson.\\nT h et e c h n i q u eh e l p ss t u d e n t sm o v ew i t he a s ea n d\\nimproved coordination. At the beginning of a move-\\nment (the lessons are a series of movements), most peo-\\nple pull back their heads, raise their shoulders toward\\ntheir ears, over-arch their lower backs, tighten their legs,\\nand otherwise produce excessive tension in their bodies.\\nAlexander referred to this as misuse of the body.\\nAt any point in a movement, proper use can be\\nestablished. If the neck muscles are not over-tensed,\\nthe head will carry slightly forward of the spine, simply\\nbecause it is heavier in the front. When the head is out\\nof balance in the forward direction, it sets off a series\\nof stretch reflexes in the extensor muscles of the back.\\nIt is skillful use of these reflexes, along with reflex\\nactivity in the feet and legs, the arms and hands, the\\nbreathing mechanism, and other parts of the body,\\nthat lessons in the technique aim to develop.\\nAlexander found that optimal functioning of the\\nbody was very hard to maintain, even for the short\\nperiod of time it took to complete a single movement.\\nPeople, especially adults, have very strong tension\\nhabits associated with movement. Chronic misuse of\\nthe muscles is common. It may be caused by slouching\\nin front of televisions or video monitors, too much\\nsitting or driving and too little walking, or by tension\\nassociated with past traumas and injuries. Stiffening\\nthe neck after awhiplash injury or favoring a broken or\\nsprained leg long after it has healed are examples of\\nhabitual tension caused 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\\ninhibit the tension. If the student prepares to sit\\ndown, for example, he will tense his muscles in his\\nhabitual way. If he is asked to put aside the intention\\nto sit and instead to free his neck and allow less con-\\nstriction in his muscles, he can begin to change his\\ntense habitual response to sitting.\\nBy leaving the head resting on the spine in its\\nnatural free balance, by keeping eyes open and\\nfocused, not held in a tense stare, by allowing the\\nshoulders to release, the knees to unlock and the\\nback to lengthen and widen, a student greatly reduces\\nstrain. In Alexander lessons students learn to direct\\nthemselves this way in activity and become skilled in\\nfluid, coordinated movement.\\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 esta-\\nblish improved coordination.\\nHabit— Referring to the particular set of physical\\nand mental tensions present in any individual.\\nInhibition— Referring to the moment in an\\nAlexander lesson when the student refrains from\\nbeginning a movement in order to avoid tensing\\nof the muscles.\\nSensory awareness— Bringing attention to the sen-\\nsations of tension and/or release in the muscles.\\nGALE ENCYCLOPEDIA OF MEDICINE 111\\nAlexander technique'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Precautions\\nSide effects\\nThe focus of the Alexander technique is educa-\\ntional. Teachers use their hands simply to gently guide\\nstudents in movement. Therefore, both contraindica-\\ntions and potential physiological side effects are kept\\nto a minimum. No forceful treatment of soft tissue or\\nbony structure is attempted, so damage to tissues, even\\nin the case of errors in teaching, is unlikely.\\nAs students’ sensory awareness develops in the\\ncourse of Alexander lessons, they become more\\nacutely aware of chronic tension patterns. As students\\nlearn to release excessive tension in their muscles and\\nto sustain this release in daily activity, they may\\nexperience tightness or soreness in the connective tis-\\nsue. This is caused by the connective tissue adapting to\\nthe lengthened and released muscles and the expanded\\nrange of movement in the joints.\\nOccasionally students may get light-headed dur-\\ning a lesson as contracted muscles release and effect\\nthe circulatory or respiratory functioning.\\nForceful contraction of muscles and rigid pos-\\ntures often indicate suppression of emotion. As mus-\\ncles release during or after an Alexander lesson,\\nstudents may experience strong surges of emotion or\\nsudden changes in mood. In some cases, somatic mem-\\nories surface, bringing to consciousness past injury or\\ntrauma. This can cause extremeanxiety, and referrals\\nmay be made by the teacher for counseling.\\nResearch and general acceptance\\nAlexander became well known among the intel-\\nlectual, artistic, and medical communities in London,\\nEngland, during the first half of the twentieth century.\\nAmong Alexander’s supporters were John Dewey,\\nAldous Huxley, Bernard Shaw, and renowned scien-\\ntists Raymond Dart, G.E. Coghill, Charles\\nSherrington, and Nikolaas Tinbergen.\\nResearchers continue to study the effects and\\napplications of the technique in the fields of education,\\npreventive medicine, and rehabilitation. The\\nAlexander technique has proven an effective treatment\\nfor reducingstress, for improving posture and perfor-\\nmance in schoolchildren, for relieving chronic pain,\\nand for improving psychological functioning. The\\ntechnique has been found to be as effective as beta-\\nblocker medications in controlling stress responses in\\nprofessional musicians, to enhance respiratory func-\\ntion in normal adults, and to mediate the effects of\\nscoliosis in adolescents and adults.\\nResources\\nBOOKS\\nDimon, Theodore.THE UNDIVIDED SELF: Alexander\\nTechnique and the Control of Stress. North Atlantic\\nBooks: 1999.\\nORGANIZATIONS\\nAlexander Technique International, 1692 Massachusetts\\nAve., 3rd Floor, Cambridge, MA 02138 USA. (888)\\n321-0856. Fax: 617-497-2615. ati@ati-net.com.\\n.\\nOTHER\\nAlexander Technique Resource Guide. (Includes list of\\nteachers) AmSAT Books. (800) 473-0620 or (804)\\n295-2840.\\nSandra Bain Cushman\\nAlkali-resistant hemoglobin test see Fetal\\nhemoglobin test\\nAlkaline phosphatase test\\nDefinition\\nAlkaline phosphatase is an enzyme found\\nthroughout the body. Like all enzymes, it is needed,\\nin small amounts, to trigger specific chemical reac-\\ntions. When it is present in large amounts, it may\\nsignify bone orliver diseaseor a tumor.\\nPurpose\\nMedical testing of alkaline phosphatase is con-\\ncerned with the enzyme that is found in liver, bone,\\nplacenta, and intestine. In a healthy liver, fluid con-\\ntaining alkaline phosphate and other substances is\\ncontinually drained away through the bile duct. In a\\ndiseased liver, this bile duct is often blocked, keeping\\nfluid within the liver. Alkaline phosphatase accumu-\\nlates and eventually escapes 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\\nan obstructive nature (cholestatic), i.e. involving the\\nbiliary drainage system, the alkaline phosphatase will\\nbe the first and foremost enzyme elevation. If, on the\\nother hand, the disease is primarily of the liver cells\\n(hepatocytes), the aminotransferases will rise promi-\\nnently. Thus, these enzymes are very useful in\\n112 GALE ENCYCLOPEDIA OF MEDICINE\\nAlkaline phosphatase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='distinguishing the type of liver disease–cholestatic or\\nhepatocellular.\\nGrowing bones need alkaline phosphatase. Any\\ncondition of bone growth will cause alkaline phospha-\\ntase levels to rise. The condition may be normal, such\\nas a childhood growth spurt or the healing of a broken\\nbone; or the condition may be a disease, such as bone\\ncancer, Paget’s disease, orrickets.\\nDuring pregnancy, alkaline phosphatase is made\\nby the placenta and leaks into the mother’s blood-\\nstream. This is normal. Some tumors, however, start\\nproduction of the same kind of alkaline phosphatase\\nproduced by the placenta. These tumors are called\\ngerm cell tumors and includetesticular cancer and\\ncertain brain tumors.\\nAlkaline phosphatase from the intestine is\\nincreased in a person with inflammatory bowel dis-\\nease, such asulcerative colitis.\\nDescription\\nAlkaline phosphatase is measured by combining\\nthe person’s serum with specific substances with which\\nalkaline phosphatase is known to react. The end\\nproduct of this reaction is measured; and from that\\nmeasurement, the amount of alkaline phosphatase in\\nthe person’s serum is determined.\\nEach tissue–liver, bone, placenta, and intestine–\\nproduces a slightly different alkaline phosphatase.\\nThese variations are called isoenzymes. In the labora-\\ntory, alkaline phosphatase is measured as the total\\namount or the amount of each of the the four isoen-\\nzymes. The isoenzymes react differently to heat, cer-\\ntain chemicals, and other processes in the laboratory.\\nMethods to measure them separately are based on\\nthese 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\\nupper arm, locates a vein in the inner elbow region,\\nand inserts a needle into that vein. Vacuum action\\ndraws the blood through the needle into an attached\\ntube. Collection of the sample takes only a few minutes.\\nA person being tested for alkaline phosphatase\\nshould not have anything to eat or drink, except\\nwater, for eight to ten hours before the test. Some\\npeople release alkaline phosphatase from the intestine\\ninto the bloodstream after eating. This will tempora-\\nrily increase the result of the test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or 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\\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 phospha-\\ntase more than any other disease, up to five times the\\nnormal level. Irritable bowel disease, germ cell tumors,\\nand infections involving the liver, such as viral hepa-\\ntitis andinfectious mononucleosis, increase the enzyme\\nalso, but to a lesser degree. Healing bones, pregnancy,\\nand normal growth in children also increase levels.\\nResources\\nBOOKS\\nLehmann, Craig A., editor.Saunders Manual of Clinical\\nLaboratory Science. Philadelphia: W. B. Saunders\\nCo., 1998.\\nNancy J. Nordenson\\nAlkalosis see Metabolic alkalosis;\\nRespiratory alkalosis\\nAllergic alveolitis see Hypersensitivity\\npneumonitis\\nKEY TERMS\\nAlkaline phosphatase— An enzyme found through-\\nout the body, primarily in liver, bone, placenta, and\\nintestine.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 113\\nAlkaline phosphatase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Allergic bronchopulmonary\\naspergillosis\\nDefinition\\nAllergic bronchopulmonary aspergillosis,o r\\nABPA, is one of four major types of infections in\\nhumans caused byAspergillus fungi. ABPA is a hyper-\\nsensitivity reaction that occurs in asthma patients who\\nare allergic to this specific fungus.\\nDescription\\nABPA is an allergic reaction to a species of\\nAspergillus called Aspergillus fumigatus .I ti ss o m e -\\ntimes grouped together with other lung disorders\\ncharacterized by eosinophilia–an abnormal increase\\nof a certain type of white blood cell in the blood–\\nunder the heading of eosinophilic pneumonia. These\\ndisorders are also call ed hypersensitivity lung\\ndiseases.\\nABPA appears to be increasing in frequency in the\\nUnited States, although the reasons for the increase\\nare not clear. The disorder is most likely to occur in\\nadult asthmatics aged 20-40. It affects males and\\nfemales equally.\\nCauses and symptoms\\nABPA develops when the patient breathes air\\ncontaining Aspergillus spores. These spores are\\nfound worldwide, especially around riverbanks,\\nmarshes, bogs, forests, and wherever there is wet or\\ndecaying vegetation. They are also found on wet\\npaint, construction materials, and in air condition-\\ning systems. ABPA is a nosocomial infection,\\nwhich means that a patient can get it in a hospital.\\nWhen Aspergillus spores reach the bronchi, which\\nare the branches of the windpipe that lead into the\\nlungs, the bronchi react by contracting spasmodi-\\ncally. So the patient has difficulty breathing and\\nusually wheezes or coughs. Many patients with\\nABPA also run a low-grade fever and lose their\\nappetites.\\nComplications\\nPatients with ABPA sometimes cough up large\\namounts of blood, a condition that is calledhemopty-\\nsis. They may also develop a serious long-term form of\\nbronchiectasis, the formation of fibrous tissue in the\\nlungs. Bronchiectasis is a chronic bronchial disorder\\ncaused by repeated inflammation of the airway, and\\nmarked by the abnormal enlargement of, or damage\\nto, the bronchial walls. ABPA sometimes occurs as a\\ncomplication of cystic fibrosis.\\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\\nand is 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\\nblood plasma that acts as an antibody to activate\\nallergic reactions. About 50% of patients with aller-\\ngic disorders have increased IgE levels in their\\nblood serum.\\nNosocomial infection— An infection that can be\\nacquired in a hospital. ABPA is a nosocomial\\ninfection.\\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.\\n114 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic bronchopulmonary aspergillosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nThe diagnosis of ABPA is based on a combination\\nof the patient’s history and the results of blood tests,\\nsputum tests, skin tests, and diagnostic imaging. The\\ndoctor will be concerned to distinguish between ABPA\\nand a worsening of the patient’sasthma,cystic fibrosis,o r\\nother lung disorders. There are seven major criteria for\\na diagnosis of allergic bronchopulmonary aspergillosis:\\n/C15a history of asthma.\\n/C15an accumulation of fluid in the lung that is visible on\\na chest x ray.\\n/C15bronchiectasis (abnormal stretching, enlarging, or\\ndestruction of the walls of the bronchial tubes).\\n/C15skin reaction toAspergillus antigen.\\n/C15eosinophilia in the patient’s blood and sputum.\\n/C15Aspergillus precipitins in the patient’s blood.\\nPrecipitins are antibodies that react with the antigen\\nto form a solid that separates from the rest of the\\nsolution in the test tube.\\n/C15a high level of IgE in the patient’s blood. IgE refers to\\na class of antibodies in blood plasma that activate\\nallergic reactions to foreign particles.\\nOther criteria that may be used to support the\\ndiagnosis include the presence ofAspergillus in sam-\\nples of the patient’s sputum, the coughing up of plugs\\nof brown mucus, or a late skin reaction to the\\nAspergillus antigen.\\nLaboratory tests\\nThe laboratory tests that are done to obtain this\\ninformation include a completeblood count(CBC), a\\nsputum culture, a blood serum test of IgE levels, and\\na skin test for theAspergillus antigen. In the skin test, a\\nsmall amount of antigen is injected into the upper\\nlayer of skin on the patient’s forearm about four\\ninches below the elbow. If the patient has a high\\nlevel of IgE antibodies in the tissue, he or she will\\ndevelop what is called a ‘‘wheal and flare’’ reaction\\nin about 15-20 minutes. A ‘‘wheal and flare’’ reaction\\nis characterized by the eruption of a reddened,itching\\nspot on the skin. Some patients with ABPA will\\ndevelop the so-called late reaction to the skin test, in\\nwhich a red, sore, swollen area develops about six to\\neight hours after the initial reaction.\\nDiagnostic imaging\\nChest x rays and CT scans are used to check for\\nthe presence of fluid accumulation in the lungs and\\nsigns of bronchiectasis.\\nTreatment\\nABPA is usually treated with prednisone\\n(Meticorten) or othercorticosteroids taken by mouth,\\nand withbronchodilators.\\nAntifungal drugs are not used to treat ABPA\\nbecause it is caused by an allergic reaction to\\nAspergillus rather than by direct infection of tissue.\\nFollow-up care\\nPatients with ABPA should be given periodic check-\\nupswith chestx rays and a spirometertest.Aspirometer is\\nan instrument that evaluates the patient’s lung capacity.\\nPrognosis\\nMost patients with ABPA respond well to corti-\\ncosteroid treatment. Others have a chronic course with\\ngradual improvement over time. The best indicator of\\na good prognosis is a long-term fall in the patient’s IgE\\nlevel. Patients with lung complications from ABPA\\nmay develop severe airway obstruction.\\nPrevention\\nABPA is difficult to prevent becauseAspergillus is\\na common fungus; it can be found in the saliva and\\nsputum of most healthy individuals. Patients with\\nABPA can protect themselves somewhat by avoiding\\nhaystacks, compost piles, bogs, marshes, and other\\nlocations with wet or rotting vegetation; by avoiding\\nconstruction sites or newly painted surfaces; and by\\nhaving their air conditioners cleaned regularly. Some\\npatients may be helped by air filtration systems for\\ntheir bedrooms or offices.\\nResources\\nBOOKS\\nStauffer, John L. ‘‘Lung.’’ InCurrent Medical Diagnosis and\\nTreatment, 1998, edited by Stephen McPhee, et al., 37th\\ned. Stamford: Appleton & Lange,1997.\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nNational Institute of Allergy and Infectious Disease.\\nBuilding 31, Room 7A-50, 31 Center Drive MSC 2520,\\nBethesda, MD 20892-2520. (301) 496-5717. .\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nRebecca J. Frey, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 115\\nAllergic bronchopulmonary aspergillosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Allergic purpura\\nDefinition\\nAllergic purpura (AP) is an allergic reaction of\\nunknown origin causing red patches on the skin and\\nother symptoms. AP is also called Henoch-Schonlein\\npurpura, named after the two doctors who first\\ndescribed it.\\nDescription\\n‘‘Purpura’’ is a bleeding disorder that occurs when\\ncapillaries rupture, allowing small amounts of blood\\nto accumulate in the surrounding tissues. In AP, this\\noccurs because the capillaries are blocked by protein\\ncomplexes formed during an abnormal immune reac-\\ntion. The skin is the most obvious site of reaction, but\\nthe joints, gastrointestinal tract, and kidneys are also\\noften affected.\\nAP affects approximately 35,000 people in the\\nUnited States each year. Most cases are children\\nbetween the ages of two and seven. Boys are affected\\nmore often than girls, and most cases occur from late\\nfall to winter.\\nCauses and symptoms\\nCauses\\nAP is caused by a reaction involving antibodies,\\nspecial 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\\ncapillary to burst, allowing a local hemorrhage.\\nThe source of the antigen causing AP is unknown.\\nAntigens may be introduced by bacterial or viral\\ninfection. More than 75% of patients report having had\\nan infection of the throat, upper respiratory tract, or\\ngastrointestinal system several weeks before the onset\\nof AP. Other complex molecules can act as antigens\\nas well, including drugs such asantibioticsor vaccines.\\nOtherwise harmless substances that stimulate an immune\\nreaction 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,a n dyellow fever.\\nSymptoms\\nThe onset of AP may be preceded by aheadache,\\nfever, and loss of appetite. Most patients first develop\\nan itchy skin rash. The rash is red, either flat or raised,\\nand may be small and freckle-like. The rash may also\\nbe larger, resembling a bruise.Rashes become purple\\nand then rust colored over the course of a day, and\\nfade after several weeks. Rashes are most common on\\nthe buttocks, abdomen, and lower extremities. Rashes\\nhigher on the body may also occur, especially in\\nyounger children.\\nJoint pain and swelling is common, especially\\nin the knees and ankles. Abdominal pain occurs in\\nalmost all patients, along with blood in the body\\nwaste (feces). About half of all patients show blood\\nin the urine, low urine volume, or other signs of kidney\\ninvolvement. Kidney failure may occur due to wide-\\nspread obstruction of the capillaries in the filtering\\nstructures called glomeruli. Kidney failure develops\\nin about 5% of all patients, and in 15% of those with\\nelevated blood or protein in the urine.\\nLess common symptoms include prolonged head-\\nache, fever, and pain and swelling of the scrotum.\\nInvolvement of other organ systems may lead to\\nheart attack (myocardial infarction), inflammation of\\nthe pancreas (pancreatitis), intestinal obstruction, or\\nbowel perforation.\\nDiagnosis\\nDiagnosis of AP is based on the symptoms and\\ntheir development, a careful medical history, and\\nblood and urine tests. X rays or computed tomogra-\\nphy scans (CT) may be performed to assess complica-\\ntions in the bowel or other internal organs.\\nTreatment\\nMost cases of AP resolve completely without\\ntreatment. Nonetheless, a hospital stay is required\\nbecause of the possibility of serious complications.\\nNon-aspirin pain relievers may be given for joint\\npain. Corticosteroids (like prednisone) are sometimes\\nused, although not all specialists agree on their utility.\\nKidney involvement requires monitoring and correc-\\ntion 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\\nKEY TERMS\\nGlomeruli— Knots of capillaries in the kidneys\\nresponsible for filtering the blood (singular,\\nglomerulus).\\n116 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic purpura'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='of blood or protein in the urine may persist for months\\nand require regular monitoring. Hypertension or kid-\\nney failure may develop months or even years after the\\nacute phase of the disease. Kidney failure requires\\ndialysis or transplantation.\\nPrognosis\\nMost people who develop AP become better on\\ntheir own after several weeks. About half of all\\npatients have at least one recurrence. Cases that do\\nnot have kidney complications usually have the best\\nprognosis.\\nResources\\nPERIODICALS\\nAndreoli, S. P. ‘‘Chronic Glomerulonephritis in\\nChildhood. Membranoproliferative\\nGlomerulonephritis, Henoch-Schonlein\\nPurpuraNnephritis, and IgA Nephropathy.’’Pediatric\\nClinics of North America 42, no. 6 (December 1995):\\n1487-1503.\\nOTHER\\n‘‘Henoch-Schonlein Purpura.’’ Vanderbilt University\\nMedical Center. .\\nRichard Robinson\\nAllergic rhinitis\\nDefinition\\nAllergic rhinitis, more commonly referred to as\\nhay fever, is an inflammation of the nasal passages\\ncaused by allergic 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 the\\nUnited States, and is responsible for 2.5% of all doctor\\nvisits.Antihistaminesand other drugs used to treat aller-\\ngic 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\\nand perennial. Seasonal AR occurs in the spring, sum-\\nmer, and early fall, when airborne plant pollens are at\\ntheir highest levels. In fact, the term hayfever is really\\na misnomer, since allergy to grass pollen is only one\\ncause of symptoms for most people. Perennial AR\\noccurs all year and is usually caused by home or work-\\nplace airborne pollutants. A person can be affected\\nby one or both types. Symptoms of seasonal AR are\\nworst after being outdoors, while symptoms of peren-\\nnial AR are worst after spending time indoors.\\nBoth types ofallergies can develop at any age,\\nalthough onset in childhood through early adulthood\\nis most common. Although allergy to a particular\\nsubstance is not inherited, increased allergic sensitivity\\nmay ‘‘run in the family.’’ While allergies can improve\\non their own over time, they can also become worse\\nover time.\\nCauses and symptoms\\nCauses\\nAllergic rhinitis is a type of immune reaction.\\nNormally, the immune system responds to foreign\\nThis illustration depicts excessive mucus production in the\\nnose after inhalation of airborne pollen. (Photo Researchers,\\nInc. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 117\\nAllergic rhinitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='microorganisms, or particles, like pollen or dust, by\\nproducing specific proteins, called antibodies, that are\\ncapable of binding to identifying molecules, or antigens,\\non the foreign particle. This reaction between antibody\\nand antigen sets off a series of reactions designed to\\nprotect the body from infection. Sometimes, this same\\nseries of reactions is triggered by harmless, everyday\\nsubstances. This is the condition known as allergy,\\nand the offending substance is 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\\nallergens, they trigger release of the granules, which\\nspill out their chemicals onto neighboring cells, includ-\\ning 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\\nleaky, leading to the fluid collection, swelling, and\\nincreased redness characteristic of a runny nose and\\nred, irritated eyes. Histamine also stimulates pain\\nreceptors, causing the itchy, scratchy nose, eyes, and\\nthroat common in allergic rhinitis.\\nThe number of possible airborne allergens is\\nenormous. Seasonal AR is most commonly caused\\nby grass and tree pollens, since their pollen is produced\\nin large amounts and is dispersed by the wind. Showy\\nflowers, like roses or lilacs, that attract insects produce\\na sticky pollen that is less likely to become airborne.\\nDifferent plants release their pollen at different times\\nof the year, so seasonal AR sufferers may be most\\naffected in spring, summer, or fall, depending on\\nwhich plants provoke a response. The amount of pollen\\nin the air is reflected in the pollen count, often broad-\\ncast on the daily news during allergy season. Pollen\\ncounts tend to be lower after a good rain that washes\\nthe pollen out of the air and higher on warm, dry,\\nwindy days.\\nVirtually any type of tree or grass may cause AR.\\nA few types of weeds that tend to cause the most\\ntrouble for people include the following:\\n/C15ragweed\\n/C15sagebrush\\n/C15lamb’s-quarters\\n/C15plantain\\n/C15pigweed\\n/C15dock/sorrel\\n/C15tumbleweed\\nPerennial AR is often triggered by house dust, a\\ncomplicated mixture of airborne particles, many of\\nwhich are potent allergens. House dust contains\\nsome or all of the following:\\n/C15house 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\\neasily become airborne.\\n/C15animal dander. Animals constantly shed fur, skin\\nflakes, and dried saliva. Carried in the air, or trans-\\nferred from pet to owner by direct contact, dander\\ncan cause allergy in many sensitive people.\\n/C15mold spores. Molds live in damp spots throughout\\nthe house, including basements, bathrooms, air\\nducts, air conditioners, refrigerator drains, damp\\nwindowsills, mattresses, and stuffed furniture.\\nMildew and other molds release airborne spores\\nthat circulate throughout the house.\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAnaphylaxis— Increased sensitivity caused by pre-\\nvious exposure to an allergen1 that can result in\\nblood vessel dilation (swelling) and smooth muscle\\ncontraction. Anaphylaxis can result in sharp blood\\npressure 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 that\\nactivates pain receptors and causes cells to become\\nleaky.\\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 immunoglo-\\nbulin type E (IgE) on its cell surface, and participates\\nin the allergic response by releasing histamine from\\nintracellular granules.\\n118 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic rhinitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Other potential causes of perennial allergic rhini-\\ntis include the following:\\n/C15cigarette smoke\\n/C15perfume\\n/C15cosmetics\\n/C15cleansers\\n/C15copier chemicals\\n/C15industrial chemicals\\n/C15construction material gases\\nSymptoms\\nInflammation of the nose, or rhinitis, is the\\nmajor symptom of AR. Inflammation causes itching,\\nsneezing, runny nose, redness, and tenderness. Sinus\\nswelling can constrict the eustachian tube that con-\\nnects the inner ear to the throat, causing a congested\\nfeeling and ‘‘ear popping.’’ The drip of mucus from the\\nsinuses down the back of the throat, combined with\\nincreased sensitivity, can also lead to throat irritation\\nand redness. AR usually also causes redness,itching,\\nand watery eyes. Fatigue and headache are also\\ncommon.\\nDiagnosis\\nDiagnosing seasonal AR is usually easy and can\\noften be done without a medical specialist. When\\nsymptoms appear in spring or summer and disappear\\nwith the onset of cold weather, seasonal AR is almost\\ncertainly the culprit. Other causes of rhinitis, includ-\\ning infection, can usually be ruled out by aphysical\\nexamination and a nasal smear, in which a sample of\\nmucus is taken on a swab for examination.\\nAllergy tests, including skin testing and provo-\\ncation testing, can help identify the precise culprit,\\nbut may not be done unless a single source is\\nsuspected and subsequent avoidance is possible.\\nSkin testing involves placing a small amount of\\nliquid containing a specific allergen on the skin and\\nthen either poking, scratching, or injecting it into\\nthe skin surface to observe whether redness and\\nswellings occurs. Provocation testing involves chal-\\nlenging an individual with either a small amount of\\nan inhalable or ingestable allergen to see if a response\\nis elicited.\\nPerennial AR can also usually be diagnosed by\\ncareful questioning about the timing of exposure\\nand the onset of symptoms. Specific allergens can be\\nidentified through allergy skin testing.\\nTreatment\\nAvoidance of the allergens is the best treatment,\\nbut this is often not possible. When it is not possible to\\navoid one or more allergens, there are two major forms\\nof medical 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\\neffective when used preventively, before symptoms\\nappear. A wide variety of antihistamines are available.\\nOlder antihistamines often produce drowsiness as\\na major side effect. Such antihistamines include the\\nfollowing:\\n/C15diphenhydramine (Benadryl and generics)\\n/C15chlorpheniramine (Chlor-trimeton and generics)\\n/C15brompheniramine (Dimetane and generics)\\n/C15clemastine (Tavist and generics).\\nNewer antihistamines that do not cause drowsi-\\nness are available by prescription and include the\\nfollowing:\\n/C15astemizole (Hismanal)\\n/C15fexofenadine (Allegra)\\n/C15cetirizine (Zyrtec)\\n/C15azelastin HCl (Astelin).\\nLoratidine (Claritin) was available only by pre-\\nscription but was released to over-the-counter status\\nby the FDA.\\nHismanal has the potential to cause serious heart\\narrhythmias when taken with the antibiotic erythro-\\nmycin, the antifungal drugs ketoconazole and itracona-\\nzole, orthe antimalarialdrugquinine.Taking morethan\\nthe 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\\nof this potential and because of the availability of an\\nequally effective, safer alternative drug, fexofenadine.\\nLEUKOTRIENE RECEPTOR ANTAGONISTS. Leuko-\\ntriene receptor antagonists (montelukast or Singulair\\nand zafirlukast or Accolate) are a newer class of drugs\\nused daily to help preventasthma. They’ve also become\\napproved in the United States to treat allergic rhinitis.\\nDECONGESTANTS. Decongestants constrict blood\\nvessels to counteract the effects of histamine. This\\ndecreases the amount of blood in the nasopahryngeal\\nGALE ENCYCLOPEDIA OF MEDICINE 119\\nAllergic rhinitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and sinus mucosa and reduces swelling. Nasal sprays\\nare available that can be applied directly to the nasal\\nlining and oral systemic preparations are available.\\nDecongestants are stimulants and may cause increased\\nheart rate and blood pressure, headaches, isomnia,\\nagitation and difficulty emptying the bladder. Use of\\ntopical decongestants for longer than several days can\\ncause loss of effectiveness and rebound congestion, in\\nwhich nasal passages become more severely swollen\\nthan before treatment.\\nTOPICAL CORTICOSTEROIDS. Topical corticoster-\\noids reduce mucous membrane inflammation and are\\navailable by prescription. Allergies tend to become\\nworse as the season progresses because the immune\\nsystem becomes sensitized to particular antigens and\\ncan produce a faster, stronger response. Topical\\ncorticosteroids are especially effective at reducing this\\nseasonal sensitization because they work more slowly\\nand last longer than most other medication types. As\\na result, they are best started before allergy season\\nbegins. Side effects are usually mild, but may include\\nheadaches, nosebleeds, and unpleasant taste sensations.\\nMAST CELL STABILIZERS. Cromolyn sodium pre-\\nvents the release of mast cell granules, thereby pre-\\nventing release of histamine and the other chemicals\\ncontained in them. It acts as a preventive treatment if it\\nis begun several weeks before the onset of the allergy\\nseason. It can be used for perennial AR as well.\\nImmunotherapy\\nImmunotherapy, also known as desensitization or\\nallergy shots, alters the balance of antibody types in the\\nbody,therebyreducingtheabilityofIgEtocauseallergic\\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 moni-\\ntored closely following each shot because of the small\\nrisk ofanaphylaxis, a condition that can result in diffi-\\nculty breathing and a sharp drop in blood pressure.\\nAlternative treatment\\nAlternative treatments for AR often focus on mod-\\nulation of the body’s immune response, and\\nfrequently center around diet and lifestyle adjustments.\\nChinese herbal medicine can help rebalance a person’s\\nsystem, as can both acute and constitutional homeo-\\npathic treatment. Vitamin C in substantial amounts can\\nhelp stabilize the mucous membrane response. For\\nsymptom relief, western herbal remedies including eyeb-\\nright(Euphrasiaofficinalis)andnettle( Urticadioica)may\\nbe helpful. Bee pollen may also be effective in alleviating\\nor eliminating AR symptoms. A 2004 report said that\\nphototherapy(treatment with a combination of ultravio-\\nlet and visible light) decreased the symptoms of allergic\\nrhinitis in a majority of patients who did not respond well\\nto traditional drug treatment.\\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\\nmay also get worse or expand to include new allergens.\\nEarly treatment can help prevent an increased sensiti-\\nzation to other allergens.\\nPrevention\\nReducing exposure to pollen may improve symp-\\ntoms of seasonal AR. Strategies include the following:\\n/C15stay indoors with windows closed during the morn-\\ning hours, when pollen levels are highest\\n/C15keep car windows up while driving\\n/C15use a surgical face mask when outside\\n/C15avoid uncut fields\\n/C15learn which trees are producing pollen in which sea-\\nsons, and avoid forests at the height of pollen season\\n/C15wash clothes and hair after being outside\\n/C15clean air conditioner filters in the home regularly\\n/C15use electrostatic filters for central air conditioning\\nMoving to a region with lower pollen levels is\\nrarely effective, since new allergies often develop\\nPreventing perennial AR requires identification of\\nthe responsible allergens.\\nMold spores:\\n/C15keep the house dry through ventilation and use of\\ndehumidifiers\\n/C15use a disinfectant such as dilute bleach to clean\\nsurfaces such as bathroom floors and walls\\n/C15have ducts cleaned and disinfected\\n/C15clean and disinfect air conditioners and coolers\\n/C15throw out moldy or mildewed books, shoes, pillows,\\nor furniture\\nHouse dust:\\n/C15vacuum frequently, and change the bag regularly. Use\\na bag with small pores to catch extra-fine particles\\n120 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergic rhinitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15clean floors and walls with a damp mop\\n/C15install electrostatic filters in heating and cooling\\nducts, and change all filters regularly\\nAnimal dander:\\n/C15avoid contact if possible\\n/C15wash hands after contact\\n/C15vacuum frequently\\n/C15keep pets out of the bedroom, and off furniture, rugs,\\nand other dander-catching surfaces\\n/C15have your pets bathed and groomed frequently\\nResources\\nPERIODICALS\\nFinn, Robert. ‘‘Rhinoohototherapy Targets Allergic\\nRhinitis.’’ Skin & Allergy News (July 2004): 62.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nRichard Robinson\\nTeresa G. Odle\\nAllergies\\nDefinition\\nAllergies are abnormal reactions of the immune\\nsystem that occur in response to otherwise harmless\\nsubstances.\\nDescription\\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\\nlargest reason for school absence and is a major source\\nof lost productivity in the workplace.\\nAn allergy is a type of immune reaction. Normally,\\nthe immune system responds to foreign microorgan-\\nisms or particles by producing specific proteins called\\nantibodies. These antibodies are capable of binding\\nto identifying molecules, or antigens, on the foreign\\nparticle. This reaction between antibody and antigen\\nsets off a series of chemical reactions designed to pro-\\ntect the body from infection. Sometimes, this same\\nseries of reactions is triggered by harmless, everyday\\nsubstances such as pollen, dust, and animal danders.\\nWhen this occurs, an allergy develops against the\\noffending substance (an allergen.)\\nMast cells, one of the major players in allergic\\nreactions, capture and display a particular type of\\nantibody, called immunoglobulin type E (IgE) that\\nbinds to allergens. Inside mast cells are small chemi-\\ncal-filled packets called granules. Granules contain a\\nvariety of potent chemicals, including histamine.\\nImmunologists separate allergic reactions into\\ntwo main types: immediate hypersensitivity reactions,\\nwhich are predominantly mast cell-mediated and\\noccur within minutes of contact with allergen; and\\ndelayed hypersensitivity reactions, mediated by\\nT cells (a type of white blood cells) and occurring\\nhours to days after exposure.\\nInhaled or ingested allergens usually cause\\nimmediate hypersensitivity reactions. Allergens bind\\nto IgE antibodies on the surface of mast cells, which\\nspill the contents of their granules out onto neighbor-\\ning cells, including blood vessels and nerve cells.\\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 increased leakiness, leading to the fluid\\ncollection, swelling and increased redness. Histamine\\nalso stimulates pain receptors, making tissue more\\nsensitive and irritable. Symptoms last from one to\\nseveral hours following contact.\\nIn the upper airways and eyes, immediate hyper-\\nsensitivity reactions cause the runny nose and itchy,\\nbloodshot eyes typical ofallergic rhinitis. In the gas-\\ntrointestinal tract, these reactions lead to swelling and\\nirritation of the intestinal lining, which causes the\\ncramping and diarrhea typical of food allergy.\\nAllergens that enter the circulation may causehives,\\nangioedema, anaphylaxis,o ratopic dermatitis.\\nAllergens on the skin usually cause delayed hyper-\\nsensitivity reaction. Roving T cells contact the aller-\\ngen, setting in motion a more prolonged immune\\nresponse. This type of allergic response may develop\\nover several days following contact with the allergen,\\nand symptoms may persist for a week or more.\\nCauses and symptoms\\nAllergens enter the body through four main\\nroutes: the airways, the skin, the gastrointestinal\\ntract, and the circulatory system.\\n/C15Airborne allergens cause the sneezing, runny nose,\\nand itchy, bloodshot eyes of hay fever (allergicrhini-\\ntis). Airborne allergens can also affect the lining of\\nthe lungs, causing asthma, or conjunctivitis (pink\\nGALE ENCYCLOPEDIA OF MEDICINE 121\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content=\"Allergic 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.)\\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\\nreducin\\ng swelling, congestion and irritation.\\nAntihistamines\\nSECOND EXPOSURE\\nSecond and subsequent exposure to allergen.(Illustration by Hans & Cassady.)\\n122 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies\"),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='eye). Exposure to cockroach allergens has been asso-\\nciated with the development of asthma. Airborne\\nallergens from household pets are another common\\nsource of environmental exposure.\\n/C15Allergens in food can causeitching and swelling of\\nthe lips and throat, cramps, and diarrhea. When\\nabsorbed into the bloodstream, they may cause\\nhives (urticaria) or more severe reactions involving\\nrecurrent, non-inflammatory swelling of the skin,\\nmucous membranes, organs, and brain (angioe-\\ndema). Some food allergens may cause anaphylaxis,\\na potentially life-threatening condition marked by\\ntissue swelling, airway constriction, and drop in\\nblood pressure. Allergies to foods such as cow’s\\nmilk, eggs, nuts, fish, and legumes (peanuts and soy-\\nbeans) are common. Allergies to fruits and vegeta-\\nbles may also occur.\\n/C15In contact with the skin, allergens can cause redden-\\ning, itching, and blistering, called contactdermatitis.\\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 caus-\\ning nonimmune damage to skin cells (such as soap,\\ncold, and chemical agents).\\n/C15Injection of allergens, from insectbites and stingsor\\ndrug administration, can introduce allergens directly\\ninto the circulation, where they may cause system-\\nwide responses (including anaphylaxis), as well as\\nthe local ones of swelling and irritation at the injec-\\ntion 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\\nsensitive to nuts but not to any other food. Allergies\\nmay get worse over time. For example, childhood rag-\\nweed allergy may progress to year-round dust and\\npollen allergy. On the other hand, a person may lose\\nallergic sensitivity. Infant or childhood atopic derma-\\ntitis disappears in almost all people. More commonly,\\nwhat seems to be loss of sensitivity is instead a reduced\\nexposure to allergens or an increased tolerance for the\\nsame level of symptoms.\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAllergic rhinitis— Inflammation of the mucous mem-\\nbranes of the nose and eyes in response to an\\nallergen.\\nAnaphylaxis— Increased sensitivity caused by pre-\\nvious exposure to an allergen that can result in\\nblood vessel dilation and smooth muscle contrac-\\ntion. Anaphylaxis 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 reacts\\nby 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 of\\nexposure 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 eyelids,\\ndisplays a type of antibody called immunoglobulin\\ntype E (IgE) on its cell surface, and participates in the\\nallergic response by releasing histamine from intra-\\ncellular granules.\\nT cells— Immune system cells or more specifically,\\nwhite blood cells, that stimulate cells to create and\\nrelease antibodies.\\nGALE ENCYCLOPEDIA OF MEDICINE 123\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='While allergy to specific allergens is not inherited, the\\nlikelihood of developing sometype of allergy seems to be,\\nat least for many people. If neither parent has allergies,\\nthe chances of a child developing allergy is approximately\\n10-20%; if one parent has allergies, it is 30-50%; and if\\nboth have allergies, it is 40-75%. One source of this\\ngenetic predisposition is in the ability to produce higher\\nlevels of IgE in response to allergens. Those who produce\\nmore IgE will develop a stronger allergic sensitivity.\\nCOMMON ALLERGENS. The most common air-\\nborne allergens are the following:\\n/C15plant pollens\\n/C15animal fur and dander\\n/C15body parts from house mites (microscopic creatures\\nfound in all houses)\\n/C15house dust\\n/C15mold spores\\n/C15cigarette smoke\\n/C15solvents\\n/C15cleaners\\nCommon food allergens include the following:\\nThe following types of drugs commonly cause\\nallergic reactions:\\n/C15penicillin or otherantibiotics\\n/C15flu vaccines\\n/C15tetanus toxoid vaccine\\n/C15gamma globulin\\nCommon causes ofcontact dermatitisinclude the\\nfollowing:\\n/C15poison ivy, oak, and sumac\\n/C15nickel or nickel alloys\\n/C15latex\\nInsects and other arthropods whose bites or stings\\ntypically cause allergy include the following:\\n/C15bees, wasps, and hornets\\n/C15mosquitoes\\n/C15fleas\\n/C15scabies\\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\\ndue to post-nasal drip. Inflammation of the thin mem-\\nbrane covering the eye (allergicconjunctivitis) causes\\nredness, irritation, and increased tearing in the eyes.\\nAsthma causeswheezing, coughing, and shortness of\\nbreath. Symptoms of food allergies depend on the\\ntissues most sensitive to the allergen and whether the\\nallergen was spread systemically by the circulatory\\nsystem. Gastrointestinal symptoms may include swel-\\nling andtingling in the lips, tongue, palate or throat;\\nnausea; cramping; diarrhea; and gas. Contact derma-\\ntitis is marked by reddened, itchy, weepy skin blisters,\\nand an eczema that is slow to heal. It sometimes has a\\ncharacteritic man-made pattern, such as a glove\\nallergy with clear demarkation on the hands, wrist,\\nand arms where the gloves are worn, or on the earlobes\\nby 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\\ncases, loss of consciousness. Other syptoms may\\ninclude, dizziness, weakness, seizures, coughing, flush-\\ning, or cramping. The symptoms may begin within five\\nminutes after exposure to the allergen up to one hour\\nor more later. Mast cells in the tissues and basophils in\\nthe blood release mediators that give rise to the clinical\\nsymptoms of this IgE-mediated hypersensitivity reac-\\ntion. Commonly, this is associated with allergies to\\nmedications, foods, and insect venoms. In some indivi-\\nduals, anaphylaxis can occur withexercise,p l a s m a\\nexchange, hemodialysis, reaction to insulin, contrast\\nmedia used in certain types of medical tests, and rarely\\nduring the administration 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 aller-\\ngic reaction and this occurs repeatedly upon exposure\\nto the suspected allergen.Allergy testscan be used to\\nidentify potential allergens, but these must be sup-\\nported by eveidence of allergic responses in the\\npatient’s clinical history.\\nSkin tests\\nSkin tests are performed by administering a tiny\\ndose of the suspected allergen by pricking, scratching,\\n124 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='puncturing or injecting the skin. The allergen is\\napplied to the skin as an auqeous extract, usually on\\nthe back, forearms, or top of the thighs. Once in the\\nskin, the allergen may produce a classic immune wheal\\nand flare response (a skin lesion with a raised, white,\\ncompressible area surrounded by a red flare). The tests\\nusually begin with prick tests or patch tests that expose\\nthe skin to small amounts of allergen to observe the\\nresponse. A positive reaction will occur on the skin\\neven if the allergen is at levels normally encountered in\\nfood or in the airways. Reactions are usually evaluated\\napproximately fifteen minutes after exposure.\\nIntradermal skin tests involved injection of the aller-\\ngen into the dermis of the skin. These tests are more\\nsensitive and are used for allergies associated with risk\\nof death, such as allergies to antibiotics.\\nAllergen-Specific IgE Measurement\\nTests that measure allergen-specific IgE antibo-\\ndies generally follow a basic method. The allergen is\\nbound to a solid support, either in the form of a\\ncellulose sponge, microtiter plate, or paper disk. The\\npatient’s serum is prepared from a blood sample and is\\nincubated with the solid phase. If allergen specific IgE\\nantibodies are present, they will bind to the solid phase\\nand be retained there when the rest of the serum is\\nwashed away. Next, an labeled antibody against the\\nIgE is added and will bind to any IgE on the solid\\nphase. The excess is washed away and the levels of IgE\\nare determined. The commonly used RAST test (radio\\nallergo sorbent test) employed radio-labeled Anti-IgE\\nantibodies. Updated methods now incorporate the use\\nof enyzme-labeled antibodies in ELISA assays\\n(enzyme-linked immunosorbent 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\\npeople. However, this may not always be the case as\\nthere is considerable overlap between the two groups.\\nThis test is useful for the diagnosis of allergic fungal\\nsinusitis and bronchopulmonaryaspergillosis. Other\\nconditions that are not allergic in nature may give\\nrise to higher IgE levels such assmoking, AIDS, infec-\\ntion with parasites, and IgE myeloma.\\nProvocation tests\\nThese tests involve the administration of allergen to\\nelicit an immune response. Provocation tests, most com-\\nmonly done with airborne allergens, present the allergen\\ndirectly through the routenormally involved. Delayed\\nallergic contact dermatitis diagnosis involves similar\\nmethods by application of a skin patch with allergen\\nto induce an allergic skin reaction. Food allergen provo-\\ncation tests require abstinence from the suspect allergen\\nf o rt w ow e e k so rm o r e ,f o l l o w e db yi n g e s t i o no fa\\nmeasured amount of the test substance administered as\\nan opaque capsule along with a placebo control.\\nProvocation tests are not used if anaphylaxis is is a\\nconcern due to the patient’s medical history.\\nFuture diagnostic methods\\nAttempts have been made for direct measurement\\nof immune mediators such as histamine, eosinophil\\ncationic protein (ECP), and mast cell tryptase.\\nAnother, somewhat controversial,test is electrodermal\\ntesting or electro-acupuncture allergy testing. This test\\nhas been used in Europe and is under investigation in\\nthe United States, though not approved by the Food\\nand Drug Administration. An electric potential is\\napplied to the skin, the allergen presented, and the\\nelectrical resistance observed for changes. This\\nmethod has not been verified.\\nTreatment\\nAvoiding allergens is the first line of defense to\\nreduce the possibility of an allergic attack. It is helpful\\nto avoid environmental irritants such as tobacco\\nsmoke, perfumes, household cleaning agents, paints,\\nglues, air fresheners, and potpourri. Nitrogen dioxide\\nfrom poorly vented gas stoves, woodburning stoves,\\nand artificial fireplaces has also been linked to poor\\nasthma control. Dust mite control is particularly\\nimportant in the bedroom areas by use of allergen-\\nimpermeable covers on mattress and pillows, frequent\\nwashing of bedding in hot water, and removal of items\\nthat collect dust such as stuffed toys. Mold growth may\\nbe reduced by lowering indoor humidity, repair of\\nhouse foundations to reduce indoor leaks and seepage,\\nand installing exhaust systems to ventilate areas where\\nsteam is generated such as the bathroom or kitchen.\\nAllergic individuals should avoid pet allergens such as\\nsaliva, body excretions, pelts, urine, or feces. For those\\nwho insist on keeping a pet, restriction of the animal’s\\nactivity to certain areas of the home may be beneficial.\\nComplete environmental control is often difficult\\nto accomplish, hence therapuetic interventions may\\nbecome necessary. A large number of prescription\\nand over-the-counter drugs are available for treatment\\nof immediate hypersensitivity reactions. Most of these\\nwork by decreasing the ability of histamine to provoke\\nsymptoms. Other drugs counteract the effects of\\nGALE ENCYCLOPEDIA OF MEDICINE 125\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='histamine by stimulating other systems or reducing\\nimmune responses 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\\npreventively, before symptoms appear. Antihistamines\\nhelp reduce sneezing, itching, and rhinorrhea. A wide\\nvariety of antihistamines are available.\\nOlder, first generation antihistamines often pro-\\nduce drowsiness as a major side effect, as well asdry\\nmouth, tachycardia, blurred vision,constipation, and\\nlower the threshold for seizures. These medications\\nalso have similar effects to a alcohol and care should\\nbe taken when operating motor vehicles, as individuals\\nmay not be aware that they are impaired. Such anti-\\nhistamines include the following:\\n/C15diphenhydramine (Benadryl and generics)\\n/C15chlorpheniramine (Chlor-trimeton and generics)\\n/C15brompheniramine (Dimetane and generics)\\n/C15clemastine (Tavist and generics)\\nNewer antihistamines that do not cause drowsi-\\nness or pass the blood-brain barrier are available by\\nprescription and include the following:\\n/C15loratidine (Claritin)\\n/C15cetirizine (Zyrtec)\\n/C15fexofenadine (Allegra)\\nDesloratadine (Clarinex) was approved in 2004 in\\nsyrup form for children two years and older for seaso-\\nnal allergies and for hives of unknown cause in chil-\\ndren as young as six months. It is the only nonsedating\\nantihistamine approved as of 2004 for children as\\nyoung as six months.\\nHismanal has the potential to cause serious heart\\narrhythmiaswhen taken with the antibiotic erythromy-\\ncin, the antifungal drugs ketoconazole and itraconazole,\\nor the antimalarial drug quinine. Taking more than the\\nrecommended 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\\nequally 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\\nlining and oral systematic preparations are available.\\nDecongestants are stimulants and may cause increased\\nheart rate and blood pressure, headaches,insomnia,\\nagitation, and difficulty emptying the bladder. Use of\\ntopical decongestants for longer than several days can\\ncause loss of effectiveness and rebound congestion,\\nin which nasal passages become more severely swollen\\nthan before treatment.\\nTopical corticosteroids\\nTopical corticosteroids reduce mucous membrane\\ninflammation by decreasing the amount of fluid moved\\nfrom the vascular spaces into the tissues. These medica-\\ntions reduce the recruitment of inflammatory cells as\\nwell as the synthesis of cytokines. They are available by\\nprescription. Allergies tend to become worse as the\\nseason progresses because the immune system becomes\\nsensitized to particular antigens and can produce a\\nfaster, stronger response. Topical corticosteroids are\\nespecially effective at reducing this seasonal sensitiza-\\ntion because they work more slowly and last longer\\nthan most other medication types. As a result, they\\nare 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\\ncause the airways or bronchial tubes to narrow, as in\\nasthma, bronchodilators, which cause the smooth mus-\\ncle lining the airways to open or dilate, can be very\\neffective. When inhalers are used, it is important that\\nthe patient be educated in the proper use of these\\nmedications. The inhaler should be shaken, and the\\npatient should breathe out to expel air from the lungs.\\nThe inhaler should be placed at least two finger-\\nbreadths in front of the mouth. The medication should\\nbe aimed at the back of the throat, and the inhaler\\nactivated while breathing in quite slowly 3-4 seconds.\\nThe breath should be held for at least ten seconds, and\\nthen expelled. At least thirty to sixty seconds should\\npass before the inhaler is used again. Care should be\\ntaken to properly wash out the mouth and brush the\\nteeth following use, as residual medication remains in\\nthis area with only a small amount actually reaching\\nthe lungs. Some bronchodilators used to treat acute\\nasthma attacks include adrenaline, albuterol, Maxair,\\nProventil, or other ‘‘adrenoceptor stimulants,’’ most\\noften administered as aerosols. Successfully managing\\nasthma and allergies can reduce the use of inhalers.\\n126 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='This is done through good communication between\\nthe physician and patient, self-management with writ-\\nten action plans, avoiding allergy triggers, and\\nthrough the use of preventive medications such as\\nmontelukast.\\nAnticholinergics\\nIpratropium bromide (atrovent) and atropine sul-\\nfate are achticholinergic drugs used for the treatment\\nof asthma. Ipratropium is used for treating asthmatics\\nin emergency situations with a nebulizer.\\nNonsteroidal drugs\\nMAST CELL STABILIZERS. Cromolyn sodium pre-\\nvents the release of mast cell granules, thereby pre-\\nventing the release of histamine and other chemicals\\ncontained in them. It acts as a preventive treatment if it\\nis begun several weeks before the onset of the allergy\\nseason. It can also be used for year round allergy\\nprevention. Cromolyn sodium is available as a nasal\\nspray for allergic rhinitis and in aerosol (a suspension\\nof particles in gas) form for asthma.\\nLEUKOTRIENE MODIFIERS. These medications are\\nuseful for individuals with aspirin sensitivity,sinusitis,\\npolposis, urticaria. Examples include zafirlukast\\n(Accolate), montelukast (Singulair), and zileuton\\n(Zyflo). When zileuton is used, care must be taken to\\nmeasure liver 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\\nmedications. A 2004 study recommended that children\\nwho have severe reactions to insect sting receive immu-\\nnotherapy to protect them against future stings.\\nTreatment of contact dermatitis\\nAn individual suffering from contact dermatitis\\nshould initially take steps to avoid possible sources of\\nexposure to the offending agent. Calamine lotion\\napplied to affected skin can reduce irritation somewhat,\\nas can cold water compresses. Side effects of topical\\nagents may include over-drying of the skin. In the case\\nof acute contact dermatitis, short-term oral corticoste-\\nroid therapy may be appropriate. Moderately strong\\ncoricosteroids can also be applied as a wrap for twenty-\\nfour hours. Health care workers are especially at risk\\nfor hand eruptions due to glove use.\\nTreatment of anaphylaxis\\nThe emergency condition of anaphylaxis is treated\\nwith injection of adrenaline, also known as epinephr-\\nine. People who are prone to anaphylaxis because\\nof food or insect allergies often carry an ‘‘Epi-pen’’\\ncontaining adrenaline in a hypodermic needle. Other\\nmedications may be given to aid the action of the epi-\\npen. Prompt injection can prevent a more serious\\nreaction from developing. Particular care should be\\ntaken to assess the affected individual’s airway status,\\nand he or she should be placed in a recumbent pose\\nand vital signs determined. If a reaction resulted from\\ninsect sting or an injection, a tourniquet may need\\nto be placed proximal to the area where the agent\\npenetrated the skin. This should then be released at\\nintervals of ten minutes at a time, for one to two\\nminutes duration. If the individual does not respond\\nto such interventions, then emergency treatment is\\nappropriate.\\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\\nis critical, as they are still ‘‘drugs’’ even though they\\nare derived from natural sources. Various categories\\nof alternative remedies may be helpful in allergy treat-\\nment, including:\\n/C15antihistamines: vitamin C and the bioflavonoid\\nhesperidin act as natural anithistamines.\\n/C15decongestants: vitamin C, the homeopathic reme-\\ndies Ferrum phosphoricum and Kali muriaticum\\n(used alternately), and the dietary supplement\\nN-acetylcysteine are believed to have deconge-\\nstant effects.\\n/C15mast cell stabilizers: the bioflavonoids quercetin and\\nhesperidin may help stabilize mast cells.\\n/C15immunotherapy: the herbs echinacea (Echinacea\\nspp.) and astragalus or milk-vetch root (Astragalus\\nmembranaceus) may possibly help to strengthen the\\nimmune system.\\n/C15bronchodilators: the herbal remedies ephedra\\n(Ephedra sinica , also known as ma huang in tradi-\\ntional Chinese medicine), khellin (Ammi visnaga) and\\ncramp bark (Viburnum opulus ) are believed to help\\nopen the airways.\\nGALE ENCYCLOPEDIA OF MEDICINE 127\\nAllergies'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment of contact dermatitis\\nA variety of herbal remedies, either applied topi-\\ncally or taken internally, may possibly assist in the\\ntreatment of contact dermatitis. A poultice (crushed\\nherbs applied directly to the affected area) made of\\njewelweed (Impatiens spp.) or chickweed (Stellaria\\nmedia) may soothe the skin. A cream or wash contain-\\ning calendula (Calendula officinalis), a natural antisep-\\ntic and anti-inflammatory agent, may help heal the\\nrash when applied topically. Homeopathic treatment\\nmay include such remedies as Rhus toxicodendron ,\\nApis mellifica ,o r Anacardium taken internally. A\\nqualified homeopathic practitioner should be con-\\nsulted to match the symptoms with the correct remedy.\\nCare should be taken with any agent taken internally.\\nPrognosis\\nAllergies can improve over time, although they\\noften worsen. While anaphylaxis and severe asthma\\nare life-threatening, other allergic reactions are not.\\nLearning to recognize and avoid allergy-provoking\\nsituations allows most people with allergies to lead\\nnormal 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 aller-\\ngens that are causing reactions, most people can learn to\\navoid allergic reactions from food, drugs, and contact\\nallergens such as poison ivy or latex. The government\\nwill help now, since passing the Food Allergen Labeling\\nand Consumer Protection Act in 2004. Beginning\\nJanuary 1, 2006, food manufacturers will be required\\nto clearly state if a product contains any of the eight\\nmajor food allergens that are responsible for more than\\n90% of allergic reactions to foods. These are milk,\\neggs, peanuts, tree nuts, fish, shellfish, wheat, and soy.\\nAirborne allergens are more difficult to avoid,\\nalthough keeping dust and animal dander from col-\\nlecting in the house may limit exposure. Cromolyn\\nsodium can prevent mast cell degranulation, thereby\\nlimiting 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\\nallergy testing to determine the precise allergens\\nresponsible. Injections involve very small but gradu-\\nally increasing amounts of allergen, over several weeks\\nor months, with periodic boosters. Full benefits may\\ntake up to several years to achieve and are not seen at\\nall in about one in five patients. Individuals receiving\\nall shots 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, such as leukotriene modifiers, are\\nused to prevent asthma attacks and in the long-term\\nmanagement of allergies and asthma.\\nResources\\nBOOKS\\nHans-Uwe, Simon, editor.CRC Desk Reference for Allergy\\nand Asthma. Boca Raton: CRC Press, 2000.\\nKemp, Stephen F., and Richard Lockey, editors.Diagnostic\\nTesting of Allergic Disease. New York: Marcel Dekker,\\nInc., 2000.\\nLieberman, Phil, and Johh Anderson, editors.Allergic\\nDiseases: Diagnosis and Treatment. 2nd ed. Totowa:\\nHumana Press, Inc., 2000.\\nPERIODICALS\\n‘‘Children With Serious Insect-sting Allergies Should Get\\nShots.’’ Drug Week (September 3, 2004): 19.\\n‘‘FDA Approves Clarinex Syrup for Allergies and Hives in\\nChildren.’’ Biotech Week (September 29, 2004): 617.\\n‘‘President Bush Signs Bill that Will Benefit Millions With\\nFood Allergies.’’Immunotherapy Weekly (September 1,\\n2004): 50.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nRichard Robinson\\nJill Granger, MS\\nTeresa G. Odle\\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.\\nNormally, the immune system responds to foreign\\nmicroorganisms and particles, like pollen or dust,\\nby producing specific proteins called antibodies that\\nare capable of binding to identifying molecules, or\\nantigens, on the foreign organisms. This reaction\\nbetween antibody and antigen sets off a series of\\nreactions designed to protect the body from infec-\\ntion. Sometimes, this sam e series of reactions is\\n128 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergy tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='triggered by harmless, everyday substances. This is\\nthe condition known as allergy, and the offending\\nsubstance is called an allergen. Common inhaled\\nallergens include pollen,dust, and insect parts from\\ntiny house mites. Common food allergens include\\nnuts, fish, and milk.\\nAllergic reactions involve a special set of cells\\nin the immune system known as mast cells. Mast\\ncells serve as guards in the tissues where the body\\nmeets the outside world: the skin, the mucous\\nmembranes of the eyes and other areas, and the lin-\\nings of the respiratory and digestive systems. Mast\\ncells display a special typeof antibody, called immu-\\nnoglobulin 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 the release of 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\\nvessels causes neighboring cells to become leaky,\\nleading to the fluid collection, swelling, and increased\\nredness characteristic of a runny nose and red, irri-\\ntated eyes. Histamine also stimulatespain receptors,\\ncausing the itchy, scratchy nose, eyes, and throat\\ncommon inallergic rhinitis.\\nThe particular allergens to which a person is sen-\\nsitive can be determined through allergy testing.\\nAllergy tests may be performed on the skin or using\\nblood serum in a test tube. During skin tests, potential\\nallergens are placed on the skin and the reaction\\nis observed. In radio-allergosorbent allergy testing\\n(RAST), a patient’s blood serum is combined\\nwith allergen in a test tube to determine if serum anti-\\nbodies react with the allergen. Provocation testing\\ninvolves direct exposure to a likely allergen, either\\nthrough inhalation or ingestion. Positive reactions\\nfrom any of these tests may be used to narrow the\\ncandidates for the actual allergen causing the allergy.\\nIdentification of the allergenic substance may\\nallow the patient to avoid the substance and reduce\\nallergic reactions. In addition, allergy testing may\\nbe done in those with asthma that is difficult to\\nmanage, eczema, or skin rashes to determine if an\\nallergy is causing the condition or making it worse.\\nAllergy tests may also be done before allergen desensi-\\ntization to ensure the safety of more 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\\nThis patient is being exposed to certain allergens as part of\\nan allergy test. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nKEY TERMS\\nAllergen— A substance that provokes an allergic\\nresponse.\\nAnaphylaxis— Increased sensitivity caused by\\nprevious exposure to an allergen that can result\\nin blood vessel dilation (swelling) and smooth\\nmuscle contraction. Anaphylaxis can result in\\nsharp blood pressure drops and difficulty\\nbreathing.\\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 that\\nactivates pain receptors and causes cells to become\\nleaky.\\nMast cells— A type of immune system cell that\\nis found in the lining of the nasal passages and\\neyelids, displays a type of antibody called immu-\\nnoglobulin type E (IgE) on its cell surface, and par-\\nticipates in the allergic response by releasing\\nhistamine from intracellular granules.\\nGALE ENCYCLOPEDIA OF MEDICINE 129\\nAllergy tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='substance to which the person is sensitive. Skin reactivity\\nis seen 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/C15pollen from a variety of trees, common grasses, and\\nweeds\\n/C15mold and fungus spores\\n/C15house dust\\n/C15house mites\\n/C15animal skin cells (dander) and saliva\\n/C15food extracts\\n/C15antibiotics\\n/C15insect venoms\\nRadio-allergosorbent testing (RAST) is a labora-\\ntory test performed when a person may be too sensi-\\ntive to risk skin testing or when medications or skin\\nconditions prevent it.\\nProvocation testing is done to positively identify\\nsuspected allergens after preliminary skin testing.\\nA purified preparation of the allergen is inhaled or\\ningested in increasing concentrations to determine if\\nit will provoke a response. In 2004, scientists intro-\\nduced an optical method to continuously measure the\\nchanges in nasal mucosa (lining) changes with an\\ninfrared light to help improve the accuracy of provo-\\ncation testing. 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 asanaphylaxis\\nexists. Anaphylaxis is a potentially dangerous condi-\\ntion that can result in difficulty breathing and a sharp\\ndrop in blood pressure. People with a known history\\nof anaphylaxis should inform the testing clinician.\\nSkin tests should never include a substance known to\\ncause anaphylaxis in the person being tested.\\nProvocation tests may cause an allergic reaction.\\nTherefore, treatment medications should be available\\nfollowing 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\\nnot provoke a reaction (negative control) and a drop of\\nhistamine that should provoke a reaction (positive con-\\ntrol). A small needle is inserted through the drop, and\\nused to prick the skin below. A new needle is used for\\neach prick. The sites are examined over the next 20 min-\\nutes for evidence of swelling and redness, indicating a\\npositive reaction. In some instances, a tracing of the set\\nof reactions may be made by placing paper over\\nthe tested area. Similarly, in intradermal testing, sepa-\\nrate injections are made for each allergen tested.\\nObservations are made over the next 20 minutes.\\nIn RAST testing, a blood sample is taken for use in\\nthe laboratory, where the antibody- containing serum\\nis separated from the blood cells. The serum is then\\nexposed to allergens bound to a solid medium. If a\\nperson has antibodies to a particular allergen, those\\nantibodies will bind to the solid medium and remain\\nbehind after a rinse. Location of allergen-antibody com-\\nbinations is done by adding antibody-reactive antibo-\\ndies, so called anti-antibodies, that are chemically linked\\nwith a radioactive dye. By locating radioactive spots on\\nthe solid medium, the reactive allergens are discovered.\\nProvocation testing may be performed to identify\\nairborne or food allergens. Inhalation testing is per-\\nformed only after a patient’s lung capacity and\\nresponse to the medium used to dilute the allergen\\nhas been determined. Once this has been determined,\\nthe patient inhales increasingly concentrated samples\\nof a particular allergen, followed each time by mea-\\nsurement of the exhalation capacity. Only one allergen\\nis tested per day. Testing forfood allergies is usually\\ndone by removing the suspect food from the diet for\\ntwo weeks, followed by eating a single portion of the\\nsuspect food and follow-up monitoring.\\nA close-up of a patient’s arm after allergy testing. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\n130 GALE ENCYCLOPEDIA OF MEDICINE\\nAllergy tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Preparation\\nSkin testing is preceded by a brief examination of\\nthe skin. The patient should refrain from using anti-\\nallergy drugs for at least 48 hours before testing. Prior\\nto inhalation testing, patients with asthma who can\\ntolerate it may be asked to stop any asthma medications.\\nTesting for foodallergies requires the person to avoid\\nall suspect food for at least two weeks before testing.\\nAftercare\\nSkin testing does not usually require any aftercare.\\nA generalized 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\\nattacks, even if the antigen administered in the test\\ninitially produced no response. Severe initial reactions\\nmay justify close professional observation for at least\\n12 hours after testing.\\nRisks\\nIntradermal testing may inadvertently result in\\nthe injection of the allergen into the circulation, with\\nan increased risk of adverse reactions. Inhalation tests\\nmay provoke an asthma attack. Exposure to new or\\nunsuspected allergens in any test carries the risk of\\nanaphylaxis. Because patients are monitored follow-\\ning allergy testing, an anaphylactic reaction is usually\\nrecognized and treated promptly. Occasionally, a\\ndelayed anaphylactic response can occur that will\\nrequire immediate care. Proper patient education\\nregarding how to recognize anaphylaxis is vital.\\nNormal results\\nLack of redness or swelling on a skin test indicates\\nno allergic response. In an inhalation test, the exhala-\\ntion capacity should remain unchanged. In a food\\nchallenge, no symptoms should occur.\\nAbnormal results\\nPresence of redness or swelling, especially over\\n5 mm (1/4 inch) in diameter, indicates an allergic\\nresponse. This does not mean the substance actually\\ncauses the patient’s symptoms, however, since he or\\nshe may have no regular exposure to the allergen. In\\nfact, the actual allergen may not have been included in\\nthe 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\\nfollowing the ingestion of a suspected food allergen\\nindicates a positive response.\\nResources\\nPERIODICALS\\nHampel, U., et al. ‘‘Optical Measurements of Nasal\\nSwellings.’’ IEEE Transactions on Biomedical\\nEngineering (September 2004): 1673–1680.\\nRichard Robinson\\nTeresa G. Odle\\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\\nconditions that make people literally pull it out to\\ncomplete hair loss caused by the toxicity of cancer\\nchemotherapy. Some causes are considered natural,\\nwhile others signal serious health problems. Some\\nconditions are confined to the scalp. Others reflect\\ndisease throughout the body. Being plainly visible,\\nthe skin and its components can provide early signs\\nof disease elsewhere in the body.\\nOftentimes, conditions affecting the skin of the\\nscalp will result in hair loss. The first clue to the specific\\ncause is the pattern of hair loss, whether it be complete\\nbaldness (alopecia totalis), patchy bald spots, thinning,\\nor hair loss confined to certain areas. Also a factor is\\nthe condition of the hair and the scalp beneath it.\\nSometimes only the hair is affected; sometimes the\\nskin is visibly diseased as well.\\nCauses and symptoms\\n/C15Male pattern baldness (androgenic alopecia) is con-\\nsidered normal in adult males. It is easily recognized\\nby the distribution of hair loss over the top and front\\nof the head and by the healthy condition of the scalp.\\nGALE ENCYCLOPEDIA OF MEDICINE 131\\nAlopecia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Alopecia areata is a hair loss condition of unknown\\ncause that can be patchy or extend to complete\\nbaldness.\\n/C15Fungal infections of the scalp usually cause patchy\\nhair loss. The fungus, similar to the ones that cause\\nathlete’s footand ringworm, often glows under ultra-\\nviolet light.\\n/C15Trichotillomania is the name of a mental disorder\\nthat causes a person to pull out his or her own hair.\\n/C15Complete hair loss is a common result ofcancer\\nchemotherapy, due to the toxicity of the drugs used.\\n/C15Systemic diseases often affect hair growth either\\nselectively or by altering the skin of the scalp. One\\nexample is thyroid disorders. Hyperthyroidism\\n(too much thyroid hormone) causes hair to become\\nthin and fine. Hypothyroidism (too little thyroid\\nhormone) thickens both hair and skin.\\n/C15Several autoimmune diseases (when protective cells\\nbegin to attack self cells within the body) affect the\\nskin, notably lupus erythemematosus.\\n/C15In 2004, a report a the annual meeting of the\\nAmerican Academy of Dermatology said that alope-\\ncia was becoming nearly epidemic among black\\nwomen as a result of some hairstyles that pull too\\ntightly on the scalp and harsh chemical treatments\\nthat damage the hair shaft and follicles.\\nDiagnosis\\nDermatologists are skilled in diagnosis by sight\\nalone. For more obscure diseases, they may have to\\nresort to askin biopsy, removing a tiny bit of skin using\\na local anesthetic so that it can be examined under a\\nmicroscope. Systemic diseases will require a complete\\nevaluation by a physician, including specific tests to\\nidentify and characterize the problem.\\nTreatment\\nS u c c e s s f u lt r e a t m e n to fu n d e r l y i n gc a u s e si sm o s t\\nlikely to restore hair growth, be it the completion of\\nchemotherapy, effective cure of a scalp fungus, or con-\\ntrol of a systemic disease. Two relatively new drugs–\\nminoxidil (Rogaine) andfinasteride(Proscar)–promote\\nhair growth in a significant minority of patients,\\nespecially those with male pattern baldness and alope-\\ncia areata. While both drugs have so far proved to be\\nquite safe when used for this purpose,minoxidil is a\\nliquid that is applied to the scalp and finasteride is\\nthe first and only approved treatment in a pill form.\\nMinoxidil was approved for over-the-counter\\nsales in 1996. When used continuously for long peri-\\nods of time, minoxidil produces satisfactory results in\\nabout one-fourth of patients with androgenic alopecia\\nand as many as half the patients with alopecia areata.\\nThere is also an over-the-counter extra-strength\\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, usually\\ncancer, with drugs (chemicals).\\nHair follicles— Tiny organs in the skin, each one of\\nwhich grows a single hair.\\nLupus erythematosus— An autoimmune disease that\\ncan damage skin, joints, kidneys, and other organs.\\nRingworm— A fungal infection of the skin, usually\\nknown as tinea corporis.\\nSystemic— Affecting all or most parts of the body.\\nTop of balding male’s head. (Photograph by Kelly A. Quin.\\nReproduced by permission.)\\n132 GALE ENCYCLOPEDIA OF MEDICINE\\nAlopecia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='version of minoxidil (5% concentration) approved for\\nuse by men only. The treatment often results in new\\nhair that is thinner and lighter in color. It is important\\nto note that new hair stops growing soon after the use\\nof minoxidil is discontinued.\\nOver the past few decades a multitude of hair\\nreplacement methods have been performed by physi-\\ncians and non-physicians. They range from simply\\nweaving someone else’s hair in with the remains of\\none’s own to surgically transplanting thousands of\\nhair follicles 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 or two hairs transplanted\\nper follicle) resulted in fewer complications and the\\nbest results.\\nAnother surgical procedure used to treat andro-\\ngenic alopecia is scalp reduction. By stretching skin,\\nthe hairless scalp can be removed and the area of bald\\nskin decreased by closing the space with hair-covered\\nscalp. Hair-bearing skin can also be folded over an\\narea of bald skin with a technique called a flap.\\nStem cell research is generating new hope for\\nbaldness. Scientists know that a part of the hair follicle\\ncalled the bulge contains stem cells that can give rise to\\nnew hair and help heal skinwounds. Early research\\nwith mice in 2004 showed promise for identifying the\\ngenes that cause baldness and to identify drugs that\\ncan reverse the process.\\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\\noriginal.\\nResources\\nPERIODICALS\\nCohen, Philip. ‘‘Stem Cells Generate Hair and Hope for the\\nBald.’’ New Scientist (March 20, 2004): 17.\\nLohr, Elizabeth. ‘‘Alopecia Nearly Epidemic Among Black\\nWomen.’’ Clinical Psychiatry News (March 2004): 96.\\nNielsen, Timothy A., and Martin Reichel. ‘‘Alopecia:\\nDiagnosis and Management.’’American Family Physician.\\nOTHER\\nAndrogenetic Alopecia.com. ‘‘How can minoxidil be used to\\ntreat baldness?’’ May1, 2001. .\\nMayo Clinic. ‘‘Alopecia’’ January 26, 2001. [cited May 1,\\n2001]. .\\nWebMD Medical News. ‘‘Hair Today, Gone Tomorrow,\\nHair Again’’ 2000. [cited May 1, 2001]. .\\nBeth A. Kapes\\nTeresa G. Odle\\nAlpha-fetoprotein test\\nDefinition\\nThe alpha-fetoprotein (AFP) test is a blood test\\nthat is performed duringpregnancy. This screening\\ntest measures the level of AFP in the mother’s blood\\nand indicates the probability that the fetus has one\\nof several serious birth defects. The level of AFP can\\nalso be determined by analyzing a sample of amniotic\\nfluid. This screening test cannot diagnose a specific\\ncondition; it only indicates increased risk for several\\nbirth defects. Outside pregnancy, the AFP test is used\\nto detectliver disease, certain cancerous tumors, and\\nto monitor the 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\\nenter the mother’s blood. The level of AFP can then\\nbe determined by analyzing a sample of the mother’s\\nblood. By analyzing the amount of AFP found in a\\nblood or amniotic fluid sample, doctors can determine\\nthe probability that the fetus is at risk for certain birth\\ndefects. It is very important that the doctor know\\nprecisely how old the fetus is when the test is performed\\nsince the AFP level changes over the length of the\\npregnancy. Alone, AFP screening cannot diagnose a\\nbirth defect. The test is used as an indicator of risk and\\nthen an appropriate line of testing (such asamniocent-\\nesis or ultrasound) follows, based on the results.\\nAbnormally high AFP may indicate that the\\nfetus has an increased risk of a neural tube defect,\\nthe most common and severe type of disorder\\nassociated with increased AFP. These types of defects\\ninclude spinal column defects ( spina bifida )a n d\\nanencephaly (a severe and usually fatal brain\\nabnormality). If the tube that becomes the brain\\nGALE ENCYCLOPEDIA OF MEDICINE 133\\nAlpha-fetoprotein test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and spinal cord does not close correctly during fetal\\ndevelopment, AFP may leak through this abnormal\\nopening and enter the amniotic fluid. This leakage\\ncreates abnormally high levels of AFP in amniotic\\nfluid and in maternal blood. If the screening test\\nindicates abnormally high AFP, ultrasound is used\\nto diagnose the problem.\\nOther fetal conditions that can raise AFP levels\\nabove normal include:\\n/C15cysts at the end of the spine\\n/C15blockage in the esophagus or intestines\\n/C15liver disease causing liver cells to die\\n/C15defects in the abdominal wall\\n/C15kidney or urinary tract defects or disease\\n/C15brittle bone disease\\nLevels may also be high if there is too little fluid in\\nthe amniotic sac around the fetus, more than one\\ndeveloping fetus, or a pregnancy that is farther along\\nthan estimated.\\nFor unknown reasons, abnormally low AFP may\\nindicate that the fetus has an increased risk ofDown\\nsyndrome. Down syndrome is a condition that includes\\nmental retardation and a distinctive physical appearance\\nlinked to an abnormality ofchromosome 21 (called\\ntrisomy 21). If the screening test indicates an abnormally\\nlow AFP, amniocentesis is used to diagnose the problem.\\nAbnormally low levels of AFP can also occur when\\nthe fetus has died or when the mother is overweight.\\nAFP is often part of a ‘‘triple check’’ blood test\\nthat analyzes three substances as risk indicators of\\npossible birth defects: AFP, estriol, and human chor-\\nionic gonadotropin (HCG). When all three substances\\nare measured in the mother’s blood, the accuracy of\\nthe test results increases.\\nIn 2004, a new study showed that the risk of an\\ninfant’s death from sudden infant death syndrome\\n(SIDS) increased if levels of AFP were higher during\\nthe second trimester of the mother’s pregnancy.\\nAlthough AFP in human blood gradually disap-\\npears after birth, it never disappears entirely. It may\\nreappear in liver disease, or tumors of the liver, ovar-\\nies, or testicles. The AFP test is used to screen people\\nat high risk for these conditions. After a cancerous\\ntumor is removed, an AFP test can monitor the\\nprogress of treatment. Continued high AFP levels\\nsuggest thecancer is growing.\\nPrecautions\\nIt is very important that the doctor know precisely\\nhow old the fetus is when the test is performed since\\nthe AFP level considered normal changes over the\\nlength of the pregnancy. Errors in determining the\\nage of the fetus lead to errors when interpreting\\nthe test results. Since an AFP test is only a screening\\ntool, more specific tests must follow to make an accu-\\nrate diagnosis. An abnormal test result does not neces-\\nsarily mean that the fetus has a birth defect. The test\\nhas a high rate of abnormal results (either high or low)\\nto prevent missing a fetus that has a serious condition.\\nDescription\\nThe AFP test is usually performed at week 16 of\\npregnancy. Blood is drawn from the patient’s\\n(mother’s) vein, usually on the inside of the elbow.\\nAFP can also be measured in the sample of amniotic\\nfluid taken at the time of amniocentesis. Test results\\nare usually available after about one week.\\nPreparation\\nThere is no specific physical preparation for the\\nAFP test.\\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\\nsite, feeling faint or lightheaded after the blood is\\ndrawn, or blood accumulating under the puncture\\nsite (hematoma).\\nNormal results\\nAlpha-fetoprotein is measured in nanograms per\\nmilliliter (ng/mL) and is expressed as a probability.\\nThe probability (1:100, for example) translates into\\nthe chance that the fetus has a defect (a one in 100\\nchance, for example).\\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.\\n134 GALE ENCYCLOPEDIA OF MEDICINE\\nAlpha-fetoprotein test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='When testing for cancer or liver diseases, AFP\\nresults are reported as nanograms per milliliter. An\\nAFP level less than or equal to 50 ng/mL is considered\\nnormal.\\nAbnormal results\\nThe doctor will inform the woman of her specific\\nincreased risk as compared to the ‘‘normal’’ risk of a\\nstandard case. If the risk of Down syndrome is greater\\nthan the standard risk for women who are 35 years old\\nor older (one in 270), 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\\nrisk; appropriate diagnostic testing will follow after an\\nabnormal screening result.\\nIn tumor or liver disease testing, an AFP level\\ngreater than 50 ng/mL is considered abnormal.\\nResources\\nPERIODICALS\\nSmith, Gordon C.S., et al. ‘‘Second-trimester Maternal\\nSerum Levels of Alpha-fetoprotein and the Subsequent\\nRisk of Sudden Infant Death Syndrome.’’New England\\nJournal of Medicine (September 2, 2004): 978.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275\\nMamaroneck Ave., White Plains, NY 10605. (914)\\n428-7100. resourcecenter@modimes.org. .\\nNational Cancer Institute. Building 31, Room 10A31, 31\\nCenter Drive, MSC 2580, Bethesda, MD 20892-2580.\\n(800) 422-6237. .\\nAdrienne Massel, RN\\nTeresa G. Odle\\nAlpha-thalassemia see Thalassemia\\nAlpha1-adrenergic blockers\\nDefinition\\nAlpha1-adrenergic blockers are drugs that work\\nby blocking the alpha1-receptors of vascular smooth\\nmuscle, thus preventing the uptake of catecholamines\\nby the smooth muscle cells. This causes vasodilation\\nand allows blood to flow more easily.\\nPurpose\\nThese drugs, called alpha blockers for short, are\\nused for two main purposes: to treat high blood pres-\\nsure (hypertension) and to treat benign prostatic\\nhyperplasia (BPH), a condition that affects men and\\nis characterized by anenlarged prostategland.\\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 causingstroke, heart fail-\\nure or kidney failure. People with high blood pressure\\nmay also be at higher risk for heart attacks.\\nControlling high blood pressure makes these problems\\nless likely. Alpha blockers help lower blood pressure\\nby causing vasodilation, meaning an increase in the\\ndiameter of the blood vessels, which allows blood to\\nflow more easily.\\nBenign prostatic hyperplasia (BPH)\\nThis condition particularly affects older men.\\nOver time, the prostate, a donut-shaped gland\\nbelow the bladder, enlarges. When this happens, it\\nmay interfere with the passage of urine from the\\nbladder out of the body. Men who are diagnosed\\nwith BPH may have to urinate more often. Or they\\nmay feel that they can not completely empty their\\nbladders. Alpha blockers inhibit the contraction of\\nprostatic smooth muscle and thus relax muscles in\\nthe prostate and the bladder, allowing urine to flow\\nmore freely.\\nDescription\\nCommonly prescribed alpha blockers for hyper-\\ntension and BPH include doxazosin (Cardura, prazo-\\nsin (Minipress) and terazosin (Hytrin). Prazosin is also\\nused in the treatment of heart failure. All are available\\nonly with a physician’s prescription and are sold in\\ntablet form.\\nRecommended dosage\\nThe recommended dose depends on the patient\\nand the type of alpha blocker and may change over\\nthe course of treatment. The prescribing physician will\\ngradually increase the dosage, if necessary. Some\\npatients may need as much as 15-20 mg per day of\\nterazosin, 16 mg per day of doxazosin, or as much as\\n40 mg per day of prazosin, but most people benefit\\nfrom lower doses. As the dosage increases, so does the\\npossibility of unwanted side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 135\\nAlpha1-adrenergic blockers'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alpha blockers should be taken exactly as direc-\\nted, even if the medication does not seem to be work-\\ning at first. It should not be stopped even if symptoms\\nimprove because it needs to be taken regularly to be\\neffective. Patients should avoid missing any doses, and\\nshould not take larger or more frequent doses to make\\nup for missed doses.\\nPrecautions\\nAlpha blockers may lower blood pressure to a\\ngreater extent than desired. This can cause dizziness,\\nlightheadedness, heart palpitations,a n d fainting.\\nActivities such as driving, using machines, or doing\\nanything else that might be dangerous for 24 hours\\nafter taking the first dose should be avoided. Patients\\nshould be reminded to be especially careful not to\\nfall when getting up in the middle of the night. The\\nsame precautions are recommended if the dosage\\nis increased or if the drug has been stopped and\\nthen started again. Anyone whose safety on the job\\ncould be affected by taking alpha blockers should\\ninform his or her physician, so that the physician\\ncan take this factor into account when increasing\\ndosage.\\nSome people may feel drowsy or less alert when\\nusing these drugs. They should accordingly avoid\\ndriving or performing activities that require full\\nattention.\\nPeople diagnosed withkidney diseaseor liver dis-\\nease may also be more sensitive to alpha blockers.\\nThey should inform their physicians about these con-\\nditions if alpha blockers are prescribed. Older people\\nmay also be more sensitive and may be more likely to\\nhave unwanted side effects, such as fainting, dizziness,\\nand lightheadedness.\\nIt should be noted that alpha blockers do not cure\\nhigh blood pressure. They simply help to keep the\\ncondition under control. Similarly, these drugs will\\nnot shrink an enlarged prostate gland. Although they\\nwill help relieve the symptoms of prostate enlarge-\\nment, the prostate may continue to grow, and it even-\\ntually may be necessary to have prostate surgery.\\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 of\\nthe nine subtypes are coded by separate genes, and\\ndisplay specific drug specificities and regulatory\\nproperties.\\nAlpha blockers— Medications that bind alpha adre-\\nnergic receptors and decrease the workload of the\\nheart and lower blood pressure. They are commonly\\nused to treat hypertension, peripheral vascular dis-\\nease, and hyperplasia.\\nArteries— Blood vessels that carry oxygenated blood\\naway from the heart to the cells, tissues, and organs\\nof the body.\\nCatecholamines— Family of neurotransmitters con-\\ntaining dopamine, norepinephrine and epinephrine,\\nproduced and secreted by cells of the adrenal\\nmedulla in the brain. Catecholamines have excita-\\ntory effects on smooth muscle cells of the vessels that\\nsupply blood to the skin and mucous membranes\\nand have inhibitory effects on smooth muscle cells\\nlocated in the wall of the gut, the bronchial tree of the\\nlungs, and the vessels that supply blood to skeletal\\nmuscle. There are two different main types of recep-\\ntors for these neurotransmitters, called alpha and beta\\nadrenergic receptors. The catecholamines are there-\\nfore are also known as adrenergic neurotransmitters.\\nHyperplasia— The abnormal increase in the number\\nof normal cells in a given tissue.\\nHypertension— Persistently high arterial blood\\npressure.\\nNeurotransmitter— Substance released from neurons\\nof the peripheral nervous system that travels across\\nthe synaptic clefts (gaps) of other neurons to excite or\\ninhibit 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 response.\\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.\\n136 GALE ENCYCLOPEDIA OF MEDICINE\\nAlpha1-adrenergic blockers'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alpha blockers may lower blood counts. Patients\\nmay need to have their blood checked regularly while\\ntaking this medicine.\\nAnyone who has had unusual reactions to alpha\\nblockers in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nThe effects of taking alpha blockers duringpreg-\\nnancy are not fully understood. Women who are preg-\\nnant or planning to become pregnant should inform\\ntheir physicians. Breastfeeding mothers who need to\\ntake alpha blockers should also talk to their physi-\\ncians. These drugs can pass into breast milk and may\\naffect nursing babies. It may be necessary to stop\\nbreastfeeding while being treated with alpha blockers.\\nSide effects\\nT h em o s tc o m m o ns i d ee f f e c t sa r ed i z z i n e s s ,d r o w -\\nsiness, tiredness, headache, nervousness, irritability,\\nstuffy or runny nose,nausea, pain in the arms and legs,\\nand weakness. These problems usually go away as the\\nbody adjusts to the drug and do not require medical\\ntreatment. If they do not subside or if they interfere with\\nnormal 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/C15fainting\\n/C15shortness of breath or difficulty breathing\\n/C15fast, pounding, or irregular heartbeat\\n/C15swollen 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\\nwith any other drugs. Terazosin (Hytrin) may interact\\nwith nonsteroidal anti-inflammatory drugs, such as\\nibuprofen (Motrin), and with other blood pressure\\ndrugs, such as enalapril (Vasotec), and verapamil\\n(Calan,Verelan). Prazosin (Minipress) may interact\\nwith beta adrenergic blocking agents such as propra-\\nnolol (Inderal) and others, and with verapamil (Calan,\\nIsoptin.) When drugs interact, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay 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\\nand eye problems. Eventually,kidney dialysisor trans-\\nplant may be necessary.\\nDescription\\nAlport syndrome affects about one in 5,000\\nAmericans, striking men more often and severely\\nthan women. There are several varieties of the syn-\\ndrome, some occurring in childhood and others not\\ncausing symptoms until men reach their 20s or 30s. All\\nvarieties of the syndrome are characterized bykidney\\ndisease that usually progresses to chronic kidney fail-\\nure and by uremia (the presence of excessive amounts\\nof urea and other waste products in the blood).\\nCauses and symptoms\\nAlport syndrome in most cases is caused by a\\ndefect in one or more genes located on the X chromo-\\nsome. It is usually inherited from the mother, who is a\\nnormal carrier. However, in up to 20% of cases there is\\nno family history of the disorder. In these cases, there\\nappears to be a spontaneous genetic mutation causing\\nAlport syndrome.\\nBlood in the urine (hematuria) is a hallmark of\\nAlport syndrome. Other symptoms that may appear in\\nvarying combinations include:\\n/C15protein in the urine (proteinuria)\\n/C15sensorineural hearing loss\\n/C15eye problems [involuntary, rhythmic eye movements\\n(nystagmus), cataracts, or cornea problems]\\n/C15skin problems\\n/C15platelet disorders\\n/C15abnormal white blood cells\\n/C15smooth muscle tumors\\nNot all patients with Alport syndrome have hear-\\ning problems. In general, those with normal hearing\\nhave less severe cases of Alport syndrome.\\nDiagnosis\\nAlport syndrome is diagnosed with a medical eva-\\nluation and family history, together with a kidney\\nbiopsy that can detect changes in the kidney typical of\\nGALE ENCYCLOPEDIA OF MEDICINE 137\\nAlport syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the condition.Urinalysismay reveal blood or protein in\\nthe urine. Blood tests can reveal a low platelet level.\\nIn addition, tests for the Alport gene are now\\navailable. Although testing is fairly expensive, it is\\ncovered by many types of health insurance. DNA\\ntests can diagnose affected children even before birth,\\nand genetic linkage tests tracing all family members at\\nrisk for Alport syndrome are also available.\\nTreatment\\nThere is no specific treatment that can ‘‘cure’’\\nAlport syndrome. Instead, care is aimed at easing the\\nproblems related to kidney failure, such as the presence\\nof too many waste products in the blood (uremia).\\nTo control kidney inflammation ( nephritis),\\npatients should:\\n/C15restrict fluids\\n/C15control high blood pressure\\n/C15manage pulmonary edema\\n/C15control 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/C15drink less\\n/C15eat a salt-free diet\\n/C15use diuretics\\n/C15have albumin transfusions\\nThe treatment forchronic kidney failureis dialysis\\nor a kidney transplant.\\nPrognosis\\nWomen with this condition can lead a normal life,\\nalthough they may have slight hearing loss. An\\naffected woman may notice blood in her urine only\\nwhen understress or pregnant.\\nMen generally have a much more serious problem\\nwith the disease. Most will experience kidney disease\\nin their 20s or 30s, which may eventually require dia-\\nlysis or transplantation, and many develop significant\\nhearing loss. Men with Alport syndrome often die of\\ncomplications by middle age.\\nPrevention\\nAlport syndrome is a genetic disease and preven-\\ntion efforts are aimed at providing affected individuals\\nand their families with information concerning the\\ngenetic mechanisms responsible for the disease. Since\\nit is possible to determine if a woman is a carrier, or if\\nan unborn child has the condition,genetic counseling\\ncan provide helpful information and support for the\\ndecisions that affected individuals and their families\\nmay have to make.\\nResources\\nORGANIZATIONS\\nAmerican Association of Kidney Patients. 100 S. Ashley Dr.,\\n#280, Tampa, FL 33602. (800) 749-2257. .\\nAmerican Kidney Fund (AKF). Suite 1010, 6110 Executive\\nBoulevard, Rockville, MD 20852. (800) 638-8299.\\n.\\nNational Kidney and Urologic Disease Information\\nClearinghouse. 3 Information Way, Bethesda, MD\\n20892. (301) 654-4415. .\\nNational Kidney Foundation. 30 East 33rd St., New York,\\nNY 10016. (800) 622-9010. .\\nNational Organization for Rare Diseases. P.O. Box 8923,\\nFairfield, CT 06812. (213) 745-6518. .\\nOTHER\\nAlport Syndrome Home Page. .\\n‘‘Alport Syndrome.’’ Pediatric Database Home Page.\\n.\\nThe Hereditary Nephritis Foundation (HNF) Home Page.\\n.\\nCarol A. Turkington\\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 of\\nthe lungs.\\nUremia— The presence of excessive amounts of\\nurea and other waste products in the blood.\\n138 GALE ENCYCLOPEDIA OF MEDICINE\\nAlport syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alprazolam 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\\nis important to understand the range of the different\\naltitudes that may be involved. High altitude is defined\\nas height greater than 8,000 feet (2,438m); medium\\naltitude is defined as height between 5,000 and 8,000\\nfeet (1,524-2,438m); 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%\\nof people ascending above 9,000 feet (2,743m) in one\\nday will develop altitude sickness. Children under six\\nyears and women in the premenstrual part of their cycles\\nmay be more vulnerable. Individuals with preexisting\\nmedical conditions–even a minor respiratory infection–\\nmay become 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 cerebraledema (HACE).\\nThese syndromes are not separate, individual syn-\\ndromes as much as they are a continuum of severity,\\nall resulting from a decrease in oxygen in the air. AMS\\nis the mildest, and the other two represent severe, life-\\nthreatening forms of altitude sickness.\\nAltitude sickness occurs because the partial pres-\\nsure of oxygen decreases with altitude. (Partial pres-\\nsure is a term applied to gases that is similar to the way\\nthe term concentration is applied to liquid solutions.)\\nFor instance, at 18,000 feet (5,486 m) the partial pres-\\nsure of oxygen drops to one-half its value at sea level\\nand, therefore, there is a substantially lower amount of\\noxygen available for the individual to inhale. This is\\nknown as hypoxia. Furthermore, since there is less\\noxygen to inhale, less oxygen reaches the blood. This\\nis known as hypoxemia. These two conditions are the\\nmajor factors that form the basis for all the medical\\nproblems associated with altitude sickness.\\nAs a person becomes hypoxemic, his natural\\nresponse is to breathe more rapidly (hyperventilate).\\nThis is the body’s attempt to bring in more oxygen at\\na rapid rate. This attempt at alleviating the effects of the\\nhypoxia at higher altitudes is known as acclimatization,\\nand it occurs during the first few days. Acclimatization\\nis a response that occurs in individuals who travel from\\nlower to higher altitudes. There are groups of people\\nwho have lived at high altitudes (for example, in the\\nHimalayan and Andes mountains) for generations, and\\nthey are simply accustomed to living at such altitudes,\\nperhaps through a genetic ability.\\nCauses and symptoms\\nAcute mountain sickness (AMS) is a mild form of\\naltitude sickness that results from ascent to altitudes\\nhigher greater than 8,000 feet (2,438m)–even 6,500 feet\\n(1,981 m) in some susceptible individuals. Although\\nhypoxia is associated with the development of AMS,\\nthe exact mechanism by which this condition develops\\nhas yet to be confirmed. It is important to realize that\\nsome individuals acclimatize to higher altitudes more\\nefficiently than others. As a result, under similar condi-\\ntions some will suffer from AMS while others will not.\\nAt present, the susceptibility of otherwise healthy indi-\\nviduals to contracting AMS cannot be accurately pre-\\ndicted. Of those who do suffer from AMS, the condition\\ntends to be most severe on the second or third day after\\nreaching the high altitude, and it usually abates after\\nthree to five days if they remain at the same\\naltitude. However, it can recur if the individuals travel\\nto an even higher altitude. Symptoms usually appear a\\nfew hours to a few days following ascent, and they\\ninclude dizziness, headache, shortness of breath, nausea,\\nvomiting,l o s so fa p p e t i t e ,a n dinsomnia.\\nHigh-altitude pulmonary edema(HAPE) is a life-\\nthreatening condition that afflicts a small percentage\\nof those who suffer from AMS. In this condition, fluid\\nleaks from within the pulmonary blood vessels into the\\nlung tissue. As this fluid begins to accumulate within\\nKEY TERMS\\nCerebral— Pertaining to the brain.\\nEdema— Accumulation of excess fluid in the tissues\\nof 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.\\nGALE ENCYCLOPEDIA OF MEDICINE 139\\nAltitude sickness'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the lung tissue (pulmonary edema), the individual\\nbegins to become more and more short of breath.\\nHAPE is known to afflict all types of individuals,\\nregardless of their level of physical fitness.\\nTypically, the individual who suffers from HAPE\\nascends quickly to a high altitude and almost imme-\\ndiately develops shortness of breath, a rapid heart\\nrate, acough productive of a large amount of some-\\ntimes bloody sputum, and a rapid rate of breathing.\\nIf no medical assistance is provided by this point,\\nthe patient goes into a coma and dies within a few\\nhours.\\nHigh-altitude cerebral edema (HACE), the rarest\\nand most severe form of altitude sickness, involves\\ncerebral edema, and its mechanism of development is\\nalso poorly understood. The symptoms often begin\\nwith those of AMS, but neurologic symptoms such\\nas an altered level of consciousness, speech abnormal-\\nities, severe headache, loss of coordination,hallucina-\\ntions, and even seizures. If no intervention is\\nimplemented, death is the result.\\nDiagnosis\\nThe diagnosis for altitude sickness may be made\\nfrom the observation of the individual’s symptoms\\nduring travel to higher altitudes.\\nTreatment\\nMild AMS requires no treatment other than an\\naspirin or ibuprofen for headache, and avoidance of\\nfurther ascent. Narcotics should be avoided because\\nthey may blunt the respiratory response, making\\nit even more difficult for the person to breathe deeply\\nand rapidly enough to compensate for the lower levels\\nof oxygen in the environment. Oxygen may also be\\nused to alleviate symptoms of mild AMS.\\nAs for HAPE and HACE, the most important\\ncourse of action is descent to a lower altitude as soon\\nas possible. Even a 1,000-2,000-foot (305-610 m) des-\\ncent can dramatically improve one’s symptoms. If\\ndescent is not possible, oxygen therapy should be\\nstarted. In addition, dexamethasone (a steroid) has\\nbeen suggested in order to reduce cerebral edema.\\nPrognosis\\nThe prognosis for mild AMS is good, if appro-\\npriate measures are taken. As for HAPE and HACE,\\nthe prognosis depends upon the rapidity and distance\\nof descent and the availability of medical intervention.\\nDescent often leads to improvement of symptoms,\\nhowever, recovery times vary among individuals.\\nPrevention\\nWhen individuals ascend from sea level, it is recom-\\nmended that they spend at least one night at\\nan intermediate altitude prior to ascending to higher\\nelevations. In general, climbers should take at least two\\ndays to go from sea level to 8,000 feet (2,438m). After\\nreaching that point, healthy climbers should generally\\nallow one day for each additional 2,000 feet (610m), and\\none day of rest should be taken every two or three days.\\nShould mild symptoms begin to surface, further ascent\\nshould be avoided. If the symptoms are severe, the indi-\\nvidual should return to a lower altitude. Some reports\\nindicate that acetazolamide (a diuretic) may be taken\\nbefore ascent as a preventative measure for AMS.\\nPaying attention to diet can also help prevent alti-\\ntude sickness. Water loss is a problem at higher alti-\\ntudes, so climbers should drink ample water (enough to\\nproduce copious amounts of relatively light-colored or\\nclear urine). Alcohol and large amounts of salt should\\nbe avoided. Eating frequent small, high-carbohydrate\\nsnacks (for example, fruits, jams and starchy foods)\\ncan help, especially in the first few days of climbing.\\nResources\\nBOOKS\\nCrystal, R. G., et al., editors.The Lung: Scientific\\nFoundations. Lippincott-Raven Publishers, 1997.\\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,\\nand is 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 andexercise judgment. Communication ability,\\n140 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='mood, and personality also may be affected. Most\\npeople who have AD die within eight years of their\\ndiagnosis, although the interval may be as short as one\\nyear or as long as 20 years. AD is the fourth leading\\ncause ofdeath in adults after heart disease,cancer,a n d\\nstroke.\\nBetween two and four million Americans have\\nAD; that number is expected to grow to as many as\\n14 million by the middle of the 21st century as the\\npopulation ages. While a small number of people in\\ntheir 40s and 50s develop the disease (called early-\\nonset AD), AD predominantly affects the elderly.\\nAD affects about 3% of all people between ages 65\\nand 74, about 19% of those between 75 and 84, and\\nabout 47% of those over 85. Slightly more women\\nthan men are affected with AD, but this may be\\nbecause women tend to live longer, leaving a higher\\nproportion of women in the most affected age groups.\\nThe cost of caring for a person with AD is con-\\nsiderable. The annual cost of caring for one AD\\npatient in 1998 was estimated as about $18,400 for a\\npatient with mild AD, $30,100 for a patient with mod-\\nerate AD, and $36,100 for a patient with severe AD.\\nThe annual direct and indirect costs of caring for AD\\npatients in the United States was estimated to be as\\nmuch as $100 billion. Slightly more than half of people\\nwith AD are cared for at home, while the remainder\\nare cared for in a variety of health care institutions.\\nCauses and symptoms\\nCauses\\nThe cause or causes of Alzheimer’s disease are lar-\\ngely unknown, though some forms have genetic links.\\nSome strong leads have been found through recent\\nresearch, however, and these have given some theoreti-\\ncal support to several new experimental treatments.\\nAt first AD destroys neurons (nerve cells) in parts\\nof the brain that control memory, including the\\nhippocampus, which is a structure deep in the deep\\nthat controls short-term memory. As these neurons\\nin the hippocampus stop functioning, the person’s\\nshort-term memory fails, and the ability to perform\\nfamiliar tasks decreases. Later AD affects the cerebral\\ncortex, particularly the areas responsible for language\\nand reasoning. Many language skills are lost and the\\nability to make judgments is affected. Personality\\nchanges occur, which may include emotional out-\\nbursts, wandering, and agitation. The severity of\\nthese changes increases with disease progression.\\nEventually many other areas of the brain become\\ninvolved, the brain regions affected atrophy (shrink\\nand lose function), and the person with AD becomes\\nbedridden, incontinent, helpless, and non-responsive.\\nAutopsy of a person with AD shows that the\\nregions of the brain affected by the disease become\\nclogged with two abnormal structures, called neuro-\\nfibrillary tangles and amyloid plaques. Neurofibrillary\\ntangles are twisted masses of protein fibers inside nerve\\ncells, or neurons. In AD, tau proteins, which normally\\nhelp bind and stabilize parts of neurons, are changed\\nchemically, become twisted and tangled, and no longer\\ncan stabilize the neurons. Amyloid plaques consist of\\ninsoluble deposits of beta-amyloid, (a protein fragment\\nfrom a larger protein called amyloid precursor protein\\n(APP), mixed with parts of neurons and non-nerve\\ncells. Plaques are found in the spaces between the\\nnerve cells of the brain. While it is not clear exactly\\nA brain segment affected by Alzheimer’s disease on the right\\ncompared with a healthy brain segment (left). The diseased\\nbrain appears shrunken, and the fissures are noticeably\\nlarger. (Simon Fraser/MRC Unit, Newcastle General Hospital/\\nScience Photo Library. Photo Researchers, Inc. Reproduced by\\npermission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 141\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='how these structures cause problems, many researchers\\nbelieve that their formation is responsible for the men-\\ntal changes of AD, presumably by interfering with the\\nnormal communication between neurons in the brain\\nand later leading to the death of neurons. By 2000,\\nthree drugs for the treatment of AD symptoms were\\napproved by the U.S. Food and Drug Administration\\n( F D A ) .T h e ya c tb yi n c r e a s i n gt h el e v e lo fc h e m i c a l\\nsignaling molecules in the brain, known as neurotrans-\\nmitters, to make up for this decreased communication\\nability. All act by inhibiting the activity of acetyl-\\ncholinesterase, which is an enzyme that breaks down\\nacetylcholine, an important neurotransmitter released\\nby neurons that is necessary for cognitive function.\\nThese drugs modestly increase cognition and improve\\none’s ability to perform normal activities of daily living.\\nExactly what triggers the formation of plaques\\nand tangles and the development of AD is unknown.\\nAD likely results from many interrelated factors,\\nincluding genetic, environmental, and others not yet\\nidentified. Two types of AD exist: familial AD (FAD),\\nwhich is a rare autosomal dominant inherited disease,\\nand sporadic AD, with no obvious inheritance pat-\\ntern. AD also is described in terms of age at onset, with\\nearly onset AD occurring in people younger than 65,\\nand late-onset occurring in those 65 and older. Early\\nonset AD comprises about 5-10 % of AD cases and\\naffects people aged 30 to 60. Some cases of early onset\\nAD are inherited and are common in some families.\\nEarly-onset AD often progresses faster than the more\\ncommon late-onset type.\\nAll cases of FAD, which is relatively uncommon,\\nthat have been identified to date are the early onset\\ntype. As many as 50% of FAD cases are known to\\nbe caused by three genes located on three different\\nchromosomes. Some families have mutations in the\\nAPP gene located on chromosome 21, which causes\\nthe production of abnormal APP protein. Others\\nhave mutations in a gene called presenilin 1 located\\non chromosome 14, which causes the production of\\nabnormal presenilin 1 protein, and others have muta-\\ntions in a similar gene called presenilin 2 located\\non chromosome 1, which causes production of abnor-\\nmal presenilin 2. Presenilin 1 may be one of the\\nenzymes that clips APP into beta-amyloid; it also\\nmay be important in the synaptic connections between\\nbrain cells.\\nThere is no evidence that the mutated genes that\\nc a u s ee a r l yo n s e tF A Da l s oc a u s el a t eo n s e tA D ,b u t\\ngenetics appears to play a role in this more common\\nform of AD. Discovered by researchers at Duke\\nUniversity in the early 1990s, potentially the most\\nimportant genetic link to AD was on chromosome 19.\\nA gene on this chromosome, called APOE (apolipo-\\nprotein E), codes for a protein involved in transporting\\nlipids into neurons. APOE occurs in at least three forms\\n(alleles), called APOE e2, APOE e3, and APOE e4.\\nEach person inherits one APOE from each parent, and\\ntherefore can either have one copy of two different\\nforms, or two copies of one. The relatively rare APOE\\ne2 appears to protect some people from AD, as it seems\\nto be associated with a lower risk of AD and a later age\\nof onset if AD develops. APOE e3 is the most common\\nversion found in the general population, and only\\nappears to have a neutral role in AD. However, APOE\\ne4 appears to increase the risk of developing late onset\\nAD with the inheritance of one or two copies of APOE\\ne4. Compared to those without APOE e4, people with\\none copy are about three times as likely to develop late-\\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 found in the brains of people\\nwith AD.\\nDiseased tissue from the brain of an Alzheimer’s patient show-\\ning senile plaques within the brain’s gray matter.(Photograph by\\nCecil Fox, Photo Researchers, Inc. Reproduced by permission.)\\n142 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='onset AD, and those with two copies are almost four\\ntimes as likely to do so. Having APOE e4 also can lower\\nthe age of onset by as much as 17 years. However,\\nAPOE e4 only increases the risk of developing AD\\nand does not cause it, as not everyone with APOE e4\\ndevelops AD, and people without it can still have the\\ndisease. Why APOE e4 increases the chances of devel-\\noping AD is not known with certainty. However, one\\ntheory is that APOE e4 facilitates beta-amyloid buildup\\nin plaques, thus contributing to the lowering of the age\\nof onset of AD; other theories involve interactions with\\ncholesterol levels and effects on nerve cell death inde-\\npendent of its effects on plaque buildup. In 2000, four\\nnew AD-related regions in the human genome were\\nidentified, where one out of several hundred genes in\\neach of these regions may be a risk factor gene for AD.\\nThese genes, which are not yet identified, appear to\\nmake a contribution to the risk of developing late-\\nonset AD that is at least as important as APOE e4.\\nOther non-genetic factors have been studied in\\nrelation to the causes of AD. Inflammation of the\\nbrain may play a role in development of AD, and use\\nof nonsteroidal anti-inflammatory drugs (NSAIDs)\\nwere once thought to reduce the risk of developing\\nAD. Other agents once thought to reduce chances of\\ndementia are now thought to increase its risk. In 2002,\\nhormone replacement therapy(HRT), which combines\\nestrogen and progestogen, was found to double the\\nrisk of developing dementia in postmenopausal\\nwomen. Highly reactive molecular fragments called\\nfree radicals damage cells of all kinds, especially\\nbrain cells, which have smaller supplies of protective\\nantioxidants thought to protect against free radical\\ndamage. Vitamin E is one such antioxidant, and its\\nuse in AD may be of possible theoretical benefit.\\nWhile the ultimate cause or causes of Alzheimer’s\\ndisease still are unknown, there are several risk factors\\nthat increase a person’s likelihood of developing the\\ndisease. The most significant one is, of course, age;\\nolder people develop AD at much higher rates than\\nyounger ones. There is some evidence that strokes and\\nAD may be linked, with small strokes that go unde-\\ntected clinically contributing to the injury of neurons.\\nA 2003 Dutch study reported that symptomless, unno-\\nticed strokes could double the risk of AD and other\\ndementias. Blood cholesterol levels also may be\\nimportant. Scientists have shown that high blood\\ncholesterol levels in special breeds of genetically\\nengineered (transgenic) mice may increase the rate of\\nplaque deposition. There are also parallels between\\nAD and other progressive neurodegenerative disor-\\nders that cause dementia, including prion diseases,\\nParkinson’s disease, and Huntington’s disease.\\nNumerous epidemiological studies of populations\\nalso are being conducted to learn more about whether\\nand to what extent early life events, socioeconomic\\nfactors, and ethnicity have an impact on the develop-\\nment of AD. For example, a 2003 report showed that\\nthe more formal education a person has, the better his\\nor her memory is, despite presence of AD. Other stu-\\ndies have related education level or participation in\\nleisure activities such as playing cards or doing cross-\\nword puzzles to delayed onset of AD.\\nMany environmental factors have been suspected\\nof contributing to AD, but epidemiological popula-\\ntion studies have not borne out these links. Among\\nthese have been pollutants in drinking water, alumi-\\nnum from commercial products, and metal dental fill-\\nings. To date, none of these factors has been shown to\\ncause AD or increase its likelihood. Further research\\nmay yet turn up links to other environmental factors.\\nSymptoms\\nThe symptoms of Alzheimer’s disease begin gra-\\ndually, usually with memory lapses. Occasional mem-\\nory lapses are of course common to everyone, and do\\nnot by themselves signify any change in cognitive\\nfunction. The person with AD may begin with only\\nthe routine sort of memory lapse — forgetting where\\nthe car keys are — but progress to more profound or\\ndisturbing losses, such as forgetting that he or she can\\neven drive a car. Becoming lost or disoriented on a walk\\naround the neighborhood becomes more likely as the\\ndisease progresses. A person with AD may forget the\\nnames of family members, or forget what was said at\\nthe beginning of a sentence by the time he hears the end.\\nAs AD progresses, other symptoms appear,\\nincluding inability to perform routine tasks, loss of\\njudgment, and personality or behavior changes.\\nSome people with AD have trouble sleeping and may\\nsuffer from confusion or agitation in the evening\\n(‘‘sunsetting’’ or Sundowner’s Syndrome). In some\\ncases, people with AD repeat the same ideas, move-\\nments, words, or thoughts. In the final stages people\\nmay have severe problems with eating, communicat-\\ning, and controlling their bladder and bowel functions.\\nThe Alzheimer’s Association has developed a list\\nof 10 warning signs of AD. A person with several of\\nthese symptoms should see a physician for a thorough\\nevaluation:\\n/C15memory loss that affects job skills\\n/C15difficulty performing familiar tasks\\n/C15problems with language\\n/C15disorientation of time and place\\nGALE ENCYCLOPEDIA OF MEDICINE 143\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15poor or decreased judgment\\n/C15problems with abstract thinking\\n/C15misplacing things\\n/C15changes in mood or behavior\\n/C15changes in personality\\n/C15loss of initiative\\nOther types of dementia, including some that are\\nreversible, can cause similar symptoms. It is impor-\\ntant for the person with these symptoms to be evalu-\\nated by a professional who can weigh the possibility\\nthat his or her symptoms may have another cause.\\nApproximately 20% of those originally suspected of\\nhaving AD turn out to have some other disorder;\\nabout half of these cases are treatable.\\nDiagnosis\\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\\nin most cases after thorough testing, AD cannot be\\ndiagnosed definitively until autopsy examination of\\nthe brain for plaques and neurofibrillary tangles.\\nThe diagnosis of AD begins with a thorough\\nphysical exam and complete medical history. Except\\nin the disease’s earliest stages, accurate history from\\nfamily members or caregivers is essential. Since there\\nare both prescription and over-the-counter drugs\\nthat can cause the same mental changes as AD, a\\ncareful review of the patient’s drug, medicine, and\\nalcohol use is important. AD-like symptoms also\\ncan be provoked by other medical conditions, includ-\\ning tumors, infection, and dementia caused by mild\\nstrokes (multi-infarct dementia). These possibilities\\nmust be ruled out as well through appropriate blood\\nand urine tests, brain magnetic resonance imaging\\n(MRI), positron emission tomography (PET)o rs i n -\\ngle photon emission computed tomography (SPECT)\\nscans, tests of the brain’s electrical activity (electro-\\nencephalographs or EEGs), or other tests. Several\\ntypes of oral and written tests are used to aid in the\\nAD diagnosis and to follow its progression, including\\ntests of mental status, functional abilities, memory,\\nand concentration. Still, the neurologic exam is\\nnormal in most patients 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, or\\nmay be mistaken for it. (Delirium involves a decreased\\nconsciousness or awareness of one’s environment.)\\nDepression and memory loss both are common\\nin the elderly, and the combination of the often can\\nbe mistaken for AD. On the other hand, depression\\ncan be a risk factor for AD. A 2003 study showed that\\na history of depressive symptoms can be associated\\nwith nearly twice the risk of eventually developing\\nAD. Depression can be treated with drugs, although\\nsome antidepressants can worsen dementia if it is\\npresent, further complicating both diagnosis and\\ntreatment.\\nAn early and accurate diagnosis of AD is impor-\\ntant in developing strategies for managing symptoms\\nand for helping patients and their families planning\\nfor the future and pursuing care options while the\\npatient can still take part in the decision-making\\nprocess.\\nA genetic test for the APOE e4 gene is available,\\nbut is not used for diagnosis, since possessing even two\\ncopies does not ensure that a person will develop AD.\\nIn addition, access to genetic information could affect\\nthe insurability of a patient if disclosed, and also affect\\nemployment status and legal rights.\\nTreatment\\nAlzheimer’s disease is presently incurable. Recent\\nreports show that prompt intervention can slow decline\\nfrom AD. The use of medications mentioned below as\\nearly as possible in the course of AD can help people\\nwith the disease maintain independent function as long\\nas possible. The remaining treatment for a person with\\nAD is good nursing care, providing both physical and\\nemotional support for a person who is gradually able to\\ndo less and less for himself, and whose behavior is\\nbecoming more and more erratic. Modifications of the\\nhome to increase safety and security often are neces-\\nsary. The caregiver also needs support to prevent anger,\\ndespair, and burnout from becoming overwhelming.\\nBecoming familiar with the issues likely to lie ahead,\\nand considering the appropriate financial and legal\\nissues early on, can help both the patient and family\\ncope with the difficult process of the disease. Regular\\nmedical care by a practitioner with a non-defeatist\\nattitude toward AD is important so that illnesses such\\nas urinary or respiratory infections can be diagnosed\\nand treated properly, rather than being incorrectly\\nattributed to the inevitable decline seen in AD.\\nPeople with AD often are depressed or anxious,\\nand may suffer from sleeplessness, poornutrition, and\\ngeneral poor health. Each of these conditions is trea-\\ntable to some degree. It is important for the person\\nwith AD to eat well and continue to exercise.\\nProfessional advice from a nutritionist may be useful\\n144 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='to provide healthy, easy-to-prepare meals. Finger\\nfoods may be preferable to those requiring utensils to\\nbe eaten. Regular exercise (supervised if necessary for\\nsafety) promotes overall health. A calm, structured\\nenvironment with simple orientation aids (such as\\ncalendars and clocks) may reduceanxiety and increase\\nsafety. Other psychiatric symptoms, such as depres-\\nsion, anxiety,hallucinations (seeing or hearing things\\nthat aren’t there), anddelusions (false beliefs) may be\\ntreated with drugs if necessary.\\nDrugs\\nAs of 2003, four drugs—tacrine (Cognex), done-\\npezil hydrochloride (Aricept), and rivastigmine\\n(Exelon)—have been approved by the FDA for its\\ntreatment. Tacrine has been shown to be effective for\\nimproving memory skills, but only in patients with\\nmild-to-moderate AD, and even then in less than half\\nof those who take it. Its beneficial effects are usually\\nmild and temporary, but it may delay the need for\\nnursing home admission. The most significant side\\neffect is an increase in a liver enzyme known as alanine\\naminotransferase, or ALT. Patients taking tacrine\\nmust have a weekly blood test to monitor their ALT\\nlevels. Other frequent side effects include nausea,\\nvomiting, diarrhea, abdominal pain,indigestion,a n d\\nskin rash. The cost of tacrine was about $125 per\\nmonth in early 1998, with additional costs for the\\nweekly blood monitoring. Despite its high cost, tacrine\\nappears to be cost-effective for those who respond to\\nit, since it may decrease the number of months a\\npatient needs nursing care. Donepezil is the drug\\nmost commonly used to treat mild to moderate symp-\\ntoms of AD, although it only helps some patients for\\nperiods of time ranging from months to about two\\nyears. Donepezil has two advantages over tacrine: it\\nhas fewer side effects, and it can be given once daily\\nrather than three times daily. Donepezil does not\\nappear to affect liver enzymes, and therefore does\\nnot require weekly blood tests. The frequency of\\nabdominal side effects is also lower. The monthly\\ncost is approximately the same. Rivastigmine,\\napproved for use in April of 2000, has been shown to\\nimprove the ability of patients to carry out daily activi-\\nties, such as eating and dressing, decrease behavioral\\nsymptoms such as delusions and agitation, and improve\\ncognitive functions such as thinking, memory, and\\nspeaking. The cost is similar to those of the other\\ntwo drugs. However, none of these three drugs stops\\nor reverses the progression of AD. Galantamine\\n(Reminyl) works in the early and moderates stages\\nof AD. It has fewer side effects than other drugs,\\nwith the exception of donepezil and must be taken\\ntwice a day. Three other drugs were being tested for\\nAD treatment in mid-2003.\\nEstrogen, the female sex hormone, is widely pre-\\nscribed for post-menopausal women to preventosteo-\\nporosis. Studies once showed that estrogen was\\nbeneficial to women with AD, but in 2003, a large\\nclinical trial called the Women’s Health Initiative\\nshowed dementia among other negative effects of\\ncombined estrogen therapy.\\nPreliminary studies once suggested a reduced risk\\nfor developing AD in elderly people who regularly used\\nnonsteroidal anti-inflammatory drugs (NSAIDs),\\nincluding aspirin, ibuprofen, and naproxen, although\\nnot acetaminophen. However, an important study\\npublished in 2003 showed that NSAIDs were not effec-\\ntive in preventing or slowing the progression of AD.\\nThe study authors recommended that people stop\\ntaking NSAIDs to slow dementia.\\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\\ntissue culture. Therefore, research is being conducted\\nto see whether antioxidants may delay or prevent AD.\\nAnother antioxidant, vitamin E, is also thought\\nto delay AD onset. Hoever, it is not yet clear whether\\nthis is due to the specific action of vitamin E on brain\\ncells, or to an increase in the overall health of those\\ntaking it.\\nDrugs such as antidepressants, anti-psychotics,\\nand sedatives are used to treat the behavioral symp-\\ntoms (agitation, aggression, wandering, and sleep dis-\\norders) of AD. Research is being conducted to search\\nfor better treatments, including non-drug approaches\\nfor AD patients.\\nNursing care and safety\\nThe person with Alzheimer’s disease will gradu-\\nally lose the ability to dress, groom, feed, bathe, or use\\nthe toilet by himself; in the later stages of the disease,\\nhe may be unable to move or speak. In addition, the\\nperson’s behavior becomes increasingly erratic. A\\ntendency to wander may make it difficult to leave\\nhim unattended for even a few minutes and make\\neven the home a potentially dangerous place. In\\naddition, some people with AD may exhibit inap-\\npropriate sexual behaviors.\\nThe nursing care required for a person with AD is\\nwell within the abilities of most people to learn. The\\ndifficulty for many caregivers comes in the constant\\nbut unpredictable nature of the demands put on them.\\nIn addition, the personality changes undergone by a\\nGALE ENCYCLOPEDIA OF MEDICINE 145\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='person with AD can be heartbreaking for family mem-\\nbers as a loved one deteriorates, seeming to become a\\ndifferent person. Not all people with AD develop\\nnegative behaviors. Some become quite gentle, and\\nspend increasing amounts of 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\\nmore common. Caregivers, especially spouses, may\\nfind these changes socially embarrassing and difficult\\nto cope with. The caregiver usually will need to spend\\nincreasing amounts of time on grooming to compensate\\nfor the loss of attention from the patient, although\\nsome adjustment of expectations (while maintaining\\ncleanliness) is often needed as the disease progresses.\\nProper nutrition is important for a person with\\nAD, and may require assisted feeding early on, to\\nmake sure the person is taking in enough nutrients.\\nLater on, as movement and swallowing become diffi-\\ncult, a feeding tube may be placed into the stomach\\nthrough the abdominal wall. A feeding tube requires\\nmore attention, but is generally easy to care for if the\\npatient is not resistant to its use.\\nFor many caregivers, incontinence becomes the\\nmost difficult problem to deal with at home, and is a\\nprincipal reason for pursuing nursing home care. In\\nthe early stages, limiting fluid intake and increasing\\nthe frequency of toileting can help. Careful attention\\nto hygiene is important to prevent skin irritation and\\ninfection from soiled clothing.\\nPersons with dementia must deal with six basic\\nsafety concerns: injury from falls, injury from ingest-\\ning dangerous substances, leaving the home and get-\\nting lost, injury to self or others from sharp objects,\\nfire orburns, and the inability to respond rapidly to\\ncrisis situations. In all cases, a person diagnosed with\\nAD should no longer be allowed to drive, because of\\nthe increased potential for accidents and the increased\\nlikelihood of wandering very far from home while\\ndisoriented. In the home, simple measures such as\\ngrab bars in the bathroom, bed rails on the bed, and\\neasily negotiable passageways can greatly increase\\nsafety. Electrical appliances should be unplugged and\\nput away when not in use, and matches, lighters, kni-\\nves, or weapons should be stored safely out of reach.\\nThe hot water heater temperature may be set lower\\nto 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\\nperiodically reevaluate the physical safety of the home\\nand introduce 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\\ntypes of illnesses. This type of caregiving also has a\\ngreater impact in terms of employment complications,\\ncaregiver strain, mental and physical health problems,\\ntime for leisure and other family members, and family\\nconflict than do other types of caregiving. It is common\\nfor AD caregivers to develop feelings of anger, resent-\\nment, guilt, and hopelessness, in addition to the sorrow\\nthey feel for their loved one and for themselves.\\nDepression is an extremely common consequence of\\nbeing a full-time caregiver for a person with AD.\\nSupport groups are an important way to deal with the\\nstress of caregiving. Becoming a member of an AD\\ncaregivers’ support group can be one of the most\\nimportant things a family member does, not only for\\nhim or herself, but for the person with AD as well. The\\nlocation and contact numbers for AD caregiver sup-\\nport groups are available from the Alzheimer’s\\nAssociation; they also may be available through a\\nlocal social service agency, the patient’s physician, or\\npharmaceutical companies that manufacture the drugs\\nused 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\\nrelieve some of the burden of around-the-clock care\\nfor a person with AD. Personal care assistants, either\\nvolunteer or paid, may be available through local social\\nservice agencies. Adult daycare facilities are becoming\\nincreasingly common. Meal delivery, shopping assis-\\ntance, or respite care may be available as well.\\nP r o v i d i n gt h et o t a lc a r er e q u i r e db yap e r s o n\\nwith late-stage AD can become an overwhelming\\nburden for a family, even with outside help. At this\\nstage, many families consider nursing home care.\\nThis decision often is one of the most difficult for\\nthe family, since it is often seen as an abandonment of\\nthe loved one and a failure of the family. Careful\\ncounseling with a sympathetic physician, clergy, or\\no t h e rt r u s t e da d v i s e rm a ye a s et h ed i f f i c u l t i e so ft h i s\\ntransition. Selecting a nursing home may require a\\ndifficult balancing of cost, services, location, and\\navailability. Keeping the entire family involved in\\nthe decision may help prevent further stress from\\ndeveloping later on.\\n146 GALE ENCYCLOPEDIA OF MEDICINE\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Several federal government programs may ease the\\ncost of caring for a person with AD, including Social\\nSecurity Disability, Medicare, and Supplemental\\nSecurity Income. Each of these programs may provide\\nsome assistance for care, medication, or other costs,\\nbut none of them will pay for nursing home care inde-\\nfinitely. Medicaid is a state-funded program that may\\nprovide for some or all of the cost of nursing home care,\\nalthough there are important restrictions. Details of\\nthe benefits and eligibility requirements of these pro-\\ngrams are available through the local Social Security\\nor Medicaid office, or from local social service agencies.\\nPrivate long-term care insurance, special ‘‘reverse\\nmortgages,’’ viatical insurance, and other financial\\ndevices are other ways of paying for care for those\\nwith the appropriate financial situations. Further\\ninformation on these options may be available\\nthrough resources listed below.\\nAlternative treatment\\nSeveral substances are currently being tested\\nfor their ability to slow the progress of Alzheimer’s\\ndisease. These include acetylcarnitine, a supplement\\nthat acts on the cellular energy structures known as\\nmitochondria. Ginkgo extract, derived from the leaves\\nof theGinkgo biloba tree, appears to have antioxidant\\nas well as anti-inflammatory and anticoagulant pro-\\nperties. Ginkgo extract has been used for many years\\nin China and is widely prescribed in Europe for treat-\\nment of circulatory problems. A 1997 study of patients\\nwith dementia seemed to show that ginkgo extract\\ncould improve their symptoms, though the study was\\ncriticized for certain flaws in its method. Large scale\\nfollow-up studies are being conducted to determine\\nwhether Ginkgo extract can prevent or delay the\\ndevelopment of AD. Ginkgo extract is available in\\nmany health food or nutritional supplement stores.\\nSome alternative practitioners also advise people\\nwith AD to take supplements of phosphatidylcholine,\\nvitamin B\\n12, gotu kola, ginseng, St. John˜os Wort,\\nrosemary, saiko-keishi-to-shakuyaku (A Japanese\\nherbal 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 infec-\\ntion, includingpneumonia. In addition, other diseases\\ncommon in old age–cancer, stroke, and heart disease–\\nmay lead to more severe consequences in a person with\\nAD. On average, people with AD live eight years past\\ntheir diagnosis, with a range from one to 20 years.\\nPrevention\\nCurrently, there is no sure way to prevent\\nAlzheimer’s disease. treatments discussed above may\\neventually be proven to reduce the risk of developing\\nthe disease. Avoiding risks such as hormone replace-\\nment therapy may help prevent development of 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\\nfrom cells but before it has a chance to aggregate\\ninto insoluble plaques. There also are promising\\nstudies being conducted to develop an AD vaccine,\\nwhere immune responses may result in the elimination\\nof the formation of amyloid plaques.\\nThe Alzheimer’s Disease Research Centers\\n(ADCs) program promotes research, training and\\neducation, technology transfer, and multicenter and\\ncooperative studies in AD, other dementias, and nor-\\nmal brain aging. Each ADC enrolls and performs\\nstudies on AD patients and healthy older people.\\nPersons can participate in research protocols and\\nclinical drug trials at these centers. Data from the\\nADCs as well as from other sources are coordinated\\nand made available for use by researchers at the\\nNational Alzheimer’s Coor dinating Center, estab-\\nlished in 1999.\\nResources\\nBOOKS\\nCohen, Donna, and Carl Eisdorfer.The Loss of Self: A\\nFamily Resource for the Care of Alzheimer’s Disease and\\nRelated Disorders. Revised. NewYork: W.W. Norton &\\nCompany, 2001.\\nGeldmacher, David S. Contemporary Diagnosis and\\nManagement ofAlzheimer’s Disease. Newtown,\\nPA: Associates in Medical Marketing Co., Inc.,\\n2001.\\nGruetzner, Howard.Alzheimer’s: A Caregiver ˜os Guideand\\nSourcebook. 3rd ed. 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 MemoryLoss\\nin Later Life. New York: Warner Books, 2001.\\nTeitel, Rosette, and Marc L. Gordon.The Handholder ˜os\\nHandbook: A Guide for Caregivers of Alzheimer ˜os and\\nother Dementias. NewBrunswick, NJ: Rutgers\\nUniversity Press, 2001.\\nPERIODICALS\\n‘‘Alzheimer’s Could be Linked to Depression.’’GP (May 26,\\n2003): 4.\\n‘‘Alzheimer’s Could Reduced by Education.’’The Lancet\\n(June 28, 2003): 2215.\\nGALE ENCYCLOPEDIA OF MEDICINE 147\\nAlzheimer’s disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='‘‘Contrary to Some Earlier Results, New Study Shows\\nNSAIDs Do Not Slow Progression of Alzheimer’s\\nDisease.’’ The Brown University Geriatric\\nPsychopharmacology Update (July 2003): 1.\\nGitlin, L.N., and M. Corcoran. ‘‘Making Homes Safer:\\nEnvironmental Adaptations for People with\\nDementia.’’ Alzheimer’s Care Quarterly 1 (2000): 50-58.\\nHelmuth, L. ‘‘Alzheimer’s Congress: Further Progress on aB-\\nAmyloid Vaccine.’’Science 289, no. 5476 (2000): 375.\\nJosefson, Deborah. ‘‘Latests HRT Trial Results Show Risk\\nof Dementia.’’British Medical Journal (June 7, 2003):\\n1232.\\nMcReady, Norah. ‘‘Prompt Intervention May Slow\\nAlzheimer’s Decline.’’Family Practice News (May 1,\\n2003): 32-41.\\nNaditz, Alan. ‘‘Deeply Affected: As the Nation Ages,\\nAlzheimer’s Will Strike More People Close to Us.’’\\nContemporary Long Term Care (July 2003): 20-23.\\n‘‘Researchers Believe ‘‘Silent’’ Strokes Boost Risk.’’GP\\n(April 14, 2003): 9.\\nOTHER\\nAlzheimer’s Disease Books and Videotapes. .\\nNational Institute on Aging, National Institutes of Health.\\n2000: Progress Report on Alzheimer’s Disease - Taking\\nthe Next Steps. NIH Publication No. 4859 (2000).\\n.\\nJudith Sims\\nTeresa G. Odle\\nAmbiguous genitals see Intersex states\\nAmblyopia\\nDefinition\\nAmblyopia is an uncorrectable decrease in vision in\\none or both eyes with no apparent structural abnor-\\nmality seen to explain it. It is a diagnosis of exclusion,\\nmeaning that when a decrease in vision is detected,\\nother causes must be ruled out. Once no other cause is\\nfound, amblyopia is the diagnosis. Generally, a differ-\\nence of two lines or more (on an eye-chart test of visual\\nacuity) between the two eyes or a best corrected vision\\nof 20/30 or worse would be defined as amblyopia. For\\nexample, if someone has 20/20 vision with the right eye\\nand only 20/40 with the left, and the left eye cannot\\nachieve better vision with corrective lenses, the left eye\\nis 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\\nis the most common cause of impaired vision in child-\\nren, affecting nearly three out of every 100 people or\\n2-4% of the population. Vision is a combination of the\\nclarity of the images of the eyes (visual acuity) and the\\nprocessing of those images by the brain. If the images\\nproduced by the two eyes are substantially different,\\nthe brain may not be able to fuse the images. Instead of\\nseeing two different images or double vision (diplo-\\npia), the brain suppresses the blurrier image. This\\nsuppression can lead to amblyopia. During the first\\nfew years of life, preferring one eye over the other may\\nlead to poor visual development in the blurrier eye.\\nCauses and symptoms\\nSome of the major causes of amblyopia are as\\nfollows:\\n/C15Strabismus. A misalignment of the eyes (strabismus)\\nis the most common cause of functional amblyopia.\\nThe two eyes are looking in two different directions at\\nthe same time. The brain is sent two different images\\nand this causes confusion. Images from the misaligned\\nor ‘‘crossed’’ eye are turned off to avoid double vision.\\n/C15Anisometropia. 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\\ndifference of prescriptions between the two eyes).\\nFor example, one eye may be more nearsighted than\\nthe other eye, or one eye may be farsighted and the\\nother eye nearsighted. Because the brain cannot fuse\\nthe two dissimilar images, the brain will suppress the\\nblurrier image, causing the eye to become amblyopic.\\n/C15Cataract. Clouding of the lens of the eye will cause\\nthe image to be blurrier than the other eye. The brain\\n‘‘prefers’’ the clearer image. The eye with the cataract\\nmay become amblyopic.\\n/C15Ptosis. This is the drooping of the upper eyelid. If\\nlight cannot enter the eye because of the drooping lid,\\nthe eye is essentially not being used. This can lead to\\namblyopia.\\n/C15Nutrition. A type of organic amblyopia in which\\nnutritional deficiencies or chemical toxicity may\\nresult in amblyopia. Alcohol, tobacco, or a deficiency\\nin the Bvitamins may result in toxic amblyopia.\\n/C15Heredity. Amblyopia can run in families.\\nBarring the presence of strabismus or ptosis,\\nchildren may or may not show signs of amblyopia.\\n148 GALE ENCYCLOPEDIA OF MEDICINE\\nAmblyopia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Children may hold their heads at an angle while trying\\nto favor the eye with normal vision. They may have\\ntrouble seeing or reaching for things when approached\\nfrom the side of the amblyopic eye. Parents should\\nsee if one side of approach is preferred by the child\\nor infant. If an infant’s good eye is covered, the child\\nmay 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\\nhave their first vision examination, their eyes can, in\\nactuality, be examined at any age, even at one day of life.\\nSome recommend that children have their vision\\nchecked by their pediatrician, family physician,\\nophthalmologist, or optometrist at or before six\\nmonths of age. Others recommend testing by at least\\nthe child’s fourth birthday. There may be a ‘‘critical\\nperiod’’ in the development of vision, and amblyopia\\nmay not be treatable after age eight or nine. The earlier\\namblyopia is found, the better the possible outcome.\\nMost physicians test vision as part of a child’s medical\\nexamination. If there is any sign of an eye problem,\\nthey may refer a child to an eye specialist.\\nThere are objective methods, such as retinoscopy,\\nto measure the refractive status of the eyes. This can\\nhelp determine anisometropia. In retinoscopy, a hand-\\nheld instrument is used to shine a light in the child’s (or\\ninfant’s) eyes. Using hand-held lenses, a rough pre-\\nscription can be obtained. Visual acuity can be deter-\\nmined using a variety of methods. Many different eye\\ncharts are available (e.g., tumbling E, pictures, or\\nletters). In amblyopia, single letters are easier to\\nrecognize than when a whole line is shown. This is\\ncalled the ‘‘crowding effect’’ and helps in diagnosing\\namblyopia. Neutral density filters may also be held\\nover the eye to aid in the diagnosis. Sometimes visual\\nfields to determine defects in the area of vision will be\\nperformed. Color vision testing may also be per-\\nformed. Again, it must be emphasized that amblyopia\\nis a diagnosis of exclusion. Visual or life-threatening\\nproblems can also cause a decrease in vision. An exam-\\nination 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\\neye (forcing the amblyopic eye to work) and the\\namblyopic eye. If the good eye is constantly patched,\\nit too may become amblyopic because of disuse. The\\ntreatment plan should be discussed with the doctor to\\nfully understand how long the patch will be on. When\\npatched, eye exercises may be prescribed to force the\\namblyopic eye to focus and work. This is called vision\\ntherapy or vision training (eye exercises). Even after\\nvision has been restored in the weak eye, part-time\\npatching may be required over a period of years to\\nmaintain 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\\nMan with a lazy eye.(Custom Medical Stock Photo. Reproduced\\nby permission.)\\nKEY TERMS\\nAnisometropia— An eye condition in which there\\nis an inequality of vision between the two eyes.\\nThere may be unequal amounts of nearsightedness,\\nfarsightedness, or astigmatism, so that one eye will\\nbe in focus while the other will not.\\nCataract— Cloudiness of the eye’s natural lens.\\nOcculsion therapy— A type of treatment for\\namblyopia in which the good eye is patched for a\\nperiod of time. This forces the weaker eye to be\\nused.\\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 sharpness\\nof vision.GALE ENCYCLOPEDIA OF MEDICINE 149\\nAmblyopia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='are errors in refraction. Surgery or vision training may\\nbe necessary in the case of strabismus. Better nutrition\\nis indicated 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.\\nHowever, treatment may be successful in older child-\\nren–even adults. Success in the treatment of amblyo-\\npia also depends upon how severe the amblyopia is,\\nthe specific type of amblyopia, and patient compli-\\nance. It is important to diagnose and treat amblyopia\\nearly because significant vision loss can occur if left\\nuntreated. The best outcomes result from early diag-\\nnosis and treatment.\\nPrevention\\nTo protect their child’s vision, parents must be\\naware of amblyopia as a potential problem. This\\nawareness may encourage parents to take young chil-\\ndren for vision exams early on in life–certainly before\\nschool age. Proper nutrition is important in the avoid-\\nance of toxic amblyopia.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Ophthalmology. 655 Beach Street,\\nP.O. Box 7424, San Francisco, CA 94120-7424.\\n.\\nAmerican Optometric Association. 243 North Lindbergh\\nBlvd., St. Louis, MO 63141. (314) 991-4100. .\\nLorraine Steefel, RN\\nAmebiasis\\nDefinition\\nAmebiasis is an infectious disease caused by a\\nparasitic one-celled microorganism (protozoan) called\\nEntamoeba histolytica . Persons with amebiasis may\\nexperience a wide range of symptoms, includingdiar-\\nrhea, fever, and cramps. The disease may also affect\\nthe intestines, liver, or other parts of the body.\\nDescription\\nAmebiasis, also known as amebicdysentery, 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 subtro-\\npical areas where living conditions are crowded, with\\ninadequate sanitation. Although most cases of ame-\\nbiasis occur in persons who carry the disease but do\\nnot exhibit any symptoms (asymptomatic), as many as\\n100,000 people die of amebiasis each year. In the\\nUnited States, between 1 and 5% of the general popu-\\nlation will develop amebiasis in any given year, while\\nmale homosexuals, migrant workers, institutionalized\\npeople, and recent immigrants develop amebiasis at a\\nhigher rate.\\nHuman beings are the only known host of the\\namebiasis organism, and all groups of people, regardless\\nof age or sex, can become affected. Amebiasis is primar-\\nily spread in food and water that has been contaminated\\nby human feces but is also spread by person-to-person\\ncontact. The number of cases is typically limited, but\\nregional outbreaks can occur in areas where human\\nfeces are used as fertilizer for crops, or in cities with\\nwater supplies contaminated with human feces.\\nCauses and symptoms\\nRecently, it has been discovered that persons\\nwith symptom-causing amebiasis are infected with\\nEntamoeba histolytica , and those individuals who\\nexhibit no symptoms are actually infected with an\\nalmost identical-looking ameba called Entamoeba\\ndispar. During their life cycles, the amebas exist in\\ntwo very different forms: the infective cyst or\\ncapsuled form, which cannot move but can survive\\noutside the human body because of its protective\\ncovering, and the disease-producing form, the\\ntrophozoite, which although capable of moving, can-\\nnot survive once excreted in the feces and, therefore,\\ncannot infect others. The disease is most commonly\\ntransmitted when a person eats food or drinks water\\ncontaining E. histolytica cysts from human feces. In\\nthe digestive tract the cysts are transported to the\\nintestine where the walls of the cysts are broken\\nopen by digestive secretions, releasing the mobile\\ntrophozoites. Once released within the intestine, the\\ntrophozoites multiply by feeding on intestinal bac-\\nteria or by invading the lining of the large intestine.\\nWithin the lining of the large intestine, the\\ntrophozoites secrete a substance that destroys intest-\\ninal tissue and creates a distinctive bottle-shaped\\nsore (ulcer). The trophozoites may remain inside the\\nintestine, in the intestinal wall, or may break through\\n150 GALE ENCYCLOPEDIA OF MEDICINE\\nAmebiasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the intestinal wall and be carried by the blood to the\\nliver, lungs, brain, or other organs. Trophozoites that\\nremain in the intestines eventually form new cysts\\nthat are carried through the digestive tract and\\nexcreted in the feces. Under favorable temperature\\nand humidity conditions, the cysts can survive in\\nsoil 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,\\nand people whose immune systems may be compressed,\\nsuch ascancer or AIDS patients and those individuals\\ntaking prescription medications that suppress the\\nimmune system, are at a greater risk for developing a\\nsevere infection.\\nThe signs and symptoms of amebiasis vary\\naccording to the location and severity of the infection\\nand are classified 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\\nof infecting others by person-to-person contact or by\\ncontaminating food or water with cysts that others\\nmay ingest, for example, by preparing food with\\nunwashed hands.\\nCHRONIC NON-DYSENTERIC INFECTION. Indivi-\\nduals may experience symptoms over a long period\\nof time during a chronic amebiasis infection and\\nexperience recurrent episodes of diarrhea that last\\nfrom one to four weeks and recur over a period of\\nyears. These patients may also suffer from abdominal\\ncramps, fatigue, and weight loss.\\nAMEBIC DYSENTERY. In severe cases of intestinal\\namebiasis, the organism invades the lining of the\\nintestine, producing sores(ulcers), bloody diarrhea,\\nsevere abdominal cramps, vomiting,c h i l l s ,a n d\\nfevers as high as 104-1058F (40-40.68C). In addition,\\nac a s eo fa c u t ea m e b i cd y s entery may cause compli-\\ncations, including inflam mation of the appendix\\n(appendicitis ), a tear in the intestinal wall (perfora-\\ntion), or a sudden, severe inflammation of the colon\\n(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 symp-\\ntoms that mimic cancer or other intestinal diseases.\\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.)\\nKEY TERMS\\nAmeboma— A mass of tissue that can develop on\\nthe wall of the colon in response to amebic\\ninfection.\\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-shaped\\norgan, such as the bowel.\\nProtozoan— A single-celled, usually microscopic\\norganism that is eukaryotic and, therefore, different\\nfrom bacteria (prokaryotic).\\nGALE ENCYCLOPEDIA OF MEDICINE 151\\nAmebiasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='PERIANAL ULCERS. Intestinal amebiasis may pro-\\nduce skin infections in the area around the patient’s\\nanus (perianal). These ulcerated areas have a\\n‘‘punched-out’’ appearanceand are painfultothe touch.\\nExtraintestinal amebiasis\\nExtraintestinal amebiasis accounts for approxi-\\nmately 10% of all reported amebiasis cases and includes\\nall forms of the disease that affect other organs.\\nThe most common form of extraintestinal amebia-\\nsis is amebicabscess of the liver. In the United States,\\namebic liver abscesses occur most frequently in young\\nHispanic adults. An amebic liver abscess can result\\nfrom direct infection of the liver byE. histolytica or as\\na complication of intestinal amebiasis. Patients with an\\namebic abscess of the liver complain ofpain in the chest\\nor abdomen, fever,nausea, and tenderness on the right\\nside directly above the liver.\\nOther forms of extraintestinal amebiasis, though\\nrare, include infections of the lungs, chest cavity,\\nbrain, or genitals. These are extremely serious and\\nhave a relatively high mortality rate.\\nDiagnosis\\nDiagnosis of amebiasis is complicated, partly\\nbecause the disease can affect several areas of the\\nbody and can range from exhibiting few, if any, symp-\\ntoms to being severe, or even life-threatening. In most\\ncases, a physician will consider a diagnosis of amebia-\\nsis when a patient has a combination of symptoms, in\\nparticular, diarrhea and a possible history of recent\\nexposure to amebiasis through travel, contact with\\ninfected persons, or anal intercourse.\\nIt is vital to distinguish between amebiasis and\\nanother disease, inflammatory bowel disease (IBD)\\nthat produces similar symptoms because, if diagnosed\\nincorrectly, drugs that are given to treat IBD can\\nencourage the growth and spread of the amebiasis\\norganism. Because of the serious consequences of\\nmisdiagnosis, potential cases of IBD must be con-\\nfirmed with multiple stool samples and blood tests,\\nand a procedure involving a visual inspection of the\\nintestinal wall using a thin lighted, tubular instrument\\n(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\\nstool sample for the presence of cysts and/or tropho-\\nzoites ofE. histolytica and not one of the many other\\nintestinal amebas that are often found but that do not\\ncause disease. A series of three stool tests is approxi-\\nmately 90% accurate in confirming a diagnosis of\\namebic dysentery. Unfortunately, however, the stool\\ntest is not useful in diagnosing amebomas or extra-\\nintestinal infections.\\nSigmoidoscopy\\nSigmoidoscopy is a useful diagnostic procedure in\\nwhich a thin, flexible, lighted instrument, called a\\nsigmoidoscope, is used to visually examine the lower\\npart of the large intestine for amebic ulcers and take\\ntissue or fluid samples from the intestinal lining.\\nBlood tests\\nAlthough tests designed to detect a specific\\nprotein produced in response to amebiasis infection\\n(antibody) are capable of detecting only about 10%\\nof cases of mild amebiasis, these tests are extremely\\nuseful in confirming 95% of dysentery diagnoses\\nand 98% of liver abscess diagnoses. Blood serum will\\nusually test positive for antibody within a week of\\nsymptom onset. Blood testing, however, cannot\\nalways distinguish between a current or past infection\\nsince the antibodies may be detectable in the blood\\nfor as long as 10 years following initial infection.\\nImaging studies\\nA number of sophisticated imaging techniques,\\nsuch as computed tomography scans (CT), magnetic\\nresonance imaging (MRI), and ultrasound, can be\\nused to determine whether a liver abscess is present.\\nOnce located, a physician may then use a fine needle\\nto withdraw a sample of tissue to determine whether\\nthe abscess is indeed caused by an amebic infection.\\nTreatment\\nAsymptomatic or mild cases of amebiasis may\\nrequire no treatment. However, because of the\\npotential for disease spread, amebiasis is generally\\ntreated with a medication to kill the disease-causing\\namebas. More severe cases of amebic dysentery are\\nadditionally treated by replacing lost fluid and\\nblood. Patients with an amebic liver abscess will\\nalso require hospitalization and bed rest. For those\\ncases of extraintestinal amebiasis, treatment can be\\ncomplicated because different drugs may be required\\nto eliminate the parasite, based on the location of\\nthe infection within the body. Drugs used to treat\\namebiasis, called amebicides, are divided into two\\ncategories:\\n152 GALE ENCYCLOPEDIA OF MEDICINE\\nAmebiasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Luminal amebicides\\nThese drugs get their name because they act on\\norganisms within the inner cavity (lumen) of the\\nbowel. They include diloxanide furoate, iodoquinol,\\nmetronidazole, and paromomycin.\\nTissue amebicides\\nTissue amebicides are used to treat infections in\\nthe liver and other body tissues and include emetine,\\ndehydroemetine, metronidazole, and chloroquine.\\nBecause these drugs have potentially serious side\\neffects, patients given emetine or dehydroemetine\\nrequire bed rest and heart monitoring. Chloroquine\\nhas been found to be the most useful drug for treating\\namebic liver abscess. Patients taking metronidazole\\nmust avoid alcohol because the drug-alcohol combi-\\nnation causes nausea, vomiting, andheadache.\\nMost patients are given a combination of luminal\\nand tissue amebicides over a treatment period of seven\\nto ten days. Follow-up care includes periodic stool\\nexaminations beginning two to four weeks after the\\nend of medication treatment to check the effectiveness\\nof drug therapy.\\nPrognosis\\nThe prognosis depends on the location of the\\ninfection and the patient’s general health prior to\\ninfection. The prognosis is generally good, although\\nthe mortality rate is higher for patients with ameboma,\\nperforation of the bowel, and liver infection. Patients\\nwho develop fulminant colitis have the most serious\\nprognosis, with over 50% mortality.\\nPrevention\\nThere are no immunization procedures or medica-\\ntions that can be taken prior to potential exposure to\\nprevent amebiasis. Moreover, people who have had\\nthe disease can become reinfected. Prevention requires\\neffective personal and community hygiene.\\nSpecific safeguards include the following:\\n/C15Purification of drinking water. Water can be purified\\nby filtering, boiling, or treatment with iodine.\\n/C15Proper food handling. Measures include protecting\\nfood from contamination by flies, cooking food\\nproperly, washing one’s hands after using the bath-\\nroom and before cooking or eating, and avoiding\\nfoods that cannot be cooked or peeled when travel-\\ning in countries with high rates of amebiasis.\\n/C15Careful disposal of human feces.\\n/C15Monitoring the contacts of amebiasis patients. The\\nstools of family members and sexual partners of\\ninfected persons should be tested for the presence of\\ncysts or trophozoites.\\nResources\\nBOOKS\\nFriedman, Lawrence S. ‘‘Liver, Biliary Tract, & Pancreas.’’\\nIn Current Medical Diagnosis and Treatment, 1998 ,\\nedited by Stephen McPhee, et al., 37th ed. Stamford:\\nAppleton & Lange, 1997.\\nRebecca J. Frey, PhD\\nAmebic dysentery see Amebiasis\\nAmenorrhea\\nDefinition\\nThe absence of menstrual periods is called ame-\\nnorrhea. Primary amenorrhea is the failure to start\\nhaving a period by the age of 16. Secondary amenor-\\nrhea is more common and refers to either the tempor-\\nary or permanent ending of periods in a woman who\\nhas menstruated normally in the past. Many women\\nmiss a period occasionally. Amenorrhea occurs if a\\nwoman misses three or more periods in a row.\\nDescription\\nThe absence of menstrual periods is a symptom,\\nnot a disease. While the average age that menstruation\\nbegins is 12, the range varies. The incidence of primary\\namenorrhea 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 gym-\\nnasts, who typically exercise strenuously and eat poorly.\\nCauses and symptoms\\nAmenorrhea can have many causes. Primary ame-\\nnorrhea can be the result of hormonal imbalances,\\npsychiatric disorders, eating disorders, malnutrition,\\nexcessive thinness or fatness, rapid weight loss, body\\nfat content too low, and excessive physical condition-\\ning. Intense physical training prior topuberty can delay\\nmenarche (the onset of menstruation). Every year of\\ntraining can delay menarche for up to five months.\\nGALE ENCYCLOPEDIA OF MEDICINE 153\\nAmenorrhea'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Some medications such as anti-depressants, tranquili-\\nzers, steroids, and heroin can induce amenorrhea.\\nPrimary amenorrhea\\nHowever, the main cause is a delay in the begin-\\nning of puberty either from natural reasons (such as\\nheredity or poornutrition) or because of a problem in\\nthe endocrine system, such as a pituitary tumor or\\nhypothyroidism. An obstructed flow tract or inflam-\\nmation in the uterus may be the presenting indications\\nof an underlying metabolic, endocrine, congenital or\\ngynecological disorder.\\nTypical causes of primary amenorrhea include:\\n/C15excessive physical activity\\n/C15drastic weight loss (such as occurs in anorexia or\\nbulimia)\\n/C15extreme obesity\\n/C15drugs (antidepressants or tranquilizers)\\n/C15chronic illness\\n/C15turner’s syndrome. (A chromosomal problem in place\\nat birth, relevant only in cases of primary amenorrhea)\\n/C15the absence of a vagina or a uterus\\n/C15imperforate hymen (lack of an opening to allow the\\nmenstrual blood through)\\nSecondary amenorrhea\\nSome of the causes of primary amenorrhea can\\nalso cause secondary amenorrhea – strenuous physical\\nactivity, excessive weight loss, use of antidepressants\\nor tranquilizers, in particular. In adolescents,preg-\\nnancy and stress are two major causes. Missed periods\\nare usually caused in adolescents by stress and changes\\nin environment. Adolescents are especially prone to\\nirregular periods with fevers, weight loss, changes in\\nenvironment, or increased physical or athletic activity.\\nHowever, any cessation of periods for four months\\nshould be evaluated.\\nThe most common cause of seconardy amenor-\\nrhea is pregnancy. Also, a woman’s periods may halt\\ntemporarily after she stops taking birth control pills.\\nThis temporary halt usually lasts only for a month or\\ntwo, though in some cases it can last for a year or\\nmore. Secondary amenorrhea may also be related to\\nhormonal problems related to stress, depression,anor-\\nexia nervosa or drugs, or it may be caused by any\\ncondition affecting the ovaries, such as a tumor. The\\ncessation of menstruation also occurs permanently\\nafter menopause or ahysterectomy.\\nDiagnosis\\nIt may be difficult to find the cause of amenor-\\nrhea, but the exam should start with a pregnancy test;\\npregnancy needs to be ruled out whenever a woman’s\\nperiod is two to three weeks overdue. Androgen\\nexcess, estrogen deficiency, or other problems with\\nthe endocrine system need to be checked. Prolactin in\\nthe blood and the thyroid stimulating hormone (TSH)\\nshould also be checked.\\nThe diagnosis usually includes a patient history\\nand a physical exam (including a pelvic exam). If a\\nwoman has missed three or more periods in a row, a\\nphysician may recommend blood tests to measure\\nhormone levels, a scan of the skull to rule out the\\npossibility of a pituitary tumor, and ultrasound scans\\nof the abdomen and pelvis to rule out a tumor of the\\nadrenal gland or ovary.\\nTreatment\\nTreatment of amenorrhea depends on the cause.\\nPrimary amenorrhea often requires no treatment, but\\nit’salwaysimportanttodiscoverthecauseoftheproblem\\nin any case. Not all conditions can be treated, but any\\nunderlying condition that is treatable should be treated.\\nIf a hormonal imbalance is the problem, progester-\\none for one to two weeks every month or two may\\ncorrect the problem. With polycystic ovary syndrome,\\nbirth control pills are often prescribed. A pituitary\\ntumor is treated with bromocriptine, a drug that reduces\\ncertain hormone (prolactin) secretions. Weight loss may\\nbring on a period in an obese woman. Easing up on\\nexcessive exercise and eating a proper diet may bring\\non periods in teen athletes. In very rare cases, surgery\\nmay be needed for women with ovarian or uterine cysts.\\nPrognosis\\nProlonged amenorrhea can lead toinfertility and\\nother medical problems such asosteoporosis (thinning\\nof the bones). If the halt in the normal period is caused\\nKEY TERMS\\nHymen— Membrane that stretches across the open-\\ning 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.\\n154 GALE ENCYCLOPEDIA OF MEDICINE\\nAmenorrhea'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='by stress or illness, periods should begin again when\\nthe stress passes or the illness is treated. Amenorrhea\\nthat occurs with discontinuing birth control pills\\nusually go away within six to eight weeks, although it\\nmay take up to a year.\\nThe prognosis for polycystic ovary disease\\ndepends on the severity of the symptoms and the\\ntreatment plan. Spironolactone, a drug that blocks\\nthe production of male hormones, can help in reducing\\nbody hair. If a woman wishes to become pregnant,\\ntreatment with clomiphene may be required or, on\\nrare occasions, surgery 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, avoidingsmoking and\\nsubstance abuse. Female athletes should be sure to eat a\\nbalanced diet and rest and exercise normally. However,\\nmany cases of amenorrhea cannot be prevented.\\nResources\\nPERIODICALS\\nHogg, Anne Cahill. ‘‘Breaking the Cycle: Often Confused\\nand Frustrated, Sufferers of Amenorrhea Now have\\nBetter Treatment Options.’’American Fitness 15, no. 4\\n(July-August 1997): 30-4.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nFederation of Feminist Women’s Health Centers.1469\\nHumboldt Rd, Suite 200, Chico, CA 96928. (530)\\n891-1911.\\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\\ncommonly done on newborns. Two tests are available,\\none using a blood sample and the other a urine sample.\\nPurpose\\nAmino acid disorder screening is done in new-\\nborns, and sometimes children and adults, to detect\\ninborn errors in metabolism of amino acids. Twenty of\\nthe 100 known amino acids are the main building\\nblocks for human proteins. Proteins regulate every\\naspect of cellular function. Of these 20 amino acids,\\nten are not made by the body and must be acquired\\nthrough diet. Congenital (present at birth) enzyme defi-\\nciencies that affect amino acid metabolism or congenital\\nabnormalities in the amino acid transport system of\\nthe kidneys creates a condition 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\\nexamples of this isphenylketonuria (PKU). This is an\\ngenetic error in metabolism of phenylalanine, an\\namino acid found in milk. Individuals with PKU do\\nnot produce the enzyme necessary to break down\\nphenylalanine.\\nPKU occurs in about one out of 16,000 live births\\nin the United States, but is more prevalent in cauca-\\nsians and less prevalent in Ashkenazi Jews and African\\nAmericans. Newborns in the United States are routi-\\nnely screened for PKU by a blood test.\\nThere are two types of aminoacidurias. Primary\\nor overflow aminoaciduria results from deficiencies in\\nthe enzymes necessary to metabolize amino acids.\\nOverflow aminoaciduria is best detected by a blood\\nplasma test.\\nSecondary or renal aminoaciduria occurs because\\nof a congenital defect in the amino acid transport\\nsystem in the tubules of the kidneys. This produces\\nincreased amino acids in the urine. Blood and urine\\ntest in combination are used to determine if the ami-\\nnoaciduria is of the overflow or renal type. Urine tests\\nare also used to monitor specific amino acid disorders.\\nNewborns are screened for amino acid disorders.\\nYoung children with acidosis (accumulation of acid\\nin the body), severevomiting and diarrhea, or urine\\nwith an abnormal color or odor, are also screened\\nwith a urine test for specific amino acid levels.\\nPrecautions\\nBoth blood and urine tests are simple tests that\\ncan be done in a doctor’s office or clinic. These tests\\ncan be done on even the youngest patients.\\nGALE ENCYCLOPEDIA OF MEDICINE 155\\nAmino acid disorders screening'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\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\\nsmall amount of blood from a baby’s heel. The proce-\\ndure is rapid and relatively painless. Total time for the\\ntest is less than ten minutes. The blood is sent to a\\nlaboratory where results will be available in about\\ntwo days.\\nUrine test\\nIn the urine test, the patient is asked to urinate\\ninto a collecting cup. For an infant, the urine is col-\\nlected in a pediatric urine collector. The process is\\npainless. The length of time the test takes is determined\\nby how long it takes the patient to urinate. Results also\\ntake about two days.\\nBoth these tests use thin layer chromatography to\\nseparate the amino acids present. Using this techni-\\nque, the amino acids form a characteristic patterns on\\na glass plate coated with a thin layer of silica gel. This\\npattern is then compared to the normal pattern to\\ndetermine if there are abnormalities.\\nPreparation\\nBefore the blood test, the patient must not eat or\\ndrink for four hours. Failure to fast will alter the\\nresults of the test.\\nThe patient should eat and drink normally before\\nthe urine test. Some drugs may affect the results of the\\nurine test. The technician handling the urine sample\\nshould be informed of any medications the patient is\\ntaking. Mothers of breastfeeding infants should report\\nany medications they are taking, since these can pass\\nfrom mother to child in breast milk.\\nAftercare\\nThe blood screening is normally done first.\\nDepending on the results, it is followed by the urine\\ntest. It takes both tests to distinguish between over-\\nflow and renal aminoaciduria. Also, if the results are\\nabnormal, a 24-hour urine test is performed along\\nwith other tests to determine the levels of specific\\namino acids. In the event of abnormal results, there\\nare many other tests that will be performed to determine\\nthe specific amino acid involved in the abnormality.\\nRisks\\nThere are no particular risks associated with\\neither of these tests. Occasionally minor bruising may\\noccur at the site where the blood was taken.\\nNormal results\\nThe pattern of amino acid banding on the thin\\nlayer chromatography plates will be normal.\\nAbnormal results\\nThebloodplasmaaminoacidpatternisabnormalin\\noverflow aminoaciduria and is normal in renal amino-\\naciduria. The pattern is abnormal in the urine test,\\nsuggesting additional tests need to be done to determine\\nwhich amino acids are involved. In addition to PKU, a\\nvariety of other amino acid metabolism disorders can\\nbe detected by these tests, including tyrosinosis, histi-\\ndinemia, maple syrup urine disease, hypervalinemia,\\nhyperprolinemia, and homocystinuria.\\nResources\\nORGANIZATIONS\\nAssociation for Neuro-Metabolic Disorders. 5223\\nBrookfield Lane, Sylvania, OH 43560-1809. (419)\\n885-1497.\\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, A.M.\\nKEY TERMS\\nAmino acid— An organic compound composed of\\nboth an amino group and an acidic carboxyl group;\\namino acids are the basic building blocks of\\nproteins.\\nAminoaciduria— The abnormal presence of amino\\nacids in the urine.\\nChromatography— A family of laboratory techni-\\nques that separate mixtures of chemicals into their\\nindividual 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.\\n156 GALE ENCYCLOPEDIA OF MEDICINE\\nAmino acid disorders screening'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aminoglycosides\\nDefinition\\nAminoglycosides are a group ofantibiotics that\\nare used to treat certain bacterial infections. This\\ngroup of antibiotics includes at least eight drugs:\\namikacin, gentamicin, kanamycin, neomycin, netil-\\nmicin, paromomycin, streptomycin, and tobramycin.\\nAll of these drugs have the same basic chemical\\nstructure.\\nPurpose\\nAminoglycosides are primarily used to combat\\ninfections due to aerobic, Gram-negative bacteria.\\nThese bacteria can be identified by their reaction to\\nGram’s stain. In Gram’s staining, a film of material\\ncontaining the possible bacteria is placed on a glass\\nslide and dried. The slide is stained with crystal violet\\nfor one minute, cleaned off with water and then placed\\ninto a solution of Gram’s iodine solution for one\\nminute. The iodine solution is rinsed off and the slide\\nis immersed in 95% ethyl alcohol. The slide is then\\nstained again with reddish carbolfuchsin or safranine\\nfor 30 seconds, rinsed in water, dried and examined.\\nGram-positive bacteria retain the violet purple stain.\\nGram-negative bacteria accept the red stain. Bacteria\\nthat can successfully be combated with aminoglyco-\\nsides include Pseudomonas, Acinetobacter, and\\nEnterobacter species, among others. Aminoglycosides\\nare also effective against mycobacteria, the bacteria\\nresponsible fortuberculosis.\\nThe aminoglycosides can be used against certain\\nGram-positive bacteria, but are not typically\\nemployed because other antibiotics are more effective\\nand have fewer side effects. Aminoglycosides are inef-\\nfective against anaerobic bacteria (bacteria that can-\\nnot grow in the presence of oxygen), viruses, and\\nfungi. And only one aminoglycoside, paromomycin,\\nis used against parasitic infection.\\nLike all other antibiotics, aminoglycosides are not\\neffective againstinfluenza, thecommon cold, or other\\nviral infections.\\nPrecautions\\nPre-existing medical conditions–such as kidney\\ndisease, eighth cranial nerve disease, myasthenia\\ngravis, and Parkinson’s disease–should be discussed\\nprior to taking any aminoglycosides. Pregnant\\nwomen are usually advised against taking aminogly-\\ncosides, because their infants may suffer damage to\\ntheir hearing, kidneys, or sense of balance. However,\\nthose factors need to be considered alongside the\\nthreat to the mother’s health and life in cases of\\nserious infection. Aminoglycosides do not pass into\\nbreast milk to any great extent, so nursing mothers\\nmay be prescribed aminoglycosides without injuring\\ntheir infants.\\nDescription\\nStreptomycin, the first aminoglycoside, was\\nisolated fromStreptomyces griseus in the mid-1940s.\\nThis antibiotic was very effective against tuberculosis.\\nOne of the main drawbacks to streptomycin is its\\ntoxicity, especially to cells in the inner and middle ear\\nand the kidney. Furthermore, some strains of tubercu-\\nlosis are resistant to treatment with streptomycin.\\nTherefore, medical researchers have put considerable\\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 Gram’s\\nstain.\\nGram’s stain—A stain used in microbiology to clas-\\nsify bacteria and help identify the species to which\\nthey belong. This identification aids in determining\\ntreatment.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 157\\nAminoglycosides'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='effort into identifying other antibiotics with strep-\\ntomycin’s efficacy, but without its toxicity.\\nAminoglycosides are absorbed very poorly from\\nthe gastrointestinal tract; in fact, aminoglycosides\\ntaken orally are excreted virtually unchanged and\\nundiminished in quantity. The route of drug admin-\\nistration depends on the type and location of the\\ninfection being treated. The typical routes of admin-\\nistration are by intramuscular (injection into a mus-\\ncle) or intravenous injection (injection into a vein),\\nirrigation, topical skin application, or inhalation.\\nIf the infection being treated involves the central\\nnervous system, the drug can be injected into the\\nspinal canal.\\nThe bactericidal ability of aminoglycosides has\\nnot been fully explained. It is known that the drug\\nattaches to a bacterial cell wall and is drawn into the\\ncell via channels made up of the protein, porin. Once\\ninside the cell, the aminoglycoside attaches to the cell’s\\nribosomes. Ribosomes are the intracellular structures\\nresponsible for manufacturing proteins. This attach-\\nment either shuts down protein production or causes\\nthe cell to produce abnormal, ineffective proteins. The\\nbacterial cell cannot survive with this impediment.\\nAntibiotic treatment using aminoglycosides may\\npair the drug with a second type of antibiotic, usually\\na beta-lactam or vancomycin, administered sepa-\\nrately. Beta-lactams disrupt the integrity of the bac-\\nteria cell wall, making it more porous. The increased\\nporosity allows more of the aminoglycoside into the\\nbacteria cell.\\nTraditionally, aminoglycosides were administered\\nat even doses given throughout the day. It was thought\\nthat a steady plasma concentration was necessary to\\ncombat infection. However, this administration sche-\\ndule is time and labor intensive. Furthermore, admin-\\nistering a single daily dose can be as effective, or more\\neffective, than several doses throughout the day.\\nDosage depends on the patient’s age, weight, gen-\\nder, and general health. Since the drug is cleared by the\\nkidneys, it is important to assess any underlying pro-\\nblems with kidney function. Kidney function is\\nassessed by measuring the blood levels of creatinine,\\na protein normally found in the body. If these levels\\nare high, it is an indication that the kidneys may not be\\nfunctioning at an optimal rate and dosage will be\\nlowered accordingly.\\nRisks\\nAminoglycosides have been shown to be toxic\\nto certain cells in the ears and in the kidneys.\\nApproximately 5-10% of the people who are\\ntreated with aminoglycosides experience some side\\neffect, affecting their hearing, sense of balance, or\\nkidneys. However, in most cases the damage is minor\\nand reversible once medication is stopped.\\nIf cells in the inner ear are damaged or destroyed,\\nan individual may experience a loss of balance and\\nfeelings of dizziness. Damage to the middle ear may\\nresult inhearing lossor tinnitus. Neomycin, kanamycin,\\nand amikacin are the most likely to cause problems with\\nhearing, and streptomycin and gentamicin carry the\\ngreatest risk of causing vertigo and loss of balance.\\nKidney damage, apparent with changes in urination\\nfrequency or urine production, is most likely precipi-\\ntated by neomycin, 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 skinrashes and\\nitching. Very rarely, certain aminoglycosides may\\ncause difficulty in breathing, weakness, or drowsiness.\\nGentamicin, when injected, may cause leg cramps,\\nskin rash,fever, or seizures.\\nIf side effects linger or become worse after medi-\\ncation is stopped, it is advisable to seek medical advice.\\nSide effects that may be of concern includetinnitus or\\nloss of hearing, dizziness or loss of balance, changes in\\nurination frequency or urine production, increased\\nthirst, appetite loss, andnausea 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\\nbecomes apparent after repeated exposure to the anti-\\nbiotic and arises from a mutation that alters the bac-\\nteria’s susceptibility to the drug. Various degrees of\\nresistance have been observed in bacteria that nor-\\nmally would be destroyed by aminoglycosides. In gen-\\neral, though, aminoglycoside effectiveness has held\\nup well over time.\\nResources\\nBOOKS\\nChambers, Henry F., W. Keith Hadley, and Ernest Jawetz.\\n‘‘Aminoglycosides & Spectinomycin.’’ InBasic and\\n158 GALE ENCYCLOPEDIA OF MEDICINE\\nAminoglycosides'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Clinical Pharmacology, edited by Bertram G. Katzung,\\n7th ed. Stamford: Appleton & Lange, 1998.\\nJulia Barrett\\nAmitriptyline see Antidepressants, tricyclic\\nAmlodipine see Calcium channel blockers\\nAmnesia\\nDefinition\\nAmnesia refers to the loss of memory. Memory\\nloss may result from two-sided (bilateral) damage to\\nparts of the brain vital for memory storage, proces-\\nsing, or recall (the limbic system, including the hippo-\\ncampus in the medial temporal lobe).\\nDescription\\nAmnesia can be a symptom of several neurode-\\ngenerative diseases; however, people whose primary\\nsymptom is memory loss (amnesiacs), typically remain\\nlucid and retain their sense of self. They may even be\\naware that they suffer from a memory disorder.\\nPeople who experience amnesia have been instru-\\nmental in helping brain researchers determine how\\nthe brain processes memory. Until the early 1970s,\\nresearchers viewed memory as a single entity.\\nMemory of new experiences, motor skills, past events,\\nand previous conditioning were grouped together in\\none system that relied on a specific area of the brain.\\nIf all memory were stored in the same way, it would\\nbe reasonable to deduce that damage to the specific\\nbrain area would cause complete memory loss. How-\\never, studies of amnesiacs counter that theory. Such\\nresearch demonstrates that the brain has multiple sys-\\ntems for processing, storing, and drawing on memory.\\nCauses and symptoms\\nAmnesia has several root causes. Most are trace-\\nable to brain injury related to physical trauma, disease,\\ninfection, drug and alcoholabuse, or reduced blood\\nflow to the brain (vascular insufficiency). In Wernicke-\\nKorsakoff syndrome, for example, damage to the\\nmemory centers of the brain results from the use of\\nalcohol ormalnutrition. Infections that damage brain\\ntissue, including encephalitis and herpes, can also\\ncause amnesia. If the amnesia is thought to be of\\npsychological origin, it is termed psychogenic.\\nThere are at least three general types of amnesia:\\n/C15Anterograde. This form of amnesia follows brain\\ntrauma and is characterized by the inability to\\nremember new information. Recent experiences and\\nshort-term memory disappear, but victims can recall\\nevents prior to the trauma with clarity.\\n/C15Retrograde. In some ways, this form of amnesia is\\nthe opposite of anterograde amnesia: the victim can\\nrecall events that occurred after a trauma, but cannot\\nremember previously familiar information or the\\nevents preceding the trauma.\\n/C15Transient global amnesia. This type of amnesia has\\nno consistently identifiable cause, but researchers\\nhave suggested that migraines or transient ischemic\\nattacks may be the trigger. (A transient ischemic\\nattack, sometimes called ‘‘a small stroke,’’ occurs\\nwhen a blockage in an artery temporarily blocks\\noff blood supply to part of the brain.) A victim\\nexperiences sudden confusion and forgetfulness.\\nAttacks can be as brief as 30-60 minutes or can\\nlast up to 24 hours. In severe attacks, a person is\\ncompletely disoriented and may experience retro-\\ngrade amnesia that extends back several years.\\nWhile very frightening for the patient, transient\\nglobal amnesia generally has an excellent prognosis\\nfor recovery.\\nAmygdalaHippocampus\\nMemory loss may result from bilateral damage to the limbic\\nsystem of the brain responsible for memory storage, proces-\\nsing, and recall. (Illustration by Electronic Illustrators Group).\\nGALE ENCYCLOPEDIA OF MEDICINE 159\\nAmnesia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nIn diagnosing amnesia and its cause, doctors look\\nat several factors. During aphysical examination,t h e\\ndoctor inquires about recent traumas or illnesses, drug\\nand medication 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\\nas magnetic 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\\nand is handled on an individual basis. Regardless of\\ncause, cognitiverehabilitationmay be helpful in learning\\nstrategies to cope with memory impairment.\\nPrognosis\\nSome types of amnesia, such as transient global\\namnesia, are completely resolved and there is no per-\\nmanent loss of memory. Others, such as Korsakoff\\nsyndrome, associated with prolonged alcohol abuse\\nor amnesias caused by severe brain injury, may be\\npermanent. Depending on the degree of amnesia and\\nits cause, victims may be able to lead relatively normal\\nlives. Amnesiacs can learn through therapy to rely on\\nother memory systems to compensate for what is lost.\\nPrevention\\nAmnesia is only preventable in so far as brain\\ninjury can be prevented or minimized. Common\\nsense approaches include wearing a helmet when bicy-\\ncling or participating in potentially dangerous sports,\\nusing automobile seat belts, and avoiding excessive\\nalcohol or drug use. Brain infections should be treated\\nswiftly and aggressively to minimize the damage due\\nto swelling. Victims of strokes, brain aneurysms, and\\ntransient ischemic attacks should seek immediate\\nmedical treatment.\\nResources\\nPERIODICALS\\nSquire, Larry R., and Stuart M. Zola. ‘‘Amnesia,\\nMemory and Brain Systems.’’Philosophical\\nTransactions of the Royal Society of London, Series B\\n352 (1997): 1663.\\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\\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\\ncrowd causes 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,\\nan amnesiac may remember he has a wife (seman-\\ntic memory), 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\\nrelates to the task at hand and coordinates recall\\nof memories necessary to complete it.\\n160 GALE ENCYCLOPEDIA OF MEDICINE\\nAmniocentesis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='in the womb, is collected through a pregnant woman’s\\nabdomen using a needle and syringe. Tests performed\\non fetal cells found in the sample can reveal the presence\\nof many types of genetic disorders, thus allowing\\ndoctors and prospective parents to make important\\ndecisions about early treatment and intervention.\\nPurpose\\nSince the mid-1970s, amniocentesis has been used\\nroutinely to test forDown syndrome, by far the most\\ncommon, nonhereditary, genetic birth defect, afflict-\\ning about one in every 1,000 babies. By 1997, approxi-\\nmately 800 different diagnostic tests were available,\\nmost of them for hereditary genetic disorders such\\nas Tay-Sachs disease, sickle cell anemia,hemophilia,\\nmuscular dystrophyand cystic fibrosis.\\nAmniocentesis, often called amnio, is recom-\\nmended for women who will be older than 35 on\\ntheir due-date. It is also recommended for women\\nwho have already borne children with birth defects,\\nor when either of the parents has a family history of a\\nbirth defect for which a diagnostic test is available.\\nAnother reason for the procedure is to confirm indica-\\ntions of Down syndrome and certain other defects\\nwhich may have shown up previously during routine\\nmaternal blood screening.\\nThe risk of bearing a child with a nonhereditary\\ngenetic defect such as Down syndrome is directly\\nrelated to a woman’s age–the older the woman, the\\ngreater the risk. Thirty-five is the recommended age to\\nbegin amnio testing because that is the age at which the\\nrisk of carrying a fetus with such a defect roughly\\nequals the risk of miscarriage caused by the proce-\\ndure–about one in 200. At age 25, the risk of giving\\nbirth to a child with this type of defect is about one in\\n1,400; by age 45 it increases to about one in 20. Nearly\\nhalf of all pregnant women over 35 in the United States\\nundergo amniocentesis and many younger women also\\ndecide to have the procedure. Notably, some 75% of all\\nDown syndrome infants born in the United States each\\nyear are to women younger than 35.\\nOne of the most common reasons for performing\\namniocentesis is an abnormal alpha-fetoprotein\\n(AFP) test. Alpha-fetoprotein is a protein produced\\nA physician uses an ultrasound monitor (left) to position the needle for insertion into the amnion when performing amniocent-\\nesis. (Photograph by Will and Deni McIntyre, Photo Researchers, Inc. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 161\\nAmniocentesis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='by the fetus and present in the mother’s blood. A\\nsimple blood screening, usually conducted around\\nthe 15th week of pregnancy, can determine the AFP\\nlevels in the mother’s blood. Levels that are too high or\\ntoo low may signal possible fetal defects. Because this\\ntest has a high false-positive rate, another test such as\\namnio is recommended whenever the AFP levels fall\\noutside the normal range.\\nAmniocentesis is generally performed during the\\n16th week ofpregnancy, with results usually available\\nwithin three weeks. It is possible to perform an amnio\\nas early as the 11th week but this is not usually\\nrecommended because there appears to be an\\nincreased risk of miscarriage when done at this time.\\nThe advantage of early amnio and speedy results lies\\nin the extra time for decision making if a problem is\\ndetected. Potential treatment of the fetus can begin\\nearlier. Important, also, isthe fact that elective abor-\\ntions are safer and less controversial the earlier they\\nare performed.\\nPrecautions\\nAs an invasive surgical procedure, amnio poses a\\nreal, although small, risk to the health of a fetus.\\nParents must weigh the potential value of the knowl-\\nedge gained, or indeed the reassurance that all is well,\\nagainst the small risk of damaging what is in all pro-\\nbability a normal fetus. The serious emotional and\\nethical dilemmas that adverse test results can bring\\nmust also be considered. The decision to undergo\\namnio 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.\\nDuring the sampling procedure, the obstetrician inserts\\na very fine needle through the woman’s abdomen into\\nthe uterus and amniotic sac and withdraws appro-\\nximately one ounce of amniotic fluid for testing. The\\nKEY TERMS\\nAlpha-fetoprotein (AFP)— A protein normally pro-\\nduced by the liver of a fetus and detectable in mater-\\nnal blood samples. AFP screening measures the\\namount 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\\nsimilar to amniocentesis, except that cells are\\ntaken from the chorionic membrane for testing.\\nThese cells, called chorionic villus cells, eventually\\nbecome the placenta. The samples are collected\\neither through the abdomen, as in amnio, or\\nthrough the vagina. CVS can be done earlier in the\\npregnancy than amnio, but carries a somewhat\\nhigher risk.\\nChromosome— Chromosomes are the strands of\\ngenetic material in a cell that occur in nearly\\nidentical pairs. Normal human cells contain 23\\nchromosome pairs–one in each pair inherited\\nfrom the mother, and one from the father. Every\\nhuman cell contains the exact same set of\\nchromosomes.\\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 of\\nbiological heredity, which are contained on the\\nchromosomes, and contain chemical instructions\\nwhich direct the development and functioning of\\nan individual.\\nHereditary— Something which is inherited–passed\\ndown from parents to offspring. In biology and med-\\nicine, 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 prob-\\nability 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-\\nfrequency sound waves to create a visual image (a\\nsonogram) of soft tissues. The technique is routinely\\nused in prenatal care and diagnosis.\\n162 GALE ENCYCLOPEDIA OF MEDICINE\\nAmniocentesis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='relatively painless procedure is performed on an out-\\npatient basis, sometimes usinglocal anesthesia.\\nThe physician uses ultrasound images to guide\\nneedle placement and collect the sample, thereby\\nminimizing the risk of fetal injury and the need for\\nrepeated needle insertions. Once the sample is col-\\nlected, the woman can return home after a brief\\nobservation period. She may be instructed to rest\\nfor the first 24 hours and to avoid heavy lifting for\\ntwo days.\\nThe sample of amniotic fluid is sent to a labora-\\ntory where fetal cells contained in the fluid are isolated\\nand grown in order to provide enough genetic material\\nfor testing. This takes about seven to 14 days. The\\nmaterial is then extracted and treated so that visual\\nexamination for defects can be made. For some dis-\\norders, like Tay-Sachs, the simple presence of a telltale\\nchemical compound in the amniotic fluid is enough to\\nconfirm a diagnosis. Depending on the specific tests\\nordered, and the skill of the lab conducting them, all\\nthe results are available between one and four weeks\\nafter the sample is taken.\\nCost of the procedure depends on the doctor, the\\nlab, and the tests ordered. Most insurers provide cov-\\nerage for women over 35, as a follow-up to positive\\nmaternal blood screening results, and when genetic\\ndisorders run in the family.\\nAn alternative to amnio, now in general use, is\\nchorionic villus sampling, or CVS, which can be per-\\nformed as early as the eighth week of pregnancy.\\nWhile this allows for the possibility of a first trimester\\nabortion, if warranted, CVS is apparently also riskier\\nand is more expensive. The most promising area of\\nnew research in prenatal testing involves expanding\\nthe scope and accuracy of maternal blood screening\\nas this poses no risk to the fetus.\\nPreparation\\nIt is important for a woman to fully understand\\nthe procedure and to feel confident in the obstetrician\\nperforming it. Evidence suggests that a physician’s\\nexperience with the procedure reduces the chance of\\nmishap. Almost all obstetricians are experienced in\\nperforming amniocentesis. The patient should feel\\nfree to ask questions and seek emotional support\\nbefore, during and after the amnio is performed.\\nAftercare\\nNecessary aftercare falls into two categories,\\nphysical and emotional.\\nPhysical aftercare\\nDuring and immediately following the sampling\\nprocedure, a woman may experience dizziness,nausea,\\na rapid heartbeat, and cramping. Once past these\\nimmediate hurdles, the physician will send the\\nwoman home with instructions to rest and to report\\nany complications requiring immediate treatment,\\nincluding:\\n/C15vaginal bleeding. The appearance of blood could\\nsignal a problem.\\n/C15premature 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/C15signs of infection. Leaking of amniotic fluid or unu-\\nsual vaginal discharge, and fever could signal the\\nonset of infection.\\nEmotional aftercare\\nOnce the procedure has been safely completed, the\\nanxiety of waiting for the test results can prove to be\\nthe worst part of the process. A woman should seek\\nand receive emotional support from family and\\nfriends, as well as from her obstetrician and family\\ndoctor. Professional counseling may also prove neces-\\nsary, particularly if a fetal defect is discovered.\\nRisks\\nMost of the risks and short-term side effects asso-\\nciated with amniocentesis relate to the sampling pro-\\ncedure and have been discussed above. A successful\\namnio sampling results in no long-term side effects.\\nRisks include:\\n/C15maternal/fetal hemorrhaging. While spotting in\\npregnancy is fairly common, bleeding following\\namnio should always be investigated.\\n/C15infection. Infection, although rare, can occur after\\namniocentesis. An unchecked infection can lead to\\nsevere complications.\\n/C15fetal injury. A very slight risk of injury to the fetus\\nresulting from contact with the amnio needle does exist.\\n/C15miscarriage. The rate of miscarriage occurring\\nduring standard, second trimester amnio appears to\\nbe approximately 0.5%. This compares to a miscarri-\\nage rate of 1% for CVS. Many fetuses with severe\\ngenetic defects miscarry naturally during the first\\ntrimester.\\n/C15the trauma of difficult family-planning decisions.\\nThe threat posed to parental and family mental\\nGALE ENCYCLOPEDIA OF MEDICINE 163\\nAmniocentesis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='health from the trauma accompanying an abnormal\\ntest result can not be underestimated.\\nNormal results\\nNegative results from an amnio analysis indicate\\nthat everything about the fetus appears normal and\\nthe pregnancy can continue without undue concern. A\\nnegative result for Down syndrome means that it is\\n99% certain that the disease does not exist.\\nAn overall ‘‘normal’’ result does not, however,\\nguarantee that the pregnancy will come to term, or\\nthat the fetus does not suffer from some other defect.\\nLaboratory tests are not 100% accurate at detecting\\ntargeted conditions, nor can every possible fetal con-\\ndition be tested for.\\nAbnormal 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\\nchoices regarding treatment options, the prospect of\\ndealing with a severely affected newborn, and the\\noption of elective abortion. At this point, the parents\\nneed expert medical advice and counseling.\\nResources\\nPERIODICALS\\nDreisbach, Shaun. ‘‘Amnio Alternative.’’Working Mother\\n(March 1997): 11.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nOTHER\\nHolbrook Jr., Harold R. Stanford University School of\\nMedicineWeb Home Page. February 2001.\\n.\\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\\na limb or body part. It is performed to remove diseased\\ntissue or relievepain.\\nPurpose\\nArms, legs, hands, feet, fingers, and toes can be\\namputated. Most amputations involve small body\\nparts such as a finger, rather than an entire limb.\\nAbout 65,000 amputations are performed in the\\nUnited States each year.\\nAmputation is performed for the following reasons:\\n/C15to remove tissue that no longer has an adequate\\nblood supply\\n/C15to remove malignant tumors\\n/C15because 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\\nthe arteries, arterial embolism, impaired circulation\\nas a complication ofdiabetes mellitus, repeated severe\\ninfection that leads to gangrene, severe frostbite,\\nRaynaud’s disease, or Buerger’s disease.\\nMore than 90% of amputations performed in the\\nUnited States are due to circulatory complications of\\ndiabetes. Sixty to eighty percent of these operations\\ninvolve the legs or feet. Although attempts have been\\nmade in the United States to better manage diabetes\\nand the foot ulcers that can be complications of the\\ndisease, the number of resulting amputations has not\\ndecreased.\\nPrecautions\\nAmputations cannot be performed on patients\\nwith uncontrolled diabetes mellitus, heart failure, or\\ninfection. Patients with blood clotting disorders are\\nalso not good candidates for amputation.\\nDescription\\nAmputations can be either planned or emergency\\nprocedures. Injury and arterial embolisms are the\\nmain reasons for emergency amputations. The opera-\\ntion is performed under regional or general anesthesia\\nby a general or orthopedic surgeon in a hospital oper-\\nating room.\\nDetails of the operation vary slightly depending\\non what part is to be removed. The goal of all\\n164 GALE ENCYCLOPEDIA OF MEDICINE\\nAmputation'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='amputations is twofold: to remove diseased tissue so\\nthat the wound will heal cleanly, and to construct a\\nstump that will allow the attachment of a prosthesis or\\nartificial replacement part.\\nThe surgeon makes an incision around the part to\\nbe amputated. The part is removed, and the bone is\\nsmoothed. A flap is constructed of muscle, connective\\ntissue, and skin to cover the raw end of the bone. The\\nflap is closed over the bone with sutures (surgical\\nstitches) that remain in place for about one month.\\nOften, a rigid dressing or cast is applied that stays in\\nplace for about two weeks.\\nPreparation\\nBefore an amputation is performed, extensive\\ntesting is done to determine the proper level of\\namputation. The goal of the surgeon is to find the\\nplace where healing is most likely to be complete,\\nwhile allowing the maximum amount of limb to\\nremain for effectiverehabilitation.\\nThe greater the blood flow through an area, the\\nmore likely healing is to occur. These tests are designed\\nto measure blood flow through the limb. Several or all\\nof them can be done to help choose the proper level of\\namputation.\\n/C15measurement of blood pressure in different parts of\\nthe limb\\n/C15xenon 133 studies, which use a radiopharmaceutical\\nto measure blood flow\\n/C15oxygen tension measurements in which an oxygen elec-\\ntrode is used to measure oxygen pressure under the skin.\\nIf the pressure is 0, the healing will not occur. If the\\nFigure DFigure C\\nFigure A\\nFemur\\nSkin flapExposed\\nmuscle\\nFigure B\\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: The\\nsurgeon saws through the exposed femur bone. Figure D: The muscles are closed and sutured over the bone. The remaining\\nskin flaps are then sutured together, creating a stump.(Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 165\\nAmputation'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='pressure reads higher than 40mm Hg (40 milliliters of\\nmercury), healing of the area is likely to be satisfactory.\\n/C15laser Doppler measurements of the microcirculation\\nof the skin\\n/C15skin fluorescent studies that also measure skin\\nmicrocirculation\\n/C15skin perfusion measurements using a blood pressure\\ncuff and photoelectric detector\\n/C15infrared measurements of skin temperature\\nNo single test is highly predictive of healing, but\\ntaken together, the results give the surgeon an excel-\\nlent idea of the best place to amputate.\\nAftercare\\nAfter amputation, medication is prescribed for\\npain, and patients are treated with antibiotics to\\ndiscourage infection. The stump is moved often to\\nencourage good circulation. Physical therapy and\\nrehabilitation are startedas soon as possible, usually\\nwithin 48 hours. Studies have shown that there is a\\npositive relationship betwe en early rehabilitation\\nand effective functioning of the stump and prosthe-\\nsis. Length of stay in the hospital depends on the\\nseverity of the amputation and the general health\\nof the amputee, but ranges from several days to\\ntwo weeks.\\nRehabilitation is a long, arduous process, espe-\\ncially for above the knee amputees. Twice daily physical\\ntherapy is not uncommon. In addition, psychological\\ncounseling is an important part of rehabilitation.\\nMany people feel a sense of loss and grief when they\\nlose a body part. Others are bothered by phantom\\nlimb syndrome, where they feel as if the amputated\\npart is still in place. They may even feel pain in the limb\\nthat does not exist. Many amputees benefit from join-\\ning self-help groups and meeting others who are also\\nliving with amputation. Addressing the emotional\\naspects of amputation often speeds the physical reha-\\nbilitation process.\\nRisks\\nAmputation is major surgery. All the risks asso-\\nciated with the administration of anesthesia exist,\\nalong with the possibility of heavy blood loss and\\nthe development of blood clots. Infection is of spe-\\ncial concern to amputees. Infection rates in amputa-\\ntions average 15%. If the stump becomes infected, it\\nis necessary to remove the prosthesis and sometimes\\nto amputate a second time at a higher level.\\nFailure of the stump to heal is another major\\ncomplication. Nonhealing is usually due to an inade-\\nquate blood supply. The rate of nonhealing varies\\nfrom 5-30% depending on the facility. Centers that\\nspecialize in amputation usually have the lowest rates\\nof complication.\\nPersistent pain in the stump or pain in the phan-\\ntom limb is experienced by most amputees to some\\ndegree. Treatment of phantom limb pain is difficult.\\nFinally, many amputees give up on the rehabilitation\\nprocess and discard their prosthesis. Better fitting\\nprosthetics and earlier rehabilitation have decreased\\nthe incidence of this problem. Researchers and pros-\\nthetic manufacturers continue to refine the materials\\nand methods used to try to improve the comfort\\nand function of prosthetic devices for amputees.\\nFor example, a 2004 study showed that a technique\\ncalled the bone bridge amputation technique helped\\nimprove comfort and stability for transtibial\\namputees.\\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,\\nabout one-half of amputees who suffer them then\\nremain wheelchair bound.\\nKEY TERMS\\nArterial embolism— A blood clot arising from\\nanother location that blocks an artery.\\nBuerger’s disease— An episodic disease that\\ncauses inflammation and blockage of the veins\\nand arteries of the limbs. It tends to be present\\nalmost exclusively on men under age 40 who\\nsmoke, and may require amputation of the hand\\nor 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\\nto the hands and feet. Its cause is unknown.\\n166 GALE ENCYCLOPEDIA OF MEDICINE\\nAmputation'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nPERIODICALS\\nEdwards, Anthony R. ‘‘Study Helps Build Functional\\nBridges for Amputee Patients.’’Biomechanics (May 1,\\n2004): 17.\\nJeffcoat, William. ‘‘Incidence of Amputation is a Poor\\nMeasure of the Quality of Ulcer Care.’’The Diabetic\\nFoot Summer (2004): 70–74.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard\\nStreet, Alexandria, VA 22311. (800) 342-2383.\\n.\\nOTHER\\nAmputation Prevention Global Resource Center Page.\\nFebruary 2001. .\\nTish Davidson, A.M.\\nTeresa G. Odle\\nAmylase 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\\nenzyme amylase is to break down starches in food so\\nthat they can be used by the body. Amylase testing\\nis usually done to determine the cause of sudden\\nabdominal pain.\\nPurpose\\nAmylase testing is performed to diagnose a num-\\nber of diseases that elevate amylase levels. Pancreatitis,\\nfor example, is the most common reason for a high\\namylase level. When the pancreas is inflamed, amylase\\nescapes from the pancreas into the blood. Within six to\\n48 hours after thepain begins, amylase levels in the\\nblood start to rise. Levels will stay high for several days\\nbefore gradually returning to normal.\\nThere are other causes of increased amylase. An\\nulcer that erodes tissue from the stomach and goes\\ninto the pancreas will cause amylase to spill into the\\nblood. During amumps infection, amylase from the\\ninflamed salivary glands increases. Amylase is also\\nfound in the liver, fallopian tubes, and small intestine;\\ninflammation of these tissues also increases levels. Gall\\nbladder disease, tumors of the lung or ovaries, alcohol\\npoisoning, ruptured aortic aneurysm, and intestinal\\nstrangulation or perforation can also cause unusually\\nhigh amylase levels.\\nPrecautions\\nThis is not a screening test for future pancreatic\\ndisease.\\nDescription\\nAmylase testing is done on both blood and\\nurine. The laboratory may use any of several testing\\nmethods that involve mixing the blood or urine sam-\\nple with a substance with which amylase is known to\\nreact. By measuring the end-product or the reaction\\ntime, technicians can calculate the amount of amy-\\nlase present in the sample. More sophisticated meth-\\nods separately measure the amylase made by the\\npancreas and the amylase made by the salivary\\nglands.\\nUrine testing is a better long-term monitor of\\namylase levels. The kidneys quickly move extra\\namylase from the blood into the urine. Urine levels\\nrise six to 10 hours after blood levels and stay high\\nlonger. Urine is usually collected throughout a 2- or\\n24-hour time period. Results are usually available the\\nsame day.\\nPreparation\\nIn most cases, no special preparation is necessary\\nfor a person undergoing an amylase blood test.\\nPatients taking longer term urine amylase tests will\\nbe given a container and instructions for collecting\\nthe urine at home. The urine should be refrigerated\\nuntil it is brought to the laboratory.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 167\\nAmylase tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='bruising. Applying warm packs to the puncture site\\nrelieves discomfort.\\nNormal results\\nNormal results vary based on the laboratory and\\nthe method used.\\nAbnormal results\\nEight out of ten persons with acutepancreatitis\\nwill have high amylase levels, up to four times the\\nnormal level. Other causes of increased amylase, such\\nas mumps, kidney failure, pregnancy occurring in\\nthe abdomen but outside the uterus (ectopicpreg-\\nnancy), certain tumors, a penetrating ulcer, certain\\ncomplications of diabetes, and advanced pancreatic\\ncancer, are further investigated based on the person’s\\nsymptoms, medical history, and the results of other\\ntests.\\nIn kidney disease, the kidneys are not as efficient\\nat removing amylase from the blood. Amylase rises in\\nthe blood, 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.\\nAmylase levels in the blood will be high; levels in the\\nurine will be low.\\nAmylase levels may be low in severeliver disease\\n(including hepatitis), conditions in which the pancreas\\nfails to secrete enough enzyme for proper digestions\\n(pancreatic insufficiency), when toxic materials build\\nup in the blood during pregnancy (pre-eclampsia),\\nfollowing burns, in thyroid disorders, and in advanced\\ncystic fibrosis. Some medications can raise or lower\\nlevels.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnosticand\\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\\nin one or more organs or body systems.\\nDescription\\nAmyloid proteins are manufactured by malfunc-\\ntioning bone marrow. Amyloidosis, which occurs\\nwhen accumulated amyloid deposits impair normal\\nbody function, can cause organ failure ordeath.I t\\nis a rare disease, occurring in about eight of every\\n1,000,000 people. It affects males and females equally\\nand usually develops after the age of 40. At least 15\\ntypes of amyloidosis have been identified. Each one\\nis associated with deposits of a different kind of\\nprotein.\\nTypes of amyloidosis\\nThe major forms of this disease are primary sys-\\ntemic, secondary, and familial or hereditary amyloi-\\ndosis. There is also another form of amyloidosis\\nassociated withAlzheimer’s disease.\\nPrimary systemic amyloidosis usually develops\\nbetween the ages of 50 and 60. With about 2,000 new\\ncases diagnosed annually, primary systemic amyloido-\\nsis is the most common form of this disease in the\\nUnited States. Also known as light-chain-related amy-\\nloidosis, it may also occur in association withmultiple\\nmyeloma (bone marrowcancer).\\nSecondary amyloidosis is a result of chronic infec-\\ntion or inflammatory disease. It is often associated\\nwith:\\n/C15familial Mediterranean fever (a bacterial infection\\ncharacterized by chills, weakness, headache, and\\nrecurring fever)\\n/C15granulomatous ileitis (inflammation of the small\\nintestine)\\n/C15Hodgkin’s disease (cancer of the lymphatic system)\\n/C15leprosy\\n/C15osteomyelitits (bacterial infection of bone and bone\\nmarrow)\\n/C15rheumatoid arthritis\\nFamilial or hereditary amyloidosis is the only\\ninherited form of the disease. It occurs in members of\\nmost ethnic groups, and each family has a distinctive\\npatternofsymptoms andorganinvolvement. Hereditary\\namyloidosis is though to be autosomal dominant,\\nwhich means that only one copy of the defective gene\\nis necessary to cause the disease. A child of a parent\\nwith familial amyloidosis has a 50-50 chance of devel-\\noping the disease.\\nAmyloidosis can involve any organ or system in\\nthe body. The heart, kidneys, gastrointestinal system,\\nand nervous system are affected most often. Other\\n168 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyloidosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='common sites of amyloid accumulation include the\\nbrain, joints, liver, spleen, pancreas, respiratory system,\\nand skin.\\nCauses and symptoms\\nThe cause of amyloidosis is unknown. Most\\npatients have gastrointestinal abnormalities, but\\nother symptoms vary according to the organ(s) or\\nsystem(s) affected by the disease. Usually the affected\\norgans are rubbery, firm, and enlarged.\\nHeart\\nBecause amyloid protein deposits can limit the\\nheart’s ability to fill with blood between beats, even\\nthe slightest exertion can causeshortness of breath.I f\\nthe heart’s electrical system is affected, the heart’s\\nrhythm may become erratic. The heart may also be\\nenlarged and heart murmurs may be present.\\nCongestive heart failure may result.\\nKidneys\\nThe feet, ankles, and calves swell when amyloidosis\\ndamages the kidneys. The kidneys become small and\\nhard, and kidney failure may result. It is not unusual for\\na patient to lose 20-25 pounds and develop a distaste for\\nmeat, eggs, and other protein-rich foods. Cholesterol\\nelevations that don’t respond to medication and protein\\nin the urine (proteinuria) are common.\\nNervous system\\nNervous system symptoms often appear in\\npatients with familial amyloidosis. Inflammation and\\ndegeneration of the peripheral nerves (peripheral neu-\\nropathy) may be present. One of four patients with\\namyloidosis has carpal tunnel syndrome, a painful\\ndisorder that causesnumbness or tingling in response\\nto pressure on nerves around the wrist. Amyloidosis\\nthat affects nerves to the feet can cause burning or\\nnumbness in the toes and soles and eventually weaken\\nthe legs. If nerves controlling bowel function are\\ninvolved, bouts ofdiarrhea alternate with periods of\\nconstipation. If the disease affects nerves that regulate\\nblood pressure, patients may feel dizzy or faint when\\nthey stand up suddenly.\\nLiver and spleen\\nThe most common symptoms are enlargement of\\nthese organs. Liver function is not usually affected\\nuntil quite late in the course of the disease. Protein\\naccumulation in the spleen can increase the risk of\\nrupture of this organ due to trauma.\\nGastrointestinal system\\nThe tongue may be inflammed, enlarged, and stiff.\\nIntestinal movement (motility) may be reduced.\\nAbsorption of food and other nutrients may be\\nimpaired (and may lead tomalnutrition), and there\\nmay also be bleeding, abdominalpain, constipation,\\nand diarrhea.\\nSkin\\nSkin symptoms occur in about half of all cases\\nof primary and secondary amyloidosis and in all\\ncases where there is inflammation or degeneration of\\nthe peripheral nerves. Waxy-looking raised bumps\\n(papules) may appear on the face and neck, in the\\ngroin, armpits, or anal area, and on the tongue or in\\nthe ear canals. Swelling, hemorrhage beneath the skin\\n(purpura), hair loss, 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\\nis necessary to positively diagnose amyloidosis. Once\\nthe diagnosis has been confirmed, additional labora-\\ntory tests and imaging procedures are performed to\\ndetermine:\\n/C15which type of amyloid protein is involved\\n/C15which organ(s) or system(s) have been affected\\n/C15how far the disease has progressed\\nTreatment\\nThe goal of treatment is to slow down or stop\\nproduction of amyloid protein, eliminate existing\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 169\\nAmyloidosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='amyloid deposits, allevi ate underlying disorders\\n(that give rise to secondary amyloidosis), and relieve\\nsymptoms caused by heart or kidney damage.\\nSpecialists in cardiology, hematology (the study of\\nblood and the tissues that form it), nephrology (the\\nstudy of kidney function and abnormalities), neuro-\\nlogy (the study of the nervous system), and rheuma-\\ntology (the study of disorders characterized by\\ninflammation or degeneration of connective tissue)\\nwork together to assess a patient’s medical status and\\nevaluate the effects of amyloidosis on every part of\\nthe body.\\nColchicine (Colebenemid, Probeneaid), predni-\\nsone, (Prodium), and other anti-inflammatory drugs\\ncan slow or stop disease progression. Bone-marrow\\nand stem-cell transplants can enable patients to toler-\\nate higher and more effective doses of melphalan\\n(Alkeran) and other chemotherapy drugs prescribed\\nto combat this non-malignant disease. Surgery can\\nrelieve nerve pressure and may be performed to correct\\nother symptom-producing conditions. Localized amy-\\nloid deposits can also be removed surgically. Dialysis\\nor kidney transplantation can lengthen and improve\\nthe quality of life for patients whose amyloidosis\\nresults in kidney failure. Heart transplants are rarely\\nperformed.\\nSupportive measures\\nAlthough no link has been established between\\ndiet and development of amyloid proteins, a patient\\nwhose heart or kidneys have been affected by the\\ndisease may be advised to use a diuretic or follow a\\nlow-salt diet.\\nPrognosis\\nMost cases of amyloidosis are diagnosed after\\nthe disease has reached an advanced stage. The course\\nof each patient’s illness is unique but death, usually\\na result of heart disease or kidney failure, generally\\noccurs within a few years. Amyloidosis associated\\nby multiple myeloma usually has a poor prognosis.\\nMost patients with both diseases die within one to\\ntwo years.\\nPrevention\\nGenetic couselingmay be helpful for patients with\\nhereditary amyloidosis and their families. Use of\\nCholchicine in patients with familial Mediterranean\\nfever has successfully prevented amyloidosis.\\nResources\\nORGANIZATIONS\\nAmyloidosis Network International. 7118 Cole Creek Drive,\\nHouston, TX 77092-1421. (888) 1AMYLOID.\\n.\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nMaureen Haggerty\\nAmyotrophic lateral sclerosis\\nDefinition\\nAmyotrophic lateral sclerosis (ALS) is a disease\\nthat breaks down tissues in the nervous system\\n(a neurodegenerative disease) of unknown cause that\\naffects the nerves responsible for movement. It is also\\nknown as motor neuron disease and Lou Gehrig’s\\ndisease, after the baseball 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\\nmovement. In ALS, for unknown reasons, these\\nneurons die, leading to a progressive loss of the ability\\nto move virtually any of the muscles in the body. ALS\\naffects ‘‘voluntary’’ muscles, those controlled by con-\\nscious thought, such as the arm, leg, and trunk mus-\\ncles. ALS, in and of itself, does not affect sensation,\\nthought processes, the heart muscle, or the ‘‘smooth’’\\nmuscle of the digestive system, bladder, and other\\ninternal organs. Most people with ALS retain function\\nof their eye muscles as well. However, various forms\\nof ALS may be associated with a loss of intellectual\\nfunction (dementia) or sensory symptoms.\\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,\\n170 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='these neurons convey electrical messages from the\\nbrain to the muscles to stimulate movement in the\\narms, legs, trunk, neck, and head. As motor neurons\\ndie, the muscles they enervate cannot be moved as\\neffectively, and weakness results. In addition, lack of\\nstimulation leads to muscle wasting, or loss of bulk.\\nInvolvement of the upper motor neurons causes\\nspasms and increased tone in the limbs, and abnormal\\nreflexes. 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\\nradicals. Some evidence suggests that a cascade of\\nevents leads to excess free radical production inside\\nmotor neurons, leading to their death. Why free radi-\\ncals should be produced in excess amounts is unclear,\\nas is whether this excess is the cause or the effect of\\nother degenerative processes. Additional agents\\nwithin this toxic cascade may include excessive levels\\nof a neurotransmitter known as glutamate, which may\\nover-stimulate motor neurons, thereby increasing\\nfree-radical production, and a faulty detoxification\\nenzyme known as SOD-1, for superoxide dismutase\\ntype 1. The actual pathway of destruction is not\\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, neck,\\nand head. As motor neurons degenerate, the muscles are weakened and cannot move as effectively, leading to muscle wasting.\\n(Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 171\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='known, however, nor is the trigger for the rapid degen-\\neration that marks ALS. Further research may show\\nthat other pathways are involved, perhaps ones even\\nmore important than this one. Autoimmune factors or\\npremature 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\\nALS cases. As the name suggests, familial ALS is\\nbelieved to be caused by the inheritance of one or\\nmore faulty genes. About 15% of families with this\\ntype of ALS have mutations in the gene for SOD-1.\\nSOD-1 gene defects are dominant, meaning only one\\ngene copy is needed to develop the disease. Therefore,\\na parent with the faulty gene has a 50% chance of\\npassing the gene along to a child.\\nSporadic ALS has no known cause. While many\\nenvironmental toxins have been suggested as causes,\\nto date no research has confirmed any of the candi-\\ndates investigated, including aluminum and mercury\\nand lead from dental fillings. As research progresses, it\\nis likely that many cases of sporadic ALS will be\\nshown to have a genetic basis as well.\\nA third type, called Western Pacific ALS, occurs\\nin Guam and other Pacific islands. This form com-\\nbines symptoms 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\\nrapid in the legs among people with familial ALS and\\nin the arms among those with sporadic ALS. Leg\\nweakness may first become apparent by an increased\\nfrequency of stumbling on uneven pavement, or an\\nunexplained difficulty climbing stairs. Arm weakness\\nmay lead to difficulty grasping and holding a cup, for\\ninstance, or loss of dexterity 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 speak-\\ning. A person with bulbar weakness may become\\nhoarse or tired after speaking at length, or speech\\nmay become slurred.\\nIn addition to weakness, the other cardinal signs\\nof ALS are muscle wasting and persistent twitching\\n(fasciculation). These are usually seen after weakness\\nbecomes obvious. Fasciculation is quite common in\\npeople without the disease, and is virtually never the\\nfirst sign of ALS.\\nWhile initial weakness may be limited to one\\nregion, ALS almost always progresses rapidly to\\ninvolve virtually all the voluntary muscle groups in\\nthe body. Later symptoms include loss of the ability\\nto walk, to use the arms and hands, to speak clearly or\\nat all, to swallow, and to hold the head up. Weakness\\nof the respiratory muscles makes breathing and\\ncoughing difficult, and poor swallowing control\\nincreases the likelihood of inhaling food or saliva\\n(aspiration). Aspiration increases the likelihood of\\nlung infection, which is often the cause of death.\\nWith a ventilator and scrupulous bronchial hygiene,\\nap e r s o nw i t hA L Sm a yl i v em u c hl o n g e rt h a nt h e\\naverage, although weakness and wasting will con-\\ntinue to erode any remaining functional abilities.\\nMost people with ALS continue to retain function\\nof the extraocular muscles that move their eyes,\\nallowing some communication to take place with\\nsimple blinks or through use of a computer-assisted\\ndevice.\\nDiagnosis\\nThe diagnosis of ALS begins with a complete\\nmedical history and physical exam, plus a neurological\\nexamination to determine the distribution and extent\\nof weakness. An electrical test of muscle function,\\ncalled an electromyogram, or EMG, is an important\\npart of the diagnostic process. Various other tests,\\nincluding blood and urine tests, x rays, and CT\\nscans, may be done to rule out other possible causes\\nof the symptoms, such as tumors of the skull base or\\nhigh cervical spinal cord, thyroid disease, spinal\\narthritis, lead poisoning, or severe vitamin deficiency.\\nALS is rarely misdiagnosed following a careful review\\nof all these factors.\\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\\nmuscle.\\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.\\n172 GALE ENCYCLOPEDIA OF MEDICINE\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nThere is no cure for ALS, and no treatment that\\ncan significantly alter its course. There are many\\nthings which can be done, however, to help maintain\\nquality of life and to retain functional ability even in\\nthe face of progressive weakness.\\nAs of the early 2000s, only one drug had been\\napproved for treatment of ALS. Riluzole (Rilutek)\\nappears to provide on average a three-month increase\\nin life expectancy when taken regularly early in the\\ndisease, and shows a significant slowing of the loss of\\nmuscle strength. Riluzole acts by decreasing gluta-\\nmate release from nerve terminals. Experimental\\ntrials of nerve growth factor have not demonstrated\\nany benefit. No other drug or vitamin currently avail-\\nable has been shown to have any effect on the course\\nof ALS.\\nA physical therapist works with an affected\\nperson and family to implementexercise and stretch-\\ning programs to maintain strength and range of\\nmotion, and to promote general health. Swimming\\nmay be a good choice for people with ALS, as it\\nprovides a low-impact workout to most muscle\\ngroups. One result of chronic inactivity is contrac-\\nture, or muscle shortening.Contractures limit a per-\\nson’s range of motion, and are often painful. Regular\\nstretching can prevent contracture. Several drugs are\\navailable to reduce cramping, a common complaint\\nin ALS.\\nAn occupational therapist can help design solu-\\ntions to movement and coordination problems, and\\nprovide advice on adaptive devices and home\\nmodifications.\\nSpeech and swallowing difficulties can be mini-\\nmized or delayed through training provided by a\\nspeech-language pathologist. This specialist can also\\nprovide advice on communication aids, including\\ncomputer-assisted devices and simpler word boards.\\nNutritional advice can be provided by a nutrition-\\nist. A person with ALS often needs softer foods to\\nprevent jaw exhaustion or choking. Later in the\\ndisease, nutrition may be provided by agastrostomy\\ntube inserted into the stomach.\\nMechanical ventilation may be used when breath-\\ning becomes too difficult. Modern mechanical venti-\\nlators are small and portable, allowing a person with\\nALS to maintain the maximum level of function and\\nmobility. Ventilation may be administered through a\\nmouth or nose piece, or through a tracheostomy tube.\\nThis tube is inserted through a small hole made in the\\nwindpipe. In addition to providing direct access to the\\nairway, the tube also decreases the risk aspiration.\\nWhile many people with rapidly progressing ALS\\nchoose not to use ventilators for lengthy periods,\\nthey are increasingly being used to prolong life for a\\nshort time.\\nThe progressive nature of ALS means that most\\npersons will eventually require full-time nursing care.\\nThis care is often provided by a spouse or other family\\nmember. While the skills involved are not difficult\\nto learn, the physical and emotional burden of care\\ncan be overwhelming. Caregivers need to recognize\\nand provide for their own needs as well as those of\\npeople with ALS, to prevent depression, burnout, and\\nbitterness.\\nThroughout the disease, a support group can pro-\\nvide important psychological aid to affected persons\\nand their caregivers as they come to terms with the\\nlosses ALS inflicts. Support groups are sponsored by\\nboth the ALS Society and the Muscular Dystrophy\\nAssociation.\\nAlternative treatment\\nGiven the grave prognosis and absence of tradi-\\ntional medical treatments, it is not surprising that a\\nlarge number of alternative treatments have been\\ntried for ALS. Two studies published in 1988 sug-\\ngested that amino-acid therapies may provide some\\nimprovement for some people with ALS. While indi-\\nvidual reports claim benefits for megavitamin the-\\nrapy, herbal medicine, and removal of dental fillings,\\nfor instance, no evidence suggests that these offer\\nany more than a brief psychological boost, often\\nfollowed by a more severe letdown when it becomes\\napparent the disease has continued unabated.\\nHowever, once the causes of ALS are better under-\\nstood, alternative therapies may be more intensively\\nstudied. For example, if damage by free radicals\\nturns out to be the root of most of the symptoms,\\nantioxidant vitamins and supplements may be used\\nmore routinely to slow theprogression of ALS. Or, if\\nenvironmental toxins are implicated, alternative\\ntherapies with the goal of detoxifying the body may\\nbe of some use.\\nPrognosis\\nALS usually progresses rapidly, and leads to\\ndeath from respiratory infection within three to five\\nyears in most cases. The slowest disease progression is\\nseen in those who are young and have their first symp-\\ntoms in the limbs. About 10% of people with ALS live\\nlonger than eight years.\\nGALE ENCYCLOPEDIA OF MEDICINE 173\\nAmyotrophic lateral sclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prevention\\nThere is no known way to prevent ALS or to alter\\nits course.\\nResources\\nBOOKS\\nFeldman, Eva L. ‘‘Motor neuron diseases.’’ InCecil\\nTextbook of Medicine, edited by Lee Goldman\\nand J. Claude Bennett, 21st ed. Philadelphia:\\nW.B. Saunders, 2000, pp. 2089-2092.\\nPERIODICALS\\nAnsevin CF. ‘‘Treatment of ALS with pleconaril.’’\\nNeurology 56, no. 5 (2001): 691-692.\\nEisen, A., and M. Weber. ‘‘The motor cortex and amyotro-\\nphiclateral sclerosis.’’Muscle and Nerve 24, no. 4\\n(2001): 564-573.\\nGelanis DF. ‘‘Respiratory Failure or Impairment in\\nAmyotrophic Lateral Sclerosis.’’Current treatment\\noptions in neurology 3, no. 2 (2001): 133-138.\\nLudolph AC. ‘‘Treatment of amyotrophic lateral sclerosis–\\nwhat is the next step?’’Journal of Neurology 246,\\nSupplement 6 (2000): 13-18.\\nPasetti, C., and G. Zanini. ‘‘The physician-patient relationship\\ninamyotrophic lateral sclerosis.’’Neurological Science21,\\nno. 5 (2000): 318-323.\\nRobberecht W. ‘‘Genetics of amyotrophic lateral sclerosis.’’\\nJournal of Neurology 246, Supplement 6 (2000): 2-6.\\nRobbins, R.A., Z. Simmons, B.A. Bremer, S.M. Walsh, and\\nS. Fischer. ‘‘Quality of life in ALS is maintained as\\nphysical function declines.’’Neurology 56, no. 4 (2001):\\n442-444.\\nORGANIZATIONS\\nAmerican Medical Association. 515 N. State Street,\\nChicago, IL 60610. (312) 464-5000. .\\nMuscular Dystrophy Association. 3300 East Sunrise Drive,\\nTucson AZ 85718-3208. (520) 529-2000 or (800)\\n572-1717. .\\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\\nAnabolic steroid use\\nDefinition\\nAnabolic steroids are drugs containing hormones,\\nor hormone-like substances, that are used to increase\\nstrength and promote muscle growth.\\nDescription\\nSteroids are a synthetic version of the human\\nhormone called testosterone. Testosterone stimulates\\nand maintains the male sexual organs. It also stimu-\\nlates development of bones and muscle, promotes\\nskin and hair growth, and can influence emotions\\nand energy levels. In males, testosterone is produced\\nby the testicles and the adrenal gland. Women have\\nonly the amount of testosterone produced by the\\nadrenal gland—much less than men have. This is\\nwhy testosterone is often called a ‘‘male’’ hormone.\\nThere are more than 100 different types of anabolic\\nsteroids that have been developed, and each requires\\nap r e s c r i p t i o nt ob eu s e dl e g a l l yi nt h eU n i t e dS t a t e s .\\nThe average adult male naturally produces 2.5 to 11\\nmilligrams of testosterone daily. The average steroid\\nabuser often takes more than 100 mg a day, through\\n‘‘stacking’’ or combining several different brands of\\nsteroids.\\nMedical uses\\nAnabolic steroids were first developed in the\\n1930s in Europe, in part to increase the physical\\nstrength of German soldiers. Anabolic steroids were\\ntried by physicians for many other purposes in the\\n1940s and 1950s with varying success. Disadvantages\\noutweighed benefits for most purposes, and during the\\nlater decades of the twentieth century medical use in\\nNorth America and Europe was restricted to a few\\nconditions. These include:\\n/C15Bone marrow stimulation: During the second half of\\nthe twentieth century anabolic steroids were the\\nmainstay of therapy for hypoplastic anemia not due\\nto nutrient deficiency, especially aplastic anemia.\\nAnabolic steroids were slowly replaced by synthetic\\nprotein hormones that selectively stimulate growth\\nof blood cell precursors.\\n/C15Growth stimulation: Anabolic steroids were used\\nheavily by pediatric endocrinologists for children\\nwith growth failure from the 1960s through the\\n1980s. Availability of synthetic growth hormone\\nand increasing social stigmatization of anabolic ste-\\nroids led to reduction of this use.\\n174 GALE ENCYCLOPEDIA OF MEDICINE\\nAnabolic steroid use'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Stimulation of appetite and preservation of muscle\\nmass: Anabolic steroids have been given to people\\nwith chronic wasting conditions such ascancer and\\nHIV/AIDS.\\n/C15Induction of malepuberty: Androgens are given to\\nmany boys distressed about extreme delay of pub-\\nerty. Testosterone is as of 2005 nearly the only andro-\\ngen used for this purpose, but synthetic anabolic\\nsteroids were often used prior to the 1980s.\\n/C15To treat certain kinds ofbreast cancerin some women.\\n/C15To treat angioedema, which causes swelling of the face,\\narms, legs, throat, windpipe, bowels, or sexual organs.\\nAbuse of steroids\\nThe controversy surrounding steroidabuse began\\nin the 1950s during the Olympic Games when the\\nathletic community discovered that athletes from\\nRussia and some East European nations, which had\\ndominated the games, had taken large doses of ster-\\noids. Many of the male athletes developed such large\\nprostate glands (a gland located near the bladder and\\nurethra that aids in semen production) that they\\nneeded a tube inserted in order to urinate. Some of\\nthe female athletes developed so many male character-\\nistics chromosome tests were necessary to prove that\\nthey were still women. Competitive weightlifters also\\nbegan using steroids in the 1950s as a way to increase\\ntheir athletic performance. Use gradually spread\\nthroughout the world among athletes in other sports.\\nConcerns over the growing illicit market and the\\nprevalence of abuse, combined with the possibility of\\nharmful long-term effects of steroids use, led the U.S.\\nCongress in 1991 to place anabolic steroids in\\nSchedule III of the Controlled Substances Act\\n(CSA). The CSA defines anabolic steroids as any\\ndrug or hormonal substance chemically and pharma-\\ncologically related to testosterone (other than estro-\\ngens, progestins, and corticosteroids) that promotes\\nmuscle growth. Most illicit anabolic steroids are sold\\nat gyms, bodybuilding competitions, and through the\\nmail and Internet. For the most part, these substances\\nare smuggled into the United States. Anabolic steroids\\ncommonly encountered on the illicit market include:\\nboldenone (Equipoise), ethlestrenol (Maxibolin),\\nfluoxymesterone (Halotestin), methandriol, methan-\\ndrostenolone (Dianabol), methyltestosterone, nan-\\ndrolone (Durabolin, DecaDurabolin), oxandrolone\\n(Anavar), oxymetholone (Anadrol), stanozolol\\n(Winstrol), testosterone (including sustanon), and\\ntrenbolone (Finajet). In addition, a number of coun-\\nterfeit products are sold as anabolic steroids.\\nKEY TERMS\\nAdrenal gland— An endocrine gland located\\nabove each kidney. The inner part of each gland\\nsecretes epinephrine and the outer part secretes\\nsteroids.\\nAndrogen— A natural or artificial steroid that acts\\nas a male sex hormone. Androgens are responsible\\nfor the development of male sex organs and sec-\\nondary sexual characteristics. Testosterone and\\nandrosterone are androgens.\\nAndrostenedione— Also called ‘‘andro,’’ this hor-\\nmone occurs naturally during the making of testos-\\nterone and estrogen.\\nCatabolic— A metabolic process in which energy is\\nreleased through the conversion of complex mole-\\ncules into simpler ones.\\nCorticosteroids— A steroid hormone produced by\\nthe adrenal gland and involved in metabolism and\\nimmune response.\\nEndocrinologist— A medical specialist who treats\\nendocrine (glands that secrete hormones intern-\\nally directly into the lymph or bloodstream)\\ndisorders.\\nEstrogen— Any of several steroid hormones, pro-\\nduced mainly in the ovaries, that stimulate estrus\\nand the development of female secondary sexual\\ncharacteristics.\\nHormone— A chemical substance produced in the\\nbody’s endocrine glands or certain other cells that\\nexerts a regulatory or stimulatory effect, for exam-\\nple, in metabolism.\\nHypoplastic anemia— Anemia that is characterized\\nby defective function of the blood-forming organs\\n(such as bone marrow) and is caused by toxic\\nagents such as chemicals or x rays. Anemia is a\\nblood condition in which there are too few red\\nblood cells or the red blood cells are deficient in\\nhemoglobin.\\nProgestins— A female steroid sex hormone.\\nProhormones— A physiologically inactive precur-\\nsor of a hormone.\\nProstate gland— An O-shaped gland in males that\\nsecretes a fluid into the semen that acts to improve\\nthe movement and viability of sperm.\\nTestosterone— A male steroid hormone produced\\nin the testicles and responsible for the development\\nof secondary sex characteristics.\\nGALE ENCYCLOPEDIA OF MEDICINE 175\\nAnabolic steroid use'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In 2004, federal health officials initiated a crack-\\ndown on companies that manufacture, market, or\\ndistribute products containing androstenedione, or\\n‘‘andro,’’ due to concerns about the safety of the sub-\\nstance. Widely marketed to athletes and body\\nbuilders, androstenedione has been advertised to pro-\\nmote muscle growth, improve muscular strength,\\nreduce fat, and slowaging. Androstenedione acts like\\na steroid once it is metabolized by the body and can\\npose similar kinds of health risks. People produce\\nandrostenedione naturally during the making of tes-\\ntosterone and estrogen. When people consume\\nandrostenedione, it is converted into testosterone\\nand estrogen. Scientific evidence shows that when\\nandrostenedione is taken over time and in sufficient\\nquantities, it may increase the risk of serious and life-\\nthreatening diseases, including liver failure.\\nOn January 20, 2005, the Anabolic Steroid Control\\nAct of 2004 took effect, amending the Controlled\\nSubstance Act by placing both anabolic steroids and\\nprohormones on a list of controlled substances, making\\npossession of the banned substances a federal crime.\\nAlso in 2005, Major League Baseball (MLB), amid\\nlong-time rumors of anabolic steroid abuse among\\nplayers, was rocked by the publication ofJuiced by\\nformer Oakland Athletics outfielder Jose Canseco\\nwho alleged steroid abuse was wide-spread in profes-\\nsional baseball. In response, Congress held hearings in\\nMarch 2005 on steroid abuse in the MLB, subpoenaing\\nsuch baseball superstars as home run champion Mark\\nMcGwire (now retired), Sammy Sosa, and Curt\\nSchilling to testify. In response, MLB officials promised\\na crackdown on anabolic steroid use among players.\\nIt has been estimated that at least one in 15 male\\nhigh school seniors in the United States—more than\\n500,000 boys—has used steroids. Some are athletes\\nattempting to increase their strength and size; others\\nare simply youths attempting to speed up their growth\\nto keep pace with their peers. In some countries, ana-\\nbolic steroids are available over the counter. In the\\nUnited States, a doctor’s prescription is necessary.\\nCauses and symptoms\\nWhile the effects of steroids can seem desirable at\\nfirst, there are serious side effects. Excessive use can\\ncause a harmful imbalance in the body’s normal hor-\\nmonal balance and body chemistry. Heart attacks,\\nwater retention leading to high blood pressure and\\nstroke, and liver and kidney tumors all are possible.\\nYoung people may developacne, sometimes severe,\\nand a halting of bone growth. Males may experience\\nshrinking testicles, falling sperm counts, enlarged\\nbreasts, and enlarged prostate glands. Women fre-\\nquently show signs of masculinity and may be at higher\\nrisk for certain types of cancer and the possibility of\\nbirth defects in their children. Steroids fool the body\\ninto thinking that testosterone is being produced. The\\nbody, sensing an excess of testosterone, shuts down\\nbodily functions involving testosterone, such as bone\\ngrowth. The ends of long bones fuse together and stop\\ngrowing, resulting in stunted growth.\\nThe psychological effects of steroid use are also\\nalarming: drastic mood swings, inability to sleep,\\ndepression, and feelings of hostility. Steroids may\\nalso be psychologically addictive. Once started,\\nusers—particularly athletes—enjoy the physical so-\\ncalled benefits of increased size, strength, and endur-\\nance so much that they are reluctant to stop even when\\ntold about the risks.\\nIn addition to these dangerous side effects, steroid\\nabuse brings other risks, some of which are connected\\nto the way some steroids are manufactured and dis-\\ntributed. The drugs are often made in motel rooms and\\nwarehouses in Mexico, Europe, and other countries\\nand then smuggled into the United States. The\\npotency, purity, and strength of the steroids produced\\nthis way are not regulated; therefore, users cannot\\nknow how much they are taking. Counterfeit steroids\\nare also sold as the real thing. So it is often impossible\\nto tell exactly what some products contain.\\nMost data on the long-term effects of anabolic\\nsteroids on humans come from case reports rather\\nthan formal scientific studies. From the case reports,\\nthe incidence of life-threatening effects appears to be\\nlow, but serious adverse effects may be under-recog-\\nnized or under-reported. Data from animal studies\\nseem to support this possibility. One study found\\nthat exposing male mice for one-fifth of their lifespan\\nto steroid doses comparable to those taken by human\\nathletes caused a high percentage of premature deaths.\\nMost effects of anabolic steroid use are reversible if\\nthe abuser stops taking the drugs, but some can be\\npermanent.\\nDiagnosis\\nAnyone who is using anabolic steroids without a\\nprescription and not under the direction of a physician\\nis considered abusing the drug and should seek medi-\\ncal help in stopping the use.\\nTreatment\\nFew studies of treatments for anabolic steroid\\nabuse have been conducted. Knowledge as of 2005 is\\n176 GALE ENCYCLOPEDIA OF MEDICINE\\nAnabolic steroid use'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='based largely on the experiences of a small number of\\nphysicians who have worked with patients undergoing\\nsteroid withdrawal. The physicians have found that\\nsupportive therapy is sufficient in some cases. Patients\\nare educated about what they may experience during\\nwithdrawal and are evaluated for suicidal thoughts. If\\nsymptoms are severe or prolonged, medications or\\nhospitalization may be needed.\\nSome medications that have been used for treating\\nsteroid withdrawal restore the hormonal system after\\nits disruption by steroid abuse. Other medications tar-\\nget specific withdrawal symptoms, for example, antide-\\npressants to treat depression, and analgesics (pain\\nkillers, such asaspirin and ibuprofen) for headaches\\nand muscle and joint pains. Some patients require assis-\\ntance beyond simple treatment of withdrawal symp-\\ntoms and are treated with behavioral therapies.\\nAlternative treatment\\nThere is little data on alternative medicines or\\ntreatments for anabolic steroid abuse. However, ana-\\nbolic steroid manufacturers recommendsaw palmetto\\nto be taken in conjunction with androstenedione as it\\ncan help reduce associated hair loss and is useful in\\ncontrolling prostate enlargement.\\nPrognosis\\nAnabolic steroid abuse is a treatable condition\\nand can be stopped. Teenagers and adults can over-\\ncome the problem with the help of parents and other\\nfamily members, support groups, psychotherapy,\\nmedication, treatment programs, and family counsel-\\ning. These programs are customized to help teens and\\nadults lead productive and normal lives. However,\\nheavy steroid use—even if it is stopped after a few\\nyears—may increase the risk ofliver cancer. A steroid\\nuser who quits may suffer a side effect commonly linked\\nto low testosterone—severe depression—which can\\nlead to suicidal thoughts and evensuicide. The risk of\\ndepression and suicide is highest among teens.\\nSome physicians recommend that athletes using\\nsteroids avoid sudden discontinuance of all steroids at\\nthe same time because their bodies may enter an\\nimmediate catabolic (sudden release of energy)\\nphase. The cortisone receptors will be free and in\\ncombination with the low testosterone and androgen\\nlevels, a considerable loss of strength and mass, and an\\nincrease of fat and water, and often breast enlarge-\\nment in males can occur. Breast enlargement is possi-\\nble because the suddenly low androgen level shifts the\\nrelationship in favor of the estrogens which suddenly\\nbecome the domineering hormone.\\nPrevention\\nThe best prevention is education to alert young\\npeople to the dangers, both medical and legal, in the\\nillegal use of anabolic steroids. In its effort to alert\\nteenagers to the dangers of steroid abuse, the U.S.\\nFood and Drug Administration (FDA) developed a\\nseries of pamphlets, posters, and public service\\nannouncements. Much of this information is available\\non-line at . Anabolic steroids\\nare in the same regulatory category ascocaine, heroin,\\nLSD, and other habit-forming drugs. This means that,\\nin addition to the FDA, the Drug Enforcement Agency\\n(DEA) helps to enforce laws relating to their abuse.\\nAthletic organizations have joined the fight. The\\nOlympic Games are now closely monitored to prevent\\nathletes who use steroids from participating. The\\nNational Football League has a strict testing policy\\nin its training camps; it delivers fines and suspensions\\nto those who test positive and bans repeat offenders.\\nThe National Collegiate Athletic Association, too, has\\nestablished stricter measures for testing and disciplin-\\ning steroid users.\\nResources\\nBOOKS\\nAretha, David.Steroids and Other Performance-Enhancing\\nDrugs. Berkeley Heights, NJ: MyReportLinks.com,\\n2005.\\nCanseco, Jose.Juiced: Wild Times, Rampant ‘Roids, Smash\\nHits, and How Baseball Got Big. New York City: Regan\\nBooks, 2005.\\nLevert, Suzanne.The Facts about Steroids. New York:\\nBenchmark Books, 2004.\\nTaylor, William N.Anabolic Therapy in Modern Medicine.\\nJefferson, NC: McFarland & Company, 2002.\\nPERIODICALS\\nAdler, Jerry. ‘‘Toxic Strength: The Headlines about Illegal\\nSteroids Have Focused on Professional and Olympic\\nAthletes. But the Most Vulnerable Users May Be Kids\\nin Your Neighborhood, High-Schoolers Who Are\\nRisking an Array of Frightful Side Effects that Can\\nLead to Death.’’Newsweek (December 20, 2004): 44.\\nBates, Betsy. ‘‘Elite Athletes Not Alone in Anabolic Steroid\\nAbuse: Missed by Drug Testing.’’Internal Medicine\\nNews (February 1, 2004): 38.\\nBrown, Tim. ‘‘McGwire Appears to Suffer Lasting Damage\\nto Credibility after Refusing to Discuss Steroids, and\\nBaseball Will Tinker with Details of Its Drug Policy.’’\\nLos Angeles Times (March 19, 2005): D–1.\\nGoodlad, Terry. ‘‘Dancing with the Dark Side: So, You\\nThink You’re Ready for Your First Steroid Cycle?’’\\nFlex (April 2004): 90–96.\\nIngram, Scott. ‘‘Buff Enough? More Teens Are Using\\nSteroids to Look Pumped and Do Better at Sports. Do\\nGALE ENCYCLOPEDIA OF MEDICINE 177\\nAnabolic steroid use'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='they Know the Terrible Risk They’re Taking?’’Current\\nScience (September 24, 2004): 4–8.\\nPoniewozik, James. ‘‘This Is Your Nation on Steroids: Why\\nDoes a Performance-Enhanced Society Scorn\\nPerformance-Enhanced Athletes?’’Time (December 20,\\n2004): 168.\\nORGANIZATIONS\\nNational Center for Drug Free Sport Inc. 810 Baltimore St.,\\nKansas City, MO 64105. (816) 474-7329. .\\nNational Institute on Drug Abuse. 6001 Executive Blvd.,\\nBethesda, MD 20892. (301)443-1124. . .\\nOTHER\\nDrug Enforcement Administration.Steroid Abuse in\\nToday’s Society, March 2004. [cited March 21, 2005].\\n.\\nFocus Adolescent Service.Teens and Anabolic Steroids ,\\n2005. [cited March 21, 2005]. .\\nKen R. Wells\\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\\ndeep wounds, deep tissues, and internal organs where\\nthere is little oxygen. These infections are character-\\nized byabscess formation, foul-smelling pus, and tis-\\nsue destruction.\\nDescription\\nAnaerobic means ‘‘life without air.’’ Anaerobic\\nbacteria grow in places which completely, or almost\\ncompletely, lack oxygen. They are normally found in\\nthe mouth, gastrointestinal tract, and vagina, and on\\nthe skin. Commonly known diseases caused by anae-\\nrobic bacteria include gasgangrene, tetanus,a n dbotu-\\nlism. Nearly all dental infections are caused by\\nanaerobic 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/C15Mouth, head, and neck. Infections can occur in the\\nroot canals, gums (gingivitis), jaw, tonsils, throat,\\nsinuses, and ears.\\n/C15Lung. Anaerobic bacteria can causepneumonia,l u n g\\nabscesses, infecton of the lining of the lung\\n(empyema), and dilated lung bronchi (bronchiectasis).\\n/C15Intraabdominal. Anaerobic infections within the\\nabdomen include abscess formation,peritonitis, and\\nappendicitis.\\n/C15Female genital tract. Anaerobic bacteria can cause\\npelvic abscesses,pelvic inflammatory disease, inflam-\\nmation of the uterine lining (endometritis), and pelvic\\ninfections following abortion,childbirth, and surgery.\\n/C15Skin and soft tissue. Anaerobic bacteria are common\\ncauses of diabetic skin ulcers, gangrene, destructive\\ninfection of the deep skin and tissues (necrotizing\\nfascitis), and bite wound infections.\\n/C15Central nervous system. Anaerobic bacteria can\\ncause brain and spinal cord abscesses.\\n/C15Bloodstream. Anaerobic bacteria can be found in the\\nbloodstream of ill patients (a condition called\\nbacteremia).\\nCauses and symptoms\\nPeople who have experienced shock, injury, or\\nsurgery, and those with blood vessel disease or\\ntumors are at an increased risk for infection by anae-\\nrobic bacteria. There are many different kinds of\\nanaerobic bacteria which can cause an infection.\\nIndeed, most anaerobic infections are ‘‘mixed infec-\\ntions’’ which means that there is a mixture of differ-\\nent bacteria growing. The anaerobic bacteria that\\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.\\n178 GALE ENCYCLOPEDIA OF MEDICINE\\nAnaerobic infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='most frequently ca use infections are Bacteroides\\nfragilis, Peptostreptococcus ,a n dClostridium species.\\nThe signs and symptoms of anaerobic infection can\\nvary depending on the location of the infection. In gen-\\neral, anaerobic infections result in tissue destruction, an\\nabscess which drains foul-smelling pus, and possibly\\nfever. Symptoms for specific infections are as follows:\\n/C15Tooth and gum infections. Swollen, tender bleeding\\ngums, bad breath,a n dpain. Severe infections may\\nproduce oozing sores.\\n/C15Throat infection. An extremely sore throat, bad\\nbreath, a bad taste in the mouth, fever, and a sense\\nof choking.\\n/C15Lung infection. Chest pain, coughing, difficulty brea-\\nthing, fever, foul-smelling sputum, and weight loss.\\n/C15Intraabdominal infection. Pain, fever, and possibly,\\nif following surgery, foul- smelling drainage from the\\nwound.\\n/C15Pelvic infection. Foul-smelling pus or blood draining\\nfrom the uterus, general or localized pelvic pain,\\nfever, and chills.\\n/C15Skin and soft tissue infection. Infected wounds are\\nred, painful, swollen, and may drain a foul-smelling\\npus. Skin infection causes localized swelling, pain,\\nredness, and possibly a painful, open sore (ulcer)\\nwhich drains foul-smelling pus. Severe skin infections\\nmay cause extensive tissue destruction (necrosis).\\n/C15Bloodstream. Bloodstream invasion causes high\\nfever (up to 1058F [40.68C]), chills, a general ill feel-\\ning, and is potentially fatal.\\nDiagnosis\\nThe diagnosis of anaerobic infection is based pri-\\nmarily on symptoms, the patient’s medical history,\\nand location of the infection. A foul-smelling infection\\nor drainage from an abscess is diagnostic of anaerobic\\ninfection. This foul smell is produced by anaerobic\\nbacteria and occurs in one third to one half of patients\\nlate in the infection. Other clues to anaerobic infection\\ninclude tissue necrosis and gas production at the infection\\nsite. A sample from the infected site may be obtained,\\nu s i n gas w a bo ran e e d l ea n ds y r i n g e ,t od e t e r m i n ew h i c h\\nbacteria is (are) causing the infection. Because these bac-\\nteria can be easily killed by oxygen, they rarely grow in\\nthe laboratory cultures of tissue or pus samples.\\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 withantibiotics\\nthat aren’t able to kill anaerobes is another clue that\\nthe infection is caused by anaerobes. The location and\\ntype of 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 anti-\\nbiotic will work best. Every antibiotic does not work\\nagainst all anaerobic bacteria but nearly all anaerobes\\nare killed by chloramphenicol (Chloromycetin), metro-\\nnidazole (Flagyl or Protostat), and imipenem\\n(Primaxin). Other antibiotics which may be used are\\nclindamycin (Cleocin) or cefoxitin (Mefoxin).\\nSurgical removal or drainage of the abscess is\\nalmost always required. This may involve drainage\\nby needle and syringe to remove the pus from a skin\\nabscess (called ‘‘aspira tion’’). The area would be\\nnumbed prior to the aspiration procedure. Also,\\nsome internal abscesses can be drained using this\\nprocedure with the help of ultrasound (a device\\nwhich uses sound waves to visualize internal organs).\\nThis type of abscess drainage may be performed in\\nthe doctor’s office.\\nPrognosis\\nComplete recovery should be achieved with the\\nappropriate surgery and antibiotic treatment.\\nUntreated or uncontrolled infections can cause severe\\ntissue and bone destruction, which would requireplas-\\ntic surgery to repair. Serious infections can be life\\nthreatening.\\nPrevention\\nAlthough anaerobic infections can occur in any-\\none, good hygiene and general health may help to\\nprevent infections.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nBelinda Rowland, PhD\\nAnaerobic myositis see Gangrene\\nGALE ENCYCLOPEDIA OF MEDICINE 179\\nAnaerobic infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Anal 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\\nboys with high anal atresia, there may be a channel\\n(fistula) connecting the large intestine to either the\\nurethra (which delivers urine from the bladder) or\\nthe bladder itself. In girls, the channel may connect\\nwith the vagina. Sixty percent of children with high\\nanal atresia have other defects, including problems\\nwith the esophagus, urinary tract, and bones. In low\\nanal atresia, the channel may open in front of the\\ncircular mass of muscles that constrict to close the\\nanal opening (anal sphincter) or, in boys, below\\nthe scrotum. Occasionally, the intestine ends just\\nunder the skin. It is estimated that overall abnormal-\\nities of the anus and rectum occur in about one in every\\n5,000 births and are slightly more common among\\nboys. A mother who has one child with these kind of\\nconditions has a 1% chance of having another child\\nwho suffers from this ailment.\\nCauses and symptoms\\nAnal atresia is a defect in the development of the\\nfetus. The cause is unknown, but genetics seem to play\\na minor 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\\nvomiting of fecal material. To determine the type of\\nanal atresia and the exact position, x rays will be taken\\nwhich include injecting opaque dye into the opening.\\nMagnetic resonance imaging (MRI) orcomputed tomo-\\ngraphy scans(CT), as well as ultrasound, are the ima-\\nging techniques used to determine the type and size of\\nthe anal atresia. Ultrasound uses sound waves, CT\\nscans pass x rays through the body at different angles,\\nand an MRI uses a magnetic field and radio waves.\\nTreatment\\nSurgery is the only treatment for anal atresia. For\\nhigh anal atresia, immediately after the diagnosis is\\nmade, a surgical incision is made in the large intestine\\nto make a temporary opening (colostomy) in the abdo-\\nmen where waste is excreted. Several months later, the\\nintestine is moved into the ring of muscle (sphincter)\\nthat is part of the anus and a hole is made in the skin.\\nThe colostomy is closed several weeks later. In low anal\\natresia, immediately after diagnosis, a hole is made in\\nthe skin to open the area where the anus should be. If\\nthe channel is in the wrong place, the intestine is\\nmoved into the correct position sometime during the\\nchild’s first year. After surgery, the pediatric surgeon\\nuses an instrument to dilate or widen the rectum and\\nteaches the parents how to do this daily at home to\\nprevent scar tissue from contracting.\\nPrognosis\\nWith high anal atresia, many children have pro-\\nblems controlling bowel function. Most also become\\nconstipated. With low anal atresia, children generally\\nhave good bowel control, but they may still become\\nconstipated.\\nPrevention\\nThere is no known way to prevent anal atresia.\\nResources\\nBOOKS\\nPaidas, Charles N., and Alberto Pena. ‘‘Rectum and Anus.’’\\nIn Surgery of Infants and Children. Philadelphia:\\nLippincott-Raven, 1997.\\nJeanine Barone, Physiologist\\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 abdomen\\nand 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.\\n180 GALE ENCYCLOPEDIA OF MEDICINE\\nAnal atresia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Anal cancer\\nDefinition\\nAnal cancer is an uncommon form of cancer\\naffecting the anus. The anus is the inch-and-a-half-\\nlong end portion of the large intestine, which opens\\nto allow solid wastes to exit the body. Other parts of\\nthe large intestine include 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. Someanal warts, for example,\\ncontain precancerous areas and can develop into can-\\ncer. Types of anal cancer include:\\n/C15Squamous Cell Carcinomas. Approximately half of\\nanal cancers are squamous cell carcinomas, which\\narise from the cells lining the anal margin and the\\nanal canal. The anal margin is the part of the anus\\nthat is half inside and half outside the body, and the\\nanal canal is the part of the anus that is inside the\\nbody. The earliest form of squamous cell carcinoma\\nis known as carcinoma in situ, or Bowen’s disease.\\n/C15Cloacogenic Carcinomas. Approximately one-\\nfourth to one-third of anal tumors are cloacogenic\\ncarcinomas. These tumors develop in the transitional\\nzone, or cloaca, which is a ring of tissue between the\\nanal canal and the rectum.\\n/C15Adenocarcinomas. About 15% of anal cancers are\\nadenocarcinomas, which affect glands in the anal\\narea. One type of adenocarcinoma that can occur in\\nthe anal area is called Paget’s disease, which can also\\naffect the vulva, breasts, and other areas of the body.\\n/C15Skin cancers. A small percentage of anal cancers are\\neither basal cell carcinomas, or malignant melano-\\nmas, two types of skin cancer. Malignant melano-\\nmas, which develop from skin cells that produce the\\nbrown pigment called melanin, are far more common\\non areas of the body exposed to the sun.\\nApproximately 3,500 Americans will be diag-\\nnosed with anal cancer in 2001, and an estimated 500\\nindividuals will die of the disease during this same\\ninterval, according to the American Cancer Society.\\nAnal cancers are fairly rare: they make up only 1% to\\n2% of cancers affecting the digestive system. The dis-\\nease affects women somewhat more often than men,\\nalthough the number of cases among men, particularly\\nhomosexual men, seems to be increasing.\\nCauses and symptoms\\nThe exact cause of most anal cancers is unknown,\\nalthough certain individuals appear to have a higher\\nrisk of developing the disease. Smokers are at higher\\nrisk, as are individuals with certain types of the human\\npapillomavirus (HPV), and those with long-term pro-\\nblems in the anal area, such as abnormal openings\\nknown as fistulas. Since it increases the risk of HPV\\ninfection, the practice of anal sex appears to increase\\nthe risk of anal cancer—male homosexuals who prac-\\ntice anal sex are about 33 times more likely to have\\nanal cancers than heterosexual men. Those with wea-\\nkened immune systems, such individuals with HIV, or\\ntransplant patients taking immunosuppressant drugs,\\nare also at higher risk. Most individuals with anal\\ncancer 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\\nnodes in the anal or groin area.\\nDiagnosis\\nAnal cancer is sometimes diagnosed during rou-\\ntine physicals, or during minor procedures such as\\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 drugs\\ndelivered into the blood stream kill cancer cells or\\nmake them more vulnerable to radiation therapy.\\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 syndrome\\n(AIDS).\\nLymph nodes— Bean-shaped structures found\\nthroughout the body that produce and store\\ninfection-fighting cells.\\nRadiation therapy— A cancer treatment that uses\\nhigh-energy rays to kill or weaken cancer cells.\\nRadiation may be delivered externally or internally\\nvia surgically implanted pellets.\\nGALE ENCYCLOPEDIA OF MEDICINE 181\\nAnal cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='hemorrhoid removal. It may also be diagnosed during\\na digital rectal examination (DRE), when a physician\\ninserts a gloved, lubricated finger into the anus to\\nfeel for unusual growths. Individuals over the age of\\n50 who have no symptoms should have a digitalrectal\\nexamination (DRE) every five to 10 years, according\\nto American Cancer Society (ACS) guidelines for early\\ndetection of colorectal cancer.\\nOther diagnostic procedures for anal cancer\\ninclude: Anoscopy. A procedure that involves use of a\\nspecial device to examine the anus. Proctoscopy. A\\nprocedure that involves use of a lighted scope to see\\nthe anal canal. Transrectal ultrasound. A procedure in\\nwhich sound waves are used to create an image of the\\nanus 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\\nperform a procedure called a fine needle aspiration\\nbiopsy, in which a needle is used to withdraw fluid\\nfrom lymph nodes located near the growth, to make\\nsure the cancer has not spread to these nodes.\\nAnal cancer severity is categorized by the follow-\\ning stages:\\n/C15Stage 0 anal cancer is found only in the top layer of\\nanal tissue.\\n/C15Stage I anal cancer has spread beyond the top layer\\nof anal tissue, but is less than 1 inch in diameter.\\n/C15Stage II anal cancer has spread beyond the top layer\\nof anal tissue and is larger than 1 inch in diameter,\\nbut has not spread to nearby organs or lymph nodes.\\n/C15Stage IIIA anal cancer has spread to the lymph nodes\\naround the rectum or to nearby organs such as the\\nvagina or bladder.\\n/C15Stage IIIB anal cancer has spread to lymph nodes in\\nthe mid-abdomen or groin, or to nearby organs and\\nthe lymph nodes around the rectum.\\n/C15Stage IV anal cancer has spread to distant lymph\\nnodes within the abdomen or to distantorgans.\\nTreatment\\nAnal cancer is treated using three methods, used\\neither in concert or individually: surgery, radiation\\ntherapy, andchemotherapy.\\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\\nthe tumor. An abdominoperineal resection is a more\\ncomplex procedure in which the anus and the lower\\nrectum are removed, and an opening called acolost-\\nomy is created for body wastes to exit. This procedure\\nis fairly uncommon today because radiation and\\nchemotherapy are just as effective.\\nChemotherapy fights cancer using drugs, which\\nmay be delivered via pill or needle. Some chemother-\\napy types kill cancer cells directly, while others act\\nindirectly by making cancer cells more vulnerable to\\nradiation. The main drugs used to treat anal cancer\\nare 5-fluorouracil (5-FU) and mitomycin or 5-FU\\nand cisplatin. Side effects of chemotherapy, which\\ndamages normal cells in addition to cancer cells, may\\ninclude nausea and vomiting, hair loss, loss of appetite,\\ndiarrhea, mouth sores, fatigue, shortness of breath,\\nand a weakened immune system.\\nAlternative treatment\\nResearch suggests acupuncture can help manage\\nchemotherapy-related nausea and vomiting and con-\\ntrol pain associated with surgery.\\nPrognosis\\nAnalcancer isoftencurable.Thechanceof recovery\\ndepends on the cancer stage and the patient’s general\\nhealth.\\nPrevention\\nReducing the risks of thesexually transmitted dis-\\neases HPV and HIV also reduces the risk of anal\\ncancer. In addition, quittingsmoking lowers the risk\\nof anal cancer.\\nResources\\nPERIODICALS\\nM u r a k a m i ,M ,K .J .G u r s k i ,a n dM .A .S t e l l e r\\n‘‘Human Papillomavirus Vaccines For Cervical Cancer.’’\\nJournal of Immunotherapy 22, no. 3 (1999): 212-8.\\nORGANIZATIONS\\nAmerican Cancer Society 1599 Clifton Road, NE, Atlanta,\\nGA 30329. (404) 320-3333 or (800) ACS-2345. Fax:\\n(404) 329-7530. .\\nAmerican College of Gastroenterology. 4900 B South 31st\\nSt., Arlington, VA 22206-1656. (703) 820-7400.\\n.\\nAmerican Gastroenterological Association. 7910\\nWoodmont Ave., Seventh Floor, Bethesda, MD 20814.\\n(301) 654-2055. .\\nAmerican Society of Colon and Rectal Surgeons. 85 W.\\nAlgonquin Road, Suite 550, Arlington Heights, Illinois\\n60005. (847) 290-9184.\\n182\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAnal cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='National Cancer Institute (National Institutes of Health).\\n9000 Rockville Pike, Bethesda, MD 20892. (800) 422-\\n6237. .\\nNational Coalition for Cancer Survivorship. 1010 Wayne\\nAvenue, 5th Floor, Suite 300, Silver Spring, MD 20910.\\n(888) 650-9127.\\nNCI Office of Cancer Complementary and Alternative\\nMedicine. .\\nNIH 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 cauli-\\nflower-like protuberances. They can be yellow, pink,\\nor light brown in color, and only rarely are painful or\\nuncomfortable. In fact, infected individuals often are\\nunaware that they exist. Most cases are caused by\\nsexual transmission.\\nMost individuals have between one to 10 genital\\nwarts thtat range in size from roughly 0.5–1.9 cm\\n2.\\nSome will complain of painless bumps oritching, but\\noften, these warts can remain completely unnoticed.\\nCauses and symptoms\\nCondyloma acuminatum is one of the most com-\\nmon sexually transmitted disease (STD) in the United\\nStates. Young adults aged 17 to 33 years are at greatest\\nrisk. Risk factors include smoking, using oral contra-\\nceptives, having multiple sexual partners, and an early\\ncoital age. 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\\nare the least likely of over 60 types of HPV to become\\ncancerous. Anal warts are usually transmitted through\\ndirect sexual contact with someone who is infected with\\ncondyloma acuminata anywhere in the genital area,\\nincluding the penis and vagina. Studies have shown\\nthat roughly 75% of those who engage in sexual con-\\ntact with someone infected with condyloma acuminata\\nwill develop these warts within three months.\\nTreatment\\nAccordingtoguidelinesfromtheCentersforDisease\\nControl (CDC), the treatment ofallgenital warts,includ-\\ning anal warts, should be conducted according to the\\nmethods preferred by the patient, the medications or\\nprocedures most readily available, and the experience\\nof the patient’s physician in removing anal warts.\\nTreatment options include electrical cautery, sur-\\ngical removal, or both. Warts that appear inside the\\nanal canal will almost always be treated with cauter-\\nization or surgical removal. Surgical removal, also\\nknown as excision, has the highest success rates and\\nlowest recurrence rates. Indeed, studies have shown\\nthat initial cure rates range from 63–91%.\\nUnfortunately, most cases require numerous\\ntreatments because the virus that causes the warts\\ncan live in the surrounding tissue. The area may seem\\nnormal and wart-free for six months or longer before\\nanother wart develops.\\nElectrocoagulation, a technique that uses electri-\\ncal energy to destroy the warts, is usually the most\\npainful of the procedures done to eliminate condy-\\nloma acuminata of the anus, and is usually reserved\\nfor larger warts. It is done withlocal anesthesia, and\\nmay cause discharge or bleeding from the anus.\\nFollow-up visits to the physician are necessary to\\nmake sure that the warts have not recurred. It is\\nrecommended that these patients see their physicians\\nevery three to six months for up to 1.5 years, which is\\nhow long the 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\\nKEY TERMS\\nElectrocoagulation— at e c h n i q u eu s i n ge l e c t r i c a l\\nenergy to destroy the warts. Usually done for warts\\nwithin the anus with a local anesthesia, electrocoa-\\ngulation is most painful form of therapy, and can\\ncause both bleeding and discharge from the anus.\\nGALE ENCYCLOPEDIA OF MEDICINE 183\\nAnal warts'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='be transmitted via the smoke caused by these proce-\\ndures, they are usually reserved for the worst infections.\\nFor small warts that affect only the skin around\\nthe anus, several medications are available, which can\\nbe applied directly to the surface of the warts by a\\nphysician or by the patients themselves.\\nSuch medications include podophyllum resin\\n(Podocon-25, Pod-Ben-25), a substance made from\\nthe cytotoxic extracts of several plants. This agent\\noffers a cure rate of 20–50% when used alone, and is\\napplied by the physician weekly and then washed off\\n6 hours later by the patient.\\nPodofilox (Condylox) is another agent, and is\\navailable for patients to use at home. It can be applied\\ntwice daily for up to 4 weeks. Podofilox offers a\\nslightly higher cure rate than podophyllin, and can\\nalso be used to prevent 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\\ncauterize the skin, and are quite caustic. Nevertheless,\\nthey cause less irritation and overall body effects than\\nthe other agents mentioned above. Recurrence, how-\\never, is higher with these acids.\\nBleomycin (Blenoxane) is another treatment\\noption, but it has several drawbacks. First, it must be\\nadministered by a physician into each lesion via injec-\\ntion, but is can have a host of side effects, and patients\\nmust be followed carefully by their physician.\\nImiquimod 5% cream is also available for patients\\nto apply themselves. It is to be applied three times\\nweekly, for up to 16 weeks, and has been shown to\\nclear warts within 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\\ninto each lesion twice a week for up to eight weeks.\\nPrognosis\\nOnce a diagnosis of anal warts has been made,\\nfurther outbreaks can be controlled or sometimes pre-\\nvented with proper care. Unfortunately, many cases of\\nanal warts either fail to respond to treatment or recur.\\nPatients have to undergo roughly six to nine treat-\\nments over several months to assure that the warts\\nare completely eradicated.\\nRecurrence rates have been estimated to be over\\n50%afteroneyearandmaybeduetothelongincubation\\nofHPV(upto1.5years),deeplesions,undetectedlesions,\\nvirus present in surrounding skin that is not treated.\\nPrevention\\nSexual abstinence and monogamous relationships\\ncan be the most effective form of prevention, and\\ncondoms may also decrease the chances of transmis-\\nsion of condyloma acuminata. Abstinence from sexual\\nrelations with people who have anal orgenital warts\\ncan prevent infection. Unfortunately, since many peo-\\nple may not be aware that they have this condition,\\nthis is not always possible.\\nIndividuals infected with anal warts should have\\nfollow-up checkups every few weeks after their initial\\ntreatment, after which self-exams can be done.\\nSexual partners of people who have anal warts\\nshould also be examined, as a precautionary preven-\\ntive measure.\\nFinally, 5-flourouracil (Adrucil, Efudex, Fluoro-\\nplex) may be useful to prevent recurrence once the\\nwarts have been removed. Treatment must, however,\\nbe initiated within 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\\nTransmitted Diseases Hotline: (800) 227-8922.\\nOTHER\\n.\\n.\\n.\\n.\\nLiz Meszaros\\nAnalgesics\\nDefinition\\nAnalgesics are medicines that relievepain.\\nPurpose\\nAnalgesics are those drugs that mainly provide\\npain relief. The primary classes of analgesics are the\\n184 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='narcotics, including additional agents that are chemi-\\ncally based on the morphine molecule but have mini-\\nmal abuse potential; nonsteroidal anti-inflammatory\\ndrugs (NSAIDs) including the salicylates; andacetami-\\nnophen. Other drugs, notably thetricyclic antidepres-\\nsants and anti-epileptic agents such as gabapentin, have\\nbeen used to relieve pain, particularly neurologic pain,\\nbut are not routinely classified as analgesics. Analgesics\\nprovide symptomatic relief, but have no effect on the\\ncause, although clearly the NSAIDs, by virtue of their\\ndual activity, may be beneficial in both regards.\\nDescription\\nPain has been classified as ‘‘productive’’ pain and\\n‘‘non-productive’’ pain. While this distinction has\\nno physiologic meaning, it may serve as a guide to\\ntreatment. ‘‘Productive’’ pain has been described as a\\nwarning of injury, and so may be both an indication of\\nneed for treatment and a guide to diagnosis. ‘‘Non-\\nproductive’’ pain by definition serves no purpose\\neither as a warning or 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 periph-\\neral nervous system, or by distorting the interpretation\\nby the central nervous system. Selection of an appro-\\npriate analgesic is based on consideration of the risk-\\nbenefit factors of each class of drugs, based on type of\\npain, severity of pain, and risk of adverse effects.\\nTraditionally, pain has been divided into two classes,\\nacute and chronic, although severity and projected\\npatient survival are other factors that must be consid-\\nered in drug selection.\\nAcute pain\\nAcute pain is self limiting in duration, and\\nincludes post-operative pain, pain of injury, andchild-\\nbirth. Because pain of these types is expected to be\\nshort term, the long-term side effects of analgesic ther-\\napy may routinely be ignored. Thus, these patients\\nmay safely be treated with narcotic analgesics without\\nconcern about possible addiction, or NSAIDs with\\nonly limited concern for the risk of ulcers. Drugs and\\ndoses should be adjusted based on observation of\\nhealing rate, switching patients from high to low\\ndoses, and from narcotic analgesics to non-narcotics\\nwhen circumstances permit.\\nAn important consideration ofpain management\\nin severe pain is that patients should not be subject to\\nthe return of pain. Analgesics should be dosed\\nadequately to ensure that the pain is at least tolerable,\\nand frequently enough to avoid the anxiety that\\naccompanies the anticipated return of pain.\\nAnalgesics should never be dosed on an as needed\\nbasis, but should be administered often enough to\\nassure constant blood levels of analgesic. This applies\\nto 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\\nanalgesics this means the addiction potential, as well\\nas respiratory depression and constipation.F o rt h e\\nNSAIDs, the risk of gastric ulcers limit dose. While\\nsome classes of drugs, such as the narcotic agonist/\\nantagonist drugs bupronophine, nalbuphine and penta-\\nzocine, and the selectiveCOX-2 inhibitorscelecoxib and\\nrofecoxib represent advances in reduction of adverse\\neffects, they are still not fully suitable for long-term\\nmanagement of severe pain. Generally, chronic pain\\nmanagement requires a combination of drug therapy,\\nlife-style modification, and other treatment modalities.\\nNarcotic analgesics\\nThe narcotic analgesics, also termed opioids, are\\nall derived from opium. The class includes morphine,\\ncodeine, and a number of semi-synthetics including\\nmeperidine (Demerol), propoxyphen (Darvon) and\\nothers. The narcotic analgesics vary in potency, but all\\nare effective in treatment of visceral pain when used\\nin adequate doses. Adverse effects are dose related.\\nBecause these drugs are all addictive, they are controlled\\nunder federal and state laws. A variety of dosage forms\\nare available, including oral solids, liquids, intravenous\\nand intrathecal injections, and transcutaneous patches.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 185\\nAnalgesics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='NSAIDs are effective analgesics even at doses too\\nlow to have any anti-inflammatory effects. There are a\\nnumber of chemical classes, but all have similar ther-\\napeutic effects and side effects. Most are appropriate\\nonly for oral administration; however ketorolac\\n(Toradol) is appropriate for injection and may be\\nused in moderate to severe pain for short periods.\\nAcetaminophen is a non-narcotic analgesic with no\\nanti-inflammatory properties. It is appropriate for mild\\nto moderate pain. Although the drug is well tolerated in\\nnormal doses, it may have significant toxicity at high\\ndoses. Because acetaminophen is largely free of side\\neffects at therapeutic doses, it has been considered the\\nfirst choice for mild pain, including that ofosteoarthritis.\\nTopical analgesics (topical being those that are\\napplied on the skin) have become much more popular\\nin recent years. Those applied for local effect include\\ncapsaicin, methylsalicylate, and transdermal lidocaine.\\nTransdermal fentanyl may be applied for systemic (the\\nentire body in general) effect. In some cases, these\\ntopical agents reduce the need for drug therapy. Sales\\nof pain relief patches have increased substantially in\\nrecent years. They are particularly useful for elderly\\npatients who may not want to take a lot of tablets.\\nRecommended dosage\\nAppropriate dosage varies by drug, and should\\nconsider the type of pain, as well as other risks asso-\\nciated with patient age and condition. For example,\\nnarcotic analgesics should usually be avoided in\\npatients with a history ofsubstance abuse, but may be\\nfully appropriate in patients withcancerpain. Similarly,\\nbecause narcotics are more rapidly metabolized in\\npatients who have used these drugs for a long period,\\nhigher than normal doses may be needed to provide\\nadequate pain management. NSAIDs, although com-\\nparatively safe in adults, represent an increased risk of\\ngastrointestinal bleeding in patients over the age of 60.\\nPrecautions\\nNarcotic analgesics may be contraindicated in\\npatients with respiratory depression. NSAIDS may\\nbe hazardous to patients with ulcers or an ulcer his-\\ntory. They should be used with care in patients with\\nrenal insufficiency orcoagulation disorders. NSAIDs\\nare contraindicated in patients allergic toaspirin.\\nSide effects\\nEach drug’s adverse effects should be reviewed\\nindividually. Drugs within a class may vary in their\\nfrequency and severity of adverse effects.\\nT h ep r i m a r ya d v e r s ee f f e c t so ft h en a r c o t i c\\nanalgesics are addiction, constipation, and respira-\\ntory depression. Because narcotic analgesics stimu-\\nlate the production of enzymes that cause the\\nmetabolism of these drugs,patients on narcotics for\\na prolonged period may require increasing doses.\\nThis is not the same thing as addiction, and is not a\\nreason for withholding medication from patients in\\nsevere pain.\\nNSAIDs can lead to ulcers and may cause kid-\\nney problems. Gastrointestinal discomfort is com-\\nmon, although in some cases, these drugs may\\ncause ulcers without the prior warning of gastroin-\\ntestinal distress. Platelet aggregation problems may\\noccur, although not to the same extent as is seen\\nwith aspirin.\\nInteractions\\nInteractions depend on the specific type of\\nanalgesic.\\nResources\\nPERIODICALS\\n‘‘Analgesics: No Pain, No Gain.’’Chemist & Druggist\\n(September 11, 2004): 38.\\nKuritzky, Louis.‘‘Topical Capsaicin for Chronic Pain.’’\\nInternal Medicine Alert (September 29, 2004): 144.\\n‘‘Pain Relief Patches Are Flying Off Store Shelves.’’Chain\\nDrug Review (August 16, 2004): 15.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnalgesics, opioid\\nDefinition\\nOpioid analgesics, also known as narcotic analge-\\nsics, arepain relievers that act on the central nervous\\nsystem. Like all narcotics, they may become habit-\\nforming 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\\nand to make anesthetics work more effectively. They\\n186 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics, opioid'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='may also be used for the same purposes during labor\\nand delivery.\\nOpioids are also given to relieve the pain of terminal\\ncancer, diabetic neuropathy, lower back pain, and other\\nchronic diseases or disorders. The World Health\\nOrganization (WHO) has established a three-stage\\n‘‘ladder’’ for the use of opioids in managing cancer pain.\\nDescription\\nOpioid analgesics relieve pain by acting directly\\non the central nervous system. However, this can also\\nlead to unwanted side effects, such as drowsiness,\\ndizziness, breathing problems, and physical or mental\\ndependence.\\nAmong the drugs in this category are codeine,\\npropoxyphene (Darvon), propoxyphene andacetami-\\nnophen (Darvocet N), meperidine (Demerol), hydro-\\nmorphone (Dilaudid), morphine, oxycodone,\\noxycodone and acetaminophen (Percocet, Roxicet),\\nand hydrocodone and acetaminophen (Lortab,\\nAnexsia). These drugs come in many forms—tablets,\\nsyrups, suppositories, and injections, and are sold only\\nby prescription. For some, a new prescription is\\nrequired for each new supply—refills are prohibited\\naccording to federal regulations.\\nOpioid analgesics\\nDrug\\nRoute of\\nadministration\\nOnset of\\naction (min)\\nTime to peak\\neffect (min)\\nDuration of\\naction (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\\nGALE ENCYCLOPEDIA OF MEDICINE 187\\nAnalgesics, opioid'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended 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 pharm-\\nacist who filled the prescription for correct dosages, and\\nmake sure to understand how to take the drug.\\nAlways take opioid analgesics exactly as directed.\\nNever take larger or more frequent doses, and do not\\ntake the drug for longer than directed. Do not stop\\ntaking the drug suddenly without checking with the\\nphysician or dentist who prescribed it. Gradually\\ntapering the dose may the chance of withdrawal\\nsymptoms.\\nPrecautions\\nAnyone who uses opioid analgesics—or any nar-\\ncotic—over a long time may become physically or\\nmentally dependent on the drug. Physical dependence\\nmay lead to withdrawal symptoms when the person\\nstops taking the medicine. Building tolerance to these\\ndrugs is also possible when they are used for a long\\nperiod. Over time, the body needs larger and larger\\ndoses 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\\nseem to be working, consult your physician. Do not\\nshare these or any other prescription drugs with others\\nbecause the drug may have a completely different\\neffect on the person for whom it was not prescribed.\\nChildren and older people are especially sensitive\\nto opioid analgesics and may have serious breathing\\nproblems after taking them. Children may also\\nbecome unusually restless or agitated when given\\nthese drugs.\\nOpioid analgesics increase the effects of alcohol.\\nAnyone taking these drugs should not drink alcoholic\\nbeverages.\\nSome of these drugs may also containaspirin,\\ncaffeine, or acetaminophen. Refer to the entries on\\neach of these drugs for additional precautions.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if they\\ntakeopioidanalgesics.Beforetakingthesedrugs,besure\\nto let the physician know about any of these conditions.\\nALLERGIES. Let the physician know about anyaller-\\ngies to foods, dyes, preservatives, or other substances\\nand about any previous reactions to opioid analgesics.\\nPREGNANCY. Women who are pregnant or plan\\nto become pregnant while taking opioid analgesics\\nshould let their physicians know. No evidence exists\\nthat these drugs causebirth defectsin people, but some\\ndo cause birth defects and other problems when given to\\npregnant animals in experiments. Babies can become\\ndependent on opioid analgesics if their mothers use\\ntoo much duringpregnancy. This can cause the baby\\nto go through withdrawal symptoms after birth. If\\ntaken just before delivery, some opioid analgesics\\nmay cause serious breathing problems in the newborn.\\nBREAST FEEDING. Some opioid analgesics can pass\\ninto breast milk. Women who are breast feeding\\nshould check with their physicians about the safety\\nof taking these drugs.\\nOTHER MEDICAL CONDITIONS. These conditions\\nmay influence the effects of opioid analgesics:\\n/C15head injury. The effects of some opioid analgesics\\nmay be stronger and may interfere with recovery in\\npeople with head injuries.\\n/C15history of convulsions. Some of these drugs may\\ntrigger convulsions.\\n/C15asthma, emphysema, or any chronic lung disease\\nKEY TERMS\\nAnalgesic— Medicine used to relieve pain.\\nCentral nervous system—The brain and spinal cord.\\nColitis— Inflammation of the colon (large bowel)\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\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 dependence\\nand 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.\\n188 GALE ENCYCLOPEDIA OF MEDICINE\\nAnalgesics, opioid'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15heart disease\\n/C15kidney disease\\n/C15liver disease\\n/C15HIV infection. Patients undergoing highly active\\nantiretroviral therapy, or HAART, are at increased\\nrisk for adverse effects from opioid analgesics.\\n/C15underactive thyroid. The chance of side effects may\\nbe greater.\\n/C15Addison’s disease (a disease of the adrenal glands)\\n/C15colitis\\n/C15gallbladder disease orgallstones. Side effects can be\\ndangerous in people with these conditions.\\n/C15enlarged prostate or other urinary problems\\n/C15current or past alcoholabuse\\n/C15current or past drug abuse, especially narcotic abuse\\n/C15current or past emotional problems. The chance of\\nside effects may be greater.\\nUSE OF CERTAIN MEDICINES. Taking opioid narco-\\ntics with certain other drugs may increase the chances\\nof serious side effects.\\nSide effects\\nSome people experience drowsiness, dizziness,\\nlightheadedness, or a false sense of well-being after\\ntaking opioid analgesics. Anyone who takes these\\ndrugs should not drive, use machines, or do anything\\nelse that might be dangerous until they know how the\\ndrug affects them.Nausea and vomitingare common\\nside effects, especially when first beginning to take the\\nmedicine. If these symptoms do not go away after the\\nfirst few doses, check with the physician or dentist who\\nprescribed 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\\nover long periods and who have dry mouth should\\nsee their dentists, as the problem can lead totooth\\ndecay and other 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\\nwith normal activity, check with the physician who\\nprescribed the medicine.\\n/C15headache\\n/C15loss of appetite\\n/C15restlessness or nervousness\\n/C15nightmares, unusual dreams, or problems sleeping\\n/C15weakness or tiredness\\n/C15mental sluggishness\\n/C15stomach pain or cramps\\n/C15blurred or double vision or other vision problems\\n/C15problems urinating, such as pain, difficulty urinat-\\ning, frequent urge to urinate, or decreased amount of\\nurine\\n/C15constipation.\\nOther side effects may be more serious and may\\nrequire quick medical attention. These symptoms\\ncould be signs of an overdose. Get emergency medical\\ncare immediately.\\n/C15cold, clammy skin\\n/C15bluish discoloration of the skin\\n/C15extremely small pupils\\n/C15serious difficulty breathing or extremely slow\\nbreathing\\n/C15extreme sleepiness or unresponsiveness\\n/C15severe weakness\\n/C15confusion\\n/C15severe dizziness\\n/C15severe drowsiness\\n/C15slow heartbeat\\n/C15low blood pressure\\n/C15severe nervousness or restlessness\\nIn addition, these less common side effects do\\nnot require emergency medical care, but should have\\nmedical attention as soon as possible:\\n/C15hallucinations or a sense of unreality\\n/C15depression or other mood changes\\n/C15ringing or buzzing in the ears\\n/C15pounding or unusually fast heartbeat\\n/C15itching, hives, or rash\\n/C15facial swelling\\n/C15trembling or twitching\\n/C15dark urine, pale stools, or yellow eyes or skin (after\\ntaking propoxyphene)\\n/C15increased sweating, red or flushed face (more com-\\nmon after taking hydrocodone and meperidine)\\nGALE ENCYCLOPEDIA OF MEDICINE 189\\nAnalgesics, opioid'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Interactions\\nAnyone taking these drugs should notify his or her\\nphysician before taking opioid analgesics:\\n/C15Central nervous system (CNS) depressants, such as\\nantihistamines and other medicines for allergies, hay\\nfever, or colds; tranquilizers; some other prescription\\npain relievers; seizure medicines;muscle relaxants;\\nsleeping pills; some anesthetics (including dental\\nanesthetics).\\n/C15Monoamine oxidase (MAO) inhibitors, such as phe-\\nnelzine (Nardil) and tranylcypromine (Parnate). The\\ncombination of the opioid analgesic meperidine\\n(Demerol) and MAO inhibitors is especially\\ndangerous.\\n/C15Tricyclic antidepressants, such as amitriptyline\\n(Elavil).\\n/C15Anti-seizure medicines, such as carbamazepine\\n(Tegretol). May lead to serious side effects, including\\ncoma, when combined with propoxyphene and acet-\\naminophen (Darvocet-N) or propoxyphene\\n(Darvon).\\n/C15Muscle relaxants, such as cyclobenzaprine (Flexeril).\\n/C15Sleeping pills, such as triazolam (Halcion).\\n/C15Blood-thinning drugs, such as warfarin (Coumadin).\\n/C15Naltrexone (Trexan, Revia). Cancels the effects of\\nopioid analgesics.\\n/C15Rifampin (Rifadin).\\n/C15Zidovudine (AZT, Retrovir). Serious side effects\\nwhen combined with morphine.\\nOpioids may also interact with certain herbal pre-\\nparations sold as dietary supplements. Among the\\nherbs known to interact with opioids are valerian\\n(Valeriana officinalis ), ginseng (Panax ginseng ), kava\\nkava (Piper methysticum), and chamomile (Matricaria\\nchamomilla). As of early 2004 the National Center for\\nComplementary and Alternative Medicine (NCCAM)\\nis beginning a study of the possible interactions\\nbetween St. John’s wort (Hypericum perforatum ,a\\nherb frequently used to relieve symptoms of depres-\\nsion, and the opioid analgesics fentanyl and oxyco-\\ndone. It is just as important for patients to inform their\\ndoctor of herbal remedies that they take on a regular\\nbasis as it is to give the doctor a list of their other\\nprescription medications.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Pain.’’ Section 14, Chapter 167 InThe Merck Manual\\nof Diagnosis and Therapy. Whitehouse Station, NJ:\\nMerck Research Laboratories, 2002.\\nPelletier, Dr. Kenneth R.The Best Alternative Medicine,\\nPart I: Western Herbal Medicine. New York: Simon\\nand Schuster, 2002.\\nWilson, Billie Ann, RN, PhD, Carolyn L. Stang, PharmD,\\nand Margaret T. Shannon, RN, PhD.Nurses Drug\\nGuide 2000. Stamford, CT: Appleton and Lange, 1999.\\nPERIODICALS\\nCampbell, D. C. ‘‘Parenteral Opioids for Labor Analgesia.’’\\nClinical Obstetrics and Gynecology 46 (September\\n2003): 616–622.\\nCompton, P., and P. Athanasos. ‘‘Chronic Pain, Substance\\nAbuse and Addiction.’’Nursing Clinics of North\\nAmerica 38 (September 2003): 525–537.\\nFaragon, J. J., and P. J. Piliero. ‘‘Drug Interactions\\nAssociated with HAART: Focus on Treatments for\\nAddiction and Recreational Drugs.’’AIDS Reader 13\\n(September 2003): 433–450.\\nMarkowitz, J. S., J. L. Donovan, C. L. DeVane, et al. ‘‘Effect\\nof St John’s Wort on Drug Metabolism by Induction of\\nCytochrome P450 3A4 Enzyme.’’Journal of the\\nAmerican Medical Association 290 (September 17,\\n2003): 1500–1504.\\nSoares, L. G., M. Marins, and R. Uchoa. ‘‘Intravenous\\nFentanyl for Cancer Pain: A ‘Fast Titration’ Protocol\\nfor the Emergency Room.’’Journal of Pain and\\nSymptom Management 26 (September 2003): 876–881.\\nWatson, C. P., D. Moulin, J. Watt-Watson, et al.\\n‘‘Controlled-Release Oxycodone Relieves Neuropathic\\nPain: A Randomized Controlled Trial in Painful\\nDiabetic Neuropathy.’’Pain 105 (September 2003):\\n71–78.\\nORGANIZATIONS\\nNational Center for Complementary and Alternative\\nMedicine (NCCAM) Clearinghouse. P.O. Box 7923,\\nGaithersburg, MD 20898-7923. (888) 644-6226.\\n.\\nU. S. Food and Drug Administration (FDA). 5600 Fishers\\nLane, Rockville, MD 20857. (888) 463-6332. .\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAnaphylactic shock see Anaphylaxis\\nAnaphylactoid purpura see Allergic purpura\\nAnaphylaxis\\nDefinition\\nAnaphylaxis is a rapidly progressing, life-threa-\\ntening allergic reaction.\\n190 GALE ENCYCLOPEDIA OF MEDICINE\\nAnaphylaxis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nAnaphylaxis is a type of allergic reaction, in which\\nthe immune system responds to otherwise harmless\\nsubstances from the environment. Unlike other aller-\\ngic reactions, however, anaphylaxis can kill. Reaction\\nmay begin within minutes or even seconds of exposure,\\nand rapidly progress to cause airway constriction, skin\\nand intestinal irritation, and altered heart rhythms. In\\nsevere cases, it can result in complete airway obstruc-\\ntion, shock,a n ddeath.\\nCauses and symptoms\\nCauses\\nLike the majority of other allergic reactions, ana-\\nphylaxis is caused by the release of histamine and\\nother chemicals from mast cells. Mast cells are a type\\nof white blood cell and they are found in large num-\\nbers in the tissues that regulate exchange with the\\nenvironment: the airways, 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\\nfrom a genuinely threatening source, such as bacteria\\nor viruses, are called antigens. A substance that most\\npeople tolerate well, but to which others have an aller-\\ngic response, is called an allergen. When IgE antibo-\\ndies bind with allergens, they cause the mast cell to\\nrelease histamine and other chemicals, which spill out\\nonto neighboring cells.\\nThe interaction of these chemicals with receptors\\non the surface of blood vessels causes the vessels to\\nleak fluid into surrounding tissues, causing fluid accu-\\nmulation, redness, and swelling. On the smooth mus-\\ncle cells of the airways and digestive system, they cause\\nconstriction. On nerve endings, they increase sensitiv-\\nity and causeitching.\\nIn anaphylaxis, the dramatic response is due both\\nto extreme hypersensivity to the allergen and its usually\\nsystemic distribution. Allergens are more likely to cause\\nanaphylaxis if they are introduced directly into the\\ncirculatory system by injection. However, exposure by\\ningestion, inhalation, or skin contact can also cause\\nanaphylaxis. In some cases, anaphylaxis may develop\\nover time from less severeallergies.\\nAnaphylaxis is most often due to allergens in foods,\\ndrugs, and insect venom. Specific causes include:\\n/C15Fish, shellfish, and mollusks\\n/C15Nuts and seeds\\n/C15Stings of bees, wasps, or hornets\\n/C15Papain from meat tenderizers\\n/C15Vaccines, including flu andmeasles vaccines\\n/C15Penicillin\\n/C15Cephalosporins\\n/C15Streptomycin\\n/C15Gamma globulin\\n/C15Insulin\\n/C15Hormones (ACTH, thyroid-stimulating hormone)\\n/C15Aspirin and other NSAIDs\\n/C15Latex, from exam gloves or condoms, for example.\\nExposure to cold orexercise can trigger anaphy-\\nlaxis in some individuals.\\nSymptoms\\nSymptoms may include:\\n/C15Urticaria (hives)\\n/C15Swelling and irritation of the tongue or mouth\\n/C15Swelling of the sinuses\\n/C15Difficulty breathing\\n/C15Wheezing\\n/C15Cramping, vomiting,o rdiarrhea\\n/C15Anxiety or confusion\\n/C15Strong, very rapid heartbeat (palpitations)\\n/C15Loss of consciousness.\\nNot all symptoms may be present.\\nKEY TERMS\\nACTH— Adrenocorticotropic hormone, a hormone\\nnormally produced by the pituitary gland, some-\\ntimes taken as a treatment for arthritis and other\\ndisorders.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 191\\nAnaphylaxis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nAnaphylaxis is diagnosed based on the rapid\\ndevelopment of symptoms in response to a suspect\\nallergen. Identification of the culprit may be done\\nwith RAST testing, a blood test that identifies IgE\\nreactions to specific allergens. Skin testing may be\\ndone for less severe anaphylactic reactions.\\nTreatment\\nEmergency treatment of anaphylaxis involves\\ninjection of adrenaline (epinephrine) which constricts\\nblood vessels and counteracts the effects of hista-\\nmine. Oxygen may be given, as well as intravenous\\nreplacement fluids. Antihistamines may be used for\\nskin rash, and aminophylline for bronchial constric-\\ntion. If the upper airway is obstructed, placement\\nof a breathing tube or tracheostomy tube may be\\nneeded.\\nPrognosis\\nThe rapidity of symptom development is an indi-\\ncation of the likely severity of reaction: the faster\\nsymptoms develop, the m ore severe the ultimate\\nreaction. Prompt emergency medical attention and\\nclose monitoring reduces the likelihood of death.\\nNonetheless, death is possible from severe anaphy-\\nlaxis. For most people who receive rapid treatment,\\nrecovery is complete.\\nPrevention\\nAvoidance of the allergic trigger is the only\\nreliable method of preven ting anaphylaxis. For\\ninsect allergies, this requires recognizing likely\\nnest sites. Preventing food allergies requires know-\\nledge of the prepared foods or dishes in which the\\nallergen is likely to occur, and careful questioning\\nabout ingredients when dining out. Use of a Medic-\\nAlert tag detailing drug allergies is vital to prevent\\ninadvertent administr ation during a medical\\nemergency.\\nPeople prone to anaphylaxis should carry an\\n‘‘Epi-pen’’ or ‘‘Ana-kit,’’ which contain an adrenaline\\ndose ready for injection.\\nResources\\nOTHER\\nThe Meck Page. February 20, 1998. .\\nRichard Robinson\\nAnemias\\nDefinition\\nAnemia is a condition characterized by abnor-\\nmally low levels of healthy red blood cells or hemoglo-\\nbin (the component of red blood cells that delivers\\noxygen to tissues throughout the body).\\nDescription\\nThe tissues of the human body need a regular\\nsupply of oxygen to stay healthy. Red blood cells,\\nwhich contain hemoglobin that allows them to deliver\\noxygen throughout the body, live for only about 120\\ndays. When they die, the iron they contain is returned\\nto the bone marrow and used to create new red blood\\ncells. Anemia develops when heavy bleeding causes\\nsignificant iron loss or when something happens to\\nslow down the production of red blood cells or to\\nincrease the rate at which they are destroyed.\\nTypes of anemia\\nAnemia can be mild, moderate, or severe enough\\nto lead to life-threatening complications. More than\\n400 different types of anemia have been identified.\\nMany of them are rare.\\nIRON DEFICIENCY ANEMIA. The onset of iron defi-\\nciency anemia is gradual and, at first, there may not be\\nany symptoms. The deficiency begins when the body\\nloses more iron than it derives from food and other\\nsources. Because depleted iron stores cannot meet the\\nred blood cell’s needs, fewer red blood cells develop. In\\nthis early stage of anemia, the red blood cells look\\nnormal, but they are reduced in number. Then the\\nbody tries to compensate for the iron deficiency by\\nproducing more red blood cells, which are character-\\nistically small in size. Symptoms develop at this stage.\\nFOLIC ACID DEFICIENCY ANEMIA. Folic acid ane-\\nmia is especially common in infants and teenagers.\\nAlthough this condition usually results from a dietary\\ndeficiency, it is sometimes due to inability to absorb\\nenough folic acid from such foods as:\\n/C15cheese\\n/C15eggs\\n/C15fish\\n/C15green vegetables\\n/C15meat\\n/C15milk\\n/C15mushrooms\\n/C15yeast\\n192 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Smoking raises the risk of developing this condi-\\ntion by interfering with the absorption of Vitamin C,\\nwhich the body needs to absorb folic acid. Folic acid\\nanemia can be a complication ofpregnancy, when a\\nwoman’s body needs eight times more folic acid than it\\ndoes otherwise.\\nVITAMIN B12 DEFICIENCY ANEMIA. Less common in\\nthis country than folic acid anemia, vitamin B12 defi-\\nciency anemia is another type of megaloblastic anemia\\nthat develops when the body doesn’t absorb enough of\\nthis nutrient. Necessary for the creation of red blood\\ncells, B\\n12 is found in meat and vegetables.\\nLarge amounts of B12 are stored in the body, so this\\ncondition may not become apparent until as much as\\nfour years after B\\n12 absorption stops or slows down. The\\nresulting drop in red blood cell production can cause:\\n/C15loss of muscle control\\n/C15loss of sensation in the legs, hands, and feet\\n/C15soreness or burning of the tongue\\n/C15weight loss\\n/C15yellow-blue color blindness\\nThe most common form of B12 deficiency isperni-\\ncious anemia. Since most people who eat meat or eggs\\nget enough B12 in theirdiets, a deficiency of this vita-\\nmin usually means that the body is not absorbing it\\nproperly. This can occur among people who have had\\nintestinal surgery or among those who do not produce\\nadequate amounts of intrinsic factor, a chemical\\nsecreted by the stomach lining that combines with\\nB\\n12 to help its absorption in the small intestine.\\nPernicious anemia usually strikes between the ages\\nof 50–60. Eating disorders or an unbalanced diet\\nincreasethe riskof developingperniciousanemia. Sodo:\\n/C15diabetes mellitus\\n/C15gastritis, stomach cancer, or stomach surgery\\n/C15thyroid disease\\n/C15family history of pernicious anemia\\nVITAMIN C DEFICIENCY ANEMIA. Ar a r ed i s o r d e r\\nthat causes the bone marrow to manufacture abnor-\\nmallysmall redblood cells, Vitamin C deficiencyanemia\\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, acceler-\\nating the destruction of red blood cells (hemolysis).\\nOther complications of hemolytic anemia include:\\n/C15pain\\n/C15shock\\n/C15gallstones and other serious health problems\\nTHALASSEMIAS. An inherited form of hemolytic\\nanemia, thalassemia stems from the body’s inability\\nto manufacture as much normal hemoglobin as it\\nneeds. There are two categories of thalassemia,\\ndepending on which of the amino acid chains is\\naffected. (Hemoglobin is composed of four chains of\\namino acids.) In alpha-thalassemia, there is an imbal-\\nance in the production of the alpha chain of amino\\nacids; in beta-thalassemia, there is an imbalance in the\\nbeta chain. Alpha-thalassemias most commonly affect\\nblacks (25% have at least one gene); beta-thalassemias\\nmost commonly affect people of Mediterranean ances-\\ntry and Southeast Asians.\\nKEY TERMS\\nAplastic— Exhibiting incomplete or faulty\\ndevelopment.\\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).\\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.\\n(Illustration by John Bavosi, Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 193\\nAnemias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Characterized by production of red blood cells\\nthat are unusually small and fragile, thalassemia only\\naffects people who inherit the gene for it from each\\nparent (autosomal recessive inheritance).\\nAUTOIMMUNE HEMOLYTIC ANEMIAS. Warm anti-\\nbody hemolytic anemia is the most common type of\\nthis disorder. This condition occurs when the body\\nproduces autoantibodies that coat red blood cells.\\nThe coated cells are destroyed by the spleen, liver, or\\nbone marrow.\\nWarm antibody hemolytic anemia is more com-\\nmon in women than in men. About one-third of\\npatients who have warm antibody hemolytic anemia\\nalso have lymphoma, leukemia, lupus, or connective\\ntissue disease.\\nIn cold antibody hemolytic anemia, the body\\nattacks red blood cells at or below normal body tem-\\nperature. The acute form of this condition frequently\\ndevelops in people who have hadpneumonia, mono-\\nneucleosis, or other acute infections. It tends to be\\nmild and short-lived, and disappears without\\ntreatment.\\nChronic cold antibody hemolytic anemia is most\\ncommon in women and most often affects those who\\nare over 40 and who have arthritis. This condition\\nusually lasts for a lifetime, generally causing few symp-\\ntoms. However, exposure to cold temperatures can\\naccelerate red blood cell destruction, causingfatigue,\\njoint aches, and discoloration of the arms and hands.\\nSICKLE CELL ANEMIA. Sickle cell anemia is a\\nchronic, incurable condition that causes the body to\\nproduce defective hemoglobin, which forces red blood\\ncells to assume an abnormal crescent shape. Unlike\\nnormal oval cells, fragile sickle cells can’t hold enough\\nhemoglobin to nourish body tissues. The deformed\\nshape makes it hard for sickle cells to pass through\\nnarrow blood vessels. When capillaries become\\nobstructed, a life-threatening condition called sickle\\ncell 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\\ncell gene from only one parent carries the sickle cell\\ntrait, but does not have the disease.\\nAPLASTIC ANEMIA. Sometimes curable by bone\\nmarrow transplant, but potentially fatal,aplastic ane-\\nmia is characterized by decreased production of red\\nand white blood cells and platelets (disc-shaped cells\\nthat allow the blood to clot). This disorder may be\\ninherited or acquired as a result of:\\n/C15recent severe illness\\n/C15long-term exposure to industrial chemicals\\n/C15use ofanticancer drugsand certain other medications\\nANEMIA OF CHRONIC DISEASE. Cancer, chronic\\ninfection or inflammation, and kidney andliver dis-\\nease often cause mild or moderate anemia. Chronic\\nliver failure generally produces the most severe symp-\\ntoms. People infected with the Humanimmunodefi-\\nciency virus (HIV) that causesAIDS often face severe\\nfatigue.\\nCauses and symptoms\\nAnemia is caused by bleeding, decreased red\\nblood cell production, or increased red blood cell\\ndestruction. Poor diet can contribute to vitamin defi-\\nciency and iron deficiency anemias in which fewer red\\nblood cells are produced. Hereditary disorders and\\ncertain diseases can cause increased blood cell destruc-\\ntion. However, excessive bleeding is the most common\\ncause of anemia, and the speed with which blood loss\\noccurs has a significant effect on the severity of symp-\\ntoms. Chronic blood loss is usually a consequence of:\\n/C15cancer\\n/C15gastrointestinal tumors\\n/C15diverticulosis\\n/C15polyposis\\n/C15heavy menstrual flow\\n/C15hemorrhoids\\n/C15nosebleeds\\n/C15stomach ulcers\\n/C15long-standing alcohol abuse\\nAcute blood loss is usually the result of:\\n/C15childbirth\\n/C15injury\\n/C15a ruptured blood vessel\\n/C15surgery\\nWhen a lot of blood is lost within a short time,\\nblood pressure and the amount of oxygen in the body\\ndrop suddenly.Heart failureand death can follow.\\nLoss of even one-third of the body’s blood volume\\nin the space of several hours can be fatal. More gra-\\ndual blood loss is less serious, because the body has\\ntime to create new red blood cells to replace those that\\nhave been lost.\\n194 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Symptoms\\nWeakness, fatigue, and a run-down feeling may be\\nsigns of mild anemia. Skin that is pasty or sallow, or\\nlack of color in the creases of the palm, gums, nail\\nbeds, or lining of the eyelids are other signs of anemia.\\nSomeone who is weak, tires easily, is often out of\\nbreath, and feels faint or dizzy may be severely anemic.\\nOther symptoms of anemia are:\\n/C15angina pectoris (chest pain, often accompanied by a\\nchoking sensation that provokes severeanxiety)\\n/C15cravings for ice, paint, or dirt\\n/C15headache\\n/C15inability to concentrate, memory loss\\n/C15inflammation of the mouth (stomatitis) or tongue\\n(glossitis)\\n/C15insomnia\\n/C15irregular heartbeat\\n/C15loss of appetite\\n/C15nails that are dry, brittle, or ridged\\n/C15rapid breathing\\n/C15sores in the mouth, throat, or rectum\\n/C15sweating\\n/C15swelling of the hands and feet\\n/C15thirst\\n/C15tinnitus (ringing in the ears)\\n/C15unexplained bleeding or bruising\\nIn pernicious anemia, the tongue feels unusually\\nslick. A patient with pernicious anemia may have:\\n/C15problems with movement or balance\\n/C15tingling in the hands and feet\\n/C15confusion, 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\\nhas been taking iron supplements develops:\\n/C15diarrhea\\n/C15cramps\\n/C15vomiting\\nDiagnosis\\nPersonal and family health history may suggest\\nthe presence of certain types of anemia. Laboratory\\ntests that measure the percentage of red blood cells or\\nthe amount of hemoglobin in the blood are used to\\nconfirm diagnosis and determine which type of anemia\\nis responsible for a patient’s symptoms. X rays and\\nexaminations of bone marrow may be used to identify\\nthe source of bleeding.\\nTreatment\\nAnemia due to nutritional deficiencies can usually\\nbe treated at home with iron supplements or self admi-\\nnistered injections of vitamin B\\n12. People with folic\\nacid anemia should take oral folic acid replacements.\\nVitamin C deficiency anemia can be cured by taking\\none vitamin C tablet a day.\\nSurgery may be necessary to treat anemia caused\\nby excessive loss of blood. Transfusions of red blood\\ncells may be used to accelerate production of red blood\\ncells.\\nMedication or surgery may also be necessary to\\ncontrol heavy menstrual flow, repair a bleeding ulcer,\\nor remove polyps (growths or nodules) from the\\nbowels.\\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\\nanemia involves regular eye examinations, immuni-\\nzations for pneumonia and infectious diseases, and\\nprompt treatment for sickle cell crises and infections\\nof any kind. Psychotherapy or counseling may help\\npatients deal with the emotional impact of this\\ncondition.\\nVITAMIN B12 DEFICIENCY ANEMIA. A life-long regi-\\nmen of B12 shots is necessary to control symptoms of\\npernicious anemia. The patient may be advised to limit\\nphysical activity until treatment restores strength and\\nbalance.\\nAPLASTIC ANEMIA. People who have aplastic ane-\\nmia are especially susceptible to infection. Treatment\\nfor aplastic anemia may involve blood transfusions\\nand bone marrow transplant to replace malfunction-\\ning cells with healthy ones.\\nANEMIA OF CHRONIC DISEASE. There is no specific\\ntreatment for anemia associated with chronic disease,\\nbut treating the underlying illness may alleviate this\\ncondition. Erythropoietin is a hormone that stimu-\\nlates production of red blood cells. It is sometimes\\nused to treat anemia fromkidney disease or cancer\\nchemotherapy. This type of anemia rarely becomes\\nsevere. If it does, transfusions or hormone treatments\\nGALE ENCYCLOPEDIA OF MEDICINE 195\\nAnemias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='to stimulate red blood cell production may be pre-\\nscribed. A working group met in 2004 to address the\\nspecific management of anemia in patients infected\\nwith HIV.\\nHEMOLYTIC ANEMIA. There is no specific treat-\\nment for cold-antibody hemolytic anemia. About\\none-third of patients with warm-antibody hemolytic\\nanemia respond well to large doses of intravenous and\\noral corticosteroids, which are gradually discontinued\\nas the patient’s condition improves. Patients with this\\ncondition who don’t respond to medical therapy must\\nhave the spleen surgically removed. This operation\\ncontrols anemia in about one-half of the patients on\\nwhom it’s performed. Immune-system suppressants\\nare prescribed for patients whose surgery is not\\nsuccessful.\\nSelf-care\\nAnyone who has anemia caused by poornutrition\\nshould modify his or her diet to include morevitamins,\\nminerals, and iron. Vitamin C can stimulate iron\\nabsorption. The following foods are also good sources\\nof iron:\\n/C15almonds\\n/C15broccoli\\n/C15dried beans\\n/C15dried fruits\\n/C15enriched breads and cereals\\n/C15lean red meat\\n/C15liver\\n/C15potatoes\\n/C15poultry\\n/C15rice\\n/C15shellfish\\n/C15tomatoes\\nBecause light and heat destroy folic acid, fruits\\nand vegetables should be eaten raw or cooked as little\\nas possible.\\nAlternative treatment\\nAs is the case in standard medical treatment, the\\ncause of the specific anemia will determine the alter-\\nnative treatment recommended. If the cause is a defi-\\nciency, for example iron deficiency, folic acid\\ndeficiency, B\\n12 deficiency, or vitamin C deficiency,\\nsupplementation is the treatment. For extensive\\nblood loss, the cause should be identified and cor-\\nrected. Other types of anemias should be addressed\\non a deep healing level with crisis intervention when\\nnecessary.\\nMany alternative therapies for iron-deficiency\\nanemia focus on adding iron-rich foods to the\\ndiet or on techniques to improve circulation and\\ndigestion. Iron supplementation, especially with\\niron citrate (less likely to cause constipation ), is\\nused by alternative practitioners. This can be given\\nin combination with herbs that are rich in iron.\\nSome examples of iron-ri ch herbs are dandelion\\n(Taraxacum officinale ), parsley ( Petroselinum\\ncrispum ), and nettle (Urtica dioica ). The homeo-\\npathic remedy ferrum phosphoricum can also be\\nhelpful.\\nAn iron-rich herbal tonic can also me made using\\nthe following recipe:\\n/C15soak 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/C15strain and simmer until the amount of liquid is\\nreduced to 1 cup\\n/C15remove from heat and add 1/2 cup black strap\\nmolasses, mixing well\\n/C15store in refrigerator; take 1 tsp-2 Tbsp daily\\nOther herbal remedies used to treat iron-\\ndeficiency anemia aim to improve the digestion.\\nGentian (Gentiana lutea ) is widely used in Europe to\\ntreat anemia and other nutritionally based disorders.\\nThe bitter qualities of gentian help stimulate the diges-\\ntive system, making iron and other nutrients more\\navailable for absorption. This bitter herb can be\\nbrewed into tea or purchased as an alcoholic extract\\n(tincture).\\nOther herbs recommended to promote digestion\\ninclude:\\n/C15anise (Pimpinella anisum )\\n/C15caraway (Carum carvi )\\n/C15cumin (Cuminum cyminum )\\n/C15linden (Tilia spp.)\\n/C15licorice (Glycyrrhiza glabra )\\nTraditional Chinese treatments for anemia\\ninclude:\\n/C15acupuncture to stimulate a weakened spleen\\n/C15asian ginseng (Panax ginseng ) to restore energy\\n/C15dong quai (Angelica sinensis ) to control heavy men-\\nstrual bleeding\\n/C15a mixture of dong quai and Chinese foxglove\\n(Rehmannia glutinosa ) to clear a sallow complexion\\n196 GALE ENCYCLOPEDIA OF MEDICINE\\nAnemias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prognosis\\nFolic-acid and iron-deficiency anemias\\nIt usually takes three to six weeks to correct folic\\nacid or iron deficiency anemia. Patients should con-\\ntinue taking supplements for another six months to\\nreplenish iron reserves. They should have periodic\\nblood tests to make sure the bleeding has stopped\\nand the anemia has not recurred.\\nPernicious anemia\\nAlthough pernicious anemia is considered incur-\\nable, regular B\\n12 shots will alleviate symptoms and\\nreverse complications. Some symptoms will disappear\\nalmost as soon 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,\\neffective treatments enable patients with this disease\\nto enjoy longer, more productive lives.\\nThalassemia\\nPeople with mild thalassemia (alpha thalassemia\\ntrait or beta thalassemia minor) lead normal lives and\\ndo not require treatment. Those with severe thalassemia\\nmay require bone marrow transplantation. Genetic ther-\\napy is is being investigated and may soon be available.\\nHemolytic anemia\\nAcquired hemolytic anemia can generally be\\ncured when 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\\na daily multivitamin can help prevent anemia.\\nMethods of preventing specific types of anemia\\ninclude:\\n/C15avoiding lengthy exposure to industrial chemicals\\nand drugs known to cause aplastic anemia\\n/C15not taking medication that has triggered hemolytic\\nanemia and not eating foods that have caused hemo-\\nlysis (breakdown of red blood cells)\\n/C15receiving regular B12 shots to prevent pernicious\\nanemia resulting from gastritis or stomach surgery\\nResources\\nPERIODICALS\\n‘‘Biopharmaceuitcal Company Announces Manufacturing\\nAgreement for Anemia Drug.’’Obesity, Wellness, &\\nFitness Week (September 4, 2004): 406.\\n‘‘Management Strategy for Anemia in HIV Infection\\nElucidated.’’ Immunotherapy Weekly (July 7, 2004): 75.\\nMaureen Haggerty\\nTeresa G. Odle\\nAnencephaly see Congenital brain defects\\nAnesthesia, general\\nDefinition\\nGeneral anesthesia is the induction of a state of\\nunconsciousness with the absence ofpain sensation\\nover the entire body, through the administration of\\nanesthetic drugs. It is used during certain medical and\\nsurgical procedures.\\nPurpose\\nGeneral anesthesia has many purposes including:\\n/C15pain relief (analgesia)\\n/C15blocking memory of the procedure (amnesia)\\n/C15producing unconsciousness\\n/C15inhibiting normal body reflexes to make surgery safe\\nand easier to perform\\n/C15relaxing the muscles of the body\\nDescription\\nAnesthesia performed with general anesthetics\\noccurs in four stages which may or may not be obser-\\nvable because they can occur very rapidly:\\n/C15Stage One: Analgesia. The patient experiences\\nanalgesia or a loss of pain sensation but remains\\nconscious and can carry on a conversation.\\n/C15Stage Two: Excitement. The patient may experience\\ndelirium or become violent. Blood pressure rises and\\nGALE ENCYCLOPEDIA OF MEDICINE 197\\nAnesthesia, general'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='becomes irregular, and breathing rate increases.\\nThis stage is typically bypassed by administering a\\nbarbiturate, such as sodium pentothal, before the\\nanesthesia.\\n/C15Stage Three: Surgical Anesthesia. During this stage,\\nthe skeletal muscles relax, and the patient’s breathing\\nbecomes regular. Eye movements slow, then stop,\\nand surgery can begin.\\n/C15Stage Four: MedullaryParalysis. This stage occurs if\\nthe respiratory centers in the medulla oblongata of\\nthe brain that control breathing and other vital func-\\ntions cease to function.Death can result if the patient\\ncannot be revived quickly. This stage should never be\\nreached. Careful control of the amounts of anes-\\nthetics administered 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 com-\\nbination of inhaled anesthetic gases and intravenous\\ndrugs are usually delivered during general anesthesia;\\nthis practice is called balanced anesthesia and is used\\nbecause it takes advantage of the beneficial effects of\\neach anesthetic agent to reach surgical anesthesia. If\\nnecessary, the extent of the anesthesia produced by\\ninhaling a general anesthetic can be rapidly modified\\nby adjusting the concentration of the anesthetic in the\\noxygen that is breathed by the patient. The degree of\\nanesthesia produced by an intravenously injected\\nanesthesic is fixed and cannot be changed as rapidly.\\nMost commonly, intravenous anesthetic agents are\\nused for induction of anesthesia and then followed\\nby inhaled anesthetic agents.\\nGeneral anesthesia works by altering the flow of\\nsodium molecules into nerve cells (neurons) through\\nthe cell membrane. Exactly how the anesthetic does\\nthis is not understood since the drug apparently does\\nANESTHETICS: HOW THEY WORK\\nType Name(s) Administered Affect\\nGeneral Halothane,\\nEnflurane\\nIsoflurane,\\nKetamine,\\nNitrous Oxide,\\nThiopental\\nIntravenously,\\nInhalation\\nProduces total\\nunconsciousness\\naffecting the entire\\nbody\\nRegional Mepivacaine,\\nChloroprocaine,\\nLidocaine\\nIntravenously Temporarily inter-\\nrupts transmission\\nof nerve impulses\\n(temperature,\\ntouch, pain) and\\nmotor functions in\\na large area to be\\ntreated; does not\\nproduce\\nunconsciousness\\nLocal Procaine,\\nLidocaine,\\nTetracaine,\\nBupivacaine\\nIntravenously Temporarily blocks\\ntransmission of\\nnerve impulses and\\nmotor functions in\\na specific area;\\ndoes not produce\\nunconsciousness\\nTopical Benzocaine,\\nLidocaine\\nDibucaine,\\nPramoxine,\\nButamben,\\nTetracaine\\nDemal\\n(Sprays,\\nDrope,\\nOintments,\\nCreams, Gels)\\nTemporarily blocks\\nnerve endings in\\nskin and mucous\\nmembranes; does\\nnot produce\\nunconsciousness\\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\\nor a loss of general sensation.\\nArrhythmia — Abnormal heart beat.\\nBarbiturate— A drug with hypnotic and sedative\\neffects.\\nCatatonia— Psychomotor disturbance character-\\nized by 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 pain.\\nHypoxia— Reduction of oxygensupply tothe tissues.\\nMalignant hyperthermia— A type of reaction\\n(probably with a genetic origin) that can occur\\nduring general anesthesia and in which the patient\\nexperiences a high fever, muscle rigidity, and irre-\\ngular heart 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 dia-\\nmeter of a passage or orifice, such as a blood vessel.\\n198 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, general'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='not bind to any receptor on the cell surface and does\\nnot seem to affect the release of chemicals that trans-\\nmit nerve impulses (neurotransmitters) from the nerve\\ncells. It is known, however, that when the sodium\\nmolecules do not get into the neurons, nerve impulses\\nare not generated and the brain becomes unconscious,\\ndoes not store memories, does not register pain\\nimpulses from other areas of the body, and does not\\ncontrol involuntary reflexes. Although anesthesia may\\nfeellike deep sleep,itisnotthe same. Insleep, someparts\\nof the brain speed up while others slow down. Under\\nanesthesia, the lossofconsciousnessismorewidespread.\\nWhen general anesthesia was first introduced in\\nmedical practice, ether and chloroform were inhaled\\nwith the physician manually covering the patient’s\\nmouth. Since then, general anesthesia has become much\\nmore sophisticated. During most surgical procedures,\\nanesthetic agents are now delivered and controlled by\\ncomputerized equipment that includes anesthetic gas\\nmonitoring as well as patient monitoring equipment.\\nAnesthesiologists are the physicians that specialize in\\nthe delivery of anesthetic agents. Currently used inhaled\\ngeneral anesthetics include halothane, enflurane, isoflur-\\nane, desfluorane, sevofluorane, and nitrous oxide.\\n/C15Halothane (Fluothane) is a powerful anesthetic and\\ncan easily be overadministered. This drug causes\\nunconsciousness but little pain relief so it is often\\nused with other agents to control pain. Very rarely,\\nit can be toxic to the liver in adults, causing death. It\\nalso has the potential for causing serious cardiac\\ndysrhythmias. Halothane has a pleasant odor, and\\nwas frequently the anesthetic of choice for use with\\nchildren, but since the introduction of sevofluorane\\nin the 1990s, halothane use has declined.\\n/C15Enflurane (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/C15Isoflurane (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/C15Desfluorane (Suprane) may increase the heart rate\\nand should not be used in patients withaortic valve\\nstenosis; however, it does not usually cause heart\\narrhythmias. Desflurane may cause coughing and exci-\\ntation during induction and is therefore used with\\nintravenous anesthetics for induction. Desflurane is\\nrapidly eliminated and awakening is therefore faster\\nthan with other inhaled agents.\\n/C15Sevofluorane (Ultane) m ay also cause increased\\nheart rate and should not be used in patients with\\nnarrowed aortic valve (stenosis); however, it does\\nnot usually cause heart arrhythmias. Unlike des-\\nfluorane, sevofluorane does not cause any coughing\\nor other related side effects, and can therefore be\\nused without intravenous agents for rapid induc-\\ntion. For this reason, sevofluorane is replacing\\nhalothane for induction in pediatric patients. Like\\ndesfluorane, this agent is rapidly eliminated and\\nallows rapid awakening.\\n/C15Nitrous oxide (laughing gas) is a weak anesthetic and\\nis used with other agents, such as thiopental, to\\nproduce surgical anesthesia. It has the fastest induc-\\ntion and recovery and is the safest because it does not\\nslow breathing or blood flow to the brain. However,\\nit diffuses rapidly into air-containing cavities and can\\nresult in a collapsed lung (pneumothorax) or lower\\nthe oxygen contents of tissues (hypoxia).\\nCommonly administered intravenous anesthetic\\nagents include ketamine, thiopental, opioids, and\\npropofol.\\n/C15Ketamine (Ketalar) affects the senses, and produces\\na dissociative anesthesia (catatonia, amnesia, analge-\\nsia) in which the patient may appear awake and\\nreactive, but cannot respond to sensory stimuli.\\nThese properties make it especially useful for use in\\ndeveloping countries and during warfare medical\\ntreatment. Ketamine is frequently used in pediatric\\npatients because anesthesia and analgesia can be\\nachieved with an intramuscular injection. It is also\\nused in high-risk geriatric patients and inshock cases,\\nbecause it also provides cardiac stimulation.\\n/C15Thiopental (Pentothal) is a barbiturate that induces\\na rapid hypnotic state of short duration. Because\\nthiopental is slowly metabolized by the liver, toxic\\naccumulation can occur; therefore, it should not be\\ncontinuously infused. Side effects includenausea and\\nvomiting upon awakening.\\n/C15Opioids include fentanyl, sufentanil, and alfentanil,\\nand are frequently used prior to anesthesia and sur-\\ngery as a sedative and analgesic, as well as a continu-\\nous infusion for primary anesthesia. Because opioids\\nrarely affect the cardiovascular system, they are par-\\nticularly useful for cardiac surgery and other high-\\nrisk cases. Opioids act directly on spinal cord recep-\\ntors, and are freqently used in epidurals for spinal\\nanesthesia. Side effects may include nausea and\\nvomiting, itching, and respiratory depression.\\nGALE ENCYCLOPEDIA OF MEDICINE 199\\nAnesthesia, general'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Propofol (Diprivan) is a nonbarbiturate hypnotic\\nagent and the most recently developed intravenous\\nanesthetic. Its rapid induction and short duration of\\naction are identical to thiopental, but recovery\\noccurs more quickly and with much less nausea and\\nvomiting. Also, propofol is rapidly metabolized in\\nthe liver and excreted in the urine, so it can be used\\nfor long durations of anesthesia, unlike thiopental.\\nHence, propofol is rapidly replacing thiopental as an\\nintravenous induction agent. It is used forgeneral\\nsurgery, cardiac surgery, neurosurgery, and pediatric\\nsurgery.\\nGeneral anesthetics are given only by anesthesio-\\nlogists, the medical professionals trained to use them.\\nThese specialists consider many factors, including a\\npatient’s age, weight, medication allergies, medical\\nhistory, and general health, when deciding which anes-\\nthetic or combination of anesthetics to use. General\\nanesthetics are usually inhaled through a mask or a\\nbreathing tube or injected into a vein, but are also\\nsometimes given rectally.\\nGeneralanesthesiaismuchsafertodaythanitwasin\\nthepast.Thisprogress isdue tofaster-actinganesthetics,\\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 includeheart\\nattack, stroke, brain damage, and death. Anyone\\nscheduled to undergo general anesthesia should thor-\\noughly discuss the benefits and risks with a physician.\\nThe risks of complications depend, in part, on a\\npatient’s age, sex, weight, allergies, general health,\\nand history of smoking, drinking alcohol, or drug\\nuse. Some of these risks can be minimized by ensuring\\nthat the physician and anesthesiologist are fully\\ninformed of the detailed health condition of the\\npatient, including any drugs that he or she may be\\nusing. Older people are especially sensitive to the\\neffects of certain anesthetics and may be more likely\\nto experience side effects from these drugs.\\nPatients who have had general anesthesia should\\nnot drink alcoholic beverages or take medication that\\nslow down the central nervous system (such asantihis-\\ntamines, sedatives, tranquilizers, sleep aids, certain pain\\nrelievers, muscle relaxants, and anti-seizure medica-\\ntion) for 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 tobarbituratesor general anesthetics\\nin the past should notify the doctor before having gen-\\neral anesthesia. In particular, people who have had\\nmalignant hyperthermia or whose family members\\nhave had malignant hyperthermia during or after\\nbeing given an anesthetic should inform the physician.\\nSigns of malignant hyperthermia include rapid, irregu-\\nlar heartbeat, breathing problems, very highfever,a n d\\nmuscle tightness or spasms. These symptoms can occur\\nfollowing the administration of general anesthesia\\nusing inhaled agents, especially halothane. In addition,\\nthe doctor should also be told about any allergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. The effects of anesthetics on preg-\\nnant women and fetuses vary, depending on the type\\nof drug. In general, giving large amounts of general\\nanesthetics to the mother during labor and delivery\\nmay make the baby sluggish after delivery. Pregnant\\nwomen should discuss the use of anesthetics during\\nlabor and delivery with their doctors. Pregnant women\\nwho may be given general anesthesia for other medical\\nprocedures should ensure that the treating physician is\\ninformed about thepregnancy.\\nBREASTFEEDING. Some general anesthetics pass\\ninto breast milk, but they have not been reported to\\ncause problems in nursing babies whose mothers were\\ngiven the drugs.\\nOTHER MEDICAL CONDITIONS. Before being given\\na general anesthetic, a patient who has any of the\\nfollowing conditions should inform his or her doctor:\\n/C15neurological conditions, such as epilepsy or stroke\\n/C15problems with the stomach or esophagus, such as\\nulcers orheartburn\\n/C15eating disorders\\n/C15loose teeth, dentures, bridgework\\n/C15heart disease or family history of heart problems\\n/C15lung diseases, such asemphysema or asthma\\n/C15history of smoking\\n/C15immune system diseases\\n200 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, general'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15arthritis or any other conditions that affect\\nmovement\\n/C15diseases 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 anesthe-\\nsia. Fuzzy thinking, blurred vision, and coordination\\nproblems are also possible. For these reasons, anyone\\nwho has had general anesthesia should not drive,\\noperate machinery, or perform other activities that\\ncould endanger themselves or others for at least 24\\nhours, or longer if necessary.\\nMost side effects usually disappear as the anes-\\nthetic wears off. A nurse or doctor should be notified if\\nthese or other side effects persist or cause problems,\\nsuch as:\\n/C15Headache\\n/C15vision problems, including blurred or double vision\\n/C15shivering or trembling\\n/C15muscle pain\\n/C15dizziness, lightheadedness, or faintness\\n/C15drowsiness\\n/C15mood or mental changes\\n/C15nausea or vomiting\\n/C15sore throat\\n/C15nightmares or unusual dreams\\nA doctor should be notified as soon as possible if\\nany of the following side effects occur within two\\nweeks of having general anesthesia:\\n/C15severe headache\\n/C15pain in the stomach or abdomen\\n/C15back or leg pain\\n/C15severe nausea\\n/C15black or bloody vomit\\n/C15unusual tiredness or weakness\\n/C15weakness in the wrist and fingers\\n/C15weight loss or loss of appetite\\n/C15increase or decrease in amount of urine\\n/C15pale skin\\n/C15yellow 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\\nanesthesia should inform the doctor about all other\\nmedication that he or she is taking. This includes pre-\\nscription drugs, nonprescription medicines, and street\\ndrugs. Serious and possibly life-threatening reactions\\nmay occur when general anesthetics are given to peo-\\nple who use street drugs, such ascocaine, marijuana,\\nphencyclidine (PCP or angel dust), amphetamines\\n(uppers), barbiturates (downers), heroin, or othernar-\\ncotics. Anyone who uses these drugs should make sure\\ntheir doctor or dentist knows what they have taken.\\nResources\\nBOOKS\\nDobson, Michael B.Anaesthesia at the District Hospital.\\n2nd ed. World Health Organization, 2000.\\nPERIODICALS\\nAdachi, Y.U., K. Watanabe, H. Higuchi, and T. Satoh.\\n‘‘The Determinants of Propofol Induction of\\nAnesthesia Dose.’’Anesthesia and Analgesia 92 (2001):\\n656-661.\\nOTHER\\nWenker, O. ‘‘Review of Currently Used Inhalation\\nAnesthetics Part I.’’ ‘‘The Internet Journal of\\nAnesthesiology.’’ 1999. .\\nJennifer Sisk\\nAnesthesia, local\\nDefinition\\nLocal or regional anesthesia involves the injection\\nor application of an anesthetic drug to a specific area\\nof the body, as opposed to the entire body and brain as\\noccurs duringgeneral anesthesia.\\nPurpose\\nLocal anesthetics are used to prevent patients\\nfrom feeling pain during medical, surgical, or dental\\nprocedures. Over-the-counter local anesthetics are\\nalso available to provide temporary relief from pain,\\nirritation, and itching caused by various conditions,\\nGALE ENCYCLOPEDIA OF MEDICINE 201\\nAnesthesia, local'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='such as cold sores,canker sores, sore throats,sunburn,\\ninsect bites, poison ivy, and minor cuts and scratches.\\nTypes of surgery or medical procedures that reg-\\nularly make use of local or regional anesthesia include\\nthe following:\\n/C15biopsies in which skin or tissue samples are taken for\\ndiagnostic procedures\\n/C15childbirth\\n/C15surgeries on the arms, hands, legs, or feet\\n/C15eye surgery\\n/C15surgeries involving the urinary tract or sexual organs\\nSurgeries involving the chest and abdomen are\\nusually performed under general anesthesia.\\nLocal and regional anesthesia have advantages\\nover general anesthesia in that patients can avoid\\nsome unpleasant side effects, can receive longer lasting\\npain relief, have reduced blood loss, and maintain a\\nsense of psychological comfort by not losing\\nconsciousness.\\nDescription\\nRegional anesthesia typically affects a larger area\\nthan local anesthesia, for example, everything below\\nthe waist. As a result, regional anesthesia may be used\\nfor more involved or complicated surgical or medical\\nprocedures. Regional anesthetics are injected. Local\\nanesthesia involves the injection into the skin or mus-\\ncle or application to the skin of an anesthetic directly\\nwhere pain will occur. Local anesthesia can be divided\\ninto four groups: injectable, topical, dental (non-\\ninjectable), and ophthalmic.\\nLocal and regional anesthesia work by altering the\\nflow of sodium molecules into nerve cells or neurons\\nthrough the cell membrane. Exactly how the anes-\\nthetic does this is not understood, since the drug\\napparently does not bind to any receptor on the cell\\nsurface and does not seem to affect the release of\\nchemicals that transmit nerve impulses (neurotrans-\\nmitters) from the nerve cells. It is known, however,\\nthat when the sodium molecules do not get into the\\nneurons, nerve impulses are not generated and pain\\nimpulses are not transmitted to the brain. The dura-\\ntion of action of an anesthetic depends on the type and\\namount of anesthetic administered.\\nRegional anesthesia\\nTypes of regional anesthesia include:\\n/C15Spinal anesthesia. Spinal anesthesia involves the\\ninjection of a small amount of local anesthetic\\ndirectly into the cerebrospinal fluid surrounding the\\nspinal cord (the subarachnoid space). Blood pressure\\ndrops are common but are easily treated.\\n/C15Epidural anesthesia. Epidural anesthesia involves\\nthe injection of a large volume of local anesthetic\\ndirectly into the space surrounding the spinal fluid\\nsac (the epidural space), not into the spinal fluid.\\nPain relief occurs more slowly but is less likely to\\nproduce blood pressure drops. Also, the block can be\\nmaintained for long periods, even days.\\n/C15Nerve blocks. Nerve blocks involve the injection of\\nan anesthetic into the area around a nerve that sup-\\nplies a particular region of the body, preventing the\\nnerve from carrying nerve impulses to the brain.\\nAnesthetics may be administered with another\\ndrug, such as epinephrine (adrenaline), which decreases\\nbleeding, and sodium bicarbonate to decrease the acid-\\nity of a drug so that it will work faster. In addition,\\ndrugs may be administered to help a patient remain\\ncalm and more comfortable or to make them sleepy.\\nLocal anesthesia\\nINJECTABLE LOCAL ANESTHETICS. These medicines\\nare given by injection to numb and provide pain relief\\nto some part of the body during surgery, dental pro-\\ncedures, or other medical procedures. They are given\\nonly by a trained health care professional and only in a\\ndoctor’s office or a hospital. Some commonly used\\ninjectable local anesthetics are procaine (Novocain),\\nlidocaine (Dalcaine, Dilocaine, L-Caine, Nervocaine,\\nKEY TERMS\\nCanker sore— A painful sore inside the mouth.\\nCold sore— A small blister on the lips or face,\\ncaused by a virus. Also called a fever blister.\\nEpidural space— The space surrounding the spinal\\nfluid sac.\\nMalignant hyperthermia— A type of reaction\\n(probably with a genetic basis) that can occur dur-\\ning general anesthesia in which the patient experi-\\nences a high fever, the muscles become rigid, and\\nthe heart rate and blood pressure fluctuate.\\nSubarachnoid space— The space surrounding the\\nspinal cord that is filled with cerebrospinal fluid.\\nTopical— Not ingested; applied to the outside of\\nthe body, for example to the skin, eye, or mouth.\\n202 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, local'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Xylocaine, and other brands), and tetracaine\\n(Pontocaine).\\nTOPICAL ANESTHETICS. Topical anesthetics, such\\nas benzocaine, lidocaine, dibucaine, pramoxine,\\nbutamben, and tetracaine, relieve pain and itching by\\ndeadening the nerve endings in the skin. They are\\ningredients in a variety of nonprescription products\\nthat are applied to the skin to relieve the discomfort of\\nsunburn, insect bites or stings, poison ivy, and minor\\ncuts, scratches, andburns. These products are sold as\\ncreams, ointments, sprays, lotions, and gels.\\nDENTAL ANESTHETICS (NON-INJECTABLE). Some\\nlocal anesthetics are intended for pain relief in the\\nmouth or throat. They may be used to relieve throat\\npain, teething pain, painful canker sores, toothaches,\\nor discomfort from dentures, braces, or bridgework.\\nSome dental anesthetics are available only with a doc-\\ntor’s prescription. Others may be purchased without a\\nprescription, including products such as Num-Zit,\\nOrajel, Chloraseptic lozenges, and Xylocaine.\\nOPHTHALMIC ANESTHETICS. Other local anes-\\nthetics are designed for use in the eye. The ophthalmic\\nanesthetics proparacaine and tetracaine are used to\\nnumb the eye before certain eye examinations. Eye\\ndoctors may also use these medicines before measur-\\ning eye pressure or removing stitches orforeign objects\\nfrom the eye. These drugs are to be given only by a\\ntrained health care professional.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nlocal anesthetic and the purpose for which it is being\\nused. When using a nonprescription local anesthetic,\\nfollow the directions on the package. Questions con-\\ncerning how to use a product should be referred to a\\nmedical doctor, dentist, or pharmacist.\\nPrecautions\\nPeople who strongly feel that they cannot psycho-\\nlogically cope with being awake and alert during cer-\\ntain procedures may not be good candidates for local\\nor regional anesthesia. Other medications may be\\ngiven in conjunction with the anesthetic, however, to\\nrelieve anxiety and help the patient relax.\\nLocal anesthetics should be used only for the con-\\nditions for which they are intended. For example, a\\ntopical anesthetic meant to relieve sunburn pain\\nshould not be used on cold sores. Anyone who has\\nhad an unusual reaction to any local anesthetic in the\\npast should check with a doctor before using any type\\nof local anesthetic again. The doctor should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nOlder people may be more sensitive to the effects\\nof local anesthetics, especially lidocaine. This\\nincreased sensitivity may increase the risk of side\\neffects. Older people who use nonprescription local\\nanesthetics should be especially careful not to use\\nmore than the recommended amount. Children also\\nmay be especially sensitive to the effects of some local\\nanesthetics, which may increase the chance of side\\neffects. Anyone using these medicines on a child\\nshould be careful not to use more than the amount\\nthat is recommended for children. Certain types of\\nlocal anesthetics should not be used at all young chil-\\ndren. Follow package directions carefully and check\\nwith a doctor of pharmacist if there are any questions.\\nRegional anesthetics\\nSerious, possibly life-threatening, side effects may\\noccur when anesthetics are given to people who use\\nstreet drugs. Anyone who uses cocaine, marijuana,\\namphetamines, barbiturates, phencyclidine (PCP, or\\nangel dust), heroin, or other street drugs should\\nmake sure their doctor or dentist knows what they\\nhave used.\\nPatients who have had a particular kind of reac-\\ntion called malignant hyperthermia (or who have one\\nor more family members who have had this problem)\\nduring or just after receiving a general anesthetic\\nshould inform their doctors before receiving any kind\\nof anesthetic. Signs of malignant hyperthermia include\\nfast and irregular heartbeat, very highfever, breathing\\nproblems, andmuscle spasmsor tightness.\\nAlthough problems are rare, some unwanted side\\neffects may occur when regional anesthetics are used\\nduring labor and delivery. These anesthetics can pro-\\nlong labor and increase the risk ofCesarean section.\\nPregnant women should discuss with their doctors the\\nrisks and benefits of being given these drugs.\\nPatients should not drive or operate other\\nmachinery immediately following a procedure invol-\\nving regional anesthesia, due tonumbness and weak-\\nness, or if local anesthesia also included drugs to make\\nthe patient sleep or strong pain medications. Injection\\nsites should be kept clean, dry, and uncovered to pre-\\nvent infection.\\nInjectable local anesthetics\\nUntil the anesthetic wears off, patients should be\\ncareful not to injure the numbed area. If the anesthetic\\nGALE ENCYCLOPEDIA OF MEDICINE 203\\nAnesthesia, local'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='was used in the mouth, do not eat or chew gum until\\nfeeling returns.\\nTopical anesthetics\\nUnless advised by a doctor, topical anesthetics\\nshould not be used on or near any part of the body\\nwith large sores, broken or scraped skin, severe injury,\\nor infection. They should also not be used on large\\nareas of skin. Some topical anesthetics contain alcohol\\nand should not be used near an open flame, or while\\nsmoking.\\nAnyone using a topical anesthetic should be care-\\nful not to get this medication in the eyes, nose, or\\nmouth. When using a spray form of this medication,\\ndo not spray it directly on the face, but apply it to the\\nface with a cotton swab or sterile gauze pad. After\\nusing a topical anesthetic on a child, make sure the\\nchild does not get the medicine in his or her mouth.\\nTopical anesthetics are intended for the tempor-\\nary relief of pain and itching. They should not be used\\nfor more than a few days at a time. Check with a\\ndoctor if:\\n/C15the discomfort continues for more than seven days\\n/C15the problem gets worse\\n/C15the treated area becomes infected\\n/C15new signs of irritation, such as skin rash, burning,\\nstinging, or swelling appear\\nDental anesthetics (non-injectable)\\nDental anesthetics should not be used if certain\\nkinds of infections are present. Check package direc-\\ntions or check with a dentist or medical doctor if\\nuncertain. Dental anesthetics should be used only for\\ntemporary pain relief. If problems such astoothache,\\nmouth sores, or pain from dentures or braces con-\\ntinue, check with a dentist. Check with a doctor if\\nsore throat pain is severe, lasts more than two days,\\nor is accompanied by other symptoms such as fever,\\nheadache, skin rash, swelling,nausea,o rvomiting.\\nPatients should not eat or chew gum while the\\nmouth is numb from a dental anesthetic. There is a\\nrisk of accidently biting the tongue or the inside of the\\nmouth. Also nothing should be eaten or drunk for one\\nhour after applying a dental anesthetic to the back of\\nthe mouth or throat, since the medicine may interfere\\nwith swallowing and may causechoking. If normal\\nfeeling does not return to the mouth within a few\\nhours after receiving a dental anesthetic or if it is\\ndifficult to open the mouth, check with a dentist.\\nOphthalmic anesthetics\\nWhen anesthetics are used in the eye, it is impor-\\ntant not to rub or wipe the eye until the effect of the\\nanesthetic has worn off and feeling has returned.\\nRubbing the eye while it is numb could cause injury.\\nSide effects\\nSide effects of regional or local anesthetics vary\\ndepending on the type of anesthetic used and the way it\\nis administered. Anyone who has unusual symptoms\\nfollowing the use of an anesthetic should get in touch\\nwith his or her doctor immediately.\\nThere is a small risk of developing a severe head-\\nache called a spinal headache following a spinal or\\nepidural block. This headache is severe when the\\npatient is upright and hardly felt when the patient\\nlies down. Though rare, it can occur and can be\\ntreated by performing a blood patch, in which a\\nsmall amount of the patient’s own blood is injected\\ninto the area in the back where the anesthetic was\\ninjected. The blood clots and closes up any area that\\nmay have been leaking spinal fluid. Relief is almost\\nimmediate. Finally, blood clots orabscess can form in\\nthe back, but these are also readily treatable and so\\npose little risk.\\nA physician should be notified immediately if any\\nof these symptoms occur:\\n/C15large swellings that look likehives on the skin, in the\\nmouth, or in the throat\\n/C15severe headache\\n/C15blurred or double vision\\n/C15dizziness or lightheadedness\\n/C15drowsiness\\n/C15confusion\\n/C15anxiety, excitement, nervousness, or restlessness\\n/C15convulsions (seizures)\\n/C15feeling hot, cold, or numb\\n/C15ringing or buzzing in the ears\\n/C15shivering or trembling\\n/C15sweating\\n/C15pale skin\\n/C15slow or irregular heartbeat\\n/C15breathing problems\\n/C15nusual weakness or tiredness\\n204 GALE ENCYCLOPEDIA OF MEDICINE\\nAnesthesia, local'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Interactions\\nSome anesthetic drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who receives a regional or\\nlocal anesthetic should let the doctor know all other\\ndrugs he or she is taking including prescription drugs,\\nnonprescription drugs, and street drugs (such as\\ncocaine, marijuana, and heroin).\\nResources\\nBOOKS\\nHarvey, Richard A., et al., editors. ‘‘Anesthetics.’’ In\\nLippincott’s Illustrated Reviews: Pharmacology.\\nPhiladelphia: J.B. Lippincott & Co., 1992.\\nNancy Ross-Flanigan\\nAneurysmectomy\\nDefinition\\nAneurysmectomy is a surgical procedure per-\\nformed to repair a weak area in the aorta. The aorta\\nis the largest artery in the body and the main blood\\nvessel leading away from the heart.\\nPurpose\\nThe purpose of aneurysmectomy is to repair an\\naortic aneurysmthat is likely to rupture if left in place.\\nAneurysmectomy is indicated for an aortic aneurysm\\nthat grows to at least 2 in(5 cm) or for an aortic\\naneurysm of any size that is symptomatic, tender, or\\nenlarging rapidly.\\nPrecautions\\nAneurysmectomy may not be appropriate for\\npatients with severely debilitating diseases such as\\ncancer, emphysema, andheart failure.\\nDescription\\nAn aortic aneurysm is a bulge in the wall of the\\naorta that is usually due to arteriosclerosis orathero-\\nsclerosis. People who are 50-80 years old are most\\nlikely to develop an aortic aneurysm, with men four\\ntimes more likely to develop one than women.\\nAn aortic aneurysm develops and grows slowly. It\\nrarely produces symptoms and is usually only diag-\\nnosed by accident during a routine physical exam or\\non an x ray or ultrasound done for another reason. As\\nthe aneurysm grows larger, the risk of bursting with no\\nwarning, which causes catastrophic bleeding, rises. A\\nruptured aortic aneurysm can cause sudden loss of a\\nfatal amount of blood within minutes or it can leak in\\na series of small bleeds that lead within hours or days\\nto massive bleeding. A leaking aortic aneurysm that is\\nnot treated is always fatal.\\nAneurysmectomy is performed to repair the two\\nmost common types of aortic aneurysms: abdominal\\naortic aneurysms that occur in the abdomen below\\nthe kidneys, and thoracic aortic aneurysms that occur\\nin the chest. It is major surgery performed in a hospital\\nunder general anesthesiaand involves removing debris\\nand then implanting a flexibletube (graft) to replace the\\nenlarged artery. Aneurysmectomy for an aneurysm of\\nthe ascending aorta (the firstpart of the aorta that travels\\nupward from the heart) requires the use of a heart-lung\\nmachine that temporarily stops the heart while the\\naneurysm is repaired. Aneurysmectomy requires a\\none-week hospital stay; the recovery period is five weeks.\\nDuring surgery, the site of the aneurysm (either\\nthe abdomen or the chest) is opened with an incision to\\nexpose the aneurysm. The aorta is clamped above and\\nbelow the aneurysm to stop the flow of blood. Then,\\nKEY TERMS\\nAneurysm— A weakening in the muscular walls of\\na part of the artery which causes the damaged\\nsection to enlarge or sag, giving it a balloon-like\\nappearance.\\nAorta— The main blood vessel that leads away\\nfrom the heart and the body’s largest artery. The\\naorta carries blood from the heart through the chest\\nand abdomen, providing major branches to all of\\nthe organs in the body.\\nArteriosclerosis— Hardening of the arteries that\\noccurs as part of the aging process.\\nArtery— A blood vessel that carries blood from the\\nheart to the body’s tissues.\\nAtherosclerosis— A form of arteriosclerosis in\\nwhich cholesterol-containing fatty deposits accu-\\nmulate in the inner most walls of the heart’s\\narteries.\\nThoracic— Relating to the chest.\\nGALE ENCYCLOPEDIA OF MEDICINE 205\\nAneurysmectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='an incision is made in the aneurysm. An artificial\\nDacron tube is sewn in place above and below the\\nopened aneurysm, but the aneurysm is not removed.\\nPlaque or clotted blood are cleaned from the diseased\\ntissue. The clamps are removed and blood flow is re-\\nestablished through the graft. The wall of the aneur-\\nysm is wrapped around the graft to protect it and the\\nskin of the abdomen or chest is sewn up.\\nAneurysmectomy can be performed as elective or\\nemergency surgery. Elective aneurysmectomy takes\\nabout an hour and is far safer than emergency aneur-\\nysmectomy, with a mortality rate of 3-5% for elective\\nabdominal aneurysmectomy and 5-10% for elective\\nthoracic aneurysmectomy. When an aneurysm\\nruptures, 62% of patients die before they reach the\\nhospital. Of those who make it into emergency aneur-\\nysmectromy, 50% die. After a successful aneurysmect-\\nomy, the patient has nearly the same life expectancy as\\nother people of the same age.\\nPreparation\\nBefore elective aneurysmectomy, blood studies, a\\nchest x ray, cardiac catherization, electrocardiogram\\n(ECG), and ultrasound are performed.\\nAftercare\\nAfter aneurysmectomy, the patient is monitored\\nin an Intensive Care Unit for the first 24–48 hours.\\nFollow-up tests include ECG, chest x ray, and\\nultrasound.\\nRisks\\nElective aneurysmectomy has a 5-10% rate of\\ncomplications, such as bleeding, kidney failure,\\nrespiratory complications,heart attack, stroke, infec-\\ntion, limb loss, bowelischemia, andimpotence. These\\ncomplications are many times more common in emer-\\ngency aneurysmectomy.\\nResources\\nPERIODICALS\\nDonaldson, M. C., M. Belkin, and A. D. Whittemore.\\n‘‘Mesenteric Revascularization During\\nAneurysmectomy.’’ Surgery Clinic of North America 77\\n(April 1997): 443-459.\\nLori De Milto\\nAneurysms see Aneurysmectomy; Cerebral\\naneurysm; Ventricular aneurysm\\nAngina\\nDefinition\\nAngina is pain, ‘‘discomfort,’’ or pressure loca-\\nlized in the chest that is caused by an insufficient\\nsupply of blood (ischemia) to the heart muscle. It is\\nalso sometimes characterized by a feeling ofchoking,\\nsuffocation, or crushing heaviness. This condition is\\nalso called angina pectoris.\\nDescription\\nOften described as a muscle spasm and choking\\nsensation, the term ‘‘angina’’ is used primarily to\\ndescribe chest (thoracic) pain originating from insuffi-\\ncient oxygen to the heart muscle. An episode of angina\\nis not an actualheart attack, but rather pain that results\\nfrom the heart muscle temporarily receiving too little\\nblood. This temporary condition may be the result of\\ndemanding activities such asexercise and does not\\nnecessarily indicate that the heart muscle is experienc-\\ning permanent damage. In fact, episodes of angina\\nseldom cause permanent damage to heart muscle.\\nAngina can be subdivided further into two cate-\\ngories: angina of effort and variant angina.\\nAngina of effort\\nAngina of effort is a common disorder caused by\\nthe narrowing of the arteries (atherosclerosis) that\\nsupply oxygen-rich blood to the heart muscle. In the\\ncase of angina of effort, the heart (coronary) arteries\\ncan provide the heart muscle (myocardium) adequate\\nblood during rest but not during periods of exercise,\\nstress, or excitement–any of which may precipitate\\npain. The pain is relieved by resting or by administer-\\ning nitroglycerin, a medication that reduces ischemia\\nof the heart. Patients with angina of effort have an\\nincreased risk of heart attack (myocardial infarction).\\nVariant angina\\nVariant angina is uncommon and occurs indepen-\\ndently of atherosclerosis which may, however, be pre-\\nsent as an incidental finding. Variant angina occurs at\\nrest and is not related to excessive work by the heart\\nmuscle. Research indicates that variant angina is\\ncaused by coronary artery muscle spasm of insufficient\\nduration or intensity to cause an actual heart attack.\\nCauses and symptoms\\nAngina causes a pressing pain or sensation of\\nheaviness, usually in the chest area under the breast\\n206 GALE ENCYCLOPEDIA OF MEDICINE\\nAngina'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='bone (sternum). It occasionally is experienced in the\\nshoulder, arm, neck, or jaw regions. Because episodes\\nof angina occur when the heart’s need for oxygen\\nincreases beyond the oxygen available from the\\nblood nourishing the heart, the condition is often pre-\\ncipitated by physical exertion. In most cases, the symp-\\ntoms are relieved within a few minutes by resting or by\\ntaking prescribed angina medications. Emotional\\nstress, extreme temperatures, heavy meals, cigarette\\nsmoking, and alcohol can also cause or contribute to\\nan episode of angina.\\nDiagnosis\\nPhysicians can usually diagnose angina based on\\nthe patient’s symptoms and the precipitating factors.\\nHowever, other diagnostic testing is often required to\\nconfirm or rule out angina, or to determine the sever-\\nity of the underlying heart disease.\\nElectrocardiogram (ECG)\\nAn electrocardiogram is a test that records elec-\\ntrical impulses from the heart. The resulting graph of\\nelectrical activity can show if the heart muscle isn’t\\nfunctioning properly as a result of a lack of oxygen.\\nElectrocardiograms are also useful in investigating\\nother possible abnormal features of the heart.\\nStress test\\nFor many individuals with angina, the results of\\nan electrocardiogram while at rest will not show any\\nabnormalities. Because the symptoms of angina occur\\nduring stress, the functioning of the heart may need to\\nbe evaluated under the physical stress of exercise. The\\nstress testrecords information from the electrocardio-\\ngram before, during, and after exercise in search of\\nstress-related abnormalities. Blood pressure is also\\nmeasured during the stress test and symptoms are\\nnoted. A more involved and complex stress test (for\\nexample, thallium scanning) may be used in some\\ncases to picture the blood flow in the heart muscle\\nduring the most intense time of exercise and after rest.\\nAngiogram\\nThe angiogram, which is basically an x ray of the\\ncoronary artery, has been noted to be the most accu-\\nrate diagnostic test to indicate the presence and extent\\nof coronary disease. In this procedure, a long, thin,\\nflexible tube (catheter) is maneuvered into an artery\\nlocated in the forearm or groin. This catheter is passed\\nfurther through the artery into one of the two major\\ncoronary arteries. A dye is injected at that time to help\\nthe x rays ‘‘see’’ the heart and arteries more clearly.\\nMany brief x rays are made to create a ‘‘movie’’ of\\nblood flowing through the coronary arteries, which\\nwill reveal any possible narrowing that causes a\\ndecrease in blood flow to the heart muscle and asso-\\nciated symptoms of angina.\\nTreatment\\nConservative treatment\\nArtery disease causing angina is addressed initi-\\nally by controlling existing factors placing the indivi-\\ndual at risk. These risk factors include cigarette\\nsmoking, high blood pressure,high cholesterollevels,\\nand obesity. Angina is often controlled by medication,\\nmost commonly with nitroglycerin. This drug relieves\\nsymptoms of angina by increasing the diameter of the\\nblood vessels carrying blood to the heart muscle.\\nNitroglycerin is taken whenever discomfort occurs or\\nis expected. It may be taken by mouth by placing the\\ntablet under the tongue or transdermally by placing a\\nmedicated patch directly on the skin. In addition,beta\\nblockers or calcium channel blockersmay be prescribed\\nto also decrease the demand on the heart by decreasing\\nthe rate and workload of the heart.\\nSurgical treatment\\nWhen conservative treatments are not effective in\\nthe reduction of angina pain and the risk of heart\\nattack remains high, physicians may recommend\\nangioplasty or surgery. Coronary artery bypass sur-\\ngery is an operation in which a blood vessel (often a\\nlong vein surgically removed from the leg) is grafted\\nonto the blocked artery to bypass the blocked portion.\\nThis newly formed pathway allows blood to flow ade-\\nquately to the heart muscle.\\nAnother procedure used to improve blood flow to\\nthe heart is balloon angioplasty. In this procedure, the\\nKEY TERMS\\nIschemia — Decreased blood supply to an organ or\\nbody part, often resulting in pain.\\nMyocardial infarction — A blockage of a coronary\\nartery that cuts off the blood supply to part of the\\nheart. In most cases, the blockage is caused by fatty\\ndeposits.\\nMyocardium — The thick middle layer of the heart\\nthat forms the bulk of the heart wall and contracts\\nas the organ beats.\\nGALE ENCYCLOPEDIA OF MEDICINE 207\\nAngina'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='physician inserts a catheter with a tiny balloon at the\\nend into a forearm or groin artery. The catheter is then\\nthreaded up into the coronary arteries and the balloon\\nis inflated to open the vessel in narrowed sections.\\nOther techniques using laser and mechanical devices\\nare being developed and applied, also by means of\\ncatheters.\\nAlternative treatment\\nDuring an angina episode, relief has been noted by\\napplying massage or kinesiological methods, but these\\ntechniques are not standard recommendations by phy-\\nsicians. For example, one technique places the palm\\nand fingers of either hand on the forehead while simul-\\ntaneously firmly massaging the sternum (breast bone)\\nup and down its entire length using the other hand.\\nThis is followed by additional massaging by the fin-\\ngertip and thumb next to the sternum, on each side.\\nOnce the angina has subsided, the cause should be\\ndetermined and treated. Atherosclerosis, a major asso-\\nciated cause, requires diet and lifestyle adjustments,\\nprimarily including regular exercise, reduction of diet-\\nary sugar and saturated fats, and increase of dietary\\nfiber. Both conventional and alternative medicine\\nagree that increasing exercise and improving diet are\\nimportant steps to reduce high cholesterol levels.\\nAlternative medicine has proposed specific choles-\\nterol-lowering treatments, with several gaining the\\nattention and interest of the public. One of the most\\nrecent popular treatments is garlic (Allium sativum ).\\nSome studies have shown that adequate dosages of\\ngarlic can reduce total cholesterol by about 10%,\\nLDL (bad) cholesterol by 15%, and raise HDL\\n(good) cholesterol by 10%. Other studies have not\\nshown significant benefit. Although its effect on cho-\\nlesterol is not as great as that achieved by medications,\\ngarlic may possibly be of benefit in relatively mild\\ncases of high cholesterol, without causing the side\\neffects associated with cholesterol-reducing drugs .\\nOther herbal remedies that may help lower cholesterol\\ninclude alfalfa ( Medicago sativa ), fenugreek\\n(Trigonella foenum-graecum ), Asian ginseng (Panax\\nginseng), and tumeric (Curcuma longa ).\\nAntioxidants, including vitamin A (beta carotene),\\nvitamin C, vitamin E, and selenium, can limit the oxi-\\ndative damage to the walls of blood vessels that may\\nbe a precursor of atherosclerotic plaque formation.\\nPrognosis\\nThe prognosis for a patient with angina depends\\non its origin, type, severity, and the general health of\\nthe individual. A person who has angina has the best\\nprognosis if he or she seeks prompt medical attention\\nand learns the pattern of his or her angina, such as\\nwhat causes the attacks, what they feel like, how long\\nepisodes usually last, and whether medication relieves\\nthe attacks. If patterns of the symptoms change sig-\\nnificantly, or if symptoms resemble those of a heart\\nattack, medical help should be sought immediately.\\nPrevention\\nIn most cases, the best prevention involves chan-\\nging one’s habits to avoid bringing on attacks of\\nangina. If blood pressure medication has been pre-\\nscribed, compliance is a necessity and should be a\\npriority as well. Many healthcare professionals–\\nincluding physicians, dietitians, and nurses–can pro-\\nvide valuable advice on proper diet, weight control,\\nblood cholesterol levels, and blood pressure. These\\nprofessionals also offer suggestions about current\\ntreatments and information to help stop smoking. In\\ngeneral, the majority of those with angina adjust their\\nlives to minimize episodes of angina, by taking neces-\\nsary precautions and using medications if recom-\\nmended and necessary.Coronary artery diseaseis the\\nunderlying problem that should be addressed.\\nResources\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nOTHER\\n‘‘Angina.’’ Healthtouch Online Page. Sepember 1997. [cited\\nMay 21, 1998]. .\\nJeffrey P. Larson, RPT\\nAngioedema see Hives\\nAngiogram see Angiography\\nAngiography\\nDefinition\\nAngiography is the x-ray study of the blood\\nvessels. An angiogram uses a radiopaque substance,\\nor dye, to make the blood vessels visible under x ray.\\nArteriography is a type of angiography that involves\\nthe study of the arteries.\\n208 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiography'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nAngiography is used to detect abnormalities or\\nblockages in the blood vessels (called occlusions)\\nthroughout the circulatorysystem and in some organs.\\nTheprocedureiscommonlyusedtoidentify atherosclero-\\nsis; to diagnose heart disease; to evaluate kidneyfunction\\nand detect kidney cysts or tumors; to detect an aneurysm\\n(an abnormal bulge of an artery that can rupture leading\\nto hemorrhage), tumor, blood clot, orarteriovenous mal-\\nformations (abnormals tangles of arteries and veins) in\\nthe brain; and to diagnose problems with the retina of the\\neye. It is also used to give surgeons an accurate ‘‘map’’ of\\ntheheart priortoopen-heart surgery,orofthebrainprior\\nto neurosurgery.\\nPrecautions\\nPatients withkidney diseaseor injury may suffer\\nfurther kidney damage from the contrast mediums\\nused for angiography. Patients who have blood clot-\\nting problems, have a known allergy to contrast med-\\niums, or are allergic to iodine, a component of some\\ncontrast mediums, may also not be suitable candidates\\nfor an angiography procedure. Because x rays carry\\nAn angiogram of a coronary artery.(Phototake NYC. Reproduced\\nby permission.)\\nKEY TERMS\\nArteriosclerosis— A chronic condition characterized\\nby thickening and hardening of the arteries and\\nthe build-up of plaque on the arterial walls.\\nArteriosclerosis can slow or impair blood circulation.\\nCarotid artery— An artery located in the neck.\\nCatheter— A long, thin, flexible tube used in angio-\\ngraphy to inject contrast material into the arteries.\\nCirrhosis— A condition characterized by the destruc-\\ntion of healthy liver tissue. A cirrhotic liver is scarred\\nand cannot break down the proteins in the blood-\\nstream.Cirrhosisisassociated with portalhypertension.\\nEmbolism— A blood clot, air bubble, or clot of foreign\\nmaterial that travels and blocks the flow of blood in an\\nartery. When blood supply to a tissue or organ is\\nblocked by an embolism, infarction, or death of the\\ntissue the artery feeds, occurs. Without immediate\\nand appropriate treatment, an embolism can be fatal.\\nFemoral artery— An artery located in the groin area\\nthat is the most frequently accessed site for arterial\\npuncture in angiography.\\nFluorescein dye— An orange dye used to illuminate the\\nblood vessels of the retina in fluorescein angiography.\\nFluoroscopic screen— A fluorescent screen which\\ndisplays ‘‘moving x-rays’’ of the body. Fluoroscopy\\nallows the radiologist to visualize the guide wire and\\ncatheter he is moving through the patient’s artery.\\nGuide wire— A wire that is inserted into an artery to\\nguides a catheter to a certain location in the body.\\nIscehmia— A lack of normal blood supply to a organ\\nor body part because of blockages or constriction of\\nthe blood vessels.\\nNecrosis— Cellular or tissue death; skin necrosis\\nmay be caused by multiple, consecutive doses of\\nradiation from fluoroscopic or x-ray procedures.\\nPlaque— Fatty material that is deposited on the\\ninside of the arterial wall.\\nPortal hypertension— A condition caused by cirrhosis\\nof the liver. It is characterized by impaired or reversed\\nblood flow from the portal vein to the liver, an enlarged\\nspleen, and dilated veins in the esophagus and stomach.\\nPortal vein thrombosis— The development of a\\nblood clot in the vein that brings blood into the\\nliver. Untreated portal vein thrombosis causes portal\\nhypertension.\\nGALE ENCYCLOPEDIA OF MEDICINE 209\\nAngiography'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='risks of ionizing radiation exposure to the fetus, preg-\\nnant women are also advised to avoid this procedure.\\nDescription\\nAngiography is usually performed at a hospital by\\na trained radiologist and assisting technician or nurse.\\nIt takes place in an x-ray or fluoroscopy suite, and for\\nmost types of angiograms, the patient’s vital signs will\\nbe monitored throughout the procedure.\\nAngiographyrequiresthe injectionofacontrastdye\\nthat makes the blood vessels visible to x ray. The dye is\\ninjectedthroughaprocedureknownas arterialpuncture.\\nThe puncture is usually made in the groin area, armpit,\\ninside elbow, or neck. The site is cleaned with an anti-\\nseptic agent and injected with a local anesthetic. First, a\\nsmall incision is made in the skin to help the needle pass.\\nA needle containing an inner wire called a stylet is\\ninserted through the skin into the artery. When the radi-\\nologist has punctured the artery with the needle, the\\nstylet is removed and replaced with another long wire\\ncalled a guide wire. It is normal for blood to spout out of\\nthe needle before the guide wire is inserted.\\nThe guide wire is fed through the outer needle into\\nthe artery and to the area that requires angiographic\\nstudy. A fluoroscopic screen that displays a view of the\\npatient’s vascular system is used to pilot the wire to the\\ncorrect location. Once it is in position, the needle is\\nremoved and a catheter is slid over the length of the\\nguide wire until it to reaches the area of study. The\\nguide wire is removed and the catheter is left in place in\\npreparation for the injection of the contrast medium,\\nor dye.\\nDepending on the type of angiography procedure\\nbeing performed, the contrast medium is either injected\\nby hand with a syringe or is mechanically injected with\\nan automatic injector connected to the catheter. An\\nautomatic injector is used frequently because it is able\\nto propel a large volume of dye very quickly to the\\nangiogram site. The patient is warned that the injection\\nwill start, and instructed to remain very still. The injec-\\ntion causes some mild to moderate discomfort. Possible\\nside effects or reactions includeheadache, dizziness,\\nirregular heartbeat, nausea, warmth, burning sensa-\\ntion, and chestpain, but they usually last only momen-\\ntarily. To view the area of study from different angles\\nor perspectives, the patient may be asked to change\\npositions several times, and subsequent dye injections\\nmay be administered. During any injection, the patient\\nor the camera may move.\\nThroughout the dye injection procedure, x-ray\\npictures and/or fluoroscopic pictures (or moving\\nx rays) will be taken. Because of the high pressure of\\narterial blood flow, the dye will dissipate through the\\npatient’s system quickly, so pictures must be taken in\\nrapid succession. An automatic film changer is used\\nbecause the manual changing of x-ray plates can eat up\\nvaluable time.\\nOnce the x rays are complete, the catheter is slowly\\nand carefully removed from the patient. Pressure is\\napplied to the site with a sandbag or other weight for\\n10-20 minutes in order for clotting to take place and\\nthe arterial puncture to reseal itself. A pressure ban-\\ndage is then applied.\\nMost angiograms follow the general procedures\\noutlined above, but vary slightly depending on the\\narea of the vascular system being studied. A variety\\nof common angiography procedures are outlined\\nbelow:\\nCerebral angiography\\nCerebral angiography is used to detect aneurysms,\\nblood clots, and other vascular irregularities in the\\nbrain. The catheter is inserted into the femoral or\\ncarotid artery and the injected contrast medium tra-\\nvels through the blood vessels on the brain. Patients\\nfrequently experience headache, warmth, or a burning\\nsensation in the head or neck during the injection\\nportion of the procedure. A cerebral angiogram\\ntakes two to four hours to complete.\\nCoronary angiography\\nCoronary angiography is administered by a car-\\ndiologist with training in radiology or, occasionally,\\nby a radiologist. The arterial puncture is typically\\ngiven in the femoral artery, and the cardiologist uses\\na guide wire and catheter to perform a contrast injec-\\ntion and x-ray series on the coronary arteries. The\\ncatheter may also be placed in the left ventricle to\\nexamine the mitral and aortic valves of the heart. If\\nthe cardiologist requires a view of the right ventricle of\\nthe heart or of the tricuspid or pulmonic valves, the\\ncatheter will be inserted through a large vein and\\nguided into the right ventricle. The catheter also serves\\nthe purpose of monitoring blood pressures in these\\ndifferent locations inside the heart. The angiogram\\nprocedure takes several hours, depending on the com-\\nplexity of the procedure.\\nPulmonary angiography\\nPulmonary, or lung, angiography is performed to\\nevaluate blood circulation to the lungs. It is also con-\\nsidered the most accurate diagnostic test for detecting\\na pulmonary embolism. The procedure differs from\\n210 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiography'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='cerebral and coronary angiograms in that the guide\\nwire and catheter are inserted into a vein instead of an\\nartery, and are guided up through the chambers of the\\nheart and into the pulmonary artery. Throughout the\\nprocedure, the patient’s vital signs are monitored to\\nensure that the catheter doesn’t causearrhythmias,o r\\nirregular heartbeats. The contrast medium is then\\ninjected into the pulmonary artery where it circulates\\nthrough the lung capillaries. The test typically takes up\\nto 90 minutes.\\nKidney angiography\\nPatients with chronic renal disease or injury can\\nsuffer further damage to their kidneys from the con-\\ntrast medium used in a kidney angiogram, yet they\\noften require the test to evaluate kidney function.\\nThese patients should be well-hydrated with a intrave-\\nnous saline drip before the procedure, and may benefit\\nfrom available medications (e.g., dopamine) that help\\nto protect the kidney from further injury due to con-\\ntrast agents. During a kidney angiogram, the guide\\nwire and catheter are inserted into the femoral artery\\nin the groin area and advanced through the abdominal\\naorta, the main artery in the abdomen, and into the\\nrenal arteries. The procedure will take approximately\\none hour.\\nFluorescein angiography\\nFluorescein angiography is used to diagnose ret-\\ninal problems and circulatory disorders. It is typically\\nconducted as an outpatient procedure. The patient’s\\npupils are dilated with eye drops and he rests his chin\\nand forehead against a bracing apparatus to keep it\\nstill. Sodium fluorescein dye is then injected with a\\nsyringe into a vein in the patient’s arm. The dye will\\ntravel through the patient’s body and into the blood\\nvessels of the eye. The procedure does not require\\nx rays. Instead, a rapid series of close-up photographs\\nof the patient’s eyes are taken, one set immediately\\nafter the dye is injected, and a second set approxi-\\nmately 20 minutes later once the dye has moved\\nthrough the patient’s vascular system. The entire\\nprocedure takes up to one hour.\\nCeliac and mesenteric angiography\\nCeliac and mesenteric angiography involves x-ray\\nexploration of the celiac and mesenteric arteries, arter-\\nial branches of the abdominal aorta that supply blood\\nto the abdomen and digestive system. The test is com-\\nmonly used to detect aneurysm, thrombosis, and signs\\nof ischemia in the celiac and mesenteric arteries, and to\\nlocate the source of gastrointestinal bleeding. It is also\\nused in the diagnosis of a number of conditions,\\nincluding portalhypertension, andcirrhosis. The pro-\\ncedure can take up to three hours, depending on the\\nnumber of blood vessels studied.\\nSplenoportography\\nA splenoportograph is a variation of an angio-\\ngram that involves the injection of contrast medium\\ndirectly into the spleen to view the splenic and portal\\nveins. It is used to diagnose blockages in the splenic\\nvein and portal vein thrombosis and to assess the\\nstrength and location of the vascular system prior to\\nliver transplantation.\\nMost angiography procedures are typically paid\\nfor by major medical insurance. Patients should check\\nwith their individual insurance plans to determine\\ntheir coverage.\\nPreparation\\nPatients undergoing an angiogram are advised to\\nstop eating and drinking eight hours prior to the pro-\\ncedure. They must remove all jewelry before the pro-\\ncedure and change into a hospital gown. If the arterial\\npuncture is to be made in the armpit or groin area,\\nshaving may be required. A sedative may be adminis-\\ntered to relax the patient for the procedure. An IV line\\nwill also be inserted into a vein in the patient’s arm\\nbefore the procedure begins in case medication or\\nblood products are required during the angiogram.\\nPrior to the angiography procedure, patients will\\nbe briefed on the details of the test, the benefits and\\nrisks, and the possible complications involved, and\\nasked to sign an informed consent form.\\nAftercare\\nBecause life-threatening internal bleeding is a pos-\\nsible complication of an arterial puncture, an over-\\nnight stay in the hospital is sometimes recommended\\nfollowing an angiography procedure, particularly with\\ncerebral and coronary angiograms. If the procedure is\\nperformed on an outpatient basis, the patient is typi-\\ncally kept under close observation for a period of at six\\nto 12 hours before being released. If the arterial punc-\\nture was performed in the femoral artery, the patient\\nwill be instructed to keep his leg straight and relatively\\nimmobile during the observation period. The patient’s\\nblood pressure and vital signs will be monitored and\\nthe puncture site observed closely. Pain medication\\nmay be prescribed if the patient is experiencing dis-\\ncomfort from the puncture, and a cold pack is applied\\nto the site to reduce swelling. It is normal for the\\nGALE ENCYCLOPEDIA OF MEDICINE 211\\nAngiography'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='puncture site to be sore and bruised for several weeks.\\nThe patient may also develop a hematoma, a hard\\nmass created by the blood vessels broken during the\\nprocedure. Hematomas should be watched carefully,\\nas they may indicate continued bleeding of the arterial\\npuncture site.\\nAngiography patients are also advised to enjoy\\ntwo to three days of rest and relaxation after the\\nprocedure in order to avoid placing any unduestress\\non the arterial puncture. Patients who experience con-\\ntinued bleeding or abnormal swelling of the puncture\\nsite, sudden dizziness, or chest pains in the days fol-\\nlowing an angiography procedure should seek medical\\nattention immediately.\\nPatients undergoing a fluorescein angiography\\nshould not drive or expose their eyes to direct sunlight\\nfor 12 hours following the procedure.\\nRisks\\nBecause angiography involves puncturing an\\nartery, internal bleeding or hemorrhage are possible\\ncomplications of the test. As with any invasive proce-\\ndure, infection of the puncture site or bloodstream is\\nalso a risk, but this is rare.\\nA stroke or heart attack may be triggered by an\\nangiogram if blood clots or plaque on the inside of the\\narterial wall are dislodged by the catheter and form a\\nblockage in the blood vessels or artery. The heart may\\nalso become irritated by the movement of the catheter\\nthrough its chambers during pulmonary and coronary\\nangiography procedures, and arrhythmias may develop.\\nPatients who develop an allergic reaction to the\\ncontrast medium used in angiography may experience\\na variety of symptoms, including swelling, difficulty\\nbreathing, heart failure, or a sudden drop in blood\\npressure. If the patient is aware of the allergy before\\nthe test is administered, certain medications can be\\nadministered at that time to counteract the reaction.\\nAngiography involves minor exposure to radia-\\ntion through the x rays and fluoroscopic guidance\\nused in the procedure. Unless the patient is pregnant,\\nor multiple radiological or fluoroscopic studies are\\nrequired, the small dose of radiation incurred during\\na single procedure poses little risk. However, multiple\\nstudies requiring fluoroscopic exposure that are con-\\nducted in a short time period have been known to\\ncause skin necrosis in some individuals. This risk can\\nbe minimized by careful monitoring and documenta-\\ntion of cumulative radiation doses administered to\\nthese patients.\\nNormal results\\nThe results of an angiogram or arteriogram\\ndepend on the artery or organ system being exam-\\nined. Generally, test results should display a normal\\nand unimpeded flow of blood through the vascular\\nsystem. Fluorescein angiography should result in no\\nleakage of fluorescein dye through the retinal blood\\nvessels.\\nAbnormal results\\nAbnormal results of an angiography may display\\na restricted blood vessel or arterial blood flow (ische-\\nmia) or an irregular placement or location of blood\\nvessels. The results of an angiography vary widely by\\nthe type of procedure performed, and should be inter-\\npreted and explained to the patient by a trained\\nradiologist.\\nResources\\nBOOKS\\nBaum, Stanley, and Michael J. Pentecost, editors.Abrams’\\nAngiography. 4th ed. Philadelphia: Lippincott-Raven,\\n1996.\\nPaula Anne Ford-Martin\\nAngiomas see Birthmarks\\nAngioplasty\\nDefinition\\nAngioplasty is a term describing a procedure used\\nto widen vessels narrowed by stenoses or occlusions.\\nThere are various types of these procedures and their\\nnames are associated with the type of vessel entry and\\nequipment used. For example, percutaneous trans-\\nluminal angioplasty (PTA) describes entry through\\nthe skin (percutaneous) and navigates to the area of\\nthe vessel of interest through the same vessel or one\\nthat communicates with it (transluminal). In the case\\nof a procedure involving the coronary arteries, the\\npoint of entry could be the femoral artery in the\\ngroin and the catheter/guidewire system is passed\\nthrough the aorta to the heart and the origin of the\\ncoronary arteries at the base of the aorta just outside\\nthe aortic valve.\\n212 GALE ENCYCLOPEDIA OF MEDICINE\\nAngioplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nIn individuals with an occulsive vascular disease\\nsuch asatherosclerosis, blood flow is impaired to an\\norgan (such as the heart) or to a distal body part ( such\\nas the lower leg) by the narrowing of the vessel’s lumen\\ndue to fatty deposits or calcium accumulation. This\\nnarrowing may occur in any vessel but may occur\\nanywhere. Once the vessel has been widened, adequate\\nblood flow is returned. The vessel may narrow again\\nover time at the same location and the procedure could\\nbe repeated.\\nPrecautions\\nAngioplasty procedures are performed on hos-\\npital inpatients in facilities for proper monitoring\\nand recovery. If the procedure is to be performed\\nin a coronary artery, the patient’s care is likely to\\nbe provided by specially trained physicians, nurses,\\nand vascular specialists. Typically, patients are\\ngiven anticoagulants prior to the procedure to\\nassist in the prevention of thromboses (blood clots).\\nAdministration of anticoagulants, however, may\\nimpede the sealing of the vascular entry point. The\\nprocedure will be performed using fluoroscopic gui-\\ndance and contrast media. Since the decision to per-\\nform angioplasty may have been made following a\\ndiagnostic angiogram, the patient’s sensitivity to iodi-\\nnated contrast media is likely to known. The proce-\\ndure may then require the use of non-ionic contrast\\nagents.\\nDescription\\nAngioplasty was originally performed by dilating\\nthe vessel with the introduction of larger and larger\\nstiff catheters through the narrowed space.\\nComplications of this procedure caused researchers\\nto develop means of widening the vessel using a mini-\\nmally sized device. Today, catheters contain balloons\\nthat are inflated to widen the vessel and stents to\\nprovide structural support for the vessel. Lasers may\\nbe used to assist in the break up of the fat or calcium\\nplaque. Catheters may also be equipped with spinning\\nwires or drill tips to clean out the plaque.\\nAngioplasty may be performed while the patient is\\nsedated or anesthetized, depending on the vessels\\ninvolved. If a percutaneous transluminal coronary\\nangioplasty (PTCA) is to be performed, the patient\\nBefore After\\nAngioplasty\\nGuidewire\\nInadequate\\nflow\\nPlaque\\nLumen\\nImproved\\nflow\\nInflated\\nballoon\\nIn balloon angioplasty, plaque is pushed out of the clogged artery by the inflation of the balloon device.(Illustration by Argosy Inc.)\\nKEY TERMS\\nplaque— In atherosclerosis, a swollen area in the\\nlining of an artery formed by fatty deposits.\\ncardiac catheterization— A procedure to pass a\\ncatheter to the heart and its vessels for the purpose\\nof diagnosing coronary artery disease, assessing injury\\nor disease of the aorta, or evaluating cardiac function.\\nEKG— Electrocardiogram, used to study and record\\nthe electrical activity of the heart.\\nGALE ENCYCLOPEDIA OF MEDICINE 213\\nAngioplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='will be kept awake to report on discomfort andcough\\nif required. PTCA procedures are performed incar-\\ndiac catheterizationlabs with sophisticated monitoring\\ndevices. If angioplasty is performed in the radiology\\ndepartment’s angiographic suite, the patient may be\\nsedated for the procedure and a nurse will monitor\\nthe patient’s vital signs during the procedure. If per-\\nformed by a vascular surgeon, the angioplasty proce-\\ndure will be performed in an operating room or\\nspecially designed vascular procedure suite.\\nThe site of the introduction of the angioplasty\\nequipment is prepared as a sterile surgical site.\\nAlthough many procedures are performed by punctur-\\ning the vessel through skin, many procedures are also\\nperformed by surgically exposing the site of entry.\\nDirect view of the vessel’s puncture site aids in mon-\\nitoring damage to the vessel or excessive bleeding at\\nthe site. Once the vessel is punctured and the guidewire\\nis introduced, fluoroscopy is used to monitor small\\ninjections of contrast media used to visualize the path\\nthrough the vessel. If the fluoroscopy system has a\\nfeature called ‘roadmap’, the amount of contrast\\nmedia injected will be greater in order to define the full\\nroute the guidewire will take. The fluoroscopy system\\nwill then superimpose subsequent images over the road-\\nmap while the vessel is traversed, that is, the physician\\nmoves the guidewire along the map to the destination.\\nHaving reached the area of stenosis, the physician\\nwill inflate the balloon on the catheter that has been\\npassed along the guidewire. Balloons are inflated in size\\nand duration depending on the size and location of the\\nv e s s e l .I ns o m ec a s e s ,t h eu s eo fas t e n t( am e s ho fw i r e\\nthat resembles a Chinese finger puzzle) may also be\\nused. The vessel may be widened before, during, or\\nafter the deployment of the stent. Procedures for deploy-\\ning stents are dependent on the type of stent used. In\\nc a s e sw h e r et h ev e s s e li st o r t u o u so ra ti n t e r s e c t i o n so f\\nvessels, the use of a graph may be necessary to provide\\nstructural strength to the vessel. Stents, graphs, and\\nballoon dilation may all be used together or separately.\\nThe procedure is verified using fluoroscopy and\\ncontrast media to produce an angiogram or by using\\nintravascular ultrasound or both. All equipment is\\nwithdrawn from the vessel and the puncture site\\nrepaired.\\nRisks\\nDuring the procedure there is a danger of punc-\\nturing the vessel with the guidewire. This is a very\\nsmall risk. Patients must be monitored for hematoma\\nor hemorrhage at the puncture site. There is also a\\nsmall risk of heart attack, emboli, and although\\nunlikely death. Hospitalization will vary in length by\\nthe patient’s overall condition, any complications, and\\navailability of home care.\\nResources\\nPERIODICALS\\n‘‘The angioplasty correct follow up strategy after stent\\nimplantation.’’ Heart 84, no. 4 (April, 2001): 363.\\nCarnall, Douglas. ‘‘Angioplasty.’’The Western Journal of\\nMedicine 173, no. 3 (September 2000): 201.\\n‘‘New Imaging Technique Could Improve Outcome of\\nPopular Heart Procedure.’’Heart Disease Weekly May\\n13, 2001: 3.\\n‘‘Success clearing clogged arteries.’’Science News 159, no. 5\\n(February 3, 2001): 72.\\nOTHER\\n‘‘Cardiovascular System’’ Miami Heart Research\\nInstitute 2001. [cited July 5, 2001]. .\\n‘‘Coronary angioplasty: Opening clogged arteries’’\\nMayoClinic.com, Condition Centers, Treatments and\\nTests. 2000. [cited July 5, 2001]. .\\n‘‘Heart American Heart Association online. 2000. [cited July\\n5, 2001]. .\\n‘‘STS Patient Information: What to Expect after your Heart\\nSurgery.’’ Society of Thoracic Surgeons online. 2000.\\n[cited July 5, 2001]. .\\n‘‘When you need to have Angioplast: A patient guide’’ Heart\\nInformation Network. 2000. [cited July 5, 2001].\\n.\\nElaine R. Proseus, MBA/TM, BSRT, RT(R)\\nAngiotensin-converting\\nenzyme inhibitors\\nDefinition\\nAngiotensin-converting enzyme inhibitors (also\\ncalled ACE inhibitors) are medicines that block the\\nconversion of the chemical angiotensin I to a substance\\nthat increases salt and water retention in the body.\\nPurpose\\nACE inhibitors are used in the treatment of high\\nblood pressure. They may be used alone or in combi-\\nnation with other medicines for high blood pressure.\\n214 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='They work by preventing a chemical in the blood,\\nangiotensin I, from being converted into a substance\\nthat increases salt and water retention in the body.\\nIncreased salt and water retention lead to high blood\\npressure. ACE inhibitors also make blood vessels\\nrelax, which helps lower blood pressure and allows\\nmore oxygen-rich blood to reach the heart.\\nTreating high blood pressure is important because\\nthe condition puts a burden on the heart and the\\narteries, which can lead to permanent damage over\\ntime. If untreated, high blood pressure increases the\\nrisk of heart attacks,heart failure, stroke, or kidney\\nfailure.\\nACE inhibitors may also be prescribed for other\\nconditions. For example, captopril (Capoten) is used\\nto treat kidney problems in people who take insulin to\\ncontrol diabetes. Captopril and lisinopril are also\\ngiven to some patients after aheart attack. Heart\\nattacks damage and weaken the heart muscle, and\\nthe damage continues even after a person recovers\\nfrom the attack. This medicine helps slow down\\nfurther damage to the heart. ACE inhibitors also\\nmay be used to treat congestive heart failure.\\nDescription\\nACE inhibitors are available only with a physi-\\ncian’s prescription and come in tablet, capsule, and\\ninjectable forms. Some commonly used ACE inhibi-\\ntors are benazepril (Lotensin), captopril (Capoten),\\nenalapril (Vasotec), fosinopril (Monopril), lisinopril\\n(Prinivil, Zestril), moexipril (Univasc), perindopril\\n(Aceon), quinapril (Accupril), ramipril (Altace) and\\ntrandolapril (Mavik).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nACE inhibitor and the medical condition for which\\nit is being taken. Check with the physician who\\nprescribed the drug or the pharmacist who filled the\\nprescription for the correct dosage.\\nThis medicine may take weeks to noticeably lower\\nblood pressure. Take it exactly as directed.\\nDo not stop taking this medicine without check-\\ning with the physician who prescribed it.\\nPrecautions\\nA person taking an ACE inhibitor should see a\\nphysician regularly. The physician will check the\\nblood pressure to make sure the medicine is working\\nas it should and will note any unwanted side effects.\\nPeople who have high blood pressure often feel per-\\nfectly fine. However, they should continue to see their\\nphysicians even when they feel well so that the physi-\\ncian can keep a close watch on their condition. It is\\nalso important for patients to keep taking their med-\\nicine even when they feel fine.\\nACE inhibitors will not cure high blood pressure,\\nbut will help control the condition. To avoid the ser-\\nious health problems that high blood pressure can\\ncause, patients may have to take medicine for the rest\\nof their lives. Furthermore, medicine alone may not be\\nenough. Patients with high blood pressure may also\\nneed to avoid certain foods, such as salty snacks, and\\nkeep their weight under control. The health care pro-\\nfessional who is treating the condition can offer advice\\non what measures may be necessary. Patients being\\ntreated for high blood pressure should not change\\ntheir diets without consulting their physicians.\\nAnyone taking this medicine for high blood pres-\\nsure should not take any other prescription or over-\\nthe-counter (OTC) medicine without first checking\\nwith his or her physician. Some medicines, such as\\ncertain cold remedies, may increase blood pressure.\\nSome people feel dizzy or lightheaded after taking\\nthe first dose of an ACE inhibitor, especially if they\\nhave been taking a water pill (diuretic). Anyone who\\ntakes these drugs should not drive, use machines or do\\nKEY TERMS\\nArteries— Blood vessels that carry blood away from\\nthe heart to the cells, tissues, and organs of the\\nbody.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gradu-\\nally and involve slow changes.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nFetus— A developing baby inside the womb.\\nScleroderma— A disease that first affects the skin\\nand later affects certain internal organs. The first\\nsymptoms are the hardening, thickening, and\\nshrinking of the skin.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease that affects the skin, joints, and certain\\ninternal organs.\\nVenom— A poisonous substance secreted by an\\nanimal, usually delivered through a bite or a sting.\\nGALE ENCYCLOPEDIA OF MEDICINE 215\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='anything else that might be dangerous until they have\\nfound out how the drugs affect them. Such symptoms\\nshould be reported to the physician or pharmacist if\\nthey do not subside within a day or so. For the first one\\nor two days of taking an ACE inhibitor, patients may\\nbecome lightheaded when arising from bed in the\\nmorning. Patienst should rise slowly to a sitting posi-\\ntion before standing up.\\nWhile a goal of treatment with an ACE inhibitor\\nis to lower the blood pressure, patients must be careful\\nnot to let their blood pressure get too low. Low blood\\npressure can lead to dizziness, lightheadedness and\\nfainting. To prevent the blood pressure from getting\\ntoo low, observe these precautions:\\n/C15Do not drink alcohol without checking with the\\nphysician who prescribed this medicine.\\n/C15Captopril and moexipril should be taken one hour\\nbefore meals. Other ACE inhinbitors may be taken\\nwith or without meals.\\n/C15Avoid overheating when exercising or in hot\\nweather. The loss of water from the body through\\nheavy sweating can cause low blood pressure.\\n/C15Check with a physician right away if illness occurs\\nwhile taking an ACE inhibitor. This is especially true\\nif the illness involves severenausea, vomiting,o rdiar-\\nrhea. Vomiting and diarrhea can cause the loss of too\\nmuch water from the body, which can lead to low\\nblood pressure.\\nAnyone who is taking ACE inhibitors should be\\nsure to tell the health care professional in charge\\nbefore having any surgical or dental procedures or\\nreceiving emergency treatment.\\nSome ACE inhibitors may change the results of\\ncertain medical tests, such as blood or urine tests.\\nBefore having medical tests, anyone taking this medi-\\ncine should alert the health care professional in charge.\\nDo not use a potassium supplement or a salt sub-\\nstitute that contains potassium without first checking\\nwith the physician who prescribed the ACE inhibitor.\\nPatients who are being treated with bee or wasp\\nvenom to prevent allergic reactions to stings may have\\na severe allergic reaction to certain ACE inhibitors.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take ACE inhibitors. Before taking these drugs,\\nbe sure to let the physician know about any of these\\nconditions.\\nALLERGIES. Anyone who has had unusual reac-\\ntions to an ACE inhibitor in the past should let his\\nor her physician know before taking this type of med-\\nicine again. The physician should also be told about\\nany allergies to foods, dyes, preservatives, or other\\nsubstances.\\nPREGNANCY. The use of ACE inhibitors inpreg-\\nnancy can cause serious problems and evendeath in the\\nfetus or newborn. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians before using this medicine. Women who become\\npregnant while taking this medicine should check with\\ntheir physicians immediately.\\nBREASTFEEDING. Some ACE inhibitors pass into\\nbreast milk. Women who are breastfeeding should\\ncheck with their physicians before using ACE\\ninhibitors.\\nOTHER MEDICAL CONDITIONS. Before using ACE\\ninhibitors, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15diabetes\\n/C15heart or blood vessel disease\\n/C15recent heart attack or stroke\\n/C15liver disease\\n/C15kidney disease\\n/C15kidney transplant\\n/C15scleroderma\\n/C15systemic lupus erythematosus (SLE)\\nUSE OF CERTAIN MEDICINES. Taking ACE inhibi-\\ntors with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side\\neffects.\\nSide effects\\nThe most common side effect is a dry, continuing\\ncough. This usually does not subside unless the medi-\\ncation is stopped. Ask the physician if the cough can\\nbe treated. Less common side effects, such ashead-\\nache, loss of taste, unusual tiredness, and nausea or\\ndiarrhea also may occur and do not need medical\\nattention unless they are severe or they interfere with\\nnormal activities.\\nMore serious side effects are rare, but may occur.\\nIf any of the following side effects occur, check with a\\nphysician immediately:\\n/C15swelling of the face, lips, tongue, throat, arms, legs,\\nhands, or feet\\n216 GALE ENCYCLOPEDIA OF MEDICINE\\nAngiotensin-converting enzyme inhibitors'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15itchy skin\\n/C15sudden breathing or swallowing problems\\n/C15chest pain\\n/C15hoarseness\\n/C15sore throat\\n/C15fever and chills\\n/C15stomach pain\\n/C15yellow eyes or skin\\nIn addition, anyone who has any of the follow-\\ning symptoms while taking an ACE inhibitor\\nshould check with his or her physician as soon as\\npossible:\\n/C15dizziness, lightheadedness, fainting\\n/C15confusion\\n/C15nervousness\\n/C15fever\\n/C15joint pain\\n/C15numbness ortingling in hands, feet, or lips\\n/C15weak or heavy feeling in the legs\\n/C15skin rash\\n/C15irregular heartbeat\\n/C15shortness of breath or other breathing problems\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking an ACE inhibitor\\nshould get in touch with his or her physician.\\nInteractions\\nACE inhibitors may interact with certain foods\\nand other medicines. For example, captopril\\n(Capoten) interacts with food and should be taken\\none hour before meals. Anyone who takes ACE inhi-\\nbitors should let the physician know all other medi-\\ncines he or she is taking and should ask about foods\\nthat should be avoided. Among the foods and drugs\\nthat may interact with ACE inhibitors are:\\n/C15water pills (diuretics)\\n/C15lithium, used to treat bipolar disorder\\n/C15tetracycline, an antibiotic\\n/C15medicines or supplements that contain potassium\\n/C15salt substitutes that contain potassium\\nThe list above may not include everything that\\ninteracts with ACE inhibitors. Be sure to check with\\na physician or pharmacist before combining ACE\\ninhibitors with any other prescription or nonprescrip-\\ntion (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAngiotensin-converting\\nenzyme test\\nDefinition\\nThis test measures blood levels of angiotensin-\\nconverting enzyme (ACE), also known as Serum\\nAngiotensin-Converting Enzyme (SASE). The pri-\\nmary function of ACE is to help regulate arterial\\npressure by converting angiotensin I to angiotensin II.\\nPurpose\\nThe ACE test is used primarily to detect and\\nmonitor the clinical course ofsarcoidosis (a disease\\nthat affects many organs, especially the lungs), to differ-\\nentiate between sarcoidosis and similar diseases, and to\\ndelineate between active and inactive sarcoid disease.\\nElevated ACE levels are also found in a number of\\nother conditions, including Gaucher’s disease (a rare\\nfamilial disorder of fat metabolism) andleprosy.\\nPrecautions\\nIt should be noted that people under 20 years of\\nage normally have very high ACE levels. Decreased\\nlevels may be seen in the condition of excess fat in the\\nblood (hyperlipidemia). Drugs that may cause\\ndecreased ACE levels include ACE inhibitor antihy-\\npertensives and steroids.\\nDescription\\nACE plays an important role in the renin/aldos-\\nterone mechanism which controls blood pressure by\\nconverting angiotensin I to angiotensin II, two pro-\\nteins involved in regulating blood pressure.\\nAngiotensin I by itself is inactive, but when converted\\nby ACE to the active form, angiotensin II, it causes\\nnarrowing of the small blood vessels in tissues, result-\\ning in an increase in blood pressure. Angiotensin II\\nalso stimulates the hormone aldosterone, which causes\\nan increase in blood pressure. Certain kidney disor-\\nders increase the production of angiotensin II, another\\ncause ofhypertension. Despite the action of ACE on\\nblood pressure regulation, determination of this\\nGALE ENCYCLOPEDIA OF MEDICINE 217\\nAngiotensin-converting enzyme test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='enzyme is not very helpful in the evaluation of hyper-\\ntension (high blood pressure).\\nPreparation\\nDetermination of ACE levels requires a blood\\nsample. The patient need not befasting.\\nRisks\\nRisks for this test are minimal, but may include\\nslight bleeding from the puncture site, fainting or\\nfeeling lightheaded after venipuncture, or hematoma\\n(blood accumulating under the puncture site).\\nNormal results\\nNormal ranges for this test are laboratory-specific\\nbut can range from 8-57 U/ml for patients over\\n20 years of age.\\nAbnormal results\\nSerum ACE levels are elevated in approximately\\n80-90% of patients with active sarcoidosis. Thyroid hor-\\nmone may have an effect on ACE activity, as hypothyr-\\noid (low thyroid) patients, as well as patients with\\nanorexia nervosawithassociatedfindingsof hypothyroid-\\nism, may have low serum ACE activity. ACE can also be\\ndecreased in lungcancer(bronchogenic carcinoma).\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests. St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAnimal bite infections\\nDefinition\\nThe most common problem following an animal\\nbite is simple infection. The saliva of dogs, cats, ferrets,\\nand rabbits is known to contain a wide variety of\\nbacteria. According to one recent study, bacteria or\\nother pathogens show up in about 85 percent of bites.\\nWhen an animal bites, it can then transmit pathogens\\ninto the wound. These microorganisms may grow\\nwithin the wound and cause an infection. The conse-\\nquences of infection range from mild discomfort to\\nlife-threatening complications.\\nDescription\\nTwo to 4.5 million animal bites occur each year in\\nthe United States; about 1% of these bites require\\nhospitalization. Animal bites result in 334,000 emer-\\ngency room visits per year, which represents approxi-\\nmately 1% of all emergency hospital visits, at an\\nannual cost of $100 million dollars in health care\\nexpenses and lost income. Children are the most fre-\\nquent victims of dog bites, with 5–9 year-old boys\\nhaving the highest incidence. Men are more often\\nbitten by dogs than are women (3:1), whereas women\\nare more often bitten by cats (3:1).\\nDog bites make up 80–85% of all reported inci-\\ndents. Cats account for about 10% of reported bites,\\nand other animals (including hamsters, ferrets, rab-\\nbits, horses, raccoons, bats, skunks, and monkeys)\\nmake up the remaining 5–10%. Cat bites become\\ninfected more frequently than dog bites. A dog’s\\nmouth is rich in bacteria, but only 15–20% of dog\\nbites become infected. In contrast, approximately\\n30–50% of cat bites become infected.\\nMany factors contribute to the infection rates,\\nincluding the type of wound inflicted, the location of\\nthe wound, pre-existing health conditions in the bitten\\nperson, the extent of delay before treatment, patient\\ncompliance and the presence of a foreign body in the\\nwound. Dogs usually inflict crush injuries because\\nthey have rounded teeth and strong jaws; thus, the\\nbite of an adult dog can exert up to 200 pounds per\\nsquare inch of pressure. This pressure usually results in\\na crushing injury, causing damage to such deep struc-\\ntures as bones, blood vessels, tendons, muscles, and\\nnerves. The canine teeth in a dog’s mouth are also\\nsharp and strong, often inflicting lacerations. Cats,\\nwith their needle-like incisors and carnassial teeth,\\ntypically cause puncture wounds. Puncture wounds\\nappear innocuous on the surface, but the underlying\\ninjury goes deep. Cat teeth essentially inject bacteria\\ninto the bite, and the deep, narrow wound is difficult\\nto clean. Persons with impaired immunocompe-\\ntence—for example, individuals with HIV infec-\\ntion—are especially vulnerable to infection from cat\\nbites. Lastly, bites or stings from marine creatures\\nKEY TERMS\\nSarcoidosis— Sarcoidosis is a rare disease of\\nunknown cause in which inflammation occurs in\\nlymph nodes and other tissues throughout the\\nbody, usually the lungs, skin, liver, and eyes.\\n218 GALE ENCYCLOPEDIA OF MEDICINE\\nAnimal bite infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(sharks, rays, eels, etc.) require immediate medical\\nattention as these bites may contain disease organisms\\nunique to the ocean environment as well as causing\\nsevere loss of blood.\\nThe bacterial species most commonly found\\nin bite wounds include Pasteurella multocida ,\\nStaphylococcus aureus , Pseudomonas sp ,a n d\\nStreptococcus sp . P. multocida , the root cause of pas-\\nteurellosis, is especially prominent in cat bite infec-\\ntions. Other infectious diseases from animal bites\\ninclude cat-scratch disease, tetanus and rabies.\\nDoctors are increasingly aware of the importance\\nof checking animal bite wounds for anaerobic organ-\\nisms, which are microbes that can live and multiply in\\nthe absence of air or oxygen. A study published in 2003\\nreported that about two-thirds of animal bite wounds\\ncontain anaerobes. These organisms can produce such\\ncomplications as septic arthritis, tenosynovitis,menin-\\ngitis, and infections of the lymphatic system.\\nWith regard to the most common types of domes-\\ntic pets, it is useful to note that biting and other\\naggressive behavior has different causes in dogs and\\ncats. To some extent these differences are rooted in\\nThis snake breeder shows the scar from his surgery after he\\nwas bitten by a venomous West African Gabon viper. His arm\\nwas cut open in order to relieve swelling from the snake bite\\nin his middle finger. (Photograph by Joe Crocetta, AP/Wide\\nWorld Photo. Reproduced by permission.)\\nKEY TERMS\\nAnaerobic— Referring to an organism that can live\\nin the absence of air or oxygen. About two-thirds of\\nanimal bites are found to contain anaerobic dis-\\nease-producing organisms.\\nCanines— The two sharp teeth located next to the\\nfront incisor teeth in mammals that are used to grip\\nand tear.\\nCarnassials— The last upper premolar teeth in the\\nmouths of cats and other carnivores, adapted to\\nshear or puncture food. Carnassial teeth often\\ncause puncture wounds when a cat bites a human.\\nCulture— A laboratory procedure in which a sam-\\nple from a wound, the blood or other body fluid is\\nt a k e nf r o ma ni n f e c t e dp e r s o n .T h es a m p l ei sp l a c e d\\nin conditions under which bacteria can grow. If\\nbacteria grow, identification tests are done to deter-\\nmine the bacteria species causing the infection.\\nImmunocompetence— An individual’s ability to\\nfight off infection.\\nMicroorganisms— Microscopic organisms, such as\\nbacteria, viruses, algae and fungi.\\nPasteurellosis— A bacterial infection caused by\\nPasteurella multocida . Pasteurellosis is characte-\\nrized by inflammation around the wound site and\\nmay be accompanied by bacteria in the blood-\\nstream and infection in tissues and organs.\\nPathogen— Any disease-producing microorganism.\\nPostexposure prophylaxis (PEP)— Any treatment\\ngiven after exposure to a disease to try to prevent\\nthe disease from occurring. In the case of rabies, PEP\\ninvolves a series of vaccines given to an individual\\nwho has been bitten by an unknown animal or one\\nthat is potentially infected with the rabies virus.\\nTenosynovitis— Inflammation of the sheath of tis-\\nsue that surrounds a tendon. Tenosynovitis is a\\ncommon complication of animal bites containing\\nanaerobic bacteria.\\nZoonosis (plural, zoonoses)— Any disease of ani-\\nmals that can be transmitted to humans. Rabies is\\nan example of a zoonosis.\\nGALE ENCYCLOPEDIA OF MEDICINE 219\\nAnimal bite infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='divergent evolutionary pathways, but they have also\\nbeen influenced by human interference through selec-\\ntive breeding. Dogs were first domesticated by humans\\nas early as 10,000\\nB.C. for hunting and as guard or\\nattack dogs. Many species travel in packs or groups\\nin the wild, and many human fatalities resulting from\\ndog bites involve a large group of dogs attacking one\\nor two persons. In addition, dogs typically relate to\\nhumans according to a hierarchical model of domi-\\nnance and submission, and many of the techniques of\\ndog training are intended to teach the dog to respect\\nhuman authority. Certain breeds of dogs are much\\nmore likely to attack humans than others; those most\\noften involved in fatal attacks are pit bulls, Rottweilers,\\nGerman shepherds, huskies, and mastiffs. According to\\nthe Centers for Disease Control (CDC), there are\\nbetween 15 and 20 fatal dog attacks on humans in the\\nUnited States each year. There are several assessment\\nor evaluation scales that veterinarians or animal trai-\\nners can use to score individual or mixed-breed dogs\\nfor dominant or aggressive behavior.\\nUnlike dogs, cats were not domesticated until\\nabout 3000\\nB.C., and were important to ancient civili-\\nzations as rodent catchers and household companions\\nrather than as protectors or hunters of wild game.\\nBiologists classify cats as solitary predators rather\\nthan as pack or herd animals; as a result, cats do not\\nrelate to humans as authority figures in the same way\\nthat dogs do, and they do not form groups that attack\\nhumans when threatened or provoked. In addition,\\ndomestic cats have been selectively bred for appear-\\nance rather than for fierceness or aggression. Most cat\\nbites are the result of fear on the cat’s part (as when\\nbeing placed in a carrier for a trip to the vet) or a\\nphenomenon known as petting-induced aggression.\\nPetting-induced aggression is a behavior in which a\\ncat that has been apparently enjoying contact with a\\nhuman suddenly turns on the human and bites. This\\nbehavior appears to be more common in cats that had\\nno contact with humans during their first seven weeks\\nof life. In other cats, this type of aggression appears to\\nbe related to a hypersensitive nervous system; petting\\nor cuddling that was pleasurable to the cat for a few\\nseconds or minutes becomes irritating, and the cat\\nbites as a way of indicating that it has had enough.\\nIn older cats, petting-induced aggression is often a sign\\nthat the cat feelspain from touching or pressure on\\narthritic joints in its neck or back.\\nCauses and symptoms\\nThe most common sign of infection from an ani-\\nmal bite is inflammation. The skin around the wound\\nis red and feels warm, and the wound may exude pus.\\nNearby lymph glands may be swollen. Complications\\ncan arise if the infection is not treated and spreads into\\ndeeper structures or into the bloodstream. If the bite is\\ndeep or occurs on the hand or at a joint, complications\\nare more likely.\\nLive disease-causing bacteria within the blood-\\nstream and tissues cause complications far from the\\nwound site. Such complications include meningitis,\\nbrain abscesses, pneumonia and lung abscesses, and\\nheart infections, among others. These complications\\ncan be fatal. Deep bites or bites near joints can damage\\njoints and bones, causing inflammation of the bone\\nand bone marrow or septic arthritis.\\nCat-scratch disease is caused by Bartonella\\nhenselae, a bacterium that is carried in cat saliva;\\ninfection may be transmitted by a bite or scratch.\\nApproximately 22,000 cases are reported each year in\\nthe United States; worldwide, nine out of every\\n100,000 individuals become infected. More than 80%\\nof reported cases occur in persons under the age of 21.\\nThe disease is not normally severe in individuals with\\nhealthy immune systems. Symptoms may become ser-\\nious, however, in immunocompromised individuals,\\nsuch as those with acquired immune deficiency\\nsyndrome (AIDS) or those undergoingchemotherapy.\\nCommon symptoms include an inflamed sore in the\\narea of the bite or scratch, swollen lymph nodes,fever,\\nfatigue, and rash.\\nRabies is caused by a virus that is transmitted\\nthrough the bite of an animal that is already\\ninfected. It is classified as a zoonosis,w h i c hi sa\\nterm that refers to any disease of animals that can\\nbe transmitted to humans. More than 90% of animal\\nrabies cases occur in such wild animals as skunks,\\nbats, and raccoons, with such domestic animals as\\ndogs and cats accounting for fewer than 10% of\\ncases. The World Health Organization (WHO) esti-\\nmates that between 35,000 and 50,000 individuals\\nworldwide die each year as a result of rabies. The\\nhighest incidence of rabies occurs in Asia where, in\\n1997, over 33,000 deaths were noted, most occurring\\nin India. Rabies is nowadays rare in the United\\nStates, as a result of good animal control practices.\\nOnset is delayed, usually weeks to months after the\\nperson has been bitten. Early symptoms of rabies\\ninclude fever, headache, and flu-like symptoms.\\nThese progress to anxiety, hallucinations , muscle\\nspasms,p a r t i a lparalysis, fear of water (hydropho-\\nbia), and other neurological symptoms as the virus\\nspreads to the central nervous system. Medical treat-\\nment must be sought soon after exposure because\\ndeath invariably follows once the infection becomes\\nestablished.\\n220 GALE ENCYCLOPEDIA OF MEDICINE\\nAnimal bite infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Most deaths from rabies in the United States\\nresult from bat bites; the most recent victim was a\\n66-year-old man in California who died in September\\n2003 after failing to report a bat bite.\\nDiagnosis\\nA medical examination involves taking the history\\nof the injury and assessing the wound type and\\ndamage. Tetanus immunization and general health\\nstatus are checked. An x ray may be ordered to assess\\nbone damage and to check forforeign objects in the\\nwound. Wound cultures are done for infected bites if\\nthe victim is at high risk for complications or if the\\ninfection does not respond to treatment. Evaluation of\\npossible exposure to rabies is also important. A biting\\nanimal suspected of having rabies is usually appre-\\nhended, tested, and observed for a period of time for\\nevidence of pre-existing infection.\\nTreatment\\nTreatment depends on the wound type, its site,\\nand risk factors for infection. All wounds are\\ncleaned and disinfected as thoroughly as possible.\\nBites to the head and face usually receive sutures, as\\ndo severe lacerations elsewhere. Puncture wounds\\nare left open. Ifabscess formation occurs, the phy-\\nsician may perform an incision so as to drain the\\nabscess.\\nIf infection occurs, antibiotics are prescribed.\\nAntibiotics may also be used for infection preven-\\ntion. Since a single bite wound may contain many\\ndifferent types of bacteria, no single antibiotic is\\nalways effective. Commonly prescribed antibiotics\\nare penicillin or a combination of amoxicillin and\\nclavulanate potassium. Aztreonam has been\\nreported to be effective in treating infections caused\\nby P. multocida .\\nBecause rabies is caused by a virus, antibiotics\\nare not effective. In addition, as of 2003, there is no\\nknown cure for the disease once symptoms become\\napparent. It is therefore recommended that indivi-\\nduals with a high risk of contracting the disease\\n(veterinarians, animal handlers, some laboratory\\nworkers) receive preexposurevaccination. Individuals\\nbitten by an unknown or potentially rapid animal\\nshould receive postexposure vaccination, also called\\npostexposure prophylaxis (PEP). The PEP regimen\\nconsists of one dose of vaccine given at the initial visit\\nas well as one dose of human immune globulin.\\nAdditional doses of vaccine are given on days 3, 7, 14,\\nand 28.\\nPrognosis\\nOnce a bacterial infection is halted, the bite victim\\nusually recovers fully. There is no known cure for\\nrabies once symptoms become evident and death is\\nalmost certain. WHO reports that 114 rabies deaths\\noccurred in the Americas in 1997, with only four\\ndeaths occurring that year in the United States, thus\\nemphasizing the importance of good animal control\\npractice and postexposure prophylaxis.\\nPrevention\\nPreventing bites obviously prevents subsequent\\ninfections. With regard to domestic pets, parents\\nshould inform themselves about the aggression level\\nand other characteristics of a particular breed before\\nbringing a purebred pet dog into the family, and\\nconsider having a specific dog evaluated by a veter-\\ninarian or animal behaviorist before adopting it. In\\naddition, parents should make sure that the dog has\\nbeen neutered or spayed, since intact dogs of either\\nsex are more likely to bite than those that have been\\naltered. Cat bites can oftenbe prevented by learning\\nabout a cat’s body language and recognizing the signs\\nof petting-induced aggression. These include dilating\\npupils, a low growl, stiffening of the body, twitching\\nof the tail, and flattening the ears backward against\\nthe head.\\nChildren under 12 years of age are at a higher risk\\nfor bites due to their small size and their inexperience\\nwith animals; therefore, they should be supervised\\nwith animals and taught to act appropriately around\\nthem. In particular, children should be taught not to\\ntease a dog by pulling its fur or tail; to leave a dog\\nalone while it is eating; and to avoid running or\\nscreaming in the presence of a dog, as the animal is\\nmore likely to chase a moving object. Direct eye con-\\ntact with a threatening dog should be avoided, as the\\ndog may interpret that as aggression. It is best to\\nstand still if at all possible, with feet together and\\narms against the chest; most dogs will lose interest\\nin an object that is not moving, and will eventually go\\naway.\\nA wild animal that is unusually aggressive or\\nbehaving strangely (e.g. a raccoon or bat that is active\\nduring the daytime or is physically uncoordinated)\\nshould be avoided and reported to the local animal\\ncontrol authorities; it may be infected with the rabies\\nvirus. Wild animals should not be taken in as pets, and\\ngarbage or pet food that might attract wild animals\\nshould not be left outside the home or camp site.\\nPeople should also avoid trying to break up fights\\nbetween animals and should as a rule approach\\nGALE ENCYCLOPEDIA OF MEDICINE 221\\nAnimal bite infections'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='unknown cats and dogs very cautiously, especially on\\ntheir territory. Finally, animals should not be trained\\nto fight.\\nDomestic pets should be vaccinated against\\nrabies; people should cons ult a veterinarian for\\nadvice about the frequency of booster vaccinations\\nfor the area in which they live. In addition, people\\nwho are traveling to countries where rabies is ende-\\nmic should consider vaccination before leaving the\\nUnited States.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Central Nervous System Viral Diseases: Rabies\\n(Hydrophobia).’’ Section 13, Chapter 162 InThe Merck\\nManual of Diagnosis and Therapy. Whitehouse Station,\\nNJ: Merck Research Laboratories, 1999.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Infections of Bones and Joints.’’ Section 5, Chapter 54\\nIn The Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1999.\\nDodman, Nicholas H., DVM.If Only They Could Speak:\\nStories About Pets and Their People . New York and\\nLondon: W. W. Norton and Company, 2002. Contains\\nseveral useful appendices about aggression in various\\ndog breeds and a sample assessment form for evaluating\\na dog’s potential for biting.\\nGarvey, Michael S., DVM, Ann E. Hohenhaus, DVM,\\nKatherine A. Houpt, VMD, PhD, et al.The\\nVeterinarians’ Guide to Your Cat’s Symptoms . New\\nYork: Villard, 1999.\\nPERIODICALS\\nBrook, I. ‘‘Microbiology and Management of Human and\\nAnimal Bite Wound Infections.’’Primary Care 30\\n(March 2003): 25–39.\\nFooks, A. R., N. Johnson, S. M. Brookes, et al. ‘‘Risk\\nFactors Associated with Travel to Rabies Endemic\\nCountries.’’ Journal of Applied Microbiology 94,\\nSupplement (2003): 31S–36S.\\nGarcia Triana, M., M. A. Fernandez Echevarria, R. L.\\nAlvaro, et al. ‘‘Pasteurella multocida Tenosynovitis of\\nthe Hand: Sonographic Findings.’’Journal of Clinical\\nUltrasound 31 (March-April 2003): 159–162.\\n‘‘Human Death Associated with Bat Rabies—California,\\n2003.’’ Morbidity and Mortality Weekly Report 53\\n(January 23, 2004): 33–35.\\nLe Moal, G., C. Landron, G. Grollier, et al. ‘‘Meningitis Due\\nto Capnocytophaga canimorsus After Receipt of a Dog\\nBite: Case Report and Review of the Literature.’’Clinical\\nInfectious Diseases 36 (February 1, 2003): 42–46.\\nMessenger, S. L., J. S. Smith, L. A. Orciari, et al. ‘‘Emerging\\nPattern of Rabies Deaths and Increased Viral\\nInfectivity.’’ Emerging Infectious Diseases 9 (February\\n2003): 151–154.\\nPerkins, R. A., and S. S. Morgan. ‘‘Poisoning,\\nEnvenomation, and Trauma from Marine Creatures.’’\\nAmerican Family Physician 69 (February 15, 2004):\\n885–890.\\nSacks, Jeffrey J., MD, MPH, Leslie Sinclair, DVM, Julie\\nGilchrist, MD, et al. ‘‘Special Report: Breeds of Dogs\\nInvolved in Fatal Human Attacks in the United States\\nBetween 1979 and 1998.’’Journal of the American\\nVeterinary Medical Association 217 (September 15,\\n2000): 836–840.\\nWeiss, R. A. ‘‘Cross-Species Infections.’’Current Topics in\\nMicrobiology and Immunology 278 (2003): 47–71.\\nWinner, J. S., C. A. Gentry, L. J. Machado, and P. Cornea.\\n‘‘Aztreonam Treatment ofPasteurella multocida\\nCellulitis and Bacteremia.’’Annals of Pharmacotherapy\\n37 (March 2003): 392–394.\\nORGANIZATIONS\\nAmerican Academy of Emergency Medicine (AAEM). 555\\nEast Wells Street, Suite 1100, Milwaukee, WI 53202.\\n(800) 884-2236. Fax: (414) 276-3349. .\\nAmerican Veterinary Medical Association (AVMA). 1931\\nNorth Meacham Road, Suite 100, Schaumburg, IL\\n60173-4360. .\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nOTHER\\nNational Association of State Public Health Veterinarians,\\nInc. ‘‘Compendium of Animal Rabies Prevention and\\nControl, 2003.’’Morbidity and Mortality Weekly\\nReport Recommendations and Reports 52 (March 21,\\n2003) (RR-5): 1–6.\\n‘‘Rabies Situation and Trends.’’ Paris: World Health\\nOrganization. 2001. .\\nJulia Barrett\\nRebecca J. Frey, PhD\\nAnkylosing spondylitis\\nDefinition\\nAnkylosing spondylitis (AS) refers to inflamma-\\ntion of the joints in the spine. AS is also known as\\nrheumatoid spondylitis or Marie-Stru¨ mpell disease\\n(among other names).\\nDescription\\nA form of arthritis, AS is characterized by chronic\\ninflammation, causingpain and stiffness of the back,\\n222 GALE ENCYCLOPEDIA OF MEDICINE\\nAnkylosing spondylitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='progressing to the chest and neck. Eventually, the\\nwhole back may become curved and inflexible if the\\nbones fuse (this is known as ‘‘bamboo spine’’). AS is a\\nsystemic disorder that may involve multiple organs,\\nsuch as the:\\n/C15eye (causing an inflammation of the iris, or iritis)\\n/C15heart (causing aortic valve disease)\\n/C15lungs\\n/C15skin (causing a scaly skin condition, or psoriasis)\\n/C15gastrointestinal tract (causing inflammation within\\nthe small intestine, called ileitis, or inflammation of\\nthe large intestine, called colitis)\\nLess than 1% of the population has AS; however,\\n20% of AS sufferers have a relative with the disorder.\\nCauses and symptoms\\nGenetics play an important role in the disease, but\\nthe cause of AS is still unknown. More than 90% of\\npatients have a gene called HLA-B27, but only\\n10-15% of those who inherit the gene develop the\\ndisease. Symptoms of AS include:\\n/C15low back and hip pain and stiffness\\n/C15difficulty expanding the chest\\n/C15pain in the neck, shoulders, knees, and ankles\\n/C15low-grade fever\\n/C15fatigue\\n/C15weight loss\\nAS is seen most commonly in males 30 years old\\nand older. Initial symptoms are uncommon after\\nthe age of 30, although the diagnosis may not be\\nestablished until after that age. The incidence of AS\\nin Afro-Americans is about 25% of the incidence in\\nCaucasians.\\nDiagnosis\\nDoctors usually diagnose the disease simply by\\nthe patient’s report of pain and stiffness. Doctors\\nalso review spinal and pelvic x rays since involvement\\nof the hip and pelvic joints is common and may be the\\nfirst abnormality seen on the x ray. The doctor may\\nalso order a blood test to determine the presence of\\nHLA-B27 antigen. When a diagnosis is made, patients\\nmay be referred to a rheumatologist, a doctor who\\nspecializes in treating arthritis. Patients may also be\\nreferred to an orthopedic surgeon, a doctor who can\\nsurgically correct joint or bone disorders.\\nTreatment\\nPhysical therapists prescribe exercises to prevent a\\nstooped posture and breathing problems when\\nthe spine starts to fuse and ribs are affected. Back\\nbraces may be used to prevent continued deformity\\nof the spine and ribs. Only in severe cases of deformity\\nis surgery performed to straighten and realign the\\nspine, or to replace knee, shoulder, or hip joints.\\nAlternative treatment\\nTo reduce inflammation various herbal remedies,\\nincluding white willow (Salix alba ), yarrow (Achillea\\nmillefolium), and lobelia (Lobelia inflata ), may be\\nhelpful. Acupuncture, performed by a trained profes-\\nsional, has helped some patients manage their pain.\\nHomeopathic practitione rs may prescribe such\\nremedies as Bryonia and Rhus toxicodendron for\\npain relief.\\nPrognosis\\nThere is no cure for AS, and the course of the\\ndisease is unpredictable. Generally, AS progresses for\\nabout 10 years and then its progression levels off.\\nMost patients can lead normal lives with treatment\\nto control symptoms.\\nPrevention\\nThere is no known way to prevent AS.\\nResources\\nORGANIZATIONS\\nArthritis Foundation.1300 W. Peachtree St., Atlanta, GA\\n30309. (800) 283-7800. .\\nNational Institute of Arthritis and Musculoskeletal and Skin\\nDiseases Information Clearinghouse. 1 AMS Circle,\\nBethesda, MD 29892-3675. (301) 495-4484.\\nKEY TERMS\\nAnkylosing— When bones of a joint are fused, stiff,\\nor rigid.\\nHLA-B27— An antigen or protein marker on cells\\nthat may indicate ankylosing spondylitis.\\nImmune suppressing— Anything that reduces the\\nactivity of the immune system.\\nInflammation— A reaction of tissues to disease or\\ninjury, often associated with pain and swelling.\\nSpondylitis— An inflammation of the spine.\\nGALE ENCYCLOPEDIA OF MEDICINE 223\\nAnkylosing spondylitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Spondylitis Association of America. P.O. Box 5872,\\nSherman Oaks, CA 91413. (800) 777-8189.\\nOTHER\\nMatsen III, Frederick, ed. ‘‘Ankylosing Spondylitis.’’\\nUniversity of Washington Orthopaedics and Sports\\nMedicine. .\\nJeanine Barone, Physiologist\\nAnorectal abscess see Anorectal disorders\\nAnorectal disorders\\nDefinition\\nAnorectal disorders are a group of medical disor-\\nders that occur at the junction of the anal canal and the\\nrectum.\\nDescription\\nThe anal canal, also called the anus, is the opening\\nat the bottom end of the digestive tract and is a com-\\nbination of external skin and tissue from the digestive\\ntract. It has many sensory nerves and is sensitive to\\npain. The rectum is the last section of the digestive\\ntract and has a mucus layer as its inside surface. It\\nhas very few sensory nerves and is, therefore, relatively\\ninsensitive to pain. The anal canal has a ring of muscle,\\ncalled the anal sphincter, which keeps the anus closed.\\nThere are a number of different anorectal disorders.\\nCauses and symptoms\\nAn anal fissure is a tear in the lining of the anus\\nthat is usually caused by a hard bowel movement.\\nFissures are painful and bleed when the tissue is\\nstressed during bowel movements.\\nAnorectal abscesses are characterized by pus-\\nforming infections in the anorectal region. Painful\\nabscesses form under the skin.\\nAn anorectal fistula is an abnormal opening or\\nchannel from the anorectal area to another part of\\nthe body. Typically, the channel leads to pockets of\\nskin near the anus. When seen in infants, anorectal\\nfistulas are considered birth defects. These are seen\\nmore frequently in boys than in girls. Fistulas are\\nalso seen more frequently in people who have other\\ndiseases, including Crohn’s disease , tuberculosis,\\ncancer, and diverticulitis. Anorectal fistulas also\\noccur following anorectal abscesses or other injury\\nto the anal area. Fistulas are usually painful and\\ndischarge pus.\\nDiagnosis\\nDiagnosis is made by visual inspection of the skin\\naround the anus. Also, the doctor may probe the\\nrectum with a gloved finger. An anoscope is a short\\ninstrument that allows the physician to view the inside\\nof the anus. A proctoscope is a longer, rigid viewing\\ntube of approximately six to ten inches in length,\\nwhich may be used to look for anorectal disorders.\\nA sigmoidoscope is a longer, flexible tube, that\\nallows the physician to view up to about two feet of\\nthe inside of the large intestine. Tissue samples and\\nmaterial for microbial culture may be obtained during\\nthe examination.\\nTreatment\\nTreatment usually isn’t required for hemorrhoids.\\nMost hemorrhoids will heal if the patient takes stool\\nsofteners to relieve the constipation. Enlarged blood\\nvesselscanbeeliminatedbysurgeryiftheyareconsidered\\na severe problem. In the case of fissures, treatment\\ninvolves stool softeners that eliminatestress on the\\nfissureduring bowelmovements,which allows the fissure\\nto heal. If the fissure doesn’t heal, surgery is required.\\nTreatment for anorectal abscesses consists of cutting the\\nabscess and draining the pus. Fistulas are treated by\\nsurgery.The usual treatment for proctitis isantibiotics.\\nResources\\nBOOKS\\nBerkow, Robert, editor.Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nJohn T. Lohr, PhD\\nAnorectal fistula see Anorectal disorders\\nAnorexia nervosa\\nDefinition\\nAnorexia nervosa is an eating disorder character-\\nized by unrealistic fear of weight gain, self-starvation,\\nand conspicuous distortion of body image. The name\\ncomes from two Latin words that mean nervous\\ninability to eat. In females who have begun to\\n224 GALE ENCYCLOPEDIA OF MEDICINE\\nAnorexia nervosa'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='menstruate, anorexia nervosa is usually marked by\\namenorrhea, or skipping at least three menstrual peri-\\nods in a row. The fourth edition of theDiagnostic and\\nStatistical Manual of Mental Disorders ,o r DSM-IV\\n(1994), defines two subtypes of anorexia nervosa–a\\nrestricting type, characterized by strict dieting and\\nexercise without binge eating; and a binge-eating/pur-\\nging type, marked by episodes of compulsive eating\\nwith or without self-inducedvomiting and the use of\\nlaxatives or enemas. DSM-IV defines a binge as a\\ntime-limited (usually under two hours) episode of\\ncompulsive eating in which the individual consumes\\na significantly larger amount of food than most people\\nwould eat in similar circumstances.\\nDescription\\nAnorexia nervosa was not officially classified as a\\npsychiatric disorder until the third edition ofDSM in\\n1980. It is, however, a growing problem among ado-\\nlescent females. Its incidence in the United States has\\ndoubled since 1970. The rise in the number of reported\\ncases reflects a genuine increase in the number of\\npersons affected by the disorder, and not simply earlier\\nor more accurate diagnosis. Estimates of the incidence\\nof anorexia range between 0.5–1% of caucasian female\\nadolescents. Over 90% of patients diagnosed with the\\ndisorder as of 1998 are female. It was originally thought\\nthat only 5% of anorexics are male, but that estimate is\\nbeing revised upward. The peak age range for onset of\\nthe disorder is 14-18 years, although there are patients\\nwho develop anorexia as late as their 40s. In the 1970s\\nand 1980s, anorexia was regarded as a disorder of\\nupper- and middle-class women, but that generalization\\nis also changing. More recent studies indicate that\\nanorexia is increasingly common among women of all\\nraces and social classes in the United States.\\nAnorexia nervosa is a serious public health\\nproblem not only because of its rising incidence, but\\nalso because it has one of the highest mortality rates\\nof any psychiatric disorder. Moreover, the disorder\\nmay cause serious long-term health complications,\\nincluding congestive heart failure , sudden death,\\ngrowth retardation, dental problems, constipation,\\nstomach rupture, swelling of the salivary glands, ane-\\nmia and other abnormalities of the blood, loss of\\nkidney function, andosteoporosis.\\nCauses and symptoms\\nAnorexia is a disorder that results from the inter-\\naction of cultural and interpersonal as well as biologi-\\ncal factors. While the precise cause of the disease is not\\nknown, it has been linked to the following:\\nSocial influences\\nThe rising incidence of anorexia is thought to\\nreflect the present idealization of thinness as a badge\\nof upper-class status as well as of female beauty. In\\naddition, the increase in cases of anorexia includes\\n‘‘copycat’’ behavior, with some patients developing\\nthe disorder from imitating other girls.\\nThe onset of anorexia in adolescence is attributed\\nto a developmental crisis caused by girls’ changing\\nbodies coupled with society’s overemphasis on\\nwomen’s looks. The increasing influence of the mass\\nmedia in spreading and reinforcing gender stereotypes\\nhas also been noted.\\nOccupational goals\\nThe risk of developing anorexia is higher among\\nadolescents preparing for careers that require atten-\\ntion to weight and/or appearance. These high-risk\\ngroups include dancers, fashion models, professional\\nathletes (including gymnasts, skaters, long-distance\\nrunners, and jockeys), and actresses.\\nGenetic and biological influences\\nWomen whose biological mothers or sisters have\\nthe disorder appear to be at increased risk.\\nKEY TERMS\\nAmenorrhea— Absence of the menses in a female\\nwho has begun to have menstrual periods.\\nBinge eating— A pattern of eating marked by epi-\\nsodes of rapid consumption of large amounts of\\nfood; usually food that is high in calories.\\nBody dysmorphic disorder— A psychiatric disorder\\nmarked by preoccupation with an imagined physi-\\ncal defect.\\nHyperalimentation— A method of refeeding anor-\\nexics by infusing liquid nutrients and electrolytes\\ndirectly into central veins through a catheter.\\nLanugo— A soft, downy body hair that develops on\\nthe chest and arms of anorexic women.\\nPurging— The use of vomiting, diuretics, or laxatives\\nto clear the stomach and intestines after a binge.\\nRussell’s sign—Scraped or raw areas on the patient’s\\nknuckles, caused by self-induced vomiting.\\nSuperior mesenteric artery syndrome— A condi-\\ntion in which a person vomits after meals due to\\nblockage of the blood supply to the intestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 225\\nAnorexia nervosa'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Psychological factors\\nA number of theories have been advanced to\\nexplain the psychological aspects of the disorder. No\\nsingle explanation covers all cases. Anorexia nervosa\\nhas been interpreted as:\\n/C15A rejection of female sexual maturity. This rejection\\nis variously interpreted as a desire to remain a child,\\nor as a desire to resemble men as closely as possible.\\n/C15A reaction to sexualabuse or assault.\\n/C15A desire to appear as fragile and nonthreatening as\\npossible. This hypothesis reflects the idea that female\\npassivity and weakness are attractive to men.\\n/C15Overemphasis on control, autonomy, and indepen-\\ndence. Some anorexics come from achievement-\\noriented families that stress physical fitness and\\ndieting. Many anorexics are perfectionistic and\\n‘‘driven’’ about schoolwork and other matters in\\naddition to weight control.\\n/C15Evidence of family dysfunction. In some families, a\\ndaughter’s eating disorder serves as a distraction\\nfrom marital discord or other family tensions.\\n/C15Inability to interpret the body’s hunger signals accu-\\nrately due to early experiences of inappropriate\\nfeeding.\\nMale anorexics\\nAlthough anorexia nervosa is still considered a\\ndisorder that largely affects women, its incidence in\\nthe male population is rising. Less is known about the\\ncauses of anorexia in males, but some risk factors are\\nthe same as for females. These include certain occupa-\\ntional goals and increasing media emphasis on exter-\\nnal appearance in men. Moreover, homosexual males\\nare under pressure to conform to an ideal body weight\\nthat is about 20 pounds lighter than the standard\\n‘‘attractive’’ weight for heterosexual males.\\nDiagnosis\\nDiagnosis of anorexia nervosa is complicated by a\\nnumber of factors. One is that the disorder varies\\nsomewhat in severity from patient to patient. A second\\nfactor is denial, which is regarded as an early sign of\\nthe disorder. Most anorexics deny that they are ill and\\nare usually brought to treatment by a family member.\\nMost anorexics are diagnosed by pediatricians or\\nfamily practitioners. Anorexics develop emaciated\\nbodies, dry or yellowish skin, and abnormally low\\nblood pressure. There is usually a history of amenor-\\nrhea (failure to menstruate) in females, and sometimes\\nof abdominal pain, constipation, or lack of energy.\\nThe patient may feel chilly or have developed lanugo,\\na growth of downy body hair. If the patient has been\\nvomiting, she may have eroded tooth enamel or\\nRussell’s sign (scars on the back of the hand). The\\nsecond step in diagnosis is measurement of the\\npatient’s weight loss.DSM-IV specifies a weight loss\\nleading to a body weight 15% below normal, with\\nsome allowance for body build and weight history.\\nThe doctor will need to rule out other physical\\nconditions that can cause weight loss or vomiting\\nafter eating, including metabolic disorders, brain\\ntumors (especially hypothalamus and pituitary gland\\nlesions), diseases of the digestive tract, and a condition\\ncalled superior mesenteric artery syndrome. Persons\\nwith this condition sometimes vomit after meals\\nbecause the blood supply to the intestine is blocked.\\nThe doctor will usually order blood tests, an electro-\\ncardiogram, urinalysis, and bone densitometry (bone\\ndensity test) in order to exclude other diseases and to\\nassess the patient’s nutritional status.\\nThe doctor will also need to distinguish between\\nanorexia and other psychiatric disorders, including\\ndepression, schizophrenia, social phobia, obsessive-\\ncompulsive disorder, and body dysmorphic disorder.\\nTwo diagnostic tests that are often used are the\\nEating Attitudes Test (EAT) and the Eating Disorder\\nInventory (EDI).\\nTreatment\\nTreatment of anorexia nervosa includes both\\nshort- and long-term measures, and requires assessment\\nby dietitians and psychiatrists as well as medical specia-\\nlists. Therapy is often complicated by the patient’s\\nresistance or failure to carry out treatment plan.\\nHospital treatment\\nHospitalization is recommended for anorexics\\nwith any of the following characteristics:\\n/C15weight of 40% or more below normal; or weight loss\\nover a three-month period of more than 30 pounds\\n/C15severely disturbed metabolism\\n/C15severe binging and purging\\n/C15signs ofpsychosis\\n/C15severe depression or risk ofsuicide\\n/C15family in crisis\\nHospital treatment includes individual andgroup\\ntherapy as well as refeeding and monitoring of the\\npatient’s physical condition. Treatment usually\\n226 GALE ENCYCLOPEDIA OF MEDICINE\\nAnorexia nervosa'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='requires two to four months in the hospital. In extreme\\ncases, hospitalized patients may be force-fed through a\\ntube inserted in the nose (nasogastric tube) or by over-\\nfeeding (hyperalimentation techniques).\\nOutpatient treatment\\nAnorexics who are not severely malnourished can\\nbe treated by outpatient psychotherapy. The types of\\ntreatment recommended are supportive rather than\\ninsight-oriented, and include behavioral approaches\\nas well as individual or group therapy.Family therapy\\nis often recommended when the patient’s eating dis-\\norder is closely tied to family dysfunction. Self-help\\ngroups are often useful in helping anorexics find social\\nsupport and encouragement. Psychotherapy with\\nanorexics is a slow and difficult process; about 50%\\nof patients continue to have serious psychiatric pro-\\nblems after their weight has stabilized.\\nMedications\\nAnorexics have been treated with a variety of\\nmedications, including antidepressants, antianxiety\\ndrugs, selective serotonin reuptake inhibitors , and\\nlithium carbonate. The effectiveness of medications\\nin treatment regimens is still debated. However, at\\nleast one study of Prozac showed it helped the patient\\nmaintain weight gained while in the hospital.\\nPrognosis\\nFigures for long-term recovery vary from study to\\nstudy, but the most reliable estimates are that 40-60%\\nof anorexics will make a good physical and social\\nrecovery, and 75% will gain weight. The long-term\\nmortality rate for anorexia is estimated at around\\n10%, although some studies give a lower figure of\\n3-4%. The most frequent causes of death associated\\nwith anorexia are starvation, electrolyte imbalance,\\nheart failure, and suicide.\\nPrevention\\nShort of major long-term changes in the larger\\nsociety, the best strategy for prevention of anorexia\\nis the cultivation of healthy attitudes toward food,\\nweight control, and beauty (or body image) within\\nfamilies.\\nResources\\nBOOKS\\nBaron, Robert B. ‘‘Nutrition.’’ InCurrent Medical Diagnosis\\nand Treatment, 1998 , edited by Stephen McPhee, et al.,\\n37th ed. Stamford: Appleton & Lange, 1997.\\nORGANIZATIONS\\nAmerican Anorexia/Bulimia Association. 418 East 76th St.,\\nNew York, NY 10021. (212) 734-1114.\\nNational Institute of Mental Health Eating Disorders\\nProgram. Building 10, Room 3S231. 9000 Rockville\\nPike, Bethesda, MD 20892. (301) 496-1891.\\nRebecca J. Frey, PhD\\nAnoscopy\\nDefinition\\nAn anoscopy is an examination of the rectum in\\nwhich a small tube is inserted into the anus to screen,\\ndiagnose, and evaluate problems of the anus and anal\\ncanal.\\nPurpose\\nThis test may be ordered for the evaluation of\\nperianal or anal pain, hemorrhoids, rectal prolapse,\\ndigital rectal examinationthat shows a mass, perianal\\nabscess and condyloma (a wart-like growth). An ana-\\nscopy may be performed to check for abnormal open-\\nings between the anus and the skin, or anal fissures.\\nThe test is also used to diagnoserectal cancer.\\nPrecautions\\nAnoscopy should not be performed on patients\\nwith acute cardiovascular problems due to the vaso-\\nvagal reaction it may cause. This test is also not recom-\\nmended for patients with acute abdominal problems\\nand those with a constricted or narrowed anal canal.\\nDescription\\nAnoscopy views the anus and anal canal by using\\nan anoscope. An anoscope is a plastic, tube-shaped\\nspeculum that is a smaller version of a sigmoidscope.\\nBefore the anoscope is used, the doctor completes a\\ndigital rectal examination with a lubricated, gloved\\nindex finger. The anoscope is then lubricated and\\ngently inserted a few inches into the rectum. This\\nprocedure enlarges the rectum to allow the doctor to\\nview the entire anal canal with a light. If any suspicious\\nareas are noticed, a piece of tissue can be biopsied.\\nDuring the anoscopy procedure there may be a\\nfeeling of pressure or the need to go to the bathroom.\\nIf a biopsy is taken, the patient may feel a slight pinch.\\nGALE ENCYCLOPEDIA OF MEDICINE 227\\nAnoscopy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The procedure is performed on an out-patient basis,\\nand takes approximately an hour to complete.\\nPreparation\\nThe patient will be instructed to clear their rectum\\nof stool before the procedure. This may be done by\\ntaking a laxative, enema, or other preparation that\\nmay help with the evacuation.\\nAftercare\\nIf a biopsy is needed during an anoscopy, there may\\nbe slight anal bleeding for less than two days following\\nthe procedure. The patient may be instructed to sit in a\\nbathtub of warm water for 10 to 15 minutes, three\\ntimes a day, to help decrease the pain and swelling.\\nRisks\\nA simple anoscopy procedure offers minimal\\nrisks. There is a limited risk of bleeding and mild\\npain is a biopsy is performed.\\nNormal results\\nNormal values to look for during an anoscopy\\ninclude an anal canal that appears healthy in size,\\ncolor, and shape. The test also looks for no evidence of\\nbleeding, polyps, hemorrhoids or other abnormalities.\\nAbnormal results\\nWhile an anoscopy is typically performed to\\ndetermine is hemorrhoids are present, other abnormal\\nfinding could include polyps, abscesses, inflammation,\\nfissures, colorectal polyps, orcancer.\\nResources\\nBOOKS\\nAltman, Roberta, and Michael J. Sarg. ‘‘Anoscopy.’’The\\nCancer Dictionary. Checkmark Books, 2000, p. 18.\\nPERIODICALS\\nColyar, Margaret. ‘‘Anascopy Basics.’’The Nurse\\nPractitioner (October 2000): 91.\\nOTHER\\nDiscovery Health. ‘‘Medical Tests: Anoscopy.’’ May 5,\\n2001. .\\nLycos Health with WebMD. ‘‘Anoscopy.’’ May 5, 2001.\\n.\\nBeth A. Kapes\\nAnosmia\\nDefinition\\nThe term anosmia means lack of the sense of\\nsmell. It may also refer to a decreased sense of smell.\\nAgeusia, a companion word, refers to a lack of taste\\nsensation. Patients who actually have anosmia may\\ncomplain wrongly of ageusia, although they retain\\nthe ability to distinguish salt, sweet, sour, and bitter–\\nhumans’ only taste sensations.\\nDescription\\nOf the five senses, smell ranks fourth in importance\\nfor humans, although it is much more pronounced in\\nother animals. Bloodhounds, for example, can smell an\\nodor a thousand times weaker than humans. Taste,\\nconsidered the fifth sense, is mostly the smell of food\\nin the mouth. The sense of smell originates from the\\nfirst cranial nerves (the olfactory nerves), which sit at\\nthe base of the brain’s frontal lobes, right behind the\\neyes and above the nose. Inhaled airborne chemicals\\nstimulate these nerves.\\nThere are other aberrations of smell beside a\\ndecrease. Smells can be distorted, intensified, or hallu-\\ncinated. These changes usually indicate a malfunction\\nof the brain.\\nCauses and symptoms\\nThe most common cause of anosmia is nasal\\nocclusion caused by rhinitis (inflammation of the\\nKEY TERMS\\nAnal fissure— An ulcer on the margin of the anus.\\nDigital rectal examination— An examination\\nwhere a gloved, lubricated index finger is inserted\\ninto the rectum to check for any abnormalities.\\nPolyps— A tumor with a small flap that attaches\\nitself to the wall of various vascular organs such as\\nthe nose, uterus and rectum. Polyps bleed easily,\\nand if they are suspected to be cancerous they\\nshould be surgically removed.\\nVasovagal reaction— Regarding the action of\\nstimuli from the vagus nerve on blood vessels.\\n228 GALE ENCYCLOPEDIA OF MEDICINE\\nAnosmia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='nasal membranes). If no air gets to the olfactory\\nnerves, smell will not happen. In turn, rhinitis and\\nnasal polyps(growths on nasal membranes) are caused\\nby irritants such as allergens, infections, cigarette\\nsmoke, and other air pollutants. Tumors such as\\nnasal polyps can also block the nasal passages and\\nthe olfactory nerves and cause anosmia.Head injury\\nor, rarely, certain viral infections can damage or\\ndestroy the olfactory nerves.\\nDiagnosis\\nIt is difficult to measure a loss of smell, and no one\\ncomplains of loss of smell in just one nostril. So a\\nphysician usually begins by testing each nostril sepa-\\nrately with a common, non-irritating odor such as\\nperfume, lemon, vanilla, or coffee. Polyps and rhinitis\\nare obvious causal agents a physician looks for.\\nImaging studies of the head may be necessary in\\norder to detect brain injury, sinus infection, or tumor.\\nTreatment\\nCessation ofsmoking is the first step. Many smo-\\nkers who quit discover new tastes so enthusiastically\\nthat they immediately gain weight. Attention to redu-\\ncing exposure to other nasal irritants and treatment of\\nrespiratory allergies or chronic upper respiratory\\ninfections will be beneficial.Corticosteroids are parti-\\ncularly helpful.\\nAlternative treatment\\nFinding and treating the cause of the loss of smell\\nis the first approach innaturopathic medicine. If rhini-\\ntis is the cause, treating acute rhinitis with herbal mast\\ncell stabilizers and herbaldecongestants can offer some\\nrelief as the body heals. If chronic rhinitis is present,\\nthis is often related to an environmental irritant or to\\nfood allergies. Removal of the causative factors is the\\nfirst step to healing. Nasal steams with essential oils\\noffer relief of the blockage and tonification of the\\nmembranes. Blockages can sometimes be resolved\\nthrough naso-specific therapy–a way of realigning\\nthe nasal cavities. Polyp blockage can be addressed\\nthrough botanical medicine treatment as well as\\nhydrotherapy. Olfactory nerve damage may not be\\nregenerable. Some olfactory aberrations, like intensi-\\nfied sense of smell, can be resolved usinghomeopathic\\nmedicine.\\nPrognosis\\nIf nasal inflammation is the cause of anosmia, the\\nchances of recovery are excellent. However, if nerve\\ndamage is the cause of the problem, the recovery of\\nsmell is much more difficult.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine. New York: McGraw-Hill, 1997.\\nJ. Ricker Polsdorfer, MD\\nAnoxemia see Anoxia\\nAnoxia\\nDefinition\\nAnoxia is a condition characterized by an absence\\nof oxygen supply to an organ or a tissue.\\nDescription\\nAnoxia results when oxygen is not being delivered\\nto a part of the body. If the condition does not involve\\ntotal oxygen deprivation, it is often called hypoxia,\\nalthough the two terms have been used interchange-\\nably. A related condition, anoxemia, occurs when the\\nblood circulates but contains a below normal amount\\nof oxygen.\\nThe five types of anoxia or hypoxia include\\nhypoxemic, anemic, affinity, stagnant, and histotoxic.\\nHypoxemic anoxia happens when the oxygen pressure\\noutside the body is so low that the hemoglobin, the\\nchemical which carries oxygen in the red blood cells\\n(RBCs), is unable to become fully loaded with the gas.\\nThis results in too little oxygen reaching the tissues\\nand can occur in suffocation when a person is at high\\nKEY TERMS\\nAllergen— Any substance that irritates only those\\nwho are sensitive (allergic) to it.\\nCorticosteroids— Cortisone, prednisone, and\\nrelated drugs that reduce inflammation.\\nRhinitis— Inflammation and swelling of the nasal\\nmembranes.\\nNasal polyps— Drop-shaped overgrowths of the\\nnasal membranes.\\nGALE ENCYCLOPEDIA OF MEDICINE 229\\nAnoxia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='altitude, where the pressure of oxygen in the air is\\nmuch less than at sea level.\\nAnemic anoxia results from a decrease in the\\namount of hemoglobin or RBCs in the blood, which\\nreduces the ability to get oxygen to the tissues. Anemia\\nmay result from lack of production of red blood cells\\n(iron deficiency), blood loss (hemorrhage), or shor-\\ntened lifespan of red blood cells (autoimmune disease).\\nAffinity anoxia involves a defect in the chemistry\\nof the blood such that the hemoglobin can no longer\\npick up as much oxygen from the air, even though the\\nquantities are normal, reducing how much is delivered\\nto the tissues.\\nStagnant anoxia occurs when there is interference\\nwith the blood flow, although the blood and its\\noxygen-carrying abilities are normal. A common\\ncause of general stagnant anoxia is heart disease or\\ninterference with the return of blood flow through the\\nveins. Examples of local stagnant anoxia include expo-\\nsure to cold, diseases that restrict circulation to the\\nextremities, and ergotpoisoning. When the tissue or\\norgan itself has a reduced ability to accept and use the\\noxygen, it is called histotoxic anoxia. The classic exam-\\nple is cyanide poisoning, where the chemical inacti-\\nvates a cellular enzyme necessary for the cell to use\\noxygen. Thus, tissue exposed to cyanide cannot use the\\noxygen even though it is in normal amounts in the\\nbloodstream. Histotoxic anoxia can also be caused\\nby exposure tonarcotics, alcohol, formaldehyde, acet-\\none, toluene, and certain anesthetic agents.\\nCauses and symptoms\\nAnoxia and hypoxia can be caused by any number\\nofdiseasestatesoftheblood,lungs,heartandcirculation\\nincluding heart attack,s e v e r easthma,o r emphysema.\\nIt can also result from smoke or carbon monoxide inha-\\nlation, improper exposure to anesthesia, poisoning,\\nstrangulation,near-drowning, or high altitude exposure\\nthrough mountain climbing or travel in an insufficiently\\npressurized airplane. Anoxia, and the resultant brain\\ndamage, is a particular problem with newborns during\\ndifficult births.\\nNo matter what the cause of anoxia, the symp-\\ntoms are similar. In severe cases, the patient is often\\nconfused and commonly stuperous or comatose (in a\\nstate of unconsciousness). Depending on the severity\\nof the injury to the brain, the organ most sensitive to\\nreduced oxygen intake, this condition can persist for\\nhours, days, weeks, or even months or years. Seizures,\\nmyoclonic jerks (involuntary muscle spasms or\\ntwitches), and neck stiffness are some other symptoms\\nof the anoxic condition.\\nSymptoms of more localized or less complete oxy-\\ngen deprivation (hypoxia) include increased breathing\\nrate, lightheadedness,dizziness, tingling or warm sen-\\nsation, sweating, reduced field of vision, sleepiness, a\\nbluish tint to skin, particularly the fingertips and lips,\\nand behavior changes, often an inappropriate sense of\\neuphoria.\\nDiagnosis\\nDiagnosis of anoxia and hypoxia is commonly\\nmade through the appearance of clinical symptoms.\\nHowever, suspected reduction in oxygen reaching the\\ntissues can be confirmed using laboratory tests. The\\nexact test that is performed is dependent on the sus-\\npected cause of the anoxia. One systemic measure of\\ntissue anoxia is the serum lactate (lactic acid) test.\\nWhen cells are forced to produce energy without oxy-\\ngen, as would happen during anoxia, lactic acid is one\\nof the byproducts. Thus, an increase in lactic acid in\\nthe blood would indicate that tissues were starved for\\noxygen and are using non-oxygen pathways to pro-\\nduce energy. Normally, the blood contains less than\\n2mmol/L of lactic acid. However, some forms of\\nanoxia do not increase lactic acid concentrations in\\nthe blood and some increases in lactic acid levels are\\nnot associated with anoxia, so an elevated value for\\nthis test is only suggestive of an anoxic or hypoxic\\ncondition.\\nTreatment\\nThe exact treatment for anoxia is dependent on\\nthe cause of the reduced oxygen reaching the tissues.\\nHowever, immediate restoration of tissue oxygen\\nlevels through supplementing the patient’s air supply\\nwith 100% oxygen is a common first step. Secondary\\nsteps often include support of the cardiovascular sys-\\ntem through drugs or other treatment, treatment of\\nKEY TERMS\\nAmnesia— Loss of memory often traceable to brain\\ntissue damage.\\nAnoxemia— An extreme lack of oxygen in the blood.\\nHemoglobin— A chemical found in red blood cells\\nthat transports oxygen.\\nMyoclonus— Involuntary contractions of a muscle\\nor group of muscles.\\n230 GALE ENCYCLOPEDIA OF MEDICINE\\nAnoxia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='lung disease, transfusions, or administration of anec-\\ndotes for poisoning, as appropriate.\\nPrognosis\\nA good prognosis is dependent on the ability to\\ntreat the underlying cause of the low oxygen levels. If\\ncardiovascular and respiratory systems can be sup-\\nported adequately, recovery from the injury to the\\ntissue is possible, although extent of injury to the\\nbrain can be difficult to assess. The exact amount of\\nrecovery varies with the amount of injury sustained,\\nwhere significant injury brings a poorer prognosis. As\\nrecovery occurs, both psychological and neurological\\nabnormalities may appear, persist, and can improve.\\nSome problems seen after anoxia include mental con-\\nfusion, personality changes,amnesia or other types of\\nmemory loss,hallucinations, and persistent myoclonus\\n(involuntary contractions of the muscles).\\nPrevention\\nHypoxemic anoxia can be avoided by utilizing\\nsupplemental oxygen when in high altitudes and\\nbeing aware of the early symptoms ofaltitude sick-\\nness and reducing altitude once recognized. Iron sup-\\nplements can avoid anemic hypoxia, although more\\nsevere anemic states are usually caused by disease or\\nbleeding. Maintaining g ood cardiovascular health\\nthrough proper diet andexercise is a good first step\\nto avoiding the most common cause of stagnant\\nanoxia. Avoiding exposure to the toxic chemicals\\nthat cause the condition can prevent histotoxic\\nanoxia.\\nResources\\nPERIODICALS\\nGutierrez, Guillermo. ‘‘Metabolic Assessement of Tissue\\nOxygenation’’ Seminars in Respiratory and Critical\\nCare Medicine 20 (January 1999): 11–15.\\nORGANIZATIONS\\nBrain Injury Association. 105 N. Alfred St. Alexandria, VA\\n22314. (800) 444-6443. .\\nPhoenix Project/Head Injury Hotline. Box 84151, Seattle,\\nWA 98124. (206) 621-8558. .\\nOTHER\\nBorron, Stephen W. ‘‘Lactic Acidosis.’’eMedicine.February 7,\\n2001. [cited May 13, 2001]. .\\nNINDS Anoxia/Hypoxia Information Page. The National\\nInstitute of Neurological Disorders and Stroke\\n(NINDS). January 22, 2001. [cited May 13, 2001].\\n.\\nMichelle Johnson, MS, JD\\nAntacids\\nDefinition\\nAntacidsaremedicinesthatneutralizestomachacid.\\nPurpose\\nAntacids are used to relieve acidindigestion, upset\\nstomach, sour stomach, and heartburn. Additional\\ncomponents of some formulations include dimethi-\\ncone, to reduce gas pains (flatulence) and alginic\\nacid, which, in combination with antacids, may help\\nmanage GERD (gastro-esophageal reflux disease).\\nAntacids should not be confused with gastric acid\\ninhibitors, such as the H-2 receptor blockers (cimeti-\\ndine, ranitide and others) or theproton pump inhibitors\\n(lansoprazole, omeprazole and others). Although all\\nthree classes of drugs act to reduce the levels of gastric\\nacid, their mechanisms are different, and this affects\\nthe appropriate use of the drug. Antacids have a rapid\\nonset and short duration of action, and are most\\nappropriate for rapid relief of gastric discomfort for\\na short period of time.\\nAntacids may be divided into two classes, those\\nthat work by chemical neutralization of gastric acid,\\nmost notably sodium bicarbonate; and those that act\\nby adsorption of the acid (non-absorbable antacids),\\nsuch as calcium and magnesium salts.\\nThe chemical antacids show the most rapid onset\\nof action, but may cause ‘‘acid rebound,’’ a condition\\nin which the gastric acid returns in greater concentra-\\ntion after the drug effect has stopped. Also, since\\nthese antacids may contain high concentrations of\\nsodium, they may be inappropriate in patients with\\nhypertension.\\nCalcium and magnesium salts act by adsorption\\nof the acid, and are less prone to the rebound effect,\\nbut may have other significant disadvantages. These\\nantacids are particularly prone todrug interactions,\\nand patients taking other medications must often\\navoid simultaneous administration of the medica-\\ntions. These antacids are more effective in liquid for-\\nmulations than in tablet or capsule form, and so may\\nbe inconvenient for routine dosing.\\nGALE ENCYCLOPEDIA OF MEDICINE 231\\nAntacids'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The non-absorbable antacids may have additional\\nuses beyond control of hyperacidity. Calcium salts\\nmay be used as diet supplements in prevention of\\nosteoporosis. Aluminum carbonate is useful for bind-\\ning phosphate, and has been effective in treatment and\\ncontrol of hyperphosphatemia or for use with a low\\nphosphate diet to prevent formation of phosphate\\nurinary stones. This application is particularly valu-\\nable in patients with chronic renal failure. Antacids\\nwith aluminum and magnesium hydroxides or alumi-\\nnum hydroxide alone effectively prevent significant\\nstress ulcer bleeding in post-operative patients or\\nthose with severeburns.\\nRecommended dosage\\nThe dose depends on the type of antacid. Consult\\nspecific references.\\nWhen using antacids in chewable tablet form,\\nchew the tablet well before swallowing. Drink a glass\\nof water after taking chewable aluminum hydroxide.\\nLozenges should be allowed to dissolve completely in\\nthe mouth. Liquid antacids should be shaken well\\nbefore using.\\nPrecautions\\nAntacids should be avoided if any signs ofappen-\\ndicitis or inflamed bowel are present. These include\\ncramping, pain, and soreness in the lower abdomen,\\nbloating, andnausea and vomiting.\\nAntacids may affect the results of some medical\\ntests, such as those that measure how much acid\\nthe stomach produces. Health care providers and\\npatients should keep this in mind when scheduling a\\nmedical test.\\nAntacids that contain magnesium may causediar-\\nrhea. Other types of antacids may causeconstipation.\\nAvoid taking antacids containing sodium bicar-\\nbonate when the stomach is uncomfortably full from\\neating or drinking.\\nAntacids should not be given to children under six\\nyears of age.\\nAntacids that contain calcium or sodium bicarbo-\\nnate may cause side effects, such asdizziness, nausea,\\nand vomiting, in people who consume large amounts\\nof calcium (from dairy products or calcium supple-\\nments). In some cases, this can lead to permanent\\nkidney damage. Before combining antacids with\\nextra calcium, check with a physician.\\nSome antacids contain large amounts of sodium,\\nparticularly sodium bicarbonate (baking soda).\\nAnyone who is on a low-sodium diet should check\\nthe list of ingredients or check with a physician or\\npharmacist before taking an antacid product.\\nExcessive use of antacids may cause or increase\\nthe severity or kidney problems. Calcium based anta-\\ncids may lead to renal stone formation.\\nPREGNANCY. Antacids are not classified under\\nthe pregnancy safety categories A, B, C, D and X.\\nOccasional use of antacids in small amounts during\\npregnancy is considered safe. However, pregnant\\nwomen should check with their physicians before using\\nantacids or any other medicines. Pregnant women\\nwho are consuming extra calcium should be aware\\nthat using antacids that contain sodium bicarbonate or\\ncalcium can lead to serious side effects.\\nBREASTFEEDING. Some antacids may pass into\\nbreast milk. However, no evidence exists that the\\ningestion of antacids through breast milk causes pro-\\nblems for nursing babies whose mothers use antacids\\noccasionally.\\nSide effects\\nSide effects are very rare when antacids are taken\\nas directed. They are more likely when the medicine is\\ntaken in large doses or over a long time. Minor side\\neffects include a chalky taste, mild constipation or\\ndiarrhea, thirst, stomach cramps, and whitish or\\nspeckled stools. These symptoms do not need medical\\nKEY TERMS\\nAcid indigestion— Indigestion that results from too\\nmuch acid in the stomach.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nHeartburn— A burning sensation, usually in the\\ncenter of the chest, near the breastbone.\\nIndigestion— A feeling of discomfort or illness that\\nresults from the inability to properly digest food.\\nInflamed bowel— Irritation of the intestinal tract.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nPregnancy safety categories— A system for report-\\ning the known safety issues of drugs for use during\\npregnancy, The ratings range from A, proven safe\\nby well controlled studies, to X, proven harmful.\\n232 GALE ENCYCLOPEDIA OF MEDICINE\\nAntacids'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='attention unless they do not go away or they interfere\\nwith normal activities.\\nOther uncommon side effects may occur. Anyone\\nwho has unusual symptoms after taking antacids\\nshould get in touch with his or her health care provider.\\nInteractions\\nAntacids have multiple drug interactions, usually\\ndue to inhibition of absorption of other medications.\\nIn rare cases, the absorbable antacids may alter the\\npH of the stomach contents or urine sufficiently to\\nalter drug absoprtion or excretion. Consult specific\\nreferences.\\nSamuel D. Uretsky, PharmD\\nAntegrade pyelography see Intravenous\\nurography\\nAntenatal testing\\nDefinition\\nAntenatal testing includes any diagnostic proce-\\ndures performed before the birth of a baby.\\nPurpose\\nThese tests and exams are essential for protecting\\nthe health of a pregnant woman and her developing\\nchild.\\nPrecautions\\nSome tests, such as amniocentisis, carry a small\\nrisk of amiscarriage or other complications that could\\nharm the mother or baby.\\nDescription\\nWomen who become pregnant undergo a wide\\nvariety of tests throughout the nine months before\\ndelivery. In the early stages, physicians order blood\\ntests to screen for possible disorders or infections, such\\nas human immunodeficiency virus (HIV), which can\\npass from the mother to the fetus. Later, the focus\\nshifts to checking on fetal well-being with a variety of\\ntechnological tools such as ultrasound scans.\\nDescriptions of the most common tests and proce-\\ndures used duringpregnancy are listed below.\\nWhen a woman first learns she is pregnant, her\\nphysician will run a series of routine urine and blood\\ntests to determine her blood type, check for anemia\\nand gestational diabetes, make sure she is immune to\\nrubella (German measles) and check for infectious\\ndiseases like HIV, hepatitis, chlamydia or syphilis.\\nPhysicians also usually dopelvic exam to screen for\\ncervical cancerand check the patient’s blood pressure.\\nAs the pregnancy progresses, more tests will follow.\\nUltrasound\\nUltrasound is a device that records sound waves\\nas they bounce off the developing fetus to create an\\nimage, which is projected onto a large computer\\nscreen. Physicians order an ultrasound scan to listen\\nfor a fetal heartbeat, determine a woman’s precise due\\ndate and check for twins, among other uses. An ultra-\\nsound scan also is known as a sonogram. The proce-\\ndure takes a few minutes, is painless and usually is\\ncovered by health insurance.\\nThe ultrasound technician will ask the pregnant\\nwoman to remove her clothes and change into a gown.\\nThe technician may rub some gel on the woman’s stom-\\nach, which helps the hand-held device pick up sound\\nwaves better. In certain cases, the technician may insert\\na plastic probe into the woman’s vaginal canal to get a\\nclearer picture of the fetus. Early in pregnancy, the\\ntest may need to be done with a full bladder.\\nKEY TERMS\\nUltrasound — A device that records sound waves\\nas they bounce off a developing fetus to create an\\nimage, which is projected onto a large computer\\nscreen\\nBreech position— When a child is oriented feet\\nfirst in the mother’s uterus just before delivery.\\nAlpha fetoprotein screen — A test that measures\\nthe level of alpha fetoprotein, a substance pro-\\nduced by a fetus with birth defects, in the mother’s\\nblood.\\nAmniocentesis— An invasive procedure that\\nallows physicians to check for birth defects by col-\\nlecting a sample of fetal cells from inside the\\namniotic sac.\\nGBS— Group B streptococci are a type of bacteria\\nthat, if passed to a can cause inflammation of the\\nbrain, spinal cord, blood or lungs. In some cases, it\\ncan result in infant death\\nGALE ENCYCLOPEDIA OF MEDICINE 233\\nAntenatal testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Unlike x rays, ultrasound is safe to use during\\npregnancy. It does not cause any known side-effects\\nthat would harm the mother or baby.\\nPregnant women usually will have their first ultra-\\nsound anytime between 8 and 12 weeks of gestation. In\\nnormal cases, the technician is able to identify a fetal\\nheartbeat, which appears as a flashing light on the\\nscreen. Closer to the due date, physicians use ultra-\\nsound to make sure the fetus is in the correct position\\nto exit the birth canal head first.\\nSometimes an ultrasound will show that a fetus\\nhas stopped growing, or a gestational sac has formed\\nwithout a fetus, and a miscarriage has occurred. Later\\nin pregnancy, it also may show that the child is in a\\nbreech position, oriented feet first, which can cause a\\ndifficult labor.\\nTests for birth defects\\nMost obstetricians offer parents a variety of ways\\nto find out if their developing child might havebirth\\ndefects such asspina bifida and Down Syndrome.A n\\nalpha fetoprotein screen can be done through a simple\\nblood test in the doctor’s office between the 16th and\\n18th week of gestation. It tells the odds that their child\\nwill have a severe congenital anomaly. The test works\\nby measuring the level of alpha fetoprotein, a sub-\\nstance produced by a fetus with birth defects. Low\\nlevels of alpha fetoprotein in the mother’s blood may\\nindicate Down’s Syndrome. In that case, the next step\\nfor most couples isamniocentesis because the alpha\\nfetoprotein test can give false-positive results.\\nAmniocentesis is a more accurate test, but it also has\\nhigher risks of complications.\\nThis procedure typically is used to diagnose Down\\nsyndrome while a developing child is still in the womb,\\nat 15-28 weeks.\\nDuring amniocentesis, a doctor inserts a needle\\nthrough a woman’s vaginal canal and inside her cer-\\nvix. Using ultrasound as a guide, the doctor pierces the\\nuterus to withdraw a sample of fluid from the amniotic\\nsac. Afterwards, tiny cells shed by the fetus can be\\nstudied in the laboratory. Scientists can analyze\\nDNA samples to determine if the fetus has Down\\nsyndrome or other genetic conditions. Amniocentesis\\nalso can determine the sex of the fetus.\\nWomen who have a history of recurring miscar-\\nriages may not want to have this procedure.\\nAmniocentesis is usually performed in a doctor’s\\noffice on an outpatient basis.\\nCommon side effects include cramping and\\nbleeding.\\nIn about one out of every 1,000 cases, amniocen-\\ntesis causes a needle to puncture the uterine wall,\\nwhich could result in miscarriage.\\nIn most cases, couples find out their baby does not\\nhave a birth defect.\\nIf the results come back positive for Down’s\\nSyndrome or other serious conditions, the couple\\nmust decide if they want to end the pregnancy.\\nOthers use the knowledge to plan and prepare any\\nspecial care needed for their future child.\\nGroup B Strep\\nThis test is for Group B streptococci (GBS)\\ninfection.\\nBy testing for GBS, physicians can determine if\\na woman is at risk of passing this infection along to\\nher child.\\nWomen who have had a prior child with GBS, or\\nwho have afever or prolonged or premature rupture of\\nthe amniotic sac may be at higher risk for this type of\\ninfection.\\nGBS is a type of bacteria commonly found in the\\nvagina and rectum. Unlike regularstrep throat, GBS\\ncan be present in a person’s body without causing any\\nsymptoms, so many women do not realize they are\\ninfected with it.\\nTo test for the presence of GBS, doctors may take\\na urine sample. They also may collect samples from the\\nvagina or rectum, which are then analyzed in a lab.\\nThis test is usually performed late in pregnancy, at\\n35-37 weeks of gestation.\\nThis is a routine urine test or pelvic exam with no\\nside effects.\\nIn many cases, doctors do not find any evidence of\\nthis type of infection.\\nIf a woman is found to be infected with Group B\\nstrep, physicians usually wait to treat it until just\\nbefore labor begins. At that time, they may give the\\nmother antibiotics so the baby is not born with the\\ninfection. Newborns who are exposed to Group B\\nstrep can have inflammation of the brain, spinal\\ncord, blood or lungs. In some cases, this serious com-\\nplication can result in infantdeath.\\nResources\\nBOOKS\\nPlanning your Pregnancy and Birth. Washington, DC: The\\nAmerican College of Obstetricians and Gynecologists,\\n2000.\\n234 GALE ENCYCLOPEDIA OF MEDICINE\\nAntenatal testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='PERIODICALS\\nParkey, Paula. ‘‘Birth Defects: Is Prenatal Screening\\nAdvisable?’’ CBS HealthWatch April, 2000. .\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nMarch of Dimes Birth Defects Foundation. 275\\nMamaroneck Avenue, White Plains, NY 10605. (888)\\n663-4637. .\\nMelissa Knopper\\nAntepartum testing\\nDefinition\\nAntepartum testing consists of a variety of tests\\nperformed late inpregnancy to verify fetal well-being,\\nas judged by the baby’s heart rate and other character-\\nistics. Antepartum tests include the nonstress test\\n(NST), biophysical profile, and contraction stress\\ntest (CST).\\nPurpose\\nAntepartum testing is performed after 32 weeks of\\npregnancy so that the couple and the doctor can be\\nwarned of any problems that may necessitate further\\ntesting or immediate delivery. The results reflect the\\nadequacy of blood flow (and oxygen delivery) to the\\nfetus from the placenta.\\nAntepartum tests are usually done in pregnancies\\nat high risk for fetal complications. Various reasons\\ninclude:\\n/C15any chronic illness in the mother, such as high blood\\npressure or diabetes\\n/C15problems with previous pregnancies, such as\\nstillbirth\\n/C15fetal complications, such asintrauterine growth retar-\\ndation (a slowing of growth of the fetus) orbirth\\ndefects\\n/C15problems in the current pregnancy, includingpree-\\nclampsia (serious pregnancy-induced high blood\\npressure), gestational (pregnancy-related) diabetes,\\npremature rupture of the membranes, excessive\\namniotic fluid (the liquid that surrounds the fetus),\\nvaginal bleeding, orplacenta previa (a condition in\\nwhich the placenta is positioned over the cervix\\ninstead of near the top of the uterus)\\n/C15twins or other multiple fetuses\\nOne of the most common indications for antepar-\\ntum testing is post-term pregnancy. A pregnancy\\nshould not be allowed to continue past 42 weeks.\\n(The usual pregnancy is 40 weeks in duration).\\nBabies should be monitored with antepartum testing\\nstarting at 41 weeks. After 41 weeks, there is an\\nincreasing risk that the placenta cannot meet the grow-\\ning baby’s needs for oxygen andnutrition. This may be\\nreflected in decreased movements of the baby,\\ndecreased amniotic fluid, and changes in the heart\\nrate pattern of the baby.\\nDescription\\nTechnology\\nThe NST and CST use a technique calledelectro-\\nnic fetal monitoringto evaluate the heartbeat of the\\nfetus. The biophysical profile is an ultrasound\\nexamination.\\nNST\\nThe NST is usually the first antepartum test used to\\nverify fetal well-being. It is based on the principle that\\nwhen the fetus moves, its heartbeat normally speeds up.\\nThe NST assesses fetal health through monitoring\\naccelerations of the heart rate in response to the\\nbaby’s own movements, i.e., in the absence ofstress.\\nKEY TERMS\\nAmniotic fluid— The liquid that surrounds the baby\\nwithin the amniotic sac. Because it is composed\\nmostly of fetal urine, a low amount of fluid can indi-\\ncate inadequate placental blood flow to the fetus.\\nDeceleration— A decrease in the fetal heart rate\\nthat can indicate inadequate blood flow through\\nthe placenta.\\nOxytocin— A natural hormone that produces uter-\\nine contractions.\\nUltrasound— A procedure in which high-\\nfrequency sound waves are used to create a picture\\nof the baby, used alone or with antepartum tests.\\nVibroacoustic stimulation— In the biophysical pro-\\nfile, use of an artificial larynx to produce a loud\\nnoise to ‘‘awaken’’ the fetus.\\nGALE ENCYCLOPEDIA OF MEDICINE 235\\nAntepartum testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The mother lays down or sits, and an electronic\\nfetal monitor is placed on her abdomen to monitor the\\nfetal heart rate. The doctor records the baby’s heart-\\nbeat on a graph or ‘‘tracing’’ to determine whether it\\ndemonstrates correct reactivity, or acceleration of the\\nheart rate. To record fetal movements on the tracing,\\nthe mother presses a button every time she feels the\\nbaby move. If the baby is inactive, the mother may be\\nasked to rub her abdomen to ‘‘awaken’’ it. Sometimes\\nan instrument is used to produce a loud noise to arouse\\nthe fetus (vibroacoustic stimulation). The test usually\\ntakes between 20–45 minutes.\\nA baby who is receiving enough oxygen should\\nmove at least twice in a 20 minute period. The baby’s\\nheart rate should increase at least 20 beats per minute\\nfor at least 20 seconds during these movements. The\\nNST is the simplest and cheapest antepartum test.\\nBiophysical profile\\nThe biophysical profile is an ultrasound exam that\\ncan add additional information to the NST. During\\nthe biophysical profile, the examiner checks for var-\\nious characteristics of the baby to evaluate its overall\\nhealth. These include: fetal movement, fetal tone,\\nbreathing movements, and the amniotic fluid volume.\\nAmniotic fluid volume is important because a\\ndecreased amount raises the possibility that the baby\\nmay be under stress. The five components of the test\\n(NST is also included) are each given a score of 2 for\\nnormal (or present), 1 if decreased, and 0 for abnor-\\nmal. The highest possible score is 10. The ‘‘modified’’\\nbiophysical profile is another option; this includes\\nonly the NST and amniotic fluid volume.\\nCST\\nThe CST is like the NST, except that the fetus is\\nevaluated in response to contractions of the mother’s\\nuterus. Because it is a more complicated test, it is often\\nused after an abnormal NST to confirm the results.\\nUterine contractions produce ‘‘stress’’ in the fetus\\nbecause they temporarily stop the flow of blood and\\noxygen. The CST is used to confirm that the fetus does\\nnot respond to this stress by a decrease in the heart rate.\\nThe CST is performed with the same equipment as\\nthe NST. Maternal blood pressure and fetal heart rate\\nare recorded along with the onset, relative intensity,\\nand duration of any spontaneous contractions. For an\\naccurate test, the contractions should be of sufficient\\nduration and frequency. If uterine activity does not\\noccur naturally, a drug called oxytocin may be given to\\nthe mother intravenously (hence the test’s alternate\\nname, the oxytocin challenge test) to provoke\\ncontractions. Another option is self-stimulation of\\nthe mother’s nipples, because this releases natural\\noxytocin. The fetal heart rate is observed until, ideally,\\nthree moderate contractions occur within 10 minutes.\\nPreparation\\nThe mother should eat just before the antepartum\\ntests to help stimulate fetal activity.\\nRisks\\nThere are no appreciable risks from the NST or\\nthe biophysical profile. Ultrasound used for the bio-\\nphysical profile is painless and safe because it uses no\\nharmful radiation, and no evidence has been found\\nthat sound waves cause any adverse effects on the\\nmother or fetus.\\nThe frequency of antepartum testing depends on\\nthe reason for its use. All of the tests occasionally give\\nincorrect results, which may prompt an unnecessary\\nearly delivery or cesarean. Repeat testing is important\\nto double-check any abnormal findings.\\nNormal results\\nIn general, ‘‘negative’’ or normal results on ante-\\npartum testing provide reassurance that the baby is\\nhealthy and should remain so for perhaps a week, with\\nno need for immediate delivery. Unfortunately, the\\ntests cannot guarantee that there are no problems,\\nbecause falsely normal results can occur, though this\\nis unusual. Even if all test results are normal, it is\\nimportant to realize that this does not guarantee a\\n‘‘perfect’’ baby.\\nThe NST is normal (‘‘reactive’’) if two or more\\ndistinct fetal movements occur in association with\\nappropriate accelerations of the fetal heart rate within\\n20 minutes. A biophysical profile score of 8-10 is con-\\nsidered reassuring. The CST is normal if the fetus\\nshows no decelerations in heart rate in response to\\nthree uterine contractions within 10 minutes.\\nAbnormal results\\nA ‘‘positive’’ result suggests that the baby is not\\nreceiving enough oxygen for some reason. However, it\\nis quite possible that the test result was falsely abnor-\\nmal. To confirm or monitor a suspected disorder,\\nfollow-up testing with the same or an alternate test\\nwill probably be performed at least weekly.\\nThe NST is abnormal (‘‘nonreactive’’) if the fetal\\nheart rate fails to speed up by at least 20 beats per\\n236 GALE ENCYCLOPEDIA OF MEDICINE\\nAntepartum testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='minute at least two times during a 20-minute period.\\nAbnormal decreases in the heart rate (decelerations)\\nare also a cause for concern.\\nA biophysical profile score of 6 is considered a\\ncause for concern and should be followed by further\\ntesting. Scores of 4 or less may require immediate\\ndelivery of the fetus.\\nAbnormal results on the CST include late decel-\\nerations, or abnormal slowing of the fetal heart rate\\nafter the uterine contractions. This can suggest that\\nthe baby is not receiving enough oxygen and may have\\ndifficulty withstanding the stress of labor and vaginal\\ndelivery. Cesarean section might be necessary so the\\nbaby can be spared the stress of labor. With either\\nNST or CST, a severe deceleration (a period of very\\nslow heartbeat) can also suggest fetal distress.\\nThe ultimate outcome will depend on the woman’s\\nindividual situation. In some cases, delivery can be post-\\nponed while medication is given to the mother (e.g., for\\nhigh blood pressure) or the fetus (e.g., to speed up lung\\nmaturitybeforedelivery).Dependinguponthereadiness\\nof the mother’s cervix, the doctor may decide to induce\\nlabor. The extra-large fetus of a diabetic woman may\\nrequire cesarean delivery; severe preeclampsia also may\\nnecessitate induction of laboror cesarean section. The\\ndoctor will determine the most prudent course of action.\\nResources\\nPERIODICALS\\nSmith-Levitin, Michelle, Boris Petrikovsky, and Elizabeth P.\\nSchneider. ‘‘Practical Guidelines for Antepartum Fetal\\nSurveillance.’’ American Family Physician 56\\n(November 15, 1997): 1981-1988.\\nORGANIZATIONS\\nAmerican College of Obstetricians and Gynecologists. 409\\n12th St., S.W., P.O. Box 96920, Washington, DC\\n20090-6920. .\\nNational Institute of Child Health and Human\\nDevelopment. Bldg 31, Room 2A32, MSC 2425, 31\\nCenter Drive, Bethesda, MD 20892-2425. (800) 505-\\n2742. .\\nLaura J. Ninger\\nAnthrax\\nDefinition\\nAnthrax is an infection caused by the bacterium\\nBacillus anthracis that primarily affects livestock but\\nthat can occasionally spread to humans, affecting\\neither the skin, intestines, or lungs. In humans, the\\ninfection can often be treated, but it is almost always\\nfatal in animals.\\nDescription\\nAnthrax is most often found in the agricultural\\nareas of South and Central America, southern and\\neastern Europe, Asia, Africa, the Caribbean, and the\\nMiddle East. In the United States, anthrax is rarely\\nreported; however, cases of animal infection with\\nanthrax are most often reported in Texas, Louisiana,\\nMississippi, Oklahoma, and South Dakota. The bac-\\nterium and its associated disease get their name from\\nthe Greek word meaning ‘‘coal’’ because of the char-\\nacteristic coal-black sore that is the hallmark of the\\nmost common form of the disease.\\nDuring the 1800s, in England and Germany,\\nanthrax was known either as ‘‘wool-sorter’s’’ or ‘‘rag-\\npicker’s’’ disease because workers contracted the dis-\\nease from bacterial spores present on hides and in\\nwool or fabric fibers. Spores are the small, thick-\\nwalled dormant stage of some bacteria that enable\\nthem to survive for long periods of time under adverse\\nconditions. The first anthrax vaccine was perfected in\\n1881 by Louis Pasteur.\\nThe largest outbreak ever recorded in the United\\nStates occurred in 1957 when nine employees of a goat\\nhair processing plant became ill after handling a con-\\ntaminated shipment from Pakistan. Four of the five\\npatients with the pulmonary form of the disease died.\\nOther cases appeared in the 1970s when contaminated\\ngoatskin drumheads from Haiti were brought into the\\nU.S. as souvenirs.\\nHumans suffering from anthrax often develop ulcerating\\nnodules on the body. Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 237\\nAnthrax'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Today, anthrax is rare, even among cattle, largely\\nbecause of widespread animalvaccination. However,\\nsome serious epidemics continue to occur among ani-\\nmal herds and in human settlements in developing\\ncountries due to ineffective control programs. In\\nhumans, the disease is almost always an occupational\\nhazard, contracted by those who handle animal hides\\n(farmers, butchers, and veterinarians) or sort wool.\\nThere are no reports of the disease spreading from\\none person to another.\\nAnthrax as a weapon\\nThere has been a great deal of recent concern\\nthat the bacteria that cause anthrax may be used as\\na type of biological warfare, since it is possible to\\nbecome infected simply by inhaling the spores, and\\ninhaled anthrax is the most serious form of the\\ndisease. The bacteria can be grown in laboratories,\\nand with a great deal of expertise and special equip-\\nment, the bacteria can be altered to be usable as a\\nweapon.\\nThe largest-ever documented outbreak of human\\nanthrax contracted through spore inhalation occurred\\nin Russia in 1979, when anthrax spores were acciden-\\ntally released from a military laboratory, causing a\\nregional epidemic that killed 69 of its 77 victims. In\\nthe United States in 2001, terrorists converted anthrax\\nspores into a powder that could be inhaled and mailed\\nit to intended targets, including news agencies and\\nprominent individuals in the federal government.\\nBecause the United States government considers\\nanthrax to be of potential risk to soldiers, the\\nDepartment of Defense has begun systematic vaccina-\\ntion of all military personnel against anthrax.\\nFor civilians in the United States, the government\\nhas instituted a program called the National\\nPharmaceutical Stockpile program in whichantibio-\\ntics and other medical materials to treat two million\\npeople are located so that they could be received any-\\nwhere in the country within twelve hours following a\\ndisaster or terrorist attack.\\nCauses and symptoms\\nThe naturally occurring bacterium Bacillus\\nanthracis produces spores that can remain dormant\\nfor years in soil and on animal products, such as\\nhides, wool, hair, or bones. The disease is often fatal\\nto cattle, sheep, and goats, and their hides, wool, and\\nbones are often heavily contaminated.\\nThe bacteria are found in many types of soil, all\\nover the world, and usually do not pose a problem for\\nhumans because the spores stay in the ground. In\\norder to infect a human, the spores have to be released\\nfrom the soil and must enter the body. They can enter\\nthe body through a cut in the skin, through consuming\\ncontaminated meat, or through inhaling the spores.\\nOnce the spores are in the body, and if antibiotics are\\nnot administered, the spores become bacteria that\\nmultiply and release a toxin that affects the immune\\nsystem. In the inhaled form of the infection, the\\nimmune system can become overwhelmed and the\\nbody can go intoshock.\\nSymptoms vary depending on how the disease was\\ncontracted, but the symptoms usually appear within\\none week of exposure.\\nCutaneous anthrax\\nIn humans, anthrax usually occurs when the\\nspores enter a cut or abrasion, causing a skin (cuta-\\nneous) infection at the site. Cutaneous anthrax, as this\\ninfection is called, is the mildest and most common\\nform of the disease. At first, the bacteria cause an\\nitchy, raised area like an insect bite. Within one to\\ntwo days, inflammation occurs around the raised\\narea, and a blister forms around an area of dying tissue\\nthat becomes black in the center. Other symptoms may\\ninclude shivering and chills. In most cases, the bacteria\\nKEY TERMS\\nAntibody— A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAntitoxin— An antibody that neutralizes a toxin.\\nBronchitis— Inflammation of the mucous mem-\\nbrane of the bronchial tubes of the lung that can\\nmake it difficult to breathe.\\nCutaneous— Pertaining to the skin\\nMeningitis— Inflammation of the membranes cov-\\nering the brain and spinal cord called the\\nmeninges.\\nPulmonary— Having to do with the lungs or\\nrespiratory system.\\nSpore— A dormant form assumed by some bac-\\nteria, such as anthrax, that enable the bacterium\\nto survive high temperatures, dryness, and lack of\\nnourishment for long periods of time. Under proper\\nconditions, the spore may revert to the actively\\nmultiplying form of the bacteria.\\n238 GALE ENCYCLOPEDIA OF MEDICINE\\nAnthrax'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='remain within the sore. If, however, they spread to the\\nnearest lymph node (or, in rare cases, escape into the\\nbloodstream), the bacteria can cause a form of blood\\npoisoning that rapidly proves fatal.\\nInhalation anthrax\\nInhaling the bacterial spores can lead to a rare,\\noften-fatal form of anthrax known as pulmonary or\\ninhalation anthrax that attacks the lungs and sometimes\\nspreads to the brain. Inhalation anthrax begins with flu-\\nlike symptoms, namelyfever, fatigue, headache,m u s c l e\\naches, andshortness of breath. As early as one day after\\nthese initial symptoms appear, and as long as two weeks\\nlater, the symptoms suddenly worsen and progress to\\nbronchitis. The patient experiences difficulty breath-\\ning, and finally, the patient enters a state of shock.\\nThis rare form of anthrax is often fatal, even if treated\\nwithin one or two days after the symptoms appear.\\nIntestinal anthrax\\nIntestinal anthrax is a rare, often-fatal form of the\\ndisease, caused by eating meat from an animal that\\ndied of anthrax. Intestinal anthrax causes stomach\\nand intestinal inflammation and sores or lesions\\n(ulcers), much like the sores that appear on the skin\\nin the cutaneous form of anthrax. The first signs of the\\ndisease arenausea and vomiting, loss of appetite, and\\nfever, followed by abdominalpain, vomiting of blood,\\nand severe bloodydiarrhea.\\nDiagnosis\\nAnthrax is diagnosed by detectingB. anthracis in\\nsamples taken from blood, spinal fluid,skin lesions,o r\\nrespiratory secretions. The bacteria may be positively\\nidentified using biochemical methods or using a tech-\\nnique whereby, if present in the sample, the anthrax\\nbacterium is made to fluoresce. Blood samples will\\nalso indicate elevated antibody levels or increased\\namounts of a protein produced directly in response\\nto infection with the anthrax bacterium. Polymerase\\nchain reaction (PCR) tests amplify trace amounts of\\nDNA to show that the anthrax bacteria are present.\\nAdditional DNA-based tests are also currently being\\nperfected.\\nTreatment\\nIn the early stages, anthrax is curable by adminis-\\ntering high doses of antibiotics, but in the advanced\\nstages, it can be fatal. If anthrax is suspected, health\\ncare professionals may begin to treat the patient with\\nantibiotics even before the diagnosis is confirmed\\nbecause early intervention is essential. The antibiotics\\nused include penicillin, doxycycline, and ciprofloxa-\\ncin. Because inhaled spores can remain in the body for\\na long time, antibiotic treatment for inhalation\\nanthrax should continue for 60 days. In the case of\\ncutaneous anthrax, the infection may be cured follow-\\ning a single dose of antibiotic, but it is important to\\ncontinue treatment so as to avoid potential serious\\ncomplications, such as inflammation of the mem-\\nbranes covering the brain and spinal cord (meningitis).\\nIn the setting of potential bioterrorism, cutaneous\\nanthrax should be treated with a 60-day dose of\\nantibiotics.\\nResearch is ongoing to develop new antibiotics\\nand antitoxins that would work against the anthrax\\nbacteria and the toxins they produce. One Harvard\\nprofessor, Dr. R. John Collier, and his team have been\\ntesting two possible antitoxins on rats. A Stanford\\nmicrobiologist and a Penn State chemist have also\\nbeen testing their new antibiotic against the bacteria\\nthat cause brucellosis and tularemia, as well as\\nthe bacteria that cause anthrax. All of these drugs\\nare still in early investigational stages, however, and\\nit is still unknown how these drugs would affect\\nhumans.\\nPrognosis\\nUntreated anthrax is often fatal, butdeath is far\\nless likely with appropriate care. Ten to twenty per-\\nc e n to fp a t i e n t sw i l ld i ef r o ma n t h r a xo ft h es k i n\\n(cutaneous anthrax) if it is not properly treated. All\\npatients with inhalation (pulmonary) anthrax will\\ndie if untreated. Intestinal anthrax is fatal 25-75%\\nof the time.\\nPrevention\\nAnthrax is relatively rare in the United States\\nbecause of widespread animal vaccination and prac-\\ntices used to disinfect hides or other animal products.\\nAnyone visiting a country where anthrax is common\\nor where herd animals are not often vaccinated should\\navoid contact with livestock or animal products and\\navoid eating meat that has not been properly prepared\\nand cooked.\\nOther means of preventing the spread of infection\\ninclude carefully handling dead animals suspected of\\nhaving the disease, burning (instead of burying) con-\\ntaminated carcasses, and providing good ventilation\\nwhen processing hides, fur, wool, or hair.\\nIn the event that exposure to anthrax spores is\\nknown, such as in the aftermath of a terrorist attack,\\nGALE ENCYCLOPEDIA OF MEDICINE 239\\nAnthrax'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='a course of antibiotics can prevent the disease from\\noccurring.\\nIn the case of contaminated mail, as was the case in\\nthe 2001 attacks, the U.S. postal service recommends\\ncertain precautions. These precautions include\\ninspecting mail from an unknown sender for excessive\\ntape, powder, uneven weight or lumpy spots, restrictive\\nendorsements such as ‘‘Personal,’’ or ‘‘Confidential,’’ a\\npostmark different from the sender’s address, or a\\nsender’s address that seems false or that cannot be\\nverified. Handwashing is also recommended after\\nhandling mail. In order to decontaminate batches of\\nmail before being opened, machines that use bacteria-\\nkilling radiation could be used to sterilize the mail.\\nThese machines are similar to systems already in place\\non assembly lines for sterile products, such as bandages\\nand medical devices, but this technique would not be\\npractical for large quantities of mail. In addition, the\\nradiation could damage some of the mail’s contents,\\nsuch as undeveloped photographic film. Microwave\\nradiation or the heat from a clothes iron is not powerful\\nenough to kill the anthrax bacteria.\\nFor those in high-risk professions, an anthrax\\nvaccine is available that is 93% effective in protecting\\nagainst infection. To provide this immunity, an indi-\\nvidual should be given an initial course of three injec-\\ntions, given two weeks apart, followed by booster\\ninjections at six, 12, and 18 months and an annual\\nimmunization thereafter.\\nApproximately 30% of those who have been\\nvaccinated against anthrax may notice mild local reac-\\ntions, such as tenderness at the injection site.\\nInfrequently, there may be a severe local reaction\\nwith extensive swelling of the forearm, and a few\\nvaccine recipients may have a more general flu-like\\nreaction to the shot, including muscle and joint\\naches, headache, and fatigue. Reactions requiring hos-\\npitalization are very rare. However, this vaccine is only\\navailable to people who are at high risk, including\\nveterinary and laboratory workers, livestock handlers,\\nand military personnel. The vaccine is not recom-\\nmended for people who have previously recovered\\nfrom an anthrax infection or for pregnant women.\\nWhether this vaccine would protect against anthrax\\nused as a biological weapon is, as yet, unclear.\\nResources\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404)\\n639-3311. .\\nNational Institute of Allergies and Infectious Diseases,\\nDivision of Microbiology and Infectious Diseases.\\nBuilding 31, Room. 7A-50, 31 Center Drive MSC 2520,\\nBethesda, MD 20892. .\\nWorld Health Organization, Division of Emerging and\\nOther Communicable Diseases Surveillance and\\nControl. Avenue Appia 20, 1211 Geneva 27,\\nSwitzerland. (+00 41 22) 791 21 11. .\\nOTHER\\n‘‘Anthrax.’’ New York State Department of Health\\nCommunicable Disease Fact Sheet. .\\n‘‘Bacillus anthracis (Anthrax).’’ .\\nBegley, Sharon and Karen Springen. ‘‘Anthrax: What\\nYou Need to Know: Exposure doesn’t guarantee disease,\\nand the illness is treatable.’’Newsweek October 29,\\n2001: 40.\\nCenters for Disease Control. .\\nKolata, Gina. ‘‘Antibiotics and Antitoxins.’’New York\\nTimes October 23, 2001: Section D, page 4, second\\ncolumn.\\nPark, Alice. ‘‘Anthrax: A Medical Guide.’’Time 158, no. 19\\n(October 29, 2001): 44.\\nShapiro, Bruce. ‘‘Anthrax Anxiety.’’The Nation 273, no. 4\\n(November 5, 2001): 4.\\nWade, Nicholas. ‘‘How a Patient Assassin Does Its Deadly\\nWork.’’ New York Times October 23, 2001: Section D,\\npage 1.\\nCarol A. Turkington\\nAntiacne drugs\\nDefinition\\nAntiacne drugs are medicines that help clear up\\npimples, blackheads, whiteheads, and more severe\\nforms ofacne.\\nPurpose\\nDifferent types of antiacne drugs are used for\\ndifferent purposes. For example, lotions, soaps, gels,\\nand creams containing benzoyl peroxide or tretinoin\\nmay be used to clear up mild to moderately severe\\nacne. Isotretinoin (Accutane) is prescribed only for\\nvery severe, disfiguring acne.\\nAcne is a skin condition that occurs when pores or\\nhair follicles become blocked. This blockage allows a\\nwaxy material called sebum to collect inside the pores\\nor follicles. Normally, sebum flows out onto the skin\\n240 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiacne drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and hair to form a protective coating, but when it\\ncannot get out, small swellings develop on the skin\\nsurface. Bacteria and dead skin cells can also collect\\nthat can cause inflammation. Swellings that are small\\nand not inflamed are whiteheads or blackheads. When\\nthey become inflamed, they turn into pimples. Pimples\\nthat fill with pus are called pustules.\\nThe severity of acne is often influenced by seaso-\\nnal changes; it is typically less severe in summer than in\\nwinter. In addition, acne in girls is often affected by the\\nmenstrual cycle.\\nAcne cannot be cured, but acne drugs can help\\nclear the skin. Benzoyl peroxide and tretinoin work\\nby mildly irritating the skin. This encourages skin\\ncells to slough off, which helps open blocked pores.\\nBenzoyl peroxide also kills bacteria, which helps pre-\\nvent whiteheads and blackheads from turning into\\npimples. Isotretinoin shrinks the glands that produce\\nsebum.\\nDescription\\nBenzoyl peroxide is found in many over-the-counter\\nacne products that are applied to the skin, such\\nas Benoxyl, Clear By Design, Neutrogena Acne,\\nPanOxyl, and some formulations of Clean & Clear,\\nClearasil, and Oxy. Some benzoyl peroxide products\\nare available without a physician’s prescription; others\\nrequire a prescription. Tretinoin (Retin-A) is available\\nonly with a physician’s prescription and comes in\\nliquid, cream, and gel forms, which are applied to the\\nskin. Isotretinoin (Accutane), which is taken by mouth\\nin capsule form, is available only with a physician’s\\nprescription. Only physicians who have experience\\nin diagnosing and treating severe acne, such as derma-\\ntologists, should prescribe isotretinoin.\\nSome newer antiacne preparations combine\\nbenzoyl peroxide with antibiotics. One combination\\nof benzoyl peroxide with clindamycin is sold under\\nthe trade name BenzaClin.\\nMany antiacne preparations contain compounds\\nderived from plants that have anti-inflammatory\\nproperties. One group of researchers listed thirty-\\neight different plants that are beneficial in treating\\nacne and other inflammatory skin conditions.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiacne drug. These drugs usually come with written\\ndirections for patients and should be used only as\\ndirected. Patients who have questions about how to\\nuse the medicine should check with a physician or\\npharmacist.\\nPatients who use isotretinoin usually take the\\nmedicine for a few months, then stop for at least two\\nmonths. Their acne may continue to improve even\\nAnti-Acne Drugs\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\nAccutane (isotretinoin) Dry skin, dry mouth, conjunctivitis\\nBenzamycin Dry and itchy skin\\nCleocin T(clindamycin\\nphosphate)\\nDry skin\\nDesquam-E(benzoyl peroxide) Itching, red and peeling skin\\nErythromycin topical (A/T/S,\\nerycette, t-stat)\\nBurning, dry skin, hives, red and\\npeeling skin\\nMinocin (minocycline\\nhydrochloride)\\nHeadache, hives, diarrhea, peeling\\nskin, vomiting\\nRetin-A (tretinoin) Darkening of the skin, blistering,\\ncrusted, or puffy skin\\nKEY TERMS\\nAcne— A skin condition in which raised bumps,\\npimples, and cysts form on the face, neck,\\nshoulders and upper back.\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nBowel— The intestine; a tube-like structure that\\nextends from the stomach to the anus. Some diges-\\ntive processes are carried out in the bowel before\\nfood passes out of the body as waste.\\nCyst— An abnormal sac or enclosed cavity in the\\nbody, filled with liquid or partially solid material.\\nDermatologist— A doctor who specializes in treat-\\ning diseases and disorders of the skin.\\nEczema— Inflammation of the skin with itching and\\na rash. The rash may have blisters that ooze and\\nform crusts.\\nPimple— A small, red swelling of the skin.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nPus— Thick, whitish or yellowish fluid that forms in\\ninfected tissue.\\nTriglyceride— A substance formed in the body from\\nfat in the diet.\\nGALE ENCYCLOPEDIA OF MEDICINE 241\\nAntiacne drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='after they stop taking the medicine. If the condition is\\nstill severe after several months of treatment and a\\ntwo-month break, the physician may prescribe a\\nsecond course of treatment.\\nPrecautions\\nIsotretinoin\\nIsotretinoin can cause seriousbirth defects, includ-\\ning mental retardation and physical deformities. This\\nmedicine should not be used during pregnancy.\\nWomen who are able to bear children should not use\\nisotretinoin unless they have very severe acne that has\\nnot cleared up with the use of other antiacne drugs. In\\nthat case, a woman who uses this drug must have a\\npregnancy test two weeks before beginning treatment\\nand each month they are taking the drug. Another\\npregnancy test must be done one month after treat-\\nment ends. The woman must use an effective birth\\ncontrol method for one month before treatment begins\\nand must continue using it throughout treatment and\\nfor one month after treatment ends. Women who are\\nable to bear children and who want to use this medi-\\ncine should discuss this information with their health\\ncare providers. Before using the medicine, they will\\nbe asked to sign a consent form stating that they\\nunderstand the danger of taking isotretinoin during\\npregnancy and that they agree to use effective birth\\ncontrol.\\nDo not donate blood to a blood bank while taking\\nisotretinoin or for 30 days after treatment with the\\ndrug ends. This will help reduce the chance of a preg-\\nnant woman receiving blood containing isotretinoin,\\nwhich could cause birth defects.\\nIsotretinoin may cause a sudden decrease in night\\nvision. If this happens, do not drive or do anything else\\nthat could be dangerous until vision returns to normal.\\nLet the physician know about the problem.\\nThis medicine may also make the eyes, nose, and\\nmouth dry. Ask the physician about using special eye\\ndrops to relieve eye dryness. To temporarily relieve\\nthe dry mouth, chew sugarless gum, suck on sugarless\\ncandy or ice chips, or use saliva substitutes, which\\ncome in liquid and tablet forms and are available\\nwithout a prescription. Ifthe problem continues for\\nmore than two weeks, check with a physician or\\ndentist. Mouth dryness that continues over a long\\ntime may contribute totooth decay and other dental\\nproblems.\\nIsotretinoin may increase sensitivity to sunlight.\\nPatients being treated with this medicine should avoid\\nexposure to the sun and should not use tanning beds,\\ntanning booths, or sunlamps until they know how the\\ndrug affects them.\\nIn the early stages of treatment with isotretinoin,\\nsome people’s acne seems to get worse before it starts\\ngetting better. If the condition becomes much worse or\\nif the skin is very irritated, check with the physician\\nwho prescribed the medicine.\\nBenzoyl peroxide and tretinoin\\nWhen applying antiacne drugs to the skin, be\\ncareful not to get the medicine in the eyes, mouth, or\\ninside of the nose. Do not put the medicine on skin\\nthat is wind burned, sunburned, or irritated, and do\\nnot apply it to openwounds.\\nBecause such antiacne drugs as benzoyl peroxide\\nand tretinoin irritate the skin slightly, avoid doing\\nanything that might cause further irritation. Wash\\nthe face with mild soap and water only two or three\\ntimes a day, unless the physician says to wash it more\\noften. Avoid using abrasive soaps or cleansers and\\nproducts that might dry the skin or make it peel,\\nsuch as medicated cosmetics, cleansers that contain\\nalcohol, or other acne products that contain resorci-\\nnol, sulfur or salicylic acid.\\nIf benzoyl peroxide or tretinoin make the skin too\\nred or too dry or cause too much peeling, check with a\\nphysician. Using the medicine less often or using a\\nweaker strength may be necessary.\\nTretinoin may increase sensitivity to sunlight.\\nWhile being treated with this medicine, avoid exposure\\nto the sun and do not use tanning beds, tanning\\nbooths, or sunlamps. If it is not possible to avoid\\nbeing in the sun, use a sunscreen with a skin protection\\nfactor (SPF) of at least 15 or wear protective clothing\\nover the treated areas. The skin may also become\\nmore sensitive to cold and wind. People who use this\\nmedicine should protect their skin from cold and wind\\nuntil they know how the medicine affects them.\\nBenzoyl peroxide may discolor hair or colored\\nfabrics.\\nSpecial conditions\\nPeople who have certain medical conditions or\\nwho are taking certain other medicines may have pro-\\nblems if they use antiacne drugs. Before using these\\nproducts, be sure to let the physician know about any\\nof these conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto etretinate, isotretinoin, tretinoin, vitamin A prepara-\\ntions, or benzoyl peroxide in the past should let his or\\n242 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiacne drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='her physician know before using an antiacne drug. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Women who are pregnant or who\\nmay become pregnant should check with a physician\\nbefore using tretinoin or benzoyl peroxide.Isotretinoin\\ncauses birth defects in humans and must not be used\\nduring pregnancy.\\nBREASTFEEDING. No problems have been reported\\nin nursing babies whose mothers used tretinoin or\\nbenzoyl peroxide. Women who are breastfeeding\\nbabies should not take isotretinoin, however, as it\\nmay cause problems in nursing babies.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nacne drugs applied to the skin, people with any of these\\nmedical problems should make sure their physicians\\nare aware of their conditions:\\n/C15eczema. Antiacne drugs that are applied to the skin\\nmay make this condition worse.\\n/C15sunburn or raw skin. Antiacne drugs that are applied\\nto the skin may increase thepain and irritation of\\nthese conditions.\\nIn people with certain medical conditions, iso-\\ntretinoin may increase the amount of triglyceride\\n(a fatty-substance) in the blood. This may lead to\\nheart or blood vessel problems. Before using isotreti-\\nnoin, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15alcoholism or heavy drinking, now or in the past\\n/C15diabetes (or family history of diabetes). Isotretinoin\\nmay also change blood sugar levels.\\n/C15family history of high triglyceride levels in the blood\\n/C15severe weight problems.\\nUSE OF CERTAIN MEDICINES. Using antiacne drugs\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nIsotretinoin\\nMinor discomforts such as dry mouth or nose,\\ndry eyes, dry skin, oritching usually go away as the\\nbody adjusts to the drug and do not require medical\\nattention unless they continue or are bothersome.\\nOther side effects should be brought to a physi-\\ncians attention. These include:\\n/C15burning, redness, or itching of the eyes\\n/C15nosebleeds\\n/C15signs of inflammation of the lips, such as peeling,\\nburning, redness or pain\\nBowel inflammation is not a common side effect,\\nbut it may occur. If any of the following signs of bowel\\ninflammation occur, stop taking isotretinoin immedi-\\nately and check with a physician:\\n/C15pain in the abdomen\\n/C15bleeding from the rectum\\n/C15severe diarrhea\\nBenzoyl peroxide and tretinoin\\nThe most common side effects of antiacne drugs\\napplied to the skin are slight redness, dryness, peeling,\\nand stinging, and a warm feeling to the skin. These\\nproblems usually go away as the body adjusts to the\\ndrug and do not require medical treatment.\\nOther side effects should be brought to a physi-\\ncian’s attention. Check with a physician as soon as\\npossible if any of the following side effects occur:\\n/C15blistering, crusting or swelling of the skin\\n/C15severe burning or redness of the skin\\n/C15darkening or lightening of the skin. (This effect will\\neventually go away after treatment with an antiacne\\ndrug ends.)\\n/C15skin rash\\nOther side effects are possible with any type of\\nantiacne drug. Anyone who has unusual symptoms\\nwhile using antiacne drugs should get in touch with\\nhis or her physician.\\nInteractions\\nPatients using antiacne drugs on their skin should\\ntell their physicians if they are using any other pre-\\nscription or nonprescription (over-the-counter) medi-\\ncine that they apply to the skin in the same area.\\nIsotretinoin may interact with other medicines.\\nWhen this happens, the effects of one or both drugs\\nmay change or the risk of side effects may be greater.\\nAnyone who takes isotretinoin should let the physi-\\ncian know about all other medicines he or she is taking\\nand should ask whether the possible interactions can\\ninterfere with drug therapy. Among the drugs that\\nmay interact with isotretinoin are:\\n/C15etretinate (Tegison), used to treat severepsoriasis.\\nUsing this medicine with isotretinoin increases side\\neffects.\\n/C15tretinoin (Retin-A, Renova). Using this medicine\\nwith isotretinoin increases side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 243\\nAntiacne drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15vitamin A or any medicine containing vitamin A.\\nUsing any vitamin A preparations with isotretinoin\\nincreases side effects. Do not take vitamin supple-\\nments containing vitamin A while taking isotretinoin.\\n/C15tetracyclines (used to treat infections). Using these\\nmedicines with isotretinoin increases the chance of\\nswelling of the brain. Make sure the physician knows\\nif tetracycline is being used to treat acne or another\\ninfection.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Acne.’’ Section 10, Chapter 116 InThe Merck\\nManual of Diagnosis and Therapy. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Warts (Verrucae).’’ Section 10, Chapter 115 In\\nThe Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nWilson, Billie Ann, Margaret T. Shannon, and Carolyn L.\\nStang. Nurse’s Drug Guide 2003. Upper Saddle River,\\nNJ: Prentice Hall, 2003.\\nPERIODICALS\\nBreneman, D., R. Savin, C. Van dePol, et al. ‘‘Double-Blind,\\nRandomized, Vehicle-Controlled Clinical Trial of\\nOnce-Daily Benzoyl Peroxide/Clindamycin Topical Gel\\nin the Treatment of Patients with Moderate to Severe\\nRosacea.’’ International Journal of Dermatology 43\\n(May 2004): 381–387.\\nDarshan, S., and R. Doreswamy. ‘‘Patented\\nAntiinflammatory Plant Drug Development from\\nTraditional Medicine.’’Phytotherapy Research 18 (May\\n2004): 343–357.\\nHalder, R. M., and G. M. Richards. ‘‘Topical Agents Used\\nin the Management of Hyperpigmentation.’’Skin\\nTherapy Letter 9 (June-July 2004): 1–3.\\nKligman, D. E., and Z. D. Draelos. ‘‘High-Strength\\nTretinoin for Rapid Retinization of Photoaged\\nFacial Skin.’’ Dermatologic Surgery 30 (June 2004):\\n864–866.\\nLeyden, J. J., D. Thiboutot, and A. Shalita. ‘‘Photographic\\nReview of Results from a Clinical Study Comparing\\nBenzoyl Peroxide 5%/Clindamycin 1% Topical Gel\\nwith Vehicle in the Treatment of Rosacea.’’Cutis 73,\\nSupplement 6 (June 2004): 11–17.\\nORGANIZATIONS\\nAmerican Academy of Dermatology (AAD). P. O. Box\\n4014, Schaumburg, IL 60168-4014. (847) 330-0230.\\n.\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888)\\nINFO-FDA. .\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAntiandrogen drugs\\nDefinition\\nAntiandrogen drugs are a diverse group of medi-\\ncations given to counteract the effects of androgens\\n(male sex hormones) on various body organs and\\ntissues. Some medications in this category work by\\nlowering the body’s production of androgens while\\nothers work by blocking the body’s ability to make\\nuse of the androgens that are produced. The first\\ngroup of antiandrogens includes such medications as\\nleuprolide (Lupron, Viadur, or Eligard), goserelin\\n(Zoladex), triptorelin (Trelstar Depot), and abarelix\\n(Plenaxis). The second group includes flutamide\\n(Eulexin), nilutamide (Nilandron), cyproterone acet-\\nate (Cyprostat, Androcur, Cyproterone), and bicalu-\\ntamide (Casodex). Flutamide, nilutamide, and\\nbicalutamide are nonsteroidal antiandrogen drugs\\nwhile cyproterone acetate is a steroidal medication.\\nSome drugs that were originally developed to treat\\nother conditions are sometimes categorized as antian-\\ndrogens because their off-label uses include some of\\nthe disorders listed below. These drugs include\\nmedroxyprogesterone (Depo-Provera), a derivative of\\nthe female sex hormone progesterone that is used as a\\ncontraceptive and treatment for abnormal uterine\\nbleeding; ketoconazole (Nizoral), an antifungal drug;\\nand spironolactone (Aldactone), a diuretic.\\nPurpose\\nAntiandrogen drugs may be given for any of\\nseveral conditions or disorders, ranging from skin\\nproblems to mental disorders:\\n/C15Prostate cancer. Antiandrogen medications may be\\nused to treat both early-stage and advanced prostate\\ncancer by lowering or blocking the supply of male sex\\nhormones that encourage the growth and spread of\\nthe cancer.\\n/C15Androgenetic alopecia. Androgenetic alopecia is a\\ntype of hair loss that is genetically determined and\\n244 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='affects both men and women. It is sometimes called\\npattern baldness.\\n/C15Acne. Acne is the end result of several factors, one of\\nwhich is excessive production of sebum, a whitish\\nsemiliquid greasy substance produced by certain\\nglands in the skin. Antiandrogens may help to clear\\nacne by slowing down the secretion of sebum, which\\ndepends on androgen production.\\n/C15Amenorrhea. Amenorrhea, or the absence of men-\\nstrual periods in females of childbearing age, is some-\\ntimes caused by excessively high levels of androgens\\nin the blood. Antiandrogen medications may help to\\nrestore normal menstrual periods.\\n/C15Hirsutism. Hirsutism is a condition in which women\\ndevelop excessive facial and body hair in a distribu-\\ntion pattern usually associated with adult males.\\nIt results from abnormally high levels of androgens\\nin the bloodstream or from increased sensitivity of\\nthe hair follicles to normal levels of androgens.\\nHirsutism may be a sign ofpolycystic ovary syn-\\ndrome (PCOS), a condition in which the ovaries\\ndevelop multiple large cysts and produce too\\nmuch androgen.\\n/C15Gender reassignment. Antiandrogen drugs are often\\nprescribed for male-to-female (MTF) transsexuals as\\npart of the hormonal treatment that precedes gender\\nreassignment surgery.\\n/C15Paraphilias. Paraphilias are a group of mental dis-\\norders characterized by intense and recurrent sexual\\nurges or behaviors involving nonhuman objects, chil-\\ndren or nonconsenting adults, orpain and humilia-\\ntion. Antiandrogen drugs have been prescribed for\\nmen diagnosed with paraphilias in order to lower\\nblood serum levels of testosterone and help them\\ncontrol their sexual urges.\\n/C15Virilization. Virilization is an extreme form of hyper-\\nandrogenism in females, marked by such changes\\nas development of male pattern baldness, voice\\nchanges, and overdevelopment of the skeletal mus-\\ncles. Antiandrogens may be given to correct this\\ncondition.\\nDescription\\n/C15Leuprolide. Leuprolide is classified as a luteinizing\\nhormone-releasing hormone (LHRH) agonist,\\nwhich means that it resembles a chemical produced\\nby the hypothalamus (a gland located in the brain)\\nthat lowers the level of testosterone in the blood-\\nstream. It also reduces levels of estrogen in girls\\na n dw o m e n ,a n dm a yb eu s e dt ot r e a tendome-\\ntriosis or tumors in the uterus. It is presently\\nunder investigation as a possible treatment for\\nthe paraphilias.\\n/C15Goserelin. Goserelin is also an LHRH agonist, and\\nworks in the same way as leuprolide.\\n/C15Triptorelin. Triptorelin is an LHRH agonist, and\\nworks in the same way as leuprolide. It is not usually\\ngiven to women, however.\\n/C15Abarelix. Abarelix is a newer drug that works by\\nblocking hormone receptors in the pituitary gland.\\nIt is recommended for the treatment of prostate can-\\ncer in men with advanced disease who refuse surgery,\\ncannot take other hormonal treatments, or are poor\\ncandidates for surgery.\\n/C15Ketoconazole. Ketoconazole is an antifungal drug\\navailable in tablets to be taken by mouth. Its use in\\ntreating hirsutism is off-label.\\n/C15Flutamide. Flutamide is a nonsteroidal antiandro-\\ngen medication that blocks the use of androgen by\\nthe body.\\n/C15Nilutamide. Nilutamide is another nonsteroidal anti-\\nandrogen drug that works by blocking the body’s use\\nof androgens.\\n/C15Bicalutamide. Bicalutamide is a nonsteroidal antian-\\ndrogen medication that works in the same way as\\nflutamide.\\n/C15Cyproterone acetate. Cyproterone acetate is a steroi-\\ndal antiandrogen drug that works by lowering testo-\\nsterone production as well as blocking the body’s use\\nof androgens.\\n/C15Medroxyprogesterone. Medroxyprogesterone is a\\nsynthetic derivative of progesterone that prevents\\novulation and keeps the lining of the uterus from\\nbreaking down, thus preventing uterine bleeding.\\n/C15Spironolactone. Spironolactone is a potassium-\\nsparing diuretic that may be given to treat androgen\\nexcess in women.\\nRecommended dosage\\n/C15Leuprolide. Leuprolide is available in an injectable\\nform and as an implant. The implant form, used to\\ntreat prostate cancer, contains 22.5 mg of leuprolide\\nand is inserted under the skin every three months.\\nThis type of slow-release medication is called depot\\nform. A longer-acting implant that lasts 12 months\\nis also available. Injectable leuprolide is injected\\nonce a day in a 1-mg dose to treat prostate cancer.\\nThe dosage for endometriosis or uterine tumors is\\n3.75 mg injected into a muscle once a month for three\\nto six months.\\nGALE ENCYCLOPEDIA OF MEDICINE 245\\nAntiandrogen drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Goserelin. Goserelin is implanted under the skin of\\nthe upper abdomen. The dosage for treating cancer\\nof the prostate is one 3.6-mg implant every 28 days\\nor one 10.8-mg implant every 12 weeks. For treating\\nendometriosis, the dosage is one 3.6-mg implant\\nevery 28 days for six months.\\n/C15Triptorelin. Triptorelin is given as a long-lasting\\ninjection for treatment of prostate cancer or\\nparaphilias. The usual dose for either condition is\\n3.75 mg, injected into a muscle once a month.\\n/C15Abarelix. Abarelix is given in 100-mg doses by deep\\ninjection into the muscles of the buttocks. It is given\\non days 1, 15, and 29 of treatment, then every four\\nweeks for a total treatment duration of 12 weeks.\\n/C15Ketoconazole. For treatment of hirsutism, 400 mg by\\nmouth once per day.\\n/C15Flutamide. Flutamide is available in capsule as\\nwell as tablet form. For treatment of prostate cancer,\\n250 mg by mouth three times a day. For virilization\\nor hyperandrogenism in women, 250 mg by mouth\\nthree times a day. It should be used in women, how-\\never, only when other treatments have proved\\nineffective.\\n/C15Nilutamide. To treat prostate cancer, nilutamide is\\ntaken in a single 300-mg daily dose by mouth for the\\nfirst 30 days of therapy, then a single daily dose of\\n150 mg..\\n/C15Bicalutamide. Bicalutamide is taken by mouth in a\\nsingle daily dose of 50 mg to treat prostate cancer.\\n/C15Cyproterone acetate. Cyproterone is taken by mouth\\nthree times a day in 100-mg doses to treat prostate\\ncancer. The dose for treating hyperandrogenism or\\nvirilization in women is one 50-mg tablet by mouth\\neach day for the first ten days of the menstrual cycle.\\nCyproterone acetate given to treat acne is usually\\ngiven in the form of an oral contraceptive (Diane-\\n35) that combines the drug (2 mg) with ethinyl estra-\\ndiol (35 mg). Diane-35 is also taken as hormonal\\ntherapy by MTF transsexuals. The dose for treating\\nparaphilias is 200–400 mg by injection in depot form\\nevery 1–2 weeks, or 50–200 mg by mouth daily.\\n/C15Medroxyprogesterone. For the treatment of para-\\nphilias, given as an intramuscular 150-mg injection\\ndaily, weekly, or monthly, depending on the patient’s\\nserum testosterone levels, or as an oral dose of 100–\\n400 mg daily. As hormonal therapy for MTF trans-\\nsexuals, 10–40 mg per day. For polycystic ovary\\nsyndrome, 10 mg daily for 10 days.\\n/C15Spironolactone. For hyperandrogenism in women,\\n100–200 mg per day by mouth; for polycystic ovary\\nsyndrome, 50–200 mg per day. For the treatment of\\nacne, 200 mg per day. For hormonal therapy for\\nMTF transsexuals, 200–400 mg per day. A topical\\nform of spironolactone is available for the treatment\\nof androgenetic alopecia.\\nPrecautions\\n/C15Leuprolide. Leuprolide should not be used by preg-\\nnant or nursing women, by patients diagnosed with\\nspinal compression, or by patients allergic to the\\ndrug. Women taking leuprolide should not try to\\nbecome pregnant, and should use methods of birth\\ncontrol that do not contain hormones.\\n/C15Goserelin. Goserelin should not be used duringpreg-\\nnancy or lactation, or by patients known to be allergic\\nto it. As with leuprolide, women taking goserelin\\nshould use methods of contraception that do not\\ncontain hormones.\\n/C15Triptorelin. Patients using triptorelin should see their\\ndoctor at regular intervals for monitoring of side\\neffects.\\n/C15Abarelix. Abarelix should not be given to children or\\nwomen. Because of the severity of this drug’s possible\\nside effects, doctors who prescribe it for men must be\\ncertified following successful completion of a safety\\nprogram for its proper use.\\n/C15Ketoconazole. Ketoconazole should not be given\\nto alcoholic patients or those allergic to the drug. In\\naddition, patients using ketoconazole should have\\ntheir liver function monitored by their doctor.\\n/C15Flutamide. Flutamide should not be used by preg-\\nnant women. Patients taking flutamide should have\\ntheir liver function monitored carefully. They should\\nnotify their doctor at once if they have pain in the\\nupper right side of the abdomen or a yellowish dis-\\ncoloration of the eyes and skin, as these are signs of\\nliver damage. In addition, patients using this drug\\nshould not discontinue taking it without telling their\\ndoctor.\\n/C15Nilutamide. This drug should not be given to\\npatients who are allergic to it, have severe respiratory\\nproblems, or have been diagnosed with a liver dis-\\norder. Patients taking this drug should discontinue\\nusing alcoholic beverages while they are being trea-\\nted with it.\\n/C15Bicalutamide. The precautions while using this drug\\nare the same as those for flutamide.\\n/C15Cyproterone acetate. This drug has not been\\napproved by the Food and Drug Administration\\n(FDA) for use in the United States, but is approved\\nfor use in Canada and the United Kingdom. It\\n246 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='should not be used during pregnancy or lactation, or\\nby patients withliver disease. Men who are taking\\nthis drug for treatment of paraphilias should not use\\nalcohol.\\n/C15Medroxyprogesterone. This drug should not be\\ngiven to patients with a history of blood clot forma-\\ntion in their blood vessels. It should be used with\\ncaution in patients withasthma, seizure disorders,\\nmigraine headaches, liver or kidney disorders, or\\nheart disease.\\n/C15Spironolactone. This drug should not be given to\\npatients with overly high levels of potassium in\\nthe blood or to patients with liver disease or kidney\\nfailure. It should also not be given to pregnant or\\nlactating women.\\nSide effects\\n/C15Leuprolide. Side effects of leuprolide in men may\\ninclude pains in the chest, groin, or legs; hot flashes,\\nloss of interest in sex, orimpotence; bone pain; sleep\\ndisturbances; and mood changes. Side effects in\\nwomen may include amenorrhea or light and irregu-\\nlar menstrual periods; loss of bone density; mood\\nchanges; burning oritching sensations in the vagina;\\nor pelvic pain.\\n/C15Goserelin. The side effects of goserelin may include\\nnausea and vomiting; they are otherwise the same as\\nfor leuprolide.\\n/C15Triptorelin. Side effects of triptorelin include pain in\\nthe bladder, difficulty urinating, or bloody or cloudy\\nurine; pain in the side or lower back; hot flashes or\\nheadache; loss of interest in sex or impotence;vomit-\\ning or diarrhea; unusual bleeding or bruising; pain at\\nthe injection site; unusual tiredness or sleep distur-\\nbances; depression or rapid mood changes. It may\\nalso cause a temporary enlargement of the tumor;\\nthis side effect is known as tumor flare.\\n/C15Abarelix. This drug may cause immediate life-threa-\\ntening allergic reactions following any dose. May\\nalso cause a loss of bone mineral density, irregular\\nheartbeat, hot flashes, sleep disturbances,gyneco-\\nmastia, or pain in the breasts and nipples.\\n/C15Ketoconazole. The side effects of ketoconazole\\ninclude nausea and vomiting, loss of appetite,\\nabdominal pain, skin rash or itching, uterine bleed-\\ning, breast pain, gynecomastia, hair loss, loss of\\ninterest in sex, and decline in sperm production.\\n/C15Flutamide. Flutamide has been reported to cause\\nbreast tenderness and gynecomastia in men as well\\nas fatigue, nausea, flu-like symptoms, and runny\\nnose; darkened urine; indigestion, constipation,\\ndiarrhea, or gas; bluish-colored or dry skin;dizziness;\\nand liver damage. These side effects may be intensi-\\nfied in patients who smoke.\\n/C15Nilutamide. The side effects of nilutamide are the\\nsame as those for flutamide. In addition, this drug\\nmay affect the ability of the eyes to adjust to sudden\\nchanges in light intensity or may make the eyes un-\\nusually sensitive to light. Another potential side effect\\nis difficulty breathing; this is more likely to occur in\\nAsian patients taking this drug than in Caucasians.\\n/C15Bicalutamide. The side effects of this drug are the\\nsame as those for flutamide.\\n/C15Cyproterone acetate. Cyproterone has been reported\\nto cause gynecomastia, impotence, loss of interest in\\nsex, deep venous thrombosis, and possible damage to\\nthe cardiovascular system.\\n/C15Medroxyprogesterone. The side effects of this drug\\ninclude high blood pressure, headache, nausea and\\nvomiting, changes in menstrual flow, breakthrough\\nbleeding, puffy skin (edema), weight gain, and sore or\\nswollen breasts.\\n/C15Spironolactone. Spironolactone may cause fatigue,\\nheadache, and drowsiness; gynecomastia and impo-\\ntence in men; abdominal cramps, nausea, vomiting,\\ndiarrhea, or loss of appetite; and skin rashes or\\nitching.\\nInteractions\\n/C15Leuprolide. No interactions with other medications\\nhave been reported.\\n/C15Goserelin. No interactions have been reported.\\n/C15Triptorelin. No interactions have been reported.\\n/C15Abarelix. Abarelix may interact with other medica-\\ntions that affect heart rhythm, including procaina-\\nmide, amiodarone, sotalol, and dofetilde.\\n/C15Ketoconazole. Ketoconazole interacts with a number\\nof drugs, including rifampin, warfarin, phenytoin,\\nantacids, cyclosporine, terfenadine, and astemizole.\\nIt may cause a sunburn-like skin reaction if used\\ntogether with alcohol.\\n/C15Flutamide. This drug has been reported to intensify\\nthe effects of warfarin (Coumadin) and other blood-\\nthinning medications. It has also been reported to\\nintensify the effects of phenytoin (Dilantin), a drug\\ngiven to control seizures.\\n/C15Nilutamide. Reported interactions are the same as for\\nflutamide; in addition, nilutamide has been reported\\nto intensify the effects of theophylline (Theo-Dur), a\\ndrug given to treat asthma.\\nGALE ENCYCLOPEDIA OF MEDICINE 247\\nAntiandrogen drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Bicalutamide. Reported interactions are the same as\\nfor flutamide.\\n/C15Cyproterone acetate. Patients taking oral medica-\\ntions to control diabetes may require dosage adjust-\\nments while taking this drug.\\n/C15Medroxyprogesterone. Patients taking phenobarbi-\\ntal, phenothiazine tranquilizers (chlorpromazine,\\nperphenazine, fluphenazine, etc.), or oral medica-\\ntions to control diabetes should consult their doctor\\nabout dosage adjustments.\\n/C15Spironolactone. Spironolactone is reported to\\ndecrease the effectiveness ofaspirin and anticoagu-\\nlants (blood thinners). It may also interact with potas-\\nsium supplements to increase the patient’s blood\\npotassium level.\\nResources\\nBOOKS\\n‘‘Amenorrhea.’’ Section 18, Chapter 235 inThe Merck\\nManual of Diagnosis and Therapy ,e d i t e db yM a r kH .\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders , 4th edition, text revision.\\nWashington, DC: American Psychiatric Association,\\n2000.\\n‘‘Paraphilias.’’ Section 15, Chapter 192 inThe Merck\\nManual of Diagnosis and Therapy ,e d i t e db yM a r k\\nH. Beers, MD, and Robert Berkow, MD.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2005.\\n‘‘Prostate Cancer.’’ Section 17, Chapter 233 inThe Merck\\nManual of Diagnosis and Therapy , edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nPERIODICALS\\nBradford, J. M. ‘‘The Neurobiology, Neuropharmacology,\\nand Pharmacological Treatment of the Paraphilias and\\nCompulsive Sexual Behavior.’’Canadian Journal of\\nPsychiatry 46 (February 2001): 26–34.\\nBrannon, Guy E., MD. ‘‘Paraphilias.’’eMedicine,1 7\\nOctober 2002. .\\nFeinstein, Robert, MD. ‘‘Androgenetic Alopecia.’’\\neMedicine, 2 October 2003. .\\nHarper, Julie C., MD, and James Fulton, Jr., MD. ‘‘Acne\\nVulgaris.’’ eMedicine, 29 July 2004. .\\nHunter, Melissa H., MD, and Peter J. Carek, MD.\\n‘‘Evaluation and Treatment of Women with\\nHirsutism.’’ American Family Physician 67 (June 15,\\n2003): 2565–2572.\\nHyperandrogenic Disorders Task Force. ‘‘American\\nAssociation of Clinical Endocrinologists Medical\\nGuidelines for Clinical Practice for the Diagnosis and\\nTreatment of Hyperandrogenic Disorders.’’Endocrine\\nPractice 7 (March-April 2001): 120–135.\\nKrueger, R. B., and M. S. Kaplan. ‘‘Depot-Leuprolide\\nAcetate for Treatment of Paraphilias: A Report of\\nTwelve Cases.’’Archives of Sexual Behavior 30 (August\\n2001): 409–422.\\nOriel, Kathleen A., MD, MS. ‘‘Medical Care of Transsexual\\nPatients.’’ Journal of the Gay and Lesbian Medical\\nAssociation 4 (April 2000): 185–194.\\nPatel, Vipul, MD, and Raymond J. Leveille, MD. ‘‘Prostate\\nCancer: Neoadjuvant Androgen Deprivation.’’\\neMedicine, 10 March 2005. .\\nRichardson, Marilyn R., MD. ‘‘Current Perspectives in\\nPolycystic Ovary Syndrome.’’American Family\\nPhysician 68 (August 15, 2003): 697–704.\\nThorneycroft, Ian, MD, PhD. ‘‘Androgen Excess.’’\\neMedicine, 28 February 2004. .\\nORGANIZATIONS\\nAmerican Academy of Dermatology (AAD). P. O. Box\\n4014, Schaumburg, IL 60168-4014. (847) 330-0230.\\nFax: (847) 330-0050. .\\nAmerican Association of Clinical Endocrinologists\\n(AACE). 1000 Riverside Avenue, Suite 205,\\nJacksonville, FL 32204. (904) 353-7878. Fax: (904)\\n353-8185. .\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nHarry Benjamin International Gender Dysphoria\\nAssociation, Inc. (HBIGDA). 1300 South Second\\nStreet, Suite 180, Minneapolis, MN 55454. (612)\\n624-9397. Fax: (612) 624-9541.\\n.\\nNational Cancer Institute (NCI). NCI Public Inquiries\\nOffice, Suite 3036A, 6116 Executive Boulevard,\\nMSC8332, Bethesda, MD 20892-8322. (800)\\n4-CANCER or (800) 332-8615 (TTY).\\n.\\nNational Institute of Mental Health (NIMH). 6001\\nExecutive Boulevard, Room 8184, MSC 9663,\\nBethesda, MD 20892-9663. (301) 443-4513 or (886)\\n615-NIMH. \\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888)\\nINFO-FDA. .\\nOTHER\\nNational Cancer Institute (NCI).Prostate Cancer (PDQ /C226):\\nTreatment, Health Professional version. .\\nRebecca J. Frey, PhD\\n248 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiandrogen drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Antianemia drugs\\nDefinition\\nAntianemia drugs are therapeutic agents which\\nincrease either the number of red cells or the amount\\nof hemoglobin in the blood.\\nPurpose\\nAnemia is a general term for a large number of\\nconditions marked by a reduction in the oxygen-\\ncarrying capacity of blood. Red blood cells carry\\noxygen in hemoglobin, so that anemia may be caused\\nby a deficiency of blood or red blood cells or of hemo-\\nglobin. These conditions may be caused by a variety\\nof other conditions. Injury can cause blood loss, which\\nin turn can cause anemia. Nutritional deficiency,\\ninadequate amounts of some of the vitamins and\\nminerals that are needed for hemoglobin production,\\nmay also cause anemia. Because hemoglobin is the\\npigment that makes blood cells red, a lack of hemo-\\nglobin will cause the cells to be a paler color, leading\\nto the term hypochromic, lacking in color.\\nOther conditions can also cause anemia. For\\nexample, certain diseases cause the condition. These\\ncan include infections andkidney disease, in which\\nthere is a deficiency of erythropoietin, a material pro-\\nduced in the kidneys which is essential for the produc-\\ntion of red blood cells. Certain genetic conditions\\naffect the absorption of nutrients and may lead to\\nanemia. In sickle cell anemia, a genetic condition in\\nwhich the red cells are curved rather than flat, the red\\ncells have reduced ability to carry oxygen.\\nThe Merck Manualreduces all types of anemia to\\nthree classes:\\n/C15blood loss\\n/C15inadequate production of blood\\n/C15excessive breakdown of blood cells\\nAnemia may be caused by one or a combination\\nof these three factors. Drug therapy is available for\\nmany types of anemia; however, the selection of the\\ndrug depends on proper diagnosis of the cause of the\\nanemia.\\nDescription\\nAnemia caused by blood loss is normally treated\\nwith either blood volume expanders such as plasma or\\nwith related blood products. More severe blood loss\\nmay require transfusions of red blood cells.\\nIn some cases, blood loss may be due to ulcers of\\nthe stomach or intestines. In these cases, treatment of\\nthe underlying cause will normally correct the anemia.\\nIron deficiency\\nThe most common cause of anemia in adults is\\niron deficiency. Although the typical American diet\\ncontains enough iron to meet normal needs, individuals\\nwho are less able to absorb and store iron may experi-\\nence inadequate hemoglobin production. Although the\\nbest way to meet daily iron requirements is through\\nimproved diet, iron supplements are widely used.\\nIron is normally taken in the form of ferrous\\nsulfate. Although other iron salts are commercially\\navailable and make claims of fewer or less severe side\\neffects, these benefits may be related to the fact that\\nother preparations cont a i nl e s si r o nb yw e i g h t .\\nFerrous sulfate contains about 37% iron, while fer-\\nrous gluconate contains only about 13% iron. People\\nwho have trouble with the side effects of ferrous\\nsulfate may benefit from some of the specialty pre-\\nparations available, but fe rrous sulfate normally\\noffers the greatest amount of iron of all commercial\\nproducts.\\nKEY TERMS\\nAnabolic steroid— Drugs, derived from the male\\nsex hormones, which increase the rate of tissue\\ngrowth. They are best known for increasing the\\nrate of muscle development.\\nAnemia— Any condition in which the amount of\\nhemoglobin in red cells, the number of red cells,\\nor the size of the red cells in blood is reduced from\\nthe normal.\\nCrohn’s disease— Chronic inflammation of the\\nintestine.\\nHemochromatosis— A disorder of iron metabolism\\ncharacterized by excessive absorption of iron from\\nfood.\\nHemoglobin— The red protein found in blood cells\\nwhich carries oxygen from the lungs to the tissues.\\nHemolytic anemia— A type of anemia marked by\\nthe breakdown of red blood cells causing the\\nrelease of hemoglobin.\\nSickle cell anemia— An inherited condition,\\nmarked by crescent-shaped red blood cells and\\nred cell breakdown.\\nGALE ENCYCLOPEDIA OF MEDICINE 249\\nAntianemia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nDosage should be calculated by iron needs, based\\non laboratory tests. Manufacturers recommend one\\ntablet a day, containing 65 mg of iron, as a supplement\\nfor patients over the age of 12 years.\\nPrecautions\\nIron can lead to lethalpoisoning in children. All\\niron supplements should be kept carefully out of reach\\nof children.\\nSome types of anemia do not respond to iron\\ntherapy, and the use of iron should be avoided in\\nthese cases. People with acquiredhemolytic anemia,\\nautoimmune hemolytic anemia, hemochromatosis,\\nhemolytic anemia and hemosiderosis should not take\\niron supplements. Hemolytic anemia is caused by\\nthe increased breakdown of red blood cells.\\nHemochromatosis and hemosiderosis and are condi-\\ntions in which there is too much, rather than too little,\\nabsorption of iron.\\nIron supplements should also be avoided by peo-\\nple who have gastric or intestinal ulcers,ulcerative\\ncolitis,o r Crohn’s disease. These conditions marked\\nby inflammation of the digestive tract, which would be\\nmade worse by use of iron.\\nSide effects\\nThe most common side effects of iron consump-\\ntion are stomach and intestinal problems, including\\nstomach upset with cramps, constipation, diarrhea,\\nnausea, and vomiting. At least 25% of patients have\\none or more of these side effects. The frequency and\\nseverity of the side effects increases with the dose of\\niron. Less frequent side effects includeheartburn and\\nurine discoloration.\\nInteractions\\nIron supplements should not be taken at the same\\ntime asantibiotics of either the tetracycline or quino-\\nlone types. The iron will reduce the effectiveness of the\\nantibiotic. Also, iron supplements reduces the effec-\\ntiveness of levodopa, which is used in treatment of\\nParkinson’s disease.\\nIron supplements should not be used with magne-\\nsium trisilicate, an antacid, or with penicillamine,\\nwhich is used for some types of arthritis.\\nTaking iron with vitamin C increases the absorp-\\ntion of iron, with no increase in side effects.\\nFolic acid\\nFolic acid is found in many common foods,\\nincluding liver, dried peas, lentils, oranges, whole-\\nwheat products, asparagus, beets, broccoli, brussel\\nsprouts, and spinach. However, in some cases, patients\\nhave difficulty absorbing folic acid or in converting it\\nfrom the form found in foods to the form that is active\\nin blood formation. In these cases, folic acid tablets are\\nappropriate for use.\\nRECOMMENDED DOSAGE. For treatment of ane-\\nmia, a daily dose of 1 mg is generally used. Patients\\nwho have trouble absorbing folic acid may require\\nhigher doses.\\nMaintenance doses are:\\n/C15infants: 0.1 mg/day\\n/C15children (under 4 years of age): up to 0.3 mg/day\\n/C15children (over 4 years of age) and adults: 0.4 mg/day\\n/C15pregnant and lactating women: 0.8 mg/day\\nPRECAUTIONS. Before treating an anemia with\\nfolic acid, diagnostic tests must be performed to verify\\nthe cause of the anemia.Pernicious anemiacaused by\\nlack of vitamin B12 shows symptoms that are very\\nsimilar to those of folic acid deficiency but also causes\\nnerve damage which shows up as atingling sensation\\nand feelings ofnumbness. Giving folic acid to patients\\nwith B\\n12 deficiency anemia improves the blood cell\\ncount, but the nerve damage continues to progress.\\nSIDE EFFECTS. Folic acid is considered extremely\\nsafe, and there are no predictable side effects. Where\\nside effects have been reported, they have been among\\npatients taking many times more than the normal\\ntherapeutic dose of the drug.\\nOn rare occasions allergic reactions to folic acid\\nhave been reported.\\nINTERACTIONS. Phenytoins, used to treat seizure\\ndisorders, interact with folic acid with a reduction in\\nphenytoin effectiveness and an increased risk of\\nseizures. If the two drugs must be used together, phe-\\nnytoin blood levels should be monitored, and the dose\\nmay have to be increased.\\nTrimethoprim (an antibacterial) and methotrex-\\nate (originally an anti-cancer drug, which is also used\\nfor arthritis andpsoriasis) act by reducing the meta-\\nbolism of folic acid. Regular blood monitoring is\\nrequired, and dose adjustments may be needed.\\nVitamin B\\n12\\nVitamin B12 is also known as cyanocobalamine\\nand hydroxocobalamine. Cyanocobalamine may be\\n250 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianemia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='given by mouth, while hydroxocobalamine must be\\ninjected. The vitamin has many functions in the\\nbody, including maintaining the nervous system, but\\nin treatment of anemia B\\n12 is needed for the metabo-\\nlism of folic acid. Lack of B12 causes pernicious ane-\\nmia, a type of anemia which is marked by a low red cell\\ncount and lack of hemoglobin. There are many other\\nsymptoms of pernicious anemia, including a feeling of\\ntingling or numbness, shortness of breath, muscle\\nweakness, faintness, and a smooth tongue. If perni-\\ncious anemia is left untreated for more than three\\nmonths, permanent damage to the nerves of the spinal\\ncord may result.\\nRECOMMENDED DOSAGE. While vitamin B12 can\\nbe given by mouth for mild vitamin deficiency states,\\npernicious anemia should always be treated with injec-\\ntions, either under the skin (subcutaneous) or into\\nmuscle (intramuscular). Hydroxocobalamine should\\nonly be injected into muscle. Intravenous injections\\nare not used because the vitamin is eliminated from\\nthe body too quickly when given this way. Elderly\\npatients, whose ability to absorb vitamin B\\n12 through\\nthe stomach may be impaired, should also be treated\\nwith injections only.\\nThe normal dose of cyanocobalamine is 100 mcg\\n(micrograms) daily for six to seven days. If improve-\\nment is seen, the dose may be reduced to 100 mcg every\\nother day for seven doses and then 100 mcg every three\\nto four days for two to three weeks. After that,\\nmonthly injections may be required for life.\\nPRECAUTIONS. Although vitamin B12 has a very\\nhigh level of safety, commercial preparations may\\ncontain preservatives which may cause allergic\\nresponses.\\nIn patients with pernicious anemia, treatment\\nwith vitamin B\\n12 may lead to loss of potassium.\\nPatients should be monitored for their potassium\\nlevels.\\nSIDE EFFECTS. Diarrhea and itching of the skin\\nhave been reported on rare occasions. Moreover,\\nthere have been reports of severe allergic reactions to\\ncyanocobalamine.\\nINTERACTIONS. Aminosalicylic acid may reduce\\nthe effectiveness of vitamin B12. Also, colchicine, a\\ndrug used for gout, may reduce the effectiveness\\nof vitamin B12. Other, infrequently used drugs and\\nexcessive use of alcohol may also affect the efficacy\\nof vitamin B12. Patients being treated for anemia\\nshould discuss all medications, both prescription\\nand nonprescription, with their physician or\\npharmacist.\\nAnabolic steroids\\nThe anabolic steroids (nandrolone, oxymetho-\\nlone, oxandrolone, and stanzolol) are the same drugs\\nthat are used improperly by body builders to increase\\nmuscle mass. Two of these drugs, nandrolone and\\noxymetholone, are approved for use in treatment of\\nanemia. Nandrolone is indicated for treatment of ane-\\nmia caused by kidney failure, while oxymetholone\\nmay be used to treat anemia caused by insufficient\\nred cell production, such asaplastic anemia.\\nAll anabolic steroids are considered to be drugs of\\nabuse under United States federal law.\\nRECOMMENDED DOSAGE. The information that\\nfollows is specific only to oxymetholone; however,\\nthe warnings and precautions apply to all drugs in\\nthe class of anabolic steroids.\\nThe dosage of oxymetholone must be individual-\\nized. The most common dose is 1 to 2 mg per kilogram\\nof body weight per day, although doses as high as 5 mg\\nper kilogram per day have been used. The response to\\nthese drugs is slow, and it may take several months to\\nsee if there is any benefit.\\nPRECAUTIONS. All anabolic steroids are danger-\\nous. The following warnings represent the most\\nsignificant hazards of these drugs. For a complete\\nlist, patients should consult the manufacturer’s pack-\\nage insert.\\n/C15Peliosis hepatitis, a condition in which liver and\\nsometimes spleen tissue is replaced with blood-filled\\ncysts, has occurred in patients receiving androgenic\\nanabolic steroids. Although this condition is usually\\nreversible by discontinuing the drug, if it is left unde-\\ntected and untreated, it may lead to life-threatening\\nliver failure or bleeding.\\n/C15Liver tumors may develop. Although most of these\\ntumors are benign and will go away when the drug is\\ndiscontinued, liver cancers may also result.\\n/C15Anabolic steroids may cause changes in blood lipids,\\nleading toatherosclerosis with greatly increased risk\\nof heart attack.\\n/C15Because anabolic steroids are derived from male sex\\nhormones, masculinization may occur when they are\\nused by women.\\n/C15Elderly men who use these drugs may be at increased\\nrisk of prostate enlargement and prostatecancer.\\n/C15Increased water retention due to anabolic steroids\\nmay lead to heart failure.\\n/C15Anabolic steroids should not be used during\\npregnancy, since this may cause masculinization of\\nthe fetus.\\nGALE ENCYCLOPEDIA OF MEDICINE 251\\nAntianemia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Anabolic steroids should be used in children only if\\nthere is no possible alternative. These drugs may\\ncause the long bones of the legs to stop growing\\nprematurely, leading to reduction in adult height.\\nRegular monitoring is essential.\\n/C15In patients with epilepsy, the frequency of seizures\\nmay be increased.\\n/C15In patients with diabetes, glucose tolerance may be\\naltered. Careful monitoring is essential.\\nSIDE EFFECTS. The list of side effects associated\\nwith anabolic steroids is extremely long. The following\\nlist covers only the most commonly observed effects:\\n/C15acne\\n/C15increased urinary frequency\\n/C15breast growth in males\\n/C15breast pain\\n/C15persistent, painful erections\\n/C15masculinization in women\\nINTERACTIONS. Anabolic steroids should not be\\nused in combination with anticoagulants such as war-\\nfarin. Anabolic steroids increase the effects of the\\nanticoagulant, possibly leading to bleeding. If the\\ncombination cannot be avoided, careful monitoring\\nis essential.\\nEpoetin alfa\\nEpoetin alfa is a synthetic form of a protein pro-\\nduced by the kidneys that stimulates the production\\nand release of red blood cells. A similar drug, dare-\\npoetin alpha, is available with the same properties, but\\nit remains active longer and so requires fewer injec-\\ntions each week. Because epoetin alfa is approved for\\nmore types of anemia than darepoetin, this discussion\\ndeals only with the older drug.\\nEpoetin alpha is approved by the Food and Drug\\nAdministration for the following uses:\\n/C15anemia associated with chronic renal failure\\n/C15anemia related to zidovudine therapy in HIV-\\ninfected patients\\n/C15anemia in cancer patients on chemotherapy\\n/C15reduction in blood transfusions in surgical patients\\nIn addition, epoetin alpha may be useful in ane-\\nmia from many other causes. These include but are not\\nlimited to anemia ofprematurity, sickle cell anemia,\\nand the anemia associated withrheumatoid arthritis.\\nThe drug has been abused by athletes due to the\\ntheory that increasing the red blood cell count\\nimproves athletic performance. The potential benefits\\nof misuse of the drug are limited, and the risks are\\nsignificant. The United States and International\\nOlympic Committees and the National Collegiate\\nAthletic Association consider the use of epoetin alfa\\nto enhance athletic ergogenic potential inappropriate\\nand unacceptable because its use by athletes is con-\\ntrary to the rules and ethical principles of athletic\\ncompetition. As of the early 200s, tests to detect the\\nmisuse of epoetin alfa by athletes are increasingly\\nreliable.\\nRECOMMENDED DOSAGE. Dosing schedules may\\nvary with the cause of the anemia. All doses should\\nbe individualized. In general, epoetin alpha dosing\\nin adults is started at 50 to 100 units per kilogram\\ngiven three times a week, either by vein or sub-\\ncutaneously.\\nThe dose should be reduced if the hemoglobin\\nlevel reaches 12 grams per decaliter or if the hemoglo-\\nbin level increases by more than 1 gram per decaliter in\\nany two-week period. The drug should be interrupted\\nif hemoglobin levels reach 13 grams or more per\\ndecaliter.\\nThe dose should be increased if the hemoglobin\\nlevel does not increase by at least 2 grams per decaliter\\nafter eight weeks of treatment.\\nMaintenance doses, if required, should be indivi-\\ndualized to keep the hemoglobin levels within the\\nrange of 10 to 12 grams per decaliter.\\nPRECAUTIONS. Epoetin alpha should not be given\\nto patients with severe, uncontrolledhypertension.\\nOther conditions in which epoetin alpha should be\\nused only when the benefits clearly outweigh the risks\\nare as follows:\\n/C15constitutional aplastic anemia\\n/C15hypertension\\n/C15thromboembolism\\nSide effects\\nThe most common adverse effects of erythopoetin\\nalpha are:\\n/C15joint pain\\n/C15chest pain\\n/C15diarrhea\\n/C15swelling\\n/C15fatigue\\n/C15fever\\n/C15weakness\\n252 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianemia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15headache\\n/C15high blood pressure\\n/C15irritation at injection site\\n/C15nausea\\n/C15vomiting\\n/C15rapid heart beat\\nA large number of additional adverse effects have\\nbeen reported. Patients should consult the manufac-\\nturer’s package insert for the full list.\\nInteractions\\nAccording to the manufacturer, as of 2004 no\\nevidence of interaction of epoetin alfa with other\\ndrugs was observed.\\nResources\\nBOOKS\\nBeers, Mark H., ed.Merck Manual of Medical Information:\\nHome Edition.Riverside, NJ: Simon & Schuster, 2004.\\nGreer John P., et al., eds.Wintrobe’s Clinical Hematology.\\nBaltimore, MD: Lippincott Williams & Wilkins, 2003.\\nPhysicians’ Desk Reference 2005.Montvale, NJ: Thomson\\nHealthcare, 2004.\\nPERIODICALS\\nSharma, N., et al. ‘‘Vitamin supplementation: what the gas-\\ntroenterologist needs to know.’’Journal of Clinical\\nGastroenterology 38, no. 10 (November/December\\n2004): 844–54.\\nSamuel D. Uretsky, PharmD\\nAntiangina drugs\\nDefinition\\nAntiangina drugs are medicines that relieve the\\nsymptoms ofangina pectoris (severe chestpain).\\nPurpose\\nThe dull, tight chest pain of angina occurs when the\\nheart’s muscular wall is not getting enough oxygen. By\\nrelaxing the blood vessels, antiangina drugs reduce the\\nheart’s work load and increase the amount of oxygen-\\nrich blood that reaches the heart. These drugs come in\\ndifferent forms, and are used in three main ways:\\n/C15taken regularly over a long period, they reduce the\\nnumber of angina attacks.\\n/C15taken just before some activity that usually brings on\\nan attack, such as climbing stairs, they prevent attacks.\\n/C15taken when an attack begins, they relieve the pain\\nand pressure.\\nNot every form of antiangina drug can be used in\\nevery way. Some work too slowly to prevent attacks\\nthat are about to begin or to relieve attacks that have\\nalready started. These forms can be used only to\\nreduce the number of attacks. Be sure to understand\\nhow and when to use the type of antiangina drug that\\nhas been prescribed.\\nDescription\\nAntiangina drugs, also known as nitrates, come in\\nmany different forms: tablets and capsules that are\\nswallowed; tablets that are held under the tongue,\\ninside the lip, or in the cheek until they dissolve;\\nstick-on patches; ointment; and in-the-mouth sprays.\\nCommonly used antiangina drugs include isosorbide\\ndinitrate (Isordil, Sorbitrate, and other brands) and\\nnitroglycerin (Nitro-Bid, Nitro-Dur, Nitrolingual\\nSpray, Nitrostat Tablets, Transderm-Nitro, and\\nother brands). These medicines are available only\\nwith a physician’s prescription.\\nAntiangina Drugs\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\nCalan (calan SR, isoptin, isoptin\\nSR, verelan)\\nConstipation, dizziness, fatigue,\\nheadache, fluid retention, low blood\\npressure, nausea\\nCardene (nicardipine\\nhydrochloride)\\nDizziness, headache, indigestion,\\nnausea, rapid heartbeat, sleepiness,\\nswelling of feet, flushing\\nCardizem (diltiazem\\nhydrochloride)\\nDizziness, fluid retention, headache,\\nnausea, rash\\nCorgard (nadolol) Behaviorial changes, dizziness,\\ndrowsiness, tiredness\\nImdur, Ismo, Monoket\\n(isosorbide mononitrate)\\nHeadache\\nIsordil (isosorbide dinitrate) Headache, dizziness, low blood\\npressure\\nLopressor (metroprolol tartrate) Depression, diarrhea, itching, rash,\\ntiredness\\nNitro-Bid, Nitro-Dur, Nitrolingual\\nSpray, Nitrostat Tables,\\nTransderm-Nitro (nitroglycerin)\\nDizziness, flushing, headache\\nNorvasc (amlodipine besylate) Dizziness, fatigue, fluid retention,\\nheadache, palpitations\\nProcardia, Procardia XL, Adalat\\n(nifedipine)\\nConstipation, dizziness, hearburn,\\nlow blood pressure, moodiness,\\nnausea, swelling\\nTenormin (atenolol) Dizziness, fatigue, nausea, slowed\\nheartbeat\\nGALE ENCYCLOPEDIA OF MEDICINE 253\\nAntiangina drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nThe recommended dosage depends on the type\\nand form of antiangina drug and may be different\\nfor different patients. Check with the physician who\\nprescribed the drug or the pharmacist who filled the\\nprescription for the correct dosage.\\nAlways take antiangina drugs exactly as directed.\\nThe medicine will not work if it is not taken correctly.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more, as this could cause\\nangina attacks to return. If it is necessary to stop taking\\nthe drug, check with the physician who prescribed it\\nfor instructions on how to taper down gradually.\\nPrecautions\\nRemember that some forms of antiangina drugs\\nwork too slowly to relieve attacks that have already\\nstarted. Check with the physician who prescribed the\\nmedicine for instructions on how to use the type that\\nhas been prescribed. Patients who are using slower-\\nacting forms to make attacks less frequent may want\\nto ask their physicians to prescribe a fast-acting type to\\nrelieve attacks. Another method of treating the fre-\\nquency of attacks is to increase the dosage of the long-\\nacting antiangina drug. Do this only with the approval\\nof a physician.\\nThese medicines make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting\\nor lying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nAntiangina drugs may also causedizziness, lighthead-\\nedness, orfainting in hot weather or when people stand\\nfor a long time orexercise. Use caution in all these\\nsituations. Drinking alcohol while taking antiangina\\ndrugs may cause the same problems. Anyone who\\ntakes this medicine should limit the amount of alcohol\\nconsumed.\\nBecause these drugs may cause dizziness, be care-\\nful when driving, using machines, or doing anything\\nelse that could be dangerous.\\nIf the person is taking the form of nitroglycerin\\nthat is placed under the tongue and symptoms are not\\nrelieved within three doses taken about 5 minutes\\napart, the person should go to the hospital emergency\\nroom as soon as possible. Aheart attack may be in\\nprogress.\\nSome people develop tolerance to antiangina\\ndrugs over time. That is, the drug no longer produces\\nthe desired effects. Anyone who seems to be develop-\\ning a tolerance to this medicine should check with his\\nor her physician.\\nAnyone who has had unusual reactions to anti-\\nangina drugs in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nWomen who are pregnant or breastfeeding or who\\nmay become pregnant should check with their physi-\\ncians before using antiangina drugs.\\nOlder people may be especially sensitive to the\\neffects of antiangina drugs and thus more likely to\\nhave side effects such as dizziness and lightheadedness.\\nBefore using antiangina drugs, people with any of\\nthese medical problems should make sure their physi-\\ncians are aware of their conditions:\\n/C15recent heart attack orstroke\\n/C15kidney disease\\n/C15liver disease\\n/C15severe anemia\\n/C15overactive thyroid\\n/C15glaucoma\\n/C15recent head injury\\nSide effects\\nA common side effect is aheadache just after\\ntaking a dose of the medicine. These headaches usually\\nbecome less noticeable as the body adjusts to the drug.\\nCheck with a physician if they are severe or they con-\\ntinue even after taking the medicine for a few weeks.\\nUnless a physician says to do so, do not change the\\ndose to avoid headaches. Other common side effects\\ninclude dizziness, lightheadedness, fast pulse, flushed\\nface and neck,nausea or vomiting, and restlessness.\\nThese problems do not need medical attention unless\\nthey do not go away or they interfere with normal\\nactivities.\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking an antiangina drug\\nshould get in touch with his or her physician.\\nKEY TERMS\\nAngina pectoris— A feeling of tightness, heaviness,\\nor pain in the chest, caused by a lack of oxygen in\\nthe muscular wall of the heart.\\n254 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiangina drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Interactions\\nAntiangina drugs may interact with other medi-\\ncines. This may increase the risk of side effects or\\nchange the effects of one or both drugs. Anyone who\\ntakes antiangina drugs should let the physician know\\nall other medicines he or she is taking. Among the\\ndrugs that may interact with antiangina drugs are:\\n/C15other heart medicines\\n/C15blood pressure medicines\\n/C15aspirin\\n/C15alcohol\\n/C15ergot alkaloids used in migraine headaches\\nNancy Ross-Flanigan\\nAntiangiogenic therapy\\nDefinition\\nAntiangiogenesis therapy is one of two types of\\ndrugs in a new class of medicines that restores health\\nby controlling blood vessel growth. The other medica-\\ntion is called pro-angiogenic therapy.\\nPurpose\\nAntiangiogenic therapy inhibits the growth of new\\nblood vessels. Because new blood vessel growth plays a\\ncritical role in many disease conditions, including\\ndisorders that cause blindness, arthritis, and\\ncancer, angiogenesis inhibition is a ‘‘common denomina-\\ntor’’ approach to treating these diseases. Antiangiogenic\\ndrugsexerttheirbeneficialeffectsinanumberofways:by\\ndisabling the agents that activate and promote cell\\ngrowth, or by directly blocking the growing blood vessel\\ncells. Angiogenesis inhibitory properties have been dis-\\ncoveredinmorethan300substances,rangingfrommole-\\ncules produced naturally in animals and plants, such as\\ngreen tea extract, to new chemicals synthesized in the\\nlaboratory. A number of medicines already approved\\nby the U.S. Food and Drug Administration (FDA)\\nhave also been found to possess antiangiogenic proper-\\nties, including celecoxib (Celebrex), bortezomib\\n(Velcade), and interferon. Many inhibitors are currently\\nbeing tested in clinical trials for a variety of diseases in\\nhuman patients, and some in veterinary settings.\\nThese diseases include:\\n/C15Eye disease—Excessive new blood vessels growing in\\nthe eye can cause vision loss and lead to blindness.\\nAntiangiogenic treatments may prevent progressive\\nloss of vision or even improve eyesight in patients.\\n/C15Arthritis—Blood vessels that invade the joint release\\nenzymes that destroy cartilage and other tissues in\\narthritis. Antiangiogenic drugs may relieve the arthritic\\npain and prevent bone joint destruction caused by\\nthese pathological and destructive blood vessels.\\n/C15Cancer—Tumors recruit their own private blood\\nsupply to obtain oxygen and nourishment for cancer\\ncells. By cutting off tumor vasculature (the arrange-\\nment of blood vessels in the body or in a particular\\norgan or tissue), antiangiogenesis therapies may lit-\\nerally starve tumors, and prevent their growth and\\nspread. Antiangiogenesis may also prove to be useful\\nwhen combined with conventionalchemotherapy or\\nradiation therapy, as part of a ‘‘multiple warhead’’\\napproach to attack cancer via different strategies\\nsimultaneously.\\nCurrently, more than 80 antiangiogenic drugs are\\nbeing tested worldwide in human clinical trials\\nsponsored by biotechnology and pharmaceutical com-\\npanies, top medical centers, and the U.S. National\\nCancer Institute. The Angiogenesis Foundation is\\nleading the application of antiangiogenic therapy in\\nveterinary medicine, for treatment of certain condi-\\ntions in dogs, cats, and exotic animal species.\\nPro-angiogenic therapy works the opposite way as\\nantiangiogenic therapy by using angiogenic growth\\nfactors or gene therapy to stimulate blood vessel\\ngrowth in tissues that require an improved blood\\nsupply. A number of angiogenic growth factors and\\ngene therapies are currently undergoing clinical trials\\nin human patients suffering from the following condi-\\ntions: ischemic heart disease,stroke, peripheral vascu-\\nlar disease, and chronicwounds.\\nPrecautions\\nSince antiangiogenic therapy is still experimental,\\nonly people enrolled in a clinical trial of a particular\\ndrug therapy can use it. The only FDA-approved\\ndrug, bevacizumab (Avastin), is prescribed to treat\\ncolon-rectal cancer. Avastin can result in intestinal\\nperforation and can cause wounds that have been\\nstitched to break open, sometimes causing death.\\nIntestinal perforation, sometimes associated with\\nabscesses inside the abdomen, occurred throughout\\ntreatment with Avastin. Symptoms included abdom-\\ninal pain associated withconstipation and vomiting.\\nAvastin therapy should be permanently discontinued\\nin patients with intestinal perforation or wound\\nbreaks requiring medical intervention. Serious, and\\nGALE ENCYCLOPEDIA OF MEDICINE 255\\nAntiangiogenic therapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='in some cases fatal,hemoptysis (coughing up of blood\\nor mucus containing blood) has occurred in patients\\nwith non-small cell lung cancertreated with chemother-\\napy and Avastin.\\nDescription\\nIn the late 1990s, many medical researchers believed\\nthat the Holy Grail of cancer treatment had been found.\\nAntiangiogenesis therapy was safe, elegant, and at first\\napparently effective. But the clinical results soon fell\\nshort of expectations. The tumors, it seemed, had\\nfound a way to circumvent even this most ingenious of\\ntreatment approaches. Despite the setbacks, however,\\nangiogenesis remains a very tempting target, and\\nresearchers are exploring new agents and approaches\\nto maximize the effects of antiangiogenic therapies.\\nNewer studies have demonstrated that in addition\\nto differences in the regulation of new blood vessel for-\\nmation in cancer compared with normal tissues, the\\nactual blood vessels that are ‘‘created’’ in cancers are\\ndifferent from those created in normal tissues. These\\ndifferences have allowed a number of antiangiogenic\\ndrugs to be developed that specifically damage tumor-\\nassociated blood vessels and not normal vessels. The\\ngoal of these drugs is to attack cancers by damaging\\ntheir blood supply. Many antiangiogenic agents also\\nappear to hasten the death of tumor-associated blood\\nvessels.\\nWith the success of targeted agents such as the\\nbiotechnology company Genentech’s Avastin, the\\nonly antiangiogenic drug approved by the FDA to\\ntreat cancer, new efforts are underway to widen and\\noptimize the field of antiangiogenic agents. As oncol-\\nogy (the study of cancer) drug development accelerates,\\nnew indications are beginning to emerge for diseases\\nsuch as ocular neovascularization and evenobesity.\\nAntiangiogenic therapy represents a novel, poten-\\ntially effective, and non-toxic treatment for cancer. It\\nis likely that these drugs will provide the next major\\nbreakthrough in the management of people and pets\\nwith cancer. Antiangiogenic therapy will likely\\nbecome part of the conventional treatment of cancer\\nand will be used in combination with surgery, radia-\\ntion therapy and chemotherapy. These agents are\\ncurrently in clinical trials and may become available\\nto both people and pets in the near future.\\nAntiangiogenic therapy offers a number of advant-\\nages over traditional therapies for cancer:\\n/C15Tumor cells often mutate and become resistant to\\nchemotherapy. Because antiangiogenic drugs only\\ntarget normal endothelial cells (a layer of cells that\\nlines the inside of certain body cavities, such as blood\\nvessels), these cells are less likely to develop acquired\\ndrug resistance.\\n/C15All tumors rely upon host vessels. Antiangiogenic\\nagents are therefore effective against a broad range\\nof cancers.\\n/C15Conventional chemotherapy and radiotherapy indis-\\ncriminately attacks all dividing cells in the body,\\nleading to side effects such asdiarrhea, mouth ulcers,\\nhair loss, and weakened immunity. Antiangiogenic\\ndrugs selectively target dividing blood vessels and\\ncause fewer side effects.\\n/C15Antiangiogenic drugs are relatively nontoxic and\\nwork at levels well below the maximum tolerated\\ndose, so may be given in lower doses over longer\\nperiods of time.\\n/C15Antiangiogenic treatment may take weeks or even\\nmonths to exhibit its full beneficial effect, but this\\nallows for continuous, chronic control of disease.\\n/C15Antiangiogenic drugs may also serve as a powerful\\nsupplement to traditional chemotherapy or radiation\\ntherapy.\\nKEY TERMS\\nAngiogenesis— The formation of new blood ves-\\nsels, for example, as a result of a tumor.\\nChemotherapy— The use of chemical agents to\\ntreat diseases, infections, or other disorders, espe-\\ncially cancer.\\nEndothelial— A layer of cells that lines the inside of\\ncertain body cavities, for example, blood vessels.\\nEpidermal— Referring to the thin outermost layer of\\nthe skin, itself made up of several layers, that covers\\nand protects the underlying dermis (skin).\\nFibroblast— A large flat cell that secretes the\\nproteins that form collagen and elastic fibers and\\nthe substance between the cells of connective\\ntissue.\\nIschemic— An inadequate supply of blood to a part\\nof the body, caused by partial or total blockage of\\nan artery.\\nOcular neovascularization— Abnormal or exces-\\nsive formation of blood vessels in the eye.\\nPeripheral vascular disease— A disease affecting\\nblood vessels, especially in the arms, legs, hands,\\nand feet.\\nVascular— Relating to blood vessels.\\n256 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiangiogenic therapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Preparation\\nSince antiangiogenic drugs are either injected or\\nadministered orally, little or no preparation is needed.\\nFor injections, the site should be first swabbed with\\nalcohol.\\nAftercare\\nLittle or no aftercare is needed following the\\nadministering of antiangiogenic therapy, except for a\\nsmall bandage on the injection site.\\nAlthough many of these agents are currently being\\ntested in clinical trials, no reliable way to monitor the\\neffects of many, if not most, of these therapeutic\\nagents on the inhibition of the complicated process\\nof angiogenesis exists. However, in late 2004, scientists\\nuncovered critical information that may lead to an\\nurgently needed method for effectively monitoring\\nantiangiogenic cancer therapies. The research is likely\\nto facilitate development of new antiangiogenic drugs\\nor treatment strategies and allow for accurate deter-\\nmination of the optimal drug doses to use for such\\ntherapies. The researchers found that measuring per-\\nipheral blood cells can be used as a reliable way to\\nmonitor antiangiogenic drug activity, which can be\\nused to help establish the optimal biologic dose of\\nsuch drugs.\\nRisks\\nIn general, early research has found the side\\neffects of antiangiogenesis agents to be mostly mini-\\nmal. Because these drugs use proteins that are pro-\\nduced in the human body, there is less likelihood that\\nthey will produce the bad side effects common in\\nradiation treatments and chemotherapy. Still, one\\ncancer study found that 6 of the 99 patients taking\\nan antiangiogenesis drug experienced severe bleeding\\nin the tumors being treated. Four of those patients\\ndied from this complication.\\nSince antiangiogenesis drugs could affect a\\ndeveloping fetus, they will probably not be used\\nfor pregnant women or women who might become\\npregnant. They may also need to be stopped before\\nsurgery, since blood vessels that are cut at such\\ntimes need to repair themselves. Also, people who\\nhave damaged blood vessels (such as those with\\nheart disease or stroke) may not be able to take\\nthese drugs. Other side effects in people are being\\ndetermined. Doctors, sci entists and specialists at\\nthe FDA will be monitoring these other side effects\\nto better understand the toxicity and risks of these\\ndrugs.\\nNormal results\\nSince all antiangiogenic therapies are still experi-\\nmental and in clinical trials, it is difficult to determine\\nwhat normal results should be. The goal of antiangio-\\ngenic drugs is to stop the development and spread of\\ncertain diseases, especially some cancers. At least four\\nmajor proteins and their receptors and signaling path-\\nways commonly govern angiogenesis in solid tumors:\\nplatelet-derived growth factor, epidermal growth fac-\\ntor, vascular endothelial growth factor (VEGF), and\\nfibroblast growth factor (basic and acidic). Therapies\\nthat either target these molecules or block their signal-\\ning pathways should be effective in preventing solid\\ntumor growth and spread of the cancer by preventing\\nthe formation of new blood vessels.\\nResources\\nBOOKS\\nCooke, Robert.Dr. Folkman’s War: Angiogenesis and the\\nStruggle to Defeat CancerCollingdale, PA: Diane\\nPublishing Co., 2003.\\nTeicher, Beverly A.Antiangiogenic Agents in Cancer Therapy\\nTotowa, NJ: Humana Press, 1999.\\nPERIODICALS\\nFrankish, Helen. ‘‘Researchers Target Tumour Blood\\nVessels With Antiangiogenic Gene Therapy.’’The\\nLancet (June 29, 2002): 2256.\\nGuttman, Cheryl. ‘‘Anti-Angiogenic Therapy Explored for\\nRetinoblastoma.’’ Ophthalmology Times(September 1,\\n2004): 11.\\nMarch, Keith. ‘‘New Approach for Easing Angina.’’\\nMedical Update(December 2003): 6.\\nSullivan. Michele G. ‘‘Experimental Antiangiogenic\\n(Therapy) May Battle Drug-Resistant Tumors.’’\\nFamily Practice News(February 15, 2003): 42.\\nORGANIZATION\\nThe Angiogenesis Foundation. P.O. Box 382111,\\nCambridge, MA 02139. (617) 576-5708. patienthel-\\np@angio.org. or (for veterinary information) vetme-\\nd@angio.org. http://www.angio.org.\\nKen R. Wells\\nAntianxiety drugs\\nDefinition\\nAntianxiety drugs are medicines that calm and\\nrelax people with excessiveanxiety, nervousness, or\\ntension, or for short-term control of social phobia\\ndisorder or specific phobia disorder.\\nGALE ENCYCLOPEDIA OF MEDICINE 257\\nAntianxiety drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nAntianxiety agents, or anxiolytics, may be used to\\ntreat mild transient bouts of anxiety as well as more\\npronounced episodes of social phobia and specific\\nphobia. Clinically significant anxiety is marked by\\nseveral symptoms. The patient experiences marked\\nor persistent fear of one or more social or performance\\nsituations in which he or she is exposed to unfamiliar\\npeople or possible scrutiny by others, and may react in\\na humiliating or embarrassing way. The exposure to\\nthe feared situation produces an anxiety attack. Fear\\nof these episodes of anxiety leads to avoidance beha-\\nvior, which impairs normal social functioning, includ-\\ning working or attending classes. The patient is aware\\nthat these fears are unjustified.\\nDescription\\nIn psychiatric practice, treatment of anxiety has\\nlargely turned from traditional antianxiety agents,\\nanxiolytics, to antidepressant therapies. In current\\nuse, thebenzodiazepines, the best known class of anxio-\\nlytics, have been largely supplanted byselective seroto-\\nnin reuptake inhibitors(SSRIs). Among the preferred\\nSSRIs forgeneralized anxiety disorderare paroxetine\\n(Paxil), escitalopram (Lexapro), and venlafaxine\\n(Effexor), which also has norepinephrine. Other\\nSSRIs are fluoxetine (Prozac) and sertraline (Zoloft).\\nVenlafaxine and Paroxetine have been shown particu-\\nlarly effective in relieving symptoms of social anxiety.\\nHowever, traditional anxiolytics remain useful for\\npatients who need a rapid onset of action, or whose\\nfrequency of exposure to anxiety provoking stimuli is\\nlow enough to eliminate the need for continued treat-\\nment. While SSRIs may require three to five weeks to\\nshow any effects, and must be taken continuously,\\nbenzodiazepines may produce a response within 30\\nminutes, and may be dosed on an as-needed basis.\\nThe intermediate action benzodiazepines, alprazo-\\nlam (Xanax), and lorazepam (Ativan) are the appropri-\\nate choice for treatment of mild anxiety and social\\nphobia. Diazepam (Valium) is still widely used for anxi-\\nety, but its active metabolite, desmethyldiazepam, which\\nhas a long half-life, may make this a poorer choice than\\nother drugs in its class. There is considerable variation\\nbetween individuals in metabolism of benzodiazepines,\\nso patient response may not be predictable. As a class,\\nbenzodiazepines are used not only as anxiolytics, but\\nalso as sedatives,muscle relaxants, and in treatment of\\nepilepsy andalcoholism. The distinctions between these\\nuses are largely determined by onset and duration of\\naction, and route of administration.\\nBuspirone (BuSpar), which is not chemically\\nrelated to other classes of central nervous system\\nAntianxiety Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nAtarax (hydroxyzine\\nhydrochloride)\\nDrowsiness, dry mouth\\nAtivan (lorazepam) Dizziness, excessive calm, weakness\\nBuSpar, Buspirone (bus-\\npirone hydrochloride)\\nDry mouth, dizziness, headache, fatigue,\\nnausea\\nCentrax (pazepam) Decreased coordination, dizziness,\\ndrowsiness, fatigue, weakness\\nLibrium, Libritabs\\n(chlordiazepoxide)\\nConstipation, drowsiness, nausea,\\nswelling\\nMiltown, Equanil\\n(meprobamate)\\nDiarrhea, bruising, fever, headache,\\nnausea, rash, slurred speech\\nSerax (oxazepam) Dizziness, fainting, headache, liver\\nproblems, decreased coordination,\\nnausea, swelling, vertigo\\nStelazine (trifluoperazine\\nhydrochloride)\\nAbnormal glucose in urine, allergic\\nreactions, blurred vision, constipation, eye\\nspasms, fluid retention and swelling\\nTranxene, Tranxene-SD\\n(clorazepate dipotassium)\\nDrowsiness\\nValium (diazepam) Decreased coordination, drowsiness,\\nlight-headedness\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or ima-\\ngined stress, danger, or dreaded situations. Physical\\nreactions, such as fast pulse, sweating, trembling, fati-\\ngue, and weakness may accompany anxiety.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nPanic disorder— An disorder in which people have\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nPhobia— An intense, abnormal, or illogical fear of\\nsomething specific, such as heights or open spaces.\\nPregnancy category B— Animal studies indicate no\\nfetal risk, but no human studies; or adverse effects in\\nanimals, but not in well-controlled human studies.\\nPregnancy category C— No adequate human or\\nanimal studies; or adverse fetal effects in animal\\nstudies, but no available human data.\\nSeizure— A sudden attack, spasm, or convulsion.\\n258 GALE ENCYCLOPEDIA OF MEDICINE\\nAntianxiety drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='drugs, is also a traditional anxiolytic, although it is\\nnow considered either a third line or adjunctive agent\\nfor use after trials of SSRIs and benzodiazepines. It is\\nappropriate for use in patients who have either failed\\ntrials of other treatments, or who should not receive\\nbenzodiazepines because of a history of substance\\nabuse problems. Buspirone, in common with antide-\\npressants, requires a two to three week period before\\nthere is clinical evidence of improvement, and must be\\ncontinuously dosed to maintain its effects.\\nBenzodiazepines are controlled drugs under fede-\\nral law. The number of U.S. drug-abuse related trips\\nto emergency departments involving benzodiazepine\\nmedications exceeded 100,000 in 2002. Buspirone is\\nnot a controlled substance and has no established\\nabuse potential.\\nRecommended dosage\\nBenzodiazepines should be administered 30 to 60\\nminutes before exposure to the anticipated stress.\\nDosage should be individualized to minimizesedation.\\nThe normal dose of alprazolam is 0.25–0.5 mg. The\\nusual dose of lorazepam is 2–3 mg. Doses may be\\nrepeated if necessary.\\nBuspirone is initially dosed at 5 mg three times a\\nday. Patients should increase the dosage 5 mg/day, at\\nintervals of two to three days, as needed and should\\nnot exceed 60 mg/day. Two to three weeks may be\\nrequired before a satisfactory response is seen.\\nPrecautions\\nBenzodiazepines should not be used in patients with\\npsychosis, acute narrow angleglaucoma,o rliver disease.\\nThe drugs can act as respiratory depressants and should\\nbe avoided in patients with respiratory conditions.\\nBenzodiazepines are potentially addictive and should\\nnot be administered to patients with substance abuse\\ndisorders. Because benzodiazepines are sedative, they\\nshould be avoided in patients who must remain alert.\\nTheir use for periods over four months has not been\\ndocumented. These drugs should not be used during the\\nsecond and third trimester ofpregnancy, although use\\nduring the first trimester appears to be safe. They should\\nnot be taken while breastfeeding. Physicians and\\npharmacists should be consulted about use in children.\\nBuspirone is metabolized by the liver and excreted\\nby the kidney, and should be used with care in patients\\nwith hepatic or renal disease. The drug is classified as\\nschedule B during pregnancy, but should not be taken\\nduring breastfeeding. Its use in children under the age\\nof 18 years has not been studied.\\nIn 2004, the FDA cautioned revealed that certain\\nSSRIs could lead to increased risk ofsuicide in child-\\nren and adolescents who took them for depression.\\nParents should check with physicians to receive more\\ninformation on SSRIs when they are prescribed for\\nteens and children with anxiety.\\nSide effects\\nThe most common side effects of benzodiazepines\\nare secondary to their C NS effects and include\\nsedation and sleepiness; depression; lethargy; apathy;\\nfatigue; hypoactivity; lightheadedness; memory impair-\\nment; disorientation; anterogradeamnesia; restlessness;\\nconfusion; crying or sobbing;delirium; headache;s l u r -\\nred speech; aphonia; dysarthria; stupor; seizures;coma;\\nsyncope; rigidity; tremor; dystonia; vertigo;dizziness;\\neuphoria; nervousness; irritability; difficulty in concen-\\ntration; agitation; inability to perform complex mental\\nfunctions; akathisia; hemiparesis; hypotonia; unsteadi-\\nness; ataxia; incoordination; weakness; vivid dreams;\\npsychomotor retardation; ‘‘glassy-eyed’’ appearance;\\nextrapyramidal symptoms; paradoxical reactions.\\nOther reactions include changes in heart rate and blood\\npressure, changes in bowel function, severe skin rash and\\nchanges in genitourinary function. Other adverse\\neffects have been reported.\\nBuspirone has a low incidence of side effects.\\nDizziness and drowsiness are the most commonly\\nreported adverse effects. Other CNS effects include\\ndream disturbances; depersonalization, dysphoria,\\nnoise intolerance, euphoria, akathisia, fearfulness,\\nloss of interest, disassociative reaction,hallucinations,\\nsuicidal ideation, seizures; feelings of claustrophobia,\\ncold intolerance, stupor and slurred speech, psychosis.\\nRarely, heart problems, including congestive heart\\nfailure and myocardial infarction, have been reported.\\nOther adverse effects have been reported.\\nInteractions\\nThe metabolism of alprazolam may be increased\\nby: cimetidine, oral contraceptives, disulfiram, fluox-\\netine, isoniazid, ketoconazole, metoprolol, propoxy-\\nphene, propranolol and valproic acid. The absorption\\nof all benzodiazepines is inhibited by concomitant use\\nof antacids. Benzodiazepines may increase blood\\nlevels of digoxin, and reduce the efficacy of levodopa.\\nOther drug interactionshave been reported.\\nBuspirone levels will be increased by concomitant\\nuse of erythromycin, itraconazole, and nefazadone.\\nDoses should be adjusted based on clinical response.\\nUse of buspirone at the same time as mono-amine\\nGALE ENCYCLOPEDIA OF MEDICINE 259\\nAntianxiety drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='oxidase inhibitors (MAOIs, phenelzine, tranycypro-\\nmine) may cause severe blood pressure elevations.\\nUse of buspirone with MAOIs should be avoided.\\nResources\\nPERIODICALS\\n‘‘Abuse of Anti-anxiety Drugs Up, Study of ER Visits\\nShows.’’ Drug Week(September 17, 2004): 225.\\nFinn, Robert. ‘‘Venlafaxine and Paroxetine Both Relieve\\nSocial Anxiety.’’Clinical Psychiatry News(September\\n2004): 41.\\nSherman, Carl. ‘‘GAD Patients Often Require Combined\\nTherapy.’’Clinical Psychiatry News(August 2004): 12–14.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntiarrhythmic drugs\\nDefinition\\nAntiarrhythmic drugs are medicines that correct\\nirregular heartbeats and slow down hearts that beat\\ntoo fast.\\nPurpose\\nNormally, the heart beats at a steady, even pace.\\nThe pace is controlled by electrical signals that begin in\\none part of the heart and quickly spread through the\\nwhole heart. If something goes wrong with this control\\nsystem, the result may be an irregular heartbeat, or an\\narrhythmia. Antiarrhythmic drugs correct irregular\\nheartbeats, restoring the normal rhythm. If the heart\\nis beating too fast, these drugs will slow it down. By\\ncorrecting these problems, antiarrhythmic drugs help\\nthe heart work more efficiently.\\nDescription\\nAntiarrhythmic drugs are available only with a\\nphysician’s prescription and are sold in capsule (regu-\\nlar and extended release), tablet (regular and\\nextended-release), and injectable forms. Commonly\\nused antiarrhythmic drugs are disopyramide\\n(Norpace, Norpace CR), procainamide (Procan SR,\\nPronestyl, Pronestyl-SR), and quinidine (Cardioquin,\\nDuraquin, Quinidex, and other brands).Do not con-\\nfuse quinidine with quinine, which is a related medicine\\nwith different uses, such as relieving leg cramps.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiarrhythmic drug and other factors. Doses may be\\ndifferent for different patients. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage.\\nAlways take antiarrhythmic drugs exactly as\\ndirected. Never take larger or more frequent doses.\\nDo not stop taking this medicine without checking\\nwith the physician who prescribed it. Stopping it sud-\\ndenly could lead to a serious change in heart function.\\nAntiarrhythmic drugs work best when they are at\\nconstant levels in the blood. To help keep levels con-\\nstant, take the medicine in doses spaced evenly through\\nthe day and night. Do not miss any doses. If taking\\nmedicine at night interferes with sleep, or if it is difficult\\nto remember to take the medicine during the day, check\\nwith a health care professional for suggestions.\\nPrecautions\\nPersons who take these drugs should see their\\nphysician regularly. The physician will check to make\\nsure the medicine is working as it should and will note\\nany unwanted side effects.\\nSome people feel dizzy, lightheaded, or faint when\\nusing these drugs. This medicine may cause blurred\\nvision or other vision problems. Because of these pos-\\nsible problems, anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them. If the medicine does cause vision pro-\\nblems, wait until vision is clear before driving or\\nengaging in other activities that require normal vision.\\nAntiarrhythmic drugs make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting or\\nlying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nAnyone taking this medicine should not drink\\nalcohol without his or her physician’s approval.\\nSome antiarrhythmic drugs may change the\\nresults of certain medical tests. Before having medical\\ntests, anyone taking this medicine should alert the\\nhealth care professional in charge.\\nAnyone who is taking antiarrhythmic drugs\\nshould be sure to tell the health care professional in\\ncharge before having any surgical or dental proce-\\ndures or receiving emergency treatment.\\nAntiarrhythmic drugs may cause low blood sugar\\nin some people. Anyone who experiences symptoms of\\nlow blood sugar should eat or drink a food that\\n260 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiarrhythmic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='contains sugar and call a physician immediately. Signs\\nof low blood sugar are:\\n/C15anxiety\\n/C15confusion\\n/C15nervousness\\n/C15shakiness\\n/C15unsteady walk\\n/C15extreme hunger\\n/C15headache\\n/C15nausea\\n/C15drowsiness\\n/C15unusual tiredness or weakness\\n/C15fast heartbeat\\n/C15pale, cool skin\\n/C15chills\\n/C15cold sweats\\nAntiarrhythmic drugs may causedry mouth.T o\\ntemporarily relieve the discomfort, chew sugarless gum,\\nsuck on sugarless candy or ice chips, or use saliva sub-\\nstitutes, which come in liquid and tablet forms and are\\navailable without a prescription. If the problem con-\\nt i n u e sf o rm o r et h a n2w e e k s ,c h e c kw i t hap h y s i c i a no r\\ndentist. Mouth dryness that continues over a long time\\nmay contribute totooth decayand other dental problems.\\nPeople taking antiarrhythmic drugs may sweat\\nless, which can cause the body temperature to rise.\\nAnyone who takes this medicine should be careful\\nnot to become overheated during exercise or hot\\nweather and should avoid hot baths, hot tubs, and\\nsaunas. Overheating could lead to heatstroke.\\nOlder people may be especially sensitive to the\\neffects of antiarrhythmic drugs. This may increase\\nthe risk of certain side effects, such as dry mouth,\\ndifficult urination, anddizziness or lightheadedness.\\nThe antiarrhythmic drug procainamide can cause\\nserious blood disorders. Anyone taking this medicine\\nshould have regular blood counts and should check\\nwith a physician if any of the following symptoms occur:\\n/C15joint or musclepain\\n/C15muscle weakness\\n/C15pain in the chest or abdomen\\n/C15tremors\\n/C15wheezing\\n/C15cough\\n/C15palpitations\\n/C15rash, sores, or pain in the mouth\\n/C15sore throat\\n/C15fever and chills\\n/C15loss of appetite\\n/C15diarrhea\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or\\nimagined stress, danger, or dreaded situations.\\nPhysical reactions, such as fast pulse, sweating, trem-\\nbling, fatigue, and weakness may accompany anxiety.\\nArrhythmia— Abnormal heart rhythm.\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nEmphysema— A lung disease in which breathing\\nbecomes difficult.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHeat stroke— A severe condition caused by pro-\\nlonged exposure to high heat. Heat stroke interferes\\nwith the body’s temperature regulating abilities and\\ncan lead to collapse and coma.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMyasthenia gravis— A chronic disease with symp-\\ntoms that include muscle weakness and sometimes\\nparalysis.\\nPalpitation— Rapid, forceful, throbbing, or flutter-\\ning heartbeat.\\nProstate— A donut-shaped gland below the bladder\\nin men that contributes to the production of semen.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease that affects the skin, joints, and certain\\ninternal organs.\\nTourette syndrome— A condition in which a per-\\nson has tics and other involuntary behavior, such as\\nbarking, sniffing, swearing, grunting, and making\\nuncontrollable movements.\\nTremor— Shakiness or trembling.\\nGALE ENCYCLOPEDIA OF MEDICINE 261\\nAntiarrhythmic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15dark urine\\n/C15yellow skin or eyes\\n/C15unusual bleeding or bruising\\n/C15dizziness\\n/C15hallucinations\\n/C15depression\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines may have problems if\\nthey take antiarrhythmic drugs. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to an antiarrhythmic drug in the past should let\\nhis or her physician know before taking this type of\\nmedicine again. Patients taking procainamide should\\nlet their physicians know if they have ever had an\\nunusual or allergic reaction to procaine or any other\\n‘‘caine-type’’ medicine, such as xylocaine or lidocaine.\\nPatients taking quinidine should mention any pre-\\nvious reactions to quinine. The physician should also\\nbe told about anyallergies to foods, dyes, preserva-\\ntives, or other substances.\\nCONGESTIVE HEART DISEASE. Antiarrhythmic\\ndrugs may cause low blood sugar, which can be a\\nparticular problem for people with congestive heart\\ndisease. Anyone with congestive heart disease should\\nbe familiar with the signs of low blood sugar (listed\\nabove) and should check with his or her physician\\nabout what to do if such symptoms occur.\\nDIABETES. Antiarrhythmic drugs may cause low\\nblood sugar, which can be a particular problem for\\npeople with diabetes. Anyone with diabetes should be\\nfamiliar with the signs of low blood sugar (listed\\nabove) and should check with his or her physician\\nabout what to do if such symptoms occur.\\nPREGNANCY. The effects of taking antiarrhythmic\\ndrugs inpregnancyhave not been studied in humans. In\\nstudies of laboratory animals, this medicine increased\\nthe risk ofmiscarriage. In addition, some women who\\nhave taken these drugs while pregnant have had con-\\ntractions of the uterus (womb). Women who are preg-\\nnant or who may become pregnant should check with\\ntheir physicians before taking this medicine. Women\\nwho become pregnant while taking this medicine\\nshould let their physicians know right away.\\nBREASTFEEDING. Antiarrhythmic drugs pass into\\nbreast milk. Women who are breastfeeding should\\ncheck with their physicians before taking this medicine.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\narrhythmic drugs, people with any of these medical\\nproblems should make sure their physicians are aware\\nof their conditions:\\n/C15heart disorders such as structural heart disease or\\ninflammation of the heart muscle\\n/C15congestive heart failure\\n/C15kidney disease\\n/C15liver disease\\n/C15diseases of the blood\\n/C15asthma oremphysema\\n/C15enlarged prostate or difficulty urinating\\n/C15overactive thyroid\\n/C15low blood sugar\\n/C15psoriasis\\n/C15glaucoma\\n/C15myasthenia gravis\\n/C15systemic lupus erythematosus\\nUSE OF CERTAIN MEDICINES.Taking antiarrhythmic\\ndrugs with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects are dry mouth and\\nthroat, diarrhea, and loss of appetite. These problems\\nusually go away as the body adjusts to the drug and do\\nnot require medical treatment. Less common side\\neffects, such as dizziness, lightheadedness, blurred\\nvision, dry eyes and nose, frequent urge to urinate,\\nbloating, constipation, stomach pain, and decreased\\nsexual ability, also may occur and do not need medical\\nattention unless they do not go away or they interfere\\nwith normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15fever and chills\\n/C15difficult urination\\n/C15swollen or painful joints\\n/C15pain when breathing\\n/C15skin rash or itching\\nPeople who are especially sensitive to quinidine\\nmay have a reaction to the first dose or doses. If any of\\nthese side effects occur after taking quinidine, check\\nwith a physician immediately:\\n262 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiarrhythmic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15dizziness\\n/C15ringing in the ears\\n/C15breathing problems\\n/C15vision changes\\n/C15fever\\n/C15headache\\n/C15skin rash\\nOther rare side effects may occur with any anti-\\narrhythmic drug. Anyone who has unusual symptoms\\nafter taking antiarrhythmic drugs should get in touch\\nwith his or her physician.\\nInteractions\\nAntiarrhythmic drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes antiarrhythmic\\ndrugs should let the physician know all other medi-\\ncines he or she is taking. Among the drugs that may\\ninteract with antiarrhythmic drugs are:\\n/C15other heart medicines, including other antiarrhyth-\\nmic drugs\\n/C15blood pressure medicine\\n/C15blood thinners\\n/C15pimozide (Orap), used to treat Tourette’s syndrome\\nThe list above does not include every drug that\\nmay interact with antiarrhythmic drugs. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning antiarrhythmic drugs with any other prescription\\nor nonprescription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntiasthmatic drugs\\nDefinition\\nAntiasthmatic drugs are medicines that treat or\\nprevent asthma attacks.\\nPurpose\\nFor people with asthma, the simple act of breath-\\ning can be a struggle. Their airways become inflamed\\nand blocked with mucus during asthma attacks, nar-\\nrowing the opening through which air passes. This is\\nnot such a problem when the person breathes in,\\nbecause the airways naturally expand when a person\\ntakes a breath. The real problem arises when the per-\\nson with asthma tries to breathe out. The air cannot\\nget out through the blocked airways, so it stays\\ntrapped in the lungs. With each new breath, the person\\ncan take in only a little more air, so breathing becomes\\nshallow and takes more and more effort.\\nAsthma attacks can be caused byallergies to pol-\\nlen, dust, pets or other things, but people without\\nknown allergies may also have asthma.Exercise, stress,\\nintense emotions, exposure to cold, certain medicines\\nand some medical conditions also can bring on attacks.\\nThe two main approaches to dealing with asthma\\nare avoiding substances and situations that trigger\\nattacks and using medicines that treat or prevent the\\nsymptoms. With a combination of the two, most peo-\\nple with asthma can find relief and live normal lives.\\nDescription\\nThree types of drugs are used in treating and pre-\\nventing asthma attacks:\\n/C15Bronchodilators relax the smooth muscles that line\\nthe airway. This makes the airways open wider, let-\\nting more air pass through them. These drugs are\\nused mainly to relieve sudden asthma attacks or to\\nprevent attacks that might come on after exercise.\\nThey may be taken by mouth, injected or inhaled.\\nBronchodilators may be taken in pill or liquid form,\\nbut normally are used as inhalers, which go directly\\nto the lungs and result in fewer side effects.\\n/C15Corticosteroids block the inflammation that narrows\\nthe airways. Used regularly, these drugs will help pre-\\nvent asthma attacks. Those attacks that do occur will\\nbe less severe. However, corticosteroids cannot stop\\nan attack that is already underway. These drugs may\\nbe taken by mouth, injected or inhaled.\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nInhalant— Medicine that is breathed into the lungs.\\nMucus— Thick fluid produced by the moist mem-\\nbranes that line many body cavities and structures.\\nNebulizer— A device that turns liquid forms of\\nmedicine into a fine spray that can be inhaled.\\nGALE ENCYCLOPEDIA OF MEDICINE 263\\nAntiasthmatic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Leukotriene modifiers (montelukast and zafirlukast)\\nare a new type of drug that can be used in place of\\nsteroids, for older children or adults who have a mild\\ndegree of asthma that persists. They work by coun-\\nteracting leukotrienes, which are substances released\\nby white blood cells in the lung that cause the air\\npassages to constrict and promote mucus secretion.\\nLeukotriene modifiers also fight off some forms of\\nrhinitis, an added bonus for people with asthma.\\nHowever, they are not proven effective in fighting\\nseasonal allergies.\\n/C15Cromolyn also is taken regularly to prevent asthma\\nattacks and may be used alone or with other asthma\\nmedicines. It cannot stop an attack that already has\\nstarted. The drug works by preventing certain cells in\\nthe body from releasing substances that cause aller-\\ngic reactions or asthma symptoms. One brand of this\\ndrug, Nasalcrom, comes in capsule and nasal spray\\nforms and is used to treat hayfever and other aller-\\ngies. The inhalation form of the drug, Intal, is used\\nfor asthma. It comes in aerosol canisters, in capsules\\nthat are inserted into an inhaler, and in liquid form\\nthat is used in a nebulizer.\\nPrecautions\\nUsing antiasthmatic drugs properly is important.\\nBecause bronchodilators provide quick relief, some peo-\\nple may be tempted to overuse them. However, with\\nsome kinds of bronchodilator s ,t h i sc a nl e a dt os e r i o u s\\nand possibly life-threatening complications. In the long\\nrun, patients are better off using bronchodilators only as\\nd i r e c t e da n da l s ou s i n gc o r t i costeroids, which eventually\\nwill reduce their need for bronchodilators. However, a\\n2004 Canadian study has questioned a standard practice\\nof increasing steroids aftera s t h m aa t t a c k so rw o r s e n e d\\nsymptoms. Also, research in 2004 showed that people\\nwith asthma who worked closely with their physicians to\\nself-manage their asthma had fewer attacks, which\\nreduces the need for bronchodilators. Carefully mana-\\nging asthma also reduces visits to the emergency depart-\\nment and hospitalizations.\\nCorticosteroids are powerful drugs that may\\ncause serious side effects when used over a long time.\\nHowever, these problems are much less likely with the\\ninhalant forms than with the oral and injected forms.\\nWhile the oral and injected forms generally should be\\nused only for one to two weeks, the inhalant forms\\nmay be used for long periods.\\nIt is important to remember that leukotriene modi-\\nfiers are used to prevent and manage asthma, not to\\nstop an attack. A physician or pharmacist can advise\\npatients on possible interactions with other drugs.\\nPatients who are using their antiasthmatic drugs\\ncorrectly but feel their asthma is not under control\\nshould see their physicians. The physician can either\\nincrease the dose, switch to another medicine or add\\nanother medicine to the regimen. A 2004 survey\\nshowed that 70% of people with mild to moderate\\nasthma were not taking the correct dose of asthma\\nmedication.\\nWhen used to prevent asthma attacks, cromolyn\\nmust be taken as directed every day. The drug may\\ntake as long as four weeks to start working. Unless\\ntold to do so by a physician, patients should not stop\\ntaking the drug just because it does not seem to be\\nworking. When symptoms do begin to improve,\\npatients should continue taking all medicines that\\nhave been prescribed, unless a physician directs\\notherwise.\\nSide effects\\nInhalant forms of antiasthmatic drugs may cause\\ndryness or irritation in the throat,dry mouth,o ra n\\nunpleasant taste in the mouth. To help prevent these\\nproblems, gargling and rinsing the mouth or taking a\\nsip of water after each dose is recommended.\\nMore serious side effects are not common when\\nthese medicines are used properly. However, anyone\\nwho has unusual or bothersome symptoms after tak-\\ning an antiasthmatic drug should get in touch with a\\nphysician.\\nInteractions\\nA physician or pharmacist should be consulted\\nbefore combining antiasthmatic drugs with any other\\nprescription or nonprescription (over-the-counter)\\nmedicine.\\nResources\\nPERIODICALS\\n‘‘Many People With Asthma Areno´ t Taking the Right\\nAmount of Medication.’’Obesity, Fitness & Wellness\\nWeek (September 25, 2004): 87.\\n‘‘Study Calls Standard Asthma Management Into Doubt.’’\\nDoctor (July 15, 2004): 4.\\n‘‘What’s New in: Asthma and Allergic Rhinitis.’’Pulse\\n(September 20, 2004): 50.\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntibacterial bath see Therapeutic baths\\n264 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiasthmatic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Antibiotic-associated colitis\\nDefinition\\nAntibiotic-associated colitis is an inflammation of\\nthe intestines that sometimes occurs following antibio-\\ntic treatment and is caused by toxins produced by the\\nbacterium Clostridium difficile.\\nDescription\\nAntibiotic-associated colitis, also called antibiotic-\\nassociated enterocolitis, can occur following antibiotic\\ntreatment. The bacteriaClostridia difficileare normally\\nfound in the intestines of 5% of healthy adults, but\\npeople can also pick up the bacteria while they are in a\\nhospital or nursing home. In a healthy person, harmless\\nresident intestinal bacteria compete with each other for\\nfood and places to ‘‘sit’’ along the inner intestinal wall.\\nWhen antibioticsare given, most of the resident bacteria\\nare killed. With fewer bacteria to compete with, the\\nnormally harmlessClostridia difficilegrow rapidly and\\nproduce toxins. These toxins damage the inner wall of\\nthe intestines and cause inflammation anddiarrhea.\\nAlthough all antibiotics can cause this disease, it is\\nmost commonly caused by clindamycin (Cleocin), ampi-\\ncillin (Omnipen), amoxicillin (Amoxil, Augmentin, or\\nWymox), and any in the cephalosporin class (such as\\ncefazolin or cephalexin). Symptoms of the condition can\\noccur during antibiotic treatment or within four weeks\\nafter the treatment has stopped.\\nIn approximately half of cases of antibiotic-asso-\\nciated colitis, the condition progresses to a more severe\\nform of colitis called pseudomembranous enterocolitis\\nin which pseudomembranes are excreted in the stools.\\nPseudomembranes are membrane-like collections of\\nwhite blood cells, mucus, and the protein that causes\\nblood to clot (fibrin) that are released by the damaged\\nintestinal wall.\\nCauses and symptoms\\nAntibiotic-associated colitis is caused by toxins\\nproduced by the bacteriumClostridium difficile after\\ntreatment with antibiotics. When most of the other\\nintestinal bacteria have been killed,Clostridium diffi-\\ncile grows rapidly and releases toxins that damage the\\nintestinal wall. The disease and symptoms are caused\\nby these toxins, not by the bacterium itself.\\nSymptoms of antibiotic-associated colitis usually\\nbegin four to ten days after antibiotic treatment has\\nbegun. The early signs and symptoms of this disease\\ninclude lower abdominal cramps, an increased need to\\npass stool, and watery diarrhea. As the disease pro-\\ngresses, the patient may experience a general ill feeling,\\nfatigue, abdominalpain, andfever. If the disease pro-\\nceeds to pseudomembranous enterocolitis, the patient\\nmay also experiencenausea, vomiting, large amounts\\nof watery diarrhea, and a very high fever (104-1058F/\\n40-40.5 8C). Complications of antibiotic-associated\\ncolitis include severe dehydration, imbalances in\\nblood minerals, low blood pressure, fluid accumula-\\ntion in deep skin (edema), enlargement of the large\\nintestine (toxic megacolon), and the formation of a\\ntear (perforation) in the wall of the large intestine.\\nThe Clostridium difficile toxin is found in the\\nstools of persons older than 60 years of age 20-100\\ntimes more frequently than in the stools of persons\\nwho are 10-20 years old. As a result, the elderly are\\nmuch more prone to developing antibiotic-associated\\ncolitis than younger individuals.\\nDiagnosis\\nAntibiotic-associated colitis can be diagnosed by\\nthe symptoms and recent medical history of the\\npatient, by a laboratory test for the bacterial toxin,\\nand/or by using a procedure called endoscopy.\\nIf the diarrhea and related symptoms occurred after\\nthe patient received antibiotics, antibiotic-associated\\ncolitis may be suspected. A stool sample may be analyzed\\nfor the presence of theClostridium difficiletoxin. This\\ntoxin test is the preferred diagnostic test for antibiotic-\\nassociated colitis. One frequently used test for the toxin\\ninvolves adding the processed stool sample to a human\\ncell culture. If the toxin is present in the stool sample, the\\ncells die. It may take up to two days to get the results\\nKEY TERMS\\nColitis— Inflammation of the colon.\\nEdema— Fluid accumulation in a tissue.\\nEndoscopy— A procedure in which a thin, lighted\\ninstrument is inserted into the interior of a hollow\\norgan, such as the rectum and used to visually\\ninspect the inner intestinal lining.\\nFibrin— A fibrous blood protein vital to coagulation\\nand blood clot formation.\\nRectum— The last part of the intestine. Stool passes\\nthrough the rectum and out through the anal\\nopening.\\nToxic megacolon— Acute enlargement or dilation\\nof the large intestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 265\\nAntibiotic-associated colitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='from this test. A simpler test, which provides results in\\ntwo to three hours, is also available. Symptoms and toxin\\ntest results are usually enough to diagnose the disease.\\nAnother tool that may be useful in the diagnosis\\nof antibiotic-associated colitis, however, is a proce-\\ndure called an endoscopy that involves inserting a\\nthin, lighted tube into the rectum to visually inspect\\nthe intestinal lining. Two different types of endoscopy\\nprocedures, the sigmoidoscopy and the colonoscopy,\\nare used to view different parts of the large intestine.\\nThese procedures are performed in a hospital or doc-\\ntor’s office. Patients are sedated during the procedure\\nto make them more comfortable and are allowed to go\\nhome after recovering from thesedation.\\nTreatment\\nDiarrhea, regardless of the cause, is always treated\\nby encouraging the individual to replace lost fluids and\\nprevent dehydration. One method to treat antibiotic-\\nassociated colitis is to simply stop taking the antibiotic\\nthat caused the disease. This allows the normal intest-\\ninal bacteria to repopulate the intestines and inhibits\\nthe overgrowth ofClostridium difficile.M a n yp a t i e n t s\\nwith mild disease respond well to this and are free from\\ndiarrhea within two weeks. It is important, however, to\\nmake sure that the original disease for which the anti-\\nbiotics were prescribed is treated.\\nBecause of the potential seriousness of this disease,\\nmost patients are given another antibiotic to control the\\ngrowth of theClostridium difficile, usually vancomycin\\n(Vancocin) or metronidazole (Flagyl or Protostat). Both\\nare designed to be taken orally four times a day for 10-14\\ndays. Upon finishing antibiotic treatment, approxi-\\nmately 15-20% of patients will experience a relapse of\\ndiarrhea within one to five weeks. Mild relapses can go\\nuntreated with great success, however, severe relapses of\\ndiarrhea require another round of antibiotic treatment.\\nInstead of further antibiotic treatment, a cholestyramine\\nresin (Questran or Prevalite) may be given. The bacterial\\ntoxins produced in the intestine stick to the resin and are\\npassed out with the resin in the stool. Unfortunately,\\nhowever, vancomycin also sticks to the resin, so these\\ntwo drugs cannot be taken at the same time. Serious\\ndisease may require hospitalization so that the patient\\ncan be monitored, treated, and rehydrated.\\nAlternative treatment\\nThe goal of alternative treatment for antibiotic-\\nassociated enterocolitis is to repopulate the intestinal\\nenvironment with microorganisms that are normal and\\nhealthy for the intestinal tract. These microorgansisms\\nthen compete for space and keep the Clostridium\\ndifficile from over-populating.\\nSeveral types of supplements can be used.\\nSupplements containingLactobacillus acidophilus,t h e\\nbacteria commonly found in yogurt and some types of\\nmilk, Lactobacillus bifidus,a n dStreptococcus faecium,\\nare available in many stores in powder, capsule, tablet,\\nand liquid form.Acidophilus also acts as a mild anti-\\nbiotic, which helps it to reestablish itself in the intestine,\\nand all may aid in the production of some Bvitamins\\nand vitamin K. These supplements can be taken indivi-\\ndually and alternated weekly or together following one\\nor more courses of antibiotics.\\nPrognosis\\nWith appropriate treatment and replenishment of\\nfluids, the prognosis is generally excellent. One or more\\nrelapses can occur. Very severe colitis can cause a tear\\n(perforation) in the wall of thelarge intestine that would\\nrequire major surgery. Perforation of the intestine can\\ncause a serious abdominal infection. Antibiotic-asso-\\nciated colitis can be fatal in people who are elderly\\nand/or have a serious underlying illness, such ascancer.\\nPrevention\\nThere are no specific preventative measures for this\\ndisease. Good general health can reduce the chance of\\ndeveloping a bacterial infection that would require anti-\\nbiotic treatment and the chance of picking up the\\nClostridia bacteria. Maintaining good general health\\ncan also reduce the seriousness and length of the con-\\ndition, should it develop following antibiotic therapy.\\nResources\\nOTHER\\nMayo Clinic Online.March 5, 1998. .\\nBelinda Rowland, PhD\\nAntibiotic prophylaxis see Prophylaxis\\nAntibiotics\\nDefinition\\nAntibiotics may be informally defined as the sub-\\ngroup of anti-infectives that are derived from bacterial\\nsources and are used to treat bacterial infections.\\nOther classes of drugs, most notably thesulfonamides,\\n266 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='may be effective antibacterials. Similarly, some anti-\\nbiotics may have secondary uses, such as the use of\\ndemeclocycline (Declomycin, a tetracycline deriva-\\ntive) to treat the syndrome of inappropriate antidiure-\\ntic hormone (SIADH) secretion. Other antibiotics\\nmay be useful in treating protozoal infections.\\nPurpose\\nAntibiotics are used for treatment or prevention\\nof bacterial infection.\\nDescription\\nClassifications\\nAlthough there are several classification schemes\\nfor antibiotics, based on bacterial spectrum (broad\\nversus narrow) or route of administration (injectable\\nversus oral versus topical), or type of activity (bacter-\\nicidal vs. bacteriostatic), the most useful is based on\\nchemical structure. Antibiotics within a structural\\nclass will generally show similar patterns of effective-\\nness, toxicity, and allergic potential.\\nPENICILLINS. The penicillins are the oldest class of\\nantibiotics, and have a common chemical structure\\nwhich they share with the cephalopsorins. The two\\ngroups are classed as the beta-lactam antibiotics, and\\nare generally bacteriocidal—that is, they kill bacteria\\nrather than inhibiting growth. The penicillins can be\\nfurther subdivided. The natural pencillins are based on\\nthe original penicillin G structure; penicillinase-resistant\\npenicillins, notably methicillin and oxacillin, are active\\neven in the presence of the bacterial enzyme that inacti-\\nvates most natural penicillins. Aminopenicillins such as\\nampicillin and amoxicillin have an extended spectrum\\nof action compared with the natural penicillins;\\nextended spectrum penicillins are effective against a\\nwider range of bacteria. These generally include cover-\\nage forPseudomonas aeruginaosaand may provide the\\npenicillin in combination with a penicillinase inhibitor.\\nCEPHALOSPORINS. Cephalosporins and the closely\\nrelated cephamycins and carbapenems, like the pencil-\\nlins, contain a beta-lactam chemical structure.\\nConsequently, there are patterns of cross-resistance\\nand cross-allergenicity among the drugs in these\\nclasses. The ‘‘cepha’’ drugs are among the most diverse\\nclasses of antibiotics, and are themselves subgrouped\\ninto 1st, 2nd and 3rd generations. Each generation has\\na broader spectrum of activity than the one before. In\\naddition, cefoxitin, a cephamycin, is highly active\\nagainst anaerobic bacteria, which offers utility in treat-\\nment of abdominal infections. The 3rd generation\\ndrugs, cefotaxime, ceftizoxime, ceftriaxone and others,\\ncross the blood-brain barrier and may be used to treat\\nmeningitis and encephalitis. Cephalopsorins are the\\nusually preferred agents for surgicalprophylaxis.\\nFLUROQUINOLONES. The fluroquinolones are syn-\\nthetic antibacterial agents,and not derived from bacteria.\\nThey are included here because they can be readily inter-\\nchanged with traditional antibiotics. An earlier, related\\nclass of antibacterial agents, the quinolones, were not\\nwell absorbed, and could be used only to treat urinary\\ntract infections. The fluroquinolones, which are based\\non the older group, are broad-spectrum bacteriocidal\\ndrugs that are chemically unrelated to the penicillins or\\nthe cephaloprosins. They are well distributed into bone\\ntissue, and so well absorbed that in general they are as\\neffective by the oral route as by intravenous infusion.\\nTETRACYCLINES. Tetracyclines got their name\\nbecause they share a chemical structure that has four\\nrings. They are derived from a species ofStreptomyces\\nbacteria. Broad-spectrum bacteriostatic agents, the tetra-\\ncyclines may be effective against a wide variety of micro-\\norganisms, including rickettsia and amoebic parasites.\\nMACROLIDES. The macrolide antibiotics are\\nderived from Streptomyces bacteria, and got their\\nname because they all have a macrocyclic lactone\\nchemical structure. Erythromycin, the prototype of\\nthis class, has a spectrum and use similar to penicillin.\\nNewer members of the group, azithromycin and\\nclarithyromycin, are particularly useful for their high\\nA penicillin culture. (Photograph by P. Barber, Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 267\\nAntibiotics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='level of lung penetration. Clarithromycin has been\\nwidely used to treat Helicobacter pylori infections,\\nthe cause of stomach ulcers.\\nOTHERS. Other classes of antibiotics include the\\naminoglycosides, which are particularly useful for\\ntheir effectiveness in treatingPseudomonas aeruginosa\\ninfections; the lincosamindes, clindamycin and linco-\\nmycin, which are highly active against anaerobic\\npathogens. There are other, individual drugs which\\nmay have utility in specific infections.\\nRecommended dosage\\nDosage varies with drug, route of administration,\\npathogen, site of infection, and severity. Additional\\nconsiderations include renal function, age of patient,\\nand other factors. Consult manufacturers’ recommen-\\ndations for dose and route.\\nSide effects\\nAll antibiotics cause risk of overgrowth by non-\\nsusceptible bacteria. Manufacturers list other major\\nhazards by class; however, the health care provider\\nshould review each drug individually to assess the degree\\nof risk. Generally, breastfeeding is not recommended\\nwhile taking antibiotics because of risk of alteration to\\nAntibiotic\\nWater enters Cell deteriorates\\nCell is destroyed\\nDifferent antibiotics destroy bacteria in different ways. Some short-circuit the processes by which bacteria receive energy.\\nOthers disturb the structure of the bacterial cell wall, as shown in the illustration above. Still others interfere with the production\\nof essential proteins. (Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMeningitis— Inflammation of tissues that surround\\nthe brain and spinal cord.\\nMicroorganism— An organism that is too small to\\nbe seen with the naked eye.\\nOrganism— A single, independent unit of life, such\\nas a bacterium, a plant or an animal.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\n268 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='infant’s intestinal flora, and risk of masking infection in\\nthe infant. Excessive or inappropriate use may promote\\ngrowth of resistant pathogens.\\nPenicillins: Hypersensitivity may be common, and\\ncross allergenicity with cephalosporins has been reported.\\nPenicillins are classed as category B duringpregnancy.\\nCephalopsorins: Several cephalopsorins and\\nrelated compounds have been associated with seizures.\\nCefmetazole, cefoperazone, cefotetan and ceftriaxone\\nmay be associated with a fall in prothrombin activity\\nand coagulation abnormalities. Pseudomembranous\\ncolitis has been reported with cephalosporins and\\nother broad spectrum antibiotics. Some drugs in this\\nclass may cause renal toxicity. Pregnancy category B.\\nFluroquinolones: Lomefloxacin has been associated\\nwithincreasedphotosensitivity.Alldrugsinthisclasshave\\nbeen associated with convulsions. Pregnancy category C.\\nTetracyclines: Demeclocycline may cause increased\\nphotosensitivity. Minocycline may cause dizziness.\\nDo not use tetracyclines in children under the age of\\neight, and specifically avoid during periods of tooth\\ndevelopment. Oral tetracyclines bind to anions such as\\ncalcium and iron. Although doxycycline and minocy-\\ncline may be taken with meals, patients must be advised\\nto take other tetracycline antibiotics on an empty sto-\\nmach, and not to take the drugs with milk or other\\ncalcium-rich foods. Expired tetracycline should never\\nbe administered. Pregnancy category D. Use during\\npregnancy may cause alterations in bone development.\\nMacrolides: Erythromycin may aggravate the weak-\\nness of patients withmyasthenia gravis.A z i t h r o m y c i n\\nhas, rarely, been associated with allergic reactions,\\nincluding angioedema,anaphylaxis, and dermatologic\\nreactions, including Stevens-Johnson syndrome and\\ntoxic epidermal necrolysis.O r a le r y t h r o m y c i nm a yb e\\nhighly irritating to the stomach and when given by\\ninjection may cause severe phlebitis. These drugs should\\nbe used with caution in patients with liver dysfunction.\\nPregnancy category B: Azithromycin, erythro-\\nmycin. Pregnancy category C: Clarithromycin, dirithro-\\nmycin, troleandomycin.\\nAminoglycosides: This class of drugs causes kid-\\nney and ototoxicity. These problems can occur even\\nwith normal doses. Dosing should be based on renal\\nfunction, with periodic testing of both kidney function\\nand hearing. Pregnancy category D.\\nRecommended usage\\nTo minimize risk of adverse reactions and develop-\\nment of resistant strains of bacteria, antibiotics should\\nbe restricted to use in cases where there is either known\\nor a reasonable presumption of bacterial infection. The\\nuse of antibiotics in viral infections is to be avoided.\\nAvoid use of fluroquinolones for trivial infections.\\nIn severe infections, presumptive therapy with a\\nbroad-spectrum antibiotic such as a 3rd generation\\ncephalosporin may be appropriate. Treatment should\\nbe changed to a narrow spectrum agent as soon as the\\npathogen has been identified. After 48 hours of treat-\\nment, if there is clinical improvement, an oral antibio-\\ntic should be considered.\\nResources\\nPERIODICALS\\n‘‘Consumer Alert: Antibiotic Resistance Is Growing!’’\\nPeople’s Medical Society Newsletter16 (August 1997): 1.\\nSamuel D. Uretsky, PharmD\\nAntibiotics, ophthalmic\\nDefinition\\nOphthalmic antibiotics are medicines that kill bac-\\nteria that cause eye infections.\\nPurpose\\nOphthalmic antibiotics are applied to the eye, or\\nundertheeyelid,totreateyeinf ectionscausedbybacteria.\\nDescription\\nThe medicine described here, tobramycin\\n(Tobrex), comes in the form of eye drops or ointment.\\nIt is available only with a physician’s prescription.\\nRecommended dosage\\nThe dosages given here are typical doses. Physicians\\nmay adjust the number of doses per day, the time\\nbetween doses, and the length of treatment with the\\nmedicine, depending on the patient’s particular medical\\nproblem. If the physician’s directions are different\\nfrom those given here, follow the physician’s directions.\\nAdults\\nEYE DROPS. Formildtomoderateinfections,useone\\nto two drops in the affected eye or eyes every four hours.\\nFor severe infections, use two drops in the affected\\neye or eyes every two hours until the condition improves.\\nGALE ENCYCLOPEDIA OF MEDICINE 269\\nAntibiotics, ophthalmic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='At that time, the physician will determine how much\\nto use until the infection is completely cleared up.\\nOINTMENT. For mild to moderate infections,\\nsqueeze a half-inch ribbon of ointment into the\\naffected eye or eyes two or three times a day. Do not\\nlet the tip of the ointment tube touch the eye.\\nFor severe infections, squeeze a half-inch ribbon\\nof ointment into the affected eye or eyes every three to\\nfour hours until the condition improves. At that time,\\nthe physician will determine how much to use until the\\ninfection is completely cleared up.\\nChildren\\nThe child’s physician should determine the proper\\ndose.\\nPrecautions\\nUse this drug as often as directed, for as long as\\ndirected. Although the symptoms may have disap-\\npeared, the infection may not clear up completely if\\nthe drug is stopped too soon. Therefore, the medica-\\ntion may be prescribed for several days after the infec-\\ntion appears to have cleared. However, it is just as\\nimportant to use the drug foronly as long as directed.\\nUsing it for too long may lead to the growth of bac-\\nteria that do not respond to the drug. These bacteria\\nmay then cause infections that can be very difficult to\\ntreat. Make sure the physician or pharmacist specifies\\nhow long the medication is to be used.\\nAnyone who has had an allergic reaction to tobra-\\nmycin or any other ingredients of Tobrex should not\\nuse this medicine. Be sure to tell the physician about\\nany past reactions to the drug or its ingredients.\\nAnyone who has an allergic reaction to tobramycin\\nshould stop using it immediately and call a physician.\\nWomen who are pregnant or breastfeeding or who\\nplan to become pregnant should check with their phy-\\nsicians before using tobramycin.\\nSide effects\\nThe main side effects of this medicine areitching,\\nredness, and swelling of the eye or eyelid. Allergic\\nreactions also are possible. If any of these symptoms\\noccur, call the physician who prescribed the medicine.\\nInteractions\\nPatients who are using any other prescription or\\nnonprescription (over-the-counter) medicines in their\\neyes should check with their physicians before using\\ntobramycin.\\nNancy Ross-Flanigan\\nAntibiotics, topical\\nDefinition\\nTopical antibiotics are medicines applied to the\\nskin to kill bacteria.\\nPurpose\\nTopical antibiotics help prevent infections caused\\nby bacteria that get into minor cuts, scrapes, and\\nburns. Treating minorwounds with antibiotics allows\\nquicker healing. If the wounds are left untreated, the\\nbacteria will multiply, causingpain, redness, swelling,\\nitching, and oozing. Untreated infections can even-\\ntually spread and become much more serious.\\nDifferent kinds of topical antibiotics kill different\\nkinds of bacteria. Many antibiotic first-aid products\\ncontain combinations of antibiotics to make them\\neffective against a broad range of bacteria.\\nWhen treating a wound, it is not enough to simply\\napply a topical antibiotic. The wound must first be\\ncleaned with soap and water and patted dry. After the\\nantibiotic is applied, the wound should be covered\\nwith a dressing, such as a bandage or a protective gel\\nor spray. For many years, it was thought that wounds\\nheal best when exposed to the air. But now most\\nexperts say it is best to keep wounds clean and moist\\nwhile they heal. The covering should still allow some\\nair to reach the wound, however.\\nDescription\\nSome topical antibiotics are available without a\\nprescription and are sold in many forms, including\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nOintment— A thick, spreadable substance that con-\\ntains medicine and is meant to be used on the skin,\\nor, if it is specifically an ophthalmic, or ‘‘eye’’ oint-\\nment, in the eye\\n270 GALE ENCYCLOPEDIA OF MEDICINE\\nAntibiotics, topical'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='creams, ointments, powders, and sprays. Some widely\\nused topical antibiotics are bacitracin, neomycin,\\nmupirocin, and polymyxin B. Among the products\\nthat contain one or more of these ingredients are\\nBactroban (a prescription item), Neosporin,\\nPolysporin, and Triple Antibiotic Ointment or Cream.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\ntopical antibiotic. Follow the directions on the pack-\\nage label or ask a pharmacist for directions.\\nIn general, topical antibiotics should be applied\\nwithin four hours after injury. Do not use more than\\nthe recommended amount and do not apply it more\\noften than three times a day. Do not apply the medi-\\ncine over large areas of skin or on open wounds.\\nPrecautions\\nMany public health experts are concerned about\\nantibiotic resistance, a problem that can develop when\\nantibiotics are overused. Over time, bacteria develop\\nnew defenses against antibiotics that once were effective\\nagainst them. Because bacteria reproduce so quickly,\\nthese defenses can be rapidly passed on through gen-\\nerations of bacteria until almost all are immune to the\\neffects of a particular antibiotic. The process happens\\nfaster than new antibiotics can be developed. To help\\ncontrol the problem, many experts advise people to use\\ntopical antibiotics only for short periods, that is, until\\nthe wound heals, and only as directed. For the topical\\nantibiotic to work best, it should be used only to pre-\\nvent infection in a fresh wound, not to treat an infection\\nthat has already started. Wounds that are not fresh may\\nneed the attention of a physician to prevent complica-\\ntions such as bloodpoisoning.\\nTopical antibiotics are meant to be used only on\\nthe skin and only for only a few days at a time. If the\\nwound has not healed in five days, stop using the\\nantibiotic and call a doctor.\\nDo not use topical antibiotics on large areas of skin\\nor on open wounds. These products should not be used\\nto treatdiaper rashin infants or incontinence rash in\\nadults.\\nOnly minor cuts, scrapes, and burns should be\\ntreated with topical antibiotics. Certain kinds of inju-\\nries may need medical care and should not be self-\\ntreated with topical antibiotics. These include:\\n/C15large wounds\\n/C15deep cuts\\n/C15cuts that continue bleeding\\n/C15cuts that may need stitches\\n/C15burns any larger than a few inches in diameter\\n/C15scrapes imbedded with particles that won’t wash\\naway\\n/C15animal bites\\n/C15deep puncture wounds\\n/C15eye injuries\\nNever use regular topical antibiotics in the eyes.\\nSpecial antibiotic products are available for treating\\neye infections.\\nAlthough topical antibiotics control infections\\ncaused by bacteria, they may allow fungal infections\\nto develop. The use of other medicines to treat the\\nfungal infections may be necessary. Check with the\\nphysician or pharmacist.\\nSome people may be allergic to one or more ingre-\\ndients in a topical antibiotic product. If an allergic\\nreaction develops, stop using the product immediately\\nand call a physician.\\nNo harmful or abnormal effects have been\\nreported in babies whose mothers used topical anti-\\nbiotics while pregnant or nursing. However, pregnant\\nwomen generally are advised not to use any drugs\\nduring the first 3 months after conception. A woman\\nwho is pregnant or breastfeeding or who plans to\\nbecome pregnant should check with her physician\\nbefore using a topical antibiotic.\\nUnless a physician says to do so, do not use topi-\\ncal antibiotics on children under two years of age.\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nConception— The union of egg and sperm to form a\\nfetus.\\nFungal— Caused by a fungus.\\nFungus— A member of a group of simple organisms\\nthat are related to yeast and molds.\\nIncontinence— The inability to control the bladder\\nor bowel.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nGALE ENCYCLOPEDIA OF MEDICINE 271\\nAntibiotics, topical'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Side effects\\nThe most common minor side effects are itching\\nor burning. These problems usually do not require\\nmedical treatment unless they do not go away or they\\ninterfere with normal activities.\\nIf any of the following side effects occur, check\\nwith a doctor as soon as possible:\\n/C15rash\\n/C15swelling of the lips and face\\n/C15sweating\\n/C15tightness or discomfort in the chest\\n/C15breathing problems\\n/C15fainting ordizziness\\n/C15low blood pressure\\n/C15nausea\\n/C15diarrhea\\n/C15hearing loss or ringing in the ears\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after using a topical antibio-\\ntic should get in touch with the physician who pre-\\nscribed or the pharmacist who recommedned the\\nmedication.\\nInteractions\\nUsing certain topical antibiotics at the same time\\nas hydrocortisone (a topical corticosteroid used to\\ntreat inflammation) may hide signs of infection or\\nallergic reaction. Do not use these two medicines at\\nthe same time unless told to do so by a health care\\nprovider.\\nAnyone who is using any other type of prescrip-\\ntion or nonprescription (over-the-counter) medicine\\non the skin should check with a doctor before using a\\ntopical antibiotic.\\nResources\\nPERIODICALS\\nFarley, Dixie. ‘‘Help for Cuts, Scrapes and Burns.’’FDA\\nConsumer May 1996:12.\\nNancy Ross-Flanigan\\nAntibody screening see Blood typing and\\ncrossmatching\\nAnticancer drugs\\nDefinition\\nAnticancer, or antineoplastic, drugs are used to\\ntreat malignancies, or cancerous growths. Drug\\ntherapy may be used alone, or in combination with\\nother treatments such as surgery orradiation therapy.\\nPurpose\\nAnticancer drugs are used to control the growth of\\ncancerous cells. Cancer is commonly defined as the\\nuncontrolled growth of cells, with loss of differentia-\\ntion and commonly, with metastasis, spread of the\\ncancer to other tissues and organs. Cancers are malign-\\nant growths. In contrast, benign growths remain\\nencapsulated and grow within a well-defined area.\\nAlthough benign tumors may be fatal if untreated,\\ndue to pressure on essential organs, as in the case of a\\nbenign brain tumor, surgery or radiation are the pre-\\nferred methods of treating growths which have a well\\ndefined location. Drug therapy is used when the tumor\\nhas spread, or may spread, to all areas of the body.\\nDescription\\nSeveral classes of drugs may be used in cancer\\ntreatment, depending on the nature of the organ\\ninvolved. For example, breast cancers are commonly\\nstimulated by estrogens, and may be treated with\\ndrugs that inactivate the sex hormones. Similarly,\\nprostate cancermay be treated with drugs that inacti-\\nvate androgens, the male sex hormone. However, the\\nmajority of antineoplastic drugs act by interfering\\nwith cell growth. Since cancerous cells grow more\\nrapidly than other cells, the drugs target those cells\\nthat are in the process of reproducing themselves. As a\\nresult, antineoplastic drugs will commonly affect not\\nonly the cancerous cells, but others cells that com-\\nmonly reproduce quickly, including hair follicles,\\novaries and testes, and the blood-forming organs.\\nNewer methods of antineoplastic drug therapy\\nhave taken different approaches, including angiogen-\\nesis—the inhibition of formation of blood vessels feed-\\ning the tumor and contributing to tumor growth.\\nAlthough these approaches hold promise, they are\\nnot yet in common use. Developing new anticancer\\ndrugs is the work of ongoing research. In 2003, a new\\ntechnique was developed to streamline the search for\\neffective drugs. Researchers pumped more than 23,000\\nchemical compounds through a screening technique to\\nidentify those that help fight cancer while leaving\\n272 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticancer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='healthy cells unharmed. The system identified nine\\ncompounds matching the profile, including one pre-\\nviously unidentified drug for fighting cancer. They\\nhave expanded their research to determine how the\\ndrug might be developed. This was an important step\\nAnti Cancer Drugs\\nGeneric (Brand Name) Clinical Uses\\nCommon Side\\nEffects To Drug\\nAltretamine(Hexalen) Treatment of\\nadvanced ovarian\\ncancer\\nBone marrow\\ndepression, nausea\\nand vomiting\\nAsparaginase(Elspar) Commonly used in\\ncombination with\\nother drugs; refrac-\\ntory acute lymphocy-\\ntic leukemia\\nLiver, kidney,\\npancreas, CNS\\nabnormalities,\\nBleomycin(Blenoxane) Lymphomas,\\nHodgkin’s disease,\\ntesticular cancer\\nHair loss, stomatitis,\\npulmonary toxicity,\\nhyperpigmentation\\nof skin\\nBusulfan(Myleran) Chronic granulocytic\\nleukemia\\nBone marrow\\ndepression,\\npulmonary toxicity\\nCarboplatin(Paraplatin) Pallilation of ovarian\\ncancer\\nBone marrow\\ndepression, nausea\\nand vomiting\\nCarmustine Hodgkin’s disease,\\nbrain tumors, multi-\\nple myeloma, malig-\\nnant melonoma\\nBone marrow\\ndepression, nausea\\nand vomiting, toxic\\ndamage to liver\\nChlorambucil(Leukeran) Chronic lymphocytic\\nleukemia, non-\\nHodgkin’s\\nlymphomas, breast\\nand ovarian cancer\\nBone marrow\\ndepression, excess\\nuric acid in blood\\nCisplatin(Platinol) Treatment of bladder,\\novarian,\\nuterine, testicular,\\nhead and neck\\ncancers\\nRenal toxicity and\\nototoxicity\\nCladribine(Leustatin) Hairy cell leukemia Bone marrow\\ndepression, nausea\\nand vomiting, fever\\nCyclophosphamide\\n(Cytoxan)\\nHodgkin’s disease,\\nnon-Hodgkin’s lym-\\nphomas, neuroblas-\\ntoma. Often used\\nwith other drugs for\\nbreast, ovarian, and\\nlung cancers; acute\\nlymphoblastic leuke-\\nmia in children; mul-\\ntiple myeloma\\nBone marrow\\ndepression, hair loss,\\nnausea and vomiting,\\ninflammation of the\\nbladder\\nCytarabine(Cytosar-U) Leukemias occurring\\nin adults and children\\nBone marrow\\ndepression, nausea\\nand vomiting,\\ndiarrhea, stomatitis\\nDacarbazine(DTIC-\\nDome)\\nHodgkin’s disease,\\nmalignant melanoma\\nBone marrow\\ndepression, nausea\\nand vomiting\\nDiethylstilbestrol (DES)\\n(Stilbestrol)\\nBreast cancer in\\npost-menopausal\\nwomen, prostate\\ncancer\\nHair loss, nausea and\\nvomiting, edema,\\nexcess calcium in\\nblood; feminizing\\neffects in men\\nEthinyl\\nestradiol(Estinyl)\\nAdvanced breast\\ncancer in post-\\nmenopausal women,\\nprostate cancer\\nExcess calcium in\\nblood, anorexia,\\nedema, nausea and\\nvomiting; feminizing\\neffects in men\\nEtoposide(VePesid) Acute leukemias,\\nlymphomas, testicu-\\nlar cancer\\nBone marrow\\ndepression, nausea\\nand vomiting, hair loss\\nAnti Cancer Drugs (continued)\\nGeneric (Brand Name) Clinical Uses\\nCommon Side\\nEffects To Drug\\nMitomycin (Mutamycin) Bladder, breast,\\ncolon, lung,\\npancreas, rectum\\ncancers, head and\\nneck cancer, malig-\\nnant melanoma\\nBone marrow\\ndepression, nausea\\nand vomiting,\\ndiarrhea, stomatitis,\\npossible tissue\\ndamage\\nMitotane (Lysodren) Cancer of the adrenal\\ncortex (inoperable)\\nDamage to adrenal\\ncortex, nausea,\\nanorexia\\nMitoxantrone (Novantrone) Acute nonlymphocy-\\ntic leukemia\\nCardiac arrhythmias,\\nlabored breating,\\nnausea and vomiting,\\ndiarrhea, fever,\\ncongestive heart\\nfailure\\nPaclitaxel (Taxol) Advanced ovarian\\ncancer\\nBone marrow\\ndepression, hair loss,\\nnausea and vomiting,\\nhypotension, allergic\\nreactions, slow heart\\naction, muscle and\\njoint pain\\nPentastatin (Nipent) Hairy cell leukemia\\nunresponsive to\\nalpha-interferon\\nBone marrow\\ndepression, fever,\\nskin rash, liver\\ndamage, nausea and\\nvomiting\\nPipobroman (Vercyte) Chronic granulocytic\\nleukemia\\nBone marrow\\ndepression\\nPlicamycin (Mithracin) Testucular tumors Toxicity/damage\\nto bone marrow,\\nkidneys, and liver\\nPrednisone (Meticorten) Used in adjunct ther-\\napy for palliation of\\nsymptoms in lympho-\\nmas, acute leukemia\\nHodgkin’s disease\\nMay be toxic to all\\nbody systems\\nProcarbazine (Matulane) Hodgkin’s disease Bone marrow\\ndepression, nausea\\nand vomiting\\nStreptozocin (Zanosar) Islet cell carcinoma of\\npancreas\\nNausea and vomiting,\\ntoxicity to kidneys\\nTamoxifen (Nolvadex) Advanced breast can-\\ncer in post\\nmenopausal\\nNausea and vomiting,\\nocular toxicity, hot\\nflashes\\nTeniposide (Vumon) Acute lymphocytic\\nleukemia in children\\nSee Etoposide\\nVinblastine (Velban) Breast cancer,\\nHodgkin’s disease,\\nmetastatic testicular\\ncancer\\nBone marrow\\ndepression,\\nneurotoxicity\\nVincristine (Oncovin) Acute leukemia,\\nHodgkin’s disease,\\nlymphomas\\nConstipation,\\nneurotoxicity,\\npossible tissue\\nnecrosis\\nGALE ENCYCLOPEDIA OF MEDICINE 273\\nAnticancer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='in identifying anticancer dugs that are not completely\\ntoxic to healthy cells.\\nAntineoplastic drugs may be divided into two\\nclasses: cycle specific and non-cycle specific. Cycle\\nspecific drugs act only at specific points of the cell’s\\nduplication cycle, such as anaphase or metaphase,\\nwhile non-cycle specific drugs may act at any point in\\nthe cell cycle. In order to gain maximum effect, anti-\\nneoplastic drugs are commonly used in combinations.\\nPrecautions\\nBecause antineoplastic agents do not target spe-\\ncific cell types, they have a number of common\\nadverse side effects. Hair loss is common due to the\\neffects on hair follicles, and anemia, immune system\\nimpairment, and clotting problems are caused by\\ndestruction of the blood-forming organs, leading to\\na reduction in the number of red cells, white cells, and\\nplatelets. Because of the frequency and severity of\\nthese side effects, it is common to administerche-\\nmotherapy in cycles, allowing time for recovery from\\nthe drug effects before administering the next dose.\\nDoses are often calculated, not on the basis of weight,\\nbut rather based on blood counts, in order to avoid\\ndangerous levels of anemia (red cell depletion),neu-\\ntropenia (white cell deficiency), orthrombocytopenia\\n(platelet deficiency.)\\nThe health professional has many responsibilities\\nin dealing with patients undergoing chemotherapy.\\nThe patient must be well informed of the risks and\\nbenefits of chemotherapy, and must be emotionally\\nprepared for the side effects. These may be permanent,\\nand younger patients should be aware of the high risk\\nof sterility after chemotherapy.\\nThe patient must also know which side effects\\nshould be reported to the practitioner, since many\\nadverse effects do not appear until several days after\\na dose of chemotherapy. When chemotherapy is self-\\nadministered, the patien tm u s tb ef a m i l i a rw i t h\\nproper use of the drugs, including dose scheduling\\nand avoidance of drug-drug and food-drug\\ninteractions.\\nAppropriate steps should be taken to minimize\\nside effects. These may include administration of anti-\\nnauseant medications to reducenausea and vomiting,\\nmaintaining fluid levels to reduce drug toxicity, parti-\\ncularly to the kidneys, or application of a scalp tour-\\nniquet to reduce blood flow to the scalp and minimize\\nhair loss due to drug therapy.\\nPatients receiving chemotherapy also are at risk of\\ninfections due to reduced white blood counts. While\\nprophylactic antibiotics may be useful, the health care\\nprofessional should also be sure to use standard pre-\\ncautions, including gowns and gloves when appropri-\\nate. Patients should be alerted to avoid risks of viral\\ncontamination, and live virus immunizations are con-\\ntraindicated until the patient has fully recovered from\\nthe effects of chemotherapy. Similarly, the patient\\nshould avoid contact with other people who have\\nrecently had live virus immunizations.\\nOther precautions which should be emphasized\\nare the risks to pregnant or nursing women. Because\\nantineoplastic drugs are commonly harmful to the\\nfetus, women of childbearing potential should be cau-\\ntioned to use two effective methods of birth control\\nwhile receiving cancer chemotherapy. This also applies\\nif the woman’s male partner is receiving chemother-\\napy. Breastfeeding should be avoided while the mother\\nis being treated.\\nBefore prescribing or administering anticancer\\ndrugs, health care providers should inquire whether\\nthe patient has any of the following conditions:\\n/C15chickenpox or recent exposure to someone with\\nchickenpox\\n/C15shingles (Herpes zoster)\\n/C15mouth sores\\n/C15current or past seizures\\n/C15head injury\\n/C15nerve or muscle disease\\n/C15hearing problems\\n/C15infection of any kind\\n/C15gout\\n/C15colitis\\n/C15intestine blockage\\n/C15stomach ulcer\\n/C15kidney stones\\n/C15kidney disease\\n/C15liver disease\\n/C15current or past alcoholabuse\\nKEY TERMS\\nCataract— Clouding of the lens of the eye, leading\\nto poor vision or blindness.\\nImpotent— Unable to achieve or maintain an erec-\\ntion of the penis.\\n274 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticancer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15immune system disease\\n/C15cataracts or other eye problems\\n/C15high cholesterol\\nOther precautions\\nThe anticancer drug methotrexate has additional\\nprecautions. Patients should be given advice on the\\neffects of sun exposure and the use of alcohol andpain\\nrelievers.\\nSide effects\\nTamoxifen\\nThe anticancer drug tamoxifen (Nolvadex) increases\\nt h er i s ko fc a n c e ro ft h eu t e r u si ns o m ew o m e n .I ta l s o\\ncauses cataracts and other eye problems. Women taking\\nthis drug may have hot flashes, menstrual changes, geni-\\ntal itching, vaginal discharge, and weight gain. Men who\\ntake tamoxifen may lose interest in sex or become impo-\\ntent. Health care providers should keep in close contact\\nwith patients to assess the individual risks associated\\nwith taking this powerful drug.\\nOther anticancer drugs\\nThese side effects are not common, but could be a\\nsign of a serious problem. Health care providers\\nshould immediately be consulted if any of the follow-\\ning occur:\\n/C15black, tarry, or bloody stools\\n/C15blood in the urine\\n/C15diarrhea\\n/C15fever or chills\\n/C15cough or hoarseness\\n/C15wheezing orshortness of breath\\n/C15sores in the mouth or on the lips\\n/C15unusual bleeding or bruising\\n/C15swelling of the face\\n/C15red ‘‘pinpoint’’ spots on the skin\\n/C15redness, pain, or swelling at the point where an inject-\\nable anticancer drug is given\\n/C15pain in the side or lower back\\n/C15problems urinating or painful urination\\n/C15dizziness or faintness\\n/C15fast or irregular heartbeat\\nOther side effects do not need immediate care, but\\nshould have medical attention. They are:\\n/C15joint pain\\n/C15skin rash\\n/C15hearing problems or ringing in the ears\\n/C15numbness ortingling in the fingers or toes\\n/C15trouble walking or balance problems\\n/C15swelling of the feet or lower legs\\n/C15unusual tiredness or weakness\\n/C15loss of taste\\n/C15seizures\\n/C15dizziness\\n/C15confusion\\n/C15agitation\\n/C15headache\\n/C15dark urine\\n/C15yellow eyes or skin\\n/C15flushing of the face\\nIn addition, there are other possible side effects\\nthat do not need medical attention unless they persist\\nor interfere with normal activities. These include\\nchanges in menstrual period, itchy skin, nausea and\\nvomiting, and loss of appetite.\\nOther rare side effects may occur. Anyone who has\\nunusual symptoms after taking anticancer drugs should\\ncontact the physician who prescribed the medication.\\nInteractions\\nAnticancer drugs may interact with a number of\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side effects\\nmaybegreater.Thehealthcareprovidershouldbeaware\\nof all other prescription or non-prescription (over-the-\\ncounter) medicines a patient is taking. The primary care\\nprovidershouldalsobetoldifthepatienthasbeentreated\\nwith radiation or has taken other anticancer drugs.\\nResources\\nPERIODICALS\\n‘‘Technique Streamlines Search for Anticancer Drugs.’’\\nCancer WeeklyApril 15, 2003: 62.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnticholinergic drugsseeAntiparkinson drugs\\nAnticlotting drugs see Anticoagulant and\\nantiplatelet drugs\\nGALE ENCYCLOPEDIA OF MEDICINE 275\\nAnticancer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Anticoagulant and antiplatelet\\ndrugs\\nDefinition\\nAnticoagulants are drugs used to prevent clot for-\\nmation or to prevent a clot that has formed from enlarg-\\ning. They inhibit clot formation by blocking the action\\nof clotting factors or platelets. Anticoagulant drugs fall\\ninto three categories: inhibitors of clotting factor synth-\\nesis, inhibitors of thrombin and antiplatelet drugs.\\nPurpose\\nAnticoagulant drugs reduce the ability of the blood\\nto form clots. Although blood clotting is essential to\\nprevent serious bleeding in the case of skin cuts, clots\\ninside the blood vessels block the flow of blood to major\\norgans and cause heart attacks and strokes. Although\\nthese drugs are sometimes called blood thinners, they\\ndo not actually thin the blood. Furthermore, this type\\nof medication will not dissolve clots that already have\\nformed, although the drug stops an existing clot from\\nworsening. However, another type of drug, used in\\nthrombolytic therapy, will dissolve existing clots.\\nAnticoagulant drugs are used for a number of con-\\nditions. For example, they may be given to preventblood\\nclotsfrom forming after the replacement of a heart valve\\nor to reduce the risk of astroke or anotherheart attack\\nafter a first heart attack. They are also used to reduce the\\nchance of blood clots forming during open heart surgery\\nor bypass surgery. Low doses of these drugs may be\\ng i v e nt op r e v e n tb l o o dc l o t si np a t i e n t sw h om u s ts t a yi n\\nbed for a long time after certain types of surgery.\\nBecause anticoagulants affect the blood’s ability\\nto clot, they can increase the risk of severe bleeding\\nand heavy blood loss. It is thus essential to take these\\ndrugs exactly as directed and to see a physician regu-\\nlarly as long as they are prescribed.\\nDescription\\nAnticoagulant drugs, also called anticlotting drugs\\nor blood thinners, are available only with a physician’s\\nprescription. They come in tablet and injectable forms.\\nThey fall into three groups:\\n/C15Inhibitors of clotting factor synthesis. These anti-\\ncoagulants inhibit the production of certain clotting\\nfactors in the liver. One example is warfarin (brand\\nname: coumadin).\\n/C15Inhibitors of thrombin. Thrombin inhibitors interfere\\nwith blood clotting by blocking the activity of throm-\\nbin. They include heparin, lepirudin (Refludan).\\n/C15Antiplatelet drugs. Antiplatelet drugs interact with\\nplatelets, which is a type of blood cell, to block plate-\\nlets from aggregating into harmful clots. They include:\\naspirin, ticlopidine (Ticlid), clopidogrel (Plavix), tiro-\\nfiban (Aggrastat), and eptifibatide (Integrilin).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nanticoagulant drug and the medical condition for\\nwhich it is prescribed. The prescribing physician or\\nthe pharmacist who filled the prescription can provide\\ninformation concerning the correct dosage. Usually,\\nthe physician will adjust the dose after checking the\\npatient’s clotting time.\\nAnticoagulant drugs must be taken exactly as direc-\\nted by the physician. Larger or more frequent doses\\nshould not be taken, and the drug should also not be\\ntaken for longer than prescribed.Taking too much of this\\nmedication can cause severe bleeding.Anticoagulants\\nshould also be taken on schedule. A record of each\\ndose should be kept as it is taken. If a dose is missed, it\\nKEY TERMS\\nAnticoagulant— Drug used to prevent clot forma-\\ntion or to prevent a clot that has formed from enlar-\\nging. Anticoagulant drugs inhibit clot formation by\\nblocking the action of clotting factors or platelets.\\nAnticoagulant drugs fall into three groups: inhibi-\\ntors of clotting factor synthesis, inhibitors of throm-\\nbin and antiplatelet drugs.\\nAntiplatelet drug— Drug that inhibits platelets from\\naggregating to form a plug. They are used to prevent\\nclotting and alter the natural course of atherosclerosis.\\nAtherosclerosis— Condition characterized by\\ndeposits of fatty plaque in the arteries.\\nClot— A soft, semi-solid mass that forms when\\nblood gels.\\nPlatelet— A small, disk-shaped body in the blood\\nthat has an important role in blood clotting: they\\nform the initial plug at the rupture site of a blood\\nvessel.\\nThrombin— Thrombin is a protein produced by the\\nbody. It is a specific clotting factor that plays an\\nimportant role in the blood clotting process.\\nThrombin inhibitor— Thrombin inhibitors are one\\ntype of anticoagulant medication, used to help pre-\\nvent formation of harmful blood clots in the body\\nby blocking the activity of thrombin.\\n276 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticoagulant and antiplatelet drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='should be taken as soon as possible followed by the\\nregular dose schedule. However, a patient who forgets\\nto take a missed dose until the next day should not take\\nthe missed dose at all and should not double the next\\ndose, as this could lead to bleeding. A record of all\\nmissed doses should be kept for the prescribing physi-\\ncian who should be informed at the scheduled visits.\\nPrecautions\\nPersons who take anticoagulants should see a phy-\\nsician regularly while taking these drugs, particularly at\\nthe beginning of therapy. The physician will order peri-\\nodic blood tests to check the blood’s clotting ability. The\\nresults of these tests will help the physician determine the\\nproper amount of medication to be taken each day.\\nTime is required for normal clotting ability to\\nreturn after anticoagulant treatment. During this per-\\niod, patients must observe the same precautions they\\nobserved while taking the drug. The length of time\\nneeded for the blood to return to normal depends on\\nthe type of anticoagulant drug that was taken. The\\nprescribing physician will advise as to how long the\\nprecautions should be observed.\\nPeople who are taking anticoagulant drugs should\\ntell all physicians, dentists, pharmacists, and other\\nmedical professionals who provide medical treatments\\nor services to them that they are taking such a medica-\\ntion. They should also carry identification stating that\\nthey are using an anticoagulant drug.\\nOther prescription drugs or over-the-counter\\nmedicine–especially aspirin–should be not be taken\\nwithout the prescribing physician being informed.\\nBecause of the risk of heavy bleeding, anyone who\\ntakes an anticoagulant drug must take care to avoid\\ninjuries. Sports and other potentially hazardous activ-\\nities should be avoided. Any falls, blows to the body or\\nhead, or other injuries should be reported to a physician,\\nas internal bleeding may occur without any obvious\\nsymptoms. Special care should be taken in shaving\\nand in brushing and flossing the teeth. Soft tooth-\\nbrushes should be used and the flossing should be very\\ngentle. Electric razors should be used instead of a blade.\\nAlcohol can change the way anticoagulant drugs\\naffect the body. Anyone who takes this medicine\\nshould not have more than one to two drinks at any\\ntime and should not drink alcohol every day.\\nSpecial conditions\\nPeople with specific medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take anticoagulant drugs. Before taking these\\ndrugs, the prescribing physician should be informed\\nabout any of these conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to anticoagulants in the past should let his or\\nher physician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nbeef, pork, or other foods; dyes; preservatives; or other\\nsubstances.\\nPREGNANCY. Anticoagulants may cause many\\nserious problems if taken during pregnancy. Birth\\ndefects, severe bleeding in the fetus, and other pro-\\nblems that affect the physical or mental development\\nof the fetus or newborn are possible. The mother may\\nalso experience severe bleeding if she takes anticoagu-\\nlants during pregnancy, during delivery, or even\\nshortly after delivery. Women should not take start\\ntaking anticoagulants during pregnancy and should not\\nbecome pregnant while taking it. Any woman who\\nbecomes pregnant or suspects that she has become preg-\\nnant while taking an anticoagulant should check with\\nher physician immediately.\\nBREASTFEEDING. Some anticoagulant drugs may\\npass into breast milk. Blood tests can be done on\\nnursing babies to see whether the drug is causing any\\nproblems. If it is, other medication may be prescribed\\nto counteract the effects of the anticoagulant drug.\\nOTHER MEDICAL CONDITIONS. Before using antic-\\noagulant drugs, people should inform their physician\\nabout any medical problems they have. They should\\nalso let the physician who prescribed the medicine\\nknow if they are being treated by any other medical\\nphysician or dentist. In addition, people who will be\\ntaking anticoagulant drugs should let their physician\\nknow if they have recently had any of the following:\\n/C15fever lasting more than one to two days\\n/C15severe or continuingdiarrhea\\n/C15childbirth\\n/C15heavy or unusual menstrual bleeding\\n/C15insertion of an intrauterine contraceptive device\\n(IUD)\\n/C15falls, injuries, or blows to the body or head\\n/C15any type of surgery, including dental surgery\\n/C15spinal anesthesia\\n/C15radiation treatment\\nUSE OF CERTAIN FOODS AND MEDICINES. Many\\nfoods and drugs may affect the way the anticoagulant\\ndrugs work or may increase the risk of side effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 277\\nAnticoagulant and antiplatelet drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Side effects\\nThe most common minor side effects are bloating or\\ngas. These problems usually go away as the body adjusts\\nto the drug and do not require medical treatment.\\nMore serious side effects may occur, especially if\\nexcessive anticoagulant is taken. If any of the follow-\\ning side effects occur, a physician should be notified\\nimmediately:\\n/C15bleeding gums\\n/C15sores or white spots in the mouth or throat\\n/C15unusual bruises or purplish areas on the skin\\n/C15unexplained nosebleeds\\n/C15unusually heavy bleeding or oozing fromwounds\\n/C15unexpected or unusually menstrual bleeding\\n/C15blood in the urine\\n/C15cloudy or dark urine\\n/C15painful or difficult urination or sudden decrease in\\namount of urine\\n/C15black, tarry, or bloody stools\\n/C15coughing up blood\\n/C15vomiting blood or something that looks like coffee\\ngrounds\\n/C15constipation\\n/C15pain or swelling in the stomach or abdomen\\n/C15back pain\\n/C15stiff, swollen, or painful joints\\n/C15painful, bluish or purplish fingers or toes\\n/C15puffy or swollen eyelids, face, feet, or lower legs\\n/C15changes in the color of the face\\n/C15skin rash,itching,o rhives\\n/C15yellow eyes or skin\\n/C15severe or continuingheadache\\n/C15sore throat and fever, with or without chills\\n/C15breathing problems orwheezing\\n/C15tightness in the chest\\n/C15dizziness\\n/C15unusual tiredness or weakness\\n/C15weight gain.\\nIn addition, patients taking anticoagulant drugs\\nshould check with their physicians as soon as possible\\nif any of these side effects occur:\\n/C15nausea or vomiting\\n/C15diarrhea\\n/C15stomach pain or cramps.\\nOther side effects may occur. Anyone who has\\nunusual symptoms while taking anticoagulant drugs\\nshould get in touch with his or her physician.\\nInteractions\\nAnticoagulants may interact with many other med-\\nications. When this happens, the effects of one or both\\nof the drugs may change or the risk of side effects may\\nbe increased.Anyone who takes anticoagulants should\\ninform the prescribing physician about other prescription\\nor nonprescription (over-the-counter medicines) he or she\\nis taking–even aspirin, laxatives, vitamins, and antacids.\\nDiet also affects the way anticoagulant drugs work\\nin the body. A normal, balanced diet should be followed\\nevery day while taking such medication. No dietary\\nchanges should be made without informing first the\\nprescribing physician, who should also be told of any\\nillness or other condition interfering with the ability to\\neat normally. Diet is a very important consideration\\nbecause the amount of vitamin K in the body affects\\nhow anticoagulant drugs work. Dicoumarol and war-\\nfarin act by reducing the effects of vitamin K. Vitamin K\\nis found in meats, dairy products, leafy, green vegeta-\\nbles, and some multiplevitamins and nutritional supple-\\nments. For the drugs to work properly, it is best to have\\nthe same amount of vitamin K in the body all the time.\\nFoods containing vitamin K in the diet should not be\\nincreased or decreased without consulting with the pre-\\nscribing physician. If the patient takes vitamin supple-\\nments, he should check the label to see if it contains\\nvitaminK.BecausevitaminK isalsoproducedbyintest-\\ninal bacteria, a severe case of diarrhea or the use of\\nlaxativesmay also alter a person’s vitamin K levels.\\nNancy Ross-Flanigan\\nAnticonvulsant drugs\\nDefinition\\nAnticonvulsant drugs are medicines used to pre-\\nvent or treat convulsions (seizures).\\nPurpose\\nAnticonvulsant drugs are used to control seizures\\nin people with epilepsy. Epilepsy is not a single dis-\\nease—it is a set of symptoms that may have different\\n278 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticonvulsant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='causes in different people. The common thread is an\\nimbalance in the brain’s electrical activity. This imbal-\\nance causes seizures that may affect part or all of the\\nbody and may or may not cause a loss of conscious-\\nness. Anticonvulsant drugs act on the brain to reduce\\nthe frequency and severity of seizures.\\nSome cases of epilepsy are brought on by head\\ninjuries, brain tumors or infections, or metabolic pro-\\nblems such as low blood sugar. But in some people\\nwith epilepsy, the cause is not clear.\\nAnticonvulsant drugs are an important part of the\\ntreatment program for epilepsy. Different kinds of\\ndrugs may be prescribed for different types of seizures.\\nIn addition to taking medicine, patients with epilepsy\\nshould get enough rest, avoidstress, and practice good\\nhealth habits.\\nSome physicians believe that giving the drugs to\\nchildren with epilepsy may prevent the condition from\\ngetting worse in later life. However, others say the\\neffects are the same, whether treatment is started\\nearly or later in life. Determining when treatment\\nbegins depends on the physician and his assessment\\nof the patient’s symptoms.\\nPhysicians also prescribe certain anticonvulsant\\ndrugs for other conditions, includingbipolar disorder\\nand migraine headaches.\\nDescription\\nAnticonvulsant drugs may be divided into several\\nclasses. The hydantoins include pheytoin (Dilantin) and\\nmephenytoin (Mesantoin.) Ther succimides include\\nethosuximide (Zarontin) and methsuccimide (Celontin.)\\nThe benzodiazepines, which are better known for their\\nuse as tranquilizers and sedatives, include clonazepam\\n(Klonopin), clorazepate (Tranxene) and diazepam\\n(Valium.) There are also a large number of other drugs\\nwhich are not related to larger groups. These include\\ncarbamazepine (Tegretol), valproic acid (Depakote,\\nDepakene) gabapentin (Neurontin), topiramate\\n(Topamax), felbamate (Felbatol) and several others.\\nPhenobarbital has been used as an anticonvulsant, and\\nis still useful for some patients. The drugs are available\\nonly with a physician’s prescription and come in tablet,\\ncapsule, liquid, and ‘‘sprinkle’’ forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nanticonvulsant, its strength, and the type of seizures\\nfor which it is being taken. Check with the physician\\nwho prescribed the drug or the pharmacist who filled\\nthe prescription for the correct dosage.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more. Gradually tapering\\nthe dose may reduce the chance of withdrawal effects.\\nDo not change brands or dosage forms of this\\nmedicine without checking with a pharmacist or phy-\\nsician. If a prescription refill does not look like the\\noriginal medicine, check with the pharmacist who\\nfilled the prescription.\\nPrecautions\\nPatients on anticonvulsant drugs should see a\\nphysician regularly while on therapy, especially during\\nthe first few months. The physician will check to make\\nsure the medicine is working as it should and will note\\nunwanted side effects. The physician may also need to\\nadjust the dosage during this period.\\nValproic acid can cause serious liver damage,\\nespecially in the first 6 months of treatment. Children\\nare particularly at risk, but anyone taking this medi-\\ncine should see their physician regularly for tests of\\nliver function and should be alert to symptoms of liver\\ndamage, such as yellow skin and eyes, facial swelling,\\nKEY TERMS\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings, such as chlorophyll which makes plants\\ngreen or hemoglobin which makes blood red.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSystemic lupus erythematosus (SLE)— A chronic\\ndisease with many symptoms, including weakness,\\nfatigue, joint pain, sores on the skin, and problems\\nwith the kidneys, spleen, and other organs.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 279\\nAnticonvulsant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='loss of appetite, general feeling of illness, loss of appe-\\ntite, andvomiting. If liver problems are suspected, call\\na physician immediately.\\nFelbatol has caused serious liver damage and\\naplastic anemia, a condition in which the bone mar-\\nrow stops producing blood cells. Patients taking this\\ndrug should have regular blood counts, and should\\nstop taking the drug if there are too few red blood\\ncells.\\nWhile taking anticonvulsant drugs, do not start or\\nstop taking any other medicines without checking with\\na physician. The other medicines may affect the way\\nthe anticonvulsant medicine works.\\nBecause anticonvulsant drugs work on the central\\nnervous system, they may add to the effects of alcohol\\nand other drugs that slow down the central nervous\\nsystem, such asantihistamines, cold medicine, allergy\\nmedicine, sleep aids, other medicine for seizures, tran-\\nquilizers, some pain relievers, and muscle relaxants.\\nAnyone taking anticonvulsant drugs should check with\\nhis or her physician before drinking alcohol or taking\\nany medicines that slow the central nervous system.\\nAnticonvulsant drugs may interact with medicines\\nused during surgery, dental procedures, or emergency\\ntreatment. These interactions could increase the\\nchance of side effects. Anyone who is taking antic-\\nonvulsant drugs should be sure to tell the health care\\nprofessional in charge before having any surgical or\\ndental procedures or receiving emergency treatment.\\nSome people feel drowsy, dizzy, lightheaded, or\\nless alert when using these drugs, especially when they\\nfirst begin taking them or when their dosage is\\nincreased. Anyone who takes anticonvulsant drugs\\nshould not drive, use machines or do anything else\\nthat might be dangerous until they have found out\\nhow the drugs affect them.\\nAnticonvulsant drugs may affect the results of\\ncertain medical tests. Before having medical tests, peo-\\nple who take anticonvulsant drugs should make sure\\nthat the medical professional in charge knows what\\nthey are taking.\\nChildren may be more likely to have certain side\\neffects from anticonvulsant drugs, such as behavior\\nchanges; tender, bleeding, or swollen gums; enlarged\\nfacial features; and excessive hair growth. Problems\\nwith the gums may be prevented by regularly brushing\\nand flossing, massaging the gums, and having the teeth\\ncleaned every 3 months whether the patient is a child\\nor an adult.\\nChildren who take high doses of this medicine for\\na long time may have problems in school.\\nOlder people may be more sensitive to the effects\\nof anticonvulsant drugs. This may increase the chance\\nof side effects and overdoses.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take anticonvulsant drugs. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to anticonvulsant drugs or totricyclic antidepres-\\nsants such as imipramine (Tofranil) or desipramine\\n(Norpramin) in the past should let his or her physician\\nknow before taking the drugs again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nPREGNANCY. Some anticonvulsant drugs taken\\nduring pregnancy may cause bleeding problems in the\\nmother during delivery and in the baby after delivery.\\nThis problem can be avoided by giving vitamin K to the\\nmother during delivery and to the baby after birth.\\nPregnancy may affect the way the body absorbs\\nanticonvulsant drugs. Women who are prone to sei-\\nzures may have more seizures during pregnancy, even\\nthough they are taking their medicine regularly. If this\\nhappens, they should check with their physicians\\nabout whether the dose needs to be increased.\\nBREASTFEEDING. Some anticonvulsant drugs pass\\ninto breast milk and may cause unwanted effects in babies\\nwhose mothers take the medicine. Women who are\\nbreastfeeding should check with their physicians about\\nthe benefits and risks of using anticonvulsant drugs.\\nDIABETES. Anticonvulsant drugs may affect blood\\nsugar levels. Patients with diabetes who notice changes\\nin the results of their urine or blood tests should check\\nwith their physicians.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nconvulsant drugs, people with any of these medical\\nproblems should make sure their physicians are\\naware of their conditions:\\n/C15liver disease\\n/C15kidney disease\\n/C15thyroid disease\\n/C15heart or blood vessel disease\\n/C15blood disease\\n/C15brain disease\\n/C15problems with urination\\n/C15current or past alcoholabuse\\n280 GALE ENCYCLOPEDIA OF MEDICINE\\nAnticonvulsant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15behavior problems\\n/C15diabetes mellitus\\n/C15glaucoma\\n/C15porphyria\\n/C15systemic lupus erythematosus\\n/C15fever higher than 1018F (38.38C) for more than\\n24 hours\\nUSE OF CERTAIN MEDICINES. Taking anticonvul-\\nsant drugs with certain other drugs may affect the\\nway the drugs work or may increase the chance of\\nside effects.\\nSide effects\\nThe most common side effects areconstipation,\\nmild nausea or vomiting, and milddizziness, drowsi-\\nness, or lightheadedness. These problems usually go\\naway as the body adjusts to the drug and do not\\nrequire medical treatment. Less common side effects,\\nsuch asdiarrhea, sleep problems, aching joints or mus-\\ncles, increased sensitivity to sunlight, increased sweat-\\ning, hair loss, enlargement of facial features, excessive\\nhair growth, muscle twitching, and breast enlargement\\nin males also may occur and do not need medical\\nattention unless they persist or are troublesome.\\nOther side effects may need medical attention. If\\nany of these side effects occur, check with a physician\\nas soon as possible:\\n/C15clumsiness or unsteadiness\\n/C15slurred speech or stuttering\\n/C15trembling\\n/C15unusual excitement, irritability, or nervousness\\n/C15uncontrolled eye movements\\n/C15blurred or double vision\\n/C15mood or mental changes\\n/C15confusion\\n/C15increase in seizures\\n/C15bleeding, tender, or swollen gums\\n/C15skin rash or itching\\n/C15enlarged glands in neck or armpits\\n/C15muscle weakness or pain\\n/C15fever\\nOther side effects are possible. Anyone who has\\nunusual symptoms after taking anticonvulsant drugs\\nshould get in touch with his or her physician.\\nInteractions\\nSome anticonvulsant drugs should not be taken\\nwithin two to three hours of takingantacids or medi-\\ncine for diarrhea. These medicines may make the\\nanticonvulsant drugs less effective. Ask the pharma-\\ncist or physician for more information.\\nBirth control pills may not work properly when\\nanticonvulsant drugs are being taken. To prevent\\npregnancy, ask the physician or pharmacist if addi-\\ntional methods of birth control should be used while\\ntaking anticonvulsant drugs.\\nAnticonvulsant drugs may interact with many\\nother medicines. When this happens, the effects of\\none or both of the drugs may change or the risk of\\nside effects may be greater. Anyone who takes antic-\\nonvulsant drugs should let the physician know all\\nother medicines he or she is taking. Among the\\ndrugs that may interact with certain anticonvulsant\\ndrugs are:\\n/C15airway opening drugs (bronchodilators) such as amino-\\nphylline, theophylline (Theo-Dur and other brands),\\nand oxtriphylline (Choledyl and other brands)\\n/C15medicines that contain calcium, such as antacids and\\ncalcium supplements\\n/C15blood thinning drugs\\n/C15caffeine\\n/C15antibiotics such as clarithromycin (Biaxin),erythro-\\nmycins, andsulfonamides (sulfa drugs)\\n/C15disulfiram (Antabuse), used to treat alcohol abuse\\n/C15fluoxetine (Prozac)\\n/C15monoamine oxidase inhibitors (MAO inhibitors)\\nsuch as phenelzine (Nardil) or tranylcypromine\\n(Parnate), used to treat conditions including depres-\\nsion and Parkinson’s disease\\n/C15tricyclic antidepressants such as imipramine (Tofranil)\\nor desipramine (Norpramin)\\n/C15corticosteroids\\n/C15acetaminophen (Tylenol)\\n/C15aspirin\\n/C15female hormones (estrogens)\\n/C15male hormones (androgens)\\n/C15cimetidine (Tagamet)\\n/C15central nervous system (CNS) depressants such as medi-\\ncine for allergies, colds, hay fever, andasthma;s e d a t i v e s ;\\ntranquilizers; prescription pain medicine; muscle relax-\\nants; medicine for seizures; sleep aids;barbiturates;a n d\\nanesthetics\\nGALE ENCYCLOPEDIA OF MEDICINE 281\\nAnticonvulsant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15alcohol\\n/C15other anticonvulsant drugs\\nThe list above does not include every drug that\\nmay interact with anticonvulsant drugs. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning anticonvulsant drugs with any other prescription\\nor nonprescription (over-the-counter) medicine.\\nResources\\nPERIODICALS\\nReynolds, E.H. ‘‘Do Anticonvulsant Drugs Alter the\\nNatural Course of Epilepsy? Treatment Should Be\\nStarted as Early as Possible.’’British Medical Journal\\n310 (January 21, 1995): 176.\\nORGANIZATIONS\\nAmerican Epilepsy Society. 638 Prospect Avenue, Hartford,\\nCT 06105. (203) 232-4825.\\nEpilepsy Foundation of America. 4351 Garden City Drive,\\n#406, Landover, MD 20785. (800) 332-1000.\\nNational Institute of Neurological Disorders and Stroke.\\nP.O. Box 5801, Bethesda, MD 20824. (301) 496-5751.\\nNancy Ross-Flanigan\\nAntidepressant drugs\\nDefinition\\nAntidepressant drugs are medicines that relieve\\nsymptoms ofdepressive disorders.\\nPurpose\\nDepressive disorders may either be unipolar\\n(depression alone) or bipolar (depression alternating\\nwith periods of extreme excitation). The formal diag-\\nnosis requires a cluster of symptoms, lasting at least\\ntwo weeks. These symptoms include, but are not limi-\\nted to, mood changes, insomnia or hypersomnia, and\\ndiminished interest in daily activities. The symptoms\\nare not caused by any medical condition, drug side\\neffect, or adverse life event. The condition is severe\\nenough to cause clinically significant distress or\\nimpairment in social, occupational, or other import-\\nant areas of functioning.\\nSecondary depression, or depression caused by\\nunfavorable life events, is normally self limiting, and\\nmay best be treated with cognitive/behavioral therapy\\nrather than drugs.\\nDescription\\nAntidepressant agents act by increasing the levels\\nof excitatory neurostransmitters, or nerve cell chemicals\\nthat act as messengers in the brain’s nervous system. In\\n2003, a report showed that in addition to treating\\ndepression, use of antidepressant drugs may protect\\nthe brain from damage depressive episodes cause to\\nthe hippocampus, the area of the brain involved in\\nlearning and memory. Antidepressant drugs may be\\nprescribed as a first-line treatment for depression, or\\nin conjunction with other methods of controlling\\ndepression, such as behavioral therapy andexercise.\\nThe main types of antidepressant drugs in use\\ntoday are listed below, though the drugs available\\nchange frequently. For example, in mid-2003, the\\nmanufacturer of Wellbutrin released Wellbutrin XL,\\nthe only once-daily norepinephrine and dopamine\\nreuptake inhibitor for treating depression in adults.\\n/C15tricyclic antidepressants, such as amitriptyline (Elavil),\\nimipramine (Tofranil), nortriptyline (Pamelor)\\n/C15selective serotonin reuptake inhibitors (SSRIs or\\nserotonin boosters), such as fluoxetine (Prozac), par-\\noxetine (Paxil), and sertraline (Zoloft)\\n/C15monoamine oxidase inhibitors(MAO inhibitors), such\\nas phenelzine (Nardil), and tranylcypromine (Parnate)\\nKEY TERMS\\nCognitive behavioral therapy— A type of psy-\\nchotherapy in which people learn to recognize\\nand change negative and self-defeating patterns of\\nthinking and behavior.\\nDepression— A mental condition in which people\\nfeel extremely sad and lose interest in life. People\\nwith depression also may have sleep problems and\\nloss of appetite and may have trouble concentrat-\\ning and carrying out everyday activities.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\n282 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15tetracyclic compounds and atypical antidepressants\\nwhich do not fall into any of the above categories\\nSelective serotonin reuptake inhibitors maintain\\nlevels of the excitatory neurohormone serotonin in the\\nbrain. They do not alter levels of norepinephrine. These\\nhave become the drugs of choice for a variety of psy-\\nchiatric disorders, primarily because of their low inci-\\nd e n c eo fs e v e r es i d ee f f e c t sa sc o m p a r e dw i t ho t h e rd r u g s\\nin this therapeutic class. SSRIs show similar actions and\\nside effect profiles, but may vary in duration of action.\\nTricyclic compounds, identified by their chemical\\nstructure containing three carbon rings, are an older\\nclass of antidepressants. Although generally effective,\\nthey have a high incidence of anticholinergic effects,\\nnotably dry mouth and dry eyes, which can cause\\ndiscomfort. They also cause cardiac arrythmias.\\nBecause tricyclics act on both serotonin and norepi-\\nnephrine, they may have some value in treatment of\\npatients who fail to respond to SSRIs. Drugs in this\\nclass often are available at low prices, which may be\\nsignificant when cost is a major factor in treatment.\\nThey also have been found useful in control of some\\nneurologic pain syndromes.\\nTricyclic antidepressants are similar, but may vary\\nin severity of side effects, most notably the degree of\\nsedation and the extent of the anticholinergic effects.\\nTetracyclic compounds and atypical antidepres-\\nsants are chemically distinct from both the major\\ngroups and each other. Although maprotilene (no\\nbrand name, marketed in generic form only) and mir-\\ntazepine (Remeron) are similar in chemical structures,\\nthey differ in their balance of activity on serotonine\\nand norepinephrine levels.\\nMonoamine oxidase inhibitors (phenelzine\\n[Nardil], tranylcypromine [Parnate]) have largely\\nbeen supplanted in therapy because of their high risk\\nof severe adverse effects, most notably severehyper-\\ntension. They act by inhibiting the enzyme monoamine\\noxidase, which is responsible for the metabolism of the\\nstimulatory neurohormones norepinephrine, epi-\\nnephrine, dopamine, and serotonin. The MAOIs are\\nnormally reserved for patients who are resistant to\\nsafer drugs. Two drugs, eldepryl (Carbex, used in\\ntreatment of Parkinson’s disease) and the herb,\\nSt. John’s wort, have some action against mono-\\namine oxidase B, and have shown some value as anti-\\ndepressants. They do not share the same risks as the\\nnon-selective MAO inhibitors.\\nAll antidepressant agents, regardless of their\\nstructure, have a slow onset of action, typically three\\nto five weeks. Although adverse effects may be seen as\\nearly as the first dose, significant therapeutic\\nimprovement is always delayed. Similarly, the effects\\nof antidepressants will continue for a similar length of\\ntime after the drugs have been discontinued.\\nRecommended dosage\\nDose varies with the specific drug and patient.\\nSpecialized references or a physician should be consulted.\\nPrecautions\\nAntidepressants have many significant cautions\\nand adverse effects. Although a few are listed here,\\nspecific references should be consulted for more com-\\nplete information.\\nSSRIs. The most common side effect of SSRIs is\\nexcitation and insomnia. Excitation has been reported\\nin over 20% of patients, and insomnia in 33%.\\nSignificant weight loss has been frequently reported,\\nbut most commonly in patients who are already\\nunderweight. A 2003 report showed that SSRIs also\\nincrease the risk of upper gastrointestinal tract bleed-\\ning. SSRIs may cause some sedation, and patients\\nshould be cautioned not to perform tasks requiring\\nalertness until they have evaluated the effects of these\\ndrugs. SSRIs arepregnancy category C drugs. In 2003,\\na new report demonstrated that late-term (third trime-\\nster) use of these drugs could cause neurological symp-\\ntoms in newborns, including tremor, restlessness and\\nrigidity. Most SSRIs are excreted in breast milk, and\\nthere have been anecdotal reports of drowsiness in\\ninfants whose mothers were taking SSRIs while\\nbreastfeeding.\\nMost notably, a joint panel of the U.S. Food and\\nDrug Administration (FDA) issued strong warnings\\nto parents and physicians in 2004 about the risk of\\nsuicidal behavior in children and adolescents taking\\nSSRIs.\\nTricyclic antidepressants. Amoxepine (not mar-\\nketed by brand, generic available), although a tricyclic\\nantidepressant rather than a neuroleptic (major tran-\\nquilizer), displays some of the more serious effects of\\nthe neuroleptics, including tardive dyskinesias (drug\\ninduced involuntary movements) and neuroleptic\\nmalignant syndrome, a potentially fatal syndrome\\nwith symptoms including high fever, altered mental\\nstatus, irregular pulse or blood pressure, and changes\\nin heart rate. These adverse effects have not been\\nreported with other tricyclic antidepressants.\\nThe most common adverse effects of tricyclic anti-\\ndepressants are sedation and the anticholinergic\\neffects, such as dry mouth, dry eyes, and difficult\\nurination. Alterations in heartbeat also are common,\\nGALE ENCYCLOPEDIA OF MEDICINE 283\\nAntidepressant drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and may progress to congestiveheart failure, stroke,\\nand suddendeath.\\nTricyclic antidepressants are in pregnancy cate-\\ngories C or D, although there have been no formal\\nstudies of the drugs on fetal development. There are no\\nstudies of effects on newborns, but some anecdotal\\nreports of malformations have resulted from animal\\nstudies. The drugs are excreted in breast milk.\\nMonoamine oxidase inhibitors. The greatest risk\\nassociated with these drugs is a hypertensive crisis\\nwhich may be fatal and most often occurs when the\\ndrugs are taken with interacting foods or drugs. More\\ncommon adverse reactions may include low blood\\npressure and slowing of heartbeat. Sedation and gas-\\ntrointestinal disturbances also are common. MAOIs\\nare in pregnancy category C. Safety in breast feeding\\nhas not been established.\\nTetracyclics and atypicals. Because these drugs\\nare individual, there are no group patterns of adverse\\nreactions. Specific references should be consulted.\\nInteractions\\nThe antidepressants have manydrug interactions,\\nsome severe. Although a few are listed here, specific\\nreferences should be consulted for more complete\\ninformation.\\nSSRIs should not be administered with MAOIs.\\nA wash-out period of about four weeks should be\\nallowed before switching from one class of drugs to\\nthe other, five weeks if switching from fluoxetine\\n(Prozac) to an MAOI.\\nMAOIs have many interactions, however the best\\nknown are those with foods containing the amino acid\\ntyramine. These include aged cheese, chianti wine, and\\nmany others. Patients and providers should review the\\nMAOI diet restrictions before using or prescribing\\nthese drugs. Because of the severity of MAOI interac-\\ntions, all additions to the patient’s drug regimen\\nshould be reviewed with care.\\nTricyclic compounds have many interactions, and\\nspecialized references should be consulted.\\nSpecifically, it is best to avoid other drugs with antic-\\nholinergic effects. Tricyclics should not be taken with\\nthe antibiotics grepafloxacin and sprafloxacin, since\\nthe combination may cause serious heart arrythmias.\\nTricyclic compounds should not be taken with the\\ngastric acid inhibitor cimetidine (Tagamet), since this\\nincreases the blood levels of the tricyclic compound.\\nOther acid inhibiting drugs do not share this\\ninteraction.\\nSSRIs interact with a number of other drugs that\\nact on the central nervous system. Care should be used\\nin combining these drugs with major or minor tran-\\nquilizers, or with anti-epileptic agents such as pheny-\\ntoin (Dilantin) or carbamazepine (Tegretol). In 2003,\\none of the biggest concerns regarding new prescrip-\\ntions for tricyclic antidepressants was data concerning\\noverdoses from these drugs. Information in Great\\nBritain showed that this class of antidepressants was\\nresponsible for more than 90% of all deaths from\\nantidepressant overdose. Physicians were being\\nadvised to prescribe SSRIs in new patients, but not\\nto change the course of those who had taken tricyclics\\nfor years with success.\\nResources\\nPERIODICALS\\n‘‘Antidepressant Drugs May Protect Brain from Damage.’’\\nMental Health Weekly Digest(August 18, 2003): 2.\\n‘‘FDA Approves Once-daily Supplement.’’Biotech Week\\n(September 24, 2003): 6.\\n‘‘FDA Panel Urges Stronger Warnings of Child Suicide.’’\\nSCRIP World Pharmaceutical News(February 6,\\n2004): 24.\\n‘‘GPs Told Not to Prescribe Tricyclics.’’Pulse (October 13,\\n2003): 1.\\n‘‘Late-term Exposure to SSRIs May Cause Neurological\\nSymptoms in Babies.’’Drug Week(August 8, 2003):\\n255.\\n‘‘SSRIs Increase the Risk of Upper GI Bleeding.’’\\nPsychiatric Times(July 1, 2003): 75.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntidepressant drugs, SSRI\\nDefinition\\nPurpose\\nSSRIs are prescribed primarily to treat mental\\ndepression. Because they are as effective as other\\ntypes of antidepressants and have less serious side\\neffects, SSRIs have become the most commonly pre-\\nscribed antidepressants for all age groups, including\\nchildren and adolescents.\\nIn addition to treating depression, some SSRIs\\nhave been approved by the U.S. Food and Drug\\nAdministration (FDA) for the treatment of other dis-\\norders including:\\n284 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15obsessive-compulsive disorder(OCD)\\n/C15generalized anxiety disorder\\n/C15panic disorder\\n/C15social anxiety disorder or social phobia\\n/C15premenstrual dysphoric disorder (PMDD) or\\npremenstrual syndrome(PMS)\\n/C15post-traumatic stress disorder (PTSD)\\n/C15bulimia nervosa, an eating disorder.\\nSSRIs often are prescribed for other ‘‘off-label’’\\nuses including:\\n/C15various mental disorders including schizophrenia\\n/C15mania\\n/C15menopause-related symptoms such as hot flashes\\n/C15geriatric depression\\n/C15loss of mental abilities in the elderly\\n/C15nicotine withdrawal\\n/C15alcoholism\\n/C15premature ejaculation\\nThe advantages of SSRIs over other types of anti-\\ndepressants include:\\n/C15Most SSRIs can be taken in one daily dose as com-\\npared with three to six daily pills.\\n/C15Because they lessen cravings for carbohydrates,\\nSSRIs usually do not cause weight gain.\\n/C15Since SSRIs do not appear to affect the cardiovas-\\ncular system, they can be prescribed for people with\\nhigh blood pressure or heart conditions.\\n/C15Since SSRIs are not particularly dangerous even in high\\ndoses and are unlikely to cause permanent damage if\\nmisused, they may be prescribed for suicidal adults.\\nSSRIs are mood enhancers only in depressed indi-\\nviduals. They have little effect on people who are not\\nclinically depressed. However some experts believe\\nthat SSRIs are over-prescribed and should be reserved\\nfor those with major disabling depression.\\nDescription\\nTypes of SSRIs\\nAs of 2005, six brand-name SSRIs and generic\\nequivalents were available in the United States:\\n/C15Celexa (citalopram hydrobromide) for treating\\ndepression\\n/C15Lexapro (escitalopram oxalate) for treating depres-\\nsion and generalized anxiety disorder\\n/C15Luvox (fluvoxamine) for treating OCD\\n/C15Paxil (paroxetine hydrochloride) for treating\\ndepression, generalized anxiety disorder, OCD,\\nKEY TERMS\\nCitalopram hydrobromide— Celexa; a SSRI that is\\nhighly specific for serotonin reuptake.\\nDopamine— A neurotransmitter and the precursor\\nof norepinephrine.\\nEscitalopram oxalate— Lexapro; a SSRI that is very\\nsimilar to Celexa but contains only the active che-\\nmical form.\\nFluoxetine— Prozac; the first SSRI; marketed as\\nSarafem for treating PMDD.\\nFluvoxamine— Luvox; a SSRI that is used to treat\\nobsessive-compulsive disorder as well as other\\nconditions.\\nMonoamine oxidase inhibitor (MAOI)— An older\\nclass of antidepressants.\\nNeurotransmitter— A substance that helps transmit\\nimpulses between two nerve cells or between a\\nnerve cell and a muscle.\\nNorepinephrine— A hormone released by nerve\\ncells and the adrenal medulla that causes constric-\\ntion of blood vessels.\\nObsessive-compulsive disorder (OCD)— An anxi-\\nety disorder characterized by obsessions, such as\\nrecurring thoughts or impulses, and compulsions,\\nsuch as repetitive behaviors.\\nOff-label use— A drug that is prescribed for uses,\\nperiods of time, or at dosages that are not FDA-\\napproved.\\nParoxetine hydrochloride— Paxil; a SSRI that is\\nused to treat mental depression, OCD, and various\\nother disorders.\\nPremenstrual dysphoric disorder (PMDD)—\\nPremenstrual syndrome (PMS); symptoms includ-\\ning back and abdominal pain, nervousness and\\nirritability, headache, and breast tenderness that\\noccur the week before menstruation.\\nSerotonin— 5-Hydroxytryptamine; a substance\\nthat occurs throughout the body with numerous\\neffects including neurotransmission.\\nSerotonin syndrome— A group of symptoms caused\\nby severely elevated serotonin levels in the body.\\nSertraline— Zoloft; a SSRI that is used to treat men-\\ntal depression and a variety of other disorders.\\nGALE ENCYCLOPEDIA OF MEDICINE 285\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='panic disorder, social anxiety disorder, PMDD, and\\nPTSD\\n/C15Prozac and Prozac Weekly (fluoxetine) for treating\\ndepression, OCD, and bulimia nervosa; marketed as\\nSarafem for treating PMDD\\n/C15Zoloft (sertraline) for treating depression, OCD,\\npanic disorder, social anxiety disorder, PMDD, and\\nPTSD.\\nWhen Prozac first became available in 1988, it was\\nhailed as a new wonder drug and quickly became the most\\npopular antidepressant everprescribed. Many millions\\nof Americans have taken Prozac and more than 70%\\nof them claim to have benefited from it. Within a few\\nyears other SSRIs became available and, by 2000, Zoloft\\nprescriptions outnumbered those for Prozac.\\nLexapro is the newest SSRI. Celexa and Lexapro\\nare very similar, with chemical structures unrelated to\\nother SSRIs. Celexa is a mixture of two isomers—\\nforms of the same chemical—whereas Lexapro is the\\nactive isomer alone. They appear to be highly selective\\nfor serotonin, only minimally inhibiting the reuptake\\nof the neurotransmitters norepinephrine and dopa-\\nmine. Paxil is structurally unrelated to other SSRIs\\nand is more selective for serotonin than Luvox,\\nProzac, or Zoloft, but less selective than Celexa and\\nLexapro. Paxil becomes distributed widely through-\\nout body tissues and the CNS, with only 1% remain-\\ning in the circulatory system.\\nMode of action\\nMental depression is believed to be related to the\\nlow activity of one or more neurotransmitters in the\\nbrain—the chemical messengers that cross the gap or\\nsynapse between nerve cells. Although it is not under-\\nstood exactly how most SSRIs work, they are designed\\nto increase the level of serotonin in the brain. This can\\nreduce the symptoms of depression and other psycho-\\nlogical disorders.\\nSerotonin is released by nerve cells and then—in a\\nprocess called reuptake—is reabsorbed by the cells to\\nbe used again. SSRIs interfere with reuptake by block-\\ning the serotonin reuptake sites on the surfaces of\\nnerve cells, thereby making more serotonin available\\nfor brain activity. Paxil inhibits the transporter mole-\\ncule that moves serotonin back into the cell. SSRIs are\\nsaid to selectively interfere with the reuptake of sero-\\ntonin, without affecting the uptake or activities of\\nother neurotransmitters. In contrast, older antidepres-\\nsants such astricyclic antidepressantsand monoamine\\noxidase inhibitors (MAOIs) affect numerous neuro-\\ntransmitters, brain cell receptors, and brain processes,\\nincreasing the likelihood of serious side effects.\\nHowever it is becoming clear that the serotonin\\nneurotransmitter system is far more complex and wide-\\nspread throughout the body than was thought initially.\\nAlthough serotonin receptors are particularly common\\nin areas of the brain that control emotion, it is known\\nnow that there are at least six different types of serotonin\\nreceptors that send different signals to different parts of\\nthe brain. Serotonin also appears to affect other neuro-\\ntransmitter systems—including dopamine—to at least\\nsome extent. Thus increasing the levels of serotonin may\\nnot be the only reason why SSRIs relieve depression.\\nEffectiveness\\nSSRIs are not effective for treating anxiety or\\ndepression in 20–40% of patients. However some\\nresearch suggests that the use of SSRIs in the early stages\\nof depression can prevent majordepressive disorders.\\nAlthough different SSRIs appear to be equally\\neffective, individuals respond differently to different\\nSSRIs and side effects may vary. Thus finding the best\\nSSRI for an individual may be a matter of trial-and-\\nerror. It usually takes two to four weeks after starting an\\nSSRI before symptoms begin to improve. Luvox may\\ntake one to two months for noticeable improvement.\\nPaxil may take as long as several months, although\\nsleeping often improves within one or two weeks of\\nbeginning the medication. If there is no response after\\na few weeks or if side effects occur, the patient may be\\nswitched to another SSRI. Prozac is the most commonly\\nprescribed SSRI for children, in part because it is avail-\\nable in liquid form that is easier to swallow.\\nAlthough Luvox is the only SSRI that is FDA-\\napproved for use in children—and only for obsessive-\\ncompulsive behavior—thousands of young people\\nhave been treated with SSRIs for:\\n/C15depression\\n/C15anxiety\\n/C15OCD\\n/C15panic\\n/C15attention deficit/hyperactivity disorder (ADHD)\\nA 2004 study found that among depressed adoles-\\ncents, 60% improved with Prozac alone, whereas 75%\\nreported improvement with Prozac combined with\\ncognitive behavioral therapy.\\nSSRIs sometimes are prescribed to relieve depres-\\nsion accompanying alcoholism. A recent study found\\nthat, although type A alcoholics responded to Zoloft\\nin conjunction with a 12-step individual therapy pro-\\ngram, type B alcoholics—those with the most severe\\n286 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='drinking problems—did not benefit from Zoloft and,\\nin some cases, increased their alcohol intake.\\nRecommended dosage\\nUsually SSRIs are started with a low dosage that\\nmay be gradually increased. In older adults SSRIs\\nremain in the body longer than in younger adults.\\nThe blood levels of Paxil can be 70–80% higher in\\nthe elderly as compared with younger patients.\\nTherefore lower doses usually are prescribed for\\nolder people. Older patients with other medical con-\\nditions or who are taking many different drugs also\\nmay need smaller or less frequent doses. The dosage\\nof an SSRI also varies according to the individual\\nand the condition that is being treated. SSRIs may be\\ntaken with or without food, on a full or empty\\nstomach. However taking SSRIs with food or drink\\nmay lessen side effects such as stomach upset or\\nnausea.\\nCelexa is supplied as tablets or as an oral solution\\nequivalent to 2 mg per ml (0.03 oz.), taken once per\\nday in the morning or evening:\\n/C15adults: 20 mg per day, increasing to 40 mg if neces-\\nsary, to a maximum of 60 mg per day\\n/C15older adults: 20 mg per day to a maximum of 40 mg\\nLexapro is supplied as 5-, 10-, or 20-mg tablets or\\nas a 1 mg per ml (0.03 oz.) liquid. The recommended\\ndose is 10 mg per day, with a possible increase to 20 mg\\nper day after at least one week.\\nAverage dosages of Luvox for treating OCD and\\ndepression are:\\n/C15adults: one 50-mg tablet at bedtime; may be\\nincreased up to a maximum of 300 mg daily; dosages\\nof more than 100 mg per day should be divided into\\ntwo doses, one taken in the evening and one in the\\nmorning\\n/C15children aged 8–17: initially one 25-mg tablet at\\nbedtime; may be gradually increased by 25 mg\\nper day every four to seven days, up to a maxi-\\nmum of 200 mg per day; daily dosages of more\\nthan 50 mg should be divided into two daily\\ndoses.\\nAverage doses of Paxil for treating depression are:\\n/C15adults: 20 mg (10 ml, 0.3 oz.) of oral suspension, one\\n20-mg tablet, or one 25-mg extended-release tablet,\\nonce a day in the morning, increased by 10 mg per\\nweek to a maximum of 50 mg—25 ml (0.75 oz.) of\\noral suspension—or a 62.5-mg extended-release\\ntablet\\n/C15older adults: 10 mg (5 ml, 0.15 oz.) of oral suspension\\nor a 10-mg tablet daily, increased to a maximum of\\n40 mg (20 ml, 0.6 oz.); one 12.5-mg extended-release\\ntablet daily, increased to a maximum of 50 mg\\nBecause of its sedating effect, Paxil may be taken\\nin the evening rather than in the morning as usually\\nrecommended. Oral suspensions need to be shaken\\nwell before measuring with a small measuring cup or\\nmeasuring spoon. Extended-release tablets should be\\nswallowed whole, not broken or chewed. Dosages may\\nbe different for treating disorders other than\\ndepression.\\nTypical dosages of Prozac are:\\n/C15one 10–20-mg daily capsule or solution taken in the\\nmorning; increased up to as much as 40 mg daily if\\nthere is no improvement in one month, up to an\\n80-mg maximum\\n/C15one 90-mg capsule per week of Prozac Weekly once\\nthe depression is under control\\n/C15one 20-mg capsule of Sarafem per day, taken in the\\nmorning, every day or for only 14 days of a men-\\nstrual cycle; maximum of 80 mg per day; Sarafem is\\nsupplied in seven-day blister packs to help keep track\\nof the days\\n/C15children: initially one 5–10-mg capsule or solution\\nper day.\\nZoloft is available as capsules, oral solutions, or\\ntablets:\\n/C15adults: 50 mg daily, taken in the morning or evening,\\nup to a maximum of 200 mg daily for severely\\ndepressed individuals\\n/C15older adults: 12.5–25 mg per day, taken in the morn-\\ning or evening; may be increased gradually\\n/C15for treating OCD in children aged 6–12: 25 mg per\\nday, taken in the morning or evening; may be\\nincreased gradually to a maximum of 200 mg per day\\n/C15children aged 13–17: initially 50 mg per day, in the\\nmorning or evening, may be increased gradually to a\\nmaximum of 200 mg per day.\\nZoloft oral concentrate should be mixed with 4 oz\\n(133 ml) of water, ginger ale, lemon-lime soda, lemon-\\nade, or orange juice and taken immediately.\\nMissed doses of SSRIs are handled differently\\ndepending on the SSRI and the number of doses\\nper day. An effective SSRI may be prescribed for\\nsix months or more. Some experts recommend continu-\\ning on the SSRI indefinitely to prevent the recurrence\\nof depression.\\nGALE ENCYCLOPEDIA OF MEDICINE 287\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Precautions\\nMedical conditions\\nMedical conditions that may affect the use or\\ndosage of at least some SSRIs include:\\n/C15drug allergies or allergies to other substances in\\nmedications\\n/C15mania\\n/C15manic-depressive (bipolar) disorder\\n/C15brain disease or mental retardation\\n/C15seizures or epilepsy\\n/C15Parkinson s disease\\n/C15liver or severe kidney disease\\n/C15abnormal bleeding problems\\n/C15diabetes mellitus\\n/C15heart disease\\n/C15a recent heart attack\\n/C15glaucoma\\nSSRI use duringpregnancy may not be safe, parti-\\ncularly during the third trimester. Exposure of fetuses\\nto Celexa and other SSRIs during the late third trime-\\nster have led to very serious complications, including\\nserotonin syndrome—a condition in which high sero-\\ntonin levels cause severe problems. Symptoms in a new-\\nborn may be the result of a direct toxic effect of the\\nSSRI or withdrawal from the drug. SSRIs pass into\\nbreast milk and may negatively affect a baby.\\nSuicidal tendencies\\nA possible link between SSRIs and suicide\\nattempts in depressed adults remains controversial.\\nThree studies in early 2005 drew conflicting conclu-\\nsions concerning an association between suicidal\\nbehavior and the use of SSRIs. However a February\\n2005 study found a close correlation between the dra-\\nmatic decrease in suicides in the United States and\\nEurope and the introduction of SSRIs.\\nIn October 2004, the FDA concluded that anti-\\ndepressants, including SSRIs, increased the risk of\\nsuicidal thoughts and behaviors in children and ado-\\nlescents who suffered from depression and other psy-\\nchiatric disorders. They recommended extreme\\ncaution in prescribing SSRIs for children. In the last\\nthree months of 2004, SSRI prescriptions for children\\nand adolescents fell by 10%.\\nSymptoms that may lead to suicidal tendencies\\ncan develop very suddenly in children and adolescents\\ntaking SSRIs; they may include:\\n/C15new or worsening depression\\n/C15severe worrying\\n/C15irritability\\n/C15agitation\\n/C15extreme restlessness\\n/C15frenzied excitement\\n/C15panic attacks\\n/C15insomnia\\n/C15impulsive behavior\\n/C15aggressive behavior\\n/C15thinking about, planning, or attempting to harm\\none’s self\\nWithdrawal\\nSSRIs remain in the body for some time after the\\nmedication is stopped:\\n/C15Celexa for at least three days\\n/C15Luvox for at least 32 hours\\n/C15Paxil for at least 42 hours\\n/C15Prozac for up to five weeks\\n/C15Zoloft for at least three to five days\\nSSRIs can cause what the manufacturers refer to\\nas ‘‘discontinuation syndrome’’ when the medication\\nis stopped. Since this occurs most often when the drug\\nis stopped abruptly, usually the dose is gradually\\nreduced before stopping the drug completely. The\\noccurrence of discontinuation syndrome depends on\\nthe SSRI, the dosage, and the length of time that the\\ndrug was used. Paxil appears to induce more serious\\nwithdrawal symptoms than other SSRIs. Symptoms of\\nPaxil withdrawal appear within 1 to 10 days of stop-\\nping the drug. Because of its long half-life in the body,\\nProzac rarely causes withdrawal symptoms, although\\nsymptoms have been known to appear within 5 to 42\\ndays of stopping Prozac.\\nWithdrawal symptoms may include:\\n/C15generally feeling sick\\n/C15dry mouth\\n/C15runny nose\\n/C15dizziness or lightheadedness\\n/C15nausea and vomiting\\n/C15diarrhea\\n/C15headache\\n/C15sweating\\n/C15muscle pain\\n288 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15weakness or fatigue\\n/C15nervousness or anxiety\\n/C15restlessness or agitation\\n/C15trembling or shaking\\n/C15insomnia\\n/C15fast heart rate\\n/C15breathing difficulties\\n/C15chest pain\\n/C15confusion\\nAlthough withdrawal symptoms usually wear off,\\nin some patients some symptoms appear to continue\\nindefinitely.\\nOther precautions\\nOther precautions concerning SSRIs include:\\n/C15a 50% chance that an episode of depression will recur\\nat some point after stopping the drug\\n/C15a 90% risk of recurrence following two episodes of\\ndepression\\n/C15reports of patients developing tolerance to an SSRI,\\nrequiring increased dosages for effectiveness\\n/C15the long-term effects of SSRIs are unknown\\n/C15SSRIs are expensive: at least $2–$3 per pill; over $150\\nfor 4 oz. (133 ml) of liquid Prozac\\n/C15some insurance plans to not cover mental health\\nmedications.\\nSide effects\\nCommon side effects\\nThe most common side effects of SSRIs include:\\n/C15dry mouth\\n/C15dizziness\\n/C15sour or acid stomach or gas\\n/C15heartburn\\n/C15decreased appetite\\n/C15stomach upset\\n/C15nausea\\n/C15diarrhea\\n/C15sweating\\n/C15headache\\n/C15weakness or fatigue\\n/C15drowsiness\\n/C15insomnia\\n/C15nervousness or anxiety\\n/C15tremors\\n/C15sexual problems\\nMost common side effects disappear as the body\\nadjusts to the drug. Nausea may be relieved by taking\\nthe medication with meals or temporarily dividing the\\ndose in half.\\nCertain side effects occur more frequently depend-\\ning on the SSRI:\\n/C15Side effects of Celexa usually are mild and disappear\\nas the body adjusts.\\n/C15Luvox and Zoloft are more likely to cause gastroin-\\ntestinal upset, including stomach irritation, nausea,\\nand diarrhea.\\n/C15Paxil is more likely to cause dry mouth,constipation,\\nand drowsiness. Paxil is significantly more sedating\\nthan other SSRIs, which may benefit patients with\\ninsomnia.\\n/C15The most common side effect of Prozac is nausea\\nduring the first two weeks on the drug; nervousness\\nand anxiety also are common with Prozac.\\n/C15Paxil, Prozac, and Zoloft often reduce appetite.\\n/C15Up to 30% of those on Zoloft suffer headaches and\\n20% suffer from insomnia.\\nStudies with Luvox have found that children may\\nexperience different side effects than adults, the most\\ncommon being:\\n/C15dry mouth\\n/C15a stuffy or bloody nose\\n/C15sweating\\n/C15drowsiness\\n/C15restlessness\\n/C15muscle twitching or tics\\n/C15tremors\\n/C15thinning hair\\n/C15abnormal thinking\\nSexual side effects\\nAny SSRI can affect sexual interest or perfor-\\nmance. Side effects include increased or, more often,\\ndecreased sexual interest, difficulty reaching orgasm\\nor ejaculation, andimpotence.\\nAlthough manufacturers initially reported that\\nsexual problems were very rare side effects of\\nSSRIs, most patients in clinical trials were never\\nGALE ENCYCLOPEDIA OF MEDICINE 289\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='asked specifically about sex and were reluctant to\\nraise the issue. After a few years it became apparent\\nthat sexual problems were commonplace among\\nSSRI users, affecting as many as 70%. Among\\nmen taking Paxil, 23% report problems with ejacu-\\nlation. Between 40% and 70% of those taking\\nProzac report negative sexual side effects, especially\\nloss of interest.\\nLess common or rare side effects\\nLess common—but potentially serious—side\\neffects of at least some SSRIs may include:\\n/C15flu-like symptoms\\n/C15sneezing\\n/C15nasal congestion or a runny nose\\n/C15sore throat\\n/C15skin rash\\n/C15itching ortingling, burning, or prickling of the skin\\n/C15fever\\n/C15chills\\n/C15body aches or pain\\n/C15muscle or joint pain\\n/C15abdominal cramps or pain\\n/C15vomiting\\n/C15decreased or increased appetite\\n/C15weight loss\\n/C15weight gain, especially after a year on an SSRI\\n/C15mouth watering\\n/C15increased frequency or amount of urination\\n/C15constipation\\n/C15menstrual changes or pain\\n/C15chest congestion or pain\\n/C15difficulty breathing\\n/C15taste changes, including a metallic taste in the mouth\\n/C15blurred vision or other visual changes\\n/C15loss of voice\\n/C15teeth grinding\\n/C15trembling or shaking\\n/C15hair loss\\n/C15sensitivity to sunlight\\n/C15anxiety or agitation\\n/C15abnormal dreams\\n/C15confusion\\n/C15lack of emotion, apathy\\n/C15memory loss\\nRare side effects that may occur with some SSRIs\\ninclude:\\n/C15symptoms of low blood sugar or sodium\\n/C15bleeding gums or nosebleeds\\n/C15unusual bruising\\n/C15irregular or slow heartbeat (less than 50 beats per\\nminute)\\n/C15fainting\\n/C15painful urination or other difficulties with urination\\n/C15purple or red spots on the skin\\n/C15skin conditions\\n/C15red or irritated eyes\\n/C15inability to move the eyes\\n/C15swelling of the face, ankles, or hands\\n/C15increased or decreased body movements\\n/C15clumsiness\\n/C15tics or other sudden or unusual body or facial move-\\nments or postures\\n/C15changes in the breasts, including leakage of milk\\n/C15seizures\\n/C15irritability\\n/C15increased depression\\n/C15mood or mental changes\\n/C15abnormal behaviors\\n/C15difficulty concentrating\\n/C15lethargy or stupor\\n/C15hallucinations\\n/C15suicidal thoughts or tendencies\\nVarious other SSRI side effects have been\\nobserved in clinical practice although their incidence\\nis not known.\\nSymptoms of overdose\\nAlthough overdose rarely occurs with SSRIs,\\nsymptoms include two or more severe side effects\\noccurring together. More common symptoms of\\nSSRI overdose include:\\n/C15flushing of the face\\n/C15enlarged pupils\\n/C15fast heart rate\\n/C15upset stomach\\n290 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15nausea and vomiting\\n/C15sweating\\n/C15dizziness\\n/C15irritability\\n/C15drowsiness\\n/C15insomnia\\n/C15trembling or shaking\\nRare symptoms of SSRI overdose include:\\n/C15deep or fast breathing with dizziness\\n/C15fainting\\n/C15muscle pain\\n/C15weakness\\n/C15difficulty urinating\\n/C15bluish skin or lips\\n/C15fast, slow, or irregular heartbeat\\n/C15low blood pressure\\n/C15confusion\\n/C15memory loss\\n/C15seizures\\n/C15coma\\nInteractions\\nSSRIs interact with many other drugs, often in\\nsimilar ways. Alcohol may increase SSRI-induced\\ndrowsiness and should not be used when taking some\\nSSRIs. Luvox appears to cause the most seriousdrug\\ninteractions, whereas Celexa has relatively few interac-\\ntions. A combination of Luvox and Clozaril can cause\\nlow blood pressure and seizures.\\nThe interaction of SSRIs with MAOIs can be\\nfatal. In addition to antidepressant MAOIs, the\\nantibiotic linezolid (Zyvox) is an MAOI. There\\nmust be at least a two-week interval between stop-\\nping one drug and starting the other. There should\\nbe at least a three-week interval between an MAOI\\nand either Paxil or Zoloft, if either type of antide-\\npressant was taken for more than three months.\\nBecause of its long half-life in the body, it is neces-\\nsary to wait five to six weeks after stopping Prozac\\nbefore starting on an MAOI.\\nSome of the drugs that can interact negatively\\nwith SSRIs include:\\n/C15other antidepressants\\n/C15antihistamines\\n/C15various medications for anxiety, mental illness, or\\nseizures\\n/C15sedatives and tranquilizers\\n/C15sleeping pills\\n/C15St. John’s wort\\nDrugs that may cause severe heart problems if\\ntaken in conjunction with some SSRIs include:\\n/C15astemizole (Hismanal)\\n/C15cisapride (Propulsid)\\n/C15terfenadine (Seldane)\\n/C15thioridazine (Mellaril), which should not be taken\\nfor at least five weeks after stopping Prozac\\nDrugs that may affect the blood levels of an SSRI\\nor the length of time that an SSRI remains in the body\\ninclude:\\n/C15antifungal drugs\\n/C15cimetidine (Tagamet)\\n/C15erythromycin\\n/C15tricyclic antidepressants\\n/C15Dilantin and phenobarbitol, which may decrease the\\nblood levels of Paxil\\nSome SSRIs may cause higher blood levels of\\nother medications including:\\n/C15alprazolam (Xanax and others)\\n/C15anticoagulants or blood-thinners such as warfarin\\n(Coumadin)—SSRIs can increase warfarin blood\\nlevels dramatically\\n/C15aspirin and other nonsteroidal anti-inflammatory\\ndrugs (NSAIDs) including ibuprofen and\\nnaproxen\\n/C15caffeine\\n/C15carbamazepine (Tegretol)\\n/C15diazepam (Valium)\\n/C15digitalis glycosides (heart medicines)\\n/C15lithium\\n/C15methadone\\n/C15phenytoin (Dilantin and others)\\n/C15propanolol (Ineral and others)\\n/C15theophylline or theophylline-containing drugs\\n/C15triazolam (Halcion and others)\\n/C15tricyclic antidepressants\\nGALE ENCYCLOPEDIA OF MEDICINE 291\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Serotonin syndrome\\nRarely, some drugs may interact with an SSRI to\\ncause serotonin syndrome including:\\n/C15buspirone (BuSpar)\\n/C15bromocriptine (Parlodel)\\n/C15dextromethorphan (coughmedicine such as Robitussin\\nDM)\\n/C15levodopa (Sinemet)\\n/C15lithium (Eskalith)\\n/C15meperidine (Demerol)\\n/C15moclobemide (Manerex)\\n/C15nefazodone (Serzone)\\n/C15pentazocine (Talwin)\\n/C15other SSRIs\\n/C15street drugs\\n/C15sumatriptan (Imitrex)\\n/C15tramadol (Ultram)\\n/C15trazodone (Desyrel)\\n/C15tryptophan\\n/C15venlafaxine (Effexor)\\nSerotonin syndrome may occur shortly after the\\ndose of a drug is increased.\\nSerotonin syndrome may be suspected when at\\nleast three of the following symptoms occur\\ntogether:\\n/C15diarrhea\\n/C15fever\\n/C15shivering\\n/C15sweating\\n/C15restlessness\\n/C15agitation\\n/C15uncontrollable excitement\\n/C15poor coordination\\n/C15twitching\\n/C15trembling or shaking\\n/C15rigidity\\n/C15confusion\\n/C15mental changes\\n/C15fluctuating vital signs\\nCombined treatments\\nIncreasingly physicians are combining an SSRI\\nwith other medications, either to increase effectiveness\\nor to counteract side effects. Prozac sometimes is pre-\\nscribed along with:\\n/C15an anti-anxiety drug such as Valium (diazepam)\\n/C15Desyrel (trazodone), a different type of antidepres-\\nsant, for patients with insomnia\\n/C15lithium\\nResources\\nBOOKS\\nGlenmullen, Joseph.Prozac Backlash: Overcoming the\\nDangers of Prozac, Zoloft, Paxil, and Other\\nAntidepressants with Safe, Effective Alternatives.New\\nYork: Simon & Schuster, 2000.\\nPreskorn, Sheldon H., and Renato D. Alarco´ n, editors.\\nAntidepressants: Past, Present, and Future.New York:\\nSpringer, 2004.\\nTrigoboff, Eileen.Psychiatric Drug Guide.Upper Saddle\\nRiver, NJ: Pearson/Prentice Hall, 2005.\\nPERIODICALS\\nJonsson, Patrik. ‘‘Zoloft Defense Tests Whether Pills Are\\nGuilty; A Murder Trial Highlights Evolving Legal\\nDebate Over Whether Antidepressants Limit Personal\\nAccountability.’’ Christian Science MonitorFebruary\\n11, 2005: 3.\\nSanz, Emilio J., et al. ‘‘Selective Serotonin Reuptake\\nInhibitors in Pregnant Women and Neonatal\\nWithdrawal Syndrome: A Database Analysis.’’Lancet\\n365, no. 9458 (February 5, 2005): 482–7.\\nTreatment for Adolescents With Depression Study (TADS)\\nTeam. ‘‘Fluoxetine, Cognitive-Behavioral Therapy,\\nand Their Combination for Adolescents with\\nDepression.’’ Journal of the American Medical\\nAssociation 292, no. 7 (August 18, 2004): 807–20.\\nWhittington, Craig, J., et al. ‘‘Selective Serotonin Reuptake\\nInhibitors in Childhood Depression: Systematic Review\\nof Published Versus Unpublished Data.’’Lancet 363,\\nno. 9418 (April 24, 2004): 1341–5.\\nORGANIZATIONS\\nNational Institute of Mental Health. Office of\\nCommunications, 6001 Executive Boulevard, Room\\n8184, MSC 9663, Bethesda, MD 20892-9663. 866-\\n615-6464. 301-443-4513. .\\nU.S. Food and Drug Administration. 5600 Fishers Lane,\\nRockville, MD 20857-0001. 1-888-INFO-FDA\\n(1-888-463-6332). .\\nOTHER\\nCelexaTM. Forest Pharmaceuticals, Inc. January 2004 [cited\\nMarch 6, 2005]. .\\n292 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressant drugs, SSRI'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Edelson, Ed. ‘‘Suicide Risk from Antidepressants Remains\\nUnclear.’’ HealthDayNews. National Health\\nInformation Center, U.S. Department of Health and\\nHuman Services. February 17, 2005 [cited March 6,\\n2005]. .\\nLexaproTM. Forest Pharmaceuticals, Inc. December 2003\\n[cited March 6, 2005]. .\\nMedications. National Institute of Mental Health. April 9,\\n2004 [cited March 13, 2005]. .\\nMundell, E. J. ‘‘Study: Benefits of Antidepressants\\nOutweigh Risks.’’HealthDayNews. National Health\\nInformation Center, U.S. Department of Health and\\nHuman Services. February 2, 2005 [cited March 25,\\n2005]. .\\nTurkington, Carol, and Eliot F. Kaplan.Selective Serotonin\\nReuptake Inhibitors (SSRIs).WebMD Medical\\nReference. 2001 [cited March 23, 2005]. .\\nMargaret Alic, Ph.D.\\nAntidepressants, tricyclic\\nDefinition\\nTricyclic antidepressants are medicines that\\nrelieve mental depression.\\nPurpose\\nSince their discovery in the 1950s, tricyclic anti-\\ndepressants have been used to treat mental depression.\\nLike otherantidepressant drugs, they reduce symptoms\\nsuch as extreme sadness, hopelessness, and lack of\\nenergy. Some tricyclic antidepressants are also used\\nto treat bulimia,cocaine withdrawal, panic disorder,\\nobsessive-compulsive disorders, certain types of\\nchronic pain, andbed-wetting in children.\\nDescription\\nNamed for their three-ring chemical structure,\\ntricyclic antidepressants work by correcting chemical\\nimbalances in the brain. But because they also affect\\nother chemicals throughout the body, these drugs may\\nproduce many unwanted side effects.\\nTricyclic antidepressants are available only with a\\nphysician’s prescription and are sold in tablet, capsule,\\nliquid, and injectable forms. Some commonly used\\ntricyclic antidepressants are amitriptyline (Elavil),\\ndesipramine (Norpramin), imipramine (Tofranil),\\nnortriptyline (Pamelor), and protriptyline (Vivactil).\\nDifferent drugs in this family have different effects,\\nand physicians can choose the drug that best fits the\\npatient’s symptoms. For example, a physician might\\nprescribe Elavil for a person with depression who has\\ntrouble sleeping, because this drug is more likely to\\nmake people feel calm and sleepy. Other tricyclic anti-\\ndepressants might be more appropriate for depressed\\npeople with low energy.\\nRecommended dosage\\nThe recommended dosage depends on many fac-\\ntors, including the patient’s age, weight, general health\\nand symptoms. The type of tricyclic antidepressant\\nand its strength also must be considered. Check with\\nthe physician who prescribed the drug or the pharma-\\ncist who filled the prescription for the correct dosage.\\nAlways take tricyclic antidepressants exactly as\\ndirected. Never take larger or more frequent doses,\\nand do not take the drug for longer than directed.\\nDo not stop taking the medicine just because it does\\nnot seem to be working. Several weeks may be needed\\nfor its effects to be felt. Visit the physician as often as\\nrecommended so that the physician can check to see if\\nthe drug is working and to note for side effects.\\nDo not stop taking this medicine suddenly after\\ntaking it for several weeks or more. Gradually taper-\\ning the dose may be necessary to reduce the chance of\\nwithdrawal symptoms.\\nTaking this medicine with food may prevent upset\\nstomach.\\nPrecautions\\nThe effects of this medicine may continue for three\\nto seven days after patients stop taking it. All precau-\\ntions should be observed during this period, as well as\\nthroughout treatment with tricyclic antidepressants.\\nSome people feel drowsy, dizzy, or lightheaded,\\nwhen taking these drugs. The drugs may also cause\\nblurred vision. Anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them.\\nBecause tricyclic antidepressants work on the cen-\\ntral nervous system, they may add to the effects of\\nalcohol and other drugs that cause drowsiness, such\\nas antihistamines, cold medicine, allergy medicine,\\nGALE ENCYCLOPEDIA OF MEDICINE 293\\nAntidepressants, tricyclic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='sleep aids, medicine for seizures, tranquilizers, some\\npain relievers, andmuscle relaxants. Anyone taking\\ntricyclic antidepressants should check with his or her\\nphysician before drinking alcohol or taking any drugs\\nthat cause drowsiness.\\nThese medicines make some people feel light-\\nheaded, dizzy, or faint when they get up after sitting\\nor lying down. To lessen the problem, get up gradually\\nand hold onto something for support if possible.\\nTricyclic antidepressants may interact with medi-\\ncines used during surgery, dental procedures, or emer-\\ngency treatment. These interactions could increase the\\nchance of side effects. Anyone who is taking tricyclic\\nantidepressants should be sure to tell the health care\\nprofessional in charge before having any surgical or\\ndental procedures or receiving emergency treatment.\\nThese drugs may also change the results of medi-\\ncal tests. Before having medical tests, anyone taking\\nthis medicine should alert the health care professional\\nin charge.\\nThis medicine may increase sensitivity to sunlight.\\nEven brief exposure to sun can cause a severesunburnor\\na rash. While being treated with this tricyclic antide-\\npressants, avoid being in direct sunlight, especially\\nbetween 10 A.M. and 3 P.M.; wear a hat and tightly\\nwoven clothing that covers the arms and legs; use a\\nsunscreen with a skin protection factor (SPF) of at\\nleast 15; protect the lips with a sun block lipstick; and\\ndo not use tanning beds, tanning booths, or sunlamps.\\nTricyclic antidepressants may causedry mouth.T o\\ntemporarily relieve the discomfort, chew sugarless\\ngum, suck on sugarless candy or ice chips, or use saliva\\nsubstitutes, which come in liquid and tablet forms and\\nare available without a prescription.\\nChildren and older people are especially sensitive to\\nthe effects of tricyclic antidepressants. This increased\\nsensitivity may increase the chance of side effects.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take tricyclic antidepressants. Before taking these\\ndrugs, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to tricyclic antidepressants or to carbamazepine\\n(Tegretol), maprotiline (Ludiomil), or trazodone\\n(Desyrel) in the past should let his or her physician\\nknow before taking tricyclic antidepressants. The phy-\\nsician should also be told about anyallergies to foods,\\ndyes, preservatives, or other substances.\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBulimia— An eating disorder in which a person\\nbinges on food and then induces vomiting, uses\\nlaxatives, or goes without food for some time.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nDelusion— An abnormal mental state characterized\\nby the acceptance of something as true that is actually\\nfalse orunreal,such asthebeliefthatoneisJesus Christ.\\nDepression— A mental condition in which a person\\nfeels extremely sad and loses interest in life. A\\nperson with depression may also have sleep pro-\\nblems and loss of appetite and may have trouble\\nconcentrating and carrying out everyday activities.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nObsessive-compulsive disorder— An anxiety disor-\\nder in which a person cannot prevent himself from\\ndwelling on unwanted thoughts, acting on urges, or\\nperforming repetitious rituals, such as washing his\\nhands or checking to make sure he turned off the lights.\\nPanic disorder— An disorder in which a person has\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nProstate— A donut-shaped gland in males below the\\nbladder that contributes to the production of semen.\\nSchizophrenia— A severe mental disorder in which\\na person loses touch with reality and may have\\nillogical thoughts, delusions, hallucinations, beha-\\nvioral problems and other disturbances.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSerotonin— A natural chemical found in the brain\\nand other parts of the body, that carries signals\\nbetween nerve cells.\\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.\\n294 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidepressants, tricyclic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='PREGNANCY. Problems have been reported in\\nbabies whose mothers took tricyclic antidepressants\\njust before delivery. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians about the safety of using tricyclic antidepressants.\\nBREASTFEEDING. Tricyclic antidepressants pass\\ninto breast milk and may cause drowsiness in nursing\\nbabies whose mothers take the drugs. Women who are\\nbreastfeeding should check with their physicians\\nbefore using tricyclic antidepressants.\\nDIABETES. Tricyclic antidepressants may affect\\nblood sugar levels. Diabetic patients who notice\\nchanges in blood or urine test results while taking\\nthis medicine should check with their physicians.\\nOTHER MEDICAL CONDITIONS. Before using tri-\\ncyclic antidepressants, people with any of these medi-\\ncal problems should make sure their physicians are\\naware of their conditions:\\n/C15current or past alcohol or drugabuse\\n/C15bipolar disorder (manic-depressive illness)\\n/C15schizophrenia\\n/C15seizures (convulsions)\\n/C15heart disease\\n/C15high blood pressure\\n/C15kidney disease\\n/C15liver disease\\n/C15overactive thyroid\\n/C15stomach or intestinal problems\\n/C15enlarged prostate\\n/C15problems urinating\\n/C15glaucoma\\n/C15asthma\\nUSE OF CERTAIN MEDICINES. Taking tricyclic anti-\\ndepressants with certain other drugs may affect the way\\nthe drugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, drow-\\nsiness, dry mouth, unpleasant taste,headache, nausea,\\nmild tiredness or weakness, increased appetite or crav-\\ning for sweets, and weight gain. These problems\\nusually go away as the body adjusts to the drug and\\ndo not require medical treatment. Less common side\\neffects, such as diarrhea, vomiting, sleep problems,\\nsweating, and heartburn also may occur and do not\\nneed medical attention unless they do not go away or\\nthey interfere with normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15blurred vision\\n/C15eye pain\\n/C15confusion\\n/C15hallucinations\\n/C15fainting\\n/C15loss of balance\\n/C15swallowing problems\\n/C15difficulty speaking\\n/C15mask-like face\\n/C15shakiness or trembling\\n/C15nervousness or restlessness\\n/C15movement problems, such as shuffling walk, stiff\\narms and legs, or slow movement\\n/C15decreased sexual ability\\n/C15fast or irregular heartbeat\\n/C15constipation\\n/C15problems urinating\\nSome side effects may continue after treatment\\nwith tricyclic antidepressants has ended. Check with\\na physician if these symptoms occur:\\n/C15headache\\n/C15nausea, vomiting, or diarrhea\\n/C15sleep problems, including vivid dreams\\n/C15unusual excitement, restlessness, or irritability\\nInteractions\\nLife-threatening reactions, such as extrememly high\\nblood pressure, may occur when tricyclic antidepres-\\nsants are taken with other antidepressants called mono-\\namine oxidase (MAO) inhibitors (such as Nardil\\nand Parnate).Do not take tricyclic antidepressants within\\n2 weeks of taking a MAO inhibitor. However, a patient\\ncan take an MAO inhibitor immediately after tricyclic\\nantidepressant therapy is stopped by the physician.\\nTricyclic antidepressants may interact with many\\nother medicines. When this happens, the effects of one\\nor both of the drugs may change or the risk of side\\neffects may be greater. Anyone who takes tricyclic\\nantidepressants should let the physician know all\\nother medicines he or she is taking. Among the drugs\\nthat may interact with tricyclic antidepressants are:\\nGALE ENCYCLOPEDIA OF MEDICINE 295\\nAntidepressants, tricyclic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Central nervous system (CNS) depressants such as\\nmedicine for allergies, colds, hayfever, and asthma;\\nsedatives; tranquilizers; prescription pain medicine;\\nmuscle relaxants; medicine for seizures; sleep aids;\\nbarbiturates; and anesthetics.\\n/C15diet pills\\n/C15amphetamines\\n/C15blood thinning drugs\\n/C15medicine for overactive thyroid\\n/C15cimetidine (Tagamet)\\n/C15other antidepressant drugs, including MAO inhibi-\\ntors (such as Nardil and Parnate) and antidepres-\\nsants that raise serotonin levels (such as Prozac and\\nZoloft)\\n/C15blood pressure medicines such as clonidine (Catapres)\\nand guanethidine monosulfate (Ismelin)\\n/C15disulfiram (Antabuse), used to treat alcohol abuse\\n/C15major tranquilizers such as thioridazine (Mellaril)\\nand chlorpromazine (Thorazine)\\n/C15antianxiety drugs such as chlordiazepoxide (Librium)\\nand alprazolam (Xanax)\\n/C15antiseizure medicines such as carbamazaepine\\n(Tegretol) and phenytoin (Dilantin)\\nThe list above does not include every drug that\\nmay interact with tricyclic antidepressants. Be sure to\\ncheck with a physician or pharmacist before combin-\\ning tricyclic antidepressants with any other prescrip-\\ntion or nonprescription (over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntidiabetic drugs\\nDefinition\\nAntidiabetic drugs are medicines that help control\\nblood sugar levels in people with diabetes mellitus\\n(sugar diabetes).\\nPurpose\\nDiabetes may be divided into type I and type II,\\nformerly termed juvenile onset or insulin-dependent,\\nand maturity onset or non insulin-dependent. Type I is\\ncaused by a deficiency of insulin production, while\\ntype II is characterized byinsulin resistance.\\nT r e a t m e n to ft y p eId i a b e t e si sl i m i t e dt oi n s u l i n\\nreplacement, while type II diabetes is treatable by a\\nnumber of therapeutic approaches. Many cases of insu-\\nlin resistance are asymptomatic due to normal increases\\nin insulin secretion, and others may be controlled by\\ndiet andexercise. Drug therapy may be directed toward\\nincreasing insulin secretion, increasing insulin sensitiv-\\nity, or increasing insulin penetration of the cells.\\nDescription\\nAntidiabetic drugs may be subdivided into six\\ngroups: insulin, sufonylureas, alpha-glucosidase inhibi-\\ntors, biguanides, meglitinides, and thiazolidinediones.\\nInsulin (Humulin, Novolin) is the hormone respon-\\nsible for glucose utilization. It is effective in both types\\nof diabetes, since, even in insulin resistance, some sen-\\nsitivity remains and the condition can be treated with\\nKEY TERMS\\nBlood sugar— The concentration of glucose in the\\nblood.\\nGlucose— A simple sugar that serves as the body’s\\nmain source of energy.\\nHormone— A substance that is produced in one part\\nof the body, then travels through the bloodstream to\\nanother part of the body where it has its effect.\\nMetabolism— All the physical and chemical changes\\nthat occur in cells to allow growth and maintain\\nbody functions. These include processes that break\\ndown substances to yield energy and processes\\nthat build up other substances necessary for life.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nSalicylates— A group of drugs that includes aspirin\\nand related compounds. Salicylates are used to\\nrelieve pain, reduce inflammation, and lower fever.\\nSeizure— A sudden attack, spasm, or convulsion.\\n296 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiabetic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='larger doses of insulin. Most insulins are now produced\\nby recombinant DNA techniques, and are chemically\\nidentical to natural human insulin. Isophane insulin\\nsuspension, insulin zinc suspension, and other formula-\\ntions are intended to extend the duration of insulin\\naction, and permit glucose control over longer periods\\nof time. In 2003, research suggested that inhaled forms\\nof insulin offered advantages to injected types, but\\nfurther study was needed on its long-term effects on\\nthe lungs and cost-effectiveness.\\nSulfonylureas (chlorpropamide [Diabinese], tola-\\nzamide [Tolinase], glipizide [Glucotrol] and others) act\\nby increasing insulin release from the beta cells of the\\npancrease. Glimepiride (Amaryl), a member of this\\nclass, appears to have a useful secondary action in\\nincreasing insulin sensitivity in peripheral cells.\\nAlpha-glucosidase inhibitors (acarbose [Precose],\\nmiglitol [Glyset]) do not enhance insulin secretion.\\nRather, they inhibit the conversion of disaccharides and\\ncomplex carbohydrates to glucose. This mechanism does\\nnot prevent conversion, but only delays it, reducing the\\npeak blood glucose levels. Alpha-glucosidase inhibitors\\nare useful for either monotherapy or in combination\\ntherapywithsulfonylureas orotherhypoglycemicagents.\\nMetformin (Glucophage) is the only available mem-\\nber of the biguanide class. Metformin decreases hepatic\\n(liver) glucose production, decreases intestinal absorp-\\ntion of glucose and increases peripheral glucose uptake\\nand use. Metformin may be used as monotherapy\\n(alone), or in combination therapy with a sulfonylurea.\\nThere are two members of the meglitinide class:\\nrepaglinide (Prandin) and nateglitinide (Starlix). The\\nmechanism of action of the meglitinides is to stimulate\\ninsulin production. This activity is both dose dependent\\nand dependent on the presence of glucose, so that the\\ndrugs have reduced effectiveness in the presence of low\\nblood glucose levels. The meglitinides may be used alone,\\nor in combination with metformin. The manufacturer\\nwarns that nateglitinide should not be used in combina-\\ntion with other drugs that enhance insulin secretion.\\nRosiglitazone (Avandia) and pioglitazone (Actos)\\nare members of the thiazolidinedione class. They act\\nby both reducing glucose production in the liver, and\\nincreasing insulin dependent glucose uptake in muscle\\ncells. They do not increase insulin production. These\\ndrugs may be used in combination with metformin or\\na sulfonylurea.\\nRecommended dosage\\nDosage must be highly individualized for all anti-\\ndiabetic agents and is based on blood glucose levels\\nwhich must be taken regularly. Patients should review\\nspecific literature that comes with antidiabetic medica-\\ntions for complete dosage information.\\nPrecautions\\nInsulin. The greatest short term risk of insulin is\\nhypoglycemia, which may be the result of either a\\ndirect overdose or an imbalance between insulin injec-\\ntion and level of exercise and diet. This also may occur\\nin the presence of other conditions which reduce the\\nglucose load, such as illness withvomiting and diar-\\nrhea. Treatment is with glucose in the form of glucose\\ntablets or liquid, although severe cases may require\\nintravenous therapy. Allergic reactions and skin reac-\\ntions also may occur. Insulin is classified as category B\\nin pregnancy, and is considered the drug of choice for\\nglucose control during pregnancy. Insulin glargine\\n(Lantus), an insulin analog which is suitable for\\nonce-daily dosing, is classified as category C, because\\nthere have been reported changes in the hearts of new-\\nborns in animal studies of this drug. The reports are\\nessentially anecdotal, and no cause and effect relation-\\nship has been determined. Insulin is not recommended\\nduring breast feeding because either low or high\\ndoses of insulin may inhibit milk production. Insulin\\nadministered orally is destroyed in the GI tract, and\\nrepresents no risk to the newborn.\\nSulonylureas. All sulfonylurea drugs may cause\\nhypoglycemia. Most patients become resistant to these\\ndrugs over time, and may require either dose adjust-\\nments or a switch to insulin. The list of adverse reactions\\nis extensive, and includes central nervous system pro-\\nblems and skin reactions, among others. Hematologic\\nreactions, although rare,may be severe and include\\naplastic anemiaand hemolytic anemia.T h ea d m i n i s t r a -\\ntion of oral hypoglycemic drugs has been associated\\nwith increased cardiovascular mortality as compared\\nwith treatment with diet alone or diet plus insulin. The\\nsulfonylureas are classified as category C during preg-\\nnancy, based on animal studies, although glyburide has\\nnot shown any harm to the fetus and is classified as\\ncategory B. Because there may be significant alterations\\nin blood glucose levels during pregnancy, it is recom-\\nmended that patients be switched to insulin. These drugs\\nhave not been fully studied during breast feeding, but it\\nis recommended that becausetheir presence in breast\\nmilk might cause hypoglycemia in the newborn, breast\\nfeeding be avoided while taking sulfonylureas.\\nAlpha-glucosidase inhibitors are generally well\\ntolerated, and do not cause hypoglycemia. The most\\ncommon adverse effects are gastrointestinal problems,\\nincluding flatulence, diarrhea, and abdominalpain.\\nGALE ENCYCLOPEDIA OF MEDICINE 297\\nAntidiabetic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='These drugs are classified as category B in pregnancy.\\nAlthough there is no evidence that the drugs are harm-\\nful to the fetus, it is important that rigid blood glucose\\ncontrol be maintained during pregnancy, and preg-\\nnant women should be switched to insulin. Alpha-\\nglucosidase inhibitors may be excreted in small\\namounts in breast milk, and it is recommended that\\nthe drugs not be administered to nursing mothers.\\nMetformin causes gastrointestinal (stomach and\\ndigestive) reactions in about a third of patients. A rare,\\nbut very serious, reaction to metformin is lactic acido-\\nsis, which is fatal in about 50% of cases. Lactic acido-\\nsis occurs in patients with multiple medical problems,\\nincluding renal (kidney-related) insufficiency. The risk\\nmay be reduced with careful renal monitoring, and\\ncareful dose adjustments to metformin. Metformin is\\ncategory B during pregnancy. There have been no\\ncarefully controlled studies of the drug during preg-\\nnancy, but there is no evidence of fetal harm from\\nanimal studies. It is important that rigid blood glucose\\ncontrol be maintained during pregnancy, and preg-\\nnant women should be switched to insulin. Animal\\nstudies show that metformin is excreted in milk. It is\\nrecommended that metformin not be administered to\\nnursing mothers.\\nMeglitinides. These drugs are generally well tol-\\nerated, with an adverse event profile similar to pla-\\ncebo. The drugs are classified as category C during\\npregnancy, based on fetal abnormalities in rabbits\\ngiven about 40 times the normal human dose. It is\\nimportant that rigid blood glucose control be main-\\ntained during pregnancy, and pregnant women\\nshould be switched to insulin. It is not known\\nwhether the meglitinides are excreted in human\\nmilk, but it is recommended that these drugs not be\\ngiven to nursing mothers.\\nThiazolidinediones. These drugs were generally\\nwell tolerated in early trials, but they are structurally\\nrelated to an earlier drug, troglitazone, which was\\nassociated with liver function problems. However, in\\n2003, researchers reported that these drugs, which are\\nused by more than 6 million Americans, may lead to\\nserious side effects. Research showed that after one to\\n16 months of therapy with pioglitazone or rosiglita-\\nzone, some patients developed seriousedema and signs\\nof congestive heart failure. Additional studies were\\nunderway in late 2003 to determine how these drugs\\ncaused fluid build-up and if the symptoms occurred\\nmore frequently in certain age groups. The mean age\\nof patients in the 2003 study was 69 years.\\nIt is strongly recommended that all patients treated\\nwith pioglitazone or rosiglitazone have regular liver\\nfunction monitoring. The drugs are classified as preg-\\nnancy category C, based on evidence of inhibition of\\nfetal growth in rats given more than four times the\\nnormal human dose. It is important that rigid blood\\nglucose control be maintained during pregnancy, and\\npregnant women should be switched to insulin. It is not\\nknown whether the thiazolidinediones are excreted in\\nhuman milk, however they have been identified in the\\nmilk of lactating rats. It is recommended that these\\ndrugs not be administered to nursing mothers.\\nInteractions\\nThe sulfonylureas have a particularly long list of\\ndrug interactions, several of which may be severe.\\nPatients should review specific literature for these drugs.\\nThe actions of oral hypoglycemic agents may be\\nstrengthened by highly protein bound drugs, including\\nNSAIDs, salicylates, sulfonamides, chloramphenicol,\\ncoumarins, probenecid, MAOIs, andbeta blockers.\\nThe literature that accompanies each medication\\nshould list possible drug-drug or food-drug interactions.\\nResources\\nPERIODICALS\\n‘‘Inhaled Insulin Means Better Quality of Life.’’Health &\\nMedicine Week(September 16, 2003): 189.\\n‘‘Two Common Diabetes Drugs May Cause Heart Failure\\nand Fluid Buildup.’’Cardiovascular Week(September\\n29, 2003): 26.\\nORGANIZATIONS\\nAmerican Diabetes Association. ADA National Service\\nCenter, 1660 Duke Street, Alexandria, VA 22314.\\n(800)232-3472. .\\nNational Diabetes Information Clearinghouse. 1\\nInformation Way, Bethesda, MD 20892-3560.\\n(301)654-3327. ndic@info.niddk.nih.gov.\\nOTHER\\nNational Institute of Diabetes and Digestive and Kidney\\nDiseases. .\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntidiarrheal drugs\\nDefinition\\nAntidiarrheal drugs are medicines that relieve\\ndiarrhea.\\n298 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiarrheal drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nAntidiarrheal drugs help control diarrhea and some\\nof the symptoms that go along with it. An average,\\nhealthy person has anywhere from three bowel move-\\nments a day to three a week, depending on that person’s\\ndiet. Normally the stool (the material that is passed in a\\nbowel movement) has a texture something like clay.\\nWithdiarrhea,bowelmovementsmaybemorefrequent,\\nandthetextureofthestool isthinandsometimes watery.\\nDiarrhea is not a disease, but a symptom of some\\nother problem. The symptom may be caused by eating\\nor drinking food or water that is contaminated with\\nbacteria, viruses, or parasites, or by eating something\\nthat is difficult to digest. People who have trouble\\ndigesting lactose (milk sugar), for example, may get\\ndiarrhea if they eat dairy products. Some cases of\\ndiarrhea are caused bystress, while others are brought\\non by taking certain medicines.\\nDescription\\nAntidiarrheal drugs work in several ways. The\\ndrug loperamide, found in Imodium A-D, for example,\\nslows the passage of stools through the intestines. This\\nallows more time for water and salts in the stools to be\\nabsorbed back into the body. Adsorbents, such as atta-\\npulgite (found in Kaopectate) pull diarrhea-causing\\nsubstances from the digestive tract. However, they\\nmay also pull out substances that the body needs,\\nsuch as enzymes and nutrients. Bismuth subsalicylate,\\nthe ingredient in Pepto-Bismol, decreases the secretion\\nof fluid into the intestine and inhibits the activity of\\nbacteria. It not only controls diarrhea, but relieves the\\ncramps that often accompany diarrhea.\\nThese medicines come in liquid, tablet, caplet, and\\nchewable tablet forms and can be bought without a\\nphysician’s prescription.\\nRecommended dosage\\nThe dose depends on the type of antidiarrheal\\ndrug. Read and follow the directions on the product\\nlabel. For questions about dosage, check with a phy-\\nsician or pharmacist. Never take larger or more fre-\\nquent doses, and do not take the drug for longer than\\ndirected.\\nPrecautions\\nDiarrhea usually improves within 24-48 hours. If\\nthe problem lasts longer or if it keeps coming back,\\ndiarrhea could be a sign of a more serious problem.\\nAnyone who has any of the symptoms listed below\\nshould get medical attention as soon as possible:\\n/C15diarrhea that lasts more than two days or gets worse\\n/C15fever\\n/C15blood in the stool\\n/C15vomiting\\n/C15cramps or tenderness in the abdomen\\n/C15signs of dehydration, such as decreased urination,\\ndizziness or lightheadedness, dry mouth, increased\\nthirst, or wrinkled skin\\nDo not use antidiarrheal drugs for more than two\\ndays unless told to do so by a physician.\\nSevere, long-lasting dia r r h e ac a nl e a dt od e h y -\\ndration. In such cases, lost fluids and salts, such as\\ncalcium, sodium, and potassium, must be replaced.\\nPeople older than 60 should not use attapulgite\\n(Kaopectate, Donnagel, Parepectolin), but may use\\nother kinds of antidiarrheal drugs. However, people\\nin this age group may be more likely to have side\\neffects, such as severeconstipation, from bismuth sub-\\nsalicylate. Ask the pharmacist for more information.\\nBismuth subsalicylate may cause the tongue or the\\nstool to temporarily darken. This is harmless.\\nHowever, do not confuse this harmless darkening of\\nthe stool with the black, tarry stools that are a sign of\\nbleeding in the intestinal tract.\\nChildren with flu or chicken pox should not be\\ngiven bismuth subsalicylate. It can lead toReye’s syn-\\ndrome, a life-threatening condition that affects the\\nliver and central nervous system. To be safe, never\\ngive bismuth subsalicylate to a child under 16 years\\nwithout consulting a physician. Children may have\\nunpredictable reactions to other antidiarrheal drugs.\\nLoperamide should not be given to children under six\\nyears and attapulgite should not be given to children\\nunder three years unless directed by a physician.\\nKEY TERMS\\nColitis— Inflammation of the colon (large bowel).\\nDehydration— Excessive loss of water from the\\nbody.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nNutrient— A food substance that provides energy or\\nis necessary for growth and repair. Examples of nutri-\\nents are vitamins, minerals, carbohydrates, fats, and\\nproteins.\\nGALE ENCYCLOPEDIA OF MEDICINE 299\\nAntidiarrheal drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Anyone who has a history ofliver diseaseor who\\nhas been takingantibiotics should check with his or her\\nphysician before taking the antidiarrheal drug loper-\\namide. A physician should also be consulted before\\nanyone with acuteulcerative colitisor anyone who has\\nbeen advised to avoid constipation uses the drug.\\nLoperamide should not be used by people whose\\ndiarrhea is caused by certain infections, such as sal-\\nmonella or shigella. To be safe, check with a physician\\nbefore using this drug.\\nAnyone who has a medical condition that causes\\nweakness should check with a physician about the best\\nway to treat diarrhea.\\nSpecial conditions\\nBefore taking antidiarrheal drugs, be sure to let\\nthe physician know about any of these conditions:\\nALLERGIES. Anyone who has had unusual reactions\\nto aspirin or other drugs containing salicylates should\\ncheck with a physician before taking bismuth subsali-\\ncylate. Anyone who has developed a rash or other\\nunusual reactions after taking loperamide should not\\ntake that drug again without checking with a physician.\\nThe physician should also be told about anyallergiesto\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY AND BREASTFEEDING. Women who\\nare pregnant or breastfeeding should check with their\\nphysicians before using antidiarrheal drugs. They should\\nalso ask advice on how to replace lost fluids and salts.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\ndiarrheal drugs, people with any of these medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15dysentery\\n/C15gout\\n/C15hemophilia or other bleeding problems\\n/C15kidney disease\\n/C15stomach ulcer\\n/C15severe colitis\\n/C15liver disease\\nUSE OF CERTAIN MEDICINES. Taking antidiarrheal\\ndrugs with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects of attapulgite\\nare constipation, bloating, and fullness. Bismuth\\nsubsalicylate may cause ringing in the ears, but\\nthat side effect is rare. Possible side effects from\\nloperamide include skin rash, constipation, drowsi-\\nness, dizziness, tiredness, dry mouth,nausea,v o m i t -\\ning, and swelling, pain, and discomfort in the\\nabdomen. Some of these symptoms are the same\\nas those that occur with diarrhea, so it may be\\ndifficult to tell if the medicine is causing the pro-\\nblems. Children may be more sensitive than adults\\nto certain side effects of loperamide, such as drow-\\nsiness and dizziness.\\nOther rare side effects may occur with any anti-\\ndiarrheal medicine. Anyone who has unusual symp-\\ntoms after taking an antidiarrhea drug should get in\\ntouch with his or her physician.\\nInteractions\\nAttapulgite can decrease the effectiveness of other\\nmedicines taken at the same time. Changing the times\\nat which the other medicines are taken may be neces-\\nsary. Check with a physician or pharmacist to work\\nout the proper dose schedule.\\nBismuth subsalicylate should not be taken with\\naspirin or any other medicine that contains salicylate.\\nThis drug may also interact with other drugs, such as\\nblood thinners (warfarin, for example), methotrexate,\\nthe antigout medicine probenecid, and the antidia-\\nbetes drug tolbutamide. In addition, bismuth subsali-\\ncylate may interact with any drug that interacts with\\naspirin. Anyone taking these drugs should check with\\na physician or pharmacist before taking bismuth\\nsubsalicylate.\\nNancy Ross-Flanigan\\nAntidiuretic hormone (ADH)\\ntest\\nDefinition\\nAntidiuretic hormone (ADH) test, also called the\\nVasopressin test, is a test for the antidiuretic hormone,\\nwhich is released from the pituitary gland and acts on\\nthe kidneys to increase their reabsorption of water into\\nthe blood.\\nPurpose\\nAn ADH test is used to aid in the diagnosis of\\ndiabetes insipidus or the syndrome of inappropriate\\nADH called SIADH.\\n300 GALE ENCYCLOPEDIA OF MEDICINE\\nAntidiuretic hormone (ADH) test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Precautions\\nCertain drugs can either increase or decrease\\nADH levels. Drugs that increase ADH levels include\\nacetaminophen, barbiturates, cholinergic agents, estro-\\ngen, nicotine, oralhypoglycemia agents, somediuretics\\n(e.g., thiazides), cyclophosphamide,narcotics, andtri-\\ncyclic antidepressants. Drugs that decrease ADH levels\\ninclude alcohol, beta-adrenergic agents, morphine\\nantagonists, and phenytoin (Dilantin).\\nDescription\\nThe purpose of ADH is to control the amount of\\nwater reabsorbed by the kidneys. Water is continu-\\nally being taken into the body in food and drink, as\\nwell as being produced by chemical reactions in cells.\\nWater is also continually lost in urine, sweat, feces,\\nand in the breath as water vapor. ADH release helps\\nmaintain the optimum amount of water in the body\\nwhen there is an increase in the concentration of the\\nblood serum or a decrease in blood volume. Physical\\nstress, surgery, and high levels ofanxiety can also\\nstimulate ADH.\\nVarious factors can affect ADH production,\\nthereby disturbing the body’s water balance. For\\nexample, alcohol consumption reduces ADH pro-\\nduction by direct action on the brain, resulting in a\\ntemporarily increased production of urine. This may\\nalso occur in diabetes insipidus, when the pituitary\\ngland produces insufficient ADH, or rarely, when the\\nkidneys fail to respond to ADH. The reverse effect of\\nwater retention can result from temporarily\\nincreased ADH production after a major operation\\nor accident. Water retention may also be caused by\\nthe secretion of ADH by some tumors, especially of\\nthe lung.\\nPreparation\\nThe test requires collection of a blood sample. The\\npatient must befasting (nothing to eat or drink) for\\n12 hours, be adequately hydrated, and limit physical\\nactivity for 10-12 hours before the test.\\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\\nADH normal ranges are laboratory-specific but\\ncan range from 1-5 pg/ml or 1.5 ng/L (SI units).\\nAbnormal results\\nPatients who are dehydrated, who have a decreased\\namount of blood in the body (hypovolemia), or who are\\nundergoing severe physical stress (e.g., trauma,pain or\\nprolonged mechanical ventilation) may exhibit increased\\nADH levels. Patients who are overly hydrated or who\\nhave an increased amount of blood in the body (hyper-\\nvolemia) may have decreased ADH levels.\\nOther conditions that cause increased levels\\ninclude SIADH, central nervous system tumors or\\ninfection, orpneumonia.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAntiemetic drugs see Antinausea drugs\\nAntiepileptic drugs see Anticonvulsant drugs\\nAntifungal drugs, systemic\\nDefinition\\nSystemic antifungal drugs are medicines taken by\\nmouth or by injection to treat deep infections caused\\nby a fungus.\\nKEY TERMS\\nDiabetes insipidus— A metabolic disorder in which\\nthe pituitary gland producesinadequate amounts of\\nantidiuretic hormone (ADH) or the kidneys are unable\\nto respond to release of the hormone. Primary symp-\\ntoms are excessive urination and constant thirst.\\nPituitary gland— The pituitary gland is sometimes\\nreferred to as the ‘‘master gland.’’ As the most impor-\\ntant of the endocrine glands (glands which release\\nhormones directly into the bloodstream), it regulates\\nand controls not only the activities of other endo-\\ncrine glands but also many body processes.\\nGALE ENCYCLOPEDIA OF MEDICINE 301\\nAntifungal drugs, systemic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nSystemic antifungal drugs are used to treat\\ninfections in various parts of the body that are\\ncaused by a fungus. A fungus is an organism that\\ncan be either one-celled or filamentous. Unlike a\\nplant, which makes its own food, or an animal,\\nwhich eats plants or other animals, a fungus sur-\\nvives by invading and living off other living things.\\nFungi thrive in moist, dark places, including some\\nparts of the body.\\nFungal infections can either be systemic, meaning\\nthat the infection is deep, or topical (dermatophytic),\\nmeaning that the infection is superficial and occurs on\\nthe skin. Additionally, yeast infections can affect the\\nmucous membranes of the body. Fungal infections on\\nthe skin are usually treated with creams or ointments\\n(topical antifungal drugs). However, systemic infec-\\ntions, yeast infections or topical infections that do\\nnot clear up after treatment with creams or ointments\\nmay need to be treated with systemic antifungal drugs.\\nThese drugs are used, for example, to treat common\\nfungal infections such as tinea (ringworm), which\\noccurs on the skin orcandidiasis (a yeast infection,\\nalso known as trush), which can occur in the throat,\\nin the vagina, or in other parts of the body. They are\\nalso used to treat other deep fungal infections such as\\nhistoplasmosis, blastomycosis, andaspergillosis, which\\ncan affect the lungs and other organs. They are some-\\ntimes used to prevent or treat fungal infections in\\npeople whose immune systems are weakened, such as\\nbone marrow or organ transplant patients and people\\nwith AIDS.\\nDescription\\nAntifungal drugs are categorized depending on\\ntheir route or site of action, their mechanism of action\\nand their chemical nature.\\nSystemic antifungal drugs, such as capsofungin\\n(Cancidas), flucytosine, fluconazole (Diflucan), itra-\\nconazole (Sporanox), ketoconazole (Nizoral), and\\nmiconazole (Monistat I.V.) are available only by pre-\\nscription. They are available in tablet, capsule, liquid,\\nand injectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantifungal drug and the nature and extent of fungal\\ninfection being treated. Doses may also be different for\\ndifferent patients. The prescribing physician or the\\npharmacist can provide dosage information.\\nSystemic antifungal drugs must be taken exactly as\\ndirected. Itraconazole and ketoconazole should be\\ntaken with food.\\nFungal infections can take a long time to clear up,\\nso it may be necessary to take the medication for several\\nmonths, or even for a year or longer. It is very import-\\nant to keep taking the medicine for as long as the\\nphysician says to take it, even if symptoms seem to\\nimprove. If the drug is stopped too soon, the symptoms\\nmay return.\\nSystemic antifungal drugs work best when their\\namount is kept constant in the body, meaning that\\nthey have to be taken regularly, at the same time\\nevery day, and without missing any doses.\\nPatients taking the liquid form of ketoconazole\\nshould use a specially marked medicine spoon or other\\nmedicine measuring device to make sure they take the\\ncorrect amount. A regular household teaspoon may\\nnot hold the right amount of medicine. Ask the phar-\\nmacists about ways to accurately measure the dose of\\nthese drugs.\\nPrecautions\\nIf symptoms do not improve within a few weeks,\\nthe prescribing physician should be informed.\\nWhile taking this medicine, regular medical visits\\nshould be scheduled. The physician needs to keep\\nchecking for side effects throughout the antifungal\\ntherapy.\\nSome people feel drowsy or dizzy while taking\\nsystemic antifungal drugs. Anyone who takes these\\ndrugs should not drive, use machines or do anything\\nKEY TERMS\\nElixir— A sweetened liquid that contains alcohol,\\nwater, and medicine.\\nFetus— A developing baby inside the womb.\\nFungus— A unicellular to filamentous organism\\nthat causes parasitic infections.\\nOintment— A thick substance that contains medi-\\ncine and is meant to be spread on the skin, or if an\\nophthalmic ointment, in the eye.\\nSystemic— At e r mu s e dt od e s c r i b eam e d i c i n e\\nthat has effects throughout the body, as opposed\\nto topical drugs that work on the skin. Most med-\\nicines that are taken by mouth or by injection are\\nsystemic drugs.\\n302 GALE ENCYCLOPEDIA OF MEDICINE\\nAntifungal drugs, systemic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='else that might be dangerous until they have found out\\nhow the drugs affect them.\\nLiver problems, stomach problems and other pro-\\nblems may occur in people who drink alcohol while\\ntaking systemic antifungal drugs. Alcohol and pre-\\nscription or nonprescription (over-the-counter) drugs\\nthat contain alcohol should be avoided while taking\\nantifungal drugs. (Medicines that may contain alcohol\\ninclude some cough syrups, tonics, and elixirs.)\\nAlcohol should be avoided for at least a day after\\ntaking an antifungal drug.\\nThe antifungal drug ketoconazole may make the\\neyes unusually sensitive to light. Wearing sunglasses\\nand avoiding exposure to bright light may help.\\nSpecial conditions\\nPeople with certain medical conditions or who\\nare taking certain other medicines can have pro-\\nblems if they take systemic antifungal drugs.\\nBefore taking these drugs, the prescribing physician\\nshould be informed about any of the following\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to systemic antifungal drugs in the past should\\nlet his or her physician know about the problem before\\ntaking the drugs again. The physician should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nPREGNANCY. In laboratory studies of animals,\\nsystemic antifungal drugs have causedbirth defects\\nand other problems in the mother and fetus.\\nStudies have not been done on pregnant women,\\nso it is not known whether these drugs cause simi-\\nlar effects in people. Women who are pregnant or\\nwho plan to become pregnant should check with\\ntheir physicians before taking systemic antifungal\\ndrugs. Any woman who becomes pregnant while\\ntaking these drugs should let her physician know\\nimmediately.\\nBREASTFEEDING. Systemic antifungal drugs pass\\ninto breast milk. Women who are breastfeeding\\nshould check with their physicians before using sys-\\ntemic antifungal drugs.\\nOTHER MEDICAL CONDITIONS. People who have\\nmedical conditions that deplete stomach acid (achlor-\\nhydria) or decrease stomach acid (hypochlorhydria)\\nshould be sure to inform their physicians about their\\ncondition before they use a systemic antifungal drug.\\nThese drugs are not active in their natural form, but\\nmust be converted to the active form by an acid. If\\nthese is not enough stomach acid, the drugs will be\\nineffective. For people with insufficient stomach acid,\\nit may help to take the medicine with an acidic drink,\\nsuch as a cola. The patient’s health care provider can\\nsuggest the best way to take the medicine.\\nBefore using systemic antifungal drugs, people\\nwith any of these medical problems should also make\\nsure their physicians are aware of their conditions:\\n/C15current or past alcoholabuse\\n/C15liver disease\\n/C15kidney disease\\nUSE OF CERTAIN MEDICINES. Taking systemic anti-\\nfungal drugs with certain other drugs may affect the\\nway the drugs work or may increase the chance of side\\neffects.\\nSide effects\\nFluconazole\\nAlthough rare, severe allergic reactions to this\\nmedicine have been reported. Call a physician imme-\\ndiately if any of these symptoms develop after taking\\nfluconazole (Diflucan):\\n/C15hives, itching, or swelling\\n/C15breathing or swallowing problems\\n/C15sudden drop in blood pressure\\n/C15diarrhea\\n/C15abdominal pain\\nKetoconazole\\nKetoconazole has caused anaphylaxis (a life-\\nthreatening allergic reaction) in some people after\\ntheir first dose. This is a rare reaction.\\nSystemic antifungal drugs in general\\nSystemic antifungal drugs may cause serious and\\npossibly life-threatening liver damage. Patients who\\ntake these drugs should haveliver function testsbefore\\nthey start taking the medicine and as often as their\\nphysician recommends while they are taking it. The\\nphysician should be notified immediately if any of\\nthese symptoms develop:\\n/C15loss of appetite\\n/C15nausea or vomiting\\n/C15yellow skin or eyes\\n/C15unusual fatigue\\n/C15dark urine\\n/C15pale stools\\nGALE ENCYCLOPEDIA OF MEDICINE 303\\nAntifungal drugs, systemic'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The most common minor side effects of systemic\\nantifungal drugs are constipation, diarrhea, nausea,\\nvomiting, headache, drowsiness,dizziness, and flush-\\ning of the face or skin. These problems usually go\\naway as the body adjusts to the drug and do not\\nrequire medical treatment. Less common side effects,\\nsuch as menstrual problems in women, breast enlar-\\ngement in men, and decreased sexual ability in men\\nalso may occur and do not need medical attention\\nunless they do not improve in a reasonable amount\\nof time.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nimmediately:\\n/C15fever and chills\\n/C15skin rash or itching\\n/C15high blood pressure\\n/C15pain, redness, or swelling at site of injection (for\\ninjectable miconazole)\\nOther rare side effects are possible. Anyone who\\nhas unusual symptoms after taking systemic antifun-\\ngal drugs should get in touch with his or her physician.\\nInteractions\\nSerious and possibly life-threatening side effects\\ncan result if the oral forms of itraconazole or ketoco-\\nnazole or the injectable form of miconazole are taken\\nwith certain drugs. Do not take those types of\\nsystemic antifungal drugs with any of the following\\ndrugs unless the physician approves of the therapy:\\n/C15astemizole (Hismanal)\\n/C15cisapride (Propulsid)\\n/C15antacids\\n/C15theophylline-containing anti-wheezing medications\\nTaking an acid blocker such as cimetidine\\n(Tagamet), famotidine (Pepcid), nizatidine (Axid),\\nomeprazole (Prilosec), or ranitidine (Zantac) at the\\nsame time as a systemic antifungal drug may prevent\\nthe antifungal drug from working properly. For best\\nresults, take the acid blocker at least 2 hours after\\ntaking the antifungal drug.\\nIn addition, systemic antifungal drugs may inter-\\nact with many other medicines. When this happens,\\nthe effects of one or both of the drugs may change or\\nthe risk of side effects may be greater.Anyone who\\ntakes systemic antifungal drugs should inform the pre-\\nscribing physician about all other prescription and non-\\nprescription (over-the-counter) medicines he or she is\\ntaking. Among the drugs that may interact with sys-\\ntemic antifungal drugs are:\\n/C15acetaminophen (Tylenol)\\n/C15birth control pills\\n/C15male hormones (androgens)\\n/C15female hormones (estrogens)\\n/C15medicine for other types of infections\\n/C15antidepressants\\n/C15antihistamines\\n/C15muscle relaxants\\n/C15medicine for diabetes, such as tolbutamide (Orinase),\\nglyburide (DiaBeta), and glipizide (Glucotrol)\\n/C15blood-thinning medicine, such as warfarin (Coumadin)\\nThe list above does not include every drug that\\nmay interact with systemic antifungal drugs. Be sure\\nto check with a physician or pharmacist before com-\\nbining systemic antifungal drugs with any other\\nmedicine.\\nNancy Ross-Flanigan\\nAntifungal drugs, topical\\nDefinition\\nTopical antifungal drugs are medicines applied to\\nthe skin to treat skin infections caused by a fungus.\\nPurpose\\nDermatologic fungal infections are usually\\ndescribed by their location on the body: tinea pedis\\n(infection of the foot), tinea unguium (infection of the\\nnails), tinia capitis (infection of the scalp.) Three types\\nof fungus are involved in most skin infections:\\nTrichophyton, Epidermophyton, and Microsporum.\\nMild infections are usually susceptible to topical\\ntherapy, however severe or resistant infections may\\nrequire systemic treatment.\\nDescription\\nThere are a large number of drugs currently\\navailable in topical form for fungal infections.\\nOther than the imidazoles, (miconazole [Micatin,\\nMiconazole], clotrimazole [Lotrimin], econazole\\n[Spectazole], ketoconazole [Nizoral], oxiconazole\\n[Oxistat], sulconazole [Exelderm]) and the\\n304 GALE ENCYCLOPEDIA OF MEDICINE\\nAntifungal drugs, topical'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='allylamine derivatives (butenafine [Mentax], nafti-\\nfine [Naftin], terbinafine [Lamisil]), the drugs in\\nthis therapeutic class are chemically distinct from\\neach other. All drugs when applied topically have\\na good margin of safety, and most show a high\\ndegree of effectiveness. There are no studies com-\\nparing drugs on which to base a recommendation\\nfor drugs of choice. Although some of the topical\\nantifungals are available over-the-counter, they\\nmay be as effective as prescription drugs for this\\npurpose.\\nTraditional antifungal drugs such as undecylinic\\nacid (Cruex, Desenex) and gentian violet (also known\\nas crystal violet) remain available, but have a lower\\ncure rate (complete eradication of fungus) than the\\nnewer agents and are not recommended. Tolnaftate\\n(Tinactin) has a lower cure rate than the newer drugs,\\nbut may be used prophylactically to prevent\\ninfection.\\nRecommended dosage\\nAll drugs are applied topically. Consult individual\\nproduct information for specific application\\nrecommendations.\\nAs with all topical products, selection of the\\ndosage form may be as important as proper drug\\nselection. Consider factors such as presence or\\nabsence of hair on the affected area, and type of\\nskin to which the medication is to be applied. Thin\\nliquids may preferable for application to hairy areas,\\ncreams for the hands and face, and ointments may be\\npreferable for the trunk and legs. Other dosage forms\\navailable include shampoos and sprays. Ciclopirox\\nand triacetin are available in formulations for topical\\ntreatment of nail fungus as well as skin infections\\n(ciclopirox as Penlac Nail Lacquer and triacetin as\\nOny-Clear Nail).\\nMost topical antifungal drugs require four weeks\\nof treatment. Infections insome areas, particularly\\nthe spaces between toes, may take up to six weeks\\nfor cure.\\nPrecautions\\nMost topical antifungal agents are well tolerated.\\nThe most common adverse effects are localized irrita-\\ntion caused by the vehicle or its components. This may\\ninclude redness, itch, and a burning sensation. Some\\ndirect allergic reactions are possible.\\nTopical antifungal drugs should only be applied in\\naccordance with labeled uses. They are not intended or\\nophthalmic (eye) or otic (ear) use. Application to\\nmucous membranes should be limited to appropriate\\nformulations.\\nThe antifungal drugs have not been evaluated for\\nsafety in pregnancy and lactation on topical applica-\\ntion under the pregnancy risk category system.\\nAlthough systemic absorption is probably low, review\\nspecific references. Gentian violet is labeled with a\\nwarning against use in pregnancy.\\nInteractions\\nTopical antifungal drugs have no recognized\\ndrug-drug or food-drug interactions.\\nSamuel D. Uretsky, PharmD\\nAntigas agents\\nDefinition\\nAntigas agents are medicines that relieve the\\nuncomfortable symptoms of too much gas in the sto-\\nmach and intestines.\\nPurpose\\nExcess gas can build up in the stomach and intes-\\ntines for a number of reasons. Eating high-fiber foods,\\nsuch as beans, grains, and vegetables is one cause.\\nSome people unconsciously swallow air when they\\nKEY TERMS\\nCream— A spreadable substance, similar to an oint-\\nment, but not as thick. Creams may be more appro-\\npriate than ointments for application to exposed\\nskin areas such as the face and hands.\\nOintment— A thick, spreadable substance that\\ncontains medicine and is meant to be used on the\\nskin, or if a vaginal preparation, in the vagina.\\nOphthalmic— Pertaining to the eye.\\nOtic— Pertaining to the ear.\\nTopical— A term used to describe medicine that\\nhas effects only in a specific area, not throughout\\nthe body, particularly medicine that is put directly\\non the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 305\\nAntigas agents'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='eat, drink, chew gum, or smoke cigarettes, which can\\nlead to uncomfortable amounts of gas in the digestive\\nsystem. Surgery and certain medical conditions, such\\nas irritable colon, peptic ulcer, anddiverticulosis, can\\nalso lead to gas build-up. Certain intestinal parasites\\ncan contribute to the production of severe gas - these\\nparasites need to be treated separately with special\\ndrugs. Abdominalpain, pressure, bloating, and flatu-\\nlence are signs of too much gas. Antigas agents help\\nrelieve the symptoms by preventing the formation of\\ngas pockets and breaking up gas that already is\\ntrapped in the stomach and intestines.\\nDescription\\nAntigas agents are sold as capsules, liquids, and\\ntablets (regular and chewable) and can be bought with-\\nout a physician’s prescription. Some commonly used\\nbrands are Gas-X, Flatulex, Mylanta Gas Relief,\\nDi-Gel, and Phazyme. The ingredient that helps relieve\\nexcess gas is simethicone. Simethicone does not relieve\\nacid indigestion, but some products also containanta-\\ncids for that purpose. Check the label of the product or\\nask the pharmacist for more information.\\nRecommended dosage\\nCheck the product container for dosing informa-\\ntion. Typically, the doses should be taken after meals\\nand at bedtime. Chewable forms should be chewed\\nthoroughly.\\nCheck with a physician before giving this medi-\\ncine to children under age 12 years.\\nPrecautions\\nSome anti-gas medicines may contain sugar,\\nsodium, or other ingredients. Anyone who is on a\\nspecial diet or is allergic to any foods, dyes,\\npreservatives, or other substances should check with\\nhis or her physician or pharmacist before using any of\\nthese products.\\nAnyone who has had unusual reactions to\\nsimethicone – the active ingredient in antigas medi-\\ncines – should check with his or her physician before\\ntaking these drugs.\\nSide effects\\nNo common or serious side effects have been\\nreported in people who use this medicine. However,\\nanyone who has unusual symptoms after taking an\\nantigas agent should get in touch with his or her\\nphysician.\\nInteractions\\nAntigas agents are not known to interact with any\\nother drugs.\\nSamuel D. Uretsky, PharmD\\nAntigastroesophageal reflux\\ndrugs\\nDefinition\\nThese drugs are used to treat gastroesophageal\\nreflux, the backward flow of stomach contents into\\nthe esophagus.\\nPurpose\\nThe drug discussed here, cisapride (Propulsid), is\\nused to treat nighttimeheartburn resulting from gas-\\ntroesophageal reflux disease (GERD). In this condi-\\ntion, food and stomach juices flow backward from the\\nstomach into the esophagus, the part of the digestive\\ntract through which food passes on its way from the\\nmouth to the stomach. Normally, a muscular ring\\ncalled the lower esophageal sphincter (LES) opens to\\nallow food into the stomach and then closes to prevent\\nthe stomach’s contents from flowing back into the\\nesophagus. In people with GERD, this muscular ring\\nis either weak or it relaxes at the wrong times. The\\nmain symptom is heartburn – a burning sensation\\ncentered behind the breastbone and spreading upward\\ntoward the neck and throat.\\nCisapride works by strengthening the lower eso-\\nphageal sphincter and making the stomach empty\\nKEY TERMS\\nDigestive tract— The stomach, intestines, and\\nother parts of the body through which food passes.\\nDiverticulosis— A condition in which the colon\\n(large intestine) develops a number of outpouch-\\nings or sacs.\\nFlatulence— Excess gas in the digestive tract.\\nIrritable colon— An intestinal disorder often\\naccompanied by abdominal pain and diarrhea.\\n306 GALE ENCYCLOPEDIA OF MEDICINE\\nAntigastroesophageal reflux drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='more quickly. This shortens the amount of time that the\\nesophagus comes in contact with the stomach contents.\\nOther drugs, such as H2-blockers are sometimes pre-\\nscribed to reduce the amount of acid in the stomach.\\nDescription\\nCisapride is available only with a physician’s pre-\\nscription. Cisapride is sold in tablet and liquid forms.\\nRecommended dosage\\nThe dose depends on the patient. The average\\ndose for adults and children age 12 and over is 5-20 mg\\ntaken two to four times a day. The medicine should be\\ntaken 15 minutes before meals and at bedtime. For\\nchildren under 12, the dose is based on body weight\\nand should be determined by the child’s physician.\\nPrecautions\\nThis medicine is effective in treating only night-\\ntime heartburn, not daytime heartburn.\\nCisapride may increase the effects of alcohol and\\ntranquilizers.\\nCisapride has caused dangerous irregular heart-\\nbeats in a few people who took it with other medicines.\\nAnyone who takes this drug should let the physician\\nknow all other medicines he or she is taking. Patients\\nwith heart problems should check with their physi-\\ncians before taking cisapride.\\nAnyone who has bleeding, blockage, or leakage in\\nthe stomach or intestines should not take cisapride.\\nCisapride should not be used by anyone who has had\\nan unusual reaction to the drug in the past. In addi-\\ntion, people with any of the following medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15Epilepsy or history of seizures\\n/C15Kidney disease\\n/C15Liver disease.\\nThe effects of taking cisapride duringpregnancy\\nhave not been fully studied. Women who are preg-\\nnant or plan to become pregnant should check with\\ntheir physicians before taking Cisapride. The drug\\npasses into breast milk and may affect nursing\\nbabies. Women who are breastfeeding and need to\\ntake this medicine should check with their physi-\\ncians. Avoiding breastfeeding while taking the drug\\nmay be necessary.\\nSide effects\\nThe most common side effects are abdominal\\npain, bloating, gas, diarrhea, constipation, nausea,\\nupper respiratory infections, inflammation of the\\nnasal passages and sinuses, headache,a n dv i r a l\\ninfections. Other side effects may occur. Anyone\\nwho has unusual or troublesome symptoms after\\ntaking this drug should get in touch with his or her\\nphysician.\\nInteractions\\nCisapride may interact with a variety of other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes Cisapride should\\nlet the physician know all other medicines he or she is\\ntaking. Among the drugs that may interact with cisa-\\npride are:\\n/C15Antifungal drugs such as ketoconazole (Nizoral),\\nmiconazole (Monistat), and fluconazole (Diflucan)\\n/C15Antibiotics such as clarithromycin (Biaxin) and ery-\\nthromycin (E-Mycin, ERYC)\\n/C15Blood-thinners such as warfarin (Coumadin)\\n/C15H2-blockers such as cimetidine (Tagamet) and rani-\\ntidine (Zantac)\\n/C15Tranquilizers such as chlordiazepoxide (Librium),\\ndiazepam (Valium), and alprazolam (Xanax).\\nThe list above does not include every drug that\\nmay interact with cisapride. Be sure to check with a\\nphysician or pharmacist before combining cisapride\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine.\\nResources\\nORGANIZATIONS\\nNational Digestive Diseases Information Clearinghouse. 2\\nInformation Way, Bethesda, MD 20892-3570. (800)\\n891-5389. .\\nKEY TERMS\\nEsophagus— The part of the digestive tract between\\nthe pharynx and the stomach. (The pharynx is the\\nspace just behind the mouth.)\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nGALE ENCYCLOPEDIA OF MEDICINE 307\\nAntigastroesophageal reflux drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Pediatric/Adolescent Gastroesophageal Reflux Association,\\nInc. P.O. Box 1153, Germantown, MD 20875-1153.\\n(301) 601-9541. .\\nOTHER\\n‘‘GERD Information Center.’’Pharmaceutical Information\\nNetwork. .\\nGERD Information Resource Center..\\nNancy Ross-Flanigan\\nAntihelminthic drugs\\nDefinition\\nAntihelminthic drugs are used to treat parasitic\\ninfestations.\\nPurpose\\nParasitic infestations are caused by protozoa or\\nworms gaining entry into the body. Most of these\\norganisms cause infections by being ingested in the\\nform of eggs or larvae, usually present on contaminated\\nfood or clothing, while others gain entry through skin\\nabrasions. Common parasitic infestations includeame-\\nbiasis, malaria, giardiasis, hookworm, pinworm,\\nthreadworm, whipworm and tapeworm infestations.\\nOnce in the body, parasitic worms may go unnoticed\\nif they cause no severe symptoms. However, if they\\nmultiply rapidly and spread to a major organ, they\\ncan cause very serious and even life-threatening condi-\\ntions. Antihelminthic drugs are prescribed to treat these\\ninfestations. They function either by destroying the\\nworms on contact or by paralyzing them, or by altering\\nthe permeability of their plasma membranes. The dead\\nworms then pass out of the body in the feces.\\nDescription\\nAntihelminthic drugs are available only with a\\nprescription and are available as liquids, tablets or cap-\\nsules. Some commonly used antihelminthics include:\\nalbendazole (Albenza), mebendazole (Vermox), niclosa-\\nmide (Niclocide), oxamniquine (Vansil), praziquantel\\n(Biltricide), pyrantel (Antiminth), pyantel pamoate\\n(Antiminth) and thiabendazole (Mintezol). Some types\\nof parasitic infestations are rarely seen in the United\\nStates, thus, the corresponding antihelminthic drugs are\\nn o tw i d e l yd i s t r i b u t e da n dn e e dt ob eo b t a i n e df r o mt h e\\nUnited States Center for Disease Control (CDC) when\\nrequired. These include for example bitional and iver-\\nm e c t i n ,u s e dt ot r e a to n c h o c e rciasis infestations. Other\\nantihelminthic drugs, such as diethylcarbamazepine\\ncitrate (Hetrezan), used for treatment of roundworms\\nand other parasites, is supplied directly by its manufac-\\nturer when needed.\\nMost antihelminthic drugs are only active against\\nspecific parasites, some are also toxic. Before treat-\\nment, the parasites must therefore be identified using\\ntests that look for parasites, eggs or larvae in feces,\\nurine, blood, sputum, or tissues. Thus, niclosamide is\\nused against tapeworms, but will not be effective for\\nthe treatment of pinworm or roundworm infestations,\\nbecause it acts by inhibiting ATP production in tape-\\nworm cells. Thiabendazole (Mintezole) is the drug\\nusually prescribed for treatment of threadworm, but\\na similar drug, mebendazole (Vermox) works better on\\nwhipworm by disrupting the microtubules of this\\nworm. Praziquantel is another drug that acts by alter-\\ning the membrane permeability of the worms.\\nPreparation\\nDosage is established depending on the patient’s\\ngeneral health status and age, the type of antihel-\\nminthic drug used, and the type of parasitic infestation\\nbeing treated. The number of doses per day, the time\\nbetween doses, and the length of treatment will also\\ndepend on these factors.\\nAntihelminthic drugs must be taken exactly as\\ndirected to completely rid the body of the parasitic\\ninfestation, and for as long as directed. A second\\nround of treatment may be required to ensure that\\nthe infection has completely cleared.\\nPrecautions\\nSome antihelminthic drugs work best when ingested\\nalong with fatty foods, such as milk or ice cream. Oral\\ndrugs should be taken with water during or after meals.\\nThe prescribing physician should be informed if the\\npatient has a low-fat or other special diet.\\nSome antihelminthic drugs, such as praziquantel,\\ncome in chewable form. These tablets should not be\\nchewed or kept in the mouth, but should swallowed\\nwhole because their bitter taste may cause gagging or\\nvomiting.\\nAntihelminthic drugs sometimes need to be taken\\nwith other medications. For example, steroids such as\\nprednisone are also prescribed together with the anti-\\nhelminthic drug for tapeworm to reduce the inflam-\\nmation that the worm may cause.\\n308 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihelminthic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='When required, pre- or post-treatment purges are\\nalso performed with magnesium or sodium sulfate.\\nRegular medical visits are recommended for peo-\\nple affected by parasitic infestations. The physician\\nmonitors whether the infection is clearing or not and\\nalso keeps track of unwanted side effects. The pre-\\nscribing physician should be informed if symptoms\\ndo not disappear or if they get worse.\\nHookworm or whipworm infections are also trea-\\nted with iron supplements along with the antihel-\\nminthic prescription.\\nSome types of parasitic infestations (e.g. pin-\\nworms) can be passed from one person to another. It\\nis then often recommended that everyone in the house-\\nhold of an infected person be asked to also take the\\nprescribed antihelminthic drug.\\nKEY TERMS\\nAmebiasis— Parasitic infestation caused by amebas,\\nespecially by Entamoeba histolytica.\\nColitis— Inflammation of the colon (large intestine).\\nFeces— The solid waste that is left after digestion.\\nFeces form in the intestines and leave the body\\nthrough the anus.\\nFlukes— Parasite worms that look like leeches. They\\nusually have one or more suckers for attaching to the\\ndigestive mucosa of the host. Liver flukes infest the\\nliver, destroying liver tissue and impairing bile pro-\\nduction and drainage.\\nGiardiasis— Parasitic infestation caused by a flagel-\\nlate protozoan of the genus Giardia, especially by\\nG. lamblia.\\nHallucination— A false or distorted perception of\\nobjective reality. Imaginary objects, sounds, and\\nevents are perceived as real.\\nHookworm— Parasitic intestinal infestation caused\\nby any of several parasitic nematode worms of the\\nfamily Ancylostomatidae. These worms have strong\\nbuccal hooks that attach to the host’s intestinal\\nlining.\\nLarva— The immature, early form of an organism\\nthat at birth or hatching is not like its parent and\\nhas to undergo metamorphosis before assuming\\nadult features.\\nMalaria— Disease caused by the presence of\\nsporozoan parasites of the genus Plasmodium in\\nthe red blood cells, transmitted by the bite\\nof anopheline mosquitoes, and characterized\\nby severe and recurring attacks of chills and\\nfever).\\nMicrotubules— Slender, elongated anatomical\\nchannels in worms.\\nNematode— Roundworm.\\nOrganism— A single, independent life form, such as\\na bacterium, a plant or an animal.\\nParasite— An organism that lives in or with another\\norganism, called the host, in parasitism, a type of\\nassociation characterized by the parasite obtaining\\nbenefits from the host, such as food, and the host\\nbeing injured as a result.\\nParasitic— Of, or relating to a parasite.\\nPinworm— Enterobius vermicularis, a nematode\\nworm of the family Oxyuridae that causes para-\\nsitic infestation of the intestines and cecum.\\nPinworm is endemic in both temperate and tro-\\npical regions and common especially in school\\nage children.\\nOnchocerciasis— Parasitic infestation caused by\\nfilamentous worms of the genus Onchocerca,\\nespecially O. volvulus, that is found in tropical\\nAmerica and is transmitted by several types of\\nblackflies.\\nProtozoan— Any unicellular or multicellular organ-\\nism containing nuclei and organelles (eukaryotic) of\\nthe subkingdom Protozoa.\\nRoundworm— Any round-bodied unsegmented\\nworm as distinguished from a flatworm. Also called\\na nematode, they look similar to the common\\nearthworm.\\nTapeworm— Flat and very long (up to 30 meters)\\nintestinal parasitic worms, similar to a long piece of\\ntape. Common tapeworms include: T. saginata (beef\\ntapeworm), T. solium (pork tapeworm) D. latum (fish\\ntapeworm), H. Nana (dwarf tapeworm) and E. gran-\\nulosus (dog tapeworm). General symptoms are\\nvague abdominal discomfort, nausea, vomiting,\\ndiarrhea and weight loss.\\nThreadworm— Any long, thin nematode worm.\\nTrematode— Any parasitic flatworm of the class\\nTrematoda, as the liver fluke.\\nWhipworm— A nematode worm of the family\\nTrichuridae with a body that is thick at one end and\\nvery long and slender at the other end.\\nGALE ENCYCLOPEDIA OF MEDICINE 309\\nAntihelminthic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Risks\\nPeople with the following medical conditions may\\nhave adverse reactions to antihelminthic drugs. The\\nprescribing physician should accordingly be informed\\nif any of these conditions are present:\\n/C15Allergies. Anyone who has had adverse reactions to\\nantihelminthic drugs should inform the prescribing\\nphysician before taking the drugs again. The physi-\\ncian should also be informed about any other pre-\\nexisting allergies.\\n/C15Ulcers. Antihelminthic drugs are also contraindi-\\ncated for persons diagnosed with ulcers of the diges-\\ntive tract, especiallyulcerative colitis.\\n/C15Pregnancy. There is research evidence reporting that\\nsome antihelminthic drugs causebirth defectsor mis-\\ncarriage in animal studies. No human birth defects\\nhave been reported, but antihelminthic drugs are\\nusually not recommended for use during pregnancy.\\nPregnant women should accordingly inform the pre-\\nscribing physician.\\n/C15Breastfeeding. Some antihelminthic drugs can pass\\ninto breast milk. Breastfeeding may have to be dis-\\ncontinued until the antihelminthic treatment has\\nended and breastfeeding mothers must also inform\\nthe prescribing physician.\\n/C15Other risk conditions. Any of the following medical\\nconditions should also be reported to the prescribing\\nphysician: Crohn’s disease, liver disease, kidney dis-\\nease and worm cysts in the eyes.\\nCommon side effects of antihelminthic drugs\\ninclude dizziness, drowsiness,headache, sweating, dry-\\nness of the mouth and eyes, and ringing in the ears.\\nAnyone taking these drugs should accordingly avoid\\ndriving, operating machines or other activities that\\nmay be dangerous until they know how they are\\naffected by the drugs. Side effects usually wear off as\\nthe body adjusts to the drug and do not usually require\\nmedical treatment. Thiabendazole may cause the urine\\nto have an unusual odor that can last for a day after\\nthe last dose. Other side effects of antihelminthic\\ndrugs, such as loss of appetite,diarrhea, nausea, vomit-\\ning, or abdominal cramps are less common. If they\\noccur, they are usually mild and do not require med-\\nical attention.\\nMore serious side effects, such asfever, chills,\\nconfusion, extreme weakness, hallucinations, severe\\ndiarrhea, nausea or vomiting, skinrashes, low back\\npain, dark urine, blurred vision, seizures, andjaundice\\nhave been reported in some cases. The patient’s phy-\\nsician should be informed immediately if any should\\ndevelop. As a rule, anyone who has unusual symptoms\\nafter starting treatment with antihelminthic drugs\\nshould notify the prescribing physician.\\nAntihelminthic drugs may interact with each\\nother or with other drugs, whether prescribed or not.\\nFor example, it has been reported that use of the\\nantihelminthic drugs pyrantel and piperazine together\\nlowers the efficiency of pyrantel. Similarly, combining\\na given antihelminthic drug with another medication\\nmay increase the risk of side effects from either drug.\\nNancy Ross-Flanigan\\nAntihemorrhoid drugs\\nDefinition\\nAntihemorrhoid drugs are medicines that reduce\\nthe swelling and relieve the discomfort ofhemorrhoids\\n(swellings in the area around the anus).\\nPurpose\\nHemorrhoids are bulges in the veins that supply\\nblood to the skin and membranes of the area around\\nthe anus. They may form for various reasons.\\nFrequent heavy lifting, sitting for long periods, or\\nstraining to have bowel movements may putstress\\non anal tissues, which can lead to hemorrhoids.\\nSome women develop hemorrhoids duringpregnancy\\nas the expanding uterus puts pressure on the anal\\ntissues. The strain of labor and delivery can also\\ncause hemorrhoids or make existing hemorrhoids\\nworse. Hemorrhoids sometimes result from certain\\nmedical problems, such as tumors pressing on the\\nlower bowel.\\nThe main symptoms of hemorrhoids are bleeding\\nfrom the rectum, especially after a bowel movement,\\nand itching, burning,pain, and general discomfort in\\nthe anal area. Over-the-counter antihemorrhoid pro-\\nducts can relieve many of these symptoms. The pro-\\nducts contain combinations of four main types of\\ningredients:\\n/C15Local anesthetics, such as benzocaine, lidocaine and\\ntetracaine, to temporarily relieve the pain\\n/C15Vasoconstrictors, such as epinephrine base, epinephr-\\nine hydrochloride, ephedrine sulfate and phenylephr-\\nine hydrochloride that reduce swelling and relieve\\nitching and discomfort by tightening blood vessels\\n/C15Astringents (drying agents), such as witch hazel, cala-\\nmine, and zinc oxide. These help shrink hemorrhoids\\n310 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihemorrhoid drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='by pulling water out of the swollen tissue. This, in\\nturn, helps relieve itching, burning, and irritation.\\n/C15Protectants, such as cocoa butter, lanolin, glycerin,\\nmineral oil, and shark liver oil which soothe irritated\\ntissues and form a protective barrier to prevent\\nfurther irritation.\\nDescription\\nAntihemorrhoid drugs are available as creams,\\nointments and suppositories. Most can be bought\\nwithout a physician’s prescription.\\nRecommended dosage\\nFollow package instructions for using these pro-\\nducts. Do not use more than the recommended\\namount of this medicine every day. For explanations\\nor further information about how to use antihemor-\\nrhoid drugs, check with a physician or pharmacist.\\nPrecautions\\nDo not use antihemorrhoid drugs for more than\\nseven days in a row. If the problem gets worse or does\\nnot improve, check with a physician.\\nIf rectal bleeding continues, check with a physi-\\ncian. This could be a sign of a condition that needs\\nmedical attention.\\nSide effects\\nSide effects are rare, however, if a rash or any\\nother sign of an allergic reaction occurs, stop using\\nthe medicine.\\nInteractions\\nSome antihemorrhoid drugs should not be used\\nby people who are taking or have recently takenmono-\\namine oxidase inhibitors (MAO inhibitors), such as\\nphenelzine (Nardil) or tranylcypromine (Parnate),\\nused to treat conditions including depression and\\nParkinson’s disease. Anyone who is not sure if he or\\nshe has taken this type of drug should check with a\\nphysician or pharmacist before using an antihemor-\\nrhoid drug. People who are taking antidepressants or\\nmedicine for high blood pressure also should not use\\ncertain antihemorrhoid drugs. Check with a pharma-\\ncist for a list of drugs that may interact with specific\\nantihemorrhoid drugs.\\nNancy Ross-Flanigan\\nAntihistamines\\nDefinition\\nAntihistamines are drugs that block the action of\\nhistamine (a compound released in allergic inflamma-\\ntory reactions) at the H1 receptor sites, responsible for\\nimmediate hypersensitivity reactions such as sneezing\\nand itching. Members of this class of drugs may also be\\nused for their side effects, includingsedation and anti-\\nemesis (prevention ofnausea and vomiting).\\nPurpose\\nAntihistamines provide their primary action by\\nblocking histamine H1 at the receptor site. They have\\nno effect on rate of histamine release, nor do they\\ninactivate histamine. By inhibiting the activity of\\nhistamine, they can reduce capillary fragility, which\\nproduces the erythema, or redness, associated with\\nallergic reactions. They will also reduce histamine-\\ninduced secretions, including excessive tears and\\nsalivation. Additional effects vary with the indivi-\\ndual drug used. Several of the older drugs, called\\nfirst-generation antihistamines, bind non-selectively\\nto H1 receptors in the central nervous system as\\nwell as to peripheral receptors, and can produce\\nsedation, inhibition of nausea and vomiting,a n d\\nreduction ofmotion sickness. The second-generation\\nantihistamines bind only to peripheral H1 receptors,\\nand reduce allergic res ponse with little or no\\nsedation.\\nThe first-generation antihistamines may be\\ndivided into several chemical classes. The side effect\\nprofile, which also determines the uses of the drugs,\\nwill vary by chemical class. The alkylamines include\\nbrompheniramine (Dimetapp) and chlorpheniramine\\nKEY TERMS\\nAnus— The opening at the end of the intestine\\nthrough which solid waste (stool) passes as it leaves\\nthe body.\\nRectum— The end of the intestine closest to the\\nanus.\\nUterus— A hollow organ in a female in which a\\nfetus develops until birth.\\nGALE ENCYCLOPEDIA OF MEDICINE 311\\nAntihistamines'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(Chlor-Trimeton.) These agents cause relatively little\\nsedation, and are used primarily for treatment of aller-\\ngic reactions. Promethazine (Phenergan), in contrast,\\nis a phenothiazine, chemically related to the major\\ntranquilizers, and while it is used for treatment ofaller-\\ngies, may also be used as a sedative, the relieve anxiety\\nprior to surgery, as an anti-nauseant, and for control of\\nmotion sickness. Diphenhydramine (Benadryl) is che-\\nmically an ethanolamine, and in addition to its role in\\nreducing allergic reactions, may be used as a nighttime\\nsedative, for control of drug-induced Parkinsonism,\\nand, in liquid form, for control of coughs. Consult\\nmore detailed references for further information.\\nThe second generation antihistamines have no\\ncentral action, and are used only for treatment of\\nallergic reactions. These are divided into two chemical\\nclasses. Cetirizine (Zyrtec) is a piperazine derivative,\\nand has a slight sedative effect. Loratidine (Claritin)\\nand fexofenadine (Allegra) are members of the piper-\\nadine class and are essentially non-sedating.\\nRecommended dosage\\nDosage varies with drug, patient and intended\\nuse. Consult more detailed references for further\\ninformation.\\nWhen used for control of allergic reactions, anti-\\nhistamines should be taken on a regular schedule,\\nrather than on an as-needed basis, since they have no\\neffect on histamine itself, nor on histamine already\\nbound to the receptor site.\\nEfficacy is highly variable from patient to patient. If\\nan antihistamine fails to provide adequate relief, switch\\nto a drug from a different chemical class. Individual\\ndrugs may be effective in no more than 40% of patients,\\nand provide 50% relief of allergic symptoms.\\nSide effects\\nThe frequency and severity of adverse effects will\\nvary between drugs. Not all adverse reactions will\\napply to every member of this class.\\nCentral nervous system reactions include drowsiness,\\nsedation, dizziness, faintness, disturbed coordination, las-\\nsitude,confusion,restlessness,excitation,tremor,seizures,\\nheadache,insomnia, euphoria, blurred vision,hallucina-\\ntions, disorientation, disturbingdreams/nightmares, schi-\\nzophrenic-like reactions, weakness, vertigo,hysteria,\\nnerve pain, and convulsions. Overdoses may cause invo-\\nluntary movements. Other problems have been reported.\\nGastrointestinal problems include increased\\nappetite, decreased appetite, nausea, vomiting,diar-\\nrhea, andconstipation.\\nHematologic reactions are rare, but may be\\nsevere. These include anemia, or breakdown of red\\nANTIHISTAMINES\\nBrand Name (Generic Name)\\nPossible Common Side Effects\\nInclude:\\n*Atarax (hydroxyzine\\nhydrochloride)\\nDrowsiness, dry mouth\\nBenadryl (diphenhydramine\\nhydrochloride)\\nDizziness, sleepiness, upset stomach,\\ndecreased coordination\\nHismanal (astemiozole) Drowsiness, dry mouth, fatigue, weight\\ngain\\nPBZ-SR (tripelennamine\\nhydrochloride)\\nDizziness, drowsiness, dry mouth and\\nthroat, chest congestion, decreased\\ncoordination, upset stomach\\nPeriactin (cyproheptadine\\nhydrochloride)\\nChest congestion, dizziness, fluttery\\nheartbeat, loss of appetite, hives, slee-\\npiness, vision problems\\nPhenergan (promethazine\\nhydrochloride)\\nChanges in blood pressure, dizziness,\\nblurred vision, nausea, rash\\nPolaramine (dexchlorphenira-\\nmine maleate)\\nDrowiness\\nSeldane, Seldane-D\\n(terfenadine)\\nUpset stomach, nausea, drowiness,\\nheadache, fatigue\\nTavist (clemastine fumarate) Decreased coordination, dizziness,\\nupset stomach\\nTrinalin Repetabs (azatadine\\nmaleate, pseudoephedrine\\nsulfate)\\nAbdominal cramps, chest pain, dry\\nmouth, headache\\n*Also used in the treatment of\\nanxiety\\nD A N I E L E B O V E T (1907–1992)\\nA gifted researcher in therapeutic chemistry,\\nDaniele Bovet was born in Neuchatel, Switzerland, one\\nof four children of a professor of experimental education.\\nBovet studied zoology and comparative anatomy at the\\nUniversity of Geneva, receiving his doctor of science\\ndegree in 1929. He then joined the Pasteur Institute in\\nParis, becoming director of the Laboratory of Therapeutic\\nChemistry in 1936.\\nBovet investigated histamine, thought to cause\\nallergy symptoms. No antagonist of histamine was\\nknown, so Bovet—with his research student Anne-Marie\\nStaub—began studying substances that blocked hormones\\nsimilar to histamine. By 1937 he had produced the first\\nantihistamine, thymoxydiethylamine. Since this substance\\nwas too toxic for human use, Bovet and Staub performed\\nthousands more experiments seeking less toxic antihista-\\nmines. This work formed the basis for the development of\\nsubsequent clinically useful antihistamines.\\n312\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAntihistamines'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='blood cells; reduced platelets; reduced white cells; and\\nbone marrow failure.\\nA large number of additional reactions have been\\nreported. Not all apply to every drug, and some reac-\\ntions may not be drug related. Some of the other adverse\\neffects are chest tightness;wheezing; nasal stuffiness; dry\\nmouth, nose and throat;sore throat; respiratory depres-\\nsion; sneezing; and a burning sensation in the nose.\\nWhen taking antihistamines during pregnancy,\\nChlorpheniramine (Chlor-Trimeton), dexchlorphenir-\\namine (Polaramine), diphenhydramine (Benadryl),\\nbrompheniramine (Dimetapp), cetirizine (Zyrtec),\\ncyproheptadine (Periactin), clemastine (Tavist), azata-\\ndine (Optimine), loratadine (Claritin) are all listed\\nas category B. Azelastine (Astelin), hydroxyzine\\n(Atarax), promethazine (Phenergan) are category C.\\nRegardless of chemical class of the drug, it is\\nrecommended that mothers not breast feed while\\ntaking antihistamines.\\nContraindications\\nThe following are absolute or relative contraindi-\\ncations to use of antihistamines. The significance of\\nthe contraindication will vary with the drug and dose.\\n/C15glaucoma\\n/C15hyperthyroidism (overactive thyroid)\\n/C15high blood pressure\\n/C15enlarged prostate\\n/C15heart disease\\n/C15ulcers or other stomach problems\\n/C15stomach or intestinal blockage\\n/C15liver disease\\n/C15kidney disease\\n/C15bladder obstruction\\n/C15diabetes\\nInteractions\\nMonoamine oxidase inhibitor antidepressants\\n(phenelzine [Nardil], tranylcypromine [Parnate]) may\\nprolong and increase the effects of some antihista-\\nmines. When used with promethazine (Phenergan)\\nthis may cause reduced blood pressure and involun-\\ntary movements.\\nResources\\nORGANIZATIONS\\nAllergy and Asthma Network. 3554 Chain Bridge Road,\\nSuite 200. (800) 878-4403.\\nAmerican Academy of Allergy, Asthma, and Immunology.\\n611 East Wells St, Milwaukee, WI 53202. (800) 822-\\n2762. .\\nAsthma and Allergy Foundation of America. 1125 15th\\nStreet NW, Suite 502, Washington, DC 20005.\\n(800)727-8462.\\nSamuel D. Uretsky, PharmD\\nAntihyperlipidemic drugs see Cholesterol-\\nreducing drugs\\nAntihypertensive drugs\\nDefinition\\nAntihypertensive drugs are medicines that help\\nlower blood pressure.\\nPurpose\\nThe overall class of antihypertensive agents lowers\\nblood pressure, although the mechanisms of action vary\\ngreatly. In 2003, a Joint National Committee on\\nKEY TERMS\\nAllergen— A substance that causes an allergy.\\nAnaphylaxis— A sudden, life-threatening allergic\\nreaction.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHistamine— A chemical released from cells in the\\nimmune system as part of an allergic reaction.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nGALE ENCYCLOPEDIA OF MEDICINE 313\\nAntihypertensive drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prevention, Detection, Evaluation, and Treatment of\\nHigh Blood Pressure report said that recent clinical trials\\nshow that antihypertensive treatment can reduce inci-\\ndence of stroke by 35-40%,heart attack by 20-25%,\\nand onset of newheart failureby 50%. Within this ther-\\napeutic class, there are several subgroups of drugs. There\\nare a large number of drugs used to controlhypertension,\\nand the drugs listed below are representative, but not the\\nonly members of their classes.\\nThe calcium channel blocking agents, also called\\nslow channel blockers or calcium antagonists, inhibit\\nthe movement of ionic calcium acrossthe cell membrane.\\nThis reduces the force of contraction of muscles of the\\nheart and arteries. Although thecalcium channel blockers\\nare treated as a group, there are four different chemical\\nclasses, leading to significant variations in the activity of\\nindividual drugs. Nifedipine (Adalat, Procardia) has the\\ngreatest effect on the blood vessels, while verapamil\\n(Calan, Isoptin) and diltiazem (Cardizem) have a greater\\neffect on the heart muscle itself.\\nPeripheral vasodilators such as hydralazine\\n(Apresoline), isoxuprine (Vasodilan), and minoxidil\\n(Loniten) act by relaxing blood vessels.\\nThere are several groups of drugs that act by\\nreducing adrenergic nerve stimulation, the excitatory\\nnerve stimulation that causes contraction of the mus-\\ncles in the arteries, veins, and heart. These drugs\\ninclude the beta-adrenergic blockers and alpha/beta\\nadrenergic blockers. There are also non-specific adre-\\nnergic blocking agents.\\nBeta-adrenergic blocking agents include propra-\\nnolol (Inderal), atenolol (Tenormin), and pindolol\\n(Visken). Propranolol acts on the beta-adrenergic\\nreceptors anywhere in the body, and has been used as\\na treatment for emotional anxiety and rapid heart\\nAntihypertensive Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nAccupril (quinapril\\nhydrochloride)\\nHeadache, dizziness\\nAldatazide Diarrhea, fever, headache, decreased\\ncoordination\\nAldactone\\n(spironolactone)\\nCramps, drowsiness, stomach disorders\\nAldomet (methyldopa) Fluid retention, headache, weak feeling\\nAltace (ramipril) Headache, cough\\nCalan, Calan SR (vera-\\npamil hydrochloride)\\nConstipation, fatigue, decreased blood\\npressure\\nCapoten (captopril) Decreased sense of taste, decreased blood\\npressure tiching, rash\\nCardene (nicardipine\\nHydrochloride)\\nDizziness, headache, indigestion and nausea,\\nincreased heartbeat\\nCardizem (diltiazem\\nhydrochloride)\\nDizziness, fluid retention, headache, nausea,\\nskin rash\\nCardura (doxazosin\\nmesylate)\\nDizziness, fatigue, drowsiness, headache\\nCatapres Dry mouth, drowsiness, dizziness, constipation\\nCorgard (nadolol) Behaviorial changes, dizziness, decreased\\nheartbeat, tiredness\\nCorzide Dizziness, decreased heartbeat, fatigue, cold\\nhands and feet\\nDiuril (chlorothiazide) Cramps, constipation or diarrhea, dizziness,\\nfever, increased glocose level in urine\\nDyazide Blurred vision, muscle and abdominal pain,\\nfatigue\\nDynaCirc (isradipine) Chest pain, fluid retention, headache, fatigue\\nHydroDIURIL\\n(hydrochlorothiazide)\\nUpset stomach, headache, cramps, loss of\\nappetite\\nHygroton\\n(chlorthalidone)\\nAnemia, constipation or diarrhea, cramps,\\nitching\\nHytrin (terazosin\\nhydrochloride)\\nDizziness, labored breathing, nausea, swelling\\nInderal (propranolol\\nhydrochloride)\\nConstipation or diarrhea, tingling sensation,\\nnausea and vomiting\\nInderide Blurred vision, cramps, fatigue, loss of appetite\\nLasix (furosemide) Back and muscle pain, indigestion, nausea\\nLopressor (metoprolol\\ntartrate)\\nDiarrhea, itching/rash, tiredness\\nLotensin (benazepril\\nhydrochloride)\\nNausea, dizziness, fatigue, headache\\nAlozol (indapamide) Anxiety, headache, loss of energy, muscle\\ncramps\\nMaxzide Cramps, labored breathing, drowsiness,\\nirritated stomach\\nMinipress (prazosin\\nhdrochloride)\\nHeadache, nausea, weakness, dizziness\\nModuretic Diarrhea, fatigue, itching, loss of appetite\\nMonopril (fosinopril\\nsodium)\\nNausea and vomiting, headache, cough\\nNormodyne (labetalol\\nhydrochloride)\\nFatigue, nausea, stuffy nose\\nPlendil (felodipine) Pain in back, chest, muscles, joints, and\\nabdomen, itching, dry mouth, respiratory\\nproblems\\nProcardia, Procardia X\\n(nifedipine)\\nSwelling, constipation, decreased blood\\npressure, nausea, fatigue\\nSectral (acebutolol\\nhydrochloride)\\nConstipation or diarrhea, gas, chest and joint\\npain\\nSer-Ap-Es Blurred vision, cramps, muscle pain, dizziness\\nTenex (guanfacine\\nhydrochloride)\\nHeadache, constipation, dry mouth, weakness\\nTenoretic Decreased heartbeat, fatigue, nausea\\nTenormin (atenolol) Nausea, fatigue, dizziness\\nVeseretic Diarrhea, muscle cramps, rash\\nAntihypertensive Drugs (continued)\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nVasotec (enalapril\\nmaleate)\\nChest pain, blurred vision, constipation or diar-\\nrhea, hives, nausea\\nVisken (pindolol) Muscle cramps, labored breathing, nausea, fluid\\nretention\\nWytensin (guanabenz\\nacetate)\\nHeadache, drowsiness, dizziness\\nZaroxolyn (metolazone) Constipation or diarrhea, chest pain, spasms,\\nnausea\\nZestoretic (lisinopril\\nhydrochlorothiazide)\\nFatigue, headache, dizziness\\nZestril (lisinopril) Labored breathing, abdominal and chest pain,\\nnausea, decreased blood pressure\\n314 GALE ENCYCLOPEDIA OF MEDICINE\\nAntihypertensive drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='beat. Atenolol and acebutolol (Sectral) act specifically\\non the nerves of the heart and circulation.\\nThere are two alpha/beta adrenergic blockers,\\nlabetolol (Normodyne, Trandate) and carvedilol\\n(Coreg). These work similarly to thebeta blockers.\\nThe ACE II inhibitors, losartan (Cozaar), cande-\\nsartan (Atacand), irbesartan (Avapro), telmisartan\\n(Micardis), valsartan (Diovan) and eprosartan\\n(Teveten) directly inhibit the effects of ACE II rather\\nthan blocking its production. Their actions are similar\\nto the ACE inhibitors, but they appear to have a more\\nfavorable side effect and safety profile.\\nIn addition to these drugs, other classes of drugs\\nhave been used to lower blood pressure, most\\nnotably the thiazidediuretics. There are 12 thiazide\\ndiuretics marketed in the United States, including\\nhydrochlorothiazide (Hydrodiuril, Esidrex), indapa-\\nmide (Lozol), polythiazide (Renese), and hydroflu-\\nmethiazide (Diucardin). The drugs in this class\\nappear to lower blood pressure through several\\nmechanisms. By promoting sodium loss they lower\\nblood volume. At the same time, the pressure of the\\nwalls of blood vessels, the peripheral vascular resis-\\ntance, is lowered. Thiazide diuretics are commonly\\nused as the first choice for reduction of mild hyper-\\ntension, and may be used in combination with other\\nantihypertensive drugs.\\nDebate continued in 2003 as to the best drugs to\\nlower blood pressure. One study seemed to prove\\nthat diuretics were the best initial choice, but a\\nstudy from Australia said that ACE inhibitors\\nwere a superior choice. However, many physicians\\nagreed that the best treatment for a particular\\npatient depends on his or her particular age, eco-\\nnomic situation, genetic factors and other existing\\nillnesses and conditions.\\nWhile designed to lower cholesterol rather than\\nblood pressure, a large clinical trial reported in 2003\\nthat people with high blood pressure may one day\\nbenefit from taking them. In the trial, participants\\nwith increased risk for heart disease, even if it was not\\nfrom high cholesterol, benefited from taking statins.\\nRecommended dosage\\nRecommended dosage varies with patient, drug,\\nseverity of hypertension, and whether the drug is being\\nused alone or in combination with other drugs.\\nSpecialized references can be consulted for further\\ninformation.\\nPrecautions\\nBecause of the large number of classes and indivi-\\ndual drugs in this group, specialized references offer\\nmore complete information.\\nPeripheral vasodilators may causedizziness and\\northostatic hypotension—a rapid lowering of blood\\npressure when the patient stands up in the morning.\\nPatients taking these drugs must be instructed to rise\\nfrom bed slowly.Pregnancy risk factors for this group\\nare generally category C. Hydralazine has been shown to\\ncausecleft palatein animal studies, but there is no human\\ndata available. Breastfeeding is not recommended.\\nACE inhibitors generally are well tolerated, but\\nrarely may cause dangerous reactions including laryn-\\ngospasm and angioedema. Persistent cough is a\\nKEY TERMS\\nAdrenergic— Activated by adrenalin (norepinephr-\\nine), loosely applied to the sympathetic nervous\\nsystem responses.\\nAngioedema— An allergic skin disease character-\\nized by patches of confined swelling involving the\\nskin the layers beneath the skin, the mucous mem-\\nbranes, and sometimes the viscera—called also\\nangioneurotic edema, giant urticaria, Quincke’s\\ndisease, or Quincke’s edema.\\nArteries— Blood vessels that carry blood away from\\nthe heart to the cells, tissues, and organs of the body.\\nLaryngospasm — Spasmodic closure of the larynx.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies;\\nor adverse effects in animals, but not in well--\\ncontrolled human studies. Category C: No adequate\\nhuman or animal studies; or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nSympathetic nervous system— The part of the auto-\\nnomic nervous system that is concerned especially\\nwith preparing the body to react to situations of\\nstress or emergency; it contains chiefly adrenergic\\nfibers and tends to depress secretion, decrease the\\ntone and contractility of smooth muscle, and\\nincrease heart rate.\\nGALE ENCYCLOPEDIA OF MEDICINE 315\\nAntihypertensive drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='common side effect. ACE inhibitors should not be\\nused in pregnancy. When used in pregnancy during\\nthe second and third trimesters, angiotension-convert-\\ning inhibitors (ACEIs) can cause injury to and even\\ndeath in the developing fetus. When pregnancy is\\ndetected, discontinue the ACE inhibitor as soon as\\npossible. Breastfeeding is not recommended.\\nACE II inhibitors are generally well tolerated and\\ndo not cause cough. Pregnancy risk factor is category C\\nduring the first trimester and category D during the\\nsecond and third trimesters. Drugs that act directly on\\nthe renin-angiotensin system can cause fetal and\\nneonatal morbidity and death when administered to\\npregnant women. Several dozen cases have been\\nreported in patients who were taking ACE inhibitors.\\nWhen pregnancy is detected, AIIRAs should be dis-\\ncontinued as soon as possible. Breastfeeding is not\\nrecommended.\\nThiazide diuretics commonly cause potassium\\ndepletion. Patients should have potassium supplemen-\\ntation either through diet or potassium supplements.\\nPregnancy risk factor is category B (chlorothiazide,\\nchlorthalidone, hydrochlorothiazide, indapamide,\\nmetolazone) or category C (bendroflume-\\nthiazide, benzthiazide, hydroflumethiazide, methy-\\nclothiazide, trichlormethiazide). Routine use during\\nnormal pregnancy is inappropriate. Thiazides are\\nfound in breast milk. Breastfeeding is not recommended.\\nBeta blockers may cause a large number of adverse\\nreactions including dangerous heart rate abnormalities.\\nPregnancy risk factor is category B (acebutolol, pindo-\\nlol, sotalol) or category C (atenolol, labetalol, esmolol,\\nmetoprolol, nadolol, timolol, propranolol, penbutolol,\\ncarteolol, bisoprolol). Breastfeeding is not recom-\\nmended. In 2003, a report announced that adavances in\\npharmacogenetics mean that in the future, physicians\\nmay be able to use a patients genetic information to\\nmake certain prescribing decisions for antihypertensives.\\nInteractions\\nSpecific drug references should be consulted, since\\ninteractions vary for antihypertensive drugs.\\nResources\\nPERIODICALS\\nBelden, Heidi. ‘‘Debate Continues Over Best Drug for\\nHypertension.’’ Drug Topics (April 21, 2003): 32.\\nMechcatie, Elizabeth. ‘‘Genetics Will Guide Prescribing for\\nHypertension: Genotype Predicts Response to Drug.’’\\nInternal Medicine News(July 1, 2003): 48-51.\\n‘‘New Hypertension Guidelines: JNC-7.’’Clinical\\nCardiology Alert (July 2003): 54-63.\\n‘‘Studies Show Thata´ Statins Benefits People With High\\nBlood Pressure.’’ Harvard Health Letter(June 2003).\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAnti-hyperuricemic drugs\\nDefinition\\nAnti-hyperuricemic drugs are used to treat hyper-\\nuricemia, the state of having too much uric acid in the\\nblood.\\nPurpose\\nAnti-hyperuricemic drugs decrease the levels\\nof uric acid in the blood, either by increasing\\nthe rate at which uric acid is excreted in the\\nurine, or by preventing the formation of excess\\nuric acid.\\nPrecautions\\nBefore taking any medication, patients should\\nnotify their physician of all other medications that\\nthey are currently taking. Patients should also notify\\ntheir physician of any health problems they are cur-\\nrently experiencing. Patients must notify physicians if\\nthey have kidney problems, since this might affect the\\ntype of drug administered. Patients must also notify\\ntheir physician if they are allergic to any of the medi-\\ncations used to treat acute or long-termgout. Since all\\nof these factors contribute to the disease, patients\\nsuffering from gout should attempt to lose weight,\\navoid excess alcohol consumption, and avoid foods\\nhigh in purines, such as asparagus, sardines, lobster,\\navocado, and peas.\\nDescription\\nGout and hyperuricemia\\nPersons with high levels of uric acid (hyperurice-\\nmia) may experience gout. Commonly gout occurs in\\nmales in their 40s and 50s. Gout is defined by the\\nattacks of (arthritic) painful, reddened joints, and is\\noften accompanied by hard lumps in the painful joints.\\nThe most common joint affected is the big toe.Kidney\\nstones, and/or poor kidney function may also be asso-\\nciated with hyperuricemia, but may not be considered\\ngout if the patient does not have painful joints. In\\npersons with gout (and associated symptoms), uric\\n316 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-hyperuricemic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='acid forms crystals, which then cause the aforemen-\\ntioned symptoms. Although uric acid levels must be\\nhigh in order for patients to have crystals form, and\\ntherefore have gout, most persons with high uric acid\\nlevels don’t ever have symptoms. Thus, recent criteria\\nfor use of anti-hyperuricemic agents suggest that\\npatients who have never experienced symptoms of\\ngout should not receive drug therapy, unless their\\nhyperuricemia is associated withcancer (may lead to\\nkidney damage) or certain rare genetic disorders\\n(McGill, Rheumatologist, University of Sydney,\\nAustralia, 2000).\\nAcute gout attacks\\nWhen patients experience acute attacks of\\ngout, drugs that lower the levels of uric acid can\\ncause an acute gout attack or cause an attack to\\nbecome more severe. Thus, drugs that lower uric\\nacid levels and are used to treat gout in the long\\nterm are not used in the short term. Medications\\nused in acute gout attacks include non-steroidal\\nanti-inflammatory drugs (such as indomethacin),\\ncolchicine, and corticosteroids . Colchicine causes\\nside effects in a large number of individuals\\n(usually diarhhea). The most important factor in\\nthe effective treatment of gout may not be the drug\\nused, but how quickly it is administered after an\\nacute attack has begun.\\nLong-term treatment\\nLong-term treatment of gout or hyperuricemia\\nusually involves one of four drugs: allopurinol,\\nprobenicid, sulphinpyrazone, or benzbromarone\\n(as of 2001, benzbromarone was not available for\\nuse in the United States). While allopurinol\\ndecreases the amount of uric acid that is produced\\n(and may help prevent acute attacks of gout), the\\nother drugs all increase the rate at which uric acid\\nis excreted in the urine. As previously mentioned,\\nlowering the concentration of uric acid can cause\\ngout attacks. Thus, patients taking these medica-\\ntions should have the dose slowly increased (and\\nuric acid levels slowly lowered) to prevent acute\\nattacks of gout. Patients may also be treated with\\ncolchicine or non-steroi dal anti-inflammatory\\ndrugs to prevent acute attacks of gout (corticoster-\\noids are not used in this scenario because over the\\nlong term corticosteroids have deleterious side\\neffects). In 2004, the FDA was seeking trial data\\non a new drug called oxypurinol (Oxyprim) for\\ntreating chronic gout. These medications may\\nhave to be taken for life to prevent further gout\\nattacks.\\nResources\\nPERIODICALS\\nCoghill, Kim. ‘‘FDA Panel Discusses Endpoints for Approval\\nof Gout Products.’’Bioworld TodayJune 3, 2004.\\nMichael V Zuck, PhD\\nTeresa G. Odle\\nAnti-insomnia drugs\\nDefinition\\nAnti-insomnia drugs are medicines that help\\npeople fall asleep or stay asleep.\\nPurpose\\nPhysicians prescribe anti-insomnia drugs for short-\\nterm treatment of insomnia—a sleep problem in which\\npeople have trouble falling asleep or staying asleep or\\nwake up too earlyand can’t go back to sleep. These drugs\\nshould be used only for occasional treatment of tempor-\\narysleepproblemsandshouldnotbetakenformorethan\\na week or two at a time. People whose sleep problems last\\nlonger than this should see a physician. Their sleep pro-\\nblems could be a sign of another medical problem.\\nDescription\\nThe anti-insomnia drug described here, zolpidem\\n(Ambien), is a classified as a central nervous system\\n(CNS) depressant. CNS depressants are medicines\\nthat slow the nervous system. Physicians also prescribe\\nmedicines in the benzodiazepine family, such as flura-\\nzepam (Dalmane), quazepam (Doral), triazolam\\n(Halcion), estazolam (ProSom), and temazepam\\n(Restoril), for insomnia. Benzodiazepine drugs are\\ndescribed in the essay onantianxiety drugs. Zaleplon\\n(Sonata) is another anti-insomnia drug that is not\\nrelated to other drugs with the same effect. Thebarbi-\\nturates, such as pentobarbital (Nembutal) and secobar-\\nbital (Seconal) are no longer commonly used to treat\\ninsomnia because they are too dangerous if they are\\ntaken in overdoses. For patients with mild insomnia,\\nsome antihistamines, such as diphenhydramine\\n(Benadryl) or hydroxyzine (Atarax) may be used,\\nsince these also cause sleepiness.\\nZolpidem is available only with a physician’s\\nprescription and comes in tablet form.\\nGALE ENCYCLOPEDIA OF MEDICINE 317\\nAnti-insomnia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nThe recommended dose for adults is 5-10 mg just\\nbefore bedtime. The medicine works quickly, often\\nwithin 20 minutes, so it should be taken right before\\ngoing to bed.\\nFor older people and others who may be more\\nsensitive to the drug’s effects, the recommended start-\\ning dosage is 5 mg just before bedtime.\\nZolpidem may be taken with food or on an\\nempty stomach, but it may work faster when taken\\non an empty stomach. Check with a physician or\\npharmacists for instructions on how to take the\\nmedicine.\\nPrecautions\\nZolpidem is meant only for short-term treatment\\nof insomnia. If sleep problems last more than seven to\\n10 days, check with a physician. Longer-lasting sleep\\nproblems could be a sign of another medical problem.\\nAlso, this drug may lose its effectiveness when taken\\nevery night for more than a few weeks.\\nSome people feel drowsy, dizzy, confused, light-\\nheaded, or less alert the morning after they have taken\\nzolpidem. The medicine may also cause clumsiness,\\nunsteadiness, double vision, or other vision problems\\nthe next day. For these reasons, anyone who takes\\nthese drugs should not drive, use machines or do any-\\nthing else that might be dangerous until they have\\nfound out how zolpidem affects them.\\nThis medicine has caused cause behavior changes\\nin some people, similar to those seen in people whose\\nbehavior changes when they drink alcohol. Examples\\ninclude giddiness and rage. More extreme changes,\\nsuch as confusion, agitation, andhallucinations, also\\nare possible. Anyone who starts having strange or\\nunusual thoughts or behavior while taking this medi-\\ncine should get in touch with his or her physician.\\nZolpidem and other sleep medicines may cause a\\nspecial type of temporary memory loss, in which the\\nperson does not remember what happens between the\\ntime they take the medicine and the time its effects\\nwear off. This is usually not a problem, because people\\ngo to sleep right after taking the medicine and stay\\nasleep until its effects wear off. But it could be a\\nproblem for anyone who has to wake up before getting\\na full night’s sleep (seven to eight hours). In particular,\\ntravelers should not take this medicine on airplane\\nflights of less than seven to eight hours.\\nBecause zolpidem works work on the central\\nnervous system, it may add to the effects of alcohol\\nand other drugs that slow down the central nervous\\nsystem, such as antihistamines, cold medicine,\\nallergy medicine, medicine for seizures, tranquili-\\nzers, some pain relievers, and muscle relaxants .\\nZolpidem may also add to the effects of anesthetics,\\nincluding those used for dental procedures. The\\ncombined effects of zolpidem and alcohol or other\\nCNS depressants (drugs that slow the central ner-\\nvous system) can be very dangerous, leading to\\nunconsciousness or even death. People who take\\nzolpidem should not drink alcohol and should\\ncheck with their physicians before taking any other\\nCNS depressant. Anyone who shows signs of an\\noverdose or of the effects of combining zolpidem\\ndrugs with alcohol or other drugs should have\\nimmediate emergency help. Warning signs include\\nKEY TERMS\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBronchitis— Inflammation of the air passages of the\\nlungs.\\nEmphysema— A lung disease in which breathing\\nbecomes difficult.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nSleep apnea— A condition in which a person tem-\\nporarily stops breathing during sleep.\\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.\\nAnti-Insomnia Drugs\\nBrand Name (Generic\\nName)\\nPossible Common Side Effects Include:\\nAmbien (zolpidem tartrate) Daytime drowsiness, dizziness, headache\\nDalmane (flurazepam\\nhydrochloride)\\nDecreased coordination, lightheadedness,\\ndizziness\\nDoral (quazepam) Daytime drowsiness, headache, dry mouth,\\nfatigue\\nHalcion (triazolam) Decreased coordination, chest pain, mem-\\nory impairment\\nProSom (estazolam) Dizziness, headache, nausea, weakness\\nRestoril (temazepam) Dizziness, fatigue, nausea, headache,\\nsluggishness\\n318 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-insomnia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='severe drowsiness, severenausea or vomiting,b r e a t h -\\ning problems, and staggering.\\nAnyone who takes zolpidem for more than 1–2\\nweeks should not stop taking it without first checking\\nwith a physician. Stopping the drug abruptly may\\ncause rebound insomnia; increased difficulty falling\\nasleep for the first one of two nights after the drug\\nhas been discontinued. In rare cases, withdrawal\\nsymptoms, such as vomiting, cramps, and unpleasant\\nfeelings may occur. Gradual tapering may be\\nnecessary.\\nOlder people may be more sensitive to the effects\\nof zolpidem. This may increase the chance of side\\neffects, such as confusion, and may also increase the\\nrisk of falling.\\nIn people with breathing problems, zolpidem may\\nworsen the symptoms.\\nSpecial conditions\\nPeople with certain other medical conditions or\\nwho are taking certain other medicines can have pro-\\nblems if they take zolpidem. Before taking this medi-\\ncine, be sure to let the physician know about any of\\nthese conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to zolpidem in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Women who are pregnant or who\\nmay become pregnant should check with their physi-\\ncians about the safety of using zolpidem during\\npregnancy.\\nBREASTFEEDING. Women who are breastfeeding\\nshould check with their physicians before using\\nzolpidem.\\nOTHER MEDICAL CONDITIONS. Before using zolpi-\\ndem, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15Chronic lung diseases ( emphysema, asthma,o r\\nchronic bronchitis)\\n/C15Liver disease\\n/C15Kidney disease\\n/C15Current or past alcohol or drug abuse\\n/C15Depression\\n/C15Sleep apnea\\nUSE OF CERTAIN MEDICINES. Taking zolpidem with\\ncertain other drugs may affect the way the drugs work\\nor may increase the chance of side effects.\\nSide effects\\nThe most common minor side effects are daytime\\ndrowsiness or a ‘‘drugged’’ feeling, vision problems,\\nmemory problems, nightmares or unusual dreams,\\nvomiting, nausea, abdominal or stomach pain,diar-\\nrhea, dry mouth, headache, and general feeling of dis-\\ncomfort or illness. These problems usually go away as\\nthe body adjusts to the drug and do not require med-\\nical treatment.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15Confusion\\n/C15Depression\\n/C15Clumsiness or unsteadiness\\nPatients who take zolpidem may notice side\\neffects for several weeks after they stop taking the\\ndrug. They should check with their physicians if\\nthese or other troublesome symptoms occur:\\n/C15Agitation, nervousness, feelings of panic\\n/C15Uncontrolled crying\\n/C15Worsening of mental or emotional problems\\n/C15Seizures\\n/C15Tremors\\n/C15Lightheadedness\\n/C15Sweating\\n/C15Flushing\\n/C15Nausea or abdominal or stomach cramps\\n/C15Muscle cramps\\n/C15Unusual tiredness or weakness\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking zolpidem should\\nget in touch with his or her physician.\\nInteractions\\nZolpidem may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Anyone who takes zolpidem should let the\\nphysician know all other medicines he or she is\\nGALE ENCYCLOPEDIA OF MEDICINE 319\\nAnti-insomnia drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='taking. Among the drugs that may interact with zol-\\npidem are:\\n/C15Other central nervous system (CNS) depressants\\nsuch as medicine for allergies, colds, hayfever, and\\nasthma; sedatives; tranquilizers; prescription pain\\nmedicine; muscle relaxants; medicine for seizures;\\nbarbiturates; and anesthetics.\\n/C15The major tranquilizer chlorpromazine (Thorazine).\\n/C15Tricyclic antidepressants such as imipramine\\n(Tofranil) and amitriptyline (Elavil).\\nNancy Ross-Flanigan\\nAnti-itch drugs\\nDefinition\\nAnti-itch drugs are medicines taken by mouth or\\nby injection to relieveitching.\\nPurpose\\nThe medicine described here, hydroxyzine, is a\\ntype of antihistamine used to relieve itching caused\\nby allergic reactions. An allergic reaction occurs\\nwhen the body is unusually sensitive to some sub-\\nstance, such as pollen, dust, mold, or certain foods or\\nmedicine. The body reacts by releasing a chemical\\ncalled histamine that causes itching and other symp-\\ntoms, such as sneezing and watery eyes.Antihistamines\\nreduce the symptoms by blocking the effects of\\nhistamine.\\nHydroxyzine is also prescribed foranxiety and to\\nhelp people relax before or after having general\\nanesthesia.\\nDescription\\nAnti-itch drugs, also called antipruritic drugs, are\\navailable only with a physician’s prescription and\\ncome in tablet and injectable forms. Some commonly\\nused brands of the anti-itch drug hydroxyzine are\\nAtarax and Vistaril.\\nRecommended dosage\\nWhen prescribed for itching, the usual dosage for\\nadults is 25 mg, three to four times a day. For children\\nover six years of age, the usual dosage 50-100 mg per\\nday, divided into several small doses. The usual dosage\\nfor children under six years of age is 50 mg per day,\\ndivided into several small doses.\\nThe dosage may be different for different people.\\nCheck with the physician who prescribed the drug\\nor the pharmacist who filled the prescription for the\\ncorrect dosage, and take the medicine exactly as\\ndirected.\\nPrecautions\\nThis medicine should not be used for more than\\nfour months at a time because its effects can wear off.\\nSee a physician regularly while taking the medicine to\\ndetermine whether it is still needed.\\nHydroxyzine may add to the effects of alcohol and\\nother drugs that slow down the central nervous sys-\\ntem, such as other antihistamines, cold medicine,\\nallergy medicine, sleep aids, medicine for seizures,\\ntranquilizers, some pain relievers, and muscle relax-\\nants. Anyone taking hydroxyzine should not drink\\nalcohol and should check with his or her physician\\nbefore taking any of the above.\\nSome people feel drowsy or less alert when using\\nthis medicine. Anyone who takes it should not drive,\\nuse machines, or do anything else that might be\\ndangerous until they have found out how the drugs\\naffect them.\\nAnyone who has had unusual reactions to hydro-\\nxyzine in the past should let his or her physician know\\nbefore taking the medicine again. The physician\\nshould also be told about any allergies to foods,\\ndyes, preservatives, or other substances.\\nA woman who is pregnant or who may become\\npregnant should check with her physician before tak-\\ning this medicine. In studies of laboratory animals,\\nhydroxyzine has causedbirth defectswhen taken du-\\nring pregnancy. Although the drug’s effects on preg-\\nnant women have not been fully studied, physicians\\nadvise against taking it in early pregnancy.\\nKEY TERMS\\nAnesthesia— Treatment with medicine that causes\\na loss of feeling, especially pain. Local anesthesia\\nnumbs only part of the body; general anesthesia\\ncauses loss of consciousness.\\nAntihistamine— Medicine that prevents or relieves\\nallergy symptoms.\\n320 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-itch drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='BREASTFEEDING. Women who are breastfeeding\\nshould also check with their physicians before using\\nhydroxyzine. The medicine may pass into breast milk\\nand may cause problems in nursing babies whose\\nmothers take it.\\nSide effects\\nThe most common side effect, drowsiness, usually\\ngoes away as the body adjusts to the drug. If it does\\nnot, reducing the dosage may be necessary. Other side\\neffects, such asdry mouth, also may occur and do not\\nneed medical attention unless they continue.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15Twitches ortremors\\n/C15Convulsions (seizures).\\nInteractions\\nHydroxyzine may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Anyone who takes hydroxyzine should let the\\nphysician know all other medicines he or she is taking.\\nAmong the drugs that may interact with hydroxyzine are:\\n/C15Barbiturates such as phenobarbital and secobarbital\\n(Seconal)\\n/C15Opioid (narcotic) pain medicines such as meperidine\\n(Demerol) and oxycodone (Percocet)\\n/C15Non-narcotic pain medicines such asacetaminophen\\n(Tylenol) and ibuprofen (Motrin, Advil).\\nThe list above may not include every drug that\\ninteracts with hydroxyzine. Be sure to check with a\\nphysician or pharmacist before combining hydroxy-\\nzine with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntimalarial drugs\\nDefinition\\nAntimalarial drugs are medicines that prevent or\\ntreat malaria.\\nPurpose\\nAntimalarial drugs treat or prevent malaria, a\\ndisease that occurs in tropical, subtropical, and\\nsome temperate regions of the world. The disease\\nis caused by a parasite,Plasmodium, which belongs\\nto a group of one-celled organisms known as proto-\\nzoa. The only way to get malaria is to be bitten by a\\ncertain type of mosquito that has bitten someone\\nwho has the disease. Thanks to mosquito control\\nprograms, malaria has been eliminated in the\\nUnited States, almost all of Europe, and large\\nparts of Central and South America. However, mos-\\nquito control has not worked well in other parts\\nof the world, and malaria continues to be a\\nmajor health problem in parts of Africa, Southeast\\nAsia, Latin America, Haiti, the Dominican Republic,\\nand some Pacific Islands. Every year, some\\n30,000 Americans and Europeans who travel to\\nthese areas get malaria. People planning to travel to\\nthe tropics are often advised to take antimalarial\\ndrugs before, during, and after their trips, to help\\nthem avoid getting the disease and bringing it home\\nwith them. These drugs killPlasmodium or prevent\\nits growth.\\nIn recent years, some strains of Plasmodium\\nhave become resistant to antimalarial drugs, and\\nmedical researchers have stepped up efforts to\\ndevelop a malaria vaccine. In early 1997, research-\\ners reported encouraging results from a small study\\nof one vaccine and planned to test the vaccine\\nin Africa.\\nKEY TERMS\\nGlucose— A simple sugar that serves as the body’s\\nmain source of energy.\\nHypoglycemia— Abnormally low levels of glucose\\nin the blood.\\nOrganism— An individual of some type of life form,\\nsuch as a plant or an animal.\\nParasite— An organism that lives and feeds in or on\\nanother organism (the host) and does nothing to\\nbenefit the host.\\nProtozoa— Animal-like, one-celled organisms,\\nsome of which cause diseases in people.\\nPsoriasis— A skin disease in which people have\\nitchy, scaly, red patches on the skin.\\nPurpura— A spotty or patchy purplish rash caused\\nby bleeding under the surface of the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 321\\nAntimalarial drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nAntimalarial drugs are available only with a phy-\\nsician’s prescription. They come in tablet, capsule, and\\ninjectable forms. Among the commonly used antima-\\nlarial drugs are chloroquine (Aralen), mefloquine\\n(Lariam), primaquine, pyrimethamine (Daraprim),\\nand quinine. Other drugs are constantly in develop-\\nment. In early 2004, scientists were researching pro-\\nmising new agents called beat-amino hydroxamates\\nand amino acid-conjugated quinolinamines.\\nRecommended dosage\\nRecommended dosage depends on the type of\\nantimalarial drug, its strength, and the form in which\\nit is being used (such as tablet or injection). The dosage\\nmay also be different for different people. The physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription can recommend the correct\\ndosage. This medicine should be taken exactly as\\ndirected and for the full time of treatment. If the\\ndrug is being taken to treat malaria, it should not be\\nstopped just because symptoms begin to improve.\\nSymptoms may return if the drug is stopped too\\nsoon. Larger or more frequent doses than the physi-\\ncian has ordered should never be taken, nor should the\\ndrug be taken for longer than directed.\\nTravelers taking this medicine to prevent malaria\\nmay be told to take it for one to two weeks before their\\ntrip and for four weeks afterward, as well as for the\\nwhole time they are away. It is important to follow\\nthese directions.\\nAntimalarial drugs work best when they are taken\\non a regular schedule. When taken once a week to\\nprevent malaria, they should be taken on the same day\\nevery week. When taken daily or several times a day to\\ntreat malaria, they should be taken at the same time\\nevery day. Doses should not be missed or skipped.\\nSome antimalarial drugs should be taken with\\nmeals or with milk to prevent upset stomach. Others\\nmust be taken with a full glass of water. It is important\\nto follow directions along with the prescription.\\nPrecautions\\nAntimalarial drugs may cause lightheadedness,\\ndizziness, blurred vision and other vision changes.\\nAnyone who takes these drugs should not drive, use\\nmachines or do anything else that might be dangerous\\nuntil they have found out how the drugs affect them.\\nThe antimalarial drug mefloquine (Lariam) has\\nreceived attention because of reports that it causes\\npanic attacks, hallucinations, anxiety, depression,\\nparanoia, and other mental and mood changes, some-\\ntimes lasting for months after the last dose. In fact, the\\nU.S. Food and Drug Administration (FDA) began\\nrequiring warnings with Lariam beginning in July\\n2003 because of serious psychiatric effects caused by\\nthe drug. Pharmacists are required to include a 2,000-\\nword medication guide detailing the warnings.\\nAnyone who has unexplained anxiety, depression,\\nrestlessness, confusion, or other troubling mental or\\nmood changes after taking mefloquine should call a\\nphysician right away. Switching to a different antima-\\nlarial drug may be an alternative and can allow the side\\neffects to stop.\\nAnyone taking antimalarial drugs to prevent\\nmalaria who develops afever or flu-like symptoms\\nwhile taking the medicine or within 2-3 months after\\ntraveling to an area where malaria is common should\\ncall a physician immediately.\\nIf the medicine is being taken to treat malaria, and\\nsymptoms stay the same or get worse, The patient\\nshould check with the physician who prescribed the\\nmedicine.\\nPatients who take this medicine over a long period\\nof time need to have a physician check them periodi-\\ncally for unwanted side effects.\\nBabies and children are especially sensitive to the\\nantimalarial drug chloroquine. Not only are they more\\nlikely to have side effects from the medicine, but they\\nare also at greater risk of being harmed by an over-\\ndose. A single 300-mg tablet could kill a small child.\\nThis medicine should be kept out of the reach of children\\nand safety vials should be used.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take antimalarial drugs. Before taking these\\ndrugs, the physician should know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to antimalarial drugs or related medicines in\\nthe past should let his or her physician know before\\ntaking the drugs again. The physician should also be\\ntold about anyallergies to foods, dyes, preservatives,\\nor other substances.\\nPREGNANCY. In laboratory animal studies, some\\nantimalarial drugs causebirth defects. But it is also\\nrisky for a pregnant woman to get malaria. Untreated\\nmalaria can cause premature birth, stillbirth, and\\nmiscarriage. When given in low doses to prevent\\nmalaria, antimalarial drugs have not been reported\\n322 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimalarial drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='to cause birth defects in humans. If possible, pregnant\\nwomen should avoid traveling to areas where they\\ncould get malaria. If travel is necessary, women who\\nare pregnant or who may become pregnant should\\ncheck with their physicians about the use of antima-\\nlarial drugs.\\nBREASTFEEDING. Some antimalarial drugs pass\\ninto breast milk. Although no problems have been\\nreported in nursing babies whose mothers took anti-\\nmalarial drugs, babies and young children are particu-\\nlarly sensitive to some of these drugs. Women who are\\nbreastfeeding should check with their physicians\\nbefore using antimalarial drugs.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nmalarial drugs, people who have any of these medi-\\ncal problems (or have had them in the past) should\\nmake sure their physicians are aware of their\\nconditions:\\n/C15Blood disease\\n/C15Liver disease\\n/C15Nerve or brain disease or disorder, including seizures\\n(convulsions)\\n/C15Past or current mental disorder\\n/C15Stomach or intestinal disease\\n/C15Deficiency of the enzyme glucose-6-phosphate dehy-\\ndrogenase (G6PD), which is important in the break-\\ndown of sugar in the body\\n/C15Deficiency of the enzyme nicotinamide adenine dinu-\\ncleotide (NADH) methemoglobin reductase\\n/C15Psoriasis\\n/C15Heart disease\\n/C15Family or personal history of the genetic condition\\nfavism (a hereditary allergic condition)\\n/C15Family or personal history ofhemolytic anemia,a\\ncondition in which red blood cells are destroyed\\n/C15Purpura\\n/C15Hypoglycemia (low blood sugar)\\n/C15Blackwater fever (a serious complication of one type\\nof malaria)\\n/C15Myasthenia gravis (a disease of the nerves and\\nmuscles).\\nUSE OF CERTAIN MEDICINES. Taking antimalarial\\ndrugs with certain other drugs may affect the way\\nthe drugs work or may increase the chance of side\\neffects.\\nSide effects\\nHigh doses of the antimalarial drug pyrimetha-\\nmine may cause blood problems that can interfere with\\nhealing and increase the risk of infection. People tak-\\ning this drug should be careful not to injure their gums\\nwhen brushing or flossing their teeth or using tooth-\\npicks. If possible, dental work should be postponed\\nuntil treatment is complete and the blood has returned\\nto normal.\\nThe most common side effects of antimalarial\\ndrugs are diarrhea, nausea or vomiting, stomach\\ncramps or pain, loss of appetite, headache, itching,\\ndifficulty concentrating, dizziness, lightheadedness,\\nand sleep problems. These problems usually go away\\nas the body adjusts to the drug and do not require\\nmedical treatment. Less common side effects, such as\\nhair loss or loss of color in the hair; skin rash; or blue-\\nblack discoloration of the skin, fingernails, or inside of\\nthe mouth also may occur and do not need medical\\nattention unless they are long-lasting.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\nthe physician who prescribed the medicine should be\\ncontacted immediately:\\n/C15Blurred vision or any other vision changes\\n/C15Convulsions (seizures)\\n/C15Mood or mental changes\\n/C15Hallucinations\\n/C15Anxiety\\n/C15Confusion\\n/C15Weakness or unusual tiredness\\n/C15Unusual bruising or bleeding\\n/C15Hearing loss or ringing or buzzing in the ears\\n/C15Fever, with or without sore throat\\n/C15Slow heartbeat\\n/C15Pain in the back or legs\\n/C15Dark urine\\n/C15Pale skin\\n/C15Taste changes\\n/C15Soreness, swelling, or burning sensation in the\\ntongue.\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking anantimalarial\\ndrug should get in touch with his or her physician.\\nGALE ENCYCLOPEDIA OF MEDICINE 323\\nAntimalarial drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Interactions\\nSome antimalarial drugs may interact with other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes antimalarial drugs\\nshould let the physician know all other medicines he or\\nshe is taking. Among the drugs that interact with some\\nantimalarial drugs are:\\n/C15Beta blockers such as atenolol (Tenormin), propra-\\nnolol (Inderal), and metoprolol (Lopressor)\\n/C15Calcium channel blockers such as diltiazem\\n(Cardizem), nicardipene (Cardene), and nifedipine\\n(Procardia)\\n/C15Other antimalarial drugs\\n/C15Quinidine, used to treat abnormal heart rhythms\\n/C15Antiseizure medicines such as vaproic acid deriva-\\ntives (Depakote or Depakene)\\n/C15Oral typhoid vaccine\\n/C15Diabetes medicines taken by mouth\\n/C15Sulfonamides (sulfa drugs)\\n/C15Vitamin K\\n/C15Anticancer drugs\\n/C15Medicine for overactive thyroid\\n/C15Antiviral drugs such as zidovudine (Retrovir).\\nThe list above does not include every medicine\\nthat may interact with every antimalarial drug. It is\\nadvised to check with a physician or pharmacist before\\ncombining an antimalarial drug with any other\\nprescription or nonprescription (over-the-counter)\\nmedicine.\\nResources\\nPERIODICALS\\n‘‘Amino Acid-conjugated Quinolinamines Are Potent\\nAntimalarials.’’ Drug Week(March 12, 2004): 142.\\n‘‘FDA Requires Warnings on Anti-malaria Drug Lariam.’’\\nConsumer Reports(January 2004): 45.\\n‘‘Glycosylated Beta-amino Hydroxamates Show Promise as\\nAntimalarials.’’ Malaria Weekly(February 2, 2004): 2.\\nOTHER\\n‘‘Should You Take Lariam?’’Travel Health Information\\nPage. .\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntimicrobial agents see Antibiotics\\nAntimigraine drugs\\nDefinition\\nAntimigraine drugs are medicines used to prevent\\nor reduce the severity of migraine headaches.\\nPurpose\\nMigraine headaches usually cause a throbbing\\npain on one side of the head.Nausea, vomiting, dizzi-\\nness, increased sensitivity to light and sound, and\\nother symptoms may accompany the pain. The attacks\\nmay last for several hours or for a day or more and\\nmay come as often as several times a week. Some\\npeople who get migraine headaches have warning sig-\\nnals before the headaches begin, such as restlessness,\\ntingling in an arm or leg, or seeing patterns of flashing\\nlights. This set of signals is called an aura. The anti-\\nmigraine drugs discussed in this section are meant to\\nbe taken as soon as the pain begins, to relieve the pain\\nand other symptoms. Other types of drugs, such as\\nantiseizure medicines, antidepressants,calcium chan-\\nnel blockers and beta blockers, are sometimes pre-\\nscribed to prevent attacks in people with very severe\\nor frequent migraines.\\nDescription\\nMigraine is thought to be caused by electrical and\\nchemical imbalances in certain parts of the brain.\\nThese imbalances affect the blood vessels in the\\nbrain – first tightening them up, then widening them.\\nAs the blood vessels widen, they stimulate the release\\nof chemicals that increase sensitivity to pain and cause\\ninflammation and swelling. Antimigraine drugs are\\nbelieved to work by correcting the imbalances and by\\ntightening the blood vessels.\\nExamples of drugs in this group are ergotamine\\n(Cafergot), naratriptan (Amerge), sumatriptan\\n(Imitrex), rizatriptan (Maxalt), almotriptan (Axert),\\nand zolmitriptan (Zomig). Methysergide maleate\\n(Sansert) may be used by patients whose headaches\\nare not controlled by other drugs, while some patients\\ndo well on other drugs. For example, combinations\\nor ergotamine and caffeine may be very effective.\\nThe caffeine acts by constricting blood vessels to\\nrelieve the headache. Sometimes, an analgesic such\\nas acetaminophen, caffeine, and a barbiturate which\\nacts as a sedative, are combined, as in Fioricet and\\nsimilar compounds. These medicines are available\\nonly with a physician’s prescription and come in\\nseveral forms. Ergotamine is available as tablets\\n324 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimigraine drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and rectal suppositories; sumatriptan as tablets,\\ninjections, and nasal spray; and zolmitriptan as\\ntablets.\\nAntimigraine drugs are used to treat headaches\\nonce they have started. These drugs should not be\\ntaken to prevent headaches.\\nSome patients are given anti-epileptic drugs,\\nwhich are also known as anticonvulsants, to treat\\nmigraine headaches. As of 2003, sodium valproate\\n(Epilim) is the only anticonvulsant approved by the\\nFood and Drug Administration (FDA) for preven-\\ntion of migraine. Such newer anticonvulsants as\\ngabapentin (Neurontin) and topiramate (Topamax)\\nare being evaluated as migraine preventives as of\\nearly 2004.\\nRecommended dosage\\nRecommended dosage depends on the type of\\ndrug. Typical recommended dosages for adults are\\ngiven below for each type of drug.\\nErgotamine\\nTake at the first sign of a migraine attack. Patients\\nwho get warning signals (aura) may take the drug as\\nsoon as they know a headache is coming.\\nTABLETS. No more than 6 tablets for any single\\nattack.\\nNo more than 10 tablets per week.\\nSUPPOSITORIES. No more than 2 suppositories for\\nany single attack.\\nNo more than 5 suppositories per week.\\nNaratriptan\\nTake as soon as pain or other migraine symptoms\\nbegin. Also effective if taken any time during an\\nattack. Do not take the drug until the pain actually\\nstarts as not all auras result in a migraine.\\nTABLETS. Usual dose is one 1-mg tablet taken with\\nwater or other liquid.\\nDoses of 2.5-mg may be used, but they may cause\\nmore side effects.\\nIf the headache returns or if there is only partial\\nresponse, the dose may be repeated once after 4 hours,\\nfor a maximum dose of 5 mg in a 24-hour period.\\nLarger doses do not seem to offer any benefit.\\nSumatriptan\\nTake as soon as pain or other migraine symptoms\\nbegin. Also effective if taken any time during an\\nattack. Do not take the drug until the pain actually\\nstarts as not all auras result in a migraine.\\nTABLETS. Usual dose is one 25-mg tablet, taken\\nwith water or other liquid.\\nDoses should be spaced at least 2 hours apart.\\nAnyone with liver disease should consult with a\\nphysician for proper dosing.\\nINJECTIONS. No more than 6 mg per dose, injected\\nunder the skin.\\nNo more than two 6-mg injections per day. These\\ndoses should be taken at least 1 hour apart.\\nZolmitriptan\\nTake as soon as symptoms begin.\\nTABLETS. Usual dose is 1–5 mg. Additional doses\\nmay be taken at 2-hour intervals.\\nNo more than 10 mg per 24 hour period.\\nKEY TERMS\\nAnticonvulsant— A type of drug given to prevent\\nseizures. Some patients with migraines can be\\ntreated effectively with an anticonvulsant.\\nAura— A set of warning symptoms, such as seeing\\nflashing lights, that some people have 10–30\\nminutes before a migraine attack.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nStatus migrainosus— The medical term for an acute\\nmigraine headache that lasts 72 hours or longer.\\nAntimigraine Drugs\\nBrand Name\\n(Generic Name) Possible Common Side Effects Include:\\nCafergot Nausea, increased blood pressure, fluid\\nretention, numbness, increased heart rate,\\ntingling sensation\\nImitrex (sumatriptan\\nsuccinate)\\nBurning, flushing, neck pain, inflammation at\\ninjection site, sore throat, tingling sensation\\nInderal (propranolol\\nhydrochloride)\\nConstipation or diarrhea, headache, nausea, rash\\nMidrin Dizziness, rash\\nGALE ENCYCLOPEDIA OF MEDICINE 325\\nAntimigraine drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='General dosage advice\\nAlways take antimigraine drugs exactly as direc-\\nted. Never take larger or more frequent doses, and do\\nnot take the drug for longer than directed.\\nIf possible, lie down and relax in a dark, quiet\\nroom for a few hours after taking the medicine.\\nPrecautions\\nThese drugs should be used only to treat the type\\nof headache for which they were prescribed. Patients\\nshould not use them for other headaches, such as those\\ncaused bystress or too much alcohol, unless directed\\nto do so by a physician.\\nAnyone whose headache is unlike any previous\\nheadache should check with a physician before taking\\nthese drugs. If the headache is far worse than any\\nother, emergency medical treatment should be sought\\nimmediately.\\nTaking too much of the antimigraine drug ergota-\\nmine (Cafergot), can lead to ergotpoisoning. Symptoms\\ninclude headache, muscle pain,numbness, coldness, and\\nunusually pale fingers and toes. If not treated, the con-\\ndition can lead togangrene(tissue death).\\nSumatriptan (Imitrex), naratriptan (Amerge),\\nrizatriptan (Maxalt) and zolmitriptan (Zomig) may\\ninteract with ergotamine. These drugs should not be\\ntaken within 24 hours of taking any drug containing\\nergotamine.\\nSome antimigraine drugs work by tightening\\nblood vessels in the brain. Because these drugs also\\naffect blood vessels in other parts of the body, people\\nwith coronary heart disease, circulatory problems, or\\nhigh blood pressure should not take these medicines\\nunless directed to do so by their physicians.\\nAbout 40% of all migraine attacks do not\\nrespond to treatment with triptans or any other\\nmedication. If the headache lasts longer than 72\\nhours—a condition known as status migrainosus—\\nthe patient may be given narcotic medications to\\nbring on sleep and stop the attack. Patients with\\nstatus migrainosus are often hospitalized because\\nthey are likely to be dehydrated from severenausea\\nand vomiting.\\nSpecial conditions\\nPeople with certain other medical conditions or\\nwho are taking certain other medicines can have pro-\\nblems if they take antimigraine drugs. Before taking\\nthese drugs, be sure to let the physician know about\\nany of these conditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to ergotamine, caffeine, sumatriptan, zolmitrip-\\ntan, or other antimigraine drugs in the past should let\\nhis or her physician know before taking the drugs\\nagain. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other\\nsubstances.\\nPREGNANCY. Women who are pregnant should\\nnot take ergotamine (Cafergot). The effects of other\\nantimigraine drugs duringpregnancy have not been\\nwell studied. Any woman who is pregnant or plans to\\nbecome pregnant should let her physician know before\\nan antimigraine drug is prescribed.\\nBREASTFEEDING. Some antimigraine drugs can\\npass into breast milk and may cause serious problems\\nin nursing babies. Women who are breastfeeding\\nshould check with their physicians about whether to\\nstop breastfeeding while taking the medicine.\\nOTHER MEDICAL CONDITIONS. Before using anti-\\nmigraine drugs, people with any of these medical pro-\\nblems should make sure their physicians know about\\ntheir conditions:\\n/C15Coronary heart disease\\n/C15Angina (crushing chest pain)\\n/C15Circulatory problems or blood vessel disease\\n/C15High blood pressure\\n/C15Liver problems\\n/C15Kidney problems\\n/C15Any infection\\n/C15Eye problems.\\nUSE OF CERTAIN MEDICINES. Taking antimigraine\\ndrugs certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects are fluid reten-\\ntion, flushing; high blood pressure; unusually fast\\nor slow heart rate; numbness; tingling; itching;\\nnausea; vomiting; weakness; neck or jaw pain and\\nstiffness; feelings of tightness, heaviness, warmth,\\nor coldness; sore throat ; and discomfort of the\\nmouth and tongue.\\nMore serious side effects are not common, but\\nthey may occur. If any of the following side effects\\noccur, call a physician immediately:\\n/C15Tightness in the chest\\n/C15Bluish tinge to the skin\\n/C15Cold arms and legs\\n326 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimigraine drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Signs of gangrene, such as coldness, dryness, and a\\nshriveled or black appearance of a body part\\n/C15Dizziness\\n/C15Drowsiness\\n/C15Shortness of breath orwheezing\\n/C15Skin rash\\n/C15Swelling of the eyelids or face.\\nPossible side effects with anticonvulsants include\\ndizziness, drowsiness, emotional upset, skin rash, tem-\\nporary hair loss, nausea, and irregular menstrual\\nperiods.\\nOther side effects may occur with any antimi-\\ngraine drug. Anyone who has unusual symptoms\\nafter taking this medicine should get in touch with\\nhis or her physician.\\nAlternative treatments\\nThere are two herbal remedies that are reported to\\nbe effective as alternative treatments for migraine. One\\nis feverfew (Tanacetum parthenium), an herb related to\\nthe daisy that is traditionally used in England to pre-\\nvent migraines. Published studies indicate that fever-\\nfew can reduce the frequency and intensity of\\nmigraines. It does not, however, relieve pain once the\\nheadache has begun. The other herbal remedy is but-\\nterbur root (Petasites hybridus). Petadolex is a natural\\npreparation made from butterbur root that has been\\nsold in Germany since the 1970s as a migraine preven-\\ntive. Petadolex has been available in the United States\\nsince December 1998.\\nInteractions\\nAntimigraine drugs may interact with other med-\\nicines. When this happens, the effects of one or both of\\nthe drugs may change, or the risk of side effects may be\\ngreater. Anyone who takes these drugs should let the\\nphysician know all other medicines he or she is taking.\\nAmong the drugs that may interact with antimigraine\\ndrugs are:\\n/C15Beta blockers such as atenolol (Tenormin) and pro-\\npranolol (Inderal)\\n/C15Drugs that tighten blood vessels such as epinephrine\\n(EpiPen) and pseudoephedrine (Sudafed)\\n/C15Nicotine such as cigarettes or Nicoderm, Habitrol,\\nand othersmoking-cessation drugs\\n/C15Certain antibiotics, such as erythromycin and clari-\\nthromycin (Biaxin)\\n/C15Monoamine oxidase inhibitors such as phenelzine\\n(Nardil) and tranylcypromine (Parnate)\\n/C15Certain antidepressants, such as sertraline (Zoloft),\\nfluoxetine (Prozac), and paroxetine (Paxil)\\n/C15Fluvoxamine (Luvox), prescribed for obsessive com-\\npulsive disorder or chronic pain.\\nAnticonvulsants should not be taken together\\nwith aspirin, alcohol, or tranquilizers.\\nRemember naratriptan, sumatriptan, rizatriptan\\nand zolmitriptan may interact with ergotamine. These\\ndrugs should not be taken within 24 hours of taking\\nany drug containing ergotamine.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders.4th ed., revised.\\nWashington, DC: American Psychiatric Association,\\n2000.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Headache.’’ Section 14, Chapter 168 InThe Merck\\nManual of Diagnosis and Therapy.Whitehouse Station,\\nNJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Psychogenic Pain Syndromes.’’ Section 14, Chapter\\n167 InThe Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nPelletier, Kenneth R., MD.The Best Alternative Medicine,\\nPart II. ‘‘CAM Therapies for Specific Conditions:\\nHeadache.’’ New York: Simon & Schuster, 2002.\\nPERIODICALS\\nCeballos Hernansanz, M. A., R. Sanchez Roy, A. Cano\\nOrgaz, et al. ‘‘Migraine Treatment Patterns and Patient\\nSatisfaction with Prior Therapy: A Substudy of a\\nMulticenter Trial of Rizatriptan Effectiveness.’’\\nClinical Therapeutics25 (July 2003): 2053–2069.\\nCorbo, J. ‘‘The Role of Anticonvulsants in Preventive\\nMigraine Therapy.’’Current Pain and Headache\\nReports 7 (February 2003): 63–66.\\nDodick, D. W. ‘‘A Review of the Clinical Efficacy and\\nTolerability of Almotriptan in Acute Migraine.’’Expert\\nOpinion in Pharmacotherapy4 (July 2003): 1157–1163.\\nDowson, A. J., and B. R. Charlesworth. ‘‘Patients with\\nMigraine Prefer Zolmitriptan Orally Disintegrating\\nTablet to Sumatriptan Conventional Oral Tablet.’’\\nInternational Journal of Clinical Practice57 (September\\n2003): 573–576.\\nJohannessen, C. U., and S. I. Johannessen. ‘‘Valproate: Past,\\nPresent, and Future.’’CNS Drug Review9 (Summer\\n2003): 199–216.\\nSahai, Soma, MD, Robert Cowan, MD, and David Y. Ko,\\nMD. ‘‘Pathophysiology and Treatment of Migraine\\nand Related Headache.’’eMedicine April 30, 2002.\\nGALE ENCYCLOPEDIA OF MEDICINE 327\\nAntimigraine drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Tepper, S. J., and D. Millson. ‘‘Safety Profile of the\\nTriptans.’’ Expert Opinion on Drug Safety2 (March\\n2003): 123–132.\\nNancy Ross-Flanigan\\nRebecca J. Frey, PhD\\nAntimyocardial antibody test\\nDefinition\\nTesting for antimyocardial antibodies is done\\nwhen evaluating a person for heart damage or heart\\ndisease.\\nPurpose\\nAntimyocardial antibodies are autoantibodies.\\nNormal antibodies are special proteins built by the\\nbody as a defense against foreign material entering the\\nbody. Autoantibodies are also proteins built by the body,\\nbut instead of attacking foreign material, they inappro-\\npriatelyattackthebody’s owncells. Antimyocardial anti-\\nbodies attack a person’s heart muscle, or myocardium.\\nThis test may be done on a person who recently\\nhad trauma to the heart, such as heart surgery or a\\nmyocardial infarction (heart attack). It also may be\\ndone on someone with heart disease, such ascardio-\\nmyopathy or rheumatic fever.\\nAlthough the presence of antimyocardial antibo-\\ndies does not diagnose heart damage or disease, there is\\na connection between the presence of these antibodies\\nand damage to the heart. The amount of damage, how-\\never, cannot be predicted by the amount of antibodies.\\nThese antibodies usually appear after heart surgery\\northebeginningofdisease,buttheymaybepresentbefore\\nsurgery or the onset of disease. In 30% of people with\\nmyocardial infarction and 70% of people having heart\\nsurgery, antimyocardial antibodies will appear within\\ntwo to three weeks and stay for three to eight weeks.\\nDescription\\nA 5-10 mL sample of venous blood is drawn from\\nthe patient’s arm in the region of the inner elbow.\\nAntimyocardial antibodies are detected by combining\\na patient’s serum (clear, thin, sticky fluid in blood)\\nwith cells from animal heart tissue, usually that of a\\nmonkey. Antimyocardial antibodies in the serum bind\\nto the heart tissue cells. A fluorescent dye is then added\\nto the mixture. This dye will attach to any antibodies\\nand heart tissue cells bound together. The final mix-\\nture is studied under a microscope that is designed to\\nshow fluorescence. If fluorescent cells are seen under\\nthe microscope, the test is positive.\\nWhen the test is positive, the next step is to find\\nout how much antibody is present. The patient’s\\nserum is diluted, or titered, and the test is done\\nagain. The serum is then further diluted and the test\\nrepeated until the serum is so dilute that fluorescence is\\nno longer seen. The last dilution that showed fluores-\\ncence is the titer reported.\\nPreparation\\nNo fasting or special prepartion is needed. Before\\nthe test is done it should be explained to the patient.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite after the blood is drawn or the person may feel\\ndizzy or faint. Pressure to the puncture site until the\\nbleeding stops reduces bruising. Warm packs on the\\npuncture site relieve discomfort.\\nNormal results\\nAntimyocardial antibodies are not normally seen\\nin healthy individuals.\\nKEY TERMS\\nAntibody— A special protein built by the body as\\na defense against foreign material entering the\\nbody.\\nAntimyocardial antibody— An autoantibody that\\nattacks a person’s own heart muscle, or\\nmyocardium.\\nAutoantibody— An antibody that attacks the\\nbody’s own cells or tissues.\\nMyocardial infarction— A block in the blood sup-\\nply to the heart, resulting in what is commonly\\ncalled a heart attack.\\nMyocardium— The muscular middle layer of the\\nheart.\\nTiter— A dilution of a substance with an exact\\nknown amount of fluid. For example, one part of\\nserum diluted with four parts of saline is a titer\\nof 1:4.\\n328 GALE ENCYCLOPEDIA OF MEDICINE\\nAntimyocardial antibody test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Abnormal results\\nA positive result means that antimyocardial antibo-\\ndiesarepresentandthatheartdiseaseordamageislikely.\\nFurther testing may be needed as other autoantibodies\\ncould also be present, causing a false abnormal test.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nNancy J. Nordenson\\nAntinausea drugs\\nDefinition\\nAntinausea drugs are medicines that control nau-\\nsea—a feeling of sickness or queasiness in the stomach\\nwith an urge to vomit. These drugs also prevent or stop\\nvomiting. Drugs that control vomiting are called antie-\\nmetic drugs.\\nPurpose\\nAntinausea drugs such as prochlorperazine\\n(Compazine), usually control bothnausea and vomit-\\ning. Prochlorperazine is also sometimes prescribed for\\nsymptoms of mental disorders, such asschizophrenia.\\nAnother commonly prescribed antinausea drug is\\npromethazine (Phenergan). Promethazine also may be\\nprescribed to relieve allergy symptoms and apprehen-\\nsion, as well asmotion sickness.\\nDescription\\nProchlorperazine is available only with a physi-\\ncian’s prescription. It is sold in syrup, capsule, tablet,\\ninjection, and suppository forms.\\nRecommended dosage\\nTo control nausea and vomiting in adults, the\\nusual dose is:\\n/C15Tablets—one 5-mg or 10-mg tablet three to four\\ntimes a day\\n/C15Extended-release capsules—one 15-mg capsule first\\nthing in the morning or one 10-mg capsule every\\n12 hours\\n/C15Suppository—25 mg, twice a day\\n/C15Syrup—5-10 mg three to four times a day\\n/C15Injection—5-10 mg injected into a muscle three to\\nfour times a day.\\nDoses for children must be determined by a\\nphysician.\\nPromethazine may be administered in pill, syrup,\\nchewable tablet, or extended release capsule form by\\nprescription only. For severe nausea, it may be admi-\\nnistered by injection or via a suppository. The physician\\nrecommends dose depending on the patient’s condition.\\nPrecautions\\nProchlorperazine may cause a movement disorder\\ncalled tardive dyskinesia. Signs of this disorder are\\ninvoluntary twitches and muscle spasms in the face\\nand body and jutting or rolling movements of the\\ntongue. The condition may be permanent. Older people,\\nespecially women, are particularly at risk of developing\\nthis problem when they take prochlorperazine.\\nAntinausea Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nCompazine\\n(phochlorperazine)\\nInvoluntary muscle spasms, dizziness,\\njitteriness, puckering of the mouth\\nPhenergan (prometha-\\nzine hydrochloride)\\nDizziness, dry mouth, nausea and vomiting,\\nrash\\nReglan (metoclopramide\\nhydrochloride)\\nFatigue, drowsiness, restlessness\\nTigan (trimethobenza-\\nmide hydrochloride)\\nBlurred vision, diarrhea, cramps, headache\\nZofan (ondansetron\\nhydrochloride)\\nConstipation, headache, fatigue, abdominal\\npain\\nKEY TERMS\\nAnesthetic— Medicine that causes a loss of feeling,\\nespecially pain. Some anesthetics also cause a loss\\nof consciousness.\\nAntihistamine— Medicine that prevents or relieves\\nallergy symptoms.\\nCentral nervous system— The brain and spinal cord.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles.\\nTranquilizer— Medicine that has a calming effect\\nand is used to treat anxiety and mental tension.\\nGALE ENCYCLOPEDIA OF MEDICINE 329\\nAntinausea drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Some people feel drowsy, dizzy, lightheaded, or less\\nalert when using this medicine. The drug may also cause\\nblurred vision, and movement problems. For these rea-\\nsons, anyone who takes this drug should not drive, use\\nmachines or do anything else that might be dangerous\\nuntil they have found out how the drug affects them.\\nProchlorperazine makes some people sweat less,\\nwhich can allow the body to overheat. The drug may\\nalso make the skin and eyes more sensitive to the sun.\\nPeople who are taking prochlorperazine should try to\\navoid extreme heat and exposure to the sun. When\\ngoing outdoors, they should wear protective clothing,\\na hat, a sunscreen with a skin protection factor (SPF)\\nof at least 15, and sunglasses that block ultraviolet\\n(UV) light. Saunas, sunlamps, tanning booths, tan-\\nning beds, hot baths, and hot tubs should be avoided\\nwhile taking this medicine. Anyone who must be\\nexposed to extreme heat while taking the drug should\\ncheck with his or her physician.\\nThis medicine adds to the effects of alcohol and\\nother drugs that slow down the central nervous sys-\\ntem, such asantihistamines, cold and flu medicines,\\ntranquilizers, sleep aids, anesthetics, somepain medi-\\ncines, and muscle relaxants. Drinking alcohol while\\ntaking prochlorperazine is not advised and patients\\nshould check with the physician who prescribed the\\ndrug before combining it with any other medicines.\\nDo not stop taking this medicine without checking\\nwith the physician who prescribed it. Stopping the drug\\nsuddenly can causedizziness, nausea, vomiting,tremors,\\nand other side effects. When stopping the medicine, it\\nmay be necessary to taper down the dose gradually.\\nProchlorperazine may cause falsepregnancy tests.\\nWomen who are pregnant (or planning to become\\npregnant) or breast feeding should check with their\\nphysicians before using antinausea medicines.\\nBefore using prochlorperazine, people with any of\\nthe medical problems should make sure their physi-\\ncians are aware of their conditions:\\n/C15Previous sensitivity or allergic reaction to\\nprochlorperazine\\n/C15Heart disease\\n/C15Glaucoma\\n/C15Brain tumor\\n/C15Intestinal blockage\\n/C15Abnormal blood conditions, such as leukemia\\n/C15Exposure to pesticides.\\nSome people may experience side effects from\\npromethazine including:\\n/C15dry mouth\\n/C15drowsiness\\n/C15confusion\\n/C15fatigue\\n/C15difficulty coordinating movements\\n/C15stuffy nose.\\nA physician should be contacted immediately if a\\npatient experiences the following effects while taking\\npromethazine:\\n/C15vision problems\\n/C15ringing in the ears\\n/C15tremors\\n/C15insomnia\\n/C15excitement\\n/C15restlessness\\n/C15yellowing of the skin or eyes\\n/C15skin rash.\\nSide effects\\nMany side effects are possible with prochlorpera-\\nzine, including, but not limited to,constipation, dizzi-\\nness, drowsiness, decreased sweating, dry mouth, stuffy\\nnose, movementproblems,changes inmenstrualperiod,\\nincreased sensitivity to sun, and swelling or pain in\\nbreasts. Anyone who has unusual or troublesome symp-\\ntoms after taking prochlorperazine should get in touch\\nwith his or her physician.\\nSide effects associated with promethazine include\\nthose listed above and interactions with various med-\\nications that may cause complications or lessen the\\neffects of the drug. A physician should be notified of\\nother medications the patient is on when taking\\npromethazine.\\nInteractions\\nProchlorperazine may interact with other medi-\\ncines. When this happens, the effects of one or both of\\nthe drugs may change or the risk of side effects may be\\ngreater. Among the drugs that may interact with pro-\\nchlorperazine are antiseizure drugs such as phenytoin\\n(Dilantin) and carbamazepine (Tegretol), anticoagu-\\nlants such as warfarin (Coumadin), and drugs that\\nslow the central nervous system such as alprazolam\\n(Xanax), diazepam (Valium), and secobarbital\\n(Seconal). Not every drug that interacts with prochlor-\\nperazine is listed here. A physician or pharmacist can\\nadvise patients about prescription or nonprescription\\n330 GALE ENCYCLOPEDIA OF MEDICINE\\nAntinausea drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(over-the-counter) drugs that might interact with\\nProchlorperazine.\\nResources\\nPERIODICALS\\nFlake, Zachary A., Robert D. Scalley, and Austin G. Bailey.\\n‘‘Practical Selection of Antiemetics.’’American Family\\nPhysician March 1, 2004: 1169.\\nOTHER\\n‘‘Promethazine’’ Medline Plus Drug Information..\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nAntinuclear antibody test\\nDefinition\\nThe antinuclear antibody (ANA) test is a test done\\nearly in the evaluation of a person for autoimmune or\\nrheumatic disease, particularlysystemic lupus erythe-\\nmatosus (SLE).\\nPurpose\\nIn autoimmune diseases, the body makes antibo-\\ndies that work against its own cells or tissues.\\nRheumatic diseases (diseases that affect connective\\ntissue, including the joints, bone, and muscle) are\\nalso associated with these antibodies. Autoantibodies\\nare proteins built by the body, but instead of guarding\\nagainst foreign material (including bacteria, viruses,\\nand fungi) as normal antibodies do, they attack the\\nbody’s own cells.\\nAutoimmune and rheumatic diseases can be diffi-\\ncult to diagnose. People with the same disease can\\nhave very different symptoms. A helpful strategy in\\nthe diagnosis of these diseases is to find and identify an\\nautoantibody in the person’s blood.\\nThe antinuclear antibody test looks for a\\ngroup of autoantibodies that attack substances\\nfound in the center (nucleus) of all cells. It is useful\\nas a screen for many autoantibodies associated\\nwith diseases that affect the entire body (systemic\\ndiseases).\\nThis test is particularly useful when diagnosing a\\nperson with symptoms of SLE, an illness that affects\\nmany body organs and tissues. If the test is negative, it\\nis unlikely that the person has SLE; if the test is positive,\\nmore tests are done to confirm whether the person has\\nSLE or another related disease. Other diseases, such as\\nscleroderma, Sjo¨gren’s syndrome, Raynaud’s disease,\\nrheumatoid arthritis,a n dautoimmune hepatitis, often\\nhave a positive test for antinuclear antibodies.\\nDescription\\nFive to 10 mL of blood is needed for this test. The\\nantinuclear antibody test is done by adding a person’s\\nserum to commercial cells mounted on a microscope\\nslide. If antinuclear antibodies are in the serum, they\\nbind to the nuclei of cells on the slide. Next, a second\\nantibody is added to the mixture. This antibody is\\n‘‘tagged’’ with a fluorescent dye so that it can be\\nseen. The second antibody attaches to any antibodies\\nand cells bound together and, because of the fluores-\\ncent ‘‘tag,’’ the areas with antinuclear antibodies seem\\nto glow, or fluoresce, when the slide is viewed under an\\nultraviolet microscope.\\nIf fluorescent cells are seen, the test is positive.\\nWhen positive, the serum is diluted, or titered, and\\nthe test done again. These steps are repeated until the\\nserum is so dilute it no longer gives a positive result.\\nThe last dilution that shows fluorescence is the titer\\nreported.\\nThe pattern of fluorescence within the cells gives\\nthe physician clues as to what the disease might be.\\nThe test result includes the titer and the pattern.\\nThis test is also called the fluorescent antinuclear\\nantibody test or FANA. Results are available within\\none to three days.\\nKEY TERMS\\nAntibody— A special protein built by the immune\\nsystem as a defense against foreign material enter-\\ning the body.\\nAutoantibody— An antibody that attacks the body’s\\nown cells or tissues.\\nAntinuclear antibodies—Autoantibodies that attack\\nsubstances found in the center, or nucleus, of all\\ncells.\\nAutoimmune disease— Disease in which the body\\nmakes antibodies against its own cells or tissues.\\nTiter— A dilution of a substance with an exact\\nknown amount of fluid. For example, one part of\\nserum diluted with four parts of saline is a titer of 1:4.\\nGALE ENCYCLOPEDIA OF MEDICINE 331\\nAntinuclear antibody test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Preparation\\nNo special preparations or diet changes are\\nrequired before a person undergoes an antinuclear\\nantibody test.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces bruis-\\ning. Warm packs relieve discomfort.\\nNormal results\\nNormal results will be negative, showing no anti-\\nnuclear antibodies.\\nAbnormal results\\nA positive test in a person with symptoms of an\\nautoimmune or rheumatic disease helps the physician\\nmake a diagnosis. More than 95% of people with SLE\\nhave a positive ANA test. Scleroderma has a 60-71%\\npositive rate; Sjo¨ gren’s disease, 50-60%, and rheuma-\\ntoid arthritis, 25-30%.\\nSeveral factors must be considered when inter-\\npreting a positive test. Diseases other than autoim-\\nmune diseases can cause autoantibodies. Some\\nhealthy people have a positive test. More testing\\nis done after a positive test to identify individual\\nautoantibodies associated with the various diseases.\\nResources\\nBOOKS\\nLehman, Craig A.Saunders Manual of Clinical Laboratory\\nScience. Philadelphia: W. B. Saunders Co., 1998.\\nNancy J. Nordenson\\nAntiparkinson drugs\\nDefinition\\nAntiparkinson drugs are medicines that relieve the\\nsymptoms of Parkinson’s disease and other forms of\\nparkinsonism.\\nPurpose\\nAntiparkinson drugs are used to treat symptoms of\\nparkinsonism, a group of disorders that share four\\nmain symptoms: tremor or trembling in the hands,\\narms, legs, jaw, and face; stiffness or rigidity of the\\narms, legs, and trunk; slowness of movement (bradyki-\\nnesia); and poor balance and coordination. Parkinson’s\\ndisease is the most common form of parkinsonism and\\nis seen more frequently with advancing age. Other\\nforms of the disorder may result from viral infections,\\nenvironmental toxins,carbon monoxide poisoning,a n d\\nthe effects of treatment withantipsychotic drugs.\\nThe immediate cause of Parkinson’s disease or\\nParkinsonian-like syndrome is the lack of the neuro-\\ntransmitter dopamine in the brain. Drug therapy may\\ntake several forms, including replacement of dopa-\\nmine, inhibition of dopamine metabolism to increase\\nthe effects of the dopamine already present, or sensi-\\ntization of dopamine receptors. Drugs may be used\\nsingly or in combination.\\nDescription\\nLevodopa (Larodopa) is the mainstay of\\nParkinson’s treatment. The drug crosses the blood-\\nbrain barrier, and is converted to dopamine. The drug\\nmay be administered alone, or in combination with\\ncarbidopa (Lodosyn) which inhibits the enzyme respon-\\nsible for the destruction of levodopa. The limitation of\\nlevodopa or levodopa-carbidopa therapy is that after\\napproximately two years of treatment, the drugs cease\\nto work reliably. This has been termed the ‘‘on-off phe-\\nnomenon.’’ Additional treatment strategies have been\\ndeveloped to retard the progression of Parkinsonism,\\nor to find alternative approaches to treatment.\\nAnticholinergic drugs reduce some of the symp-\\ntoms of Parkinsonism, and reduce the reuptake of\\ndopamine, thereby sustaining the activity of the nat-\\nural neurohormone. They may be effective in all stages\\nof the disease. All drugs with anticholinergic\\nAntiparkinson Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nArtane (trihexyphenidyl\\nhydrochloride)\\nDry mouth, nervousness, blurred vision,\\nnausea\\nBenadryl (diephenhydra-\\nmine hydrochloride)\\nDizziness, sleepiness, upset stomach,\\ndecreased coordination\\nCogentin (benztropine\\nmesylate)\\nConstipation, dry mouth, nausea and\\nvomiting, rash\\nEldepryl (selegiline\\nhydrochloride)\\nAbdominal and back pain, drowsiness,\\ndecreased coordination\\nParlodel (bromocriptine\\nmesylate)\\nConstipation, decreased blood pressure,\\nabdominal cramps\\nSinemet CR Involuntary body movements, confusion,\\nnausea, hallucinations\\n332 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiparkinson drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='properties, the naturally occurring belladonna alka-\\nloids (atropine, scopolamine, hyoscyamine), some\\nantihistamines with anticholinergic properties, and\\nsynthetics such as benztropin (Cogentin), procyclidine\\n(Kemadrin) and biperiden (Akineton) are members of\\nthisgroup.Althoughtheanticholinergicdrugshaveonly\\nlimited activity against Parkinson’s disease, they are\\nuseful in the early stages, and may be adjuncts to levo-\\ndopa as the disease progresses.\\nAmantadine (Symmetrel), was developed for pre-\\nvention of influenza virus infection, but has anti-\\nParkinsonian properties. Its mechanism of action is\\nnot known.\\nBromocriptine (Parlodel) is a prolactin inhibitor,\\nwhich is used for a variety of indications including\\namenorrhea/galactorrhea, femaleinfertility, and acro-\\nmegaly. It appears to work by direct stimulation of the\\ndopamine receptors. Bromocriptine is used as a late\\nadjunct to levodopa therapy, and may permit reduc-\\ntion in levodopa dosage. Pergolide (Permax) is similar\\nto bromocriptine, but has not been studied as exten-\\nsively in Parkinson’s disease.\\nEntacapone (Comtan) appears to act by main-\\ntaining levels of dopamine through enzyme inhibi-\\ntion. It is used as an adjunct to levodopa was the\\npatient is beginning to experience the on-off effect.\\nTolcapone (Tasmar) is a similar agent, but has\\ndemonstrated the potential for inducing severe\\nliver failure. As such, tolcapone is reserved for\\ncases where all other adjunctive therapies have\\nfailed or are contraindicated.\\nSelegeline (Carbex, Eldepryl) is a selective mono-\\namine oxidase B (MAO-B) inhibitor, however its\\nmechanism of action in Parkinsonism is unclear,\\nsince other drugs with MAO-B inhibition have failed\\nto show similar anti-Parkinsonian effects. Selegeline is\\nused primarily as an adjunct to levodopa, although\\nsome studies have indicated that the drug may be\\nuseful in the early stages of Parkinsonism, and may\\ndelay the progression of the disease.\\nPramipexole (Mirapex) and ropinirole (Requip)\\nare believed to act by direct stimulation of the dopa-\\nmine receptors in the brain. They may be used alone in\\nearly Parkison’s disease, or as adjuncts to levodopa in\\nadvanced stages.\\nRecommended dosage\\nDosages of anti-Parkinsonian medications must\\nbe highly individualized. All doses must be carefully\\ntitrated. Consult specific references.\\nPrecautions\\nThere are a large number of drugs and drug\\nclasses used to treat Parkinson’s disease, and indivi-\\ndual references should be consulted.\\nKEY TERMS\\nAnorexia— Lack or loss of appetite.\\nAnticholigerginc— An agent that blocks the para-\\nsympathetic nerves and their actions.\\nBradykinesia— Extremely slow movement.\\nBruxism— Compulsive grinding or clenching of the\\nteeth, especially at night.\\nCarbon monoxide— A colorless, odorless, highly\\npoisonous gas.\\nCentral nervous system— The brain and spinalcord.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nHallucination— A false or distorted perception\\nof objects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHeat stroke— A severe condition caused by pro-\\nlonged exposure to high heat. Heat stroke interferes\\nwith the body’s temperature regulating abilities and\\ncan lead to collapse and coma.\\nParkinsonism— A group of conditions that all have\\nthese typical symptoms in common: tremor, rigi-\\ndity, slow movement, and poor balance and\\ncoordination.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category\\nB: Animal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles.\\nTremor— Shakiness or trembling.\\nGALE ENCYCLOPEDIA OF MEDICINE 333\\nAntiparkinson drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The anticholinergics have a large number of\\nadverse effects, all related to their primary mode of\\nactivity. Their cardiovascular effects include tachycar-\\ndia, palpitations, hypotension, postural hypotension,\\nand mild bradycardia. They may also cause a wide\\nrange of central nervous system effects, including\\ndisorientation, confusion, memory loss,hallucinations,\\npsychoses, agitation, nervousness,delusions, delirium,\\nparanoia, euphoria, excitement, lightheadedness,\\ndizziness, headache, listlessness, depression, drowsiness,\\nweakness, and giddiness. Dry mouth, dry eyes and\\ngastrointestinal distress are common problems.\\nSedation has been reported with some drugs in this\\ngroup, but this may be beneficial in patients who suffer\\nfrom insomnia. Pregnancy risk factor is C. Because\\nanticholinergic drugs may inhibit milk production,\\ntheir use during breastfeeding is not recommended.\\nPatients should be warned that anticholinergic medica-\\ntions will inhibit perspiration, and soexercise during\\nperiods of high temperature should be avoided.\\nLevodopa has a large number of adverse effects.\\nAnorexia, loss of appetite, occurs in roughly half the\\npatients using this drug. Symptoms of gastrointestinal\\nupset, such asnausea and vomiting, have been reported\\nin 80% of cases. Other reported effects include\\nincreased hand tremor; headache; dizziness;numbness;\\nweakness and faintness; bruxism; confusion; insom-\\nnia; nightmares; hallucinations and delusions; agita-\\ntion and anxiety; malaise; fatigue and euphoria.\\nLevodopa has not been listed under the pregnancy\\nrisk factor schedules, but should be used with caution.\\nBreastfeeding is not recommended.\\nAmantadine is generally well tolerated, but may\\ncause dizziness andnausea. It is classified as pregnancy\\nschedule C. Since amantadine is excreted in breast\\nmilk, breastfeeding while taking amantidine is not\\nrecommended.\\nPergolide and bromocriptine have been generally\\nwell tolerated. Orthostatic hypotension are common\\nproblems, and patients must be instructed to risk\\nslowly from bed. This problem can be minimized by\\nlow initial doses with small dose increments.\\nHallucinations may be a problem. Bromocriptine has\\nnot been evaluated for pregnancy risk, while pergolide\\nis category B. Since both drugs may inhibitlactation,\\nbreastfeeding while taking these drugs is not\\nrecommended.\\nPramipexole and ropinirole cause orthostatic\\nhypotension, hallucinations and dizziness. The two\\ndrugs are in pregnancy category C. In animals, ropi-\\nnirole has been shown to have adverse effects on\\nembryo-fetal development, including teratogenic\\neffects, decreased fetal body weight, increased fetal\\ndeath and digital malformation. Because these drugs\\ninhibit prolactin secretion, they should not be taken\\nwhile breastfeeding.\\nSide effects\\nThe most common side effects are associated with\\nthe central nervous system, and include dizziness,\\nlightheadedness, mood changes and hallucinations.\\nGastrointestinal problems, including nausea and\\nvomiting, are also common.\\nInteractions\\nAll anti-Parkinsonian regimens should be care-\\nfully reviewed for possible drug interactions. Note\\nthat combination therapy with anti-Parkinsonian\\ndrugs is, in itself, use of additive and potentiating\\ninteractions between drugs, and so careful dose adjust-\\nment is needed whenever a drug is added or\\nwithdrawn.\\nSamuel D. Uretsky, PharmD\\nAntiplatelet drugs see Anticoagulant\\nand antiplatelet drugs\\nAntiprotozoal drugs\\nDefinition\\nAntiprotozoal drugs are medicines that treat\\ninfections caused by protozoa.\\nPurpose\\nAntiprotozoal drugs are used to treat a variety of\\ndiseases caused by protozoa. Protozoa are animal-\\nlike, one-celled animals, such as amoebas. Some are\\nparasites that cause infections in the body. African\\nsleeping sickness, giardiasis, amebiasis, Pneumocystis\\ncarinii pneumonia (PCP), andmalaria are examples of\\ndiseases caused by protozoa.\\nDescription\\nAntiprotozoal drugs come in liquid, tablet, and\\ninjectable forms and are available only with a doctor’s\\nprescription. Some commonly used antiprotozoal\\ndrugs are metronidazole (Flagyl), eflornithine\\n334 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiprotozoal drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(Ornidyl), furazolidone (Furoxone), hydroxychloro-\\nquine (Plaquenil), iodoquinol (Diquinol, Yodoquinol,\\nYodoxin), and pentamidine (Pentam 300).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantiprotozoal drug, its strength, and the medical pro-\\nblem for which it is being used. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage. Always\\ntake antiprotozoal drugs exactly as directed.\\nPrecautions\\nSome people feel dizzy, confused, lightheaded, or\\nless alert when using these drugs. The drugs may also\\ncause blurred vision and other vision problems. For\\nthese reasons, anyone who takes these drugs should\\nnot drive, use machines or do anything else that might\\nbe dangerous until they have found out how the drugs\\naffect them.\\nThe antiprotozoal drug furazolidone may cause\\nvery dangerous side effects when taken with certain\\nfoods or beverages. Likewise, metronidazole (Flagyl)\\ncan cause serious liver damage if taken with alcohol.\\nCheck with the physician who prescribed the drug or\\nthe pharmacist who filled the prescription for a list of\\nproducts to avoid while taking these medicines.\\nAnyone who has ever had unusual reactions to\\nantiprotozoal drugs or related medicines should let his\\nor her physician know before taking the drugs again.\\nThe physician should also be told about anyallergies\\nto foods, dyes, preservatives, or other substances.\\nSome antiprotozoal drugs may cause problems with\\nthe blood. This can increase the risk of infection or\\nexcessive bleeding. Patientstaking these drugs shouldbe\\ncareful not to injure their gums when brushing or floss-\\ning their teeth or using a toothpick. They shouldcheck\\nwith the physician before having any dentalwork done.\\nCare should also be taken to avoidcuts from razors, nail\\nclippers, or kitchen knives, orhousehold tools. Anyone\\nwho has any of these symptoms while taking antiproto-\\nzoal drugs should call the physician immediately:\\n/C15Fever or chills\\n/C15Signs of cold or flu\\n/C15Signs of infection, such as redness, swelling, or\\ninflammation\\n/C15Unusual bruising or bleeding\\n/C15Black, tarry stools\\n/C15Blood in urine or stools\\n/C15Pinpoint red spots on the skin\\n/C15Unusual tiredness or weakness.\\nAnyone taking this medicine should also check with\\na physician immediately if any of these symptoms occur:\\n/C15Blurred vision or other vision changes\\n/C15Skin rash,hives,o ritching\\n/C15Swelling of the neck\\n/C15Clumsiness or unsteadiness\\n/C15Numbness, tingling, pain, or weakness in the hands\\nor feet\\n/C15Decrease in urination.\\nChildren are especially sensitive to the effects of\\nsome antiprotozoal drugs.Never give this medicine to a\\nchild unless directed to do so by a physician, and always\\nkeep this medicine out of the reach of children. Use\\nsafety vials.\\nThe effects of antiprotozoal drugs on pregnant\\nwomen have not been studied. However, in experi-\\nments with pregnant laboratory animals, some anti-\\nprotozoal drugs cause birth defects or death of the\\nfetus. Women who are pregnant or who plan to\\nbecome pregnant should check with their physicians\\nbefore taking antiprotozoal drugs. Mothers who are\\nbreastfeeding should also check with their physicians\\nabout the safety of taking these drugs.\\nBefore using antiprotozoal drugs, people with any\\nof these medical problems should make sure their\\nphysicians are aware of their conditions:\\nKEY TERMS\\nAmebiasis— An infection caused by an ameba,\\nwhich is a type of protozoan.\\nFetus— A developing baby inside the womb.\\nGiardiasis— A condition in which the intestines are\\ninfected with Giardia lamblia, a type of protozoan.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nParasite— An organism that lives and feeds in or on\\nanother organism (the host) and does nothing to\\nbenefit the host.\\nPneumocystis carinii pneumonia— A severe\\nlung infection caused by a parasitic protozoan.\\nThe disease mainly affects people with weakened\\nimmune systems, such as people with AIDS.\\nGALE ENCYCLOPEDIA OF MEDICINE 335\\nAntiprotozoal drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Anemia or other blood problems\\n/C15Kidney disease\\n/C15Heart disease\\n/C15Low blood pressure\\n/C15Diabetes\\n/C15Hypoglycemia (low blood sugar)\\n/C15Liver disease\\n/C15Stomach or intestinal disease\\n/C15Nerve or brain disease or disorder, including convul-\\nsions (seizures)\\n/C15Psoriasis (a skin condition)\\n/C15Hearing loss\\n/C15Deficiency of the enzyme glucose-6-phosphate dehy-\\ndrogenase (G6PD)\\n/C15Eye or vision problems\\n/C15Thyroid disease.\\nSide effects\\nThe most common side effects arediarrhea, nau-\\nsea, vomiting, and stomach pain. These problems\\nusually go away as the body adjusts to the drug and\\ndo not require medical treatment.\\nOther rare side effects may occur. Anyone who\\nhas unusual symptoms after taking an antiproto-\\nzoal drug should get in touch with his or her\\nphysician.\\nInteractions\\nAntiprotozoal drugs may interact with other med-\\nicines. When this happens, the effects of one or both of\\nthe drugs may change or the risk of side effects may be\\ngreater. Anyone who takes antiprotozoal drugs should\\nlet the physician know all other medicines he or she is\\ntaking. Among the drugs that may interact with anti-\\nprotozoal drugs are:\\n/C15Alcohol\\n/C15Anticancer drugs\\n/C15Medicine for overactive thyroid\\n/C15Antiviral drugs such as zidovudine (Retrovir)\\n/C15Antibiotics\\n/C15Medicine used to relieve pain or inflammation\\n/C15Amphetamine\\n/C15Diet pills (appetite suppressants)\\n/C15Monoamine oxidase inhibitors (MAO inhibitors)\\nsuch as phenelzine (Nardil) and tranylcypromine\\n(Parnate), used to treat conditions including depres-\\nsion and Parkinson’s disease.\\n/C15Tricyclic antidepressants such as amitriptyline\\n(Elavil) and imipramine (Tofranil)\\n/C15Decongestants such as phenylephrine (Neo-\\nSynephrine) and pseudoephedrine (Sudafed)\\n/C15Other antiprotozoal drugs.\\nThe list above does not include every medicine\\nthat may interact with an antifungal drug. Be sure\\nto check with a physician or pharmacist before\\ncombining antifungal drugs with any other pre-\\nscription or nonprescripti on (over-the-counter)\\nmedicine.\\nNancy Ross-Flanigan\\nAntipruritic drugs see Anti-itch drugs\\nAntipsychotic drugs\\nDefinition\\nAntipsychotic drugs are a class of medicines used\\nto treat psychosis and other mental and emotional\\nconditions.\\nPurpose\\nPsychosis is defined as ‘‘a serious mental disorder\\n(as schizophrenia) characterized by defective or lost\\ncontact with reality often withhallucinations or delu-\\nsions.’’ Psychosis is an end-stage condition arising\\nfrom a variety of possible causes. Anti-psychotic\\ndrugs control the symptoms of psychosis, and in\\nmany cases are effective in controlling the symptoms\\nof other disorders that may lead to psychosis, includ-\\ning bipolar mood disorder (formerly termed manic-\\ndepressive), in which the patient cycles from severe\\ndepression to feelings of extreme excitation. This\\nclass of drugs is primarily composed of the major\\ntranquilizers; however, lithium carbonate, a drug\\nthat is largely specific to bipolar mood disorder, is\\ncommonly classified among the antipsychotic agents.\\nDescription\\nThe antipsychotic agents may be divided by che-\\nmical class. The phenothiazines are the oldest group,\\nand include chlorpromazine (Thorazine), mesoridazine\\n336 GALE ENCYCLOPEDIA OF MEDICINE\\nAntipsychotic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(Serentil), prochlorperazine (Compazine), and thiori-\\ndazine (Mellaril). These drugs are essentially similar in\\naction and adverse effects. They may also be used as\\nanti-emetics, although prochlorperazine is the drug\\nmost often used for this indication.\\nThe phenylbutylpiperadines are haloperidol\\n(Haldol) and pimozide (Orap). They find primary\\nuse in control of Tourette’s syndrome. Haloperidol\\nhas been extremely useful in controlling aggressive\\nbehavior.\\nThe debenzapine derivatives, clozapine (Clozaril),\\nloxapine (Loxitane), olanzapine (Zyprexa) and quetia-\\npine (Seroquel), have been effective in controlling psy-\\nchotic symptoms that have not been responsive to\\nother classes of drugs.\\nThe benzisoxidil group is composed of resperidone\\n(Resperidal) and ziprasidone (Geodon). Resperidone\\nhas been found useful for controlling bipolar mood\\ndisorder, while ziprasidone is used primarily as sec-\\nond-line treatment for schizophrenia.\\nIn addition to these drugs, the class of antipsycho-\\ntic agents includes lithium carbonate (Eskalith,\\nLithonate), which is used for control of bipolar\\nmood disorder, and thiothixene (Navane), which is\\nused in the treatment of psychosis.\\nNewer agents\\nSome newer antipsychotic drugs have been\\napproved by the Food and Drug administration\\n(FDA) in the early 2000s. These drugs are sometimes\\ncalled second-generation antipsychotics or SGAs.\\nAripiprazole (Abilify), which is classified as a partial\\ndopaminergic agonist, received FDA approval in\\nAugust 2003. Two drugs that are still under investiga-\\ntion, a neurokinin antagonist and a serotonin 2A/2C\\nantagonist respectively, show promise in the treatment\\nof schizophrenia andschizoaffective disorder.\\nRecommended dosage\\nDose varies with the drug, condition being trea-\\nted, and patient response. See specific references.\\nPrecautions\\nNeuroleptic malignant syndrome (NMS). NMS is\\na rare, idiosyncratic combination of extra-pyramidal\\nsymptoms (EPS), hyperthermia, and autonomic dis-\\nturbance. Onset may be hours to months after drug\\ninitiation, but once started, proceeds rapidly over\\n24 to 72 hours. It is most commonly associated with\\nhaloperidol, long-acting fluphenazine, but has occurred\\nwith thiothixene, thioridazine, and clozapine, and may\\nAntipsychotic Drugs\\nBrand Name (Generic\\nName) Possible Common Side Effects Include:\\nClozaril (clozapine) Seizures, agranulocytosis, dizziness,\\nincreased blood pressure\\nCompazine\\n(prochlorperazine)\\nInvoluntary muscle spasms, dizziness,\\njitteriness, puckering of the mouth\\nHaldol (haloperidol) Involuntary muscle spasms, blurred vision,\\ndehydration, headache, puckering of the\\nmouth\\nMellaril (thioridazine) Involuntary muscle spasms, constipation and\\ndiarrhea, sensitivity to light\\nNavane (thiothixene) Involuntary muscle spasms, dry mouth, rash,\\nhives\\nRisperdal\\n(risperidone)\\nInvoluntary muscle spasms, abdominal and\\nchest pain, fever, headache\\nStelazine (trifluopera-\\nzine hydrochloride)\\nInvoluntary muscle spasms, drowsiness,\\nfatigue\\nThorazine\\n(chlorpromazine)\\nInvoluntary muscle spasms, labored breathing,\\nfever, puckering of the mouth\\nTriavil Involuntary muscle spasms, disorientation,\\nexcitability, lightheadedness\\nKEY TERMS\\nAgranulocytosis— An acute condition marked by\\nsevere depression of the bone marrow, which pro-\\nduces white blood cells, and by prostration, chills,\\nswollen neck, and sore throat sometimes with local\\nulceration. Aalso called agranulocytic angina or\\ngranulocytopenia.\\nAnticholinergic— Blocking the action of the neuro-\\nhormone acetylcholine. The most obvious effects\\ninclude dry mouth and dry eyes.\\nAnticonvulsants— A class of drugs given to control\\nseizures.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies,\\nor adverse effects in animals, but not in well-con-\\ntrolled human studies. Category C: No adequate\\nhuman or animal studies, or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nGALE ENCYCLOPEDIA OF MEDICINE 337\\nAntipsychotic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='occur with other agents. NMS is potentially fatal, and\\nrequires intensive symptomatic treatment and immedi-\\nate discontinuation of neuroleptic treatment. There is\\nno established treatment. Most patients who develop\\nNMS will have the same problem if the drug is\\nrestarted.\\nAgranulocytosis has been associated with cloza-\\npine. This is a potentially fatal reaction, but can be\\nprevented with careful monitoring of the whiteblood\\ncount. There are no well-established risk factors for\\ndeveloping agranulocytosis, and so all patients treated\\nwith this drug must follow the clozapine Patient\\nManagement System. For more information, the\\nreader should call 1-800-448-5938.\\nAnticholinergic effects, particularly dry mouth,\\nhave been reported with all of the phenothiazines,\\nand can be severe enough to cause patients to discon-\\ntinue their medication.\\nPhotosensitization is a common reaction to chlor-\\npromazine. Patients must be instructed to use precau-\\ntions when exposed to sunlight.\\nLithium carbonate commonly causes increased\\nfrequency of urination.\\nThe so-called atypical antipsychotics are asso-\\nciated with a substantial increase in the risk of devel-\\noping diabetes mellitus. A study done at the University\\nof Rochester (New York) reported in 2004 that 15.2%\\nof patients receiving atypical antipsychotics developed\\ndiabetes, compared with 6.3% of patients taking other\\nantipsychotic medications.\\nAntipsychotic drugs are pregnancy category C.\\n(Clozapine is category B.) The drugs in this class\\nappear to be generally safe for occasional use at low\\ndoses during pregnancy, but should be avoided near\\ntime of delivery. Although the drugs do not appear\\nto be teratogenic, when used near term, they may\\ncross the placenta and have adverse effects on the\\nnewborn infant, including causing involuntary\\nmovements. There is no information about safety\\nin breast feeding.\\nAs a class, the antipsychotic drugs have a large\\nnumber of potential side effects, many of them serious.\\nBecause of the potential severity of side effects, these\\ndrugs must be used with special caution in children.\\nSpecific references should be consulted.\\nInteractions\\nBecause the phenothiazines have anticholinergic\\neffects, they should not be used in combination with\\nother drugs that may have similar effects.\\nBecause the drugs in this group may causehypo-\\ntension, or low blood pressure, they should be used\\nwith extreme care in combination with blood pressure-\\nlowering drugs.\\nThe antipsychotic drugs have a large number of\\ndrug interactions. Consult specific references.\\nResources\\nBOOKS\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Childhood Psychosis.’’ Section 19, Chapter 274 InThe\\nMerck Manual of Diagnosis and Therapy.Whitehouse\\nStation, NJ: Merck Research Laboratories, 2002.\\nBeers, Mark H., MD, and Robert Berkow, MD., editors.\\n‘‘Psychiatric Emergencies.’’ Section 15, Chapter 194\\nIn The Merck Manual of Diagnosis and Therapy.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2002.\\nWilson, Billie Ann, Margaret T. Shannon, and Carolyn L.\\nStang. Nurse’s Drug Guide 2003.Upper Saddle River,\\nNJ: Prentice Hall, 2003.\\nPERIODICALS\\nDeLeon, A., N. C. Patel, and M. L. Crismon. ‘‘Aripiprazole:\\nA Comprehensive Review of Its Pharmacology, Clinical\\nEfficacy, and Tolerability.’’Clinical Therapeutics26\\n(May 2004): 649–666.\\nEmsley, R., H. J. Turner, J. Schronen, et al. ‘‘A Single-Blind,\\nRandomized Trial Comparing Quetiapine and\\nHaloperidol in the Treatment of Tardive Dyskinesia.’’\\nJournal of Clinical Psychiatry65 (May 2004): 696–701.\\nLamberti, J. S., J. F. Crilly, K. Maharaj, et al. ‘‘Prevalence of\\nDiabetes Mellitus among Outpatients withSevere Mental\\nDisorders Receiving Atypical Antipsychotic Drugs.’’\\nJournal of Clinical Psychiatry65 (May 2004): 702–706.\\nMeltzer, H. Y., L. Arvanitis, D. Bauer, et al. ‘‘Placebo-\\nControlled Evaluation of Four Novel Compounds for\\nthe Treatment of Schizophrenia and Schizoaffective\\nDisorder.’’ American Journal of Psychiatry161 (June\\n2004): 975–984.\\nStahl, S. M. ‘‘Anticonvulsants as Mood Stabilizers and\\nAdjuncts to Antipsychotics: Valproate, Lamotrigine,\\nCarbamazepine, and Oxcarbazepine and Actions at\\nVoltage-Gated Sodium Channels.’’Journal of Clinical\\nPsychiatry 65 (June 2004): 738–739.\\nORGANIZATIONS\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888) INFO-\\nFDA. .\\nSamuel D. Uretsky, PharmD\\nRebecca J. Frey, PhD\\n338 GALE ENCYCLOPEDIA OF MEDICINE\\nAntipsychotic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Antipsychotic drugs, atypical\\nDefinition\\nThe atypical antipsychotic agents, sometimes\\ncalled the ‘‘novel’’ antipsychotic agents are a group\\nof drugs which are different chemically from the older\\ndrugs used to treat psychosis. The ‘‘conventional’’\\nantipsychotic drugs are classified by their chemical\\nstructures as the phenothiazines, thioxanthines\\n(which are chemically very similar to the phenothia-\\nzines), butyrophenones, diphenylbutylpiperadines\\nand the indolones. All of the atypical antipsychotic\\nagents are chemically classified as dibenzepines. They\\nare considered atypical or novel because they have\\ndifferent side effects from the conventional antipsy-\\nchotic agents. The atypical drugs are far less likely to\\ncause extra-pyrammidal side-effects(EPS), drug\\ninduced involuntary movements, than are the older\\ndrugs. The atypical antipsychotic drugs may also be\\neffective in some cases that are resistant to older drugs.\\nThe drugs in this group are clozapine (Clozaril),\\nloxapine (Loxitane), olanzapine (Zyprexa), and que-\\ntiapine (Seroquel).\\nPurpose\\nThe antipsychotic drugs are used to treat severe\\nemotional disorders. Although there may be different\\nnames for these disorders, depending on severity and\\nhow long the symptoms last, psychotic disorders all\\ncause at least one of the following symptoms:\\nLoxapine has also been used to treatanxiety with\\nmental depression.\\nRecommended dosage\\nThe recommended dose depends on the drug, the\\npatient, and the condition being treated. The normal\\npractice is to start each patient at a low dose, and\\ngradually increase the dose until a satisfactory\\nresponse is achieved. The odse should be held at the\\nlowest level that gives satisfactory results.\\nClozapine usually requires doses between 300 and\\n600 milligrams a day, but some people require as much\\nas 900 milligrams/day. Doses higher than 900 mill-\\ngrams/day are not recommended.\\nLoxapine is usually effective at doses of 60-100\\nmilligrams/day, but may be used in doses as high as\\n250 mg/day if needed.\\nOlanzapine doses vary with the condition being\\ntreated. The usual maximum dose is 20 milligrams/day.\\nQuetiapine may be dosed anywhere from 150-750\\nmilligrams/day, depending on how well the patient\\nresponds.\\nPrecautions\\nAlthough the atypical antipsychotics are generally\\nsafe, clozapine has been associated with severe agra-\\nnulocytosis, a shortage of white blood cells. For this\\nreason, people who may be treated with clozapine\\nshould have blood counts before starting the drug,\\nblood counts every week for as long as they are using\\nclozapine, and blood counts every week for the first\\n4 weeks after they stop taking clozapine. If there is any\\nevidence of a drop in the whiteblood countwhile using\\nclozapine, the drug should be stopped.\\nAtypical antipsychotics should not be used in\\npatients with liver damage, brain or circulatory pro-\\nblems, or some types of blood problems.\\nAllergies\\nPeople who have had an allergic reaction to one of\\nthe atypical antipsychotics should not use that\\nKEY TERMS\\nAnxiety— An abnormal and overwhelming sense of\\napprehension and fear often marked by physiological\\nsigns (as sweating, tension, and increased pulse), by\\ndoubt concerning the reality and nature of the threat,\\nand by self-doubt about one’s capacity to cope with it.\\nDelusions— A false belief regarding the self or per-\\nsons or objects outside the self that persists despite\\nthe facts.\\nDepression— A state of being depressed marked\\nespecially by sadness, inactivity, difficulty with\\nthinking and concentration, a significant increase or\\ndecrease in appetite and time spent sleeping, feelings\\nof dejection and hopelessness, and sometimes suici-\\ndal thoughts or an attempt to commit suicide.\\nGlucocorticoid— Any of a group of corticosteroids\\n(as hydrocortisone or dexamethasone) that are anti-\\ninflammatory and immunosuppressive, and that\\nare used widely in medicine (as in the alleviation\\nof the symptoms of rheumatoid arthritis).\\nPsychosis— A serious mental disorder character-\\nized by defective or lost contact with reality often\\nwith hallucinations or delusions.\\nGALE ENCYCLOPEDIA OF MEDICINE 339\\nAntipsychotic drugs, atypical'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='medication again. However, sometimes it is possible to\\nuse a different drug from the same group safely.\\nPregnancy\\nThe atypical antipsychotics have not been proved\\nsafe in pregnancy. They should be used only when\\nclearly needed and when potential benefits outweigh\\npotential hazards to the fetus. These drugs have not\\nbeen reported in human milk.\\nSide effects\\nAlthough the atypical antipsychotics are less\\nlikely to cause involuntary movements than the older\\nantipsychotic drugs, they still have a large number of\\nadverse effects. The following list is not complete.\\nReview each drug individually for a full list of possible\\nadverse effects.\\nInteractions\\nTaking atypical antipsychotic medications with\\ncertain other drugs may affect the way the drugs work\\nor may increase the chance of side effects. While taking\\nantipsychotic drugs, do not take any other prescription\\nor nonprescription (over-the-counter) drugs without\\nfirst checking with a physician.\\nBecause the atypical antipsychotics may cause\\nlowering of blood pressure, care should be used when\\nthese drugs are taken at the same time as other drugs\\nwhich lower blood pressure.\\nQuetiapine has many interactions. Doses should\\nbe carefully adjusted when quetiapine is used with\\nketoconazole, itraconazole, fluconazole, erythromy-\\ncin, carbamazepine, barbiturates, rifampin or gluco-\\ncorticoids including prednisone, dexamethasone and\\nmethylprednisolone.\\nThese drugs will also require dose adjustments\\nwhen used with anti-Parkinson medications.\\nResources\\nBOOKS\\nBrain Basics: An Integrated Biological Approach to\\nUnderstanding and Assessing Human Behavior.Phoenix:\\nBiological-Psychiatry-Institute, June 1999.\\nPERIODICALS\\nMcDougle, C. J. ‘‘A double-blind, placebo-controlled study\\nof risperidone addition in serotonin reuptake inhibitor-\\nrefractory obsessive-compulsive disorder.’’Archives of\\nGeneral PsychiatryAugust 2000: 794.\\nSamuel D. Uretsky, PharmD\\nAnti-rejection drugs\\nDefinition\\nAnti-rejection drugs are daily medications taken by\\norgan transplant patients to prevent organ rejection.\\nPurpose\\nAnti-rejection drugs, which are also called immuno-\\nsuppressants, help to suppress the immune system’s\\nresponse to a new organ. When a new organ is placed\\ninside a patient s body, the patient’s immune system\\nrecognizes the organ as foreign tissue and tries to reject it.\\nDescription\\nWhen a physician prescribes anti-rejection drugs,\\nthe patient’s risk of rejection and susceptibility to side\\neffects are considered. The most common drugs pre-\\nscribed to prevent organ rejection are cyclosporine,\\nprednisone, azathioprine, tacrolimus or FK506,\\nmycophenolate mofetil, sirolimus, and OKT3, as well\\nas ATGAM and Thymoglobulin. As is true with all\\nmedications, each of these drugs has benefits and\\ndrawbacks. Cyclosporine, which is one of the most\\nfrequently used anti-rejection drugs, is usually com-\\nbined with prednisone. An extremely powerful medi-\\ncine, cyclosporine is usually taken by a patient over the\\ncourse of his or her lifetime. Cortisol, which is the\\nnaturally produced form of prednisone in a person’s\\nbody, helps the body managestress, such as infections\\nor organ rejection. Taking prednisone results in less\\ncortisol production in a person’s body, thus minimizing\\nthe risk of rejection. Azathioprine, which needs to be\\ntaken with food to avoid stomach upset, is frequently\\ncombined with cyclosporine, prednisone, or tacrolimus.\\nMycophenolate mofetil is a relatively new immunosup-\\npressant that is similar to azathioprine; therefore, the\\ntwo drugs should not be taken together. It is preferable\\nto take mycophenolate mofetil on an empty stomach;\\nhowever, like azathioprine, it can be taken with food\\nbecause it, too, can cause stomach problems, such as\\nheartburn and nausea. Like azathioprine, mycopheno-\\nlate mofetil is not a stand-alone drug; instead, it must be\\nused, in combination with other medications. This is\\nalso the case with regard to sirolimus.\\nPhysicians prescribe either mycophenolate mofetil\\nor azathioprine (in combination with otherimmuno-\\nsuppressant drugs) to help patients cope with acute\\nbouts of organ rejection. The medications work by\\ninterfering with the multiplication process of white\\nblood cells, which is part of the body’s natural defense\\n340 GALE ENCYCLOPEDIA OF MEDICINE\\nAnti-rejection drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='system when foreign invaders, such as a new organ, are\\ndetected. However, researchers at Duke University\\nand the University of Florida found that mycopheno-\\nlate mofetil doesn’t work any better than azathioprine,\\nbut costs significantly more. Aside from cost, another\\nconsideration also needs to be the type of organ trans-\\nplanted, because acute rejection rates differ. For\\nexample, six months after surgery, approximately\\n15% of kidney recipients will have an acute rejection\\nepisode as compared to approximately 60% of lung\\nrecipients. And because study results vary depending\\non the organ transplanted, more research is needed\\nwith regard to the success of mycophenolate mofetil as\\ncompared to azathioprine.\\nOKT3 prevents is prescribed to prevent organ rejec-\\ntion immediately after surgery and is also used to treat\\nacute rejection episodes; ATGAM and Thymoglobulin,\\nwhich are similar to OKT3, are used for the same rea-\\nsons. All three drugs are given intravenously.\\nTacrolimus, which is also known as FK506, is a\\nfairly new drug that is considered by many experts to\\nbe as effective as cyclosporine. An alternative drug\\nchoice for patients that cannot tolerate cyclosporine,\\ntacrolimus has been the subject of much research in\\nrecent years. Used to treat rejection episodes that are\\nacute or chronic in nature, tacrolimus is being studied\\nto see if using it will allow patients to reduce their\\ndosage of prednisone without organ rejection.\\nIn a presentation at the 2003 American\\nTransplant Congress, surgeons from the University\\nof Pittsburgh reported that an innovative clinical pro-\\ntocol developed by Dr. Thomas E. Starzl was imple-\\nmented, which reduced the dosage of tacrolimus\\nneeded by lung transplant patients with excellent suc-\\ncess. Patients required lower doses of prednisone as\\nwell. In fact, in some cases, patients were taking tacro-\\nlimus only once a day (rather than twice a day) or only\\nfour times a week. Over the long-term, physicians\\nhope that there will be less risk of lung recipients\\ndeveloping the kinds of complications normally asso-\\nciated with high levels of immunosuppressants, such\\nas kidney dysfunction, which is a common problem\\nfaced by lung transplant patients.\\nDr. Thomas E. Strazl, the renowned physician\\noften referred to as the modern-day father of transplan-\\ntation, developed the protocol based on the knowledge\\nthat some of his patients had stopped taking their daily\\npills with no ill effects. Starzl theorized that giving sev-\\neral drugs to a patient immediately after surgery, which\\nwas the normal practice, might inhibit the immune sys-\\ntem from developing a tolerance for the new organ.\\nTherefore, his new protocol embraced a different\\napproach. Shortly before the transplantation, patients\\nwere given a drug that killed their T-cells and after the\\noperation, patients received only one anti-rejection\\nmedicine rather than the multi-pill cocktail normally\\nprescribed. In an article published byLancet in 2003,\\nStarzl and colleagues reported the results of their pilot\\nstudy involving 82 two kidney, liver, pancreas or small\\nbowel transplant patients treated according to the new\\ndrug protocol. Out of the 72 patients with successful\\ntransplants after one year, over half the patients were\\ntaking anti-rejection medication either every other day,\\nthree times per week or twice per week. Amazingly, 11 of\\nthe patients were taking only one pill a week and they\\nexhibited no signs of organ rejection or complications.\\nCertainly more research needs to be conducted, but\\nthese results are very promising.\\nRecommended dosage\\nThe dosages vary depending on the drug or drug\\ncombination being taken by the patient. In general,\\ncyclosporine is taken every 12 hours in liquid or capsule\\nform. Tacrolimus is generally taken every 12 hours as\\nw e l l .T h el e v e lo fe i t h e rd r u gi nap a t i e n t ’ sb l o o di s\\nmonitored carefully and doses are adjusted accordingly\\nin order to not only prevent reject, but also unpleasant\\nside effects. Azathioprine is taken once a day in tablet\\nform, whereas mycophenolate mofetil is generally taken\\nevery 12 hours. High doses of prednisone are usually\\ngiven at first and then tapered down slowly.\\nPrecautions\\nPatients should discuss proper storage methods\\nwith regard to their medications. Sirolimus, for exam-\\nple, should be stored at room temperature with special\\ncare taken to keep it out of excessive heat and humidity.\\nAlthough pregnant women taking anti-rejection\\ndrugs have delivered healthy babies, women planning\\non becoming pregnant while taking anti-rejection\\ndrugs should talk with their physicians regarding any\\npossible complications. For example, the safety of\\ntaking mycophenolate mofetil during pregnancy or\\nwhile breastfeeding is questionable and not advised.\\nSide effects\\nSide effects vary depending on the individual and\\nthe drug therapy chosen. Patients should talk with\\ntheir doctors regarding the various side effects they\\ncan expect and under what conditions emergency\\nmedical care needs to be sought.\\nInteractions\\nIt is essential that patients talk with their pharma-\\ncist and transplant team before taking any medications,\\nGALE ENCYCLOPEDIA OF MEDICINE 341\\nAnti-rejection drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='regardless of whether they are prescription or over-the-\\ncounter drugs to ensure that the combinations will\\nnot interact. For example,antacids can diminish the\\neffectiveness of mycophenolate mofetil and drugs used\\nto treat high cholesterol may increase the potency of\\nsirolimus. In addition, certain food products can also\\nalter the potency of some anti-rejection drugs. For\\nexample, grapefruit and grapefruit juice can cause\\ncyclosporine blood levels to increase.\\nResources\\nPERIODICALS\\nMazariegos, G. V., Zahorchak, A. F., Reyes, J., et al.\\n‘‘Dendritic cell subset ratio in peripheral blood\\ncorrelates with successful withdrawal of\\nimmunosuppression in liver transplant patients.’’\\nAmerican Journal of Transplantation3 (2003): 689–696.\\nStarzl, T. E., Murase, N., Abu-Elmagd, K., et al.\\n‘‘Tolerogenic immunosuppression for organ\\ntransplantation.’’ Lancet 361 (2003): 1502–1510.\\nOTHER\\nRoss, Melanie Fridl ‘‘Duke/UF Researchers compare\\nanti-rejection medicines in lung transplant patients.’’\\nUniversity of Florida9 Aug 2001 University of Florida\\nNews. 22 Feb 2005 .\\nRossi, Lisa ‘‘Studies of liver transplant patients off\\nanti-rejection drugs have altered cell profile.’’\\nUniversity of Pittsburgh Medical Center2 June 2003\\nUniversity of Pittsburgh Medical Center. 22 Feb 2005\\n.\\nSrikameswaran, Anita ‘‘Protocol reduces transplant patients\\nneed for anti-rejection drugs.’’Post-Gazette.com Health\\nand Science 2 May 2003 PG Publishing Company, Inc.\\n22 Feb 2005 .\\nUniversity of Pittsburgh Medical Center ‘‘Our Experts:\\nThomas E. Starzl, M.D., Ph.D.’’University of\\nPittsburgh Medical Center2005 University of\\nPittsburgh Medical Center. 22 Feb 2005 .\\nLee Ann Paradise\\nAntiretroviral drugs\\nDefinition\\nAntiretroviral drugs inhibit the reproduction of\\nretroviruses—viruses composed of RNA rather than\\nDNA. The best known of this group is HIV, human\\nimmunodeficiency virus, the causative agent ofAIDS.\\nPurpose\\nAntiretroviral agents are virustatic agents which\\nblock steps in the replication of the virus. The drugs\\nare not curative; however continued use of drugs,\\nparticularly in multi-drug regimens, significantly\\nslows disease progression.\\nDescription\\nThere are three main types of antiretroviral drugs,\\nalthough only two steps in the viral replication process\\nare blocked. Nucleoside analogs, or nucleoside reverse\\ntranscriptase inhibitors (NRTIs), such as didanosine\\n(ddI, Videx), lamivudine (3TC, Epivir), stavudine\\n(d4T, Zerit), zalcitabine (ddC, Hivid), and zidovudine\\n(AZT, Retrovir), act by inhibiting the enzyme reverse\\ntranscriptase. Because a retrovirus is composed of\\nRNA, the virus must make a DNA strand in order to\\nreplicate itself. Reverse transcriptase is an enzyme that\\nis essential to making the DNA copy. The nucleoside\\nreverse transcriptase inhibitors are incorporated into\\nthe DNA strand. This is a faulty DNA molecule that is\\nincapable of reproducing.\\nThe non-nucleoside reverse transcriptase inhibitors\\n(NNRTIs), such as delavirdine (Rescriptor), loviride,\\nand nevirapine (Viramune) act by binding directly to\\nthe reverse transcriptase molecule, inhibiting its\\nactivity.\\nA fourth class of drugs was under clinical trials in\\n2003. Called fusion inhibitors, they block HIV from\\nfusing with healthy cells. The first to receive FDA\\napproval will likely be a drug called Enfurvitide.\\nBecause HIV mutates readily, the virus can\\ndevelop resistance to single drug therapy. However,\\ntreatment with drug combinations appears to produce\\na durable response. Proper treatment appears to\\nslow the progression of HIV infections and reduce\\nthe frequency of opportunistic infections. One of the\\nmost notable advances in recent years has been the\\nsuccess of highly active antiretroviral therapy\\n(HAART). This multidrug approach reduced the\\nrisk of opportunistic infections in persons with HIV/\\nAIDS and slowed the progression of the disease and\\ndeath. Usually, patients receive triple combination\\ntherapy, however research in 2003 showed a new\\nonce-daily regimen of quadruple therapy effective.\\nThe combination included adefovir, lamivudine,\\ndidanosine, and efavirenz. In short, the scientific com-\\nmunity continues to make rapid advancements in\\ndeveloping and evaluating antiretroviral drug therapy.\\nIt is best to keep well informed and frequently check\\nwith a physician.\\n342 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiretroviral drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nDoses must be individualized based on the patient\\nand use of interacting drugs. The optimum combina-\\ntions of antiretroviral drugs have not been determined,\\nnor is there agreement on the stage of infection at\\nwhich to start treatment. In fact, starting treatment\\ntoo early has led to unwanted side effects in some\\npatients or problems with patient readiness to comply.\\nTreatment should begin when the time and circum-\\nstances are right.\\nPrecautions\\nAlthough the antiretroviral drugs fall into several\\ngroups, each drug has a unique pattern of adverse\\neffects anddrug interactions. Since the drugs are used\\nin various combinations, the frequency and severity\\nof adverse effects will vary with the combination.\\nAlthough most drug combinations show a higher\\nrate of adverse events than single drug therapy,\\nsome patterns are not predictable. For example, indi-\\nnavir has been reported to causeinsomnia in 3% of\\npatients, however, when used in combination with\\nzidovudine, only 1.5% of patients complained of\\nsleep difficulties.\\nThe most severe adverse effects associated with\\nthe protease inhibitors are kidney and liver toxicity.\\nPatients also have reported a syndrome of abdominal\\ndistention (selling and expansion) and increased body\\nodor, which may be socially limiting. Hemophilic\\npatients have reported increased bleeding tendencies\\nwhile taking protease inhibitors. The drugs arepreg-\\nnancy category B. There have been no controlled stu-\\ndies of safety in pregnancy. HIV-infected mothers are\\nadvised not to breast feed in order to prevent transmis-\\nsion of the virus to the newborn.\\nThe nucleoside reverse transcriptase inhibitors\\nhave significant levels of toxicity. Lactic acidosis in\\nthe absence of hypoxemia and severe liver enlargement\\nwith fatty degeneration have been reported with zido-\\nvudine and zalcitabine, and are potentially fatal. Rare\\ncases of liver failure, considered possibly related to\\nunderlying hepatitis B and zalcitabine monotherapy,\\nhave been reported.\\nAbacavir has been associated with fatal hyper-\\nsensitivity reactions. Didanosine has been associated\\nwith severe pancreatitis . Nucleoside reverse tran-\\nscriptase inhibitors are pregnancy category C.\\nThere is limited information regarding safety during\\npregnancy. Zidovudine has been used during preg-\\nnancy to reduce the risk of HIV infection to the\\ninfant. HIV-infected mothers are advised not to\\nbreast feed in order to prevent transmission of the\\nvirus to the newborn.\\nEfavirenz has been associated with a high fre-\\nquency of skin rash, 27% in adults and 40% in child-\\nren. Nevirapine has been associated with severe liver\\ndamage and skin reactions. All of the non-nucleoside\\nreverse transcriptase inhibitors are pregnancy cate-\\ngory C, based on animal studies.\\nUsing antiretroviral drugs in combination also\\nhelps lower risk of developing viral resistance. Fifty\\npercent of patients who fail antiretroviral therapy are\\nKEY TERMS\\nAntiviral drugs— Medicines that cure or control\\nvirus infections.\\nBioavailability— A measure of the amount of drug\\nthat is actually absorbed from a given dose.\\nHypoxemia— Lower than normal oxygenation of\\narterial blood.\\nImmune system— The body’s natural defenses\\nagainst disease and infection.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nPancreas— A gland located beneath the stomach.\\nThe pancreas produces juices that help break down\\nfood and secretes insulin that helps the body use\\nsugar for energy.\\nInsomnia— A sleep disorder characterized by\\ninability to either fall asleep or to stay asleep.\\nMutates— Undergoes a spontaneous change in the\\nmake-up of genes or chromosomes.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B:\\nAnimal studies indicate no fetal risk, but no\\nhuman studies; or adverse effects in animals, but\\nnot in well-controlled human studies. Category C:\\nNo adequate human or animal studies; or adverse\\nfetal effects in animal studies, but no available\\nhuman data. Category D: Evidence of fetal risk,\\nbut benefits outweigh risks. Category X: Evidence\\nof fetal risk. Risks outweigh any benefits.\\nRetrovirus— A virus composed of ribonucleic acid\\n(RNA) instead of deoxynucleic acid (DNA).\\nVirus— A tiny, disease-causing particle that can\\nreproduce only in living cells.\\nGALE ENCYCLOPEDIA OF MEDICINE 343\\nAntiretroviral drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='resistant to one class of drug. Recent research into\\nmultiple drugs and combinations is promising.\\nInteractions\\nBecause of the high frequency of drug interactions\\nassociated with AIDS therapy, specialized references\\nshould be consulted. Use of recreational drugs while\\non antriretroviral therapy can trigger potentially lethal\\nside effects or negate the positive effects of the therapy.\\nSaquinavir is marketed in both hard and soft\\ngelatin capsules. Because saquinavir in the hard gela-\\ntin capsule formulation (Invirase) has poor bioavail-\\nability, it is recommended that this formulation only\\nbe used in combination with other drugs which inter-\\nact to raise saquinavir blood levels. Saquinavir soft\\ngelatin capsules (Fortovase) are the preferred dosage\\nform of this drug.\\nResources\\nPERIODICALS\\n‘‘Grant Awarded for Evaluation of Once-Daily\\nAntiretroviral.’’ Virus Weekly(November 26, 2002): 12.\\nIsaac, A., and D. Pillay. ‘‘New Drugs for Treating Drug\\nResistant HIV–1: Clinical Management of Virological\\nFailure Remains an Important and Difficult Issue for\\nHIV Physicians.’’Sexualy Transmitted Diseases(June\\n2003): 176–183.\\n‘‘New Therapy Strategies Focusing on Long Term: DrugsÆ\\nImpact on Heart is Debated.’’AIDS AlertApril 2003: 45.\\n‘‘Once-Daily Quadruple Regimen Safe, Effective.’’AIDS\\nWeekly (October 7, 2003): 4.\\n‘‘Recreational Drugs can Reduce Safety, Efficacy of\\nAntiretroviral Agents.’’AIDS Weekly(December 16,\\n2003): 3.\\nThanker, H.K., and M.H. Snow. ‘‘HIV Viral Suppression in\\nthe Era of Antiretroviral Therapy.’’Postgraduate\\nMedical Journal(January 2003): 36.\\nORGANIZATIONS\\nProject Inform. 205 13th Street, #2001, San Francisco, CA\\n94103. (415) 558-8669. .\\nOTHER\\nAIDS Clinical Trials Information Service website and tele-\\nphone information line. Sponsored by Centers for\\nDisease Control and Prevention, Food and Drug\\nAdministration, National Institute of Allergy and\\nInfectious Diseases, and National Library of Medicine.\\n(800) TRIALS-A or (800) 874-2572. .\\nHIV/AIDS Treatment Information Service website and\\ntelephone information line. Sponsored by Agency for\\nHealth Care Policy and Research, Centers for Disease\\nControl and Prevention, Health Resources and Services\\nAdministration, Indian Health Service, National\\nInstitutes of Health, and Substance Abuse and Mental\\nHealth Services Administration. (800) HIV-0440 (800)\\n448-0440. .\\nProject Inform National HIV/AIDS Treatment Hotline.\\n(800) 822-7422.\\nSamuel D. Uretsky, PharmD\\nTeresa G. Odle\\nAntirheumatic drugs\\nDefinition\\nAntirheumatic drugs are drugs used to treatrheu-\\nmatoid arthritis.\\nPurpose\\nRheumatoid arthritis is a progressive form of\\narthritis that has devastating effects on joints and\\ngeneral health. It is classified as an auto-immune dis-\\nease, because the disease is caused by the body’s own\\nimmune system acting against the body itself.\\nSymptoms include painful, stiff, swollen joints,fever,\\nfatigue, and loss of appetite.\\nIn recent years, there has been a change in attitude\\nconcerning the treatment of rheumatoid arthritis.\\nPhysicians now use Disease Modifying Anti-Rheumatic\\nDrugs (DMARDs) early in the history of the disease and\\na r el e s si n c l i n e dt ow a i tf o rc rippling stages before resort-\\ning to the more potent drugs. Fuller understanding of the\\nside-effects of non-steroidal anti-inflammatory drugs\\n(NSAIDs) has also stimulatedr e l i a n c eo no t h e rt y p e s\\nof antirheumatic drugs.\\nDescription\\nThe major classes of antirheumatic drugs include:\\n/C15Nonsteroidal Anti-Inflammatory Drugs (NSAIDs.\\nDrugs belonging to this class bring symptomatic\\nrelief of both inflammation andpain, but have a\\nlimited effect on the progressive bone and cartilage\\nloss associated with rheumatoid arthritis. They act\\nby slowing the body’s production of prostaglandins.\\nCommon NSAIDs include: ibuprofen (Motrin,\\nNuprin or Advil), naproxen (Naprosyn, Aleve) and\\nindomethacin (Indocin).\\n/C15Corticosteroids. These drugs are very powerful anti-\\ninflammatory agents. They are the synthetic analogs\\nof cortisone, produced by the body. Corticosteroids\\nare used to reduce inflammation and suppress\\n344 GALE ENCYCLOPEDIA OF MEDICINE\\nAntirheumatic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='activity of the immune system. The most commonly\\nprescribed are prednisone and dexamethasone.\\n/C15Disease Modifying Anti-Rheumatic Drugs\\n(DMARDs). DMARDs influence the disease process\\nitself and do not only treat symptoms, hence their\\nname. DMARDs also have anti-inflammatory effects,\\nand most were borrowed from the treatment of other\\ndiseases, such ascancer and malaria. Antimalarials\\nDMARDs include chloroquine (Aralen) and hydroxy-\\nchloroquine (Plaquenil). Powerful DMARDs include:\\nmethotrexate (Rheumatrex), sulfasalazine, cyclospor-\\nine, azathioprine (Imuran) and cyclophosphamide\\n(Cytoxan), azathioprine, sulfasalazine, penicillamine,\\nand organic gold compounds such as aurothioglucose\\n(Solganol), gold sodium thiomalate (Aurolate) and\\nauranofin (Ridaura).\\n/C15Slow-Acting Antirheumatic Drugs (SAARDs).\\nSAARDs are a special class of DMARDs and the\\neffect of these drugs is slow acting and not so quickly\\napparent as that of the NSAIDs. Examples are\\nhydroxychloroquine and aurothioglucose.\\n/C15Immunosuppresive cytotoxic drugs. This class of\\ndrugs is used if treatment with NSAIDs and\\nSAARDs have no effect. Immunosuppresive drugs\\nhave a stabilizing effect on the immune system.\\nSince the inflammation associated with chronic\\narthritis is due to malfunctions of the immune\\nsystem, use of this class of drugs has been shown\\nto be beneficial for the treatment of rheumatoid\\narthritis as well. Examples are: methotrexate,\\nmechlorethamine, cyclophosphamide, chlorambu-\\ncil, and azathioprine.\\nKEY TERMS\\nAnti-inflammatory drugs— A class of drugs that\\nlower inflammation and that includes NSAIDs and\\ncorticosteroids.\\nArthritis— A painful condition that involves inflam-\\nmation of one or more joints.\\nConception— The union of egg and sperm to form a\\nfetus.\\nCorticosteroids— A class of drugs that are synthetic\\nversions of the cortisone produced by the body. They\\nrank among the most powerful anti-inflammatory\\nagents.\\nCortisone— Glucocorticoid produced by the adrenal\\ncortex in response to stress. Cortisone is a steroid and\\nhas anti-inflammatory and immunosuppressive\\nproperties.\\nCytotoxic drugs— Drugs that function by destroying\\ncells.\\nDisease Modifying Anti-Rheumatic Drugs\\n(DMARDs)— A class of antirheumatic drugs, includ-\\ning chloroquine, methotrexate, cyclosporine, and\\ngold compounds, that influence the disease process\\nitself and do not only treat its symptoms.\\nInflammation— A process occurring in body tissues,\\ncharacterized by increased circulation and the accu-\\nmulation of white blood cells. Inflammation also occurs\\nin disorders such as arthritis and causes harmful effects.\\nInflammatory— Pertaining to inflammation.\\nImmune response— Physiological response of the\\nbody controlled by the immune system that involves\\nthe production of antibodies to fight off specific for-\\neign substances or agents (antigens).\\nImmune system— The sum of the defence mechan-\\nisms of the body that protects it against foreign sub-\\nstances and organisms causing infection.\\nImmunosuppressive— Any agent that suppresses the\\nimmune response of an individual.\\nImmunosuppresive cytotoxic drugs— A class of\\ndrugs that function by destroying cells and suppres-\\nsing the immune response.\\nMethotrexate— A drug that interferes with cell\\ngrowth and is used to treat rheumatoid arthritis as\\nwell as various types of cancer. Side-effects may\\ninclude mouth sores, digestive upsets, skin rashes,\\nand hair loss.\\nNon steroidal— Not containing steroids or cortisone.\\nUsually refers to a class of drugs called Non Steroidal\\nAnti-Inflammatory Drugs (NSAID).\\nNonsteroidal Anti-Inflammatory Drugs (NSAIDs)—\\nA class of drugs that is used to relieve pain, and\\nsymptoms of inflammation, such as ibuprofen and\\nketoprofen.\\nOsteoarthritis— A form of arthritis that occurs\\nmainly in older people and involves the gradual\\ndegeneration of the cartilage of the joints.\\nProstaglandins— Prostaglandins are produced by\\nthe body and are responsible for inflammation\\nfeatures, such as swelling, pain, stiffness, redness\\nand warmth.\\nGALE ENCYCLOPEDIA OF MEDICINE 345\\nAntirheumatic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nRecommended dosage depends on the type of\\ndrug. The prescribing physician or the pharmacist\\nprovide information for the correct dosage. The\\ndrugs must be taken exactly as directed.\\nWhen taking methotrexate for rheumatoid arthri-\\ntis, it should be taken onlyonce or twice a week as\\nprescribed, not every day. Taking it every day can lead\\nto a fatal overdose.\\nPrecautions\\nMany antirheumatic drugs such as, for example,\\nazathioprine (Imuran) and methotrexate\\n(Rheumatrex), are very powerful drugs. They are\\nusually prescribed in severe cases, when all other treat-\\nments have failed. Thus, they may have serious side\\neffects, so it is important to be monitored closely by a\\nphysician while taking any of these drugs.\\nSide effects\\nHydroxychloroquine (Plaquenil) may cause vision\\nproblems. Anyone taking it should see an ophthalmol-\\nogist (a physician who specializes in treating eyes) for a\\nthorough eye examinationevery six months.\\nMethotrexate and penicillamine may causebirth\\ndefects. Women taking these drugs must stop taking\\nthem duringpregnancy and for several months before\\na planned pregnancy. Methotrexate may also cause\\nlung damage or fertility problems and should not be\\ntaken by anyone with serious kidney orliver diseaseor\\nby anyone who drinks alcohol.\\nAzathioprine may cause birth defects if either the\\nman or woman is using it at the time of conception.\\nAnyone who uses this drug and is sexually active\\nshould consult with a physician about an effective\\nbirth control method.\\nOther common side effects of antirheumatic drugs\\ninclude abdominal cramps,diarrhea, dizziness,l o s so f\\nappetite, headache, nausea, vomiting, fever and chills,\\nand mouth sores. A variety of other side effects may\\noccur. Anyone who has unusual symptoms while taking\\nantirheumatic drugs should notify the treating physician.\\nThe gold compounds may cause serious blood\\nproblems by reducing the ability of the blood forming\\norgans to produce blood cells. These drugs may\\ndecrease the number of white blood cells, red blood\\ncells, or both. Patients taking these drugs should have\\nregular blood counts.\\nEntanercept (Enbrel) may also cause blood pro-\\nblems, and some patients who received this drug have\\ndeveloped eye problems andmultiple sclerosis.I ti sn o t\\ncertain whether these reactions were caused by entaner-\\ncept, but multiple sclerosis has been seen in patients tak-\\ning other drugs which act against tumor necrosis factor.\\nInteractions\\nAntirheumatic drugs may interact with a variety of\\nother medicines or other antirheumatic drugs. When this\\nhappens, the effects of one or both of the drugs may\\nchange, or the risk of side effects may be greater. Anyone\\nwho takes this type of drug should inform the prescribing\\nphysician about any other medication he or she is taking.\\nAmong the drugs that may interact with antirheumatic\\ndrugs are phenytoin (Dilantin),aspirin, sulfa drugs such\\nas Bactrim and Gantrisin, tetracycline and some other\\nantibiotics and cimetidine (Tagamet). NSAIDs such as\\nibuprofen (Motrin, Advil)are also known to interact\\nwith other classes of antirheumatic drugs.\\nNancy Ross-Flanigan\\nAntiseptics\\nDefinition\\nAn antiseptic is a substance which inhibits the\\ngrowth and development of microorganisms. For\\npractical purposes, antiseptics are routinely thought\\nof as topical agents, for application to skin, mucous\\nmembranes, and inanimate objects, although a formal\\ndefinition includes agents which are used internally,\\nsuch as the urinary tract antiseptics.\\nPurpose\\nAntiseptics are a diverse class of drugs which are\\napplied to skin surfaces or mucous membranes for\\ntheir anti-infective effects. This may be either bacter-\\niocidal or bacteriostatic. Their uses include cleansing\\nof skin and wound surfaces after injury, preparation of\\nskin surfaces prior to injections or surgical procedures,\\nand routine disinfection of the oral cavity as part of a\\nprogram oforal hygiene. Antiseptics are also used for\\ndisinfection of inanimate objects, including instru-\\nments and furniture surfaces.\\nCommonly used antiseptics for skin cleaning\\ninclude benzalkonium chloride, chlorhexidine, hexa-\\nchlorophine, iodine compounds, mercury compounds,\\nalcohol and hydrogen peroxide. Other agents which\\nhave been used for this purpose, but have largely been\\nsupplanted by more effective or safer agents, include\\n346 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiseptics'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='boric acid and volatile oils such as methyl salicylate\\n(oil of wintergreen.)\\nChlorhexidine shows a high margin of safety when\\napplied to mucous membranes, and has been used in\\noral rinses and preoperative total body washes.\\nBenzalkonium chloride and hexachlorophine are\\nused primarily as hand scrubs or face washes.\\nBenzalkonium may also find application is a disinfect-\\ning agent for instruments, and in low concentration as\\na preservative for drugs including ophthalmic solu-\\ntions. Benzalkonium chloride is inactivated by organic\\ncompounds, including soap, and must not be applied\\nto areas which have not been fully rinsed.\\nIodine compounds include tincture of iodine and\\npovidone iodine compounds. Iodine compounds have\\nthe broadest spectrum of all topical anti-infectives, with\\naction against bacteria, fungi, viruses, spores, protozoa,\\nand yeasts. Iodine tincture is highly effective, but its\\nalcoholic component is drying and extremely irritating\\nwhen applied to abraided (scraped or rubbed) skin.\\nPovidone iodine, an organic compound, is less irritating\\nand less toxic, but not as effective. Povidone iodine has\\nbeen used for hand scrubs and disinfection of surgical\\nsites. Aqueous solutions of iodine have also been used\\nas antiseptic agents, but are less effective than alcoholic\\nsolutions and less convenient to use that the povidone\\niodine compounds.\\nHydrogen peroxide acts through the liberation of\\noxygen gas. Although the antibacterial activity of hydro-\\ngen peroxide is relatively weak, the liberation of oxygen\\nbubbles produces an effervescent action, which may be\\nuseful for wound cleansing through removal of tissue\\ndebris. The activity of hydrogen peroxide may be\\nreduced by the presence of blood and pus. The appro-\\npriate concentration of hydrogen peroxide for antiseptic\\nuse is 3%, although higher concentrations are available.\\nThimerosol (Mersol) is a mercury compound with\\nactivity against bacteria and yeasts. Prolonged use\\nmay result in mercury toxicity.\\nRecommended dosage\\nDosage varies with product and intended use.\\nConsult individualized references.\\nPrecautions\\nPrecautions vary with individual product and use.\\nConsult individualized references.\\nHypersensitivity reactions should be considered\\nwith organic compounds such as chlorhexidine, ben-\\nzalkonium and hexachlorophine.\\nSkin dryness and irritation should be considered\\nwith all products, but particularly with those contain-\\ning alcohol.\\nSystemic toxicity may result from ingestion of\\niodine containing compounds or mercury compounds.\\nChlorhexidine should not be instilled into the ear.\\nThere is one anecdotal report of deafness following\\nuse of chlorhexidine in a patient with aperforated\\neardrum. Safety inpregnancy and breastfeeding have\\nnot been reported, however there is one anecdotal\\nreport of an infant developing slowed heartbeat\\napparently related to maternal use of chlorhexidine.\\nIodine compounds should be used sparingly\\nduring pregnancy andlactation due to risk of infant\\nabsorption of iodine with alterations in thyroid function.\\nInteractions\\nAntiseptics are not known to interact with any\\nother medicines. However, they should not be used\\ntogether with any other topical cream, solution, or\\nointment.\\nResources\\nPERIODICALS\\nFarley, Dixie. ‘‘Help for Cuts, Scrapes and Burns.’’FDA\\nConsumer May 1996: 12.\\nSamuel D. Uretsky, PharmD\\nAntispasmodic drugs\\nDefinition\\nAntispasmodic drugs relieve cramps or spasms of\\nthe stomach, intestines, and bladder.\\nKEY TERMS\\nAntibiotic— A medicine used to treat infections.\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nMucous membrane— The moist lining of a body\\ncavity or structure, such as the mouth or nose.\\nResidue— Traces that remain after most of the rest\\nof the material is gone.\\nGALE ENCYCLOPEDIA OF MEDICINE 347\\nAntispasmodic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nAntispasmodic drugs have been used to treat\\nstomach cramps. Traditionally, they were used to\\ntreat stomach ulcers, but for this purpose they have\\nlargely been replaced by the acid inhibiting\\ncompoundsa, the H-2 receptor blockers such as\\ncimetidine and ranitidine and the proton pump\\ninhibtors such as omeprazole, lansoprazole and\\nrabetazole.\\nMost of the drugs used for this purpose as ‘‘anti-\\ncholinergics’’, since they counteract the effects of the\\nneurohormone acetylcholine. Some of these drugs are\\nderived from the plant belladonna, also known as\\nDeadly Nightshade. There is also a group of drugs\\nwith similar activity, but not taken from plant sources.\\nThe anticholingergics decrease both the movements of\\nthe stomach and intestine, and also the secretions of\\nstomach acid and digestive enzymes. They may be\\nused for other purposes including treatment of\\nParkinson’s Disease, and bladder urgency. Because\\nthese drugs inhibit secretions, they causedry mouth\\nand dry eyes because of reduced salivation and tear-\\ning. Dicyclomine is an antispasmodic with very lettle\\neffect on secretions. It is used to treatirritable bowel\\nsyndrome.\\nDescription\\nDicyclomine is available only with a prescription\\nand is sold as capsules, tablets (regular and extended-\\nrelease forms), and syrup.\\nRecommended dosage\\nThe usual dosage for adults is 20 mg, four times a\\nday. However, the physician may recommend starting\\nat a lower dosage and gradually increasing the dose to\\nreduce the chance of unwanted side effects.\\nThe dosage for children depends on the child’s\\nage. Check with the child’s physician for the correct\\ndosage.\\nPrecautions\\nDicyclomine makes so me people sweat less,\\nwhich allows the body to overheat and may lead to\\nheat prostration ( fever and heat stroke). Anyone\\ntaking this drug should try to avoid extreme heat.\\nIf that is not possible, check with the physician\\nwho prescribed the drug. If heat prostration occurs,\\nstop taking the medicine and call a physician\\nimmediately.\\nThis medicine can cause drowsiness and blurred\\nor double vision. People who take this drug should not\\ndrive, use machines, or do anything else that might be\\ndangerous until they have found out how the medicine\\naffects them.\\nDicyclomine should not be given to infants or\\nchildren unless the physician decides the use of this\\ndrug is necessary. Diclyclomine should not be used by\\nwomen who are breast feeding. Women who are preg-\\nnant or plan to become pregnant should check with\\ntheir physicians before using this drug.\\nAnyone with the following medical conditions\\nshould not take dicyclomine unless directed to do so\\nby a physician:\\n/C15Previous sensitivity or allergic reaction to\\ndicyclomine\\n/C15Glaucoma\\n/C15Myasthenia gravis\\n/C15Blockage of the urinary tract, stomach, or intestines\\n/C15Severe ulcerative colitis\\n/C15Reflux esophagitis.\\nKEY TERMS\\nHeat stroke— A serious condition that results from\\nexposure to extreme heat. The body loses its ability\\nto cool itself. Severe headache, high fever, and hot,\\ndry skin may result. In severe cases, a person with\\nheat stroke may collapse or go into a coma.\\nHiatal hernia— A condition in which part of the\\nstomach protrudes through the diaphragm.\\nHyperthyroidism— Secretion of excess thyroid hor-\\nmones by the thyroid gland.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMyasthenia gravis— A condition in which certain\\nmuscles weaken and may become paralyzed.\\nReflux esophagitis— Inflammation of the lower\\nesophagus caused by the backflow of stomach\\ncontents.\\nSpasm— Sudden, involuntary tensing of a muscle or\\na group of muscles\\nUlcerative colitis— Long-lasting and repeated\\ninflammation of the colon with the development\\nof sores.\\n348 GALE ENCYCLOPEDIA OF MEDICINE\\nAntispasmodic drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In addition, patients with these conditions should\\ncheck with their physicians before using dicyclomine:\\n/C15Liver disease\\n/C15Kidney disease\\n/C15High blood pressure\\n/C15Heart problems\\n/C15Enlarged prostate gland\\n/C15Hiatal hernia\\n/C15Autonomic neuropathy (a nerve disorder)\\n/C15Hyperthyroidism.\\nSide effects\\nThe most common side effects aredizziness, drow-\\nsiness, lightheadedness, nausea, nervousness, blurred\\nvision, dry mouth, and weakness. Other side effects\\nmay occur. Anyone who has unusual symptoms after\\ntaking dicyclomine should get in touch with his or her\\nphysician.\\nInteractions\\nDicyclomine may interact with other medicines.\\nWhen this happens, the effects of one or both of the\\ndrugs may change or the risk of side effects may be\\ngreater. Among the drugs that may interact with\\nDicyclomine are:\\n/C15Antacids such as Maalox\\n/C15Antihistamines such as clemastine fumarate (Tavist)\\n/C15Bronchodilators (airway opening drugs) such as\\nalbuterol (Proventil, Ventolin)\\n/C15Corticosteroids such as prednisone (Deltasone)\\n/C15Monoamine oxidase inhibitors (MAO inhibitors) such\\nas phenelzine (Nardil) and tranylcypromine (Parnate)\\n/C15Tranquilizers such as diazepam (Valium) and alpra-\\nzolam (Xanax).\\nThe list above does not include every drug that\\nmay interact with dicyclomine. Be sure to check with a\\nphysician or pharmacist before combining dicyclo-\\nmine with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nNancy Ross-Flanigan\\nAntistreptolysin O titer (ASO) see\\nStreptococcal antibody tests\\nAntithrombin III deficiency see\\nHypercoagulation disorders\\nAntituberculosis drugs\\nDefinition\\nAntituberculosis drugs are medicines used to treat\\ntuberculosis, an infectious disease that can affect the\\nlungs and other organs.\\nPurpose\\nTuberculosis is a disease caused by Mycobacterium\\ntuberculae, a bacteria that is passed between people\\nthrough the air. The disease can be cured with proper\\ndrug therapy, but because the bacteria may become\\nresistant to any single drug, combinations of antituber-\\nculosis drugs are used to treat tuberculosis (TB) are\\nnormally required for effective treatment. At the start\\nof the 20th Century, tuberculosis was the most common\\ncause of death in the United States, but was laregly\\neliminated with better living conditions. It is most com-\\nmon in areas of crowding and poor ventilation, suich as\\ncrowded urban areas and prisons. In some areas, the\\nAIDS epidemic has been accompanied by an increase\\nin the prevalence of tuberculosis.\\nSome antituberculosis drugs also are used to treat\\nor prevent other infections such asMycobacterium\\navium complex (MAC), which causes disease through-\\nout the bodies of people with AIDS or other diseases\\nof the immune system.\\nDescription\\nAntituberculosis drugs are available only with a\\nphysician’s prescription and come in tablet, capsule,\\nliquid and injectable forms. Some commonly used\\nantituberculosis drugs are cycloserine (Seromycin),\\nethambutol (Myambutol), ethionamide (Trecator-\\nSC), isoniazid (Nydrazid, Laniazid), pyrazinamide,\\nrifabutin (Mycobutin), and rifampin (Rifadin,\\nRimactane).\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nantituberculosis drug and may be different for differ-\\nent patients. Check with the physician who prescribed\\nthe medicine or the pharmacist who filled the prescrip-\\ntion for the proper dosage. The physician may gradu-\\nally increase the dosage during treatment. Be sure to\\nfollow the physician’s orders. Patients who are infected\\nwith HIV must usually take larger combinations of\\ndrugs for a longer period of time than is needed for\\npatients with an unimpaired immune system.\\nGALE ENCYCLOPEDIA OF MEDICINE 349\\nAntituberculosis drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Some antituberculosis drugs must be taken with\\nother drugs. If they are taken alone, they may encou-\\nrage the bacteria that cause tuberculosis to become\\nresistant to drugs used to treat the disease. When the\\nbacteria become resistant, treating the disease\\nbecomes more difficult.\\nTo clear up tuberculosis completely, antitubercu-\\nlosis drugs must be taken for as long as directed. This\\nmay mean taking the medicine every day for a year or\\ntwo or even longer. Symptoms may improve very\\nquickly after treatment with this medicine begins.\\nHowever, they may come back if the medicine is\\nstopped too quickly. Do not stop taking the medicine\\njust because symptoms improve.\\nBecause people may neglect to take their medica-\\ntion for tuberculosis, it is common to have tuberculo-\\nsis centers develop a program of Directly Observed\\nTherapy (DOT.) In these programs, patients come to\\nthe hospital or clinic, and take their medication in\\nfront of an observer. These programs may be annoy-\\ning to the patients, but are justified by the risks to\\npublic health if tuberculosis germs which have become\\nresistant to drugs were to be spread.\\nCycloserine works best when it is at constant\\nlevels in the blood. To help keep levels constant, take\\nthe medicine in doses spaced evenly through the day\\nand night. Do not miss any doses. If taking medicine at\\nnight interferes with sleep, or if it is difficult to\\nremember to take the medicine during the day, check\\nwith a health care professional for suggestions.\\nDo not takeantacids that contain aluminum, such\\nas Maalox, within 1 hour of taking isoniazid, as this\\nmay keep the medicine from working.\\nPrecautions\\nSeeing a physician regularly while taking antitu-\\nberculosis drugs is important. The physician will check\\nto make sure the medicine is working as it should and\\nwill watch for unwanted side effects. These visits also\\nwill help the physician know if the dosage needs to be\\nchanged.\\nSymptoms should begin to improve within a few\\nweeks after treatment begins with antituberculosis\\ndrugs. If they do not, or if they become worse, check\\nwith a physician.\\nSome people feel drowsy, dizzy, confused, or less\\nalert when using these drugs. Some may also cause\\nvision changes, clumsiness, or unsteadiness. Because\\nof these possible problems, anyone who takes antitu-\\nberculosis drugs should not drive, use machines, or do\\nanything else that might be dangerous until they have\\nfound out how the medicine affects them.\\nDaily doses of pyridoxine (vitamin B\\n6) may lessen\\nor prevent some side effects of ethionamide or isoniazid.\\nIf the physician who prescribed the medicine recom-\\nmends this, be sure to take the pyridoxine every day.\\nCertain kinds of cheese (such as Swiss and\\nCheshire) and fish (such as tuna and skipjack) may\\ncause an unusual reaction in people taking isoniazid.\\nSymptoms of this reaction include fast or pounding\\nheartbeat, sweating or a hot feeling, chills or a clammy\\nfeeling,headache, lightheadedness, and red or itchy skin.\\nThis reaction is very rare. However, if any of these symp-\\ntoms occur, check with a physician as soon as possible.\\nRifabutin and rifampin will make saliva, sweat,\\ntears, urine, feces, and skin turn reddish orange to\\nreddish brown. This is nothing to worry about.\\nHowever, the discolored tears may permanently stain\\nsoft contact lenses (but not hard contact lenses). To\\navoid ruining contact lenses, do not wear soft contacts\\nwhile taking these medicines.\\nRifampin may temporarily lower the number of\\nwhite blood cells. Because the white blood cells are\\nimportant in fighting infection, this effect increases the\\nchance of getting an infection. This drug also may\\nlower the number of platelets that play an important\\nrole in clotting. To reduce the risk of bleeding and\\ninfection in the mouth while taking this medicine, be\\nKEY TERMS\\nBacteria— Tiny, one-celled forms of life that cause\\nmany diseases and infections.\\nFeces— (Also called stool.) The solid waste that is\\nleft after food is digested. Feces form in the intes-\\ntines and pass out of the body through the anus.\\nFetus— A developing baby inside the womb.\\nGout— A disease in which uric acid, a waste pro-\\nduct that normally passes out of the body in urine,\\ncollects in the joints and the kidneys. This causes\\narthritis and kidney stones.\\nImmune system— The body’s natural defenses\\nagainst disease and infection.\\nMicroorganism— An organism (life form) that is too\\nsmall to be seen with the naked eye.\\nPlatelets— Disk-shaped bodies in the blood that are\\nimportant in clotting.\\nSeizure— A sudden attack, spasm, or convulsion.\\n350 GALE ENCYCLOPEDIA OF MEDICINE\\nAntituberculosis drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='especially careful when brushing and flossing the\\nteeth. Check with a physician or dentist for sugges-\\ntions on how to keep the teeth and mouth clean with-\\nout causing injuries. Put off any dental work until\\nblood counts return to normal.\\nRifampin may affect the results of some medical\\ntests. Before having medical tests, anyone taking this\\nmedicine should alert the health care professional in\\ncharge.\\nPeople who have certain medical conditions may\\nhave problems if they take antituberculosis drugs. For\\nexample:\\n/C15cycloserine or isoniazid may increase the risk of sei-\\nzures (convulsions) in people with a history of\\nseizures.\\n/C15the dosage of cycloserine may need to be adjusted for\\npeople withkidney disease.\\n/C15ethambutol or pyrazinamide may cause or worsen\\nattacks of gout in people who are prone to having\\nthem.\\n/C15ethambutol may cause or worsen eye damage.\\n/C15diabetes may be harder to control in patients who\\ntake ethionamide.\\n/C15isoniazid may cause false results on some urine sugar\\ntests, and pyrazinamide may cause false results on\\nurine ketone tests. Diabetic patients who either of\\nthese medicines should discuss the possibility of false\\ntest results with their physicians.\\n/C15people with liver disease or a history of alcohol\\nabuse may be more likely to develop hepatitis\\nwhen taking isoniazid and are more likely to have\\nside effects that affect the liver when taking\\nrifampin.\\n/C15in people with kidney disease, ethambutol, ethiona-\\nmide, or isoniazid may be more likely to cause side\\neffects.\\n/C15side effects are also more likely in people with liver\\ndisease who take pyrazinamide.\\nBefore taking antituberculosis drugs, be sure to let\\nthe physician know about these or any other medical\\nproblems.\\nIn laboratory tests of pregnant animals, high\\ndoses of some antituberculosis drugs have caused\\nbirth defectsand other problems in the fetus or new-\\nborn. However, pregnant women with tuberculosis\\nneed to take antituberculosis drugs to clear up their\\ndisease. Knowing that many women have had healthy\\nbabies after taking these drugs during pregnancy may\\nbe reassuring. Pregnant women who need to take this\\nmedicine and are worried about birth defects or other\\nproblems should talk to their physicians.\\nAnyone who has had unusual reactions to anti-\\ntuberculosis drugs or to niacin should let his or her\\nphysician know before taking any antituberculosis\\ndrug. The physician should also be told about any\\nallergies to foods, dyes, preservatives, or other\\nsubstances.\\nPatients who are on specialdiets, such as low-\\nsodium or low-sugar diets, should make sure their\\nphysicians know. Some antituberculosis medicines\\nmay contain sodium, sugar, or alcohol.\\nSide effects\\nCycloserine\\nIn some people, this medicine causes depression\\nand thoughts ofsuicide. If this happens, check with a\\nphysician immediately. Switching to another medicine\\nwill usually stop these troubling thoughts and feelings.\\nAlso let the physician know immediately about any\\nother mood or mental changes; such as nervousness,\\nnightmares, anxiety, confusion, or irritability; and\\nabout symptoms such as muscle twitches, convulsions,\\nor speech problems.\\nHeadache is a common side effect that usually\\ngoes away as the body adjusts to this medicine. This\\nproblem does not need medical attention unless it\\ncontinues or it interferes with everyday life.\\nEthambutol\\nThis medicine may cause eye pain or vision\\nchanges, including loss of vision or changes in color\\nvision. Check with a physician immediately if any of\\nthese problems develop.\\nIn addition, anyone who has any of these symp-\\ntoms while taking ethambutol should check with a\\nphysician immediately:\\n/C15painful or swollen joints, especially in the knee,\\nankle, or big toe\\n/C15a tight, hot sensation in the skin over painful or\\nswollen joints\\n/C15chills.\\nOther side effects may occur but do not need\\nmedical attention unless they are bothersome or they\\ndo not go away as the body adjusts to the medicine.\\nThese include: headache, confusion, nausea and\\nvomiting, stomach pain, and loss of appetite.\\nGALE ENCYCLOPEDIA OF MEDICINE 351\\nAntituberculosis drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Ethionamide\\nCheck with a physician immediately if eye pain,\\nblurred vision, or other vision changes occur while\\ntaking this medicine.\\nSymptoms such as unsteadiness, clumsiness and\\npain, numbness, tingling, or burning in the hands or\\nfeet could be the first signs of nerve problems that may\\nbecome more serious. If any of these symptoms occur,\\ncheck with a physician immediately. Other side effects\\nthat should be brought to a physician’s attention\\nimmediately include yellow eyes or skin and mood or\\nmental changes such as depression or confusion.\\nLess serious side effects such asdizziness, nausea\\nor vomiting, appetite loss, sore mouth, or metallic\\ntaste may also occur. These problems usually go\\naway as the body adjusts to the medicine. They do\\nnot need medical attention unless they continue or\\nthey interfere with normal activities.\\nIsoniazid\\nThis medicine may cause serious liver damage, espe-\\ncially in people over 40 years of age. However, taking\\nmedicine for tuberculosis is very important for people\\nwith the disease. Anyone who has tuberculosis and has\\nbeen advised to take this drug should thoroughly discuss\\ntreatment options with his or her physician.\\nRecognizing the early signs of liver and nerve\\ndamage can help prevent the problems from getting\\nworse. If any of these symptoms occur, check with a\\nphysician immediately:\\n/C15unusual tiredness or weakness\\n/C15clumsiness or unsteadiness\\n/C15pain, numbness, tingling, or burning in the hands\\nand feet\\n/C15loss of appetite\\n/C15vomiting\\nThis medicine may also cause less serious side\\neffects such asdiarrheaand stomach pain. These usually\\ngo away as the body adjusts to the medicine and do not\\nneed medical attention unless they continue.\\nIf eye pain, blurred vision, or other vision changes\\noccur while taking this medicine, check with a physi-\\ncian immediately.\\nPyrazinamide\\nCheck with a physician immediately if pain in the\\njoints occurs.\\nRifabutin\\nCheck with a physician immediately if a skin rash\\noccurs.\\nRifampin\\nStop taking rifampin and check with a physician\\nimmediately if any of the following symptoms occur.\\nThese symptoms could be early signs of problems that\\nmay become more serious. Getting prompt medical\\nattention could prevent them from getting worse.\\n/C15unusual tiredness or weakness\\n/C15nausea or vomiting\\n/C15loss of appetite\\nIn addition, anyone who has any of these symp-\\ntoms while taking rifampin should check with a phy-\\nsician immediately:\\n/C15breathing problems\\n/C15fever\\n/C15chills\\n/C15shivering\\n/C15headache\\n/C15dizziness\\n/C15itching\\n/C15skin rash or redness\\n/C15muscle and bone pain\\nOther side effects, such as diarrhea and stomach\\npain, may occur with this medicine, but should go\\naway as the body adjusts to the drug. Medical treat-\\nment is not necessary unless these problems continue.\\nOther side effects may occur with any antituber-\\nculosis drug. Anyone who has unusual symptoms\\nwhile taking an antituberculosis drug should get in\\ntouch with his or her physician.\\nInteractions\\nTaking cycloserine and ethionamide together may\\nincrease the risk of seizures and other nervous system\\nproblems. These and other side effects also are more\\nlikely in people who drink alcohol while taking cyclo-\\nserine. To avoid these problems,do not drink alcohol\\nwhile taking cycloserine and check with a physician\\nbefore combining cycloserine and ethionamide.\\nDrinking alcohol regularly may prevent isoniazid\\nfrom working properly and may increase the chance of\\nliver damage. Anyone taking this medicine should\\nstrictly limit the use of alcohol. Check with a health\\n352 GALE ENCYCLOPEDIA OF MEDICINE\\nAntituberculosis drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='care professional for advice on the amount of alcohol\\nthat may safely be used.\\nMany drugs may interact with isoniazid or rifampin,\\nincreasing the chance of liver damage or other side effects.\\nAmong these drugs are acetaminophen (Tylenol), birth\\ncontrol pills and other drugs that contain female hor-\\nmones, and the antiseizure drugs divalproex (Depakote)\\nand valproic acid (Depakene). For a complete list of\\ndrugs that may have this effect, check with a pharmacist.\\nIsoniazid may also decrease the effects of the anti-\\nfungal drug ketoconazole (Nizoral) and the antituber-\\nculosis drug rifampin (Rifadin).\\nRifampin may make many drugs less effective.\\nAmong the drugs that may be affected are diabetes\\nmedicines taken by mouth (oral hypoglycemics), digi-\\ntalis heart drugs, many antifungal drugs, and birth\\ncontrol pills. Because it makes birth control pills less\\neffective, taking rifampin may increase the chance of\\nbecoming pregnant. Women who take this medicine\\nalong with birth control pills should use an additional\\nform of birth control. For a complete list of drugs that\\nmay be affected by rifampin, check with a pharmacist.\\nUsing rifabutin with the antiretroviral drug zido-\\nvudine (AZT, Retrovir) may make the zidovudine less\\neffective. Consult with a physician if both drugs are\\nprescribed.\\nNot every drug that may interact with an antitu-\\nberculosis drug is listed here. Be sure to check with a\\nphysician or pharmacist before combining an antitu-\\nberculosis drug with any other prescription or nonpre-\\nscription (over-the-counter) medicine.\\nResources\\nPERIODICALS\\nCornwall, Janet. ‘‘Tuberculosis: A Clinical Problem of\\nInternational Importance.’’The Lancet(August 30,\\n1997): 660.\\nNancy Ross-Flanigan\\nAntiulcer drugs\\nDefinition\\n‘Antiulcer drugs are a class of drugs, exclusive of\\nthe antibacterial agents, used to treat ulcers in the\\nstomach and the upper part of the small intestine.\\nPurpose\\nRecurrent gastric and duodenal ulcers are caused\\nby Helicobacter pylori infections, and are treated\\nwith combination treatments that incorporate anti-\\nbiotic therapy with gastric acid suppression.\\nAdditionally, bismuth compounds have been used.\\nThe primary class of drugs used for gastric acid\\nsuppression are the proton pump inhibitors, omepra-\\nzole, lansoprazole, pantoprazole and rabeprazole. The\\nH-2 receptor blocking agents, cimetidine, famotidine,\\nnizatidine, and ranitidine have been used for this\\npurpose, but are now more widely used for mainte-\\nnance therapy after treatment with the proton pump\\ninhibitors. Sucralfate, which acts by forming a protec-\\ntive coating over the ulcerate lesion, is also used in\\nulcer treatment and may be appropriate for patients in\\nwhom other classes of drugs are not indicated, or those\\nwhose gastric ulcers are caused by non-steroidal anti-\\ninflammatory drugs (NSAIDs) rather thanH. pylori\\ninfections.\\nDescription\\nThe proton pump inhibitorsblock the secretion of\\ngastric acid by the gastric parietal cells. The extent of\\ninhibition of acid secretion is dose related. In some\\ncases, gastric acid secretion is completely blocked for\\nover 24 hours on a single dose. In addition to their role\\nin treatment of gastric ulcers, the proton pump inhibi-\\ntors are used to treat syndromes of excessive acid\\nsecretion (Zollinger-Ellison Syndrome) and gastroeso-\\nphageal reflux disease (GERD).\\nAntiulcer Drugs\\nBrand Name\\n(Generic Name) Possible Common Side Effects Include:\\nAxid (nitzatidine) Diarrhea, headache, nausea and vomiting, sore\\nthroat\\nCarafate (sucralfate) Constipation, insomnia, hives, upset stomach,\\nvomiting\\nCytotec (misoprostol) Cramps, diarrhea, nausea, gas, headache,\\nmenstrual disorders (including heavy bleeding\\nand severe cramping)\\nPepcid (famotidine) Constipation or diarrhea, dizziness, fatigue,\\nfever\\nPrilosec (omeprazole) Nausea and vomiting, headache, diarrhea,\\nabdominal pain\\nTagamet (cimetidine) Headache, breast development in men, depres-\\nsion and disorientation\\nZantac (ranitidine\\nhydrochloride)\\nHeadache, constipation or diarrhea, joint pain\\nGALE ENCYCLOPEDIA OF MEDICINE 353\\nAntiulcer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Histamine H-2 receptor blockers stop the action\\nof histamine on the gastric parietal cells, inhibiting the\\nsecretion of gastric acid. These drugs are less effective\\nthan the proton pump inhibitors, but may achieve a\\n75–79% reduction in acid secretion. Higher rates of\\nacid inhibition may be achieved when the drug is\\nadministered by the intravenous route. The H-2 recep-\\ntor blockers may also be used to treatheartburn and\\nhypersecretory syndromes. When given before sur-\\ngery, the H-2 receptor blockers are useful in preven-\\ntion of aspirationpneumonia.\\nSucralfate (Carafate), a substituted sugar molecule\\nwith no nutritional value, does not inhibit gastric acid,\\nbut rather, reacts with existing stomach acid to form a\\nthick coating that covers the surface of an ulcer, protect-\\ning the open area from further damage. A secondary\\neffect is to act as an inhibitor of the digestive enzyme\\npepsin. Sucralfate does not bind to the normal stomach\\nlining. The drug has been used for prevention ofstress\\nulcers, the type seen in patients exposed to physical stress\\nsuch asburns and surgery. It has no systemic effects.\\nRecommended dosage\\nThe doses of the proton pump inhibitors and H-2\\nreceptor blockers vary depending on the drug and\\ncondition being treated. Consult individual references.\\nThe dose of sucralfate for acute ulcer therapy is\\n1 gram four times a day. After the ulcer has healed,\\nmaintenance treatment may continue at 1 gram two\\ntimes daily.\\nPrecautions\\nThe proton pump inhibitors are generally well\\ntolerated, and the most common adverse effects are\\ndiarrhea, itching, skin rash, dizziness and headache.\\nMuscle aches and a higher than normal rate of respira-\\ntory infections are among the other adverse reactions\\nreported. Omeprazole has an increased rate of fetal\\ndeaths in animal studies. It is not known if these drugs\\nare excreted in human milk, but because of reported\\nadverse effects to infants in animal studies, it is recom-\\nmended that proton pump inhibitors not be used by\\nnursing mothers.\\nThe H-2 receptor blockers vary widely in their\\nadverse effects. Although they are generally well tol-\\nerated, cimetidine may cause confusion in elderly\\npatients, and has an antiandrogenic effect that may\\ncause sexual dysfunction in males. Famotidine has\\nbeen reported to causeheadache in 4.7% of patients.\\nIt is advisable that mothers not take H-2 receptor\\nblockers while nursing.\\nSucralfate is well tolerated. It is poorly absorbed,\\nand its most common side effect is constipation in 2%\\nof patients. Diarrhea, nausea, vomiting, gastric dis-\\ncomfort, indigestion, flatulence, dry mouth, rash, prur-\\nitus (itching), back pain, headache, dizziness,\\nsleepiness, and vertigo have been reported, as well as\\nrare allergic responses. Because sucralfate releases\\nsmall amounts of aluminum into the system, it should\\nbe used with caution in patients with renal insuffi-\\nciency. There is no information available about sucral-\\nfate’s safety in breastfeeding.\\nInteractions\\nProton pump inhibitors may increase the pH of\\nthe stomach. This will inactivate some antifungal\\ndrugs that require an acid medium for effectiveness,\\nnotable itraconazole and ketoconazole.\\nH-2 receptor blocking agents have a large number\\nof drug interactions. Consult individualized references.\\nSucralfate should not be used with aluminum\\ncontaining antacids, because of the risk of increased\\naluminum absorption. Sucralfate may inhibit\\nabsorption and reduce blood levels of anticoagu-\\nlants, digoxin, quinidine, ketoconazole, quinolones\\nand phenytoin.\\nKEY TERMS\\nAntibiotic— Medicine used to treat infections.\\nEnzyme— A type of protein, produced in the body,\\nthat brings about or speeds up chemical reactions.\\nGastrointestinal tract— The stomach, small intes-\\ntine and large intestine.\\nHypersecretory— Excessive production of a bodily\\nsecretion. The most common hypersecretory\\nsyndrome of the stomach is Zollinger-Ellison\\nSyndrome, a syndrome consisting of fulminating\\nintractable peptic ulcers, gastric hypersecretion and\\nhyperacidity, and the occurrence of gastrinomas\\nof the pancreatic cells of the islets of Langerhans.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nMucous— Thick fluid produced by the moist mem-\\nbranes that line many body cavities and structures.\\nNonsteroidal anti-inflammatory drug (NSAID)— A\\ntype of medicine used to relieve pain, swelling, and\\nother symptoms of inflammation, such as ibuprofen\\nor ketoprofen.\\n354 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiulcer drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nORGANIZATIONS\\nDigestive Disease National Coalition. 507 Capitol Court\\nNE, Suite 200, Washington, DC 20003. (202) 544-7497.\\nNational Digestive Diseases Information Clearinghouse.\\n2 Information Way, Bethesda, MD 20892-3570.\\nnddic@aerie.com. .\\nOTHER\\nDuodenal UlcerFact sheet. Johns Hopkins Health\\nInformation Adult Health Advisor. .\\nNational Institute of Diabetes and Digestive and Kidney\\nDiseases. .\\nPharmInfoNet’s Digestive Disease Center. .\\nStomach Ulcer (Gastric Ulcer).Fact sheet. Johns Hopkins\\nHealth Information Adult Health Advisor. .\\nSamuel D. Uretsky, PharmD\\nAntiviral drugs\\nDefinition\\nAntiviral drugs are medicines that cure or control\\nvirus infections.\\nPurpose\\nAntivirals are used to treat infections caused by\\nviruses. Unlike antibacterial drugs, which may cover a\\nwide range of pathogens, antiviral agents tend to be\\nnarrow in spectrum, and have limited efficacy.\\nDescription\\nExclusive of the antiretroviral agents used in HIV\\n(AIDS) therapy, there are currently only 11 antiviral\\ndrugs available, covering four types of virus. Acyclovir\\n(Zovirax), famciclovir (Famvir), and valacyclovir\\n(Valtrex) are effective against herpesvirus, including\\nherpes zoster and herpes genitalis. They may also be of\\nvalue in either conditions caused by herpes, such as\\nchickenpox and shingles. These drugs are not curative,\\nbut may reduce thepain of a herpes outbreak and\\nshorten the period of viral shedding.\\nAmantadine (Symmetrel), oseltamivir (Tamiflu),\\nrimantidine (Flumadine), and zanamivir (Relenza) are\\nuseful in treatment ofinfluenza virus. Amantadine,\\nrimantadine, and oseltamivir may be administered\\nthroughout the flu season as preventatives for patients\\nwho cannot take influenza virus vaccine.\\nCidofovir (Vistide), foscarnet (Foscavir), and\\nganciclovir (Cytovene) have been beneficial in treat-\\nment of cytomegalovirus in immunosupressed\\npatients, primarily HIV-positive patients and trans-\\nplant recipients. Ribavirin (Virazole) is used to treat\\nKEY TERMS\\nAsthenia— Muscle weakness.\\nCytomegalovirus (CMV)— A type of virus that\\nattacks and enlarges certain cells in the body. The\\nvirus also causes a disease in infants.\\nHerpes simplex— A virus that causes sores on the\\nlips (cold sores) or on the genitals (genital herpes).\\nHIV— Acronym for human immunodeficiency\\nvirus, the virus that causes AIDS.\\nParkinsonism— A group of conditions that all have\\nthese typical symptoms in common: tremor, rigidity,\\nslowmovement,andpoorbalanceandcoordination.\\nPregnancy category— A system of classifying drugs\\naccording to their established risks for use during\\npregnancy. Category A: Controlled human studies\\nhave demonstrated no fetal risk. Category B: Animal\\nstudies indicate no fetal risk, but no human studies,\\nor adverse effects in animals, but not in well-\\ncontrolled human studies. Category C: No adequate\\nhuman or animal studies, or adverse fetal effects in\\nanimal studies, but no available human data.\\nCategory D: Evidence of fetal risk, but benefits out-\\nweigh risks. Category X: Evidence of fetal risk. Risks\\noutweigh any benefits.\\nProphylactic— Guarding from or preventing the\\nspread or occurrence of disease or infection.\\nRetrovirus— A group of viruses that contain RNA\\nand the enzyme reverse transcriptase. Many viruses\\nin this family cause tumors. The virus that causes\\nAIDS is a retrovirus.\\nShingles— An disease caused by an infection with\\nthe Herpes zoster virus, the same virus that causes\\nchickenpox. Symptoms of shingles include pain\\nand blisters along one nerve, usually on the face,\\nchest, stomach, or back.\\nVirus— A tiny, disease-causing structure that can\\nreproduce only in living cells and causes a variety\\nof infectious diseases.\\nGALE ENCYCLOPEDIA OF MEDICINE 355\\nAntiviral drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='respiratory syncytial virus. In combination with\\ninterferons, ribavirin has shown some efficacy\\nagainst hepatitis C, and there have been anecdotal\\nreports of utility against other types of viral\\ninfections.\\nAs a class, the antivirals are not curative, and\\nmust be used either prophylactically or early in the\\ndevelopment of an infection. Their mechanism of\\naction is typically to inactivate the enzymes needed\\nfor viral replication. This will reduce the rate of viral\\ngrowth, but will not inactive the virus already present.\\nAntiviral therapy must normally be initiated within 48\\nhours of the onset of an infection to provide any\\nbenefit. Drugs used for influenza may be used\\nthroughout the influenza season in high risk patients,\\nor within 48 hours of exposure to a known carrier.\\nAntiherpetic agents should be used at the first signs of\\nan outbreak. Anti-cytomegaloviral drugs must routi-\\nnely be used as part of a program of secondarypro-\\nphylaxis (maintenance therapy following an initial\\nresponse) in order to prevent reinfection in immuno-\\ncompromised patients.\\nRecommended dosage\\nDosage varies with the drug, patient age and con-\\ndition, route of administration, and other factors. See\\nspecific references.\\nPrecautions\\nGanciclovir is available in intravenous injection,\\noral capsules, and intraoccular inserts. The capsules\\nshould be reserved for prophylactic use in organ trans-\\nplant patients, or for HIV infected patients who can-\\nnot be treated with the intravenous drug. The toxicity\\nprofile of this drug when administered systemically\\nincludes granulocytopenia, anemia andthrombocyto-\\npenia. The drug is in pregnancy category C, but has\\ncaused significant fetal abnormalities in animal studies\\nincluding cleft palate and organ defects. Breast feeding\\nis not recommended.\\nCidofovir causes renal toxicity in 53% of patients.\\nPatients should be well hydrated, and renal function\\nshould be checked regularly. Other common adverse\\neffects are nausea and vomiting in 65% or patients,\\nasthenia in 46% and headache and diarrhea, both\\nreported in 27% of cases. The drug is category C in\\npregnancy, due to fetal abnormalities in animal\\nstudies. Breast feeding is not recommended.\\nFoscarnet is used in treatment of immunocom-\\npromised patients with cytomegalovirus infections\\na n di na c y c l o v i r - r e s i s t a n therpes simples virus. The\\nprimary hazard is renal toxicity. Alterations in elec-\\ntrolyte levels may cause seizures. Foscarnet is cate-\\ngory C during pregnancy. The drug has caused\\nskeletal abnormailities in developing fetuses. It is\\nnot known whether foscarnet is excreted in breast\\nmilk, however the drug does appear in breast milk in\\nanimal studies.\\nValaciclovir is metabolized to acyclovir, so that\\nthe hazards of the two drugs are very similar. They\\nare generally well tolerated, butnausea and headache\\nare common adverse effects. They are both preg-\\nnancy category B. Although there have been no\\nreports of fetal abnormalities attributable to either\\ndrug, the small number of reported cases makes it\\nimpossible to draw conclusions regarding safety in\\npregnancy. Acyclovir is found in breast milk, but\\nno adverse effects have been reported in the new-\\nborn. Famciclovir is similar in actions and adverse\\neffects.\\nRibavirin is used by aerosol for treatment of hos-\\npitalized infants and young children with severe lower\\nrespiratory tract infections due to respiratory syncytial\\nvirus (RSV). When administered orally, the drug has\\nbeen used in adultys to treat other viral diseases\\nincluding acute and chronic hepatitis, herpes genitalis,\\nmeasles, and Lassa fever, however there is relatively\\nlittle information about these uses. In rare cases, initia-\\ntion of ribavirin therapy has led to deterioration of\\nrespiratory function in infants. Careful monitoring is\\nessential for safe use.\\nThe anti-influenza drugs are generally well toler-\\nated. Amantadine, which is also used for treatment\\nof Parkinsonism, may show more frequent CNS\\neffects, includingsedation and dizziness. Rapid discon-\\ntinuation of amantidine may cause an increase in\\nParkinsonian symptoms in patients using the drug\\nfor that purpose. All are schedule C for pregnancy.\\nIn animal studies, they have caused fetal malforma-\\ntions in doses several times higher than the normal\\nhuman dose. Use caution in breast feeding.\\nInteractions\\nConsult specific references for information on\\ndrug interactions.\\nUse particular caution in HIV-positive patients,\\nsince these patients are commonly on multi-drug regi-\\nmens with a high frequency of interactions.\\nGanciclovir should not be used with other drugs\\nwhich cause hematologic toxicity, and cidofovir\\nshould not be used with other drugs that may cause\\nkidney damage.\\n356 GALE ENCYCLOPEDIA OF MEDICINE\\nAntiviral drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nPERIODICALS\\nGray, Mary Ann. ‘‘Antiviral Medications.’’Orthopaedic\\nNursing 15 (November-December 1996): 82.\\nSamuel D. Uretsky, PharmD\\nAnxiety\\nDefinition\\nAnxiety is a multisystem response to a perceived\\nthreat or danger. It reflects a combination of biochem-\\nical changes in the body, the patient’s personal history\\nand memory, and the social situation. As far as we\\nknow, anxiety is a uniquely human experience. Other\\nanimals clearly know fear, but human anxiety involves\\nan ability, to use memory and imagination to move\\nbackward and forward in time, that animals do\\nnot appear to have. The anxiety that occurs in post-\\ntraumatic syndromes indicates that human memory is\\na much more complicated mental function than ani-\\nmal memory. Moreover, a large portion of human\\nanxiety is produced by anticipation of future events.\\nWithout a sense of personal continuity over time,\\npeople would not have the ‘‘raw materials’’ of anxiety.\\nIt is important to distinguish between anxiety as a\\nfeeling or experience, and an anxiety disorder as a\\npsychiatric diagnosis. A person may feel anxious with-\\nout having an anxiety disorder. In addition, a person\\nfacing a clear and present danger or a realistic fear is\\nnot usually considered to be in a state of anxiety. In\\naddition, anxiety frequently occurs as a symptom in\\nother categories of psychiatric disturbance.\\nDescription\\nAlthough anxiety is a commonplace experience\\nthat everyone has from time to time, it is difficult to\\ndescribe concretely because it has so many different\\npotential causes and degrees of intensity. Doctors\\nsometimes categorize anxiety as an emotion or an\\naffect depending on whether it is being described by\\nthe person having it (emotion) or by an outside obser-\\nver (affect). The wordemotion is generally used for the\\nbiochemical changes and feeling state that underlie a\\nperson’s internal sense of anxiety.Affect is used to\\ndescribe the person’s emotional state from an obser-\\nver’s perspective. If a doctor says that a patient has an\\nanxious affect, he or she means that the patient\\nappears nervous or anxious, or responds to others in\\nan anxious way (for example, the individual is shaky,\\ntremulous, etc.).\\nAlthough anxiety is related to fear, it is not the\\nsame thing. Fear is a direct, focused response to a\\nspecific event or object, and the person is consciously\\naware of it. Most people will feel fear if someone\\npoints a loaded gun at them or if they see a tornado\\nforming on the horizon. They also will recognize that\\nthey are afraid. Anxiety, on the other hand, is often\\nunfocused, vague, and hard to pin down to a specific\\ncause. In this form it is called free-floating anxiety.\\nKEY TERMS\\nAffect— An observed emotional expression or\\nresponse. In some situations, anxiety would be\\nconsidered an inappropriate affect.\\nAnxiolytic— A type of medication that helps to\\nrelieve anxiety.\\nAutonomic nervous system (ANS)— The part of the\\nnervous system that supplies nerve endings in the\\nblood vessels, heart, intestines, glands, and smooth\\nmuscles, and governs their involuntary functioning.\\nThe autonomic nervous system is responsible for\\nthe biochemical changes involved in experiences\\nof anxiety.\\nEndocrine gland— A ductless gland, such as the\\npituitary, thyroid, or adrenal gland, that secretes\\nits products directly into the blood or lymph.\\nFree-floating anxiety— Anxiety that lacks a definite\\nfocus or content.\\nHyperarousal— A state or condition of muscular\\nand emotional tension produced by hormones\\nreleased during the fight-or-flight reaction.\\nHypothalamus— A portion of the brain that regu-\\nlates the autonomic nervous system, the release of\\nhormones from the pituitary gland, sleep cycles,\\nand body temperature.\\nLimbic system— A group of structures in the brain\\nthat includes the hypothalamus, amygdala, and\\nhippocampus. The limbic system plays an impor-\\ntant part in regulation of human moods and emo-\\ntions. Many psychiatric disorders are related to\\nmalfunctioning of the limbic system.\\nPhobia— In psychoanalytic theory, a psychological\\ndefense against anxiety in which the patient dis-\\nplaces anxious feelings onto an external object,\\nactivity, or situation.\\nGALE ENCYCLOPEDIA OF MEDICINE 357\\nAnxiety'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Sometimes anxiety being experienced in the present\\nmay stem from an event or person that produced\\npain and fear in the past, but the anxious individual\\nis not consciously aware of the original source of the\\nfeeling. It is anxiety’s aspect of remoteness that makes\\nit hard for people to compare their experiences of it.\\nWhereas most people will be fearful in physically dan-\\ngerous situations, and can agree that fear is an appro-\\npriate response in the presence of danger, anxiety is\\noften triggered by objects or events that are unique\\nand specific to an individual. An individual might be\\nanxious because of a unique meaning or memory\\nbeing stimulated by present circumstances, not\\nbecause of some immediate danger. Another indivi-\\ndual looking at the anxious person from the outside\\nmay be truly puzzled as to the reason for the person’s\\nanxiety.\\nCauses and symptoms\\nAnxiety can have a number of different causes. It is\\na multidimensional response to stimuli in the person’s\\nenvironment, or a response to an internal stimulus (for\\nexample, a hypochondriac’s reaction to a stomach\\nrumbling) resulting from a combination of general\\nbiological and individual psychological processes.\\nPhysical\\nIn some cases, anxiety is produced by physical\\nresponses tostress, or by certain disease processes or\\nmedications.\\nTHE AUTONOMIC NERVOUS SYSTEM (ANS).The ner-\\nvous system of human beings is ‘‘hard-wired’’ to\\nrespond to dangers or threats. These responses are\\nnot subject to conscious control, and are the same in\\nhumans as in lower animals. They represent an evolu-\\ntionary adaptation to the animal predators and other\\ndangers with which all animals, including primitive\\nhumans, had to cope. The most familiar reaction of\\nthis type is the so-called ‘‘fight-or-flight’’ response.\\nThis response is the human organism’s automatic\\n‘‘red alert’’ in a life-threatening situation. It is a state\\nof physiological and emotional hyperarousal marked\\nby high muscle tension and strong feelings of fear or\\nanger. When a person has a fight-or-flight reaction,\\nthe level of stress hormones in their blood rises. They\\nbecome more alert and attentive, their eyes dilate, their\\nheartbeat increases, their breathing rate increases, and\\ntheir digestion slows down, allowing more energy to be\\navailable to the muscles.\\nThis emergency reaction is regulated by a part\\nof the nervous system called the autonomic nervous\\nsystem, or ANS. The ANS is controlled by the\\nhypothalamus, a specialized part of the brainstem\\nthat is among a group of structures called the limbic\\nsystem. The limbic system controls human emotions\\nthrough its connections to glands and muscles; it also\\nconnects to the ANS and ‘‘higher’’ brain centers, such\\nas parts of the cerebral cortex. One problem with this\\narrangement is that the limbic system cannot tell the\\ndifference between a realistic physical threat and an\\nanxiety-producing thought or idea. The hypothalamus\\nmay trigger the release of stress hormones by the\\npituitary gland, even when there is no external and\\nobjective danger. A second problem is caused by the\\nbiochemical side effects of too many ‘‘false alarms’’ in\\nthe ANS. When a person responds to a real danger,\\nhis or her body gets rid of the stress hormones by\\nrunning away or by fighting. In modern life, however,\\npeople often have fight-or-flight reactions in situations\\nin which they can neither run away nor lash out\\nphysically. As a result, their bodies have to absorb all\\nthe biochemical changes of hyperarousal, rather\\nthan release them. These biochemical changes can\\nproduce anxious feelings, as well as muscle tension\\nand other physical symptoms associated with anxiety.\\nThey may even produce permanent changes in the\\nbrain, if the process occurs repeatedly. Moreover,\\nchronic physical disorders, such as coronary artery\\ndisease, may be worsened by anxiety, as chronic\\nhyperarousal puts undue stress on the heart, stomach,\\nand other organs.\\nDISEASES AND DISORDERS. Anxiety can be a symp-\\ntom of certain medical conditions. Some of these dis-\\neases are disorders of the endocrine system, such as\\nCushing’s syndrome (overproduction of cortisol by\\nthe adrenal cortex), and include over- or underactivity\\nof the thyroid gland. Other medical conditions that\\ncan produce anxiety includerespiratory distress syn-\\ndrome, mitral valve prolapse, porphyria, and chest\\npain caused by inadequate blood supply to the heart\\n(angina pectoris).\\nA study released in 2004 showed that people who\\nhad experienced traumatic bone injuries may have\\nunrecognized anxiety in the form ofpost-traumatic\\nstress disorder. This disorder can result from witnes-\\nsing or experiencing an event involving serious injury,\\nor threatened death (or experiencing the death or\\nthreatened death of another.)\\nMEDICATIONS AND SUBSTANCE USE. Numerous\\nmedications may cause anxiety-like symptoms as a\\nside effect. They include birth control pills; some thyr-\\noid or asthma drugs; some psychotropic agents;\\noccasionally, local anesthetics;corticosteroids; antihy-\\npertensive drugs; and nonsteroidal anti-inflammatory\\ndrugs (like flurbiprofen and ibuprofen).\\n358 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Although people do not usually think ofcaffeineas\\na drug, it can cause anxiety-like symptoms when con-\\nsumed in sufficient quantity. Patients who consume caf-\\nfeine rich foods and beverages, such as chocolate, cocoa,\\ncoffee, tea, or carbonated soft drinks (especially cola\\nbeverages), can sometimes lower their anxiety symptoms\\nsimply by reducing their intake of these substances.\\nWithdrawal from certain prescription drugs,\\nprimarily beta blockers and corticosteroids, can\\ncause anxiety. Withdrawal from drugs of abuse,\\nincluding LSD, cocaine, alcohol, and opiates, can\\nalso cause anxiety.\\nLearned associations\\nSome aspects of anxiety appear to be unavoidable\\nbyproducts of the human developmental process.\\nHumans are unique among animals in that they\\nspend an unusually long period of early life in a rela-\\ntively helpless condition, and a sense of helplessness\\ncan lead to anxiety. The extended period of human\\ndependency on adults means that people may remem-\\nber, and learn to anticipate, frightening or upsetting\\nexperiences long before they are capable enough to feel\\na sense of mastery over their environment. In addition,\\nthe fact that anxiety disorders often run in families\\nindicates that children can learn unhealthy attitudes\\nand behaviors from parents, as well as healthy ones.\\nAlso, recurrent disorders in families may indicate that\\nthere is a genetic or inherited component in some\\nanxiety disorders. For example, there has been found\\nto be a higher rate of anxiety disorders (panic) in\\nidentical twins than in fraternal twins.\\nCHILDHOOD DEVELOPMENT AND ANXIETY.\\nResearchers in early childhood development regard\\nanxiety in adult life as a residue of childhood mem-\\nories of dependency. Humans learn during the first\\nyear of life that they are not self-sufficient and that\\ntheir basic survival depends on the care of others. It is\\nthought that this early experience of helplessness\\nunderlies the most common anxieties of adult life,\\nincluding fear of powerlessness and fear of being\\nunloved. Thus, adults can be made anxious by sym-\\nbolic threats to their sense of competence and/or\\nsignificant relationships, even though they are no\\nlonger helpless children.\\nSYMBOLIZATION. The psychoanalytic model gives\\nconsiderable weight to the symbolic aspect of human\\nanxiety; examples include phobic disorders, obsessions,\\ncompulsions, and other forms of anxiety that are highly\\nindividualized. The length of the human maturation\\nprocess allows many opportunities for children and\\nadolescents to connect their experiences with certain\\nobjects or events that can bring back feelings in later\\nlife. For example, a person who was frightened as a child\\nb yat a l lm a nw e a r i n gg l a s s e sm a yf e e lp a n i c k yy e a r s\\nlater by something that reminds him of that person or\\nexperience without consciously knowing why.\\nFreud thought that anxiety results from a per-\\nson’s internal conflicts. According to his theory,\\npeople feel anxious when they feel torn between\\ndesires or urges toward certain actions, on the one\\nhand, and moral restrictions, on the other. In some\\ncases, the person’s anxiety may attach itself to an\\nobject that represents the inner conflict. For exam-\\nple, someone who feels anxious around money may\\nbe pulled between a desire to steal and the belief that\\nstealing is wrong. Money becomes a symbol for the\\ninner conflict between doing what is considered right\\nand doing what one wants.\\nPHOBIAS. Phobias are a special type of anxiety\\nreaction in which the person’s anxiety is concentrated\\non a specific object or situation that the person then\\ntries to avoid. In most cases, the person’s fear is out of\\nall proportion to its ‘‘cause.’’ Prior to theDiagnostic\\nand Statistical Manual of Mental Disorders,4th edition\\n(DSM-IV), these specific phobias were called simple\\nphobias. It is estimated that 10-11% of the population\\nwill develop a phobia in the course of their lives. Some\\nphobias, such asagoraphobia (fear of open spaces),\\nclaustrophobia (fear of small or confined spaces), and\\nsocial phobia, are shared by large numbers of people.\\nOthers are less common or unique to the patient.\\nSocial and environmental stressors\\nAnxiety often has a social dimension because\\nhumans are social creatures. People frequently report\\nfeelings of high anxiety when they anticipate and,\\ntherefore, fear the loss of social approval or love.\\nSocial phobia is a specific anxiety disorder that is\\nmarked by high levels of anxiety or fear of embarrass-\\nment in social situations.\\nAnother social stressor is prejudice. People who\\nbelong to groups that are targets of bias are at higher\\nrisk for developing anxiety disorders. Some experts\\nthink, for example, that the higher rates of phobias\\nand panic disorderamong women reflects their greater\\nsocial and economic vulnerability.\\nSome controversial studies indicate that the\\nincrease in violent or upsetting pictures and stories in\\nnews reports and entertainment may raise the anxiety\\nlevel of many people. Stress and anxiety management\\nprograms often suggest that patients cut down their\\nexposure to upsetting stimuli.\\nGALE ENCYCLOPEDIA OF MEDICINE 359\\nAnxiety'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Anxiety may also be caused by environmental or\\noccupational factors. People who must live or work\\naround sudden or loud noises, bright or flashing lights,\\nchemical vapors, or similar nuisances, which they cannot\\navoid or control, may develop heightened anxiety levels.\\nExistential anxiety\\nAnother factor that shapes human experiences of\\nanxiety is knowledge of personal mortality. Humans are\\nthe only animals that appear to be aware of their limited\\nlife span. Some researchers think that awareness of\\ndeath influences experiences of anxiety from the time\\nthat a person is old enough to understand death.\\nSymptoms of anxiety\\nIn order to understand the diagnosis and treat-\\nment of anxiety, it is helpful to have a basic under-\\nstanding of its symptoms.\\nSOMATIC. The somatic or physical symptoms of\\nanxiety include headaches,dizziness or lightheaded-\\nness, nausea and/or vomiting, diarrhea, tingling, pale\\ncomplexion, sweating,numbness, difficulty in breath-\\ning, and sensations of tightness in the chest, neck,\\nshoulders, or hands. These symptoms are produced\\nby the hormonal, muscular, and cardiovascular reac-\\ntions involved in the fight-or-flight reaction. Children\\nand adolescents withgeneralized anxiety disordershow\\na high percentage of physical complaints.\\nBEHAVIORAL. Behavioral symptoms of anxiety\\ninclude pacing, trembling, general restlessness, hyper-\\nventilation, pressured speech, hand wringing, or finger\\ntapping.\\nCOGNITIVE. Cognitive symptoms of anxiety\\ninclude recurrent or obsessive thoughts, feelings of\\ndoom, morbid or fear-inducing thoughts or ideas,\\nand confusion, or inability to concentrate.\\nEMOTIONAL. Feeling states associated with anxi-\\nety include tension or nervousness, feeling ‘‘hyper’’ or\\n‘‘keyed up,’’ and feelings of unreality, panic, or terror.\\nDEFENSE MECHANISMS. In psychoanalytic theory,\\nthe symptoms of anxiety in humans may arise from or\\nactivate a number of unconscious defense mechan-\\nisms. Because of these defenses, it is possible for a\\nperson to be anxious without being consciously\\naware of it or appearing anxious to others. These\\npsychological defenses include:\\n/C15Repression. The person pushes anxious thoughts or\\nideas out of conscious awareness.\\n/C15Displacement. Anxiety from one source is attached\\nto a different object or event. Phobias are an example\\nof the mechanism of displacement in psychoanalytic\\ntheory.\\n/C15Rationalization. The person justifies the anxious\\nfeelings by saying that any normal person would\\nfeel anxious in their situation.\\n/C15Somatization. The anxiety emerges in the form of\\nphysical complaints and illnesses, such as recurrent\\nheadaches, stomach upsets, or muscle and joint pain.\\n/C15Delusion formation. The person converts anxious\\nfeelings into conspiracy theories or similar ideas\\nwithout reality testing. Delusion formation can\\ninvolve groups as well as individuals.\\nOther theorists attribute some drugaddictionto the\\ndesire to relieve symptoms of anxiety. Most addictions,\\nthey argue, originate in the use of mood-altering sub-\\nstances or behaviors to ‘‘medicate’’ anxious feelings.\\nDiagnosis\\nThe diagnosis of anxiety is difficult and complex\\nbecause of the variety of its causes and the highly\\npersonalized and individualized nature of its symptom\\nformation. There are no medical tests that can be used\\nto diagnose anxiety by itself. When a doctor examines\\nan anxious patient, he or she will first rule out physical\\nconditions and diseases that have anxiety as a symp-\\ntom. Apart from these exclusions, thephysical exam-\\nination is usually inconclusive. Some anxious patients\\nmay have their blood pressure or pulse rate affected by\\nanxiety, or may look pale or perspire heavily, but\\nothers may appear physically completely normal.\\nThe doctor will then take the patient’s medication,\\ndietary, and occupational history to see if they are\\ntaking prescription drugs that might cause anxiety, if\\nthey are abusing alcohol or mood-altering drugs,\\nif they are consuming large amounts of caffeine, or if\\ntheir workplace is noisy or dangerous. In most cases,\\nthe most important source of diagnostic information is\\nthe patient’s psychological and social history. The\\ndoctor may administer a brief psychological test to\\nhelp evaluate the intensity of the patient’s anxiety and\\nsome of its features. Some tests that are often given\\ninclude the Hamilton Anxiety Scale and the Anxiety\\nDisorders Interview Schedule (ADIS). Many doctors\\nwill check a number of chemical factors in the blood,\\nsuch as the level of thyroid hormone and blood sugar.\\nTreatment\\nNot all patients with anxiety require treatment,\\nbut for more severe cases, treatment is recommended.\\nBecause anxiety often has more than one cause and is\\nexperienced in highly individual ways, its treatment\\n360 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='usually requires more than one type of therapy. In\\naddition, there is no way to tell in advance how\\npatients will respond to a specific drug or therapy.\\nSometimes the doctor will need to try different medi-\\ncations or methods of treatment before finding the\\nbest combination for the particular patient. It usually\\ntakes about six to eight weeks for the doctor to evalu-\\nate the effectiveness of a treatment regimen.\\nMedications\\nMedications are often prescribed to relieve the\\nphysical and psychological symptoms of anxiety.\\nMost agents work by counteracting the biochemical\\nand muscular changes involved in the fight-or-flight\\nreaction. Some work directly on the chemicals in the\\nbrain that are thought to underlie the anxiety.\\nANXIOLYTICS. Anxiolytics are sometimes called\\ntranquilizers. Most anxiolytic drugs are eitherbenzo-\\ndiazepines or barbiturates. Barbiturates, once com-\\nmonly used, are now rarely used in clinical practice.\\nBarbiturates work by slowing down the transmission\\nof nerve impulses from the brain to other parts\\nof the body. They include such drugs as phenobarbital\\n(Luminal) and pentobarbital (Nembutal). Benzodia-\\nzepines work by relaxing the skeletal muscles and\\ncalming the limbic system. They include such drugs\\nas chlordiazepoxide (Librium) and diazepam\\n(Valium). Both barbiturates and benzodiazepines are\\npotentially habit-forming and may cause withdrawal\\nsymptoms, but benzodiazepines are far less likely than\\nbarbiturates to cause physical dependency. Both drugs\\nalso increase the effects of alcohol and should never be\\ntaken in combination with it.\\nTwo other types of anxiolytic medications\\ninclude meprobamate (Equanil), which is now\\nrarely used, and buspirone (BuSpar), a new type\\nof anxiolytic that appears to work by increasing\\nthe efficiency of the body’s own emotion-regulating\\nbrain chemicals. Buspirone has several advantages\\nover other anxiolytics. It does not cause depen-\\ndence problems, does not interact with alcohol,\\nand does not affect the patient’s ability to drive\\nor operate machinery. However, buspirone is not\\neffective against certain types of anxiety, such as\\npanic disorder.\\nANTIDEPRESSANTS AND BETA-BLOCKERS. For some\\nanxiety disorders, such as obsessive-compulsive disor-\\nder and panic type anxiety, a type of drugs used to treat\\ndepression, selective serotonin reuptake inhibitors\\n(SSRIs; such as Prozac and Paxil), are the treatment\\nof choice. A newer drug that has been shown as effec-\\ntive as Paxil is called escitalopram oxalate (Lexapro).\\nBecause anxiety often coexists with symptoms of\\ndepression, many doctors prescribe antidepressant\\nmedications for anxious/depressed patients. While\\nSSRIs are more common, antidepressants are some-\\ntimes prescribed, including tricyclic antidepressants\\nsuch as imipramine (Tofranil) ormonoamine oxidase\\ninhibitors (MAO inhibitors) such as phenelzine\\n(Nardil).\\nBeta-blockers are medications that work by\\nblocking the body’s reaction to the stress hormones\\nthat are released during the fight-or-flight reaction.\\nThey include drugs like propranolol (Inderal) or ate-\\nnolol (Tenormin). Beta-blockers are sometimes given\\nto patients with post-traumatic anxiety symptoms.\\nMore commonly, the beta-blockers are given to\\npatients with a mild form of social phobic anxiety,\\nsuch as fear of public speaking.\\nPsychotherapy\\nMost patients with anxiety will be given some\\nform of psychotherapy along with medications.\\nMany patients benefit from insight-oriented therapies,\\nwhich are designed to help them uncover unconscious\\nconflicts and defense mechanisms in order to under-\\nstand how their symptoms developed. Patients who\\nare extremely anxious may benefit from supportive\\npsychotherapy, which aims at symptom reduction\\nrather than personality restructuring.\\nTwo newer approaches that work well with\\nanxious patients are cognitive-behavioral therapy\\n(CBT), and relaxation training. In CBT, the patient\\nis taught to identify the thoughts and situations that\\nstimulate his or her anxiety, and to view them more\\nrealistically. In the behavioral part of the program, the\\npatient is exposed to the anxiety-provoking object,\\nsituation, or internal stimulus (like a rapid heart\\nbeat) in gradual stages until he or she is desensitized\\nto it. Relaxation training, which is sometimes called\\nanxiety management training, includes breathing exer-\\ncises and similar techniques intended to help the\\npatient prevent hyperventilation and relieve the mus-\\ncle tension associated with the fight-or-flight reaction.\\nBoth CBT and relaxation training can be used in\\ngroup therapy as well as individual treatment. In addi-\\ntion to CBT, support groups are often helpful to\\nanxious patients, because they provide a social net-\\nwork and lessen the embarrassment that often accom-\\npanies anxiety symptoms.\\nPsychosurgery\\nSurgery on the brain is very rarely recommended\\nfor patients with anxiety; however, some patients with\\nsevere cases of obsessive-compulsive disorder (OCD)\\nGALE ENCYCLOPEDIA OF MEDICINE 361\\nAnxiety'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='have been helped by an operation on a part of\\nthe brain that is involved in OCD. Normally, this\\noperation is attempted after all other treatments have\\nfailed.\\nAlternative treatment\\nAlternative treatments for anxiety cover a variety\\nof approaches. Meditation and mindfulness training\\nare thought beneficial to patients with phobias and\\npanic disorder. Hydrotherapy is useful to some\\nanxious patients because it promotes general relaxa-\\ntion of the nervous system.Yoga, aikido, t’ai chi, and\\ndance therapy help patients work with the physical, as\\nwell as the emotional, tensions that either promote\\nanxiety or are created by the anxiety.\\nHomeopathy and traditional Chinese medicine\\napproach anxiety as a symptom of a systemic disorder.\\nHomeopathic practitioners select a remedy based on\\nother associated symptoms and the patient’s general\\nconstitution. Chinese medicine regards anxiety as a\\nblockage of qi, or vital force, inside the patient’s\\nbody that is most likely to affect the lung and large\\nintestine meridian flow. The practitioner of Chinese\\nmedicine choosesacupuncture point locations and/or\\nherbal therapy to move the qi and rebalance the entire\\nsystem in relation to the lung and large intestine.\\nPrognosis\\nThe prognosis for resolution of anxiety depends\\non the specific disorder and a wide variety of factors,\\nincluding the patient’s age, sex, general health, living\\nsituation, belief system, social support network, and\\nresponses to different anxiolytic medications and\\nforms of therapy.\\nPrevention\\nHumans have significant control over thoughts,\\nand, therefore, may learn ways of preventing anxiety\\nby changing irrational ideas and beliefs. Humans\\nalso have some power over anxiety arising from\\nsocial and environmental conditions. Other forms\\nof anxiety, however, are built into the human organ-\\nism and its life cycle, and cannot be prevented or\\neliminated.\\nResources\\nPERIODICALS\\n‘‘Lexapro Found to be as Effective as Paxil.’’Mental Health\\nWeekly Digest(April 12, 2004): 16.\\nMasi, Gabriele, et al. ‘‘Generalized Anxiety Disorder in\\nReferred Children and Adolescents.’’Journal of the\\nAmerican Academy of Child and Adolescent Psychiatry\\n(June 2004): 752–761.\\n‘‘Patients With Traumatic Bone Injuries Have Unrecognized\\nAnxiety.’’Health & Medicine Week(June 28, 2004): 824.\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAnxiety disorders\\nDefinition\\nThe anxiety disorders are a group of mental dis-\\nturbances characterized by anxiety as a central or core\\nsymptom. Although anxiety is a commonplace experi-\\nence, not everyone who experiences it has an anxiety\\ndisorder. Anxiety is associated with a wide range of\\nphysical illnesses, medication side effects, and other\\npsychiatric disorders.\\nThe revisions of the Diagnostic and Statistical\\nManual of Mental Disorders (DSM)that took place\\nafter 1980 brought major changes in the classification\\nof the anxiety disorders. Prior to 1980, psychiatrists\\nclassified patients on the basis of a theory that defined\\nanxiety as the outcome of unconscious conflicts in the\\npatient’s mind. DSM-III (1980), DSM-III-R (1987),\\nand DSM-IV (1994) introduced and refined a new\\nclassification that considered recent discoveries\\nabout the biochemical and post-traumatic origins\\nof some types of anxiety. The present definitions\\nare based on the external and reported symptom\\npatterns of the disorders rather than on theories\\nabout their origins.\\nDescription\\nAnxiety disorders are the most common form of\\nmental disturbance in the United States population. It is\\nestimated that 28 million people suffer from an anxiety\\ndisorder every year. These disorders are a serious pro-\\nblem for the entire society because of their interference\\nwith patients’ work, schooling, and family life. They\\nalso contribute to the high rates of alcohol and sub-\\nstance abuse in the United States. Anxiety disorders\\nare an additional problem for health professionals\\nbecause the physical symptoms of anxiety frequently\\nbring people to primary care doctors or emergency\\nrooms.\\nDSM-IV defines 12 types of anxiety disorders in\\nthe adult population. They can be grouped under\\nseven headings:\\n362 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Panic disorders with or withoutagoraphobia. The\\nchief characteristic ofpanic disorderis the occurrence\\nof panic attacks coupled with fear of their recurrence.\\nIn clinical settings, agoraphobia is usually not a dis-\\norder byitself, but is typically associated with some\\nform of panic disorder. Patients with agoraphobia\\nare afraid of places or situations in which they might\\nhave a panic attack and be unable to leave or to find\\nhelp. About 25% of patients with panic disorder\\ndevelop obsessive-compulsive disorder(OCD).\\n/C15Phobias. These include specific phobias and social\\nphobia. A phobia is an intense irrational fear of a\\nspecific object or situation that compels the patient\\nto avoid it. Some phobias concern activities or\\nobjects that involve some risk (for example, flying\\nor driving) but many are focused on harmless ani-\\nmals or other objects. Social phobia involves a fear of\\nbeing humiliated, judged, or scrutinized. It manifests\\nitself as a fear of performing certain functions in the\\npresence of others, such as public speaking or using\\npublic lavatories.\\n/C15Obsessive-compulsive disorder (OCD). This disorder\\nis marked by unwanted, intrusive, persistent\\nthoughts or repetitive behaviors that reflect the\\npatient’s anxiety or attempts to control it. It affects\\nbetween 2-3% of the population and is much more\\ncommon than was previously thought.\\n/C15Stress disorders. These includepost-traumatic stress\\ndisorder (PTSD) and acute stress disorder. Stress\\ndisorders are symptomatic reactions to traumatic\\nevents in the patient’s life.\\n/C15Generalized anxiety disorder (GAD). GAD is the\\nmost commonly diagnosed anxiety disorder and\\noccurs most frequently in young adults.\\n/C15Anxiety disorders due to known physical causes.\\nThese include general medical conditions or sub-\\nstance abuse.\\n/C15Anxiety disorder not otherwise specified. This last\\ncategory is not a separate type of disorder, but is\\nincluded to cover symptoms that do not meet the\\nspecific DSM-IV criteria for other anxiety disorders.\\nAll DSM-IV anxiety disorder diagnoses include a\\ncriterion of severity. The anxiety must be severe\\nenough to interfere significantly with the patient’s\\noccupational or educational functioning, social activ-\\nities or close relationships, and other customary\\nactivities.\\nThe anxiety disorders vary widely in their fre-\\nquency of occurrence in the general population, age\\nof onset, family patterns, and gender distribution. The\\nstress disorders and anxiety disorders caused by\\nmedical conditions or substance abuse are less age-\\nand gender-specific. Whereas OCD affects males and\\nfemales equally, GAD, panic disorder, and specific\\nphobias all affect women more frequently than men.\\nGAD and panic disorders are more likely to develop in\\nyoung adults, while phobias and OCD can begin in\\nchildhood.\\nAnxiety disorders in children and adolescents\\nDSM-IV defines one anxiety disorder as specific\\nto children, namely, separation anxiety disorder. This\\ndisorder is defined as anxiety regarding separation\\nfrom home or family that is excessive or inappropriate\\nfor the child’s age. In some children, separation anxi-\\nety takes the form of school avoidance.\\nChildren and adolescents can also be diagnosed\\nwith panic disorder, phobias, generalized anxiety dis-\\norder, and the post-traumatic stress syndromes.\\nCauses and symptoms\\nThe causes of anxiety include a variety of indivi-\\ndual and general social factors, and may produce phy-\\nsical, cognitive, emotional, or behavioral symptoms.\\nThe patient’s ethnic or cultural background may also\\ninfluence his or her vulnerability to certain forms of\\nanxiety. Genetic factors that lead to biochemical\\nabnormalities may also play a role.\\nAnxiety in children may be caused by suffering\\nfrom abuse, as well as by the factors that cause anxiety\\nin adults.\\nKEY TERMS\\nAgoraphobia— Abnormal anxiety regarding public\\nplaces or situations from which the patient may\\nwish to flee or in which he or she would be helpless\\nin the event of a panic attack.\\nCompulsion— A repetitive or ritualistic behavior\\nthat a person performs to reduce anxiety.\\nCompulsions often develop as a way of controlling\\nor ‘‘undoing’’ obsessive thoughts.\\nObsession— A repetitive or persistent thought,\\nidea, or impulse that is perceived as inappropriate\\nand distressing.\\nPanic attack— A time-limited period of intense fear\\naccompanied by physical and cognitive symptoms.\\nPanic attacks may be unexpected or triggered by\\nspecific cues.\\nGALE ENCYCLOPEDIA OF MEDICINE 363\\nAnxiety disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nThe diagnosis of anxiety disorders is complicated by\\nthe variety of causes of anxiety and the range of disor-\\nders that may include anxiety as a symptom. Many\\npatients who suffer from anxiety disorders have features\\nor symptoms of more than one disorder. Patients whose\\nanxiety is accounted for by another psychic disorder,\\nsuch as schizophrenia or major depression, are not\\ndiagnosed with an anxiety disorder. A doctor examining\\nan anxious patient will usually begin by ruling out dis-\\neases that are known to cause anxiety and then proceed\\nto take the patient’s medication history, in order to\\nexclude side effects of prescription drugs. Most doctors\\nwill ask about caffeine consumption to see if the\\npatient’s dietary habits are a factor. The patient’s work\\nand family situation will also be discussed. Often, pri-\\nmary care physicians will exhaust resources looking for\\nmedical causes for general patient complaints which\\nmay indicate a physical illness. In 2004, the Anxiety\\nDisorders Association of American published guide-\\nl i n e st ob e t t e ra i dp h y s i c i a n si nd i a g n o s i n ga n dm a n a -\\nging generalized anxiety disorder. Laboratory tests for\\nblood sugar and thyroid function are also common.\\nDiagnostic testing for anxiety\\nThere are no laboratory tests that can diagnose\\nanxiety, although the doctor may order some specific\\ntests to rule out disease conditions. Although there is\\nno psychiatric test that can provide definite diagnoses\\nof anxiety disorders, there are several short-answer\\ninterviews or symptom inventories that doctors can\\nuse to evaluate the intensity of a patient’s anxiety\\nand some of its associated features. These measures\\ninclude the Hamilton Anxiety Scale and the Anxiety\\nDisorders Interview Schedule (ADIS).\\nTreatment\\nFor relatively mild anxiety disorders, psychother-\\napy alone may suffice. In general, doctors prefer to use\\na combination of medications and psychotherapy with\\nmore severely anxious patients. Most patients respond\\nbetter to a combination of treatment methods than to\\neither medications or psychotherapy in isolation.\\nBecause of the variety of medications and treatment\\napproaches that are used to treat anxiety disorders, the\\ndoctor cannot predict in advance which combination\\nwill be most helpful to a specific patient. In many cases\\nthe doctor will need to try a new medication or treat-\\nment over a six- to eight-week period in order to assess\\nits effectiveness. Treatment trials do not necessarily\\nmean that the patient cannot be helped or that the\\ndoctor is incompetent.\\nAlthough anxiety disorders are not always easy to\\ndiagnose, there are several reasons why it is important\\nfor patients with severe anxiety symptoms to get help.\\nAnxiety doesn’t always go away by itself; it often\\nprogresses to panic attacks, phobias, and episodes of\\ndepression. Untreated anxiety disorders may even-\\ntually lead to a diagnosis of major depression, or\\ninterfere with the patient’s education or ability to\\nkeep a job. In addition, many anxious patients develop\\naddictions to drugs or alcohol when they try to ‘‘med-\\nicate’’ their symptoms. Moreover, since children learn\\nways of coping with anxiety from their parents, adults\\nwho get help for anxiety disorders are in a better\\nposition to help their families cope with factors that\\nlead to anxiety than those who remain untreated.\\nAlternative treatment\\nAlternative treatments for anxiety cover a variety\\nof approaches. Meditation and mindfulness training\\nare thought beneficial to patients with phobias and\\npanic disorder. Hydrotherapy is useful to some\\nanxious patients because it promotes general relaxa-\\ntion of the nervous system.Yoga, aikido, t’ai chi, and\\ndance therapy help patients work with the physical, as\\nwell as the emotional, tensions that either promote\\nanxiety or are created by the anxiety.\\nHomeopathy and traditional Chinese medicine\\napproach anxiety as a symptom of a systemic disorder.\\nHomeopathic practitioners select a remedy based on\\nother associated symptoms and the patient’s general\\nconstitution. Chinese medicine regards anxiety as a\\nblockage of qi, or vital force, inside the patient’s\\nbody that is most likely to affect the lung and large\\nintestine meridian flow. The practitioner of Chinese\\nmedicine choosesacupuncture point locations and/or\\nherbal therapy to move the qi and rebalance the entire\\nsystem in relation to the lung and large intestine.\\nPrognosis\\nThe prognosis for recovery depends on the speci-\\nfic disorder, the severity of the patient’s symptoms, the\\nspecific causes of the anxiety, and the patient’s degree\\nof control over these causes.\\nPrevention\\nAnxiety is an unavoidable feature of human exis-\\ntence. However, humans have some power over their\\nreactions to anxiety-provoking events and situations.\\nCognitive therapy and meditation or mindfulness\\ntraining appear to be beneficial in helping people\\nlower their long-term anxiety levels.\\n364 GALE ENCYCLOPEDIA OF MEDICINE\\nAnxiety disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nPERIODICALS\\n‘‘Guidelines to Assist Primary Care Physicians in Diagnosing\\nGAD.’’ Psychiatric Times( J u l y1 ,2 0 0 4 ) :1 6 .\\nRebecca J. Frey, PhD\\nTeresa G. Odle\\nAnxiolytics see Antianxiety drugs\\nAortic aneurysm\\nDefinition\\nAn aneurysm is an abnormal bulging or swelling\\nof a portion of a blood vessel. The aorta, which can\\ndevelop these abnormal bulges, is the large blood\\nvessel that carries oxygen-rich blood away from the\\nheart to the rest of the body.\\nDescription\\nThe aorta carries oxygen-rich blood to the body,\\nand is therefore called an artery. Because the aorta is an\\nartery, its walls are made of up three layers; a thin inner\\nlayer, a muscular middle layer (that gives the vessel its\\nflexibility under pressure from the filling blood), and a\\nfiber-like outer layer that gives the vessel strength to not\\nburst when the heart pumps blood to the body.\\nAortic aneurysms occur when a weakness devel-\\nops in part of the wall of the aorta; three basic\\ntypes are usually found. If all three layers of the\\nvessel are affected and weakness develops along an\\nextended area of the vessel, the weakened area will\\nappear as a large, bulging region of blood vessel;\\nthis is called a fusiform aneurysm. If weakness\\ndevelops between the inner and outer layers of the\\naortic wall, a bulge results as blood from the inter-\\nior of the vessel is pushed around the damaged\\nregion in the wall and collects between these layers.\\nThis is called a dissecting aneurysm because one\\nlayer is ‘‘dissected’’ or separated from another. If\\ndamage occurs to only the middle (muscular) layer\\nof the vessel, a sack-like bulge can form; therefore,\\nthis is a saccular aneurysm.\\nCauses and symptoms\\nAortic aneurysms occur in different portions of\\nthe aorta, which begins in the chest (at the heart) and\\ntravels downward through the abdomen. Aneurysms\\nfound in the region of the aorta within the chest are\\ncalled thoracic aortic aneurysms. Aneurysms that\\noccur in the part of the aorta within the abdomen are\\ncalled abdominal aortic aneurysms.\\nThoracic aortic aneurysms do not usually pro-\\nduce any noticeable symptoms. However, as the\\naneurysm becomes larger, chest, shoulder, neck,\\nlower back, or abdominal pain can result.\\nAbdominal aortic aneurysms occur more often in\\nmen, and these aneurysms can cause pain in the\\nlower back, hips, and abdomen. A painful abdomi-\\nnal aortic aneurysm usually means that the aneurysm\\ncould burst very soon.\\nMost abdominal aortic aneurysms are caused by\\natherosclerosis, a condition caused when fat (mostly\\ncholesterol) carried in the blood builds up in the inner\\nwall of the aorta. As more and more fat attaches to the\\naortic wall, the wall itself becomes abnormally weak\\nand often results in an aneurysm or bulge.\\nAn aneurysm in progress. An aneurysm is an abnormal\\nbulging or swelling of a portion of a blood vessel. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\nSurgery being performed to correct aortic aneurysm.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 365\\nAortic aneurysm'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aortic aneurysms are also caused by a breakdown\\nof the muscular middle layer of the artery wall, by high\\nblood pressure, by direct injury to the chest, and\\nalthough rare, by bacteria that can infect the aorta.\\nDiagnosis\\nSilent, stable aneurysms are often detected when a\\nperson has an x ray as part of a routine examination or\\nfor other medical reasons. Otherwise, when chest,\\nabdominal, or back pain is severe, aortic aneurysm is\\nsuspected and x-ray (radiographic) studies can con-\\nfirm or rule out that condition.\\nTreatment\\nAortic aneurysms are potentially life-threatening\\nconditions. Small aneurysms should be monitored for\\ntheir rate of growth and large aneurysms require con-\\nsideration for a surgical repair. The most common\\nAortic \\naneurysm\\nAorta\\nSubclavian artery\\nCarotid artery\\nHeart\\nHepatic artery\\nMessentric artery\\nIliac artery\\nRenal artery\\nPulmonary artery\\nLiver\\nKidney\\nAortic aneurysms occur when a weakness develops in a part of the wall of the aorta. The aorta is the large blood vessel that\\ncarries oxygen-rich blood away from the heart to the rest of the body.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nAtherosclerosis— The accumulation of fat on the\\ninner wall of an artery. This fat is largely made up\\nof cholesterol being carried in the blood.\\nDacron— A synthetic polyester fiber used to surgi-\\ncally repair damaged sections of blood vessel walls.366 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic aneurysm'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='method of surgical repair is to cut out the bulging\\nsection of artery wall and sew a Dacron fiber material\\ninto its place in the vessel wall.\\nPrognosis\\nOnly 1-2% of people die from having surgical\\nrepair of an aortic aneurysm. However, if the aneurysm\\nis untreated and eventually ruptures, less than half of\\nthe people with ruptured aneurysms will survive. The\\nchallenge for the physician is to decide when or if to do\\nthe preventive surgery.\\nPrevention\\nAneuryms can develop in people with athero-\\nsclerosis. High blood pressure can also lead to this\\ncondition. Although no definite prevention exists, life-\\nstyle and dietary changes that help lower blood pres-\\nsure and the amount of fat in the blood stream may\\nslow the development of aneurysms.\\nResources\\nPERIODICALS\\nvan der Vleit, J. Adam, and Albert P. M. Boll. ‘‘Abdominal\\nAorticAneurysm.’’The Lancet349 (March 22, 1997): 863.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nDominic De Bellis, PhD\\nAortic dissection\\nDefinition\\nAortic dissection is a rare, but potentially fatal,\\ncondition in which blood passes through the inner\\nlining and between the layers of the aorta. The dissect-\\ning aorta usually does not burst, but has an abnormal\\nsecond channel within it.\\nDescription\\nA defect in the inner lining of the aorta allows an\\nopening or tear to develop. The aorta is the main\\nartery of the body and is an area of high blood\\npressure. When a defect develops, blood pressure can\\nforce the tear to open and allow blood to pass through.\\nSince the blood is under pressure, it eventually splits\\n(dissecting) the middle layer of the blood vessel, creat-\\ning a new channel for blood. The length of the channel\\ngrows over time and can result in the closing off of\\nconnection points to other arteries. This can lead to\\nheart attack, strokes, abdominal pain, and nerve\\ndamage. Blood may leak from the dissection and col-\\nlect in the chest an around the heart.\\nA second mechanism leading to aortic dissection\\nis medial hemorrhage. A medial hemorrhage occurs in\\nthe middle layer of the blood vessel and spills through\\nthe inner lining of the aorta wall. This opening then\\nallows blood from the aorta to enter the vessel wall\\nand begin a dissection. Approximately 2,000 cases of\\naortic dissection occur yearly in the United States.\\nCauses and symptoms\\nAortic dissection is caused by a deterioration of\\nthe inner lining of the aorta. There are a number of\\nconditions that predispose a person to develop defects\\nof the inner lining, including high blood pressure,\\nMarfan’s disease,Ehlers-Danlos syndrome, connective\\ntissue diseases, and defects of heart development\\nwhich begin during fetal development. A dissection\\ncan also occur accidentally following insertion of a\\ncatheter, trauma, or surgery. The main symptom is sud-\\nden, intense pain. The pain can be so intense as to\\nimmobilize the patient and cause him to fall to the\\nground. The pain is frequently felt in both the chest\\nand in the back, between the shoulder blades. The extent\\nof the pain isproportional tothe lengthof the dissection.\\nDiagnosis\\nThe pain experienced by the patient is the first\\nsymptom of aortic dissection and is unique. The pain is\\nusually described by the patient as ‘‘tearing, ripping, or\\nstabbing.’’ This is in contrastto the pain associated with\\nheart attacks. The patient frequently has a reduced or\\nabsent pulse in the extremities. A murmur may be heard\\nif the dissection is close to the heart. An enlarged aorta\\nwill usually appear in the chest x rays and ultrasound\\nKEY TERMS\\nDissection— A cut or divide.\\nHemorrhage— A large discharge of blood, profuse\\nbleeding.\\nGALE ENCYCLOPEDIA OF MEDICINE 367\\nAortic dissection'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='exams of most patients. The use of a blood dye in angio-\\ngrams and/or CT scans (computed tomography scans)\\nwill aid in diagnosing and visualizing the dissection.\\nTreatment\\nBecause of the potentially fatal nature of aortic\\ndissection, patients are treated immediately. Drugs are\\nadministered to reduce the blood pressure and heart\\nrate. If the dissection is small, drug therapy alone may\\nbe used. In other cases, surgery is performed. In sur-\\ngery, damaged sections of the aorta are removed and a\\nsynthetic graft is often used to reconstruct the\\ndamaged vessel.\\nPrognosis\\nDepending on the nature and extent of the dissec-\\ntion, death can occur within a few hours of the start of\\na dissection. Approximately 75% of untreated people\\ndie within two weeks of the start of a dissection. Of\\nthose who are treated, 40% survive more than 10\\nyears. Patients are usually given long term treatment\\nwith drugs to reduce their blood pressure, even if they\\nhave had surgery.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nAortic incompetence see Aortic valve\\ninsufficiency\\nAortic regurgitation see Aortic valve\\ninsufficiency\\nAortic stenosis see Aortic valve stenosis\\nAortic valve insufficiency\\nDefinition\\nThe aortic valve separates the left ventricle of the\\nheart (the heart’s largest pumping chamber) from the\\naorta, the large artery that carries oxygen-rich blood out\\nof the left ventricle to the rest of the body. In aortic valve\\ninsufficiency, the aortic valve becomes leaky, causing\\nblood to flow backwards into the left ventricle.\\nDescription\\nAortic valve insufficie ncy occurs when this\\nvalve cannot properly close after blood that is leav-\\ning the heart’s left ventricle enters the aorta. With\\neach contraction of the heart more and more blood\\nflows back into the left ventricle, causing the ven-\\ntricle to become overfilled. This larger-than-normal\\namount of blood that collects in the left ventricle\\nputs pressure on the walls of the heart, causing the\\nheart muscle to increase in thickness (hypertrophy).\\nIf this thickening continues, the heart can be per-\\nmanently damaged.\\nAorticvalveinsufficiencyisalsoknowasaorticvalve\\nregurgitation because of the abnormal reversed flow of\\nblood leaking through the poorly functioning valve.\\nCauses and symptoms\\nThe faulty working of the aortic valve can be\\ncaused by a birth defect; by abnormal widening\\nof the aorta (which can be caused by very high blood\\npressure and a variety of other less common condi-\\ntions); by various diseases that cause large amounts of\\nswelling (inflammation) in different areas of the body,\\nlike rheumatic fever; and, although rarely, by the sexu-\\nally transmitted disease,syphilis.\\nNormal\\nblood flow\\nDiseased valve\\nBlood backflow\\nA human heart with a diseased valve that doesn’t open and\\nclose properly, allowing blood to backflow to the heart.\\n(Illustration by Argosy, Inc.)\\n368 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic valve insufficiency'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='About 75% of people with aortic valve insuffi-\\nciency are men. Rheumatic (inflammatory) diseases\\nhave been the main cause of this condition in both\\nmen and women.\\nAortic valve insufficiency can remain unnoticed\\nfor 10 to 15 years. In cases of severe insufficiency a\\nperson may notice a variety of symptoms, including an\\nuncomfortable pounding of the heart when lying\\ndown, a very rapid or hard heart beat (palpitations),\\nshortness of breath, chest pain, and if untreated for\\nvery long times, swelling of the liver, ankles, and belly.\\nDiagnosis\\nA poorly functioning or insufficient aortic valve\\ncan be identified when a doctor listens to the heart\\nduring aphysical examination.A chest x ray,a ne l e c -\\ntrocardiogram (ECG, an electrical printout of the heart\\nbeats), as well as an echocardiogram (a test that uses\\nsound waves to create an image of the heart and its\\nvalves), can further evaluate or confirm the condition.\\nTreatment\\nAortic insufficiency is usually corrected by having\\nthe defective valve surgically replaced. However, such\\nan operation is done in severe cases. Before the condi-\\ntion worsens, certain drugs can be used to help manage\\nthis condition.\\nDrugs that remove water from the body, drugs\\nthat lower blood pressure, and drugs that help the\\nheart beat more effectively can each be used for this\\ncondition. Reducing the amount of salt in the diet also\\nhelps lower the amount of fluid the body holds and can\\nhelp the heart to work more efficiently as well.\\nIn cases of a severely malfunctioning valve that\\nhas been untreated for a long time, surgery is the\\ntreatment of choice, especially if the heart is not func-\\ntioning normally. Human heart valves can be replaced\\nwith man-made valves or with valves taken from pig\\nhearts.\\nPrognosis\\nAlthough drug treatment can help put off the need\\nfor surgical valve replacement, it is important to\\nreplace the faulty valve before the heart muscle itself\\nis damaged beyond recovery.\\nResources\\nPERIODICALS\\nCondos Jr., William R. ‘‘Decade-old Heart Drug May Have a\\nNew Use.’’San Diego Business Journal18 (21 July 1997): 24.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nDominic De Bellis, PhD\\nAortic valve stenosis\\nDefinition\\nWhen aortic valve stenosis occurs, the aortic\\nvalve, located between the aorta and left ventricle of\\nthe heart, is narrower than normal size.\\nDescription\\nA normal aortic valve, when open, allows the free\\nflow of blood from the left ventricle to the aorta. When\\nthe valve narrows, as it does with stenosis, blood flow\\nis impeded. Because it is more difficult for blood\\nto flow through the valve, there is increased strain on\\nthe heart. This can cause the left ventricle to enlarge\\nand malfunction, resulting in reduced blood supply to\\nthe heart muscle and body, as well as fluid build up in\\nthe lungs.\\nCause and symptoms\\nAortic valve stenosis can occur because of a birth\\ndefect in the formation of the valve. Calcium deposits\\nmay form on the valve withaging, causing the valve to\\nbecome stiff and narrow. Stenosis can also occur as a\\nresult of rheumatic fever. Mild aortic stenosis may\\nproduce no symptoms at all. The most common symp-\\ntoms, depending on the severity of the disease, are\\nchest pain, blackouts, and difficulty breathing.\\nKEY TERMS\\nRheumatic fever— A disease believed to be caused\\nby a bacterium named group A streptococcus. This\\nbacterium causes a sore ‘‘strep throat’’ and can also\\nresult in fever. Infection by this bacterium can also\\ndamage the heart and its valves, but how this takes\\nplace is not clearly understood.\\nGALE ENCYCLOPEDIA OF MEDICINE 369\\nAortic valve stenosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nUsing a stethoscope, a physician may hear a mur-\\nmur and other abnormal heart sounds. An ECG, also\\ncalled an electrocardiogram, records the electrical\\nactivity of the heart. This technique andchest x ray\\ncan show evidence that the left ventricle is enlarged.\\nAn x ray can also reveal calcium deposits on the valve,\\nas well as congestion in the lungs.Echocardiography\\ncan pick up thickening of the valve, heart size, and\\nwhether or not the valve is working properly. This is\\na procedure in which high frequency sound waves\\nharmlessly bounce off organs in the body. Cardiac\\ncatheterization, in which a contrast dye is injected in\\nan artery using a catheter, is the key tool to confirm\\nstenosis and gauge its severity.\\nTreatment\\nTreatment depends on the symptoms and how\\nthe heart’s function is affected. The valve can be\\nopened without surgery by using a balloon catheter,\\nbut this is often a temporary solution. The proce-\\ndure involves inserting a deflated balloon at the end\\nof a catheter through the arteries to the valve.\\nInflating the balloon should widen the valve. In\\nsevere stenosis, heart valve replacement is recom-\\nmended, most often involving open-heart surgery.\\nThe valve can be replaced with a mechanical valve,\\na valve from a pig, or by moving the patient’s other\\nheart valve (pulmonary) into the position of the\\naortic valve and then replacing the pulmonary\\nvalve with an mechanical one. Anyone with aortic\\nstenosis needs to take antibiotics (amoxicillin, ery-\\nthromycin, or clindamycin) before dental and some\\nother surgical procedures, to prevent a heart valve\\ninfection.\\nPrognosis\\nThe prognosis for aortic valve stenosis depends on\\nthe severity of the disease. With surgical repair, the\\ndisease is curable. Patients suffering mild stenosis can\\nusually lead a normal life; a minority of the patients\\nprogress to severe disease. Anyone with moderate\\nstenosis should avoid vigorous physical activity.\\nMost of these patients end up suffering some kind of\\ncoronary heart disease over a 10 year period. Because\\nit is a progressive disease, moderate and severe stenosis\\nwill be treated ultimately with surgery. Severe disease,\\nif left untreated, leads to death within 2 to 4 years once\\nthe symptoms start.\\nPrevention\\nThere is no way to prevent aortic stenosis.\\nResources\\nBOOKS\\nBender, Jeffrey R. ‘‘Heart Valve Disease.’’ InYale University\\nSchool of Medicine Heart Book, edited by Barry L.\\nZaret, et al. New York: HearstBooks, 1992.\\nA close-up view of a calcified stenosis of the aortic valve.\\n(Custom Medical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAorta— The largest artery in the body, which\\nmoves blood from the left ventricle to the rest of\\nthe body.\\nECG— Also called an electrocardiogram, it records\\nthe electrical activity of the heart.\\nEchocardiogram— A procedure in which high fre-\\nquency sound waves harmlessly bounce off organs\\nin the body providing an image so one can deter-\\nmine their structure and function.\\nCardiac catheterization— A procedure in which\\ndye is injected through a tube or catheter into an\\nartery to more easily observe valves or blood ves-\\nsels seen on an x ray.\\nLeft ventricle— One of the lower chambers of the\\nheart, which pumps blood to the aorta.\\nMurmur— An abnormal heart sound that can\\nreflect a valve dysfunction.\\nRheumatic fever— A bacterial infection that often\\ncauses heart inflammation.\\nPulmonary valve— The valve located between the\\npulmonary artery and the right ventricle, which\\nbrings blood to the lungs.\\n370 GALE ENCYCLOPEDIA OF MEDICINE\\nAortic valve stenosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='OTHER\\n‘‘Aortic Stenosis.’’Ochsner Heart and VascularInstitute.\\n.\\nRahimtoola, Aly. ‘‘Aortic Stenosis.’’Loyola University\\nHealth System Page..\\nJeanine Barone, Physiologist\\nApgar testing\\nDefinition\\nApgar testing is the assessment of the newborn\\nrating color, heart rate, stimulus response, muscle\\ntone, and respirations on a scale of zero to two, for a\\nmaximum possible score of 10. It is performed twice,\\nfirst at one minute and then again at five minutes after\\nbirth.\\nPurpose\\nApgar scoring was originally developed in the\\n1950s by the anesthesiologist Virginia Apgar to assist\\npractitioners attending a birth in deciding whether or\\nnot a newborn was in need of resuscitation. Using a\\nscoring method fosters consistency and standardiza-\\ntion among different practitioners. A February 2001\\nstudy published in the New England Journal of\\nMedicine investigated whether Apgar scoring con-\\ntinues to be relevant. Researchers concluded that\\n‘‘The Apgar scoring system remains as relevant for\\nthe prediction of neonatal survival today as it was\\nalmost 50 years ago.’’\\nDescription\\nThe five areas are scored as follows:\\n/C15Appearance, or color: 2 if the skin is pink all over; 1\\nfor acrocyanosis, where the trunk and head are pink,\\nbut the arms and legs are blue; and 0 if the whole\\nbody is blue. Newborns with naturally darker skin\\ncolor will not be pink. However, pallor is still notice-\\nable, especially in the soles and palms. Color is\\nrelated to the neonate’s ability to oxygenate its\\nbody and extremities, and is dependent on heart\\nrate and respirations. A perfectly healthy newborn\\nwill often receive a score of 9 because of some blue-\\nness in the hands and feet.\\n/C15Pulse (heart rate): 2 for a pulse of 100+ beats per\\nminute (bpm); 1 for a pulse below 100 bpm; 0 for no\\npulse. Heart rate is assessed by listening with a\\nstethoscope to the newborn’s heart and counting\\nthe number of beats.\\n/C15Grimace, or reflex irritability: 2 if the neonate\\ncoughs, sneezes, or vigorously cries in response to a\\nstimulus (such as the use of nasal suctioning, stroking\\nthe back to assess for spinal abnormalities, or having\\nthe foot tapped); 1 for a slight cry or grimace in\\nresponse to the stimulus; 0 for no response.\\n/C15Activity, or muscle tone: 2 for vigorous movements\\nof arms and legs; 1 for some movement; 0 for no\\nmovement, limpness.\\n/C15Respirations: 2 for visible breathing and crying; 1\\nfor slow, weak, irregular breathing; 0 for apnea,\\nor no breathing. A crying newborn can ade-\\nquately oxygenate its lungs. Respirations are best\\nassessed by watching the rise and fall of the neo-\\nnate’s abdomen, as inf ants are diaphragmatic\\nbreathers.\\nThe combined first letters in these five areas spell\\nApgar.\\nPreparation\\nNo preparation is needed to perform the test.\\nHowever, while being born the neonate may receive\\nnasal and oral suctioning to remove mucus and\\namniotic fluid. This may be done when the head of\\nthe newborn is safely out, while the mother rests\\nbefore she continues to push.\\nAftercare\\nSince the test is primarily observational in nature,\\nno aftercare is needed. However, the test may flag the\\nneed for immediate intervention or prolonged\\nobservation.\\nNormal results\\nThe maximum possible score is 10, the minimum\\nis zero. It is rare to receive a true 10, as some acrocya-\\nnosis in the newborn is considered normal, and there-\\nfore not a cause for concern. Most infants score\\nbetween 7 and 10. These infants are expected to have\\nan excellent outcome. A score of 4, 5, or 6 requires\\nimmediate intervention, usually in the form of oxygen\\nand respiratory assistance, or perhaps just suctioning\\nif breathing has been obstructed by mucus. While\\nsuctioning is being done, a source of oxygen may be\\nplaced near, but not over the newborn’s nose and\\nmouth. This form of oxygen is referred to asblow-by.\\nA score in the 4-6 range indicates that the neonate is\\nhaving some difficulty adapting to extrauterine life.\\nGALE ENCYCLOPEDIA OF MEDICINE 371\\nApgar testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='This may be due to medications given to the mother\\nduring a difficult labor, or at the very end of labor,\\nwhen these medications have an exaggerated effect on\\nthe neonate.\\nAbnormal results\\nWith a score of 0-3, the newborn is unresponsive,\\napneic, pale, limp and may not have a pulse.\\nInterventions to resuscitate will begin immediately.\\nThe test is repeated at five minutes after birth and\\nboth scores are documented. Should the resuscitation\\neffort continue into the five-minute time period, inter-\\nventions will not stop in order to perform the test. The\\none-minute score indicates the need for intervention at\\nbirth. It addresses survival and prevention of birth-\\nrelated complications resulting from inadequate\\noxygen supply. Poor oxygenation may be due to\\ninadequate neurological and/or chemical control of\\nrespiration. The five-minute score appears to have a\\nmore predictive value for morbidity and normal devel-\\nopment, although research studies on this are incon-\\nsistent in their conclusions.\\nResources\\nBOOKS\\nFeinbloom, Richard I.Pregnancy, Birth and the EarlyMonths.\\nCambridge, MA: Perseus Publishing, 2000.\\nKEY TERMS\\nAcrocyanosis— A slight cyanosis, or blueness of the\\nhands and feet of the neonate is considered normal.\\nThis impaired ability to fully oxygenate the extre-\\nmities is due to an immature circulatory system\\nwhich is still in flux.\\nAmniotic fluid— The protective bag of fluid that\\nsurrounds the fetus while growing in the uterus.\\nNeonate— A term referring to the newborn infant,\\nfrom birth until one month of age.\\nNeonatologist— A physician who specializes in\\nproblems of newborn infants.\\nPallor— Extreme paleness in the color of the skin.\\nD R . V I R G I N I A A P G A R (1909–1974)\\n(AP/Wide World Photos. Reproduced by permission.)\\nAs one of very few female medical students at\\nColumbia University College of Physicians and Surgeons\\nin New York during the early 1930s and one of the first\\nwomen to graduate from its medical school, Apgar knew\\nthat her goal of becoming a surgeon would not be\\nachieved easily in a male-dominated profession.\\nReluctantly, she switched her medical specialty to anes-\\nthesiology, she embraced her new field with typical intel-\\nligence and energy. At this time, anesthesiology was a\\nrelatively new field, having been left by the doctors\\nmostly to the attention of nurses. Apgar realized immedi-\\nately how much in need of scientifically trained personnel\\nwas this significant part of surgery, and she set out to\\nmake anesthesiology a separate medical discipline. By\\n1937, she had become the fiftieth physician to be certified\\nas an anesthesiologist in the United States. The following\\nyear she was appointed director of anesthesiology at the\\nColumbia-Presbyterian Medical Center, becoming the\\nfirst woman to head a department at that institution.\\nAs the attending anesthesiologist who assisted in the\\ndelivery of thousands of babies during these years, Apgar\\nrealized that infants had died from respiratory or circula-\\ntory complications that early treatment could have pre-\\nvented. Apgar decided to bring her considerable research\\nskills to this childbirth dilemma, and her careful study\\nresulted in her publication of the Apgar Score System\\nin 1952.\\n372\\nGALE ENCYCLOPEDIA OF MEDICINE\\nApgar testing'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content=\"Pillitteri, Adele.Maternal & Child Nursing; Care ofthe\\nChildbearing and Childrearing Family.3rd ed.\\nPhiladelphia: Lippincott, 1999.\\nPERIODICALS\\nCasey, B. M., D. D. McIntire, and K. J. Leveno. ‘‘The\\nContinuing Value of Apgar Score for the Assessment of\\nNewborn Infants’’.NewEngland Journal of Medicine\\n344 (February 15, 2000): 467-71.\\nOTHER\\nApgar, Virginia.A Proposal for a New Method of Evaluation\\nof the Newborn Infant..\\nThe National Childbirth Trust. .\\nPregnancyWeekly.com .\\nEsther Csapo Rastegari, RN, BSN, EdM\\nAphasia\\nDefinition\\nAphasia is condition characterized by either par-\\ntial or total loss of the ability to communicate verbally\\nor using written words. A person with aphasia may\\nhave difficulty speaking, reading, writing, recognizing\\nthe names of objects, or understanding what other\\npeople have said. Aphasia is caused by a brain injury,\\nas may occur during a traumatic accident or when\\nthe brain is deprived of oxygen during astroke.I t\\nmay also be caused by abrain tumor, a disease such\\nas Alzheimer’s, or an infection, like encephalitis.\\nAphasia may be temporary or permanent. Aphasia\\ndoes not include speech impediments caused by loss\\nof muscle control.\\nDescription\\nTo understand and use language effectively, an\\nindividual draws upon word memory–stored informa-\\ntion on what certain words mean, how to put them\\ntogether, and how and when to use them properly. For\\na majority of people, these and other language func-\\ntions are located in the left side (hemisphere) of the\\nbrain. Damage to this side of the brain is most com-\\nmonly linked to the development of aphasia.\\nInterestingly, however, left-handed people appear to\\nhave language areas in both the left and right hemi-\\nspheres of the brain and, as a result, may develop\\naphasia from damage to either side of the brain.\\nStroke is the most common cause of aphasia in the\\nUnited States. Approximately 500,000 individuals suf-\\nfer strokes each year, and 20% of these individuals\\ndevelop some type of aphasia. Other causes of brain\\ndamage include head injuries, brain tumors, and infec-\\ntion. About half of the people who show signs of apha-\\nsia have what is called temporary or transient aphasia\\nand recover completely within a few days. An estimated\\none million Americans suffer from some form of per-\\nmanent aphasia. As yet, no connection between aphasia\\nand age, gender, or race has been found.\\nAphasia is sometimes confused with other condi-\\ntions that affect speech, such as dysarthria and\\napraxia. These condition affect the muscles used in\\nspeaking rather than language function itself.\\nDysarthria is a speech disturbance caused by lack of\\ncontrol over the muscles used in speaking, perhaps due\\nto nerve damage. Speech apraxia is a speech distur-\\nbance in which language comprehension and muscle\\ncontrol are retained, but the memory of how to use the\\nmuscles to form words is not.\\nBroca's area\\nWernicke's area\\nBroca’s aphasia results from damage to the frontal lobe of the\\nlanguage-dominant area of the brain. Individuals with\\nBroca’s aphasia may become mute or may be able to use\\nsingle-word statements or full sentences, although it may\\nrequire great effort. Wernicke’s aphasia is caused by damage\\nto the temporal lobe of the language-dominant area of the\\nbrain. People with this condition speak in long, uninterrupted\\nsentences, but the words used are often unnecessary and\\nunintelligible. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 373\\nAphasia\"),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nAphasia can develop after an individual sustains\\na brain injury from a stroke, head trauma, tumor, or\\ninfection, such as herpes encephalitis. As a result of\\nthis injury, the pathways for language comprehen-\\nsion or production are disrupted or destroyed. For\\nmost people, this means damage to the left hemi-\\nsphere of the brain. (In 95 to 99% of right-handed\\npeople, language centers are in the left hemisphere,\\nand up to 70% of left-handed people also have left-\\nhemisphere language dominance.) According to the\\ntraditional classification scheme, each form of\\naphasia is caused by damage to a different part of\\nthe left hemisphere of the brain. This damage affects\\none or more of the basic language functions: speech,\\nnaming (the ability to identify an object, color, or\\nother item with an appropriate word or term), repe-\\ntition (the ability to repeat words, phrases, and sen-\\ntences), hearing comprehension (the ability to\\nunderstand spoken language), reading (the ability\\nto understand written words and their meaning),\\nand writing (the ability to communicate and record\\nevents with text).\\nThe traditional classification scheme includes\\neight types of aphasia:\\n/C15Broca’s aphasia, also called motor aphasia, results\\nfrom damage to the front portion or frontal lobe of\\nthe language-dominant area of the brain. Individuals\\nwith Broca’s aphasia may be completely unable to\\nuse speech (mutism) or may be able to use single-\\nword statements or even full sentences, though\\nthese sentences may require a great deal of effort to\\nconstruct. Small words, such as conjunctions (and,\\nor, but) and articles (the, an, a), may be omitted,\\nleading to a ‘‘telegraph’’ quality in their speech.\\nHearing comprehension is usually not affected, so\\nthey are able to understand other people’s speech\\nand conversation and can follow commands. Often,\\nKEY TERMS\\nAnomic aphasia— A condition characterized by\\neither partial or total loss of the ability to recall the\\nnames of persons or things as a result of a stroke,\\nhead injury, brain tumor, or infection.\\nBroca’s aphasia—A condition characterized by either\\npartial or total loss of the ability to express oneself,\\neither through speech or writing. Hearing comprehen-\\nsion is not affected. This condition may result from a\\nstroke, head injury, brain tumor, or infection.\\nComputed tomography (CT)— An imaging techni-\\nque that uses cross-sectional x rays of the body to\\ncreate a three-dimensional image of the body’s inter-\\nnal structures.\\nConduction aphasia— A condition characterized by\\nthe inability to repeat words, sentences, or phrases as\\na result of a stroke, head injury, brain tumor, or\\ninfection.\\nFrontal lobe— The largest, most forward-facing part\\nof each side or hemisphere of the brain.\\nGlobal aphasia— A condition characterized by either\\npartial or total loss of the ability to communicate verb-\\nally or using written words as a result of widespread\\ninjury to the language areasof the brain. This condition\\nmay be caused by a stroke, head injury, brain tumor,\\nor infection. The exact language abilities affected vary\\ndepending on the location and extent of injury.\\nHemisphere— One of the two halves or sides-the left\\nand the right-of the brain.\\nMagnetic resonance imaging (MRI)— An imaging\\ntechnique that uses a large circular magnet and\\nradio waves to generate signals from atoms in the\\nbody. These signals are used to construct images of\\ninternal structures.\\nSubcortical aphasia— A condition characterized by\\neither partial or total loss of the ability to commu-\\nnicate verbally or using written words as a result of\\ndamage to non language-dominated areas of the\\nbrain. This condition may be caused by a stroke,\\nhead injury, brain tumor, or infection.\\nTemporal lobe— The part of each side or hemisphere\\nof the brain that is on the side of the head, nearest the\\nears.\\nTranscortical aphasia— A condition characterized\\nby either partial or total loss of the ability to commu-\\nnicate verbally or using written words that does not\\naffect an individual’s ability to repeat words,\\nphrases, and sentences.\\nWernicke’s aphasia— A condition characterized by\\neither partial or total loss of the ability to understand\\nwhat is being said or read. The individual maintains\\nthe ability to speak, but speech may contain unne-\\ncessary or made-up words.\\n374 GALE ENCYCLOPEDIA OF MEDICINE\\nAphasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='they may experience weakness on the right side of\\ntheir bodies, which can make it difficult to write.\\nReading ability is impaired, and they may have diffi-\\nculty finding the right word when speaking.\\nIndividuals with Broca’s aphasia may become fru-\\nstrated and depressed because they are aware of their\\nlanguage difficulties.\\n/C15Wernicke’s aphasia is caused by damage to the side\\nportion or temporal lobe of the language-dominant\\narea of the brain. Individuals with Wernicke’s apha-\\nsia speak in long, uninterrupted sentences; however,\\nthe words used are frequently unnecessary or even\\nmade-up. They have a great deal of difficulty under-\\nstanding other people’s speech, sometimes to the\\npoint of being unable to understand spoken language\\nat all. Reading ability is diminished, and although\\nwriting ability is retained, what is written may be\\nabnormal. No physical symptoms, such as the\\nright-sided weakness seen with Broca’s aphasia, are\\ntypically observed. Also, in contrast to Broca’s apha-\\nsia, individuals with Wernicke’s aphasia are not\\naware of their language errors.\\n/C15Global aphasia is caused by widespread damage to\\nthe language areas of the left hemisphere. As a result,\\nall basic language functions are affected, but some\\nareas may be more affected than others. For exam-\\nple, an individual may have difficulty speaking but\\nmay be able to write well. The individual may experi-\\nence weakness and loss of feeling on the right side of\\ntheir body.\\n/C15Conduction aphasia, also called associative aphasia,\\nis rather uncommon. Individuals with conduction\\naphasia are unable to repeat words, sentences, and\\nphrases. Speech is fairly unbroken, although indivi-\\nduals may frequently correct themselves and words\\nmay be skipped or repeated. Although able to under-\\nstand spoken language, it may also be difficult for the\\nindividual with conduction aphasia to find the right\\nword to describe a person or object. The impact of\\nthis condition on reading and writing ability varies.\\nAs with other types of aphasia, right-sided weakness\\nor sensory loss may be present.\\n/C15Anomic or nominal aphasia primarily influences an\\nindividual’s ability to find the right name for a per-\\nson or object. As a result, an object may be described\\nrather than named. Hearing comprehension, repeti-\\ntion, reading, and writing are not affected, other than\\nby this inability to find the right name. Speech is\\nfluent, except for pauses as the individual tries to\\nrecall the right name. Physical symptoms are vari-\\nable, and some individuals have no symptoms of one-\\nsided weakness or sensory loss.\\n/C15Transcortical aphasia is caused by damage to the\\nlanguage areas of the left hemisphere outside the\\nprimary language areas. There are three types of\\naphasia: transcortical motor aphasia, transcortical\\nsensory aphasia, and mixed transcortical aphasia.\\nAll of the transcortical aphasias are distinguished\\nfrom other types by the individual’s ability to repeat\\nwords, phrases, or sentences. Other language func-\\ntions may also be impaired to varying degrees,\\ndepending on the extent and particular location of\\nbrain damage.\\nAs researchers continue to learn more about the\\nbrain’s structure and function, new types of aphasia\\nare being recognized. One newly recognized type of\\naphasia, subcortical aphasia, mimics the symptoms\\nof other traditional types of aphasia but involves\\nlanguage disorders that are not typical. This type of\\naphasia is associated with injuries to areas of the brain\\ntypically not identified with language and language\\nprocessing.\\nDiagnosis\\nFollowing brain injury, an initial bedside assess-\\nment is made to determine whether language func-\\ntion has been affected. If the individual experiences\\ndifficulty communicati ng, attempts are made to\\ndetermine whether this difficulty arises from\\nimpaired language comprehension or an impaired\\nability to speak. A typical examination involves\\nlistening to spontaneous speech and evaluating the\\nindividual’s ability to recognize and name objects,\\ncomprehend what is heard, and repeat sample words\\nand phrases. The individual may also be asked to\\nread text aloud and explain what the passage\\nmeans. In addition, writing ability is evaluated by\\nhaving the individual copy text, transcribe dictated\\ntext, and write something without prompting.\\nA speech pathologist or neuropsychologist may\\nbe asked to conduct more extensive examinations\\nusing in-depth, standardized tests. Commonly used\\ntests include the Boston Diagnostic Aphasia\\nExamination, the Western Aphasia Battery, and pos-\\nsibly, the Porch Index of Speech Ability.\\nThe results of these tests indicate the severity of\\nthe aphasia and may also provide information regard-\\ning the exact location of the brain damage. This more\\nextensive testing is also designed to provide the infor-\\nmation necessary to design an individualized speech\\ntherapy program. Further information about the loca-\\ntion of the damage is gained through the use of ima-\\nging technology, such asmagnetic resonance imaging\\n(MRI) andcomputed tomography scans(CT).\\nGALE ENCYCLOPEDIA OF MEDICINE 375\\nAphasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nInitially, the underlying cause of aphasia must be\\ntreated or stabilized. To regain language function,\\ntherapy must begin as soon as possible following the\\ninjury. Although there are no medical or surgical pro-\\ncedures currently available to treat this condition,\\naphasia resulting from stroke or head injury may\\nimprove through the use of speech therapy. For most\\nindividuals, however, the primary emphasis is placed\\non making the most of retained language abilities and\\nlearning to use other means of communication to\\ncompensate for lost language abilities.\\nSpeech therapy is tailored to meet individual\\nneeds, but activities and tools that are frequently\\nused include the following:\\n/C15Exercise and practice. Weakened muscles are exer-\\ncised by repetitively speaking certain words or mak-\\ning facial expressions, such as smiling.\\n/C15Picture cards. Pictures of everyday objects are used\\nto improve word recall and increase vocabulary. The\\nnames of the objects may also be repetitively spoken\\naloud as part of an exercise and practice routine.\\n/C15Picture boards. Pictures of everyday objects and\\nactivities are placed together, and the individual\\npoints to certain pictures to convey ideas and com-\\nmunicate with others.\\n/C15Workbooks. Reading and writing exercises are used\\nto sharpen word recall and regain reading and writ-\\ning abilities. Hearing comprehension is also redeve-\\nloped using these exercises.\\n/C15Computers. Computer software can be used to\\nimprove speech, reading, recall, and hearing compre-\\nhension by, for example, displaying pictures and\\nhaving the individual find the right word.\\nPrognosis\\nThe degree to which an individual can recover\\nlanguage abilities is highly dependent on how much\\nbrain damage occurred and the location and cause of\\nthe original brain injury. Other factors include the\\nindividual’s age, general health, motivation and will-\\ningness to participate in speech therapy, and whether\\nthe individual is left or right handed. Language areas\\nmay be located in both the left and right hemispheres\\nin left-handed individuals. Left-handed individuals\\nare, therefore, more likely to develop aphasia follow-\\ning brain injury, but because they have two language\\ncenters, may recover more fully because language abil-\\nities can be recovered from either side of the brain. The\\nintensity of therapy and the time between diagnosis\\nand the start of therapy may also affect the eventual\\noutcome.\\nPrevention\\nBecause there is no way of knowing when a\\nstroke, traumatic head injury, or disease will occur,\\nvery little can be done to prevent aphasia. The extent\\nof recovery, however, in some cases, can be affected\\nby an individual’s willingness to cooperate and parti-\\ncipate in speech therapy directly following the injury.\\nResources\\nBOOKS\\nLyon, Jon G., and Marianne B. Simpson.Coping with\\nAphasia. San Diego: Singular Publishing Group, 1998.\\nORGANIZATIONS\\nNational Aphasia Association. 156 5th Ave., Suite 707, New\\nYork, NY 10010. (800) 922-4622. .\\nJulia Barrett\\nApheres see Transfusion\\nAplastic anemia\\nDefinition\\nAplastic anemia is a disorder in which the bone\\nmarrow greatly decreases or stops production of\\nblood cells.\\nDescription\\nThe bone marrow (soft tissue that is located\\nwithin the hard outer shell of the bones) is responsible\\nfor the production of all types of blood cells. The\\nmature forms of these cells include red blood cells,\\nwhich carry oxygen throughout the body; white\\nblood cells, which fight infection; and platelets,\\nwhich are involved in clotting. In aplastic anemia,\\nthe basic structure of the marrow becomes abnormal,\\nand those cells responsible for generating blood cells\\n(hematopoietic cells) are greatly decreased in number\\nor absent. These hematopoietic cells are replaced by\\nlarge quantities of fat.\\nYearly, aplastic anemia strikes about 5-10 people\\nin every one million. Although aplastic anemia strikes\\nboth males and females of all ages, there are two age\\ngroups that have an increased risk. Both young adults\\n376 GALE ENCYCLOPEDIA OF MEDICINE\\nAplastic anemia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='(between 15-30 years of age) and the elderly (over the\\nage of 60) have higher rates of aplastic anemia than the\\ngeneral population. While the disorder occurs world-\\nwide, young adults in Asia have a higher disease rate\\nthan do populations in North America and Europe.\\nCauses and symptoms\\nAplastic anemia falls into three basic categories,\\nbased on the origin of its cause: idiopathic, acquired,\\nand hereditary.\\nIn about 60% of cases, aplastic anemia is consid-\\nered to be idiopathic, meaning that the cause of the\\ndisorder is unknown.\\nAcquired aplastic anemia refers to those cases\\nwhere certain environmental factors and physical con-\\nditions seem to be associated with development of the\\ndisease. Acquired aplastic anemia can be associated\\nwith:\\n/C15exposure to drugs, especially anti-cancer agents,\\nantibiotics, anti-inflammatory agents, seizure\\nmedications, and antithyroid drugs (drugs given to\\nstop the functioning of an overactive thyroid)\\n/C15exposure to radiation\\n/C15chemical exposure (especially to the organic solvent\\nbenzene and certain insecticides)\\n/C15infection with certain viruses (especially those caus-\\ning viral hepatitis, as well as Epstein-Barr virus, par-\\nvovirus, and HIV, the virus that can causeAIDS)\\n/C15pregnancy\\n/C15certain other disorders, including a disease called par-\\noxysmal nocturnal hemoglobinuria, an autoimmune\\nreaction called graft-vs-host disease (which occurs\\nwhen the body’s immune system attacks and destroys\\nthe body’s own cells), and certain connective tissue\\ndiseases\\nHereditary aplastic anemia is relatively rare, but\\noccurs in Fanconi’s anemia, Shwachman-Diamond\\nsyndrome, and dyskeratosis congenita.\\nSymptoms of aplastic anemia tend to be those of\\nother anemias,i n c l u d i n gfatigue, weakness, tiny red-\\ndish-purple marks (petechiae) on the skin (evidence of\\npinpoint hemorrhages into the skin), evidence of abnor-\\nmal bruising, and bleeding from the gums, nose, intes-\\ntine, or vagina. The patient is likely to appear pale. If\\nthe anemia progresses, decreased oxygen circulating in\\nthe blood may lead to an increase in heart rate and the\\nsudden appearance of a new heart murmur.\\nDiagnosis\\nThe blood countin aplastic anemia will reveal low\\nnumbers of all formed blood cells. Red blood cells will\\nappear normal in size and coloration, but greatly\\ndecreased in number. Cells called reticulocytes (very\\nyoung red blood cells, which are usually produced in\\ngreat numbers by the bone marrow in order to com-\\npensate for a severe anemia) will be very low in num-\\nber. Platelets and white blood cells will also be\\ndecreased in number, though normal in structure.\\nA sample of the patient’s bone marrow will need\\nto be removed by needle (usually from the hip bone)\\nand examined under a microscope. If aplastic anemia\\nis present, this examination will reveal very few or no\\nhematopoietic cells, and replacement with fat.\\nTreatment\\nThe first step in the treatment of aplastic anemia\\ninvolves discontinuing exposure to any substance that\\nmay be causing the disorder. Although it would seem\\nthat blood transfusions would be helpful in this dis-\\nease, in fact, they only serve as a temporary help, and\\nmay complicate future attempts at bone marrow\\ntransplantation.\\nThe most successful treatment for aplastic anemia\\nis bone marrow transplantation. To do this, a marrow\\ndonor (often a sibling) must be identified. There are a\\nnumber of tissue markers that must be examined to\\ndetermine whether a bone marrow donation is likely to\\nbe compatible with the patient’s immune system.\\nCompatibility is necessary to avoid complications,\\nincluding the destruction of the donor marrow by the\\npatient’s own immune system.\\nKEY TERMS\\nBone marrow— A substance found in the cavities of\\nbones, especially the long bones and the sternum\\n(breast bone). The bone marrow contains those cells\\nthat are responsible for the production of the blood\\ncells (red blood cells, white blood cells, and platelets).\\nBone marrow transplant— A procedure in which a\\nquantity of bone marrow is extracted through a nee-\\ndle from a donor, and then passed into a patient to\\nreplace the patient’s diseased or absent bone marrow.\\nHematopoietic cells— Those cells that are lodged\\nwithin the bone marrow, and which are responsible\\nfor producing the cells which circulate in the blood\\n(red blood cells, white blood cells, and platelets).\\nGALE ENCYCLOPEDIA OF MEDICINE 377\\nAplastic anemia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Patients who cannot undergo bone marrow\\ntransplant can be treated with a number of agents,\\nincluding antithymocyte globulin (ATG), cyclopho-\\nsphamide, steroids, and cyclosporine. These agents\\nall have the potential to cause a number of trouble-\\nsome side-effects and may have a success rate of only\\n60% to 80%. Still, even among those patients who\\nhave a good response, many later suffer a relapse\\n(return) of aplastic anemia. Researchers are trying to\\nidentify the molecules in certain stem cells that the\\nimmune system targets in aplastic anemia.\\nPrognosis\\nAplastic anemia is a life-threatening illness.\\nWithout treatment, it will almost surely progress to\\ndeath. Survival depends on how severe the disease is at\\ndiagnosis, which type of treatment a patient is eligible\\nfor, and what kind of response their body has to that\\ntreatment. The worst-prognosis type of aplastic anemia\\nis one associated with very low numbers of a particular\\ntype of white blood cell. These patients have a high\\nchance of dying from overwhelming bacterial infec-\\ntions. In fact, 80% of all patients treated with blood\\ntransfusions alone die within 18 months to two years.\\nPatients who undergo bone marrow transplantation\\nh a v ea6 0 - 9 0 %c h a n c eo fb e i n gc u r e do ft h ed i s e a s e .\\nResources\\nPERIODICALS\\nMarsh, Judith C.W., Edward C. Gordon-Smith. ‘‘Insights\\nInto the Autoimmune Nature of Aplastic Anemia.’’The\\nLancet (July 24, 2004): 308.\\nORGANIZATIONS\\nAplastic Anemia Foundation of America. P.O. Box 613,\\nAnnapolis, MD 21404. (800) 747-2820. .\\nRosalyn Carson-DeWitt, MD\\nTeresa G. Odle\\nAplastic crisis see Fifth disease\\nAppendectomy\\nDefinition\\nAppendectomy is the surgical removal of the\\nappendix. The appendix is a worm-shaped hollow\\npouch attached to the cecum, the beginning of the\\nlarge intestine.\\nPurpose\\nAppendectomies are performed to treatappendi-\\ncitis, an inflamed and infected appendix.\\nPrecautions\\nSince appendicitis occurs most commonly in\\nmales between the ages of 10-14 and in females\\nbetween the ages of 15-19, appendectomy is most\\noften performed during this time. The diagnosis of\\nappendicitis is most difficult in the very young (less\\nthan two years of age) and in the elderly.\\nDescription\\nAppendectomy is considered a major surgical\\noperation. Therefore, a general surgeon must perform\\nthis operation in the operating room of a hospital. An\\nanesthesiologist is also present during the operation to\\nadminister an anesthetic. Most often the anesthesiol-\\nogist uses a general anesthetic technique whereby\\npatients are put to sleep and made pain free by\\nadministering drugs in the vein or by agents inhaled\\nthrough a tube placed in the windpipe. Occasionally a\\nspinal anesthetic may be used.\\nAfter the patient is anesthetized, the general\\nsurgeon can remove the appendix either by using\\nthe traditional open procedure (in which a 2-3 in\\n[5-7.6 cm] incision is made in the abdomen) or via\\nlaparoscopy (in which four 1 in [2.5cm] incisions are\\nmade in the abdomen).\\nTraditional open appendectomy\\nWhen the surgeon uses the open approach, he\\nmakes an incision in the lower right section of the\\nabdomen. Most incisions are less than 3 in (7.6 cm)\\nin length. The surgeon then identifies all of the organs\\nin the abdomen and examines them for other disease\\nor abnormalities. The appendix is located and brought\\nup into thewounds. The surgeon separates the appen-\\ndix from all the surrounding tissue and its attachment\\nto the cecum and then removes it. The site where the\\nappendix was previously attached, the cecum, is closed\\nand returned to the abdomen. The muscle layers and\\nthen the skin are sewn together.\\nLaproscopic appendectomy\\nWhen the surgeon conducts a laproscopic appen-\\ndectomy, four incisions, each about 1 in (2.5 cm) in\\nlength, are made. One incision is near the umbilicus, or\\nnavel, and one is between the umbilicus and the pubis.\\nTwo other incisions are smaller and are in the right\\n378 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='side of the lower abdomen. The surgeon then passes a\\ncamera and special instruments through these inci-\\nsions. With the aid of this equipment, the surgeon\\nvisually examines the abdominal organs and identifies\\nthe appendix. Similarly, the appendix is freed from\\nall of its attachments and removed. The place where\\nthe appendix was formerly attached, the cecum, is\\nstitched. The appendix is removed through one of the\\nincisions. The instruments are removed and then all of\\nthe incisions are closed.\\nStudies and opinions about the relative advan-\\ntages and disadvantages of each method are divided.\\nA skilled surgeon can perform either one of these\\nprocedures in less than one hour. However, lapro-\\nscopic appendectomy (LA) always takes longer than\\ntraditional appendectomy (TA). The increased time\\nrequired to do a LA increases the patient’s exposure\\nto anesthetics, which increases the risk of complica-\\ntions. The increased time requirement also escalates\\nfees charged by the hospital for operating room time\\nand by the anesthesiologist. Since LA also requires\\nspecialized equipment, the fees for its use also\\nincreases the hospital charges. Patients with either\\noperation have similar pain medication needs, begin\\neating diets at comparable times, and stay in the hos-\\npital equivalent amounts of time. LA is of special\\nbenefit in women in whom the diagnosis is difficult\\nand gynecological disease (such asendometriosis,p e l -\\nvic inflammatory disease, ruptured ovarian follicles,\\nruptured ovarian cysts, and tubal pregnancies) may be\\nthe source of pain and not appendicitis. If LA is done\\nin these patients, the pelvic organs can be more thor-\\noughly examined and a definitive diagnosis made prior\\nto removal of the appendix. Most surgeons select\\nLarge intestine\\nAppendix\\nSwollen and\\ninflamed appendix\\nRectum\\nCecum\\nCecum\\nA traditional open appendectomy. After the surgeon makes an incision in the lower right section of the abdomen, he/she pulls\\nthe appendix up, separates it from the surrounding tissue and its attachment to the cecum, and then removes it.(Illustration by\\nElectronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 379\\nAppendectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='either TA or LA based on the individual needs and\\ncircumstances of the patient.\\nInsurance plans do cover the costs of appendect-\\nomy. Fees are charged independently by the hospital\\nand the physicians. Hospital charges include fees for\\noperating and recovery room use, diagnostic and\\nlaboratory testing, as well as the normal hospital\\nroom charges. Surgical fees vary from region to region\\nand range between $250-$750. The anesthesiologist’s\\nfee depends upon the health of the patient and the\\nlength of the operation.\\nPreparation\\nOnce the diagnosis of appendicitis is made and the\\ndecision has been made to perform an appendectomy,\\nthe patient undergoes the standard preparation for an\\noperation. This usually takes only one to two hours\\nand includes signing the operative consents, patient\\nidentification procedures, evaluation by the anesthe-\\nsiologist, and moving the patient to the operating suites\\nof the hospital. Occasionally, if the patient has been ill\\nfor a prolonged period of time or has had protracted\\nvomiting, a delay of few to several hours may be neces-\\nsary to give the patient fluids and antibiotics.\\nAftercare\\nRecovery from an appendectomy is similar to\\nother operations. Patients are allowed to eat when\\nthe stomach and intestines begin to function again.\\nUsually the first meal is a clear liquid diet–broth,\\njuice, soda pop, and gelatin. If patients tolerate this\\nmeal, the next meal usually is a regular diet. Patients\\nare asked to walk and resume their normal physical\\nactivities as soon as possible. If TA was done, work\\nand physical education classes may be restricted for a\\nfull three weeks after the operation. If a LA was done,\\nmost patients are able to return to work and strenuous\\nactivity within one to three weeks after the operation.\\nRisks\\nCertain risks are present when any operation\\nrequires a general anesthetic and the abdominal cavity\\nis opened. Pneumonia and collapse of the small air-\\nways (atelectasis) often occurs. Patients who smoke\\nare at a greater risk for developing these complica-\\ntions. Thrombophlebitis, or inflammation of the\\nveins, is rare but can occur if the patient requires\\nprolonged bed rest. Bleeding can occur but rarely is a\\nblood transfusion required. Adhesions (abnormal con-\\nnections to abdominal organs by thin fibrous tissue) is\\na known complication of any abdominal procedure\\nsuch as appendectomy. Theseadhesions can lead to\\nintestinal obstruction which prevents the normal flow\\nof intestinal contents.Hernia is a complication of any\\nincision, However, they are rarely seen after appen-\\ndectomy because the abdominal wall is very strong in\\nthe area of the standard appendectomy incision.\\nThe overall complication rate of appendectomy\\ndepends upon the status of the appendix at the time\\nit is removed. If the appendix has not ruptured the\\ncomplication rate is only about 3%. However, if the\\nappendix has ruptured the complication rate rises to\\nalmost 59%. Wound infections do occur and are more\\ncommon if the appendicitis was severe, far advanced,\\nor ruptured. Anabscess may form in the abdomen as a\\ncomplication of appendicitis.\\nOccasionally, an appendix will rupture prior to its\\nremoval, spilling its contents into the abdominal cavity.\\nPeritonitis or a generalized infection in the abdomen\\nwill occur. Treatment of peritonitis as a result of a\\nruptured appendix includes removal of what remains\\nof the appendix, insertion of drains (rubber tubes that\\npromote the flow of infection inside the abdomen to\\nKEY TERMS\\nAbscess— A collection of pus buried deep in the\\ntissues or in a body cavity.\\nAnesthesiologist— A physician who has special\\ntraining and expertise in the delivery of anesthetics.\\nAnesthetics— Drugs or methodologies used to\\nmake a body area free of sensation or pain.\\nCecum— The beginning of the large intestine and\\nthe place where the appendix attaches to the intest-\\ninal tract.\\nGeneral surgeon— A physician who has special\\ntraining and expertise in performing a variety of\\noperations.\\nPelvic organs— The organs inside of the body that\\nare located within the confines of the pelvis. This\\nincludes the bladder and rectum in both sexes and\\nthe uterus, ovaries, and fallopian tubes in females.\\nPubis— The anterior portion of the pelvis located in\\nthe anterior abdomen.\\nThrombophlebitis— Inflammation of the veins,\\nusually in the legs, which causes swelling and ten-\\nderness in the affected area.\\nUmbilicus— The navel.\\n380 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='outside of the body), andantibiotics. Fistula formation\\n(an abnormal connection between the cecum and the\\nskin) rarely occurs. It is only seen if the appendix has a\\nbroad attachment to the cecum and the appendicitis is\\nfar advanced causing destruction of the cecum itself.\\nNormal results\\nMost patients feel better immediately after an\\noperation for appendicitis. Many patients are dis-\\ncharged from the hospital within 24 hours after the\\nappendectomy. Others may require a longer stay–\\nthree to five days. Almost all patients are back to\\ntheir normal activities within three weeks.\\nThe mortality rate of appendicitis has dramatically\\ndecreased over time. Currently, the mortality rate is\\nestimated at one to two per 1,000,000 cases of appendi-\\ncitis. Death is usually due to peritonitis, intra abdom-\\ninal abscess or severe infection following rupture.\\nThe complications associated with undiagnosed,\\nmisdiagnosised, or delayed diagnosis of appendect-\\nomy are very significant. The diagnosis is of appendi-\\ncitis is difficult and never certain. This has led surgeons\\nto perform an appendectomy any time that they feel\\nappendicitis is the diagnosis. Most surgeons feel that\\nin approximately 20% of their patients, a normal\\nappendix will be removed. Rates much lower than\\nthis would seem to indicate that the diagnosis of\\nappendicitis was being frequently missed.\\nResources\\nPERIODICALS\\nMcCall, J. L., K. Sharples, and F. Jafallah. ‘‘Systematic\\nReview of Randomized Controlled Trial Comparing\\nLaproscopic with Open Appendectomy.’’British\\nJournal of Surgery84, no. 8 (August 1997): 1045-1950.\\nOTHER\\n‘‘Appendectomy.’’ ThriveOnline. .\\n‘‘The Appendix.’’ Mayo Clinic Online. .\\nMary Jeanne Krob, MD, FACS\\nAppendicitis\\nDefinition\\nAppendicitis is an inflammation of the appendix,\\nwhich is the worm-shaped pouch attached to the\\ncecum, the beginning of the large intestine. The appen-\\ndix has no known function in the body, but it can\\nbecome diseased. Appendicitis is a medical emergency,\\nand if it is left untreated the appendix may rupture and\\ncause a potentially fatal infection.\\nDescription\\nAppendicitis is the most common abdominal\\nemergency found in children and young adults. One\\nperson in 15 develops appendicitis in his or her life-\\ntime. The incidence is highest among males aged\\n10-14, and among females aged 15-19. More males\\nthan females develop appendicitis between puberty\\nand age 25. It is rare in the elderly and in children\\nunder the age of two.\\nThe hallmark symptom of appendicitis is increas-\\ningly severe abdominalpain. Since many different con-\\nditions can cause abdominal pain, an accurate\\ndiagnosis of appendicitis can be difficult. A timely\\ndiagnosis is important, however, because a delay can\\nresult in perforation, or rupture, of the appendix.\\nWhen this happens, the infected contents of the appen-\\ndix spill into the abdomen, potentially causing a ser-\\nious infection of the abdomen calledperitonitis.\\nAn extracted appendix. (Photograph by Lester V. Bergman,\\nCorbis Images. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 381\\nAppendicitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Other conditions can have similar symptoms,\\nespecially in women. These include pelvic inflamma-\\ntory disease, ruptured ovarian follicles, ruptured ovar-\\nian cysts, tubal pregnancies, and endometriosis.\\nVarious forms of stomach upset and bowel inflamma-\\ntion may also mimic appendicitis.\\nThe treatment for acute (sudden, severe) appendi-\\ncitis is anappendectomy, surgery to remove the appen-\\ndix. Because of the potential for a life-threatening\\nruptured appendix, persons suspected of having\\nappendicitis are often taken to surgery before the\\ndiagnosis is certain.\\nCauses and symptoms\\nThe causes of appendicitis are not well under-\\nstood, but it is believed to occur as a result of one or\\nmore of these factors: an obstruction within the\\nappendix, the development of an ulceration (an abnor-\\nmal change in tissue accompanied by the death of\\ncells) within the appendix, and the invasion of\\nbacteria.\\nUnder these conditions, bacteria may multiply\\nwithin the appendix. The appendix may become swol-\\nlen and filled with pus (a fluid formed in infected tissue,\\nconsisting of while blood cells and cellular debris), and\\nmay eventually rupture. Signs of rupture include the\\npresence of symptoms for more than 24 hours, afever,a\\nhigh white blood cell count, and a fast heart rate. Very\\nrarely, the inflammation and symptoms of appendicitis\\nmay disappear but recur again later.\\nThe distinguishing symptom of appendicitis is\\npain beginning around or above the navel. The pain,\\nwhich may be severe or only achy and uncomfortable,\\neventually moves into the right lower corner of the\\nabdomen. There, it becomes more steady and more\\nsevere, and often increases with movement, coughing,\\nand so forth. The abdomen often becomes rigid and\\ntender to the touch. Increasing rigidity and tenderness\\nindicates an increased likelihood of perforation and\\nperitonitis.\\nLoss of appetite is very common. Nausea and\\nvomiting may occur in about half of the cases and\\noccasionally there may be constipation or diarrhea.\\nThe temperature may be normal or slightly elevated.\\nThe presence of a fever may indicate that the appendix\\nhas ruptured.\\nDiagnosis\\nA careful examination is the best way to diag-\\nnose appendicitis. It is o ften difficult even for\\nexperienced physicians to distinguish the symptoms\\nof appendicitis from those of other abdominal dis-\\norders. Therefore, very specific questioning and a\\nthorough physical examination are crucial. The\\nphysician should ask questions, such as where the\\npain is centered, whether the pain has shifted, and\\nwhere the pain began. The physician should press\\non the abdomen to judge the location of the pain\\nand the degree of tenderness.\\nThe typical sequence of symptoms is present in\\nabout 50% of cases. In the other half of cases, less\\ntypical patterns may be seen, especially in pregnant\\nwomen, older patients, and infants. In pregnant\\nwomen, appendicitis is easily masked by the fre-\\nquent occurrence of mild abdominal pain and\\nnausea from other causes. Elderly patients may\\nfeel less pain and tenderness than most patients,\\nthereby delaying diagnosis and treatment, and\\nleading to rupture in 30% of cases. Infants and\\nyoung children often have diarrhea, vomiting,\\nand fever in addition to pain.\\nWhile laboratory tests cannot establish the diag-\\nnosis, an increased white cell count may point to\\nappendicitis. Urinalysis may help to rule out a urinary\\ntract infection that can mimic appendicitis.\\nPatients whose symptoms andphysical examina-\\ntion are compatible with a diagnosis of appendicitis\\nare usually taken immediately to surgery, where a\\nlaparotomy (surgical exploration of the abdomen) is\\ndone to confirm the diagnosis. In cases with a ques-\\ntionable diagnosis, other tests, such as a computed\\ntomography scan (CT) may be performed to avoid\\nunnecessary surgery. An ultrasound examination of\\nthe abdomen may help to identify an inflamed appen-\\ndix or other condition that would explain the symp-\\ntoms. Abdominal x-rays are not of much value except\\nwhen the appendix has ruptured.\\nKEY TERMS\\nAppendectomy (or appendicectomy)— Surgical\\nremoval of the appendix.\\nAppendix— The worm-shaped pouch attached to\\nthe cecum, the beginning of the large intestine.\\nLaparotomy— Surgical incision into the loin,\\nbetween the ribs and the pelvis, which offers sur-\\ngeons a view inside the abdominal cavity.\\nPeritonitis— Inflammation of the peritoneum,\\nmembranes lining the abdominal pelvic wall.\\n382 GALE ENCYCLOPEDIA OF MEDICINE\\nAppendicitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Often, the diagnosis is not certain until an opera-\\ntion is done. To avoid a ruptured appendix, surgery\\nmay be recommended without delay if the symptoms\\npoint clearly to appendicitis. If the symptoms are not\\nclear, surgery may be postponed until they progress\\nenough to confirm a diagnosis.\\nWhen appendicitis is strongly suspected in a\\nwoman of child-bearing age, a diagnostic laparoscopy\\n(an examination of the interior of the abdomen) is\\nsometimes recommended before the appendectomy in\\norder to be sure that a gynecological problem, such as a\\nruptured ovarian cyst, is not causing the pain. In this\\nprocedure, a lighted viewing tube is inserted into the\\nabdomen through a small incision around the navel.\\nA normal appendix is discovered in about 10-20%\\nof patients who undergo laparotomy, because of sus-\\npected appendicitis. Sometimes the surgeon will\\nremove a normal appendix as a safeguard against\\nappendicitis in the future. During the surgery, another\\nspecific cause for the pain and symptoms of appendi-\\ncitis is found for about 30% of these patients.\\nTreatment\\nThe treatment of appendicitis is an immediate\\nappendectomy. This may be done by opening the abdo-\\nmen in the standard open appendectomy technique, or\\nthrough laparoscopy. In laparoscopy, a smaller incision\\nis made through the navel. Both methods can success-\\nfully accomplish the removal of the appendix. It is not\\ncertain that laparoscopy holds any advantage over open\\nappendectomy. When the appendix has ruptured,\\npatients undergoing a laparoscopic appendectomy may\\nhave to be switched to the open appendectomy proce-\\ndure for the successful management of the rupture. If a\\nruptured appendix is left untreated, the condition is fatal.\\nPrognosis\\nAppendicitis is usually treated successfully by\\nappendectomy. Unless there are complications, the\\npatient should recover without further problems. The\\nmortality rate in cases without complications is less\\nthan 0.1%. When an appendix has ruptured, or a\\nsevere infection has developed, the likelihood is higher\\nfor complications, with slower recovery, or death from\\ndisease. There are higher rates of perforation and\\nmortality among children and the elderly.\\nPrevention\\nAppendicitis is probably not preventable, although\\nthere is some indication that a diet high in green vege-\\ntables and tomatoes may help prevent appendicitis.\\nResources\\nPERIODICALS\\nVan Der Meer, Antonia. ‘‘Do You Know the Warning Signs\\nof Appendicitis?’’Parents Magazine(April 1997): 49.\\nCaroline A. Helwick\\nAppendix removal see Appendectomy\\nAppetite-enhancing drugs\\nDefinition\\nAppetite-enhancing drugs are a diverse group of\\nmedications given to prevent undesired weight loss in\\nthe elderly and in patients suffering from such diseases\\nas AIDS and cancer, which often result in wasting of\\nthe body’s muscle tissue as well as overall weight loss.\\nThe medical term for these drugs is orexigenic, which\\nis derived from the Greek word for ‘‘appetite’’ or\\n‘‘desire.’’ None of the orexigenic drugs in common\\nuse as of 2005, however, were originally formulated\\nor prescribed as appetite stimulants; they range from\\nantihistamines and antiemetics (drugs given to treat or\\nprevent nausea and vomiting) to antidepressants and\\nsynthetic hormones. The medications most often used\\nin the early 2000s include mirtazapine (Remeron), a\\ntetracyclic antidepressant; cyproheptadine (Periactin),\\nan antihistamine; dronabinol (Marinol, THC), an\\nantiemetic; nandrolone, oxymetholone, and oxandro-\\nlone (Anadrol-50, Durabolin, Hybolin, Oxandrin, and\\nother brand nam! es), which are anabolic steroids\\nrelated to the male sex hormone testosterone; and\\nmegestrol acetate (Megace), a synthetic derivative of\\nthe female sex hormone progesterone. In addition to\\nthese prescription drugs, fish oil (eicosapentaenoic acid\\nor EPA) has been recommended as an alternative\\nor complementary treatment for undesired weight loss.\\nPurpose\\nThe reader should note the distinction between\\nappetite and hunger in order to understand why a\\ngroup of such different medications could be used to\\nstimulate the desire for food. Hunger is defined as the\\nbody’s basic physical need for food, whether in terms\\nof calorie content or specific nutrients. Appetite, on\\nthe other hand, refers to the complex desires in\\nhumans for food and drink that are often conditioned\\nor influenced by previous experiences or cultural fac-\\ntors as well as by a person’s present health status.\\nGALE ENCYCLOPEDIA OF MEDICINE 383\\nAppetite-enhancing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='People may have an appetite for food in the absence of\\nhunger; conversely, they may be hungry in the physical\\nsense but have little or no appetite. Loss of appetite\\nmay lead to a type ofmalnutrition known as under-\\nnutrition, which is characterized by food intake that\\nfalls below a recommended daily allowance of calories\\nor by the body’s inability to make use of the nutrients\\nin the food that is consumed.\\nPeople may become anorexic (lose their appetite\\nfor food) for a variety of physical, emotional, and\\nsocial reasons:\\n/C15Sensory changes related toaging. Elderly persons\\noften experience a partial loss of the senses of taste\\nand smell, which means that they may not enjoy their\\nmeals as much as they did when they were younger.\\nIn addition, many elderly persons feel full after eat-\\ning relatively small amounts of food. It is thought\\nthat this early feeling of fullness is caused by\\nincreased secretion of gastric hormones known as\\ncholecystokinins.\\n/C15Gastrointestinal disorders. Patients with such disor-\\nders as Crohn’s disease or gastric atonia (abnormally\\nslow emptying of the stomach) may lose their appe-\\ntite for food.\\n/C15Severe diseases that affect the entire body, particu-\\nlarly cancer and AIDS. Patients with these diseases\\nmay develop cachexia, a potentially life-threatening\\ncondition characterized by unintended weight loss\\nand wasting of lean muscle tissue. Cachexia is often\\naccompanied by loss of appetite.\\n/C15Medication side effects. In addition to the drugs used\\nin cancer chemotherapy, such drugs as fluoxetine\\n(Prozac), digoxin (Lanoxin), quinidine (Duraquin,\\nCardioquin), hydralazine (Alazine, Apresoline), cer-\\ntain antibiotics, and vitamin A may cause loss of\\nappetite.\\n/C15Emotional stress. Many people do not feel like eating\\nbefore examinations, job interviews, public speaking,\\nartistic performances, athletic competitions, or simi-\\nlar stressful situations.\\n/C15Depression and othermood disorders. Loss of appe-\\ntite is a common feature of depressive episodes as\\nwell as of major depressive disorder.\\n/C15Cultural factors. The types of food that people find\\nappetizing are influenced by their respective cultures;\\nfor example, Westerners usually find the use of cats\\nand dogs for food in China and Korea upsetting or\\ndisgusting because they regard these animals as\\ndomestic pets rather than dietary items. In addition,\\nmany people lose their appetite when they discover\\ninsects, hair, or other evidence of unsanitary\\nconditions in their food, or when they find that a\\ndish’s ingredients violate the dietary laws of their\\nreligion.\\n/C15Social isolation. Research indicates that human\\nappetite for food is stimulated by eating in the com-\\npany of others. Loss of appetite in many elderly\\npeople is associated with living alone.\\n/C15Previous experience. People who have developed\\nfood poisoning after eating contaminated or impro-\\nperly refrigerated salads, raw clams or oysters, or\\nsimilar foods may develop a long-term distaste for\\nthe food that made them sick.\\nGiven the complexity and variety of factors that\\ninfluence the desire for food in humans, doctors often\\nuse such questionnaires as the Mini Nutritional\\nAssessment or theNutrition Screening Index before\\nprescribing any appetite-enhancing drug. Many\\npatients can be successfully treated by changes in the\\ntype or dosage of medications they are taking for\\nother conditions, or by therapy directed at an under-\\nlying mood disorder or gastrointestinal disease.\\nOthers can be helped by changes in their living situa-\\ntions that allow them to share mealtimes with others\\nor by assistance in preparing foods that they particu-\\nlarly enjoy. The American Academy of Home Care\\nPhysicians (AAHCP) noted in a report published in\\nMay 2004 that the use of orexigenic drugs in the\\nelderly is ‘‘controversial and not generally FDA-\\napproved.’’\\nDescription\\nOrexigenic drugs used in the United States as of\\n2005 are classified as follows:\\n/C15Mirtazapine. Mirtazapine is a tetracyclic antidepres-\\nsant that was approved by the Food and Drug\\nAdministration (FDA) in 1996 for the treatment of\\nmajor depression. Although researchers do not fully\\nunderstand why mirtazapine relieves mood disor-\\nders, they think that it increases the levels of nora-\\ndrenaline and serotonin (chemicals that transmit\\nnerve impulses across the gaps between cells) in the\\nbrain. Mirtazapine is most often prescribed as an\\nappetite stimulant for patients who have been pre-\\nviously diagnosed with depression.\\n/C15Cyproheptadine. Cyproheptadine is an antihista-\\nmine given to relieve the symptoms of colds, nasal\\nallergies, and hayfever. It is also prescribed to relieve\\nthe itching associated with insect bites and stings,\\npoison ivy, and poison oak. It appears to be most\\neffective in treating loss of appetite in children and\\nadults diagnosed with cystic fibrosis.\\n384 GALE ENCYCLOPEDIA OF MEDICINE\\nAppetite-enhancing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Dronabinol. Dronabinol is a synthetic version of tet-\\nrahydrocannabinol (THC), the mood-altering com-\\npound found in marijuana (Cannabis sativa ).\\nMarijuana has been known as an appetite stimulant\\nfor centuries, having been recommended for that pur-\\npose by Ayurvedic practitioners and by the Arabic\\nphysician Al Badri, who first described its orexigenic\\nproperties in 1251. Dronabinol is most commonly\\nused to treat thenausea and vomiting associated with\\nAIDS and with cancer chemotherapy.\\n/C15Anabolic steroids. These drugs are given to older per-\\nsons to increase muscle mass and strength, or to help\\npatients recovering from severe illness or injury to\\nregain lost weight.\\n/C15Megestrol acetate. Megestrol acetate was first\\napproved by the FDA in 1976 for palliative treat-\\nment of metastatic breast orendometrial cancer.I t\\nreceived additional approval in 1993 for the\\ntreatment of anorexia or unexplained weight loss in\\npatients with AIDS. Researchers do not fully under-\\nstand how the drug prevents the growth of cancer\\ncells or how it stimulates appetite.\\n/C15Fish oil. Fish oil is recommended by some practi-\\ntioners as a nutritional supplement for weight loss\\ncaused by cancer or AIDS. It is thought that the\\nomega-3 fatty acids in fish oil help to reduce the\\ninflammation associated with some forms of cancer\\ntherapy as well as helping patients regain lost weight.\\nAlthough some studies question the effectiveness of\\nfish oil as a complementary treatment for undesired\\nweight loss, the National Center for Complementary\\nand Alternative Medicine (NCCAM) is recruiting\\npatients as of April 2005 for a clinical trial of fish\\noil as a dietary supplement to maintain weight in\\npatients with pancreatic cancer. The study will be\\ncompleted in September 2007.\\nRecommended dosage\\nRecommended dosages for orexigenic drugs are\\nas follows:\\n/C15Mirtazapine. Mirtazapine is available in 15- and 30-\\nmg tablets or disintegrating tablets. The usual start-\\ning dose is 15 mg once daily, usually at bedtime. The\\ndrug can be taken with or without food, as the\\npatient prefers.\\n/C15Cyproheptadine. Cyproheptadine is taken by mouth,\\neither as tablets or in liquid form. Adults are usually\\ngiven 4 mg three or four times per day. Children\\nbetween 2 and 6 years of age are usually given 12\\nmg per day in 3–4 divided doses while older children\\nare given 16 mg per day in divided doses.\\n/C15Dronabinol. As an appetite stimulant, dronabinol is\\ngiven as a 2.5-mg capsule twice a day, before lunch\\nand dinner. Some AIDS patients may be given as\\nmuch as 10 mg per day.\\n/C15Anabolic steroids. Oxandrolone and oxymetholone\\nare available in the United States and Canada as\\ntablets, while nandrolone is given by injection. To\\nbuild up body tissues after injury or serious illness,\\nthe adult dosage of oxandrolone is a 2.5-mg tablet\\ntaken by mouth two to four times daily for a period\\nof four weeks, although the total daily dosage may be\\nraised as high as 20 mg. To treat anemia, oxymetho-\\nlone is prescribed according to the patient’s body\\nweight, usually 0.45–2.3 mg per pound of body\\nweight per day in adults and children. Nandrolone\\nis given by injection every three to four weeks for a\\nperiod of 12 weeks. The usual dosage for women and\\ngirls over 14 is 50–100 mg; for men and boys over 14,\\nKEY TERMS\\nAnabolic steroids— A group of drugs derived from\\nthe male sex hormone testosterone, most com-\\nmonly prescribed to promote growth or to help\\nthe body repair tissues weakened by severe illness\\nor aging. Some anabolic steroids are given as appe-\\ntite stimulants.\\nAnorexia— Loss of appetite for food.\\nAntiemetic— A type of medication given to relieve\\nor prevent nausea and vomiting. Some appetite-\\nenhancing drugs are also used as antiemetics.\\nAppetite— The natural instinctive desire for food. It\\nshould be distinguished from hunger, which is the\\nbody’s craving or need for food (either calories or\\nspecific nutrients).\\nCachexia— A condition of general ill health, mal-\\nnutrition, undesired weight loss, and physical\\nweakness, often associated with cancer.\\nOff-label— Referring to the use of a drug for a con-\\ndition or disorder not listed in the official FDA\\nlabeling.\\nOrexigenic— The medical term for drugs that\\nincrease or stimulate the appetite.\\nPalliative— Referring to drugs or other therapies\\nintended to relieve the symptoms of a disease rather\\nthan to cure it.\\nUndernutrition— A type of malnutrition caused by\\ninadequate food intake or the body’s inability to\\nmake use of needed nutrients.\\nGALE ENCYCLOPEDIA OF MEDICINE 385\\nAppetite-enhancing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='50–200 mg; for children between the ages of 2 and 13,\\n15–50 mg.\\n/C15Megestrol acetate. Megestrol acetate is given as a\\nliquid suspension in 200-mg doses every 6 hours.\\n/C15Fish oil. A recommended dose for cancer-induced\\nweight loss is 12 g daily, taken by mouth. Fish oil is\\navailable in capsules as well as liquid forms.\\nPrecautions\\nPrecautions for orexigenic drugs are as follows:\\n/C15Mirtazapine. In January 2005 the FDA required\\nlabeling changes for mirtazapine to warn of the\\nincreased risk ofsuicide or self-harm in children or\\nadolescents taking this drug. Mirtazapine should not\\nbe given to children below 18 years of age, and\\nshould be used with caution in pregnant or lactating\\nwomen. Patients taking mirtazapine should not stop\\ntaking it without telling their doctor; it should not be\\ndiscontinued abruptly but taken in progressively\\nsmaller doses over a period of time. This precaution\\nis particularly important in patients who have been\\ntaking the drug for a long time.\\n/C15Cyproheptadine. This drug should not be given to\\npatients who suffer acute asthma attacks or are\\nhypersensitive to antihistamines. It should not be\\ngiven to patients who have taken phenelzine\\n(Nardil), tranylcypromine (Parnate), or other MAO\\ninhibitors within the last two weeks. Cyproheptadine\\nshould be used cautiously in the elderly and in\\npatients withglaucoma, high blood pressure, or car-\\ndiovascular disease.\\n/C15Dronabinol. Patients t aking dronabinol should\\nbe closely supervised by their doctor, as the\\ndrug may cause unpredictable changes in blood\\npressure and heart rate. In addition, it may make\\ncertain mental disorders worse. It also has a high\\npotential for abuse; for this reason, it should be\\nused cautiously in patients with a history of\\nalcohol or drug abuse. Dronabinol should not\\nbe used by nursing mothers because it passes\\ninto breast milk. It should be used with great\\ncaution in children or patients diagnosed with\\nsevere mental illness because of its effects on\\nthe mind. Patients taking dronabinol should\\nnotify their dentist or surgeon before any proce-\\ndure requiring local or general anesthesia ,a st h e\\ndrug may intensify the effects of the anesthetic.\\nIn addition, these patients should not drive a car\\nor operate dangerous machinery until they know\\nwhether dronabinol make s them dizzy, drowsy,\\nor uncoordinated.\\n/C15Anabolic steroids. Patients taking these drugs must\\nfollow a diet high in protein and calories in order to\\nbenefit from the medications, and should be carefully\\nsupervised by their doctor because of possible side\\neffects. Children or teenagers taking these drugs\\nshould have x-rays every six months to make sure\\nthey are growing normally, as anabolic steroids can\\ninterfere with growth. Patients with diabetes should\\ncheck their blood sugar levels with extra care, as\\nthese drugs may cause rapid changes in blood sugar\\nlevels.\\n/C15Megestrol acetate. This drug should not be used by\\npregnant or lactating women, or by women planning\\nto become pregnant. Women of childbearing age\\nwho are taking megestrol should use a reliable form\\nof contraception.\\n/C15Fish oil. Fish oil is not a prescription drug; however,\\npatients who choose to take cod liver oil as their fish\\noil supplement should make sure that they are not\\ngetting more than the safe maximum daily allowan-\\nces ofvitamins A and D. These vitamins tend to build\\nup in the body and may reach toxic levels. The max-\\nimum safe daily level of vitamin A for adults is 3000\\nmicrograms (mcg).\\nSide effects\\nSide effects reported for orexigenic drugs are as\\nfollows:\\n/C15Mirtazapine. Mirtazapine may cause mood changes,\\nincluding worsening depression or thoughts of sui-\\ncide. It may also cause panic attacks, irritability,\\ndifficulty with impulse control, abnormal levels of\\nexcitement, or difficulty sleeping. Physical side\\neffects may include sleepiness,dry mouth, constipa-\\ntion, nausea and vomiting, flu-like symptoms, chest\\npain, and rapid heartbeat. Patients who have any of\\nthese side effects should consult their doctor at once.\\n/C15Cyproheptadine. Side effects include drowsiness,\\nfatigue, dry mouth, skin rash, chest congestion,head-\\nache, diarrhea, nausea and vomiting, difficulty uri-\\nnating, and blurred vision. Patients who experience\\nurinary or vision problems should consult their doc-\\ntor at once.\\n/C15Dronabinol. Dronabinol may cause a variety of\\nchanges in mental status, includingdelirium, confu-\\nsion, hallucinations, memory loss,delusions, euphoria\\n(false sense of well-being), nervousness oranxiety.\\nBecause of the possibility of severe mental side\\neffects, anyone who has taken an overdose of dronabi-\\nnol needs immediate emergency medical help. The\\ndrug may also cause clumsiness or lightheadedness,\\n386 GALE ENCYCLOPEDIA OF MEDICINE\\nAppetite-enhancing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='dry mouth, fatigue, headache, sweating, facial flush-\\ning, diarrhea or constipation, muscle pains, high\\nblood pressure, seizures, problems in urinating, red\\neyes, or vomiting.\\n/C15Anabolic steroids. These drugs have been reported to\\ncause a rare form ofliver disease; patients who notice\\nyellowing of the eyes or skin, or black, tarry stools,\\nsore throatand fever, vomiting of blood, or purplish\\nor reddish spots on the body should contact their\\ndoctor at once. Other side effects include feeling\\nchilly, diarrhea,muscle cramps, unusual increase or\\ndecrease in sexual desire,acne or oily skin, bone pain,\\nnausea, or vomiting. Women may notice deepening\\nof the voice, hair loss, unnatural hair growth (hirsut-\\nism), or irregular menstrual periods. Adult males\\nmay notice enlargement of the breasts (gynecomas-\\ntia), frequent need to urinate, or frequent erections.\\nElderly males may have difficulty urinating.\\n/C15Megestrol acetate. Side effects of megestrol acetate\\ninclude swelling of the hands, feet, or lower legs;\\nheadaches; sore breasts; or decreased sexual desire.\\nMen taking this drug may become impotent. Women\\nmay notice vaginal bleeding or abdominal pain.\\n/C15Fish oil. Some people taking fish oil as a dietary\\nsupplement experience an increased tendency to\\nburp followed by a fishy taste in the mouth.\\nInteractions\\nMost orexigenic drugs interact with a number of\\nother medications:\\n/C15Mirtazapine. Mirtazapine may cause high blood\\npressure or abnormally high body temperature if\\ntaken together with MAO inhibitors (furazolidone,\\nphenelzine, procarbazine, selegiline, or tranylcypro-\\nmine). It intensifies the sedating (sleep-inducing)\\neffects of alcohol, benzodiazepine tranquilizers, anti-\\nhistamines, tricyclic antidepressants, narcotic pain\\nrelievers, and some medications given for high\\nblood pressure.\\n/C15Cyproheptadine. Cyproheptadine intensifies and\\nprolongs the effects of other antihistamines, alcohol,\\nbarbiturates, narcotic pain relievers, benzodiazepine\\ntranquilizers, and antidepressant medications.\\n/C15Dronabinol. Dronabinol intensifies the effects of\\nalcohol and other medications that act ascentral\\nnervous system depressants. These groups of drugs\\ninclude barbiturates, benzodiazepine tranquilizers,\\ntetracyclic and tricyclic antidepressants, narcotic\\npain relievers, antiseizure medications, antihista-\\nmines, muscle relaxants, and anesthetics, including\\ndental anesthetics.\\n/C15Anabolic steroids. Anabolic steroids may intensify\\nthe effects of blood thinners (aspirin, coumadin, war-\\nfarin). They may increase the risk of liver damage in\\npatients who are taking phenothiazines, valproic\\nacid, oral contraceptives containing estrogen, gold\\nsalts, methotrexate, carbamazepine, amiodarone,\\nmercaptopurine, phenytoin, plicamycin, disulfiram,\\ndaunorubicin, chloroquine, methyldopa, or\\nnaltrexone.\\n/C15Megestrol acetate. No significant interactions with\\nother drugs have been reported. Patients taking\\nmegestrol acetate should, however, notify their phy-\\nsician of all other drugs and dietary supplements\\n(including herbal preparations) that they use on a\\nregular basis, as dosage adjustments are sometimes\\nneeded.\\n/C15Fish oil. Fish oil has been reported to intensify the\\neffects of such blood-thinning medications as cou-\\nmadin and warfarin. Persons who take these drugs\\nand wish to use fish oil as a dietary supplement\\nshould consult their doctor first.\\nResources\\nBOOKS\\n‘‘Malnutrition.’’ Section 1, Chapter 2 inThe Merck Manual\\nof Diagnosis and Therapy, edited by Mark H. Beers,\\nMD, and Robert Berkow, MD. Whitehouse Station,\\nNJ: Merck Research Laboratories, 2004.\\n‘‘Protein-Energy Undernutrition.’’ Section 8, Chapter 61 in\\nThe Merck Manual of Geriatrics, edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2004.\\nWilson, Billie A., Margaret T. Shannon, and Carolyn L.\\nStang. Nurses Drug Guide 2000, Stamford, CT:\\nAppleton & Lange, 2000.\\nPERIODICALS\\nAnttila, S. A., and E. V. Leinonen. ‘‘A Review of the\\nPharmacological and Clinical Profile of Mirtazapine.’’\\nCNS Drug Reviews7 (Fall 2001): 249–264.\\nGrinspoon, S., and K. Mulligan. ‘‘Weight Loss and Wasting\\nin Patients Infected with Human Immunodeficiency\\nVirus.’’ Clinical Infectious Diseases36 (April 1, 2003)\\n(Supplement 2): S69–S78.\\nHolder, H. ‘‘Nursing Management of Nutrition in Cancer\\nand Palliative Care.’’British Journal of Nursing12 (June\\n12–25, 2003): 667–674.\\nHomnick, D. N., B. D. Homnick, A. J. Reeves, et al.\\n‘‘Cyproheptadine Is an Effective Appetite Stimulant in\\nCystic Fibrosis.’’Pediatric Pulmonology38 (August\\n2004): 129–134.\\nJatoi, A., K. Rowland, C. L. Loprinzi, et al. ‘‘An\\nEicosapentaenoic Acid Supplement Versus Megestrol\\nAcetate Versus Both for Patients with Cancer-\\nAssociated Wasting: A North Central Cancer\\nTreatment Group and National Cancer Institute of\\nGALE ENCYCLOPEDIA OF MEDICINE 387\\nAppetite-enhancing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Canada Collaborative Project.’’Journal of Clinical\\nOncology 22 (June 15, 2004): 2469–2476.\\nJatoi, A., H. E. Windschitl, C. L. Loprinzi, et al.\\n‘‘Dronabinol Versus Megestrol Acetate Versus\\nCombination Therapy for Cancer-Associated\\nAnorexia: A North Central Cancer Treatment Group\\nStudy.’’ Journal of Clinical Oncology20 (January 15,\\n2002): 567–573.\\nMorley, J. E. ‘‘Orexigenic and Anabolic Agents.’’Clinics in\\nGeriatric Medicine18 (November 2002): 853–866.\\nVickers, S. P., and G. A. Kennett. ‘‘Cannabinoids and the\\nRegulation of Ingestive Behaviour.’’Current Drug\\nTargets 6 (March 2005): 215–223.\\nORGANIZATIONS\\nAmerican Academy of Home Care Physicians (AAHCP).\\nP. O. Box 1037, Edgewood, MD 21040-0337. (410) 676-\\n7966. Fax: (410) 676-7980. .\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nAmerican Society of Health-System Pharmacists (ASHP).\\n7272 Wisconsin Avenue, Bethesda, MD 20814. (301)\\n657-3000. .\\nNational Cancer Institute (NCI). NCI Public Inquiries\\nOffice, Suite 3036A, 6116 Executive Boulevard,\\nMSC8332, Bethesda, MD 20892-8322. (800)\\n4-CANCER or (800) 332-8615 (TTY).\\n.\\nUnited States Food and Drug Administration (FDA). 5600\\nFishers Lane, Rockville, MD 20857-0001. (888) INFO-\\nFDA. .\\nOTHER\\nFood and Drug Administration (FDA) MedWatch, January\\n2005. ‘‘Summary View: Safety Labeling Changes\\nApproved by FDA Center for Drug Evaluation and\\nResearch (CDER)—January 2005.’’ .\\nMorley, John E., David R. Thomas, and Margaret-Mary G.\\nWilson. ‘‘Appetite and Orexigenic Drugs.’’ St. Louis,\\nMO: Council for Nutrition, Clinical Strategies in Long-\\nTerm Care, 2001.\\nNational Center for Complementary and Alternative\\nMedicine (NCCAM). ‘‘Clinical Trial: A Fish Oil\\nSupplement to Maintain Body Weight in Pancreatic\\nCancer Patients.’’ .\\nTaler, George, MD, and Christine Ritchie, MD.\\n‘‘Unintended Weight Loss Guidelines.’’. Edgewood,\\nMD: American Academy of Home Care Physicians,\\n2004.\\nRebecca J. Frey, PhD\\nApplied kinesiology see Kinesiology, applied\\nApraxia\\nDefinition\\nApraxia is neurological condition characterized\\nby loss of the ability to perform activities that a person\\nis physically able and willing to do.\\nDescription\\nApraxia is caused by brain damage related to\\nconditions such as head injury, stroke, brain tumor,\\nand Alzheimer’s disease. The damage affects the\\nbrain’s ability to correctly signal instructions to the\\nbody. Forms of apraxia include the inability to say\\nsome words or make gestures.\\nVarious conditions cause apraxia, and it can affect\\npeople of all ages. A baby might be born with the\\ncondition. A car accident or fall that resulted in head\\ntrauma could lead to apraxia.\\nFrom 500,000 to 750,000 people need to be hospi-\\ntalized each year for head injuries according to the\\nAmerican Medical Association (AMA). Men between\\nthe ages of 18 and 24 form the largest group of people\\nwith head injuries. While not all severe injuries result\\nin apraxia, men in that age group are at risk.\\nRisk factors for strokes include high blood pres-\\nsure, diabetes, and heart disease. Cigarettesmoking\\nalso puts a person at risk for a stroke. Brain tumors\\nare abnormal tissue growths in the skull. They may be\\nsecondary tumors caused by the spread of cancer\\nthrough the body.\\nThere is more than one type of apraxia, and a\\nperson may have one or more form of this condition.\\nFurthermore, a milder form of apraxia is called\\ndyspraxia.\\nCauses and symptoms\\nApraxia is caused by conditions that affect parts\\nof the brain that control movements. Apraxia is a\\nresult of damage to the brain’s cerebral hemispheres.\\nThese are the two halves of the cerebrum and are the\\nlocation of brain activities such as voluntary\\nmovements.\\nApraxia causes a lapse in carrying out movements\\nthat a person knows how to do, is physically able to\\nperform, and wants to do. A person may be willing\\nand able to do something like bathe. However, the\\nbrain does not send the signals that allow the person\\nto perform the necessary sequence of activities to do\\nthis correctly.\\n388 GALE ENCYCLOPEDIA OF MEDICINE\\nApraxia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Types of apraxia\\nThere are several types of apraxia, and a patient\\ncould be diagnosed with one or more forms of this\\ncondition. The types of apraxia include:\\n/C15Buccofacial or orofacial apraxia is the inability of a\\nperson to follow through on commands involving\\nface and lip motions. These activities include cough-\\ning, licking the lips, whistling, and winking. Also\\nknown as facial-oral apraxia, it is the most common\\nform of apraxia, according to the National Institute\\nof Neurological Disorders and Stroke (NINDS).\\n/C15Limb-kinetic apraxia is the inability to make precise\\nmovements with an arm or leg.\\n/C15Ideomotor apraxia is the inability to make the proper\\nmovement in response to a command to pantomime\\nan activity like waving.\\n/C15Constructional apraxia is the inability to copy, draw,\\nor build simple figures.\\n/C15Ideational apraxia is the inability to do an activity\\nthat involves performing a series of movements in a\\nsequence. A person with this condition could have\\ntrouble dressing, eating, or bathing. It is also known\\nas conceptual apraxia.\\n/C15Oculomotor apraxia is characterized by difficulty\\nmoving the eyes.\\n/C15Verbal apraxia is a condition involving difficulty\\ncoordinating mouth and speech movements. It is\\nreferred to as apraxia of speech by organizations\\nincluding the American Speech Language Hearing\\nAssociation (ASHA).\\nA baby who does not coo or babble may display a\\nsymptom of apraxia of speech, according to ASHA. A\\nyoung child may only say a few consonant sounds, and\\nan older child may have difficulty imitating speech. An\\nadult also has this difficulty. Other symptoms include\\nsaying the wrong words. A person wants to say\\n‘‘kitchen,’’ but says ‘‘bipem’’ instead, according to an\\nASHA report.\\nA person diagnosed with apraxia may also have\\naphasia, a condition caused by damage to the brain’s\\nspeech centers. This results in difficulty reading, wit-\\nting, speaking, and understanding when others speak.\\nPost-apraxia changes\\nA person with apraxia could experience frustra-\\ntion about difficulty communicating or trouble per-\\nforming tasks. In some cases, the condition could\\naffect the person’s ability to live independently.\\nDiagnosis\\nDiagnosis of apraxia could begin with testing of\\nits underlying cause. Testing for conditions like a\\nstroke or cancer includes the MRI (magnetic resonance\\nimaging) and CT scanning (computer tomography\\nscanning). Abrain biopsyis used to measure changes\\ncaused by Alzheimer’s disease. In all cases, the physi-\\ncian takes a family history. Head trauma that could\\ncause apraxia is first treated in the emergency room.\\nOther diagnostic treatment is related to identify-\\ning the type of apraxia. For example, the physician\\nmay ask the patient to demonstrate how to blow out a\\ncandle, wave, use a fork, or use a toothbrush.\\nAssessment for speech apraxia in children\\nincludes a hearing evaluation to determine if difficulty\\nin speaking is related to ahearing loss. If the condition\\nappears related to apraxia, a speech-language pathol-\\nogist examines muscle development in the jaw, lips,\\nand tongue. The examination of adults and children\\nincludes an evaluation of how words are pronounced\\nindividually and in conversation. The pathologist\\nobserves how the patient breathes when speaking\\nand the ability to perform actions like smiling.\\nThe costs of diagnosis vary because the process\\ncould include examinations and diagnostic screening\\nrelated to the underlying cost of the apraxia. Insurance\\ngenerally covers part of these costs.\\nTreatment\\nThe treatment for apraxia usually involvesreha-\\nbilitation through speech-language therapy, physical\\ntherapy, or occupational therapy. In addition, treat-\\nment such as chemotherapy is administered for the\\ncondition that caused the apraxia.\\nFamily education is an important component of\\napraxia treatment. The rehabilitation process takes\\ntime, and relatives can offer encouragement and support\\nto the patient. They may be asked to help the patient\\nwith in-home exercises. Furthermore, family members\\ns o m e t i m e sn e e dt ot a k eo nt h er o l eo fc a r e g i v e r s .\\nKEY TERMS\\nCT scanning— Computer tomography scanning is a\\ndiagnostic imaging tool that uses x rays sent\\nthrough the body at different angles.\\nMRI— Magnetic resonance imaging is a diagnostic\\nimaging tool that utilizes an electromagnetic field\\nand radio waves.\\nGALE ENCYCLOPEDIA OF MEDICINE 389\\nApraxia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Speech-language therapy\\nSpeech-language therapy focuses on helping the\\npatients learn or regain communication skills.\\nTherapists teach exercises to strengthen facial muscles\\nused in speech. Other exercises concentrate on patients\\nlearning to correctly pronounce sounds and then turn\\nthose sounds into words.\\nIn cases where apraxia limits the ability to speak,\\ntherapists help patients develop alternate means of\\ncommunication. These alternatives range from gestur-\\ning to using a portable computer that writes and pro-\\nduces speech, according to ASHA.\\nOccupational and physical therapies\\nOccupational and physical therapies focus on\\nhelping patients regain the skills impaired by apraxia.\\nPhysical therapy exercises concentrate on areas such\\nas mobility and balance. Occupational therapy helps\\npatients relearn daily living skills.\\nTreatment costs\\nThe costs of therapy vary by the type of treatment,\\nregional location, and where the therapy is offered.\\nFees can range for $40 per hour for in-office speech\\ntherapy for a child to $85 per hour for in-home physi-\\ncal or occupational therapy for a senior citizen. Part of\\ntherapy costs may be covered by insurance.\\nAlternative treatment\\nMost alternative treatments target Alzheimer’s\\ndisease and other conditions that cause apraxia.\\nHerbal remedies thought to help people with\\nAlzheimer’s include ginkgo biloba, a plant extract.\\nHowever, organizations including the Alzheimer’s\\nAssociation caution that the effectiveness and safety\\nof this herbal remedy has not been evaluated by the\\nU.S. Food and Drug Administration. The government\\ndoes not require a review of supplements like ginkgo.\\nFurthermore, there is a risk of internal bleeding if\\nginkgo is taken in combination with aspirin and\\nblood-thinning medications.\\nPrognosis\\nThe prognosis for apraxia depends on factors such\\nas what caused the condition. While Alzheimer’s is a\\ndegenerative condition, a child with verbal apraxia or\\na stroke patient could make progress.\\nIn some cases, treatment helps a person to relearn\\nor acquire skills needed to function. A caregiver may\\nbe required, and some people withdementia require\\nsupervised, longterm care.\\nPrevention\\nThe methods of preventing apraxia focus on pre-\\nventing the underlying causes of this condition. This\\nmay not be entirely possible when there is a family\\nhistory of conditions such as stroke, dementia, and\\ncancer. However, a person at risk by not smoking,\\nexercising, and eating a diet based on the American\\nHeart Association guidelines.\\nHead injury can be prevented by wearing a helmet\\nwhen participating in activities like sports and bicy-\\ncling. Wearing a seatbelt when in a vehicle also helps\\nreduce the risk of head injury.\\nResources\\nBOOKS\\nPERIODICALS\\nORGANIZATIONS\\nAmerican Speech Language Hearing Association. 10801\\nRockville Pike, Rockville, MD 20852-3279. 800-638-\\n8255. .\\nAlzheimer’s Association. 225 North Michigan Avenue,\\nFloor 17, Chicago, IL 60601. 800-272-3900. .\\nNational Institute of Neurological Disorders and Stroke,\\nNIH Neurological Institute. P.O. Box 5801, Bethesda,\\nMD 20824. 800-352-9424..\\nNational Rehabilitation Information Center. 4200 Forbes\\nBoulevard Suite 202, Lanham, MD 20706-4829. 800-\\n346-2742. .\\nNational Stroke Association. 9707 East Easter Lane,\\nEnglewood, CO 80112. 1-800-787-6537. .\\nOTHER\\n‘‘Apraxia in Adults.’’ American Speech Language Hearing\\nAssociation. 2005. [cited March 29, 2005]. .\\n‘‘Childhood Apraxia of Speech.’’ American Speech\\nLanguage Hearing Association. 2005. [cited March 29,\\n2005]. .\\nJacobs, Daniel H., M.D.‘‘Apraxia and Related Syndromes.’’\\ne-medicine. October 27, 2004 [cited March 29, 2005].\\n.\\n‘‘NINDS Apraxia Information Page.’’ National Institute of\\nNeurological Disorders and Stroke February 09, 2005\\n[cited March 29, 2005]. .\\nLiz Swain,\\n390 GALE ENCYCLOPEDIA OF MEDICINE\\nApraxia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='APSGN see Acute poststreptococcal\\nglomerulonephritis\\nAPTT see Partial thromboplastin time\\nArachnodactyly see Marfan syndrome\\nArbovirus encephalitis\\nDefinition\\nEncephalitis is a serious inflammation of the\\nbrain, Arbovirus encephalitis is caused by a virus\\nfrom the Arbovirus group. The termarbovirus stands\\nfor Arthro-pod-borne virus because these viruses are\\npassed to humans by members of the phylum\\nArthropoda (which includes insects and spiders).\\nDescription\\nOf the huge number of arboviruses known to\\nexist, about 80 types are responsible for human dis-\\nease. In addition to the virus, there are usually two\\nother types of living creatures involved in the cycle\\nleading to human disease. When large quantities of\\nvirus are present in an arthropod (often a tick or\\nmosquito), the viruses are passed to a bird or small\\nmammal when the arthropod attempts to feed on the\\nblood of that creature. The virus thrives within the\\nnew host, sometimes causing illness, sometimes not.\\nMore ticks or mosquitoes are infected with the virus\\nwhen they feed on the host’s blood. Eventually, a tick\\nor mosquito bites a human, and the virus is passed\\nalong. Just a few types of arboviruses cycle only\\nbetween arthropods and humans, with no intermedi-\\nate stop in a bird or small mammal.\\nBecause the arboviruses require an arthropod to\\npass them along to humans, the most common times\\nof year for these illnesses include summer and fall,\\nwhen mosquitoes and ticks are most prevalent.\\nDamp environments favor large populations of mos-\\nquitoes, and thus also increase the risk of arbovirus\\ninfections.\\nThe major causes of arbovirus encephalitis\\ninclude the members of the viral families alphavirus\\n(causing Eastern equine encephalitis, Western equine\\nencephalitis, and Venezuelan equine encephalitis), fla-\\nvivirus (responsible for St. Louis encephalitis,\\nJapanese encephalitis , Tick-borne encephalitis,\\nMurray Valley encephalitis, Russian spring-summer\\nencephalitis, and Powassan), and bunyavirus (causing\\nCalifornia encephalitis).\\nIn the United States, the most important types of\\narbovirus encephalitis include Western equine ence-\\nphalitis (WEE), Eastern equine encephalitis (EEE),\\nSt. Louis encephalitis, and California encephalitis.\\nWEE strikes young infants in particular, with a 5%\\nchance ofdeath from the illness. Of those who survive,\\nabout 60% suffer permanent brain damage. EEE\\nstrikes infants and children, with a 20% chance of\\ndeath, and a high rate of permanent brain damage\\namong survivors. St. Louis encephalitis tends to strike\\nadults older than 40 years of age, and older patients\\ntend to have higher rates of death and long-term dis-\\nability from the infection. California virus primarily\\nstrikes 5-18 year olds, with a lower degree of perma-\\nnent brain damage.\\nCauses and symptoms\\nEncephalitis occurs because specific arboviruses\\nhave biochemical characteristics which cause them to\\nbe particularly attracted to the cells of the brain and the\\nnerves. The virus causes cell death and inflammation,\\nwith fever and swelling within the brain and nerves. The\\nmembranous coverings of the brain and spinal cord\\n(the meninges) may also become inflamed, a condition\\ncalled meningitis. The brain is swollen, and patches of\\nbleeding occur throughout the brain and spinal cord.\\nPatients with encephalitis suffer from headaches,\\nfever, nausea and vomiting, stiff neck, and sleepiness.\\nAs the disease progresses, more severe symptoms\\ndevelop, including tremors, confusion, seizures,\\ncoma, and paralysis. Loss of function occurs when\\nspecific nerve areas are damaged and/or killed.\\nDiagnosis\\nEarly in the disease, laboratory testing of blood\\nmay reveal the presence of the arbovirus. The usual\\ntechnique used to verify the presence of arbovirus\\ninvolves injecting the patient’s blood into the brain\\nof a newborn mouse, then waiting to see if the mouse\\ndevelops encephalitis. Diagnosis is usually based on\\nthe patient’s symptoms, history of tick or mosquito\\nbites, and knowledge that the patient has been in an\\narea known to harbor the arbovirus.\\nKEY TERMS\\nArthropods— A phylum name referring to certain\\ninsects (including mosquitoes and ticks) and spiders.\\nEncephalitis— A condition in which the brain swells.\\nGALE ENCYCLOPEDIA OF MEDICINE 391\\nArbovirus encephalitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nTreatment is mostly supportive, meaning it is\\ndirected at improving the symptoms, but does not\\nshorten the course of the illness. The main concerns\\nof treatment involve lowering fever, treating pain,\\navoiding dehydration or other chemical imbalances,\\nand decreasing swelling in the brain with steroids.\\nPrognosis\\nPrognosis depends on the particular type of arbo-\\nvirus causing disease, and on the age and prior health\\nstatus of the patient. Death rates range all the way up\\nto 20% for arbovirus encephalitis, and the rates of\\nlifelong effects due to brain damage reach 60% for\\nsome types of arboviruses.\\nPrevention\\nPrevention involves avoiding contact with\\narthropods which carry these viruses. This means\\nwearing appropriate insect repellents, and dressing\\nproperly in areas known to be infested. Insecticides\\nand the avoidance of collections of standing water\\n(which are good breeding ground for arthropods) is\\nalso effective at decreasing arthropod populations.\\nThere are immunizations available against EEE\\nand WEE. These have primarily been used to safe-\\nguard laboratory workers who have regular exposure\\nto these viruses.\\nResources\\nBOOKS\\nStoffman, Phyllis.The Family Guide to Preventing and\\nTreating 100 Infectious Diseases.New York: John\\nWiley & Sons, 1995.\\nRosalyn Carson-DeWitt, MD\\nARDS see Adult respiratory distress\\nsyndrome\\nAromatherapy\\nDefinition\\nAromatherapy is the therapeutic use of plant-\\nderived, aromatic essential oils to promote physical\\nand psychological well-being. It is sometimes used in\\ncombination with massage and other therapeutic tech-\\nniques as part of a holistic treatment approach.\\nPurpose\\nAromatherapy offers diverse physical and psy-\\nchological benefits, depending on the essential oil or\\noil combination and method of application used.\\nSome common medicinal properties of essential oils\\nused in aromatherapy include: analgesic, antimicro-\\nbial, antiseptic, anti-inflammatory, astringent, seda-\\ntive, antispasmodic, expectorant, diuretic, and\\nsedative. Essential oils are used to treat a wide range\\nof symptoms and conditions, including, but not limi-\\nted to, gastrointestinal discomfort, skin conditions,\\nmenstrual pain and irregularities, stress-related condi-\\ntions, mood disorders, circulatory problems, respira-\\ntory infections, andwounds.\\nAromatherapy Oils\\nName Description Conditions treated\\nBay laurel Antiseptic, diuretic,\\nsedative, etc.\\nDigestive problems,\\nbronchitis, common cold,\\ninfluenza, and scabies\\nand lice. CAUTION: Don’t\\nuse if pregnant.\\nClary sage Relaxant, anticonvulsive,\\nantiinflammatory, and\\nantiseptic\\nMenstrual and menopausal\\nsymptoms, burns, eczema,\\nand anxiety. CAUTION:\\nDon’t use if pregnant.\\nEucalyptus Antiseptic, antibacterial,\\nastringent, expectorant,\\nand analgesic\\nBoils, breakouts, cough,\\ncommon cold, influenza,\\nand sinusitis. CAUTION:\\nNot to be taken orally.\\nChamomile Sedative,\\nantiinflammatory,\\nantiseptic, and pain\\nreliever\\nHay fever, burns, acne,\\narthritis, digestive\\nproblems, sunburn, and\\nmenstrual an menopausal\\nsymptoms.\\nLavender Analgesic, antiseptic,\\ncalming/soothing\\nHeadache, depression,\\ninsomnia, stress, sprains,\\nand nausea.\\nPeppermint Pain reliever Indigestion, nausea,\\nheadache, motion\\nsickness, and muscle\\npain.\\nRosemary Antiseptic, stimulant,\\nand diuretic\\nIndigestion, gas, bronchitis,\\nfluid retention, and\\ninfluenza. CAUTION: Don’t\\nuse if pregnant or have\\nepilepsy or hypertension.\\nTarragon Diuretic, laxative,\\nantispasmodic, and\\nstimulant\\nMenstrual and menopausal\\nsymptoms, gas, and\\nindigestion. CAUTION:\\nDon’t use if pregnant.\\nTea tree Antiseptic and soothing Common cold, bronchitis,\\nabscesses, acne, vaginitis,\\nand burns.\\nThyme Stimulant, antiseptic,\\nantibacterial, and\\nantispasmodic\\nCough, laryngitis,\\ndiarrhea, gas, and\\nintestinal worms.\\nCAUTION: Don’t use if\\npregnant or have\\nhypertension.392 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nOrigins\\nAromatic plants have been employed for their\\nhealing, preservative, and pleasurable qualities\\nthroughout recorded history in both the East and\\nWest. As early as 1500 B.C. the ancient Egyptians\\nused waters, oils, incense, resins, and ointments\\nscented with botanicals for their religious ceremonies.\\nThere is evidence that the Chinese may have\\nrecognized the benefits of herbal and aromatic reme-\\ndies much earlier than this. The oldest known herbal\\ntext, Shen Nung’sPen Ts’ao(c. 2700-3000\\nB.C.) cata-\\nlogs over 200 botanicals. Ayurveda, a practice of tra-\\nditional Indian medicine that dates back over 2,500\\nyears, also used aromatic herbs for treatment.\\nThe Romans were well-known for their use of\\nfragrances. They bathed with botanicals and integrated\\nthem into their state and religious rituals. So did the\\nGreeks, with a growing awareness of the medicinal\\nproperties of herbs, as well. Greek physician and sur-\\ngeon Pedanios Dioscorides, whose renown herbal text\\nDe Materia Medica(60\\nA.D.) was the standard textbook\\nfor Western medicine for 1,500 years, wrote extensively\\non the medicinal value of botanical aromatics. The\\nMedica contained detailed information on over 500\\nplants and 4,740 separate medicinal uses for them,\\nincluding an entire section on aromatics.\\nWritten records of herbal distillation are found as\\nearly as the first century\\nA.D., and around 1000A.D.,\\nthe noted Arab physician and naturalist Avicenna\\ndescribed the distillation of rose oil from rose petals,\\nand the medicinal properties of essential oils in his\\nwritings. However, it wasn’t until 1937, when French\\nchemist Rene ´ -Maurice Gattefosse ´ published\\nAromatherapie: Les Huiles essentielles, hormones ve´ge´\\ntales, that aromatherapie, or aromatherapy, was\\nintroduced in Europe as a medical discipline.\\nGattefosse´ , who was employed by a French perfu-\\nmeur, discovered the healing properties of lavender\\noil quite by accident when he suffered a severe burn\\nwhile working and used the closest available liquid,\\nlavender oil, to soak it in.\\nIn the late 20th century, French physician Jean\\nValnet used botanical aromatics as a front line\\nAromatic substances\\nNasal cavity\\nOlfactory bulb\\nOlfactory\\nneurons\\nLimbic system of the brain\\nAs a holistic therapy, aromatherapy is believed to benefit both the mind and body. Here, the aromatic substances from a flower\\nstimulates the olfactory bulb and neurons. The desired emotional response (such as relaxation) is activated from the limbic\\nsystem of the brain. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 393\\nAromatherapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='treatment for wounded soldiers in World War II. He\\nwrote about his use of essential oils and their healing\\nand antiseptic properties, in his 1964 book\\nAromatherapie, traitement des maladies par les essences\\ndes plantes, which popularized the use of essential oils\\nfor medical and psychiatric treatment throughout\\nFrance. Later, French biochemist Mauguerite Maury\\npopularized the cosmetic benefits of essential oils, and\\nin 1977 Robert Tisserand wrote the first English lan-\\nguage book on the subject,The Art of Aromatherapy,\\nwhich introduced massage as an adjunct treatment to\\naromatherapy and sparked its popularity in the\\nUnited Kingdom.\\nIn aromatherapy, essential oils are carefully\\nselected for their medicinal properties. As essential oils\\nare absorbed into the bloodstream through application\\nto the skin or inhalation, their active components trig-\\nger certain pharmalogical effects (e.g., pain relief ).\\nIn addition to physical benefits, aromatherapy\\nhas strong psychological benefits. The volatility of an\\noil, or the speed at which it evaporates in open air, is\\nthought to be linked to the specific psychological effect\\nof an oil. As a rule of thumb, oils that evaporate\\nquickly are considered emotionally uplifting, while\\nslowly-evaporating oils are thought to have a calming\\neffect.\\nEssential oils commonly used in aromatherapy\\ntreatment include:\\n/C15Roman chamomile (Chamaemelum nobilis). An anti-\\ninflammatory and analgesic. Useful in treatingotitis\\nmedia (earache), skin conditions, menstrual pains,\\nand depression.\\n/C15Clary sage (Salvia sclarea). This natural astringent is\\nnot only used to treat oily hair and skin, but is also\\nsaid to be useful in regulating the menstrual cycle,\\nimproving mood, and controlling high blood pres-\\nsure. Clary sage should not be used by pregnant\\nwomen.\\n/C15Lavender (Lavandula officinalis). A popular aro-\\nmatherapy oil which mixes well with most essential\\noils, lavender has a wide range of medicinal and\\ncosmetic applications, including treatment of insect\\nbites, burns, respiratory infections, intestinal discom-\\nfort, nausea, migraine, insomnia, depression, and\\nstress.\\n/C15Myrtle (Myrtus communis). Myrtle is a fungicide,\\ndisinfectant, and antibacterial. It is often used in\\nsteam aromatherapy treatments to alleviate the\\nsymptoms ofwhooping cough, bronchitis, and other\\nrespiratory infections.\\n/C15Neroli (bitter orange), (Citrus aurantium). Citrus oil\\nextracted from bitter orange flower and peel and\\nused to treatsore throat, insomnia, and stress and\\nanxiety-related conditions.\\n/C15Sweet orange (Citrus sinensis). An essential oil used\\nto treat stomach complaints and known for its\\nreported ability to lift the mood while relieving stress.\\n/C15Peppermint (Mentha piperita). Relaxes and soothes\\nthe stomach muscles and gastrointestinal tract.\\nPeppermint’s actions as an anti-inflammatory, anti-\\nseptic, and antimicrobial also make it an effective\\nskin treatment, and useful in fighting cold and flu\\nsymptoms.\\nKEY TERMS\\nAntiseptic— Inhibits the growth of microorganisms.\\nBactericidal— An agent that destroys bacteria (e.g.,\\nStaphylococci aureus, Streptococci pneumoniae,\\nEscherichia coli, Salmonella enteritidis).\\nCarrier oil— An oil used to dilute essential oils for\\nuse in massage and other skin care applications.\\nContact dermatitis— Skin irritation as a result of con-\\ntact with a foreign substance.\\nEssential oil— A volatile oil extracted from the\\nleaves, fruit, flowers, roots, or other components of\\na plant and used in aromatherapy, perfumes, and\\nfoods and beverages.\\nHolistic— A practice of medicine that focuses on the\\nwhole patient, and addresses the social, emotional,\\nand spiritual needs of a patient as well as their phy-\\nsical treatment.\\nPhototoxic— Causes a harmful skin reaction when\\nexposed to sunlight.\\nRemedy antidote— Certain foods, beverages, pre-\\nscription medications, aromatic compounds, and\\nother environmental elements that counteract the\\nefficacy of homeopathic remedies.\\nSteam distillation— A process of extracting essential\\noils from plant products through a heating and eva-\\nporation process.\\nVolatile— Something that vaporizes or evaporates\\nquickly when exposed to air.\\n394 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Rosemary ( Rosmarinus officinalis ). Stimulating\\nessential oil used to treat muscular and rheumatic\\ncomplaints, as well as low blood pressure, gastroin-\\ntestinal problems, and headaches.\\n/C15Tea tree (Melaleuca alternifolia). Has bactericidal,\\nvirucidal, fungicidal, and anti-inflammatory proper-\\nties that make it a good choice for fighting infection.\\nRecommended for treating sore throat and respira-\\ntory infections, vaginal and bladder infections,\\nwounds, and a variety of skin conditions.\\n/C15Ylang ylang (Cananga odorata). A sedative essential\\noil sometimes used to treat hypertension and\\ntachycardia.\\nEssential oils contain active agents that can have\\npotent physical effects. While some basic aromather-\\napy home treatments can be self-administered, medi-\\ncal aromatherapy should always be performed under\\nthe guidance of an aromatherapist, herbalist, massage\\ntherapist, nurse, or physician.\\nInhalation\\nThe most basic method of administering aroma-\\ntherapy is direct or indirect inhalation of essential\\noils. Several drops of an essential oil can be applied\\nto a tissue or handkerchief and gently inhaled. A\\nsmall amount of essential oil can also be added to a\\nbowl of hot water and used as a steam treatment.\\nThis technique is recommended when aromatherapy\\nis used to treat respiratory and/or skin conditions.\\nAromatherapy steam devices are also available com-\\nmercially. A warm bath containing essential oils can\\nhave the same effect as steam aromatherapy, with\\nthe added benefit of promoting relaxation. When\\nused in a bath, water should be lukewarm rather\\nthan hot to slow the evaporation of the oil.\\nEssential oil diffusers, vaporizers, and light bulb\\nrings can be used to disperse essential oils over a large\\narea. These devices can be particularly effective in\\naromatherapy that uses essential oils to promote a\\nhealthier home environment. For example, eucalyptus\\nand tea tree oil are known for their antiseptic qualities\\nand are frequently used to disinfect sickrooms, and\\ncitronella and geranium can be useful in repelling\\ninsects.\\nDirect application\\nBecause of their potency, essential oils are diluted\\nin a carrier oil or lotion before being applied to the\\nskin to prevent an allergic skin reaction. The carrier oil\\ncan be a vegetable or olive based one, such as wheat\\ngerm or avocado. Light oils, such as safflower, sweet\\nalmond, grapeseed, hazelnut, apricot seed, or peach\\nkernel, may be absorbed more easily by the skin.\\nStandard dilutions of essential oils in carrier oils\\nrange from 2–10%. However, some oils can be used\\nat higher concentrations, and others should be diluted\\nfurther for safe and effective use. The type of carrier\\noil used and the therapeutic use of the application\\nmay also influence how the essential oil is mixed.\\nIndividuals should seek guidance from a healthcare\\nprofessional and/or aromatherapist when diluting\\nessential oils.\\nMassage is a common therapeutic technique\\nused in conjunction with aromatherapy to both\\nrelax the body and thoroughly administer the essen-\\ntial oil treatment. Essential oils can also be used in\\nhot or cold compresses and soaks to treat muscle\\naches and pains (e.g., lavender and ginger). As a\\nsore throat remedy, antiseptic and soothing essential\\noils (e.g., tea tree and sage) can be thoroughly\\nmixed with water and used as a gargle or\\nmouthwash.\\nInternal use\\nSome essential oils can be administered internally\\nin tincture, infusion, or suppository form to treat cer-\\ntain symptoms or conditions; however, this treatment\\nshould never be self-administered. Essential oils\\nshould only be taken internally under the supervision\\nof a qualified healthcare professional.\\nAs non-prescription botanical preparations, the\\nessential oils used in aromatherapy are typically not\\npaid for by health insurance. The self-administered\\nnature of the therapy controls costs to some degree.\\nAromatherapy treatmen t sessions from a profes-\\nsional aromatherapist are not covered by health\\ninsurance in most cases, although aromatherapy per-\\nformed in conjunction with physical therapy, nur-\\nsing, therapeutic massage,or other covered medical\\nservices may be. Individuals should check with their\\ninsurance provider to find out about their specific\\ncoverage.\\nThe adage ‘‘You get what you pay for’’ usually\\napplies when purchasing essential oils, as bargain oils\\nare often adulterated, diluted, or synthetic. Pure essen-\\ntial oils can be expensive; and the cost of an oil will\\nvary depending on its quality and availability.\\nPreparations\\nThe method of extracting an essential oil varies by\\nplant type. Common methods include water or steam\\ndistillation and cold pressing. Quality essential oils\\nGALE ENCYCLOPEDIA OF MEDICINE 395\\nAromatherapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='should be unadulterated and extracted from pure\\nbotanicals. Many aromatherapy oils on the market\\nare synthetic and/or diluted, contain solvents, or are\\nextracted from botanicals grown with pesticides or\\nherbicides. To ensure best results, essential oils should\\nbe made from pure organic botanicals and labeled by\\ntheir full botanical name. Oils should always be stored\\ndark bottles out of direct light.\\nBefore using essential oils on the skin, indivi-\\nduals should perform a skin patch test by applying\\na small amount of the diluted oil behind the wrist\\nand covering it with a bandage or cloth for up to\\n12 hours. If redness or irri tation occurs, the oil\\nshould be diluted further and a second skin test\\nperformed, or it should be avoided altogether.\\nIndividuals should never apply undiluted essential\\noils to the skin unless advised to do so by a trained\\nhealthcare professional.\\nPrecautions\\nIndividuals should only take essential oils\\ninternally under the guidance and close supervision\\nof a health-care professional. Some oils, such as\\neucalyptus, wormwood, and sage, should never be\\ntaken internally. Many essential oils are highly\\ntoxic and should never be used at all in aromather-\\napy. These include (but are not limited to) bitter\\nalmond, pennyroyal, mustard, sassafras, rue, and\\nmugwort.\\nCitrus-based essential oils, including bitter and\\nsweet orange, lime, lemon, grapefruit, and tangerine,\\nare phototoxic, and exposure to direct sunlight should\\nbe avoided for at least four hours after their\\napplication.\\nOther essential oils, such as cinnamon leaf,\\nblack pepper, juniper, lemon, white camphor,\\neucalyptus blue gum, ginger, peppermint, pine\\nneedle, and thyme can be extremely irritating to\\nthe skin if applied in high enough concentration\\nor without a carrier oil or lotion. Caution should\\nalways be exercised when applying essential oils\\ntopically. Individuals should never apply undi-\\nluted essential oils to the skin unless directed to\\ndo so by a trained healthcare professional and/or\\naromatherapist.\\nIndividuals taking homeopathic remedies should\\navoid black pepper, camphor, eucalyptus, and pepper-\\nmint essential oils. These oils may act as a remedy\\nantidote to the homeopathic treatment.\\nChildren should only receive aromatherapy treat-\\nment under the guidance of a trained aromatherapist\\nor healthcare professional. Some essential oils may not\\nbe appropriate for treating children, or may require\\nadditional dilution before use on children.\\nCertain essential oils should not be used by preg-\\nnant or nursing women or by people with specific ill-\\nnesses or physical conditions. Individuals suffering\\nfrom any chronic or acute health condition should\\ninform their healthcare provider before starting treat-\\nment with any essential oil.\\nAsthmatic individuals should not use steam inha-\\nlation for aromatherapy, as it can aggravate their\\ncondition.\\nEssential oils are flammable, and should be kept\\naway from heat sources.\\nSide effects\\nSide effects vary by the type of essential oil used.\\nCitrus-based essential oils can cause heightened sensi-\\ntivity to sunlight. Essential oils may also causecontact\\ndermatitis, an allergic reaction characterized by red-\\nness and irritation. Anyone experiencing an allergic\\nreaction to an essential oil should discontinue its use\\nand contact their healthcare professional for further\\nguidance. Individuals should do a small skin patch test\\nwith new essential oils before using them extensively\\n(see ‘‘Preparations’’ above).\\nResearch and general acceptance\\nThe antiseptic and bactericidal qualities of some\\nessential oils (such as tea tree and peppermint) and\\ntheir value in fighting infection has been detailed\\nextensively in both ancient and modern medical\\nliterature.\\nRecent research in mainstream medical literature\\nhas also shown that aromatherapy has a positive\\npsychological impact on patients, as well. Several\\nclinical studies involvin g both post-operative and\\nchronically ill subjects showed that massage with\\nessential oils can be helpful in improving emotional\\nwell-being, and consequently, promoting the healing\\nprocess.\\nToday, the use of holistic aromatherapy is widely\\naccepted in Europe, particularly in Great Britain,\\nwhere it is commonly used in conjunction with mas-\\nsage as both a psychological and physiological healing\\ntool. In the United States, where aromatherapy is\\noften misunderstood as solely a cosmetic treatment,\\nthe mainstream medical community has been slower\\nto accept it.\\n396 GALE ENCYCLOPEDIA OF MEDICINE\\nAromatherapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nBOOKS\\nSchnaubelt, Kurt.Medical Aromatherapy: Healing With\\nEssential Oils.Berkeley, CA: Frog Ltd, 1999.\\nORGANIZATIONS\\nNational Association of Holistic Aromatherapy. 836 Hanley\\nIndustrial Court, St. Louis, MO 63144. (888) ASK-\\nNAHA. .\\nPaula Anne Ford-Martin\\nArrhythmias\\nDefinition\\nAn arrhythmia is an abnormality in the heart’s\\nrhythm, or heartbeat pattern. The heartbeat can be\\ntoo slow, too fast, have extra beats, skip a beat, or\\notherwise beat irregularly.\\nDescription\\nArrhythmias are deviations from the normal\\ncadence of the heartbeat, which cause the heart to\\npump improperly. The normal heartbeat starts in the\\nright atrium, where the heart’s natural pacemaker (the\\nsinus node) sends an electrical signal to the center of\\nthe heart to the atrioventricular node. The atrioven-\\ntricular node then sends signals into the main pumping\\nchamber to make the ventricle contract. Arrhythmias\\noccur when the heartbeat starts in a part of the heart\\nother than the sinus node, an abnormal rate or rhythm\\ndevelops in the sinus node, or a heart conduction\\n‘‘block’’ prevents the electrical signal from traveling\\ndown the normal pathway.\\nMore than four million Americans have arrhyth-\\nmias, most of which are h armless. Middle-aged\\nadults commonly experience arrhythmias. As people\\nage, the probability of experiencing an arrhythmia\\nincreases. Arrhythmias often occur in people who\\ndo not have heart disease. In people with heart dis-\\nease, it is usually the heartdisease which is danger-\\nous, not the arrhythmia. Arrhythmias often occur\\nduring and after heart attacks. Some types of\\narrhythmias, such as ventricular tachycardia ,a r e\\nserious and even life threatening. In the United\\nStates, arrhythmias are the primary cause ofsudden\\ncardiac death , accounting for more than 350,000\\ndeaths each year.\\nSlow heart rates (less than 60 beats per minute) are\\ncalled bradycardias, while fast heart rates (more than\\n100 beats per minute) are called tachycardias.\\nBradycardia can result in poor circulation of blood,\\nand, hence, a lack of oxygen throughout the body,\\nespecially the brain. Tachycardias also can compro-\\nmise the heart’s ability to pump effectively because the\\nventricles do not have enough time to completely fill.\\nArrhythmias are characterized by their site of\\norigin: the atria or the ventricles. Supraventricular\\narrhythmias occur in the upper areas of the heart and\\nare less serious than ventricular arrhythmias.\\nVentricular fibrillationis the most serious arrhythmia\\nand is fatal unless medical help is immediate.\\nCauses and symptoms\\nIn many cases, the cause of an arrhythmia is\\nunknown. Known causes of arrhythmias include\\nheart disease, stress, caffeine, tobacco, alcohol, diet\\npills, anddecongestants in cough and cold medicines.\\nSymptoms of an arrhythmia include a fast heart-\\nbeat, pounding or fluttering chest sensations, skipping\\na heartbeat, ‘‘flip-flops,’’dizziness, faintness,shortness\\nof breath, and chest pains.\\nDiagnosis\\nExamination with a stethoscope, electrocardio-\\ngrams, and electrophysiologic studies is used to diag-\\nnose arrhythmias. Sometimes arrhythmias can be\\nidentified by listening to the patient’s heart through\\na stethoscope, but, sincearrhythmias are not always\\npresent, they may not occur during the physical\\nexam.\\nKEY TERMS\\nBradycardia— A slow heart rate. Bradycardia is one\\nof the two types of arrhythmia\\nElectrocardiogram— A test which uses electric sen-\\nsors placed on the body to monitor the heartbeat.\\nElectrophysiology study— A test using cardiac\\ncatheterization to stimulate an electrical current\\nto provoke an arrhythmia. The test identifies the\\norigin of arrhythmias and is used to test the effec-\\ntiveness of antiarrhythmic drugs.\\nTachycardia— A fast heart rate. Tachycardia is one\\nof the two types of arrhythmia.\\nGALE ENCYCLOPEDIA OF MEDICINE 397\\nArrhythmias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='An electrocardiogram (ECG) shows the heart’s\\nactivity and may reveal a lack of oxygen from poor\\ncirculation (ischemia). Electrodes covered with con-\\nducting jelly are placed on the patient’s chest, arms,\\nand legs. They send impulses of the heart’s activity\\nthrough an electrical activity monitor (oscilloscope)\\nto a recorder that traces them on paper. The test\\ntakes about 10 minutes and is performed in a physi-\\ncian’s office. Another type of ECG, commonly known\\nas theexercise stress test, measures how the heart and\\nblood vessels respond to exertion while the patient is\\nexercising on a treadmill or a stationary bike. This test\\nis performed in a physician’s office or an exercise\\nlaboratory and takes 15-30 minutes. Other types of\\nECGs include 24-hour ECG monitoring and trans-\\ntelephonic monitoring. In 24-hour ECG (Holter)\\nmonitoring, the patient wears a small, portable tape\\nrecorder connected to disks on his/her chest that\\nrecord the heart’s rhythm during daily activities.\\nTranstelephonic monitoring can identify arrhythmias\\nthat occur infrequently. Similar toHolter monitoring,\\ntranstelephonic monitoring can continue for days or\\nweeks, and it enables patients to send the ECG via\\ntelephone to a monitoring station when an arrhythmia\\nis felt, or the patient can store the information in the\\nrecorder and transmit it later.\\nElectrophysiologic studies are invasive proce-\\ndures performed in a hospital to identify the origin of\\nserious arrhythmias and responses to various treat-\\nments. They involvecardiac catheterization, in which\\ncatheters tipped with electrodes are passed from a vein\\nin the arm or leg through the blood vessels into the\\nheart. The electrodes record impulses in the heart,\\nhighlighting where the arrhythmia starts. During the\\nprocedure, physicians can test the effects of various\\ndrugs by provoking an arrhythmia through the elec-\\ntrodes and trying different drugs. The procedure takes\\none to three hours, during which the patient is awake\\nbut mildly sedated. Local anesthetic is injected at the\\ncatheter insertion sites.\\nTreatment\\nMany arrhythmias do not require any treatment.\\nFor serious arrhythmias, treating the underlying heart\\ndisease sometimes controls the arrhythmia. In some\\ncases, the arrhythmia itself is treated with drugs, elec-\\ntrical shock (cardioversion), automatic implantable\\ndefibrillators, artificialpacemakers, catheter ablation,\\nor surgery. Supraventricular arrhythmias often can be\\ntreated with drug therapy. Ventricular arrhythmias\\nare more complex to treat.\\nDrug therapy can manage many arrhythmias, but\\nfinding the right drug and dose requires care and can\\ntake some time. Common drugs for suppressing\\narrhythmias include beta-blockers, calcium channel\\nblockers, quinidine, digitalis preparations, and procai-\\nnamide. Because of their potential serious side effects,\\nstronger, desensitizing drugs are used only to treat life-\\nthreatening arrhythmias. All of the drugs used to treat\\narrhythmias have possible side effects, ranging from\\nmild complications with beta-blockers and calcium\\nchannel blockers to more serious effects of desensitiz-\\ning drugs that can, paradoxically, cause arrhythmias\\nor make them worse. Response to drugs is usually\\nmeasured by ECG, Holter monitor, or electrophysio-\\nlogic study.\\nIn emergency situations, cardioversion ordefibril-\\nlation (the application of an electrical shock to the\\nchest wall) is used. Cardioversion restores the heart\\nto its normal rhythm. It is followed by drug therapy to\\nprevent recurrence of the arrhythmia.\\nArtificial pacemakers that send electrical signals\\nto make the heart beat properly can be implanted\\nunder the skin during a simple operation. Leads from\\nthe pacemaker are anchored to the right side of the\\nheart. Pacemakers are used to correct bradycardia and\\nare sometimes used after surgical or catheter ablation.\\nAutomatic implantable defibrillators correct life-\\nthreatening ventricular arrhythmias by recognizing\\nthem and then restoring a normal heart rhythm by\\npacing the heart or giving it an electric shock. They\\nare implanted within the chest wall without major\\nsurgery and store information for future evaluation\\nby physicians. Automatic implantable defibrillators\\nhave proven to be more effective in saving lives than\\ndrugs alone. They often are used in conjunction with\\ndrug therapy.\\nAblation, a procedure to alter or remove the\\nheart tissue causing the arrhythmia in order to pre-\\nvent a recurrence, can be performed through a cathe-\\nt e ro rs u r g e r y .S u p r a v e n t r i c u l a rt a c h y c a r d i ac a nb e\\ntreated successfully with ablation. Catheter ablation\\nis performed in a catheterization laboratory with the\\npatient under sedation. A catheter equipped with a\\ndevice that maps the heart’s electrical pathways is\\ninserted into a vein and is threaded into the heart.\\nHigh-frequency radio waves are then used to remove\\nthe pathway(s) causing the arrhythmia. Surgical\\nablation is similar in principle but it is performed in\\na hospital, using a cold probe instead of radio waves\\nto destroy tissue. Ablation treatments are used when\\nmedications fail.\\nMaze surgery treats atrial fibrillation by making\\nmultiple incisions through the atrium to allow electri-\\ncal impulses to move effectively. This is often\\n398 GALE ENCYCLOPEDIA OF MEDICINE\\nArrhythmias'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='recommended for patients who have not responded to\\ndrugs or cardioversion.\\nAlternative treatment\\nSince some arrhythmias can be life threatening, a\\nconventional medical doctor should always be con-\\nsulted first. Acupuncture can correct an insignificant\\nnumber (1.5%) of atrial fibrillation cases. For new,\\nminor arrhythmias, acupuncture may be effective in\\nup to 70% of cases, but this figure may not differ\\nmuch from placebo thera py. Both western and\\nChinese herbal remedies are also used in the treat-\\nment of arrhythmias. Since hawthorn (Crataegus lae-\\nvigata) dilates the blood vessels and stimulates the\\nheart muscle, it may help to stabilize arrhythmias. It\\nis gentle and appropriate for home use, unlike fox-\\nglove (Digitalis purpurea), an herb whose action on\\nthe heart is too potent for use without supervision by\\na qualified practitioner. Homeopathic practitioners\\nmay prescribe remedies such asLachesis and aconite\\nor monkshood ( Aconitum napellus ) to treat mild\\narrhythmias.\\nPrognosis\\nAdvances in diagnostic techniques, new drugs,\\nand medical technology have extended the lives of\\nmany patients with serious arrhythmias. Diagnostic\\ntechniques enable physicians to accurately identify\\narrhythmias, while new drugs, advances in pacemaker\\ntechnology, the development of implantable defibril-\\nlators, and progress in ablative techniques offer effec-\\ntive treatments for many types of arrhythmia.\\nPrevention\\nSome arrhythmias can be prevented by managing\\nstress, controllinganxiety, and avoiding caffeine, alco-\\nhol, decongestants,cocaine, and cigarettes.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nArt therapy\\nDefinition\\nArt therapy, sometimes called creative arts ther-\\napy or expressive arts therapy, encourages people to\\nexpress and understand emotions through artistic\\nexpression and through the creative process.\\nPurpose\\nArt therapy provides the client-artist with critical\\ninsight into emotions, thoughts, and feelings. Key\\nbenefits of the art therapy process include:\\n/C15Self-discovery. At its most successful, art therapy\\ntriggers an emotional catharsis.\\n/C15Personal fulfillment. The creation of a tangible\\nreward can build confidence and nurture feelings of\\nself-worth. Personal fulfillment comes from both the\\ncreative and the analytical components of the artistic\\nprocess.\\n/C15Empowerment. Art therapy can help people visually\\nexpress emotions and fears that they cannot express\\nthrough conventional means, and can give them\\nsome sense of control over these feelings.\\n/C15Relaxation and stress relief. Chronic stress can be\\nharmful to both mind and body. Stress can weaken\\nand damage the immune system, can causeinsomnia\\nand depression, and can trigger circulatory problems\\n(like high blood pressure and irregular heartbeats).\\nWhen used alone or in combination with other\\nrelaxation techniques such as guided imagery, art\\ntherapy can effectively relieve stress.\\n/C15Symptom relief and physicalrehabilitation. Art the-\\nrapy can also help patients cope withpain. This\\ntherapy can promote physiological healing when\\npatients identify and work through anger, resent-\\nment, and other emotional stressors. It is often\\nprescribed to accompany pain control therapy for\\nchronically and terminally ill patients.\\nDescription\\nOrigins\\nHumans have expressed themselves with symbols\\nthroughout history. Masks, ritual pottery, costumes,\\nother objects used in rituals, cave drawings, Egyptian\\nhieroglyphics, and Celtic art and symbols are all visual\\nrecords of self-expression and communication\\nthrough art. Art has also been associated spiritual\\npower, and artistic forms such as the Hindu and\\nGALE ENCYCLOPEDIA OF MEDICINE 399\\nArt therapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Buddhist mandala and Native American sand paint-\\ning are considered powerful healing tools.\\nIn the late nineteenth century, French psychia-\\ntrists Ambrose Tardieu and Paul-Max Simon both\\npublished studies on the similar characteristics of and\\nsymbolism in the artwork of the mentally ill. Tardieu\\nand Simon viewed art therapy as an effective diagnos-\\ntic tool to identify specific types of mental illness or\\ntraumatic events. Later, psychologists would use this\\ndiagnostic aspect to develop psychological drawing\\ntests (the Draw-A-Man test, the Draw-A-Person\\nQuestionnaire [DAP.Q]) and projective personality\\ntests involving visual symbol recognition (e.g., the\\nRorschach Inkblot Test, the Thematic Apperception\\nTest [TAT], and the Holtzman Inkblot Test [HIT]).\\nThe growing popularity of milieu therapies at\\npsychiatric institutions in the twentieth century was\\nan important factor in the development of art therapy\\nin the United States. Milieu therapies (or environmen-\\ntal therapy) focus on putting the patient in a controlled\\ntherapeutic social setting that provides the patient\\nwith opportunities to gain self-confidence and interact\\nwith peers in a positive way. Activities that encourage\\nself-discovery and empowerment such as art, music,\\ndance, and writing are important components of this\\napproach.\\nEducator and therapist Margaret Naumburg was\\na follower of both Freud and Jung, and incorporated\\nart into psychotherapy as a means for her patients to\\nvisualize and recognize the unconscious. She founded\\nthe Walden School in 1915, where she used students’\\nartworks in psychological counseling. She published\\nextensively on the subject and taught seminars on the\\ntechnique at New York University in the 1950s.\\nToday, she is considered the founder of art therapy\\nin the United States.\\nIn the 1930s, Karl, William, and Charles Menninger\\nintroduced an art therapy program at their Kansas-\\nbased psychiatric hospital, the Menninger Clinic. The\\nMenninger Clinic employed a number of artists in resi-\\ndence in the following years, and the facility was also\\nconsidered a leader in the art therapy movement\\nthrough the 1950s and 60s. Other noted art therapy\\npioneers who emerged in the 50s and 60s include Edith\\nKramer, Hanna Yaxa Kwiatkowska (National Institute\\nof Mental Health), and Janie Rhyne.\\nArt therapy, sometimes called expressive art or art\\npsychology, encourages self-discovery and emotional\\ngrowth. It is a two part process, involving both the\\ncreation of art and the discovery of its meaning.\\nRooted in Freud and Jung’s theories of the subcon-\\nscious and unconscious, art therapy is based on the\\nassumption that visual symbols and images are the\\nmost accessible and natural form of communication\\nto the human experience. Patients are encouraged to\\nvisualize, and then create, the thoughts and emotions\\nthat they cannot talk about. The resulting artwork is\\nthen reviewed and its meaning interpreted by the\\npatient.\\nThe ‘‘analysis’’ of the artwork produced in art\\ntherapy typically allows patients to gain some level of\\ninsight into their feelings and lets them to work\\nthrough these issues in a constructive manner. Art\\ntherapy is typically practiced with individual, group,\\nor family psychotherapy (talk therapy). While a thera-\\npist may provide critical guidance for these activities, a\\nkey feature of effective art therapy is that the patient/\\nartist, not the therapist, directs the interpretation of\\nthe artwork.\\nArt therapy can be a particularly useful treatment\\ntool for children, who frequently have limited lan-\\nguage skills. By drawing or using other visual means\\nto express troublesome feelings, younger patients\\ncan begin to address these issues, even if they cannot\\nidentify or label these emotions with words. Art\\ntherapy is also valuable for adolescents and adults\\nwho are unable or unwilling to talk about thoughts\\nand feelings.\\nBeyond its use in mental health treatment, art\\ntherapy is also used with traditional medicine to\\ntreat organic diseases and conditions. The connec-\\ntion between mental and physical health is well\\ndocumented, and art therapy can promote healing\\nby relieving stress and allowing the patient to\\ndevelop coping skills.\\nArt therapy has traditionally centered on visual\\nmediums, like paintings, sculptures, and drawings.\\nSome mental healthcare providers have now\\nKEY TERMS\\nCatharsis— Therapeutic discharge of emotional\\ntension by recalling past events.\\nMandala— A design, usually circular, that appears\\nin religion and art. In Buddhism and Hinduism, the\\nmandala has religious ritual purposes and serves as\\na yantra (a geometric emblem or instrument of\\ncontemplation).\\nOrganic illness— A physically, biologically based\\nillness.\\n400 GALE ENCYCLOPEDIA OF MEDICINE\\nArt therapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='broadened the definition to include music, film, dance,\\nwriting, and other types of artistic expression.\\nArt therapy is often one part of a psychiatric\\ninpatient or outpatient treatment program, and can\\ntake place in individual or group therapy sessions.\\nGroup art therapy sessi ons often take place in\\nhospital, clinic, shelter, and community program\\nsettings. These group therapy sessions can have\\nthe added benefits of positive social interaction,\\nempathy, and support from peers. The client-artist\\ncan learn that others have similar concerns and\\nissues.\\nPreparations\\nBefore starting art therapy, the therapist may\\nhave an introductory session with the client-artist to\\ndiscuss art therapy techniques and give the client the\\nopportunity to ask questions about the process. The\\nclient-artist’s comfort with the artistic process is criti-\\ncal to successful art therapy.\\nThe therapist ensures that appropriate materials\\nand space are available for the client-artist, as well as\\nan adequate amount of time for the session. If the\\nindividual artist is exploring art as therapy without\\nthe guidance of a trained therapist, adequate materi-\\nals, space, and time are still important factors in a\\nsuccessful creative experience.\\nThe supplies used in art therapy are limited only\\nby the artist’s (and/or therapist’s) imagination. Some\\nof the materials often used include paper, canvas,\\nposter board, assorted paints, inks, markers, pencils,\\ncharcoals, chalks, fabrics, string, adhesives, clay,\\nwood, glazes, wire, bendable metals, and natural\\nitems (like shells, leaves, etc.). Providing artists with\\na variety of materials in assorted colors and textures\\ncan enhance their interest in the process and may\\nresult in a richer, more diverse exploration of their\\nemotions in the resulting artwork. Appropriate tools\\nsuch as scissors, brushes, erasers, easels, supply trays,\\nglue guns, smocks or aprons, and cleaning materials\\nare also essential.\\nAn appropriate workspace should be available for\\nthe creation of art. Ideally, this should be a bright,\\nquiet, comfortable place, with large tables, counters,\\nor other suitable surfaces. The space can be as simple\\nas a kitchen or office table, or as fancy as a specialized\\nartist’s studio.\\nThe artist should have adequate time to become\\ncomfortable with and explore the creative process.\\nThis is especially true for people who do not consider\\nthemselves ‘‘artists’’ and may be uncomfortable with\\nthe concept. If performed in a therapy group or one-\\non-one session, the art therapist should be available to\\nanswer general questions about materials and/or the\\ncreative process. However, the therapist should be\\ncareful not to influence the creation or interpretation\\nof the work.\\nPrecautions\\nArt materials and techniques should match the\\nage and ability of the client. People with impairments,\\nsuch as traumatic brain injury or an organic neurolo-\\ngical condition, may have difficulties with the self-\\ndiscovery portion of the art therapy process depending\\non their level of functioning. However, they may still\\nbenefit from art therapy through the sensory stimula-\\ntion it provides and the pleasure they get from artistic\\ncreation.\\nWhile art is accessible to all (with or without a\\ntherapist to guide the process), it may be difficult to\\ntap the full potential of the interpretive part of art\\ntherapy without a therapist to guide the process.\\nWhen art therapy is chosen as a therapeutic tool\\nto cope with a physical condition, it should be\\ntreated as a supplemental therapy and not as a\\nsubstitute for conventional medical treatments.\\nResearch and general acceptance\\nA wide body of literature supports the use of art\\ntherapy in a mental health capacity. And as the mind-\\nbody connection between psychological well-being\\nand physical health is further documented by studies\\nin the field, art therapy gains greater acceptance by\\nmainstream medicine as a therapeutic technique for\\norganic illness.\\nResources\\nBOOKS\\nGanim, Barbara.Art and Healing: Using expressive art\\ntoheal your body, mind, and spirit.New York: Three\\nRivers Press, 1999.\\nORGANIZATIONS\\nAmerican Art Therapy Association.1202 Allanson Rd.,\\nMundelein, IL 60060-3808. 888-290-0878 or 847-949-\\n6064. Fax: 847-566-4580. E-mail: arttherapy@ntr.net\\n.\\nPaula Anne Ford-Martin\\nArterial blood gas analysis see Blood gas\\nanalysis\\nGALE ENCYCLOPEDIA OF MEDICINE 401\\nArt therapy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Arterial embolism\\nDefinition\\nAn embolus is a blood clot, bit of tissue or\\ntumor, gas bubble, or other foreign body that cir-\\nculates in the blood stream until it becomes stuck in\\na blood vessel.\\nDescription\\nWhen a blood clot develops in an artery and\\nremains in place, it is called a thrombosis. If all or\\npart of the blockage breaks away and lodges in\\nanother part of the artery, it is called anembolism.\\nBlockage of an artery in this manner can be the result\\nof a blood clot, fat cells, or an air bubble.\\nWhen an embolus blocks the flow of blood\\nin an artery, the tissues beyond the plug are\\ndeprived of normal blood flow and oxygen. This\\ncan cause severe damage and even death of the\\ntissues involved.\\nEmboli can affect any part of the body. The most\\ncommon sites are the legs and feet. When the brain is\\naffected, it is called a stroke. When the heart is\\ninvolved, it is called a heart attack or myocardial\\ninfarction (MI).\\nCauses and symptoms\\nA common cause of embolus is when an artery\\nwhose lining has become thickened or damaged,\\nusually with age, allows cholesterol to build up\\nmore easily than normal on the artery wall. If\\nsome of the cholesterol breaks off, it forms an\\nembolus. Emboli also commonly form from blood\\nclots in a heart that has been damaged from heart\\nattack or when the heart contracts abnormally from\\natrial fibrillation.\\nOther known causes are fat cells that enter the\\nblood after a major bone fracture, infected blood\\ncells, cancer cells that enter the blood stream, and\\nsmall gas bubbles.\\nSymptoms of an embolus can begin suddenly or\\nbuild slowly over time, depending on the amount of\\nblocked blood flow.\\nIf the embolus is in an arm or leg, there will be\\nmuscle pain, numbness or tingling, pale skin color,\\nlower temperature in the limb, and weakness or loss\\nof muscle function. If it occurs in an internal organ,\\nthere is usually pain and/or loss of the organ’s\\nfunction.\\nDiagnosis\\nThe following tests can be used to confirm the\\npresence of an arterial embolism:\\n/C15Electrocardiogram, also known as an EKG or ECG.\\nFor this test, patches that detect electrical impulses\\nfrom the heart are attached to the chest and extremi-\\nties. The information is displayed on a monitor\\nscreen or a paper tape in the form of waves.\\nReduced blood and oxygen supply to the heart\\nshows as a change in the shape of the waves.\\n/C15Noninvasive vascular tests. These involve measuring\\nblood pressure in various parts of the body and\\ncomparing the results from each location. When\\nthere is a decrease in blood pressure beyond what is\\nnormal between two points, a blockage is presumed\\nto be present.\\n/C15Angiography. In this procedure, a colored liquid\\nmaterial (a dye, or contrast material) that can be\\nseen with x rays is injected into the blood stream\\nthrough a small tube called a catheter. As the dye\\nfills the arteries, they are easily seen on x ray motion\\npictures. If there is a blockage in the artery, it shows\\nup as a sudden cut off in the movement of contrast\\nmaterial. Angiography is an expensive procedure\\nand does carry some risk. The catheter may cause\\na blood clot to form, blocking blood flow. There is\\nalso the risk of poking the catheter through the artery\\nor heart muscle. Some people may be allergic to the\\ndye. The risk of any of these injuries occurring is\\nsmall.\\nTreatment\\nArterial embolism can be treated with medication\\nor surgery, depending on the extent and location of the\\nblockage.\\nMedication to dissolve the clot is usually given\\nthrough a catheter directly into the affected artery. If\\nthe embolus was caused by a blood clot, medications\\nthat thin the blood will help reduce the risk of another\\nembolism.\\nKEY TERMS\\nAtrial fibrillation— An arrhythmia; chaotic quiver-\\ning of the arteries.\\nThrombosis— A blockage in a blood vessel that\\nbuilds and remains in one place.\\n402 GALE ENCYCLOPEDIA OF MEDICINE\\nArterial embolism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='A surgeon can remove an embolus by making an\\nincision in the artery above the blockage and, using a\\ncatheter inserted past the embolus, drag it out through\\nthe incision.\\nIf the condition is severe, a surgeon may elect to\\nbypass the blocked vessel by grafting a new vessel in its\\nplace.\\nPrognosis\\nAn arterial embolism is serious and should be\\ntreated promptly to avoid permanent damage to the\\naffected area. The outcome of any treatment depends\\non the location and seriousness of the embolism. New\\narterial emboli can form even after successful treat-\\nment of the first event.\\nPrevention\\nPrevention may include diet changes to reduce\\ncholesterol levels, medications to thin the blood, and\\npracticing an active, healthy lifestyle.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nOTHER\\n‘‘Arterial Embolism.’’ HealthAnswers.com. .\\nDorothy Elinor Stonely\\nArteriogram see Angiography\\nArteriography see Angiography\\nArteriosclerosis see Atherosclerosis\\nArteriovenous fistula\\nDefinition\\nAn arteriovenousfistula is an abnormal channel\\nor passage between an artery and a vein.\\nDescription\\nAn arteriovenous fistula is a disruption of the nor-\\nmal blood flow pattern. Normally, oxygenated blood\\nflows to the tissue through arteries and capillaries.\\nFollowing the release of oxygen in the tissues, the\\nblood returns to the heart in veins. An arteriovenous\\nfistula is an abnormal connection of an artery and a\\nvein. The blood bypasses the capillaries and tissues, and\\nreturns to the heart. Arterial blood has a higher blood\\npressure than veins and causes swelling of veins\\ninvolved in a fistula. Although both the artery and the\\nvein retain their normal connections, the new opening\\nbetween the two will cause some arterial blood to shunt\\ninto the vein because of the blood pressure difference.\\nCauses and symptoms\\nThere are two types of arteriovenous fistulas, con-\\ngenital and acquired. A congenital arteriovenous fis-\\ntula is one that formed during fetal development. It is a\\nbirth defect. In congenital fistulas, blood vessels of the\\nlower extremity are more frequently involved than\\nother areas of the body. Congenital fistulas are not\\ncommon. An acquired arteriovenous fistula is one that\\ndevelops after a person is born. It usually occurs when\\nan artery and vein that are side-by-side are damaged\\nand the healing process results in the two becoming\\nlinked. After catheterizations, arteriovenous fistulas\\nmay occur as a complication of the arterial puncture\\nin the leg or arm. Fistulas also form without apparent\\ncause. In the case of patients on hemodialysis, physi-\\ncians perform surgery to create a fistula. These\\npatients receive many needle sticks to flush their\\nblood through dialysis machines and for routine\\nblood analysis testing. The veins used may scar and\\nbecome difficult to use. Surgery is used to connect an\\nartery and vein so that arterial blood pressure and flow\\nrate widens the vein and decreases the chance ofblood\\nclots forming inside the vein.\\nThe main symptoms of arteriovenous fistulas near\\nthe surface of the skin are bulging and discolored\\nveins. In some cases, the bulging veins can be mistaken\\nfor varicose veins. Other fistulas can cause more seri-\\nous problems depending on their location and the\\nblood vessels involved.\\nDiagnosis\\nUsing a stethoscope, a physician can detect the\\nsound of a pulse in the affected vein (bruit). The sound\\nis a distinctive to-and-fro sound. Dye into the blood can\\nbe tracked by x ray to confirm the presence of a fistula.\\nTreatment\\nSmall arteriovenous fistulas can be corrected by\\nsurgery. Fistulas in the brain or eye are very difficult to\\ntreat. If surgery is not possible or very difficult, injec-\\ntion therapy may be used. Injection therapy is the\\nGALE ENCYCLOPEDIA OF MEDICINE 403\\nArteriovenous fistula'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='injection of substances that cause the blood to clot at\\nthe site of the injection. In the case of an arteriovenous\\nfistula, the blood clot should stop the passage of blood\\nfrom the artery to the vein. Surgery is usually used to\\ncorrect acquired fistulas once they are diagnosed.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, eds.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nBerkow, Robert, ed.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nBraunwald, E.Heart Disease.Philadelphia: W. B. Saunders\\nCo., 1997.\\nJohn T. Lohr, PhD\\nArteriovenous malformations\\nDefinition\\nArteriovenous malformations are blood vessel\\ndefects that occur before birth when the fetus is grow-\\ning in the uterus (prenatal development). The blood\\nvessels appear as a tangled mass of arteries and veins.\\nThey do not possess the capillary (very fine blood\\nvessels) bed which normally exists in the common\\narea where the arteries and veins lie in close proximity\\n(artery-vein interface). An arteriovenous malforma-\\ntion (AVM) may hemorrhage, or bleed, leading to\\nserious complications that can be life-threatening.\\nDescription\\nAVMs represent an abnormal interface between\\narteries and veins. Normally, arteries carry oxyge-\\nnated blood to the body’s tissues through progres-\\nsively smaller blood vessels. The smallest are\\ncapillaries, which form a web of blood vessels (the\\ncapillary bed) through the body’s tissues. The arterial\\nblood moves through tissues by these tiny pathways,\\nexchanging its load of oxygen and nutrients for carbon\\ndioxide and other waste products produced by the\\nbody cells (cellular wastes). The blood is carried\\naway by progressively larger blood vessels, the veins.\\nAVMs lack a capillary bed and arterial blood is moved\\n(shunted) directly from the arteries into the veins.\\nAVMs can occur anywhere in the body and have\\nbeen found in the arms, hands, legs, feet, lungs, heart,\\nliver, and kidneys. However, 50% of these malforma-\\ntions are located in the brain, brainstem, and spinal\\ncord. Owing to the possibility of hemorrhaging, such\\nAVMs carry the risk of stroke,paralysis, and the loss\\nof speech, memory, or vision. An AVM that hemor-\\nrhages can be fatal.\\nApproximately three of every 100,000 people have\\na cerebral AVM and roughly 40-80% of them will\\nexperience some bleeding from the abnormal blood\\nvessels at some point. The annual risk of an AVM\\nbleeding is estimated at about 1-4%. After age 55, the\\nrisk of bleeding decreases. Pre-existing high blood pres-\\nsure or intense physical activity do not seem to be\\nassociated with AVM hemorrhage, butpregnancy and\\nlabor could cause a rupture or breaking open of a blood\\nvessel. An AVM hemorrhage is not as dangerous as an\\naneurysmal rupture. (An aneurysm is a swollen, blood\\nfilled vessel where the pressure of the blood causes the\\nwall to bulge outward.) There is an approximate 10%\\nfatality rate associated with AVM hemorrhage, com-\\npared to a 50% fatality rate for ruptured aneurysms.\\nAlthough AVMs are congenital defects, meaning\\na person is born with them, they are rarely discovered\\nbefore age 20. A genetic link has been proposed for\\nsome AVMs, but studies are only suggestive, not posi-\\ntive. The majority of AVMs are discovered in people\\nage 20-40. Medical researchers estimate that the mal-\\nformations are created during days 45-60 of fetal\\ndevelopment. A second theory suggests that AVMs\\nare primitive structures that are left over from the\\nKEY TERMS\\nCongenital— Present at the time of birth.\\nArteriovenous malformations. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n404 GALE ENCYCLOPEDIA OF MEDICINE\\nArteriovenous malformations'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='period when fetal blood circulating systems began to\\ndevelop.\\nHowever they form, AVMs have blood vessels\\nthat are abnormally fragile. The arteries that feed\\ninto the malformation are unusually swollen and thin\\nwalled. They lack the usual amount of smooth muscle\\ntissue and elastin, a fibrous connective tissue. These\\nblood vessels commonly accumulate deposits of cal-\\ncium salts and hyalin. The venous part of the malfor-\\nmation receives blood directly from the artery.\\nWithout the intervening capillary bed, the veins\\nreceive blood at a higher pressure than they were\\ndesigned to handle. This part of the malformation is\\nalso swollen (dilated) and thin walled. There is a mea-\\nsurable risk of an aneurysm forming near an AVM,\\nincreasing the threat of hemorrhage, brain damage,\\nand death. Approximately 10-15% of AVMs are\\naccompanied by saccular aneurysms, a type of aneur-\\nysm that looks like a small sac attached to the outer\\nwall of the blood vessel.\\nAlthough the malformation itself lacks capillaries,\\nthere is often an abnormal proliferation of capillaries\\nnext to the defect. These blood vessels feed into the\\nmalformation, causing it to grow larger in some cases.\\nAs the AVM receives more blood through this ‘‘steal,’’\\nadjacent brain tissue does not receive enough. These\\nareas show abnormal nerve cell growth, cell death,\\nand deposits of calcium in that area (calcification).\\nNerve cells within the malformation may demons-\\ntrate abnormal growth and are believed to be\\nnonfunctional.\\nCauses and symptoms\\nMost people do not realize that they have an\\nAVM unless it hemorrhages enough to produce symp-\\ntoms. Small AVMs are more likely to hemorrhage. If a\\nhemorrhage occurs, it produces a sudden, severehead-\\nache. The headache may be focused in one specific\\narea or it may be more general. It can be mistaken\\nfor a migraine in some cases. The headache is accom-\\npanied by other symptoms, such asvomiting, a stiff\\nneck, sleepiness, lethargy, confusion, irritability, or\\nweakness anywhere in the body. Seizures occur in\\nabout a quarter of AVM cases. A person may experi-\\nence decreased, double, or blurred vision.\\nHemorrhaging from an AVM is generally less danger-\\nous than hemorrhaging from an aneurysm, with a\\nsurvival rate of 80-90%.\\nOther symptoms occur less frequently, but some-\\ntimes appear alongside major symptoms such as the\\nsudden severe headache. Additional warning signs of a\\nbleeding AVM are impaired speech or smell,fainting,\\nfacial paralysis, a drooping eyelid, dizziness, and ring-\\ning or buzzing in the ears.\\nAlthough large AVMs are less likely to hemor-\\nrhage, they can induce symptoms based on their mass\\nalone. Large AVMs exert pressure against brain tissue,\\ncause abnormal development in the surrounding brain\\ntissue, and slow down or block blood flow.\\nHydrocephalus, a swelling of brain tissue caused by\\naccumulated fluids, may develop. The warning signs\\nassociated with a large non-bleeding AVM are similar\\nto the symptoms of a small malformation that is bleed-\\ning. Unexplained headaches, seizures, dizziness, and\\nneurological symptoms, such as sensory changes, are\\nsignals that demand medical attention.\\nDiagnosis\\nBased on the clinical symptoms such as severe\\nheadache and neurological problems, and after a com-\\nplete neurologic exam, a computed tomography scan\\n(CT) of the head will be done. In some cases, a\\nwhooshing sound from arteries in the neck or over\\nthe eye or jaw (called a bruit), can be heard with a\\nstethoscope. The CT scan will reveal whether there has\\nbeen bleeding in the brain and can identify AVMs\\nlarger than 1 inch (2.5 cm).Magnetic resonance ima-\\nging (MRI) is also used to identify an AVM. A lumbar\\npuncture, or spinal tap, may follow the MRI or CT\\nscan. A lumbar puncture involves removing a small\\namount of cerebrospinal fluid from the lower part of\\nthe spine. Blood cells or blood breakdown products in\\nthe cerebrospinal fluid indicate bleeding.\\nKEY TERMS\\nAneurysm— A weak point in a blood vessel where\\nthe pressure of the blood causes the vessel wall to\\nbulge outwards.\\nAngiography— A mapping of the brain’s blood\\nvessels, using x-ray imaging.\\nCapillary bed— A dense network of tiny blood ves-\\nsels that enables blood to fill a tissue or organ.\\nHydrocephalus— Swelling of the brain caused by\\nan accumulation of fluid.\\nLumbar puncture— A diagnostic procedure in\\nwhich a needle is inserted into the lower spine to\\nwithdraw a small amount of cerebrospinal fluid.\\nThis fluid is examined to assess trauma to the brain.\\nSaccular aneurysm— A type of aneurysm that\\nresembles a small sack of blood attached to the\\nouter surface of a blood vessel by a thin neck.\\nGALE ENCYCLOPEDIA OF MEDICINE 405\\nArteriovenous malformations'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='To pinpoint where the blood is coming from, a\\ncerebral angiography is done. This procedure uses\\nx rays to map out the blood vessels in the brain,\\nincluding the vessels that feed into the malformation.\\nThe information gained from angiography comple-\\nments the MRI and helps distinguish the precise\\nlocation of the AVM.\\nTreatment\\nNeurosurgeons consider several factors before\\ndeciding on a treatment option. There is some debate\\nover whether or not to treat AVMs that have not\\nruptured and are not causing any symptoms. The\\nrisks and benefits of proceeding with treatment need\\nto be measured on an individual basis, taking into\\naccount factors such as the person’s age and general\\nhealth, as well as the AVM’s size and location. Several\\ntreatment options are available, both for symptomatic\\nor asymptomatic AVMs. These treatment options\\nmay be used alone or in combination.\\nSurgery\\nRemoving the AVM is the surest way of preventing\\nit from causing future problems. Both small and large\\nAVMs can be handled in surgery. Surgery is recom-\\nmended for superficial AVMs, but may be too danger-\\nous for deep or very large AVMs. Unless it is\\nan emergency situation, an AVM that has hemorrhaged\\nis treated conservatively for several weeks. Conservative\\ntreatment consists of managing the immediate symp-\\ntoms and allowing the patient’s condition to stabilize.\\nSurgery requiresgeneral anesthesiaand a longer period\\nof recuperation than any other treatment option.\\nRadiation\\nRadiation is particularly useful to treat small\\n(under 1 in) malformations that are deep within the\\nbrain. Ionizing radiation is directed at the malforma-\\ntion, destroying the AVM without damaging the sur-\\nrounding tissue. Radiation treatment is accomplished\\nin a single session and it is not necessary to open the\\nskull. However, success can only be measured over\\nthe course of the following two years. A year after\\nthe procedure, 50-75% of treated AVMs are comple-\\ntely blocked; two years after radiation treatment, the\\npercentage increases to 85-95%.\\nEmbolization\\nEmbolization involves plugging up access to the\\nmalformation. This technique does not require open-\\ning the skull to expose the brain and can be used to\\ntreat deep AVMs. Using x-ray images as a guide, a\\ncatheter is threaded through the artery in the thigh\\n(femoral artery) to the affected area. The patient\\nremains awake during the procedure and medications\\ncan be administered to prevent discomfort. The blood\\nvessel leading into the AVM is assessed for its impor-\\ntance to the rest of the brain before a balloon or other\\nblocking agent is inserted via the catheter. The block\\nchokes off the blood supply to the malformation.\\nThere may be a mild headache ornausea associated\\nwith the procedure, but patients may resume normal\\nactivities after leaving the hospital. At least two to\\nthree embolization procedures are usually necessary\\nat intervals of two to six weeks. At least a three-day\\nhospital stay is associated with each embolization.\\nPrognosis\\nApproximately 10% of AVM cases are fatal.\\nSeizures and neurological changes may be permanent\\nin another 10-30% cases of AVM rupture. If an AVM\\nbleeds once, it is about 20% likely to bleed again in the\\nnext year. As time passes from the initial hemorrhage,\\nthe risk for further bleeding drops to about 3-4%. If\\nthe AVM has not bled, it is possible, but not guaran-\\nteed, that it never will. Untreated AVMs can grow\\nlarger over time and rarely go away by themselves.\\nOnce an AVM is removed and a person has recovered\\nfrom the procedure, there should be no further symp-\\ntoms associated with that malformation.\\nResources\\nPERIODICALS\\nHenning, Mast. ‘‘Risk of Spontaneous Hemorrhage after\\nDiagnosis of Cerebral Arteriovenous Malformation.’’\\nThe Lancet350 (October 11, 1997): 1065.\\nORGANIZATIONS\\nAmerican Chronic Pain Association. PO Box 850, Rocklin,\\nCA 95677-0850. (916) 632-0922. .\\nArteriovenous Malformation Support Group. 168\\nSix Mile Canyon Road, Dayton, NV 89403. (702)\\n246-0682.\\nNational Chronic Pain Outreach Association, Inc. P.O. Box\\n274, Millboro, VA 24460. (540) 997-5004.\\nJulia Barrett\\nArthritis see Juvenile arthritis;\\nOsteoarthritis; Psoriatic arthritis;\\nRheumatoid arthritis\\nArthrocentesis see Joint fluid analysis\\nArthrogram see Arthrography\\n406 GALE ENCYCLOPEDIA OF MEDICINE\\nArteriovenous malformations'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Arthrography\\nDefinition\\nArthrograpy is a procedure involving multiple\\nx rays of a joint using a fluoroscope, or a special\\npiece of x-ray equipment which shows an immediate\\nx-ray image. A contrast medium (in this case, a con-\\ntrast iodine solution) injected into the joint area helps\\nhighlight structures of the joint.\\nPurpose\\nFrequently, arthrography is ordered to determine\\nthe cause of unexplained jointpain. This fluoroscopic\\nprocedure can show the internal workings of specific\\njoints and outline soft tissue structures. The procedure\\nmay also be conducted to identify problems with the\\nligaments, cartilage, tendons, or the joint capsule of\\nthe hip, shoulder, knee, ankle or wrist. An arthrogra-\\nphy procedure may locate cysts in the joint area, eval-\\nuate problems with the joint’s arrangement and\\nfunction, or indicate the need forjoint replacement\\n(prostheses). The most commonly studied joints are\\nthe knee and shoulder.\\nPrecautions\\nPatients who are pregnant or may be pregnant\\nshould not have this procedure unless the benefits of\\nthe findings outweigh the risk of radiation exposure.\\nPatients who are known to be allergic to iodine need to\\ndiscuss this complication with their physician. Patients\\nwho have a known allergy to shellfish are more likely\\nto be allergic to iodine contrast.\\nDescription\\nArthrograpy may be referred to as ‘‘joint radio-\\ngraphy’’ or ‘‘x rays of the joint.’’ The term arthrogram\\nmay be used interchangeably with arthrography. The\\njoint area will be cleaned and a local anesthetic\\nwill be injected into the tissues around the joint\\nto reduce pain. Next, if fluids are present in the\\njoint, the physician may suction them out (aspi-\\nrate) with a needle. These fluids may be sent to a\\nlaboratory for further study. Contrast agents are\\nthen injected into the joint through the same loca-\\ntion by attaching the aspirating needle to a syringe\\ncontaining the contrast medium. The purpose of\\ncontrast agents in x-ray procedures is to help high-\\nlight details of areas under study by making them\\nopaque. Agents for arthrography are generally air\\nand water-soluble dyes, the most common\\ncontaining iodine. Air and iodine may be used\\ntogether or independent ly. After the contrast\\nagent is administered, the site of injection will be\\nsealed and the patient may be asked to move the\\njoint around to distribute the contrast.\\nBefore the contrast medium can be absorbed by\\nthe joint itself, several films will be quickly taken\\nunder the guidance of the fluoroscope. The patient\\nwill be asked to move the joint into a series of\\npositions, keeping still between positioning.\\nSometimes, the patient will experience sometingling\\nor discomfort during the procedure, which is\\nAn x-ray image of the knees of a patient with cysts caused by\\nrheumatoid arthritis. The cysts appear as dark areas just\\nbelow the knee joints. (Custom Medical Stock Photo.\\nReproduced by permission.)\\nKEY TERMS\\nAspirate— Remove fluids by suction, often through\\na needle.\\nContrast (agent, medium)— A substance injected\\ninto the body that illuminates certain structures\\nthat would otherwise be hard to see on the radio-\\ngraph (film).\\nFluoroscope— A device used in some radiology\\nprocedures that provides immediate images and\\nmotion on a screen much like those seen at airport\\nbaggage security stations.\\nRadiologist— A medical doctor specially trained in\\nradiology (x ray) interpretation and its use in the\\ndiagnosis of diseases and injuries.\\nX ray— A form of electromagnetic radiation with\\nshorter wavelengths than normal light. X rays can\\npenetrate most structures.\\nGALE ENCYCLOPEDIA OF MEDICINE 407\\nArthrography'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='normal and due to the contrast. Following fluoro-\\nscopic tracking of the contrast, standard x rays of\\nthe area may also be taken. The entire procedure\\nwill last about one hour.\\nPreparation\\nIt is important to discuss any known sensitivity to\\nlocal anesthetics or iodine prior to this procedure. A\\nphysician should explain the procedure and the risks\\nassociated with contrast agents and ask the patient to\\nsign an informed consent. If iodine contrast will be\\nadministered, the patient may be instructed not to eat\\nbefore the exam. The timeframe offasting may extend\\nfrom only 90 minutes prior to the exam up to the night\\nbefore. There is no other preparation necessary.\\nAftercare\\nThe affected joint should be rested for appro-\\nximately 12 hours following the procedure. The joint\\nmay be wrapped in an elastic bandage and the patient\\nshould receive instructions on the care and changing of\\nt h eb a n d a g e .N o i s e si nt h ej o i n ts u c ha sc r a c k i n g\\nor clicking are normal for a few days following arthro-\\ngraphy. These noises are the result of liquid in the joints.\\nSwelling may also occur and can be treated with appli-\\ncation of ice or cold packs. A mild pain reliever can be\\nused to lessen pain in the first few days. However, if any\\nof these symptoms persist for more than a few days,\\npatients are advised to contact their physician.\\nRisks\\nIn some patients iodine can cause allergic reactions,\\nranging from mildnausea to severe cardiovascular or\\nnervous system complications. Since the contrast dye is\\nput into a joint, rather than into a vein, allergic reactions\\nare rare. Facilities licensed to perform contrast exams\\nshould meet requirements for equipment, supplies and\\nstaff training to handle a possible severe reaction.\\nInfection or joint damage are possible, although not\\nfrequent, complications of arthrography.\\nNormal results\\nA normal arthrography exam will show proper pla-\\ncement of the dye or contrast medium throughout the\\njoint structures, joint space, cartilage and ligaments.\\nAbnormal results\\nThe abnormal placement of dye may indicate\\nrheumatoid arthritis, cysts, joint dislocation, rupture\\nof the rotator cuff, tears in the ligament and other\\nconditions. The entire lining of the joint becomes opa-\\nque from the technique, which allows the radiologist\\nto see abnormalities in the intricate workings of the\\njoint. In the case of recurrent shoulderdislocations,\\narthrography results can be used to evaluate damage.\\nPatients with hip prostheses may receive arthrography\\nto evaluate proper placement or function of their\\nprostheses.\\nResources\\nORGANIZATIONS\\nAmerican College of Radiology. 1891 Preston White Drive,\\nReston, VA 22091. (800) 227-5463. .\\nArthritis Foundation. 1300 W. Peachtree St., Atlanta, GA\\n30309. (800) 283-7800. .\\nTeresa Odle\\nArthroplasty\\nDefinition\\nArthroplasty is surgery to relievepain and restore\\nrange of motion by realigning or reconstructing a joint.\\nPurpose\\nThe goal of arthroplasty is to restore the function\\nof a stiffened joint and relieve pain. Two types of\\narthroplastic surgery exist. Joint resection involves\\nremoving a portion of the bone from a stiffened\\njoint, creating a gap between the bone and the socket,\\nto improve the range of motion. Scar tissue eventually\\nfills the gap. Pain is relieved and motion is restored,\\nbut the joint is less stable.\\nInterpositional reconstruction is surgery to\\nreshape the joint and add a prosthetic disk between\\nthe two bones forming the joint. The prosthesis can\\nbe made of plastic and metal or from body tissue\\nsuch as fascia and skin. When interpositional\\nreconstruction fails, total joint replacement may be\\nnecessary. Joint replacement is also called total\\njoint arthroplasty.\\nIn recent years, joint replacement has become the\\noperation of choice for most knee and hip problems.\\nElbow, shoulder, ankle, and finger joints are more\\nlikely to be treated with joint resection or interposi-\\ntional reconstruction.\\n408 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Arthroplasty is performed on people suffering\\nfrom severe pain and disabling joint stiffness that\\nresult from osteoarthritis or rheumatoid arthritis .\\nJoint resection, rather than joint replacement, is\\nmore likely to be performed on people with rheuma-\\ntoid arthritis, especially when the elbow joint is\\ninvolved. Total joint replacement is usually reserved\\nfor people over the age of 60.\\nPrecautions\\nIf both the bone and socket of a joint are\\ndamaged, joint replacement is usually the preferred\\ntreatment.\\nDescription\\nArthroplasty is performed under general or regio-\\nnal anesthesia in a hospital, by an orthopedic surgeon.\\nCertain medical centers specialize in joint surgery and\\ntend to have higher success rates than less specialized\\ncenters.\\nIn joint resection, the surgeon makes an incision\\nat the joint, then carefully removes minimum amount\\nof bone necessary to allow free motion. The more bone\\nthat remains, the more stable the joint. Ligament\\nattachments are preserved as much as possible. In\\ninterpositional reconstruction, both bones of the\\njoint are reshaped, and a disk of material is placed\\nbetween the bones to prevent their rubbing together.\\nLength of hospital stay depends on which joint is\\ntreated, but is normally only a few days.\\nPreparation\\nPrior to arthroplasty, allthe standard preopera-\\ntive blood and urine tests are performed. The patient\\nmeets with the anesthesiologist to discuss any\\nspecial conditions that affect the administration of\\nanesthesia.\\nAftercare\\nPatients who have undergone arthroplasty must\\nbe careful not to overstress or destabilize the joint.\\nPhysical therapy is begun immediately.Antibiotics are\\ngiven to prevent infection.\\nRisks\\nJoint resection and interpositional reconstruction\\ndo not always produce successful results, especially in\\npatients with rheumatoid arthritis. Repeat surgery or\\ntotal joint replacement may be necessary. As with any\\nmajor surgery, there is always a risk of an allergic\\nreaction to anesthesia or thatblood clots will break\\nloose and obstruct the arteries.\\nNormal results\\nMost patients recover with improved range of\\nmotion in the joint and relief from pain.\\nResources\\nBOOKS\\n‘‘Joint Replacement.’’ InEverything You Need to Know\\nAbout Medical Treatments.Springhouse, PA:\\nSpringhouse Corp., 1996.\\nOTHER\\n‘‘Darrach’s Procedure.’’Wheeless’ Textbook of Orthopaedics\\nPage. .\\nTish Davidson, A.M.\\nArthroscopic surgery\\nDefinition\\nArthroscopic surgery is a procedure to visualize,\\ndiagnose, and treat joint problems. The name is\\nderived from the Greek wordsarthron, which means\\njoint, and skopein, which meansto look at.\\nPurpose\\nArthroscopic surgery is used to identify, monitor,\\nand diagnose joint injuries and disease; or to remove\\nbone or cartilage or repair tendons or ligaments.\\nDiagnostic arthroscopic surgery is performed when\\nmedical history, physical exam, x rays, and other\\ntests such as MRIs or CTs don’t provide a definitive\\ndiagnosis.\\nKEY TERMS\\nFascia— Thin connective tissue covering or separ-\\nating the muscles and internal organs of the\\nbody.\\nRheumatoid arthritis— A joint disease of\\nunknown origins that may begin at an early age,\\ncausing deformity and loss of function in the\\njoints.\\nGALE ENCYCLOPEDIA OF MEDICINE 409\\nArthroscopic surgery'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Precautions\\nDiagnostic arthroscopic surgery should not be\\nperformed unless conservative treatment does not fix\\nthe problem.\\nDescription\\nIn arthroscopic surgery, an orthopedic surgeon\\nuses an arthroscope, a fiber-optic instrument, to see\\nt h ei n s i d eo faj o i n t .A f t e rm a k i n ga ni n c i s i o na b o u t\\nthe size of a buttonhole in the patient’s skin, a sterile\\nsodium chloride solution is injected to distend the joint.\\nThe arthroscope, an instrument the size of a pencil, is\\nthen inserted into the joint. The arthroscope has a lens\\nand a lighting system through which the structures\\ninside the joint are transmitted to a miniature television\\ncamera attached to the end of the arthroscope. The\\nsurgeon uses irrigation and suction to remove blood\\nand debris from the joint before examining it. Other\\nincisions may be made in order to see other parts of the\\njoint or to insert additional instruments. Looking at the\\ninterior of the joint on the television screen, the surgeon\\ncan then determine the amount or type of injury and, if\\nnecessary, take a biopsy specimen or repair or correct\\nthe problem. Arthroscopic surgery can be used to\\nremove floating bits of cartilage and treat minor tears\\nand other disorders. When the procedure is finished,\\nthe arthroscope is removed and the joint is irrigated.\\nThe site of the incision is bandaged.\\nArthroscopic surgery is used to diagnose and treat\\njoint problems, most commonly in the knee, but also\\nin the shoulder, elbow, ankle, wrist, and hip. Some of\\nthe most common joint problems seen with an arthro-\\nscope are:\\n/C15inflammation in the knee, shoulder, elbow, wrist, or\\nankle\\n/C15injuries to the shoulder (rotator cuff tendon tears,\\nimpingement syndrome, and recurrent dislocations),\\nknee (cartilage tears, wearing down of or injury to the\\ncartilage cushion, and anterior cruciate ligament tears\\nwith instability), and wrist (carpal tunnel syndrome)\\nCamera\\nTelescope\\nAn arthroscope uses optical fibers to form an image of the damged cartilage, which it sends to a television monitor that helps the\\nsurgeon perform surgery. (Illustration by Argosy Inc.)\\n410 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroscopic surgery'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15loose bodies of bone and/or cartilage in the knee,\\nshoulder, elbow, ankle, or wrist\\nCorrective arthroscopic surgery is performed with\\ninstruments that are inserted through additional inci-\\nsions. Arthritis can sometimes be treated with arthro-\\nscopic surgery. Some problems are treated with a\\ncombination of arthroscopic and standard surgery.\\nAlso calledarthroscopy, the procedure is performed\\nin a hospital or outpatient surgical facility. The type of\\nanesthesia (local, spinal, or general) and the length of\\nthe procedure depends on the joint operated on and the\\ncomplexity of the suspected problem. Arthroscopic sur-\\ngery rarely takes more than an hour. Most patients who\\nhave arthroscopic surgery are released that same day;\\nsome patients stay in the hospital overnight.\\nConsidered the most important orthopedic devel-\\nopment in the 20th century, arthroscopic surgery is\\nwidely used. The use of arthroscopic surgery on famous\\nathletes has been well publicized. It is estimated that\\n80% of orthopedic surgeons practice arthroscopic sur-\\ngery. Arthroscopic surgery was initially a diagnostic\\ntool used prior to open surgery, but as better instru-\\nments and techniques were developed, it began to be\\nused to actually treat a variety of joint problems. New\\ntechniques currently under development are likely to\\nlead to other joints being treated with arthroscopic\\nsurgery in the future. Recently, lasers were introduced\\nin arthroscopic surgery and other new energy sources\\nare being explored. Lasers and electromagnetic radia-\\ntion can repair rather than resect injuries and may be\\nmore cost effective than instruments.\\nPreparation\\nBefore the procedure, blood and urine studies and\\nx rays of the joint will be conducted.\\nAftercare\\nImmediately after the procedure, the patient will\\nspend several hours in the recovery room. An ice pack\\nwill be put on the joint that was operated on for up to\\n48 hours after the procedure. Pain medicine, prescrip-\\ntion or non-prescription, will be given. The morning\\nafter the surgery, the dressing can be removed and\\nreplaced by adhesive strips. The patient should call\\nhis/her doctor upon experiencing an increase inpain,\\nswelling, redness, drainage or bleeding at the site of the\\nsurgery, signs of infection (headache, muscle aches,\\ndizziness, fever), ornausea or vomiting.\\nIt takes several days for the puncture wounds\\nto heal, and several weeks for the joint to fully recover.\\nMany patients can resume their daily activities, includ-\\ning going back to work, within a few days of the\\nprocedure. Arehabilitation program, including physi-\\ncal therapy, may be suggested to speed recovery and\\nimprove the future functioning of the joint.\\nRisks\\nComplications are rare in arthroscopic surgery,\\noccurring in less than 1% of patients. These include\\ninfection and inflammation, blood vessel clots, damage\\nto blood vessels or nerves, and instrument breakage.\\nResources\\nPERIODICALS\\nWilkinson, Todd. ‘‘Pop, Crackle, Snap.’’Women’s Sports &\\nFitness (April 1998): 68.\\nLori De Milto\\nArthroscopy\\nDefinition\\nArthroscopy is the examination of a joint, specifi-\\ncally, the inside structures. The procedure is performed\\nby inserting a specifically designed illuminated device\\ninto the joint through a small incision. This instrument\\nis called an arthroscope. The procedure of arthroscopy\\nis primarily associated with the process of diagnosis.\\nHowever, when actual repair is performed, the proce-\\ndure is calledarthroscopic surgery.\\nPurpose\\nArthroscopy is used primarily by doctors who\\nspecialize in treating disorders of the bones and\\nKEY TERMS\\nJoint— The point where bones meet. Arthroscopic\\nsurgery is used on joint problems.\\nLaser— A device that concentrates electromagnetic\\nradiation into a narrow beam and treats tissue\\nquickly without heating surrounding areas.\\nOrthopedics— The medical specialty that deals\\nwith preserving, restoring, and developing form\\nand function in the extremities, spine, and other\\nstructures using medical, surgical, and physical\\nmethods. Arthroscopic surgery is performed by\\northopedic surgeons.\\nGALE ENCYCLOPEDIA OF MEDICINE 411\\nArthroscopy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='related structures (orthopedics) to help diagnose\\njoint problems. Once described as essential for those\\nwho primarily care for athletic injuries, arthroscopy\\nis now a technique commonly used by orthopedic\\nsurgeons for the treatment of patients of all ages.\\nThis procedure is most commonly used to diagnose\\nknee and shoulder problems, although the elbow,\\nhip, wrist, and ankle may also be examined with an\\narthroscope.\\nA joint is a complex system. Within a joint, liga-\\nments attach bones to other bones, tendons attach\\nmuscles to bones, cartilage lines and helps protect the\\nends of bones, and a special fluid (synovial fluid)\\ncushions and lubricates the structures. Looking inside\\nthe joint allows the doctors to see exactly which struc-\\ntures are damaged. Arthroscopy also permits earlier\\ndiagnosis of many types of joint problems which had\\nbeen difficult to detect in previous years.\\nPrecautions\\nMost arthroscopic procedures today are per-\\nformed in same-day surgery centers where the patient\\nis admitted just before surgery. A few hours following\\nthe procedure, the patient is allowed to return home,\\nArthroscope\\nSuperolateral Superomedial\\nCommon entry sites for the arthroscope\\nInferomedial\\nCentral\\nMedialLateral\\nInferolateral\\nArthroscopy is primarily used to help diagnose joint problems. This procedure, most commonly associated with knee and\\nshoulder problems, allows accurate examination and diagnosis of damaged joint ligaments, surfaces, and other related joint\\nstructures. The illustration above indicates the most common entry sites, or portals, in knee arthroscopy. (Illustration by\\nElectronic Illustrators Group.)\\n412 GALE ENCYCLOPEDIA OF MEDICINE\\nArthroscopy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='although usually someone else must drive. Depending\\non the type of anesthesia used, the patient may be told\\nnot to eat for several hours before arriving. Before the\\nprocedure, the anesthesiologist will ask if the patient\\nhas any knownallergies to local or general anesthetics.\\nAirway obstruction is always possible in any patient\\nwho receives a general anesthesia. Because of this,\\noxygen, suction, and monitoring equipment must be\\navailable. The patient’s cardiac status should always\\nbe monitored in the event that any cardiac abnormal-\\nities arise during the arthroscopy.\\nDescription\\nThe arthroscope is an instrument used to look\\ndirectly into the joint. It contains magnifying lenses\\nand glass-coated fibers that send concentrated light\\ninto the joint. A camera attached to the arthroscope\\nallows the surgeon to see a clear image of the joint.\\nThis image is then transferred to a monitor located in\\nthe operating room at the time of the arthroscopy.\\nThis video technology is also important for docu-\\nmentation of the arthroscopic procedure. For exam-\\nple, if the surgeon decides after the arthroscopic\\nexamination that a conventional approach to surgi-\\ncally expose or ‘‘open’’ the joint (arthrotomy) must\\nbe used, a good photographic record will be useful\\nwhen the surgeon returns to execute the final surgical\\nplan.\\nThe procedure requires the surgeon to make sev-\\neral small incisions (portals) through the skin’s surface\\ninto the joint. Through one or two of the portals, a\\nlarge-bore needle, called a cannula, is attached to tub-\\ning and inserted into the joint. The joint is inflated\\nwith a sterile saline solution to expand the joint and\\nensure clear arthroscopic viewing. Often, following a\\nrecent traumatic injury to a joint, the joint’s natural\\nfluid may be cloudy, making interior viewing of the\\njoint difficult. In this condition, a constant flow of the\\nsaline solution is necessary. This inflow of saline solu-\\ntion may be through the cannula with the outflow\\nthrough the arthroscope, or the positions may be\\nreversed. The arthroscope is placed through one of\\nthe portals to view and evaluate the condition of the\\njoint.\\nPreparation\\nBefore an arthroscopy can take place, the surgeon\\ncompletes a thorough medical history and evaluation.\\nImportant for the accuracy of this diagnostic\\nprocedure, a medical history and evaluation may dis-\\ncover other disorders of the joint or body parts, prov-\\ning the procedure unnecessary. This is always\\nan important preliminary step, because pain can\\noften be referred to a joint from another area of\\nthe body. Anatomical models and pictures are\\nuseful aids to explain to the patient the proposed\\narthroscopy and what the surgeon may be looking at\\nspecifically.\\nProper draping of the body part is important to\\nprevent contamination from instruments used in\\narthroscopy, such as the camera, light cords, and\\ninflow and outflow drains placed in the portals.\\nDraping packs used in arthroscopy include disposable\\npaper gowns and drapes with adhesive backing. The\\nsurgeon may also place a tourniquet above the joint to\\ntemporarily block blood flow to the area during the\\narthroscopic exam.\\nGeneral or local anesthesia may be used during\\narthroscopy. Local anesthesia is usually used\\nbecause it reduces the risk of lung and heart com-\\nplications and allows the patient to go home sooner.\\nThe local anesthetic may be injected in small\\namounts in multiple locations in skin and joint\\ntissues in a process called infiltration. In other\\ncases, the anesthetic is injected into the spinal cord\\nor a main nerve supplying the area. This process is\\ncalled a ‘‘block,’’ and it blocks all sensation below\\nthe main trunk of the nerve. For example, a femoral\\nblock anesthetizes the leg from the thigh down (its\\nname comes from femur, the thighbone). Most\\npatients are comfortable once the skin, muscles,\\nand other tissues around the joint are numbed by\\nthe anesthetic; however, some patients are also\\ngiven a sedative if they express anxiety about the\\nprocedure. (It’s important for the patient to remain\\nstill during the arthroscopic examination.)\\nGeneral anesthesia, in which the patient becomes\\nunconcious, may be used if the procedure may be\\nunusually complicated or painful. For example,\\npeople who have relatively ‘‘tight’’ joints may be can-\\ndidates for general anesthesia because the procedure\\nmay take longer and cause more discomfort.\\nKEY TERMS\\nHemarthrosis— A condition of blood within a joint.\\nPulmonary embolus— Blockage of an artery of the\\nlung by foreign matter such as fat, tumor, tissue, or\\na clot originating from a vein.\\nThrombophlebitis— Inflamation of a vein with the\\nformation of a thrombus or clot.\\nGALE ENCYCLOPEDIA OF MEDICINE 413\\nArthroscopy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aftercare\\nThe portals are closed by small tape strips or\\nstitches and covered with dressings and a bandage.\\nThe patient spends a short amount of time in the\\nrecovery room after arthroscopy. Most patients can\\ngo home after about an hour in the recovery room.\\nPain medication may be prescribed for a short period;\\nhowever, many patients find various over-the-counter\\npain relievers sufficient.\\nFollowing the surgical procedure, the patient\\nneeds to be aware of the signs of infection, which\\ninclude redness, warmth, excessive pain, and swelling.\\nThe risk of infection increases if the incisions become\\nwet too early following surgery. Because of this, it is\\ngood practice to cover the joint with plastic (for exam-\\nple, a plastic bag) while showering after arthroscopy.\\nThe use of crutches is commonplace after arthro-\\nscopy, with progression to independent walking on an\\n‘‘as tolerated’’ basis by the patient. Generally, areha-\\nbilitation program, supervised by a physical therapist,\\nfollows shortly after the arthroscopy to help the\\npatient regain mobility and strength of the affected\\njoint and limb.\\nRisks\\nThe incidence of complications is low compared\\nto the high number of arthroscopic procedures per-\\nformed every year. Possible complications include\\ninfection, swelling, damage to the tissues in the joint,\\nblood clotsin the leg veins (thrombophlebitis), leakage\\nof blood into the joint (hemarthrosis), blood clots that\\nmove to the lung (pulmonary embolus), and injury to\\nthe nerves around the joint.\\nNormal results\\nThe goal of arthroscopy is to diagnose a joint\\nproblem causing pain and/or restrictions in normal\\njoint function. For example, arthroscopy can be a\\nuseful tool in locating a tear in the joint surface of\\nthe knee or locating a torn ligament of the shoulder.\\nArthroscopic examination is often followed by arthro-\\nscopic surgery performed to repair the problem with\\nappropriate arthroscopic tools. The final result is to\\ndecrease pain, increase joint mobility, and thereby\\nimprove the overall quality of the patient’s activities\\nof daily living.\\nAbnormal results\\nLess optimal results that may require further treat-\\nment include adhesive capsulitis. In this condition, the\\njoint capsule that naturally forms around the joint\\nbecomes thickened, formingadhesions.T h i sr e s u l t si n\\na stiff and less mobile joint. This problem is frequently\\ncorrected by manipulation and mobilization of the\\njoint with the patient placed under general anesthesia.\\nResources\\nPERIODICALS\\nGlassman, Scott. ‘‘Advances in Treating Shoulder Injuries.’’\\nAdvanced Magazine for Physical Therapists(December\\n1997): 10-12.\\nJeffrey P. Larson, RPT\\nArtificial insemination see Infertility\\ntherapies\\nAsbestosis\\nDefinition\\nAsbestosis is chronic, progressive inflammation of\\nthe lung. It is not contagious.\\nDescription\\nAsbestosis is a consequence of prolonged expo-\\nsure to large quantities of asbestos, a material once\\nwidely used in construction, insulation, and manufac-\\nturing. When asbestos is inhaled, fibers penetrate the\\nbreathing passages and irritate, fill, inflame, and scar\\nlung tissue. In advanced asbestosis,, the lungs shrink,\\nstiffen, and become honeycombed (riddled with tiny\\nholes).\\nLegislation has reduced use of asbestos in the\\nUnited States, but workers who handle automobile\\nbrake shoe linings, boiler insulation, ceiling acoustic\\ntiles, electrical equipment, and fire-resistant materials\\nare still exposed to the substance. Asbestos is used in\\nthe production of paints and plastics. Significant\\namounts can be released into the atmosphere when\\nold buildings or boats are razed or remodeled.\\nAsbestosis is most common in men over 40 who\\nhave worked in asbestos-related occupations.\\nSmokers or heavy drinkers have the greatest risk of\\ndeveloping this disease. Between 1968 and 1992,\\nmore than 10,000 Americans over the age of 15 died\\nas a result of asbestosis. Nearly 25% of those who\\ndied lived in California or New Jersey, and most of\\nthem had worked in the construction or shipbuilding\\ntrades.\\n414 GALE ENCYCLOPEDIA OF MEDICINE\\nAsbestosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nOccupational exposure is the most common cause\\nof asbestosis, but the condition also strikes people who\\ninhale asbestos fiber or who are exposed to waste\\nproducts from plants near their homes. Family mem-\\nbers can develop the disease as a result of inhaling\\nparticles of asbestos dust that cling to workers’\\nclothes.\\nIt is rare for asbestosis to develop in anyone who\\nhasn’t been exposed to large amounts of asbestos on a\\nregular basis for at least 10 years. Symptoms of the\\ndisease do not usually appear until 15–20 years after\\ninitial exposure to asbestos.\\nThe first symptom of asbestosis is usually short-\\nness of breath following exercise or other physical\\nactivity. The early stages of the disease are also char-\\nacterized by a drycough and a generalized feeling of\\nillness.\\nAs the disease progresses and lung damage\\nincreases, shortness of breath occurs even when\\nthe patient is at rest. Recurrent respiratory infec-\\ntions and coughing up blood are common. So is\\nswelling of the feet, ankles, or hands. Other symp-\\ntoms of advanced asbestosis include chest pain,\\nhoarseness, and restless sleep. Patients who have\\nasbestosis often have clubbed (widened and thick-\\nened) fingers. Other potential complications\\ninclude heart failure, collapsed (deflated) lung,\\nand pleurisy (inflammation of the membrane that\\nprotects the lung).\\nDiagnosis\\nScreening of at-risk workers can reveal lung\\ninflammation and lesions characteristic of asbestosis.\\nPatients’ medical histories can identify occupations,\\nhobbies, or other situations likely to involve exposure\\nto asbestos fibers.\\nX rays can show shadows or spots on the lungs\\nor an indistinct or shaggy outline of the heart that\\nsuggests the presence of asbestosis. Blood tests are\\nused to measure concentrations of oxygen and carbon\\ndioxide. Pulmonary function tests can be used to\\nassess a patient’s ability to inhale and exhale, and a\\ncomputed tomography scan (CT) of the lungs can\\nshow flat, raised patches associated with advanced\\nasbestosis.\\nTreatment\\nThe goal of treatment is to help patients breathe\\nmore easily, prevent colds and other respiratory infec-\\ntions, and control complications associated with\\nadvanced disease. Ultrasonic, cool-mist humidifiers\\nor controlled coughing can loosen bronchial\\nsecretions.\\nRegular exercise helps maintain and improve lung\\ncapacity. Although temporary bed rest may be recom-\\nmended, patients are encouraged to resume their reg-\\nular activities as soon as they can.\\nAnyone who develops symptoms of asbestosis\\nshould see a family physician or lung disease specialist.\\nA doctor should be notified if someone who has been\\ndiagnosed with asbestosis:\\n/C15coughs up blood\\n/C15continues to lose weight\\n/C15is short of breath\\n/C15has chestpain\\n/C15develops a suddenfever of 1018F (38.38C) or higher\\n/C15develops unfamiliar, unexplained symptoms\\nPrognosis\\nAsbestosis can’t be cured, but its symptoms\\ncan be controlled. Doctors don’t know why the\\nMicrograph of asbestos fibers embedded in lung tissue.\\n(Photograph by Dr. E. Walker, Custom Medical Stock Photo.\\nReproduced by permission.)\\nKEY TERMS\\nAsbestos— A silicate (containing silica) mineral\\nthat occurs in a variety of forms; it is characterized\\nby a fibrous structure and resistance to fire.\\nGALE ENCYCLOPEDIA OF MEDICINE 415\\nAsbestosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='health of some patients deteriorates and the condi-\\ntion of others remain the same, but believe the\\ndifference may be due to varying exposures of\\nasbestos. People with asbestosis who smoke, parti-\\ncularly those who smoke more than one pack of\\ncigarettes each day, are at increased risk for devel-\\noping lung cancer and should be strongly advised\\nto quit smoking.\\nPrevention\\nWorkers in asbestosis-related industries should\\nhave regular x rays to determine whether their\\nlungs are healthy. A person whose lung x ray\\nshows a shadow should eliminate asbestos expo-\\nsure even if no symptoms of the condition have\\nappeared.\\nAnyone who works with asbestos should wear a\\nprotective mask or a hood with a clean-air supply and\\nobey recommended procedures to control asbestos\\ndust. Anyone who is at risk of developing asbestosis\\nshould:\\n/C15not smoke\\n/C15be vaccinated againstinfluenza and pneumonia\\n/C15exercise regularly to maintain cardiopulmonary\\nfitness\\n/C15avoid crowds and people who have respiratory\\ninfections\\nA person who has asbestosis should exercise\\nregularly, relax, and conserve energy whenever\\nnecessary.\\nResources\\nBOOKS\\nBurton, George G., John E. Hodgkin, and Jeffrey J. Ward,\\neditors. Respiratory Care: A Guide to Clinical Practice.\\n4th ed. Philadelphia: Lippincott, 1997.\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York,\\nNY 10019. (800) 586-4872. .\\nMaureen Haggerty\\nAscariasis see Roundworm infections\\nAscending cholangitis see Cholangitis\\nAscending contrast phlebography see\\nVenography\\nAscites\\nDefinition\\nAscites is an abnormal accumulation of fluid in\\nthe abdomen.\\nDescription\\nRapidly developing (acute) ascites can occur as a\\ncomplication of trauma, perforated ulcer, appendici-\\ntis, or inflammation of the colon or other tube-shaped\\norgan (diverticulitis). This condition can also develop\\nwhen intestinal fluids, bile, pancreatic juices, or bacteria\\ninvade or inflame the smooth, transparent membrane\\nthat lines the inside of the abdomen (peritoneum).\\nHowever, ascites is more often associated withliver\\ndisease and other long-lasting (chronic) conditions.\\nTypes of ascites\\nCirrhosis, which is responsible for 80% of all\\ninstances of ascities in the United States, triggers a\\nseries of disease-producing changes that weaken the\\nkidney’s ability to excrete sodium in the urine.\\nPancreatic ascites develops when a cyst that has\\nthick, fibrous walls (pseudocyst) bursts and permits\\npancreatic juices to enter the abdominal cavity.\\nChylous ascites has a milky appearance caused by\\nlymph that has leaked into the abdominal cavity.\\nAlthough chylous ascites is sometimes caused by\\ntrauma, abdominal surgery,tuberculosis, or another\\nperitoneal infection, it is usually a symptom of lym-\\nphoma or some othercancer.\\nCancer causes 10% of all instances of ascites in the\\nUnited States. It is most commonly a consequence of\\ndisease that originates in the peritoneum (peritoneal\\ncarcinomatosis) or of cancer that spreads (metasta-\\nsizes) from another part of the body.\\nEndocrine and renal ascites are rare disorders.\\nEndocrine ascites, sometimes a symptom of an endo-\\ncrine system disorder, also affects women who are\\ntaking fertility drugs. Renal ascites develops when\\nblood levels of albumin dip below normal. Albumin\\nis the major protein in blood plasma. It functions to\\nkeep fluid inside the blood vessels.\\nCauses and symptoms\\nCauses\\nThe two most important factors in the production\\nof ascites due to chronic liver disease are:\\n416 GALE ENCYCLOPEDIA OF MEDICINE\\nAscites'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Low levels of albumin in the blood that cause a\\nchange in the pressure necessary to prevent fluid\\nexchange (osmotic pressure). This change in pressure\\nallows fluid to seep out of the blood vessels.\\n/C15An increase in the pressure within the branches of\\nthe portal vein that run through liver (portal\\nhypertension). Portal hypertension is caused by\\nthe scarring that occurs in cirrhosis. Blood that\\ncannot flow through the liver because of the\\nincreased pressure leaks into the abdomen and\\ncauses ascites.\\nOther conditions that contribute to ascites devel-\\nopment include:\\n/C15hepatitis\\n/C15heart or kidney failure\\n/C15inflammation and fibrous hardening of the sac that\\ncontains the heart (constrictive pericarditis)\\nPersons who have systemic lupus erythematosus\\nbut do not have liver disease or portal hypertension\\noccasionally develop ascites. Depressed thyroid\\nactivity sometimes causes pronounced ascites, but\\ninflammation of the pancreas (pancreatitis) rarely\\ncauses significant accumulations of fluid.\\nSymptoms\\nSmall amounts of fluid in the abdomen do not\\nusually produce symptoms. Massive accumulations\\nmay cause:\\n/C15rapid weight gain\\n/C15abdominal discomfort and distention\\n/C15shortness of breath\\n/C15swollen ankles\\nDiagnosis\\nSkin stretches tightly across an abdomen that con-\\ntains large amounts of fluid. The navel bulges or lies\\nflat, and the fluid makes a dull sound when the doctor\\ntaps the abdomen. Ascitic fluid may cause the flanks\\nto bulge.\\nPhysical examinationgenerally enables doctors to\\ndistinguish ascities from pregnancy, intestinal gas,\\nobesity, or ovarian tunors. Ultrasound orcomputed\\ntomography scans (CT)can detect even small amounts\\nof fluid. Laboratory analysis of fluid extracted by\\ninserting a needle through the abdominal wall (diag-\\nnostic paracentesis) can help identify the cause of the\\naccumulation.\\nA computed tomography (CT) scan of an axial section\\nthrough the abdomen, showing ascites. At right is the liver\\noccupying much of the abdomen; the stomach and spleen are\\nalso seen. Around these organs is fluid giving rise to this\\ncondition. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nKEY TERMS\\nComputed tomography scan (CT)— An imaging\\ntechnique in which cross-sectional x rays of the\\nbody are compiled to create a three-dimensional\\nimage of the body’s internal structures.\\nInterferon— A protein formed when cells are\\nexposed to a virus. Interferon causes other nonin-\\nfected cells to develop translation inhibitory\\nprotein (TIP). TIP blocks viruses from infecting\\nnew cells.\\nParacentesis— A procedure in which fluid is\\ndrained from a body cavity by means of a catheter\\nplaced through an incision in the skin.\\nSystemic lupus erythematosus— An inflammatory\\ndisease that affects many body systems, including\\nthe skin, blood vessels, kidneys, and nervous sys-\\ntem. It is characterized, in part, by arthritis, skin\\nrash, weakness, and fatigue.\\nUltrasonography— A test using sound waves to\\nmeasure blood flow. Gel is applied to a hand-held\\ntransducer that is pressed against the patient’s\\nbody. Images are displayed on a monitor.\\nGALE ENCYCLOPEDIA OF MEDICINE 417\\nAscites'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nReclining minimizes the amount of salt the kid-\\nneys absorb, so treatment generally starts with bed rest\\nand a low-salt diet. Urine-producing drugs (diuretics)\\nmay be prescribed if initial treatment is ineffective.\\nThe weight and urinary output of patients using diure-\\ntics must be carefully monitored for signs of :\\n/C15hypovolemia (massive loss of blood or fluid)\\n/C15azotemia (abnormally high blood levels of nitrogen-\\nbearing materials)\\n/C15potassium imbalance\\n/C15high sodium concentration. If the patient consumes\\nmore salt than the kidneys excrete, increased doses of\\ndiuretics should be prescribed\\nModerate-to-severe accumulations of fluid are\\ntreated by draining large amounts of fluid (large-\\nvolume paracentesis) from the patient’s abdomen.\\nThis procedure is safer than diuretic therapy. It\\ncauses fewer complications and requires a shorter\\nhospital stay.\\nLarge-volume paracentesis is also the preferred\\ntreatment for massive ascites. Diuretics are sometimes\\nused to prevent new fluid accumulations, and the pro-\\ncedure may be repeated periodically.\\nAlternative treatment\\nDietary alterations, focused on reducing salt\\nintake, should be a part of the treatment. In less severe\\ncases, herbal diuretics like dandelion (Taraxacum offi-\\ncinale) can help eliminate excess fluid and provide\\npotassium. Potassium-rich foods like low-fat yogurt,\\nmackerel, cantaloupe, and baked potatoes help bal-\\nance excess sodium intake.\\nPrognosis\\nThe prognosis depends upon the condition that is\\ncausing the ascites. Carcinomatous ascites has a very\\nbad prognosis. However, salt restriction and diuretics\\ncan control ascites caused byliver disease in many cases.\\nTherapy should also be directed towards the\\nunderlying disease that produces the ascites.\\nCirrhosis should be treated by abstinence from alcohol\\nand appropriate diet. The new interferon agents\\nmaybe helpful in treating chronic hepatitis.\\nPrevention\\nModifying or restricting use of salt can prevent\\nmost cases of recurrent ascites.\\nResources\\nBOOKS\\nBerkow, Robert, editor.The Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nOTHER\\n‘‘Hepatic and Liver Disorders.’’The Meck Page.April 20,\\n1998. .\\nMaureen Haggerty\\nAscorbic acid deficiency see Scurvy\\nASD see Atrial septal defect\\nAsian American health see Minority health\\nAsian flu see Influenza\\nAspartate aminotransferase test\\nDefinition\\nThe Aspartate aminotransferase test measures\\nlevels of AST, an enzyme released into the blood\\nwhen certain organs or tissues, particularly the liver\\nand heart, are injured. Aspartate aminotransferase\\n(AST) is also known as serum glutamic oxaloacetic\\ntransaminase (SGOT).\\nPurpose\\nThe determination of AST levels aids primarily in\\nthe diagnosis ofliver disease. In the past, the AST test\\nwas used to diagnoseheart attack(myocardial infarc-\\ntion or MI) but more accurate blood tests have largely\\nreplaced it for cardiac purposes.\\nDescription\\nAST is determined by analysis of a blood sample,\\nusually from taken from a venipuncture site at the\\nbend of the elbow.\\nAST is found in the heart, liver, skeletal muscle,\\nkidney, pancreas, spleen, lung, red blood cells, and\\nbrain tissue. When disease or injury affects these\\ntissues, the cells are destroyed and AST is released\\ninto the bloodstream. Theamount of AST is directly\\n418 GALE ENCYCLOPEDIA OF MEDICINE\\nAspartate aminotransferase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='related to the number of cells affected by the disease\\nor injury, but the level of elevation depends on the\\nlength of time that the blood is tested after the\\ninjury. Serum AST levels become elevated eight\\nhours after cell injury, peak at 24-36 hours, and\\nreturn to normal in three to seven days. If the\\ncellular injury is chronic (ongoing), AST levels will\\nremain elevated.\\nOne of the most important uses for AST determi-\\nnation has formerly been in the diagnosis of a heart\\nattack, or MI. AST can assist in determining the\\ntiming and extent of a recent MI, although it is less\\nspecific than creatine phosphokinase (CPK), CKMB,\\nmyglobin, troponins, and lactic dehydrogenase\\n(LDH). Assuming no further cardiac injury occurs,\\nthe AST level rises within 6-10 hours after an acute\\nattack, peaks at 12-48 hours, and returns to normal\\nin three to four days. Myocardial injuries such as\\nangina (chest pain)o r pericarditis (inflammation of\\nthe pericardium, the membrane around the heart) do\\nnot increase AST levels.\\nAST is also a valuable aid in the diagnosis of liver\\ndisease. Although not specific for liver disease, it can\\nbe used in combination with other enzymes to monitor\\nthe course of various liver disorders. Chronic, silent\\nhepatitis (hepatitis C) is sometimes the cause of ele-\\nvated AST. Inalcoholic hepatitis, caused by excessive\\nalcohol ingestion, AST values are usually moderately\\nelevated; in acute viral hepatitis, AST levels can rise to\\nover 20 times normal. Acute extrahepatic (outside the\\nliver) obstruction (e.g. gallstone), produces AST levels\\nthat can quickly rise to 10 times normal, and then\\nrapidly fall. In cases of cirrhosis, the AST level is\\nrelated to the amount of active inflammation of the\\nliver. Determination of AST also assists in early recog-\\nnition of toxic hepatitis that results from exposure to\\ndrugs toxic to the liver, like acetaminophen and\\ncholesterol lowering medications.\\nOther disorders or diseases in which the AST\\ndetermination can be valuable include acute\\npancreatitis, muscle disease, trauma, severe burn, and\\ninfectious mononucleosis.\\nPreparation\\nThe physician may require discontinuation of any\\ndrugs that might affect the test. These types include\\nsuch drugs as antihypertensives (for treatment of\\nhigh blood pressure), coumarin-type anticoagulants\\n(blood-thinning drugs), digitalis, erythromycin (an\\nantibiotic), oral contraceptives, and opiates, among\\nothers. The patient may also need to cut back on\\nstrenuous activities temporarily, becauseexercise can\\nalso elevate AST for a day or two.\\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 ranges for the AST are laboratory-\\nspecific, but can range from 3-45 units/L (units per\\nliter).\\nAbnormal results\\nStriking elevations of AST (400-4000 units/L) are\\nfound in almost all forms of acute hepatic necrosis,\\nsuch as viral hepatitis and carbon tetrachloridepoison-\\ning. In alcoholics, even moderate doses of the analgesic\\nacetaminophen have caused extreme elevations\\n(1, 960-29, 700 units/L). Moderate rises of AST are\\nseen injaundice, cirrhosis, and metastatic carcinoma.\\nApproximately 80% of patients with infectious mono-\\nnucleosis show elevations in the range of 100-600\\nunits/L.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nJanis O. Flores\\nAsperger’s syndromesee Pervasive develop-\\nmental disorders\\nAspergilloma see Aspergillosis\\nKEY TERMS\\nCirrhosis— Disease of the liver caused by chronic\\ndamage to its cells.\\nMyocardial infarction— Commonly known as a\\nheart attack. Sudden death of part of the heart\\nmuscle, characterized, in most cases, by severe,\\nunremitting chest pain.\\nGALE ENCYCLOPEDIA OF MEDICINE 419\\nAspartate aminotransferase test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Aspergillosis\\nDefinition\\nAspergillosis refers to several forms of disease\\ncaused by a fungus in the genus Aspergillus.\\nAspergillosis fungal infections can occur in the ear\\ncanal, eyes, nose, sinus cavities, and lungs. In some\\nindividuals, the infection can even invade bone and the\\nmembranes that enclose the brain and spinal cord\\n(meningitis).\\nDescription\\nAspergillosis is primarily an infection of the lungs\\ncaused by the inhalation of airborne spores of the\\nfungus Aspergillus. Spores are the small particles that\\nmost fungi use to reproduce. Although virtually every-\\none is exposed to this fungus in their daily environ-\\nment, it rarely causes disease. WhenAspergillus does\\ncause disease, however, it usually occurs in those\\nindividuals with weakened immune systems (immuno-\\ncompromised) or who have a history of respiratory\\nailments. Because it does not present distinctive symp-\\ntoms, aspergillosis is generally thought to be under-\\ndiagnosed and underreported. Furthermore, many\\npatients with the more severe forms of aspergillosis\\ntend to have multiple, complex health problems, such\\nas AIDS or a blood disorder like leukemia, which can\\nfurther complicate diagnosis and treatment.\\nOnce considered particularly rare, the incidence of\\nreported aspergillosis has risen somewhat with the\\ndevelopment of more sophisticated methods of diag-\\nnosis and advances made in other areas of medicine,\\nsuch as with the increased use of certain chemother-\\napeutic and corticosteroid drugs that are extremely\\nuseful in treating various types ofcancer but that\\ndecrease the individual’s immune response, making\\nthem more susceptible to other diseases like\\naspergillosis.\\nOur advanced ability to perform tissue and organ\\ntransplants has also increased the number of people\\nvulnerable to fungal infections. Transplant recipients,\\nparticularly those receiving bone marrow or heart\\ntransplants, are highly susceptible to Aspergillus,\\nwhich may be circulating in the hospital air.\\nAspergillosis can be a serious, potentially deadly\\nthreat for two primary reasons:\\n/C15Aspergillosis usually occurs in those individuals who\\nare already ill or have weakened immune systems,\\nsuch as patients who have undergonechemotherapy\\nfor cancer.\\nAspergillus\\nAspergillosis is an infection of the lungs caused by inhala-\\ntion of airborne spores of the fungusAspergillus. (Illustration\\nby Electronic Illustrators Group).\\nKEY TERMS\\nAntibody— A specific protein produced by the\\nimmune system in response to a specific foreign\\nprotein or particle called an antigen.\\nAspergilloma— A ball or mass made of Aspergillus\\nfungi that can form in the lungs of patients with\\nsuppressed immune systems.\\nBronchial lavage— A procedure that involves\\nrepeatedly washing the inside of the bronchial\\ntubes of the lung.\\nHemoptysis— Spitting up blood from the lungs or\\nsputum stained with blood.\\nImmunocompromised— A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nMeningitis— Inflammation of the membranes cover-\\ning the brain and spinal cord, called the meninges.\\nNebulizer— A device that produces an extremely\\nfine mist that is readily inhalable.\\nSpores— The small, thick-walled reproductive\\nstructures of fungi.\\nSputum— Mucus and other matter coughed up\\nfrom the airways.\\n420 GALE ENCYCLOPEDIA OF MEDICINE\\nAspergillosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15None of the currently available antifungal drugs are\\nreliably effective againstAspergillus.\\nCauses and symptoms\\nAirborne Aspergillus spores enter the body pri-\\nmarily through inhalation but can also lodge in the\\near or eye. Normally functioning immune systems are\\ngenerally able to cope without consequent develop-\\nment of aspergillosis.\\nIt is important to make distinctions between the\\nvarious forms of aspergillosis, as the treatment and\\nprognosis varies considerably among types.\\nAspergillosis as a diagnosis refers to three general\\nforms:\\n/C15Allergic bronchopulmonary aspergillosis (ABPA) is\\nseen in patients with long-standing asthma, particu-\\nlarly in patients taking oralcorticosteroids for a long\\nperiod of time. This is usually the least serious and\\nmost treatable form.\\n/C15Aspergilloma refers to the mass formed when fungal\\nspores settle into or colonize areas of the lung that\\nhave been pitted and scarred as a result of tubercu-\\nlosis or priorpneumonia. There are several available\\ntreatments, although the success rate varies with each\\ntreatment.\\n/C15Invasive fungal infection refers to rare cases in which\\nthe fungus spreads throughout the body via the\\nblood stream and invades other organ systems.\\nOnce established, invasive fungal infections are\\nextremely difficult to cure and, as a result, the asso-\\nciated death rate is extremely high.\\nDiagnosis\\nAspergillosis can be quite difficult to diagnose\\nbecause the symptoms, such as coughing andwheezing,\\nif present at all, are common to many respiratory\\ndisorders. Furthermore, blood and sputum cultures\\nare not very helpful. The presence ofAspergillus is\\nso common, even in asthmatics, that a positive culture\\nalone is insufficient for a diagnosis. Other, potentially\\nmore useful, screening tools include examining the\\nsample obtained after repeatedly washing the bronchial\\ntubes of the lung with water (bronchial lavage), but\\nexamining a tissue sample (biopsy) is the most reliable\\ndiagnostic tool. Researchers are currently attempting\\nto develop a practical, specific, and rapid blood test\\nthat would confirmAspergillus infection.\\nSigns of ABPA include a worsening of bronchial\\nasthmaaccompanied by a low-grade fever. Brown flecks\\nor clumps may be seen in the sputum. Pulmonary\\nfunction tests may show decreased blood flow, suggest-\\ning an obstruction within the lungs. Elevated blood levels\\nof an antibody produced in response toAspergillusand\\nof certain immune system cells may indicate a specific\\nallergic-type immune system response.\\nA fungal mass (aspergilloma) in the lung usually\\ndoes not produce clear symptoms and is generally diag-\\nnosed when seen on chest x rays. However, 70% or\\nmore of patients spit up blood from the lungs (hemop-\\ntysis) at least once, and this may become repetitive and\\nserious. Hemoptysis, then, is another indication that\\nthe patient may be suffering from an aspergilloma.\\nIn patients with lowered immune systems who are\\nat risk for developing invasive aspergillosis, the physi-\\ncian may use a combination of blood culture with\\nvisual diagnostic techniques, such as computed tomo-\\ngraphy scans (CT) and radiography, to arrive at a\\nlikely diagnosis.\\nTreatment\\nThe treatment method selected depends on the\\nform of aspergillosis. ABPA can usually be treated\\nwith many of the same drugs used to treat asthma,\\nsuch as systemic steroids. Long-term therapy may be\\nrequired, however, to prevent recurrence. Antifungal\\nagents are not recommended in the treatment of\\nABPA. In cases of aspergilloma, it may become neces-\\nsary to surgically remove or reduce the size of a fungal\\nmass, especially if the patient continues to spit up\\nblood. In aspergillosis cases affecting the nose and\\nnasal sinuses, surgery may also be required.\\nIn non-ABPA cases, the use of antifungal drugs\\nmay be indicated. In such cases, amphotericin B\\n(Fungizone) is the first-line therapy. The prescribed\\ndose will depend on the patient’s condition but usually\\nbegins with a small test dose and then escalates. Less\\nthan one-third of patients are likely to respond to\\namphotericin B, and its side effects often limit its use.\\nFor patients who do not respond to oral amphotericin\\nB, another option is a different formulation of the\\nsame drug called liposomal amphotericin B.\\nFor patients who fail to respond or who cannot\\ntolerate amphotericin B, another drug called itracona-\\nzole (Sporanox), given 400-600 mg daily, has also been\\napproved. Treatment generally lasts about 3 months.\\nGiving itraconazole can produce adverse reactions if\\nprescribed in combination with certain other drugs by\\nincreasing the concentrations of both drugs in the\\nblood and creating a potentially life-threatening situa-\\ntion. Even antacids can significantly affect itracona-\\nzole levels. As a result, drug levels must be continually\\nGALE ENCYCLOPEDIA OF MEDICINE 421\\nAspergillosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='monitored to ensure that absorption is occurring at\\nacceptable levels.\\nTwo other methods of treatment are being\\nstudied: direct instillat ion of an antifungal agent\\ninto the lungs and administration of antifungals\\nusing a nebulizer. Instilling or injecting amphoter-\\nicin B or itraconazole directly into the lung cavity\\nor into the fungal ball (aspergilloma) itself has\\nbeen helpful in stopping episodes of hemoptysis,\\nbut not in preventing future recurrences.\\nFurthermore, many patients with aspergillomas\\nare poor risks for surgery because their lung func-\\ntion is already compromise d .A sar e s u l t ,i n s t i l l a -\\ntion of a fungal agent should only be considered in\\nthose who have significant hempotysis.\\nA popular method of treating some respiratory\\ndisorders is to add a liquid drug to another carrier liquid\\nand aerosolize or produce a fine mist that can be inhaled\\ninto the lungs through a device called a nebulizer.\\nHowever, this has not yet been shown to improve the\\npatient’s condition in cases of aspergillosis, possibly\\nbecause the drug is not reaching the aspergilloma.\\nAt this point, preventative therapy for aspergillo-\\nsis is not suggested for susceptible individuals, primar-\\nily because overuse of the drugs used to fight fungal\\ninfections may lead to the development of drug-\\nresistant aspergillosis against which current antifungal\\ndrugs are no longer effective.\\nPrognosis\\nThe likelihood of recovery from aspergillosis\\ndepends on any underlying medical conditions, the\\npatient’s general health, and the specific type of asper-\\ngillosis. If the problem is based on an allergic response,\\nas in ABPA, the patient will likely respond well to\\nsystemic steroids.\\nPatients who requirelung surgery, especially those\\nwho have problems with coughing up blood, have a\\nmortality rate of about 7-14%, and complications or\\nrecurrence may result in a higher overall death rate.\\nHowever, by treating aspergilloma with other, non-\\nsurgical methods, that risk rises to 26%, making sur-\\ngery a better option in some cases.\\nUnfortunately, the prognosis for the most serious\\nform, invasive aspergillosis, is quite poor, largely\\nbecause these patients have little resilience due to\\ntheir underlying disorders. Death rates have ranged\\nfrom about 50% in some studies to as high as 95% for\\nbone-marrow recipients and patients with AIDS. The\\ncourse of the illness can be rapid, resulting in death\\nwithin a few months of diagnosis.\\nPrevention\\nFungal infection byAspergillus presents a major\\nchallenge, particularly in the patient with a suppressed\\nimmune system (immunocompr omised). Hospitals\\nand government health agencies continually seek\\nways to minimize exposure for hospitalized patients.\\nPractical suggestions are minimal but include moving\\nleaf piles away from the house. Unfortunately, overall\\navoidance of this fungus is all but impossible because\\nit is present in the environment virtually everywhere.\\nResearch efforts are being directed at enhancing\\npatients’ resistance toAspergillus rather than trying\\nto eliminate exposure to the fungus. Given the grow-\\ning number of people with immune disorders or whose\\nimmune systems have been suppressed in the course of\\ntreating another disease, research and clinical trials\\nfor new antifungal agents will be increasingly impor-\\ntant in the future.\\nResources\\nORGANIZATIONS\\nAmerican College of Allergy, Asthma, and Immunology.\\n85 West Algonquin Road, Suite 550, Arlington Heights,\\nIL 60005. .\\nOTHER\\n‘‘Lung, Allergic and Immune Diseases: Mold Allergy:\\nPrevention Techniques.’’ National Jewish Medical and\\nResearch..\\nOffice of Rare Diseases (ORD) at National Institutes\\nof Health, Bldg. 31,1BO3, Bethesda, MD 20892-\\n2082. (301) 402-4336.\\nJill S. Lasker\\nAspirin\\nDefinition\\nAspirin is a medicine that relievespain and reduces\\nfever.\\nPurpose\\nAspirin is used to relieve many kinds of minor\\naches and pains–headaches, toothaches, muscle pain,\\nmenstrual cramps, the joint pain from arthritis, and\\naches associated with colds and flu. Some people take\\naspirin daily to reduce the risk of stroke, heart attack,\\nor other heart problems.\\n422 GALE ENCYCLOPEDIA OF MEDICINE\\nAspirin'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nAspirin–also known as acetylsalicylic acid–is sold\\nover the counter and comes in many forms, from the\\nfamiliar white tablets to chewing gum and rectal sup-\\npositories. Coated, chewable, buffered, and extended\\nrelease forms are available. Many other over-the-\\ncounter medicine contain aspirin. Alka-Seltzer\\nOriginal Effervescent Antacid Pain Reliever, for\\nexample, contains aspirin for pain relief and sodium\\nbicarbonate to relieve acid indigestion, heartburn, and\\nsour stomach.\\nAspirin belongs to a group of drugs called salicy-\\nlates. Other members of this group include sodium\\nsalicylate, choline salicylate, and magnesium salicy-\\nlate. These drugs are more expensive and no more\\neffective than aspirin. However, they are a little easier\\non the stomach. Aspirin is quickly absorbed into the\\nbloodstream and provides quick and relatively long-\\nlasting pain relief. Aspirin also reduces inflammation.\\nResearchers believe these effects come about because\\naspirin blocks the production of pain-producing che-\\nmicals called prostaglandins.\\nIn addition to relieving pain and reducing inflam-\\nmation, aspirin also lowersfever by acting on the part\\nof the brain that regulates temperature. The brain then\\nsignals the blood vessels to widen, which allows heat to\\nleave the body more quickly.\\nRecommended dosage\\nAdults\\nTO RELIEVE PAIN OR REDUCE FEVER. One to two\\ntablets every three to four hours, up to six times per day.\\nTO REDUCE THE RISK OF STROKE. One tablet four\\ntimes a day or two tablets twice a day.\\nTO REDUCE THE RISK OF HEART ATTACK.Check with\\na physician for the proper dose and number of times\\nper week aspirin should, if at all, be taken.\\nChildren\\nCheck with a physician.\\nPrecautions\\nAspirin–even children’s aspirin–should never be\\ngiven to children or teenagers with flu-like symptoms\\nor chickenpox. Aspirin can causeReye’s syndrome,a\\nlife-threatening condition that affects the nervous sys-\\ntem and liver. As many as 30% of children and teen-\\nagers who develop Reye’s syndrome die. Those who\\nsurvive may have permanent brain damage.\\nCheck with a physician before giving aspirin to a\\nchild under 12 years for arthritis, rheumatism, or any\\ncondition that requires long-term use of the drug.\\nNo one should take aspirin for more than 10 days\\nin a row unless told to do so by a physician. Anyone\\nwith fever should not take aspirin for more than 3 days\\nwithout a physician’s consent. Do not to take more\\nthan the recommended daily dosage.\\nPeople in the following categories should not use\\naspirin without first checking with their physician:\\n/C15Pregnant women. Aspirin can cause bleeding pro-\\nblems in both the mother and the developing fetus.\\nAspirin can also cause the infant’s weight to be too\\nlow at birth.\\n/C15Women who are breastfeeding. Aspirin can pass into\\nbreast milk and may affect the baby.\\nKEY TERMS\\nDiuretic— Medicine that increases the amount of\\nurine produced and relieves excess fluid buildup in\\nbody tissues. Diuretics may be used in treating high\\nblood pressure, lung disease, premenstrual syn-\\ndrome, and other conditions.\\nInflammation— Pain, redness, swelling, and heat\\nthat usually develop in response to injury or illness.\\nNSAIDs— Nonsteroidal anti-inflammatory drugs.\\nDrugs such as ketoprofen and ibuprofen which\\nrelieve pain and reduce inflammation.\\nPolyp— A lump of tissue protruding from the lining\\nof an organ, such as the nose, bladder, or intestine.\\nPolyps can sometimes block the passages in which\\nthey are found.\\nProstaglandin— A hormonelike chemical produced\\nin the body. Prostaglandins have a wide variety of\\neffects, and may be responsible for the production\\nof some types of pain and inflammation.\\nReye’s syndrome— A life-threatening disease that\\naffects the liver and the brain and sometimes occurs\\nafter a viral infection, such as flu or chickenpox.\\nChildren or teenagers who are given aspirin for flu\\nor chickenpox are at increased risk of developing\\nReye’s syndrome.\\nRhinitis— Inflammation of the membranes inside\\nthe nose.\\nSalicylates— A group of drugs that includes aspirin\\nand related compounds. Salicylates are used to\\nrelieve pain, reduce inflammation, and lower fever.\\nGALE ENCYCLOPEDIA OF MEDICINE 423\\nAspirin'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15People with a history of bleeding problems.\\n/C15People who are taking blood-thinning drugs, such as\\nwarfarin (Coumadin).\\n/C15People with a history of ulcers.\\n/C15People with a history ofasthma, nasal polyps, or\\nboth. These people are more likely to be allergic to\\naspirin.\\n/C15People who are allergic to fenoprofen, ibuprofen,\\nindomethacin, ketoprofen, meclofenamate sodium,\\nnaproxen, sulindac, tolmetin, or the orange food-\\ncoloring tartrazine. They may also be allergic to\\naspirin.\\n/C15People withAIDS or AIDS-related complex who are\\ntaking AZT (zidovudine). Aspirin can increase the\\nrisk of bleeding in these patients.\\n/C15People taking certain other drugs (discussed in\\nInteractions).\\n/C15People with liver damage or severe kidney failure.\\nAspirin should not be taken before surgery, as it\\ncan increase the risk of excessive bleeding. Anyone\\nwho is scheduled for surgery should check with his or\\nher surgeon to find out how long before surgery to\\navoid taking aspirin.\\nAspirin can cause stomach irritation. To reduce\\nthe likelihood of that problem, take aspirin with food\\nor milk or drink a full 8-oz glass of water with it.\\nTaking coated or buffered aspirin can also help. Be\\naware that drinking alcohol can make the stomach\\nirritation worse.\\nStop taking aspirin immediately and call a physi-\\ncian if any of these symptoms develop:\\n/C15ringing or buzzing in the ears\\n/C15hearing loss\\n/C15dizziness\\n/C15stomach pain that does not go away\\nDo not take aspirin that has a vinegary smell.\\nThat is a sign that the aspirin is too old and ineffective.\\nFlush such aspirin down the toilet.\\nBecause aspirin can increase the risk of exces-\\nsive bleeding, do not take aspirin daily over long\\nperiods–to reduce the risk of stroke or heart\\nattack, for example–unless advised to do so by a\\nphysician.\\nSide effects\\nThe most common side effects include stomach-\\nache, heartburn, loss of appetite, and small amounts of\\nblood in stools. Less common side effects are rashes,\\nhives, fever, vision problems, liver damage, thirst, sto-\\nmach ulcers, and bleeding. People who are allergic to\\naspirin or those who have asthma,rhinitis, or polyps in\\nthe nose may have trouble breathing after taking\\naspirin.\\nInteractions\\nAspirin may increase, decrease, or change the\\neffects of many drugs. Aspirin can make drugs such\\nas methotrexate (Rheumatrex) and valproic acid\\n(Depakote, Depakene) more toxic. If taken with\\nblood-thinning drugs, such as warfarin (Coumadin)\\nand dicumarol, aspirin can increase the risk of\\nexcessive bleeding. Aspirin counteracts the effects\\nof other drugs, such as angiotensin-converting\\nenzyme (ACE) inhibitors and beta blockers, which\\nlower blood pressure, and medicines used to treat\\ngout (probenecid and sulfinpyrazone). Blood pres-\\nsure may drop unexpectedly and cause fainting or\\ndizziness if aspirin is taken along with nitroglycerin\\ntablets. Aspirin may also interact with diuretics,\\ndiabetes medicines, other nonsteroidal anti-inflam-\\nmatory drugs (NSAIDs), seizure medications, and\\nsteroids. Anyone who is taking these drugs should\\nask his or her physician whether they can safely\\ntake aspirin.\\nResources\\nPERIODICALS\\n‘‘What’s the Best Pain Reliever? Depends on Your Pain.’’\\nConsumer ReportsMay 1996: 62.\\nNancy Ross-Flanigan\\nAST see Aspartate aminotransferase test\\nAstemizole see Antihistamines\\nAsthma\\nDefinition\\nAsthma is a chronic (long-lasting) inflammatory\\ndisease of the airways. In those susceptible to asthma,\\nthis inflammation causes the airways to narrow peri-\\nodically. This, in turn, produceswheezing and breath-\\nlessness, sometimes to the point where the patient\\ngasps for air. Obstruction to air flow either stops\\nspontaneously or responds to a wide range of treat-\\nments, but continuing inflammation makes the\\n424 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='airways hyper-responsive to stimuli such as cold air,\\nexercise, dust mites, pollutants in the air, and even\\nstress and anxiety.\\nDescription\\nBetween 17 million and 26 million Americans\\nhave asthma, and the number seems to be increasing.\\nIn about 1992, the number with asthma was about\\n10 million, and had risen 42% from 1982, just 10 years\\nprior. Not only is asthma becoming more frequent,\\nbut it also is a more severe disease than before, despite\\nmodern drug treatments. Asthma accounts for almost\\n500,000 hospitalizations, two million emergency\\ndepartment visits, and 5,000 deaths in the United\\nStates each year.\\nThe changes that take place in the lungs of asth-\\nmatic persons makes the airways (the ‘‘breathing\\ntubes,’’ orbronchi and the smallerbronchioles) hyper-\\nreactive to many different types of stimuli that don’t\\naffect healthy lungs. In an asthma attack, the muscle\\ntissue in the walls of bronchi go into spasm, and the\\ncells lining the airways swell and secrete mucus into the\\nair spaces. Both these actions cause the bronchi to\\nbecome narrowed (bronchoconstriction). As a result,\\nan asthmatic person has to make a much greater effort\\nto breathe in air and to expel it.\\nCells in the bronchial walls, called mast cells,\\nrelease certain substances that cause the bronchial\\nmuscle to contract and stimulate mucus formation.\\nThese substances, which include histamine and a\\nIn normal bronchioles the airway\\nis open and unobstructed.\\nDuring an attack, the bronchioles of an\\nasthma sufferer are constricted by bands\\nof muscle around them. They may be\\nfurther obstructed by increased mucus\\nproduction and tissue inflammation.\\nA comparison of normal bronchioles and those of an asthma sufferer.(Illustration by Hans & Cassady.)\\nGALE ENCYCLOPEDIA OF MEDICINE 425\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='group of chemicals called leukotrienes, also bring\\nwhite blood cells into the area, which is a key part of\\nthe inflammatory response. Many patients with\\nasthma are prone to react to such ‘‘foreign’’ sub-\\nstances as pollen, house dust mites, or animal dander;\\nthese are called allergens. On the other hand, asthma\\naffects many patients who are not allergic in this way.\\nAsthma usually begins in childhood or adoles-\\ncence, but it also may first appear during adult years.\\nWhile the symptoms may be similar, certain important\\naspects of asthma are different in children and adults.\\nChild-onset asthma\\nNearly one-third on the 17 to 26 million\\nAmericans with asthma are children. When asthma\\nbegins in childhood, it often does so in a child who is\\nlikely, for genetic reasons, to become sensitized to\\ncommon allergens in the environment (atopic person).\\nWhen these children are exposed to house-dust mites,\\nanimal proteins, fungi, or other potential allergens,\\nthey produce a type of antibody that is intended to\\nengulf and destroy the foreign materials. This has the\\neffect of making the airway cells sensitive to particular\\nmaterials. Further exposure can lead rapidly to an\\nasthmatic response. This condition of atopy is present\\nin at least one-third and as many as one-half of the\\ngeneral population. When an infant or young child\\nwheezes during viral infections, the presence of allergy\\n(in the child or a close relative) is a clue that asthma\\nmay well continue throughout childhood.\\nAdult-onset asthma\\nAllergenic materials may also play a role when\\nadults become asthmatic. Asthma can actually start\\nat any age and in a wide variety of situations. Many\\nadults who are not allergic have conditions such as\\nsinusitis or nasal polyps, or they may be sensitive to\\naspirin and related drugs. Another major source of\\nadult asthma is exposure at work to animal products,\\ncertain forms of plastic, wood dust, or metals.\\nCauses and symptoms\\nIn most cases, asthma is caused by inhaling an\\nallergen that sets off the chain of biochemical and\\ntissue changes leading to airway inflammation,\\nbronchoconstriction, and wheezing. Because avoiding\\n(or at least minimizing) exposure is the most effective\\nway of treating asthma, it is vital to identify which\\nallergen or irritant is causing symptoms in a particular\\npatient. Once asthma is present, symptoms can be set\\noff or made worse if the patient also has rhinitis\\n(inflammation of the lining of the nose) or sinusitis.\\nWhen, for some reason, stomach acid passes back up\\nthe esophagus (acid reflux), this can also make asthma\\nworse. A viral infection of the respiratory tract can\\nalso inflame an asthmatic reaction. Aspirin and a type\\nof drug called beta-blockers, often used to treat high\\nblood pressure, can also worsen the symptoms of\\nasthma.\\nThe most important inhaled allergens giving rise\\nto attacks of asthma are:\\n/C15animal dander\\n/C15mites in house dust\\n/C15fungi (molds) that grow indoors\\n/C15cockroach allergens\\n/C15pollen\\n/C15occupational exposure to chemicals, fumes, or parti-\\ncles of industrial materials in the air\\nInhaling tobacco smoke, either by smoking or\\nbeing near people who are smoking, can irritate the\\nairways and trigger an asthmatic attack. Air pollu-\\ntants can have a similar effect. In addition, there are\\nthree important factors that regularly produce attacks\\nin certain asthmatic patients, and they may sometimes\\nbe the sole cause of symptoms. They are:\\n/C15inhaling cold air (cold-induced asthma)\\n/C15exercise-induced asthma (in certain children, asthma\\nis caused simply by exercising)\\n/C15stress or a high level of anxiety\\nKEY TERMS\\nAllergen— A foreign substance, such as mites in\\nhouse dust or animal dander which, when inhaled,\\ncauses the airways to narrow and produces symp-\\ntoms of asthma.\\nAtopy— A state that makes persons more likely to\\ndevelop allergic reactions of any type, including\\nthe inflammation and airway narrowing typical of\\nasthma.\\nHypersensitivity— The state where even a tiny\\namount of allergen can cause the airways to con-\\nstrict and bring on an asthmatic attack.\\nSpirometry— A test using an instrument called a\\nspirometer that shows how difficult it is for an asth-\\nmatic patient to breathe. Used to determine the\\nseverity of asthma and to see how well it is respond-\\ning to treatment.\\n426 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Wheezing is often obvious, but mild asthmatic\\nattacks may be confirmed when the physician listens\\nto the patient’s chest with a stethoscope. Besides\\nwheezing and being short of breath, the patient\\nmay cough and may report a feeling of ‘‘tightness’’\\nin the chest. Children may have itching on their\\nback or neck at the start of an attack. Wheezing is\\noften loudest when the patient breathes out, in an\\nattempt to expel used air through the narrowed\\nairways. Some asthmatics are free of symptoms\\nmost of the time but may occasionally be short of\\nbreath for a brief time. Others spend much of their\\ndays (and nights) coughing and wheezing, until\\nproperly treated. Crying or even laughing may\\nbring on an attack. Severe episodes are often seen\\nwhen the patient gets a viral respiratory tract infec-\\ntion or is exposed to a heavy load of an allergen or\\nirritant. Asthmatic attacks may last only a few min-\\nutes or can go on for hours or even days (a condi-\\ntion called status asthmaticus).\\nBeing short of breath may cause a patient to\\nbecome very anxious, sit upright, lean forward, and\\nuse the muscles of the neck and chest wall to help\\nbreathe. The patient may be able to say only a few\\nwords at a time before stopping to take a breath.\\nConfusion and a bluish tint to the skin are clues\\nthat the oxygen supply is much too low, and that\\nemergency treatment is needed. In a severe attack\\nthat lasts for some time, some of the air sacs in the\\nlung may rupture so that air collects within the\\nchest. This makes it even harder to breathe in\\nenough air.\\nDiagnosis\\nApart from listening to the patient’s chest, the\\nexaminer should look for maximum chest expansion\\nwhile taking in air. Hunched shoulders and contract-\\ning neck muscles are other signs of narrowed airways.\\nNasal polypsor increased amounts of nasal secretions\\nare often noted in asthmatic patients. Skin changes,\\nlike atopic dermatitis or eczema, are a tipoff that the\\npatient has allergic problems.\\nInquiring about a family history of asthma or\\nallergies can be a valuable indicator of asthma. The\\ndiagnosis may be strongly suggested when typical\\nsymptoms and signs are present. A test called spiro-\\nmetry measures how rapidly air is exhaled and how\\nmuch is retained in the lungs. Repeating the test after\\nthe patient inhales a drug that widens the air passages\\n(a bronchodilator) will show whether the airway nar-\\nrowing is reversible, which is a very typical finding in\\nasthma. Often patients use a related instrument, called\\na peak flow meter, to keep track of asthma severity\\nwhen at home.\\nOften, it is difficult to determine what is triggering\\nasthma attacks. Allergy skin testing may be used,\\nalthough an allergic skin response does not always\\nmean that the allergen being tested is causing the\\nasthma. Also, the body’s immune system produces\\nantibody to fight off the allergen, and the amount of\\nantibody can be measured by a blood test. This will\\nshow how sensitive the patient is to a particular aller-\\ngen. If the diagnosis is still in doubt, the patient can\\ninhale a suspect allergen while using a spirometer to\\ndetect airway narrowing. Spirometry can also be\\nrepeated after a bout of exercise if exercise-induced\\nasthma is a possibility. A chest x ray will help rule\\nout other disorders.\\nTreatment\\nPatients should be periodically examined and\\nhave their lung function measured by spirometry to\\nmake sure that treatment goals are being met. These\\ngoals are to prevent troublesome symptoms, to main-\\ntain lung function as close to normal as possible, and\\nto allow patients to pursue their normal activities\\nincluding those requiring exertion. The best drug ther-\\napy is that which controls asthmatic symptoms while\\ncausing few or no side-effects.\\nDrugs\\nMETHYLXANTHINES. The chief methylxanthine\\ndrug is theophylline. It may exert some anti-inflam-\\nmatory effect, and is especially helpful in controlling\\nnighttime symptoms of asthma. When, for some rea-\\nson, a patient cannot use an inhaler to maintain long-\\nterm control, sustained-release theophylline is a good\\nalternative. The blood levels of the drug must be mea-\\nsured periodically, as too high a dose can cause an\\nabnormal heart rhythm or convulsions.\\nBETA-RECEPTOR AGONISTS. These drugs, which\\nare bronchodilators , are the best choice for relieving\\nsudden attacks of asthma and for preventing attacks\\nfrom being triggered by exercise. Some agonists, such\\nas albuterol, act mainly in lung cells and have little\\neffect on other organs, such as the heart. These\\ndrugs generally start acting within minutes, but\\ntheir effects last only four tosix hours. Longer-acting\\nbrochodilators have been developed. They may last\\nup to 12 hours. Bronchodilators may be taken in pill\\nor liquid form, but normally are used as inhalers,\\nwhich go directly to the lungs and result in fewer\\nside effects.\\nGALE ENCYCLOPEDIA OF MEDICINE 427\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='STEROIDS. These drugs, which resemble natural\\nbody hormones, block inflammation and are extre-\\nmely effective in relieving symptoms of asthma.\\nWhen steroids are taken by inhalation for a long\\nperiod, asthma attacks become less frequent as the\\nairways become less sensitive to allergens. This is\\nthe strongest medicine for asthma, and can control\\neven severe cases over the long term and maintain\\ngood lung function. Steroids can cause numerous\\nside-effects, however, including bleeding from the\\nstomach, loss of calcium from bones, cataracts in\\nthe eye, and a diabetes-like state. Patients using\\nsteroids for lengthy periods may also have problems\\nwith wound healing, may gain weight, and may\\nsuffer mental problems. In children, growth may\\nbe slowed. Besides being inhaled, steroids may be\\ntaken by mouth or injected, to rapidly control\\nsevere asthma.\\nLEUKOTRIENE MODIFIERS. Leukotriene modifiers\\n(montelukast and zafirlukast) are a new type of\\ndrug that can be used in place of steroids, for\\nolder children or adults who have a mild degree of\\nasthma that persists. They work by counteracting\\nleukotrienes, which are substances released by white\\nblood cells in the lung that cause the air passages to\\nconstrict and promote mucus secretion. Leukotriene\\nmodifiers also fight off some forms of rhinitis, an\\nadded bonus for people with asthma. However, they\\nare not proven effective in fighting seasonal\\nallergies.\\nOTHER DRUGS. Cromolyn and nedocromil are\\nanti-inflammatory drugs that are often used as\\ninitial treatment to prevent asthmatic attacks over\\nthe long term in children. They can also prevent\\nattacks when given before exercise or when expo-\\nsure to an allergen cannot be avoided. These are\\nsafe drugs but are expensive, and must be taken\\nregularly even if there are no symptoms. Anti-cho-\\nlinergic drugs, such as atropine, are useful in con-\\ntrolling severe attacks when added to an inhaled\\nbeta-receptor agonist. They help widen the airways\\nand suppress mucus production.\\nIf a patient’s asthma is caused by an allergen that\\ncannot be avoided and it has been difficult to control\\nsymptoms by drugs, immunotherapy may be worth\\ntrying. Typically, increasing amounts of the allergen\\nare injected over a period of three to five years, so that\\nthe body can build up an effective immune response.\\nThere is a risk that this treatment may itself cause the\\nairways to become narrowed and bring on an asth-\\nmatic attack. Not all experts are enthusiastic about\\nimmunotherapy, although some studies have shown\\nthat it reduces asthmatic symptoms caused by\\nexposure to house-dust mites, ragweed pollen, and\\ncat dander.\\nManaging asthmatic attacks\\nA severe asthma attack should be treated as\\nquickly as possible. It is most important for a patient\\nsuffering an acute attack to be given extra oxygen.\\nRarely, it may be necessary to use a mechanical venti-\\nlator to help the patient breathe. A beta-receptor ago-\\nnist is inhaled repeatedly or continuously. If the\\npatient does not respond promptly and completely, a\\nsteroid is given. A course of steroid therapy, given\\nafter the attack is over, will make a recurrence less\\nlikely.\\nMaintaining control\\nLong-term asthma treatment is based on inhaling\\na beta-receptor agonist using a special inhaler that\\nmeters the dose. Patients must be instructed in proper\\nuse of an inhaler to be sure that it will deliver the right\\namount of drug. Once asthma has been controlled for\\nseveral weeks or months, it is worth trying to cut down\\non drug treatment, but this must be done gradually.\\nThe last drug added should be the first to be reduced.\\nPatients should be seen every one to six months,\\ndepending on the frequency of attacks.\\nStarting treatment at home, rather than in a hos-\\npital, makes for minimal delay and helps the patient to\\ngain a sense of control over the disease. All patients\\nshould be taught how to monitor their symptoms so\\nthat they will know when an attack is starting, and\\nthose with moderate or severe asthma should know\\nh o wt ou s eaf l o wm e t e r .T h e ys h o u l da l s oh a v ea\\nwritten ‘‘action plan’’ to follow if symptoms suddenly\\nbecome worse, including how to adjust their medica-\\ntion and when to seek medical help. A 2004 report said\\nthat a review of medical studies revealed that patients\\nwith self-management written action plans had fewer\\nhospitalizations, fewer emergency department visits,\\nand improved lung function. They also had a 70%\\nlower mortality rate. If more intense treatment is neces-\\nsary, it should be continued for several days. Over-the-\\ncounter ‘‘remedies’’ should be avoided. When deciding\\nwhether a patient should be hospitalized, the past his-\\ntory of acute attacks, severity of symptoms, current\\nmedication, and whether good support is available at\\nhome all must be taken into account.\\nReferral to an asthma specialist should be consid-\\nered if:\\n/C15there has been a life-threatening asthma attack or\\nsevere, persistent asthma\\n428 GALE ENCYCLOPEDIA OF MEDICINE\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15treatment for three to six months has not met its\\ngoals\\n/C15some other condition, such as nasal polyps or\\nchronic lung disease, is complicating asthma\\n/C15special tests, such as allergy skin testing or an aller-\\ngen challenge, are needed\\n/C15intensive steroid therapy has been necessary\\nSpecial populations\\nINFANTS AND YOUNG CHILDREN. It is especially\\nimportant to closely watch the course of asthma in\\nyoung patients. Treatment is cut down when possible\\nand if there is no clear improvement, some other treat-\\nment should be tried. If a viral infection leads to severe\\nasthmatic symptoms, steroids may help. The health\\ncare provider should write out an asthma treatment\\nplan for the child’s school. Asthmatic children often\\nneed medication at school to control acute symptoms\\nor to prevent exercise-induced attacks. Proper man-\\nagement will usually allow a child to take part in play\\nactivities. Only as a last resort should activities be\\nlimited.\\nTHE ELDERLY. Older persons often have other\\ntypes of obstructive lung disease, such as chronic\\nbronchitis or emphysema. This makes it important\\nto know to what extent the symptoms are caused\\nby asthma. Giving steroids for two to three weeks\\ncan help determine this. Side-effects from beta-\\nreceptor agonist drugs (including a speeding heart\\nand tremor) may be more common in older\\npatients. These patients may benefit from receiving\\nan anti-cholinergic drug,along with the beta-recep-\\ntor agonist. If theophylline is given, the dose\\nshould be limited, as older patients are less able\\nto clear this drug from their blood. Steroids should\\nbe avoided, as they often make elderly patients\\nconfused and agitated. Steroids may also further\\nweaken the bones.\\nPrognosis\\nMost patients with asthma respond well when\\nthe best drug or combination of drugs is found, and\\nthey are able to lead relatively normal lives. More\\nthan one-half of affected children stop having\\nattacks by the time they reach 21 years of age.\\nMany others have less frequent and less severe\\nattacks as they grow older. Urgent measures to\\ncontrol asthma attacks and ongoing treatment to\\nprevent attacks are equally important. A small min-\\nority of patients will have progressively more trou-\\nble breathing and run a risk of going into\\nrespiratory failure, for which they must receive\\nintensive treatment.\\nPrevention\\nMinimizing exposure to allergens\\nThere are a number of ways to cut down exposure\\nto the common allergens and irritants that provoke\\nasthmatic attacks, or to avoid them altogether:\\n/C15If the patient is sensitive to a family pet, removing the\\nanimal or at least keeping it out of the bedroom (with\\nthe bedroom door closed), as well as keeping the pet\\naway from carpets and upholstered furniture and\\nRemoving hair and feathers.\\n/C15To reduce exposure to house dust mites, removing\\nwall-to-wall carpeting, keeping humidity down, and\\nusing special pillows and mattress covers. Cutting\\ndown on stuffed toys, and washing them each week\\nin hot water.\\n/C15If cockroach allergen is causing asthma attacks, kill-\\ning the roaches (using poison, traps, or boric acid\\nrather than chemicals). Taking care not to leave food\\nor garbage exposed.\\n/C15Keeping indoor air clean by vacuuming carpets\\nonce or twice a week (with the patient absent),\\navoiding using humidifiers. Using air conditioning\\nduring warm weather (so that the windows can be\\nclosed).\\n/C15Avoiding exposure to tobacco smoke.\\n/C15Not exercising outside when air pollution levels are\\nhigh.\\n/C15When asthma is related to exposure at work, taking\\nall precautions, including wearing a mask and, if\\nnecessary, arranging to work in a safer area.\\nMore than 80% of people with asthma have\\nrhinitis and recent research emphasizes that treating\\nrhinitis helps benefit ashtma. Prescription nasal ster-\\noids and other methods to control rhinitis (in addit-\\nion to avoiding known allergens) can help prevent\\nasthma attacks. It is also important for patients to\\nkeep open communication with physicians to ensure\\nthat the correcnt amount of medication is being\\ntaken.\\nResources\\nPERIODICALS\\n‘‘Many People With Asthma ArenÆt Taking the Right\\nAmount of Medication.’’Obesity, Fitness & Wellness\\nWeek (September 25, 2004): 87.\\nGALE ENCYCLOPEDIA OF MEDICINE 429\\nAsthma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Mintz, Matthew. ‘‘Asthma Update: Part 1. Diagnosis,\\nMonitoring, and Prevention of Disease Progression.’’\\nAmerican Family PhysicianSeptember 1, 2004: 893.\\nSolomon, Gina, Elizabeth H. Humphreys, and Mark D.\\nMiller. ‘‘Asthma and the Environment: Connecting the\\nDots: What Role do Environmental Exposures Play in\\nthe Rising Prevalence and Severity of Asthma?’’\\nContemporary PeditatricsAugust 2004: 73–81.\\n‘‘WhatÆs New in: Asthma and Allergic Rhinitis.’’Pulse\\nSeptember 20, 2004: 50.\\nORGANIZATIONS\\nAsthma and Allergy Foundation of America. 1233 20th\\nStreet, NW, Suite 402, Washington, DC 20036. (800)\\n727-8462. .\\nMothers of Asthmatics, Inc. 3554 Chain Bridge Road, Suite\\n200, Fairfax, VA 22030. (800) 878-4403.\\nNational Asthma Education Program. 4733 Bethesda Ave.,\\nSuite 350, Bethesda, MD 20814. (301) 495-4484.\\nNational Jewish Medical and Research Center. 1400\\nJackson St., Denver, CO 80206. (800) 222-LUNG.\\nDavid A. Cramer, MD\\nTeresa G. Odle\\nAstigmatism\\nDefinition\\nAstigmatism is the result of an inability of the\\ncornea to properly focus an image onto the retina.\\nThe result is a blurred image.\\nDescription\\nThe cornea is the outermost part of the eye. It is a\\ntransparent layer that covers the colored part of the eye\\n(iris), pupil, and lens. The cornea bends light and helps\\nto focus it onto the retina where specialized cells (photo\\nreceptors) detect light and transmit nerve impulses via\\nthe optic nerve to the brain where the image is formed.\\nThe cornea is dome shaped. Any incorrect shaping of\\nthe cornea results in an incorrect focusing of the light\\nthat passes through that part of the cornea. The bending\\nof light is called refraction and focusing problems with\\nthe cornea are called diseases of refraction or refractive\\ndisorders. Astigmatism is an image distortion that\\nresults from an improperly shaped cornea. Usually the\\ncornea is spherically shaped, like a baseball. However, in\\nastigmatism the cornea is elliptically shaped, more like a\\nfootball. There is a long meridian and a short meridian.\\nThese two meridians generally have a constant curva-\\nture and are generally perpendicular to each other\\n(regular astigmatism). Irregular astigmatism may have\\nmore than two meridians of focus and they may not be\\n908 apart. A point of light, therefore, going through an\\nastigmatic cornea will have two points of focus, instead\\nof one nice sharp image on the retina. This will cause the\\nperson to have blurry vision. What the blur looks like\\nwill depend upon the amount and the direction of the\\nastigmatism. A person with nearsightedness (myopia)o r\\nfarsightedness (hyperopia) may see a dot as a blurred\\ncircle. A person with astigmatism may see the same dot\\nas a blurred oval or frankfurter-shaped blur.\\nSome cases of astigmatism are caused by problems\\nin the lens of the eye. Minor variations in the curvature\\nof the lens can produce minor degrees of astigmatism\\n(lenticular astigmatism). In these patients, the cornea is\\nusually normal in shape. Infants, as a group, have the\\nleast amount of astigmatism. Astigmatism may increase\\nduring childhood, as the eye is developing.\\nCornea\\nLens\\nLight\\nRetina\\nHorizontal line out of focus\\nAstigmatism corrected by lens\\nLight\\nAstigmatism can be treated by the use of cylindrical lenses.\\nThe lenses are shaped to counteract the shape of the sec-\\ntions of the cornea that are causing the difficulty.(Illustration\\nby Electronic Illustrators Group.)\\n430 GALE ENCYCLOPEDIA OF MEDICINE\\nAstigmatism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nThe main symptom of astigmatism is blurring.\\nPeople can also experience headaches and eyestrain.\\nParents can notice that a child may have astigma-\\ntism when the child can see some part of a pattern\\nor picture more clearly than others. For example,\\nlines going across may seem clearer than lines going\\nup and down.\\nRegular astigmatism can be caused by the weight\\nof the upper eyelid resting on the eyeball creating\\ndistortion, surgical incisions in the cornea, trauma or\\nscarring to the cornea, the presence of tumors in the\\neyelid, or a developmental factor. Irregular astigma-\\ntism can be caused by scarring or keratoconus.\\nKeratoconus is a condition in which the cornea thins\\nand becomes cone shaped. It usually occurs around\\npuberty and is more common in women. Although the\\ncauses of keratoconus are unknown, it may be heredi-\\ntary or a result of chronic eye rubbing, as in people\\nwith allergies. The center of the cone may not be in line\\nwith the center of the cornea. Diabetes can play a role\\nin the development of astigmatism. High blood sugar\\nlevels can cause shape changes in the lens of the eye.\\nThis process usually occurs slowly and, often, is only\\nnoticed when the diabetic has started treatment to\\ncontrol their blood sugar. The return to a more normal\\nblood sugar allows the lens to return to normal and\\nthis change is sometimes noticed by the patient as\\nfarsightedness. Because of this, diabetics should wait\\nuntil their blood sugar is under control for at least one\\nmonth to allow vision to stabilize before being mea-\\nsured for eyeglasses.\\nDiagnosis\\nPatients seek treatment because of blurred vision.\\nA variety of tests can be used to detect astigmatism\\nduring the eye exam. The patient may be asked to\\ndescribe the astigmatic dial, a series of lines that radi-\\nate outward from a center. People with astigmatism\\nwill see some of the lines more clearly than others.\\nOne diagnostic instrument used is the keratometer.\\nThis measures the curvature of the central cornea.\\nIt measures the amount and direction of the curvature.\\nA corneal topographer can measure a larger area of\\nthe cornea. It can measure the central area and\\nmid-periphery of the cornea. A keratoscope projects\\na series of concentric light rings onto the cornea.\\nMisshapen areas of the cornea are revealed by noting\\nareas of the light pattern that do not appear con-\\ncentric on the cornea. Because these instruments are\\nmeasuring the cornea, it is also important to have a\\nrefraction in case the lens is also contributing to the\\nastigmatism. The refraction measures the optics or\\nvisual status of the eye and the result is the eyeglass\\nprescription. The refraction is when the patient is look-\\ning at an eye chart and the doctor is putting different\\nlenses in front of the patient’s eyes and asks which one\\nlooks better.\\nTreatment\\nAstigmatism can be treated by the use of cylind-\\nrical lenses. They can be in eyeglasses or contact lenses.\\nThe unit of measure describing the power of the lens\\nsystem or lens is called the diopter (D). The lenses are\\nshaped to counteract the shape of the sections of\\ncornea that are causing the difficulty. Because the\\ncorrection is in one direction, it is written in terms of\\nthe axis the correction is in. On a prescription, for\\nexample, it may say-1.00 /C21808. Cylinders correct\\nastigmatism, minus spheres correct myopia, and plus\\nspheres correct hyperopia.\\nThere is some debate as to whether people with\\nvery small amounts of astigmatism should be treated.\\nGenerally, if visual acuity is good and the patient\\nexperiences no overt symptoms, treatment is not\\nnecessary. When treating larger amounts of astigma-\\ntism, or astigmatism for the first time, the doctor may\\nnot totally correct the astigmatism. The cylindrical\\ncorrection in the eyeglasses may make the floor appear\\nto tilt, thus making it difficult for the patient at first.\\nGenerally, the doctor will place lenses in a trial frame\\nto allow the patient to try the prescription at the exam.\\nIt may take a week or so to get used to the glasses,\\nhowever, if the patient is having a problem they should\\ncontact their doctor, who might want to recheck the\\nprescription.\\nContact lenses that are used to correct astigma-\\ntism are called toric lenses. When a person blinks, the\\ncontact lens rotates. In toric lenses, it is important for\\nKEY TERMS\\nMeridian— A section of a sphere. For example,\\nlongitude or latitude on the globe. Or, on a clock, a\\nsection going through 12:00-6:00 or 3:00-9:00, etc.\\nRefraction— The turning or bending of light waves\\nas the light passes from one medium or layer to\\nanother. In the eye it means the ability of the eye\\nto bend light so that an image is focused onto the\\nretina.\\nGALE ENCYCLOPEDIA OF MEDICINE 431\\nAstigmatism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the lens to return to the same position each time.\\nLenses have thin zones, or cut-off areas (truncated),\\nor have other ways to rotate and return to the correct\\nposition. Soft toric lenses are available in a variety of\\nprescriptions, materials, and even in tints. Patients\\nshould ask their doctors about the possibility of toric\\nlenses.\\nIn 1997, the Food and Drug Administration\\n(FDA) approved laser treatment of astigmatism.\\nPatients considering this should make sure the surgeon\\nhas a lot of experience in the procedure and discuss the\\npossible side effects or risks with the doctor. In the\\ncase of keratoconus, a corneal transplant is performed\\nif the astigmatism can not be corrected with hard\\ncontact lenses.\\nPrognosis\\nAstigmatism is a condition that may be present at\\nbirth. It may also be acquired if something is distorting\\nthe cornea. Vision can generally be corrected with\\neyeglasses or contact lenses. The major risks of surgery\\n(aside from the surgical risks) are over and under\\ncorrection of the astigmatism. There is no cure for\\nover correction. Under correction can be solved by\\nrepeating the operation.\\nResources\\nBOOKS\\nBerkow, Robert, editor.Merck Manual of Medical\\nInformation. Whitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nJohn T. Lohr, PhD\\nAston-Patterning\\nDefinition\\nAston-Patterning is an integrated system of move-\\nment education, bodywork, ergonomic adjustments,\\nand fitness training that recognizes the relationship\\nbetween the body and mind for well being. It helps\\npeople who seek a remedy from acute or chronicpain\\nby teaching them to improve postural and movement\\npatterns.\\nPurpose\\nAston-Patterning assists people in finding more\\nefficient and less stressful ways of performing the\\nsimple movements of everyday life to dissipate tension\\nin the body. This is done through massage, alteration\\nof the environment, and fitness training.\\nDescription\\nSeeking to solve movement problems, Aston-\\nPatterning helps make the most of their own unique\\nbody types rather than trying to force them to conform\\nto an ideal. UnlikeRolfing, it doesn’t strive for linear\\nsymmetry. Rather it works with asymmetry in the\\nhuman body to develop patterns of alignment and\\nmovement that feel right to the individual. Aston\\nalso introduced the idea of working in a three-dimen-\\nsional spinal pattern. Aston-Patterning sessions have\\nfour general components. They are:\\n/C15A personal history that helps the practitioner assess\\nthe client’s needs.\\n/C15Pre-testing, in which the practitioner and the client\\nexplore patterns of movement and potential for\\nimprovement.\\n/C15Movement education and bodywork, including mas-\\nsage, myofacial release, and arthrokinetics, to help\\nreleasetensionandmakenewmovementpatternseasier.\\nJUDITH ASTON\\nJudith Aston was born in Long Beach, California. She\\ngraduated from University of California at Los Angeles\\nwith a B.A. and a M.F.A. in dance. Her interest in move-\\nment arose from working as a dancer. In 1963 Aston\\nestablished her first movement education program for\\ndancers, actors, and athletes at Long Beach City College.\\nFive years later, while recovering from injuries sus-\\ntained during two consecutive automobile accidents,\\nAston met Ida Rolf, the developer of Rolfing. Aston\\nbegan working for Rolf, teaching a movement education\\nprogram called Rolf-Aston Structural Patterning that\\nemphasized using the body with minimum effort and\\nmaximum precision.\\nIn time, Rolf and Aston’s views on movement diverged,\\nand the partnership was dissolved in 1977. Aston formed her\\nown company called the Aston Paradigm Corporation in\\nLake Tahoe, California. This company provides training\\nand certification for Aston practitioners. She also began\\nexploring how environmental conditions affect body\\nmovement, foreshadowing the ergonomic movement in\\nthe workplace that developed in the 1990s. Over time,\\nAston has expanded her movement work to include a\\nfitness program for older adults. Today, Judith Aston\\nserves as director of Aston Paradigm Corporation.\\n432\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAston-Patterning'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Post-testing, when pre-testing movements are\\nrepeated, allowing the client to feel the changes that\\nhave taken place and integrate them into daily life.\\nAston-Patterning requires more participation\\nfrom the client than many bodywork techniques. The\\nmassage aspect of Aston-Patterning is designed\\naround a three-dimensional, non-compressive touch\\nthat releases patterns of tension in the body. It is\\ngentler than Rolfing. Myokinetics uses touch to\\nrelease tension in the face and neck. Arthrokinetics\\naddresses tension at bones and joints. This massage\\nis accompanied by education about how new move-\\nment patterns may be established.\\nIn addition to Aston-Patterning sessions, clients\\nare also helped to examine their environment for fac-\\ntors, such as seating or sleeping arrangements, that\\nmay limit their body function and introduce tension.\\nFinally, they may choose to participate in the Aston\\nfitness training program that includes loosening tech-\\nniques based on self-massage, toning, stretching, and\\ncardiovascular fitness.\\nPreparations\\nNo special preparation need be taken.\\nPrecautions\\nNo special precautions are necessary when\\nparticipating.\\nSide effects\\nNo undesirable side effects are reported. Usually\\nclients report a diminution of tension, improved body\\nmovement, and an enhanced feeling of well being.\\nResearch and general acceptance\\nAston-Patterning is an outgrowth of Rolfing,\\nwhich has been shown to be of benefit in a limited\\nnumber of controlled studies. Little controlled\\nresearch has been done on the either benefits or\\nlimitations of Aston-Patterning. Its claims have been\\nneither proven nor disproved, although anecdotally\\nmany clients report relief from pain and tension and\\nalso improved body movement.\\nResources\\nORGANIZATIONS\\nAston Training Center. P. O. Box 3568, Incline Village, NV\\n89450. (775) 831-8228. Astonpat@aol.com .\\nTish Davidson, A.M.\\nAstrocytoma see Brain tumor\\nAtaxia-telangiectasia\\nDefinition\\nAtaxia-telangiectasia (A-T), also called Louis-Bar\\nsyndrome, is a rare, genetic neurological disorder of\\nchildhood that progressively destroys part of the\\nmotor control area of the brain, leading to a lack of\\nbalance and coordination. A-T also affects the\\nimmune system and increases the risk of leukemia\\nand lymphoma in affected individuals.\\nDescription\\nThe disorder first appeared in the medical litera-\\nture in the mid-1920s, but was not named specifically\\nuntil 1957. The name is a combination of two recog-\\nnized abnormalities: ataxia (lack of muscle control)\\nand telangiectasia (abnormal dilatation of capillary\\nvessels that often result in tumors and redskin lesions).\\nHowever, A-T involves more than just the sum of\\nthese two findings. Other associated A-T problems\\ninclude immune system deficiencies, extreme sensitiv-\\nity to radiation, and blood cancers.\\nMedical researchers initially suspected that multi-\\nple genes (the units responsible for inherited features)\\nwere involved. However, in 1995, mutations in a single\\nlarge gene were identified as causing A-T. Researchers\\nnamed the gene ATM for A-T, mutated. Subsequent\\nresearch revealed that ATM has a significant role in\\nregulating cell division. The symptoms associated with\\nA-T reflect the main role of the AT gene, which is to\\ninduce several cellular responses to DNA damage,\\nsuch as preventing damaged DNA from being repro-\\nduced. When the AT gene is mutated into ATM, the\\nKEY TERMS\\nRolfing— Developed by Dr. Ida Rolf (1896–1979),\\nrolfing is a systematic approach to relieving stress\\npatterns and dysfunctions in the body’s structure\\nthrough the manipulation of the highly pliant myo-\\nfacial (connective) tissue. It assists the body in reor-\\nganizing its major segments into vertical alignment.\\nGALE ENCYCLOPEDIA OF MEDICINE 433\\nAtaxia-telangiectasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='signaling networks are affected and the cell no longer\\nresponds correctly to minimize the damage.\\nA-T is very rare, but it occurs in every popula-\\ntion world wide, with an estimated frequency of\\nbetween 1/40,000 and 1/100,000 live births. But it\\nis believed that many A-T cases, particularly those\\nwho die at a young age, are never properly diag-\\nnosed. Therefore, this disease may actually be\\nmuch more prevalent. According to the A-T\\nProject Foundation, an estimated 1% (2.5 million\\nin the United States) of the general population\\ncarries defective A-T genes. Carriers of one copy\\nof this gene do not develop A-T, but have a sig-\\nnificantly increased risk of cancer.T h i sm a k e st h e\\nA-T gene one of the most important cancer-related\\ngenes identified to date.\\nCauses and symptoms\\nThe ATM gene is autosomal recessive, meaning\\nthe disease occurs only if a defective gene is inher-\\nited from both parents. Infants with A-T initially\\noften appear very healthy. At around age two,\\nataxia and nervous system abnormalities becomes\\napparent. The root cause of A-T-associated ataxia\\nis cell death in the brain, specifically the large\\nbranching cells of the nervous system (Purkinje’s\\ncells) which are located in the cerebellum. A tod-\\ndler becomes clumsy, loses balance easily and lacks\\nmuscle control. Speech becomes slurred and more\\ndifficult, and the symptoms progressively worsen.\\nBetween ages two and eight, telangiectases, or tiny,\\nred ‘‘spider’’ veins, appear on the cheeks and ears\\na n di nt h ee y e s .\\nB ya g e1 0 - 1 2 ,c h i l d r e nw i t hA - Tc a nn ol o n g e r\\ncontrol their muscles. Immune system deficiencies\\nbecome common, and affected individuals are extre-\\nmely sensitive to radiation. Immune system defi-\\nciencies vary between individuals but include\\nlower-than-normal levels of proteins that function\\nas antibodies (immunoglobulins) and white blood\\ncells (blood cells not containing ‘‘iron’’ proteins).\\nThe thymus gland, which aids in development of\\nthe body’s immune system, is either missing or has\\nKEY TERMS\\nAngioma— A tumor (such as a hemangioma or lym-\\nphangioma) that mainly consists of blood vessels or\\nlymphatic vessels.\\nAntibody— Any of a large number of proteins pro-\\nduced by specialized blood cells after stimulation by\\nan antigen and that act specifically against the anti-\\ngen in an immune response.\\nAntigen— Any substance (such as a toxin or enzyme)\\ncapable of stimulating an immune response in the\\nbody.\\nAtaxia— The inability to control voluntary muscle\\nmovement, most frequently resulting from disorders\\nin the brain or spinal cord.\\nAutosomal— Relating to any of the chromosomes\\nexcept for X and Y, the sex chromosomes.\\nCerebellum— The part of the brain responsible for\\ncoordination of voluntary movements.\\nGamma-globulin— An extract of human blood that\\ncontains antibodies.\\nImmune response— A response from the body to an\\nantigen that occurs when the antigen is identified as\\nforeign and that induces the production of antibodies\\nand lymphocytes capable of destroying the antigen\\nor making it harmless.\\nImmunoglobulin— A protein in the blood that is the\\ncomponent part of an antibody.\\nLeukemia— A cancer of blood cells characterized by\\nthe abnormal increase in the number of white blood\\ncells in the tissues. There are many types of leuke-\\nmias and they are classified according to the type of\\nwhite blood cell involved.\\nLymphoma— A blood cancer in which lymphocytes,\\na variety of white blood cells, grow at an unusually\\nrapid rate.\\nMutation— Any change in the hereditary material of\\ngenes.\\nPurkinje’s cells—Large branching cells of the nervous\\nsystem.\\nRecessive— Producing little or no phenotypic effect\\nwhen occurring in heterozygous condition with a\\ncontrasting allele.\\nTelangiectases— Spidery red skin lesions caused by\\ndilated blood vessels.\\nTelangiectasia— Abnormal dilation of capillary blood\\nvessels leading to the formation of telangiectases or\\nangiomas.\\nThymus— A gland located in the front of the neck that\\ncoordinates the development of the immune system.\\n434 GALE ENCYCLOPEDIA OF MEDICINE\\nAtaxia-telangiectasia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='developed abnormally. Intelligence is normal, but\\ngrowth may be retarded owing to immune system\\nor hormonal deficiencies. Individuals with A-T are\\nalso sometimes afflicted with diabetes, prematurely\\ngraying hair, and difficulty swallowing. As the chil-\\ndren grow older, the immune system becomes\\nweaker and less capable of fighting infection. In\\nthe later stages, recurrent respiratory infections\\nand blood cancers, such as leukemia or lymphoma,\\nare common.\\nDiagnosis\\nDiagnosis relies on recognizing the hallmarks\\nof A-T: progressive ataxi a and telangiectasia.\\nHowever, this may be difficult as ataxia symptoms\\ndo appear prior to telangiectasia symptoms by sev-\\neral years. Other symptoms can vary between indi-\\nviduals; for example, 70% of individuals with A-T\\nhave a high incidence of respiratory infection, 30%\\ndo not. The identification of the ATM gene raises\\nhopes that screening, and perhaps treatment, may\\nbe possible.\\nTreatment\\nThere is currently no cure for A-T, and treatment\\nfocuses on managing the individual’s multiple symp-\\ntoms. Physical therapy and speech therapy can help\\nthe patient adjust to ataxia. Injections of gamma glo-\\nbulin, or extracts of human blood that contain anti-\\nbodies, are used to strengthen the weakened immune\\nsystem. High-dose vitamin administrations may also\\nbe prescribed. Research continues in many countries\\nto find effective treatments. Individuals and families\\nliving with this disorder may benefit from attending\\nsupport groups.\\nPrognosis\\nA-T is a fatal condition. Children with A-T\\nbecome physically disabled by their early teens and\\ntypically die by their early 20s, usually from the asso-\\nciated blood cancers and malignancies. In very rare\\ncases, individuals with A-T may experience slower\\nprogression and a slightly longer life span, surviving\\ninto their 30s. A-T carriers have a five-fold higher risk\\nthan non-carriers of developing certain cancers, espe-\\ncially breast cancer.\\nPrevention\\nMedical researchers are investigating methods for\\nscreening individuals who may be carriers of the\\ndefective gene. Prenatal testing for A-T is possible\\nbut not done routinely, because commercial screening\\ntests have yet to be developed.\\nAtaxia see Movement disorders\\nAtelectasis\\nDefinition\\nAtelectasis is a collapse of lung tissue affecting\\npart or all of one lung. This condition prevents normal\\noxygen absoption to healthy tissues.\\nDescription\\nAtelectasis can result from an obstruction (block-\\nage) of the airways that affects tiny air scas called\\nalveoli. Alveoli are very thin-walled and contain a\\nrich blood supply. They are important for lung func-\\ntion, since their purpose is the exchange of oxygen and\\ncarbon dioxide. When the airways are blocked by a\\nmucous ‘‘plug,’’ foreign object, or tumor, the alveoli\\nare unable to fill with air and collapse of lung tissue\\ncan occur in the affected area. Atelectasis is a potential\\ncomplication following surgery, especially in indivi-\\nduals who have undergone chest or abdominal opera-\\ntions resulting in associated abdominal or chestpain\\nduring breathing. Congenital atelectasis can result\\nfrom a failure of the lungs to expand at birth. This\\ncongenital condition may be localized or may affect all\\nof both lungs.\\nCauses and symptoms\\nCauses of atelectasis include insufficient attemps\\nat respiration by the newborn, bronchial obstruction,\\nor absence of surfactant (a substance secreted by\\nalveoli that maintains the stability of lung tissue by\\nreducing the surface tension of fluids that coat the\\nlung). This lack of surfactant reduces the surface\\narea available for effective gas exchange causing it to\\ncollapse if severe. Pressure on the lung from fluid or air\\ncan cause atelectasis as well as obstruction of lung air\\npassages by thick mucus resulting from various infec-\\ntions and lung diseases. Tumors and inhaled objects\\ncan also cause obstruction of the airway, leading to\\natelectasis.\\nAnyone undergoing chest or abdominal surgery\\nusing general anesthesiais at risk to develop atelecta-\\nsis, since breathing is often shallow after surgery to\\nGALE ENCYCLOPEDIA OF MEDICINE 435\\nAtelectasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='avoid pain from the surgical incision. Any significant\\ndecrease in airflow to the alveoli contributes to pool-\\ning of secretions, which in turn can cause infection.\\nChest injuries causing shallow breathing, including\\nfractured ribs, can cause atelectasis. Common symp-\\ntoms of atelectasis include shortness of breath and\\ndecreased chest wall expansion. If atelectasis only\\nafects a small area of the lung, symptoms are ususally\\nminimal. If the condition affects a large area of the\\nlung and develops quickly, the individual may turn\\nblue (cyanotic) or pale, have extreme shortness of\\nbreath, and feel a stabbing pain on the affected side.\\nFever and increased heart rate may be present if infec-\\ntion accompanies atelectasis.\\nDiagnosis\\nTo diagnose atelectasis, a doctor starts by record-\\ning the patient’s symptoms and performing a tho-\\nrough physical examination. When the doctor listens\\nto the lungs through a stethoscope (ausculation),\\ndiminished or bronchial breath sounds may be heard.\\nBy tapping on the chest (percussion) while listening\\nthrough the stethoscope, the doctor can often tell if the\\nlung is collapsed. Achest x raythat shows an airless\\narea in the lung confirms the diagnosis of atelectasis. If\\nan obstruction of the airways is suspected, a computed\\ntomography scan (CT) or bronchoscopy may be\\nperformed to locate the cause of the blockage.\\nTreatment\\nIf atelectasis is due to obstruction of the airway,\\nthe first step in treatment is to remove the cause of\\nthe blockage. This may be done by coughing, suction-\\ning, or bronchoscopy. If a tumor is the cause of atelec-\\ntasis, surgery may be necessary to remove it.\\nAntibiotics are commonly used to fight the infection\\nthat often accompanies atelectasis. In cases where\\nrecurrent or long-lasting infection is disabling or\\nwhere significant bleeding occurs, the affected section\\nof the lung may be surgically removed.\\nPrognosis\\nIf atelectasis is caused by a thick mucus ‘‘plug’’ or\\ninhaled foreign object, the patient usually recovers com-\\npletely when the blockage is removed. If it is caused by a\\ntumor, the outcome depends on the nature of the tumor\\ninvolved. If atelectasis is a result of surgery, other post-\\noperative conditions and/or complications affect the\\nprognosis.\\nA computed tomography (CT) scan through a patient’s chest.\\nThe collapsed lung appears at the right of the image. (Photo\\nResearchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAlveoli— Tiny air sacs in the lungs where gas\\nexchange takes place between alveolar air and\\npulmonary blood within the capillaries\\nBronchial— Relating to the air passages to and from\\nthe lungs including the bronchi and the bronchioles.\\nBronchoscopy— A procedure in which a hollow,\\nflexible tube is inserted into the airway to allow\\nvisual examination of the larynx, trachea, bronchi,\\nand bronchioles. It isalso used to collect specimens for\\nbiopsyorculturingandtoremoveairwayobstructions.\\nIncentive spirometer— A breathing device that\\nprovides feedback on performance to encourage\\ndeep breathing.\\nMucus— A thin, slippery film secreted by the\\nmucous membranes and glands.\\nPostural drainage— Techniques to help expel excess\\nmucus by specific poistions of the body (that decrease\\nthe effects of gravity) combined with manual percus-\\nsion and vibration over various parts of the lung.\\nSurfactant— A substance secreted by the alveoli in\\nthe lungs that reduces the surface tension of lung\\nfluids, allowing gas exchange and helping maintain\\nthe elasticity of lung tissue.\\nTumor— Anabnormalgrowthoftissueresultingfrom\\nuncontrolled, progressive multiplication of cells.436 GALE ENCYCLOPEDIA OF MEDICINE\\nAtelectasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prevention\\nWhen recovering from surgery, frequent reposition-\\ning in bed along with coughing and deep breathing are\\nimportant. Coughing and breathing deeply every one to\\ntwo hours after any surgical operation with general\\nanesthesia is recommended. Breathing exercises and the\\nuse of breathing devices, such as an incentive spirometer,\\nmay also help prevent atelectasis. Although smokers\\nhave a higher risk of developing atelectasis following\\nsurgery, stoppingsmokingsix to eight weeks before sur-\\ngery can help reduce the risk. Increasing fluid intake\\nduring respiratory illness or after surgery (by mouth or\\nintravenously) helps lung secretions to remain loose.\\nIncreasing humidity may also be beneficial.\\nPostural drainage techniques can be learned from\\na respiratory therapist or physical therapist and are a\\nuseful tool for anyone affected with a respiratiory ill-\\nness that could cause atelectasis. Because foreign\\nobjects blocking the airway can cause atelectasis, it is\\nvery important to keep small objects that might be\\ninhaled away from young children.\\nResources\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nJeffrey P. Larson, RPT\\nAtenolol see Beta blockers\\nAtherectomy\\nDefinition\\nAtherectomy is a non-surgical procedure to open\\nblocked coronary arteries or vein grafts by using a device\\non the end of a catheter to cut or shave away athero-\\nsclerotic plaque (a depositof fat and other substances\\nthat accumulate in the lining of the artery wall).\\nPurpose\\nAtherectomy is performed to restore the flow of\\noxygen-rich blood to the heart, to relieve chestpain,\\nand to prevent heart attacks. It may be done on\\npatients with chest pain who have not responded to\\nother medical therapy and on certain of those who are\\ncandidates for balloonangioplasty (a surgical proce-\\ndure in which a balloon catheter is used to flatten\\nplaque against an artery wall) or coronary artery\\nbypass graft surgery. It is sometimes performed to\\nremove plaque that has built up after acoronary artery\\nbypass graft surgery.\\nPrecautions\\nAtherectomy should not be performed when the\\nplaque is located where blood vessels divide into\\nbranches, when plaque is angular or inside an angle\\nof a blood vessel, on patients with weak vessel walls,\\non ulcerated or calcium-hardened lesions, or on\\nblockages through which a guide wire won’t pass.\\nDescription\\nAtherectomy uses a rotating shaver or other device\\nplaced on the end of a catheter to slice away or destroy\\nplaque. At the beginning of the procedure, medications\\nto control blood pressure, dilate the coronary arteries,\\nand preventblood clotsare administered. The patient is\\nawake but sedated. The catheter is inserted into an\\nartery in the groin, leg, or arm, and threaded through\\nthe blood vessels into the blocked coronary artery. The\\ncutting head is positioned against the plaque and acti-\\nvated, and the plaque is ground up or suctioned out.\\nThe types of atherectomy are rotational, direc-\\ntional, and transluminal extraction. Rotational ather-\\nectomy uses a high speed rotating shaver to grind up\\nplaque. Directional atherectomy was the first type\\napproved, but is no longer commonly used; it scrapes\\nplaque into an opening in one side of the catheter.\\nTransluminal extraction coronary atherectomy uses a\\ndevice that cuts plaque off vessel walls and vacuums it\\ninto a bottle. It is used to clear bypass grafts.\\nPerformed in acardiac catheterizationlab, atherect-\\nomy is also called removal of plaque from the coronary\\narteries. It can be used instead of, or along with, balloon\\nangioplasty. Atherectomy issuccessful about 95% of the\\ntime. Plaque forms again in 20-30% of patients.\\nPreparation\\nThe day before atherectomy, the patient takes\\nmedication to prevent blood clots and may be asked\\nto bathe and shampoo with an antiseptic skin cleaner.\\nAftercare\\nAfter the procedure, the patient spends several days\\nin the hospital’s cardiac monitoring area. For at least\\n20 minutes, pressure is applied to a dressing on the\\ninsertion site. For the first hour, an electrocardiogram\\nand close monitoring are conducted; vital signs are\\nGALE ENCYCLOPEDIA OF MEDICINE 437\\nAtherectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='checked every 15 minutes. Pain medication is then\\nadministered. The puncture site is checked once an\\nhour or more. For most of the first 24 hours, the patient\\nremains in bed.\\nRisks\\nChest pain is the most common complication of\\natherectomy. Other common complications are injury\\nto the blood vessel lining, plaque that re-forms, blood\\nclots (hematoma), and bleeding at the site of insertion.\\nMore serious but less frequent complications are\\nblood vessel holes, blood vessel wall tears, or reduced\\nblood flow to the heart.\\nResources\\nBOOKS\\nMcPhee, Stephen, et al., editors.Current Medical Diagnosis\\nand Treatment, 1998.37th ed. Stamford: Appleton &\\nLange, 1997.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nIn this digitized ultrasound of a blood vessel, C is the catheter, D is the dissection, and F is the artherosclerotic flap. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAtherosclerotic plaque— A deposit of fat and other\\nsubstances that accumulate in the lining of the\\nartery wall.\\nBalloon angioplasty— A surgical procedure in\\nwhich a balloon catheter is used to flatten plaque\\nagainst an artery wall.\\nCoronary arteries— The two main arteries that pro-\\nvide blood to the heart. The coronary arteries sur-\\nround the heart like a crown, coming out of the\\naorta, arching down over the top of the heart, and\\ndividing into two branches. These are the arteries\\nwhere coronary artery disease occurs.\\nHematoma— A localizedcollectionofblood,usually\\nclotted, due to a break in the wall of blood vessel.\\n438 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherectomy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Atherosclerosis\\nDefinition\\nAtherosclerosis is the build up of a waxy plaque\\non the inside of blood vessels. In Greek,athere means\\ngruel, andskleros means hard. Atherosclerosis is often\\ncalled arteriosclerosis. Arteriosclerosis (from the\\nGreek arteria, meaning artery) is a general term for\\nhardening of the arteries. Arteriosclerosis can occur in\\nseveral forms, including atherosclerosis.\\nDescription\\nAtherosclerosis, a progressive process responsible\\nfor most heart disease, is a type of arteriosclerosis\\nor hardening of the arteries. An artery is made up of\\nseveral layers: an inner lining called the endothelium,\\nan elastic membrane that allows the artery to expand\\nand contract, a layer of smooth muscle, and a layer of\\nconnective tissue. Arteriosclerosis is a broad term that\\nincludes a hardening of the inner and middle layers of\\nthe artery. It can be caused by normalaging, by high\\nblood pressure, and by diseases such as diabetes.\\nAtherosclerosis is a type of arteriosclerosis that affects\\nonly the inner lining of an artery. It is characterized by\\nplaque deposits that block the flow of blood.\\nPlaque is made of fatty substances, cholesterol,\\nwaste products from the cells, calcium, and fibrin, a\\nstringy material that helps clot blood. The plaque for-\\nmation process stimulates the cells of the artery wall to\\nproduce substances that accumulate in the inner layer.\\nFat builds up within these cells and around them, and\\nthey form connective tissue and calcium. The inner\\nlayer of the artery wall thickens, the artery’s diameter\\nis reduced, and blood flow and oxygen delivery are\\ndecreased. Plaques can rupture or crack open, causing\\nthe sudden formation of a blood clot (thrombosis).\\nAtherosclerosis can cause aheart attackif it completely\\nblocks the blood flow in the heart (coronary) arteries. It\\ncan cause astroke if it completely blocks the brain\\n(carotid) arteries. Atherosclerosis can also occur in the\\narteries of the neck, kidneys, thighs, and arms, causing\\nkidney failure organgrene and amputation.\\nCauses and symptoms\\nAtherosclerosis can begin in the late teens, but it\\nusually takes decades to cause symptoms. Some people\\nexperience rapidly progressing atherosclerosis during\\ntheir thirties, others during their fifties or sixties.\\nAtherosclerosis is complex. Its exact cause is still\\nunknown. It is thought that atherosclerosis is caused\\nby a response to damage to the endothelium from high\\ncholesterol, high blood pressure, and cigarettesmoking.\\nA person who has all three of these risk factors is eight\\ntimes more likely to develop atherosclerosis than is a\\nperson who has none. Physical inactivity, diabetes, and\\nobesity are also risk factors for atherosclerosis. High\\nlevels of the amino acidhomocysteine and abnormal\\nlevels of protein-coated fats called lipoproteins also\\nraise the risk ofcoronary artery disease. These sub-\\nstances are the targets of much current research. The\\nrole of triglycerides, another fat that circulates in the\\nblood, in forming atherosclerotic plaques is unclear.\\nHigh levels of triglycerides are often associated with\\ndiabetes, obesity, and low levels of high-density lipo-\\nproteins (HDL cholesterol). The more HDL (‘‘good’’)\\ncholesterol, in the blood, the less likely is coronary\\nartery disease. These risk factors are all modifiable.\\nNon-modifiable risk factors are heredity, sex, and age.\\nRisk factors that can be changed:\\n/C15Cigarette/tobacco smoke–Smoking increases both\\nthe chance of developing atherosclerosis and the\\nchance of dying from coronary heart disease.\\nSecond hand smoke may also increase risk.\\n/C15High blood cholesterol–Cholesterol, a soft, waxy\\nsubstance, comes from foods such as meat, eggs,\\nand other animal products and is produced in the\\nliver. Age, sex, heredity, and diet affect cholesterol.\\nTotal blood cholesterol is considered high at levels\\nabove 240 mg/dL and borderline at 200-239 mg/dL.\\nHigh-risk levels of low-density lipoprotein (LDL\\ncholesterol) begin at 130-159 mg/dL.\\n/C15High triglycerides–Most fat in food and in the body\\ntakes the form of triglycerides. Blood triglyceride\\nlevels above 400 mg/dL have been linked to coronary\\nartery disease in some people. Triglycerides, how-\\never, are not nearly as harmful as LDL cholesterol.\\n/C15High blood pressure–Blood pressure of 140 over 90\\nor higher makes the heart work harder, and over\\ntime, both weakens the heart and harms the arteries.\\n/C15Physical inactivity–Lack of exercise increases the\\nrisk of atherosclerosis.\\n/C15Diabetes mellitus–The risk of developing atherosclero-\\nsis is seriously increased for diabetics and can be low-\\nered by keeping diabetes under control. Most diabetics\\ndie from heart attacks caused by atherosclerosis.\\n/C15Obesity–Excess weight increases the strain on the\\nheart and increases the risk of developing athero-\\nsclerosis even if no other risk factors are present.\\nRisk factors that cannot be changed:\\n/C15Heredity–People whose parents have coronary\\nartery disease, atherosclerosis, or stroke at an early\\nGALE ENCYCLOPEDIA OF MEDICINE 439\\nAtherosclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='age are at increased risk. The high rate of severe\\nhypertension among African-Americans puts them\\nat increased risk.\\n/C15Sex–Before age 60, men are more likely to have heart\\nattacks than women are. After age 60, the risk is\\nequal among men and women.\\n/C15Age–Risk is higher in men who are 45 years of age and\\nolder and women who are 55 years of age and older.\\nSymptoms differ depending upon the location of\\nthe atherosclerosis.\\n/C15In the coronary (heart) arteries: Chestpain, heart\\nattack, or suddendeath.\\n/C15In the carotid (brain) arteries: Sudden dizziness,\\nweakness, loss of speech, or blindness.\\n/C15In the femoral (leg) arteries: Disease of the blood\\nvessels in the outer parts of the body (peripheral\\nvascular disease) causes cramping andfatigue in the\\ncalves when walking.\\n/C15In the renal (kidney) arteries: High blood pressure\\nthat is difficult to treat.\\nDiagnosis\\nPhysicians may be able to make a diagnosis of\\natherosclerosis during a physical exam by means of a\\nstethoscope and gentle probing of the arteries with the\\nhand (palpation). More definite tests areelectrocardio-\\ngraphy, echocardiography or ultrasonography of the\\narteries (for example, the carotids), radionuclide\\nscans, andangiography.\\nThe result is a fibrous \\nlesion, made up in part\\nof muscle cells, proteins, \\nand collagen, that has at \\nits center a pool of lipids \\nand dead cells. Blood \\nflow can be very nearly \\ncut off by the blockage.\\nWhen the arterial lining becomes \\nseparated over the growing mass of \\nfoam cells, platelets are attracted to the \\nsite and begin the process of clot formation.\\nPlatelets\\nHigh cholesterol levels, \\nhigh blood pressure, \\ndiabetes, obesity, viruses,\\ncigarette smoking, etc., \\ncause injuries to the \\nlining of the artery, \\ncreating areas where \\nhigher levels of lipids\\nare trapped.\\nFurther injury is inflicted by foam cells\\nattempting to remove lipids back to the\\nlungs, liver, spleen and lymph nodes\\nby again passing through the lining of\\nthe artery.\\nMonocyteLining of\\nartery\\nMuscle\\nT- c e l l\\nMonocytes (the largest of the \\nwhite blood cells) and T -cells \\nare attracted to the injury.\\nFoam cell\\nMonocytes, which become \\nmacrophages when they leave \\nthe bloodstream, and T -cells \\npenetrate the lining of the artery.\\nThe macrophages soak up lipids, \\nbecoming large foam cells and \\ndistorting the inner surface of the \\nartery. Blood flow becomes\\nrestricted.\\nThe progression of atherosclerosis. (Illustration by Hans & Cassady.)\\n440 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherosclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='An electrocardiogram shows the heart’s activity.\\nElectrodes covered with conducting jelly are placed on\\nthe patient’s body. They send impulses of the heart to a\\nrecorder. The test takes about 10 minutes and is per-\\nformed in a physician’s office. Exercise electrocardio-\\ngraphy (stress test) is conducted while the patient\\nexercises on a treadmill or a stationary bike. It is\\nperformed in a physician’s office or an exercise labora-\\ntory and takes 15-30 minutes.\\nEchocardiography, cardiac ultrasound, uses sound\\nwaves to create an image of the heart’s chambers and\\nvalves. A technician applies gel to a hand-held transdu-\\ncer, presses it against the patient’s chest, and images are\\ndisplayed on a monitor. This technique cannot evaluate\\nthe coronary arteries directly. They are too small and\\nare in motion with the heart. Severe coronary artery\\ndisease, however, may cause abnormal heart motion\\nthat is detected by echocardiography. Performed in a\\ncardiology outpatient diagnostic laboratory, the test\\ntakes 30-60 minutes. Ultrasonography is also used to\\nassess arteries of the neck and thighs.\\nRadionuclide angiography and thallium (or ses-\\ntamibi) scanning enable physicians to see the blood\\nflow through the coronary arteries and the heart\\nchambers. Radioactive material is injected into the\\nbloodstream. A device that uses gamma rays to\\nproduce an image of the radioactive material\\n(gamma camera) records pictures of the heart.\\nRadionuclide angiography is usually performed in\\na hospital’s nuclear medicine department and takes\\n30-60 minutes. Thallium scanning is usually done\\nafter an exercise stress test or after injection of a\\nvasodilator, a drug to enlarge the blood vessels, like\\ndipyridamole (Persantine). Thallium is injected, and\\nthe scan is done then and again four hours (and\\npossibly 24 hours) later. Thallium scanning is\\nusually performed in a hospital’s nuclear medicine\\ndepartment. Each scan takes 30-60 minutes.\\nCoronary angiography is the most accurate diag-\\nnostic method and the only one that requires entering\\nthe body (invasive procedure). A cardiologist inserts a\\ncatheter equipped with a viewing device into a blood\\nvessel in the leg or arm and guides it into the heart. The\\npatient has been given a contrast dye that makes\\nthe heart visible to x rays. Motion pictures are taken\\nof the contrast dye flowing though the arteries.\\nPlaques and blockages, if present, are well defined.\\nThe patient is awake but has been given a sedative.\\nCoronary angiography is performed in a cardiac\\ncatheterization laboratory and takes from 30 minutes\\nto two hours.\\nTreatment\\nTreatment includes lifestyle changes, lipid-lower-\\ning drugs, percutaneous transluminal coronaryangio-\\nplasty, and coronary artery bypass surgery.\\nAtherosclerosis requires lifelong care.\\nPatients who have less severe atherosclerosis may\\nachieve adequate control through lifestyle changes\\nand drug therapy. Many of the lifestyle changes that\\nprevent disease progression–a low-fat, low-cholesterol\\ndiet, losing weight (if necessary), exercise, controlling\\nblood pressure, and not smoking–also help prevent the\\ndisease.\\nMost of the drugs prescribed for atherosclerosis\\nseek to lower cholesterol. Many popular lipid-lower-\\ning drugs can reduce LDL-cholesterol by an average\\nof 25-30% when combined with a low-fat, low-\\ncholesterol diet. Lipid-lowering drugs include bile\\nacid resins, ‘‘statins’’ (drugs that effect HMG-CoA\\nreductase, an enzyme that controls the processing of\\ncholesterol), niacin, and fibric acid derivatives such as\\ngemfibrozil (Lobid).Aspirin helps prevent thrombosis\\nand a variety of other medications can be used to treat\\nthe effects of atherosclerosis.\\nKEY TERMS\\nArteriosclerosis— Hardening of the arteries. It\\nincludes atherosclerosis, but the two terms are\\noften used synonymously.\\nCholesterol— A fat-like substance that is made by\\nthe human body and eaten in animal products.\\nCholesterol is used to form cell membranes and\\nprocess hormones and vitamin D. High cholesterol\\nlevels contribute to the development of\\natherosclerosis.\\nHDL Cholesterol— About one-third or one-fourth\\nof all cholesterol is high-density lipoprotein choles-\\nterol. High levels of HDL, nicknamed ‘‘good’’ cho-\\nlesterol, decrease the risk of atherosclerosis.\\nLDL Cholesterol— Low-density lipoprotein choles-\\nterol is the primary cholesterol molecule. High\\nlevels of LDL, nicknamed ‘‘bad’’ cholesterol,\\nincrease the risk of atherosclerosis\\nPlaque— A deposit of fatty and other substances\\nthat accumulates in the lining of the artery wall.\\nTriglyceride— A fat that comes from food or is\\nmade from other energy sources in the body.\\nElevated triglyceride levels contribute to the devel-\\nopment of atherosclerosis.\\nGALE ENCYCLOPEDIA OF MEDICINE 441\\nAtherosclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Percutaneous transluminal coronary angioplasty\\nand bypass surgery are invasive procedures that\\nimprove blood flow in the coronary arteries.\\nPercutaneous transluminal coronary angioplasty (cor-\\nonary angioplasty) is a non-surgical procedure in\\nwhich a catheter tipped with a balloon is threaded\\nfrom a blood vessel in the thigh into the blocked\\nartery. The balloon is inflated, compresses the plaque\\nto enlarge the blood vessel, and opens the blocked\\nartery. Coronary angioplasty is performed by a cardi-\\nologist in a hospital and generally requires a hospital\\nstay of one or two days. It is successful about 90% of\\nthe time, but for one-third of patients the artery nar-\\nrows again within six months. It can be repeated and a\\n‘‘stent’’ may be placed in the artery to help keep it open\\n(see below).\\nIn coronary artery bypass surgery (bypass sur-\\ngery), a detour is built around the blockage with a\\nhealthy vein or artery, which then supplies oxygen-\\nrich blood to the heart. It is major surgery appropriate\\nfor patients with blockages in two or three major\\ncoronary arteries or severely narrowed left main cor-\\nonary arteries, and for those who have not responded\\nto other treatments. It is performed in a hospital under\\ngeneral anesthesia and uses a heart-lung machine.\\nAbout 70% of patients experience full relief; about\\n20% partial relief.\\nThree other semi-experimental surgical proce-\\ndures may be used to treat atherosclerosis. In ather-\\nectomy, a cardiologist shaves off and removes strips\\nof plaque from the blocked artery. In laser angio-\\nplasty, a catheter with a laser tip is inserted to burn\\nor break down the plaque. A metal coil called a\\nstent may be permanently implanted to keep a\\nblocked artery open.\\nAlternative treatment\\nAlternative therapies that focus on diet and life-\\nstyle can help prevent, retard, or reverse atherosclero-\\nsis. Herbal therapies that may be helpful include:\\nhawthorn (Crataegus laevigata ), notoginseng root\\n(Panax notoginseng), garlic (Allium sativum), ginger\\n(Zingiber officinale), hot red or chili peppers, yarrow\\n(Achillea millefolium), and alfalfa (Medicago sativum).\\nRelaxation techniques including yoga, meditation,\\nguided imagery, biofeedback, and counseling and\\nother ‘‘talking’’ therapies may also be useful to prevent\\nor slow the progress of the disease. Dietary modifica-\\ntions focus on eating foods that are low in fats (espe-\\ncially saturated fats), cholesterol, sugar, and animal\\nproteins and high in fiber and antioxidants (found in\\nfresh fruits and vegetables). Liberal use of onions and\\ngarlic is recommended, as is eating raw and cooked\\nfish, especially cold-water fish like salmon. Smoking,\\nalcohol, and stimulants like coffee should be avoided.\\nChelation therapy, which usesanticoagulant drugsand\\nnutrients to dissolve plaque and flush it through the\\nkidneys, is controversial. Long-term remedies can be\\nprescribed by specialists in ayurvedic medicine, which\\ncombines diet, herbal remedies, relaxation and exer-\\ncise, and homeopathy, which treats a disease with\\nsmall doses of a drug that causes the symptoms of\\nthe disease.\\nPrognosis\\nAtherosclerosis can be successfully treated but not\\ncured. Recent clinical studies have shown that athero-\\nsclerosis can be delayed, stopped, and even reversed by\\naggressively lowering LDL cholesterol. New diagnos-\\ntic techniques enable physicians to identify and treat\\natherosclerosis in its earliest stages. New technologies\\nand surgical procedures have extended the lives of\\nmany patients who would otherwise have died.\\nResearch continues.\\nPrevention\\nA healthy lifestyle–eating right, regular exercise,\\nmaintaining a healthy weight, not smoking, and con-\\ntrolling hypertension–can reduce the risk of develop-\\ning atherosclerosis, help keep the disease from\\nprogressing, and sometimes cause it to regress.\\n/C15Eat right-A healthy diet reduces excess levels of LDL\\ncholesterol and triglycerides. It includes a variety of\\nfoods that are low in fat and cholesterol and high in\\nfiber; plenty of fruits and vegetables; and limited\\nsodium. Fat should comprise no more than 30%,\\nand saturated fat no more than 8-10%, of total\\ndaily calories according to the American Heart\\nAssociation. Cholesterol should be limited to about\\n300 milligrams per day and sodium to about 2,400\\nmilligrams. The ‘‘Food Guide’’ Pyramid developed\\nby the U.S. Departments of Agriculture and Health\\nand Human Services provides daily guidelines: 6-11\\nservings of bread, cereal, rice, and pasta; 3-5 servings\\nof vegetables; 2-4 servings of fruit; 2-3 servings of\\nmilk, yogurt, and cheese; and 2-3 servings of meat,\\npoultry, fish, dry beans, eggs, and nuts. Fats, oils,\\nand sweets should be used sparingly. Mono-unsatu-\\nrated oils, like olive and rapeseed (Canola) are good\\nalternatives to use for cooking.\\n/C15Exercise regularly–Aerobic exercise can lower blood\\npressure, help control weight, and increase HDL\\n(‘‘good’’) cholesterol. It may keep the blood vessels\\n442 GALE ENCYCLOPEDIA OF MEDICINE\\nAtherosclerosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='more flexible. Moderate to intense aerobic exercise\\nlasting about 30 minutes (or three 10-minute exercise\\nperiods) four or more times per week is recom-\\nmended, according to the Centers for Disease\\nControl and Prevention and the American College\\nof Sports Medicine. Aerobic exercise includes walk-\\ning, jogging, and cycling, active gardening, climbing\\nstairs, or brisk housework. A physician should be\\nconsulted before exercise if a person has athero-\\nsclerosis or is at increased risk for it.\\n/C15Maintain a desirable body weight–Losing weight can\\nhelp reduce total and LDL cholesterol, reduce trigly-\\ncerides, and boost HDL cholesterol. It may also\\nreduce blood pressure. Eating right and exercising\\nare two key components in maintaining a desirable\\nbody weight.\\n/C15Do not smoke or use tobacco–Smoking has many\\nadverse effects on the heart but quitting can repair\\ndamage. Ex-smokers face the same risk of heart dis-\\nease as non-smokers within five to 10 years of quit-\\nting. Smoking is the worst thing a person can do to\\ntheir heart and lungs.\\n/C15Seek treatment for hypertension–High blood pres-\\nsure can be controlled through lifestyle changes–\\nreducing sodium and fat, exercising, managing\\nstress, quitting smoking, and drinking alcohol in\\nmoderation–and medication. Drugs that provide\\neffective treatment are:diuretics, beta-blockers, sym-\\npathetic nerve inhibitors, vasodilators, angiotensin\\nconverting enzyme inhibitors, and calcium antago-\\nnists. Hypertension usually has no symptoms so it\\nmust be checked to be known. Like cholesterol,\\nhypertension is called a ‘‘silent killer.’’\\nResources\\nPERIODICALS\\nMorgan, Peggy. ‘‘What Your Heart Wishes You Knew\\nAbout Cholesterol.’’Prevention (September 1997): 96.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nAthetosis see Movement disorders\\nAthlete’s foot\\nDefinition\\nA common fungus infection between the toes in\\nwhich the skin becomes itchy and sore, cracking and\\npeeling away. Athlete’s foot (also known as tinea pedis\\nor footringworm) can be treated, but it can be tena-\\ncious and difficult to clear up completely.\\nDescription\\nAthlete’s foot is a very common condition of\\nitchy, peeling skin on the feet. In fact, it’s so common\\nthat most people will have at least one episode at least\\nonce in their lives. It’s less often found in women and\\nchildren under age 12. (Symptoms that look like ath-\\nlete’s foot in young children most probably are caused\\nby some other skin condition).\\nBecause the fungi grow well in warm, damp areas,\\nthey flourish in and around swimming pools, showers,\\nand locker rooms. Tinea pedis got its common name\\nbecause the infection was common among athletes\\nwho often used these areas.\\nCauses and symptoms\\nAthlete’s foot is caused by a fungal infection that\\nmost often affects the fourth and fifth toe webs.\\nTrichophyton rubrum , T. mentagrophytes ,a n d\\nEpidermophyton floccosum, the fungi that cause ath-\\nlete’s foot, are unusual in that they live exclusively on\\ndead body tissue (hair, the outer layer of skin, and\\nnails). The fungus grows best in moist, damp, dark\\nplaces with poor ventilation. The problem doesn’t\\noccur among people who usually go barefoot.\\nMany people carry the fungus on their skin.\\nHowever, it will only flourish to the point of causing\\nathlete’s foot if conditions are right. Many people\\nbelieve athlete’s foot is highly contagious, especially in\\npublic swimming pools and shower rooms. Research\\nhas shown, however, that it is difficult to pick up the\\ninfection simply by walking barefoot over a contami-\\nnated damp floor. Exactly why some people develop\\nthe condition and others don’t is not well understood.\\nSweaty feet, tight shoes, synthetic socks that don’t\\nabsorb moisture well, a warm climate, and not drying\\nthe feet well after swimming or bathing, all contribute\\nto the overgrowth of the fungus.\\nSymptoms of athlete’s foot include itchy, sore skin\\non the toes, with scaling, cracking, inflammation, and\\nblisters. Blisters that break, exposing raw patches of\\nGALE ENCYCLOPEDIA OF MEDICINE 443\\nAthlete’s foot'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='tissue, can cause pain and swelling. As the infection\\nspreads, itching and burning may get worse.\\nIf it’s not treated, athlete’s foot can spread to the\\nsoles of the feet and toenails.Stubborn toenail infections\\nmay appear at the same time, with crumbling, scaling and\\nthickened nails, and nail loss. The infection can spread\\nfurther if patients scratch and then touch themselves\\nelsewhere (especially in the groin or under the arms).\\nIt’s also possible to spread the infection to other parts\\nof the body via contaminated bed sheets or clothing.\\nDiagnosis\\nNot all footrashesare athlete’s foot, which is why a\\nphysician should diagnose the condition before any\\nremedies are used. Using nonprescription products on a\\nrash that is not athlete’s foot could make the rash worse.\\nA dermatologist can diagnose the condition by\\nphysical examination and by examining a preparation\\nof skin scrapings under a microscope. This test, called\\na KOH preparation, treats a sample of tissue scraped\\nfrom the infected area with heat and potassium hydro-\\nxide (KOH). This treatment dissolves certain sub-\\nstances in the tissue sample, making it possible to see\\nthe fungi under the microscope.\\nTreatment\\nAthlete’s foot may be resistant to medication and\\nshould not be ignored. Simple cases usually respond\\nwell to antifungal creams or sprays (clotrimazole, keto-\\nconazole, miconazole nitrate, sulconazole nitrate, or\\ntolnaftate). If the infection is resistant to topical treat-\\nment, the doctor may prescribe an oral antifungal drug.\\nUntreated athlete’s foot may lead to a secondary\\nbacterial infection in the skin cracks.\\nAlternative treatment\\nA footbath containing cinnamon has been shown\\nto slow down the growth of certain molds and fungi,\\nand is said to be very effective in clearing up athlete’s\\nfoot. To make the bath:\\n/C15heat four cups of water to a boil\\n/C15add eight to 10 broken cinnamon sticks\\n/C15reduce heat and simmer five minutes\\n/C15remove and let the mixture steep for 45 minutes until\\nlukewarm\\n/C15soak feet\\nOther herbal remedies used externally to treat\\nathlete’s foot include: a foot soak or powder contain-\\ning goldenseal (Hydrastis canadensis); tea tree oil\\n(Melaleuca spp.); or calendula (Calendula officinalis)\\ncream to help heal cracked skin.\\nPrognosis\\nAthlete’s foot usually responds well to treatment,\\nbut it is important to take all medication as directed by\\na dermatologist, even if the skin appears to be free of\\nfungus. Otherwise, the infection could return. The toe-\\nnail infections that may accompany athlete’s foot,\\nhowever, are typically very hard to treat effectively.\\nPrevention\\nGood personal hygiene and a few simple precau-\\ntions can help prevent athlete’s foot. To prevent\\nspread of athlete’s foot:\\n/C15wash feet daily\\n/C15dry feet thoroughly (especially between toes)\\nAthlete’s foot fungus on toes of patient.(Custom Medical Stock\\nPhoto. Reproduced by permission.)\\nAthlete’s foot fungus on bottom of patient’s foot. (Custom\\nMedical Stock Photo. Reproduced by permission.)\\n444 GALE ENCYCLOPEDIA OF MEDICINE\\nAthlete’s foot'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15avoid tight shoes (especially in summer)\\n/C15wear sandals during warm weather\\n/C15wear cotton socks and change them often if they get\\ndamp\\n/C15don’t wear socks made of synthetic material\\n/C15go barefoot outdoors when possible\\n/C15wear bathing shoes in public bathing or showering\\nareas\\n/C15use a good quality foot powder\\n/C15don’t wear sneakers without socks\\n/C15wash towels, contaminated floors, and shower stalls\\nwell with hot soapy water if anyone in the family has\\nathlete’s foot.\\nResources\\nBOOKS\\nThompson, June, et al.Mosby’s Clinical Nursing.St. Louis:\\nMosby, 1998.\\nORGANIZATIONS\\nAmerican Podiatric Medical Association. 9312 Old\\nGeorgetown Road, Bethesda, MD 20814-1698. (301)\\n571-9200. .\\nCarol A. Turkington\\nAthletic heart syndrome\\nDefinition\\nAthletic heart syndrome is the adaptation of\\nan athlete’s heart in response the physiologic stresses\\nof strenuous physical training. It can be difficult to\\ndistinguish a significant medical condition from an\\nathletic heart.\\nDescription\\nThe heart adapts to physical demands by enlar-\\nging, especially the left ventricle. Enlargement increases\\nthe cardiac output, the amount of blood pumped with\\neach beat of the heart. The exact type of adaptation\\ndepends on the nature of the physical demand. There\\nare two types of demand, static and dynamic. Static\\ndemand involves smaller groups of muscles under\\nextreme resistance for brief period. An example is\\nweight lifting. Dynamic training involves larger groups\\nof muscles at lower resistance for extended periods of\\ntime. Examples are aerobic training and tennis.\\nCardiac enlargement is associated with dynamic train-\\ning. The heart’s response to static training is hypertro-\\nphy, thickening of the muscle walls of the heart. As\\nthe wall of the heart adapts, there are changes in the\\nelectrical conducting system of the heart. Because of\\nthe larger volume of blood being pumped with each\\nheart beat, the heart rate when at rest decreases\\nbelow the normal level for nonathletes.\\nSudden unexpecteddeath (SUD) is the death of an\\nathlete, usually during or shortly after physical acti-\\nvity. Often, there is no warning that the person will\\nexperience SUD, although in some cases, warning\\nsigns appear which cause the person to seek medical\\nadvice. Importantly, cases of death occurring during\\nphysical activity are not caused by athletic heart\\nsyndrome, but by undiagnosed heart disorders.\\nCauses and symptoms\\nAthletic heart syndrome is the consequence of a\\nnormal adaptation by the heart to increased physical\\nactivity. The changes in the electrical conduction sys-\\ntem of the heart may be pronounced and diagnostic,\\nbut should not cause problems. In the case of SUD,\\nother heart problems are involved. In 85-97% of the\\ncases of SUD, an underlying structural defect of the\\nheart has been noted.\\nDiagnosis\\nThe changes in the heart beat caused by the elec-\\ntrical conduction system of the heart are detectable on\\nan electrocardiogram. Many of the changes seen in\\nathletic heart syndrome mimic those of various heart\\ndiseases. Careful examination must be made to distin-\\nguish heart disease from athletic heart syndrome.\\nPrognosis\\nThe yearly rate for occurrence of SUD in people\\nless than 35 years of age is less than 7 incidents per\\n100,000. Of all SUD cases, only about 8% areexercise\\nrelated. On a national basis, this means that each year\\napproximately 25 athletes experience SUD. In persons\\nover age 35, the incidence of SUD is approximately 55\\nin 100,000, with only 3% of the cases occurring during\\nexercise.\\nResources\\nBOOKS\\nAlexander, R. W., R. C. Schlant, and V. Fuster, editors.The\\nHeart. 9th ed. New York: McGraw-Hill, 1998.\\nJohn T. Lohr, PhD\\nGALE ENCYCLOPEDIA OF MEDICINE 445\\nAthletic heart syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Atkins diet\\nDefinition\\nThe Atkins diet is a high-protein, high-fat, and\\nvery low-carbohydrate regimen. It emphasizes meat,\\ncheese, and eggs, while discouraging foods such as\\nbread, pasta, fruit, and sugar. It is a form of keto-\\ngenic diet.\\nPurpose\\nThe primary benefit of the diet is rapid and sub-\\nstantial weight loss. By restricting carbohydrate\\nintake, the body will burn more fat stored in the\\nbody. Since there are no limits on the amount of\\ncalories or quantities of foods allowed on the diet,\\nthere is little hunger between meals. According to\\nAtkins, the diet can alleviate symptoms of conditions\\nsuch asfatigue, irritability, headaches, depression, and\\nsome types of joint and musclepain.\\nDescription\\nThe regimen is a low-carbohydrate, or ketogenic\\ndiet, characterized by initial rapid weight loss, usually\\ndue to water loss. Drastically reducing the amount of\\ncarbohydrate intake causes liver and muscle glycogen\\nloss, which has a strong but temporary diuretic effect.\\nLong-term weight loss occurs because with a low\\namount of carbohydrate intake, the body burns stored\\nfat for energy.\\nThe four-step diet starts with a two-week induc-\\ntion program designed to rebalance an individual’s\\nmetabolism. Unlimited amounts of fat and protein\\nare allowed but carbohydrate intake is restricted to\\n20 grams per day. Foods allowed include butter, oil,\\nmeat, poultry, fish, eggs, cheese, and cream. The daily\\namount of carbohydrates allowed equals about three\\ncups of salad vegetables, such as lettuce, cucumbers,\\nand celery.\\nThe second stage is for ongoing weight loss. It\\nallows 20-40 grams of carbohydrates a day. When\\nthe individual is about 10 pounds from their desired\\nweight, they begin the pre-maintenance phase. This\\ngradually adds one to three servings a week of high\\ncarbohydrate foods, such as a piece of fruit or slice of\\nwhole-wheat bread. When the desired weight is\\nreached, the maintenance stage begins. It allows\\n40-60 grams of carbohydrates per day.\\nOpinion from the general medical community\\nremains mixed on the Atkins diet. There have been\\nno significant long-term scientific studies on the diet.\\nA number of leading medical and health organiza-\\ntions, including the American Medical Association,\\nAmerican Dietetic Association (ADA), and the\\nAmerican Heart Association oppose it. It is drastically\\ndifferent than the dietary intakes recommended by the\\nU.S. Department of Agriculture and the National\\nInstitutes of Health. Much of the opposition is because\\nthe diet is lacking in somevitamins and nutrients, and\\nbecause it is high in fat. In a hearing before the U.S.\\nCongress on February 24, 2000, an ADA representa-\\ntive called the Atkins diet ‘‘hazardous’’ and said it\\nlacked scientific credibility.\\nPreparations\\nNo advance preparation is needed to go on the\\ndiet. However, as with mostdiets, it is generally con-\\nsidered appropriate to consult with a physician and to\\nhave a physical evaluation before starting such a nutri-\\ntional regimen. The evaluation should include blood\\ntests to determine levels of cholesterol, triglycerides,\\nglucose, insulin, and uric acid. A glucose tolerance test\\nis also recommended.\\nPrecautions\\nAdherence to the Atkins diet can result in vitamin\\nand mineral deficiencies. In his books, Atkins recom-\\nmends a wide-range ofnutritional supplements, includ-\\ning a multi-vitamin. Among his recommendations,\\nAtkins suggests the following daily dosages: 300-600\\nmicrograms (mcg) of chromium picolinate, 100-400\\nmilligrams (mg) of pantetheine, 200 mcg of selenium,\\nand 450-675 mcg of biotin.\\nThe diet is not recommended for lacto-ovo vege-\\ntarians, since it cannot be done as successfully without\\nprotein derived from animal products. Also, vegans\\ncannot follow this diet, since a vegan diet is too high in\\ncarbohydrates, according to Atkins. Instead, he\\nrecommends vegetarians with a serious weight pro-\\nblem give upvegetarianism, or at least include fish in\\ntheir diet.\\nSide effects\\nAccording to Atkins, the diet causes no adverse\\nside effects. Many health care professionals dis-\\nagree. In a fact sheet for the Healthcare Reality\\nCheck Web site (), Ellen\\nColeman, a registered dietician and author, said\\nthe diet may have serious side effects for some peo-\\nple. She said complicationsassociated with the diet\\ninclude ketosis,dehydration, electrolyte loss, calcium\\ndepletion, weakness, nausea, and kidney problems.\\n446 GALE ENCYCLOPEDIA OF MEDICINE\\nAtkins diet'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='‘‘It is certainly riskier for overweight individuals with\\nmedical problems such as heart disease,hypertension,\\nkidney disease, and diabetes than it is for overweight\\npeople with no health problems,’’ she said.\\nPeople with diabetes taking insulin are at risk of\\nbecoming hypoglycemic if they do not eat appropriate\\ncarbohydrates. Also, persons whoexercise regularly\\nmay experience low energy levels and muscle fatigue\\nfrom low carbohydrate intake.\\nResources\\nBOOKS\\nAtkins, Dr. Robert C.Dr. Atkins’ Age-Defying Diet\\nRevolution. New York: St. Martin’s Press. 1999.\\nPERIODICALS\\nCray, Dan, et al. ‘‘The Low-Carb Diet Craze.’’Time\\nNovember 1, 1999: 72-79.\\nGotthardt, Melissa Meyers. ‘‘The New Low-Carb Diet\\nCraze.’’ Cosmopolitan February 2000: 148.\\nMerrell, Woodson. ‘‘How I Became a Low-Carb Believer.’’\\nTime November 1, 1999: 80.\\nTurner, Richard. ‘‘The Trendy Diet That Sizzles.’’\\nNewsweek September 6, 1999: 60.\\nDR.ROBERT C. ATKINS (1930–2003)\\n(AP/Wide World Photos. Reproduced by permission.)\\nDr. Robert C. Atkins graduated from the University\\nof Michigan in 1951 and received his medical degree\\nfrom Cornell University Medical School in 1955 with a\\nspecialty in cardiology. As an internist and cardiologist\\nhe developed the Atkins Diet in the early 1970s. The diet is\\na ketogenic diet—a high protein, high fat, and very low\\ncarbohydrate regimen resulting in ketosis. It emphasizes\\nmeat, cheese, and eggs, while discouraging foods such as\\nbread, pasta, fruit, and sugar. It first came to public atten-\\ntion in 1972 with the publication of Dr. Atkins’ Diet\\nRevolution. The book quickly became a bestseller but\\nunlike most other fad diet books, this one has remained\\npopular. At last count, it had been reprinted 28 times and\\nsold more than 10 million copies worldwide. Since then,\\nAtkins has authored a number of other books on his diet\\ntheme, including Dr. Atkins’ New Diet Revolution(1992),\\nDr. Atkins’ Quick and Easy New Diet Cookbook (1997),\\nand The Vita-Nutrient Solution: Nature’s Answer to Drugs\\n(1998).\\nAtkins has seen about 60,000 patients in his more\\nthan 30 years of practice. He has also appeared on numer-\\nous radio and television talk shows, has his own syndi-\\ncated radio program, Your Health Choices , and authors\\nthe monthly newsletter Dr. Atkins’ Health Revelations .\\nAtkins has received the World Organization of\\nAlternative Medicine’s Recognition of Achievement\\nAward and been named the National Health Federation’s\\nMan of the Year. He was the director of the Atkins Center\\nfor Complementary Medicine which he founded in the\\nearly 1980s until his death. The center is located at 152\\nE. 55th St., New York, NY 10022.\\nKEY TERMS\\nBiotin— A B complex vitamin, found naturally in\\nyeast, liver, and egg yolks.\\nCarbohydrates— Neutral compounds of carbon,\\nhydrogen, and oxygen found in sugar, starches,\\nand cellulose.\\nHypertension— Abnormally high arterial blood\\npressure, which if left untreated can lead to heart\\ndisease and stroke.\\nKetogenic diet— A diet that supplies an abnormally\\nhigh amount of fat, and small amounts of carbohy-\\ndrates and protein.\\nKetosis— An abnormal increase in ketones in the\\nbody, usually found in people with uncontrolled\\ndiabetes mellitus.\\nPantetheine— A growth factor substance essential\\nin humans, and a constituent of coenzyme A.\\nTriglycerides— A blood fat lipid that increases the\\nrisk for heart disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 447\\nAtkins diet'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='OTHER\\nAtkins Center for Complementary Medicine. 152 E. 55th St.,\\nNew York, NY 10022. 212-758-2110. .\\nKen R. Wells\\nAtopic dermatitis\\nDefinition\\nEczema is a general term used to describe a variety\\nof conditions that cause an itchy, inflamed skin\\nrash. Atopic dermatitis, a form of eczema, is a non-\\ncontagious disorder characterized by chronically\\ninflamed skin and sometimes intolerable itching.\\nDescription\\nAtopic dermatitis refers to a wide range of dis-\\neases that are often associated with stress and allergic\\ndisorders that involve the respiratory system, like\\nasthma and hay fever. Although atopic dermatitis\\ncan appear at any age, it is most common in children\\nand young adults. Symptoms usually abate before the\\nage of 25 and do not affect the patient’s general health.\\nAbout one in ten babies develop a form of atopic\\ndermatitis called infantile eczema. Characterized by skin\\nthatoozesand becomes encrusted, infantile eczema most\\noften occurs on the face and scalp. The condition usually\\nimproves before the child’ssecond birthday,andmedical\\nattention can keep symptoms in check until that time.\\nWhen atopic dermatitis develops after infancy,\\ninflammation, blistering, oozing, and crusting are less\\npronounced. The patient’s sores become dry, turn from\\nred to brownish-gray, and skin may thicken and become\\nscaly. In dark-skinned individuals, this condition can\\ncause the complexion to lighten or darken.Itchingasso-\\nciated with this condition is usually worst at night. It\\ncan be so intense that patients scratch until their sores\\nbleed, sometimes causing scarring and infection.\\nAtopic dermatitis affects about 3% of the popula-\\ntion of the United States, and about 80% of the people\\nwho have the condition have one or more relatives with\\nthe same condition or a similar one. Symptoms tend to\\nbe most severe in females. Atopic dermatitis can erupt on\\nany part of the skin, and crusted, thickened patches on\\nthe fingers, palms, or the soles of the feet can last for\\nyears. In teenagers and young adults, atopic dermatitis\\noften appears on one or more of the following areas:\\n/C15elbow creases\\n/C15backs of the knees\\n/C15ankles\\n/C15wrists\\n/C15face\\n/C15neck\\n/C15upper chest\\n/C15palms and between the fingers\\nCauses and symptoms\\nWhile allergic reactions often trigger atopic\\ndermatitis, the condition is thought to be the result\\nof an inherited over-active immune system or a\\ngenetic defect that causes the skin to lose abnor-\\nmally large amounts of moisture. The condition can\\nA close-up view of atopic dermatitis in the crook of the\\nelbow of a 12-year-old patient. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n448 GALE ENCYCLOPEDIA OF MEDICINE\\nAtopic dermatitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='be aggravated by a cycle that develops in which the\\nskin itches, the patient scratches, the condition wor-\\nsens, the itching worsens, the patient scratches, etc.\\nThis cycle must be broken by relieving the itching to\\nallow the skin time to heal. If the skin becomes\\nbroken, there is also a risk of developing skin infec-\\ntions which, if not recognized and treated promptly,\\ncan become more serious.\\nSymptoms of atopic dermatitis include the\\nfollowing:\\n/C15an itchy rash and dry, thickened skin on areas of the\\nbody where moisture can be trapped\\n/C15continual scratching\\n/C15chronic fatigue, caused when itching disrupts sleep\\nInfant Adult\\nAtopic dermatitis can erupt on any part of the skin. In infants, it often appears on the face, scalp, and knees, while it develops on\\nthe elbows, neck, back of the knees, and ankles in adults.(Illustration by Electronic Illustrators Group.)\\nKEY TERMS\\nCorticosteroid— A steroid hormone produced by\\nthe adrenal gland or as a synthetic compound that\\nreducesinflammation, redness,rashes, andirritation.\\nDermatitis— Inflammation of the skin.\\nGALE ENCYCLOPEDIA OF MEDICINE 449\\nAtopic dermatitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='An individual is more at-risk for developing the\\ncondition if there is a personal or family history of\\natopic dermatitis, hay fever, asthma, or other allergies.\\nExposure to any of the following can cause a flare-up:\\n/C15hot or cold temperatures\\n/C15wool and synthetic fabrics\\n/C15detergents, fabric softeners, and chemicals\\n/C15use of drugs that suppress immune-system activity\\nCertain foods, such as peanuts, cow’s milk, eggs,\\nand fish, can trigger symptoms of atopic dermatitis.\\nA small percentage of patients with atopic dermatitis\\nfind that their symptoms worsen after having been\\nexposed to dust, feather pillows, rough-textured fab-\\nrics, or other materials to which dust adheres.\\nDiagnosis\\nDiagnosis of atopic dermatitis is usually based on\\nthe patient’s symptoms and personal and family\\nhealth history. Skin tests do not generally provide\\nreliable information about this condition.\\nTreatment\\nAtopic dermatitis cannot be cured, but the sever-\\nity and duration of symptoms can be controlled.\\nA dermatologist should be consulted when symptoms\\nfirst appear, and is likely to recommend warm baths to\\nloosen encrusted skin, followed by applications of\\npetroleum jelly or vegetable shortening to prevent the\\nskin’s natural moisture from escaping.\\nExternally applied (topical) steroids or prepara-\\ntions containing coal tar can relieve minor itching, but\\ncoal tar has an unpleasant odor, stains clothes, and\\nmay increase skin-cancer risk. Excessive use of steroid\\ncreams in young children can alter growth. Pregnant\\nwomen should not use products that contain coal tar.\\nTopical steroids can cause itching, burning,acne,p e r -\\nmanent stretch marks, and thinning and spotting of\\nthe skin. Applying topical steroids to the area around\\nthe eyes can causeglaucoma.\\nOral antihistamines, such as diphenhydramine\\n(Benadryl), can relieve symptoms of allergy-related\\natopic dermatitis. More concentrated topical steroids\\nare recommended for persistent symptoms. A mild\\ntranquilizer may be prescribed to reducestress and\\nhelp the patient sleep, and antibiotics are used to\\ntreat secondary infections.\\nCortisone ointments should be used sparingly,\\nand strong preparations should never be applied\\nto the face, groin, armpits, or rectal area. Regular\\nmedical monitoring is recommended for patients\\nwho use cortisone salves or lotions to control wide-\\nspread symptoms. Oral cortisone may be prescribed\\nif the patient does not respond to other treatments,\\nbut patients who take the medication for more than\\ntwo weeks have a greater-than-average risk of devel-\\noping severe symptoms when the treatment is\\ndiscontinued.\\nAllergy shots rarely improve atopic dermatitis\\nand sometimes aggravate the symptoms. Sincefood\\nallergies may trigger atopic dermatitis, the doctor\\nmay suggest eliminating certain foods from the diet if\\nother treatments prove ineffective.\\nIf symptoms are extremely severe, ultraviolet\\nlight therapy may be prescribed, and a wet body\\nw r a pr e c o m m e n d e dt oh e l pt h es k i nr e t a i nm o i s t -\\nure. This technique, used most often with children,\\ninvolves sleeping in a warm room while wearing\\nwet pajamas under dry clothing, rain gear, or a\\nnylon sweatsuit. The patient’s face may be covered\\nwith wet gauze covered by elastic bandages, and\\nhis hands encased in wet socks covered by dry\\nones.\\nA physician should be notified if the condition is\\nwidespread or resists treatment, or the skin oozes,\\nbecomes encrusted, or smells, as this may indicate an\\ninfection.\\nAlternative treatment\\nAlternative therapies can sometimes bring relief\\nor resolution of atopic dermatitis when conventional\\ntherapies are not helping. If the condition becomes\\nincreasingly widespread or infected, a physician\\nshould be consulted.\\nHelpful alternative treatments for atopic dermati-\\ntis may include:\\n/C15Taking regular brisk walks, followed by bathing in\\nwarm water sprinkled with essential oil of lavender\\n(Lavandula officinalis); lavender oil acts as a nerve\\nrelaxant for the whole body including the skin\\n/C15Supplementing the diet daily with zinc, fish oils, vita-\\nmin A, vitamin E, and evening primrose oil (Oenothera\\nbiennis)–all good sources of nutrients for the skin\\n/C15Reducing or eliminating red meat from the diet\\n/C15Eliminating or rotating potentially allergic foods\\nsuch as cow’s milk, peanuts, wheat, eggs, and soy\\n/C15Implementing stress reduction techniques in daily\\nlife.\\nHerbal therapies also can be helpful in treating\\natopic dermatitis. Western herbal remedies used in the\\n450 GALE ENCYCLOPEDIA OF MEDICINE\\nAtopic dermatitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='treatment of this condition include burdock (Arctium\\nlappa) andRuta (Ruta graveolens). Long-term herbal\\ntherapy requires monitoring and should be guided by\\nan experienced practitioner.\\nOther alternative techniques that may be useful in\\nthe treatment of atopic dermatitis include:\\n/C15Acupressure (acupuncture without needles) to relieve\\ntension that may trigger a flare\\n/C15Aromatherapy, using essential oils like lavender,\\nthyme (Thymus vulgaris), jasmine (Jasminum offici-\\nnale) and chamomile (Matricaria recutita) in hot\\nwater, to add a soothing fragrance to the air\\n/C15Shiatsu massage and reflexology, performed by\\nlicensed practitioners, to alleviate symptoms by\\nrestoring the body’s natural balance\\n/C15Homeopathy, which may temporarily worsen\\nsymptoms before relieving them, and should be\\nsupervised by a trained alternative healthcare\\nprofessional\\n/C15Hydrotherapy, which uses water, ice, liquid, and\\nsteam, to stimulate the immune system\\n/C15Juice therapy to purify the liver and relieve bowel\\ncongestion\\n/C15Yoga to induce a sense of serenity.\\nPrognosis\\nAtopic dermatitis is unpredictable. Although\\nsymptoms occur less often with age and sometimes\\ndisappear altogether, they can recur without warn-\\ning. Atopic dermatitis lowers resistance to infection\\nand increases the risk of developingcataracts. Sixty\\npercent of patients with atopic dermatitis will\\nexperience flares and remissions throughout their\\nlives.\\nPrevention\\nResearch has shown that babies weaned from\\nbreast milk before they are four months old are almost\\nthree times more likely than other babies to develop\\nrecurrent eczema. Feeding eggs or fish to a baby less\\nthan one year old can activate symptoms, and babies\\nshould be shielded from such irritants as mites, molds,\\npet hair, and smoke.\\nPossible ways to prevent flare-ups include the\\nfollowing:\\n/C15eliminate activities that cause sweating\\n/C15lubricate the skin frequently\\n/C15avoid wool, perfumes, fabric softeners, soaps that\\ndry the skin, and other irritants\\n/C15avoid sudden temperature changes\\nA doctor should be notified whenever any of the\\nfollowing occurs:\\n/C15fever or relentless itching develop during a flare\\n/C15an unexplained rash develops in someone who has a\\npersonal or family history of eczema or asthma\\n/C15inflammation does not decrease after seven days of\\ntreatment with an over-the-counter preparation con-\\ntaining coal tar or steroids\\n/C15a yellow, tan, or brown crust or pus-filled blisters\\nappear on top of an existing rash\\n/C15a person with active atopic dermatitis comes into\\ncontact with someone who has cold sores,genital\\nherpes, or another viral skin disease\\nResources\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham Road,\\nP.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-\\n0230. Fax: (847) 330-0050. .\\nMaureen Haggerty\\nAtrial ectopic beats\\nDefinition\\nAtrial ectopic beats (AEB) refers to a contraction\\nof the upper heart chamber which occurs before it\\nwould be expected. Atrial ectopic beats are also\\nknown as premature atrial beats, premature atrial\\ncomplex (PAC), or atrial extrasystole.\\nDescription\\nAn AEB is usually a harmless disturbance in the\\nnormal rhythm of the heart. It can occur only occa-\\nsionally, in a regular pattern, or several may occur in\\nsequence and then disappear. Most often, the person is\\nunaware of the event.\\nCauses and symptoms\\nAs people age, extra beats tend to happen more\\nfrequently even in perfectly healthy individuals. AEB\\nmay be triggered or increased bystress, caffeine, smok-\\ning, and some medicines. Cold remedies containing\\nGALE ENCYCLOPEDIA OF MEDICINE 451\\nAtrial ectopic beats'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='ephedrine or pseudoephedrine have been known to\\nincrease the incidence of atrial ectopic beats. AEB\\nmay also be the result of an enlarged atria, lung dis-\\nease, or the result of reduced blood supply to that area\\nof the heart.\\nIf a person is aware of the event, the first symptom\\nof AEB is usually a feeling that the heart has skipped\\nor missed a beat. This is often accompanied by a\\nfeeling that the heart is thumping or pounding in the\\nchest. The thumping or pounding is caused by the fact\\nthat when there is an AEB, the pause before the next\\nbeat is usually longer than normal. The next beat must\\nbe stronger than usual to pump the accumulated blood\\nout of the chamber.\\nDiagnosis\\nDiagnosis of AEB is often suspected on the basis of\\nthe patient’s description of the occurrence. An electro-\\ncardiogram (ECG) can confirm the diagnosis. An ECG\\nshows the heart beat as three wave forms. The first wave\\nis called P, the second is called QRS, and the last is T. An\\natrial ectopic beat will show up on the ECG as a P wave\\nthat occurs closer than usual to the preceding T wave.\\nTreatment\\nAtrial ectopic beats do not usually require treat-\\nment. If treatment is necessary because the beats occur\\nfrequently and cause intolerable discomfort, the doc-\\ntor may prescribe medication.\\nPrognosis\\nOccasional AEB usually have no significance. If\\nthey increase in frequency, they can lead to atrial\\ntachycardia or fibrillation and to a decrease in cardiac\\noutput.\\nPrevention\\nAEB cannot usually be prevented. Aggravating\\nfactors can be addressed, like excessive stimulants,\\nand uncontrolled pulmonary disorders.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nDorothy Elinor Stonely\\nAtrial extrasystole see Atrial ectopic beats\\nAtrial fibrillation and flutter\\nDefinition\\nAtrial fibrillation and flutter are abnormal heart\\nrhythms in which the atria, or upper chambers of the\\nheart, are out of sync with the ventricles, or lower\\nchambers of the heart. In atrial fibrillation, the atria\\n‘‘quiver’’ chaotically and the ventricles beat irregu-\\nlarly. In atrial flutter, the atria beat regularly and\\nfaster than the ventricles.\\nDescription\\nAtrial fibrillation and flutter are two types of\\ncardiac arrhythmias, irregularities in the heart’s\\nrhythm. Nearly 2 million Americans have atrial fibril-\\nlation, according to the American Heart Association.\\nIt is the most common chronic arrhythmia. Atrial\\nflutter is less common, but both of these arrhythmias\\ncan cause a blood clot to form in the heart. This can\\nlead to astroke or a blockage carried by the blood flow\\n(an embolism) anywhere in the body’s arteries. Atrial\\nfibrillation is responsible for about 15% of strokes.\\nThe atria are the heart’s two small upper cham-\\nbers. In atrial fibrillation, the heart beat is comple-\\ntely irregular. The atrial muscles contract very\\nquickly and irregularly; the ventricles, the heart’s\\ntwo large lower chambers, beat irregularly but not\\nas fast as the atria. When the atria fibrillate, blood\\nthat is not completely pumped out can pool and\\nform a clot. In atrial flutter, the heart beat is\\nusually very fast but steady. The atria beat faster\\nthan the ventricles.\\nAtrial fibrillation often occurs in people with var-\\nious types of heart disease. Atrial fibrillation may also\\nresult from an inflammation of the heart’s covering\\n(pericarditis), chest trauma or surgery, pulmonary dis-\\nease, and certain medications. Atrial fibrillation is\\nmore common in older people; about 10% of people\\nover the age of 75 have it. Atrial flutter and fibrillation\\nusually occur in people with hypertensive or coronary\\nheart disease and other types of heart disorders.\\nCauses and symptoms\\nIn most cases, the cause of atrial fibrillation and\\nflutter can be found, but often it cannot. Causes of\\nthese heart beat abnormalities include:\\n/C15many types of heart disease\\n/C15stress and anxiety\\n/C15caffeine\\n452 GALE ENCYCLOPEDIA OF MEDICINE\\nAtrial fibrillation and flutter'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15alcohol\\n/C15tobacco\\n/C15diet pills\\n/C15some prescription and over-the-counter medications\\n/C15open heart surgery\\nSymptoms, when present, include:\\n/C15a fluttering feeling in the chest\\n/C15a pulse that feels like the heart is skipping, racing,\\njumping, or is irregular\\n/C15low energy\\n/C15a faint or dizzy feeling\\n/C15pressure or discomfort in the chest\\n/C15shortness of breath\\n/C15anxiety\\nDiagnosis\\nA doctor can sometimes hear these arrhythmias\\nusing an instrument (a stethoscope) to listen to the\\nsounds within the chest. Atrial fibrillation and flutter\\nare usually diagnosed through electrocardiography\\n(EKGs), an exercise stress test, a 24-hour Holter\\nEKG monitor, or a telephone cardiac monitor. An\\nEKG shows the heart’s activity and may reveal a\\nlack of oxygen (ischemia). Electrodes covered with\\nconducting jelly are placed on the patient’s chest,\\narms, and legs. The electrodes send impulses of the\\nheart’s activity through a monitor (called an oscillo-\\nscope) to a recorder that traces the pattern of the\\nimpulses onto paper. The test takes about 10 minutes\\nand is performed in a doctor’s office. The exercise\\nstress test measures how the heart and blood vessels\\nrespond to work when the patient is exercising on a\\ntreadmill or a stationary bike. This test is performed in\\na doctor’s office within an exercise laboratory and\\ntakes 15-30 minutes.\\nIn 24-hour EKG (Holter) monitoring, the\\npatient wears a small, portable tape recorder con-\\nnected to disks on his/her chest that record the\\nheart’s rhythm during normal activities. An EKG\\ncalled transtelephonic monitoring identifies arrhyth-\\nmias that occur infrequently. Like Holter monitor-\\ning, transtelephonic monitoring continues for days\\nor weeks and enables patients to send the EKG via\\ntelephone to a monitoring station when an arrhythmia\\nis felt, or to store the information in the recorder and\\ntransmit it later. Doctors can also use high-frequency\\nsound waves (echocardiography) to determine the\\nstructure and function of the heart. This diagnostic\\nmethod is often helpful to evaluate for underlying\\nheart disease.\\nTreatment\\nAtrial fibrillation and flutter are usually treated\\nwith medications and/or electrical shock (cardiover-\\nsion). In some cases, removal of a small portion of the\\nheart (ablation), implantation of a pacemaker or a\\ncardioverter defibrillator, or maze surgery is needed.\\nIf the heart rate cannot be quickly controlled,\\nelectrical cardioversion may be used. Cardioversion,\\nthe electric shock to the chest wall, is usually per-\\nformed emergencies. This device briefly suspends the\\nheart’s activity and allows it to return to a normal\\nrhythm.\\nAblation destroys the heart tissue that causes the\\narrhythmia. The tissue can be destroyed by catheter-\\nization or surgery. Radiofrequency catheter ablation,\\nperformed in acardiac catheterizationlaboratory, can\\ncure atrial flutter and control the heart rate in atrial\\nfibrillation. The patient is awake but sedated. A thin\\ntube called a catheter is inserted into a vein and is\\nthreaded into the heart. At the end of the catheter, a\\ndevice maps the electrical pathways of the heart. A\\ncardiologist, a doctor specializing in the heart, uses\\nthis map to identify the pathway(s) causing the\\narrhythmia, and then eliminates it (them) with bursts\\nof high-frequency radio waves. Surgical ablation is\\nperformed in an operating room under general\\nanesthesia. Computerized mapping techniques are\\ncombined with a cold probe to destroy arrhythmia-\\ncausing tissue. Ablation is generally successful. When\\nablation is used for atrial fibrillation, it is usually\\nfollowed by implantation of a pacemaker as well as\\ndrug therapy.\\nKEY TERMS\\nArrhythmia— A variation in the normal rhythm of\\nthe heart beat. Atrial fibrillation and flutter are two\\ntypes of arrhythmia.\\nAtria— The two small upper chambers of the heart\\nthat receive blood from the lungs and the body.\\nStroke— A brain attack caused by a sudden disrup-\\ntion of blood flow to the brain, in this case because\\nof a blood clot.\\nVentricles— The two large lower chambers of the\\nheart that pump blood to the lungs and to the rest of\\nthe body.\\nGALE ENCYCLOPEDIA OF MEDICINE 453\\nAtrial fibrillation and flutter'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='A pacemaker is a battery-powered device about the\\nsize of a matchbox that is surgically implanted near the\\ncollarbone to regulate the heart beat. Lead wires\\nthreaded to the right side ofthe heart supply electrical\\nenergy to pace the atria and ventricles. The implantable\\ncardioverter defibrillator is a treatment for serious\\narrhythmias. The battery-powered device senses an\\nabnormal heart rhythm and automatically provides elec-\\ntrical shock(s). The shock(s)suspends heart activity and\\nthen allows the heart to initiate a normal rhythm. Wire\\nelectrodes on the device are attached to the heart. Some\\nof the electrodes are attached to the outside of the heart\\nand some are attached to the inside of the heart through\\nveins. The newest implantablecardioverter defibrillators\\ncan be implanted in the chest wall and do not require\\nopen chest surgery. These devices weigh less than 10 oz\\nand generally last seven or eight years. An implantable\\ncardioverter defibrillator is usually used with drug ther-\\napy, but the amount medication is reduced. In maze\\nsurgery, often the last resort, surgeons create a maze of\\nstitches (sutures) that help theheart’s electrical impulses\\ntravel effectively.\\nMost of the drugs used for treatment have poten-\\ntial side effects and should be carefully monitored by a\\ndoctor. The goal of treatment is to control the rate and\\nrhythm of the heart and to prevent the formation of\\nblood clots. If the arrhythmia is caused by heart dis-\\nease, the heart disease will also be treated. The\\nAmerican Heart Association recommends aggressive\\ntreatment.\\nA digitalis drug, most commonly digoxin, is\\nusually prescribed to control the heart rate. Digitalis\\ndrugs slow the heart’s electrical impulses, helping to\\nrestore the normal rate and rhythm. These drugs also\\nincrease the ability of the heart’s muscular layer to\\ncontract and pump properly. Beta-blockers and\\ncalcium channel blockers can also be used for this\\npurpose. Beta-blockers slow the speed of electrical\\nimpulses through the heart. Some calcium channel\\nblockers dampen the heart’s response to erratic elec-\\ntrical impulses.\\nTo prevent blood clots, aspirin or warfarin\\n(Coumadin) is administered. Warfarin, however, has\\npotential bleeding side effects, especially in older\\npatients. Amiodarone is fairly efffective for atrial flut-\\nter. This drug is often able to maintain the heart’s\\nproper rhythm and can also help control the heart\\nrate when the flutter occurs.\\nPrognosis\\nPatients with atrial fibrillation and flutter can\\nlive a normal life for many years as long as the\\narrhythmia is controlled and serious blood clots\\nare prevented.\\nPrevention\\nAtrial fibrillation and flutter can sometimes be\\nprevented when the cause can be identified and con-\\ntrolled. Depending on the cause, prevention could\\ninclude:\\n/C15treating the underlying heart disease\\n/C15reducing stress and anxiety\\n/C15reducing or stopping consumption of caffeine, alco-\\nhol, or tobacco; and/or\\n/C15discontinuing diet pills or other medications (over-\\nthe-counter or prescription)\\nResources\\nPERIODICALS\\nKosinski, Daniel, et al. ‘‘Catheter Ablation for Atrial Flutter\\nand Fibrillation: An Effective Alternative to Medical\\nTherapy.’’ Postgraduate Medicine103, no. 1 (January\\n1998): 103-110.\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nNational Heart, Lung and Blood Institute. PO Box 30105,\\nBethesda, MD 20824-0105. (301) 251-1222. .\\nTexas Heart Institute. Heart Information Service. PO Box\\n20345, Houston, TX 77225-0345. .\\nLori De Milto\\nAtrial flutter see Atrial fibrillation and flutter\\nAtrial septal defect\\nDefinition\\nAn atrial septal defect is an abnormal opening in\\nthe wall separating the left and right upper chambers\\n(atria) of the heart.\\nDescription\\nDuring the normal development of the fetal\\nheart, there is an opening in the wall (the septum)\\nseparating the left and right upper chambers of the\\nheart. Normally, this opening closes before birth,\\n454 GALE ENCYCLOPEDIA OF MEDICINE\\nAtrial septal defect'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='but if it does not, the child is born with a hole\\nbetween the left and right atria. This abnormal\\nopening is called an atrial septal defect and causes\\nblood from the left atrium to flow into the right\\natrium.\\nDifferent types of atrial septal defects can\\noccur, and they are classified according to where\\nin the separating wall they are found. The most\\ncommonly found atrial septal defect occurs in the\\nmiddle of the atrial septum and accounts for about\\n70% of all atrial septal defects. Abnormal openings\\ncan form in the upper and lower parts of the atrial\\nseptum as well.\\nCauses and symptoms\\nAbnormal openings in the atrial septum occur\\nduring fetal development and are twice as common\\nin females as in males. These abnormalities can go\\nunnoticed if the opening is small, producing no\\nabnormal symptoms. If the defect is big, large\\namounts of blood flowing from the left to the\\nright atrium will cause the right atrium to swell to\\nhold the extra blood.\\nPeople born with an atrial septal defect can have\\nno symptoms through their twenties, but by age 40,\\nmost people with this condition have symptoms that\\ncan includeshortness of breath, rapid abnormal beat-\\ning of the atria (atrial fibrillation), and eventually\\nheart failure.\\nDiagnosis\\nAtrial septal defects can be identified by various\\nmethods. Abnormal changes in the sound of the\\nheart beats can be heard when a doctor listens to\\nthe heart with a stethoscope. In addition, a chest\\nxr a y, an electrocardiogram (ECG, an electrical\\nprintout of the heartbeats), and an echocardiogram\\n(a test that uses sound waves to form a detailed\\nimage of the heart) can also be used to identify\\nthis condition.\\nAn atrial septal defect can also be diagnosed by\\nusing a test calledcardiac catheterization.T h i st e s t\\ninvolves inserting a very thin tube (catheter) into the\\nheart’s chambers to measure the amount of oxygen\\npresent in the blood within the heart. If the heart\\nhas an opening between the atria, oxygen-rich blood\\nfrom the left atrium enters the right atrium.\\nThrough cardiac catheterization, doctors can detect\\nthe higher-than-normal amount of oxygen in the\\nheart’s right atrium, right ventricle, and the large\\nblood vessels that carry blood to the lungs, where\\nthe blood would normally subsequently get its\\noxygen.\\nTreatment\\nAtrial septal defects often correct themselves with-\\nout medical treatments by the age of two. If this dose\\nnot happen, surgery is done by sewing the hole closed,\\nor by sewing a patch of Dacron material or a piece of\\nthe sac that surrounds the heart (the pericardium),\\nover the opening.\\nSome patients can have the defect fixed by having\\nan clam-shaped plug placed over the opening. This\\nplug is a man-made device that is put in place through\\na catheter inserted into the heart.\\nPrognosis\\nIndividuals with small defects can live a normal\\nlife, but larger defects require surgical correction. Less\\nthan 1% of people younger than 45 years of age die\\nfrom corrective surgery. Five to ten percent of patients\\ncan die from the surgery if they are older than 40 and\\nhave other heart-related problems. When an atrial\\nseptal defect is corrected within the first 20 years of\\nlife, there is an excellent chance for the individual to\\nlive normally.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nDominic De Bellis, PhD\\nAtrioventricular block see Heart block\\nAttapulgite see Antidiarrheal drugs\\nKEY TERMS\\nCardiac catheterization— A test that involves hav-\\ning a tiny tube inserted into the heart through a\\nblood vessel.\\nDacron— A synthetic polyester fiber used to surgi-\\ncally repair damaged sections of heart muscle and\\nblood vessel walls.\\nEchocardiogram— A test that uses sound waves to\\ngenerate an image of the heart, its valves, and\\nchambers.\\nGALE ENCYCLOPEDIA OF MEDICINE 455\\nAtrial septal defect'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Attention-deficit/\\nHyperactivity disorder\\n(ADHD)\\nDefinition\\nAttention-deficit/hyperactivity disorder (ADHD)\\nis a developmental disorder characterized by distract-\\nibility, hyperactivity, impulsive behaviors, and the\\ninability to remain focused on tasks or activities.\\nDescription\\nADHD, also known as hyperkinetic disorder\\n(HKD) outside of the United States, is estimated to\\naffect 3-9% of children, and afflicts boys more often\\nthan girls. Although difficult to assess in infancy and\\ntoddlerhood, signs of ADHD may begin to appear as\\nearly as age two or three, but the symptom picture\\nchanges as adolescence approaches. Many symptoms,\\nparticularly hyperactivity, diminish in early adult-\\nhood, but impulsivity and inattention problems\\nremain with up to 50% of ADHD individuals\\nthroughout their adult life.\\nChildren with ADHD have short attention\\nspans, becoming easily bored and/or frustrated\\nwith tasks. Although they may be quite intelligent,\\ntheir lack of focus frequently results in poor grades\\nand difficulties in school. ADHD children act\\nimpulsively, taking action first and thinking later.\\nThey are constantly moving, running, climbing,\\nsquirming, and fidgeting, but often have trouble\\nwith gross and fine motor skills and, as a result,\\nmay be physically clumsy and awkward. Their\\nclumsiness may extend to the social arena, where\\nthey are sometimes shunned due to their impulsive\\nand intrusive behavior.\\nCauses and symptoms\\nThe causes of ADHD are not known. However,\\nit appears that heredity plays a major role in the\\ndevelopment of ADHD. Children with an ADHD\\nparent or sibling are more likely to develop the\\ndisorder themselves. In 2004, scientists reported at\\nleast 20 candidate genes that might contribute to\\nADHD, but no single gene stood out as the gene\\ncausing the condition. Before birth, ADHD children\\nmay have been exposed to poor maternalnutrition,\\nviral infections, or maternal substance abuse .I n\\nearly childhood, exposure to lead or other toxins\\ncan cause ADHD-like symptoms. Traumatic brain\\ninjury or neurological disorders may also trigger\\nADHD symptoms. Although the exact cause of\\nADHD is not known, an imbalance of certain neu-\\nrotransmitters, the chemicals in the brain that trans-\\nmit messages between nerve cells, is believed to be\\nthe mechanism behind ADHD symptoms.\\nA widely publicized study conducted by Dr. Ben\\nFeingold in the early 1970s suggested that allergies to\\ncertain foods and food additives caused the character-\\nistic hyperactivity of ADHD children. Although some\\nchildren may have adverse reactions to certain foods\\nthat can affect their behavior (for example, a rash\\nmight temporarily cause a child to be distracted from\\nother tasks), carefully controlled follow-up studies\\nhave uncovered no link betweenfood allergies and\\nADHD. Another popularly held misconception\\nabout food and ADHD is that the consumption of\\nsugar causes hyperactive behavior. Again, studies\\nhave shown no link between sugar intake and\\nADHD. It is important to note, however, that a nutri-\\ntionally balanced diet is important for normal devel-\\nopment inall children.\\nPsychologists and other mental health profes-\\nsionals typically use the criteria listed in theDiagnostic\\nand Statistical Manual of Mental Disorders, Fourth\\nDrugs Used To Treat ADHD\\nBrand Name (Generic Name) Possible Common Side Effects\\nInclude:\\nCylert (pemoline) Insomnia\\nDexedrine (dextroamphetamine\\nsulfate)\\nExcessive stimulation, restlessness\\nRitalin (methylphenidate\\nhydrochloride)\\nInsomnia, nervousness, loss of\\nappetite\\nKEY TERMS\\nConduct disorder— A behavioral and emotional\\ndisorder of childhood and adolescence. Children\\nwith a conduct disorder act inappropriately,\\ninfringe on the rights of others, and violate societal\\nnorms.\\nNervous tic— A repetitive, involuntary action, such\\nas the twitching of a muscle or repeated blinking.\\nOppositional defiant disorder— A disorder charac-\\nterized by hostile, deliberately argumentative, and\\ndefiant behavior toward authority figures.\\n456 GALE ENCYCLOPEDIA OF MEDICINE\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Edition (DSM-IV)as a guideline for determining the\\npresence of ADHD. For a diagnosis of ADHD,DSM-\\nIV requires the presence of at least six of the following\\nsymptoms of inattention, or six or more symptoms of\\nhyperactivity and impulsivity combined:\\nInattention:\\n/C15fails to pay close attention to detail or makes careless\\nmistakes in schoolwork or other activities\\n/C15has difficulty sustaining attention in tasks or\\nactivities\\n/C15does not appear to listen when spoken to\\n/C15does not follow through on instructions and does not\\nfinish tasks\\n/C15has difficulty organizing tasks and activities\\n/C15avoids or dislikes tasks that require sustained mental\\neffort (e.g., homework)\\n/C15is easily distracted\\n/C15is forgetful in daily activities\\nHyperactivity:\\n/C15fidgets with hands or feet or squirms in seat\\n/C15does not remain seated when expected to\\n/C15runs or climbs excessively when inappropriate (in\\nadolescents and adults, feelings of restlessness)\\n/C15has difficulty playing quietly\\n/C15is constantly on the move\\n/C15talks excessively\\nImpulsivity:\\n/C15blurts out answers before the question has been\\ncompleted\\n/C15has difficulty waiting for his or her turn\\n/C15interrupts and/or intrudes on others\\nDiagnosis\\nThe first step in determining if a child has ADHD\\nis to consult with a pediatrician. The pediatrician can\\nmake an initial evaluation of the child’s developmental\\nmaturity compared to other children in his or her age\\ngroup. The physician should also perform a compre-\\nhensive physical examination to rule out any organic\\ncauses of ADHD symptoms, such as an overactive\\nthyroid or vision or hearing problems.\\nIf no organic problem can be found, a psycholo-\\ngist, psychiatrist, neurologist, neuropsychologist, or\\nlearning specialist is typically consulted to perform a\\ncomprehensive ADHD assessment. A complete medi-\\ncal, family, social, psychiatric, and educational history\\nis compiled from existing medical and school records\\nand from interviews with parents and teachers.\\nInterviews may also be conducted with the child,\\ndepending on his or her age. Along with these inter-\\nviews, several clinical inventories may also be used,\\nsuch as the Conners Rating Scales (Teacher’s\\nQuestionnaire and Parent’s Questionnaire), Child\\nBehavior Checklist (CBCL), and the Achenbach\\nChild Behavior Rating Scales. These inventories pro-\\nvide valuable information on the child’s behavior in\\ndifferent settings and situations. In addition, the\\nWender Utah Rating Scale has been adapted for use\\nin diagnosing ADHD in adults.\\nIt is important to note that mental disorders such\\nas depression andanxiety disorder can cause symp-\\ntoms similar to ADHD. A complete and comprehen-\\nsive psychiatric assessment is critical to differentiate\\nADHD from other possible mood and behavioral dis-\\norders. Bipolar disorder, for example, may be misdiag-\\nnosed as ADHD.\\nPublic schools are required by federal law to offer\\nfree ADHD testing upon request. A pediatrician can\\nalso provide a referral to a psychologist or pediatric\\nspecialist for ADHD assessment. Parents should\\ncheck with their insurance plans to see if these services\\nare covered.\\nTreatment\\nPsychosocial therapy, usually combined with\\nmedications, is the treatment approach of choice to\\nalleviate ADHD symptoms. Psychostimulants, such\\nas dextroamphetamine (Dexedrine), pemoline\\n(Cylert), and methylphenidate (Ritalin) are commonly\\nprescribed to control hyperactive and impulsive beha-\\nvior and increase attention span. They work by stimu-\\nlating the production of certain neurotransmitters in\\nthe brain. Possible side effects of stimulants include\\nnervous tics, irregular heartbeat, loss of appetite, and\\ninsomnia. However, the medications are usually well-\\ntolerated and safe in most cases. In 2004, longer-acting\\nstimulants had been released to treat adult ADHD.\\nIn 2004, the American Academy of Child and\\nAdolescent Psychiatry listed the first nonstimulant as a\\nfirst-line therapy for ADHD. Called atomoxetine HCI\\n(Strattera), it is a norepinephrine reuptake inhibitor.\\nIn children who do not respond well to stimulant\\ntherapy, tricyclic antidepressantssuch as desipramine\\n(Norpramin, Pertofane) and amitriptyline (Elavil) are\\nsometimes recommended. Reported side effects of\\nthese drugs include persistent dry mouth, sedation,\\ndisorientation, and cardiac arrhythmia (particularly\\nGALE ENCYCLOPEDIA OF MEDICINE 457\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='with desipramine). Other medications prescribed for\\nADHD therapy include buproprion (Wellbutrin), an\\nantidepressant; fluoxetine (Prozac), anSSRI antide-\\npressant; and carbamazepine (Tegretol, Atretol), an\\nanticonvulsant drug. Clonidine (Catapres), an antihy-\\npertensive medication, has also been used to control\\naggression and hyperactivity in some ADHD children,\\nalthough it should not be used with Ritalin. A child’s\\nresponse to medication will change with age and\\nmaturation, so ADHD symptoms should be moni-\\ntored closely and prescriptions adjusted accordingly.\\nBehavior modification therapy uses a reward sys-\\ntem to reinforce good behavior and task completion\\nand can be implemented both in the classroom and at\\nhome. A tangible reward such as a sticker may be\\ngiven to the child every time he completes a task or\\nbehaves in an acceptable manner. A chart system may\\nbe used to display the stickers and visually illustrate\\nthe child’s progress. When a certain number of stickers\\nare collected, the child may trade them in for a bigger\\nreward such as a trip to the zoo or a day at the beach.\\nThe reward system stays in place until the good beha-\\nvior becomes ingrained.\\nA variation of this technique,cognitive-behavioral\\ntherapy, works to decrease impulsive behavior by get-\\nting the child to recognize the connection between\\nthoughts and behavior, and to change behavior by\\nchanging negative thinking patterns.\\nIndividual psychotherapy can help an ADHD\\nchild build self-esteem, give them a place to discuss\\ntheir worries and anxieties, and help them gain insight\\ninto their behavior and feelings. Family therapy may\\nalso be beneficial in helping family members develop\\ncoping skills and in working through feelings of guilt\\nor anger parents may be experiencing.\\nADHD children perform better within a familiar,\\nconsistent, and structured routine with positive rein-\\nforcements for good behavior and real consequences\\nfor bad. Family, friends, and caretakers should all be\\neducated on the special needs and behaviors of the\\nADHD child. Communication between parents and\\nteachers is especially critical to ensuring an ADHD\\nchild has an appropriate learning environment.\\nAlternative treatment\\nA number of alternative treatments exist for\\nADHD. Although there is a lack of controlled studies\\nto prove their efficacy, proponents report that they are\\nsuccessful in controlling symptoms in some ADHD\\npatients. Some of the more popular alternative treat-\\nments include:\\n/C15EEG (electroencephalograph)biofeedback. By mea-\\nsuring brainwave activity and teaching the ADHD\\npatient which type of brainwave is associated with\\nattention, EEG biofeedback attempts to train\\npatients to generate the desired brainwave activity.\\n/C15Dietary therapy. Based in part on the Feingold food\\nallergy diet, dietary therapy focuses on a nutritional\\nplan that is high in protein and complex carbohy-\\ndrates and free of white sugar and salicylate-contain-\\ning foods such as strawberries, tomatoes, and grapes.\\n/C15Herbal therapy. Herbal therapy uses a variety of\\nnatural remedies to address the symptoms of\\nADHD, such as ginkgo (Gingko biloba) for memory\\nand mental sharpness and chamomile (Matricaria\\nrecutita) extract for calming. The safety of herbal\\nremedies has not been demonstrated in controlled\\nstudies. For example, it is known that gingko may\\naffect blood coagulation, but controlled studies have\\nnot yet evaluated the risk of the effect.\\n/C15Homeopathic medicine. The theory of homeopathic\\nmedicine is to treat the whole person at a core level.\\nConstitutional homeopathic care requires consulting\\nwith a well-trained homeopath who has experience\\nworking with ADD and ADHD individuals.\\nPrognosis\\nUntreated, ADHD negatively affects a child’s\\nsocial and educational performance and can seriously\\ndamage his or her sense of self-esteem. ADHD child-\\nren have impaired relationships with their peers, and\\nmay be looked upon as social outcasts. They may be\\nperceived as slow learners or troublemakers in the\\nclassroom. Siblings and even parents may develop\\nresentful feelings towards the ADHD child.\\nSome ADHD children also develop a conduct\\ndisorder problem. For those adolescents who have\\nboth ADHD and aconduct disorder, as many as 25%\\ngo on to develop antisocial personality disorder and\\nthe criminal behavior, substanceabuse, and high rate\\nof suicide attempts that are symptomatic of it.\\nChildren diagnosed with ADHD are also more likely\\nto have a learning disorder, a mood disorder such as\\ndepression, or an anxiety disorder.\\nApproximately 70-80% of ADHD patients trea-\\nted with stimulant medication experience significant\\nrelief from symptoms, at least in the short-term.\\nApproximately one-half of ADHD children seem to\\n‘‘outgrow’’ the disorder in adolescence or early adult-\\nhood; the other half will retain some or all symptoms\\nof ADHD as adults. With early identification and\\nintervention, careful compliance with a treatment\\n458 GALE ENCYCLOPEDIA OF MEDICINE\\nAttention-deficit/Hyperactivity disorder (ADHD)'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='program, and a supportive and nurturing home and\\nschool environment, ADHD children can flourish\\nsocially and academically.\\nResources\\nPERIODICALS\\n‘‘AACAP Guidelines Include Strattera as a First-line ADHD\\nTherapy Option.’’Drug Week(May 28, 2004): 54.\\n‘‘More Long-acting Stimulants to Treat Adult ADHD.’’\\nSCRIP World Pharmaceutical News(May 14, 2004): 101-\\n23.\\n‘‘Study Updates Genetics of ADHD.’’Drug Week(May 21,\\n2004): 55.\\nORGANIZATIONS\\nAmerican Academy of Child and Adolescent Psychiatry.\\n(AACAP). 3615 Wisconsin Ave. NW, Washington, DC\\n20016. (202) 966-7300. .\\nChildren and Adults with Attention Deficit Disorder\\n(CH.A.D.D.). 8181 Professional Place, Suite 201.\\nNational Attention Deficit Disorder Association. (ADDA).\\n9930 Johnnycake Ridge Road, Suite 3E, Mentor, OH\\n44060. (800) 487-2282. .\\nPaula Anne Ford-Martin\\nTeresa G. Odle\\nAttention deficit disorder see Attention-defi-\\ncit/Hyperactivity disorder (ADHD)\\nAtypical mycobacterial infections see\\nMycobacterial infections, atypical\\nAtypical pneumonia see Mycoplasma\\ninfections\\nAudiometry\\nDefinition\\nAudiometry is the testing of a person’s ability to\\nhear various sound frequencies. The test is performed\\nwith the use of electronic equipment called an audio-\\nmeter. This testing is usually administered by a trained\\ntechnician called an audiologist.\\nPurpose\\nAudiometry testing is used to identify and diag-\\nnose hearing loss. The equipment is used in health\\nscreening programs, for example in grade schools, to\\ndetect hearing problems in children. It is also used in\\nthe doctor’s office or hospital audiology department\\nto diagnose hearing problems in children, adults, and\\nthe elderly. With correct diagnosis of a person’s spe-\\ncific pattern of hearing impairment, the right type of\\ntherapy, which might includehearing aids, corrective\\nsurgery, or speech therapy, can be prescribed.\\nPrecautions\\nTesting with audiometry equipment is simple and\\npainless. No special precautions are required.\\nDescription\\nA trained audiologist (a specialist in detecting\\nhearing loss) uses an audiometer to conduct audiome-\\ntry testing. This equipment emits sounds or tones, like\\nmusical notes, at various frequencies, or pitches, and\\nat differing volumes or levels of loudness. Testing is\\nusually done in a soundproof testing room.\\nThe person being tested wears a set of head-\\nphones that blocks out other distracting sounds and\\ndelivers a test tone to one ear at a time. At the sound\\nof a tone, the patient holds up a hand or finger to\\nindicate that the sound is detected. The audiologist\\nlowers the volume and repeats the sound until the\\npatient can no longer detect it. This process is\\nrepeated over a wide range of tones or frequencies\\nfrom very deep, low sounds, like the lowest note\\nplayed on a tuba, to very high sounds, like the\\npinging of a triangle. Each ear is tested separately.\\nIt is not unusual for levels of sensitivity to sound to\\ndiffer from one ear to the other.\\nA second type of audiometry testing uses a head-\\nband rather than headphones. The headband is worn\\nwith small plastic rectangles that fit behind the ears to\\nAn audiologist conducting a hearing test. (Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 459\\nAudiometry'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='conduct sound through the bones of the skull. The\\npatient being tested senses the tones that are trans-\\nmitted as vibrations through the bones to the inner\\near. As with the headphones, the tones are repeated at\\nvarious frequencies and volumes.\\nThe results of the audiometry test may be recorded\\non a grid or graph called an audiogram. This graph is\\ngenerally set up with low frequencies or tones at one end\\nand high ones at the other end, much like a piano key-\\nboard. Low notes are graphed on the left and high notes\\non the right. The graph also charts the volume of the\\ntones used; from soft, quiet sounds at the top of the\\nchart to loud sounds at the bottom. Hearing is mea-\\nsured in units called decibels. Most of the sounds asso-\\nciated with normal speech patterns are generally spoken\\nin the range of 20-50 decibels. An adult with normal\\nhearing can detect tones between 0-20 decibels.\\nSpeech audiometry is another type of testing that\\nuses a series of simple recorded words spoken at var-\\nious volumes into headphones worn by the patient\\nbeing tested. The patient repeats each word back to\\nthe audiologist as it is heard. An adult with normal\\nhearing will be able to recognize and repeat 90-100%\\nof the words.\\nPreparation\\nThe ears may be examined with an otoscope prior\\nto audiometry testing to determine if there are any\\nblockages in the ear canal due to ear wax or other\\nmaterial.\\nNormal results\\nA person with normal hearing will be able to\\nrecognize and respond to all of the tone frequencies\\nadministered at various volumes in both ears by the\\naudiometry test. An adult with normal hearing can\\ndetect a range of low and high pitched sounds that\\nare played as softly as between nearly 0-20 decibels.\\nNormal speech is generally spoken in the range of\\n20-50 decibels.\\nAbnormal results\\nAudiometry test results are considered abnormal\\nif there is a significant or unexplained difference\\nbetween the levels of sound heard between the two\\nears, or if the person being tested is unable to hear in\\nthe normal range of frequencies and volume. The\\npattern of responses displayed on the audiogram can\\nbe used by the audiologist to identify if a significant\\nhearing loss is present and if the patient might benefit\\nfrom hearing aids or corrective surgery.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Audiology. 8201 Greensboro Drive,\\nSuite 300, McLean, VA 22102. (703) 610-9022. .\\nAudiology Awareness Campaign. 3008 Millwood Ave.,\\nColumbia, SC 29205. (800) 445-8629.\\nOTHER\\n‘‘How to Read Your Hearing Test.’’Hearing Alliance\\nofAmerica. .\\n‘‘Understanding Your Audiogram.’’The League for the\\nHard of Hearing..\\nAltha Roberts Edgren\\nAuditory integration training\\nDefinition\\nAuditory integration training, or AIT, is one spe-\\ncific type of music/auditory therapy based upon the\\nwork of French otolaryngologists Dr.Alfred Tomatis\\nand Dr. Guy Berard.\\nOrigins\\nThe premise upon which most auditory integra-\\ntion programs are based is that distortion in how\\nthings are heard contributes to commonly seen\\nbehavioral or learning disorders in children. Some\\nof these disorders includeattention deficit/hyperac-\\ntive disorder (ADHD), autism, dyslexia, and central\\nKEY TERMS\\nAudiogram— A chart or graph of the results of a hear-\\ning test conductedwith audiographic equipment. The\\nchart reflects the softest (lowest volume) sounds that\\ncan be heard at various frequencies or pitches.\\nDecibel— A unit of measure for expressing the\\nloudness of a sound. Normal speech is typically\\nspoken in the range of about 20-50 decibels.\\nOtoscope— A hand-held instrument with a tiny\\nlight and a funnel-shaped attachment called an\\near speculum, which is used to examine the ear\\ncanal and eardrum.\\n460 GALE ENCYCLOPEDIA OF MEDICINE\\nAuditory integration training'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='auditory processing disorders (CAPD). Training the\\npatient to listen can stimulate central and cortical\\norganization.\\nAuditory integration is one facet of what audiol-\\nogists call central auditory processing. The simplest\\ndefinition of central auditory processing, or CAP, is\\nUniversity of Buffalo Professor of Audiology Jack\\nKatz’s, which is: ‘‘What we do with what we hear.’’\\nCentral auditory integration is actually the perception\\nof sound, including the ability to attend to sound, to\\nremember it, retaining it in both the long- and short-\\nterm memory, to be able to listen to sound selectively,\\nand to localize it.\\nGuy Berard developed one of the programs com-\\nmonly used. Berard’s auditory integration training\\nconsists of twenty half-hour sessions spent listening\\nto musical sounds via a stereophonic system. The\\nmusic is random, with filtered frequencies, and the\\nperson listens through earphones. These sound waves\\nvibrate andexercise structures in the middle ear. This\\nis normally done in sessions twice a day for 10 days.\\nAlfred Tomatis is also the inventor of the\\nElectronic Ear. This device operates through a series\\nof filters, and reestablishes the dominance of the right\\near in hearing. The basis of Tomatis’ work is a series of\\nprinciples that follow:\\n/C15The most important purpose of the ear is to adapt\\nsound waves into signals that charge the brain.\\n/C15Sound is conducted via both air and bone. It can be\\nconsidered something that nourishes the nervous\\nsystem, either stimulating or destimulating it.\\n/C15Just as seeing is not the same as looking, hearing is not\\nthe same as listening. Hearing is passive. Listening is\\nactive.\\n/C15A person’s ability to listen affects all language devel-\\nopment for that person. This process influences every\\naspect of self-image and social development.\\nA L F R E D T O M A T I S (1920– )\\n(Photograph by V. Brynner. Gamma Liaison. Reproduced by\\npermission.)\\nInternationally renowned French otolaryngologist,\\npsychologist, educator and inventor Alfred Tomatis per-\\nceived the importance of sound and hearing early in\\nhis career. He took his degree as a Doctor of Medicine\\nfrom the University of Paris and specialized in ear,\\nnose and throat medicine. The son of two opera sing-\\ners, Tomatis early in his career treated some of his\\nparents’ fellow opera singers. From these experiences with\\nthe sound of music, he developed the principle that has\\ncome to be known as the Tomatis Effect, i.e. that the human\\nvoice can only sing what it hears.\\nTomatis has been called the Einstein of the ear. It was\\nhis research that made the world aware that the ears of an\\ninfant in utero are already functioning at four and half\\nmonths of age. Just as the umbilical cord provides nourish-\\nment to the unborn infant’s body, Tomatis postulated that\\nthe sound of the mother’s voice is also a nutrient heard by\\nthe fetus. This sound literally charges and stimulates the\\ngrowth of the brain.\\nTomatis took this further, into the realm of language.\\nTomatis concluded that the need to communicate and to\\nbe understood are among our most basic needs. He was a\\npioneer in perceiving that language problems convert into\\nsocial problems for people. ‘‘Language is what charac-\\nterizes man and makes him different from other creatures,’’\\nTomatis is quoted as saying. The techniques he developed\\nto teach people how to listen effectively are internationally\\nrespected tools used in the treatment of autism, attention-\\ndeficit disorder, and other learning disabilities.\\nHis listening program, the invention of the Electronic\\nEar, and his work with the therapeutic use of sound and\\nmusic for the past fifty years have made Tomatis arguably\\nthe best known and most successful ear specialist in the\\nworld. There are more than two hundred Tomatis Centers\\nworldwide, treating a vast variety of problems related to\\nthe ability to hear.\\nGALE ENCYCLOPEDIA OF MEDICINE 461\\nAuditory integration training'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15The capacity to listen can be changed or improved\\nthrough auditory stimulation using musical and\\nvocal sounds at high frequencies.\\n/C15Communication begins in the womb. As early as the\\nbeginning of the second trimester, fetuses can hear\\nsounds. These sounds literally cause the brain and\\nnervous system of the baby to develop.\\nDescription\\nA quartet of CAP defects have been identified that\\ncan unfavorably alter how each person processes\\nsound. Among these are:\\n/C15Phonetic decoding, a problem that occurs when the\\nbrain incorrectly decodes what is being heard.\\nSounds are unrecognizable, often because the person\\nspeaking talks too fast.\\n/C15Tolerance-fading memory, a condition with little or\\npoor tolerance for background sounds.\\n/C15Auditory integration involves a person’s ability to\\nput together things heard with things seen.\\nCharacteristically there are long response delays\\nand trouble with phonics, or recognizing the symbols\\nfor sounds.\\n/C15The fourth problem area, often called auditory orga-\\nnization, overlaps the previous three. It is character-\\nized by disorganization in handling auditory and\\nother information.\\nCertain audiological tests are carried out to see if\\nthe person has a CAP problem, and if so, how severe it\\nis. Other tests give more specific information regard-\\ning the nature of the CAP problem. They include:\\n/C15Puretone air-conduction threshold testing, which mea-\\nsures peripheral hearing loss. If loss is found, then\\nbone-conduction testing, or evaluation of the vibra-\\ntion of small bones in the inner ear, is also carried out.\\n/C15Word discrimination scores (WDS) determines a per-\\nson’s clarity in hearing ideal speech. This is done by\\npresenting 25–50 words at 40 decibels above the\\nperson’s average sound threshold in each ear. Test\\nscores equal the percentage of words heard correctly.\\n/C15Immittance testing is made up of two parts, assessing\\nthe status of, and the protective mechanisms of the\\nmiddle ear.\\n/C15Staggered sporadic word (SSW) testing delivers 40\\ncompound words in an overlapping way at 50 deci-\\nbels above threshold to each ear of the person being\\ntested. This test provides expanded information that\\nmakes it possible to break down CAP problems into\\nthe four basic types.\\n/C15Speech in noise discrimination (SN) testing is similar\\nto Staggered Sporadic Word testing except that other\\nnoise is also added and the percentage correct in\\nquiet is compared with that correct when there is\\nadded noise.\\n/C15Phonemic synthesis (PS) determines serious learning\\nproblems. The types of errors made in sounding out\\nwritten words or associating written letters with the\\nsounds they represent help in determining the type\\nand severity of CAP problems.\\nPurpose\\nUpon completion of an auditory integration\\ntraining program, the person’s hearing should be cap-\\nable of perceiving all frequencies at, or near, the same\\nlevel. Total improvement from this therapy, in both\\nhearing and behavior, can take up to one year.\\nResearch and general acceptance\\nAuditory integration training is based upon newly\\nlearned information about the brain. Though brain\\nstructures and connections are predetermined, prob-\\nably by heredity, another factor calledplasticity also\\ncomes into play. Learning, we now know, continues\\nfrom birth todeath. Plasticity is the ability of the brain\\nto actually change its structuring and connections\\nthrough the process of learning.\\nProblems with auditory processing are now\\nviewed as having a wide–reaching ripple effect on our\\nsociety. It is estimated that 30–40% of children start-\\ning school have language-learning skills that can be\\ndescribed as poor. CAP difficulties are a factor in\\nseveral different learning disabilities. They affect not\\nonly academic success, but also nearly every aspect of\\nsocietal difficulties. One example to illustrate this is a\\n1989 University of Buffalo study where CAP problems\\nwere found to be present in a surprising 97% of youth\\ninmates in an upstate New York corrections facility.\\nResources\\nOTHER\\nCooper, Rachel. ‘‘What is Auditory Integration Training?’’\\nDecember 2000. .\\nDejean, Valerie.About the Tomatis Method, 1997.Tomatis\\nAuditory Training Spectrum Center, Bethseda, MD.\\nThe Spectrum Center. ‘‘Auditory Integration and\\nAlfredTomatis.’’ December 2000. .\\nJoan Schonbeck\\nAustralia antigen-associated hepatitis see\\nHepatitis B\\n462 GALE ENCYCLOPEDIA OF MEDICINE\\nAuditory integration training'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Autism\\nDefinition\\nAutism is a severe disorder of brain function\\nmarked by problems with social contact, intelligence\\nand language, together with ritualistic or compulsive\\nbehavior and bizarre responses to the environment.\\nDescription\\nAutism is a lifelong disorder that interferes with\\nthe ability to understand what is seen, heard, and\\ntouched. This can cause profound problems in perso-\\nnal behavior and in the ability to relate to others. A\\nperson with autism must learn how to communicate\\nnormally and how to relate to people, objects and\\nevents. However, not all patients suffer the same\\ndegree of impairment. There is a full spectrum of\\nsymptoms, which can range from mild to severe.\\nAutism occurs in as many as one or two per 1,000\\nchildren. It is found four times more often in boys\\n(usually the first-born) and occurs around the world\\nin all races and social backgrounds. Autism usually is\\nevident in the first three years of life, although in some\\nchildren it’s hard to tell when the problem develops.\\nSometimes the condition isn’t diagnosed until the\\nchild enters school.\\nWhile a person with autism can have symptoms\\nranging from mild to severe, about 10% have an\\nextraordinary ability in one area, such as in mathe-\\nmatics, memory, music, or art. Such children are\\nknown as ‘‘autistic savants’’ (formerly known as\\n‘‘idiot savants.’’).\\nCauses and symptoms\\nAutism is a brain disorder that affects the way the\\nbrain uses or transmits information. Studies have\\nfound abnormalities in several parts of the brain that\\nalmost certainly occurred during fetal development.\\nThe problem may be centered in the parts of the\\nbrain responsible for processing language and infor-\\nmation from the senses.\\nThere appears to be a strong genetic basis for\\nautism. Identical twins are more likely to both be\\naffected than twins who are fraternal (not genetically\\nidentical). In a family with one autistic child, the\\nchance of having another child with autism is about\\n1 in 20, much higher than in the normal population.\\nSometimes, relatives of an autistic child have mild\\nbehaviors that look very much like autism, such as\\nrepetitive behaviors and social or communication\\nproblems. Research also has found that some emo-\\ntional disorders (such as manic depression) occur\\nmore often in families of a child with autism.\\nAt least one group of researchers has found a link\\nbetween an abnormal gene and autism. The gene may\\nbe just one of at least three to five genes that interact in\\nsome way to cause the condition. Scientists suspect\\nthat a faulty gene or genes might make a person vul-\\nnerable to develop autism in the presence of other\\nfactors, such as a chemical imbalance, viruses or che-\\nmicals, or a lack of oxygen at birth.\\nIn a few cases, autistic behavior is caused by a\\ndisease such as:\\n/C15rubella in the pregnant mother\\n/C15tuberous sclerosis\\n/C15fragile X syndrome\\n/C15encephalitis\\n/C15untreated phenylketonuria\\nThe severity of the condition varies between indi-\\nviduals, ranging from the most severe (extremely unu-\\nsual, repetitive, self- injurious, and aggressive\\nbehavior) to very mild, resembling a personality dis-\\norder with some learning disability.\\nProfound problems with social interaction are the\\nmost common symptoms of autism. Infants with the\\ndisorder won’t cuddle; they avoid eye contact and\\ndon’t seem to want or need physical contact or affec-\\ntion. They may become rigid or flaccid when they are\\nheld, cry when picked up, and show little interest in\\nhuman contact. Such a child doesn’t smile or lift his\\narms in anticipation of being picked up. He forms no\\nattachment to parents nor shows any normal anxiety\\ntoward strangers. He doesn’t learn typical games of\\nchildhood, such as peek-a-boo.\\nLanguage problems\\nThe child with autism may not speak at all; if he\\ndoes, it is often in single words. He may endlessly\\nrepeat words or phrases that are addressed to him\\nand may reverse pronouns (‘‘You go sleep’’ instead\\nof ‘‘I want to go to sleep’’).\\nRestricted interests and activity\\nUsually a child with autism has many problems\\nplaying normally. He probably won’t act out adultroles\\nduring play time, and instead of enjoying fantasy play,\\nhe may simply repeatedly mimic the actions of someone\\nelse. Bizarre behavior patterns are very common among\\nautistic children and may include complex rituals,\\nscreaming fits, rhythmic rocking, arm flapping, finger\\nGALE ENCYCLOPEDIA OF MEDICINE 463\\nAutism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='twiddling, and crying without tears. Autistic children\\nmay play with their own saliva, feces or urine.They\\nmay be self-destructive, biting their own hands, gouging\\nat their eyes, pulling their hair, or banging their head.\\nSensory problems\\nThe sensory world poses a real problem to many\\nautistic children, who seem overwhelmed by their own\\nsenses. A child with autism may ignore objects or become\\nobsessed with them, continually watching the object\\nor the movement of his fingers over it. Many of these\\nchildren may react to sounds by banging their head\\nor flapping fingers. Some high-functioning autistic\\nadults who have written books about their childhood\\nexperiences report that sounds were often excruciatingly\\npainful to them, forcing them to withdraw from their\\nenvironment or try to cope by withdrawing into their\\nown world of sensation and movement.\\nIntellectual problems\\nMost autistic children appear to be moderately\\nmentally retarded. They may giggle or cry for no\\nreason, have no fear of real danger, but exhibit terror\\nof harmless objects.\\nDiagnosis\\nThere is no medical test for autism. Because the\\nsymptoms of autism are so varied, the condition may\\ngo undiagnosed for some time (especially in those with\\nmild cases or if other handicaps are also present).\\nIt may be confused with other diseases, such as fragile\\nX syndrome, tuberous sclerosis, and untreated\\nphenylketonuria.\\nAutism is diagnosed by observing the child’s\\nbehavior, communication skills, and social interac-\\ntions. Medical tests should rule out other possible\\ncauses of autistic symptoms. Criteria that mental\\nhealth experts use to diagnose autism include:\\n/C15problems with developing friendships\\n/C15problems with make-believe or social play\\n/C15endlessly repeated words or strings of words\\n/C15difficulty in carrying on a conversation\\nThis autistic child is encouraged to interact with the guinea pig in an effort to improve his social interaction. (Helen B. Senisi.\\nPhoto Researchers, Inc. Reproduced by permission.)\\n464 GALE ENCYCLOPEDIA OF MEDICINE\\nAutism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15obsessions with rituals or restricted patterns\\n/C15preoccupation with parts of objects\\nSome children have a few of the symptoms of\\nautism, but not enough to be diagnosed with the\\n‘‘classical’’ form of the condition. Children who have\\nautistic behavior but no problems with language may\\nbe diagnosed with ‘‘Asperger syndrome.’’ Children\\nwho seem normal at first but who begin to show\\nautistic behavior as they get older might be diagnosed\\nwith ‘‘childhood disintegrative disorder’’ (CDD).\\nThese problems are sometimes called ‘‘autistic spec-\\ntrum disorders.’’ It is also important to rule out other\\nproblems that seem similar to autism.\\nTreatment\\nThere is no cure for autism. Treatments are\\naimed at reducing specific symptoms. Because the\\nsymptoms vary so widely from one person to the\\nnext, there is not a single approach that works for\\nevery person. A spectrum of interventions include\\ntraining in music, listening, vision, speech and lan-\\nguage, and senses. Specialdiets and medications may\\nalso be prescribed.\\nStudies show that people with autism can improve\\nsignificantly with proper treatment. A child with aut-\\nism can learn best with special teachers in a\\nstructured program that emphasizes individual\\ninstruction. The two most-often studied types of treat-\\nment are:\\nEducational or behavioral treatment\\nTypically, behavioral techniques are used to help\\nthe child respond and decrease symptoms. This might\\ninclude positive reinforcement (food and rewards) to\\nboost language and social skills. This training includes\\nstructured, skill-oriented instruction designed to boost\\nsocial and language abilities. Training needs to begin\\nas early as possible, since early intervention appears to\\ninfluence brain development.\\nMost experts believe that modern treatment is\\nmost effective when carried out at home, although\\ntreatment may also take place in a psychiatric hospi-\\ntal, specialized school, or day care program.\\nMedication\\nNo single medication has yet proved highly effec-\\ntive for the major features of autism. However, a\\nvariety of drugs can control self-injurious, aggressive,\\nand other of the more difficult behaviors. Drugs also\\ncan control epilepsy, which afflicts up to 20% of peo-\\nple with autism.\\nFive types of drugs are sometimes prescribed to\\nhelp the behavior problems of people with autism:\\n/C15stimulants, such as methylphenidate (Ritalin)\\n/C15antidepressants, such as fluroxamine (Luvox)\\n/C15opiate blockers, such as naltrexone (ReVia)\\nKEY TERMS\\nAntidepressants— A type of medication that is used\\nto treat depression; it is also sometimes used to treat\\nautism.\\nAsperger syndrome— Children who have autistic\\nbehavior but no problems with language.\\nEncephalitis— A rare inflammation of the brain\\ncaused by a viral infection. It has been linked to\\nthe develoment of autism.\\nFragile X syndrome— A genetic condition related to\\nthe X chromosome that affects mental, physical and\\nsensory development.\\nMajor tranquilizers— The family of drugs that\\nincludes the psychotropic or neuroleptic drugs,\\nsometimes used to help autistic people. They carry\\nsignificant risk of side effects, including Parkinsonism\\nand movement disorders, and should be prescribed\\nwith caution.\\nOpiate blockers— At y p eo fd r u gt h a tb l o c k st h e\\neffects of natural opiates in the system. This\\nmakes some people, including some people with\\nautism, appear more responsive to their\\nenvironment.\\nPhenylketonuria (PKU)— An enzyme deficiency\\npresent at birth that disrupts metabolism and causes\\nbrain damage. This rare inherited defect may be\\nlinked to the development of autism.\\nRubella— Also known as German measles. When a\\nwoman contracts rubella during pregnancy, her\\ndeveloping infant may be damaged. One of the\\nproblems that may result is autism.\\nStimulants— A class of drugs, including Ritalin,\\nused to treat people with autism. They may make\\nchildren calmer and better able to concentrate, but\\nthey also may limit growth or have other side\\neffects.\\nTuberous sclerosis— A genetic disease that causes\\nskin problems, seizures, and mental retardation. It\\nmay be confused with autism.\\nGALE ENCYCLOPEDIA OF MEDICINE 465\\nAutism'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15antipsychotics\\n/C15tranquilizers.\\nToday, most experts recommend a complex treat-\\nment regimen that begins early and continues through\\nthe teenage years. Behavioral therapies are used in\\nconjunction with medications.\\nAlternative treatment\\nMany parents report success with megavitamin\\ntherapy. Some studies have shown that vitamin B6\\nimproves eye contact and speech and lessens tantrum\\nbehavior. Vitamin B6 causes fewer side effects than\\nother medications and is considered safe when used\\nin appropriate doses. However, not many health prac-\\ntitioners advocate its use in the treatment of autism,\\nciting that the studies showing its benefit were flawed.\\nDMG (dimethylglycine)\\nThis compound, available in many health food\\nstores, is legally classified as a food, not a vitamin or\\ndrug. Some researchers claim that it improves speech\\nin children with autism. Those who respond to this\\ntreatment will usually do so within a week. Again,\\nmany doctors do not feel that the studies are adequate\\nto promote this treatment.\\nExercise\\nOne researcher found that vigorousexercise (20\\nminutes or longer, three or four days a week) seems to\\ndecrease hyperactivity, aggression, self-injury and\\nother autistic symptoms.\\nPrognosis\\nWhile there is no cure, with appropriate treatment\\nthe negative behaviors of autism may improve. Earlier\\ngenerations placed autistic children in institutions;\\ntoday, even severely disabled children can be helped in\\na less restrictive environment to develop to their highest\\npotential. Many can eventually become more respon-\\nsive to others as they learn to understand the world\\naround them, and some can lead nearly normal lives.\\nPeople with autism have a normal life expectancy.\\nSome people with autism can handle a job; they do\\nbest with structured jobs that involve a degree of\\nrepetition.\\nPrevention\\nUntil the cause of autism is discovered, prevention\\nis not possible.\\nResources\\nORGANIZATIONS\\nAutism Network International. PO Box 448, Syracuse, NY\\n13210.\\nAutism Research Institute. 4182 Adams Ave., San Diego,\\nCA 92116. (619) 281-7165.\\nAutism Society of America. 7910 Woodmont Avenue, Suite\\n300, Bethesda, Maryland 20814-3067. (800) 328-8476.\\n.\\nNational Alliance for Autism Research.\\n.\\nNational Autism Hotline. c/o Autism Services Center, PO\\nBox 507, 605 Ninth St., Huntington, WV 25710. (304)\\n525-8014.\\nNational Fragile X Foundation. PO Box 190488, San\\nFrancisco, CA 94119. (800) 688-8765. .\\nNational Institute of Neurological Disorders and Stroke. PO\\nBox 5801, Bethesda, MD 20824. (800) 352-9424.\\n.\\nOTHER\\nAutism Society of America. 7910 Woodmont Avenue.\\n.\\nNational Alliance for Autism Research (NAAR). .\\nNational Information Center for Children and Youth with\\nDisabilities. .\\nCarol A. Turkington\\nAutograft see Skin grafting\\nAutoimmune disorders\\nDefinition\\nAutoimmune disorders are conditions in which a\\nperson’s immune system attacks the body’s own cells,\\ncausing tissue destruction.\\nDescription\\nAutoimmunity is accepted as the cause of a wide\\nrange of disorders, and it is suspected to be responsible\\nfor many more. Autoimmune diseases are classified as\\neither general, in which the autoimmune reaction\\ntakes place simultaneously in a number of tissues, or\\norgan specific, in which the autoimmune reaction tar-\\ngets a single organ.\\nAutoimmune disorders include the following:\\n/C15Systemic lupus erythematosus. A general autoim-\\nmune disease in which antibodies attack a number\\n466 GALE ENCYCLOPEDIA OF MEDICINE\\nAutoimmune disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='of different tissues. The disease recurs periodically\\nand is seen mainly in young and middle-aged women.\\n/C15Rheumatoid arthritis. Occurs when the immune sys-\\ntem attacks and destroys the tissues that line bone\\njoints and cartilage. The disease occurs throughout\\nthe body, although some joints may be more affected\\nthan others.\\n/C15Goodpasture’s syndrome. Occurs when antibodies\\nare deposited in the membranes of both the lung\\nand kidneys, causing both inflammation of kidney\\nglomerulus (glomerulonephritis) and lung bleeding. It\\nis typically a disease of young males.\\n/C15Grave’s disease. Caused by an antibody that binds to\\nspecific cells in the thyroid gland, causing them to\\nmake excessive amounts of thyroid hormone.\\n/C15Hashimoto’s thyroiditis. Caused by an antibody that\\nbinds to cells in the thyroid gland. Unlike in Grave’s\\ndisease, however, this antibody’s action results in less\\nthyroid hormone being made.\\n/C15Pemphigus vulgaris. A group of autoimmune disor-\\nders that affect the skin.\\n/C15Myasthenia gravis. A condition in which the immune\\nsystem attacks a receptor on the surface of muscle\\ncells, preventing the muscle from receiving nerve\\nimpulses and resulting in severe muscle weakness.\\n/C15Scleroderma. Also called CREST syndrome or pro-\\ngressive systemic sclerosis, scleroderma affects the\\nconnective tissue.\\n/C15Autoimmune hemolytic anemia. Occurs when the\\nbody produces antibodies that coat red blood cells.\\n/C15Autoimmune thrombocytopenic purpura. Disorder\\nin which the immune system targets and destroys\\nblood platelets.\\n/C15Polymyositis and Dermatomyositis. Immune disor-\\nders that affect the neuromuscular system.\\n/C15Pernicious anemia. Disorder in which the immune\\nsystem attacks the lining of the stomach in such a\\nway that the body cannot metabolize vitamin B\\n12.\\n/C15Sjo¨ gren’s syndrome. Occurs when the exocrine\\nglands are attacked by the immune system, resulting\\nin excessive dryness.\\n/C15Ankylosing spondylitis . Immune system induced\\ndegeneration of the joints and soft tissue of the spine.\\n/C15Vasculitis. A group of autoimmune disorders in\\nwhich the immune system attacks and destroys\\nblood vessels.\\n/C15Type Idiabetes mellitus. May be caused by an anti-\\nbody that attacks and destroys the islet cells of the\\npancreas, which produce insulin.\\n/C15Amyotrophic lateral schlerosis. Also called Lou\\nGehrig’s disease. An immune disorder that causes\\nthe death of neurons which leads to progressive loss\\nof muscular control.\\n/C15Guillain-Barre syndrome. Also called infectious\\npolyneuritis. Often occurring after an infection or\\nan immunization (specifically Swine flu), the disease\\naffects the myelin sheath, which coats nerve cells. It\\ncauses progressive muscle weakness andparalysis.\\n/C15Multiple sclerosis. An autoimmune disorder that may\\ninvolve a virus affects the central nervous system,\\ncausing loss of coordination and muscle control.\\nCauses and symptoms\\nTo further understand autoimmune disorders, it is\\nhelpful to understand the workings of the immune\\nsystem. The purpose of the immune system is to defend\\nthe body against attack by infectious microbes (germs)\\nand foreign objects. When the immune system attacks\\nan invader, it is very specific—a particular immune\\nsystem cell will only recognize and target one type of\\ninvader. To function properly, the immune system must\\nnot only develop this specialized knowledge of indivi-\\ndual invaders, but it must also learn how to recognize\\nand not destroy cells that belong to the body itself.\\nEvery cell carries protein markers on its surface that\\nidentifies it in one of two ways: what kind of cell it is\\n(e.g. nerve cell, muscle cell, blood cell, etc.) and to\\nwhom that cell belongs. These markers are called\\nmajor histocompatability complexes (MHCs). When\\nfunctioning properly, cells of the immune system will\\nnot attack any other cell with markers identifying it as\\nbelonging to the body. Conversely, if the immune sys-\\ntem cells do not recognize the cell as ‘‘self,’’ they attach\\nthemselves to it and put out a signal that the body has\\nbeen invaded, which in turn stimulates the production\\nof substances such as antibodies that engulf and destroy\\nthe foreign particles. In case of autoimmune disorders,\\nthe immune system cannot distinguish between ‘‘self’’\\ncells and invader cells. As a result, the same destructive\\noperation is carried out on the body’s own cells that\\nwould normally be carried out on bacteria, viruses, and\\nother such harmful entities.\\nThe reasons why immune systems become dys-\\nfunctional in this way is not well understood.\\nHowever, most researchers agree that a combination\\nof genetic, environmental, and hormonal factors\\nplay into autoimmunity. Researchers also speculate\\nthat certain mechanisms may trigger autoimmunity.\\nFirst, a substance that is normally restricted to one\\npart of the body, and therefore not usually exposed\\nto the immune system, is released into other areas\\nGALE ENCYCLOPEDIA OF MEDICINE 467\\nAutoimmune disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='where it is attacked. Second, the immune system\\nmay mistake a component of the body for a similar\\nforeign component. Third, cells of the body may be\\naltered in some way, either by drugs, infection, or\\nsome other environmental factor, so that they are\\nno longer recognizable as ‘‘self’’ to the immune\\nsystem. Fourth, the immune system itself may be\\ndamaged, such as by a genetic mutation, and there-\\nfore cannot function properly.\\nThe symptoms of the above disorders include:\\n/C15Systemic lupus erythematosus. Symptoms include\\nfever, chills,fatigue, weight loss, skinrashes (particu-\\nlarly the classic ‘‘butterfly’’ rash on the face), vasculi-\\ntis, polyarthralgia, patchy hair loss, sores in the mouth\\nor nose, lymph-node enlargement, gastric problems,\\nand, in women, irregular periods. About half of those\\nwho suffer from lupus develop cardiopulmonary pro-\\nblems, and some may also develop urinary problems.\\nLupus can also effect the central nervous system,\\ncausing seizures, depression, and psychosis.\\n/C15Rheumatoid arthritis. Initially may be characterized\\nby a low-gradefever, loss of appetite, weight loss,\\nand a generalizedpain in the joints. The joint pain\\nthen becomes more specific, usually beginning in the\\nfingers, then spreading to other areas, such as the\\nwrists, elbows, knees, and ankles. As the disease\\nprogresses, joint function diminishes sharply and\\ndeformities occur, particularly the characteristic\\n‘‘swan’s neck’’ curling of the fingers.\\n/C15Goodpasture’s syndrome. Symptoms are similar to\\nthat of iron deficiency anemia, including fatigue and\\npallor. Symptoms involving the lungs may range\\nfrom a cough that produces bloody sputum to out-\\nright hemorrhaging. Symptoms involving the urin-\\nary system include blood in the urine and/or swelling.\\n/C15Grave’s disease. This disease is characterized by an\\nenlarged thyroid gland, weight loss without loss of\\nappetite, sweating, heart palpitations, nervousness,\\nand an inability to tolerate heat.\\n/C15Hashimoto’s thyroiditis. This disorder generally dis-\\nplays no symptoms.\\n/C15Pemphigus vulgaris. This disease is characterized by\\nblisters and deep lesions on the skin.\\n/C15Myasthenia gravis. Characterized by fatigue and mus-\\ncle weakness that at first may be confined to certain\\nmuscle groups, but then may progress to the point of\\nparalysis. Myasthenia gravis patients often have\\nexpressionless faces as well as difficulty chewing and\\nswallowing. If the disease progresses to the respiratory\\nsystem, artificial respiration may be required.\\n/C15Scleroderma. Disorder is usually preceded by\\nRaynaud’s phenomenon. Symptoms that follow\\ninclude pain, swelling, and stiffness of the joints,\\nand the skin takes on a tight, shiny appearance. The\\ndigestive system also becomes involved, resulting in\\nweight loss, appetite loss, diarrhea,constipation, and\\ndistention of the abdomen. As the disease progresses,\\nthe heart, lungs, and kidneys become involved, and\\nmalignant hypertension causes death in approxi-\\nmately 30% of cases.\\n/C15Autoimmune hemolytic anemia. May be acute or\\nchronic. Symptoms include fatigue and abdominal\\ntenderness due to an enlarged spleen.\\n/C15Autoimmune thrombocytopenic purpura. Character-\\nized by pinhead-size red dots on the skin, unexplained\\nbruises, bleeding from the nose and gums, and blood in\\nthe stool.\\n/C15Polymyositis and Dermatomyositis. In polymyositis,\\nsymptoms include muscle weakness, particularly in\\nthe shoulders or pelvis, that prevents the patient from\\nperforming everyday activities. In dermatomyositis,\\nthe same muscle weakness is accompanied by a rash\\nthat appears on the upper body, arms, and fingertips.\\nA rash may also appear on the eyelids, and the area\\naround the eyes may become swollen.\\n/C15Pernicious anemia. Signs of pernicious anemia\\ninclude weakness, sore tongue, bleeding gums, and\\ntingling in the extremities. Because the disease causes\\na decrease in stomach acid, nausea,vomiting, loss of\\nappetite, weight loss,diarrhea, and constipation are\\npossible. Also, because Vitamin B\\n12 is essential for\\nthe nervous system function, the deficiency of it\\nbrought on by the disease can result in a host of\\nneurological problems, including weakness, lack of\\ncoordination, blurred vision, loss of fine motor skills,\\nloss of the sense of taste, ringing in the ears, and loss\\nof bladder control.\\n/C15Sjo¨ gren’s syndrome. Characterized by excessive dry-\\nness of the mouth and eyes.\\n/C15Ankylosing spondylitis. Generally begins with lower\\nback pain that progresses up the spine. The pain may\\neventually become crippling.\\n/C15Vasculitis. Symptoms depend upon the group of\\nveins affected and can range greatly.\\nKEY TERMS\\nAutoantibody— An antibody made by a person that\\nreacts with their own tissues.\\nParesthesias— A prickly, tingling sensation.\\n468 GALE ENCYCLOPEDIA OF MEDICINE\\nAutoimmune disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Type I diabetes mellitus. Characterized by fatigue\\nand an abnormally high level of glucose in the\\nblood (hyperglycemia).\\n/C15Amyotrophic lateral schlerosis. First signs are stum-\\nbling and difficulty climbing stairs. Later,muscle\\ncramps and twitching may be observed as well as\\nweakness in the hands making fastening buttons or\\nturning a key difficult. Speech may become slowed or\\nslurred. There may also be difficluty swallowing. As\\nrespiratory muscles atrophy, there is increased dan-\\nger of aspiration or lung infection.\\n/C15Guillain-Barre syndrome. Muscle weakness in the legs\\noccurs first, then the arms and face. Paresthesias (a\\nprickly, tingling sensation) is also felt. This disorder\\naffects both sides of the body and may involve paraly-\\nsis and the muscles that control breathing.\\n/C15Multiple sclerosis. Like Lou Gehrig’s disease, the\\nfirst symptom may be clumsiness. Weakness or\\nexhaustion is often reported, as well as blurry or\\ndouble vision. There may be dizziness, depression,\\nloss of bladder control, and muscle weakness so\\nsevere that the patient is confined to a wheelchair.\\nDiagnosis\\nA number of tests are involved in the diagnosis\\nof autoimmune diseases, depending on the particular\\ndisease; e.g. blood tests, cerebrospinal fluid analysis,\\nelectromylogram (measur es muscle function), and\\nmagnetic resonance imaging of the brain. Usually,\\nthese tests determine the location and extent of\\ndamage or involvement. They are useful in charting\\nprogress of the disease and as baselines for\\ntreatment.\\nThe principle tool, however, for authenticating\\nautoimmune disease is antibody testing. Such tests\\ninvolve measuring the level of antibodies found in\\nthe blood and determining if they react with specific\\nantigens that would give rise to an autoimmune reac-\\ntion. An elevated amount of antibodies indicates that\\na humoral immune reaction is occurring. Since ele-\\nvated antibody levels are also seen in common infec-\\ntions, they must be ruled out as the cause for the\\nincreased antibody levels.\\nAntibodies can also be typed by class. There are\\nfive classes of antibodies, and they can be separated in\\nthe laboratory. The class IgG is usually associated\\nwith autoimmune diseases. Unfortunately, IgG class\\nantibodies are also the main class of antibody seen in\\nnormal immune responses.\\nThe most useful antibody tests involve introdu-\\ncing the patient’s antibodies to samples of his or her\\nown tissue, usually thyroid, stomach, liver, and kidney\\ntissue. If antibodies bind to the ‘‘self’’ tissue, it is\\ndiagnostic for an autoimmune disorder. Antibodies\\nfrom a person without an autoimmune disorder\\nwould not react to ‘‘self ’’ tissue.\\nTreatment\\nTreatment of autoimmune diseases is specific to\\nthe disease, and usually concentrates on alleviating or\\npreventing symptoms rather than correcting the\\nunderlying cause. For example, if a gland involved in\\nan autoimmune reaction is not producing a hormone\\nsuch as insulin, administration of that hormone is\\nrequired. Administration of a hormone, however,\\nwill restore the function of the gland damaged by the\\nautoimmune disease.\\nThe other aspect of treatment is controlling the\\ninflammatory and proliferative nature of the immune\\nresponse. This is generally accomplished with two\\ntypes of drugs. Steroid compounds are used to control\\ninflammation. There are many different steroids, each\\nhaving side effects. The proliferative nature of the\\nimmune response is controlled with immunosuppres-\\nsive drugs. These drugs work by inhibiting the replica-\\ntion of cells and, therefore, also suppress non-immune\\ncells leading to side effects such as anemia.\\nSystemic enzyme therapyis a new treatment that is\\nshowing results for rheumatoid arthritis, multiple\\nsclerosis, ankylosing spondylitis, and other inflamma-\\ntory diseases. Enzymes combinations of pancreatin,\\ntrypsin, chymotrypsin, bromelain, and papain help\\nstimulate the body’s own defenses, accelerate inflam-\\nmation in order to reduce swelling and improve circu-\\nlation, and break up the immune complexes within the\\nbloodstream. Symptoms have been reduced using this\\ntreatment.\\nOther treatments that hold some promise are irra-\\ndiation of the spleen andgene therapy. Splenic irradia-\\ntion is touted to be a safe, alternative for patients with\\nautoimmune blood diseases, especially autoimmune\\nhemolytic anemia, or others with compromised\\nimmune systems, such as HIV patients and the elderly.\\nIt is reported to have few side effects and seems to be\\nworking. Cytokine and cytokine inhibitor genes\\ninjected directly into muscle tissue also appear to be\\neffective in treating Type I diabetes mellitus, systemic\\nlupus erythematosus, thyroditis, and arthritis.\\nPrognosis\\nPrognosis depends upon the pathology of each\\nautoimmune disease.\\nGALE ENCYCLOPEDIA OF MEDICINE 469\\nAutoimmune disorders'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prevention\\nMost autoimmune diseases cannot be prevented.\\nThough the mechanisms involved in how these dis-\\neases affect the body are known, it is still unclear\\nwhy the body turns on itself. Since more women than\\nmen seem to be affected by some of these disorders\\n(e.g. lupus), some researchers are looking into hor-\\nmones as a factor. This, and gene therapy, may be\\nthe preventatives of the future.\\nResources\\nPERIODICALS\\nCichoke, Anthony J. ‘‘Natural Relief for Autoimmune\\nDisorders.’’ Better Nutrition.62, no. 6 (June 2000): 24.\\nHenderson, Charles W. ‘‘Gene Therapy Uses Vectors\\nEncodingCytokines or Cytokine Inhibitors (for\\ntreatment of autoimmune disorders).’’\\nImmunotherapyWeekly September 27, 2000: pNA.\\nRiccio, Nina M. ‘‘Autoimmune Disorder: When the Body\\nAttacksItself.’’ Current Health 226, no. 5 (January\\n2000): 13.\\n‘‘Splenic Irradiation Is an Option for Patients with\\nAutoimmuneDisorders and Those with HIV.’’AIDS\\nWeekly (April 9, 2001): pNA.\\nJanie F. Franz\\nAutoimmune hepatitis see Hepatitis,\\nautoimmune\\nAutologous transfusion see Transfusion\\nAutologous transplant see Bone marrow\\ntransplantation\\nAutomatic implantable cardioverter-\\ndefibrillator see Implantable cardioverter-\\ndefibrillator\\nAutopsy\\nDefinition\\nAn autopsy is a postmortem assessment or exam-\\nination of a body to determine the cause of death. An\\nautopsy is performed by a physician trained in\\npathology.\\nPurpose\\nMost autopsies advance medical knowledge and\\nprovide evidence for legal action. Medically, autopsies\\ndetermine the exact cause and circumstances ofdeath,\\ndiscover the pathway of a disease, and provide valuable\\ninformation to be used in the care of the living. When\\nfoul play is suspected, a government coroner or medical\\nexaminer performs autopsies for legal use. This branch\\nof medical study is called forensic medicine. Forensic\\nspecialists investigate deaths resulting from violence\\nor occurring under suspicious circumstances.\\nBenefits of research from autopsies include the\\nproduction of new medical information on diseases\\nsuch as toxic shock syndrome, acquired immunodefi-\\nciency syndrome (AIDS). Organ donation, which can\\npotentially save the lives of other patients, is also\\nanother benefit of autopsies.\\nPrecautions\\nWhen performed for medical reasons, autopsies\\nrequire formal permission from family members or the\\nlegal guardian. (Autopsies required for legal reasons\\nwhen foul play is suspected do not need the consent\\nKEY TERMS\\nAcquired immunodeficiency syndrome (AIDS) —\\nA group of diseases resulting from infection with\\nthe human immunodeficiency virus (HIV). A per-\\nson infected with HIV gradually loses immune\\nfunction, becoming less able to resist aliments and\\ncancers, resulting in eventual death.\\nComputed tomography scan (CT scan) —The tech-\\nnique used in diagnostic studies of internal bodily\\nstructures in the detection of tumors or brain aneur-\\nysms. This diagnostic test consists of a computer\\nanalysis of a series of cross-sectional scans made\\nalong a single axis of a bodily structure or tissue that\\nis used to construct a three-dimensional image of\\nthat structure\\nCreutzfeld-Jakob disease— A rare, often fatal dis-\\nease of the brain, characterized by gradual demen-\\ntia and loss of muscle control that occurs most often\\nin middle age and is caused by a slow virus.\\nHepatitis— Inflammation of the liver, caused by\\ninfectious or toxic agents and characterized by jaun-\\ndice, fever, liver enlargement, and abdominal pain.\\nMagnetic resonance imaging (MRI)— A diagnostic\\ntool that utilizes nuclear magnetic energy in the\\nproduction of images of specific atoms and mole-\\ncular structures in solids, especially human cells,\\ntissues, and organs.\\nPostmortem— After death.\\n470 GALE ENCYCLOPEDIA OF MEDICINE\\nAutopsy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='of next of kin.) During the autopsy, very concise notes\\nand documentation must be made for both medical\\nand legal reasons. Some religious groups prohibit\\nautopsies.\\nDescription\\nAn autopsy can be described as the examination\\nof a deceased human body with a detailed exam of\\nthe person’s remains. This procedure dates back to\\nthe Roman era when few human dissections were\\nperformed; autopsies were utilized, however, to\\ndetermine the cause of death in criminal cases. At\\nthe beginning of the procedure the exterior body is\\nexamined and then the internal organs are removed\\nand studied. Some pathologists argue that more\\nautopsies are performed than necessary. However,\\nrecent studies show that autopsies can detect major\\nfindings about a person’s condition that were not\\nsuspected when the person was alive. And the grow-\\ning awareness of the influence of genetic factors in\\ndisease has also emphasized the importance of\\nautopsies.\\nDespite the usefulness of autopsies, fewer autop-\\nsies have been performed in the United States during\\nthe past 10-20 years. A possible reason for this decline\\nis concern about malpractice suits on the part of the\\ntreating physician. Other possible reasons are that\\nhospitals are performing fewer autopsies because of\\nthe expense or because modern technology, such as\\nCT scans and magnetic resonance imaging, can\\noften provide sufficient diagnostic information.\\nNonetheless, federal regulators and pathology groups\\nhave begun to establish new guidelines designed to\\nincrease the number and quality of autopsies being\\nperformed.\\nMany experts are concerned that if the number of\\nautopsies increases, hospitals may be forced to charge\\nfamilies a fee for the procedure as autopies are not\\nnormally covered by insurance companies or\\nMedicare. Yet, according to several pathologists, the\\nbenefit of the procedure for families and doctors does\\njustify the cost. In medical autopsies, physicians\\nremain cautious to examine only as much of the\\nbody as permitted according to the wishes of the\\nfamily. It is important to note that autopsies can also\\nprovide peace of mind for the bereaved family in cer-\\ntain situations.\\nPreparation\\nIf a medical autopsy is being performed, written\\npermission is secured from the family of the deceased\\nAftercare\\nOnce the autopsy has been completed, the body is\\nprepared for final arrangements according to the\\nfamily’s wishes\\nRisks\\nThere are some risks of disease transmission from\\nthe deceased. In fact, some physicans may refuse to do\\nautopsies on specific patients because of a fear of\\ncontracting diseases such as AIDS, hepatitis, or\\nCreutzfeld-Jakob disease.\\nNormal results\\nIn most situations the cause of death is determined\\nfrom the procedure of an autopsy without any trans-\\nmission of disease.\\nAbnormal results\\nAbnormal results would include inconclusive\\nresults from the autopsy and transmission of infec-\\ntious disease during the autopsy.\\nResources\\nORGANIZATIONS\\nAmerican Medical Association. 515 N. State St., Chicago,\\nIL 60612. (312) 464-5000. .\\nJeffrey P. Larson, RPT\\nAviation medicine\\nDefinition\\nAlso known as aerospace medicine, flight medi-\\ncine, or space medicine, aviation medicine is a medi-\\ncal specialty that focuses on the physical and\\npsychological conditions associated with flying and\\nspace travel.\\nPurpose\\nSince flying airplanes and spacecraft involves\\ngreat risk and physical demands, such as changes in\\ngravity and oxygen, pilots and astronauts need medi-\\ncal experts to protect their safety and the public’s\\nsafety.\\nGALE ENCYCLOPEDIA OF MEDICINE 471\\nAviation medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nPressure changes\\nIn the United States, the Federal Aviation\\nAdministration (FAA) requires all pilots who fly\\nabove 14,500 ft (4,420 m) to be prepared for pressure\\nchanges caused by lower oxygen levels at high altitude.\\nPilots must either have a pressurized cabin or access to\\nan oxygen mask. Without these protections, they\\ncould experience hypoxia, or altitude sickness.\\nHypoxia reduces the amount of oxygen in the brain,\\ncausing such symptoms as dizziness, shortness of\\nbreath, and mental confusion. These symptoms\\ncould cause the pilot to lose control of the plane.\\nHypoxia can be treated withoxygen therapy.\\nRapid altitude increases and decreases can cause\\npain because there is an air pocket in the middle por-\\ntion of the ear. To equalize pressure in the ear, physi-\\ncians typically advise pilots and passengers to clear\\ntheir sinuses by plugging their nose and blowing until\\nthe eardrums ‘‘pop.’’ Other options include yawning,\\nswallowing or chewing gum. For people with a cold or\\na severely blocked middle ear, the use ofdecongestants,\\nantihistamines, or nasal sprays may help. Without tak-\\ning steps to equalize pressure, the tympanic membrane\\ncould rupture, causing hearing loss, vertigo, dizziness,\\nand nausea.\\nGravity’s impact\\nFighter pilots who fly high-performance jets can\\nexperience health problems during rapid acceleration\\nand when executing tight turns at high speed. During\\nthese moves, a pilot experiences extreme gravity con-\\nditions that can pull blood away from the brain and\\nheart and into the lower body. This can cause the pilot\\nto have tunnel vision or pass out. To prevent these\\npotentially deadly situations, the military requires\\nfighter pilots to wear special flight suits, or G suits,\\nwhich have compartments that fill with air or fluid to\\nkeep blood from pooling in the lower body.\\nSome pilots, like the Blue Angels, use a technique\\ncalled the Valsalva Maneuver instead of G suits to\\nprevent black outs during high-performance flying.\\nThe Valsalva Maneuver involves grunting and tigh-\\ntening the abdominal muscles to stop blood from\\ncollecting in the wrong parts of the body.\\nPREVENTIVE CARE. Since any routine health pro-\\nblem that affects a pilot could mean the loss of\\nhundreds of lives, aviation medicine specialists who\\nwork for commercial airlines and the military take\\nspecial care to educate pilots about proper diet,\\nexercise and preventive health tools. For example,\\nphysicians may frequently screen pilots for vision\\nchanges caused by glaucoma or cataracts. They\\nalso will check for hearing loss and encourage the\\npilot to wear earplugs or headphones to buffer\\nengine noise. To monitor for heart disease, physi-\\ncians will check blood pressure and may order diag-\\nnostic tests such as an ECG orstress test.\\nMotion sickness\\nMany people experience nausea, vertigo, and dis-\\norientation when they first arrive in space. This is\\ncaused by changes in the fluid in the inner ear, which\\nis sensitive to gravity and affects our sense of spatial\\norientation. The symptoms typically ease after several\\ndays, but often recur when the astronaut returns to\\nEarth. To treat this condition, physicians give astro-\\nnauts motion sicknessmedication, such as lorazepam.\\nBone and muscle loss\\nIn zero-gravity conditions, astronauts lose bone\\nand muscle mass. On earth, the natural resistance of\\ngravity helps build stronger muscles and bones during\\nnormal weight-bearing activities like walking or even\\nsitting at a desk. In space, however, astronauts must\\nwork harder to prevent bone and muscle loss. Exercise\\nis an important treatment. Crew members may use an\\nexercise cycle or resistive rubber bands to stay in\\nshape. Physicians also may give them medication to\\nprevent bone loss and prescribe nutritional supple-\\nments, such as a mixture of essential amino acids and\\ncarbohydrates, to limit muscle atrophy.\\nKEY TERMS\\nG suits— Special flight suits, worn by fighter pilots,\\nwhich have compartments that fill with air or fluid\\nto keep blood from pooling in the lower body dur-\\ning rapid acceleration and tight turns.\\nHypoxia— Hypoxia, or altitude sickness, reduces\\nthe amount of oxygen in the brain causing such\\nsymptoms as dizziness, shortness of breath, and\\nmental confusion.\\nTympanic membrane— A structure in the middle\\near that can rupture if pressure in the ear is\\nnot equalized during airplane ascents and\\ndescents.\\nValsalva Maneuver — Pilots grunt and tighten their\\nabdominal muscles to prevent black outs during\\nhigh-performance flying.\\n472 GALE ENCYCLOPEDIA OF MEDICINE\\nAviation medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Radiation\\nAnother health threat to space travelers is radia-\\ntion. Harmful rays can alter the DNA in human cells\\nand cause cancer. Excess radiation also can weaken\\nthe immune system. To prevent these problems, phy-\\nsicians may give astronauts nutritional supplements.\\nFor example, research has show that n-3 fatty acids\\nfound in fish oil reduce DNA damage.\\nCardiovascular issues\\nWhen astronauts return to earth after a long mis-\\nsion, they tend to feel dizzy and black out. Scientists are\\nconcerned about this dilemma because it could be dan-\\ngerous if the crew members need to make an emergency\\nexit. One way to prevent this problem, which is caused\\nby a drop in blood pressure, is to have the astronauts\\ndrink extra fluids and increase salt intake to increase\\nblood volume. Physicians also may prescribe medication\\nthat causes blood vessels to contract. As another pre-\\ncaution, astronauts also put on protective flight suits, or\\nG suits, before they re-enter the earth’s atmosphere.\\nResources\\nPERIODICALS\\nAviation, Space and Environmental Medicine.Monthly peer-\\nreviewed journal published by the Aerospace Medical\\nAssociation. Contact theeditor: 3212 Swandale Dr.,\\nSan Antonio, TX 78230-4404. (210) 342-5670.\\nASEMJournal@worldnet.att.net.\\nORGANIZATIONS\\nAerospace Medical Association. 320 S. Henry St.,\\nAlexandria, VA 22314-3579. (703) 739-2240. .\\nNational Space Biomedical Research Institute. One Baylor\\nPlaza, NA-425, Houston, TX 77030. (713) 798-7412.\\ninfo@www.nsbri.org. .\\nWright State University Aerospace Medicine Program. P.O.\\nBox 92, Dayton, Ohio 45401-0927. (937) 276-8338.\\n.\\nOTHER\\nFederal Aviation Administration Office of Aviation\\nMedicine. .\\nNational Aeronautics and Space Administration Aerospace\\nMedicine. .\\nSociety of USAF Flight Surgeons Online Catalog. .\\nMelissa Knopper\\nAVM see Arteriovenous malformations\\nAvoidant personality disorder see\\nPersonality disorders\\nAvulsions see Wounds\\nAyurvedic medicine\\nDefinition\\nAyurvedic medicine is a system of healing that ori-\\nginated in ancient India. In Sanskrit,ayur means life or\\nliving,and vedameans knowledge, soAyurveda hasbeen\\ndefined as the ‘‘knowledge of living’’ or the ‘‘science of\\nlongevity.’’ Ayurvedic medicine utilizes diet,detoxifica-\\ntion and purification techniques, herbal and mineral\\nremedies, yoga, breathing exercises, meditation,a n d\\nmassage therapyas holistic healing methods. Ayurvedic\\nmedicine is widely practiced in modern India and has\\nbeen steadily gaining followers in the West.\\nPurpose\\nAccording to the original texts, the goal of\\nAyurveda is prevention as well as promotion of the\\nbody’s own capacity for maintenance and balance.\\nAyurvedic treatment is non-invasive and non-toxic, so\\nit can be used safely as an alternative therapy or along-\\nside conventional therapies. Ayurvedic physicians\\nclaim that their methods can also help stress-related,\\nmetabolic, and chronic conditions. Ayurveda has been\\nused to treatacne, allergies, asthma, anxiety, arthritis,\\nchronic fatigue syndrome, colds, colitis, constipation,\\ndepression, diabetes, flu, heart disease,hypertension,\\nimmune problems, inflammation, insomnia, nervous\\ndisorders, obesity, skin problems, and ulcers.\\nAyurvedic physicians seek to discover the roots\\nof a disease before it gets so advanced that more\\nradical treatments are necessary. Thus, Ayurveda\\nseems to be limited in treating severely advanced\\nconditions, traumatic injuries, acutepain, and con-\\nditions and injuries requiring invasive surgery.\\nAyurvedic techniques have also been used alongside\\nchemotherapy and surgery to assist patients in\\nrecovery and healing.\\nDescription\\nOrigins\\nAyurvedic medicine originated in the early civili-\\nzations of India some 3,000-5,000 years ago. It is\\nmentioned in the Vedas, the ancient religious and\\nphilosophical texts that are the oldest surviving litera-\\nture in the world, which makes Ayurvedic medicine\\nthe oldest surviving healing system. According to the\\ntexts, Ayurveda was conceived by enlightened wise\\nmen as a system of living harmoniously and maintain-\\ning the body so that mental and spiritual awareness\\ncould be possible. Medical historians believe that\\nGALE ENCYCLOPEDIA OF MEDICINE 473\\nAyurvedic medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Ayurvedic ideas were transported from ancient India\\nto China and were instrumental in the development of\\nChinese medicine.\\nToday, Ayurvedic medicine is used by 80% of the\\npopulation in India. Aided by the efforts ofDeepak\\nChopra and the Maharishi, it has become an increas-\\ningly accepted alternative medical treatment in\\nAmerica during the last two decades. Chopra is an\\nM.D. who has written several bestsellers based on\\nAyurvedic ideas. He also helped develop the Center\\nfor Mind/Body Medicine in La Jolla, California, a\\nmajor Ayurvedic center that trains physicians in\\nAyurvedic principles, produces herbal remedies, and\\nconducts research and documentation of its healing\\ntechniques.\\nKey ideas\\nTo understand Ayurvedic treatment, it is necessary\\nto have an idea how the Ayurvedic system views the\\nbody. The basic life force in the body isprana,w h i c hi s\\nalso found in the elements and is similar to the Chinese\\nnotion ofchi. As Swami Vishnudevananda, a yogi and\\nexpert, put it, ‘‘Prana is in the air, but is not the oxygen,\\nnor any of its chemical constituents. It is in food, water,\\nand in the sunlight, yet it is not vitamin, heat, or light-\\nrays. Food, water, air, etc., are only the media through\\nwhich the prana is carried.’’\\nIn Ayurveda, there are five basic elements that\\ncontain prana: earth, water, fire, air, and ether.\\nThese elements interact and are further organized in\\nthe human body as three main categories or basic\\nphysiological principles in the body that govern all\\nbodily functions known as the doshas. The three\\ndoshas arevata, pitta, and kapha. Each person has a\\nunique blend of the three doshas, known as the per-\\nson’s prakriti, which is why Ayurvedic treatment is\\nalways individualized. In Ayurveda, disease is viewed\\nas a state of imbalance in one or more of a person’s\\ndoshas, and an Ayurvedic physician strives to adjust\\nand balance them, using a variety of techniques.\\nThe vata dosha is associated with air and ether,\\nand in the body promotes movement and lightness.\\nD E E P A K C H O P R A (1946– )\\n(AP/Wide World Photos. Reproduced by permission.)\\nDeepak Chopra was born in India and studied medi-\\ncine at the All India Institute of Medical Science. He left his\\nhome for the United States in 1970 and completed resi-\\ndencies in internal medicine and endocrinology. He went\\non to teaching posts at major medical institutions—Tufts\\nUniversity and Boston University schools of medicine—\\nwhile establishing a very successful private practice. By\\nthe time he was thirty-five, Chopra had become chief of\\nstaff at New England Memorial Hospital.\\nDisturbed by Western medicine’s reliance on medica-\\ntion, he began a search for alternatives and discovered one\\nin the teachings of the Maharishi Mahesh Yogi, an Indian\\nspiritualist who had gained a cult following in the late sixties\\nteaching Transcendental Meditation (TM). Chopra began\\npracticing TM fervently and eventually met the Maharishi.\\nIn 1985 Chopra established the Ayurvedic Health Center for\\nStress Management and Behavioral Medicine in Lancaster,\\nMassachusetts, where he began his practice of integrating\\nthe best aspects of Eastern and Western medicine.\\nIn 1993, he published Creating Affluence: Wealth\\nConsciousness in the Field of All Possibilities, and the enor-\\nmously successful best seller,Ageless Body, Timeless Mind.\\nIn the latter he presents his most radical thesis: that aging is\\nnot the inevitable deterioration of organs and mind that we\\nhave been traditionally taught to think of it as. It is a process\\nthat can be influenced, slowed down, and even reversed\\nwith the correct kinds of therapies, almost all of which are\\nself-administered or self-taught. He teaches that applying a\\nregimen of nutritional balance, meditation, and emotional\\nclarity characterized by such factors as learning to easily\\nand quickly express anger, for instance, can lead to\\nincreased lifespans of up to 120 years.\\n474\\nGALE ENCYCLOPEDIA OF MEDICINE\\nAyurvedic medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Vata people are generally thin and light physically,\\ndry-skinned, and very energetic and mentally restless.\\nWhen vata is out of balance, there are often nervous\\nproblems, hyperactivity, sleeplessness, lower back\\npains, and headaches.\\nPitta is associated with fire and water. In the body,\\nit is responsible for metabolism and digestion. Pitta\\ncharacteristics are medium-built bodies, fair skin,\\nstrong digestion, and good mental concentration.\\nPitta imbalances show up as anger and aggression\\nand stress-related conditions like gastritis, ulcers,\\nliver problems, and hypertension.\\nThe kapha dosha is associated with water and\\nearth. People characterized as kapha are generally\\nlarge or heavy with more oily complexions. They\\ntend to be slow, calm, and peaceful. Kapha disorders\\nmanifest emotionally as greed and possessiveness, and\\nphysically as obesity, fatigue, bronchitis, and sinus\\nproblems.\\nDiagnosis\\nIn Ayurvedic medicine, disease is always seen as\\nan imbalance in the dosha system, so the diagnostic\\nprocess strives to determine which doshas are\\nunderactive or overactive in a body. Diagnosis is\\noften taken over a course of days in order for the\\nAyurvedic physician to most accurately determine\\nwhat parts of the body are being affected. To diag-\\nnose problems, Ayurvedic physicians often use\\nlong questionnaires and interviews to determine a\\nperson’s dosha patterns and physical and psycholo-\\ngical histories. Ayurvedic physicians also intricately\\nobserve the pulse, tongue, face, lips, eyes, and fin-\\ngernails for abnormalities or patterns that they\\nbelieve can indicate deeper problems in the internal\\nsystems. Some Ayurvedic physicians also use\\nlaboratory tests to assist in diagnosis.\\nTreatment\\nAyurvedic treatment seeks to re-establish balance\\nand harmony in the body’s systems. Usually the first\\nmethod of treatment involves some sort of detoxifica-\\ntion and cleansing of the body, in the belief that accu-\\nmulated toxins must be removed before any other\\nmethods of treatment will be effective. Methods of\\ndetoxification include therapeuticvomiting, laxatives,\\nmedicated enemas, fasting, and cleansing of the\\nsinuses. Many Ayurvedic clinics combine all of these\\ncleansing methods into intensive sessions known as\\npanchakarma. Panchakarma can take several days or\\neven weeks and they are more than elimination thera-\\npies. They also include herbalized oil massage and\\nherbalized heat treatments . After purification,\\nAyurvedic physicians use herbal and mineral remedies\\nto balance the body as well. Ayurvedic medicine con-\\ntains a vast knowledge of the use of herbs for specific\\nhealth problems.\\nAyurvedic medicine also emphasizes how people\\nlive their lives from day to day, believing that proper\\nlifestyles and routines accentuate balance, rest, diet,\\nand prevention. Ayurveda recommends yoga as a\\nform of exercise to build strength and health, and\\nalso advises massage therapy and self-massage as\\nways of increasing circulation and reducingstress.\\nYogic breathing techniques and meditation are also\\npart of a healthy Ayurvedic regimen, to reduce stress\\nand improve mental energy.\\nAyurvedic Body Types\\nVata Pitta Kapha\\nPhysical\\ncharacteristics\\nThin.\\nProminent\\nfeatures.\\nCool, dry\\nskin.\\nConstipation.\\nCramps.\\nAverage\\nbuild. Fair,\\nthin hair.\\nWarm, moist\\nskin. Ulcers,\\nheartburn,\\nand hemor-\\nrhoids. Acne.\\nLarge build.\\nWavy, thick\\nhair. Pale, cool,\\noily skin.\\nObesity, aller-\\ngies, and sinus\\nproblems. High\\ncholesterol.\\nEmotional\\ncharacteristics\\nMoody.\\nVivacious.\\nImaginative.\\nEnthusiastic.\\nIntuitive.\\nIntense.\\nQuick tem-\\npered.\\nIntelligent.\\nLoving.\\nArticulate.\\nRelaxed. Not\\neasily angered.\\nAffectionate.\\nTolerant.\\nCompassionate.\\nBehavioral\\ncharacteristics\\nUnscheduled\\nsleep and\\nmeal times.\\nNervous dis-\\norders.\\nAnxiety.\\nOrderly.\\nStructured\\nsleep and\\nmeal times.\\nPerfectionist.\\nSlow, graceful.\\nLong sleeper\\nand slow eater.\\nProcrastination.\\nKEY TERMS\\nDosha— One of three constitutional types, either\\nvata, pitta, or kapha, found in Ayurvedic medicine.\\nMeditation— Technique of calming the mind.\\nPanchakarma— Intensive Ayurvedic cleansing and\\ndetoxification program.\\nPrakriti— An individual’s unique dosha pattern.\\nPrana— Basic life energy found in the elements.\\nYoga— System of body and breathing exercises.\\nGALE ENCYCLOPEDIA OF MEDICINE 475\\nAyurvedic medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Of all treatments, though, diet is one of the most\\nbasic and widely used therapy in the Ayurvedic sys-\\ntem. An Ayurvedic diet can be a very well planned and\\nindividualized regimen. According to Ayurveda, there\\nare six basic tastes: sweet, sour, salty, pungent, bitter,\\nand astringent. Certain tastes and foods can either\\ncalm or aggravate a particular dosha. For instance,\\nsweet, sour, and salty decrease vata problems and\\nincrease kapha. Sour, salty, and pungent can increase\\npitta. After an Ayurvedic physician determines a per-\\nson’s dosha profile, they will recommend a specific\\ndiet to correct imbalances and increase health. The\\nAyurvedic diet emphasizes primarily vegetarian\\nfoods of high quality and freshness, tailored to the\\nseason and time of day. Cooling foods are eaten in\\nthe summer and heating ones in the winter, always\\nwithin a person’s dosha requirements. In daily routine,\\nthe heaviest meal of the day should be lunch, and\\ndinner should eaten well before bedtime, to allow for\\ncomplete digestion. Also, eating meals in a calm man-\\nner with proper chewing and state of mind is impor-\\ntant, as is combining foods properly and avoiding\\novereating.\\nCost\\nCosts of Ayurvedic treatments can vary, with\\ninitial consultations running anywhere from $40 to\\nover $100, with follow-up visits costing less. Herbal\\ntreatments may cost from $10 to $50 per month, and\\nare often available from health food or bulk herb\\nstores. Some clinics offer panchakarma, the intensive\\nAyurvedic detoxification treatment, which can include\\novernight stays for up to several weeks. The prices for\\nthese programs can vary significantly, depending on\\nthe services and length of stay. Insurance reimburse-\\nment may depend on whether the primary physician is\\na licensed M.D.\\nPreparations\\nAyurveda is a mind/body system of health that\\ncontains some ideas foreign to the Western scien-\\ntific model. Those people considering Ayurveda\\nshould approach it with an open mind and will-\\ningness to experiment. Also, because Ayurveda is a\\nwhole-body system of healing and health, patience\\nand discipline are helpful, as some conditions and\\ndiseases are believed to be brought on by years of\\nbad health habits and require time and effort to\\ncorrect. Finally, the Ayurvedic philosophy believes\\nthat each person has the ability to heal themselves,\\nso those considering Ayurveda should be prepared\\nto bring responsibility and participation into the\\ntreatment.\\nPrecautions\\nAn Ayurvedic practitioner should always be\\nconsulted.\\nSide effects\\nDuring Ayurvedic detoxification programs, some\\npeople report fatigue, muscle soreness, and general\\nsickness. Also, as Ayurveda seeks to release mental\\nstresses and psychological problems from the patient,\\nsome people can experience mental disturbances and\\ndepression during treatment, and psychological coun-\\nseling may be part of a sound program.\\nResearch and general acceptance\\nBecause Ayurveda had been outside the Western\\nscientific system for years, research in the United\\nStates is new. Another difficulty in documentation\\narises because Ayurvedic treatment is very individua-\\nlized; two people with the same disease but different\\ndosha patterns might be treated differently. Much\\nmore scientific research has been conducted over the\\npast several decades in India. Much research in the\\nUnited States is being supported by the Maharishi\\nAyur-Ved organization, which studies the Ayurvedic\\nproducts it sells and its clinical practices.\\nSome Ayurvedic herbal mixtures have been pro-\\nven to have high antioxidant properties, much stron-\\nger than vitamins A, C, and E, and some have also\\nbeen shown in laboratory tests to reduce or eliminate\\ntumors in mice and to inhibitcancer growth in human\\nlung tumor cells. In a 1987 study at MIT, an Ayurvedic\\nherbal remedy was shown to significantly reducecolon\\ncancer in rats. Another study was performed in the\\nNetherlands with Maharishi Ayur-Ved products. A\\ngroup of patients with chronic illnesses, including\\nasthma, chronic bronchitis, hypertension, eczema,\\npsoriasis, constipation, rheumatoid arthritis , head-\\naches, and non-insulin dependent diabetes mellitus,\\nwere given Ayurvedic treatment. Strong results were\\nobserved, with nearly 80% of the patients improving\\nand some chronic conditions being completely cured.\\nOther studies have shown that Ayurvedic therapies\\ncan significantly lower cholesterol and blood pressure in\\nstress-related problems. Diabetes, acne, and allergies\\nhave also been successfully treated with Ayurvedic reme-\\ndies. Ayurvedic products have been shown to increase\\nshort-term memory and reduce headaches. Also,\\nAyurvedic remedies have been used successfully to sup-\\nport the healing process of patients undergoing che-\\nmotherapy, as these remedies have been demonstrated\\nto increase immune system activity.\\n476 GALE ENCYCLOPEDIA OF MEDICINE\\nAyurvedic medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nBOOKS\\nLad, Dr. Vasant.The Complete Book of Ayurvedic Home\\nRemedies. Minneapolis: Three Rivers Press, 1999.\\nORGANIZATIONS\\nAmerican Institute of Vedic Studies. P.O. Box 8357, Santa\\nFe, NM 87504. (505) 983-9385\\nAyurveda Holistic Center. Bayville, Long Island, NY.\\n(516)759-7731 mail@Ayurvedahc.com .\\nAyurvedic and Naturopathic Medical Clinic. 10025 NE 4th\\nStreet, Bellevue, WA 98004. (206)453-8022.\\nAyurvedic Institute. 11311 Menaul, NE Albuquerque, New\\nMexico 87112. (505) 291-9698. info@Ayurveda.com\\n.\\nBastyr University of Natural Health Sciences. 144 N.E. 54th\\nStreet, Seattle, WA 98105. (206) 523-9585.\\nCenter for Mind/Body Medicine. P.O. Box 1048, La Jolla,\\nCA 92038. (619)794-2425.\\nCollege of Maharishi Ayur-Ved, Maharishi International\\nUniversity. 1000 4th Street, Fairfield, IA 52557. (515)\\n472-7000.\\nNational Institute of Ayurvedic Medicine. (914) 278-8700.\\ndrgerson@erols.com. .\\nRocky Mountain Institute of Yoga and Ayurveda. P.O. Box\\n1091, Boulder, CO 80306. (303) 443-6923.\\nOTHER\\n‘‘Inside Ayurveda: An Independent Journal of Ayurvedic\\nHealth Care.’’ P.O. Box 3021, Quincy, CA 95971.\\n.\\nDouglas Dupler, MA\\nAzithromycin see Erythromycins\\nAZT see Antiretroviral drugs\\nGALE ENCYCLOPEDIA OF MEDICINE 477\\nAyurvedic medicine'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content=''),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='B\\nB-cell count see Lymphocyte typing\\nBabesiosis\\nDefinition\\nBabesiosis is an infection of red blood cells caused\\nby the single-celled parasite,Babesia microti, which is\\nspread to humans by a tick bite.\\nDescription\\nBabesiosis is a rare, tick-transmitted disease that\\nis caused most often by the single-celled parasite\\nBabesia microti. By 1995, fewer than 500 cases of\\nbabesiosis had been reported in the United States.\\nThe disease occurs primarily in New England and\\nNew York, especially on the coastal islands.\\nHowever, cases have occurred in other parts of the\\nUnited States. Because of tick activity, the risk for\\nbabesiosis is highest during June and July.\\nTicks are small, blood-sucking arachnids.\\nAlthough some ticks carry diseasecausing organisms,\\nmost do not. Babesia microti is spread to humans\\nthrough the bite of the tickIxodes scapularis (also\\ncalled Ixodes dammini). Ixodes scapularis, called the\\n‘‘blacklegged deer tick,’’ usually feeds on deer and\\nmice. A tick picks up the parasites by feeding on an\\ninfected mouse and then passes them on by biting a\\nnew host, possibly a human. To pass on the parasites,\\nthe tick must be attached to the skin for 36-48 hours.\\nOnce in the bloodstream,Babesia microtienters a red\\nblood cell, reproduces by cell division, and destroys\\nthe cell, causing anemia. Humans infected with\\nBabesia microtiproduce antibodies that can be helpful\\nin diagnosing the infection.\\nCauses and symptoms\\nBabesia microti live and divide within red blood\\ncells, destroying the cells and causing anemia. The\\nmajority of people who are infected have no visible\\nsymptoms. In those who become ill, symptoms appear\\none to six weeks following the tick bite. Because the\\nticks are small, many patients have no recollection of a\\ntick bite. The symptoms are flu-like and include tired-\\nness, loss of appetite, fever, drenching sweats, and\\nmuscle pain. Nausea, vomiting, headache, shaking\\nchills, blood in the urine, and depression can occur.\\nPersons who are over 40 years old, have had their\\nspleen removed (splenectomized), and/or have a ser-\\nious disease (cancer, AIDS, etc.) are at a greater risk\\nfor severe babesiosis. In severe cases of babesiosis, up\\nto 85% of the blood cells can be infected. This causes a\\nserious, possibly fatal, blood deficiency.\\nDiagnosis\\nBabesiosis can be diagnosed by examining a blood\\nsample microscopically and detecting the presence of\\nBabesia microtiwithin the blood cells. The blood can\\nalso be checked for the presence of antibodies to the\\nparasite.\\nTreatment\\nIn serious cases, babesiosis is treated with a\\ncombination of clindamycin (Cleocin) and quinine.\\nClindamycin is given by injection and quinine is given\\norally three to four times a day for four to seven days.\\nTo reduce the number of parasites in the blood, severely\\nill patients have been treated with blood transfusions.\\nPrognosis\\nOtherwise healthy patients will recover comple-\\ntely. Babesiosis may last several months without\\nGALE ENCYCLOPEDIA OF MEDICINE 479'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='treatment and is a severe, potentially fatal disease in\\nsplenectomized patients.\\nPrevention\\nThe only prevention for babesiosis is to minimize\\nexposure to ticks by staying on trails when walking\\nthrough the woods, avoiding tall grasses, wearing long\\nsleeves and tucking pant legs into socks, wearing insect\\nrepellent, and checking for ticks after an outing.\\nRemove a tick as soon as possible by grasping the\\ntick with tweezers and gently pulling. Splenectomized\\npeople should avoid northeastern coastal regions\\nduring the tick season.\\nResources\\nOTHER\\nMayo Clinic Online.March 5, 1998. .\\nBelinda Rowland, PhD\\nBach flower remedies see Flower remedies\\nBacillary angiomatosis\\nDefinition\\nA life-threatening but curable infection that\\ncauses an eruption of purple lesions on or under the\\nskin that resembleKaposi’s sarcoma. The infection,\\nwhich occurs almost exclusively in patients with\\nAIDS, can be a complication ofcat-scratch disease.\\nDescription\\nBacillary angiomatosis is a re-emerging bacterial\\ninfection that is identical or closely related to one\\nwhich commonly afflicted thousands of soldiers during\\nWorld War I. Today, the disease, caused by two ver-\\nsions of the same bacteria, is linked to homeless AIDS\\npatients and to those afflicted with cat-scratch disease.\\nThe infection is rarely seen today in patients who\\ndon’t have HIV. According to the U.S. Centers for\\nDisease Control and Prevention (CDC), an HIV\\npatient diagnosed with bacillary angiomatosis is con-\\nsidered to have progressed to full-blown AIDS.\\nCauses and symptoms\\nScientists have recently isolated two varieties of\\nthe Bartonella bacteria as the cause of bacillary angio-\\nmatosis: Bartonella (formerly Rochalimaea quintana)\\nand B. henselae(cause of cat-scratch disease).\\nB. quintanainfection is known popularly astrench\\nfever, and is the infection associated with body lice that\\nsickened European troops during World War I. Lice\\ncarry the bacteria, and can transmit the infection to\\nhumans. The incidence of trenchfever was believed to\\nhave faded away with the end of World War I. It was\\nnot diagnosed in the United States until 1992, when 10\\ncases were reported among homeless Seattle men.\\nThe related bacteriaB. henselae was first identi-\\nfied several years ago as the cause of cat-scratch fever.\\nIt also can lead to bacillary angiomatosis in AIDS\\npatients. Bacillary angiomatosis caused by this bac-\\nteria is transmitted to AIDS patients from cat fleas.\\nThese two different types of bacteria both cause\\nbacillary angiomatosis, a disease which is character-\\nized by wildly proliferating blood vessels that form\\ntumor-like masses in the skin and organs. The nodules\\nthat appear in bacillary angiomatosis are firm and\\ndon’t turn white when pressed. The lesions can occur\\nanywhere on the body, in numbers ranging from one\\nto 100. They are rarely found on palms of the hands,\\nsoles of the feet, or in the mouth. As the number of\\nlesions increase, the patient may develop a high fever,\\nsweats, chills, poor appetite,vomiting, and weight loss.\\nIf untreated, the infection may be fatal.\\nIn addition to the basic disease process, the two\\ndifferent types of bacteria cause some slightly different\\nsymptoms. Patients infected with B. henselae also\\nKEY TERMS\\nAnemia— A below normal number of red blood\\ncells in the bloodstream.\\nParasite— An organism that lives upon or within\\nanother organism.\\nKEY TERMS\\nCat-scratch disease— An infectious disease caused\\nby bacteria transmitted by the common cat flea that\\ncauses a self-limiting, mild infection in healthy\\npeople.\\nKaposi’s sarcoma— A malignant condition that\\nbegins as soft brown or purple lesions on the skin\\nthat occurs most often in men with AIDS.\\n480 GALE ENCYCLOPEDIA OF MEDICINE\\nBacillary angiomatosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='experience blood-filled cysts within the liver and\\nabnormal liver function, whereasB. quintanapatients\\nmay have tumor growths in the bone.\\nDiagnosis\\nThis life-threatening but curable infection is often\\nmisdiagnosed, because it may be mistaken for other\\nconditions (such as Kaposi’s sarcoma). A blood test\\ndeveloped in 1992 by the CDC detects antibodies to\\nthe bacteria. It can be confirmed by reviewing symp-\\ntoms, history and negative tests for other diseases that\\ncause swollen lymph glands. It isn’t necessary to\\nbiopsy a small sample of the lymph node unless there\\nis a question of cancer of the lymph node or some\\nother disease.\\nTreatment\\nRecent research indicates thatantibiotics used to\\ntreat other HIV opportunistic infections can both pre-\\nvent and treat bacillary angiomatosis. Treatment is\\nusually given until the lesions disappear, which typi-\\ncally takes three or four weeks. A severely affected\\nlymph node or blister may have to be drained, and a\\nheating pad may help swollen, tender lymph glands.\\nAcetaminophen (Tylenol) may relievepain, aches, and\\nfever over 1018F (38.38C).\\nPrognosis\\nIn most cases, prompt antibiotic treatment in\\npatients with AIDS cured the infection caused by\\neither variety of the bacteria, and patients may resume\\nnormal life. Early diagnosis is crucial to a cure.\\nPrevention\\nStudies suggest that antibiotics may prevent\\nthe disease. Patients also should be sure to treat cats\\nfor fleas.\\nResources\\nPERIODICALS\\nKoehler, J. E. ‘‘Zoonoses: Cats, Fleas and Bacteria.’’\\nJournal of the American Medical Association271 (1994):\\n531-535.\\nCarol A. Turkington\\nBacillary dysentery see Shigellosis\\nBacitracin see Antibiotics, topical\\nBacteremia\\nDefinition\\nBacteremia is an invasion of the bloodstream by\\nbacteria.\\nDescription\\nBacteremia occurs when bacteria enter the\\nbloodstream. This may occur through a wound or\\ninfection, or through a surgical procedure or injec-\\ntion. Bacteremia may cause no symptoms and resolve\\nwithout treatment, or it may producefever and other\\nsymptoms of infection. In some cases, bacteremia\\nleads to septic shock, a potentially life-threatening\\ncondition.\\nCauses and symptoms\\nCauses\\nSeveral types of bacteria live on the surface of the\\nskin or colonize the moist linings of the urinary tract,\\nlower digestive tract, and other internal surfaces. These\\nbacteria are normally harmless as long as they are kept\\nin check by the body’s natural barriers and the immune\\nsystem. People in good health with strong immune\\nsystems rarely develop bacteremia. However, when\\nbacteria are introduced directly into the circulatory\\nsystem, especially in a person who is ill or undergoing\\naggressive medical treatment, the immune system may\\nnot be able to cope with the invasion, and symptoms of\\nbacteremia may develop. For this reason, bacteremia is\\nmost common in people who are already affected by or\\nbeing treated for some other medical problem. In addi-\\ntion, medical treatment may bring a person in contact\\nwith new types of bacteria that are more invasive than\\nthose already residing in that person’s body, further\\nincreasing the likelihood of bacterial infection.\\nConditions which increase the chances of devel-\\noping bacteremia include:\\n/C15immune suppression, either due to HIV infection or\\ndrug therapy\\n/C15antibiotic therapy which changes the balance of bac-\\nterial types in the body\\n/C15prolonged or severe illness\\n/C15alcoholism or other drugabuse\\n/C15malnutrition\\n/C15diseases or drug therapy that cause ulcers in the\\nintestines, e.g.chemotherapy for cancer\\nGALE ENCYCLOPEDIA OF MEDICINE 481\\nBacteremia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Common immediate causes of bacteremia include:\\n/C15drainage of anabscess, including an abscessed tooth\\n/C15urinary tract infection, especially in the presence of a\\nbladder catheter\\n/C15decubitus ulcers (pressure sores)\\n/C15intravenous procedures using unsterilized needles,\\nincluding IV drug use\\n/C15prolonged IV needle placement\\n/C15use ofostomy tubes, includinggastrostomy(surgically\\nmaking a new opening into the stomach), jejunostomy\\n(surgically making an opening from the abdominal\\nwall into the jejunum), and colostomy (surgically\\ncreating an articifical opening into the colon).\\nThe bacteria most likely to cause bacteremia include\\nmembers of the Staphylococcus, Streptococcus,\\nPseudomonas,Haemophilus,and Esherichia coli(E. coli)\\ngenera.\\nSymptoms\\nSymptoms of bacteremia may include:\\n/C15fever over 1018F (38.38C)\\n/C15chills\\n/C15malaise\\n/C15abdominal pain\\n/C15nausea\\n/C15vomiting\\n/C15diarrhea\\n/C15anxiety\\n/C15shortness of breath\\n/C15confusion\\nNot all of these symptoms are usually present. In\\nthe elderly, confusion may be the only prominent symp-\\ntom. Bacteremia may lead toseptic shock, whose symp-\\ntoms include decreased consciousness, rapid heart and\\nbreathing rates and multiple organ failures.\\nDiagnosis\\nBacteremia is diagnosed by culturing the blood\\nfor bacteria. Samples may need to be tested several\\ntimes over several hours. Blood analysis may also\\nreveal an elevated number of white blood cells.\\nBlood pressure is monitored closely; a decline in\\nblood pressure may indicate the onset of septicshock.\\nTreatment\\nBacteremia may cause no symptoms, but may be\\ndiscovered through a blood test for another condition.\\nIn this situation, it may not need to be treated, except\\nin patients especially at risk for infection, such as those\\nwith heart valve defects or whose immune systems are\\nsuppressed.\\nPrognosis\\nPrompt antibiotic therapy usually succeeds in clear-\\ning bacteria from the bloodstream. Recurrence may\\nindicate an undiscovered site of infection. Untreated\\nbacteria in the blood may spread, causing infection of\\nthe heart (endocarditisor pericarditis) or infection of the\\ncovering of the central nervous system (meningitis).\\nPrevention\\nBacteremia can be prevented by preventing the\\ninfections which often precede it. Good personal\\nhygiene, especially during viral illness, may reduce the\\nrisk of developing bacterial infection. Treating bacterial\\ninfections quickly and thoroughly can minimize the risk\\nof spreading infection. During medical procedures, the\\nburden falls on medical professionals to minimize the\\nnumber and duration of invasive procedures, to reduce\\npatients’ exposure to sources of bacteria when being\\ntreated, and to use scrupulous technique.\\nResources\\nOTHER\\nThe Merck Page.April 13, 1998. .\\nRichard Robinson\\nBacterial meningitis see Meningitis\\nKEY TERMS\\nColostomy— Surgical creation of an artificial anus\\non the abdominal wall by cutting into the colon and\\nbringing it up to the surface.\\nGastrostomy— Surgical creation of an artificial\\nopening into the stomach through the abdominal\\nwall to allow tube feeding.\\nJejunostomy— Surgical creation of an opening to\\nthe middle portion of the small intestine (jejunum),\\nthrough the abdominal wall.\\nSeptic shock— A life-threatening drop in blood\\npressure caused by bacterial infection.\\n482 GALE ENCYCLOPEDIA OF MEDICINE\\nBacteremia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Bacterial vaginosis\\nDefinition\\nBacterial vaginosis (BV) is a type of vaginal infec-\\ntion in which the normal balance of bacteria in the\\nvagina is disrupted, allowing the overgrowth of harmful\\nanaerobic bacteria at the expense of protective bacteria.\\nDescription\\nBV is the most, common and the most serious type\\nof vaginal infection in women of childbearing age. As\\nmany as 10 to 26 percent of pregnant women in the\\nUnited States have BV; BV has been found in 12 to 25\\npercent of women in routine clinic populations, and in 32\\nto 64 percent of women in clinics forsexually transmitted\\ndiseases(STDs). BV is different than vaginal yeast infec-\\ntions and requires different methods of treatment.\\nIn most cases, BV does not have lasting effects on\\nwomen. However, there can be risks associated with BV:\\nCauses and symptoms\\nBacteria that dominate the vaginal flora in a BV\\ninfection includeGardnerella vaginalisor Mobiluncus,\\nalthough other bacteria, such asEscherichia colifrom\\nthe rectum have also been shown to cause the disease.\\nThe overgrowth of these harmful bacteria are at the\\nexpense of the protective bacteria lactobacilli, which\\nsecrete a natural disinfectant, hydrogen peroxide, that\\nmaintains the healthy, normal balance of vaginal\\nmicroorganisms. The factors that upset the normal\\nbalance of bacteria in the vagina are not well-under-\\nstood; however, the following activities or behaviors\\nthat have been associated with BV include:\\n/C15having a new sex partner or multiple sex partners\\n/C15stress\\n/C15douching\\n/C15using an intrauterine device (IUD) for contraception\\nBV is not transmitted through toilet seats, bed-\\nding, swimming pools, or touching of objects. Women\\nwho have not had sexual intercourse rarely have BV.\\nHowever BV is not considered an STD, although it\\ndoes appear to act like an STD in women who have sex\\nwith women.\\nThe main symptom of BV is a thin, watery or\\nfoamy, white (milky) or gray vaginal discharge with\\nan unpleasant, foul, fish-like or musty odor. The odor\\nis sometimes stronger after a woman has sex, when the\\nsemen mixes with the vaginal secretions. Burning or\\npain during urination can also be present with BV.\\nItching on the outside of the vagina and redness can\\nalso occur, but are seen less frequently. However,\\nmany women with BV do not exhibit any symptoms.\\nDiagnosis\\nBV is diagnosed through a examination of the\\nvagina by a health care provider. A woman who sus-\\npects that she may have BV should not douche or use a\\nfeminine hygiene spray before the appointment with\\nthe health care provider. Laboratory tests are con-\\nducted on a sample of the vaginal fluid to see if the\\nbacteria present are those associated with BV. The\\nhealth care provider may also check to see if there is\\ndecreased vaginal acidity. Potassium hydroxide, when\\nadded to a vaginal discharge sample, enhances vaginal\\nodors and allows the health care provider to determine\\nif the odor is fishy or foul.\\nTreatment\\nIn a few cases, BV might clear up without treat-\\nment. However, all women with symptoms of BV\\nshould be treated to relieve symptoms and to avoid\\nthe development of complications such as pelvic inflam-\\nmatory disease (PID). In most cases, male partners are\\nnot treated, but female sexual partners should be exam-\\nined to see if they have BV and require treatment.\\nBV is treated with prescriptionantibiotics such as\\nmetronidazole or clindamycin creams or oral metronida-\\nzole (both are antibiotics that can also be used by preg-\\nnantwomen,althoughatdifferentdoses).Metronidazole\\nkills anaerobic bacteria but does not harm the protective\\nlactobacilli. Drinking alcohol should be avoided when\\ntaking metronidazole, for this medicine can cause severe\\nnausea and vomitingwhen combined with alcohol.\\nFor postmenopausal women, in addition to the\\nuse of antibiotics, the health care provider may also\\nprescribe estrogen suppositories or topical cream to\\nthicken and lubricate vaginal tissues. Sexual activity\\nshould be avoided during treatment; acondom should\\nbe used if the woman does have sexual intercourse.\\nKEY TERMS\\nAnaerobic bacteria— Bacteria that do not require\\noxgyen, found in low concentrations in the normal\\nvagina\\nVaginal discharge— discharge of secretions from the\\ncervical glands of the vagina; normally clear or white\\nGALE ENCYCLOPEDIA OF MEDICINE 483\\nBacterial vaginosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The woman should be tested after treatment to ensure\\nthat the infection has been cured.\\nAlternative treatment\\nSupplement therapies are available in addition to\\nthe use of prescription medicines to ease recovery.\\nHerbal therapies\\nFresh garlic (Allium sativum) has antibacterial\\nproperties and can be added to a woman’s diet. A\\nfresh, peeled garlic wrapped in gauze can also be\\ninserted into the vagina to help treat BV. The insert\\nshould be changed twice daily.\\nTo soothe itching or irritation of the vaginal tis-\\nsues, a woman can bathe the tissues in an infusion of\\nfresh chickweed (Stellaria media). The infusion is\\nmade by pouring one cup of boiling water on one to\\ntwo teaspoons of the herb, steeping for five minutes,\\nand allowing the mixture to cool before use.\\nPrognosis\\n/C15Pre gn an twome nwithB Vofte nh av eb ab ieso flo wbirth\\nweight (less than 5.5 pounds) or who are premature\\n/C15Bacteria that cause BV may also causepelvic inflam-\\nmatory disease(PID), an infection of the uterus and\\nfallopian tubes. The risk of a woman with BV devel-\\noping PID is higher after the woman undergoes sur-\\ngical procedures such as a hysterectomy or an\\nabortion. PID can result ininfertility and can also\\nincrease the risk of an ectopic pregnancy\\n/C15BV may increase the risk of a woman becoming\\ninfected with HIV, the virus that causes AIDS\\n/C15A woman with BV and HIV is more likely to pass\\nHIV to her sexual partner\\n/C15BV increases the chance that a woman will contract\\nother STDs, such as chlamydia and gonorrhea\\nBV can be successfully treated with antibiotics.\\n/C15practicing abstinence\\n/C15delaying having sex for the first time, as younger\\npeople who have sex are more likely to contract BV\\nand STDs\\n/C15limiting the number of sexual partners\\n/C15having a sexual relationship with only one partner\\nwho does not have an STD\\n/C15practicing safer sex, which means using a condom\\nevery time when having sex\\nPrevention\\nSince the development of BV often appears to be\\nassociated with sexual activities, recommended ways\\nto avoid BV include:\\nOther ways to prevent BV include:\\n/C15discontinuing the use of tampons for six months\\n/C15practicing good hygiene by wiping from front to\\nback (away from the vagina) after bowel movements\\nto avoid spreading bacteria from the rectum to the\\nvagina\\n/C15wearing cotton panties and panty-hose with a cotton\\ncrotch and avoiding tight or latex clothing to keep\\nthe vagina cool and dry\\n/C15avoiding the use of perfumed soaps and feminine\\nsprays\\n/C15lowering stress levels\\n/C15avoiding douching, as douching removes some of the\\nnormal bacteria in the vagina that protects women\\nfrom infection\\n/C15finishing the course of antibiotic treatment, even if\\nthe symptoms are relieved, to prevent reoccurrence\\nof the disease\\n/C15routinely being tested for BV during regular gyneco-\\nlogical examinations\\nSome physicians recommend that all women who\\nhave a hysterectomy or an abortion be treated for BV,\\nto reduce the risk of developing PID.\\nResources\\nBOOKS\\nIcon Health Publications.Bacterial Vaginosis - a Medical\\nDictionary, Bibliography, and Annotated Research Guide\\nto Internet References.San Diego, CA: Icon Health\\nPublications, 2003.\\nParker, James N. and Parker, Philip M., editors.The Official\\nPatient’s Sourcebook on Vaginitis.San Diego, CA: Icon\\nHealth Publications, 2002.\\nParker, James N. and Parker, Philip M., editors.The Official\\nPatient’s Sourcebook on Bacterial Vaginosis.San Diego,\\nCA: Icon Health Publications, 2003.\\nTime-Life Books.Vaginal Problems The Medical Advisor..\\nRichmond, VA: Time-Life Books, 1996.\\nPERIODICALS\\nORGANIZATIONS\\nAmerican Social Health Association, P.O. Box 13827,\\nResearch Triangle Park, NC 27709. Telephone: (919)\\n361-8400; Fax: (919) 361-8425; Web site: http://\\nwww.ashastd.org/.\\n484\\nGALE ENCYCLOPEDIA OF MEDICINE\\nBacterial vaginosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='3M National Vaginitis Association. 3M Center, 275-3W-01,\\nP.O. Box 33275 Saint Paul, MN 55133-3275. Website:\\nwww3.3m.com/pdas-nva/\\nNational Women’s Health Information Center. U.S.\\nDepartment of Health and Human Services. Telephone:\\n(800) 994-9662: Website: www.4woman.gov\\nOTHER\\n3M National Vaginitis Association.Women’s Guide to\\nVaginal Infections.Brochure available for download:\\nwww3.3m.com/pdas-nva/cons_addresources.html\\nJudith Sims\\nBacteroides infection see Anaerobic\\ninfections\\nBad breath\\nDefinition\\nBad breath, sometimes called halitosis, is an\\nunpleasant odor of the breath.\\nDescription\\nBad breath is likely to be experienced by most\\nadults at least occasionally. Bad breath, either real or\\nimagined, can have a significant impact on a person’s\\nsocial and professional life.\\nCauses and symptoms\\nBad breath can be caused by a number of pro-\\nblems. Oral diseases, fermentation of food particles in\\nthe mouth, sinus infections, and unclean dentures can\\nall contribute to mouth odor. Many non-oral diseases,\\nsuch as lung infections, kidney failure, or severeliver\\ndisease, can also cause bad breath, though rarely.\\nMany people think that bad breath can originate in\\nthe stomach or intestines; this is extremely rare. The\\nesophagus is usually collapsed and closed, and,\\nalthough a belch may carry odor up from the stomach,\\nthe chance of bad breath being caused from air con-\\ntinually escaping from the stomach is remote.\\nCigarette smoke can cause bad breath, not only in\\nthe cigarette smoker, but also in one who is constantly\\nexposed to second-hand smoke.\\nDiagnosis\\nThe easiest way to determine if one has bad breath\\nis to ask someone who is trustworthy and discrete.\\nThis is usually not too difficult. Another, more pri-\\nvate, method of determining if one has bad breath is to\\nlick one’s wrist, wait until it dries, then smell the area.\\nScraping the rear area of the tongue with a plastic\\nspoon, then smelling the spoon, is another method\\none can use to assess bad breath.\\nTreatment\\nThe most effective treatment of bad breath is to\\ntreat the cause. Poor oral hygiene can be improved by\\nregular brushing and flossing, as well as regular dental\\ncheckups. Gentle brushing of the tongue should be\\npart of dailyoral hygiene. In addition to good oral\\nhygiene, the judicious use of mouthwashes is helpful.\\nMouth dryness, experienced at night or duringfasting,\\nor due to certain medications and medical conditions,\\ncan contribute to bad breath. Dryness can be avoided\\nby drinking adequate amounts of water. Chewing gum\\nmay be beneficial.\\nAs mentioned, some medications, such as some\\nhigh blood pressure medications, can cause dry mouth.\\nIf this problem is significant, a medication change, under\\nthe supervision of one’s health care provider, may\\nimprove the dry-mouth condition. Oral or sinus infec-\\ntions, once diagnosed, can be treated medically, usually\\nwith antibiotics. Lung infections and kidney or liver\\nproblems will, of course, need medical treatment.\\nAlternative treatment\\nDepending on the cause, a multitude of alterna-\\ntive therapeutic remedies can be used. For example,\\nsinusitis can be treated with steam inhalation of essen-\\ntial oils and/or herbs.\\nPrognosis\\nMost bad breath can be treated successfully with\\ngood oral hygiene and/or medical care. Occasionally,\\nfor patients who feel that these therapies are unsuccessful,\\nsome delusional or obsessivebehavior pattern might per-\\ntain, and mental health counseling may be appropriate.\\nResources\\nORGANIZATIONS\\nAmerican Dental Association. 211 E. Chicago Ave., Chicago,\\nIL 60611. (312) 440-2500. .\\nKEY TERMS\\nHalitosis— The medical term for bad breath.\\nGALE ENCYCLOPEDIA OF MEDICINE 485\\nBad breath'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='American Medical Association. 515 N. State St., Chicago, IL\\n60612. (312) 464-5000. .\\nJoseph Knight, PA\\nBalance and coordination tests\\nDefinition\\nBalance is the ability to maintain a position.\\nCoordination is the capacity to move through a complex\\nset of movements. Balance and coordination depend on\\nthe interaction of multiple body organs and systems\\nincluding the eyes, ears, brain and nervous system, car-\\ndiovascular system, and muscles. Tests or examination\\nof any or all of these organs or systems may be necessary\\nto determine the causes of loss of balance,dizziness,o r\\nthe inability to coordinate movement or activities.\\nPurpose\\nTests of balance and coordination, and the exam-\\nination of the organs and systems that influence\\nbalance and coordination, can help to identify causes\\nof dizziness,fainting, falling, or incoordination.\\nPrecautions\\nTests for balance and coordination should be con-\\nducted in a safe and controlled area where patients will\\nnot experience injury if they become dizzy or fall.\\nDescription\\nAssessment of balance and coordination can\\ninclude discussion of the patient’s medical history and\\nac o m p l e t ephysical examinationincluding evaluation of\\nthe heart, head, eyes, and ears. A slow pulse or heart\\nrate, or very low blood pressure may indicate a circula-\\ntory system problem, which can cause dizziness or faint-\\ning. During the examination, the patient may be asked\\nto rotate the head from side to side while sitting up or\\nwhile lying down with the head and neck extended over\\nthe edge of the examination table. If these tests produce\\ndizziness or a rapid twitching of the eyeballs (nystag-\\nmus), the patient may have a disorder of the inner ear,\\nwhich is responsible for maintaining balance.\\nAn examination of the eyes and ears may also give\\nclues to episodes of dizziness or incoordination. The\\npatient may be asked to focus on a light or on a distant\\npoint or object, and to look up, down, left, and right\\nmoving only the eyes while the eyes are examined.\\nProblems with vision may, in themselves, contribute\\nto balance and coordination disturbances, or may\\nindicate more serious problems of the nervous system\\nor brain function.Hearing loss, fluid in the inner ear,\\nor ear infection might indicate the cause of balance\\nand coordination problems.\\nVarious physical tests may also be used. A patient\\nmay be asked to walk a straight line, stand on one foot,\\nor touch a finger to the nose to help assess balance.\\nThe patient may be asked to squeeze or push against\\nthe doctor’s hands, to squat down, to bend over, stand\\non tiptoes or stand on their heels. Important aspects of\\nthese tests include holding positions for a certain num-\\nber of seconds, successfully repeating movements a\\ncertain number of times, and repeating the test accu-\\nrately with eyes closed. The patient’s reflexes may also\\nbe tested. For example, the doctor may tap on the\\nA patient sits on a ball, working on his balance. He wears a\\nbelt so that the physical therapist can catch him if he loses\\nbalance. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\n486 GALE ENCYCLOPEDIA OF MEDICINE\\nBalance and coordination tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='knees, ankles, and elbows with a small rubber mallet to\\ntest nervous system functioning. These tests may\\nreveal muscle weakness or nervous system problems\\nthat could contribute to incoordination.\\nPreparation\\nNo special preparation is required prior to admin-\\nistration of balance and coordination tests. The\\npatient may be asked to disrobe and put on an exam-\\nination gown to make it easier for the doctor to\\nobserve muscles and reflex responses.\\nAftercare\\nNo special aftercare is generally required, however,\\nsome of the tests may cause episodes of dizziness or\\nincoordination. Patients may need to use caution in\\nreturning to normal activities if they are experiencing\\nanysymptomsofdizziness,lightheadedness,orweakness.\\nRisks\\nThese simple tests of balance and coordination are\\ngenerally harmless.\\nNormal results\\nUnder normal conditions, these test will not cause\\ndizziness, loss of balance, or incoordination.\\nAbnormal results\\nThe presence of dizziness, lightheadedness, loss of\\ncoordination, unusual eye movements, muscle weak-\\nness, or impaired reflexes are abnormal results and\\nmay indicate the problem causing the loss of balance\\nor incoordination. In some cases, additional testing\\nmay be needed to diagnose the cause of balance or\\ncoordination problems.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Otolaryngology-Head and Neck\\nSurgery, Inc. One Prince St., Alexandria VA 22314-\\n3357. (703) 836-4444. .\\nEar Foundation. 1817 Patterson St., Nashville, TN 37203.\\n(800) 545-4327. .\\nVestibular Disorders Association (VEDA). P.O. Box 4467,\\nPortland, OR 97208-4467. (800) 837-8428 or (503) 229-\\n7705. Fax: (503) 229-8064.\\nAltha Roberts Edgren\\nBalanitis\\nDefinition\\nBalanitis is an inflammation of the head and fore-\\nskin of the penis.\\nDescription\\nBalanitis generally affects uncircumcised males.\\nThese are men who have a foreskin, which is the\\n‘‘hood’’ of soft skin that partially covers the head of\\nthe penis. In balanitis, the head and foreskin become\\nred and inflamed. (In circumcised men, who lack a\\nforeskin, these symptoms only affect the tip of the\\npenis.) The condition often occurs due to the fungus\\nCandida albicans, the same organism that causes vagi-\\nnal yeast infections in women. Balanitis (which is also\\nreferred to as balanoposthitis) can be caused by a\\nvariety of other fungal or bacterial infections, or may\\noccur due to a sensitivity reaction to common chemi-\\ncal agents.\\nUncircumcised men are more at risk for balanitis\\ndue to the presence of the foreskin. The snug fit of the\\nforeskin around the top of the penis tends to create a\\ndamp, warm environment that encourages the growth\\nof microorganisms. Most of the organisms associated\\nwith balanitis are already present on the penis, but in\\nvery small numbers. However, if the area between the\\nhead and foreskin is not cleansed thoroughly on a\\nregular basis, these organisms can multiply and lead\\nto infection.\\nDiabetes can increase the risk of developing the\\ncondition.\\nCauses and symptoms\\nBalanitis is usually a result of poor hygiene—for\\nexample, neglecting to bathe for several days. A failure\\nto properly wash (or rinse) the area between the head and\\nforeskin can lead to the development of fungal or bacter-\\nial infections that cause the condition. In other cases,\\nbalanitis may occur due to an allergic reaction: Some\\nKEY TERMS\\nMeniere’s disease—An abnormality of the inner ear\\nthat causes dizziness, ringing in the ears, and hear-\\ning loss.\\nGALE ENCYCLOPEDIA OF MEDICINE 487\\nBalanitis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='men may be sensitive to chemicals found in harsh soaps,\\nlaundry detergents, or contraceptive creams. Men who\\ncontract a sexually transmitted disease (STD) such as\\ntrichimoniasis may also develop symptoms.\\nThe symptoms of balanitis are limited to the fore-\\nskin and head of the penis (in circumcised men, only\\nthe head is affected). These include redness, inflamma-\\ntion, pain, discharge, sore or itchy skin, and difficulty\\nretracting the foreskin.\\nDiagnosis\\nBalanitis is usually diagnosed based on a brief\\nphysical examination. This may be conducted by\\nyour regular health care provider or by a urologist,\\nthe type of doctor who specializes in such disorders.\\nThe doctor may take a sample of the discharge (if any)\\nto determine the nature of the possible infection. A\\nurine test may be recommended to evaluate glucose\\n(sugar) levels in the urine. Balanitis treatment is typi-\\ncally covered by medical insurance.\\nTreatment\\nThe treatment of balanitis depends on the specific\\ncause, which can vary from case to case. Antibiotics are\\nused to treat bacterial infections, while topical antifun-\\ngals such as clotrimazole can combat balanitis caused by\\nCandida. If an allergic reaction is causing symptoms, the\\ngoal is to identify the chemical agent responsible.\\nOintments or creams may be used to ease skin irritation.\\nNo matter what the cause, it is important to thor-\\noughly clean the penis on a daily basis in order to\\nalleviate symptoms. If the condition keeps occurring,\\nor if the inflammation is interfering with urination,\\ncircumcision may be advised.\\nAlternative treatment\\nAccording to practitioners of alternative medi-\\ncine, certain herbs may be effective in controlling or\\npreventing yeast infections–a common cause of bala-\\nnitis. These remedies include garlic, calendula, and\\ngoldenseal. Eating yogurt that contains acidophilus\\nmay also help to clear up aCandida infection.\\nPrognosis\\nMost cases go away quickly once the cause is\\nidentified and treated. However, regular bouts of bala-\\nnitis can result in urethral stricture.\\nPrevention\\nProper hygiene is the best way to avoid balanitis.\\nCircumcision is sometimes performed to prevent\\nrepeated cases.\\nResources\\nBOOKS\\nTierney, Lawrence M., et al.Current Medical Diagnosis and\\nTreatment. McGraw-Hill, 2000.\\nPERIODICALS\\nMayser, P. ‘‘Mycotic infections of the penis.’’Andrologia 31\\nSupplement 1 (1999): 13-6.\\nORGANIZATIONS\\nU.S. National Library of Medicine. 8600 Rockville Pike,\\nBethesda, MD 20894. (888) 346-3656. .\\nGreg Annussek\\nBalantidiasis\\nDefinition\\nBalantidiasis is an infectious disease produced by\\na single-celled microorganism (protozoan) called\\nBalantidium coli that infects the digestive tract. It is\\nprimarily a disease of the tropics, although it is also\\nfound in cooler, temperate climates. Most persons\\nwith balantidiasis do not exhibit any noticeable symp-\\ntoms (asymptomatic), but a few individuals will\\ndevelop diarrhea with blood and mucus and an\\ninflamed colon (colitis).\\nDescription\\nBalantidiasis is caused byBalantidium coli, a para-\\nsitic protozoan that infects the large intestine.B. coliis\\nthe largest and only protozoan, having cilia or hair-\\nlike structures, that is capable of causing disease in\\nKEY TERMS\\nAcidophilus— A bacteria believed to combat yeast\\ninfections.\\nCircumcision— The surgical removal of the\\nforeskin.\\nUrethral stricture— A narrowing of the urethra\\n(urine tube).\\n488 GALE ENCYCLOPEDIA OF MEDICINE\\nBalantidiasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='humans. Balantidiasis occurs most commonly in areas\\nwith poor sanitation and in settings where humans live\\nin close contact with pigs, sheep, or goats.\\nCauses and symptoms\\nBalantidiasis is transmitted primarily by eating food\\nor drinking water that has been contaminated by human\\nor animal feces containingB. colicysts. During its life\\ncycle, this organism exists in two very different forms: the\\ninfective cyst or capsuled form, which cannot move but\\ncan survive outside the human body because of its thick,\\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. In the digestive tract, the cysts are trans-\\nported to the intestine where the walls of the cysts are\\nbroken open by digestive secretions, releasing the mobile\\ntrophozoites. Once released within the intestine, the tro-\\nphozoites multiply by feeding on intestinal bacteria or by\\ninvadingtheliningof the largeintestine.Within the lining\\nof the largeintestine, the trophozoites secrete a substance\\nthat destroys intestinal tissue and creates sores (ulcers) or\\nabscesses. Trophozoites eventually form new cysts that\\nare carried through the digestive tract and excreted in the\\nfeces. Under favorable temperature and humidity condi-\\ntions, the cysts can survive in soil or water for weeks to\\nmonths, ready to begin the cycle again.\\nMost individuals with balantidiasis have no\\nnoticeable symptoms. Even though these individuals\\nmay not feel ill, they are still capable of infecting\\nothers by person-to-person contact or by contaminat-\\ning food or water with cysts that others may ingest, for\\nexample, by preparing food with unwashed hands.\\nThe most common symptoms of balantidiasis are\\nchronic diarrhea or severe colitis with abdominal\\ncramps, pain, and bloody stools. Complications may\\ninclude intestinal perforation in which the intestinal\\nwall becomes torn, but the organisms do not spread to\\nother parts of the body in the blood stream.\\nDiagnosis\\nDiagnosis of balantidiasis, as with other similar\\ndiseases, can be complicated, partly because symp-\\ntoms may or may not be present. A diagnosis of\\nbalantidiasis may be considered when a patient has\\ndiarrhea combined with a possible history of recent\\nexposure to amebiasis through travel, contact with\\ninfected persons, or anal intercourse.\\nSpecifically, a diagnosis of balantidiasis is made\\nby findingB. colicysts or trophozoites in the patient’s\\nstools or by finding trophozoites in tissue samples\\n(biopsy) taken from the large bowel. A diagnostic\\nblood test has not yet been developed.\\nStool examination\\nThis test involves microscopically examining a\\nstool sample for the presence of cysts and/or tropho-\\nzoites ofB. coli.\\nSigmoidoscopy\\nTo take a tissue sample from the large intestine, a\\nprocedure called a sigmoidoscopy is performed.\\nDuring a sigmoidoscopy, a thin, flexible instrument\\nis used to visually examine the intestinal lining and\\nobtain small tissue specimens.\\nTreatment\\nPatients with balantidiasis are treated with pre-\\nscription medication, typically consisting of a ten day\\ncourse of either tetracycline or metronidazole.\\nAlternative drugs that have proven effective in treat-\\ning balantidiasis include iodoquinol or paromomycin.\\nPrognosis\\nAlthough somewhat dependent on the patient’s\\noverall health, in general, the prognosis for most\\nKEY TERMS\\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.\\nBiopsy— The removal of a tissue sample for diag-\\nnostic purposes.\\nCiliated— Covered with short, hair-like protru-\\nsions, like B. coli and certain other protozoa. The\\ncilia or hairs help the organism to move.\\nColitis— An inflammation of the large intestine that\\noccurs in some cases of balantidiasis. It is marked\\nby cramping pain and the passing of bloody mucus.\\nProtozoan— A single-celled, usually microscopic\\norganism, such as B. coli, that is eukaryotic and,\\ntherefore, different from bacteria (prokaryotic).\\nSigmoidoscopy— A procedure in which a thin, flex-\\nible, lighted instrument, called a sigmoidoscope, is\\nused to visually examine the lower part of the large\\nintestine.\\nGALE ENCYCLOPEDIA OF MEDICINE 489\\nBalantidiasis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='patients with balantidiasis is good. Severely infected\\npatients occasionally die as a result of a tear in the\\nintestinal wall (intestinal perforation) and consequent\\nloss of blood.\\nPrevention\\nThere are no immunization procedures or medica-\\ntions that can be taken prior to potential exposure to\\nprevent balantidiasis. Moreover, people who have had\\nthe disease can become reinfected. Prevention requires\\neffective personal and community hygiene. Specific\\nsafeguards include the following:\\n/C15Purification of drinking water. Water can be purified\\nby filtering, boiling, or treatment with iodine.\\n/C15Proper food handling. Measures include protecting\\nfood from contamination by flies, cooking food\\nproperly, washing one’s hands after using the bath-\\nroom and before cooking or eating, and avoiding\\nfoods that cannot be cooked or peeled when travel-\\ning in countries with high rates of balantidiasis.\\n/C15Careful disposal of human feces.\\n/C15Monitoring the contacts of balantidiasis patients.\\nThe stools of family members and sexual partners\\nof infected persons should be tested for the presence\\nof cysts or trophozoites.\\nResources\\nBOOKS\\nGoldsmith, Robert S. ‘‘Infectious Diseases: Protozoal &\\nHelminthic.’’ InCurrent Medical Diagnosis and\\nTreatment, 1998, edited by Stephen McPhee, et al., 37th\\ned. Stamford: Appleton & Lange, 1997.\\nRebecca J. Frey, PhD\\nBaldness see Alopecia\\nBalloon angioplasty see Angioplasty\\nBalloon valvuloplasty\\nDefinition\\nBalloon valvuloplasty is a procedure in which a\\nnarrowed heart valve is stretched open using a proce-\\ndure that does not require open heart surgery.\\nPurpose\\nThere are four valves in the heart, which are\\nlocated at the exit of each of the four chambers of\\nthe heart. They are called aortic valve, pulmonary\\nvalve, mitral valve, and tricuspid valve. The valves\\nopen and close to regulate the blood flow from one\\nchamber to the next. They are vital to the efficient\\nfunctioning of the heart.\\nIn some people the valves are too narrow (a con-\\ndition called stenosis). Balloon valvuloplasty is per-\\nformed on children and adults to improve valve\\nfunction and blood flow by enlarging the valve open-\\ning. It is a treatment for aortic, mitral, and pulmonary\\nstenosis. Balloon valvuloplasty has the best results as a\\ntreatment for narrowed pulmonary valves. Results in\\ntreating narrowing of the mitral valve are generally\\ngood. It is more difficult to perform and less successful\\nin treating narrowing of the aortic valve.\\nDescription\\nBalloon valvuloplasty is a procedure in which a\\nthin tube (catheter) that has a small deflated balloon at\\nthe tip is inserted through the skin in the groin area\\ninto a blood vessel, and then is threaded up to the\\nopening of the narrowed heart valve. The balloon is\\ninflated, which stretches the valve open. This proce-\\ndure cures many valve obstructions. It is also called\\nballoon enlargement of a narrowed heart valve.\\nThe procedure is performed in a cardiac catheteriza-\\ntion laboratory and takes up to four hours. The patient is\\nusually awake, but is givenlocal anesthesiato make the\\narea where the catheter is inserted numb. After the site\\nwhere the catheter will be inserted is prepared and\\nanesthetized, the cardiologist inserts a catheter into the\\nappropriate blood vessel, then passes a balloon-tipped\\nKEY TERMS\\nCardiac catheterization— A technique used to\\nevaluate the heart and fix certain problems.\\nCatheterization is far less invasive than traditional\\nsurgery.\\nStenosis— The narrowing of any valve, especially\\none of the heart valves or the opening into the\\npulmonary artery from the right ventricle.\\nValve— Tissue in the passageways between the\\nheart’s upper and lower chambers that controls\\npassage of blood and prevents regurgitation.\\n490 GALE ENCYCLOPEDIA OF MEDICINE\\nBalloon valvuloplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='catheter through the first catheter. Guided by a video\\nmonitor and an x ray, the physician slowly threads the\\ncatheter into the heart. The deflated balloon is posi-\\ntioned in the valve opening, then is inflated repeatedly.\\nThe inflated balloon widens the valve’s opening by split-\\nting the valve leaflets apart. Once the valve is widened,\\nthe balloon-tipped catheter is removed. The other cathe-\\nter remains in place for 6 to 12 hours because in some\\ncases the procedure must be repeated.\\nPreparation\\nFor at least six hours before balloon valvulo-\\nplasty, the patient will have to avoid eating or drinking\\nanything. An intravenous line is inserted so that med-\\nications can be administered. The patient’s groin area\\nis shaved and cleaned with an antiseptic. About an\\nhour before the procedure, the patient is given an\\noral sedative such as diazepam (Valium).\\nAftercare\\nAfter balloon valvuloplasty, the patient is sent to\\nthe recovery room for several hours, where he or she is\\nmonitored for vital signs (such as pulse and breathing)\\nand heart sounds. An electrocardiogram, which is a\\nrecord of the electrical impulses in the heart, is done.\\nThe leg in which the catheter was inserted is tempora-\\nrily prevented from moving. The skin condition is\\nmonitored. The insertion site, which will be covered\\nby a sandbag, is observed for bleeding until the cathe-\\nter is removed. Intravenous fluids will be given to help\\neliminate the x-ray dye; intravenous blood thinners or\\nother medications to dilate the coronary arteries may\\nbe given. Pain medication is available.\\nFor at least 30 minutes after removal of the cathe-\\nter, direct pressure is applied to the site of insertion; after\\nthis a pressure dressing will be applied. Following dis-\\ncharge from the hospital, the patient can usually resume\\nnormal activities. After balloon valvuloplasty lifelong\\nfollow-up is necessary because valves sometimes degen-\\nerate or narrowing recurs, making surgery necessary.\\nRisks\\nBalloon valvuloplasty can have serious complica-\\ntions. For example, the valve can become misshapen so\\nthat it doesn’t close completely, which makes the condi-\\ntionworse. Embolism,wherepiecesofthevalvebreakoff\\nand travel to the brain or the lungs, is another possible\\nrisk. If the procedure causes severe damage to the valve\\nleaflets, immediate surgery is required. Less frequent\\ncomplications are bleeding and hematoma (a local col-\\nlection of clotted blood) at the puncture site, abnormal\\nheart rhythms, reduced blood flow, heart attack, heart\\npuncture, infection, and circulatory problems.\\nResources\\nORGANIZATIONS\\nAmerican Heart Association. 7320 Greenville Ave. Dallas,\\nTX 75231. (214) 373-6300. .\\nLori De Milto\\nBancroftian filariasis see Elephantiasis\\nBang’s diseasesee Brucellosis\\nBarbiturate-induced coma\\nDefinition\\nA barbiturate-induced coma, or barb coma, is a\\ntemporary state of unconsciousness brought on by a\\ncontrolled dose of a barbiturate drug, usually pento-\\nbarbital or thiopental.\\nPurpose\\nBarbiturate comas are used to protect the brain\\nduring major brain surgery, such as the removal of\\narteriovenous malformationsor aneurysms. Coma may\\nalso be induced to control intracranialhypertension\\ncaused by brain injury.\\nPrecautions\\nBarbiturate-induced comas are used when con-\\nventional therapy to reduce intracranial hypertension\\nhas failed. Barbiturate dosing is geared toward burst\\nsuppression–that is, reducing brain activity as mea-\\nsured by electroencephalography. This reduction in\\nbrain activity has to be balanced against the potential\\nside effects ofbarbiturates, which include allergic reac-\\ntions and effects on the cardiovascular system.\\nDescription\\nOne of the greatest hazards associated with brain\\ninjury is intracranial hypertension. Brain injury may be\\ncaused by an accidentalhead injuryor a medical condi-\\ntion, such as stroke, tumor, or infection. When the\\nbrain is injured, fluids accumulate in the brain, causing\\nit to swell. The skull does not allow for the expansion of\\nthe brain; in effect, the brain becomes compressed.\\nGALE ENCYCLOPEDIA OF MEDICINE 491\\nBarbiturate-induced coma'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='If the pressure does not abate, oxygenated blood\\nmay not reach all areas of the brain. Also, the brain\\ntissue may be forced against hard, bony edges on the\\ninterior of the skull. In either case, the brain tissue may\\ndie, causing permanent brain damage ordeath.\\nBarbiturates reduce the metabolic rate of brain\\ntissue, as well as the cerebral blood flow. With these\\nreductions, the blood vessels in the brain narrow,\\ndecreasing the amount of swelling in the brain. With\\nthe swelling relieved, the pressure decreases and some\\nor all brain damage may be averted.\\nControversy exists, however, over the benefits of\\nusing barbiturates to control intracranial hyperten-\\nsion. Some studies have shown that barbiturate-\\ninduced coma can reduce intracranial hypertension\\nbut does not necessarily prevent brain damage.\\nFurthermore, the reduction in intracranial hyperten-\\nsion may not be sustained.\\nPreparation\\nInducing a barbiturate coma is usually kept in\\nreserve for cases in which conventional treatments\\nfor controlling intracranial hypertension have\\nfailed. Before coma is induced, intracranial hyper-\\ntension may be treated by hyperventilation; by\\nfacilitation of blood flow from the brain; by\\ndecompressive surgical procedures, such as draining\\nexcess fluids from under the skull or from the\\nchambers within the brain (ventricles); or by drug\\ntherapy, including osmotherapy, diuretic agents, or\\nsteroids.\\nRisks\\nAn estimated 25% of barbiturate-induced\\ncomas are accompanied by severe side effects. The\\nside effects of barbiturates, especially the depres-\\nsive effect on the cardiovascular system, can be too\\nrisky for some patients. Other side effects include\\nimpaired gastrointestinal motility and impaired\\nimmune response and infection. Since barbiturates\\ndepress activity in the brain, measurements of\\nbrain activity may be unreliable. Careful monitor-\\ning of the patient is required to ensure nutritional\\nneeds are being met and to guard against compli-\\ncations, such as lung infection, fevers, or deep vein\\nblood clots.\\nNormal results\\nIn many patients who do not respond to conven-\\ntional therapy, barbiturate-induced coma can\\nachieve the necessary control of intracranial\\nhypertension.\\nResources\\nPERIODICALS\\nSchwab, Stefan, et al. ‘‘Barbiturate Coma in Severe\\nHemispheric Stroke: Useful or Obsolete?’’Neurology 48\\n(1997): 1608.\\nJulia Barrett\\nBarbiturate withdrawal see Withdrawal\\nsyndromes\\nBarbiturates\\nDefinition\\nBarbiturates are medicines that act on the central\\nnervous system and cause drowsiness and can control\\nseizures.\\nKEY TERMS\\nAneurysm— A bulge or sack-like projection from a\\nblood vessel.\\nArteriovenous malformation— An abnormal tangle\\nof arteries and veins in which the arteries feed\\ndirectly into the veins without a normal intervening\\ncapillary bed.\\nDiuretic agent— A drug which increases urine\\noutput.\\nElectroencephalography— The recording of elec-\\ntrical potentials produced by the brain. These\\npotentials indicate brain activity.\\nHyperventilation— A respiratory therapy involving\\ndeeper and/or faster breathing to keep the carbon\\ndioxide pressure in the blood below normal.\\nIntracranial hypertension— Abnormally high\\nblood pressure within the skull.\\nOsmotherapy— Intravenous injection or oral\\nadministration of an agent that induces dehydra-\\ntion. The goal of dehydration is to reduce the\\namount of accumulated fluid in the brain.\\nSteroid— A type of drug used to reduce swelling.\\n492 GALE ENCYCLOPEDIA OF MEDICINE\\nBarbiturates'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Purpose\\nBarbiturates are in the group of medicines known\\nas central nervous system depressants (CNS). Also\\nknown as sedative-hypnotic drugs, barbiturates make\\npeople very relaxed, calm, and sleepy. These drugs are\\nsometimes used to help patients relax before surgery.\\nSome may also be used to control seizures (convul-\\nsions). Although barbiturates have been used to treat\\nnervousness and sleep problems, they have generally\\nbeen replaced by other medicines for these purposes.\\nThese medicines may become habit forming and\\nshould not be used to relieve everydayanxiety and\\ntension or to treat sleeplessness over long periods.\\nDescription\\nBarbiturates are available only with a physician’s\\nprescription and are sold incapsule, tablet, liquid,\\nand injectable forms. Some commonly used barbitu-\\nrates are phenobarbital (Barbita) and secobarbital\\n(Seconal).\\nRecommended dosage\\nRecommended dosage depends on the type of\\nbarbiturate and other factors such as the patient’s\\nage and the condition for which the medicine is being\\ntaken. Check with the physician who prescribed the\\ndrug or the pharmacist who filled the prescription for\\nthe correct dosage.\\nAlways take barbiturates exactly as directed.\\nNever take larger or more frequent doses, and do\\nnot take the drug for longer than directed. If the\\nmedicine does not seem to be working, even after\\ntaking it for several weeks, do not increase the\\ndosage. Instead, check with the physician who pre-\\nscribed the medicine.\\nDo not stop taking this medicine suddenly with-\\nout first checking with the physician who prescribed it.\\nIt may be necessary to taper down gradually to reduce\\nthe chance of withdrawal symptoms. If it is necessary\\nto stop taking the drug, check with the physician for\\ninstructions on how to stop.\\nPrecautions\\nSee a physician regularly while taking barbitu-\\nrates. The physician will check to make sure the med-\\nicine is working as it should and will note unwanted\\nside effects.\\nBecause barbiturates work on the central nervous\\nsystem, they may add to the effects of alcohol and\\nother drugs that slow the central nervous system,\\nsuch as antihistamines, cold medicine, allergy medi-\\ncine, sleep aids, medicine for seizures, tranquilizers,\\nsome pain relievers, and muscle relaxants. They may\\nalso add to the effects of anesthetics, including those\\nused for dental procedures. The combined effects of\\nbarbiturates and alcohol or other CNS depressants\\n(drugs that slow the central nervous system) can be\\nvery dangerous, leading to unconsciousness or even\\ndeath. Anyone taking barbiturates should not drink\\nalcohol and should check with his or her physician\\nbefore taking any medicines classified as CNS\\ndepressants.\\nTaking an overdose of barbiturates or combining\\nbarbiturates with alcohol or other central nervous\\nsystem depressants can cause unconsciousness and\\neven death. Anyone who shows signs of an overdose\\nor a reaction to combining barbiturates with alcohol\\nKEY TERMS\\nAdrenal glands— Two glands located next to the\\nkidneys. The adrenal glands produce the hormones\\nepinephrine and norepinephrine and the corticos-\\nteroid (cortisone-like) hormones.\\nAnemia— A lack of hemoglobin – the compound in\\nblood that carries oxygen from the lungs through-\\nout the body and brings waste carbon dioxide from\\nthe cells to the lungs, where it is released.\\nCentral nervous system— The brain and spinal\\ncord.\\nHallucination— A false or distorted perception of\\nobjects, sounds, or events that seems real.\\nHallucinations usually result from drugs or mental\\ndisorders.\\nHypnotic— A medicine that causes sleep.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings, such as chlorophyll, that makes plants\\ngreen and hemoglobin which makes blood red.\\nSedative— Medicine that has a calming effect and\\nmay be used to treat nervousness or restlessness.\\nSeizure— A sudden attack, spasm, or convulsion.\\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.\\nGALE ENCYCLOPEDIA OF MEDICINE 493\\nBarbiturates'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='or other drugs should get emergency medical help\\nimmediately. Signs include:\\n/C15severe drowsiness\\n/C15breathing problems\\n/C15slurred speech\\n/C15staggering\\n/C15slow heartbeat\\n/C15severe confusion\\n/C15severe weakness\\nBarbiturates may change the results of certain\\nmedical tests. Before having medical tests, anyone\\ntaking this medicine should alert the health care pro-\\nfessional in charge.\\nPeople may feel drowsy, dizzy, lightheaded, or\\nless alert when using these drugs. These effects may\\neven occur the morning after taking a barbiturate\\nat bedtime. Because of these possible effects, any-\\none who takes these drugs should not drive, use\\nmachines or do anything else that might be dan-\\ngerous until they have found out how the drugs\\naffect them.\\nBarbiturates may cause physical or mental depen-\\ndence when taken over long periods. Anyone who\\nshows these signs of dependence should check with\\nhis or her physician right away:\\n/C15the need to take larger and larger doses of the med-\\nicine to get the same effect\\n/C15a strong desire to keep taking the medicine\\n/C15withdrawal symptoms, such as anxiety,nausea or\\nvomiting, convulsions, trembling, or sleep problems,\\nwhen the medicine is stopped\\nChildren may be especially sensitive to barbitu-\\nrates. This may increase the chance of side effects such\\nas unusual excitement.\\nOlder people may also be more sensitive that\\nothers to the effects of this medicine. In older people,\\nbarbiturates may be more likely to cause confusion,\\ndepression, and unusual excitement. These effects are\\nalso more likely in people who are very ill.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take barbiturates. Before taking these drugs, be\\nsure to let the physician know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to barbiturates in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\nfoods, dyes, preservatives, or other substances.\\nPREGNANCY. Taking barbiturates during preg-\\nnancy increases the chance ofbirth defects and may\\ncause other problems such as prolonged labor and\\nwithdrawal effects in the baby after birth. Pregnant\\nwomen who must take barbiturates for serious or life-\\nthreatening conditions should thoroughly discuss with\\ntheir physicians the benefits and risks of taking this\\nmedicine.\\nBREASTFEEDING. Barbiturates pass into breast\\nmilk and may cause problems such as drowsiness,\\nbreathing problems, or slow heartbeat in nursing\\nbabies whose mothers take the medicine. Women\\nwho are breastfeeding should check with their physi-\\ncians before using barbiturates.\\nOTHER MEDICAL CONDITIONS. Before using barbi-\\nturates, people with any of these medical problems\\nshould make sure their physicians are aware of their\\nconditions:\\n/C15alcohol or drugabuse\\n/C15depression\\n/C15hyperactivity (in children)\\n/C15pain\\n/C15kidney disease\\n/C15liver disease\\n/C15diabetes\\n/C15overactive thyroid\\n/C15underactive adrenal gland\\n/C15chronic lung diseases such asasthma or emphysema\\n/C15severe anemia\\n/C15porphyria\\nUSE OF CERTAIN MEDICINES. Taking barbiturates\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, light-\\nheadedness, drowsiness, and clumsiness or unsteadiness.\\nThese problems usually go away as the body adjusts to\\nthe drug and do not require medical treatment unless\\nthey persist or interfere with normal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nimmediately:\\n494 GALE ENCYCLOPEDIA OF MEDICINE\\nBarbiturates'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15fever\\n/C15muscle or joint pain\\n/C15sore throat\\n/C15chest pain or tightness in the chest\\n/C15wheezing\\n/C15skin problems, such as rash,hives, or red, thickened,\\nor scaly skin\\n/C15bleeding sores on the lips\\n/C15sores or painful white spots in the mouth\\n/C15swollen eyelids, face, or lips\\nIn addition, check with a physician as soon as\\npossible if confusion, depression, or unusual excite-\\nment occur after taking barbiturates.\\nPatients who take barbiturates for a long time or\\nat high doses may notice side effects for some time\\nafter they stop taking the drug. These effects usually\\nappear within 8-16 hours after the patient stops taking\\nthe medicine. Check with a physician if these or other\\ntroublesome symptoms occur after stopping treatment\\nwith barbiturates:\\n/C15dizziness, lightheadedness or faintness\\n/C15anxiety or restlessness\\n/C15hallucinations\\n/C15vision problems\\n/C15nausea and vomiting\\n/C15seizures (convulsions)\\n/C15muscle twitches or trembling hands\\n/C15weakness\\n/C15sleep problems, nightmares, or increased dreaming\\nOther side effects may occur. Anyone who has\\nunusual symptoms during or after treatment with bar-\\nbiturates should get in touch with his or her physician.\\nInteractions\\nBirth control pills may not work properly when\\ntaken while barbiturates are being taken. To prevent\\npregnancy, use additional or additional methods of\\nbirth control while taking barbiturates.\\nBarbiturates may also interact with other medicines.\\nWhen this happens, the effects of one or both of the drugs\\nmay change or the risk of side effects may be greater.\\nAnyone who takes barbiturates should let the physician\\nknow all other medicines he or she is taking. Among the\\ndrugs that may interact with barbiturates are:\\n/C15Other central nervous system (CNS) depressants\\nsuch as medicine for allergies, colds, hay fever, and\\nasthma; sedatives; tranquilizers; prescription pain\\nmedicine; muscle relaxants; medicine for seizures;\\nsleep aids; barbiturates; and anesthetics.\\n/C15Blood thinners.\\n/C15Adrenocorticoids (cortisone-like medicines).\\n/C15Antiseizure medicines such as valproic acid (Depakote\\nand Depakene), and carbamazepine (Tegretol).\\nThe list above does not include every drug that\\nmay interact with barbiturates. Be sure to check with\\na physician or pharmacist before combining barbitu-\\nrates with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nResources\\nPERIODICALS\\nMiller, Norman S. ‘‘Sedative-Hypnotics: Pharmacology and\\nUse.’’ Journal of Family Practice29 (December 1989):\\n665.\\nNancy Ross-Flanigan\\nBariatric surgery\\nDefinition\\nBariatric surgery promotes weight loss by chan-\\nging the digestive system’s anatomy, limiting the\\namount of food that can be eaten and digested.\\nPurpose\\nObesity normally is defined through the use of\\nbody mass index (BMI) measurement. Physician\\noffices, obesity associations, nutritionists, and others\\noffer methods for calculating BMI, which is a compar-\\nison of height to weight. Those with a BMI of 30 or\\nhigher are considered obese. However, at 40 or higher,\\nthey are considered severely obese—approximately\\nabout 100 pounds overweight for men and 80 pounds\\noverweight for women.\\nMany people who are obese struggle to lose\\nweight through diet andexercise but fail. Only after\\nthey have tried other methods of losing weight will\\nthey be candidates for bariatric surgery, which today\\nis considered a ‘‘last resort’’ for weight loss. In general,\\nguidelines agree that those with a BMI of 40 or more,\\nor a BMI of 35 to 39.9 and a serious obesity-related\\nGALE ENCYCLOPEDIA OF MEDICINE 495\\nBariatric surgery'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='health problem, qualify for bariatric surgery. More\\nthan 23 million Americans are candidates for bariatric\\nsurgery. More than 100,000 of the procedures were\\nperformed in 2003 and the number of surgeries per-\\nformed will probably continue to rise for many years.\\nPrecautions\\nBariatric surgery is not for everyone and the\\nsurgeon and other physicians will evaluate all med-\\nical conditions before allowing a patient to pro-\\nceed. As a major surgery, there are associated\\nrisks and side effects. Women of childbearing age\\nshould be aware that rapid weight loss and nutri-\\ntional deficiency associate dw i t hb a r i a t r i cs u r g e r y\\nmay be harmful to a developing fetus. It is impor-\\ntant that a patient reveal all current medications\\nand conditions during any pre-operative discus-\\nsions or examinations. Also, the physician will\\ncarefully evaluate the patient to ensure that he or\\nshe is prepared to make a lifelong commitment to\\nthe changes in eating and lifestyle required to make\\nthe surgery successful.\\nThough many studies have shown general safety\\nassociated with the major surgeries, they are relatively\\nnew and research on long-term effects are not as wide-\\nspread as they are for many other surgeries and pro-\\ncedures. When choosing a surgeon to perform the\\noperation, patients should check with organizations\\nsuch as the American Society for Bariatric Surgery\\nfor certification. A patient also should ask about the\\nsurgeon’s experience in performing the particular\\noperation.\\nAlthough the number of obese teenagers and\\nresulting bariatric surgeries has increased, some\\nexperts are questioning the decision to perform\\nbariatric surgery on teens. There are no specific clin-\\nical guidelines for determining a safe age for the\\nprocedure, but some physicians agree that bariatric\\nsurgery is not appropriatefor children younger than\\nage 15, since they are still growing and forming\\nbones.\\nDescription\\nWhen food is chewed and swallowed, it moves\\nalong the digestive tract. In the stomach, a strong\\nacid helps break down food so it can be digested\\nand the body can absorb the food’s nutrients and\\ncalories. The stomach can hold about three pints\\nof food at one time. As digestion continues, food\\nparticles become smaller and move from the stomach\\ninto the intestine. The various parts of the small\\nintestine are nearly 20 feet long if laid out straight.\\nThose food particles not digested in the small intes-\\ntine are stored in the large intestine until they are\\neliminated as waste.\\nWhen a patient has bariatric surgery, this diges-\\ntive process is altered to help the patient lose weight.\\nThere are three main types of bariatric surgery, but\\nonly two types are commonly used today. The types\\nare restrictive, malabsorptive, and combined restric-\\ntive/malabsorptive.\\nRestrictive surgery, often referred to as ‘‘sto-\\nmach stapling’’ uses bands or staples to create a\\nsmall pouch at the top of the stomach where food\\nenters from the esophagus. This smaller pouch may\\nhold only about 1 ounce of food at first and may\\nstretch to hold about 2-3 ounces. The pouch’s\\nlower opening is made small, so that food moves\\nslowly to the lower part of the stomach, adding to\\nthe feeling of fullness. The most frequently per-\\nformed types of restrictive surgeries are vertical\\nbanded gastroplasty (VBG), gastric banding, and\\nlaparoscopic gastric ba nding. VBG is used less\\ntoday in favor of gastric banding, which involves\\nan adjustable hollow band made of silicone rubber.\\nLaparoscopic gastric banding, or Lap-band, was\\napproved by the U.S. Food and Drug Administration\\n(FDA) in 2001. Sometimes referred to as ‘‘minimally\\ninvasive’’ bariatric surgery, the surgeon uses small\\nincisions and a laparoscope, or a small, tubular instru-\\nment with a camera attached, to see inside the abdo-\\nmen and apply the band.\\nMalabsorptive procedures help patients lose\\nweight by limiting the amount of nutrients and cal-\\nories the intestine can absorb. Sometimes called intest-\\ninal bypasses, they are no longer used in the United\\nStates because they have often resulted in severe nutri-\\ntional deficiencies.\\nCombined restrictive/malabsorptive operations\\nare the most common bariatric surgeries. They work\\nKEY TERMS\\nDigestive tract— The organs that perform diges-\\ntion, or changing of food into a form that can be\\nabsorbed by the body. They are the esophagus,\\nstomach, small intestine, and large instestine.\\nEsophagus— A muscular tube about nine inches\\nlong that carries food from the throat (pharynx) to\\nthe stomach.\\n496 GALE ENCYCLOPEDIA OF MEDICINE\\nBariatric surgery'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='by restricting both the amount of food the stomach\\ncan hold and the amount of calories and nutrients the\\nbody absorbs. The most common and successful com-\\nbined surgery in recent years is called the Roux-en-Y\\ngastric bypass (RGB). In this operation, the surgeon\\nfirst creates a small pouch at the top of the stomach.\\nNext, a Y-shaped section of the small intestine is con-\\nnected to the small pouch, allowing food to bypass the\\nlower stomach, the first part of the small intestine\\n(duodenum), and the first portion of the next section\\nof the small intestine ( jejunum). It connects into the\\nsecond half of the jejunum, reducing the amount of\\ncalories and nutrients the body absorbs. RGB may be\\nperformed with a laparoscope and a series of tiny\\nincisions or with a large abdominal incision.\\nProcedure times vary, depending on the type of\\nbariatric surgery chosen. However, most patients are\\nin surgery for about one to two hours. Though costs\\ncan be as high as $35,000, more insurance companies\\nare beginning to pay for the procedures if they are\\nproven medically necessary. In 2004, the agency that\\npays for Medicare costs recognized obesity and many\\nof its treatments as a medical cost for the first time,\\nrecognizing that obesity leads to many other medical\\nproblems.\\nPreparation\\nThe physician will first make sure that a patient is\\nmentally prepared for the surgery and the commit-\\nment to follow-up care that will be required. Patients\\nshould have a consultation appointment with the\\nsurgeon prior to the procedure to discuss risks and\\nbenefits. Pre-operative instructions will be given that\\nwill tell the patient specific preparations prior to the\\nsurgery. These may include instructions about avoid-\\ning food or liquids, certainmedications, and other\\ninstructions on the day before or the day of the pro-\\ncedure. Patients also may have several laboratory or\\nother diagnostic tests prior to the surgery.\\nAftercare\\nDepending on the type of procedure and any pos-\\nsible complications, patients can expect to stay at the\\nhospital or surgery center for about two to four days\\nfollowing the surgery. Those who have laparoscopic\\noperations typically have shorter hospital stays and\\nspeedier recovery times. The physician and nurses will\\nprovide instructions for wound care and other follow-\\nup when the patient is discharged from the hospital.\\nUsually, bariatric surgery patients can resume normal\\nactivity within about six weeks following surgery, and\\nas little as two weeks after laparoscopic procedures. It\\nis important for bariatric surgery patients to lose\\nweight at the recommended pace, takenutritional sup-\\nplements as recommended, and attend follow-up visits\\nwith physicians and nutritionists.\\nHow a patient complies with instructions from\\nphysicians following bariatric surgery is important.\\nMost patients will require lifelong use of nutritional\\nsupplements such as multivitamins, calcium, and other\\nvitamin supplements to prevent nutritional deficien-\\ncies. Because the stomach is smaller, patients will have\\nto eat small portions of food and often must avoid\\ncertain types of food such as sugar.\\nRisks\\nThe surgeon performing the procedure should\\ndiscuss its specific risks prior to surgery. Risks for\\nbariatric surgery include infection,blood clots, abdom-\\ninal hernia, gallstones, nutritional deficiencies, possi-\\nble nerve complications, anddeath. Death rates have\\nbeen reported lowest for RGB and VBG, at less than\\n1% of patients.\\nNormal results\\nWeight loss will occur gradually, as patients can\\neat less food and absorb fewer calories. When patients\\nfollow post-operative instructions, they can lead nor-\\nmal lives, eating less food and being careful to limit\\ncertain foods that may irritate their new stomach\\npouches. Most patients will lose 50–60% of their\\nexcess weight in the first year or two. With gastric\\nbypass surgery, many can lose up to two-thirds of\\nexcess weight by the second postoperative year.\\nResources\\nPERIODICALS\\n‘‘Gastric Bypass Patients Should Recognize Risk of Nerve\\nInjury Post-surgery.’’Life Science Weekly(Nov. 2,\\n2004):973.\\nMacNeil, Jane Saladoff. ‘‘Gastric Bypass Beat Medical Care\\nfor Moderate Obesity.’’Family Practice News(Jan. 15,\\n2005):60–61.\\nSantora, Marc. ‘‘Teenagers Turn to Surgery to Shrink Their\\nStomachs.’’ The New York Times(Nov. 26, 2004):B1.\\nORGANIZATION\\nAmerican Obesity Association. 1250 12th St. NW, Suite 300,\\nWashington, DC 20037. 202-776-7711. http://\\nwww.obesity.org.\\nSociety of American Gastrointestinal Endoscopic Surgeons.\\n11300 West Olympic Blvd., Suuite 600, Los Angeles,\\nCA 90064. 310-437-0544. http://www.sages.org.\\nGALE ENCYCLOPEDIA OF MEDICINE 497\\nBariatric surgery'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='OTHER\\nGastrointestinal Surgery for Severe ObesityWeight-control\\nInformation Network, National Institutes of Health,\\n2004. http://win.niddk.nih.gov/publications/\\ngastric.htm.\\nTeresa G. Odle\\nBarium enema\\nDefinition\\nA barium enema, also known as a lower GI (gas-\\ntrointestinal) exam, is a test that uses x-ray examina-\\ntion to view the large intestine. There are two types of\\nthis test: the single-contrast technique where barium\\nsulfate is injected into the rectum in order to gain a\\nprofile view of the large intestine; and the double-\\ncontrast (or ‘‘air contrast’’) technique where air is\\ninserted into the rectum.\\nPurpose\\nA barium enema may be performed for a variety of\\nreasons, including to aid in the diagnosis of colon and\\nrectal cancer(or colorectalcancer), and inflammatory\\ndisease. Detection of polyps (a benign growth in the\\ntissue lining of the colon and rectum), diverticula (a\\npouch pushing out from the colon), and structural\\nchanges in the large intestine can also be established with\\nthis test. The double-contrast barium enema is the best\\nmethod for detecting small tumors (such as polyps), early\\ninflammatory disease, and bleeding caused by ulcers.\\nThe decision to perform a barium enema is based\\non a person’s history of altered bowel habits. These\\ncan includediarrhea, constipation, any lower abdom-\\ninal pain they are currently exhibiting, blood, mucus,\\nor pus in their stools. It is also recommended that this\\nexam be used every five to 10 years to screen healthy\\npeople for colorectal cancer, the second most deadly\\ntype of tumor in the United States. Those who have\\na close relative with colorectal cancer or have had\\na precancerous polyp are considered to be at an\\nincreased risk for the disease and should be screened\\nmore frequently to look for abnormalities.\\nPrecautions\\nWhile barium enema is an effective screening\\nmethod in the detection of symptoms and may lead\\nto a timely diagnosis of several diseases, it is not the\\nonly method to do this. As of 1997, some studies have\\nshown that thecolonoscopy procedure performed by\\nexperienced gastroenterologists is a more accurate\\ninitial diagnostic tool for detecting early signs of color-\\nectal cancer. A colonoscopy is the most accurate way\\nfor the physician to examine the entire colon and\\nrectum for polyps. If abnormalities are seen at this\\ntime the procedure is accompanied by a biopsy.\\nSome physicians use sigmoidoscopy plus a barium\\nenema instead of colonoscopy.\\nDescription\\nTo begin a barium enema, the patient will lie with\\ntheir back down on a tilting radiographic table in order\\nto have x rays of the abdomen taken. After being\\nassisted to a different position, a well-lubricated rectal\\ntube is inserted through the anus. This tube allows the\\nphysician or assistant to slowly administer the barium\\ninto the intestine. While this filling process is closely\\nmonitored, it is important for the patient to keep the\\nanus tightly contracted against the rectal tube to help\\nmaintain its position and prevent the barium from\\nleaking. This step is emphasized to the patient due to\\nthe inaccuracy that may be caused if the barium leaks.\\nA rectal balloon may also be inflated to help retain the\\nbarium. The table may be tilted or the patient moved to\\na different position to aid in the filling process.\\nKEY TERMS\\nBarium sulfate— A barium compound used during\\na barium enema to block the passage of x rays\\nduring the exam.\\nBowel lumen— The space within the intestine.\\nColonoscopy— An examination of the upper por-\\ntion of the rectum performed with a colonoscope or\\nelongated speculum.\\nDiverticula— A diverticulum of the colon is a sac or\\npouch in the colon walls which is usually asympto-\\nmatic (without symptoms) but may cause difficulty\\nif it becomes inflamed.\\nDiverticulitis— A condition of the diverticulum of\\nthe intestinal tract, especially in the colon, where\\ninflammation may cause distended sacs extending\\nfrom the colon and pain.\\nUlcerative colitis— An ulceration or erosion of the\\nmucosa of the colon.\\nProctosigmoidoscopy— A visual examination of the\\nrectum and sigmoid colon using a sigmoidoscope.\\n498 GALE ENCYCLOPEDIA OF MEDICINE\\nBarium enema'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='As the barium fills the intestine, x rays of the abdo-\\nmen are taken to distinguish significant findings.There\\nare many ways to perform a barium enema. One way is\\nthat shortly after filling, the rectal tube is removed and\\nthe patient expels as much of the barium as possible.\\nUpon completing this, an additional x ray is taken, and\\na double-contrast enema may follow. If this is done\\nimmediately, a thin film of barium will remain in the\\nintestine, and air is then slowly injected to expand the\\nbowel lumen. Sometimes no x rays will be taken until\\nafter the air is injected.\\nPreparation\\nIn order to conduct the most accurate barium\\nenema test, the patient must follow a prescribed diet\\nand bowel preparation instructions prior to the test.\\nThis preparation commonly includes restricted intake\\nof diary products and a liquid diet for 24 hours prior to\\nthe test, in addition to drinking large amounts of water\\nor clear liquids 12–24 hours before the test. Patients\\nmay also be givenlaxatives, and asked to give them-\\nselves a cleansing enema.\\nIn addition to the prescribed diet and bowel pre-\\nparation prior to the test, the patient can expect the\\nfollowing during a barium enema:\\n/C15They will be well draped with a gown as they are\\nsecured to a tilting x-ray table.\\n/C15As the barium or air is injected into the intestine, they\\nmay experience cramping pains or the urge to defecate.\\n/C15The patient will be instructed to take slow, deep\\nbreaths through the mouth to ease any discomfort.\\nAftercare\\nPatients should follow several steps immediately\\nafter undergoing a barium enema, including:\\n/C15Drink plenty of fluids to help counteract the dehy-\\ndrating effects of bowel preparation and the test.\\n/C15Take time to rest. A barium enema and the bowel\\npreparation taken before it can be exhausting.\\n/C15A cleansing enema may be given to eliminate any\\nremaining barium. Lightly colored stools will be pre-\\nvalent for the next 24–72 hours following the test.\\nRisks\\nWhile a barium enema is considered a safe screening\\ntest used on a routine basis, it can cause complications in\\ncertain people. The following indications should be kept\\nin mind before a barium enema is performed:\\n/C15Those who have a rapid heart rate, severe ulcerative\\ncolitis, toxic megacolon, or a presumed perforation\\nin the intestine should not undergo a barium enema.\\n/C15The test can be cautiously performed if the patient\\nhas a blocked intestine, ulcerative colitis,diverticuli-\\ntis, or severe bloody diarrhea.\\n/C15Complications that may be caused by the test include\\nperforation of the colon, water intoxication, barium\\ngranulomas (inflamed nodules), and allergic reac-\\ntion. These are all very rare.\\nNormal results\\nWhen the patient undergoes a single-contrast\\nenema, their intestine is steadily filled with barium\\nto differentiate the colon’s markings. A normal result\\ndisplays uniform filling of the colon. As the barium is\\nexpelled, the intestinal walls collapse. A normal result\\non the x ray after defecation will show the intestinal\\nlining as having a standard, feathery appearance.\\nAccordingly, the double-contrast enema expands\\nthe intestine which is already lined with a thin layer of\\nbarium, but with air to display a detailed image of the\\nmucosal pattern. Varying positions taken by the\\npatient allow the barium to collect on the dependent\\nwalls of the intestine by way of gravity.\\nAbnormal results\\nA barium enema allows abnormalities to appear on\\nan x ray that may aid in the diagnosis of several different\\nconditions. Although most colon cancers occur in the\\nrectosigmoid region, or upper part of the rectum and\\nadjoining portion of the sigmoid colon, and are better\\ndetected with a different test called a proctosigmoido-\\nscopy, an enema can identify other early signs of cancer.\\nIdentification of polyps,diverticulosis, inflamma-\\ntory disease, such as diverticulitis and ulcerative colitis\\nis attainable through a barium x ray. Structural\\nchanges in the intestine, gastroenteritis, and some\\ncases of acuteappendicitis may also be apparent by\\nviewing this x ray.\\nResources\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta, GA\\n30329-4251. (800) 227-2345. .\\nBeth A. Kapes\\nBarium swallow see Upper GI exam\\nBarlow’s syndromesee Mitral valve prolapse\\nGALE ENCYCLOPEDIA OF MEDICINE 499\\nBarium enema'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Bartholin’s gland cyst\\nDefinition\\nA Bartholin’s gland cyst is a swollen fluid-filled\\nlump that develops from a blockage of one of the\\nBartholin’s glands, which are small glands located on\\neach side of the opening to the vagina. Bartholin’s\\ngland cysts and abscesses are commonly found in\\nwomen of reproductive age, developing in approxi-\\nmately 2% of all women.\\nDescription\\nThe Bartholin’s glands are located in the lips of the\\nlabia that cover the vaginal opening. The glands (nor-\\nmally the size of a pea) provide moisture for the vulva\\narea. A Bartholin’s gland cyst may form in the gland itself\\nor in the duct draining the gland. A cyst normally does\\nnot cause pain, grows slowly, and may go away with-\\nout treatment. It usually ranges in size from 0.4-1.2 in.\\n(1–3 cm), although some may grow much larger.\\nIf infected, a Bartholin’s gland cyst can form an\\nabscess that will increase in size over several days and\\nis very painful. In order to heal, a Bartholin’s gland\\ncyst usually must be drained.\\nCauses and symptoms\\nA Bartholin’s gland cyst occurs if the duct\\nbecomes blocked for any reason, such as infection,\\ninjury, or chronic inflammation. Very rarely a cyst is\\ncaused bycancer, which usually occurs only in women\\nover the age of 40. In many cases, the cause of a\\nBartholin’s gland cyst is unknown.\\nSymptoms of an uninfected Bartholin’s gland cyst\\ninclude a painless jump on one side of the vulva area\\n(most common symptom) and redness or swelling in\\nthe vulva area.\\nSymptoms of an abscessed Bartholin’s gland\\ninclude:\\n/C15pain that occurs with walking, sitting, physical activ-\\nity, or sexual intercourse\\n/C15fever and chills\\n/C15increased swelling in the vulva area over a two- to\\nfour-day period\\n/C15drainage from the cyst, normally occurring four to\\nfive days after the swelling starts\\nAbscesses may be caused by sexually transmitted\\nbacteria, such as those causing chlamydial or gonococ-\\ncal infections, while others are caused by bacteria\\nnormally occurring in the vagina. Over 60 types of\\nbacteria have been found in Bartholin’s gland abscesses.\\nDiagnosis\\nA Bartholin’s gland cyst or abscess is diagnosed\\nby a gynecologicalpelvic exam. If the cyst appears to\\nbe infected, a culture is often performed to identify the\\ntype of bacteria causing the abscess.\\nTreatment\\nTreatment for this condition depends on the size\\nof the cyst, whether it is painful, and whether the cyst is\\ninfected.\\nIf the cyst is not infected, treatment options\\ninclude:\\n/C15watchful waiting by the woman and her health care\\nprofessional\\n/C15soaking of the genital area with warm towel\\ncompresses\\n/C15soaking of the genital area in a sitz bath\\n/C15use of non-prescription pain medication to relieve\\nmild discomfort\\nIf the Bartholin’s gland is infected, there are several\\ntreatments available to treat the abscess, including:\\n/C15soaking of the genital area in a sitz bath\\n/C15treatment withantibiotics\\n/C15useofprescriptionornon-prescriptionpainmedication\\n/C15incision and drainage, i.e., cutting into the cyst and\\ndraining the fluid (not usually successful, as the cyst\\noften reoccurs)\\nKEY TERMS\\nMarsupialization— Cutting out a wedge of the cyst\\nwall and putting in stitches so the cyst cannot reoccur.\\nSitz bath— A warm bath in which just the buttocks\\nand genital area soak in water; used to reduce pain\\nand aid healing in the genital area.\\nWindow operation— Cutting out a large oval-\\nshaped piece of the cyst wall and putting in stitches\\nto create a window so the cyst cannot reoccur.\\nWord catheter— A small rubber catheter with an\\ninflatable balloon tip that is inserted into a stab\\nincision in the cyst, after the contents of the cyst\\nhave been drained.\\n500 GALE ENCYCLOPEDIA OF MEDICINE\\nBartholin’s gland cyst'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15placement of a drain (Word catheter) in the cyst for\\ntwo to four weeks so fluid can drain and prevent\\nreoccurrence of the cyst\\n/C15marsupialization\\n/C15window operation\\n/C15use of a carbon dioxide laser to open the cyst and\\nheat the cyst wall tissue so that the cyst cannot form a\\nsac and reoccur\\n/C15incision and drainage, followed by treatment with\\nsilver nitrate to burn the cyst wall so the cyst cannot\\nform a sac and reoccur\\n/C15removal of the entire Bartholin’s gland cyst, if the\\ncyst has reoccurred several times after use of other\\ntreatment methods\\nDuring surgical treatment, the area will be numbed\\nwith a local anesthetic to reduce pain. General anesthe-\\nsia may be used for treatment of an abscess, as the\\nprocedure can be painful.\\nIn a pregnant woman, surgical treatment of cysts\\nthat are asymptomatic should be delayed until after\\ndelivery to avoid the possibility of excessive bleeding.\\nHowever, if the Bartholin’s gland is infected and must\\nbe drained, antibiotics andlocal anesthesiaare gener-\\nally considered safe.\\nIf the cyst is caused by cancer, the gland must be\\nexcised, and the woman should be under the care of a\\ngynecologist familiar with the treatment of this type of\\ncancer.\\nAlternative treatment\\nIf a Bartholin’s gland cyst has no or mild symp-\\ntoms, or has opened on its own to drain, a woman may\\ndecide to use watchful waiting, warm sitz baths, and\\nnon-prescription pain medication. If symptoms\\nbecome worse or do not improve, a health care profes-\\nsional should then be consulted.\\nInfected Bartholin’s glands should be evaluated\\nand treated by a health care professional.\\nPrognosis\\nA Bartholin’s gland cyst should respond to treat-\\nment in a few days. If an abscess requires surgery,\\nhealing may take days to weeks, depending on the\\nsize of the abscess and the type of surgical procedure\\nused. Most of the surgical procedures, except for inci-\\nsion and drainage, should be effective in preventing\\nrecurring infections.\\nPrevention\\nThere are few ways to prevent the formation of\\nBartholin’s gland cysts or abscesses. However, as a\\nBartholin’s gland abscess may be caused by a sexually\\ntransmitted disease, the practice of safe sex is recom-\\nmended. Using good hygiene, i.e., wiping front to back\\nafter a bowel movement, is also recommended to pre-\\nvent bacteria from the bowels from contaminating the\\nvaginal area.\\nResources\\nBOOKS\\nToth, P. P. ‘‘Management of Bartholin’s Gland Duct Cysts\\nand Abscesses.’’ InSaunders Manual of Medical\\nPractice. Philadelphia: W.B. Saunders, 2000.\\nJudith Sims\\nBartonella bacilliformis infection see\\nBartonellosis\\nBartonellosis\\nDefinition\\nBartonellosis is an infectious bacterial disease\\nwith an acute form (which has a sudden onset and\\nshort course) and a chronic form (which has more\\ngradual onset and longer duration). The disease is\\ntransmitted by sandflies and occurs in western South\\nAmerica. Characterized by a form of red blood cell\\ndeficiency (hemolytic anemia)a n dfever, the poten-\\ntially fatal acute form is called Oroya fever or\\nCarrion’s disease. The chronic form is identified by\\npainful skin lesions.\\nDescription\\nThe acute form of the disease gets its name from an\\noutbreak that occurred in 1871 near La Oroya, Peru.\\nMore than 7,000 people perished. Some survivors later\\ndeveloped a skin disease, called verruga peruana\\n(Peruvian warts). These skin lesions were observed\\nprior to the 1871 outbreak–perhaps as far back as the\\npre-Columbian era–but a connection to Oroya fever\\nwas unknown. In 1885, a young medical researcher,\\nDaniel Carrion, inoculated himself with blood from a\\nlesion to study the course of the skin disease. When he\\nbecame ill with Oroya fever, the connection became\\napparent. Oroya fever is often called Carrion’s disease\\nin honor of his fatal experiment.\\nGALE ENCYCLOPEDIA OF MEDICINE 501\\nBartonellosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The bacteria,Bartonella bacilliformis, was isolated\\nby Alberto Barton in 1909, but wasn’t identified as the\\ncause of the fever until 1940. TheBartonella genus\\nincludes at least 11 bacteria species, four of which\\ncause human diseases, including cat-scratch disease\\nand bacillary angiomatosis. However, bartonellosis\\nrefers exclusively to the disease caused byB. bacillifor-\\nmis. The disease is limited to a small area of the Andes\\nMountains in western South America; nearly all cases\\nhave been in Peru, Colombia, and Ecuador. A large\\noutbreak involving thousands of people occurred in\\n1940–41, but bartonellosis has since occurred sporadi-\\ncally. Control of sandflies, the only known disease carrier\\n(vector), has been credited with managing the disease.\\nCauses and symptoms\\nBartonellosis is transmitted by the nocturnal\\nsandfly and arises from infection withB. bacilliformis.\\nThe sandfly,Lutzomyia verrucarum, dines on human\\nblood and, in so doing, can inject bacteria into the\\nbloodstream. The sandfly is found only in certain\\nareas of the Peruvian Andes; other, as-yet-unidentified\\nvectors are suspected in Ecuador and Colombia.\\nOnce in the bloodstream, the bacteria latch onto\\nred blood cells (erythrocytes), burrow into the cells,\\nand reproduce. In the process, up to 90% of the host’s\\nerythrocytes are destroyed, causing severe hemolytic\\nanemia. The anemia is accompanied by high fever,\\nmuscle and jointpain, delirium, and possiblycoma.\\nTwo to eight weeks after the acute phase, an\\ninfected individual develops verruga peruana. However,\\nindividuals may exhibit the characteristic lesions with-\\nout ever experiencing the acute phase. Left untreated,\\nthe lesions may last months or years. These lesions\\nresemble blood-filled blisters, up to 1.6 in (4 cm) in\\ndiameter, and appear primarily on the head and limbs.\\nThey can be painful to the touch and may bleed or\\nulcerate.\\nDiagnosis\\nBartonellosis is identified by symptoms and the\\npatient’s history, such as recent travel in areas where\\nbartonellosis occurs. Isolation ofB. bacilliformisfrom\\nthe bloodstream or lesions can confirm the diagnosis.\\nTreatment\\nAntibiotics are the mainstay of bartonellosis treat-\\nment. The bacteria are susceptible to several antibiotics,\\nincluding chloramphenicol,penicillins,a n daminoglyco-\\nsides. Blood transfusions may be necessary to treat the\\nanemia caused by bartonellosis.\\nPrognosis\\nAntibiotics have dramatically decreased the fatal-\\nity associated with bartonellosis. Prior to the develop-\\nment of antibiotics, the fever was fatal in 40% of cases.\\nWith antibiotic treatment, that rate has dropped to\\n8%. Fatalities can result from complications associated\\nwith severe anemia and secondary infections. Once\\nthe infection is halted, an individual can recover fully.\\nPrevention\\nAvoiding sandfly bites is the primary means of\\nprevention. Sandfly eradication programs have been\\nhelpful in decreasing the sandfly population, and insect\\nrepellant can be effective in preventing sandfly bites.\\nResources\\nBOOKS\\nDaly, Jennifer S. ‘‘Bartonella Species.’’ InInfectious\\nDiseases, edited by Sherwood F. Gorbach, John S.\\nBartlett, and Neil R. Blacklow, 2nd ed. Philadelphia:\\nW. B. Saunders Co., 1998.\\nJulia Barrett\\nBasal cell cancer see Skin cancer,\\nnon-melanoma\\nBasal gastric secretion test see Gastric acid\\ndetermination\\nKEY TERMS\\nAcute— Referring to the course of a disease, or\\na phase of a disease, the short-term experience of\\nprominent symptoms.\\nChronic— Referring to the course of a disease, or\\na phase of a disease, the long-term experience of\\nprominent symptoms.\\nErythrocytes— Red blood cells.\\nHemolytic anemia—A form of erythrocyte deficiency\\ncaused by the destruction of the red blood cells.\\nHost— The organism that harbors or nourishes\\nanother organism (parasite). In bartonellosis, the\\nperson infected with Bartonella basilliformis.\\nVector— An organism, such as insects or rodents,\\nthat can transmit disease to humans.\\n502 GALE ENCYCLOPEDIA OF MEDICINE\\nBartonellosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Battered child syndrome\\nDefinition\\nBattered child syndrome refers to injuries sus-\\ntained by a child as a result of physical abuse, usually\\ninflicted by an adult caregiver. Alternative terms\\ninclude: shaken baby; shaken baby syndrome; child\\nabuse; and non-accidental trauma (NAT).\\nDescription\\nInternal injuries, cuts,burns, bruises and broken or\\nfractured bones are all possible signs of battered child\\nsyndrome. Emotional damage to a child is also often\\nthe by-product of childabuse, which can result in serious\\nbehavioral problems such assubstance abuse or the\\nphysical abuse of others. Approximately 14% of chil-\\ndren in the United States are physically abused each\\nyear, and an estimated 2,000 of those children die as a\\nresult of the abuse. Between 1994-1995, 1.1 million cases\\nof child abuse were recorded in the United States; of that\\nnumber, 55% of the victims were less than a year old.\\nCauses and symptoms\\nBattered child syndrome (BCS) is found at every\\nlevel of society, although the incidence may be higher\\nin low-income households where adult caregivers suf-\\nfer greaterstress and social difficulties, without having\\nhad the benefit of higher education. The child abuser\\nmost often injures a child in the heat of anger, and was\\noften abused as a child himself. The incessant crying of\\nan infant or child may trigger abuse. Symptoms may\\ninclude a delayed visit to the emergency room with an\\ninjured child; an implausible explanation of the cause\\nof a child’s injury; bruises that match the shape of a\\nhand, fist or belt; cigarette burns; scald marks; bite\\nmarks; black eyes; unconsciousness; bruises around\\nthe neck; and a bulging fontanel in infants.\\nDiagnosis\\nBattered child syndrome is most often diagnosed\\nby an emergency room physician or pediatrician, or by\\nteachers or social workers. Physical examination will\\ndetect bruises, burns, swelling, retinal hemorrhages.\\nX rays, and other imaging techniques, such as MRI\\nor scans may confirmfractures or other internal inju-\\nries. The presence of injuries at different stages of\\nhealing (i.e. having occurred at different times) is\\nnearly always indicative of BCS. Establishing the diag-\\nnosis is often hindered by the excessive cautiousness\\nof caregivers or by actual concealment of the true\\norigin of the childþs injuries, as a result of fear,\\nshame and avoidance or denial mechanisms.\\nTreatment\\nMedical treatment for battered child syndrome\\nwill vary according to the type of injury incurred.\\nCounseling and the implementation of an intervention\\nplan for the child’s parents or guardians is necessary.\\nThe child abuser may be incarcerated, and/or the\\nabused child removed from the home to prevent\\nfurther harm. Reporting child abuse to authorities is\\nmandatory for doctors, teachers, and childcare work-\\ners in most states as a way to prevent continued abuse.\\nBoth physical and psychological therapy are often\\nrecommended as treatment for the abused child.\\nPrognosis\\nThe prognosis for battered child syndrome will\\ndepend on the severity of injury, actions taken by the\\nauthorities to ensure the future safety of the injured\\nchild, and the willingness of parents or guardians to\\nseek counseling for themselves as well as for the child.\\nPrevention\\nRecognizing the potential for child abuse in a situa-\\ntion, and the seeking or offering of intervention and\\ncounseling before battered child syndrome occurs is the\\nbest way to prevent it. Signs that physical abuse may be\\nforthcoming include parental alcohol or substance\\nabuse; previous abuse of the child or the child’s siblings;\\nhistory of mental or emotional problems in parents;\\nparents abused as children; absence of visible parental\\nlove or concern for the child; child’s hygiene neglected.\\nResources\\nBOOKS\\nLukefahr, James L.Treatment of Child Abuse.Baltimore,\\nMD: Johns Hopkins University Press, 2000.\\nPERIODICALS\\nMulryan, Kathleen, ‘‘Protecting the Child.’’Nursing (July\\n2000).\\nKEY TERMS\\nFontanel— Soft spot on top of an infant’s skull.\\nSubdural hematoma— Bleeding over the brain.\\nMultiple retinal hemorrhages— Bleeding in the\\nback of the eye.\\nGALE ENCYCLOPEDIA OF MEDICINE 503\\nBattered child syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='ORGANIZATIONS\\nChildhelp National Abuse Hotline. (800)422-4453.\\nMary Jane Tenerelli, MS\\nBecker muscular dystrophy see Muscular\\ndystrophy\\nBeclomethasone see Corticosteroids\\nBed-wetting\\nDefinition\\nBed-wetting is the unintentional (involuntary) dis-\\ncharge of urine during the night. Although most chil-\\ndren between the ages of three and five begin to stay\\ndry at night, the age at which children are physically\\nand emotionally ready to maintain complete bladder\\ncontrol varies. Enuresis is a technical term that refers\\nto the continued, usually involuntary, passage of urine\\nduring the night or the day after the age at which\\ncontrol is expected.\\nDescription\\nMost children wet the bed occasionally, and defi-\\nnitions of the age and frequency at which bed-wetting\\nbecomes a medical problem vary somewhat. Many\\nresearchers consider bed-wetting normal until age 6.\\nAbout 10% of 6-year-old children wet the bed about\\nonce a month. More boys than girls have this problem.\\nThe American Psychiatric Association, however,\\ndefines enuresis as repeated voiding of urine into the\\nbed or clothes at age five or older. The wetting is usually\\ninvoluntary but in some cases it is intentional. For a\\ndiagnosis of enuresis, wetting must occur twice a week\\nfor at least three months with no underlying physio-\\nlogical cause. Enuresis, both nighttime (nocturnal) and\\ndaytime (diurnal), at age five affects 7% of boys and\\n3% of girls. By age 10, it affects 3% of boys and 2% of\\ngirls; only 1% of adolescents experience enuresis.\\nEnuresis is divided into two classes. A child with\\nprimary enuresis has never established bladder con-\\ntrol. A child with secondary enuresis begins to wet\\nafter a prolonged dry period. Some children have\\nboth nocturnal and diurnal enuresis.\\nCauses and symptoms\\nThe causes of bed-wetting are not entirely known.\\nIt tends to run in families. Most children with primary\\nenuresis have a close relative–a parent, aunt, or uncle–\\nwho also had the disorder. About 70% of children\\nwith two parents who wet the bed will also wet the\\nbed. Twin studies have shown that both of a pair of\\nidentical twins experience enuresis more often than\\nboth of a pair of fraternal twins.\\nSometimes bed-wetting can be caused by a serious\\nmedical problem like diabetes, sickle-cell anemia, or\\nepilepsy. Snoring and episodes of interrupted breath-\\ning during sleep (sleep apnea) occasionally contribute\\nto bed-wetting problems. Enlarged adenoids can cause\\nthese conditions. Other physiological problems, such\\nas urinary tract infection, severeconstipation,o rspinal\\ncord injury, can cause bed-wetting.\\nChildren who wet the bed frequently may have a\\nsmaller than normal functional bladder capacity.\\nFunctional bladder capacity is the amount of urine a\\nKEY TERMS\\nAcupressure— At e c h n i q u eu s i n gp r e s s u r et ov a r -\\nious points on the body to alleviate health problems.\\nADH— Antidiuretic hormone, or the hormone that\\nhelps to concentrate urine during the night.\\nBehavior modification— Techniques used to\\nchange harmful behavior patterns.\\nBladder— The muscular sac or container that stores\\nurine until it is released from the body through the\\ntube that carries urine from the bladder to the out-\\nside of the body (urethra).\\nDDAVP— Desmopressin acetate, a drug used to\\nregulate urine production.\\nHypnosis— The technique by which a trained pro-\\nfessional relaxes the subject and then asks ques-\\ntions or gives suggestions.\\nImipramine hydrochloride— A drug used to\\nincrease bladder capacity.\\nKidneys— A pair of organs located on each side of\\nthe spine in the lower back area. They excrete, or\\nget rid of, urine.\\nNocturnal enuresis— Involuntary discharge of\\nurine during the night.\\nUrinalysis— A urine test.\\nUrine— The fluid excreted by the kidneys, stored in\\nthe bladder, then discharged from the body through\\nthe tube that carries urine from the bladder to the\\noutside of the body (urethra).\\nVoid— To empty the bladder.\\n504 GALE ENCYCLOPEDIA OF MEDICINE\\nBed-wetting'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='person can hold in the bladder before feeling a strong\\nurge to urinate. When functional capacity is small, the\\nbladder will not hold all the urine produced during the\\nnight. Tests have shown that bladder size in these\\nchildren is normal. Nevertheless, they experience fre-\\nquent strong urges to urinate. Such children urinate\\noften during the daytime and may wet several times at\\nnight. Although a small functional bladder capacity\\nmay be caused by a developmental delay, it may also\\nbe that the child’s habit of voiding frequently slows\\nbladder development.\\nParents often report that their bed-wetting child is\\nan extremely sound sleeper and difficult to wake.\\nHowever, several research studies found that bed-\\nwetting children have normal sleep patterns and that\\nbed-wetting can occur in any stage of sleep.\\nRecent medical research has found that many\\nchildren who wet the bed may have a deficiency of\\nan important hormone known as antidiuretic hor-\\nmone (ADH). ADH helps to concentrate urine during\\nsleep hours, meaning that the urine contains less\\nwater and therefore takes up less space. This decreased\\nvolume of water usually prevents the child’s bladder\\nfrom overfilling during the night, unless the child\\ndrank a lot just before going to bed. Testing of\\nmany bed-wetting children has shown that these\\nchildren do not have the usual increase in ADH dur-\\ning sleep. Children who wet the bed, therefore, often\\nproduce more urine during the hours of sleep than\\ntheir bladders can hold. If they do not wake up, the\\nbladder releases the excess urine and the child wets\\nthe bed.\\nResearch demonstrates that in most cases bed-\\nwetting does not indicate that the child has a physical\\nor psychological problem. Children who wet the bed\\nusually have normal-sized bladders and have sleep\\npatterns that are no different from those of non-bed-\\nwetting children. Sometimes emotionalstress,s u c ha s\\nthe birth of a sibling, adeath in the family, or separa-\\ntion from the family, may be associated with the onset\\nof bed-wetting in a previously toilet-trained child.\\nDaytime wetting, however, may indicate that the pro-\\nblem has a physical cause.\\nWhile most children have no long-term problems\\nas a result of bed-wetting, some children may develop\\npsychological problems. Low self-esteem may occur\\nwhen these children, who already feel embarrassed,\\nare further humiliated by angry or frustrated parents\\nwho punish them or who are overly aggressive about\\ntoilet training. The problem can by aggravated when\\nplaymates tease or when social activities such as sleep-\\naway camp are avoided for fear of teasing.\\nDiagnosis\\nIf a child continues to wet the bed after the age of\\nsix, parents may feel the need to seek evaluation and\\ndiagnosis by the family doctor or a children’s specia-\\nlist (pediatrician). Typically, before the doctor can\\nmake a diagnosis, a thorough medical history is\\nobtained. Then the child receives aphysical examina-\\ntion, appropriate laboratory tests, including a urine\\ntest (urinalysis), and, if necessary, radiologic studies\\n(such as x rays).\\nIf the child is healthy and no physical problem is\\nfound, which is the case 90% of the time, the doctor\\nmay not recommend treatment but rather may pro-\\nvide the parents and the child with reassurance, infor-\\nmation, and advice.\\nTreatment\\nOccasionally a doctor will determine that the pro-\\nblem is serious enough to require treatment. Standard\\ntreatments for bed-wetting include bladder training\\nexercises, motivational therapy, drug therapy, psy-\\nchotherapy, and diet therapy.\\nBladder training exercises are based on the theory\\nthat those who wet the bed have small functional\\nbladder capacity. Children are told to drink a large\\nquantity of water and to try to prolong the periods\\nbetween urinations. These exercises are designed to\\nincrease bladder capacity but are only successful in\\nresolving bed-wetting in a small number of patients.\\nIn motivational therapy, parents attempt to\\nencourage the child to combat bed-wetting, but the\\nchild must want to achieve success. Positive reinforce-\\nment, such as praise or rewards for staying dry, can\\nhelp improve self-image and resolve the condition.\\nPunishment for ‘‘wet’’ nights will hamper the child’s\\nself-esteem and compound the problem.\\nThe following motivational techniques are com-\\nmonly used:\\n/C15Behavior modification. This method of therapy is\\naimed at helping children take responsibility for their\\nnighttime bladder control by teaching new behaviors.\\nFor example, children are taught to use the bathroom\\nbefore bedtime and to avoid drinking fluids after\\ndinner. While behavior modification generally pro-\\nduces good results, it is long-term treatment.\\n/C15Alarms. This form of therapy uses a sensor placed\\nin the child’s pajamas or in a bed pad. This sensor\\ntriggers an alarm that wakes the child at the first sign\\nof wetness. If the child is awakened, he or she can then\\ngo to the bathroom and finish urinating. The intention\\nGALE ENCYCLOPEDIA OF MEDICINE 505\\nBed-wetting'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='is to condition a response to awaken when the bladder\\nis full. Bed-wetting alarms require the motivation\\nof both parents and children. They are considered\\nthe most effective form of treatment now available.\\nA number of drugs are also used to treat bed-\\nwetting. These medications are usually fast acting;\\nchildren often respond to them within the first week\\nof treatment. Among the drugs commonly used are a\\nnasal spray of desmopressin acetate (DDAVP), a sub-\\nstance similar to the hormone that helps regulate urine\\nproduction; and imipramine hydrochloride, a drug\\nthat helps to increase bladder capacity. Studies show\\nthat imipramine is effective for as many as 50% of\\npatients. However, children often wet the bed again\\nafter the drug is discontinued, and it has some side\\neffects. Some bed-wetting with an underlying physical\\ncause can be treated by surgical procedures. These\\ncauses include enlarged adenoids that cause sleep\\napnea, physical defects in the urinary system, or a\\nspinal tumor.\\nPsychotherapy is indicated when the child exhibits\\nsigns of severe emotional distress in response to events\\nsuch as a death in the family, the birth of a new child, a\\nchange in schools, or divorce. Psychotherapy is also\\nindicated if a child shows signs of persistently low self-\\nesteem or depression.\\nIn rare cases,allergies or intolerances to certain\\nfoods–such as dairy products, citrus products, or cho-\\ncolate–can cause bed-wetting. When children have food\\nsensitivities, bed-wetting may be helped by discovering\\nthe substances that trigger the allergic response and\\neliminating these substances from the child’s diet.\\nAlternative treatment\\nA number of alternative treatments are available\\nfor bed-wetting.\\nMassage\\nAccording to practitioners of this technique, pres-\\nsure applied to various points on the body may help\\nalleviate the condition.Acupressure or massage, when\\ndone by a trained therapist, may also be helpful in bed-\\nwetting caused by a neurologic problem.\\nHerbal and homeopathic remedies\\nSome herbal remedies, such as horsetail (Equisetum\\narvense) have also been used to treat bed-wetting. A\\ntrained homeopathic practitioner, working at the consti-\\ntutional level, will seek to rebalance the child’s vital force,\\neliminating the imbalanced behavior of bed-wetting.\\nCommon homeopathic remedies used in this treatment\\nincludeCausticum, Lycopodium,and Pulsatilla.\\nHypnosis\\nHypnosis is another approach that is being used\\nsuccessfully by practitioners trained in this therapy. It\\ntrains the child to awaken and go to the bathroom\\nwhen his or her bladder feels full. Hypnosis is less\\nexpensive, less time-consuming, and less dangerous\\nthan most approaches; it has virtually no side effects.\\nRecent medical studies show thathypnotherapy can\\nwork quickly–within four to six sessions.\\nPrognosis\\nOccasional bed-wetting is not a disease and it does\\nnot have a ‘‘cure.’’ If the child has no underlying\\nphysical or psychological problem that is causing the\\nbed-wetting, in most cases he or she will outgrow the\\ncondition without treatment. About 15% of bedwetters\\nbecome dry each year after age 6. If bed-wetting is\\nfrequent, accompanied by daytime wetting, or falls\\ninto the American Psychiatric Association’s diagnostic\\ndefinition of enuresis, a doctor should be consulted. If\\ntreatment is indicated, it usually successfully resolves\\nthe problem. Marked improvement is seen in about\\n75% of cases treated with wetness alarms.\\nPrevention\\nAlthough preventing a child from wetting the bed\\nis not always possible, parents can take steps to help\\nthe child keep the bed dry at night. These steps include:\\n/C15Encouraging and praising the child for staying dry\\ninstead of punishing when the child wets.\\n/C15Reminding the child to urinate before going to bed, if\\nhe or she feels the need.\\n/C15Limiting liquid intake at least two hours before\\nbedtime.\\nResources\\nORGANIZATIONS\\nAssociation for the Care of Children’s Health (ACCH). 7910\\nWoodmont Ave., Suite 300, Bethesda, MD 20814. (800)\\n808-2224.\\nNational Association for Continence. P.O. Box 8310,\\nSpartenburg, SC 29305. (800) 252-3337. .\\nNational Enuresis Society. 7777 Forest Lane, Suite C-737,\\nDallas, TX 75230-2518. (800) 697-8080. .\\nGenevieve Slomski, Ph.D.\\n506 GALE ENCYCLOPEDIA OF MEDICINE\\nBed-wetting'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Bedsores\\nDefinition\\nBedsores are also called decubitus ulcers, pressure\\nulcers, or pressure sores. These tender or inflamed\\npatches develop when skin covering a weight-bearing\\npart of the body is squeezed between bone and another\\nbody part, or a bed, chair, splint, or other hard object.\\nDescription\\nEach year, about one million people in the\\nUnited States develop bedsores ranging from mild\\ninflammation to deep wounds that involve muscle\\nand bone. This often painful condition usually starts\\nwith shiny red skin that quickly blisters and deterio-\\nrates into open sores that can harbor life-threatening\\ninfection.\\nBedsores are not cancerous or contagious. They\\nare most likely to occur in people who must use wheel-\\nchairs or who are confined to bed. In 1992, the federal\\nAgency for Health Care Policy and Research reported\\nthat bedsores afflict:\\n/C1510% of hospital patients\\n/C1525% of nursing home residents\\n/C1560% of quadriplegics\\nThe Agency also noted that 65% of elderly people\\nhospitalized with broken hips develop bedsores and\\nthat doctors fees for treatment of bedsores amounted\\nto $2,900 per person.\\nBedsores are most apt to develop on the:\\n/C15ankles\\n/C15back of the head\\n/C15heels\\n/C15hips\\n/C15knees\\n/C15lower back\\n/C15shoulder blades\\n/C15spine\\nPeople over the age of 60 are more likely than\\nyounger people to develop bedsores. Risk is also\\nincreased by:\\n/C15atherosclerosis (hardening of arteries)\\n/C15diabetes or other conditions that make skin more\\nsusceptible to infection\\n/C15diminished sensation or lack of feeling\\n/C15heart problems\\n/C15incontinence (inability to control bladder or bowel\\nmovements)\\n/C15malnutrition\\n/C15obesity\\n/C15paralysis or immobility\\n/C15poor circulation\\n/C15prolonged bed rest, especially in unsanitary condi-\\ntions or with wet or wrinkled sheets\\n/C15spinal cord injury\\nCauses and symptoms\\nBedsores most often develop when constant pres-\\nsure pinches tiny blood vessels that deliver oxygen and\\nnutrients to the skin. When skin is deprived of oxygen\\nand nutrients for as little as an hour, areas of tissue can\\ndie and bedsores can form.\\nSlight rubbing or friction against the skin can\\ncause minor pressure ulcers. They can also develop\\nwhen a patient stretches or bends blood vessels by\\nslipping into a different position in a bed or chair.\\nUrine, feces, or other moisture increases the risk\\nof skin infection, and people who are unable to move\\nor recognize internal cues to shift position have a\\ngreater than average risk of developing bedsores.\\nOther risk factors include:\\n/C15malnutrition\\n/C15anemia (lack of red blood cells)\\n/C15diuse atrophy (muscle loss or weakness from lack of\\nuse)\\n/C15infection\\nBedsore. (Photograph by Michael English, M.D., Custom Medical\\nStock Photo. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 507\\nBedsores'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Diagnosis\\nBedsores usually follow six stages:\\n/C15redness of skin\\n/C15redness, swelling, and possible peeling of outer layer\\nof skin\\n/C15dead skin, draining wound, and exposed layer of fat\\n/C15tissue death through skin and fat, to muscle\\n/C15inner fat and muscle death\\n/C15destruction of bone, bone, infection, fracture, and\\nblood infection\\nTreatment\\nPrompt medical attention can prevent surface\\npressure sores from deepening into more serious infec-\\ntions. For mild bedsores, treatment involves relieving\\npressure, keeping the wound clean and moist, and\\nkeeping the area around the ulcer clean and dry.\\nAntiseptics, harsh soaps, and other skin cleansers can\\ndamage new tissue, so a saline solution should be used\\nto cleanse the wound whenever a fresh non-stick dres-\\nsing is applied.\\nThe patient’s doctor may prescribe infection-\\nfighting antibiotics, special dressings or drying agents,\\nor lotions or ointments to be applied to the wound in a\\nthin film three or four times a day. Warm whirlpool\\ntreatments are sometimes recommended for sores on\\nthe arm, hand, foot, or leg.\\nIn a procedure called debriding, a scalpel may be\\nused to remove dead tissue or other debris from the\\nwound. Deep, ulcerated sores that don’t respond to\\nother therapy may require skin grafts orplastic surgery.\\nA doctor should be notified whenever a person:\\n/C15will be bedridden or immobilized for an extended time\\n/C15is very weak or unable to move\\n/C15develops bedsores\\nImmediate medical attention is required whenever:\\n/C15skin turns black or becomes inflamed, tender, swol-\\nlen, or warm to the touch.\\n/C15the patient develops afever during treatment.\\n/C15the sore contains pus or has a foul-smelling discharge.\\nWith proper treatment, bedsores should begin to\\nheal two to four weeks after treatment begins.\\nAlternative treatment\\nZinc and vitamins A, C, E, and B complex help\\nskin repair injuries and stay healthy, but large doses of\\nvitamins or minerals should never be used without a\\ndoctor’s approval.\\nA poultice made of equal parts of powdered slip-\\npery elm (Ulmus fulva), marsh mallow (Althaea officina-\\nlis), and echinacea (Echinaceaspp.) blended with a small\\namount of hot water can relieve minor inflammation.\\nAn infection-fighting rinse can be made by diluting two\\ndrops of essential tea tree oil (Melaleuca spp.) in eight\\nounces of water. An herbal tea made from the calendula\\n(Calendula officinalis) can act as an antiseptic and\\nwound healing agent. Calendula cream can also be used.\\nContrasting hot and cold local applications can\\nincrease circulation to the area and help flush out\\nwaste products, speeding the healing process. The tem-\\nperatures should be extreme (hot hot and ice cold), yet\\ntolerable to the skin. Hot compresses should be applied\\nfor three minutes, followed by 30 seconds of cold com-\\npress application, repeating the cycle three times. The\\ncycle should always end with the cold compress.\\nPrevention\\nIt is usually possible to prevent bedsores from\\ndeveloping or worsening. The patient should be\\ninspected regularly; should bathe or shower every\\nday, using warm water and mild soap; and should\\navoid cold or dry air. A bedridden patient should be\\nrepositioned at least once every two hours while\\nawake. A person who uses a wheelchair should shift\\nhis weight every 10 or 15 minutes, or be helped to\\nreposition himself at least once an hour. It is impor-\\ntant to lift, rather than drag, a person being reposi-\\ntioned. Bony parts of the body should not be\\nmassaged. Even slight friction can remove the top\\nlayer of skin and damage blood vessels beneath it.\\nIf the patient is bedridden, sensitive body parts\\ncan be protected by:\\n/C15sheepskin pads\\n/C15special cushions placed on top of a mattress\\n/C15a water-filled mattress\\n/C15a variable-pressure mattress whose sections can be\\nindividually inflated or deflated to redistribute\\npressure.\\nPillows or foam wedges can prevent a bedridden\\npatient’s ankles from irritating each other, and pillows\\nplaced under the legs from mid-calf to ankle can raise\\nthe heels off the bed. Raising the head of the bed\\nslightly and briefly can provide relief, but raising the\\nhead of the bed more than 30 degrees can cause the\\npatient to slide, thereby causing damage to skin and\\ntiny blood vessels.\\n508 GALE ENCYCLOPEDIA OF MEDICINE\\nBedsores'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='A person who uses a wheelchair should be encour-\\naged to sit up as straight as possible. Pillows behind\\nthe head and between the legs can help prevent bed-\\nsores, as can a special cushion placed on the chair seat.\\nDonut-shaped cushions should not be used because\\nthey restrict blood flow and cause tissues to swell.\\nPrognosis\\nBedsores can usually be cured, but about 60,000\\ndeaths a year are attributed to complications caused\\nby bedsores. Bedsores can be slow to heal. Without\\nproper treatment, they can lead to:\\n/C15gangrene (tissue death)\\n/C15osteomyelitis (infection of the bone beneath the\\nbedsore)\\n/C15sepsis (tissue-destroying bacterial infection)\\n/C15other localized or systemic infections that slow the\\nhealing process, increase the cost of treatment,\\nlengthen hospital or nursing home stays, or cause\\ndeath\\nResources\\nORGANIZATIONS\\nInternational Association of Enterstomal Therapy. 27241\\nLa Paz Road, Suite 121, Laguna Niguel, CA 92656.\\n(714) 476-0268.\\nNational Pressure Ulcer Advisory Panel. SUNY at Buffalo,\\nBeck Hall, 3435 Main St., Buffalo, NY 14214. (716)\\n881-3558. .\\nMaureen Haggerty\\nBeef tapeworm infection see Tapeworm\\ndiseases\\nBehavior therapy see Cognitive-behavioral\\ntherapy\\nBehcet’s syndrome\\nDefinition\\nA group of symptoms that affect a variety of body\\nsystems, including musculoskeletal, gastrointestinal,\\nand the central nervous system. These symptoms\\ninclude ulceration of the mouth or the genital area,\\nskin lesions, and inflammation of the uvea (an area\\naround the pupil of the eye).\\nDescription\\nBehcet’s syndrome is a chronic disease that\\ninvolves multiple body systems. The disease is named\\nfor a Turkish dermatologist, Hulusi Behcet, who first\\nreported a patient with recurrent mouth and genital\\nulcers along withuveitis in 1937. The disease occurs\\nworldwide, but is most prevalent in Japan, the Middle\\nEast, and in the Mediterranean region. There is a\\nwider prevalence among males than females in a\\nratio of two to one.\\nCauses and symptoms\\nThe cause of Behcet’s syndrome is unknown.\\nSymptoms include recurring ulcers in the mouth or\\nthe genital area, skin lesions, arthritis that affects\\nmainly the knees and ankles,pain and irritation in\\nthe eyes, andfever. The mouth and genital ulcers tend\\nto occur in multiples and can be quite painful. In the\\nmouth, these ulcers are generally found on the ton-\\ngue, gums, and the inside of the lips or jaws. In the\\ngenital area, the ulcers usually occur on the penis and\\nscrotum in males and on the vulva of women. The eye\\ninflammation can lead to blindness.\\nDiagnosis\\nBecause Behcet’s syndrome is a multisystem dis-\\nease, it is difficult to diagnose. International criteria\\nhave been proposed to assist in classifying this disease.\\nThere is no one diagnostic feature of this disease, so\\ndiagnosis depends on grouping together enough\\nsymptoms in order to identify the disease. Symptoms\\nof Behcet’s syndrome also occur in other diseases, so it\\nis often necessary to rule out the other diseases before\\na definitive diagnosis can be reached.\\nTreatment\\nSome of the current drugs used to treat Behcet’s\\nsyndrome include corticosteroids, cyclosporine,\\nazathioprine, chlorambucil, interferon alpha, thali-\\ndomide, levamisole and pulse cyclophosphamide.\\nPrognosis\\nThe prognosis for Behcet’s syndrome is generally\\npoor. There has been a documented case of Behcet’s\\nlasting for 17 years. Although the disease is considered\\npainful but not fatal, when the central nervous system is\\ninvolved there is usually severe disability anddeath\\noften occurs. The condition is usually chronic, although\\nthere can be remissions during the course of the disease.\\nThere is no predictable method to determine which\\nGALE ENCYCLOPEDIA OF MEDICINE 509\\nBehcet’s syndrome'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='patients will progress into the more serious symptoms,\\nand which might move into remission.\\nPrevention\\nThere is no known prevention for Behcet’s\\nsyndrome.\\nResources\\nBOOKS\\nRuddy, Shaun.Kelley’s Textbook of Rheumatology.\\nPhiladelphia: W.B. Saunders Company, 2001.\\nTierney, Lawrence, et al.Current Medical Diagnosis and\\nTreatment.Los Altos: Lange Medical Publications, 2001.\\nPERIODICALS\\nOkada, A. A. ‘‘Drug Therapy in Behcet’s Disease.’’\\nOcularImmunology and InflammationJune 2000: 85-91.\\nShed, L. P. ‘‘Thalomide Responsiveness in an Infant with\\nBehcet’s Syndrome.’’Pediatrics June 1999: 1295-1297.\\nORGANIZATIONS\\nAmerican Behcet’s Disease Association. P.O. Box 280240,\\nMemphis, TN 38168-0240. .\\nBehcet’s Organization Worldwide, Head Office. P.O. Box\\n27, Watchet, Somerset TA23 OYJ, United Kingdom.\\n.\\nNational Eye Institute. National Institute of Health. Bldg. 31,\\nRm. 6A32, Bethesda, MD 30892-2510. (800) 869-2020.\\n2020@nei.nih.gov. .\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nKim A. Sharp, M.Ln.\\nBejel\\nDefinition\\nBejel, also known as endemic syphilis,i sa\\nchronic but curable disease,s e e nm o s t l yi nc h i l d r e n\\nin arid regions. Unlike the better-known venereal\\nsyphilis, endemic syphilis is not a sexually trans-\\nmitted disease.\\nDescription\\nBejel has many other names depending on the\\nlocality: siti, dichuchwa, njovera, belesh, and skerljevo\\nare some of the names. It is most commonly found in\\nthe Middle East (Syria, Saudi Arabia, Iraq), Africa,\\ncentral Asia, and Australia. Bejel is related toyaws\\nand pinta, but has different symptoms.\\nCauses and symptoms\\nTreponema pallidum, the bacteria that causes\\nbejel, is very closely related to the one that causes the\\nsexually transmitted form of syphilis, but transmission\\nis very different. In bejel, transmission is by direct\\ncontact, with broken skin or contaminated hands, or\\nindirectly by sharing drinking vessels and eating uten-\\nsils. T. pallidumis passed on mostly between children\\nliving in poverty in very unsanitary environments and\\nwith poor hygiene.\\nThe skin, bones, and mucous membranes are\\naffected by bejel. Patches and ulcerated sores are com-\\nmon in the mouth, throat, and nasal passages.\\nGummy lesions may form, even breaking through\\nthe palate. Other findings may include a region of\\nswollen lymph nodes and deep bonepain in the legs.\\nEventually, bones may become deformed.\\nDiagnosis\\nT. pallidumcan be detected by microscopic study\\nof samples taken from the sores or lymph fluid.\\nHowever, since antibody tests don’t distinguish\\nbetween the types of syphilis, specific diagnosis of the\\ntype of syphilis depends on the patient’s history, symp-\\ntoms, and environment.\\nTreatment\\nLarge doses of benzathine penicillin G given by\\ninjection into the muscle can cure this disease in any\\nstage, although it may take longer and require\\nadditional doses in later stages. If penicillin cannot\\nbe given, the alternative is tetracycline. Since tetracy-\\ncline can permanently discolor new teeth still forming,\\nit is usually not prescribed for children unless no viable\\nalternative is available.\\nPrognosis\\nBejel is completely curable with antibiotic\\ntreatment.\\nKEY TERMS\\nRemission— When active symptoms of a chronic\\ndisease are absent.\\nUveitis— Inflammation of the area of the eye\\naround the pupil.\\n510 GALE ENCYCLOPEDIA OF MEDICINE\\nBejel'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Prevention\\nThe World Health Organization (WHO) has\\nworked with many countries to prevent this and\\nother diseases, and the number of cases has been\\nreduced somewhat. Widespread use of penicillin has\\nbeen responsible for reducing the number of existing\\ncases, but the only way to eliminate bejel is by improv-\\ning living and sanitation conditions.\\nResources\\nBOOKS\\nFauci, Anthony S., et al., editors.Harrison’s Principles of\\nInternal Medicine.New York: McGraw-Hill, 1997.\\nJill S. Lasker\\nBenazepril see Angiotensin-converting\\nenzyme inhibitors\\nBence Jones protein test\\nDefinition\\nBence Jones proteins are small proteins (light\\nchains of immunoblobulin) found in the urine.\\nTesting for these proteins is done to diagnose and\\nmonitor multiple myelomaand other similar diseases.\\nPurpose\\nBence Jones proteins are considered the first\\ntumor marker. A tumor marker is a substance, made\\nby the body, that is linked to a certaincancer,o r\\nmalignancy. Bence Jones proteins are made by plasma\\ncells, a type of white blood cell. The presence of these\\nproteins in a person’s urine is associated with a malig-\\nnancy of plasma cells.\\nMultiple myeloma, a tumor of plasma cells, is the\\ndisease most often linked with Bence Jones proteins.\\nThe amount of Bence Jones proteins in the urine indi-\\ncates how much tumor is present. Physicians use Bence\\nJones proteins testing to diagnose the disease as well as\\nto check how well the disease is responding to\\ntreatment.\\nOther diseases involving cancerous or excessive\\ngrowth of plasma cells or cells similar to plasma cells\\ncan cause Bence Jones proteins in the urine. These\\ndiseases include: Waldenstro¨m’s macroglobulinemia,\\nsome lymphomas and leukemias, osteogenic sarcoma,\\ncryoglobulinemia, malignant B-cell disease,amyloidosis,\\nlight chain disease, and cancer that has spread to bone.\\nDescription\\nUrine is the best specimen in which to look for\\nBence Jones proteins. Proteins are usually too large to\\nmove through a healthy kidney, from the blood into\\nthe urine. Bence Jones proteins are an exception. They\\nare small enough to move quickly and easily through\\nthe kidney into the urine.\\nA routine urinalysis will not detect Bence Jones\\nproteins. There are several methods used by labora-\\ntories to detect and measure these proteins. The classic\\nBence Jones reaction involves heating urine to 1408F\\n(608C). At this temperature, the Bence Jones proteins\\nwill clump. The clumping disappears if the urine is\\nfurther heated to boiling and reappears when the\\nurine is cooled. Other clumping procedures using\\nsalts, acids, and other chemicals are also used to detect\\nthese proteins. These types of test will reveal whether\\nor not Bence Jones proteins are present, but not how\\nmuch is present.\\nA more complex procedure is done to measure the\\nexact amount of Bence Jones proteins. This proce-\\ndure–immunoelectrophoresis–is usually done on\\nurine that has been collected for 24-hours.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available within several\\ndays.\\nPreparation\\nUrine is usually collected throughout a 24-hour\\ntime period. A person is given a large container in\\nKEY TERMS\\nEndemic disease— An infectious disease that\\noccurs frequently in a specific geographical locale.\\nThe disease often occurs in cycles. Influenza is an\\nexample of an endemic disease.\\nLymph— This is a clear, colorless fluid found in\\nlymph vessels and nodes. The lymph nodes contain\\norganisms that destroy bacteria and other disease\\ncausing organisms (also called pathogens).\\nSyphilis— This disease occurs in two forms. One is\\na sexually transmitted disease caused by a bacteria.\\nThe second form is not sexually transmitted, but\\npassed on by direct contact with the patient or\\nthrough use of shared food dishes and utensils.\\nGALE ENCYCLOPEDIA OF MEDICINE 511\\nBence Jones protein test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='which to collect the urine. The urine should be refri-\\ngerated until it is brought to the laboratory or physi-\\ncian’s office.\\nNormal results\\nBence Jones proteins normally are not present in\\nthe urine.\\nAbnormal results\\nBence Jones proteins are present in 50–80% of\\npeople with multiple myeloma. People with other\\nmalignancies also can have a positive Bence Jones\\nproteins test, but less frequently.\\nCertain nonmalignant diseases, such asrheuma-\\ntoid arthritis , systemic lupus erythematosus , and\\nchronic renal insufficiency, can have Bence Jones pro-\\nteins in the urine. High doses of penicillin oraspirin\\nbefore collecting the urine can give a false positive\\nresult.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nNancy J. Nordenson\\nBender-Gestalt test\\nDefinition\\nThe Bender Visual Motor Gestalt test (or Bender-\\nGestalt test) is a psychological assessment used to\\nevaluate visual-motor functioning, visual-perceptual\\nskills, neurological impairment, and emotional distur-\\nbances in children and adults ages three and older.\\nPurpose\\nThe Bender-Gestalt is used to evaluate visual-\\nmotor maturity and to screen children for develop-\\nmental delays. The test is also used to assess brain\\ndamage and neurological deficits. Individuals who\\nhave suffered a traumatic brain injury may be given\\nthe Bender-Gestalt as part of a battery of neuropsy-\\nchological measures, or tests.\\nThe Bender-Gestalt is sometimes used in conjunc-\\ntion with other personality tests to determine the pre-\\nsence of emotional and psychiatric disturbances such\\nas schizophrenia.\\nPrecautions\\nPsychometric testing requires a clinically trained\\nexaminer. The Bender Visual Motor Gestalt Test\\nshould be administered and interpreted by a trained\\npsychologist or psychiatrist. The Bender-Gestalt should\\nalways be employed as only one element of a complete\\nbattery of psychological or developmental tests, and\\nshould never be used alone as the sole basis for a\\ndiagnosis.\\nDescription\\nThe original Bender Visual Motor Gestalt test was\\ndeveloped in 1938 by psychiatrist Lauretta Bender.\\nThere are several different versions of the Bender-\\nGestalt available today (i.e., the Bender-Gestalt test;\\nModified Version of the Bender-Gestalt test for\\nPreschool and Primary School Children; the Hutt\\nAdaptation of the Bender-Gestalt test; the Bender\\nVisual Motor Gestalt test for Children; the Bender-\\nGestalt test for Young Children; the Watkins Bender-\\nGestalt Scoring System; the Canter Background\\nInterference Procedure for the Bender-Gestalt test).\\nAll use the same basic test materials, but vary in their\\nscoring and interpretation methods.\\nThe standard Bender Visual Motor Gestalt test\\nconsists of nine figures, each on its own3 x 5 card. An\\nexaminer presents each figure to the test subject one at\\na time and asks the subject to copy it onto a single\\npiece of blank paper. The only instruction given to the\\nsubject is that he or she should make the best repro-\\nduction of the figure possible. The test is not timed,\\nalthough standard administration time is typically\\n10-20 minutes. After testing is complete, the results\\nare scored based on accuracy and organization.\\nInterpretation depends on the form of the test in use.\\nCommon features considered in evaluating the draw-\\nings are rotation, distortion, symmetry, and persevera-\\ntion. As an example, a patient with frontal lobe injury\\nKEY TERMS\\nBence Jones protein— Small protein, composed of\\na light chain of immunoglobulin, made by plasma\\ncells.\\nMultiple myeloma— A tumor of the plasma cells.\\nPlasma cells— A type of white blood cell.\\n512 GALE ENCYCLOPEDIA OF MEDICINE\\nBender-Gestalt test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='may reproduce the same pattern over and over\\n(perserveration).\\nThe Bender-Gestalt can also be administered in a\\ngroup setting. In group testing, the figures are shown\\nto test subjects with a slide projector, in a test booklet,\\nor on larger versions of the individual test cards. Both\\nthe individual and group- administered Bender-\\nGestalt evaluation may take place in either an out-\\npatient or hospital setting. Patients should check\\nwith their insurance plans to determine if these or\\nother mental health services are covered.\\nNormal results\\nChildren normally improve in this test as they age,\\nbut, because of the complexity of the scoring process,\\nresults for the Bender-Gestalt should only be inter-\\npreted by a clinically trained psychologist or\\npsychiatrist.\\nResources\\nORGANIZATIONS\\nAmerican Psychological Association (APA). 750 First St.\\nNE, Washington, DC 20002-4242. (202) 336-5700.\\n.\\nERIC Clearinghouse on Assessment and Evaluation. 1131\\nShriver Laboratory (Bldg 075).\\nPaula Anne Ford-Martin\\nBends see Decompression sickness\\nBenign see Uterine fibroids\\nBenign prostatic hyperplasia see Enlarged\\nprostate\\nBenign prostatic hypertrophy see Enlarged\\nprostate\\nBenzocaine see Antiseptics\\nBenzodiazepines\\nDefinition\\nBenzodiazepines are medicines that help relieve\\nnervousness, tension, and other symptoms by slowing\\nthe central nervous system.\\nPurpose\\nBenzodiazepines are a type ofantianxiety drugs.\\nWhile anxiety is a normal response to stressful situa-\\ntions, some people have unusually high levels of anxi-\\nety that can interfere with everyday life. For these\\npeople, benzodiazepines can help bring their feelings\\nunder control. The medicine can also relieve troubling\\nsymptoms of anxiety, such as pounding heartbeat,\\nbreathing problems, irritability,nausea, and faintness.\\nPhysicians may sometimes prescribe these drugs for\\nother conditions, such asmuscle spasms, epilepsy and\\nother seizure disorders,phobias, panic disorder,w i t h d r a -\\nwal from alcohol, and sleeping problems. However,\\nthis medicine should not be used every day for sleep\\nproblems that last more than a few days. If used this\\nway, the drug loses its effectiveness within a few weeks.\\nDescription\\nThe family of antianxiety drugs known as benzo-\\ndiazepines includes alprazolam (Xanax), chlordiazep-\\noxide (Librium), diazepam (Valium), and lorazepam\\n(Ativan). These medicines take effect fairly quickly,\\nstarting to work within an hour after they are taken.\\nBenzodiazepines are available only with a physician’s\\nprescription and are available in tablet, capsule,\\nliquid, or injectable forms.\\nRecommended dosage\\nThe recommended dosage depends on the type of\\nbenzodiazepine, its strength, and the condition for\\nwhich it is being taken. Doses may be different for\\ndifferent people. Check with the physician who pre-\\nscribed the drug or the pharmacist who filled the pre-\\nscription for the correct dosage.\\nKEY TERMS\\nNeuropsychological test— A test or assessment\\ngiven to diagnose a brain disorder or disease.\\nPerserveration— The persistence of a repetitive\\nresponse after the cause of the response has been\\nremoved, or the response continues to different\\nstimuli.\\nVisual-motor skills— Hand-eye coordination; in\\nthe Bender-Gestalt test, visual-motor skills are mea-\\nsured by the subject’s ability to accurately perceive\\nand then reproduce figures.\\nVisual-perceptual skills— The capacity of the mind\\nand the eye to ‘‘see’’ something as it objectively\\nexists.\\nGALE ENCYCLOPEDIA OF MEDICINE 513\\nBenzodiazepines'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Always take benzodiazepines exactly as directed.\\nNever take larger or more frequent doses, and do not\\ntake the drug for longer than directed. If the medicine\\ndoes not seem to be working, check with the physician\\nwho prescribed it. Do not increase the dose or stop\\ntaking the medicine unless the physician says to do so.\\nStopping the drug suddenly may cause withdrawal\\nsymptoms, especially if it has been taken in large\\ndoses or over a long period. People who are taking\\nthe medicine for seizure disorders may have seizures\\nif they stop taking it suddenly. If it is necessary to stop\\ntaking the medicine, check with a physician for direc-\\ntions on how to stop. The physician may recommend\\ntapering down gradually to reduce the chance of with-\\ndrawal symptoms or other problems.\\nPrecautions\\nSeeing a physician regularly while taking benzo-\\ndiazepines is important, especially during the first few\\nmonths of treatment. The physician will check to make\\nsure the medicine is working as it should and will note\\nunwanted side effects.\\nPeople who take benzodiazepines to relieve ner-\\nvousness, tension, or symptoms of panic disorder\\nshould check with their physicians every two to three\\nmonths to make sure they still need to keep taking the\\nmedicine.\\nPatients who are taking benzodiazepines for sleep\\nproblems should check with their physicians if they are\\nnot sleeping better within 7-10 days. Sleep problems\\nthat last longer than this may be a sign of another\\nmedical problem.\\nPeople who take this medicine to help them sleep\\nmay have trouble sleeping when they stop taking the\\nmedicine. This effect should last only a few nights.\\nSome people, especially older people, feel\\ndrowsy, dizzy, lightheaded, or less alert when using\\nbenzodiazepines. The drugs may also cause clumsi-\\nness or unsteadiness. When the medicine is taken at\\nbedtime, these effects may even occur the next morn-\\ning. Anyone who takes these drugs should not drive,\\nuse machines or do anything else that might be\\ndangerous until they have found out how the drugs\\naffect them.\\nBenzodiazepines may also cause behavior changes\\nin some people, similar to those seen in people who act\\ndifferently when they drink alcohol. More extreme\\nchanges, such as confusion, agitation, andhallucina-\\ntions, also are possible. Anyone who starts having\\nstrange or unusual thoughts or behavior while taking\\nthis medicine should get in touch with his or her\\nphysician.\\nBecause benzodiazepines work on the central ner-\\nvous system, they may add to the effects of alcohol and\\nother drugs that slow down the central nervous\\nKEY TERMS\\nAnxiety— Worry or tension in response to real or\\nimagined stress, danger, or dreaded situations.\\nPhysical reactions, such as fast pulse, sweating, trem-\\nbling, fatigue, and weakness may accompany anxiety.\\nAsthma— A disease in which the air passages of the\\nlungs become inflamed and narrowed.\\nBronchitis— Inflammation of the air passages of the\\nlungs.\\nCentral nervous system— The brain and spinal\\ncord.\\nChronic— A word used to describe a long-lasting\\ncondition. Chronic conditions often develop gra-\\ndually and involve slow changes.\\nEmphysema— An irreversible lung disease in which\\nbreathing becomes increasingly difficult.\\nEpilepsy— A brain disorder with symptoms that\\ninclude seizures.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nMyasthenia gravis— A chronic disease with symp-\\ntoms that include muscle weakness and sometimes\\nparalysis.\\nPanic disorder— A disorder in which people have\\nsudden and intense attacks of anxiety in certain\\nsituations. Symptoms such as shortness of breath,\\nsweating, dizziness, chest pain, and extreme fear\\noften accompany the attacks.\\nPhobia— An intense, abnormal, or illogical fear of\\nsomething specific, such as heights or open spaces.\\nPorphyria— A disorder in which porphyrins build\\nup in the blood and urine.\\nPorphyrin— A type of pigment found in living\\nthings.\\nSeizure— A sudden attack, spasm, or convulsion.\\nSleep apnea— A condition in which a person tem-\\nporarily stops breathing during sleep.\\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.\\n514 GALE ENCYCLOPEDIA OF MEDICINE\\nBenzodiazepines'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='system, such asantihistamines, cold medicine, allergy\\nmedicine, sleep aids, medicine for seizures, tranquili-\\nzers, somepain relievers, andmuscle relaxants. They\\nmay also add to the effects of anesthetics, including\\nthose used for dental procedures. These effects may\\nlast several days after treatment with benzodiazepines\\nends. The combined effects of benzodiazepines and\\nalcohol or other CNS depressants (drugs that slow the\\ncentral nervous system) can be very dangerous, leading\\nto unconsciousness or, rarely, even death.Anyone tak-\\ning benzodiazepines should not drink alcohol and\\nshould check with his or her physician before using\\nany CNS depressants.Taking an overdose of benzodia-\\nzepines can also cause unconsciousness and possibly\\ndeath. Anyone who shows signs of an overdose or of the\\neffects of combining benzodiazepines with alcohol or\\nother drugs should get immediate emergency help.\\nWarning signs include slurred speech or confusion,\\nsevere drowsiness, staggering, and profound weakness.\\nSome benzodiazepines may change the results of\\ncertain medical tests. Before having medical tests, any-\\none taking this medicine should alert the health care\\nprofessional in charge.\\nChildren are generally more sensitive than adults\\nto the effects of benzodiazepines. This sensitivity may\\nincrease the chance of side effects.\\nOlder people are more sensitive than younger\\nadults to the effects of this medicine and may be at\\ngreater risk for side effects. Older people who take\\nthese drugs to help them sleep may be drowsy during\\nthe day. Older people also increase their risk of falling\\nand injuring themselves when they take these drugs.\\nSpecial conditions\\nPeople with certain medical conditions or who are\\ntaking certain other medicines can have problems if\\nthey take benzodiazepines. Before taking these drugs,\\nbe sure to let the physician know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to benzodiazepines or other mood-altering\\ndrugs in the past should let his or her physician know\\nbefore taking the drugs again. The physician should\\nalso be told about anyallergies to foods, dyes, preser-\\nvatives, or other substances.\\nPREGNANCY. Some benzodiazepines increase the\\nlikelihood ofbirth defects. Using these medicines dur-\\ning pregnancy may also cause the baby to become\\ndependent on them and to have withdrawal symptoms\\nafter birth. When taken late in pregnancy or around\\nthe time of labor and delivery, these drugs can cause\\nother problems in the newborn baby, such as\\nweakness, breathing problems, slow heartbeat, and\\nbody temperature problems.\\nBREASTFEEDING. Benzodiazepines may pass into\\nbreast milk and cause problems in babies whose\\nmothers taken the medicine. These problems include\\ndrowsiness, breathing problems, and slow heartbeat.\\nWomen who are breastfeeding their babies should not\\nuse this medicine without checking with their\\nphysicians.\\nOTHER MEDICAL CONDITIONS. Before using ben-\\nzodiazepines, people with any of these medical pro-\\nblems should make sure their physicians are aware of\\ntheir conditions:\\n/C15current or past drug or alcoholabuse\\n/C15depression\\n/C15severe mental illness\\n/C15epilepsy or other seizure disorders\\n/C15swallowing problems\\n/C15chronic lung disease such asemphysema, asthma,o r\\nchronic bronchitis\\n/C15kidney disease\\n/C15liver disease\\n/C15brain disease\\n/C15glaucoma\\n/C15hyperactivity\\n/C15myasthenia gravis\\n/C15porphyria\\n/C15sleep apnea\\nUSE OF CERTAIN MEDICINES. Taking benzodiaze-\\npines with certain other drugs may affect the way the\\ndrugs work or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness, light-\\nheadedness, drowsiness, clumsiness, unsteadiness, and\\nslurred speech. These problems usually go away as the\\nbody adjusts to the drug and do not require medical\\ntreatment unless they persist or they interfere with\\nnormal activities.\\nMore serious side effects are not common, but\\nmay occur. If any of the following side effects occur,\\ncheck with the physician who prescribed the medicine\\nas soon as possible:\\n/C15behavior changes\\n/C15memory problems\\n/C15difficulty concentrating\\nGALE ENCYCLOPEDIA OF MEDICINE 515\\nBenzodiazepines'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15confusion\\n/C15depression\\n/C15seizures (convulsions)\\n/C15hallucinations\\n/C15sleep problems\\n/C15increased nervousness, excitability, or irritability\\n/C15involuntary movements of the body, including\\nthe eyes\\n/C15low blood pressure\\n/C15unusual weakness or tiredness\\n/C15skin rash oritching\\n/C15unusual bleeding or bruising\\n/C15yellow skin or eyes\\n/C15sore throat\\n/C15sores in the mouth or throat\\n/C15fever and chills\\nPatients who take benzodiazepines for a long time\\nor at high doses may notice side effects for several\\nweeks after they stop taking the drug. They should\\ncheck with their physicians if these or other trouble-\\nsome symptoms occur:\\n/C15irritability\\n/C15nervousness\\n/C15sleep problems\\nOther rare side effects may occur. Anyone who has\\nunusual symptoms during or after treatment with benzo-\\ndiazepines should get in touch with his or her physician.\\nInteractions\\nBenzodiazepines may interact with a variety of\\nother medicines. When this happens, the effects of\\none or both of the drugs may change or the risk\\nof side effects may be greater. Anyone who takes\\nbenzodiazepines should let the physician know all\\nother medicines he or she is taking. Among the drugs\\nthat may interact with benzodiazepines are:\\n/C15Central nervous system (CNS) depressants such as\\nmedicine for allergies, colds, hay fever, and asthma;\\nsedatives; tranquilizers; prescription pain medicine;\\nmuscle relaxants; medicine for seizures; sleep aids;\\nbarbiturates; and anesthetics.\\nMedicines other than those listed above may\\ninteract with benzodiazepines. Be sure to check with\\na physician or pharmacist before combining benzodia-\\nzepines with any other prescription or nonprescription\\n(over-the-counter) medicine.\\nResources\\nOTHER\\n‘‘Medications.’’ National Institute of Mental Health Page.\\n1995. .\\nNancy Ross-Flanigan\\nBenzoyl peroxide see Antiacne drugs\\nBenztropine see Antiparkinson drugs\\nBereavement\\nDefinition\\nBereavement refers to the period of mourning and\\ngrief following thedeath of a beloved person or ani-\\nmal. The English wordbereavement comes from an\\nancient Germanic root word meaning ‘‘to rob’’ or ‘‘to\\nseize by violence.’’Mourning is the word that is used to\\ndescribe the public rituals or symbols of bereavement,\\nsuch as holding funeral services, wearing black cloth-\\ning, closing a place of business temporarily, or low-\\nering a flag to half mast.Grief refers to one’s personal\\nexperience of loss; it includes physical symptoms as\\nwell as emotional and spiritual reactions to the loss.\\nWhile public expressions of mourning are usually\\ntime-limited, grief is a process that takes most people\\nseveral months or years to work through.\\nDescription\\nBereavement is a highly individual as well as a\\ncomplex experience. It is increasingly recognized that\\nno two people respond the same way to the losses\\nassociated with the death of a loved one. People’s\\nreactions to a death are influenced by such factors\\nas ethnic or religious traditions; personal beliefs\\nabout life after death; the type of relationship ended\\nby death (relative, friend, colleague, etc.); the cause of\\ndeath; the person’s age at death; whether the death\\nwas sudden or expected; and many others. In addi-\\ntion, the death of a loved one inevitably confronts\\nadults (and older adolescents) with the fact that they\\ntoo will die. As a result of this variety and emotional\\ncomplexity, most doctors and other counselors advise\\npeople to trust their own feelings about bereave-\\nment,0 and grieve in the way that seems most helpful\\nto them.\\nIt is also increasingly understood in the early\\n2000s that people can experience bereavement with\\nregard to other losses. Some examples of these\\n516 GALE ENCYCLOPEDIA OF MEDICINE\\nBereavement'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='so-called ‘‘silent losses’’ include miscarriages in early\\npregnancy, the death of a child in the womb shortly\\nbefore birth, or the news that a loved one has\\nAlzheimer’s disease or another illness that slowly\\ndestroys their personality. In addition, many counse-\\nlors recognize that bereavement has two dimensions,\\nthe actual loss and the symbolic losses. For example, a\\nperson whose teenage son or daughter is killed in an\\naccident suffers a series of symbolic losses—knowing\\nthat their child will never graduate from high school,\\nget married, or have children—as well as the actual\\nloss of the adolescent to death.\\nCauses and symptoms\\nCauses\\nThe immediate cause of bereavement is usually\\nthe death of a loved friend or relative. There are a\\nnumber of situations, however, which can affect or\\nprolong the grief process:\\n/C15The relationship with the dead person was a source\\nof pain rather than love and support. Examples\\nwould include an abusive parent or spouse.\\n/C15The person died in military service or in a natural,\\ntransportation, or workplace disaster. Bereavement in\\nthese cases is often made more difficult by intrusive\\nnews reporters as well asanxiety over the loved one’s\\npossible physical or mental suffering prior to death.\\n/C15The person was murdered. Survivors of homicide\\nvictims often find the criminal justice system as well\\nas the media frustrating and upsetting.\\n/C15The person is missing and presumed dead but their\\ndeath has not been verified. As a result, friends and\\nrelatives may alternate between grief and hope that\\nthe person is still alive.\\n/C15The person committed suicide. Survivors may feel\\nguilt over their inability to foresee or prevent the\\nsuicide, shame that the death was self-inflicted, or\\nanger at the person who committed suicide.\\n/C15The relationship with the dead person cannot be\\nopenly acknowledged. This situation often leads to\\nwhat is called disenfranchised grief. The most com-\\nmon instances are homosexual or extramarital sexual\\nrelationships that have been kept secret for the sake\\nof spouses or other family members.\\n/C15The loved one was an animal rather than a human\\nbeing. Western societies are only beginning to accept\\nthat adults as well as children can grieve for a dead\\nanimal; many adults still feel that there is ‘‘some-\\nthing wrong’’ about grieving for their pet. The ques-\\ntion of euthanasia may be an additional source of\\nsorrow; even when the pet is terminally ill, many\\npeople are very uneasy about making the decision\\nto end its life.\\nSymptoms\\nBereavement typically affects a person’s physical\\nwell-being as well as emotions. Common symptoms of\\ngrief include changes in appetite and weight,fatigue,\\ninsomnia and other sleep disturbances, loss of interest\\nin sex, low energy levels,nausea and vomiting, chest or\\nthroat pain, and headache. People who have lost a\\nloved one in traumatic circumstances may have such\\nsymptoms ofpost-traumatic stress disorderas an exag-\\ngerated startle response, visual or auditoryhallucina-\\ntions, or high levels of muscular tension.\\nDoctors and other counselors have identified four\\nstages or phases in uncomplicated bereavement:\\nColumbine High School students in Littleton, Colorado,\\ngrieving for their slain classmates. (Photo by David\\nZalubowski. AP/Wide World Photos. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 517\\nBereavement'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Shock, disbelief, feelings of numbness. This initial\\nphase lasts about two weeks, during which the\\nbereaved person finally accepts the reality of the\\nloved one’s death.\\n/C15Suffering the pain of grief. This phase typically lasts\\nfor several months. Some people undergo a mild\\ntemporary depression about six months after the\\nloved one’s death.\\n/C15Adjusting to life without the loved one. In this phase\\nof bereavement, survivors may find themselves\\ntaking on the loved one’s roles and responsibilities\\nas well as redefining their own identities.\\n/C15Moving forward with life, forming new relation-\\nships, and having positive expectations of the future.\\nMost people reach this stage within one to two years\\nafter the loved one’s death.\\nBEREAVEMENT IN CHILDREN. Children do not\\nexperience bereavement in the same way as adolescents\\nand adults. Preschool children usually do not under-\\nstand death as final and irreversible, and may talk or act\\nas if the dead pet or family member will wake up or\\ncome back. Children between the ages of five and nine\\nare better able to understand the finality of death, but\\nthey tend to assume it will not affect them or their\\nfamily. They are likely to be shocked and severely\\nupset by a death in their immediate family. In addition\\nto the physical disturbances that bereaved adults often\\nexperience, children sometimes begin to act like infants\\nagain (wanting bottle feeding, using baby talk, etc.)\\nThis pattern of returning to behaviors characteristic of\\nan earlier life stage is called regression.\\nTRAUMATIC AND COMPLICATED GRIEF. Since the\\nearly 1990s, thanatologists (doctors and other counse-\\nlors who specialize in issues related to death and\\ndying) have identified two types of grief that do not\\nresolve normally with the passage of time. Traumatic\\ngrief is defined as grief resulting from a sudden trau-\\nmatic event that involves violent suffering, mutilation,\\nand/or multiple deaths; appears to be random or pre-\\nventable; and often involves the survivor’s own brush\\nwith death. The symptoms of traumatic grief are simi-\\nlar to those of post-traumaticstress disorder (PTSD).\\nSuch events as the terrorist attacks of September 11,\\n2001, the East Asian tsunami of December 2004, and\\nairplane crashes or other transportation disasters may\\nproduce traumatic grief in survivors.\\nIn contrast to traumatic grief, complicated grief\\ndoes not necessarily result from a specific type of event\\nbut rather refers to an abnormally intense and pro-\\nlonged response to bereavement. While most people\\nare able to move through a period of bereavement and\\nrecover a sense of purpose and meaning in life, people\\nwith complicated grief feel as if their entire worldview\\nhas been shattered. They cannot stop thinking of the\\ndead person, long to be with him or her, and may feel\\nthat part of them died along with the loved one. They\\nsometimes start acting like the deceased person,\\nmimicking the symptoms of his or her illness, behav-\\ning in reckless ways, talking about ‘‘joining’’ the loved\\none, or refusing to accept the reality of the death.\\nIn general they are unable to function normally.\\nComplicated grief should not be regarded as simply\\nKEY TERMS\\nBibliotherapy— The use of books (usually self-help\\nor problem-solving works) to improve one’s under-\\nstanding of personal problems and/or to heal pain-\\nful feelings.\\nBiofield healing— A general term for a group of\\nalternative therapies based on the belief that the\\nhuman body is surrounded by an energy field (or\\naura) that reflects the condition of the person’s\\nbody and spirit. Rebalancing or repairing the\\nenergy field is thought to bring about healing in\\nmind and body. Reiki, therapeutic touch, polarity\\nbalancing, Shen therapy, and certain forms of color\\ntherapy are considered forms of biofield healing.\\nComplicated grief— An abnormal response to\\nbereavement that includes unrelieved yearning for\\nthe dead person, the complete loss of previous\\npositive beliefs or worldviews, and a general inabil-\\nity to function.\\nDisenfranchised grief— Grief that cannot be\\nopenly expressed because the death or other loss\\ncannot be publicly acknowledged.\\nEuthanasia— The act of putting a person or animal\\nto death painlessly or allowing them to die by with-\\nholding medical services, usually because of a\\npainful and incurable disease.\\nMourning— The public expression of bereavement;\\nit may include funerals and other rituals, special\\nclothing, and symbolic gestures.\\nRegression— A return to earlier, particularly infan-\\ntile, patterns of thought and behavior.\\nThanatology— The medical, psychological, or\\nlegal study of death and dying.\\nTraumatic grief— Grief resulting from the loss of a\\nloved one in a traumatic situation (natural or transpor-\\ntation disaster, act of terrorism or mass murder, etc.)\\n518 GALE ENCYCLOPEDIA OF MEDICINE\\nBereavement'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='a subtype of clinical depression; the two conditions\\nmay coexist or overlap in some patients but are none-\\ntheless distinct entities.\\nDiagnosis\\nBereavement is considered a normal response to a\\ndeath or other loss. A doctor who suspects that a\\npatient is suffering from traumatic or complicated\\ngrief, however, may use various psychological inven-\\ntories or questionnaires to see whether the patient\\nmeets the criteria for PTSD, major depression, or\\nacute stress disorder. In addition, there are several spe-\\ncific questionnaires to help diagnose complicated grief.\\nTreatment\\nMost people do not require formal treatment\\nfor bereavement. In the early 2000s, however, many\\npeople choose to participate in support groups for\\nrecently bereaved people or hospice follow-up programs\\nfor relatives of patients who died in that hospice.\\nBereavement support groups are particularly helpful in\\nguiding members through such common but painful\\nproblems as disposing of the dead person’s possessions,\\ncelebrating holidays without the loved one, coping with\\nanniversaries, etc.\\nTraumatic grief is usually treated in the same way\\nas post-traumatic stress, with temporary use of medi-\\ncations to control sleep disturbances and anxiety\\nsymptoms along with long-term psychotherapy.\\nThose suffering from traumatic grief may also be\\nreferred to support groups of people dealing with the\\nsame type of sudden and violent loss. Some of these\\norganizations are listed below. Complicated grief is\\nusually managed with a combination of group and\\nindividual psychotherapy.\\nAlternative treatment\\nAlternative therapies that have been reported to\\nhelp with the sleep disturbances and other physical\\nsymptoms of bereavement include prayer andmedita-\\ntion; such movement therapies asyoga and tai chi;\\ntherapeutic touch, Reiki, and other forms of biofield\\nhealing; bibliotherapy and journaling;music therapy,\\nart therapy, hydrotherapy,a n dmassage therapy.\\nPrognosis\\nMost people move through the stages of the nor-\\nmal grief process within several months to two years,\\ndepending on the length and closeness of the relation-\\nship. Traumatic grief and complicated grief, however,\\nmay take three years or longer to resolve, even with\\nappropriate treatment.\\nPrevention\\nBereavement is considered a normal response to\\ndeath and loss, which are universal human experi-\\nences. It should ordinarily be allowed to run its course;\\nmost counselors maintain that trying to stifle or cut\\nshort the grief process is more likely to cause emo-\\ntional problems later on than to prevent them.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders, 4th edition, text revision.\\nWashington, DC: American Psychiatric Association,\\n2000.\\nDossey, Larry, MD.Healing Beyond the Body: Medicine and\\nthe Infinite Reach of the Mind.Boston and London:\\nShambhala, 2001. The chapters on ‘‘The Return of\\nPrayer’’ and ‘‘Immortality’’ are particularly relevant to\\nbereavement.\\n‘‘Mood Disorders.’’ Section 15, Chapter 189 inThe Merck\\nManual of Diagnosis and Therapy, edited by Mark H.\\nBeers, MD, and Robert Berkow, MD. Whitehouse\\nStation, NJ: Merck Research Laboratories, 2005.\\nPERIODICALS\\nBowles, Stephen B., Larry C. James, Diane S. Solursh, et al.\\n‘‘Acute and Post-Traumatic Stress Disorder after\\nSpontaneous Abortion.’’American Family Physician61\\n(March 15, 2000): 1689–1696.\\nKersting, Karen. ‘‘A New Approach to Complicated Grief.’’\\nMonitor on Psychology35 (November 2004): 51.\\nLubit, Roy, MD. ‘‘Acute Treatment of Disaster Survivors.’’\\neMedicine, 17 June 2004. .\\nOgrodniczuk, John S., William E. Piper, Anthony S. Joyce,\\net al. ‘‘Differentiating Symptoms of Complicated Grief\\nand Depression among Psychiatric Outpatients.’’\\nCanadian Journal of Psychiatry/Revue canadienne de\\npsychiatrie 48 (March 2003): 87–93.\\nORGANIZATIONS\\nAlzheimer’s Association. 225 North Michigan Avenue, 17th\\nFloor, Chicago, IL 60601-7633. (312) 335-8700.\\n24-hour hotline: (800) 272-3900. .\\nThis website is an excellent resource for anyone with a\\nloved one suffering from Alzheimer’s or another\\ndementing illness.\\nAmerican Academy of Child and Adolescent Psychiatry.\\n3615 Wisconsin Avenue, NW, Washington, DC\\n20016-3007. (202) 966-7300. Fax: (202) 966-2891.\\n.\\nAmerican Veterinary Medical Association (AVMA). 1931\\nNorth Meacham Road, Suite 100, Schaumburg, IL\\nGALE ENCYCLOPEDIA OF MEDICINE 519\\nBereavement'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='60173-4360. . The AVMA\\nwebsite includes links to resources about pet loss.\\nDougy Center for Grieving Children and Families. 3909 SE\\n52nd Avenue, Portland, OR 97206. (866) 775-5683 or\\n(503) 775-5683. Fax: (503) 777-3097. . Provides age-appropriate\\nsupport groups, information, and referral services for\\nbereaved children and adolescents.\\nNational Air Disaster Alliance/Foundation (NADA). 2020\\nPennsylvania Avenue #315, Washington, DC 20006-\\n1846. (888) 444-NADA. Fax: (336) 643-1394. . NADA was founded in 1995\\nfollowing the loss of USAir Flight 427 to meet the needs\\nof people who have lost loved ones in air disasters as\\nwell as work for better transportation safety standards.\\nNational Hospice and Palliative Care Organization\\n(NHPCO). 1700 Diagonal Road, Suite 625, Alexandria,\\nVA 22314. (703) 837-1500. Fax: (703) 837-1233.\\n. This website is a good source\\nof information about hospice-based bereavement ser-\\nvices and support groups.\\nNational Institute of Mental Health (NIMH). 6001\\nExecutive Boulevard, Room 8184, MSC 9663,\\nBethesda, MD 20892-9663. (301) 443-4513 or (886) 615-\\nNIMH. \\nTragedy Assistance Program for Survivors, Inc. (TAPS).\\nNational Headquarters, 1621 Connecticut Avenue NW,\\nSuite 300, Washington, DC 20009. (202) 588-TAPS.\\nHotline: (800) 959-TAPS. .\\nTAPS provides grief support for those who have lost a\\nloved one serving in the Armed Forces.\\nOTHER\\nAlzheimer’s Association.Fact Sheet: About Grief, Mourning\\nand Guilt.Chicago, IL: Alzheimer’s Association, 2004.\\nAmerican Academy of Child and Adolescent Psychiatry\\n(AACAP). Children and Grief. AACAP Facts for\\nFamilies #8. Washington, DC: AACAP, 2004.\\nAmerican Academy of Child and Adolescent Psychiatry\\n(AACAP). When a Pet Dies. AACAP Facts for\\nFamilies #78. Washington, DC: AACAP, 2000.\\nHarper, Linda R., PhD.Healing after the Loss of Your Pet.\\n.\\nNational Institute of Mental Health (NIMH).Mental Health\\nand Mass Violence: Evidence-Based Early Psychological\\nInterventions for Victims/Survivors of Mass Violence.\\nNIH Publication No. 02-5138. Washington, DC: U. S.\\nGovernment Printing Office, 2002.\\nNational Organization of Parents of Murdered Children\\n(POMC). Information Bulletin: Survivors of Homicide\\nVictims. .\\nRebecca Frey, PhD\\nBerger’s diseasesee Idiopathic primary renal\\nhematuric/proteinuric syndrome\\nBeriberi\\nDefinition\\nBeriberi is a disease caused by a deficiency of\\nthiamine (vitamin B1) that affects many systems of\\nthe body, including the muscles, heart, nerves, and\\ndigestive system. Beriberi literally means ‘‘I can’t, I\\ncan’t’’ in Singhalese, which reflects the crippling effect\\nit has on its victims. It is common in parts of southeast\\nAsia, where white rice is the main food. In the United\\nStates, beriberi is primarily seen in people with chronic\\nalcoholism.\\nDescription\\nBeriberi puzzled medical experts for years as it\\nravaged people of all ages in Asia. Doctors thought it\\nwas caused by something in food. Not until the early\\n1900s did scientists discover that rice bran, the outer\\ncovering that was removed to create the polished white\\nrice preferred by Asians, actually contained something\\nthat prevented the disease. Thiamine was the first\\nvitamin identified. In the 1920s, extracts of rice polish-\\nings were used to treat the disease.\\nIn adults, there are different forms of beriberi,\\nclassified according to the body systems most affected.\\nDry beriberi involves the nervous system; wet beriberi\\naffects the heart and circulation. Both types usually\\noccur in the same patient, with one set of symptoms\\npredominating.\\nA less common form of cardiovascular, or wet\\nberiberi, is known as ‘‘shoshin.’’ This condition\\ninvolves a rapid appearance of symptoms and acute\\nheart failure. It is highly fatal and is known to cause\\nsudden death in young migrant laborers in Asia whose\\ndiet consists of white rice.\\nCerebral beriberi, also known as Wernicke-\\nKorsakoff syndrome, usually occurs in chronic alco-\\nholics and affects the central nervous system (brain\\nand spinal cord). It can be caused by a situation that\\naggravates a chronic thiamine deficiency, like an alco-\\nholic binge or severevomiting.\\nInfantile beriberi is seen in breastfed infants of\\nthiamine-deficient mothers, who live in developing\\nnations.\\nAlthough severe beriberi is uncommon in the\\nUnited States, less severe thiamine deficiencies do\\noccur. About 25% of all alcoholics admitted to a\\nhospital in the United States show some evidence of\\nthiamine deficiency.\\n520 GALE ENCYCLOPEDIA OF MEDICINE\\nBeriberi'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nThiamine is one of the Bvitamins and plays an\\nimportant role in energy metabolism and tissue build-\\ning. It combines with phosphate to form the coenzyme\\nthiamine pyrophosphate (TPP), which is essential in\\nreactions that produce energy from glucose or that\\nconvert glucose to fat for storage in the tissues.\\nWhen there is not enough thiamine in the diet, these\\nbasic energy functions are disturbed, leading to pro-\\nblems throughout the body.\\nSpecial situations, such as an over-active meta-\\nbolism, prolonged fever, pregnancy, and breastfeed-\\ning, can increase the body’s thiamine requirements\\nand lead to symptoms of deficiency. Extended peri-\\nods ofdiarrhea or chronic liver disease can result in\\nthe body’s inability to maintain normal levels of\\nmany nutrients, including thiamine. Other persons\\nat risk are patients with kidney failure on dialysis\\nand those with severe digestive problems who are\\nunable to absorb nutrients. Alcoholics are susceptible\\nbecause they may substitute alcohol for food and\\ntheir frequent intake of alcohol decreases the body’s\\nability to absorb thiamine.\\nThe following systems are most affected by\\nberiberi:\\n/C15Gastrointestinal system. When the cells of the\\nsmooth muscles in the digestive system and glands\\ndo not get enough energy from glucose, they are\\nunable to produce more glucose from the normal\\ndigestion of food. There is a loss of appetite,indiges-\\ntion, severeconstipation, and a lack of hydrochloric\\nacid in the stomach.\\n/C15Nervous System. Glucose is essential for the central\\nnervous system to function normally. Early defi-\\nciency symptoms arefatigue, irritability, and poor\\nmemory. If the deficiency continues, there is damage\\nto the peripheral nerves that causes loss of sensation\\nand muscle weakness, which is calledperipheral neu-\\nropathy. The legs are most affected. The toes feel\\nnumb and the feet have a burning sensation; the leg\\nmuscles become sore and the calf muscles cramp. The\\nindividual walks unsteadily and has difficulty getting\\nup from a squatting position. Eventually, the muscles\\nshrink (atrophy) and there is a loss of reflexes in the\\nknees and feet; the feet may hang limp (footdrop).\\n/C15Cardiovascular system. There is a rapid heartbeat\\nand sweating. Eventually the heart muscle weakens.\\nBecause the smooth muscle in the blood vessels is\\naffected, the arteries and veins relax, causing swel-\\nling, known asedema, in the legs.\\n/C15Musculoskeletal system. There is widespread mus-\\ncle pain caused by the lack of TPP in the muscle\\ntissue.\\nInfants who are breastfed by a thiamine-\\ndeficient mother usually develop symptoms of\\ndeficiency between the second and fourth month of\\nlife. They are pale, restless, unable to sleep, prone\\nto diarrhea, and have muscle wasting and edema in\\ntheir arms and legs. They have a characteristic,\\nsometimes silent, cry and develop heart failure and\\nnerve damage.\\nDiagnosis\\nA physical examination will reveal many of the\\nearly symptoms of beriberi, such as fatigue, irrita-\\ntion, nausea, constipation, and poor memory, but\\nthe deficiency may be difficult to identify.\\nInformation about the individual’s diet and general\\nhealth is also needed.\\nThere are many biochemical tests based on thia-\\nmine metabolism or the functions of TPP that can\\ndetect a thiamine deficiency. Levels of thiamine can\\nbe measured in the blood and urine and will be\\nreduced if there is a deficiency. The urine can be\\nKEY TERMS\\nB vitamins— This family of vitamins consists of\\nthiamine (B1), riboflavin (B2), niacin (B3), pantothe-\\nnic acid (B5), pyridoxine (B6), biotin, folic acid (B9),\\nand cobalamin (B12). They are interdependent and\\ninvolved in converting glucose to energy.\\nCoenzyme— A substance needed by enzymes to\\nproduce many of the reactions in energy and pro-\\ntein metabolism in the body.\\nEdema— An excess accumulation of fluid in the\\ncells and tissues.\\nEnzyme— A protein that acts as a catalyst to pro-\\nduce chemical changes in other substances without\\nbeing changed themselves.\\nMetabolism— All the physical and chemical\\nchanges that take place within an organism.\\nPeripheral neuropathy— A disease affecting the\\nportion of the nervous system outside the brain\\nand spinal chord. One or more nerves can be\\ninvolved, causing sensory loss, muscle weakness\\nand shrinkage, and decreased reflexes.\\nThiamine pyrophosphate (TPP)— The coenzyme\\ncontaining thiamine that is essential in converting\\nglucose to energy.\\nGALE ENCYCLOPEDIA OF MEDICINE 521\\nBeriberi'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='collected for 24 hours to measure the level of thia-\\nmine excreted. Another reliable test measures the\\neffect of TPP on red blood cell activity since all\\nforms of beriberi affect the metabolism of red blood\\ncells.\\nAn electroencephalogram (EEG), which measures\\nelectrical activity in the brain, may be done to rule out\\nother causes of neurologic changes. Observing\\nimprovements in the patient after giving thiamine\\nsupplements will also confirm the diagnosis.\\nTreatment\\nTreatment with thiamine reverses the deficiency in\\nthe body and relieves most of the symptoms. Severe\\nthiamine deficiency is treated with high doses of thia-\\nmine given by injection into a muscle (intramuscular)\\nor in a solution that goes into a vein (intravenously)\\nfor several days. Then smaller doses can be given\\neither by injection or in pill form until the patient\\nrecovers. Usually there are other deficiencies in the\\nB vitamins that will also need treatment.\\nThe cardiovascular symptoms of wet beriberi can\\nrespond to treatment within a few hours if they are\\nnot too severe. Heart failure may require additional\\ntreatment with diuretics that help eliminate excess\\nfluid and with heart-strengthening drugs like\\ndigitalis.\\nRecovery from peripheral neuropathy and other\\nsymptoms of dry beriberi may take longer and patients\\nfrequently become discouraged. They should stay\\nactive; physical therapy will also help in recovery.\\nInfantile beriberi is treated by giving thiamine to\\nboth the infant and the breast feeding mother until\\nlevels are normal.\\nIn Wernicke-Korsakoff syndrome, thiamine should\\nbe given intravenously or by injection at first because the\\nintestinal absorption of thiamine is probably impaired\\nand the patient is very ill. Most of the symptoms will be\\nrelieved by treatment, though there may be residual\\nmemory loss.\\nExcess thiamine is excreted by the body in the\\nurine, and negative reactions to too much thiamine\\nare rare. Thiamine is unstable in alkali solutions, so it\\nshould not be taken withantacids or barbiturates.\\nAlternative treatment\\nAlternative treatments for beriberi deal first with\\ncorrecting the thiamine deficiency. As in conventional\\ntreatments, alternative treatments for beriberistress\\na diet rich in foods that provide thiamine and other\\nB vitamins, such as brown rice, whole grains, raw\\nfruits and vegetables, legumes, seeds, nuts, and yogurt.\\nDrinking more than one glass of liquid with a meal\\nshould be avoided, since this may wash out the vita-\\nmins before they can be absorbed by the body.\\nThiamine should be taken daily, with the dose depend-\\ning on the severity of the disease. Additional supple-\\nments of B vitamins, a multivitamin and mineral\\ncomplex, and Vitamin C are also recommended.\\nOther alternative therapies may help relieve the per-\\nson’s symptoms after the thiamine deficiency is\\ncorrected.\\nPrognosis\\nBeriberi is fatal if not treated and the longer the\\ndeficiency exists, the sicker the person becomes. Most\\nof the symptoms can be reversed and full recovery is\\npossible when thiamine levels are returned to normal\\nand maintained with a balanced diet and vitamin sup-\\nplements as needed.\\nPrevention\\nA balanced diet containing all essential nutrients\\nwill prevent a thiamine deficiency and the develop-\\nment of beriberi. People who consume large quantities\\nof junk food like soda, pretzels, chips, candy, and high\\ncarbohydrate foods made with unenriched flours may\\nbe deficient in thiamine and other vital nutrients. They\\nmay need to take vitamin supplements and should\\nimprove theirdiets.\\nDietary Requirements\\nThe body’s requirements for thiamine are tied\\nto carbohydrate metabolism and expressed in terms\\nof total intake of calories. The current recom-\\nmended dietary allowances (RDA) are 0.5 mg for\\nevery 1000 calories, with a minimum daily intake\\nof 1 mg even for those who eat fewer than 2,000\\ncalories in a day. The RDA for children and teen-\\nagers is the same as for adults: 1.4 mg daily for\\nmales over age eleven, and 1.1 mg for females.\\nDuring pregnancy, an increase to 1.5 mg daily is\\nneeded. Because of increased energy needs and the\\nsecretion of thiamine in breast milk, breast feeding\\nmothers need 1.5 mg every day. In infants, 0.4 mg\\nis advised.\\nFood Sources\\nThe best food sources of thiamine are lean\\npork, beef, liver, brewer’s yeast, peas and beans,\\n522 GALE ENCYCLOPEDIA OF MEDICINE\\nBeriberi'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='whole or enriched grains, and breads. The more\\nrefined the food, as in white rice, white breads,\\nand some cereals, the lower the thiamine. Many\\nfood products are enriche d with thiamine, along\\nwith riboflavin, niacin, and iron, to prevent dietary\\ndeficiency.\\nDuring the milling process, rice is polished and all\\nthe vitamins in the exterior coating of bran are lost.\\nBoiling the rice before husking preserves the vitamins\\nby distributing them throughout the kernel. Food\\nenrichment programs have eliminated beriberi in\\nJapan and the Phillipines.\\nLike all B vitamins, thiamine is water soluble,\\nwhich means it is easily dissolved in water. It will\\nleach out during cooking in water and is destroyed\\nby high heat and overcooking.\\nResources\\nPERIODICALS\\nRyan, Ruth, et al. ‘‘Beriberi Unexpected.’’Psychosomatics\\nMay-June 1997: 191-294.\\nKaren Ericson, RN\\nBerry aneurysm see Cerebral aneurysm\\nBerylliosis\\nDefinition\\nBerylliosis is lung inflammation caused by inhal-\\ning dust or fumes that contain the metallic element\\nberyllium. Found in rocks, coal, soil, and volcanic\\ndust, beryllium is used in the aerospace industry and\\nin many types of manufacturing. Berylliosis occurs in\\nboth acute and chronic forms. In some cases, appear-\\nance of the disease may be delayed as much as 20 years\\nafter exposure to beryllium.\\nDescription\\nIn the 1930s, scientists discovered that beryllium\\ncould make fluorescent light bulbs last longer. During\\nthe following decade, the hard, grayish metal was\\nidentified as the cause of a potentially debilitating,\\nsometimes deadly disease characterized byshortness\\nof breathand inflammation, swelling, and scarring of\\nthe lungs.\\nThe manufacture of fluorescent light bulbs is no\\nlonger a source of beryllium exposure, but serious\\nhealth hazards are associated with any work\\nenvironment or process in which beryllium fumes or\\nparticles become airborne. Working with pure beryl-\\nlium, beryllium compounds (e.g. beryllium oxide), or\\nberyllium alloys causes occupational exposure. So do\\njobs involving:\\n/C15electronics\\n/C15fiber optics\\n/C15manufacturing ceramics, bicycle frames, golf clubs,\\nmirrors, and microwave ovens\\n/C15mining\\n/C15nuclear weapons and reactors\\n/C15reclaiming scrap metal\\n/C15space and atomic engineering\\n/C15dental and laboratory technology\\nBeryllium dust and fumes are classified as toxic air\\npollutants by the Environmental Protection Agency\\n(EPA). It is estimated that 2–6% of workers exposed\\nto these contaminants eventually develop berylliosis.\\nCauses and symptoms\\nCoughing, shortness of breath, and weight loss\\nthat begin abruptly can be a symptom of acute ber-\\nylliosis. This condition is caused by beryllium air pol-\\nlution that inflames the lungs making them rigid; it can\\naffect the eyes and skin as well. People who have acute\\nberylliosis are usually very ill. Most recover, but some\\ndie of the disease.\\nChronic berylliosis is an allergic reaction to long-\\nterm exposure to even low levels of beryllium dust or\\nfumes. A systemic disease that causes formation of\\nabnormal lung tissue and enlargement of the lymph\\nnodes, chronic berylliosis also may affect other parts\\nof the body. The symptoms of chronic berylliosis are\\nKEY TERMS\\nBeryllium— A steel-grey, metallic mineral used in\\nthe aerospace and nuclear industries and in a vari-\\nety of manufacturing processes.\\nChelation therapy— A treatment using chelating\\nagents, compounds that surround and bind to target\\nsubstances allowing them to be excreted from the\\nbody.\\nCorticosteroids— A group of anti-inflammatory\\ndrugs.\\nGALE ENCYCLOPEDIA OF MEDICINE 523\\nBerylliosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='largely the same as those seen in acute berylliosis, but\\nthey develop more slowly.\\nDiagnosis\\nBerylliosis is initially suspected if a patient with\\nsymptoms of the disease has a history of beryllium\\nexposure. Achest x rayshows characteristic changes\\nin the lungs. However, since these changes can resem-\\nble those caused by other lung diseases, further testing\\nmay be necessary.\\nThe beryllium lymphocyte proliferation test\\n(BeLPT), a blood test that can detect beryllium sensi-\\ntivity (i.e. an allergic reaction to beryllium), is used to\\nscreen individuals at risk of developing berylliosis.\\nWhen screening results reveal a high level of sensitiv-\\nity, BeLPT is performed on cells washed from the\\nlungs. This test is now considered the most definitive\\ndiagnostic test for berylliosis.\\nTreatment\\nIndividuals with beryllium sensitivity or early-\\nstage berylliosis should be transferred from tasks\\nthat involve beryllium exposure and regularly exam-\\nined to determine whether the disease has progressed.\\nAcute berylliosis is a serious disease that occasion-\\nally may be fatal. Ventilators can help patients with\\nacute berylliosis breathe. Prompt corticosteroid ther-\\napy is required to lessen lung inflammation.\\nChronic beryllium disease is incurable.\\nCorticosteroid therapy is often prescribed, but it is\\nnot certain that steroids can alter the progression of\\nthe disease, and they have no effect on scarring of lung\\ntissue. Cleansing the lungs of beryllium is a slow pro-\\ncess, so long-term therapy may be required.Chelation\\ntherapy is currently under investigation as a treatment\\nfor the disease.\\nPrognosis\\nMost patients with acute berylliosis recover fully\\n7–10 days after treatment begins, and the disease\\nusually causes no after effects.\\nPatients whose lungs are severely damaged by\\nchronic berylliosis may experience fatalheart failure\\nbecause of the strain placed on the heart.\\nPrevention\\nEliminating exposure to beryllium is the surest way\\nto prevent berylliosis. Screening workers who are\\nexposed to beryllium fumes or dust or who develop an\\nallergic reaction to these substances is an effective way\\nto control symptoms and prevent disease progression.\\nResources\\nORGANIZATIONS\\nAmerican Lung Association. 1740 Broadway, New York,\\nNY 10019. (800) 586-4872. .\\nBeryllium Support Group. P.O. Box 2021, Broomfield, CO\\n80038-2021. (303) 412-7065. .\\nEnvironmental Health Center. 1025 Connecticut Ave., NW,\\nWashington, DC 20036. (202) 293-2270.\\nMaureen Haggerty\\nBeryllium pneumonosis see Berylliosis\\nBeryllium poisoning see Berylliosis\\nBeta-adrenergic blockers see beta blockers\\nBeta blockers\\nDefinition\\nBeta blockers are medicines that affect the body’s\\nresponse to certain nerve impulses. This, in turn,\\ndecreases the force and rate of the heart’s contrac-\\ntions, which lowers blood pressure and reduces the\\nheart’s demand for oxygen.\\nPurpose\\nThe main use of beta blockers is to treat high\\nblood pressure. Some also are used to relieve the type\\nof chestpain called angina or to prevent heart attacks\\nin people who already have had oneheart attack.\\nThese drugs may also be prescribed for other condi-\\ntions, such as migraine,tremors, and irregular heart-\\nbeat. In eye drop form, they are used to treat certain\\nkinds ofglaucoma.\\nDescription\\nBeta blockers, also known as beta-adrenergic\\nblockers, are available only with a physician’s\\nprescription. They come in capsule, tablet, liquid, and\\ninjectable forms. Some common beta blockers are\\natenolol (Tenormin), metoprolol (Lopressor), nadolol\\n(Corgard), propranolol (Inderal), and timolol\\n(Blocadren). Timolol and certain other beta blockers\\nare also sold in eye drop form for treating glaucoma.\\n524 GALE ENCYCLOPEDIA OF MEDICINE\\nBeta blockers'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Eye drops that contain beta blockers include betaxolol\\n(Betoptic), cartelol (Ocupress), and timolol (Timoptic).\\nRecommended dosage\\nThe recommended dosage depends on the type,\\nstrength, and form of beta blocker and the condition\\nfor which it is prescribed. The physician who pre-\\nscribed the drug or the pharmacist who filled the pre-\\nscription can recommend the correct dosage.\\nThis medicine may take several weeks to notice-\\nably lower blood pressure. Taking it exactly as direc-\\nted is important.\\nThis medicine should not be stopped without\\nchecking with the physician who prescribed it. Some\\nconditions may get worse when patients stop taking\\nbeta blockers abruptly. This may also increase the risk\\nof heart attack in some people. Because of these possi-\\nble effects, it is important to keep enough medicine on\\nhand to get through weekends, holidays, and vacations.\\nPhysicians may recommend that patients check\\ntheir pulse before and after taking this medicine. If the\\npulse becomes too slow, circulation problems may result.\\nPrecautions\\nSeeing a physician regularly while taking beta\\nblockers is important. The physician will check to\\nmake sure the medicine is working as it should and\\nwill watch for unwanted side effects. People who have\\nhigh blood pressure often feel perfectly fine. However,\\nthey should continue to see their physicians even when\\nthey feel well so that the physician can keep a close\\nwatch on their condition. Patients also need to keep\\ntaking their medicine even when they feel fine.\\nBeta blockers will not cure high blood pressure,\\nbut will help control the condition. To avoid the ser-\\nious health problems that high blood pressure can\\ncause, patients may have to take medicine for the rest\\nof their lives. Furthermore, medicine alone may not be\\nenough. Patients with high blood pressure may also\\nneed to avoid certain foods and keep their weight\\nunder control. The health care professional who is\\ntreating the condition can offer advice on what mea-\\nsures may be necessary. Patients being treated for high\\nblood pressure should not change theirdiets without\\nconsulting their physicians.\\nAnyone taking beta blockers for high blood pres-\\nsure should not take any other prescription or over-the-\\ncounter medicine without first checking with his or her\\nphysician. Some medicines may increase blood pressure.\\nAnyone who is taking beta blockers should be\\nsure to tell the health care professional in charge\\nbefore having any surgical or dental procedures or\\nreceiving emergency treatment.\\nSome beta blockers may change the results of\\ncertain medical tests. Before having medical tests, any-\\none taking this medicine should alert the health care\\nprofessional in charge.\\nSome people feel drowsy, dizzy, or lightheaded\\nwhen taking beta blockers. Anyone who takes these\\ndrugs should not drive, use machines or do anything\\nelse that might be dangerous until they have found out\\nhow the drugs affect them.\\nBeta blockers may increase sensitivity to cold,\\nespecially in older people or people who have poor\\ncirculation. Anyone who takes this medicine should\\nBlister packs of Tenormin LS (atenolol), a type of beta-recep-\\ntor blocking drug or beta blocker. This type of drug is widely\\nused to treat angina, to lower blood pressure, or to correct\\nabnormal heart rhythms. (Photograph by Adam Hart-Davis,\\nPhoto Researchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAngina pectoris— A feeling of tightness, heaviness,\\nor pain in the chest, caused by a lack of oxygen in\\nthe muscular wall of the heart.\\nGlaucoma— A condition in which pressure in the\\neye is abnormally high. If not treated, glaucoma\\nmay lead to blindness.\\nMigraine— A throbbing headache that usually\\naffects only one side of the head. Nausea, vomiting,\\nincreased sensitivity to light, and other symptoms\\noften accompany migraine.\\nGALE ENCYCLOPEDIA OF MEDICINE 525\\nBeta blockers'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='dress warmly in cold weather and should be careful\\nnot to be exposed to the cold for too long.\\nPeople who usually have chest pain when they\\nexercise or exert themselves may not have the pain\\nwhen they are taking beta blockers. This could lead\\nthem to be more active than they should be. Anyone\\ntaking this medicine should ask his or her physician\\nhow much exercise and activity is safe.\\nOlder people may be unusually sensitive to the\\neffects of beta blockers. This may increase the chance\\nof side effects.\\nPhysicians may advise people taking beta blockers\\nto wear or carry medical identification indicating that\\nthey are taking this medicine.\\nSpecial conditions\\nPeople who have certain medical conditions or\\nwho are taking certain other medicines may have pro-\\nblems if they take beta blockers. Before taking these\\ndrugs, the physician should know about any of these\\nconditions:\\nALLERGIES. Anyone who has had unusual reac-\\ntions to beta blockers in the past should let his or her\\nphysician know before taking the drugs again. The\\nphysician should also be told about anyallergies to\\ninsect stings, medicines, foods, dyes, preservatives, or\\nother substances. In people with allergies to medicines,\\nfoods, or insect stings, beta blockers may make the\\nallergic reactions more severe and harder to treat.\\nAnyone who has an allergic reaction while taking\\nbeta blockers should get medical attention right\\naway and should make sure the physician in charge\\nknows that he or she is taking this medicine.\\nBeta blockers may also cause serious reactions in\\npeople who take allergy shots. Anyone taking this\\nmedicine should be sure to alert the physician before\\nhaving any allergy shots.\\nDIABETES. Beta blockers may make blood sugar\\nlevels rise and may hide some symptoms of low\\nblood sugar. Diabetic patients should discuss these\\npossible problems with their physicians.\\nPREGNANCY. Some studies of beta blockers show\\nthat these drugs cause problems in newborns whose\\nmothers use them duringpregnancy. Other studies do\\nnot show such effects. Women who are pregnant or\\nwho may become pregnant should check with their\\nphysicians about the use of beta blockers.\\nBREASTFEEDING. Some beta blockers pass into\\nbreast milk and may cause breathing problems, slow\\nheartbeat, and low blood pressure in nursing babies\\nwhose mothers take the drugs. Women who need to\\ntake beta blockers and who want to breastfeed their\\nbabies should check with their physicians.\\nOTHER MEDICAL CONDITIONS. Beta blockers may\\nincrease breathing problems or make allergic reactions\\nmore severe in people who have allergies,bronchitis,o r\\nemphysema. However, while breathing diseases were\\nonce thought to outrule use of beta blockers, new\\nresearch in 2004 shows that this may have been a\\nlarge misconception. A clinical trial showed that\\nmore than 98% of patients with chronic obstructive\\npulmonary disease safely used beta blockers. It is\\nadvised for patients with emphysema and other ser-\\nious pulmonary disease to check with a physician and\\ndiscuss the new findings.\\nIn people with an overactive thyroid, stopping beta\\nblockers suddenly may cause an increase in symptoms.\\nAlso, taking this medicine may hide a fast heartbeat,\\nwhich is one of the symptoms of overactive thyroid.\\nEffects of these drugs may be greater in people\\nwith kidney orliver disease because the medicine is\\ncleared from the body more slowly.\\nBeta blockers may also make the following med-\\nical conditions worse:\\n/C15Heart or blood vessel disease\\n/C15Unusually slow heartbeat (bradycardia)\\n/C15Myasthenia gravis (chronic disease causing muscle\\nweakness and possiblyparalysis)\\n/C15Psoriasis (itchy, scaly, red patches of skin)\\n/C15Depression (now, or in the past).\\nBefore using beta blockers, people with any of the\\nmedical problems listed in this section should make\\nsure their physicians are aware of their conditions.\\nUSE OF CERTAIN MEDICINES. Taking beta blockers\\nwith certain other drugs may affect the way the drugs\\nwork or may increase the chance of side effects.\\nSide effects\\nThe most common side effects aredizziness,d r o w s -\\niness, lightheadedness, sleep problems, unusual tiredness\\nor weakness, and decreased sexual ability. In men, this\\ncan occur asimpotence or delayed ejaculation. These\\nproblems usually go away as the body adjusts to the\\ndrug and do not require medical treatment unless they\\npersist or they interfere with normal activities. On the\\npositive side, research in 2004 showed that use of beta\\nblockers helps reduce risk for boenfractures.\\nMore serious side effects are possible. If any of the\\nfollowing side effects occur, the physician who prescribed\\nthe medicine should be notified as soon as possible:\\n526 GALE ENCYCLOPEDIA OF MEDICINE\\nBeta blockers'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='/C15Breathing problems\\n/C15Slow heartbeat\\n/C15Cold hands and feet\\n/C15Swollen ankles, feet, or lower legs\\n/C15Mental depression.\\nOther side effects may occur. Anyone who has\\nunusual symptoms after taking beta blockers should\\nget in touch with his or her physician.\\nInteractions\\nBeta blockers may interact with a number of other\\nmedicines. When this happens, the effects of one or\\nboth of the drugs may change or the risk of side effects\\nmay be greater. Anyone who takes beta blockers\\nshould let the physician know all other medicines he\\nor she is taking. Among the drugs that may interact\\nwith beta blockers are:\\n/C15Calcium channel blockers and other blood pressure\\ndrugs. Using these drugs with beta blockers may\\ncause unwanted effects on the heart.\\n/C15Insulin and diabetes medicines taken by mouth. Beta\\nblockers cause high blood sugar or hide the symp-\\ntoms of low blood sugar.\\n/C15Monoamine oxidase inhibitors (MAO) such as phe-\\nnelzine (Nardil) or tranylcypromine (Parnate), used\\nto treat conditions including depression and\\nParkinson’s disease. Taking beta blockers at the\\nsame time or within two weeks of taking MAO inhi-\\nbitors may cause severe high blood pressure.\\n/C15Airway-opening drugs (bronchodilators) such as ami-\\nnophylline (Somophyllin), dyphylline (Lufyllin)\\noxtriphylline (Choledyl), or theophylline\\n(Somophyllin-T). When combined with beta block-\\ners, the effects of both the beta blockers and the\\nairway-opening drugs may be lessened.\\n/C15Cocaine. High blood pressure, fast heartbeat, and\\nheart problems are possible when cocaine and beta\\nblockers are combined. Also, cocaine may interfere\\nwith the effects of beta blockers.\\n/C15Allergy shots or allergy skin tests. Beta blockers may\\nincrease the chance of serious reactions to these\\nmedicines.\\nThe list above may not include every drug that\\ninteracts with beta blockers. Checking with a physi-\\ncian or pharmacist before combining beta blockers\\nwith any other prescription or nonprescription (over-\\nthe-counter) medicine is advised.\\nResources\\nPERIODICALS\\n‘‘Study Reveals Fears Over Beta Blockers in COPD\\nUnfounded.’’ Pulse September 13, 2004: 8.\\n‘‘Use of Beta Blockers Associated With Decreased Risk for\\nFractures.’’ Life Science WeeklySeptember 28, 2004:\\n944.\\nNancy Ross-Flanigan\\nTeresa G. Odle\\nBeta-thalassemia see Thalassemia\\nBetamethasone see Corticosteroids\\nBeta2-microglobulin test\\nDefinition\\nBeta2-microglobulin is a protein found on the sur-\\nface of many cells. Testing is done primarily when\\nevaluating a person for certain kinds ofcancer affect-\\ning white blood cells including chronic lymphocytic\\nleukemia, non-Hodgkin’s lymphoma, and multiple\\nmyeloma or kidney disease.\\nPurpose\\nBeta2-microglobulin is plentiful on the surface of\\nwhite blood cells. Increased production or destruction\\nof these cells causes Beta\\n2-microglobulin levels in the\\nblood to increase. This increase is seen in people with\\ncancers involving white blood cells, but it is particu-\\nlarly meaningful in people newly diagnosed with mul-\\ntiple myeloma. Multiple myeloma is a malignancy\\n(cancer) of a certain kind of white blood cell, called a\\nplasma cell. At the time of diagnosis, the Beta\\n2-micro-\\nglobulin levels reflect how advanced the disease is and\\nthe likely prognosis for that person.\\nWhen kidney disease is suspected, comparing\\nblood and urine levels helps identify where the kidney\\nis damaged. Beta\\n2-microglobulin normally is filtered\\nout of the blood by the kidney’s glomeruli (a round\\nmass of capillary loops leading to each kidney tubule),\\nonly to be partially reabsorbed back into the blood\\nwhen it reaches the kidney’s tubules. In glomerular\\nkidney disease, the glomeruli can’t filter it out of the\\nblood, so levels increase in the blood and decrease in\\nthe urine. In tubular kidney disease, the tubules can’t\\nreabsorb it back into the blood, so urine levels rise and\\nblood levels fall. After a kidney transplant, increased\\nblood levels may be an early sign of rejection.\\nGALE ENCYCLOPEDIA OF MEDICINE 527\\nBeta2-microglobulin test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Increased urinary levels are found in people with\\nkidney damage caused by high exposure to the heavy\\nmetals cadmium and mercury. Periodic testing of\\nworkers exposed to these metals helps to detect begin-\\nning kidney damage.\\nBeta\\n2-microglobulin levels also rise during infec-\\ntion with some viruses, including cytomegalovirus and\\nhuman immunodeficiency virus (HIV). Studies show\\nthat as HIV disease advances, beta\\n2-microglobulin\\nlevels rise.\\nDescription\\nTesting methods vary, but most involve adding\\nthe person’s serum–the yellow, liquid part of blood–\\nor urine to one or more substances that bind to beta\\n2-\\nmicroglobulin in the serum or urine. The amount of\\nthe substance(s) bound to beta\\n2-microglobulin is mea-\\nsured and the original amount of beta2-microglobulin\\nis determined.\\nThe test is covered by insurance when medically\\nnecessary. Results are usually available the next day.\\nPreparation\\nThe blood test requires 5 mL of blood. A health-\\ncare worker ties a tourniquet on the person’s upper\\narm, locates a vein in the inner elbow region, and\\ninserts a needle into that vein. Vacuum action draws\\nthe blood through the needle into an attached tube.\\nCollection of the sample takes only a few minutes.\\nUrine may be a single collection or collected\\nthroughout a 24-hour time period. The urine should\\nbe refrigerated until it is brought to the laboratory and\\nmust not become acidic.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to the\\npuncture site until the bleeding stops reduces bruising.\\nWarm packs on the puncture site relieve discomfort.\\nNormal results\\n/C15Serum: less than or equ to 2.7 g/ml\\n/C15Urine: less than 1 mg 24 hours 0–160 g/L\\nAbnormal results\\nThe meaning of an abnormal result varies with the\\nclinical condition of the person tested. In a person with\\nmultiple myeloma, a higher level means a poorer prog-\\nnosis than a lower level. In a person with kidney dis-\\nease, an increased blood level means the problem is\\ntubular, not glomerular. In a kidney transplant\\npatient, an increase may be a sign of rejection, toxic\\namounts of antirejection medication, or a viral infec-\\ntion. An increased level in a worker exposed to cad-\\nmium or mercury may signal beginning kidney\\ndamage and in a person with HIV, advancing disease.\\nResources\\nBOOKS\\nLehmann, Craig A.Saunders Manual of Clinical Laboratory\\nScience. Philadelphia: W. B. Saunders Co., 1998.\\nNancy J. Nordenson\\nBile duct infection see Cholangitis\\nBile duct cancer\\nDefinition\\nBile duct cancer, or cholangiocarcinoma, is a\\nmalignant tumor of the bile ducts within the liver\\n(intrahepatic), or leading from the liver to the small\\nKEY TERMS\\nBeta2-microglobulin— A protein found on the sur-\\nface of many cells, particularly white blood cells.\\nChronic lymphocytic leukemia— A cancer of the\\nblood cells characterized by large numbers of can-\\ncerous, mature white blood cells and enlarged\\nlymph nodes.\\nGlomerular kidney disease— Disease of the kidney\\nthat affects the glomeruli, the part of the kidney that\\nfilters certain substances out of the blood.\\nMuliple myeloma— A malignancy (cancer) of a cer-\\ntain kind of white blood cell, called a plasma cell.\\nNon-Hodgkin’s lymphoma— Cancer that origi-\\nnates in the lymphatic system and typically spreads\\nthroughout the body.\\nTubular kidney disease— Disease of the kidney that\\naffect the tubules, the part of the kidney that allows\\ncertain substances to be reabsorbed back into the\\nblood.\\n528 GALE ENCYCLOPEDIA OF MEDICINE\\nBile duct cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='intestine (extrahepatic). It is a rare tumor with poor\\noutcome for most patients.\\nDescription\\nBile is a substance manufactured by the liver that\\naids in the digestion of food. Bile ducts are channels\\nthat carry the bile from the liver to the small intestine.\\nLike the tributaries of a river, the small bile ducts in\\nthe liver converge into two large bile ducts called the\\nleft and right hepatic ducts. These exit the liver and\\njoin to form the common hepatic duct. The gallblad-\\nder, which concentrates and stores the bile, empties\\ninto the common hepatic duct to form the common\\nbile duct. Finally, this large duct connects to the small\\nintestine where the bile can help digest food.\\nCollectively, this network of bile ducts is called the\\nbiliary tract.\\nBile duct cancer originates from the cells that line\\nthe inner surface of the bile ducts. A tumor may arise\\nanywhere along the biliary tract, either within or out-\\nside of the liver. Bile duct tumors are typically slow-\\ngrowing tumors that spread by local invasion of neigh-\\nboring structures and by way of lymphatic channels.\\nBile duct cancer is an uncommon malignancy. In\\nthe United States, approximately one case arises per\\n100,000 people per year, but it is more common in\\nSoutheast Asia. It occurs in men only slightly more\\noften than in women and it is most commonly diag-\\nnosed in people in their 50s and 60s. In fact, about\\n65% of patients with bile duct cancer are over age 65.\\nCauses and symptoms\\nA number of risk factors are associated with the\\ndevelopment of bile duct cancer:\\n/C15Primary sclerosingcholangitis. This disease is char-\\nacterized by extensive scarring of the biliary tract,\\nsometimes associated with inflammatory bowel\\ndisease.\\n/C15Choledochal cysts. These are abnormal dilatations of\\nthe biliary tract that usually form during fetal devel-\\nopment. There is evidence that these cysts may rarely\\narise during adulthood.\\n/C15Hepatolithiasis. This is the condition of stone forma-\\ntion within the liver (not including gallbladder stones).\\n/C15Liver flukes. Parasitic infection with certain worms is\\nthought to be at least partially responsible for the\\nhigher prevalence of bile duct cancer in Southeast\\nAsia.\\n/C15Thorotrast. This is a chemical that was previously\\ninjected intravenously during certain types of x rays.\\nIt is not in use anymore. Exposure to Thorotrast has\\nbeen implicated in the development of cancer of the\\nliver as well as the bile ducts.\\nSymptoms\\nJaundice is the first symptom in 90% of patients.\\nThis occurs when the bile duct tumor causes an\\nobstruction in the normal flow of bile from the liver\\nto the small intestine. Bilirubin, a component of bile,\\nbuilds up within the liver and is absorbed into the\\nbloodstream in excess amounts. This can be detected\\nin a blood test, but it can also manifest as yellowish\\ndiscoloring of the skin and eyes. The bilirubin in the\\nbloodstream also makes the urine appear dark.\\nAdditionally, the patient may experience generalized\\nitching due to the deposition of bile components in the\\nskin. Normally, a portion of the bile is excreted in\\nstool; bile actually gives stool its brown color. But\\nwhen the biliary tract is obstructed by tumor, the\\nstools may appear pale.\\nAbdominal pain, fatigue, weight loss, and poor\\nappetite are less common symptoms. Occasionally, if\\nobstruction of the biliary tract causes the gallbladder\\nto swell enormously yet without causing pain, the\\nphysician may be able to feel the gallbladder during a\\nKEY TERMS\\nAngiography— Radiographic examination of blood\\nvessels after injection with a special dye.\\nCholangiography— Radiographic examination of\\nthe bile ducts after injection with a special dye.\\nComputed tomography— Radiographic examina-\\ntion that obtains cross-sectional images of the\\nbody.\\nJaundice— Yellowish staining of the skin and eyes\\ndue to excess bilirubin in the bloodstream.\\nLymphatic— Pertaining to lymph, the clear fluid\\nthat is collected from tissues, flows through special\\nvessels, and joins the venous circulation.\\nMetastasis— The spread of cancerous tumor cells\\nfrom one part of the body to another.\\nResection— To surgically remove a part of the body\\nStent— Slender hollow catheter or rod placed\\nwithin a vessel or duct to provide support or main-\\ntain patency.\\nUltrasound— Radiographic imaging technique uti-\\nlizing high frequency sound waves.\\nGALE ENCYCLOPEDIA OF MEDICINE 529\\nBile duct cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='physical examination. Sometimes the biliary tract can\\nbecome infected, but this is normally a rare conse-\\nquence of invasive tests. Infection causesfever, chills,\\nand pain in the right upper portion of the abdomen.\\nDiagnosis\\nCertain laboratory tests of the blood may aid in\\nthe diagnosis. The most important one is the test for\\nelevated bilirubin levels in the bloodstream. Levels of\\nalkaline phosphatase and CA 19-9 may also be\\nelevated.\\nWhen symptoms, physical signs, and blood tests\\npoint toward an abnormality of the biliary tract, the\\nnext step involves radiographic exams. Ultrasound,\\ncomputed tomography (CT scan), andmagnetic reso-\\nnance imaging (MRI) are noninvasive and rapid. In\\nrecent years, MRI has become the favored imaging\\nchoice for initial diagnosis of cholangiocarcinoma\\nwhen the exam is available and affordable or covered\\nby insurance. These tests can often detect the actual\\ntumor as well as dilatation of the obstructed biliary\\ntract. If these tests indicate the presence of a tumor,\\ncholangiography is required. This procedure involves\\ninjecting dye into the biliary tract to obtain anatomic\\nimages of the bile ducts and the tumor. The specialist\\nthat performs this test can also insert small tubes, or\\nstents, into a partially obstructed portion of the bile\\nduct to prevent further obstruction by growth of the\\ntumor. This is vitally important since it may be the\\nonly intervention that is possible in certain patients.\\nCholangiography is an invasive test that carries a\\nsmall risk of infection of the biliary tract. The objective\\nof these radiological tests is to determine the size and\\nlocation of the tumor, as well as the extent of spread to\\nnearby structures.\\nThe treatment of bile duct tumors is usually not\\naffected by the specific type of cancer cells that com-\\nprise the tumor. For this reason, some physicians\\nforego biopsy of the tumor.\\nTreatment\\nThe treatment is with surgical resection (removal)\\nof the tumor and all involved structures. Unfortunately,\\nsometimes the cancer has already spread too far when\\nthe diagnosis is made. Thus, in the treatment of bile\\nduct cancer, the first question to answer is if the tumor\\nmay be safely resected by surgery with reasonable\\nbenefit to the patient. If the cancer involves\\ncertain blood vessels or has spread widely throughout\\nthe liver, resection may not be possible. Sometimes\\nfurther invasive testing is required.\\nAngiography can determine if the blood vessels are\\ninvolved. Laparoscopy is a surgical procedure that\\nallows the surgeon to directly assess the tumor and\\nnearby lymph nodes without making a large incision\\nin the abdomen. Only about 45% of bile duct cancers\\nare ultimately resectable.\\nIf the tumor is resectable, and the patient is\\nhealthy enough to tolerate the operation, the specific\\ntype of surgery performed depends on the location of\\nthe tumor. For tumors within the liver or high up in\\nthe biliary tract, resection of part of the liver may be\\nrequired. Tumors in the middle portion of the biliary\\ntract can be removed alone. Tumors of the lower end\\nof the biliary tract may require extensive resection of\\npart of the pancreas, small intestine, and stomach to\\nensure complete resection.\\nUnfortunately, sometimes the cancer appears\\nresectable by all the radiological and invasive tests,\\nbut is found to be unresectable during surgery. In\\nthis scenario, a bypass operation can relieve the biliary\\ntract obstruction, but does not remove the tumor\\nitself. This does not produce a cure but it can offer a\\nbetter quality of life for the patient.\\nPrognosis\\nPrognosis depends on the stage and resectability\\nof the tumor. If the patient cannot undergo surgical\\nresection, the survival rate is commonly less than one\\nyear. If the tumor is resected, the survival rate\\nimproves, with 20% of these patients surviving past\\nfive years.\\nClinical trials\\nStudies of new treatments in patients are known as\\nclinical trials. These trials seek to compare the stan-\\ndard method of care with a new method, or the trials\\nmay be trying to establish whether one treatment is\\nmore beneficial for certain patients than others.\\nSometimes, a new treatment that is not being offered\\non a wide scale may be available to patients participat-\\ning in clinical trials, but participating in the trials may\\ninvolve some risk. To learn more about clinical trials,\\npatients can call the National Cancer Institute (NCI)\\nat 1-800-4-CANCER or visit the NCI web site for\\npatients at .\\nPrevention\\nOther than the avoidance of infections caused by\\nliver flukes, there are no known preventions for this\\ncancer.\\n530 GALE ENCYCLOPEDIA OF MEDICINE\\nBile duct cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nBOOKS\\nAbeloff, Martin D., editor. ‘‘Cholangiocarcinoma.’’ In\\nClinical Oncology.2nd ed. New York: Churchill\\nLivingstone, 2000, pp.1722-1723.\\nAhrendt, Steven A., and Henry A. Pitt. ‘‘Biliary Tract.’’ In\\nSabiston Textbook of Surgery, edited by Courtney\\nTownsend Jr., 16th ed. Philadelphia: W.B. Saunders\\nCompany, 2001, pp. 1076-1111.\\nPERIODICALS\\n‘‘COX–2 Promoter Enhances the Efficacy of\\nCholangiosarcoma Gene Therapy.’’Cancer Weekly\\n(May 20, 2003): 167.\\nKhan, S.A., et al. ‘‘Guidelines for the Diagnosis and\\nTreatment of Cholangiosarcoma: Consensus\\nDocument.’’ Gut (November 2002): vi1–9.\\nORGANIZATIONS\\nThe American Cancer Society. 1-800-ACS 2345. .\\nAmerican Liver Foundation.1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nNational Cancer Institute (National Institutes of Health).\\n9000 Rockville Pike, Bethesda, MD 20892. (800) 422-\\n6237. .\\nKevin O. Hwang M.D.\\nTeresa G. Odle\\nBile duct atresia see Biliary atresia\\nBile flow obstruction see Cholestasis\\nBilharziasis see Schistosomiasis\\nBiliary atresia\\nDefinition\\nBiliary atresia is the failure of a fetus to develop an\\nadequate pathway for bile to drain from the liver to the\\nintestine.\\nDescription\\nBiliary atresia is the most common lethalliver\\ndisease in children, occurring once every 10,000–\\n15,000 live births. Half of all liver transplants are\\ndone for this reason.\\nThe normal anatomy of the bile system begins\\nwithin the liver, where thousands of tiny bile ducts\\ncollect bile from liver cells. These ducts merge into\\nlarger and larger channels, like streams flowing into\\nrivers, until they all pour into a single duct that empties\\ninto the duodenum (first part of the small intestine).\\nBetween the liver and the duodenum this duct has a side\\nchannel connected to the gall bladder. The gall bladder\\nstores bile and concentrates it, removing much of its\\nwater content. Then, when a meal hits the stomach, the\\ngall bladder contracts and empties its contents.\\nBile is a mixture of waste chemicals that the liver\\nremoves from the circulation and excretes through the\\nbiliary system into the intestine. On its way out, bile\\nassists in the digestion of certain nutrients. If bile\\ncannot get out because the channels are absent or\\nblocked, it backs up into the liver and eventually into\\nthe rest of the body. The major pigment in bile is a\\nchemical called bilirubin, which is yellow. Bilirubin is a\\nbreakdown product of hemoglobin (the red chemical\\nin blood that carries oxygen). If the body accumulates\\nan excess of bilirubin, it turns yellow (jaundiced). Bile\\nalso turns the stool brown. Without it, stools are the\\ncolor of clay.\\nCauses and symptoms\\nIt is possible that a viral infection is responsible\\nfor this disease, but evidence is not yet convincing. The\\ncause remains unknown.\\nThe affected infant will appear normal at birth\\nand during the newborn period. After two weeks the\\nnormal jaundice of the newborn will not disappear,\\nand the stools will probably be clay-colored. At this\\npoint, the condition will come to the attention of a\\nphysician. If not, the child’s abdomen will begin to\\nswell, and the infant will get progressively more ill.\\nNearly all untreated children will die of liver failure\\nwithin two years.\\nDiagnosis\\nThe persistence of jaundice beyond the second\\nweek in a newborn with clay-colored stools is a sure\\nsign of obstruction to the flow of bile. An immediate\\nevaluation that includes blood tests and imaging of the\\nbiliary system will confirm the diagnosis.\\nTreatment\\nSurgery is the only treatment. Somehow the sur-\\ngeon must create an adequate pathway for bile to\\nescape the liver into the intestine. The altered anatomy\\nof the biliary system is different in every case, calling\\nupon the surgeon’s skill and experience to select and\\nexecute the most effective among several options. If\\nthe obstruction is only between the gall bladder and\\nGALE ENCYCLOPEDIA OF MEDICINE 531\\nBiliary atresia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='the intestine, it is possible to attach a piece of intestine\\ndirectly to the gall bladder. More likely, the upper\\nbiliary system will also be inadequate, and the surgeon\\nwill attach a piece of intestine directly to the liver–the\\nKasai procedure. In its wisdom, the body will discover\\nthat the tiny bile ducts in that part of the liver are\\ndischarging their bile directly into the intestine. Bile\\nwill begin to flow in that direction, and the channels\\nwill gradually enlarge. Survival rates for the Kasai\\nprocedure are commonly 50% at five years and 15%\\nat 10 years. Persistent disease in the liver gradually\\ndestroys the organ.\\nPrognosis\\nBefore liver transplants became available, even\\nprompt and effective surgery did not cure the whole\\nproblem. Biliary drainage can usually be established,\\nbut the patients still have a defective biliary system\\nthat develops progressive disease and commonly leads\\nto an earlydeath. Transplantation now achieves up to\\n90% one-year survival rates and promises to prevent\\nthe chronic disease that used to accompany earlier\\nprocedures.\\nPrevention\\nThe specific cause of this birth defect is unknown,\\nso all that women can do is to practice the many\\ngeneral preventive measures, even before they\\nconceive.\\nLiverCystic duct\\nPyloric sphincter\\nPancreas\\nDuodenum\\nGallbladder\\nCommon bile duct\\nBiliary atresia is a congenital condition in which the pathway for bile to drain from the liver to the intestine is undeveloped. It is\\nthe most common lethal liver disease in children.(Illustration by Electronic Illustrators Group).\\nKEY TERMS\\nDuodenum— The first part of the small intestine,\\nbeginning at the outlet of the stomach.\\nHemoglobin— The red, iron-containing chemical\\nin the blood that carries oxygen to the tissues.\\nJaundice— The yellow color taken on by a patient\\nwhose liver is unable to excrete bilirubin. A normal\\ncondition in the first week of life due to the infant’s\\ndelayed ability to process certain waste products.\\nKernicterus— A potentially lethal disease of new-\\nborns caused by excessive accumulation of the bile\\npigment bilirubin.\\n532 GALE ENCYCLOPEDIA OF MEDICINE\\nBiliary atresia'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Biliary atresia is a congenital condition in which\\nthe pathway for bile to drain from the liver to the\\nintestine is undeveloped. It is the most common lethal\\nliver disease in children.\\nResources\\nBOOKS\\nFeldman, Mark, et al. ‘‘Diseases of the Bile Ducts.’’\\nSleisenger & Fordtran’s Gastrointestinal and Liver\\nDisease. Philadelphia: W. B. Saunders Co., 1998.\\nJ. Ricker Polsdorfer, MD\\nBiliary duct cancer see Gallbladder cancer\\nBiliary tract cancer see Bile duct cancer\\nBilirubin test see Liver function tests\\nBinge-eating disorder\\nDefinition\\nBinge eating disorder (BED) is characterized by a\\nloss of control over eating behaviors. The binge eater\\nconsumes unnaturally large amounts of food in a short\\ntime period, but unlike a bulimic, does not regularly\\nengage in any inappropriate weight-reducing beha-\\nviors (for example, excessiveexercise, vomiting, taking\\nlaxatives) following the binge episodes.\\nDescription\\nBED typically strikes individuals sometime between\\nadolescence and the early twenties. Because of the nat-\\nure of the disorder, most BED patients are overweight\\nor obese. Studies of weight loss programs have shown\\nthat an average of 30% of individuals enrolling in these\\nprograms report binge eating behavior.\\nCauses and symptoms\\nBinge eating episodes may act as a psychological\\nrelease for excessive emotionalstress. Other circum-\\nstances that may predispose an individual to BED\\ninclude heredity and affective disorders, such as\\nmajor depression. BED patients are also more likely\\nto have a comorbid, or co-existing, diagnosis of impul-\\nsive behaviors (for example, compulsive buying),post-\\ntraumatic stress disorder (PTSD), panic disorder,o r\\npersonality disorders.\\nIndividuals who develop BED often come from\\nfamilies who put an unnatural emphasis on the\\nimportance of food, for example, as a source of com-\\nfort in times of emotional distress. As children, BED\\npatients may have been taught to clean their plate\\nregardless of their appetite, or that finishing a meal\\nmade them a ‘‘good’’ girl or boy. Cultural attitudes\\ntowards beauty and thinness may also be a factor in\\nthe BED equation.\\nDuring binge episodes, BED patients experience a\\ndefinite sense of lost control over their eating. They eat\\nquickly and to the point of discomfort even if they\\naren’t hungry. They typically binge alone two or more\\ntimes a week, and often feel depressed and guilty once\\nthe episode has concluded.\\nDiagnosis\\nBinge eating disorder is usually diagnosed and\\ntreated by a psychiatrist and/or a psychologist. In\\naddition to an interview with the patient, personality\\nand behavioral inventories, such as the Minnesota\\nMultiphasic Personality Inventory (MMPI), may be\\nadministered as part of the assessment process. One\\nof several clinical inventories, or scales, may also be\\nused to assess depressive symptoms, including the\\nHamilton Depression Scale (HAM-D) or Beck\\nDepression Inventory (BDI). These tests may be admi-\\nnistered in an outpatient or hospital setting.\\nTreatment\\nMany BED individuals binge after long intervals\\nof excessive dietary restraint; therapy helps normalize\\nthis pattern. The initial goal of BED treatment is\\nto teach the patient to gain control over his eating\\nbehavior by focusing on eating regular meals and\\navoiding snacking. Cognitive-behavioral therapy ,\\ngroup therapy, or interpersonal psychotherapy may\\nbe employed to uncover the emotional motives, dis-\\ntorted thinking, and behavioral patterns behind the\\nbinge eating.\\nKEY TERMS\\nBulimia— An eating disorder characterized by\\nbinge eating and inappropriate compensatory\\nbehavior, such as vomiting, misusing laxatives, or\\nexcessive exercise.\\nCognitive behavioral therapy— A therapy that pays\\nparticular attention to a patient’s behavior and\\nthinking processes rather than underlying psycho-\\nlogical causes of an activity.\\nGALE ENCYCLOPEDIA OF MEDICINE 533\\nBinge-eating disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Because the prevalence of depression in BED\\npatients is high, psychopharmacological treatment\\nwith antidepressants may also be prescribed. Once\\nthe binge eating behavior is curbed and depressive\\nsymptoms are controlled, the physical symptoms\\nof BED can be addressed. The overweight BED\\npatient may be placed on a moderate exercise pro-\\ngram and a nutritionist may be consulted to educate\\nthe patient on healthy food choices and strategies for\\nweight loss.\\nPrognosis\\nThe poor dietary habits andobesity that are symp-\\ntomatic of BED can lead to serious health problems,\\nsuch as high blood pressure, heart attacks, and dia-\\nbetes, if left unchecked. BED is a chronic condition\\nthat requires ongoing medical and psychological man-\\nagement. To bring long-term relief to the BED patient,\\nit is critical to address the underlying psychological\\ncauses behind binge eating behaviors. It appears that\\nup to 50% of BED patients will stop bingeing with\\ncognitive behavioral therapy (CBT).\\nResources\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nAmerican Psychological Association (APA). 750 First St.\\nNE, Washington, DC 20002-4242. (202) 336-5700.\\n.\\nEating Disorders Awareness and Prevention. 603 Stewart\\nSt., Suite 803, Seattle, WA 98101. (206) 382-3587.\\nNational Eating Disorders Organization (NEDO). 6655\\nSouth Yale Ave., Tulsa, OK 74136. (918) 481-4044.\\nOvereaters Anonymous World Service Office. 6075 Zenith\\nCt. NE, Rio Rancho, NM 87124. (505) 891-2664.\\n.\\nPaula Anne Ford-Martin\\nBiofeedback\\nDefinition\\nBiofeedback, or applied psychophysiological\\nfeedback, is a patient-guided treatment that teaches\\nan individual to control muscle tension,pain, body\\ntemperature, brain waves, and other bodily functions\\nand processes through relaxation, visualization, and\\nother cognitive control techniques. The name\\nbiofeedback refers to the biological signals that are\\nfed back, or returned, to the patient in order for the\\npatient to develop techniques of manipulating them.\\nPurpose\\nBiofeedback has been used to successfully treat a\\nnumber of disorders and their symptoms, including\\ntemporomandibular joint disorder (TMJ), chronic\\npain, irritable bowel syndrome (IBS), Raynaud’s\\nsyndrome, epilepsy, attention-deficit hyperactivity\\ndisorder ( ADHD), migraine headaches, anxiety,\\ndepression, traumatic brain injury, andsleep disorders.\\nIllnesses that may be triggered at least in part by\\nstress are also targeted by biofeedback therapy. Certain\\ntypes of headaches, high blood pressure,bruxism (teeth\\ngrinding), post-traumatic stress disorder,e a t i n gd i s o r -\\nders, substance abuse, and someanxiety disordersmay\\nbe treated successfully by teaching patients the ability\\nto relax and release both muscle and mental tension.\\nBiofeedback is often just one part of a comprehensive\\ntreatment program for some of these disorders.\\nNASA has used biofeedback techniques to treat\\nastronauts who suffer from severe space sickness, dur-\\ning which the autonomic nervous system is disrupted.\\nScientists at the University of Tennessee have adapted\\nthese techniques to treat individuals suffering from\\nsevere nausea and vomiting that is also rooted in\\nautonomic nervous system dysfunction.\\nA patient undergoing biofeedback therapy. (Photo\\nResearchers, Inc. Reproduced by permission.)\\n534 GALE ENCYCLOPEDIA OF MEDICINE\\nBiofeedback'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recent research also indicates that biofeedback may\\nbe a useful tool in helping patients withurinary incon-\\ntinence regain bladder control. Individuals learning pel-\\nvic-floor muscle strengthening exercises can gain better\\ncontrol over these muscles by using biofeedback. Sensors\\na r ep l a c e do nt h em u s c l e st ot r a i nt h ep a t i e n tw h e r et h e y\\nare and when proper contractions are taking place.\\nDescription\\nOrigins\\nIn 1961, Neal Miller, an experimental psycholo-\\ngist, suggested that autonomic nervous system\\nresponses (for instance, heart rate, blood pressure,\\ngastrointestinal activity, regional blood flow) could\\nbe under voluntary control. As a result of his experi-\\nments, he showed that such autonomic processes were\\ncontrollable. This work led to the creation of biofeed-\\nback therapy. Willer’s work was expanded by other\\nresearchers. Thereafter, research performed in the\\n1970s by UCLA researcher Dr. Barry Sterman estab-\\nlished that both cats and monkeys could be trained to\\ncontrol their brain wave patterns. Sterman then used\\nhis research techniques on human patients with epi-\\nlepsy, where he was able to reduce seizures by 60%\\nwith the use of biofeedback techniques. Throughout\\nthe 1970s, other researchers published reports of their\\nuse of biofeedback in the treatment of cardiacarrhyth-\\nmias, headaches, Raynaud’s syndrome, and excess\\nstomach acid, and as a tool for teaching deep relaxa-\\ntion. Since the early work of Miller and Sterman,\\nbiofeedback has developed into a front-line behavioral\\ntreatment for an even wider range of disorders and\\nsymptoms.\\nDuring biofeedback, special sensors are placed on\\nthe body. These sensors measure the bodily function\\nthat is causing the patient problem symptoms, such as\\nheart rate, blood pressure, muscle tension (EMG or\\nelectromyographic feedback), brain waves (EEC or elec-\\ntroencophalographic feedback), respiration, and body\\ntemperature (thermal feedback), and translates the\\ninformation into a visual and/or audible readout, such\\nas a paper tracing, a light display, or a series of beeps.\\nWhile the patient views the instantaneous feed-\\nback from the biofeedback monitors, he or she begins\\nto recognize what thoughts, fears, and mental images\\ninfluence his or her physical reactions. By monitor-\\ning this relationship between mind and body, the\\npatient can then use these same thoughts and mental\\nimages as subtle cues, as these act as reminders to\\nbecome deeply relaxed, instead of anxious. These\\nreminders also work to manipulate heart beat, brain\\nwave patterns, body temperature, and other bodily\\nfunctions. This is achieved through relaxation exer-\\ncises, mental imagery, and other cognitive therapy\\ntechniques.\\nAs the biofeedback response takes place, patients\\ncan actually see or hear the results of their efforts\\ninstantly through the sensor readout on the biofeed-\\nback equipment. Once these techniques are learned\\nand the patient is able to recognize the state of relaxa-\\ntion or visualization necessary to alleviate symptoms,\\nthe biofeedback equipment itself is no longer needed.\\nThe patient then has a powerful, portable, and self-\\nadministered treatment tool to deal with problem\\nsymptoms.\\nKEY TERMS\\nAutonomic nervous system— The part of the ner-\\nvous system that controls so-called involuntary\\nfunctions, such as heart rate, salivary gland secre-\\ntion, respiratory function, and pupil dilation.\\nBruxism— Habitual, often unconscious, grinding of\\nthe teeth.\\nEpilepsy— A neurological disorder characterized\\nby the sudden onset of seizures.\\nPlacebo effect— Placebo effect occurs when a treat-\\nment or medication with no known therapeutic\\nvalue (a placebo) is administered to a patient, and\\nthe patient’s symptoms improve. The patient\\nbelieves and expects that the treatment is going to\\nwork, so it does. The placebo effect is also a factor to\\nsome degree in clinically-effective therapies, and\\nexplains why patients respond better than others to\\ntreatment despite similar symptoms and illnesses.\\nRaynaud’s syndrome— A vascular, or circulatory\\nsystem, disorder which is characterized by abnor-\\nmally cold hands and feet. This chilling effect is\\ncaused by constriction of the blood vessels in the\\nextremities, and occurs when the hands and feet\\nare exposed to cold weather. Emotional stress can\\nalso trigger the cold symptoms.\\nSchizophrenia— Schizophrenia is a psychotic dis-\\norder that causes distortions in perception (delu-\\nsions and hallucinations), inappropriate moods\\nand behaviors, and disorganized or incoherent\\nspeech and behavior.\\nTemporomandibular joint disorder—Inflammation,\\nirritation, and pain of the jaw caused by improper\\nopening and closing of the temporomandibular\\njoint. Other symptoms include clicking of the jaw\\nand a limited range of motion.\\nGALE ENCYCLOPEDIA OF MEDICINE 535\\nBiofeedback'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Biofeedback that specializes in reading and alter-\\ning brain waves is sometimes calledneurofeedback.\\nThe brain produces four distinct types of brain\\nwaves—delta, theta, alpha, and beta—that all operate\\nat a different frequency. Delta, the slowest frequency\\nwave, is the brain wave pattern associated with sleep.\\nBeta waves, which occur in a normal, waking state,\\ncan range from 12-35 Hz. Problems begin to develop\\nwhen beta wave averages fall in the low end (under-\\narousal) or the high end (overarousal) of that spec-\\ntrum. Underarousal might be present in conditions\\nsuch as depression or attention-deficit disorder, and\\noverarousal may be indicative of an anxiety disorder,\\nobsessive compulsive disorder, or excessive stress.\\nBeta wave neurofeedback focuses on normalizing\\nthat beta wave pattern to an optimum value of around\\n14 Hz. A second type of neurofeedback, alpha-theta,\\nfocuses on developing the more relaxing alpha (8-13\\nHz) and theta waves (4-9 Hz) that are usually asso-\\nciated with deep, meditative states, and has been used\\nwith some success in substanceabuse treatment.\\nThrough brain wave manipulation, neurofeedback\\ncan be useful in treating a variety of disorders that are\\nsuspected or proven to impact brain wave patterns,\\nsuch as epilepsy, attention-deficit disorder, migraine\\nheadaches, anxiety, depression, traumatic brain injury,\\nand sleep disorders. The equipment used for neurofeed-\\nback usually uses a monitor as an output device. The\\nmonitor displays specific patterns that the patient\\nattempts to change by producing the appropriate type\\nof brain wave. Or, the monitor may reward the patient\\nfor producing the appropriate brain wave by producing\\na positive reinforcer, or reward. For example, children\\nmay be rewarded with a series of successful moves in a\\ndisplayed video game.\\nDepending on the type of biofeedback, individuals\\nm a yn e e du pt o3 0s e s s i o n sw i t hat r a i n e dp r o f e s s i o n a lt o\\nlearn the techniques required to control their symptoms\\non a long-term basis. Therapists usually recommend\\nthat their patients practice both biofeedback and relaxa-\\ntion techniques on their own at home.\\nPreparations\\nBefore initiating biofeedback treatment, the\\ntherapist and patient will have an initial consultation\\nto record the patients medical history and treatment\\nbackground and discuss goals for therapy.\\nBefore a neurofeedback session, an EEG is taken\\nfrom the patient to determine his or her baseline brain-\\nwave pattern.\\nBiofeedback typically is performed in a quiet and\\nrelaxed atmosphere with comfortable seating for the\\npatient. Depending on the type and goals of biofeed-\\nback being performed, one or more sensors will be\\nattached to the patient’s body with conductive gel\\nand/or adhesives. These may include:\\n/C15Electromyographic (EMG) sensors. EMG sensors\\nmeasure electrical activity in the muscles, specifically\\nmuscle tension. In treating TMJ or bruxism, these\\nsensors would be placed along the muscles of the jaw.\\nChronic pain might be treated by monitoring electri-\\ncal energy in other muscle groups.\\n/C15Galvanic skin response (GSR) sensors. These are\\nelectrodes placed on the fingers that monitor per-\\nspiration, or sweat gland, activity. These may also\\nbe called skin conductance level (SCL).\\n/C15Temperature sensors. Temperature, or thermal, sen-\\nsors measure body temperature and changes in blood\\nflow.\\n/C15Electroencephalography (EEG) sensors. These elec-\\ntrodes are applied to the scalp to measure the elec-\\ntrical activity of the brain, or brain waves.\\n/C15Heart rate sensors. A pulse monitor placed on the\\nfinger tip can monitor pulse rate.\\n/C15Respiratory sensors. Respiratory sensors monitor\\noxygen intake and carbon dioxide output.\\nPrecautions\\nIndividuals who use a pacemaker or other implan-\\ntable electrical devices should inform their biofeed-\\nback therapist before starting treatments, as certain\\ntypes of biofeedback sensors have the potential to\\ninterfere with these devices.\\nBiofeedback may not be suitable for some\\npatients. Patients must be willing to take a very active\\nrole in the treatment process. And because biofeed-\\nback focuses strictly on behavioral change, those\\npatients who wish to gain insight into their symptoms\\nby examining their past might be better served by\\npsychodynamic therapy.\\nBiofeedback may also be inappropriate for cogni-\\ntively impaired individuals, such as those patients with\\norganic brain disease or a traumatic brain injury,\\ndepending on their levels of functioning.\\nPatients with specific pain symptoms of unknown\\norigin should undergo a thorough medical examina-\\ntion before starting biofeedback treatments to rule out\\nany serious underlying disease. Once a diagnosis has\\nbeen made, biofeedback can be used concurrently with\\nconventional treatment.\\n536 GALE ENCYCLOPEDIA OF MEDICINE\\nBiofeedback'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Biofeedback may only be one component of a\\ncomprehensive treatment plan. For illnesses and\\nsymptoms that are manifested from an organic disease\\nprocess, such as cancer or diabetes, biofeedback\\nshould be an adjunct to (complementary to), and not\\na replacement for, conventional medical treatment.\\nSide effects\\nThere are no known side effects to properly admi-\\nnistered biofeedback or neurofeedback sessions.\\nResearch and general acceptance\\nPreliminary research published in late 1999 indi-\\ncated that neurofeedback may be a promising new tool\\nin the treatment of schizophrenia. Researchers\\nreported that schizophrenic patients had used neuro-\\nfeedback to simulate brain wave patterns that antipsy-\\nchotic medications produce in the brain. Further\\nresearch is needed to determine what impact this may\\nhave on treatment for schizophrenia.\\nThe use of biofeedback techniques to treat an array\\nof disorders has been extensively described in the med-\\nical literature. Controlled studies for some applications\\nare limited, such as for the treatment of menopausal\\nsymptoms and premenstrual disorder (PMS). There is\\nalso some debate over the effectiveness of biofeedback\\nin ADHD treatment, and the lack of controlled studies\\non that application. While many therapists, counselors,\\nand mental health professionals have reported great\\nsuccess with treating their ADHD patients with neuro-\\nfeedback techniques, some critics attribute this positive\\ntherapeutic impact to a placebo effect.\\nThere may also be some debate among mental\\nhealth professionals as to whether biofeedback should\\nbe considered a first line treatment for some mental\\nillnesses, and to what degree other treatments, such as\\nmedication, should be employed as an adjunct therapy.\\nResources\\nBOOKS\\nRobbins, Jim.A Symphony in the Brain: The Evolution of the\\nNew Brain Wave Biofeedback.Boston, MA: Atlantic\\nMonthly Press, 2000.\\nPERIODICALS\\nRobbins, Jim. ‘‘On the Track with Neurofeedback.’’\\nNewsweek 135, no. 25 (June 2000): 76.\\nORGANIZATIONS\\nAssociation for Applied Psychotherapy and Biofeedback.\\n10200 W. 44th Avenue, Suite 304, Wheat Ridge, CO\\n80033-2840. (303) 422-8436. .\\nBiofeedback Certification Institute of America.10200 W.\\n44th Avenue, Suite 310, Wheat Ridge, CO 80033. (303)\\n420-2902.\\nPaula Anne Ford-Martin\\nBiopsy see Bone biopsy; Bone marrow\\naspiration and biopsy; Brain biopsy;\\nBreast biopsy; Cervical conization; CT-\\nguided biopsy; Endometrial biopsy; Joint\\nbiopsy; Kidney biopsy; Liver biopsy; Lung\\nbiopsy; Lymph node biopsy; Myocardial\\nbiopsy; Pleural biopsy; Prostate biopsy;\\nSkin biopsy; Small intestine biopsy;\\nThyroid biopsy\\nBipolar disorder\\nDefinition\\nBipolar, or manic-depressive disorder, is a mood\\ndisorder that causes radical emotional changes and\\nmood swings, from manic highs to depressive lows.\\nThe majority of bipolar individuals experience alter-\\nnating episodes ofmania and depression.\\nDescription\\nIn the United States alone, more than two million\\npeople are diagnosed with bipolar disorder. Research\\nshows that as many as 10 million people might be\\naffected by bipolar disorder, which is the sixth-leading\\ncause of disability worldwide. The average age of\\nonset of bipolar disorder is from adolescence through\\nthe early twenties. However, because of the complexity\\nof the disorder, a correct diagnosis can be delayed for\\nseveral years or more. In a survey of bipolar patients\\nconducted by the National Depressive and Manic\\nDepressive Association (MDMDA), one-half of\\nrespondents reported visiting three or more profes-\\nsionals before receiving a correct diagnosis, and over\\none-third reported a wait of ten years or more before\\nthey were correctly diagnosed.\\nBipolar I disorder is characterized by manic epi-\\nsodes, the ‘‘high’’ of the manic-depressive cycle. A\\nperson with bipolar disorder experiencing mania often\\nhas feelings of self-importance, elation, talkativeness,\\nincreased sociability, and a desire to embark on goal-\\noriented activities, coupled with the characteristics of\\nirritability, impatience, impulsiveness, hyperactivity,\\nGALE ENCYCLOPEDIA OF MEDICINE 537\\nBipolar disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='and a decreased need for sleep. Usually this manic\\nperiod is followed by a period of depression, although\\na few bipolar I individuals may not experience a major\\ndepressive episode. Mixed states, where both manic or\\nhypomanic symptoms and depressive symptoms occur\\nat the same time, also occur frequently with bipolar I\\npatients (for example, depression with the racing\\nthoughts of mania). Also, dysphoric mania is common\\n(mania characterized by anger and irritability).\\nBipolar II disorder is characterized by major\\ndepressive episodes alternating with episodes of hypo-\\nmania, a milder form of mania. Bipolar depression\\nmay be difficult to distinguish from a unipolar major\\ndepressive episode. Patients with bipolar depression\\ntend to have extremely low energy, retarded mental\\nand physical processes, and more profoundfatigue\\n(for example, hypersomnia; a sleep disorder marked\\nby a need for excessive sleep or sleepiness when awake)\\nthan unipolar depressives.\\nCyclothymia refers to the cycling of hypomanic\\nepisodes with depression that does not reach major\\ndepressive proportions. One-third of patients with\\ncyclothymia will develop bipolar I or II disorder\\nlater in life.\\nA phenomenon known as rapid cycling occurs in\\nup to 20% of bipolar I and II patients. In rapid cycling,\\nmanicanddepressiveepisodesmustalternatefrequently;\\nat least four times in 12 months; to meet the diagnostic\\ndefinition. In some cases of ‘‘ultra-rapid cycling,’’ the\\npatient may bounce between manic and depressive\\nstates several times within a 24-hour period. This con-\\ndition is very hard to distinguish from mixed states.\\nBipolar NOS is a category for bipolar states that\\ndo not clearly fit into the bipolar I, II, or cyclothymia\\ndiagnoses.\\nCauses and symptoms\\nThe source of bipolar disorder has not been\\nclearly defined. Because two-thirds of bipolar patients\\nhave a family history of affective or emotional disor-\\nders, researchers have searched for a genetic link to the\\ndisorder. Several studies have uncovered a number of\\npossible genetic connections to the predisposition for\\nbipolar disorder. A 2003 study found thatschizophre-\\nnia and bipolar disorder could have similar genetic\\ncauses that arise from certain problems with genes\\nassociated with myelin development in the central\\nnervous system. (Myelin is a white, fat-like substance\\nthat forms a sort of layer or sheath around nerve\\nfibers.) Another possible biological cause under inves-\\ntigation is the presence of an excessive calcium build-\\nup in the cells of bipolar patients. Also, dopamine and\\nother neurochemical transmitters appear to be impli-\\ncated in bipolar disorder and these are under intense\\ninvestigation.\\nOver one-half of patients diagnosed with bipolar\\ndisorder have a history ofsubstance abuse. There is a\\nKEY TERMS\\nAffective disorder— An emotional disorder invol-\\nving abnormal highs and/or lows in mood. Now\\ntermed mood disorder.\\nAnticonvulsant medication— A drug used to pre-\\nvent convulsions or seizures; often prescribed in\\nthe treatment of epilepsy. Several anticonvulsant\\nmedications have been found effective in the treat-\\nment of bipolar disorder.\\nAntipsychotic medication— A drug used to treat\\npsychotic symptoms, such as delusions or halluci-\\nnations, in which patients are unable to distinguish\\nfantasy from reality.\\nBenzodiazpines— A group of tranquilizers having\\nsedative, hypnotic, antianxiety, amnestic, anticon-\\nvulsant, and muscle relaxant effects.\\nDSM-IV— Diagnostic and Statistical Manual of\\nMental Disorders, Fourth Edition (DSM-IV). This\\nreference book, published by the American\\nPsychiatric Association, is the diagnostic standard\\nfor most mental health professionals in the United\\nStates.\\nECT— Electroconvulsive therapy sometimes is used\\nto treat depression or mania when pharmaceutical\\ntreatment fails.\\nHypomania— A milder form of mania which is\\ncharacteristic of bipolar II disorder.\\nMixed mania/mixed state— A mental state in\\nwhich symptoms of both depression and mania\\noccur simultaneously.\\nMania— An elevated or euphoric mood or irritable\\nstate that is characteristic of bipolar I disorder.\\nNeurotransmitter— A chemical in the brain that\\ntransmits messages between neurons, or nerve\\ncells. Changes in the levels of certain neurotrans-\\nmitters, such as serotonin, norepinephrine, and\\ndopamine, are thought to be related to bipolar\\ndisorder.\\nPsychomotor retardation— Slowed mental and\\nphysical processes characteristic of a bipolar\\ndepressive episode.\\n538 GALE ENCYCLOPEDIA OF MEDICINE\\nBipolar disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='high rate of association betweencocaine abuse and\\nbipolar disorder. Some studies have shown up to 30%\\nof abusers meeting the criteria for bipolar disorder. The\\nemotional and physical highs and lows of cocaine use\\ncorrespond to the manic depression of the bipolar\\npatient, making the disorder difficult to diagnosis.\\nFor some bipolar patients, manic and depressive\\nepisodes coincide with seasonal changes. Depressive\\nepisodes are typical during winter and fall, and\\nmanic episodes are more probable in the spring and\\nsummer months.\\nSymptoms of bipolar depressive episodes include\\nlow energy levels, feelings of despair, difficulty con-\\ncentrating, extreme fatigue, and psychomotor retarda-\\ntion (slowed mental and physical capabilities). Manic\\nepisodes are characterized by feelings of euphoria,\\nlack of inhibitions, racing thoughts, diminished need\\nfor sleep, talkativeness, risk taking, and irritability. In\\nextreme cases, mania can inducehallucinations and\\nother psychotic symptoms such as grandiose illusions.\\nDiagnosis\\nBipolar disorder usually is diagnosed and treated\\nby a psychiatrist and/or a psychologist with medical\\nassistance. In addition to an interview, several clinical\\ninventories or scales may be used to assess the patient’s\\nmental status and determine the presence of bipolar\\nsymptoms. These include the Millon Clinical\\nMultiaxial Inventory III (MCMI-III), Minnesota\\nMultiphasic Personality Inventory II (MMPI-2), the\\nInternal State Scale (ISS), the Self-Report Manic\\nInventory (SRMI), and the Young Mania Rating\\nScale (YMRS). The tests are verbal and/or written\\nand are administered in both hospital and outpatient\\nsettings.\\nPsychologists and psychiatrists typically use the\\ncriteria listed in theDiagnostic and Statistical Manual\\nof Mental Disorders, Fourth Edition (DSM-IV )a s\\na guideline for diagnosis of bipolar disorder and\\nother mental illnesses. DSM-IV describes a manic\\nepisode as an abnormally elevated or irritable mood\\nlasting a period of at least one week that is distinguished\\nby at least three of the mania symptoms: inflated self-\\nesteem, decreased need for sleep, talkativeness, racing\\nthoughts, distractibility, increase in goal-directed activ-\\nity, or excessive involvement in pleasurable activities\\nthat have a high potential for painful consequences. If\\nthe mood of the patient is irritable and not elevated,\\nfour of the symptoms are required.\\nAlthough many clinicians find the criteria too\\nrigid, a hypomanic diagnosis requires a duration\\nof at least four days with at least three of the symptoms\\nindicated for manic episodes (four if mood is irritable\\nand not elevated).DSM-IV notes that unlike manic\\nepisodes, hypomanic episodes do not cause a marked\\nimpairment in social or occupational functioning, do\\nnot require hospitalization, and do not have psychotic\\nfeatures. In addition, because hypomanic episodes are\\ncharacterized by high energy and goal directed activ-\\nities and often result in a positive outcome, or are\\nperceived in a positive manner by the patient, bipolar\\nII disorder can go undiagnosed.\\nBipolar symptoms often present differently in\\nchildren and adolescents. Manic episodes in these age\\ngroups are typically characterized by more psychotic\\nfeatures than in adults, which may lead to a misdiag-\\nnosis of schizophrenia. Children and adolescents also\\ntend toward irritability and aggressiveness instead of\\nelation. Further, symptoms tend to be chronic, or\\nongoing, rather than acute, or episodic. Bipolar chil-\\ndren are easily distracted, impulsive, and hyperactive,\\nwhich can lead to a misdiagnosis of attention deficit\\nhyperactivity disorder (ADHD). Furthermore, their\\naggression often leads to violence, which may be mis-\\ndiagnosed as aconduct disorder.\\nSubstance abuse, thyroid disease, and use of\\nprescription or over-the-counter medication can mask\\nor mimic the presence of bipolar disorder. In cases of\\nsubstance abuse, the patient must ordinarily undergo a\\nperiod ofdetoxification and abstinence before a mood\\ndisorder is diagnosed and treatment begins.\\nTreatment\\nTreatment of bipolar disorder is usually achieved\\nwith medication. A combination of mood stabilizing\\nagents with antidepressants, antipsychotics, and antic-\\nonvulsants is used to regulate manic and depressive\\nepisodes.\\nMood stabilizing agents such as lithium, carba-\\nmazepine, and valproate are prescribed to regulate the\\nmanic highs and lows of bipolar disorder:\\n/C15Lithium (Cibalith-S, Eskalith, Lithane, Lithobid,\\nLithonate, Lithotabs) is one of the oldest and most\\nfrequently prescribed drugs available for the treat-\\nment of bipolar mania and depression. Because the\\ndrug takes four to ten days to reach a therapeutic\\nlevel in the bloodstream, it sometimes is prescribed in\\nconjunction with neuroleptics and/or benzodiaze-\\npines to provide more immediate relief of a manic\\nepisode. Lithium also has been shown to be effective\\nin regulating bipolar depression, but is not recom-\\nmended for mixed mania. Lithium may not be an\\nGALE ENCYCLOPEDIA OF MEDICINE 539\\nBipolar disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='effective long-term treatment option for rapid cyclers,\\nwho typically develop a tolerance for it, or may not\\nrespond to it. Possible side effects of the drug include\\nweight gain, thirst, nausea, and hand tremors.\\nProlonged lithium use also may causehyperthyroid-\\nism (a disease of the thryoid that is marked by heart\\npalpitations, nervousness, the presence of goiter,\\nsweating, and a wide array of other symptoms.)\\n/C15Carbamazepine (Tegretol, Atretol) is an anticonvul-\\nsant drug usually prescribed in conjunction with\\nother mood stabilizing agents. The drug often is\\nused to treat bipolar patients who have not\\nresponded well to lithium therapy. Blurred vision\\nand abnormal eye movement are two possible side\\neffects of carbamazepine therapy.\\n/C15Valproate (divalproex sodium, or Depakote; valproic\\nacid, or Depakene) is one of the few drugs available\\nthat has been proven effective in treating rapid cycling\\nbipolar and mixed states patients. Valproate is pre-\\nscribed alone or in combination with carbamazepine\\nand/or lithium. Stomach cramps,indigestion, diar-\\nrhea, hair loss, appetite loss, nausea, and unusual\\nweight loss or gain are some of the common side\\neffects of valproate. Note: valproate also is approved\\nfor the treatment of mania. A 2003 study found that\\nthe risk ofdeath from suicide is about two and one-\\nhalf times higher in people with bipolar disorder\\ntaking divalproex than those taking lithium.\\nTreating the depression associated with bipolar\\ndisorder has proven more challenging. In early 2004,\\nthe first drug to treat bipolar administration was\\napproved by the U.S. Food and Drug Administration\\n(FDA). It is called Symbyax, a combination of olanzi-\\npine and fluoxetine, the active ingredient in Prozac.\\nBecause antidepressants may stimulate manic\\nepisodes in some bipolar patients, their use typically\\nis short-term. Selective serotonin reuptake inhibitors\\n(SSRIs) or, less often,monoamine oxidase inhibitors\\n(MAO inhibitors) are prescribed for episodes of bipo-\\nlar depression.Tricyclic antidepressantsused to treat\\nunipolar depression may trigger rapid cycling in bipo-\\nlar patients and are, therefore, not a preferred treat-\\nment option for bipolar depression.\\n/C15SSRIs, such as fluoxetine (Prozac), sertraline\\n(Zoloft), and paroxetine (Paxil), regulate depression\\nby regulating levels of serotonin, a neurotransmitter.\\nAnxiety, diarrhea, drowsiness, headache, sweating,\\nnausea, sexual problems, andinsomnia are all possi-\\nble side effects of SSRIs.\\n/C15MAOIs such as tranylcypromine (Parnate) and phe-\\nnelzine (Nardil) block the action of monoamine oxi-\\ndase (MAO), an enzyme in the central nervous\\nsystem. Patients taking MAOIs must cut foods high\\nin tyramine (found in aged cheeses and meats) out of\\ntheir diet to avoid hypotensive side effects.\\n/C15Bupropion (Wellbutrin) is a heterocyclic antidepres-\\nsant. The exact neurochemical mechanism of the\\ndrug is not known, but it has been effective in reg-\\nulating bipolar depression in some patients. Side\\neffects of bupropion include agitation, anxiety, con-\\nfusion, tremor,dry mouth, fast or irregular heartbeat,\\nheadache, and insomnia.\\n/C15ECT, orelectroconvulsive therapy, has a high success\\nrate for treating both unipolar and bipolar depres-\\nsion, and mania. However, because of the conveni-\\nence of drug treatment and the stigma sometimes\\nattached to ECT therapy, ECT usually is employed\\nafter all pharmaceutical treatment options have been\\nexplored. ECT is given under anesthesia and patients\\nare given a muscle relaxant medication to prevent\\nconvulsions. The treatment consists of a series of\\nelectrical pulses that move into the brain through\\nelectrodes on the patient’s head. Although the exact\\nmechanisms behind the success of ECT therapy are\\nnot known, it is believed that this electrical current\\nalters the electrochemical processes of the brain, con-\\nsequently relieving depression. Headaches, muscle\\nsoreness, nausea, and confusion are possible side\\neffects immediately following an ECT procedure.\\nTemporary memory loss has also been reported in\\nECT patients. In bipolar patients, ECT is often used\\nin conjunction with drug therapy.\\nAdjunct treatments are used in conjunction with\\na long-term pharmaceutical treatment plan:\\n/C15Long-acting benzodiazepines such as clonazepam\\n(Klonapin) and alprazolam (Xanax) are used for\\nrapid treatment of manic symptoms to calm and\\nsedate patients until mania or hypomania have\\nwaned and mood stabilizing agents can take effect.\\nSedation is a common effect, and clumsiness, light-\\nheadedness, and slurred speech are other possible\\nside effects of benzodiazepines.\\n/C15Neuroleptics such as chlorpromazine (Thorazine) and\\nhaloperidol (Haldol) also are used to control mania\\nwhile a mood stabilizer such as lithium or valproate\\ntakes effect. Because neuroleptic side effects can be\\nsevere (difficulty in speaking or swallowing,paralysis\\nof the eyes, loss of balance control,muscle spasms,\\nsevere restlessness, stiffness of arms and legs, tremors\\nin fingers and hands, twisting movements of body,\\nand weakness of arms and legs), benzodiazepines are\\ngenerally preferred over neuroleptics.\\n/C15Psychotherapy and counseling. Because bipolar dis-\\norder is thought to be biological in nature, therapy is\\n540 GALE ENCYCLOPEDIA OF MEDICINE\\nBipolar disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='recommended as a companion to, but not a substi-\\ntute for, pharmaceutical treatment of the disease.\\nPsychotherapy, such ascognitive-behavioral therapy,\\ncan be a useful tool in helping patients and their\\nfamilies adjust to the disorder, in encouraging com-\\npliance to a medication regimen, and in reducing the\\nrisk of suicide. Also, educative counseling is recom-\\nmended for the patient and family. In fact, a 2003\\nreport revealed that people on medication for bipolar\\ndisorder had better results if they also participated in\\nfamily-focused therapy.\\nClozapine (Clozaril) is an atypical antipsychotic\\nmedication used to control manic episodes in patients\\nwho have not responded to typical mood stabilizing\\nagents. The drug has also been a useful prophylactic,\\nor preventative treatment, in some bipolar patients.\\nCommon side effects of clozapine include tachycardia\\n(rapid heart rate), hypotension, constipation,a n d\\nweight gain. Agranulocytosis, a potentially serious but\\nreversible condition in which the white blood cells that\\ntypically fight infection in the body are destroyed, is a\\npossible side effect of clozapine. Patients treated with\\nthe drug should undergo weekly blood tests to monitor\\nwhite blood cell counts.\\nRisperidone (Risperdal) is an atypical antipsycho-\\ntic medication that has been successful in controlling\\nmania when low doses were administered. In early\\n2004, the FDA approved its use for treating bipolar\\nmania. The side effects of risperidone are mild com-\\npared to many other antipsychotics (constipation,\\ncoughing, diarrhea, dry mouth, headache,heartburn,\\nincreased length of sleep and dream activity, nausea,\\nrunny nose,sore throat, fatigue, and weight gain).\\nOlanzapine (Zyprexa) is another atypical antipsy-\\nchotic approved in 2003 for use in combination with\\nlithium or valproate for treatment of acute manic\\nepisodes associated with bipolar disorder. Side effects\\ninclude hypotension (low blood pressure) associated\\nwith dizziness, rapid heartbeat, and syncope, or low\\nblood pressure to the point offainting.\\nLamotrigine (Lamictal, or LTG), an anticonvul-\\nsant medication, was found to alleviate manic symp-\\ntoms in a 1997 trial of 75 bipolar patients. The drug\\nwas used in conjunction with divalproex (divalproate)\\nand/or lithium. Possible side effects of lamotrigine\\ninclude skin rash, dizziness, drowsiness, headache,\\nnausea, andvomiting.\\nAlternative treatment\\nGeneral recommendations include maintaining a\\ncalm environment, avoiding overstimulation, getting\\nplenty of rest, regular exercise, and proper diet.\\nChinese herbs may soften mood swings.Biofeedback\\nis effective in helping some patients control symptoms\\nsuch as irritability, poor self control, racing thoughts,\\nand sleep problems. A diet low in vanadium (a mineral\\nfound in meats and other foods) and high in vitamin C\\nmay be helpful in reducing depression.\\nA surprising study in 2004 found that a rarely used\\ncombination of magnetic fields used inmagnetic reso-\\nnance imaging(MRI) scanning improved the moods of\\nsubjects with bipolar disorder. The discovery was\\nmade while scientists were using MRI to investigate\\neffectiveness of certain medications. However, they\\nfound that a particular type of echo-planar magnetic\\nfield led to reports of mood improvement. Further\\nstudies may one day lead to a smaller, more conveni-\\nent use of magnetic treatment.\\nPrognosis\\nWhile most patients will show some positive\\nresponse to treatment, response varies widely, from\\nfull recovery to a complete lack of response to all\\ndrug and/or ECT therapy. Drug therapies frequently\\nneed adjustment to achieve the maximum benefit for\\nthe patient. Bipolar disorder is a chronic recurrent\\nillness in over 90% of those afflicted, and one that\\nrequires lifelong observation and treatment after diag-\\nnosis. Patients with untreated or inadequately treated\\nbipolar disorder have a suicide rate of 15-25% and a\\nnine-year decrease in life expectancy. With proper\\ntreatment, the life expectancy of the bipolar patient\\nwill increase by nearly seven years and work produc-\\ntivity increases by ten years.\\nPrevention\\nThe ongoing medical management of bipolar dis-\\norder is critical to preventing relapse, or recurrence, of\\nmanic episodes. Even in carefully controlled treatment\\nprograms, bipolar patients may experience recurring\\nepisodes of the disorder. Patient education in the form\\nof psychotherapy or self-help groups is crucial for\\ntraining bipolar patients to recognize signs of mania\\nand depression and to take an active part in their\\ntreatment program.\\nResources\\nPERIODICALS\\n‘‘Family-focused Therapy May Reduce Relapse Rate.’’\\nHealth & Medicine Week(September 29, 2003): 70.\\n‘‘FDA Approves Medication for Bipolar Depression.’’Drug\\nWeek (January 23, 2004): 320.\\nGALE ENCYCLOPEDIA OF MEDICINE 541\\nBipolar disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='‘‘FDA Approves Risperidone for Bipolar Mania.’’\\nPsychopharmacology Update(January 2004): 8.\\n‘‘Lithium and Risk of Suicide.’’The Lancet(September 20,\\n2003): 969.\\nRossiter, Brian. ‘‘Bipolar Disorder.’’Med Ad News(March\\n2004): 82.\\n‘‘Schizophrenia and Bipolar Disorder Could Have Similar\\nGenetic Causes.’’Genomics & Genetics Weekly\\n(September 26, 2003): 85.\\nSherman, Carl. ‘‘Bipolar’s Clinical, Financial Impact Widely\\nMissed. (Prevalence May be Greater Than Expected).’’\\nClinical Psychiatry News(August 2002): 6.\\n‘‘Unique Type of MRI Scan Shows Promise in Treating\\nBipolar Disorder.’’AScribe Health News Service\\n(January 1, 2004).\\n‘‘Zyprexa.’’ Formulary 9 (September 2003): 513.\\nORGANIZATIONS\\nAmerican Psychiatric Association. 1400 K Street NW,\\nWashington DC 20005. (888) 357-7924. .\\nNational Alliance for the Mentally Ill (NAMI). Colonial\\nPlace Three, 2107 Wilson Blvd., Ste. 300, Arlington,\\nVA 22201-3042. (800) 950-6264. .\\nNational Depressive and Manic-Depressive Association\\n(NDMDA). 730 N. Franklin St., Suite 501, Chicago,\\nIL 60610. (800) 826-3632. .\\nNational Institute of Mental Health. Mental Health Public\\nInquiries, 5600 Fishers Lane, Room 15C-05, Rockville,\\nMD 20857. (888) 826-9438. .\\nPaula Anne Ford-Martin\\nTeresa G. Odle\\nBird flu\\nDefinition\\nBird flu is an infectious disease caused by strains\\nof the Type Ainfluenza viruses that ordinarily only\\ninfect birds. Avian influenza A (H5N1) virus infected\\nand caused the deaths of people.\\nDescription\\nBird flu, which is also known as avian influenza,\\nwas first identified in Italy more than 100 years ago.\\nAvian viruses occur naturally in birds, and can infect\\nbirds including chickens, ducks, geese, turkeys,\\npheasants, quail, and guinea fowl. The avian influenza\\nviruses generally do not infect humans.\\nAvian viruses are carried around the world by\\nmigratory birds. Wild ducks are natural reservoirs of\\nthe infection, according to the World Health\\nOrganization (WHO). Those wild birds generally\\ndon’t become ill, but avian flu is extremely contagious\\nand has caused some domesticated birds to become\\nvery ill and die. The casualties included chickens, tur-\\nkeys, and ducks.\\nVirus suptypes\\nReaction to the infection varies among the species\\nbecause flu viruses are constantly mutating into new\\nstrains or subgroups. Low-pathogenic viruses cause\\nfew or no symptoms in infected birds. However,\\nsome strains can mutate into highly pathogenic avian\\ninfluenza (HPAI) strains that are extremely infectious\\nand deadly to birds.\\nThe viruses are identified by a series of letters and\\nnumbers that refer to two proteins, hemagglutinin\\n(HA) and neuraminidase (NA). There are 16 HA sub-\\ntypes and nine NA subtypes of influenza A virus.\\nNumerous combinations of the two proteins are\\npossible, and each combination forms a new subtype.\\nThere are 15 different Influenza A subtypes that\\ncan infect birds, according to the United States\\nCenters for Disease Control (CDC). In comparison,\\nthere are three known subtypes of human flu virus A:\\nH1N1, H1N2, and H3N2. Avian viruses can infect\\npigs, but people are generally not affected. That chan-\\nged when there was an outbreak of H5N1 in Hong\\nKong in 1997.\\nDeadly outbreaks\\nThe highly pathogenic H5N1 virus was first isolated\\nin terns in South Africa in 1961, and then in Hong Kong\\nin 1997. Hong Kong’s avian flu outbreak coincided\\nwith 18 cases of severe respiratory disease in people.\\nThose diagnosed with bird flu had close contact with\\npoultry. Six people died, according to WHO. There\\nwas ‘‘limited transmission’’ of the virus to health care\\nworkers, but they did not become seriously ill.\\nMedical research showed that the avian virus had\\njumped from birds to people. Within three days, Hong\\nKong’s poultry population of about 1.5 million birds\\nwas destroyed to prevent further infection. There was\\nanother H5N1 outbreak in Hong Kong in February\\nof 2003. It affected two members of a family that had\\nrecently visited China. One person died, according to\\nthe WHO.\\n542 GALE ENCYCLOPEDIA OF MEDICINE\\nBird flu'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='In the Netherlands in February of 2003, there was\\nan outbreak of another highly pathogenic avian virus,\\nH7N7. Two months later, a veterinarian died from the\\nvirus. It also caused mild illness in 83 people.\\nIn Hong Kong, the avian virus subtype H9N2\\ncaused mild cases of flu in two children in 1999 and\\none child in the middle of December of 2003, accord-\\ning to WHO. While H9N2 was not highly pathogenic\\nin birds, there was an outbreak of H5N1 in Korea in\\nmid-December of 2003. The next month, there was an\\noutbreak in Vietnam that was followed by outbreaks\\nin other Asian countries.\\nHuman bird flu cases\\nThe World Health Organization tracks bird flu out-\\nbreaks and the charts the numbers of human cases that\\nhave been confirmed by a laboratory. There were 74\\ncases and 49 deaths between January of 2004 and March\\n31, 2005. The flu caused two deaths in Cambodia. In\\nThailand, 12 of 17 people with bird flu died. In Vietnam,\\nthe flu was fatal in 35 of 55 diagnosed cases. Deaths\\nrelated to the H5N1 viruses have been caused bypneu-\\nmonia and pulmonary complications.\\nMoreover, the Democratic People’s Republic of\\nKorea (North Korea) officially reported the country’s\\nfirst outbreak of avian influenza in poultry on March 27,\\n2005. Outbreaks occurred at chicken farms, and there\\nwere no human cases at that time, according to WHO.\\nIn October 2005, an outbreak of bird flu was\\nreported at a farm near the Mongolian capital of\\nHohhot in the People’s Republic of China. The H5N1\\nstrain of the virus was detected in a parrot located in\\nBritain. The parrot contracted the disease while in quar-\\nantine with birds originating in Taiwan. In January 2006,\\nthe H5N1 strain was confirmed as the cause of death in at\\nleast two cases in Dogubeyazit, Turkey. This case, as well\\nas others documented in countries across Europe, indi-\\ncate the potential for the disease to spread worldwide.\\nPreparing for a pandemic\\nThe World Health Organization and nations\\nincluding the United States are troubled about the\\ndeadly consequences that could occur if H5N1 mutated\\ninto a new virus subtype that could be transferred from\\none human to another. That subtype would develop if\\nthe avian virus acquired human influenza genes,\\naccording to the U.S. Department of Agriculture\\n(USDA). A strain of bird flu spread by human-to-\\nhuman contact could cause an influenza pandemic.\\nA pandemic is a worldwide epidemic that is dan-\\ngerous because people have little or no immunity to\\nthe new virus strain. Historically, pandemics occur\\nthree to four times during a century when new virus\\nsubtypes appear. After World War I, the great influ-\\nenza pandemic of 1917-1918 caused from 40 to 50\\nmillion deaths globally, according to WHO. The flu\\npandemic of 1968-1969 claimed 1 to 4 million lives.\\nAccording to a 2004 WHO report, medical influ-\\nenza experts agree that another flu pandemic is ‘‘inevi-\\ntable and possibly imminent.’’ In a December 8, 2004\\nreport, WHO warned that the ‘‘best case scenario’’\\nprojection for next pandemic was that the new flu strain\\nwould kill from 2 to 7 million people. Moreover, ‘‘tens\\nof millions’’ of people would require medical attention.\\nThe appearance of H5N1 signals that the world is\\nmoving closer to a pandemic, WHO reported.\\nThe spread of H5N1 to humans increased the\\nlikelihood of a new strain emerging that could be\\ntransmitted by people. That could create a pandemic.\\nNations and the World Health Organization are\\nworking to prevent a pandemic or cause it to be less\\ndeadly. Their strategies include efforts to decrease the\\nspread of flu strains in poultry and the development of\\nvaccines to treat the virus in people.\\nCauses and symptoms\\nAvian flu is caused by an influenza virus that birds\\ncarry in their intestines. The virus spreads as infected\\nbirds excrete saliva, nasal secretions, and feces. Birds\\nvulnerable to the flu become infected when they come\\ninto contact with the excretions or surfaces contami-\\nnated by the infected matter.\\nBirds that survive the H5N1 infection can\\nexcrete the virus for at least 10 days, according to a\\nWHO report. The strain had proliferated through\\nbird-to-bird contact to flocks on farms and poultry\\nin live bird markets. The virus can also spread in\\nsurfaces including manure, bird feed, equipment,\\nvehicles, egg flats, and crates, and the clothing and\\nshoes of people who came into contact with the\\nvirus.\\nA small amount of a highly pathogenic avian\\ninfluenza virus could be deadly. One gram (0.035\\nounces) of contaminated manure could hold enough\\nvirus to infect 1 million birds, according to the USDA.\\nFrom 1997 through the spring of 2005, the viruses\\nprimarily infected people in Asia who had contact\\nwith infected birds and surfaces.\\nBird flu symptoms in people\\nIn early 2005, information about symptoms of\\nH5N1 in humans was based on the 1997 Hong Kong\\nGALE ENCYCLOPEDIA OF MEDICINE 543\\nBird flu'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='outbreak. People experienced traditional flu symptoms\\nsuch as afever, cough, sore throat, and aching muscles.\\nOther symptoms included eye infections (conjunctivi-\\ntis), pneumonia, acute respiratory distress, viral pneu-\\nmonia, and other severe and life-threatening\\ncomplications.\\nAvian flu symptoms in birds\\nThe sudden death of a bird that had not appeared\\nill is one symptom of the highly pathogenic bird flu.\\nAccording to the USDA, infected live birds may dis-\\nplay one or more of the following symptoms: lack\\nof energy, appetite loss, nasal discharge, coughing,\\nsneezing, a lack of coordination, and diarrhea.I n\\naddition, the bird may lay fewer eggs or produce eggs\\nthat are soft-shelled or misshapen. Furthermore, there\\nmay be swelling of the head, eyelids, comb, and wat-\\ntles. Another symptom is purple discoloration on the\\ncombs, wattles, and legs.\\nIf there is an outbreak of the highly pathogenic\\nflu in birds, they are destroyed to prevent the spread of\\nthe virus.\\nVirus mixing vessels\\nInfluenza viruses undergo frequent changes and\\nform new subtypes. In addition, influenza A viruses\\ncan trade genetic materials with the viruses of other\\nspecies. Two different strains trade or merge material,\\na process known as an antigenic shift. That shift pro-\\nduces a new subtype that is different from the two\\nparent viruses. When the new subtype contains genes\\nfrom the human virus, a pandemic resulted because\\nthere was no immunity to the virus and no vaccine to\\nprotect against it.\\nThe genetic shift occurs in a ‘‘mixing vessel’’ that\\nwas susceptible to both types of flu. In the past, the\\nshift was thought to be related to people living close to\\npigs and domestic poultry. Pigs can be infected by\\navian viruses and mammalian viruses like the human\\nstrains, according to WHO. However, research into\\nthe H5N1 strain indicates that people can serve as the\\nmixing vessels. As more people become infected with\\nbird flu, the probability increases that humans would\\nserve as the mixing vessel for a new subtype that could\\nbe transmitted from one person to another.\\nDiagnosis\\nThe symptoms of avian flu and human flu are very\\nsimilar, so laboratory testing is needed to diagnose\\navian influenza. In addition to diagnosing the indivi-\\ndual, testing in 2005 was performed to determine\\nwhether the infection was spreading from birds to\\npeople or from humans to humans.\\nDiagnostic tests for human flu are rapid and reli-\\nable, according to WHO. The international organiza-\\ntion noted that laboratories within WHO’s global\\nnetwork have high-security facilities and experienced\\nstaff. Test methods include a viral culture that ana-\\nlyses a blood sample and swabbings of the nose or\\nthroat. Other testing examines respiratory secretions.\\nIn the United States, the Centers for Disease\\nControl is among the organizations preparing for a\\npossible outbreak of bird flu in humans. In addition to\\nspecifics related to diagnosing bird flu, CDC refers\\nhealthcare workers to precautions to prevent the\\nspread of flu and other respiratory infections in med-\\nical settings.\\nPrecautionary measures include directing people\\nto observe cough etiquette. People with symptoms of\\nrespiratory infection should cover their mouths or use\\nfacial tissues when coughing or sneezing. After cough-\\ning or sneezing, the person should wash their hands\\nwith a non-antimicrobial soap and water, alcohol-\\nbased hand rub, or antiseptic handwash.\\nFurthermore, people with flu-like symptoms may\\nbe given masks to wear while they are waiting to be\\nexamined by medical personnel. The healthcare work-\\ners should wear masks in some circumstances.\\nUndoubtedly, they will wear masks when working\\nwith people with symptoms of bird flu.\\nTreatment\\nAs of March of 2005, there was no vaccine to\\nprotect people from the H5N1 virus, according to the\\nCDC. However, the U.S. agency and the World\\nHealth Organization had isolated seed strains of the\\nvirus in order to make a vaccine. Safety tests were\\nscheduled to start in April of 2005 on a vaccine man-\\nufactured by Sanofi pasteur, a firm in Swiftwater,\\nPennsylvania, formerly known as Aventis Pasteur.\\nOn March 23, 2005, the National Institute of\\nAllergy and Infectious Diseases (NIAID) announced\\nthat fast-track recruitment had started for volunteers\\nto participate in an investigative study of the vaccine.\\nDuring the Phase I trial, the trial vaccine will be tested\\non 450 healthy adults between the ages of 18 to 64,\\naccording to NIAID, which is part of the National\\nInstitutes of Health.\\nStudies were to be conducted at University of\\nCalifornia at Los Angeles, University of Maryland\\nSchool of Medicine in Baltimore, and the University\\nof Rochester School of Medicine and Dentistry,\\n544 GALE ENCYCLOPEDIA OF MEDICINE\\nBird flu'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Rochester, New York. If the vaccine is proven safe for\\nadults, there were plans to test it in people in other age\\ngroups such as children and the elderly.\\nFurthermore, research was underway on a vaccine\\nto fight H9N2, another avian flu virus subtype.\\nTreatment with existing drugs\\nExisting anti-viral medications may sometimes be\\neffective against avian flu viruses, according to a\\nMarch 18, 2005, report from CDC. In the United\\nStates, four drugs have been approved by the U.S.\\nFood and Drug Administration (FDA) for the treat-\\nment and prevention of influenza A viruses.\\nThe medications amantadine (Symmetrel),\\nrimantadine (Flumadine), seltamivir (Tamiflu), and\\nzanamivir (Relenza) were clinically effective in the\\ntreatment of influenza A viruses in otherwise healthy\\nadults.\\nHowever, avian flu research indicated that the\\nH5N1 virus was resistant to amantadine and rimanta-\\ndine, according to CCDC. The other two drugs would\\n‘‘probably work,’’ according to CDC. However, stu-\\ndies were needed of the medication’s effectiveness.\\nDuring the 2004 human flu season in the United\\nStates, the Associated Press reported that Relenza cost\\nabout $55 for the typical 10-day treatment. Tamiflu\\ncost approximately $66 for the same course of treat-\\nment. Insurance frequently covered part of the pre-\\nscription costs.\\nFor people diagnosed with bird flu, the World\\nHealth Organization recommends that patients take\\nTamiflu twice daily for five days. Treatment should\\nbegin as soon as possible. Patients may also receive\\nmedication to lower fevers and antibiotics to fight\\nsecondary infections.\\nIn the spring of 2005, there was no H5N1 vaccine.\\nCountries including the United States were reportedly\\nstockpiling Tamiflu in the event a pandemic erupted.\\nAt that time, WHO and CDC recommended the issu-\\ning of anti-viral medication as a preventive measure to\\npeople working in poultry production. Those people,\\nalong with health care workers, would have priority\\nfor the medications.\\nAlternative treatment\\nIn March of 2005, people in South Korea began\\neating more kimchi to ward off avian flu infection,\\naccording to the reports from the British Broadcasting\\nCompany and other news organizations. The public\\nturned to the spicy vegetable dish after scientists at\\nSeoul National University announced that kimchi\\naided in the recovery of 11 out of 13 infected chickens.\\nThe scientists fed the birds an extract of kimchi, a dish\\nmade by fermenting cabbage with red peppers,\\nradishes, and large amounts of garlic and ginger. A\\nweek later, all but two birds showed signs of recovery.\\nThe researchers acknowledged that their study\\nwas unscientific. At that time, they were not sure\\nhow or why kimchi was related to the recovery.\\nHowever, the announcement led people to again\\nregard kimchi as a health remedy. In 2003, interest in\\nkimchi increased when people thought eating it helped\\nprevent SARS (severe acute respiratory syndrome).\\nNo scientific confirmation was made between kimchi\\nand SARS prevention.\\nPrognosis\\nBird flu has been fatal to people, and there was\\nconcern in 2005 about the virus mutating into a strain\\nthat could be transmittedby people. Health organi-\\nzations and government agencies focused on pre-\\nventing or reducing the risks of a pandemic caused\\nby bird flu.\\nIn the United States, research was underway on\\nvaccines to fight the flu. Other efforts include the\\nUSDA Safety’s guidelines for people working with\\npoultry. Strategies included trade restrictions on poul-\\ntry and poultry products from Asia, according to the\\nUSDA. Imported live birds and eggs were quarantined\\nfor 30 days. During that time, they were tested for bird\\nflu and exotic Newcastle disease. The United States\\nbans the import of poultry meat from Asia because\\nmeat processing plants were not approved by the\\nUSDA’s Food Safety and Inspection Service.\\nPrevention\\nIn the spring of 2005, bird flu was primarily a risk\\nfor people in the United States who worked with\\npoultry. Potentially vulnerable people included those\\nworking with poultry on farms and avian health work-\\ners like veterinarians. People working with birds in\\nlocations such as commercial poultry facilities, veter-\\ninary offices, and live bird markets should wear pro-\\ntective clothing. That equipment includes boots,\\ncoveralls, face masks, gloves, and headgear, according\\nto the USDA. If necessary, they should receive anti-\\nviral medications as a safeguard.\\nFurthermore, poultry producers should imple-\\nment security measures to prevent the outbreak of a\\nhighly pathogenic virus. Those actions include keep-\\ning flocks away from wild or migratory birds and\\nGALE ENCYCLOPEDIA OF MEDICINE 545\\nBird flu'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='providing clothing and disinfectant facilities for\\nemployees. Plastic crates should be used at live bird\\nmarkets because they were easier to clean than wood\\ncrates. Cleaning and disinfecting areas were also\\nimportant for preventing an outbreak.\\nIf necessary birds would be quarantined or\\ndestroyed.\\nResources\\nPERIODICALS\\nAssociated Press. ‘‘Bird Flu Called Global Human Threat:\\nAsia Outbreak Poses ‘Gravest Possible Danger,’ U.N.\\nOfficial Says, Urging Controls.’’ Washington Post.\\nFebruary 24, 2005 [cited March 30, 2005] .\\nORGANIZATIONS\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRoad, Atlanta, GA 30333. 800-CDC-INFO (232-\\n5636)..\\nNational Institute of Allergy and Infectious Diseases. 6610\\nRockledge Drive, MSC 6612, Bethesda, MD 20892-\\n6612. 301-496-5717. .\\nWorld Health Organization. Regional Office for the\\nAmericas. 525, 23rd Street NW, Washington, DC\\n20037. 202-974-3000..\\nHighly Pathogenic Avian Influenza. United States\\nDepartment of Agriculture Animal and Plant\\nInspection Safety. March 2004 [Cited March 31, 2005].\\n.\\nOTHER\\nAvian Influenza. World Health Organization. Continuously\\nupdated [cited March 31, 2005]. .\\nAvian Flu Index. Centers for Disease Control and\\nPrevention. Continuously updated [cited April 1, 2005].\\n.\\nChazan, David. ‘‘Korean dish ‘may cure bird flu.’’’BBC\\nNews. March 14, 2005 [cited March 30, 2005]. .\\nFocus on the Flu. National Institute of Allergy and\\nInfectious Diseases. Continuously updated [cited\\nMarch 31, 2005]. .\\nLiz Swain\\nBirth control see Diaphragm (birth control);\\nCondom; Contraception\\nBirth control pills see Oral contraceptives\\nBirth defects\\nDefinition\\nBirth defects are physical abnormalities that are\\npresent at birth; they also are called congenital\\nabnormalities. More than 3,000 have been identified.\\nDescription\\nBirth defects are found in 2-3% of all newborn\\ninfants. This rate doubles in the first year, and reaches\\n10% by age five, as more defects become evident and\\ncan be diagnosed. Almost 20% of deaths in newborns\\nare caused by birth defects.\\nAbnormalities can occur in any major organ or\\npart of the body. Major defects are structural abnor-\\nmalities that affect the way a person looks and require\\nmedical and/or surgical treatment. Minor defects are\\nabnormalities that do not cause serious health or social\\nproblems. When multiple birth defects occur together\\nand have a similar cause, they are called syndromes. If\\ntwo or more defects tend to appear together but do not\\nshare the same cause, they are called associations.\\nCauses and symptoms\\nThe specific cause of many congenital abnormal-\\nities is unknown, but several factors associated with\\npregnancy and delivery can increase the risk of birth\\ndefects.\\nTeratogens\\nAny substance that can cause abnormal develop-\\nment of the egg in the mother’s womb is called a\\nteratogen. In the first two months after conception,\\nthe developing organism is called an embryo; develop-\\nmental stages from two months to birth are called\\nfetal. Growth is rapid, and each body organ has a\\ncritical period in which it is especially sensitive to out-\\nside influences. About 7% of all congenital defects are\\ncaused by exposure to teratogens.\\nDRUGS. Only a few drugs are known to cause birth\\ndefects, but all have the potential to cause harm.\\nFor example, in 2003, a study found that use of topical\\n(local) corticosteroidsin the first trimester of pregnancy\\nmay be associated withcleft lip. Thalidomide is known\\nto cause defects of the arms and legs; several other\\ntypes also cause problems.\\n/C15Alcohol. Drinking large amounts of alcohol while\\npregnant causes a cluster of defects calledfetal alco-\\nhol syndrome, which includes mental retardation,\\n546 GALE ENCYCLOPEDIA OF MEDICINE\\nBirth defects'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='heart problems, and growth deficiency. In 2004,\\nexperts warned that binge drinking early in pregnancy\\nwas dangerous even if the woman quit drinking later.\\n/C15Antibiotics. Certain antibiotics are known tetrato-\\ngens. Tetracycline affects bone growth and discolors\\nthe teeth. Drugs used to treattuberculosis can lead to\\nhearing problems and damage to a nerve in the head\\n(cranial damage).\\n/C15Anticonvulsants. Drugs given to prevent seizures can\\ncause serious problems in the developing fetus,\\nincluding mental retardation and slow growth.\\nStudies in the United Kingdom and Australia have\\ntracked the percentage of birth defects caused by\\ncertain antiepileptic drugs.\\n/C15Antipsychotic and antianxiety agents. Several drugs\\ngiven for anxiety and mental illness are known to\\ncause specific defects.\\n/C15Antineoplastic agents. Drugs given to treatcancer\\ncan cause major congenital malformations, espe-\\ncially central nervous system defects. They also may\\nbe harmful to the health care worker who is giving\\nthem while pregnant.\\n/C15Hormones. Male hormones may cause masculiniza-\\ntion of a female fetus. A synthetic estrogen (DES)\\ngiven in the 1940s and 1950s caused an increased risk\\nof cancer in the adult female children of the mothers\\nwho received the drug.\\n/C15Recreational drugs. Drugs such asLSD have been\\nassociated with arm and leg abnormalities and cen-\\ntral nervous system problems in infants. Crack\\ncocaine also has been associated with birth defects.\\nSince drug abusers tend to use many drugs and have\\npoor nutrition and prenatal care, it is hard to deter-\\nmine the effects of individual drugs.\\nUnknown causes–70%\\nCytogenetic diseases–4%\\nDrugs, chemicals, radiation–2%\\nMaternal infection–2%\\nMaternal metabolic factors–1%\\nBirth trauma and uterine factors–1%\\nHereditary diseases–20%\\nThe specific cause of many birth defects is unknown, but several factors associated with pregnancy and delivery can increase\\nthe risk of birth defects. These factors include exposure to teratogens, drugs and other chemicals, exposure to radiation, and\\ninfections present in the womb. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 547\\nBirth defects'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='CHEMICALS. Environmental chemicals such as\\nfungicides, food additives, and pollutants are sus-\\npected of causing birth defects, though this is difficult\\nto prove.\\nRADIATION. Exposure of the mother to high levels\\nof radiation can cause small skull size (microcephaly),\\nblindness, spina bifida,a n dcleft palate. How severe the\\ndefect is depends on the duration and timing of the\\nexposure.\\nINFECTIONS. Three viruses are known to harm a\\ndeveloping baby: rubella, cytomegalovirus (CMV),\\nand herpes simplex. Toxoplasma gondii, a parasite\\nthat can be contracted from undercooked meat, from\\ndirt, or from handling the feces of infected cats, causes\\nserious problems. Untreated syphilis in the mother\\nalso is harmful.\\nGenetic factors\\nA gene is a tiny, invisible unit containing informa-\\ntion (DNA) that guides how the body forms and func-\\ntions. Each individual inherits tens of thousands of\\ngenes from each parent, arranged on 46 chromosomes.\\nGenes control all aspects of the body, how it works,\\nand all its unique characteristics, including eye color\\nand body size. Genes are influenced by chemicals and\\nradiation, but sometimes changes in the genes are\\nunexplained accidents. Each child gets half of its\\ngenes from each parent. In each pair of genes one\\nwill take precedence (dominant) over the other (reces-\\nsive) in determining each trait, or characteristic. Birth\\ndefects caused by dominant inheritance include a form\\nof dwarfism called achondroplasia; high cholesterol;\\nHuntington’s disease, a progressive nervous system\\ndisorder; Marfan syndrome, which affects connective\\ntissue; some forms ofglaucoma, andpolydactyly (extra\\nfingers or toes).\\nIf both parents carry the same recessive gene,\\nthey have a one-in-four chance that the child will\\ninherit the disease. Recessive diseases are severe and\\nmay lead to an earlydeath. They include sickle cell\\nanemia, a blood disorder that affects blacks, and\\nTay-Sachs disease, which causes mental retardation\\nin people of eastern European Jewish heritage. Two\\nrecessive disorders that affect mostly whites are:\\ncystic fibrosis, a lung and digestive disorder, and\\nphenylketonuria (PKU), a metabolic disorder. If only\\nCongenital absence of three fingers. Deformities such as this\\nare usually caused by damage to the developing fetusin utero.\\n(Photograph by Dr. P. Marazzi, Photo Researchers, Inc.\\nReproduced by permission.)\\nKEY TERMS\\nChromosome— One of the bodies in the cell\\nnucleus that carries genes. There are normally 46\\nchromosomes in humans.\\nCleft lip and palate— An opening in the lip, the roof\\nof the mouth (hard palate), or the soft tissue in the\\nback of the mouth (soft palate).\\nEmbryo— The developing baby from conception to\\nthe end of the second month.\\nGene— The The functional unit of heredity that\\ndirects all growth and development of an organism.\\nEach human being has more than 100,000 genes\\nthat determine hair color, body build, and all other\\ntraits.\\nFetus— In humans, the developing organism from\\nthe end of the eighth week to the moment of birth.\\nNeural tube defects— A group of birth defects that\\naffect the backbone and sometimes the spinal chord.\\nRubella— A mild, highly contagious childhood\\nillness caused by a virus; it is also called German\\nmeasles. It causes severe birth defects if a pregnant\\nwoman is not immune and gets the illness in the\\nfirst three months of pregnancy.\\nSpina bifida— One of the more common birth\\ndefects in which the backbone never closes.\\nTrait— A distinguishing feature of an individual.\\nVirus— A very small organism that causes infection\\nand needs a living cell to reproduce.\\n548 GALE ENCYCLOPEDIA OF MEDICINE\\nBirth defects'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='one parent passes along the genes for the disorder, the\\nnormal gene received from the other parent will\\nprevent the disease, but the child will be a carrier.\\nHaving the gene is not harmful to the carrier, but\\nthere is the 25% chance of the genetic disease showing\\nup in the child of two carriers.\\nSome disorders are linked to the sex-determining\\nchromosomes passed along by parents.Hemophilia,a\\ncondition that prevents blood from clotting, and\\nDuchenne muscular dystrophy, which causes muscle\\nweakness, are carried on the X chromosome. Genetic\\ndefects also can take place when the egg or sperm are\\nforming if the mother or father passes along some\\nfaulty gene material. This is more common in older\\nmothers. The most common defect of this kind is\\nDown syndrome, a pattern of mental retardation and\\nphysical abnormalities, often including heart defects,\\ncaused by inheriting three copies of a chromosome\\nrather than the normal pair.\\nA less understood cause of birth defects results\\nfrom the interaction of genes from one or both parents\\nplus environmental influences. These defects are\\nthought to include:\\n/C15Cleft lip and palate, which are malformations of the\\nmouth.\\n/C15Clubfoot, ankle or foot deformities.\\n/C15Spina bifida, an open spine caused when the tube\\nthat forms the brain and spinal chord does not\\nclose properly.\\n/C15Water on the brain (hydrocephalus), which causes\\nbrain damage.\\n/C15Diabetes mellitus, an abnormality in sugar metabo-\\nlism that appears later in life.\\n/C15Heart defects.\\n/C15Some forms of cancer.\\nA serious illness in the mother, such as an under-\\nactive thyroid, or diabetes mellitus, in which her body\\ncannot process sugar, also can cause birth defects in the\\nchild. In fact, in 2003, it was shown that babies of\\ndiabetic mothers are five times as likely to have struc-\\ntural heart defects as other babies. An abnormal\\namount of amniotic fluid may indicate or cause birth\\ndefects. Amniotic fluid is the liquid that surrounds and\\nprotects the unborn child in the uterus. Too little of this\\nfluid can interfere with lung or limb development. Too\\nmuch amniotic fluid can accumulate if the fetus has a\\ndisorder that interferes with swallowing. In 2003, a\\nstudy linked the mother’s weight to risk of birth defects.\\nObese women were about three times more likely to\\nhave an infant with spina bifida or omphalocele\\n(protrusion of part of the intestine through the abdom-\\ninal wall) than women of average weight. Women who\\nwere overweight or classified as obese also were twice as\\nlikely to have an infant with a heart defect or multiple\\nbirth defects than women classified as average weight.\\nDiagnosis\\nIf there is a family history of birth defects or if the\\nmother is over 35 years old, then screening tests can be\\ndone during pregnancy to gain information about\\nthe health of the baby.\\n/C15Alpha-fetoprotein test. This is a simple blood test\\nthat measures the level of a substance called alpha-\\nfetoprotein that is associated with some major birth\\ndefects. An abnormally high or low level may indi-\\ncate the need for further testing.\\n/C15Ultrasound. The use of sound waves to examine the\\nshape, function, and age of the fetus is a common\\nprocedure. It also can detect many malformations,\\nsuch as spina bifida, limb defects, and heart and\\nkidney problems. In 2003, researchers in England\\nannouncedanewcombinationofbloodtestsandultra-\\nsound to detect Down syndrome sooner and more\\naccurately than with the usual blood screenings done\\nat 20 weeks of pregnancy.\\n/C15Amniocentesis. This test usually is done between the\\n13th and 15th weeks of pregnancy. A small sample of\\namniotic fluid is withdrawn through a thin needle\\ninserted into the mother’s abdomen. Chromosomal\\nanalysis can rule out Down syndrome and other\\ngenetic conditions.\\n/C15Chorionic villus sampling (CVS). This test can be\\ndone as early as the ninth week of pregnancy to\\nidentify chromosome disorders and some genetic\\nconditions. A thin needle is inserted through the\\nabdomen or a slim tube is inserted through the\\nvagina that takes a tiny tissue sample for testing.\\nIf a birth defect is suspected after a baby is born,\\nthen confirmation of the diagnosis is very important.\\nThe patient’s medical records and medical history may\\nhold essential information. A carefulphysical exami-\\nnation and laboratory tests should be done. Special\\ndiagnostic tests also can provide genetic informa-\\ntion in some cases. In 2003, the March of Dimes, a\\nnonprofit organization, recommended that every baby\\nborn in the United States receive, at minimum, screen-\\ning for the same core group of birth defects including\\nphenylketonuria, congenital adrenal hyperplasia, con-\\ngenital hypothryroidism, biotinidase deficiency, and\\nothers. They were concerned that newborn screening\\nvaried too much from state to state.\\nGALE ENCYCLOPEDIA OF MEDICINE 549\\nBirth defects'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Treatment\\nTreatment depends on the type of birth defect and\\nhow serious it is. When an abnormality has been\\nidentified before birth, delivery can be planned at a\\nhealth care facility that is prepared to offer any special\\ncare needed. Some abnormalities can be corrected\\nwith surgery. Experimental procedures have been\\nused successfully in correcting some defects, like\\nexcessive fluid in the brain (hydrocephalus), even\\nbefore the baby is born. Early reports have shown\\nsuccess with fetal surgery on spina bifida patients.\\nBy operating on these fetuses while still in the womb,\\nsurgeons have prevented the need for shunts and\\nimproved outcomes at birth for many newborns.\\nHowever, long-term studies still are needed. Patients\\nwith complicated conditions usually need the help of\\nexperienced medical and educational specialists with\\nan understanding of the disorder.\\nPrognosis\\nThe prognosis for a disorder varies with the spe-\\ncific condition.\\nPrevention\\nPregnant women should eat a nutritious diet.\\nTaking folic acidsupplements before and during preg-\\nnancy reduces the risk of having a baby with serious\\nproblems of the brain or spinal chord (neural tube\\ndefects). It is important to avoid any teratogen that\\ncan harm the developing baby, including alcohol and\\ndrugs. When there is a family history of congenital\\ndefects in either parent,genetic counselingand testing\\ncan help parents plan for future children. Often, coun-\\nselors can determine the risk of a genetic condition\\noccurring and the availability of tests for it. Talking to\\na genetic counselor after a child is born with a defect\\ncan provide parents with information about medical\\nmanagement and available community resources.\\nResources\\nPERIODICALS\\n‘‘Babies of Diabetic Mothers Have Fivefold Increase in\\nStructural Heart Defects.’’Diabetes Week(October 6,\\n2003): 8.\\nBauer, Jeff. ‘‘Researchers Link Momo´s Weight to Babyo´s\\nRisk of Birth Defects.’’RN (August 2003): 97–102.\\n‘‘Fetal Alcohol Syndrome Is Still a Threat, Says\\nPublication.’’ Science Letter(September 28, 2004): 448.\\n‘‘Fetal Diagnostic Test Combo Shows Promise.’’Health &\\nMedicine Week(October 27, 2003): 224.\\n‘‘Fetal Surgery for Spina Bifida Shows Benefits in Leg\\nFunction, Fewer Shunts.’’Health & Medicine Week\\n(October 20, 2003): 608.\\n‘‘March of Dimes Pushes Newborn Screening.’’Diagnostics &\\nImaging Week(July 31, 2003): 10–11.\\n‘‘Studies Reveal Risk of Birth Defects from AEDs.’’Pharma\\nMarketletter (September 13, 2004).\\n‘‘Topical Corticosteroids Use During Pregnancy May\\nAssociate With Cleft Lip.’’Biotech Week(September\\n24, 2003): 190.\\nORGANIZATIONS\\nMarch of Dimes Birth Defects Foundation. 1275\\nMamaroneck Ave., White Plains, NY 10605. (914) 428-\\n7100. resourcecenter@modimes.org. .\\nOTHER\\nMarch of Dimes.Public Health Education Information Sheets.\\nKaren Ericson, RN\\nTeresa G. Odle\\nBirthmarks\\nDefinition\\nBirthmarks, including angiomas and vascular\\nmalformations, are benign (noncancerous) skin\\ngrowths composed of rapidly growing or poorly\\nformed blood vessels or lymph vessels. Found at\\nbirth (congenital) or developing later in life (acquired)\\nanywhere on the body, they range from faint spots to\\ndark swellings covering wide areas.\\nDescription\\nSkin angiomas, also called vascular (pertaining to\\nvessel) nevi (marks), are composed of blood vessels\\n(hemangiomas) or lymph vessels (lymphangiomas),\\nthat lie beneath the skin’s surface. Hemangiomas,\\ncomposed of clusters of cells that line the capillaries,\\nthe body’s smallest blood vessels, are found on the face\\nand neck (60%), trunk (25%), or the arms and legs\\n(15%). Congenital hemangiomas, 90% of which\\nappear at birth or within the first month of life, grow\\nquickly, and disappear over time. They are found in 1-\\n10% of full-term infants, and 25% of premature\\ninfants. About 65% are capillary hemangiomas\\n(strawberry marks), 15% are cavernous (deep) heman-\\ngiomas, and the rest are mixtures. Hemangiomas are\\nthree times more common in girls. Usually, only one\\nhemangioma is found, in 20% two are found, while\\nfewer than 5% have three or more. Lymphangiomas\\nare skin bumps caused by enlarged lymph vessels any-\\nwhere on the body.\\n550 GALE ENCYCLOPEDIA OF MEDICINE\\nBirthmarks'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Vascular malformations are poorly formed blood\\nor lymph vessels that appear at birth or later in life.\\nOne type, the salmon patch (nevus simplex), a pink\\nmark composed of dilated capillaries, is found on the\\nback of the neck (also called a stork bite) in 40% of\\nnewborns, and on the forehead and eyelids (also called\\nan angel’s kiss) in 20%. Stork bites are found in 70%\\nof white and 60% of black newborns.\\nFound in fewer than 1% of newborns, port-wine\\nstains (nevus flammeus), are vascular malformations\\ncomposed of dilated capillaries in the upper and lower\\nlayers of the skin of the face, neck, arms, and legs.\\nOften permanent, these flat pink to red marks develop\\ninto dark purple bumpy areas in later life; 85% appear\\non only one side of the body.\\nAcquired hemangiomas include spider angiomas\\n(nevus araneus), commonly known as spider veins,\\nand cherry angiomas (senile angiomas or Campbell\\nde Morgan spots). Found around the eyes, cheek-\\nbones, arms, and legs, spider angiomas are red marks\\nformed from dilated blood vessels. They occur during\\npregnancy in 70% of white women and 10% of black\\nwomen, in alcoholics andliver diseasepatients, and in\\n50% of children. Cherry angiomas, dilated capillaries\\nfound mainly on the trunk, appear in the 30s, and\\nmultiply withaging.\\nCauses and symptoms\\nThere are no known causes for congenital skin\\nangiomas; they may be related to an inherited weak-\\nness of vessel walls. Exposure to estrogen causes spider\\nangiomas in pregnant women or those takingoral\\ncontraceptives. Spider angiomas tend to run in\\nfamilies, and may be associated with liver disease,\\nsun exposure, and trauma.\\nHemangiomas\\nHemangiomas first appear as single or multiple,\\nwhite or pale pink marks, ranging from 2-20 cm (aver-\\nage 2-5 cm) in size. Some are symptomless while others\\ncause pain or bleeding, or interfere with normal func-\\ntioning when they are numerous, enlarged, infected, or\\nulcerated. Vision is affected by large marks on the\\neyelids. Spider and cherry angiomas are unsightly\\nbut symptomless.\\nEach type of hemangioma has a characteristic\\nappearance:\\n/C15Capillary hemangiomas (strawberry marks). These\\nround, raised marks are bright red and bumpy like\\na strawberry, and become white or gray when fading.\\n/C15Cavernous hemangiomas. These slightly raised,\\ndome-shaped, blue or purple swellings are sometimes\\nassociated with lymphangiomas or involve the soft\\ntissues, bone, or digestive tract.\\n/C15Spider angiomas. These are symptomless, reddish\\nblue marks formed from blood-filled capillaries\\nradiating around a central arteriole (small artery) in\\nthe shape of a spider web.\\n/C15Cherry angiomas. These harmless, dilated capillaries\\nappear as tiny, bright red-to-violet colored bumps.\\n/C15Lymphangiomas. These dilated lymph vessels form\\nlight pink or yellow cysts (fluid- filled sacs) or swellings.\\nKEY TERMS\\nAngioma— A benign skin tumor composed of\\nrapidly growing, small blood or lymph vessels.\\nCapillaries— The smallest blood vessels, they con-\\nnect the arteries and veins.\\nCorticosteroids— Drugs that fight inflammation.\\nHemangioma— A benign skin tumor composed of\\nabnormal blood vessels.\\nLymph vessels— Part of the lymphatic system, these\\nvessels connect lymph capillaries with the lymph\\nnodes; they carry lymph, a thin, watery fluid resem-\\nbling blood plasma and containing white blood\\ncells.\\nLymphangioma— A benign skin tumor composed\\nof abnormal lymph vessels.\\nNevus— A mark on the skin.\\nUlcer— A red, shallow sore on the skin.\\nVascular malformation— A poorly formed blood or\\nlymph vessels.\\nA fading capillary hemangioma on the nose of a child.\\n(Photograph by Dr. P. Marazzi, Custom Medical Stock Photo.\\nReproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 551\\nBirthmarks'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Vascular malformations\\nThese are faint, flat, pink stains that grow as the\\nchild grows into larger dark red or purple marks. Some\\nare symptomless but others bleed if enlarged or injured.\\nDisfiguring port-wine stains can cause emotional and\\nsocial problems. About 5% of port-wine stains on\\nthe forehead and eyelids increase eye pressure due to\\ninvolvement of the eye and surrounding nerves.\\nAbnormalities of the spinal cord, soft tissues, or bone\\nmay be associated with severe port-wine stains.\\nEach type has a characteristic appearance:\\n/C15Salmon patches. These symptomless, light red-to-\\npink marks usually fade with time.\\n/C15Port-wine stains. These flat, pink marks progress to\\nraised, dark red-to-purple grape-like lumps distort-\\ning the facial features, arms, or legs.\\nDiagnosis\\nPatients are treated by pediatricians (doctors who\\nspecialize in the care of children), dermatologists (skin\\ndisease specialists), plastic surgeons (doctors who spe-\\ncialize in correcting abnormalities of the appearance),\\nand ophthalmologists (eye disease specialists).\\nAngiomas and vascular malformations are not dif-\\nficult to diagnose. The doctor takes a complete medical\\nhistory and performs aphysical examinationincluding\\ninspection and palpation of the marks. The skin is\\nexamined for discoloration, scarring, bleeding, infec-\\ntion, or ulceration. The type, location, size, number,\\nand severity of the marks are recorded. The doctor may\\nempty the mark of blood by gentle pressure. Biopsies or\\nspecialized x rays or scans of the abnormal vessels and\\ntheir surrounding areas may be performed. Patients\\nwith port-wine stains near the eye may requireskull x\\nrays, computed tomography scans, and vision and\\ncentral nervous system tests. Most insurance plans\\npay for diagnosis and treatment of these conditions.\\nTreatment\\nTreatment choices for skin angiomas and vascular\\nmalformations depend on their type, location, and\\nseverity, and whether they cause symptoms, pain, or\\ndisfigurement.\\nWatchful waiting\\nNo treatment is given, but the mark is regularly\\nexamined. This continues until the mark disappears,\\nor requires treatment. This approach is particularly\\nappropriate for the treatment of hemangiomas,\\nwhich often do not require treatment, since they even-\\ntually shrink by themselves.\\nDrugs\\nCORTICOSTEROIDS. Daily doses of the anti-\\ninflammatory drugs prednisone or prednisolone are\\ngiven for up to 2 months with gradual reduction of\\nthe dose. The marks begin to subside within 7-10 days,\\nbut may take up to 2 months to fully disappear. If no\\nresponse is seen in 2 weeks, the drug is discontinued.\\nTreatment may be repeated. Side effects include growth\\nretardation, increased blood pressure and blood sugar,\\ncataracts, glandular disorders, and infection. Thecor-\\nticosteroids triamcinolone acetate and betamethasone\\nsodium phosphate or acetate are injected directly into\\nthe marks with a response usually achieved within a\\nweek; additional injections are given in 4-6 weeks. Side\\neffects include tissue damage at the injection site.\\nINTERFERON ALPHA-2A. This drug reduces cell\\ngrowth, and is used for vascular marks that affect\\nvision, and that are unresponsive to corticosteroids.\\nGiven in daily injections under the skin, a response\\nrate of 50% is achieved after about 7 months. Side\\neffects include fever, chills, muscle and joint pain,\\nvision disorders, low white and red blood cell counts,\\nfatigue, elevated liver enzymes,nausea, blood clotting\\nproblems, and nerve damage.\\nANTIBIOTICS. Oral or topical (applied to the skin)\\nantibiotics are prescribed for infected marks.\\nSurgery\\nLASER SURGERY. Lasers create intense heat that\\ndestroys abnormal blood vessels beneath the skin,\\nwithout damaging normal skin. Two types of lasers\\nare used: the flashlamp-pulsed dye laser (FPDL) and\\nthe neodymium:YAG (Nd:YAG) laser. The FPDL,\\nused mainly for strawberry marks and port-wine\\nstains, penetrates to a depth of 1.8 mm and causes\\nlittle scarring, while the Nd:YAG laser penetrates to\\na depth of 6 mm, and is used to treat deep hemangio-\\nmas. Laser surgeryis not usually painful, but can be\\nuncomfortable. Anesthetic cream is used for FPDL\\ntreatment. Treatment with the Nd:YAG laser requires\\nlocal or general anesthesia . Children are usually\\nsedated or anesthetized. Healing occurs within 2\\nweeks. Side effects include bruising, skin discolora-\\ntion, swelling, crusting, and minor bleeding.\\nSURGICAL EXCISION. Under local or general\\nanesthesia, the skin is cut with a surgical instrument,\\nand vascular marks or theirscars are removed. The cut\\nis repaired with stitches or skin clips.\\n552 GALE ENCYCLOPEDIA OF MEDICINE\\nBirthmarks'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='CRYOSURGERY. Vascular marks are frozen with an\\nextremely cold substance sprayed onto the skin.\\nWounds heal with minimal scarring.\\nELECTRODESICCATION. Affected vessels are\\ndestroyed with the current from an electric needle.\\nOther treatments\\nThese include:\\n/C15Sclerotherapy. Injection of a special solution causes\\nblood clotting and shrinkage with little scarring. Side\\neffects include stinging, swelling, bruising, scarring,\\nmuscle cramping, and allergic reactions. This treat-\\nment is used most commonly for spider angiomas.\\n/C15Embolization. Material injected into the vessel\\nblocks blood flow which helps control blood loss\\nduring or reduces the size of inoperable growths. A\\nserious side effect,stroke, can occur if a major blood\\nvessel becomes blocked.\\n/C15Make-up. Special brands are designed to cover birth-\\nmarks (Covermark or Dermablend).\\n/C15Cleaning and compression. Bleeding marks are\\ncleaned with soap and water or hydrogen peroxide,\\nandcompressedwith asterilebandagefor 5-10minutes.\\nAlternative treatment\\nAlternative treatments for strengthening weak\\nblood vessels include eating high-fiber foods and\\nthose containing bioflavonoids, including citrus fruit,\\nblueberries, and cherries, supplementing the diet with\\nvitamin C, and taking the herbs, ginkgo (Ginkgo\\nbiloba) and bilberry (Vaccinium myrtillus.)\\nPrognosis\\nThe various types of birthmarks have different\\nprognoses:\\n/C15Capillary hemangiomas. Fewer than 10% require\\ntreatment. Without treatment, 50% disappear by\\nage 5, 70% by age 7, and 90% by age 9. No skin\\nchanges are found in half while others have some\\ndiscoloration, scarring, or wrinkling. From 30-90%\\nrespond to oral corticosteroids, and 45% respond to\\ninjected corticosteroids; 50% respond to interferon\\nAlpha-2a. About 60% improve after laser surgery.\\n/C15Cavernous hemangiomas. Some do not disappear\\nand some are complicated by ulceration or infection.\\nAbout 75% respond to Nd:YAG laser surgery but\\nhave scarring. Severe marks respond to oral corticos-\\nteroids, but some require excision.\\n/C15Spider angiomas. These fade followingchildbirth and\\nin children, but may recur. About 90% respond to\\nsclerotherapy, electrodesiccation, or laser therapy.\\n/C15Cherry angiomas. These are easily removed by\\nelectrodesiccation.\\n/C15Lymphangiomas. These require surgery.\\n/C15Salmon patches. Eyelid marks disappear by 6-12\\nmonths of age, and forehead marks fade by age 6;\\nhowever, 50% of stork bites on the neck persist into\\nadulthood.\\n/C15Port-wine stains. Some flat birthmarks are easily\\ncovered with make-up. Treatment during infancy\\nor childhood improves results. About 95% of the\\nstains respond to FPDL surgery with minimal scarring;\\n25% will completely and 70% will partially disappear.\\nFor unknown reasons, 5% show no improvement.\\nPrevention\\nCongenital hemangiomas or vascular malform-\\nations cannot be prevented, but spider angiomas\\nmay be prevented byexercise, weight control, and a\\nhigh-fiber diet, as well as avoidance of sun exposure,\\nalcohol drinking, or wearing tight hosiery.\\nResources\\nORGANIZATIONS\\nAmerican Academy of Dermatology. 930 N. Meacham\\nRoad, P.O. Box 4014, Schaumburg, IL 60168-4014.\\n(847) 330-0230. Fax: (847) 330-0050. .\\nAmerican Academy of Pediatrics. 141 Northwest Point\\nBoulevard, Elk Grove Village, IL 60007-1098. (847)\\n434-4000. .\\nCongenital Nevus Support Group. 1400 South Joyce St.,\\nNumber C-1201, Arlington, VA 22202. (703) 920-3249.\\nNational Congenital Port Wine Stain Foundation. 123 East\\n63rd St., New York, NY 10021. (516) 867-5137.\\nMercedes McLaughlin\\nBismuth subsalicylate see Antidiarrheal\\ndrugs\\nBites and stings\\nDefinition\\nHumans can be injured by the bites or stings of\\nmany kinds of animals, including mammals such as\\ndogs, cats, and fellow humans; arthropods such as\\nGALE ENCYCLOPEDIA OF MEDICINE 553\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='spiders, bees, and wasps; snakes; and marine animals\\nsuch as jellyfish and stingrays.\\nDescription\\nMammals\\nDOGS. In the United States, where the dog popula-\\ntion exceeds 50 million, dogs surpass all other mammals\\nin the number of bites inflicted on humans. However,\\nmost dog-bite injuries are minor. A telephone survey of\\nU.S. households conducted in1994 led researchers to\\nestimate that 3,737,000 dogbites not requiring medical\\nattention occurred in the United States that year, versus\\n757,000 that required medical treatment. Studies also\\nshow that most dog bites are from pets or other dogs\\nknown to the bitten person, that males are more likely\\nthan females to be bitten, and that children face a greater\\nrisk than adults. Each year, about 10-20 Americans,\\nmostly children under 10 years of age, are killed by dogs.\\nDog bites result in an estimated 340,000 emergency\\nroom visits annually throughout the United States.\\nMore than half of the bites seen by emergency depart-\\nments occur at home. Children under 10 years old,\\nespecially boys between 5 and 9 years of age, are more\\nlikely than older people to visit an emergency room for\\nbite treatment. Children under 10 years old were also\\nmuch more liable to be bitten on the face, neck, and\\nhead. Nearly all of the injuries suffered by people seek-\\ning treatment in emergency rooms were of ‘‘low sever-\\nity,’’ and most were treated and released without being\\nadmitted to the hospital or sent to another facility.\\nMany of the bites resulted from people attempting to\\nbreak up fights between animals.\\nCATS. Although cats are found in nearly a third of\\nU.S. households, cat bites are far less common than\\ndog bites. According to one study, cats inflict perhaps\\n400,000 harmful bites in the United States each year.\\nThe tissue damage caused by cat bites is usually lim-\\nited, but they carry a high risk of infection. Whereas\\nthe infection rate for dog bite injuries is 15-20%, the\\ninfection rate for cat bites is 30-40%.\\nHUMANS. Bites from mammals other than dogs\\nand cats are uncommon, with one exception—human\\nbites. There are approximately 70,000 human bites\\neach year in the United States. Because the human\\nmouth contains a multitude of potentially harmful\\nmicroorganisms, human bites are more infectious\\nthan those of most other animals.\\nArthropods\\nArthropods are invertebrates belonging to the phy-\\nlum Arthropoda, which includes insects, arachnids,\\ncrustaceans, and other subgroups. There are more than\\n700,000 species in all. The list of arthropods that bite or\\nstinghumansisextensiveandincludeslice,bedbugs,fleas,\\nmosquitoes, black flies, ants, chiggers, ticks, centipedes,\\nscorpions, and other species.Spiders, bees, and wasps are\\nthe three kinds of arthropod that most often bite people.\\nSPIDERS. In the United States, only two kinds of\\nvenomous spider are truly dangerous: widow spiders\\nand brown (violin or fiddle) spiders. The black widow,\\nwhich is found in every state but Alaska, is probably\\nthe most notorious widow spider. It prefers dark, dry\\nplaces such as barns, garages, and outhouses, and also\\nlives under rocks and logs. Disturbing a female black\\nwidow or its web may provoke a bite. Brown spiders\\nalso prefer sheltered places, including clothing, and\\nmay bite if disturbed.\\nBEES AND WASPS. Bees and wasps will sting\\nto defend their nests or if they are disturbed. Species\\nAn insect bite caused this person’s lower lip to swell.(Custom\\nMedical Stock Photo. Reproduced by permission.)\\nA close-up view of lacerations on the shin of an adult woman\\ninflicted by a Rottweiler dog. (Custom Medical Stock Photo.\\nReproduced by permission.)\\n554 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='common to the United States include honeybees, bum-\\nblebees, yellow jackets, bald-faced hornets, brown hor-\\nnets, and paper wasps. Of note are also Africanized bee\\nspecies, also called ‘‘killer bees’’ that have been found in\\nthe United States since 1990. More than 50 Americans\\ndie each year after being stung by a bee, wasp, or ant.\\nAlmost all of those deaths are the result of allergic\\nreactions, and not of exposure to the venom itself.\\nSnakes\\nThere are 20 species of venomous snakes in the\\nUnited States. These snakes are found in every state\\nexcept Maine, Alaska, and Hawaii. Each year about\\n8,000 Americans receive a venomous snakebite, but no\\nmore than about 15 die, mostly from rattlesnake bites.\\nThe venomous snakes of the United States are\\ndivided into two families, the Crotalidae (pit vipers)\\nand the Elapidae. Pit vipers, named after the small\\nheat-sensing pit that lies between each eye and nostril,\\nare responsible for about 99% of the venomous snake-\\nbites suffered by Americans. Rattlesnakes, copperheads,\\nand cottonmouths (also called water moccasins) are pit\\nvipers. This family of snakes delivers its venom through\\ntwo long, hinged fangs in the upper jaw. Some pit vipers\\ncarry a potent venom that can threaten the brain and\\nspinal cord. The venom of others, such as the copper-\\nheads, is less harmful.\\nThe Elapidae family includes two kinds of veno-\\nmous coral snakes indigenous to the southern and\\nwestern states. Because coral snakes are bashful crea-\\ntures that come out only at night, they almost never\\nbite humans, and are responsible for approximately 25\\nbites a year in the United States. Coral snakes also\\nhave short fangs and a small mouth, which lowers the\\nrisk of a bite actually forcing venom into a person’s\\nbody. However, their venom is quite poisonous.\\nMarine animals\\nSeveral varieties of marine animal may bite or sting.\\nJellyfish and stingrays aretwo kinds that pose a threat\\nto people who live or vacation in coastal communities.\\nCauses and symptoms\\nMammals\\nDOGS. A typical dog bite results in a laceration,\\ntear, puncture, or crush injury. Bites from large,\\npowerful dogs may even causefractures and danger-\\nous internal injuries. Also, dogs trained to attack may\\nbite repeatedly during a single episode. Infected bites\\nusually causepain, cellulitis (inflammation of the con-\\nnective tissues), and a pus-filled discharge at the\\nwound site within 8-24 hours. Most infections are\\nconfined to the wound site, but many of the micro-\\norganisms in the mouths of dogs can cause systemic\\nand possibly life-threatening infections. Examples are\\nbacteremia and meningitis, especially severe in people\\ndiagnosed with acquiredimmunodeficiency syndrome\\n(AIDS) or other health condition that increases their\\nsusceptibility to infection.Rabies is rare among pet\\ndogs in the United States, most of which have been\\nvaccinated against the disease.Tetanus is also rare but\\nTriangular head\\nPit\\nProfile and top views of typically nonpoisonous and poisonous snakes. Characteristic triangular head and pits on the side of the\\nhead are indicative of poisonous pit vipers found in the United States.(Illustration by Argosy Inc.)\\nGALE ENCYCLOPEDIA OF MEDICINE 555\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='can be transmitted by a dog bite if the victim is not\\nimmunized.\\nCATS. T h em o u t h so fc a t sa n dd o g sc o n t a i nm a n y\\nof the same microorganisms. Cat scratches and bites are\\nalso capable of transmitting theBartonella henselae\\nbacterium, which can lead tocat-scratch disease,a n\\nunpleasant but usually not life-threatening illness.\\nCat bites are mostly found on the arms and hands.\\nSharp cat teeth typically leave behind a deep puncture\\nwound that can reach muscles, tendons, and bones,\\nwhich are vulnerable to infection because of their\\ncomparatively poor blood supply. This is why cat\\nbites are much more likely to become infected than\\ndog bites. Also, people are less inclined to view cat\\nbites as dangerous and requiring immediate attention;\\nthe risk that infection has set in by the time a medical\\nprofessional is consulted is thus greater.\\nHUMANS. Humans bites result from fights, sexual\\nactivity, medical and dental treatment, and seizures.\\nBites also raise the possibility of spousal orchild abuse.\\nYellow jacket\\nPaper wasp\\nBlack\\nwidow\\nspider\\n(underside)\\nBrown\\nrecluse\\nspider\\nLouse\\nHornet\\nFire antHoney bee\\nTypes of spiders and insects that bite and sting.(Illustration by Argosy Inc.)\\n556 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Children often bite other children, but those bites are\\nhardly ever severe. Human bites are capable of trans-\\nmitting a wide range of dangerous diseases, including\\nhepatitis B, syphilis,a n dtuberculosis.\\nHuman bites fall into two categories: occlusional\\n(true) bites and clenched-fist injuries. The former pre-\\nsent a lower risk of infection. The latter, which are very\\ninfectious and can permanently damage the hand,\\nusually result from a fist hitting teeth during a fight.\\nPeople often wait before seeking treatment for a\\nclenched-fist injury, with the result that about half of\\nsuch injuries are infected by the time they are seen by a\\nmedical professional.\\nArthropods\\nSPIDERS. As a rule, people rarely see a black\\nwidow bite, nor do they feel the bite as it occurs. The\\nfirst (and possibly only) evidence that a person has\\nbeen bitten may be a mild swelling of the injured area\\nand two red puncture marks. Within a short time,\\nhowever, some victims begin to experience severemus-\\ncle cramps and rigidity of the abdominal muscles.\\nOther possible symptoms include excessive sweating,\\nnausea, vomiting, headaches, and vertigo as well as\\nbreathing, vision, and speech problems.\\nA brown spider’s bite can lead to necrotic ara-\\nchnidism, in which the tissue in an area of up to several\\ninches around the bite becomes necrotic (dies), produ-\\ncing an open sore that can take months or years to\\ndisappear. In most cases, however, the bite simply\\nproduces a hard, painful, itchy, and discolored area\\nthat heals without treatment in 2-3 days. The bite may\\nalso be accompanied by a fever, chills, edema (an\\naccumulation of excess tissue fluid),nausea and vomit-\\ning, dizziness, muscle and joint pain, and a rash.\\nBEES AND WASPS. The familiar symptoms of bee\\nand wasp stings include pain, redness, swelling, and\\nitchiness in the area of the sting. Multiple stings can\\nhave much more severe consequences, such asanaphy-\\nlaxis, a life-threatening allergic reaction that occurs in\\nhypersensitive persons.\\nSnakes\\nVenomous pit viper bites usually begin to swell\\nwithin 10 minutes and sometimes are painful. Other\\nsymptoms include skin blisters and discoloration,\\nweakness, sweating, nausea, faintness, dizziness,\\nbruising, and tender lymph nodes. Severepoisoning\\ncan also lead to tingling in the scalp, fingers, and\\ntoes, muscle contractions, an elevated heart rate,\\nrapid breathing, large drops in body temperature and\\nblood pressure, vomiting of blood, andcoma.\\nMany pit viper and coral snake bites (20-60%) fail\\nto poison (envenomate) their victim, or introduce only a\\nsmall amount of venom into the victim’s body. The\\nwounds, however, can still become infected by the harm-\\nful microorganisms that snakes carry in their mouths.\\nCoral snake bites are painful but may be hard to\\nsee. One to seven hours after the bite, a bitten person\\nbegins to experience the effects of the venom, which\\ninclude tingling at the wound site, weakness, nausea,\\nvomiting, excessive salivation, and irrational beha-\\nvior. Major nerves of the body can become paralyzed\\nfor 6-14 days, causing double vision, difficulty swal-\\nlowing and speaking, respiratory failure, and other\\nKEY TERMS\\nAnaphylaxis— A life-threatening allergic reaction\\noccurring in persons hypersensitive to bites and\\nstings.\\nAntibiotics— Substances used against bacteria that\\ncause infection.\\nAntibodies— Substances created by the body to\\ncombat infection.\\nAntihistamines— Drugs used to treat allergic reac-\\ntions by acting against a substance called histamine.\\nArachnid— Large class of arthropods that includes\\nspiders, scorpions, mites, and ticks. Arachnids have\\na segmented body divided into two parts, one of\\nwhich has four pairs of legs but no antennae.\\nArachnidism— Poisoning resulting from the bite or\\nsting of an arachnid.\\nBacteremia— Bacteria in the blood.\\nBlood serum— A component of blood.\\nImmune system— The body system that fights\\ninfection and protects the body against foreign\\ninvaders and disease.\\nKiller bees— Hybrids of African bees accidentally\\nintroduced into the wild in South and North\\nAmerica in 1956 and first reported in Texas in\\n1990. They were first imported by Brazilian scien-\\ntists attempting to create a new hybrid bee to\\nimprove honey production.\\nLymph nodes— Small, kidney-shaped organs that\\nfilter a fluid called lymph and that are part of the\\nbody’s immune system.\\nPus— A thick yellowish or greenish fluid composed\\nof the remains of dead white blood cells, pathogens\\nand decomposed cellular debris.\\nGALE ENCYCLOPEDIA OF MEDICINE 557\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='problems. Six to eight weeks may be needed before\\nnormal muscular strength is regained.\\nMarine animals\\nJELLYFISH. Jellyfish venom is delivered by barbs\\ncalled nematocysts, which are located on the crea-\\nture’s tentacles and penetrate the skin of people who\\nbrush up against them. Instantly painful and itchy\\nred lesions usually result. The pain can continue up\\nto 48 hours. Severe cases may lead to skin necrosis,\\nmuscle spasms and cramps, vomiting, nausea, diar-\\nrhea, headaches, excessive sweating, and other symp-\\ntoms. In rare instances, cardiorespiratory failure may\\nalso occur.\\nSTINGRAYS. Tail spines are the delivery mechan-\\nism for stingray venom. Deep puncture wounds result\\nthat can cause an infection if pieces of spine become\\nembedded in the wound. A typical stingray injury\\nscenario involves a person who inadvertently steps\\non a resting stingray and is lashed in the ankle by its\\ntail. Stingray venom produces immediate, excruciating\\npain that lasts several hours. Sometimes the victim\\nsuffers a severe reaction, including vomiting, diarrhea,\\nhemorrhage (bleeding), a drop in blood pressure, and\\ncardiac arrhythmia (disordered heart beat).\\nDiagnosis\\nMammals\\nDOGS. Gathering information on the circum-\\nstances of a dog attack is a crucial part of treatment.\\nMedical professionals need to know when the attack\\noccurred (the chances of infection increase dramati-\\ncally if the wound has been left untreated for more\\nthan eight hours) and what led to the attack (unpro-\\nvoked attacks are more likely to be associated with\\nrabies). A person’s general health must also be\\nassessed, including the tetanus immunization history\\nif any, as well as information concerning possible\\nallergies to medication and pre-existing health pro-\\nblems that may increase the risk of infection.\\nA physical examinationrequires careful scrutiny of\\nthe wound, with special attention to possible bone,\\njoint, ligament, muscle, tendon, nerve, or blood-vessel\\ndamage caused by deep punctures or severe crush inju-\\nries. Serious hand injuries should be evaluated by a\\nspecialized surgeon. Most of the time, laboratory tests\\nfor identifying the microorganisms in bite wounds are\\nperformed if infection is present. X rays and other\\ndiagnostic procedures may also be necessary.\\nCATS. The diagnostic procedures used for dog\\nbites also apply to cat bites.\\nHUMANS. Testing the blood of a person who has\\nbeen bitten for immunity to hepatitis B and other\\ndiseases is always necessary after a human bite.\\nIdeally, the biter should be tested as well for the pre-\\nsence of transmissible disease. Clenched-fist injuries\\noften require evaluation by a hand surgeon or orthope-\\ndist. Because many people will deny having been in a\\nfight, medical professionals usually consider lacerations\\nover the fourth and fifth knuckles—the typical result of\\na clenched-fist injury—to be evidence of a bite wound.\\nMedical professionals also look for indications of\\nspousal or childabuse when evaluating human bites.\\nArthropods\\nSPIDERS. Because bites from widow spiders and\\nbrown spiders require different treatments, capturing\\nand identifying the spider helps to establish diagnosis.\\nSnakes\\nDiagnosis relies on a physical examination of the\\nvictim, information about the circumstances of the\\nbite, and a look at the snake itself (if it can safely be\\nkilled and brought in for identification). Blood tests\\nand urinalysis supply important data on the victim’s\\ncondition. Chest x-rays and electrocardiography (a\\nprocedure for measuring heart activity) may also be\\nnecessary.\\nTreatment\\nMammals\\nDOGS. Minor dog bites can be treated at home. The\\nAmerican Academy of Family Physicians recommends\\ngently washing the wound with soap and water and then\\napplying pressure to the injured area with a clean towel\\nto stop the bleeding. The next step is to apply anti-\\nbiotic ointment and a sterile bandage to the wound.\\nTo reduce swelling and fend off infection, ice should\\nbe applied and the injured area kept elevated above\\nthe level of the heart. The wound should be cleaned\\nand covered with ointment twice a day until it heals.\\nAny dog bite that does not stop bleeding after\\n15 minutes of pressure must be seen by a medical\\nprofessional. The same is true for bites that are deep\\nor gaping; for bites to the head, hands, or feet; and for\\nbites that may have broken a bone, damaged nerves,\\nor caused a major injury of another kind. Bite victims\\nmust also watch for infection. A fever is one sign of\\ninfection, as are redness, swelling, warmth, increased\\ntenderness, and pus at the wound site. Diabetics, peo-\\nple with AIDS orcancer, individuals who have not had\\na tetanus shot in five years, and anyone else who has a\\n558 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='medical problem that can increase susceptibility to\\ninfection should seek medical treatment no matter\\nhow minor the bite appears.\\nMedical treatment of dog bites involves washing\\nthe wound with an anti-infective solution. Removal of\\ndead and damaged tissue (under local, regional, or\\ngeneral anesthetic) may be required after the wound\\nhas been washed, and any person whose tetanus shots\\nare not up to date should receive a booster injection.\\nSome wounds are left open and allowed to heal on\\ntheir own, while others require stitches (stitching may\\nbe delayed a few days if infection is a concern). Many\\nemergency departments prescribe antibiotics for all\\npeople with dog bites, but some researchers suggest\\nthat antibiotics are usually unnecessary and should\\nbe limited to those whose injuries or other health\\nproblems make them likely candidates for infection.\\nA follow-up visit after one or two days is generally\\nrequired for anyone who has received bite treatment.\\nCATS. Because of the high risk of infection, people\\nwho are bitten by a cat should always see a doctor. Cat\\nscratches do not require professional medical treat-\\nment unless the wound appears infected or the\\nscratched person has a weakened immune system.\\nMedical treatment for cat bites generally follows\\nthe procedures used for dog bites. Experts advise,\\nhowever, that cat-bite wounds should always be left\\nopen to prevent infection. Persons who have been\\nbitten by cats generally receive antibiotics as a preven-\\ntive measure.\\nHUMANS. Human bites should always be exam-\\nined by a doctor. Such bites are usually treated with\\nantibiotics and left open because of the high risk of\\ninfection. A study released in June 2004 showed that\\nroutine use of antibiotics for human bites may not be\\nnecessary, as physicians try to minimize overuse of\\nantibiotics. Superficial wounds in low-risk areas may\\nno longer need antibiotic treatment, but more serious\\nhuman bites to high-risk areas such as the hands\\nshould be treated with antibiotics to prevent serious\\ninfection. A person who has been bitten may also\\nrequire immunization against hepatitis B and other\\ndiseases. Persons who are being treated for a\\nclenched-fist injury will require a daily follow-up\\nexamination for 3-5 days.\\nArthropods\\nSPIDERS. No spider bite should be ignored.\\nThe antidote for severe widow spider bites is a sub-\\nstance called antivenin, which contains antibodies\\ntaken from the blood serum of horses injected with\\nspider venom. Doctors exercise caution in using\\nantivenin, however, because it can trigger anaphylac-\\ntic shock, a potentially deadly (though treatable) aller-\\ngic reaction, and serum sickness, an inflammatory\\nresponse that can give rise to joint pain, a fever,rashes,\\nand other unpleasant, though rarely serious,\\nconsequences.\\nAn antivenin for brown spider bites exists as well,\\nbut it is not yet available in the United States. The drug\\ndapsone, used to treatleprosy, can sometimes stop the\\ntissue death associated with a brown spider bite.\\nNecrotic areas may need debridement (removal of\\ndead and damaged tissue) and skin grafts. Pain medica-\\ntions, antihistamines, antibiotics, and tetanus shots are\\na few of the other treatments that are sometimes neces-\\nsary after a bite from a brown spider or widow spider.\\nBEES AND WASPS. Most stings can be treated at\\nhome. A stinger that is stuck in the skin can be scraped\\noff with a blade, fingernail, credit card, or piece of\\npaper (using tweezers may push more venom out of\\nthe venom sac and into the wound). The area should\\nbe cleaned and covered with an ice pack.Aspirin and\\nother pain medications, oral antihistamines, and cala-\\nmine lotion are good for treating minor symptoms.\\nPutting meat tenderizer on the wound has no effect.\\nPersons who have been stung and experience an\\nallergic reaction, or who are at risk due to their medical\\nhistory, require immediate medical attention. The danger\\nsigns, which usually begin 10 minutes after an individual\\nis stung (though possibly not for several hours), include\\nnausea, faintness, chest pain, abdominal cramps,\\ndiarrhea, and difficulty swallowing or breathing.\\nSnakes\\nAlthough most snakes are not venomous, any sna-\\nkebite should immediately be examined at a hospital.\\nWhile waiting for emergency help to arrive, the victim\\nshould wash the wound site with soap and water, and\\nthen keep the injured area still and at a level lower than\\nthe heart. Ice should never be used on the wound site\\nnor should attempts be made to suck out the venom.\\nMaking a cut at the wound site is also dangerous. It is\\nimportant to stay calm and wait for emergency medical\\naid if it can arrive quickly. Otherwise, the victim should\\nproceed directly to a hospital.\\nWhen the victim arrives at a hospital, the medical\\nstaff must determine whether the bite was inflicted by\\na venomous snake and, if so, whether envenomation\\noccurred and how much venom the person has\\nreceived. Patients may develop low blood pressure,\\nabnormal blood clotting, or severe pain, all of which\\nrequire aggressive treatment. Fortunately, the effects\\nof some snakebites can be counteracted with\\nGALE ENCYCLOPEDIA OF MEDICINE 559\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='antivenin. Minor rattlesnake envenomations can be\\nsuccessfully treated without antivenin, as can copper-\\nhead and water-moccasin bites. However, coral snake\\nenvenomations and the more dangerous rattlesnake\\nenvenomations require antivenin, sometimes in large\\namounts. Other treatment measures include antibiotics\\nto prevent infection and a tetanus booster injection.\\nMarine animals\\nJELLYFISH. Vinegar and other acidic substances\\nare used to neutralize jellyfish nematocysts still cling-\\ning to the skin, which are then scraped off. Anesthetic\\nointments, antihistamine creams, and steroid lotions\\napplied to the skin are sometimes beneficial. Other\\nmeasures may be necessary to counter the many harm-\\nful effects of jellyfish stings, which, if severe, require\\nemergency medical care.\\nSTINGRAYS. Stingray wounds should be washed\\nwith saltwater and then soaked in very hot water for\\n30-90 minutes to neutralize the venom. Afterwards,\\nthe wound should be examined by a doctor to ensure\\nthat no pieces of spine remain.\\nAlternative treatment\\nArthropods\\nSeveral alternative self-care approaches are used\\nto treat minor bee, wasp, and other arthropod stings,\\nincluding aromatherapy, ayurvedic medicine, flower\\nremedies, herbs, homeopathy, and nutritional therapy.\\nPrognosis\\nMammals\\nPrompt treatment and recognizing that even\\napparently minor bites can have serious consequences\\nare the keys to a good outcome after a mammal bite.\\nInfected bites can be fatal if neglected. Surgery and\\nhospitalization may be needed for severe bites.\\nArthropods\\nSPIDERS. Even without treatment, adults usually\\nrecover from black widow bites after 2-3 days. Those\\nmost at risk of dying are very young children, the\\nelderly, and people with high blood pressure. In the\\ncase of brown spider bites, the risk of death is greatest\\nfor children, though rare.\\nBEES AND WASPS. The pain and other symptoms of\\na bee or wasp sting normally fade away after a few\\nhours. People who are allergic to such stings, however,\\ncan experience severe and occasionally fatal\\nanaphylaxis.\\nSnakes\\nA snakebite victim’s chances of survival are excel-\\nlent if medical aid is obtained in time. Some bites,\\nhowever, result inamputation, permanent deformity,\\nor loss of function in the injured area.\\nMarine animals\\nSTINGRAYS. Stingray venom kills its human vic-\\ntims on rare occasions.\\nPrevention\\nMammals\\nDOGS. The risk of a dog bite injury can be reduced\\nby avoiding sick or stray dogs, staying away from\\ndogfights (people often get bitten when they try to\\nseparate the animals), and not behaving in ways that\\nmight provoke or upset dogs, such as wrestling with\\nthem or bothering them while they are sleeping, eating,\\nor looking after their puppies. Special precautions\\nneed to be taken around infants and young children,\\nwho must never be left alone with a dog. Pit bulls,\\nrottweilers, and German shepherds (responsible for\\nnearly half of all fatal dog attacks in the United\\nStates in 1997-2000) are potentially dangerous pets in\\nhouseholds where children live or visit. For all breeds\\nof dog, obedience training as well as spaying or neu-\\ntering lessen the chances of aggressive behavior.\\nCATS. Prevention involves warning children to\\nstay away from strange cats and to avoid rough play\\nand other behavior that can anger cats and cause them\\nto bite.\\nArthropods\\nSPIDERS. Common-sense precautions include\\nclearing webs out of garages, outhouses, and other\\nplaces favored by venomous spiders; keeping one’s\\nhands away from places where spiders may be lurking;\\nand, when camping or vacationing, checking clothing,\\nshoes, and sleeping areas.\\nBEES AND WASPS. When possible, it is advised to\\navoid the nests of bees and wasps and to not eat sweet\\nfood or wear bright clothing, perfumes, or cosmetics\\nthat attract bees and wasps.\\nEmergency medical kits containing self-adminis-\\ntrable epinephrine to counter anaphylactic shock are\\navailable for allergic people and should be carried by\\n560 GALE ENCYCLOPEDIA OF MEDICINE\\nBites and stings'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='them at all times. People who suspect they are allergic\\nshould consult an allergist about shots that can reduce\\nreactions to bee and wasp venom.\\nSnakes\\nSnakes should not be kept as pets. Measures such\\nas mowing the lawn, keeping hedges trimmed, and\\nremoving brush from the yard also discourages snakes\\nfrom living close to human dwellings. Tongs should be\\nused to move brush, lumber, and firewood, to avoid\\nexposing one’s hands to snakes that might be lying\\nunderneath. Similarly, golfers should never use their\\nhands to retrieve golf balls from a water hole, since\\nsnakes can be hiding in the rocks and weeds. Caution\\nis also necessary when walking through weedy or grassy\\nareas, and children should be prevented from playing in\\nweedy, vacant lots and other places where snakes may\\nlive. Leather boots and long pants offer hikers and\\ncampers some protection from bites. Approaching a\\nsnake, even a dead one, can be dangerous, for the\\nvenom of recently killed snakes may still be active.\\nMarine animals\\nJELLYFISH. Prevention of jellyfish stings includes\\nobeying posted warning signs at the beach. Also, jelly-\\nfish tentacles may be transparent and up to 120 ft\\n(36.5 m) long, therefore great caution must be exer-\\ncised whenever a jellyfish is sighted nearby. An over-\\nthe-counter cream was being tested at the Stanford\\nUniversity School of Medicine in the summer of\\n2004. In early tests, it was effective in helping to pre-\\nvent some jellyfish contact.\\nSTINGRAYS. Shuffling while walking through shal-\\nlow areas that may be inhabited by stingrays will dis-\\nturb the water, causing the animal to move before it\\ncan be stepped on.\\nResources\\nBOOKS\\nHolve, Steve. ‘‘Envenomations.’’ InCecil Textbook of\\nMedicine, edited by Lee Goldman and J. Claude\\nBennett, 21st ed. Philadelphia: W. B. Saunders, 2000,\\npp. 2174-2178.\\nSutherland, Struan, and Tibballs, James.Australian Animal\\nToxins. 2nd ed. New York, Oxford Univ Press, 2001.\\nPERIODICALS\\n‘‘Cream May Ward Off Jellyfish.’’Drug Week(June 25,\\n2004): 553.\\n‘‘Do All Human Bite Wounds Need Antibiotics?’’\\nEmergency Medicine Alert(June 2004): 3.\\nGraudins, A., M. Padula, K. Broady, and G. M. Nicholson.\\n‘‘Red-back spider (Latrodectus hasselti) antivenom\\nprevents the toxicity of widow spider venoms.’’Annals\\nof Emergency Medicine37, no. 2 (2001): 154-160.\\nJarvis R. M., M. V. Neufeld, and C. T. Westfall. ‘‘Brown\\nrecluse spider bite to the eyelid.’’Ophthalmology 107,\\nno. 8 (2000): 1492-1496.\\nMetry, D. W., and A. A. Hebert. ‘‘Insect and arachnid\\nstings, bites, infestations, and repellents.’’Pediatric\\nAnnals 29, no. 1 (2000): 39-48.\\nSams, H. H., C. A. Dunnick, M. L. Smith, and L. E. King.\\n‘‘Necrotic arachnidism.’’Journal of the American\\nAcademy of Dermatology44, no. 4 (2001): 561-573.\\nSams, HH. ‘‘Nineteen documented cases of Loxosceles\\nreclusa envenomation.’’Journal of the American\\nAcademy of Dermatology44, no.4 (2001): 603-608.\\nORGANIZATIONS\\nAmerican Academy of Emergency Medicine. 611 East Wells\\nStreet, Milwaukee, WI 53202. (800) 884-2236. Fax:\\n(414) 276-3349. .\\nAmerican Academy of Family Physicians. 11400 Tomahawk\\nCreek Parkway, Leawood, KS 66211-2672. (913) 906-\\n6000. . fp@aafp.org.\\nAmerican Medical Association. 515 N. State Street, Chicago,\\nIL60610. (312) 464-5000..\\nOTHER\\nCity of Phoenix, Arizona..\\nSouthwestern University School of Medicine..\\nToxicology Professional Groups..\\nUniversity of Sydney, Australia..\\nVanderbilt University..\\nL. Fleming Fallon Jr., MD, PhD\\nTeresa G. Odle\\nBlack death see Plague\\nBlack lung disease\\nDefinition\\nBlack lung disease is the common name for coal\\nworkers’ pneumoconiosis (CWP) or anthracosis, a\\nlung disease of older workers in the coal industry,\\ncaused by inhalation, over many years, of small\\namounts of coal dust.\\nDescription\\nThe risk of having black lung disease is directly\\nrelated to the amount of dust inhaled over the\\nGALE ENCYCLOPEDIA OF MEDICINE 561\\nBlack lung disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='years; the disease typically affects workers over age 50.\\nIts common name comes from the fact that the inhala-\\ntion of heavy deposits of coal dust makes miners lungs\\nlook black instead of a healthy pink. Although people\\nwho live in cities often have some black deposits in\\ntheir lungs from polluted air, coal miners have much\\nmore extensive deposits.\\nIn the years since the federal government has\\nregulated dust levels in coal mines, the number of\\ncases of black lung disease has fallen sharply. Since\\nthe Federal Coal Mine Health and Safety Act of 1969,\\naverage dust levels have fallen from 8.0 mg. per cubic\\nmeter to the current standard of 2.0 mg. per cubic\\nmeter. The 1969 law also set up a black lung disability\\nbenefits program to compensate coal miners who have\\nbeen disabled by on-the-job dust exposure.\\nDespite the technology available to control the\\nhazard, however, miners still run the risk of develop-\\ning this lung disease. The risk is much lower today,\\nhowever; fewer than 10% of coal miners have any x\\nray evidence of coal dust deposits. When there is such\\nevidence, it often shows up as only small black spots\\nless than 0.4 in (1 cm). in diameter, and may have been\\ncaused bysmoking rather than coal dust. This condi-\\ntion is called ‘‘simple CWP’’ and does not lead to\\nsymptoms or disability.\\nCauses and symptoms\\nSince the particles of fine coal dust, which a miner\\nbreathes when he is in the mines, cannot be destroyed\\nwithin the lungs or removed from them, builds up.\\nEventually, this build-up causes thickening and\\nscarring, making the lungs less efficient in supplying\\noxygen to the blood.\\nThe primary symptom of the disease isshortness\\nof breath, which gradually gets worse as the disease\\nprogresses. In severe cases, the patient may develop\\ncor pulmonale, an enlargement and strain of the right\\nside of the heart caused by chronic lung disease. This\\nmay eventually cause right-sidedheart failure.\\nSome patients developemphysema (a disease in\\nwhich the tiny air sacs in the lungs become damaged,\\nleading to shortness of breath, and respiratory and\\nheart failure) as a complication of black lung disease.\\nOthers develop a severe type of black lung disease\\ncalled progressive massive fibrosis, in which damage\\ncontinues in the upper parts of the lungs even after\\nexposure to the dust has ended. Scientists aren’t sure\\nwhat causes this serious complication. Some think\\nthat it may be due to the breathing of a mixture of\\ncoal and silica dust that is found in certain mines.\\nSilica is far more likely to lead to scarring than coal\\ndust alone.\\nDiagnosis\\nBlack lung disease can be diagnosed by checking a\\npatient’s history for exposure to coal dust, followed by\\na chest x-ray to discover if the characteristic spots in\\nthe lungs caused by coal dust are present. Apulmonary\\nfunction testmay aid in diagnosis.\\nX rays can detect black lung disease before it\\ncauses any symptoms. If exposure to the dust is\\nA light micrograph of a human lung containing particles of\\ninspired coal dust (anthracosis). The black masses shown\\nare groups of coal dust particles. (Photograph by Astrid &\\nHanns-Frieder Michler, Photo Researchers, Inc. Reproduced by\\npermission.)\\nKEY TERMS\\nEmphysema— A disease in which the tiny air sacs in\\nthe lungs become damaged, leading to shortness of\\nbreath, and respiratory and heart failure.\\nFibrosis— The growth of scar tissue, often as a\\nresponse to injury, infection, or inflammation.\\nPulmonary function test— A group of procedures\\nused to evaluate the function of the lungs and con-\\nfirm the presence of certain lung disorders.\\nSilica dust— A type of dust from silica (crystalline\\nquartz) which causes breathing problems in work-\\ners in the fields of mining, stone cutting, quarrying\\n(especially granite), blasting, road and building\\nconstruction industries that manufacture abrasives,\\nand farming. Breathing the dust causes silicosis, a\\nsevere disease that can scar the lungs.\\n562 GALE ENCYCLOPEDIA OF MEDICINE\\nBlack lung disease'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='stopped at that point, progression of the disease may\\nbe prevented.\\nTreatment\\nThere is no treatment or cure for this condition,\\nalthough it is possible to treat complications such as\\nlung infections and cor pulmonale. Further exposure\\nto coal dust must be stopped.\\nPrognosis\\nThose miners with simple CWP can lead a normal\\nlife. However, patients who develop black lung disease\\nat an early age, or who have progressive massive\\nfibrosis, have a higher risk of prematuredeath.\\nPrevention\\nThe only way to prevent black lung disease is to\\navoid long-term exposure to coal dust. Coal mines\\nmay help prevent the condition by lowering coal dust\\nlevels and providing protective clothes to coal\\nminers.\\nA light micrograph of a human lung containing\\nparticles of inspired coal dust (anthracosis). The black\\nmasses shown are groups of coal dust particles.\\nResources\\nORGANIZATIONS\\nMine Safety and Health Administration. 4015 Wilson Blvd.\\nArlington, VA 22203. (703) 235-1910. .\\nCarol A. Turkington\\nBladder calculi see Bladder stones\\nBladder cancer\\nDefinition\\nBladder cancer is a disease in which the cells lining\\nthe urinary bladder lose the ability to regulate their\\ngrowth and start dividing uncontrollably. This abnor-\\nmal growth results in a mass of cells that form a tumor.\\nDescription\\nBladder cancer is the sixth most common cancer\\nin the United States. The American Cancer Society\\n(ACS) estimated that in 2001, approximately 54,300\\nnew cases of bladder cancer would be diagnosed\\n(about 39,200 men and 15,100 women), causing\\napproximately 12,400 deaths. The rates for men of\\nAfrican descent and Hispanic men are similar and\\nare approximately one-half of the rate among white\\nnon-Hispanic men. The lowest rate of bladder cancer\\noccurs in the Asian population. Among women, the\\nhighest rates also occur in white non-Hispanic females\\nand are approximately twice the rate for Hispanics.\\nWomen of African descent have higher rates of blad-\\nder cancer than Hispanic women.\\nThe urinary bladder is a hollow muscular organ\\nthat stores urine from the kidneys until it is excreted out\\nof the body. Two tubes called the ureters bring the urine\\nfrom the kidneys to the bladder. The urethra carries\\nthe urine from the bladder to the outside of the body.\\nBladder cancer has a very high rate of recurrence.\\nEven after superficial tumors are completely removed,\\nthere is a 75% chance that new tumors will develop\\nin other areas of the bladder. Hence, patients need\\nfrequent and thorough follow-up care.\\nCauses and symptoms\\nAlthough the exact cause of bladder cancer is not\\nknown, smokers are twice as likely as nonsmokers to get\\nthe disease. Hence,smoking is considered the greatest\\nrisk factor for bladder cancer. Workers who are exposed\\nto certain chemicals used in the dye industry and in the\\nrubber, leather, textile, and paint industries are believed\\nto be at a higher risk for bladder cancer. The disease also\\nis three times more common in men than in women;\\ncaucasians also are at an increased risk. The risk of\\nbladder cancer increases with age. Most cases are\\nfound in people who are 50–70 years old. In 2003, studies\\nshowed that hormone replacement therapy(HRT), a\\ntreatment used by many postmenopausal women, sig-\\nnificantly increased the risk of bladder and other cancers.\\nFrequent urinary infections, kidney andbladder\\nstones, and other conditions that cause long-term\\nirritation to the bladder may increase the risk of getting\\nbladder cancer. A past history of tumors in the bladder\\nalso could increase one’s risk of getting other tumors.\\nOne of the first warning signals of bladder cancer is\\nblood in the urine. Sometimes, there is enough blood to\\nchange the color of the urine to a yellow-red or a dark\\nred. At other times, the color of the urine appears\\nnormal but chemical testing of the urine reveals the\\npresence of blood cells. A change in bladder habits\\nsuch as painful urination, increased frequency of\\nurination and a feeling of needing to urinate but not\\nbeing able to do so are some of the signs of possible\\nGALE ENCYCLOPEDIA OF MEDICINE 563\\nBladder cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='bladder cancer. All of these symptoms also may be\\ncaused by conditions other than cancer, but it is impor-\\ntant to see a doctor and have the symptoms evaluated.\\nWhen detected early and treated appropriately, patients\\nhave a very good chance of being cured completely.\\nDiagnosis\\nIf a doctor has any reason to suspect bladder can-\\ncer, several tests can help find out if the disease is\\npresent. As a first step, a complete medical history\\nwill be taken to check for any risk factors. A thorough\\nphysical examinationwill be conducted to assess all the\\nsigns and symptoms. Laboratory testing of a urine\\nsample will help to rule out the presence of a bacterial\\ninfection. In a urine cytology test, the urine is examined\\nunder a microscope to look for any abnormal or can-\\ncerous cells. A catheter (tube) can be advanced into\\nthe bladder through the urethra, and a salt solution is\\npassed through it to wash the bladder. The solution\\ncan then be collected and examined under a microscope\\nto check for the presence of cancerous cells.\\nA test known as the intravenous pyelogram (IVP)\\nis an x–ray examination that is done after a dye is\\ninjected into the blood stream through a vein in the\\narm. The dye travels through the blood stream and\\nthen reaches the kidneys to be excreted. It clearly out-\\nlines the kidneys, ureters, bladder, and urethra.\\nMultiple x rays are taken to detect any abnormality\\nin the lining of these organs.\\nThe physician may use a procedure known as a\\ncystoscopy to view the inside of the bladder. A thin\\nhollow lighted tube is introduced into the bladder\\nthrough the urethra. If any suspicious looking masses\\nare seen, a small piece of the tissue can be removed\\nfrom it using a pair of biopsy forceps. The tissue is then\\nexamined microscopically to verify if cancer is present,\\nand if so, to identify the type of cancer.\\nIf cancer is detected and there is evidence to indi-\\ncate that it has metastasized (spread) to distant sites in\\nthe body, imaging tests such as chest x rays, computed\\ntomography scans (CT), and magnetic resonance ima-\\nging (MRI) may be done to determine which organs\\nare affected. Bladder cancer generally tends to spread\\nto the lungs, liver, and bone.\\nTreatment\\nTreatment for bladder cancer depends on the\\nstage of the tumor. The patient’s medical history,\\noverall health status, and personal preferences also\\nare taken into account when deciding on an appropri-\\nate treatment plan. The three standard modes of treat-\\nment available for bladder cancer are surgery,\\nradiation therapy, and chemotherapy. In addition,\\nnewer treatment methods such as photodynamic ther-\\napy and immunotherapy also are being investigated in\\nclinical trials.\\nSurgery is considered an option only when the dis-\\nease is in its early stages. If the tumor is localized to a\\nUrethra\\nEpithalial Lining\\nMuscle\\nUreterBladder\\nCancer\\nBladder cancer on the inner lining of the bladder.(Illustration by Argosy Inc.)\\n564 GALE ENCYCLOPEDIA OF MEDICINE\\nBladder cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='small area and has not spread to the inner layers of the\\nbladder, then the surgery is done without cutting open\\nthe abdomen. A cytoscope is introduced into the blad-\\nder through the urethra, and the tumor is removed\\nthrough it. This procedure is called a transurethral\\nresection (TUR). Passing a high-energy laser beam\\nthrough the cytoscope and burning the cancer may\\ntreat any remaining cancer. This procedure is known\\nas electrofulguration. If the cancer has invaded the walls\\nof the bladder, surgery will be done through an incision\\nin the abdomen. Cancer that is not very large can be\\nremoved by partialcystectomy, a procedure where a\\npart of the bladder is removed. If the cancer is large or\\nis present in more than one area of the bladder, a radical\\ncystectomy is done. In this operation, the entire bladder\\nand adjoining organs also may be removed. In men, the\\nprostate is removed, while in women, the uterus, ovar-\\nies, and fallopian tubes are removed.\\nIf the entire urinary bladder is removed, an alter-\\nnate place must be created for the urine to be stored\\nbefore it is excreted out of the body. To do this, a piece\\nof intestine is converted into a small bag and attached\\nto the ureters. This is then connected to an opening\\n(stoma) that is made in the abdominal wall. The pro-\\ncedure is called a urostomy. In some urostomy proce-\\ndures, the urine from the intestinal sac is routed into a\\nbag that is placed over the stoma in the abdominal\\nwall. The bag is hidden by the clothing and has to be\\nemptied occasionally by the patient. In a different\\nprocedure, the urine is collected in the intestinal sac,\\nbut there is no bag on the outside of the abdomen. The\\nintestinal sac has to be emptied by the patient, by\\nplacing a drainage tube through the stoma.\\nRadiation therapy that uses high-energy rays to\\nkill cancer cells is generally used after surgery to\\nKEY TERMS\\nBiopsy— The surgical removal and microscopic\\nexamination of living tissue for diagnostic purposes.\\nChemotherapy— Treatment with anticancer drugs.\\nComputed tomography (CT) scan— A medical pro-\\ncedure where a series of x rays are taken and put\\ntogether by a computer in order to form detailed\\npictures of areas inside the body.\\nCystoscopy— A diagnostic procedure where a hol-\\nlow lighted tube, (cystoscope) is used to look inside\\nthe bladder and the urethra.\\nElectrofulguration— A procedure where a high-\\nenergy laser beam is used to burn the cancerous tissue.\\nImmunotherapy— Treatment of cancer by stimulat-\\ning the body’s immune defense system.\\nIntravenous pyelogram (IVP)— A procedure where a\\ndye is injected into a vein in the arm. The dye travels\\nthrough the body and then concentrates in the urine\\nto be excreted. It outlines the kidneys, ureters, and\\nthe urinary bladder. An x ray of the pelvic region is\\nthen taken and any abnormalities of the urinary tract\\nare revealed.\\nMagnetic Resonance Imaging (MRI)— A medical\\nprocedure used for diagnostic purposes where pic-\\ntures of areas inside the body can be created using a\\nmagnet linked to a computer.\\nPartial cystectomy— A surgical procedure where the\\ncancerous tissue is removed by cutting out a small\\npiece of the bladder.\\nPhotodynamic therapy— A novel mode of treat-\\nment that uses a combination of special light\\nrays and drugs are used to destroy the cancerous\\ncells. First, the drugs, which make cancerous cells\\nmore susceptible to the light rays, are introduced\\ninto the bladder. Then the light is shone on the\\nbladder to kill the cells.\\nRadiation therapy— Treatment using high-energy\\nradiation from x-ray machines, cobalt, radium, or\\nother sources.\\nRadical cystectomy— A surgical procedure that is\\nused when the cancer is in more than one area of\\nthe bladder. Along with the bladder, the adjoining\\norgans also are removed. In men, the prostate is\\nremoved, while in women, the ovaries, fallopian\\ntubes and uterus may be removed.\\nStoma— An artificial opening between two cav-\\nities or between a cavity and the surface of the\\nbody.\\nTransurethral resection— A surgical procedure to\\nremove abnormal tissue from the bladder. The tech-\\nnique involves the insertion of an instrument called a\\ncytoscope into the bladder through the urethra, and\\nthe tumor is removed through it.\\nUrostomy— A surgical procedure consisting of cut-\\nting the ureters from the bladder and connecting\\nthem to an opening (see stoma) on the abdomen,\\nallowing urine to flow into a collection bag.\\nGALE ENCYCLOPEDIA OF MEDICINE 565\\nBladder cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='destroy any remaining cancer cells that may not have\\nbeen removed during surgery. If the tumor is in a\\nlocation that makes surgery difficult, or if it is large,\\nradiation may be used before surgery to shrink the\\ntumor. In cases of advanced bladder cancer, radiation\\ntherapy is used to ease the symptoms such aspain,\\nbleeding, or blockage. Radiation can be delivered by\\nexternal beam, where a source of radiation that is\\noutside the body focuses the radiation on the area of\\nthe tumor. Occasionally, a small pellet of radioactive\\nmaterial may be placed directly into the cancer. This is\\nknown as interstitial radiation therapy.\\nChemotherapy uses anticancer drugs to destroy\\nthe cancer cells that may have migrated to distant\\nsites. The drugs are introduced into the bloodstream\\nby injecting them into a vein in the arm or taking\\nthem orally in pill form. Generally a combination of\\ndrugs is more effective than any single drug in treating\\nbladder cancer. Chemotherapy may be given follow-\\ning surgery to kill any remaining cancer cells. It also\\nmay be given even when no remaining cancer cells\\ncan be seen. This is called adjuvant chemotherapy.\\nAnticancer drugs, including thiotepa, doxorubicin,\\nand mitomycin, also may be instilled directly into\\nthe bladder (intravesicular chemotherapy) to treat\\nsuperficial tumors. In 2003, the FDA was giving fast\\ntrack designation to a form of paclitaxel, a common\\nanticancer drug, that was shown effective in treating\\nmetastatic or locally advanced bladder cancer.\\nA 2003 report stated that giving patients with blad-\\nder cancer chemotherapy followed by surgery may\\nimprove their outcomes. In the study of 307 patients,\\nthose with this combination of therapy lived two\\nyears longer than those treated with surgery only.\\nImmunotherapy, or biological therapy, uses the\\nbody’s own immune cells to fight the disease. To treat\\nsuperficial bladder cancer, bacille Calmette-Guerin\\n(BCG) may be instilled directly into the bladder. BCG\\nis a weakened (attenuated) strain of thetuberculosis\\nbacillus that stimulates the body’s immune system to\\nfight the cancer. This therapy has been shown to be\\neffective in controlling superficial bladder cancer.\\nPhotodynamic treatment is a novel mode of treat-\\nment that uses special chemicals and light to kill the\\ncancerous cells. First, a drug is introduced into the\\nbladder that makes the cancer cells more susceptible\\nto light. Following that, a special light is shone on the\\nbladder in an attempt to destroy the cancerous cells.\\nNew treatments are continuously being investi-\\ngated. Scientists have made great strides in gene map-\\nping and research in the twenty-first century. In 2003,\\na type ofgene therapy was being tested on patients\\nwith bladder cancer with success, but further enhance-\\nments were needed.\\nPrognosis\\nWhen detected in early stages, the prognosis for\\nthose with bladder cancer is excellent. At least 94% of\\npeople survive five years or more after initial diagno-\\nsis. However, if the disease has spread to the nearby\\ntissues, the survival rate drops to 49%. If it has metas-\\ntasized to distant organs such as the lung and liver,\\ncommonly only 6% of patients will survive five years\\nor more. As newer treatment methods are developed,\\nsome prognoses improve. For example, neoadjuvant\\nchemotherapy, or giving certain chemotherapy drugs\\nfollowing surgery, may help people live up to\\n31 months longer than previous treatments allowed.\\nPrevention\\nSince the exact causes of bladder cancer are not\\nknown, there is no certain way to prevent it. Avoiding\\nrisk factors whenever possible is the best alternative.\\nSince smoking doubles one’s risk of getting blad-\\nder cancer, avoiding tobacco may prevent at least half\\nthe deaths that result from bladder cancer. Taking\\nappropriate safety precautions when working with\\norganic cancer-causing chemicals is another way of\\npreventing the disease. Women should discuss the\\nrisks vs. benefits of hormone replacement therapy\\nwith their physicians.\\nIf a person has had a history of bladder cancer, or\\nhas been exposed to cancer-causing chemicals, he or\\nshe is considered to be at an increased risk of getting\\nbladder cancer. Similarly,kidney stones, frequent urin-\\nary infections, and other conditions that cause long-\\nterm irritation to the bladder also increase the chance\\nof getting the disease. In such cases, it is advisable to\\nundergo regular screening tests such as urine cytology,\\ncystoscopy and x rays of the urinary tract, so that\\nbladder cancer can be detected at its early stages and\\ntreated appropriately.\\nResources\\nPERIODICALS\\nGood, Brian. ‘‘Battle Against Bladder Cancer.’’Men’s\\nHealth 18 (December 2003): 32.\\nGrossman, H. Barton, et al. ‘‘Neoadjuvant Chemotherapy\\nPlus Cystectomy Compared With Cystectomy Alone\\nfor Locally Advanced Bladder Cancer.’’The New\\nEngland Journal of Medicine(August 28, 2003): 859.\\n‘‘HRT Increases Risk of Gallbladder, Breast, Endometrial,\\nand Bladder Cancer.’’Women’s Health Weekly(July 17,\\n2003): 31.\\n566\\nGALE ENCYCLOPEDIA OF MEDICINE\\nBladder cancer'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='‘‘Intravesical Gene Therapy Appears Safe for Those\\nWith Local Bladder Cancer.’’Cancer Weekly(July 8,\\n2003): 144.\\n‘‘Tocosol Paclitaxel Receives Expedited Review for Bladder\\nCancer Indication.’’Biotech Week(November 26,\\n2003): 443.\\nORGANIZATIONS\\nAmerican Cancer Society. 1599 Clifton Rd., NE, Atlanta,\\nGA 30329-4251. (800) 227-2345. .\\nAmerican Foundation for Urologic Disease. 300 W. Pratt\\nSt., Suite 401. Baltimore, MD 21201. Phone: (800)-\\n828-7866.\\nCancer Research Institute. 681 Fifth Ave., New York, N.Y.\\n10022. (800) 992-2623. .\\nNational Cancer Institute. Building 31, Room 10A31, 31\\nCenter Drive, MSC 2580, Bethesda, MD 20892-2580.\\n(800) 422-6237. .\\nOncolink. University of Pennsylvania Cancer Center.\\n.\\nOTHER\\n‘‘Bladder Cancer.’’ National Cancer Institute Page..\\nLata Cherath, PhD\\nTeresa G. Odle\\nBladder removal see Cystectomy\\nBladder resection see Transurethral bladder\\nresection\\nBladder stones\\nDefinition\\nBladder stones are crystalline masses that form\\nfrom the minerals and proteins, which naturally\\noccur in urine. These types of stones are much less\\ncommon thankidney stones.\\nDescription\\nBladder stones can form anywhere in the urinary\\ntract before depositing in the bladder. They begin as tiny\\ngranules about the size of a grain of sand, but they can\\ngrow to more than an inch in diameter. These stones\\ncan block the flow of urine causingpain and difficulty\\nwith urination. They can also scratch the bladder\\nwall, which may lead to bleeding or infection.\\nCauses and symptoms\\nWhile the exact causes of the formation of bladder\\nstones are not completely understood, bladder stones\\nusually occur because of urinary tract infection (UTI),\\nobstruction of the urinary tract, enlargement of the\\nprostate gland in men, or the presence of foreign\\nbodies in the urinary tract. Diet and the amount of\\nfluid intake also appear to be important factors in the\\ndevelopment of bladder stones.\\nNinety-five percent of all bladder stones occur\\nin men, most of who have anenlarged prostategland or\\na UTI. These stones are rarely seen in children or\\nin African Americans. People withgout may deve-\\nlop bladder stones composed almost entirely of uric acid.\\nThe symptoms of bladder stones may become\\nevident when the wall of the bladder is scratched or\\nwhen the urinary tract becomes obstructed by the\\nstone. These symptoms include:\\n/C15abnormally dark colored urine\\n/C15blood in the urine\\n/C15difficulty urinating\\n/C15frequent urge to urinate\\n/C15lower abdominal pain\\n/C15pain or discomfort in the penis\\nSome people with bladder stones also may experi-\\nence an inability to control urination ( urinary\\nincontinence).\\nDiagnosis\\nThe diagnosis of bladder stones is usually made\\nafter a physical examination, which may include a\\nrectal examination to check for enlargement of the\\nprostate gland. Urine tests are then used to determine\\nKEY TERMS\\nBladder— A small organ that serves as the reservoir\\nfor urine prior to its passing from the body during\\nurination.\\nProstate gland— A small gland in the male genitals\\nthat contributes to the production of seminal fluid.\\nUrinary tract— The system of organs that produces\\nand expels urine from the body. This system begins\\nat the kidneys, where the urine is formed; passes\\nthrough the bladder; and, ends at the urethra,\\nwhere urine is expelled.\\nGALE ENCYCLOPEDIA OF MEDICINE 567\\nBladder stones'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='if there is blood or indications of an UTI in the urine. If\\nbladder stones are suspected, bladder or pelvic x rays\\nmay be ordered. Stones that are large enough to cause\\nproblems with urinary function are almost always\\ndetectable by x ray.\\nTreatment\\nMany bladder stones can be passed out of the\\nbody in the urine. People with small bladder stones\\nwill be asked to increase their fluid intakes to at least\\nsix to eight eight-ounce glasses of water per day to\\nincrease urinary output. If the stones do not pass\\nafter two weeks, or if the patient’s symptoms become\\nworse, further medical treatment may be required.\\nA large bladder stone, or small stone that the patient\\ncannot pass in the urine, may be broken up into smaller\\nstones using ultrasound (shock waves). These smaller\\nstones may then pass in the urine. Stones that cannot\\nbe broken into pieces by these methods, or that the\\npatient cannot pass, may have to be surgically removed.\\nAlternative treatment\\nTraditional herbal remedies for bladder stones\\ninclude celery seed and horsetail. Also, because incom-\\nplete bladder emptying may cause bladder stones, many\\npatients may benefit from methods and remedies aimed\\nat improving overall bladder function. These include\\nKegel exercises, which are used to strengthen the\\nmuscles involved in urination; herbal supplements\\n(cornsilk, hydrangea, juniper berries, parsley, and uva\\nursi) used to increase urine flow and flush out sediment\\nfrom the bladder; and, the consumption of cranberry\\njuice and/or fresh, unsweetened, lemon juice.\\nCranberry juice helps to control urinary tract infection\\nand contains a chemical that coats the walls of the\\nbladder, making them more resistant to infection.\\nLemon juice helps to flush out the urinary system.\\nPrognosis\\nMost bladder stones can be, and are, passed out of\\nthe body in the urine without any permanent damage\\nto the bladder or the rest of the urinary tract.\\nHowever, most bladder stones arise from an under-\\nlying medical condition. Therefore, if this medical\\ncondition is not corrected approximately half of all\\npatients will experience a recurrence of bladder stones\\nwithin five years.\\nPrevention\\nBladder stones may, in some cases, be prevented\\nby the patient receiving prompt medical treatment for\\nan enlarged prostate gland or UTI. The consumption\\nof at least six to eight eight-ounce glasses of water per\\nday and/or the regular consumption of cranberry juice\\nmay help to prevent recurrences of bladder stones.\\nResources\\nPERIODICALS\\nSchwartz, B.F., and M.L. Stoller. ‘‘The vesical calculus.’’\\nUrologic Clinics of North America27 (May 2000):\\n333-46.\\nORGANIZATIONS\\nAmerican Foundation for Urologic Disease. 1128 North\\nCharles Street, Baltimore, Maryland 21201. (410)\\n468-1800. Fax: (410) 468-1808. .\\nOTHER\\n‘‘Bladder Stones.’’ MEDLINEplus Health Information.\\nMay 12, 2001. .\\nPaul A. Johnson, Ed.M.\\nBladder training\\nDefinition\\nBladder training is a behavioral modification treat-\\nment technique forurinary incontinencethat involves\\nplacing a patient on a toileting schedule. The time\\ninterval between urination is gradually increased in\\norder to train the patient to remain continent.\\nPurpose\\nBladder training is used to treat urinary urge\\nincontinence. Urge incontinence occurs when an\\nindividual feels a sudden need to urinate and cannot\\ncontrol the urge to do so and, as a consequence, invo-\\nluntarily loses urine before making it to the toilet.\\nPrecautions\\nIncontinence may be controlled through a num-\\nber of invasive and non-invasive treatment options,\\nincluding Kegel exercises, biofeedback, bladder\\ntraining, medication, insertable incontinence devices,\\nand surgery. Each patient should undergo a full\\ndiagnostic work-up to determine the type and cause\\nof the incontinence in order to determine the best\\ncourse of treatment.\\n568 GALE ENCYCLOPEDIA OF MEDICINE\\nBladder training'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nBladder training may be prescribed and implemen-\\nted by a general physician, urologist, or urogynecolo-\\ngist. A urination schedule is created for the patient.\\nThe schedule typically starts out with fairly short inter-\\nvals between bathroom breaks (e.g., an hour). As soon\\nas the patient is able to consistently remain continent\\nfor several days at a certain toileting time interval, the\\ntime span is increased. Bladder training continues until\\nthe patient regularly achieves continence at a time\\ninterval he/she feels comfortable with.\\nPreparation\\nA complete evaluation to determine the cause of\\nurinary incontinence is critical to proper treatment.\\nA thorough medical history andphysical examination\\nshould be performed on patients considering bladder\\ntraining. Diagnostic testing may include x rays, ultra-\\nsound, urine tests, and a physical examination of\\nthe pelvis. It may include a series of exams called\\nurodynamic testing that measure bladder pressure\\nand capacity and the urinary flow. The patient may\\nalso be asked to keep a diary of their urination output\\nand frequency and episodes of incontinence over a\\nperiod of several days or a week.\\nRisks\\nBladder training may not be successful in all\\npatients with urge incontinence. Patients who demon-\\nstrate a strong desire to control their continence and\\nare committed to sticking with a training program\\ntend to have the most success with bladder training.\\nNormal results\\nPatients who undergo successful bladder training\\ngain complete or improved control over their urina-\\ntion. In some cases, additional alternate treatment\\nsuch as biofeedback or pelvic muscle exercises may\\nbe recommended to supplement the progress made\\nwith bladder training.\\nResources\\nORGANIZATIONS\\nAmerican Foundation for Urologic Disease. 1128 North\\nCharles St., Baltimore, MD 21201. (800) 242-2383.\\n.\\nNational Association for Continence. P.O. Box 8310,\\nSpartanburg, SC 29305-8310. (800) 252-3337. .\\nPaula Anne Ford-Martin\\nBlastomyces dermatitidis see Blastomycosis\\nBlastomycosis\\nDefinition\\nBlastomycosis is an infection caused by inhaling\\nmicroscopic particles (spores) produced by the fungus\\nBlastomyces dermatitidis. Blastomycosis may be limited\\nto the lungs or also involve the skin and bones. In its\\nmost severe form, the infection can spread throughout\\nthe body and involve many organ systems (systemic).\\nDescription\\nBlastomycosis is a fungal infection caused by\\nBlastomyces dermatitidis. Although primarily an air-\\nborne disease, farmers and gardeners may become\\ninfected from contact with spores in the soil through\\ncuts and scrapes. The fungus that causes the disease is\\nfound in moist soil and wood in the southeastern\\nUnited States, the Mississippi River valley, southern\\nCanada, and Central America. Blastomycosis is also\\ncalled Gilchrist’s disease, Chicago disease, or North\\nAmerican blastomycosis. Another South and Central\\nAmerican disease, paracoccidioidomycosis, is some-\\ntimes called South American blastomycosis, but\\ndespite the similar name, this disease is substantially\\ndifferent from North American blastomycosis. Canine\\nblastomycosis, a common dog disease, is caused by the\\nsame fungus that infects humans. However, people do\\nnot get this disease from their dogs except only very\\nrarely through dog bites.\\nBlastomycosis is a rare disease infecting only\\nabout 4 in every 100,000 people. It is at least six\\ntimes more common in men than in women and\\ntends to more often infect children and individuals in\\nthe 30–50 year old age group. People who have\\nKEY TERMS\\nBiofeedback— Biofeedback training monitors tem-\\nperature and muscle contractions in the vagina to\\nhelp incontinent patients control their pelvic\\nmuscles.\\nPelvic muscle exercises— Exercises that tighten and\\ntone the pelvic floor, or perineal, muscles. Also\\nknown as Kegel and PC muscle exercises.\\nGALE ENCYCLOPEDIA OF MEDICINE 569\\nBlastomycosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='diabetes mellitus or who are taking drugs that sup-\\npress the immune system (immunocompromised) are\\nmore likely to develop blastomycosis. Although peo-\\nple with AIDS can get blastomycosis because of their\\nweakened immune system, blastomycosis has not been\\none of the more common fungal infections associated\\nwith AIDS.\\nCauses and symptoms\\nOnce inhaled, the spores ofB. dermatitidis can\\nlodge in the lungs and cause a localized inflammation.\\nThis is known as primary pulmonary blastomycosis.\\nThe disease does not spread from one person to\\nanother. In the early stages, symptoms may include a\\ndry cough, fever, heavy sweating, fatigue, and a general\\nfeeling of ill health. In approximately 25% of blasto-\\nmycosis cases, only the lungs are affected. As the dis-\\nease progresses, small lesions form in the lungs causing\\nthe air sacs deep within the lungs (alveoli) to break\\ndown and form small cavities.\\nIn another 35%, the disease involves both the\\nlungs and the skin. Bumps develop on the skin,\\ngradually becoming small, white, crusted blisters\\nfilled with pus. The blisters break open, creating\\nabscesses that do not heal. Approximately 19% of\\ninfected people have skin sores without infection in\\nthe lungs.\\nThe remaining approximately 20% of the\\ninfected population has blastomycosis that has\\nspread or disseminated to other systems of the\\nbody. Symptoms may include pain and lesions on\\none or more bones, the male genitalia, and/or parts\\nof the central nervous system. The liver, spleen,\\nlymph nodes, heart, adrenal glands, and digestive\\nsystem may also be infected.\\nDiagnosis\\nA positive diagnosis of blastomycosis is made when\\nthe fungusB. dermatitidisis identified by direct micro-\\nscopic examination of body fluids such as sputum and\\nprostate fluid or in tissue samples (biopsies) from the\\nlung or skin. Another way to diagnose blastomycosis is\\nto culture and isolate the fungus from a sample of\\nsputum. Chest x rays are used to assess lung damage,\\nbut alone cannot lead to a definitive diagnosis of blas-\\ntomycosis because any damage caused by other dis-\\neases, such as by pneumonia or tuberculosis,m a y\\nappear look on the x ray. Because its symptoms vary\\nwidely, blastomycosis is often misdiagnosed.\\nTreatment\\nBlastomycosis must be treated or it will gradually\\nlead to death. Treatment with the fungicidal drug\\nketoconazole (Nizoral) taken orally is effective in\\nabout 75% of patients. Amphotericin B (Fungizone)\\ngiven intravenously is also very effective, but it has\\nmore toxic side effects than ketoconazole. Treatment\\nwith amphotericin B usually requires hospitalization,\\nand the patient may also receive other drugs to mini-\\nmize the its side effects.\\nBlastomycosis is usually attributed to contact with yeast-like\\nfungi. (Custom Medical Stock Photo. Reproduced by permission.)\\nKEY TERMS\\nAbscess— An area of inflamed and injured body\\ntissue that fills with pus.\\nAcidophilus— The bacteria called Lactobacillus\\nacidophilus that is usually found in yogurt.\\nAlveoli— Small air pockets in the lungs that\\nincrease the surface area for oxygen absorption.\\nBifidobacteria— A group of bacteria normally pre-\\nsent in the intestine. Commercial supplements con-\\ntaining these bacteria are available.\\nBiopsy— The removal of a tissue sample for diag-\\nnostic purposes.\\nImmunocompromised— A state in which the\\nimmune system is suppressed or not functioning\\nproperly.\\nSpores— The small, thick-walled reproductive\\nstructures of fungi.\\nSputum— Mucus and other matter coughed up\\nfrom airways.\\nSystemic— Not localized to a single area of the\\nbody but, instead, involving one or more body\\nsystems.\\n570 GALE ENCYCLOPEDIA OF MEDICINE\\nBlastomycosis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Alternative treatment\\nAlternative treatment for fungal infections\\nfocuses on creating an internal environment where\\nthe fungus cannot survive. This is accomplished by\\neating a diet low in dairy products, sugars, including\\nhoney and fruit juice, and foods like beer that contain\\nyeast. This is complemented by a diet consisting, in\\nlarge part, of uncooked and unprocessed foods.\\nSupplements ofvitamins C, E, A-plus, and B complex\\nmay also be useful. Lactobacillus acidophilus and\\nBifidobacterium will replenish the good bacteria in\\nthe intestines. Some antifungal herbs, like garlic\\n(Allium sativum), can be consumed in relatively large\\ndoses and for an extended period of time in order to\\nincrease effectiveness. A variety of antifungal herbs,\\nsuch as myrrh (Commiphora molmol), tea tree oil\\n(Melaleuca spp.), citrus seed extract, pau d’arco tea\\n(Tabebuia impetiginosa ), and garlic may also be\\napplied directly to the infected skin.\\nPrognosis\\nLeft untreated, blastomycosis gradually leads to\\ndeath. When treated, however, patients begin to\\nimprove within one week and, with intensive treat-\\nment, may be cured within several weeks. The highest\\nrate of recovery is among patients who only have skin\\nlesions. People with the disseminated form of the dis-\\nease are least likely to be cured and and most likely to\\nsuffer a relapse.\\nPrevention\\nBecause the fungus that causes blastomycosis is\\nairborne and microscopic, the only form of preven-\\ntion is to avoid visiting areas where it is found in the\\nsoil. For many people this is impractical. Since the\\ndisease is rare, people who maintain general good\\nhealth do not need to worry much about infection.\\nResources\\nORGANIZATIONS\\nNational Organization for Rare Disorders. P.O. Box 8923,\\nNew Fairfield, CT 06812-8923. (800) 999-6673.\\n.\\nOTHER\\n‘‘Blastomycosis.’’ Vanderbilt University Medical Center.\\n.\\nTish Davidson, A.M.\\nBleeding disorders see Coagulation\\ndisorders\\nBleeding time\\nDefinition\\nBleeding time is a crude test of hemostasis (the arrest\\nor stopping of bleeding). It indicates how well platelets\\ninteract with blood vessel walls to formblood clots.\\nPurpose\\nBleeding time is used most often to detect quali-\\ntative defects of platelets, such as Von Willebrand’s\\ndisease. The test helps identify people who have\\ndefects in their platelet function. This is the ability\\nof blood to clot following a wound or trauma.\\nNormally, platelets interact with the walls of blood\\nvessels to cause a blood clot. There are many factors\\nin the clotting mechanism, and they are initiated by\\nplatelets. The bleeding time test is usually used on\\npatients who have a history of prolonged bleeding\\nafter cuts, or who have a family history of bleeding\\ndisorders. Also, the bleeding time test is sometimes\\nperformed as a preoperative test to determine a\\npatient’s likely bleeding response during and after\\nsurgery. However, in patients with no history of\\nbleeding problems, or who are not taking anti-\\ninflammatory drugs, the bleeding time test is not\\nusually necessary.\\nPrecautions\\nBefore administering the test, patients should be\\nquestioned about what medications they may be\\ntaking. Some medications will adversely affect the\\nresults of the bleeding time test. These medications\\ninclude anticoagulants,diuretics, anticancer drugs, sul-\\nfonamides, thiazide, aspirin and aspirin-containing\\npreparations, and nonsteroidal anti-inflammatory\\ndrugs. The test may also be affected by anemia (a\\ndeficiency in red blood cells). Since the taking of\\naspirin or related drugs are the most common cause\\nof prolonged bleeding time, no aspirin should be taken\\ntwo weeks prior to the test.\\nDescription\\nThere are four methods to perform the bleeding\\ntest. The Ivy method is the traditional format for this\\ntest. In the Ivy method, a blood pressure cuff is\\nplaced on the upper arm and inflated to 40 mM\\nHg. A lancet or scalpel blade is used to make a stab\\nwound on the underside of the forearm. An auto-\\nmatic, spring-loaded blade device is most commonly\\nused to make a standard-sized cut. The area stabbed\\nGALE ENCYCLOPEDIA OF MEDICINE 571\\nBleeding time'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='is selected so that no superficial or visible veins are\\ncut. These veins, because of their size, may have\\nlonger bleeding times, es pecially in people with\\nbleeding defects. The time from when the stab\\nwound is made until all bleeding has stopped is\\nmeasured and is called the bleeding time. Every 30\\nseconds, filter paper or a paper towel is used to draw\\noff the blood. The test is finished when bleeding has\\nstopped completely.\\nThe three other methods of performing the bleed-\\ning test are the template, modified template, and Duke\\nmethods. The template and modified template meth-\\nods are variations of the Ivy method. A blood pressure\\ncuff is used and the skin on the forearm prepared as in\\nthe Ivy method. A template is placed over the area to\\nbe stabbed and two incisions are made in the forearm\\nusing the template as a location guide. The main dif-\\nference between the template and the modified method\\nis the length of the cut made.\\nFor the Duke method, a nick is made in an ear\\nlobe or a fingertip is pricked to cause bleeding. As in\\nthe Ivy method, the test is timed from the start of\\nbleeding until bleeding is completely stopped. The\\ndisadvantage to the Duke method is that the pressure\\non the blood veins in the stab area is not constant and\\nthe results achieved are less reliable. The advantage to\\nthe Duke method is that no scar remains after the test.\\nThe other methods may result in a tiny, hairline scar\\nwhere the wound was made. However, this is largely a\\ncosmetic concern.\\nPreparation\\nThere is no special preparation required of the\\npatient for this test. The area to be stabbed should be\\nwiped clean with an alcohol pad. The alcohol should\\nbe left on the skin long enough for it to kill bacteria at\\nthe wound site. The alcohol must be removed before\\nstabbing the arm because alcohol will adversely affect\\nthe tests results by inhibiting clotting.\\nAftercare\\nIf a prolonged bleeding time is caused by unknown\\nfactors or diseases, further testing is required to identify\\nthe exact cause of the bleeding problem.\\nNormal results\\nA normal bleeding time for the Ivy method is less\\nthan five minutes from the time of the stab until all\\nbleeding from the wound stops. Some texts extend the\\nnormal range to eight minutes. Normal values for the\\ntemplate method range up to eight minutes, while for\\nthe modified template methods, up to 10 minutes is\\nconsidered normal. Normal for the Duke method is\\nthree minutes.\\nAbnormal results\\nA bleeding time that is longer than normal is an\\nabnormal result. The test should be stopped if the\\npatient hasn’t stopped bleeding by 20-30 minutes.\\nBleeding time is longer when the normal function of\\nplatelets is impaired, or there are a lower-than-normal\\nnumber of platelets in the blood.\\nA longer-than-normal bleeding time can indicate\\nthat one of several defects in hemostasis is present,\\nincluding severe thrombocytopenia, platelet dysfunc-\\ntion, vascular defects, Von Willebrand’s disease, or\\nother abnormalities.\\nResources\\nBOOKS\\nHenry, J. B.Clinical Diagnosis and Management by\\nLaboratory Methods.Philadelphia: W. B. Saunders Co.,\\n1996.\\nJohn T. Lohr, PhD\\nBleeding varices\\nDefinition\\nBleeding varices are bleeding, dilated (swollen)\\nveins in the esophagus (gullet), or the upper part of\\nthe stomach, caused byliver disease.\\nDescription\\nEngorged veins are called varices (plural of varix).\\nVarices may occur in the lining of the esophagus, the\\ntube that connects the mouth to the stomach, or in the\\nupper part of the stomach. Such varices are called\\nesophageal varices. These varices are fragile and can\\nbleed easily because veins are not designed to handle\\nhigh internal pressures.\\nKEY TERMS\\nHemostasis— The stopping of bleeding or blood\\nflow through a blood vessel or organ.\\n572 GALE ENCYCLOPEDIA OF MEDICINE\\nBleeding varices'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Causes and symptoms\\nLiver disease often causes an increase in the\\nblood pressure in the main veins that carry blood\\nfrom the stomach and intestines to the liver (portal\\nveins). As the pressure in the portal veins increases,\\nthe veins of the stomach and esophagus swell, until\\nthey eventually become varices. Bleeding varices are a\\nlife-threatening complication of this increase in blood\\npressure (portal hypertension). The most common\\ncause of bleeding varices is cirrhosis of the liver\\ncaused by chronic alcohol abuse or hepatitis.\\nBleeding varices occur in approximately one in\\nevery 10,000 people.\\nSymptoms of bleeding varices include:\\n/C15vomiting blood, sometimes in massive amounts\\n/C15black, tarry stools\\n/C15decreased urine output\\n/C15excessive thirst\\n/C15nausea\\n/C15vomiting\\n/C15blood in the vomit\\nIf bleeding from the varices is severe, a patient\\nmay go intoshock from the loss of blood, character-\\nized by pallor, a rapid and weak pulse, rapid and\\nshallow respiration, and lowered systemic blood\\npressure.\\nDiagnosis\\nBleeding varices may be suspected in a patient\\nwho has any of the above-mentioned symptoms, and\\nwho has either been diagnosed with cirrhosis of the\\nliver or who has a history of prolonged alcohol abuse.\\nThe definitive diagnosis is established via a specialized\\ntype of endoscopy, namely,esophagogastroduodeno-\\nscopy (EGD), a procedure that involves the visual\\nexamination of the lining of the esophagus, stomach,\\nand upper duodenum with a flexible fiberoptic\\nendoscope.\\nTreatment\\nThe objective during treatment of bleeding\\nvarices is to stop and/or prevent bleeding and to\\nrestore/maintain normal blood circulation through-\\nout the body. Patients with severe bleeding should be\\ntreated in intensive care since uncontrolled bleeding\\ncan lead todeath.\\nInitial treatment of bleeding varices begins\\nwith standard resuscitation, including intravenous\\nfluids and blood transfusions as needed. Definitive\\ntreatment is usually endoscopic, with the endo-\\nscope used to locate the sites of the bleeding. An\\ninstrument, inserted along with the endoscope, is\\nused either to inject these sites with a clotting agent\\nor to tie off the bleeding sites with tiny rubber\\nbands.\\nKEY TERMS\\nCirrhosis of the liver— A type of liver disease, most\\noften caused by chronic alcohol abuse. It is\\ncharacterized by scarring of the liver, which\\nleads to an increase in the blood pressure in the\\nportal veins.\\nEndoscopy— Medical imaging technique for visua-\\nlizing the interior of a hollow organ.\\nEsophagus— The tube in the body which takes food\\nfrom the mouth to the stomach.\\nEsophagogastroduodenoscopy (EGD)— An ima-\\nging test that involves visually examining the lining\\nof the esophagus, stomach, and upper duodenum\\nwith a flexible fiberoptic endoscope.\\nPortal hypertension— Portal hypertension forces\\nthe blood flow backward, causing the portal veins\\nto enlarge and the emergence of bleeding varices\\nacross the esophagus and stomach from the\\npressure in the portal vein. Portal hypertension is\\nmost commonly caused by cirrhosis, but can also\\nbe seen in portal vein obstruction from unknown\\ncauses.\\nPortal veins— The main veins that carry blood from\\nthe stomach and intestines to the liver.\\nShock— A state of depression of the vital processes\\nof the body characterized by pallor, a rapid and\\nweak pulse, rapid and shallow respiration, and\\nlowered blood pressure. Shock results from severe\\ntrauma, such as crushing injuries, hemorrhage,\\nburns, or major surgery.\\nTransjugular intrahepatic portosystemic shunt\\n(TIPS)— A transjugular intrahepatic portosystemic\\nshunt (TIPS) is a radiology procedure in which a\\ntubular device is inserted in the middle of the liver\\nto redirect the blood flow.\\nVarices— A type of varicose vein that develops in\\nveins in the linings of the esophagus and upper\\nstomach when these veins fill with blood and\\nswell due to an increase in blood pressure in the\\nportal veins.\\nGALE ENCYCLOPEDIA OF MEDICINE 573\\nBleeding varices'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Repeated endoscopic treatments (usually four/\\nsix) are generally required to eliminate the varices\\nand to prevent the recurrence of bleeding. These endo-\\nscopic techniques are successful in about 90 percent\\nof cases.\\nPatients who cannot be treated endoscopically\\nmay be considered for an alternative procedure called\\nTIPS (transjugular intrahepatic portosystemic shunt).\\nThis procedure involves placing a hollow metal\\ntube (shunt) in the liver connecting the portal veins\\nwith the hepatic veins (veins that leave the liver and\\ndrain to the heart). This shunt lowers the pressure in\\nthe portal veins and prevents bleeding and portal\\nhypertension. The TIPS procedure is performed by a\\nradiologist and has become an accepted method for\\nreducing portal vein pressure since 1992. Although the\\nprocedure continues to evolve, TIPS can routinely be\\ncreated in more than 93% of patients.\\nMedications aimed at controlling bleeding\\nmay also be prescribed. These include propanolol,\\nvasopressin, octreotide acetate, and isosorbide\\nmononitrate.\\nAlternative treatment\\nSome alternative treatments are aimed at prevent-\\ning the cirrhosis of the liver that often causes bleeding\\nvarices and most are effective. However, once a patient\\nhas reached the bleeding varice stage, standard inter-\\nvention to stop the bleeding is required or the patient\\nmay die.\\nPrognosis\\nBleeding varices represent one of the most feared\\ncomplications of portal hypertension. They contribute\\nto the estimated 32,000 deaths per year attributed to\\ncirrhosis. Half or more of patients who survive episodes\\nof bleeding varices are at risk of renewed esophageal\\nbleeding during the first one to two years. The risk of\\nrecurrence can be lowered by endoscopic and drug\\ntreatment. Prognosis is usually more related to the\\nunderlying liverdisease. Approximately 30 to 50 percent\\nof people with bleeding varices will die from this con-\\ndition within the six weeks of the first bleeding episode.\\nPrevention\\nThe best way to possibly prevent the development\\nor recurrence of bleeding varices is to eliminate the risk\\nfactors for cirrhosis of the liver. The most common\\ncause of cirrhosis is prolonged alcohol abuse, and alco-\\nhol consumption must be completely eliminated. People\\nwith hepatitis Bor hepatitis Calso have an increased\\nrisk of developing cirrhosis of the liver.Vaccination\\nagainst hepatitis B and avoidance of intravenous drug\\nusage reduce the risk of contracting hepatitis.\\nResources\\nBOOKS\\nShannon, Joyce Brennfleck, editor.Liver Disorders\\nSourcebook. Detroit, MI: Omnigraphics, Inc., 2000.\\nPERIODICALS\\nBurroughs, Andrew K. and David Patch. ‘‘Primary\\nprevention of bleeding from esophageal varices.’’New\\nEngland Journal of Medicine340 (April 1, 1999): 1033-5.\\nHegab, Ahmed M., and Velimir A. Luketic. ‘‘Bleeding\\nesophageal varices: How to treat this dreaded compli-\\ncation of portal hypertension.’’Postgraduate Medicine\\n109 (February 2001): 75-89.\\nORGANIZATIONS\\nAmerican Liver Foundation. 1425 Pompton Ave., Cedar\\nGrove, NJ 07009. (800) 223-0179. .\\nOTHER\\nGoff, John.‘‘Portal hypertensive bleeding.’’May 12, 2001.\\n.\\nPaul A. Johnson, Ed.M.\\nBlepharitis see Eyelid disorders\\nBlepharoplasty\\nDefinition\\nBlepharoplasty is a cosmetic surgical procedure\\nthat removes fat deposits, excess tissue, or muscle\\nfrom the eyelids to improve the appearance of the eyes.\\nPurpose\\nThe primary use of blepharoplasty is for improv-\\ning the cosmetic appearance of the eyes. In some older\\npatients, however, sagging and excess skin surround-\\ning the eyes can be so extensive that it limits the range\\nof vision. In those cases, blepharoplasty serves a more\\nfunctional purpose.\\nPrecautions\\nBefore performing blepharoplasty, the surgeon will\\nassess whether the patient is a good candidate for the\\n574 GALE ENCYCLOPEDIA OF MEDICINE\\nBlepharoplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='treatment. A good medical history is important. The\\nsurgeon will want to know about any history of thyroid\\ndisease, hypertension, or eye problems, which may\\nincrease the risk of complications.\\nDescription\\nBlepharoplasty can be performed on the upper or\\nlower eyelid; it can involve the removal of excess skin\\nand fat deposits and the tightening of selected muscles\\nsurrounding the eyelids. The goal is to provide a more\\nyouthful appearance.\\nThe surgeon will begin by deciding whether excess\\nskin, fat deposits, or muscle looseness are at fault.\\nWhile the patient is sitting upright, the surgeon will\\nmark on the skin where incisions will be made. Care\\nwill be taken to hide the incision lines in the natural\\nskin folds above and below the eye. The patient then\\nreceives injections of a local anesthetic to numb the\\npain. Many surgeons also give the patient a sedative\\nintravenously during the procedure.\\nAfter a small, crescent-shaped section of eyelid\\nskin is removed, the surgeon will work to tease out\\nsmall pockets of fat that have collected in the lids. If\\nmuscle looseness is also a problem, the surgeon may\\ntrim tissue or add a stitch to pull it tighter. Then the\\nincision is closed with stitches.\\nIn some patients, fat deposits in the lower eyelid\\nmay be the only or primary problem. Such patients\\nmay be good candidates for transconjunctival ble-\\npharoplasty. In this procedure the surgeon makes no\\nincision on the surface of the eyelid, but instead enters\\nfrom behind to tease out the fat deposits from a small\\nincision. The advantage of this procedure is that there\\nis no visible scar.\\nPreparation\\nP r i o rt os u r g e r y ,p a t i e n t sm e e tw i t ht h e i rs u r -\\ngeon to discuss the procedure, clarify the results\\nthat can be achieved, and discuss the potential pro-\\nblems that might occur. Having realistic expecta-\\ntions is important in any cosmetic procedure.\\nPatients will learn, for example, that although ble-\\npharoplasty can improve the appearance of the eye-\\nlid, other procedures, such as a chemical peel, will be\\nKEY TERMS\\nEctropion— A complication of blepharoplasty, in\\nwhich the lower lid is pulled downward, exposing\\nthe surface below.\\nIntravenous sedation— A method of injecting a\\nfluid sedative into the blood through the vein\\nRetrobulbar hematoma— A rare complication of\\nblepharoplasty, in which a pocket of blood forms\\nbehind the eyeball.\\nTransconjuctival blepharoplasty— At y p eo fb l e -\\npharoplasty in which the surgeon makes no\\nincision on the surface of the eyelid, but,\\ninstead, enters from behind to tease out the fat\\ndeposits.\\nPinching the \\nredundant skin\\nCutting the skin off Closing the incisions\\nBlepharoplasty is one of the most common cosmetic surgical procedures. The illustration above depicts a procedure to\\neliminate dermochalasia, or baggy skin around the eyes. (Illustration by Electronic Illustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 575\\nBlepharoplasty'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='necessary to reduce the appearance of wrinkles\\naround the eye. Some surgeons prescribe vitamin C\\nand vitamin K for 10 days prior to surgery in the\\nbelief that this helps the healing process. Patients are\\nalso told to stopsmoking in the weeks before and\\nafter the procedure, and to refrain from alcohol and\\naspirin.\\nAftercare\\nAn antibiotic ointment is applied to the line of\\nstitches for several days after surgery. Patients also\\ntake an antibiotic several times a day to prevent\\ninfection. Ice-cold compresses are applied to the\\neyes continuously for the first day following sur-\\ngery, and several times a day for the next week or\\nso, to reduce swelling. Some swelling and discolora-\\ntion around the eyes is expected with the procedure.\\nPatients should avoid aspirin or alcoholic beverages\\nfor one week and should limit their activities,\\nincluding bending, straining, and lifting. The\\nstitches are removed a few days after surgery.\\nPatients can generally return to their usual activities\\nwithin a week to 10 days.\\nRisks\\nAs with any surgical procedure, blepharo-\\np l a s t yc a nl e a dt oi n f e c t i o na n ds c a r r i n g .G o o d\\ncare of the wound following surgery can minimize\\nthese risks. In cases where too much skin is\\nremoved from the eyelids, the patient may have\\ndifficulty closing his eyes. Dry eye syndrome may\\ndevelop, requiring the use of artificial tears to\\nlubricate the eye. In a rar e complication, called\\nretrobulbar hematoma, a pocket of blood forms\\nbehind the eyeball.\\nNormal results\\nMost patients can expect good results from ble-\\npharoplasty, with the removal of excess eyelid skin\\nand fat producing a more youthful appearance.\\nSome swelling and discoloration is expected immedi-\\nately following the procedure, but this clears in time.\\nSmall scars will be left where the surgeon has made\\nincisions; but these generally lighten in appearance\\nover several months, and, if placed correctly, will not\\nbe readily noticeable.\\nAbnormal results\\nAs noted, if too much excess skin is removed\\nfrom the upper eyelid, the patient may be unable to\\nclose his eyes completely; another surgery to correct\\nthe defect may be required. Similarly, too much skin\\ncan be removed from the lower eyelid, allowing too\\nmuch of the white of the eye (the sclera) to show. In\\nextreme cases, the lower lid may be pulled down too\\nfar, revealing the underlying tissue. Called an ectro-\\npion, this, too, may require a second, corrective\\nsurgery. The eye’s ability to make tears may also be\\ncompromised, leading to dry eye syndrome. Dry eye\\nsyndrome is potentially dangerous; in rare cases\\nit leads to damage to the cornea of the eye and\\nvision loss.\\nResources\\nORGANIZATIONS\\nAmerican Society for Dermatologic Surgery. 930 N.\\nMeacham Road, P.O. Box 4014, Schaumburg, IL\\n60168-4014. (847) 330-9830. .\\nAmerican Society of Plastic and Reconstructive Surgeons.\\n44 E. Algonquin Rd., Arlington Heights, IL 60005.\\n(847) 228-9900. .\\nRichard H. Camer\\nBlindness see Visual impairment\\nBlood-viscosity reducing drugs\\nDefinition\\nBlood-viscosity reducing drugs are medicines that\\nimprove blood flow by making the blood less viscous\\n(sticky).\\nPurpose\\nThe main use of blood-viscosity reducing drugs\\nis to relieve painful leg cramps caused by poor cir-\\nculation, a condition calledintermittent claudication.\\nPhysicians also may prescribe this medicine for other\\nconditions, including stroke, impotence, male inferti-\\nlity, Raynaud’s disease, and nerve and circulation\\nproblems caused by diabetes.\\nDescription\\nBlood-viscosity reducing drugs are available only\\nwith a physician’s prescription and come in extended-\\nrelease tablet form. Examplesof blood-viscosity reducing\\ndrugs are pentoxifylline (Trental) and oxypentifylline.\\n576 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood-viscosity reducing drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Recommended dosage\\nThe usual dosage for adults is 400 mg, two to three\\ntimes a day, with meals. However, the dose may be\\ndifferent for different patients. Check with the physi-\\ncian who prescribed the drug or the pharmacist who\\nfilled the prescription for the correct dosage. Dosages\\nfor children must be determined by a physician.\\nTaking an antacid with this medicine may help\\nprevent upset stomach.\\nPrecautions\\nThis medicine may relieve legpain that results\\nfrom poor circulation, but it should not be considered\\na substitute for other treatments the physician recom-\\nmends, such as physical therapy or surgery.\\nThis medicine may take several weeks to produce\\nnoticeable results. Be sure to keep taking it as directed,\\neven if it doesn’t seem to be helping.\\nPatients being treated with this medicine should\\nnot smoke, assmoking may worsen the conditions for\\nwhich the medicine is prescribed.\\nAnyone who has had unusual reactions to pentox-\\nifylline, aminophylline,caffeine, dyphylline, ethylene-\\ndiamine (contained in aminophylline), oxtriphylline,\\ntheobromine, or theophylline in the past should let his\\nor her physician know before taking a blood-viscosity\\nreducing drug. The physician should also be told\\nabout any allergies to foods, dyes, preservatives, or\\nother substances.\\nWomen who are pregnant or breastfeeding or who\\nmay become pregnant should check with their physi-\\ncians before using a blood-viscosity reducing drug.\\nOlder people may be especially sensitive to the\\neffects of this medicine, which may increase the chance\\nof side effects.\\nBefore using blood-viscosity reducing drugs, peo-\\nple with any of these medical problems should make\\nsure their physicians are aware of their conditions:\\n/C15recent stroke\\n/C15any condition in which there is an increased chance\\nof bleeding\\n/C15kidney disease\\n/C15liver disease\\nSide effects\\nMinor discomforts, such asdizziness, headache,\\nupset stomach, nausea,o r vomiting usually go away\\nas the body adjusts to the drug and do not require\\nmedical treatment unless they persist or they interfere\\nwith normal activities.\\nMore serious side effects are rare. However, if\\nthese or any other unusual or troublesome symptoms\\noccur, check with the physician who prescribed the\\nmedicine as soon as possible:\\n/C15chest pain\\n/C15irregular heartbeat\\nInteractions\\nBlood-viscosity reducing drugs may interact\\nwith a other medicines, changing the effects of one\\nor both of the drugs or increasing the risk of side\\neffects. Anyone who takesblood-viscosity reducing\\ndrugs should let the physician know all other pre-\\nscription or nonprescrip tion (over-the-counter)\\nmedicines he or she is taking. Among the drugs\\nthat may interact with bl ood-viscosity reducing\\ndrugs are:\\n/C15anticoagulants such as warfarin (Coumadin)(also\\ncalled blood thinners or clot inhibitors)\\n/C15calcium channel blockers such as diltiazem\\n(Cardizem), used to treat high blood pressure\\n/C15angiotensin-converting enzyme (ACE) inhibitors\\nsuch as enalapril (Vasotec), used to treat high blood\\npressure\\n/C15theophylline (Theo-Dur)\\n/C15medicines such as cimetidine (Tagamet), taken for\\nulcers or heartburn\\nNancy Ross-Flanigan\\nBlood clots\\nDefinition\\nA blood clot is a thickened mass in the blood\\nformed by tiny substances called platelets. Clots form\\nto stop bleeding, such as at the site of cut. But clots\\nKEY TERMS\\nRaynaud’s disease— A blood vessel disorder in\\nwhich the fingers and toes become numb and turn\\nwhite when exposed to cold.\\nGALE ENCYCLOPEDIA OF MEDICINE 577\\nBlood clots'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='should not form when blood is moving through the\\nbody; when clots form inside blood vessels or when\\nblood has a tendency to clot too much, serious health\\nproblems can occur.\\nDescription\\nAs soon as a blood vessel wall is damaged—by a\\ncut or similar trauma—a series of reactions normally\\ntakes place to activate platelets to stop the bleeding.\\nPlatelets are the tiny particles in the blood released\\ninto the bone marrow that gather together and form\\na barrier to further bleeding. Several proteins in the\\nbody are involved in the platelets clotting process.\\nChief among these proteins are collagen, thrombin,\\nand von Willebrand factor. Collagen and thrombin\\nhelp platelets stick together. As platelets gather at\\nthe site of injury, they change in shape from round\\nto spiny, releasing proteins and other substances\\nthat help catch more platelets and clotting proteins.\\nThis enlarges the plug that becomes a blood\\nclot. Formation of blood clots also is called\\n‘‘coagulation’’.\\nThe series of reactions that cause proteins and\\nplatelets to create blood clots also are balanced by\\nother reactions that stop the clotting process and dis-\\nsolve clots after the blood vessel has healed. If this\\ncontrol system fails, minor blood vessel injuries can\\ntrigger clotting throughout the body. The tendency to\\nclot too much is called ‘‘hypercoagulation’’. Anytime\\nclots form inside blood vessels, they can lead to serious\\ncomplications.\\nThe formation of a clot in a blood vessels may be\\ncalled thrombophlebitis. The term refers to swelling of\\none or more veins caused by a blood clot. Although\\nsome clots occur in the arms or small, surface blood\\nvessels, most occur in the lower legs. When the blood\\nclot occurs in a deep vein, it is calleddeep vein throm-\\nbosis, or DVT. As many as one of every 1,000\\nAmericans develops DVT each year. The danger of\\nDVT comes when pieces of the clot, known as emboli,\\nbreak off and travel through the bloodstream to an\\nartery.\\nA blood clot that blocks an artery to the brain can\\ncause a stroke. If the clot blocks blood flow to the\\nlungs pulmonary embolism can occur. A blood clot\\nthat blocks a coronary artery can cause aheart attack.\\nCertain people are at higher risk for blood clots than\\nothers; surgery, some injuries,childbirth and lying or\\nsitting still for extended periods of time put people at\\nhigher risk, as do inherited disorders. Once a person\\nhas a blood clot, he or she may have to take blood-\\nthinning drugs to prevent clots from recurring. Men\\nand women are at similar risk for blood clots. A recent\\nstudy in Austria found that men run a higher risk of\\nrecurring blood clots than women, though the reason\\nis unknown.\\nCauses and symptoms\\nMany causes can lead to blood clots, some\\ngenetic and some environmental. An environmental\\ncause of DVT is prolonged inactivity. For instance,\\nhaving to sit in a car or airplane for a long period of\\ntime decreases blood flowin the lower legs. Recent\\nstudies have shown that 1% of air travelers develop\\nblood clots, usually on long flights of five hours or\\nmore. However, one study in 2004 found that air\\ntravelers developed clots onf l i g h t sa ss h o r ta st h r e e\\nhours, though they often dissolved naturally and did\\nnot lead to complications. Other environmental\\ncauses of blood clots include use ofhormone replace-\\nment therapy to ease menopausal symptoms, oral\\ncontraceptives for birth control, pregnancy (and a\\nchildbirth within the past six weeks), recent surgery\\nor procedures involving use of a central venous\\naccess catheter, and cancer. Smoking also is an\\nimportant and preventable environmental risk for\\nblood clots.\\nSome people are born with a higher risk for blood\\nclots. Hypercoagulation disorders are genetic condi-\\ntions. Usually the body doesn t produce enough of\\nthe proteins involved in the clotting process, so they\\ncannot do their job to stop the clotting; in other cases,\\nthey have an extra protein that causes too much\\nclotting.\\nKEY TERMS\\nCentral venous access catheter— A tube placed\\njust beneath the skin to allow doctors and nurses\\nconstant and pain-free access to the veins, often\\nwhen a patient is in the hospital or has a chronic\\ndisease such as cancer. The doctors and nurses can\\ndraw blood and give medications and nutrients\\nthrough the catheter.\\nGenetic— A trait or condition that is acquired\\nor inherited because it was related to genes and\\nDNA.\\nPulmonary embolism— The sudden obstruction of\\na pulmonary (lung) artery or one of its branches by\\nan abnormal particle (such as a blood clot) floating\\nin the blood.\\n578 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood clots'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='There may be no symptoms of blood clots until\\nthey grow so large that they block the flow of blood\\nthrough the vein. Then, symptoms may develop sud-\\ndenly around the area and include:\\n/C15Pain or tenderness in the affected area.\\n/C15Warmth or redness of the skin in the affected area.\\n/C15Sudden swelling in the affected limb.\\nAdditional symptoms may indicate serious com-\\nplications of blood clots such as pulmonaryembolism,\\nstroke, and heart attack. If vein swelling or pain are\\naccompanied by high fever or shortness of breath,\\nrapid pulse, or chest pain, or other symptoms that\\nmay indicate stroke, heart attack, or pulmonary\\nembolism, it is advised to go to an emergency room\\nimmediately.\\nDiagnosis\\nA physician will diagnose blood clots based on\\npatient history and one of several diagnostic imaging\\nexams. The patient’s history will help determine pos-\\nsible risk factors that may lead to suspected blood\\nclots. In addition to family history or known genetic\\ndisorders, the patient may mention an environmental\\nfactor such as recent air travel or use of high-risk\\nmediations.\\nTo help get a picture of suspected clots inside the\\nveins, the first test chosen normally is an ultrasound.\\nDoppler or duplex ultrasound uses sound waves that\\ntravel through tissue and reflect back. A computer\\ntransforms the sound waves into moving images on\\nthe screen that may show the clot, as well as blood flow\\nnear the clot and any abnormalities. Ultrasound does\\nnot use x rays and is a noninvasive method. Computed\\ntomography (CT) scans also might be used to image\\nthe blood vessels. It is similar to x rays, except the\\nimages are much like cross-section slices with greater\\ndetail that can be computerized and even viewed three-\\ndimensionally. A special dye called a contrast agent\\nmay be injected before the exam to help highlight the\\nveins. Magnetic resonanceangiography uses magnetic\\nresonance imaging(MRI) to image the blood vessels.\\nIt also may involve injection of a contrast dye.\\nVenography is less commonly used, but involves inject-\\ning a contrast and using x rays to image the vein.\\nTreatment\\nMedicines can help thin blood, making it less\\nlikely to clot. The two most common blood thin-\\nners are heparin and warfarin. Heparin works\\nright away, keeping blood clots from growing. It\\nusually is injected. In re cent years, more physi-\\ncians have been prescribing low-molecular weight\\nheparin, purified versions of the drug that can be\\ngiven with less monitoring . Warfarin (coumadin)\\noften is used for long-term treatment of blood\\nclots and is taken orally. Patients must work clo-\\nsely with their physicians to constantly monitor its\\neffects and adjust dose if necessary. Too little\\nw a r f a r i nc a nl e a dt oc l o t t i n g ,b u tt o om u c hc a n\\nthin the blood so much that causing life-threaten-\\ning bleeding can occur. The same can be true of\\nlow-molecular weight heparin when used on a\\nlong-term, at-home basis.\\nOther treatments for blood clots include injecting\\nclot busting drugs directly into the clot through a\\ncatheter, or in rare instances, installation of a filter to\\nblock a clot from lodging in the lungs. Sometimes,\\nsurgery also is needed to remove a clot blocking a\\npelvic or abdominal vein or one that is chronic and\\ndisabling. A cardiovascular surgeon or interventional\\nradiologist may perform balloonangioplasty or insert\\na stent to open a narrowed or damaged vein. In an\\nemergency situation, a drug called tissue plasminogen\\nactivator, or tPA, may be given to immediately dis-\\nsolve a life-threatening blood clot to the brain or heart.\\nIn 2004, the U.S. Food and Drug Administration\\napproved a new, small, corklike device that can be\\nused to remove blood clots from the brains of patients\\nwho cannot receive clot-busting drugs.\\nAlternative treatment\\nGarlic is thought to lower blood clotting poten-\\ntial. Less evidence suggests onions and cayenne pepper\\nmay help keep blood thin. New research from\\nAustralia adds tomato juice to the list of potential\\nblood thinners. Subjects who drank a glass of tomato\\njuice a day reduced their risk for DVT, stroke and\\ncardiovascular disease. Research has shown that a\\nnatural soy and pine product called pinokinase has\\nbeen effective in controlling DVT in air travelers.\\nPatients seeking alternative treatments for blood\\nclots should work with certified practitioners and\\nshould inform their allopathic provider about their\\nalternative care.\\nPrognosis\\nIf detected and controlled with medications,\\nblood clots can be safely managed. However, if the\\nclots become dislodged and travel to an artery, they\\ncan cause nearly instant death. For instance, more\\nthan 600,000 people have a pulmonary embolism\\neach year and more than 10% of them die from the\\nGALE ENCYCLOPEDIA OF MEDICINE 579\\nBlood clots'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='embolism, most of them within 30 to 60 minutes after\\nsymptoms start.\\nPrevention\\nClots may be avoided by not smoking, and by not\\nusing medications that add to the risk. Clotting can be\\nprevented by following physician recommendations\\nconcerning medications. Sometimes, physicians will\\nprescribe special support stockings that prevent swel-\\nling and reduce chances of DVT. When taking an air\\nflight of six hours or longer, drinking plenty of fluids\\nto avoiddehydration, avoiding tight clothing around\\nthe waist, and stretching calves every hour can help\\nprevent DVT. It is advised that those on long flights\\nget up and move about once an hour during the flight.\\nIf not possible, moving the legs regularly while seated\\nby flexing the ankles, then pressing the feet against the\\nseat in the row ahead or on the floor can help stretch\\nthe calves. A physician may advise those at high risk of\\nDVT wear support stockings during the flight or take\\nlow-molecular weight heparin two to four hours\\nbefore departure.\\nResources\\nPERIODICALS\\n‘‘Air Travel, Especially Long Flights, May Increase the Risk\\nof Blood Clots.’’Women’s Health Weekly(Dec. 25,\\n2003):119.\\n‘‘In-flight Exercises for a Healthy Trip: Prevent\\nDangerous Blood Clots With These Three Easy\\nMoves the Next Time You Fly.’’Natural Health\\n(Jan–Feb. 2003):27.\\nStephenson, Joan. ‘‘FDA Orders Estrogen Safety Warnings:\\nAgency Offers Guidance for HRT Use.’’JAMA, The\\nJournal of the American Medical Association(Feb. 5,\\n2003):537–539.\\n‘‘Study Finds One Percent of Air Travelers Develop\\nInjurious Blood Clots.’’Heart Disease Weekly(Jan. 25,\\n2004):41.\\n‘‘Tiny Corkscrew Clears Blood Clots.’’Hematology Week\\n(Sept. 6, 2004):99.\\nORGANIZATIONS\\nNational Heart, Lung and Blood Institute. P.O. Box 30105,\\nBehtesda, MD 20824-0105. 301-592-8573.\\nwww.nhlbi.nih.gov.\\nSociety of Interventional Radiology. 10201 Lee Highway,\\nSuite 500, Fairfax, VA 22030. 703-691-1805. http://\\nwww.sirweb.org.\\nOTHER\\nAvoid Deep Vein Thrombosis: Keep the Blood Flowing.FDA\\nWeb site, 2005. www.fda.gov/fdac/features/2004/\\n604_vein.html.\\nTeresa G. Odle\\nBlood count\\nDefinition\\nOne of the most commonly ordered clinical\\nlaboratory tests, a blood count, also called a com-\\nplete blood count (CBC), is a basic evaluation of\\nthe cells (red blood cells, white blood cells, and plate-\\nlets) suspended in the liquid part of the blood\\n(plasma). It involves determining the numbers, con-\\ncentrations, and conditions of the different types of\\nblood cells.\\nPurpose\\nThe CBC is a useful screening and diagnostic test\\nthat is often done as part of a routinephysical exam-\\nination. It can provide valuable information about the\\nblood and blood-forming tissues (especially the bone\\nmarrow), as well as other body systems. Abnormal\\nresults can indicate the presence of a variety of condi-\\ntions—including anemias, leukemias, and infections—\\nsometimes before the patient experiences symptoms of\\nthe disease.\\nDescription\\nA complete blood count is actually a series of tests\\nin which the numbers of red blood cells, white blood\\ncells, and platelets in a given volume of blood are\\ncounted. The CBC also measures the hemoglobin con-\\ntent and the packed cell volume (hematocrit) of the red\\nblood cells, assesses the size and shape of the red blood\\ncells, and determines the types and percentages of\\nwhite blood cells. Components of the complete blood\\ncount (hemoglobin, hematocrit, white blood cells,\\nplatelets, etc.) can also be tested separately, and are\\nsometimes done that way when a doctor wants to\\nmonitor a specific condition, such as the white cell\\ncount of a patient diagnosed with leukemia, or the\\nhemoglobin of a patient who has recently received a\\nblood transfusion. Because of its value, though, as an\\nindicator of a person’s overall health, the CBC pack-\\nage is most frequently ordered.\\nThe blood count is performed relatively inexpen-\\nsively and quickly. Most laboratories routinely use\\nsome type of automated equipment to dilute the\\nblood, sample a measured volume of the diluted sus-\\npension, and count the cells in that volume. In addi-\\ntion to counting actual numbers of red cells, white\\ncells, and platelets, the automated cell counters also\\nmeasure the hemoglobin and calculate the hematocrit\\nand thered blood cell indices(measures of the size and\\nhemoglobin content of the red blood cells).\\n580 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood count'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Technologists then examine a stained blood smear\\nunder the microscope to identify any abnormalities\\nin the appearance of the red blood cells and to report\\nthe types and percentages of white blood cells\\nobserved.\\nThe red blood cell (RBC) count determines the\\ntotal number of red cells (erythrocytes) in a sample of\\nblood. The red cells, the most numerous of the cellu-\\nlar elements, carry oxygen from the lungs to the\\nbody’s tissues. Hemoglobin (Hgb) is the protein-\\niron compound in the red blood cells that enables\\nthem to transport oxygen. Its concentration corre-\\nsponds closely to the RBC count. Also closely tied\\nto the RBC and hemoglobin values is the hematocrit\\n(Hct), which measures the percentage of red blood\\ncells in the total blood volume. The hematocrit\\n(expressed as percentage points) is normally about\\nthree times the hemoglobin concentration (reported\\nas grams per deciliter).\\nRed blood cell indices provide information\\nabout the size and hemoglobin content of the red\\ncells. They are useful in differentiating types of ane-\\nmias. The indices include four measurements that are\\ncalculated using the RBC count, hemoglobin, and\\nhematocrit results. Mean corpuscular volume\\n( M C V )i sam e a s u r e m e n to ft h ea v e r a g es i z eo ft h e\\nred blood cells and indicates whether that is small,\\nlarge or normal. The red blood cell distribution width\\n( R D W )i sa ni n d i c a t i o no ft h ev a r i a t i o ni nR B Cs i z e .\\nMean corpuscular hemoglobin (MCH) measures the\\naverage amount (weight) of hemoglobin within a red\\nblood cell. A similar measurement, mean corpuscular\\nhemoglobin concentration (MCHC), expresses the\\naverage concentration of hemoglobin in the red\\nblood cells.\\nThe white blood cell (WBC) count determines the\\ntotal number of white cells (leukocytes) in the blood\\nsample. Fewer in number than the red cells, WBCs\\nare the body’s primary means of fighting infection.\\nThere are five main types of white cells (neutrophils,\\nlymphocytes, monocytes, eosinophils, and baso-\\nphils), each of which plays a different role in respond-\\ning to the presence of foreign organisms in the body.\\nA differential white cell count is done by staining a\\nsmear of the patient’s blood with a Wright’s stain,\\nallowing the different types of white cells to be clearly\\nseen under the microscope. A technologist then\\ncounts a minimum of 100 WBCs and reports each\\ntype of white cell as a percentage of the total white\\nblood cells counted.\\nThe platelet countis an actual count of the number\\nof platelets (thrombocytes) in a given volume of blood.\\nPlatelets, the smallest of the cellular elements of blood,\\nare involved in blood clotting. Because platelets\\ncan clump together, the automated counting method\\nis subject to a certain level of error and may not\\nbe accurate enough for low platelet counts. For this\\nreason, very low platelet levels are often counted\\nmanually.\\nNormal results\\nBlood count values can vary by age and sex. The\\nnormal red blood cell count ranges from 4.2–5.4 mil-\\nlion RBCs per microliter of blood for men and 3.6–5.0\\nmillion for women. Hemoglobin values range\\nfrom 14–18 grams per deciliter of blood for men and\\n12–16 grams for women. The normal hematocrit is\\n42–54% for men and 36–48% for women. The normal\\nnumber of white blood cells for both men and women\\nis approximately 4,000–10,000 WBCs per microliter of\\nblood.\\nAbnormal results\\nAbnormal blood count results are seen in a vari-\\nety of conditions. One of the most common is ane-\\nmias, which are characterized by low RBC counts,\\nhemoglobins, and hematocrits. Infections and leuke-\\nmias are associated wit h increased numbers of\\nWBCs.\\nA white blood cell. (Photograph by Institut Pasteur, Phototake\\nNYC. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 581\\nBlood count'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Resources\\nBOOKS\\nBerkow, Robert, ed.Merck Manual of Medical Information.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 1997.\\nHenry, J. B.Clinical Diagnosis and Management by Laboratory\\nMethods.New York: W. B. Saunders Co., 1996.\\nKaren A. Boyden\\nBlood crossmatching see Blood typing and\\ncrossmatching\\nBlood culture\\nDefinition\\nA blood culture is done when a person has symp-\\ntoms of a blood infection, also called bacteremia.\\nBlood is drawn from the person one or more times\\nand is tested in a laboratory to find and identify any\\nmicroorganism present and growing in the blood. If a\\nmicroorganism is found, more testing is done to deter-\\nmine theantibiotics that will be effective in treating the\\ninfection.\\nPurpose\\nBacteremia is a serious clinical condition and can\\nlead to death. To give the best chance for effective\\ntreatment and survival, a blood culture is done as\\nsoon as an infection is suspected.\\nSymptoms of bacteremia arefever, chills, mental\\nconfusion, anxiety, rapid heart beat, hyperventilation,\\nblood clotting problems, andshock. These symptoms\\nare especially significant in a person who already has\\nanother illness or infection, is hospitalized, or has\\ntrouble fighting infections because of a weak immune\\nsystem. Often, the blood infection results from an\\ninfection somewhere else in the body that has now\\nspread.\\nAdditionally, blood cultures are done to find the\\ncauses of other infections. These include bacterial\\npneumonia (an infection of the lung), and infectious\\nendocarditis (an infection of the inner layer of the\\nheart). Both of these infections leak bacteria into the\\nblood.\\nAfter a blood infection has been diagnosed, con-\\nfirmed by culture, and treated, an additional blood\\nculture may be done to make sure the infection is\\ngone.\\nDescription\\nCulture strategies\\nThere are many variables involved in performing\\na blood culture. Before the person’s blood is drawn,\\nthe physician must make several decisions based on a\\nknowledge of infections and the person’s clinical con-\\ndition and medical history.\\nSeveral groups of microorganisms, including\\nbacteria, viruses, mold, and yeast, can cause blood\\ninfections. The bacteriagroup can be further broken\\ndown into aerobes and anaerobes. Most aerobes do\\nnot need oxygen to live. They can grow with oxygen\\n(aerobic microbes) or without oxygen (anaerobic\\nmicrobes).\\nBased on the clinical condition of the patient, the\\nphysician determines what group of microorganisms\\nis likely to be causing the infection and then orders\\none or more specific types of blood culture, including\\naerobic, anaerobic, viral, or fungal (for yeasts and\\nmolds). Each specific type of culture is handled differ-\\nently by the laboratory. Most blood cultures test for\\nboth aerobic and anaerobic microbes. Fungal, viral,\\nand mycobacterial blood cultures can also be done,\\nbut are less common.\\nThe physician must also decide how many blood\\ncultures should be done. One culture is rarely\\nenough, but two to three are usually adequate.\\nFour cultures are occasionally required. Some fac-\\ntors influencing this decision are the specific micro-\\norganisms the physician expects to find based on the\\nperson’s symptoms or previous culture results, and\\nKEY TERMS\\nAerobe— Bacteria that require oxygen to live.\\nAnaerobe— Bacteria that live where there is no\\noxygen.\\nBacteremia— Bacteria in the blood.\\nContinuous bacteremia— A kind of bacteremia\\nwhere bacteria is always in the blood.\\nIntermittent bacteremia— A kind of bacteremia\\nwhere the bacteria enter the blood at various time\\nintervals.\\n582 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood culture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='whether or not the person has had recent antibiotic\\ntherapy.\\nThe time at which the cultures are to be drawn is\\nanother decision made by the physician. During\\nmost blood infections (called intermittent bactere-\\nmia) microorganisms enter the blood at various\\ntime intervals. Blood drawn randomly may miss the\\nmicroorganisms. Since mic roorganisms enter the\\nblood 30–90 minutes bef ore the person’s fever\\nspikes, collecting the culture just after the fever\\nspike offers the best likelihood of finding the micro-\\norganism. The second and third cultures may be\\ncollected at the same time, but from different places\\non the person, or spaced at 30-minute or one-hour\\nintervals, as the physician chooses. During continu-\\nous bacteremia, such as i nfective endocarditis,\\nmicroorganisms are always in the blood and the\\ntiming of culture collection is less important. Blood\\ncultures should always be collected before antibiotic\\ntreatment has begun.\\nLaboratory analysis\\nBacteria are the most common microorganisms\\nfound in blood infections. Laboratory analysis of a\\nbacterial blood culture differs slightly from that of a\\nfungal culture and significantly from that of a viral\\nculture.\\nBlood is drawn from a person and put directly\\ninto a blood culture bottle containing a nutritional\\nbroth. After the laboratory receives the blood culture\\nbottle, several processes must be completed:\\n/C15provide an environment for the bacteria to grow\\n/C15detect the growth when it occurs\\n/C15identify the bacteria that grow\\n/C15test the bacteria against certain antibiotics to deter-\\nmine which antibiotic will be effective\\nThere are several types of systems, both manual\\nand automated, available to laboratories to carry out\\nthese processes.\\nThe broth in the blood culture bottle is the first\\nstep in creating an environment in which bacteria will\\ngrow. It contains all the nutrients that bacteria need to\\ngrow. If the physician expects anaerobic bacteria to\\ngrow, oxygen will be kept out of the blood culture\\nbottle; if aerobes are expected, oxygen will be allowed\\nin the bottle.\\nThe bottles are placed in an incubator and kept at\\nbody temperature. They are watched daily for signs of\\ngrowth, including cloudiness or a color change in the\\nbroth, gas bubbles, or clumps of bacteria. When there\\nis evidence of growth, the laboratory does a gram stain\\nand a subculture. To do the gram stain, a drop of\\nblood is removed from the bottle and placed on a\\nmicroscope slide. The blood is allowed to dry and\\nthen is stained with purple and red stains and exam-\\nined under the microscope. If bacteria are seen, the\\ncolor of stain they picked up (purple or red), their\\nshape (such as round or rectangular), and their size\\nprovide valuable clues as to what type of microorgan-\\nism they are and what antibiotics might work best. To\\ndo the subculture, a drop of blood is placed on a\\nculture plate, spread over the surface, and placed in\\nan incubator.\\nIf there is no immediate visible evidence of growth\\nin the bottles, the laboratory looks for bacteria by\\ndoing gram stains and subcultures. These steps are\\nrepeated daily for the first several days and periodi-\\ncally after that.\\nWhen bacteria grows, the laboratory identifies it\\nusing biochemical tests and the gram stain. Sensitivity\\ntesting, also called antibiotic susceptibility testing, is\\nalso done. The bacteria are tested against many differ-\\nent antibiotics to see which antibiotics can effectively\\nkill it.\\nAll information is passed on to the physician as\\nsoon as it is known. An early report, known as a\\npreliminary report, is usually available after one day.\\nThis report will tell if any bacteria have been found\\nyet, and if so, the results of the gram stain. The next\\npreliminary report may include a description of the\\nbacteria growing on the subculture. The laboratory\\nnotifies the physician immediately when an organism\\nis found and as soon as sensitivity tests are complete.\\nSensitivity tests may be complete before the bacteria\\nis completely identified. The final report may not be\\navailable for five to seven days. If bacteria was\\nfound, the report will include its complete identifica-\\ntion and a list of the antibiotics to which the bacteria is\\nsensitive.\\nOne automated system is considered one of\\nthe most important recent technical advances in\\nblood cultures. It is called continuous-monitoring\\nblood culture systems (CMCCS). The instruments\\nautomatically monitor the bottles containing the\\npatient blood for evidence of microorganisms, usually\\nevery 10 minutes. Many data points are collected daily\\nfor each bottle, and fed into a computer for analysis.\\nSophisticated mathematical calculations can deter-\\nmine when microorganisms have grown. This, com-\\nbined with more frequent blood tests, make it possible\\nGALE ENCYCLOPEDIA OF MEDICINE 583\\nBlood culture'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='to detect microbial growth earlier. In addition, all\\nCMBCS instruments have the detection system, incu-\\nbator, and agitation unit in one unit.\\nPreparation\\nTen ml (milliliter) of blood is usually needed for\\neach blood culture bottle. First a healthcare worker\\nlocates a vein in the inner elbow region. The area of\\nskin where the blood will be drawn must be disin-\\nfected to prevent any microorganisms on a person’s\\nskin from entering the blood culture bottle and con-\\ntaminating it. The area is disinfected by wiping the\\narea with alcohol in a circular fashion, starting with\\ntiny circles at the spot where the needle will puncture\\nthe skin and enlarging the size of the circles while\\nwiping away from the puncture site. The same\\npattern of wiping is repeated using an iodine or iodo-\\nphor solution. The top of the bottle is disinfected\\nusing alcohol. After the person’s skin has been\\ndisinfected, the healthcare worker draws the blood\\nand about 10 ml of blood is injected into each\\nblood culture bottle. The type of bottles used will\\nvary based on whether the physician is looking\\nfor bacteria (aerobes or anaerobes), yeast, mold, or\\nviruses.\\nAftercare\\nDiscomfort or bruising may occur at the puncture\\nsite or the person may feel dizzy or faint. Pressure to\\nthe puncture site until the bleeding stops reduces bruis-\\ning. Warm packs relieve discomfort.\\nNormal results\\nNormal results will be negative. A single negative\\nculture does not rule out a blood infection. False\\nnegatives can occur if the person was started on\\nantibiotics before the blood was drawn, if the\\nenvironment for growth was not right, the timing\\nwas off, or for some unknown reason the micro-\\norganism just didn’t grow. Three negative cultures\\nmay be enough to rule out bacteremia in the case of\\nendocarditis.\\nAbnormal results\\nThe physician’s skill in interpreting the culture\\nresults and assessing the person’s clinical condition is\\nessential in distinguishing a blood culture that is posi-\\ntive because of a true infection from a culture that is\\npositive because it became contaminated. In true\\nbacteremia, the patient’s clinical condition should be\\nconsistent with a blood infection caused by the micro-\\norganism that was found. The microorganism is\\nusually found in more than one culture, it usually\\ngrows soon after the bottles are incubated, and it is\\noften the cause of an infection somewhere else in the\\nperson’s body.\\nWhen the culture is positive because of contam-\\nination, the patient’s clinical condition usually is not\\nconsistent with an infection from the identified\\nmicroorganism. In addition, the microorganism is\\noften one commonly found on skin, it rarely causes\\ninfection, it is found in only one bottle, and it may\\nappear after several days of incubation. More than\\none microorganism often grow in contaminated\\ncultures.\\nResources\\nORGANIZATIONS\\nAmerican Society of Microbiology. 1752 N Street N.W.,\\nWashington, D.C. 20036. (202) 737-3600. .\\nNancy J. Nordenson\\nBlood donation and registry\\nDefinition\\nBlood donation refers to the process of collecting,\\ntesting, preparing, and storing blood and blood com-\\nponents. Donors are most commonly unpaid volun-\\nteers, but they may also be paid by commercial\\nenterprises. Blood registry refers to the collection and\\nsharing of data about donated blood and ineligible\\ndonors.\\nPurpose\\nThe purpose of the blood collection and distribu-\\ntion system is to help ensure an adequate supply of\\nblood for accident victims, people needing surgery,\\nand people suffering from certain diseases, as well as\\nfor medical research.\\nSometimes, donors give blood specifically to\\nbenefit a particular person.People preparing for elec-\\ntive surgery may donate their own blood to be held\\nand then returned to them during surgery. This is\\nknown as autologous blood donation. Directed\\ndonor blood has been donated by someone known\\n584 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood donation and registry'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='to the intended recipient, such as a family member or\\nfriend.\\nEach year, more than four million Americans\\nreceive blood transfusions involving more than\\n26 million units of blood (one unit equals 450 milli-\\nliters, or about one pint), or an average of about\\n32,000 units per day. All of that blood must be\\ncollected, tested, prepared, stored, and delivered\\nto the appropriate sites. Roughly eight million\\npeople in the United States donate blood each year;\\nabout half of the total amount needed is provided\\nby the 36 regional blood centers of the American\\nRed Cross.\\nWhole blood and the various blood components\\nhave many uses. Red blood cells, which carry oxygen,\\nare used to treat anemia. Platelets, which play a role in\\ncontrolling bleeding, are commonly used in the treat-\\nment of leukemia and other cancers. Fresh frozen\\nplasma is also used to control bleeding in people defi-\\ncient in certain clotting factors. Cryoprecipitated\\nAHF, made from fresh frozen plasma, contains a few\\nspecific clotting factors.\\nPrecautions\\nTo ensure the safety of the blood supply, a multi-\\ntiered process of donor screening and deferral is\\nemployed. This involves donor education, taking a\\ndetailed health history of each prospective donor, and\\ngiving potential donors a simplephysical examination\\n(which includes taking a few drops of blood to test for\\nanemia). At any point in the process, a potential donor\\nmay be ‘‘deferred,’’ or judged ineligible to donate blood.\\nThis deferral may be temporary or permanent, depend-\\ning on the reason. Potential donors are also encouraged\\nto ‘‘self-defer,’’ or voluntarily decline to donate, rather\\nthan put future blood recipients at risk.\\nAll donated blood is extensively tested before\\nbeing used. The first step is determining the blood\\ntype, which indicates who can receive the blood.\\nReceiving the wrong type of blood can cause\\ndeath. Blood is also screened for any antibodies that\\ncould cause complications for recipients. In addition,\\nblood is tested to screen out donors infected with\\nthe following diseases: Hepatitis B surface antigen\\nADD, hepatitis B core antibody, hepatitis C\\nvirus antibody, HIV-1 and HIV-2 antibody, HIV p24\\nantigen, HTLV-I and HTLV-II antibodies, and\\nsyphilis. Nucleic Acid Amplification testing is also\\nperformed, and other tests may be done if a doctor\\nrequests them.\\nIn order to detect the greatest possible number of\\ninfections, these screening tests are extremely sensi-\\ntive. For this reason, however, donors sometimes\\nreceive false positive test results. In these cases,\\nmore specific confirmatory tests are performed, to\\nhelp rule out false positive results. Blood found to\\nbe abnormal is discarded, and all items coming into\\ndirect contact with donors are used only once and\\nthen discarded. Donors of infected blood are entered\\ninto the Donor Deferral Register, a confidential\\nnational data base used to prevent deferred people\\nfrom donating blood.\\nIn general, blood donors must be at least 17 years\\nold (some states allow younger people to donate blood\\nwith their parents’ consent), must weigh at least 110\\npounds (50 kg), and must be in good health.\\nMany factors can temporarily or permanently\\ndisqualify potential donors. Most of them have to\\ndo with having engaged in behaviors that put them\\nat risk of infection or having spent time in certain\\nspecified areas. Among these factors are having had a\\ntattoo, having had sex with people in high-risk\\ngroups, having had certain diseases, and having\\nbeen raped.\\nDescription\\nThere are eight different blood types in all—four\\nABO groups, each of which may be either Rh positive\\nor Rh negative. These types, and their approximate\\ndistribution in the U.S. population, are as follows:\\nO+ (38%), O- (7%), A+ (34%), A- (6%), B+ (9%),\\nB- (2%), AB+ (3%), AB- (1%). In an emergency,\\nanyone can safely receive type O red blood cells,\\nand people with this blood type are known as\\n‘‘universal donors.’’ People with type AB blood,\\nknown as ‘‘universal recipients,’’ can receive any type\\nof red blood cells and can give plasma to all blood\\ntypes.\\nKEY TERMS\\nApheresis— Extraction of a specific component\\nfrom donated blood, with the remainder returned\\nto the donor.\\nAutologous donation— Blood donated for the\\ndonor’s own use.\\nGranulocytes— White blood cells.\\nPlasma— The liquid part of blood.\\nPlatelets— Tiny, disklike elements of plasma that\\npromote clotting.\\nGALE ENCYCLOPEDIA OF MEDICINE 585\\nBlood donation and registry'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Blood donations can be made in community\\nblood centers, at hospitals or in bloodmobiles, which\\nvisit schools, churches and workplaces. The actual\\nprocess of donating whole blood takes about 20\\nminutes. A sterile needle is inserted into a vein in the\\ndonor’s arm. The blood flows through plastic tubing\\ninto a blood bag. Donors may be asked to clench their\\nfist to encourage blood to flow. Usually, one unit of\\nblood is collected. Afterward, donors are escorted to\\nan observation area, given light refreshments, and\\nallowed to rest.\\nPlasma, the liquid portion of the blood in which red\\nblood cells, platelets and other elements are suspended,\\nis also collected, often by commercial enterprises that\\nsell it to companies manufacturing clotting factors and\\nother blood products. This is done using a process\\nknown as apheresis, in which whole blood is coll-\\nected, the desired blood component is removed, and\\nthe remainder is returned to the donor. Collecting\\nplasma generally takes one to two hours. Apheresis\\nmay also be used to collect other blood components,\\nsuch as platelets and granulocytes.\\nPreparation\\nOnce whole blood has been collected, it is sent to a\\nlab for testing and processing. Most donated blood is\\nseparated into its constituent components, such as red\\nblood cells, platelets, and cryoprecipitate. This enables\\nmore than one person to benefit from the same unit of\\ndonated blood.\\nDifferent blood components vary in how long\\nthey can be stored. Red blood cells can be refrigerated\\nfor up to 42 days or frozen for as much as 10 years.\\nPlatelets, stored at room temperature, may be kept for\\nup to five days. Fresh frozen plasma and cryoprecipi-\\ntated AHF can be kept for as much as one year.\\nAftercare\\nIt generally takes about 24 hours for the donor’s\\nbody to replenish the lost fluid. Replacing the lost red\\nblood cells, however, may take as much as two\\nmonths. Whole blood donors must wait a minimum\\nof eight weeks before donating again. Some states\\nplace further limits on the frequency and/or total\\nnumber of times an individual may donate blood\\nwithin a 12-month period.\\nRisks\\nThanks to the use of a multi-tiered screening\\nsystem and advances in the effectiveness of\\nscreening tests, the transmission of infectious dis-\\neases via transfusion has been significantly dimin-\\nished. Nonetheless, ther e is still a minuscule risk\\nthat blood recipients could contract HIV, Hepatitis\\nC or other infections via transfusion. Other diseases\\nthat could conceivably be contracted in this way, or\\nthat are of particular concern to blood-collection\\nagencies, include babesiosis,C h a g a sd i s e a s e ,H T L V -\\nIa n d- I I ,Creutzfeldt-Jakob disease , cytomegalo-\\nvirus, Lyme disease , malaria, and new variant\\nCreutzfeldt-Jakob disease.\\nAutologous blood donors run a tiny risk of having\\nthe wrong blood returned to them due to clerical error.\\nThere is also a faint possibility of bacterial contamina-\\ntion of the autologous blood.\\nNormal results\\nFor most donors, the process is quick and painless\\nand they leave feeling fine. They may also find satis-\\nfaction in knowing that they have contributed to the\\nnation’s blood supply and may even have helped save\\nlives.\\nAbnormal results\\nMost blood donors suffer no significant afteref-\\nfects. Occasionally, however, donors feel faint or\\ndizzy, nauseous, and/or havepain, redness, or a bruise\\nwhere the blood was taken. More serious complica-\\ntions, which rarely occur, include fainting, muscle\\nspasms, and nerve damage.\\nResources\\nPERIODICALS\\nMcKenna, C. ‘‘Blood Minded’’Nursing TimesApril 6, 2000:\\n27-28.\\nWagner, H. ‘‘Umbilical Cord Blood Banking: Insurance\\nAgainst Future Diseases?’’USA Today Magazine\\n(March 2000) : 59-61.\\nORGANIZATIONS\\nAmerican Association of Blood Banks. 8101 Glenbrook\\nRoad, Bethesda, MD 20814-2749. (301) 907-6977.\\n.\\nAmerican Red Cross. 430 17th Street NW, Washington,\\nD.C. 20006. .\\nNational Blood Data Resource Center. (301) 215-6506.\\n.\\nPeter Gregutt\\nBlood fluke infection see Schistosomiasis\\n586 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood donation and registry'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Blood gas analysis\\nDefinition\\nBlood gas analysis, also called arterial blood gas\\n(ABG) analysis, is a test which measures the amounts\\nof oxygen and carbon dioxide in the blood, as well as\\nthe acidity (pH) of the blood.\\nPurpose\\nAn ABG analysis evaluates how effectively the\\nlungs are delivering oxygen to the blood and how\\nefficiently they are eliminating carbon dioxide from\\nit. The test also indicates how well the lungs and\\nkidneys are interacting to maintain normal blood pH\\n(acid-base balance). Blood gas studies are usually\\ndone to assess respiratory disease and other conditions\\nthat may affect the lungs, and to manage patients\\nreceiving oxygen therapy (respiratory therapy). In\\naddition, the acid-base component of the test provides\\ninformation on kidney function.\\nDescription\\nBlood gas analysis is performed on blood from an\\nartery. It measures the partial pressures of oxygen and\\ncarbon dioxide in the blood, as well as oxygen content,\\noxygen saturation, bicarbonate content, and blood pH.\\nOxygen in the lungs is carried to the tissues through\\nthe bloodstream, but only a small amount of this oxy-\\ngen can actually dissolve in arterial blood. How much\\ndissolves depends on the partial pressure of the oxygen\\n(the pressure that the gas exerts on the walls of the\\narteries). Therefore, testing the partial pressure of oxy-\\ngen is actually measuring how much oxygen the lungs\\nare delivering to the blood. Carbon dioxide is released\\ninto the blood as a by-product of cell metabolism. The\\npartial carbon dioxide pressure indicates how well the\\nlungs are eliminating this carbon dioxide.\\nThe remainder of oxygen that is not dissolved in\\nthe blood combines with hemoglobin, a protein–iron\\ncompound found in the red blood cells. The oxygen\\ncontent measurement in an ABG analysis indicates\\nhow much oxygen is combined with the hemoglobin.\\nA related value is the oxygen saturation, which com-\\npares the amount of oxygen actually combined with\\nhemoglobin to the total amount of oxygen that the\\nhemoglobin is capable of combining with.\\nCarbon dioxide dissolves more readily in the blood\\nthan oxygen does, primarily forming bicarbonate and\\nsmaller amounts of carbonic acid. When present in\\nnormal amounts, the ratio of carbonic acid to bicar-\\nbonate creates an acid-base balance in the blood, help-\\ning to keep the pH at a level where the body’s cellular\\nfunctions are most efficient. The lungs and kidneys\\nA blood gas analyzer from Corning Corporation.(Photograph by\\nHank Morgan, Photo Researchers, Inc. Reproduced by permission.)\\nKEY TERMS\\nAcid-base balance— The condition that exists\\nwhen the body’s carbonic acid-bicarbonate buffer\\nsystem is in equilibrium, helping to maintain the\\nblood pH at a normal level of 7.35–7.45.\\nHemoglobin— A protein—iron compound in red\\nblood cells that functions primarily in carrying\\noxygen from the lungs to the tissues of the body.\\npH— A measure of the acidity of a solution. Normal\\nblood pH ranges from 7.35–7.45.\\nGALE ENCYCLOPEDIA OF MEDICINE 587\\nBlood gas analysis'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='both participate in maintaining the carbonic acid-\\nbicarbonate balance. The lungs control the carbonic\\nacid level and the kidneys regulate the bicarbonate. If\\neither organ is not functioning properly, an acid-base\\nimbalance can result. Determination of bicarbonate\\nand pH levels, then, aids in diagnosing the cause of\\nabnormal blood gas values.\\nThe procedure\\nThe blood sample is obtained by arterial puncture\\n(usually in the wrist, although it could be in the groin\\nor arm) or from an arterial line already in place. If a\\npuncture is needed, the skin over the artery is cleaned\\nwith an antiseptic. A technician then collects the blood\\nwith a small sterile needle attached to a disposable\\nsyringe. The patient may feel a brief throbbing or\\ncramping at the site of the puncture. After the blood\\nis drawn, the sample must be transported to the\\nlaboratory as soon as possible for analysis.\\nPreparation\\nThere are no special preparations. Patients have no\\nrestrictions on drinking or eating before the test. If the\\npatient is receiving oxygen, the oxygen concentration\\nmust remain the same for 20 minutes before the test; if\\nthe test is to be taken without oxygen, the gas must be\\nturned off for 20 minutes before the test is taken. The\\npatient should breathe normally during the test.\\nAftercare\\nAfter the blood has been taken, the technician\\nor the patient applies pressure to the puncture site\\nfor 10–15 minutes to stop the bleeding, and then places\\na dressing over the puncture.The patient should rest\\nquietly while applying the pressure to the puncture\\nsite. Health care workers will observe the patient for\\nsigns of bleeding or circulation problems\\nRisks\\nRisks are very low when the test is done correctly.\\nRisks include bleeding or bruising at the site, or delayed\\nbleeding from the site. Very rarely, there may be a\\nproblem with circulation in the puncture area.\\nNormal results\\nNormal blood gas values are as follows:\\n/C15partial pressure of oxygen (PaO2): 75–100 mm Hg\\n/C15partial pressure of carbon dioxide (PaCO2): 35–45\\nmm Hg\\n/C15oxygen content (O2CT): 15–23%\\n/C15oxygen saturation (SaO2): 94–100%\\n/C15bicarbonate (HCO3): 22–26 mEq/liter\\n/C15pH: 7.35–7.45\\nAbnormal results\\nValues that differ from those listed above may\\nindicate respirat ory, metabolic, or kidney disease .\\nThese results also may be abnormal if the patient\\nhas experienced trauma that may affect breathing\\n(especially head and neck injuries). Disorders, such\\nas anemia, that affect the oxygen-carrying capacity\\nof blood, can produce an abnormally low oxygen\\ncontent value.\\nResources\\nBOOKS\\nThompson, June, et al.Mosby’s Clinical Nursing.4th ed.\\nSt. Louis: Mosby, 1997.\\nCarol A. Turkington\\nBlood poisoning see Acute lymphangitis\\nBlood registry see Blood donation and\\nregistry\\nBlood removal see Phlebotomy\\nBlood sugar tests\\nDefinition\\nBlood sugar tests include several different tests\\nthat measure the amount of sugar (glucose) in a per-\\nson’s blood. These tests are performed either on an\\nempty stomach, or after consuming a meal or pre-\\nmeasured glucose drink. Blood sugar tests are done\\nprimarily to diagnose and evaluate a person with\\ndiabetes mellitus.\\nPurpose\\nThe body uses sugar, also called glucose, to supply\\nthe energy it needs to function. People get sugar from\\ntheir diet and from their body tissues. Insulin is made\\nby the pancreas and affects the outer membrane of\\ncells, making it easy for glucose to move from the\\nblood into the cells. When insulin is active, blood\\nglucose levels fall. Sugar from body tissues is stored\\n588 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood sugar tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='in the form of glycogen. When glycogen is active,\\nblood glucose levels rise.\\nAfter a meal, blood glucose levels rise sharply.\\nThe pancreas responds by releasing enough insulin to\\ntake care of all the newly added sugar found in the\\nbody. The insulin moves the sugar out of the blood\\nand into the cells. Only then does the blood sugar start\\nto level off and begin to fall. A person with diabetes\\nmellitus either does not make enough insulin, or\\nmakes insulin that does not work properly. The result\\nis blood sugar that remains high, a condition called\\nhyperglycemia.\\nDiabetes must be diagnosed as early as possible. If\\nleft untreated, it can damage or cause failure of the\\neyes, kidneys, nerves, heart, blood vessels, and other\\nbody organs.Hypoglycemia, or low blood sugar, also\\nmay be discovered through blood sugar testing.\\nHypoglycemia is caused by various hormone disorders\\nand liver disease, as well as by too much insulin.\\nDescription\\nThere are a variety of ways to measure a person’s\\nblood sugar.\\nWhole blood glucose test\\nWhole blood glucose testing can be performed by\\na person in his or her home, and kits are available for\\nthis purpose. The person pricks his or her finger (a\\nfinger stick) with a sterile sharp blade from the kit. A\\nsingle drop of blood is placed on a strip in a portable\\ninstrument called a glucometer. The glucometer\\nquickly determines the blood sugar and shows the\\nresults on a small screen in usually a few seconds.\\nNew technologies for monitoring glucose levels\\nwill help diabetics better control their glucose levels.\\nThese tests are particularly important for children\\nand adolescents. In mid-2002, the U.S. Food and\\nDrug Administration (FDA) approved a new home\\ntest for use by children and adolescents (it had\\nalready been approved for adults) called the Cygnus\\nGlucoWatch biographer that helped better detect\\nhypoglycemia. Studies show that more frequent\\nchecks are better; new monitors such as this allow\\nfor simpler frequent testing. Continuous monitoring\\nwas in development in early 2004, as a company\\ncalled TheraSense, Inc. received preapproval from\\nthe FDA for clinical trials on its home continuous\\nglucose monitor. The monitor was designed to pro-\\nvide users with real-time glucose data, alarms for\\nhypoglycemia and hyperglycemia and to show trends\\ni nt h e i rb l o o ds u g a rl e v e l s .\\nFasting plasma glucose test\\nThe fasting plasma glucose test is done on an\\nempty stomach. For the eight hours before the test,\\nthe person must fast (nothing to eat or drink, except\\nwater). The person’s blood is drawn from a vein by a\\nhealth care worker. The blood sample is collected into\\na tube containing an anticoagulant. Anticoagulants\\nstop the blood from clotting. In the laboratory, the\\ntube of blood spins at high speed within a machine\\ncalled a centrifuge. The blood cells sink to the bottom\\nand the liquid stays on the top. This straw-colored\\nliquid on the top is the plasma. To measure the\\nglucose, a person’s plasma is combined with other\\nsubstances. From the resulting reaction, the amount\\nof glucose in the plasma is determined.\\nOral glucose tolerance test\\nThe oral glucose tolerance test is conducted to see\\nhow well the body handles a standard amount of\\nglucose. This test measures the amount of glucose in\\na person’s plasma before and two hours after drinking\\na large premeasured beverage containing glucose. The\\nperson must eat a consistent diet, containing at least\\n5.25 oz (150g) of carbohydrates each day, for three\\ndays before this test. For eight hours before the test,\\nthe person must fast. A health care provider draws the\\nfirst sample of blood at the end of the fast to determine\\nthe glucose level at the start of the test. The health care\\nprovider then gives the person a beverage containing\\n2.6oz (75g) of glucose. Two hours later, the person’s\\nblood is drawn again. These blood samples are centri-\\nfuged and processed in the laboratory. A doctor can\\nthen compare the before and after glucose levels to see\\nhow well the patient’s body processed the sugar.\\nTwo-hour postprandial blood glucose test\\nThe two-hour postprandial blood glucose test mea-\\nsures the amount of glucose in plasma after a person eats\\na specific meal containing a certain amount of sugar.\\nAlthough the meal follows a predetermined menu, it is\\ndifficult to control many factors associated with this\\ntesting method.\\nBlood sugar tests can be used in a variety of situa-\\ntions including:\\n/C15Testing people suspected for diabetes. The American\\nDiabetic Association (ADA) recommends that either\\na fasting plasma glucose test or an oral glucose toler-\\nance test be used to diagnose diabetes. If the person\\nalready has symptoms of diabetes, a blood glucose test\\nwithout fasting (called a casual plasma glucose test)\\nmay be done. If the test result is abnormal, it must be\\nconfirmed with another test performed on another\\nGALE ENCYCLOPEDIA OF MEDICINE 589\\nBlood sugar tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='day. The two tests can be different or they can be the\\nsame, but they must be done on different days. If the\\nsecond test also is abnormal, the person has diabetes.\\nA two-hour postprandial test is not recommended by\\nthe ADA as a test to use for the diagnosis of diabetes.\\nA doctor may order this test, and follow it with the\\noral glucose tolerance test or the fasting plasma glu-\\ncose test if the results are abnormal.\\n/C15Testing pregnant women. Diabetes that occurs dur-\\ning pregnancy (gestational diabetes) is dangerous for\\nboth the mother and the baby. Women who may be\\nat risk are screened when they are 24-28 weeks preg-\\nnant. A woman is considered at risk if she is older\\nthan 25 years, is not at her normal body weight, has a\\nparent or sibling with diabetes, or if she is in an ethnic\\ngroup that has a high rate of diabetes (Hispanics,\\nNative Americans, Asians, African Americans).\\nThe blood sugar test to screen for gestational dia-\\nbetes is a variation of the oral glucose tolerance test.\\nFasting is not required. If the result is abnormal,\\na more complete test is done on another day.\\n/C15Testing healthy people. Healthy people without\\nsymptoms of diabetes should be screened for dia-\\nbetes when they are 45 years old and again every\\nthree years. Either the fasting plasma glucose or\\noral glucose tolerance test is used for screening.\\nPeople in high risk groups should be tested before\\nthe age of 45 and tested more frequently.\\n/C15Testing of people already diagnosed with diabetes.\\nThe ADA recommends that a person with diabetes\\nkeep the amount of glucose in the blood at a normal\\nlevel as much as possible. This can be done by the\\ndiabetic person testing his or her own blood at home\\none or more times a day.\\nPreparation\\nEach blood sugar test that uses plasma requires a\\n5 mL blood sample. A healthcare worker ties a tight\\nband (tourniquet) on the person’s upper arm, locates a\\nvein in the inner elbow region, and inserts a needle into\\nthe vein. Vacuum action draws the blood through the\\nneedle into an attached tube. Collection of the sample\\ntakes only a few minutes.\\nWhen fasting is required, the person should have\\nnothing to eat or drink (except water) for eight hours\\nbefore the test and until the test or series of tests is\\ncompleted. The person should not smoke before or\\nduring the testing period because this can temporarily\\nincrease the amount of glucose in the blood. Other\\nfactors that can cause inaccurate results are a change\\nin diet before the test, illness or surgery two weeks\\nbefore the test, certain drugs, and extended bed rest.\\nThe doctor may tell a person on insulin or taking pills\\nfor diabetes to stop the medication until after the test.\\nAftercare\\nAfter the test or series of tests is completed (and\\nwith the approval of his or her doctor), the person\\nshould eat, drink, and take any medications that\\nwere stopped for the test.\\nThe patient may feel discomfort when blood is\\ndrawn from a vein. Bruising may occur at the puncture\\nsite or 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.\\nRisks\\nIf the person experiences weakness, fainting,\\nsweating, or any other unusual reaction while fasting\\nor during the test, he or she should immediately tell the\\nperson giving the test.\\nNormal results\\nNormal results are:\\n/C15fasting plasma glucose test less than 120 mg/dL\\n/C15oral glucose tolerance test, 2 hours less than 140 mg/dL\\nFor the diabetic person, the ADA recommends\\nan ongoing blood sugar goal of less than or equal to\\n120 mg/dL.\\nAbnormal results\\nThese abnormal results indicate diabetes and\\nmust be confirmed with repeat testing:\\n/C15fasting plasma glucose test less than or equal to\\n126 mg/dL\\n/C15oral glucose tolerance test, 2 hours less than or equal\\nto 200 mg/dL\\n/C15casual plasma glucose test (nonfasting, with symp-\\ntoms) less than or equal to 200 mg/dL\\n/C15gestational oral glucose tolerance test, 1 hour less\\nthan or equal to 140 mg/dL\\nBrain damage can occur from glucose levels below\\n40 mg/dL andcoma from levels above 470 mg/dL.\\nA condition known as prediabetes or impaired\\nglucose tolerance, which may lead to Type 2 diabetes,\\nusually is indicated with a reading of 100 mg/dL. Other\\nhormone disorders can cause both hyperglycemia and\\n590 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood sugar tests'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='hypoglycemia. Abnormal results must be interpreted by\\na doctor who is aware of the person’s medical condition\\nand medical history.\\nResources\\nPERIODICALS\\n‘‘New Guidelines Set Lower Threshold for Precursor to\\nDiabetes.’’ RN (January 2004): 17.\\nPlotnick, Leslie P. ‘‘The Next Step in Blood Glucose\\nMonitoring?’’ Pediatrics (April 2003): 885.\\n‘‘Premarket Approval Application Filed for Continuous\\nGlucose Monitor.’’Medical Letter on the CDC & FDA\\n(January 4, 2004): 26.\\nORGANIZATIONS\\nAmerican Diabetes Association. 1701 North Beauregard\\nStreet, Alexandria, VA 22311. (800) 342-2383. .\\nCenters for Disease Control and Prevention. 1600 Clifton\\nRd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-\\n3311. .\\nNational Diabetes Information Clearinghouse.\\n1 Information Way, Bethesda, MD 20892-3560. (800)\\n860-8747. .\\nNancy J. Nordenson\\nTeresa G. Odle\\nBlood thinners see Anticoagulant and\\nantiplatelet drugs\\nBlood transfusion see Transfusion\\nBlood typing and\\ncrossmatching\\nDefinition\\nBlood typing is a laboratory test done to deter-\\nmine a person’s blood type. If the person needs a blood\\ntransfusion, another test called crossmatching is done\\nafter the blood is typed to find blood from a donor\\nthat the person’s body will accept.\\nPurpose\\nBlood typing and crossmatching are most com-\\nmonly done to make certain that a person who needs a\\ntransfusion will receive blood that matches (is compa-\\ntible with) his own. People must receive blood of the\\nsame blood type, otherwise, a serious, even fatal,\\ntransfusion reaction can occur.\\nParents who are expecting a baby have their blood\\ntyped to diagnose and prevent hemolytic disease of the\\nnewborn (HDN), a type of anemia also known as\\nerythroblastosis fetalis. Babies who have a blood type\\ndifferent from their mothers are at risk for developing\\nthis disease. The disease is serious with certain blood\\ntype differences, but is milder with others.\\nA child inherits factors or genes from each parent\\nthat determine his blood type. This fact makes blood\\ntyping useful in paternity testing. To determine\\nwhether or not the alleged father could be the true\\nfather, the blood types of the child, mother, and\\nalleged father are compared.\\nLegal investigations may require typing of blood\\nor other body fluids, such as semen or saliva, to iden-\\ntify persons involved in crimes or other legal matters.\\nDescription\\nBlood typing and crossmatching tests are per-\\nformed in a blood bank laboratory by technologists\\ntrained in blood bank and transfusion services. The\\ntests are done on blood, after it has separated into cells\\nand serum (serum is the yellow liquid left after the\\nblood clots.) Costs for both tests are covered by insur-\\nance when the tests are determined to be medically\\nnecessary.\\nBlood bank laboratories are usually located in\\nfacilities, such as those operated by the American\\nRed Cross, that collect, process, and supply blood\\nthat is donated, as well as in facilities, such as most\\nhospitals, that prepare blood for transfusion. These\\nlaboratories are regulated by the United States Food\\nand Drug Administration (FDA) and are often\\ninspected and accredited by a professional association\\nsuch as the American Association of Blood Banks\\n(AABB).\\nBlood typing and crossmatching tests are based\\non the reaction between antigens and antibodies. An\\nantigen can be anything that causes the body to launch\\nan attack, known as an immune response, against it.\\nThe attack begins when the body builds a special\\nprotein, called an antibody, that is uniquely designed\\nto attack and make ineffective (neutralize) the specific\\nantigen that caused the attack. A person’s body nor-\\nmally doesn’t make antibodies against its own anti-\\ngens, only against antigens that are foreign to it.\\nA person’s body contains many antigens. The anti-\\ngens found on the surface of red blood cells are impor-\\ntant because they determine a person’s blood type.\\nWhen red blood cells having a certain blood type anti-\\ngen are mixed with serum containing antibodies against\\nGALE ENCYCLOPEDIA OF MEDICINE 591\\nBlood typing and crossmatching'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='that antigen, the antibodies attack and stick to the\\nantigen. In a test tube, this reaction is observed as the\\nformation of clumps of cells (clumping).\\nWhen blood is typed, a person’s cells and serum\\nare mixed in a test tube with commercially-prepared\\nserum and cells. Clumping tells which antigens or\\nantibodies are present and reveals the person’s blood\\ntype. When blood is crossmatched, patient serum\\nis mixed with cells from donated blood that might be\\nused for transfusion. Clumping or lack of clumping\\nin the test tube tells whether or not the blood is\\ncompatible.\\nAlthough there are over 600 known red blood cell\\nantigens, organized into 22 blood group systems, rou-\\ntine blood typing and crossmatching is usually con-\\ncerned with only two systems: the ABO and Rh blood\\ngroup systems.\\nBlood typing\\nABO BLOOD GROUP SYSTEM. In 1901, Karl\\nLandsteiner, an Austrian pathologist, randomly com-\\nbined the serum and red blood cells of his colleagues.\\nFrom the reactions he observed in test tubes, he dis-\\ncovered the ABO blood group system. This discovery\\nearned him the 1930 Nobel Prize in Medicine.\\nA person’s ABO blood type–A, B, AB, or O–is\\nbased on the presence or absence of the A and B\\nantigens on his red blood cells. The A blood type has\\nonly the A antigen and the B blood type has only the\\nB antigen. The AB blood type has both A and B\\nantigens, and the O blood type has neither A nor B\\nantigen.\\nBy the time a person is six months old, he natu-\\nrally will have developed antibodies against the anti-\\ngens his red blood cells lack. That is, a person with A\\nblood type will have anti-B antibodies, and a person\\nwith B blood type will have anti-A antibodies. A per-\\nson with AB blood type will have neither antibody, but\\na person with O blood type will have both anti-A and\\nanti-B antibodies. Although the distribution of each of\\nthe four ABO blood types varies between racial\\ngroups, O is the most common and AB is the least\\ncommon.\\nABO typing is the first test done on blood when it\\nis tested for transfusion. A person must receive ABO-\\nmatched blood. ABO incompatibilities are the major\\ncause of fatal transfusion reactions. ABO antigens are\\nalso found on most body organs, so ABO compatibil-\\nity is also important for organ transplants.\\nAn ABO incompatibility between a pregnant\\nwoman and her baby is a minor cause of HDN and\\nusually causes no problem for the baby. The structure\\nof ABO antibodies makes it unlikely they will cross the\\nplacenta to attack the baby’s red blood cells.\\nPaternity testing compares the ABO blood types of\\nthe child, mother, and alleged father. The alleged father\\ncan’t be the true father if the child’s blood type requires\\na gene that neither he nor the mother have. For exam-\\nple, a child with blood type B whose mother has blood\\ntype O, requires a father with either AB or B blood type;\\na man with blood type O cannot be the true father.\\nIn some people, ABO antigens can be found in\\nbody fluids other than blood, such as saliva and\\nsemen. ABO typing of these fluids provides clues in\\nlegal investigations.\\nRH BLOOD GROUP SYSTEM. The Rh, or Rhesus,\\nsystem was first detected in 1940 by Landsteiner and\\nWiener when they injected blood from rhesus monkeys\\ninto guinea pigs and rabbits. More than 50 antigens have\\nsince been discovered belonging to this system, making\\nit the most complex red blood cell antigen system.\\nIn routine blood typing and crossmatching tests,\\nonly one of these 50 antigens, the D antigen, also\\nknown as the Rh factor or Rh\\no[D], is tested for.\\nIf the D antigen is present, that person is Rh-positive;\\nif the D antigen is absent, that person is Rh-negative.\\nOther important antigens in the Rh system are C,\\nc, E, and e. These antigens are not usually tested for in\\nroutine blood typing tests. However, testing for the\\npresence of these antigens is useful in paternity testing,\\nand when a technologist tries to identify unexpected\\nFrequency (%) Of ABO And Rh Blood Types In U.S. Population\\nRacial Group ABO Blood Type Rh Blood Type\\nO A B AB Positive Negative\\nWhites 45% 40% 11% 4% 85% 15%\\nBlacks 49% 27% 20% 4% 90% 10%\\n592 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood typing and crossmatching'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content=\"Rh antibodies or find matching blood for a person\\nwith antibodies to one or more of these antigens.\\nUnlike the ABO system, antibodies to Rh anti-\\ngens don’t develop naturally. They develop only as an\\nimmune response after a transfusion or during\\npregnancy.\\nThe incidence of the Rh blood types varies\\nbetween racial groups, but not as widely as the ABO\\nblood types: 85% of whites and 90% of blacks are\\nRh-positive; 15% of whites and 10% of blacks are\\nRh-negative.\\nIn transfusions, the Rh system is next in impor-\\ntance after the ABO system. Most Rh-negative people\\nwho receive Rh-positive blood will develop anti-D\\nantibodies. A later transfusion of Rh-positive blood\\ncould result in a severe or fatal transfusion reaction.\\nRh incompatibility is the most common and\\nsevere cause of HDN. This incompatibility can\\nhappen when an Rh-negative woman and an Rh-\\npositive man produce an Rh-positive baby. Cells\\nfrom the baby can cross the placenta and enter the\\nmother’s bloodstream, causing the mother to make\\nanti-D antibodies. Unlike ABO antibodies, the struc-\\nture of anti-D antibodies makes it likely that they will\\ncross the placenta and enter the baby’s bloodstream.\\nThere, they can destroy the baby’s red blood cells,\\ncausing severe or fatal anemia.\\nThe first step in preventing HDN is to find out\\nthe Rh types of the expectant parents. If the mother is\\nRh-negative and the father is Rh-positive, the baby is\\nat risk for developing HDN. The next step is to test the\\nmother’s serum to make sure she doesn’t already have\\nanti-D antibodies from a previous pregnancy or trans-\\nfusion. This procedure is similar to blood typing.\\nFinally, the Rh-negative mother is given an injection\\nof Rh Immunoglobulin (RhIg) at 28 weeks of gesta-\\ntion and again after delivery, if the baby is Rh positive.\\nRecipient's blood\\nABO\\nantigens\\nABO\\nantibodies\\nDonor type\\nO cells\\nDonor type\\nA cells\\nDonor type\\nB cells\\nDonor type\\nAB cells\\nABO blood\\ntype\\nO\\nA\\nB\\nAB\\nNone Anti-A\\nAnti-B\\nA Anti-B\\nB Anti-A\\nA & B None\\nCompatible Not compatible\\nReactions with donor's red blood cells\\nBlood typing is a laboratory test done to discover a person’s blood type. If the person needs a blood transfusion, cross-\\nmatching is done following blood typing to locate donor blood that the person’s body will accept. (Illustration by Electronic\\nIllustrators Group.)\\nGALE ENCYCLOPEDIA OF MEDICINE 593\\nBlood typing and crossmatching\"),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='The RhIg attaches to any Rh-positive cells from the\\nbaby in the mother’s bloodstream, preventing them\\nfrom triggering anti-D antibody production in the\\nmother. An Rh-negative woman should also receive\\nRhIg following a miscarriage, abortion, or ectopic\\npregnancy.\\nOTHER BLOOD GROUP SYSTEMS. Several other\\nblood group systems may be involved in HDN and\\ntransfusion reactions, although they are much less\\nfrequent than ABO and Rh. They are the Duffy,\\nKell, Kidd, MNS, and P systems. Tests for antigens\\nfrom these systems are not included in routine blood\\ntyping, but they are commonly used in paternity\\ntesting.\\nLike Rh antibodies, antibodies in these systems\\ndo not develop naturally, but as an immune response\\nafter transfusion or during pregnancy. An antibody\\nscreening test is done before a crossmatch to check\\nfor unexpected antibodies to antigens in these sys-\\ntems. A person’s serum is mixed in a test tube with\\ncommercially-prepared cells containing antigens\\nfrom these systems. If clumping occurs, the antibody\\nis identified.\\nCrossmatching\\nCrossmatching is the final step in pretransfusion\\ntesting. It is commonly referred to as compatibility\\ntesting, or ‘‘Type and Cross.’’\\nBefore blood from a donor and the recipient are\\ncrossmatched, both are ABO and Rh typed. In addi-\\ntion, antibody screening is done to look for antibo-\\ndies to certain Rh, Duffy, MNS, Kell, Kidd, and\\nP system antigens. If an antibody to one of these\\nantigens is found, only blood without that antigen\\nwill be compatible in a crossmatch. This sequence\\nmust be repeated before each transfusion a person\\nreceives.\\nTo begin the crossmatch, blood from a donor with\\nthe same ABO and Rh type as the rcipient is selected.\\nIn a test tube, serum from the patient is mixed with red\\nblood cells from the donor. If clumping occurs, the\\nblood is not compatible; if clumping does not occur,\\nthe blood is compatible. If an unexpected antibody is\\nfound in either the patient or the donor, the blood\\nbank does further testing to make sure the blood is\\ncompatible.\\nIn an emergency, when there is not enough time\\nfor blood typing and crossmatching, O red blood cells\\nmay be given, preferably Rh-negative. O blood type is\\ncalled the universal donor because it has no ABO\\nantigens for a patient’s antibodies to attack. In con-\\ntrast, AB blood type is called the universal recipient\\nbecause it has no ABO antibodies to attack the anti-\\ngens on transfused red blood cells. If there is time\\nfor blood typing, red blood cells of the recipient type\\n(type specific cells) are given. In either case, the cross-\\nmatch is continued, even though the transfusion has\\nbegun.\\nPreparation\\nTo collect the 10 mL blood needed for these tests,\\na healthcare worker ties a tourniquet above the\\npatient’s elbow, locates a vein in the inner elbow\\nregion, and inserts a needle into that vein. Vacuum\\nKEY TERMS\\nABO blood type— Blood type based on the pre-\\nsence or absence of the A and B antigens on the\\nred blood cells.\\nAntibody— A special protein made by the body as a\\ndefense against foreign material that enters the\\nbody. It is uniquely designed to attack and neutra-\\nlize the specific antigen that triggered the immune\\nresponse.\\nAntigen— Anything that causes the body to launch\\nan immune response against that antigen through\\nthe production of antibodies.\\nBlood bank— A laboratory that specializes in blood\\ntyping, antibody identification, and transfusion\\nservices.\\nBlood type— Blood categories based on the pre-\\nsence or absence of certain antigens on the red\\nblood cells.\\nCrossmatch— A laboratory test done to confirm\\nthat blood from a donor and blood from the recipi-\\nent are compatible.\\nGene— A piece of DNA, located on a chromo-\\nsome, that determines how traits such as blood\\ntype are inherited and expressed.\\nImmune response— The body’s attack against an\\nantigen that it considers foreign to itself. The attack\\nbegins with the production of antibodies against\\nthe antigen.\\nRh blood type— Blood type based on the presence\\nor absence of the D antigen on the red blood cells.\\nTransfusion— The therapeutic introduction of\\nblood or a blood component into a patient’s\\nbloodstream.\\n594 GALE ENCYCLOPEDIA OF MEDICINE\\nBlood typing and crossmatching'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='action draws the blood through the needle into an\\nattached tube. Collection of the sample takes only a\\nfew minutes.\\nBlood typing and crossmatching must be done\\nthree days or less before a transfusion. A person\\ndoesn’t need to change diet, medications, or activities\\nbefore these tests. He should tell his healthcare provi-\\nder if, during the last three months, he has received a\\nblood transfusion or a plasma substitute, or has had a\\nradiology procedure using intravenous contrast\\nmedia. These can give false clumping reactions in\\nboth typing and crossmatching tests.\\nAftercare\\nThe possible side effects of any blood collection\\nare discomfort or bruising at the site where the\\nneedle punctured the skin, as well asdizziness or faint-\\ning. Bruising is reduced if pressure is applied with a\\nfinger to the puncture site until the bleeding stops.\\nDiscomfort is treated with warm packs to the\\npuncture site.\\nRisks\\nThere are no risks from the blood collection or\\ntest procedures. Blood transfusions always have the\\nrisk of an unexpected transfusion reaction. A nurse\\nwatches a patient for signs of a reaction during the\\nentire transfusion.\\nNormal results\\nThere is no normal blood type. The desired result\\nof a crossmatch is that compatible donor blood is\\nfound. Compatibility testing procedures are designed\\nto provide the safest blood product possible for the\\nrecipient, but a compatible crossmatch is no guarantee\\nthat an unexpected adverse reaction will not appear\\nduring the transfusion.\\nAbnormal results\\nExcept in an emergency, a person cannot receive a\\ntransfusion without a compatible crossmatch result.\\nResources\\nORGANIZATIONS\\nAmerican Association of Blood Banks. 8101 Glenbrook\\nRoad, Bethesda, MD 20814. (301) 907-6977. .\\nNancy J. Nordenson\\nBlood urea nitrogen test\\nDefinition\\nThe blood urea nitrogen (BUN) test measures the\\nlevel of urea nitrogen in a sample of the patient’s\\nblood. Urea is a substance that is formed in the liver\\nwhen the body breaks down protein. Urea then circu-\\nlates in the blood in the form of urea nitrogen. In\\nhealthy people, most urea nitrogen is filtered out by\\nthe kidneys and leaves the body in the urine. If the\\npatient’s kidneys are not functioning properly or if the\\nbody is using large amounts of protein, the BUN level\\nwill rise. If the patient has severeliver disease, the BUN\\nwill drop.\\nPurpose\\nThe BUN level may be checked in order to assess\\nor monitor:\\n/C15the presence or progression of kidney or liver disease.\\n/C15blockage of urine flow.\\n/C15mental confusion. Patients with kidney failure are\\nsometimes disoriented and confused.\\n/C15abnormal loss of water from the body (dehydration).\\n/C15recovery from severe burns. The body uses larger\\nthan normal amounts of protein following serious\\nburns.\\nDescription\\nThe BUN test is performed on a sample of the\\npatient’s blood, withdrawn from a vein into a vacuum\\ntube. The procedure, which is called a venipuncture,\\ntakes about five minutes.\\nPreparation\\nThe doctor should check to make sure that the\\npatient is not taking any medications that can affect\\nBUN results. These drugs include theantibiotics chlor-\\namphenicol, streptomycin, amphotericin B, methicil-\\nlin, gentamicin, tobramycin, and kanamycin, as well\\nas diuretics and corticosteroids.\\nThe patient should be advised not to eat large\\namounts of meat the day before the test.\\nAftercare\\nAftercare consists of routine care of the area\\naround the venipuncture.\\nGALE ENCYCLOPEDIA OF MEDICINE 595\\nBlood urea nitrogen test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Risks\\nThe primary risk is the possibility of a bruise or\\nswelling in the area of the venipuncture. The patient\\ncan apply moist warm compresses.\\nNormal results\\nNormal BUN levels are 5-18 mg/dL for children;\\n7-18 mg/dL for adults; and 8-20 mg/dL in the elderly.\\nAbnormal results\\nBUN levels can be too low as well as too high.\\nAbnormally low BUN\\nLow levels of BUN may indicateoverhydration,\\nmalnutrition, celiac disease[a disease characterized by\\nthe inability ot tolerate foods containing wheat pro-\\ntein (gluten)], liver damage or disease, or use of corti-\\ncosteroids. Low BUN may also occur in early\\npregnancy.\\nAbnormally high BUN\\nHigh levels of BUN may indicatekidney diseaseor\\nfailure; blockage of the urinary tract by a kidney stone\\nor tumor; aheart attack or congestive heart failure;\\ndehydration; fever; shock; or bleeding in the digestive\\ntract. High BUN levels can sometimes occur during\\nlate pregnancy or result from eating large amounts of\\nprotein-rich foods. A BUN level higher than 100 mg/\\ndL points to severe kidney damage.\\nResources\\nBOOKS\\nPagana, Kathleen Deska.Mosby’s Manual of Diagnostic and\\nLaboratory Tests.St. Louis: Mosby, Inc., 1998.\\nRebecca J. Frey, PhD\\nBlood vessel scan see Doppler\\nultrasonography\\nBody dysmorphic disorder\\nDefinition\\nBody dysmorphic disorder (BDD) is defined by\\nDSM-IV-TR as a condition marked by excessive pre-\\noccupation with an imaginary or minor defect in a\\nfacial feature or localized part of the body. The diag-\\nnostic criteria specify that the condition must be suffi-\\nciently severe to cause a decline in the patient’s social,\\noccupational, or educational functioning. The most\\ncommon cause of this decline is the time lost\\nin obsessing about the ‘‘defect’’—one study found\\nthat 68 percent of patients in a sample of adolescents\\ndiagnosed with BDD spent three or more hours every\\nday thinking about the body part or facial feature of\\nconcern. DSM-IV assigns BDD to the larger category\\nof somatoform disorders, which are disorders charac-\\nterized by physical complaints that appear to be\\nmedical in origin but that cannot be explained in\\nterms of a physical disease, the results ofsubstance\\nabuse, or by another mental disorder.\\nThe earliest known case of BDD in the medical\\nliterature was reported by an Italian physician named\\nEnrique Morselli in 1886, but the disorder was not\\ndefined as a formal diagnostic category until DSM-\\nIII-R in 1987. The World Health Organization\\n(WHO) did not add BDD to the International\\nClassification of Diseases (ICD) until 1992. The\\nword dysmorphic comes from two Greek words that\\nmean ‘‘bad’’ or ‘‘ugly’’ and ‘‘shape’’ or ‘‘form.’’ BDD\\nwas previously known as dysmorphophobia.\\nDescription\\nBDD is characterized by an unusual degree of\\nworry or concern about a specific part of the face or\\nbody, rather than the general size or shape of the body.\\nIt is distinguished fromanorexia nervosaand bulimia\\nnervosa in that patients with eating disorders are\\npreoccupied with their overall weight and body\\nshape. As many as 50 percent of patients diagnosed\\nwith BDD undergo plastic surgery to correct their\\nperceived physical defects.\\nSince the publication of DSM-IV in 1994, some\\npsychiatrists have suggested that there is a subtype of\\nBDD, namely muscle dysmorphia. Muscle dysmor-\\nphia is marked by excessive concern with one’s mus-\\ncularity and/or fitness. Persons with muscle\\ndysmorphia spend unusual amounts of time working\\nout in gyms or exercising rather than dieting obses-\\nsively or seeking plastic surgery. DSM-IV-TR added\\nreferences to concern about body build and excessive\\nKEY TERMS\\nUrea— A compound containing nitrogen that\\noccurs in the urine and other body fluids as a result\\nof protein metabolism.\\n596 GALE ENCYCLOPEDIA OF MEDICINE\\nBody dysmorphic disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='weight lifting to DSM-IV’s description of BDD in\\norder to cover muscle dysmorphia.\\nBDD and muscle dysmorphia can both be\\ndescribed as disorders resulting from the patient’s\\ndistorted body image. Body image refers to a per-\\nson’s mental picture of his or her outward appear-\\nance, including size, shape, and form. It has two\\nmajor components: how the person perceives their\\nphysical appearance, and how they feel about their\\nbody. Significant distortions in self-perception can\\nlead to intense dissatisfaction with one’s body and\\ndysfunctional behaviors aimed at improving one’s\\nappearance. Some patients with BDD are aware\\nthat their concerns are excessive, but others do\\nnot have this degree of insight; about 50 percent\\nof patients diagnosed with BDD also meet the\\ncriteria for a delusional disorder.\\nThe usual age of onset of BDD is late childhood or\\nearly adolescence; the average age of patients diag-\\nnosed with the disorder is 17. BDD has a high rate of\\ncomorbidity, which means that people diagnosed with\\nthe disorder are highly likely to have been diagnosed\\nwith another psychiatric disorder—most commonly\\nmajor depression, social phobia, orobsessive-compul-\\nsive disorder (OCD). About 29% of patients with\\nBDD eventually try to commitsuicide.\\nBDD is thought to affect 1–2 percent of the gen-\\neral population in the United States and Canada,\\nalthough some doctors think that it is underdiagnosed\\nbecause it coexists so often with depression and other\\ndisorders. In addition, patients are often ashamed of\\ngrooming rituals and other behaviors associated with\\nBDD, and may avoid telling their doctor about them.\\nBDD is thought to affect men and women equally;\\nhowever, there are no reliable data as of the early\\n2000s regarding racial or ethnic differences in the inci-\\ndence of the disorder.\\nCauses and symptoms\\nCauses\\nThe causes of BDD fall into two major categories,\\nneurobiological and psychosocial.\\nNEUROBIOLOGICAL CAUSES. Research indicates\\nthat patients diagnosed with BDD have serotonin\\nlevels that are lower than normal. Serotonin is a neu-\\nrotransmitter— a chemical produced by the brain that\\nhelps to transmit nerve impulses across the junctions\\nbetween nerve cells. Low serotonin levels are asso-\\nciated with depression and othermood disorders.\\nPSYCHOSOCIAL CAUSES. Another important fac-\\ntor in the development of BDD is the influence of the\\nmass media in developed countries, particularly the\\nrole of advertising in spreading images of physically\\n‘‘perfect’’ men and women. Impressionable children\\nand adolescents absorb the message that anything\\nshort of physical perfection is unacceptable. They\\nmay then develop distorted perceptions of their own\\nfaces and bodies.\\nA young person’s family of origin also has a power-\\nful influence on his or her vulnerability to BDD.\\nChildren whose parents are themselves obsessed with\\nappearance, dieting, and/or body building, or who are\\nKEY TERMS\\nBody image— A term that refers to a person s inner\\npicture of his or her outward appearance. It has\\ntwo components: perceptions of the appearance\\nof one’s body, and emotional responses to those\\nperceptions.\\nDelusion— A false belief that is resistant to reason\\nor contrary to actual fact. Common delusions\\ninclude delusions of persecution, delusions about\\none s importance (sometimes called delusions of\\ngrandeur), or delusions of being controlled by\\nothers. In BDD, the delusion is related to the\\npatient’s perception of his or her body.\\nDisplacement— A psychological process in which\\nfeelings originating from one source are expressed\\noutwardly in terms of concern or preoccupation\\nwith an issue or problem that the patient considers\\nmore acceptable. In some BDD patients, obsession\\nabout the body includes displaced feelings, often\\nrelated to a history of childhood abuse.\\nMuscle dysmorphia— A subtype of BDD, described\\nas excessive preoccupation with muscularity and\\nbody building to the point of interference with\\nsocial, educational, or occupational functioning.\\nSerotonin— A chemical produced by the brain that\\nfunctions as a neurotransmitter. Low serotonin\\nlevels are associated with mood disorders, particu-\\nlarly depression. Medications known as selective\\nserotonin reuptake inhibitors (SSRIs) are used to\\ntreat BDD and other disorders characterized by\\ndepressed mood.\\nSomatoform disorders— A group of psychiatric dis-\\norders in the DSM-IV-TR classification that are\\ncharacterized by external physical symptoms or\\ncomplaints. BDD is classified as a somatoform\\ndisorder.\\nGALE ENCYCLOPEDIA OF MEDICINE 597\\nBody dysmorphic disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='highly critical of their children’s looks, are at greater\\nrisk of developing BDD.\\nAn additional factor in some young people is a\\nhistory of childhood trauma orabuse. Buried feelings\\nabout the abuse or traumatic incident may emerge\\nin the form of obsession about a part of the face or\\nbody. This ‘‘reassignment’’ of emotions from the unac-\\nknowledged true cause to another issue is called dis-\\nplacement. For example, an adolescent who frequently\\nfelt overwhelmed in childhood by physically abusive\\nparents may develop a preoccupation at the high\\nschool level with muscular strength and power.\\nSymptoms\\nThe central symptom of BDD is excessive concern\\nwith a specific facial feature or body part. Research\\nindicates that the features most likely to be the focus of\\nthe patient’s attention are (in order of frequency) com-\\nplexion flaws (acne, blemishes, scars, wrinkles); hair\\n(on the head or the body, too much or too little); and\\nfacial features (size, shape, or lack of symmetry). The\\npatient’s concerns may, however, involve other body\\nparts, and may shift over time from one feature to\\nanother.\\nOther symptoms of body dysmorphic disorder\\ninclude:\\n/C15Ritualistic behavior. Ritualistic behavior refers to\\nactions that the patient performs to manageanxiety\\nand that take up excessive amounts of his or her time.\\nPatients are typically upset if someone or something\\ninterferes with or interrupts their ritual. Ritualistic\\nbehaviors in BDD may includeexercise or makeup\\nroutines, assuming specific poses or postures in front\\nof a mirror, etc.\\n/C15Camouflaging the ‘‘problem’’ feature or body part\\nwith makeup, hats, or clothing. Camouflaging\\nappears to be the single most common symptom\\namong patients with BDD; it is reported by 94%.\\n/C15Abnormal behavior around mirrors, car bumpers,\\nlarge windows, or similar reflecting surfaces. A\\nmajority of patients diagnosed with BDD frequently\\ncheck their appearance in mirrors or spend long\\nperiods of time doing so. A minority, however,\\nreact in the opposite fashion and avoid mirrors\\nwhenever possible.\\n/C15Frequent requests for reassurance from others about\\ntheir appearance.\\n/C15Frequently comparing one’s appearance to others.\\n/C15Avoiding activities outside the home, including\\nschool and social events.\\nDiagnosis\\nThe diagnosis of BDD in children or adolescents\\nis often made by physicians in family practice because\\nthey are more likely to have developed long-term rela-\\ntionships of trust with young people. At the adult\\nlevel, it is often specialists in dermatology,cosmetic\\ndentistry, or plastic surgery who may suspect that the\\npatient suffers from BDD because of frequent requests\\nfor repeated or unnecessary procedures. Reported\\nrates of BDD among dermatology andcosmetic sur-\\ngery patients range between 6 and 15 percent. The\\ndiagnosis is made on the basis of the patient’s history\\ntogether with the physician’s observations of the\\npatient’s overall mood and conversation patterns.\\nPeople with BDD often come across to others as gen-\\nerally anxious and worried. In addition, the patient’s\\ndress or clothing styles may suggest a diagnosis of\\nBDD. It is not unusual, however, for patients with\\nBDD to take offense if their primary care doctor\\nsuggests referral to a psychiatrist.\\nSome physicians may use a self-report question-\\nnaire, such as the Multidimensional Body-Self\\nRelations Questionnaire (MBSRQ) or the short form\\nof the Situational Inventory of Body-Image Dysphoria\\n(SIBID), to evaluate patients during an office visit.\\nThere are no brain imaging studies or laboratory\\ntests as of the early 2000s that can be used to diagnose\\nBDD.\\nTreatment\\nThe standard course of treatment for body dys-\\nmorphic disorder is a combination of medications and\\npsychotherapy. Surgical, dental, or dermatologic\\ntreatments have been found to be ineffective.\\nThe medications most frequently prescribed for\\npatients with BDD are theselective serotonin reuptake\\ninhibitors, most commonly fluoxetine (Prozac) or ser-\\ntraline (Zoloft). Other SSRIs that have been used with\\nthis group of patients include fluvoxamine (Luvox)\\nand paroxetine (Paxil). In fact, it is the relatively high\\nrate of positive responses to SSRIs among BDD\\npatients that led to the hypothesis that the disorder\\nhas a neurobiological component related to serotonin\\nlevels in the body. An associated finding is that\\npatients with BDD require higher dosages ofSSRI\\nmedications than patients who are being treated for\\ndepression with these drugs.\\nThe most effective approach to psychotherapy\\nwith BDD patients is cognitive-behavioral restructur-\\ning. Since the disorder is related todelusionsabout one’s\\nappearance, cognitive-oriented therapy that challenges\\n598 GALE ENCYCLOPEDIA OF MEDICINE\\nBody dysmorphic disorder'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='inaccurate self-perceptions is more effective than purely\\nsupportive approaches. Thought-stopping and relaxa-\\ntion techniques also work well with BDD patients\\nwhen they are combined with cognitive restructuring.\\nSome doctors recommend couples therapy or\\nfamily therapyin order to involve the patient s parents,\\nspouse, or partner in his or her treatment. This\\napproach may be particularly helpful if family mem-\\nbers are critical of the patient s looks or are reinforcing\\nhis or her unrealistic body image.\\nAlternative treatment\\nAlthough no alternative or complementary\\nform of treatment has been recommended specifi-\\ncally for BDD, such herbal remedies for depression\\nas St. John’s worthave been reported as helping some\\nBDD patients. Aromatherapy appears to be a useful\\naid to relaxation techniques as well as a pleasurable\\nphysical experience for BDD patients. Yoga has\\nhelped some persons with BDD acquire more realistic\\nperceptions of their bodies and to replace obsessions\\nabout external appearance with new respect for their\\nbody’s inner structure and functioning.\\nPrognosis\\nAs of early 2005, the prognosis of BDD is consid-\\nered good for patients receiving appropriate treat-\\nment. On the other hand, researchers do not know\\nenough about the lifetime course of body dysmorphic\\ndisorder to offer detailed statistics. DSM-IV-TR notes\\nthat the disorder ‘‘has a fairly continuous course, with\\nfew symptom-free intervals, although the intensity of\\nsymptoms may wax and wane over time.’’\\nPrevention\\nGiven the pervasive influence of the mass media in\\ncontemporary Western societies, the best preventive\\nstrategy involves challenging their unrealistic images\\nof attractive people. Parents, teachers, primary health\\ncare professionals, and other adults who work with\\nyoung people can point out and discuss the pitfalls of\\ntrying to look ‘‘perfect.’’ In addition, parents or other\\nadults can educate themselves about BDD and its\\nsymptoms, and pay attention to any warning signs in\\ntheir children’s dress or behavior.\\nResources\\nBOOKS\\nAmerican Psychiatric Association.Diagnostic and Statistical\\nManual of Mental Disorders, 4th edition, text revision.\\nWashington,DC:AmericanPsychiatricAssociation,2000.\\n‘‘Body Dysmorphic Disorder,’’ Section 15, Chapter 186\\ninThe Merck Manual of Diagnosis and Therapy, edited\\nby Mark H. Beers, MD, and Robert Berkow, MD.\\nWhitehouse Station, NJ: Merck Research\\nLaboratories, 2004.\\nJohnston, Joni E., Psy D.Appearance Obsession: Learning to\\nLove the Way You Look.Deerfield Beach, FL: Health\\nCommunications, Inc., 1994.\\nRodin, Judith, PhD.Body Traps: Breaking the Binds That\\nKeep You from Feeling Good About Your Body.New\\nYork: William Morrow, 1992.\\nPERIODICALS\\nArthur, Gary K., MD, and Kim Monnell, DO. ‘‘Body\\nDysmorphic Disorder.’’eMedicine, 3 September 2004.\\n.\\nCafri, G., J. K. Thompson, L. Ricciardelli, et al. ‘‘Pursuit of\\nthe Muscular Ideal: Physical and Psychological\\nConsequences and Putative Risk Factors.’’Clinical\\nPsychology Review25 (February 2005): 215–239.\\nKirchner, Jeffrey T. ‘‘Treatment of Patients with Body\\nDysmorphic Disorder.’’American Family Physician61\\n(March 2000): 1837–1843.\\nSlaughter, James R. ‘‘In Pursuit of Perfection: A Primary\\nCare Physician’s Guide to Body Dysmorphic\\nDisorder.’’ American Family Physician60 (October\\n1999): 569–580.\\nORGANIZATIONS\\nAmerican Academy of Child and Adolescent Psychiatry.\\n3615 Wisconsin Avenue, NW, Washington, DC 20016-\\n3007. (202) 966-7300. Fax: (202) 966-2891.\\n.\\nAmerican Psychiatric Association (APA). 1000 Wilson\\nBoulevard, Suite 1825, Arlington, VA 22209-3901.\\n(800) 368-5777 or (703) 907-7322. Fax: (703) 907-1091.\\n.\\nRebecca Frey, PhD\\nBody lice see Lice infestation\\nBoils\\nDefinition\\nBoils and carbuncles are bacterial infections of\\nhair follicles and surrounding skin that form pustules\\n(small blister-like swellings containing pus) around\\nthe follicle. Boils are sometimes called furuncles. A\\ncarbuncle is formed when several furuncles merge\\nto form a single deepabscess with several heads or\\ndrainage points.\\nGALE ENCYCLOPEDIA OF MEDICINE 599\\nBoils'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Description\\nBoils and carbuncles are firm reddish swellings\\nabout 0.2–0.4in (5-10 mm) across that are slightly raised\\nabove the skin surface. They are sore to the touch. A\\nboil usually has a visible central core of pus; a carbuncle\\nis larger and has several visible heads. Boils occur most\\ncommonly on the face, back of the neck, buttocks,\\nupper legs and groin area, armpits, and upper torso.\\nCarbuncles are less common than single boils; they are\\nmost likely to form at the back of the neck. Males are\\nmore likely to develop carbuncles.\\nBoils and carbuncles are common problems in the\\ngeneral population, particularly among adolescents\\nand adults. People who are more likely to develop\\nthese skin infections include those with:\\n/C15diabetes, especially when treated by injected insulin\\n/C15alcoholism or drugabuse\\n/C15poor personal hygiene\\n/C15crowded living arrangements\\n/C15jobs or hobbies that expose them to greasy or oily\\nsubstances, especially petroleum products\\n/C15allergies or immune system disorders, including HIV\\ninfection.\\n/C15family members with recurrent skin infections\\nCauses and symptoms\\nBoils and carbuncles are caused byStaphylococcus\\naureus, a bacterium that causes an infection in an oil\\ngland or hair follicle. Although the surface of human\\nskin is usually resistant to bacterial infection,S. aureus\\nc a ne n t e rt h r o u g hab r e a ki nthe skin surface–including\\nbreaks caused by needle punctures for insulin or drug\\ninjections. Hair follicles that are blocked by greasy\\ncreams, petroleum jelly, or similar products are\\nmore vulnerable to infection.Bacterial skin infections\\ncan be spread by shared cosmetics or washcloths, close\\nhuman contact, or by contact with pus from a boil or\\ncarbuncle.\\nAs the infection develops, an area of inflamed tis-\\nsue gradually forms a pus-filled swelling or pimple that\\nis painful to touch. As the boil matures, it forms a\\nyellowish head or point. It may either continue to\\nswell until the point bursts open and allows the pus to\\ndrain, or it may be gradually reabsorbed into the skin.\\nIt takes between one and two weeks for a boil to heal\\ncompletely after it comes to a head and discharges\\npus. The bacteria that cause the boil can spread into\\nother areas of the skin or even into the bloodstream\\nif the skin around the boil is injured by squeezing. If the\\ninfection spreads, the patient will usually develop chills\\nand fever, swollen lymph nodes (lymphadenitis), and red\\nlines in the skin running outward from the boil.\\nFurunculosis is a word that is sometimes used\\nto refer to recurrent boils. Many patients have\\nrepeated episodes of furunculosis that are difficult to\\ntreat because their nasal passages carry colonies of\\nS. aureus. These bacterial colonies make it easy for\\nthe patient’s skin to be reinfected. They are most likely\\nto develop in patients with diabetes, HIV infection, or\\nother immune system disorders.\\nCarbuncles are formed when the bacteria infect\\nseveral hair follicles that are close together.\\nCarbunculosis is a word that is sometimes used to\\nrefer to the development of carbuncles. The abscesses\\nspread until they merge with each other to form a\\nsingle large area of infected skin with several pus-filled\\nBoils often occur from a bacterial infection in a hair follicle or\\nskin gland. (Custom Medical Stock Photo. Reproduced by\\npermission.)\\nA close-up view of a carbuncle on person’s back.(Photograph\\nby John Watney, Photo Researchers, Inc. Reproduced by\\npermission.)\\n600 GALE ENCYCLOPEDIA OF MEDICINE\\nBoils'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='heads. Patients with carbuncles may also have a low-\\ngrade fever or feel generally unwell.\\nDiagnosis\\nThe diagnosis of boils and carbuncles is usually\\nmade by the patient’s primary care doctor on the basis\\nof visual examination of the skin. In some cases invol-\\nving recurrent boils on the face, the doctor may need\\nto consider acne as a possible diagnosis, but for the\\nmost part boils and carbuncles are not difficult to\\ndistinguish from other skin disorders.\\nTreatment\\nPatient and family education\\nPatient education is an important part of the\\ntreatment of boils and carbuncles. Patients need to\\nbe warned against picking at or squeezing boils\\nbecause of the danger of spreading the infection into\\nother parts of the skin or bloodstream. It is especially\\nimportant to avoid squeezing boils around the mouth\\nor nose because infections in these areas can be carried\\nto the brain. Patients should also be advised about\\nkeeping the skin clean, washing their hands carefully\\nbefore and after touching the boil or carbuncle, avoid-\\ning the use of greasy cosmetics or creams, and keeping\\ntheir towels and washcloths separate from those of\\nother family members. Some doctors may recommend\\nan antiseptic soap or gel for washing the infected\\nareas.\\nIf the patient has had several episodes of furuncu-\\nlosis, the doctor may examine family members or close\\ncontacts to see if they are carriers ofS. aureus. In many\\ncases they also need treatment for boils or carbuncles.\\nSkin infections and reinfections involving small\\ngroups or clusters of people are being reported more\\nfrequently in the United States.\\nMedications\\nBoils are usually treated with application of antibio-\\ntic creams–usually clindamycin or polymyxin–following\\nthe application of hot compresses. The compresses help\\nthe infection to come to a head and drain.\\nCarbuncles and furunculosis are usually treated\\nwith oral antibiotics as well as antibiotic creams or\\nointments. The specific medications that are given\\nare usually dicloxacillin (Dynapen) or cephalexin\\n(Keflex). Erythromycin may be given to patients who\\nare allergic to penicillin. The usual course of oral anti-\\nbiotics is 5-10 days; however, patients with recurrent\\nfurunculosis may be given oral antibiotics for longer\\nperiods. Furunculosis is treated with a combination of\\ndicloxacillin and rifampin (Rifadin).\\nPatients with bacterial colonies in their nasal pas-\\nsages are often given mupirocin (Bactroban) to apply\\ndirectly to the lining of the nose.\\nSurgical treatment\\nBoils and carbuncles that are very large, or that\\nare not draining, may be opened with a sterile needle\\nor surgical knife to allow the pus to drain. The doctor\\nwill usually give the patient a local anesthetic if a knife\\nis used; surgical treatment of boils is painful and\\nusually leaves noticeablescars.\\nAlternative treatment\\nNaturopathic therapy\\nNaturopathic practitioners usually recommend\\nchanges in the patient’s diet as well as applying herbal\\npoultices to the infected area. The addition of zinc\\nsupplements and vitamin A to the diet is reported to\\nbe effective in treating boils. The application of a paste\\nor poultice containing goldenseal (Hydrastis canaden-\\nsis) root is recommended by naturopaths on the\\ngrounds that goldenseal helps to kill bacteria and\\nreduce inflammation.\\nHomeopathy\\nHomeopaths maintain that taking the proper\\nhomeopathic medication in the first stages of a boil\\nor carbuncle will bring about early resolution of the\\ninfection and prevent pus formation. The most likely\\nchoices areBelladonna or Hepar sulphuris. If the boil\\nKEY TERMS\\nAbscess— A localized collection of pus in the skin\\nor other body tissue.\\nCarbuncle— A large, deep skin abscess formed by a\\ngroup or cluster of boils.\\nFollicle— The small sac at the base of a hair shaft.\\nThe follicle lies below the skin surface.\\nFurunculosis— A condition in which the patient\\nsuffers from recurrent episodes of boils.\\nPustule— A small raised pimple or blister-like swel-\\nling of the skin that contains pus.\\nGALE ENCYCLOPEDIA OF MEDICINE 601\\nBoils'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='has already formed,Mercurius vivusor Silica may be\\nrecommended to bring the pus to a head.\\nWestern herbal therapies\\nA variety of herbal remedies can be applied topically\\nto boils to fight infection. These include essential oils\\nof bergamot (Citrus bergamia), chamomile (Matricaria\\nrecutita), lavender (Lavandula officinalis), and sage\\n(Salvia officinalis), as well as tea tree oil (Melaleuca\\nspp.). Herbalists also recommend washing the skin\\nwith a mixture of goldenseal and witch hazel. To\\nfight the inflammation associated with boils, herbalists\\nsuggest marsh mallow (Althaea officinalis) ointment,\\ntinctures (herbal solutions made with alcohol) of blue\\nflag (Iris versicolor)o rm y r r h(Commiphora molmol), and\\nslippery elm (Ulmus fulva) made into a poultice.\\nPrognosis\\nThe prognosis for most boils is excellent. Some\\npatients, however, suffer from recurrent carbuncles or\\nfurunculosis. In addition, although the spread of infec-\\ntion from boils is relatively unusual, there have been\\ndeaths reported from brain infections caused by\\nsqueezing boils on the upper lip or in the tissue folds\\nat the base of the nose.\\nPrevention\\nThere are some precautions that people can take\\nto minimize the risk of developing bacterial skin\\ninfections:\\n/C15cleanse skin properly with soap and water, and take\\nshowers rather than tub baths\\n/C15do not share washcloths, towels, or facial cosmetics\\nwith others\\n/C15cut down on greasy or fatty foods and snacks\\n/C15always wash hands before touching the face\\n/C15consider using antiseptic soaps and shower gels\\n/C15consult a doctor if furunculosis is a persistent pro-\\nblem–it may indicate an underlying disease such as\\ndiabetes\\nResources\\nBOOKS\\nHacker, Steven M. ‘‘Common Bacterial and Fungal\\nInfections of the Integument.’’ InCurrent Diagnosis,\\nedited by Rex B. Conn, et al. Vol 9. Philadelphia: W. B.\\nSaunders Co., 1997.\\nRebecca J. Frey, PhD\\nBone biopsy\\nDefinition\\nBone biopsy is the removal of a piece of bone\\nfor laboratory examination and analysis.\\nPurpose\\nBone biopsy is used to distinguish between malig-\\nnant tumors and benign bone disease such asosteo-\\nporosis and osteomyelitis. This test may be ordered\\nto determine why a patient’s bones ache or feel sore,\\nor when a mass or deformity is found on an x ray,\\nCT scan, bone scan, or other diagnostic imaging\\nprocedure.\\nPrecautions\\nThe patient’s doctor and the surgeon who per-\\nforms the bone biopsy must be told about any pre-\\nscription and over-the-counter medications the\\npatient is taking, and aboutallergies or reactions the\\npatient has had to anesthetics orpain relievers. Special\\ncare must be taken with patients who have experienced\\nbleeding problems.\\nDescription\\nA bone biopsy involves using a special drill or\\nother surgical instruments to remove bone from the\\npatient’s body. The procedure usually lasts about 30\\nminutes and may be performed in the hospital, a doc-\\ntor’s office, or a surgical center.\\nA drill biopsy is generally used to obtain a small\\nspecimen. After the skin covering the bone has been\\ncleansed with an antiseptic and shaved, the patient\\nis given a local anesthetic. The doctor will not begin\\nthe procedure until the anesthetic has numbed the\\narea from which the bone is to be removed, but the\\npatient may feel pressure or mild pain when\\nthe needle pierces the bone. The surgeon turns the\\nneedle in a half-circle to extract a sample from the\\ncore, or innermost part, of the bone. The sample is\\ndrawn into the hollow stem of the biopsy needle. The\\nsample is then sent to a laboratory, where it is exam-\\nined under a microscope.\\nAn open biopsy is used when a larger specimen is\\nneeded. After the area covering the bone has been\\ncleansed with an antiseptic and shaved, the patient\\nis given a general anesthetic. After the anesthetic\\ntakes effect and the patient is unconscious, the\\n602 GALE ENCYCLOPEDIA OF MEDICINE\\nBone biopsy'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='surgeon makes an incision and removes a bone speci-\\nmen. The specimen is sent to the laboratory for\\nimmediate analysis. Results of that analysis may\\nindicate that additional surgery should be performed\\nright away.\\nPreparation\\nNo special preparation is needed for a drill biopsy,\\nbut a patient must fast for at least 12 hours before an\\nopen biopsy.\\nAftercare\\nPain medication will be prescribed after a biopsy,\\nand vital signs will be monitored until they return to\\nnormal. Most patients can go home in about an hour.\\nIf bone was removed from the spine, the patient may\\nstay in the hospital overnight. The surgical site must be\\nkept clean and dry for 48 hours, and the patient’s\\ndoctor should be notified if any of these symptoms\\nappear:\\n/C15fever\\n/C15headache\\n/C15pain on movement\\n/C15inflammation or pus near the biopsy site\\n/C15bleeding through the bandage at the biopsy site\\nRisks\\nRisks include bone fracture, injury to nearby\\ntissue, and infection. Bleeding is a rare complication.\\nFactors that increase risk include:\\n/C15stress\\n/C15obesity\\n/C15poor nutrition\\n/C15chronic illness\\n/C15some medications\\n/C15mind-altering drugs\\nNormal results\\nNormal bone is made up of collagen fibers and\\nbone tissue.\\nAbnormal results\\nBone biopsy can reveal the presence of benign\\ndisease, infection, or malignant tumors that have\\nspread to the bone from other parts of the body.\\nResults of this test are considered reliable, but\\nmay be affected by:\\n/C15failure to fast before open biopsy\\n/C15failure to obtain an adequate specimen\\n/C15delayed microscopic examination or laboratory\\nanalysis\\nResources\\nORGANIZATIONS\\nCancer Group Institute. 1814 N.E. Miami Gardens\\nDrive, North Miami Beach, FL 33179. (305)\\n651-5070. .\\nNational Institute of Arthritis and Musculoskeletal and Skin\\nDiseases Information Clearinghouse. National\\nInstitutes of Health. 1 AMS Circle, Bethesda, MD\\n20892-3695. (301) 495-3675.\\nMaureen Haggerty\\nBone break fever see Dengue fever\\nBone cancer see Sarcomas\\nBone densitometry see Bone density test\\nBone density test\\nDefinition\\nA bone density test, or scan, is designed to check\\nfor osteoporosis, a disease that occurs when the bones\\nbecome thin and weak. Osteoporosis happens when\\nthe bones lose calcium and otherminerals that keep\\nthem strong. Osteoporosis begins aftermenopause in\\nmany women, and worsens after age 65, often result-\\ning in seriousfractures. These fractures may not only\\nKEY TERMS\\nBiopsy— Removal and examination of tissue to\\ndetermine if cancer is present.\\nOsteomyelitis— An infection of the bone that is\\nusually treated with antibiotics but sometimes\\nrequires surgery.\\nOsteoporosis— Thinning and loss of bone tissue.\\nGALE ENCYCLOPEDIA OF MEDICINE 603\\nBone density test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='bring disability, but may affect longevity. As many as\\none-fourth of women who fracture their hip after age\\n50 die within one year.\\nMost people today will get a bone density scan\\nfrom a machine using a technology called Dual Energy\\nX-ray Absorptiometry or DEXA for short. This\\nmachine takes a picture of the bones in the spine,\\nhip, total body and wrist, and calculates their density.\\nIf a DEXA machine is not available, bone density\\nscans can also be done with dual photon absorptiome-\\ntry (measuring the spine, hip and total body) and\\nquantitative computed tomography scans (measuring\\nthe spine). Bone density scanners that use DEXA tech-\\nnology to just measure bone density in the wrist (called\\npDEXA scans) provide scans at some drugstores. Yet\\nthese tests are not as accurate as those that measure\\ndensity in the total body, spine or hip–where most\\nfractures occur.\\nPurpose\\nA bone density scan measures the strength of an\\nindividual’s bones and determines the risk of fracture.\\nAn observation of any osteoporosis present can be\\nmade.\\nDescription\\nTo take a DEXA bone density scan, the patient\\nlies on a bed underneath the scanner, a curving plastic\\narm that emits x rays. These low-dose x rays form a\\nfan beam that rotates around the patient. During the\\ntest, the scanner moves to capture images of the\\npatient’s spine, hip or entire body. A computer then\\ncompares the patient’s bone strength and risk of\\nfracture to that of other people in the United States\\nat the same age and to young people at peak bone\\ndensity. Bones reach peak density at age 30 and then\\nstart to lose mass. The test takes about 20 minutes to\\ndo and is painless. The DEXA bone scan costs about\\n$250. Some insurance companies and Medicare cover\\nthe cost. pDEXA wrist bone scans in drugstores are\\navailable for about $30.\\nPreparation\\nThe patient puts on a hospital gown and lies\\non the bed underneath the scanner. Not all doctors\\nroutinely schedule this test. If the following factors\\napply to a patient, they may need a bone density\\nscan and can discuss this with their doctor. The\\npatient:\\n/C15is at risk for osteoporosis\\n/C15is near menopause\\n/C15has broken a bone after a modest trauma\\n/C15has a family history of osteoporosis\\n/C15uses steroid or antiseizure medications\\n/C15has had a period of restricted mobility for more than\\nsix months\\nRisks\\nThe DEXA bone scan exposes the patient to only\\na small amount of radiation–about one-fiftieth that\\nof a chest x ray, or about the amount you get from\\ntaking a cross-country airplane flight.\\nComputer read-out of a bone density scan. (Photo\\nResearchers. Reproduced by permission.)\\nPatient undergoing a bone density scan. (Photo Researchers.\\nReproduced by permission.)\\n604 GALE ENCYCLOPEDIA OF MEDICINE\\nBone density test'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Normal results\\nThe patient, when compared with people at\\n‘‘young normal bone density’’ (called the T-score)\\nhas the same or denser bones than a healthy 30-year-\\nold. T scores above 1 mean that a patient has a healthy\\nbone mass. Scores from 0 to/C01 mean that the patient\\nhas borderline bone mass and should repeat the test in\\ntwo to five years.\\nAbnormal results\\nThe patient has two to four times the risk of a\\nbroken bone as other people in the United States at the\\nsame age and those at peak bone density. If a patient’s T\\nscore ranges from/C01t o/C02.5 they have low bone mass\\nand are at risk for osteoporosis. A T score below/C02.5\\nmeans osteoporosis is already evident. These patients\\nshould have a repeat bone density scan every year or two.\\nResources\\nORGANIZATIONS\\nNational Osteoporosis Foundation. 1150 17th St., NW,\\nSuite 500, Washington, DC 20036-4603. (800) 223-\\n9994. .\\nBarbara Boughton\\nBone disorder drugs\\nDefinition\\nBone disorder drugs are medicines used to treat\\ndiseases that weaken the bones.\\nPurpose\\nThe drugs described here are used to treat or pre-\\nvent osteoporosis (brittle bone disease) in women past\\nmenopause as well as older men. They also are used\\nprescribed for Paget’s disease, a painful condition that\\nweakens and deforms bones, and they are used to\\ncontrol calcium levels in the blood.\\nBone is living tissue. Like other tissue, bone is\\nconstantly being broken down and replaced with new\\nmaterial. Normally, there is a balance between the\\nbreakdown of old bone and its replacement with new\\nbone. But when something goes wrong with the\\nprocess, bone disorders may result.\\nOsteoporosis is a particular concern for women\\nafter menopause, as well as for older men. In osteo-\\nporosis, the inside of the bones become porous and\\nKEY TERMS\\nCalcium— A mineral that helps build bone. After\\nmenopause, when women start making less of the\\nbone-protecting hormone estrogen, they may need\\nto increase their intake of calcium.\\nDEXA bone density scan— A bone density scan\\nthat uses a rotating x-ray beam to measure the\\nstrength of an individual’s bones and his or her\\nfracture risk.\\nOsteoporosis— A disease that occurs when the\\nbones lose the calcium and structure that keep\\nthem strong. It often occurs after menopause\\n(around age 50) in women and in old age in men.\\nA bone densitometry scan of identical twins. Their bone\\ndensity is normal and identical to one another. (Photo\\nResearchers. Reproduced by permission.)\\nGALE ENCYCLOPEDIA OF MEDICINE 605\\nBone disorder drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='thin. Over time, this condition weakens the bones\\nand makes them more likely to break. Osteoporosis\\nis four times more common in women than in men.\\nThis is because women have less bone mass than men,\\ntend to live longer and take in less calcium, and need\\nthe female hormone estrogen to keep their bones\\nstrong. If men live long enough, they are also at risk\\nof getting osteoporosis later in life. Once total bone\\nmass has peaked–around age 35–all adults start to lose\\nit. In women, the rate of bone loss speeds up during\\nmenopause, when estrogen levels fall. Bone loss may\\nalso occur if both ovaries are removed by surgery.\\nOvaries make estrogen.Hormone replacement therapy\\nis one approach to preventing osteoporosis. However,\\nnot all people can use hormone replacement therapy.\\nBone disorder drugs are a good alternative for people\\nwho already have osteoporosis or who are at risk\\nof developing it. Risk factors include lack of regular\\nexercise, early menopause, being underweight, and a\\nstrong family history of osteoporosis.\\nDescription\\nBone disorder drugs are available only with a physi-\\ncian’s prescription and come in tablet, nasal spray, and\\ninjectable forms. Commonly used bone disorder drugs\\nare alendronate (Fosamax), calcitonin (Miacalcin,\\nCalcimar), and raloxifene (Evista). Raloxifene belongs\\nto a group of drugs known as selective estrogen recep-\\ntor modulators (SERMs), which act like estrogen in\\nsome parts of the body but not in others. This makes\\nthe drugs less likely to cause some of the harmful\\neffects that estrogen may cause. Unlike estrogen,\\nraloxifene does not increase the risk ofbreast cancer.\\nIn fact, research suggests that raloxifene may even\\nreduce that risk.\\nRecommended dosage\\nAlendronate\\nFOR OSTEOPOROSIS. The usual dose is 10 mg once\\na day. Treatment usually continues over many years.\\nFOR PAGET’S DISEASE. The usual dose is 40 mg\\nonce a day for six months.\\nThis medicine works only when it is taken with a\\nfull glass of water first thing in the morning, at least 30\\nminutes before eating or drinking anything or taking\\nany other medicine. Do not lie down for at least 30\\nminutes after taking it because the drug can irritate the\\nesophagus, the tube that delivers food form the mouth\\nto the stomach.\\nCalcitonin\\nNASAL SPRAY. The usual dose is one spray into the\\nnose once a day. Alternate nostrils, spraying the right\\nnostril one day, the left nostril the next day, and so on.\\nINJECTABLE. The recommended dosage depends\\non the condition for which the medicine is prescribed\\nand may be different for different people. Check with\\nthe physician who prescribed the medicine or the\\npharmacist who filled the prescription for the proper\\ndosage.\\nRaloxifene\\nThe usual dose is one 60-mg tablet daily.\\nPrecautions\\nAldendronate\\nPeople with low levels of calcium in their blood\\nshould not take this medicine. It also is not recom-\\nmended for women on hormone replacement therapy\\nor for anyone with kidney problems. Before using\\nalendronate, anyone who has digestive or swallowing\\nproblems should make sure that his or her physician\\nknows about the condition.\\nCalcitonin\\nCalcitonin nasal spray may cause irritation or\\nsmall sores in the nose. Check with a physician if this\\nKEY TERMS\\nEstrogen— The main sex hormone that controls\\nnormal sexual development in females. During\\nthe menstrual cycle, estrogen helps prepare the\\nbody for possible pregnancy.\\nFracture— A break or crack in a bone.\\nHormone— A substance that is produced in one\\npart of the body, then travels through the blood-\\nstream to another part of the body where it has its\\neffect.\\nMenopause— The stage in a woman’s life when the\\novaries stop producing egg cells at regular times\\nand menstruation stops.\\nOsteoporosis— A disease in which bones become\\nvery porous and weak. The bones are then more\\nlikely to fracture and take longer to heal. The con-\\ndition is most common in women after menopause\\nbut can also occur in older men.\\n606 GALE ENCYCLOPEDIA OF MEDICINE\\nBone disorder drugs'),\n", " Document(metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='becomes very uncomfortable or if there is bleeding\\nfrom the nose.\\nThe injectable form of calcitonin has caused ser-\\nious allergic reactions in a few people. The nasal spray\\nis not known to cause such reactions, but the possi-\\nbility exists. Before starting treatment with calcitonin,\\nthe physician who prescribes the drug may order an\\nallergy test to make sure there will not be a problem.\\nRaloxifene\\nA rare, but serious side effect of raloxifene is an\\nincreased risk ofblood clotsthat form in the veins and\\nmay break away and travel to the lungs. This is about\\nas likely in women who take raloxifene as it is in\\nwomen who take estrogen. Because of this possible\\nproblem, women with a history of blood clots in\\ntheir veins should not take raloxifene.\\nWomen who have had breastcancer or cancer of\\nthe uterus should check with their physicians about\\nwhether they can safely use raloxifene.\\nGeneral precautions for bone disorder drugs\\nTo keep bones strong, the body needs calcium and\\nvitamin D. Dairy products and fish such as salmon,\\nsardines and tuna are good sources of both calcium and\\nvitamin D. People who are taking bone disorder drugs\\nfor osteoporosis and who do not get enough of these\\nnutrients in theirdiets should check with their physi-\\ncians about taking supplements. Other important\\nbone-saving steps are avoidingsmoking and alcohol\\nand getting enough of the kind of exercise that puts\\nweight on the bones (such as walking or lifting weights).\\nPeople who are taking these drugs because they\\nhave too much calcium in their blood may need to\\nlimit the amount of calcium in their diets. Too much\\ncalcium may prevent the medicine from working prop-\\nerly. Discuss the proper diet with the physician who\\nprescribed the drug, and do not make any diet changes\\nwithout the physician’s approval.\\nAnyone who has had unusual reactions to bone\\ndisorder drugs in the past should let his or her physi-\\ncian know before taking the drugs again. The physi-\\ncian also should be told about anyallergies to foods,\\ndyes, preservatives, or other substances.\\nWomen who are pregnant or who may become\\npregnant and women who are breastfeeding should\\ncheck with their physicians before using this alendro-\\nnate or calcitonin. Raloxifene should not be used by\\nwomen who are pregnant or who may become preg-\\nnant. In laboratory studies of rats, raloxifene caused\\nbirth defects.\\nSide effects\\nAldendronate\\nCommon side effects includeconstipation, diar-\\nrhea, indigestion, nausea, pain in the abdomen, and\\npain in the muscles and bones. These problems usually\\ngo away as the body adjusts to the medicine and do not\\nneed medical attention unless they continue or they\\ninterfere with normal activities.\\nCalcitonin\\nThe most common side effects of calcitonin nasal\\nspray are nose problems, such as dryness, redness,\\nitching, sores, bleeding and general discomfort. These\\nproblems should go away as the body adjusts to the\\nmedicine, but if they do not or if they are very uncom-\\nfortable, check with a physician. Other side effects that\\nshould be brought to a physician’s attention include\\nheadache, back pain and joint pain.\\nInjectable calcitonin may cause minor side effects\\nsuch as nausea orvomiting; diarrhea; stomach pain;\\nloss of appetite; flushing of the face, ears, hands or\\nfeet; and discomfort or redness at the place on the\\nbody where it is injected. Medical attention is not\\nnecessary unless these problems persist or cause unusual\\ndiscomfort.\\nAnyone who has a skin rash orhives after taking\\ninjectable calcitonin should check with a physician as\\nsoon as possible.\\nRaloxifene\\nCommon side effects include hot flashes, leg\\ncramps, nausea and vomiting. Women who have these\\nproblems while taking raloxifene should check with\\ntheir physicians.\\nInteractions\\nAldendronate\\nTaking aspirin with alendronate may increase the\\nchance of upset stomach, especially if the dose of\\nalendronate is more than 10 mg per day. If an analge-\\nsic is necessary, switch to another drug, such asacet-\\naminophen (Tylenol) or use buffered aspirin. Ask a\\nphysician or pharmacist for the correct medication\\nto use.\\nSome calcium supplements, antacids and other\\nmedicines keep the body from absorbing alendronate.\\nTo prevent this problem, do not take any other med-\\nicine within 30 minutes of taking alendronate.\\nGALE ENCYCLOPEDIA OF MEDICINE 607\\nBone disorder drugs')]" ] }, "execution_count": 14, "metadata": {}, "output_type": "execute_result" } ], "source": [ "minimal_docs" ] }, { "cell_type": "code", "execution_count": 19, "id": "84e9ff13", "metadata": {}, "outputs": [], "source": [ "def text_splitter(minimal_docs):\n", " text_splitter = RecursiveCharacterTextSplitter(\n", " chunk_size=500,\n", " chunk_overlap=20\n", " )\n", " text_chunks=text_splitter.split_documents(minimal_docs)\n", " return text_chunks" ] }, { "cell_type": "code", "execution_count": 20, "id": "c481d852", "metadata": {}, "outputs": [ { "ename": "NameError", "evalue": "name 'minimal_docs' is not defined", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mNameError\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[20], line 1\u001b[0m\n\u001b[1;32m----> 1\u001b[0m text_chunks \u001b[38;5;241m=\u001b[39m text_splitter(\u001b[43mminimal_docs\u001b[49m)\n\u001b[0;32m 3\u001b[0m \u001b[38;5;28mprint\u001b[39m(\u001b[38;5;28mlen\u001b[39m(text_chunks))\n", "\u001b[1;31mNameError\u001b[0m: name 'minimal_docs' is not defined" ] } ], "source": [ "text_chunks = text_splitter(minimal_docs)\n", "\n", "print(len(text_chunks))" ] }, { "cell_type": "code", "execution_count": 22, "id": "4597c5f3", "metadata": {}, "outputs": [], "source": [ "from langchain.embeddings import HuggingFaceEmbeddings\n", "\n", "def download_embeddings():\n", "\n", " model_name = \"sentence-transformers/all-MiniLM-L6-v2\"\n", " embeddings= HuggingFaceEmbeddings(\n", " model_name=model_name,\n", " \n", " )\n", " return embeddings\n", "embeddings = download_embeddings()" ] }, { "cell_type": "code", "execution_count": null, "id": "379f4aeb", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "HuggingFaceEmbeddings(client=SentenceTransformer(\n", " (0): Transformer({'max_seq_length': 256, 'do_lower_case': False}) with Transformer model: BertModel \n", " (1): Pooling({'word_embedding_dimension': 384, 'pooling_mode_cls_token': False, 'pooling_mode_mean_tokens': True, 'pooling_mode_max_tokens': False, 'pooling_mode_mean_sqrt_len_tokens': False, 'pooling_mode_weightedmean_tokens': False, 'pooling_mode_lasttoken': False, 'include_prompt': True})\n", " (2): Normalize()\n", "), model_name='sentence-transformers/all-MiniLM-L6-v2', cache_folder=None, model_kwargs={}, encode_kwargs={}, multi_process=False, show_progress=False)" ] }, "execution_count": 18, "metadata": {}, "output_type": "execute_result" } ], "source": [ "embeddings" ] }, { "cell_type": "code", "execution_count": 23, "id": "23f4eb17", "metadata": {}, "outputs": [ { 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-0.002187494421377778,\n", " -7.526956323999912e-05,\n", " 0.01416971255093813,\n", " -0.0011437988141551614,\n", " 0.00379356206394732,\n", " 0.01561384554952383,\n", " 0.043046195060014725,\n", " 0.05026082322001457,\n", " -0.08589546382427216,\n", " -0.025811441242694855,\n", " 0.038511086255311966,\n", " 0.08055450767278671,\n", " 0.004532495979219675,\n", " -0.0740506649017334,\n", " -0.036521635949611664,\n", " 0.10819683969020844,\n", " 0.01855718158185482,\n", " 0.04710019752383232,\n", " -0.04516879841685295,\n", " 0.014359969645738602,\n", " 0.012810474261641502,\n", " 0.03182659298181534,\n", " 0.014045109041035175,\n", " 0.062315668910741806,\n", " 0.025323620066046715,\n", " 0.0026031851302832365,\n", " -0.08313484489917755,\n", " -0.024011535570025444,\n", " 0.11681527644395828,\n", " 0.08735472708940506,\n", " -0.006519721355289221,\n", " -0.020402247086167336]" ] }, "execution_count": 23, "metadata": {}, "output_type": "execute_result" } ], "source": [ "vector=embeddings.embed_query(\"What is the purpose of this study?\")\n", "vector" ] }, { "cell_type": "code", "execution_count": 67, "id": "680d411f", "metadata": {}, "outputs": [], "source": [ "from dotenv import load_dotenv\n", "load_dotenv()\n", "import os" ] }, { "cell_type": "code", "execution_count": 69, "id": "517909ad", "metadata": {}, "outputs": [ { "ename": "TypeError", "evalue": "str expected, not NoneType", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mTypeError\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[69], line 7\u001b[0m\n\u001b[0;32m 5\u001b[0m os\u001b[38;5;241m.\u001b[39menviron[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mPINECONE_API_KEY\u001b[39m\u001b[38;5;124m\"\u001b[39m] \u001b[38;5;241m=\u001b[39m Pinecone_API_KEY\n\u001b[0;32m 6\u001b[0m os\u001b[38;5;241m.\u001b[39menviron[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mOPENAI_API_KEY\u001b[39m\u001b[38;5;124m\"\u001b[39m] \u001b[38;5;241m=\u001b[39m OpenAI_API_KEY\n\u001b[1;32m----> 7\u001b[0m \u001b[43mos\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43menviron\u001b[49m\u001b[43m[\u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43mHUGGINGFACEHUB_API_KEY\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m]\u001b[49m \u001b[38;5;241m=\u001b[39m HUGGINGFACEHUB_API_KEY\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\os.py:685\u001b[0m, in \u001b[0;36m_Environ.__setitem__\u001b[1;34m(self, key, value)\u001b[0m\n\u001b[0;32m 683\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21m__setitem__\u001b[39m(\u001b[38;5;28mself\u001b[39m, key, value):\n\u001b[0;32m 684\u001b[0m key \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mencodekey(key)\n\u001b[1;32m--> 685\u001b[0m value \u001b[38;5;241m=\u001b[39m \u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mencodevalue\u001b[49m\u001b[43m(\u001b[49m\u001b[43mvalue\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 686\u001b[0m putenv(key, value)\n\u001b[0;32m 687\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_data[key] \u001b[38;5;241m=\u001b[39m value\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\os.py:743\u001b[0m, in \u001b[0;36m_createenviron..check_str\u001b[1;34m(value)\u001b[0m\n\u001b[0;32m 741\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mcheck_str\u001b[39m(value):\n\u001b[0;32m 742\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;129;01mnot\u001b[39;00m \u001b[38;5;28misinstance\u001b[39m(value, \u001b[38;5;28mstr\u001b[39m):\n\u001b[1;32m--> 743\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;167;01mTypeError\u001b[39;00m(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mstr expected, not \u001b[39m\u001b[38;5;132;01m%s\u001b[39;00m\u001b[38;5;124m\"\u001b[39m \u001b[38;5;241m%\u001b[39m \u001b[38;5;28mtype\u001b[39m(value)\u001b[38;5;241m.\u001b[39m\u001b[38;5;18m__name__\u001b[39m)\n\u001b[0;32m 744\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m value\n", "\u001b[1;31mTypeError\u001b[0m: str expected, not NoneType" ] } ], "source": [ "Pinecone_API_KEY = os.getenv(\"Pinecone_API_KEY\")\n", "OpenAI_API_KEY = os.getenv(\"OpenAI_API_KEY\")\n", "HUGGINGFACEHUB_API_KEY = os.getenv(\"HUGGINGFACEHUB_API_KEY\")\n", "\n", "os.environ[\"PINECONE_API_KEY\"] = Pinecone_API_KEY\n", "os.environ[\"OPENAI_API_KEY\"] = OpenAI_API_KEY\n", "os.environ[\"HUGGINGFACEHUB_API_KEY\"] = HUGGINGFACEHUB_API_KEY" ] }, { "cell_type": "code", "execution_count": null, "id": "31281269", "metadata": {}, "outputs": [], "source": [ "Hugg" ] }, { "cell_type": "code", "execution_count": 26, "id": "a8d480c7", "metadata": {}, "outputs": [], "source": [ "from pinecone import Pinecone\n", "pinecone_API_key=Pinecone_API_KEY\n", "\n", "pc = Pinecone(api_key=pinecone_API_key)" ] }, { "cell_type": "code", "execution_count": 11, "id": "36a7989e", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "" ] }, "execution_count": 11, "metadata": {}, "output_type": "execute_result" } ], "source": [ "pc" ] }, { "cell_type": "code", "execution_count": 27, "id": "9e6f0d70", "metadata": {}, "outputs": [], "source": [ "from pinecone import ServerlessSpec\n", "\n", "index_name = \"medical-chatbot\"\n", "\n", "if not pc.has_index(index_name):\n", " pc.create_index(\n", " name=index_name,\n", " dimension=384,\n", " metric=\"cosine\",\n", " spec=ServerlessSpec(\n", " cloud=\"aws\",\n", " region=\"us-east-1\"\n", " ))\n", "index = pc.Index(index_name) \n", " \n" ] }, { "cell_type": "code", "execution_count": null, "id": "954f17fe", "metadata": {}, "outputs": [ { "ename": "NameError", "evalue": "name 'text_chunks' is not defined", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mNameError\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[13], line 4\u001b[0m\n\u001b[0;32m 1\u001b[0m \u001b[38;5;28;01mfrom\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21;01mlangchain_pinecone\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;28;01mimport\u001b[39;00m PineconeVectorStore\n\u001b[0;32m 3\u001b[0m docssearch\u001b[38;5;241m=\u001b[39mPineconeVectorStore\u001b[38;5;241m.\u001b[39mfrom_documents(\n\u001b[1;32m----> 4\u001b[0m documents\u001b[38;5;241m=\u001b[39m\u001b[43mtext_chunks\u001b[49m,\n\u001b[0;32m 5\u001b[0m embedding\u001b[38;5;241m=\u001b[39membeddings,\n\u001b[0;32m 6\u001b[0m index_name\u001b[38;5;241m=\u001b[39mindex_name\n\u001b[0;32m 7\u001b[0m \n\u001b[0;32m 8\u001b[0m )\n", "\u001b[1;31mNameError\u001b[0m: name 'text_chunks' is not defined" ] } ], "source": [ "#Storing vectors into pinecone\n", "\n", "\n", "from langchain_pinecone import PineconeVectorStore\n", "\n", "docssearch=PineconeVectorStore.from_documents(\n", " documents=text_chunks,\n", " embedding=embeddings,\n", " index_name=index_name\n", " \n", ")" ] }, { "cell_type": "code", "execution_count": null, "id": "3e0073a4", "metadata": {}, "outputs": [], "source": [ "#loading existing index(data in the db) from pinecone\n", "\n", "from langchain_pinecone import PineconeVectorStore\n", "\n", "docsearch=PineconeVectorStore.from_existing_index(\n", " index_name=index_name,\n", " embedding=embeddings\n", ")" ] }, { "cell_type": "markdown", "id": "802930a4", "metadata": {}, "source": [ "# Add more data to existing index in pinecone\n" ] }, { "cell_type": "code", "execution_count": 29, "id": "1df130eb", "metadata": {}, "outputs": [], "source": [ "dswith = Document(\n", " page_content=\"Adding more data to the existing index in Pinecone.\",\n", " metadata={\n", " \"source\": \"Myself\"\n", " }\n", ")" ] }, { "cell_type": "code", "execution_count": 30, "id": "02a03382", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "['e565ff0a-69c4-4ad7-8f6f-c2f92f1456d5']" ] }, "execution_count": 30, "metadata": {}, "output_type": "execute_result" } ], "source": [ "docsearch.add_documents(documents=[dswith])" ] }, { "cell_type": "markdown", "id": "2a447c9b", "metadata": {}, "source": [ "# Retrieving" ] }, { "cell_type": "code", "execution_count": 31, "id": "922a519b", "metadata": {}, "outputs": [], "source": [ "retriever= docsearch.as_retriever(\n", " search_type=\"similarity\",\n", " search_kwargs={\n", " \"k\": 3\n", " }\n", ")" ] }, { "cell_type": "code", "execution_count": 33, "id": "21ec391f", "metadata": {}, "outputs": [ { "data": { "text/plain": [ "[Document(id='77aa7726-3e3f-4ea8-a96d-ce69f9edb92a', metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Researchers, Inc. Reproduced by permission.)\\n26 GALE ENCYCLOPEDIA OF MEDICINE\\nAcne'),\n", " Document(id='feee8aef-f54b-4ea6-b205-8919199ad568', metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Sebaceous 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.\\nAcne vulgaris affecting a woman’s face. Acne is the general\\nname given to a skin disorder in which the sebaceous glands\\nbecome inflamed. (Photograph by Biophoto Associates, Photo'),\n", " Document(id='c7bcf54d-a4e9-4e93-8377-010a40098330', metadata={'source': 'data\\\\encyclopedia-of-medicine-vol-1-5-3rd-edition.pdf'}, page_content='Pathological Stage and Recurrence in Radical\\nProstatectomy Cases.’’Journal of Urology (March\\n1998): 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\\nthe pores of the skin become clogged with oil, dead\\nskin cells, and bacteria.\\nDescription\\nAcne vulgaris, the medical term for common acne,')]" ] }, "execution_count": 33, "metadata": {}, "output_type": "execute_result" } ], "source": [ "retrieved_docs= retriever.invoke(\"What is acne?\")\n", "retrieved_docs" ] }, { "cell_type": "code", "execution_count": 41, "id": "c5f04042", "metadata": {}, "outputs": [], "source": [ "from langchain_openai import ChatOpenAI\n", "\n", "chat_model = ChatOpenAI( model=\"gpt-3.5-turbo\")" ] }, { "cell_type": "code", "execution_count": 42, "id": "ac65e000", "metadata": {}, "outputs": [], "source": [ "from langchain.chains import create_retrieval_chain\n", "from langchain.chains.combine_documents import create_stuff_documents_chain\n", "from langchain_core.prompts import ChatPromptTemplate" ] }, { "cell_type": "code", "execution_count": 43, "id": "cc44506f", "metadata": {}, "outputs": [], "source": [ "system_prompt=(\n", " \"Your are a medical assistant to help the user with their medical queries, diagnosis on the basis of symptoms, and prescription of medicines. \"\n", " \"Use the following pieces of retrieved context to answer the questions. if you don't know the answer, just say that you don't know, don't try to make up an answer. Use three sentences maximun and keep the naswer concise\"\n", " \"\\n \\n\"\n", " \"{context}\"\n", ")\n", "\n", "prompt= ChatPromptTemplate.from_messages(\n", " [\n", " (\"system\", system_prompt),\n", " (\"human\", \"{input}\")\n", " ]\n", ")" ] }, { "cell_type": "code", "execution_count": 44, "id": "a8e73612", "metadata": {}, "outputs": [], "source": [ "question_answer_chain = create_stuff_documents_chain(chat_model, prompt)\n", "rag_chain = create_retrieval_chain(retriever, question_answer_chain)" ] }, { "cell_type": "code", "execution_count": 45, "id": "78d5aa36", "metadata": {}, "outputs": [ { "ename": "RateLimitError", "evalue": "Error code: 429 - {'error': {'message': 'You exceeded your current quota, please check your plan and billing details. For more information on this error, read the docs: https://platform.openai.com/docs/guides/error-codes/api-errors.', 'type': 'insufficient_quota', 'param': None, 'code': 'insufficient_quota'}}", "output_type": "error", "traceback": [ "\u001b[1;31m---------------------------------------------------------------------------\u001b[0m", "\u001b[1;31mRateLimitError\u001b[0m Traceback (most recent call last)", "Cell \u001b[1;32mIn[45], line 1\u001b[0m\n\u001b[1;32m----> 1\u001b[0m response\u001b[38;5;241m=\u001b[39m \u001b[43mrag_chain\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43minvoke\u001b[49m\u001b[43m(\u001b[49m\u001b[43m{\u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43minput\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m:\u001b[49m\u001b[43m \u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43mWhat is acne?\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m}\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 2\u001b[0m \u001b[38;5;28mprint\u001b[39m(response[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124manswer\u001b[39m\u001b[38;5;124m\"\u001b[39m])\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:5441\u001b[0m, in \u001b[0;36mRunnableBindingBase.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 5434\u001b[0m \u001b[38;5;129m@override\u001b[39m\n\u001b[0;32m 5435\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21minvoke\u001b[39m(\n\u001b[0;32m 5436\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 5439\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs: Optional[Any],\n\u001b[0;32m 5440\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m Output:\n\u001b[1;32m-> 5441\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mbound\u001b[38;5;241m.\u001b[39minvoke(\n\u001b[0;32m 5442\u001b[0m \u001b[38;5;28minput\u001b[39m,\n\u001b[0;32m 5443\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_merge_configs(config),\n\u001b[0;32m 5444\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m{\u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mkwargs, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs},\n\u001b[0;32m 5445\u001b[0m )\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:3049\u001b[0m, in \u001b[0;36mRunnableSequence.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 3047\u001b[0m input_ \u001b[38;5;241m=\u001b[39m context\u001b[38;5;241m.\u001b[39mrun(step\u001b[38;5;241m.\u001b[39minvoke, input_, config, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n\u001b[0;32m 3048\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[1;32m-> 3049\u001b[0m input_ \u001b[38;5;241m=\u001b[39m \u001b[43mcontext\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mrun\u001b[49m\u001b[43m(\u001b[49m\u001b[43mstep\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43minvoke\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43minput_\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mconfig\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 3050\u001b[0m \u001b[38;5;66;03m# finish the root run\u001b[39;00m\n\u001b[0;32m 3051\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\passthrough.py:513\u001b[0m, in \u001b[0;36mRunnableAssign.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 506\u001b[0m \u001b[38;5;129m@override\u001b[39m\n\u001b[0;32m 507\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21minvoke\u001b[39m(\n\u001b[0;32m 508\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 511\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs: Any,\n\u001b[0;32m 512\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m \u001b[38;5;28mdict\u001b[39m[\u001b[38;5;28mstr\u001b[39m, Any]:\n\u001b[1;32m--> 513\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_call_with_config(\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_invoke, \u001b[38;5;28minput\u001b[39m, config, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:1938\u001b[0m, in \u001b[0;36mRunnable._call_with_config\u001b[1;34m(self, func, input_, config, run_type, serialized, **kwargs)\u001b[0m\n\u001b[0;32m 1934\u001b[0m child_config \u001b[38;5;241m=\u001b[39m patch_config(config, callbacks\u001b[38;5;241m=\u001b[39mrun_manager\u001b[38;5;241m.\u001b[39mget_child())\n\u001b[0;32m 1935\u001b[0m \u001b[38;5;28;01mwith\u001b[39;00m set_config_context(child_config) \u001b[38;5;28;01mas\u001b[39;00m context:\n\u001b[0;32m 1936\u001b[0m output \u001b[38;5;241m=\u001b[39m cast(\n\u001b[0;32m 1937\u001b[0m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mOutput\u001b[39m\u001b[38;5;124m\"\u001b[39m,\n\u001b[1;32m-> 1938\u001b[0m context\u001b[38;5;241m.\u001b[39mrun(\n\u001b[0;32m 1939\u001b[0m call_func_with_variable_args, \u001b[38;5;66;03m# type: ignore[arg-type]\u001b[39;00m\n\u001b[0;32m 1940\u001b[0m func,\n\u001b[0;32m 1941\u001b[0m input_,\n\u001b[0;32m 1942\u001b[0m config,\n\u001b[0;32m 1943\u001b[0m run_manager,\n\u001b[0;32m 1944\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs,\n\u001b[0;32m 1945\u001b[0m ),\n\u001b[0;32m 1946\u001b[0m )\n\u001b[0;32m 1947\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n\u001b[0;32m 1948\u001b[0m run_manager\u001b[38;5;241m.\u001b[39mon_chain_error(e)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\config.py:429\u001b[0m, in \u001b[0;36mcall_func_with_variable_args\u001b[1;34m(func, input, config, run_manager, **kwargs)\u001b[0m\n\u001b[0;32m 427\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m run_manager \u001b[38;5;129;01mis\u001b[39;00m \u001b[38;5;129;01mnot\u001b[39;00m \u001b[38;5;28;01mNone\u001b[39;00m \u001b[38;5;129;01mand\u001b[39;00m accepts_run_manager(func):\n\u001b[0;32m 428\u001b[0m kwargs[\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mrun_manager\u001b[39m\u001b[38;5;124m\"\u001b[39m] \u001b[38;5;241m=\u001b[39m run_manager\n\u001b[1;32m--> 429\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m func(\u001b[38;5;28minput\u001b[39m, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\passthrough.py:499\u001b[0m, in \u001b[0;36mRunnableAssign._invoke\u001b[1;34m(self, value, run_manager, config, **kwargs)\u001b[0m\n\u001b[0;32m 494\u001b[0m msg \u001b[38;5;241m=\u001b[39m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mThe input to RunnablePassthrough.assign() must be a dict.\u001b[39m\u001b[38;5;124m\"\u001b[39m\n\u001b[0;32m 495\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;167;01mValueError\u001b[39;00m(msg) \u001b[38;5;66;03m# noqa: TRY004\u001b[39;00m\n\u001b[0;32m 497\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m {\n\u001b[0;32m 498\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mvalue,\n\u001b[1;32m--> 499\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mmapper\u001b[38;5;241m.\u001b[39minvoke(\n\u001b[0;32m 500\u001b[0m value,\n\u001b[0;32m 501\u001b[0m patch_config(config, callbacks\u001b[38;5;241m=\u001b[39mrun_manager\u001b[38;5;241m.\u001b[39mget_child()),\n\u001b[0;32m 502\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs,\n\u001b[0;32m 503\u001b[0m ),\n\u001b[0;32m 504\u001b[0m }\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:3777\u001b[0m, in \u001b[0;36mRunnableParallel.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 3772\u001b[0m \u001b[38;5;28;01mwith\u001b[39;00m get_executor_for_config(config) \u001b[38;5;28;01mas\u001b[39;00m executor:\n\u001b[0;32m 3773\u001b[0m futures \u001b[38;5;241m=\u001b[39m [\n\u001b[0;32m 3774\u001b[0m executor\u001b[38;5;241m.\u001b[39msubmit(_invoke_step, step, \u001b[38;5;28minput\u001b[39m, config, key)\n\u001b[0;32m 3775\u001b[0m \u001b[38;5;28;01mfor\u001b[39;00m key, step \u001b[38;5;129;01min\u001b[39;00m steps\u001b[38;5;241m.\u001b[39mitems()\n\u001b[0;32m 3776\u001b[0m ]\n\u001b[1;32m-> 3777\u001b[0m output \u001b[38;5;241m=\u001b[39m {key: future\u001b[38;5;241m.\u001b[39mresult() \u001b[38;5;28;01mfor\u001b[39;00m key, future \u001b[38;5;129;01min\u001b[39;00m \u001b[38;5;28mzip\u001b[39m(steps, futures)}\n\u001b[0;32m 3778\u001b[0m \u001b[38;5;66;03m# finish the root run\u001b[39;00m\n\u001b[0;32m 3779\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:3777\u001b[0m, in \u001b[0;36m\u001b[1;34m(.0)\u001b[0m\n\u001b[0;32m 3772\u001b[0m \u001b[38;5;28;01mwith\u001b[39;00m get_executor_for_config(config) \u001b[38;5;28;01mas\u001b[39;00m executor:\n\u001b[0;32m 3773\u001b[0m futures \u001b[38;5;241m=\u001b[39m [\n\u001b[0;32m 3774\u001b[0m executor\u001b[38;5;241m.\u001b[39msubmit(_invoke_step, step, \u001b[38;5;28minput\u001b[39m, config, key)\n\u001b[0;32m 3775\u001b[0m \u001b[38;5;28;01mfor\u001b[39;00m key, step \u001b[38;5;129;01min\u001b[39;00m steps\u001b[38;5;241m.\u001b[39mitems()\n\u001b[0;32m 3776\u001b[0m ]\n\u001b[1;32m-> 3777\u001b[0m output \u001b[38;5;241m=\u001b[39m {key: \u001b[43mfuture\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mresult\u001b[49m\u001b[43m(\u001b[49m\u001b[43m)\u001b[49m \u001b[38;5;28;01mfor\u001b[39;00m key, future \u001b[38;5;129;01min\u001b[39;00m \u001b[38;5;28mzip\u001b[39m(steps, futures)}\n\u001b[0;32m 3778\u001b[0m \u001b[38;5;66;03m# finish the root run\u001b[39;00m\n\u001b[0;32m 3779\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\concurrent\\futures\\_base.py:458\u001b[0m, in \u001b[0;36mFuture.result\u001b[1;34m(self, timeout)\u001b[0m\n\u001b[0;32m 456\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m CancelledError()\n\u001b[0;32m 457\u001b[0m \u001b[38;5;28;01melif\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_state \u001b[38;5;241m==\u001b[39m FINISHED:\n\u001b[1;32m--> 458\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43m__get_result\u001b[49m\u001b[43m(\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 459\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[0;32m 460\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;167;01mTimeoutError\u001b[39;00m()\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\concurrent\\futures\\_base.py:403\u001b[0m, in \u001b[0;36mFuture.__get_result\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 401\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_exception:\n\u001b[0;32m 402\u001b[0m \u001b[38;5;28;01mtry\u001b[39;00m:\n\u001b[1;32m--> 403\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_exception\n\u001b[0;32m 404\u001b[0m \u001b[38;5;28;01mfinally\u001b[39;00m:\n\u001b[0;32m 405\u001b[0m \u001b[38;5;66;03m# Break a reference cycle with the exception in self._exception\u001b[39;00m\n\u001b[0;32m 406\u001b[0m \u001b[38;5;28mself\u001b[39m \u001b[38;5;241m=\u001b[39m \u001b[38;5;28;01mNone\u001b[39;00m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\concurrent\\futures\\thread.py:58\u001b[0m, in \u001b[0;36m_WorkItem.run\u001b[1;34m(self)\u001b[0m\n\u001b[0;32m 55\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m\n\u001b[0;32m 57\u001b[0m \u001b[38;5;28;01mtry\u001b[39;00m:\n\u001b[1;32m---> 58\u001b[0m result \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mfn(\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39margs, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mkwargs)\n\u001b[0;32m 59\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m exc:\n\u001b[0;32m 60\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mfuture\u001b[38;5;241m.\u001b[39mset_exception(exc)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:3761\u001b[0m, in \u001b[0;36mRunnableParallel.invoke.._invoke_step\u001b[1;34m(step, input_, config, key)\u001b[0m\n\u001b[0;32m 3755\u001b[0m child_config \u001b[38;5;241m=\u001b[39m patch_config(\n\u001b[0;32m 3756\u001b[0m config,\n\u001b[0;32m 3757\u001b[0m \u001b[38;5;66;03m# mark each step as a child run\u001b[39;00m\n\u001b[0;32m 3758\u001b[0m callbacks\u001b[38;5;241m=\u001b[39mrun_manager\u001b[38;5;241m.\u001b[39mget_child(\u001b[38;5;124mf\u001b[39m\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmap:key:\u001b[39m\u001b[38;5;132;01m{\u001b[39;00mkey\u001b[38;5;132;01m}\u001b[39;00m\u001b[38;5;124m\"\u001b[39m),\n\u001b[0;32m 3759\u001b[0m )\n\u001b[0;32m 3760\u001b[0m \u001b[38;5;28;01mwith\u001b[39;00m set_config_context(child_config) \u001b[38;5;28;01mas\u001b[39;00m context:\n\u001b[1;32m-> 3761\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[43mcontext\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mrun\u001b[49m\u001b[43m(\u001b[49m\n\u001b[0;32m 3762\u001b[0m \u001b[43m \u001b[49m\u001b[43mstep\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43minvoke\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 3763\u001b[0m \u001b[43m \u001b[49m\u001b[43minput_\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 3764\u001b[0m \u001b[43m \u001b[49m\u001b[43mchild_config\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 3765\u001b[0m \u001b[43m \u001b[49m\u001b[43m)\u001b[49m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:5441\u001b[0m, in \u001b[0;36mRunnableBindingBase.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 5434\u001b[0m \u001b[38;5;129m@override\u001b[39m\n\u001b[0;32m 5435\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21minvoke\u001b[39m(\n\u001b[0;32m 5436\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 5439\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs: Optional[Any],\n\u001b[0;32m 5440\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m Output:\n\u001b[1;32m-> 5441\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mbound\u001b[38;5;241m.\u001b[39minvoke(\n\u001b[0;32m 5442\u001b[0m \u001b[38;5;28minput\u001b[39m,\n\u001b[0;32m 5443\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_merge_configs(config),\n\u001b[0;32m 5444\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m{\u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39m\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mkwargs, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs},\n\u001b[0;32m 5445\u001b[0m )\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\runnables\\base.py:3049\u001b[0m, in \u001b[0;36mRunnableSequence.invoke\u001b[1;34m(self, input, config, **kwargs)\u001b[0m\n\u001b[0;32m 3047\u001b[0m input_ \u001b[38;5;241m=\u001b[39m context\u001b[38;5;241m.\u001b[39mrun(step\u001b[38;5;241m.\u001b[39minvoke, input_, config, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n\u001b[0;32m 3048\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[1;32m-> 3049\u001b[0m input_ \u001b[38;5;241m=\u001b[39m \u001b[43mcontext\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mrun\u001b[49m\u001b[43m(\u001b[49m\u001b[43mstep\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43minvoke\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43minput_\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mconfig\u001b[49m\u001b[43m)\u001b[49m\n\u001b[0;32m 3050\u001b[0m \u001b[38;5;66;03m# finish the root run\u001b[39;00m\n\u001b[0;32m 3051\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\language_models\\chat_models.py:383\u001b[0m, in \u001b[0;36mBaseChatModel.invoke\u001b[1;34m(self, input, config, stop, **kwargs)\u001b[0m\n\u001b[0;32m 371\u001b[0m \u001b[38;5;129m@override\u001b[39m\n\u001b[0;32m 372\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21minvoke\u001b[39m(\n\u001b[0;32m 373\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 378\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs: Any,\n\u001b[0;32m 379\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m BaseMessage:\n\u001b[0;32m 380\u001b[0m config \u001b[38;5;241m=\u001b[39m ensure_config(config)\n\u001b[0;32m 381\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m cast(\n\u001b[0;32m 382\u001b[0m \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mChatGeneration\u001b[39m\u001b[38;5;124m\"\u001b[39m,\n\u001b[1;32m--> 383\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mgenerate_prompt(\n\u001b[0;32m 384\u001b[0m [\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_convert_input(\u001b[38;5;28minput\u001b[39m)],\n\u001b[0;32m 385\u001b[0m stop\u001b[38;5;241m=\u001b[39mstop,\n\u001b[0;32m 386\u001b[0m callbacks\u001b[38;5;241m=\u001b[39mconfig\u001b[38;5;241m.\u001b[39mget(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mcallbacks\u001b[39m\u001b[38;5;124m\"\u001b[39m),\n\u001b[0;32m 387\u001b[0m tags\u001b[38;5;241m=\u001b[39mconfig\u001b[38;5;241m.\u001b[39mget(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mtags\u001b[39m\u001b[38;5;124m\"\u001b[39m),\n\u001b[0;32m 388\u001b[0m metadata\u001b[38;5;241m=\u001b[39mconfig\u001b[38;5;241m.\u001b[39mget(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmetadata\u001b[39m\u001b[38;5;124m\"\u001b[39m),\n\u001b[0;32m 389\u001b[0m run_name\u001b[38;5;241m=\u001b[39mconfig\u001b[38;5;241m.\u001b[39mget(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mrun_name\u001b[39m\u001b[38;5;124m\"\u001b[39m),\n\u001b[0;32m 390\u001b[0m run_id\u001b[38;5;241m=\u001b[39mconfig\u001b[38;5;241m.\u001b[39mpop(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mrun_id\u001b[39m\u001b[38;5;124m\"\u001b[39m, \u001b[38;5;28;01mNone\u001b[39;00m),\n\u001b[0;32m 391\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs,\n\u001b[0;32m 392\u001b[0m )\u001b[38;5;241m.\u001b[39mgenerations[\u001b[38;5;241m0\u001b[39m][\u001b[38;5;241m0\u001b[39m],\n\u001b[0;32m 393\u001b[0m )\u001b[38;5;241m.\u001b[39mmessage\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\language_models\\chat_models.py:1006\u001b[0m, in \u001b[0;36mBaseChatModel.generate_prompt\u001b[1;34m(self, prompts, stop, callbacks, **kwargs)\u001b[0m\n\u001b[0;32m 997\u001b[0m \u001b[38;5;129m@override\u001b[39m\n\u001b[0;32m 998\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mgenerate_prompt\u001b[39m(\n\u001b[0;32m 999\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 1003\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs: Any,\n\u001b[0;32m 1004\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m LLMResult:\n\u001b[0;32m 1005\u001b[0m prompt_messages \u001b[38;5;241m=\u001b[39m [p\u001b[38;5;241m.\u001b[39mto_messages() \u001b[38;5;28;01mfor\u001b[39;00m p \u001b[38;5;129;01min\u001b[39;00m prompts]\n\u001b[1;32m-> 1006\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mgenerate(prompt_messages, stop\u001b[38;5;241m=\u001b[39mstop, callbacks\u001b[38;5;241m=\u001b[39mcallbacks, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\language_models\\chat_models.py:825\u001b[0m, in \u001b[0;36mBaseChatModel.generate\u001b[1;34m(self, messages, stop, callbacks, tags, metadata, run_name, run_id, **kwargs)\u001b[0m\n\u001b[0;32m 822\u001b[0m \u001b[38;5;28;01mfor\u001b[39;00m i, m \u001b[38;5;129;01min\u001b[39;00m \u001b[38;5;28menumerate\u001b[39m(input_messages):\n\u001b[0;32m 823\u001b[0m \u001b[38;5;28;01mtry\u001b[39;00m:\n\u001b[0;32m 824\u001b[0m results\u001b[38;5;241m.\u001b[39mappend(\n\u001b[1;32m--> 825\u001b[0m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_generate_with_cache(\n\u001b[0;32m 826\u001b[0m m,\n\u001b[0;32m 827\u001b[0m stop\u001b[38;5;241m=\u001b[39mstop,\n\u001b[0;32m 828\u001b[0m run_manager\u001b[38;5;241m=\u001b[39mrun_managers[i] \u001b[38;5;28;01mif\u001b[39;00m run_managers \u001b[38;5;28;01melse\u001b[39;00m \u001b[38;5;28;01mNone\u001b[39;00m,\n\u001b[0;32m 829\u001b[0m \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs,\n\u001b[0;32m 830\u001b[0m )\n\u001b[0;32m 831\u001b[0m )\n\u001b[0;32m 832\u001b[0m \u001b[38;5;28;01mexcept\u001b[39;00m \u001b[38;5;167;01mBaseException\u001b[39;00m \u001b[38;5;28;01mas\u001b[39;00m e:\n\u001b[0;32m 833\u001b[0m \u001b[38;5;28;01mif\u001b[39;00m run_managers:\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_core\\language_models\\chat_models.py:1072\u001b[0m, in \u001b[0;36mBaseChatModel._generate_with_cache\u001b[1;34m(self, messages, stop, run_manager, **kwargs)\u001b[0m\n\u001b[0;32m 1070\u001b[0m result \u001b[38;5;241m=\u001b[39m generate_from_stream(\u001b[38;5;28miter\u001b[39m(chunks))\n\u001b[0;32m 1071\u001b[0m \u001b[38;5;28;01melif\u001b[39;00m inspect\u001b[38;5;241m.\u001b[39msignature(\u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_generate)\u001b[38;5;241m.\u001b[39mparameters\u001b[38;5;241m.\u001b[39mget(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mrun_manager\u001b[39m\u001b[38;5;124m\"\u001b[39m):\n\u001b[1;32m-> 1072\u001b[0m result \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_generate(\n\u001b[0;32m 1073\u001b[0m messages, stop\u001b[38;5;241m=\u001b[39mstop, run_manager\u001b[38;5;241m=\u001b[39mrun_manager, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs\n\u001b[0;32m 1074\u001b[0m )\n\u001b[0;32m 1075\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[0;32m 1076\u001b[0m result \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_generate(messages, stop\u001b[38;5;241m=\u001b[39mstop, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\langchain_openai\\chat_models\\base.py:1071\u001b[0m, in \u001b[0;36mBaseChatOpenAI._generate\u001b[1;34m(self, messages, stop, run_manager, **kwargs)\u001b[0m\n\u001b[0;32m 1069\u001b[0m generation_info \u001b[38;5;241m=\u001b[39m {\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mheaders\u001b[39m\u001b[38;5;124m\"\u001b[39m: \u001b[38;5;28mdict\u001b[39m(raw_response\u001b[38;5;241m.\u001b[39mheaders)}\n\u001b[0;32m 1070\u001b[0m \u001b[38;5;28;01melse\u001b[39;00m:\n\u001b[1;32m-> 1071\u001b[0m response \u001b[38;5;241m=\u001b[39m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39mclient\u001b[38;5;241m.\u001b[39mcreate(\u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mpayload)\n\u001b[0;32m 1072\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_create_chat_result(response, generation_info)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\openai\\_utils\\_utils.py:287\u001b[0m, in \u001b[0;36mrequired_args..inner..wrapper\u001b[1;34m(*args, **kwargs)\u001b[0m\n\u001b[0;32m 285\u001b[0m msg \u001b[38;5;241m=\u001b[39m \u001b[38;5;124mf\u001b[39m\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mMissing required argument: \u001b[39m\u001b[38;5;132;01m{\u001b[39;00mquote(missing[\u001b[38;5;241m0\u001b[39m])\u001b[38;5;132;01m}\u001b[39;00m\u001b[38;5;124m\"\u001b[39m\n\u001b[0;32m 286\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;167;01mTypeError\u001b[39;00m(msg)\n\u001b[1;32m--> 287\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m func(\u001b[38;5;241m*\u001b[39margs, \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39mkwargs)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\openai\\resources\\chat\\completions\\completions.py:1150\u001b[0m, in \u001b[0;36mCompletions.create\u001b[1;34m(self, messages, model, audio, frequency_penalty, function_call, functions, logit_bias, logprobs, max_completion_tokens, max_tokens, metadata, modalities, n, parallel_tool_calls, prediction, presence_penalty, prompt_cache_key, reasoning_effort, response_format, safety_identifier, seed, service_tier, stop, store, stream, stream_options, temperature, tool_choice, tools, top_logprobs, top_p, user, verbosity, web_search_options, extra_headers, extra_query, extra_body, timeout)\u001b[0m\n\u001b[0;32m 1104\u001b[0m \u001b[38;5;129m@required_args\u001b[39m([\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmessages\u001b[39m\u001b[38;5;124m\"\u001b[39m, \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmodel\u001b[39m\u001b[38;5;124m\"\u001b[39m], [\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmessages\u001b[39m\u001b[38;5;124m\"\u001b[39m, \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mmodel\u001b[39m\u001b[38;5;124m\"\u001b[39m, 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1151\u001b[0m \u001b[43m \u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43m/chat/completions\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1152\u001b[0m \u001b[43m \u001b[49m\u001b[43mbody\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mmaybe_transform\u001b[49m\u001b[43m(\u001b[49m\n\u001b[0;32m 1153\u001b[0m \u001b[43m \u001b[49m\u001b[43m{\u001b[49m\n\u001b[0;32m 1154\u001b[0m \u001b[43m \u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43mmessages\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m:\u001b[49m\u001b[43m \u001b[49m\u001b[43mmessages\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1155\u001b[0m \u001b[43m \u001b[49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[38;5;124;43mmodel\u001b[39;49m\u001b[38;5;124;43m\"\u001b[39;49m\u001b[43m:\u001b[49m\u001b[43m \u001b[49m\u001b[43mmodel\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1156\u001b[0m \u001b[43m 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\u001b[49m\u001b[43mcompletion_create_params\u001b[49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mCompletionCreateParamsNonStreaming\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1192\u001b[0m \u001b[43m \u001b[49m\u001b[43m)\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1193\u001b[0m \u001b[43m \u001b[49m\u001b[43moptions\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mmake_request_options\u001b[49m\u001b[43m(\u001b[49m\n\u001b[0;32m 1194\u001b[0m \u001b[43m \u001b[49m\u001b[43mextra_headers\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mextra_headers\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mextra_query\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mextra_query\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mextra_body\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mextra_body\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mtimeout\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mtimeout\u001b[49m\n\u001b[0;32m 1195\u001b[0m \u001b[43m \u001b[49m\u001b[43m)\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1196\u001b[0m \u001b[43m \u001b[49m\u001b[43mcast_to\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mChatCompletion\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1197\u001b[0m \u001b[43m \u001b[49m\u001b[43mstream\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mstream\u001b[49m\u001b[43m \u001b[49m\u001b[38;5;129;43;01mor\u001b[39;49;00m\u001b[43m \u001b[49m\u001b[38;5;28;43;01mFalse\u001b[39;49;00m\u001b[43m,\u001b[49m\n\u001b[0;32m 1198\u001b[0m \u001b[43m \u001b[49m\u001b[43mstream_cls\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mStream\u001b[49m\u001b[43m[\u001b[49m\u001b[43mChatCompletionChunk\u001b[49m\u001b[43m]\u001b[49m\u001b[43m,\u001b[49m\n\u001b[0;32m 1199\u001b[0m \u001b[43m \u001b[49m\u001b[43m)\u001b[49m\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\openai\\_base_client.py:1259\u001b[0m, in \u001b[0;36mSyncAPIClient.post\u001b[1;34m(self, path, cast_to, body, options, files, stream, stream_cls)\u001b[0m\n\u001b[0;32m 1245\u001b[0m \u001b[38;5;28;01mdef\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;21mpost\u001b[39m(\n\u001b[0;32m 1246\u001b[0m \u001b[38;5;28mself\u001b[39m,\n\u001b[0;32m 1247\u001b[0m path: \u001b[38;5;28mstr\u001b[39m,\n\u001b[1;32m (...)\u001b[0m\n\u001b[0;32m 1254\u001b[0m stream_cls: \u001b[38;5;28mtype\u001b[39m[_StreamT] \u001b[38;5;241m|\u001b[39m \u001b[38;5;28;01mNone\u001b[39;00m \u001b[38;5;241m=\u001b[39m \u001b[38;5;28;01mNone\u001b[39;00m,\n\u001b[0;32m 1255\u001b[0m ) \u001b[38;5;241m-\u001b[39m\u001b[38;5;241m>\u001b[39m ResponseT \u001b[38;5;241m|\u001b[39m _StreamT:\n\u001b[0;32m 1256\u001b[0m opts \u001b[38;5;241m=\u001b[39m FinalRequestOptions\u001b[38;5;241m.\u001b[39mconstruct(\n\u001b[0;32m 1257\u001b[0m method\u001b[38;5;241m=\u001b[39m\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mpost\u001b[39m\u001b[38;5;124m\"\u001b[39m, url\u001b[38;5;241m=\u001b[39mpath, json_data\u001b[38;5;241m=\u001b[39mbody, files\u001b[38;5;241m=\u001b[39mto_httpx_files(files), \u001b[38;5;241m*\u001b[39m\u001b[38;5;241m*\u001b[39moptions\n\u001b[0;32m 1258\u001b[0m )\n\u001b[1;32m-> 1259\u001b[0m \u001b[38;5;28;01mreturn\u001b[39;00m cast(ResponseT, \u001b[38;5;28;43mself\u001b[39;49m\u001b[38;5;241;43m.\u001b[39;49m\u001b[43mrequest\u001b[49m\u001b[43m(\u001b[49m\u001b[43mcast_to\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mopts\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mstream\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mstream\u001b[49m\u001b[43m,\u001b[49m\u001b[43m \u001b[49m\u001b[43mstream_cls\u001b[49m\u001b[38;5;241;43m=\u001b[39;49m\u001b[43mstream_cls\u001b[49m\u001b[43m)\u001b[49m)\n", "File \u001b[1;32mc:\\Users\\manai\\anaconda3\\envs\\Medical-Chatbot\\lib\\site-packages\\openai\\_base_client.py:1047\u001b[0m, in \u001b[0;36mSyncAPIClient.request\u001b[1;34m(self, cast_to, options, stream, stream_cls)\u001b[0m\n\u001b[0;32m 1044\u001b[0m err\u001b[38;5;241m.\u001b[39mresponse\u001b[38;5;241m.\u001b[39mread()\n\u001b[0;32m 1046\u001b[0m log\u001b[38;5;241m.\u001b[39mdebug(\u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mRe-raising status error\u001b[39m\u001b[38;5;124m\"\u001b[39m)\n\u001b[1;32m-> 1047\u001b[0m \u001b[38;5;28;01mraise\u001b[39;00m \u001b[38;5;28mself\u001b[39m\u001b[38;5;241m.\u001b[39m_make_status_error_from_response(err\u001b[38;5;241m.\u001b[39mresponse) \u001b[38;5;28;01mfrom\u001b[39;00m\u001b[38;5;250m \u001b[39m\u001b[38;5;28;01mNone\u001b[39;00m\n\u001b[0;32m 1049\u001b[0m \u001b[38;5;28;01mbreak\u001b[39;00m\n\u001b[0;32m 1051\u001b[0m \u001b[38;5;28;01massert\u001b[39;00m response \u001b[38;5;129;01mis\u001b[39;00m \u001b[38;5;129;01mnot\u001b[39;00m \u001b[38;5;28;01mNone\u001b[39;00m, \u001b[38;5;124m\"\u001b[39m\u001b[38;5;124mcould not resolve response (should never happen)\u001b[39m\u001b[38;5;124m\"\u001b[39m\n", "\u001b[1;31mRateLimitError\u001b[0m: Error code: 429 - {'error': {'message': 'You exceeded your current quota, please check your plan and billing details. For more information on this error, read the docs: https://platform.openai.com/docs/guides/error-codes/api-errors.', 'type': 'insufficient_quota', 'param': None, 'code': 'insufficient_quota'}}" ] } ], "source": [ "response= rag_chain.invoke({\"input\": \"What is acne?\"})\n", "print(response[\"answer\"])" ] }, { "cell_type": "code", "execution_count": null, "id": "43405e16", "metadata": {}, "outputs": [], "source": [] } ], "metadata": { "kernelspec": { "display_name": "Medical-Chatbot", "language": "python", "name": "python3" }, "language_info": { "codemirror_mode": { "name": "ipython", "version": 3 }, "file_extension": ".py", "mimetype": "text/x-python", "name": "python", "nbconvert_exporter": "python", "pygments_lexer": "ipython3", "version": "3.10.18" } }, "nbformat": 4, "nbformat_minor": 5 }