A severe or life-threatening reaction is often termed ANAPHYLAXIS. Many immune mechanisms also contribute to allergic disorders; however, adverse reactions to drugs, diagnostic materials and other substances often do not involve recognised immunological mechanisms and the term ‘hypersensitivity’ is preferable. (See also IMMUNITY.)
Adverse reactions may manifest themselves as URTICARIA, wheezing or di?culty in breathing owing to spasm of the BRONCHIOLES, swollen joints, nausea, vomiting and headaches. Severe allergic reactions may cause a person to go into SHOCK. Although symptoms of an allergic reaction can usually be controlled, treatment of the underlying conditon is more problematic: hence, the best current approach is for susceptible individuals to ?nd out what it is they are allergic to and avoid those agents. For some people, such as those sensitive to insect venom, IMMUNOTHERAPY or desensitisation is often e?ective. If avoidance measures are unsuccessful and desensitisation ine?ective, the in?ammatory reactions can be controlled with CORTICOSTEROIDS, while the troublesome symptoms can be treated with ANTIHISTAMINE DRUGS and SYMPATHOMIMETICS. All three types of drugs may be needed to treat severe allergic reactions.
One interesting hypothesis is that reduced exposure to infective agents, such as bacteria, in infancy may provoke the development of allergy in later life.
Predicted developments in tackling allergic disorders, according to Professor Stephen Holgate writing in the British Medical Journal (22 January 2000) include:
Identi?cation of the principal environmental factors underlying the increase in incidence, to enable preventive measures to be planned.
Safe and e?ective immunotherapy to prevent and reverse allergic disease.
Treatments that target the protein reactions activated by antigens.
Identi?cation of how IgE is produced in the body, and thus of possible ways to inhibit this process.
Identi?cation of genes a?ecting people’s susceptibility to allergic disease.... Medical Dictionary
Cause Asthma runs in families, so that parents with asthma have a strong risk of having children with asthma, or with other atopic (see ATOPY) illnesses such as HAY FEVER or eczema (see DERMATITIS). There is therefore a great deal of interest in the genetic basis of the condition. Several GENES seem to be associated with the condition of atopy, in which subjects have a predisposition to form ANTIBODIES of the IgE class against allergens (see ALLERGEN) they encounter – especially inhaled allergens.
The allergic response in the lining of the airway leads to an in?ammatory reaction. Many cells are involved in this in?ammatory process, including lymphocytes, eosinophils, neutrophils and mast cells. The cells are attracted and controlled by a complex system of in?ammatory mediators. The in?amed airway-wall produced in this process is then sensitive to further allergic stimuli or to non-speci?c challenges such as dust, smoke or drying from the increased respiration during exercise. Recognition of this in?ammation has concentrated attention on anti-in?ammatory aspects of treatment.
Continued in?ammation with poor control of asthma can result in permanent damage to the airway-wall such that reversibility is reduced and airway-narrowing becomes permanent. Appropriate anti-in?ammatory therapy may help to prevent this damage.
Many allergens can be important triggers of asthma. House-dust mite, grass pollen and animal dander are the commonest problems. Occupational factors such as grain dusts, hard-metals fumes and chemicals in the plastic and paint industry are important in some adults. Viral infections are another common trigger, especially in young children.
The prevalence of asthma appears to be on the increase in most countries. Several factors have been linked to this increase; most important may be the vulnerability of the immature immune system (see IMMUNITY) in infants. High exposure to allergens such as house-dust mite early in life may prime the immune system, while reduced exposure to common viral infections may delay the maturation of the immune system. In addition, maternal smoking in pregnancy and infancy increases the risk.
Clinical course The major symptoms of asthma are breathlessness and cough. Occasionally cough may be the only symptom, especially in children, where night-time cough may be mistaken for recurrent infection and treated inappropriately with antibiotics.
The onset of asthma is usually in childhood, but it may begin at any age. In childhood, boys are a?ected more often than girls but by adulthood the sex incidence is equal. Children who have mild asthma are more likely to grow out of the condition as they go through their teenaged years, although symptoms may recur later.
The degree of airway-narrowing, and its change with time and treatment, can be monitored by measuring the peak expiratory ?ow with a simple monitor at home – a peak-?ow meter. The typical pattern shows the peak ?ow to be lowest in the early morning and this ‘morning dipping’ is often associated with disturbance of sleep.
Acute exacerbations of asthma may be provoked by infections or allergic stimuli. If they do not respond quickly and fully to medication, expert help should be sought urgently since oxygen and higher doses of drugs will be necessary to control the attack. In a severe attack the breathing rate and the pulse rate rise and the chest sounds wheezy. The peak-?ow rate of air into the lungs falls. Patients may be unable to talk in full sentences without catching their breath, and the reduced oxygen in the blood in very severe attacks may produce the blue colour of CYANOSIS in the lips and tongue. Such acute attacks can be very frightening for the patient and family.
Some cases of chronic asthma are included in the internationally agreed description CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – a chronic, slowly progressive disorder characterised by obstruction of the air?ow persisting over several months.
Treatment The ?rst important consideration in the treatment of asthma is avoidance of precipitating factors. When this is a speci?c animal or occupational exposure, this may be possible; it is however more di?cult for house-dust mite or pollens. Exercise-induced asthma should be treated adequately rather than avoiding exercise.
Desensitisation injections using small quantities of speci?c allergens are used widely in some countries, but rarely in the UK as they are considered to have limited value since most asthma is precipitated by many stimuli and controlled adequately with simple treatment.
There are two groups of main drugs for the treatment of asthma. The ?rst are the bronchodilators which relax the smooth muscle in the wall of the airways, increase their diameter and relieve breathlessness. The most useful agents are the beta adrenergic agonists (see ADRENERGIC RECEPTORS) such as salbutamol and terbutaline. They are best given by inhalation into the airways since this reduces the general side-e?ects from oral use. These drugs are usually given to reverse airway-narrowing or to prevent its onset on exercise. However, longer-acting inhaled beta agonists such as salmeterol and formoterol or the theophyllines given in tablet form can be used regularly as prevention. The beta agonists can cause TREMOR and PALPITATION in some patients.
The second group of drugs are the antiin?ammatory agents that act to reduce in?ammation of the airway. The main agents in this group are the CORTICOSTEROIDS. They must be taken regularly, even when symptoms are absent. Given by inhalation they have few side-e?ects. In acute attacks, short courses of oral steroids are used; in very severe disease regular oral steroids may be needed. Other drugs have a role in suppressing in?ammation: sodium cromoglycate has been available for some years and is generally less e?ective than inhaled steroids. Newer agents directed at speci?c steps in the in?ammatory pathway, such as leukotriene receptor-antagonists, are alternative agents.
Treatment guidelines have been produced by various national and international bodies, such as the British Thoracic Society. Most have set out treatment in steps according to severity, with objectives for asthma control based on symptoms and peak ?ow. Patients should have a management plan that sets out their regular treatment and their appropriate response to changes in their condition.
Advice and support for research into asthma is provided by the National Asthma Campaign.
Prognosis Asthma is diagnosed in 15–20 per cent of all pre-school children in the developed world. Yet by the age of 15 it is estimated that fewer than 5 per cent still have symptoms. A study in 2003 reported on a follow-up of persons born in 1972–3 who developed asthma and still had problems at the age of nine. By the time these persons were aged 26, 27 per cent were still having problems; around half of that number had never been free from the illness and the other half had apparently lost it for a few years but it had returned.... Medical Dictionary
The blood pressure is biphasic, being greatest (systolic pressure) at each heartbeat and falling (diastolic pressure) between beats. The average systolic pressure is around 100 mm Hg in children and 120 mm Hg in young adults, generally rising with age as the arteries get thicker and harder. Diastolic pressure in a healthy young adult is about 80 mm Hg, and a rise in diastolic pressure is often a surer indicator of HYPERTENSION than is a rise in systolic pressure; the latter is more sensitive to changes of body position and emotional mood. Hypertension has various causes, the most important of which are kidney disease (see KIDNEYS, DISEASES OF), genetic predisposition and, to some extent, mental stress. Systolic pressure may well be over 200 mm Hg. Abnormal hypertension is often accompanied by arterial disease (see ARTERIES, DISEASES OF) with an increased risk of STROKE, heart attack and heart failure (see HEART, DISEASES OF). Various ANTIHYPERTENSIVE DRUGS are available; these should be carefully evaluated, considering the patient’s full clinical history, before use.
HYPOTENSION may result from super?cial vasodilation (for example, after a bath, in fevers or as a side-e?ect of medication, particularly that prescribed for high blood pressure) and occur in weakening diseases or heart failure. The blood pressure generally falls on standing, leading to temporary postural hypotension – a particular danger in elderly people.... Medical Dictionary
Benign disease is much more common than cancer, particularly in young women, and includes acute in?ammation of the breast (mastitis); abscess formation; and benign breast lumps, which may be ?broadenosis – di?use lumpiness also called chronic mastitis or ?brocystic disease – in which one or more ?uid-?lled sacs (cysts) develop.
Women who are breast feeding are particularly prone to mastitis, as infection may enter the breast via the nipple. The process may be arrested before a breast abscess forms by prompt treatment with antibiotics. Non-bacterial in?ammation may result from mammary duct ectasia (dilatation), in which abnormal or
blocked ducts may over?ow. Initial treatments should be with antibiotics, but if an abscess does form it should be surgically drained.
Duct ectasia, with or without local mastitis, is the usual benign cause of various nipple complaints, with common symptoms being nipple retraction, discharge and skin change.
Breast lumps form the chief potential danger and may be either solid or cystic. Simple examination may fail to distinguish the two types, but aspiration of a benign cyst usually results in its disappearance. If the ?uid is bloodstained, or if a lump still remains, malignancy is possible, and all solid lumps need histological (tissue examination) or cytological (cell examination) assessment. As well as having their medical and family history taken, any women with a breast lump should undergo triple assessment: a combination of clinical examination, imaging
– mammography for the over-35s and ultrasonagraphy for the under-35s – and ?ne-needle aspiration. The medical history should include details of any previous lumps, family history (up to 10 per cent of breast cancer in western countries is due to genetic disposition), pain, nipple discharge, change in size related to menstrual cycle and parous state, and any drugs being taken by the patient. Breasts should be inspected with the arms up and down, noting position, size, consistency, mobility, ?xity, and local lymphadenopathy (glandular swelling). Nipples should be examined for the presence of inversion or discharge. Skin involvement (peau d’orange) should be noted, and, in particular, how long changes have been present. Fine-needle aspiration and cytological examination of the ?uid are essential with ULTRASOUND, MAMMOGRAPHY and possible BIOPSY being considered, depending on the patient’s age and the extent of clinical suspicion that cancer may be present.
The commonest solid benign lump is a ?broadenoma, particularly in women of childbearing age, and is a painless, mobile lump. If small, it is usually safe to leave it alone, provided that the patient is warned to seek medical advice if its size or character changes or if the lump becomes painful. Fibroadenosis (di?use lumpiness often in the upper, outer quadrant) is a common (benign) lump. Others include periductal mastitis, fat NECROSIS, GALACTOCELE, ABSCESS, and non-breast-tissue lumps – for example, a LIPOMA (fatty tissue) or SEBACEOUS CYST. A woman with breast discharge should have a mammograph, ductograph, or total duct excision until the cause of any underlying duct ectasia is known. Appropriate treatment should then be given.
Malignant disease most commonly – but not exclusively – occurs in post-menopausal women, classically presenting as a slowly growing, painless, ?rm lump. A bloodstained nipple discharge or eczematous skin change may also be suggestive of cancer.
The most commonly used classi?cation of invasive cancers has split them into two types, ductal and lobular, but this is no longer suitable. There are also weaknesses in the tumour node metastases (TNM) system and the International Union Against Cancer (UICC) classi?cation.
The TNM system – which classi?es the lump by size, ?xity and presence of a?ected axillary glands and wider metastatic spread – is best combined with a pathological classi?cation, when assessing the seriousness of a possibly cancerous lump. Risk factors for cancer include nulliparity (see NULLIPARA), ?rst pregnancy over the age of 30 years, early MENARCHE, late MENOPAUSE and positive family history. The danger should be considered in women who are not breast feeding or with previous breast cancer, and must be carefully excluded if the woman is taking any contraceptive steroids or is on hormone-replacement therapy (see under MENOPAUSE).
Screening programmes involving mammography are well established, the aim being to detect more tumours at an early and curable stage. Pick-up rate is ?ve per 1,000 healthy women over 50 years. Yearly two-view mammograms could reduce mortality by 40 per cent but may cause alarm because there are ten false positive mammograms for each true positive result. In premenopausal women, breasts are denser, making mammograms harder to interpret, and screening appears not to save lives. About a quarter of women with a palpable breast lump turn out to have cancer.
Treatment This remains controversial, and all options should be carefully discussed with the patient and, where appropriate, with her partner. Locally contained disease may be treated by local excision of the lump, but sampling of the glands of the armpit of the same side should be performed to check for additional spread of the disease, and hence the need for CHEMOTHERAPY or RADIOTHERAPY. Depending on the extent of spread, simple mastectomy or modi?ed radical mastectomy (which removes the lymph nodes draining the breast) may be required. Follow-up chemotherapy, for example, with TAMOXIFEN (an oestrogen antagonist), much improves survival (it saves 12 lives over 100 women treated), though it may occasionally cause endometrial carcinoma. Analysis in the mid-1990s of large-scale international studies of breast-cancer treatments showed wide variations in their e?ectiveness. As a result the NHS has encouraged hospitals to set up breast-treatment teams containing all the relevant health professional experts and to use those treatments shown to be most e?ective.
As well as the physical treatments provided, women with suspected or proven breast cancer should be o?ered psychological support because up to 30 per cent of a?ected women develop an anxiety state or depressive illness within a year of diagnosis. Problems over body image and sexual di?culties occur in and around one-quarter of patients. Breast conservation and reconstructive surgery can improve the physical e?ects of mastectomy, and women should be advised on the prostheses and specially designed brassieres that are available. Specialist nurses and self-help groups are invaluable in supporting a?ected women and their partners with the problems caused by breast cancer and its treatment. Breast Cancer Care, British Association of Cancer United Patients (BACUP), Cancerlink, and Cancer Relief Macmillan Fund are among voluntary organisations providing support.... Medical Dictionary
The presentation of dystonia may be focal (usually in adults) causing blepharospasm (forceful eye closure), oromandibular dystonia (spasms of the tongue and jaw), cranial dystonia/Meige syndrome/Brueghel’s syndrome (eyes and jaw both involved), spastic or spasmodic dysphonia/laryngeal dystonia (strained or whispering speech), spasmodic dysphagia (di?culty swallowing), spasmodic torti/latero/ ante/retrocollis (rotation, sideways, forward or backward tilting of the neck), dystonic writer’s cramp or axial dystonia (spasms deviating the torso). Foot dystonia occurs almost exclusively in children and adolescents. In adults, the condition usually remains focal or involves at most an adjacent body part. In children, it may spread to become generalised. The condition has always been considered rare, but commonly is either not diagnosed or mistakenly thought to be of psychological origin. It may, in fact, be half as common as MULTIPLE SCLEROSIS (MS). Similar features can occur in some subjects treated with major tranquillising drugs, in whom a predisposition to develop dystonia may be present.
One rare form, called dopa-responsive dystonia, can be largely abolished by treatment with LEVODOPA. Particularly in paediatric practice this drug will often be tried on a child with dystonia.... Medical Dictionary
The options for individuals would include taking no action; modifying their behaviour; or taking some form of direct action. For those at risk of having an a?ected child, where prenatal diagnosis is available, this would involve either carrying on with reproduction regardless of risk; deciding not to have children; or deciding to go ahead to have children but opting for prenatal diagnosis. For an adult-onset disorder such as a predisposition to ovarian cancer, an individual may choose to take no action; to take preventive measures such as use of the oral contraceptive pill; to have screening of the ovaries with measures such as ultrasound; or to take direct action such as removing the ovaries to prevent ovarian cancer from occurring.
There are now regional genetics centres throughout the United Kingdom, and patients can be referred through their family doctor or specialists.... Medical Dictionary
Dominant genes A dominant characteristic is an e?ect which is produced whenever a gene or gene defect is present. If a disease is due to a dominant gene, those a?ected are heterozygous – that is, they only carry a fault in the gene on one of the pair of chromosomes concerned. A?ected people married to normal individuals transmit the gene directly to one-half of the children, although this is a random event just like tossing a coin. HUNTINGTON’S CHOREA is due to the inheritance of a dominant gene, as is neuro?bromatosis (see VON RECKLINGHAUSEN’S DISEASE) and familial adenomatous POLYPOSIS of the COLON. ACHONDROPLASIA is an example of a disorder in which there is a high frequency of a new dominant mutation, for the majority of a?ected people have normal parents and siblings. However, the chances of the children of a parent with the condition being a?ected are one in two, as with any other dominant characteristic. Other diseases inherited as dominant characteristics include spherocytosis, haemorrhagic telangiectasia and adult polycystic kidney disease.
Recessive genes If a disease is due to a recessive gene, those a?ected must have the faulty gene on both copies of the chromosome pair (i.e. be homozygous). The possession of a single recessive gene does not result in overt disease, and the bearer usually carries this potentially unfavourable gene without knowing it. If that person marries another carrier of the same recessive gene, there is a one-in-four chance that their children will receive the gene in a double dose, and so have the disease. If an individual su?erer from a recessive disease marries an apparently normal person who is a heterozygous carrier of the same gene, one-half of the children will be a?ected and the other half will be carriers of the disease. The commonest of such recessive conditions in Britain is CYSTIC FIBROSIS, which a?ects about one child in 2,000. Approximately 5 per cent of the population carry a faulty copy of the gene. Most of the inborn errors of metabolism, such as PHENYLKETONURIA, GALACTOSAEMIA and congenital adrenal hyperplasia (see ADRENOGENITAL SYNDROME), are due to recessive genes.
There are characteristics which may be incompletely recessive – that is, neither completely dominant nor completely recessive – and the heterozygotus person, who bears the gene in a single dose, may have a slight defect whilst the homozygotus, with a double dose of the gene, has a severe illness. The sickle-cell trait is a result of the sickle-cell gene in single dose, and sickle-cell ANAEMIA is the consequence of a double dose.
Sex-linked genes If a condition is sex-linked, a?ected males are homozygous for the mutated gene as they carry it on their single X chromosome. The X chromosome carries many genes, while the Y chromosome bears few genes, if any, other than those determining masculinity. The genes on the X chromosome of the male are thus not matched by corresponding genes on the Y chromosome, so that there is no chance of the Y chromosome neutralising any recessive trait on the X chromosome. A recessive gene can therefore produce disease, since it will not be suppressed by the normal gene of the homologous chromosome. The same recessive gene on the X chromosome of the female will be suppressed by the normal gene on the other X chromosome. Such sex-linked conditions include HAEMOPHILIA, CHRISTMAS DISEASE, DUCHENNE MUSCULAR
DYSTROPHY (see also MUSCLES, DISORDERS OF – Myopathy) and nephrogenic DIABETES INSIPIDUS.
If the mother of an a?ected child has another male relative a?ected, she is a heterozygote carrier; half her sons will have the disease and half her daughters will be carriers. The sister of a haemophiliac thus has a 50 per cent chance of being a carrier. An a?ected male cannot transmit the gene to his son because the X chromosome of the son must come from the mother; all his daughters, however, will be carriers as the X chromosome for the father must be transmitted to all his daughters. Hence sex-linked recessive characteristics cannot be passed from father to son. Sporadic cases may be the result of a new mutation, in which case the mother is not the carrier and is not likely to have further a?ected children. It is probable that one-third of haemophiliacs arise as a result of fresh mutations, and these patients will be the ?rst in the families to be a?ected. Sometimes the carrier of a sex-linked recessive gene can be identi?ed. The sex-linked variety of retinitis pigmentosa (see EYE, DISORDERS OF) can often be detected by ophthalmoscopic examination.
A few rare disorders are due to dominant genes carried on the X chromosome. An example of such a condition is familial hypophosphataemia with vitamin-D-resistant RICKETS.
Polygenic inheritance In many inherited conditions, the disease is due to the combined action of several genes; the genetic element is then called multi-factorial or polygenic. In this situation there would be an increased incidence of the disease in the families concerned, but it will not follow the Mendelian (see MENDELISM; GENETIC CODE) ratio. The greater the number of independent genes involved in determining a certain disease, the more complicated will be the pattern of inheritance. Furthermore, many inherited disorders are the result of a combination of genetic and environmental in?uences. DIABETES MELLITUS is the most familiar of such multi-factorial inheritance. The predisposition to develop diabetes is an inherited characteristic, although the gene is not always able to express itself: this is called incomplete penetrance. Whether or not the individual with a genetic predisposition towards the disease actually develops diabetes will also depend on environmental factors. Diabetes is more common in the relatives of diabetic patients, and even more so amongst identical twins. Non-genetic factors which are important in precipitating overt disease are obesity, excessive intake of carbohydrate foods, and pregnancy.
SCHIZOPHRENIA is another example of the combined e?ects of genetic and environmental in?uences in precipitating disease. The risk of schizophrenia in a child, one of whose parents has the disease, is one in ten, but this ?gure is modi?ed by the early environment of the child.... Medical Dictionary
Arrhythmias An abnormal rate or rhythm of the heartbeat. The reason is a disturbance in the electrical impulses within the heart. Sometimes a person may have an occasional irregular heartbeat: this is called an ECTOPIC beat (or an extrasystole) and does not necessarily mean that an abnormality exists. There are two main types of arrhythmia: bradycardias, where the rate is slow – fewer than 60 beats a minute and sometimes so slow and unpredictable (heartblock) as to cause blackouts or heart failure; and tachycardia, where the rate is fast – more than 100 beats a minute. A common cause of arrhythmia is coronary artery disease, when vessels carrying blood to the heart are narrowed by fatty deposits (ATHEROMA), thus reducing the blood supply and damaging the heart tissue. This condition often causes myocardial infarction after which arrhythmias are quite common and may need correcting by DEFIBRILLATION (application of a short electric shock to the heart). Some tachycardias result from a defect in the electrical conduction system of the heart that is commonly congenital. Various drugs can be used to treat arrhythmias (see ANTIARRHYTHMIC DRUGS). If attacks constantly recur, the arrhythmia may be corrected by electrical removal of dead or diseased tissue that is the cause of the disorder. Heartblock is most e?ectively treated with an arti?cial CARDIAC PACEMAKER, a battery-activated control unit implanted in the chest.
Cardiomyopathy Any disease of the heart muscle that results in weakening of its contractions. The consequence is a fall in the e?ciency of the circulation of blood through the lungs and remainder of the body structures. The myopathy may be due to infection, disordered metabolism, nutritional excess or de?ciency, toxic agents, autoimmune processes, degeneration, or inheritance. Often, however, the cause is not identi?ed. Cardiomyopathies are less common than other types of heart diseases, and the incidence of di?erent types of myopathy (see below) is not known because patients or doctors are sometimes unaware of the presence of the condition.
The three recognised groups of cardiomyopathies are hypertrophic, dilated and restrictive.
•Hypertrophic myopathy, a familial condition, is characterised by great enlargement of the muscle of the heart ventricles. This reduces the muscle’s e?ciency, the ventricles fail to relax properly and do not ?ll suf?ciently during DIASTOLE.
In the dilated type of cardiomyopathy, both ventricles overdilate, impairing the e?ciency of contraction and causing congestion of the lungs.
In the restrictive variety, proper ?lling of the ventricles does not occur because the muscle walls are less elastic than normal. The result is raised pressure in the two atria (upper cavities) of the heart: these dilate and develop FIBRILLATION. Diagnosis can be di?cult and treatment is symptomatic, with a poor prognosis. In suitable patients, heart TRANSPLANTATION may be considered. Disorders of the heart muscle may also be
caused by poisoning – for example, heavy consumption of alcohol. Symptoms include tiredness, palpitations (quicker and sometimes irregular heartbeat), chest pain, di?culty in breathing, and swelling of the legs and hands due to accumulation of ?uid (OEDEMA). The heart is enlarged (as shown on chest X-ray) and ECHOCARDIOGRAPHY shows thickening of the heart muscle. A BIOPSY of heart muscle will show abnormalities in the cells of the heart muscle.
Where the cause of cardiomyopathy is unknown, as is the case with most patients, treatment is symptomatic using DIURETICS to control heart failure and drugs such as DIGOXIN to return the heart rhythm to normal. Patients should stop drinking alcohol. If, as often happens, the patient’s condition slowly deteriorates, heart transplantation should be considered.
Congenital heart disease accounts for 1–2 per cent of all cases of organic heart disease. It may be genetically determined and so inherited; present at birth for no obvious reason; or, in rare cases, related to RUBELLA in the mother. The most common forms are holes in the heart (atrial septal defect, ventricular septal defect – see SEPTAL DEFECT), a patent DUCTUS ARTERIOSUS, and COARCTATION OF THE AORTA. Many complex forms also exist and can be diagnosed in the womb by fetal echocardiography which can lead to elective termination of pregnancy. Surgery to correct many of these abnormalities is feasible, even for the most severe abnormalities, but may only be palliative giving rise to major di?culties of management as the children become older. Heart transplantation is now increasingly employed for the uncorrectable lesions.
Coronary artery disease Also known as ischaemic heart disease, this is a common cause of symptoms and death in the adult population. It may present for the ?rst time as sudden death, but more usually causes ANGINA PECTORIS, myocardial infarction (heart attack) or heart failure. It can also lead to a disturbance of heart rhythm. Factors associated with an increased risk of developing coronary artery disease include diabetes, cigarette smoking, high blood pressure, obesity, and a raised concentration of cholesterol in the blood. Older males are most a?ected.
Coronary thrombosis or acute myocardial infarction is the acute, dramatic manifestation of coronary-artery ischaemic heart disease – one of the major killing diseases of western civilisation. In 1999, ischaemic heart disease was responsible for about 115,000 deaths in England and Wales, compared with 153,000 deaths in 1988. In 1999 more than 55,600 people died of coronary thrombosis. The underlying cause is disease of the coronary arteries which carry the blood supply to the heart muscle (or myocardium). This results in narrowing of the arteries until ?nally they are unable to transport su?cient blood for the myocardium to function e?ciently. One of three things may happen. If the narrowing of the coronary arteries occurs gradually, then the individual concerned will develop either angina pectoris or signs of a failing heart: irregular rhythm, breathlessness, CYANOSIS and oedema.
If the narrowing occurs suddenly or leads to complete blockage (occlusion) of a major branch of one of the coronary arteries, then the victim collapses with acute pain and distress. This is the condition commonly referred to as a coronary thrombosis because it is usually due to the a?ected artery suddenly becoming completely blocked by THROMBOSIS. More correctly, it should be described as coronary occlusion, because the ?nal occluding factor need not necessarily be thrombosis.
Causes The precise cause is not known, but a wide range of factors play a part in inducing coronary artery disease. Heredity is an important factor. The condition is more common in men than in women; it is also more common in those in sedentary occupations than in those who lead a more physically active life, and more likely to occur in those with high blood pressure than in those with normal blood pressure (see HYPERTENSION). Obesity is a contributory factor. The disease is more common among smokers than non-smokers; it is also often associated with a high level of CHOLESTEROL in the blood, which in turn has been linked with an excessive consumption of animal, as opposed to vegetable, fats. In this connection the important factors seem to be the saturated fatty acids (low-density and very low-density lipoproteins [LDLs and VLDLs] – see CHOLESTEROL) of animal fats which would appear to be more likely to lead to a high level of cholesterol in the blood than the unsaturated fatty acids of vegetable fats. As more research on the subject is carried out, the arguments continue about the relative in?uence of the di?erent factors. (For advice on prevention of the disease, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELFHELP.)
Symptoms The presenting symptom is the sudden onset, often at rest, of acute, agonising pain in the front of the chest. This rapidly radiates all over the front of the chest and often down over the abdomen. The pain is frequently accompanied by nausea and vomiting, so that suspicion may be aroused of some acute abdominal condition such as biliary colic (see GALLBLADDER, DISEASES OF) or a perforated PEPTIC ULCER. The victim soon goes into SHOCK, with a pale, cold, sweating skin, rapid pulse and dif?culty in breathing. There is usually some rise in temperature.
Treatment is immediate relief of the pain by injections of diamorphine. Thrombolytic drugs should be given as soon as possible (‘rapid door to needle time’) and ARRHYTHMIA corrected. OXYGEN is essential and oral ASPIRIN is valuable. Treatment within the ?rst hour makes a great di?erence to recovery. Subsequent treatment includes the continued administration of drugs to relieve the pain; the administration of ANTIARRHYTHMIC DRUGS that may be necessary to deal with the heart failure that commonly develops, and the irregular action of the heart that quite often develops; and the continued administration of oxygen. Patients are usually admitted to coronary care units, where they receive constant supervision. Such units maintain an emergency, skilled, round-the-clock sta? of doctors and nurses, as well as all the necessary resuscitation facilities that may be required.
The outcome varies considerably. The ?rst (golden) hour is when the patient is at greatest risk of death: if he or she is treated, then there is a 50 per cent reduction in mortality compared with waiting until hospital admission. As each day passes the prognosis improves with a ?rst coronary thrombosis, provided that the patient does not have a high blood pressure and is not overweight. Following recovery, there should be a gradual return to work, care being taken to avoid any increase in weight, unnecessary stress and strain, and to observe moderation in all things. Smoking must stop. In uncomplicated cases patients get up and about as soon as possible, most being in hospital for a week to ten days and back at work in three months or sooner.
Valvular heart disease primarily a?ects the mitral and aortic valves which can become narrowed (stenosis) or leaking (incompetence). Pulmonary valve problems are usually congenital (stenosis) and the tricuspid valve is sometimes involved when rheumatic heart disease primarily a?ects the mitral or aortic valves. RHEUMATIC FEVER, usually in childhood, remains a common cause of chronic valvular heart disease causing stenosis, incompetence or both of the aortic and mitral valves, but each valve has other separate causes for malfunction.
Aortic valve disease is more common with increasing age. When the valve is narrowed, the heart hypertrophies and may later fail. Symptoms of angina or breathlessness are common and dizziness or blackouts (syncope) also occur. Replacing the valve is a very e?ective treatment, even with advancing age. Aortic stenosis may be caused by degeneration (senile calci?c), by the inheritance of two valvular leaflets instead of the usual three (bicuspid valve), or by rheumatic fever. Aortic incompetence again leads to hypertrophy, but dilatation is more common as blood leaks back into the ventricle. Breathlessness is the more common complaint. The causes are the same as stenosis but also include in?ammatory conditions such as SYPHILIS or ANKYLOSING SPONDYLITIS and other disorders of connective tissue. The valve may also leak if the aorta dilates, stretching the valve ring as with HYPERTENSION, aortic ANEURYSM and MARFAN’S SYNDROME – an inherited disorder of connective tissue that causes heart defects. Infection (endocarditis) can worsen acutely or chronically destroy the valve and sometimes lead to abnormal outgrowths on the valve (vegetations) which may break free and cause devastating damage such as a stroke or blocked circulation to the bowel or leg.
Mitral valve disease leading to stenosis is rheumatic in origin. Mitral incompetence may be rheumatic but in the absence of stenosis can be due to ISCHAEMIA, INFARCTION, in?ammation, infection and a congenital weakness (prolapse). The valve may also leak if stretched by a dilating ventricle (functional incompetence). Infection (endocarditis) may a?ect the valve in a similar way to aortic disease. Mitral symptoms are predominantly breathlessness which may lead to wheezing or waking at night breathless and needing to sit up or stand for relief. They are made worse when the heart rhythm changes (atrial ?brillation) which is frequent as the disease becomes more severe. This leads to a loss of e?ciency of up to 25 per cent and a predisposition to clot formation as blood stagnates rather than leaves the heart e?ciently. Mitral incompetence may remain mild and be of no trouble for many years, but infection must be guarded against (endocarditis prophylaxis).
Endocarditis is an infection of the heart which may acutely destroy a valve or may lead to chronic destruction. Bacteria settle usually on a mild lesion. Antibiotics taken at vulnerable times can prevent this (antibiotic prophylaxis) – for example, before tooth extraction. If established, lengthy intravenous antibiotic therapy is needed and surgery is often necessary. The mortality is 30 per cent but may be higher if the infection settles on a replaced valve (prosthetic endocarditis). Complications include heart failure, shock, embolisation (generation of small clots in the blood), and cerebral (mental) confusion.
PERICARDITIS is an in?ammation of the sac covering the outside of the heart. The sac becomes roughened and pain occurs as the heart and sac rub together. This is heard by stethoscope as a scratching noise (pericardial rub). Fever is often present and a virus the main cause. It may also occur with rheumatic fever, kidney failure, TUBERCULOSIS or from an adjacent lung problem such as PNEUMONIA or cancer. The in?ammation may cause ?uid to accumulate between the sac and the heart (e?usion) which may compress the heart causing a fall in blood pressure, a weak pulse and circulatory failure (tamponade). This can be relieved by aspirating the ?uid. The treatment is then directed at the underlying cause.... Medical Dictionary
A localised (focal) form of liver disease in all tropical/subtropical countries results from invasive Entamoeba histolytica infection (amoebic liver ‘abscess’); serology and imaging techniques assist in diagnosis. Hydatidosis also causes localised liver disease; one or more cysts usually involve the right lobe of the liver. Serological tests and imaging techniques are of value in diagnosis. Whilst surgery formerly constituted the sole method of management, prolonged courses of albendazole and/or praziquantel have now been shown to be e?ective; however, surgical intervention is still required in some cases.
Hepato-biliary disease is also a problem in many tropical/subtropical countries. In southeast Asia, Clonorchis sinensis and Opisthorchis viverini infections cause chronic biliary-tract infection, complicated by adenocarcinoma of the biliary system. Praziquantel is e?ective chemotherapy before advanced disease ensues. Fasciola hepatica (the liver ?uke) is a further hepato-biliary helminthic infection; treatment is with bithionol or triclabendazole, praziquantel being relatively ine?ective.... Medical Dictionary
The predisposition to psoriasis is genetic, multiple genes being involved, but postnatal factors such as acute infection, hormonal disturbance, pregnancy and drugs can in?uence or provoke it. The sexes are equally a?ected and onset is most common in the second or third decade of life.
The psoriatic lesion is dull red, scaly and well de?ned. Scale is shed constantly, either in tiny pieces or as large plaques. The scalp is usually a?ected but the disease does not cause signi?cant hair loss. The ?ngernails may be pitted or ridged and the toenails grossly thickened. Several clinical patterns occur: in guttate psoriasis, a sudden explosion of multiple tiny lesions may follow a streptococcal throat infection, especially in children. Larger lesions are characteristic of discoid (plaque) psoriasis, the usual adult form. In the elderly the plaques may be mainly in the large body folds – ?exural psoriasis. Rarely, psoriasis may be universal (psoriatic erythroderma), or a sterile pustular eruption may supervene (pustular psoriasis).
Mucous membranes in the mouth and elsewhere are not a?ected. Psoriasis does not a?ect internal organs, but in about 1 per cent of subjects an in?ammatory joint disease (psoriatic arthritis) may be associated with the condition.
Treatment There is no absolute cure, but several agents used topically are of value including coal-tar extracts, DITHRANOL, CORTICOSTEROIDS and synthetic derivatives of vitamins A and D. Ultraviolet B phototherapy (and natural sunlight) bene?ts most but not all psoriatics. Systemic therapy, including PHOTOCHEMOTHERAPY, is reserved for severe forms of psoriasis. METHOTREXATE, CICLOSPORIN A and oral RETINOIDS are the most e?ective drugs, but they are potentially dangerous and require expert monitoring.
Patient information may be obtained through the Psoriasis Association.... Herbal Medical
Causes There is a major immunogenetic predisposition to rheumatoid arthritis in people carrying the HLA-DR4 antigen (see HLA SYSTEM). Other minor immunogenetic factors have also been implicated. In addition, there is a degree of familial clustering which suggests other unidenti?ed genetic factors. Genetic factors cannot alone explain aetiology, and environmental and chance factors must be important, but these have yet to be identi?ed.
Epidemiology Rheumatoid arthritis more commonly occurs in women from the age of 30 onwards, the sex ratio being approximately 4:1. Typical rheumatoid arthritis may occur in adolescence, but in childhood chronic SYNOVITIS usually takes one of a number of di?erent patterns, classi?ed under juvenile chronic arthritis.
Pathology The primary lesion is an in?ammation of the synovial membrane of joints. The synovial ?uid becomes diluted with in?ammatory exudate: if this persists for months it leads to progressive destruction of articular CARTILAGE and BONE. Cartilage is replaced by in?ammatory tissue known as pannus; a similar tissue invades bone to form erosions. Synovitis also a?ects tendon sheaths, and may lead to adhesion ?brosis or attrition and rupture of tendons. Subcutaneous and other bursae may be involved. Necrobiotic nodules also occur at sites outside synovium, including the subcutaneous tissues, the lungs, the pericardium and the pleura.
Clinical features Rheumatoid arthritis varies from the very mild to the severely disabling. Many mild cases probably go undiagnosed. At least 50 per cent of patients continue to lead a reasonably normal life; around 25 per cent are signi?cantly disabled in terms of work and leisure activities; and a minority become markedly disabled and are limited in their independence. There is often an early acute phase, followed by substantial remission, but in other patients gradual step-wise deterioration may occur, with progressive involvement of an increasing number of joints.
The diagnosis of rheumatoid arthritis is largely based on clinical symptoms and signs. Approximately 70 per cent of patients have rheumatoid factor ANTIBODIES in the SERUM but, because of the large number of false positives and false negatives, this test has very little value in clinical practice. It may be a useful pointer to a worse prognosis in early cases if the level is high. X-RAYS may help in diagnosing early cases and are particularly helpful when considering surgery or possible complications such as pathological fracture. Patients commonly develop ANAEMIA, which may be partly due to gastrointestinal blood loss from antiin?ammatory drug treatment (see below).
Treatment involves physical, pharmacological, and surgical measures, together with psychological and social support tailored to the individual patient’s needs. Regular activity should be maintained. Resting of certain joints such as the wrist with splints may be helpful at night or to assist prolonged manual activities. Sound footwear is important. Early use of antirheumatic drugs reduces long-term disability. Drug treatment includes simple ANALGESICS, NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS), and slow-acting drugs including GOLD SALTS (in the form of SODIUM AUROTHIOMALATE), PENICILLAMINE, SULFASALAZINE, METHOTREXATE and AZATHIOPRINE.
The non-steroidal agents are largely e?ective in reducing pain and early-morning sti?ness, and have no e?ect on the chronic in?ammatory process. It is important, especially in the elderly, to explain to patients the adverse e?ects of NSAIDs, the dosage of which can be cut by prescribing paracetamol at the same time. Combinations of anti-rheumatic drugs seem better than single agents. The slow-acting drugs take approximately three months to act but have a more global e?ect on chronic in?ammation, with a greater reduction in swelling and an associated fall in erythrocyte sedimentation rate (ESR) and rise in the level of HAEMOGLOBIN. Local CORTICOSTEROIDS are useful, given into individual joints. Systemic corticosteroids carry serious problems if continued long term, but may be useful under special circumstances. Much research is currently going on into the use of tumour necrosis factor antagonists such as INFLIXIMAB and etanercept, but their precise role remains uncertain.... Medical Dictionary
Idiopathic stammering begins at some time between the onset of speech and puberty, mostly between 2–5 years of age. Acquired stammering at a later age due to brain damage is rare. The prevalence of stammering (the percentage of the population actually stammering at any point in time) is approximately 0·9 per cent. Three times as many boys as girls stammer. About 70 per cent of stammering children recover with little or no therapy. Stammerers have not been shown to demonstrate di?erences in personality from non-stammerers; there are, however, indications that at least some stammerers show minimal di?erences from ?uent speakers in cerebral processing of verbal material.
There is a genetic predisposition towards stammering. The risk of stammering among ?rst-degree relatives of stammerers is more than three times the population risk. In 77 per cent of identical twins, either both stammer or both are ?uent. Only 33 per cent of non-identical twins agree in this way. As there are identical twins who di?er for stammering, environmental factors must be important for some stammerers. There are relatively large numbers of stammerers in highly competitive societies, where status and prestige are important and high standards of speech competence are valued.
Di?erent treatments have been demonstrated to produce considerable bene?t, their basic outline being similar. A long period of time is spent in training stammerers to speak in a di?erent way (?uency-shaping techniques). This may include slowing down the rate of speech, gentle onset of utterance, continuous ?ow with correct juncturing, etc. When the targets have been achieved within the clinic, a series of planned speech assignments outside the clinic is undertaken. In these assignments, and initially in everyday situations, the ?uency-enchancing techniques have to be used conscientiously. Gradually speech is shaped towards normality requiring less and less e?ort. Therapy may also include some work on attitude change (i.e. helping the client to see him or herself as a ?uent speaker) and possibly general communicative skills training.
For information about organisations concerned with stammering, see Appendix 2.... Medical Dictionary
– resistant CTEV – which is harder to correct; and the infant has reduced calf-muscle bulk and abnormally shaped bones.
Treatment should be started at birth with the foot corrected to an improved position and then maintained in plaster of Paris or strapping
– a procedure performed weekly or more often. If the deformity is not corrected by around six weeks of age, a decision has to be made about whether to carry out surgical correction. If a deformity persists to maturity, a triple arthrodosis – fusion of three a?ected joints – may be required.... Medical Dictionary