See RUBELLA.... german measles

A combined vaccine o?ering protection against MEASLES, MUMPS and RUBELLA (German measles), it was introduced in the UK in 1988 and has now replaced the measles vaccine. The combined vaccine is o?ered to all infants in their second year; health authorities have an obligation to ensure that all children have received the vaccine by school entry – it should be given with the pre-school booster doses against DIPHTHERIA, TETANUS and POLIOMYELITIS, if not earlier – unless there is a valid contra-indication (such as partial immunosuppression), parental refusal, or evidence of previous infection. MMR vaccine may also be used in the control of measles outbreaks, if o?ered to susceptible children within three days of exposure to infection. The vaccine is e?ective and generally safe, though minor symptoms such as malaise, fever and rash may occur 5–10 days after immunisation. The incidence of all three diseases has dropped substantially since MMR was introduced in the UK and USA.

A researcher has suggested a link between the vaccine and AUTISM, but massive studies of children with and without this condition in several countries have failed to ?nd any evidence to back the claim. Nonetheless, the publicity war has been largely lost by the UK health departments so that vaccine rates have dropped to a worryingly low level.

(See IMMUNISATION.)... mmr vaccine

The name applied generally to dead or attenuated living infectious material introduced into the body, with the object of increasing its power to resist or to get rid of a disease. (See also IMMUNITY.)

Healthy people are inoculated with vaccine as a protection against a particular disease; this produces ANTIBODIES which will confer immunity against a subsequent attack of the disease. (See IMMUNISATION for programme of immunisation during childhood.)

Vaccines may be divided into two classes: stock vaccines, prepared from micro-organisms known to cause a particular disease and kept in readiness for use against that disease; and autogenous vaccines, prepared from microorganisms which are already in the patient’s body and to which the disease is due. Vaccines intended to protect against the onset of disease are of the former variety.

Autogenous vaccines are prepared by cultivating bacteria found in SPUTUM, URINE and FAECES, and in areas of in?ammation such as BOILS (FURUNCULOSIS). This type of vaccine was introduced by Wright about 1903.

Anthrax vaccine was introduced in 1882 for the protection of sheep and cattle against this disease. A safe and e?ective vaccine for use in human beings has now been evolved. (See ANTHRAX.)

BCG vaccine is used to provide protection against TUBERCULOSIS. (See also separate entry on BCG VACCINE.)

Cholera vaccine was introduced in India about 1894. Two injections are given at an interval of at least a week; this gives a varying degree of immunity for six months. (See CHOLERA.)

Diphtheria vaccine is available in several forms. It is usually given along with tetanus and pertussis vaccine (see below) in what is known as TRIPLE VACCINE. This is given in three doses: the ?rst at the age of two months; the second at three months; and the third at four months, with a booster dose at the age of ?ve years. (See DIPHTHERIA.)

Hay fever vaccine is a vaccine prepared from the pollen of various grasses. It is used in gradually increasing doses for prevention of HAY FEVER in those susceptible to this condition.

In?uenza vaccine A vaccine is now available for protection against INFLUENZA due to the in?uenza viruses A and B. Its use in Britain is customarily based on advice from the health departments according to the type of in?uenza expected in a particular year.

Measles, mumps and rubella (MMR) vaccines are given in combination early in the second year of life. A booster dose may prove necessary, as there is some interference between this vaccine and the most recent form of pertussis vaccine (see below) o?ered to children. Uptake has declined a little because of media reports suggesting a link with AUTISM – for which no reliable medical evidence (and much to the contrary) has been found by investigating epidemiologists. (See also separate entry for each disease, and for MMR VACCINE.)

Pertussis (whooping-cough) vaccine is prepared from Bordetella pertussis, and is usually given along with diphtheria and tetanus in what is known as triple vaccine. (See also WHOOPING-COUGH.)

Plague vaccine was introduced by Ha?kine, and appears to give useful protection, but the duration of protection is relatively short: from two to 20 months. Two injections are given at an interval of four weeks. A reinforcing dose should be given annually to anyone exposed to PLAGUE.

Poliomyelitis vaccine gives a high degree of protection against the disease. This is given in the form of attenuated Sabin vaccine which is taken by mouth – a few drops on a lump of sugar. Reinforcing doses of polio vaccine are recommended on school entry, on leaving school, and on travel abroad to countries where POLIOMYELITIS is ENDEMIC.

Rabies vaccine was introduced by Pasteur in 1885 for administration, during the long incubation period, to people bitten by a mad dog, in order to prevent the disease from developing. (See RABIES.)

Rubella vaccine, usually given with mumps and measles vaccine in one dose – called MMR VACCINE, see also above – now provides protection against RUBELLA (German measles). It also provides immunity for adolescent girls who have not had the disease in childhood and so ensures that they will not acquire the disease during any subsequent pregnancy – thus reducing the number of congenitally abnormal children whose abnormality is the result of their being infected with rubella via their mothers before they were born.

Smallpox vaccine was the ?rst introduced. As a result of the World Health Organisation’s successful smallpox eradication campaign – it declared the disease eradicated in 1980 – there is now no medical justi?cation for smallpox vaccination. Recently, however, there has been increased interest in the subject because of the potential threat from bioterrorism. (See also VACCINATION.)

Tetanus vaccine is given in two forms: (1) In the so-called triple vaccine, combined with diphtheria and pertussis (whooping-cough) vaccine for the routine immunisation of children (see above). (2) By itself to adults who have not been immunised in childhood and who are particularly exposed to the risk of TETANUS, such as soldiers and agricultural workers.

Typhoid vaccine was introduced by Wright and Semple for the protection of troops in the South African War and in India. TAB vaccine, containing Salmonella typhi (the causative organism of typhoid fever – see ENTERIC FEVER) and Salmonella paratyphi A and B (the organisms of paratyphoid fever – see ENTERIC FEVER) has now been replaced by typhoid monovalent vaccine, containing only S. typhi. The change has been made because the monovalent vaccine is less likely to produce painful arms and general malaise, and there is no evidence that the TAB vaccine gave any protection against paratyphoid fever. Two doses are given at an interval of 4–6 weeks, and give protection for 1–3 years.... vaccine

Screening and surveillance uncover problems which then need careful attention. Most NHS districts have a CDT to carry out this task – working from child development centres – usually separate from hospitals. Various therapists, as well as consultant paediatricians in community child health, contribute to the work of the team. They include physiotherapists, occupational therapists, speech therapists, psychologists, health visitors and, in some centres, pre-school teachers or educational advisers and social workers. Their aims are to diagnose the child’s problems, identify his or her therapy needs and make recommendations to the local health and educational authorities on how these should be met. A member of the team will usually be appointed as the family’s ‘key worker’, who liaises with other members of the team and coordinates the child’s management. Regular review meetings are held, generally with parents sharing in the decisions made. Mostly children seen by CDTs are under ?ve years old, the school health service and educational authorities assuming responsibility thereafter.

Special needs The Children Act 1989, Education Acts 1981, 1986 and 1993, and the Chronically Sick and Disabled Persons Legislation 1979 impose various statutory duties to identify and provide assistance for children with special needs. They include the chronically ill as well as those with impaired development or disabilities such as CEREBRAL PALSY, or hearing, vision or intellectual impairment. Many CDTs keep a register of such children so that services can be e?ciently planned and evaluated. Parents of disabled children often feel isolated and neglected by society in general; they are frequently frustrated by the lack of resources available to help them cope with the sheer hard work involved. The CDT, through its key workers, does its best to absorb anger and divert frustration into constructive actions.

There are other groups of children who come to the attention of child health services. Community paediatricians act as advisers to adoption and fostering agencies, vital since many children needing alternative homes have special medical or educational needs or have behavioural or psychiatric problems. Many see a role in acting as advocates, not just for those with impairments but also for socially disadvantaged children, including those ‘looked after’ in children’s homes and those of travellers, asylum seekers, refugees and the homeless.

Child protection Regrettably, some children come to the attention of child health specialists because they have been beaten, neglected, emotionally or nutritionally starved or sexually assaulted by their parents or carers. Responsibility for the investigation of these children is that of local-authority social-services departments. However, child health professionals have a vital role in diagnosis, obtaining forensic evidence, advising courts, supervising the medical aspects of follow-up and teaching doctors, therapists and other professionals in training. (See CHILD ABUSE.)

School health services Once children have reached school age, the emphasis changes. The prime need becomes identifying those with problems that may interfere with learning – including those with special needs as de?ned above, but also those with behavioural problems. Teachers and parents are advised on how to manage these problems, while health promotion and health education are directed at children. Special problems, especially as children reach secondary school (aged 11–18) include accidents, substance abuse, psychosexual adjustment, antisocial behaviour, eating disorders and physical conditions which loom large in the minds of adolescents in particular, such as ACNE, short stature and delayed puberty.

There is no longer, in the UK, a universal school health service as many of its functions have been taken over by general practitioners and hospital and community paediatricians. However, most areas still have school nurses, some have school doctors, while others do not employ speci?c individuals for these tasks but share out aspects of the work between GPs, health visitors, community nurses and consultant paediatricians in child health.

Complementing their work is the community dental service whose role is to monitor the whole child population’s dental health, provide preventive programmes for all, and dental treatment for those who have di?culty using general dental services – for example, children with complex disability. All children in state-funded schools are dentally screened at ages ?ve and 15.

Successes and failures Since the inception of the NHS, hospital services for children have had enormous success: neonatal and infant mortality rates have fallen by two-thirds; deaths from PNEUMONIA have fallen from 600 per million children to a handful; and deaths from MENINGITIS have fallen to one-?fth of the previous level. Much of this has been due to the revolution in the management of pregnancy and labour, the invention of neonatal resuscitation and neonatal intensive care, and the provision of powerful antibiotics.

At the same time, some children acquire HIV infection and AIDS from their affected mothers (see AIDS/HIV); the prevalence of atopic (see ATOPY) diseases (ASTHMA, eczema – see DERMATITIS, HAY FEVER) is rising; more children attend hospital clinics with chronic CONSTIPATION; and little can be done for most viral diseases.

Community child health services can also boast of successes. The routine immunisation programme has wiped out SMALLPOX, DIPHTHERIA and POLIOMYELITIS and almost wiped out haemophilus and meningococcal C meningitis, measles and congenital RUBELLA syndrome. WHOOPING COUGH outbreaks continue but the death and chronic disability rates have been greatly reduced. Despite these huge health gains, continuing public scepticism about the safety of immunisation means that there can be no relaxation in the educational and health-promotion programme.

Services for severely and multiply disabled children have improved beyond all recognition with the closure of long-stay institutions, many of which were distinctly child-unfriendly. Nonetheless, scarce resources mean that families still carry heavy burdens. The incidence of SUDDEN INFANT DEATH SYNDROME (SIDS) has more than halved as a result of an educational programme based on ?rm scienti?c evidence that the risk can be reduced by putting babies to sleep on their backs, avoidance of parental smoking, not overheating, breast feeding and seeking medical attention early for illness.

Children have fewer accidents and better teeth but new problems have arisen: in the 1990s children throughout the developed world became fatter. A UK survey in 2004 found that one in ?ve children are overweight and one in 20 obese. Lack of exercise, the easy availability of food at all times and in all places, together with the rise of ‘snacking’, are likely to provoke signi?cant health problems as these children grow into adult life. Adolescents are at greater risk than ever of ill-health through substance abuse and unplanned pregnancy. Child health services are facing new challenges in the 21st century.... child development teams (cdts)

The schedule laid down by most countries to recommend which routine immunizations should be given to children and the intervals at which boosters should be administered. Such routine immunizations usually include tetanus, diphtheria, pertussis, polio, Hepatitis B, Haemophilus influenzae type b (H.I.B.) and after one year of age, measles, rubella and mumps vaccines.... childhood immunization schedule

Paediatrics is the branch of medicine which deals with diseases of children, but many paediatricians have a wider role, being employed largely outside acute hospitals and dealing with child health in general.

History Child health services were originally designed, before the NHS came into being, to ?nd or prevent physical illness by regular inspections. In the UK these were carried out by clinical medical o?cers (CMOs) working in infant welfare clinics (later, child health clinics) set up to ?ll the gap between general practice and hospital care. The services expanded greatly from the mid 1970s; ‘inspections’ have evolved into a regular screening and surveillance system by general practitioners and health visitors, while CMOs have mostly been replaced by consultant paediatricians in community child health (CPCCH).

Screening Screening begins at birth, when every baby is examined for congenital conditions such as dislocated hips, heart malformations, cataract and undescended testicles. Blood is taken to ?nd those babies with potentially brain-damaging conditions such as HYPOTHYROIDISM and PHENYLKETONURIA. Some NHS trusts screen for the life-threatening disease CYSTIC FIBROSIS, although in future it is more likely that ?nding this disease will be part of prenatal screening, along with DOWN’S (DOWN) SYNDROME and SPINA BIFIDA. A programme to detect hearing impairment in newborn babies has been piloted from 2001 in selected districts to ?nd out whether it would be a useful addition to the national screening programme. Children from ethnic groups at risk of inherited abnormalities of HAEMOGLOBIN (sickle cell disease; thalassaemia – see under ANAEMIA) have blood tested at some time between birth and six months of age.

Illness prevention At two months, GPs screen babies again for these abnormalities and start the process of primary IMMUNISATION. The routine immunisation programme has been dramatically successful in preventing illness, handicap and deaths: as such it is the cornerstone of the public health aspect of child health, with more potential vaccines being made available every year. Currently, infants are immunised against pertussis (see WHOOPING COUGH), DIPHTHERIA, TETANUS, POLIOMYELITIS, haemophilus (a cause of MENINGITIS, SEPTICAEMIA, ARTHRITIS and epiglottitis) and meningococcus C (SEPTICAEMIA and meningitis – see NEISSERIACEAE) at two, three and four months. Selected children from high-risk groups are o?ered BCG VACCINE against tuberculosis and hepatitis vaccine. At about 13 months all are o?ered MMR VACCINE (measles, mumps and rubella) and there are pre-school entry ‘boosters’ of diphtheria, tetanus, polio, meningococcus C and MMR. Pneumococcal vaccine is available for particular cases but is not yet part of the routine schedule.

Health promotion and education Throughout the UK, parents are given their child’s personal health record to keep with them. It contains advice on health promotion, including immunisation, developmental milestones (when did he or she ?rst smile, sit up, walk and so on), and graphs – called centile charts – on which to record height, weight and head circumference. There is space for midwives, doctors, practice nurses, health visitors and parents to make notes about the child.

Throughout at least the ?rst year of life, both parents and health-care providers set great store by regular weighing, designed to pick up children who are ‘failing to thrive’. Measuring length is not quite so easy, but height measurements are recommended from about two or three years of age in order to detect children with disorders such as growth-hormone de?ciency, malabsorption (e.g. COELIAC DISEASE) and psychosocial dwar?sm (see below).

All babies have their head circumference measured at birth, and again at the eight-week check. A too rapidly growing head implies that the infant might have HYDROCEPHALUS – excess ?uid in the hollow spaces within the brain. A too slowly growing head may mean failure of brain growth, which may go hand in hand with physically or intellectually delayed development.

At about eight months, babies receive a surveillance examination, usually by a health visitor. Parents are asked if they have any concerns about their child’s hearing, vision or physical ability. The examiner conducts a screening test for hearing impairment – the so-called distraction test; he or she stands behind the infant, who is on the mother’s lap, and activates a standardised sound at a set distance from each ear, noting whether or not the child turns his or her head or eyes towards the sound. If the child shows no reaction, the test is repeated a few weeks later; if still negative then referral is made to an audiologist for more formal testing.

The doctor or health visitor will also go through the child’s developmental progress (see above) noting any signi?cant deviation from normal which merits more detailed examination. Doctors are also recommended to examine infants developmentally at some time between 18 and 24 months. At this time they will be looking particularly for late walking or failure to develop appropriate language skills.... child health

Rash caused by a systemic infection. Several childhood infections – for example, MEASLES and RUBELLA – have characteristic exanthemata.... exanthem

Heart disease can affect any of the structures of the HEART and may affect more than one at a time. Heart attack is an imprecise term and may refer to ANGINA PECTORIS (a symptom of pain originating in the heart) or to coronary artery thrombosis, also called myocardial infarction.

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 diffculties 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 affected.

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 affected 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 affects 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 affects 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 affect 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.... heart, diseases of

Dioscorea spp.

Dioscoreaceae

The growing need for steroidal drugs and the high cost of obtaining them from animal sources led to a widespread search for plant sources of steroidal sapogenins, which ultimately led to the most promising one. It is the largest genus of the family constituted by 600 species of predominantly twining herbs. Among the twining species, some species twine clockwise while others anti-clockwise (Miege, 1958). All the species are dioceous and rhizomatous. According to Coursey (1967), this genus is named in honour of the Greek physician Pedenios Dioscorides, the author of the classical Materia Medica Libri Quinque. Some of the species like D. alata and D. esculenta have been under cultivation for a long time for their edible tubers. There are about 15 species of this genus containing diosgenin. Some of them are the following (Chopra et al, 1980).

D. floribunda Mart. & Gal.

D. composita Hemsl; syn. D. macrostachya Benth.

D. deltoidea Wall. ex Griseb; syn. D. nepalensis Sweet ex Bernardi.

D. aculeata Linn. syn. D. esculenta

D. alata Linn. syn. D. atropurpurea Roxb.

D. Globosa Roxb; D. purpurea Roxb; D. rubella Roxb.

D. bulbifera Linn. syn. D. crispata Roxb.

D. pulchella Roxb.; D. sativa Thunb. Non Linn.

D. versicolor Buch. Ham. Ex Wall.

D. daemona Roxb. syn. D. hispida Dennst.

D. oppositifolia Linn.

D. pentaphylla Linn. syn. D. jacquemontii Hook. f.

D. triphylla Linn.

D. prazeri Prain & Burkil syn. D. clarkei Prain & Burkill

D. deltoidea Wall. var. sikkimensis Prain

D. sikkimensis Prain & Burkill

Among the above said species, D. floribunda, D. composita and D. deltoidea are widely grown for diosgenin production.

1. D. floribunda Mart. & Gal D. floribunda Mart. & Gal. is an introduction from central America and had wide adaptation as it is successfully grown in Karnataka, Assam, Meghalaya, Andaman and Goa. The vines are glabrous and left twining. The alternate leaves are borne on slender stems and have broadly ovate or triangular ovate, shallowly cordate, coriaceous lamina with 9 nerves. The petioles are 5-7cm long, thick and firm. Variegation in leaves occurs in varying degrees. The male flowers are solitary and rarely in pairs. Female flowers have divericate stigma which is bifid at apex. The capsule is obovate and seed is winged all round. The tubers are thick with yellow coloured flesh, branched and growing upto a depth of 30cm (Chadha et al, 1995).

2. D. composita Hemsl.

D. composita Hemsl. according to Knuth (1965) has the valid botanical name as D. macrostachya Benth. However, D. composita is widely used in published literature. It is a Central American introduction into Goa, Jammu, Bangalore, Anaimalai Hills of Tami Nadu and Darjeeling in W. Bengal. The vines are right twinning and nearly glabrous. The alternate leaves have long petioles, membraneous or coriaceous lamina measuring upto 20x18cm, abruptly acute or cuspidate-acuminate, shallowly or deeply cordate, 7-9 nerved. The fasciculate-glomerate inflorescence is single or branched with 2 or 3 sessile male flowers having fertile stamens. Male fascicle is 15-30cm long. The female flowers have bifid stigma. Tubers are large, white and deep-rooted (upto 45cm) (Chadha et al, 1995).

3. D. deltoidea Wall. ex. Griseb.

D. deltoidea Wall. ex. Griseb. is distributed throughout the Himalayas at altitudes of 1000-3000m extending over the states of Jammu-Kashmir, H. P, U. P, Sikkim and further into parts of W. Bengal. The glabrous and left twining stem bears alternate petiolate leaves. The petioles are 5-12 cm long. The lamina is 5-15cm long and 4-12cm wide widely cordate. The flowers are borne on axillary spikes, male spikes 8-40cm long and stamens 6. Female spikes are 15cm long, 3. 5cm broad and 4-6 seeded. Seeds are winged all round. Rhizomes are lodged in soil, superficial, horizontal, tuberous, digitate and chestnut brown in colour (Chadha et al, 1995). D. deltoidea tuber grows parallel to ground covered by small scale leaves and is described as rhizome. The tubers are morphologically cauline in structure with a ring of vascular bundles in young tubers which appear scattered in mature tubers (Purnima and Srivastava, 1988). Visible buds are present unlike in D. floribunda and D. composita where the buds are confined to the crown position (Selvaraj et al, 1972).

Importance of Diosgenin: Diosgenin is the most important sapogenin used as a starting material for synthesis of a number of steroidal drugs. For commercial purposes, its -isomer, yamogenin is also taken as diosgenin while analysing the sample for processing. Various steroidal drugs derived from diosgenin by artificial synthesis include corticosteroids, sex hormones, anabolic steroids and oral contraceptives. Corticosteroids are the most important group of steroidal drugs synthesized from diosgenin. First group of corticosteroids regulates carbohydrate and protein metabolism. The second group consists of aldosterone, which controls balance of potassium, sodium and water in the human body. The glucocorticoids in the form of cortisone and hydrocortisone are used orally, intramuscularly or topically for treatment of rheumatoid arthritis, rheumatic fever, other collegen diseases, ulcerative colitis, certain cases of asthma and a number of allergic diseases affecting skin, eye and the ear. These are also used for treatment of gout and a variety of inflammations of skin, eye and ear and as replacement therapy in Addison’s diseases. The minerato corticoides, desoxycorticosterone or desoxycortone are used in restoring kidney functions in cases of cortical deficiency and Addison’s disease.

Both male and female sex hormones are also synthesized from disosgenin. The main male sex hormone (androgen) which is produced from disogenin is testosterone. The main female sex hormones produced are oestrogen and progesterone. Recently oestrogen has also been used in cosmetic lotions and creams to improve the tone and colour of skin. One of the main uses of progesterone during recent years has been as antifertility agent for oral contraceptives. These artificial steroids have increased oral activity and fewer side effects, as they can be used in reduced doses. Oral contraceptives are also used for animals like pigs, cows and sheep to control fertility and to give birth at a prescribed period in a group of animals at the same time. These compounds are also used to reduce the interval between the lactation periods to have more milk and meat production. Anti-fertility compounds are also used as a pest-control measure for decreasing the multiplication of pests like rodents, pigeons and sea gulls (Husain et al, 1979).

Although yam tubers contain a variety of chemical substances including carbohydrates, proteins, alkaloids and tannins, the most important constituents of these yams are a group of saponins which yield sapogenins on hydrolysis. The most imp ortant sapogenin found in Dioscorea are diosgenin, yamogenin and pannogenin. Diosgenin is a steroid drug precursor. The diogenin content varies from 2-7% depending on the age of the tubers. Saponins including 5 spirastanol glucoside and 2 furostanol glucoside, 4 new steroid saponins, floribunda saponins C, D, E and F. Strain of A and B are obtained from D. floribunda (Husain et al, 1979). Rhizomes of D. deltoidea are a rich source of diosgenin and its glycoside. Epismilagenin and smilagenone have been isolated from D. deltoidea and D. prazeri (Chakravarti et al, 1960; 1962). An alkaloid dioscorine has been known to occur in D. hispida (Bhide et al,1978). Saponin of D. prazeri produced a fall of blood pressure when given intravenously and saponin of D. deltoidea has no effect on blood pressure (Chakravarti et al,1963). Deltonin, a steroidal glycoside, isolated from rhizomes of D. deltoidea showed contraceptive activity (Biokova et al, 1990).

Agrotechnology: Dioscorea species prefer a tropical climate without extremity in temperature. It is adapted to moderate to heavy rainfall area. Dioscorea plants can be grown in a variety of soils, but light soil is good, as harvesting of tubers is easier in such soils. The ideal soil pH is 5.5-6.5 but tolerates fairly wide variation in soil pH. Dioscorea can be propagated by tuber pieces, single node stem cuttings or seed. Commercial planting is normally established by tuber pieces only. Propagation through seed progeny is variable and it may take longer time to obtain tuber yields. IIHR, Bangalore has released two improved varieties, FB(c) -1, a vigorously growing strain relatively free from diseases and Arka Upkar, a high yielding clone. Three types of tuber pieces can be distinguished for propagation purpose, viz. (1) crown (2) median and (3) tip, of which crowns produce new shoots within 30 days and are therefore preferred. Dipping of tuber pieces for 5 minutes in 0.3% solution of Benlate followed by dusting the cut ends with 0.3% Benlate in talcum powder in mo ist sand beds effectively checks the tuber rot. The treatment is very essential for obtaining uniform stand of the crop. The best time of planting is the end of April so that new sprouts will grow vigorously during the rainy season commencing in June in India. Land is to be prepared thoroughly until a fine tilth is obtained. Deep furrows are made at 60cm distance with the help of a plough. The stored tuber pieces which are ready for planting is to be planted in furrows with 30cm between the plants for one year crop and 45cm between the plants for 2 year crop at about 0.5 cm below soil level. The new sprouts are to be staked immediately. After sprouting is complete, the plants are to be earthed up. Soil from the ridges may be used for earthing up so that the original furrows will become ridges and vice versa. Dioscorea requires high organic matter for good tuber formation. Besides a basal doze of 18-20t of FYM/ha, a complete fertilizer dose of 300kg N, 150kg P2O5 and K2O each are to be applied per hectare. P and K are to be applied in two equal doses one after the establishment of the crop during May-June and the other during vigorous growth period of the crop (August- September). Irrigation may be given at weekly intervals in the initial stage and afterwards at about 10 days interval. Dioscorea vines need support for their optimum growth and hence the vines are to be trailed over pandal system or trellis. Periodic hand weeding is essential for the first few months. Intercropping with legumes has been found to smother weeds and provide extra income. The major pests of Dioscorea are the aphids and red spider mites. Aphids occur more commonly on young seedlings and vines. Young leaves and vine tips eventually die if aphids are not controlled. Red spider mites attack the underside of the leaves at the base near the petiole. Severe infestations result in necrotic areas, which are often attacked by fungi. Both aphids and spider mites can be very easily controlled by Kelthane. No serious disease is reported to infect this crop. The tubers grow to about 25-30 cm depth and hence harvesting is to be done by manual labour. The best season for harvesting is Feb-March, coinciding with the dry period. On an average 50-60t/ha of fresh tubers can be obtained in 2 years duration. Diosgenin content tends to increase with age, 2.5% in first year and 3-3.5% in the second year. Hence, 2 year crop is economical (Kumar et al, 1997).... medicinal yams

Abnormal smallness of the head, usually associated with LEARNING DISABILITY. It may occur as a result of infection of the fetus by, for example, RUBELLA (German measles) or from hypoxic damage to the brain before or during birth.... microcephaly

Pregnancy The time when a woman carries a developing baby in her UTERUS. For the ?rst 12 weeks (the ?rst trimester) the baby is known as an EMBRYO, after which it is referred to as the FETUS.

Pregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.

Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.

Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.

The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.

Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.

Common complications of pregnancy

Some of the more common complications of pregnancy are listed below.

As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.

Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:

threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.

inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.

missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.

THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.

Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).

Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.

Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).

Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).

The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.

Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.

Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.

Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.

The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.

The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.

Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).

Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.

Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent

P

of the 600,000 or so annual deliveries in England) has been put down to defensive medicine

– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:

absolute and relative cephalopelvic disproportion.

placenta previa.

fetal distress.

prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.

malpresentation of the fetus such as breech or transverse lie in the womb.

unsatisfactory previous pregnancies or deliveries.

a request from the mother.

Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.

Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head

moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:

to hasten the second stage of labour if the fetus is distressed.

to facilitate the use of forceps or vacuum extractor.

to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained

to undertake and repair (with sutures) episiotomies.

(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour

A transient EXANTHEM of toddlers. Mild malaise is followed by a RUBELLA-like rash. It is caused by herpes virus 6 (see HERPES VIRUSES).... roseola infantum

Administration of a combined vaccine that gives protection against measles, mumps, and rubella. The vaccination is offered to all children at 12–15 months of age, with a booster shot at 3–5 years. Vaccination is postponed if a child is feverish, and it is not given to children with untreated cancer or allergies to aminoglycoside antibiotic drugs such as neomycin.

Mild fever, rash, and malaise may occur after vaccination. In 1 per cent of cases, mild, noninfectious swelling of the parotid glands develops 3–4 weeks after vaccination. There is no evidence for a link between and Crohn’s disease or autism.... mmr vaccination

Eruption, or rash, means an outbreak, in a scattered form, upon the surface of the skin. The skin is usually raised and red, or it may be covered with scales, or crusts, or vesicles containing ?uid. Eruptions di?er in appearance: for example, the eruption of MEASLES is always distinguishable from that of CHICKENPOX. But the same disease may also produce di?erent eruptions in di?erent people; or in the same person in di?erent states of health; or even on di?erent parts of the body at one time.

Eruptions may be acute or chronic. Most of the acute eruptions belong to the exanthemata (see EXANTHEM): that is, they are bright in col-our and burst out suddenly like a ?ower. These are the eruptions of SCARLET FEVER, measles, German measles (see RUBELLA), SMALLPOX and chickenpox. In general, the severity of these diseases can be measured by the amount of eruption. Some eruptions are very transitory, like nettle-rash, appearing and vanishing again in the course of a few hours. (See also SKIN, DISEASES OF.)... eruption

See IMMUNITY.

Age Disease and mode of administration

3 days BCG (Bacille Calmette-Guerin) by injection if tuberculosis in family in past 6 months.

2 months Poliomyelitis (oral); adsorbed diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3

3 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3

4 months Poliomyelitis (oral); diphtheria, whooping-cough (pertussis)1 and tetanus2 (triple vaccine given by injection); HiB injection.3

12–18 months Measles, mumps, and rubella (German measles)4 (given together live by injection).

(SCHOOL ENTRY)

4–5 years Poliomyelitis (oral); adsorbed diphtheria and tetanus (given together by injection); give MMR vaccine if not already given at 12–18 months.

10–14 females Rubella (by injection) if they have missed MMR.

10–14 BCG (Bacille Calmette-Guerin) by injection to tuberculin-negative children to prevent tuberculosis.

15–18 Poliomyelitis single booster dose (oral); tetanus (by injection).

1 Pertussis may be excluded in certain susceptible individuals.

2 Known as DPT or triple vaccine.

3 Haemophilus in?uenzae immunisation (type B) is being introduced to be given at same time, but di?erent limb.

4 Known as MMR vaccine. (Some parents are asking to have their infants immunised with single-constituent vaccines because of controversy over possible side-effects – yet to be con?rmed scienti?cally – of the combined MMR vaccine.)

Recommended immunisation schedules in the United Kingdom... immune system

Measles, formerly known as morbilli, is an acute infectious disease occurring mostly in children and caused by an RNA paramyxovirus.

Epidemiology There has been a dramatic fall in the number of sufferers from 1986, when more than 80,000 cases were reported. This is due to the introduction in 1988 of the measles, mumps and rubella vaccine (MMR VACCINE – see also IMMUNISATION); 1990, when the proportion of children immunised reached 90 per cent, was the ?rst year in which no deaths from measles were reported. Even so, fears of side-effects of the vaccine against measles – including scienti?cally unproven and discredited claims of a link with AUTISM – mean that some children in the UK are not being immunised, and since 2002 local outbreaks of measles have been reported in a few areas of the UK. Side-effects are, however, rare and the government is campaigning to raise the rate of immunisation, with GPs being set targets for their practices.

There are few diseases as infectious as measles, and its rapid spread in epidemics is no doubt due to the fact that this viral infection is most potent in the earlier stages. Hence the dif?culty of timely isolation, and the readiness with which the disease is spread, which is mostly by infected droplets. In developing countries measles results in the death of more than a million children annually.

Symptoms The incubation period, during which the child is well, lasts 7–21 days. Initial symptoms are CATARRH, conjunctivitis (see EYE, DISORDERS OF), fever and a feeling of wretchedness. Then Koplik spots – a classic sign of measles – appear on the roof of the mouth and lining of the cheeks. The macular body rash, typical of measles, appears 3–5 days later. Common complications include otitis media (see under EAR, DISEASES OF) and PNEUMONIA. Measles ENCEPHALITIS can cause permanent brain damage. A rare event is a gradual dementing disease (see DEMENTIA) called subacute sclerosing panenecephalitis (SSPE).

Treatment Isolation of the patient and treatment of any secondary bacterial infection, such as pneumonia or otitis, with antibiotics. Children usually run a high temperature which can be relieved with cool sponging and antipyretic drugs. Calamine lotion may alleviate any itching.... measles

A physical, chemical, or biological agent, such as radiation, the drug thalidomide, and the rubella virus, that causes abnormalities in a developing embryo or fetus.... teratogen

The presence of virus particles in the blood. Viraemia can occur at certain stages in a variety of viral infections. Some viruses, such as those responsible for viral hepatitis, yellow fever, and poliomyelitis, are transported in the bloodstream. Others, such as the rubella virus and HIV, multiply in, and spread via, certain white blood cells. If viraemia is a feature of a viral infection, there is a risk that the infection may be transmitted to other people in blood or blood products, or by insects that feed on blood.... viraemia

‘Rheumatism’ is the colloquial term for nonspeci?c musculoskeletal symptoms arising in the joints, ligaments, tendons and muscles. ‘Arthritis’ describes a pathological musculoskeletal disorder. Most common are sprains of ligaments, strains of tendons and muscles,

BURSITIS, TENDINITIS and non-speci?c back pain (see BACKACHE).

Osteoarthritis (OA) rarely starts before 40, but by the age of 80 affects 80 per cent of the population. There are structural and functional changes in the articular cartilage, as well as changes in the collagenous matrix of tendons and ligaments. OA is not purely ‘wear and tear’; various sub-groups have a genetic component. Early OA may be precipitated by localised alteration in anatomy, such as a fracture or infection of a joint. Reactive new bone growth typically occurs, causing sclerosis (hardening) beneath the joint, and osteophytes – outgrowths of bone – are characteristic at the margins of the joint. The most common sites are the ?rst metatarsal (great toe), spinal facet joints, the knee, the base of the thumb and the terminal ?nger joints (Heberden’s nodes).

OA has a slow but variable course, with periods of pain and low-grade in?ammation. Acute in?ammation, common in the knee, may result from release of pyrophosphate crystals, causing pseudo-gout.

Urate gout results from crystallisation of URIC ACID in joints, against a background of hyperuricaemia. This high concentration of uric acid in the blood may result from genetic and environmental factors, such as excess dietary purines, alcohol or diuretic drugs.

In?ammatory arthritis is less common than OA, but potentially much more serious. Several types exist, including: SPONDYLARTHRITIS This affects younger men, chie?y involving spinal and leg joints. This may lead to in?ammation and eventual ossi?cation of the enthesis – that is, where the ligaments and tendons are inserted into the bone around joints. This may be associated with disorders in other parts of the body: skin in?ammation (PSORIASIS), bowel and genito-urinary in?ammation, sometimes resulting in infection of the organs (such as dysentery). The syndromes most clearly delineated are ankylosing spondylitis (see SPINE AND SPINAL CORD, DISEASES AND INJURIES OF), psoriatic or colitic spondylitis, and REITER’S SYNDROME. The diagnosis is made clinically and radiologically; no association has been found with autoantibodies (see AUTOANTIBODY). A particularly clear gene locus, HLA B27, has been identi?ed in ankylosing spondylitis. Psoriasis can be associated with a characteristic peripheral arthritis.

Systemic autoimmune rheumatic diseases (see AUTOIMMUNE DISORDERS). RHEUMATOID ARTHRITIS (RA) – see also main entry. The most common of these diseases. Acute in?ammation causes lymphoid synovitis, leading to erosion of the cartilage, associated joints and soft tissues. Fibrosis follows, causing deformity. Autoantibodies are common, particularly Rheumatoid Factor. A common complication of RA is Sjögren’s syndrome, when in?ammation of the mucosal glands may result in a dry mouth and eyes. SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) and various overlap syndromes occur, such as systemic sclerosis and dermatomyositis. Autoantibodies against nuclear proteins such as DNA lead to deposits of immune complexes and VASCULITIS in various tissues, such as kidney, brain, skin and lungs. This may lead to various symptoms, and sometimes even to organ failure.

Infective arthritis includes: SEPTIC ARTHRITIS An uncommon but potentially fatal disease if not diagnosed and treated early with approriate antibiotics. Common causes are TUBERCLE bacilli and staphylococci (see STAPHYLOCOCCUS). Particularly at risk are the elderly and the immunologically vulnerable, such as those under treatment for cancer, or on CORTICOSTEROIDS or IMMUNOSUPPRESSANT drugs. RHEUMATIC FEVER Now rare in western countries. Resulting from an immunological reaction to a streptococcal infection, it is characterised by migratory arthritis, rash and cardiac involvement.

Other infections which may be associated with arthritis include rubella (German measles), parvovirus and LYME DISEASE.

Treatment Septic arthritis is the only type that can be cured using antibiotics, while the principles of treatment for the others are similar: to reduce risk factors (such as hyperuricaemia); to suppress in?ammation; to improve function with physiotherapy; and, in the event of joint failure, to perform surgical arthroplasty. NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS) include aspirin, paracetamol and many recently developed ones, such as the proprionic acid derivatives IBUPROFEN and naproxen, along with other drugs that have similar properties such as PIROXICAM. They all carry a risk of toxicity, such as renal dysfunction, or gastrointestinal irritation with haemorrhage. Stronger suppression of in?ammation requires corticosteroids and CYTOTOXIC drugs such as azathioprine or cyclophosphamide. Recent research promises more speci?c and less toxic anti-in?ammatory drugs, such as the monoclonal antibodies like in?iximab. An important treatment for some osteoarthritic joints is surgical replacement of the joints.... joints, diseases of

Mumps, also known as epidemic parotitis, is an infectious disease characterised by in?ammatory swelling of the PAROTID GLAND and other SALIVARY GLANDS – often occurring as an EPIDEMIC and affecting mostly young people. Its name comes from the old verb, ‘mump’, meaning to mope or assume a disconsolate appearance – an apt description of the victim of the disease at its height.

Causes Mumps is due to infection with a virus and is highly infectious from person to person. It is predominantly a disease of childhood and early adult life, but it can occur at any age. Epidemics usually occur in the winter and spring. It is infectious for two or three days before the swelling of the glands appears. A vaccine is now available that gives a high degree of protection against the disease, the incidence of which is falling sharply. The vaccine is combined with those for MEASLES and RUBELLA – see MMR VACCINE; IMMUNISATION.

Symptoms There is an incubation period of 2–3 weeks after infection before the glands begin to swell. The gland ?rst affected is generally the parotid, situated in front of and below the ear. The swelling usually spreads to the submaxillary and sublingual glands lying beneath the jaw. The patient is feverish and the gland is tender. The swelling disappears after about ?ve days. In 15–30 per cent of males, in?ammation of the testicles (orchitis) develops. This usually occurs during the second week of the illness, but may not occur until 2–3 weeks later; it may result in partial ATROPHY of the testicles, but practically never in INFERTILITY. In a much smaller proportion of females with mumps, in?ammation of the OVARIES or BREASTS may occur. In?ammation of the PANCREAS, accompanied by tenderness in the upper part of the abdomen and digestive disturbances, sometimes results, and MENINGITIS is also an occasional complication. The various complications are found much more often when the disease affects adults than when it occurs in childhood.

Treatment There is no speci?c treatment but ANALGESICS and plenty of ?uid should be available. The child may need to be in bed for a few days and should not return to school until the symptoms have settled. Adults with orchitis may need strong painkillers, and CORTICOSTEROIDS may be required to reduce the painful swelling.... mumps

Diseases, usually of an infectious nature, which are required by law to be made known to a health o?cer or local authority. (See INFECTION.) Certain occupational diseases are also noti?able.

Noti?able diseases in the UK (For more information on a speci?c disease, refer to the separate dictionary entry.) Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery (amoebic or bacillary) Ebola virus disease Food poisoning Lassa fever Leprosy (reported to Chief Medical O?cer at the Department of Health) Leptospirosis Malaria Marburg disease Measles Meningitis Meningococcal septicaemia (without meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Rubella Scarlet fever Smallpox Tetanus Tuberculosis Typhoid fever Typhus Viral haemorrhagic fever (including Lassa fever) Viral hepatitis Whooping cough Yellow fever

Reporting AIDS is voluntary (and in con?dence) to the Director, Communicable Diseases Surveillance Centre (PHLS).... notifiable diseases

Tea Tree Essential Oil

Tea tree oil is often referred to as “medicine cabinet in a bottle,” as it’s remedies are seemingly endless. Check out these 79 uses for the ultimate survival remedy:

1. Abrasions and minor cuts
2. Acne
3. Air freshener
4. Allergies
5. Arthritus
6. Asthma
7. Athletes foot
8. Baby care
9. Bacterial infections
10. Bad breath
11. Bladder infection
12. Blisters
13. Boils
14. Bronchial congestion
15. Bronchitus
16. Bruises
17. Bunions
18. Burns
19. Calluses/corns
20. Canker sores
21. Carbuncies
22. Chapped lips
23. Chicken pox
24. Chigger bite
25. Cold sores
26. Coughs
27. Dandruff
28. Dermatitus
29. Dry skin
30. Eczema
31. Emphysema
32. Flea bites
33. Gout
34. Gum disease
35. Head lice
36. Hives
37. Homemade mouthwash
38. Household cleaning
39. Immune system
40. Infected wounds
41. Inflammation
42. Ingrown hair
43. Insect repellant
44. Jock itch
45. Laryngitis
46. Laundry helper
47. Mildew/mold remover
48. Mosquito bites
49. Muscle aches/pains
50. Mumps
51. Nail fungus
52. Pest control
53. Plantar warts
54. Psoriasis
55. Rashes
56. Rheumatism
57. Ringworm
58. Rubella
59. Scabies
60. Sciatica
61. Seborrhea
62. Shingles
63. Shock
64. Sinusitis
65. Sore muscles
66. Sore throat
67. Staph infection
68. Stye
69. Sunburn
70. Tattoos
71. Thrush
72. Ticks
73. Toenail fungus
74. Toothbrush cleaner
75. Tonsillitus
76. Vaginal infection
77. Viral infections
78. Warts
79. Wounds

 ... tea tree essential oil

The term applied to a group of infective agents which are so small that they are able to pass through the pores of collodion ?lters. They are responsible for some of the most devastating diseases affecting humans: for example, INFLUENZA, POLIOMYELITIS, SMALLPOX and YELLOW FEVER. The virus of in?uenza measures 80 nanometres, whereas the STAPHYLOCOCCUS measures 1,000 nanometres (1 nanometre = one thousand-millionth of a metre).

A single virus particle, known as a virion, comprises an inner core of NUCLEIC ACID which is surrounded by one or two protective coverings (capsid) made of protein. Sometimes the capsid is enclosed by another layer called the viral envelope (also a protein structure). The envelope often disintegrates when the virus invades a cell. Viruses enter cells and then indulge in a complex and variable process of replication using some of the cells’ own structure. Viruses may stay in a host’s nucleus, being reactivated months or years later. There are more than a score of large families of viruses, from papoviruses, which cause WARTS, through HERPES viruses (cold sores, CHICKENPOX, SHINGLES) and orthomyxoviruses (in?uenza), to corona viruses (common cold) and retroviruses (AIDS/HIV). Viral diseases are more dif?cult to treat than those caused by bacteria: ANTIBIOTICS are ine?ective but INTERFERON, a group of natural substances, shows promise. IMMUNISATION is the most e?ective way of combating viral infections; smallpox, poliomyelitis, MUMPS, MEASLES and RUBELLA are examples of viral diseases which have been successfully combated. Research is progressing to ?nd a vaccine against HIV.... virus

Abnormalities that are obvious at birth or detectable early in infancy. Also called congenital defects, they encompass both minor abnormalities, such as birthmarks, and serious disorders such as spina bifida.

Causes include chromosomal abnormalities, genetic defects, drugs taken during pregnancy, exposure to radiation, and infections. In some cases, the cause of a defect is unknown. Defects that are due to chromosomal abnormalities include Down’s syndrome. Some defects, such as achondroplasia and albinism, are usually inherited from 1 or both parents (see gene; genetic disorders). Certain drugs and chemicals (called teratogens) can damage the fetus if the mother takes or is exposed to them during early pregnancy. Teratogenic drugs include thalidomide (now rarely prescribed) and isotretinoin, which is used in the treatment of severe acne. Alcohol can affect the development of the brain and face (see fetal alcohol syndrome).

Irradiation of the embryo in early pregnancy can cause abnormalities. Very small doses of radiation increase the child’s risk of developing leukaemia later in life (see radiation hazards).

Certain illnesses, such as rubella (German measles) and toxoplasmosis, can cause birth defects if they are contracted during pregnancy.

Brain and spinal cord abnormalities, such as spina bifida and hydrocephalus, and congenital heart disorders (see heart disease, congenital) result from interference with the development of particular groups of cells. Other common defects include cleft lip and palate.

Ultrasound scanning and blood tests during pregnancy can identify women at high risk of having a baby with a birth defect. Further tests such as chorionic villus sampling, amniocentesis, or fetoscopy may then be carried out.... birth defects

Loss of transparency of the crystalline lens of the eye, due to changes in its delicate protein fibres. At an advanced stage, the front part of the lens becomes densely opaque, but the cataract never causes total blindness.

Almost everyone over 65 has some degree of cataract. Regular exposure to ultraviolet light increases the risk. Other causes include injury to the eye, particularly if a foreign body enters the lens. Cataract is common in people who have diabetes mellitus. Long-term use of corticosteroid drugs may contribute to cataract development. Congenital cataract may be due to an infection of the mother in early pregnancy, especially with rubella, to the toxic effects of certain drugs in pregnancy, or be associated with Down’s syndrome or galactosaemia.

Onset of symptoms is almost imperceptible, although night driving may be affected early on.

There is slow, progressive loss of visual acuity.

The person may become shortsighted and notice disturbances in colour perception.

When vision has become seriously impaired, cataract surgery is performed to remove the lens.... cataract

Complete or partial loss of hearing in 1 or both ears. There are 2 types of deafness: conductive deafness, which results from faulty propagation of sound from the outer to the inner ear; and sensorineural deafness, in which there is a failure in transmission of sounds to the brain. Hearing tests can determine whether deafness is conductive or sensorineural.

The most common cause of conductive deafness in adults is earwax. Otosclerosis is a less common cause and is usually treated by an operation called stapedectomy, in which the stapes (a small bone in the middle ear) is replaced with an artificial substitute. In a child, conductive deafness usually results from otitis media or glue ear. This condition may be treated by surgery (see myringotomy). In rare cases, deafness results from a perforated eardrum (see eardrum, perforated). Sensorineural deafness may be present from birth. This type of deafness may result from a birth injury or damage resulting from maternal infection with rubella at an early stage of pregnancy. Inner-ear damage may also occur soon after birth as the result of severe jaundice. Deafness at birth is incurable. Many children who are born deaf can learn to communicate effectively, often by using sign language. Cochlear implants may help those children born profoundly deaf to learn speech.

In later life, sensorineural deafness can be due to damage to the cochlea and/or labyrinth. It may result from prolonged exposure to loud noise, to Ménière’s disease, to certain drugs, or to some viral infections. The cochlea and labyrinth also degenerate naturally with old age, resulting in presbyacusis. Sensorineural deafness due to damage to the acoustic nerve may be the result of an acoustic neuroma. Deafness may be accompanied by tinnitus and vertigo. Sometimes it can lead to depression.

People with sensorineural deafness usually need hearing-aids to increase the volume of sound reaching the inner ear. Lip-reading is invaluable for deaf people. Other aids, such as an amplifier for the earpiece of a telephone, are available. (See also ear; hearing.)... deafness

The ear is susceptible to various disorders, some of which can lead to deafness. In rare cases, the ear canal, ossicles in the middle ear, or pinna are absent or deformed at birth. Rubella in early pregnancy can damage the baby’s developing ear, leading to deafness. Most cases of congenital sensorineural deafness are genetic.

Infection is the most common cause of ear disorders; it may occur in the ear canal, leading to otitis externa, or affect the middle ear, causing otitis media. This can lead to perforation of the eardrum (see eardrum, perforated). Persistent glue ear, often due to infection, is the most common cause of childhood hearing difficulties. Viral infection of the inner ear may cause labyrinthitis.

Cauliflower ear is the result of one large or several small injuries to the pinna. Perforation of the eardrum can result from poking objects into the ear or loud noise. Prolonged exposure to loud noise can cause tinnitus and/or deafness. Pressure changes associated with flying or scuba diving can also cause minor damage (see barotrauma).Tumours of the ear are rare. Acoustic neuroma is a noncancerous tumour of the acoustic nerve that may press on structures in the ear to cause deafness, tinnitus, and problems with balance.

In cholesteatoma, skin cells and debris collect in the middle ear. Obstruction of the ear canal is most often the result of earwax, although in small children, an object may have been pushed into the ear (see ear, foreign body in).

In otosclerosis, a hereditary condition, a bone in the middle ear becomes fixed, causing deafness. Meniérè’s disease is an uncommon condition in which deafness, vertigo, and tinnitus result from the accumulation of fluid in the inner ear. Deafness in many elderly people is due to presbyacusis, in which hair cells in the cochlea deteriorate.

Certain drugs, such as aminoglycoside drugs and some diuretic drugs, can damage ear function.... ear, disorders of

Inflammation of the brain and spinal cord, causing damage to the nervous system. Encephalomyelitis develops as a rare complication of measles or, less commonly, of other viral infections such as chickenpox, rubella, or infectious mononucleosis. Symptoms include fever, headache, drowsiness, seizures, partial paralysis or loss of sensation, and, in some cases, coma.

Diagnosis is as for encephalitis. There is no cure, but corticosteroid drugs are given to reduce inflammation and anticonvulsant drugs to control seizures. The disease is often fatal; those who survive may have permanent damage to the nervous system.

Myalgic encephalomyelitis is another term for chronic fatigue syndrome.... encephalomyelitis

Any abnormality of the heart present from birth. Defects may affect the heart chambers, valves, or main blood vessels. Major abnormalities are septal defects, coarctation of the aorta, transposition of the great vessels, patent ductus arteriosus, tetralogy of Fallot, hypoplastic left heart syndrome, pulmonary stenosis, and aortic stenosis.

Developmental errors leading to defects arise early in the life of the embryo. In most cases, there is no known cause. Rubella in the mother is the most common known cause.

The onset and severity of symptoms depend on the defect. Some anomalies cause cyanosis and breathlessness but others may go undetected. Possible complications of an untreated heart defect include impaired growth, pneumonia as a result of mild respiratory infections, rapid tiring during exercise, and Eisenmenger complex.

Antenatal diagnosis, using specialized ultrasound scanning, is possible for most defects. After birth, any suspected defect is investigated using chest Xrays, ECG, or echocardiography.

Oxygen and various drug treatments may improve the symptoms of heart block. Some conditions, such as small septal defects or patent ductus arteriosus, may get smaller or disappear of their own accord. Other defects will require surgical correction. Narrowed heart valves can often be treated by balloon valvuloplasty. In other cases, open heart surgery or a heart transplant may be required.

Children with heart defects are at an increased risk of bacterial endocarditis; to prevent this, they are given antibiotic drugs before all surgical procedures including dental treatments.... heart disease, congenital

The process of inducing immunity as a preventive measure against infectious diseases. Immunization may be active or passive. In the passive form,antibodies are injected into the blood to provide immediate but short-lived protection against specific bacteria, viruses, or toxins. Active immunization, also called vaccination, primes the body to make its own antibodies and confers longer-lasting immunity.

Routine childhood immunization programmes exist for diseases such as diphtheria, pertussis, and tetanus (see DPT vaccination), haemophilus influenza (Hib), measles, mumps, and rubella (see MMR vaccination), meningitis C, and poliomyelitis. Additional immunizations before foreign travel may also be necessary (see travel immunization).

Most immunizations are given by injection, and usually have no after effects. However, some vaccines cause pain and swelling at the injection site and may produce a slight fever or flu-like symptoms. Some may produce a mild form of the disease. Very rarely, severe reactions occur due, for example, to an allergy to 1 of the vaccine’s components. Not all vaccines provide complete protection. Cholera and typhoid fever vaccinations, in particular, give only partial protection.

People with immunodeficiency disorders, widespread cancer, those taking corticosteroid drugs, or those who have previously had a severe reaction to a vaccine should not be immunized. Some vaccines should not be given to young children or during pregnancy.... immunization

Infection acquired in the uterus or during birth. Many microorganisms can pass from the mother, by way of the placenta, into the circulation of the growing fetus. Particularly serious infections acquired in the uterus are rubella, syphilis, toxoplasmosis, and cytomegalovirus; all these infections may cause intrauterine growth retardation. Rubella that occurs in early pregnancy may cause deafness, congenital heart disease, and eye disorders. Some infections in later pregnancy, particularly with a herpes virus, may also damage the fetus severely. A woman infected with HIV risks passing on the virus to her baby during pregnancy, but the risk can be reduced by use of antiretroviral drugs during the pregnancy.

Infections acquired during birth are almost always the result of microorganisms in the mother’s vaginal secretions or uterine fluid. Premature rupture of the membranes is associated with increased risk of infection, particularly streptococcal. Conditions that can be acquired during delivery include herpes, chlamydial infections, and gonorrhoea.

Treatment of the baby depends on the type of infection. Some birth defects caused by infection (such as certain types of heart defect) can be treated; others (such as congenital deafness) are usually not treatable.... infection, congenital