Hyperthyroidism

 Introduction

Thyroid hormones regulate our body's metabolism and influence virtually every organ system in the body. They tell organs how fast or slow they should work. Thyroid hormones also regulate the body's consumption of oxygen and production of heat.  Thyroid problems, such as an overactive or underactive thyroid, can severely affect metabolism.  There are several thyroid conditions you may want to be aware of.

Symptoms of Hyperthyroidism:

Hyperthyroidism, the result of an overactive thyroid, more commonly affects women between the ages of 20 and 40, but men can also develop this condition. The symptoms of this thyroid condition can be frightening.
Symptoms can include:

• Muscle weakness
• Trembling hands
• Rapid heartbeat
• Fatigue
• Weight loss
• Diarrhea or frequent bowel movements
• Irritability and anxiety
• Vision problems (irritated eyes or difficulty seeing)
• Menstrual irregularities
• Intolerance to heat and increased sweating
• Infertility

Causes of Hyperthyroidism:

Graves' disease is the most common cause of hyperthyroidism. It occurs when the immune system produces antibodies that attack the thyroid gland, making it produce too much thyroid hormone and creating a hormone imbalance. This condition happens often in people with a family history of thyroid disease. In some patients with Graves' disease, one of the noticeable symptoms may be swelling behind the eyes, causing discomfort or increased tearing or causing the eyes to push forward or bulge.
Other causes of hyperthyroidism include the following:

• Thyroid nodules. (Read more on THYROID NODULES.)
• Taking too much thyroid hormone medication to treat other conditions.
• Subacute thyroiditis. This painful inflammation of the thyroid is usually caused by a virus. When the infection leaves, the condition improves.
• Lymphocytic thyroiditis and postpartum thyroiditis. These related autoimmune disorders cause a temporary painless inflammation of the gland. Thyroiditis is marked by lymphocytes (white blood cells) inside the thyroid and leads to leakage of thyroid hormone from the infmlamed gland, raising hormone levels in the bloodstream.

Treatments of Hyperthyroidism:

Antithyroid Drugs: These drugs work to decrease the amount of hormone the thyroid gland makes. For most patients, the preferred drug is methimazole because of its safety record. Another drug, propylthiouracil (PTU) may be preferred for patients who are allergic to or intolerant of methimazole and for pregnant women in their first trimester of pregnancy.
Antithyroid drugs may have to be taken for an extended period - even one to two years or longer. The thyroid condition may go away, but there could be a relapse, even years later. Therapy with antithyroid drugs is typically thought of as either short term or long term. Short-term therapy is used to make the thyroid blood tests normal before a decision is reached about definitive therapy. Long-term therapy is used in some patients to try to make the disease go into remission even after the antithyroid drug is stopped.
Beta-blockers: Beta-blocker drugs, such as atenolol, do not block the production of thyroid hormone. Instead, they control many troubling symptoms of this hormone imbalance, especially rapid heart rate, trembling, anxiety, and the high amount of heat the body produces with this condition.
Radioactive iodine: The thyroid gland normally collects iodine out of the bloodstream to make thyroid hormone. Radioactive iodine treatment involves taking a radioactive form of iodine that causes the permanent destruction of the thyroid. The response to treatment can take from 6 to 18 weeks. Because the radioiodine often destroys some of the normal function of the thyroid gland, people who have this therapy will likely need to take thyroid hormone for the rest of their lives to replace their hormone levels. Most physicians agree that the desirable goal of radioactive therapy is to completely remove thyroid gland function since then there is a very low chance of hyperthyroidism coming back.
Surgery: Removal of the thyroid gland (thyroidectomy) is another permanent solution, but is often the least preferred option. This procedure must be performed by a highly skilled and experienced thyroid surgeon because of the risk of damage to nerves around the larynx (voice box) and to the nearby parathyroid glands, which control calcium metabolism in the body. Surgery is recommended when there is a large goiter (enlarged thyroid gland) that makes breathing difficult or when antithyroid drugs are not working, or when there are reasons not to take radioactive iodine. It may also be used in patients who also have thyroid nodules, especially when the nodules may be cancerous.  In the latter instance, additional thyroid cancer treatment is often required.
After both radioactive iodine and surgery treatments, the patient will need to be monitored regularly for adequate thyroid hormone levels in the blood. After such treatment, most patients become hypothyroid and no longer produce enough thyroid hormone. For this reason, they must take a daily supplement of synthetic thyroid hormone to correct the hormone imbalance.
If left untreated, hyperthyroidism can lead to other health problems including congestive heart failure as well as osteoporosis, which causes brittle bones.

Treatment,Prognosis,Complications & Preventions of Diabetes

Treatment of Diabetes:

The immediate goals are to treat diabetic ketoacidosis and high blood glucose levels. Because type 1 diabetes can start suddenly and have severe symptoms, people who are newly diagnosed may need to go to the hospital.

The long-term goals of treatment are to:

• Prolong life
• Reduce symptoms
• Prevent diabetes-related complications such as blindness, heart disease, kidney failure, and amputation of limbs

These goals are accomplished through:

• Blood pressure and cholesterol control
• Careful self testing of blood glucose levels
• Education
• Exercise
• Foot care
• Meal planning and weight control
• Medication or insulin use

There is no cure for diabetes. Treatment involves medicines, diet, and exercise to control blood sugar and prevent symptoms.

LEARN THESE SKILLS

Basic diabetes management skills will help prevent the need for emergency care. These skills include:

• How to recognize and treat low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia)
• What to eat and when
• How to take insulin or oral medication
• How to test and record blood glucose
• How to test urine for ketones (type 1 diabetes only)
• How to adjust insulin or food intake when changing exercise and eating habits
• How to handle sick days
• Where to buy diabetes supplies and how to store them

After you learn the basics of diabetes care, learn how the disease can cause long-term health problems and the best ways to prevent these problems. Review and update your knowledge, because new research and improved ways to treat diabetes are constantly being developed.

SELF-TESTING

If you have diabetes, your doctor may tell you to regularly check your blood sugar levels at home. There are a number of devices available, and they use only a drop of blood. Self-monitoring tells you how well diet, medication, and exercise are working together to control your diabetes. It can help your doctor prevent complications.

The American Diabetes Association recommends keeping blood sugar levels in the range of:

• 80 - 120 mg/dL before meals
• 100 - 140 mg/dL at bedtime

Your doctor may adjust this depending on your circumstances.

WHAT TO EAT

You should work closely with your health care provider to learn how much fat, protein, and carbohydrates you need in your diet. A registered dietician can help you plan your dietary needs.

People with type 1 diabetes should eat at about the same times each day and try to be consistent with the types of food they choose. This helps to prevent blood sugar from becoming extremely high or low.

People with type 2 diabetes should follow a well-balanced and low-fat diet.

HOW TO TAKE MEDICATION

Medications to treat diabetes include insulin and glucose-lowering pills called oral hypoglycemic drugs.

People with type 1 diabetes cannot make their own insulin. They need daily insulin injections. Insulin does not come in pill form. Injections are generally needed one to four times per day. Some people use an insulin pump. It is worn at all times and delivers a steady flow of insulin throughout the day. Other people may use inhaled insulin.

Unlike type 1 diabetes, type 2 diabetes may respond to treatment with exercise, diet, and medicines taken by mouth. There are several types of medicines used to lower blood glucose in type 2 diabetes.

Medications may be switched to insulin during pregnancy and while breastfeeding.

Gestational diabetes may be treated with exercise and changes in diet.

EXERCISE

Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or stroke than those who do not exercise regularly.

Here are some exercise considerations:

• Always check with your doctor before starting a new exercise program.
• Ask your doctor or nurse if you have the right footwear.
• Choose an enjoyable physical activity that is appropriate for your current fitness level.
• Exercise every day, and at the same time of day, if possible.
• Monitor blood glucose levels before and after exercise.
• Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise.
• Carry a diabetes identification card and a cell phone in case of emergency.
• Drink extra fluids that do not contain sugar before, during, and after exercise.

You may need to change your diet or medication dose if you change your exercise intensity or duration to keep blood sugar levels from going too high or low.

FOOT CARE

People with diabetes are more likely to have foot problems. Diabetes can damage blood vessels and nerves and decrease the body's ability to fight infection. You may not notice a foot injury until an infection develops. Death of skin and other tissue can occur.

If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations.

To prevent injury to the feet, check and care for your feet every day.

Prognosis of Diabetes:

With good blood glucose and blood pressure control, many of the complications of diabetes can be prevented.

Studies have shown that strict control of blood sugar, cholesterol, and blood pressure levels in persons with diabetes helps reduce the risk of kidney disease, eye disease, nervous system disease, heart attack, and stroke.

Possible Complications of Diabetes:
Emergency complications include:

• Diabetic hyperglycemic hyperosmolar coma
• Diabetic ketoacidosis

Long-term complications include:

Diabetic Retinopathy

• Atherosclerosis
• Coronary artery disease
• Diabetic nephropathy
• Diabetic neuropathy
• Diabetic retinopathy
• Erection problems
• Hyperlipidemia
• Hypertension
• Infections of the skin, female urinary tract, and urinary tract
• Peripheral vascular disease
• Stroke

When to Contact a Medical Professional:
Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of ketoacidosis:

• Abdominal pain
• Deep and rapid breathing
• Increased thirst and urination
• Loss of consciousness
• Nausea
• Sweet-smelling breath

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of extremely low blood sugar (hypoglycemic coma or severe insulin reaction):

• Confusion
• Convulsions or unconsciousness
• Dizziness
• Double vision
• Drowsiness
• Headache
• Lack of coordination
• Weakness

Preventions of Diabetes:

Maintaining an ideal body weight and an active lifestyle may prevent type 2 diabetes.

Currently there is no way to prevent type 1 diabetes.

There is no effective screening test for type 1 diabetes in people who don't have symptoms.

Screening for type 2 diabetes and people with no symptoms is recommended for:

• Overweight children who have other risk factors for diabetes starting at age 10 and repeating every 2 years
• Overweight adults (BMI greater than 25) who have other risk factors
• Adults over 45, repeated every 3 years

To prevent complications of diabetes, visit your health care provider or diabetes educator at least four times a year. Talk about any problems you are having.
Regularly have the following tests:

• Have your blood pressure checked every year (blood pressure goals should be 130/80 mm/Hg or lower).
• Have your glycosylated hemoglobin (HbA1c) checked every 6 months if your diabetes is well controlled, otherwise every 3 months.
• Have your cholesterol and triglyceride levels checked yearly (aim for LDL levels below 100 mg/dL).
• Get yearly tests to make sure your kidneys are working well (microalbuminuria and serum creatinine).
• Visit your ophthalmologist (preferably one who specializes in diabetic retinopathy) at least once a year, or more often if you have signs of diabetic retinopathy.
• See the dentist every 6 months for a thorough dental cleaning and exam. Make sure your dentist and hygienist know that you have diabetes.
• Make sure your health care provider inspects your feet at each visit.

Stay up-to-date with all of your vaccinations and get a flu shot every year in the fall.

Diagnosis of Pneumonia

Pneumonia Diagnosis:

Pneumonia can be hard to diagnose because it may seem like a cold or the flu. People may not realize it’s more serious until it lasts longer than these other conditions.

Your doctor will diagnose pneumonia based on your medical history and the results from a physical exam and tests.

Medical History
Your doctor will ask about your signs and symptoms and how and when they began. To find out what type of germ is causing the pneumonia, he or she also may ask about:

• Any recent traveling you’ve done
• Your hobbies
• Your exposure to animals
• Your exposure to sick people at home, school, or work
• Your past and current medical conditions, and whether any have gotten worse recently
• Any medicines you take
• Whether you smoke
• Whether you've had a flu or pneumonia vaccination

Physical Exam

Your doctor will listen to your lungs with a stethoscope. If you have pneumonia, your lungs may make crackling, bubbling, and rumbling sounds when you inhale. It may be hard to hear sounds of breathing in some areas of your chest. Your doctor also may hear wheezing.

Diagnostic Tests
If your doctor suspects you have pneumonia, he or she also may order one or more of the following tests.

Chest X Ray

A chest x ray is a painless test that creates pictures of the structures inside your chest, such as your heart and lungs.

X-ray of chest in pneumonia

A chest x ray is the best test for diagnosing pneumonia. However, this test won’t tell your doctor what kind of germ is causing the pneumonia.

Blood Tests

Blood tests involve taking a sample of blood from a vein in your body. A complete blood count (CBC) measures many parts of your blood, including the number of white blood cells in the blood sample. The number of white blood cells can show whether you have a bacterial infection.

Your doctor also may order a blood culture to find out whether the infection has spread to your bloodstream. This test is used to detect germs in the bloodstream. It may show which germ caused the infection. If so, your doctor can decide how to treat the infection.

Other Tests

You may need other tests if you’re in the hospital, have serious symptoms, are older, or have other health problems.

Sputum test. Your doctor may look at a sample of sputum (spit) collected from you after a deep cough. This may help your doctor find out what germ is causing your pneumonia . Then, he or she can plan treatment.

Chest CT scan. A chest CT scan is a painless test that creates precise pictures of the structures in your chest, such as your lungs. A chest CT scan is a kind of x ray, but its pictures show more detail than those of a standard chest x ray.

Pleural fluid culture. For this test, a sample of fluid is taken from the space between your lungs and chest wall (the pleural space). This is done using a procedure called thoracentesis (THOR-a-sen-TE-sis). The fluid is studied for germs that may cause pneumonia.

Pulse oximetry. For this test, a small clip is attached to your finger or ear to show how much oxygen is in your blood. Pneumonia can keep your lungs from moving enough oxygen into your bloodstream.

If you’re very sick, your doctor may need to measure the level of oxygen in your blood using a blood sample. The sample is taken from an artery, usually in your wrist.

Bronchoscopy. Bronchoscopy (bron-KOS-ko-pee) is a procedure used to look inside the lungs' airways. If you’re in the hospital and treatment with antibiotics isn’t working well, your doctor may use this test.

Your doctor passes a thin, flexible tube with a camera on its tip through your nose or mouth, down your throat, and into the airways.

This test allows your doctor to see whether something is blocking your airways or whether another factor is contributing to your pneumonia.

Multiple Sclerosis

Multiple Sclerosis

Introduction:

Multiple Sclerosis (MS) is a disease of the central nervous system which leads to recurring attacks of neurological symptoms. The deterioration in function is related to something termed "demyelination".

Nerve cells connect to other nerve cells at a distance by way of a long wire-like extension of the cell called an axon. The axon carries an electrical signal along its length to transmit messages from one cell to the next. These can be quite long, carrying nervous system impulses up to feet at a time through the spinal cord and brain. Most of these long axons are myelinated, wrapped in an insulating substance called myelin. The myelin helps the electrical impulses conduct quickly and efficiently down the length of the axon.

In MS, the myelin sheath around some axons in the central nervous system becomes damaged. This damage makes conduction along these axons faulty, slowing or stopping completely, leading to symptoms. These areas of demyelination, called MS plaques, are patchy and can occur almost anywhere in the brain or spinal cord at various times. The specific symptoms that occur depend on the specific location of the demyelination within the nervous system. The pattern and time course of these occurrences varies depending on the type of multiple sclerosis. Most commonly, the demyelination occurs in attacks which then resolve, the symptoms improving partially or completely. Further attacks then occur at a later date.

Cause of Multiple Sclerosis:

The exact cause of multiple sclerosis is not well understood. What is fairly well accepted is that the damage to the myelin sheath, the "insulation" of nerve fibers, which characterizes MS and causes its primary symptoms, is caused by an autoimmune (against your own body tissues) attack on the myelin producing cells, called oligodendrocytes. It is unclear what initiates this inflammatory reaction, but the immune system, which should usually be able to tell "self" from "non-self", gets confused and attacks the myelin sheath in the central nervous system. Normally the immune system is important for fighting disease, fighting off invaders (bacteria, viruses, fungi, etc.), getting rid of foreign substances and abnormal cells. There are several types of autoimmune diseases and for most the underlying cause is not well understood. Likely, the underlying etiology that leads to the disease is multifactorial, resulting from some combination of environmental and genetic factors.

Environmental Factors:

An interesting finding in the prevalence of multiple sclerosis is that it occurs more frequently in parts of the world which are further from the equator. It is quite common in northern Europe, in Scotland and the Scandinavian countries. However, if people born in these areas move to areas with lower risk (closer to the equator) their risk of developing the disease drops to about that of others. This implies that some environmental factor in higher latitudes may play a part in the underlying cause of multiple sclerosis. The details of this environmental influence are not well understood.

Genetic Factors:

People with close relatives with MS are at higher risk for MS. Therefore it is assumed that there are some genetic factors which help predispose to the disease, although this does not seem to be the only cause. It is likely that any such genetic predisposition is related to multiple genes as no single gene abnormality has been associated with the disease.

Other Factors:

Researchers have long hypothesized that some virus could be linked to MS, perhaps setting off the autoimmune attack. However, this has not been proven and no virus has been consistently to be associated with MS. There is also some evidence that hormone activity, particularly the sex hormones, may be associated with the disease; but again the details of this association are not clear.

Multiple Sclerosis Symptoms:

Generalizing multiple sclerosis symptoms can be difficult because it can affect each patient differently. Because multiple sclerosis can cause demyelination of nerve fibers in any part of the central nervous system (brain and spinal cord) the variety of types of symptoms which can occur is great. In theory, just about any normal function of the central nervous system can become dysfunctional if affected by multiple sclerosis and lead to related symptoms of nervous system function.

Commonly, multiple sclerosis symptoms come on in attacks which affect one or more parts of the nervous system. These attacks last a variable amount of time and in the most common types of MS will then slowly recover. Each new attack of MS can vary in the parts of the nervous system that is affected and, therefore, the associated symptoms.

While the exhaustive list of possible symptoms of MS is long, there are some common types of symptoms which can affect many patients at one time or another. Again, the specifics of these symptoms, their location in the body, their severity and their duration varies considerably from one patient to the next.

Types of Possible MS Symptoms:

• Sensory: Including numbness, tingling, and pain.
• Motor: Including weakness in one or more limbs, spasticity and muscle spasm, tremors, facial paralysis, etc.
• Coordination and Balance: Including lack of fine motor or gross motor coordination, clumsiness, loss of balance and falls, difficulty walking, etc.
• Vision: Blurred or double vision, blindness, loss of vision in part of the visual field, etc.
• Speech: Such as slurred speech.
• Non-Specific Symptoms: Various other symptoms are possible such as fatigue (quite common), heat sensitivity, dizziness, impaired thinking, etc.

The progression of these types of symptoms and the course of the disease throughout a patient's life can vary quite considerably as there are many different types of multiple sclerosis.

Unfortunately, many of the symptoms associated with multiple sclerosis can be caused by many different nervous system diseases. Therefore, diagnosis of MS can sometimes be difficult. However, while any one attack of MS may have several potential causes, a thorough work-up can lead to the correct diagnosis.

Types of Multiple Sclerosis:

There are several types of multiple sclerosis varying primarily in the course of the disease throughout a patient's life. These differences in the natural history of the disease can be quite dramatic. It is unclear what determines which sub-type a given patient will have. Likewise, once a patient presents with early signs of multiple sclerosis it can be initially difficult (or impossible) to predict which progression they can expect in the future. It may only be once considerable time has passed, and the course of the disease and its related symptoms has been observed, that a given patient can be classified under one of the general types.

In a general sense, there are four sub types of multiple sclerosis, distinguished by the course the disease takes in that patient:

• Relapsing-remitting: This is the most common form of MS, particularly in the early course of the disease. Some patients who initially have relapsing-remitting MS later develop more progressive forms. It is characterized by periodic acute attacks or exacerbations of symptoms. These attacks can evolve over several days to weeks. Following the acute period, the symptoms can persist or can improve partially or fully. This recovery can take weeks to months. In between the acute attacks, the symptoms do no get worse.
• Primarily-progressive: Overall, this type is less common, only occurring in around 15% of patients, most commonly in people who present with the disease later in life (after around 40 years of age). It is characterized by a steady progression of symptoms and disability without the acute attacks and relapses that are seen in the more common relapsing-remitting type. These patients have a gradual worsening of central nervous system function and do no have periods of improvement.
• Secondary-progressive: In some patients who initially present with a relapsing-remitting form of MS, symptoms may become progressive, like in the primarily-progressive form described above, at some point in their life. These patients first have some period of relapsing-remitting MS, which can last anywhere from months to many years or decades. They then begin progressing without the acute attacks and remissions associated with that form.
• Progressive-relapsing: The least common form of MS, these patients have what amounts to be a superimposition of relapsing-remitting MS on top of primarily-progressive MS. They will experience gradual, steady progression of symptoms and disability but will also experience superimposed acute attacks where their symptoms get acutely worse and may or may not be followed by some improvement.

Multiple Sclerosis Diagnosis:

Multiple sclerosis diagnosis can initially be tricky because it can affect any part of the central nervous system and can therefore present quite differently in each individual patient. There is no single test which confirms the diagnosis of MS. Therefore there are various criteria which are evaluated to assess whether a patient's symptoms and progression are consistent with the disease. Typically, this process of diagnosis is undertaken by a neurologist.

Some disease that can initially be misdiagnosed as MS or confused with MS include vasculitis, migraine headaches, multiple strokes, vitamin deficiencies, lupus or brain infections.

Making the Diagnosis:

First of all, a good medical history and thorough neurological examination can help your physician identify those aspects of the disease which are consistent with MS. Details of the onset, progression of the symptoms and types of symptoms are particularly important parts of the medical history which can help distinguish multiple sclerosis from other diseases.

In addition, there are several tests or imaging studies which help to make the diagnosis or rule out other similar diseases. These can include brain and spine MRI, spinal taps (lumbar puncture), evoked potentials and blood tests.

With all of this clinical information gathered, there are several criteria which are then used to arrive at the diagnosis:

• Onset of disease: typically occurs between 20 and 50 years of age.
• Objective signs and symptoms referable to disease of the brain and/or spinal cord (peripheral nerve disease is not caused by MS).
• MRI evidence of two or more lesions in the brain and/or spinal cord.
• A history of two or more episodes lasting at least 24 hours and occurring at least one month apart (particularly for relapsing-remitting forms of the disease).
• No other explanation for the symptoms

Only if these criteria are met and a full work-up has been done can a physician make the working diagnosis of multiple sclerosis.

Multiple Sclerosis Treatment:

Although there is no cure for MS, multiple sclerosis treatment aims to improve each patient's quality of life by preventing attacks, slowing disease progression, minimizing symptom severity and duration and treating symptoms.

For example, several drugs are used to prevent or minimize symptoms. These drugs are generally immune suppressing or modulating drugs, which inhibit or modify the way the immune system works, hopefully preventing or reducing the severity of the autoimmune attacks on the central nervous system. Some of these drugs are used chronically to prevent exacerbations and delay progression while others are used acutely (such as steroid drugs like prednisone) during attacks to lessen symptom severity and duration.

Additionally, some treatment is simply symptomatic, meaning that it aims at making patients more comfortable with their symptoms. This includes pain medications for patients with pain. Many patients complain of muscle spasms and there are various anti-spasmodics which can help with this. Some patients may experience urinary incontinence and there are some drugs which can improve bladder control.

Finally, there are a number of procedures which are sometimes employed. Plasmapheresis is a procedure which attempts to minimize the antibodies in the blood, hopefully getting rid of some of the antibodies which may be involved in the autoimmune disease. Although it is controversial it may be recommended in some cases. Other types of multiple sclerosis treatment are aimed at a specific symptom. For example, in patients with severe tremor a deep brain stimulator procedure may be recommended to help control the tremors.

Cure for Multiple Sclerosis:

Unfortunately, there is no cure for multiple sclerosis. As with most autoimmune type diseases, no cure can completely eradicate the problem. Multiple sclerosis is a chronic disease, which, once diagnosed, continues throughout the patient's life. However, there are many sub-types of the disease with different natural histories and disease courses. While any given patient may experience periods of remission during which they have no new symptoms, the disease will typically rear its ugly head again at some point in the future.

However, although there is no absolute cure, there are a number of treatment options for MS which help to control or modify the symptoms in some patients. They may slow the progression of the disease and improve the quality of life in many patients. In general, multiple sclerosis treatment consists of various forms of immune suppression, drug treatments which suppress the activity of the immune system and thus lessen its attack on the myelin sheath in the central nervous system.

Multiple Sclerosis Medications:

There are many multiple sclerosis medications used to treat the symptoms of MS. Most are some form of immune suppressing or altering drugs which decrease or modify the activity of the immune system. While none represent a cure for MS, they can slow the progression of the disease, lessen symptoms, delay disability and improve the quality of life for many patients.

Some medications used to treat MS include:

Avonex (interferon beta-1a)
Betaseron (interferon beta-1b)
Copaxone (glatiramer acetate)
Novantrone (mitoxantrone)
Rebif (interferon beta-1a)
Tysabri (natalizumab)

Additionally, in acute attacks of MS, steroid medications, such as prednisone or hydrocortisone, are used to suppress the immune system and limit the duration and severity of the attack. However, because of their side effects they are not typically used long-term for the chronic control of the disease.

In addition to these immune suppressing or modulating drugs, a number of multiple sclerosis treatments are aimed at simple symptomatic control. For example, medications may be prescribed for pain, muscle spasms and bladder control.

Breast cancer

Breast cancer

Introduction:

Breast cancer (malignant breast neoplasm) is cancer originating from breast tissue, most commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas.

Mammograms showing a normal breast (left) and a breast cancer (right).

Prognosis and survival rate varies greatly depending on cancer type and staging. Computerized models are available to predict survival. With best treatment and dependent on staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes surgery, drugs (hormonal therapy and chemotherapy), and radiation.

Worldwide, breast cancer comprises 10.4% of all cancer incidence among women, making it the most common type of non-skin cancer in women and the fifth most common cause of cancer death. In 2004, breast cancer caused 519,000 deaths worldwide (7% of cancer deaths; almost 1% of all deaths). Breast cancer is about 100 times more common in women than, although males tend to have poorer outcomes due to delays in diagnosis.

Some breast cancers are sensitive to hormones such as estrogen and/or progesterone which makes it possible to treat them by blocking the effects of this hormones in the target tissues. These have better prognosis and require less aggressive treatment than hormone negative cancers.

Breast cancers without hormone receptors, or which have spread to the lymph nodes in the armpits, or which express certain genetic characteristics, are higher-risk, and are treated more aggressively. One standard regimen, popular in the U.S., is cyclophosphamide plus doxorubicin (Adriamycin), known as CA; these drugs damage DNA in the cancer, but also in fast-growing normal cells where they cause serious side effects. Sometimes a taxane drug, such as docetaxel, is added, and the regime is then known as CAT; taxane attacks the microtubules in cancer cells. An equivalent treatment, popular in Europe, is cyclophosphamide, methotrexate, and fluorouracil (CMF). Monoclonal antibodies, such as trastuzumab (Herceptin), are used for cancer cells that have the HER2 mutation. Radiation is usually added to the surgical bed to control cancer cells that were missed by the surgery, which usually extends survival, although radiation exposure to the heart may cause damage and heart failure in the following years.

Types of Breast Cancer:

Breast cancer can begin in different areas of the breast – the ducts, the lobules, or in some cases, the tissue in between. In this section, you can learn about the different types of breast cancer, including non-invasive, invasive, recurrent, and metastatic breast cancers.They are classified as-

•  DCIS – Ductal Carcinoma In Situ
• IDC – Invasive Ductal Carcinoma
• IDC - Less Common Types
• ILC – Invasive Lobular Carcinoma
• Inflammatory Breast Cancer
• LCIS – Lobular Carcinoma In Situ
• Male Breast Cancer
• Paget's Disease of the Nipple
• Phyllodes Tumors of the Breast
• Recurrent and Metastatic Breast Cancer

Risk factors:

The primary epidemiologic and risk factors that have been identified are sex, age, lack of childbearing or breastfeeding, higher hormone levels, race, economic status and also dietary iodine deficiency.

Women can reduce their risk by maintaining a healthy weight, drinking less alcohol, being physically active and breastfeeding their children.

In addition to the risk factors specified above, demographic and medical risk factors include:

• Personal history of breast cancer: A woman who had breast cancer in one breast has an increased risk of getting cancer in her other breast.
• Family history: A woman's risk of breast cancer is higher if her mother, sister, or daughter had breast cancer. The risk is higher if her family member got breast cancer before age 40. An Australian study found that having other relatives with breast cancer (in either her mother's or father's family) may also increase a woman's risk of breast cancer and other forms of cancer, including brain and lung cancers.
• Certain breast changes: Atypical hyperplasia and lobular carcinoma in situ found in benign breast conditions such as fibrocystic breast changes are correlated with an increased breast cancer risk

Sign and symptoms:

The first noticeable symptom of breast cancer is typically a lump that feels different from the rest of the breast tissue. More than 80% of breast cancer cases are discovered when the woman feels a lump. By the time a breast lump is noticeable, it has probably been growing for years. The earliest breast cancers are detected by a mammogram. Lumps found in lymph nodes located in the armpits can also indicate breast cancer.

Indications of breast cancer other than a lump may include changes in breast size or shape, skin dimpling, nipple inversion, or spontaneous single-nipple discharge. Pain ("mastodynia") is an unreliable tool in determining the presence or absence of breast cancer, but may be indicative of other breast health issues.

When breast cancer cells invade the dermal lymphatics—small lymph vessels in the skin of the breast—its presentation can resemble skin inflammation and thus is known as inflammatory breast cancer (IBC). Symptoms of inflammatory breast cancer include pain, swelling, warmth and redness throughout the breast, as well as an orange-peel texture to the skin referred to as peau d'orange.

Another reported symptom complex of breast cancer is Paget's disease of the breast. This syndrome presents as eczematoid skin changes such as redness and mild flaking of the nipple skin. As Paget's advances, symptoms may include tingling, itching, increased sensitivity, burning, and pain. There may also be discharge from the nipple. Approximately half of women diagnosed with Paget's also have a lump in the breast.

In rare cases, what initially appears as a fibroadenoma (hard movable lump) could in fact be a phyllodes tumor. Phyllodes tumors are formed within the stroma (connective tissue) of the breast and contain glandular as well as stromal tissue. Phyllodes tumors are not staged in the usual sense; they are classified on the basis of their appearance under the microscope as benign, borderline, or malignant.

Occasionally, breast cancer presents as metastatic disease, that is, cancer that has spread beyond the original organ. Metastatic breast cancer will cause symptoms that depend on the location of metastasis. Common sites of metastasis include bone, liver, lung and brain. Unexplained weight loss can occasionally herald an occult breast cancer, as can symptoms of fevers or chills. Bone or joint pains can sometimes be manifestations of metastatic breast cancer, as can jaundice or neurological symptoms. These symptoms are "non-specific", meaning they can also be manifestations of many other illnesses.

Most symptoms of breast disorder do not turn out to represent underlying breast cancer. Benign breast diseases such as mastitis and fibroadenoma of the breast are more common causes of breast disorder symptoms. The appearance of a new symptom should be taken seriously by both patients and their doctors, because of the possibility of an underlying breast cancer at almost any age.

Diagnosis:

While screening techniques (which are further discussed below) are useful in determining the possibility of cancer, a further testing is necessary to confirm whether a lump detected on screening is cancer, as opposed to a benign alternative such as a simple cyst.

In a clinical setting, breast cancer is commonly diagnosed using a "triple test" of clinical breast examination (breast examination by a trained medical practitioner), mammography, and fine needle aspiration cytology. Both mammography and clinical breast exam, also used for screening, can indicate an approximate likelihood that a lump is cancer, and may also identify any other lesions. Fine Needle Aspiration and Cytology (FNAC), which may be done in a GP's office using local anaesthetic if required, involves attempting to extract a small portion of fluid from the lump. Clear fluid makes the lump highly unlikely to be cancerous, but bloody fluid may be sent off for inspection under a microscope for cancerous cells. Together, these three tools can be used to diagnose breast cancer with a good degree of accuracy.

Other options for biopsy include core biopsy, where a section of the breast lump is removed, and an excisional biopsy, where the entire lump is removed.

In addition vacuum-assisted breast biopsy (VAB) may help diagnose breast cancer among patients with a mammographically detected breast in women.

Screening:

Breast cancer screening refers to testing otherwise-healthy women for breast cancer in an attempt to achieve an earlier diagnosis. The assumption is that early detection will improve outcomes. A number of screening test have been employed including: clinical and self breast exams, mammography, genetic screening, ultrasound, and magnetic resonance imaging.

A clinical or self breast exam involves feeling the breast for lumps or other abnormalities. Research evidence does not support the effectiveness of either type of breast exam, because by the time a lump is large enough to be found it is likely to have been growing for several years and will soon be large enough to be found without an exam. Mammographic screening for breast cancer uses x-rays to examine the breast for any uncharacteristic masses or lumps. The Cochrane collaboration in 2009 concluded that mammograms reduce mortality from breast cancer by 15 percent but also result in unnecessary surgery and anxiety, resulting in their view that mammography screening may do more harm than good. Many national organizations recommend regular mammography, nevertheless. For the average woman, the U.S. Preventive Services Task Force recommends mammography every two years in women between the ages of 50 and 74. The Task Force points out that in addition to unnecessary surgery and anxiety, the risks of more frequent mammograms include a small but significant increase in breast cancer induced by radiation.

In women at high risk, such as those with a strong family history of cancer, mammography screening is recommended at an earlier age and additional testing may include genetic screening that tests for the BRCA genes and / or magnetic resonance imaging.

Treatment:

Breast cancer is usually treated with surgery and then possibly with chemotherapy or radiation, or both. Hormone positive cancers are treated with long term hormone blocking therapy. Treatments are given with increasing aggressiveness according to the prognosis and risk of recurrence.
Stage 1 cancers (and DCIS) have an excellent prognosis and are generally treated with lumpectomy and sometimes radiation. The aggressive HER2+ cancers should be treated with the trastuzumab (Herceptin) regime but chemotherapy is otherwise uncommon.
Stage 2 and 3 cancers with a progressively poorer prognosis and greater risk of recurrence are generally treated with surgery (lumpectomy or mastectomy with or without lymph node removal), chemotherapy (plus trastuzumab for HER2+ cancers) and sometimes radiation (particularly following large cancers, multiple positive nodes or lumpectomy).
Stage 4, metastatic cancer, (i.e. spread to distant sites) is not curable and is managed by various combination of all treatments from surgery, radiation, chemotherapy and targeted therapies. However, stage 4 breast cancer management has been very disappointing, with only a 6 month increase in median survival following these treatments. But there is still about 8 percent of living.

Prevention:

Exercise may decrease breast cancer risk.

Parkinson's Disease

Parkinson's Disease

Introduction:

It is a nervous system disease which falls into the category of motor system diseases or movement disorders because it primarily affects motor control and its primary manifestations affect movement.

The disease leads to a loss of neurons, the nerve cells in the brain, in specific locations, particularly a large group of cells called the substantia nigra. This nucleus is part of the basal ganglia which is important principally for coordinating and controlling the initiation of movement. Therefore, as these cells are lost, the symptoms that become apparent are generally disorders of movement and its initiation. Common symptoms that are classic for Parkinson's disease include tremor (shakiness at rest), rigidity and slowed movements (bradykinesia) and others.

Parkinson's primarily affects older individuals and its incidence increases with age. Although its initial symptoms primarily affect movement, as it progresses it can involve other functions of the brain including cognition and lead to a form of dementia.

Causes of Parkinson's Disease:

The underlying etiology (causative factors) that lead to Parkinson's disease are poorly understood. It is probably multifactorial, meaning that there are several factors which contribute to its development. Clues to the causes of Parkinson's disease can be found in the risk factors which are associated with the disease. Although most cases are sporadic, there does seem to be some genetic predisposition. People with a close relative with the disease are slightly more likely to develop the disease themselves, although the risk is still rather small. Likewise, it is known that older age and male gender are risk factors as the risk increases with age and is higher in men than women. There may also be some toxins or viruses, exposure to which may increase one's risk for Parkinson's.

Although the actual initial causes of Parkinson's Disease are poorly understood, the actual pathophysiology that occurs in the brains of patients is well described. For unknown reasons, abnormal clumps of protein build up in certain neurons (nerve cells) in the brain. These clumps are called Lewy Bodies. As the disease progresses, neurons in certain parts of the brain die. One of the most pronounced areas of damage in this disease is in a group of cells (nucleus) in the brain called the substantia nigra. These cells normally use dopamine as their neurotransmitter and are part of the basal ganglia, a collection of nuclei important for control and coordination of initiation of motor functions.

The death of these dopamine-secreting cells in the brain lead to imbalance and dysfunction of the basal ganglia, affecting motor system control. This imbalance is progressive, getting worse over time, and explains the motor symptoms (tremor, rigidity, etc.) that are common in patients with Parkinson's disease.

Although the cells of the substantia nigra is the most profoundly affected early, other areas of the brain can become affected with time, leading to imbalance in other systems and with other neurotransmitters (such as norepinephrine), leading to other late symptoms such as dementia and dysfunction of the autonomic nervous system.

Just as what causes Parkinson's Disease is not clear, why the dopamine containing cells of the substantia nigra are most affected by this disease is poorly understood. There is ongoing current research that aims to more clearly elucidate the underlying risk factors, pathophysiology and causes of Parkinson's Disease.

Symptoms of Parkinson's Disease:

There are several symptoms of Parkinson's Disease, most of the affecting motor functions of the nervous system. Parkinsons disease is a progressive degenerative disease, meaning that the cell death and resulting dysfunction in the brain begin slowly and continue in a progressive way. They slowly get more pronounced over time. Therefore, Parkinson's disease symptoms generally present slowly and subtly. As time progresses the symptoms will become more pronounced and severe. Additionally, further symptoms that were not first evident can become apparent.

The classic "triad" of symptoms of Parkinson's disease include tremor, rigidity and bradykinesia because they are common in patients with the disease and are some of the first symptoms to present.

Tremor is an involuntary shaking of the body, usually most pronounced at rest (called a "resting tremor"). Other forms of tremor sometimes seen include a "pill-rolling" tremor.

Rigidity is an increased tone of muscles, meaning the passive movement of the extremities (arms or legs) is more difficult than normal.

Bradykinesia means "slow movement". Most movements are slowed. This can particularly affect fine motor control, making fine motor skills quite difficult. This can also be evident in the general lack of excessive movements, such as decreased expressive gestures (waving hands when talking, etc.) and decreased facial movement and facial expressions (sometimes described as "masked" face).

Other symptoms include freezing (sudden cessation of movement), akinesia (difficulty initiating movements), inbalance, impaired posture, speech changes, abnormal gait (a "shuffling" gate), and others.

As the disease progresses and becomes more severe, these initial symptoms will become more pronounced, but other symptoms may become evident as well. For example, a form of dementia can develop with slowed thinking (bradyphrenia) and problems with memory.

While some of these symptoms are classic symptoms of Parkinson's Disease, many can be caused by other nervous system diseases as well. Therefore, the diagnosis of Parkinson's disease requires a careful assessment by a neurologist to distinguish Parkinsons disease from other similar movement disorders which may cause tremor, rigidity or other such symptoms.

Parkinson's Disease Diagnosis:

Parkinson's Disease diagnosis can be tricky. Without looking at the cells of the brain itself, there are no definitive tests, exams or studies which can be performed that make the diagnosis. Because there are other diseases which can share some of the common symptoms of Parkinson's disease, it can be difficult to distinguish this disease from others and make a confident diagnosis.

However, an accurate diagnosis is required to initiate the most appropriate management and treatment plan for Parkinson's disease. The treatment and prognosis of other similar diseases may be quite different.

Therefore, patients with symptoms suggestive of Parkinsons disease generally undergo a thorough work-up by a competent neurologist with experience in diagnosing Parkinsons. This generally consists of a thorough history and physical examination, focusing on the patient's symptoms, their personal and family history and an examination of the nervous system, focusing on motor function which is most affected by Parkinson's.

A Parkinson's disease diagnosis is considered a "diagnosis of exclusion". Because there is no gold-standard test that can be performed to confirm the diagnosis, all other similar or related diseases must be ruled out before the confident diagnosis of Parkinsons Disease can be made. This may include tests and imaging studies (such as brain MRI or CT scan) to help rule out other potential causes of the patient's symptoms.

Even though there are other diseases which can present with similar symptoms, most do not overlap 100% in the details of their presentation. Therefore, careful care is taken to document all the signs and symptoms in each patient to make sure Parkinsons Disease is the best fit diagnosis, rather than some other diagnosis.

Other movement disorders which may have some similar symptoms include Huntington's Disease, multisystem atrophy, Lewy body dementia, progressive supranuclear palsy, corticobasal degeneration and others. Likewise, Alzheimer's disease, the most common cause of dementia, should be distinguished from Parkinsons, in which dementia can occur but is generally a later finding in more advanced disease. Other causes of tremor (such as essential tremor or "limb-shaking TIAs) and abnormal gait (normal pressure hydrocephalus, etc.) should be ruled out as well. As you can see, because the differential diagnosis is quite large, an experience physician is needed to help make a Parkinson's disease diagnosis.

Once the diagnosis is confident, then management options can be discussed.

Parkinson's Disease Treatment:

Parkinson's Disease treatment aims to reduce the symptoms of this progressive disease and improve each patient's quality of life. There is no cure for Parkinson's, all the treatments simply aim to lessen symptoms of the disease.

When a diagnosis is first made, the initial treatment is generally medical, focusing on prescription of medications which are known to reduce symptoms in most patients.

Of all the drug options for treatment of Parkinson's Disease, levodopa (or L-dopa) is the most commonly used and the most effective. Levodopa is a compound which is a naturally-occurring precursor to dopamine which is lacking in parts of the brain in Parkinsons disease. The idea is that brain cells can pick up the levodopa and make dopamine and at least partially replace the lack of the neurotransmitter in the brain. While this does often improve symptoms, it is not a perfect treatment. Its benefits are often modest. Also, the drug must be given frequently and its effect may deteriorate over time. Another drug, carbidopa is often given along with levodopa to help prolong its effect. As Parkinson's disease symptoms progress, the use of levodopa, and/or carbidopa, will often change dramatically with frequent adjustments in doses, timing of dosing and going on and off the medication.

There are several other medications which may also be used in Parkinson's disease treatment. Dopamine agonists are drugs that act like dopamine to stimulate cells in the brain. MAO B inhibitors and COMT inhibitors may be used to help increase the availability of dopamine and levodopa. Anticholinergic medications and NMDA blocking drugs may also be used in some patients. All these alternative medications may be used alone or in addition to levodopa therapy to help maximize symptom control. They may be frequently swapped or adjusted as the patient learns what works best in their own particular case.

In addition to medications, initial medical treatment of Parkinson's Disease may often include physical therapy to help maintain mobility, improve general health and to maintain flexibility and muscle strength. While these treatments do not stop the progression of the disease, they may help patients to maintain function for longer and to improve their quality of life and ability to care for themselves.

Surgical Treatments: In patients with more advanced disease, when medications alone are no longer controlling symptoms, surgical options may be considered as part of Parkinson's disease treatment. The most common surgical option offered to patients is called a deep brain stimulator which uses an implanted electrode to stimulate parts of the brain. The goal is to restore some balance to the activity in the parts of the brain most affected in Parkinson's disease and therefore reduce symptoms. It is particularly good at controlling tremor. However, the effects of surgical procedures such as this are quite variable, and, like other treatments, are not a cure for the disease.

Deep Brain Stimulator for Parkinson's Disease:

A deep brain stimulator is an implanted device which is used to treat some patients with Parkinson's Disease, as well as a few other diseases. It is currently the most commonly employed surgical treatment for Parkinsons disease.

Most patients with Parkinsons disease are first treated with medication and physical therapy. However, in patients with more advanced disease which is no longer adequately and reliably controlled with medication, these procedures may help to stabilize symptoms and resolve abnormal movements such as tremor.

Pneumonia

 Pneumonia

Introduction of Pneumonia:

Pneumonia (nu-MO-ne-ah) is an infection in one or both of the lungs. Many small germs, such as bacteria, viruses, and fungi, can cause pneumonia.

The infection causes your lungs’ air sacs, called alveoli (al-VEE-uhl-eye), to become inflamed. The air sacs may fill up with fluid or pus, causing symptoms such as a cough (with phlegm), fever, chills, and trouble breathing.

Pneumonia

Pneumonia tends to be more serious for:

• Infants and young children.
• Older adults (people 65 years or older).
• People who have other health problems like heart failure, diabetes, or COPD (chronic obstructive pulmonary disease).
• People who have weak immune systems as a result of diseases or other factors. These may include HIV/AIDS, chemotherapy (a treatment for cancer), or an organ or bone marrow transplant. 

Common Types of Pneumonia:

Aspiration Pneumonia

This type of pneumonia occurs when you accidentally inhale food, drink, vomit, or saliva from your mouth into your lungs. This usually happens when something disturbs your normal gag reflex, such as a brain injury, swallowing problem, or excessive use of alcohol or drugs.

Aspiration pneumonia can cause pus to form in a cavity in the lung. This is called a lung abscess.

Atypical Pneumonia

Several types of bacteria—Legionella pneumophila, mycoplasma pneumonia, and Chlamydophila pneumoniae—cause this type of CAP. Atypical pneumonia is passed from person to person.

Causes of Pneumonia

Many different germs can cause pneumonia. These include different kinds of bacteria, viruses, and, less often, fungi.

Most of the time, the body filters germs out of the air that we breathe to protect the lungs from infection.Sometimes, though, germs manage to enter the lungs and cause infections. This is more likely to occur when:

• Your immune system is weak
• A germ is very strong
• Your body fails to filter germs out of the air that you breathe

Your mouth and airways are exposed to germs as you inhale air through your nose and mouth. Your immune system, the shape of your nose and throat, your ability to cough, and fine, hair-like structures called cilia (SIL-e-ah) help stop the germs from reaching your lungs.

For example, coughing is one way the body keeps germs from reaching the lungs. Some people may not be able to cough because, for example, they’ve had a stroke or are sedated (given medicine to make them sleepy). This means germs may remain in the airways rather than being coughed out.

When germs do reach your lungs, your immune system goes into action. It sends many kinds of cells to attack the germs. These cells cause the alveoli (air sacs) to become red and inflamed and to fill up with fluid and pus. This causes the symptoms of pneumonia.

Germs That Can Cause Pneumonia

Bacteria

Bacteria are the most common cause of pneumonia in adults. Some people, especially the elderly and those who are disabled, may get bacterial pneumonia after having the flu or even a common cold.

Dozens of different types of bacteria can cause pneumonia. Bacterial pneumonia can occur on its own or develop after you've had a cold or the flu. This type of pneumonia often affects one lobe, or area, of a lung. When this happens, the condition is called lobar pneumonia.

The most common cause of pneumonia in the United States is the bacterium Streptococcus (strep-to-KOK-us) pneumoniae, or pneumococcus (nu-mo-KOK-us).

Lobar Pneumonia

 Figure A shows the location of the lungs and airways in the body. It also shows pneumonia that’s affecting the lower lobe of the left lung. Figure B shows normal alveoli. Figure C shows infected alveoli.

Another type of bacterial pneumonia is called atypical pneumonia. Atypical pneumonia includes:

• Legionella pneumophila. This is sometimes called Legionnaire's disease. This type of pneumonia has caused serious outbreaks. Outbreaks have been linked to exposure to cooling towers, whirlpool spas, and decorative fountains.
• Mycoplasma pneumonia. This is a common type of pneumonia that usually affects people younger than 40. People who live or work in crowded places like schools, homeless shelters, and prisons are most likely to get it. It’s usually mild and responds well to treatment with antibiotics. But, it can be very serious in some people. It may be associated with a skin rash and hemolysis (the breakdown of red blood cells).
• Chlamydophila pneumoniae. This kind of pneumonia can occur all year and is often mild. The infection is most common in people 65 to 79 years of age.

Viruses

Respiratory viruses cause up to one-third of the pneumonia cases in the United States each year. These viruses are the most common cause of pneumonia in children younger than 5 years.

Most cases of viral pneumonia are mild. They get better in about 1 to 3 weeks without treatment. Some cases are more serious and may require treatment in a hospital.

If you have viral pneumonia, you run the risk of getting bacterial pneumonia also.

The flu virus is the most common cause of viral pneumonia in adults. Other viruses that cause pneumonia include respiratory syncytial virus, rhinovirus, herpes simplex virus, severe acute respiratory syndrome (SARS), and more.

Fungi

Three types of fungi in the soil in some parts of the United States can cause pneumonia. These fungi are coccidioidomycosis (kok-sid-e-OY-do-mi-KO-sis) in Southern California and the desert Southwest, histoplasmosis (HIS-to-plaz-MO-sis) in the Ohio and Mississippi River Valleys, and cryptococcus (krip-to-KOK-us). Most people exposed to these fungi don’t get sick, but some do and require treatment.

Serious fungal infections are most common in people who have weak immune systems as a result of long-term use of medicines to suppress their immune systems or having HIV/AIDS.

Pneumocystis jirovecii (nu-mo-SIS-tis ye-RO-VECH-e), formerly Pneumocystis carinii, is sometimes considered a fungal pneumonia. However, it’s not treated with the usual antifungal medicines. It usually affects people who:

• Have HIV/AIDS or cancer
• Have had an organ and/or bone marrow transplant
• Take medicines that affect their immune systems

Other kinds of fungal infections also can lead to pneumonia.

Signs and Symptoms of Pneumonia:

The symptoms of pneumonia vary from mild to severe. Many factors affect how serious pneumonia is, including the type of germ causing the infection and your age and overall health.

See your doctor promptly if you:

• Have a high fever
• Have shaking chills
• Have a cough with phlegm, which doesn’t improve or worsens
• Develop shortness of breath with normal daily activities
• Have chest pain when you breathe or cough
• Feel suddenly worse after a cold or the flu

People with pneumonia may have other symptoms, including nausea (feeling sick to your stomach), vomiting, and diarrhea.

Symptoms may vary in certain populations. Newborns and infants may not show any signs of the infection or may vomit, have a fever and cough, or appear restless, sick, or tired and without energy.

Older adults and people who have serious illnesses or weak immune systems may have fewer and milder symptoms. They may even have a lower than normal temperature. If they already have a lung disease, it may get worse. Older adults who have pneumonia sometimes have sudden changes in mental awareness.

Rheumatoid Arthritis

Introduction of Rheumatoid Arthritis:

Rheumatoid arthritis is an autoimmune disease. That means that the immune system attacks parts of the body. For reasons that aren't clear, the joints are the main areas affected by this malfunction in the immune system. Over time, chronic inflammation can lead to severe joint damage and deformities. About one out of every five people who have rheumatoid arthritis develop lumps on their skin called rheumatoid nodules. These often develop over joint areas that receive pressure, such as over knuckles, elbows, or heels.

Rheumatoid arthritis is a chronic type of arthritis. Early symptoms of RA include fatigue, joint pain, and stiffness. As it progresses, rheumatoid arthritis symptoms may feel like the flu, with achiness, muscle aches, and loss of appetite. The causes of rheumatoid arthritis are unknown, although there may be a genetic component. Early and effective rheumatoid arthritis treatment can improve the prognosis and may help prevent joint and bone destruction associated with RA.

Common Types of Arthritis:

There are two major types of arthritis -- osteoarthritis, which is the "wear and tear" arthritis, and rheumatoid arthritis, an inflammatory type of arthritis that happens when the body's immune system does not work properly.

Gout, which is caused by crystals that collect in the joints, is another common type of arthritis. Psoriatic arthritis, lupus, and septic arthritis are other types of the condition.

Types of Rheumatoid Arthritis:

• Hand and Finger RA
• Knee RA 
• Hip RA

Symptoms of Rheumatoid Arthritis:

Symptoms of rheumatoid arthritis can come on gradually or start suddenly. Unlike osteoarthritis, symptoms of rheumatoid arthritis are often more severe, causing pain, fatigue, loss of appetite, stiffness, and even fever.

With rheumatoid arthritis, you may feel pain and stiffness and experience swelling in your hands, wrists, elbows, shoulders, knees, ankles, feet, jaw, and neck. Sometimes the pain occurs in one body part. But more commonly, rheumatoid arthritis pain occurs in combinations of several joints such as in the hands, knees, and feet.

With rheumatoid arthritis, the joints tend to be involved in a symmetrical pattern. That is, if the knuckles on the left hand are inflamed, the knuckles on the right hand will also be inflamed. After a period of time, more of your joints may gradually become involved with pain and swelling and may feel warm to the touch. The joint swelling is persistent and interferes with activities. For example, it can interfere with opening a jar, driving, working, and walking -- the very activities that allow us to function in our daily lives.

The stiffness on arising in the morning, which may have started as a temporary nuisance, can soon last for hours or even most of the day. Fatigue can be debilitating. Inflammation can cause reduced appetite and weight loss. Fever, rash, and even involvement of the heart or lungs can occur with rheumatoid arthritis. These feelings and symptoms -- other than joint pain and the inflammation in other organs -- happen when the damage done by the immune system spills over from the joints to other areas of the body. The exact causes of rashes and heart and lung involvement are not known.

Causes of Rheumatoid Arthritis:

With rheumatoid arthritis, some of your body's cells recognize one of your own proteins as a foreign intruder. The exact protein involved in rheumatoid arthritis has not yet been discovered. Some experts believe the immune system becomes "confused" after infection with a bacteria or virus and begins attacking the normal joint tissues. Certain immune cells called lymphocytes are stimulated to react to this protein. The reaction causes the release of cytokines, which are chemical messengers that trigger more inflammation and destruction. This battle between the body's chemicals occurs mainly in the joints, but it can spresd to other areas of the body.

There are many cytokines, but the most important in terms of causing inflammation are tumor necrosis factor (TNF) and interleukin-1. These cytokines are thought to trigger other parts of the immune system in rheumatoid arthritis. Medicines that block TNF and interleukin-1 can improve the symptoms and prevent joint damage in rheumatoid arthritis.

Diagnosis of rheumatoid Arthritis:

Diagnosing rheumatoid arthritis (RA), in the early stages, can be difficult. There is no single test that can clearly identify rheumatoid arthritis. Instead, doctors diagnose rheumatoid arthritis based on factors that are strongly associated with this disease. The American College of Rheumatology uses this list of criteria:

1. Morning stiffness in and around the joints for at least one hour.
2. Swelling or fluid around three or more joints simultaneously.
3. At least one swollen area in the wrist, hand, or finger joints.
4. Arthritis involving the same joint on both sides of the body (symmetric arthritis).
5. Rheumatoid nodules, which are firm lumps in the skin of people with rheumatoid arthritis. These nodules are usually in pressure points of the body, most commonly the elbows.
6. Abnormal amounts of rheumatoid factor in the blood.
7. X-ray changes in the hands and wrists typical of rheumatoid arthritis, with destruction of bone around the involved joints.

Rheumatoid arthritis is officially diagnosed if four or more of these seven factors are present. The first four factors must have been present for at least six weeks.

Symptoms of rheumatoid arthritis can come and go. To diagnose RA your doctor may need to see your joints when the disease is active for several reasons:

• Patients may find it hard to describe symptoms to doctors in a way that allows them to make the diagnosis.
• Rheumatoid arthritis can appear similar to other common causes of joint pain, leading to the wrong diagnosis.
• Patients often think they are feeling "normal" aches and pains and ignore or just live with their symptoms for a long time before seeking treatment.

Several diseases can masquerade as rheumatoid arthritis, which contributes to the difficulty in diagnosis. These other diseases include:

• Osteoarthritis, or "regular" arthritis
• Gout
• Fibromyalgia
• Other autoimmune diseases such as systemic lupus erythematosus (lupus)
• Joint inflammation caused by infections

Because of these difficulties, a proper diagnosis is often missed early on. In fact, the average time between the onset of symptoms and the official diagnosis of rheumatoid arthritis is almost nine months!

Though diagnosing rheumatoid arthritis isn't easy, it is extremely important to correctly identify those with the disease. Delaying the diagnosis can be harmful because joint damage can occur early in the disease. Some experts think that blocking early joint damage can have huge long-term benefits.

The problem arises when it looks like someone has rheumatoid arthritis but they don't yet meet the criteria for diagnosis. If someone doesn't actually have it, it would be wrong to treat them because the medicines are powerful and can have serious side effects.

If you or your doctor suspects rheumatoid arthritis, your doctor will follow a series of steps to either diagnose or rule out the disease. It will take time, but eventually you will have a definite answer. There is some information and a few tools that are valuable to doctors in diagnosing rheumatoid arthritis. They include:

• A careful history. Take note of the frequency, severity, and time of day of your symptoms. Pass this information on to your doctor.
• A physical examination. Your doctor will look closely at your joints to detect signs of inflammation or damage.
• Laboratory tests. These can include tests for inflammation in your blood or joint fluid and more specific tests for rheumatoid arthritis.
• X-rays. They can be useful to identify any joint damage that has already occurred.

In early rheumatoid arthritis, there may be no instant answers, either for you or your doctors. The best strategy is close follow-up by a physician. If you think you have rheumatoid arthritis, see a rheumatologist or consult with your primary care doctor, and visit regularly.

Rheumatoid Arthritis Treatment:

The main treatment goals with rheumatoid arthritis are to control inflammation and slow or stop progression of RA.

Treatment is usually a multifaceted program of medications, occupational or physical therapy, and regular exercise. Sometimes surgery is used to correct joint damage. Early, aggressive treatment is key to good results. And with today’s treatments, joint damage can be slowed or stopped in many cases.

Medications used to treat rheumatoid Arthritis:

NSAIDs

As part of your rheumatoid arthritis treatment, your doctor will probably prescribe a nonsteroidal anti-inflammatory drug (NSAID). These medications reduce pain and inflammation but do not slow progression of RA. Therefore, people with moderate to severe RA often require additional medications to prevent further joint damage.

Over-the-counter NSAIDs include ibuprofen (Advil or Motrin) and naproxen sodium (Aleve). Most people with RA require a prescription NSAID as they offer longer lasting results and require fewer doses throughout the day. There are many prescription NSAIDs to choose from.

All prescription NSAIDs carry a warning regarding the increased risk of heart attack and stroke. NSAIDs can also raise blood pressure. In addition, NSAIDs can cause stomach irritation, ulcers, and bleeding.

You and your doctor can weigh the benefits of NSAIDs against the potential risks. You may have to try a few different ones to find the one that’s right for you.

NSAIDs decrease symptoms of rheumatoid arthritis but do not slow progression of RA. Therefore, people with moderate to severe RA require additional medications to prevent further joint damage.

DMARDs

Disease-modifying antirheumatic drugs (DMARDs) help slow or stop progression of RA. The most common DMARD used to treat rheumatoid arthritis is methotrexate. Other DMARDs include Arava, Azulfidine, Cytoxan, Imuran, Neoral, and Plaquenil.

In rheumatoid arthritis, an overactive immune system targets joints and other areas of the body. DMARDs work to suppress the immune system. However, they aren’t selective in their targets. Thus, they decrease the immune system overall and increase the likelihood of catching infections.

DMARDs, particularly methotrexate, have produced dramatic improvements in severe rheumatoid arthritis and can help preserve joint function.

Biologics

The newest and most effective treatments for rheumatoid arthritis are biologics. Biologics are genetically engineered proteins. They are designed to inhibit specific components of the immune system that play a pivotal role in inflammation, a key component in rheumatoid arthritis.

Biologics are usually used when other medications have failed to stop the inflammation of rheumatoid arthritis. Biologics may slow or even stop RA progression.

TNF blockers help to reduce pain and joint damage by blocking an inflammatory protein called tumor necrosis factor (TNF). There is some evidence that TNF blockers may stop the progression of rheumatoid arthritis. Recent studies have shown benefits when they are combined with methotrexate. TNF blockers include Enbrel, Humira, Remicade, Cimzia, and Simponi.

Other biologics suppress different areas of the immune system and include Actemra, Kineret, Orencia, and Rituxan.

Since biologics suppress the immune system, they also increase the risk of infection. Severe infections have been reported with biologics.

Steroids

For severe RA or when RA symptoms flare, your doctor may recommend steroids to ease the pain and stiffness of affected joints. In most cases, they can be used temporarily to calm a symptom flare. However, in certain people, steroids are needed long term to control pain and inflammation.

Steroids can be given as injections directly into an inflamed joint or can be taken as a pill. Potential side effects of long-term steroid use include high blood pressure, osteoporosis, and diabetes. But when used appropriately, steroids are often effective and quickly improve pain and inflammation.

When is surgery needed for rheumatoid arthritis?

If joint pain and inflammation become truly unbearable or joints simply refuse to function, some people choose joint replacement surgery. Today, joint replacement is commonly done on the hips and knees and sometimes the shoulders. Surgery can dramatically improve pain and mobility and is typically done only after age 50 since artificial joints tend to wear down after 15 to 20 years.

Some joints, such as the ankles, don't respond well to artificial replacement and do better with joint fusion.

What’s the best way to manage the daily pain of RA?

Because one of the most trying aspects of arthritis is learning to live with pain, many doctors recommend pain management training. Cognitive therapy for pain management combines behavior modification with relaxation techniques. These programs focus on improving your emotional and psychological well-being by teaching you how to relax and conduct your daily activities at a realistic pace.

Learning to overcome mental stress and anxiety can be the key to coping with the physical limitations that may accompany chronic arthritis. Cognitive therapy may include various techniques for activity scheduling, guided imagery, relaxation, distraction, and creative problem-solving.