Rash

Red, itchy bumps or patches all over the place

Outbreaks of this sort are usually either viral or allergic.
Viral rash: While viral infections of the skin itself, like herpes or shingles (a cousin of chickenpox), are mostly localized to one part of the body, viral rashes are more often symmetrical and everywhere. Patients with such rashes may or may not have other viral symptoms like coughing, sneezing, or stomach upset (nausea). Viral rashes usually last a few days to a week and go way on their own. Treatment is directed at relief of itch, if there is any.
Allergic drug rash: Most allergic drug rashes start within two or three weeks of taking a new medication, especially if the person has taken the drug before. It is very unlikely for medicine that has been prescribed for months or years to cause an allergic reaction. Because there is usually no specific test to prove whether a rash is allergic, doctors may recommend stopping a suspected drug to see what happens. If the rash doesn't disappear within a week of not taking the medication, allergy is unlikely.
Although foods, soaps, and detergents are often blamed for widespread rashes, they are rarely the culprits.
Other rashes
Hives (urticaria) are itchy, red welts that come and go on various parts of the body. Most hives are not allergic, run their course, and disappear as mysteriously as they came. Heat rash is a skin irritation caused by excessive sweating during hot, humid weather. It can occur at any age but is most common in young children. Heat rash looks like a red cluster of pimples or small blisters. It is more likely to occur on the neck and upper chest, in the groin, under the breasts, and in elbow creases.

What is the treatment for a rash?

Most rashes are not dangerous to a person or people in the vicinity (unless they are part of an infectious disease such as chickenpox). Many rashes last a while and get better on their own. It is therefore not unreasonable to treat symptoms like itchy and/or dry skin for a few days to see whether the condition gets milder and goes away.
Nonprescription (over-the-counter) remedies include

• anti-itch creams containing camphor, menthol, pramoxine (Itch-X, Sarna Sensitive), or diphenhydramine (Benadryl);
• antihistamines like diphenhydramine (Benadryl), chlorpheniramine (Chlor-Trimeton), or loratadine (Claritin, Claritin RediTabs, Alavert); and cetirizine (Zyrtec);
• moisturizing lotions.

If these measures do not help, or if the rash persists or becomes more widespread, a visit to a general physician or dermatologist is advisable.
There are many, many other types of rashes that we have not covered in this article. So, it is doubly important, if you have any questions about the cause or treatment of a rash, to contact your doctor. This article is really just as the title indicates: "Rash 101: Introduction to Common Skin Rashes."
A word on smallpox vaccination in patients with rashes
People with atopic dermatitis or eczema should not be vaccinated against smallpox, whether or not the condition is active. Patients with atopic dermatitis are more susceptible to having the virus spread on their skin, which can lead to a serious, even life-threatening condition called eczema vaccinatum. In the case of other rashes, the risk of complications is much less. Consult your doctor about the smallpox vaccine.

Rash 101: Introduction to Common Skin Rashes

What are the different types of common skin rashes?

Whether it is used by patients or doctors, the word rash does not have an exact meaning or refer to a specific disease or kind of disorder. It's a general term that means an outbreak of bumps on the body that changes the way the skin looks and feels. Rashes can be localized to one area or else be widespread. The way people use this term, a rash can refer to many different skin conditions. Common categories of rash are

• scaly patches of skin not caused by infection,
• scaly patches of skin produced by fungal or bacterial infection,
• red, itchy bumps or patches over the body, such as on the chest and back.

Although rashes are seldom dangerous, self-diagnosis is not usually a good idea. Proper evaluation of a skin rash requires a visit to a doctor or other health-care professional. The following guidelines may help you decide what category your rash falls into.

Scaly patches of skin not caused by infection

Scaly, itchy skin patches often represent one of the conditions referred to as eczema.
Atopic dermatitis: Atopic dermatitis is perhaps the most common form of eczema. This is a hereditary skin problem that often begins in childhood as chapped cheeks and scaly patches on the scalp, arms, legs, and torso. Later in childhood, atopic dermatitis may affect the inner aspects of the elbows and knees. Adults get atopic dermatitis on the hands, around the eyelids, on the genitals, as well as on the body as a whole.
The word dermatitis means inflammation of the skin. Atopic refers to diseases that may be associated with allergies and tend to run in families. Atopic diseases include asthma, hay fever, and atopic dermatitis. In fact, people may refer to what doctors call eczema as "allergic skin." In fact, however, patients with atopic dermatitis may have allergies, but most cases of atopic dermatitis are not themselves allergic.
Eczema comes and goes on its own schedule and is not related to the allergy usual suspects -- foods, soaps, and detergents -- which may be blamed for flare-ups. In most cases, changing diet and detergents helps eczema very little.
Atopic dermatitis is often worse in the winter months, when the air is cold and dry, so that frequent washing may irritate the skin and aggravate the condition. Although the skin feels "dry," it really isn't; it is inflamed, and therefore moisturizing alone does not help much. The rash of some patients with atopic dermatitis, however, becomes worse in the summer, while others experience no significant seasonal variation. At times, eczema can be especially troublesome for one or more years, only to largely subside for extended periods afterward and require little treatment and attention.
Skin affected by atopic dermatitis becomes extremely itchy and inflamed. It may look red, swollen, and cracked. In some cases, the skin can also weep and crust. This is especially true in infants and children. Liquid that oozes out of such crusts is often not infected; what comes out is the body's normal tissue fluid. Treatment specific for eczema is helpful, not antibiotics.
Patches of atopic dermatitis may appear on various parts of the body, but the condition is not contagious. It may appear off and on throughout life, but there may be long intervals between outbreaks. Also, the condition does not get progressively worse with age; if anything, it is most extensive during childhood.
Treatment of eczema involves minimizing irritation if that is contributing to the problem and using prescription-strength steroids (cortisone creams). Milder ones are best for children and sensitive parts of the body (face, groin); these include hydrocortisone in its over-the-counter strengths of 0.5% and 1% as well as higher concentrations that need a prescription. In adults and on thicker-skinned areas (trunk, arms, legs), more potent cortisone (steroid) preparations are safe and useful. Some of these include triamcinolone 0.1% (Triamcinolone), fluocinonide 0.05% (Lidex), and clobetasol 0.05% (Temovate).
Nonsteroidal creams like tacrolimus (Protopic) and pimecrolimus (Elidel) have become less popular both because of relative lack of effectiveness and concerns about safety. Tap water soaks with Burow's solution (available without prescription) can help dry up atopic dermatitis in its oozy stages.
Contact dermatitis: Contact dermatitis is a rash that is brought on either by contact with a specific material that causes allergy on the skin or with something that irritates the skin, like too-frequent hand washing.
Common examples of contact dermatitis caused by allergy are poison ivy or poison oak (same chemical, different plant) and reactions to costume jewelry containing nickel. With occasional exceptions, allergic contact dermatitis affects just those parts of the skin touched by whatever material causes the allergy, as opposed to atopic dermatitis, which can be widespread because, as explained above, it is not an allergy to a specific substance.
Treatment of contact dermatitis involves avoiding the allergen that caused it, if there is one, or minimizing whatever exposure is irritating the skin (water on the hands, solvents at work, saliva around the mouth from lip licking). Effective treatments include topical steroids, including over-the-counter 1% hydrocortisone and many prescription-strength creams. Here, too, nonsteroidal creams like tacrolimus and pimecrolimus are used less than they once were. Tap water soaks with Burow's solution can help dry up oozy contact dermatitis as well.
There are of course many other scaly rashes. Two worth mentioning are psoriasis, a hereditary condition affecting elbows, knees, and elsewhere, and pityriasis rosea, which primarily affects teens and young adults, producing scaly patches on the chest and back and generally disappearing in about a month. Xerosis, very dry skin, may also appear as a rash during the cold, dry months of the year.

Scaly patches of skin produced by fungal or bacterial infection

When infections appear as rashes, the most common culprits are funguses or bacterial infections.
Fungal infections: Fungal infections are fairly common but don't appear nearly as often as rashes in the eczema category. Perhaps the most common diagnostic mistake made by both patients and non-dermatology physicians is to almost automatically call scaly rashes "a fungus." For instance, someone with several scaly spots on the arms, legs, or torso is much more likely to have a form of eczema or dermatitis than actual ringworm (the layman's term for fungus). Likewise, yeasts are botanically related to fungi and can cause skin rashes. These tend to affect folds of skin (like the skin under the breasts or the groin). They look fiery red and have pustules around the edges. As is the case with ringworm, many rashes that are no more than eczema or irritation get labeled "yeast infections."
Fungus and yeast infections have little to do with hygiene -- clean people get them, too. Despite their reputation, fungal rashes are not commonly caught from dogs or other animals, nor are they easily transmitted in gyms, showers, pools, or locker rooms. In most cases, they are not highly contagious between people either.
Treatment is usually straightforward. Many effective antifungal creams can be bought at the drugstore without a prescription, including 1% clotrimazole (Lotrimin, Mycelex) and 1% terbinafine (Lamisil). When these fail, prescription creams like econazole 1% (Econazole) and ketoconazole 2% (Nizoral) may help. In extensive cases, or when toenails are involved, oral terbinafine (Lamisil) may be useful.
If a fungus has been repeatedly treated without success, it is worthwhile considering the possibility that it was never really a fungus to begin with but rather a form of eczema that should be treated entirely differently.
Bacterial infections: The most common bacterial infection of the skin is impetigo. Impetigo is caused by staph or strep germs and is much more common in children than adults. Again, poor hygiene plays little or no role. Nonprescription antibacterial creams like bacitracin (Neosporin) are not very effective. Oral antibiotics or prescription-strength creams like mupirocin (Bactroban) are usually needed.

Sinus Headache (cont.)

How is a sinus headache diagnosed?

It is important that the cause of the headache be diagnosed. Many patients who believe that they have sinus headaches may instead have migraine or tension headaches.
The health care practitioner will likely begin with a history of the symptoms to help come to the diagnosis. Contributing factors in the development of sinusitis and headache may include a recent cold or upper respiratory tract infection, history of smoking, environmental allergies to dust or molds, as well as recent airplane travel, swimming or SCUBA diving, or other activities involving air pressure changes.
Physical examination may reveal tenderness to percussion, or tapping, over the affected sinus that reproduces the pain. Examination of the ears may reveal a serous otitis, or fluid levels behind the eardrum in the middle ear, that may suggest drainage problems in the face and sinuses. Examination of the nose may reveal swollen nasal passages and discharge.
The health care practitioner may want to consider imaging studies of the sinuses using a CT scan to look for fluid collections or thickening of the mucus membranes that line the sinus walls. Blood tests tend not to be helpful in making the diagnosis.

What is the treatment for a sinus headache?

The treatment goal for sinus headache is twofold. The first step is to decrease the inflammation within the sinuses and the help them drain. Once drainage occurs and the pressure is relieved, the pain should subside. The second aspect is to make the patient comfortable while the treating the underlying problem.
There are mechanical ways to help decrease congestion within the nasal passages. Drinking plenty of fluids will help with the general hydration in the body. Humidified air and salt water nasal spray will help with congestion as well. Neti pots are an alternative way to get humidity into the nasal passages and assist with drainage to prevent inflammation and infection.
Over-the-counter medications are available to help decrease inflammation within the sinuses and promote drainage. Brand name and generic drugs may be considered, but many contain pseudoephedrine (Sudafed), a medication that is related to adrenaline. People with high blood pressure and other heart conditions should consult their health care practitioner or pharmacist before taking these medications.
Some nasal sprays, other than salt water sprays (Ocean NasalSpray), may be used, but only for a short period of time because of side effects and complications. For example, Afrin nasal spray should be used for only three days in a row; otherwise, rebound inflammation may occur. With rebound inflammation, when the spray is stopped, the linings of the nasal passages may swell and potentially cause even more drainage complications.
For those whose sinus headaches are due to allergies, inhaled nasal steroids may be helpful in decreasing inflammation within the nasal passages to treat or prevent sinusitis.
If a bacterial infection is suspected, the health care practitioner may prescribe antibiotics to treat the infection while at the same time make suggestions to treat the underlying inflammation. If the inflammation does not resolve before the antibiotic course is complete, the bacterial infection may recur.
If the sinus headache persists, and repeated courses of treatment fail to relieve the sinusitis, surgery may be an option. Otolaryngologists (ear, nose, and throat surgeons) may be able to widen the openings that allow the sinuses to drain and decrease the risk that recurrent inflammation will obstruct the sinuses from draining.

Sinus Headache

What are the sinuses?

Sinuses of the face are cavities or spaces within the bones that help humidify air and secrete mucus to help with air filtration. Additionally, they contribute to the strength of the skull and its ability to resist trauma and allow more resonance in the voice.
The sinuses are often referred to as the paranasal sinuses because of their location and connection to the back of the nose. The sinuses develop as air sacs within the bones of the skull and are named by their location:

• Frontal sinus: located above the eyes within the frontal bone of the skull
  
• Maxillary sinus: located beneath the eyes under the cheekbones within the maxilla bone of the face
  
• Ethmoid sinus: located in the ethmoid bone separating the eyes from the nose
  
• Sphenoid sinus: located in the sphenoid bone at the base of the skull

What is a sinus headache?

Should the ducts that connect the sinuses to the back of the nose become inflamed, the ability of the sinuses to drain is decreased, and pressure builds within the affected sinus. There may also be associated swelling and inflammation of the lining of the sinuses, possibly resulting in increased mucus and fluid secretion. This increase in fluid and pressure causes the pain of a sinus headache. The term sinusitis is used to describe inflammation of the sinus (sinus + itis = inflammation).

What causes a sinus headache?

While a sinus infection (sinusitis) can be due to a viral infection much like a cold that causes swelling in the nose and decreases drainage of the sinuses, an allergic reaction (such as hay fever) may also begin the process of inflammation. As with any inflammation, there is swelling that in this case decreases the ability of the sinuses to drain and increased inflammatory fluid production (just like the weeping observed with a skin injury). The combination of more fluid and less drainage leads to the pain and pressure of a sinus headache.
Nature does not like stagnant fluid, and after a period of time bacteria and viruses can travel from the nasal cavities into the fluid and cause an infection. Less commonly, fungal infections may cause a sinus infection, and even more rarely, tumors can invade the sinus.
The maxillary sinus sits underneath the eye within the cheekbone. The upper teeth attach to the lower portion of this bone, and dental infections can travel up the root of the tooth and infect the sinus directly.

What are the symptoms of a sinus headache?

Pain is the primary symptom of a sinus headache, usually due to the increased pressure and decreased drainage from the affected sinus cavity. The pain of a sinus headache is often described as an increasing pressure sensation overlying the area with an associated tenderness to the touch. The pain occurs upon changing position of the head or when first getting up out of bed, which is due to the increased pressure within the sinus cavities.
Symptoms with sinus infection

• If an infection is present, there may be fever, chills, malaise (feeling poorly) or myalgias (achy muscles).
  
• Greenish-yellow nasal drainage may occur.
  
• Swollen lymph nodes (swollen glands) may occur in the neck if an infection is present, no different than the swelling of lymph nodes that accompanies acute pharyngitis (sore throat) or otitis media (ear infection).

Symptoms with sinus inflammation

• If there is sinus inflammation without infection, the drainage may be clear.
  
• If the maxillary sinus is inflamed, there may be pain felt in the upper teeth since the sinus is located in the bone where those teeth are located.

When should I seek medical care for a sinus headache?

Many people correctly self-diagnose sinusitis and treat themselves at home with fluids by mouth and breathing humidified air to loosen secretions and promote drainage. However, accessing medical care should be considered if a fever is present, there is swelling that can be felt in the face (perhaps signaling an abscess formation), or if the person exhibits a change in behavior or thinking.
Medical care may be appropriate if the pain does not respond to over-the-counter pain medications such as ibuprofen or acetaminophen or if symptoms last longer than 10 to 14 days.

(AIDS) (cont.)

What are symptoms and signs of AIDS?

AIDS is an advanced stage of HIV infection. Because the CD4 cells in the immune system have been largely destroyed, people with AIDS develop symptoms and signs of unusual infections or cancers. When a person with HIV infection gets one of these infections or cancers, it is referred to as an "AIDS-defining condition." Examples of AIDS-defining conditions are listed in Table 1. Significant, unexplained weight loss is also an AIDS-defining condition. It is possible for people without AIDS to get some of these conditions, especially the more common infections like tuberculosis.
People with AIDS may develop symptoms of pneumonia due to Pneumocystis jiroveci, which is rarely seen in people with normal immune systems. They also are more likely to get pneumonia due to common bacteria. Globally, tuberculosis is one of the most common infections associated with AIDS. In addition, people with AIDS may develop seizures, weakness, or mental changes due to toxoplasmosis, a parasite that infects the brain. Neurological signs also may be due to meningitis caused by the fungus Cryptococcus. Complaints of painful swallowing may be caused by a yeast infection of the esophagus called candidiasis. Because these infections take advantage of the weakened immune system, they are called opportunistic infections.
The weakening of the immune system in AIDS can lead to unusual cancers like Kaposi's sarcoma. Kaposi's sarcoma develops as raised lesions on the skin which are red, brown, or purple. Kaposi's sarcoma can spread to the mouth, intestine, or respiratory tract. AIDS also may cause lymphoma (a type of cancer) of the brain or other types of lymphomas.
In people with AIDS, HIV itself may cause symptoms. Some people experience relentless fatigue and weight loss, known as "wasting syndrome." Others may develop confusion or sleepiness due to infection of the brain with HIV, known as HIV encephalopathy. Both wasting syndrome and HIV encephalopathy are AIDS-defining illnesses.

What are risk factors for AIDS?

Because AIDS is caused by HIV, the risk factors for developing AIDS are the same as for HIV. Specifically, behaviors that result in contact with infected blood or secretions pose the main risk of HIV transmission. These behaviors include sexual intercourse and injection drug use. The presence of sores in the genital area, like those caused by herpes, makes it easier for the virus to pass from person to person during intercourse. HIV also has been spread to health-care workers through accidental sticks with needles contaminated with blood from HIV-infected people, or when broken skin has come into contact with infected blood or secretions. Blood products used for transfusions or injections also may spread infection, although this has become extremely rare (less than one in 2 million transfusions in the U.S.) due to testing of blood donors and blood supplies. Finally, infants may acquire HIV from an infected mother either while they are in the womb, during birth, or by breastfeeding after birth.
The risk that HIV infection will progress to AIDS increases with the number of years since the infection was acquired. If the HIV infection is untreated, 50% of people will develop AIDS within 10 years. This time is shortened if the person already has a weak immune system or if HIV was acquired through transfusion. Of people with HIV, the risk of progressing to AIDS is increased if there is evidence that the immune system is weakening as shown by falling levels of CD4 cells or if the virus is reproducing rapidly as shown by a high number of viral particles in the blood (high viral load).
Treatment substantially reduces the risk that HIV will progress to AIDS. In developed countries, use of highly active antiretroviral therapy (HAART) has turned HIV into a chronic disease that may never progress to AIDS. Conversely, if infected people are not able to take their medications or have a virus that has developed resistance to several medications, they are at increased risk for progression to AIDS. If AIDS is not treated, 50% of people will die within nine months of the diagnosis.

What is the treatment for HIV/AIDS?

Medications that fight HIV are called anti-retroviral medications. Different anti-retroviral medications attack the virus in different ways. When used in combination with each other, they are very effective at suppressing the virus. These effective combinations are called highly active anti-retroviral therapy or HAART. It is important to note that there is no cure for AIDS or for HIV. HAART only suppresses reproduction of the virus.
All people with a diagnosis of AIDS should receive HAART therapy. Of course, it is even better to give the medications earlier in HIV infection to prevent progression to AIDS. Current Department of Health and Human Services guidelines recommend starting HAART when CD4 falls below 350 cells per milliliter. Most experts would also consider therapy if the viral load is more than 100,000 copies per milliliter or if the CD4 count is falling rapidly. Recent studies suggest that starting treatment earlier, at CD4 counts from 350 to 500 and possibly even when greater than 500 per milliliter, may be beneficial.
There are five major classes of anti-retroviral medications: (1) nucleoside reverse transcriptase inhibitors (NRTIs), (2) non-nucleoside reverse transcriptase inhibitors (NNRTIs), (3) protease inhibitors (PIs), (4) entry inhibitors, and (5) integrase inhibitors. These drugs are used in different combinations according to the needs of the patient and depending on whether the virus has become resistant to a specific drug or class of medications. Treatment regimens usually consist of three to four medications at the same time. The most commonly recommended regimen includes two medications from the NRTI class in combination with either a protease inhibitor or an NNRTI or, less commonly, an integrase inhibitor. Entry inhibitors and integrase inhibitors are relatively newer classes of anti-retroviral medications and are useful for those patients who have failed to respond to other agents or who have a resistant virus. Combination treatment with HAART is essential because using only one class of medication by itself allows the virus to become resistant to the medication.
Before starting HAART, blood tests are usually done to make sure the virus is not already resistant to the chosen medications. These resistance tests may be repeated if it appears the drug regimen is not working or stops working. Patients are taught the importance of taking all of their medications as directed and are told what side effects to watch for. Noncompliance with medications is the most common cause of treatment failure and can cause the virus to develop resistance to the medication. Because successful therapy often depends on taking several pills, it is important for the patient to understand that this is an "all or nothing" regimen. If the person cannot tolerate one of the pills, then he or she should call their physician, ideally prior to stopping any medication. Taking just one or two of the recommended medications is strongly discouraged because it allows the virus to mutate and become resistant. It is best to inform the doctor quickly about any problems so that a better-tolerated combination can be prescribed. To reduce the number of pills needed each day, there are pills that contain multiple medications.

Acquired Immunodeficiency Syndrome (AIDS)

What does AIDS stand for? What causes AIDS?

AIDS stands for "acquired immunodeficiency syndrome." AIDS is a disease that weakens the immune system to the point where an affected person is vulnerable to a wide range of infections and cancers that result in death if not treated. AIDS is caused by the human immunodeficiency virus (HIV). The virus is spread through contact with infected blood or secretions. At first (stage 1 HIV infection), there is little evidence of harm. Over time, the virus attacks the immune system, focusing on special cells called "CD4 cells" which are important in protecting the body from infections and cancers, and the number of these cells starts to fall (stage 2). Eventually, the CD4 cells fall to a critical level and/or the immune system is weakened so much that it can no longer fight off certain types of infections and cancers. This advanced stage of infection (stage 3) with HIV is called AIDS.
HIV is a very small virus that contains ribonucleic acid (RNA) as its genetic material. (Animal cells, plant cells, bacteria, parasites, and some viruses use deoxyribonucleic acid [DNA] as their primary genetic material rather than RNA.) When HIV infects animal cells, it uses a special enzyme, reverse transcriptase, to turn (transcribe) its RNA into DNA which, in turn, directs the formation of HIV RNA that can be used to form new HIV. This is different from the way human cells reproduce (directly transcribing their DNA into RNA), so HIV is classified as a "retrovirus." When HIV reproduces, it is prone to making small genetic mistakes or mutations, resulting in viruses that vary slightly from each other. This ability to create minor variations allows HIV to evade the body's immunologic defenses, essentially leading to lifelong infection, and has made it difficult to make an effective vaccine. The mutations also allow HIV to become resistant to medications.

What is the history of AIDS?

Careful investigation has helped scientists determine where AIDS came from. Studies have shown that the human immunodeficiency virus first arose in Africa. It spread from primates to people decades ago, possibly when humans came into contact with infected blood during a chimpanzee hunt. By testing stored blood samples, scientists have found evidence of human infection as long ago as 1959. Once introduced into humans, HIV was spread through sexual intercourse from person to person. As infected people moved around, the virus spread from Africa to other areas of the world. In 1981, U.S. physicians noticed that a large number of young men were dying of unusual infections and cancers. Initially, U.S. victims were predominately homosexual men, probably because the virus inadvertently entered this population first in this country and because the virus is transmitted easily during anal intercourse. However, it is important to note that the virus also is efficiently transmitted through heterosexual activity and contact with infected blood or secretions. In Africa, which remains the center of the AIDS pandemic, most cases are heterosexually transmitted.
In the years since the virus was first identified, AIDS has spread to every corner of the globe. Statistics from the World Health Organization show that approximately 2 million people die each year from AIDS, resulting in 15 million new orphan children. Worldwide, half of HIV-infected people are women and 6% are children under 15 years of age. Two-thirds of current cases are in sub-Saharan Africa.
In the U.S., more than 1 million people have been diagnosed with AIDS since the start of the epidemic. There are approximately 430,000 people currently living with AIDS in the U.S. Each year, another 37,000 people are newly diagnosed with AIDS. Over the years, more than half a million people in the U.S. have died from AIDS, many of them during what should have been their most productive years of life.

Eye Allergy (Allergic Eye Disease)

Eye allergy introduction

The eyes are the windows to the soul because they reflect our state of mind. This certainly can't be true if our eyes are red, swollen, watery, and itchy from an allergic reaction. Severe allergic eye symptoms can be very distressing and are a common reason for visits to the allergist, ophthalmologist, and even the emergency room. Occasionally, severe eye allergies cause serious damage that can threaten eyesight.
Eye allergies usually are associated with other allergic conditions, particularly hay fever (allergic rhinitis) and atopic eczema (dermatitis). The causes of eye allergies are similar to those of allergic asthma and hay fever. Medications and cosmetics can play a significant role in causing eye allergies. Reactions to eye irritants and other eye conditions (for example, infections such as pinkeye) are often confused with eye allergy.

What is the basic anatomy of the outer eye?

Eye allergies mainly involve the conjunctiva, which is the tissue lining (mucus membrane) that covers the white surface of the eyeball and the inner folds of the eyelids. The conjunctiva is a barrier structure that is exposed to the environment and the many different allergens (substances that stimulate an allergic response) that become airborne. It is rich in blood vessels and contains more mast cells (histamine-releasing cells) than the lungs.
The lacrimal (tear) glands are located in the upper and outer portions of the eye. They are responsible for producing the watery component of tears, which keeps the eye moist and washes away irritants. The tears also contain important components of the immune defense such as immunoglobulin (antibodies), lymphocytes (specialized white blood cells), and enzymes.
The cornea is the transparent sheath in front of the lens of the eye. The cornea has no blood vessels and very little immune activity.

Why are the eyes an easy target for allergies?

When you open your eyes, the conjunctiva becomes directly exposed to the environment without the help of a filtering system such as the cilia, the hairs commonly found in the nose.

Allergy fact

Approximately 54 million people, about 20% of the U.S. population, have allergies. Almost half of these people have allergic eye disease.

People who are more susceptible to allergic eye disease are those with a history of allergic rhinitis and atopic dermatitis and those with a strong family and/or personal history of allergy. Symptoms usually appear before the age of 30.
The scenario for developing allergy symptoms is much the same for the eyes as that for the nose. Allergens cause the allergy antibody IgE to coat numerous mast cells in the conjunctiva. Upon reexposure to the allergen, the mast cell is prompted to release histamine and other mediators. The result is itching, burning, and runny eyes that become red and irritated due to inflammation, which results in congestion. The eyelids may swell, even to the point of closing altogether. Sometimes, the conjunctiva swells with fluid and protrudes from the surface of the eye, resembling a "hive" on the eye. These reactions may also induce light sensitivity. Typically, both eyes are affected by an allergic reaction. Occasionally, only one eye is involved, particularly when only one eye is rubbed with an allergen, as this causes mast cells to release more histamine.
Allergic conjunctivitis is inflammation of the conjunctiva that is caused by a reaction to allergens. The inflammation causes enlargement of the blood vessels in the conjunctiva ("congestion"), resulting in a red or bloodshot appearance of the eyes.

What are allergic eye conditions?

Allergic conjunctivitis
Allergic conjunctivitis, also called "allergic rhinoconjunctivitis," is the most common allergic eye disorder. The condition is usually seasonal and is associated with hay fever. The main cause is pollens, although indoor allergens such as dust mites, molds, and dander from household pets such as cats and dogs may affect the eyes year-round. Typical complaints include itching, redness, tearing, burning, watery discharge, and eyelid swelling. To a large degree, the acute (initial) symptoms appear related to histamine release.
The treatments of choice are topical antihistamine drops such as olopatadine (Patanol), decongestants, and the newer mast-cell stabilizer medications. Topical steroids should be used only if prescribed by a doctor for severe reactions and on a short-term basis because of the potential for side effects. In general, oral antihistamines like loratadine (Claritin) or cetirizine (Zyrtec) are the least effective option, but they are often used for treating allergic rhinitis together with allergic conjunctivitis.

Allergy assist

Rubbing itchy eyes is a natural response. However, rubbing usually worsens the allergic reaction due to the physical impact on the mast cells, which causes them to release more mediators of the immune response. Translation: Do not rub your eyes!

Conjunctivitis with atopic dermatitis
Commonly called "atopic keratoconjunctivitis," this condition is a notorious cause of severe eye changes, particularly in young adults. Atopic keratoconjunctivitis implies inflammation of both the conjunctiva and cornea. "Kerato" means pertaining to the cornea. This form of conjunctivitis usually affects adolescent boys (three times more frequently than girls) and is more common in those who had atopic dermatitis in early childhood. The condition is characterized by intensely itchy, red areas that appear on the eyelids. A heavy discharge from the eyes can occur, and the skin of the eyelid may show scales and crusts. In severe cases, the eyes become sensitive to light, and the eyelids noticeably thicken. If managed poorly, there can be permanent scarring of the cornea due to chronic rubbing and scratching of the eyes. This scarring can cause visual changes.
The triggers for atopic keratoconjunctivitis appear to be similar to those of atopic dermatitis. A search for common food allergies, such as eggs, peanuts, milk, soy, wheat, or fish is important. Airborne allergens, particularly dust mites and pet dander, have been overlooked as a significant contributing factor and should be evaluated and controlled.
The hallmark of treatment for allergic conjunctivitis is the use of potent antihistamines (similar to those used in atopic dermatitis) to subdue the itching. Topical antihistamines, mast-cell stabilizers, and the short-term use of oral steroids are all beneficial for relief of the itching. Occasionally, an infection of the area (usually with staphylococcus, commonly referred to as "staph") worsens the symptoms, and antibiotic treatment may help control the itching. Allergy shots are useful in selected cases.

Allergy alert

Atopic keratoconjunctivitis can lead to cataract formation in up to 10% of cases. In rare cases, blindness can occur.

Vernal keratoconjunctivitis

Vernal keratoconjunctivitis is an uncommon condition that tends to occur in preadolescent boys (3:1 male to female ratio) and is usually outgrown during the late teens or early adulthood. (Vernal is another term for "spring.") Vernal keratoconjunctivitis usually appears in the late spring and particularly occurs in rural areas where dry, dusty, windy, and warm conditions prevail. The eyes become intensely itchy, sensitive to light, and the lids feel uncomfortable and droopy. The eyes produce a "stringy" discharge and, when examined, the surface under the upper eyelids appears "cobblestoned." A closer examination of the eye reveals severe inflammation due to the vast number of mast cells and accumulated eosinophils, producing so-called called "Trantas dots."
Improper treatment of vernal keratoconjunctivitis can lead to permanent visual impairment. The most effective treatment appears to be a short-term course of low-dose topical steroids. Topical mast-cell stabilizers and topical antihistamines can also be beneficial. Wraparound sunglasses are helpful to protect the eyes against wind and dust.

Allergy fact

Keratitis, or the inflammation of the cornea, in vernal and atopic keratoconjunctivitis is largely caused by a substance that is released from the eosinophils, called major basic protein.

Giant papillary conjunctivitis (GPC)

This condition is named for its typical feature, large papillae, or bumps, on the conjunctiva under the upper eyelid. These bumps are likely the result of irritation from a foreign substance, such as contact lenses. Hard, soft, and rigid gas-permeable lenses are all associated with the condition. The reaction is possibly linked to the protein buildup on the contact lens surface. This condition is believed, in part, to be due to an allergic reaction to either the contact lens itself, protein deposits on the contact lens, or the preservative in the solution for the contact lenses. Redness and itching of the eye develop, along with a thick discharge.
Allergy to contact lenses is most common among wearers of hard contact lenses and is least common among those who use disposable lenses, especially the one-day or one-week types. Sleeping with the contact lenses on greatly increases the risk of developing GPC. The most effective treatment is to stop wearing the contact lenses. Occasionally, changing the type of lens in addition to more frequent cleaning or using disposable daily wear lenses will prevent the condition from recurring.
The giant papillae on the conjunctiva, which are characteristic of GPC, however, may persist for months despite these measures. Eye medications, such as cromolyn (Opticrom) or lodoxamide (Alomide), often are used in this condition, sometimes for several months. Contact lenses should not be worn while these medications are being used.

acetylsalicylic acid, Aspirin, Ecotrin

GENERIC NAME: aspirin

BRAND NAMES: Aspirin, Arthritis Foundation Safety Coated Aspirin, Bayer Aspirin, Bayer Children's Aspirin, Ecotrin, and many others.

DRUG CLASS AND MECHANISM: Aspirin is a nonsteroidal antiinflammatory drug (NSAID) effective in treating fever, pain, and inflammation in the body. It also prevents blood clots (i.e., is antithrombotic). As a group, NSAIDs are non-narcotic relievers of mild to moderate pain of many causes, including headaches, injury, menstrual cramps, arthritis, and other musculoskeletal conditions. Other members of this class include ibuprofen (Motrin), indomethacin (Indocin), nabumetone (Relafen) and several others. They all work by reducing the levels of prostaglandins, chemicals that are released when there is inflammation and that cause pain and fever. NSAIDs block the enzyme that makes prostaglandins (cyclooxygenase), resulting in lower concentrations of prostaglandins. As a consequence, inflammation, pain, and fever are reduced. Inhibition of prostaglandins also reduces the function of platelets and the ability of blood to clot. Aspirin, inhibits the function of platelets in a manner that is different from other NSAIDs, and its antithrombotic effects last longer than other NSAIDs. This is why aspirin is used for preventing heart attacks and strokes. The FDA approved Bayer aspirin in June 1965.
PRESCRIPTION: No
GENERIC AVAILABLE: Yes
PREPARATIONS: Chewable tablets: 81mg; caplets and tablets: 325mg, 500mg; enteric coated (safety coated) caplets and tablets: 325mg, 500mg.
STORAGE: Aspirin should be stored at room temperature, 20-25 C (68-77 F), in a sealed container, avoiding moisture.
PRESCRIBED FOR: Aspirin is used for the treatment of inflammation, fever, and pain that results from many forms of arthritis, including rheumatoid arthritis, juvenile arthritis, systemic lupus erythematosus, ankylosing spondylitis, Reiter's syndrome, and osteoarthritis, as well as for soft tissue injuries, such as tendinitis and bursitis. Aspirin also is used for rapid relief of mild to moderate pain and fever in other inflammatory conditions. Because aspirin inhibits the function of platelets for prolonged periods of time, it is used for reducing the risk of strokes and heart attacks.
DOSING: Aspirin should be taken with food. Doses range from 50 mg to 6000 mg daily depending on the use.

• Usual doses for mild to moderate pain are 350 or 650 mg every 4 hours or 500 mg every 6 hours.
• Doses for rheumatoid arthritis include 500 mg every 4-6 hours; 650 mg every 4 hours; 1000 mg every 4-6 hours; 1950 mg twice daily.
• Heart attacks are prevented with 81, 162 or 325 mg daily.

DRUG INTERACTIONS: Aspirin is associated with several suspected or probable interactions that affect the action of other drugs. The following examples are the most common of the suspected interactions.
NSAIDs may increase the blood levels of lithium (Eskalith) by reducing the excretion of lithium by the kidneys. Increased levels of lithium may lead to lithium toxicity.
Aspirin may reduce the blood pressure lowering effects of blood pressure medications. This may occur because prostaglandins have a role in the regulation of blood pressure.
When aspirin is used in combination with methotrexate (Rheumatrex, Trexall) or aminoglycoside antibiotics (for example, gentamicin) the blood levels of the methotrexate or aminoglycoside may increase, presumably because their elimination from the body is reduced. This may lead to more methotrexate or aminoglycoside-related side effects.
Individuals taking oral blood thinners or anticoagulants, for example, warfarin, (Coumadin) should avoid aspirin because aspirin also thins the blood, and excessive blood thinning may lead to serious bleeding.
PREGNANCY: Aspirin is generally avoided during pregnancy because it may adversely effect the fetus. However, low aspirin doses have been safely used for the prevention of complications of pregnancy.
NURSING MOTHERS: Aspirin is excreted into breast milk and may cause adverse effects in the infant.
SIDE EFFECTS: Most patients benefit from aspirin and other NSAIDs with few side effects. However, serious side effects can occur and generally tend to be dose-related. Therefore, it is advisable to use the lowest effective dose to minimize side effects.
The most common side effects of aspirin involve the gastrointestinal system and ringing in the ears. With respect to the gastrointestinal system, it can cause ulcerations, abdominal burning, pain, cramping, nausea, gastritis, and even serious gastrointestinal bleeding and liver toxicity. Sometimes, ulceration and bleeding can occur without any abdominal pain. Black tarry stools, weakness, and dizziness upon standing may be the only signs of internal bleeding.
Should ringing in the ears occur, the daily dose should be reduced. Rash, kidney impairment, vertigo, and dizziness also can occur. Aspirin should be avoided by patients with peptic ulcer disease or poor kidney function, since this medication can aggravate both conditions. Aspirin may exacerbate asthma. Aspirin can raise the blood uric acid level and is avoided in patients with hyperuricemia and gout. Children and teenagers should avoid aspirin for symptoms of the flu or chickenpox because of the associated risk of Reye's Syndrome, a serious disease of the liver and nervous system that can lead to coma and death. Aspirin can increase the effect of medicines used to treat diabetes mellitus, resulting in abnormally low blood sugars if blood sugar levels are not monitored. NSAIDs should be discontinued prior to elective surgery because of a mild tendency to interfere with blood clotting. Aspirin, because of its prolonged effect on platelets, is best discontinued at least ten to fourteen days in advance of the procedure.

USES: Aspirin is used to reduce fever and relieve mild to moderate pain from conditions such as muscle aches, toothaches, common cold, and headaches. It may also be used to reduce pain and swelling in conditions such as arthritis. Aspirin is known as a salicylate and a nonsteroidal anti-inflammatory drug (NSAID). It works by blocking a certain natural substance in your body to reduce pain and swelling. Consult your doctor before treating a child younger than 12 years.Your doctor may direct you to take a low dose of aspirin to prevent blood clots. This effect reduces the risk of stroke and heart attack. If you have recently had surgery on clogged arteries (such as bypass surgery, carotid endarterectomy, coronary stent), your doctor may direct you to use aspirin in low doses as a "blood thinner" to prevent blood clots.
HOW TO USE: If you are taking this medication for self-treatment, follow all directions on the product package. If you are uncertain about any of the information, consult your doctor or pharmacist. If your doctor has directed you to take this medication, take it exactly as prescribed.Take this medication by mouth. Drink a full glass of water (8 ounces/240 milliliters) with it unless your doctor tells you otherwise. Do not lie down for at least 30 minutes after you have taken this drug. If stomach upset occurs while you are taking this medication, you may take it with food or milk.Swallow the enteric-coated and the long-acting forms of this medication whole. Do not chew or crush the medication. Doing so increases the risk of side effects.The dosage and length of treatment are based on your medical condition and response to treatment. Read the product label to find recommendations on how many tablets you can take in a 24-hour period and how long you may self-treat before seeking medical advice. Do not take more medication or take it for longer than recommended unless directed by your doctor. Consult your doctor or pharmacist if you have any questions.If you are taking this medication for self-treatment of headache, seek immediate medical attention if you also have slurred speech, weakness on one side of the body, or sudden vision changes. Before using this drug, consult a doctor or pharmacist if you have headaches caused by head injury, coughing, or bending, or if you have a headache with persistent/severe vomiting, fever, and stiff neck.If you are taking this medication as needed (not on a regular schedule), remember that pain medications work best if they are used as the first signs of pain occur. If you wait until the pain has worsened, the medicine may not work as well. Aspirin with a special coating (enteric coating) or slow release may take longer to stop pain because it is absorbed more slowly. Ask your doctor or pharmacist to help select the best type of aspirin for you.You should not take this medication for self-treatment of pain for longer than 10 days. You should not use this drug to self-treat a fever that lasts longer than 3 days. In these cases, consult a doctor because you may have a more serious condition. Tell your doctor promptly if you develop ringing in the ears or difficulty hearing.If your condition persists or worsens (such as new or unusual symptoms, redness/swelling of the painful area, pain/fever that does not go away or gets worse) or if you think you may have a serious medical problem, tell your doctor promptly.

ACE Inhibitors

What are ACE inhibitors, and how do they work?

Angiotensin II is a very potent chemical that causes the muscles surrounding blood vessels to contract, thereby narrowing the vessels. The narrowing of the vessels increases the pressure within the vessels causing high blood pressure (hypertension). Angiotensin II is formed from angiotensin I in the blood by the enzyme angiotensin converting enzyme (ACE). ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, the blood vessels enlarge or dilate, and blood pressure is reduced. This lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart. In addition, the progression of kidney disease due to high blood pressure or diabetes is slowed.

For what conditions are ACE inhibitors used?

ACE inhibitors are used for controlling blood pressure, treating heart failure, preventing strokes, and preventing kidney damage in people with hypertension or diabetes. They also improve survival after heart attacks. In studies, individuals with hypertension, heart failure, or prior heart attacks who were treated with an ACE inhibitor lived longer than patients who did not take an ACE inhibitor. Because they prevent early death resulting from hypertension, heart failure or heart attacks, ACE inhibitors are one of the most important group of drugs. Some individuals with hypertension do not respond sufficiently to ACE inhibitors alone. In these cases, other drugs are used in combination with ACE inhibitors.

Are there any differences among the different types of ACE inhibitors?

ACE inhibitors are very similar. However, they differ in how they are eliminated from the body and their doses. Some ACE inhibitors need to be converted into an active form in the body before they work. In addition, some ACE inhibitors may work more on ACE that is found in tissues than on ACE that is present in the blood. The importance of this difference or whether one ACE inhibitor is better than another has not been determined.

What are the side effects of ACE inhibitors?

ACE inhibitors are well-tolerated by most individuals. Nevertheless, they are not free of side effects, and some patients should not use ACE inhibitors.
ACE inhibitors usually are not prescribed for pregnant patients because they may cause birth defects.
Individuals with bilateral renal artery stenosis (narrowing) may experience worsening of kidney function, and people who have had a severe reaction to ACE inhibitors probably should avoid them.
The most common side effects are:

• cough,
  
• elevated blood potassium levels,
  
• low blood pressure, dizziness,
  
• headache,
  
• drowsiness,
  
• weakness,
  
• abnormal taste (metallic or salty taste), and
  
• rash.

It may take up to a month for coughing to subside, and if one ACE inhibitor causes cough it is likely that the others will too. The most serious, but rare, side effects of ACE inhibitors are kidney failure, allergic reactions, a decrease in white blood cells, and swelling of tissues (angioedema).

With which drugs do ACE inhibitors interact?

ACE inhibitors have few interactions with other drugs. Since ACE inhibitors may increase blood levels of potassium, the use of potassium supplements, salt substitutes (which often contain potassium), or other drugs that increase the body's potassium may result in excessive blood potassium levels. ACE inhibitors also may increase the blood concentration of lithium (Eskalith) and lead to an increase in side effects from lithium. There have been reports that aspirin and other non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever etc.), indomethacin (Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the effects of ACE inhibitors.

What are some examples of ACE inhibitors

The following is a list of the ACE inhibitors that are available in the United States:

• benazepril (Lotensin),
  
• captopril (Capoten),
  
• enalapril (Vasotec),
  
• fosinopril (Monopril),
  
• lisinopril (Prinivil, Zestril)
  
• moexipril (Univasc), and
  
• perindopril(Aceon),
  
• quinapril (Accupril),
  
• ramipril (Altace),
  
• trandolapril (Mavik).

What is the treatment for liver disease?

Each liver disease will have its own specific treatment regimen. For example, hepatitis A requires supportive care to maintain hydration while the body's immune system fights and resolves the infection. Patients with gallstones may require surgery to remove the gallbladder. Other diseases may need long-term medical care to control and minimize the consequences of their disease
In patients with cirrhosis and end-stage liver disease, medications may be required to control the amount of protein absorbed in the diet. The liver affected by cirrhosis may not be able to metabolize the waste products, resulting in elevated blood ammonia levels and hepatic encephalopathy. Low sodium diet and water pills (diuretics) may be required to minimize water retention.
In those with large amounts of ascites fluid, the excess fluid may have to be occasionally removed with a needle and syringe (paracentesis). Using local anesthetic, a needle is inserted through the abdominal wall and the fluid withdrawn.
Operations may be required to treat portal hypertension and minimize the risk of bleeding.
Liver transplantation is the final option for patients whose liver has failed.

Liver Disease (Hepatic Disease)

What is liver disease?

Liver disease is any disturbance of liver function that causes illness. The liver is responsible for many critical functions within the body and should it become diseased or injured, the loss of those functions can cause significant damage to the body. Liver disease is also referred to as hepatic disease.
Liver disease is a broad term that covers all the potential problems that may occur to cause the liver to fail to perform its designated functions. Usually, more than 75% or three quarters of liver tissue needs to be affected before decrease in function occurs.
The liver the largest solid organ in the body; and is also considered a gland because among its many functions, it makes and secretes bile. The liver is located in the upper right portion of the abdomen protected by the rib cage. It has two main lobes that are made up of tiny lobules. The liver cells have two different sources of blood supply. The hepatic artery supplies oxygen rich blood that is pumped from the heart, while the portal vein supplies nutrients from the intestine and the spleen.
Normally, veins return blood from the body to the heart, but the portal vein allows chemicals from the digestive tract to enter the liver for "detoxification" and filtering prior to entering the general circulation. The portal vein also efficiently delivers the chemicals and proteins that liver cells need to produce the proteins, cholesterol, and glycogen required for normal body activities.
As part of its function, the liver makes bile, a fluid that contains among other substances, water, chemicals, and bile acids (made from stored cholesterol in the liver). Bile is stored in the gallbladder and when food enters the duodenum (the first part of the small intestine), bile is secreted into the duodenum, to aid in digestion of food.

The liver is the only organ in the body that can easily replace damaged cells, but if enough cells are lost, the liver may not be able to meet the needs of the body. 
The liver can be considered a factory; and among its many functions include the:

• production of bile that is required in the digestion of food, in particular fats;
  
• conversion of the extra glucose in the body into stored glycogen in liver cells; and  then converting it back into glucose when the need arises;
  
• production of blood clotting factors;
  
• production of amino acids (the building blocks for making proteins), including those used to help fight infection;
  
• the processing and storage iron necessary for red blood cell production;
  
• manufacture of cholesterol and other chemicals required for fat transport;
  
• conversion of waste products of body metabolism into urea that is excreted in the urine; and
  
• metabolization medications into their active ingredient in the body.

Cirrhosis is a term that describes permanent scarring of the liver. Normal liver cells are replaced by scar tissue that cannot perform any liver function.
Acute liver failure may or may not be reversible, meaning that is there is a treatable cause and the liver is able to recover and resume its normal functions.

What are the causes of liver disease?

The liver can be damaged in a variety of ways.

• Cells can become inflamed (such as in hepatitis: hepar=liver + itis=inflammation).
  
• Bile flow can be obstructed (such as in cholestasis: chole=bile + stasis=standing).
  
• Cholesterol or triglycerides can accumulate (such as in steatosis; steat=fat + osis=accumulation).
  
• Blood flow to the liver may be compromised.
  
• Liver tissue can be damaged by chemicals and minerals, or infiltrated by abnormal cells.

Alcohol abuse
Alcohol abuse is the most common cause of liver disease in North America. Alcohol is directly toxic to liver cells and can cause liver inflammation, referred to as alcoholic hepatitis. In chronic alcohol abuse, fatty accumulation (steatosis) occurs in liver cells causing the cells to malfunction.
Cirrhosis
Cirrhosis is a late-stage liver disease. Scarring of the liver and loss of functioning liver cells cause the liver to fail.
Drug-induced liver disease
Liver cells may become temporarily inflamed or permanently damaged by exposure to medications or drugs. Some medications or drugs require an overdose to cause liver injury while others may cause the damage even when taken in the appropriately prescribed dosage.
Taking excess amounts of acetaminophen (Tylenol, Panadol) can cause liver failure that is permanent. This is the reason that warning labels exist on many over-the-counter medications that contain acetaminophen and why prescription narcotic-acetaminophen combination medications (for example, Vicodin, Lortab, Norco, Tylenol #3) limit the numbers of tablets to be taken in a day.
Statin medications are commonly prescribed to control elevated blood levels of cholesterol. Even when taken in the appropriately prescribed dose, liver inflammation may occur and can be detected by blood tests that measure liver enzymes. Stopping the medication usually results in return of the liver function to normal.
Niacin is another medication used to control elevated blood levels of cholesterol, but liver inflammation for this medication is related to the dose taken. Similarly, patients with underlying liver disease may be at higher risk of developing liver disease due medications such as niacin.
There are numerous other medications that may cause liver inflammation, most of which will resolve when the medication is stopped. These include antibiotics such as nitrofurantoin (Macrodantin, Furadantin, Macrobid), amoxicillin and clavulanic acid (Augmentin, Augmentin XR), tetracycline (Sumycin), and isoniazid (INH, Nydrazid, Laniazid). Methotrexate (Rheumatrex, Trexall), a drug used to treat autoimmune disorders and cancers, has a variety of side effects including liver inflammation that can lead to cirrhosis. Disulfiram (Antabuse) used to treat alcoholics and can cause liver inflammation.
Some herbal remedies and excessive amounts of vitamins can cause hepatitis, cirrhosis and liver failure. Examples include vitamin A, kava kava, ma-huang, and comfrey.
Many mushrooms are poisonous to the liver and eating unidentified mushrooms gathered in the woods can be lethal.
Infectious hepatitis
The term "hepatitis" means inflammation, and liver cells can become inflamed because of infection.
Hepatitis A is a viral infection that is caused primarily through the fecal-oral route when small amounts of infected fecal matter are inadvertently ingested. Hepatitis A causes an acute inflammation of the liver which generally resolves spontaneously. The hepatitis A vaccine can prevent this infection.
Hepatitis B is spread by exposure to body fluids (needles from drug abusers, contaminated blood, and sexual contact) and can cause an acute infection, but can also progress to cause chronic inflammation (chronic hepatitis) that can lead to cirrhosis and liver cancer. The hepatitis B vaccine prevents this infection.
Hepatitis C causes chronic hepatitis. An infected individual may not recall any acute illness. Hepatitis C is spread by exposure to body fluids (needles from drug abusers, contaminated blood, and sexual contact). Chronic hepatitis C may lead to cirrhosis and liver cancer. At present, there is no vaccine against this virus.
Hepatitis D is a virus that requires concomitant infection with hepatitis B to survive, and is spread via body fluid exposure (needles from drug abusers, contaminated blood, and sexual contact).
Hepatitis E is a virus that is spread via contaminated food and water exposure.
Other viruses
Other viruses can also cause liver inflammation or hepatitis as part of the cluster of symptoms. Viral infections with infectious mononucleosis (Epstein Barr virus), adenovirus, and cytomegalovirus can inflame the liver. Non-viral infections such as toxoplasmosis and Rocky Mountain spotted fever are less common causes.
Non-Alcoholic fatty liver disease
Accumulation of fat within the liver can cause gradual decrease in liver function. Also known as nonalcoholic steatohepatitis, fatty liver disease, or NASH.
Hemochromatosis
Hemachromatosis (iron overload) is a metabolic disorder that leads to abnormally elevated iron stores in the body. The excess iron may be found in the tissues of the liver, pancreas, and heart and can lead to inflammation, cirrhosis, liver cancer, and liver failure. Hemachromatosis is an inherited disease.
Wilson's Disease
Wilson's disease is another inherited disease that affects the body's ability to metabolize copper. Wilson's disease may lead to cirrhosis and liver failure.
Gilbert's Disease
In Gilbert's disease, there is an abnormality in bilirubin metabolism in the liver. It is a common disease that affects up to 7% of the North American population. There are no symptoms and it is usually diagnosed incidentally when an elevated bilirubin level is found on routine blood tests. Gilbert's disease is a benign condition and no treatment is necessary.
Cancers
Primary cancers of the liver arise from liver structures and cells. Two examples include hepatocellular carcinoma and cholangiocarcinoma.
Metastatic cancer (secondary cancer of the liver) begins in another organ and spreads to the liver, usually through the blood stream. Common cancers that spread to the liver begin in the lung, breast, large intestine, stomach, and pancreas. Leukemia and Hodgkin's lymphoma may also involve the liver.
Blood flow abnormalities
Budd Chiari syndrome is a disease in which blood clots form in the hepatic vein and prevent blood from leaving the liver. This can increase portal vein pressure and lead to cirrhosis and liver failure. Causes of Budd Chiari syndrome include polycythemia (elevated red blood cell count), inflammatory bowel diseases, sickle cell disease, and pregnancy.
Congestive heart failure, where fluid and blood backs up in the large veins of the body can cause liver swelling and inflammation.
Bile flow abnormalities
Normally, bile flows from the liver into the gallbladder and ultimately into the intestine to help with the digestion of food. If bile flow is obstructed, it can cause inflammation within the liver. Most commonly, gallstones can cause an obstruction of the ducts that drains bile from the liver.
Abnormalities of the opening of the bile duct into the intestine (sphincter of Oddi) can lead to abnormalities of bile flow. The sphincter of Oddi acts as a "valve" that allows bile to flow from the common bile duct into the intestine.
Primary biliary cirrhosis and primary sclerosing cholangitis can lead to progressive scarring of the bile ducts, causing them to become narrow, which results in reduced bile flow through the liver. Eventually, damage and scarring of the liver architecture causes liver failure to develop.
Other diseases and conditions
Conditions such as portal hypertension (increased blood pressure within the portal vein), abnormal blood clotting, and hepatic encephalopathy (abnormal brain function due to elevated levels of ammonia in the blood stream).

What is the treatment for bone cancer?

There are many different methods available for your doctor to treat bone cancer. The best treatment is based on the type of bone cancer, the location of the cancer, how aggressive the cancer is, and whether or not the cancer has invaded surrounding or distant tissues (metastasized). There are three main types of treatment for bone cancer: surgery, chemotherapy, and radiation therapy. These can be used either individually or combined with each other.
Surgery is often used to treat bone cancer. The goal of surgery is usually to remove the entire tumor and a surrounding area of normal bone. After the tumor has been removed, a pathologist examines it to determine if there is normal bone completely surrounding the tumor. If a portion of the cancer is left behind, it can continue to grow and spread, requiring further treatment. If the tumor specimen has normal cells completely surrounding it, there is a much better chance that the entire tumor has been removed and less chance for recurrence. Historically, amputations were frequently used to remove bone cancer. Newer techniques have decreased the need for amputation. In many cases, the tumor can be removed with a rim of normal bone without the need for an amputation. Depending on the amount of bone removed, the surgeon will replace something in its location. For smaller areas, this may be either bone cement or a bone graft from another place in your body or from the bone bank. For larger areas, the surgeon may place larger grafts from the bone bank or metal implants. Some of these metal implants have the ability to lengthen when used in growing children.
You may be referred to a medical oncologist for chemotherapy. This is the use of various medications used to try to stop the growth of the cancer cells. Chemotherapy can be used prior to surgery to try to shrink the bone tumor to make surgery easier. It can also be used after surgery to try to kill any remaining cancer cells left following surgery.
You could also be referred to a radiation oncologist for radiation therapy. The radiation therapy uses high-energy X-ray aimed at the site of the cancer to try to kill the cancer cells. This treatment is given in small doses daily over a period of days to months. As with chemotherapy, radiation therapy can be used either before or after a potential surgery, depending on the specific type of cancer.

What are the side effects of treatment for bone cancer?

Unfortunately, there are risks and side effects with each of the treatments for bone cancer. The main risks associated with surgery include infection, recurrence of the cancer, and injury to the surrounding tissues. In order to remove the entire cancer and reduce the risk of recurrence, some surrounding normal tissue must also be removed. Depending on the location of the cancer, this may require the removal of portions of bone, muscle, nerves, or blood vessels. This could cause weakness, loss of sensation, and the risk of fracture of the remaining bone. You could be referred to a rehabilitation specialist for physical and occupational therapy after surgery to try to improve your strength and function.
Chemotherapy uses very powerful medication to try to kill cancer cells. Unfortunately, some normal cells are also killed in the process. The medications are designed to kill rapidly dividing or growing cells. The normal cells that are affected often include hair, blood-forming cells, and cells lining the digestive system. Side effects include nausea and vomiting, loss of hair, infection, and fatigue. Fortunately, these side effects usually resolve after the chemotherapy is over. Good nutrition is important for your body to fight the cancer. You may be referred to nutrition specialist to help with this, especially if you experience nausea and loss of appetite.
The main side effects from radiation therapy include fatigue, loss of appetite, and damage to the surrounding skin and soft tissues. Prior radiation therapy can also increase the risk of wound problems from surgery in the same area.

Bone Cancer

What are bones for?

Your body has 206 bones. These bones serve multiple different functions. First, your bones provide structure to your body and help provide its shape. Muscles attach to the bones and allow you to move. Without the bones, your body would become a pile of soft tissues without structure, and you would be unable to stand, walk, or move. Second, the bones help to protect the more fragile organs of the body. For example, the bones of the skull protect the brain, the vertebrae of the spine protect the spinal cord, and the ribs protect the heart and lungs. Third, the bones contain bone marrow, which makes and stores new blood cells. Finally, the bones help control your body's collection of various proteins and nutrients including calcium and phosphorus.

What is cancer?

Your body is made up of many small structures called cells. There are many different types of cells that grow to form the different parts of your body. During normal growth and development, these cells continuously grow, divide, and make new cells. This process continues throughout life even after you are no longer growing. The cells continue to divide and make new cells to replace old and damaged cells. In a healthy person, the body is able to control the growth and division of cells according to the needs of the body. Cancer is when this normal control of cells is lost and the cells begin to grow and divide out of control. The cells also become abnormal and have altered functions in patients with cancer. The cancer cells can become very destructive to the surrounding cells.
There are many different type of cancer. The cancer is usually named based on the type of cell that is affected. For example, lung cancer is caused by out of control cells that form the lungs and breast cancer by cells that form the breast. A tumor is a collection of abnormal cells grouped together. However, not all tumors are cancerous. A tumor can be benign (not cancerous) or malignant (cancerous). Benign tumors are usually less dangerous and are not able to spread to other parts of the body. Benign tumors can still be dangerous. They can continue to grow and expand locally. This can lead to compression and damage to the surrounding structures. Malignant tumors are usually more serious and can spread to other areas in the body. The ability of cancer cells to leave their initial location and move to another location in the body is called metastasis. Metastasis can occur by the cancer cells entering the body's bloodstream or lymphatic system to travel to other sites in the body. When cancer cells metastasize to other parts of the body, they are still named by the original type of abnormal cell. For example, if a group of breast cells becomes cancerous and metastasizes to the bones or liver, it is called metastatic breast cancer instead of bone cancer or liver cancer. Many different types of cancer are able to metastasize to the bones. The most common types of cancer that spread to the bones are cancers of the lung, breast, prostate, thyroid, and kidney. Cancers arising from lymphatic or blood cells, including lymphoma and multiple myeloma, can also frequently affect the bones.
Most of the time, when people have cancer in their bones, it is caused by cancer that has spread from elsewhere in the body to the bones. It is much less common to have a true bone cancer, a cancer that arises from cells that make up the bone. It is important to determine whether the cancer in the bone is from another site or is from a cancer of the bone cells themselves. The treatments for cancers that have metastasized to the bone are often based on the initial type of cancer.

What causes bone cancer?

Bone cancer is caused by a problem with the cells that make bone. More than 2,000 people are diagnosed in the United States each year with a bone tumor. Bone tumors occur most commonly in children and adolescents and are less common in older adults. Cancer involving the bone in older adults is most commonly the result of metastatic spread from another tumor.
There are many different types of bone cancer. The most common primary bone tumors include osteosarcoma, Ewing's sarcoma, chondrosarcoma, malignant fibrous histiocytoma, fibrosarcoma, and chordoma.

• Osteosarcoma is the most common primary malignant bone cancer. It most commonly affects males between 10 and 25 years old but can less commonly affect older adults. It often occurs in the long bones of the arms and legs at areas of rapid growth around the knees and shoulders of children. This type of cancer is often very aggressive with risk of spread to the lungs. The five-year survival rate is about 65%.
• Ewing's sarcoma is the most aggressive bone tumor and affects younger people between 4-15 years of age. It is more common in males and is very rare in people over 30 years of age. It most commonly occurs in the middle of the long bones of the arms and legs. The three-year survival rate is about 65%, but this rate is much lower if there has been spread to the lungs or other tissues of the body.
• Chondrosarcoma is the second most common bone tumor and accounts for about 25% of all malignant bone tumors. These tumors arise from the cartilage cells and can either be very aggressive or relatively slow growing. Unlike many other bone tumors, chondrosarcoma is most common in people over 40 years of age. It is slightly more common in males and can potentially spread to the lungs and lymph nodes. Chondrosarcoma most commonly affects the bones of the pelvis and hips. The five-year survival for the aggressive form is about 30%, but the survival rate for slow-growing tumors is 90%.
• Malignant fibrous histiocytoma (MFH) affects the soft tissues, including muscle, ligaments, tendons, and fat. It is the most common soft-tissue malignancy in later adult life, usually occurring in people 50-60 years of age. It most commonly affects the extremities and is about twice as common in males as females. MFH also has a wide range of severity. The overall five-year survival rate is about 35%-60%.
• Fibrosarcoma is much more rare than the other bone tumors. It is most common in people 35-55 years of age. It most commonly affects the soft tissues of the leg behind the knee. It is slightly more common in males than females.
• Chordoma is a very rare tumor with an average survival of about six years after diagnosis. It occurs in adults over 30 years of age and is about twice as common in males as females. It most commonly affects either the lower or upper end of the spinal column.

In addition to bone cancer, there are various types of benign bone tumors. These include osteoid osteoma, osteoblastoma, osteochondroma, enchondroma, chondromyxoid fibroma, aneurysmal bone cyst, unicameral bone cyst, and giant cell tumor (which has the potential to become malignant). As with other types of benign tumors, these are not cancerous.
There are two other relatively common types of cancer than develop in the bones: lymphoma and multiple myeloma. Lymphoma, a cancer arising from the cells of the immune system, usually begins in the lymph nodes but can begin in the bone. Multiple myeloma begins in the bones, but it is not usually considered a bone tumor because it is a tumor of the bone marrow cells and not of the bone cells.

Heart Disease (cont.)

How is heart disease diagnosed?

The diagnosis of heart disease begins with obtaining a history that the potential for coronary artery disease exists. Risk factors need to be assessed, and then testing may be required to confirm the presence of heart disease.
Heart disease tests
Not every patient with chest pain needs heart catheterization (the most invasive test). Instead, the healthcare provider will try to choose the testing modality that will best provide the diagnosis, and if coronary artery disease is present, decide what impairment, if any, is present.

Electrocardiogram (ECG or EKG)

The heart is an electrical pump, and the electrical impulses it generates can be detected on the surface of the skin. Normal muscle conducts electricity in a reproducible fashion. Muscle that has decreased blood supply conducts electricity poorly. Muscle that has lost its blood supply and has been replaced with scar tissue cannot conduct electricity. The electrocardiogram (EKG) is a noninvasive test used to reflect underlying heart conditions by measuring the electrical activity of the heart.
Some people have "abnormal" EKGs at baseline but this may be normal for them. It is important that an electrocardiogram be compared to previous tracings. If a patient has a baseline abnormal EKG, they should carry a copy with them for reference if they ever need another EKG.

Stress testing

If the baseline EKG is relatively normal, then monitoring the EKG tracing while the patient exercises may uncover electrical changes that may indicate the presence of coronary artery disease. There are a variety of testing protocols used to determine whether the exercise intensity is high enough to prove that the heart is normal.
Some patients are unable to exercise on a treadmill test, but they can still undergo cardiac stress testing by using intravenous medication that causes the heart to work harder.
Stress testing is done under the supervision of medical personnel because of the potential of provoking angina, shortness of breath, abnormal heart rhythms, and heart attack.

Echocardiography

Used with or without exercise, echocardiography can assess how the heart works. Using sound waves to generate an image, a cardiologist can evaluate many aspects of the heart. Echocardiograms can examine the structure of the heart including the thickness of the heart muscle, the septum (the tissues that separate the four heart chambers from each other) and the pericardial sac (the outside lining of the heart).
The test can indirectly assess blood flow to parts of the heart muscle. If there is decreased blood flow, then segments of the heart wall may not beat as strongly as adjacent heart muscle. These wall motion abnormalities signal the potential for coronary artery disease.
The echocardiogram can also assess the efficiency of the heart by measuring ejection fraction. Normally when the heart beats, it pushes more than 60% of the blood in the ventricle out to the body. Many diseases of the heart, including coronary artery disease, can decrease this percentage (the ejection fraction).

Perfusion studies

Radioactive chemicals like thallium or technetium can be injected into a vein and their uptake measured in heart muscle cells. Abnormally decreased uptake can signify decreased blood flow to parts of the heart because of coronary artery narrowing. This test may be used when the patient's baseline EKG is not normal and is less reliable when used to monitor a stress test.

Computerized tomography

The latest generation of CT scanners can take detailed images of blood vessels and may be used as an adjunct to determine whether coronary artery disease is present. In some institutions, the heart CT is used as a negative predictor. That means that the test is done to prove that the coronary arteries are normal rather than to prove that the disease is present.

Heart catheterization or coronary angiography

This test is the gold standard for the diagnosis of coronary artery disease. A cardiologist inserts and then threads a small tube through the groin or arm into the coronary arteries, where dye is injected to directly visualize the arteries on an x-ray. This test defines the anatomy of the coronary arteries.
CT coronary angiogram is a fairly new test to diagnose coronary artery disease. During this procedure, intravenous dye containing iodine is injected into the patient and CT scanning is performed to image the coronary arteries.

Heart Disease (Coronary Artery Disease)

Introduction to heart disease
The heart is like any other muscle, requiring blood to supply oxygen and nutrients for it to function. The heart's needs are provided by the coronary arteries, which begin at the base of the aorta and spread across the surface of the heart, branching out to all areas of the heart muscle.
The coronary arteries are at risk for narrowing as cholesterol deposits, called plaques, build up inside the artery. If the arteries narrow enough, blood supply to the heart muscle may be compromised (slowed down), and this slowing of blood flow to the heart causes pain, or angina.
A heart attack or myocardial infarction occurs when a plaque ruptures, allowing a blood clot to form. This completely obstructs the artery, stopping blood flow to part of the heart muscle, and that portion of muscle dies.

What are the risk factors for heart disease

Risk factors for heart disease include:

• Smoking
  
• High blood pressure (hypertension)
  
• High cholesterol
  
• Diabetes
  
• Family history
  
• Peripheral artery disease
  
• Obesity

What are the symptoms of heart disease?

The typical symptoms of coronary artery disease are associated chest pain with shortness of breath. Classically, the pain of angina is described as a pressure or heaviness behind the breast bone with radiation to the jaw and down the arm accompanied by shortness of breath and sweating. Unfortunately, angina has a variety of presentations, and there may not even be specific chest pain. There may be shoulder or back ache, nausea, indigestion or upper abdominal pain.
Women, the elderly, and people with diabetes may have different perceptions of pain or have no discomfort at all. Instead, they may complain of malaise or fatigue.
Healthcare providers and patients may have difficulty understanding each other when symptoms of angina are described. Patients may experience pressure or tightness but may deny any complaints of pain.
People with coronary artery disease usually have gradual progression of their symptoms over time. As an artery narrows over time, the symptoms that it causes may increase in frequency and/or severity. Healthcare providers may inquire about changes in exercise tolerance (How far can you walk before getting symptoms? Is it to the mailbox? Up a flight of stairs?) and whether there has been an acute change in the symptoms.
Once again, patients may be asymptomatic until a heart attack occurs. Of course, some patients also may be in denial as to their symptoms and procrastinate in seeking care.

What are breast cancer prevention treatments?

Selective estrogen receptor modulator (SERM) and its effect of estrogen on breast cell growth
A selective estrogen receptor modulator (SERM) is a chemical that is designed to act like estrogen in certain tissue such as the bones and not like estrogen in other tissue such as the breast. The use of SERMs takes advantage of the benefits of estrogen while trying to avoid the risks associated with estrogen. Two SERMs, tamoxifen (Nolvadex) and raloxifene (Evista), have been used as preventive treatment. The advantages and disadvantages of each are discussed in more detail below.
Tamoxifen
Tamoxifen is the first SERM to receive approval by the United States Food and Drug Administration in the treatment of breast cancer. Some breast cancer cells are "estrogen sensitive," meaning they possess so-called estrogen receptors and need estrogen to grow and divide. But estrogen has to bind to the receptors of these cancer cells in order to stimulate them. Binding of estrogen to the receptors is analogous to fitting a key into a lock. Tamoxifen blocks the action of estrogen on the cancer cells by occupying the receptors (the locks), thus preventing estrogen (the keys) from fitting into the receptors. Blocking estrogen from the estrogen-sensitive cancer cells stops the growth and multiplication of these cells. Tamoxifen (in higher than usual doses) may also possess other properties that cause the death of breast cancer cells that are not estrogen sensitive.
Tamoxifen has been used to treat both advanced and early stage breast cancers. This drug has also proven valuable to women who have had cancer in one breast in reducing the chances of developing cancer in the second breast.
Even though tamoxifen behaves like an anti-estrogen agent in breast tissue, it acts like a weak estrogen in the bones. Thus, tamoxifen may have some benefit in preventing osteoporosis fractures in postmenopausal women.
Tamoxifen also decreases cysts and lumps in the breasts, especially among younger women. Fewer cysts and lumps make early detection by breast examinations and mammograms easier. This use of the drug would only be in extreme situations and is not an approved use.
Primary prevention of breast cancer with tamoxifen
The term "primary prevention" means trying to reduce the risks of developing breast cancer in women without a prior history of breast cancer. Tamoxifen not only blocks the action of estrogen on estrogen-sensitive cancer cells, but it also blocks estrogen from acting on cells that are not cancerous. Therefore, by reducing the growth and division of normal breast cells, tamoxifen decreases the population of cells that can develop cancer-causing DNA damage.
In the National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1, more than 13,000 women considered at high risk for developing breast cancer were given either tamoxifen or a placebo for five years. The women receiving tamoxifen developed 49% fewer breast cancers than women receiving the placebo. A further study, the International Breast Cancer Intervention Study (IBIS-I) in Europe, also confirmed a reduction in the rate of breast cancer development in high-risk women.
The United States Food and Drug Administration (FDA) has approved the use of tamoxifen for primary prevention in women at high risk for developing breast cancer. There is no evidence to suggest that tamoxifen can reduce breast cancer incidence in women considered to have a normal risk for the development of breast cancer.
Risks and side effects of tamoxifen
The risk of tamoxifen is the development of uterine cancer. Although the overall risk of developing uterine cancer is small (probably less than 1%), in the NSABP-P1 trial, more women on tamoxifen developed uterine cancer than women taking the placebo.
Additionally, women over 50 years of age on tamoxifen have a slightly heightened chance of developing blood clots in the veins of the lower extremities. These blood clots can occasionally break off and travel to cause blockage of blood vessels in the lungs (a process called pulmonary embolism). Symptoms of pulmonary embolism include shortness of breath, chest pain, and sometimes shock. Some studies have also reported an increased risk of stroke in patients taking tamoxifen.
The other side effects of tamoxifen include weight gain, hot flashes, irregular periods, vaginal dryness or discharge, and a slightly enhanced risk of cataracts.
Many of these side effects also depend on the age group being studied.
Raloxifene
Raloxifene is the second SERM to be approved by the FDA. It has been approved for use in preventing osteoporosis in postmenopausal women. Data suggest that raloxifene, like tamoxifen, can reduce the chance of developing breast cancer in high-risk women. Unlike tamoxifen, raloxifene does not stimulate cells of the uterus and is not believed to increase the risk of uterine cancer.
Studies that examined the effects of both tamoxifen and raloxifene (including the STAR trial, which studied over 19,000 postmenopausal women at high risk for developing breast cancer) showed that both drugs lowered the incidence of breast cancer in a similar manner. While both tamoxifen and raloxifene increased a woman's risk of blood clots, the observed increase was smaller with raloxifene. Raloxifene was also associated with a lower risk of uterine cancer and hysterectomy for noncancerous reasons than tamoxifen. However, some data suggested that raloxifene might not be as effective in preventing the development of early, noninvasive cancers as tamoxifen.
Data are not available on the effects of raloxifene in premenopausal women, and it is a potential teratogen, meaning that it may cause harm to the developing fetus. Therefore, raloxifene is limited to use by postmenopausal women and not used in women of childbearing age.
Controversies or other concerns about the use of tamoxifen or raloxifene as a primary prevention for patients at high risk
The data from studies of raloxifene and tamoxifen are encouraging. But there are still unresolved issues:

1. Do women treated with tamoxifen or raloxifene for primary prevention have a higher long-term survival rate than women who received the placebo do?
2. Does tamoxifen or raloxifene really prevent breast cancer, or do they only suppress the growth of existing breast cancer, thus delaying detection?
3. If tamoxifen is offered to healthy, young women, what are the long-term side effects? Does breast-cancer reduction translate into better long-term survival and quality of life?
4. How many years should patients be kept on the medication?

Select groups of high-risk women for whom a preventive medication such as tamoxifen or raloxifene should considered for use as primary prevention.
A specific model has been developed to assist doctors in predicting breast cancer risks for their patients. This model was used in the NSABP tamoxifen trial and is available to help evaluate patients considering this question. Some doctors would consider recommending tamoxifen to perimenopausal (the years around menopause) or raloxifene to postmenopausal patients with several first-degree relatives who have had breast cancer if the patient has had biopsies with abnormal but not yet cancerous cell changes (atypical hyperplasia) or a type of localized breast cancer (lobular carcinoma in situ). This recommendation would be even stronger if the patient has had a hysterectomy.
Studies are also ongoing to determine whether tamoxifen or raloxifene are effective in preventing breast cancer in women with inherited BRCA1 or BRCA2 genes.
Aromatase inhibitors
Other medications, known collectively as aromatase inhibitors, are also used to block the effects of estrogen. Examples of aromatase inhibitors include anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin). Their main activity is to inhibit (block) the action of a particular enzyme (aromatase) that creates estrogen from other normally circulating hormones. Tamoxifen and aromatase inhibitors, therefore, act differently and have different side effects. Studies are under way to compare their use as breast cancer preventive drugs together and in sequence.
Surgical measures to prevent breast cancer
Preventive or prophylactic mastectomy is the surgical removal of one or both breasts in women who have moderate to high risk of developing breast cancer. Studies have shown that this technique reduces a woman's chance of developing breast cancer by up to 90%. Since small amounts of breast tissue can remain on the chest wall, in the underarm, or even in the abdomen following a mastectomy, it is impossible to completely prevent development of breast cancer by prophylactic mastectomy. Women often choose to have surgical reconstruction of the breasts at the time of surgery.
It is very important for a woman considering preventive mastectomy to have a frank discussion with her physician concerning her cancer risk, other available treatments, and the potential complications and implications of the surgery before making a decision.